Evaluation of a New 'Mix-In' Style Glycomacropeptide-Based Protein Substitute for Food and Drinks in Patients with Phenylketonuria and Tyrosinemia

(1) Background: Poor palatability, large volume, and lack of variety of some liquid and powdered protein substitutes (PSs) for patients with phenylketonuria (PKU) and tyrosinemia (TYR) can result in poor adherence. This study aimed to evaluate a new unflavoured, powdered GMP-based PS designed to be mixed into drinks, foods, or with other PSs, in patients with PKU and TYR. (2) Methods: Paediatric and adult community-based patients were recruited from eight metabolic centres and prescribed ≥1 sachet/day (10 g protein equivalent (PE)) of the Mix-In-style PS over 28 days. Adherence, palatability, GI tolerance, and metabolic control were recorded at baseline and follow-up. Patients who completed at least 7 days of intervention were included in the final analysis. (3) Results: Eighteen patients (3-45 years, nine males) with PKU (n = 12) and TYR (n = 6) used the Mix-In-style PS for ≥7 days (mean 26.4 days (SD 4.6), range 11-28 days) alongside their previous PS, with a mean intake of 16.7 g (SD 7.7) PE/day. Adherence was 86% (SD 25), and GI tolerance was stable, with n = 14 experiencing no/no new symptoms and n = 3 showing improved symptoms compared to baseline. Overall palatability was rated satisfactory by 78% of patients, who successfully used the Mix-In-style PS in various foods and drinks, including smoothies, squash, and milk alternatives, as a top-up to meet their protein needs. There was no concern regarding safety/metabolic control during the intervention. (4) Conclusions: The 'Mix-In'-style PS was well adhered to, accepted, and tolerated. Collectively, these data show that providing a flexible, convenient, and novel format of PS can help with adherence and meet patients' protein needs.

Evaluation of a New Glycomacropeptide-Based Protein Substitute in Powdered and Liquid Format in Patients with PKU

(1) Background: Good adherence to a Phe-restricted diet supplemented with an adequate amount of a protein substitute (PS) is important for good clinical outcomes in PKU. Glycomacropeptide (cGMP)-PSs are innovative, palatable alternatives to amino acid-based PSs (AA-PS). This study aimed to evaluate a new cGMP-PS in liquid and powder formats in PKU. (2) Methods: Children and adults with PKU recruited from eight centres were prescribed at least one serving/day of cGMP-PS for 7-28 days. Adherence, acceptability, and gastrointestinal tolerance were recorded at baseline and the end of the intervention. The blood Phe levels reported as part of routine care during the intervention were recorded. (3) Results: In total, 23 patients (powder group, n = 13; liquid group, n = 10) completed the study. The majority assessed the products to be palatable (77% of powder group; 100% of liquid group) and well tolerated; the adherence to the product prescription was good. A total of 14 patients provided blood Phe results during the intervention, which were within the target therapeutic range for most patients (n = 11) at baseline and during the intervention. (4) Conclusions: These new cGMP-PSs were well accepted and tolerated, and their use did not adversely affect blood Phe control.

Are women with gestational diabetes being screened for type 2 diabetes following pregnancy? A nationwide retrospective cohort study in Aotearoa New Zealand

AIM

To estimate the proportion of women with a first episode of gestational diabetes mellitus (GDM) in Aotearoa (New Zealand) who received postpartum screening for type 2 diabetes mellitus (T2DM).

METHODS

Data from 941,468 pregnancies occurring between 2005 and 2015 were linked with laboratory, community pharmacy, and hospital discharge data from the Ministry of Health's National Collections to identify a cohort of women who had a first episode of GDM (n = 14,443). Proportions receiving a glycated haemoglobin (HbA1c) test or oral glucose tolerance test (OGTT) during the first year postpartum were estimated overall, and by calendar year, ethnic group, age, deprivation, and region.

RESULTS

Overall, 40.9% (95% CI 40.1-41.7%) received an HbA1c test or OGTT within 3 months, 53.3% (52.5-54.1%) within 6 months, and 61.0% (60.2-61.8%) within 12 months postpartum. Screening proportions within 12 months were stable over time. Indigenous Māori were less likely to receive screening within 6 months postpartum (35.0% [33.1-37.0%]) than other ethnic groups, as were younger women and those with higher deprivation. There were marked variations by region (between 15.3% and 67.5%).

CONCLUSION

Postpartum T2DM screening was low over the period studied, with substantial ethnic and regional inequities across New Zealand.

Antidepressant dispensing before, during, and after pregnancy in New Zealand, 2005-2014

BACKGROUND

Depression during pregnancy is associated with a number of negative impacts on maternal and infant health, therefore good control of depression in pregnant women is crucial. There is a lack of population-level information about patterns of antidepressant use during pregnancy in New Zealand.

AIM

To describe antidepressant dispensing patterns before, during, and after pregnancy in New Zealand, 2005-2014.

MATERIALS AND METHODS

Antidepressant dispensing records from 270 days prior to pregnancy through to 360 days after pregnancy end were linked with 805 990 pregnancies in the New Zealand Pregnancy Cohort. Proportions (and 95% confidence intervals) with at least one dispensing were calculated for the periods before, during, and after pregnancy and compared over time and by maternal characteristics.

RESULTS

Dispensing during the first trimester was lower than in the pre-pregnancy and post-pregnancy periods, and dropped further in later trimesters. The proportion of pregnancies during which an antidepressant was dispensed rose from 3.1 to 4.9% over the study years. Around 80% of those with a dispensing received a selective serotonin reuptake inhibitor. Dispensing before, during, and after pregnancy varied by ethnicity, age, smoking status, and body mass index. Among women taking an antidepressant before pregnancy, younger women and those of Māori, Pacific, or Asian ethnicity were less likely to continue therapy during pregnancy.

