Exercise combined with Acceptance and Commitment Therapy for chronic pain: One-year follow-up from a randomized controlled trial

BACKGROUND

Acceptance and Commitment Therapy (ACT) is a type of Cognitive Behavioural Therapy, which has demonstrated positive outcomes in individuals with chronic pain. The purpose of this study was to compare the effect of an 8-week programme combining Exercise with Acceptance and Commitment Therapy (ExACT) with a standalone supervised exercise programme at 1-year follow-up.

METHODS

One hundred and seventy-five people with chronic pain were randomly assigned to ExACT or supervised exercise only. The primary outcome was pain interference measured with the Brief Pain Inventory-Interference Scale. Secondary and treatment process outcomes included pain severity, depression, anxiety, pain catastrophizing, pain self-efficacy, fear avoidance, pain acceptance, committed action, healthcare utilization, patient satisfaction, and global impression of change. Estimates of treatment effects at 1-year follow-up were based on intention-to-treat analyses, implemented using a linear mixed-effects model.

RESULTS

Eighty-three participants (47.4%) returned the outcome measures at 1-year follow-up. No significant difference was observed between the groups for the primary outcome, pain interference. There was a statistically significant difference between the groups, in favour of ExACT for pain catastrophizing. Within group improvements that were observed within both groups at earlier timepoints were maintained at 1-year follow-up for many of the secondary and treatment process outcomes. ExACT group participants reported higher levels of satisfaction with treatment and global perceived change.

CONCLUSIONS

The study results showed no significant difference between the two groups for the primary outcome pain interference at 1-year follow-up. Future research could investigate factors that may predict and optimize outcomes from these types of intervention for people living with chronic pain.

SIGNIFICANCE

Few previous randomized controlled trials investigating ACT for chronic pain have included long-term follow-up. This study found that Exercise combined with ACT was not superior to supervised exercise alone for reducing pain interference at 1-year follow-up. Further research is necessary to identify key processes of therapeutic change and to explore how interventions may be modified to enhance clinical outcomes for people with chronic pain.

Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Acute physiological effects following Bacillus subtilis DE111 oral ingestion - a randomised, double blinded, placebo-controlled study

Previous studies using ileostomy samples from study participants demonstrated that the spore-forming probiotic Bacillus subtilis DE111® can germinate in the small intestine as early as 4 hours after ingestion. Metabolomics, proteomics and sequencing technologies, enabled further analysis of these samples for the presence of hypoglycaemic, hypolipidemic, antioxidant, anti-inflammatory and antihypertensive molecules. In the DE111 treatment group, the polyphenols trigonelline and 2,5-dihydroxybenzoic acid, orotic acid, the non-essential amino acid cystine and the lipokine 12,13-diHome were increased. DE111 also reduced acetylcholine levels in the ileostomy samples, and increased the expression of leucocyte recruiting proteins, antimicrobial peptides and intestinal alkaline phosphatases of the brush border in the small intestine. The combination of B. subtilis DE111 and the diet administered during the study increased the expression of the proteins phosphodiesterase ENPP7, ceramidase ASAH2 and the adipokine Zn-alpha-2-glycoprotein that are involved in fatty acid and lipid metabolism. Acute B. subtilis DE111 ingestion had limited detectable effect on the microbiome, with the main change being its increased presence. These findings support previous data suggesting a beneficial role of DE111 in digestion, metabolism, and immune health that appears to begin within hours of consumption.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

222 TOWARDS A DELIRIUM FRIENDLY EMERGENCY DEPARTMENT

Background

Delirium affects approx. 10-30 % of patients over the age of 65. Up to 70% of cases are missed in the Emergency Department (ED). Delirium results in increased morbidity, mortality, increased length of stay and decreased functional status with increased discharges to residential care centres. Delirium in the ED is an independent predictor of death within 6 months.

Methods

We completed an audit which showed 40% of those &gt; 65 years of age in the ED were delirious and 60% of those had dementia. None of these had been identified as delirious prior to review. We have approx. 5,000 patients &gt;75 years of age attending our ED annually (1/7th of presentations). This audit was used as a catalyst for our quality improvement project. We established a steering group with a small quality improvement sub-committee. We combed the literature, identified areas for improvement and costed our project. We also looked at reliance on 1:1 carers for those with delirium and potential benefits to patient, staff and management.

Results

We used the SPARK ignite programme as a means to gain momentum and also educate ourselves on business management and change management. We competed in the finals with our “delirium package” – focussing on orientation, stimulation, safety and education. These 4 pillars of delirium care have been shown to prevent delirium, reduce hospital stay for those with delirium and also augment their delirium cycle. Competing and winning a prize highlighted the importance of delirium care and brought our project to a bigger stage.

Conclusion

Due to our multi-disciplinary team composed of non-consultant hospital doctors, advanced nurse practitioners and occupational therapists, we have been able to introduce the national dementia programme for early identification of delirium in the emergency department. We now have a space for managing those with delirium and have received funding to put our package in place. This can be replicated in hospitals around the country highlighting the non-pharmacological treatments for delirium.

109 FRAILTY CARE BUNDLE EAT WALK TALK: MAKING GERIATRIC ATTUNED CARE EVERYONE'S BUSINESS

Background

Older adults living with frailty are predisposed to functional decline, worsening malnutrition and delirium when admitted to the acute hospital. EAT, WALK and TALK is a comprehensive framework that promotes optimal nutrition and hydration, supports functional recovery and helps prevent delirium [1].

