Identifying provider, patient and practice factors that shape long-term opioid prescribing for cancer pain: a qualitative study of American and Australian providers

INTRODUCTION

Prescribing long-term opioid therapy is a nuanced clinical decision requiring careful consideration of risks versus benefits. Our goal is to understand patient, provider and context factors that impact the decision to prescribe opioids in patients with cancer.

METHODS

We conducted a secondary analysis of the raw semistructured interview data gathered from 42 prescribers who participated in one of two aligned concurrent qualitative studies in the USA and Australia. We conducted a two-part analysis of the interview: first identifying all factors influencing long-term prescribing and second open coding-related content for themes.

RESULTS

Factors that influence long-term opioid prescribing for cancer-related pain clustered under three key domains (patient-related, provider-related and practice-related factors) each with several themes. Domain 1: Patient factors related to provider-patient continuity, patient personality, the patient's social context and patient characteristics including racial/ethnic identity, housing and socioeconomic status. Domain 2: Provider-related factors centred around provider 'personal experience and expertise', training and time availability. Domain 3: Practice-related factors included healthcare interventions to promote safer opioid practices and accessibility of quality alternative pain therapies.

CONCLUSION

Despite the differences in the contexts of the two countries, providers consider similar patient, provider and practice-related factors when long-term prescribing opioids for patients with cancer. Some of these factors may be categorised as cognitive biases that may intersect in an already disadvantaged patient and exacerbate disparities in the treatment of their pain. A more systematic understanding of these factors and how they impact the quality of care can inform appropriate interventions.

A Tool to Identify and Engage Patients on Risky Opioid Regimens

BACKGROUND

Concerns around opioid safety for patients living with chronic pain have led to a growing number of collaborative and multimodal pain care initiatives. A major challenge in these efforts has been identifying and engaging patients on high-risk opioid regimens in a timely manner.

OBJECTIVES

In this clinical informatics case report, we describe the development and implementation of a web-based tool to support providers as they implement an integrated pain support clinical initiative at primary care clinics across three health care systems.

METHODS

The tool identifies patients on risky opioid medication regimens and generates autopopulated patient outreach letters. It contains three core functions that: (1) identify patients prescribed high-dose opioids or coprescribed opioids and benzodiazepines, (2) generate automated letters for patients with an upcoming primary care appointment, and (3) allow clinic staff to write back to a database to track outreach and referrals. Qualitative stakeholder feedback was gathered through interviews and user testing to assess perceived usefulness and ease of use of the tool.

RESULTS

Over a 24-month period, the tool identified 1,125 patients prescribed risky medication regimens and generated 1,315 total letters as some patients became reeligible. Stakeholder feedback revealed that the tool was useful to quickly find patients on risky medication regimens and efficient in generating prepopulated letters that could be mailed in large batches. Additional feedback led to iterative refinements and improved system capabilities that varied across clinics.

CONCLUSION

Deploying clinical informatics tools that prioritize, engage, and track high-risk patient populations supports reduction of risky medication regimens. Such tools can reduce workload burden on busy primary care staff, particularly during implementation studies, and enhance patient-centered care through the use of direct-to-consumer outreach.

Effects of buprenorphine on opioid craving in comparison to other medications for opioid use disorder: A systematic review of randomized controlled trials

BACKGROUND

Craving is a distressing symptom of opioid use disorder (OUD) that can be alleviated with medications for OUD (MOUD). Buprenorphine is an effective MOUD that may suppress craving; however, treatment discontinuation and resumed opioid use is common during the early phases of treatment. More information on the craving response through the high-risk period of initiating buprenorphine may provide meaningful information on how to better target craving, which in turn may enhance outcomes. This systematic review investigated buprenorphine doses and formulations on craving during the induction and maintenance phases of treatment, and for context also compared the craving response to other MOUD (i.e., methadone, extended-release naltrexone [XR-NTX]).

METHODS

PubMed, PsycInfo, Embase, and Cochrane Central databases were searched for randomized trials of buprenorphine versus placebo, various buprenorphine formulations/doses, or other MOUD that included a measure of opioid craving.

RESULTS

A total of 10 studies were selected for inclusion. Buprenorphine and buprenorphine/naloxone (BUP/NAL) were each associated with lower craving than placebo over time. Craving was greater among those prescribed lower versus higher buprenorphine doses. In comparison to other MOUD, buprenorphine or BUP/NAL was linked to greater craving than methadone in 3 of the 6 studies. BUP/NAL was associated with greater reported craving than XR-NTX.

DISCUSSION

Craving is reduced over time with buprenorphine and BUP/NAL, although other MOUD may provide greater reductions in craving. Although there is currently considerable variability in the measurement of craving, it may be a valuable concept to address with individuals receiving MOUD, especially early in treatment.

Opioid use and opioid use disorder in mono and dual-system users of veteran affairs medical centers

Introduction

Efforts to achieve opioid guideline concordant care may be undermined when patients access multiple opioid prescription sources. Limited data are available on the impact of dual-system sources of care on receipt of opioid medications.

Objective

We examined whether dual-system use was associated with increased rates of new opioid prescriptions, continued opioid prescriptions and diagnoses of opioid use disorder (OUD). We hypothesized that dual-system use would be associated with increased odds for each outcome.

Methods

This retrospective cohort study was conducted using Veterans Administration (VA) data from two facilities from 2015 to 2019, and included active patients, defined as Veterans who had at least one encounter in a calendar year (2015-2019). Dual-system use was defined as receipt of VA care as well as VA payment for community care (non-VA) services. Mono users were defined as those who only received VA services. There were 77,225 dual-system users, and 442,824 mono users. Outcomes were three binary measures: new opioid prescription, continued opioid prescription (i.e., received an additional opioid prescription), and OUD diagnosis (during the calendar year). We conducted a multivariate logistic regression accounting for the repeated observations on patient and intra-class correlations within patients.

Results

Dual-system users were significantly younger than mono users, more likely to be women, and less likely to report white race. In adjusted models, dual-system users were significantly more likely to receive a new opioid prescription during the observation period [Odds ratio (OR) = 1.85, 95% confidence interval (CI) 1.76-1.93], continue prescriptions (OR = 1.24, CI 1.22-1.27), and to receive an OUD diagnosis (OR = 1.20, CI 1.14-1.27).

Discussion

The prevalence of opioid prescriptions has been declining in the US healthcare systems including VA, yet the prevalence of OUD has not been declining at the same rate. One potential problem is that detailed notes from non-VA visits are not immediately available to VA clinicians, and information about VA care is not readily available to non-VA sources. One implication of our findings is that better health system coordination is needed. Even though care was paid for by the VA and presumably closely monitored, dual-system users were more likely to have new and continued opioid prescriptions.

Yin and yang of cannabinoid CB1 receptor: CB1 deletion in immune cells causes exacerbation while deletion in non-immune cells attenuates obesity

While blockade of cannabinoid receptor 1 (CB1) has been shown to attenuate diet-induced obesity (DIO), its relative role in different cell types has not been tested. The current study investigated the role of CB1 in immune vs non-immune cells during DIO by generating radiation-induced bone marrow chimeric mice that expressed functional CB1 in all cells except the immune cells or expressed CB1 only in immune cells. CB1^−/− recipient hosts were resistant to DIO, indicating that CB1 in non-immune cells is necessary for induction of DIO. Interestingly, chimeras with CB1^−/− in immune cells showed exacerbation in DIO combined with infiltration of bone-marrow-derived macrophages to the brain and visceral adipose tissue, elevated food intake, and increased glucose intolerance. These results demonstrate the opposing role of CB1 in hematopoietic versus non-hematopoietic cells during DIO and suggests that targeting immune CB1 receptors provides a new pathway to ameliorate obesity and related metabolic disorders.

