Incidence, risk factors and outcomes of checkpoint inhibitor-induced liver injury: A 10-year real-world retrospective cohort study

Background & Aims

Checkpoint inhibitors (CPI) account for increasing numbers of drug-induced liver injury (DILI) cases. We aimed to determine the incidence rate and risk factors associated with checkpoint inhibitor-induced liver injury (ChILI).

Methods

Prescription event monitoring was performed on all melanoma and renal cancer patients who received CPI at a tertiary centre between 2011 and 2021. ChILI cases were identified using the definitions, grading, and causality assessment methods validated for DILI. We assessed risk factors associated with ChILI in CPI-naive patients using multivariable logistic regression model. Consecutive patients with suspected ChILI from two other tertiary centres were adjudicated and combined for case characterisation and outcomes of ChILI.

Results

Out of 432 patients who received CPI over 10 years, ChILI occurred in 38 (8.8%) with an overall incidence rate of 11.5 per 1,000 person-months (95% CI 8.2-15.8). Probability of ChILI was highest in combination therapy (32%) and no new events occurred beyond 135 days of treatment. Risk factor analysis showed that combination therapy, female sex, higher baseline alanine transferase level and lower baseline alkaline phosphatase level were independently associated with higher risk of ChILI. In total, 99 patients were adjudicated to have ChILI from three centres. Although Common Terminology Criteria for Adverse Events classified 20 patients (20.2%) to have 'life-threatening' grade 4 hepatitis, ChILI severity was graded as mild in 45 (45.5%) and moderate in the remaining 54 (54.5%) cases.

Conclusions

The real-world risk of ChILI is higher than previously reported. Among patients receiving dual CPI, this risk falls markedly after 4.5 months. As Common Terminology Criteria for Adverse Events overestimates its clinical severity, case-definition, evaluation and management of ChILI should be revised to harmonise care.

Impact and implications

Using prescription event monitoring over a 10-year period, the incidence rate of checkpoint inhibitor induced liver injury (ChILI) based on established case definitions for drug-induced liver injury (DILI) is 11.5 per 1,000 person-months. Formal causality assessment identified an alternative cause in 19% of patients with suspected ChILI highlighting the importance of systematic evaluation by clinicians to minimise unnecessary immunosuppression. Intensity of monitoring in patients receiving combination therapy regime after 4.5 months of therapy can be reduced as the risk of new onset ChILI beyond this point is minimal. Current Common Terminology Criteria for Adverse Events (CTCAE) grading overestimates clinical severity of ChILI and hence contributes to avoidable hospitalisation.

Novel treatment of acute and acute-on-chronic liver failure: Interleukin-22

Acute liver failure (ALF) is a life-threatening medical condition, characterized by rapidly progressive hepatic dysfunction, coagulopathy and hepatic encephalopathy in patients without chronic liver disease, while acute-on-chronic liver failure (ACLF) occurs in patients with existing chronic liver disease. ALF and ACLF are often associated with multiple organ failure and a high short-term mortality. In this review, we briefly discuss the causes and pathogenesis of ALF and ACLF, the current options available for the treatment of both deadly maladies and interleukin-22 (IL-22), a novel promising drug that may have great therapeutic potential for ALF and ACLF treatment. IL-22 is a cytokine produced by immune cells but mainly targets epithelial cells including hepatocytes. IL-22 has been shown to protect against organ damage and reduce bacterial infection in many preclinical models and several clinical trials including alcohol-associated hepatitis. The potential application of IL-22 for the treatment of ALF and ACLF is also elaborated.

Left bundle area pacing: Guiding implant depth by ring measurements

BACKGROUND

Criteria for successful left bundle area pacing (LBAP) are in flux and currently guided by lead tip measurements. Lead ring measurements during LBAP have not been well studied.

OBJECTIVE

The purpose of this study was to investigate dynamics in pacing parameters during successful and unsuccessful lead implant attempts.

METHODS

SelectSecure 3830 pacing leads (Medtronic, Inc) guided by C315 sheaths for LBAP were placed for standard pacing indications in 73 patients. Retrospective review of procedural, echocardiographic, and standard pacing data were performed. Depth and lead-septal angle of implanted electrodes were determined from fluoroscopy with septal contrast delineation. Depth was graded in 4 categories according to the degree of ring penetration into the septum. Successful implant was defined by the ability to advance the lead deep into the septum and achieve LBAP criteria (ventricular activation time, QRS width/shape).

RESULTS

Ring impedance increased stepwise during successful attempts as opposed to unsuccessful attempts (P = .039). A wider lead-septal angle at implant position correlated with higher ring impedance (P = .036), whereas no association was found with tip impedance. Unipolar ring threshold correlated with depth of lead implant (P = .029). Tip impedance measurements at implant position were less predictive of lead depth and did not correlate with septal thickness.

CONCLUSION

Ring pacing parameters are more predictive of lead progress than tip measurements. Lead depth and lead-septal angle can be determined from ring impedance measurements. These measurements may provide determination of lead depth and could obviate the need for contrast injection.