Comprehensive geriatric assessment and interdisciplinary care on an older adult ward can improve outcomes for older adults [2]. However, not all older adults receive care on specialist wards. The frailty care bundle framework could be utilised on general medical wards to apply older adult attuned principles of good care.

Methods

A quality improvement initiative using PDSA was undertaken. Engagement with stakeholders was made through the Quality and Patient Safety Committee. The overall aim was to prevent hospital associated functional decline by increasing mobility, improving nutrition and cognitive engagement on general medical wards. The blue plate initiative, patient mobility and delirium screening was audited.

Results

The audit showed a 13.3% reduction in patients screening positive for delirium and a 100% increase in the use of delirium care plans. Nutritional intake had improved by 50% with the addition of blue crockery. Baseline mobility audit showed gaps in communication between health professionals. Whiteboards were introduced to address this.

Conclusion

The EAT WALK and TALK care bundle prioritises the critical components of good care for the older person living with frailty. The audit data shows improvement in care processes and outcome measurements.

References

1. Mudge AM, et al. Eat Walk Engage: An interdisciplinary Collaborative Model to Improve Care of Hospitalized Elders. American Journal of Medical Quality 2015. Vol. 30(1) 5–13.

2. Ellis G et al. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane database Syst Rev. 2011(7): CD006211.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

221 PREVALENCE AND DOCUMENTATION OF DELIRIUM IN A UNIVERSITY HOSPITAL

Background

Delirium can complicate approximately 10% of all medical admissions and prevalence increases in those with cognitive impairment, increasing age and medical complexity. Delirium is associated with increased morbidity and mortality as well as increased length of stay. Prompt recognition and treatment is essential. The National Delirium Care Bundle suggests assessment and recognition at the earliest opportunity and documentation of delirium if patients screen positive.

Methods

We carried out an audit among patients admitted in all medical wards to identify delirium and assess if it was documented and a care bundle opened. All patients were screened using the 4AT tool at least once over the space of one week. Medical notes were also screened to assess for documentation of delirium.

Results

95 patients were screened and 32 (33%) of these screened positive. Of these only 11 patients had a diagnosis of delirium documented in medical/nursing notes and a delirium care bundle opened. 50% of CCU patients were delirious. The Geriatric Medicine Ward had a lower prevalence of 19% with 66% identified in medical notes.

Conclusion

These results are disappointing with only 34% of patients identified as having a delirium. This audit is part of a quality improvement project with education sessions ongoing and roll out of the national delirium/dementia pathways across the medical wards. We hope to present our interventions and completed audit loop shortly.

Reactivation of a developmentally silenced embryonic globin gene

The α- and β-globin loci harbor developmentally expressed genes, which are silenced throughout post-natal life. Reactivation of these genes may offer therapeutic approaches for the hemoglobinopathies, the most common single gene disorders. Here, we address mechanisms regulating the embryonically expressed α-like globin, termed ζ-globin. We show that in embryonic erythroid cells, the ζ-gene lies within a ~65 kb sub-TAD (topologically associating domain) of open, acetylated chromatin and interacts with the α-globin super-enhancer. By contrast, in adult erythroid cells, the ζ-gene is packaged within a small (~10 kb) sub-domain of hypoacetylated, facultative heterochromatin within the acetylated sub-TAD and that it no longer interacts with its enhancers. The ζ-gene can be partially re-activated by acetylation and inhibition of histone de-acetylases. In addition to suggesting therapies for severe α-thalassemia, these findings illustrate the general principles by which reactivation of developmental genes may rescue abnormalities arising from mutations in their adult paralogues.

Understanding the effect of mechanical forces on ovarian cancer progression

OBJECTIVE

Mechanical forces including tension, compression, and shear stress are increasingly implicated in tumor progression and metastasis. Understanding the mechanisms behind epithelial ovarian cancer (EOC) progression and metastasis is critical, and this study aimed to elucidate the effect of oscillatory and constant tension on EOC.

METHODS

SKOV-3 and OVCAR-8 EOC cell lines were placed under oscillatory tension for 3 days and compared to cells placed under no tension. Cell proliferation, migration, and invasion were analyzed while RNAseq and Western Blots helped investigate the biological mechanisms underlying the increasingly aggressive state of the experimental cells. Finally, in vivo experiments using SCID mice assisted in confirming the in vitro results.

RESULTS

Oscillatory tension (OT) and constant tension (CT) significantly increased SKOV-3 proliferation, while OT caused a significant increase in proliferative genes, migration, and invasion in this cell line. CT did not cause significant increases in these areas. Neither OT nor CT increased proliferation or invasion in OVCAR-8 cells, while both tension types significantly increased cellular migration. Two proteins involved in metastasis, E-cadherin and Snail, were both significantly affected by OT in both cell lines, with E-cadherin levels decreasing and Snail levels increasing. In vivo, tumor growth and weight for both cell types were significantly increased, and ascites development was significantly higher in the experimental OVCAR-8 group than in the control group.

CONCLUSIONS

This study found that mechanical forces are influential in EOC progression and metastasis. Further analysis of downstream mechanisms involved in EOC metastasis will be critical for improvements in EOC treatment.

