Highly reversible extrinsic electrocaloric effects over a wide temperature range in epitaxially strained SrTiO3 films

Electrocaloric effects have been experimentally studied in ferroelectrics and incipient ferroelectrics, but not incipient ferroelectrics driven ferroelectric using strain. Here we use optimally oriented interdigitated surface electrodes to investigate extrinsic electrocaloric effects in low-loss epitaxial SrTiO3 films near the broad second-order 243 K ferroelectric phase transition created by biaxial in-plane coherent tensile strain from DyScO3 substrates. Our extrinsic electrocaloric effects are an order of magnitude larger than the corresponding effects in bulk SrTiO3 over a wide range of temperatures including room temperature, and unlike electrocaloric effects associated with first-order transitions they are highly reversible in unipolar applied fields. Additionally, the canonical Landau description for strained SrTiO3 films works well if we set the low-temperature zero-field polarization along one of the in-plane pseudocubic <100> directions. In future, similar strain engineering could be exploited for other films, multilayers and bulk samples to increase the range of electrocaloric materials for energy efficient cooling.

Presurgical Infant Orthopedic Videos on YouTube™: A Thematic Analysis of Caregiver Narratives

OBJECTIVE

Information regarding how caregivers cope when using presurgical infant orthopedic (PSIO) appliances is sparse. This study aimed to understand caregivers' perspectives and experiences with contemporary PSIO treatment.

DESIGN

PSIO videos shared on the YouTube™ platform were used as the data source. Videos with caregivers were identified (n = 21) and portions with caregiver narratives were transcribed. This was followed by the application of a six-step thematic analysis as conceptualized by Braun and Clarke (2006, 2019).

RESULTS

Two themes were identified from the caregiver narratives in the PSIO videos. The Family Journey theme included reaction to diagnosis, choice of center, burden of care, care commitment, coping, and testimonials. The Information theme included PSIO techniques and PSIO benefits.

CONCLUSION

Multifaceted challenges and coping strategies were described by caregivers during the PSIO phase. Caregivers remained committed to treatment despite the burden of care, were motivated by an understanding of the benefits of PSIO, and customized care based on their individual strengths and needs. Study results can help providers gain an understanding of what caregivers experience outside the clinical environment.

Medical students' perception of resilience and of an innovative curriculum-based resilience skills building course: A participant-focused qualitative analysis

BACKGROUND

Medicine is one of the most demanding academic fields with an extensive curriculum that entails plenty of potential stressors. There is sufficient evidence that medical students are more prone to psychological distress when compared to their peer group of other disciplines. Despite the established need to prioritize resilience skills building within the medical curriculum, very few medical programmes in the Middle East and North Africa region (MENA) proactively empower the students to help themselves in sustaining their mental health. The purpose of the current study is to explore the perception of medical students in Dubai, United Arab Emirates (UAE) regarding their understanding of, and personal experience with building resilience, and their engagement with the content of an innovative curriculum-based resilience skills building course, designed in alignment with the constructivism theory of education.

METHOD

The current study utilized a qualitative phenomenological research design. The curriculum-based resilience skills building course, that was investigated as part of this study, is offered at a medical school in Dubai, UAE. A total of 37 students submitted reflective essays about resilience building, in general, and the respective course, in specific. The collected data was inductively analysed following a six-step framework.

FINDINGS

The qualitative analysis generated three interlinked themes, namely: Awareness, Application, and Appraisal.

CONCLUSION

This study showed that integrating a resilience skills building course into medical curricula is likely to be positively appraised by the students, where it raises their level of awareness and likelihood of proactively applying the learned concepts in their daily lives. This is especially true when the course is anchored in constructivism experiential learning theory and designed to foster self-directed learning.

Profiling of Learners in Medical Schools as a Move Toward Precision Education: Protocol for a Scoping Review

Background

Academic experiences seek to get the best out of learners, maximizing performance and developing the skills and competencies needed to foster lifelong learning. The more personalized and tailored the academic experience among learners, the better the outcome. Precision education is a novel approach to research and practice, which is concerned with identifying and tailoring education to the precise needs of the learner. An emerging area of precision education is using data to develop learner profiles for a better understanding of individual learners relative to the characteristics and competencies of lifelong learners.

Objective

This scoping review aims to identify literature that reports on profiling learners within medical schools. Our review, as described in this paper, will describe the characteristics being measured, the methods and data sources used to generate profiles, and the resulting profiles that emerge. This review aims to provide guidance to those supporting medical school learners on the current state of learner profiling.

Methods

This scoping review will use the Population, Concept, and Context framework, published by Joanna Briggs Institute, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. The search strategy was developed in collaboration with a library specialist. An initial search was conducted in PubMed, ERIC, Google Scholar, Cochrane, CINAHL, and SCOPUS. Data will be extracted, and 2 authors will undertake the screening procedure using the Preferred Reporting Items for Systematic reviews and Meta-Analyses Extension for Scoping Reviews checklist.

Results

The database searches yielded 166 results, and title and abstract screening of 135 extracted articles is currently underway after eliminating 31 duplicates. We anticipate the scoping review to be completed in the first week of October 2022. The final scoping review will present the findings in a narrative and pictorial fashion.

Conclusions

This review will help guide scholars looking to understand the current state of learner profiling within medical schools.

International Registered Report Identifier (IRRID)

PRR1-10.2196/41828

719 2WW Prostate Cancer Referrals - Are We Over Investigating Patients with Normal PSA Results?

Aim

Nationally, men are referred by GPs to urologists for suspected prostate cancer using a cancer pathway proforma for an appointment within two weeks. Criteria include a PSA level above the age-specific range, or an abnormal DRE regardless of PSA result. In this study, we look at the number of cancers detected from patients referred with abnormal DREs and a normal PSA.

Method

In a single major tertiary urological centre, data on patients referred with suspected prostate cancer were retrospectively collected over a 12-month period. Variables focussed on included those referred with a normal PSA, but abnormal DRE, and analysed using descriptive statistics.

