Barriers and facilitators for surgical site infection surveillance for adult cardiac surgery in a high-income setting: an in-depth exploration

BACKGROUND

Surgical site infection (SSI) surveillance aims to facilitate a reduction in SSIs through identifying infection rates, benchmarking, triggering clinical review and instituting infection control measures. Participation in surveillance is, however, variable suggesting opportunities to improve wider adoption.

AIM

To gain an in-depth understanding of the barriers and facilitators for SSI surveillance in a high-income European setting.

METHODS

Key informant interviews with 16 surveillance staff, infection prevention staff, nurses and surgeons from nine cardiac hospitals in England. Data were analysed thematically.

FINDINGS

SSI surveillance was reported to be resource intensive. Barriers to surveillance included challenges associated with data collection: data being located in numerous places, multiple SSI data reporting schemes, difficulty in finding denominator data, lack of interface between computerized systems, 'labour intensive' or 'antiquated' methods to collect data (e.g., using postal systems for patient questionnaires). Additional reported concerns included: relevance of definitions, perceived variability in data reporting, lack of surgeon engagement, unsupportive managers, low priority of SSIs among staff, and a 'blame culture' around high SSI rates. Facilitators were increased resources, better use of digital technologies (e.g., remote digital wound monitoring), integrating surveillance within routine clinical work, having champions, mandating surveillance, ensuring a closer relationship between surveillance and improved patient outcomes, increasing the focus on post-discharge surveillance, and integration with primary care data.

CONCLUSION

Using novel interviews with 'front-line' staff, identified opportunities for improving participation in SSI surveillance. Translating these findings into action will increase surveillance activity and bring patient safety benefits to a larger pool of surgical patients.

Comparison of Four Software Packages for Automated Contouring

PURPOSE/OBJECTIVE(S)

We are an academic radiation oncology center and treat 1500-2000 patients annually. The majority of target volume definition and organ at risk (OAR) contouring is performed by radiation oncologists (RO) and is estimated to require 10-15 hours per week for each RO. Artificial intelligence (AI) solutions for contouring are a possible method of reducing the time required. Several packages are commercially available. The purpose of this exercise was to evaluate 4 packages to identify one which would meet our department's need. The primary objective was to calculate the potential time savings associated with each of the 4 packages. The second objective was to perform a qualitative evaluation and comparison.

MATERIALS/METHODS

Approval from the hospital's Research Ethics Committee was obtained. CT Simulation datasets for 15 patients were anonymized for use as test cases for AI contouring. This included 5 datasets from each of 3 sites - head and neck (H+N), breast/thorax, and prostate/pelvis. 4 potential vendors provided access to their product for automated contouring of OARs +/- target volumes of each of the 15 datasets. Analysis was as follows: 1. One RO used a stopwatch to assess the time taken for them to contour each of the OARs +/- targets on each dataset 2. The AI contours from each of the vendors for each of the datasets was reviewed. 3. The time taken to correct each auto-contoured organ to make it clinically useful was timed. These were summed to give a time for each vendor for each dataset. 4. The time saving was calculated by subtracting the result of step (3) from step (1) 5. For the purpose of qualitative assessment, 2 ROs reviewed each dataset and assigned an objective score of 1-5 to each auto-contoured organ (e.g., 5 = no, or almost no, edits required; clinically useful as is) 6. The scores for each organ in each of the 15 datasets were averaged to give a mean value for the software package.

RESULTS

Baseline contouring time was 32.8 minutes for H+N, 23.0 minutes for breast/thorax, and 64.8 minutes for prostate/pelvis. One package was removed from consideration after assessment of H+N only as it was deemed to be of insufficient standard to be of clinical use. The average time saving for each of the remaining 3 software packages ranged were 15.7, 17.9, and 12.8 minutes for H+N, 3.1, 13.1, and 11.0 minutes for breast/thorax, and 32.6, 35.2, and 36.2 minutes for prostate/pelvis. Percentage time savings ranged from 39-55% for H+N, 13-57% for breast/thorax, and 50-56% for prostate/pelvis. The overall qualitative assessments on a 5-point scale were 3.5, 4.0, and 3.6.

CONCLUSION

The AI contouring solutions were associated with meaningful savings in the time taken to contour. The introduction of one of these products into clinical practice within our department will permit ROs to focus more of their time on other clinical activities.

CT in the detection of latent tuberculosis: a systematic review

AIM

To evaluate the use of computed tomography (CT) and low-dose CT in the detection of latent tuberculosis (TB).

MATERIALS AND METHODS

A systematic search of literature in adherence with the PRISMA guidelines was carried out. Quality assessment of the included studies was conducted.

RESULTS

The search strategy identified a total of 4,621 studies. Sixteen studies were considered eligible and included in the review. There was high heterogeneity among all studies. CT was identified as much more sensitive for the detection of latent TB in all studies despite chest radiography often being recommended in guidelines to assess patients for latent TB. Low-dose CT showed promising results in four of the studies; however, these results were limited due to small sample sizes.

