Mitigating provider burnout due to infusion center delays: Analysis of sustainability

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Background: Physician burnout affects over 50% of physicians in the US and is related to the high workload and loss of anonymity. The result is physical exhaustion, moral distress, and increased rates of suicide. At our institution, burnout was identified in 42.1% of providers & 55.6% of staff surveyed using AMA/ASCO burnout questionnaires with treatment delays in the infusion center (IC) implicated as the biggest culprit. Methods: We tracked causes of delay in starting chemotherapy in the IC and utilizing Pareto Chart identified that over 80% of delays were due to missing chemotherapy orders on the day of IC appointment. Process flow charts for providers noted significant variations in practices. Retrospective chart review, 6/21/2019 to 8/30/ 2019, revealed that an average of 13.18% of patients scheduled to receive chemotherapy at the IC had missing orders on the day of the infusion, resulting in up to a 111-minute delay in starting chemotherapy. We set out to sustainably decrease the number of missing chemotherapy orders in the IC by 50%, decreasing the resultant stress on providers and IC nurses. Results: Four interventions were implemented over 2 plan-study-do-act (PDSA) cycles and resulted in decreasing the average number of missing orders on the day of IC appointment to 7% achieving our aim (Table). To ensure sustainability of results, we continued the interventions and maintained faculty engagement via periodic updates. Sustainability analysis revealed that the median number of patients with missing orders between 12/2/2019 and 2/28/2020 remained at 5% effectively achieving our goal. The effects of this intervention on physician/staff burnout will be reassessed after 1 year of intervention implementation using the same AMA/ASCO burnout questionnaires. Conclusions: Systematically standardizing a process achieves a sustainable impact, promotes a more effective workplace environment and decreases burnout on physicians and staff. [Table: see text]

Assessment of knowledge and perception about silver diamine fluoride (SDF) for treating older adults among graduating dental students

PURPOSE/OBJECTIVES

Silver diamine fluoride (SDF) is a promising therapy for arresting and preventing caries in difficult to treat, high-risk populations, including institutionalized older adults. This study investigates the knowledge and perceptions about SDF of graduating dental students in multiple U.S. dental schools, as well as their willingness to use SDF in their practices.

METHODS

A survey was designed consisting of 21 total questions: 6 questions regarding students' demographic information and their SDF content exposure contextualization, 8 questions tailored to investigate 2 domains regarding students' knowledge about SDF (properties and indication), and 7 questions aiming to investigate 3 domains regarding students' perceptions about SDF (SDF usefulness, appropriateness of using SDF, and willingness to use SDF when in private practice). The survey was then distributed to graduating dental students at 7 U.S. dental schools.

RESULTS

A total of 386 surveys (response rate of 55%) was collected from 7 schools in the Spring of 2019. The median score resulting from the SDF content exposure questions was 3 (SD = 1.43) from a range of 0-5. The median score from knowledge about SDF properties was 4 (SD = 1.18) from a range of 0 to 6. In the multivariate analysis, a linear model found that the covariates "SDF Usefulness", "SDF Appropriateness" and "SDF Patient Willingness to Use" were significantly associated with higher student willingness to use SDF (R²  = 0.395).

CONCLUSION

The results indicated that the graduating students have a positive perception of SDF regarding its usefulness and appropriateness. Graduating students appear inclined to utilize SDF upon entering private practice.

Physician burnout: An innovative way to find “sanity out of madness” in the infusion center of a cancer institute

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Background: Physician burnout is affecting over 50% of physicians in the US alone and is related to the high workload, loss of anonymity and a sense of powerlessness in the face of multiple bureaucratic hurdles. The result is physical exhaustion, moral distress, high turnover and increased rates of suicide. Methods: The faculty and staff at Washington Cancer Institute (WCI) were surveyed using AMA/ASCO burnout questionnaire to identify burnout rates. A brainstorming session with staff captured the perceived causes of burnout in a fishbone diagram, and the most prominent cause was noted to be pertaining to delays in the infusion center (IC) related to chemotherapy orders. We tracked causes of delay in starting chemotherapy from 7/23/19 to 8/7/19, and utilizing a Pareto Chart identified that over 80% of the delays were due to missing chemotherapy orders on the day of IC appointment. Process flow charts were developed for all provider teams at WCI noting variations that may be leading to delays. The aim was to decrease the number of missing chemotherapy orders for patients coming to the IC by 50%, decreasing the resultant stress on providers and IC nurses. Results: By retrospective chart review, 6/21/2019 to 8/30/ 2019, an average of 13.18% of patients scheduled to receive chemotherapy at WCI IC had missing orders on the day of the infusion, which resulted in up to a 111-minute delay in starting chemotherapy. This, in turn, resulted in stress/burnout among 42.1% of providers and 55.6% of supportive staff. To remedy the problem, we implemented 4 interventions over two plan-do-study-act (PDSA) cycles. In the first PDSA cycle the process was standardized to obtain necessary labs 48 hours prior to IC appointment and review and sign orders by 2 pm the day prior to IC appointment. Email notifications were also sent to all providers and nurse navigators regarding missing orders 48 hours prior to IC appointment. In the second PDSA cycle we continued with the previous interventions in addition to addressing pharmacy related delays in releasing premedication if dose adjustments of chemotherapy are needed. In the time period of 10/2/2019 to 11/11/2019, two PDSA cycles were implemented and resulted in a decrease in the average number of missing orders on the day of IC appointment to 7% achieving our aim. Conclusions: Using a systems approach to standardize the process promotes a more effective environment in the work place and decreases burnout on physicians and staff.

