A192 EFFICACY OF USTEKINUMAB IN SMALL BOWEL STRICTURES OF FIBROSTENOTIC CROHN'S DISEASE AS ASSESSED BY INTESTINAL ULTRASOUND

Background

Small bowel Crohn’s disease (CD) strictures can lead to debilitating obstructive symptoms and the deterioration of quality of life. Imaging modalities such as intestinal ultrasound (IUS) are invaluable in the diagnosis of strictures. The use of IUS in CD is rapidly growing, is cost-effective, easily repeatable, and similar in accuracy to magnetic resonance enterography. Evidence for medical management of fibrostenotic CD has been limited to anti-tumor necrosis factor biologics. Studies on the efficacy of other biologic therapies for strictures such as ustekinumab, a p40/interleukin 12 and 23 inhibitor, are lacking.

Purpose

The objective of this study was to evaluate the efficacy of ustekinumab in the treatment of small bowel strictures on IUS.

Method

This retrospective cohort study evaluated the IUS changes of terminal ileal (TI) CD strictures at baseline and 12 months following ustekinumab initiation from 2016 to 2020 at a single tertiary care center. Strictures identified were defined as 1) increased bowel wall thickness (BWT) > 3mm, 2) narrowed luminal apposition, and 3) presence of pre-stenotic dilation (PSD) or the inability to pass the colonoscope through the narrowed area. Changes in sonographic parameters (BWT, luminal size, PSD, length, hyperemia, inflammatory fat, dysfunctional peristalsis) were recorded at baseline prior to initiation of ustekinumab and compared 12 months after treatment. Differences from baseline to 12 months were paired within-person and statistical analysis was performed using paired T-tests for continuous variables and McNemar’s test for categorical variables.

Result(s)

Of the 18 patients identified, 55% (n = 10) were male, median age was 49 years (Q1-Q3: 33-63 years) at initial scan, with median CD duration of 10 years (Q1-Q3: 8-20 years). The majority of TI strictures were surgically naïve (67%, n = 12). Between pre- and 12-month post ustekinumab therapy scans, there was significant improvement in BWT [8.2 mm vs 7.2 mm, p = 0.048], however there was no significant difference in the presence of peri-enteric inflammatory fat (p = 0.10), mean stricture length (17.7 vs 21.7 cm, p = 0.18), and mean stricture lumen diameter (3.3 mm vs 2.7 mm, p = 0.44) (Table 1). There was also no significant difference in the presence of stricture-associated peri-enteric fat (89% vs 67%, p = 0.10), stricture-associated hyperemia (83% vs 89%, p = 0.65) or dysfunctional peristalsis (50% vs 61%, p = 0.41) (Table 1).

Image

Conclusion(s)

Our study is the first to report the efficacy of ustekinumab in small bowel CD strictures using IUS at baseline and 12 months. This study shows that although ustekinumab leads to improvement in overall sonographic appearance of bowel thickness, it does not improve luminal narrowing nor PSD, two hallmark criteria of fibrostenosis. More extensive studies with larger sample sizes evaluating ustekinumab, or combination therapies, are required to identify their role in stricturing CD.

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None

Disclosure of Interest

None Declared

A170 ADVERSE EVENTS & SEROLOGICAL RESPONSES FOLLOWING SARS-COV-2 VACCINATION IN INDIVIDUALS WITH INFLAMMATORY BOWEL DISEASE

Background

The rapid development and distribution of SARS-CoV-2 vaccines has raised concerns surrounding vaccine safety in immunocompromised populations, such as those with inflammatory bowel disease (IBD).

Purpose

We described adverse events (AEs) following SARS-CoV-2 vaccination in those with IBD and determined relationships between AEs to post-vaccination antibody titres.

Method

Individuals with IBD from a prospective cohort in Calgary, Canada (n=670) who received a 1^st, 2^nd, 3^rd, and/or 4^th dose of a SARS-CoV-2 vaccine (Pfizer-BioNTech, Moderna, and/or AstraZeneca) were interviewed via telephone for AEs using the Adverse Events Following Immunization form. Subsequently, we assessed injection site reaction as a specific AE outcome. Multivariable logistic regression models were used to assess the association between anti-SARS-CoV-2 spike protein antibody (anti-S) levels within 1–12 weeks of vaccination and injection site reaction following 1st, 2nd, and 3rd dose vaccination. Models were adjusted for age, sex, IBD type, IBD medications, vaccine type, and prior COVID-19 infection. Additionally, we evaluated the risk of flare of IBD within 30 days of vaccination via chart review.

Result(s)

Table 1 describes AEs in individuals with IBD following 1^st dose (n=331), 2^nd dose (n=331), 3^rd dose (n=195), and 4^th dose (n=100) of a SARS-CoV-2 vaccine. AEs were reported in 83.3% of participants after 1^st dose, 79.1% after 2^nd dose, 77.4% after 3^rd dose, and 67.0% after 4^th dose. Injection site reaction (pain, redness, etc.) was the most common AE (50.8% of AEs), with fatigue and malaise (18.1%), headache and migraine (8.6%), musculoskeletal discomfort (8.2%), and fever and chills (6.5%) also commonly reported. Multivariable logistic regression determined no associations between anti-S concentration and injection site reaction for all doses. Age above 65 years was associated with decreased injection site reaction following 1^st and 3^rd doses, while female sex and mRNA vaccine type were associated with increased injection site reaction following 1^st and 2^nd doses. Prior COVID-19 infection, IBD type, and medication class were not associated with injection site reaction with any dose. Only one participant was diagnosed with a severe AE requiring hospitalization: Immune thrombocytopenic purpura (ITP) following 2^nd dose of a Pfizer vaccination. No cases of IBD flare occurred within 30 days of vaccination.

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Conclusion(s)

AEs following SARS-CoV-2 vaccination are generally mild and become less common with each consecutive dose. Antibody levels following each dose of the vaccine were not associated with injection site reactions. Females, those under 65 years of age, and those administered mRNA vaccines were more likely to experience an injection site reaction. Prior COVID-19 infection, IBD type, and IBD medication class did not predict injection site reactions. Vaccination was not associated with IBD flare within 30 days of vaccination.

