P03 Identification of intervention opportunities through assessment of the appropriateness of antibiotic prescribing in surgical patients in a UK hospital using a national audit tool: a single centre retrospective audit

Background

Identifying opportunities to safely reduce antibiotic prescribing is necessary for prescribers and antibiotic stewardship teams to minimize unwarranted antibiotic use. We aimed to quantify excess antibiotic use in General Surgery.

Methods

We retrospectively audited the antibiotic prescribing for patients discharged from the General Surgery specialty in an acute hospital in the south-west of England between 01/08/21 and 31/08/21 using an audit tool developed by Public Health England. The appropriateness of prescribing was determined for each patient at three antibiotic decision time-points: at initiation, the pre-72h antibiotic review, and treatment duration. Two infection specialists and a general surgeon reviewed each patient. Indication and excess days of therapy (DOTs) were calculated at each decision time-point and expressed as a proportion of total DOTs.

Results

Eighty-six patients were prescribed 1162 DOTs; 192 (16.5%) excess DOTs were prescribed in 38 patients (44%), with zero excess days identified in the remaining 48 patients (56%). Seventy-five of 192 (39%) excess DOTs occurred at initiation; 55/192 (29%) after the pre-72hour antibiotic review; and 62/192 (32%) due to protracted antibiotic courses. There was concordance between the general surgeon and infection specialist for the majority of apportioned excess DOTs. However, the surgeon apportioned fewer excess DOTs 160/1162 (13.8%). Overall IV antibiotics accounted for 53.4% of total DOTs. Seventy-two of 86 (83.7%) patients received 620 intravenous DOTs; of these, 79 (12.7%) IV DOTS were unnecessary.

Conclusions

We have identified excess antibiotic prescribing in General surgery with comparable excess DOTs at all three time-points.

Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

The impact of penicillin allergy de-labelling on the WHO AWaRe antibiotic categories: a retrospective cohort study

BACKGROUND

The WHO's AWaRe classification categorizes antibiotics into three stewardship groups: Access, Watch and Reserve. The Access group includes antibiotics with lower resistance potential than antibiotics in the other two groups. The UK five-year AMR strategy has set targets for reducing non-Access antibiotic use. The majority of penicillins are in the Access group and therefore patients with a penicillin allergy record are likely to receive more non-Access antibiotics. This study aimed to quantify the impact of penicillin allergy records on non-Access antibiotic prescribing and to estimate potential reductions in non-Access antibiotic use through penicillin allergy de-labelling.

METHODS

Inpatients of a 750-patient-bed UK district general hospital in England prescribed antibiotics between 1^st April 2018 and 31^st March 2019 were included. Variables included: age, sex, co-morbidity, infection treated, antibiotic usage, hospital length of stay, penicillin allergy status. Multivariable logistic regression was used to explore the association between patient characteristics and their receipt of antibiotics in the Access and non-Access groups.

RESULTS

A total of 67,059 antibiotic prescriptions for 23,356 inpatients were analysed. Penicillin allergy records were present in 14.3% of hospital admissions. Patients with a penicillin allergy record were around four times more likely (odds ratio = 4.7) to receive an antibiotic from the non-Access groups (i.e. Reserve and Watch groups). We estimate de-labelling 50% of hospital inpatients with a penicillin allergy record could reduce non-Access antibiotic use by 5.8% and total antibiotic use by 0.86%.

CONCLUSION

Penicillin allergy records are associated with non-Access antibiotic prescribing. Penicillin allergy de-labelling has potential to reduce non-Access antibiotic use.

Mechanisms of checkpoint inhibition-induced adverse events

Immune checkpoint inhibition has revolutionized the treatment of several solid cancers, most notably melanoma and non-small-cell lung cancer (NSCLC). Drugs targeting cytotoxic T lymphocyte antigen (CTLA)-4 and programmed cell death 1 (PD-1) have made their way into routine clinical use; however, this has not been without difficulties. Stimulation of the immune system to target cancer has been found to result in a reduction of self-tolerance, leading to the development of adverse effects that resemble autoimmunity. These adverse effects are erratic in their onset and severity and can theoretically affect any organ type. Several mechanisms for immune-related toxicity have been investigated over recent years; however, no consensus on the cause or prediction of toxicity has been reached. This review seeks to examine reported evidence for possible mechanisms of toxicity, methods for prediction of those at risk and a discussion of future prospects within the field.

Depressive symptoms in inflammatory bowel disease: an extraintestinal manifestation of inflammation?

