A phase 3 study evaluating the lot consistency, immunogenicity, safety, and tolerability of a Clostridioides difficile vaccine in healthy adults 65 to 85 years of age

BACKGROUND

A toxoid-based Clostridioides difficile vaccine is currently in development. Here, we report lot-to-lot consistency, immunogenicity, safety, and tolerability of 3 C difficile vaccine doses in healthy older adults.

METHODS

This phase 3, placebo-controlled study randomized (1:1:1:1) healthy adults 65 to 85 years of age to 1 of 3 C difficile vaccine lots or placebo. Participants received C difficile vaccine (200 μg total toxoid) or placebo (Months 0, 1, 6). The primary immunogenicity objective was lot-to-lot consistency (2-sided 95 % CIs within 0.5 and 2 for comparisons of geometric mean concentration [GMC] ratios) for toxins A- and B-specific neutralizing antibody levels 1 month after Dose 3. Safety outcomes included local reactions and systemic events ≤7 days after vaccination, adverse events (AEs), and serious AEs (SAEs).

RESULTS

Of 1317 enrolled participants, 1218 completed the study. C difficile vaccine immunogenicity was consistent across lots, with neutralizing antibody responses 1 month after Dose 3 for both toxin A (GMC [95 % CI]: lot 1, 878.8 [786.3, 982.2]; lot 2, 873.0 [779.2, 978.1]; lot 3, 872.9 [782.6, 973.5]) and toxin B (lot 1, 5823.9 [5041.0, 6728.4]; lot 2, 5462.8 [4733.4, 6304.7]; lot 3, 5426.0 [4724.4, 6231.8]). Two-sided 95 % CIs for GMC ratios were within 0.5 and 2 for toxins A and B, indicating lot-to-lot consistency was achieved. C difficile vaccine was well tolerated, with similar rates of local reactions and systemic events among vaccine lots. AE and SAE rates were similar across C difficile vaccine (36.5 % and 4.5 %, respectively) and placebo (35.3 % and 6 %).

CONCLUSIONS

Three doses (Months 0,1,6) of toxoid-based C difficile vaccine induced robust neutralizing antibody responses and were well tolerated in healthy participants 65 to 85 years of age. Lot-to-lot consistency was excellent, indicating the manufacturing process for this C difficile vaccine formulation was well controlled.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03579459.

Efficacy and Safety of a Bivalent RSV Prefusion F Vaccine in Older Adults

BACKGROUND

Respiratory syncytial virus (RSV) infection causes considerable illness in older adults. The efficacy and safety of an investigational bivalent RSV prefusion F protein-based (RSVpreF) vaccine in this population are unknown.

METHODS

In this ongoing, phase 3 trial, we randomly assigned, in a 1:1 ratio, adults (≥60 years of age) to receive a single intramuscular injection of RSVpreF vaccine at a dose of 120 μg (RSV subgroups A and B, 60 μg each) or placebo. The two primary end points were vaccine efficacy against seasonal RSV-associated lower respiratory tract illness with at least two or at least three signs or symptoms. The secondary end point was vaccine efficacy against RSV-associated acute respiratory illness.

RESULTS

At the interim analysis (data-cutoff date, July 14, 2022), 34,284 participants had received RSVpreF vaccine (17,215 participants) or placebo (17,069 participants). RSV-associated lower respiratory tract illness with at least two signs or symptoms occurred in 11 participants in the vaccine group (1.19 cases per 1000 person-years of observation) and 33 participants in the placebo group (3.58 cases per 1000 person-years of observation) (vaccine efficacy, 66.7%; 96.66% confidence interval [CI], 28.8 to 85.8); 2 cases (0.22 cases per 1000 person-years of observation) and 14 cases (1.52 cases per 1000 person-years of observation), respectively, occurred with at least three signs or symptoms (vaccine efficacy, 85.7%; 96.66% CI, 32.0 to 98.7). RSV-associated acute respiratory illness occurred in 22 participants in the vaccine group (2.38 cases per 1000 person-years of observation) and 58 participants in the placebo group (6.30 cases per 1000 person-years of observation) (vaccine efficacy, 62.1%; 95% CI, 37.1 to 77.9). The incidence of local reactions was higher with vaccine (12%) than with placebo (7%); the incidences of systemic events were similar (27% and 26%, respectively). Similar rates of adverse events through 1 month after injection were reported (vaccine, 9.0%; placebo, 8.5%), with 1.4% and 1.0%, respectively, considered by the investigators to be injection-related. Severe or life-threatening adverse events were reported in 0.5% of vaccine recipients and 0.4% of placebo recipients. Serious adverse events were reported in 2.3% of participants in each group through the data-cutoff date.

