Anti-Gephyrin Antibodies: A Novel Specificity in Patients With Systemic Sclerosis and Lower Bowel Dysfunction

OBJECTIVE

Autoantibodies are clinically useful in phenotyping patients with systemic sclerosis (SSc). Gastrointestinal (GI) function is regulated by the enteric nervous system (ENS) and commonly impaired in SSc, suggesting that the SSc autoimmune response may target ENS antigens. We sought to identify novel anti-ENS autoantibodies with an aim to clinically phenotype SSc GI dysfunction.

METHODS

Serum from a patient with SSc with GI dysfunction but without defined SSc-associated autoantibodies was used for autoantibody discovery. Immunoprecipitations performed with murine myenteric plexus lysates were on-bead digested, and autoantigens were identified by mass spectrometry. Prevalence was determined, and clinical features associated with novel autoantibodies were evaluated in a SSc cohort using regression analyses. The expression of gephyrin in human GI tract tissue was examined by immunohistochemistry.

RESULTS

We identified gephyrin as a novel SSc autoantigen. Anti-gephyrin antibodies were present in 9% of patients with SSc (16/188) and absent in healthy controls (0/46). Anti-gephyrin antibody-positive patients had higher constipation scores (1.00 vs 0.50, P = 0.02) and were more likely to have severe constipation and severe distention/bloating (46% vs 15%, P = 0.005; 54% vs 25%, P = 0.023, respectively). Anti-gephyrin antibody levels were significantly higher among patients with severe constipation (0.04 vs 0.00; P = 0.001) and severe distention and bloating (0.03 vs 0.004; P = 0.010). Severe constipation was associated with anti-gephyrin antibodies even in the adjusted model. Importantly, gephyrin was expressed in the ENS, which regulates gut motility.

CONCLUSION

Gephyrin is a novel ENS autoantigen that is expressed in human myenteric ganglia. Anti-gephyrin autoantibodies are associated with the presence and severity of constipation in patients with SSc.

Age-associated changes in lineage composition of the enteric nervous system regulate gut health and disease

The enteric nervous system (ENS), a collection of neural cells contained in the wall of the gut, is of fundamental importance to gastrointestinal and systemic health. According to the prevailing paradigm, the ENS arises from progenitor cells migrating from the neural crest and remains largely unchanged thereafter. Here, we show that the lineage composition of maturing ENS changes with time, with a decline in the canonical lineage of neural-crest derived neurons and their replacement by a newly identified lineage of mesoderm-derived neurons. Single cell transcriptomics and immunochemical approaches establish a distinct expression profile of mesoderm-derived neurons. The dynamic balance between the proportions of neurons from these two different lineages in the post-natal gut is dependent on the availability of their respective trophic signals, GDNF-RET and HGF-MET. With increasing age, the mesoderm-derived neurons become the dominant form of neurons in the ENS, a change associated with significant functional effects on intestinal motility which can be reversed by GDNF supplementation. Transcriptomic analyses of human gut tissues show reduced GDNF-RET signaling in patients with intestinal dysmotility which is associated with reduction in neural crest-derived neuronal markers and concomitant increase in transcriptional patterns specific to mesoderm-derived neurons. Normal intestinal function in the adult gastrointestinal tract therefore appears to require an optimal balance between these two distinct lineages within the ENS.

Anal Canal Adenocarcinomas: Prognostic Factors and Outcomes at a Single Institution

PURPOSE/OBJECTIVE(S)

Adenocarcinomas of the anal canal (AAC) represent a rarity among cancers of the digestive tract. Data guiding management is limited to retrospective studies and optimal treatment paradigms of AAC are still evolving. Here, we aim to investigate their prognostic factors and outcomes.

MATERIALS/METHODS

We reviewed anorectal adenocarcinoma patients who underwent curative-intent neo/adjuvant therapy +/- surgery at a single institution from 2015-2019. AAC were defined as tumor epicenters ≤ 2 cm from the dentate line. Our primary outcome was 5-year overall survival (OS). We also analyzed 5-year local recurrence, distant metastasis, and disease-free survival (DFS), defined as the interval after treatment completion to the first occurrence of local, regional, distant recurrence, or death. All tumors were staged according to the Rectal Cancer paradigm per AJCC 7th Staging. Kaplan-Meier and Cox-Proportional Hazards Model were used for survival analyses.

RESULTS

In our cohort, 57 patients met inclusion criteria. Median follow-up time was 54 months. The median age was 64 years; 35% of the cohort was female. The majority of tumors were adenocarcinomas (77%), with a minority of mucinous (12%) and signet ring cell (11%) histologies. The median tumor size was 4 cm, located 1 cm from the anal verge. Most tumors (63%) were grade 2, 77% had T3 disease, and 53% had clinical nodal involvement. Most patients completed neoadjuvant chemoradiation, total mesorectal excision, and adjuvant chemotherapy (54%). Fifty-four percent underwent abdominopelvic resection. Of those who received neoadjuvant therapy, 11% achieved a pathologic complete response. Seventy percent of patients completed chemotherapy, either in the neoadjuvant or adjuvant setting. At 5 years, local recurrence was 9%, regional pelvic recurrence was 12%, inguinal nodal recurrence was 2%, and distant recurrence was 25%. Five-year DFS was 63% and 5-year OS was 70%. Multivariate analysis demonstrated age, female gender, CEA, grade 3 disease, mucinous histology, and nodal involvement to be prognostic of lower OS. Receipt of neo/adjuvant chemotherapy was found to be prognostic of higher OS (HR 0.13, p<0.05).

