Updates in the pathogenesis and management of immune-related enterocolitis, hepatitis and cardiovascular toxicities

Immune checkpoint inhibitors (ICIs) have become a cornerstone of treatment for many solid organ malignancies. Alongside increasing use, the occurrence of immune-related adverse events (irAEs) has also increased and remains a significant challenge when treating patients with ICI. The underlying pathophysiology of irAE development for many organ systems is yet to be elucidated, but may involve unmasking of latent autoimmunity, increased T-cell recognition of shared antigens on cancer and normal tissue and ICI-triggered immune dysregulation with overactivation of proinflammatory pathways and suppression of immune control pathways. Management strategies for irAEs have historically been borrowed from paradigms for conventional autoimmune conditions such as inflammatory bowel disease and autoimmune hepatitis; however, recent translational efforts have clearly demonstrated key differences in underlying immune signalling pathways. As we begin to understand these differences, we must adapt a more targeted approach to immunosuppression and exercise a more nuanced approach with the multiple biologic agents available to mitigate ICI-related toxicity without reversing the antitumour effect of ICI. In this review, we focus on three key immune-related toxicities where recent clinical and translational work has provided nuanced insights into pathogenesis and treatment strategies: enterocolitis, hepatitis and cardiovascular toxicity including myocarditis.

Bacterial lipopolysaccharide modulates immune response in the colorectal tumor microenvironment

Immune responses can have opposing effects in colorectal cancer (CRC), the balance of which may determine whether a cancer regresses, progresses, or potentially metastasizes. These effects are evident in CRC consensus molecular subtypes (CMS) where both CMS1 and CMS4 contain immune infiltrates yet have opposing prognoses. The microbiome has previously been associated with CRC and immune response in CRC but has largely been ignored in the CRC subtype discussion. We used CMS subtyping on surgical resections from patients and aimed to determine the contributions of the microbiome to the pleiotropic effects evident in immune-infiltrated subtypes. We integrated host gene-expression and meta-transcriptomic data to determine the link between immune characteristics and microbiome contributions in these subtypes and identified lipopolysaccharide (LPS) binding as a potential functional mechanism. We identified candidate bacteria with LPS properties that could affect immune response, and tested the effects of their LPS on cytokine production of peripheral blood mononuclear cells (PBMCs). We focused on Fusobacterium periodonticum and Bacteroides fragilis in CMS1, and Porphyromonas asaccharolytica in CMS4. Treatment of PBMCs with LPS isolated from these bacteria showed that F. periodonticum stimulates cytokine production in PBMCs while both B. fragilis and P. asaccharolytica had an inhibitory effect. Furthermore, LPS from the latter two species can inhibit the immunogenic properties of F. periodonticum LPS when co-incubated with PBMCs. We propose that different microbes in the CRC tumor microenvironment can alter the local immune activity, with important implications for prognosis and treatment response.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration

BACKGROUND

Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings.

METHODS

PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations.

DISCUSSION

The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Overnight variation in tidal expiratory flow limitation in COPD patients and its correction: an observational study

Background

Tidal expiratory flow limitation (EFL_T) is common among COPD patients. Whether EFL_T changes during sleep and can be abolished during home ventilation is not known.

Methods

COPD patients considered for noninvasive ventilation used a ventilator which measured within-breath reactance change at 5 Hz (∆Xrs) and adjusted EPAP settings to abolish EFL_T. Participants flow limited (∆Xrs > 2.8) when supine underwent polysomnography (PSG) and were offered home ventilation for 2 weeks. The EPAP pressure that abolished EFL_T was measured and compared to that during supine wakefulness. Ventilator adherence and subjective patient perceptions were obtained after home use.

Results

Of 26 patients with supine EFL_T, 15 completed overnight PSG and 10 the home study. In single night and 2-week home studies, EFL_T within and between participants was highly variable. This was unrelated to sleep stage or body position with only 14.6% of sleep time spent within 1 cmH₂O of the awake screening pressure. Over 2 weeks, mean EPAP was almost half the mean maximum EPAP (11.7 vs 6.4 cmH₂O respectively). Group mean ∆Xrs was ≤ 2.8 for 77.3% of their home use with a mean time to abolish new EFL_T of 5.91 min. Adherence to the ventilator varied between 71 and 100% in prior NIV users and 36–100% for naïve users with most users rating therapy as comfortable.