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Other

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Helmsley

Disclosure of Interest

A. Markovinovic: None Declared, M. Herauf: None Declared, J. Quan: None Declared, L. Hracs: None Declared, J. Windsor: None Declared, N. Sharifi: None Declared, S. Coward: None Declared, L. Caplan: None Declared, J. Gorospe: None Declared, C. Ma Grant / Research support from: Ferring, Pfizer, , Consultant of: AbbVie, Alimentiv, Amgen, Ferring, Pfizer, Takeda, , Speakers bureau of: AbbVie, Alimentiv, Amgen, Ferring, Pfizer, Takeda, R. Panaccione Grant / Research support from: AbbVie, Ferring, Janssen, Pfizer, Takeda, Consultant of: Abbott, AbbVie, Alimentiv, Amgen, Arena, AstraZeneca, Boehringer Ingelheim, Bristol Myers Squibb, Celgene, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Eli Lilly, Ferring, Galapagos, Genentech, Gilead Sciences, GlaxoSmithKline, Janssen, Merck, Mylan, Oppilan Pharma, Pandion Therapeutics, Pandion Pharma, Pfizer, Progenity, Protagonist, Roche, Sandoz, Satisfai Health, Schering-Plough, Shire, Sublimity Therapeutics, Takeda, Theravance, UCB, Speakers bureau of: AbbVie, Arena, Celgene, Eli Lilly, Ferring, Gilead Sciences, Janssen, Merck, Pfizer, Roche, Sandoz, Shire, Takeda, R. Ingram: None Declared, J. Kanji: None Declared, G. Tipples: None Declared, J. Holodinsky: None Declared, C. Berstein Grant / Research support from: AbbVie, Amgen, Janssen, Pfizer, Takeda, Speakers bureau of: AbbVie, Janssen, Pfizer, Takeda, D. Mahoney: None Declared, S. Bernatsky: None Declared, E. Benchimol: None Declared, G. Kaplan Grant / Research support from: Ferring, Speakers bureau of: AbbVie, Janssen, Pfizer

A54 DIETARY COMPONENTS ARE ASSOCIATED WITH FECAL CALPROTECTIN IN ULCERATIVE COLITIS

Background

Ulcerative colitis (UC) is thought to arise from dysregulated immune responses due to intestinal dysbiosis and altered epithelial barrier function. Dietary components may affect the gut microbiome and contribute to either inflammation or its resolution. The relationship between diet and disease activity in UC warrants further investigation.

Aims

This prospective cohort study explored the relationship between dietary components, and markers of disease activity: fecal calprotectin (FCP) and partial Mayo score (PMS) in patients with UC.

Methods

40 participants were recruited from University of Calgary IBD clinics. Study staff obtained two 24-hour diet recalls using the validated automated self administered (ASA)-24 and captured PMS at baseline (T1) and follow-up at week 12 (T2). FCP samples were collected at T1 and T2. Diet variables included adjusted macro/micronutrients (n=44), food groups (n=36) and the validated Canadian healthy eating index-2009 (CHEI) where higher scores reflect healthier intake. CHEI captures intake of dark green and orange foods (DGO) and moderation scoring (MOD) of saturated fats (SF), sodium and added sugars. Higher CHEI scores result from increased intake of DGO and lower intake of SF, sodium and added sugars (higher MOD score). Associations with outcome variables were examined at T1 and T2 individually and across both timepoints (BT). Mixed effect logistic regression models identified relationships between dietary variables, FCP and PMS. Models were adjusted for age, sex, BMI, medications, probiotics, and for repeated measures in both timepoint analyses.

Results

A positive association was identified between FCP as a continuous variable and SF (T1:Coef=0.22, p_adj=0.02) and a negative association identified between FCP with citrus/melon/berries (BT:Coef=-1.01, p_adj =0.04), total sugars (BT:Coef=-0.06, p_adj=0.025) and HEI (BT:Coef=-0.13, p_adj =0.06 and T1 coef=-0.18, p_adj =7.0 e-5). FCP increased as SF (-0.30,p_adj=0.01), DGO (-0.60, p_adj=0.02), and MOD (-0.21, p_adj=0.02) scores decreased. The presence of inflammation (as a binary variable, FCP >250) was negatively associated with higher fiber intake (BT: Odds Ratio (OR)= 0.016, CI(0.001,0.40) p_adj=0.08). For PMS as a continuous variable, HEI had a negative association with PMS (T2: -0.05, p_adj=0.06). With PMS as a discrete score (remission=PMS<2) there was no significant association with any diet components.

Conclusions

This study suggests that a healthier diet, both in overall pattern and specific dietary components, was associated with lower FCP and PMS. Our findings related to SF, citrus/melons/berries, and DGO parallel the IOIBD dietary guidelines. Future research should explore through controlled intervention studies whether modifying dietary patterns and components independently reduces disease activity.

Funding Agencies

Crohn’s and Colitis Foundation

Differential regulation of STP, LTP and LTD by structurally diverse NMDA receptor subunit-specific positive allosteric modulators

Different types of memory are thought to rely on different types of synaptic plasticity, many of which depend on the activation of the N-Methyl-D Aspartate (NMDA) subtype of glutamate receptors. Accordingly, there is considerable interest in the possibility of using positive allosteric modulators (PAMs) of NMDA receptors (NMDARs) as cognitive enhancers. Here we firstly review the evidence that NMDA receptor-dependent forms of synaptic plasticity: short-term potentiation (STP), long-term potentiation (LTP) and long-term depression (LTD) can be pharmacologically differentiated by using NMDAR ligands. These observations suggest that PAMs of NMDAR function, depending on their subtype selectivity, might differentially regulate STP, LTP and LTD. To test this hypothesis, we secondly performed experiments in rodent hippocampal slices with UBP714 (a GluN2A/2B preferring PAM), CIQ (a GluN2C/D selective PAM) and UBP709 (a pan-PAM that potentiates all GluN2 subunits). We report here, for the first time, that: (i) UBP714 potentiates sub-maximal LTP and reduces LTD; (ii) CIQ potentiates STP without affecting LTP; (iii) UBP709 enhances LTD and decreases LTP. We conclude that PAMs can differentially regulate distinct forms of NMDAR-dependent synaptic plasticity due to their subtype selectivity.

This article is part of the Neuropharmacology Special Issue on ‘Glutamate Receptors – NMDA receptors’.