Fibrosis progression rate in a systematic review of placebo-treated nonalcoholic steatohepatitis

BACKGROUND & AIMS

Liver fibrosis is the critical determinant of liver-related outcomes in persons with nonalcoholic fatty liver disease. The rate that fibrosis develops determines the time taken to reach cirrhosis and consequent clinical outcomes. Estimates of the fibrosis progression rate (FPR) are uncertain having been defined in small observational series that rely largely on nonstandardised repeat biopsy in selected patients. The aim of this study was to evaluate the FPR in placebo-treated participants with nonalcoholic steatohepatitis (NASH) in randomised controlled trials (RCTs).

METHODS

Systematic review and meta-analysis of RCTs in NASH with data on fibrosis change extracted. Calculated fibrosis progression rates were pooled in meta-analysis. The pooled estimate was then used to model the proportion of hypothetical cohorts starting with no fibrosis at the age of 30 who develop cirrhosis.

RESULTS

A total of 35 trials including 1419 placebo-treated participants who underwent repeat liver biopsy were evaluated. Considering all trials, the overall FPR was 0.00 stages per year, increasing to 0.03 stages per year in both trials at low risk of bias and trials including >50 placebo-treated participants. This estimate was markedly lower than the value derived from previously pooled analyses of observational data. Using a FPR of 0.03 resulted in a substantial reduction in the proportion of patients developing cirrhosis compared with the FPR derived from observational studies (13% vs 28%).

CONCLUSIONS

The FPR in placebo-treated participants in RCTs is lower than that described from observational data. Slower fibrosis progression predicts fewer persons with NASH will progress to cirrhosis than previously estimated.

Comparison of droplet spread in standard and laminar flow operating theatres: SPRAY study group

BACKGROUND

Reducing COVID-19 transmission relies on controlling droplet and aerosol spread. Fluorescein staining reveals microscopic droplets.

AIM

To compare the droplet spread in non-laminar and laminar air flow operating theatres.

METHODS

A 'cough-generator' was fixed to a theatre trolley at 45°. Fluorescein-stained 'secretions' were projected on to a series of calibrated targets. These were photographed under UV light and 'source detection' software measured droplet splatter size and distance.

FINDINGS

The smallest droplet detected was ∼120 μm and the largest ∼24,000 μm. An average of 25,862 spots was detected in the non-laminar theatre, compared with 11,430 in the laminar theatre (56% reduction). The laminar air flow mainly affected the smaller droplets (<1000 μm). The surface area covered with droplets was: 6% at 50 cm, 1% at 2 m, and 0.5% at 3 m in the non-laminar air flow; and 3%, 0.5%, and 0.2% in the laminar air flow, respectively.

CONCLUSION

Accurate mapping of droplet spread in clinical environments is possible using fluorescein staining and image analysis. The laminar air flow affected the smaller droplets but had limited effect on larger droplets in our 'aerosol-generating procedure' cough model. Our results indicate that the laminar air flow theatre requires similar post-surgery cleaning to the non-laminar, and staff should consider full personal protective equipment for medium- and high-risk patients.

The Association of Introducing a Faecal Calprotectin Testing Pathway for Suspected Inflammatory Bowel Disease in Primary Care and Time to Diagnosis or Treatment

Background

Primary care faecal calprotectin (FC) was introduced in Leeds in 2014 to distinguish inflammatory bowel disease (IBD) from irritable bowel syndrome and with the hope that it may reduce time to IBD diagnosis and treatment. This study examines the association of FC with referral routes, time to diagnosis, and time to treatment.

Methods

All patients newly referred to IBD clinics in 2013 and 2016 were studied. Data on referral routes and dates, FC, date of first treatment, and proxy outcomes for disease severity were collected.

Results

In 248 patients, there were no differences between 2013 and 2016 cohorts regarding baseline data and disease severity. The number of direct referrals to gastroenterology rose from 3% (2013) to 17% (2016), whilst 10% were diagnosed during emergency admissions. Referrals via suspected cancer pathways remained high (38% in 2013, 28% in 2016), whilst many had initial investigations at independent centres (16% in 2013, 24% in 2016). Time from referral to diagnosis was similar between 2013 (0.77 month) and 2016 (1.10 months, p = 0.2). A total of 48 (33.3%) patients had FC checked prior to referral, and 37.5% of these were referred directly to gastroenterology. Time from diagnosis to treatment reduced from 1.37 months (2013) to 0.72 month (2016, p = 0.01).

Conclusion

Patients present via a multitude of referral pathways, but FC was associated with increased direct referrals to gastroenterology. We found a variation in time to diagnosis and treatment depending on referral routes. Further work is required to ensure patients with suspected IBD get referred to IBD services in a timely manner.

0112 Lucid Dreaming Associated with Positive Waking Mood

Introduction

Lucid dreaming (being aware that one is dreaming) is typically a positive experience that may enhance positive mood even after waking. There is concern, however, that lucid dreaming may interfere with sleep quality. In the current experiment, participants practiced common lucid dream induction techniques over the course of a week, and kept a daily sleep and dream diary. The study objective was to assess relationships between dream lucidity and subjective sleep quality, dream emotional content, and subsequent waking mood.

