Dynamics of antibiotic resistance markers and Escherichia coli invasion in riverine heterotrophic biofilms facing increasing heat and flow stagnation

As motivation to address environmental dissemination of antimicrobial resistance (AMR) is mounting, there is a need to characterize mechanisms by which AMR can propagate under environmental conditions. Here we investigated the effect of temperature and stagnation on the persistence of wastewater-associated antibiotic resistance markers in riverine biofilms and the invasion success of genetically-tagged Escherichia coli. Biofilms grown on glass slides incubated in-situ downstream of a wastewater treatment plant effluent discharge point were transferred to laboratory-scale flumes fed with filtered river water under potentially stressful temperature and flow conditions: recirculation flow at 20 °C, stagnation at 20 °C, and stagnation at 30 °C. After 14 days, quantitative PCR and amplicon sequencing were used to quantify bacteria, biofilms diversity, resistance markers (sul1, sul2, ermB, tetW, tetM, tetB, blaCTX-M-1, intI1) and E. coli. Resistance markers significantly decreased over time regardless of the treatment applied. Although invading E. coli were initially able to colonize the biofilms, its abundance subsequently declined. Stagnation was associated with a shift in biofilm taxonomic composition, but there was no apparent effect of flow conditions or the simulated river-pool warming (30 °C) on AMR persistence or invasion success of E. coli. Results however indicated that antibiotic resistance markers in the riverine biofilms decreased under the experimental conditions in the absence of exposure to external inputs of antibiotics and AMR.

N-Methyl-D-Aspartate Receptor availability in First-Episode Psychosis: a multi-modal PET-MR brain imaging study

Introduction

N-Methyl-D-Aspartate Receptor (NMDAR) hypofunction is hypothesised to underlie psychosis but this has not been tested early in illness.

Objectives

Our aim was to determine if NMDAR availability was lower in patients with first episode psychosis compared to healthy controls.

Methods

To address this, we studied 40 volunteers (21 patients with first episode psychosis and 19 matched healthy controls) using PET imaging with an NMDAR selective ligand, [¹⁸F]GE179, that binds to the ketamine binding site to index its distribution volume ratio (DVR) and volume of distribution (V_T). Striatal glutamatergic indices (glutamate and Glx) were measured simultaneously using magnetic resonance spectroscopy imaging (¹H-MRS).

Results

Hippocampal DVR, but not V_T, was significantly lower in patients relative to controls (p=0.02, Cohen’s d=0.81; p=0.15, Cohen’s d=0.49), and negatively associated with total (rho=-0.47, p= 0.04), depressive (rho=-0.67, p=0.002), and general symptom severity (rho=-0.74, p<0.001). Exploratory analyses found no significant differences in other brain regions (anterior cingulate cortex, thalamus, striatum and temporal cortex). We found an inverse relationship between hippocampal NMDAR availability and striatal glutamate levels in people with first-episode psychosis (rho = -0.74, p <0.001) but not in healthy controls (rho = -0.22, p = 0.44).

Conclusions

These findings are consistent with the NMDAR hypofunction hypothesis and identify the hippocampus as a key locus for relative NMDAR hypofunction, although further studies should test specificity and causality.

Disclosure

No significant relationships.

Practical issues and limitations of brain attenuation correction on a simultaneous PET-MR scanner

BACKGROUND

Despite the advent of clinical PET-MR imaging for routine use in 2011 and the development of several methods to address the problem of attenuation correction, some challenges remain. We have identified and investigated several issues that might affect the reliability and accuracy of current attenuation correction methods when these are implemented for clinical and research studies of the brain. These are (1) the accuracy of converting CT Hounsfield units, obtained from an independently acquired CT scan, to 511 keV linear attenuation coefficients; (2) the effect of padding used in the MR head coil; (3) the presence of close-packed hair; (4) the effect of headphones. For each of these, we have examined the effect on reconstructed PET images and evaluated practical mitigating measures.

RESULTS

Our major findings were (1) for both Siemens and GE PET-MR systems, CT data from either a Siemens or a GE PET-CT scanner may be used, provided the conversion to 511 keV μ-map is performed by the PET-MR vendor's own method, as implemented on their PET-CT scanner; (2) the effect of the head coil pads is minimal; (3) the effect of dense hair in the field of view is marked (> 10% error in reconstructed PET images); and (4) using headphones and not including them in the attenuation map causes significant errors in reconstructed PET images, but the risk of scanning without them may be acceptable following sound level measurements.

CONCLUSIONS

It is important that the limitations of attenuation correction in PET-MR are considered when designing research and clinical PET-MR protocols in order to enable accurate quantification of brain PET scans. Whilst the effect of pads is not significant, dense hair, the use of headphones and the use of an independently acquired CT-scan can all lead to non-negligible effects on PET quantification. Although seemingly trivial, these effects add complications to setting up protocols for clinical and research PET-MR studies that do not occur with PET-CT. In the absence of more sophisticated PET-MR brain attenuation correction, the effect of all of the issues above can be minimised if the pragmatic approaches presented in this work are followed.