Results

Over a 12-month period, 935 referrals were made by GPs for suspected prostate cancer. Of those, 15.3% (n=143) were referred due to an abnormal DRE but a normal PSA. The median age of our cohort was 73 (38–92, mean 70.15) with a median PIRADS score of 2, and a median PSA density of 0.04 (0.01–0.19, mean 0.05).

From our cohort, 6.3% of men (n=9) had malignant histology. From those with malignant histology, 2.1% (n=3) had clinically significant prostate cancer with a mean age of 79. None of the three men were suitable for radical treatment. Only one man with non-clinically significant prostate cancer went on to have radical treatment.

Conclusions

Significant time and resources are used for those referred with abnormal DREs and normal PSA results, who for the overwhelming majority do not require any treatment. There may be scope to streamline referral criteria to reduce burden on services.

Antibody-drug conjugate as targeted therapeutics against hepatocellular carcinoma: preclinical studies and clinical relevance

An antibody-drug conjugate (ADC) is an advanced chemotherapeutic option with immense promises in treating many tumor. They are designed to selectively attack and kill neoplastic cells with minimal toxicity to normal tissues. ADCs are complex engineered immunoconjugates that comprise a monoclonal antibody for site-directed delivery and cytotoxic payload for targeted destruction of malignant cells. Therefore, it enables the reduction of off-target toxicities and enhances the therapeutic index of the drug. Hepatocellular carcinoma (HCC) is a solid tumor that shows high heterogeneity of molecular phenotypes and is considered the second most common cause of cancer-related death. Studies show enormous potential for ADCs targeting GPC3 and CD24 and other tumor-associated antigens in HCC with their high, selective expression and show potential outputs in preclinical evaluations. The review mainly highlights the preclinical evaluation of different antigen-targeted ADCs such as MetFab-DOX, Anti-c-Met IgG-OXA, Anti CD 24, ANC-HN-01, G7mab-DOX, hYP7-DCand hYP7-PC, Anti-CD147 ILs-DOX and AC133-vcMMAF against hepatocellular carcinoma and its future relevance.

Promoting University Students' Mental Health: A Systematic Literature Review Introducing the 4M-Model of Individual-Level Interventions

Objective: The purpose of this study is to systematically review recently published individual student-level interventions aimed at alleviating the burden of mental health challenges faced by the students and/ or at equipping them with coping mechanism that will foster their resilience. Methods: This study relied on a systematic literature review. PubMed dataset was used; the search was confined to the following period: July 2016-December 2020. Results: A total of 1,399 records were identified by the electronic search, out of which 40 studies were included in this study. The authors inductively identified four overlapping categories of interventions across all included articles, and coded them as follows: Mindfulness, Movement, Meaning, and Moderator. Accordingly, each study was linked to at least one of four overlapping categories based on the nature of the intervention(s) under investigation, leading to differing assortments of categories. Conclusions: The 4M-Model generated by this study encourages focusing on devising holistic, university-based interventions that embrace the individuality of students to improve their mental health through elements of mindfulness, movement, meaning, and moderator. Through this focused approach, university counselors are enabled to design interventions that address students' physical, psychological, emotional, and social needs.

Exchange-bias via nanosegregation in novel Fe2-x Mn1+x Al (x = -0.25, 0, 0.25) Heusler films

Exchange-bias has been reported in bulk nanocrystalline Fe₂MnAl, but individual thin films of this Heusler alloy have never been studied so far. Here we study the structural and magnetic properties of nanocrystalline thin films of Fe_2-x Mn_1+x Al (x = -0.25, 0 and 0.25) obtained by sputtering and ex situ post-deposition annealing. We find that Fe₂MnAl films display exchange-bias, and that varying Mn concentration determines the magnitude of the effect, which can be either enhanced (in Fe_1.75Mn_1.25Al) or suppressed (in Fe_2.25Mn_0.75Al). X-ray diffraction shows that our films present a mixed L2₁-B2 Heusler structure where increasing Mn concentration favors the partial transformation of the L2₁ phase into the B2 phase. Scanning transmission electron microscopy (STEM) and energy dispersive X-ray spectroscopy (EDX) reveal that this composition-driven L2₁ → B2 transformation is accompanied by phase segregation at the nanoscale. As a result, the Fe_2-x Mn_1+x Al films that show exchange-bias (x = 0, 0.25) are heterogeneous, with nanograins of an Fe-rich phase embedded in a Mn-rich matrix (a non-negative matrix factorisation algorithm was used to give an indication of the phase composition from EDX data). Our comparative analysis of XRD, magnetometry and X-ray magnetic circular dichroism (XMCD), shows that the Fe-rich nanograins and Mn-rich matrix are composed of a ferromagnetic L2₁ phase and an antiferromagnetic B2 phase, respectively, thus revealing that exchange-coupling between these two phases is the cause of the exchange-bias effect. Our work should inspire the development of single-layer, environmentally friendly spin valve devices based on nanocomposite Heusler films.

Voltage-driven annihilation and creation of magnetic vortices in Ni discs

Using photoemission electron microscopy (PEEM) to image ferromagnetism in polycrystalline Ni disks, and ferroelectricity in their single-crystal BaTiO₃ substrates, we find that voltage-driven 90° ferroelectric domain switching serves to reversibly annihilate each magnetic vortex via uniaxial compressive strain, and that the orientation of the resulting bi-domain reveals the chirality of the annihilated vortex. Micromagnetic simulations reveal that only 60% of this strain is required for annihilation. Voltage control of magnetic vortices is novel, and should be energetically favourable with respect to the use of a magnetic field or an electrical current. In future, stray field from bi-domains could be exploited to read vortex chirality. Given that core polarity can already be read via stray field, our work represents a step towards four-state low-power memory applications.

