POS1329 SECONDARY HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS: A SINGLE-CENTRE EXPERIENCE

Background

Haemophagocytic lymphohistiocytosis (HLH) is a life-threatening hyperinflammatory syndrome characterised by fever, organomegaly, cytopaenias, activated macrophages in haematopoietic organs and elevated ferritin. Primary HLH is caused by inherited defects in cytolytic pathway proteins and manifests in infancy[1]. Secondary HLH (sHLH) develops in individuals with a genetic susceptibility to hyperinflammation triggered by strongly immunogenic stimulus such as autoimmune conditions, haematological malignancy, organ transplantation or infection[2].

We present a cohort of patients with sHLH and detail their characteristics.

Objectives

To evaluate the characteristics and aetiology of sHLH patients at our Centre.

Methods

A single-centre retrospective observational study of all cases of sHLH between January 2018 and July 2021. Patients were identified from referrals and included if there was a diagnosis of HLH made by a rheumatologist with an H-score of 169 or greater. P-values were calculated using the Mann-Whitney test, unpaired t-test or Fisher exact as appropriate.

Results

30 patients (10 female) with sHLH were identified with a median age of 46, a mean H-score of 238 (range 186-317). 15 (50%) had pre-existing immunosuppression, which did not influence mortality (p=0.26). The following primary drivers were identified: lymphoma (n=8), non-HIV viral infections (n=9), first presentation of HIV/AIDS with opportunistic infections (n=4), Adult-onset Still’s disease (n=4), miliary tuberculosis (n=1), M. falciparum infection (n=1), meningococcal meningitis (n=1), checkpoint inhibitor therapy-related (n=1), and no diagnosis (n=1) - Table 1.

Table 1.

§ = Mann Whitney U test, τ = unpaired t-test, φ = Fisher exact

Total (n=30)Survived (n=18)Died (n=12)p-valueDemographicsMale2010100.78§Female1082Mean age4341470.348§Median H-score2402302540.059 τFerritin (ng/ml)4027734690484040.0949Trilineage cytopenia, n (%)9 (33%)5 (31%)4 (36%)0.28§Subgroup (not mutually exclusive)1 yr survivalLymphoma81712.5% (p=0.0025 φ)HIV/AIDS440100%AOSD440100%Transplant recipient41325%Other viral infection95444%  HSV330100%  CMV110100%  EBV1010%  Yellow fever2020%  Influenza A110100%Tuberculosis32166% with HIV220100%

Non-HIV viral infections were the most common cause overall. 6 of 9 were caused by Herpes virus family and all were primary infections. Two followed yellow fever viraemia following live vaccination and both patients died.

Mortality varied with aetiology. All four patients with AOSD survived, while 7 of 8 with lymphoma died, as per previous reports3. There was a strong association between lymphoma and mortality vs non-lymphoma sHLH (p=0.0025). Four patients post-solid organ transplantation were identified (three liver, one kidney), three with post-transplant lymphoproliferative disorder and one with CMV viraemia (50% mortality).

There was no significant difference between age, ferritin or H-score between surviving and deceased patients (Figure 1), but H-score trended higher in the deceased (p=0.059). Number of treatments given for HLH was higher in the deceased group vs survival (mean 3.41 deceased, mean 2.44 in survived). Anakinra was used in all 30 patients as treatment, including as monotherapy in one patient with HSV viraemia who survived.

Figure 1.

Conclusion

Ferritin, H-score at diagnosis or age do not appear to correlate with mortality in sHLH. Lymphoma is associated with a significantly worse outcome. Poor response to treatment and increasing numbers of treatment options is associated with increased mortality. Causes are varied and often co-exist.

References

[1]Jordan MB et al. An animal model of hemophagocytic lymphohistiocytosis (HLH): CD8+ T cells and interferon gamma are essential for the disorder. Blood. 2004.

[2]Carter SJ et al. Macrophage activation syndrome in adults: recent advances in pathophysiology, diagnosis and treatments. Rheumatology. 2019.

[3]Parikh SA et al. Prognostic Factors and Outcomes of Adults with Hemophagocytic Lymphohistiocytosis. Mayo Clin Proc. 2014.

Disclosure of Interests

None declared

POS0842 NON-INVASIVE COHERENT RAMAN IMAGING OF INVOLVED FOREARM SKIN REVEALS ALIGNED COLLAGEN IN DERMIS OF SYSTEMIC SCLEROSIS PATIENTS

Background

Systemic sclerosis (SSc) is an immune-mediated connective tissue disease with clinical hallmark of inflammation, vasculopathy and fibrosis resulting in abnormal collagen and intercellular matrix formation in the dermis and internal organ. Skin severity correlates with systemic complications and mortality in SSc.

Many skin assessment tools studied do not fulfilled all standards set by OMERACT which include criterion validity, construct validity, discrimination, responsiveness, reliability and feasibility.

Modified Rodnan skin score (mRSS) is commonly used as outcome measure in clinical trials of SSc. It is however, limited by inter-rater variability. Studies also showed that skin biopsy samples from body part of SSc patients with clinically normal mRSS had demonstrable pathological deposition of collagen. While repeat skin biopsy to track longitudinally, may be unacceptable to patients. Hence, ongoing research for non-invasive tools are encouraged.