Primary colorectal linitis plastica presenting as rapid acute deterioration: a diagnostic dilemma

We present a rare case of primary colorectal linitis plastica presenting as an acute admission to hospital with a wide range of systemic symptoms, sudden rapid deterioration and subsequent mortality. A postmortem examination revealed a primary linitis plastica of the colon and rectum with diffuse metastatic disease. To our knowledge, this is the first report of primary colorectal linitis plastica presenting as an acute deterioration as a result of extensive metastatic disease.

Urban rats have less variable, higher protein diets

Over the past 1000 years, rats (Rattus spp.) have become one of the most successful and prolific pests in human society. Despite their cosmopolitan distribution across six continents and ubiquity throughout the world's cities, rat urban ecology remains poorly understood. We investigate the role of human foods in brown rat (Rattus norvegicus) diets in urban and rural areas over a 100 year period (ca AD 1790–1890) in Toronto, Canada using stable carbon (δ¹³C) and nitrogen (δ¹⁵N) isotope analyses of archaeological remains. We found that rat diets from urban sites were of higher quality and were more homogeneous and stable over time. By contrast, in rural areas, they show a wide range of dietary niche specializations that directly overlap, and probably competed, with native omnivorous and herbivorous species. These results demonstrate a link between rodent diets and human population density, providing, to our knowledge, the first long-term dietary perspective on the relative value of different types of human settlements as rodent habitat. This study highlights the potential of using the historical and archaeological record to provide a retrospective on the urban ecology of commensal and synanthropic animals that could be useful for improving animal management and conservation strategies in urban areas.

Diagnostic accuracy of IgG-specific versus polyspecific enzyme-linked immunoassays in heparin-induced thrombocytopenia: a systematic review and meta-analysis

Essentials Immunoassay specificity varies in heparin-induced thrombocytopenia (HIT) testing. This meta-analysis examined 9 studies that tested samples by both IgG and polyspecific methods. IgG-specific assays confer superior diagnostic accuracy compared with polyspecific assays. These results further support recommendations in favor of IgG-specific testing.

SUMMARY

Background There are conflicting data on whether the IgG-specific or polyspecific antiplatelet factor 4/heparin (PF4/H) enzyme-linked immunosorbent assay (ELISA) is preferred for the laboratory diagnosis of heparin-induced thrombocytopenia (HIT). Objectives To directly compare diagnostic accuracy of IgG-specific versus polyspecific ELISA in HIT. Patients/Methods A systematic search yielded nine studies comprising 1948 patients with suspected HIT tested by both IgG-specific and polyspecific ELISAs and a reference standard against which the diagnostic accuracy of the ELISAs could be measured. Study quality was assessed by QUADAS-2 criteria. Results There was identical sensitivity for IgG-specific and polyspecific ELISAs (0.97; 95% confidence interval (CI), 0.95-0.99) and superior specificity of IgG-specific compared with polyspecific ELISA (0.87 [0.85-0.88] vs. 0.82 [0.80-0.84], respectively). Performance was similar in subgroups using the serotonin release assay and a single commercial ELISA manufacturer. The negative predictive values of IgG-specific and polyspecific ELISA were similarly high (0.99, [0.99-1.00], but the positive predictive value was superior with IgG-specific compared with polyspecific ELISA (0.56 [0.52-0.61] vs. 0.32 [0.28-0.35], respectively). The positive likelihood ratio (LR) was higher in IgG-specific than polyspecific ELISA, although negative LRs were similar. There was high risk of quality concerns in domains of index test and reference standard. Conclusions The superior diagnostic accuracy of IgG-specific ELISA reinforces the ISTH-SSC recommendation for standardization of laboratory testing for HIT. Likelihood ratios of individual assays may be used in combination with clinical scoring systems as part of an integrated diagnostic algorithm for HIT.

An extranet architecture for inter-operability among healthcare systems

Most federations of healthcare systems have operated in an in-house environment where local area networks coupled with layers of interoperability were used to connect various information systems. More recently, a need has arisen to connect large institutions such as hospitals, with wider area applications such as general practice systems in order to create the complete patient record. In this paper we present a model and architecture, which addresses the problem of connecting all parties involved in patient healthcare.

Enhancements to the JET poloidally scanning vacuum ultraviolet∕visible spectrometers

Enhancements to the JET poloidally scanning spectrometers are presented, which will aid the exploitation of the recently installed ITER-like wall in JET. They include the installation of visible filter∕photomultiplier tube assemblies and spectrometers and the replacement of large rotating mirrors in the JET vacuum with small oscillating mirrors outside. The upgrade has resulted in a more robust and reliable diagnostic than before, which is described. Drifts in the mirror angle reconstructed from quadrature encoder signals are found, a reference signal being required. The use of the small scanning mirrors necessitated the inclusion of focusing mirrors to maintain throughput into the vacuum ultraviolet spectrometers. The mirror design has taken account of the extreme sensitivity of the focusing to the grazing angle of incidence, an aspect of importance in the design of grazing incidence focusing components on future machines, such as ITER. The visible system has been absolutely calibrated using an in-vessel light source.

Pancreatico pleural fistula: an unusual complication of chronic pancreatitis

Pancreatico-pleural fistula secondary to chronic pancreatitis is a rare cause of pleural effusion. This case report presents a case of a middle aged female, a known case of chronic pancreatitis who presented with severe epigastric pain and progressive shortness of breath. CT and MRCP were useful in visualising the fistulous communication between the pancreas and pleural cavity. Treatment consisted of ERCP placement of a pancreatic stent, which facilitated internal drainage of pancreatic fluid thus resolving the pleural effusion and promoting healing of the fistula.

