Health Professionals Organizing for Climate Action: A Novel Community Organizing Fellowship

PROBLEM

Climate change is a public health and health equity crisis. Health professionals are well positioned to advance solutions but may lack the training and self-efficacy needed to achieve them.

APPROACH

The Center for Health Equity Education and Advocacy at Cambridge Health Alliance, a Harvard Medical School Teaching Hospital, developed a novel, longitudinal fellowship that taught health professionals about health and health equity effects of climate change, as well as community organizing practices that may help them mitigate these effects. The fellowship cohort included 40 fellows organized into 12 teams and was conducted from January to June 2022. Each team developed a project to address climate change and received coaching from an experienced community organizer coach. Effects of the fellowship on participants' knowledge, skills, and attitudes were evaluated using pre- and postfellowship surveys.

OUTCOMES

Surveys were analyzed for 38 of 40 (95%) participants who consented to the evaluation and completed both surveys. Surveys used a 7-point Likert scale for item responses. McNemar's test for paired data was used to assess changes in the proportion of respondents who agreed ("somewhat agree"/"agree"/"strongly agree") with statements in pre- vs postfellowship surveys. Statistically significant improvements were found for 11 of the 17 items assessing knowledge, skills, and attitudes. Participants' views of the fellowship and its effects were assessed through additional items in the postfellowship survey. Most respondents agreed that the fellowship increased their knowledge of the connections between climate change and health equity (32/38, 84.2%) and prepared them to effectively participate in a community organizing campaign (37/38, 94.7%). Each of the 12 groups developed climate health projects by the fellowship's end.

NEXT STEPS

This novel fellowship was well received and effective in teaching community organizing to health professionals concerned about climate change. Future studies are needed to assess longer-term effects of the fellowship.

Does diversity beget diversity? A scientometric analysis of over 150,000 studies and 49,000 authors published in high-impact medical journals between 2007 and 2022

Background

Health research that significantly impacts global clinical practice and policy is often published in high-impact factor (IF) medical journals. These outlets play a pivotal role in the worldwide dissemination of novel medical knowledge. However, researchers identifying as women and those affiliated with institutions in low- and middle-income countries (LMIC) have been largely underrepresented in high-IF journals across multiple fields of medicine. To evaluate disparities in gender and geographical representation among authors who have published in any of five top general medical journals, we conducted scientometric analyses using a large-scale dataset extracted from the New England Journal of Medicine (NEJM), Journal of the American Medical Association (JAMA), The British Medical Journal (BMJ), The Lancet, and Nature Medicine.

Methods

Author metadata from all articles published in the selected journals between 2007 and 2022 were collected using the DimensionsAI platform. The Genderize.io API was then utilized to infer each author's likely gender based on their extracted first name. The World Bank country classification was used to map countries associated with researcher affiliations to the LMIC or the high-income country (HIC) category. We characterized the overall gender and country income category representation across the medical journals. In addition, we computed article-level diversity metrics and contrasted their distributions across the journals.

Findings

We studied 151,536 authors across 49,764 articles published in five top medical journals, over a long period spanning 15 years. On average, approximately one-third (33.1%) of the authors of a given paper were inferred to be women; this result was consistent across the journals we studied. Further, 86.6% of the teams were exclusively composed of HIC authors; in contrast, only 3.9% were exclusively composed of LMIC authors. The probability of serving as the first or last author was significantly higher if the author was inferred to be a man (18.1% vs 16.8%, P < .01) or was affiliated with an institution in a HIC (16.9% vs 15.5%, P < .01). Our primary finding reveals that having a diverse team promotes further diversity, within the same dimension (i.e., gender or geography) and across dimensions. Notably, papers with at least one woman among the authors were more likely to also involve at least two LMIC authors (11.7% versus 10.4% in baseline, P < .001; based on inferred gender); conversely, papers with at least one LMIC author were more likely to also involve at least two women (49.4% versus 37.6%, P < .001; based on inferred gender).

Conclusion

We provide a scientometric framework to assess authorship diversity. Our research suggests that the inclusiveness of high-impact medical journals is limited in terms of both gender and geography. We advocate for medical journals to adopt policies and practices that promote greater diversity and collaborative research. In addition, our findings offer a first step towards understanding the composition of teams conducting medical research globally and an opportunity for individual authors to reflect on their own collaborative research practices and possibilities to cultivate more diverse partnerships in their work.

Increased antitumor efficacy of PD-1-deficient melanoma-specific human lymphocytes

Background

Genome editing offers unique perspectives for optimizing the functional properties of T cells for adoptive cell transfer purposes. So far, PDCD1 editing has been successfully tested mainly in chimeric antigen receptor T (CAR-T) cells and human primary T cells. Nonetheless, for patients with solid tumors, the adoptive transfer of effector memory T cells specific for tumor antigens remains a relevant option, and the use of high avidity T cells deficient for programmed cell death-1 (PD-1) expression is susceptible to improve the therapeutic benefit of these treatments.

Methods

Here we used the transfection of CAS9/sgRNA ribonucleoproteic complexes to edit PDCD1 gene in human effector memory CD8⁺ T cells specific for the melanoma antigen Melan-A. We cloned edited T cell populations and validated PDCD1 editing through sequencing and cytometry in each T cell clone, together with T-cell receptor (TCR) chain’s sequencing. We also performed whole transcriptomic analyses on wild-type (WT) and edited T cell clones. Finally, we documented in vitro and in vivo through adoptive transfer in NOD scid gamma (NSG) mice, the antitumor properties of WT and PD-1KO T cell clones, expressing the same TCR.

Results

Here we demonstrated the feasibility to edit PDCD1 gene in human effector memory melanoma-specific T lymphocytes. We showed that PD-1 expression was dramatically reduced or totally absent on PDCD1-edited T cell clones. Extensive characterization of a panel of T cell clones expressing the same TCR and exhibiting similar functional avidity demonstrated superior antitumor reactivity against a PD-L1 expressing melanoma cell line. Transcriptomic analysis revealed a downregulation of genes involved in proliferation and DNA replication in PD-1-deficient T cell clones, whereas genes involved in metabolism and cell signaling were upregulated. Finally, we documented the superior ability of PD-1-deficient T cells to significantly delay the growth of a PD-L1 expressing human melanoma tumor in an NSG mouse model.

