Borderline Values Research Articles

DIABETES

Objectives: The objective of this study was to evaluate the variations in HbA1con repetition over a span of about two weeks. Period: June 2015 to May 2016. Setting:Department of pathology, Continental Medical College Lahore, attached with Ch. Rehmat AliMemorial Trust Teaching Hospital. Method: A total of 60 newly diagnosed or with no apparentdiabetic complications were included in this study. Venous blood repeated samples wereobtained for evaluation of HbA1c. Results: The result of our study show that in 65% of patientsthe repeated values were lower than the initial values, 25% were higher and 10% were below thediagnostic threshold. So it is indicated that HbA1c values vary over a span of time and repeatedtests values should be considered for borderline patients. Conclusion: It is concluded from thisstudy that values of HbA1c do differ on retest. Therefore, physicians should understand and notbe confused with a little bit variations in values. It is recommended to repeat the test for newlydiagnosed and borderline value patients to reach a final conclusion about diagnosis. It is alsorecommended that a separate study should be conducted to evaluate the cause/mechanismbehind variations in HbA1c over a short period of time in our settings.

Wartości referencyjne wskaźników krzyżowo-biodrowych w scyntygrafi i kośćca

Scintigraphy of sacroiliac joints as functional imaging provides unique information on the existing disease process. By using radiopharmaceuticals that allow imaging of the metabolic activity within the joint, it is possible to assess the stage of the disease, even when there are no lesions in radiological images. Quantitative analysis of scintigrams of sacroiliac joints is performed by comparing the uptake in both of them in relation to the uptake in the sacral bone area. The values of sacroiliac (SI/S) indices are influenced by the age of the patient, sex, state of health, and a range of individual biological features. Therefore, reference values of SI/S ratios are very important for medical specialists who describe and diagnose locomotor system diseases. The aim of this paper is to develop a reference range of sacroiliac ratios. The innovativeness of this paper involves examining sacroiliac ratios for various age groups, in children and adult patients, taking their sex into consideration. The study comprised a group of 335 people with proper bone scintigraphy. These people were divided into children and patients aged ≥21. Children were divided into 4 age groups (1–5; 6–10; 11–15; 16–20) and adults into 6 age groups (21–30; 31–40; 41–50; 51–60; 61–70; ≥71). Sacroiliac ratios were calculated using the method of three rectangular region of interests located on the left and right sacroiliac joint and on the sacral bone. The sacroiliac ratio was calculated for both joints by dividing the average number of counts within a selected sacroiliac joint by the average number of counts within the sacral bone. SI/S borderline reference values covered the range of 1.18÷2.28 that was obtained for children aged ≤5 and for the group of 11–15-year-olds. Considerable discrepancies in the values of the coefficient for women and men were seen among 31–50-year-olds. Borderline reference results for the entire control group cover the range of 1.18 ±2.28. The lower reference value applies to ≤5-year-olds, whereas the higher value applies to the group of 11–15-year-olds. The standard deviation value obtained was highest in paediatric patients. The results indicate the occurrence of significant individual differences between patients in this age group.

Persistent hemifacial spasm after microvascular decompression: a risk assessment model

Objective: Microvascular decompression (MVD) for hemifacial spasm (HFS) provides resolution of disabling symptoms such as eyelid twitching and muscle contractions of the entire hemiface. The primary aim of this study was to evaluate the predictive value of patient demographics and spasm characteristics on long-term outcomes, with or without intraoperative lateral spread response (LSR) as an additional variable in a risk assessment model.Methods: A retrospective study was undertaken to evaluate the associations of pre-operative patient characteristics, as well as intraoperative LSR and need for a staged procedure on the presence of persistent or recurrent HFS at the time of hospital discharge and at follow-up. A risk assessment model was constructed with the inclusion of six clinically or statistically significant variables from the univariate analyses. A receiving operator characteristic curve was generated, and area under the curve was calculated to determine the strength of the predictive model.Results: A risk assessment model was first created consisting of significant pre-operative variables (Model 1) (age >50, female gender, history of botulinum toxin use, platysma muscle involvement). This model demonstrated borderline predictive value for persistent spasm at discharge (AUC .60; p=.045) and fair predictive value at follow-up (AUC .75; p=.001). Intraoperative variables (e.g. LSR persistence) demonstrated little additive value (Model 2) (AUC .67). Patients with a higher risk score (three or greater) demonstrated greater odds of persistent HFS at the time of discharge (OR 1.5 [95%CI 1.16–1.97]; p=.035), as well as greater odds of persistent or recurrent spasm at the time of follow-up (OR 3.0 [95%CI 1.52–5.95]; p=.002)Conclusions: A risk assessment model consisting of pre-operative clinical characteristics is useful in prognosticating HFS persistence at follow-up.

A model of multi-agent consensus for vague and uncertain beliefs.

