A CLEAR CASE OF MRSA SEPSIS, OF AN UNEXPECTED ORIGIN

A 56-year-old man with a history of uncontrolled type 2 diabetes mellitus, benign prostatic hypertrophy and history of recent knee and elbow abscess presented to the emergency department with nausea, vomiting, and fevers. Two days prior, he presented to the ER and was diagnosed with acute presumed prostatitis and urinary retention. He was discharged on ciprofloxacin and an indwelling Foley catheter with urology follow-up. After being unable to tolerate oral medications, he presented again to the emergency department, at which time, he was febrile and tachycardic. Physical exam was benign except for a boggy and tender prostate and bilateral CVA tenderness. Labs demonstrated leukocytosis, elevated HbA1C, and pyuria on urinalysis. Urine cultures collected at the patient's earlier emergency department visit demonstrated no growth. Computed tomography indicated an enlarged prostate with patchy areas of low density. He was admitted with sepsis secondary to prostatitis. Blood cultures on day one showed gram-positive cocci , methicillin resistant staph aureus (MRSA isolate) and persistent bacteremia for three days despite therapy with vancomycin. After adequate dosing of vancomycin, sterilization of the blood was achieved, yet urine culture demonstrated growth of MRSA. Transthoracic rchocardiogram (TTE) showed no signs of endocarditis with good visualization of valves. He was successfully treated with 14 days of vancomycin.

Heart failure: novel therapeutic approaches

Heart failure (HF) is a complex clinical syndrome that can result from any structural or functional cardiac disorders that impairs the ability of the ventricle to fill with or eject blood. Despite effective medical interventions, mortality and morbidity remain substantial. There have been significant advances in the therapy of HF in recent decades, such as the introduction of beta-blockers and antagonists of the renin-angiotensin system but still there is a major unmet need for better therapies for HF. In the present era, pathophysiology of HF has been explored. Various novel pathways, molecular sites have been identified, which contribute to the progression of the disease. By targeting these sites, newer pharmacological agents have been developed, which can play a promising role in the treatment of HF. This article focuses on recent advancements in pharmacotherapy of HF, which include agents targeting myocardial contractility, cytokines and inflammation, fibrosis and remodeling, myocardial metabolism, oxidative stress, and other newly defined pathways.

Large-scale discovery of novel genetic causes of developmental disorders

Despite three decades of successful, predominantly phenotype-driven discovery of the genetic causes of monogenic disorders, up to half of children with severe developmental disorders of probable genetic origin remain without a genetic diagnosis. Particularly challenging are those disorders rare enough to have eluded recognition as a discrete clinical entity, those with highly variable clinical manifestations, and those that are difficult to distinguish from other, very similar, disorders. Here we demonstrate the power of using an unbiased genotype-driven approach to identify subsets of patients with similar disorders. By studying 1,133 children with severe, undiagnosed developmental disorders, and their parents, using a combination of exome sequencing and array-based detection of chromosomal rearrangements, we discovered 12 novel genes associated with developmental disorders. These newly implicated genes increase by 10% (from 28% to 31%) the proportion of children that could be diagnosed. Clustering of missense mutations in six of these newly implicated genes suggests that normal development is being perturbed by an activating or dominant-negative mechanism. Our findings demonstrate the value of adopting a comprehensive strategy, both genome-wide and nationwide, to elucidate the underlying causes of rare genetic disorders.

The impact of early intra-articular administration of interleukin-1 receptor antagonist on lubricin metabolism and cartilage degeneration in an anterior cruciate ligament transection model

OBJECTIVE

Study the impact of intra-articular interleukin-1 receptor antagonist (IL-1 ra) treatment on lubricin biosynthesis following anterior cruciate ligament transection (ACLT) in the rat and evaluate the effect of combined IL-1 ra and recombinant human lubricin (rhPRG4) treatments on chondrocyte apoptosis.