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NMDAR-dependent STP, LTP and LTD can be dissociated pharmacologically

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GluN2A/2B PAM UBP714 potentiates LTP and reduces LTD

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GluN2C/D PAM CIQ potentiates STP without affecting LTP

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NMDAR pan-PAM UBP709 potentiates LTD and reduces LTP

Effect of Practice on Visual Backward Masking

Five experiments studied practice effects for 4, 7, 11 subjects on visual backward masking using a signal-detection procedure under various conditions. Exp. I determined the minimum perceptible critical stimulus duration (CSD) for criterion identification of a target stimulus, the letter T or A. In Exp. II, the stimulus was presented at the critical stimulus duration (CSD) followed by a pattern mask at intervals of 20 to 120 msec. for 15 separate sessions. In Exp. III ( N = 4) the mask followed the CSD in intervals of 2-msec. increments until subjects reached criterion accuracy. Exps. IV and V ( Ns = 4, 7) provided partial replications of Exps. II and III. Naive subjects were used, and the stimulus duration was constant for all subjects. When masking functions were obtained at a threshold, considerable variability was found and subjects improve slowly or not at all over sessions. With a fixed suprathreshold stimulus, all subjects improve with practice. The importance of these findings is discussed as they relate to common (and largely untested) assumptions made in the backward masking and perception literature.

A173 INNOVATIVE CARE FOR INFLAMMATORY BOWEL DISEASE PATIENTS DURING THE COVID-19 PANDEMIC: USE OF BEDSIDE INTESTINAL ULTRASOUND TO OPTIMIZE MANAGEMENT

Background

The COVID-19 pandemic has led to significant alterations in the ability to deliver outpatient care to patients with inflammatory bowel disease (IBD) including endoscopic evaluation. This has highlighted the need for alternative, accurate, non-invasive strategies to safely assess disease activity.

Aims

The aim of this study is to describe the impact of point of care intestinal ultrasound (IUS) in a university-based tertiary care IBD urgent access clinic.

Methods

We prospectively evaluated a comprehensive care pathway which incorporated outpatient sigmoidoscopy and intestinal ultrasound with the purpose of directing further ambulatory clinical care and avoiding hospitalization or hospital-based investigations including endoscopy during the COVID pandemic for patients with established IBD with symptoms suggestive of a disease flare, or those at high risk of a new diagnosis of IBD. Non-invasive markers C Reactive Protein (CRP) and fecal calprotectin (fCal) were collected where available. Patients were pre-screened for influenza-like illness, as COVID-19 testing was not available for this population during the study period. Substantial management changes were defined as addition of any medications, biologic switch/ optimization, and or referral for surgical consultation.

Results

Between March 15^th and June 30^th 2020, a total of 72 patients were seen in the urgent access clinic. All patients were seen within 7 days of referral. The majority were female 57% (41/72) and/ or had Crohn’s disease 65.5% (47/72) (Table 1). Of these, 84.7% (61/72) underwent a substantial management change based on features of active inflammation detected by either IUS alone (53% 38/72) sigmoidoscopy alone (12.5% 9/72) or combination IUS with in-clinic sigmoidoscopy (32% 23/72) in addition to CRP and fCal. Three new diagnoses of IBD were made: one colonic Crohn’s and 2 with ulcerative colitis. One pregnant patient avoided all acute care utilization. Five patients were referred to colorectal surgery for urgent resection including two patients admitted directly for emergent operations. No patients required visits to the emergency department. Furthermore, there have been no unscheduled hospitalizations occurred in this cohort since inception March 23, 2020 til November 15^th 2020.

Conclusions

The implementation of IUS in a centralized, urgent access clinic pathway resulted in efficient and meaningful changes in IBD management while sparing the need for acute care services including ER visits, need for in-hospital endoscopy, and hospitalization. The pandemic highlights the utility of this patient-center tool and supports expansion of wider IUS adoption.

Funding Agencies

None

Determination of Glyphosate and Aminomethylphosphonic Acid in Crops by Capillary Gas Chromatography with Mass-Selective Detection: Collaborative Study

A collaborative study was conducted to validate a method for the determination of glyphosate and aminomethylphosphonic acid (AMPA) in crops. The analytes are extracted from crops with water, and the crude extracts are then subjected to a cation exchange cleanup. The analytes are derivatized by the direct addition of the aqueous extract into a mixture of heptafluorobutanol and trifluoroacetic anhydride. The derivatized analytes are quantitated by capillary gas chromatography with mass-selective detection (MSD). The collaborative study involved 13 laboratories located in 5 countries 12 laboratories returned valid data sets. The crops tested were field corn grain, soya forage, and walnut nutmeat at concentrations of 0.050, 0.40, and 2.0 mg/kg. The study used a split-level pair replication scheme with blindly coded laboratory samples. Twelve materials were analyzed, including 1 control and 3 split-level pairs for each matrix, 1 pair at each nominal concentration. For glyphosate, the mean recovery was 91%, the average intralaboratory variance, the repeatability relative standard deviation (RSDr), was 11%, and the interlaboratory variance, the reproducibility relative standard deviation (RSDR), was 16%. For AMPA, the mean recovery was 87%, the RSDr was 16%, and the RSDR was 25% at mg/kg levels.

P1909Cryobaloon pulmonary vein isolation without pulmonary venography

Introduction

Cryoballoon pulmonary vein isolation (PVI) has been shown to be non-inferior to radiofrequency PVI and have several advantages including shorter procedure times. Cryoballoon PVI traditionally requires the use of occlusive pulmonary venography to assess for balloon position and contact however, some patients have contraindications to the use of iodinated radiocontrast.

Purpose

We assessed the feasibility of performing cryoballoon PVI without pulmonary venography.

Methods

Thirty-five initial consecutive patients with paroxysmal or persistent atrial fibrillation underwent cryoballoon PVI as a primary procedure under conscious sedation by a single operator. None had a contraindication to radiocontrast administration. Left atrial CT was obtained the day prior in all patients to assess pulmonary vein anatomy. Transeptal puncture was performed using 1–5 ml of contrast given the non-routine availability of intracardiac echocardiography. CT images obviated the requirement for pre-balloon deployment venography and pulmonary vein balloon occlusion was assessed by tactile feedback as well as the fluoroscopic appearance of balloon deformation (Fig 1.). If adequate temperature was not obtained with initial cooling during ablation, application was discontinued and the balloon repositioned. If repeated ablation did not result in sufficient cooling and vein isolation, pulmonary venography was utilised to assess adequacy of vein occlusion and sites of leak.