Methods

There were 32 participants aged 19–33 in this open label, single arm study (mean=22.63±3.48; 6 males, 24 females). All participants completed a sleep and dream diary for 7 days that included scaled items (1–7 scale) concerning subjective sleep quality, negative and positive emotional intensity of a dream (if recalled). Participants also completed a 19-item lucidity questionnaire, and the Positive and Negative Affect Schedule. Average scores for the week were computed for all measures and Pearson’s correlations conducted between lucidity and all other measures. Participants with no dream recall (n=5) were excluded. Within-subjects analyses were undertaken by selecting each participant’s highest and lowest lucidity night (n=22; 5 participants with only minimum lucidity excluded).

Results

Positive correlations were found between lucidity and dream positive emotion (r=.490, n=27, p=.009) and positive waking mood (r=.638, n=27, p&lt;.001); there were no other significant correlations (all p&gt;.1). Higher lucidity was associated with more positive dream content (t(21)= -3.214, p=.004) and positive waking mood (t(25)=-4.568, p&lt;.001); no other significant differences were observed.

Conclusion

These data indicate that lucidity is associated with positive dreams and waking mood, with no detriment to self-reported sleep quality. The findings provide preliminary support of lucid dreaming as an intervention to improve wellbeing and mood in the short term.

Support

N/A

Direct Visualization of the His Bundle Pacing Lead Placement by 3-Dimensional Electroanatomic Mapping: Technique, Anatomy, and Practical Considerations

BACKGROUND

His bundle pacing (HBP) remains technically challenging and is currently guided by electrograms and 2-dimensional fluoroscopy. Our objective was to describe a new technique for HBP directly guided by electroanatomic mapping (EAM).

METHODS

Twenty-eight patients were included. The atrioventricular septum was mapped via EAM, and His bundle (HB) electrograms, selective, and nonselective HB capture sites were tagged. Pacing leads were connected to EAM, navigated to tagged HB target sites and deployed. Intracardiac electrograms and pacing parameters were recorded. Lead location was tagged on the cloud of HB sites, which was divided into 3 arbitrary segments. In 5 patients, atrioventricular nodal ablation was performed with direct visualization of the HBP lead by EAM.

RESULTS

Reproducible navigation of the pacing lead to predetermined HBP locations guided by EAM was achieved in all patients. The lead was successfully deployed in 25 patients. HB cloud area was 360 (212) mm². There was no correlation between HBP threshold and lead location on the His cloud. The intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlated with its EAM position on the His cloud ( P=0.045). Procedure, fluoroscopy, and mapping times were 116.0 (38.8), 8.6 (6.3), and 9.0 (11.4) minutes, respectively. HBP threshold at implant was 1.5 (2.3) V at 1.5 (1.0) ms. Distance between HB lead and ablation sites was 10.0 (1.3) mm in patients undergoing atrioventricular nodal ablation.

CONCLUSIONS

Direct guidance of HBP by EAM allows for direct visualization of the pacing lead on the HB cloud and reproducible navigation to predetermined HB capture sites. Intracardiac electrograms atrial/ventricular ratio at the lead deployment site correlates with His cloud location. EAM can be applied during standard HBP procedures or combined with atrioventricular nodal ablation.

Permanent His-bundle pacing using stylet-directed, active-fixation leads placed via coronary sinus sheaths compared to conventional lumen-less system

BACKGROUND

The use of coronary sinus (CS) sheaths to deliver stylet-driven leads (SDLs) for His-bundle pacing (HBP) has not been described. Conventionally, HBP is achieved using a stylet-less lead delivered through a customized catheter.

OBJECTIVE

The purpose of this study was to characterize the acute and early-term HBP experience with stylet-driven, active-fixation leads delivered through CS sheaths compared to the conventional approach.

METHODS

Delivery of Medtronic 4471 and 7742 SDLs was attempted in 27 patients. Delivery was facilitated using CS guide catheters and custom-shaped stylets. Procedural characteristics and lead performance were compared to those of a group of 17 patients in whom delivery of 3830 lumen-less leads (LLLs) was attempted. Patients had heterogeneous pacing indications.

RESULTS

HBP with SDL was successful in 24 of 27 patients(89%) compared to 15 of 17 patients (88%) in the LLL group. Mean procedural and fluoroscopy times in the SDL and LLL groups were 129 ± 43 minutes vs 104 ± 43 minutes and 9.6 ± 5.2 minutes vs 8.3 ± 5.0 minutes, respectively (both P = NS). There was a significant difference in procedure and fluoroscopy times within the SDL group between the first and second halves of the series, probably secondary to a learning curve. Acute HBP thresholds were higher with SDL than with LLL (2.6 ± 1.5 V vs 1.5 ± 1.2 V; P = .02) and remained stable at 8.4 ± 5.3 months. Both SDLs exhibited similar pacing thresholds. Two crossovers between groups occurred (1 in each group). Four patients with SDL and 1 patient with LLL exhibited high thresholds during follow-up.