CONCLUSION

In this cohort, the majority of whom received surgical management, we show numerically similar or higher overall survival in comparison with prior studies. This study is limited by its retrospective nature and sample sizes of an exceedingly rare entity. Receipt of neo/adjuvant chemotherapy appears to have an impact on survival. Further investigation is needed to explore the role of total neoadjuvant therapy in improving outcomes in this patient population.

A randomized controlled trial evaluating a theory driven, complex intervention centered on task sharing and mobile health to improve selfcare and outcomes in heart failure - The PANACEA-HF RCT: Design and rationale

Background

We developed a three-pronged complex intervention to improve selfcare and deliver whole person care for patients with heart failure, underpinned by the 'extant cycle' theory - a theory based on our formative work.

Methods

This is a 3 centre, 2-arm, 1:1, open, adaptive stratified, randomized controlled trial. We included patients aged ≥ 18 years with heart failure, taking any of the key guideline directed medical treatments, with a history of or currently on a high ceiling diuretic. We excluded end stage renal disease, clinically diagnosed severe mental illness or cognitive dysfunction and having no caregivers. Interventions included, (i) trained hospital based lay health worker mediated assessment of patients' current selfcare behaviour, documenting barriers and facilitators and implementing a plan to 'transition' the patient toward optimal selfcare. (ii) m-health mediated remote monitoring and (iii) dose optimization through a 'physician supervisor'.

Results

We recruited 301 patients between Jan 2021 and Jan 2022. Mean age was 59.8 (±11.7) years, with 195 (64.8 %) from rural or semi-urban areas and 67.1 % having intermediate to low health literacy. 190 (63.1 %) had an underlying ischemic cardiomyopathy. In the intervention arm, 142 (94.1 %) had a Selfcare in Heart Failure Index (SCHFI) score of ≤70, with significant barriers being 'lack of knowledge' 105 (34.5 %) and 'behavioural passivity' 23 (7.5 %).

Conclusion

This is the first South Asian trial evaluating a complex intervention underpinned by behaviour change theory for whole person heart failure care. These learnings can be applied to heart failure patient care in other resource constrained health systems.

Systemic sclerosis gastrointestinal dysmotility: risk factors, pathophysiology, diagnosis and management

Nearly all patients with systemic sclerosis (SSc) are negatively affected by dysfunction in the gastrointestinal tract, and the severity of gastrointestinal disease in SSc correlates with high mortality. The clinical complications of this dysfunction are heterogeneous and include gastro-oesophageal reflux disease, gastroparesis, small intestinal bacterial overgrowth, intestinal pseudo-obstruction, malabsorption and the requirement for total parenteral nutrition. The abnormal gastrointestinal physiology that promotes the clinical manifestations of SSc gastrointestinal disease throughout the gastrointestinal tract are diverse and present a range of therapeutic targets. Furthermore, the armamentarium of medications and non-pharmacological interventions that can benefit affected patients has substantially expanded in the past 10 years, and research is increasingly focused in this area. Here, we review the details of the gastrointestinal complications in SSc, tie physiological abnormalities to clinical manifestations, detail the roles of standard and novel therapies and lay a foundation for future investigative work.

Manipulation of distal radius fractures: a comparison of Bier’s block vs haematoma block

Introduction

Displaced distal radius fractures often require manipulation under anaesthesia. Many anaesthetic techniques are described, with the two most commonly used being Bier’s block (BB) and haematoma block (HB). Despite national guidance preferring a BB, an HB is often performed instead. This study aims to compare the analgesic properties of a BB with those of an HB when manipulating distal radius fractures.

Methods

This is an observational cohort study comparing the management of displaced distal radius fractures requiring reduction across two National Health Service trusts. Patients aged over 18 with isolated, displaced distal radius fractures were recruited. Patient demographics, AO fracture classification and grade of clinician performing the procedure were recorded. A numeric rating scale (NRS) pain score was obtained for each patient after manipulation. The quality of reduction was judged against standardised anatomical parameters.

Results

Some 200 patients were recruited (100 HB, 100 BB). There were no differences in age (BB: median 66.5 years, interquartile range [IQR] 55–74; HB: median 67 years, IQR 55–74; p = 0.79) or fracture characteristics (p = 0.29) between cohorts. Patients undergoing BB had significantly lower pain scores with a lower IQR than those undergoing HB (p < 0.005). Patients undergoing BB manipulation were more likely to have the fracture reduced and normal anatomy restored (p < 0.005). BBs were performed mainly by Foundation Year 2 junior doctors, whereas HB manipulations were performed by a range of clinicians from emergency nurse practitioners to consultants.

Conclusions

BB provides better analgesia than an HB. This can be performed successfully and reliably by Senior House Officer-level junior doctors.

1028 Systematic Review of Outcomes of Applications of Prineo-Dermabond

Aim

The aims of this study are to assess published data regarding infection rates, delayed wound healing, cosmetic appearance and application time compared to conventional wound closure techniques across multiple surgical procedures.

