A retrospective observational study of early experiences of vedolizumab treatment for inflammatory bowel disease in the UK: The REVIVE study

Results from clinical trials show that vedolizumab is an efficacious treatment for inflammatory bowel disease, namely Crohn's disease (CD) and ulcerative colitis (UC). However, there is limited evidence from real-world clinical practice, especially on early clinical experiences in the UK.To describe real-world early experiences of vedolizumab to treat CD and UC in the UK.A retrospective, chart review study of patients with CD or UC treated with vedolizumab across 5 UK hospitals. All eligible adults (≥18 years at initiation) with a diagnosis of CD and ≥14 weeks of data or UC and ≥10 weeks of data available following vedolizumab initiation were included.Data were analyzed for 112 patients (CD: 66; UC: 46). Patients with CD had a median of 7.4 (interquartile range 5.7-9.4) months follow-up and patients with UC had a median of 7.4 (5.6-10.2) months follow-up post-vedolizumab initiation. Most patients, 80% (53/66) with CD and 89% (41/46) with UC, remained on vedolizumab treatment at the time of data collection. No new safety signals were identified during the study.These results add to the body of evidence supporting vedolizumab as an effective and well-tolerated treatment for CD and UC in real-world clinical practice.

Epithelial Microvesicles Promote an Inflammatory Phenotype in Fibroblasts

Microvesicles (MVs) are extracellular vesicles secreted by various cell types that are involved in intercellular communication. We hypothesized that in human periodontal disease, the pocket epithelium releases MVs, which then modulate gene expression in the underlying fibroblasts to control periodontal inflammation. MVs were isolated from culture medium of gingival epithelial cells (GECs) treated with oral bacterial biofilm extract or left untreated. Biofilm treatment significantly increased MV release from the GECs. Mass spectrometry of GEC-MVs identified a total of 2,173 proteins, of which about 80% were detected in MVs from both control and biofilm-treated GECs. Among 80 signature genes of human gingival fibroblasts, 20 were significantly regulated ( P < 0.05) by MVs from control and biofilm-treated GECs in a similar manner. Matrix metalloproteinase 1 and 3 and interleukin 6 and 8 showed the strongest regulation at the mRNA and protein levels. Several cellular signaling pathways were activated by GEC-MVs in human gingival fibroblasts, including Smad and mitogen-activated protein kinase–associated pathways ERK1/2, JNK, and p38. However, ERK1/2 signaling dominated in the MV-induced gene expression changes. The results demonstrate that GEC-MVs have a strong regulatory effect on the expression of fibroblast genes associated with inflammation and matrix degradation and that bacterial biofilm stimulates the generation of GEC-MVs. This suggests that bacterial biofilms can contribute to the initiation and progression of periodontal disease by promoting a tissue-destructive phenotype in gingival fibroblasts via the enhanced secretion of epithelial MVs.

High sodium intake is associated with increased glucocorticoid production, insulin resistance and metabolic syndrome

OBJECTIVE

High sodium (HS) diet is associated with hypertension (HT) and insulin resistance (IR). We evaluated whether HS diet was associated with a dysregulation of cortisol production and metabolic syndrome (MetS).

PATIENTS AND MEASUREMENTS

We recruited 370 adults (18-85 years, BMI 29·3 ± 4·4 kg/m(2) , 70% women, 72% HT, 61% MetS). HS diet (urinary sodium >150 mEq/day) was observed in 70% of subjects. We measured plasma hormones, lipid profile, urinary free cortisol (UFC) and cortisol tetrahydrometabolites (THM).

RESULTS

Urinary sodium was correlated with UFC (r = +0·45, P < 0·001), cortisol THM (r = +0·41, P < 0·001) and inversely with adiponectin, HDL and aldosterone, after adjusting by age, gender and BMI. Subjects with high, compared with adequate sodium intake (50-149 mEq/day) had higher UFC (P < 0·001), THM (P < 0·001), HOMA-IR (P = 0·04), HT (81% vs 50%, P < 0·001), MetS (69% vs 41%, P < 0·001) and lower adiponectin (P = 0·003). A multivariate predictive model adjusted by confounders showed a high discriminative capacity for MetS (ROC curve 0·878) using four clinical variables: HS intake [OR = 5·6 (CI 2·3-15·3)], HOMA-IR [OR 1·7 (1·3-2·2)] cortisol THM [OR 1·2 (1·1-1·4)] and adiponectin [OR = 0·9 (0·8-0·9)], the latter had a protective effect.