Depressive symptoms are reported by more than 20% of people with inflammatory bowel disease (IBD), while sleep difficulties and fatigue are even more common. Co-morbid depressive symptoms predict a poor IBD course, including increased risk of relapse and surgery, which is inconsistently improved by psychological treatments. Rather than being distinct systems, there is compelling evidence for bidirectional communication between gut and brain, driven by neural, metabolic, endocrine and inflammatory mediators. An emerging concept is that depressive symptoms may be mechanistically linked to excess inflammation and dysregulation of the gut-brain axis. Given the close link between the intestinal microbiota and host immune responses, patients prone to shifts in their intestinal microbiome, including smokers, those with poor diet and early life stress, may be exposed to exaggerated immune responses. Excess inflammation is associated with brain changes (depressive symptoms, fatigue, sleep difficulties) and worsening gastrointestinal symptoms, which are exacerbated by psychological distress. Equally, treatments both for depressive symptoms and IBD provide opportunities to break this cycle by reducing the causes and effects of inflammation. As well as addressing potential risk factors such as smoking and diet, treatments to alter the microbiome may reduce depressive symptoms. Observational evidence suggests that anti-inflammatory treatments for IBD may improve co-morbid depressive symptoms correlating with reduction in inflammation. With a growing range of treatments targeting inflammation centrally, peripherally and in the gut, IBD provides a unique model to understand the interplay between brain and gut in the pathogenesis of depressive symptoms, both in IBD and in the whole population.

Recurrence of vulval intraepithelial neoplasia following treatment with cidofovir or imiquimod: results from a multicentre, randomised, phase II trial (RT3VIN)

OBJECTIVE

To compare the recurrence rates after complete response to topical treatment with either cidofovir or imiquimod for vulval intraepithelial neoplasia (VIN) 3.

DESIGN

A prospective, open, randomised multicentre trial.

SETTING

32 general hospitals located in Wales and England.

POPULATION OR SAMPLE

180 patients were randomised consecutively between 21 October 2009 and 11 January 2013, 89 to cidofoovir (of whom 41 completely responded to treatment) and 91 to imiquimod (of whom 42 completely responded to treatment).

METHODS

After 24 weeks of treatment, complete responders were followed up at 6-monthly intervals for 24 months. At each visit, the Common Terminology Criteria for Adverse Events (CTCAE) v3.0 was assessed and any new lesions were biopsied for histology.

MAIN OUTCOME MEASURES

Time to histologically confirmed disease recurrence (any grade of VIN).

RESULTS

The median length of follow up was 18.4 months. At 18 months, more participants were VIN-free in the cidofovir arm: 94% (95% CI 78.2-98.5) versus 71.6% (95% CI 52.0-84.3) [univariable hazard ratio (HR) 3.46, 95% CI 0.95-12.60, P = 0.059; multivariable HR 3.53, 95% CI 0.96-12.98, P = 0.057). The number of grade 2+ events was similar between treatment arms (imiquimod: 24/42 (57%) versus cidofovir: 27/41 (66%), χ2 = 0.665, P = 0.415), with no grade 4+.

CONCLUSIONS

Long-term data indicates a trend towards response being maintained for longer following treatment with cidofovir than with imiquimod, with similar low rates of adverse events for each drug. Adverse event rates indicated acceptable safety of both drugs TWEETABLE ABSTRACT: Long-term follow up in the RT3VIN trial suggests cidofovir may maintain response for longer than imiquimod.

Recent advances in gut immunology

In recent years, there have been significant advances in our understanding of the mucosal immune system. In addition to unravelling some of the complexities of this system, including the discovery of completely new cells types, further insights into the three-way interactions between mucosal immune cells, the intestinal epithelium and the microbial communities colonizing the GI tract promise to redefine our understanding of how intestinal homeostasis is maintained, but also how dysregulation of these highly integrated interactions conspires to cause disease. In this review, we will discuss major recent advances in the role of key immune players in the gut, including innate lymphoid cells (ILCs), mucosa-associated invariant T cells (MAIT cells) and cells of the mononuclear phagocyte system (MPS), including how these cells interact with the intestinal epithelial and their crosstalk with components of the intestinal microbiota, and how these interactions shape host health.

