Trypanosomiasis: An emerging disease in Alpine swift (Tachymarptis melba) nestlings in Switzerland?

Alpine swifts (Tachymarptis melba) are sub-Saharan migratory birds, which, in Switzerland, nest in colonies that have been continuously monitored for over 40 years. In the summer of 2022, despite favourable environmental conditions, an unexpectedly high number of sudden mortalities (30-80%) occurred in 20 to 45-day-old nestlings from several nesting sites, of which 3 were monitored in detail. Nestlings submitted for post-mortem analysis (n = 5) were in good body condition but exhibited extensive subcutaneous haematomas (n = 5), myocardial petechiae (n = 2) and stunted growth of primary feathers (n = 1). In all birds, 4-5 μm large, amastigote-like protozoans were identified in skeletal and cardiac muscle sections. These tissues tested positive in a PCR targeting the 18S-rRNA gene of Trypanosoma spp. Amplified sequences showed 99.63% identity with sequences of Trypanosoma corvi (JN006854 and AY461665) and Trypanosoma sp. (AJ620557, JN006841). 72 blood smears of 45-day-old nestlings from two colonies were assessed, of which 20 contained trypomastigote forms, some with high parasitaemia (highest average of 56.4 in 10 high power fields, 400x magnification). Trypomastigote morphometrics (n = 36; mean total length = 30.0 μm; length of free flagellum = 5.8 μm) were consistent with those of T. bouffardi. These findings suggest that an avian trypanosomiasis causing mass nestling mortality could be an emerging disease in Swiss Alpine swift populations.

Patient Perspectives of Skeletal Muscle Cramping in Dialysis: A Focus Group Study

Key Points

This first step demonstrated content validity for a patient-reported outcome measure for skeletal muscle cramping in dialysis. This work lays the foundation for developing a patient-reported outcome measure for regulatory use to assess skeletal muscle cramping in people receiving dialysis.

Background

Skeletal muscle cramping is a common, painful, and debilitating symptom experienced by people receiving dialysis. Neither a standardized, patient-endorsed definition of skeletal muscle cramping nor full understanding of patients' perspectives of skeletal muscle cramping exist. We conducted focus groups, within a Kidney Health Initiative (KHI) project, to elicit skeletal muscle cramping experiences of people receiving dialysis as the basis for patient-reported outcome measure (PROM) development.

Methods

Eligible participants (English-speaking adults aged 18–85 years treated by dialysis and a skeletal muscle cramping episode within 30 days) were purposively recruited from a panel (L&E Research) of people receiving dialysis at home or in-center. Standard qualitative methods were used to conduct virtual 90-minute sessions discussing the following: skeletal muscle cramping clinical characteristics, participants' skeletal muscle cramping experiences, and feedback on a draft skeletal muscle cramping definition and a patient-facing conceptual model developed by the KHI project workgroup. We used qualitative thematic analysis.

Results

There were 20 diverse participants in three focus groups. Universally experienced skeletal muscle cramping attributes differed by dialysis setting in onset, worst pain rating, duration, and timing. Variably experienced attributes (applied to home and in-center dialysis) were gross and fine motor effect, sleep disruption, mood-related themes of fear, and annoyance/frustration/irritability. Avoidance/adaptive behaviors included reluctance or avoiding movement, adjusting what they ate or drink (e.g. , yellow mustard, pickles, pickle juice, and tonic water), heat application, massage, and cannabidiol use. The skeletal muscle cramping definition was endorsed, and insightful suggestions for conceptual model were collected.

Conclusions

This qualitative study of in-center and home patients' skeletal muscle cramping experiences identified universally and variably experienced attributes. The patient-endorsed skeletal muscle cramping definition can serve as a standard for assessment. These results provide the foundation to develop a PROM for regulatory use with people receiving maintenance dialysis who experience skeletal muscle cramping.

Differential Item Functioning of the Jaw Functional Limitation Scale

AIMS

To assess the differential item functioning (DIF) of the Jaw Functional Limitation Scale (JFLS) due to gender, age, and language (English vs Spanish).

METHODS

JFLS data were collected from a consecutive sample of 2,115 adult dental patients from HealthPartners dental clinics in Minnesota. Participants with missing data were excluded, and analyses were performed using data from 1,678 participants. Whether the item response theory (IRT) model assumptions of essential unidimensionality and local independence held up for the JFLS was examined. Then, using Samejima's graded response model, the IRT log-likelihood ratio approach was used to detect DIF. The magnitude and impact of DIF based on Raju's noncompensatory DIF (NCDIF) cutoff value of 0.096, Cohen's effect sizes, and test (or scale) characteristic curves were also assessed.

RESULTS

Essential unidimensionality was confirmed, but locally dependent items were found on the JFLS. A few items were flagged with statistically significant DIF after adjustment for multiple comparisons. The NCDIF indices associated with all DIF items were < 0.096, and they had small effect sizes of ≤ 0.2. The differences between the expected scores shown in the test characteristic curves were little to none.

CONCLUSION

The present results support the use of the JFLS summary score to obtain psychometrically robust score comparisons across English- and Spanish-speaking, male and female, and younger and older dental patients. Overall, the magnitude of DIF was relatively small, and the practical impact minimal.

Conceptual Framework for Patient-Reported Outcome Measures in Clinical Trials of Skeletal Muscle Cramping Experienced in Dialysis: A Kidney Health Initiative Workgroup Report

Skeletal muscle cramping is a common and bothersome symptom for patients on maintenance dialysis therapy, regardless of modality, and it has not been prioritized for innovative assessments or treatments. Research to prevent or treat skeletal muscle cramping in patients receiving dialysis is hindered by poorly understood pathophysiology, lack of an accepted definition, and the absence of a standardized measurement method. The Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a multidisciplinary workgroup to define a set of patient-reported outcome measures for use in clinical trials to test the effect of new dialysis devices, new KRTs, lifestyle/behavioral modifications, and medications on skeletal muscle cramping. Upon determining that foundational work was necessary, the workgroup undertook a multistep process to elicit concepts central to developing the basis for demonstrating content validity of candidate patient-reported outcome measures for skeletal muscle cramping in patients on dialysis. The workgroup sought to (1) create an accepted, patient-endorsed definition for skeletal muscle cramping that applies to all dialysis modalities, (2) construct a conceptual model for developing and evaluating a skeletal muscle cramping-specific patient-reported outcome measure, and (3) identify potential questions from existing patient-reported outcome measures that could be modified or adapted and subsequently tested in the dialysis population. We report the results of the workgroup's efforts, provide our recommendations, and issue a call to action to address the gaps in knowledge and research needs we identified. These action steps are urgently needed to quantify skeletal muscle cramping burden, assess the effect, and measure meaningful changes of new interventions to improve the experience of patients receiving dialysis and suffering from skeletal muscle cramping.

Comparison of two rating scales with the orofacial esthetic scale and practical recommendations for its application

Purpose

We compared measurement properties of 5-point and 11-point response formats for the orofacial esthetic scale (OES) items to determine whether collapsing the format would degrade OES score precision.

Methods

Data were collected from a consecutive sample of adult dental patients from HealthPartners dental clinics in Minnesota (N = 2,078). We fitted an Item Response Theory (IRT) model to the 11-point response format and the six derived 5-point response formats. We compared all response formats using test (or scale) information, correlation between the IRT scores, Cronbach’s alpha estimates for each scaling format, correlations based on the observed scores for the seven OES items and the eighth global item, and the relationship of observed and IRT scores to an external criterion using orofacial appearance (OA) indicators from the Oral Health Impact Profile (OHIP).

Results

The correlations among scores based on the different response formats were uniformly high for observed (0.97–0.99) and IRT scores (0.96–0.99); as were correlations of both observed and IRT scores and the OHIP measure of OA (0.66–0.68). Cronbach’s alpha based on any of the 5-point formats (α = 0.95) was nearly the same as that based on the 11-point format (α = 0.96). The weighted total information area for five of six derived 5-point response formats was 98% of that for the 11-point response format.