Long-term rates of remission and late psychotic transition of individuals at risk for psychosis

Introduction

In the growing research field of early psychosis detection in patients with an at risk mental state (ARMS), most studies focus on the transition to frank psychosis. However, the majority of ARMS patients do not go on to develop frank psychosis and reported transition rates are declining. Little is known about the long-term outcome of these non-transitioned patients (ARMS-NT).

Objectives

To investigate in preliminary analyses the long-term outcome of ARMS-NT patients with respect to persistence of ARMS signs and symptoms and the rates of late psychotic transition.

Methods

The ongoing study “FePsy-BHS-NT” follows up ARMS-NT without transition during at least the first two years for up to 15 years after their initial assessment. ARMS status is ascertained with the Basel Screening Instrument for Psychosis (BSIP). ARMS remission is defined as the absence of attenuated psychotic symptoms or brief limited intermittent psychotic symptoms for at least 12 consecutive months.

Results

In this preliminary sample of 51 ARMS-NT, the majority of patients (70.6%) have remitted from their at risk mental state, 13.7% remain at risk and 15.7% have made a late psychotic transition during the course of long-term follow up (median = 5.75, range 4–11 years after initial assessment).

Conclusions

The considerable rates of ARMS persistence and late psychotic transition indicate that longer follow-up durations than commonly recommended should be contemplated in ARMS patients. Potential predictors of favorable long-term clinical outcome, as well as psychosocial, neurocognitive and other outcomes of ARMS-NT patients will be further evaluated in the present study.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

The severity and associated comorbidities of retinopathy of prematurity among micro-premature infants with birth weights less than 750 grams

OBJECTIVES

To evaluate the characteristics and comorbidities associated with ROP in micro-premature infants and their results.

METHODS

This is a retrospective chart review involving multiple intensive care units in Central Texas from 2011 to 2016. Infants were included if birth weight (BW) was≤750 g with confirmed ROP by the International Classification of Retinopathy of Prematurity (ICROP). Neonates were examined and treated with laser ablation or intravitreal ranibizumab (IVR) with subsequent laser treatment, guided by fluorescein angiography, if met treatment criteria defined as type 1 ROP by the Early Treatment of Retinopathy of Prematurity standards. Time to regression was defined clinically. Results were analyzed using chi-squared test.

RESULTS

100 neonates were included in the study. Mean BW was 599 grams and mean gestational age was 24.2 weeks. Forty neonates were classified as type 1 ROP and therefore required intervention; of them 21 received laser alone and 19 required IVR with subsequent laser. Only 2 patients received more than one IVR injection. None of the patients progressed to stage 4 or 5 ROP.

CONCLUSIONS

Despite such low birth weights, none of these neonates progressed to stage 4 or 5 ROP likely because of prompt examination and treatment with laser or with IVR and subsequent laser. IVR might serve as a bridge to laser in type 1 ROP allowing some retinal vessel development prior to definitive laser treatment.

Nitrergic signaling via interstitial cells of Cajal and smooth muscle cells influences circular smooth muscle contractility in murine colon

BACKGROUND

Regulation of gastrointestinal motility involves excitatory and inhibitory neurotransmission. Nitric oxide (NO), the major inhibitory neurotransmitter, acts via its receptor NO-sensitive guanylyl cyclase (NO-GC). In the GI tract, NO-GC is expressed in several cell types such as smooth muscle cells (SMC) and interstitial cells of Cajal (ICC). Using cell-specific knockout mice, we have previously shown that NO-GC modulates spontaneous contractions in colonic longitudinal smooth muscle. However, its detailed role in the colonic circular smooth muscle is still unclear.

METHODS

Myography was performed to evaluate spontaneous contractions in rings of proximal colon (2.5 mm) from global (GCKO) and cell-specific knockout mice for NO-GC. Immunohistochemistry and in situ hybridization were used to specify NO-GC expression.

KEY RESULTS

Colonic circular smooth muscle showed three different contraction patterns: high-frequency ripples, slow phasic contractions, and large contractions. Ripples formed independently of NO-GC. Slow phasic contractions occurred intermittently in WT, SMC-GCKO, and ICC-GCKO tissue, whereas they were more prominent and prolonged in GCKO and SMC/ICC-GCKO tissue. Tetrodotoxin and the NO-GC inhibitor ODQ transformed slow phasic contractions of WT and single cell-specific knockout into GCKO-like contractions. ODQ increased the frequency of large contractions in WT and ICC-GCKO colon but not in GCKO, SMC-GCKO, and SMC/ICC-GCKO preparations. Tetrodotoxin and hexamethonium abolished large contractions.