Objectives

We follow through our previous work studying commercially available non-invasive imaging tools in SSc skin assessment by using Coherent-Raman scattering microscopy (CRS).

Methods

Skin biopsies of 4mm were obtained from SSc (n=3) and HC (n=1). Skin samples were collected at anterior surface of forearm from newly diagnosed diffuse SSc which were treatment naïve. Samples were frozen at -80c prior to analysis under CRS at skin depth of 150-200um. The laser setting was 3% pump (802nm) and 6% stokes (1045nm) to avoid tissue burn. 3 contrast methods used are Coherent anti-Stokes Raman scattering (CARS) for imaging of lipids, Second Harmonic Generation (SHG) for collagen and Two-Photon Fluorescence (TPF) for elastin fibers. We analysed collagen and elastin fibers in the skin samples which is disease relevant end products of fibroblast activation in SSc. Descriptive study of the skin CRS characteristics is reported.

Results

The SHG analysis revealed denser collagen fibers in dermal layer of diseased skin. It also appears that the collagen deposition occurs in more superficial layers of the skin. Peak of collagen curve were at depth of 110-130um HC vs 75-90um in SSc. Collagen fibres were more aligned in the SSc (Figure 1).

Figure 1.

Microscopy analysis of SSc (B) vs HC (A) skin. I: 3D image of biopsy samples with three contrasts. Red is CARS for lipid, blue is SHG for collagen and green is TPF for elastin fibers. II. SHG. Imaging revealed denser and more aligned collagen fibers in SSc.

Furthermore, TPF revealed larger number of disordered elastin fibres in the dermal layer of SSc than HC.

Conclusion

Nailfold capillaroscopy is used to define and stage micro-vasculopathy in SSc. Inflammatory pro-fibrotic processes on the other hand cause abnormal collagen and intercellular matrix formation in the dermis and internal organ.

With the demand of better tools in diagnosis of early SSc and therapeutic research, our work with CRS prove better in objective evaluation of skin changes at the molecular level. Here, we demonstrate that the SHG is altered in the early diffuse SSc skin with increased and aligned collagen in the SSc dermis compatible with mRSS score. Others have observed this alignment of the collagen, and we have published that SSc fibroblasts migrate/invade along aligned collagen and modify the underlying extracellular matrix, adding collagens I and III, cross-linking enzymes and other factors including TSP-1.

Our future work include:

1.Generating a computer module in defining pathological collagen level

2.Analysis of metabolites and pathological pathways in SSc

3.In-vivo trials with novel therapeutic peptides.

4.Lastly, manufacturing of non-invasive handheld device that is capable of diagnosis subclinical SSc and for outcome measure in clinical-therapeutic research

References

[1]Abignano G, et al. Virtual skin biopsy by optical coherence tomography: the first quantitative imaging biomarker for scleroderma. Ann Rheum Dis. 2013

[2]Ahmed Abdi B, et.al. Use of Patterned Collagen Coated Slides to Study Normal and Scleroderma Lung Fibroblast Migration. Sci Rep. 2017

Acknowledgements

We want to acknowledge our colleagues and patients in Royal Free Hospital, to make this project a success.

Disclosure of Interests

None declared

AB0403 ORBITAL MYOSITIS: AN UNCOMMON OPHTHALMIC PRESENTATION IN RHEUMATIC DISEASES - CASE SERIES AND SYSTEMIC REVIEW OF CASE REPORTS

Background:

Ophthalmic conditions are common manifestations in patients with rheumatic diseases (RDs), orbital myositis (OM) remain rare. Only 1 case each for scleroderma and undifferentiated connective tissue disease (UCTD) reported.

Objectives:

Report frequency of Rheumatic Diseases with OM (RDs-OM), diagnosis and treatments.

Methods:

Patients database were obtained from trust electronic record and literature review of case reports were performed.

Results:

4 out of 7 patients in our clinic with RDs-OM. Both Scleroderma-myositis (SCM) patients were positive for anti-PM/SCL antibody. All received glucocorticosteroid (GCS) and Mycophenolate as steroid-sparing or rescue therapy with good tolerance and outcome. One idiopathic OM has residual muscle paresis.

Table 1.

Case series of patients with Orbital Myositis

IdiopathicOM(n=3)Rheumatology Diseases(n=4)p-valueAge (years)48 (27-72)42.75 (21-60)P= 0.8571Gender – Female (Male)2 (1)4(0)Median Period Of Follow Up (months)24.60 (7-37)47.25(1-120)Underlying RDI.UCTD-1II.Overlap Scleromyositis-2III.Behcet’s Disease-1BiopsyI.Pathological significant11II.Normal11III.Not done12

Total 93 cases with RDs-OM reviewed and the characteristic of patients represented in Figure 1.

Figure 1.