Tissue magnetic susceptibility mapping as a marker of tau pathology in Alzheimer's disease

Alzheimer's disease is connected to a number of other neurodegenerative conditions, known collectively as 'tauopathies', by the presence of aggregated tau protein in the brain. Neuroinflammation and oxidative stress in AD are associated with tau pathology and both the breakdown of axonal sheaths in white matter tracts and excess iron accumulation grey matter brain regions. Despite the identification of myelin and iron concentration as major sources of contrast in quantitative susceptibility maps of the brain, the sensitivity of this technique to tau pathology has yet to be explored. In this study, we perform Quantitative Susceptibility Mapping (QSM) and T2* mapping in the rTg4510, a mouse model of tauopathy, both in vivo and ex vivo. Significant correlations were observed between histological measures of myelin content and both mean regional magnetic susceptibility and T2* values. These results suggest that magnetic susceptibility is sensitive to tissue myelin concentrations across different regions of the brain. Differences in magnetic susceptibility were detected in the corpus callosum, striatum, hippocampus and thalamus of the rTg4510 mice relative to wild type controls. The concentration of neurofibrillary tangles was found to be low to intermediate in these brain regions indicating that QSM may be a useful biomarker for early stage detection of tau pathology in neurodegenerative diseases.

Systematic review: bile acids and intestinal inflammation-luminal aggressors or regulators of mucosal defence?

BACKGROUND

Inflammatory bowel diseases (IBD), comprising Crohn's disease and ulcerative colitis (UC), are chronic conditions attributed to an aberrant immune response to luminal triggers. Recently, published work suggests a pathogenic role for bile acids in this context.

AIM

To perform a systematic review of studies investigating the role of bile acids in intestinal inflammation and present potentially relevant clinical implications.

METHODS

Pubmed search for English language articles published up to May 2015. Terms used were: 'bile', 'bile acid', 'barrier', 'small bowel injury', 'Crohn's' and 'colitis'.

RESULTS

Experimental studies support a variable role for bile acids in intestinal barrier homoeostasis. This may be attributed to different physicochemical properties, variable effects on epithelia and immune cells via bile acids-specific receptors, or through a cross-talk with the gut microbiome. A reduction in the bile acids pool, with lower concentrations of secondary forms, has been recognised for some time in Crohn's disease and associated to ileal dysfunction and bile acids malabsorption. Recent work suggests that these changes, including an increase in sulphated forms, are related to inflammatory activity in both Crohn's disease and UC. The detrimental effects of 'western diet' elements such as emulsifiers and fat, which have been implicated in the development of the current IBD and obesity epidemics, may also be bile acid-mediated.

CONCLUSIONS

Although there are only a few observational clinical studies to support an interaction, in vivo human and animal studies support an association between bile acids metabolism, the gut microbiome and intestinal inflammation. This may well prove to have significant diagnostic and therapeutic implications.

Can someone call my PA?

The aim of this paper is to outline the background of the Physician Associate (known in the USA as physician assistant¹) role in the USA and follow its recent journey to the UK where it is becoming a rapidly developing new healthcare role. Through the use of two case studies from UK Hospital Trusts who are currently utilising Physician Associates (PAs) in their workforce we describe the implementation and development opportunities for the role, with particular reference to their role in Acute Medicine teams of the future.

Enhanced biogas production using cow manure to stabilize co-digestion of whey and primary sludge

Increasing biogas production from municipal anaerobic digesters via additional loading with industrial/agricultural wastes offers a low-cost, sustainable energy generation option of significant untapped potential. In this work, bench-top reactors were used to mimic a full-scale primary sludge digester operating at an organic loading rate (OLR) of 2.4 kg COD/m3 d and a 20 d hydraulic retention time (HRT). Co-digestion of whey with primary sludge was sustained at a loading rate of 3.2 kg COD/m3 d (17 d HRT) and boosted gas production to 151% compared to primary sludge digestion alone. Addition of chemical alkalinity enabled co-digestion of whey with primary sludge to be maintained at an elevated OLR of 6.4 kg COD/m3 d (11 d HRT) with gas production increased to 208%. However, when the chemical addition was simply replaced by cow manure, stable operation was maintained at OLRs of 5.2-6.9 kg COD/m3 d (11-14 d HRT) with gas production boosted up to 268%.

Effect of whey storage on biogas produced by co-digestion of sewage sludge and whey

Biogas production from municipal anaerobic digesters could potentially be boosted via co-digestion with organic wastes such as whey. The challenge is that whey production is seasonal. This research examined the effect of storing whey at ambient temperature on: (1) whey composition; (2) biogas production from co-digestion of the stored whey with municipal primary sludge. Whey storage resulted in acidification with formation of acetate, propionate and butyrate and a 9% reduction in total chemical oxygen demand (COD) over the 9-month trial. A control digester fed with primary sludge produced 0.18-0.23 m3 CH4/kgCOD(added). Co-digestion of fresh whey and sludge increased biogas production and the methane contribution from the whey was 0.29 m3CH4/kgCOD(added). When the fresh whey was substituted with stored whey, methane production by the whey remained at 0.29 m3CH4/kgCOD(added). The ability to store whey at ambient temperature and allow co-digestion year round will significantly improve the economics of biogas production from whey.