CONCLUSION

CT is much superior to chest radiography consistently identifying additional cases of latent TB. There are limited high-quality publications available using low-dose CT but findings thus far suggest low-dose CT could be used as an alternative to standard-dose CT for the detection of latent TB. It is recommended that a randomised controlled trial investigating low-dose CT should be carried out.

Acute arterial haemodynamics activation of endothelial to mesenchymal transition in long saphenous veins. Impact on vein graft disease

Introduction

The long saphenous vein (LSV) is frequently used in cardiac surgery; however, its use is complicated by late stenosis or occlusion due to the development of intimal hyperplasia (IH). TGF-β has been implicated in the process of IH however the impact of acute haemodynamic changes on the activation of TGF-β endothelial-to mesenchymal transition (EndMT) has not been assessed and it's the focus of this study.

Purpose

To assess the role of acute haemodynamics changes in veins implanted into arterial circulation on EndMT.

Methods

Surplus LSV were exposed to acute arterial haemodynamics using a perfusion bioreactor. Changes in EndMT markers at the RNA and protein level evaluated by quantitative real time PCR, RNAScope and immunofluorescence.

Results

The acute exposure of veins to arterial haemodynamics ex-vivo induced significant increase in inflammatory marker IL-8 expression and transcription factor TWIST1 in LSV (both p≤0.01, Figure 1A) endothelium. Furthermore, immunostaining demonstrated the activation of pSMAD (p≤0.01, Figure 1B) acutely in endothelium after 45 minutes of exposure to arterial haemodynamics. This was followed by significant increase of SMC related markers (Vimentin and α-SMA; Figure 1C, both p≤0.001) and the suppression of endothelial cell related marker CD31 after 4 hours of LSV exposure to acute arterial haemodynamics. RNAScope and IHC results showed localisation of TWIST1 RNA and protein in CD31+ (p≤0.001) and VECAD+ (p≤0.001) cells respectively following exposure to acute arterial haemodynamics (Figure 1D). Furthermore, TGF-β pathway phosphorylation array identified the activation of Smad1 (p≤0.05) but not TAK1 in LSV endothelial cells indicating that acute arterial haemodynamics activates the TGF-β–SMAD pathway specifically (Figure 1E).

Conclusion

The exposure of LSV to acute arterial haemodynamics is associated with the activation of TGF-β–SMAD pathway leading to EndMT changes in the endothelium of vein grafts ex-vivo. This contributes to our understanding of the changes that occur in veins after implantation into arterial circulation and that the acute changes in the endothelium and suggests that strategies to modulate TGF-β–SMAD can be utilised to modulate IH in vein grafts.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Van Geest Foundation Heart and Cardiovascular Diseases Research Fund

Drug-eluting balloons and drug-eluting stents in the treatment of small vessel coronary artery disease: a systematic review and metanalysis of long-term clinical and angiographic outcomes

Introduction

Coronary artery disease is a leading cause of mortality and morbidity worldwide. For those undergoing PCI, there are 20–30% with disease of the small coronary arteries on presentation [1]. Small coronary artery disease asserts a significant risk factor for adverse events. It is often diffuse and multi-vessel on presentation and confers higher rates of major adverse cardiac events, (MACE) and target lesion failure after intervention [2,3]. Best practice guidelines on the management of SvCAD interventions remain limited.

Drug-eluting balloons are a novel therapy, which has shown promise in treating in-stent restenosis (ISR), however their use in small coronary arteries when compared to drug-eluting stents remains unclear.

Purpose

This systematic review and meta-analysis compare long-term outcomes (>1 year), of drug-eluting balloons (DEB), vs. drug-eluting stents (DES), in the treatment of small coronary artery disease (<3mm).

Methods

A systematic review was completed within PRISMA guidelines. The primary outcome was non-inferiority of DEB Vs. DES in major adverse cardiac events (MACE). Secondary outcomes include all-cause mortality, MI, vessel thrombosis, major bleeding and target vessel revascularization at one, two and three years follow-up. Two independent reviewers extracted data. All outcomes used the Mantel-Haenszel and Random effect model. Odds ratios (OR), were presented with a 95% confidence interval (CI).

Result

Of 4661 articles, four RCTs were included (1414 patients). DEB demonstrated reduced rates of non-fatal MI at one year, OR 0.44 (95% CI 0.2, 0.94) and Basket-2 small reported a significant reduction in two-year bleeding rates OR 0.3 (95% CI 0.1, 0.91). DEBs were non-inferior to DES for all other outcomes.

Conclusion

Long duration follow-up of DEB and DES use in small coronary arteries demonstrates DEB to be non-inferior to DES in all outcomes across all years of follow-up. There was a significant reduction in rates of non-fatal MI at one year in the DEB arm and a reduction in major bleeding episodes at two years in the Basket Small 2 trial. These data highlight the potential utility and long-term safety of novel DEBs in small coronary artery disease revascularization.

Funding Acknowledgement

Type of funding sources: None.

