Effect of add-on cathodal transcranial direct current stimulation (c-TDCS) over pre-supplementary motor area (pre-SMA) in patients with obsessive compulsive disorder: A randomized sham controlled study

Introduction

Patients with OCD often show unsatisfactory response to first-line treatment, giving rise to a need for novel therapeutic approaches. Recent studies using tDCS for OCD treatment have shown promise.

Objectives

To assess efficacy and safety of add-on c-tDCS over pre-SMA compared to sham stimulation in patients with OCD.

Methods

In this double-blinded study, fourteen patients with OCD were randomized to receive 10 sessions of either active (Cathode over pre-SMA, anode over right deltoid, 2mA, 20 minutes per session, 2 sessions per day, 2 hours apart) or sham tDCS. YBOCS, HAM-D, HAM-A, CGI, Wisconsin Card Sorting Test (WCST), and Stroop Test were administered at baseline, post-tDCS, and 1 month post-tDCS.

Results

Group×time interaction effect for YBOCS scores with Repeated Measures ANOVA was not statistically significant, however, reduction in scores in active group was higher, with large effect size (YBOCS scores: Obsessions-η_p²=.344, Compulsions-η_p²= .384, Total-η_p²=.392) (Fig.1 & 2). At 1 month, 42.9% patients in active group and none in sham group showed response. CGI-S score (p=0.016, η_p²=.531) (Fig. 3) and four parameters of WCST (Perseverative responses:p=0.038, η_p²=.448;Percent perseverative responses:p=0.026, η_p²=.485;Percent perseverative errors:p=0.038, η_p²=.447;Trials to complete first category:p=0.011, η_p²=.563) significantly reduced in active group. No significant difference in change in depressive and anxiety symptoms between groups, or change in Stroop Test performance was noted. Adverse effects included transient headache and tingling sensation.

Conclusions

Cathodal tDCS over pre-SMA may be effective in reduction of obsessions, compulsions, illness severity, and enhancing cognitive flexibility in patients with OCD, with no major adverse effects. Larger studies are required to confirm these findings.

Disclosure

No significant relationships.

Impact of rituximab on anthropometric indices among childhood steroid-dependent nephrotic syndromes

BACKGROUND

There is scarcity of data on impact of rituximab on anthropometrical parameters (weight, height and body mass index i.e. BMI SD score (SDS)) among children with steroid-dependent nephrotic syndromes (SDNS).

METHODS

Multicentre retrospective review.

RESULTS

102 children with SDNS (male: 63%; n=64), median age 7 (IQR: 4.3-9.6) years, received a total of 217 rituximab infusions (total 110 cycles). At median follow-up of 2.1 (IQR: 1.3-2.8) years, 58 (57%) children were off steroids and a significant fall in steroid threshold for relapse was noted (median 0.6; IQR 0.4-0.9 to median 0.3; IQR 0.12 - 0.5 mg/kg/alternate day, p=0.005). Anthropometric parameters (BMI SDS: 0.92±1.8 to 0.25±1.47, p=0.003; weight SDS: 0.20±1.6 to -0.11±1.3, p=0.01; and height SDS: -0.93±1.88 to -0.45±1.54, p=0.04) as well as obesity (38% to 20%, p=0.003) and short stature (11% to 3%, p=0.02) improved. Results remained significant even when analysis was restricted to children ≤12 years (n=88), (BMI SDS: 0.97±1.98 to 0.25±1.5, p=0.001; weight SDS: 0.33±1.6 to 0.02±1.2, p=0.01; and height SDS: -0.67±1.84 to -0.186±1.42, p=0.001).

CONCLUSIONS

Use of rituximab resulted in significant steroid sparing effect with an improvement in both growth and obesity parameters.

Identifying emotional facial expressions in practice: a study on Indian medical students

Background

Successful identification of emotional expression in patients is of considerable importance in the diagnosis of diseases and while developing rapport between physicians and patients. Despite the importance of such skills, this aspect remains grossly overlooked in conventional medical training in India. This study aims to explore the extent to which medical students can identify emotions by observing photographs of male and female subjects expressing different facial expressions.