CONCLUSIONS AND INFERENCES

We conclude that short rings of murine colon can be effectively used to record spontaneous contractions. Although NO-GC in SMC determines smooth muscle tone, concerted action of NO-GC in both SMC and ICC modulates slow phasic contractions and large contractions.

Comparison of nitrergic signaling in circular and longitudinal smooth muscle of murine ileum

BACKGROUND

Gastrointestinal (GI) motility originates from coordinated movements of circular (CM) and longitudinal (LM) smooth muscle. How the two muscle layers react individually to nitrergic input and how they integrate nitrergic signaling is not thoroughly understood.

METHODS

We used immunohistochemistry to unveil expression of NO-sensitive guanylyl cyclase (NO-GC) in the ileum. For functional analyses, we measured tone of ileal CM and spontaneous contractions in both ileal muscle layers from mice lacking NO-GC globally (GCKO) and specifically in smooth muscle cells (SMC-GCKO).

KEY RESULTS

In contrast to other parts of the GI tract, NO-GC was not expressed in ckit-positive cells in ileum. NO-GC expression was intense in platelet-derived growth factor receptor α-positive cells and in yet unidentified cells of myenteric plexus and serosa. Both CM and LM developed spontaneous contractile activity; frequency and duration of their spontaneous contractions were identical. The amplitude of spontaneous contractions in CM was increased in the absence of NO-GC. In ileum from control (ctrl) animals, inhibition of NO-GC increased whereas NO-GC stimulation decreased tissue tone. In contrast, contractile activity in LM was not different between ctrl and knockout strains. Here, NO led to suppression of spontaneous contractions of ctrl ileum whereas GCKO tissue was unaffected. To our surprise, NO suppressed spontaneous contractions in SMC-GCKO ileum indicating participation of other cell type(s).

CONCLUSIONS AND INFERENCES

NO-GC in SMC is involved in the regulation of tone and amplitude of spontaneous contractions in ileal CM. In LM, NO induces suppression of spontaneous contractions via NO-GC in a non-SMC type.

Antipsychotic plasma levels in the assessment of poor treatment response in schizophrenia

OBJECTIVE

Treatment resistance is a challenge for the management of schizophrenia. It is not always clear whether inadequate response is secondary to medication ineffectiveness, as opposed to medication underexposure due to non-adherence or pharmacokinetic factors. We investigated the prevalence of subtherapeutic antipsychotic plasma levels in patients identified as treatment-resistant by their treating clinician.

METHOD

Between January 2012 and April 2017, antipsychotic plasma levels were measured in 99 individuals provisionally diagnosed with treatment-resistant schizophrenia by their treating clinicians, but not prescribed clozapine. Patients were followed up to determine whether they were subsequently admitted to hospital.

RESULTS

Thirty-five per cent of plasma levels were subtherapeutic, and of these, 34% were undetectable. Black ethnicity (P = 0.006) and lower dose (P < 0.001) were significantly associated with subtherapeutic/undetectable plasma levels. Individuals with subtherapeutic/undetectable levels were significantly more likely to be admitted to hospital (P = 0.02).

CONCLUSION

A significant proportion of patients considered treatment-resistant have subtherapeutic antipsychotic plasma levels, and this is associated with subsequent admission. The presence of subtherapeutic plasma levels may suggest a need to address adherence or pharmacokinetic factors as opposed to commencing clozapine treatment. While antipsychotic levels are not recommended for the routine adjustment of dosing, they may assist with the assessment of potential treatment resistance in schizophrenia.

Comorbidities in Patients with an At-risk Mental State and First Episode Psychosis

Introduction

Non-psychotic axis I diagnoses are highly prevalent in at-risk mental state (ARMS) and first episode psychosis (FEP) patients, the most common being affective and anxiety disorders. Few studies have examined differences between ARMS and FEP patients or gender effects regarding such diagnoses.

Objective

To examine current and lifetime comorbidities in ARMS and FEP patients. Furthermore, to examine gender differences, and differences between patients with (ARMS-T) and without later transition to psychosis (ARMS-NT).

Methods

This study was part of the Früherkennung von Psychosen (FePsy) study. Current and lifetime axis I comorbidities were assessed using the Structured Clinical Interview for DSM-IV (SCID-I).

Results

One hundred and thirty-two ARMS and 98 FEP patients were included. Current comorbidities were present in 53.1% of FEP and 64.4% of ARMS patients, the most common being affective, anxiety and substance use disorders. Current affective disorders were significantly more common in ARMS than FEP. Lifetime comorbidities were diagnosed in 58.2% of FEP and 69.7% of ARMS patients, with significantly more affective and anxiety disorders in ARMS than FEP. Male FEP patients had more current and lifetime substance use disorders (across all substances) compared to female FEP. No differences emerged between ARMS-T and ARMS-NT.