Method

A literature search was conducted according to PRISMA guideline using PubMed, SCOPUS and Science Direct. The primary outcome was the incidence of wound infection after Prineo Dermabond compared to controls. Secondary outcome measures included allergic reactions and time for application. Literature search identified 52 studies, of which 19 were eligible for qualitative synthesis and 12 for meta-analysis.

Results

Studies included reflected a broad range of applications of Dermeo-Prineo to wound closure in Abdominoplasty, Mammoplasty and Arthroplasty.

Overall, all studies reporting on time of application found a positive indicator of Prineo Dermabond reducing time for wound closure.

Meta-analysis identified a statistically significant reduction in rates of the 6 studies that described wound infection (Prineo 1.51%, Control N=2.13%, OR 0.65 (0.46–0.91); P=0.01) and in the 5 studies reporting delayed wound healing (Prineo 0.99%, Control N=1.79%, OR 0.42 (0.18–0.98); P=0.05) in the use of Prineo Dermabond versus controls.

Three studies reported outcomes of scar cosmesis or long-term maturation. All attested to better cosmetic results in comparison to sutures.

Two studies discussed cost-effectiveness of Dermabond with a hypothetical model concluded that Skin Closure System of Prineo Dermabond could achieve savings of $50–76 per patient, whilst a retrospective model found no statistically significant difference in Total Hospital costs or Operating room time.

Conclusions

Prineo Dermabond provides an alternative method of wound closure in reported studies.

Identification of a novel mutation in thyroxine-binding globulin (TBG) gene associated with TBG-deficiency and its effect on the thyroid function

PURPOSE

This study presents a case of familial transmission of thyroxine-binding globulin (TBG) deficiency. The SERPINA7-gene which codes for TBG is located on the X-chromosome (Xq21-22). More than 45 mutations have been reported to cause TBG- deficiency from various countries, but none from India so far. Genetic analysis of SERPINA7 gene was carried out to determine the cause of low TBG levels in one family.

METHODS

DNA samples of the propositus and the family members were subjected to Polymerase Chain Reaction (PCR) followed by direct sequencing. Allele-specific PCR and Next-gen sequencing (NGS) were employed to confirm the site of the mutation. Thyroid function tests were estimated by Radioimmunoassay (RIA) and Immunoradiometric assay (IRMA) kits. X-chromosomal inactivation status was analyzed in the female members harboring the mutation.

RESULTS

A mutational screening in this family revealed a novel frame-shift mutation S353Q, 354fs3X in the exon 4 of the SERPINA7 gene which will be referred to as TBG-complete deficiency-India (TBG-CD-Ind). One out of four female family members harboring the mutation showed selective X-chromosomal inactivation. The affected family members were clinically euthyroid initially, showed changes in the thyroid function when tested after a long time span. However, the changes in the thyroid function in the affected family members had an autoimmune etiology.

CONCLUSION

This study presents the first report of TBG-CD from India wherein a novel frameshift mutation referred to as TBG-CD-Ind (S353Q, 354fs3X) in the SERPINA7 gene was detected. No apparent association was identified between thyroid function and the TBG-mutation in the affected subjects. A detailed biochemical and genomic testing to determine the exact cause of discordant TFT in the patients would certainly aid in the unequivocal diagnosis of the thyroid function and for the precise individualized treatment.

Relationship Between Gastrointestinal Transit, Medsger Gastrointestinal Severity, and University of California-Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 Symptoms in Patients With Systemic Sclerosis

OBJECTIVE

Systemic sclerosis (SSc)-associated gastrointestinal (GI) complications are attributed to a variety of factors, including diet, microbiota dysbiosis, or GI transit abnormalities. Our objective was to examine the contribution of abnormal GI transit to SSc Medsger GI severity scores and/or University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract (UCLA GIT) 2.0 symptoms.

METHODS

Patients with SSc and GI symptoms (n = 71) and healthy controls (n = 18) underwent whole gut transit (WGT) scintigraphy to assess transit from the esophagus to the colon. The presence of delayed transit and percent emptying in each GI region were measured. We compared the WGT measurements between categories of the Medsger GI severity score (0-4) and across UCLA GIT 2.0 domains and total score (0-3).

RESULTS

A total of 88% of patients had >1 abnormal region of the gut on WGT scintigraphy. All patients requiring total parenteral nutrition had delayed small bowel transit, compared to only approximately 11% of patients in other Medsger GI severity groups (P ≤ 0.01). Severe colonic transit delays were more likely in patients with Medsger GI scores of 3 (pseudo-obstruction and/or malabsorption) compared to other Medsger GI groups (P = 0.02). Seventy-percent of these patients had ≤30% colonic emptying at 72 hours. Modest associations were noted between gastroesophageal reflux disease symptoms and delayed esophageal (r = -0.31, P = 0.05) and gastric emptying (r = -0.32, P = 0.05).

CONCLUSION

These data are important in providing evidence that SSc bowel disease affects transit of GI content and that delay in transit accounts in part for both bowel symptoms and Medsger GI severity. Prospective studies examining the benefit of early therapeutic intervention targeting GI transit abnormalities in patients at high risk for severe GI complications are needed.

An assessment of a multipoint dosing approach for exothermic nitration in CSTRs in series

Multipoint dosing strategy for scale-up of exothermic aromatic nitration.

