Semaphorin 4B is an ADAM17-cleaved adipokine that inhibits adipocyte differentiation and thermogenesis

OBJECTIVE

The metalloprotease ADAM17 (also called TACE) plays fundamental roles in homeostasis by shedding key signaling molecules from the cell surface. Although its importance for the immune system and epithelial tissues is well-documented, little is known about the role of ADAM17 in metabolic homeostasis. The purpose of this study was to determine the impact of ADAM17 expression, specifically in adipose tissues, on metabolic homeostasis.

METHODS

We used histopathology, molecular, proteomic, transcriptomic, in vivo integrative physiological and ex vivo biochemical approaches to determine the impact of adipose tissue-specific deletion of ADAM17 upon adipocyte and whole organism metabolic physiology.

RESULTS

ADAM17adipoq-creΔ/Δ mice exhibited a hypermetabolic phenotype characterized by elevated energy consumption and increased levels of adipocyte thermogenic gene expression. On a high fat diet, these mice were more thermogenic, while exhibiting elevated expression levels of genes associated with lipid oxidation and lipolysis. This hypermetabolic phenotype protected mutant mice from obesogenic challenge, limiting weight gain, hepatosteatosis and insulin resistance. Activation of beta-adrenoceptors by the neurotransmitter norepinephrine, a key regulator of adipocyte physiology, triggered the shedding of ADAM17 substrates, and regulated ADAM17 expression at the mRNA and protein levels, hence identifying a functional connection between thermogenic licensing and the regulation of ADAM17. Proteomic studies identified Semaphorin 4B (SEMA4B), as a novel ADAM17-shed adipokine, whose expression is regulated by physiological thermogenic cues, that acts to inhibit adipocyte differentiation and dampen thermogenic responses in adipocytes. Transcriptomic data showed that cleaved SEMA4B acts in an autocrine manner in brown adipocytes to repress the expression of genes involved in adipogenesis, thermogenesis, and lipid uptake, storage and catabolism.

CONCLUSIONS

Our findings identify a novel ADAM17-dependent axis, regulated by beta-adrenoceptors and mediated by the ADAM17-cleaved form of SEMA4B, that modulates energy balance in adipocytes by inhibiting adipocyte differentiation, thermogenesis and lipid catabolism.

The ADAM17 sheddase complex regulator iTAP/Frmd8 modulates inflammation and tumor growth

The metalloprotease ADAM17 is a sheddase of key molecules, including TNF and epidermal growth factor receptor ligands. ADAM17 exists within an assemblage, the "sheddase complex," containing a rhomboid pseudoprotease (iRhom1 or iRhom2). iRhoms control multiple aspects of ADAM17 biology. The FERM domain-containing protein iTAP/Frmd8 is an iRhom-binding protein that prevents the precocious shunting of ADAM17 and iRhom2 to lysosomes and their consequent degradation. As pathophysiological role(s) of iTAP/Frmd8 have not been addressed, we characterized the impact of iTAP/Frmd8 loss on ADAM17-associated phenotypes in mice. We show that iTAP/Frmd8 KO mice exhibit defects in inflammatory and intestinal epithelial barrier repair functions, but not the collateral defects associated with global ADAM17 loss. Furthermore, we show that iTAP/Frmd8 regulates cancer cell growth in a cell-autonomous manner and by modulating the tumor microenvironment. Our work suggests that pharmacological intervention at the level of iTAP/Frmd8 may be beneficial to target ADAM17 activity in specific compartments during chronic inflammatory diseases or cancer, while avoiding the collateral impact on the vital functions associated with the widespread inhibition of ADAM17.

1255 IMPROVING COMMUNICATION BETWEEN NEXT OF KIN AND MEDICAL STAFF FOR OUR MOST VULNERABLE PATIENTS: A QUALITY IMPROVEMENT PROJECT

Background

This project was completed by a team of junior doctors working across two general medical wards at Queen Alexandra Hospital.

Introduction

Due to persistently high bed occupancy, patients are increasingly subject to multiple moves, increasing the risk of missed or delayed communication (Toye C et al, Clin interv aging, 2019, 14, 2223-2237). Importantly, families who receive good communication from staff are more likely to feel satisfied with the care of their loved one (Ersek M et al, J pain symptom manage, 2021, 62(2), 213–222). Our aim was to increase the occurrence and comprehensiveness of documented discussions between next of kin (NOK) and the medical team, especially in vulnerable patients who may be unable to advocate for themselves.

Methods

We conducted a retrospective, cross-sectional analysis of patient notes across two PDSA cycles. NICE guidelines NG27, NG97 and NG96 provided an audit standard. Patients were identified as at-risk of poor communication if diagnosed with dementia, cognitive impairment, addiction, learning difficulties or needing an interpreter. Targeted intervention prior to re-audit included education of the medical team and introduction of a written prompt within the patient’s notes.

Results

25/55 patients were identified as at-risk in cycle one, with 39/71 patients at-risk in cycle two. Post-intervention, the number of at-risk patients with a documented NOK discussion increased from 74% to 82%. Patient treatment plan discussions increased from 81% to 97%. Discussions, where applicable, regarding escalation of care, Deprivation of Liberty Safeguards (DoLS), capacity and Mental Health Act (MHA) slightly decreased. Conversations regarding patient consent for data sharing were rarely documented.