Protein and mineral characterisation of rendered meat and bone meal

We report the characterisation of meat and bone meal (MBM) standards (Set B-EFPRA) derived from cattle, sheep, pig and chicken, each rendered at four different temperatures (133, 137, 141 and 145 °C). The standards, prepared for an EU programme STRATFEED (to develop new methodologies for the detection and quantification of illegal addition of mammalian tissues in feeding stuffs), have been widely circulated and used to assess a range of methods for identification of the species composition of MBM. The overall state of mineral alteration and protein preservation as a function of temperature was monitored using small angle X-ray diffraction (SAXS), amino acid composition and racemization analyses. Progressive increases in protein damage and mineral alteration in chicken and cattle standards was observed. In the case of sheep and pig, there was greater damage to the proteins and alteration of the minerals at the lowest treatment temperature (133 °C), suggesting that the thermal treatments must have been compromised in some way. This problem has probably impacted upon the numerous studies which tested methods against these heat treatments. We use protein mass spectrometric methods to explore if thermostable proteins could be used to identify rendered MBM. In more thermally altered samples, so-called 'thermostable' proteins such as osteocalcin which has been proposed as a ideal target to speciate MBM were no longer detectable, but the structural protein type I collagen could be used to differentiate all four species, even in the most thermally altered samples.

Transforming growth factor beta signalling and matrix metalloproteinases in the mucosa overlying Crohn's disease strictures

BACKGROUND AND AIMS

In addition to its crucial role in dampening tissue-damaging immune responses in the gut, transforming growth factor beta (TGFbeta) is a potent profibrogenic agent inducing collagen synthesis and regulating the balance between matrix-degrading matrix metalloproteinases (MMPs) and their inhibitors (TIMPs). TGFbeta signalling was investigated by analysis of Smad proteins and MMPs/TIMPs in the mucosa overlying strictures in patients with Crohn's disease (CD).

METHODS

Specimens were collected from macroscopically normal mucosa overlying strictured and non-strictured gut of patients with fibrostenosing CD. Isolated myofibroblasts were cultured with anti-TGFbeta blocking antibody or TGF beta 1. TGFbeta transcripts were analysed by quantitative reverse transcription-PCR (RT-PCR). Smad proteins and MMPs were determined by immunoblotting. MMP-12 activity was measured by a real-time MMP-12 activity assay. An in vitro wound-healing scratch assay was used to assess myofibroblast migration.

RESULTS

TGFbeta transcripts, phosphorylated Smad2-Smad3 (pSmad2-3) and TIMP-1 proteins were higher in mucosa overlying strictures than in mucosa overlying non-strictured areas. In contrast, mucosa overlying strictured gut had lower expression of Smad7, MMP-12 and MMP-3. Myofibroblasts from mucosa overlying strictured gut showed higher TGFbeta transcripts, a greater pSmad2-3 response to TGFbeta, increased TIMP-1, lower Smad7, increased collagen production and reduced migration ability compared with myofibroblasts from mucosa overlying non-strictured gut. TGFbeta blockade increased myofibroblast MMP-12 production and migration, more obviously in myofibroblasts isolated from mucosa overlying non-strictured compared with strictured gut.

CONCLUSIONS

Changes in TGF-beta signalling and MMP production were identified in the mucosa overlying strictures in CD which may give a window into the process of fibrosis.

An unusual cause of collapse and neck pain

Following a collapse at home, a previously well 24-year-old Ukrainian man living in Ireland was brought to the emergency department. He complained of neck pain and cervical spine radiographs revealed loss of lordosis, scalloping of the posterior vertebral bodies and widening of the neural exit foramina at C7. In view of these unusual radiological findings, further examination of the patient demonstrated multiple flat uniformly hyperpigmented brown macules with multiple subcutaneous well-circumscribed lesions along the distribution of the peripheral nerves. An MRI scan of the neck revealed multiple neurofibromas in the vertebral canal with cord compression at C7-T1. A diagnosis of neurofibromatosis type 1 was made. Other investigations to determine the aetiology of the collapse were normal and the patient was discharged with follow-up at specialist neurology and neurosurgical clinics. In recent years there have been increased numbers of economic migrants presenting to the emergency department in the UK and Ireland from European Union accession states. This case highlights the need for increased awareness among emergency physicians to previously undiagnosed genetic and congenital conditions.