Conclusions

Our results support the use of scores based on a 5-point response format for the OES items. The measurement properties of scores based on a 5-point response format are comparable to those of scores based on the 11-point response format.

Patient-Reported Outcome Measures for Individuals with Temporomandibular Disorders: A Systematic Review and Evaluation

OBJECTIVE

We used consensus-based, systematic protocols to evaluate the reliability and validity of patient-reported outcome measures (PROMs) for use in documenting treatment outcomes for temporomandibular disorders (TMDs).

STUDY DESIGN

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we conducted a focused search of 5 literature databases resulting in a yield of 445 articles that qualified for full-text review. Our review identified 124 PROMs, from which we selected 19 directly related to symptoms of TMD including temporomandibular joint (TMJ) function.

RESULTS

We abstracted data on 9 Consensus-based Standards of the selection of health Measurements INstruments (COSMIN) measurement properties and analyzed these data according to COSMIN criteria. Only 3 PROMs provided evidence for at least half of the COSMIN properties: Eight-item Jaw Function Limitations Scale, Oral Health Impact Profile (OHIP)-TMD (OHIP-TMD), and TMJ Ankylosis Specific Quality of Life Questionnaire. Only the OHIP-TMD provided evidence for properties essential to evaluating change over time: reliability, measurement error, and responsiveness.

CONCLUSION

We believe these results can alert clinical practitioners to gaps in our knowledge about the most widely used PROMs in TMD practice, and identify topics requiring further study for clinical researchers.

Assessing sleep and pain among adults with myalgic encephalomyelitis/chronic fatigue syndrome: psychometric evaluation of the PROMIS® sleep and pain short forms

PURPOSE

To evaluate the psychometric properties of the patient-reported outcome measurement information system® (PROMIS) short forms for assessing sleep disturbance, sleep-related impairment, pain interference, and pain behavior, among adults with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).

METHODS

Data came from the Multi-Site ME/CFS study conducted between 2012 and 2020 at seven ME/CFS specialty clinics across the USA. Baseline and follow-up data from ME/CFS and healthy control (HC) groups were used to examine ceiling/floor effects, internal consistency reliability, differential item functioning (DIF), known-groups validity, and responsiveness.

RESULTS

A total of 945 participants completed the baseline assessment (602 ME/CFS and 338 HC) and 441 ME/CFS also completed the follow-up. The baseline mean T-scores of PROMIS sleep and pain measures ranged from 57.68 to 62.40, about one standard deviation above the national norm (T-score = 50). All four measures showed high internal consistency (ω = 0.92 to 0.97) and no substantial floor/ceiling effects. No DIF was detected by age or sex. Known-groups comparisons among ME/CFS groups with low, medium, and high functional impairment showed significant small-sized differences in scores (η² = 0.01 to 0.05) for the two sleep measures and small-to-medium-sized differences (η² = 0.01 to 0.15) for the two pain measures. ME/CFS participants had significantly worse scores than HC (η² = 0.35 to 0.45) for all four measures. Given the non-interventional nature of the study, responsiveness was evaluated as sensitivity to change over time and the pain interference measure showed an acceptable sensitivity.

CONCLUSION

The PROMIS sleep and pain measures demonstrated satisfactory psychometric properties supporting their use in ME/CFS research and clinical practice.

LB0002 BARICITINIB IN JUVENILE IDIOPATHIC ARTHRITIS: A PHASE 3, DOUBLE-BLIND, PLACEBO-CONTROLLED, WITHDRAWAL, EFFICACY AND SAFETY STUDY

Background

Baricitinib is a JAK1/2 selective inhibitor approved for the treatment of rheumatoid arthritis. Juvenile idiopathic arthritis (JIA) is a group of diseases characterized by immune mediated chronic arthritis which often requires treatment with conventional synthetic or biologic disease-modifying antirheumatic drugs (cs or b-DMARDs).

Objectives

To investigate baricitinib efficacy and safety in pediatric patients with JIA and an inadequate response to cs or b-DMARDs.

Methods

This Phase 3 multicenter, double-blind, withdrawal, efficacy, and safety study, enrolled patients (pts) age 2 to <18 years with extended oligo- or poly-articular JIA, ERA, or JPsA, per ILAR criteria, and an inadequate response to ≥1 cs and/or b-DMARDs (NCT03773978). There were 3 periods: a 2-week (wk) pharmacokinetic/safety assessment (PKS), a 12-wk open-label lead-in (OLLI), and an up-to 32-wk double-blind withdrawal (DBW). Dosage and safety were confirmed in the PKS and then pts, including those from the PKS, enrolled in the OLLI, receiving age-based, oral, once daily doses of baricitinib. Pts with a JIA-ACR30 response at wk12, end of OLLI, entered the DBW to be randomized 1:1 to continued baricitinib or newly started placebo (PBO) and remained until flare or up to wk32. Primary endpoint was time to flare during the DBW. Secondary endpoints included JIA-ACR30/50/70/90 response rates at wk12, and proportion of pts with a flare during the DBW. Survival curves were estimated using the Kaplan-Meier method.

Results

Of 220 pts enrolled, 29 participated in the PKS, 219 entered the OLLI, and 163 entered the DBW. The JIA-ACR30/50/70/90 response at wk12 was 76.3%/63.5%/46.1%/20.1%, respectively. During the DBW, time of flare was significantly shorter with PBO vs baricitinib (hazard ratio 0.24 [95% CI 0.13,0.45], p<0.001; Figure 1). The proportion of pts with a flare during the DBW was significantly lower for baricitinib vs PBO (14 (17.1%) vs. 41 (50.6%), p<0.001). In the PKS and OLLI periods, 126 (57.3%) pts reported ≥1 treatment emergent adverse event (TEAE), while 6 (2.7%) reported ≥1 serious adverse event (SAE); Table 1. In the DBW, 38 (46.9%) and 54 (65.9%) pts reported ≥1 TEAE for PBO and baricitinib, respectively, whereas those with ≥1 SAE were 3 (3.7%) and 4 (4.9%). The mean wks of exposure was higher in the baricitinib vs PBO group during DBW (26.34 vs 18.91) due to study design. There were no deaths, cardiovascular events or uveitis and 1 case of herpes zoster. Table 1.

Conclusion

Baricitinib significantly reduced time to and frequency of JIA flares in pts with JIA versus PBO, and improved JIA-ACR scores in the majority of pts within 12wks. Safety findings were consistent with the known safety profile in adult rheumatoid arthritis indications. These findings support baricitinib as a treatment for signs and symptoms of JIA with an inadequate response to cs or b-DMARDs.

References

[1]Giannini EH, et. al. Preliminary definition of improvement in juvenile arthritis. Arthritis Rheum 1997; 40: 1202-1209.

[2]Brunner HI, et. al. Preliminary definition of disease flare in juvenile rheumatoid arthritis. J Rheumatol 2002; 29(5):1058-64.