Reducing emergency department utilization by improving patient access to their oncology care team

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Background: At Monter Cancer Center, we observed that when patients on active intravenous chemotherapy presented to our local ED about 70% arrived during the hours of 8am and 6pm. ED utilization by active chemotherapy patients results in cancer care by providers not familiar with their disease or treatment, increased costs, poor patient experience and potential treatment delays. Our goal was to create 20% reduction in daytime ED utilization, compared to Q4 2018, by patients that received intravenous chemotherapy within 30 days of their ED visit. Methods: Through the ASCO Quality Training program, a multidisciplinary team of frontline staff was formed to create a Process map, Cause and effect diagram and Priority Matrix to develop solutions. Our first PDSA created a simplified criteria to help office secretaries triage urgent and non-urgent calls to providers. This allowed patients with urgent issues to speak to their care team on first call rather than await a callback. In our second PDSA, our treatment room nurses emphasized to patients on their treatment discharge to contact their care team first for symptom management rather than going to the ED. Results: Compared to our baseline, we have seen a 33% decrease in ED utilization by re-educating patients to call us first for symptoms and providing a clear tool to help secretaries triage calls to the care team. Conclusions: Our study shows improving patient access to their oncology care teams can decrease ED utilization, increase cancer center utilization while improving patient safety across multiple disease types.

Care coordination for oral oncolytics through pharmacy integration and cycle 1-day 1 documentation

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Background: The growing number of oral oncolytic therapies (OOTs) necessitates a standardized EMR workflow that integrates pharmacy activities for dispense and patient management and standardizes cycle-1/day-1 (C1D1) documentation. Our practice’s treatment plans contain appropriately timed OOT follow-up activities including labs, physician follow-up visits, and pharmacy calls for toxicity and adherence checks, however complications in prescription fulfillment such as prior authorization, co-pay assistance, or inability of in-practice pharmacy to dispense limit the predictability of C1D1 dates of OOTs. Methods: An EMR query identified patients at a single clinic location of 5-medical oncologists (MDs) for whom oral oncolytic treatment plans were entered from January 1 to June 30, 2018. C1D1 date entered by the MD in the EMR was compared to the pharmacy processing system dispense date. Ten patients were identified, and 10% (1/10) had an accurate C1D1 documented within the EMR. As part of the ASCO Quality Training Program, to improve the accuracy of C1D1 documentation, a new workflow was implemented whereby: (1) a “hold” activity was added to new EMR treatment plans so that C1D1 remained pending until patients had received medication; (2) clinic checkout staff provided patients with information on the in-practice pharmacy and expectations for next steps; (3) pharmacists utilized existing reporting tools to identify newly entered treatment plans and transcribed orders into e-prescriptions sent to our practice pharmacy; (4) the pharmacy workflow ensued with pharmacy staff leading patient engagement, drug counseling; (5) pharmacists confirm C1D1, document within EMR (6) subsequent treatment plan activities were scheduled. Results: Following education and process changes within the clinic and pharmacy, accurate C1D1 documentation occurred in 90% (9/10) of patients initiating OOTs. Conclusions: Including pharmacy fulfillment time in EMR workflow can improve C1D1 documentation accuracy and associated management of OOTs. Education regarding roles and processes of prescribing MDs, pharmacy staff and clinic staff will be required to scale this process improvement throughout the organization.

ASCO Quality Training Program: Five-year review

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Background: ASCO introduced a Quality Training Program (QTP) in 2013 with an aim: train oncology professionals to design, implement and lead successful quality improvement (QI) activities and assume leadership positions to champion culture change in their practices. Methods: The QTP is a formal 6-month program taught by QI faculty and mentored by QI coaches over five days of in-person learning across three sessions, and hands-on learning at the participants’ practices. Sessions include seminars, case examples, and small group exercises. Participants attend in multi-disciplinary teams and focus on a problem they wish to solve in their practice. Scheduled conference calls with QI coaches were held between sessions. Participants complete pre and post QTP surveys (10 point Likert scale; 1 - no knowledge/competence to 10 - complete knowledge/competence) and provide direct written feedback. Results: Since its inception, QTP has had 15 courses (10 domestic and 5 international) with 120 teams and 544 total participants. QTP is led by an 8-member steering group with 16 faculty and coaches. All post-survey items had an increase in knowledge and competence. Each item’s score was calculated as the mean difference between ‘before’ and ‘after’ score. Participants stated increase of 46% to 84%: overall mean increase for knowledge 38% and competence 37%. The greatest increase were: methodology and practical tools to make changes in practice (writing an aim statement, implementing rapid improvement, process analysis tools, and flowcharting the process). Most common suggestion for improvement was allowing more time for the project. Participants are encouraged to write articles and present work in poster and plenary sessions. QTP have led to 7 manuscripts and 21 abstract presentations to national meetings. Six QTP alumni currently are now QI coaches and faculty. Conclusions: The QTP is a successful QI course for oncology professionals who need to measure performance, investigate quality and safety issues, and implement change. It is the only oncology-focused QI training, as all faculty and coaches are providers and QI specialists with oncology experience, making this a unique opportunity. The success will provide further momentum to offer QTP domestically and around the world.

