An exploratory study on the association between blood-based biomarkers and subacute neurometabolic changes following mild traumatic brain injury

BACKGROUND AND OBJECTIVES

Blood-based biomarkers and advanced neuroimaging modalities such as magnetic resonance spectroscopy (MRS) or diffusion tensor imaging (DTI) have enhanced our understanding of the pathophysiology of mild traumatic brain injury (mTBI). However, there is limited published data on how blood biomarkers relate to neuroimaging biomarkers post-mTBI.

METHODS

To investigate this, 30 patients with mTBI and 21 healthy controls were enrolled. Data was collected at two timepoints postinjury: acute, < 24 h, (blood) and subacute, four-to-six weeks, (blood and imaging). Interleukin (IL) 6 and 10 (inflammation), free thiols (systemic oxidative stress) and neurofilament light (NF-L) (axonal injury) were quantified in plasma. The neurometabolites total N-acetyl aspartate (tNAA) (neuronal energetics), Myo-Inositol (Ins) and total Choline (tCh) (inflammation) and, Glutathione (GSH, oxidative stress) were quantified using MRS.

RESULTS

Concentrations of IL-6 and IL-10 were significantly elevated in the acute phase post-mTBI, while NF-L was elevated only in the subacute phase. Total NAA was lowered in patients with mTBI, although this difference was only nominally significant (uncorrected P < 0.05). Within the patient group, acute IL-6 and subacute tNAA levels were negatively associated (r =  - 0.46, uncorrected-P = 0.01), albeit not at a threshold corrected for multiple testing (corrected-P = 0.17). When age was added as a covariate a significant increase in correlation magnitude was observed (ρ =  - 0.54, corrected-P = 0.03).

CONCLUSION

This study demonstrates potential associations between the intensity of the inflammatory response in the acute phase post-mTBI and neurometabolic perturbations in the subacute phase. Future studies should assess the longitudinal dynamics of blood-based and imaging biomarkers after injury.

A Pilot Study on the Effect of Peer Support on Quality of Life of Adolescents with Autism Spectrum Disorder and Gender Dysphoria

Gender dysphoria (GD) and Autism Spectrum Disorder (ASD) co-occur relatively often, but there is no evidence-based treatment for this specific group. Therefore, we examined the effects of a group intervention for adolescents with ASD and GD in a pilot study with a pre-post-test design. The adolescents completed questionnaires on quality of life, self-esteem, gender dysphoric feelings, and social responsiveness. Results show that participating in this peer support group seems to increase aspects of quality of life, i.e., increased parent-reported psychological well-being and decreased psychological complaints. Even though more research is needed, these results indicate that peer support is an invaluable part of treatment for adolescents with ASD and GD.

Evaluation of Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Using a Rapid Point of Care Test for Predicting Head Computed Tomography Lesions After Mild Traumatic Brain Injury in a Dutch Multi-Center Cohort

Mild traumatic brain injury (mTBI) is a common condition seen in emergency departments worldwide. Blood-based biomarkers glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) are recently U.S. Food and Drug Administration-approved for the prediction of intracranial lesions on head computed tomography (CT) scans in mTBI. We evaluated the diagnostic performance of GFAP and UCH-L1 in a Dutch cohort using the i-STAT TBI assay. In a multi-center observational study, we enrolled 253 mTBI patients. Head CT scans were scored using the Marshall classification system. Logistic regression models were used to assess the contribution of biomarkers and clinical parameters to diagnostic performance. Detection of UCH-L1 and GFAP resulted in a sensitivity of 97% and specificity of 19% for CT positivity in mTBI patients, along with a negative predictive value of 95% (88-100%) and a positive predictive value of 27% (21-33%). Combining biomarker testing with loss of consciousness and time to sample increased specificity to 46%. Combined testing of UCH-L1 and GFAP testing resulted in possibly more unnecessary CT scans compared with GFAP testing alone, with only limited increase in sensitivity. This study confirmed high sensitivity of GFAP and UCH-L1 for CT abnormalities in mTBI patients using the i-STAT TBI test. The results support the potential use of GFAP and UCH-L1 as tools for determining the indication for CT scanning in mTBI patients, possibly offering a cost- and time-effective approach to management of patients with mTBI. Prospective studies in larger cohorts are warranted to validate our findings.

Dynamic phase-locking states and personality in sub-acute mild traumatic brain injury: An exploratory study

Research has shown that maladaptive personality characteristics, such as Neuroticism, are associated with poor outcome after mild traumatic brain injury (mTBI). The current exploratory study investigated the neural underpinnings of this process using dynamic functional network connectivity (dFNC) analyses of resting-state (rs) fMRI, and diffusion MRI (dMRI). Twenty-seven mTBI patients and 21 healthy controls (HC) were included. After measuring the Big Five personality dimensions, principal component analysis (PCA) was used to obtain a superordinate factor representing emotional instability, consisting of high Neuroticism, moderate Openness, and low Extraversion, Agreeableness, and Conscientiousness. Persistent symptoms were measured using the head injury symptom checklist at six months post-injury; symptom severity (i.e., sum of all items) was used for further analyses. For patients, brain MRI was performed in the sub-acute phase (~1 month) post-injury. Following parcellation of rs-fMRI using independent component analysis, leading eigenvector dynamic analysis (LEiDA) was performed to compute dynamic phase-locking brain states. Main patterns of brain diffusion were computed using tract-based spatial statistics followed by PCA. No differences in phase-locking state measures were found between patients and HC. Regarding dMRI, a trend significant decrease in fractional anisotropy was found in patients relative to HC, particularly in the fornix, genu of the corpus callosum, anterior and posterior corona radiata. Visiting one specific phase-locking state was associated with lower symptom severity after mTBI. This state was characterized by two clearly delineated communities (each community consisting of areas with synchronized phases): one representing an executive/saliency system, with a strong contribution of the insulae and basal ganglia; the other representing the canonical default mode network. In patients who scored high on emotional instability, this relationship was even more pronounced. Dynamic phase-locking states were not related to findings on dMRI. Altogether, our results provide preliminary evidence for the coupling between personality and dFNC in the development of long-term symptoms after mTBI.