Consensus formation is investigated for multi-agent systems in which agents’ beliefs are both vague and uncertain. Vagueness is represented by a third truth state meaning borderline. This is combined with a probabilistic model of uncertainty. A belief combination operator is then proposed, which exploits borderline truth values to enable agents with conflicting beliefs to reach a compromise. A number of simulation experiments are carried out, in which agents apply this operator in pairwise interactions, under the bounded confidence restriction that the two agents’ beliefs must be sufficiently consistent with each other before agreement can be reached. As well as studying the consensus operator in isolation, we also investigate scenarios in which agents are influenced either directly or indirectly by the state of the world. For the former, we conduct simulations that combine consensus formation with belief updating based on evidence. For the latter, we investigate the effect of assuming that the closer an agent’s beliefs are to the truth the more visible they are in the consensus building process. In all cases, applying the consensus operators results in the population converging to a single shared belief that is both crisp and certain. Furthermore, simulations that combine consensus formation with evidential updating converge more quickly to a shared opinion, which is closer to the actual state of the world than those in which beliefs are only changed as a result of directly receiving new evidence. Finally, if agent interactions are guided by belief quality measured as similarity to the true state of the world, then applying the consensus operator alone results in the population converging to a high-quality shared belief.

Cardiovascular Safety of Oral Antidiabetic Drugs.

Croatia belongs to a group of European countries with a high cardiovascular risk and growing prevalence of diabetes mellitus type 2 (DMT2). According to data of the National Diabetes Registry (CroDiab registry), a total of 254,296 individuals aged >18 suffering from diabetes were registered in 2014 (7.9%). Along with hypertension and hyperlipidemia, DMT2 is one of the leading cardiovascular risk factors. Prompted by adverse cardiovascular effects of rosiglitazone, demonstrated in the RECORD study and subsequent meta-analyses, the main drug regulatory agencies require clinical trials of the effect on cardiovascular outcomes and safety evidence for all antidiabetic drugs. On assessing the effects of antidiabetic drugs on cardiovascular risk, the two-sided confidence interval upper borderline value of 95% (95% CI) is highly relevant for the estimated risk ratio. Additional safety testing is required for all antidiabetic drugs with the risk ratio upper limit ≥1.3. Cardiovascular safety of oral antidiabetic drugs is of special importance in patients with heart failure. Considering the great number of antidiabetic drugs on the market, decision on optimal DMT2 therapy should be made in dependence of specific characteristics of each individual patient and cardiovascular risk assessment.

Detecting borderline infection in an automated monitoring system for healthcare-associated infection using fuzzy logic.

Many electronic infection detection systems employ dichotomous classification methods, classifying patient data as pathological or normal with respect to one or several types of infection. An electronic monitoring and surveillance system for healthcare-associated infections (HAIs) known as Moni-ICU is being operated at the intensive care units (ICUs) of the Vienna General Hospital (VGH) in Austria. Instead of classifying patient data as pathological or normal, Moni-ICU introduces a third borderline class. Patient data classified as borderline with respect to an infection-related clinical concept or HAI surveillance definition signify that the data nearly or partly fulfill the definition for the respective concept or HAI, and are therefore neither fully pathological nor fully normal. Using fuzzy sets and propositional fuzzy rules, we calculated how frequently patient data are classified as normal, borderline, or pathological with respect to infection-related clinical concepts and HAI definitions. In dichotomous classification methods, borderline classification results would be confounded by normal. Therefore, we also assessed whether the constructed fuzzy sets and rules employed by Moni-ICU classified patient data too often or too infrequently as borderline instead of normal. Electronic surveillance data were collected from adult patients (aged 18 years or older) at ten ICUs of the VGH. All adult patients admitted to these ICUs over a two-year period were reviewed. In all 5099 patient stays (4120 patients) comprising 49,394 patient days were evaluated. For classification, a part of Moni-ICU's knowledge base comprising fuzzy sets and rules for ten infection-related clinical concepts and four top-level HAI definitions was employed. Fuzzy sets were used for the classification of concepts directly related to patient data; fuzzy rules were employed for the classification of more abstract clinical concepts, and for top-level HAI surveillance definitions. Data for each clinical concept and HAI definition were classified as either normal, borderline, or pathological. For the assessment of fuzzy sets and rules, we compared how often a borderline value for a fuzzy set or rule would result in a borderline value versus a normal value for its associated HAI definition(s). The statistical significance of these comparisons was expressed in p-values calculated with Fisher's exact test. The results showed that, for clinical concepts represented by fuzzy sets, 1-17% of the data were classified as borderline. The number was substantially higher (20-81%) for fuzzy rules representing more abstract clinical concepts. A small body of data were found to be in the borderline range for the four top-level HAI definitions (0.02-2.35%). Seven of ten fuzzy sets and rules were associated significantly more often with borderline values than with normal values for their respective HAI definition(s) (p<0.001). The study showed that Moni-ICU was effective in classifying patient data as borderline for infection-related concepts and top-level HAI surveillance definitions.

A Family with γ-Thalassemia and High Hb A2 Levels

We describe a family carrying a γ-globin gene deletion associated with an increase of Hb A2 level beyond the normal range. The family included the proband, his sister and their father, all with increased Hb A2 and normal Hb F levels. The proband and his sister showed borderline values of mean corpuscular volume (MCV) and reduced values of mean corpuscular hemoglobin (Hb) (MCH). The proband was referred to our Medical Genetics Service for preconception counseling together with his partner, a typical β-thalassemia (β-thal) carrier. The results were negative for the most frequent α-thalassemia (α-thal) mutations, and had no significant sequence variations of the coding sequences and promoter of the β- and δ-globin genes. Quantitative analysis by multiplex ligation-dependent probe amplification (MPLA) of the β-globin gene cluster detected a heterozygous deletion, ranging between 2.1 and 4.7 kb, in the proband, his sister and the father. The deletion involved the Gγ gene and Gγ-Aγ intergenic region, whereas the 3' region of the Aγ gene was preserved. A subsequent gap-polymerase chain reaction (gap-PCR) showed that a hybrid GAγ fusion gene was present. The deletion segregated with the elevation of Hb A2. The MLPA analysis of the β-globin gene cluster in 150 control alleles excluded a common polymorphism. Despite stronger evidence being needed, the described family suggests a possible role of this γ-globin gene deletion in contributing to Hb A2 elevation, possibly by altering the transcription regulation of the cluster. We propose γ-globin gene dosage analysis to be performed in patients with unexplained elevated Hb A2 levels.