Conclusions

As expected ARMS patients have many comorbidities, while clearly diagnosed FEP have less comorbidities. There were few gender differences in axis I comorbidities. Moreover, no differences between ARMS-T and NT emerged, suggesting that axis I comorbidities do not improve prediction of transition. Nevertheless, the high comorbidity prevalence is relevant for global functioning and clinical treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Distinct immune responses and virus shedding in pigs following aerosol, intra-nasal and contact infection with pandemic swine influenza A virus, A(H1N1)09

Influenza virus infection in pigs is a major farming problem, causing considerable economic loss and posing a zoonotic threat. In addition the pig is an excellent model for understanding immunity to influenza viruses as this is a natural host pathogen system. Experimentally, influenza virus is delivered to pigs intra-nasally, by intra-tracheal instillation or by aerosol, but there is little data comparing the outcome of different methods. We evaluated the shedding pattern, cytokine responses in nasal swabs and immune responses following delivery of low or high dose swine influenza pdmH1N1 virus to the respiratory tract of pigs intra-nasally or by aerosol and compared them to those induced in naturally infected contact pigs. Our data shows that natural infection by contact induces remarkably high innate and adaptive immune response, although the animals were exposed to a very low virus dose. In contacts, the kinetics of virus shedding were slow and prolonged and more similar to the low dose directly infected animals. In contrast the cytokine profile in nasal swabs, antibody and cellular immune responses of contacts more closely resemble immune responses in high dose directly inoculated animals. Consideration of these differences is important for studies of disease pathogenesis and assessment of vaccine protective efficacy.

Autoantibodies to central nervous system neuronal surface antigens: psychiatric symptoms and psychopharmacological implications

RATIONALE

Autoantibodies to central nervous system (CNS) neuronal surface antigens have been described in association with autoimmune encephalopathies which prominently feature psychiatric symptoms in addition to neurological symptoms. The potential role of these autoantibodies in primary psychiatric diseases such as schizophrenia or bipolar affective disorder is of increasing interest.

OBJECTIVES

We aimed to review the nature of psychiatric symptoms associated with neuronal surface autoantibodies, in the context of autoimmune encephalopathies as well as primary psychiatric disorders, and to review the mechanisms of action of these autoantibodies from a psychopharmacological perspective.

RESULTS

The functional effects of the autoantibodies on their target antigens are described; their clinical expression is at least in part mediated by their effects on neuronal receptor function, primarily at the synapse, usually resulting in receptor hypofunction. The psychiatric effects of the antibodies are related to known functions of the receptor target or its complexed proteins, with reference to supportive genetic and pharmacological evidence where relevant. Evidence for a causal role of these autoantibodies in primary psychiatric disease is increasing but remains controversial; relevant methodological controversies are outlined. Non-receptor-based mechanisms of autoantibody action, including neuroinflammatory mechanisms, and therapeutic implications are discussed.

CONCLUSIONS

An analysis of the autoantibodies from a psychopharmacological perspective, as endogenous, bioactive, highly specific, receptor-targeting molecules, provides a valuable opportunity to understand the neurobiological basis of associated psychiatric symptoms. Potentially, new treatment strategies will emerge from the improving understanding of antibody-antigen interaction within the CNS.

The impact of HLA class I and EBV latency-II antigen-specific CD8(+) T cells on the pathogenesis of EBV(+) Hodgkin lymphoma

In 40% of cases of classical Hodgkin lymphoma (cHL), Epstein–Barr virus (EBV) latency‐II antigens [EBV nuclear antigen 1 (EBNA1)/latent membrane protein (LMP)1/LMP2A] are present (EBV⁺cHL) in the malignant cells and antigen presentation is intact. Previous studies have shown consistently that HLA‐A*02 is protective in EBV⁺cHL, yet its role in disease pathogenesis is unknown. To explore the basis for this observation, gene expression was assessed in 33 cHL nodes. Interestingly, CD8 and LMP2A expression were correlated strongly and, for a given LMP2A level, CD8 was elevated markedly in HLA‐A*02^–versus HLA‐A*02⁺ EBV⁺cHL patients, suggesting that LMP2A‐specific CD8⁺ T cell anti‐tumoral immunity may be relatively ineffective in HLA‐A*02^– EBV⁺cHL. To ascertain the impact of HLA class I on EBV latency antigen‐specific immunodominance, we used a stepwise functional T cell approach. In newly diagnosed EBV⁺cHL, the magnitude of ex‐vivo LMP1/2A‐specific CD8⁺ T cell responses was elevated in HLA‐A*02⁺ patients. Furthermore, in a controlled in‐vitro assay, LMP2A‐specific CD8⁺ T cells from healthy HLA‐A*02 heterozygotes expanded to a greater extent with HLA‐A*02‐restricted compared to non‐HLA‐A*02‐restricted cell lines. In an extensive analysis of HLA class I‐restricted immunity, immunodominant EBNA3A/3B/3C‐specific CD8⁺ T cell responses were stimulated by numerous HLA class I molecules, whereas the subdominant LMP1/2A‐specific responses were confined largely to HLA‐A*02. Our results demonstrate that HLA‐A*02 mediates a modest, but none the less stronger, EBV‐specific CD8⁺ T cell response than non‐HLA‐A*02 alleles, an effect confined to EBV latency‐II antigens. Thus, the protective effect of HLA‐A*02 against EBV⁺cHL is not a surrogate association, but reflects the impact of HLA class I on EBV latency‐II antigen‐specific CD8⁺ T cell hierarchies.