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Cannabinoid Receptor 1 (CB1), and not CB2, regulates diet-induced obesity (DIO)

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CB1 deficiency in non-immune cell types promotes DIO resistance

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CB1 deficiency in immune cells exacerbates DIO disease phenotype

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CB1 activation in immune cells is a potential therapeutic target for DIO attenuation

Classification of Patients for Whom Benefit of Long-term Opioid Therapy No Longer Outweighs Harm: Protocol for a Delphi Study

Background

Patients with chronic pain prescribed long-term opioid therapy may come to a point where the benefits of the therapy are outweighed by the risks and tapering is indicated. At the 2019 Veterans Health Administration State of the Art Conference, there was an acknowledgment of a lack of clinical guidance with regard to treating this subset of patients. Some of the participants believed clinicians and patients would both benefit from a new diagnostic entity describing this situation.

Objective

The aim of this study was to determine if a new diagnostic entity was needed and what the criteria of the diagnostic entity would be. Given the ability of the Delphi method to synthesize input from a broad range of experts, we felt this technique was the most appropriate for this study.

Methods

We designed a modified Delphi technique involving 3 rounds. The first round is a series of open-ended questions asking about the necessity of this diagnostic entity, how this condition is different from opioid use disorder, and what its possible diagnostic criteria would be. After synthesizing the responses collected, a second round will be conducted to ask participants to rate the different responses offered by their peers. These ratings will be collected and analyzed, and will generate a preliminary definition for this clinical phenomena. In the third round, we will circulate this definition with the aim of achieving consensus.

Results

The modified Delphi study was initiated in July of 2020 and analysis is currently underway.

Conclusions

This protocol has been approved by the Internal Review Board at the Connecticut Veterans Affairs and the study is in process. This protocol may assist other researchers conducting similar studies.

International Registered Report Identifier (IRRID)

DERR1-10.2196/33310

Optimizing the Impact of Pragmatic Clinical Trials for Veteran and Military Populations: Lessons From the Pain Management Collaboratory

Pragmatic clinical trials (PCTs) are well-suited to address unmet healthcare needs, such as those arising from the dual public health crises of chronic pain and opioid misuse, recently exacerbated by the COVID-19 pandemic. These overlapping epidemics have complex, multifactorial etiologies, and PCTs can be used to investigate the effectiveness of integrated therapies that are currently available but underused. Yet individual pragmatic studies can be limited in their reach because of existing structural and cultural barriers to dissemination and implementation. The National Institutes of Health, Department of Defense, and Department of Veterans Affairs formed an interagency research partnership, the Pain Management Collaboratory. The partnership combines pragmatic trial design with collaborative tools and relationship building within a large network to advance the science and impact of nonpharmacological approaches and integrated models of care for the management of pain and common co-occurring conditions. The Pain Management Collaboratory team supports 11 large-scale, multisite PCTs in veteran and military health systems with a focus on team science with the shared aim that the "whole is greater than the sum of the parts." Herein, we describe this integrated approach and lessons learned, including incentivizing all parties; proactively offering frequent opportunities for problem-solving; engaging stakeholders during all stages of research; and navigating competing research priorities. We also articulate several specific strategies and their practical implications for advancing pain management in active clinical, "real-world," settings.

Risk Factors Associated With Nonfatal Opioid Overdose Leading to Intensive Care Unit Admission: A Cross-sectional Study

BACKGROUND

Opioid overdose (OD) and related deaths have significantly increased in the United States over the last 2 decades. Existing studies have mostly focused on demographic and clinical risk factors in noncritical care settings. Social and behavioral determinants of health (SBDH) are infrequently coded in the electronic health record (EHR) and usually buried in unstructured EHR notes, reflecting possible gaps in clinical care and observational research. Therefore, SBDH often receive less attention despite being important risk factors for OD. Natural language processing (NLP) can alleviate this problem.

OBJECTIVE

The objectives of this study were two-fold: First, we examined the usefulness of NLP for SBDH extraction from unstructured EHR text, and second, for intensive care unit (ICU) admissions, we investigated risk factors including SBDH for nonfatal OD.

METHODS

We performed a cross-sectional analysis of admission data from the EHR of patients in the ICU of Beth Israel Deaconess Medical Center between 2001 and 2012. We used patient admission data and International Classification of Diseases, Ninth Revision (ICD-9) diagnoses to extract demographics, nonfatal OD, SBDH, and other clinical variables. In addition to obtaining SBDH information from the ICD codes, an NLP model was developed to extract 6 SBDH variables from EHR notes, namely, housing insecurity, unemployment, social isolation, alcohol use, smoking, and illicit drug use. We adopted a sequential forward selection process to select relevant clinical variables. Multivariable logistic regression analysis was used to evaluate the associations with nonfatal OD, and relative risks were quantified as covariate-adjusted odds ratios (aOR).

RESULTS

The strongest association with nonfatal OD was found to be drug use disorder (aOR 8.17, 95% CI 5.44-12.27), followed by bipolar disorder (aOR 2.69, 95% CI 1.68-4.29). Among others, major depressive disorder (aOR 2.57, 95% CI 1.12-5.88), being on a Medicaid health insurance program (aOR 2.26, 95% CI 1.43-3.58), history of illicit drug use (aOR 2.09, 95% CI 1.15-3.79), and current use of illicit drugs (aOR 2.06, 95% CI 1.20-3.55) were strongly associated with increased risk of nonfatal OD. Conversely, Blacks (aOR 0.51, 95% CI 0.28-0.94), older age groups (40-64 years: aOR 0.65, 95% CI 0.44-0.96; >64 years: aOR 0.16, 95% CI 0.08-0.34) and those with tobacco use disorder (aOR 0.53, 95% CI 0.32-0.89) or alcohol use disorder (aOR 0.64, 95% CI 0.42-1.00) had decreased risk of nonfatal OD. Moreover, 99.82% of all SBDH information was identified by the NLP model, in contrast to only 0.18% identified by the ICD codes.

CONCLUSIONS

This is the first study to analyze the risk factors for nonfatal OD in an ICU setting using NLP-extracted SBDH from EHR notes. We found several risk factors associated with nonfatal OD including SBDH. SBDH are richly described in EHR notes, supporting the importance of integrating NLP-derived SBDH into OD risk assessment. More studies in ICU settings can help health care systems better understand and respond to the opioid epidemic.

Pain and smoking study (PASS): A comparative effectiveness trial of smoking cessation counseling for veterans with chronic pain

Introduction

Smoking is associated with greater pain intensity and pain-related functional interference in people with chronic pain. Interventions that teach smokers with chronic pain how to apply adaptive coping strategies to promote both smoking cessation and pain self-management may be effective.

Methods

The Pain and Smoking Study (PASS) is a randomized clinical trial of a telephone-delivered, cognitive behavioral intervention among Veterans with chronic pain who smoke cigarettes. PASS participants are randomized to a standard telephone counseling intervention that includes five sessions focusing on motivational interviewing, craving and relapse management, rewards, and nicotine replacement therapy versus the same components with the addition of a cognitive behavioral intervention for pain management. Participants are assessed at baseline, 6, and 12 months. The primary outcome is smoking cessation.