Psychosocial stress and inflammation in cancer

Stress-induced immune dysregulation results in significant health consequences for immune related disorders including viral infections, chronic autoimmune disease, and tumor growth and metastasis. In this mini-review we discuss the sympathetic, neuroendocrine and immunologic mechanisms by which psychosocial stress can impact cancer biology. Both human and animal studies have shown the sympathetic and neuroendocrine responses to psychosocial stress significantly impacts cancer, in part, through regulation of inflammatory mediators. Psychosocial stressors stimulate neuroendocrine, sympathetic, and immune responses that result in the activation of the hypothalamic-pituitary-adrenal (HPA)-axis, sympathetic nervous system (SNS), and the subsequent regulation of inflammatory responses by immune cells. Social disruption (SDR) stress, a murine model of psychosocial stress and repeated social defeat, provides a novel and powerful tool to probe the mechanisms leading to stress-induced alterations in inflammation, tumor growth, progression, and metastasis. In this review, we will focus on SDR as an important model of psychosocial stress in understanding neural-immune mechanisms in cancer.

Helicobacter pylori induces in-vivo expansion of human regulatory T cells through stimulating interleukin-1β production by dendritic cells

Helicobacter pylori is one of the most common infections in the world. Despite inciting inflammation, immunological clearance of the pathogen is often incomplete. CD4(+) CD25(hi) forkhead box protein 3 (FoxP3(+)) regulatory T cells (T(regs)) are potent suppressors of different types of immune responses and have been implicated in limiting inflammatory responses to H. pylori. Investigating the influence of H. pylori on T(reg) function and proliferation, we found that H. pylori-stimulated dendritic cells (DCs) induced proliferation in T(regs) and impaired their suppressive capability. This effect was mediated by interleukin (IL)-1β produced by H. pylori-stimulated DCs. These data correlated with in-vivo observations in which H. pylori(+) gastric mucosa contained more T(regs) in active cell division than uninfected stomachs. Inciting local proliferation of T(regs) and inhibiting their suppressive function may represent a mechanism for the chronic gastritis and carcinogenesis attributable to H. pylori.

Dietary intakes and food sources of phytoestrogens in the European Prospective Investigation into Cancer and Nutrition (EPIC) 24-hour dietary recall cohort

BACKGROUND/OBJECTIVES

Phytoestrogens are estradiol-like natural compounds found in plants that have been associated with protective effects against chronic diseases, including some cancers, cardiovascular diseases and osteoporosis. The purpose of this study was to estimate the dietary intake of phytoestrogens, identify their food sources and their association with lifestyle factors in the European Prospective Investigation into Cancer and Nutrition (EPIC) cohort.

SUBJECTS/METHODS

Single 24-hour dietary recalls were collected from 36,037 individuals from 10 European countries, aged 35-74 years using a standardized computerized interview programe (EPIC-Soft). An ad hoc food composition database on phytoestrogens (isoflavones, lignans, coumestans, enterolignans and equol) was compiled using data from available databases, in order to obtain and describe phytoestrogen intakes and their food sources across 27 redefined EPIC centres.

RESULTS

Mean total phytoestrogen intake was the highest in the UK health-conscious group (24.9 mg/day in men and 21.1 mg/day in women) whereas lowest in Greece (1.3 mg/day) in men and Spain-Granada (1.0 mg/day) in women. Northern European countries had higher intakes than southern countries. The main phytoestrogen contributors were isoflavones in both UK centres and lignans in the other EPIC cohorts. Age, body mass index, educational level, smoking status and physical activity were related to increased intakes of lignans, enterolignans and equol, but not to total phytoestrogen, isoflavone or coumestan intakes. In the UK cohorts, the major food sources of phytoestrogens were soy products. In the other EPIC cohorts the dietary sources were more distributed, among fruits, vegetables, soy products, cereal products, non-alcoholic and alcoholic beverages.

CONCLUSIONS

There was a high variability in the dietary intake of total and phytoestrogen subclasses and their food sources across European regions.