Conclusions

Tidal expiratory flow limitation varies significant during sleep in COPD patients. This can be controlled by auto-titrating the amount of EPAP delivered. This approach appears to be practical and well tolerated by patients.

Trial registration: The trial was retrospectively registered at CT.gov NCT04725500.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12931-021-01913-7.

Comparing the performance of three methods to assess DOM dynamics within two distinct glacierized watersheds of the tropical Andes

Dissolved organic matter (DOM) is recognized as a good indicator of water quality as its concentration is influenced by land use, rainwater, windborne material and anthropogenic activities. Recent technological advances make it possible to characterize fluorescent dissolved organic matter (FDOM), the fraction of DOM that fluoresces. Among these advances, portable fluorometers and benchtop fluorescence excitation and emission spectroscopy coupled with a parallel factor analysis (EEM-PARAFAC) have shown to be reliable. Despite their rising popularity, there is still a need to evaluate the extent to which these techniques can assess DOM dynamics at the watershed scale. We compare the performance of in-situ measurements of FDOM with laboratory measurements of fluorescence spectroscopy within the context of two distinct glacierized watersheds in Peru. Glacierized watersheds represent unique testing environments with contrasting DOM conditions, flowing from pristine, vegetation-free headwaters through locations with obvious anthropogenic influences. We used an in-situ fluorometer and a portable multimeter to take 38 measurements of FDOM, pH and turbidity throughout the two catchments. Additionally, samples were analyzed in the laboratory using the EEM-PARAFAC method. Results were compared to dissolved organic carbon (DOC) measurements using standard high-temperature catalytic oxidation. Our results show that the three techniques together were able to capture the DOM dynamics for both studied watersheds. Taken individually, all three methods allowed detection of the watershed DOM main points of sources but in a more limited way. Due to the narrow bandwidth of the portable fluorometer used in the study, FDOM measurements were almost non-detectable to protein-like substances. Indeed, the more demanding EEM-PARAFAC was able to both differentiate between potential sources of DOM and provide an estimate of relative concentrations of different organic components. Finally, similar to FDOM but to a lesser extent, the DOC measurements showed some limits where protein-like substances make up most of the DOM composition.

From NCLB to ESSA: Implications for Teacher Preparation and Policy

With the 2001 reauthorization of the Elementary and Secondary Education Act (ESEA), the term highly qualified teacher (HQT) became an important component of teacher licensure, including for special educators. However, when ESEA was reauthorized in 2015 as the Every Student Succeeds Act (ESSA), the highly qualified regulations were removed. The purpose of this study was to look back at the historical record of policy implementation of HQT and compare the record across states to provide implications for teacher preparation and licensure policy in the era of ESSA. This was accomplished through a review of the history of special education teacher licensure and completion of a comprehensive analysis of state licensure requirements under the Individuals with Disabilities Education Improvement Act. Despite a general consistency across three domains (i.e., degree, examination, and licensure) of the highly qualified statute, inconsistencies among states at both the elementary and secondary levels of special educator licensure may yield significant challenges related to the impact of teacher quality on student outcomes. Better understanding of these challenges is important as policymakers will be better able to make decisions regarding what teachers need to know prior to entering the field to meet students’ needs and generate student achievement.

L-arginase induces vascular dysfunction in old spontaneously hypertensive rats

BACKGROUND

Aging is a major non-modifiable risk factor for hypertension. Changes in aging are similar to those seen in hypertension in the vasculature. Also, aging increases the vascular dysfunction that occurs in hypertension. L-arginase action reduces substrate (L-arginine) availability for the formation of nitric oxide (NO). This reduces the level of NO and leads to reduced vasodilation and ultimately, vascular dysfunction. This study examines the hypothesis that age-dependent vascular dysfunction in SHRs is mediated by arginase.

