Safety and Efficacy of Intramuscular Tixagevimab-Cilgavimab in Prevention of COVID-19 in Patients Who Are Immunocompromised

INTRODUCTION

Patients who are immunocompromised face an increased chance of severe COVID-19 infection compared with patients who are immunocompetent. However, vaccine efficacy for COVID-19 appears to be lower in patients who are immunocompromised. Tixagevimab-cilgavimab are monoclonal antibodies designed to enhance immune defense against COVID-19. Nevertheless, the safety and efficacy of tixagevimab-cilgavimab specifically in patients who are immunocompromised remains unknown.

METHODS

The authors conducted a retrospective case study of patients who were immunocompromised and received tixagevimab-cilgavimab between January 3, 2022 to July 31, 2022 at Kaiser Permanente Southern California. All patients were monitored for 180 days following tixagevimab-cilgavimab administration. Patients who were immunocompromised included those with solid tumors, hematologic malignancies, primary immunodeficiencies, recipients of solid organ or hematopoietic stem cell transplants, and patients undergoing treatment with immunosuppressive medications (eg, chemotherapy, high-dose corticosteroids, tumor necrosis factor blockers, and certain biologic agents).

RESULTS

A total of 2352 patients who were immunocompromised were included in the study. Among them, 101 patients (4.3%) tested positive for COVID-19, and 13 patients (0.6%) required COVID-19-related hospital admissions. Notably, no deaths were reported within 180 days following tixagevimab-cilgavimab administration. Additionally, 4 patients (0.17%) sought same-day medical care after receiving tixagevimab-cilgavimab. Within 30 days, there were 39 non-COVID-19-related hospital admissions (1.7%) and within 7 days, 11 hospital admissions (0.5%) occurred after tixagevimab-cilgavimab administration.

DISCUSSION

Tixagevimab-cilgavimab demonstrated a low incidence of COVID-19 and COVID-19-related hospital admissions in patients who were immunocompromised, with no reported mortality. Furthermore, there were no significant adverse effects associated with the use of these monoclonal antibodies.

CONCLUSION

Tixagevimab-cilgavimab exhibited a low incidence of COVID-19 and adverse effects in patients who were immunocompromised.

Health-related quality of life and lifestyle changes in patients with chronic kidney disease and hyperkalaemia: Real-world data from the US, five European countries and China

BACKGROUND

Chronic kidney disease patients have impaired health-related quality of life and an increased risk of hyperkalaemia.

AIMS

The objective was to evaluate the impact of hyperkalaemia on health-related quality of life, and investigate lifestyle change recommendations, in these patients.

METHODS

The Adelphi Real World Chronic Kidney Disease Specific Programme™ was used. Data were collected from physicians and patients with non-dialysis dependent stage 3a, 3b and 4 chronic kidney disease from the US, France, Germany, Spain, Italy, the UK and China. Patients completed the Kidney Disease Quality of Life Instrument and EuroQol-5D-3L. Analyses compared data between hyperkalaemic (serum potassium >5.0 mmol/L) and normokalaemic (serum potassium 3.5-5.0 mmol/L) patients.

RESULTS

Overall, 1149 patients were included (hyperkalaemic: n = 216, normokalaemic: n = 933; US: n = 376, Europe: n = 490, China: n = 283). Hyperkalaemic vs normokalaemic patients experienced more symptoms (P < .001) and had numerically lower scores, indicating poorer health-related quality of life, in all Kidney Disease Quality of Life domains, with significant differences for three/five domains. Hyperkalaemic patients reported numerically lower EuroQol-5D-3L utility index and visual analogue scores, indicating poorer health status, than normokalaemic patients. A higher proportion of hyperkalaemic than normokalaemic patients were recommended to reduce dietary potassium (P < .05). More normokalaemic than hyperkalaemic patients reported making a radical change in five/six recommended lifestyle changes, with the difference significant for four/six recommendations.

CONCLUSIONS

Hyperkalaemia is associated with an incremental impairment of the health-related quality of life in chronic kidney disease patients. A better understanding of the impact of hyperkalaemia in these patients could improve patient outcomes.

Drug treatment patterns and work productivity in chronic kidney disease patients with anemia in China: Cross sectional analysis of real-world data

Background

We explored the association of anemia severity in patients with chronic kidney disease (CKD) and anemia treatment with work productivity in China.

Methods

Cross-sectional survey data from Chinese physicians and their CKD patients were collected in 2015. Physicians recorded demographics, disease characteristics, and treatment. Patients completed the Work Productivity and Activity Impairment questionnaire. Data were stratified by dialysis-dependence, hemoglobin (Hb) level, and anemia treatment.

Results

Based on data from 1,052 patients (704 non-dialysis-dependent [NDD] and 348 dialysis-dependent [DD] patients), prescribed anemia treatment differed significantly across Hb levels (P < 0.001). In NDD patients, anemia treatment also differed significantly by on-treatment Hb level (P < 0.001). In treated NDD patients with Hb < 10 g/dL, Hb 10 to 12 g/dL, and Hb > 12 g/dL, 31%, 59%, and 38% of patients, respectively, were prescribed oral iron, and 34%, 19%, and 0% of patients, respectively, were prescribed oral iron with erythropoiesis-stimulating agents (ESA). NDD patients were less likely to be prescribed any anemia treatment, and ESA specifically, than DD patients. When treated, 67% and 45% of NDD and DD patients, respectively, had Hb ≥ 10 g/dL (P < 0.001). Overall work and activity impairment differed significantly across Hb levels in NDD and DD patients, with the least impairment observed at the highest Hb level.