Images of the terminal ileum are more convincing than cecal images for verifying the extent of colonoscopy

BACKGROUND AND STUDY AIMS

Independent verification of colonoscopy completion is important for quality assurance. Cecal photographs aimed at showing key landmarks, including the ileocecal valve (ICV) and appendiceal orifice are the currently recommended standard, but are often perceived as unreliable. Images of the terminal ileum demonstrating villi may provide more robust evidence of completion. We sought to prospectively evaluate the ease of routine intubation of the terminal ileum and to compare the effectiveness of terminal ileum and cecal photographs in convincing independent reviewers that total colonoscopy had been accomplished.

PATIENTS AND METHODS

A prospective, observational study evaluated 216 consecutively completed colonoscopies performed in routine clinical practice. Cecal and terminal ileum photographs were evaluated and scored by independent reviewers. Frequency of terminal ileum intubation, time required, and safety parameters were recorded.

RESULTS

The terminal ileum was intubated and photographed in 188/216 (87%) of cases. Median time taken to intubate, or attempt to intubate the terminal ileum was 1 min 24 s, and was achieved without complications or requirement for additional sedation. Terminal ileum images were significantly more likely to be considered convincing than cecal images ( P<0.0001 for all reviewers). There was excellent interobserver agreement amongst the opinion of reviewers regarding terminal ileum photographs (kappa=0.91).

CONCLUSION

Terminal ileum intubation is achievable rapidly and safely in the majority of patients undergoing colonoscopy. Terminal ileum images provide more convincing evidence of complete examination of the colon than cecal images, even when attempts to capture images specifically of the ICV and appendiceal orifice are made.

Luxury uptake of phosphorus by microalgae in full-scale waste stabilisation ponds

Biological phosphorus removal was studied in two full-scale waste stabilisation ponds (WSP). Luxury uptake by microalgae was confirmed to occur and in one pond the biomass contained almost four times the phosphorus required by microalgae for normal metabolism. However, the phosphorus content within the biomass was variable. This finding means that assumptions made in prior publications on modelling of phosphorus removal in WSP are questionable. While fluctuations in microalgal growth causes variation in many water quality parameters, this further variation in luxury uptake explains the high degree of variability in phosphorus removal commonly reported in the literature. To achieve effective biological phosphorus removal high levels of both luxury uptake and microalgal concentration are needed. The findings of this work show that while high levels of these parameters did occur at times in the WSP monitored, they did not occur simultaneously. This is explained because accumulated phosphorus is subsequently consumed during rapid growth of biomass resulting in a high biomass concentration with a low phosphorus content. Previous laboratory research has allowed a number of key considerations to be proposed to optimise both luxury uptake and biomass concentration. Now that is has been shown that high levels of biomass concentration and luxury uptake can occur in the field it may be possible to redesign WSP to optimise these parameters.

Phosphate release from waste stabilisation pond sludge: significance and fate of polyphosphate

Net phosphorus removal from waste stabilisation pond (WSP) systems is governed by the rate of phosphorus incorporation into the sludge layer and the rate of phosphorus release from this sludge back to the overlying wastewater. Luxury uptake of phosphorus by microalgae has been shown to occur under WSP conditions in the laboratory; however, the significance of this mechanism and the fate of polyphosphate contained in the settled solids have not previously been investigated. In this work the analysis of sludge samples from three WSP showed that up to 71% of the total phosphorus in the sludge was in the form of polyphosphate. This indicates that polyphosphate accumulation could potentially be an important mechanism for phosphorus sequestration in WSP and challenges the common view that chemical precipitation is the predominant phosphorus removal mechanism in these systems. The release of phosphate from WSP sludge samples was monitored in the laboratory. The samples from two different pond systems had release rates in the order of 4.3 microgP/gTSS.d. However, the third sample which was collected during an algal bloom had a release rate of 12.4 microgP/gTSS.d. Phosphate release from fresh microalgal sludge grown under laboratory conditions was also studied and was shown to have a release rate of 160 microgP/gTSS.d. Analysis of polyphosphate during the experiments on laboratory grown microalgal sludge showed that polyphosphate was indeed degraded resulting in phosphate release. Interestingly, after the initial release phase phosphorus was assimilated by the biomass and some polyphosphate was reformed. It is likely that this is due to bacterial growth in the sludge.