Spatial and temporal regulation of GH-IGF-related gene expression in growth plate cartilage

Previous studies of the GH-IGF system gene expression in growth plate using immunohistochemistry and in situ hybridization have yielded conflicting results. We therefore studied the spatial and temporal patterns of mRNA expression of the GH-IGF system in the rat proximal tibial growth plate quantitatively. Growth plates were microdissected into individual zones. RNA was extracted, reverse transcribed and analyzed by real-time PCR. In 1-week-old animals, IGF-I mRNA expression was minimal in growth plate compared with perichondrium, metaphyseal bone, muscle, and liver (70-, 130-, 215-, and 400-fold less). In contrast, IGF-II mRNA was expressed at higher levels than in bone and liver (65- and 2-fold). IGF-II expression was higher in the proliferative and resting zones compared with the hypertrophic zone (P < 0.001). GH receptor and type 1 and 2 IGF receptors were expressed throughout the growth plate. Expression of IGF-binding proteins (IGFBPs)-1 through -6 mRNA was low throughout the growth plate compared with perichondrium and bone. With increasing age (3-, 6-, 9-, and 12-week castrated rats), IGF-I mRNA levels increased in the proliferative zone (PZ) but remained at least tenfold lower than levels in perichondrium and bone. IGF-II mRNA decreased dramatically in PZ (780-fold; P < 0.001) whereas, type 2 IGF receptor and IGFBP-1, IGFBP-2, IGFBP-3, and IGFBP-4 increased significantly with age in growth plate and/or surrounding perichondrium and bone. These data suggest that IGF-I protein in the growth plate is not produced primarily by the chondrocytes themselves. Instead, it derives from surrounding perichondrium and bone. In addition, the decrease in growth velocity that occurs with age may be caused, in part, by decreasing expression of IGF-II and increasing expression of type 2 IGF receptor and multiple IGFBPs.

BAY 43–9006 (sorafenib-BAY) alters proliferation pathways and mutant specific-PCR (MS-PCR) improves detection of BRAF mutations in metastatic melanoma (MM)

8542

Background: Approximately 60% of melanomas carry BRAF mutations (mut). BAY is a multi-kinase inhibitor that inhibits the BRAF pathway. A phase II trial of BAY in MM is being conducted to: 1) determine if treatment (tx) with BAY can alter proliferation as measured by cyclin D1, Ki-67 and ERK, 2) assess for differential anti-tumor responses and 3) to assess a newly developed fluorescent-based PCR assay to detect mutant BRAF. Methods: Eligibility criteria: Biopsy (bx)-accessible, untreated MM. Measurable disease (RECIST). Stratification of tumor BRAF status determined by routine PCR sequencing for codon 600 mut prior to tx and fluorescent MS-PCR sequencing for confirmation. MS-PCR specifically amplified the M-BRAF allele without amplifying the wild-type (WT)allele. Tx: BAY 400 mg po BID D1–28 q4w. Repeat bx on Day 28. Bx assessed for Ki-67, cyclin-D1 and ERK. Serum collagen cryptic epitopes were measured serially. Re-imaging was done every 2 cycles and pts treated until POD. Results: 29 pts (9-M1a, 8-M1b, 12-M1c) enrolled. 26 wild type (WT) and 3 mutant (M) BRAF by routine PCR. Due to the low yield of mut on routine PCR, MS-PCR was done. 6 mutants were detected in the first 16 pts with MS-PCR compared to 2 with routine sequencing. Median age: 68 (range 22–91). 8 pts with LDH ≥ 1.5 × nl. Tox: Gr I-diarrhea(7), alopecia(4), rash(6), mucositis(4), nausea(4), pain(4), hand-foot(2); Gr II- HTN(4), fatigue(2),mucositis(1), rash(3), pain(3), hand-foot(2); Gr III-hand-foot(1), rash(1), fatigue(1) and intestinal perforation(1). Responses: 12 NE (2 WD, 8 early POD, 1 tox, 1 too early); M BRAF- 1 PR (lymph nodes and large SQ arm masses) and 2 PD; WT BRAF- 1 PR, 7 POD after 2 cycles, 6 SD. Matched paired biopsies demonstrated down regulation of tumor ki-67, erk and cyclin-D1. Collagen cryptic epitopes correlated with tumor responses. Conclusions: MM patients with tumors that were molecularly characterized for BRAF mutational status were entered on this single agent BAY trial and responses were seen in both M and WT arms. Down-regulation of Ki-67, cyclin D1 and ERK was demonstrated and MS-PCR improved the sensitivity to detect BRAF mut. Supported by NCI N01-CM17103 and TRI.

No significant financial relationships to disclose.

Synchronized, interactive teleconferencing with digital cardiac images

St James's Hospital is a tertiary referral center for percutaneous intervention and cardiothoracic surgery for a number of referring hospitals. This article reports on the development and implementation of a synchronized, interactive teleconferencing system for cardiac images that links St. James's Hospital with a remote site (Sligo General Hospital) and overcomes the problems of transmission of large image files. Teleconferencing was achieved by setting up lossless auto transmission of patient files overnight and conferencing the next morning with linked control signals and databases. As a suitable product was not available, a commercially new software was developed. The system links the imaging databases, monitors and synchronizes progress through imaging sequences, and links a range of image processing and control functions. All parties to the conference are ensured that they are looking at the same images as they are played or at specific aspects of an image that the other party is highlighting. The system allows patient management decisions to be made at a weekly joint teleconference with cardiothoracic surgeons and interventional cardiologists from both sites. Rapid decision making was facilitated with 70% of decisions obtained within 24 h, and 88% within 1 week of their procedure. In urgent cases, data can be transmitted within 20 min of the diagnostic procedure. The system allows increased access to angiography for patients living in rural areas, and provides a more focused referral for revascularization. Participation of the referring cardiologist has improved the quality of decision making.