CONCLUSIONS

RSVpreF vaccine prevented RSV-associated lower respiratory tract illness and RSV-associated acute respiratory illness in adults (≥60 years of age), without evident safety concerns. (Funded by Pfizer; RENOIR ClinicalTrials.gov number, NCT05035212; EudraCT number, 2021-003693-31.).

Overcoming barriers to the adoption and implementation of predictive modeling and machine learning in clinical care: what can we learn from US academic medical centers?

There is little known about how academic medical centers (AMCs) in the US develop, implement, and maintain predictive modeling and machine learning (PM and ML) models. We conducted semi-structured interviews with leaders from AMCs to assess their use of PM and ML in clinical care, understand associated challenges, and determine recommended best practices. Each transcribed interview was iteratively coded and reconciled by a minimum of 2 investigators to identify key barriers to and facilitators of PM and ML adoption and implementation in clinical care. Interviews were conducted with 33 individuals from 19 AMCs nationally. AMCs varied greatly in the use of PM and ML within clinical care, from some just beginning to explore their utility to others with multiple models integrated into clinical care. Informants identified 5 key barriers to the adoption and implementation of PM and ML in clinical care: (1) culture and personnel, (2) clinical utility of the PM and ML tool, (3) financing, (4) technology, and (5) data. Recommendation to the informatics community to overcome these barriers included: (1) development of robust evaluation methodologies, (2) partnership with vendors, and (3) development and dissemination of best practices. For institutions developing clinical PM and ML applications, they are advised to: (1) develop appropriate governance, (2) strengthen data access, integrity, and provenance, and (3) adhere to the 5 rights of clinical decision support. This article highlights key challenges of implementing PM and ML in clinical care at AMCs and suggests best practices for development, implementation, and maintenance at these institutions.

Breast Health Disparities: A Primer for Medical Students

INTRODUCTION

While breast cancer incidence rates have remained stable and mortality rates have declined for white women, breast cancer mortality has steadily increased for African American women since the 1950s. It has often been assumed that genetic risks linked to African ancestry are the cause for these disparities. However, a better understanding of the role of stress and social and environmental factors in health lends evidence to the social determinants behind the increasing gaps in breast health outcomes. This resource's goal is to raise awareness among undergraduate medical students about breast cancer disparities, particularly the late-stage diagnoses and the higher mortality rate for African American women.

METHODS

Our educational session included a lecture on basic epidemiological data and information on breast cancer etiology followed by a case study, which was created with the founder of a local cancer support and resource center serving mainly African American women diagnosed with breast cancer. As part of the case exercise, we utilized concept mapping as a tool to apply learning.

RESULTS

Pre-/postquizzes showed significant improvements in knowledge and confidence in working with patients. Narrative reflections from students indicated an improvement in targeting at-risk populations, educating patients about their risk and options, and understanding the complex role that socioeconomic factors may play in patient outcomes.

DISCUSSION

By raising awareness and exposing medical students to the socioeconomic and cultural aspects of breast health, we hope to improve medical students' knowledge of risk factors and preventive strategies, as well as their abilities to guide patients through appropriate screening and follow-up.

Acceptability and Feasibility of Human Papilloma Virus Self-Sampling for Cervical Cancer Screening

OBJECTIVES

Women in safety-net institutions are less likely to receive cervical cancer screening. Human papilloma virus (HPV) self-sampling is an alternative method of cervical cancer screening. We examine the acceptability and feasibility of HPV self-sampling among patients and clinic staff in two safety-net clinics in Miami.

MATERIALS AND METHODS

Haitian and Latina women aged 30-65 years with no Pap smear in the past 3 years were recruited. Women were offered HPV self-sampling or traditional Pap smear screening. The acceptability of HPV self-sampling among patients and clinic staff was assessed. If traditional screening was preferred the medical record was reviewed.

RESULTS

A total of 180 women were recruited (134 Latinas and 46 Haitian). HPV self-sampling was selected by 67% women. Among those selecting traditional screening, 22% were not screened 5 months postrecruitment. Over 80% of women agreed HPV self-sampling was faster, more private, easy to use, and would prefer to use again. Among clinic staff, 80% agreed they would be willing to incorporate HPV self-sampling into practice.

CONCLUSIONS

HPV self-sampling was both acceptable and feasible to participants and clinic staff and may help overcome barriers to screening.