CONCLUSIONS

High sodium diet was associated with increased urinary cortisol and its metabolites. Also, HS diet was associated with HT, insulin resistance, dyslipidaemia and hypoadiponectinaemia, even when adjusting by confounding variables. Further, we observed that high salt intake, IR and higher cortisol metabolites, alone or combined in a clinical simple model, accurately predicted MetS status, suggesting an additive mechanism in obesity-related metabolic disorders.

Implementing the national invasive cervical cancer audit: a local perspective

OBJECTIVE

 To monitor the effectiveness of the cervical screening programme and identify suboptimal management in order to improve patient care.

DESIGN

 Retrospective study.

SETTING

  A university hospital serving a population of 1 million people.

POPULATION

 All women diagnosed with a cervical cancer between 2003 and 2006.

METHODS

  Analysis of data from invasive cervical cancer reviews.

MAIN OUTCOME MEASURE

 Categorisation of cervical cancer cases according to the Invasive Cervical Cancer Audit classification.

RESULTS

  Eighty-seven women were diagnosed with cervical cancer during the 3-year study period. The 'lapsed attender' group accounted for the greatest number of cases (30%), followed by screen detected (26%), interval cancers (13%), never attended (12%), lost to follow-up (10%) and never invited (9%). Women who had never attended for cytology presented with higher stage disease, stage-II or above, compared with the screen-detected cases: 60% were stage II or above, compared with 13.0%, Chi-square P = 0.018. The most frequently identified screening programme problem was patient compliance, which was determined to be the principle contributing factor in 39 cases (45%) and a secondary factor in a further ten cases.

CONCLUSIONS

 The categorisation of cervical cancer cases has the potential of yielding invaluable information for improving programme effectiveness. Patient compliance is the greatest challenge to the screening programme, and the need for regular screening and adherence to follow-up regimens needs to be reinforced in order to maximise the efficacy of the national screening programme.

Proliferation in murine epidermis after minor mechanical stimulation. Part 2. Alterations in keratinocyte cell cycle fluxes

We have recently shown that a mild mechanical irritation (tape strip) of the epidermis on the back skin of adult mice induces a strong and long lasting increase in proliferative activity and cell production. This was revealed by following the fate of 3HTdR-pulse labelled cells within the basal and suprabasal layers. To obtain further insight into the dynamics of cell kinetic changes we also performed double labelling experiments with 3HTdR and BrdUrd at various times after tape stripping. The technique for analysing the data had to account for a non stationary cell flux. A novel biometrical technique was developed which provides parameter estimates on the S-phase duration, the cell cycle duration and a parameter characterizing the degree of nonstationarity. When applied to the mechanically irritated epidermis we observed that the cell flux through the S-phase in the basal layer was accelerated by a factor of 10 between 18 and 36 h post tape strip. This activation declined slightly in the subsequent days and remained 4-6 fold higher than in the normal steady state for over 7 days post tape strip. The duration of the S-phase was 3-5 h and showed little variation. We conclude that mild mechanical irritation only affecting the stratum corneum has major stimulatory effects on the cell kinetics of proliferative keratinocytes in the basal layer of the epidermis indicating the existence of a powerful regulatory mechanism.

Nurse-led ‘one stop’ clinic for elective tonsillectomy referrals

Objectives: Balancing new referrals with limited clinic capacity is a challenge. At Lincoln County Hospital, referrals for tonsillectomy have been managed by an experienced ENT nurse practitioner, in order to deal with this problem more effectively. We reviewed tonsillectomy referrals made in a one year period to determine if surgical outcomes were satisfactory. Results were compared with figures available from the national prospective tonsillectomy audit.

Methods: This was a retrospective study, assessing patients referred to the ENT department at Lincoln County Hospital. We reviewed the number of patients who had proceeded to surgery and the rate of complications.