CONCLUSIONS

This study has established a baseline for antidepressant use around pregnancy in New Zealand, documented increasing use over time, and demonstrated that known ethnic differences in antidepressant use are also evident in the pregnant population.

Engineering an Effective Human SNAP-23 Cleaving Botulinum Neurotoxin A Variant

Botulinum neurotoxin (BoNT) serotype A inhibits neurotransmitter release by cleaving SNAP-25 and represents an established pharmaceutical for treating medical conditions caused by hyperactivity of cholinergic nerves. Oversecretion from non-neuronal cells is often also the cause of diseases. Notably, excessive release of inflammatory messengers is thought to contribute to diseases such as chronic obstructive pulmonary disease, asthma, diabetes etc. The expansion of its application to these medical conditions is prevented because the major non-neuronal SNAP-25 isoform responsible for exocytosis, SNAP-23, is, in humans, virtually resistant to BoNT/A. Based on previous structural data and mutagenesis studies of SNAP-23 we optimized substrate binding pockets of the enzymatic domain for interaction with SNAP-23. Systematic mutagenesis and rational design yielded the mutations E148Y, K166F, S254A, and G305D, each of which individually increased the activity of LC/A against SNAP-23 between 3- to 23-fold. The assembled quadruple mutant showed approximately 2000-fold increased catalytic activity against human SNAP-23 in in vitro cleavage assays. A comparable increase in activity was recorded for the full-length BoNT/A quadruple mutant tested in cultivated primary neurons transduced with a fluorescently tagged-SNAP-23 encoding gene. Equipped with a suitable targeting domain this quadruple mutant promises to complete successfully tests in cells of the immune system.

Patterns of prescription medicine dispensing before and during pregnancy in New Zealand, 2005-2015

Objective

To describe prescription medicine dispensing before and during pregnancy in New Zealand, 2005–2015.

Methods

Members of the New Zealand Pregnancy Cohort were linked with their dispensing records in a national database of prescription products dispensed from community pharmacies. We identified the proportion of pregnancies during which at least one prescription medicine was dispensed, the number of different medicines used and the most commonly dispensed medicine groups both during pregnancy and in the 270 days before conception. Dispensing during pregnancy was assessed by several maternal characteristics.

Results

874,884 pregnancies were included. Over the study timeframe, the proportion of pregnancies exposed to a non-supplement prescription medicine increased from 38.5% to 67.2%. The mean number of different non-supplement medicines dispensed during pregnancy increased from 2.5 to 3.2. Dispensing during pregnancy was weakly associated with body mass index, smoking status and ethnicity. Pregnancy exposure was highest for Antibacterials (26.0%), Analgesics (16.7%) and Antinausea & Vertigo Agents (11.0%).

Conclusions

From 2005–2015, both the proportion of exposed pregnancies and the number of different medicines dispensed to pregnant women in New Zealand increased.

Nutritional and Metabolic Characteristics of UK Adult Phenylketonuria Patients with Varying Dietary Adherence

The nutritional and metabolic characteristics of adult phenylketonuria (PKU) patients in the UK with varying dietary adherence is unknown. In other countries, nutritional and metabolic abnormalities have been reported in nonadherent patients compared to adherent counterparts. A pooled analysis of primary baseline data from two UK multi-centre studies was therefore performed to establish whether this is true from a UK perspective. Adult PKU patients who had provided 3-day food records and amino acid blood samples were included and grouped according to dietary adherence (adherent; n = 16 vs. nonadherent; n = 14). Nonadherent patients consumed greater amounts of natural protein compared to adherent patients (61.6 ± 30.7 vs. 18.3 ± 7.7 g/day; q < 0.001). In contrast, the contribution of protein substitutes to total protein intake was lower in nonadherent compared to adherent patients (3.9 ± 9.2 g/day vs. 58.6 ± 10.2 g/day; q < 0.001). Intakes of iron, zinc, vitamin D₃, magnesium, calcium, selenium, iodine, vitamin C, vitamin A and copper were significantly lower in nonadherent compared to adherent patients and were below UK Reference Nutrient Intakes. Similarly, intakes of thiamin, riboflavin, niacin, vitamin B₆ and phosphorus were significantly lower in nonadherent compared to adherent patients but met the UK Reference Nutrient Intakes. Phenylalanine concentrations in nonadherent patients were significantly higher than adherent patients (861 ± 348 vs. 464 ± 196 µmol/L; q=0.040) and fell outside of European treatment target ranges. This study shows the nutritional and metabolic consequences of deviation from phenylalanine restriction and intake of PKU protein substitutes in nonadherent adult PKU patients. Collectively, these data further underlie the importance of life-long adherence to the PKU diet.