Fertilizer best management practices by SSNM and customized fertilizers for elephant foot yam (Amorphophallus paeoniifolius) cultivation in India

Elephant foot yam [Amorphophallus paeoniifolius (Dennst.) Nicolson] is an important tuber crop grown in many parts of India for its starchy corm and the average yield of this crop is far below the potential productivity of 100 tonnes/ha. One of the reasons attributed to the lower yield is the imbalanced application of essential plant nutrients. Site specific nutrient management (SSNM) is the application of plant nutrients based on the soil and crop need, yield target and developed with the aid of models such as QUEFTS. This paper gives the result of four year study conducted to calibrate and validate the QUEFTS model for elephant foot yam cultivation and the development of SSNM zonation maps and secondary and micronutrient fortified customised fertilizers for the crop in major growing environments of India. Data collected from different field experiments conducted in major elephant foot yam-production regions of India during 1968 to 2011 were used to calibrate the model. The derived parameters of minimum and maximum accumulation of N (130 and 460), P (900 and 2100) and K (100 and 170) are proposed as standard borderline values in the QUEFTS model for elephant foot yam. A linear increase in corm yield was suggested by the model with N, P and K uptakes of 3.97, 0.71, and 7.05 kg N, P and K/1 000 kg corm. The average NPK ratio in total plant dry matter was 5.56:1:9.88. Based on these results, the model was calibrated using historical data as well as by conducting field experiments. It can be observed that fertilizer best management practices by SSNM resulted in an average actual corm yield of 33.45 tonnes/ha, whereas, the model predicted a yield of 35 tonnes/ha. The results of the study showed good agreement between predicted and measured corm yields during the four years, which indicated that the calibrated model can be used to improve NPK fertilizer recommendations for elephant foot yam in India. Based on the results and using soil fertility maps and agro ecological unit maps, SSNM zonation maps and secondary and micronutrient fortified customised fertilizers were developed for major elephant foot yam growing environments of India.

Effect of resistance training on muscular strength and indicators of abdominal adiposity, metabolic risk, and inflammation in postmenopausal women: controlled and randomized clinical trial of efficacy of training volume.

This study evaluated the effect of resistance training (RT) volume on muscular strength and on indicators of abdominal adiposity, metabolic risk, and inflammation in post-menopausal women (PW). Thirty-two volunteers were randomly allocated into the following three groups: control (CT, no exercise, n=11), low-volume RT (LV, three sets/exercise, n=10), and high-volume RT (HV, six sets/exercise, n=11). The LV and HV groups performed eight exercises at 70% of one maximal repetition, three times a week, for 16weeks. Muscular strength and indicators of abdominal adiposity, metabolic risk, and inflammation were measured at baseline and after 16weeks. No differences were found in baseline measures between the groups. The PW showed excess weight and fat percentage (F%), large waist circumference (WC), high waist-hip ratio (WHR), and hypercholesterolemia and borderline values of glycated hemoglobin (HbA1c%). Following the RT, a similar increase in muscle strength and reduction in F% from baseline were found in both trained groups. In HV, a decrease in total cholesterol, LDL-c, WC, and WHR was noted. Moreover, the HV showed a lower change (delta%) of interleukin-6 (IL-6) when compared to CT (HV=11.2%, P 25-75=-7.6-28.4% vs. CT=99.55%, P 25-75=18.5-377.0%, p=0.049). In LV, a decrease was noted for HbA1c%. There were positive correlations (delta%) between WHR and IL-6 and between IL-6 and TC. These results suggest that while a low-volume RT improves HbA1c%, F%, and muscular strength, a high-volume RT is necessary to improve indicators of abdominal adiposity and lipid metabolism and also prevent IL-6 increases in PW.

Abstract P113: Female Gender is Associated with a Low Ankle Brachial Index in the General Population

Background: The ankle-brachial index (ABI) is a predictor of cardiovascular events, mortality and functional status. Gender differences in ABI have been reported in some population studies. Differences in height might account for these observed gender differences, but findings are conflicting. Objective: This study investigated the association between gender, height and ABI in the general population, independent of traditional cardiovascular disease (CVD) risk factors. Methods: Participants ≥ 40 years from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 with ABI data, were included. A low ABI was defined as a value &lt; 1.0 (including borderline values). Sample-weighted multivariable logistic regression modeling was performed with low ABI as the dependent variable and height and gender as primary predictor variables of interest. A backward elimination model selection technique was performed to identify significant covariates. Results: There were 3,052 participants with ABI data (mean age 57, 51% female (1570 of 3052). The sample-weighted mean (±SE) ABI was 1.09 (±0.006) and 1.13 (±0.005) for females and males, respectively. Women were more likely to have a low ABI compared to men, 42% (659 of 1570) versus 28% (415 of 1482), respectively (p&lt;0.0001). Female gender was associated with a low ABI (OR 1.34, [95% CI, 1.04-1.72]; p=0.025), independent of traditional CVD risk factors (see Figure). Age, diabetes, tobacco use, known CVD, BMI and black race were also associated with a low ABI (all p&lt;0.003). Self-reported hypertension and non-HDL cholesterol levels, however, were not associated with a low ABI. An interaction between height and body mass index (BMI) was identified. Conclusions: Female gender is associated with a low ABI in the general population. This association appears to be independent of height and other traditional CVD risk factors and warrants further investigation.