A distinct immunogenic region of glutamic acid decarboxylase 65 is naturally processed and presented by human islet cells to cytotoxic CD8 T cells

CD8 T cells specific for islet autoantigens are major effectors of β cell damage in type 1 diabetes, and measurement of their number and functional characteristics in blood represent potentially important disease biomarkers. CD8 T cell reactivity against glutamic acid decarboxylase 65 (GAD65) in HLA-A*0201 subjects has been reported to focus on an immunogenic region 114-123 (VMNILLQYVV), with studies demonstrating both 114-123 and 114-122 epitopes being targeted. However, the fine specificity of this response is unclear and the key question as to which epitope(s) β cells naturally process and present and, therefore, the pathogenic potential of CD8 T cells with different specificities within this region has not been addressed. We generated human leucocyte antigen (HLA)-A*0201-restricted CD8 T cell clones recognizing either 114-122 alone or both 114-122 and 114-123. Both clone types show potent and comparable effector functions (cytokine and chemokine secretion) and killing of indicator target cells externally pulsed with cognate peptide. However, only clones recognizing 114-123 kill target cells transfected with HLA-A*0201 and GAD2 and HLA-A*0201(+) human islet cells. We conclude that the endogenous pathway of antigen processing by HLA-A*0201-expressing cells generates GAD65114-123 as the predominant epitope in this region. These studies highlight the importance of understanding β cell epitope presentation in the design of immune monitoring for potentially pathogenic CD8 T cells.

The practical management of refractory schizophrenia--the Maudsley Treatment REview and Assessment Team service approach

OBJECTIVE

To describe a practical approach to the community management of treatment-resistant schizophrenia (TRS).

METHOD

A descriptive review of an approach to the assessment and management of patients with TRS, including the community titration of clozapine treatment, and a report of the management recommendations for the first one hundred patients assessed by the Treatment REview and Assessment Team (TREAT).

RESULTS

The standardized model for the community assessment, management and titration of clozapine is described. To date, 137 patients have been referred to this service and 100 patients (72%) attended for assessment. Of these, 33 have been initiated on clozapine while fifteen have had clozapine recommended but have not wished to undertake clozapine treatment. Other management options recommended have included augmentation strategies and long-acting injectable antipsychotics.

CONCLUSION

The service had increased the number of patients receiving community assessment and initiation of clozapine by five-fold relative to the rate prior to the establishment of the service. The large number of referrals and high attendance rate indicates that there is clinical demand for the model. Systematic evaluation is required to determine the clinical and cost-effectiveness of this model and its potential application to other clinical settings.

Arterial stiffness results from eccentrically biased downhill running exercise

OBJECTIVES

There is increasing evidence that select forms of exercise are associated with vascular changes that are in opposition to the well-accepted beneficial effects of moderate intensity aerobic exercise. To determine if alterations in arterial stiffness occur following eccentrically accentuated aerobic exercise, and if changes are associated with measures of muscle soreness.

DESIGN

Repeated measures experimental cohort.

METHODS

Twelve (m=8/f=4) moderately trained (VO₂max=52.2 ± 7.4 ml kg(-1)min(-1)) participants performed a downhill run at -12° grade using a speed that elicited 60% VO₂max for 40 min. Cardiovascular and muscle soreness measures were collected at baseline and up to 72 h post-running.

RESULTS

Muscle soreness peaked at 48 h (p=<0.001). Arterial stiffness similarly peaked at 48 h (p=0.04) and remained significantly elevated above baseline through 72 h.

CONCLUSIONS

Eccentrically accentuated downhill running is associated with arterial stiffening in the absence of an extremely prolonged duration or fast pace. The timing of alterations coincides with the well-documented inflammatory response that occurs from the muscular insult of downhill running, but whether the observed changes are a result of either systemic or local inflammation is yet unclear. These findings may help to explain evidence of arterial stiffening in long-term runners and following prolonged duration races wherein cumulative eccentric loading is high.

