Central vein sign: A diagnostic biomarker in multiple sclerosis (CAVS-MS) study protocol for a prospective multicenter trial

The specificity and implementation of current MRI-based diagnostic criteria for multiple sclerosis (MS) are imperfect. Approximately 1 in 5 of individuals diagnosed with MS are eventually determined not to have the disease, with overreliance on MRI findings a major cause of MS misdiagnosis. The central vein sign (CVS), a proposed MRI biomarker for MS lesions, has been extensively studied in numerous cross sectional studies and may increase diagnostic specificity for MS. CVS has desirable analytical, measurement, and scalability properties. "Central Vein Sign: A Diagnostic Biomarker in Multiple Sclerosis (CAVS-MS)" is an NIH-supported, 2-year, prospective, international, multicenter study conducted by the North American Imaging in MS Cooperative (NAIMS) to evaluate CVS as a diagnostic biomarker for immediate translation into clinical care. Study objectives include determining the concordance of CVS and McDonald Criteria to diagnose MS, the sensitivity of CVS to detect MS in those with typical presentations, and the specificity of CVS among those with atypical presentations. The study will recruit a total of 400 participants (200 with typical and 200 with atypical presentations) across 11 sites. T2*-weighted, high-isotropic-resolution, segmented echo-planar MRI will be acquired at baseline and 24 months on 3-tesla scanners, and FLAIR* images (combination of FLAIR and T2*) will be generated for evaluating CVS. Data will be processed on a cloud-based platform that contains clinical and CVS rating modules. Imaging quality control will be conducted by automated methods and neuroradiologist review. CVS will be determined by Select6* and Select3* lesion methods following published criteria at each site and by central readers, including neurologists and neuroradiologists. Automated CVS detection and algorithms for incorporation of CVS into McDonald Criteria will be tested. Diagnosis will be adjudicated by three neurologists who served on the 2017 International Panel on the Diagnosis of MS. The CAVS-MS study aims to definitively establish CVS as a diagnostic biomarker that can be applied broadly to individuals presenting for evaluation of the diagnosis of MS.

POS0462 ALCOHOL AND INFLAMMATORY ARTHRITIS DISEASE ACTIVITY: PERSPECTIVES FROM A 979-PATIENT COHORT WITH SYSTEMATIC REVIEW AND META-ANALYSIS

Background:

The effect of alcohol on disease activity in inflammatory arthritis remains poorly understood. Studies of alcohol and the incidence or risk of inflammatory arthritis are conflicting [1,2]. Alcohol does downregulate pro-inflammatory cytokines and may therefore reduce immune-mediated disease activity.

Objectives:

This study investigates the relationship between alcohol consumption and disease activity in our inflammatory arthritis patient cohort and performs a systematic review with meta-analysis.

Methods:

Cohort Study Design and data analysis

Patients attending a rheumatology clinic between 2010-2020 were prospectively followed. Information on demographics, alcohol use, smoking habits, and disease outcome measures were collected. Statistical analysis included univariate and multivariate linear and binary logistic regressions, Mann Whitney-U tests, and one-way ANOVA with Tukey’s HSD.

Meta-analysis

EMBASE, Pubmed, the Cochrane library, and Web of Science were searched. Studies reporting on alcohol consumption and disease activity in a cohort of RA patients were included for further investigation. Forest plots were generated from 95% confidence intervals of extracted data using mean differences. Linear regression was used to determine correlations between alcohol and antibody status, gender, and smoking status.

Results:

Cohort Study

Of the 979 analysed patients, 62% had RA, 26.7% had PsA, and 11.2% had AS. Mean DAS28-CRP in RA and PsA at one year was 2.96 ± 1.39, and 64.2% of patients were in remission (DAS28-CRP ≤ 2.6 or BASDAI ≤ 4). Both male gender and risky drinking (>15 units of weekly alcohol) were both significantly associated with remission. Compared to women, men had an odds ratio of 1.78 [1.04, 2.52] (p=0.034) for any alcohol consumption and 6.9 [4.7, 9.1] (p=0.001) for drinking at least 15 weekly drinks. when adjusted for gender, there was no significant association between alcohol and disease activity. Yet, when adjusted for alcohol consumption, gender still influenced disease activity.