CONCLUSION

Permanent HBP using stylet-driven, active-fixation leads delivered through conventional CS sheaths is feasible. Procedural characteristics and lead performance were clinically acceptable.

BET bromodomain ligands: Probing the WPF shelf to improve BRD4 bromodomain affinity and metabolic stability

Ligands for the bromodomain and extra-terminal domain (BET) family of bromodomains have shown promise as useful therapeutic agents for treating a range of cancers and inflammation. Here we report that our previously developed 3,5-dimethylisoxazole-based BET bromodomain ligand (OXFBD02) inhibits interactions of BRD4(1) with the RelA subunit of NF-κB, in addition to histone H4. This ligand shows a promising profile in a screen of the NCI-60 panel but was rapidly metabolised (t½ = 39.8 min). Structure-guided optimisation of compound properties led to the development of the 3-pyridyl-derived OXFBD04. Molecular dynamics simulations assisted our understanding of the role played by an internal hydrogen bond in altering the affinity of this series of molecules for BRD4(1). OXFBD04 shows improved BRD4(1) affinity (IC50 = 166 nM), optimised physicochemical properties (LE = 0.43; LLE = 5.74; SFI = 5.96), and greater metabolic stability (t½ = 388 min).

Epidemiological investigation of grass seed foreign body-related disease in dogs of the Riverina District of rural Australia

OBJECTIVE

To characterise disease presentations caused by grass seed foreign body-related disease (GSFBD) in dogs, identify predisposing risk factors and suggest effective prevention strategies.

METHODS

A retrospective, case-control, telephone survey was conducted to obtain information on GSFBD in dogs from the Riverina district of New South Wales (NSW). Additionally, retrospective case records were obtained from Wagga Wagga Veterinary Hospital and Charles Sturt University Veterinary Teaching Hospital over the period July 2006 to October 2011. Signalment, history, investigative strategies, location and severity of lesion(s), cost of therapy, length of hospitalisation, recurrence rate and microbiology data were recorded.

RESULTS

Cases (473 dogs) meeting stringent inclusion criteria were identified. GSFBD comprised 2.0% of hospital presentations. Breeds with high-density coats were overrepresented. Otitis externa was the most common manifestation of GSFBD in the general practice (47%). In the referral practice pyothorax was the most common entity (34%). In both practices the range of clinical manifestations was broad, including a small number of dogs with catastrophic intracranial disease. Univariable and multivariable logistic regression analyses demonstrated dogs with GSFBD had 3-fold greater odds of having medium coats than short coats and 5-fold less odds of being groomed.

CONCLUSIONS AND CLINICAL RELEVANCE

Grass seeds are a major cause of disease in the dogs of south-west rural NSW, with presentations ranging from mild lameness to severe neurological disease. Some protection from GSFBD was achieved with frequent grooming. Clipping or coat searching without grooming was ineffective as a prevention strategy.

Chronic inactive pulmonary tuberculosis and treatment sequelae: chest radiographic features

The chest radiograph (CXR) is a key initial tool in the diagnosis of many lung conditions, including pulmonary tuberculosis (TB). With proper use of anti-tuberculosis drugs, TB can be treated effectively and many CXR changes are limited. However, anti-tuberculosis drugs have not always been available, and in some cases they have not been started early in the disease process. The infection has then been able to take hold and cause significant radiologically visible damage, such as calcification and fibrosis. Before the use of anti-tuberculosis drugs, a variety of surgical techniques were employed to control pulmonary infection, including plombage, oleothorax, phrenic nerve crush and thoracoplasty. Each of these led to distinctive CXR features. This article sets out to describe the CXR features of chronic disease and surgical treatments, as their increasing rarity with the passage of time has meant that they can be misinterpreted. However, with increasing life expectancy and the revival of surgery due to the development of anti-tuberculosis drug resistance, the correct interpretation of these CXR changes is still of importance.

Lower limb injuries caused by improvised explosive devices: proposed 'Bastion classification' and prospective validation

BACKGROUND

Complex lower limb injury caused by improvised explosive devices (IEDs) has become the signature wounding pattern of the conflict in Afghanistan. Current classifications neither describe this injury pattern well, nor correlate with management. There is need for a new classification, to aid communication between clinicians, and help evaluate interventions and outcomes. We propose such a classification, and present the results of an initial prospective evaluation.

PATIENTS AND METHODS

The classification was developed by a panel of military surgeons whilst deployed to Camp Bastion, Afghanistan. Injuries were divided into five classes, by anatomic level. Segmental injuries were recognised as a distinct entity. Associated injuries to the intraperitoneal abdomen, genitalia and perineum, pelvic ring, and upper limbs, which impact on clinical management and resources, were also accounted for.

RESULTS

Between 1 November 2010 and 20 February 2011, 179 IED-related lower limb injuries in 103 consecutive casualties were classified, and their subsequent vascular and musculoskeletal treatment recorded. 69% of the injuries were traumatic amputations, and the remainder segmental injuries. 49% of casualties suffered bilateral lower limb amputation. The most common injury was class 3 (involving proximal lower leg or thigh, permitting effective above-knee tourniquet application, 49%), but more proximal patterns (class 4 or 5, preventing effective tourniquet application) accounted for 18% of injuries. Eleven casualties had associated intraperitoneal abdominal injuries, 41 suffered genital or perineal injuries, 9 had pelvic ring fractures, and 66 had upper limb injuries. The classification was easy to apply and correlated with management.