Results

The median age was 57 yrs with 69% male and 63% having paroxysmal AF. 137/138 pulmonary veins were successfully isolated with mean 1.77 ablations per vein. Median nadir ablation temperature was −45°C (range −62 to −30°C) with a median time to isolation of 36.5 seconds. 120/138 (87%) of veins were isolated without the use of contrast, however 18/138 required venography. Overall, 63% of patients had successful PVI without requiring any pulmonary venography. Average procedure time was 104 minutes. One patient sustained a mediastinal hematoma that resolved with conservative management. Median follow up was 3.6 months, with 74% of patients being free from atrial fibrillation at last follow up.

Conclusion

This study demonstrates that it is feasible to perform cryoballoon PVI without pulmonary venography in 87% of targeted veins. In this series, 63% of patients had successful 4 vein isolation without pulmonary vein contrast administration. This technique combined with imaging guided transeptal puncture can allow for truly contrast-less PVI in patients with severe contrast allergy or severe renal dysfunction.

Rorschach From Quality: A Comparison of the Exner and Beck Systems

The Beck and Exner systems of assigning Rorschach form quality were compared, There are some inherent differences in the form quality tables of these two Rorschach systematizers. The Beck system is more extensive and seems slightly biased toward-or "poor" form quality in comparison to the Exner system. When the Rorschach records of psychiatric patients were scored for form quality, the Beck system yielded a significantly lower Extended F+% than the Exner system. This effect is probably related to the inherent differences in the respective form quality tables which resulted from the different procedures used in deriving these listings of form quality.

Mercury empirical relationships in sediments from three Ontario lakes

Total mercury (THg), methyl mercury (MeHg), total organic carbon (TOC), sediment bulk density (SBD), redox potential (Eh) and percent fines measurements were made on sediment cores collected along transects from littoral to profundal depths in Harp, Dickie, and Blue Chalk lake located on the Canadian Shield near Dorset, Ontario, Canada to determine whether empirical relationships exist among these sediment properties. MeHg was positively correlated with THg in all sediments with a MeHg:THg ratio (0.004+/-0.004) comparable to other uncontaminated profundal lakes. MeHg, MeHg:THg and TOC decreased with sediment depth within the core for all lakes, whereas THg only showed a decrease in Harp Lake. MeHg:THg ratio in surficial sediments was positively correlated with Eh and negatively correlated with TOC [MeHg:THg=-0.009 TOC (%)+0.001 Eh (mV)-1.902, p=0.026]; whereas THg was positively correlated with TOC [log THg (ppb)=0.026 TOC (%)+1.400, p<0.0001].

Weight Changes Following Lower Limb Arthroplasty: a Prospective Observational Study

The aim of this study was to assess patterns of weight loss/gain following total hip or knee joint replacement.

Four hundred and fifty primary lower limb arthroplasty patients, where the current surgery was the last limiting factor to improved mobility, were selected.

Over a one year period 212 gained weight (mean 5.03kg), 92 remained static, and 146 lost weight. The median change was a weight gain of 0.50Kg (p=0.002). All patients had a significant improvement in Oxford outcome scores. Hip arthroplasty patients were statistically more likely to gain weight than knee arthroplasty patients.

A successful arthroplasty, restoring a patient's mobility, does not necessarily lead to subsequent weight loss. The majority of patients put on weight with an overall net weight gain. No adverse effect on functional outcome was noted.

PAP-LMPCR for improved, allele-specific footprinting and automated chromatin fine structure analysis

The analysis of chromatin fine structure and transcription factor occupancy of differentially expressed genes by in vivo footprinting and ligation-mediated-PCR (LMPCR) is a powerful tool to understand the impact of chromatin on gene expression. However, as with all PCR-based techniques, the accuracy of the experiments has often been reduced by sequence similarities and the presence of GC-rich or repeat sequences, and some sequences are completely refractory to analysis. Here we describe a novel method, pyrophosphorolysis activated polymerization LMPCR or PAP-LMPCR, which is capable of generating accurate and reproducible footprints specific for individual alleles and can read through sequences previously not accessible for analysis. In addition, we have adapted this technique for automation, thus enabling the simultaneous and rapid analysis of chromatin structure at many different genes.

Endogenous corticosteroid biosynthesis in subjects after bilateral adrenalectomy

OBJECTIVE

Corticosteroids can be synthesized in extra-adrenal tissues but the contribution of this to circulating levels in humans is not known. Previous in vitro studies suggest that the 'hybrid' corticosteroid 18-oxocortisol (18-oxoF) is produced from cortisol by aldosterone synthase. We looked for evidence of extra-adrenal production of this and other corticosteroids in 10 subjects stable on long-term glucocorticoid replacement following bilateral adrenalectomy.

METHODS

In phase 1, patients were maintained on cortisol alone (30 mg/day), in phase 2 dexamethasone (2 mg/day), and in phase 3, both cortisol and dexamethasone. Each phase lasted 3 days.

MEASUREMENTS

On the last day of each phase, 24-h urine collection was performed for analysis of steroid metabolite excretion [using gas chromatography-mass spectrometry (GCMS)] and plasma aldosterone and renin were measured (by radioimmunoassay).

RESULTS

Cortisol metabolite excretion rate [tetrahydrocortisone (THE) + tetrahydrocortisol (THF) + allotetrahydrocortisol (aTHF)] fell from 9169 nmol/24 h in phase 1 to 22 nmol/24 h in phase 2, rising to 6843 nmol/24 h in phase 3. Tetrahydroaldosterone (THAldo) excretion was readily detectable and did not alter significantly between phases (26.5, 23.5 and 28.5 nmol/24 h, respectively; P = 0.474). 18-Hydroxycortisol (18-OHF) excretion was easily detectable in phases 1 and 3 (252.5 and 212 nmol/24 h), falling in phase 2 (12 nmol/24 h). 18-oxoF excretion rates were lower but followed a similar pattern (1.62, 0.085 and 1.785 nmol/24 h in phases 1, 2 and 3, respectively).