Conclusion

Approximately 40% of NDD patients and 60% of DD patients receiving anemia treatment had Hb < 10 g/dL. Compared with mild anemia patients, severe anemia patients were more likely to be treated for anemia and have impaired work productivity. Chinese CKD patients could benefit from improved anemia treatment.

P0864PHYSICIAN ATTITUDES TOWARDS DIAGNOSING ANAEMIA, TREATMENT INITIATION AND THE CURRENT UNMET NEED IN THE MANAGEMENT AND TREATMENT OF ANAEMIA: INTERIM RESULTS FROM A CROSS-SECTIONAL REAL-WORLD SURVEY IN GERMANY, ITALY AND THE UK

Background and Aims

Anaemia, a complication of chronic kidney disease (CKD), is commonly defined as serum haemoglobin (Hb) levels of &lt;12 g/dL in women and &lt;13 g/dL in men. Its prevalence and severity increase with the decline in renal function and it is often associated with a decreased quality of life (QoL), and an increase in number of hospitalisations and comorbidities. Traditionally, primary care physicians (PCPs) have less involvement managing patients with CKD anaemia and nephrologists have a greater role in treatment decisions. We describe current physician perception towards the diagnosis and treatment of anaemia and the current unmet need in anaemia management, in a real-world setting.

Method

Preliminary data were drawn from the Adelphi CKD Disease Specific ProgrammeTM, a point-in-time study conducted between November 2019 and January 2020 with nephrologists and PCPs from Germany, Italy and the United Kingdom. Physicians completed a detailed online survey providing information on their demographics, opinions on the diagnosis and treatment of anaemia, and the current unmet needs they believe exist in the management and treatment of anaemia. Results are based on interim data and analysed descriptively.

Results

A total of 144 physicians (n=94 nephrologists; n=50 PCPs) were included in the analysis. Among those who responded, the majority used Hb levels to diagnose anaemia in CKD patients. Over two thirds of physicians mentioned using ferritin to diagnose anaemia and over half reported using transferrin saturation (TSAT) levels. Reported use of ferritin and TSAT testing was lower among PCPs.

Three quarters of nephrologists and PCPs (76% of each respectively) reported Hb levels to be the most important factor that triggers initiation of anaemia treatment in CKD patients, followed by fatigue/weakness (53% of both nephrologists and PCPs) and overall health/QoL (29% nephrologists; 18% PCPs). Ferritin levels (24% of each respectively); TSAT levels (23% nephrologists; 24% PCPs) and shortness of breath (22% nephrologists; 24% PCPs) were also among the most important factors.

The top three unmet needs in the management and treatment of CKD anaemia, as reported by nephrologists were: treatment for refractory/resistant patients (34%), lower cost of therapy (34%) and need for more oral treatments (33%). PCPs’ top three unmet needs were reported as: treatment for refractory/resistant patients (42%), fewer side effects (42%) and need for more oral treatments (34%). Differences observed between nephrologists and PCPs related to a need for alternative treatments (19% nephrologists; 26% PCPs), access to ESA treatment (17% nephrologists; 30% PCPs) and treatments with lower risk of CV events (26% nephrologists; 12% PCPs).

Conclusion

This data reinforced that Hb levels, ahead of ferritin and TSAT levels have an important role in the diagnosis and initial prescription of therapy for anaemia in CKD patients. It also highlighted an unmet need for treatment of refractory/resistant patients and the desire among both nephrologists and PCPs for safer and affordable novel treatments for anaemia patients.

Real-world treatment patterns in patients with advanced (stage III-IV) ovarian cancer in the USA and Europe

Aim: To analyze real-world data relating to treatment decision-making in stage III-IV ovarian cancer (OC). Materials & methods: Real world data were collected from a survey of physicians and their patients (n = 2413) across Europe and the USA in 2017-2018. Results: 49% had stage IVb disease. 39, 54 and 7% of patients received first-line (1L), second-line, or 7% third-line or later treatment. In the 1L (ongoing or completed), 93% received platinum-containing regimens, 26% bevacizumab-containing regimens and 1% a PARP inhibitor-containing regimen. In 1L maintenance treatment, 81% received bevacizumab, 17% platinum-containing treatments and 6% a PARP inhibitor. Conclusion: The most common 1L treatment for advanced ovarian cancer was platinum-containing chemotherapy. Of those receiving 1L maintenance therapy, 70-99% (across countries) received targeted therapy.

Impact of chronic kidney disease and anemia on health-related quality of life and work productivity: analysis of multinational real-world data

Background

Reductions in health-related quality of life (HRQoL) in patients with chronic kidney disease (CKD) are thought to be exacerbated by the low hemoglobin (Hb) levels that define anemia, a common complication of CKD. The current analysis evaluated the impact of anemia on HRQoL and work productivity in patients with non-dialysis dependent and dialysis-dependent CKD using real-world data.

Methods

Data were collected in France, Germany, Italy, Spain, the UK, the USA and China in 2012–2018 in the Adelphi Real World Disease Specific Programme™ for CKD, a large, cross-sectional, survey of physicians and their patients. Patients completed three patient-reported outcomes (PRO) instruments: the EuroQol 5-Dimension 3-level (EQ-5D-3 L), the Kidney Disease Quality of Life (KDQOL-36) instrument and the Work Productivity and Activity Impairment questionnaire. PROs were assessed by CKD stage and Hb levels, and regression analyses were performed with CKD stage and Hb level as independent variables and PROs as outcome variables, while adjusting for age, sex, CKD stage, comorbidities and cardiovascular risk.