Disclosure of Interests

Athimalaipet Ramanan Consultant of: Eli Lilly and Company, Abbvie, Roche, UCB, Novartis, Pfizer, and Sobi, Grant/research support from: Eli Lilly and Company, Pierre Quartier Consultant of: Eli Lilly and Company, Abbvie, Amgen, BMS, Novartis, Novimmune, Pfizer, Swedish Orphan Biovitrum, SANOFI, Speakers bureau: Abbvie, Novartis, Pfizer, Swedish Orphan Biovitrum, Nami Okamoto Consultant of: Swedish Orphan Biovitrum, Eli Lilly and Company, Speakers bureau: AbbVie, Eli Lilly and Company, Sanofi, Asahi Kasei Medical, Mitsubishi Tanabe Pharma, Bristol Myers Squibb, Pfizer Japan, Ayumi Pharma, Eisai, Torii Pharma, GlaxoSmithKline, Kyorin Pharma, Novartis, Chugai Pharmaceutical, Teijin Pharma, Gabriella Meszaros Employee of: Eli Lilly and Company, Joana Araujo Employee of: Eli Lilly and Company, Zhongkai Wang Employee of: Eli Lilly and Company, Ran Liao Employee of: Eli Lilly and Company, Brenda Crowe Employee of: Eli Lilly and Company, Xin Zhang Employee of: Eli Lilly and Company, Rodney Decker Employee of: Eli Lilly and Company, Stuart Keller Employee of: Eli Lilly and Company, Hermine Brunner Consultant of: AbbVie, Astra Zeneca-Medimmune, Biogen, Boehringer, Bristol-Myers Squibb, Celgene, Eli Lilly, EMD Serono, Idorsia, Cerocor, Janssen, GlaxoSmithKline, F. Hoffmann-La Roche, Merck, Novartis, R-Pharm, Sanofi, Speakers bureau: Novartis, Pfizer, GlaxoSmithKline, Nicolino Ruperto Consultant of: Eli Lilly and Company, Ablynx, Amgen, Astrazeneca-Medimmune, Aurinia, Bayer, Bristol Myers and Squibb, Cambridge Healthcare Research (CHR), Celgene, Domain therapeutic, Eli-Lilly, EMD Serono, Glaxo Smith and Kline, Idorsia, Janssen, Novartis, Pfizer, Sobi, UCB, Speakers bureau: Eli Lilly and Company, Glaxo Smith and Kline, Pfizer, Sobi, UCB

Should the frequency, severity, or both response scales be used for multi-item dental patient-reported outcome measures?

BACKGROUND

The Oral Impacts on Daily Performances (OIDP) index asks the respondents to indicate both, the frequency and severity of the impact. However, it is not clear if the two scaling methods are correlated, and if using one scale is sufficient. The purpose of the study was to investigate the correlation between frequency and severity rating scales of the OIDP instrument, and whether only one of the rating scales can be used instead of both.

METHODS

A battery of patient-reported outcome questionnaires were administered to a consecutive sample of adult dental patients from HealthPartners dental clinics in Minnesota (N = 2,115). Only those who responded to any of the OIDP items were included in the analysis for this study (N = 873). We assessed correlations between the frequency and severity scales for all OIDP items, and for the summary scores of the two OIDP response scales. We additionally fit a categorical structural equation model (SEM) (or an item factor analysis model) and examined the correlation between two latent variables (Frequency and Severity).

RESULTS

The correlation estimates for all OIDP items were greater than 0.50, indicating large correlations between the frequency and severity scores for each OIDP item. The correlation estimate between the two summary scores was 0.85 (95% CI [0.82-0.86]). When we calculated the correlation coefficient using a latent variable model, the value increased to 0.96 (95% CI [0.93-1.00]).

CONCLUSION

Our study findings show that OIDP frequency and severity scores are highly correlated, which indicates the use of one scale only. Based on previous evidence, we recommend applying the frequency rating scale only in research and clinical settings.

Unravelling caramelization and Maillard reactions in glucose and glucose + leucine model cakes: Formation and degradation kinetics of precursors, α-dicarbonyl intermediates and furanic compounds during baking

Understanding the mechanisms leading to the multitude of newly-formed compounds generated during the thermal processing of food is important for the reasoned construction of quality. Thanks to a solid food model with a structure and technological history comparable to that of a real sponge cake and containing only known amounts of precursors (glucose with or without leucine), an adapted reaction scheme unravelling Maillard and caramelization reactions was built and then compared to experimental kinetic data measured on numerous reaction markers (precursors, α-dicarbonyl intermediates and furanic compounds). For caramelization, this study showed that glucose mainly formed 1,2-enediol and then fructose rather than glucosone and glyoxal. 5-hydroxymethylfurfural started to form when there were sufficient quantities of fructose, and 3,4-dideoxyoglucosone was not generated until after this step. Furfural was mainly formed via 3-deoxyglucosone. The involvement of leucine tended to accelerate the breakdown of sugars as more degradation pathways (via enaminols) were added.

[Myofasciitis under nivolumab treatment]

We report the case of a 73-year-old female patient with malignant melanoma who developed rapidly progressive dermatosclerosis of the arms and legs as well as myalgia and flexion contractures during treatment with the immune checkpoint inhibitor nivolumab. The diagnosis of a myofasciitis was confirmed by imaging and biopsy. Following consultation with the treating dermato-oncologists nivolumab treatment was paused and treatment with methotrexate and prednisolone was initiated. Immune checkpoint inhibitors can induce a variety of immune-mediated side effects and can also imitate symptoms of rheumatological diseases. The occurrence of myofasciitis under immune checkpoint inhibition has been reported in the literature only in a few cases. Further oncological and rheumatological treatment management should be carried out in close interdisciplinary coordination.

Experimental Reptarenavirus Infection of Boa constrictor and Python regius

Boid inclusion body disease (BIBD) causes losses in captive snake populations globally. BIBD is associated with the formation of cytoplasmic inclusion bodies (IBs), which mainly comprise reptarenavirus nucleoprotein (NP). In 2017, BIBD was reproduced by cardiac injection of boas and pythons with reptarenaviruses, thus demonstrating a causative link between reptarenavirus infection and the disease. Here, we report experimental infections of Python regius (n = 16) and Boa constrictor (n = 16) with three reptarenavirus isolates. First, we used pythons (n = 8) to test two virus delivery routes: intraperitoneal injection and tracheal instillation. Viral RNAs but no IBs were detected in brains and lungs at 2 weeks postinoculation. Next, we inoculated pythons (n = 8) via the trachea. During the 4 months following infection, snakes showed transient central nervous system (CNS) signs but lacked detectable IBs at the time of euthanasia. One of the snakes developed severe CNS signs; we succeeded in reisolating the virus from the brain of this individual and could demonstrate viral antigen in neurons. In a third attempt, we tested cohousing, vaccination, and sequential infection with multiple reptarenavirus isolates on boas (n = 16). At 10 months postinoculation, all but one snake tested positive for viral RNA in lung, brain, and/or blood, but none exhibited the characteristic IBs. Three of the four vaccinated snakes seemed to sustain challenge with the same reptarenavirus; however, neither of the two snakes rechallenged with different reptarenaviruses remained uninfected. Comparison of the antibody responses in experimentally versus naturally reptarenavirus-infected animals indicated differences in the responses.IMPORTANCE In the present study, we experimentally infected pythons and boas with reptarenavirus via either intraperitoneal injection or tracheal instillation. The aims were to experimentally induce boid inclusion body disease (BIBD) and to develop an animal model for studying disease transmission and pathogenesis. Both virus delivery routes resulted in infection, and infection via the trachea could reflect the natural route of infection. In the experimentally infected snakes, we did not find evidence of inclusion body (IB) formation, characteristic of BIBD, in pythons or boas. Most of the boas (11/12) remained reptarenavirus infected after 10 months, which suggests that they developed a persistent infection that could eventually have led to BIBD. We demonstrated that vaccination using recombinant protein or an inactivated virus preparation prevented infection by a homologous virus in three of four snakes. Comparison of the antibody responses of experimentally and naturally reptarenavirus-infected snakes revealed differences that merit further studies.

Toward Patient-Centered Innovation: A Conceptual Framework for Patient-Reported Outcome Measures for Transformative Kidney Replacement Devices

Individuals with dialysis-dependent kidney failure experience considerable disease- and treatment-related decline in functional status and overall well-being. Despite these experiences, there have been few substantive technological advances in KRT in decades. As such, new federal initiatives seek to accelerate innovation. Historically, integration of patient perspectives into KRT product development has been limited. However, the US Food and Drug Administration recognizes the importance of incorporating patient perspectives into the total product life cycle (i.e., from product conception to postmarket surveillance) and encourages the consideration of patient-reported outcomes in regulatory-focused clinical trials when appropriate. Recognizing the significance of identifying patient-reported outcome measures (PROMs) that capture contemporary patient priorities, the Kidney Health Initiative, a public-private partnership between the American Society of Nephrology and US Food and Drug Administration, convened a workgroup to (1) develop a conceptual framework for a health-related quality of life PROM; (2) identify and map existing PROMs to the conceptual framework, prioritizing them on the basis of their supporting evidence for use in the regulatory environment; and (3) describe next steps for identifying PROMs for use in regulatory clinical trials of transformative KRT devices. This paper summarizes the proposed health-related quality-of-life PROM conceptual framework, maps and prioritizes PROMs, and identifies gaps and future needs to advance the development of rigorous, meaningful PROMS for use in clinical trials of transformative KRT devices.