CONCLUSIONS

Significant levels of adrenal steroids are found in adrenalectomized subjects. We speculate that this occurs at extra-adrenal sites or in residual adrenal cortex tissue in an ACTH-independent manner. Our data suggest that aldosterone synthase, acting on cortisol, is the source of 18-oxoF and 18-OHF in these subjects. Further studies of corticosteroid production within adrenalectomized subjects, looking for evidence of adrenal regrowth or residual adrenal tissue, are justified.

Hepatitis C virus NS3-4A serine protease inhibitors: SAR of moiety with improved potency

We have discovered that introduction of appropriate amino acid derivatives at P'2 position improved the binding potency of P3-capped alpha-ketoamide inhibitors of HCV NS3 serine protease. X-ray crystal structure of one of the inhibitors (43) bound to the protease revealed the importance of the P'2 moiety.

Serological evidence of Helicobacter pylori infection in UK South Asian and European populations: implications for gastric cancer and coronary heart disease

OBJECTIVES

To describe the prevalence of serological evidence of infection with Helicobacter pylori among people of South Asian and European ethnic origins and to assess its association with prevalent coronary heart disease (CHD).

METHODS

We used a quantitative method to compare IgG antibodies to H. pylori in a population sample of 300 South Asians and 302 Europeans in Newcastle upon Tyne, UK.

RESULTS

For men and women, respectively, H. pylori IgG (95% confidence interval) was 16.7 microg/ml (13.9, 20.2) and 11.3 (9.4, 13.5) among Europeans and 11.6 (9.8, 13.7) and 14.3 (12.1, 16.9) among South Asians. Levels were higher in older participants and in those of lower socioeconomic status. The ratio of geometric mean IgG, (95% confidence interval) adjusted for age, sex and socioeconomic status, in those with and without CHD was 1.02 (0.49, 2.11) among Europeans and 1.79 (1.01, 3.17) among South Asians. Antibodies against staphylococcal enterotoxins A and B were higher among South Asians than Europeans.

CONCLUSIONS

The prevalence of H. pylori infection among UK South Asians does not reflect that of their countries of origin, nor their lower prevalence of gastric cancer. The association with CHD in South Asians requires corroboration in other studies.

Heat resistance of Bacillus cereus, Salmonella typhimurium and Lactobacillus delbrueckii in relation to pH and ethanol

The aim of the present work was to investigate the effect of ethanol alone and in combination with low pH on the heat resistance of specific bacteria. The bacteria chosen are representative of heat resistant and heat sensitive pathogens (Bacillus cereus and Salmonella typhimurium) and of relatively heat resistant spoilage microorganisms (Lactobacillus delbrueckii). The chosen bacteria were treated at different temperatures ranging between 70 and 97 degrees C for B. cereus, 48 and 54 degrees C for S. typhimurium and 44 and 60 degrees C for L. delbrueckii, in media of different pH (3, 5 and 7) and ethanol content (0, 2.5, 5, 7.5 and 10%). Both factors proved to be very effective in reducing the heat resistance of the bacteria examined in this work. At pH 7, an increase in ethanol content up to 10% caused D values to decrease by up to 100-fold (S. typhimurium). A drop from pH 7 to pH 3 also caused up to a 100-fold reduction in the D values (S. typhimurium). For B. cereus the regression analysis of the log10 of the D value in relation to temperature, pH and ethanol content was used to produce a second order polynomial equation. The z values increased at decreasing pH and cells were more sensitive to ethanol at lower pH. For S. typhimurium the polynomial equation produced to describe the relationship between log10 of the D values and temperature and ethanol content was also a second order equation indicating that the relationship between z values and ethanol was non-linear. For L. delbrueckii, z values were independent of the ethanol content of the heating medium. Acid tolerance at 25 and 37 degrees C (L. delbrueckii and S. typhimurium) and acid adaptation (S. typhimurium) were also tested. L. delbrueckii was more ethanol and pH tolerant than S. typhimurium at heat treatment temperatures whilst S. typhimurium was more acid tolerant than L. delbrueckii at incubation temperatures (25 and 37 degrees C). Acid adaptation increased the tolerance of S. typhimurium to low pH at 25 degrees C but failed to improve its thermal resistance at 48 degrees C. In all bacteria used, the effects of pH and ethanol were more evident at lower treatment temperatures and therefore their significance becomes greater in view of reduced thermal processing and/or changes in product formulation.

Heat resistance of Paenibacillus polymyxa in relation to pH and acidulants

The efficacy of different organic acids in decreasing the heat resistance of Paenibacillus polymyxa spores was assessed. The relationship between concentration of the undissociated form of different organic acids and decrease in heat resistance was also investigated. The heat resistance of P. polymyxa spores was tested in distilled water at 85, 90 and 95 degrees C, at pH4 and in the presence of 50, 100 and 200 mmol l(-1) of the undissociated form of lactic, citric or acetic acid and sodium citrate or acetate. The undissociated form of organic acids was responsible for increasing the heat sensitivity of spores. The most effective acid was lactic acid. The D values of the spores decreased rapidly (between 74 and 43%) in the presence of 50 mmol l(-1) of the undissociated form of organic acid, and increasing concentrations of these forms affected the heat resistance of spores less than proportionally. The heat resistance of the spores in milk was approximately threefold lower than in distilled water. This work has shown that the undissociated fraction of organic acids increases, albeit non-linearly, the sensitivity of spores to heat, even in complex substrates such as milk. By knowing the amount of organic acids added to a given substrate, their dissociation constants and the final pH, it could be possible to estimate the concentration of undissociated forms and the corresponding increase in lethality of heat treatments. This would help the food industry to maximize the lethality achieved by heat processes and/or safely reduce the heat treatments already in use.