Results

Overall, 5276 patients participated in the survey, including 28% stage 4 and 36% dialysis patients. Patients with lower Hb levels more often reported problems/issues on all EQ-5D-3 L domains (p < 0.0001). Regression analyses showed significant associations between lower Hb levels and the probability of low (< 0.8) EQ-5D-3 L utility scores (p < 0.0001) and low visual analog scale scores (p < 0.05), indicating poorer health status. Associations were seen even when adjusting for CKD stage and other potential confounding factors. Significant associations were observed between Hb level and the 12-Item Short-Form Health Survey (SF-12) Physical Component Summary, SF-12 Mental Component Summary and the three KDQOL-36 subscales (all p < 0.0001), and were confirmed using linear regression analyses adjusting for CKD stage and other potential confounders. Numerically greater work productivity losses and greater activity impairment were observed with lower Hb levels.

Conclusions

Lower Hb levels worsen the impact of CKD on HRQoL, and are associated with lower work productivity in patients with CKD. Assessment and treatment of anemia should be recognized as a key component of integral CKD management throughout all stages of the disease.

Mapping the kidney disease quality of life 36-item short form survey (KDQOL-36) to the EQ-5D-3L and the EQ-5D-5L in patients undergoing dialysis

OBJECTIVES

To develop algorithms mapping the Kidney Disease Quality of Life 36-Item Short Form Survey (KDQOL-36) onto the 3-level EQ-5D questionnaire (EQ-5D-3L) and the 5-level EQ-5D questionnaire (EQ-5D-5L) for patients with end-stage renal disease requiring dialysis.

METHODS

We used data from a cross-sectional study in Europe (France, n = 299; Germany, n = 413; Italy, n = 278; Spain, n = 225) to map onto EQ-5D-3L and data from a cross-sectional study in Singapore (n = 163) to map onto EQ-5D-5L. Direct mapping using linear regression, mixture beta regression and adjusted limited dependent variable mixture models (ALDVMMs) and response mapping using seemingly unrelated ordered probit models were performed. The KDQOL-36 subscale scores, i.e., physical component summary (PCS), mental component summary (MCS), three disease-specific subscales or their average, i.e., kidney disease component summary (KDCS), and age and sex were included as the explanatory variables. Predictive performance was assessed by mean absolute error (MAE) and root mean square error (RMSE) using 10-fold cross-validation.

RESULTS

Mixture models outperformed linear regression and response mapping. When mapping to EQ-5D-3L, the ALDVMM model was the best-performing one for France, Germany and Spain while beta regression was best for Italy. When mapping to EQ-5D-5L, the ALDVMM model also demonstrated the best predictive performance. Generally, models using KDQOL-36 subscale scores showed better fit than using the KDCS.

CONCLUSIONS

This study adds to the growing literature suggesting the better performance of the mixture models in modelling EQ-5D and produces algorithms to map the KDQOL-36 onto EQ-5D-3L (for France, Germany, Italy, and Spain) and EQ-5D-5L (for Singapore).

Real-world bevacizumab utilization and outcomes in first-line ovarian cancer

5578

Background: Bevacizumab (B) is approved in combination with carboplatin and paclitaxel, followed by B monotherapy, for the treatment of advanced ovarian cancer (OC) following surgery. We sought to describe B utilization and outcomes of B in first-line (1L) OC within the US and EU. Methods: This cross-sectional study included patients who were actively receiving treatment for OC. Data were collected at a single time point from 2496 patient forms between December 2017 and March 2018 from 340 oncologists/ gynecologists across the US, France, Germany, Italy, Spain, and the UK. Patients were platinum sensitive if progression was noted > 6 months after frontline platinum therapy and resistant if the interval was 0-6 months. This analysis included patients who received 1L chemotherapy (chemo) with no maintenance or 1L chemo with bevacizumab maintenance. Results: B was used in combination with chemo at 1L and as 1L maintenance monotherapy in 11% total study patients. Those receiving 1L + B were more likely to have Stage IV disease, have good performance status (PS) at diagnosis, and receive BRCA testing than patients receiving chemo only. Treatment response, platinum sensitivity, and activities of daily living are shown in the Table. Results did not vary by BRCA status. Conclusions: This study highlights differences in patient characteristics and outcomes between patients receiving/ who received 1L chemo only and those receiving/ who received B, however, this study was not designed to formally compare 1L treatment options. [Table: see text]

Expansion of hedgehog disrupts mesenchymal identity and induces emphysema phenotype

GWAS have repeatedly mapped susceptibility loci for emphysema to genes that modify hedgehog signaling, but the functional relevance of hedgehog signaling to this morbid disease remains unclear. In the current study, we identified a broad population of mesenchymal cells in the adult murine lung receptive to hedgehog signaling, characterized by higher activation of hedgehog surrounding the proximal airway relative to the distal alveoli. Single-cell RNA-sequencing showed that the hedgehog-receptive mesenchyme is composed of mostly fibroblasts with distinct proximal and distal subsets with discrete identities. Ectopic hedgehog activation in the distal fibroblasts promoted expression of proximal fibroblast markers and loss of distal alveoli and airspace enlargement of over 20% compared with controls. We found that hedgehog suppressed mesenchymal-derived mitogens enriched in distal fibroblasts that regulate alveolar stem cell regeneration and airspace size. Finally, single-cell analysis of the human lung mesenchyme showed that segregated proximal-distal identity with preferential hedgehog activation in the proximal fibroblasts was conserved between mice and humans. In conclusion, we showed that differential hedgehog activation segregates mesenchymal identities of distinct fibroblast subsets and that disruption of fibroblast identity can alter the alveolar stem cell niche, leading to emphysematous changes in the murine lung.