Conclusion

The use of such lymphocytes for adoptive cell transfer purposes, associated with other approaches modulating the tumor microenvironment, would be a promising alternative to improve immunotherapy efficacy in solid tumors.

Exploring factors influencing physiotherapists' perceptions of measuring reactive balance following a theory-based multi-component intervention: a qualitative descriptive study

Purpose: Reactive balance is a critical consideration for mobility and fall avoidance, but is under-assessed among physiotherapists. The objective of this study was to explore factors influencing physiotherapist perceptions about measuring reactive balance upon completion of a 12-month theory-based, multi-component intervention to increase use of a measure of reactive balance.Methods: A qualitative descriptive approach was used. Semi-structured interviews were conducted with 28 physiotherapists treating adults with balance impairment in three urban Canadian rehabilitation hospitals that participated in the intervention. Interviews explored perceptions of reactive balance measurement and perceived changes in clinical behavior. Thematic analysis involved multiple rounds of coding, review and discussion, theme generation, and interpretation of findings through individual analysis and team meetings.Findings: Participants expressed contrasting views about integrating reactive balance measurement in their practice, despite consistent acknowledgement of the importance of reactive balance for function. Three themes were identified highlighting factors that mediated perceptions about measuring reactive balance: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Conclusions: The findings highlight that decision making for measuring reactive balance in rehabilitation settings is complex. There is a need for additional work to facilitate long-term implementation of clinical reactive balance measurement, such as refining patient criteria for administration, ensuring sufficient time to establish a trusting relationship, and developing and testing strategies to address physiotherapist fear.IMPLICATIONS FOR REHABILITATIONReactive balance is important for falls prevention and mobility, but is under-assessed among physiotherapists.This study identified three factors that influenced uptake of reactive balance measurement among physiotherapists in rehabilitation settings: patient characteristics; trust between physiotherapist and patient; and the role of physiotherapist fear.Knowledge of the identified factors may assist with design and use of reactive and other balance measurements.Strategies aimed at developing trusting relationships between physiotherapist and patient along with addressing physiotherapist fear could facilitate the uptake of clinical reactive balance measurement.

Hyperarousal Symptoms in Survivors of Cardiac Arrest Are Associated With 13 Month Risk of Major Adverse Cardiovascular Events and All-Cause Mortality

BACKGROUND

Key dimensions of cardiac arrest-induced posttraumatic stress disorder (PTSD) symptoms include reexperiencing, avoidance, numbing, and hyperarousal. It remains unknown which dimensions are most predictive of outcome.

PURPOSE

To determine which dimensions of cardiac arrest-induced PTSD are predictive of clinical outcome within 13 months posthospital discharge.

METHODS

PTSD symptoms were assessed in survivors of cardiac arrest who were able to complete psychological screening measures at hospital discharge via the PTSD Checklist-Specific scale, which queries for 17 symptoms using five levels of severity. Responses on items for each symptom dimension of the four-factor numbing model (reexperiencing, avoidance, numbing, and hyperarousal) were converted to Z-scores and treated as continuous predictors. The combined primary endpoint was all-cause mortality (ACM) or major adverse cardiovascular events (MACE; hospitalization for myocardial infarction, unstable angina, heart failure, emergency coronary revascularization, or urgent defibrillator/pacemaker placements) within 13 months postdischarge. Four bivariate Cox proportional hazards survival models evaluated associations between individual symptom dimensions and ACM/MACE. A multivariable model then evaluated whether significant bivariate predictors remained independent predictors of the primary outcome after adjusting for age, sex, comorbidities, premorbid psychiatric diagnoses, and initial cardiac rhythm.

RESULTS

A total of 114 patients (59.6% men, 52.6% white, mean age: 54.6 ± 13 years) were included. In bivariate analyses, only hyperarousal was significantly associated with ACM/MACE. In a fully adjusted model, 1 standard deviation increase in hyperarousal symptoms corresponded to a two-times increased risk of experiencing ACM/MACE.

CONCLUSIONS

Greater level of hyperarousal symptoms was associated with a higher risk of ACM/MACE within 13 months postcardiac arrest. This initial evidence should be further investigated in a larger sample.

Dental Caries Severity and Nutritional Status of Nigerian Preschool Children

INTRODUCTION

Malnutrition in children is one of the most prevalent global health challenges, and malnourished children have a higher risk of death from childhood diseases. Early childhood caries (ECC) is the most common chronic disease of childhood. Complications from ECC such as pain, loss of tooth/teeth, and infection can undermine a child's nutrition and growth.

AIM

This study aims to evaluate the severity of decay, missing, and filled tooth (dmft) by nutritional status using the z scores of the anthropometric measurements: height for age (HFA), weight for age (WFA), weight for height (WFH), and body mass index for age (BMIA) among children with ECC in Nigeria.

STUDY DESIGN

This is a cross-sectional study conducted in 5 local government areas (LGAs) in Lagos State, Nigeria. A multistage sampling technique was used.

RESULTS

A total of 273 cases of ECC were included in the analyses (mean age 4.19 ± 0.96 y). Overall, the mean dmft was 3.04 ± 2.28, and most (96%) were accounted for by untreated decay. The distribution of dmft within the different z score categories of BMIA (<-3 = severely wasted, -2 to -3 = wasted, -2 to +2 = normal, +2 to +3 = overweight and >+3 = obese) showed the highest dmft scores among the combined severely wasted and wasted groups, lowest among children with normal z scores, and intermediate in the overweight and obese groups. There was a significant negative correlation between BMIA z score, WFH z score, and dmft (r = -0.181, P < 0.05 and r = -0.143, P < 0.05, respectively). However, the correlations between HFA z score, WFA z score, and dmft were positive but not significant (r = 0.048, P = 0.44 and r = 0.022, P = 0.77, respectively).

CONCLUSION

Our study showed an increased severity of dental caries among severely wasted or wasted children with ECC compared to those of normal or overweight.

KNOWLEDGE TRANSFER STATEMENT

The results from this study will raise awareness among clinicians and policy makers on the need for a primary prevention program for early childhood caries in countries with high burden of malnutrition and limited resources. Also, it will help draw the attention of clinicians to the caries status of malnourished children that can be managed to improve the nutritional outcomes.

Correlates of health-related quality of life in youth with psychogenic non-epileptic seizures

BACKGROUND

Few studies have examined factors associated with health-related quality of life (HRQoL) in youth with psychogenic non-epileptic seizures (PNES). In adults, internalizing symptoms such as depression have been shown to be more closely associated with HRQoL than seizure frequency, however, this has not been studied in samples of youth. Investigations into these areas are needed in order to enhance our understanding of the impact of this condition on children and adolescents and inform future clinical intervention.