Conclusion

Our intervention increased the proportion of documented patient discussions; however, it did highlight the need to improve the frequency of documented conversations surrounding escalation of care, DoLS, capacity and MHA. This has provided impetus for further improvement projects.

Cholecalciferol (VD3) Attenuates L-DOPA-Induced Dyskinesia in Parkinsonian Mice Via Modulation of Microglia and Oxido-Inflammatory Mechanisms

L-DOPA, the gold standard for managing Parkinson's disease (PD) is fraught by motor fluctuations termed L-Dopa-Induced Dyskinesia (LID). LID has very few therapeutic options. Hence, the need for preclinical screening of new interventions. Cholecalciferol (VD3) treatment reportedly improves motor deficit in experimental Parkinsonism. Therefore, the novel anti-dyskinetic effect of VD3 and its underlying mechanisms in LID was investigated. Dyskinesia was induced by chronic L-DOPA administration in parkinsonian (6-OHDA- lesioned) mice. The experimental groups: Control, Dyskinesia, Dyskinesia/VD3, and Dyskinesia/Amantadine were challenged with L-DOPA to determine the abnormal involuntary movements (AIMs) score during 14 days of VD3 (30 mg/kg) or Amantadine (40 mg/kg) treatment. Behavioral Axial, Limb & Orolingual (ALO) AIMs were scored for 1 min at every 20 mins interval, over a duration of 100 mins on days 1,3,7,11 and 14. Using western blot, striatum was assessed for expression of dopamine metabolic enzymes: Tyrosine Hydroxylase (TH) and Monoamine Oxidase-B (MAO-B); CD11b, BAX, P47phox, and IL-1β. Cholecalciferol significantly attenuated AIMs only on days 11 & 14 with maximal reduction of 32.7%. Expression of TH and MAO-B was not altered in VD3 compared with dyskinetic mice. VD3 significantly inhibited oxidative stress (P47phox), apoptosis (BAX), inflammation (IL-1β) and microglial activation (CD11b). VD3 showed anti-dyskinetic effects behaviorally by attenuating abnormal involuntary movements, modulation of striatal oxidative stress, microglial responses, inflammation, and apoptotic signaling; without affecting dopamine metabolic enzymes. Its use in the management of dyskinesia is promising. More studies are required to further evaluate these findings. Keywords: Cholecalciferol; L-DOPA-Induced Dyskinesia; Parkinson's Disease; Microglial; Oxidative stress; Inflammation.

The effect of eplerenone on the disease onset and progression of phospholamban cardiomyopathy in presymptomatic mutation carriers: results of the i-PHORECAST trial

Background

A pathogenic variant in the gene encoding phospholamban (PLN; p.Arg14del) may cause cardiomyopathy, the pathophysiologic hallmark of which is cardiac fibrosis that may cause malignant ventricular arrhythmias and severe heart failure. There is no evidence-based therapy to modify disease progression in presymptomatic pathogenic variant carriers. Eplerenone is a selective mineralocorticoid receptor antagonist with established antifibrotic properties, and may be a potentially interesting treatment in PLN p.Arg14del mutation carriers.

Purpose

To investigate if preventive therapy with eplerenone attenuates disease onset and progression in PLN cardiomyopathy.

Methods

84 presymptomatic PLN p.Arg14del mutation carriers (median age 39 [27–50] years, 44% males) were randomized 1:1 to receive eplerenone (50mg once daily) or no treatment, and endpoints were adjudicated in a blinded fashion (PROBE design). Baseline values were acquired including demographics, cardiac magnetic resonance imaging (CMR) parameters (ventricular volumes, systolic function, late gadolinium enhancement (LGE)), and electrocardiographic parameters (QRS voltages and ventricular ectopy per 24 hour). Subjects were re-evaluated every year and CMR was performed at baseline and after three years. The composite endpoint included LVEDV/RVEDV increase (>10%), LVEF/RVEF decrease (5%), newly developed LGE on CMR, increase in ventricular ectopy (>100% PVCs/24h if >1000 PVCs/24h), decrease in QRS voltage (>25%), non-sustained ventricular tachycardia, symptoms or arrhythmias necessitating treatment, and cardiovascular death.

Results

Two out of 84 subjects (2%) were lost to follow up. 49 out of 82 remaining subjects (60%) reached the composite end point, 25 (60%) in the control group, 24 (60%) in the treatment group (p=0.825). There was no significant difference between the groups when considering the individual end points, see Table 1. Baseline and follow up CMR was performed on 76 subjects, 39 in the control group, 37 in the treatment group. In total there were 10 (13%) cases of newly developed LGE, 6 (18%) in the control group, 4 (12%) in the treatment group (p=0.556), see Figure 1.

Conclusions

Eplerenone did not significantly attenuate disease onset and progression in presymptomatic PLN p.Arg14del mutation carriers. There was no significant difference in new incidence of LGE between the treatment and control groups.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was financially supported by the Netherlands Cardiovascular Research Initiative, an initiative supported by the Dutch Heart Foundation (The Hague, Netherlands).