CONCLUSIONS

The 'Bastion classification' is a pragmatic yet clinically relevant injury categorisation, which describes current injury patterns well, and should facilitate communication between clinicians, and the evaluation of interventions and outcomes. The validation cohort confirms that the injury burden from IEDs in the Helmand Province of Afghanistan remains high, with most casualties sustaining amputation through or above the knee. The rates of associated injury to the abdomen, perineum, pelvis and upper limbs are high. These findings have important implications for the training of military surgeons, staffing and resourcing of medical treatment facilities, to ensure an adequate skill mix to manage these complex and challenging injuries.

Increased delivery stride length places greater loads on the ankle joint in elite male cricket fast bowlers

The purpose of this study was to investigate the effect stride length has on ankle biomechanics of the leading leg with reference to the potential risk of injury in cricket fast bowlers. Ankle joint kinematic and kinetic data were collected from 51 male fast bowlers during the stance phase of the final delivery stride. The bowling cohort comprised national under-19, first class and international-level athletes. Bowlers were placed into either Short, Average or Long groups based on final stride length, allowing statistical differences to be measured. A multivariate analysis of variance with a Bonferroni post-hoc correction (α = 0.05) revealed significant differences between peak plantarflexion angles (Short-Long P = 0.005, Average and Long P = 0.04) and negative joint work (Average-Long P = 0.026). This study highlighted that during fast bowling the ankle joint of the leading leg experiences high forces under wide ranges of movement. As stride length increases, greater amounts of negative work and plantarflexion are experienced. These increases place greater loads on the ankle joint and move the foot into positions that make it more susceptible to injuries such as posterior impingement syndrome.

Amniotic fluid stem cells improve survival and enhance repair of damaged intestine in necrotising enterocolitis via a COX-2 dependent mechanism

OBJECTIVE

Necrotising enterocolitis (NEC) remains one of the primary causes of morbidity and mortality in neonates and alternative strategies are needed. Stem cells have become a therapeutic option for other intestinal diseases, which share some features with NEC. We tested the hypothesis that amniotic fluid stem (AFS) cells exerted a beneficial effect in a neonatal rat model of NEC.

DESIGN

Rats intraperitoneally injected with AFS cells and their controls (bone marrow mesenchymal stem cells, myoblast) were analysed for survival, behaviour, bowel imaging (MRI scan), histology, bowel absorption and motility, immunofluorescence for AFS cell detection, degree of gut inflammation (myeloperoxidase and malondialdehyde), and enterocyte apoptosis and proliferation.

RESULTS

AFS cells integrated in the bowel wall and improved rat survival and clinical conditions, decreased NEC incidence and macroscopic gut damage, improved intestinal function, decreased bowel inflammation, increased enterocyte proliferation and reduced apoptosis. The beneficial effect was achieved via modulation of stromal cells expressing cyclooxygenase 2 in the lamina propria, as shown by survival studies using selective and non-selective cyclooxygenase 2 inhibitors. Interestingly, AFS cells differentially expressed genes of the Wnt/β-catenin pathway, which regulate intestinal epithelial stem cell function and cell migration and growth factors known to maintain gut epithelial integrity and reduce mucosal injury.

CONCLUSIONS

We demonstrated here for the first time that AFS cells injected in an established model of NEC improve survival, clinical status, gut structure and function. Understanding the mechanism of this effect may help us to develop new cellular or pharmacological therapies for infants with NEC.

Dual bronchodilatory and pulmonary anti-inflammatory activity of RO5024118, a novel agonist at vasoactive intestinal peptide VPAC2 receptors

BACKGROUND AND PURPOSE

Vasoactive intestinal peptide is expressed in the respiratory tract and induces its effects via its receptors, VPAC(1) and VPAC(2). RO5024118 is a selective VPAC(2) receptor agonist derived via chemical modification of an earlier VPAC(2) agonist, RO0251553. In the present studies, we characterized the pharmacological activity of RO5024118.

EXPERIMENTAL APPROACH

Stability of RO5024118 to human neutrophil elastase was assessed. Bronchodilatory activity of RO5024118 was investigated in guinea pig and human isolated airway smooth muscle preparations and in a guinea pig bronchoconstriction model. Pulmonary anti-inflammatory activity of RO5024118 was investigated in a lipopolysaccharide mouse model and in a porcine pancreatic elastase (PPE) rat model.

KEY RESULTS

RO5024118 demonstrated increased stability to neutrophil elastase compared with RO0251553. In human and guinea pig isolated airway preparations, RO5024118 induced bronchodilatory effects comparable with RO0251553 and the long-acting β-agonist salmeterol and was significantly more potent than native vasoactive intestinal peptide and the short-acting β-agonist salbutamol. In 5-HT-induced bronchoconstriction in guinea pigs, RO5024118 exhibited inhibitory activity with similar efficacy as, and longer duration than, RO0251553. In a lipopolysaccharide-mouse model, RO5024118 inhibited neutrophil and CD8(+) cells and myeloperoxidase levels. In rats, intratracheal instillation of PPE induced airway neutrophilia that was resistant to dexamethasone. Pretreatment with RO5024118 significantly inhibited PPE-induced neutrophil accumulation.