Efficacy and safety of inhaled anaesthetic for postoperative sedation during mechanical ventilation in adult cardiac surgery patients: a systematic review and meta-analysis

The aim was to evaluate the efficacy and safety of volatile anaesthetic for postoperative sedation in adult cardiac surgery patients through a systematic review and meta-analysis. We retrieved randomized controlled trials from MEDLINE, EMBASE, CENTRAL, Web of Science, clinical trials registries, conference proceedings, and reference lists of included articles. Independent reviewers extracted data, including patient characteristics, type of intraoperative anaesthesia, inhaled anaesthetic used, comparator sedation, and outcomes of interest, using pre-piloted forms. We assessed risk of bias using the Cochrane Tool and evaluated the strength of the evidence using the GRADE approach. Eight studies enrolling 610 patients were included. Seven had a high and one a low risk of bias. The times to extubation after intensive care unit (ICU) admission and sedation discontinuation were, respectively, 76 [95% confidence interval (CI) -150 to - 2, I2=79%] and 74 min (95% CI - 126 to - 23, I2=96%) less in patients who were sedated using volatile anaesthetic. There was no difference in ICU or hospital length of stay. Patients who received volatile anaesthetic sedation had troponin concentrations that were 0.71 ng ml-1 (95% CI 0.23-1.2) lower than control patients. Reporting on other outcomes was varied and not suitable for meta-analysis. Volatile anaesthetic sedation may be associated with a shorter time to extubation after cardiac surgery but no change in ICU or hospital length of stay. It is associated with a significantly lower postoperative troponin concentration, but the impact of this on adverse cardiovascular outcomes is uncertain. Blinded randomized trials using intention-to-treat analysis are required. PROSPERO registry number: 2016:CRD42016033874. Available from http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016033874.

A comparison of biological activity of commercially available purified native botulinum neurotoxin serotypes A1 to F1 in vitro, ex vivo, and in vivo

Botulinum neurotoxin (BoNT) is a major therapeutic agent. Of seven native BoNT serotypes (A to G), only A and B are currently used in the clinic. Here we compared the potency of commercially available purified native serotypes A1 to F1 across in vitro, ex vivo, and in vivo assays. BoNT potency in vitro was assessed in rat primary cells (target protein cleavage and neurotransmitter release assays) in supraspinal, spinal, and sensory systems. BoNT potency ex vivo was measured in the mouse phrenic nerve hemidiaphragm (PNHD) assay, measuring muscle contractility. In vivo, BoNT-induced muscle relaxation in mice and rats was assessed in the Digit Abduction Score (DAS) test, while effects on body weight (BW) gain were used to assess tolerability. In all assays, all BoNT serotypes were potent toxins, except serotype D1 in vivo which failed to produce significant muscle flaccidity in mice and rats. In rats, all serotypes were well-tolerated, whereas in mice, reductions in BW were detected at high doses. Serotype A1 was the most potent serotype across in vitro, ex vivo, and in vivo assays. The rank order of potency of the serotypes revealed differences among assays. For example, species-specificity was seen for serotype B1, and to a lesser extent for serotype C1. Serotypes F1 and C1, not currently in the clinic, showed preference for sensory over motor models and therefore could be considered for development in conditions involving the somatosensory system.

Generation of a pregnancy cohort for medicine utilisation and medicine safety studies in New Zealand

PURPOSE

The aim of this study was to use national health databases to assemble a pregnancy cohort for undertaking medicine utilisation and safety studies in New Zealand.

METHOD

Pregnancies conceived between January 2005 and March 2015 were identified in the National Maternity Collection, the National Minimum Dataset, the Mortality Collection, and the Laboratory Claims Collection. Pregnancy start and end dates were calculated and used in conjunction with the National Health Index number to merge the records from the four collections to create the New Zealand Pregnancy Cohort. Records of live born and stillborn infants identified in the National Maternity Collection and the Mortality Collection that were linkable with a cohort member formed the baby cohort.

RESULTS

The cohort consists of 941 468 pregnancies to 491 272 women. One-third of the pregnancies, predominantly early pregnancy losses and terminations, were not found in the National Maternity Collection. Records of 632 090 live born or stillborn infants are linked with 623 099 pregnancies.

CONCLUSIONS

The New Zealand Pregnancy Cohort is a comprehensive collection of virtually all pregnancies which ended in a live or stillbirth and many, though not all, which ended as early pregnancy losses or terminations in New Zealand over the past decade, and better represents the pregnant population than a cohort generated from the National Maternity Collection alone would do. This cohort will be valuable for investigating patterns of medicine use during pregnancy in New Zealand and developing a fuller understanding of potential impacts of foetal exposure in early pregnancy.

Botulinum neurotoxin A and an engineered derivate targeted secretion inhibitor (TSI) A enter cells via different vesicular compartments

Botulinum neurotoxins (BoNTs) are highly potent multi-domain proteins, responsible for botulism in animals and humans. The modular structural organization of BoNTs has led to the development of novel engineered bio-therapeutic proteins called targeted secretion inhibitors (TSIs). We report here that botulinum neurotoxin A (BoNT/A) and a TSI/A in which the neuronal binding domain of BoNT/A has been substituted by an epidermal growth factor (EGF) ligand, named EGFR-targeted TSI/A, exploit different routes to gain entry in the same in vitro neuroblastoma cell system, SiMa cells. We found that the EGF ligand conferred the affinity to the EGFR-targeted TSI/A at the EGF receptor when compared to an untargeted TSI/A and also the ability to internalize into the cells and cleave its cytosolic target protein SNAP-25. Using high content analysis we found that both BoNT/A and the EGFR-targeted TSI/A enter the cell in a concentration-dependent manner and in compartments which are able to translocate the proteins into the cytosol within 4 h. The EGFR-targeted TSI/A internalized into a compartment which gave a punctate staining pattern by immunofluorescence and partially overlapped with structures positive for the early endosomal marker EAA1; whereas BoNT/A did not internalize into a punctate compartment but did so in an acidifying compartment consistent with local synaptic vesicle recycling. These findings show that the BoNT/A translocation domain, common to both BoNT/A and the EGFR-targeted TSI/A, is a versatile tool for cytosolic delivery from distinct intracellular vesicular compartments.