Methods

A total of 106 medical students aged 18-25 without any diagnosed mental illnesses were shown images of the six universal facial expressions (anger, sadness, fear, happiness, disgust and surprise) at 100% intensity with an exposure time of 2 seconds for each image. The participants marked their responses after each image was shown. Collected data were analyzed using SPSS.

Results

Participants could identify 76.54% of the emotions on average, with higher accuracy for positive emotions (95.6% for happiness) and lower for negative emotions (46% for fear). There were no significant variations in identification with respect to gender of observers. On the other hand, statistically significant differences were observed in identification when gender of the expressors were considered.

Conclusions

Male participants identified emotions better from male faces, while females identified positive emotions better from female faces and negative ones from male faces.

Key messages

Misidentification of emotions, especially negative emotions, from static facial expressions was common in physician students of both sexes. This is an aspect that needs to be addressed during the training of medical students in India.

FRI0465 TOFACITINIB POPULATION PHARMACOKINETICS IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS: A POOLED ANALYSIS OF DATA FROM THREE CLINICAL STUDIES

Background:

Tofacitinib is an oral JAK inhibitor that is being investigated for juvenile idiopathic arthritis (JIA).

Objectives:

To describe tofacitinib pharmacokinetics (PK) in patients with JIA, identify potential covariates accounting for variability in exposure, assess the formulation effect of oral solution vs tablet and propose a simplified dosing regimen.

Methods:

This was a pooled analysis of data from 3 tofacitinib clinical studies in patients with JIA aged 2−<18 years: a Phase 1, open-label (OL), non-randomised study (NCT01513902); a Phase 3, randomised, double-blind, placebo-controlled, withdrawal study (NCT02592434); and an OL long-term extension study (NCT01500551). Tofacitinib was dosed at 5 mg twice daily (BID) in patients ≥40 kg or at body weight (BW)-based lower doses BID in patients <40 kg, to achieve average concentrations (Cavg) comparable with those in patients receiving 5 mg BID. A sparse PK sampling scheme was applied, and the plasma samples were assayed using a validated, sensitive and specific high-performance liquid chromatography tandem mass spectrometric method (lower limit of quantification = 0.100 ng/mL). A nonlinear mixed-effects modelling approach was used for the population PK model, and population parameter variability was assumed to be log-normally distributed. Covariates relating to patient demographics, disease characteristics, concomitant medications and formulation (oral solution vs tablet) were selected using a stepwise covariate modelling approach, and parameter-covariate relationships were evaluated using stepwise forward-inclusion (p<0.05) backward-deletion (p<0.001) procedures. The effect of time-varying BW on oral clearance (CL/F) and apparent volume of distribution (V/F) was characterised using an allometric model. Final model quality was assessed by Visual Predictive Checks (VPCs).

Results:

Of 246 patients in the analysis, 74.0% were female; 87.8% were white, 2% were black, 10.2% were ‘other’ races and no patients were Asian. Median (range) BW was 46.3 (11.1−121.8) kg. Initially, 100 patients received oral solution and 146 patients received tablets; 11 patients switched formulations during the studies. A one compartment disposition model with first-order absorption and a lag time sufficiently described the data. Final estimates for CL/F, V/F and the first-order absorption rate constant (ka) for tablets were 26.1 L/hr, 89.2 L and 2.78 hr-1, respectively. The only statistically significant covariate was a formulation effect on ka. All parameters were estimated adequately. Estimated allometric exponents were 0.310 for CL/F and 0.537 for V/F. Absorption was described with an estimated lag time of 0.186 hr, and the oral solution had a 1.64-fold faster absorption rate vs the tablet. VPCs sufficiently described the observed data over time, across BWs and ages. Given the PK characterisation and variability in patients with JIA, a simplified dosing scheme was proposed, targeting Cavgvalues equivalent to those in patients receiving 5 mg BID: 3.2 mg BID solution in patients 10−<20 kg; 4 mg BID solution in patients 20−<40 kg; and 5 mg BID tablet or solution in patients ≥40 kg.