Selecting Patient-Reported Outcome Measures to Contribute to Primary Care Performance Measurement: a Mixed Methods Approach

New models of primary care include patient-reported outcome measures (PROMs) to promote patient-centered care. PROMs provide information on patient functional status and well-being, can be used to enhance care quality, and are proposed for use in assessing performance. Our objective was to identify a short list of candidate PROMs for use in primary care practice and to serve as a basis for performance measures (PMs). We used qualitative and quantitative methods to identify relevant patient-reported outcome (PRO) domains for use in performance measurement (PRO-PM) and their associated PROMs. We collected data from key informant groups: patients (n = 13; one-on-one and group interviews; concept saturation analysis), clinical thought leaders (n = 9; group discussions; thematic analysis), primary care practices representatives (n = 37; six focus groups; thematic analysis), and primary care payer representatives (n = 10; 12-question survey; frequencies of responses). We merged the key informant group information with findings from environmental literature scans. We conducted a targeted evidence review of measurement properties for candidate PROMs. We used a scoping review and key informant groups to identify PROM evaluation criteria, which were linked to the National Quality Forum measure evaluation criteria. We developed a de novo schema to score candidate PROMs against our criteria. We identified four PRO domains and 10 candidate PROMs: 3 for depressive symptoms, 2 for physical function, 3 for self-efficacy, 2 for ability to participate. Five PROMs met ≥ 70% of the evidence criteria for three PRO domains: PHQ-9 or PROMIS Depression (depression), PF-10 or PROMIS-PF (physical functioning), and PROMIS Self-Efficacy for Managing Treatments and Medications (self-efficacy). The PROMIS Ability to Participate in Social Roles and Activities met 68% of our criteria and might be considered for inclusion. Existing evidence and key informant data identified 5 candidate PROMs to use in primary care. These instruments can be used to develop PRO-PMs.

Uterine expression of smooth muscle alpha- and gamma-actin and smooth muscle myosin in bitches diagnosed with uterine inertia and obstructive dystocia

Primary uterine inertia (PUI) is the most common type of dystocia in dogs. We hypothesized that PUI develops because of lower than normal expression of the basic contractile elements in the uterus, i.e., smooth muscle (SM) α- and γ-actin and SM-myosin, and that the expression of these proteins is influenced by the number of fetuses present in utero. Full-thickness inter-placental uterine biopsies were collected during Cesarean sections from dogs with PUI (n = 11), and from bitches with obstructive dystocia (OD) still presenting strong labor contractions (designated as the control group, n = 7). Relative gene expression was determined by semi-quantitative real-time (TaqMan) PCR, and protein localization by immunohistochemistry. Gene expression between PUI and OD bitches, and between PUI bitches carrying small, large, or average number of fetuses according to their breed, were compared. Uterine SM-γ-actin and SM-myosin mRNA levels were significantly higher in PUI than in OD dogs, while SM-α-actin did not differ. PUI bitches carrying large litters had lower uterine SM-γ-actin gene expression than those with small litters (P = 0.008). Immunostaining for SM-actin isoforms and SM-myosin was present in the myometrium, and localization pattern and staining intensity appeared similar in the PUI and OD groups. All proteins stained in blood vessels, and SM-γ-actin was also present in endometrial luminal and glandular epithelium. In conclusion, higher uterine SM-γ-actin and SM-myosin gene expression in PUI bitches, compared with OD dogs, might be an indication of abnormal progression with labor. Whether this is the cause of PUI due to an intrinsic error of the myometrium not becoming committed to labor, or the consequence of inadequate endocrine or mechanical stimuli, is not clear. Litter size was previously shown to be one of the risk factors for the development of uterine inertia in dogs, and our findings suggest possible differing uterine pathophysiology of PUI with respect to litter size.

Efficacy and safety of ixekizumab in a phase III, randomized, double-blind, placebo-controlled study in paediatric patients with moderate-to-severe plaque psoriasis (IXORA-PEDS)

Background

Plaque psoriasis affects children and adults, but treatment options for paediatric psoriasis are limited.

Objectives

To evaluate the efficacy and safety of ixekizumab (IXE), a high‐affinity monoclonal antibody that selectively targets interleukin‐17A, for moderate‐to‐severe paediatric psoriasis.

Methods

In a randomized, double‐blind, placebo‐controlled, phase III study (IXORA‐PEDS), patients aged 6 to < 18 years with moderate‐to‐severe plaque psoriasis were randomized 2 : 1 to weight‐based dosing of IXE every 4 weeks (IXE Q4W, n = 115) or placebo (n = 56) through week 12, followed by open‐label IXE Q4W. Coprimary endpoints were the proportions of patients at week 12 achieving ≥ 75% improvement in Psoriasis Area and Severity Index (PASI 75) and those achieving a static Physician's Global Assessment score of 0 or 1 (sPGA 0,1).

Results

IXE was superior (P < 0·001) to placebo for both coprimary endpoints of PASI 75 (IXE Q4W, 89%; placebo, 25%) and sPGA (0,1) (IXE Q4W, 81%; placebo, 11%). IXE was also superior for all gated secondary endpoints, including PASI 75 and sPGA (0,1) at week 4, improvement in itch, and complete skin clearance. IXE Q4W provided significant (P < 0·001) improvements vs. placebo in quality of life and clearance of scalp and genital psoriasis. Responses at week 12 were sustained or further improved through week 48. Through week 12, 45% (placebo) and 56% (IXE) of patients reported treatment‐emergent adverse events. One serious adverse event was reported (IXE), one patient discontinued due to an adverse event (placebo) and no deaths were reported.

Conclusions

IXE was superior to placebo in the treatment of moderate‐to‐severe paediatric psoriasis, and the safety profile was generally consistent with that observed in adults.

What is already known about this topic?

Paediatric psoriasis affects approximately 1% of children and can negatively impact health‐related quality of life.

Treatment options for paediatric psoriasis are typically limited to off‐label treatments and approved systemic biologics.

Ixekizumab, a high‐affinity monoclonal antibody that selectively targets interleukin‐17A, is approved for moderate‐to‐severe plaque psoriasis in adults and was recently approved by the US Food and Drug Administration for moderate‐to‐severe paediatric psoriasis.

What does this study add?

Ixekizumab resulted in rapid and statistically significant improvements over placebo in skin involvement, itch and health‐related quality of life, which persisted through 48 weeks of treatment in paediatric patients with moderate‐to‐severe plaque psoriasis.

The safety profile of ixekizumab was generally consistent with that seen in adults.

Ixekizumab may be an additional potential therapeutic option and an additional class of biologic therapy (interleukin‐17A antagonist) for the treatment of moderate‐to‐severe paediatric psoriasis.