Results

The 371 participants are 88% male, a median age of 60 years old (range 24–82), and smoke a median of 15 cigarettes per day. Participants are mainly white (61%), unemployed (70%), 33% had a high school degree or less, and report their overall health as “Fair” (40%) to “Poor” (11%). Overall, pain was moderately high (mean pain intensity in past week = 5.2 (Standard Deviation (SD) = 1.6) and mean pain interference = 5.5 (SD = 2.2)). Pain-related anxiety was high (mean = 47.0 (SD = 22.2)) and self-efficacy was low (mean = 3.8 (SD = 1.6)).

Conclusions

PASS utilizes an innovative smoking and pain intervention to promote smoking cessation among Veterans with chronic pain. Baseline characteristics reflect a socioeconomically vulnerable population with a high burden of mental health comorbidities.

Dataset for multidimensional assessment to incentivise decentralised energy investments in Sub-Saharan Africa

In this data article, we present datasets from the construction of a composite indicator, the Photovoltaic Decentralised Energy Investment (PV-DEI) index, presented in detail in [1]. This article consists of a comprehensive energy-related data collected in practice from several sources, and from the outputs of the methodology described in [1]. The PV-DEI was designed and developed to measure the multidimensional factors that currently direct decentralised renewable energy investments. The PV-DEI index includes 52 indicators and was constructed because factors stimulating investment cannot be captured by a single indicator, e.g. competitiveness, affordability, or governance [1]. The PV-DEI index was built in alignment with a theoretical framework guided by an extensive review of the literature surrounding investment in decentralised Photovoltaic (PV), which led to the selection of its indicators. The structure of the PV-DEI was evaluated for its soundness using correlational assessments and principal component analyses (PCA). The raw data provided in this article can enable stakeholders to focus on specific country indicators, and how scores on these indicators contributed to a countries overall rank within the PV-DEI index. The data can be used to weight indicators depending on the specifications of several different stakeholders (such as NGOs, private sector or international institutions).

Tryptamine Attenuates Experimental Multiple Sclerosis Through Activation of Aryl Hydrocarbon Receptor

Tryptamine is a naturally occurring monoamine alkaloid which has been shown to act as an aryl hydrocarbon receptor (AHR) agonist. It is produced in large quantities from the catabolism of the essential amino acid tryptophan by commensal microorganisms within the gastrointestinal (GI) tract of homeothermic organisms. Previous studies have established microbiota derived AHR ligands as potent regulators of neuroinflammation, further defining the role the gut-brain axis plays in the complex etiology in multiple sclerosis (MS) progression. In the current study, we tested the ability of tryptamine to ameliorate symptoms of experimental autoimmune encephalomyelitis (EAE), a murine model of MS. We found that tryptamine administration attenuated clinical signs of paralysis in EAE mice, decreased the number of infiltrating CD4⁺ T cells in the CNS, Th17 cells, and RORγ T cells while increasing FoxP3+Tregs. To test if tryptamine acts through AHR, myelin oligodendrocyte glycoprotein (MOG)-sensitized T cells from wild-type or Lck-Cre AHR^flox/flox mice that lacked AHR expression in T cells, and cultured with tryptamine, were transferred into wild-type mice to induce passive EAE. It was noted that in these experiments, while cells from wild-type mice treated with tryptamine caused marked decrease in paralysis and attenuated neuroinflammation in passive EAE, similar cells from Lck-Cre AHR^flox/flox mice treated with tryptamine, induced significant paralysis symptoms and heightened neuroinflammation. Tryptamine treatment also caused alterations in the gut microbiota and promoted butyrate production. Together, the current study demonstrates for the first time that tryptamine administration attenuates EAE by activating AHR and suppressing neuroinflammation.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Cannabinoid Receptor Activation on Haematopoietic Cells and Enterocytes Protects against Colitis

BACKGROUND AND AIMS

Cannabinoid receptor [CB] activation can attenuate inflammatory bowel disease [IBD] in experimental models and human cohorts. However, the roles of the microbiome, metabolome, and the respective contributions of haematopoietic and non-haematopoietic cells in the anti-colitic effects of cannabinoids have yet to be determined.

METHODS

Female C57BL/6 mice were treated with either cannabidiol [CBD], Δ 9-tetrahydrocannabinol [THC], a combination of CBD and THC, or vehicle, in several models of chemically induced colitis. Clinical parameters of colitis were assessed by colonoscopy, histology, flow cytometry, and detection of serum biomarkers; single-cell RNA sequencing and qRT-PCR were used to evaluate the effects of cannabinoids on enterocytes. Immune cell transfer from CB2 knockout mice was used to evaluate the contribution of haematopoietic and non-haematopoietic cells to colitis protection.

RESULTS

We found that THC prevented colitis and that CBD, at the dose tested, provided little benefit to the amelioration of colitis, nor when added synergistically with THC. THC increased colonic barrier integrity by stimulating mucus and tight junction and antimicrobial peptide production, and these effects were specific to the large intestine. THC increased colonic Gram-negative bacteria, but the anti-colitic effects of THC were independent of the microbiome. THC acted both on immune cells via CB2 and on enterocytes, to attenuate colitis.

CONCLUSIONS

Our findings demonstrate how cannabinoid receptor activation on both immune cells and colonocytes is critical to prevent colonic inflammation. These studies also suggest how cannabinoid receptor activation can be used as a preventive and therapeutic modality against colitis.

High-fat diet-fed ovariectomized mice are susceptible to accelerated subcutaneous tumor growth potentially through adipose tissue inflammation, local insulin-like growth factor release, and tumor associated macrophages

Background: The association between obesity and colorectal cancer (CRC) risk has been well established. This relationship appears to be more significant in men than in women, which may be attributable to sex hormones. However, controlled animal studies to substantiate these claims and the mechanisms involved are lacking.

Materials and Methods: MC38 murine colon adenocarcinoma cells were injected subcutaneously into high-fat diet (HFD) fed male, female and ovariectomized (OVX) female C57BL/6 mice.

Results: HFD increased tumor growth (main effect) that was consistent with metabolic perturbations (P < 0.01). HFD OVX mice exhibited the most significant tumor growth compared to HFD male and female mice (p < 0.05) and this was associated with increased subcutaneous adipose tissue (p < 0.05). Further, the subcutaneous adipose tissue depots within HFD OVX mice exhibited more severe macrophage associated inflammation compared to female (P < 0.01), but not male mice. Conditioned media from subcutaneous adipose tissue of HFD OVX contained higher IGF-1 levels compared to male (P < 0.01), but not female mice. Finally, HFD OVX mice had increased M2-like gene expression in their tumor-associated macrophages (TAMs) compared to female mice (P < 0.01).

Conclusions: This work provides evidences suggesting adiposity, adipose specific IGF-1, macrophage associated adipose inflammation, and TAMs as potential mechanisms driving obesity-enhanced CRC in females lacking ovarian hormones.

Utilizing a multi-class classification approach to detect therapeutic and recreational misuse of opioids on Twitter

BACKGROUND

Opioid misuse (OM) is a major health problem in the United States, and can lead to addiction and fatal overdose. We sought to employ natural language processing (NLP) and machine learning to categorize Twitter chatter based on the motive of OM.