A Multifaceted Approach to Improve Physician Communication Scores

Improving patient satisfaction scores has become a key focus of health-care organizations nationwide but can be a struggle for community hospitals with constrained resources, and particularly challenging for hospitalist programs due to provider variance and turnover. Using the framework of appreciative inquiry, we implemented a multipronged intervention including a rounding model whereby hospitalist leaders rounded on patients and relayed commentary back to their hospitalist providers. We communicated positive feedback preferentially over negative feedback to the entire hospitalist group through regular communication. Providers were encouraged to employ best practices including sitting with the patient, reviewing recommendations using teach back, and providing business cards. Scores improved in the physician communication category by approximately 1% annually from fiscal year 2015 through 2018, with our percentile rank improving 35 percentile points during that time. These findings indicate that a multifaceted approach including best practices is associated with improved patient experience regarding communication with physicians.

Age-Related CT-scan Study of the Incidence of Sinusitis in Children

Because standard radiographies are not able to give exact information about the diseased state of the sinuses, 196 children with chronic nasal complaints, aged from 3 to 14 years were examined with computed tomographic scan. The aim of the study was to investigate whether an age-related pattern in the occurrence of rhinosinusitis in children could be found. The patient group was subdivided into six age groups (3 to 4, 5 to 6, 7 to 8, 9 to 10, 11 to 12, and 13 to 14 years). Especially younger children, until the age of 7 to 8 years seem to be prone to inflammatory changes of all their sinuses. In older children, mainly the maxillary sinuses stay frequently involved. Septal deviations occur in 16% of the youngest to 72% in the oldest age group. The occurrence of bullous conchae increases with age too, although less prominently.

Data Standardization, Pharmaceutical Drug Development, and the 3Rs

Despite the efforts, cost, and extensive use of animals for nonclinical research, only a small number of studies have methodically compared findings from animal toxicology studies to those from human clinical trials. Impediments to understanding the translation of nonclinical safety have included the lack of easy access to data and the need for extensive data curation given the diverse terminologies, formats, and data platforms in use. SEND and SDTM study data standards, developed by CDISC and about to become mandated by FDA, can address this and other drug development issues by facilitating access to data in ways that are not currently feasible. A consistent data standard across clinical and nonclinical will discourage the development of data silos, which easily become obstacles to data sharing and maximizing the value of animal and human data. The confluence of rapid scientific advances, increasingly larger quantities of diverse data, technological advances in data mining, and the FDA's requirements for standardized study data create new opportunities for the advancement of drug development and for refinement in the way we use animals.

Barriers to Implementing Person-Centered Recovery Planning in Public Mental Health Organizations in Texas: Results from Nine Focus Groups

Despite being an established practice in the disabilities service systems, person-centered planning is a relatively new practice in the behavioral health system. As a result, little is known about the barriers that mental health organizations face in implementing person-centered recovery planning (PCRP). To fill this gap, results are presented from a qualitative analysis of nine focus groups at three public mental health organizations in Texas that have been implementing PCRP for at least 2 years. Findings suggest that organizations experienced 12 distinct barriers to PCRP implementation which were categorized into the Consolidated Framework for Implementation Research domains of intervention characteristics, the outer setting, the inner setting, characteristics of individuals, and the implementation process. Half of these 12 barriers fell within the inner setting domain, suggesting that implementation efforts should be flexible and adaptable to organizational culture and context. One-quarter of the barriers fell into the domain of characteristics of individuals involved in the intervention, which further suggests implementation efforts should assess the impact that both staff and consumers have on implementation success.

Medical Record Keeping in the Summer Camp Setting

BACKGROUND

Approximately one fifth of school-aged children spend a significant portion of their year at residential summer camp, and a growing number have chronic medical conditions. Camp health records are essential for safe, efficient care and for transitions between camp and home providers, yet little research exists regarding these systems.

OBJECTIVE

To survey residential summer camps for children to determine how camps create, store, and use camper health records. To raise awareness in the informatics community of the issues experienced by health providers working in a special pediatric care setting.

METHODS

We designed a web-based electronic survey concerning medical recordkeeping and healthcare practices at summer camps. 953 camps accredited by the American Camp Association received the survey. Responses were consolidated and evaluated for trends and conclusions.

RESULTS

Of 953 camps contacted, 298 (31%) responded to the survey. Among respondents, 49.3% stated that there was no computer available at the health center, and 14.8% of camps stated that there was not any computer available to health staff at all. 41.1% of camps stated that internet access was not available. The most common complaints concerning recordkeeping practices were time burden, adequate completion, and consistency.

CONCLUSIONS

Summer camps in the United States make efforts to appropriately document healthcare given to campers, but inconsistency and inefficiency may be barriers to staff productivity, staff satisfaction, and quality of care. Survey responses suggest that the current methods used by camps to document healthcare cause limitations in consistency, efficiency, and communications between providers, camp staff, and parents. As of 2012, survey respondents articulated need for a standard software to document summer camp healthcare practices that accounts for camp-specific needs. Improvement may be achieved if documentation software offers the networking capability, simplicity, pediatrics-specific features, and avoidance of technical jargon.

Characterization of Calflagin, a Flagellar Calcium-Binding Protein from Trypanosoma congolense

Background

Identification of species-specific trypanosome molecules is important for laboratory- and field-based research into epidemiology and disease diagnosis. Although Trypanosoma congolense is the most important trypanosome pathogen of cattle in Africa, no species-specific molecules found in infective bloodstream forms (BSF) of the parasites have been identified, thus limiting development of diagnostic tests.