Meta-analysis

The search identified 4126 citations of which 14 were included. The pooled mean difference in DAS28 (95% CI) was 0.34 (0.24,0.44) (p<10-5) between non-drinkers and drinkers, 0.33 (0.05,0.62) (p=0.02) between non-drinkers and heavy drinkers, and 0 (-0.3,0.3) (p=0.98). between low- and high-risk drinkers. There was a significant difference in the mean difference of HAQ assessments between those who drink alcohol compared to those who do not (0.3 (0.18,0.41), p<10-5). There was no significant correlation between drinking and gender, smoking status, or antibody positivity.

Conclusion:

While it appears that alcohol is linked to remission in inflammatory arthritis, this association is lost when adjusted for gender. Men with inflammatory arthritis drink significantly more than women and men generally have less severe disease activity. However, the meta-analysis suggests alcohol consumption is associated with lower disease activity and self-reported health assessment in rheumatoid arthritis.

References:

[1]Bae S-C, Lee YH. Alcohol intake and risk of rheumatoid arthritis: a Mendelian randomization study. Z Rheumatol 2019;78:791–6. doi:10.1007/s00393-018-0537-z

[2]Scott IC, Tan R, Stahl D, et al. The protective effect of alcohol on developing rheumatoid arthritis: a systematic review and meta-analysis. Rheumatology (Oxford) 2013;52:856–67. doi:10.1093/rheumatology/kes376

Figure 1.

Mean differences in DAS28 between drinking groups. A between non-drinkers and drinkers. B between non-drinkers and high-risk drinkers. C between low-risk and high-risk drinkers.

Disclosure of Interests:

None declared

AIM2 in regulatory T cells restrains autoimmune diseases

The inflammasome initiates innate defense and inflammatory response by activating caspase-1 and pyroptotic cell death in myeloid cells^1,2. It is comprised of an innate immune receptor/sensor, pro-caspase-1, and a common adaptor molecule, ASC (apoptotic speck-containing protein with a CARD). Consistent with their pro-inflammatory function, caspase-1, ASC and NLRP3 exacerbate autoimmunity during experimental autoimmune encephalomyelitis (EAE) by enhancing IL-1β and IL-18 secretion in myeloid cells^3–6. Here we reveal an unexpected function of a DNA-binding inflammasome receptor, AIM2 (Absent in Melanoma 2)^7–10, in T regulatory cells (Tregs) to restrain two models of autoimmunity (experimental autoimmune encephalomyelitis and T cell-mediated colitis) by studying whole-body and Treg-specific Aim2^–/– mice. AIM2 is highly expressed by human and mouse Tregs, with its expression induced by TGF-β and its promoter occupied by transcription factors associated with Tregs, including Runx1, Ets1, Bcl11b and CREB. RNA-seq, biochemical and metabolic analyses revealed that AIM2 attenuates Akt-phosphorylation, mTOR, c-Myc and glycolysis, but promotes lipid oxidative phosphorylation in Tregs. Mechanistically, AIM2 interacts with the RACK1/PP2A-phosphatase complex to restrain Akt-phosphorylation. Lineage tracing demonstrates that AIM2 promotes the stability of Tregs during inflammation. While AIM2 is generally accepted as an inflammasome effector in myeloid cells, this report reveals a T cell-intrinsic role of AIM2 in restraining autoimmunity by diminishing Akt-mTOR signaling and altering immune-metabolism to enhance Treg stability.