OP0070 INTERVENTION WITH METHOTREXATE IN ARTHRALGIA AT RISK FOR RHEUMATOID ARTHRITIS TO REDUCE THE DEVELOPMENT OF PERSISTENT ARTHRITIS AND ITS DISEASE BURDEN (TREAT EARLIER): A DOUBLE-BLIND, RANDOMISED, PLACEBO-CONTROLLED TRIAL

Background

Rheumatoid arthritis (RA) is the most common autoimmune disease, and requires long-term treatment to suppress inflammation. Currently, methotrexate is initiated as first-line treatment when arthritis becomes clinically apparent with joint swelling. However, disease processes begin long before and become clinically recognizable when patients develop symptoms. We hypothesized that the ‘at risk phase’ of symptoms and subclinical joint-inflammation is a therapeutic window to permanently modify the disease course.

Objectives

We studied if intervention in the pre-arthritis phase of arthralgia and subclinical joint inflammation prevents the development of clinical arthritis or reduces the burden of disease.

Methods

In this randomised, double-blind, 2-year proof-of-concept trial, adults with arthralgia clinically suspected of progressing to RA and MRI-detected subclinical joint-inflammation, recruited from all rheumatology outpatient-clinics in the southwest-Netherlands, were randomly assigned (1:1) to a single intramuscular glucocorticoid injection (120 mg) and a one-year course of oral methotrexate (up to 25 mg/week), or placebo injection and placebo tablets. Subsequently, participants were followed for another year without study medication. The primary endpoint was the development of clinically detectable arthritis (fulfilling the 2010 RA-criteria or involving ≥2 joints) that persisted for at least 2 weeks. Patient reported physical functioning, along with symptoms and workability, were key secondary endpoints and measured 4-monthly. Additionally, the course of MRI-detected inflammation was studied (the sum of tenosynovitis, synovitis, osteitis, scored with the RA-MRI Scoring (RAMRIS) method). All participants entered the intention-to-treat analysis. We performed two prespecified subgroup analyses. Firstly, analyses were restricted in participants with high risk of clinical arthritis development (PPV ≥70%). Secondly, analyses were stratified for ACPA-status. The trial is registered with the Netherlands Trials Registry (NTR4853 trial NL4599).

Results

From April 16th, 2015 to September 11th, 2019, we randomly assigned 236 participants to treatment (n=119) or placebo (n=117). After 24 months, arthritis free survival was similar in both groups (80% versus 82%, HR 0.81 (95%CI 0.45, 1.48)). Physical functioning improved more in the treatment-group during the first months and remained better (mean between-group difference over two-years HAQ -0·1(-0·2,-0·03;p=0·004). Similarly, pain (-9 on scale 0-100: (95%CI -12,-4; p<0·001), morning stiffness (-12 (95%CI -16,-8;p<0·001), presenteeism (-8% (95%CI -13%,-3%;p=0·001) showed sustained improvement compared to placebo. MRI-detected joint-inflammation was also persistently improved (mean difference over 2 years -1·4 points (95%CI -2·0,-0.9;p<0·001). High-risk participants in the treatment group showed a delay in clinical arthritis development: they developed the endpoint less often during treatment, but frequencies became similar at 24 months (67% in both groups). A similar delaying effect was observed in ACPA-positive participants, where 48% and 52% had developed persistent clinical arthritis at 24 months. The number of serious adverse events was equal between the groups; adverse events were as expected from methotrexate.

Conclusion

Methotrexate, the cornerstone treatment of RA, initiated at the pre-arthritis stage of joint symptoms and subclinical inflammation, did not prevent the development of clinical arthritis, but modified the disease course as measured by sustained improvement in MRI-detected inflammation, related symptoms and impairments. These findings of sustained disease modification may open up a new treatment landscape in a pre-arthritis phase of RA, where limitations can be just as severe as at the onset of clinical arthritis.

Figure 1.

Acknowledgements

We thank Prof. dr. R. ten Cate, prof. dr. S. le Cessie and dr. A.M.J. Langers for their role in the Data Safety and Monitoring Board. We thank all participants, and all rheumatologist of the following hospitals: Albert Schweitzer Hospital, Alrijne Hospital, Erasmus Medical Center, Haven-policlinic Rotterdam, IJselland Hospital, Ikazia Hospital, Franciscus Gasthuis & Vlietland Hospital, Groene Hart Hospital, Haaglanden Medical Center (all locations), Haga Hospital, Langeland Hospital, Meander Medical Center, Maasstad, Hospital, Reinier de Graaf Gasthuis, Reumazorg Zuid-West Nederland and Spaarne Gasthuis. We acknowledge the team of treating rheumatologists and research nurses of the LUMC, in particular Dr F.J. van der Giesen. Our gratitude also goes to the PhD students who scored MRIs for trial screening, in particular dr. H.W. van Steenbergen, dr. W. Nieuwenhuis, dr. R.M. ten Brink, dr. D.M. Boeters, dr. L. Mangnus, X.M.E. Matthijssen and F. Wouters. We thank dr. M. Reijnierse, prof. dr. S.C. Cannegieter and prof. dr. D. van der Heijde for their advice, and dr. J. Schoones for his help with the systematic literature search. We acknowledge the funder of the study: NWO ZonMW grant (program ‘translationeel onderzoek’, project number 95104004).

Disclosure of Interests

None declared.

Long-Term Stability of Blood Serum Biomarkers in Traumatic Brain Injury: A Feasibility Study

Few studies on traumatic brain injury (TBI) have investigated the stability of blood serum biomarkers after long-term storage at low temperatures. In the current feasibility study we analyzed acute phase serum samples from patients with mild TBI as well as patients with moderate and severe TBI that were collected more than 10 years ago (old samples). We were particularly interested in mild TBI, because injury effects are more subtle in this category as compared to moderate-severe TBI. Therefore, the primary objective was to find out whether several biomarkers were still detectable for these patients. Additionally, we examined whether biomarker levels varied as a function of injury severity. For comparison, we also analyzed samples from an ongoing mTBI cohort (new samples) and healthy controls. Samples were treated with care and were not being subjected to freeze-thaw cycles. We measured concentrations of interleukins (IL6 and 10) and brain specific markers (total tau, UCH-L1, GFAP, and NF-L). No significant differences in biomarker concentrations were found between old and new mild TBI samples. For IL6, IL10, and UCH-L1 higher concentrations were found in moderate and severe TBI as compared to mild TBI. In conclusion, our study shows that long-term storage does not rule out the detection of meaningful biomarker concentrations in patients with TBI, although further research by other laboratories is warranted.