Methods

Immuno-mass spectrometric methods were used to identify a protein that is recognized by a T. congolense-specific monoclonal antibody (mAb) Tc6/42.6.4. The identified molecule was expressed as a recombinant protein in E. coli and was tested in several immunoassays for its ability to interact with the mAb. The three dimensional structure of the protein was modeled and compared to crystal- and NMR-structures of the homologous proteins from T. cruzi and T. brucei respectively, in order to examine structural differences leading to the different immunoreactivity of the T. congolense molecule. Enzyme-linked immunosorbent assays (ELISA) were used to measure antibodies produced by trypanosome-infected African cattle in order to assess the potential for use of T. congolense calflagin in a serodiagnostic assay.

Results

The antigen recognized by the T. congolense-specific mAb Tc6/42.6.4 was identified as a flagellar calcium-binding protein, calflagin. The recombinant molecule showed immunoreactivity with the T. congolense-specific mAb confirming that it is the cognate antigen. Immunofluorescence experiments revealed that Ca²⁺ modulated the localization of the calflagin molecule in trypanosomes. Structural modelling and comparison with calflagin homologues from other trypanosomatids revealed four non-conserved regions on the surface of the T. congolense molecule that due to differences in surface chemistry and structural topography may form species-specific epitopes. ELISAs using the recombinant calflagin as antigen to detect antibodies in trypanosome-infected cattle showed that the majority of cattle had antibody responses. Area under the Receiver-Operating Characteristic (ROC) curves, associated with host IgG and IgM, were calculated to be 0.623 and 0.709 respectively, indicating a positive correlation between trypanosome infection and the presence of anti-calflagin antibodies.

Conclusions

While calflagin is conserved among different species of African trypanosomes, our results show that T. congolense calflagin possesses unique epitopes that differentiate this protein from homologues in other trypanosome species. MAb Tc6/42.6.4 has clear utility as a laboratory tool for identifying T. congolense. T. congolense calflagin has potential as a serodiagnostic antigen and should be explored further for its utility in antigen-detection assays for diagnosis of cattle infections.

African trypanosomes are parasites that infect humans and domestic animals, causing severe socioeconomic distress in sub-Saharan Africa. Thus developing tools for laboratory- and field-based research for application to epidemiology and disease diagnosis is important if the diseases caused by these parasites are to be controlled. Although Trypanosoma congolense is the most important trypanosome pathogen of cattle in Africa, no species-specific molecules found in infective bloodstream forms (BSF) of the parasites have been identified, thus limiting development of diagnostic tests and epidemiological tools. We have biochemically characterized and modeled the structure of one such molecule, called calflagin, from this parasite and genetically engineered and purified a form of the protein for use in testing cattle for trypanosome infections. In addition, we made new monoclonal antibodies to the calflagin molecule. Our results show that the calflagin and its specific antibodies are useful tools for research in epidemiological and diagnostic applications.

Use of labetalol during hypotensive anaesthesia and in the management of phaeochromocytoma

1 The circulatory effects of labetalol have been studied in 88 patients undergoing plastic surgery, 8 patients with carcinoma of the breast, 10 with carcinoma in the head and neck, and in 2 patients with phaeochromocytoma, each anaesthetized twice. 2 The use of labetalol intravenously produced hypotension and a bloodless operating field in patients undergoing plastic surgery and in those undergoing radical surgery for the removal of carcinoma. 3 Two patients with phaeochromocytoma pre-treated with oral labetalol before anaesthesia, had well controlled BPs and heart rates during surgery, although in one instance additional intravenous labetalol was required. 4 Pre-operative preparation of patients with phaeochromocytoma with labetalol seems to be simpler and safer than previous techniques involving drugs with separate alpha- and beta-adrenoceptor-blocking effects.

Responses to the Standard for Exchange of Nonclinical Data (SEND) in non-US countries

The Standard for the Exchange of Nonclinical Data (SEND), adopted by the US FDA, is part of a set of regulations and guidances requiring the submission of standardized electronic study data for nonclinical and clinical data submissions. SEND is the nonclinical implementation of SDTM (Study Data Tabulation Model), the standard electronic format for clinical regulatory submissions to FDA. SEND, SDTM, and the associated Controlled Terminology have been developed by CDISC (Clinical Data Interchange Standards Consortium). In order to successfully implement SEND, interdisciplinary contributions between sponsors and CROs, need a model for task allocation. This is being undertaken by the Pharmaceutical Users Software Exchange (PhUSE). Because SEND is currently the preferred submission format of the US FDA only and will become required by it starting in December 2016, only American academic societies and companies are actively involved. An exception to this is the INHAND initiative, which leads the way in standardizing terminology for toxicological pathology. On the other hand, international globalization of other clinical and nonclinical practices is not feasible because there are substantial differences between the US and non-US countries in CRO involvement in drug development. Thus, non-US countries must consider and develop approaches to SEND that meet their needs. This paper summarizes the activities of the major organizations involved in SEND development and implementation, discusses the effective use of SEND, and details a compliance scheme (research material of the Showa University School of Medicine) illustrating how pharmaceutical companies can complete a large amount of work up to an FDA application with the effective utilization of CROs and solution providers.

Urgency and other lower urinary tract symptoms in men aged ≥ 40 years: a Belgian epidemiological survey using the ICIQ-MLUTS questionnaire

BACKGROUND AND AIMS

The aim of this study was to assess prevalence and associated bother of male lower urinary tract symptoms (LUTS), especially of urgency and other storage symptoms, since these are generally assumed to be underdiagnosed/undertreated in men.