Repeated social defeat activates dendritic cells and enhances Toll-like receptor dependent cytokine secretion

Stress hormones significantly impact dendritic cell (DC) activation and function, typically in a suppressive fashion. However, a social stressor termed social disruption (SDR) has been shown to induce an increase in inflammatory responses and a state of glucocorticoid resistance in splenic CD11b+ monocytes. These experiments were designed to determine the effects of SDR on DC activation, Toll-like receptor-induced cytokine secretion, and glucocorticoid sensitivity. Compared to cells obtained from control animals, splenic DCs from SDR mice displayed increased levels of MHC I, CD80, and CD44, indicative of an activated phenotype. In addition, DCs from SDR mice produced comparatively higher TNF-alpha, IL-6, and IL-10 in response to in vitro stimulation with LPS and CpG DNA. Increased amounts of TNF-alpha and IL-6 were also evident in SDR DC cultures stimulated with poly(I:C). Furthermore, as shown previously in CD11b+ monocytes, the CD11c+ DCs obtained from SDR mice were glucocorticoid resistant. Taken together, the data suggest that social stress, in the absence of any immune challenge, activates DCs, increases DC cytokine secretion in response to Toll-specific stimuli and renders DCs glucocorticoid resistant.

Human papillomavirus prevalence in women attending routine cervical screening in South Wales, UK: a cross-sectional study

In this cross-sectional population-based study we determine human papillomavirus (HPV) prevalence in South Wales to provide comprehensive baseline data for future assessment of the impact of prophylactic HPV vaccination and to help inform future screening strategies. Liquid-based cytology samples from women attending routine cervical screening were collected (n=10 000: mean age 38 years, 93% cytology negative, and 64.8% from the 50% least deprived LSOA according to social deprivation score (SDS)). High-Risk (HR) and Low-Risk HPV screening was performed using HPV PCR-EIA with genotyping of HR positives and data correlated with age, SDS and cytology. Overall HPV prevalence was 13.5% (9.3% age standardised) and the most frequent HR types were HPV 16, 31, 18 and 58. In HR HPV-positive cases 42.4% had a single HR type and they were predominant in women with severe cytological abnormalities. Here, 66% of all HR HPV cases were in women aged 30 years of age or less and SDS had no significant effect on HPV status. HPV prevalence increased significantly with degree of dyskarosis from 7% in cytology negative samples to 80% in samples with severe cytological abnormalities (P-value <0.0001). Overall, 46% of HR HPV cases were positive for the two HR types targeted by the prophylactic vaccines (HPV 16 and HPV 18). The data presented represents the largest type-specific investigation of HPV prevalence in an unselected UK population.

Will vaccination against human papillomavirus prevent eye disease? A review of the evidence

The role of human papillomavirus (HPV) infection in eye disease is controversial. However, a recent case illustrates the possible role of HPV in conjunctival squamous carcinoma and the potentially devastating effects of this disease. The development of two vaccines to prevent infection with HPV types most commonly associated with anogenital cancers has led to debate about the pros and cons of a national immunisation programme to prevent cervical cancer. The introduction of such a vaccination programme may have an additional beneficial effect on the occurrence of some head and neck, including ocular, cancers. This review discusses the nature of papillomaviruses, mechanisms of infection and carcinogenesis, the possible role of HPV in eye disease, and finally the likely impact of the new prophylactic vaccines.

Solar-powered aeration and disinfection, anaerobic co-digestion, biological CO2 scrubbing and biofuel production: the energy and carbon management opportunities of waste stabilisation ponds

Waste stabilisation pond (WSP) technology offers some important advantages and interesting possibilities when viewed in the light of sustainable energy and carbon management. Pond systems stand out as having significant advantages due to simple construction; low (or zero) operating energy requirements; and the potential for bio-energy generation. Conventional WSP requires little or no electrical energy for aerobic treatment as a result of algal photosynthesis. Sunlight enables WSP to disinfect wastewaters very effectively without the need for any chemicals or electricity consumption and their associated CO(2) emissions. The energy and carbon emission savings gained over electromechanical treatment systems are immense. Furthermore, because algal photosynthesis consumes CO(2), WSP can be utilised as CO(2) scrubbers. The environmental and financial benefits of pond technology broaden further when considering the low-cost, energy production opportunities of anaerobic ponds and the potential of algae as a biofuel. As we assess future best practice in wastewater treatment technology, perhaps one of the greatest needs is an improved consideration of the carbon footprint and the implications of future increases in the cost of electricity and the value of biogas.