Conclusion:

Tofacitinib population PK in patients with JIA were adequately described by a one compartment model parameterised in terms of CL/F, V/F and first-order absorption with a lag time. Drug absorption from the oral solution was faster than from the tablet. Tofacitinib does not require dose modification or restrictions for any covariates, except BW, to account for differences in Cavg. Based on the results of this analysis, a simplified BW-based dosing regimen was proposed.

Acknowledgments:

Study sponsored by Pfizer Inc. Medical writing support was provided by Sarah Piggott of CMC Connect and funded by Pfizer Inc.

Disclosure of Interests:

Camille Vong Shareholder of: Pfizer Inc, at time of analysis, Employee of: Pfizer Inc, at time of analysis, Xiaoxing Wang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Anasuya Hazra Shareholder of: Pfizer Inc, at time of analysis, Employee of: Pfizer Inc, at time of analysis, Arnab Mukherjee Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Timothy Nicholas Shareholder of: Pfizer Inc, Employee of: Pfizer Inc, Cheng Chang Shareholder of: Pfizer Inc, Employee of: Pfizer Inc

Development of fluorescent protein-based biosensing strains: A new tool for the detection of aromatic hydrocarbon pollutants in the environment

The major sources for release of hydrocarbons into the environment include the effluents generated from chemical processing industries and ports. The introduction of such hazardous compounds into natural water bodies creates considerable disturbances in aquatic life and causes a threat to humans. Thus, it is essential to detect and quantify pollutants at various stages of the wastewater generation and treatment before they reach natural aquatic environments and contaminate them. This study reports the development of "biosensing strains" by cloning hydrocarbon recognizing promoter-operator and a reporter gene in bacterial strains for sensing the presence of pollutants at their lowest possible concentration. So far, various biosensing strains have been constructed with a fused promoter-operator region of the hydrocarbon degrading operons, but most of them use luxAB as a reporter gene. A novel approach in the present study aimed at constructing strains harboring two different fluorescent protein (FP)-based reporter genes for the quantification of multiple pollutants at a time. Two vectors were designed with a fusion of tbuT-gfp and phnR-cfp for the quantification of mono- and poly-aromatic hydrocarbons, respectively. The designed vectors were transformed into E. coli DH5α, and these strains were designated as E. coli DH5α 2296-gfp (containing pPROBE-Tbut-RBS-gfp-npt) and E. coli DH5α 2301-cfp (containing pPROBE-phn-RBS-cfp-npt). Both the developed recombinant strains were capable of successfully detecting mono- and poly-aromatic hydrocarbons in the range of 1-100 μM. The sensing capacity of recombinant strains was successfully validated with actual wastewater samples against available physico-chemical analytical techniques. The development of such recombinant microbial strains indicates the future for online contaminant detection, treatment quality monitoring and protection of aquatic flora and fauna.

P01.02 Serum-derived DNA methylation markers distinguish functional and invasiveness subtypes in patients harboring pituitary tumors

BACKGROUND

Molecular profiling of circulating biomarkers released by tumors has a relevant clinical value in central nervous system (CNS) tumors, but its feasibility has not been investigated in pituitary tumors (PT) despite being the second common intraaxial tumors of the CNS (~15%). Although usually benign and slow-growing, they can be nonfunctioning and invade surrounding structures resulting in significant comorbidities. DNA methylation aberrations distinguish PT according to their functional status but their role in invasiveness is still unclear. Pre-surgical detection of clinically relevant molecular markers associated with tumor behavior can address current diagnostic and therapeutic challenges. We hypothesized that PT release cell-free DNA (cfDNA) into the bloodstream allowing for the profiling of epigenetic markers associated with relevant clinicopathological features.

MATERIAL AND METHODS

Genome-wide methylome profile of paired serum cfDNA (EPIC array) and tissue from 13 patients with pituitary macroadenomas (9 males; median age: 62; 9 NFPT, 6 invasive) and 3 controls serum (patients with epilepsy).