P-432 Biologic use during conception and pregnancy and its impact on fetal and maternal outcomes: systematic review and meta-analysis

Study question

To determine pregnancy outcomes in women with chronic inflammatory disease exposed to biologics during conception and pregnancy.

Summary answer

Meta-analysis of 11172 pregnancies exposed to biologic medications show no evidence of harm for the fetus or the mother.

What is known already

Chronic inflammatory diseases (CIDs) are a group of autoimmune diseases which affect between 5-7% of the population and include rheumatoid arthritis (RA), psoriatic arthritis and inflammatory bowel disease (IBD). Many CIDs have a female preponderance and are often associated with activity during reproductive years. Biologic medications, specifically the TNF-α inhibitors, have become increasingly prevalent in the treatment of chronic inflammatory disease (CID) in women of childbearing age.

Study design, size, duration

PubMed and EMBASE databases January 1998-July 2021.Peer reviewed, English language cohort, case-control, cross-sectional studies, and case series which contained original data. P- diagnosis of CID pregnancy. I- Biologic medication. C- diagnosis of CID without treatment with biologics and a CID free population. O- fetal:congenital malformations, preterm delivery (<37 weeks), severe neonatal infection requiring hospitalisation, low birth weight (<2.5Kg) and small for gestational age (<10th Centile). Maternal: severe maternal infection requiring hospitalisation, miscarriage and pre-eclampsia.

Participants/materials, setting, methods

Two authors independently conducted data extraction. A meta-analysis of proportions using a random-effects model was used to pool outcomes. Linear regression analysis was used to compare the mean of proportions of outcomes across exposure groups using the ‘treated’ group as the reference category. All studies were evaluated using an appropriate quality assessment tool described by McDonald et al. The GRADE approach was used to assess the overall certainty of evidence.

Main results and the role of chance

35 studies, 11172 pregnancies, were eligible for inclusion. Analysis showed pooled proportions for congenital malformations: treated 0.04(95% CI 0.03-0.04; I2 77) vs disease matched 0.04(0.03-0.05. I2 86) p = 0.238. Preterm delivery treated 0.04(0.10-0.14. I2 88) vs disease matched 0.10(0.09-0.12. I2 87) p = 0.250. Severe neonatal infection: treated 0.05(0.03-0.07. I2 88) vs disease matched 0.05(0.02-0.07. I2 94) p = 0.970. Low birth weight: treated 0.10(0.07-0.12. I2 93) vs disease matched 0.08(0.07-0.09. I2 0) p = 0.241. The pooled Miscarriage: treated 0.13(0.10-0.15. I2 77) vs disease matched 0.08(0.04-0.11. I2 5) p = 0.078. Pre-eclampsia; treated 0.01(0.01-0.02. I2 0) vs disease matched 0.01(0.00-0.01. I2 0). p = 0.193. No statistical differences in proportions were observed.

Limitations, reasons for caution

GRADE certainty of findings were low to very low.

Wider implications of the findings

We demonstrated comparable pregnancy outcomes in pregnancies exposed to biologics, disease matched controls and CID free pregnancies using the GRADE approach.

Trial registration number

NA

A Systematic Review of Autistic People and the Criminal Justice System: An Update of King and Murphy (2014)

The purpose of this paper was to determine whether recommendations made by King & Murphy (Journal of Autism and Developmental Disorders 44:2717-2733, 2014) in their review of the evidence on autistic people in contact with the criminal justice system (CJS) have been addressed. Research published since 2013 was systematically examined and synthesised. The quality of 47 papers was assessed using the Mixed Methods Appraisal Tool. Findings suggest a limited amount of good quality research has been conducted that has focused on improving our understanding of autistic people in contact with the CJS since 2013. Methodological limitations make direct comparisons between autistic and non-autistic offenders difficult. Autistic people commit a range of crimes and appear to have unique characteristics that warrant further exploration (i.e., vulnerabilities, motivations for offending).

POS1465-HPR THE RELATIONSHIP BETWEEN SEDENTARY BEHAVIOR AND SLEEP IN RHEUMATOID ARTHRITIS: A CROSS-SECTIONAL STUDY

Background:

Rheumatoid arthritis (RA) is a chronic, autoimmune inflammatory condition that affects 0.5% of the adult population worldwide (1). Sedentary behavior (SB) is any waking behavior characterized by an energy expenditure of ≤1.5 METs (metabolic equivalent) and a sitting or reclining posture, e.g. computer use (2) and has a negative impact on health in the RA population (3). Sleep is an important health behavior, but sleep quality is an issue for people living with RA (4, 5). Poor sleep quality is associated with low levels of physical activity in RA (4) however the association between SB and sleep in people who have RA has not been examined previously.

Objectives:

The aim of this study was to investigate the relationship between SB and sleep in people who have RA.