A role for the NLR family members NLRC4 and NLRP3 in sterile inflammasome activation in glial cells

The inflammasome is implicated in many inflammatory diseases including neurological diseases but has been primarily studied in the macrophage-myeloid lineage. Here we demonstrate a physiologic role for nucleotide-binding domain, leucine-rich repeat, CARD domain containing proteins, NLRC4 and NLRP3, in brain astrocytes and microglia under the sterile neuroinflammation condition. In vitro, lysophosphatidylcholine (LPC), a molecule associated with neurodegeneration and demyelination, elicits an inflammasome activation dependent on both NLRC4 and NLRP3 in microglia and astrocytes, which are central players in neuroinflammation. Canonical inflammasome components ASC and caspase-1 but not non-canonical inflammasome component caspase-11 is required for LPC-activated inflammasome. Mechanistically, LPC-activated inflammasome also requires cathepsin B protease, calcium mobilization and potassium efflux. In an in vivo cuprizone model of neuroinflammation and demyelination, we found only mice lacking both Nlrc4 and Nlrp3 genes show the significant reduction in astrogliosis and microglial accumulation accompanied by decreased expression of the LPC receptor, G2A, while multiple sclerosis (MS) patient samples show increased G2A. These results reveal that both NLRC4 and NLRP3 are involved in activating LPC-induced inflammasome and are important in astrogliosis and microglial accumulation in a neurological disease model.

NLR members NLRC4 and NLRP3 mediate sterile inflammasome activation in microglia and astrocytes

Lysophosphatidylcholine is associated with neurodegeneration and demyelination. Freeman et al. demonstrate that lysophosphatidylcholine triggers NLRP3- and NLRC4-dependent inflammasome activation, and in a synergistic fashion, NLRP3 and NLRC4 contribute to a cuprizone-induced demyelination model in vivo.

Inflammation in the brain accompanies several high-impact neurological diseases including multiple sclerosis (MS), stroke, and Alzheimer’s disease. Neuroinflammation is sterile, as damage-associated molecular patterns rather than microbial pathogens elicit the response. The inflammasome, which leads to caspase-1 activation, is implicated in neuroinflammation. In this study, we reveal that lysophosphatidylcholine (LPC), a molecule associated with neurodegeneration and demyelination, elicits NLRP3 and NLRC4 inflammasome activation in microglia and astrocytes, which are central players in neuroinflammation. LPC-activated inflammasome also requires ASC (apoptotic speck containing protein with a CARD), caspase-1, cathepsin-mediated degradation, calcium mobilization, and potassium efflux but not caspase-11. To study the physiological relevance, Nlrc4^−/− and Nlrp3^−/− mice are studied in the cuprizone model of neuroinflammation and demyelination. Mice lacking both genes show the most pronounced reduction in astrogliosis and microglial accumulation accompanied by decreased expression of the LPC receptor G2A, whereas MS patient samples show increased G2A. These results reveal that NLRC4 and NLRP3, which normally form distinct inflammasomes, activate an LPC-induced inflammasome and are important in astrogliosis and microgliosis.

Underestimating the Impact of Ventilator-Associated Pneumonia by Use of Surveillance Data

We calculated rates of ventilator-associated pneumonia (VAP) by using surveillance data, clinical data, and coding data. Compared with the VAP rates calculated on the basis of surveillance data, the VAP rates calculated on the basis of coding data were significantly overestimated in 4 of 5 intensive, care units. Efforts to improve coding and clinical documentation will address much but not all of this discrepancy between surveillance and administrative data.

A national network to advance the field of cancer and female sexuality

INTRODUCTION

Understanding sexual health issues in cancer patients is integral to care for the continuously growing cancer survivor population.

AIM

To create a national network of active clinicians and researchers focusing on the prevention and treatment of sexual problems in women and girls with cancer.

METHODS

Interdisciplinary teams from the University of Chicago and Memorial Sloan-Kettering Cancer Center jointly developed the mission for a national conference to convene clinicians and researchers in the field of cancer and female sexuality. The invitee list was developed by both institutions and further iterated through suggestions from invitees. The conference agenda focused on three high-priority topics under the guidance of a professional facilitator. Breakout groups were led by attendees recognized by collaborators as experts in those topics. Conference costs were shared by both institutions.

MAIN OUTCOME MEASURE

Development of Scientific Working Groups (SWGs).