A distinct role for PI3Kgamma in suppressing the development and progression of experimental autoimmune encephalomyelitis (EAE) (129.30)

Phosphoinositide 3-kinases (PI3K) are intracellular signaling proteins involved in cellular responses such as chemotaxis, proliferation and apoptosis. Selective inhibitors of the PI3Kγ-isoform have recently become available. This study explores the role of PI3Kγ in the development and progression of EAE. PI3Kγ +/+ (wt) and PI3Kγ −/− (ko) mice were immunized for EAE using myelin oligodendrocyte glycoprotein p35-55 (MOG) and assessed for clinical signs, CNS histopathology and T cell activation. WT mice showed a progressive disease course with elevations in inflammatory cytokines increased CNS mononuclear infiltrates. In contrast, ko mice exhibited a delayed onset and dramatically less severe EAE course characterized by decreased T cell activation and inflammatory cytokines (TNF-α, IFN-γ, IL-2, IL-12p40, IL-6, IL-17 and MCP-1). Male ko mice were significantly more protected than ko females. Adoptive transfer of MOG-activated T cells into ko recipients show that ko mice are resistant to passive disease induction. Interestingly, wt recipients of ko donors immunized for EAE were also protected. Furthermore, adoptive transfer of activated GFP+ T cells show marked decreased infiltration of GFP+ T cells into the CNS. Taken together, these findingssuggest that depletion of PI3Kγ results in a down-regulation of the inflammatoryresponse caused by impaired trafficking of cells critical to generation of the immune response.

(Supported by NIH grant AI 064320 and National MS Society Grant RG 3272).

Migration inhibitory factor modulates experimental autoimmune encephalomyelitis through a novel combination of suppressive mediators (131.34)

Multiple sclerosis (MS), an autoimmune disease of the central nervous system (CNS), is more prevalent in women than men. Recent studies suggest that the cytokine migration inhibitory factor (MIF) plays a role in the progression of MS and experimental autoimmune encephalomyelitis (EAE). We have shown that MIF−/− mice have decreased EAE severity relative to wt controls. Here, we evaluate the role of MIF in the context of known suppressive hormones. Serum levels of corticosterone (CORT) and testosterone (TEST) were measured prior to and following EAE induction in the presence and absence of MIF. Basal levels of TEST in MIF−/− mice were notably higher than controls; basal levels of CORT were low and similar between groups. Following EAE, there was little change in CORT and TEST in wt mice; however, TEST decreased and CORT increased in MIF−/− mice following immunization. To evaluate the role of TEST, we removed the testes of male MIF−/− mice and induced EAE. We found no difference in disease severity whether MIF−/− mice were gonadectomized or not; control mice had significantly more severe EAE in the absence of TEST. These findings suggest that CORT plays a larger role than TEST in disease progression, although both hormones appear to be influenced by MIF. Further study of the mechanism of MIF could lead to improved therapies for a variety of autoimmune diseases.

(Supported by NIH grant AI 064320 and National MS Society grant RG3272)

Colonic involvement in Stevens-Johnson syndrome

Severe gastrointestinal tract involvement is a rare manifestation of Stevens-Johnson syndrome (SJS). The case is described of a 17 year old man who developed SJS secondary to phenytoin. In addition to the cutaneous, ocular, and oral mucosal lesions typical of SJS, he also developed persistent, bloody diarrhoea associated with life threatening malnutrition. Serial colonoscopy showed severe and progressive colitis. He was treated with a combination of long term nutritional support, probiotic therapy, and supportive measures. He was eventually discharged from hospital six months after admission when the diarrhoea improved and he began to gain weight.

The immunomodulatory drugs cyclosporin A, mycophenolate mofetil, and sirolimus (rapamycin) inhibit allergen-induced proliferation and IL-5 production by PBMCs from atopic asthmatic patients

We have used an optimized, physiologically relevant in vitro assay system to show that in a concentration-dependent fashion the immunomodulatory drugs cyclosporin A, mycophenolate mofetil, and sirolimus (rapamycin), as well as the glucocorticoid dexamethasone, inhibit allergen-driven T-cell proliferation and IL-5 production in PBMCs from allergen-sensitized atopic asthmatic individuals at physiologic concentrations. This effect of cyclosporin A might at least partially account for its established clinical efficacy in sparing systemic glucocorticoid therapy while improving lung function in chronic, severe, glucocorticoid-dependent asthma. The data are also compatible with the hypothesis that the newer immunomodulatory drugs mycophenolate mofetil and sirolimus exert similar effects, perhaps with a more favorable benefit/risk ratio.