CONCLUSIONS AND IMPLICATIONS

These results demonstrate that RO5024118 induces dual bronchodilatory and pulmonary anti-inflammatory activity and may be beneficial in treating airway obstructive and inflammatory diseases.

LINKED ARTICLES

This article is part of a themed section on Analytical Receptor Pharmacology in Drug Discovery. To view the other articles in this section visit http://dx.doi.org/10.1111/bph.2010.161.issue-6.

Factors influencing infection patterns of trophically transmitted parasites among a fish community: host diet, host-parasite compatibility or both?

Parasite infection patterns were compared with the occurrence of their intermediate hosts in the diet of nine sympatric fish species in a New Zealand lake. Stomach contents and infection levels of three gastrointestinal helminth species were examined from the entire fish community. The results highlighted some links between fish host diet and the flow of trophically transmitted helminths. Stomach contents indicated that all but one fish species were exposed to these helminths through their diet. Host feeding behaviour best explained infection patterns of the trematode Coitocaecum parvum among the fish community. Infection levels of the nematode Hedruris spinigera and the acanthocephalan Acanthocephalus galaxii, however, were not correlated with host diets. Host specificity is thus likely to modulate parasite infection patterns. The data indicate that host diet and host-parasite compatibility both contribute to the distribution of helminths in the fish community. Furthermore, the relative influence of encounter (trophic interactions between prey and predator hosts) and compatibility (host suitability) filters on infection levels appeared to vary between host-parasite species associations. Therefore, understanding parasite infection patterns and their potential impacts on fish communities requires determining the relative roles of encounter and compatibility filters within and across all potential host-parasite associations.

SNL fibroblast feeder layers support derivation and maintenance of human induced pluripotent stem cells

Induced pluripotent stem (iPS) cells can be derived from human somatic cells by cellular reprogramming. This technology provides a potential source of non-controversial therapeutic cells for tissue repair, drug discovery, and opportunities for studying the molecular basis of human disease. Normally, mouse embryonic fibroblasts (MEFs) are used as feeder layers in the initial derivation of iPS lines. The purpose of this study was to determine whether SNL fibroblasts can be used to support the growth of human iPS cells reprogrammed from somatic cells using lentiviral expressed reprogramming factors. In our study, iPS cells expressed common pluripotency markers, displayed human embryonic stem cells (hESCs) morphology and unmethylated promoters of NANOG and OCT4. These data demonstrate that SNL feeder cells can support the derivation and maintenance of human iPS cells.

Achalasia: an unusual cause of airway obstruction

Achalasia is a disorder of the lower oesophageal sphincter and the smooth musculature of the oesophageal body. Although oesophageal obstruction is common, concurrent airway obstruction is exceptional. A case is presented of a 79-year-old woman admitted to the emergency department requiring intubation following out-of-hospital airway obstruction and subsequent respiratory arrest.

Simple measures are as effective as invasive techniques in the diagnosis of pulmonary tuberculosis in Malawi

SETTING

Detection of smear-positive pulmonary tuberculosis (PTB) cases is vital for tuberculosis (TB) control. Methods to augment sputum collection are available, but their additional benefit is uncertain in resource-limited settings.

OBJECTIVE

To compare the diagnostic yields using five methods to obtain sputum from adults diagnosed with smear-negative PTB in Malawi.

DESIGN

Self-expectorated sputum was collected under supervision for microscopy and mycobacterial culture in the study laboratory. Confirmed smear-negative patients provided physiotherapy-assisted sputum and induced sputum, followed the next morning by gastric washing and bronchoalveolar lavage (BAL) samples.

RESULTS

A total of 150 patients diagnosed with smear-negative PTB by the hospital service were screened; 39 (26%) were smear-positive from supervised self-expectorated sputum examined in the study laboratory. The remaining 111 confirmed smear-negative patients were enrolled in the study; 89% were human immunodeficiency virus positive. Seven additional smear-positive cases were diagnosed using the augmented sputum collection techniques. No differences were observed in the numbers of cases detected using the different methods. Of the 46 smear-positive cases, 44 (95.6%) could be detected from self-expectorated and physiotherapy-assisted samples.

CONCLUSIONS

For countries such as Malawi, the best use of limited resources to detect smear-positive PTB cases would be to improve the quality of self-expectorated sputum collection and microscopy. The additional diagnostic yield using BAL after induced sputum is limited.