Is greater acculturation associated with an increased prevalence of cardiovascular risk factors among Latinos in South Florida?

OBJECTIVE

To examine the association of acculturation with various cardiovascular risk factors (CRFs) among Latinos with diabetes in South Florida.

METHODS

In a cross-sectional analysis of data collected from 300 Latinos with poorly controlled diabetes we measured acculturation using the Marin Short Acculturation Scale. We examined correlations between acculturation and the following 7 CRFs: hemoglobin A1C, low-density lipoprotein, systolic blood pressure, body mass index, smoking status, physical activity, and fruit and vegetable intake.

RESULTS

Cubans made up 38% of our population; no other Latino subgroup represented over 17% of the sample. Of the 8 outcomes examined, only smoking was associated with increased acculturation; 12% of Latinos in the 2 lowest acculturation groups were current smokers versus 25% in the highest acculturation group (P=0.02). Furthermore, Cuban Americans from our sample had over double the prevalence of smoking compared with non-Cubans in both the lowest and highest acculturation groups.

CONCLUSIONS

With the exception of smoking, our data does not support a link between increased acculturation and higher prevalence of CRFs in Latinos with diabetes. Smoking prevention and cessation programs targeting Latinos and particularly among Cubans are needed.

Abstract B58: Differences in cervical cancer knowledge among minority women in Miami

Background: Minority women suffer disproportionately from cervical cancer incidence and mortality. Education initiatives aimed at improving cervical cancer knowledge may lead to increased appropriate screening and reductions in morbidity. Baseline data describing the variable levels of knowledge among specific minority and underserved communities will aid the design of such programs.

Methods: The South Florida Center for Reducing Cancer Disparities is a comprehensive NCI initiative focused on the reduction and ultimate elimination of cervical cancer disparities in Miami-Dade County. As part of an ongoing randomized intervention study, we collected baseline data on cervical cancer knowledge among three minority communities: Little Haiti, Hialeah (90% Latino), and West Perrine (mixed community). Eligibility criteria included women aged 30-65 years and not having had a Pap smear in the past three years. Knowledge was assessed using questions from the NCI's Health Information National Trends Survey (HINTS), which we translated and back translated into Haitian Kreyol and Spanish. We used Fisher's exact test to examine differences in knowledge across minority subgroups. We then used univariate and multivariate logistic regression models to control for additional sociodemographic correlates of higher cervical cancer knowledge.

Results: Among the 334 women enrolled to date, 53% are Latina, 39% Haitian, and 8% African American (AA). We found 44% of Latinas, 25% of AAs and 7% of Haitians answered >50% of questions correctly (P<0.0001). Years of education and marital status, but not age, were significantly associated with higher levels of knowledge (P<0.05). In multivariate analysis, adjusting for these potential confounders, Haitians (OR=0.17; 95%CI: 0.08-0.38; P<0.0001) and AAs (OR=0.56; 95%CI: 0.2-1.53; P=0.2565) were less likely to answer >50% of questions correctly compared to Latinas. In a subgroup analysis of Latinas, we found 49% of Cubans (n=101) answered >50% of questions correctly versus 37% of non-Cubans (n=76), however there was no significant difference in knowledge between groups, including when adjusting for potential confounders (OR =1.41; 95%CI: 0.74-2.69; P=0.2957).

Conclusions: Among minority women in Miami who had not been adequately screened for cervical cancer, Haitians had the lowest levels of cervical cancer knowledge, even after correcting for sociodemographic differences. Among Latinas, Cubans had a higher level of knowledge but this result was not statistically significant. As more women are enrolled in our study (target 600) we will have greater power to detect potential differences among AAs. We have developed and are now testing culturally tailored educational interventions aimed at decreasing the cervical cancer knowledge gap in these vulnerable groups.

Citation Format: Kumar Ilangovan, Tulay Koru-Sengul, Erin Kobetz-Kerman, Olveen Carrasquillo. Differences in cervical cancer knowledge among minority women in Miami. [abstract]. In: Proceedings of the Sixth AACR Conference: The Science of Cancer Health Disparities; Dec 6–9, 2013; Atlanta, GA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2014;23(11 Suppl):Abstract nr B58. doi:10.1158/1538-7755.DISP13-B58

Rationale and design of the research project of the South Florida Center for the Reduction of Cancer Health Disparities (SUCCESS): study protocol for a randomized controlled trial

BACKGROUND

In the United States certain minority groups, such as racial/ethnic immigrant women, are less likely than non-Hispanic White women to be screened for cervical cancer. Barriers to such care include health insurance, cost, knowledge, attitudes, health literacy, and cultural norms and practices. Among the most promising approaches to increase screening in these groups are patient navigators that can link women to sources of appropriate care. Another recent promising approach is using human papilloma virus (HPV) self-sampling. In this manuscript, we describe our National Cancer Institute-sponsored study testing such approaches among immigrant minority women.