The effects of growth hormone and IGF-1 deficiency on cerebrovascular and brain ageing

Research studies clearly indicate that age-related changes in cellular and tissue function are linked to decreases in the anabolic hormones, growth hormone and insulin-like growth factor (IGF)-1. Although there has been extensive research on the effects of these hormones on bone and muscle mass, their effect on cerebrovascular and brain ageing has received little attention. We have also observed that in response to moderate calorie restriction (a treatment that increases mean and maximal lifespan by 30-40%), age-related decreases in growth hormone secretion are ameliorated (despite a decline in plasma levels of IGF-1) suggesting that some of the effects of calorie restriction are mediated by modifying the regulation of the growth hormone/IGF-1 axis. Recently, we have observed that microvascular density on the surface of the brain decreases with age and that these vascular changes are ameliorated by moderate calorie restriction. Analysis of cerebral blood flow paralleled the changes in vasculature in both groups. Administration of growth hormone for 28 d was also found to increase microvascular density in aged animals and further analysis indicated that the cerebral vasculature is an important paracrine source of IGF-1 for the brain. In subsequent studies, administration of GHRH (to increase endogenous release of growth hormone) or direct administration of IGF-I was shown to reverse the age-related decline in spatial working and reference memory. Similarly, antagonism of IGF-1 action in the brains of young animals impaired both learning and reference memory. Investigation of the mechanisms of action of IGF-1 suggested that this hormone regulates age-related alterations in NMDA receptor subtypes (e.g. NMDAR2A and R2B). The beneficial role of growth hormone and IGF-1 in ameliorating vascular and brain ageing are counterbalanced by their well-recognised roles in age-related pathogenesis. Although research in this area is still evolving, our results suggest that decreases in growth hormone and IGF-1 with age have both beneficial and deleterious effects. Furthermore, part of the actions of moderate calorie restriction on tissue function and lifespan may be mediated through alterations in the growth hormone/IGF-1 axis.

Transgenic tobacco plants expressing the Drosophila Polycomb (Pc) chromodomain show developmental alterations: possible role of Pc chromodomain proteins in chromatin-mediated gene regulation in plants

The chromodomain of the Drosophila Polycomb (Pc) protein has been introduced into tobacco nuclei to determine its location in the nucleus and its effect on plant development. Pc is a repressor of homeotic Drosophila genes that shares a well-conserved, although not identical, chromodomain with a structural heterochromatin component, Heterochromatin Protein 1. The chromodomains might therefore play a common role in chromatin repression. An analysis of transgenic plants expressing the Pc chromodomain, which was linked to the green fluorescent protein, suggested that the Pc chromodomain has distinct target regions in the plant genome. Transgenic plants expressing the Pc chromodomain had phenotypic abnormalities in their leaves and flowers, indicating a disruption in development. In axillary shoot buds of plants displaying altered leaf phenotypes, enhanced expression of a homeodomain gene, which is downregulated in wild-type leaves, was found. In Drosophila, Pc has been shown to possess distinct chromosome binding activity and to be involved in the regulation of development-specific genes. Our results support the assumptions that the heterologous chromodomain affects related functions in Drosophila and in plants, and that chromatin modification mechanisms are involved in the regulation of certain plant genes, in a manner similar to chromatin-mediated gene regulation in Drosophila.

A continuous spectrophotometric assay for the hepatitis C virus serine protease

The hepatitis C virus (HCV) encodes a chymotrypsin-like serine protease responsible for the processing of HCV nonstructural proteins and which is a promising target for antiviral intervention. Its relatively low catalytic efficiency has made standard approaches to continuous assay development only modestly successful. In this report, four continuous spectrophotometric substrates suitable for both high-throughput screening and detailed kinetic analysis are described. One of these substrates, Ac-DTEDVVP(Nva)-O-4-phenylazophenyl ester, is hydrolyzed by HCV protease with a second-order rate constant (kcat/Km) of 80,000 +/- 10,000 M-1 s-1. Together with its negligible rate of nonenzymatic hydrolysis under assay conditions (0.01 h-1), analysis of as little as 2 nM protease can be completed in under 10 min.

Serine protease of hepatitis C virus expressed in insect cells as the NS3/4A complex

Hepatitis C virus (HCV) protease NS3 and its protein activator NS4A participate in the processing of the viral polyprotein into its constituent nonstructural proteins. The NS3/4A complex is thus an attractive target for antiviral therapy against HCV. We expressed the full-length NS3 and NS4A in insect cells as a soluble fusion protein with an N-terminal polyhistidine tag and purified the two proteins to homogeneity. Cleavage at the junction between HisNS3 and NS4A occurs during expression, producing a noncovalent complex between HisNS3 and NS4A with a subnanomolar dissociation constant. We purified the HisNS3/4A complex by detergent extraction of cell lysate and by metal chelate chromatography. We removed the His tag by thrombin cleavage and then further purified the complex by gel filtration. The purified NS3/4A complex is active in a protease assay using a synthetic peptide substrate derived from the NS5A-NS5B junction, with kcat/K(m) of 3700 (+/- 600) M-1 s-1, an order of magnitude above those previously reported for NS3 expressed by other strategies. This high protease activity implies that the full-length sequences of NS3 and NS4A are required for optimal activity of the NS3 protease domain. We examined the dependence of the NS3/4A protease activity on buffer conditions, temperature, and the presence of detergents. We find that, under most conditions, NS3 protease activity is dependent on the aggregation state of the NS3/4A complex. The monodisperse, soluble form of the NS3/4A complex is associated with the highest protease activity.

Enhancement of hepatitis C virus NS3 proteinase activity by association with NS4A-specific synthetic peptides: identification of sequence and critical residues of NS4A for the cofactor activity

The NS3 proteinase of hepatitis C virus utilizes NS4A as a cofactor for cleavages at four sites (3/4A, 4A/4B, 4B/5A, and 5A/5B) in the nonstructural region of the viral polyprotein. To characterize NS4A for its role in modulating the NS3 proteinase activity at various cleavage sites, synthetic peptides spanning various parts of NS4A were synthesized and tested in a cell-free trans-cleavage reaction using purified NS3 proteinase domain and polyprotein substrates. The NS3 proteinase domain was expressed in Escherichia coli, purified, denatured, and refolded to an enzymatically active form. We found that a 12-amino-acid peptide containing amino acid residues 22 to 33 in NS4A (CVVIVGRIVLSG) was sufficient for cofactor activity in NS3-mediated proteolysis. The peptide enhanced the cleavage at the NS5A/5B site and was necessary for NS3-mediated cleavage at NS4A/4B and NS4B/5A. Sequential amino acid substitution within the designated peptide identified residues I29 and I25 as critical for potential cofactor activity. We provide evidence that the NS4A peptide and the NS3 catalytic domain form an enzymatically active complex. These data suggest that the central 12-amino-acid peptide (aa 22-33) of NS4A is primarily important for the cofactor activity through complex formation with NS3, and the interaction may represent a new target for antiviral drug development.