Which way ahead?: I want my doctor to.... The mechanics of market research for medics in the millenium: special communication

A brief description is given of the changing politico-social structure today involving medicine and especially the cosy personal doctor-patient relationship of the past which has now become triangular involving Managed Health Care Organisations in many cases. The Medical Practitioners' and Dentists' Board (the Board) appointed the Ethics Conference Committee largely composed of non-Board members to collect and collate information of what doctors, paramedics and the lay public expected from their doctors today. It is planned that the Committee's Report summarising this information would form the basis of the new guidelines to modern ethics to be published by the Board later. In this paper the mechanics, funding and production of the report are described but not the contents of the report which is still being considered by the new Board.

Identification of medication-related attendances at an A & E department

BACKGROUND

The use of medication is the most common medical intervention, but it has associated risks. These have been described as drug-related problems (DRPs). Other non-UK studies have reported DRPs to be the cause of 3-16% of hospital admissions and around 4% of attendances at emergency departments. The size of the problem in the UK has not been quantified.

AIM

The aim of this study was to identify the number of patients attending a central London accident and emergency (A & E) department with symptoms or conditions caused by DRPs.

METHOD

A 2-week retrospective, case-review study was conducted in the A & E department of St Thomas' Hospital, London, during March 1999. DRPs were identified using recognized criteria. Statistical analysis identified patient characteristics which could be associated with the incidence of DRPs. The types of DRP and the drugs involved were identified.

RESULTS

During the study period, 106 patients attended the A & E department with a DRP. This equates to 4% of the A & E population. During this period the demographics of the A & E attenders were no different to the annual A & E cohort. The most common DRPs were adverse drug reactions and overdose. The most frequently involved drugs included analgesics, antibiotics, those with narrow therapeutic indices and illegal drugs. The mean age of this patient group was 38 years (non-significant). They attended significantly more frequently during the early hours of the morning and on Saturdays than the A & E general population (chi-squared P = 0.004 and P = 0.003, respectively).

DISCUSSION

The incidence of DRP as a cause of attendance at A & E reflects that in the literature. No statistical association with a specific age group of patients could be made, but the mean age of 38 years is younger than previously reported. The demographic differences which were statistically significant can be explained by the increased incidence of DRP associated with the use of illegal drugs than reported in other studies. Other drug groups identified by this study are representative of other reports.

CONCLUSION

DRPs account for 4% of attendances at a central London A & E Department.

Developments in education and training for nursing home staff

The independent sector has always provided a proportion of the care needed for a variety of client groups in the UK. Although the vast majority of the recipients of care are older people, groups such as those with mental health problems and those suffering from various disabilities are also cared for. The sector is currently facing the need for major changes in the way it provides care. Legislation and a number of reports and strategy documents mean that these changes are necessary for the sector to survive. To drive and to respond to the new situation, education and training has a part to play. This article will examine how the new situation following the sector will impact on the education needs for nurses.

Nedocromil sodium in golfers with seasonal allergic conjunctivitis

To evaluate nedocromil sodium 2% ophthalmic solution for the treatment of seasonal allergic conjunctivitis, 24 golfers with documented ragweed-pollen allergy instilled eyedrops twice daily for 4 days prior to golf-course intervention and 15 minutes before playing a round of golf during peak ragweed season. Ocular symptoms were scored at baseline (7 days before golfing), prior to instillation on the day of golf, and 30 minutes, and 1, 4, 8, and 12 hours after tee-off. Physician assessment was performed prior to tee-off, before tee-off on the ninth hole, and at the end of the 18th hole. Itching, burning, grittiness, tearing, redness, and light sensitivity were significantly decreased after nedocromil administration, as were erythema, edema, conjunctival hyperemia, and overall findings in the conjunctiva. Symptom severity scores fell approximately 30 minutes after instillation, with improvements persisting 8 and 12 hours after treatment. Most patients (92%) rated the treatment moderately or completely effective, and 83% were willing to continue its use. Physician assessments of effectiveness agreed with those of the patients. In this open-label study, nedocromil sodium eyedrops relieved the ocular symptoms of seasonal allergic conjunctivitis for up to 12 hours, well beyond a usual round of golf.

Inhibitory and enhancing effects of IFN-gamma and IL-4 on SHIV(KU) replication in rhesus macaque macrophages: correlation between Th2 cytokines and productive infection in tissue macrophages during late-stage infection

HIV-1 is dual-tropic for CD4+ T lymphocytes and macrophages, but virus production in the macrophages becomes manifest only during late-stage infection, after CD4+ T cell functions are lost, and when opportunistic pathogens begin to flourish. In this study, the SHIV/macaque model of HIV pathogenesis was used to assess the role of cytokines in regulating virus replication in the two cell types. We injected complete Freund's adjuvant (CFA) intradermally into SHIV(KU)-infected macaques, and infused Schistosoma mansoni eggs into the liver and lungs of others. Tissues examined from these animals demonstrated that macrophages induced by CFA did not support viral replication while those induced by S. mansoni eggs had evidence of productive infection. RT-PCR analysis showed that both Th1 (IL-2 and IFN-gamma) and Th2 cytokines (IL-4 and IL-10) were present in the CFA lesions but only the Th2 cytokines were found in the S. mansoni lesions. Follow-up studies in macaque cell cultures showed that whereas IFN-gamma caused enhancement of virus replication in CD4+ T cells, it curtailed viral replication in infected macrophages. In contrast, IL-4 enhanced viral replication in infected macrophages. These studies strongly suggest that cytokines regulate the sequential phases of HIV replication in CD4 T cells and macrophages.