A comparison of a prototype electromyograph vs. a mechanomyograph and an acceleromyograph for assessment of neuromuscular blockade

The extent of neuromuscular blockade during anaesthesia is frequently measured using a train‐of‐four stimulus. Various monitors have been used to quantify the train‐of‐four, including mechanomyography, acceleromyography and electromyography. Mechanomyography is often considered to be the laboratory gold standard of measurement, but is not commercially available and has rarely been used in clinical practice. Acceleromyography is currently the most commonly used monitor in the clinical setting, whereas electromyography is not widely available. We compared a prototype electromyograph with a newly constructed mechanomyograph and a commercially available acceleromyograph monitor in 43 anesthetised patients. The mean difference (bias; 95% limits of agreement) in train‐of‐four ratios was 4.7 (−25.2 to 34.6) for mechanomyography vs. electromyography; 14.9 (−13.0 to 42.8) for acceleromyography vs. electromyography; and 9.8 (−31.8 to 51.3) for acceleromyography vs. mechanomyography. The mean difference (95% limits of agreement) in train‐of‐four ratios between opposite arms when using electromyography was −0.7 (−20.7 to 19.3). There were significantly more acceleromyography train‐of‐four values > 1.0 (23%) compared with electromyography or mechanomography (2–4%; p < 0.0001). Electromyography most closely resembled mechanomyographic assessment of neuromuscular blockade, whereas acceleromyography frequently produced train‐of‐four ratio values > 1.0, complicating the interpretation of acceleromyography results in the clinical setting.

Elastic and anelastic relaxation behaviour of perovskite multiferroics II: PbZr0.53Ti0.47O3 (PZT)-PbFe0.5Ta0.5O3 (PFT)

Elastic and anelastic properties of ceramic samples of multiferroic perovskites with nominal compositions across the binary join PbZr_0.53Ti_0.47O₃-PbFe_0.5Ta_0.5O₃ (PZT-PFT) have been assembled to create a binary phase diagram and to address the role of strain relaxation associated with their phase transitions. Structural relationships are similar to those observed previously for PbZr_0.53Ti_0.47O₃-PbFe_0.5Nb_0.5O₃ (PZT-PFN), but the magnitude of the tetragonal shear strain associated with the ferroelectric order parameter appears to be much smaller. This leads to relaxor character for the development of ferroelectric properties in the end member PbFe_0.5Ta_0.5O₃. As for PZT-PFN, there appear to be two discrete instabilities rather than simply a reorientation of the electric dipole in the transition sequence cubic-tetragonal-monoclinic, and the second transition has characteristics typical of an improper ferroelastic. At intermediate compositions, the ferroelastic microstructure has strain heterogeneities on a mesoscopic length scale and, probably, also on a microscopic scale. This results in a wide anelastic freezing interval for strain-related defects rather than the freezing of discrete twin walls that would occur in a conventional ferroelastic material. In PFT, however, the acoustic loss behaviour more nearly resembles that due to freezing of conventional ferroelastic twin walls. Precursor softening of the shear modulus in both PFT and PFN does not fit with a Vogel-Fulcher description, but in PFT there is a temperature interval where the softening conforms to a power law suggestive of the role of fluctuations of the order parameter with dispersion along one branch of the Brillouin zone. Magnetic ordering appears to be coupled only weakly with a volume strain and not with shear strain but, as with multiferroic PZT-PFN perovskites, takes place within crystals which have significant strain heterogeneities on different length scales.

Is early removal of prophylactic ureteric stents beneficial in live donor renal transplantation?

Prophylactic ureteric stenting has been shown to reduce ureteric leaks and collecting system obstruction following renal transplantation and is in widespread use. However, the optimal time for removal of ureteric stents after renal transplantation remains unclear. Aim of this study was to compare the result of early versus late removal of ureteric stents after kidney transplantation of the laparoscopically retrieved live related donor grafts. Eligible patients were live donor kidney transplant recipients with normal urinary tracts. All recipients underwent extravesical Lich-Gregoire ureteroneocystostomy over 4F/160 cm polyurethane double J stents by a uniform technique. They were randomized on seventh postoperative day for early removal of stents on postoperative day 7 (Group I), or for late removal on postoperative day 28 (Group II). The incidence of urinary tract infections, asymptomatic bacteriuria, and urological complications were compared. Between 2007 and 2009, 130 kidney transplants were performed at one centre of which 100 were enrolled for the study, and 50 each were randomized into the two groups. Donor and recipient age, sex, native renal disease, immunosupression, number of rejection episodes, and antirejection therapy were similar in the two groups. The occurrence of symptomatic urinary tract infection during the follow-up period of 6 months was significantly less in the early stent removal group [5 out of 50 (10%) in Group I, vs 50 out of 15 (30%) in Group II, P=0.02]. Asymptomatic bacteriuria was documented in 2 out of 50 (4%) in Group I and 4 out of 50 (8%) in Group II (P=0.3). There was no statistically significant difference in the rate of ureteric leak, ureteric obstruction, or hematuria in the two groups (P=1.0). We conclude that, in kidney transplant recipients of laparoscopically retrieved live donor grafts, early stent removal at the end of first week reduces the incidence of urinary tract infection without increasing the rate of urine leak or ureteric obstruction.

Improvement in long-term outcomes with successive Total Therapy trials for multiple myeloma: are patients now being cured?

The concept of applying all active therapeutic agents in Total Therapy (TT) clinical trials for newly diagnosed multiple myeloma was pursued with the intent of developing curative treatment. The results of TT1 (n=231), TT2 (n=668) without or with thalidomide and TT3 with added bortezomib (n=303) have been reported. An update with median follow-up times of 17.1, 8.7 and 5.5 years, respectively, is provided. Conditional overall survival (OS) analysis from a 4-year landmark was applied to account for earlier protocol failure owing to disease aggressiveness and toxicities. Cumulative relative survival was computed in the context of age- and gender-matched US population, and interval-specific relative survival ratios were estimated to determine times to normal survival expectation. Based on Cox model-adjusted statistics, OS, progression-free survival and complete-response duration all improved with the transitions from TT1 to TT2 to TT3; improvement was also evident from time-to-progression estimates, 4-year conditional survival data and cumulative relative survival. Interval-specific relative survival normalized progressively sooner, reaching near-normal levels with TT3 in patients who attained complete response. Thus, a strategy using all myeloma-effective agents up-front seems effective at preventing, in progressively larger patient cohorts over time, the outgrowth of resistant tumor cells that account for ongoing relapses.