RESULTS

One hundred two clinicians and researchers were invited to attend the 1st National Conference on Cancer and Female Sexuality. Forty-three individuals from 20 different institutions across 14 states attended, including representation from eight National Cancer Institute (NCI)-funded cancer centers. Attendees included PhD researchers (N = 19), physicians (N = 16), and other healthcare professionals (N = 8). Breakout groups included (i) Defining key life course sexuality issues; (ii) Building a registry; and (iii) Implementing sexual health assessment. Breakout group summaries incorporated group consensus on key points and priorities. These generated six SWGs with volunteer leaders to accelerate future research and discovery: (i) Technology-based interventions; (ii) Basic science; (iii) Clinical trials; (iv) Registries; (v) Measurement; and (vi) Secondary data analysis. Most attendees volunteered for at least one SWG (N = 35), and many volunteered for two (N = 21).

CONCLUSION

This 1st National Conference demonstrated high motivation and broad participation to address research on cancer and female sexuality. Areas of need were identified, and SWGs established to help promote research in this field.

Effect of telavancin (Vibativ) on routine coagulation test results

Telavancin (Vibativ, Astellas Pharma US, Deerfield, IL) is a lipoglycopeptide antibiotic that has activity against gram-positive microorganisms, but also has the ability to bind to artificial phospholipids found in coagulation reagents. Normal pooled plasma was spiked with telavancin to obtain concentrations of 0, 12.5, 25, 50, 75, 100, 125, and 150 μg/mL of drug. Samples were tested using 3 different prothrombin time/international normalized ratio (INR) and activated partial thromboplastin time (aPTT) reagent systems, as well as for fibrinogen level, thrombin time, D-dimer level, dilute Russell viper venom time (DRVVT), protein C activity, and protein S activity. There was no effect of telavancin seen with non-phospholipid-dependent assays: fibrinogen level, thrombin time, and D-dimer testing. All INR and aPTT systems demonstrated concentration-dependent increases in clotting times, with Innovin (Siemens Healthcare Diagnostics, Deerfield, IL) INRs the most dramatic. False-positive DRVVT ratios started at 12.5 μg/mL of telavancin, with no effect on protein C or protein S levels until the telavancin level reached more than 100 μg/mL.

Anatomical study of the gastrointestinal tract of a pudu (Pudu puda) using contrast-enhanced abdominal computed tomography

The pudu (Pudu puda), which is the smallest deer in the world and inhabits central and southern Chile and Argentina, is a ruminant and a browsing herbivore. The aim of this study was to provide a reference for interpretation of the normal anatomy of the pudu's gastrointestinal tract as imaged by abdominal computed tomography (CT). For the study, one adult female pudu was used. After a 24-h fast, the pudu was anaesthetized and positioned in sternal recumbency at the CT table. Image acquisition began immediately after intravenous injection of contrast media (MD-76(®); 370 mgI/ml) into the cephalic vein. Injection of contrast material was administered as a biphasic protocol. First, a manual bolus of contrast material was injected at a rate of 4 ml/s. Then, an additional continuous infusion injection (0.1 ml/min) was performed for adequate opacification of vascular structures. Transverse images of 5 mm thickness and 5 mm interval were obtained with a fourth-generation CT scanner, from the ninth thoracic vertebra (T9) until the first sacral (S1) vertebrae. CT images were labelled and compared with anatomical reference images for ruminants. Structures that were identified in the abdominal cavity included the stomach with its four compartments (rumen, reticulum, omasum and abomasum), the small and large intestines, liver, spleen, kidneys and some major blood vessels (aorta, caudal vena cava). The distal loop of the ascending colon, the transverse colon, the pancreas and lymph nodes could not be identified. The resulting CT images provide a reference for normal cross-sectional abdominal anatomy of the adult pudu.

Antioxidant status and biomarkers of oxidative stress in dogs with lymphoma

BACKGROUND

Oxidative stress might play a role in carcinogenesis, as well as impacting morbidity and mortality of veterinary cancer patients. The purpose of this study was to evaluate antioxidant concentrations and biomarkers of oxidative stress in dogs with newly diagnosed lymphoma before treatment and once in remission, with comparison with healthy controls.