METHODS

Data on bladder condition of men ≥ 40 years were prospectively collected by 124 general practitioners (GPs) during a regular visit for any reason, using the validated ICIQ-MLUTS questionnaire. For 13 symptoms, prevalence (scale 0-4) and bother (scale 0-10) were scored. General bladder-related quality of life (scale 0-3) was also assessed.

RESULTS

Data from 5890 men (mean age: 61.2 years) were analysed. A total of 7.7% had urgency most or all of the time (score ≥ 3) and 6.2% had bothersome urgency (score ≥ 3 + bother score ≥ 5). Nocturia (69.2%) and urgency (58.3%) were the most prevalent and bothersome symptoms. Both prevalence and bother of all LUTS increased with age. Additionally, 28.9% of men reported to be a little bothered by their bladder condition in everyday life, while 11.9% were bothered a lot/very much (2.5% in age group 40-49 years increasing to 29.2% in those > 80 years).

CONCLUSIONS

In the general population of men ≥ 40 years who visited a GP for any reason, 41% indicated to be at least a little bothered by their bladder condition. The prevalence of LUTS, especially nocturia and urgency, is high and a significant number of men indicated to be seriously bothered. Increasing awareness of male LUTS, and storage symptoms in particular, is warranted to discuss management options that could increase quality of life.

Overactive bladder symptoms, stress urinary incontinence and associated bother in women aged 40 and above; a Belgian epidemiological survey

AIM

 This Belgian epidemiological study aimed to assess the prevalence of overactive bladder (OAB) and stress urinary incontinence (SUI) and associated bother in a female primary care population.

METHODS

Data on OAB and SUI were prospectively collected among women ≥ 40 years by general practitioners (GP) during a regular visit for any reason. The validated Bladder Control Self-Assessment Questionnaire (B-SAQ) was used and complemented with a question on SUI and bladder bother. The presence of mild bladder control symptoms (BCS) was defined as an overall B-SAQ symptom score (OSS) ≥ 4 and an overall bother score (OBS) ≥ 1. Descriptive statistics were performed.

RESULTS

Data from 7139 women were analysed. About 33.9% had mild BCS. Most women reported overall mild OAB symptoms (46.9%) and 34.9% had moderate-to-(very) severe symptoms. The prevalence of moderate-severe urgency, frequency or nocturia was higher than that of moderate-severe incontinence. Urgency and nocturia were considered the most bothersome symptoms. Moderate-severe SUI affected 17.7% of women. About 16.4% of women reported to be moderately-severely bothered by their bladder in everyday life. The risk of severe symptoms and bother increased with age. About 10% of women had clinically significant BCS (OSS ≥ 7 and OBS ≥ 4).

CONCLUSIONS

In Belgian women ≥ 40 years visiting a GP for any reason, one in three had mild BCS and might benefit from further evaluation. Up to 10% of these women had clinically significant BCS for which medical therapy might be necessary. This warrants awareness for early diagnosis and intervention.

A product analog bound form of 3-oxoadipate-enol-lactonase (PcaD) reveals a multifunctional role for the divergent cap domain

Lactones are a class of structurally diverse molecules that serve essential roles in biological processes ranging from quorum sensing to the aerobic catabolism of aromatic compounds. Not surprisingly, enzymes involved in the bioprocessing of lactones are often targeted for protein engineering studies with the potential, for example, of optimized bioremediation of aromatic pollutants. The enol-lactone hydrolase (ELH) represents one such class of targeted enzymes and catalyzes the conversion of 3-oxoadipate-enol-lactone into the linear β-ketoadipate. To define the structural details that govern ELH catalysis and assess the impact of divergent features predicted by sequence analysis, we report the first structural characterization of an ELH (PcaD) from Burkholderia xenovorans LB400 in complex with the product analog levulinic acid. The overall dimeric structure of PcaD reveals an α-helical cap domain positioned atop a core α/β-hydrolase domain. Despite the localization of the conserved catalytic triad to the core domain, levulinic acid is bound largely within the region of the active site defined by the cap domain, suggesting a key role for this divergent substructure in mediating product release. Furthermore, the architecture of the cap domain results in an unusually deep active-site pocket with topological features to restrict binding to small or kinked substrates. The evolutionary basis for this substrate selectivity is discussed with respect to the homologous dienelactone hydrolase. Overall, the PcaD costructure provides a detailed insight into the intimate role of the cap domain in influencing all aspects of substrate binding, turnover, and product release.

Immunological studies with an m-deficient histoplasmin skin-test antigen

Previous studies have shown that a single skin test to histoplasmin may induce complement-fixing antibodies or M precipitins (or both) to histoplasmin in histoplasmin-sensitive, but serologically negative, individuals. Ideally a skin-test antigen should be one which detects hypersensitivity without stimulating humoral antibodies. Histoplasmin skin-test antigens presently used contain both H and M antigens. The present study was undertaken to evaluate an histoplasmin skin-test antigen deficient in the M component but containing the H antigen. Thirty histoplasmin-hypersensitive subjects were bled prior to administration of the experimental skin-test antigen and at various time intervals thereafter. Only six of the thirty hypersensitive subjects showed serological responses. The sera of the six, however, only showed weak precipitin reactions, five showed M bands, and only one showed an M and an H band. None showed complement-fixation titers with either the yeast or mycelial antigens of Histoplasma capsulatum. Our data suggest that the use of a skin-test antigen purified to contain only H component would detect histoplasmin hypersensitivity without inducing antibodies and would eliminate false-positive serological reactions caused by the M component.