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Association between common cardiovascular risk factors and clinical phenotype in patients with hypertrophic cardiomyopathy from the European Society of Cardiology (ESC) EurObservational Research Programme (EORP) Cardiomyopathy/Myocarditis registry

AIMS

The interaction between common cardiovascular risk factors (CVRF) and hypertrophic cardiomyopathy (HCM) is poorly studied. We sought to explore the relation between CVRF and the clinical characteristics of patients with HCM enrolled in the EURObservational Research Programme (EORP) Cardiomyopathy registry.

METHODS AND RESULTS

1739 patients with HCM were studied. The relation between hypertension (HT), diabetes (DM), body mass index (BMI), and clinical traits was analysed. Analyses were stratified according to the presence or absence of a pathogenic variant in a sarcomere gene. The prevalence of HT, DM, and obesity (Ob) was 37, 10, and 21%, respectively. HT, DM, and Ob were associated with older age (P<0.001), less family history of HCM (HT and DM P<0.001), higher New York Heart Association (NYHA) class (P<0.001), atrial fibrillation (HT and DM P<0.001; Ob p = 0.03) and LV (left ventricular) diastolic dysfunction (HT and Ob P<0.001; DM P = 0.003). Stroke was more frequent in HT (P<0.001) and mutation-positive patients with DM (P = 0.02). HT and Ob were associated with higher provocable LV outflow tract gradients (HT P<0.001, Ob P = 0.036). LV hypertrophy was more severe in Ob (P = 0.018). HT and Ob were independently associated with NYHA class (OR 1.419, P = 0.017 and OR 1.584, P = 0.004, respectively). Other associations, including a higher proportion of females in HT and of systolic dysfunction in HT and Ob, were observed only in mutation-positive patients.

CONCLUSION

Common CVRF are associated with a more severe HCM phenotype, suggesting a proactive management of CVRF should be promoted. An interaction between genotype and CVRF was observed for some traits.

Outcome of Heart Transplant Candidates Based on a High Volume Heart Transplant Center Experience in Iran

Background

The waiting list for heart transplants is a valuable data registry that would offer very useful information on the characteristics of patients who have various outcomes while waiting in the list.

Objective

The purpose of this study was to look at the prognosis of those waiting for heart transplants as well as the factors that increase mortality.

Methods

Advanced heart failure patients' demographic, clinical, hemodynamic, and echocardiographic results, as well as their prognosis, were retrieved from the national registry for heart transplantation between 2011 and 2018. The study population was defined and compared in four groups: 1) Death while awaiting HTX, 2) Death after HTX, 3) Alive without a transplant, 4) Transplanted and alive.

Results

The data of 207 patients [75% male, mean (SD) age of 34(10) years] were analyzed. The most common etiology of heart failure was idiopathic dilated cardiomyopathy. A total of 86 patients (41%) were successfully transplanted, with a median (IQR) time between listing and transplantation of 84 (30¬219) days, 54 patients (26.1%) were dead and 32% were still alive. The multivariate analysis showed right atrial pressure, pulmonary capillary wedge pressure, cardiac index, and systolic blood pressure at the time of listing as independent predictors of death.

Conclusion

The study on HTX waiting list is very useful for both allocation strategies and administrative planning for patients with advanced heart failure by development of accurate models and scoring systems using predictors of death in the waiting list.

Anti-hyperglycemic and anti-hyperlipidemic effects of a methanolic extract of Debregeasia salicifolia in Alloxan-induced diabetic albino mice

Diabetes mellitus (DM), an endocrine syndrome characterized by high blood glucose levels due to abrogated insulin activity. The existing treatments for DM have side effects and varying degrees of efficacy. Therefore, it is paramount that novel approaches be developed to enhance the management of DM. Therapeutic plants have been accredited as having comparatively high efficacy with fewer adverse effects. The current study aims to elucidate the phytochemical profile, anti-hyperlipidemic, and anti-diabetic effects of methanolic extract D. salicifolia (leaves) in Alloxan-induced diabetic mice. Alloxan was injected intraperitoneally (150 mg kg-1, b.w), to induced diabetes in mice. The mice were divided into three groups (n=10). Group 1 (normal control) received normal food and purified water, Group II (diabetic control) received regular feed and clean water and group III (diabetic treated) received a methanolic extract of the plant (300 mg kg-1) for 28 days with a typical diet and clean water throughout the experiment. Blood samples were collected to checked serum glucose and concentration of LDL, TC, TG. The extract demonstrated significant antihyperglycemic activity (P<0.05), whereas improvements in mice's body weight and lipid profiles were observed after treatment with the extract. This study establishes that the extract has high efficacy with comparatively less toxicity that can be used for DM management.

Selenium reduces nociceptive response in acute 1-methyl-4-phenyl-1, 2, 3, 6-tetrahydropyridine (MPTP)-induced neurotoxicity

The potential of Se to alleviate pain associated with 1-methyl-4-phenyl-1,2,3,6-tetrahydropyridine (MPTP)-induced neurotoxicity was investigated.