Insights into complex nanopillar-bacteria interactions: Roles of nanotopography and bacterial surface proteins

Nanopillared surfaces have emerged as a promising strategy to combat bacterial infections on medical devices. However, the mechanisms that underpin nanopillar-induced rupture of the bacterial cell membrane remain speculative. In this study, we have tested three medically relevant poly(ethylene terephthalate) (PET) nanopillared-surfaces with well-defined nanotopographies against both Gram-negative and Gram-positive bacteria. Focused ion beam scanning electron microscopy (FIB-SEM) and contact mechanics analysis were utilised to understand the nanobiophysical response of the bacterial cell envelope to a single nanopillar. Given their importance to bacterial adhesion, the contribution of bacterial surface proteins to nanotopography-mediated cell envelope damage was also investigated. We found that, whilst cell envelope deformation was affected by the nanopillar tip diameter, the nanopillar density affected bacterial metabolic activities. Moreover, three different types of bacterial cell envelope deformation were observed upon contact of bacteria with the nanopillared surfaces. These were attributed to bacterial responses to cell wall stresses resulting from the high intrinsic pressure caused by the engagement of nanopillars by bacterial surface proteins. Such influences of bacterial surface proteins on the antibacterial action of nanopillars have not been previously reported. Our findings will be valuable to the improved design and fabrication of effective antibacterial surfaces.

Neurodegenerative disorders and gut-brain interactions

Neurodegenerative disorders (NDs) affect essential functions not only in the CNS, but also cause persistent gut dysfunctions, suggesting that they have an impact on both CNS and gut-innervating neurons. Although the CNS biology of NDs continues to be well studied, how gut-innervating neurons, including those that connect the gut to the brain, are affected by or involved in the etiology of these debilitating and progressive disorders has been understudied. Studies in recent years have shown how CNS and gut biology, aided by the gut-brain connecting neurons, modulate each other's functions. These studies underscore the importance of exploring the gut-innervating and gut-brain connecting neurons of the CNS and gut function in health, as well as the etiology and progression of dysfunction in NDs. In this Review, we discuss our current understanding of how the various gut-innervating neurons and gut physiology are involved in the etiology of NDs, including Parkinson's disease, Alzheimer's disease, Huntington's disease, and amyotrophic lateral sclerosis, to cause progressive CNS and persistent gut dysfunction.

Annular pancreas causing pyloric stenosis in a 66-year-old patient treated with gastrojejunostomy: a case report

Annular pancreas is defined by a ring of pancreatic tissue encircling the descending portion of the duodenum. It is exceptionally rare in adults and commonly diagnosed during the investigation of symptoms arising due to its complications. Treatment usually involves the surgical correction with a duodenoduodenostomy, gastrojejunostomy or duodenojejunostomy. We discuss the case of a 66-year-old male patient who presented with symptoms of gastric outlet obstruction and was found to have an annular pancreas encircling the pylorus and the first and second portions of the duodenum and was treated by performing a gastrojejunostomy. Upper gastrointestinal series, computerized tomography (CT) scans, and magnetic resonance cholangeopancreatographys can all be used for preoperative diagnosis; however, endoscopic retrograde cholangiopancreatography (ERCP) is the diagnostic modality of choice. Nonetheless, many patients may only be diagnosed intraoperatively, especially those who cannot undergo an ERCP due to stenosis proximal to the duodenum or patients in whom the annulus may not be visible on CT scan.

Neuro-innate immune interactions in gut mucosal immunity

The gastrointestinal (GI) tract performs a set of vital physiological functions related to food and water consumption. To help regulate these complex physiological processes, the GI tract is innervated by extensive neural networks. The GI tract also serves as the largest immune organ aimed to protect hosts from harmful microbes and toxins ingested with food. It emerges that the enteric nervous and immune systems are highly integrated to optimize digestion while reinforcing immune protection. In this review, we will discuss key cellular players involved in the neuro-immune interactions within the GI mucosa with the focus on the recently uncovered neural pathways that regulate mucosal immunity in a context relevant to GI health and disease.

Cholinergic-induced anion secretion in murine jejunal enteroids involves synergy between muscarinic and nicotinic pathways

Acetylcholine induces robust electrogenic anion secretion in mammalian intestine and it has long been hypothesized that it mediates the epithelial response through the M3 and, to a lesser extent, the M1 muscarinic receptors in the mouse. However, nicotinic receptors have recently been identified in intestinal enterocytes by quantitative real-time (qRT)-PCR/RNAseq, although any direct influence on intestinal transport has not been identified. We tested the hypothesis that cholinergic-induced anion secretion in the intestine is a result of both muscarinic and nicotinic pathways that are intrinsic to the intestinal epithelia. We developed a method to generate mouse jejunal enteroid monolayers which were used to measure active electrogenic anion secretion by the Ussing chamber/voltage-clamp technique. Here, we show that the cholinergic agonist carbachol (CCh) and the muscarinic agonist bethanechol (BCh) stimulate short-lived, concentration-dependent anion secretion in the epithelial cell-only enteroid monolayers. The muscarinic antagonist atropine completely inhibited CCh- and BCh-induced secretion, while the nicotinic antagonist hexamethonium reduced the CCh response by ~45%. While nicotine alone did not alter anion secretion, it increased the BCh-induced increase in short-circuit current in a concentration-dependent manner; this synergy was prevented by pretreatment with hexamethonium. In addition to being sensitive to hexamethonium, monolayers express both classes of cholinergic receptor by qRT-PCR, including 13 of 16 nicotinic receptor subunits. Our findings indicate that an interaction between muscarinic and nicotinic agonists synergistically stimulates anion secretion in mouse jejunal epithelial cells and identify a role for epithelial nicotinic receptors in anion secretion.