Reverse Phase HPLC Analysis of Commercial Surfactants used as Melt Additives

Reverse phase HPLC (High Performance Liquid Chromatography) was used to analyze the length distribution of polyoxyethylene (POE) chains in commercial surfactants that can be used as melt additives for hydrophilic polypropylene surface modification. Ten nonionic surfactants including ethoxylated alcohols, nonyl phenols and amines, PEG esters, and mono glycerides were investigated. HPLC methods described herein are capable of analyzing ethoxylated nonionic surfactants and offer the advantage of separating the components in surfactants according to both the hydrophobe and hydrophile chain length. Moreover, the method is rapid and gradient elution allows for good baseline separation of the several components in the additives.

Expression levels of Activated Leukocyte Cell Adhesion Molecule (ALCAM/CD166) in primary breast carcinoma and distant breast cancer metastases

Introduction: Activated Leukocyte Cell Adhesion Molecule (ALCAM/CD166) gained increasing attention regarding tumorprogression and metastatic spread in breast cancer. The aim of this study was to examine ALCAM expression levels in primary breast cancer and distant metastases of the same patient within 29 autopsy cases to better understand the underlying mechanisms of metastases and the role of adhesion molecules in this process.

Material and Methods: Paraffin-embedded tissue of the primary and distant metastases (N = 84) were collected and ALCAM immunohistochemistry was performed.

Results: The primary tumor and all metastases showed a statistically normally distributed ALCAM expression. ALCAM expression level average differs between immunoreactive score (IRS) (mean) 4.16 (lung)-5.00 (adrenal gland). Of the metastatic ALCAM expression levels we obtained an intra-class correlation (ICC) of 80.9%, indicating a strong cluster effect of measurements in the same patient. ALCAM expression scores in metastatic sites and in the primary analyzed by hierarchical regression analysis showed that ALCAM expression in the primary is prognostic for ALCAM expression in all different sites of metastases (slope = 0.773, p < 0.001, r² = 0.504).

Conclusion: ALCAM expression in the primary is positively correlated to ALCAM expression in metastases within one single patient. This could show a tumorbiological context of ALCAM for the development of metastases in breast cancer.

Weathering effects in an urban environment: a case study of tuffeau, a French porous limestone

A case study is carried out on a highly porous limestone called tuffeau located in an urban environment. Weathering effects are characterized by several complementary techniques: mechanical resistance (compressive test), imbibition (capillarity test), mercury intrusion porosimetry, chemical analysis [inductively coupled plasma-optical emission spectrometer (ICP-OES)], scanning electron microscope (SEM) image analysis and X-ray diffraction (XRD). The results show the different composition of the deteriorated zone of the stone and mainly the presence of high gypsum content in the black crust surface. The analysis also shows that the natural penetration of water into this stone under environmental conditions (atmospheric precipitation, relative humidity and temperature) is limited to 20 mm. Moreover, the presence of gypsum is only detected in this limited zone, which demonstrates the depth of alteration in this stone. Finally, this study clearly highlights the important role of water movements in the deterioration of stone.

Risk equalization and voluntary deductibles: a complex interaction

The presence of voluntary deductibles in the Swiss and Dutch mandatory health insurance has important implications for the respective risk equalization systems. In a theoretical analysis, we discuss the consequences of equalizing three types of expenditures: the net claims that are reimbursed by the insurer, the out-of-pocket expenditures and the expenditure savings due to moral hazard reduction. Equalizing only the net claims, as done in Switzerland, creates incentives for cream skimming and prevents insurers from incorporating out-of-pocket expenditures and moral hazard reductions into their premium structure. In an empirical analysis, we examine the effect of self-selection and conclude that the Swiss and Dutch risk equalization systems do not fully adjust for differences in health status between those who choose a deductible and those who do not. We discuss how this may lead to incentives for cream skimming and to a reduction of cross-subsidies from healthy to unhealthy individuals compared to a situation without voluntary deductibles.

Does risk equalization reduce the viability of voluntary deductibles?

Theoretically, a risk avers consumer takes a deductible if the premium rebate (far) exceeds his/her expected out-of-pocket expenditures. In the absence of risk equalization, insurers are able to offer high rebates because those who select into a deductible plan have below-average expenses. This paper shows that, for high deductibles, such rebates cannot be offered if risk equalization would “perfectly” adjust for the effect of self selection. Since the main goal of user charges is to reduce moral hazard, some effect of self selection on the premium rebate can be justified to increase the viability of voluntary deductibles.

Rapid alleviation of signs and symptoms of rheumatoid arthritis with intravenous or subcutaneous administration of adalimumab in combination with methotrexate

OBJECTIVE

This randomized, placebo-controlled, double-blind, Phase 1 study assessed the magnitude, onset, and duration of response with intravenous (i.v.) and subcutaneous (s.c.) adalimumab (Humira, Abbott Laboratories) combined with methotrexate (MTX) in patients with active rheumatoid arthritis (RA) despite previous MTX therapy.

