OP0243 OSTEOPOROSIS CASE-FINDING IN PEOPLE UNDERGOING ROUTINE DIAGNOSTIC CT SCANS ALMOST TRIPLED THE RATE OF OSTEOPOROSIS TREATMENT AT 12 MONTHS. A RANDOMISED, MULTI-CENTRE FEASIBILITY STUDY USING WAITING ROOM FRAX, OPPORTUNISTIC CT BONE DENSITY AND VERTEBRAL FRACTURE ASSESSMENT VERSUS USUAL CARE

Background

Up to 40% of all diagnostic computed tomography (CT) scans include views of the spine or hips. Among older people, osteoporosis or vertebral fractures have been found in 30% of such CT scans. Our ‘PHOENIX’ intervention repurposes CT scans taken for other reasons to identify fractures and measure bone density as an ‘added extra’. Early detection and treatment of osteoporosis in CT-attending patients could improve health outcomes.

Objectives

To determine the feasibility and efficacy of PHOENIX versus usual care in a multi-centre, randomised, pragmatic study conducted in Eastern England involving our Cambridge Specialist Hospital ‘hub’ and four regional General Hospital ‘spokes’.

Methods

Women ≥65 and men ≥75 years attending for routine diagnostic CT scans were invited to participate via a novel consent form incorporating FRAX Fracture Risk Assessment questions. After calculating their FRAX 10-year risk score, higher risk patients were block randomised (1:1:1) to Group 1) PHOENIX intervention, 2) Active Control, where the GP was sent the patients’ FRAX answers only, or 3) Usual Care where data were only analysed after 13 months had elapsed. The CT scans of high FRAX risk patients in Group 1 were retrieved by the Cambridge team using NHS Connecting for Health (Burnbank, UK). The team performed vertebral fracture assessment and measured bone density using QCT Pro (Mindways, USA). They added patient-specific treatment and investigation management advice from ‘drop down’ menus before results were reviewed by a physician, authorised and sent to general practitioners (GPs). Baseline CT scans from groups 2 and 3 were assessed in the same way after 13 months to ensure no patient with osteoporosis/fractures was neglected long term. Assuming 25% attrition, the study was powered to find a superior osteoporosis treatment rate in Group 1 (estimated 20%) versus 16% (Active Control) and 5% (Usual Care). Co-primary feasibility endpoints were the ability to a) randomise 375 patients within 10 months and b) retain 75% of survivors able to complete a 1-year bone health outcome questionnaire. Secondary outcomes included osteoporosis/vertebral fracture identification rates and osteoporosis treatment rates. Stakeholder acceptability and economic aspects will be reported separately.

Results

From 1828 invites, 595 participants consented to participate of whom 213 were excluded due to ‘low’ FRAX score. Mortality at 12 months was 20%. Both feasibility objectives were achieved: 1) 382 people were randomised within 10 months; 2) 84.4% of survivors at 1 year (95%CI: 80.5, 88.3) were successfully followed-up. Groups were well matched at baseline. The average age of 375 patients (334 female, 41 male) was 75.2 years (74.6, 75.9). Osteoporosis of the hip/spine was present in 41% of 362 analysable CT scans. From the 264 spines that were suitable for VFA, 20% (n=53) were found to have vertebral fractures, with 8.3% having multiple vertebral fractures (n=22). Osteoporosis treatment was reported in 8.5% of Usual Care group (2.9, 14.2) and 24.2% (15.4, 33.0) of PHOENIX group participants, while in the Active Control group (FRAX only) it was 18.8% (10.9, 26.6 p=0.021). In the PHOENIX group, a recommendation to treat was sent to 50 patients’ GPs at baseline. Only 18 of the 50 patients (36%) were found to be taking osteoporosis treatment 12 months after this advice was sent.

Conclusion

Osteoporosis treatment rates were almost tripled by screening patients attending for routine diagnostic CT scans with waiting room FRAX, CT-bone densitometry and vertebral fracture analysis.