Gemcitabine (G) plamsa and intracellular pharmacokinetics in E6201: Greater metabolite levels using fixed dosing rate (FDR) delivery

2024

Background: Gemcitabine (G) is an antimetabolite which requires activation by the rate-limiting enzyme dCK to its active metabolite, dFdCTP. FDR delivery of G at 10 mg/m2/minute may allow greater formation of active metabolite and improved activity. E6201 randomly assigned first line pancreatic cancer patients to three arms: A (G 1000 mg/m2 over 30 minutes), B FDR G (1500 mg/m2 over 150 minutes), and C GemOx (1000 mg/m2 over 100 minutes with oxaliplatin 100 mg/m2). Methods: Investigators from 18 centers contributed 23 sample sets on the first dose of G. Five time points over 4 hrs were sampled (baseline, mid infusion, end infusion, 1–2 post and 4 hrs). Plasma fractionation along with the PBMC purification and subsequent perchloric acid extraction were conducted locally with THU 1 mg (cytidine deaminase inhibitor). Samples were shipped overnight to the central lab where G and its metabolite dFdU were quantified from deproteinized plasma by reverse phase HPLC. dFdCTP was quantified by ion-exchange HPLC in neutralized PBMC extracts after removal of ribonucleotide triphosphates. Data were fit to nonlinear models (WinNonLin, v4.1) and comparisons amongst dosing groups employed the non-parametric, 2-sided Mann-Whitney test. Results: For Arms A, B and C the plasma AUCs were respectively (median ± SD): 4542 ± 2472 (N=9), 8603 ± 2608 (N=8) and 9130 ± 8788 (N=6) ng/ml x hr. The difference between group A and B (p=0.003) and A and C (p=0.05) were statistically different. Intracellular dFdCTP AUCs for groups A, B, and C were: 1862 ± 794 (N=8); 3725 ± 7763 (N=8) and 5024 ± 2113 (N=5) and significantly different for both A vs. B (p=0.05) and borderline significant for A vs C (p=0.065). The latter comparison is limited by a small number of samples. Conclusions: When studied in a multi-centered, randomized cooperative group setting, FDR delivery of G results in higher plasma AUC, and increased intracellular levels of active metabolite dFdCTP. These data support the concept that fixed dose rate delivery of G results in greater intracellular metabolite production at similar and equitoxic doses. Supported by ECOG NYU620HH04–00, NCI CA16087, CA2115, and from Eli Lilly.

No significant financial relationships to disclose.

Continuous intravenous infusion (CIVI) topotecan may be safely combined with tipifarnib

2064

Background: Dose limiting (DL) myelosuppression occurred when topotecan 1.0 mg/m2/d × 5d was combined with tipifarnib (Proc ASCO, 2001, abst 321). We now report on a 3+3 cohort design to determine the safety and pharmacokinetics (PK) of this combination with topotecan given as CIVI in patients (pts) with refractory solid tumors. Methods: Pts were treated with escalating dose levels of topotecan (0.2–0.4 mg/m2/d) given as 21-day infusion in combination with tipifarnib 200 mg PO bid for 21 d every 28 d. Blood was drawn for topotecan PK and intracellular (PBMC) toposisomerase I on d 1 (baseline) and d 5 (tipifarnib omitted d1, cycle 1), and weekly × 8 for ras-farnesylation (membrane bound fraction). Plasma levels of the closed form of topotecan were determined by SPE and HPLC with fluorometric detection. Topoisomerase I in PBMCs was detected by Western blot. Results: 14 patients were accrued at 3 dose levels: topotecan 0.2 mg/m2/d (3 pts), 0.3 mg/m2/d (3), and 0.4 mg/m2/d (8), combined with tipifarnib. Median age was 50 years (33–62). 32 cycles (median 2) were given. Grade 1–3 fatigue, nausea, thrombocytopenia, neutropenia and anemia were common, and at dose level 3, two heavily-pretreated patients had DL myelosuppression. Six others had no significant toxicity over prolonged times. Of nine evaluable for response, a mucinous peritoneal cancer had a minor response for 5 m, an ovarian granulosa cell tumor had a mixed response in lung metastases for 15 m, and a PNET of bone had a minor response for 17 m; six had progression. Mean steady state (± SD) levels of topotecan for dose levels I, II and III were, respectively, 0.48 ± 08 (N = 3), 1.26 ± 0.32 (N = 3) and 1.47 ± 0.1 (N = 5) ng/ml, and were linear with respect to topotecan dose (r = 0.95). By the end of the 21 d infusion, 90% of baseline topoisomerase I signal was depleted in PBMCs. Conclusions: In contrast with bolus topotecan, CIVI topotecan may be combined at known effective doses with tipifarnib. Recommended phase II doses are 0.4 mg/m2/d × 21 days and 200 mg bid daily for those with limited prior therapy. Phase II studies in gynecologic and breast tumors are planned. Supported by UO1- 76642; CA 16087.

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Tumour necrosis factor (TNFalpha) as a novel therapeutic target in symptomatic corticosteroid dependent asthma

BACKGROUND

Tumour necrosis factor alpha (TNFalpha) is a major therapeutic target in a range of chronic inflammatory disorders characterised by a Th1 type immune response in which TNFalpha is generated in excess. By contrast, asthma is regarded as a Th2 type disorder, especially when associated with atopy. However, as asthma becomes more severe and chronic, it adopts additional characteristics including corticosteroid refractoriness and involvement of neutrophils suggestive of an altered inflammatory profile towards a Th1 type response, incriminating cytokines such as TNFalpha.