Characteristics of orbital myositis in patients with rheumatic diseases. F: female, M:male, NS: not-specified, PrePD: onset before RD, AtD: onset with RD,PostPD: onset after RD, GCS 1st: Glucocorticoid as first line treatment, GCS res: Glucocorticoid responder, BxEOM: biopsy of extra-ocular muscle, OtherTs: Other Biopsy A: Median age at diagnosis, Sarc: sarcoidosis, SLE: Lupus, EGPA: Eosinophilic Granulomatous Polyangitis, GPA: Granulomatous Polyangitis, RA: rheumaoid Arthritis, BD: Behcet;s Disease, RP: Relapsing Polychondritis, DM: Dermatomyositis, LoSSC: Localized Sclerderma, SPA: Spondyloarthropathy, ASOD: Adult Onset Still’s Disease, RPF: Retroperitoneal Fibrosis, GCOM: Giant Cell OM, SJS: Sjogren Syndrome, DL: Discoid Lupus, KD: Kawasaki Disease, SAPHO: Synovitis, acne, pustulosis, hyperostosis, and osteitis, APLS: Antiphospholipid Syndrome.

OM although is rare but can present in most RDs. Our review showed OM commonest in patients with RA, GPA, EGPA and sarcoidosis. Only 1 each for SCM, APLS, UCTD, SAPHO and Kawasaki Disease.

Most RDs-OM patients are female. 89.2% OM diagnosed concurrently with primary RD diagnosis. Majority RA, BD and GPA developed OM along the course of RDs (83%-90%).

Except for routine RDs screening, thyroid eye disease, infections, malignancy (eg. lymphoma) and myasthenia gravis, atypical infective screenings include mycobacterium, fungal, Borrelia and spirochetes were excluded. Histopathological diagnosis is important diagnostic tool for IgG4 disease, neoplasm, sarcoidosis and vasculitis. 59% patients underwent tissue biopsy, 71% of these were sampled from EOM, some from involved organs. Orbital MRI or CT were the commonest diagnostic imaging, 5 reported had Ocular ultrasound as single or complementary imaging and 1 had PET-CT for exclusion of other diagnosis.

Only 40% GPA and 20% of EGPA patients were positive for ANCA either c-ANCA, p-ANCA and MPO which is similar in other literatures.

97.8% (n=91) patients received GCS with 79% of these patients reported improvement or resolution of ocular symptom with or without steroid-sparing agents. Immunosuppressants used are those not foreign among rheumatologists while biologics prescribed for refractory cases were Rituximab(2), Infliximab(4), Adalimumab(2) and Tocilizumab(1). Orbital decompression and orbital radiation were other measures. 13 patients had residual EOM paresis.

Conclusion:

1.RDs-OM is increasing recognized.

2.Most OM in RA, BD and GPA occurs along its primary RDs.

3.40% GPA and 20% of EGPA patients were ANCA positive.

4.GCS remain the primary treatment, three quarter patients responded.

References:

[1]Murray PI. The eye and inflammatory rheumatic diseases. Best Practice & Research Clinical Rheumatology. 2016.

Disclosure of Interests:

None declared

POS0893 NON-INVASIVE CUTANEOUS ASSESSMENT OF SYSTEMIC SCLEROSIS- THE NEW OUTLOOKS

Background:

Systemic sclerosis (SSc) is a rare connective tissue disease with abnormalities in vasculopathy, immune dysregulation and fibrosis resulting in skin and internal organ damages. Severity of skin involvement is known to correlate with organ-related mortality in particular pulmonary involvement. Variables skin assessment tools are available, modified Rodnan Skin Score (mRSS) is currently best validated and used widely. The immediate action of finding an ideal, clinically convenient objective methods is crucial to better clinicians‘ care for SSc patents.

Objectives:

Explore the potential of commercially available handheld, non-invasive devices for SSc skin analysis.

Methods:

1.Measure skin surface Adenosine Triphosphate (ATP) level with handheld ATP bioluminator (SystemSURE Plus, Hygiena) over the forearm of SSc(n= 51) and controls (n=50) 60seconds after sterilization to eliminate extrinsic factors. The bioluminometer expresses ATP test results in Relative Light Units (RLU) that is directly proportional to the amount of ATP on the test sample (Unit conversion: 1RLU = 1fM).

2.In-vivo Raman Spectra measurement of SSc skin comparing with matched healthy controls on proximal phalangeal, area between 2nd and 3rd metacarpal and forearm. Our measurments include laser power of 250mw, excitation length of 785nm and spectral range from 500 to 2800cm-1.

Measurements were analysed with patients’ phenotypes and clinical characteristics.

Results:

Flow cytometry showed increase expression of P2X7 (purinergic) receptor and CD206 in M2-Macrophage in SSc compare to controls [(724.4 vs 472.9, 776.1 vs 632.2)]. CD206 expression positively correlated with P2X7 levels (p<0.001, r2=0.76) and mRSS (p<0.05, r2=0.26). In real life scenario, measurement of purinergic metabolites is laboratorial tedious. ATP bioluminator measurement reviewed significant higher skin surface ATP in SSc than controls (188fM ± 53 [95% CI = 84, 300] vs 44fM ± 6 [95% CI = 33, 56], p< 0.003). And the intensity is negatively correlate with duration of disease in SSc (r = - 0.25, p = 0.096).