Ankle-brachial index and eicosapentaenoic acid/arachidonic acid ratio in smokers with type 2 diabetes mellitus

BackgroundThe ankle-brachial index (ABI) is an indicator of peripheral arterial damage and a low (ABI ≤ 1.0) or borderline (ABI = 1.00–1.09) value is associated with risk of cardiovascular disease events. A low ratio of serum eicosapentaenoic acid to arachidonic acid (EPA/AA) is also a risk factor for cardiovascular disease events. This study examined associations between the ABI and the EPA/AA ratio in smokers and non-smokers with type 2 diabetes mellitus (T2DM).FindingsBlood data including EPA, AA, and ABI were measured in smokers and non-smokers with T2DM enrolled at Jichi Medical University (n = 116, male 86 %, mean age 59 yr). The patients were classified into two groups according to their ABI level: <1.1 (low to borderline) or ≥1.1 (high). The EPA/AA ratio in smoking patients with ABI < 1.1 (n = 26; EPA/AA = 0.25) was significantly lower than in those with ABI ≥ 1.1 (n = 32; EPA/AA = 0.34; p = 0.03), but was not significantly different in non-smoking patients. The EPA/AA ratio was independently, significantly, and positively correlated with the ABI level (β = 0.41; p < 0.01) after adjusting for multiple variables only in smoking patients with T2DM.ConclusionsThe EPA/AA ratio may be associated with subclinical peripheral arterial damage in smokers with T2DM. Further studies are warranted.

Physical Activity Improves Borderline Ankle–Brachial Index Values in a Cardiovascular Risk Population

Peripheral arterial disease (PAD) is an underdiagnosed and undertreated disease because it remains asymptomatic for so long. The ankle-brachial index (ABI) is a valid method for detecting PAD in lower extremities. ABI ≤0.90 indicates incident PAD. Recent studies have found that subjects with borderline ABI values (0.91-1.00) have increased mortality rates. The objective of our 7-year follow-up study was to investigate the progression of PAD in borderline ABI subjects, who underwent a multifactorial cardiovascular intervention. A total of 193 subjects with borderline ABI were examined in 2005-2006. None of them had previously diagnosed diabetes, cardiovascular or renal disease or intermittent claudication. They were given conventional treatment for multiple risk factors of cardiovascular diseases (hypertension, hypercholesterolemia, elevated blood glucose, smoking, and overweight). Sixty-four percent of these subjects (n = 123) attended a follow-up visit in 2012. Of the 123 subjects with borderline ABI (mean age 59.0 ± 6.5 years, 62% female) at baseline, 18 (15%, 95% confidence intervals [CI]: 9%-22%) developed incident PAD during the follow-up. The mean ABI was 0.97 ± 0.03 at baseline and 1.01 ± 0.12 at 7-year follow-up visit. The change in mean ABI was +0.04 (95% CI: 0.03-0.07), P < 0.001. ABI improved significantly in 25 (20%) subjects. In multivariate ordered logistic regression analyses high and even moderate leisure-time physical activity (LTPA; odds ratio 6.15; 95% CI: 1.99-19.1) predicted a rise in ABI in comparison to low LTPA. Physical activity seems to improve significantly ABI values among men and women with borderline ABI (0.91-1.00).

Soluble receptor for advanced glycation end products in late-onset neonatal infection.

To assess the plasma levels of sRAGE (soluble receptor for advanced glycation end products) in infected and non-infected preterm neonates and to compare their diagnostic values with standard infection biomarkers. RAGE activates pathways responsible for acute and chronic inflammation. The soluble type of this receptor, sRAGE, which acts as a decoy receptor, has been linked to the severity of sepsis and its outcome. Prospective clinical study was carried out from January 2011 to August 2013. There were 33 neonates included according to their infection status and divided into subgroups as follows: infected (I), septic (S), non-infected controls (C). We found significantly lower values of sRAGE in the subgroup S (905.54±220.53 pg/mL; p < 0.028), while borderline values were higher in the subgroup I vs C (2158.33±197.33 pg/mL vs 1744.80±157.74 pg/mL; p < 0.064). By analysing the interobserver concordance we detected 70 % agreement as to sRAGE values detected in neonatal late-onset infections and sepsis, while procalcitonin was used as golden standard. Plasma sRAGE values reflect the severity of the inflammatory status in late-onset infection and sepsis in preterm neonates. Our results indicate that sRAGE could be a good potential biomarker of late-onset neonatal infection and sepsis (Tab. 2, Ref. 14).