METHODS

Young (12-14 weeks) and old (11-12 months) male Wistar and spontaneously hypertensive rats (SHR) were used. Mean arterial pressure (MAP) was measured in the rats. They were then euthanized and mesenteric resistance arteries (MRAs) and thoracic aortae were excised and placed in ice-cold physiological salt solution (PSS). Arterial segments were either snap-frozen in liquid nitrogen and stored for immunoblotting studies or cut into 2mm rings for reactivity studies. Cumulative concentration-response curves to acetylcholine (Ach: 10^-9 - 3x10^-5M) and sodium nitroprusside (SNP: 10^-12 - 3x10^-5 M) were performed in the absence or presence (30-minute exposure) of L-arginase, 0.05U/ML (MRA) or 0.5U/ML (aorta). Vessels were pre-contracted with phenylephrine (PE; 3x10^-6M).

RESULTS

MAP increased during aging in the SHRs p<0.05 but not in the Wistar rats. Arginase impaired the endothelium-dependent relaxation responses of thoracic aortic and MRA arterial rings to Ach in the old Wistars and SHRs (Emax aorta: 29.42±2.19% vs 7.94±1.86%). Arginase also impaired endothelium-independent relaxation response to SNP in the old SHRs only (Emax aorta: 88.62±4.10% vs 31.45±10.61%). We also observed no differences in the serum arginase activity in the four groups of rats. On the contrary, arginase activity in the aortae of young Wistar rats was reduced compared to other groups.

CONCLUSIONS

Arginase impairs both endothelium-dependent and -independent vasorelaxation responses, through the NO signaling pathway.

Osteocyte Death and Bone Overgrowth in Mice Lacking Fibroblast Growth Factor Receptors 1 and 2 in Mature Osteoblasts and Osteocytes

Fibroblast growth factor (FGF) signaling pathways have well-established roles in skeletal development, with essential functions in both chondrogenesis and osteogenesis. In mice, previous conditional knockout studies suggested distinct roles for FGF receptor 1 (FGFR1) signaling at different stages of osteogenesis and a role for FGFR2 in osteoblast maturation. However, the potential for redundancy among FGFRs and the mechanisms and consequences of stage-specific osteoblast lineage regulation were not addressed. Here, we conditionally inactivate Fgfr1 and Fgfr2 in mature osteoblasts with an Osteocalcin (OC)-Cre or Dentin matrix protein 1 (Dmp1)-CreER driver. We find that young mice lacking both receptors or only FGFR1 are phenotypically normal. However, between 6 and 12 weeks of age, OC-Cre Fgfr1/Fgfr2 double- and Fgfr1 single-conditional knockout mice develop a high bone mass phenotype with increased periosteal apposition, increased and disorganized endocortical bone with increased porosity, and biomechanical properties that reflect increased bone mass but impaired material properties. Histopathological and gene expression analyses show that this phenotype is preceded by a striking loss of osteocytes and accompanied by activation of the Wnt/β-catenin signaling pathway. These data identify a role for FGFR1 signaling in mature osteoblasts/osteocytes that is directly or indirectly required for osteocyte survival and regulation of bone mass during postnatal bone growth. © 2019 American Society for Bone and Mineral Research.

Randomised clinical trial: efficacy, safety and dosage of adjunctive allopurinol in azathioprine/mercaptopurine nonresponders (AAA Study)

BACKGROUND

Thiopurine hypermethylation towards 6-methylmercaptopurine (6MMP) instead of 6-thioguanine nucleotides (6TGN) is associated with inefficacy in patients with IBD. Allopurinol reverses such hypermethylation.

AIMS

To prospectively determine efficacy of allopurinol-thiopurine combination and to compare 2 doses of allopurinol.

DESIGN

In a multicentre, double-blind trial, patients with clinically active or steroid-dependent IBD and thiopurine shunting were randomised to 50 or 100 mg/d allopurinol and 25% of their screening thiopurine dose, which was subsequently optimised, aiming for 6TGN of 260-500 pmol/8x10⁸ RBCs. The primary endpoint was steroid-free clinical remission at 24 weeks.

RESULTS

Of 73 patients, 39 (53% [95% CI 42-65]) achieved steroid-free remission, (54% with 50 mg/d and 53% with 100 mg/d). 81% were able to discontinue steroids. Therapeutic 6TGN levels were achieved in both groups. Final thiopurine doses were lower with 100 mg/d allopurinol (P < 0.005). 6MMP: 6TGN ratio decreased from mean 64 to 4 (P < 0.001), being higher with 50 mg/d (6 ± 1.83) than for 100 mg/d ([1 ± 0.16], P = 0.003). Three patients on 50 mg/d failed to sustain low ratios at 24 weeks. Toxicity was minimal; three patients on 50 mg/d allopurinol developed transient leukopenia. Alanine aminotransferase concentrations decreased (P < 0.001) similarly in both arms. Faecal calprotectin levels at study end were lower in patients who achieved the primary endpoint (median 171 [85-541] vs 821[110-5892] ug/g, P = 0.03).