Humanistic burden of disease in earlier stage metastatic (stage IIIb/c-IVM1a) versus late stage metastatic (IVM1b/c) melanoma patients in a real-world setting in the U.S

9561

Background: To assess melanoma specific health-related quality of life (HRQoL) and health states in patients with earlier stage metastatic (IIIb/c-IVM1a) versus late stage metastatic (IVM1b/c) melanoma. Methods: Data were collected from the Adelphi Real World Advanced Melanoma Disease-Specific Programme, a cross-sectional survey of 112 physicians and their patients (N = 666). Data were collected between March and July 2016 in the US. A subset of 183 patients completed the Functional Assessment of Cancer Therapy Melanoma (FACT-M) and EuroQol-5D (EQ-5D) one time. Patients were classified by stage of melanoma at time of consultation. Descriptive analyses of HRQoL scores between earlier and late stage metastatic melanoma were assessed using Mann-Whitney U tests. Results: The mean age of the earlier stage and late stage metastatic patients was 62 and 64 respectively. More earlier stage metastatic patients had an ECOG status of 0 or 1 versus late stage metastatic patients (85%, 75% respectively). A total of 31% of late stage metastatic patients required caregiver support and had a median time since primary diagnosis of 5.0 months whereas earlier stage metastatic patients reported 14% and 5.2 months respectively. Patients with earlier stage metastatic melanoma had better mean EQ-5D index scores versus late stage metastatic melanoma patients (0.81 (n = 84), 0.76 (n = 93); p = 0.0103). Higher scores indicating better HRQoL were observed between earlier stage metastatic versus late stage metastatic melanoma patients for the FACT-M (120.7 (n = 81), 107.4 (n = 91); p = 0.0017) and subscales (except Social Well Being). Clinically meaningful differences between groups using published minimal important differences (MIDs) were observed in in 6/7 FACT-M subscales and EQ-5D VAS. Conclusions: Differences in HRQoL and health states were observed between earlier stage metastatic and late stage metastatic melanoma populations, highlighting the detrimental effect of developing metastatic disease. These results suggest that treatments that delay progression of the disease are important to conserve patients HRQoL

English translation and validation of the SarQoL®, a quality of life questionnaire specific for sarcopenia

Background

the first quality of life questionnaire specific to sarcopenia, the SarQoL®, has recently been developed and validated in French. To extend the availability and utilisation of this questionnaire, its translation and validation in other languages is necessary.

Objective

the purpose of this study was therefore to translate the SarQoL® into English and validate the psychometric properties of this new version.

Design

cross-sectional.

Setting

Hertfordshire, UK.

Subjects

in total, 404 participants of the Hertfordshire Cohort Study, UK.

Methods

the translation part was articulated in five stages: (i) two initial translations from French to English; (ii) synthesis of the two translations; (iii) backward translations; (iv) expert committee to compare the backward translations with the original questionnaire and (v) pre-test. To validate the English SarQoL®, we assessed its validity (discriminative power, construct validity), reliability (internal consistency, test-retest reliability) and floor/ceiling effects.

Results

the SarQoL® questionnaire was translated without any major difficulties. Results indicated a good discriminative power (lower score of quality of life for sarcopenic subjects, P = 0.01), high internal consistency (Cronbach's alpha of 0.88), consistent construct validity (high correlations found with domains related to mobility, usual activities, vitality, physical function and low correlations with domains related to anxiety, self-care, mental health and social problems) and excellent test-retest reliability (intraclass coefficient correlation of 0.95, 95%CI 0.92-0.97). Moreover, no floor/ceiling has been found.

Conclusions

a valid SarQoL® English questionnaire is now available and can be used with confidence to better assess the disease burden associated with sarcopenia. It could also be used as a treatment outcome indicator in research.

Relationships between bone geometry, volumetric bone mineral density and bone microarchitecture of the distal radius and tibia with alcohol consumption

PURPOSE

Chronic heavy alcohol consumption is associated with bone density loss and increased fracture risk, while low levels of alcohol consumption have been reported as beneficial in some studies. However, studies relating alcohol consumption to bone geometry, volumetric bone mineral density (vBMD) and bone microarchitecture, as assessed by high-resolution peripheral quantitative computed tomography (HR-pQCT), are lacking.

METHODS

Here we report an analysis from the Hertfordshire Cohort Study, in which we studied associations between HR-pQCT measures at the distal radius and tibia and alcohol consumption in 376 participants (198 men and 178 women) aged 72.1-81.4 years.

RESULTS

A total of 30 (15.2%), 90 (45.5%) and 78 (39.4%) men drank minimal/none (<1 unit/week), low (≥1 unit/week and <11 units/week) and moderate/high (≥11 units/week) amounts of alcohol respectively. These figures were 74 (41.8%), 80 (45.2%) and 23 (13.0%) respectively in women for minimal/none (<1 unit/week), low (≥1 unit/week and <8 units/week) and moderate/high (≥8 units/week). At the distal radius, after adjustment for confounding factors (age, BMI, smoking status, dietary calcium intake, physical activity and socioeconomic status and years since menopause and HRT use for women), men that drank low alcohol had lower cortical thickness (p=0.038), cortical vBMD (p=0.033), and trabecular vBMD (p=0.028) and higher trabecular separation (p=0.043) than those that drank none/minimal alcohol. Similar differences were shown between minimal/none and moderate/high alcohol although these only reached statistical significance for the cortical parameters. Interestingly, after similar adjustment, women showed similar differences in the trabecular compartment between none/minimal alcohol and low alcohol at the distal tibia. However, women that drank moderate/high alcohol had significantly higher trabecular vBMD (p=0.007), trabecular thickness (p=0.026), and trabecular number (p=0.042) and higher trabecular separation (p=0.026) at the distal radius than those that drank low alcohol.

CONCLUSIONS

Our results suggest that alcohol consumption (low and moderate/high) may have a detrimental impact on bone health in men in both the cortical and trabecular compartments at the distal radius with similar results in women in the trabecular compartment between none/minimal alcohol and low alcohol at the distal tibia suggesting that avoidance of alcohol may be beneficial for bone health.