HYPOTHESIS

Dogs with lymphoma have increased oxidant and reduced antioxidant concentrations compared with healthy controls, and that these abnormalities normalize once remission is achieved.

ANIMALS

Seventeen dogs with lymphoma and 10 healthy controls.

METHODS

Prospective, observational study. Measures of oxidative stress [malondialdehyde and total isoprostanes (isoP)] and antioxidants [alpha-tocopherol, gamma-tocopherol, oxygen radical absorbance capacity (ORAC), and glutathione peroxidase (GSHPx)] were assessed in dogs with newly diagnosed lymphoma before treatment compared with healthy control dogs. The same parameters were measured in the dogs with lymphoma on week 7 of the chemotherapy protocol when all dogs were in remission.

RESULTS

At baseline, dogs with lymphoma had significantly lower alpha-tocopherol (P <.001) and gamma-tocopherol (P= .003) but higher GSHPx (P= .05), ORAC (P= .001), and isoP (P < .001) compared with healthy controls. In the dogs with lymphoma, alpha-tocopherol concentrations were higher (P= .005) and ascorbic acid were lower (P= .04) after treatment.

CONCLUSIONS AND CLINICAL IMPORTANCE

Results suggest that dogs with lymphoma have alterations in oxidant and antioxidant concentrations and that the status of some of these biomarkers normalize after remission. Further studies are warranted to determine whether antioxidant interventions to correct these are beneficial in the treatment of canine lymphoma.

The effects of Neotrofin on septodentate sprouting after unilateral entorhinal cortex lesions in rats

PURPOSE

Recent research on the purine derivative of hypoxanthine Neotrofin (4-[[3-(1,6-dihydro-6-oxo-9-purin-9-yl)-1-oxopropyl]amino]benzoic acid; AIT-082) has indicated that Neotrofin treatment elevates the mRNA levels of various neurotrophic factors, including nerve growth factor (NGF), in the CNS. Several previous studies have indicated that NGF may regulate septodentate sprouting after entorhinal cortex lesions in rats. Thus, the objective of this investigation was to determine whether Neotrofin treatment would enhance lesion-induced septodentate sprouting from 4 to 15 days postlesion.

METHODS

Sham-operated rats or rats with EC lesions were injected (i.p.) with either Neotrofin (30 mg/kg) or saline (0.9%) immediately after surgery and every day thereafter until the end of the treatment regimen. Septodentate sprouting, as indicated by intensity of acetylcholinesterase (AChE) label in the dentate gyrus, was assessed with optical densitometry.

RESULTS

We observed that Neotrofin elevated the AChE-label in the outer molecular layer of the ventral dentate gyrus at 4 days postlesion and of the dorsal dentate gyrus at 15 days postlesion.

CONCLUSIONS

Neotrofin appears to have exerted limited stimulatory effects on lesion-induced sprouting by a cholinergic pathway.

Evaluation of ambulatory and self-initiated blood pressure monitors by pregnant and postpartum women

OBJECTIVE

To investigate the acceptability of an ambulatory blood pressure (ABP) monitor (SpaceLabs 90207) and a self-initiated blood pressure monitor (Omron HEM-705CP) to pregnant women.

METHODS

Acceptability of the SpaceLabs 90207 and Omron HEM- 705CP monitors was evaluated, using a modified British Hypertension Device assessment form, by () healthy, pregnant women at <15 weeks (n = 120), 35-37 weeks (n = 81), and 5-9 weeks postpartum (n = 86); and () women with preeclampsia (n = 52).

MAIN OUTCOME MEASURES

A monitor was acceptable if a woman graded the overall impression as "good" or "very good."

RESULTS

Healthy women at <15 and 35-37 weeks' gestation and preeclamptic women reported the SpaceLabs 90207 monitor caused discomfort in 54%, 52%, and 60%, interfered with activities in 38%, 40%, and 23%, and disturbed sleep in 62%, 52% and 31%, respectively. Fewer than 12% in any group reported these problems with the Omron HEM-705CP monitor. In the 78 women who evaluated both monitors at 35-37 weeks, the SpaceLabs 90207 and Omron HEM-705CP were acceptable to 78% and 95% of healthy women, respectively (p = 0.005). Women with preeclampsia rated the Space-Labs 90207 as "bad" or "fair" (14%), "good" (58%), and "very good" (28%) compared with "bad" or "fair" (8%), "good" (28%), and "very good" (64%) for the Omron HEM-705CP monitor (p = 0.009).