De Novo Anemia and Relationship with Vitamin C Deficiency and Zinc Deficiency in a Southern Delaware Population, a Retrospective Analysis

Background:Vitamin C is an essential dietary nutrient. It is a water soluble vitamin that exists in the body primarily in the reduced form Ascorbic acid. It's deficiency leads to a disease called Scurvy which is rare in developed countries. The relationship between anemia, Iron deficiency and Vitamin C deficiency is not clear and not evidence-based although many hematologists recommend Vitamin C intake to help Iron absorption.Method:We reviewed the data from a single institution where cases of de novo anemia underwent diagnostic workup. The study was approved by the hospital IRB and it was a retrospective analysis of data from October 2007 through July 2014. In addition to checking patient's CBC, iron studies, ferritin, b12, folic acid all patients (pts) went through testing for Vitamin C, Copper and Zinc. All reference labs were send to Mayo medical laboratories for consistency and standardization. Vitamin C level was determined by a High-Performance Liquid Chromatography (HLPC) and samples were collected after a 12-14 hour fasting-overnight. The normal range for Vitamin C is 0.6-2.0 mg/dL. We divided patients into 5 categories Severe deficiency (<0.1 mg/dL), Moderate deficiency (0.1-0.3 mg/dL), Mild deficiency (0.4-0.6 mg/dL), Low normal or Borderline values (0.7-0.8 mg/dL) and Normal results (0.9-2.0 mg/dL).Results: Of the 482 pts with de novo anemia tested, 273 subjects were found to have a Vitamin C deficiency (56.6% of population). Of those 30 pts (10.9%) had severe Vit C deficiency, 96 (35.1%) had moderate deficiency, 84 (30.7%) mild deficiency and 63 (23%) had low normal or borderline values and 209 (43.3%) had normal results. In pts with Vitamin C deficiency, iron studies indicated a serum iron saturation below 20% (range 20-50%) in 115 out of 212 subjects tested giving an incidence of 54.2%. Pts who had Vitamin C deficiency about 212 of those pts were tested for zinc levels and 103 pts (48.5%) were found to have Zinc deficiency that's value below 0.66 mcg/ml (Normal range being 0.66-1.1 mcg/ml). Of the group with severe Vitamin C deficiency or undetectable levels (30 pts), average hemoglobin for that group was 8.8 gm/dl range being 11.3-15.5 (CI 5.5-14.9), average iron saturation was 31% range (20-50%)(CI 3-92%), average Zinc levels were 0.49 mcg/ml range 0.66-1.1 (CI 0.19-0.79) average copper value 1.26 mcg/ml range 0.75-1.45 mcg/ml (CI 0.77-1.74), average Ferritin value 1048 ng/ml range 22-322 ng/ml (CI 13.8-5621). This means that in pts with severe anemia and severe vitamin C deficiency we see a profile where 77% pts also present with Zinc deficiency, their copper values are normal, iron saturation is normal but Ferritin which is a marker of inflammation is elevated (66.6%). Taking all of Vitamin C deficiency cases in our study(#273) the average age of females was 57.35 years (CI 15-97) 67.3% of study group & average age for males was 59.61 years (CI 25-90) which is 32.7%Pts who were found to have Vitamin C deficiency were given Vitamin C tablet 500 mg orally daily and if they have Zinc deficiency also supplemented with Zinc 50 mg orally daily. We have data on 67 of those 212 pts who had significant C deficiency (severe, moderate or mild). The average improvement in Vitamin C level for the group was 0.43 mg with average hemoglobin improvement of 0.96 gm.Conclusion: Vitamin C deficiency appears to play an important role in pathogenesis of nutritional anemia and it's incidence was more common than any other identifiable cause in our group. It can present as anemia regardless of the iron status and there appears to be a very strong correlation between Vit C deficiency and Zinc deficiency in patients with anemia. It also causes an Inflammatory response with elevation of Ferritin. Diet appears to play a major role in this type of anemia regardless of the body habitus. Malabsorption of Vitamin C and Zinc can be a reason as well. It is more common in females. Patients may or may not have other signs and symptoms of scurvy but in our population gum disease, bone pain, impaired wound healing and some degree of psychosis and mood disorder (scorbutic psychosis) was common. We believe that Vitamin C Deficiency is very common and under recognized cause of anemia. The exact pathophysiology needs to be established. Further studies need to be done to validate this important clinical finding but we recommend adding a fasting Vitamin C level and Zinc level as part of de novo anemia workup. DisclosuresNo relevant conflicts of interest to declare.