Swiss mice were intraperitoneally injected with MPTP (20 mg/kg) 4 times with an interval of 2 h in 1 day. Seven days after MPTP injection, the mice (n = 5 mice per group) were randomly assigned to groups: MPTP-, DOPA (50 mg/kg)-, Se4 (0.4 mg/kg)-, Se6 (0.6 mg/kg)-, DOPA+Se4-, and DOPA+Se6-treated groups were compared with controls. MPTP mice were treated for seven days; thereafter, motor-coordination and nociceptive-motor reactions were assessed. Pro-inflammatory cytokines (IL-1β, IL-6 and TNFα), and selected pain biomarkers (substance P (SP), glutamate and β-endorphin) were assessed in the serum and the substantial nigra pars compacta (SNpc).

Motor activity was increased slightly by Se (0.6 or 0.4 mg/kg) vs. MPTP (10.48 ± 2.71 or 11.81 ± 1.28 s vs. 3.53 ± 0.06 s respectively) but considerably increased by DOPA (50 mg/kg) vs. MPTP (50.47 ± 3.06 s vs. 3.53 ± 0.06 s respectively). Se and DOPA increased nociceptive threshold but Se alone reduced both serum and SN pro-inflammatory cytokines. Se modulates SP while DOPA modulates SP and glutamate in the SNpc of mice treated with MPTP.

Se suppressed pro-inflammatory cytokines and restored the basal pain biomarkers in the SNpc of mice treated with MPTP. Se requires further study as analgesic adjuvant.

Malignant Melanoma of the Genitourinary System

Introduction/Objective

Malignant melanoma (MM) of mucosal membranes (excluding anus and head and neck) is a rare but aggressive disease with poor outcome. There is little information available on the development mechanism, risk factors, and management of this tumor, mainly due to the low number of cases.

Methods/Case Report

We performed a comprehensive literature review on mucosal MM (between 1970-2020). We identified 52 papers reporting 242 patients with primary genitourinary melanomas (limited to urothelium, vagina and cervix). A comprehensive review of the demographics, stage, treatment and survival was performed.

Results (if a Case Study enter NA)

The demographics are provided in Table 1. In 204 cases, lesions were located in the urothelium (urethra: 202, bladder: 2) followed by 34 in the vagina and 4 in uterine cervix. None of the cases had any other known primary source of MM. Molecular studies in a subset of cases revealed alterations in c-KIT, NRAS, BRAF (non-V600E and V600E), TP53 and NF1 (Table 2). Tumor stage was provided in a few (n=10) cases (stage 1=1, stage 2=1, stage 3=3 & stage 4=5). 3 patients had distant metastasis (brain, retroperitoneal and inguinal lymph nodes). Treatment data was available in 178 cases. 177 patients were managed by surgery. In addition to surgery, 10 received chemotherapy, 7 received immunotherapy and chemotherapy, 2 received chemoradiation, 1 received immunotherapy and 1 received radiotherapy. In 43 patients, the treatment regimen was not provided. The outcome was available in 178 cases (range of follow up between 3-97 months), showing 15 deaths of disease. Median survival based on available information in 28 patients was 82% (5-year survival). Table 1 legend: Demographics of genitourinary malignant melanoma cases.

Table 2 legend: Frequency of molecular alterations in genitourinary malignant melanoma.

Conclusion

Similarities in genetic signatures of mucosal and skin MM suggest similar mechanism of development; however, unlike skin melanoma, there is less BRAF mutation and more of PI3K/AKT/mTOR pathway alterations in mucosal MM. Prolonged administration of chemotherapy (i.e., methotrexate) and immune-modulating agents (i.e., natalizumab) may be a risk factor. In light of absence of a definite adjuvant therapy, tumor stage at the time of diagnosis and proper surgical removal have central role in the prognosis and survival of patients.

Atrial fibrillation in unexplained syncope: observations from the Reveal LINQ registry

Background

Implantable loop recorders (ILRs) have come to play an important role in the workup of patients with recurrent syncope of uncertain origin. In addition to detecting bradyarrhythmias related to syncope, which is the main diagnostic focus in these patients, ILRs are also capable of uncovering subclinical atrial fibrillation (AF).

Purpose

We sought to determine the percentage of patients monitored with an ILR for unexplained syncope who have AF detected and to describe clinical actions taken in these patients.

Methods

Patients enrolled in the Reveal LINQ Registry who received an ILR for unexplained syncope and had at least one follow-up form were included. The device automatically detects AF episodes lasting ≥2 minutes. Patients were considered to have AF based on an AF diagnosis made by the treating physician during follow-up or if device-detected AF was adjudicated as true AF by an external reviewer. AF detection rates were calculated using Kaplan-Meier methods.

Results

In total, 498 patients (aged 61.8±20.0 years, 49.6% female, CHA2DS2VASc score 2.2±1.7) were included and followed for 22±12 months. A history of AF was present in 97 (20%) patients, while 401 patients had no history. By 18 months, the incidence of AF was 70.9% (95% CI, 60.8%, 80.3%) in patients with a history of AF and 21.4% (95% CI, 17.4%, 26.1%) in patients without (Figure). AF detection in those with (30.4%) and without (30.1%) syncope during follow-up was similar. By the end of follow-up, and among patients with newly detected AF, 29/86 (33.7%) were on oral anticoagulation, 7 (8.1%) underwent AF ablation, 6 (7.0%) underwent other type of ablation, and 2 (2.3%) received cardioversion. Other actions among the whole cohort included implant of an IPG, ICD, or CRT in 98/498 (19.7%).