METHODS

The current study includes 37 youth and one of their parents who attended a clinic visit for treatment of PNES. Children and parents completed measures of psychological functioning, and medical data were extracted from patient charts.

RESULTS

Parent-reported anxiety (B=-0.45, p = 0.05) and depression (B=-0.60, p = 0.01) were related to parent-report of HRQoL; self-report of depression was related to self-reported HRQoL (B=-0.90, p < 0.001). Seizure frequency, somatic complaints, and social problems were not related to HRQoL in this sample.

CONCLUSIONS

Internalizing symptoms, not seizure frequency, are associated with poorer overall functioning in youth with PNES. Interventions focused on improving anxiety and depression in addition to seizure cessation may contribute to improved HRQoL in youth with PNES more so than those focused on seizure cessation alone.

Medical and psychosocial outcomes of youth with psychogenic nonepileptic seizures: An observational study

BACKGROUND

Few studies have examined both medical and psychosocial outcomes of youth with psychogenic nonepileptic seizures (PNES). The current observational study aimed to fill this gap by examining changes in seizure frequency, school absences, emergency department (ED) visits, psychological functioning, and health-related quality of life (HRQoL) in youth attending a clinic for brief treatment of PNES.

METHODS

Nineteen youth with PNES and their families presented to an integrated clinic and received psychoeducation and recommendations by medical and mental health professionals. Patients returned to the clinic, on average six months later, for follow-up. Parent proxy-report and self-report measures of psychological functioning and HRQoL were collected at each visit, and medical data were extracted from patient charts.

RESULTS

Forty-six percent of youth in the study experienced a reduction in seizure frequency, and 58% reported improvements in school attendance. Emergency department visits decreased by over 50%, and significant improvements in parent proxy-report of depression and HRQoL were observed.

CONCLUSIONS

Results provide valuable information regarding the clinical profiles of youth with PNES and demonstrate the possibility for improved medical and psychosocial prognoses in response to psychoeducation and treatment guidance. Information obtained in this study may aid in the design of future clinical trials and research, assisting in the development of appropriate interventions.

HR practices and counterproductive behaviors: a meta-ethnographic study

Purpose

Drawing on the resource-based view (RBV) of the firm and the norm of reciprocity, this paper examines the relationship between high-performance human resources practices (HPHRPs) and employee counterproductive work behavior (CWB), and whether HPHRP interact with coercive control systems to predict these outcomes.

Design/methodology/approach

Using meta-ethnographic data collected from 149 organizational ethnographies, the authors test the hypotheses that (a) HPHRP are negatively related to CWB and (b) HPHRP and coercive control interact such that the relationship between HPHRP and CWB is weaker when coercive control is high.

Findings

The analysis finds that HPHRP and coercive control interacted such that HPHRP was negatively associated with CWB, but only when coercive control was low. When coercive control was high, the relationship between HPHRP was negated.

Practical implications

The results suggest that HPHRP are negatively related to counterproductive behaviors; but when coercive control systems are strong, the potential benefits of HPHRP in terms of reducing CWB may be lost.

Originality/value

This study examines the relationship between HPHRP and a comprehensive set of CWB. By examining the interaction between HPHRP and coercive control, the authors add to literature demonstrating that the effects of HPHRP may be dependent on an organization’s operational strategy. Finally, our use of meta-ethnographic data offers a methodological approach that may increase the generalizability of our findings.

Development and Initial Psychometric Testing of the Midwifery Practice Climate Scale - Part 2

INTRODUCTION

A supportive practice climate is demonstrated to improve patient outcomes, health care provider well-being, and workforce stability. Midwives are an integral component to improving maternal health care; however, there has been limited research into the qualities and measurement of a supportive practice climate for midwives.

METHODS

The Midwifery Practice Climate Scale is a self-report instrument designed to measure midwives' perceptions of their work environments. We tested the scale's validity and reliability in multiphase, national cross-sectional survey of the full roster of certified nurse-midwives and certified midwives practicing in the United States. To test structural validity and reliability testing, 2 subsamples of 330 participants were randomly extracted from the sample of 2887 for exploratory and confirmatory factor analyses and internal consistency determination. Convergent validity was tested in the remaining sample of 1673 respondents.

RESULTS

Exploratory factor analysis revealed 2 5-subscale structures consistent with the loading values and theoretical structure. Confirmatory factor analysis revealed a mediocre fit of the models identified in the exploratory analysis. Consequently, items were systematically reviewed for redundancy, skew, and generalizability and 24 items were removed from the scale. The resulting structure is a 10-item scale comprising 2 subscales: Practice Leadership and Participation and Support for the Midwifery Model of Care. The revised Midwifery Practice Climate Scale was a good fit with the data demonstrating adequate construct validity (χ² = 60.397, df = 34, P < 0.001; comparative fit index, 0.987; root mean square of approximation, 0.049) and internal consistency (α = 0.89-0.84).

DISCUSSION

These findings indicate that the Midwifery Practice Climate Scale accurately and reliably measures the midwives' perceptions of their practice environment. The next steps include determining the scale's sensitivity to change and assessing the relationship with maternal health outcomes.

Pre-analytical factors affecting the establishment of a single tube assay for multiparameter liquid biopsy detection in melanoma patients

The combination of liquid biomarkers from a single blood tube can provide more comprehensive information on tumor development and progression in cancer patients compared to single analysis. Here, we evaluated whether a combined analysis of circulating tumor cells (CTCs), circulating tumor DNA (ctDNA), and circulating cell-free microRNA (miRNA) in total plasma and extracellular vesicles (EV) from the same blood sample is feasible and how the results are influenced by the choice of different blood tubes. Peripheral blood from 20 stage IV melanoma patients and five healthy donors (HD) was collected in EDTA, Streck, and Transfix tubes. Peripheral blood mononuclear cell fraction was used for CTC analysis, whereas plasma and EV fractions were used for ctDNA mutation and miRNA analysis. Mutations in cell-free circulating DNA were detected in 67% of patients, with no significant difference between the tubes. CTC was detected in only EDTA blood and only in 15% of patients. miRNA NGS (next-generation sequencing) results were highly influenced by the collection tubes and could only be performed from EDTA and Streck tubes due to hemolysis in Transfix tubes. No overlap of significantly differentially expressed miRNA (patients versus HD) could be found between the tubes in total plasma, whereas eight miRNA were commonly differentially regulated in the EV fraction. In summary, high-quality CTCs, ctDNA, and miRNA data from a single blood tube can be obtained. However, the choice of blood collection tubes is a critical pre-analytical variable.