EGR2 Mutations in Chronic Lymphocytic Leukemia: A New Bad Player

Abstract *Contributed equally as first authors. **Contributed equally as senior authors. Recurrent mutations within EGR2, a versatile transcription factor involved in differentiation of hematopoietic cells, were recently reported in 8% of advanced-stage chronic lymphocytic leukemia (CLL) patients, where they appear to be associated with a worse outcome. EGR2 is activated through ERK phosphorylation upon B-cell receptor (BcR) stimulation, and we have previously shown that EGR2 -mutated CLL patients display altered expression of EGR2 down-stream target genes compared to wildtype (wt) patients, thereby pointing to a pathogenic role for EGR2 mutations in dysregulating BcR signaling. To gain further insight into the incidence and prognostic impact of EGR2 mutations in CLL, we screened samples from a well-characterized series of 1430 patients, either by Sanger sequencing (n=1019) or targeted deep-sequencing (n=370), both covering the recently reported EGR2 hotspot in exon 2. In addition, whole-exome data was available for an additional 43 patients. Different cohorts were included in our analysis ranging from 'general practice' CLL (33% IGHV-unmutated (U-CLL), 6% TP53 -aberrant (TP53abn), n=693), to adverse-prognostic CLL (89% U-CLL, 26% TP53abn, n=325), patients belonging to clinically aggressive stereotyped subsets #1-3 &amp; #5-8 (n=342), patients relapsing after FCR therapy (n=41) and Richter transformed cases (n=31), thus reflecting the heterogeneous nature of CLL. Nineteen EGR2 mutations were detected by Sanger sequencing, while 22 additional mutations were identified with deep-sequencing using a 5% variant allele frequency (VAF) cutoff (median 39%, range 5.6-63.9%, median coverage 43,000X). With the exception of one in-frame deletion, all mutations were missense alterations located within the three zinc-finger domains. Significant enrichment of EGR2 mutations was observed in adverse-prognostic (18/325, 5.5%) and FCR-relapsing (4/41, 9.8%) CLL compared to the 'general practice' cohort (18/693, 2.6%, Figure 1A). A surprisingly low frequency was observed among clinically aggressive stereotyped subsets (5/342, 1.5%), although the cause for this observation is currently unknown. Finally, 2/31 (6.5%) cases with Richter transformation carried an EGR2 mutation. Of the 4 FCR-relapsing, EGR2 -mutated cases with available overtime samples, all demonstrated a significant expansion of the EGR2 -mutated clone at relapse (VAF-increase between 15-41%). In addition, subclonal levels of EGR2 hotspot mutations (VAF 0.5-5%) were detected in an additional 13/370 (3.5%) cases by deep-sequencing. The majority of EGR2 -mutated CLL patients (32/39, 82%) concerned U-CLL and the following aberrations co-occurred: 11q-deletions (n=10), TP53abn (n=6), NOTCH1 (n=3)or SF3B1 (n=3) mutations. EGR2 -mutated patients displayed a significantly worse overall survival compared to wt patients (median survival 59 vs. 141 months, p=0.003, using a conservative 10% VAF cutoff), and a poor outcome similar to cases with TP53abn (Figure 1B). In multivariate analysis (n=583), EGR2 status remained an independent factor (p=0.038), along with stage (p=0.048) and IGHV status (p&lt;0.0001), while TP53abn and del(11q) showed borderline significant values (p=0.069 and p=0.059, respectively). To investigate the impact of EGR2 mutations in a homogeneously treated patient cohort, EGR2 mutation analysis of the UK CLL4 trial is underway. To date, 8/247 patients have been identified as EGR2 -mutated by deep-sequencing and they show a decrease of their median overall survival (42 vs. 77 months) compared to wt patients; however, this did not reach statistical significance, probably due to the low number of EGR2 -mutated cases. Final results of the UK CLL4 trial will be presented at the ASH meeting. In summary, EGR2 -mutant cases appear to constitute a novel poor-prognostic subgroup of CLL, with mutations occurring either as disease-initiating aberrations, i.e. in cases where mutations were found in the entire clone, or as subclonal driver events linked to progressive disease. The latter is reflected by the enrichment of EGR2 mutations in aggressive CLL and the association of EGR2 mutations with an overall dismal prognosis. Considering the potential role of mutated EGR2 in altering BcR signaling, it will be particularly relevant to study the efficacy of BcR inhibitors in this patient group. Figure 1. Figure 1. Figure 2. Figure 2. Disclosures Langerak: Roche: Other: Lab services in the field of MRD diagnostics provided by Dept of Immunology, Erasmus MC (Rotterdam); InVivoScribe: Patents &amp; Royalties: Licensing of IP and Patent on BIOMED-2-based methods for PCR-based Clonality Diagnostics.; DAKO: Patents &amp; Royalties: Licensing of IP and Patent on Split-Signal FISH. Royalties for Dept. of Immunology, Erasmus MC, Rotterdam, NL. Schuh:Acerta Pharma BV: Research Funding. Strefford:Roche: Research Funding.

ATM Mutations in Major Stereotyped CLL Subsets: Enrichment in Subset #2 is Associated with Unfavourable Outcome