Blood-based biomarkers of inflammation in mild traumatic brain injury: A systematic review

VISSER, K., M. Koggel, J. Blaauw, H.J.v.d. Horn, B. Jacobs, and J.v.d. Naalt. Blood based biomarkers of inflammation in mild traumatic brain injury: A systematic review. NEUROSCI BIOBEHAV REV XX(X) XXX-XXX, 2021. - Inflammation is an important secondary physiological response to traumatic brain injury (TBI). Most of the current knowledge on this response is derived from research in moderate and severe TBI. In this systematic review we summarize the literature on clinical studies measuring blood based inflammatory markers following mild traumatic brain injury (mTBI) and identify the value of inflammatory markers as biomarkers. Twenty-three studies were included. This review suggests a distinct systemic inflammatory response following mTBI, quantifiable within 6 h up to 12 months post-injury. Interleukin-6 is the most promising biomarker for the clinical diagnosis of brain injury while interleukin-10 is a potential candidate for triaging CT scans. The diagnostic and prognostic utility of inflammatory markers may be more fully appreciated as a component of a panel of biomarkers. However, discrepancies in study design, analysis and reporting make it difficult to draw any definite conclusions. For the same reasons, a meta-analysis was not possible. We provide recommendations to follow standardized methodologies to allow for reproducibility of results in future studies.

Gadoxetic acid-enhanced magnetic resonance imaging significantly influences the clinical course in patients with colorectal liver metastases

Background

Gadoxetic acid (Primovist™)-enhanced magnetic resonance imaging (P-MRI) scans have higher accuracy and increased detection of small colorectal liver metastases (CRLM) compared to CT scans or conventional MRI scans. But, P-MRI scans are still inconsistently acquired in the diagnostic work up of patients with CRLM. The aim of this study was to determine the influence of P-MRI scans on treatment plan proposition and subsequently the clinical course of the patient.

Methods

Eighty-three consecutive patients with potentially resectable CRLM based on a conventional CT scan underwent P-MRI scanning prior to treatment. Treatment plans proposed by the multidisciplinary team were compared before and after P-MRI scanning and related to the final treatment and diagnosis, the accuracy for the CT scan and P-MRI scan was calculated.

Results

P-MRI scans led to a change of treatment in 15 patients (18%) and alteration of extensiveness of local therapy in another 17 patients (20%). All changes were justified leading to an accuracy of 93% for treatment proposition based on P-MRI scan, compared to an accuracy of 75% for the CT scan.

Conclusions

P-MRI scans provide additional information that can aid in proposing the most suitable treatment for patients with CRLM and might prevent short-term reintervention.

Electronic supplementary material

The online version of this article (10.1186/s12880-018-0289-x) contains supplementary material, which is available to authorized users.

Divide and Conquer May Not Be the Optimal Approach to Retain the Desirable Estrogenic Attributes of the Cyclopia Nutraceutical Extract, SM6Met

The genus Cyclopia, an indigenous South African fynbos plant used to prepare honeybush tea, contains phytoestrogenic compounds. An extract from C. subternata, SM6Met, displays three desirable estrogenic attributes for future development of a phytoestrogenic nutraceutical, namely, ERα antagonism, ERβ agonism, and also antagonism of E₂-induced breast cancer cell proliferation. Activity-guided fractionation of SM6Met was used in an attempt to isolate and identify compounds conferring the desirable estrogenic profile to SM6Met. Initial liquid-liquid fractionation of SM6Met yielded a polar fraction (PF) and a non-polar fraction (NPF), with the desirable estrogenic attributes retained in the NPF. Subsequent high performance counter-current chromatography (HPCCC) fractionation of the NPF yielded three fractions (F1-F3). Interestingly, the fractions revealed separation of the previously demonstrated positive estrogenic attributes of the NPF into separate fractions, with F1 and F2 acting as ERα antagonists, only F2 inducing antagonism of E₂-induced breast cancer cell proliferation and only F3 retaining robust ERβ agonist activity. In terms of major polyphenols, quantitative HPLC and liquid chromatography tandem mass spectrometry (LC-MS/MS) indicated that HPCCC fractionation resulted in a divergence of polyphenolic classes, with F1 emerging as the dihydrochalcone-rich fraction and F2 as the flavanone- and benzophenone-rich fraction, while the xanthones, flavones and phenolic acids were retained in F3. F3 was re-engineered into F3R by reassembling the major polyphenols identified in the fraction. F3R could, however, not replicate the effect of F3. In conclusion, although activity-guided fractionation results suggest that retention of all the desirable estrogenic attributes of the original SM6Met in one fraction is not an attainable goal, fractionation is a useful tool to enhance specific desirable estrogenic attributes.

Four-month metacarpal bone mineral density loss predicts radiological joint damage progression after 1 year in patients with early rheumatoid arthritis: exploratory analyses from the IMPROVED study

AIM

To assess whether in early (rheumatoid) arthritis (RA) patients, metacarpal bone mineral density (BMD) loss after 4 months predicts radiological progression after 1 year of antirheumatic treatment.

METHODS

Metacarpal BMD was measured 4 monthly during the first year by digital X-ray radiogrammetry (DXR-BMD) in patients participating in the IMPROVED study, a clinical trial in 610 patients with recent onset RA (2010 criteria) or undifferentiated arthritis, treated according to a remission (disease activity score<1.6) steered strategy. With Sharp/van der Heijde progression ≥0.5 points after 1 year (yes/no) as dependent variable, univariate and multivariate logistic regression analyses were performed.

RESULTS

Of 428 patients with DXR-BMD results and progression scores available, 28 (7%) had radiological progression after 1 year. Independent predictors for radiological progression were presence of baseline erosions (OR (95% CI) 6.5 (1.7 to 25)) and early DXR-BMD loss (OR (95% CI) 1.5 (1.1 to 2.0)). In 366 (86%) patients without baseline erosions, early DXR-BMD loss was the only independent predictor of progression (OR (95% CI) 2.0 (1.4 to 2.9)).