Intestinal Bacteria Maintain Adult Enteric Nervous System and Nitrergic Neurons via Toll-like Receptor 2-induced Neurogenesis in Mice

BACKGROUND & AIMS

The enteric nervous system (ENS) exists in close proximity to luminal bacteria. Intestinal microbes regulate ENS development, but little is known about their effects on adult enteric neurons. We investigated whether intestinal bacteria or their products affect the adult ENS via toll-like receptors (TLRs) in mice.

METHODS

We performed studies with conventional C57/BL6, germ-free C57/BL6, Nestin-creER^T2:tdTomato, Nestin-GFP, and ChAT-cre:tdTomato. Mice were given drinking water with ampicillin or without (controls). Germ-free mice were given drinking water with TLR2 agonist or without (controls). Some mice were given a blocking antibody against TLR2 or a TLR4 inhibitor. We performed whole gut transit, bead latency, and geometric center studies. Feces were collected and analyzed by 16S ribosomal RNA gene sequencing. Longitudinal muscle myenteric plexus (LMMP) tissues were collected, analyzed by immunohistochemistry, and levels of nitric oxide were measured. Cells were isolated from colonic LMMP of Nestin-creER^T2:tdTomato mice and incubated with agonists of TLR2 (receptor for gram-positive bacteria), TLR4 (receptor for gram-negative bacteria), or distilled water (control) and analyzed by flow cytometry.

RESULTS

Stool from mice given ampicillin had altered composition of gut microbiota with reduced abundance of gram-positive bacteria and increased abundance of gram-negative bacteria, compared with mice given only water. Mice given ampicillin had reduced colon motility compared with mice given only water, and their colonic LMMP had reduced numbers of nitrergic neurons, reduced neuronal nitric oxide synthase production, and reduced colonic neurogenesis. Numbers of colonic myenteric neurons increased after mice were switched from ampicillin to plain water, with increased markers of neurogenesis. Nestin-positive enteric neural precursor cells expressed TLR2 and TLR4. In cells isolated from the colonic LMMP, incubation with the TLR2 agonist increased the percentage of neurons originating from enteric neural precursor cells to approximately 10%, compared with approximately 0.01% in cells incubated with the TLR4 agonist or distilled water. Mice given an antibody against TLR2 had prolonged whole gut transit times; their colonic LMMP had reduced total neurons and a smaller proportion of nitrergic neurons per ganglion, and reduced markers of neurogenesis compared with mice given saline. Colonic LMMP of mice given the TLR4 inhibitor did not have reduced markers of neurogenesis. Colonic LMMP of germ-free mice given TLR2 agonist had increased neuronal numbers compared with control germ-free mice.

CONCLUSIONS

In the adult mouse colon, TLR2 promotes colonic neurogenesis, regulated by intestinal bacteria. Our findings indicate that colonic microbiota help maintain the adult ENS via a specific signaling pathway. Pharmacologic and probiotic approaches directed towards specific TLR2 signaling processes might be developed for treatment of colonic motility disorders related to use of antibiotics or other factors.

Point-of-care lung ultrasound in intensive care during the COVID-19 pandemic

Coronavirus disease 2019 has spread to every inhabited continent in the world. So far, plain radiography and computed tomography have been the mainstay of imaging methods used. The present analytical paper on the role of point-of-care lung ultrasound in this pandemic examines its diagnostic accuracy, clinical utility, and physical practicality in the intensive care unit.

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POCUS has a high sensitivity for pulmonary manifestations of COVID-19.

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POCUS minimises nosocomial spread.

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POCUS can prognosticate and assess response to therapy.

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Healthcare providers with skills in POCUS are encouraged to help provide this service.

'Nervous' Immunity: Walking the Tightrope

There is a major gap in our understanding of how the intestinal immune and nervous systems are integrated to regulate protective adaptations to enteric infections while maintaining tissue homeostasis. Three recent complementary reports published in Cell (2020) provide new mechanistic insights into how this enteric neuro-immune crosstalk may occur.

Botulinum toxin in the management of temporomandibular disorders: a systematic review

The aim of this review was to critically investigate and assess the evidence relating to the use and efficacy of botulinum toxin (BTX) in the management of temporomandibular joint disorders (TMD) and masticatory myofascial pain. A comprehensive search was conducted of PubMed, Scopus, Embase, and Cochrane CENTRAL, to find relevant studies from the last 30 years up to the end of July 2018. Seven were identified. Three showed a significant reduction in pain between the BTX and placebo groups and one showed a clinical, but not a significant, difference. In one that compared BTX with another novel treatment, myofascial pain reduced equally in both groups, and in the remaining two there was no significant difference in pain reduction between the BTX and control groups. Of the four studies that assessed mouth opening, two reported that BTX had resulted in a slight improvement; one reported no improvement, and the other a worsening of the condition. A meta-analysis was not possible because of the considerable variation in the studies' designs, the heterogeneity between the groups, and the different assessment tools used. Despite showing benefits, consensus on the therapeutic benefit of BTX in the management of myofascial TMD is lacking. Further randomised controlled trials with larger sample sizes, minimal bias, and longer follow-up periods are now needed.