Components of sleep quality and sleep fragmentation in rheumatoid arthritis and osteoarthritis

OBJECTIVES

Poor sleep is increasingly recognized as contributing to a decreased quality of life, increased morbidity/mortality and heightened pain perception. The purpose of the present study was to assess components of sleep quality and self-identified contributors to sleep fragmentation in rheumatoid arthritis (RA) and osteoarthritis (OA) patient populations.

METHODS

Consecutive RA and OA clinic patients were invited to participate in a self-administered questionnaire study which included the validated multi-domain Pittsburgh Sleep Quality Index (PSQI), visual analogue scales for pain, fatigue, global functioning, modified Health Assessment Questionnaire (mHAQ), stress scores, the Centre for Epidemiologic Studies-Depression (CES-D) score, the 36-item short form (SF-36) quality of life measure, the Rheumatoid Arthritis Disease Activity Index (RADAI), the Epworth Sleepiness Scale (ESS), Berlin score for obstructive sleep apnoea (OSA) risk and the International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria.

RESULTS

The study population included 145 RA and 78 OA patients. PSQI global scores were >5 in 62% of RA and 67% of OA patients. Multivariate analysis identified global functioning and the CES-D to be independent predictors for higher global PSQI scores in RA patients, whereas in OA patients predictors were the mHAQ and SF-36 mental component summary. Abnormalities in subjective sleep assessment, sleep latency, sleep duration, sleep efficiency, daytime dysfunction and increased sleep-aid medication use were observed in both populations. The most common abnormality reported by both RA and OA patients was increased sleep fragmentation. The most frequent self-identified cause for sleep disturbance was 'need to use the washroom' by 51% of RA and 49% of OA patients, and, second most common, 'pain' was identified as a cause for awakening by 33% of RA and 45% of OA patients.

CONCLUSIONS

A high prevalence of abnormal sleep quality in both RA and OA patient populations was observed. The most common abnormality was sleep fragmentation, with an increased sleep disturbance score. 'Need to use the washroom' and 'pain' were the most common self-identified reasons for awakening from sleep. A review of sleep hygiene, optimization of urological status, and rheumatological disease symptomatic control may prove beneficial in terms of sleep health.

Proteomic analyses of the effects of drugs of abuse on monocyte-derived mature dendritic cells

Drug abuse has become a global health concern. Understanding how drug abuse modulates the immune system and how the immune system responds to pathogens associated with drug abuse, such hepatitis C virus (HCV) and human immunodeficiency virus (HIV-1), can be assessed by an integrated approach comparing proteomic analyses and quantitation of gene expression. Two-dimensional (2D) difference gel electrophoresis was used to determine the molecular mechanisms underlying the proteomic changes that alter normal biological processes when monocyte-derived mature dendritic cells were treated with cocaine or methamphetamine. Both drugs differentially regulated the expression of several functional classes of proteins including those that modulate apoptosis, protein folding, protein kinase activity, and metabolism and proteins that function as intracellular signal transduction molecules. Proteomic data were validated using a combination of quantitative, real-time PCR and Western blot analyses. These studies will help to identify the molecular mechanisms, including the expression of several functionally important classes of proteins that have emerged as potential mediators of pathogenesis. These proteins may predispose immunocompetent cells, including dendritic cells, to infection with viruses such as HCV and HIV-1, which are associated with drug abuse.

Potential Role of Pargyline in Overcoming Adaptive Resistance in Breast Cancer Cells

Background: Estrogen-induced breast carcinogenesis is shown to be characterized by global changes in histone modifications. LSD1 (KDM1), a histone demethylase enzyme, play a key role in establishing specific histone methyl marks at target gene promoters. Recent evidence suggest that LSD1 is recruited to a significant fraction of estrogen receptor (ER) target genes and is required to demethylate proximal histones to enable productive ER transcription. These emerging findings also suggest that deregulation of LSD1 epigenetic pathway could contribute to hormonal independence and adaptive resistance in breast cancer cells. In this study, we examined the therapeutic efficacy of treating breast tumor cells with Pargyline, an FDA approved drug for blocking LSD1 functions, and evaluated the therapeutic benefit.Methods: To test this hypothesis, we used model cells that acquired resistance to hormonal therapy including (a) MCF7-HER2 that overexpress oncogene neu/HER2, (b) MCF7-Tam that have acquired resistance to Tamoxifen, (c) MCF7-Ca-LTLT cells that have acquired resistance to Letrozole, (d) MCF7 cells that overexpress proto-oncogene PELP1 (MCF7-PELP1). Parental MCF7 cells were used as a control. Cells were treated with LSD1 inhibitor Pargyline either alone or in combination with Letrozole and Dasatinib. Activation of ER genomic functions was studied using luciferase reporter gene assays. Epigenetic modifications at target promoters were analyzed by Chromatin immune precipitation (CHIP) assays using H3 methyl (di and Tri -H3K4, -K9) specific antibodies. Biological significance and hormonal therapy sensitivity was measured by in vitro cell proliferation assays. Xenograft studies were used to validate the drug effect in vivo. Pilot studies were performed for delivery of drug combinations using nanoparticle formulation.Results: Reporter gene assays showed that LSD1 has potential to enhance ER mediated transcription. LSD1 functionally interacts with ER coregulator PELP1 and is recruited to ER target genes. Pargyline substantially inhibited ER transactivation functions. ChIP analysis revealed that aggressively growing breast cancer cells and therapy resistant cells have distinct activating histone methyl modifications at growth regulatory ER target genes. Treatment of breast cancer models with LSD1 inhibitor Pargyline facilitated reversal of these specific modifications and thereby inhibited the growth of breast cancer cells in vitro and in vivo models. Combinatorial therapy using three agents; (a) that block Estrogen receptor genomic actions (Tamoxifen or Letrozole), (b) ER nongenomic actions (Dasatinib) and (c) ER epigenetic modifications (Pargyline) showed the most promising therapeutic effect compared to single agent therapy on the growth of therapy resistant cells.Conclusions: Our results suggest that histone methyl modification plays a role in therapy resistance and validates the therapeutic potential of Pargyline in combinational therapies. Collectively, these results suggest that targeting LSD1 axis with Pargyline in combination with current endocrine therapies will have better therapeutic effect and may inhibit or delay development of hormonal resistance, thus providing major benefits to patients care. This study is funded by Komen grant KG090447.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 409.