Four-year metabolic outcome of a randomised controlled CD3-antibody trial in recent-onset type 1 diabetic patients depends on their age and baseline residual beta cell mass

AIMS/HYPOTHESIS

The aim of the study was to examine the 48 month outcome of treating recent-onset type 1 diabetic patients for 6 days with humanised CD3-antibody, ChAglyCD3.

METHODS

Eighty patients, aged 12-39 years, were recruited for a phase 2 multicentre trial and randomised to placebo (n=40) or ChAglyCD3 (n=40) treatment by a third party member; participants and care-givers were blinded. The change in insulin dose (U kg(-1)day(-1)) over 48 months was chosen as primary endpoint and compared in 31 placebo-and 33 ChAglyCD3-treated patients. Adverse events were followed in 35 and 38 patients, respectively.

RESULTS

Treatment with ChAglyCD3 delayed the rise in insulin requirements of patients with recent-onset diabetes and reduced its amplitude over 48 months (+0.09 vs +0.32 U kg(-1)day(-1) in the placebo group). Using multivariate analysis this effect was correlated with higher baseline residual beta cell function and a younger age. It was associated with better outcome variables in subgroups selected according to these variables. In the ChAglyCD3 subgroup with higher initial beta cell function, 0/11 patients became C-peptide-negative over 48 months vs 4/9 in the corresponding placebo subgroup. In the subgroup aged <27 years old, antibody treatment preserved initial beta cell function for 36 months (vs >80% decline within 24 months in the placebo subgroup <27 years old), resulted in lower HbA1c concentrations and tended to reduce glycaemic variability (p=0.08). No longterm adverse events were observed.

CONCLUSIONS/INTERPRETATION

A 6 day ChAglyCD3 treatment can suppress the rise in insulin requirements of recent-onset type 1 diabetic patients over 48 months, depending on their age and initial residual beta cell function. In younger patients this effect is associated with reduced deterioration of metabolic variables. These observations help to define inclusion criteria for prevention trials.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00627146

FUNDING

Center grants from the Juvenile Diabetes Research Foundation (4-2001-434, 4-2005-1327) and grants from the Belgian Fund for Scientific Research-Flanders and from Brussels Free University-VUB.

Hepatitis C genotype 4 response rate to pegylated interferon and ribavirin treatment in Belgium is similar to genotype 1

BACKGROUND AND AIMS

Patients with genotype 4 (G4) chronic hepatitis C from the Middle East respond better to treatment than genotype 1 (G1) patients. There are few data on the response rates to treatment of G4 patients living in Western Europe. Many G4 patients in Belgium originate from Central Africa, and their response to treatment seems lower.

METHODS

We analysed the data from 2 randomized phase III studies conducted in Belgium, BerNar-1 and BerNar-2, comparing the sustained virological response (SVR) to pegylated interferon and ribavirin of 78 G4 patients (34 Caucasians, 44 Blacks) and 477 G1 patients (455 Caucasians, 12 Blacks), and assessing the predictors of SVR.

RESULTS

Baseline characteristics of G4 and G1 patients were similar except mainly for race. Complete early virological response (cEVR) was similar in G4 (73.2%) and G1 (68.1%). cEVR was also similar between Black and Caucasian G4 and between Black and Caucasian G1 patients. Partial early virological response was similar for G4 and G1. SVR was similar for G4 (51.3%) and G1 (51.8%). There was a trend for a higher SVR in Caucasians than in Blacks. In multivariate analysis, the only predictors for SVR were the presence of cirrhosis, HCV viral load, age < 40 vs > or = 40 yrs, and treatment status (relapsers vs naive).

CONCLUSIONS

G4 patients in Belgium have the same SVR as G1 patients. It is lower than the SVR described in Arab countries, especially for Black G4 patients.

Global patterns of speciation and diversity

In recent years, strikingly consistent patterns of biodiversity have been identified over space, time, organism type and geographical region. A neutral theory (assuming no environmental selection or organismal interactions) has been shown to predict many patterns of ecological biodiversity. This theory is based on a mechanism by which new species arise similarly to point mutations in a population without sexual reproduction. Here we report the simulation of populations with sexual reproduction, mutation and dispersal. We found simulated time dependence of speciation rates, species-area relationships and species abundance distributions consistent with the behaviours found in nature. From our results, we predict steady speciation rates, more species in one-dimensional environments than two-dimensional environments, three scaling regimes of species-area relationships and lognormal distributions of species abundance with an excess of rare species and a tail that may be approximated by Fisher's logarithmic series. These are consistent with dependences reported for, among others, global birds and flowering plants, marine invertebrate fossils, ray-finned fishes, British birds and moths, North American songbirds, mammal fossils from Kansas and Panamanian shrubs. Quantitative comparisons of specific cases are remarkably successful. Our biodiversity results provide additional evidence that species diversity arises without specific physical barriers. This is similar to heavy traffic flows, where traffic jams can form even without accidents or barriers.