Results: One hundred and fifty-nine patients had been referred for tonsillectomy over the one year period. One hundred and forty-seven patients had been seen in clinic and 12 had not attended their clinic appointment. Following consultation with the nurse practitioner, 125 patients had proceeded to surgery. Five episodes of bleeding were recorded as complications postoperatively; giving a bleeding complication rate of 4.7 per cent, compared with a rate of 5.7 per cent from the national prospective tonsillectomy audit.

Conclusion: A trained nurse practitioner can safely and effectively facilitate the complete process of managing a routine pre-operative tonsillectomy patient, from primary care referral to arranging admission for surgery.

Post-awakening cortisol secretion during basic military training

Salivary free cortisol concentrations in the first 30 min after awakening were assessed in 12 healthy army recruits at the beginning, middle and end of an 11-week intensive physical training course. To ensure strict adherence to protocol saliva collection was supervised and collected on each sampling day immediately on waking and again 15 and 30 min later. Self-rated psychological assessments of state levels of stress, arousal and fatigue were performed in the evening of each sampling day. A within-subjects repeated-measures analysis of participants who completed the course (12 of the original 20) showed a significant main effect of cortisol concentration across all three sampling points after awakening (F((2,22))=54.516, p<0.0001) and a significant main effect of weeks into the training course (F((3,33))=4.390, p=0.010). Further analysis of this effect of measurement-week revealed that at weeks 3 and 6 total cortisol secretion estimated by area under the curve was lower (F((3,33))=4.602, p=0.008) compared to the beginning and end of the course. Surprisingly self-reported stress, arousal and fatigue did not differ significantly across weeks, despite the large dropout rate (40%) and self-evident pressures of the course. We conclude that when controlling for many confounding variables, including participant adherence, post-awakening cortisol levels are sensitive to stressful challenge over a period of weeks.

Time evolution of sigma 3 annealing twins in secondary recrystallized nickel

Samples of commercially pure nickel have been annealed in air at 0.68T(m) (900 degrees C) for 1, 2 and 3 h in order to study the relationship between the grain growth characteristics and grain boundary misorientation, particularly annealing twins (Sigma 3). Orientation mapping by electron backscatter diffraction was used to obtain the experimental data. Anomalous grain growth was observed in commercially pure nickel after each of the anneals. The main findings are as follows. The texture was mainly {100}<001> and {112}<111> and it was more pronounced in coarse-grained areas than in fine-grained areas. The length fraction of Sigma 3s (annealing twins) increased with annealing time and therefore with the level of anomalous grain growth. Two to three twins per grain were sited in coarse-grained regions whereas less than one twin per grain was sited in fine-grained regions. It is suggested that the nucleation and growth of twinning is mechanistically linked to anomalous grain growth.

The palmomental reflex: a useful clinical sign?

The palmomental reflex, an involuntary contraction of the mentalis muscle of the chin caused by stimulation of the thenar eminence, can be tested easily and rapidly. Its presence may alert the clinician to the possibility of cerebral pathology. However, the reflex is often present in normal people and may be absent in disease states. Testing merely for the presence or absence of the reflex therefore lacks both specificity and sensitivity. A strong, sustained, and easily repeatable contraction of the mentalis muscle, which can be elicited by stimulation of areas other than the palm, is more likely to indicate cerebral damage.

Comparison of neonatal hearing screening devices

Incidence studies estimate that 1-3 per 1000 full term normal neonates and 2-4% of high-risk newborns per 100 have severe bilateral hearing loss. In response, universal hearing screening has been proposed; however, choosing the most appropriate technology continues to be an obstacle. The purpose of the current preliminary study was to compare test results from thirty-two full-term newborns using three types of screening devices, Natus Algo 2 AABR, Otodynamics EchoCheck TEE, and Biologic AuDx DPE. Results indicate that the Natus had the highest pass percentage rate for the right and left ears at 97% and 91% respectively, while the other two devices had pass percentage rates between 31% and 56%. Test duration time for the Natus was 22.5 minutes compared with 5.8-6.4 minutes for the other devices. Despite the longer duration time, our findings favor using the Natus, given its accurate representation of incidence data.