CONCLUSIONS

Pregnant women found the less intensive blood pressure monitoring with the Omron HEM-705CP more acceptable than the 24-h ABP monitoring with the SpaceLabs 90207. If accurate self-initiated blood pressure devices become available, pregnant women would prefer this method of home blood pressure monitoring.

A fall prevention program for the home environment

Falls are the leading cause of injury, death, and disability among people older than 65. When elders fall, they sustain such injuries as hip, spine, hand, and/or pelvic fractures. The prognosis after such a fall is poor--only half of older adults hospitalized for hip fractures are able to return home or live independently again. Even without injury, falls cause a loss of confidence that results in reduced physical activity, increased dependency, and social withdrawal. As a home care agency dealing with a geriatric population, our goal was to develop a user-friendly fall prevention program that would promote multidisciplinary assessment and intervention. We have developed a preventive approach through which clinicians and patients can collaborate on preventing falls in the home and maintaining our patients' first priority: quality of life.

Patterns of attendance and treatment at an emergency dental clinic: a three year follow-up

OBJECTIVES

Patterns of attendance at the Dublin Dental Hospital's Accident and Emergency Clinic in 1996 were compared with figures from 1993 to look for changes, especially in the light of changing provision of public funding for dental treatment for medical card holders and dependants.

METHODS

An audit of patient clinical records for one month in 1996 was compared to previously published data relating to 1993.

RESULTS

While patient numbers were similar in the two time periods (718 in 1993 versus 708 in 1996), the proportion of attendances by medical card holders or their dependants dropped from 48 per cent to 36 per cent. The proportion of non urgent treatments had also dropped over the three years.

CONCLUSIONS

Changes in the provision of publicly funded dental treatment for medical card holders and dependants has reduced the proportion of such patients attending the clinic. However, their places have been taken by other patients.

Inherited infantile dilated cardiomyopathy in dogs: genetic, clinical, biochemical, and morphologic findings

Dilated cardiomyopathy, a lethal disease characterized by left ventricular dilation and systolic dysfunction, is relatively common in humans and other mammals. Idiopathic dilated cardiomyopathy (IDCM) is a primary myocardial disease of unknown cause and can be a familial disorder. This report describes autosomal recessive IDCM in dogs. It occurs in Portuguese Water Dog (PWD) pups and is manifested by acute, vague clinical signs and sudden death. Affected pups have progressive reduction of fractional shortening that can be demonstrated by echocardiography prior to the development of clinical signs. Furthermore, these pups have low plasma taurine levels when consuming certain diets. Affected pups had dilation of the left ventricle and alterations in the sarcomere appearance, while immunohistochemical and biochemical studies demonstrate an increase in desmin, a cytoskeleton protein. The clinical and morphologic findings of IDCM in PWDs are distinct from those reported in adult IDCM. Finally, the clinical and echocardiographic manifestations were reversible in some pups following oral taurine supplementation for 2 months. These results suggest that IDCM in PWDs is correlated with low plasma taurine levels.

Serial laparoscopic biopsies of liver and spleen from Schistosoma-infected baboons (Papio spp.)

PURPOSE

To obtain large, serial biopsy samples from the liver and spleen by using laparoscopy. Large samples were needed for measurement of inflammatory mediators during various stages of schistosomiasis.

METHODS

Each of the seven female baboons (Papio sp.) underwent as many as three laparoscopies, for a total of 19 laparoscopic procedures. This process permitted sampling of the liver, spleen, and mesenteric lymph nodes before and at 6 and 9 weeks after infection with Schistosoma mansoni. All surgery was performed through three trocar sites. Postoperative care included preemptive analgesia. After surgery, we monitored the animals' appetite and measured the core body temperature and activity by using implanted radiofrequency transmitters.