CONCLUSIONS

In early RA patients, metacarpal BMD loss after 4 months of treatment is an independent predictor of radiological progression after 1 year. In patients without baseline erosions, early metacarpal BMD loss is the main predictor of radiological progression.

A two-step treatment strategy trial in patients with early arthritis aimed at achieving remission: the IMPROVED study

OBJECTIVES

To assess which treatment strategy is most effective in inducing remission in early (rheumatoid) arthritis.

METHODS

610 patients with early rheumatoid arthritis (RA 2010 criteria) or undifferentiated arthritis (UA) started treatment with methotrexate (MTX) and a tapered high dose of prednisone. Patients in early remission (Disease Activity Score <1.6 after 4 months) tapered prednisone to zero and those with persistent remission after 8 months, tapered and stopped MTX. Patients not in early remission were randomised to receive either MTX plus hydroxychloroquine plus sulfasalazine plus low-dose prednisone (arm 1) or to MTX plus adalimumab (ADA) (arm 2). If remission was present after 8 months both arms tapered to MTX monotherapy; if not, arm 1 changed to MTX plus ADA and arm 2 increased the dose of ADA. Remission rates and functional and radiological outcomes were compared between arms and between patients with RA and those with UA.

RESULTS

375/610 (61%) patients achieved early remission. After 1 year 68% of those were in remission and 32% in drug-free remission. Of the randomised patients, 25% in arm 1 and 41% in arm 2 achieved remission at year 1 (p<0.01). Outcomes were comparable between patients with RA and those with UA.

CONCLUSIONS

Initial MTX and prednisone resulted in early remission in 61% of patients with early (rheumatoid) arthritis. Of those, 68% were in remission and 32% were in drug-free remission after 1 year. In patients not in early remission, earlier introduction of ADA resulted in more remission at year 1 than first treating with disease-modifying antirheumatic drug combination therapy plus prednisone.

Inflation and deflation timing of the AutoCAT 2 WAVE intra-aortic balloon pump using the autoPilot mode in a clinical setting

The primary goal of this observational clinical study was to register the occurrence of incorrect inflation and deflation timing of an intra-aortic balloon pump in autoPilot mode. The secondary goal was to identify possible causes of incorrect timing. During IABP assistance of 60 patients, every four hours a strip was printed with the IABP frequency set to 1:2. Strips were examined for timing discrepancies beyond 40 ms from the dicrotic notch (inflation) and the end of the diastolic phase (deflation). In this way, 320 printed strips were examined. A total of 52 strips (16%) showed incorrect timing. On 24 of these strips, the incorrect timing was called incidental, as it showed on only one or a few beats. The other 28 cases of erroneous timing were called consistent, as more than 50% of the beats on the strip showed incorrect timing. We observed arrhythmia in 69% of all cases of incorrect timing. When timing was correct, arrhythmia was found on 13 (5%) of 268 strips. A poor quality electrocardiograph (ECG) signal showed on 37% of all strips with incorrect timing and 11% of all strips with proper timing. We conclude that inflation and deflation timing of the IABP is not always correct when using the autoPilot mode. The quality of the ECG input signal and the occurrence of arrhythmia appear to be related to erroneous timing. Switching from autoPilot mode to operator mode may not always prevent incorrect timing.

Use of methotrexate in undifferentiated arthritis

The prognosis of patients with undifferentiated arthritis (UA) may vary from self-limited to severe destructive rheumatoid arthritis (RA). Based on the chance that these patients will develop RA and based on the safety profile of a course of methotrexate for 30-90 days, many clinicians consider using methotrexate in this patient category using the "n of 1" trial principle. During the last few years, more data on interventions in UA have become available that provide guidance in the prescription of drugs to UA patients.

A matrix risk model for the prediction of rapid radiographic progression in patients with rheumatoid arthritis receiving different dynamic treatment strategies: post hoc analyses from the BeSt study

OBJECTIVES

To develop a matrix model for the prediction of rapid radiographic progression (RRP) in subpopulations of patients with recent-onset rheumatoid arthritis (RA) receiving different dynamic treatment strategies.

METHODS

Data from 465 patients with recent-onset RA randomised to receive initial monotherapy or combination therapy were used. Predictors for RRP (increase in Sharp-van der Heijde score > or =5 after 1 year) were identified by multivariate logistic regression analysis. For subpopulations, the estimated risk of RRP per treatment group and the number needed to treat (NNT) were visualised in a matrix.

RESULTS

The presence of autoantibodies, baseline C-reactive protein (CRP) level, erosion score and treatment group were significant independent predictors of RRP in the matrix. Combination therapy was associated with a markedly reduced risk of RRP. The positive and negative predictive values of the matrix were 62% and 91%, respectively. The NNT with initial combination therapy to prevent one patient from RRP with monotherapy was in the range 2-3, 3-7 and 7-25 for patients with a high, intermediate and low predicted risk, respectively.

CONCLUSION

The matrix model visualises the risk of RRP for subpopulations of patients with recent-onset RA if treated dynamically with initial monotherapy or combination therapy. Rheumatologists might use the matrix for weighing their initial treatment choice.

Risk and management of liver toxicity during methotrexate treatment in rheumatoid and psoriatic arthritis: a systematic review of the literature

OBJECTIVES

To systematically review the literature on liver toxicity in rheumatoid arthritis (RA) and psoriatic arthritis (PsA) patients treated with methotrexate (MTX), as an evidence base for generating clinical practice recommendations for the management of MTX and the indication for a liver biopsy (LB) in case of elevated liver enzymes (LE).

METHODS

A systematic literature search was carried out in MEDLINE, EMBASE, Cochrane Library and ACR/EULAR meeting abstracts. Data on the incidence of elevated LE, subsequent adjustments in MTX therapy and the prevalence of fibrosis/cirrhosis in pre-MTX and post-MTX LB were pooled.

RESULTS

Forty-seven out of 426 identified references were included in the systematic review. For RA, the incidence rate of elevated LE in the first three years of MTX use was 13/100 patient-years with a cumulative incidence of 31%. MTX was permanently discontinued in 7%, paused or reduced in 26% and continued without any adjustment in 67% of patients with an abnormal test. After 4 years of MTX use, LB showed in 15.3% of the (unrelated) cases mild fibrosis, in 1.3% severe fibrosis and in 0.5% cirrhosis, while pre-MTX biopsies showed 9%, 0.3% and 0.3% abnormalities, respectively. For PsA, evidence is limited. Additional studies suggest that cumulative MTX dose and serial LE elevations among other risk factors are related to liver pathology.