P4396Patients explanations of self-care in chronic heart failure: a grounded theory analysis of qualitative data from PANACEA-HF Phase 1

Background

Sub-optimal self-care and non-adherence to treatments are important predictors of poor clinical outcomes in patients with heart failure. Task-sharing and technology have each contributed modest improvements, but the combined effect on outcomes is unknown. We aim to develop a complex intervention package to improve self-care predicated on task sharing and smartphone based remote monitoring among heart failure patients.

Purpose

As a formative step, we conducted a qualitative study among heart failure patients and their caregivers to explore self-care and to inform the development of a contextualized intervention package.

Methods

We conducted in-depth interviews among 22 patients admitted to in-patient wards with a clinical diagnosis of chronic heart failure (diagnosis made at least 1 month prior to index hospitalization) and 18 caregivers (n=40), sampled from 4 states in southern India. Patients were purposively sampled based on sex, socioeconomic status, health literacy and past one month's history of adherence to heart failure medications. The middle range theory of self-care informed the drafting of the interview guide. We recorded and transcribed interviews translated from 5 regional languages. We inductively coded the data from a social constructionist viewpoint, created categories, prepared memos, compared extreme cases, identified key emergent themes and their inter-relationships.

Results

Patients' mean age was 60.5 (±13.4), with representation from socioeconomic strata, urban and rural areas. Patients had a high pill burden [median 10; IQR (6, 31)] and 8 (44%) reported irregular adherence to prescribed medications in the last month. Key categories associated with sub-optimal self-care included “Passivity”, “Entrenched Belief systems”, “Negative Emotions/Affect”, “Ageing causes disease”, and “inability to control situations” across all socioeconomic strata. These themes appear to impair self-actualization that negatively impacts self efficacy/confidence and in turn self-care reciprocally (Refer Figure). Key facilitators of self-care were: Intrinsic patient distinctive facilitators (situational awareness, resilience) and extraneous facilitators (insurance/financial protection, positive caregiver relationships and ease of healthcare access). Patients and caregivers generally expressed their readiness to use mobile technology for remote monitoring and to be counseled by trained lay workers to address beliefs and be trained on self-care.

Framework explaining self-care in HF

Conclusions

Findings from this formative study show opportunities for providers and community-based care workers to address task-sharing of beliefs by educating patients on self-care, including through the use of technology-based solutions. These findings regarding a self-care framework identify opportunities to improve self-care among heart failure patients using task-sharing and technology to support the patient-caregiver-provider triad.

Acknowledgement/Funding

India Alliance - Wellcome Trust and Department of Biotechnology

Lymphatic vessel remodeling and invasion in pancreatic cancer progression

Background

The lymphatic system is involved in metastasis in pancreatic cancer progression. In cancer staging, lymphatic spread has been used to assess the invasiveness of tumor cells. However, from the endothelium's perspective, the analysis downplays the peri-lesional activities of lymphatic vessels. This unintended bias is largely due to the lack of 3-dimensional (3-D) tissue information to depict the lesion microstructure and vasculature in a global and integrated fashion.

Methods

We targeted the pancreas as the model organ to investigate lymphatic vessel remodeling in cancer lesion progression. Transparent pancreases were prepared by tissue clearing to facilitate deep-tissue, tile-scanning microscopy for 3-D lymphatic network imaging.

Findings

In human pancreatic ductal adenocarcinoma, we identify the close association between the pancreatic intraepithelial neoplasia (PanIN) lesions and the lymphatic network. In mouse models of PanIN (elastase-CreER;LSL-Kras^G12D and elastase-CreER;LSL-Kras^G12D;p53^+/−), the 3-D image data reveal the peri-lesional lymphangiogenesis, endothelial invagination, formation of the bridge/valve-like luminal tubules, vasodilation, and luminal invasion. In the orthotopic mouse model of pancreatic cancer, we identify the localized, graft-induced lymphangiogenesis and the peri- and intra-tumoral lymphatic vessel invasion.

Interpretation

The integrated view of duct lesions and vascular remodeling suggests an active role, rather than a passive target, of lymphatic vessels in the metastasis of pancreatic cancer. Our 3-D image data provide insights into the pancreatic cancer microenvironment and establish the technical and morphological foundation for systematic detection and 3-D analysis of lymphatic vessel invasion.

Fund

Taiwan Academia Sinica (AS-107-TP-L15 and AS-105-TP-B15), Ministry of Science and Technology (MOST 106-2321-B-001-048, 106-0210-01-15-02, 106-2321-B-002-034, and 106-2314-B-007-004-MY2), and Taiwan National Health Research Institutes (NHRI EX107-10524EI).