CONCLUSIONS

Low-dose allopurinol-thiopurine combination safely reverses shunting and optimises 6TGN with associated improvement in disease activity. 100 mg/d allopurinol is preferable due to greater metabolite profile stability and lower thiopurine dose without additional toxicity.

Imaging characteristics and treatment of a penetrating brain injury caused by an oropharyngeal foreign body in a dog

A 4-year-old Border collie was presented with one episode of collapse, altered mentation, and a suspected pharyngeal stick injury. Magnetic resonance imaging (MRI) and computed tomography showed a linear foreign body penetrating the right oropharynx, through the foramen ovale and the brain parenchyma. The foreign body was surgically removed and medical treatment initiated. Complete resolution of clinical signs was noted at recheck 8 weeks later. Repeat MRI showed chronic secondary changes in the brain parenchyma. To the authors' knowledge, this is the first report of the advanced imaging findings and successful treatment of a penetrating oropharyngeal intracranial foreign body in a dog.

Mapping HPV Vaccination and Cervical Cancer Screening Practice in the Pacific Region-Strengthening National and Regional Cervical Cancer Prevention

OBJECTIVE

To provide background information for strengthening cervical cancer prevention in the Pacific by mapping current human papillomavirus (HPV) vaccination and cervical cancer screening practices, as well as intent and barriers to the introduction and maintenance of national HPV vaccination programmes in the region.

MATERIALS AND METHODS

A cross-sectional questionnaire-based survey among ministry of health officials from 21 Pacific Island countries and territories (n=21).

RESULTS

Cervical cancer prevention was rated as highly important, but implementation of prevention programs were insufficient, with only two of 21 countries and territories having achieved coverage of cervical cancer screening above 40%. Ten of 21 countries and territories had included HPV vaccination in their immunization schedule, but only two countries reported coverage of HPV vaccination above 60% among the targeted population. Key barriers to the introduction and continuation of HPV vaccination were reported to be: (i) Lack of sustainable financing for HPV vaccine programs; (ii) Lack of visible government endorsement; (iii) Critical public perception of the value and safety of the HPV vaccine; and (iv) Lack of clear guidelines and policies for HPV vaccination.

CONCLUSION

Current practices to prevent cervical cancer in the Pacific Region do not match the high burden of disease from cervical cancer. A regional approach, including reducing vaccine prices by bulk purchase of vaccine, technical support for implementation of prevention programs, operational research and advocacy could strengthen political momentum for cervical cancer prevention and avoid risking the lives of many women in the Pacific.

Describing the burden of non-communicable disease risk factors among adults with diabetes in Wallis and Futuna

BACKGROUND

The South Pacific Territory of Wallis and Futuna has a high burden of non-communicable diseases (NCD): 18% of adults have diabetes mellitus (DM) and 87% are classified as overweight or obese.

OBJECTIVE

To characterise the burden of additional World Health Organization (WHO) recognised NCD risk factors, such as smoking, obesity, high blood pressure, eating less than five fruit or vegetable servings per day and a sedentary lifestyle, among adults with DM.

DESIGN

Re-analysis of cross-sectional data from a 2009 national survey. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated.

RESULTS

Of 487 adults sampled, 87 (18%) had DM. Nearly 99% of individuals with DM had at least one additional NCD risk factor, and 62% had three or more concurrent NCD risk factors. Individuals with DM were more likely to be obese (OR 1.66, 95%CI 1.01-2.74) and had a much higher prevalence of high blood pressure (OR 3.02, 95%CI 1.87-4.86).

CONCLUSION

DM is rarely identified in the absence of other NCD risk factors. We recommend an integrated approach to the management of DM and other NCD risk factors in routine care rather than a disease-specific approach.