CONCLUSIONS

This review suggests that LE elevations during MTX therapy are a frequent but transient problem, that serial abnormal LE tests might be associated with liver pathology, but that cirrhosis is relatively rare. It is, however, not clear from the literature how therapy should be adjusted in case of elevated LE and to what extent MTX independently attributes to liver toxicity.

Interleukin-11 and leukemia inhibitory factor regulate the adhesion of endometrial epithelial cells: implications in fertility regulation

Embryo implantation requires the closely harmonized processes of apposition, attachment, and adhesion of the conceptus to the maternal endometrial epithelium. IL-11 and leukemia inhibitory factor (LIF), two IL-6 family cytokines, are produced by the endometrium and are absolutely required for implantation in mice. We examined the effect of IL-11 and LIF on human endometrial epithelial cell adhesion. Both cytokines increased adhesion of primary human endometrial epithelial cells to fibronectin and collagen IV. IL-11 stimulated, whereas LIF had no effect on the adhesion of trophoblast to endometrial epithelial cells. Focused oligogene arrays were used to identify extracellular matrix and adhesion molecules mRNAs regulated by endometrial epithelial cells. We demonstrated by real-time RT-PCR and antibody arrays that both cytokines increased integrin-alpha2 mRNA and protein by endometrial epithelial cells. Signal transducers and activators of transcription (STAT)-3 inhibition reduced IL-11- and LIF-mediated epithelial cell adhesion to fibronectin, suggesting both cytokines regulated adhesion via phosphorylation of STAT3. Addition of either IL-11 neutralizing antibody and IL-11 or LIF and LIF antagonist to endometrial epithelial cells abolished cytokine induced phosphorylated STAT3. LIF but not IL-11 induced adhesion to collagen IV was reduced by an integrin-alpha2beta1 neutralizing antibody. This study demonstrated that IL-11 and LIF regulated endometrial epithelial cell adhesion, suggesting that targeting IL-11 and LIF may be useful in regulating fertility by either enhancing or blocking implantation.

Optimal dosage and route of administration of methotrexate in rheumatoid arthritis: a systematic review of the literature

Objectives:

To review systematically the available literature on the optimal dosage and route of administration of methotrexate in patients with rheumatoid arthritis (RA), as an evidence base for generating clinical practice recommendations.

Methods:

A systematic literature search was carried out in MEDLINE, EMBASE, Cochrane Library and American College of Rheumatology/European League Against Rheumatism meeting abstracts, searching for randomised controlled trials evaluating various dosages or routes of administration of methotrexate in RA. Articles that fulfilled predefined inclusion criteria were systematically reviewed and the quality was appraised. Effect sizes and odds ratios for clinical, radiological and toxicity outcomes were calculated and directly or indirectly compared between study groups using methotrexate in different dosages or by different routes.

Results:

A total of 38 publications out of 1748 identified references was included in the review. Start doses of 25 mg/week or fast escalation with 5 mg/month to 25–30 mg/week were associated with higher clinical effect sizes and more (gastrointestinal) adverse events in comparison with doses of 5–15 mg/week or slow escalation. Starting with 15 mg/week subcutaneous versus oral methotrexate was associated with higher clinical efficacy but more withdrawal due to toxicity in early RA. In longstanding RA, after failure on 15–20 mg/week orally, a switch to 15 mg/week intramuscularly with subsequent dose escalation did not result in increased efficacy.

Conclusions:

Starting on methotrexate 15 mg/week orally, escalating with 5 mg/month to 25–30 mg/week, or the highest tolerable dose, with a subsequent switch to subcutaneous administration in the case of an insufficient response, seems to be the optimal evidence-based dosing and routing recommendation for methotrexate in RA.

Multinational evidence-based recommendations for the use of methotrexate in rheumatic disorders with a focus on rheumatoid arthritis: integrating systematic literature research and expert opinion of a broad international panel of rheumatologists in the 3E Initiative

Objectives:

To develop evidence-based recommendations for the use of methotrexate in daily clinical practice in rheumatic disorders.

Methods:

751 rheumatologists from 17 countries participated in the 3E (Evidence, Expertise, Exchange) Initiative of 2007–8 consisting of three separate rounds of discussions and Delphi votes. Ten clinical questions concerning the use of methotrexate in rheumatic disorders were formulated. A systematic literature search in Medline, Embase, Cochrane Library and 2005–7 American College of Rheumatology/European League Against Rheumatism meeting abstracts was conducted. Selected articles were systematically reviewed and the evidence was appraised according to the Oxford levels of evidence. Each country elaborated a set of national recommendations. Finally, multinational recommendations were formulated and agreement among the participants and the potential impact on their clinical practice was assessed.

Results:

A total of 16 979 references was identified, of which 304 articles were included in the systematic reviews. Ten multinational key recommendations on the use of methotrexate were formulated. Nine recommendations were specific for rheumatoid arthritis (RA), including the work-up before initiating methotrexate, optimal dosage and route, use of folic acid, monitoring, management of hepatotoxicity, long-term safety, mono versus combination therapy and management in the perioperative period and before/during pregnancy. One recommendation concerned methotrexate as a steroid-sparing agent in other rheumatic diseases.

Conclusions:

Ten recommendations for the use of methotrexate in daily clinical practice focussed on RA were developed, which are evidence based and supported by a large panel of rheumatologists, enhancing their validity and practical use.

Patients' Preferences for MR Angiography and Duplex US in the Work-up of Peripheral Arterial Disease

PURPOSE

To measure patients' preferences for magnetic resonance (MR) angiography and duplex ultrasound (US) in the imaging work-up of peripheral arterial disease (PAD).

METHODS

Ninety-eight patients, who underwent both MR angiography and duplex US, received a questionnaire by mail and their preferences for imaging work-up were assessed in a telephone interview. The questionnaire consisted of one question on which imaging test they preferred, a rating scale score ranging from 0 (not bothersome at all) to 10 (extremely bothersome), and specific questions on whether patients experienced discomfort due to the imaging work-up. Responses were presented as means and frequencies, and differences were tested by non-parametric tests.