Chronic lymphocytic leukemia (CLL) is a paradigmatic malignancy where the interplay of cell-extrinsic and cell-intrinsic factors has a major impact on disease evolution. Indeed, extrinsic triggering, e.g. antigenic stimulation through the B-cell receptor (BcR), together with intrinsic aberrations, e.g. accumulation of genetic defects, play a major role throughout the natural history of CLL. The importance of antigen involvement is underscored by the existence of 'stereotyped' BcR in up to 30% of CLL patients. Notably, CLL patients with stereotyped BcR can be grouped into different subsets, each with a subset-biased biological and clinical profile. For instance, while the clinically aggressive subset #2 (IGHV3-21/IGLV3-21, comprising both mutated (M-CLL) and unmutated (U-CLL) IGHV genes) displays a remarkably high frequency of SF3B1 mutations, subset #8, a subset with the highest risk of Richter transformation, shows a strong association with trisomy 12 and NOTCH1 mutations. ATM defects are implicated in the evolution of CLL and are associated with a dismal prognosis, however the extent to which they contribute to the genetic landscape in stereotyped subsets remains unexplored.To gain insight into this issue, we assessed the frequency of ATM mutations in 249 well-characterized CLL patients assigned to major subsets #1-8. The entire coding region of ATM (62 exons) was investigated with two different targeted deep-sequencing approaches, i.e. Haloplex technology (HiSeq, coverage ~1500X) or the Nextera XT kit (MiSeq, coverage ~4000X). A conservative variant allele frequency cut-off of 10% was selected, and mutations were validated by Sanger sequencing.Altogether, we identified 61 ATM mutations in 47/249 (19%) patients across all major subsets (Fig. 1). As expected, the majority of identified ATM mutations (n=43, 70%) have not yet been reported while the remaining 30% were listed in the HGMD or COSMIC mutation databases. The spectrum of ATM mutations included missense (n=31), nonsense (n=9), splicing (n=6), and frame-shift (n=14) mutations, and one in-frame deletion. Missense substitutions were distributed along the entire gene without any 'hotspot' region or preferred domain. The highest mutation frequency was detected in subset #2 (26%), with a significant enrichment in U-CLL vs. M-CLL cases, (13/33 vs. 8/48 subset #2 cases, respectively; p=0.021). Within poor-prognostic U-CLL subsets, ATM mutations were also frequent in subsets #6 (25%) and #7 (23%), while subsets #3, #5, #1, and #8 showed lower frequencies (17%, 17%, 13%, and 7%, respectively). The favorable prognostic M-CLL subset #4 exhibited a low frequency (7%) of ATM mutations. Notably, when comparing the two most populated subsets, i.e. #1 and #2, ATM mutations were overrepresented in the latter with a borderline significance value (p=0.086); when restricting the analysis to U-CLL #2 cases a significantly higher frequency was observed compared to #1 (13/33 vs 9/68; p=0.0045).Regarding the clinical impact of ATM defects in subset #2, we divided patients into subgroups with biallelic inactivation (def-ATM), sole 11q-, sole ATM -mutation, TP53 -aberrations and WT. While both groups with mono-allelic ATM disruption showed a significantly reduced overall survival compared to WT (median survival sole ATM -mutation, 71 months, sole 11q-, 40 months, vs. 123 months in the WT group; p=0.002 and 0.02, respectively), a non-significant reduction of overall survival was observed for patients with bi-allelic ATM aberrations (70 months, p=0.29) (Fig. 2). The few subset #2 patients with TP53 defects showed a similar survival as WT group, underscoring previous observations that TP53 dysfunction per se plays a minor role in this subset.In summary, we demonstrate that ATM mutations can be added to the list of genetic defects with a biased distribution in stereotyped subsets. The enrichment of ATM defects in subset #2 was associated with a negative impact on overall survival, suggesting a role for ATM inactivation in shaping the aggressive phenotype of this subset. This study further supports the recent suggestion that CLL development is driven by antigenic selection, coupled with preferential acquisition of specific genetic defects. The work was supported by the projects MSMT CR CZ.1.05/1.1.00/02.0068, IGA NT13493-4/2012 and TACR TE02000058. [Display omitted] [Display omitted] DisclosuresLangerak:Roche: Other: Lab services in the field of MRD diagnostics provided by Dept of Immunology, Erasmus MC (Rotterdam); DAKO: Patents & Royalties: Licensing of IP and Patent on Split-Signal FISH. Royalties for Dept. of Immunology, Erasmus MC, Rotterdam, NL; InVivoScribe: Patents & Royalties: Licensing of IP and Patent on BIOMED-2-based methods for PCR-based Clonality Diagnostics. . Strefford:Roche: Research Funding. Stamatopoulos:Gilead Sciences: Research Funding; Janssen Pharmaceuticals: Research Funding.

Eligibility and Disqualification Recommendations for Competitive Athletes With Cardiovascular Abnormalities: Task Force 6: Hypertension: A Scientific Statement from the American Heart Association and the American College of Cardiology.

An elevation of blood pressure (BP) in the systemic circulation (hypertension) is the most common cardiovascular condition in the general population and considered to be the most ubiquitous cardiovascular risk factor in competitive athletes. Competitive athletes include those athletes involved in organized sports that typically occur in schools, communities, and professional leagues, including but not limited to intramural and league sports in which medical supervision is typically required. Although most competitive athletes are between the ages of 20 and 40 years, many younger people now participate in competitive athletics. The 2013 update from the American Heart Association using the National Health and Nutrition Examination (NHANES) data from 2007 to 2010 estimates that 9.1% of men aged 20 to 34 years and 6.7% of women of that age are hypertensive, based on having an elevated BP measurement or answering “yes” to the question, “Are you taking antihypertensive medication or were you told that you had hypertension?”1 The prevalence in children and adolescents is estimated to be ≈3.5%, with higher percentages in older and obese children.2 The diagnosis of hypertension is based on the subject having an elevated BP at or above certain levels measured by routine sphygmomanometry under appropriate conditions on at least 2 separate occasions separated by at least 1 week.3 However, BP measurements in the competitive athlete are typically obtained by different healthcare providers, which makes it particularly necessary that the testing conditions be standardized before the diagnosis of hypertension is made. People >18 years of age with a BP >140 mm Hg systolic and/or >90 mm Hg diastolic are considered to have hypertension.3 In children and adolescents, hypertension is defined as average systolic or diastolic BP levels greater than the 95th percentile for sex, age, and height; however, earlier physical maturation of the competitive athlete leaves …