Hodgkin's disease of appendix: report of a case

BACKGROUND

A number of cases of non Hodgkin's lymphoma of the appendix have been described, but Hodgkin's lymphoma is extremely rare. To our knowledge there are only two reports up to 1966 and none since then.

METHOD

We report a case of a 65-year-old gentleman who was treated for suspected Crohn's disease. He failed to respond to medical treatment and underwent right haemicolectomy. The resected segment of bowel demonstrated classical Hodgkin's disease originating in the appendix. He recovered well from the operation and responded well to postoperative chemotherapy.

CONCLUSION

Hodgkin's lymphoma of appendix is extremely rare. This case demonstrates the significance of repeated clinical evaluation of patients particularly in the absence of expected response to therapy.

Arthritis and bursitis in multiple sclerosis patients treated with interferon‐beta

Interferon-beta (IFN-beta) is a type I interferon used in the management of multiple sclerosis. Therapy with IFN-beta has rarely been associated with the development of autoimmune disorders. We present the cases of two female patients diagnosed with relapsing-remitting multiple sclerosis (RRMS) who developed inflammatory musculoskeletal manifestations, following IFN-beta therapy. The first patient developed a monoarthritis 2 weeks after initiation of IFN-beta, which persisted during the 14 months of therapy and resolved with discontinuation of the medication. The second patient developed both autoimmune thyroid disease and a refractory pre-patellar bursitis after 50 months of IFN-beta therapy. Our literature review revealed an additional six cases of onset of inflammatory arthritis in MS patients receiving IFN-beta. We review these reports with comparison to our two cases. The role of IFN-beta in inflammatory musculoskeletal disease is unclear. The potential autoimmune complications of this therapeutic agent should be comprehended when monitoring patients receiving such treatment.

MDS-associated cytogenetic abnormalities (MDS-CA) after total therapy (TT) regimens for newly diagnosed multiple myeloma (MM): Apparent surge after introduction of post-transplant consolidation chemotherapy (CONS) in TT2 and TT3

8595

Background: We have previously reported on the variables associated with the development of MDS-CA in the context of autologous transplant-supported high-dose therapy regimens for MM (Barlogie et al, Blood 2008). Methods: Due to a perceived increase in MDS-CA frequency, our MM data base was reviewed again to determine the potential effect of CONS introduced in TT2 and retained in TT3 trials. The frequency of MDS-CA post-transplant was determined, using Kaplan-Meier estimate plots, for 183 patients who received TT1, 554 enrolled in TT2 and 305 receiving TT3. Persistence of MDS-CA implied their documentation on 3 successive occasions. Results: 3-year MDS-CA estimates were 2% for both TT1 and TT2 and 4% for TT3 (TT3 v TT2, p=0.04; TT3 v TT1, p=0.11); persistent MDS-CA were also more frequently observed in TT3 in comparison with TT2 and TT1 (2% v 0% v 0%, both p=0.01). Multivariate analysis of features associated with transient and persistent MDS-CA revealed TT3 as an adverse feature (HR=2.84, p=0.043), along with incomplete platelet recovery of <165,000/uL 3mo after 1st transplant. Conclusions: Despite reduced induction chemotherapy prior to and CONS after tandem melphalan (200mg/m2)-based autotransplants from 4 in TT2 to 2 in TT3, overall and persistent MDS-CA increased significantly in TT3. Clinical MDS and AML were rarely observed and a full account of hematopathologic findings will be presented.

[Table: see text]

Gene expression profiling (GEP)-defined risk and molecular subgroups assessed at baseline and at relapse: Collective impact on post-relapse survival of multiple myeloma (MM) treated with total therapies 2 and 3

8589

Background: GEP-defined risk has evolved as the most robust predictor of overall and event-free survival (OS, EFS) in MM with TT2 and TT3 protocols, distinguishing 85% with low-risk (LR) and 15% with high-risk (HR). Upon relapse, the original risk designation may change typically in the direction LR to HR. Here we examine, among patients with available GEP data at baseline (BL) and relapse (REL), the contributions of both observations on post-relapse survival (PRS). Methods: Paired REL-BL GEP data were available in 77 patients, while information on metaphase cytogenetic abnormalities (CA) was obtained in 76 patients at both time-points. Results: PRS was significantly affected by both BL and REL HR status so that, among the 52 patients with LR at BL, HR status at REL conferred significantly poorer outcome compared to those with LR at REL (p=0.0005) with 30-mo estimates of 71% v 13%; likewise, among the 25 patients with HR at baseline, HR present also at relapse further diminished PRS (p=0.09) with 30-mo estimates in both settings of less than 20%. Similar considerations for CA status revealed, among the 29 patients without CA at BL, marked attrition of PRS with CA v no CA at REL with 30-mo estimates of 29% v 81% (p=0.04); for the 47 patients with CA at BL, CA also at REL further diminished the poor PRS from 46% to 22% (p=0.06). When all standard BL and REL prognostic factors were examined in a multivariate model, GEP-derived HR contributed to poor PRS both when present at BL (HR=2.79, p=0.005) and at REL (HR=2.77, p=0.002), in addition to CA at BL (HR=2.44, p=0.018). Conclusions: In estimating PRS in TT protocols, genetic characteristics at BL (HR, CA) have enduring adverse consequences aggravated further by HR status at REL. Therefore, in HR/CA BL settings, aiming at REL prevention appears as the best overall treatment strategy.