Phase I study of high-dose etoposide phosphate in man

Etoposide is a widely used cytotoxic agent with a broad spectrum of activity in human malignancies. This agent has been incorporated into many transplant regimens although toxicity occurs because of its poor water solubility and toxic excipients. Etoposide phosphate, a water soluble prodrug of etoposide, has been studied at conventional dosages in man and shown to have advantages over the parent compound. We have extended our previous experience with this new agent to evaluate the levels needed in transplantation protocols. This phase I study of intravenous high-dose etoposide phosphate over 2 h on days 1 and 2 was designed to determine whether or not dose linearity between the amount of etoposide phosphate administered to patients and generation of etoposide in vivo as seen with conventional dosages of this agent would be present at transplant-dose levels. In addition, the toxicities of these dose levels with the short infusion schedule were defined. A conservative dose escalation scheme was chosen based upon prior knowledge of etoposide. Thirty-one patients (19 male, 12 female) with CALGB performance status 0-1 with a variety of solid tumors entered this study. The patients were treated with dose levels of etoposide phosphate given as the etoposide-equivalent doses of 250, 500, 750, 1000, 1200, 1400, and 1600 mg/m2/day in 250-400 ml of normal saline given as an intravenous infusion over 2 h on days 1 and 2 every 28 days. After the maximal tolerated dose level was determined on this schedule, additional patients received etoposide phosphate as a 4 h infusion on both days in an attempt to reduce toxicities. G-CSF (5 micrograms/kg/day) was administered subcutaneously to all patients from day 3 until the WBC > or = 10000/microliters. Nonhematologic toxicity was considered to be dose limiting. Serial plasma samples for pharmacokinetics were obtained from patients on day 1 of cycle 1. For the 2 h infusion, the maximum tolerated dose of etoposide phosphate was 1000 mg/m2/day x 2 with dose limiting mucositis. In the small number of patients studied, the maximum tolerated dose was reached for the 4 h infusion at 1400 mg/m2/day of drug, again due to mucositis. Other toxicities, despite the rapid infusion schedule, were modest with transient mild headache being most common. At the highest doses etoposide phosphate was efficiently and rapidly dephosphorylated to etoposide. Etoposide generated by dephosphorylation of etoposide phosphate had plasma disposition curves characteristic of etoposide administered parenterally. One partial response occurred in a patient with small cell lung cancer. Etoposide phosphate can be rapidly infused in modest fluid volumes at dosages required for transplantation protocols with minimal acute side-effects. On a 2 h schedule, mucositis becomes the dose limiting nonhematologic toxicity. Mucositis seems to correlate with peak dose levels of the drug rather than total drug administered. On a 4 h infusion schedule given sequentially for 2 days, the maximum tolerated dosage could be increased 40% compared to the 2 h schedule. The relative ease of administration and the rapid conversion of this prodrug into etoposide should make it useful in high-dose therapy settings.

Pharmacokinetic evaluation of high-dose etoposide phosphate after a 2-hour infusion in patients with solid tumors

Etoposide phosphate, a water soluble prodrug of etoposide, was evaluated at levels potentially useful in transplantation settings in patients with malignancies. For pharmacokinetic studies of etoposide phosphate in this phase I study, 21 patients with solid tumors were treated with etoposide phosphate given as etoposide equivalents of 250, 500, 750, 1000 and 1200 mg/m2 infused over 2 h on days 1 and 2, and G-CSF 5 micrograms/kg per day starting on day 3 until WBC was > or = 10,000/microliters. Qualitative, quantitative, and pharmacokinetic analysis was performed as reported previously. Rapid conversion of etoposide phosphate into etoposide by dephosphorylation occurred at all dosage levels without indication of saturation of phosphatases. Plasma levels (C(pmax)) and area under the curve (AUC) of etoposide phosphate and etoposide demonstrated linear dose effects. For etoposide, plasma disposition demonstrated biphasic clearance, with mean T1/2 alpha of 2.09 +/- 0.61 h, and T1/2 beta of 5.83 +/- 1.71 h. An AUC as high as 1768.50 micrograms.h/ml was observed at a dose of 1200 mg/m2. The total body clearance (TBC) showed an overall mean of 15.72 +/- 4.25 ml/min per m2, and mean volume of distribution (VDss) of 5.64 +/- 1.06 l/m2. The mean residual time (MRT) for etoposide was 6.24 +/- 1.61 h. In urine, etoposide but not etoposide phosphate, was identified with large quantitative variations (1.83% to 33.45% of injected etoposide equivalents). These results indicate that etoposide phosphate is converted into etoposide with the linear dose-related C(pmax) and AUCs necessary for use of this agent at the high dosage levels needed in transplantation protocols. A comparison of pharmacokinetic parameters of high-dose etoposide with the values observed in our study with etoposide phosphate revealed comparable values for the clinically important C(pmax) and AUCs, clearance, terminal T1/2 and MRT. In contrast to the use of etoposide, etoposide phosphate can be delivered in aqueous vehicles and therefore may offer the advantage of ease of administration.

Taking a pro-active approach: communicating with women experiencing violence from a known man in the emergency department

Studies have shown that as many as 35% of women attending Accident and Emergency units do so as a result of their experience of violence from a known man. Far fewer women are currently identified as attending for those reasons. This article outlines the factors behind this discrepancy and describes how Accident and Emergency units can take a proactive approach, enabling staff to enable women to take positive steps towards living free from violence and abuse.