RESULTS

Unsupervised analysis of the serum methylome from patients harboring PT was distinct from controls and other diseases (hypopituitarism, glioma and colorectal cancer) and supervised analysis (Wilcoxon Rank-sum Test) identified significant differentially methylated probes (DMP) that segregated PT from control serum specimens. Nonfunctioning and invasive-specific DMPs identified in the serum also defined functional, and less prominently invasive status, in the tissue of an independent cohort of PT.

CONCLUSION

This is the first study to show the feasibility to profile the methylome in the serum of patients with PT using cfDNA. In addition, we identified unique methylation signatures that distinguished PT according to functional and invasiveness subtypes. These results underpin the potential role of methylation profile and liquid biopsy as a noninvasive approach to assess clinically relevant molecular features in the serum of patients harboring PT.

OS1.5 Detection of glioma and prognostic subtypes by non-invasive circulating cell-free DNA methylation markers

BACKGROUND: Genome-wide DNA methylation profiling has shown that epigenetic abnormalities are biologically important in glioma and can be used to classify these tumors into distinct prognostic groups. Thus far, DNA profiling has required surgically resected glioma tissue; however, gliomas release tumoral material into biofluids providing an opportunity for a minimally invasive testing. While prior studies have shown that molecular markers can be detected in liquid biopsy (LB), there has been low sensitivity for tumor-specific markers. We hypothesize that the low sensitivity is due to the targeted assay methods. METHODS: Genome-wide CpG methylation levels in DNA of tumor tissue and cell-free DNA serum of glioma patients. RESULTS: We defined glioma-specific and IDH-specific epigenetic LB (eLB) signatures (Glioma-eLB and IDH-eLB, respectively) from serum cell-free DNA from patients diagnosed with glioma (N=15 IDH mutant and N=7 IDH wildtype) and with epilepsy (N=3). The epigenetic profiles of the matched tissue demonstrate that these eLB signatures reflected the signature of the tumor. Through cross-validation we show that Glioma-eLB can accurately predict a patient’s glioma from those with other neoplasias (N=6 Colon; N=14 Pituitary; N=3 Breast; N=4 Lung), non-neoplastic immunological conditions (N=22 sepsis; N=9 pancreatic islet transplantation), and from healthy individuals (sensitivity: 98%; specificity: 99%). Finally, IDH-eLB includes promoter methylated markers associated with genes known to be involved in glioma tumorigenesis (PVT1 and CXCR6). CONCLUSIONS: The application of the non-invasive eLB signature discovered in this study has the potential to complement the standard of care for patients harboring glioma.

This project is supported by the Henry Ford Health System, Department of Neurosurgery and the Hermelin Brain Tumor Center Foundation (A30935), United States National Institutes of Health (R01CA222146), and United States Department of Defense (CA170278)

Role of Andaman and Nicobar Islands in eddy formation along western boundary of the Bay of Bengal

Eddies along western boundary of the Bay of Bengal (WBoB) play an important role in regulating regional climate and marine productivity of the north Indian Ocean. In this paper, role of Andaman and Nicobar islands (ANIs) in the formation of eddies along the WBoB is studied using an ocean general circulation model. Our analysis shows that, in the absence of ANIs, there is a significant reduction in the total number of mesoscale eddies in this region. The impact is particularly evident for the cyclonic eddies as a reduction of ~50% can be noticed in the absence of the islands. In contrast, influence of ANIs on anticyclonic eddies is not homogeneous in the WBoB; while absence of ANIs significantly increases anticyclonic eddies in the central part of the WBoB, a decrease can be noticed in the southern part. We further show that the reduction in number of cyclonic eddies along the WBoB is primarily driven by reduced baroclinic and barotropic instabilities. This process is more conspicuous during winter (October–January) season compared to summer (June–September) and spring (February–May) seasons.

Conversion of clinically isolated syndrome to multiple sclerosis: a prospective multi-center study in Eastern India

Background

In White populations more than 60% of clinically isolated syndrome (CIS) convert to multiple sclerosis (MS) on a long-term follow-up; several predictors for conversion have been identified.