The impact of one HF-rTMS session on mood and salivary cortisol in treatment resistant unipolar melancholic depressed patients

BACKGROUND

Recent studies indicate that medication resistant depressed patients can be successfully treated by a series of sessions of High Frequency repetitive Transcranial Magnetic Stimulation (HF-rTMS), delivered on the left dorsolateral prefrontal cortex (DLPFC). However, changes in subjectively experienced mood give only limited insight into the underlying physiological responses. Previous studies in depressed patients, as well as in healthy volunteers, have reported a possible impact of HF-rTMS on the hypothalamic-pituitary-adrenal (HPA) axis.

OBJECTIVE

We wanted to evaluate the emotional and neurobiological impact of one session of HF-rTMS applied on the left DLPFC in a sample of unipolar treatment resistant depressed patients of the melancholic subtype.

METHODS

20 right-handed antidepressant-free depressed patients were studied using a sham-controlled, 'single' blind, crossover design. We examined subjective mood changes with Visual Analogue Scales (VAS). To examine HF-rTMS effects on the HPA-axis, we analyzed salivary cortisol levels. Mood assessment and salivary cortisol levels were assessed before and immediately after stimulation. To detect any delayed effects, all measurements were also re-assessed 30 min post HF-rTMS. The left DLPFC was determined under MRI guidance.

RESULTS

One session of HF-rTMS did not result in any subjectively experienced mood changes. However, salivary cortisol concentrations decreased significantly immediately and 30 min after active HF-rTMS.

CONCLUSIONS

Although one session of HF-rTMS on the left DLPFC did not influence mood subjectively in melancholic unipolar depressed patients, we found support for the hypothesis that a single session has a significant impact on the HPA-axis, as measured by salivary cortisol. Our results may provide more insight into the underlying working mechanisms of HF-rTMS in unipolar melancholic depression, and could add further information about endocrinological functioning in affective disorders.

Pulmonary Mycobacterium simiae infection: comparison with pulmonary tuberculosis

To identify the clinical and radiological features distinguishing Mycobacterium simiae respiratory infection from pulmonary tuberculosis, the demographics, underlying conditions, and clinical and radiological findings of 121 consecutive patients with pulmonary tuberculosis and 102 with M. simiae respiratory infection were compared retrospectively. In the M. simiae group, the patients were older (mean age 69 +/- 16 years vs. 47 +/- 21 years, p = 0.0001), with a female predominance (62% vs. 45%, p = 0.008). Only 4% were of Ethiopian origin compared to 25% of the tuberculosis group (p = 0.0001). M. simiae infection was associated with significantly higher rates of smoking history, underlying chronic obstructive pulmonary disease, zero human immunodeficiency virus (HIV) infection compared to 10% in the tuberculosis group (p = 0.001), blunted symptoms, and noncavitary infiltrates in the lower/middle lobes on chest X-ray. HIV-negative patients with M. simiae respiratory infection are distinguishable from patients with pulmonary tuberculosis by several demographic, clinical, and radiological features. These findings have important diagnostic and therapeutic implications.

Tolerance of adjuvant letrozole outside of clinical trials

Recently aromatase inhibitors have become a standard care as an adjuvant treatment for many postmenopausal patients with hormone receptor positive early breast cancer. Adjuvant letrozole was made available either immediately postoperative, after 2-3 years of tamoxifen, or as an extended treatment after 5 years of tamoxifen. Between October 2003 and October 2005, we analyzed the subjective tolerance in 185 postoperative early breast cancer patients receiving letrozole outside of a clinical trial. The most prominent toxicity was musculoskeletal pain. In addition hot flushes, increased fatigue, nausea, vomiting, anorexia, mood disturbances, vaginal dryness, hair loss and rash were also recorded. In contrast to the prospective randomized clinical trials, a high drop-out rate of 20% was documented, mainly due to aromatase inhibitor-associated arthralgia syndrome interfering significantly with the daily life of our patients. Although adjuvant aromatase inhibitors have proven to be generally superior to tamoxifen in the adjuvant setting, it is important to focus attention on the tolerance during the adjuvant therapy and to balance this against the potential benefit in individual patients. Alternative options including switching to tamoxifen remain available.

Factors affecting peak performance in the swimming competition of the Athens Olympic Games

AIM

The aim of this study was to examine the separate and combined effects of several factors deemed important in determining peaking in the Athens Olympic swimming competition.

METHODS

Data on 301 Olympic swimmers, who competed in 424 events, were used to analyze the relative swimming performance gain (RSPG%: the relative differences between the entry swimming results obtained in national trials or another competition, and in the Olympic competition expressed as a percentage). RSPG% was described with respect to 24 National, stroke-type, swimming distance, swimmer's rank, gender, mode of selection and duration of the final stage preparation (FSP) prior the Olympics. Analysis of variance (ANOVA) and cluster linear regression were performed to estimate the effect of these factors on RSPG%.

RESULTS

The average RSPG% gain equaled 0.58% (standard deviation: 1.13%) indicating performance decline, embracing 68.2% of all the swimming events. However, two Olympians' categories, medalists and swimmers ranked 4-8, broke their personal best on average by 0.35% and 0.12%, respectively. One-way ANOVA considering nations with ''rigid selection'' vs ''liberal selection'', revealed significant superiority (P=0.04) of the swimmers who were selected rigorously over swimmers selected liberally.

CONCLUSION

The results indicate the marked tendency of performance decline in all the swimming events and strokes during the FSP. This general tendency was not representative of swimmers who reached the finals. Furthermore, a highly significant superiority of peaking in the teams was revealed, which required ''rigid selection'' rather than ''liberal selection''.