DESIGN

The South Florida Center for the Reduction of Cancer Health Disparities (SUCCESS) is conducting a three-arm randomized trial among Hispanic, Haitian, and African American women in Miami-Dade County. Community health workers (CHW) based in each of three communities are recruiting 200 women at each site (600 total). Eligibility criteria include women aged 30-65 years who have not had a Pap smear test in the last 3 years. Prior to randomization, all women undergo a standardized structured interview. Women randomized to public health outreach, Group 1, receive culturally tailored educational materials. Women in Group 2 receive an individualized comprehensive cervical cancer CHW-led education session followed by patient navigation to obtain the Pap smear test at community-based facilities. Women in Group 3 have the option of navigation to a Pap smear test or performing HPV self-sampling. The primary outcome is self-report of completed screening through a Pap smear test or HPV self-sampling within 6 months after enrollment.

DISCUSSION

SUCCESS is one of the first trials testing HPV self-sampling as a screening strategy among underserved minority women. If successful, HPV self-sampling may be an important option in community outreach programs aimed at reducing disparities in cervical cancer.

TRIAL REGISTRATION

Clinical Trials.gov # NCT02121548, registered April 21, 2014.

The impact of ammonia nitrogen concentration and zeolite addition on the specific methanogenic activity of granular and flocculent anaerobic sludges

This work presents the effect of ammonia nitrogen concentration and zeolite addition on the specific methanogenic activity (SMA) of different anaerobic sludges with various physical structures (granular and flocculent), operating in batch conditions. Piggery, malting production and urban sludges derived from full-scale anaerobic reactors were tested in the experiment as the source of inoculum in batch digesters. It was found that piggery sludge was the most affected by the increase of ammonia nitrogen concentration while malting producing and municipal sludges were less affected. In general, the addition of zeolite at doses in the range of 0.01-0.1 g/g VSS reduced the inhibitory effect of N-NH(4)(+) for piggery sludge (P.S.). For this sludge, the propionic:acetic ratio increased when the concentration of N-NH(4)(+) increased, indicating that methanogenesis was affected. Finally, a study of the microbial population involved in this study for P.S. by using 16S rRNA based molecular techniques revealed a presence of microorganisms following the order: Methanococcaceae > Methanosarcina > Methanosaeta.

2,4,8-Trioxa-2-aza-1,3,6(1,2)-tri-benzena-2(2,3)-bicyclo-[3.3.0]octa-na-cyclo-octa-phane

The crystal structure of the title compound, C₂₆H₂₅NO₃, was determined as part of an investigation of host–guest and electron donor–acceptor complexes. The oxazole and the pyrrole rings both adopt envelope conformations. The dihedral angle between the two benzene rings directly linked to the oxazole ring is 49.5 (1)°. The crystal structure is stabilized by a C—H⋯π inter­action.

2,5-Dimethyl-1-phenyl-sulfonyl-1H-pyrrole-3,4-dicarbaldehyde

In the title compound, C₁₄H₁₃NO₄S, the mean planes of the pyrrole and phenyl rings form a dihedral angle of 88.7 (1)°. The aldehyde groups are slightly twisted from the pyrrole plane. In the crystal structure, mol­ecules are linked into a three-dimensional framework by C—H⋯O hydrogen bonds.

Inactivation of Cryptosporidium parvum oocysts in water using ultrasonic treatment

Ultrasound in a liquid phase cause mass and heat transfer across the liquid through cavitational processes which act as nanoreactors to generate unstable mechanical equilibrium. The effect of 1 MHz ultrasound on the inactivation of Cryptosporidium parvum was investigated. Continuous irradiation of ultrasound (20 min) increased temperature due to cavitational phenomena. Ultrasound irradiation of liquid containing C. parvum showed significant quantitative changes in pH, temperature and inactivation of C. parvum (102.7 oocysts killed/s) with a minimum energy consumption (0.05 oocysts/s).

Epidemiology and outcomes of out-of-hospital cardiac arrest in Rochester, New York

OBJECTIVE

To characterize out-of-hospital cardiac arrest (OHCA) and factors that affect survival in a medium sized city that uses system status management for dispatch.