Acknowledgements

This project is funded by the National Institute for Health Research (NIHR) under its Research for Patient Benefit (RfPB) Programme (Grant Reference Number PB-PG-0816-20027) and by the Cambridge NIHR Biomedical Research Centre (BRC-1215-20014). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. Funding is in place to 31.03.2022. Three individuals, Mr Jeremy Dearling, Mrs Tessa Plume and Dr Ann Frost joined our trial group as PPI representatives; they were specifically involved in patient documentation design (particularly the PHOENIX pack, informed consent form which facilitated consent without having a researcher present) and contributed to suggestions for increasing patient recruitment and follow up.

Disclosure of Interests

None declared

Sex disparate gut microbiome and metabolome perturbations precede disease progression in a mouse model of Rett syndrome

Rett syndrome (RTT) is a regressive neurodevelopmental disorder in girls, characterized by multisystem complications including gut dysbiosis and altered metabolism. While RTT is known to be caused by mutations in the X-linked gene MECP2, the intermediate molecular pathways of progressive disease phenotypes are unknown. Mecp2 deficient rodents used to model RTT pathophysiology in most prior studies have been male. Thus, we utilized a patient-relevant mouse model of RTT to longitudinally profile the gut microbiome and metabolome across disease progression in both sexes. Fecal metabolites were altered in Mecp2e1 mutant females before onset of neuromotor phenotypes and correlated with lipid deficiencies in brain, results not observed in males. Females also displayed altered gut microbial communities and an inflammatory profile that were more consistent with RTT patients than males. These findings identify new molecular pathways of RTT disease progression and demonstrate the relevance of further study in female Mecp2 animal models.

Prevalence factors associated with equine herpesvirus type 1 infection in equids with upper respiratory tract infection and/or acute onset of neurological signs from 2008 to 2014

The objective of the present case-control study was to determine prevalence factors associated with the detection of equine herpesvirus type 1 (EHV-1) by quantitative PCR (qPCR) in horses presented to veterinarians with clinical signs related to an upper respiratory tract infection and/or acute onset of neurological disease from March 2008 to December 2014. Nasal secretions and whole blood from 4228 equids with acute onset of fever, respiratory signs and/or neurological deficits were tested by qPCR for EHV-1. Categorical analyses were performed to determine the association between observations and EHV-1. A total of 117/4228 (2.7 per cent) equids tested qPCR-positive for EHV-1, with most of the isolates belonging to the non-neuropathogenic genotype (N752). EHV-1 PCR-positive equids were over-represented in racing horses. Depression, anorexia, nasal discharge and coughing were significantly less frequently reported in the EHV-1 qPCR-positive equids compared with the EHV-1 qPCR-negative cases. Neurological deficits were more frequently reported in the EHV-1 qPCR-positive cases. This study provides contemporary information on the frequency of EHV-1 detection by qPCR in blood and nasal secretions from horses with fever, respiratory signs and neurological deficits.

Placental syncytiotrophoblast maintains a specific type of glycocalyx at the fetomaternal border: the glycocalyx at the fetomaternal interface in healthy women and patients with HELLP syndrome

Recent studies showed that considerable amounts of glycosaminoglycans are released into maternal blood during normal pregnancy and in hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. Maternal endothelia and the syncytiotrophoblast layer have been discussed as a possible origin of these glycocalyx components. Our study aimed to visualize the glycocalyx on the syncytiotrophoblast by electron microscopy, to analyze its structure and composition by immunohistochemistry, and to determine potential differences between healthy women and women with HELLP syndrome. For electron microscopy, a cotyledon was fixed by perfusion of the intervillous space with a 2% lanthanum-nitrate glutaraldehyde solution followed by immersion fixation in the same fixative. For immunohistochemistry, sections of 16 placentas (HELLP patients/healthy women, n = 8 each) were stained with monoclonal antibodies against the main glycocalyx constituents syndecan 1, hyaluronic acid, and heparan sulfate. Semiquantitative evaluation of staining intensity focused on the apical surface of the syncytiotrophoblast and fetal intravillous endothelia as possible localizations of a placental glycocalyx. Electron microscopy revealed a glycocalyx of approximately 250 nm, covering the syncytiotrophoblast layer. This was found to contain large amounts of syndecan 1, but neither hyaluronic acid nor heparan sulfate as major components. Intravillous fetal endothelium did not express any of the investigated glycosaminoglycans. Healthy women and patients with HELLP showed no differences concerning glycocalyx composition and thickness of the syncytiotrophoblast. The composition of the "placental" glycocalyx differs from the adult and fetal vascular glycocalyx. Obviously, the human placental syncytiotrophoblast maintains a special kind of glycocalyx at the fetomaternal interface.