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Hyaluronic acid as a macromolecular crowding agent for production of cell-derived matrices

Cell-derived matrices (CDMs) provide an exogenous source of human extracellular matrix (ECM), with applications as cell delivery vehicles, substrate coatings for cell attachment and differentiation, and as biomaterial scaffolds. However, commercial application of CDMs has been hindered due to the prolonged culture time required for sufficient ECM accumulation. One approach to increasing matrix deposition in vitro is macromolecular crowding (MMC), which is a biophysical phenomenon that limits the diffusion of ECM precursor proteins, resulting in increased ECM accumulation at the cell layer. Hyaluronic acid (HA), a natural MMC highly expressed in vivo during fetal development, has been shown to play a role in ECM production, but has not been investigated as a macromolecule for increasing cell-mediated ECM deposition in vitro. In the current study, we hypothesized that HA can act as a MMC, and increase cell-mediated ECM production. Human dermal fibroblasts were cultured for 3, 7, or 14 days with 0%, 0.05%, or 0.5% high molecular weight HA. Ficoll 70/400 was used as a positive control. SDS-PAGE, Sircol, and hydroxyproline assays indicated that 0.05% HA-treated cultures had significantly higher mean collagen deposition at 14 days, whereas Ficoll 70/400-treated cultures had significantly lower collagen production compared to the HA and untreated controls. However, fluorescent immunostaining of ECM proteins and quantification of mean gray values did not indicate statistically significant differences in ECM production in HA or Ficoll 70/400-treated cultures compared to untreated controls. Raman imaging (a marker-free spectral imaging method) indicated that HA increased ECM deposition in human dermal fibroblasts. These results are consistent with decreases in CDM stiffness observed in Ficoll 70/400-treated cultures by atomic force microscopy. Overall, these results indicate that there are macromolecule- and cell type- dependent effects on matrix assembly, turnover, and stiffness in cell-derived matrices. STATEMENT OF SIGNIFICANCE: Cell-derived matrices (CDMs) are versatile biomaterials with many regenerative medicine applications, including as cell and drug delivery vehicles and scaffolds for wound healing and tissue regeneration. While CDMs have several advantages, their commercialization has been limited due to the prolonged culture time required to achieve CDM synthesis in vitro. In this study, we explored the use of hyaluronic acid (HA) as a macromolecular crowder in human fibroblast cell cultures to support production of CDM biomaterials. Successful application of macromolecular crowding will allow development of human cell-derived, xeno-free biomaterials that re-capitulate the native human tissue microenvironment.

P1760Incidence and effects of stroke, MI and bleeding on mortality among patients with ACS undergoing PCI: a comparative analysis from the PROMETHEUS registry

Background

Stroke represents a potentially calamitous complication among patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) even though its rates are relatively low. Data on the distribution of stroke occurrence over time and its overlap with myocardial infarction (MI) and bleeding after PCI is scarce.

Purpose

We sought to compare the occurrence and impacts of stroke, MI and bleeding on subsequent mortality in ACS patients undergoing PCI in contemporary clinical practice.

Methods

A total of 19,914 ACS patients who underwent PCI in the PROMETHEUS multi-center observational study were analyzed. We calculated the cumulative stroke incidence at 30 days and 1 year using Kaplan Meier (KM) method. We also compared the distribution of stroke, myocardial infarction (MI) and bleeding across time and evaluated the overlap between their occurrences. Predictors of 1 year stroke occurrence were identified through multivariable Cox-regression and stroke, MI and bleeding were entered as time-updated covariates to estimate their individual effects on subsequent mortality.

Results

Of the total number of patients, 244 patients (1.5%) had a stroke within 1 year. 48 of these patients also experienced an MI while another 48 patients experienced a bleeding event. Furthermore, 14 of these overlapping patients experienced a stroke, MI and bleeding event, all within the 1-year follow-up. Patients who sustained a stroke were more likely to have a prior history of cerebrovascular disease, peripheral artery disease, MI and heart failure compared to those who did not have a stroke. Mortality risk was significantly higher among those with stroke versus those without stroke (adjusted HR 4.84, p<0.0001). However, the association attenuated over time with a much larger effect in the first 30 days of its occurrence (adjusted HR 17.7, p<0.0001) versus beyond 30 days (adjusted HR 1.22; 95% CI: 0.6–2.46, p=0.58). Although the effects of MI and bleeding on subsequent mortality within 30 days of occurrence were significantly lower than stroke (adjusted HR 6.22, p<0.0001; adjusted HR 7.30, p<0.0001, respectively), their effects were more sustained on mortality beyond 30 days (adjusted HR 2.89, p<0.0001; adjusted HR 3.05, p<0.0001, respectively).

Conclusion

When compared with MI and bleeding, stroke had a substantially stronger impact on mortality that attenuated rapidly over time among ACS patients undergoing PCI. Optimization of modifiable risk factors and medication adherence are essential parts of management of stroke following PCI for ACS.

Psychometric properties of the PROMIS® Fatigue Short Form 7a among adults with myalgic encephalomyelitis/chronic fatigue syndrome

PURPOSE

To evaluate the psychometric properties of the Patient-Reported Outcome Measurement Information System® Fatigue Short Form 7a (PROMIS F-SF) among people with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS).

METHODS

Analyses were conducted using data from the Multi-Site Clinical Assessment of ME/CFS study, which recruited participants from seven ME/CFS specialty clinics across the US. Baseline and follow-up data from ME/CFS participants and healthy controls were used. Ceiling/Floor effects, internal consistency reliability, differential item functioning (DIF), known-groups validity, and responsiveness were examined.

RESULTS

The final sample comprised 549 ME/CFS participants at baseline, 386 of whom also had follow-up. At baseline, the sample mean of PROMIS F-SF T-score was 68.6 (US general population mean T-score of 50 and standard deviation of 10). The PROMIS F-SF demonstrated good internal consistency reliability (Cronbach's α = 0.84) and minimal floor/ceiling effects. No DIF was detected by age or sex for any item. This instrument also showed good known-groups validity with medium-to-large effect sizes (η² = 0.08-0.69), with a monotonic increase of the fatigue T-score across ME/CFS participant groups with low, medium, and high functional impairment as measured by three different variables (p < 0.01), and with significantly higher fatigue T-scores among ME/CFS participants than healthy controls (p < 0.0001). Acceptable responsiveness was found with small-to-medium effect sizes (Guyatt's Responsiveness Statistic = 0.28-0.54).

CONCLUSIONS

Study findings support the reliability and validity of PROMIS F-SF as a measure of fatigue for ME/CFS and lend support to the drug development tool submission for qualifying this measure to evaluate therapeutic effect in ME/CFS clinical trials.

Development and Testing of the CAHPS Cancer Care Survey

PURPOSE

The Consumer Assessment of Healthcare Providers and Systems (CAHPS) Cancer Care Survey is a systematic assessment of health care experiences of patients with cancer. It supports comparisons among all cancer treatment settings and modalities.

METHODS

Formative research included 16 focus groups with patients receiving treatment and family members; advice from a panel of oncology and quality improvement experts; and interviews with stakeholders representing oncology associations, accredited cancer centers, and community oncology practices. We conducted cognitive tests of the instrument and field tests at six cancer centers and four community oncology practices, after which the survey was finalized and obtained the CAHPS trademark.

RESULTS

The survey includes 56 questions that form six core composite measures (Getting Timely Care; Supporting Patient Self-Management; Available to Provide Care and Information; Provider Communication; Care Coordination; and Courteous Office Staff); two single-item measures of family participation in care and interpreter services; and two global ratings of cancer care and the treatment team. Sixteen additional items form three supplemental composite measures: Shared Decision-Making, Keeping Patients Informed, and Access to Care.

CONCLUSION

Mail-only, mail-telephone mixed-mode, and Web-mail mixed-mode data collection methods are recommended. The questionnaires and instructions for use are free and available in English and Spanish on the CAHPS Website (www.ahrq.gov/cahps).

Structural determinants of the interaction between influenza A virus matrix protein M1 and lipid membranes

Influenza A virus is a pathogen responsible for severe seasonal epidemics threatening human and animal populations every year. One of the ten major proteins encoded by the viral genome, the matrix protein M1, is abundantly produced in infected cells and plays a structural role in determining the morphology of the virus. During assembly of new viral particles, M1 is recruited to the host cell membrane where it associates with lipids and other viral proteins. The structure of M1 is only partially known. In particular, structural details of M1 interactions with the cellular plasma membrane as well as M1-protein interactions and multimerization have not been clarified, yet. In this work, we employed a set of complementary experimental and theoretical tools to tackle these issues. Using raster image correlation, surface plasmon resonance and circular dichroism spectroscopies, we quantified membrane association and oligomerization of full-length M1 and of different genetically engineered M1 constructs (i.e., N- and C-terminally truncated constructs and a mutant of the polybasic region, residues 95-105). Furthermore, we report novel information on structural changes in M1 occurring upon binding to membranes. Our experimental results are corroborated by an all-atom model of the full-length M1 protein bound to a negatively charged lipid bilayer.