Objective

This study aimed to determine the conversion rate and the predictors of conversion from CIS to MS (McDonald 2010) among Indians. The other objective was to evaluate the diagnostic accuracy of the new McDonald 2017 criteria in prediction of a second clinical attack.

Methods

Clinical and demographic data of CIS cohorts were collected. Baseline investigations included cerebrospinal magnetic resonance imaging (MRI) with contrast and cerebrospinal fluid (CSF) testing for oligoclonal band (OCB). Follow-up clinical and MRI examinations were performed annually for at least 24 months.

Results

Of the 82 subjects (age range 15-58 years), 36 (43.9%) converted to MS; 31/82 (37.8%) converted in 24 months. The predictors for conversion were earlier age of onset, CSF-OCB, cerebral MRI T2 lesion count, and periventricular and juxtacortical location of lesions. Twenty-two (26.83%) CIS fulfilled the McDonald MS 2017 criteria at baseline.

Conclusion

In this first prospective study of CIS in India, the risk factors for conversion are similar but the conversion rate to MS is lower than that in the western nations.

Evidence-Based Guideline on Laparoscopy in Pregnancy: Commissioned by the British Society for Gynaecological Endoscopy (BSGE) Endorsed by the Royal College of Obstetricians & Gynaecologists (RCOG)

Laparoscopy is widely utilised to diagnose and treat acute and chronic, gynaecological and general surgical conditions. It has only been in recent years that laparoscopy has become an acceptable surgical alternative to open surgery in pregnancy. To date there is little clinical guidance pertaining to laparoscopic surgery in pregnancy. This is why the BSGE commissioned this guideline. MEDLINE, EMBASE, CINAHL and the Cochrane library were searched up to February 2017 and evidence was collated and graded following the NICE-approved process. The conditions included in this guideline are laparoscopic management of acute appendicitis, acute gall bladder disease and symptomatic benign adnexal tumours in pregnancy. The intended audience for this guideline is obstetricians and gynaecologists in secondary and tertiary care, general surgeons and anaesthetists. However, only laparoscopists who have adequate laparoscopic skills and who perform complex laparoscopic surgery regularly should undertake laparoscopy in pregnant women, since much of the evidence stems from specialised centres.

Nano-Magnesium Oxide: A Novel Bactericide Against Copper-Tolerant Xanthomonas perforans Causing Tomato Bacterial Spot

Bacterial spot caused by Xanthomonas perforans causes significant damage on tomato in Florida. Due to the presence of copper (Cu)-tolerant X. perforans strains, Cu bactericides are not effective in disease management. Hence, there is a critical need to find alternatives for Cu. Antibacterial activity of magnesium oxide (Nano-MgO), and other metal oxide nanoparticles, were evaluated against a Cu-tolerant and -sensitive X. perforans strain. In vitro experiments demonstrated high antibacterial activity of Nano-MgO against both strains compared with the commercial Cu. The minimum inhibitory concentration of Nano-MgO is 25 µg/ml and the minimum bactericidal concentration is 100 µg/ml against a Cu-tolerant X. perforans strain after 4 h of exposure. Structural changes in the bacterial membrane following exposure to Nano-MgO treatments compared with the controls were observed using transmission electron microscopy. In two greenhouse experiments with a Cu-tolerant strain, bacterial spot severity was significantly reduced by Nano-MgO at 200 µg/ml compared with Cu-ethylene bis-dithiocarbamate (grower standard), and the untreated control (P = 0.05). In three field experiments, Nano-MgO at 200 µg/ml significantly reduced disease severity with no negative impact on yield compared with the untreated control. Inductively coupled plasma mass spectrometric analysis of the fruit confirmed that Nano-MgO application did not lead to the accumulation of Mg, Cu, Ca, K, Mn, P, and S. This study is the first to demonstrate the potential of Nano-MgO against bacterial spot of tomato.