Serum heparan sulfate levels are elevated in endotoxemia

BACKGROUND

Increased vascular permeability is a characteristic feature of sepsis which, in the past, has been ascribed exclusively to a malfunction of endothelial cells. However, recently it has become evident that the endothelial glycocalyx is of considerable importance concerning various aspects of vascular physiology, e.g. the vascular barrier and inflammation. Heparan sulfate, one of its essential components is characteristically traceable in blood, in case the endothelial glycocalyx is damaged or destroyed.

METHODS

In 15 pigs we investigated whether the administration of endotoxin from gram-negative bacteria (Escherichia coli) results in increased serum levels of heparan sulfate, signalizing a shedding of the glycocalyx. In addition, markers of inflammation (white blood cell count, platelet count, tumour necrosis factor-α and interleukin-6) were evaluated over an observation period of 6 hours.

RESULTS

Serum heparan sulfate concentrations significantly increased over time in the endotoxin group and were significantly elevated in comparison to the control group 6 hours after administration of endotoxin (p<0.001). In the endotoxin group all markers of inflammation significantly changed during the time course.

CONCLUSIONS

The administration of bacterial endotoxin induced a significant rise in degradation products of the endothelial glycocalyx.

[Hypernatremic alkalosis. Possible counterpart of hyperchloremic acidosis in intensive care patients?]

BACKGROUND

With broad acceptance of Stewart's acid-base model "hyperchloremic acidosis" is regarded as an independent form of metabolic disorder. It is unknown whether hypernatremia plays a corresponding role with respect to the development of alkalosis.

METHODS

A total of 201 artificially ventilated, critically ill patients were monitored for hypernatremic episodes. Inclusion criterion was a serum sodium concentration above 145 mmol/l.

RESULTS

In 20 patients a total of 78 periods of elevated plasma sodium levels lasting at least 24 h were observed. In 86% of these cases sodium and chloride concentrations were simultaneously increased. The development of alkalosis correlated with the strong ion difference (r=0.80, p<0.01) but not with the serum sodium concentration (r=-0.031, p=0.78). In cases without accompanying hyperchloremia (13%) metabolic alkalosis regularly occurred and a correlation between serum sodium concentration and base excess could be verified (r=0.66, p=0.03). Alkalosis occurred in 84.8% of cases where the strong on difference exceeded 39 mmol/l.

CONCLUSION

From the available data hypernatremic alkalosis could not be defined as an independent metabolic disorder. In would seem more appropriate to use the term "strong ion alkalosis" in this context.

[Methylnaltrexone. A new approach for therapy of opioid-induced obstipation]

Chronic pain patients using opioids frequently suffer from constipation which compromises well-being. Such an opioid-induced gastro-intestinal complication can occur regularly in patients in palliative care as well as in analgesic sedated intensive care patients or during prolonged perioperative pain therapy. Discomfort and distress in the affected patients can be so severely pronounced that they would rather suffer from the pain than from the side effect of constipation. Conventional therapy can be insufficient in providing satisfactory relief of constipation, mostly because this opioid-induced bowel hypomotility can be laxative-resistant. Moreover, constipation does not decrease during the course of therapy as do other side effects. It is well known that opioid-induced constipation is mediated via activation of micro-opioid receptors in the gastrointestinal tract. Selective peripheral micro-receptor antagonists (such as methylnaltrexone, Relistor) can effectively treat opioid-induced constipation. An interference with central analgesia does not occur as the molecules cannot pass the blood-brain barrier due to their charged states. A reduction of opioid therapy or the development of withdrawal symptoms can be avoided. Studies have shown that methylnaltrexone is not only safe and efficient for chronically constipated palliative care patients but offers promising therapeutic options for further patient collectives.