Soft drink consumption in Pacific Island countries and territories: a review of trade data

INTRODUCTION

Pacific Islands Countries and Territories (PICTs) have some of the highest rates of obesity and diabetes in the world. Research has demonstrated a strong link between sugar-sweetened beverage (SSB) consumption and subsequent risk of overweight, obesity, dental caries and type II diabetes. To address the impact of SSBs on noncommunicable diseases, it is crucial to understand the level of SSB consumption in PICTs.

METHODS

The volume of soft drinks imported and exported was requested from PICTs to estimate the litres of soft drink consumption per head of population. Analysis was confined to PICTs who did not produce their own soft drinks because production data was limited. The Harmonised Commodity Description and Coding System (HS) category 22.02 was used which includes both diet and sugar-sweetened soft drinks. The trade data estimates were then compared with school survey data to explore how the data sources corresponded given the strengths and weaknesses of each.

RESULTS

Soft drink import volumes were a feasible way of estimating total soft drink consumption in PICTs and look at trends over time. Seven out of eleven non-producing PICTs contacted were able to provide volume of soft drinks imported. In 2011, estimates of soft drink consumption per person were 84L in Palau, 47L in the Commonwealth of the Northern Mariana Islands (CNMI), 41L in Niue, 31L in Tonga, 22L in Federates States of Micronesia, 8L in Tuvalu and 1L in Kiribati.

CONCLUSIONS

Trade data is a feasible way of monitoring soft drink consumption and may be useful to evaluate the impact of changes in government policy on importation of soft drinks. Data quality could be maximised by including export data, adjusting for visitor numbers and cross-checking exports from corresponding countries. To monitor SSB consumption, a wider range of categories could be included such as categories for sugar-sweetened juice and sweetened-milk drinks.

Using new electrofishing technology to amp-up fish sampling in estuarine habitats

A prototype, boat-mounted electrofisher capable of operation in estuarine waters (where electrical conductivities often exceed 20 000 µS cm(-1)) was assessed. Electrofishing was compared to fyke and mesh netting in four riverine estuaries and to seining in a lagoonal estuary (consisting of a series of brackish coastal lakes separated from the sea by a barrier system of sand dunes). Fish assemblage composition, length distributions and the probability of detecting ecological fish guilds (relating to estuary use, position in the water column and body size) were compared among gears. The assemblage composition of electrofishing samples differed from those of fyke nets in all riverine estuaries and from mesh netting in two. The assemblage composition of electrofishing samples differed from those of seining in structured seagrass habitats of the lagoonal estuary. When all species were pooled, the electrofisher sampled a broader range of lengths than either fyke or mesh netting in riverine estuaries or seining in lagoonal estuaries. The bias of electrofishing and netting towards particular species and size classes affected the probability of detecting some ecological guilds, highlighting the potential implications of gear choice on understanding estuarine ecological function. The detection of guilds varied with gear type and environmental conditions, including stratification, water depth and surface electrical conductivity. Assessments with the aim to characterize the structure of fish assemblages will benefit from the use of multiple gears. Electrofishing shows immense promise for discretely sampling highly structured habitats to test hypotheses about their use.

Premature mortality in Scottish injecting drug users: a life-history approach

In Scotland, deaths in drug users are known to be higher than in the rest of the UK and most of Europe. Reducing drug-related deaths is currently a national priority for the Scottish Government.  This study aimed to present a description of the life histories of a group of injecting drug users who have recently died, with a view to highlighting areas for further research. The Edinburgh Addiction Cohort study recently carried out 432 follow-up interviews between the years 2005 and 2007. Thirty-three cases who completed this extensive interview detailing early life, education, employment, drug use, opiate substitution treatment, criminal history, mental health problems and overdose have subsequently died, leaving this source of rich information about their lives. The design of the interview used the life grid approach. Information was also compiled from full primary care records and General Register Office death certificates. Early life adversity was apparent for many cases, with a steady progression into early criminal behaviour and drug misuse. Poor adult life outcomes illustrated the lifelong damaging effects of drug injecting. Death occurred significantly earlier than in the general population or those living in deprived communities who did not use drugs. In conclusion, a clearer understanding of the life histories of problem drug users would be advantageous for health-care professionals and policy-makers. More qualitative research studies are needed to highlight areas which might require early intervention and also complement the existing secondary data studies.