METHODS

ACLT was performed in male Lewis rats. Treatments included IL-1 ra or vehicle (n = 36 in each group). IL-1 ra intra-articular dosing was performed on days 1, 3, 5 and 7 following ACLT using Anakinra (150 mg/ml; 40 μl). At 3 and 5 weeks, animals were sacrificed and RNA was isolated. Histological analyses included Safranin O and H&E. Lubricin synovial fluid (SF) lavage concentrations were determined at 5 weeks. ACLT animals were treated with a single injection of vehicle, IL-1 ra (75 mg/ml; 40 μl), rhPRG4 (200 μg/ml; 40 μl), or IL-1 ra + rhPRG4 (75 mg/ml + 200 μg/ml; 40 μl) (n = 6 in each group) on day 7 following ACLT and cartilage was probed for cleaved caspase-3 at 5 weeks.

RESULTS

IL-1 ra treatment improved lubricin expression (P < 0.001) and lubricin SF lavage concentrations in the IL-1 ra group was higher (P = 0.005) than the vehicle. IL-1 ra treatment reduced cartilage and synovial scores (P < 0.001) compared to vehicle. IL-1 ra and rhPRG4 acted synergistically to reduce caspase-3 positive chondrocytes (P < 0.001) compared to individual treatments.

CONCLUSION

IL-1 ra treatment preserved lubricin following ACLT and a combined treatment of IL-1 ra + rhPRG4 may act synergistically to reduce cartilage catabolism.

Diagnostic accuracy of integrated (18)F-FDG PET/CT for restaging patients with malignant germ cell tumours

OBJECTIVE

Evaluation of utility of fluorine-18 fludeoxyglucose ((18)F-FDG) positron emission tomography/CT (PET/CT) for restaging patients with primary malignant germ cell tumours (GCTs).

METHODS

Data of 92 patients (age, 31.94 ± 10.1 years; male/female, 86/6) with histopathologically confirmed malignant GCTs (gonadal, 88; mediastinal, 4; seminomatous, 47 and non-seminomatous, 45) who underwent (18)F-FDG PET/CT for restaging (suspected recurrence/post-therapy evaluation) were retrospectively analysed. Two experienced nuclear medicine physicians reviewed the PET/CT images in consensus, qualitatively and semi-quantitatively [maximum standardized uptake value (SUVmax)]. Histopathology (if available) and clinical/imaging/biochemical follow-up (minimum of 6 months) were employed as the reference standard.

RESULTS

(18)F-FDG PET/CT was interpreted as positive in 59 and negative in 33 patients. Local disease was seen in 5, nodal disease in 50 and distant metastasis in 22 patients. PET/CT was true positive in 49, false positive in 10, true negative in 30 and false negative in 3 patients. (18)F-FDG PET/CT showed sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 94.2%, 75.0%, 83.0%, 90.9% and 85.8% overall; 90.0%, 74.0%, 72.0%, 90.9% and 80.8% in seminomatous GCT; and 96.8%, 76.9%, 91.1%, 90.9% and 91.1% in non-seminomatous GCT, respectively. Difference in PET/CT accuracy for seminomatous and non-seminomatous GCTs was not significant (p = 0.263). PET/CT demonstrated disease in 13 patients with negative/equivocal conventional imaging findings and in 9 patients with normal tumour markers. No site- or histology-based difference was seen in SUVmax.

CONCLUSION

(18)F-FDG PET/CT demonstrates high diagnostic accuracy for restaging patients with malignant GCTs. It has comparable diagnostic performance in both seminomatous and non-seminomatous malignant GCTs.

ADVANCES IN KNOWLEDGE

The present article demonstrates high diagnostic accuracy of (18)F-FDG PET/CT for restaging both seminomatous and non-seminomatous malignant GCTs in a large patient population.

Ilaprazole: Is this a superior proton pump inhibitor for duodenal ulcer?

BACKGROUND

Preclinical studies have found ilaprazole to be significantly effective in preventing the development of reflux oesophagitis and gastric secretion in a dose-dependent manner; the drug also has a broad dose range and safety feature. Till date only one clinical study on patients with gastro-oesophageal reflux disease has shown its potency in suppressing gastric acid secretion.

OBJECTIVES

To review the published randomized controlled trials (RCTs) assessing the efficacy of ilaprazole in duodenal ulcer (DU) compared to other available proton pump inhibitors (PPI).