Methods:

A cross-sectional study was conducted. Patients were recruited from rheumatology clinics in a large acute public hospital serving a mix of urban and rural populations. Inclusion criteria were diagnosis of RA by a rheumatologist according to the American College of Rheumatology criteria age ≥ 18 and ≤ 80 years; ability to mobilize independently or aided by a stick; and to understand written and spoken English. Demographic data on age, gender, disease duration and medication were recorded. Pain and fatigue were measured by the Visual Analogue Scale (VAS), anxiety and depression were assessed using the Hospital Anxiety and Depression Scale (HADS), and sleep quality was assessed using the Pittsburgh Sleep Quality Index. SB was measured using the ActivPAL4™ activity monitor, over a 7-day wear period. Descriptive statistics were calculated to describe participant characteristics. Relationships between clinical characteristics and SB were examined using Pearson’s correlation coefficients and regression analyses.

Results:

N=76 participants enrolled in the study with valid data provided by N=72 participants. Mean age of participants was 61.5years (SD10.6) and the majority 63% (n = 47) were female. Participant mean disease duration was 17.8years (SD10.9). Mean SB time was 533.7 (SD100.1) minutes (8.9 hours per day/59.9% of waking hours). Mean sleep quality score was 7.2 (SD5.0) (Table 1). Correlation analysis and regression analysis found no significant correlation between sleep quality and SB variables. Regression analysis demonstrated positive statistical associations for SB time and body mass index (p-value=0.03846, R2 = 0.05143), SB time and pain VAS (p-value=0.009261, R2 = 0.07987), SB time and HADS (p-value = 0.009721, R2 = 0.08097) and SB time and HADSD (p-value = 0.01932, R2 = 0.0643).

Conclusion:

We found high levels of sedentary behavior and poor sleep quality in people who have RA, however no statistically significant relationship was found in this study. Future research should further explore the complex associations between sedentary behavior and sleep quality in people who have RA.

References:

[1]Carmona L, et al. Rheumatoid arthritis. Best Pract Res Clin Rheumatol 2010;24:733–745.

[2]Anon. Letter to the editor: standardized use of the terms “sedentary” and “sedentary behaviours”. Appl Physiol Nutr Metab = Physiol Appl Nutr Metab 2012;37:540–542.

[3]Fenton, S.A.M. et al. Sedentary behaviour is associated with increased long-term cardiovascular risk in patients with rheumatoid arthritis independently of moderate-to-vigorous physical activity. BMC Musculoskelet Disord 18, 131 (2017).

[4]McKenna S, et al. Sleep and physical activity: a cross-sectional objective profile of people with rheumatoid arthritis. Rheumatol Int. 2018 May;38(5):845-853.

[5]Grabovac, I., et al. 2018. Sleep quality in patients with rheumatoid arthritis and associations with pain, disability, disease duration, and activity. Journal of clinical medicine, 7(10)336.

Table 1.

Sleep quality in people who have RA

Sleep variableBed Time N(%) before 10pm13(18%) 10pm-12pm43 (60%) after 12pm16 (22%)Hours Sleep mean(SD)6.56 (1.54)Fall Asleep minutes mean(SD)33.3(27.7)Night Waking N(%)45(63%)Self-Rate Sleep mean(SD)2.74 (0.90)Hours Sleep mean(SD)6.56 (1.54)

Disclosure of Interests:

None declared

Dyslipidaemia management in the cardiac rehabilitation clinic of a tertiary referral centre; analysis of the impact of new ESC guidance on LDL-C target achievement

Funding Acknowledgements

Type of funding sources: None.

Background

Cardiac rehabilitation (CR) programs provide an opportunity to measure low density lipoprotein cholesterol (LDL-C) levels and optimise lipid lowering therapy (LLT) accordingly. New ESC guidelines released in August 2019 recommend lower absolute LDL-C target levels and an >50% reduction from baseline in those at the highest risk.

Purpose

This study investigated the proportion of those patients who finished CR in 2019 that reached both their absolute and relative reduction in LDL-C levels, before and after the introduction of these new guidelines. We also analysed the choice and appropriateness of LLT. 

Methods

A retrospective chart review of 163 patients who completed CR in 2019. A database was created containing baseline patient characteristics and LDL-C levels both prior and post CR; as well as the patient’s contemporary LLT. Those patients who did not have a previous diagnosis of atherosclerotic cardiovascular disease (ASCVD) were risk stratified as per ESC guidance. 

Baseline LDL-C levels were recorded, where possible, and otherwise calculated using pre-CR LDL profile with an adjustment made based on the projected effects of their LLT.

Results

Mean (SD) patient age was 62 (10) years, 123/163 (75%) were male and 142 (87%) patients had established ASCVD. 90/142 (63%) of very high-risk patients were treated with a high intensity LLT and 5/163 overall (3%) were prescribed ezetimibe.

Overall, 96/163 (59%) patients in 2019 met their absolute LDL-C targets; 62% of applicable patients achieved an >50% reduction in LDL-C levels. 104 (64%) of patients were treated in compliance with their contemporary guidelines.

Both pre (n = 112) and post (n = 51) September 2019 cohorts were well matched. Fewer patients who were treated under the August 2019 guidelines reached their absolute LDL-C (51% v 63%, p < 0.005) targets; achieved a >50% reduction in LDL-C from baseline (48% vs 61%, p < 0.005), or were compliant with the guidelines for their risk category (43% vs 73%, p < 0.005).