How strict is galactose restriction in adults with galactosaemia? International practice

Dietary management of 418 adult patients with galactosaemia (from 39 centres/12 countries) was compared. All centres advised lactose restriction, 6 restricted galactose from galactosides ± fruits and vegetables and 12 offal. 38% (n=15) relaxed diet by: 1) allowing traces of lactose in manufactured foods (n=13) or 2) giving fruits, vegetables and galactosides (n=2). Only 15% (n=6) calculated dietary galactose. 32% of patients were lost to dietetic follow-up. In adult galactosaemia, there is limited diet relaxation.

Impact of community based peer support in type 2 diabetes: a cluster randomised controlled trial of individual and/or group approaches

Background

Diabetes peer support, where one person with diabetes helps guide and support others, has been proposed as a way to improve diabetes management. We have tested whether different diabetes peer support strategies can improve metabolic and/or psychological outcomes.

Methods

People with type 2 diabetes (n = 1,299) were invited to participate as either ‘peer’ or ‘peer support facilitator’ (PSF) in a 2x2 factorial randomised cluster controlled trial across rural communities (130 clusters) in England. Peer support was delivered over 8–12 months by trained PSFs, supported by monthly meetings with a diabetes educator. Primary end point was HbA1c. Secondary outcomes included quality of life, diabetes distress, blood pressure, waist, total cholesterol and weight. Outcome assessors and investigators were masked to arm allocation. Main factors were 1:1 or group intervention. Analysis was by intention-to-treat adjusting for baseline.

Results

The 4 arms were well matched (Group n = 330, 1:1(individual) n = 325, combined n = 322, control n = 322); 1035 (79•7%) completed the mid-point postal questionnaire and 1064 (81•9%) had a final HbA1c. A limitation was that although 92.6% PSFs and peers were in telephone contact, only 61.4% of intervention participants attended a face to face session. Mean baseline HbA1c was 57 mmol/mol (7•4%), with no significant change across arms. Follow up systolic blood pressure was 2•3mm Hg (0.6 to 4.0) lower among those allocated group peer-support and 3•0mm Hg (1.1 to 5.0) lower if the group support was attended at least once. There was no impact on other outcomes by intention to treat or significant differences between arms in self-reported adherence or medication.

Conclusions

Group diabetes peer support over 8–12 months was associated with a small improvement in blood pressure but no other significant outcomes. Long term benefits should be investigated.

Trial Registration

ISRCTN.com ISRCTN6696362166963621

Body mass index in adult patients with diet-treated phenylketonuria

BACKGROUND

There is an increasing number of adults with phenylketonuria (PKU) on a low phenylalanine diet. In the general population, an increasing body mass index (BMI) in the UK is a major problem with associated co-morbidities. The present study aimed to identify whether patients with diet-treated PKU have obesity rates comparable to those in the general population.

METHODS

Two hundred and thirty-six PKU subjects (49% male, 51% female), aged >16 years, who were diagnosed by newborn screening and were receiving a low phenylalanine diet, were identified from seven metabolic centres in the UK. Retrospective data were collated on age, sex, BMI and mean phenylalanine concentration over the previous 12 months.

RESULTS

Mean (SD) phenylalanine concentration for all 236 subjects was 789 (311) μm; mean (SD) BMI was 26 (5.4) kg m(-2) [males 25 (4.3) kg m(-2) , females 27 (6.2) kg m(-2) ]; mean (SD) age was 26 (7) years; and 55% had a BMI > 25 kg m(-2) . The percentage of subjects with a BMI >25 kg m(-2) and >30 kg m(-2) , as well as increasing obesity with age, was similar to the UK population. A correlation was observed between increasing BMI and a higher phenylalanine concentration (r = 0.243, P = 0.001).

CONCLUSIONS

The number of overweight and obese patients with diet-treated PKU in the UK is a concern. This could lead to other obesity-related complications increasing the complexity of diet and the cost of their care. There is a need to educate patients with respect to adopting a healthy, low phenylalanine diet and lifestyle to prevent further rises in BMI.

Testing a peer support intervention for people with type 2 diabetes: a pilot for a randomised controlled trial

BACKGROUND

People with Type 2 diabetes face various psycho-social, self-management and clinical care issues and evidence is mixed whether support from others with diabetes, 'peer support', can help. We now describe a 2 month pilot study of different peer support interventions.

METHODS

The intervention was informed by formative evaluation using semi-structured interviews with health professionals, community support groups and observation of diabetes education and support groups. Invitations to participate were mailed from 4 general practices and included a survey of barriers to care. Participants were randomized by practice to receive individual, group, combined (both individual and group) or no peer support. Evaluation included ethnographic observation, semi-structured interviews and questionnaires at baseline and post-intervention.

RESULTS

Of 1,101 invited, 15% expressed an interest in participating in the pilot. Sufficient numbers volunteered to become peer supporters, although 50% of these (8/16) withdrew. Those in the pilot were similar to other patients, but were less likely to feel they knew enough about diabetes (60.8% vs 44.6% p = 0.035) and less likely to be happy with the diabetes education/care to date (75.4% vs 55.4% p = 0.013). Key issues identified were the need to recruit peer supporters directly rather than through clinicians, to address participant diabetes educational needs early and the potential for group sessions to have lower participation rates than 1:1 sessions.

CONCLUSIONS

Recruitment to a full trial of peer support within the existing study design is feasible with some amendments. Attendance emerged as a key issue needing close monitoring and additional intervention during the trial.