TP3-1 Memory impairment in epilepsy

Objectives

Memory impairment is an extremely common complaint in people with epilepsy (PWE). The purpose of our cross sectional study was to identify factors associated with self-reported memory impairment in PWE.

Methods

514 PWE and 52 controls completed the Liverpool Adverse Event Profile, a 19 item questionnaire which includes items on memory and depression and provided clinical data on age, sex, medication, seizure onset, frequency and severity. For memory impairment, sleep disturbance, depression and seizure type scores were dichotomised into minor deficits (Likert scores 1 and 2), and major deficits (Likert scores 3 and 4).

Results

In univariate analysis we found significant associations for mono vs polytherapy (χ2=14.85, p<0.001); minor/major depression (χ2=29.41, p<0.001); minor/major sleep disturbance (χ2=65.34, p<0.001); seizure freedom/persistence (χ2=14.40, p<0.001), the number of seizures in the last four weeks (p<0.001, U=17530.50, z=−5.11, but not sex, mean age of onset, mean duration of epilepsy or seizure type. Multinomial logistic regression revealed that sleep disturbance (p<0.001), AED poly therapy (p=0.004), depression (p<0.001) all retained significance whereas seizure persistence did not (p=0.377). Applying ANOVA to examine mean age with memory deficit outcomes, older age was significantly linked to poorer memory (F=3.34, p=0.002).

Conclusions

Sleep disturbance, poly therapy and depression are potentially treatable factors associated with self-reported memory impairment in PWE.

Adaptive changes in pancreas post Roux-en-Y gastric bypass induced weight loss

BACKGROUND

Obesity has been shown to trigger adaptive increases in pancreas parenchymal and fat volume. Consecutively, pancreatic steatosis may lead to beta-cell dysfunction. However, it is not known whether the pancreatic tissue components decrease with weight loss and pancreatic steatosis is reversible following Roux-en-Y gastric bypass (RYGB). Therefore, the objective of the study was to investigate the effects of RYGB-induced weight loss on pancreatic volume and glucose homeostasis.

METHODS

Eleven patients were recruited in the Obesity Centre of the University Medical Centre Hamburg-Eppendorf. Before and 6 months after RYGB, total GLP-1 levels were measured during oral glucose tolerance test. To assess changes in visceral adipose tissue and pancreatic volume, MRI was performed. Measures of glucose homeostasis and insulin indices were assessed. Fractional beta-cell area was estimated by correlation with the C-peptide-to-glucose ratio; beta-cell mass was calculated by the product of beta-cell area and pancreas parenchymal weight.

RESULTS

Pancreas volume decreased from 83.8 (75.7-92.0) to 70.5 (58.8-82.3) cm³ (mean [95% CI], P = .001). The decrease in total volume was associated with a significant decrease in fat volume. Fasting insulin and C-peptide were lower post RYGB. HOMA-IR levels decreased, whereas insulin sensitivity increased (P = .03). This was consistent with a reduction in the estimated beta-cell area and mass.

CONCLUSIONS

Following RYGB, pancreatic volume and steatosis adaptively decreased to "normal" levels with accompanying improvement in glucose homeostasis. Moreover, obesity-driven beta-cell expansion seems to be reversible; however, future studies must define a method to more accurately estimate functional beta-cell mass to increase our understanding of glucose homeostasis after RYGB.

Prospective comparison of diffusion-weighted MRI and dynamic Gd-EOB-DTPA-enhanced MRI for detection and staging of hepatic fibrosis in primary sclerosing cholangitis

PURPOSE

To assess the diagnostic value of multiparametric magnetic resonance imaging (MRI) including dynamic Gd-EOB-DTPA-enhanced (DCE) and diffusion-weighted (DW) imaging for diagnosis and staging of hepatic fibrosis in primary sclerosing cholangitis (PSC) using transient elastography as a standard reference.

MATERIAL AND METHODS

Multiparametric MRI was prospectively performed on a 3.0-Tesla scanner in 47 patients (age 43.9±14.3 years). Transient elastography derived liver stiffness measurements (LSM), DCE-MRI derived parameters (hepatocellular uptake rate (Ki), arterial (Fa), portal venous (Fv) and total (Ft) blood flow, mean transit time (MTT), and extracellular volume (Ve)) and the apparent diffusion coefficient (ADC) were calculated. Correlation and univariate analysis of variance with post hoc pairwise comparison were applied to test for differences between LSM derived fibrosis stages (F0/F1, F2/3, F4). ROC curve analysis was used as a performance measure.

RESULTS

Both ADC and Ki correlated significantly with LSM (r= -0.614; p<0.001 and r= -0.368; p=0.01). The ADC significantly discriminated fibrosis stages F0/1 from F2/3 and F4 (p<0.001). Discrimination of F0/1 from F2/3 and F4 reached a sensitivity/specificity of 0.917/0.821 and 0.8/0.929, respectively. Despite significant inter-subject effect for classification of fibrosis stages, post hoc pairwise comparison was not significant for Ki (p>0.096 for F0/1 from F2/3 and F4). LSM, ADC and Ki were significantly associated with serum-based liver functional tests, disease duration and spleen volume.

CONCLUSION

DW-MRI provides a higher diagnostic performance for detection of hepatic fibrosis and cirrhosis in PSC patients in comparison to Gd-EOB-DTPA-enhanced DCE-MRI.

KEY POINTS

• Both ADC and hepatocellular uptake rate (Ki) correlate significantly with liver stiffness (r= -0.614; p<0.001 and r= -0.368; p=0.01). • The DCE-imaging derived quantitative parameter hepatocellular uptake rate (Ki) fails to discriminate pairwise intergroup differences of hepatic fibrosis (p>0.09). • DWI is preferable to DCE-imaging for discrimination of fibrosis stages F0/1 to F2/3 (p<0.001) and F4 (p<0.001).

Follow-up magnetic resonance imaging/3D-magnetic resonance cholangiopancreatography in patients with primary sclerosing cholangitis: challenging for experts to interpret

BACKGROUND

In patients with primary sclerosing cholangitis follow-up magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) is performed by many centres, particularly for the early detection of biliary malignancies and strictures. Clinically meaningful MRI-based definitions of primary sclerosing cholangitis related complications are, however, lacking.

AIM

To investigate how primary sclerosing cholangitis experts interpret follow-up MRI/MRCP with a focus on conclusions that may impact clinical decision-making in primary sclerosing cholangitis.

METHODS

Within the International Primary Sclerosing Cholangitis Study Group, an online survey on 16 real-life primary sclerosing cholangitis cases including clinical and biochemical information as well as a T2-weighted liver MRI/3D-MRCP was conducted. The interpretation of images and subsequent recommendations were assessed using a multiple-choice questionnaire. An inter-rater reliability calculation (Fleiss' kappa) was performed and factors potentially affecting the interpretation of magnetic resonance images were analysed using generalised linear mixed-effect models.

RESULTS

Forty-four members/associates of the International Primary Sclerosing Cholangitis Study Group (median experience in the care of primary sclerosing cholangitis patients: 14 years) completed the survey. The MRI interpretation significantly varied among the participants. The lowest agreement was found with respect to the indication to perform subsequent endoscopic retrograde cholangiopancreatography (ERCP; Κ = 0.12, 95%CI 0.11-0.14). Elevated total bilirubin was the variable with the strongest effect on the rate of suspected dominant strictures, cholangiocarcinoma or ERCP recommendations. Liver cirrhosis did not prevent participants from recommending ERCP. Overall, the survey participants' recommendations contrasted the real-life management and outcome.