A case of disseminated tuberculosis mimicking metastatic cancer

BACKGROUND

Disseminated tuberculosis (TB) or miliary TB is defined as lymphohematogenous dissemination of Mycobacterium tuberculosis bacilli, which may then affect virtually any organ system. The multiple organ involvement in disseminated TB can mimic metastatic cancer and can make the diagnosis challenging. False negatives are common therefore repeating microbiologic and histologic samples is essential.

CASE REPORT

We report the case of a young immunocompetent patient presenting with multiple atypical extra-pulmonary TB involvement. The patient presented with pulmonary, pleural, bilateral testicular and multiple bone involvement including calcanerium abscesses. These lesions were initially described as metastasis by the radiologist. Therefore lymphoma and metastatic testicular cancer as well as TB were high on the differential in this young foreign-born male. Pleural, broncho-alveolar lavage, bone marrow and cerebrospinal fluid acid-fast bacilli smear and microbiologic culture were all negative. However the histologic examination of the trans-bronchial biopsy and pleural biopsy showed necrotizing granuloma and helped to narrow down the diagnosis. The patient improved with RIPE therapy.

CONCLUSION

This case illustrates the diagnostic difficulty of disseminated TB with atypical organ involvement. Culture is the gold standard for diagnosing TB but is a long process and with 23% of culture negative TB in the United-States, the diagnosis sometimes relies on thoroughly ruling-out differential diagnosis and histologic examination.

Deep urban groundwater vulnerability in India revealed through the use of emerging organic contaminants and residence time tracers

Demand for groundwater in urban centres across Asia continues to rise with ever deeper wells being drilled to avoid shallow contamination. The vulnerability of deep alluvial aquifers to contaminant migration is assessed in the ancient city of Varanasi, India, using a novel combination of emerging organic contaminants (EOCs) and groundwater residence time tracers (CFC and SF₆). Both shallow and intermediate depth private sources (<100 m) and deep (>100 m) municipal groundwater supplies were found to be contaminated with a range of EOCs including pharmaceuticals (e.g. sulfamethoxazole, 77% detection frequency, range <0.0001-0.034 μg L^-1), perfluoroalkyl substances (e.g. PFOS, range <0.0001-0.033 μg L^-1) as well as a number of pesticides (e.g. phenoxyacetic acid, range <0.02-0.21 μg L^-1). The profile of EOCs found in groundwater mirror those found in surface waters, albeit at lower concentrations, and reflect common waste water sources with attenuation in the subsurface. Mean groundwater residence times were found to be comparable between some deep groundwater and shallow groundwater sources with residence times ranging from >70 to 30 years. Local variations in aquifer geology influence the extent of modern recharge at depth. Both tracers provide compelling evidence of significant inputs of younger groundwater to depth >100 m within the aquifer system.

Immunosuppressive effect of the gut microbiome altered by high-dose tacrolimus in mice

The alterations induced in gut microbiota by tacrolimus may affect immune function and organ transplantation. Mice were treated with high-dose tacrolimus for 14 days. The fecal microbiota were analyzed by pyrosequencing the 16S rRNA genes, and the effect on metabolism was predicted using the sequence data. The subgroups of T cells in the serum, gut-associated lymphoid tissue, and draining lymph nodes were determined by flow cytometry. Tacrolimus treatment significantly altered the relative abundance of Allobaculum, Bacteroides, and Lactobacillus and CD4⁺ CD25^hi FoxP3⁺ regulatory T cells in the colonic mucosa and the circulation. These were significantly increased after either tacrolimus treatment or treatment by fecal microbiota transfer from tacrolimus-treated donors. Further, treatment with low-dose tacrolimus plus fecal microbiota transfer from high-dose tacrolimus-altered mice increased skin allograft survival rate in a skin transplantation model. Thus, high-dose tacrolimus alters the compositions and taxa of the gut microbiota. Administration of these conditioned gut microbiota plus low-dose tacrolimus resulted in regulation of colonic and systemic immune responses and an increased allograft survival rate. This study demonstrated a new strategy for controlling allograft rejection by combining an immunosuppressive agent with gut microbiome transplantation.