Successful use of acarbose to manage post-prandial glycaemia in two patients with type 1 diabetes on continuous subcutaneous insulin infusion

Post-prandial hyperglycaemia is a particular problem for some patients with diabetes despite administering continuous subcutaneous insulin infusion (CSII) to deliver insulin flexibly. We describe two cases of patients on CSII with persistent post-prandial hyperglycaemia despite varying insulin doses and timing. Treatment with acarbose improved their glycaemic control.

Reduced insulin requirements during participation in the DAFNE (dose adjustment for normal eating) structured education programme

Dose adjustment for normal eating (DAFNE) is a well-established structured education programme for patients with type 1 diabetes. We conducted a retrospective analysis of insulin dose changes associated with DAFNE training. Our results show significant reductions in total, quick acting and basal insulin doses in patients undergoing DAFNE training.

P-Rex1 and Vav1 cooperate in the regulation of formyl-methionyl-leucyl-phenylalanine-dependent neutrophil responses

G protein-coupled receptor (GPCR) activation elicits neutrophil responses such as chemotaxis and reactive oxygen species (ROS) formation, which depend on the small G protein Rac and are essential for host defense. P-Rex and Vav are two families of guanine-nucleotide exchange factors (GEFs) for Rac, which are activated through distinct mechanisms but can both control GPCR-dependent neutrophil responses. It is currently unknown whether they play specific roles or whether they can compensate for each other in controlling these responses. In this study, we have assessed the function of neutrophils from mice deficient in P-Rex and/or Vav family GEFs. We found that both the P-Rex and the Vav family are important for LPS priming of ROS formation, whereas particle-induced ROS responses and cell spreading are controlled by the Vav family alone. Surprisingly, fMLF-stimulated ROS formation, adhesion, and chemotaxis were synergistically controlled by P-Rex1 and Vav1. These responses were more severely impaired in neutrophils lacking both P-Rex1 and Vav1 than those lacking the entire P-Rex family, the entire Vav family, or both P-Rex1 and Vav3. P-Rex1/Vav1 (P1V1) double-deficient cells also showed the strongest reduction in fMLF-stimulated activation of Rac1 and Rac2. This reduction in Rac activity may be sufficient to cause the defects observed in fMLF-stimulated P1V1 neutrophil responses. Additionally, Mac-1 surface expression was reduced in P1V1 cells, which might contribute further to defects in responses involving integrins, such as GPCR-stimulated adhesion and chemotaxis. We conclude that P-Rex1 and Vav1 together are the major fMLFR-dependent Dbl family Rac-GEFs in neutrophils and cooperate in the control of fMLF-stimulated neutrophil responses.

Differential survival after prostate cancer by race: Role of NCI-designated comprehensive cancer centers

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Background: A significant gap exists between Caucasians and African-Americans (AAs) in prostate cancer mortality, possibly due to sociodemographics, disease biology, or treatment. Furthermore, differential access to care at NCI-designated Comprehensive Cancer Centers (NCICCCs) conceivably contributes to this difference. Methods: Using data from the Los Angeles Cancer Surveillance Program, we studied the underlying causes of differences in mortality in 18,790 men (AAs: 4,211; Caucasians: 14,579) diagnosed with prostate cancer between 1998 and 2003, and followed until 2006. Three NCICCCs serve this area: USC-Norris, UCLA-Jonsson, and City of Hope. Results: Median age at diagnosis was 67.5 yrs; AAs were significantly more likely to have lower SES; carry no insurance; have distant disease; and be managed with “watchful waiting.” The overall and prostate-specific survival was significantly superior for patients treated at NCICCCs, and for Caucasians (Table). Multivariate analysis, after adjustment for sociodemographics, race, insurance, tumor-related factors, and treatment-modality, revealed that treatment at NCICCCs was associated with lower overall (HR=0.74, 95% CI=0.6–0.9) and prostate-specific mortality (HR=0.69, 95% CI=0.5–0.97). AAs were less likely to utilize NCICCCs (OR=0.42, 95%CI=0.4–0.5). Finally, adjustment for sociodemographic, tumor/treatment-related factors, and treatment site abrogated the racial difference in overall (HR=1.08, 95%CI=0.99–1.2) and prostate-specific (HR=1.11, 95%CI=0.9–1.3) mortality. Conclusions: Patients treated at NCICCCs have lower mortality compared with other facilities. AAs are less likely to utilize NCICCCs for prostate cancer. AAs and Caucasians have comparable overall and prostate-specific survival, after adjustment for sociodemographic, tumor/treatment-related factors, and treatment site. Future studies are needed to understand barriers and facilitators to utilization of NCICCCs for management of prostate cancer.

[Table: see text]

No significant financial relationships to disclose.

Gastroenterology service in a teaching hospital in rural New Zealand, 1991-2003

AIM: To retrospectively collect inpatient and outpatient data and to assess the use of endoscopic procedures during the years 1991, 1997 and 2003 to analyse for trends.

METHODS: This retrospective survey was conducted in a University-associated Gastroenterology Unit offering secondary and tertiary health care services for a population of approximately 182 000 people in Southern New Zealand. Data collected included patient contacts (in- and outpatients), gastroscopic and colonoscopic investigations.

RESULTS: We observed a significant increase in the absolute numbers of patient contacts over the years (1991: 2308 vs 1997: 2022 vs 2003: 2783, P < 0.0001) with inflammatory bowel disease, other diseases of the colon, anus and rectum and iron studies related disorders decreasing significantly but liver disease and constipation increasing linearly over time. The use of endoscopy services remained relatively stable but colonoscopic investigations for a positive family history of colorectal cancer increased significantly while more gastroscopies were performed for unexplained anaemia.