Conclusions

Both high intensity statin therapy and ezetimibe are under-prescribed. Fewer patients are meeting the lower absolute LDL-C targets set out in the 2019 ESC guidelines. For those at high risk, determining the reduction in LDL-C from baseline reveals that even those meeting their absolute LDL-C targets may still be undertreated.

LDL-C Target Achievement N Mean LDL Pre-CR (95% CI) Mean LDL-C Post CR (95% CI) Absolute LDL-C Target Met (%) Mean % LDL-C Reduction from Baseline (95% CI) > 50% Reduction (% of applicable patients) Guidelines Achieved Pre-Sept"20 112 2.7 (2.46-2.93) 1.64 (1.49- 1.79) 70 (63) 61 (56-66) 50 (65) 82 (73) Post Sept 20 51 2.83 (2.41-3.25) 1.83 (1.41-2.25) 26 (51) 48 (37-59) 11 (34) 22 (43) Total 163 2.72 (2.52- 2.91) 1.69 (1.57-1.82) 96 (59) 57 (52- 62) 61 (52) 104 (64 LDL-C targets met, stratified by contemporary guidelines followed.

Abstract Figure. Choice of lipid lowering therapy in 2019

A plastic surgery service response to COVID-19 in one of the largest teaching hospitals in Europe

COVID-19 is presenting a colossal challenge to frontline NHS staff. This paper highlights how plastic surgery teams can use their diverse skills and resources in times of crisis. Through effective strategy and leadership we present how we are adapting as a department to serve our plastic surgery patients, other hospital teams and the Trust.

IgG4 Related Disease, A Case of Large Vessel Vasculitis

Aim This report describes a case of large vessel vasculitis highlighting diagnostic and therapeutic challenges. It describes the use of the B cell depleting agent Rituximab in this setting. This is the case of a 50 year old lady with bipolar disorder presenting with lower limb pain. Method PET CT and CT angiography were employed in the diagnosis of a large vessel vasculitic process. Serum IgG4 was elevated. Histological sampling was not clinically feasible. A presumptive diagnosis of IgG4 related disease was made. Results The patient responded well to steroids and later rituximab. A prompt taper of steroids was required due to labile mood and Rituximab proved to be effective in this case as a maintenance therapy. Conclusion This case demonstrates that a combination of clinical findings, laboratory results and radiological imaging may be necessary for diagnosis for IgG4 related disease, especially in the absence of a histological diagnosis. Rituximab was used in this case as a maintenance therapy allowing for a relatively rapidly reducing course of steroids.

Clinical Pharmacokinetics and Drug-Drug Interaction Potential for Coadministered SCY-078, an Oral Fungicidal Glucan Synthase Inhibitor, and Tacrolimus

SCY-078 is an orally bioavailable triterpenoid glucan synthase inhibitor in clinical development as an intravenous and oral treatment of fungal infections caused by Candida and Aspergillus species. This was a sequential, single-center, open-label phase 1 study to assess the drug-drug interaction potential between SCY-078 and tacrolimus during concomitant administration in healthy subjects. In cohort 1, period 1, subjects received a single oral dose of tacrolimus 2 mg in the fasted state. In period 2 after a ≥15 day washout, subjects received a single loading dose of SCY-078 1250 mg on day 1 followed by maintenance doses of SCY-780 750 mg on days 2 through 8. On day 3 of period 2, subjects also received a single dose of tacrolimus 2 mg concurrent with SCY-078. In cohort 2, subjects received a loading dose of SCY-078 1250 mg on day 1 followed by maintenance doses of SCY-780 750 mg on days 2 and 3. Pharmacokinetic (PK) parameters were compared to assess both the impact of steady-state SCY-078 on tacrolimus and the impact of tacrolimus on the PK of steady-state SCY-078. The concurrent coadministration of tacrolimus and SCY-078 had no effect on the maximum blood levels of tacrolimus, as evidenced by no change in maximum concentration of drug in blood plasma and a 1.4-fold increase in total area under the plasma drug concentration-time curve. The concurrent coadministration of tacrolimus and SCY-078 resulted in a weaker interaction than typically observed with the azole class of antifungals. The current data indicate that an initial dose adjustment for tacrolimus may not be warranted when combined with SCY-078, as the modest increase in exposure is less than the therapeutic window, although tacrolimus monitoring, as with addition of any new medication, is recommended. These results support the coadministration of SCY-078 and tacrolimus.