Conclusion

Among patients monitored with ILRs to determine the cause of recurrent syncope episodes, approximately 1 in 5 patients had new AF detected. In addition to improving the management of patients with syncope, ILR data served to support AF-related clinical decisions.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Medtronic Inc Incidence of AF according to baseline AF

1512 A Service Evaluation of Transoral Laser Resection Procedures for Oral Cancer and Dysplasia

Aim

The use of the diode laser is a frequently employed treatment modality in primary surgical excision, especially for early oral cancer. This is due to advantages offered in precision of excision, and potential reduced post-operative pain compared to other excision methods. Additionally, haemostasis can often be obtained simultaneous to excision. Despite frequent use of laser excision for oral cancer/dysplasia, there is limited information on the incidence of postoperative complications.

Method

Data was collected retrospectively by review of electronic healthcare records for a 5-year period (Jan 2015-Jan 2020) for patients who underwent transoral laser excision of oral dysplasia in a major UK teaching hospital. The number of short (&lt;30 days) and longer-term complications was evaluated and categorised using the Clavien-Dindo classification.

Results

A total 260 patients received diode laser resection for oral cancer/dysplasia in this period. Approximately one third of patients had the diagnosis of SCC and 52% of patients were treated on a day case basis. Approximately one third of patients experienced postoperative complications.; including positive or close resection margins (16%), bleeding (8%), superficial infection (6%) and significant postoperative pain (2%). A total of 16% of patients required further treatment in theatre (Clavien-Dindo IIIb).

Conclusions

The use of lasers for excision of oral tumours and dysplastic lesions is a frequently employed modality, offering advantages to the operating surgeon (improved haemostasis, excellent manoeuvrability) and patients (reduced pain and scarring). Complications are largely predictable in nature, but the surgical team should be aware of potential issues to ensure safe, effective patient care.

Current Status of Endoplasmic Reticulum Stress in Type II Diabetes

The endoplasmic reticulum (ER) plays a multifunctional role in lipid biosynthesis, calcium storage, protein folding, and processing. Thus, maintaining ER homeostasis is essential for cellular functions. Several pathophysiological conditions and pharmacological agents are known to disrupt ER homeostasis, thereby, causing ER stress. The cells react to ER stress by initiating an adaptive signaling process called the unfolded protein response (UPR). However, the ER initiates death signaling pathways when ER stress persists. ER stress is linked to several diseases, such as cancer, obesity, and diabetes. Thus, its regulation can provide possible therapeutic targets for these. Current evidence suggests that chronic hyperglycemia and hyperlipidemia linked to type II diabetes disrupt ER homeostasis, thereby, resulting in irreversible UPR activation and cell death. Despite progress in understanding the pathophysiology of the UPR and ER stress, to date, the mechanisms of ER stress in relation to type II diabetes remain unclear. This review provides up-to-date information regarding the UPR, ER stress mechanisms, insulin dysfunction, oxidative stress, and the therapeutic potential of targeting specific ER stress pathways.

Two decades of neuroscience publication trends in Africa

Neuroscience research in Africa remains sparse. Devising new policies to boost Africa's neuroscience landscape is imperative, but these must be based on accurate data on research outputs which is largely lacking. Such data must reflect the heterogeneity of research environments across the continent's 54 countries. Here, we analyse neuroscience publications affiliated with African institutions between 1996 and 2017. Of 12,326 PubMed indexed publications, 5,219 show clear evidence that the work was performed in Africa and led by African-based researchers - on average ~5 per country and year. From here, we extract information on journals and citations, funding, international coauthorships and techniques used. For reference, we also extract the same metrics from 220 randomly selected publications each from the UK, USA, Australia, Japan and Brazil. Our dataset provides insights into the current state of African neuroscience research in a global context.

896 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt; 62.5mL/Hr for hip fracture patients.

Method

Three prospective audits, each including 100 consecutive acute hip fracture patients, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included implementation of admission/post-take checklist tools and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

In cycle one and two, many patients received inadequate fluids (46/100 and 56/100 respectively). There was no significant difference in the incidence of AKI between patients receiving adequate or inadequate fluid in either cycle (p &lt; 0.05).

In cycle three, more patients received adequate fluids (79/100, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

205 Internal Herniation of The Caecum and Ascending Colon Through the Foramen of Winslow: A Case Report

Introduction

An internal hernia occurs when part of the bowel protrudes through a mesenteric or a peritoneal orifice which could be either normally present or acquired. These hernias usually represent a challenge to diagnose. Of the natural anatomical orifices is the Foramen of Winslow through which the caecum and the ascending colon could herniate.

Case

Report

Conclusions

With the scarcity of similar cases, we currently have no consensus of management. Dealing with the hernia at laparotomy would be usually the choice of the surgeon depending on tissue viability and other operative findings.

P9: MANAGEMENT OF ESOPHAGEAL FOOD BOLUS OBSTRUCTION AT A UNIVERSITY TEACHING HOSPITAL – A RETROSPECTIVE ANALYSIS

Introduction

Despite the fact that esophageal food bolus obstruction is a common surgical problem, there are no clear guidelines on its management. Medical treatment with Buscopan and Glucagon is mostly in-effective, requiring a therapeutic Oesophago-Gastro-Duodenoscopy (OGD).