We obtain Raman spectra in SSc patient and control. Our study both groups have similar Raman curve when Raman Spectrometry were performed on skin surfaces. However, the relative intensity of each peaks of the curve were overtly flatter in SSc. This finding were similar for both Limited and Diffuse SSc in gross review of the graph representative. In addition to that, our analysis reviewed a peak at Raman shift of 2410 cm-1 that is characteristically present in forearm of a SSc but not in controls (Figure 1). Its significant yet to be determined.

Conclusion:

Both ATP bioluminator and Raman Spectrometry is widely available commercially which are widely used in industrial, agriculture and cosmetology and dermatology in particular for Raman Spectrometry. It is commonly for assessing physically property of skin, determine drug administration and diagnosis of variable skin condition in particular cancer diagnosis. The advantages of these tools in SSc skin analysis include:

1.Non-invasive nature of skin analysis (compares to skin biopsy),

2.Portable devices easily mobilized in clinic setting,

3.Advanced technology allows molecular analysis of skin hence able to objectively classify grades of skin inflammation and determine drug efficacy

4.Possible better accuracy compares to other methods (eg. Ultrasound) which are operators dependent,

5.Widely available Raman signal database of different types of chemical compounds and expertise made the collection and analysis of date convenient

Our study has provide preliminary outlook and idea of utilizing commercially available devices on skin analysis in SSc. Further study in larger cohort are to be considered.

References:

[1]Burnstock G, Knight GE, Greig AV. Purinergic signaling in healthy and diseased skin. The Journal of investigative dermatology. 2012;132(3 Pt 1):526-46.

[2]Franzen L, Windbergs M. Applications of Raman spectroscopy in skin research. Advanced Drug Delivery Reviews.Volume 89.2015. Pages 91-104.

Disclosure of Interests:

None declared

OP0254 CHROMATIN CONFORMATION SIGNATURE ANALYSIS IN EARLY VS LATE SCLERODERMA PHENOTYPES

Background:

Systemic sclerosis (scleroderma, SSc) is a heterogeneous disease in which clinical outcomes vary widely. Predicting outcomes on an individual basis remains challenging despite progress made through autoantibody analysis and gene expression profiling. Effective targeted therapies are evolving and accurately predicting outcomes is important to enable patient stratification for therapy.

Chromatin Conformation Signature (CCS) profiling of peripheral blood for systemic epigenetic deregulations could be used for such a purpose. The EpiSwitch platform offering high throughput and resolution chromosome conformation (3C) capture detects significant regulatory changes in 3D genome architecture and maps long range interaction between distant genomic locations. This then reveals the spatial disposition and physical properties of the chromosome, such as chromatin loops and inter-chromosomal connections, which have a role in network organization and genetic epistasis controlling gene expression. EpiSwitch automated platform has been successfully utilised in patient stratification in RA, MS and other indications.

This methodology could be applied to patients with SSc to identify CCS associated with different phenotypes and may ultimately be used to stratify and identify patients into pathogenic subtypes.

Objectives:

We aimed to determine significant CCSs associated with early and late phenotypes of SSc.

Methods:

The EpiSwitch-based chromosome conformation capture (3C) method was applied to blood samples from early phenotype, and late phenotype SSc patients. Intact nuclei were isolated from peripheral blood mononuclear cells and subjected to formaldehyde fixation resulting in crosslinking between physically touching segments of the genome via contacts between their DNA bound proteins. For quantification of cross-linking frequencies, the cross linked DNA was digested and then subjected to ligation. Cross-linking was then reversed and individual ligation products detected and quantified by EpiSwitch custom oligo array annotated across the whole genome to the anchoring sites of 3D genome architecture.

Results:

7 significant CCSs were found over the HLA-C, HLA-B and TNF regions on Chromosome 6 in the early phenotype. The top 8 pathways for genetic locations associated to the CCSs are shown in Table 1.

Table 1.

Top 8 pathways for genetic locations associated to significant CCS for the early phenotype.

GeneSet1Natural Killer cell mediated cytotoxicity2Immunoregulatory interations between a lymphoid cell and a non-lymphoid cell3Antigen Processing & presentation4Phagosome5Graft versus host disease6Type 1 diabetes mellitus7Osteoclast differentiation8Class 1 MHC mediated antigen processing & presentation

2 significant CCSs were found centred around the IFNG region of chromosome 12 in the late phenotype. The top 8 pathways for genetic locations associated to significant CCSs are shown in Table 2.

Table 2.

Top 8 pathways for genetic locations associated to significant CCS for the late phenotype.

GeneSet1Surfactant metabolism2IL12 signalling mediated by STAT43Protein digestion & absorption4Calcineruin regulated NFAT dependent transcription in lymphocytes5Transcriptional misregulation in cancer6Kaposi’s sarcoma associated herpes virus infection7IL2 mediated signalling events8Inflammatory bowel disease

Conclusion:

Significant CCSs, as part of 3D genomic regulatory control, and their associated pathways for the genetic locations, were identified in both late and early phenotypes. There were distinct CCSs in the early phenotype compared to the late suggesting the CCSs change as the disease progresses and varies between phenotypes. If CCSs could be linked to each clinically defined subgroup across a SSc cohort they could be used as a biomarker tool to predict outcome and progression in patients.