Lack of Impact by SCY-078, a First-in-Class Oral Fungicidal Glucan Synthase Inhibitor, on the Pharmacokinetics of Rosiglitazone, a Substrate for CYP450 2C8, Supports the Low Risk for Clinically Relevant Metabolic Drug-Drug Interactions

SCY‐078, the first in a new class of β 1,3‐glucan synthesis inhibitors, is being developed as an oral and intravenous antifungal treatment for Candida and Aspergillus species fungal infections. In vitro, studies indicated SCY‐078 is an inhibitor of cytochrome P450 (CYP) 2C8 with markedly lower effect over other CYP isozymes. To examine clinically relevant effects of the potential interaction with SCY‐078, this phase 1, open‐label, 2‐period crossover study evaluated the pharmacokinetic parameters of rosiglitazone, a sensitive substrate of CYP2C8 metabolism, in the absence and presence of SCY‐078 dosed to therapeutically relevant SCY‐078 concentration exposure after repeat dosing. Healthy adult subjects were randomized to 2 treatment sequences: a single oral 4‐mg rosiglitazone dose alone on day 1 or a 1250‐mg SCY‐078 loading dose on day 1 followed by a once‐daily 750‐mg SCY‐078 dose for an additional 7 days (reflecting the clinical regimen evaluated during phase 2 studies for infections by Candida species) and concurrent administration of a single oral 4‐mg rosiglitazone dose on day 3, before alternating following a ≥10‐day washout. The exposure to SCY‐078 observed in this study was in line with the intended exposure for treatment of invasive fungal infections. The 90% confidence intervals for rosiglitazone exposure geometric mean ratios were within the prespecified no effect interval of 0.70‐1.43. Additionally, maximum concentration values for rosiglitazone and its metabolite, N‑desmethylrosiglitazone, were not significantly affected by co‐administration with SCY‐078. Overall, rosiglitazone exposure was not impacted to a clinically meaningful extent with co‐administration of therapeutically relevant SCY‐078 concentration exposure after repeat dosing. The results are indicative of low risk for interaction of SCY‐078 with drugs metabolized via the CYP family of enzymes.

Hypoglycemia in Diabetics on Dialysis with Poor Glycemic Control: Hemodialysis versus Continuous Ambulatory Peritoneal Dialysis

Eight diabetic men with poor glycemic control, probably worsened by severe congestive heart failure and gastroparesis, were sequentially dialyzed by CAPD and hemodialysis. Mean blood glucose concentration, blood glycosylated hemoglobin, and insulin dose were higher during CAPD than during hemodialysis. Among blood glucose determinations, however, the frequency of hypoglycemia (glucose <3.3 mmol/L) was higher during hemodialysis (13.2 ± 8.9%) than during CAPD (2.8 ± 2.1% p = 0.012), whereas the frequencies of hyperglycemia (glucose >11.1 mmol/L) and euglycemia (glucose between 3.5 and 11.1 mmol/L) did not differ between the two dialysis modalities. Furthermore, hypoglycemia was severe during hemodialysis and was associated with two deaths. There were no deaths linked to abnormalities in blood glucose concentration during CAPD. When hypoglycemia is frequent in diabetics with poor glycemic control, CAPD is preferable to hemodialysis.

Cytokine responses to exercise and activity in patients with chronic fatigue syndrome: case-control study

Chronic fatigue syndrome (CFS) is characterized by fatigue after exertion. A systematic review suggested that transforming growth factor (TGF)-β concentrations are often elevated in cases of CFS when compared to healthy controls. This study attempted to replicate this finding and investigate whether post-exertional symptoms were associated with altered cytokine protein concentrations and their RNA in CFS patients. Twenty-four patients fulfilling Centers for Disease Control criteria for CFS, but with no comorbid psychiatric disorders, were recruited from two CFS clinics in London, UK. Twenty-one healthy, sedentary controls were matched by gender, age and other variables. Circulating proteins and RNA were measured for TGF-β, tumour necrosis factor (TNF), interleukin (IL)-8, IL-6 and IL-1β. We measured six further cytokine protein concentrations (IL-2, IL-4, IL-5, IL-10, IL-12p70, and interferon (IFN)-γ). Measures were taken at rest, and before and after both commuting and aerobic exercise. CFS cases had higher TGF-β protein levels compared to controls at rest (median (quartiles) = 43·9 (19·2, 61·8) versus 18·9 (16·1, 30·0) ng/ml) (P = 0·003), and consistently so over a 9-day period. However, this was a spurious finding due to variation between different assay batches. There were no differences between groups in changes to TGF-β protein concentrations after either commuting or exercise. All other cytokine protein and RNA levels were similar between cases and controls. Post-exertional symptoms and perceived effort were not associated with any increased cytokines. We were unable to replicate previously found elevations in circulating cytokine concentrations, suggesting that elevated circulating cytokines are not important in the pathophysiology of CFS.

International cancer seminars: a focus on esophageal squamous cell carcinoma

The International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) have initiated a series of cancer-focused seminars [Scelo G, Hofmann JN, Banks RE et al. International cancer seminars: a focus on kidney cancer. Ann Oncol 2016; 27(8): 1382-1385]. In this, the second seminar, IARC and NCI convened a workshop in order to examine the state of the current science on esophageal squamous cell carcinoma etiology, genetics, early detection, treatment, and palliation, was reviewed to identify the most critical open research questions. The results of these discussions were summarized by formulating a series of 'difficult questions', which should inform and prioritize future research efforts.