Method

All consecutive cases of food bolus obstructions (FBO) presenting to the Emergency Department (ED) for 18 month period between 01/01/2018 and 30/06/2019 were retrospectively reviewed.

Result

A total of 30 patients were admitted with food bolus obstruction via ED (1.67 per month). Females (67%) constituted most of these patients. Average age was 55 with range of 19-83. 84% of patients presented with Dysphagia, while Odynophagia (10%) and chest pain (6%) were other presenting symptoms. Average duration of symptoms was 17 hours (Range 2 – 48 hours). 44% of patients had OGD done under sedation while others (56%) had under General Anaesthesia (GA). In 70% of cases, food bolus was pushed into stomach, while it was retrieved out in 20%. In 10%, it had already spontaneously passed in stomach on OGD. The etiology of FBO was inflammatory in 60% cases, while an esophageal stricture was seen in 10% only. In 30% cases no cause of FBO was identified. Post-OGD length of stay was on average 1.15 days (range 12 hours – 7 days). 2 patients had aspiration pneumonia prolonging their hospital stay, there was no esophageal perforation or mortality.

Conclusion

Esophageal food bolus obstruction is a common surgical problem, OGD under GA is a safe recommended procedure, which often picks up an underlying pathology.

Take-home message

Esophageal food bolus obstruction is a common surgical problem, OGD under GA is a safe recommended procedure, which often picks up an underlying pathology.

113 Improving Intravenous Fluid Therapy to Reduce the Incidence of Acute Kidney Injury in Elderly Hip Fracture Patients

Background

Acute kidney injury (AKI) in hip fracture patients is associated with morbidity, mortality, and increased length of stay. To avoid this our unit policy recommends maintenance crystalloid IV fluids of &gt;62.5 mL/Hr for hip fracture patients. However, audits have shown that many patients still receive inadequate IV fluids.

Methods

Three prospective audits, each including 100 consecutive acute hip fracture patients aged &gt;55, were completed with interventional measures employed between each cycle. Data collection points included details of IV fluid administration and pre/post-operative presence of AKI. Interventions between cycles included a revised checklist for admissions with a structured ward round tool for post-take ward round and various educational measures for Emergency Department, nursing and admitting team staff with dissemination of infographic posters, respectively.

Results

Cycle 1: 64/100 (64%) patients received adequate fluids. No significant difference in developing AKI post operatively was seen in patients given adequate fluids (2/64, 3.1%) compared to inadequate fluids (4/36, 11.1%; p = 0.107). More patients with pre-operative AKI demonstrated resolution of AKI with appropriate fluid prescription (5/6, 83.3%, vs 0/4, 0%, p &lt; 0.05) Cycle 2: Fewer patients were prescribed adequate fluids (54/100, 54%). There was no significant difference in terms of developing AKI post operatively between patients with adequate fluids (4/54, 7.4%) or inadequate fluids (2/46, 4.3%; p = 0.52). Resolution of pre-operative AKI was similar in patients with adequate or inadequate fluid administration (4/6, 67% vs 2/2, 100%). Cycle 3: More patients received adequate fluids (79/100, 79%, p &lt; 0.05). Patients prescribed adequate fluids were less likely to develop post-operative AKI than those receiving inadequate fluids (2/79, 2.5% vs 3/21, 14.3%; p &lt; 0.05).

Discussion

This audit demonstrates the importance of administering appropriate IV fluid in hip fracture patients to avoid AKI. Improving coordination with Emergency Department and ward nursing/medical ward staff was a critical step in improving our unit’s adherence to policy.

Case of Renal Aspergillosis after Heart Transplant: Diagnosis and Treatment

Invasive aspergillosis (IA) is a severe complication after heart transplantation (HTx), with a high mortality rate. Invasive pulmonary aspergillosis (IPA) is the most common presentation. We herein describe a unique case of Renal aspergillosis (RAsp) diagnosed on month 10 post-HTx with no known risk factors for IPA in cardiac transplant recipients. The diagnosis of RAsp was made based on radiographic findings, renal biopsy, and tissue cultures. The patient initially received combined antifungal therapy (caspofungin and voriconazole) without radical or partial nephrectomy, followed by voriconazole maintenance monotherapy with favorable clinical outcomes.

CNS Post-Transplant Lymphoproliferative Disorder in a Heart Recipient: A Case Report

Solid organ recipients have increased risk of malignancy in comparison with general population. Although post-transplant lymphoproliferative disorders are the second most common cancer in transplanted patients, primary CNS lymphoma is a rare presentation of these disorders. Among the wide range of neurologic complications in post- transplant period, some characteristics could be helpful for diagnosing of this disorder. Rarity of CNS lymphoma may lead to late diagnosis of this disease while early detection has utmost importance for better management of it. Here, we describe a heart recipient young woman with focal neurologic symptoms 14 months after transplantation and some features that could be helpful for on-time diagnosis.

Clinical and imaging predictors of recovery in patient with pulmonary emboli

Background

Post-pulmonary emboli impairment (PPEI), comprised significant morbidity and mortality. A single center registry of patients with PE was established in order to estimate patients' risk, monitor clinical management and develop a simple model to assess the risk for PPEI for the entire spectrum of patients treated in general clinical practice.