RESULTS

Half of the patient population (50%) had no preference for MR angiography or duplex US, 41% had a preference for MR angiography, and 9% had a preference for duplex US. The average rating scale scores for MR angiography (1.6) and duplex US (1.7) were not significantly different (p=0.53). Four out of 98 (4%) patients responded that they experienced pain during the MR angiography versus 18 (18%) for duplex US (p=0.001). Eight out of 98 (8%) patients responded that they were anxious during the MR angiography versus 1 (1%) for duplex US (p=0.02).

CONCLUSION

The results suggest that the majority of patients have no preference between MR angiography and duplex US in the diagnostic work-up of PAD. Among patients who do have a preference, MR angiography was preferred over duplex US.

Preoperative prediction of severe postoperative pain

We developed and validated a prediction rule for the occurrence of early postoperative severe pain in surgical inpatients, using predictors that can be easily documented in a preoperative setting. A cohort of surgical inpatients (n=1416) undergoing various procedures except cardiac surgery and intracranial neurosurgery in a University Hospital were studied. Preoperatively the following predictors were collected: age, gender, type of scheduled surgery, expected incision size, blood pressure, heart rate, Quetelet index, the presence and severity of preoperative pain, health-related quality of life the (SF-36), Spielberger's State-Trait Anxiety Inventory (STAI) and the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The outcome was the presence of severe postoperative pain (defined as Numeric Rating Scale > or =8) within the first hour postoperatively. Multivariate logistic regression in combination with bootstrapping techniques (as a method for internal validation) was used to derive a stable prediction model. Independent predictors of severe postoperative pain were younger age, female gender, level of preoperative pain, incision size and type of surgery. The area under the receiver operator characteristic (ROC) curve was 0.71 (95% CI: 0.68-0.74). Adding APAIS scores (measures of preoperative anxiety and need for information), but not STAI, provided a slightly better model (ROC area 0.73). The reliability of this extended model was good (Hosmer and Lemeshow test p-value 0.78). We have demonstrated that severe postoperative pain early after awakening from general anesthesia can be predicted with a scoring rule, using a small set of variables that can be easily obtained from all patients at the preoperative visit. Before this internally validated preoperative prediction rule can be applied in clinical practice to support anticipatory pain management, external validation in other clinical settings is necessary.

Cost-effectiveness of diagnostic imaging work-up and treatment for patients with intermittent claudication in The Netherlands

OBJECTIVE

to determine the societal cost-effectiveness of various management strategies, including both the diagnostic imaging work-up and treatment, for patients with intermittent claudication in The Netherlands.

METHODS

a decision-analytic model was used and included probability and quality of life data available from the literature. A cost-analysis was performed in a university setting in The Netherlands. Imaging work-up options included magnetic resonance angiography (MRA), color-guided duplex ultrasound, or intraarterial digital subtraction angiography (DSA) and treatment options were percutaneous transluminal angioplasty with selective stent placement if feasible or bypass surgery. Management strategies were defined as combinations of imaging work-up and treatment options. A conservative strategy with no imaging work-up and walking exercises was considered as reference. Main outcome measures were quality-adjusted life years (QALYs), lifetime costs (euro), and incremental cost-effectiveness (CE) ratios. The base-case analysis evaluated 60-year-old men with severe unilateral intermittent claudication of at least one year duration.

RESULTS

the range in QALYs and costs across management strategies that considered angioplasty as only treatment option was small (maximum difference: 0.0033 QALYs and 451 euros). Similarly, the range was small across management strategies that considered angioplasty if feasible otherwise bypass surgery (maximum difference: 0.0033 QALYs and 280 euros). MRA in combination with angioplasty (6.1487 QALYs and 8556 euros) had a CE ratio of 20,000 euros/QALY relative to the conservative strategy. The most effective strategy was DSA in combination with angioplasty if feasible otherwise bypass surgery (6.2254 QALYs and 18,583 euros) which had a CE ratio of 131,000 euros/QALY relative to MRA in combination with angioplasty.

CONCLUSION

the results suggest that the imaging work-up with non-invasive imaging modalities can replace DSA for the work-up of patients with intermittent claudication without a substantial loss in effectiveness and a minimal cost-reduction. Management strategies including angioplasty are cost-effective in the Netherlands but although strategies including bypass surgery are more effective, their incremental costs are very high.

Randomized controlled trial of total intravenous anesthesia with propofol versus inhalation anesthesia with isoflurane-nitrous oxide: postoperative nausea with vomiting and economic analysis

BACKGROUND

To assess the incidence of postoperative nausea and vomiting after total intravenous anesthesia (TIVA) with propofol versus inhalational anesthesia with isoflurane-nitrous oxide, the authors performed a randomized trial in 2,010 unselected surgical patients in a Dutch academic institution. An economic evaluation was also performed.

METHODS

Elective inpatients (1,447) and outpatients (563) were randomly assigned to inhalational anesthesia with isoflurane-nitrous oxide or TIVA with propofol-air. Cumulative incidence of postoperative nausea and vomiting was recorded for 72 h by blinded observers. Cost data of anesthetics, antiemetics, disposables, and equipment were collected. Cost differences caused by duration of postanesthesia care unit stay and hospitalization were analyzed.

RESULTS

Total intravenous anesthesia reduced the absolute risk of postoperative nausea and vomiting up to 72 h by 15% among inpatients (from 61% to 46%, P < 0.001) and by 18% among outpatients (from 46% to 28%, P < 0.001). This effect was most pronounced in the early postoperative period. The cost of anesthesia was more than three times greater for propofol TIVA. Median duration of stay in the postanesthesia care unit was 135 min after isoflurane versus 115 min after TIVA for inpatients (P < 0.001) and 160 min after isoflurane versus 150 min after TIVA for outpatients (P = 0.039). Duration of hospitalization was equal in both arms.