Vitamin D supplementation in pregnancy: a systematic review

BACKGROUND

It is unclear whether or not the current evidence base allows definite conclusions to be made regarding the optimal maternal circulating concentration of 25-hydroxyvitamin D [25(OH)D] during pregnancy, and how this might best be achieved.

OBJECTIVES

To answer the following questions: (1) What are the clinical criteria for vitamin D deficiency in pregnant women? (2) What adverse maternal and neonatal health outcomes are associated with low maternal circulating 25(OH)D? (3) Does maternal supplementation with vitamin D in pregnancy lead to an improvement in these outcomes (including assessment of compliance and effectiveness)? (4) What is the optimal type (D2 or D3), dose, regimen and route for vitamin D supplementation in pregnancy? (5) Is supplementation with vitamin D in pregnancy likely to be cost-effective?

METHODS

We performed a systematic review and where possible combined study results using meta-analysis to estimate the combined effect size. Major electronic databases [including Database of Abstracts of Reviews of Effects (DARE), Centre for Reviews and Dissemination (CRD), Cochrane Database of Systematic Reviews (CDSR) and the Health Technology Assessment (HTA) database] were searched from inception up to June 2012 covering both published and grey literature. Bibliographies of selected papers were hand-searched for additional references. Relevant authors were contacted for any unpublished findings and additional data if necessary. Abstracts were reviewed by two reviewers.

INCLUSION AND EXCLUSION CRITERIA

SUBJECTS

pregnant women or pregnant women and their offspring.

EXPOSURE

either assessment of vitamin D status [dietary intake, sunlight exposure, circulating 25(OH)D concentration] or supplementation of participants with vitamin D or food containing vitamin D (e.g. oily fish).

OUTCOMES

offspring - birthweight, birth length, head circumference, bone mass, anthropometry and body composition, risk of asthma and atopy, small for gestational dates, preterm birth, type 1 diabetes mellitus, low birthweight, serum calcium concentration, blood pressure and rickets; mother - pre-eclampsia, gestational diabetes mellitus, risk of caesarean section and bacterial vaginosis.

RESULTS

Seventy-six studies were included. There was considerable heterogeneity between the studies and for most outcomes there was conflicting evidence. The evidence base was insufficient to reliably answer question 1 in relation to biochemical or disease outcomes. For questions 2 and 3, modest positive relationships were identified between maternal 25(OH)D and (1) offspring birthweight in meta-analysis of three observational studies using log-transformed 25(OH)D concentrations after adjustment for potential confounding factors [pooled regression coefficient 5.63 g/10% change maternal 25(OH)D, 95% confidence interval (CI) 1.11 to 10.16 g], but not in those four studies using natural units, or across intervention studies; (2) offspring cord blood or postnatal calcium concentrations in a meta-analysis of six intervention studies (all found to be at high risk of bias; mean difference 0.05 mmol/l, 95% CI 0.02 to 0.05 mmol/l); and (3) offspring bone mass in observational studies judged to be of good quality, but which did not permit meta-analysis. The evidence base was insufficient to reliably answer questions 4 and 5.

LIMITATIONS

Study methodology varied widely in terms of study design, population used, vitamin D status assessment, exposure measured and outcome definition.

CONCLUSIONS

The evidence base is currently insufficient to support definite clinical recommendations regarding vitamin D supplementation in pregnancy. Although there is modest evidence to support a relationship between maternal 25(OH)D status and offspring birthweight, bone mass and serum calcium concentrations, these findings were limited by their observational nature (birthweight, bone mass) or risk of bias and low quality (calcium concentrations). High-quality randomised trials are now required.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001426.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Chemoprevention of respiratory-tract neoplasia in the hamster by oltipraz, alone and in combination

Two doses of oltipraz (300, 600 mg/kg diet) and alpha-difluoromethylornithine DFMO; 1600, 3200 mg/kg diet), alone and in combinations with N-(4-hydroxyphenyl) retinamide (4-HPR; 98, 196 mg/kg diet) and/or beta-carotene (3, 1.5 mg; sc, 2x/week), were investigated for prevention of hamster respiratory carcinogenesis. After 25 weeks, only high dose oltipraz (-100%) inhibited the incidence of DEN-induced (17.8 mg/kg BW, sc, 2x/week, 20 weeks) bronchial carcinomas when given alone. Low dose oltipraz (-34%, n.s.) synergistically decreased carcinoma incidence in combinations with 4-HPR (-80%), beta-carotene (-90%) or both (-100%). Other effective combinations were low dose DFMO + beta-carotene (-64%) and high dose DFMO with 4-HPR (-56%), beta-carotene (-63%) or both (-67%).

Expression, crystallization and preliminary X-ray studies of the PDZ domain of Dishevelled protein

Dishevelled (Dsh) protein is an important component of the Wnt signal-transduction pathway. It has three relatively conserved domains: DIX, PDZ and DEP. The PDZ domain of the Xenopus laevis homolog of Dsh, which consists of residues 254-348, was overexpressed as a soluble protein in Escherichia coli, purified and crystallized. The crystals were obtained by the vapor-diffusion method, using 1.4 M sodium formate as a precipitant. The crystals diffracted to 2.3 A resolution. The space group was determined to be P6(1)22 or P6(5)22, with unit-cell dimensions a = b = 95.9, c = 93.9 A.