Physiotherapy in Mount Hagen General Hospital: an audit of activity over a six-month period

There is a lack of a sustainable physiotherapy service in most hospitals in Papua New Guinea. Many clinicians, managers and senior administrators appear unaware of the benefits that such a service can provide. This survey uses an audit tool, a modified Körner form, to evaluate the impact of a physiotherapy service within a provincial hospital during a six-month period. The audit measures number of patients seen, types of diagnosis, time spent with individual patients and number of treatment sessions provided. 571 patients were seen in the 6 months, of whom 308 were outpatients and 263 were inpatients. Inpatients received an average of 3 hours of treatment per patient, outpatients received 1 hour. Most patients seen were those who suffer disability as a result of their condition and who would traditionally have a poor prognosis without physiotherapy intervention. The most common conditions seen were neurological disability in adults and children, conditions requiring orthopaedic rehabilitation, burns, arthritic conditions and those requiring respiratory physiotherapy techniques. The physiotherapy department at the hospital was the only establishment in the district able to provide a rehabilitation service for these patients. Hence physiotherapy greatly improved the services available to the most sick and disabled patients within the community. The fact that outpatient follow-ups proved problematic for so many patients suggests that patients should be kept in hospital until their rehabilitation needs have been fully met.

The topical glucocorticoids beclomethasone dipropionate and fluticasone propionate inhibit human T-cell allergen-induced production of IL-5, IL-3 and GM-CSF mRNA and protein

BACKGROUND

T-cell production of eosinophil-active cytokines (IL-5, IL-3, GM-CSF) is thought to be fundamental to asthma pathogenesis. Inhaled aeroallergens may be one important stimulus for T-cell cytokine production in asthma.

OBJECTIVE

To compare the potency and efficacy of the topical anti-asthma glucocorticoids beclomethasone dipropionate (BDP) and fluticasone propionate (FP) in inhibiting allergen-driven peripheral blood T-cell proliferation and production of IL-3, IL-5 and GM-CSF mRNA and protein.

METHODS

Peripheral blood mononuclear cells from six atopic asthmatics sensitized to house dust mite (HDM) were cultured in the presence of HDM and serial dilutions of BDP or FP in vitro. Cellular proliferation (7 days) and culture supernatant cytokine concentrations (6 days) were measured by uptake of tritiated thymidine and ELISA, respectively. Cytokine mRNA expression (24 h) was measured in three subjects using a quantitative PCR technique.

RESULTS

Both BDP and FP inhibited allergen-induced T-cell proliferation, expression of IL-3, IL-5 and GM-CSF mRNA, and secretion of the corresponding proteins in a concentration-dependent fashion. FP was considerably more potent, but not more efficacious, in exerting these actions.

CONCLUSIONS

Both BDP and FP have the potential markedly to inhibit allergen-induced T-cell production of asthma-relevant cytokines. This activity is effected at the level of T-cell proliferation and cytokine gene transcription. These properties may be key features of the anti-asthma activity of these drugs. The greater potency of FP in vitro may be responsible for its greater clinical potency.

Radiofrequency (pacing and thermic effects) in the treatment of sleep-disordered breathing

Radiofrequency, whether it is used for pacing or for its thermal liberation properties, has been investigated as a treatment for sleep-disordered breathing. Diaphragmatic pacing has a long history. The problems associated with pacing, which are related to patient selection, equipment failure, disturbances at the electrode/nerve interface, neuromuscular function failure, muscle fatigue, and the physiological consequences of stimulation, will have to be resolved with XIIth nerve stimulation. Radiofrequency thermal ablation has been applied on the tongue of an animal model. In man, turbinates, soft palate tissue and the base of tongue have been treated. These feasibility studies have demonstrated that obstructive sleep apnea syndrome and upper airway resistance syndrome can be completely controlled using radiofrequency thermal ablation in some subjects. These results can be obtained without complications related to speech, taste or swallowing. The treatment can be administered as an outpatient procedure, but many applications are needed, and treatment may span 6 months. Too high a level of radiofrequency will cause pain or otherwise avoidable complications. The determination of which patients will benefit most from these procedures will require further multi-center, placebo-controlled studies.

Upper airway resistance syndrome and its treatment

Although upper airway resistance syndrome (UARS) is being recognized by a growing number of specialists, its prevalence remains unknown. UARS is associated with nocturnal and daytime complaints and oro-naso-maxillo-mandibular signs. Spectrum analysis of the nocturnal sleep EEG from the central leads indicates significant differences in absolute power in the 12-14 Hz and the 7-9 Hz bands of UARS patients compared to controls. The 0.5-2.0 Hz band also appears to be involved when analyses performed on matched controls are compared to results obtained in subjects treated with nasal CPAP. Several treatment avenues--nasal CPAP, dental devices, surgical procedures, and radiofrequency thermal ablation--have been used for the treatment of UARS. The number of subjects treated have been too low and the protocols too limited to arrive at appropriate outcome recommendations, but many of the approaches have shown positive results, suggesting the possibility of several treatment avenues.