Disclosure of Interests:

Megan Galloway: None declared, Ewan Hunter: None declared, Alexandre Akoulitchev: None declared, Shivanee Vigneswaran: None declared, Bahja Abdi: None declared, Christopher Denton Grant/research support from: GlaxoSmithKline, Inventiva, CSF Behring, Consultant of: Roche-Genentech, Actelion, GlaxoSmithKline, Sanofi Aventis, Inventiva, CSL Behring, Boehringer Ingelheim, Bayer, David Abraham: None declared, Richard Stratton: None declared

Case of eosinophilic fasciitis during military training in a Nepalese British infantry soldier

We present the case of a Nepalese British soldier with peripheral oedema and a significantly raised eosinophil count. After extensive investigation looking for a parasitic cause of his illness, he was diagnosed with eosinophilic fasciitis, a connective tissue disorder, often triggered by heavy exertion and responsiveness to immunosuppression. In a military setting, in which clinicians are likely to encounter patients who have spent time in tropical areas, it is important to still consider non-infectious causes of eosinophilia.

Economic Impact of Implementing Malnutrition Screening and Nutritional Management in Older Adults in General Practice

OBJECTIVES

Malnutrition is a common and significant public health problem, especially for older adults, as the consequences are costly. National guidelines (NICE CG32/QS24) highlight the need to identify and manage malnutrition, the implementation of which was deemed "high impact to produce cost savings". The 'Malnutrition Pathway', endorsed by NICE and other professional bodies, is a practical evidence-based guide to help community healthcare professionals (HCP) to implement guidance on malnutrition management. Published evaluations of its use are needed.

DESIGN

This service evaluation in older adults assessed the impact of implementing the 'Malnutrition Pathway' on health care use and costs, as well as the acceptability of the management strategies and effect on malnutrition risk.

SETTING

5 GP surgeries in Gloucestershire.

PARTICIPANTS

163 older adults (80±9 years) with a range of primary diagnoses, living in their own home, were screened using the Malnutrition Universal Screening Tool ('MUST') (n50 low risk (LR); n41 medium risk (MR); n72 high risk (HR)). All patients were managed according to risk (LR: no further management; MR: dietary advice (DA); and HR: DA plus two oral nutritional supplements (ONS) (1 serve 300kcal, 18g protein; 125ml).

MEASUREMENTS

At each review (6weeks, 3 and 6 months), 'MUST' score, compliance and satisfaction to their management plan were recorded. Healthcare use was collected from GP records 6 months before and after implementation of the pathway. A simple cost analysis was completed.

RESULTS

Implementing appropriate management of malnutrition led to significant reductions in hospital admissions (p=0.028), length of hospital stay (p=0.05), GP visits (p=0.007) and antibiotic prescriptions (p=0.05). Over 6 months, the costs to manage malnutrition (HCP time, ONS) were more than offset by the savings associated with these reductions in health care use (per patient savings of -£395.64 MR+HR; -£997.02 HR). The proportion of individuals at risk of malnutrition reduced over time, and patients reported being satisfied with the DA (97%) and ONS (96%), consuming 90% of their ONS prescription.

CONCLUSION

Managing malnutrition significantly reduces healthcare use, with a positive budget impact, in older malnourished patients in primary care. This represents an opportunity to improve patient care with benefit on health care spend.

Community nurses' practices in managing perianal abscesses

A survey of community nurses identified that a wide range of dressings, and in some cases unethical practices, are being used for this simple postoperative condition. Communication between hospital, community staff and patients was poor.

Proteomic analysis of scleroderma lesional skin reveals activated wound healing phenotype of epidermal cell layer

OBJECTIVE

To identify using proteomic analysis, proteins of altered abundance in the skin of patients with SSc.

METHODS

4 mm excision biopsies were obtained from the forearm involved skin of 12 diffuse SSc patients and 12 healthy controls. Two-dimensional gel electrophoresis was used to separate and define proteins in normal and SSc skin biopsy material. Proteins of altered abundance in the disease were formally identified by mass spectroscopy. Abnormalities of the epidermis were confirmed by immunohistochemistry.

RESULTS

Proteomic analysis revealed altered abundance of proteins involved in extracellular matrix production, myofibroblast contractility, energy metabolism and response to oxidative stress. In addition, proteins specific to the epidermis and involved in epidermal cell differentiation were altered in abundance in the disease. SSc epidermis is thickened, has an expanded nucleated cell layer, and exhibits abnormal persistence of basal marker keratin 14, delayed expression of maturation markers keratin 1/10 and the induction of keratins 6 and 16, normally absent from interfollicular skin and induced following epidermal injury. These changes closely resemble the activated phenotype seen during wound healing.

CONCLUSIONS

Consistent with previous models of SSc pathogenesis these data are showing increased contractility, increased extracellular matrix and response to oxidative stress in the involved skin of recent onset SSc patients. In addition, we show that SSc epidermis has an activated, wound healing phenotype. These findings are important because epidermal cells activated by injury induce and regulate local fibroblasts during wound repair.