HIV incidence in the Estonian population in 2013 determined using the HIV-1 limiting antigen avidity assay

OBJECTIVES

Estonia has one the highest number of new HIV diagnoses in the European Union, mainly among injecting drug users and heterosexuals. Little is known of HIV incidence, which is crucial for limiting the epidemic. Using a recent HIV infection testing algorithm (RITA) assay, we aimed to estimate HIV incidence in 2013.

METHODS

All individuals aged ≥18 years newly-diagnosed with HIV in Estonia January- December 2013, except blood donors and those undergoing antenatal screening, were included. Demographic and clinical data were obtained from the Estonian Health Board and the Estonian HIV-positive patient database. Serum samples were tested for recent infection using the LAg-avidity EIA assay. HIV incidence was estimated based on previously published methods.

RESULTS

Of 69,115 tested subjects, 286 (0.41%) were newly-diagnosed with HIV with median age of 33 years (IQR: 28-42) and 65% male. Self-reported routes of HIV transmission were mostly heterosexual contact (n = 157, 53%) and injecting drug use (n = 62, 21%); 64 (22%) were with unknown risk group. Eighty two (36%) were assigned recent, resulting in estimated HIV incidence of 0.06%, corresponding to 642 new infections in 2013 among the non-screened population. Incidence was highest (1.48%) among people who inject drugs.

CONCLUSIONS

These high HIV incidence estimates in Estonia call for urgent action of renewed targeted public health promotion and HIV testing campaigns.

Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

The microphysics of collisionless shock waves

Collisionless shocks, that is shocks mediated by electromagnetic processes, are customary in space physics and in astrophysics. They are to be found in a great variety of objects and environments: magnetospheric and heliospheric shocks, supernova remnants, pulsar winds and their nebulæ, active galactic nuclei, gamma-ray bursts and clusters of galaxies shock waves. Collisionless shock microphysics enters at different stages of shock formation, shock dynamics and particle energization and/or acceleration. It turns out that the shock phenomenon is a multi-scale non-linear problem in time and space. It is complexified by the impact due to high-energy cosmic rays in astrophysical environments. This review adresses the physics of shock formation, shock dynamics and particle acceleration based on a close examination of available multi-wavelength or in situ observations, analytical and numerical developments. A particular emphasis is made on the different instabilities triggered during the shock formation and in association with particle acceleration processes with regards to the properties of the background upstream medium. It appears that among the most important parameters the background magnetic field through the magnetization and its obliquity is the dominant one. The shock velocity that can reach relativistic speeds has also a strong impact over the development of the micro-instabilities and the fate of particle acceleration. Recent developments of laboratory shock experiments has started to bring some new insights in the physics of space plasma and astrophysical shock waves. A special section is dedicated to new laser plasma experiments probing shock physics.

Sweat facilitated losses of amino acids in Standardbred horses and the application of supplementation strategies to maintain condition during training

Little is known about the amino acid composition of horse sweat, but significant fluid losses can occur during exercise with the potential to facilitate substantial nutrient losses. Sweat and plasma amino acid compositions for Standardbred horses were assessed to determine losses during a standardised training regime. Two cohorts of horses 2013 (n=5) and 2014 (n=6) were assessed to determine baseline levels of plasma and sweat amino acids. An amino acid supplement designed to counter losses in sweat during exercise was provided after morning exercise daily for 5 weeks (2013, n=5; 2014, n=4). After the supplementation period, blood and sweat samples were collected to assess amino acid composition changes. From baseline assessments of sweat in both cohorts, it was found that serine, glutamic acid, histidine and phenylalanine were present at up to 9 times the corresponding plasma concentrations and aspartic acid at 0-2.2 μmol/l in plasma was measured at 154-262 μmol/l in sweat. In contrast, glutamine, asparagine, methionine and cystine were conserved in the plasma by having lower concentrations in the sweat. The predominant plasma amino acids were glycine, glutamine, alanine, valine, serine, lysine and leucine. As the sweat amino acid profile did not simply reflect plasma composition, it was proposed that mechanisms exist to generate high concentrations of certain amino acids in sweat whilst selectively preventing the loss of others. The estimated amino acid load in 16 l of circulating plasma was 3.8-4.3 g and the calculated loss via sweat during high intensity exercise was 1.6-3.0 g. Following supplementation, total plasma amino acid levels from both cohorts increased from initial levels of 2,293 and 2,044 µmol/l to post-supplementation levels of 2,674 and 2,663 µmol/l respectively (P<0.05). It was concluded that the strategy of providing free amino acids immediately after exercise resulted in raising resting plasma amino acid levels.