[Metabolic alkalosis despite hyperlactatemia and hypercapnia. Interpretation and therapy with help of the Stewart concept]

Acid-base disturbances are commonly found in critically ill patients and are often associated with fatal complications. The basis of a successful treatment is a thorough understanding of the causes of these disorders. The "classical methods" to explain acid-base disorders--pH, base excess and bicarbonate concentration--mostly do not provide a causal correlation to the underlying pathology. An unusual case of a combined respiratory-metabolic disorder with hyperlactatemia and hypercapnia is presented. An acidosis masked by hypochloremic and hypoalbuminemic alkalosis was identified with the help of Stewart's concept and finally permitted a successful therapy. The modern Stewart concept provides enhanced information, enabling an exact diagnosis and causal therapy even in complex cases.

Blood volume is normal after pre-operative overnight fasting

BACKGROUND

Pre-operative fasting is assumed to cause a deficit in intravascular blood volume (BV), as a result of ongoing urine production and insensible perspiration. Standard regimes consist of volume loading prior or simultaneous to any anaesthetic procedure to minimise the risk of hypotension. However, fluid overload in the context of major abdominal surgery has been shown to deteriorate patient outcome. Our study aimed to quantify total intravascular BV after fasting by direct measurements and to compare it with calculated normal values in comparable non-fasted patients.

METHODS

After 10 h of fasting, total plasma volume (PV) and red cell volume (RCV) were measured via the double-label technique (indocyanine green dilution and erythrocytes labelled with fluorescein, respectively) following induction of general anaesthesia in 53 gynaecological patients suffering from malignoma of the cervix. The corresponding normal values were calculated individually from age, body height and body weight.

RESULTS

Measured BV, RCV and PV after fasting were 4123+/-589, 1244+/-196 and 2879+/-496 ml, respectively. The differences to the corresponding calculated normal values were not significant (3882+/-366, 1474+/-134 and 2413+/-232 ml, respectively). The measured haematocrit reflected a slight anaemic state (0.35+/-0.03).

CONCLUSION

Our data suggest that even after prolonged pre-operative fasting, cardio-pulmonary healthy patients remain intravascularly normovolaemic. Therefore, hypotension associated with induction of general or neuraxial anaesthesia should perhaps be treated with moderate doses of vasopressors rather than with undifferentiated volume loading.

Determinanten des insensiblen Flüssigkeitsverlustes

Accurate perioperative fluid balance is the basis of a targeted infusion regimen. However, neither the initial status nor perioperative changes of the fluid compartments can be reliably measured in daily routine. In particular, insensible losses are not consistently assessed, so that substitution therapy is generally empirical. The object of this paper is to communicate the scientific data on this topic. Preoperative fasting (10 h) does not per se cause intravascular hypovolemia. In adults, total basal evaporation by way of the skin and airways and of any wounds during major abdominal interventions is usually less than 1 ml/kg/h. An inconstant fluid and protein shift towards the interstitial space perioperatively seems to be associated with hypervolemia, which suggests it should be preventable. The decisive factor in this context seems to be deterioration of the endothelial glycocalyx, whose further patho-physiological impact is currently only partially known. Clinical studies have revealed a link between fluid restriction and improved outcome after major abdominal surgery.

Morphological assessment of reperfusion injury in a concordant xenogeneic primate model

Ischemia and consecutive reperfusion injury of the graft cannot be avoided in organ transplantation. One principal characteristic of this process is the temporary and permanent adherence of leukocytes to endothelial cells of the graft as well as damage of the associated tissue. Polyclonal antithymocyte globulins (ATGs) are used to prevent acute rejection after transplantation and to overcome graft vs. host disease. ATGs induce apoptosis and complement-mediated cell death in peripheral T-lymphocytes having the potential to inhibit leukocyte adhesion by direct binding to adhesion molecules. The aim of the present study was to analyse in a non-human primate model (cynomolgus monkeys) morphological changes within the microvasculature and the different cell-subpopulations upon ischemia/reperfusion after immunosuppressive treatment. Our results show a decrease of the tissue damage and WBC infiltration in muscular structures as well as a lower number of mononuclear cells in peripheral blood in the ATG-treated group compared to a non-treated control group. We may conclude that pATGs have a beneficial effect on the early mechanisms of ischemia/reperfusion injury.