MATERIALS AND METHODS

We collected data from Twitter using opioid-related keywords, and manually annotated 6988 tweets into three classes-No-OM, Pain-related-OM, and Recreational-OM-with the No-OM class representing tweets indicating no use/misuse, and the Pain-related misuse and Recreational-misuse classes representing misuse for pain or recreation/addiction. We trained and evaluated multi-class classifiers, and performed term-level k-means clustering to assess whether there were terms closely associated with the three classes.

RESULTS

On a held-out test set of 1677 tweets, a transformer-based classifier (XLNet) achieved the best performance with F₁-score of 0.71 for the Pain-misuse class, and 0.79 for the Recreational-misuse class. Macro- and micro-averaged F₁-scores over all classes were 0.82 and 0.92, respectively. Content-analysis using clustering revealed distinct clusters of terms associated with each class.

DISCUSSION

While some past studies have attempted to automatically detect opioid misuse, none have further characterized the motive for misuse. Our multi-class classification approach using XLNet showed promising performance, including in detecting the subtle differences between pain-related and recreation-related misuse. The distinct clustering of class-specific keywords may help conduct targeted data collection, overcoming under-representation of minority classes.

CONCLUSION

Machine learning can help identify pain-related and recreational-related OM contents on Twitter to potentially enable the study of the characteristics of individuals exhibiting such behavior.

Activation of Cannabinoid Receptor 2 Prevents Colitis-Associated Colon Cancer through Myeloid Cell De-activation Upstream of IL-22 Production

Intestinal disequilibrium leads to inflammatory bowel disease (IBD), and chronic inflammation predisposes to oncogenesis. Antigen-presenting dendritic cells (DCs) and macrophages can tip the equilibrium toward tolerance or pathology. Here we show that delta-9-tetrahydrocannabinol (THC) attenuates colitis-associated colon cancer and colitis induced by anti-CD40. Working through cannabinoid receptor 2 (CB2), THC increases CD103 expression on DCs and macrophages and upregulates TGF-β1 to increase T regulatory cells (Tregs). THC-induced Tregs are necessary to remedy systemic IFNγ and TNFα caused by anti-CD40, but CB2-mediated suppression of APCs by THC quenches pathogenic release of IL-22 and IL-17A in the colon. By examining tissues from multiple sites, we confirmed that THC affects DCs, especially in mucosal barrier sites in the colon and lungs, to reduce DC CD86. Using models of colitis and systemic inflammation we show that THC, through CB2, is a potent suppressor of aberrant immune responses by provoking coordination between APCs and Tregs.

First results of computer-enhanced optical diagnosis of bladder cancer

Bladder cancer is the sixth leading cancer cause worldwide. Non-muscle invasive tumors can be diagnosed and treated endoscopically. Based on biopsies alone, pathologists cannot determine the spatial organization of specimens, their relationship with each other, or their complete removal. To extend white light cystoscopy as the gold standard for bladder cancer detection, diagnosis and removal of small or flat lesions, new image-based technologies have been investigated. These include a stereo-cystoscope for improved orientation and navigation, computation of 2D and 3D panoramic images for extended visualization and documentation, as well as label-free fiber-based fluorescence-lifetime imaging (FLIM) and Raman-spectroscopy in combination with statistical data analysis. Combining all these technologies, cystoscopy can will be further enhanced to include new diagnostic possibilities.

Long Noncoding RNA AW112010 Promotes the Differentiation of Inflammatory T Cells by Suppressing IL-10 Expression through Histone Demethylation

Long noncoding RNAs (lncRNAs) have been demonstrated to play important regulatory roles in gene expression, from histone modification to protein stability. However, the functions of most identified lncRNAs are not known. In this study, we investigated the role of an lncRNA called AW112010. The expression of AW112010 was significantly increased in CD4⁺ T cells from C57BL/6J mice activated in vivo with myelin oligodendrocyte glycoprotein, Staphylococcal enterotoxin B, or in vitro with anti-CD3 anti-CD28 mAbs, thereby demonstrating that activation of T cells leads to induction of AW112010. In contrast, anti-inflammatory cannabinoids such as cannabidiol or δ-9-tetrahydrocannabinol decreased the expression of AW112010 in T cells. Interestingly, the expression of AW112010 was high in in vitro-polarized Th1 and Th17 cells but low in Th2 cells, suggesting that this lncRNA may regulate inflammation. To identify genes that might be regulated by AW112010, we used chromatin isolation by RNA purification, followed by sequencing. This approach demonstrated that AW112010 regulated the transcription of IL-10. Additionally, the level of IL-10 in activated T cells was low when the expression of AW112010 was increased. Use of small interfering RNA to knock down AW112010 expression in activated T cells led to increased IL-10 expression and a decrease in the expression of IFN-γ. Further studies showed that AW112010 interacted with histone demethylase KDM5A, which led to decreased H3K4 methylation in IL-10 gene locus. Together, these studies demonstrate that lncRNA AW112010 promotes the differentiation of inflammatory T cells by suppressing IL-10 expression through histone demethylation.

Development of a bioeconomy monitoring framework for the European Union: An integrative and collaborative approach

The EU Bioeconomy Strategy, updated in 2018, in its Action Plan pledges an EU-wide, internationally coherent monitoring system to track economic, environmental and social progress towards a sustainable bioeconomy. This paper presents the approach taken by the European Commission's (EC) Joint Research Centre (JRC) to develop such a system. To accomplish this, we capitalise on (1) the experiences of existing indicator frameworks; (2) stakeholder knowledge and expectations; and (3) national experiences and expertise. This approach is taken to ensure coherence with other bioeconomy-related European monitoring frameworks, the usefulness for decision-making and consistency with national and international initiatives to monitor the bioeconomy. We develop a conceptual framework, based on the definition of a sustainable bioeconomy as stated in the Strategy, for a holistic analysis of the trends in the bioeconomy sectors, following the three pillars of sustainability (economy, society and environment). From this conceptual framework, we derive an implementation framework that aims to highlight the synergies and trade-offs across the five objectives of the Bioeconomy Strategy in a coherent way. The EU Bioeconomy Monitoring System will be publicly available on the web platform of the EC Knowledge Centre for Bioeconomy.

Indole-3-carbinol prevents colitis and associated microbial dysbiosis in an IL-22-dependent manner

Colitis, an inflammatory bowel disease, is caused by a variety of factors, but luminal microbiota are thought to play crucial roles in disease development and progression. Indole is produced by gut microbiota and is believed to protect the colon from inflammatory damage. In the current study, we investigated whether indole-3-carbinol (I3C), a naturally occurring plant product found in numerous cruciferous vegetables, can prevent colitis-associated microbial dysbiosis and attempted to identify the mechanisms. Treatment with I3C led to repressed colonic inflammation and prevention of microbial dysbiosis caused by colitis, increasing a subset of gram-positive bacteria known to produce butyrate. I3C was shown to increase production of butyrate, and when mice with colitis were treated with butyrate, there was reduced colonic inflammation accompanied by suppression of Th17 and induction of Tregs, protection of the mucus layer, and upregulation in Pparg expression. Additionally, IL-22 was increased only after I3C but not butyrate administration, and neutralization of IL-22 prevented the beneficial effects of I3C against colitis, as well as blocked I3C-mediated dysbiosis and butyrate induction. This study suggests that I3C attenuates colitis primarily through induction of IL-22, which leads to modulation of gut microbiota that promote antiinflammatory butyrate.