Contact patterns as a risk factor for bovine tuberculosis infection in a free-living adult brushtail possum Trichosurus vulpecula population

The aim of this study was to identify risk factors for bovine tuberculosis (TB) in a free-roaming, capture-mark-recapture monitored possum Trichosurus vulpecula population in a 22-ha study site at Castlepoint, New Zealand from 1 April 1989 to 31 March 1994. A matched case-control design was used to evaluate the influence of sex, habitat and contact opportunities on TB risk. Cases comprised possums identified as TB-positive throughout the study period. Controls were selected from the group of possums that were captured and showed no clinical signs of TB throughout the study period. Measures derived from a social network analysis of possum capture locations such as degree, clustering coefficient (CC) and betweenness were used to represent potential contact opportunities among possums. Network analysis measures recorded for individual possums in the 12-month period before a diagnosis of TB were evaluated in a conditional logistic regression model. We found no evidence of an association between case status and the total number of possums with which there was potential contact (degree) (P=0.5). The odds of cases being exposed to unit increases in the number of TB-positive contacts was 2.50 (95% CI 1.24-5.05; P<0.01) times that of controls. This effect was conditional on the total number of potential contacts made, with a negative interaction with increasing degree. These findings indicate that potential contact with TB-positive possums increases the odds of disease whereas potential contact with large numbers of possums does not. This suggests that multiple contacts with TB-positive possum(s) are necessary for transmission of TB and this is more likely to occur in networks that are smaller. We challenge the hypothesis that contact with large numbers of individuals increases the probability of becoming TB infected and argue that individual contact behaviour is a determinant of the creation of TB foci within free-living possum populations.

Dyspepsia treatment guidelines in general practice — an observational study

An observational study of prescribing for dyspepsia, in Glasgow, used Scottish Prescribing Analysis (SPA) and Prescribing Information for Scotland Computer Programme (PRISMS) data to monitor the implementation of a set of locally produced guidelines on dyspepsia. The main outcomes measured were the proportion of cimetidine prescribed generically, the ratio of prescriptions for cimetidine and ranitidine, the number of prescriptions for omeprazole per 1,000 patients per month and the total number of prescriptions for tripotassium dicitratobismuthate (De-Nol) per month. The results suggest that the dyspepsia guidelines have been successfully implemented as there has been an increase in the proportion of cimetidine prescribed generically, an increase in the use of cimetidine as the H2 antagonist of choice and an increase in the use of the recommended triple therapy regimen to eradicate Helicobacter pylori infection from patients with peptic ulcer disease. This study shows that consensus guidelines on a common clinical condition can be widely accepted in primary care if appropriately designed, developed and implemented. Their implementation can be followed from routine prescription information.

Dermatological findings in 61 mutation-positive individuals with cardiofaciocutaneous syndrome

BACKGROUND

The RASopathies are a class of human genetic syndromes that are caused by germline mutations in genes which encode components of the Ras/mitogen-activated protein kinase (MAPK) pathway. Cardiofaciocutaneous (CFC) syndrome is characterized by distinctive craniofacial features, congenital heart defects, and abnormalities of the skin and hair.

OBJECTIVES

Systematically to characterize the spectrum of dermatological findings in mutation-positive individuals with CFC syndrome.

METHODS

Dermatological surveys were designed by the authors and distributed to the study participants through CFC International or directly by the authors (K.A.R. and D.H.S.) between July 2006 and August 2009. A second follow-up survey was collected between December 2007 and August 2009. When available, digital images and medical records of the participants were obtained. Study participants included individuals with CFC syndrome who have a mutation in BRAF, MAP2K1, MAP2K2 or KRAS.

RESULTS

Individuals with CFC syndrome have a variety of dermatological manifestations caused by dysregulation of the MAPK pathway in development. Numerous acquired melanocytic naevi were one of the most striking features: more than 50 naevi were reported by 23% (14/61) of participants and of those, more than 100 naevi were reported by 36% (5/14). Keratosis pilaris was reported in 80% (49/61) of cases. Ulerythema ophryogenes was common, occurring in 90% (55/61). Infantile haemangiomas occurred at a greater frequency, 26% (16/61), as compared with the general population.

CONCLUSIONS

CFC syndrome has a complex dermatological phenotype with many cutaneous features, some of which allow it to be differentiated from the other Ras/MAPK pathway syndromes. Multiple café-au-lait macules and papillomas were not identified in this CFC cohort, helping to distinguish CFC from other RASopathies such as neurofibromatosis type 1 and Costello syndrome.