Thyroid hormone receptor-interacting protein 1 modulates cytokine and nuclear hormone signaling in erythroid cells

Erythropoietin (Epo) and thyroid hormone (T(3)) are key molecules in the development of red blood cells. We have shown previously that the tyrosine kinase Lyn is involved in differentiation signals emanating from an activated erythropoietin receptor. Here we demonstrate that Lyn interacts with thyroid hormone receptor-interacting protein 1 (Trip-1), a transcriptional regulator associated with the T(3) receptor, providing a link between the Epo and T(3) signaling pathways. Trip-1 co-localized with Lyn and the T(3) receptor alpha in the cytoplasm/plasma membrane of erythroid cells but translocated to discrete nuclear foci shortly after Epo-induced differentiation. Our data reveal that T(3) stimulated the proliferation of immature erythroid cells, and inhibited maturation promoted by erythropoietin. Removal of T(3) reduced cell division and enhanced terminal differentiation. This was accompanied by large increases in the cell cycle inhibitor p27(Kip1) and by increasing expression of erythroid transcription factors GATA-1, EKLF, and NF-E2. Strikingly, a truncated Trip-1 inhibited both erythropoietin-induced maturation and T(3)-initiated cell division. This mutant Trip-1 acted in a dominant negative fashion by eliminating endogenous Lyn, elevating p27(Kip1), and blocking T(3) response elements. These data demonstrate that Trip-1 can simultaneously modulate responses involving both cytokine and nuclear receptors.

Dominant action of mutated erythropoietin receptors on differentiation in vitro and erythroleukemia development in vivo

J2E cells produce rapid, fatal erythroleukemias in vivo but still respond to erythropoietin (epo) in vitro by differentiating, proliferating and remaining viable in the absence of serum. Mutant epo receptors were introduced into these cells to determine whether they could influence the different biological responses to epo in vitro and the development of erythroleukemias. Three mutant receptors were used as cytoplasmic truncation mutants Delta257 and Delta321 (above box 1 and below box 2 respectively), and the cytoplasmic point mutant W282R (defective for JAK2 activation). Strikingly, the Delta321 mutation produced a hyper-sensitive response in vitro to epo-induced differentiation and viability, but not to proliferation. In contrast with the Delta321 receptor, the Delta257 and W282R mutants inhibited all biological responses to epo due to impaired JAK2 phosphorylation. Significantly, erythroleukemias took almost twice as long to develop with cells containing the W282R mutation, indicating that JAK2 plays an important role in the emergence of these leukemias. These data demonstrate that mutant epo receptors dominantly altered responses of J2E cells to epo in culture and the development of erythroleukemias. Oncogene (2000) 19, 953 - 960.

Prevention of apoptosis in J2E erythroid cells by erythropoietin: involvement of JAK2 but not MAP kinases

The J2E erythroid cell line, transformed by retroviral v-raf/v-myc oncogenes, proliferates and differentiates in response to erythropoietin. Here we show that J2E cells undergo apoptosis rapidly after serum withdrawal and that only erythropoietin of seven growth factors tested, could protect the cells from death. The role of JAK2 and MAP kinases in transmitting viability signals initiated by erythropoietin was examined in these cells. Despite constitutive raf kinase activity, phosphorylation of MAP kinases fell after serum withdrawal. However, an antisense oligonucleotide strategy revealed that JAK2, but not the MAP kinases, was involved in transmitting signals to maintain the viability of J2E cells. Several cell cycle proteins and transcription factors were also studied; although c-jun rose sharply during apoptosis, erythropoietin could not suppress this increase. It was concluded that erythropoietin-induced protection from apoptosis involved JAK2, but not MAP kinases or c-jun.

Haemoglobin synthesis in erythropoietin-stimulated J2E cells does not require increased numbers of transferrin receptors