Shared decision making about opioid therapy for cancer patients: Do patients and providers take the same factors into consideration?

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Background: Many patients with cancerpain are appropriately managed on long-term opioid therapy (LTOT), but are at similar risk of overdose and addiction as are patients with non-cancer pain. Whether to commence opioids for cancer pain is often a shared decision between patient and provider. Little is known about this process. Methods: Semi-structured interviews with 20 cancer patients on LTOT and 20 interdisciplinary providers who prescribe LTOT from two VA medical centers. Transcripts were coded and analyzed using constant comparison to find common themes. Results: Providers and patients largely weighed the risks and benefits of LTOT similarly, except in the case of cancer patients with past/present substance use disorder (SUD). In those cases, providers felt the risks outweighed the benefits, while patients felt the benefits outweighed the risks. Generally, patients considered pain relief their overarching concern. Other factors that impacted their risk/benefit calculus included: personal/family experience with opioids and the opinions of trusted providers. Only rarely did patients defer decision making to providers. Factors that impacted the risk/benefit calculus of providers included: disease status, patient goals, patient characteristics, and providers' past experiences/biases. Of note, patients with past opioid exposure generally viewed their experience with opioids as positive, and usually anchored their risk assessment for opioids relative to those of chemotherapy. Patients also expressed that they would prefer to spend less physician time discussing LTOT and more time discussing cancer treatment instead. Conclusions: Patients and providers often agree on when it is appropriate to use LTOT for cancer pain. In cases where they disagree, providers are well advised to explore and address patients’ fears about the adequacy of pain management without opioids, as well as their lived experience with opioids. Patients are comfortable having such discussions with physician extenders in order to reserve face-to-face physician time to discuss cancer treatment instead.

Acute and short-term administrations of delta-9-tetrahydrocannabinol modulate major gut metabolomic regulatory pathways in C57BL/6 mice

Delta-9-tetrahydrocannabinol (THC) is the primary psychoactive compound in Cannabis, which is studied extensively for its medicinal value. A central gap in the science is the underlying mechanisms surrounding THC's therapeutic effects and the role of gut metabolite profiles. Using a mass-spectrometry based metabolomics, we show here that intraperitoneal injection of THC in C57BL/6 mice modulates metabolic profiles that have previously been identified as integral to health. Specifically, we investigated the effects of acute (single THC injection denoted here as '1X') and short -term (five THC injections on alternate days denoted as '5X') THC administration on fecal and intestinal tissue metabolite profiles. Results are consistent with the hypothesis that THC administration alters host metabolism by targeting two prominent lipid metabolism pathways: glycerophospholipid metabolism and fatty acid biosynthesis.

Multiparametric Time-Correlated Single Photon Counting Luminescence Microscopy

Classic time-correlated single photon counting (TCSPC) technique involves detection of single photons of a periodic optical signal, registration of the photon arrival time in respect to the reference pulse, and construction of photon distribution with regard to the detection times. This technique achieves extremely high time resolution and near-ideal detection efficiency. Modern TCSPC is multi-dimensional, i.e., in addition to the photon arrival time relative to the excitation pulse, spatial coordinates within the image area, wavelength, time from the start of the experiment, and many other parameters are determined for each photon. Hence, the multi-dimensional TCSPC allows generation of photon distributions over these parameters. This review describes both classic and multi-dimensional types of TCSPC microscopy and their application for fluorescence lifetime imaging in different areas of biological studies.

Randomized Trials of Nasal Patency and Dermal Tolerability With External Nasal Dilators in Healthy Volunteers

Background

External nasal dilator strips are used as nonpharmacological therapy to reduce snoring and daytime sleepiness. In a product improvement initiative, a marketed strip (BRNS) and 2 prototype nasal strips were evaluated.

Objective

To compare the nasal patency and multiple-use dermal tolerability of the BRNS and prototype nasal strips using both objective and subject-reported outcome measures.

Methods

Two studies were conducted separately in healthy volunteers ≥18 years of age. A single-day nasal patency randomized crossover study assessed minimal cross-sectional area (MCA; second restriction) and nasal volume (using acoustic rhinometry); nasal inspiratory flow and resistance (using posterior rhinomanometry); and subject-reported evaluations of the BRNS compared with the butterfly strip and teardrop strip prototypes. A single-center, randomized, controlled, parallel-group, evaluator-blinded study assessed dermal tolerability of the BRNS and the butterfly strip over 7 consecutive nights of use, using the Dermal Response Scale (DRS) and subject-reported comfort and ease of removal.

Results

In the Patency study (N = 50), all 3 strips demonstrated significant improvement from baseline in MCA, nasal volume, and nasal flow parameters (resistance and peak flow). The prototype strips demonstrated significantly more improvement in nasal volume than the BRNS, and the butterfly strip showed significantly more improvement in MCA than the BRNS; all strips were similar with respect to nasal flow and subject-reported nasal breathing outcomes. In the Dermal Tolerability study (N = 82), all subjects scored 0 (no evidence of irritation) on the DRS at all 7 morning assessments; the BRNS was numerically, but not significantly, superior to the butterfly strip on subject-reported outcomes.

Conclusion

The Patency study demonstrated significant improvement from baseline in nasal dimensions and flow for all 3 evaluated strips; between-strip differences were confined to nasal dimensions. Both the BRNS and butterfly strip were generally well tolerated, with no evidence of dermal response over 7 consecutive nights of use.

ClinicalTrials.gov identifiers: NCT01105949 and NCT01495494

Targeting head movements in humans: Compensation for disturbance from simultaneous body rotations

Vestibular information plays an important role in spatially oriented motor control and perception. With regard to reorienting head movements, little is known of (1) how vestibular mechanisms compensate for disturbances from concurrent passive trunk rotations (e.g. in a veering vehicle), and (2) whether and how this disturbance compensation is related to the perception of body orientation in space. We here address these two questions in a single experiment. Six healthy subjects (Ss) seated on a turning chair in darkness performed two tasks. (1) Head pointing: Ss made swift head movements in darkness towards the angular position in space of a previously shown visual target. These movements were disturbed by concurrent rotations of the chair, and hence the trunk, which were driven by scaled down versions of the Ss' own head-on-trunk rotations. Although unaware of the disturbance, Ss adjusted their head movements so as to attenuate its effect on head-in-space (HS) position by about 45%. (2) Visual straight ahead (VSA): Using a light pointer, Ss indicated their VSA before each head-pointing trial and tried to reproduce it after the trial. In all Ss, VSA accounted for the disturbing trunk rotation, although to individually varying degrees. No correlation could be detected between VSA reproduction and motor performance, neither within nor across subjects. A vestibular loss subject who performed the same two tasks made no compensatory movements during head pointing and did not account for the disturbance of his HS position during VSA reproduction. Three concepts of vestibular information processing for head movement control were explored with regard to their compatibility with the head-pointing results: (1) Conventional negative feedback, (2) Interaction with an efference copy, and (3) Interaction with neck proprioceptive information. Theoretical analyses and model simulations indicated that all three concepts can explain the observed disturbance compensation. However, they differ in terms of control stability in the presence of feedback time delays, with (3) being best and (1) worst. The different concepts might correspond to fast simple and slower complex compensation mechanisms, respectively, and possibly complement each other during natural behaviours. VSA reproduction may be based on analogous processing principles, but appears to involve different neural circuitries.