Efficacy and acceptability of nedocromil sodium 2% and olopatadine hydrochloride 0.1% in perennial allergic conjunctivitis

In this 2-week, randomized, crossover study, ophthalmic solutions of nedocromil sodium 2% and olopatadine hydrochloride 0.1% were compared for effectiveness and acceptability in 28 patients with perennial allergic conjunctivitis and previous olopatadine experience. Patients received nedocromil twice daily or olopatadine twice daily for 1 week, then were crossed over to the alternate medication for 1 week. Outcome measures were patient satisfaction (questionnaire), severity of ocular symptoms (daily diary scores), clinical signs (physician assessments), quality of life (questionnaire), and global assessments of effectiveness. Both medications were well accepted. Of the 28 patients, 16 (57.1%) would request a nedocromil prescription, 10 (35.7%) an olopatadine prescription (P = .157); 22 patients (78.6%) would recommend nedocromil to other allergy sufferers, while 18 (64.3%) would recommend olopatadine (P = .480). Light sensitivity scores were significantly lower with nedocromil (P = .0125); other symptom scores were comparable between medications. Both drugs significantly (P < .01) and comparably decreased erythema, conjunctival injection, and overall conjunctival signs from baseline. Comparable improvement also occurred in quality-of-life scores. Both physicians and patients judged nedocromil and olopatadine to be similarly effective in preventing signs and symptoms. Nedocromil sodium 2% is an effective treatment for perennial allergic conjunctivitis. Patients receiving olopatadine can be switched to nedocromil with no loss in efficacy or satisfaction, but with a reduction in cost.

The optimal joint angle for adductor pollicis force production in men and women

The purpose of this study was to determine the joint angle that allows for the greatest MVC and evoked twitch forces from the adductor pollicis (AP), and also whether there is a gender difference in either the above forces or the optimum thumb angle. Ten men (25.2 yrs) and 10 women (27.6 yrs) participated. The nondominant hand was placed palm-down with the thumb fixed at four angles of abduction (55, 70, 85, 100 degrees). Male MVC forces were significantly greater than female, and there was no significant effect of joint angle on MVC force in either gender. For the evoked twitch, men were significantly stronger than women when tested at the 100 and 85 degrees angles, and a significant effect was found for joint angle such that the lowest twitch force occurred at 55 degrees. Men also tended to have a greater rate of force development than women (p = 0.07). These data suggest that studies using the AP muscle in stimulated and voluntary paradigms should use a thumb angle between 70 and 100 degrees of abduction, or approximately 85 degrees, and that the same angle can be used for both men and women.

Tissue oxygenation by near-infrared spectroscopy and muscle blood flow during isometric contractions of the forearm

The relationship between tissue oxygenation measured by near-infrared spectroscopy (NIRS) and forearm muscle blood flow (FBF) measured by Doppler ultrasound was tested during isometric contractions at 10 and 30% maximal voluntary contraction (MVC) under conditions of normoxia and hypoxia (14% inspired O2). Six subjects maintained contractions at 10% MVC for 5 min and 30% for 2 min in both gas conditions. FBF was elevated during exercise at 10% MVC in hypoxia compared to normoxia, but there was no further increase in flow at 30% MVC. Median power frequency calculations from electromyographic recordings suggested progressive development of fatigue throughout both 10 and 30% MVC contractions. NIRS indicated no change in muscle oxygenation at 10% MVC, but deep venous blood O2 saturation was reduced in normoxia and more so in hypoxia. At 30% MVC, both NIRS and venous O2 saturation were reduced, with no effect of hypoxia on the NIRS signal. While NIRS might provide an indication of muscle oxygenation during isometric exercise, the conflicting findings for NIRS and direct venous blood sampling at 10 vs 30% MVC suggest caution in the application of this noninvasive technique.

Becoming ADEPT (Applying Diagnosis, Etiology, Prognosis, and Therapy Programme): delivering distance learning on evidence-based medicine for librarians

Evidence-based medicine (EBM) brings new challenges and opportunities for librarians. However, their ability to respond to this agenda is constrained by their difficulties in acquiring the requisite new skills and techniques while continuing to work in a busy information practice setting. The authors describe a joint initiative, between a specialist evidence-based healthcare information unit and a regional library network, to deliver training materials using a mixed workshop and distance learning format. The Applying Diagnosis, Etiology, Prognosis, and Therapy filters (ADEPT) Programme draws upon research conducted at McMaster University, Canada and, using techniques adapted from the teaching evidence-based medicine paradigm, seeks to equip health care librarians with the skills and techniques required to support evidence-based practice locally. The authors describe the thinking behind the programme, its main features, the extensive evaluation mechanisms incorporated into the course, the results of the evaluation and the lessons learnt. They conclude with a description of the way forward for participants on the programme who are adapting their newly acquired knowledge to their work situations. Further planned developments from the course's designers are also outlined briefly.