CONCLUSIONS

In primary sclerosing cholangitis, the interpretation of follow-up MRI/3D-MRCP significantly varies even among experts and seems to be primarily affected by bilirubin levels. Generally accepted MRI-based definitions of primary sclerosing cholangitis-related complications are urgently needed.

Gadolinium-based relative contrast enhancement in primary sclerosing cholangitis: additional benefit for clinicians?

AIM

To evaluate the benefit of extracellular gadolinium-based contrast agent (GBCA) enhanced magnetic resonance imaging (MRI) in addition to conventional non-enhanced T2-weighted imaging (WI) for quantification of inflammatory or fibrotic alterations in the liver parenchyma of patients with primary sclerosing cholangitis (PSC).

MATERIAL AND METHODS

MRI (3 T) examinations were reviewed retrospectively by two radiologists in 27 PSC patients (age 42.9±15.6 years), and 19 controls. Regions of interest (ROIs) were drawn onto T2 hyperintense and T2 isointense areas and copied to section position matched non-enhanced and delayed-phase contrast-enhanced T1WI. Signal intensities (SI) obtained from ROIs of the multiphase T1WI were used to calculate relative liver enhancement (RLE). The interobserver agreement of RLE and quantified T2 signal was calculated using Bland-Altman analysis. RLE assessed for both T2 hyperintense (RLE_hyper) and T2 isointense (RLE_iso) areas were compared in patients and controls (RLE_healthy).

RESULTS

The interobserver agreement of RLE in affected hyperintense areas (bias -0.77, limits of agreement -51.7 to 50.1) was superior to the quantification of T2 signal only in these areas (bias -3.35, limits of agreement -162.4 to 155.7). The RLE_hyper (86.2±9.7%) was higher than the RLE_iso (59.8±6.2%, p=0.03) and the RLE_healthy (53.2±2.7%, p=0.002). The mean RLE_iso was not significantly different from the RLE_healthy (p=0.3).

CONCLUSION

The extracellular gadolinium-based RLE of T2 hyperintense areas could be a useful add-on for routine follow up MRI in the detection of early inflammatory changes, possibly preceding formation of fibrotic scarring in PSC patients, if validated in larger cohorts.

Blood calcium, glucose and haematology profiles of parturient bitches diagnosed with uterine inertia or obstructive dystocia

Bitches with dystocia most often present with clinical signs of uterine inertia (UI). The aetiology of myometrial dysfunction in most of these cases is still not elucidated. We compared blood ionized calcium (iCa) and glucose concentrations in bitches diagnosed with primary UI (PUI, n = 14), secondary UI (SUI, n = 6) or obstructive dystocia (OD, n = 6), and we described their haematology profiles. Bitches diagnosed with UI had a patent birth canal and delivered no puppies yet (PUI) or only part of the whole litter (SUI). The OD group had no UI and showed strong abdominal contractions. Blood iCa did not differ between the PUI, SUI and OD groups and was not influenced by litter size. There was a significant positive relationship (R²  = .241, p = .013) between iCa concentrations and the dam's body weight. Glucose concentrations were also not significantly different between dystocia groups or influenced by body weight and litter size. Hypocalcaemia was detected in 11 bitches, and hypoglycaemia in two bitches. Pregnancy-associated anaemia was seen in about one-third of the bitches. Eight of 12 dogs had increased platelet counts, and ten had leukocytosis with mature neutrophilia. Although iCa did not differ between dystocia groups, low concentrations may have contributed to the development of UI in some of the small size bitches. Hypoglycaemia was uncommon, and therefore, we consider low glucose concentrations not to have played an important role in the pathogenesis of UI in our study population. Pregnancy-associated anaemia, thrombocytosis, leukocytosis and mature neutrophilia were common findings in otherwise healthy bitches diagnosed with different forms of dystocia.

Phagosomal transport depends strongly on phagosome size

Macrophages internalize pathogens for intracellular degradation. An important part of this process is the phagosomal transport from the cell periphery to the perinuclear region. Biochemical factors are known to influence the fate of phagosomes. Here, we show that the size of phagosomes also has a strong influence on their transport. We found that large phagosomes are transported persistently to the nucleus, whereas small phagosomes show strong bidirectional transport. We show that dynein motors play a larger role in the transport of large phagosomes, whereas actin filament-based motility plays a larger role in the transport of small phagosomes. Furthermore, we investigated the spatial distribution of dyneins and microtubules around phagosomes and hypothesize that dynein and microtubule density differences between the nucleus-facing side of phagosomes and the opposite side could explain part of the observed transport characteristics. Our findings suggest that a size-dependent cellular sorting mechanism might exist that supports macrophages in their immunological roles.

Sensitivity of alternative measures of functioning and wellbeing for adults with sickle cell disease: comparison of PROMIS® to ASCQ-Me℠

BACKGROUND

Sickle Cell Disease (SCD) causes profound suffering and decrements in daily functioning. Demand is growing for valid and reliable measures to systematically document these effects, particularly in adults. The Adult Sickle Cell Quality of Life Measurement System, ASCQ-Me℠, was developed for this purpose. ASCQ-Me℠ is one of four measurement systems housed within the Person-Centered Assessment Resource (PCAR), funded by the National Institutes of Health, to support clinical research. To help users select the best of these measures for adults with SCD, we evaluated and compared two PCAR systems: one designed to be "universally applicable" (the Patient-Reported Outcome Measurement Information System, PROMIS®) and one designed specifically for SCD (ASCQ-Me℠).

METHODS

Respondents to PROMIS and ASCQ-Me questions were 490 adults with SCD from seven geographically-disbursed clinics within the US. Data were collected for six ASCQ-Me measures (Emotional Impact, Sleep Impact, Social Impact, Stiffness Impact, Pain Impact, SCD Pain Episode Frequency and Severity) and ten PROMIS measures (Pain Impact, Pain Behavior, Physical Functioning, Anxiety, Depression, Fatigue, Satisfaction with Discretionary Social Activities, Satisfaction with Social Roles, Sleep Disturbance, and Sleep-Related Impairment). Statistical analyses, including analysis of variance and multiple linear regression, were conducted to determine the sensitivity of measures to SCD severity. SCD severity was assessed via a checklist of associated treatments and conditions.

RESULTS

For those with the most severe SCD, PROMIS scores showed worse health compared to the general population for nine of ten health domains: the magnitude of the difference ranged 0.5 to 1.1 standard deviation units. The PROMIS domains most severely affected were Physical Functioning and Pain (Impact and Behavior). Significant differences by tertile of the SCD-MHC were shown for most PROMIS short forms and all ASCQ-Me short and fixed forms. In most models, ASCQ-Me measures explained statistically significant unique variance in SCD-MHC scores complementary to that explained by corresponding PROMIS measures.

CONCLUSIONS

Study results supported the validity of both PROMIS and ASCQ-Me measures for use in adults with SCD. Compared to comparable PROMIS scores, most ASCQ-Me scores were better predictors of SCD disease severity, as measured by a medical history checklist. The clinical implications of these results require further investigation.

clickECM: Development of a cell-derived extracellular matrix with azide functionalities

In vitro cultured cells produce a complex extracellular matrix (ECM) that remains intact after decellularization. The biological complexity derived from the variety of distinct ECM molecules makes these matrices ideal candidates for biomaterials. Biomaterials with the ability to guide cell function are a topic of high interest in biomaterial development. However, these matrices lack specific addressable functional groups, which are often required for their use as a biomaterial. Due to the biological complexity of the cell-derived ECM, it is a challenge to incorporate such functional groups without affecting the integrity of the biomolecules within the ECM. The azide-alkyne cycloaddition (click reaction, Huisgen-reaction) is an efficient and specific ligation reaction that is known to be biocompatible when strained alkynes are used to avoid the use of copper (I) as a catalyst. In our work, the ubiquitous modification of a fibroblast cell-derived ECM with azides was achieved through metabolic oligosaccharide engineering by adding the azide-modified monosaccharide Ac₄GalNAz (1,3,4,6-tetra-O-acetyl-N-azidoacetylgalactosamine) to the cell culture medium. The resulting azide-modified network remained intact after removing the cells by lysis and the molecular structure of the ECM proteins was unimpaired after a gentle homogenization process. The biological composition was characterized in order to show that the functionalization does not impair the complexity and integrity of the ECM. The azides within this "clickECM" could be accessed by small molecules (such as an alkyne-modified fluorophore) or by surface-bound cyclooctynes to achieve a covalent coating with clickECM.