Nurse practitioner primary care organizational climate questionnaire: Item response theory and differential item functioning

AIMS AND OBJECTIVES

To validate Nurse Practitioner Primary Care Organizational Climate Questionnaire (NP-PCOCQ) items using item response theory (IRT) models and conduct differential item functioning (DIF) analysis to test the item functioning among nurse practitioners (NPs) practicing in different U.S. states with variable regulations governing NP practice.

BACKGROUND

Nurse Practitioner Primary Care Organizational Climate Questionnaire is the only NP-specific tool measuring NP work environment and is being used in different U.S. states with variable NP scope of practice regulations and internationally to produce evidence about NP work environments within their organisations.

DESIGN

Cross-sectional survey design was used to collect data from 278 primary care NPs in New York (NY) and 314 NPs in Massachusetts (MA).

METHODS

NPs completed the 29-item NP-PCOCQ. Data collection involved an online survey in NY and a mail survey in MA in 2012. We used Samejima's graded response model for IRT and ordinal logistic regression for DIF analysis. A STROBE checklist was completed.

RESULTS

IRT models yielded discrimination parameters ranging from 0.98-4.65 in NY and 1.25-6.94 in MA. Item difficulty parameters were within -3 to +3 range, suggesting a fair range of item difficulties exist in the scale. Only five of the 29 items on NP-PCOCQ exhibited DIF, suggesting some other state-related factor besides the measured construct influenced item responses; thus, the items were removed.

CONCLUSION

Our findings indicate that a shortened, 24-item NP-PCOCQ is capable of measuring organisational climate of NPs practicing in different U.S. states. NP-PCOCQ can be used in future research to measure NP work environment.

RELEVANCE TO CLINICAL PRACTICE

The tool can also be used by practice administrators to assess NP work environment and identify deficiencies to address them. This evidence about NP work environment can be used by practice administrators to promote favourable work environments for NPs to deliver high-quality care.

Development and Psychometric Testing of the Provider Co-Management Index: Measuring Nurse Practitioner-Physician Co-Management

BACKGROUND AND PURPOSE

Provider co-management has emerged in practice to alleviate demands of larger, more complex patient panels, yet no tools exist to measure nurse practitioner (NP)-physician co-management. The purpose of this study is to develop a tool that measures NP-physician co-management.

METHODS

Items were generated based on three theoretical dimensions of co-management. Face and content validity were established with six experts. Pilot testing was conducted with a convenience sample of 40 NPs and physicians. We computed mean, standard deviation, skewness, interitem and corrected item-total correlations, and Cronbach's alpha.

RESULTS

Psychometric analysis yielded high subscale reliability: effective communication (α = .811); mutual respect and trust (α = .746); and shared philosophy of care (α = .779).

CONCLUSIONS

PCMI demonstrates strong internal reliability consistency. Future research to examine construct validity is recommended.

Abstract 5596: Impact of blood collection tubes on CTC-, ctDNA- and miRNA recoveries in malignant melanoma patients

Liquid biopsy represents a powerful clinical tool that makes use of the detection of circulating tumor cells (CTCs), circulating tumor DNA (ctDNA) and exosomes in peripheral blood. Each different analysis is complementary to each other and can give additional valuable clinical information. These biomarkers are susceptible to quick degradation, presenting a challenge in a clinical environment and may require different blood collection tubes. The aim of this CANCER-ID study was to analyze the influence of different blood tubes on quantity and quality of CTCs, ctDNA and total and exosomal miRNA isolated from the same blood tube.

After confirming that plasma removal does not influence CTC recovery rates, peripheral blood from 20 cases of metastatic melanoma patients was collected in EDTA, Streck and Transfix tubes. CTC isolation from the PBMC fraction was performed by the ClearCell device (Clearbridge BioMedics). CTCs were identified by immunofluorescence staining. CtDNA was extracted from Streck and EDTA plasma samples, quantity (Qubit) and quality (Tapestation) measurements were performed before analyzing 86 hot-spot mutations in 13 genes by the UltraSEEK chemistry (Agena Bioscience). Ten of the 20 metastatic melanoma patients and 5 healthy donors were chosen for miRNA analysis. MiRNAs were extracted with miRNeasy Serum/Plasma Advanced Kit and miRNeasy Serum/Plasma Kit (QIAGEN) from total plasma and from extracellular vesicles (EVs), respectively. EVs were isolated by ultracentrifugation. QIAseq miRNA libraries were produced and sequenced (Illumina NextSeq 550). The reads were mapped to miRBase and normalized (geNorm). Volcano plots of fold change versus p-value were used to display the miRNAs that are significantly regulated.

The CTC enrichment results showed that 3/20 of the EDTA blood samples were positive, whereas samples from Streck and Transfix tubes were negative. The quantity or quality of the ctDNA did not significantly differ between the EDTA and Streck tubes. Mutation analysis of ctDNA performed so far showed similar detection sensitivities between the two tubes. The morphology, particle concentration and size distribution of EVs did not either differ between the two tubes. MiRNA-NGS analyses from plasma revealed that seven (EDTA) and four (Streck) miRNAs are significantly differentially expressed in patients compared with healthy donors. No overlap of these miRNAs was found between the two tubes. In the EV fraction 24 and 31 miRNAs were found significantly differentially expressed in the EDTA and Streck tubes, respectively. Here, one EV miRNA is up-regulated and six are down-regulated in both tubes.

In conclusion, the CTC recovery rates and minimal overlap of circulating miRNAs indicate that the different tubes affect CTC, ctDNA and miRNA results. Thus, the outcome of liquid biopsy analyses strongly depends on the choice of blood collection tubes as important pre-analytical variable.

Citation Format: Svenja Schneegans, Lelia Lück, Leonie Bluhm, Janina Staub, Rüdiger Greinert, Beate Volkmer, Alexander Sartori, Darryl Irwin, Taija af Hallstrom, Melanie Hussong, Jonathan Shaffer, Markus Sprenger-Haussels, Stefan W. Schneider, Peter Mohr, Klaus Pantel, Harriet Wikman. Impact of blood collection tubes on CTC-, ctDNA- and miRNA recoveries in malignant melanoma patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5596.