METHODS

TNFalpha levels in bronchoalveolar lavage (BAL) fluid of 26 healthy controls, 42 subjects with mild asthma and 20 with severe asthma were measured by immunoassay, and TNFalpha gene expression was determined in endobronchial biopsy specimens from 14 patients with mild asthma and 14 with severe asthma. The cellular localisation of TNFalpha was assessed by immunohistochemistry. An open label uncontrolled clinical study was then undertaken in 17 subjects with severe asthma to evaluate the effect of 12 weeks of treatment with the soluble TNFalpha receptor-IgG1Fc fusion protein, etanercept.

RESULTS

TNFalpha levels in BAL fluid, TNFalpha gene expression and TNFalpha immunoreative cells were increased in subjects with severe corticosteroid dependent asthma. Etanercept treatment was associated with improvement in asthma symptoms, lung function, and bronchial hyperresponsiveness.

CONCLUSIONS

These findings may be of clinical significance in identifying TNFalpha as a new therapeutic target in subjects with severe asthma. The effects of anti-TNF treatment now require confirmation in placebo controlled studies.

Systemic administration of the chemokine macrophage inflammatory protein 1alpha exacerbates inflammatory bowel disease in a mouse model

INTRODUCTION

Exacerbations of inflammatory bowel disease are thought to be related to concurrent infections. As infections are associated with elevated local and serum concentrations of chemokines, we have determined whether systemic administration of the CC chemokine macrophage inflammatory protein 1alpha (MIP-1alpha) exacerbates colitis in a mouse model.

METHODS

Colitis was induced in Balb/c mice using trinitrobenzene sulfonic acid (TNBS). Starting four days later, animals received daily intraperitoneal injections of recombinant MIP-1alpha. On day 7, mice were killed and pieces of colon taken for immunohistology and polymerase chain reaction analysis. The direct effects of MIP-1alpha on mucosal T cells and fibroblasts in vitro were also investigated.

RESULTS

Systemic administration of MIP-1alpha markedly enhanced colitis with mice developing large transmural ulcers filled with granulation tissue. Treatment resulted in increased numbers of CD4 cells infiltrating the colonic lamina propria, increased interferon gamma (IFN-gamma) levels, and increased transcripts for tumour necrosis factor alpha (TNF-alpha) and matrix metalloproteinase 3 (MMP3). Isolated lamina propria lymphocytes from mice with TNBS colitis contained increased numbers of IFN-gamma and TNF-alpha transcripts when stimulated with MIP-1alpha in vitro. Colonic lamina propria fibroblasts also responded to MIP-1alpha with increased proliferation and decreased collagen 1 synthesis but fibroblast proliferation was not seen in vivo.

CONCLUSIONS

These experiments show that increasing serum concentrations of a chemokine, MIP-1alpha, exacerbates immune mediated colitis. The effect seems to be due to the ability of MIP-1alpha to boost Th1 responses in the gut wall. Our findings also suggest a potential pathway by which peripheral infections can exacerbate inflammatory bowel disease.

Hepatitis C among drug users: consensus guidelines on management in general practice

BACKGROUND

Hepatitis C (HCV) is a common cause of morbidity among patients who attend general practitioners (GPs) in Ireland for methadone maintenance treatment.

AIMS

To describe the development and content of guidelines for the management of HCV among current or former opiate users in the Eastern Regional Health Authority area attending GPs for methadone treatment.

METHODS

The guidelines were produced in five stages: identification of key stakeholders; development of evidence-based draft guidelines; discussion of content; determination of 'Delphi'-facilitated consensus and review by a sample of GPs for whom the guidelines would be intended.

RESULTS

The guidelines contain advice for GPs on all aspects of care of patients at risk of HCV, including general and preventative care, care of other bloodborne and hepatotoxic viruses, and the factors to be considered and appropriate evaluation prior to referring a patient for assessment at a hepatology unit.

CONCLUSIONS

GPs have an important role to play in the care of patients at risk of, or infected with, HCV.

Appropriateness of gastric antisecretory therapy in hospital practice

BACKGROUND

Recent data indicate an exponential increase in proton pump inhibitor (PPI) prescribing, and concerns are raised regarding the appropriateness of these prescriptions and the financial implications.

AIM

To survey the appropriateness of PPI prescription in a cohort of patients in a tertiary referral hospital.

METHODS

Prescription records of all inpatients on a randomly selected day were reviewed. The appropriateness of prescription and relevant investigations were identified by interview of patients, review of patient records and of a computerised endoscopy records system.

RESULTS

Thirty-two per cent (87 of 272) of all patients were on PPIs. A valid indication for therapy was not apparent in 63% of the patients on PPIs with the only predictive factor for inappropriate prescription being increasing age. Only 36 of the 87 patients on PPIs had undergone appropriate investigations for their gastrointestinal symptoms. Gender, age, speciality of admission or duration of hospital stay did not influence the appropriateness of prescription or performance of relevant investigations.

CONCLUSION

There appears to be a widespread and inappropriate use of PPIs in hospital practice.

Review article: test and treat or test and scope for Helicobacter pylori infection. Any change in gastric cancer prevention?