[Table: see text]

Plerixafor (P) plus G-CSF (G) in previous peripheral blood progenitor cell (HPC) mobilization failures (MF)

7095

Background: Successful autologous stem cell transplantation (AT) requires harvesting sufficient HPC to ensure reliable engraftment, which cannot be accomplished in ∼10% of previously treated patients. Methods: MF was defined as the inability to collect at least 2 x106 CD34+ cells/kg with growth factor alone (GF) (n=38) or in combination with chemotherapy (GF-CT) (n=27). Of 65 patients reported here, 45 were enrolled in a compassionate use program and 20 were part of a clinical trial (AMD3100–2102); 55 had MM, 9 had lymphoma and 1 had primary amyloidosis. All patients had been treated previously and included prior AT in 26 patients, 15 of whom had 2 AT and 2 had ≥3 AT. The P+G regimen started with G (10 μg/kg) for 4 days, P (240 μg/kg) was added on the evening of day 4; both P and G were continued until completion of collection. In the case of MM, all collected products were analyzed for tumor contamination by DNA/cIg flow cytometry. Results: Of all 65 patients, 63 initiated apheresis which yielded a median 3.6x106 CD34/ kg (range, 0.3–17.8) during a median of 5 days (d) of collection (range, 2–7), with successive median daily CD34 yields of 1.1, 0.9, 0.6, 0.5, 0.3, 0.4 and 0.5 x106/kg. MM cells were mobilized in only 2/55 patients. Additional collection was undertaken in 25 patients, using GF or GF-CT in 19 (median, 3.2x106 CD34 cells; range, 0–8.5), further P+G in 5 (median, 1.7x106 CD34 cells/kg; range, 0.9–3.5), and 1 patient received P+G on a third occasion (2.2x106 CD34 cells /kg). Of 63 patients, 51 (81%) and 24 (38%), respectively, collected ≥2.0 and ≥5.0x106 CD34 /kg. AT was supported with P+G derived products in 43 patients including 7 who received 2 AT. With median infused CD34+cells of 3.6x106 / kg (range, 1.0–7.7), the median times to neutrophils > 500/μl and platelets >20,000/ μl were 14 d (range, 11–35) and 15 d (range, 9–253). Conclusions: P+G ensures collection of an adequate HPC product after MF in 81% that affords durable engraftment even though 40% had prior AT.

[Table: see text]

The hyponatremic hypertensive syndrome in renal artery stenosis: An infrequent cause of hyponatremia

The hyponatremic hypertensive syndrome is a rare but serious complication of reno-vascular disease. The syndrome is characterized by hypertension and profound natriuresis, leading to body sodium and water depletion. Hypertension is typically refractory to treatment. We report an 82-year-old patient with this syndrome and describe the results of an audit of the clinical records of patients admitted to a teaching hospital over a two-year period with confirmed renal artery stenosis and hyponatremia. The syndrome should be suspected in patients in whom severe hypertension is associated with hyponatremia without other apparent cause, especially in the presence of reno-vascular disease.

Final report on the safety assessment of Benzyl Alcohol, Benzoic Acid, and Sodium Benzoate

Benzyl Alcohol is an aromatic alcohol used in a wide variety of cosmetic formulations as a fragrance component, preservative, solvent, and viscosity-decreasing agent. Benzoic Acid is an aromatic acid used in a wide variety of cosmetics as a pH adjuster and preservative. Sodium Benzoate is the sodium salt of Benzoic Acid used as a preservative, also in a wide range of cosmetic product types. Benzyl Alcohol is metabolized to Benzoic Acid, which reacts with glycine and excreted as hippuric acid in the human body. Acceptable daily intakes were established by the World Health Organization at 5 mg/kg for Benzyl Alcohol, Benzoic Acid, and Sodium Benzoate. Benzoic Acid and Sodium Benzoate are generally recognized as safe in foods according to the U.S. Food and Drug Administration. No adverse effects of Benzyl Alcohol were seen in chronic exposure animal studies using rats and mice. Effects of Benzoic Acid and Sodium Benzoate in chronic exposure animal studies were limited to reduced feed intake and reduced growth. Some differences between control and Benzyl Alcohol-treated populations were noted in one reproductive toxicity study using mice, but these were limited to lower maternal body weights and decreased mean litter weights. Another study also noted that fetal weight was decreased compared to controls, but a third study showed no differences between control and Benzyl Alcohol-treated groups. Benzoic Acid was associated with an increased number of resorptions and malformations in hamsters, but there were no reproductive or developmental toxicty findings in studies using mice and rats exposed to Sodium Benzoate, and, likewise, Benzoic Acid was negative in two rat studies. Genotoxicity tests for these ingredients were mostly negative, but there were some assays that were positive. Carcinogenicity studies, however, were negative. Clinical data indicated that these ingredients can produce nonimmunologic contact urticaria and nonimmunologic immediate contact reactions, characterized by the appearance of wheals, erythema, and pruritus. In one study, 5% Benzyl Alcohol elicited a reaction, and in another study, 2% Benzoic Acid did likewise. Benzyl Alcohol, however, was not a sensitizer at 10%, nor was Benzoic Acid a sensitizer at 2%. Recognizing that the nonimmunologic reactions are strictly cutaneous, likely involving a cholinergic mechanism, it was concluded that these ingredients could be used safely at concentrations up to 5%, but that manufacturers should consider the nonimmunologic phenomena when using these ingredients in cosmetic formulations designed for infants and children. Additionally, Benzyl Alcohol was considered safe up to 10% for use in hair dyes. The limited body exposure, the duration of use, and the frequency of use were considered in concluding that the nonimmunologic reactions would not be a concern. Because of the wide variety of product types in which these ingredients may be used, it is likely that inhalation may be a route of exposure. The available safety tests are not considered sufficient to support the safety of these ingredients in formulations where inhalation is a route of exposure. Inhalation toxicity data are needed to complete the safety assessment of these ingredients where inhalation can occur.