Observational study of the differential impact of time-varying depressive symptoms on all-cause and cause-specific mortality by health status in community-dwelling adults: the REGARDS study

OBJECTIVE

To assess the association between time-varying depressive symptoms with all-cause and cause-specific mortality.

DESIGN

The REGARDS (Reasons for Geographic and Racial Differences in Stroke) is a national, population-based longitudinal study conducted from 2003 to 2007.

SETTING

General continental US communities.

PARTICIPANTS

29 491 black and white US adults ≥45 years randomly sampled within race-sex-geographical strata.

EXPOSURE

Elevated depressive symptoms (Centre for Epidemiologic Studies Depression (CES-D) 4≥4) measured at baseline and on average 5 and 7 years later.

MAIN OUTCOME MEASURES

Cox proportional hazard regression models assessed cancer, non-cardiovascular (cardiovascular disease (CVD)), CVD and all-cause mortality.

RESULTS

The average age was 64.9 years; 55% were women; 41% black; 11.0% had elevated depressive symptoms; 54% had poor, fair or good health. Time-varying depressive symptoms were significantly associated with non-CVD (adjusted HR (aHR)=1.29, 95% CI 1.16 to 1.44) and all-cause (aHR=1.24, 95% CI 1.14 to 1.39), but not cancer (aHR=1.15, 95% CI 0.96 to 1.38) or CVD (aHR=1.13, 95% CI 0.98 to 1.32) death adjusting for demographics, chronic clinical diseases, behavioural risk factors and physiological factors. Depressive symptoms were related to all-cause (aHR=1.48, 95% CI 1.27 to 1.78), CVD (aHR=1.37, 95% CI 0.99 to 1.91), non-CVD (aHR=1.54, 95% CI 1.24 to 1.92) and cancer (aHR=1.36, 95% CI 0.97 to 1.91) death in those who reported excellent or very good health. The analyses of the association between one measure of baseline depressive symptoms and mortality analyses yielded similar results.

CONCLUSIONS

Time-varying depressive symptoms confer an increased risk for all-cause mortality, CVD, non-CVD death and cancer death, particularly in those with excellent or very good health. These findings may have implications for timely treatment, regardless of health status.

Abstract P360: Diagnostic Accuracy Provided by Different Approaches to Office Blood Pressure Measurement: How Many Readings Are Enough?

Importance: Guidelines lack consensus about the optimal approach to measuring office blood pressure (BP) when screening for hypertension.

Objective: To compare the accuracy provided by different office BP measurement approaches that differ based on number of office BP readings within a visit, number of visits, and assessment method.

Design: Cross-sectional

Setting: Primary care.

Participants: 707 employees without prior diagnosis of hypertension or cardiovascular disease and with screening BP <160/105 mmHg.

Measures: Six standardized BP readings were taken during each of 3 office visits at least 1 week apart, using 2 assessment methods (mercury sphygmomanometer and BpTRU oscillometric device) for a total of 12,645 readings. Confirmatory factor analysis was used to develop a model from which estimates of the probability of correctly classifying an individual’s office BP status using differing numbers and types of office BP readings were generated.

Results: A single systolic BP reading correctly classified an individual as having BP above or below the cutpoint for elevated office BP (i.e. 140 mmHg) when the reading was <129 mmHg or >155 mmHg, respectively. Averaging three systolic BP readings across two visits correctly classified an individual 95% of the time if the averaged reading was <134 mmHg or >148 mmHg. There was more confidence gained by increasing the number of visits than the number of readings within a visit. There was no clinically significant confidence gained by dropping the first reading versus averaging all readings, nor by measuring with a manual mercury device versus with an automated oscillometric device.

Limitations: Only evaluated research quality BP readings. Similar probabilities may not apply to BP measured in routine clinical practice.

Conclusions and Relevance: Averaging BP readings across two or more office visits might best balance increased confidence in BP status with efficiency of BP measurement, though the preferred measurement strategy may vary with the clinical context. Patients with average readings modestly below the 140/90 mmHg cutpoint (e.g., 134-139 mmHg) might be appropriate for referral to out-of-office BP testing as one cannot gain strong confidence that their “true” office BP is below goal.

Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review

IMPORTANCE

Concerns exist about the current quality of undergraduate medical education and its effect on students' well-being.

OBJECTIVE

To identify best practices for undergraduate medical education learning environment interventions that are associated with improved emotional well-being of students.

DATA SOURCES

Learning environment interventions were identified by searching the biomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and ERIC from database inception dates to October 2016. Studies examined any intervention designed to promote medical students' emotional well-being in the setting of a US academic medical school, with an outcome defined as students' reports of well-being as assessed by surveys, semistructured interviews, or other quantitative methods.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed abstracts and full-text articles. Data were extracted into tables to summarize results. Study quality was assessed by the Medical Education Research Study Quality Instrument (MERQSI), which has a possible range of 5 to 18; higher scores indicate higher design and methods quality and a score of 14 or higher indicates a high-quality study.

FINDINGS

Twenty-eight articles including at least 8224 participants met eligibility criteria. Study designs included single-group cross-sectional or posttest only (n = 10), single-group pretest/posttest (n = 2), nonrandomized 2-group (n = 13), and randomized clinical trial (n = 3); 89.2% were conducted at a single site, and the mean MERSQI score for all studies was 10.3 (SD, 2.11; range, 5-13). Studies encompassed a variety of interventions, including those focused on pass/fail grading systems (n = 3; mean MERSQI score, 12.0), mental health programs (n = 4; mean MERSQI score, 11.9), mind-body skills programs (n = 7; mean MERSQI score, 11.3), curriculum structure (n = 3; mean MERSQI score, 9.5), multicomponent program reform (n = 5; mean MERSQI score, 9.4), wellness programs (n = 4; mean MERSQI score, 9.0), and advising/mentoring programs (n = 3; mean MERSQI score, 8.2).

CONCLUSIONS AND RELEVANCE

In this systematic review, limited evidence suggested that some specific learning environment interventions were associated with improved emotional well-being among medical students. However, the overall quality of the evidence was low, highlighting the need for high-quality medical education research.