Decoy receptors block TRAIL sensitivity at a supracellular level: the role of stromal cells in controlling tumour TRAIL sensitivity

Tumour necrosis factor-related apoptosis-inducing ligand (TRAIL) is a death ligand cytokine known for its cytotoxic activity against malignantly transformed cells. TRAIL induces cell death through binding to death receptors DR4 and DR5. The inhibitory decoy receptors (DcR1 and DcR2) co-expressed with death receptor 4 (DR4)/DR5 on the same cell can block the transmission of the apoptotic signal. Here, we show that DcRs also regulate TRAIL sensitivity at a supracellular level and thus represent a mechanism by which the microenvironment can diminish tumour TRAIL sensitivity. Mathematical modelling and layered or spheroid stroma-extracellular matrix-tumour cultures were used to model the tumour microenvironment. By engineering TRAIL to escape binding by DcRs, we found that DcRs do not only act in a cell-autonomous or cis-regulatory manner, but also exert trans-cellular regulation originating from stromal cells and affect tumour cells, highlighting the potent inhibitory effect of DcRs in the tumour tissue and the necessity of selective targeting of the two death-inducing TRAIL receptors to maximise efficacy.

Targeting ADAM-17 with an inhibitory monoclonal antibody has antitumour effects in triple-negative breast cancer cells

Background:

Identification and validation of a targeted therapy for triple-negative breast cancer (TNBC), that is, breast cancers negative for oestrogen receptors, progesterone receptors and HER2 amplification, is currently one of the most urgent problems in breast cancer treatment. EGFR is one of the best-validated driver genes for TNBC. EGFR is normally activated following the release of ligands such as TGFα, mediated by the two MMP-like proteases ADAM (a disintegrin and metalloproteinase)-10 and ADAM-17. The aim of this study was to investigate the antitumour effects of a monoclonal antibody against ADAM-17 on an in vitro model of TNBC.

Methods:

We investigated an inhibitory cross-domain humanised monoclonal antibody targeting both the catalytic domain and the cysteine-rich domain of ADAM17-D1(A12) in the HCC1937 and HCC1143 cell lines.

Results:

D1(A12) was found to significantly inhibit the release of TGFα, and to decrease downstream EGFR-dependent cell signalling. D1(A12) treatment reduced proliferation in two-dimensional clonogenic assays, as well as growth in three-dimensional culture. Furthermore, D1(A12) reduced invasion of HCC1937 cells and decreased migration of HCC1143 cells. Finally, D1(A12) enhanced cell death in HCC1143 cells.

Conclusion:

Our in vitro findings suggest that targeting ADAM-17 with D1(A12) may have anticancer activity in TNBC cells.

Impact of (18)F-FDG PET/CT on the staging and management of follicular lymphoma

Follicular lymphoma (FL) is the most common indolent lymphoma. Despite the evidence-based utilization of fluorine-18 fludeoxyglucose positron emission tomography ((18)F-FDG PET)/CT in aggressive lymphomas, the utility of PET in FL remains controversial and varies across different jurisdictions. The management of patients with FL differs from aggressive lymphomas and is usually reserved for patients with localized disease in whom long-term control may potentially be achieved by involved field radiotherapy, or for symptomatic patients with advanced-stage disease in whom systemic therapy is indicated. There is a growing body of literature supporting the use of PET/CT in initial staging of FL to guide management decisions. In this review, we summarize the existing literature and present cases from our experience to illustrate current knowledge on the potential role of (18)F-FDG PET/CT in FL.

Non-cutaneous melanoma: is there a role for (18)F-FDG PET-CT?

Non-cutaneous melanomas (NCM) are diverse and relatively uncommon. They often differ from cutaneous melanomas in their epidemiology, genetic profile and biological behaviour. Despite the growing body of evidence regarding the utility of positron emission tomography (PET)/CT in cutaneous melanoma, the data on its use in NCM are scarce. In this review, we will summarize the existing literature and present cases from our experience with NCM to illustrate current knowledge on the potential role and limitations of fluorine-18 fludeoxyglucose PET/CT in NCM.

Recent infection testing algorithm (RITA) applied to new HIV diagnoses in England, Wales and Northern Ireland, 2009 to 2011

In 2009, Public Health England (PHE) introduced the routine application of a recent infection testing algorithm (RITA) to new HIV diagnoses, where a positive RITA result indicates likely acquisition of infection in the previous six months. Laboratories submit serum specimens to PHE for testing using the HIV 1/2gO AxSYM assay modified for the determination of HIV antibody avidity. Results are classified according to avidity index and data on CD₄ count, antiretroviral treatment and the presence of an AIDS-defining illness. Between 2009 and 2011, 38.4% (6,966/18,134) of new HIV diagnoses in England, Wales and Northern Ireland were tested. Demographic characteristics of those tested were similar to all persons with diagnosed HIV. Overall, recent infection was 14.7% (1,022/6,966) and higher among men who have sex with men (MSM) (22.3%, 720/3,223) compared with heterosexual men and women (7.8%, 247/3,164). Higher proportions were among persons aged 15-24 years compared with those ≥50 years (MSM 31.2% (139/445) vs 13.6% (42/308); heterosexual men and women 17.3% (43/249) vs 6.2% (31/501)). Among heterosexual men and women, black Africans were least likely to have recent infection compared with whites (4.8%, 90/1,892 vs 13.3%, 97/728; adjusted odds ratio: 0.6; 95% CI: 0.4-0.9). Our results indicate evidence of ongoing HIV transmission during the study period, particularly among MSM.