Immunochemical mapping of domains in human interleukin 4 recognized by neutralizing monoclonal antibodies

Human interleukin 4 is a highly pleiotropic cytokine secreted by activated T cells that exerts multiple biological effects on B and T lymphocytes and other cell types. Elucidation of structure-function relations was accomplished by epitope mapping of a panel of monoclonal antibodies and by mutagenesis of selected amino acid residues. Epitope mapping of these monoclonal antibodies was achieved through binding studies with recombinant human interleukin 4 (rhuIL-4), proteolytic fragments produced by digestion with Staphylococcus aureus V8 protease and synthetic peptides derived from the sequence of the parent molecule. Monoclonal antibodies 25D2, 35F2, and 11B4 neutralized the in vitro T-cell proliferation activity of rhuIL-4 and also prevented binding of rhuIL4 to its cell surface receptor. These antibodies recognized sequences 104-129, 70-92, and 61-82, respectively. These regions comprise the BC loop/helix C (residues 61-92) and helix D (residues 104-129). A nonneutralizing monoclonal antibody (1A2) recognized a nonoverlapping region (residues 43-59) comprising almost entirely helix B. Mutagenesis of a cluster of residues within helix C showed that at least three residues (K84, R88, and N89) were potentially involved in receptor recognition. The existence of two distinct nonneighboring binding domains in the three-dimensional structure of rhuIL-4 provided preliminary evidence for a model of receptor interaction involving the formation of a ternary complex consisting of two molecules of the extracellular portion of the receptor and one molecule of rhuIL-4.

Why does nursing need theory?

The last 25 years have witnessed a growing support for and recognition of the importance of nursing theory, both in education and practice. This paper seeks to explore this movement, and also the issues in theory development, study and application. Definitions of theory are reviewed, and linked to the purpose of theory and theory development in nursing. The origins and motivation for developing nursing theory are identified, and arguments for the use of theory in nursing are raised. Further questions from the discussion of these issues are identified, questions likely to provide continued debate and investigation within the profession for decades to come.

Treatment of fractures of the medial epicondyle of the humerus

Forty-three children with a fracture of the medial epicondyle were reviewed; 20 had had non-operative treatment and 23 had been treated by operation. Any final disability was slight, irrespective of the treatment used. Although surgery was more likely to restore the fragment to its normal position (P = 0.0001) and achieve bony union (P = 0.04), minor symptoms were less common in the non-operatively treated group (P = 0.02). Instability of the elbow could not be demonstrated in any of the patients. It is recommended that operative treatment is employed only when an intra-articular fragment cannot be removed from the joint by manipulation.

Salmonella virchow osteomyelitis. A case report

A case of salmonella osteomyelitis of the spine complicated by meningitis after needle biopsy is described. The importance of obtaining definitive bacteriological diagnosis in bone infection is emphasised and the changing pattern of salmonella infection discussed.

The control of chiasma formation in colchicine treated meiocytes of Senecio squalidus

Colchicine induced multivalent formation is used to examine the effects of multivalent formation on chiasma frequency in Senecio squalidus. The increases observed are interpreted as the results of increases in numbers of pairing segments or decreases of chiasma interference following pairing partner exchange.

Reviewing RAWP. Variations in admission rates: implications for equitable allocation of resources

The review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board has considered the method used to account for cross boundary flows between health authorities. There is no consensus on how this should be done subregionally, as it raises the unresolved problem of the best method of estimating the size of catchment populations. Different methods produce different population sizes when the admission rates of individuals living in different districts vary. The National Health Service/Department of Health and Social Security acute services working group on performance indicators recently considered the assumptions made by different methods in terms of admission thresholds set by hospital clinicians. More complicated methods of assessing catchment areas seem to offer little advantage over the simplest method, but none of the methods answer the underlying questions of what truly determines admission rates and whether higher admission rates are better than lower ones. Empirical research into variations in admission rates and their relation to outcomes is important for determining the fair allocation of resources in future.

Gender roles and female drinking-driving

Using roadside survey data on 2044 drivers in a southern metropolitan community, the potential of gender roles for explaining the role behavior of female drinking drivers was examined. Although female drinking drivers are like female nondrinking drivers in previous driving and drinking-driving experiences, overall they are more like male drinking drivers. Both female and male drinking drivers tend to drive in similar places and to be on the roads at similar times and days. They also carry similar numbers and types of passengers. The greater similarity of female drinking drivers to male drinking drivers than to nondrinking female drivers suggests caution in leaning too heavily on gender roles as explanations of female drinking-driving behavior.

Multiple regulatory elements in the intergenic region between the alpha-fetoprotein and albumin genes

Three enhancer elements spanning a distance of 7 kilobases have been found at the 5' end of the alpha-fetoprotein (AFP) gene. These elements were identified by transient expression assay after the introduction of a modified mouse AFP gene with variable amounts of 5' flanking sequence into a human hepatoma cell line, Hep G2. These regulatory elements function in a position-independent and orientation-independent manner that is typical of enhancers. All three elements will stimulate transcription from the promoter of the herpes simplex virus thymidine kinase gene. In Hep G2 cells, transcriptional activation from the heterologous promoter was approximately 25- to 50-fold higher than the basal levels obtained in the absence of AFP enhancer elements. In HeLa cells, the increase in thymidine kinase gene transcription varied from 6- to 14-fold, indicating that the enhancer elements exhibit some cell type specificity. Deletion analysis of the region proximal to the AFP transcription initiation site identified an essential region between 85 and 52 bases upstream of the site of initiation of transcription whose removal resulted in almost complete extinction of transcriptional activity. This region, which has been shown to be dispensable for transcription in HeLa cells, defines a second tissue-specific regulatory region in the gene.

Nonhomogeneous alveolar pressure swings: effect of different respiratory muscles

We tested the hypothesis in dogs that during isovolumic inspiratory efforts the degree of nonhomogeneity of alveolar pressure changes is influenced by regional differences in respiratory muscle activity. Pressure distal to an occluded right lower lobe bronchus (PRLL) was compared with pressure in the occluded airway opening (PaO) during spontaneous inspiratory efforts (S), during right (RP), left (LP), and bilateral (BP) phrenic nerve stimulation, and during spontaneous inspiratory efforts after cutting both phrenic nerves (SCP), Upper and lower rib cage and abdominal dimensional changes were monitored by magnetometers. PRLL was greater than Pao during S and the difference was greater during BP and greater during RP, whereas with LP and SCP Pao exceeded PRLL. Compared with S, during RP, LP, and BP there was greater upper rib cage inward motion relative to abdominal outward motion. SCP resulted in opposite upper rib cage-abdomen relative motions. Thus activities of various muscle groups produced different regional pressures and deformations of rib cage and abdomen. These results may relate to potential errors in plethysmographic determination of thoracic gas volume in the presence of airway closure.