IgG reactivities against recombinant Rhoptry-Associated Protein-1 (rRAP-1) are associated with mixed Plasmodium infections and protection against disease in Tanzanian children

A cross-sectional sero-epidemiological study was performed in Magoda, Tanzania, an area where malaria is holoendemic. Blood samples were collected from children (1-4 years) and tested for IgG antibody reactivity against 2 recombinant protein fragments of Plasmodium falciparum Rhoptry-Associated Protein-1 (rRAP-1). The data were related to the prevalence of malarial disease and single P. falciparum or mixed Plasmodium infections. Fever (> or = 37.5 degrees C) in combination with parasite densities > 5000/microliter were used to distinguish between children with asymptomatic malaria infections and those with acute clinical disease. Furthermore, C-reactive protein (CRP) was applied as a surrogate marker of malaria morbidity. The prevalence of Plasmodium infections was 96.0%. Eleven children were defined as clinical malaria cases, all with single P. falciparum infections. The density of P. falciparum was significantly lower in children with mixed Plasmodium infections compared to those with single P. falciparum infections. Children with asymptomatic P. falciparum infections had higher IgG reactivities to rRAP-1, compared to IgG reactivities of children with malarial disease. Children with mixed Plasmodium infections generally showed elevated IgG reactivity to rRAP-1, when compared to children with single P. falciparum infections. The possible relationship between mixed species infections, clinical outcome of the disease and antibody responses to RAP-1 is discussed.

Stress response decreases the interleukin-1beta-induced production of complement component C3 in human intestinal epithelial cells

Interleukin-1beta (IL-1beta) increases the production of complement component C3 in enterocytes. Heat shock regulates the response to cytokines and other inflammatory mediators in various cell types. We tested the hypothesis that the heat-shock response regulates IL-1beta-induced C3 production in the enterocyte. Cultured Caco-2 cells, a human intestinal epithelial cell line, were treated with sodium arsenite (10-500 microM) for 1 h or subjected to hyperthermia (43 degrees C) for 1-4 h, and allowed to recover for 1 h. The cells were then treated with IL-1beta (0.5 ng/ml) for up to 24 h, whereafter C3 levels were measured by ELISA and C3 mRNA by Northern blot analysis. Heat-shock protein of 72 kDa (hsp72) was determined by Western blot analysis. Treatment of the cells with sodium arsenite or subjecting them to hyperthermia induced the expression of hsp72. The IL-1beta-induced expression of C3 mRNA and C3 production were down-regulated by hyperthermia and sodium arsenite in a dose-dependent fashion. The results suggest that the stress response induced by hyperthermia or sodium arsenite decreases IL-1beta-induced C3 production in human enterocytes.

Nuclear factor-kappaB is activated in intestinal mucosa during endotoxemia

BACKGROUND

The transcription factor nuclear factor-kappaB (NF-kappaB) regulates a large number of genes involved in the inflammatory response to critical illness. The intestinal mucosa plays an active role in the inflammatory and metabolic response to sepsis and endotoxemia, but it is not known if NF-kappaB is activated in the mucosa during these conditions.

OBJECTIVE

To test the hypothesis that endotoxemia in mice activates NF-kappaB in intestinal mucosa.

METHODS

Mice were injected subcutaneously with lipopolysaccharide, 12.5 mg/kg, or a corresponding volume of saline. At various intervals following injection, jejunal mucosa was harvested and nuclear and cytoplasmic fractions were prepared. The nuclear fractions were analyzed by electrophoretic mobility shift assay for NF-kappaB activation and by Western blot analysis for the NF-kappaB subunits p50 and p65. Cytoplasmic fractions were analyzed by Western blotting for the NF-kappaB inhibitory proteins IkappaB-alpha and IkappaB-beta.

RESULTS

Electrophoretic mobility shift assay showed that NF-kappaB was activated in jejunal mucosa 1 hour after injection of lipopolysaccharide and persisted for at least 4 hours. The NF-kappaB subunits p50 and p65 were present in nuclear fractions of mucosa from endotoxemic mice at the corresponding time points. Cytoplasmic levels of the inhibitory proteins IkappaB-alpha and IkappaB-beta decreased during endotoxemia, and the proteins were nearly absent 60 minutes after injection of lipopolysaccharide.

CONCLUSIONS

The results suggest that IkappaB is degraded and NF-kappaB is activated in intestinal mucosa during endotoxemia. The findings support the concept that the intestinal mucosa is an important component of the inflammatory response to sepsis and endotoxemia.

Complement C3 production in human intestinal epithelial cells is regulated by interleukin 1beta and tumor necrosis factor alpha

BACKGROUND

Sepsis and endotoxemia are associated with increased mucosal production of complement component C3; the enterocyte may be a source of C3 in these conditions.

OBJECTIVE

To test the hypothesis that interleukin 1beta (IL-1beta) and tumor necrosis factor alpha (TNF-alpha) regulate the production of C3 in the enterocyte at the transcriptional level and that this regulation is potentiated by interferon gamma (IFN-gamma).

METHODS

Cultured Caco-2 cells, a human intestinal epithelial cell line, were treated with various concentrations of human recombinant IL-1beta (0.005-1.25 ng/mL) or TNF-alpha (1-1000 U/mL) with or without the addition of IFN-gamma (250 U/mL). C3 levels in the culture medium were measured by enzyme-linked immunosorbent assay and cellular messenger RNA levels by Northern blot analysis.

RESULTS

Treatment of the Caco-2 cells with IL-1beta or TNF-alpha resulted in a time- and dose-dependent increase in C3 production. The use of IFN-gamma alone did not affect C3 production but potentiated the effect of IL-1beta and TNF-alpha in a synergistic manner. C3 messenger RNA levels were increased following stimulation with either cytokine.

CONCLUSIONS

C3 production in the enterocyte is regulated by IL-1beta and TNF-alpha at the transcriptional level, and this response is potentiated by IFN-gamma. The results suggest that C3 production in the intestinal mucosa may be regulated locally by cytokines in a paracrine or autocrine manner.