Subset of individuals with autism spectrum disorders and extreme macrocephaly associated with germline PTEN tumour suppressor gene mutations

The genetic aetiology of autism remains elusive. Occasionally, individuals with Cowden syndrome (a cancer syndrome) and other related hamartoma disorders such as Bannayan-Riley-Ruvalcaba syndrome, Proteus syndrome, and Proteus-like conditions, are characterised by germline PTEN mutations, and may have neurobehavioural features resembling autism as well as overgrowth and macrocephaly. Therefore, we undertook PTEN gene mutation analysis in 18 subjects mainly prospectively ascertained with autism spectrum disorder and macrocephaly. Of these 18 autistic subjects (13 males and five females; ages 3.1-18.4 years) with a head circumference range from 2.5 to 8.0 standard deviations above the mean, three males (17%) carried germline PTEN mutations. These three probands had previously undescribed PTEN mutations: H93R (exon 4), D252G (exon 7), and F241S (exon 7). They had the larger head circumference measurements amongst all our study subjects. The three residues altered in our patients were highly evolutionarily conserved. We suggest that PTEN gene testing be considered for patients with autistic behaviour and extreme macrocephaly. The gene findings may impact on recurrence risks as well as medical management for the patient.

Macro- and nanoscale observations of adhesive behavior for several E. coli strains (O157:H7 and environmental isolates) on mineral surfaces

Subsurface biobarriers can be conceived to attenuate the migration of pathogens by adhesion to mineral surfaces. Candidate biobarrier materials of varied surface characteristics (dolomite, alpha-alumina, silica, pyrophyllite, and Pyrax (a composite form of pyrophyllite, mica, and silica)) were tested for Escherichia coli adhesive capacity in macroscale continuous-flow columns. Atomic force microscopy (AFM) was used to determine nanoscale interaction energies. Predicted attractive interaction energies correlated well with macroscale adhesive behavior for tested E. coli strains. AFM measurements confirmed ExDLVO model predictions of attachment in the primary minima for E. coli O157:H7 and two environmental isolates E. coli (UCFL339 and UCFL-348) with MOPS conditioned Pyrax. In macroscale column experiments, pyrophyllite and Pyrax demonstrated significantly higher bacterial retention, higher deposition coefficients and lower initial cell breakthrough values for E. coli O157:H7 than did alpha-alumina, silica, or dolomite (pyrophyllite, 0.93, 3.56 h(-1), 3.2% ODo; Pyrax, 0.95, 3.73 h(-1), 2.8% ODo; alpha-alumina, 0.74, 1.60 h(-1), 33% ODo; silica, 0.63, 0.43 h(-1), 73% ODo; and dolomite, 0.33, 0.17 h(-1), 89% ODo, respectively). Bacterial hydrophilicity impacted cell retention in Pyrax columns with the relatively hydrophobic E. coli isolate UCFL-339 (0.99, 6.13 h(-1), 0.4% ODo) retained better than the more hydrophilic E. coli isolate UCFL348 (0.94, 3.70 h(-1), 3.6% ODo). The strong adhesive behavior of Pyrax was attributed to the hydrophobic (deltaGiwi = -32.4 mJ/m2) pyrophyllite component of the mineral. Vicinal water appears poised between the bacterial and the mineral surface during initial attachment. Overall, observed behavior of the various E. coli strains and the selected mineral surfaces was consistent with surface analyses, conducted at both the macro- and nanoscale.

N-terminal connective tissue growth factor is a marker of the fibrotic phenotype in scleroderma

BACKGROUND

Over-expression of connective tissue growth factor (CTGF) is a hallmark of fibrotic disease, including scleroderma. CTGF acts with the pro-fibrotic cytokine TGFbeta to promote sustained fibrotic responses in vivo. Elevated production of CTGF might be responsible for maintenance of the fibrotic phenotype in scleroderma. Assays of CTGF or of its fragments are potential non-invasive measures of the fibrotic response in scleroderma.

AIM

To determine the utility of whole, N-terminal, and C-terminal CTGF as surrogate markers for fibrosis in scleroderma.

DESIGN

Cross-sectional controlled study.

METHODS

Plasma was collected prospectively from 47 scleroderma patients (26 diffuse scleroderma, 21 limited scleroderma) and 18 healthy controls. At the same time, dermal interstitial fluid was derived by a suction blister technique from the lesional skin of scleroderma patients, and from the forearm skin of healthy controls. Whole, N-terminal, and C-terminal CTGF were assayed by ELISA, using monoclonal antibodies specific for N- and C-terminal epitopes.

RESULTS

N-terminal cleavage products of CTGF were present at elevated levels in the plasma and dermal interstitial fluid of scleroderma patients, compared to healthy controls. N-terminal CTGF levels in plasma and dermal interstitial fluid correlated with severity of skin disease and (negatively) with disease duration. Whole and C-terminal CTGF levels were low in blister fluid and plasma levels were not elevated in disease.