Influence of hypoglycaemia, with or without caffeine ingestion, on visual sensation and performance

Full-field visual evoked potentials and visual information processing were measured in 16 normal, healthy subjects during a hyperinsulinaemic clamp. A randomized cross-over design was used across three conditions: hypoglycaemia and caffeine; hypoglycaemia and placebo; and euglycaemia and caffeine. The latency of the P100 component of the pattern-reversal visual evoked potential increased significantly from rest to hypoglycaemia, but no effect of caffeine was found. Subjects were subsequently divided into two median groups based on the increase in P100 latency in the placebo condition (Group 1, +0.5 ms; Group 2, +5.6 ms). In the absence of caffeine, an inverse correlation between the increase in P100 latency from rest and a deterioration in visual movement detection was found for Group 2, but not for Group 1. Caffeine ingestion resulted in a further increase in P100 latency, from rest to hypoglycaemia, for subjects in Group 2. Hypoglycaemia in the absence of caffeine produces changes in visual sensation from rest to hypoglycaemia. In those subjects most sensitive to the effects of hypoglycaemia (Group 2), the increase in P100 latency was associated with poorer performance in tests of visual information processing. Caffeine ingestion produced further increases in P100 latency in these subjects.

The ixodid tick species attaching to domestic dogs and cats in Great Britain and Ireland

The species of ixodid ticks, attached to dogs and cats presented to veterinary practices in Great Britain and Ireland were identified. Most host animals carried only one tick species with Ixodes ricinus Linné (Acari: Ixodidae) being the most common, identified on 52% of animals, Ixodes hexagonus Leach (Acari: Ixodidae) the second most common (on 39%) and Ixodes canisuga Johnston (Acari: Ixodidae) the third most common (on 11%). A significantly higher proportion of dogs than cats carried I. ricinus, while I. hexagonus was more frequently carried by cats. One animal carried a single specimen of Haemaphysalis punctata Canestrini & Fanzago (Acari: Ixodidae), one carried a Dermacentor reticulatus Fabricius (Acari: Ixodidae) but none carried Rhipicephalus sanguineus Latreille (Acari: Ixodidae). This indicates that the latter two species, vectors of 'exotic' tick-borne diseases, remain at low densities in Great Britain and Ireland. Retrospective information on exposure of the animals to different habitats and geographic regions was collected by questionnaire and subject to contingency table and logistic regression analysis. Woodlands and moorlands were habitats significantly associated with I. ricinus attachment. Exposure to urban parks was significantly associated with I. hexagonus attachment and exposure to boarding kennels and catteries was significantly associated with I. canisuga attachment. Ixodes hexagonus, rather than I. ricinus, was the ixodid tick species most likely to be encountered by urban populations of dogs and cats and, by inference, possibly also humans. The implications of these findings, for the transmission of tick-borne pathogens to dogs, cats and humans are discussed.

A novel BTB/POZ transcriptional repressor protein interacts with the Fanconi anemia group C protein and PLZF

Fanconi anemia (FA) is an autosomal recessive cancer susceptibility syndrome. The phenotype includes developmental defects, bone marrow failure, and cell cycle abnormalities. At least eight complementation groups (A-H) exist, and although three of the corresponding complementation group genes have been cloned, they lack recognizable motifs, and their functions are unknown. We have isolated a binding partner for the Fanconi anemia group C protein (FANCC) by yeast two-hybrid screening. We show that the novel gene, FAZF, encodes a 486 amino acid protein containing a conserved amino terminal BTB/POZ protein interaction domain and three C-terminal Krüppel-like zinc fingers. FAZF is homologous to the promyelocytic leukemia zinc finger (PLZF) protein, which has been shown to act as a transcriptional repressor by recruitment of nuclear corepressors (N-CoR, Sin3, and HDAC1 complex). Consistent with a role in FA, BTB/POZ-containing proteins have been implicated in oncogenesis, limb morphogenesis, hematopoiesis, and proliferation. We show that FAZF is a transcriptional repressor that is able to bind to the same DNA target sequences as PLZF. Our data suggest that the FAZF/FANCC interaction maps to a region of FANCC deleted in FA patients with a severe disease phenotype. We also show that FAZF and wild-type FANCC can colocalize in nuclear foci, whereas a patient-derived mutant FANCC that is compromised for nuclear localization cannot. These results suggest that the function of FANCC may be linked to a transcriptional repression pathway involved in chromatin remodeling.