Association of social support during emergency department evaluation for acute coronary syndrome with subsequent posttraumatic stress symptoms

We examined the associations of different aspects of social support during emergency department (ED) evaluation for an acute cardiac event with perceptions of threat in the ED and subsequent posttraumatic stress symptoms (PSS) in 484 patients. Participants were enrolled in the ED where they reported on their perceptions of threat in the ED. Social support in the ED and PSS were assessed at inpatient bedside or by telephone a median of 3 days later. Positive aspects of social support were not associated with subsequent PSS. Anxiety-provoking social support was significantly associated with increased PSS at follow-up. Greater ED threat perception partially mediated that relationship.

Association Between Chronic Physical Conditions and the Effectiveness of Collaborative Care for Depression: An Individual Participant Data Meta-analysis

IMPORTANCE

Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions.

OBJECTIVE

To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions.

DATA SOURCES

Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015.

STUDY SELECTION

This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care.

DATA EXTRACTION AND SYNTHESIS

Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed.

MAIN OUTCOMES AND MEASURES

Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures.

RESULTS

Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect.

CONCLUSIONS AND RELEVANCE

There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.

Proceedings From FDA/A.S.P.E.N. Public Workshop: Clinical Trial Design for Intravenous Fat Emulsion Products, October 29, 2013

The development of intravenous fat emulsion (IVFE) is the culmination of physiological, biochemical, nutritional, and medical scientific advancements. IVFEs have the ability to deliver critical nutritional substrates to the patient. Recent literature purports that they may also play roles in modulation of immune functionality and pulmonary physiology, but data supporting these potential benefits are limited. While soybean-based IVFEs have comprised the dominant fat in U.S. markets, a number of other novel IVFEs may prove to optimize the care of children and adults in both hospitalized and home settings. The October 2013 U.S. Food and Drug Administration (FDA)/American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Public Workshop brought together scientists, researchers, and clinical experts to present updated clinical perspectives of IVFEs, including historical development, current state of usage throughout the world, and considerations for the regulatory approval of new IVFEs in the United States.

Gene-centric meta-analyses for central adiposity traits in up to 57 412 individuals of European descent confirm known loci and reveal several novel associations

Waist circumference (WC) and waist-to-hip ratio (WHR) are surrogate measures of central adiposity that are associated with adverse cardiovascular events, type 2 diabetes and cancer independent of body mass index (BMI). WC and WHR are highly heritable with multiple susceptibility loci identified to date. We assessed the association between SNPs and BMI-adjusted WC and WHR and unadjusted WC in up to 57 412 individuals of European descent from 22 cohorts collaborating with the NHLBI's Candidate Gene Association Resource (CARe) project. The study population consisted of women and men aged 20-80 years. Study participants were genotyped using the ITMAT/Broad/CARE array, which includes ∼50 000 cosmopolitan tagged SNPs across ∼2100 cardiovascular-related genes. Each trait was modeled as a function of age, study site and principal components to control for population stratification, and we conducted a fixed-effects meta-analysis. No new loci for WC were observed. For WHR analyses, three novel loci were significantly associated (P < 2.4 × 10(-6)). Previously unreported rs2811337-G near TMCC1 was associated with increased WHR (β ± SE, 0.048 ± 0.008, P = 7.7 × 10(-9)) as was rs7302703-G in HOXC10 (β = 0.044 ± 0.008, P = 2.9 × 10(-7)) and rs936108-C in PEMT (β = 0.035 ± 0.007, P = 1.9 × 10(-6)). Sex-stratified analyses revealed two additional novel signals among females only, rs12076073-A in SHC1 (β = 0.10 ± 0.02, P = 1.9 × 10(-6)) and rs1037575-A in ATBDB4 (β = 0.046 ± 0.01, P = 2.2 × 10(-6)), supporting an already established sexual dimorphism of central adiposity-related genetic variants. Functional analysis using ENCODE and eQTL databases revealed that several of these loci are in regulatory regions or regions with differential expression in adipose tissue.

Gene-centric meta-analysis in 87,736 individuals of European ancestry identifies multiple blood-pressure-related loci

Blood pressure (BP) is a heritable risk factor for cardiovascular disease. To investigate genetic associations with systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), and pulse pressure (PP), we genotyped ~50,000 SNPs in up to 87,736 individuals of European ancestry and combined these in a meta-analysis. We replicated findings in an independent set of 68,368 individuals of European ancestry. Our analyses identified 11 previously undescribed associations in independent loci containing 31 genes including PDE1A, HLA-DQB1, CDK6, PRKAG2, VCL, H19, NUCB2, RELA, HOXC@ complex, FBN1, and NFAT5 at the Bonferroni-corrected array-wide significance threshold (p < 6 × 10(-7)) and confirmed 27 previously reported associations. Bioinformatic analysis of the 11 loci provided support for a putative role in hypertension of several genes, such as CDK6 and NUCB2. Analysis of potential pharmacological targets in databases of small molecules showed that ten of the genes are predicted to be a target for small molecules. In summary, we identified previously unknown loci associated with BP. Our findings extend our understanding of genes involved in BP regulation, which may provide new targets for therapeutic intervention or drug response stratification.

Loci influencing blood pressure identified using a cardiovascular gene-centric array

Blood pressure (BP) is a heritable determinant of risk for cardiovascular disease (CVD). To investigate genetic associations with systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP) and pulse pressure (PP), we genotyped ∼50 000 single-nucleotide polymorphisms (SNPs) that capture variation in ∼2100 candidate genes for cardiovascular phenotypes in 61 619 individuals of European ancestry from cohort studies in the USA and Europe. We identified novel associations between rs347591 and SBP (chromosome 3p25.3, in an intron of HRH1) and between rs2169137 and DBP (chromosome1q32.1 in an intron of MDM4) and between rs2014408 and SBP (chromosome 11p15 in an intron of SOX6), previously reported to be associated with MAP. We also confirmed 10 previously known loci associated with SBP, DBP, MAP or PP (ADRB1, ATP2B1, SH2B3/ATXN2, CSK, CYP17A1, FURIN, HFE, LSP1, MTHFR, SOX6) at array-wide significance (P < 2.4 × 10(-6)). We then replicated these associations in an independent set of 65 886 individuals of European ancestry. The findings from expression QTL (eQTL) analysis showed associations of SNPs in the MDM4 region with MDM4 expression. We did not find any evidence of association of the two novel SNPs in MDM4 and HRH1 with sequelae of high BP including coronary artery disease (CAD), left ventricular hypertrophy (LVH) or stroke. In summary, we identified two novel loci associated with BP and confirmed multiple previously reported associations. Our findings extend our understanding of genes involved in BP regulation, some of which may eventually provide new targets for therapeutic intervention.