Influence of owner personality type on expression and treatment outcome of dominance aggression in dogs

OBJECTIVE

To determine the success rate of positive training methods and behavioral modification techniques in dogs with dominance aggression and to compare personality profiles between owners of dominant-aggressive and nondominant dogs.

DESIGN

Prospective clinical study.

ANIMALS

10 dominant-aggressive dogs and 10 non-dominant, nonaggressive control dogs.

PROCEDURE

Dominance aggression was quantified, using an aggression score, in the 10 dominant dogs before and after a nonconfrontational behavior modification program. The personality profile of the owners of dominant and control dogs, assessed by means of a Keirsey temperament sorter, was compared, as was the influence of owner personality on the outcome of behavioral modification in the dominant dogs.

RESULTS

9 of 10 dominant dogs responded to the nonconfrontational treatment program by a decrease in aggressive response to similar eliciting stimuli. Significant differences were not found between the personality of the owners of dominant versus control dogs, and owner personality did not significantly affect the outcome of behavior modification treatment.

CLINICAL IMPLICATIONS

Nonconfrontational behavior modification programs are effective in reducing owner-directed dominance aggression in dogs. Owner personality does not necessarily predispose certain individuals to assaults by dominant dogs or profoundly affect their ability to engage in a successful behavioral modification program.

Organic Electroluminescent Devices

Electroluminescence from organic materials has the potential to enable low-cost, full-color flat-panel displays, as well as other emissive products. Some materials have now demonstrated adequate efficiencies (1 to 15 lumens/watt) and lifetimes (>5000 hours) for practical use; however, the factors that govern lifetime remain poorly understood. This article provides a brief review of device principles and applications requirements and focuses on the understanding of reliability issues.

Combined third-generation implantable cardioverter defibrillator with permanent unipolar pacemakers: preliminary observations

As implantable cardioverter defibrillators (ICDs) are strictly contraindicated in the presence of unipolar pacemakers, currently available options in patients having such chronic pacing systems include: abandoning the implanted pacemaker and selecting an ICD with ventricular demand (VVI) pacing; or replacing the chronic (dual chamber) unipolar pacing system with a dedicated bipolar version prior to ICD implantation. In three patients with previously implanted unipolar pacemakers, we challenged the premise that all ICD systems are incompatible by combining with a third-generation transvenous ICD system (Medtronic 7217B PCD) incorporating true bipolar sensing, a self-limiting auto-adjusting sensitivity, and a tolerant VF detection algorithm. The potential for pacemaker-ICD interaction was minimized by separating the tip of the ICDs transvenous right ventricular pace/sense-defibrillation coil lead from that of the chronic pacemaker lead by > or = 2-3 cm, and by performing "worst case" intraoperative testing. Although ICD double-counting of the dual chamber pacemaker's atrial and ventricular pacing spikes could be provoked at extreme high output settings, it did not occur at clinically appropriate settings. More importantly, continuous high output asynchronous pacing during ventricular fibrillation (VF) did not interfere with ICD detection. During a mean follow-up period of 18 months, one patient has had VF appropriately terminated by the ICD. In the remaining two patients, proper VF detection and ICD function was reassessed at 3 months and/or at 1 year during noninvasive testing.

CONCLUSION

These preliminary findings demonstrate that this transvenous ICD system's VF sensing and detection features combined with careful implant technique, rigorous "worst case" testing for possible pacemaker-ICD interaction with regular follow-up, may permit implantation of this ICD system in patients with chronic unipolar pacing systems. Further studies are needed to validate the long-term clinical safety of this promising revised approach to a currently contraindicated device combination.

Settings as an important dimension in health education/promotion policy, programs, and research

Settings--community, worksite, schools, and healthcare sites--constitute an important dimension of health education/health promotion policy and programs and for research about program needs, feasibility, efficacy, and effectiveness. These settings vary in the extent of coverage of and relationships with their respective constituencies, valued outcomes, and quantity and quality of evidence about the effectiveness of setting-specific and cross-setting programs. Main sources of evidence for program efficacy and effectiveness are summarized, leading to the conclusion that strides have been made toward building a strong evidentiary base for health education/health promotion in these settings. Gaps in research exist, especially for diffusion of effective programs, new technologies, the influence of policy, relations between settings, and approaches to marginal and special subgroups. Recommendations are offered for cross-setting and within-setting research related to intervention.

Distribution of epidermal growth-factor receptors in normal and neoplastic mammary tissues

Epidermal growth factor (EGF) is considered to be mitogenic for proliferation of mammary glands in animals. The action of EGF is mediated by specific EGF receptors (EFG-R). In the present study, we investigated distribution of EGF receptors during various physiological stages of mammary glands, N-methyl-N-nitrosourea (MNU)-induced mammary tumors in rats and human breast cancer samples. EGF receptor concentrations were determined by Scatchard analyses in the membrane fraction of the tissues. Results showed increased EGF receptor levels in the structurally differentiated mammary tissues from pregnant rats; whereas lower concentrations were observed in the functionally differentiated glands from lactating rats. EGF receptors were absent in the majority of the tumors induced by MNU. The loss of EGF receptor was not observed during the first 20 days post carcinogen treatment, but appeared to be correlated with the onset of the tumor. Consistent with the literature, the majority of the steroid receptor positive human breast cancer samples were EGF receptor negative, whereas steroid receptor negative samples contained EGF receptors. These results suggest that the loss of EGF receptors in ovarian hormone dependent mammary tumors does not occur gradually during carcinogenesis but appears to be a characteristic of hormone dependent mammary tumor cells.