Methods

For developing the mentioned model, apart from approved imaging parameters, potential novel imaging parameters were also evaluated. Recovery were assessed according to Pulmonary Embolism Thrombolysis (PEITHO) trial definition (Figure 1).

Results

140 patients have been registered with at least 6-month imaging follow up. PPEI was confirmed in 75 (53.6%) patients with PE. The prognostic value of traditional and novel imaging parameters on 6-month complete recovery were summarized in Table. A multivariable logistic regression model was developed using 140 patients. Previous PE, HRfollowing five in-hospital-parameters accounted for simple prognostic model for incomplete recovery: history of PE, heart rate≥110, serum blood urea nitrogen level, RV/LV ratio and right atrium area, The overall prediction ability was excellent with 80.6 overall percentage for PPEI.

Conclusions

PPPEI rate was considerable in our study. Our proposed simple prediction model might have a role on identification of patients at risk for PPEI.

Figure 1

Funding Acknowledgement

Type of funding source: None

Paper currency harbours antibiotic-resistant coliform bacteria and integron integrase

AIMS

This study was designed to analyse the prevalence of class 1 and class 2 integron integrase genes among antibiotic-resistant coliform bacteria isolated from paper currency circulating in Pakistan.

METHODS AND RESULTS

A total of 500 individual currency notes were collected from different food vending sites at Lahore, Pakistan. Bacterial population were identified by biochemical and PCR techniques. Antimicrobial susceptibility testing was performed by disc diffusion assay. The highest bacterial population on currency was found from street vendors and butcher shops. Escherichia coli was found to be the most prevalent coliform bacteria followed by Klebsiella sp. and Enterobacter sp. PCR amplification of antimicrobial resistance gene showed the presence of ampC, bla_TEM , bla_NDM-1 , qnrA, tet(A) and tet(B) genes among coliform isolates. A total of 47 integron integrase bearing strains of coliform bacteria were analysed. Sequence analysis showed the presence of dfrA1-aadA1, dfrA1, dfrA5, dfrA7, aadA1, aadA4 cassette arrays in class 1 integron and dfrA1-sat2-aadA1 in class 2 integrase genes.

CONCLUSION

Circulating currency was heavily contaminated with antimicrobial-resistant coliform bacteria bearing class 1 and class 2 integron integrase genes.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study describes a potential threat of severe bacterial infections due to improper hand hygiene and community sanitation when dealing with the currency notes.

Vitamin D attenuated 6-OHDA-induced behavioural deficits, dopamine dysmetabolism, oxidative stress, and neuro-inflammation in mice

Background: L-DOPA, the predominant therapy for Parkinson's disease (PD) is associated with motor deficits after prolonged use. The nigrostriatal tract, a primary target of neurodegeneration in PD, contains abundant Vitamin-D receptors, suggesting a potential role for VD in the disease. Therefore, we tested the impact of Vitamin D3 (VD3) in a mouse model of PD.Methods: PD was induced in adult male C57BL6 mice by a single intrastriatal injection of 6-hydroxydopamine. Two weeks post lesion, these mice received injections of a vehicle, VD3, L-DOPA, or a combination of VD3/L-DOPA and compared with sham controls. Treatment lasted three weeks, during which motor-cognitive neurobehaviour was assessed. Five weeks post lesion, brains were collected and striatal levels of the following proteins assessed: tyrosine hydroxylase (TH), dopamine decarboxylase (DDC), monoamine oxidase (MAO-B), Catechol-O-methyl transferase (COMT), dopamine transporter (DAT), brain-derived neurotrophic factor (BDNF), microglia marker (CD11b), inflammation (IL-1β), apoptotic signaling (BAX) and oxidative stress (p47phox).Results: Treatment with VD3 attenuated behavioural deficits induced by 6-OHDA, protein associated with dopamine metabolism and biomarkers of oxidative stress. VD3 significantly increased contralateral wall touches, exploratory motor and cognitive activities. VD3 significantly enhanced the expression of TH, DAT, BDNF, while significantly reducing expression of MAO-B, CD11b, IL-I β and p47phox.Conclusion: VD3 reversed some of the 6-OHDA induced changes in proteins involved in modulating the dopamine system, behavioural deficits and oxidative stress biomarkers. The data suggests that VD3 might be beneficial in reducing L-DOPA dosage, thereby reducing problems associated with dosage and prolonged use of L-DOPA in PD management.

Crosstalk between metabolism and immunity: the 3rd Annual Research Symposium of Instituto Gulbenkian de Ciência

The 'Crosstalks of immunity and metabolism' Symposium was focused on how the intercommunication between different organs and the immune system affects organismal health. At this meeting, experts in immunology and metabolic research provided novel insights into the growing field of immunometabolism. This report attempts to review and integrate views, ideas, propositions, and conclusions that emanated from the symposium.