On Implant Prosthodontics: One Narrative, Twelve Voices - 9

No abstract available.

Helicity asymmetry in strong-field ionization of atoms by a bicircular laser field

Ionization of atoms by an intense bicircular laser field is considered, which consists of two coplanar corotating or counterrotating circularly polarized field components with frequencies that are integer multiples of a fundamental frequency. Emphasis is on the effect of a reversal of the helicities of the two field components on the photoelectron spectra. The velocity maps of the liberated electrons are calculated using the direct strong-field approximation (SFA) and its improved version (ISFA), which takes into account rescattering off the parent ion. Under the SFA all symmetries of the driving field are preserved in the velocity map while the ISFA violates certain reflection symmetries. This allows one to assess the significance of rescattering in actual data obtained from an experiment or a numerical simulation.

Detecting Opioid-Related Aberrant Behavior using Natural Language Processing

The United States is in the midst of a prescription opioid epidemic, with the number of yearly opioid-related overdose deaths increasing almost fourfold since 20001. To more effectively prevent unintentional opioid overdoses, the medical profession requires robust surveillance tools that can effectively identify at-risk patients. Drug-related aberrant behaviors observed in the clinical context may be important indicators of patients at risk for or actively abusing opioids. In this paper, we describe a natural language processing (NLP) method for automatic surveillance of aberrant behavior in medical notes relying only on the text of the notes. This allows for a robust and generalizable system that can be used for high volume analysis of electronic medical records for potential predictors of opioid abuse.

miR-466a Targeting of TGF-β2 Contributes to FoxP3+ Regulatory T Cell Differentiation in a Murine Model of Allogeneic Transplantation

The promise of inducing immunological tolerance through regulatory T cell (Treg) control of effector T cell function is crucial for developing future therapeutic strategies to treat allograft rejection as well as inflammatory autoimmune diseases. In the current study, we used murine allograft rejection as a model to identify microRNA (miRNA) regulation of Treg differentiation from naïve CD4 cells. We performed miRNA expression array in CD4+ T cells in the draining lymph node (dLN) of mice which received syngeneic or allogeneic grafts to determine the molecular mechanisms that hinder the expansion of Tregs. We identified an increase in miRNA cluster 297-669 (C2MC) after allogeneic transplantation, in CD4+ T cells, such that 10 of the 27 upregulated miRNAs were all from this cluster, with one of its members, mmu-miR-466a-3p (miR-466a-3p), targeting transforming growth factor beta 2 (TGF-β2), as identified through reporter luciferase assay. Transfection of miR-466a-3p in CD4+ T cells led to a decreased inducible FoxP3+ Treg generation while inhibiting miR-466a-3p expression through locked nucleic acid resulting in increased Tregs and a reduction in effector T cells. Furthermore, in vivo inhibition of miR-466a-3p in an allogeneic skin-graft model attenuated T cell response against the graft through an increase in TGF-β2. TGF-β2 was as effective as TGF-β1 at both inducing Tregs and through adoptive transfer, mitigating host effector T cell response against the allograft. Together, the current study demonstrates for the first time a new role for miRNA-466a-3p and TGF-β2 in the regulation of Treg differentiation and thus offers novel avenues to control inflammatory disorders.

99mTc-Labelled Polyclonal Human Immunoglobulin for Localization of Inflammatory Sites - Early in vitro-Results

99mTc-labelled polyclonal human immunoglobulin (HIG) has been shown to be able to localize inflammatory sites. Hypothetically these immunoglobulins bind directly to bacteria, HIG binds directly to Fc-receptors on the surface membrane of leucocytes or HIG simply passes vessels of increased permeability. To collect further information experiments were carried out in vitro with the blood of human volunteers. 0.5 mg 99mTc-HIG, 2 mg 99mTc-human albumin and 0.5 mg 99mTc-labelled murine monoclonal antigranulocyte antibodies were added to in vitro isolated human “mixed” leucocyte pellets and to 30 ml whole blood of 6 healthy volunteers. The whole blood and the directly labelled leucocyte pellet were layered and separated on a discontinuous Percoll®/ plasma gradient. The activity distribution was measured within the gradient. The 99mTc-HIG labelled gradients showed a significant uptake of the activity within the monocyte band whereas the 99mTc-albumin gradients showed no specific albumin uptake in any cellular band. The 99mTc-antibody labelled gradients showed a significantly increased uptake on granulocytes . It is concluded that in man a specific monocyte-associated uptake and binding mechanism of 99mTc-HIG plays an important role in the localisation of inflamed sites.

Hysterosalpingoscintigraphy: A Simple and Accurate Method of Evaluating Fallopian Tube Patency

A prospective study was designed to evaluate the efficacy of radionuclide hysterosalpingoscintigraphy using 99mTc-labelled human serum albumin macroaggregates in 17 patients (34 tubes). In normal females the niacroaggregates migrate spontaneously through the female reproductive tract following application into the posterior vaginal fornix. They can be seen in the uterine fornix 20 min p. i. (range: 5-90 min) and as free pelvic activity 120 min p. i. (range 40-180 min). Free pelvic activity could also be demonstrated by culdocentesis. In infertile patients with failure of tubal patency images after 180 min offered no additional information. For the routine diagnosis camera images 5, 60 and 180 min p. i. are recommended. Using 5-10 MBq 99mTc the radiation exposure to the ovaries is about 1/9th of the exposure from a normal radiologic hysterosalpingogram. The reported data show results comparable with those of hysterosalpingography (HSG) in females with patent or with nonpermeable tubes, but in cases of high-pressure patency by HSG the results of scintigraphy are superior to those of HSG. Moreover, this method provides new insights into sperm motility under various physiological and pathological conditions.

Kinetics of 99mTc-Labelled Antibodies against CD4 (T-Helper) Lymphocytes in Man

Die Verfügbarkeit 99mTc-markierter CD4-Antikörper erlaubt das Studium ihres kinetischen Verhaltens bei rheumatischen Patienten. Prospektiv wurden Patienten mit rheumatoider Arthritis untersucht. Drei dieser Patienten erhielten 250 µg eines mit 555 MBq 99mTc markierten CD4-Antikörpers (MAX16H5) injiziert. Ein Patient erhielt in vitro mit 99mTc markierte Lymphozyten. 4% der Aktivität wurden renal eliminiert. Von 4 nach 24 h p. i. fiel der Milzuptake von 7,5 auf 4%, der Leberuptake stieg von 25 auf 30%, der Knochemarkuptake blieb vergleichbar (50%), während der Uptake über einem großen erkrankten Gelenk von 2 geringfügig auf 2,5% stieg. 15 bis 30 min nach der Antikörperinjektion war eine Umverteilung von Aktivität zu registrieren, die einer Lymphozytenredistribution vergleichbar war. Die Recoveryrate (0-1 h) der in vivo markierten Zellen betrug 30%, die der in vitro markierten Zellen 19%. Ein Patient wurde mit in vitro CD4-Antikörper-markierten Lymphozyten untersucht. Ein signifikanter Unterschied der Kinetik beider Präparationen war nicht zu registrieren. Zusammenfassend schließen die Autoren, daß zirkulierende CD4-exprimierende Lymphozyten mit CD4-Antikörpern markiert werden können. Die kinetischen Daten erinnern an jene rezirkulierender Lymphozyten.