METHODS

Fifty-four patients were randomized to two injections of i.v. or s.c. adalimumab (1 mg/kg) or placebo while continuing on MTX (mean dose, 15.7 mg/week). Dosing intervals were determined by the European League Against Rheumatism (EULAR) response criteria, and were allowed to range from 1 to 3 months. Efficacy was mainly assessed using the EULAR response criteria and the American College of Rheumatology (ACR) response criteria.

RESULTS

Moderate EULAR response was achieved at least once within 29 days after the first injection in 83% and 61% of patients receiving i.v. and s.c. adalimumab respectively, compared with 44% for placebo [probability (p) < or = 0.05 for i.v. adalimumab versus placebo]. A 20% improvement in disease activity according to the ACR criteria (ACR20 response) was achieved by 72% and 67% of patients receiving i.v. and s.c. adalimumab respectively, compared with 28% for placebo (p < or = 0.01 and p < or = 0.05, respectively, versus placebo). By Day 15 after the first and second injections, statistically significant moderate EULAR and ACR20 response rates were achieved with either i.v. or s.c. adalimumab compared with placebo (p < or = 0.05). The mean times to second injection for i.v. adalimumab, s.c. adalimumab, and placebo were 42.2 days (range: 27-84 days), 38.3 days (range: 26-85 days), and 28.4 days (range: 26-32 days), respectively (minimum time allowed by the protocol between the first and second injections was 4 weeks). Adalimumab in combination with MTX was well tolerated, with no patients being withdrawn because of adverse events.

CONCLUSION

Either i.v. or s.c. adalimumab added to MTX significantly improved the signs and symptoms of RA compared with MTX alone. Subcutaneously administered adalimumab appeared to provide a response that was as great, as rapid, and as enduring as that with i.v. adalimumab.

Efficacy and safety of the fully human anti-tumour necrosis factor alpha monoclonal antibody adalimumab (D2E7) in DMARD refractory patients with rheumatoid arthritis: a 12 week, phase II study

OBJECTIVES

To evaluate efficacy, dose response, safety, and tolerability of adalimumab (D2E7) in disease modifying antirheumatic drug (DMARD) refractory patients with longstanding, active rheumatoid arthritis (RA).

METHODS

During a 12 week, double blind, placebo controlled study, 284 patients were randomly allocated to receive weekly subcutaneous injections of adalimumab 20 mg (n = 72), 40 mg (n = 70), or 80 mg (n = 72) or placebo (n = 70) without concomitant DMARDs.

RESULTS

Adalimumab significantly improved the signs and symptoms of RA for all efficacy measures. ACR20 responses with adalimumab were significant at each assessment versus placebo (p</=0.01). Additionally, ACR responses with adalimumab were achieved more rapidly than with placebo, with 82/115 (71%) of the ultimate ACR20 response rate to adalimumab treatment achieved at week 2. At week 12, for adalimumab 20, 40, and 80 mg, ACR20 response rates were 50.7%, 57.1%, and 54.2%, respectively, versus 10.0% for placebo (p</=0.001 for all comparisons); ACR50 rates were 23.9%, 27.1%, and 19.4%, respectively, versus 1.4% for placebo (p</=0.001 for all comparisons); and ACR70 rates were 11.3%, 10.0%, and 8.3%, respectively, versus 0.0% for placebo (p</=0.05 for all comparisons). All adalimumab doses significantly improved all ACR core criteria at all assessments. The 40 mg and 80 mg doses provided similar benefit. Adalimumab at all doses was generally well tolerated, with only mild or moderate adverse events. Completion rates were 87% for adalimumab and 67% for placebo.

CONCLUSIONS

Adalimumab given as monotreatment to patients with longstanding, severe RA refractory to traditional DMARDs produced a rapid, sustained response and was safe and well tolerated, with no dose limiting side effects.

Impact of sepsis, lung injury, and the role of lipid infusion on circulating prostacyclin and thromboxane A(2)

OBJECTIVE

To investigate whether plasma levels of prostacyclin (PGI2) and thromboxane A(2) (TxA2) are a function of the infusion rate of soybean-based fat emulsions, severity of systemic inflammation, and pulmonary organ failure.

DESIGN

Prospective, randomized, crossover study.

SETTING

Intensive care unit of a university hospital.

PATIENTS

Eighteen critically ill patients, ten presenting with severe sepsis, eight with SIRS or sepsis complicated with ARDS.

INTERVENTIONS

Patients were randomly assigned to receive rapid fat infusion over 6 h (rFI) or slow fat infusion over 24 h (sFI) along with parenteral nutrition.