Investigation of proton-proton short-range correlations via the 12C(e,e'pp) reaction

We investigated simultaneously the 12C(e,e'p) and 12C(e,e'pp) reactions at Q2=2 (GeV/c)2, xB=1.2, and in an (e, e'p) missing-momentum range from 300 to 600 MeV/c. At these kinematics, with a missing momentum greater than the Fermi momentum of nucleons in a nucleus and far from the delta excitation, short-range nucleon-nucleon correlations are predicted to dominate the reaction. For (9.5+/-2)% of the 12C(e,e'p) events, a recoiling partner proton was observed back-to-back to the 12C(e,e'p) missing-momentum vector, an experimental signature of correlations.

Identification of prediabetes in first-degree relatives at intermediate risk of type I diabetes

Prevention trials of type I diabetes are limited by recruitment of individuals at high risk of the disease. We investigated whether demographic and biological characteristics can identify rapid progressors among first-degree relatives of known patients at intermediate (< 10%) 5-year risk. Diabetes-associated antibodies, random proinsulin : C-peptide (PI/C) ratio and HLA DQ genotype were determined (repeatedly) in 258 islet antibody-positive IA-2Antibody-negative (Abpos/IA-2Aneg) normoglycaemic first-degree relatives. During follow-up (median 81 months), 14 of 258 Abpos/IA-2Aneg relatives developed type I diabetes; 13 (93%) of them had persistent antibodies conferring a 12% [95% confidence interval (CI): 5-19%] 5-year risk of diabetes. In Abpos/IA-2Aneg relatives with persistent antibodies (n = 126), the presence of >/= 1 HLA DQ susceptibility haplotype in the absence of a protective haplotype (P = 0.033) and appearance on follow-up of a high PI/C ratio (P = 0.007) or IA-2A-positivity (P = 0.009) were identified as independent predictors of diabetes. In persistently antibody-positive relatives with HLA DQ risk a recurrently high PI/C ratio or development of IA-2A identified a subgroup (n = 32) comprising 10 of 13 (77%) prediabetic relatives and conferred a 35% (95% CI: 18-53%) 5-year risk. Under age 15 years, 5-year progression (95% CI) was 57% (30-84%) and sensitivity 62%. In the absence of IA-2A, the combination of antibody persistence, HLA DQ risk and elevated PI/C ratio or later development of IA-2A and young age defines a subgroup of relatives with a high risk of type I diabetes (>/= 35% in 5 years). Together with initially IA-2A-positive relatives these individuals qualify for standardized beta cell function tests in view of prevention trials.

Persistent pulmonary hypertension late after neonatal aortic valvotomy: a consequence of an expanded surgical cohort

BACKGROUND

Survival of neonates with critical aortic stenosis has improved over the past decade. Models based on morphological characteristics have been designed to help determine whether early survival is more likely after biventricular repair (surgical or balloon aortic valvotomy) or after a single ventricle staged palliative surgical strategy. However, late follow up data are lacking.

OBJECTIVE

To report follow up data on survivors of neonatal aortic valvotomy who had persistent pulmonary hypertension caused by restriction to left ventricular filling.

RESULTS

Of four medium term survivors of neonatal valvotomy for critical aortic stenosis who had persistent pulmonary hypertension, one died aged 4 years and the other three have severe limitation of effort tolerance.

CONCLUSIONS

This previously unreported late complication of "successful" biventricular repair for neonatal critical aortic stenosis is an important consideration in determining the initial management.

Seasonality in clinical onset of type 1 diabetes in belgian patients above the age of 10 is restricted to HLA-DQ2/DQ8-negative males, which explains the male to female excess in incidence

AIMS/HYPOTHESIS

Type 1 diabetes arises from an interplay between environmental and genetic factors. The reported seasonality at diagnosis supports the hypothesis that currently unknown external triggers play a role in the onset of the disease. We investigated whether a seasonal pattern is observed at diagnosis in Belgian Type 1 diabetic patients, and if so whether seasonality varies according to age, sex and genetic risk, all known to affect the incidence of Type 1 diabetes.

METHODS

The seasonal pattern at clinical diagnosis was assessed in 2176 islet antibody-positive diabetic patients aged 0 to 39 years diagnosed between 1989 and 2000. Additional stratification was performed for age, sex and HLA-DQ genotype.

RESULTS

Overall, a significant seasonal pattern at clinical diagnosis of diabetes was observed (p<0.001). More subjects were diagnosed in the period of November to February (n=829) than during the period of June to September (n=619) characterised by higher averages of maximal daily temperature and daily hours of sunshine. However, the seasonal pattern was restricted to patients diagnosed above the age of 10 (0-9 years: p=0.398; 10-19 years: p<0.001; 20-29 years: p=0.003; 30-39 years: p=0.015). Since older age at diagnosis is associated with a male to female excess and a lower prevalence of the genetic accelerator HLA-DQ2/DQ8, we further stratified the patients aged 10 to 39 years (n=1675) according to HLA-DQ genotype and sex, and we found that the seasonal pattern was largely restricted to male subjects lacking DQ2/DQ8 (n=748; p<0.00 vs all others: n=927; p=0.031).

CONCLUSIONS/INTERPRETATION

In a subgroup of male patients diagnosed over the age of 10, the later stages of the subclinical disease process may be more driven by sex- and season-dependent external factors than in younger, female and genetically more susceptible subjects. These factors may explain the male to female excess in diabetes diagnosed in early adulthood.