The 'perfect storm' and acute coronary syndrome onset: do psychosocial factors play a role?

The revolution in cardiac care over the past two decades, characterized by emergent revascularization, drug eluting stents, anti-platelet medications, and advanced imaging has had little impact on overall ACS recurrence, or ACS prevention. The "Perfect Storm" refers to a confluence of events and processes, including atherosclerotic plaque, coronary flow dynamics, hemostatic and fibrinolytic function, metabolic and inflammatory conditions, neurohormonal dysregulation, and environmental events that give rise to, and result in an ACS event. In this article we illustrate the limits of the traditional main effect research model, giving a brief description of the current state of knowledge regarding the development of atherosclerotic plaque and the rupturing of these plaques that defines an ACS event. We then apply the Perfect Storm conceptualization to describe a program of research concerning a psychosocial vulnerability factor that contributes to increased risk of recurrent ACS and early mortality, and that has defied our efforts to identify underlying pathophysiology and successfully mount efforts to fully mitigate this risk.

Review article: the management of long-term parenteral nutrition

BACKGROUND

Home parenteral nutrition (HPN) is currently the management of choice for patients with chronic intestinal failure.

AIM

To summarise the major issues in delivering long-term parenteral nutrition (>3 months) and assess outcome as per complications, mortality and quality of life. To assess the evidence for the therapeutic use of trophic factors such as teduglutide and to review evolving therapeutic options in the treatment of chronic intestinal failure.

METHODS

A literature search using PubMed and MEDLINE databases was performed.

RESULTS

Safe delivery of HPN relies upon individualised formulations of parenteral nutrition administered via carefully maintained central venous catheters by trained patients or carers, supported by a skilled multidisciplinary team. Early diagnosis and treatment of complications including catheter-associated blood stream infection (reported incidence 0.14-0.83 episodes/patient-year on HPN) and central venous thrombosis (reported incidence 0.03 episodes/patient-year) is important to minimise mortality and morbidity. There is a significant variation in the reported incidence of both hepatobiliary complications (19-75%) and advanced liver disease (0-50%). Five-year survival rates in large centres are reported between 60% and 78% with survival primarily related to underlying diagnosis. Long-term survival remains higher on HPN than with intestinal transplantation. The role of intestinal lengthening procedures is yet to be validated in adults.

CONCLUSIONS

Home parenteral nutrition delivered by skilled nutrition teams has low incidences of catheter-related complications. Most deaths relate to the underlying disease. Therapies such as teduglutide and small bowel transplantation appear promising, but home parenteral nutrition appears likely to remain the bedrock of management in the near term.

Coronary artery disease in South Asian immigrants living in New York City: angiographic findings and risk factor burdens

BACKGROUND

The prevalence of coronary artery disease (CAD) among South Asians (SAs) significantly exceeds that of Caucasians. South Asians also suffer from more premature, clinically aggressive and angiographically extensive (3-vessel) disease. The role of conventional CAD risk factors (CCRFs) remains controversial.

OBJECTIVES

We sought to determine if the CCRF burdens of SA immigrants differed from Caucasians. We also sought to determine whether angiographic CAD was more extensive among SAs and whether SA ethnicity was an independent predictor of 3-vessel disease.

METHODS

We reviewed the CCRFs and angiograms of 520 SAs and 219 Caucasians consecutively referred with stable angina pectoris or acute coronary syndrome.

RESULTS

Three-vessel CAD was significantly more common among SAs than Caucasians (32.5% vs 22.4%; P = .006). Diabetes mellitus (DM), age and male sex independently predicted 3-vessel disease. South Asian ethnicity showed a trend toward predicting 3-vessel disease (P = .06). The frequency of DM (55% vs 31.1%; P < .001), hypertension (77.5% vs 68.5%; P = .01), obesity (63.1% vs 44.3%; P < .001) and dyslipidemia (75.6% vs 61.6%; P < .001) were significantly greater among SAs; however, smoking was significantly more common among Caucasians (44.3% vs 21.3%; P < .001). Compared to Caucasians, SAs were significantly younger at the time of presentation for coronary angiography (58.5 vs 61.1 yrs; P = .001).

CONCLUSIONS

SAs referred for coronary angiography with stable angina and acute coronary syndromes are younger, have significantly higher rates of 3-vessel disease, as well as higher rates of DM, hypertension, obesity and dyslipidemia than Caucasians. Aggressive screening, prevention and treatment may be warranted in this population.

Large-scale gene-centric meta-analysis across 32 studies identifies multiple lipid loci

Genome-wide association studies (GWASs) have identified many SNPs underlying variations in plasma-lipid levels. We explore whether additional loci associated with plasma-lipid phenotypes, such as high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), and triglycerides (TGs), can be identified by a dense gene-centric approach. Our meta-analysis of 32 studies in 66,240 individuals of European ancestry was based on the custom ∼50,000 SNP genotyping array (the ITMAT-Broad-CARe array) covering ∼2,000 candidate genes. SNP-lipid associations were replicated either in a cohort comprising an additional 24,736 samples or within the Global Lipid Genetic Consortium. We identified four, six, ten, and four unreported SNPs in established lipid genes for HDL-C, LDL-C, TC, and TGs, respectively. We also identified several lipid-related SNPs in previously unreported genes: DGAT2, HCAR2, GPIHBP1, PPARG, and FTO for HDL-C; SOCS3, APOH, SPTY2D1, BRCA2, and VLDLR for LDL-C; SOCS3, UGT1A1, BRCA2, UBE3B, FCGR2A, CHUK, and INSIG2 for TC; and SERPINF2, C4B, GCK, GATA4, INSR, and LPAL2 for TGs. The proportion of explained phenotypic variance in the subset of studies providing individual-level data was 9.9% for HDL-C, 9.5% for LDL-C, 10.3% for TC, and 8.0% for TGs. This large meta-analysis of lipid phenotypes with the use of a dense gene-centric approach identified multiple SNPs not previously described in established lipid genes and several previously unknown loci. The explained phenotypic variance from this approach was comparable to that from a meta-analysis of GWAS data, suggesting that a focused genotyping approach can further increase the understanding of heritability of plasma lipids.