Transneuronal Propagation of Pathologic α-Synuclein from the Gut to the Brain Models Parkinson's Disease

Analysis of human pathology led Braak to postulate that α-synuclein (α-syn) pathology could spread from the gut to brain via the vagus nerve. Here, we test this postulate by assessing α-synucleinopathy in the brain in a novel gut-to-brain α-syn transmission mouse model, where pathological α-syn preformed fibrils were injected into the duodenal and pyloric muscularis layer. Spread of pathologic α-syn in brain, as assessed by phosphorylation of serine 129 of α-syn, was observed first in the dorsal motor nucleus, then in caudal portions of the hindbrain, including the locus coeruleus, and much later in basolateral amygdala, dorsal raphe nucleus, and the substantia nigra pars compacta. Moreover, loss of dopaminergic neurons and motor and non-motor symptoms were observed in a similar temporal manner. Truncal vagotomy and α-syn deficiency prevented the gut-to-brain spread of α-synucleinopathy and associated neurodegeneration and behavioral deficits. This study supports the Braak hypothesis in the etiology of idiopathic Parkinson's disease (PD).

Study of Rheology and Plug Assist Thermoforming of Linear and Branched PP Homopolymer and Impact Copolymer

Polypropylene (PP) is one of the fastest growing thermoplastic polymers in the world, second only to polyethylene. This is primarily due to its excellent balance of physical and chemical properties at a lower cost. PP however possesses low melt strength on account of its linear structure and hence is not easily amenable to processing techniques that involve free surface stretching deformations like thermoforming, blow molding and extrusion film casting. One way to enhance the melt strength of PP is to incorporate long chain branches in its molecular architecture. The present study focuses on the impact of rheology of linear and branched PP on their thermoforming characteristics. Two grades each of linear and long chain branched (LCB) PP homopolymer and impact copolymer (ICP) were used. It was observed that the LCB-PP homopolymer and LCB-ICP showed higher flow activation energy, reduced value of loss tangent and nearly equal frequency dependence of storage and loss moduli in shear rheology. Also, a strong strain hardening behavior was displayed in extensional rheology by the LCB grades. Plug assist thermoforming experiments were carried out to assess the effect of long chain branching on surface strain and thickness distribution for axisymmetric cups of two draw ratios. Biaxial surface strain maps of the formed cups were quantified using Grid Strain Analysis (GSA). Thermoformed cups made from LCB-PP homopolymer and LCB-impact copolymer showed lower surface strain and overall higher thickness as compared to cups made from their linear counterparts, which is in accordance with what might be expected from their rheology.

Abstract P6-21-12: Local transdermal therapy (LTT): Drug permeation and distribution of telapristone acetate (TPA) in a pre-surgical window study of women undergoing mastectomy

Background: Low uptake and poor adherence to oral drugs for breast cancer prevention and ductal carcinoma in situ has led to an interest in local routes of delivery with the intent of decreasing systemic exposure and reducing toxicity. LTT has emerged as a possible alternative; previous studies have shown selectively higher concentrations in the breast than in the serum with this delivery route. A question related to LTT is whether or not the drug will permeate and distribute throughout the breast, as is expected with oral delivery.

Methods: We conducted a double-blind study of oral versus LTT delivery of the selective progesterone receptor modulator, telapristone acetate (TPA), in a presurgical window setting, enrolling 82 women planning therapeutic or prophylactic mastectomy. We randomized 67 women 1:1, to oral TPA 12 mg daily, or gel TPA applied to both breasts daily (12 mg/breast), for 4 weeks ±1 week. Mastectomy specimens were sampled at 5 non-tumor locations as well as the tumor and lymph node when available. Samples were split in two: drug concentration (conc.) assay using LC-MS/MS and histological evaluation of tissue composition (fat, fibrous stroma, epithelium). The primary endpoint was mean drug conc. across all breast locations (anticipating that the gel would deliver a mean concentration that was &gt;50% of the mean in the oral group). A secondary endpoint was the drug distribution pattern across the breast, expecting that the distribution would be similar. The tumor sample was saved for biomarker assays related to TPA action; these are ongoing, for a pre-planned pooled analysis of data with NCT01800422 (reported in SABCS abstract 851863).

Results: Of 63 evaluable women (33 oral and 30 gel group), 27 had unilateral and 36 had bilateral mastectomy. The mean drug conc. in the oral group was 166.3 ng/G (SE 11.7), and in the gel group was 10.6 ng/G (SE 10.8), (p&lt;.0001). The conc. was variable across the 7 locations tested in both groups. High concentrations were found in the superficial and deep central locations, retroareolar and lateral locations ranked in the middle, and the medial location was discrepant, being high in the oral and low in the gel group. The variation in drug concentration across all locations was not significantly different between groups (Kolmogorov-Smirnov p=0.99). Among women with bilateral mastectomy, drug concentrations were similar between breasts in both oral and gel groups. In the gel group, despite low TPA concentrations, there was evidence of drug metabolism. The major metabolite, CDB 4453 was detectable in 192/193 samples with detectable parent drug. Analysis of drug concentration adjusted for tissue composition is ongoing.

Conclusions: The gel formulation of TPA did not permeate the skin well. However, the drug delivered to the breast was distributed throughout the breast, similar to the oral delivery route, with the highest concentration in the deep central location. These drug distribution data are novel; drug distribution at multiple locations throughout the breast has not previously been shown. Further work is needed to understand breast distribution with formulations known to have good dermal permeation.

Citation Format: Lee O, Pilewskie M, Xu Y, Benante K, Blanco L, Helenowski I, Tull MB, Muzzio M, Jovanovic B, Karlan S, Hansen N, Bethke K, Kulkarni S, Perloff M, Dimond EP, Heckman-Stoddard BM, Khan SA. Local transdermal therapy (LTT): Drug permeation and distribution of telapristone acetate (TPA) in a pre-surgical window study of women undergoing mastectomy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-21-12.