MEASUREMENTS AND RESULTS

The stable prostanoids 6-keto-PGF1alpha and TxB2 were measured in arterial and mixed venous blood samples, and at 6-h periods trans-pulmonary balances (TPB) were calculated. Free linoleic acid fraction was determined in arterial blood. rFI induced greater increase of linoleic acid than sFI in both groups. Enhanced prostanoid levels and correlations with linoleic acid availabilities were found, however, in ARDS patients only, revealing the highest sepsis- and lung injury scores. Averaged TPB per 24 h was positive in the sepsis group and negative in the ARDS group as rFI induced lowest TPB values for TxB2 at 6 h.

CONCLUSION

The quantity of prostanoids formed and their subsequent utilization are dependent on the availability of precursor linoleic acid and are probably affected by the severity of SIRS or sepsis and the existence of pulmonary organ failure, respectively. Because TxA2 might be extracted by the injured lung, rapid infusion of soybean-based fat emulsions should be avoided in patients suffering from severe pulmonary organ failure.

[Control of tachycardia with intravenous amiodarone in acute left heart failure]

The treatment of atrial tachycardia in critically ill patients can be difficult. Nine cases were presented with atrial tachyarrhythmias (mean heart rate > 130 beats/min) and left heart failure. Congestive heart failure was diagnosed in 6 patients (ejection fraction < 25%) and hypertensive heart failure in 3 patients (ejection infarction > 55%). The infusion of amiodarone (450 mg over 10 min and 0.5 mg/min after the bolus administration) was associated with a decrease in heart rate 31 beats/min and an increase in systolic blood pressure of 13 mm Hg after one hour. There was only one adverse effect secondary to amiodarone therapy. In this case the sinus rhythm converted within 24 hours but T-waves alternans and short running torsade de pointes ventricular tachycardia was observed and amiodarone therapy was discontinued.

A Drosophila haemocyte-specific protein, hemolectin, similar to human von Willebrand factor

We identified a novel Drosophila protein of approximately 400 kDa, hemolectin (d-Hml), secreted from haemocyte-derived Kc167 cells. Its 11.7 kbp cDNA contains an open reading frame of 3843 amino acid residues, with conserved domains in von Willebrand factor (VWF), coagulation factor V/VIII and complement factors. The d-hml gene is located on the third chromosome (position 70C1-5) and consists of 26 exons. The major part of d-Hml consists of well-known motifs with the organization: CP1-EG1-CP2-EG2-CP3-VD1-VD2-VD'-VD3-VC1-VD"-VD"'-FC1-FC2-VC2-LA1-VD4-VD5-VC3-VB1-VB2-VC4-VC5-CK1 (CP, complement-control protein domain; EG, epidermal-growth-factor-like domain; VB, VC, VD, VWF type B-, C- and D-like domains; VD', VD", VD"', truncated C-terminal VDs; FC, coagulation factor V/VIII type C domain; LA, low-density-lipoprotein-receptor class A domain; CK, cysteine knot domain). The organization of VD1-VD2-VD'-VD3, essential for VWF to be processed by furin, to bind to coagulation factor VIII and to form interchain disulphide linkages, is conserved. The 400 kDa form of d-Hml was sensitive to acidic cleavage near the boundary between VD2 and VD', where the cleavage site of pro-VWF is located. Agarose-gel electrophoresis of metabolically radiolabelled d-Hml suggested that it is secreted from Kc167 cells mainly as dimers. Resembling VWF, 7.9% (305 residues) of cysteine residues on the d-Hml sequence had well-conserved positions in each motif. Coinciding with the development of phagocytic haemocytes, d-hml transcript was detected in late embryos and larvae. Its low-level expression in adult flies was induced by injury at any position on the body.

Olefin metathesis in supercritical carbon dioxide

Liquid or supercritical carbon dioxide (scCO(2)) is a versatile reaction medium for ring-opening metathesis polymerization (ROMP) and ring-closing olefin metathesis (RCM) reactions using well-defined metal catalysts. The molybdenum alkylidene complex 1 and ruthenium carbenes 2 and 3 bearing PCy(3) or N-heterocyclic carbene ligands, respectively, can be used and are found to exhibit efficiency similar to that in chlorinated organic solvents. While compound 1 is readily soluble in scCO(2), complexes 2 and 3 behave like heterogeneous catalysts in this reaction medium. Importantly, however, the unique properties of scCO(2) provide significant advantages beyond simple solvent replacement. This pertains to highly convenient workup procedures both for polymeric and low molecular weight products, to catalyst immobilization, to reaction tuning by density control (RCM versus acyclic diene metathesis polymerization), and to applications of scCO(2) as a protective medium for basic amine functions. The latter phenomenon is explained by the reversible formation of the corresponding carbamic acid as evidenced by (1)H NMR data obtained in compressed CO(2). Together with its environmentally and toxicologically benign character, these unique physicochemical features sum up to a very attractive solvent profile of carbon dioxide for sustainable synthesis and production.