Diagxxnostic Accuracy of 99mTc-Anti-CEA Immuno- scintigraphy in Patients with Liver Metastases from Colorectal Carcinoma

17 Patienten mit 43 Lebermetastasen kolorektaler Karzinome wurden der Immunszintigraphie (IS) mit 99mTc-markierten monoklonalen Anti-CEA-Antikörpern (BW 431/26) unterzogen. Im Hinblick auf die Gesamtzahl der Raumforderungen wurden Sensitivität und diagnostische Treffsicherheit mit 21% bestimmt, bezogen auf die Patientenzahl betrugen sie 47% (mindestens eine positive Darstellung bei multiplen Metastasen) bzw. 77% bei nur einer Solitärmetastase. Die Sensitivität wurde durch Verwendung der SPECT- Technik nicht wesentlich verbessert. Eine Korrelation mit den Serum-CEA- Spiegeln ließ sich nicht nachweisen. Am besten schienen sich Lebermetastasen mittlerer Größe mit mäßiger Tumornekrose darzustellen. Die Ursache für die geringe Sensitivität ist vor allem in der ausgeprägten unspezifischen Anreicherung 99mTc-markierter Antikörper im RES der Leber zu sehen. Im Augenblick scheint die Immunszintigraphie lediglich eine ergänzende Methode zu konventionellen diagnostischen Maßnahmen darzustellen.

Ist ein TSH-Screening zur Diagnose oder zum Ausschluß der funktionellen Autonomie der Schilddrüse sinnvoll?

Ein im Normbereich gelegener TSH-Basalspiegel erlaubt heute im Screening den Ausschluß einer Schilddrüsenfunktionsstörung. Die vorliegende Studie überprüfte die Wertigkeit der TSH-Bestimmung zum Hinweis auf eine Schilddrüsenautonomie und damit die Indikation zur weiterführenden Schilddrüsendiagnostik. Hierzu wurden in einer retrospektiven Analyse 310 Patienten, die eine klinische Euthyreose bei normalen peripheren Schilddrüsenhormonparametern boten, ausgewertet. Der positive prädiktive Wert zur Diagnose einer Schilddrüsenautonomie errechnete sich mit 55,5%, der negative prädiktive Wert zum Ausschluß einer Schilddrüsenautonomie mit 87%. Somit erlaubt der TSH-Basisspiegel die Diagnose einer Schilddrüsenautonomie nicht. Der Ausschluß der Schilddrüsenautonomie kann jedoch mit einer Wahrscheinlichkeit von 87,7% geführt werden, wenn der TSH-Spiegel über 0,5 mU/l liegt. Ein TSH-Spiegel unter 0,3 mU/l läßt mit einer Wahrscheinlichkeit von 72,5% auf das Vorliegen einer Autonomie schließen.

Supprimierbarkeit autonomen Schilddrüsengewebes unter endogener und zusätzlicher exogener TSH-Suppression bei Patienten mit Schilddrüsenautonomie

Ziel: Diese retrospektive Studie überprüft bei Patienten mit funktionell relevanter Schilddrüsenautonomie den Effekt einer zusätzlich exogenen Schilddrüsenhormonsuppression auf den 99mTechnetium-Thyreoidea-Uptake (TcTU) bei bestehender endogener Suppression. Methode: Bei 21 Patienten, untersucht in den Jahren 1992-1996, wurde nach vorab endogener Suppression (end) des TSH-b und Bestimmung des TcTU nach einer zusätzlichen exogenen Suppression (ex) mit über zunächst 2 Wochen 75 μ/dl und weitere 2 Wochen 150 μg/d oder dem Körpergewicht entsprechend 2 μg/kg Levothyroxin, eine weitere TcTU-Bestimmung durchgeführt. Die gesamte Patientengruppe wird als Gruppe I mit einem TcTUend von 1,6%-7,4% unter endogener Suppression bezeichnet. Die Untergruppen wurden nach verschiedenen TcTU-Schwellen erstellt. Gruppe la TcTUend≥1,6% und <2,5%, Gruppelb TcTUend ≥2,5%, Gruppe Ic TcTUend ≥3%. Ergebnisse: Der intraindividuelle Vergleich zeigt eine signifikante Verminderung des TcTU nach zusätzlich exogener Suppression mit Levothyroxin. Im einzelnen zeigen sich folgende TcTU Werte: Die Gruppe I zeigt alle Patienten mit einem TcTUend = 3,47 ± 1,65 und einem TcTUex = 2,91 ± 1,38, entsprechend einer Reduktion von 20 rel.% (p ≤0,001); Gruppe la TcTUend = 2,5% ± 0,27, TcTUex = 1.85% ± 0,22, entsprechend 10 rel.% (p ≤0,01); Gruppe Ib TcTUend = 4,18% ± 1,59, TcTUex = 3,45% ± 1,34, entsprechend 20 rel.% (p ≤0,001); Gruppe lc TcTUend = 5,00% ± 1,43, TcTUex = 4,05% ± 1,32, entsprechend 20 rel.% (p≤0,001). Schlußfolgerung: Ausgehend von einer möglichen’ strukturellen Variabilität des autonomen SD-Gewebes mit heterogenen TSH-Rezeptoren zeigt unsere Studie eine signifikante zusätzliche exogene Supprimierbarkeit von bereits endogen supprimierten TSH-Rezeptoren.

Somatostatin Receptor Expression in the Thyroid Demonstrated with 111In-Octreotide Scintigraphy

Neuroendocrine tumors with somatostatin receptor expression may be localized by 111ln-octreotide scintigraphy. This study examines those thyroid conditions where 111 ln-octreotide uptake could be observed also in the thyroid gland. 26 consecutive patients who underwent 111 ln-octreotide scintigraphy for tumor localization were additionally examined for thyroid disease by sonography and 99mTc-pertechnetate scintigraphy. 12 of these patients had no significant thyroid uptake and had an euthyroid normal-sized thyroid gland. 14 patiens with 111ln thyroid uptakes had endemic goiters, two of them with thyroid autonomy and one with Graves’ disease. Thus, 111 ln-octreotide thyroid uptake was predominantly seen in patients with endemic goiter with or without thyroid autonomy.

Arthroscintigraphy in Suspected Rotator Cuff Rupture

Aim: In order to evaluate the diagnostic efficiency of arthroscintigraphy in suspected rotator cuff ruptures this new imaging procedure was performed 20 times in 17 patients with clinical signs of a rotator cuff lesion. The scintigraphic results were compared with sonography (n = 20), contrast arthrography (n = 20) and arthroscopy (n = 10) of the shoulder joint. Methods: After performing a standard bone scintigraphy with intravenous application of 300 MBq 99m-Tc-methylene diphosphonate (MDP) for landmarking of the shoulder region arthroscintigraphy was performed after an intraarticular injection of 99m-Tc microcolloid (ALBURES 400 μCi/5 ml). The application was performed either in direct combination with contrast arthrography (n = 10) or ultrasound conducted mixed with a local anesthetic (n = 10). Findings at arthroscopical surgery (n = 10) were used as the gold standard. Results: In case of complete rotator cuff rupture (n = 5), arthroscintigraphy and radiographic arthrography were identical in 5/5. In one patient with advanced degenerative alterations of the shoulder joint radiographic arthrography incorrectly showed a complete rupture which was not seen by arthroscintigraphy and endoscopy. In 3 patients with incomplete rupture, 2/3 results were consistant. A difference was seen in one patient with a rotator cuff, that has been already revised in the past and that suffered of capsulitis and calcification. Conclusion: Arthroscintigraphy is a sensitive technique for detection of rotator cuff ruptures. Because of the lower viscosity of the active compound, small ruptures can be easily detected, offering additional value over radiographic arthrography and ultrasound, especially for evaluation of incomplete cuff ruptures.