Evidence for a natural humoral response in dairy cattle affected by persistent botulism sustained by non-chimeric type C strains

Bovine botulism is a sporadic acute disease that usually causes catastrophic losses in the herds. The unusual clinical evolution of a persistent mild outbreak in a dairy herd, prompted us to characterize the neurotoxin gene profile of the strain involved and to evaluate whether seroconversion had occurred.Diagnosis was based on mild classical symptoms and was supported by PCR and bacteriological findings, which revealed the involvement of a non-mosaic type C strain.An in-house ELISA was developed to detect antibodies to botulinum neurotoxin type C and its performance was evaluated in a vaccination study.Fifty days after the index case, fecal and serum samples were collected from the 14 animals of the herd and screened for Clostridium botulinum and anti-botulinum neurotoxin antibodies type C, respectively. The in-house developed ELISA was also used to test 100 sera samples randomly collected from 20 herds.Strong ELISA reactions were observed in 3 convalescent and 5 asymptomatic animals involved in the studied outbreak. The ELISA-positive cows all tested positive for non-mosaic C. botulinum type C in the feces and the same strain was also detected in the alfalfa hay, suspected to be the carrier source. Ten out of the 100 randomly collected sera tested positive for anti-botulinum neurotoxin type C antibodies: 7 had borderline values and 3 from the same herd showed titers three times higher than the cut-off.We concluded that type C botulism in cattle may occur with variable severity and that prolonged exposure to sublethal doses of botulinum neurotoxin C may occur, resulting in detectable antibodies.

Effect of antiretroviral therapy on hemoglobin A2 values can have implications in antenatal beta-thalassemia screening programs

Background: Raised hemoglobin-A2 (HbA2) is the diagnostic hallmark of beta-thalassemia trait (βTT). Diagnostic difficulties may arise in HIV-positive patients on antiretroviral therapy (ART). We compared the effect of various antiretroviral drugs on HbA2 levels. We attempted to determine which drugs elevate HbA2 levels causing a false-positive diagnosis of βTT and correlate the findings with red cell indices. Methods: A retrospective analysis of the records of an antenatal thalassemia screening program was carried out for 78 HIV-positive adults (70 antenatal women and 8 husbands) to study the effect of antiretroviral drugs on HbA2 levels. Three had βTT; 20 treatment-naïve subjects constituted controls. The effects of zidovudine (36 cases), stavudine (7 cases), and tenofovir (12 cases) were evaluated. High-performance liquid chromatography was done for HbA2 levels. Values of 3.5–3.9% were borderline and ≥ 4% with hypochromic microcytosis was considered to be βTT. Results: Twenty individuals not on ART had normal HbA2%. Three patients had βTT and showed hypochromic microcytosis despite being on zidovudine. Fourteen of 55 patients on treatment (25.5%) had borderline HbA2 values (mean 3.7%): 11 were on a zidovudine-based regimen and 3 on a stavudine-based regimen. One patient on zidovudine had 4.1% HbA2 with normal Hb and severe macrocytosis (MCV 128.5 fl), leading to a false suspicion of βTT. All patients on tenofovir had normal HbA2. Hematological parameters, including mean corpuscular volume (MCV), mean corpuscular haemoglobin (MCH), and HbA2 levels were increased due to antiretroviral drugs zidovudine and stavudine. Conclusion: Treatment-naïve subjects and those on tenofovir showed no effect on HbA2 levels compared with zidovudine and stavudine. A proportion of patients on zidovudine or stavudine had borderline elevated HbA2 levels, which could lead to a false impression of βTT.

Comparison of Risk of Re-hospitalization, All-Cause Mortality, and Medical Care Resource Utilization in Patients With Heart Failure and Preserved Versus Reduced Ejection Fraction

Because heart failure (HF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) are different clinical entities with differing demographic characteristics, common HF outcomes may occur at different rates. Comparative outcome studies have been equivocal, and studies comparing resource utilization are scant. We used an observational cohort design to study 6,513 patients hospitalized for HF who had an EF measured during the hospitalization and were discharged alive within 30days. We excluded 677 patients with borderline EF values (41% to 49%) and categorized the remaining as HFrEF (EF ≤40%, n= 2,205) and HFpEF (EF >50%, n= 3,631). Patients were followed for up to 1 year for all-cause re-hospitalization and mortality and annualized medical resource utilization. Patients with HFrEF and HFpEF experienced similar adjusted incidence rates of re-hospitalization, but those with HFrEF had a 39% increased risk of mortality at 30days (rate ratio 1.39, 95% confidence interval 1.10 to 1.76) and 25% greater risk at 1year (rate ratio1.25, 95% confidence interval 1.12 to 1.41). After adjustment for covariates, patients with HFpEF incurred significantly more annualized outpatient visits (21.5 vs 20.1, p=0.002) and emergency room visits (3.24 vs 2.94, p= 0.002) than those with HFrEF, but absolute differences were small. High inpatient and pharmacy utilization did not differ. Our study suggests that whether a patient has HFrEF or HFpEF has little bearing on risk of re-hospitalization or inpatient resource utilization in the year after an HF hospitalization. Both groups experienced high mortality, but those with HFrEF had greater risk. In conclusion, from the standpoint of resource use, HF can be considered a single entity.