RESULTS

We obtained samples of the liver and splenic biopsies during all 19 laparoscopic procedures. The mean weight of the liver biopsies was 3.7 g and that of the spleen samples was 5.3 g. We encountered small adhesions during 5 of the 12 reoperations. Eating and activity rapidly returned after surgery.

CONCLUSIONS

Laparoscopy permitted collection of large, serial biopsies with apparently limited stress to the animals. Laparoscopy can be used for biopsies in studies to characterize disease response, confirm normal organ histology prior to drug toxicity studies, determine target-organ drug concentrations in pharmacokinetic studies, and measure drug residues. This refinement likely will reduce required animal numbers by decreasing the effect of surgery compared to that of the experimental conditions, enhance animal well-being, and permit repeated measurements in an animal that serves as its own control.

Determination of synovial fluid and serum concentrations, and morphologic effects of intraarticular ceftiofur sodium in horses

OBJECTIVES

To determine the serum and synovial fluid concentrations of ceftiofur sodium after intraarticular (IA) and intravenous (IV) administration and to evaluate the morphologic changes after intraarticular ceftiofur sodium administration.

STUDY DESIGN

Strip plot design for the ceftiofur sodium serum and synovial fluid concentrations and a split plot design for the cytologic and histopathologic evaluation.

ANIMALS

Six healthy adult horses without lameness.

METHODS

Stage 1: Ceftiofur sodium (2.2 mg/kg) was administered IV. Stage 2: 150 mg (3 mL) of ceftiofur sodium (pHavg 6.57) was administered IA into 1 antebrachiocarpal joint. The ceftiofur sodium was reconstituted with sterile sodium chloride solution (pH 6.35). The contralateral joint was injected with 3 mL of 0.9% sterile sodium chloride solution (pH 6.35). Serum and synovial fluid samples were obtained from each horse during each stage. For a given stage, each type of sample (serum or synovial fluid) was collected once before injection and 12 times after injection over a 24-hour period. All horses were killed at 24 hours, and microscopic evaluation of the cartilage and synovium was performed. Serum and synovial fluid concentrations of ceftiofur sodium were measured by using a microbiologic assay, and pharmacokinetic variables were calculated. Synovial fluid was collected from the active joints treated during stage 2 at preinjection and postinjection hours (PIH) 0 (taken immediately after injection of either the ceftiofur sodium or sodium chloride), 12, and 24, and evaluated for differential cellular counts, pH, total protein concentration, and mucin precipitate quality.

RESULTS

Concentrations of ceftiofur in synovial fluid after IA administration were significantly higher (P = .0001) than synovial fluid concentrations obtained after IV administration. Mean peak synovial fluid concentrations of ceftiofur after IA and IV administration were 5825.08 microg/mL at PIH .25 and 7.31 microg/mL at PIH 4, respectively. Mean synovial fluid ceftiofur concentrations at PIH 24 after IA and IV administration were 4.94 microg/mL and .12 microg/mL, respectively. Cytologic characteristics of synovial fluid after IA administration did not differ from cytologic characteristics after IA saline solution administration. White blood cell counts after IA ceftiofur administration were < or =3,400 cells/ML. The mean synovial pH of ceftiofur treated and control joints was 7.32 (range, 7.08-7.5) and 7.37 (range, 7.31-7.42), respectively. Grossly, there were minimal changes in synovium or cartilage, and no microscopic differences were detected (P = .5147) between ceftiofur-treated joints and saline-treated joints. The synovial half-life of ceftiofur sodium after IA administration joint was 5.1 hours.

CONCLUSIONS

Synovial concentrations after intraarticular administration of 150 mg of ceftiofur sodium remained elevated above minimal inhibitory concentration (MIC90) over 24 hours. After 2.2 mg/kg IV, the synovial fluid ceftiofur concentration remained above MIC no longer than 8 hours.

CLINICAL RELEVANCE

Ceftiofur sodium may be an acceptable broad spectrum antimicrobial to administer IA in septic arthritic equine joints.