CONCLUSION: The whole spectrum of gastroenterology contacts was studied. A substantial proportion of colonoscopies and outpatient consultations were undertaken to screen for colorectal cancer. This proportion is likely to grow further. Our findings have implications for the recruitment and training of the next generation of gastroenterologists.

Evaluation of use of cellphones to aid compliance with drug therapy for HIV patients

Key to the care of people living with HIV is effective data on use of ARVs, their responses to the medication and additional needs. An adaptation of cellphone technology by Cell-Life provides an easy-to-use data capturing devise for use by therapeutic counsellors (home based carers). Individual in-depth interviews were conducted with all the counsellors using the technology at two points in time, six months apart. The technology was found to be easy to use, especially for those who had previously used a cellphone. It eased data collection considerably and reduced fears around loosing notes. Improvements in technology between the two sets of interviews showed responsiveness from Cell-Life to the users of the technology. The patients also responded well to the technology, feeling that it improved their treatment. The major concern for home-based carers was the risk of crime due to having a cellphone, which led to the therapeutic counsellors eventually leaving the cellphones at home when visiting patients and entering the data at a later point. While the carers initially felt that the technology was an intrusion in their lives they later adapted to it.

Membrane translocation of P-Rex1 is mediated by G protein betagamma subunits and phosphoinositide 3-kinase

P-Rex1 is a guanine-nucleotide exchange factor (GEF) for the small GTPase Rac that is directly activated by the betagamma subunits of heterotrimeric G proteins and by the lipid second messenger phosphatidylinositol (3,4,5)-trisphosphate (PIP(3)), which is generated by phosphoinositide 3-kinase (PI3K). Gbetagamma subunits and PIP(3) are membrane-bound, whereas the intracellular localization of P-Rex1 in basal cells is cytosolic. Activation of PI3K alone is not sufficient to promote significant membrane translocation of P-Rex1. Here we investigated the subcellular localization of P-Rex1 by fractionation of Sf9 cells co-expressing P-Rex1 with Gbetagamma and/or PI3K. In basal, serum-starved cells, P-Rex1 was mainly cytosolic, but 7% of the total was present in the 117,000 x g membrane fraction. Co-expression of P-Rex1 with either Gbetagamma or PI3K caused only an insignificant increase in P-Rex1 membrane localization, whereas Gbetagamma and PI3K together synergistically caused a robust increase in membrane-localized P-Rex1 to 23% of the total. PI3K-driven P-Rex1 membrane recruitment was wortmannin-sensitive. The use of P-Rex1 mutants showed that the isolated Dbl homology/pleckstrin homology domain tandem of P-Rex1 is sufficient for synergistic Gbetagamma- and PI3K-driven membrane localization; that the enzymatic GEF activity of P-Rex1 is not required for membrane translocation; and that the other domains of P-Rex1 (DEP, PDZ, and IP4P) contribute to keeping the enzyme localized in the cytosol of basal cells. In vitro Rac2-GEF activity assays showed that membrane-derived purified P-Rex1 has a higher basal activity than cytosol-derived P-Rex1, but both can be further activated by PIP(3) and Gbetagamma subunits.

P-Rex2, a new guanine-nucleotide exchange factor for Rac

We have identified a new guanine-nucleotide exchange factor, P-Rex2, and cloned it from human skeletal muscle and brain libraries. It has widespread tissue distribution but is not expressed in neutrophils. P-Rex2 is a 183 kDa protein that activates the small GTPase Rac and is regulated by phosphatidylinositol (3,4,5)-trisphosphate and the beta gamma subunits of heterotrimeric G proteins in vitro and in vivo. P-Rex2 has structure, activity and regulatory properties similar to P-Rex1 but has divergent tissue distribution, as P-Rex1 is mainly expressed in neutrophils. Together, they form an enzyme family capable of mediating Rac signalling downstream of G protein-coupled receptors and phosphoinositide 3-kinase.

Dietary agent indole-3-carbinol protects female rats against the hepatotoxicity of the antitumor drug ET-743 (trabectidin) without compromising efficacy in a rat mammary carcinoma

ET-743, an experimental antitumor drug with promising activity in sarcoma, breast and ovarian carcinoma, is currently under phase 2 clinical evaluation. It is hepatotoxic in animals and patients. We tested the hypothesis that indole-3-carbinol (I3C), the hydrolysis product of glucosinolates occurring in cruciferous vegetables, may protect against ET-743-induced hepatotoxicity in the female Wistar rat, the animal species with the highest sensitivity toward the adverse hepatic effect of this drug. Hepatotoxicity was adjudged by measurement of plasma levels of bilirubin, alkaline phosphatase (ALP) and aspartate aminotransferase (AST) and by liver histopathology. The effect of I3C on the kinetics of ET-743 in rat plasma and liver was investigated by high-pressure liquid chromatography. The effect of I3C on the antitumor efficacy of ET-743 was explored in rats bearing the 13762 mammary carcinoma. ET-743 (40 microg/kg i.v.) alone caused an elevation of plasma bilirubin, ALP and AST levels and degeneration and patchy focal necrosis of bile duct epithelial cells. Addition of I3C to the diet (0.5%) for 6 days prior to ET-743 administration almost completely abolished manifestations of hepatotoxicity. In contrast, a dietary concentration of 0.1% I3C did not protect, nor did dietary diindolylmethane (0.2%), an acid-catalyzed condensation product of I3C. Ingestion by rats of I3C for 6 days prior to ET-743 (40 microg/kg i.v.) decreased plasma but not hepatic concentrations of ET-743 compared to animals that received ET-743 alone. I3C did not interfere with the antitumor efficacy of ET-743. The results suggest that ingestion of I3C may counteract the unwanted effect of ET-743 in the liver. I3C should be investigated as a hepatoprotectant in patients who receive ET-743 therapy.