Changes in transferrin-receptor numbers and iron utilisation were monitored during erythropoietin-induced maturation of J2E erythroid cells. Uptake of transferrin and iron doubled 24 h after exposure to erythropoietin, due to a twofold rise in surface transferrin receptors. In addition, a tenfold increase in iron incorporation into haem was observed after erythropoietin stimulation, as iron taken up from transferrin was directed towards haem biosynthesis and away from storage in ferritin. The rise in iron chelation into haem correlated extremely well with haemoglobin synthesis. However, the increase in numbers of transferrin receptors was not essential for haemoglobin synthesis; rather, it was linked with a burst in proliferation stimulated by erythropoietin. We have shown previously that amiloride blocks erythropoietin-enhanced proliferation of J2E cells, but potentiates maturation [Callus, B. A., Tilbrook, P. A., Busfield, S. J. & Klinken, S. P. (1995) Exp. Cell Res. 219, 39-46]. Here we demonstrate that amiloride suppressed the hormone-induced increase in transferrin receptors, whereas the enhanced incorporation of iron into haem was not inhibited. Similarly, when sodium butyrate was used to induce differentiation of J2E cells, proliferation ceased and surface transferrin receptors remained unaltered, while haemoglobin production was accelerated. It was concluded from these experiments that the erythropoietin-stimulated rise in transferrin receptors during the final stages of J2E cell maturation is linked to cell division, and is not essential for haemoglobin synthesis.

Disrupted signaling in a mutant J2E cell line that shows enhanced viability, but does not proliferate or differentiate, with erythropoietin

The immature erythroid J2E cell line proliferates and terminally differentiates following erythropoietin stimulation. In contrast, the mutant J2E-NR clone does not respond to erythropoietin by either proliferating or differentiating. Here we show that erythropoietin can act as a viability factor for both the J2E and J2E-NR lines, indicating that erythropoietin-initiated maturation is separable from the prevention of cell death. The inability of J2E-NR cells to mature in response to erythropoietin was not due to a defect in the erythropoietin receptor sequence, although surface receptor numbers were reduced. Both the receptor and Janus kinase 2 were phosphorylated after erythropoietin stimulation of J2E-NR cells. However, protein interactions with the erythropoietin receptor and Grb2 were restricted in the mutant cells. Subsequent investigation of several other signaling molecules exposed numerous alterations in J2E-NR cells; phosphorylation changes to phosphatidylinositol 3-kinase, phospholipase Cgamma, p120 GAP, and mitogen-activated protein kinases (p42 and p44) observed in erythropoietin-stimulated J2E cells were not seen in the J2E-NR line. These data indicate that some pathways activated during erythropoietin-induced differentiation may not be essential for the prevention of apoptosis.

Mechanical and biochemical properties of human articular cartilage from the femoral head after subcapital fracture

Articular cartilage from the femoral heads of 27 patients having an arthroplasty for subcapital fracture was studied, and its mechanical and chemical properties compared to those of a group of 33 age-matched macroscopically normal autopsy specimens. Water and proteoglycan contents were measured, as were swelling ability, compressive and tensile strength of the cartilage, and the density of the underlying bone. Cartilage from the fracture specimens had a significantly reduced proteoglycan content, as measured by fixed charge density, and increased swelling ability. These results indicate that this group differs from the "normal" population and care should be taken before they are accepted as control material for studies on osteoarthritic cartilage. Another finding was that bone density was much the same in the fracture and the normal group. This casts some doubt upon the concept that patients who sustain subcapital fractures are more osteoporotic than the average for the same age range.

Mechanical and biochemical properties of human articular cartilage in osteoarthritic femoral heads and in autopsy specimens

We studied the mechanical and biochemical properties of articular cartilage from 22 osteoarthritic femoral heads obtained at operation and 97 femoral heads obtained at autopsy. Cartilage from the zenith and from the antero-inferior aspect of each head was tested both in tension and in compression. Water content, swelling ability and proteoglycan content were measured, the cartilage was examined histologically and the density of the underlying bone was assessed. Fifty-five of the autopsy specimens were defined as macroscopically normal because they exhibited no progressive fibrillation patterns on staining with Indian ink; but significant changes in water content, bone density and tensile strength related to age were seen in this group. In 20 pairs of femoral heads which were both macroscopically normal, we found, surprisingly, that cartilage from the left and right sides of the same patient was sometimes very different. Compared with the normal autopsy specimens the osteoarthritic specimens had a significantly increased swelling ability, a lower proteoglycan content and impaired mechanical properties, being both weaker in tension and softer in compression. Abnormal autopsy specimens had values intermediate between those of osteoarthritic and normal groups. Results from this abnormal group suggest that there is no primary loss of proteoglycan in early osteoarthritis.