The efficacy of endovascular stenting in the treatment of supraclinoid internal carotid artery blister aneurysms using a stent-in-stent technique

BACKGROUND AND PURPOSE

Blister aneurysms of the supraclinoid ICA represent a rare but well-documented cause of subarachnoid hemorrhage. These aneurysms are difficult to detect, and their surgical treatment is challenging, with high morbidity and mortality rates. The reports currently in the literature that describe the surgical and endovascular treatment of these aneurysms offer no clear consensus on the optimal treatment. We describe a staged endovascular treatment entailing stenting using a stent-in-stent technique, as well as planned but delayed embolization as the aneurysm increases in size to allow the introduction of coils.

MATERIALS AND METHODS

We performed a retrospective review of all cerebral angiograms performed at our institution over an 8-month period for evaluation of subarachnoid hemorrhage, identifying 6 ICA blister aneurysms.

RESULTS

All 6 blister aneurysms were located in the supraclinoid ICA. The stent-in-stent technique was used for the initial treatment of all patients. Three patients had no residual or recurrent aneurysm following initial treatment. Three patients required retreatment with coils after continued growth of the aneurysm, identified on follow-up angiography. Five patients had good recovery (average mRS score of 1), and 1 patient had poor neurologic recovery (mRS score of 3) due to a large hemorrhagic infarction.

CONCLUSIONS

Our case series suggests that staged endovascular treatment entailing the use of a stent-in-stent technique, augmented with subsequent coil embolization as necessary for progressive disease, is a viable endovascular option for treating ruptured supraclinoid blister aneurysms, allowing for parent artery preservation.

Progression of dopaminergic dysfunction in a LRRK2 kindred: a multitracer PET study

OBJECTIVE

Little is known about the progression of dopaminergic dysfunction in LRRK2-associated Parkinson disease (PD). We sought to characterize the neurochemical progression with multitracer PET in asymptomatic members of parkinsonian kindred (family D, Western Nebraska) carrying LRRK2 (R1441C) mutation.

METHOD

Thirteen family D subjects underwent PET scans of presynaptic dopaminergic integrity and five subjects were rescanned 2 to 3 years later.

RESULTS

In subjects 8, 9 (mutation carriers), and 13 (genealogically at risk subject), there was a decline in PET markers over the course of the study that was significantly greater than the expected rate of decline in healthy controls. Reduced dopamine transporter binding was the earliest indication of subclinical dopaminergic dysfunction and progression to clinical disease was generally associated with the emergence of abnormal fluorodopa uptake.

CONCLUSION

PET study of presymptomatic members of our LRRK2 kindred revealed dopaminergic dysfunction that progressed over time. This represents an ideal group to study the natural history of early disease and the potential effects of neuroprotective interventions.

Farm exposure in utero may protect against asthma, hay fever and eczema

The aim of the present study was to assess which factors contribute to the lower prevalence of allergic diseases in farmers' children, and the importance of timing of exposure. In a cross-sectional questionnaire survey, asthma symptoms, hay fever and eczema were assessed, as well as current, early and prenatal farm-related exposures in 1,333 farmers' children and 566 reference children aged 5-17 yrs. Farmers' children had a lower incidence of asthma symptoms and eczema. Current and maternal exposure during pregnancy to animals and/or grain and hay reduced the risk of asthma symptoms, hay fever and eczema. The exposure-response association for maternal exposure was nonlinear for most outcomes. After mutual adjustment, the effects of prenatal exposure remained unchanged whereas current exposure remained protective only for asthma medication, asthma ever and hay fever. Exposure during the first 2 yrs was not associated with symptoms, after controlling for prenatal exposure. A combination of prenatal and current exposure was most strongly associated with wheeze (odds ratio (OR) 0.48, 95% confidence interval (CI) 0.28-0.80), asthma medication (OR 0.50, 95% CI 0.30-0.82), asthma ever (OR 0.50, 95% CI 0.33-0.76), hay fever (OR 0.47, 95% CI 0.30-0.73) and eczema (OR 0.46, 95% CI 0.30-0.70). Prenatal exposure may contribute to the low prevalence of asthma, hay fever and eczema in farmers' children, but continued exposure may be required to maintain optimal protection.