Flavonoids as DNA topoisomerase antagonists and poisons: structure-activity relationships

Selected flavonoids were tested for their ability to inhibit the catalytic activity of DNA topoisomerase (topo) I and II. Myricetin, quercetin, fisetin, and morin were found to inhibit both enzymes, while phloretin, kaempferol, and 4',6,7-trihydroxyisoflavone inhibited topo II without inhibiting topo I. Flavonoids demonstrating potent topo I and II inhibition required hydroxyl group substitution at the C-3, C-7, C-3', and C-4' positions and also required a keto group at C-4. Additional B-ring hydroxylation enhanced flavonoid topo I inhibitory action. A C-2, C-3 double bond was also required, but when the A ring is opened, the requirement for the double bond was eliminated. Genistein has been previously reported to stabilize the covalent topo II-DNA cleavage complex and thus function as a topo II poison. All flavonoids were tested for their ability to stabilize the cleavage complex between topo I or topo II and DNA. None of the agents stabilized the topo I-DNA cleavage complex, but prunetin, quercetin, kaempferol, and apigenin stabilized the topo II DNA-complex. Competition experiments have shown that genistein-induced topo II-mediated DNA cleavage can be inhibited by myricetin, suggesting that both types of inhibitors (antagonists and poisons) interact with the same functional domain of their target enzyme. These results are of use for the selection of flavonoids that can inhibit specific topoisomerases at specific stages of the topoisomerization reaction.

The dietary anticancer agent ellagic acid is a potent inhibitor of DNA topoisomerases in vitro

Ellagic acid and 12 related agents have been tested for their ability to inhibit the activities of human DNA topoisomerase (topo) I and II. Using specific in vitro assays, we found ellagic acid and flavellagic acid to be potent inhibitors of the catalytic activities of the two topoisomerases. The minimum concentration required to inhibit > or = 50% of catalytic activity (IC50) of ellagic acid was determined at 0.6 and 0.7 micrograms/ml for topo I and topo II, respectively. Flavellagic acid's IC50 was determined at 3.0 and 3.6 micrograms/ml for topo I and topo II, respectively. Unlike topoisomerase poisons, these two plant phenols did not trap the enzyme-DNA reaction intermediate, known as the cleavable complex. In contrast, ellagic acid prevented other topo I and topo II poisons from stabilizing the cleavable complex, suggesting that the mode of its action is that of an antagonist. Structure-activity studies identified the 3,3'-hydroxyl groups and the lactone groups as the most essential elements for the topoisomerase inhibitory actions of plant phenols. On the basis of these findings and other properties of ellagic acid, a mechanistic model for the documented anticarcinogenic effects of the agent is proposed.

Tumour necrosis factor and interleukin-6 production induced by components associated with merozoite proteins of Plasmodium falciparum

P. falciparum merozoite antigens, merozoite surface protein-1 (MSP-1) and rhoptry associated protein-1 (RAP-1), were shown to be liberated into the supernatant of in vitro parasite cultures and to be included in the endotoxin-like exoantigen complex, previously designated Ag7. Material affinity purified from culture supernatants, using immobilized monoclonal antibodies specific for RAP-1 or MSP-1, stimulated normal human mononuclear cells to produce TNF and IL-6 in vitro. However, stimulation of TNF was absent, and that of IL-6 was reduced, when the antigens were purified from detergent extracts of infected erythrocytes. These results indicate that the RAP-1 and MSP-1 proteins themselves do not stimulate the production of TNF. Instead, other components associating with these exoantigens may be responsible for the TNF production. Mouse antisera blocking TNF production stimulated by P. yoelii exoantigens also blocked TNF production stimulated by material affinity purified from P. falciparum culture supernatants using RAP-1 specific monoclonal antibody, indicating the conserved structure of the TNF inducing component.

Adjunctive hyperbaric oxygen for treatment of rhinocerebral mucormycosis

The therapy of rhinocerebral mucormycosis includes aggressive surgical debridement, administration of high-dose amphotericin B, and control of underlying predisposing conditions, especially diabetes and immunosuppression or immunodeficiency. Hyperbaric oxygen suppresses fungal growth in vitro and has theoretical value in treating mucormycosis because it reduces the tissue hypoxia and acidosis that accompany vascular invasion by the fungus. In a retrospective review of patients at Duke University Medical Center with rhinocerebral mucormycosis, six patients were treated with hyperbaric oxygen and seven cases (involving six patients) were treated without hyperbaric oxygen. All patients received surgical debridement and amphotericin B. Two of six patients receiving hyperbaric oxygen therapy died, and four of seven patients not receiving hyperbaric oxygen therapy died. Adverse effects from hyperbaric oxygen were minimal. Because mucormycosis occurs infrequently, this retrospective review involved a small number of patients. Despite this limitation, adjunctive hyperbaric oxygen appears to be a promising clinical modality for the treatment of rhinocerebral mucormycosis and warrants further investigation.

Enalapril maleate and atenolol combined with hydrochlorothiazide in moderate to severe essential hypertension

This open randomised parallel trial compared the antihypertensive efficacy of enalapril and atenolol given alone once a day or with hydrochlorothiazide in 20 patients with moderate to severe hypertension. Active treatment was over a 26 week period, consisting of an initial titration phase followed by a fixed dose phase. Both treatment regimes effectively lowered systolic and diastolic blood pressures. All patients on enalapril reached normotension (supine diastolic blood pressure less than or equal to 90 mmHg) compared with 78% on atenolol. Pulse rate was not appreciably changed by enalapril, but was significantly reduced by atenolol. No serious adverse reactions or significant changes in laboratory values were noted in either group. The commonest adverse reaction with enalapril was dizziness which occurred in two cases and resolved on dosage reduction. Enalapril with hydrochlorothiazide given once daily may provide a useful combination in the treatment of moderate to severe hypertension.