An antibiotic policy associated with reduced risk of Clostridium difficile-associated diarrhoea

BACKGROUND

antibiotic-associated diarrhoea caused by Clostridium difficile is increasing in hospitals, and older people are at particular risk.

OBJECTIVE

to establish whether reducing patient exposure to injectable third-generation cephalosporins by substituting alternative antibiotics can produce a cost-effective reduction in the incidence of antibiotic-associated diarrhoea.

DESIGN

we prospectively investigated 2157 patients admitted to the department of elderly medicine in the year before introduction of antibiotic restrictions and 2037 patients admitted in the following year. Patients admitted to other wards, where antibiotic prescribing was unchanged, acted as controls.

SETTING

a 900-bed teaching hospital in Cambridge, UK.

MEASUREMENTS

use and cost of injectable antibiotics prescribed in the department of elderly medicine and the other wards studied; occurrence of C. difficile-associated diarrhoea.

RESULTS

in the wards for older people, consumption of injectable cephalosporins fell by 92% (compared with 8% on other wards) and cases of C. difficile-associated diarrhoea fell from 98 to 45 (cases in other wards rose from 213 to 253; P < 0.001). The Pound Sterling 8062 increase in injectable antibiotic costs on the elderly wards were offset by the release of 1087 wasted bed-days attributable to the 53 fewer cases, with potential savings of Pound Sterling 212,000.

CONCLUSIONS

restricting the consumption of injectable third-generation cephalosporins is a cost-effective method of reducing the incidence of C. difficile-associated diarrhoea.

Toxic shock syndrome secondary to a dental abscess

A 9-year-old girl presented with arthralgia and myalgia which progressed to developing renal failure and overwhelming septic shock. The underlying cause was assumed to be a periodontal abscess from an upper right deciduous canine tooth. The pus from the abscess grew a toxic shock syndrome toxin 1-producing Staphylococcus aureus. This case illustrates the importance of an oral surgical review of patients presenting with features of toxic shock syndrome if the source of the infection is not immediately obvious.

Convergence of progesterone with growth factor and cytokine signaling in breast cancer. Progesterone receptors regulate signal transducers and activators of transcription expression and activity

STATS (signal transducers and activators of transcription) are latent transcription factors activated in the cytoplasm by diverse cell surface signaling molecules. Like progesterone receptors (PR), Stat5a and 5b are required for normal mammary gland growth and differentiation. These two proteins are up-regulated during pregnancy, a period dominated by high levels of progesterone. We now show that progestin treatment of breast cancer cells regulates Stat5a and 5b, Stat3, and Stat1 protein levels in a PR-dependent manner. In addition, progestin treatment induces translocation of Stat5 into the nucleus, possibly mediated by the association of PR and Stat5. Last, progesterone pretreatment enhances the phosphorylation of Stat5 on tyrosine 694 induced by epidermal growth factor. Functional data show that progestin pretreatment of breast cancer cells enhances the ability of prolactin to stimulate the transcriptional activity of Stat5 on a beta-casein promoter. Progesterone and epidermal growth factor synergize to control transcription from p21(WAF1) and c-fos promoters. These data demonstrate the convergence of progesterone and growth factor/cytokine signaling pathways at multiple levels, and suggest a mechanism for coordination of PR and Stat5-mediated proliferative and differentiative events in the mammary gland.

Selective down-regulation of progesterone receptor isoform B in poorly differentiated human endometrial cancer cells: implications for unopposed estrogen action