Final report on the safety assessment of Mentha Piperita (Peppermint) Oil, Mentha Piperita (Peppermint) Leaf Extract, Mentha Piperita (Peppermint) Leaf, and Mentha Piperita (Peppermint) Leaf Water

Mentha Piperita (Peppermint) Oil, Mentha Piperita (Peppermint) Leaf Extract, Mentha Piperita (Peppermint) Leaf, Mentha Piperita (Peppermint) Leaf Water are obtained from the Mentha piperita plant. The oil is currently used in cosmetic formulations as a fragrance component, but previously had been also described as a denaturant. The extract and leaves are described as biological additives, but only the extract is reported to be used. Peppermint Water is described as a flavoring agent or fragrance component, but is not currently in use. Peppermint Oil is used at a concentration of < or = 3% in rinse-off formulations and < or = 0.2% in leave-on formulations. Peppermint Oil is composed primarily of menthol and menthone. Other possible constituents include pulegone, menthofuran, and limone. Most of the safety test data concern Peppermint Oil. The oil is considered to present the "worst case scenario" because of its many constituents, so data on the oil were considered relevant to the entire group of ingredients. Peppermint Oil was minimally toxic in acute oral studies. Short-term and sub-chronic oral studies reported cystlike lesions in the cerebellum in rats that were given doses of Peppermint Oil containing pulegone, pulegone alone, or large amounts (>200 mg/kg/day) of menthone. Pulegone is also a recognized hepatotoxin. Repeated intradermal dosing with Peppermint Oil produced moderate and severe reactions in rabbits, although Peppermint Oil did not appear to be phototoxic. Peppermint Oil was negative in the Ames test and a mouse lymphoma mutagenesis assay but gave equivocal results in a Chinese hamster fibroblast cell chromosome aberration assay. In a carcinogenicity study of toothpaste and its components, no apparent differences were noted between mice treated with Peppermint Oil and those treated with the toothpaste base. Isolated clinical cases of irritation and/or sensitization to Peppermint Oil and/or its constituents have been reported, but Peppermint Oil (8%) was not a sensitizer when tested using a maximization protocol. It was expected that dermal absorption of Peppermint Oil would be rapid, following that of menthol, a major component, but in no case would be greater than absorption through the gastrointestinal tract. Because of the toxicity of pulegone, the safe concentration of this constituent was limited to < or = 1%. This concentration was achievable both by controlling the time of harvest and processing technique. There is evidence that menthol can enhance penetration of other agents. Formulators were cautioned that this enhanced penetration can affect the use of other ingredients whose safety assessment was based on their lack of absorption. With the limitation that the concentration of pulegone in these ingredients should not exceed 1%, it was concluded that Mentha Piperita (Peppermint) Oil, Mentha Piperita (Peppermint) Extract, Mentha Piperita (Peppermint) Leaves, Mentha Piperita (Peppermint) Water are safe as used in cosmetic formulations.

Early versus deferred androgen suppression in the treatment of advanced prostatic cancer

BACKGROUND

Prostate cancer is a leading cause of cancer death in men. Treatment goals for men with advanced prostate cancer include prolonging survival, preventing or delaying symptoms due to disease progression, improving and maintaining quality of life, reducing treatment related morbidity. Androgen suppression therapy is considered a mainstay of treatment for men with advanced prostate cancer. However it is not clear whether early androgen suppression for men with locally advanced disease or asymptomatic metastases improves length and quality of life compared to androgen suppression deferred until signs and symptoms of clinical progression.

OBJECTIVES

This systematic review assessed the efficacy and adverse effects of primary therapy with early versus deferred androgen suppression therapy in men with advanced prostate cancer.

SEARCH STRATEGY

Randomized controlled trials were searched in general and specialized databases (MEDLINE, EMBASE, CancerLIT, Cochrane Library, VA Cochrane Prostate Disease register) and by reviewing bibliographies including those of the Blue Cross and Blue Shield Association Technology Evaluation Center/Evidence-based Practice Center of the Agency for Healthcare Research and Quality (BCBS/TEC-AHRQ) report No.4.

SELECTION CRITERIA

All published randomized trials were eligible for inclusion provided they: randomized men with advanced prostate cancer to early versus deferred androgen suppression; reported overall, progression-free, and cancer-specific survival, and/or adverse events; did not utilize androgen suppression as adjuvant therapy to radiation treatment.

DATA COLLECTION AND ANALYSIS

An independent reviewer using a standardized form extracted information on trial characteristics, interventions, and outcomes. Results were reviewed for accuracy and discrepancies resolved by discussion. The main outcome measure for comparing effectiveness was the overall survival at 1, 2, 5 and 10 years. Progression-free survival, cancer-specific survival, complications due to disease progression and the incidence of adverse effects of treatment were also measured.

MAIN RESULTS

Four trials involving 2,167 patients were included in this review. All of the trials were conducted prior to use of prostate specific antigen (PSA) testing. There was variability between studies regarding the treatments used and the requirements for initiation of treatments. The percent overall survival at 1, 2, 5, and 10 years for the early treatment group was 88%, 73%, 44%, and 18%. For the deferred therapy group the percent overall survival was 86%, 71%, 37%, and 12%. The pooled estimate for the difference in overall survival favored early therapy but was significant only at 10 years when few patients had survived [OR = 1.16 (95% CI: 0.90 to 1.49) at 1 year, 1.08 (95% CI: 0.89 to 1.33) at 2 years, 1.19 (95% CI: 0.95 to 1.50) at 5 years, and 1.50 (95% CI: 1.04 to 2.16) at 10 years]. The pooled estimate of prostate cancer specific survival at 2, 5, and 10 years favored early therapy though the confidence intervals were wide and the results not statistically different. The risk differences at 2, 5, and 10 years were 2.7%, 5.8%, and 4.6%. Although each study used unique definitions of progression free survival, all studies found progression free survival was consistently better in the early intervention group at all time points. Complications due to disease progression were only reported in one study but were more frequent in the deferred treatment group. Adverse events due to treatment were also only reported in one study but occurred more frequently in the early treatment group.