Complete genomic sequence of the human ABCA1 gene: analysis of the human and mouse ATP-binding cassette A promoter

The ABCA1 gene, a member of the ATP-binding cassette A (ABCA1) transporter superfamily, encodes a membrane protein that facilitates the cellular efflux of cholesterol and phospholipids. Mutations in ABCA1 lead to familial high density lipoprotein deficiency and Tangier disease. We report the complete human ABCA1 gene sequence, including 1,453 bp of the promoter, 146,581 bp of introns and exons, and 1 kb of the 3' flanking region. The ABCA1 gene spans 149 kb and comprises 50 exons. Sixty-two repetitive Alu sequences were identified in introns 1-49. The transcription start site is 315 bp upstream of a newly identified initiation methionine codon and encodes an ORF of 6,783 bp. Thus, the ABCA1 protein is comprised of 2,261 aa. Analysis of the 1,453 bp 5' upstream of the transcriptional start site reveals multiple binding sites for transcription factors with roles in lipid metabolism. Comparative analysis of the mouse and human ABCA1 promoter sequences identified specific regulatory elements, which are evolutionarily conserved. The human ABCA1 promoter fragment -200 to -80 bp that contains binding motifs for SP1, SP3, E-box, and AP1 modulates cellular cholesterol and cAMP regulation of ABCA1 gene expression. These combined findings provide insights into ABCA1-mediated regulation of cellular cholesterol metabolism and will facilitate the identification of new pharmacologic agents for the treatment of atherosclerosis in humans.

Management of bladder problems in patients with multiple sclerosis

Bladder problems are a common feature in patients with multiple sclerosis (MS). Many patients experience distressing symptoms such as frequency, urgency and incontinence, unaware of the range of treatments which are available to either overcome or manage their bladder problems. While patients with MS may experience many types of bladder dysfunction, certain types of problem are more common in this patient group. These problems can be grouped under the headings of storage, emptying or combined dysfunction. Community nurses are well-placed to offer methods of containment by providing first-line treatment as well as identifying which patients need to be referred to other members of the multidisciplinary team.

Pulmonary embolism in a 13-year-old boy

Pulmonary embolism and thromboembolic disease are uncommon entities in the pediatric population. The importance of risk factor assessment is paramount to considering the diagnosis in children. Clinical presentations are similar to those in adults; however, children may present with minimal objective findings on preliminary ancillary testing that would make one consider pulmonary embolus as a diagnosis. This report involves a 13-year-old boy with a well-defined risk factor for thromboembolism who presented with a classic history and without hypoxemia.

The efficacy of diagnostic laparoscopic ultrasound

Precise staging of malignant disease is required to define the optimum therapeutic strategy. In spite of technical advances, the sensitivity of conventional imaging techniques is usually limited to defining lesions of at least 1 cm in size. Laparoscopy is a sensitive technique that is very valuable for visual inspection of the abdominal cavity and the identification of small surface lesions. However, non-superficial lesions may escape detection due to the lack of tactile sensitivity. As an adjunct to laparoscopy, this study, utilizing a young swine model, has analyzed the detectability of intra-abdominal lymph nodes by laparoscopic ultrasound (LU). Lymph nodes in and around the hepatoduodenal ligament, examined and measured by LU, were resected by subsequent open laparotomy in eight young, mixed-breed swine. The numbers and sizes of lymph nodes detected by LU and resected at laparotomy were compared and analyzed statistically. Forty-six lymph nodes were resected by laparotomy, while LU failed to detect 3 small nodes (sensitivity, 43/46 = 93.5%). The sizes of lymph nodes in the LU group correlated strongly with the sizes actually measured in the laparotomy group (r = 0.936, P < 0.001). Twenty-six small lymph nodes, which conventional extracorporeal imaging might have failed to diagnose, were detected accurately by LU (r = 0.877, P < 0.001). This new technology may not only be effective for staging intra-abdominal malignant disease, but adds the benefit of obtaining tissue samples under direct vision using minimally invasive techniques.