Coronary angiographic findings and conventional coronary artery disease risk factors of Indo-Guyanese immigrants with stable angina pectoris and acute coronary syndromes

BACKGROUND

The prevalence of coronary artery disease (CAD) among migrant Indian populations exceeds that of Caucasians. Migrant Indians also suffer from more premature, clinically aggressive and angiographically extensive, (i.e., 3-vessel disease). It is not known whether the extent of angiographic CAD or the conventional CAD risk factors of Indo-Guyanese (IG) immigrants differs from that of Caucasians.

METHODS

We reviewed the conventional CAD risk factors and angiographic findings of 198 IG and 191 Caucasians who were consecutively referred for cardiac catheterization with a diagnosis of stable angina pectoris or acute coronary syndrome.

RESULTS

Three-vessel CAD was approximately 1.5 times more common among IG than Caucasians (34.8% vs. 24.0%; P = .02). Age (P = .01), male sex (P = .03) and diabetes mellitus (P = .05) were independently associated with an increased likelihood of 3-vessel CAD and there was a trend towards IG ethnicity predicting 3-vessel disease (P = .13). The frequency of diabetes mellitus (51.5% vs. 30.9%; P <.001), hypertension (82.3% vs. 67.0%; P < .001) and dyslipidemia (75.5% vs. 60.2%; P = .001) were significantly greater among IG, however, that of smoking was not. While IG were significantly leaner than Caucasians (27.7 kg/m2 vs. 30.0 kg/m2 ; P < .001), their mean body mass index fell within the ethnic-specific range for obesity.

CONCLUSIONS

We conclude that IG immigrants presenting for coronary angiography have significantly higher rates of 3-vessel CAD as well as higher rates of diabetes mellitus, hypertension and dyslipidemia than Caucasians. Aggressive screening, prevention and treatment may be warranted in this cohort.

Mechanisms of donor-specific tolerance in recipients of haploidentical combined bone marrow/kidney transplantation

We recently reported long-term organ allograft survival without ongoing immunosuppression in four of five patients receiving combined kidney and bone marrow transplantation from haploidentical donors following nonmyeloablative conditioning. In vitro assays up to 18 months revealed donor-specific unresponsiveness. We now demonstrate that T cell recovery is gradual and is characterized by memory-type cell predominance and an increased proportion of CD4⁺ CD25⁺ CD127⁻ FOXP3⁺ Treg during the lymphopenic period. Complete donor-specific unresponsiveness in proliferative and cytotoxic assays, and in limiting dilution analyses of IL-2-producing and cytotoxic cells, developed and persisted for the 3-year follow-up in all patients, and extended to donor renal tubular epithelial cells. Assays in two of four patients were consistent with a role for a suppressive tolerance mechanism at 6 months to 1 year, but later (≥ 18 months) studies on all four patients provided no evidence for a suppressive mechanism. Our studies demonstrate, for the first time, long-term, systemic donor-specific unresponsiveness in patients with HLA-mismatched allograft tolerance. While regulatory cells may play an early role, long-term tolerance appears to be maintained by a deletion or anergy mechanism.

B-cell immunity in the context of T-cell tolerance after combined kidney and bone marrow transplantation in humans

Five patients with end-stage kidney disease received combined kidney and bone marrow transplants from HLA haploidentical donors following nonmyeloablative conditioning to induce renal allograft tolerance. Immunosuppressive therapy was successfully discontinued in four patients with subsequent follow-up of 3 to more than 6 years. This allograft acceptance was accompanied by specific T-cell unresponsiveness to donor antigens. However, two of these four patients showed evidence of de novo antibodies reactive to donor antigens between 1 and 2 years posttransplant. These humoral responses were characterized by the presence of donor HLA-specific antibodies in the serum with or without the deposition of the complement molecule C4d in the graft. Immunofluorescence staining, ELISA assays and antibody profiling using protein microarrays demonstrated the co-development of auto- and alloantibodies in these two patients. These responses were preceded by elevated serum BAFF levels and coincided with B-cell reconstitution as revealed by a high frequency of transitional B cells in the periphery. To date, these B cell responses have not been associated with evidence of humoral rejection and their clinical significance is still unclear. Overall, our findings showed the development of B-cell allo- and autoimmunity in patients with T-cell tolerance to the donor graft.

New insights into the link between cardiovascular disease and depression

INTRODUCTION

Although the association between depression and cardiovascular disease (CVD) is well documented, the underlying mechanisms for this relationship remain unclear. In this paper, we present three possible models which account for the comorbidity between depression and cardiovascular disease.

MODELS

The first model outlines depression as a risk factor for CVD and the second model presents CVD as a risk factor for depression. The third model proposes a common underlying pathway related to the effects of chronic stress on the body in manifesting as depression or cardiovascular disease.

CONCLUSIONS

If the proposed model holds true, it may be possible that an intervention initiated before overt manifestations of CVD or depression become apparent, may delay or prevent the onset of these serious clinical entities.

Home parenteral nutrition--an effective and safe long-term therapy for systemic sclerosis-related intestinal failure

OBJECTIVES

To examine the outcome in patients with SSc requiring parenteral nutrition (PN), and to compare their clinical characteristics with those of other SSc patients and of patients requiring PN/home parenteral nutrition (HPN) for other conditions.

METHODS

Retrospective review of SSc and Intestinal Failure Unit databases at a tertiary referral centre for SSc/national unit for intestinal failure over a 13-yr period.

RESULTS

Eight patients with SSc requiring PN during the study period were identified (2 males, 6 females: median age at commencement of PN 51 yrs, range 42-56 yrs). All patients commencing PN had bacterial overgrowth and malabsorption not responding to antibiotic therapy. The median duration of PN therapy in the eight patients was 40 months (range 0.8-192 months). Between them the eight patients had a total of 13,851 catheter-use days and only two line infections (0.14/1000 catheter days), a lower rate of line infection than in other HPN-treated patients at Hope Hospital (0.52/1000 catheter days). Three patients died during the 13-yr period, none of causes related to their PN. Six were unable to manage their HPN regime themselves, mainly because of problems with hand function.

CONCLUSIONS

Although patient numbers were small, our findings suggest that HPN can be safely and successfully used long-term in patients with SSc and should be considered for patients unable to maintain their nutritional status because of severe gastrointestinal involvement. Impaired hand function should not preclude SSc patients from receiving HPN: family members or community nurses may be trained in the care of the HPN line.