STATEMENT OF SIGNIFICANCE

The clickECM was produced by the incorporation of azide-functionalized sugar analogues into the extracellular glycans of fibroblast cell cultures by metabolic oligosaccharide engineering. By introducing these azide groups into the glycan structures, we enabled this cell-derived ECM for bioorthogonal click reactions. Click chemistry provides extremely specific reactions with high efficiency, high selectivity, and high reaction yields. We could show that the azide functionalities within the clickECM are chemically accessible. Based on our here described clickECM technique it will be possible to create and investigate new clickECM materials with tunable bioactive properties and additional functionalities, which offers a promising approach for basic and applied research in the field of biomaterial science, biomedical applications, and tissue engineering.

CAHPS Cancer Care Survey: Development, testing, and final content of a survey of patient experience with cancer care

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Background: The objective of this work was to develop a reliable and valid survey measuring aspects of cancer care important to patients to be used in both inpatient and outpatient settings, and that allows comparisons of patient experiences across treatment centers and treatment modalities (medical oncology, radiation, surgery). Other objectives included testing various modes of data collection and developing a standardized sampling methodology based on ICD diagnosis and procedure codes. Methods: We conducted focus groups with patients who had received cancer treatment and with family members of cancer patients. We convened a panel of experts representing quality improvement, oncology, shared decision-making, patient safety, and patient advocacy to obtain feedback on the development of the survey. We interviewed stakeholder groups representing oncology associations to obtain feedback on focal provider, attribution and sampling. We then conducted a field test of the survey among six cancer centers around the country, conducted psychometric analyses, revised the survey, conducted a second field test among four community oncology practices in CA, re-analyzed the data, and finalized the survey. Results: Final survey content was determined using results of the formative research, psychometric analyses, and input from the CAHPS Consortium. The core survey includes 56 questions, 23 of which map to eight composites: Provider Communication, Enabling Patient Self-management, Team Available to Provide Information, Access to Care, Care Coordination, and Office Staff. Supplemental item sets include seven items assessing Shared Decision Making, four items measuring Keeping Patients Informed, and two additional Access to Care items. Mail-only, mail-telephone mixed-mode, and web-mail mixed-mode are recommended methods of data collection. The survey and all recruiting materials are available in English and Spanish. Conclusions: The CAHPS Cancer Care Survey is a rigorously developed, well-tested, reliable and valid survey of patient experiences with their cancer care. The survey and supporting materials are available free of charge on the CAHPS website (www.ahrq.gov/cahps).

Examining measurement properties of the consumer-based cancer care value index (CCCVI) survey: A measure to identify quality improvement priorities in cancer care

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Background: Current approaches to measuring the quality of cancer care may not produce sufficient information to enable providers to structure care that aligns closely with their patients’ preferences. To close this gap, we developed the Consumer-based Cancer Care Value Index (CCCVI) survey, which assesses the aspects of cancer care that patients value the most and how their values align with their experience in receiving cancer care. Methods: The CCCVI field test included 721 adults who received cancer care in the last 12 months from 4 geographically diverse cancer care centers, including patients with varying stages of cancer, types of cancer, types of treatment (e.g., surgery, radiation, medical oncology), and demographic characteristics. The survey included items that asked patients to directly rate the “importance” of 24 aspects of cancer care, along with 24 corresponding items that measured the “frequency” with which they received each aspect of care. We evaluated the reliability and validity of the survey items, and developed “value grids” plots which visually depicted the “importance” scores against the “frequency” scores. We conducted subgroup analysis to examine income and racial/ethnic disparities in the extent of misalignment between patients’ values and experiences. Results: The survey demonstrated good internal consistency reliability (Cronbach’s alpha = 0.91) and acceptable-to-good construct and criterion validity. Value grids identified potential areas of improvement in the areas of how doctors communicate and how quickly patients get care. The subgroup analysis showed the most misalignments between patients’ values and experiences in the aspects of doctor communication for lower-income patients and in the aspects of getting care quickly for patients from racial/ethnic minority groups. Conclusions: The CCCVI survey is a reliable and valid tool for cancer care providers to identify top priority areas (i.e., high-importance but low-frequency areas) to facilitate their quality improvement efforts. It also recognizes subgroup variations in the misalignment between patients’ values and care experiences.

Encapsulated benzoic acid supplementation in broiler diets influences gut bacterial composition and activity

1. The present study investigated the effects of encapsulated benzoic acid (BA) supplementation in broiler feed on performance and gastrointestinal microbiota. 2. Eighty broilers were randomly divided into two groups. Birds in the control group were fed on maize-soybean-based diets. Birds in the treatment group were provided the same diet supplemented with 2 g/kg BA encapsulated in a vegetable oil matrix. 3. At the end of the trial (d 35), pH, bacterial composition and metabolites were determined in the crop, jejunum, ileum and caecum. 4. Growth performance variables and pH were not significantly different. 5. BA concentration decreased rapidly in the proximal gut. However, the treatment diet showed higher BA in the crop, jejunum, ileum and caecum. 6. Total lactate in the crop and D-lactate in the jejunum was higher in the BA treated group. Caecal total and branched chain fatty acids were decreased due to the treatment. 7. Lactobacilli populations were significantly altered by BA supplementation. A trend for increased lactobacilli was observed in the crop, while it became significant in the jejunum and ileum. Lactobacillus species responded differently to the treatment. Four of 5 measured Lactobacillus species, particularly in the ileum, followed the course observed for total lactobacilli; only Lactobacillus salivarius was not modified. 8. Correlation analysis showed that BA modified the intestinal microbiota. Lactobacilli correlated negatively to all studied clostridial clusters and enterobacteria. Clostridial clusters IV and XIVa were significantly increased in the jejunum, whereas only clostridial cluster XIVa was increased in the caecum. 9. Encapsulated BA modified the intestinal microbiota which can lead to the conclusion, that the main beneficial mode of action of BA in the gut appears to be the enhancement of lactic acid bacteria, which in turn may act as a vanguard against pathogens.

Quality of care in sickle cell disease: Cross-sectional study and development of a measure for adults reporting on ambulatory and emergency department care

Documented deficiencies in adult sickle cell disease (SCD) care include poor access to knowledgeable providers and inadequate treatment in emergency departments (EDs).The aim of this study was to create patient-reported outcome measures of the quality of ambulatory and ED care for adults with SCD.We developed and pilot tested SCD quality of care questions consistent with Consumer Assessments of Healthcare Providers and Systems surveys. We applied psychometric methods to develop scores and evaluate reliability and validity.The participants of this study were adults with SCD (n = 556)-63% aged 18 to 34 years; 64% female; 64% SCD-SS-at 7 US sites.The measure used was Adult Sickle Cell Quality of Life Measurement information system Quality of Care survey.Most participants (90%) reported at least 1 severe pain episode (pain intensity 7.8 ± 2.3, 0-10 scale) in the past year. Most (81%) chose to manage pain at home rather than the ED, citing negative ED experiences (83%). Using factor analysis, we identified Access, Provider Interaction, and ED Care composites with reliable scores (Cronbach α 0.70-0.83) and construct validity (r = 0.32-0.83 correlations with global care ratings). Compared to general adult Consumer Assessments of Healthcare Providers and Systems scores, adults with SCD had worse care, adjusted for age, education, and general health.Results were consistent with other research reflecting deficiencies in ED care for adults with SCD. The Adult Sickle Cell Quality of Life Measurement Quality of Care measure is a useful self-report measure for documenting and tracking disparities in quality of SCD care.