Abstract P5-04-04: Withdrawn

This abstract was withdrawn by the authors.

Citation Format: Das GM, Kulkarni S, Oturkar C, Edge SB, Wilton JH, Wang J, Swetzig WM, Adjei AA, Bies R, Hutson AD, Morrison CD, Kaipparettu BA, Groman A, Kumar S, Capuccino H. Withdrawn [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-04-04.

Abstract P1-13-08: A prospective non-randomized clinical trial of adjuvant carboplatin chemotherapy in triple negative breast cancer

Background: The addition of carboplatin in the neoadjuvant setting has demonstrated improved outcomes in patients with triple negative breast cancer (TNBC). Carboplatin in the adjuvant setting has not been demonstrated to be an accepted regimen to date. This trial addresses this issue.

Methods: The primary objectives of this study were to assess the toxicity of an adjuvant carboplatin-containing regimen for early stage TNBC patients, and to correlate outcomes with molecular markers including Spy-1. Secondary objectives included determination of progression free (PFS) and overall survival (OS), and comparing these to our institutional historical controls. Patients received the backbone of a dose dense anthracycline, taxane, cyclophosphamide (DD ACT), with the addition of carboplatin.

Results: Ninety patients with stage I to III patients with triple negative breast cancer were accrued to this trial between Jan 2011 and June 2017. We discovered that DD ACT with carboplatin with an AUC of 5 given on the second and last paclitaxel was well tolerated. Chemotherapy delays were minimized when the parameters for administration of the carboplatin was to allow chemotherapy to proceed if the platelet count was &gt;/= 70,000 x10^9/L and dose adjustment of paclitaxel was allowed based on neuropathy. There were no grade 4 adverse events. 4% of patients had grade 3 peripheral neuropathy (PN), 28% had grade 2 PN and 45% had grade 1 PN. Results of molecular profiles will be reported. Univariate analysis are reported, and were found to be very promising. Using log-rank statistic, a trend to improvement in overall survival was found when compared to historical controls (p=0.089). Median follow-up is 24 months. Longer follow-up is necessary to determine PFS and overall survival benefit.

Conclusion: If considering an adjuvant regimen for triple negative breast cancer patients DDAC/TC with the carboplatin administered with an AUC of 5 on the second and fourth taxol of DDACT is a well-tolerated regimen.

Univariate Analysis Comparing Carboplatin vs Historical Controls that did not receive CarboplatinVariableHistorical (no carbo)Carbo containing chemop overall n = 179n = 82 Age56.3 (13.1)49.8 (11.0)&lt; 0.001Stage0.188Stage I47 (26.3%)15 (18.3%) Stage II88 (49.2%)50 (61.0%) Stage III44 (24.6%)17 (20.7%) Grade0.011Grade 18 (4.5%)0 (0.0%) Grade 233 (18.4%)7 (8.8%) Grade 3138 (77.1%)73 (91.2%) Remission Status0.009In Remission126 (70.4%)70 (86.4%) Relapsed53 (29.6%)11 (13.6%) Survival&lt; 0.001Alive121 (67.6%)73 (90.1%) Deceased58 (32.4%)8 (9.9%) 

Citation Format: Hamm C, Kulkarni S, Gupta R, Mathews J, Amin K, Hussein A, Porter L. A prospective non-randomized clinical trial of adjuvant carboplatin chemotherapy in triple negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-13-08.

Quantitation of class IA PI3Ks in mice reveals p110-free-p85s and isoform-selective subunit associations and recruitment to receptors

Class IA PI3Ks have many roles in health and disease. The rules that govern intersubunit and receptor associations, however, remain unclear. We engineered mouse lines in which individual endogenous class IA PI3K subunits were C-terminally tagged with 17aa that could be biotinylated in vivo. Using these tools we quantified PI3K subunits in streptavidin or PDGFR pull-downs and cell lysates. This revealed that p85α and β bound equivalently to p110α or p110β but p85α bound preferentially to p110δ. p85s were found in molar-excess over p110s in a number of contexts including MEFs (p85β, 20%) and liver (p85α, 30%). In serum-starved MEFs, p110-free-p85s were preferentially, compared with heterodimeric p85s, bound to PDGFRs, consistent with in vitro assays that demonstrated they bound PDGFR-based tyrosine-phosphorylated peptides with higher affinity and co-operativity; suggesting they may act to tune a PI3K activation threshold. p110α-heterodimers were recruited 5-6× more efficiently than p110β-heterodimers to activated PDGFRs in MEFs or to PDGFR-based tyrosine-phosphorylated peptides in MEF-lysates. This suggests that PI3Kα has a higher affinity for relevant tyrosine-phosphorylated motifs than PI3Kβ. Nevertheless, PI3Kβ contributes substantially to acute PDGF-stimulation of PIP3 and PKB in MEFs because it is synergistically, and possibly sequentially, activated by receptor-recruitment and small GTPases (Rac/CDC42) via its RBD, whereas parallel activation of PI3Kα is independent of its RBD. These results begin to provide molecular clarity to the rules of engagement between class IA PI3K subunits in vivo and past work describing "excess p85," p85α as a tumor suppressor, and differential receptor activation of PI3Kα and PI3Kβ.