A 'test and treat' strategy is advocated for patients with dyspepsia under the age of 45 years, with endoscopy reserved for those with alarm symptoms or aged over 45 years. One of the consequences of this strategy will be a reduction in population infection rates of Helicobacter pylori. It is now clear that H. pylori is one of the prime initiators of gastric cancer with up to 70% of gastric cancers attributable to H. pylori. What remains unclear is if H. pylori reduction will lead to a reduction in gastric cancer.

Does Helicobacter pylori eradication affect symptoms in nonulcer dyspepsia: a 5-year follow-up study

The role of Helicobacter pylori infection in nonulcer dyspepsia remains controversial. To date studies exploring the effect of H. pylori eradication on symptoms have reported conflicting results. Randomised control trials employing validated outcome measures have also been difficult to interpret because of several important issues such as the large placebo response seen in patients with nonulcer dyspepsia and both the natural variability in symptoms and symptom severity with time. The association of symptom improvement with resolution of gastritis has meant that the length of follow up employed in most studies has been insufficient. We report the findings of a randomised placebo controlled trial (n = 100), using a validated symptom questionnaire and 5 year follow up to determine the effect of H. pylori eradication on symptoms in nonulcer dyspepsia. In all 64 that were reviewed at 5 years there was a significant difference between patients who were H. pylori negative and those who remained positive with regard to complete symptom resolution, consumption of relevant medications and peptic ulcer disease development, in favour of active treatment. There was a trend for gradual symptom improvement over time irrespective of H. pylori status, which may reflect the natural history of this condition. For those who remained symptomatic at 5 years, there was no difference in symptom severity based on H. pylori status. The findings of this study support the use of H. pylori eradication in symptomatic patients with nonulcer dyspepsia both to induce symptom resolution and to prevent disease progression.

Helicobacter pylori-induced duodenal ulcer frequently coincides with gastro-oesophageal reflux disease

BACKGROUND

The relationship between Helicobacter pylori infection and gastro-oesophageal reflux disease is complicated. Evidence does not support a causal link. There have been reports, which have implicated successful eradication of Helicobacter pylori, in patients with a duodenal ulcer, with the subsequent development of gastro-oesophageal reflux disease. However, eradication of Helicobacter pylori in these patients with improvement in their condition and a return to normal lifestyle, weight gain and discontinuation of antacids may unmask pre-existing gastro-oesophageal reflux disease.

AIMS

To determine the true prevalence of gastro-oesophageal reflux disease in patients with Helicobacter pylori-related duodenal ulceration.

METHOD

Dyspeptic patients undergoing endoscopy were prospectively screened for the presence of a duodenal ulcer. Concomitant oesophagitis, when present, was recorded. All subjects with a Helicobacter pylori-related duodenal ulcer without endoscopic evidence of gastro-oesophageal reflux disease were invited to undergo a 24-hr ambulatory oesophageal pH assessment prior to receiving treatment.

RESULTS

A total of 97 patients with a duodenal ulcer were identified and 83.5% were Helicobacter pylori positive. Overall, 27.8% had associated endoscopic evidence of oesophagitis, 70% grade I-II and 30% grade III-IV. Of those without evidence of oesophagitis at endoscopy, 68% underwent a 24-hr pH assessment. An additional 17% were identified by this means as having gastro-oesophageal reflux disease. Overall, 44% of symptomatic subjects with Helicobacter pylori and a duodenal ulcer were found to have coexistent gastro-oesophageal reflux disease.

CONCLUSION

Gastro-oesophageal reflux disease is frequently found to coexist with Helicobacter pylori-related duodenal ulcer. In addition, almost 20% of symptomatic patients without endoscopic evidence of oesophagitis will have an abnormal oesophageal pH exposure. It is plausible that the development of gastro-oesophageal reflux disease following successful eradication of Helicobacter pylori represents unmasking of existing disease rather than de novo development.

Carditis: all Helicobacter pylori or is there a role for gastro-oesophageal reflux?

BACKGROUND

Recent epidemiological studies have reported a threefold increase in the incidence of adenocarcinoma of the lower oesophagus and gastro-oesophageal junction (cardia). There are conflicting reports available implicating both gastro-oesophageal reflux disease and Helicobacter pylori infection in the aetiology of carditis and cardia intestinal metaplasia, despite strong evidence to show that these two conditions are, if anything, inversely related. We aimed to determine the prevalence of carditis and cardia intestinal metaplasia in dyspeptic subjects and also their association with H. pylori infection and gastro-oesophageal reflux disease.

METHOD

Histological samples from the gastric cardia were obtained from dyspeptic subjects. H. pylori status was assessed based on histological, microbiological and rapid urease testing. Gastro-oesophageal disease was diagnosed on the basis of histological evidence and/or erosive oesophagitis. Patient demographics were recorded. Cardia intestinal metaplasia (CIM), when present, was subgrouped as complete or incomplete.

RESULTS

Overall, 276 subjects were enrolled; 163 (59%) had carditis and 36 (13%) CIM. H. pylori infection and gastro-oesophageal reflux disease occurred in 64 (23%) and 150 (54%), respectively. H. pylori infection was strongly associated with carditis and CIM (P<0.001 and P<0.01). Older age and male gender were also associated with inflammation and intestinal metaplasia of the cardia. Gastro-oesophageal reflux was not associated with either entity.

CONCLUSION

Carditis and CIM occur frequently. Both conditions are strongly associated with H. pylori infection, older age and male gender. There was no association with gastro-oesophageal reflux disease.