Comparison of four modulators of drug metabolism as protectants against the hepatotoxicity of the novel antitumor drug yondelis (ET-743) in the female rat and in hepatocytes in vitro

PURPOSE

Yondelis (ET-743), a tetrahydroisoquinoline alkaloid isolated from a marine tunicate, is a novel drug with demonstrated anticancer activity in early clinical trials against sarcoma, breast and ovarian carcinoma. Yondelis has myelotoxic and hepatotoxic side effects, the latter reflected by reversible transaminitis and cholangitis. In the female rat pretreatment with high-dose dexamethasone has been shown to abrogate yondelis-mediated hepatotoxicity, an effect tentatively linked to its ability to induce cytochrome P450 CYP3A isoenzymes, which metabolize yondelis. Here we tested the hypothesis that pretreatment of rats with modulators of hepatic drug metabolism, beta-naphthoflavone, phenobarbitone or N-acetylcysteine, protect rat livers against the effects of yondelis.

METHODS

Female rats received yondelis (40 microg/kg intravenously) and liver damage in vivo was assessed in terms of changes in plasma levels of bilirubin, alkaline phosphatase (ALP) and aspartate aminotransferase (AST) and by histopathology. In order to investigate yondelis toxicity in vitro, hepatocytes isolated from untreated rats or from rats pretreated with dexamethasone, beta-naphthoflavone or phenobarbitone were maintained in culture and exposed to yondelis.

RESULTS

Pretreatment with beta-naphthoflavone and phenobarbitone ameliorated yondelis-mediated hepatotoxicity in vivo. The former abrogated plasma indicators on day 3, but hardly on day 6, and the latter suppressed elevation of bilirubin, but not of ALP or AST. Pretreatment with N-acetylcysteine did not protect from, but slightly exacerbated, yondelis-induced liver changes. Hepatocytes from naive animals or from pretreated rats did not differ in their susceptibility towards yondelis-induced cytotoxicity in vitro. Nor did inclusion of N-acetylcysteine (1 m M) in the cellular incubation medium affect yondelis-induced hepatocytotoxicity.

CONCLUSIONS

The results suggest that certain inducers of cytochrome P450 enzymes such as dexamethasone and beta-naphthoflavone can protect rat liver against the unwanted effects of yondelis, but such protection cannot be mimicked in in vitro experiments using liver cells in culture.

Complete protection by high-dose dexamethasone against the hepatotoxicity of the novel antitumor drug yondelis (ET-743) in the rat

Yondelis (ET-743) is a promising antitumor drug with hepatotoxic properties in animals and humans. Here the hypothesis was tested that dexamethasone can ameliorate manifestations of yondelis-induced hepatotoxicity in the female Wistar rat, which is the animal species with the highest sensitivity toward the adverse hepatic effect of yondelis. Hepatotoxicity was adjudged by measurement of plasma levels of alkaline phosphatase, aspartate aminotransferase, and bilirubin, and by liver histopathology. Yondelis (40 micro g/kg i.v.) alone caused a dramatic elevation of plasma alkaline phosphatase, aspartate aminotransferase, and bilirubin levels, and degeneration and patchy focal necrosis of bile duct epithelial cells. Pretreatment of rats with dexamethasone (5-20 mg/kg, p.o.) 24 h before yondelis ameliorated or abrogated the biochemical and histopathological manifestations of yondelis-induced liver changes. In contrast, when dexamethasone was administered simultaneously with yondelis, its toxicity was not reduced. Pretreatment with dexamethasone (10 mg/kg) also reversed the gene expression changes induced by yondelis in rat liver. However, dexamethasone pretreatment did not interfere with the antitumor efficacy of yondelis in rats bearing the 13762 mammary carcinoma or in four murine models. Dexamethasone (10 mg/kg) administered 24 h before yondelis decreased hepatic levels of yondelis dramatically compared with those obtained after administration of yondelis alone, whereas yondelis plasma levels after the drug combination were not markedly different from those in rats on yondelis alone. The results suggest that pretreatment with high-dose dexamethasone effectively protects rats against yondelis-mediated hepatic damage by decreasing hepatic exposure to yondelis, perhaps linked to induction of metabolism by cytochrome P450 enzymes. Pretreatment with high-dose dexamethasone should be investigated in patients who receive yondelis to ameliorate its unwanted effect on the liver.

Hepatobiliary damage and changes in hepatic gene expression caused by the antitumor drug ecteinascidin-743 (ET-743) in the female rat

Ecteinascidin-743 (ET-743) is a novel marine-derived anticancer drug with clinical activity in soft tissue sarcoma and ovarian cancer. Reversible transaminitis and subclinical cholangitis have frequently been described in patients who receive ET-743. To facilitate understanding of this adverse effect and help design suitable therapeutic rescue strategies, we characterized the hepatic effects of ET-743 in rats. Female rats received ET-743 (single dose, 40 microg/kg) i.v., and liver changes were assessed from 6 h up to 3 months after dosing by histopathology, immunohistochemistry, electron microscopy, hepatic and plasma biochemistry, and DNA microarray analysis. At 24 h posttreatment and beyond, livers displayed degeneration and patchy focal necrosis of bile duct epithelial cells associated with mild inflammation followed by fibrosis. Sporadic and focal zones of hepatic necrosis and hemorrhage were observed from day 2 onward, although the majority of hepatocytes appeared normal as judged by electron microscopy. Pathological alterations persisted up to 3 months after dosing. Plasma levels of total bilirubin were elevated up to 7-fold over those in untreated rats from day 2 onward and returned to control values by day 24. Activities of alkaline phosphatase and aspartate aminotransferase in plasma were elevated for 2 and 3 months, respectively. Activities of the hepatic microsomal drug-metabolizing enzymes cytochrome P-450 A1/2, CYP2E1, and CYP3A2 were decreased. DNA microarray analysis of livers from ET-743-treated animals showed a dramatic increase in the expression of ATP binding cassette transport genes Abcb1a and Abcb1b, which impart resistance to anticancer drugs, and of Cdc2a and Ccnd1, the rodent homologues of human cell cycle genes CDC2 and cyclin D1, respectively. The cell cycle gene expression changes mirrored ET-743-induced increases in liver weight and Ki-67 labeling of liver nuclei. The results suggest that the toxicity exerted by ET-743 in the rat liver is a consequence of biliary rather than hepatocellular damage and that it is accompanied by a wave of mitogenic activity, which may be driven by the transcriptional increase in Cdc2a expression.