REVIEWER'S CONCLUSIONS

The evidence from randomized controlled trials is limited by the variability in study design, stage of cancer and subjects enrolled, interventions utilized, definitions and reporting of outcomes and the lack of PSA testing for diagnostic and monitoring purposes. However, the available information suggests that early androgen suppression for treatment of advanced prostate cancer reduces disease progression and complications due to progression. Early androgen suppression may provide a small but statistically significant improvement in overall survival at 10 years. There was no statistically significant difference in prostate cancer specific survival but a clinically important difference could not be excluded. These outcomes need to be evaluated with the evidence suggesting higher costs and more frequent treatment related adverse effects with early therapy. Additional studies are required to evaluate more definitively the efficacy and adverse effects of early versus delayed androgen suppression in men with prostate cancer. In particular trials should evaluate patients with advanced prostate cancer diagnosed by PSA testing and men with persistent or rising PSA levels following treatment options (e.g. radical prostatectomy, radiation therapy or observation) for clinically localized disease.

Advance care planning in residential care

BACKGROUND

To provide optimal care for our ageing population, some form of advance care planning (ACP) is essential. Overseas data suggest that the process of ACP and the use of advance care directives (ACD) is suboptimal in residential care institutions. By comparison there are few Australian data.

AIM

To study the process of ACP and the prevalence of ACD in residential care.

METHODS

Cross-sectional study using a questionnaire in the Hunter area, NSW, Australia.

RESULTS

Very low levels of formal advance directives were found (available for only 0.2%). Only 1.1% of residents had 'no-CPR' orders documented in the medical record, while 5.6% had a formal guardian and 2.8% had an enduring guardian. Informal processes of advance planning were much more prevalent. Sixty-five per cent had a 'person responsible' recorded to make decisions for them while in 13% of cases, there was 'staff consensus' as to the optimal care for the patient. However, in 10.6% there was no clear process for medical decision making identified.

CONCLUSIONS

Advanced directives are infrequently used in residential care. Further qualitative and quantitative studies are warranted to explore current processes of decision making.

Use of patient restraints in four Australian teaching hospitals

To examine the patterns of use of patient restraints in Australian hospitals and the level of adherence to accepted guidelines, we undertook a point-prevalence study in four teaching hospitals in three different States. This involved ward inspections and review of case notes. Overall, 51 (12.5%) of the 408 people audited were being restrained with a variety of physical and chemical agents. The rate of restraint use varied from 8.5% to 18.5% between hospitals. Although the overall prevalence of restraint use increased with age, the hospital with the oldest patients used restraints least. At all hospitals, there was scant documentation in the case notes concerning the use of restraints. The prevalence of restraint use varies widely in different hospitals. As this is not explained by the patient profile, it probably reflects different philosophies of care. Documentation of the use of restraints needs to be improved in all the centres studied.

Gender differences and other determinants of the rise in plasma homocysteine after L-methionine loading

The methionine load test is widely used to identify subjects with mild homocysteinemia. We studied factors influencing the rise in plasma homocysteine (tHcy) levels following oral methionine loading, after taking into account determinants of the basal level. The study population comprised 522 persons (mean age 53, range 17 to 95; 63% male; 60% with coronary disease). tHcy was measured fasting and 4 h after administration of L-methionine (dose 4 g/m2). The percentage rise in tHcy was greater in females, at younger ages, and with lower serum creatinine. Basal tHcy was lower in those with high levels of serum folate, red cell folate and serum B12; they also showed a greater percentage rise with loading. After adjustment for age, creatinine and serum vitamins the percent rise was greater in females (mean 230%, S.D. 92) than in males (mean 172%, S.D. 71, P < 0.0001). About 1/4 of this effect was explained by the methionine dose, but important independent gender effects remained. When the results of the loading test were compared with an overall reference range, females were systematically labelled as 'high' but comparison with age and gender-specific reference ranges normalised the sex distribution. Our data show that a single L-methionine loading protocol for both sexes is not appropriate. Gender-specific reference ranges should be used to define post-load homocysteinemia and previous studies which have identified a high proportion of females with this trait probably reflect the need for gender specific reference ranges.

Fasting and post-methionine homocyst(e)ine levels in a healthy Australian population

BACKGROUND

Plasma homocyst(e)ine (H[e]) is frequently measured in patients with occlusive vascular disease, but levels vary between populations and between laboratories.

AIMS

We sought to derive reference values for an Australian population over a wide age range.

METHODS

We measured plasma H(e) in the fasting state and after methionine loading in 116 volunteers selected at random from the Hunter districts of the New South Wales electoral roll and in 49 apparently healthy, active subjects recruited from the region's lawn bowling clubs. Reference ranges were derived for both sexes, in three age strata. We collaborated with two international laboratories in standardising our results.

RESULTS

Mean fasting H(e) levels were approximately 2.7 mumol/L higher in men than women, at all ages (95% CI for the difference, 1.2 to 4.1 mumol/L). Levels increased with age (approximately 1.0 mumol/L/decade, 95% CI 0.5 to 1.5) and were correlated with serum creatine (r = 0.48), serum folate (r = -0.30), red cell folate (r = -0.25) and serum B12 (r = -0.31) (all p < 0.001). These results are similar to those reported in other populations.

CONCLUSIONS

We have defined reference ranges for a typical Australian population, following careful laboratory standardisation. H(e) levels must be interpreted with regard to age, sex, renal function and vitamin B12 and folate status.

Expression of epidermal growth factor receptor in gestational trophoblastic diseases

Gestational trophoblastic disease is an abnormal condition of the placenta, the incidence of which is very high in the State of Kerala, India. The biology of this disease is vague and methods to determine the malignant potential are limited. Placentae of normal (50) and molar pregnancies (95), including 32 showing persistent disease, were used for the study. Epidermal growth factor (EGFR), expression was evaluated by immunohistochemistry using monoclonal antibody, and quantified using the 125I-EGF-binding assay. EGFR was expressed more strongly in molar placentae than in normal placentae of similar gestational age, and was strong in the molar placentae of all gestational ages, whereas expression was mainly restricted to the first and second trimesters in normal placentae. Moles with early presenting symptoms (before 16 weeks) were at a higher risk of developing persistent disease. To conclude, the immunohistochemical study shows high expression of EGFR in early normal placentae and in moles, linking its role to the proliferative and differentiating activity of trophoblasts. Tumours with a histological diagnosis of invasive moles and choriocarcinoma showed very strong binding of EGFR. The present observations also suggest the possibility of mutated EGF receptors being present in persistent trophoblastic disease.