CONCLUSION

Propofol TIVA results in a clinically relevant reduction of postoperative nausea and vomiting compared with isoflurane-nitrous oxide anesthesia (number needed to treat = 6). Both anesthetic techniques were otherwise similar. Anesthesia costs were more than three times greater for propofol TIVA, without economic gains from shorter stay in the postanesthesia care unit

Duplex scan surveillance during the first year after infrainguinal autologous vein bypass grafting surgery: costs and clinical outcomes compared with other surveillance programs

PURPOSE

In this study we assessed the costs and clinical outcomes of duplex scan surveillance during the first year after infrainguinal autologous vein bypass grafting surgery and compared duplex scan surveillance, ankle-brachial index surveillance, and clinical follow-up.

METHODS

In a clinical study, 293 patients (mean age, 70.1 years; 58.7% men) with peripheral arterial disease were observed in a duplex scan surveillance program after infrainguinal autologous vein bypass grafting surgery. Costs were calculated from the health care perspective for surveillance and subsequent interventions from 30 days to 1 year postoperatively. All costs are presented in 1995 US dollars per patient. In a simulation model, we estimated the costs and amputations of duplex scan surveillance, ankle-brachial index surveillance, and clinical follow-up conditional on the indication for surgery. The main outcome measure was the incremental cost per major amputation per patient avoided during the first postoperative year.

RESULTS

Duplex scan surveillance was the least expensive ($2823) and resulted in the fewest major amputations (17 per 1000 patients examined), compared with ankle-brachial index surveillance ($5411 and 77 amputations per 1000 patients) and clinical follow-up ($5072 and 77 amputations per 1000 patients). In patients treated for critical limb ischemia, duplex scan surveillance was the least expensive ($2974) and resulted in the fewest major amputations (19 per 1000 patients). Under all surveillance programs, 13 major amputations per 1000 patients treated for intermittent claudication were performed, and clinical follow-up had the lowest costs ($1577). In a sensitivity analysis that assumed that duplex scan surveillance could have avoided six major amputations per 1000 patients treated for intermittent claudication compared with the other programs, duplex scan surveillance had an incremental cost of $80,708 per major amputation per patient avoided compared with clinical follow-up.

CONCLUSION

Duplex scan surveillance is highly effective for patients treated for critical limb ischemia, leading to a reduction of major amputations and consequently to a reduction in costs compared with other surveillance programs. In patients treated for intermittent claudication, the evidence supporting duplex scan surveillance is less firm, but if duplex scan can avoid six major amputations per 1000 patients examined, the incremental costs are justified.

Peripheral arterial disease: gadolinium-enhanced MR angiography versus color-guided duplex US--a meta-analysis

PURPOSE

To summarize and compare the published data on gadolinium-enhanced magnetic resonance (MR) angiography and color-guided duplex ultrasonography (US) for the work-up for peripheral arterial disease.

MATERIALS AND METHODS

Studies published between January 1984 and November 1998 were included if (a) gadolinium-enhanced MR angiography and/or color-guided duplex US were performed for evaluation of arterial stenoses and occlusions in the work-up for peripheral arterial disease of the lower extremities, (b) conventional angiography was the reference standard, and (c) absolute numbers of true-positive, false-negative, true-negative, and false-positive results were available or derivable.

RESULTS

With a random effects model, pooled sensitivity for MR angiography (97.5% [95% CI: 95.7%, 99.3%]) was higher than that for duplex US (87.6% [95% CI: 84.4%, 90.8%]). Pooled specificities were similar: 96.2% (95% CI: 94.4%, 97.9%) for MR angiography and 94.7% (95% CI: 93.2%, 96.2%) for duplex US. Summary receiver operating characteristic analysis demonstrated better discriminatory power for MR angiography than for duplex US. Regression coefficients for MR angiography versus US were 1.67 (95% CI: -0.23, 3.56) with adjustment for covariates, 2.11 (95% CI: 0.12, 4.09) without such adjustment, and 1.73 (95% CI: 0.44, 3.02) with a random effects model.

CONCLUSION

Gadolinium-enhanced MR angiography has better discriminatory power than does color-guided duplex US and is a highly sensitive and specific method, as compared with conventional angiography, for the work-up for peripheral arterial disease.

Blood-injury-injection phobia and dental phobia

The present study was carried out to explore the relation between BII phobia and dental phobia. An additional aim was to determine the fainting tendency of dental phobics and BII phobics during an invasive treatment procedure. Participants were 63 patients undergoing treatment in a dental fear clinic, and 173 patients undergoing dental surgery in a university hospital. They completed measures on fears of particular medical and dental stimuli, fainting history, general trait anxiety, dental anxiety, BII anxiety, BII avoidance, and a questionnaire aimed to define a phobia based on DSM-IV criteria. Immediately after treatment information was obtained on exposures to blood or injections, state anxiety, and feelings of faintness during treatment. The results did not indicate any significant relationship between measures of dental anxiety and BII anxiety or BII avoidance. However, 57% of the dental phobic patients could also be classified as BII phobic. The proportion of dental phobics who reported fainting episodes in their past was similar to that of the BII phobics (37%), but none of the participants fainted during treatment. It is concluded that, albeit the level of co-occurrence for both types of phobias is high, dental phobia should be considered as a specific phobia, independent for the BII subtype within DSM-IV. Further, the findings are inconsistent with the notion that individuals with BII phobia have a remarkably high tendency to faint in the presence of their phobic stimuli.

Molecular cloning and characterization of an inorganic pyrophosphatase from barley

A cDNA clone with sequence homology to soluble inorganic pyrophosphatase (IPPase) was isolated from a library of developing barley grains. The protein encoded by this clone was produced in transgenic Escherichia coli, and showed IPPase activity. In nondormant barley grains, the gene appeared to be expressed in metabolically active tissue such as root, shoot, embryo and aleurone. During inhibition, a continuous increase of the steady state mRNA level of IPPase was observed in embryos of non-dormant grains. In the embryos of dormant grains its production declined, after an initial increase. With isolated dormant and nondormant embryos, addition of recombinant IPPase, produced by E. coli, enhanced the germination rate. On the other hand, addition of pyrophosphate (PPi), substrate for this enzyme, appeared to reduce the germination rate. A role for this IPPase in germination is discussed.