METHODS

A retrospective cohort study of all adult OHCA patients treated by EMS between 1998 and 2001 was conducted using Utstein definitions. The primary endpoint was 1-year survival.

RESULTS

Of the 1177 patients who experienced OHCA during the study period, 539 (46%) met inclusion criteria. Age ranged from 18 to 98 years (median 67). The median call-response interval was 5 min (range 0-21), and 93% were 9 min or less. There was no significant difference in the median call-response intervals between call location zip (Post) codes (p=0.07). Twenty percent of experienced ROSC (95% CI 17-23), 7% survived more than 30 days (95% CI 5-9%), and 5% survived to 1 year (95% CI 3-7%). In bivariate analysis, first rhythm and bystander CPR affected survival to 1 year. There was no significant difference in survival between male (4%) and female (7%), black (4%) and white (6%), or witnessed (7%) and unwitnessed arrest (4%). Logistic regression identified younger age, CPR initiated by bystander (19%) or first responder (41%), and presenting rhythm of VF/VT (32%) as factors associated with survival to 1 year.

CONCLUSIONS

This study finds a 5% survival to 1 year among OHCA patients in Rochester, NY. A presenting rhythm of VF/VT and bystander CPR were associated with increased survival.

Effect of natural and modified zeolite addition on anaerobic digestion of piggery waste

The effect of natural and modified zeolites on the anaerobic degradation of acetate and methanol was evaluated by the determination of specific methane productivity (SMP) in batch minidigesters of 50 mL at doses of 0.01, 0.05 and 0.1 g of zeolite/g of VSS. The effects of the different zeolite concentrations were determined by the results of the SMP. A kinetic characterization with data of accumulated methane gas volume was also carried out. In the second phase of the study, the effects of natural and nickel zeolite concentrations were tested with piggery waste in laboratory scale digesters of 2.5 L operating at semi continuous mode, by increasing the organic load applied from 0.2 to 22.0 g TCOD/d corresponding to organic loading rates (OLR) of 0.1-8.8 g TCOD/l x d. A greater effect of modified zeolite on SMP was observed, with an increase of 8.5 times with magnesium zeolite, 4.4 times with cobalt zeolite and 2.8 times with nickel zeolite. Two phases were defined in the kinetic study and an increase of more than 2 times the apparent constant of digesters with modified zeolites was observed in the second phase when compared to unmodified natural zeolite. Modified natural zeolite addition to digesters can allow an increase in the potential biodegradability of piggery waste solid fraction and/or a considerable reduction of digestion volume.

Influence of different natural zeolite concentrations on the anaerobic digestion of piggery waste

The effect of different natural zeolite concentrations on the anaerobic digestion of piggery waste was studied. Natural zeolite doses in the range 0.2-10 g/l of wastewater were used in batch experiments, which were carried out at temperatures between 27 degrees C and 30 degrees C. Total chemical oxygen demand (COD), total and volatile solids, ammonia and organic nitrogen, pH, total volatile fatty acids (TVFA), alkalinity (Alk) and accumulative methane production were determined during 30 days of digestion. The anaerobic digestion process was favored by the addition of natural zeolite at doses between 2 and 4 g/l and increasingly inhibited at doses beyond 6 g/l. A first-order kinetic model of COD removal was used to determine the apparent kinetic constants of the process. The kinetic constant values increased with the zeolite amount up to a concentration of 4 g/l. The values of the maximum accumulative methane production (Gm) increased until zeolite concentrations of 2-4 g/l. The addition of zeolite reduced the values of the TVFA/ Alk ratio while increasing the pH values, and these facts could contribute to the process failure at zeolite doses of 10 g/l.

The removal of bacteria by modified natural zeolites

The removal effect of natural and modified zeolites containing different heavy metals (Ni2+, Zn2+, Fe3+ and Cu2+) on pure cultures of Escherichia coli and Staphylococcus aureus in a solid medium was evaluated in this work. These experiments were carried out in a continuous mode treating municipal wastewater. Faecal coliform species and Pseudomonas aeruginosa were identified. The rate constants of heavy metal lixiviation were determined using a first order kinetic model. The removal effect of modified natural zeolites in both a solid medium and in continuous mode showed an increased elimination of the bacterial population. The results established a decreasing order of the removal effect as follows: Cu2+ > Fe3+ > Zn2+ > Ni2+. The best performance of columns was obtained for inlet bacterial concentrations below 10(6) cells/100 ml. Most of the identified bacterial species were affected by copper modified zeolites, although Serratia marcescens presented the highest sensitivity and Klebsiella pneumoniae the greatest resistance.