METHODS

RCTs comparing ilaprazole with other PPIs in DU were searched in the PubMed and Cochrane Library database using the term 'ilaprazole and duodenal ulcer'. All clinical studies showing effectiveness of ilaprazole in patients with DU, either full texts or scientific abstracts and found to be potentially eligible for the systematic review, were included and evaluated.

RESULTS

Four RCTs having follow-up data were included. A total of 1077 patients with DU were assessed. All the trials had included omeprazole as a comparator PPI. The majority of patients (80%) became asymptomatic after treatment in both the groups. None of the trials data predict ilaprazole to be superior to omeprazole in terms of efficacy in patients with DU.

CONCLUSION

The trials conducted were limited in numbers and all the trial data indicated the efficacy of ilaprazole to be similar to that of omeprazole. None of the trials indicated superiority of ilaprazole over the existing PPIs.

Glycoengineered factor IX variants with improved pharmacokinetics and subcutaneous efficacy

BACKGROUND

The rapid clearance of factor IX (FIX) necessitates frequent intravenous administration to achieve effective prophylaxis for patients with hemophilia B. Subcutaneous administration would be a preferred route of administration but is limited by bioavailability.

OBJECTIVES

To improve the pharmacokinetics (PK) and bioavailability of FIX, a screen was performed to identify positions for the introduction of novel glycosylation sites with maximal effect on PK and maintenance of coagulation activity.

METHODS

Two hundred fifty-one variants, each containing one additional N-linked glycosylation site, were screened in vitro, and the PK profiles of selected variants mapping to spatially distinct regions of FIX were evaluated in mice. Optimal variants were combined, and their PK and efficacy were determined in mice with hemophilia B.

RESULTS

Variants that mapped to spatially distinct regions of the FIX structure exhibited different degrees of improved PK and enabled selection of optimized sites while minimizing the loss of FIX activity. Combining the most effective N-glycan sites in the same FIX molecule resulted in further improvements in PK. An optimized variant containing three novel N-glycan sites (at amino acids 103, 151, and 228), and the activity enhancing 338A variant had double the specific activity of wild-type FIX, exhibited 4.5-fold reduced clearance and 2.4-fold increased subcutaneous bioavailability, and was efficacious at a fivefold lower mass dose than wild-type FIX after subcutaneous injection in a bleeding model in mice with hemophilia B.

CONCLUSIONS

Glycoengineering was used to significantly improve the subcutaneous PK and efficacy of FIX and may have advantages for subcutaneous dosing.

The impact of introducing thioguanine nucleotide monitoring into an inflammatory bowel disease clinic

BACKGROUND

Thioguanine nucleotides (TGNs) are the active product of thiopurine metabolism. Levels have been correlated with effective clinical response. Nonetheless, the value of TGN monitoring in clinical practice is debated. We report the influence of introducing TGN monitoring into a large adult inflammatory bowel disease (IBD) clinic.

PATIENTS AND METHODS

Patients with IBD undergoing TGN monitoring were identified from Purine Research Laboratory records. Whole blood TGNs and methylated mercaptopurine nucleotides were hydrolysed to the base and measured using HPLC. Clinical and laboratory data were obtained retrospectively.

RESULTS

One hundred and eighty-nine patients with 608 available TGN results were identified. In non-responders, TGNs directed treatment change in 39/53 patients. When treatment was changed as directed by TGN, 18/20 (90%) improved vs. 7/21 (33%) where the treatment decision was not TGN-directed, p < 0.001. Where treatment change was directed at optimisation of thiopurine therapy, 14/20 achieved steroid-free remission at 6 months vs. 3/10 where the TGN was ignored, (p = 0.037). Six per cent of patients were non-adherent, 25% under-dosed and 29% over-dosed by TGN. Twelve per cent of patients predominantly methylated thiopurines, this group had low TGN levels and high risk of hepatotoxicity. In responders, adherence and dosing issues were identified and TGN-guided dose-reduction was possible without precipitating relapse. Mean cell volume (MCV), white blood cell count (WBC) and lymphocyte counts were not adequate surrogate markers. MCV/WBC ratio correlated with clinical response, but was less useful than TGN for guiding clinical decisions.

CONCLUSIONS

Monitoring TGNs enables thiopurine therapy to be optimised and individualised, guiding effective treatment decisions and improving clinical outcomes.