Clinical Implications of a New TSH-receptor-antibody-assay (DYNOtest® TRAKhuman) in Autoimmune Thyroid Diseases

Aim: Conventional radioreceptor-antibody-assays (RAAs) fail in the detection of TSH-receptor antibodies (TRAKs) in 10–30% of patients with Graves’ disease (GD). The aim of this study was the evaluation of the diagnostic and clinical impact of a new RRA (DYNOtest® TRAKhuman) which uses the human recombinant TSH-Receptor in the diagnosis of autoimmune thyroid disease. Methods: Sera from 142 consecutive patients (GD: n=50, autoimmune thyroiditis/AIT: n=92) and from 55 controls (31 patients without any thyroid disease and 14 with euthyroid goiter) were evaluated both with the DYNOtest® TRAKhuman-assay and a conventional RRA (TRAK-Assay®). Thyroid in vitro parameters and thyroid sonography were performed in all patients. Results: The DYNOtest® TRAK-assay was significantly superior to the conventional RRA in the diagnosis of GD (p < 0,00012), especially in those who were treated by thionamides (p < 0,003) and in the diagnosis of TRAK-positive patients with AIT(p < 0,003). The majority of TRAK-positive AIT-patients suffered from hypothyroidism. One false positive result in patients with euthyroid goiter was found in the TRAK-Assay® as well as in the DYNOtest® TRAKhuman-Assay. Therefore the specifity of the DYNOtest® TRAKhuman was not inferior compared with the conventional assay. Conclusion: The DYNOtest® TRAK-assay is superior in the diagnostic work up of Graves’ disease compared with a conventional TRAK-assay and offeres an equal specifity.

Immunoscintigraphy in Medullary Thyroid Cancer Using an 123I- or 111ln-Labelled Monoclonal Anti-CEA Antibody Fragment

The monoclonal anti-CEA F(ab’)2 fragment MAb BW 431/31, labelled with 123I or111 In, was used for immunoscintigraphy (IS) in 9 patients with medullary cancer of the thyroid (CCC). The results of 11 studies lead to the following conclusions: 1) When using radioiodine as a label for MAb in IS, potassium iodide is absolutely necessary to block the thyroid which is of special importance in patients with thyroid cancer; 2) Preinjection of “cold” MAb reduces the relatively high unspecific uptake (especially in bone marrow) of MAb BW 431/31, which is of special importance for the antibody labelled with 111 In; 3) IS with MAb BW 413/31 in patients with CCC and elevated serum CEA is positive only in cases with large secondaries; and 4) In patients with CCC and several manifestations of secondaries, only a single (large) metastasis may be apparent.

Radioiodination of monoclonal antibodies, proteins and peptides for diagnosis and therapy

Simple and reliable methodologies for radioiodination of proteins and peptides are described. The labeling systems are easy to assemble, capable of radioiodinating any protein or, with slight modifications, also peptide (molecular mass 1000-300,000) from kBq to GBq levels of activity for use in diagnosis and/or therapy. Furthermore, the procedures are feasible in any nuclear medicine department. Gigabecquerel amounts of activity can be handled safely. The most favored iodination methodology relies on the Iodogen system, a mild oxidating agent without reducing agents. Thus, protein degradation is minimized. Labeling yields are between 60 and 90%, and immunoreactivities remain ≥ 85%. Other radioiodination methods (chloramine-T, Bolton-Hunter) are described and briefly discussed.

F-18-FDG-hybrid-camera-PET in patients with postoperative fever

Aim: Evaluation of F-18-FDG-hybrid-camera-PET imaging in patients with undetermined postoperative fever (POF). Methods: Prospective study of 18 patients (9 women, 9 men; age 23-85 years) suffering from POF with 2-fluoro-2’-deoxyglucose (F-18-FDG) using a dual headed coincidence camera (DHCC). Surgery had been performed 5-94 days prior to our investigation. 13 of the 18 patients received antibiotic therapy during the time of evaluation. Ten (55%) had an infectious and eight (45%) a non infectious cause of fever. Results: Increased F-18-FDG-uptake outside the surgical wound occurred in 13 regions (infection n = 11, malignancy n = 2). The sensitivity of F-18-FDG-hybrid-camera-PET in imaging infection in areas outside the surgical wound was 86% and the specificity 100%, respectively. Antibiotic therapy did not negatively influence the results of F-18-FDG-scanning. Increased F-18-FDG-uptake within the surgical wound was seen in 8 of 18 patients. The sensitivity of F-18-FDG-hybrid-camera-PET in imaging infection within the surgical wound was 100% and the specificity 56%, respectively. The interval between surgery and F-18-FDG-scanning was significantly shorter in patients with false positive results compared with patients showing true negative results (median 34 vs. 54 days; p = 0,038). Conclusion: In POF-Patients, F-18-FDG transaxial tomography performed with a F-18-FDG-hybrid-camera-PET is sensitive in the diagnosis of inflammation and malignant disease within and outside the surgical wound. Because of the accumulation of the tracer both in granulation tissue and infection, the specificity in detecting the focus of fever within the surgical wound is poor.

Minimal contribution of cell-bound antibodies to the immunoscintigraphy of inflamed joints with 99mTc-anti-CD4 monoclonal antibodies

Aim: The cellular joint infiltrate in rheumatoid arthritis patients is rich in CD4-positive T-helper lymphocytes and macrophages, rendering anti-CD4 monoclonal antibodies (mAbs) suitable for specific immunoscintigraphy of human/ experimental arthritis. Following intravenous injection, however, mAbs are present both in the free form and bound to CD4-positive, circulating monocytes and T-cells. Thus, the present study aimed at analyzing the relative contribution of the free and the cell-bound component to the imaging of inflamed joints in experimental adjuvant arthritis (AA). Methods: AA rat peritoneal macrophages or lymph node T-cells were incubated in vitro with saturating amounts of 99mTc-anti-CD4 mAb (W3/25) and injected i.v. into rats with AA. Results: In vitro release of 99mTc-anti-CD4 mAb from the cells was limited (on average 1.57%/h for macrophages and 0.84%/h for T-cells). Following i.v. injection, whole body/joint scans and tissue measurements showed only negligible accumulation of radioactivity in inflamed ankle joints (tissue: 0.22 and 0.34% of the injected activity, respectively), whereas the radioactivity was concentrated in liver (tissue: 79% and 71%, respectively), kidney, and urinary bladder. Unlike macrophages, however, anti-CD4 mAb-coated T-cells significantly accumulated in lymphoid organs, the inflamed synovial membrane of the ankle joints, as well as in elbow and knee joints. Conclusion: While the overall contribution of cell-bound mAbs to the imaging of arthritic joints with anti-CD4 mAbs is minimal, differential accumulation of macrophages and T-cells in lymphoid organs and the inflamed synovial membrane indicates preferential migration patterns of these 2 cell populations in arthritic rats. Although only validated for 99mTc-anti-CD4 mAbs, extrapolation of the results to other anticellular mAbs with similar affinity for their antigen may be possible.