INCIDENCE OF BREAST LYMPHEDEMA AND PREDICTORS OF ITS DEVELOPMENT IN PATIENTS RECEIVING WHOLE BREAST RADIATION THERAPY AFTER BREAST-CONSERVATION SURGERY

One common adverse effect following breast-conservation surgery and adjuvant radiation is lymphedema. While lymphedema of the arm has been well-characterized, there has been less investigation into lymphedema of the breast. We sought to characterize rates of breast lymphedema (BLE) in women with early-stage breast cancer and identify potential predictors in its development. Two hundred and thirty consecutive patients treated with lumpectomy and adjuvant whole breast radiation therapy (WBRT) from January 2016 - June 2017 were included. All patients were seen in our lymphedema monitoring clinic for baseline and at least one follow-up lymphedema measurement. BLE grades were assigned by trained nurses in the lymphedema clinic. Data regarding patient demographic and treatment factors were extracted from the electronic medical record. Comparisons between groups were made using Chi-Square analysis performed in SAS. The median age of the sample was 62 (range 31-90). Median follow-up from surgery was 15.3 months. Forty-three patients were diagnosed with lymphedema of the breast (18.7%). Rates of grade 1 and 2 BLE were 93% and 7%, respectively; there were no cases of severe lymphedema. Sixty-three percent of cases resolved by last follow-up with treatment recommendations. There was no association between development of BLE and patient factors investigated, including age, T stage, radiation dose and fractionation, lymph node biopsy, number of lymph nodes removed, development of arm lymphedema, and use of chemotherapy. Tumor subtype was found to be significant (P = 0.04) and there was a trend towards significance for receipt of trastuzumab (P = 0.09). BLE is a distinct entity from arm lymphedema and is a common finding in women treated with breast-conserving surgery and adjuvant WBRT. It is a generally mild and self-limiting process. There were no treatment or patient-related factors that correlated with increased risk of lymphedema development in our sample except for HER-2 positive disease and receipt of trastuzamab.

Deletion of iRhom2 protects against diet-induced obesity by increasing thermogenesis

Objective

Obesity is the result of positive energy balance. It can be caused by excessive energy consumption but also by decreased energy dissipation, which occurs under several conditions including when the development or activation of brown adipose tissue (BAT) is impaired. Here we evaluated whether iRhom2, the essential cofactor for the Tumour Necrosis Factor (TNF) sheddase ADAM17/TACE, plays a role in the pathophysiology of metabolic syndrome.

Methods

We challenged WT versus iRhom2 KO mice to positive energy balance by chronic exposure to a high fat diet and then compared their metabolic phenotypes. We also carried out ex vivo assays with primary and immortalized mouse brown adipocytes to establish the autonomy of the effect of loss of iRhom2 on thermogenesis and respiration.

Results

Deletion of iRhom2 protected mice from weight gain, dyslipidemia, adipose tissue inflammation, and hepatic steatosis and improved insulin sensitivity when challenged by a high fat diet. Crucially, the loss of iRhom2 promotes thermogenesis via BAT activation and beige adipocyte recruitment, enabling iRhom2 KO mice to dissipate excess energy more efficiently than WT animals. This effect on enhanced thermogenesis is cell-autonomous in brown adipocytes as iRhom2 KOs exhibit elevated UCP1 levels and increased mitochondrial proton leak.

Conclusion

Our data suggest that iRhom2 is a negative regulator of thermogenesis and plays a role in the control of adipose tissue homeostasis during metabolic disease.

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Deletion of iRhom2 protects mice from metabolic syndrome.

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In obesity, iRhom2 deletion increases energy expenditure, thermogenesis and white adipose tissue beiging.

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iRhom2 deletion enhances thermogenesis in naïve brown adipocytes.

Exercise capacity reflects airflow limitation rather than hypoxaemia in patients with pulmonary arteriovenous malformations

BACKGROUND

Pulmonary arteriovenous malformations (PAVMs) generate a right-to-left shunt. Impaired gas exchange results in hypoxaemia and impaired CO2 clearance. Most patients compensate effectively but some are dyspneic, and these are rarely the most hypoxaemic.

AIM

To test degrees of concurrent pathology influencing exercise capacity.

DESIGN

Replicate, sequential single centre, prospective studies.

METHODS

Cardiopulmonary exercise tests (CPETs) were performed in 26 patients with PAVMs, including individuals with and without known airflow obstruction. To replicate, relationships were tested prospectively in an independent cohort where self-reported exercise capacity evaluated by the Veterans Specific Activity Questionnaire (VSAQ) was used to calculate metabolic equivalents (METs) at peak exercise (n = 71). Additional measurements included oxygen saturation (SpO2), forced expiratory volume in 1 s (FEV1), vital capacity (VC), fractional exhaled nitric oxide (FeNO), haemoglobin and iron indices.

RESULTS

By CPET, the peak work rate was only minimally associated with low SpO2 or low arterial oxygen content (calculated as CaO2=1.34 × SpO2 × haemoglobin), but was reduced in patients with low FEV1 or VC. Supranormal work rates were seen in patients with severe right-to-left shunting and SpO2 < 90%, but only if FEV1 was >80% predicted. VSAQ-calculated METS also demonstrated little relationship with SpO2, and in crude and CaO2-adjusted regression, were lower in patients with lower FEV1 or VC. Bronchodilation increased airflow even where spirometry was in the normal range: exhaled nitric oxide measurements were normal in 80% of cases, and unrelated to any PAVM-specific variable.

CONCLUSIONS

Exercise capacity is reduced by relatively mild airflow limitation (obstructive or restrictive) in the setting of PAVMs.