DISCUSSION

These results support a role for CTGF in scleroderma-associated fibrosis and the utility of N-terminal CTGF as a marker of fibrosis.

Iloprost suppresses connective tissue growth factor production in fibroblasts and in the skin of scleroderma patients

Patients with scleroderma receiving Iloprost as a treatment for severe Raynaud's phenomenon report a reduction in skin tightness, suggesting that this drug inhibits skin fibrosis. Connective tissue growth factor (CTGF), a recently described profibrotic cytokine, acts downstream and in concert with TGF-beta to stimulate the fibrotic process and is involved in the fibrosis seen in scleroderma. Here we show that Iloprost, acting by elevation of cAMP, blocks the induction of CTGF and the increase in collagen synthesis in fibroblasts exposed to TGF-beta. The potency of Iloprost with respect to suppression of CTGF far exceeds that of other prostanoid receptor agonists, suggesting that its effect is mediated by the prostacyclin receptor IP. By sampling dermal interstitial fluid using a suction blister device, we show that CTGF levels are greatly elevated in the dermis of scleroderma patients compared with healthy controls and that Iloprost infusion causes a marked decrease in dermal CTGF levels. These studies suggest that Iloprost could be reducing the level of a key profibrotic cytokine in scleroderma patients and that endogenous production of eicosanoids may limit the fibrotic response to TGF-beta.

Description and evaluation of a Newton-based electronic appetite rating system for temporal tracking of appetite in human subjects

This study assessed the reliability and validity of a palm-top-based electronic appetite rating system (EARS) in relation to the traditional paper and pen method. Twenty healthy subjects [10 male (M) and 10 female (F)] - mean age M=31 years (S.D.=8), F=27 years (S.D.=5); mean BMI M=24 (S.D.=2), F=21 (S.D.=5) - participated in a 4-day protocol. Measurements were made on days 1 and 4. Subjects were given paper and an EARS to log hourly subjective motivation to eat during waking hours. Food intake and meal times were fixed. Subjects were given a maintenance diet (comprising 40% fat, 47% carbohydrate and 13% protein by energy) calculated at 1.6xResting Metabolic Rate (RMR), as three isoenergetic meals. Bland and Altman's test for bias between two measurement techniques found significant differences between EARS and paper and pen for two of eight responses (hunger and fullness). Regression analysis confirmed that there were no day, sex or order effects between ratings obtained using either technique. For 15 subjects, there was no significant difference between results, with a linear relationship between the two methods that explained most of the variance (r(2) ranged from 62.6 to 98.6). The slope for all subjects was less than 1, which was partly explained by a tendency for bias at the extreme end of results on the EARS technique. These data suggest that the EARS is a useful and reliable technique for real-time data collection in appetite research but that it should not be used interchangeably with paper and pen techniques.

The use of visual analogue scales to assess motivation to eat in human subjects: a review of their reliability and validity with an evaluation of new hand-held computerized systems for temporal tracking of appetite ratings

This present paper reviews the reliability and validity of visual analogue scales (VAS) in terms of (1) their ability to predict feeding behaviour, (2) their sensitivity to experimental manipulations, and (3) their reproducibility. VAS correlate with, but do not reliably predict, energy intake to the extent that they could be used as a proxy of energy intake. They do predict meal initiation in subjects eating their normal diets in their normal environment. Under laboratory conditions, subjectively rated motivation to eat using VAS is sensitive to experimental manipulations and has been found to be reproducible in relation to those experimental regimens. Other work has found them not to be reproducible in relation to repeated protocols. On balance, it would appear, in as much as it is possible to quantify, that VAS exhibit a good degree of within-subject reliability and validity in that they predict with reasonable certainty, meal initiation and amount eaten, and are sensitive to experimental manipulations. This reliability and validity appears more pronounced under the controlled (but more artificial) conditions of the laboratory where the signal:noise ratio in experiments appears to be elevated relative to real life. It appears that VAS are best used in within-subject, repeated-measures designs where the effect of different treatments can be compared under similar circumstances. They are best used in conjunction with other measures (e.g. feeding behaviour, changes in plasma metabolites) rather than as proxies for these variables. New hand-held electronic appetite rating systems (EARS) have been developed to increase reliability of data capture and decrease investigator workload. Recent studies have compared these with traditional pen and paper (P&P) VAS. The EARS have been found to be sensitive to experimental manipulations and reproducible relative to P&P. However, subjects appear to exhibit a significantly more constrained use of the scale when using the EARS relative to the P&P. For this reason it is recommended that the two techniques are not used interchangeably.