Inhibition of the conjugation of PABA with glycine in vitro by sulfamoyl benzoic acids, sulfonamides, and penicillins and its relation to tubular secretion

Elimination of drug molecules via tubular secretion is an important pharmacokinetic parameter especially for oral dosage forms where an extremely short half-life would prevent their application. We have studied the inhibition in vitro of the glycination of p-aminobenzoic acid (PABA) using rat liver microsomal preparations. The I50 values, the concentration of the inhibitor that leads to 50% inhibition of glycine conjugation of PABA as compared to the control, have been determined for sulfamoyl benzoic acids, sulfonamides, and penicillins. Statistically significant regression equations were derived explaining the observed variation in I50 values as a function of lipophilicity and steric bulk of the substituents for the combined set of sulfamoyl benzoic acids and sulfonamides (n = 33). For the penicillins studied, only steric effects seem to be important for the explanation of the I50 values. Finally, regression analysis and the use of neural networks allowed the classification of compounds by their in vitro I50 values as being tubular secreted or not. Therefore, it can be concluded that the inhibition in vitro of the glycine conjugation of PABA is a useful model for the estimation of tubular secretion and drug interaction potential of acidic drug molecules in this process in vivo.

Structure-activity relationship studies on benzofuran analogs of propafenone-type modulators of tumor cell multidrug resistance

A series of benzofurylethanolamine analogs of propafenone (1a) have been prepared and evaluated for multidrug resistance-reversing activity in two in vitro assay systems. As for propafenones, an excellent correlation of biological data with calculated lipophilicity values was found for benzofurans, whereby the latter generally had lower activity/lipophilicity ratios. Almost identical slopes of the regression lines were obtained for both propafenones and benzofurans. Multiple linear regression analysis of the complete data set yielded an equation with excellent predictive power (r2 cross-valid = 0.968). Interaction measurements with artificial membranes indicated that the differences in activity between these two series of compounds are not due to differences in the interaction pattern with biological membranes.

Rapid Germination of a Barley Mutant Is Correlated with a Rapid Turnover of Abscisic Acid Outside the Embryo

In our study of the role of abscisic acid (ABA) in controlling the germination of barley grains, we tested a barley mutant line with a gigantum appearance (Hordeum distichum cv Quantum) for an ABA-insensitive phenotype by assaying germination in the presence of 10-4 M ABA. Dissected embryos of the mutant germinated at least 10 h earlier than did those of the wild type. The half-maximal concentrations of ABA inhibitory for germination were determined to be 5 x 10-4 M for the mutant and 10-6 M for the wild type. Expression of an ABA-induced Rab gene was studied to determine ABA responsiveness. The ABA concentration required for a half-maximal induction of Rab gene expression was 4 x 10-6 M in isolated embryos of both the mutant and wild type. This result suggests that ABA signal transduction pathways were not affected in the mutant. When isolated embryos were allowed to imbibe in water, ABA was released from the mutant and wild-type embryos at the same rate. However, the free ABA level in the incubation medium of the mutant showed a much faster decrease than that of the wild type, as demonstrated by two independent ABA assay methods (high-performance liquid chromatography and enzyme-linked immunosorbent assay). Our results suggest that turnover of ABA outside the embryo is a determining factor in the germination of barley seeds.

Duplex scanning for grading aortoiliac obstructive disease and guiding treatment

Standard assessment of aortoiliac obstructive disease (AIOD) includes arteriography preferably supplemented with femoral artery pressure (FAP) measurements. This study investigated the value of Duplex scanning in classifying AIOD and compared the outcome of Duplex scanning with clinical decision making. One-hundred-and-fifty-three aortoiliac segments of 87 patients were prospectively examined by Duplex scanning, arteriography, and FAP measurements to establish the presence or absence of significant AIOD. The results of these tests were compared to each other and to the subsequent vascular interventions and their success rates. Excellent agreement (kappa 0.82) was found between Duplex scanning and arteriography. The agreement between Duplex scanning and FAP measurements was much lower (kappa 0.52). The correlation between the performed treatment and the assessment of AIOD by Duplex scanning or arteriography was good, whereas the FAP results correlated only moderately with the performed treatment. Endovascular or operative treatment was actually performed in only 63% of the aortoiliac segments with an abnormal FAP test (success rate 80%). Aortoiliac segments with significant AIOD according to arteriography or Duplex scanning were treated invasively in 86% (success rate 81%) and 82% (success rate 80%), respectively. In conclusion, Duplex scanning can replace arteriography as a screening tool for the identification of treatable aortoiliac lesions whereas the value of FAP measurements in the decision making process is limited.

Penetration of rifampicin into the cerebrospinal fluid of adults with uninflamed meninges

The penetration of rifampicin into CSF was studied in seven patients who had undergone external ventriculostomy for occlusive hydrocephalus without major disturbance of the blood-CSF barrier. After the first dose of rifampicin 600 mg i.v. over 3 h, blood and CSF concentrations were determined serially by HPLC. Peak CSF concentrations obtained 0-8 h (median = 1 h) after the end of the infusion ranged from 0.57 to 1.24 mg/L (median = 0.73 mg/L). Elimination from CSF was slower than from serum (T1/2 beta CSF: 9.1-21.0 h (median = 14.5 h, n = 5); T1/2 beta serum: 2.2-5.8 h (median = 3.6 h, n = 7)). Based on the ratios of the areas under the concentration-time curves in CSF and serum, the overall penetration of rifampicin into CSF was 0.13-0.42 (median = 0.22). These results demonstrate effective CSF penetration and favourable pharmacokinetics of rifampicin in the absence of meningeal inflammation. They support the use of rifampicin as part of a combination therapy not only for tuberculosis of the central nervous system (CNS), but also for staphylococcal and listerial infections of the CNS in which there may be little meningeal inflammation.

In vitro activity of the new quinoline derivative ciprofloxacin alone and in combination against various Mycobacterium-, Salmonella- and Escherichia coli strains

The antibacterial effect of 1-cyclopropyl-6-fluoro-1,4-dihydro-4-oxo-7-piperazine-1-ylquinoline++ + 3-carboxylic acid (ciprofloxacin, Bay o 9867) has been tested using different test systems and various strains, especially of Escherichia coli, Mycobacterium and Salmonella. Ciprofloxacin shows low MIC's against most of the tested strains. The high in vitro and in vivo activity against Salmonella is most promising for cure of salmonellosis.