The uterine endometrium responds to unopposed estrogen stimulation with rapid cell proliferation. Progesterone protects the endometrium against the hyperplastic effects of estradiol (E2) through progesterone receptors (PRs), of which two isoforms are expressed: human (h) PRA and PRB. hPRB has a longer NH2 terminus and may function differently from hPRA. Thus, the relative expression of hPRA:hPRB is likely to be important for the action of progesterone. We hypothesized that the hPRA:hPRB ratios may be abnormal in endometrial cancer, leading to a lack of normal progesterone protection against the growth-promoting effects of E2. To test this hypothesis, well-differentiated Ishikawa endometrial cancer cells were compared to poorly differentiated Hec50 and KLE cells. Reverse transcription-PCR was chosen as a sensitive method to detect transcripts for the two forms of PR. The relative expression of PR isoforms under hormonal stimulation was determined by Western blotting. Transient transfections of hPRA and hPRB into endometrial cells allowed the evaluation of the transcriptional activity of each isoform independently on reporter gene transcription under the control of a simple progesterone response element-containing promoter. The effect of coexpressing the estrogen receptor on PR expression was also studied. Ishikawa cells (well-differentiated) express both hPRA and hPRB. Both isoforms, but predominantly hPRB, are up-regulated by E2 and not by tamoxifen or the pure antiestrogen ICI 182,780. Hec50 and KLE cells (poorly differentiated) express only hPRA. No hPRB is present in the poorly differentiated cells, and it is not induced by estrogen receptor expression and/or estrogen treatment. In all cells, hPRB expression, whether endogenous or produced as a result of transfection, acts as a stronger transcription factor than hPRA on a simple progesterone-dependent promoter. We speculate that down-regulation of hPRB may predict for poorly differentiated endometrial cancers that do not respond to progestin therapy.

Analysis of pulse oximetry data in normal sleeping children

This study was designed to determine the range of oxygen saturation levels encountered in normal sleeping children up to 10 years of age in their own home environment. Subjects were chosen by stratified random sampling from the general practice list of the town of Frome, Somerset, UK. Analysis of overnight pulse oximetry recordings allowed a normal range for the following parameters of oxygen saturation level to be reported: mean, median, mode, maximum, fifth centile, upper and lower quartiles and the number of greater than 4% dips in oxygen saturation per hour. As a consequence of this study the values given can now be used to identify those children with abnormal sleep patterns.

Ligation of CD40 with soluble CD40 ligand reverses anti-immunoglobulin-mediated negative signalling in murine B lymphoma cell lines but not in immature B cells from neonatal mice

Ligation of surface immunoglobulin (sIg) on certain murine B-lymphoma lines has been shown to initiate a programme leading to growth arrest and death of the cells by apoptosis. The cell lines WEHI 231 and CH33 which respond in this way to receptor cross-linking have phenotypic characteristics resembling those of immature normal B cells, and their responses have been taken to model those responsible for clonal deletion or anergy. Cross-linking of sIg on normal neonatal B cells has also been shown to inhibit their responsiveness to polyclonal activators. We have examined the ability of various co-stimuli to modify the response of growth-inhibitable B lymphoma lines to sIg cross-linking. Our findings indicate that cell-cell contact between cells of the WEHI 231 or CH33 lines and activated T cells rescues these cells from growth arrest and apoptosis. Cell-free supernatants from some T-cell lines were also protective although recombinant IL-4 had no effect. Analysis of the most effective signals and timing for inducing this protection suggested that it might, in part, be mediated by CD40 ligand (CD40L) expressed on or secreted by activated T cells. Using a soluble recombinant CD40L-CD8 fusion protein we have now shown that co-ligation of CD40 is sufficient to rescue WEHI231 and CH33 cells from anti-Ig-induced apoptosis. In contrast, the inhibitory effect of anti-Ig antibodies on the lipopolysaccharide (LPS)-driven proliferation of neonatal B cells was not relieved by co-ligation of CD40 with CD40L. These findings bring into question the usefulness of 'immature' B-cell lines as models for tolerance induction.

The reproducibility of urinary growth hormone measurement in children undergoing adenotonsillectomy: a pilot study

The reproducibility of urinary growth hormone levels in normal children and in children undergoing adenotonsillar surgery was investigated. Thirty normal children and 32 children pre- and post-adenotonsillectomy had overnight urinary growth hormone levels measured on two consecutive nights using the technique of immunoradiometric assay. There was no significant difference when levels in each of these groups were compared. Therefore, the results were pooled (n = 94) and the correlation coefficient comparing levels obtained on the first and the second consecutive nights sample was calculated, r = 0.644 (P < 0.001). This work suggests that studies of urinary growth hormone levels in children give reproducible results. Further investigation of this technique as a screening or diagnostic procedure in the clinical setting can now be more widely evaluated.