Mechanical closure of the vocal cords with the laryngeal mask airway ProSeal

We report a case of mechanical closure of the vocal cords with the laryngeal mask airway ProSeal (PLMA) in an anaesthetized, paralysed 59-yr-old, 88 kg female undergoing lower-limb vascular surgery. Near-complete airway obstruction developed after a size-5 PLMA was inserted and the cuff inflated with 20 ml of air. Fibreoptic inspection revealed that the PLMA was correctly positioned, but the vocal cords were closed. Withdrawal of air from the cuff and/or moving the head and neck into the sniffing position resolved this problem.

Role of juvenile hormone-esterase in mating-stimulated egg development in the moth Heliothis virescens

Juvenile hormone (JH) titer in virgin females of Heliothis virescens is significantly lower than that in mated females of the same age. The JH titer in virgin females follows a diel pattern in which it begins to increase towards the end of photophase, remains high around the onset of scotophase, and declines during scotophase. The titer reaches its lowest levels at the onset of photophase, and remains low during the first half of photophase. In mated females, the diel pattern of JH titers is not as pronounced. JH-esterase (JHE) activity in mated females is significantly lower than that of virgin females during photophase; JHE levels in the former are similar to levels seen in newly emerged females. JHE activity in mated females also exhibits a diel pattern, in which activity is low during photophase and high at the onset of scotophase. Evidence for the indirect involvement of JHE in the mating-stimulated egg development is provided by the effect of selected JHE inhibitors in inhibiting JHE activity and stimulating egg production in virgin females.

The food consumption patterns and perceptions of dietary advice of older people

BACKGROUND: Prevention policies do not have an upper age limit, and as the overwhelming majority of older people continue to reside in the community there is a growing role for community dietetics and primary care team members in the promotion of healthy eating. METHOD: The multi-method project ascertained the dietary beliefs and practices of older people residing in high-income, low-income and rural localities of Scotland. One hundred and fifty-two people aged 75 years and over were interviewed using a semistructured interview schedule and 24-h food recall questionnaire. RESULTS: An analysis of the food recall questionnaire demonstrated that the diets of the elderly appear to differ little from the Scottish population as a whole. In all groups there was an under consumption of fruits and vegetables reported. Findings from the interviews demonstrated that dietary beliefs were found to be firmly rooted in childhood and lifetime experiences. Participants defined healthy eating as 'proper meals', 'proper foods', and a variety of foods eaten in moderation. These definitions were based upon the consumption of fresh foods which would be considered healthy. Changing and conflicting advice on health and nutrition was contrasted with personal experiences. Few knew of the role of the dietitian or community dietitian. CONCLUSIONS: This study demonstrates a contrast between stated beliefs and actual consumption patterns. Access to food, and the cost and quality of foods impacted upon food practices. The role of the community dietitian should be promoted. Advice on healthy eating must work with contemporary practices and beliefs building upon positive aspects of diet and eating and involving the food industry, retail sector and health services.

Know how. Wet wraps in atopic eczema

Wet wraps play an important part in the management of children with eczema that does not respond to first-line treatment. They are used in hospitals and in the community, and provide great relief and comfort, but the procedure requires considerable input from the health team until the parents are confident of their technique.

Prevention in primary care: the annual assessment of elderly people

The recent reforms of the NHS have clearly emphasised the potential role of prevention in reducing mortality and morbidity. The specific focus of this paper is the preventive aspects of the new GP contract, and in particular the contractual obligation on GPs to offer an annual assessment to all patients within their practice aged 75 years and over. In reviewing the literature for evidence pertaining to the assessment of elderly people, it is argued that there are a number of unresolved issues which raise certain question marks over the Government's decision to include such assessments in the GP contract. The most fundamental of these issues is whether the costs of such screening are justified by the associated benefits. Other issues relate to the organisation of the assessments. In an attempt to cast some light on these unresolved issues, the results from a recent national survey of GPs in Scotland are presented. The results do not allow a categorical statement to be made on whether or not the assessments are worthwhile per se. However, they do help to clarify the current state of screening elderly people in general practice. In the light of this, directions for future research into the screening of elderly people are suggested.

Registered private nursing homes in Scotland: referral and assessment practice

The results on referral to and assessment for nursing homes, taken from a national survey of all registered private nursing homes in Scotland, are reported in this paper. The findings challenge the view that nursing homes do little by way of assessing potential candidates and that what is done is somehow at variance with the type of assessments carried out in the public long-stay sector. The implications for the future of the traditional view of which professionals should be involved in the assessment of candidates for nursing homes are discussed as are the criteria they might use to make their assessments.