Systemic vasculitis with multiple aneurysms complicating systemic lupus erythematosus

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Growth hormone improves weight velocity and height velocity in prepubertal children with cystic fibrosis

We undertook this study to determine if growth hormone treatment of prepubertal children with cystic fibrosis could improve their height and weight. Nine prepubertal children with cystic fibrosis were treated with human recombinant growth hormone for one year. Results obtained during this year were compared to similar measurements made for each patient for the one year prior to the treatment year. Anthropometric data including: height, height velocity, weight, weight velocity and skin fold thickness were measured at three month intervals. Pulmonary function and skeletal muscle strength were measured at three month intervals. Glucose tolerance was evaluated by HbAlc and by fasting blood glucose and insulin levels every three months. Our results demonstrate that growth hormone treatment resulted in significant improvement in height velocity and height Z scores. Weight increased in all subjects, with a significant increase in weight velocity (year prior to treatment = 1.7+/-1.0 kg/yr, treatment year = 3.8+/-1.6 kg/yr; p=0.03). Measurements of skin fold thickness suggests that lean body mass improved with growth hormone treatment. Pulmonary function improved in all but two patients, whose pulmonary function remained the same and muscle strength improved in all subjects. These results suggest that growth hormone used in prepubertal children with cystic fibrosis can improve height and weight and may improve lean body mass.

The value of SPECT scans in identifying back pain likely to benefit from facet joint injection

Lumbar facet disease is sometimes implicated in low back pain. Identification is difficult and this may account for a variable response. Single photon emission computerized tomography (SPECT) is a scanning technique which enables localization of facet joint pathology. We determined whether recognition of facet disease by this method improved the response to corticosteroid injection treatment. Fifty-eight patients with low back pain and displaying accepted clinical criteria for facet joint disease were evaluated by SPECT. Twenty-two had facetal uptake of isotope. These and the tender facet joints of 36 scan-negative patients were injected with 40 mg methylprednisolone and 1 ml 1% lignocaine under X-ray control. Pain was assessed by a blind observer using the McGill questionnaire (MGQ), Present Pain Intensity score (PPI) and a Visual Analogue Scale (VAS). VAS, PPI and MGQ were reduced in the scan-positive patients at 1 month (P = 0.05, P = 0.0005, P = 0.005) and MGQ at 3 months (P = 0.01), whilst scan-negative patients were unchanged. The percentage of scan-positive patients who reported improvement was 95% at 1 month and 79% at 3 months, significantly greater than the control group (P = 0.0005, P = 0.01). Within 6 months, pain improvement in the SPECT-positive group was no longer statistically significant. Tenderness did not correlate with increased uptake on SPECT scan. Osteoarthritis of the facets was more common in the SPECT-positive patients (P < 0.001), but did not correspond with sites of increased uptake on SPECT scan. These results suggest that SPECT can enhance the identification of back pain sufferers likely to obtain short-term benefit from facet joint injection.

Xq-Yq interchange resulting in supernormal X-linked gene expression in severely retarded males with 46,XYq- karyotype

The critical importance of dosage compensation is underscored by a novel human syndrome ("XYXq syndrome") in which we have detected partial X disomy, demonstrated supernormal gene expression resulting from the absence of X inactivation, and correlated this overexpression with its phenotypic consequences. Studies of three unrelated boys with 46,XYq- karyotypes and anomalous phenotypes (severe mental retardation, generalized hypotonia and microcephaly) show the presence of a small portion of distal Xq on the long arm of the Y derivative. Cells from these boys exhibit twice-normal activity of glucose-6-phosphate dehydrogenase, a representative Xq28 gene product. In all three cases, the presence of Xq DNA on a truncated Y chromosome resulted from an aberrant Xq-Yq interchange occurring in the father's germline.

Nucleotide sequence of the gene coding for a 130-kDa mosquitocidal protein of Bacillus thuringiensis israelensis

The nucleotide sequence of pVB131 containing the gene coding for a 130-kDa Bacillus thuringiensis israelensis (B.t.isr) mosquitocidal protein was determined. The pVB131 plasmid was constructed by Sekar and Carlton [Gene 33 (1985) 151-158]. Our sequencing revealed only one open reading frame large enough to code for a protein of 130 kDa. The translation start site was determined by sequencing the protein isolated from B.t.isr. The amino acid sequence of the protein was deduced from the nucleotide sequence, and its Mr was determined as 128,505. Immunological and biochemical analyses of B.t.isr mosquitocidal proteins indicated that the 130-kDa protein coded by pVB131 was indeed expressed in B.t.isr. Comparing the peptide sequence of the 130-kDa B.t.isr toxin with the sequences of other B.t. toxins having activities specific to lepidopteran species showed that several domains were highly homologous. This suggests that they are evolutionarily related to each other, and in the evolutionary process the sequences in the homologous domains that are important to the insecticidal activity have been conserved.

Acute Glycemic Effects of Exercise in Adolescents with Insulin-Dependent Diabetes Mellitus

In brief: The acute effect of exercise on blood glucose was observed on 130 occasions in eight adolescents with insulin-dependent diabetes mellitus. All subjects engaged in 30 minutes of either structured aerobic exercise or unstructured recreational activity. The magnitude of decline in the blood glucose level with exercise corresponded to the preexercise blood glucose value: Higher preexercise values were associated with larger declines, while nonelevated preexercise values were associated with smaller declines. No significant differences in glycemic effect were observed between the two categories of exercise. The authors conclude that in adolescents with moderately well-controlled diabetes, recreational activities can be as effective in lowering elevated blood glucose levels as structured exercise.

Improved glycemic control after supervised 8-wk exercise program in insulin-dependent diabetic adolescents

Eight insulin-dependent adolescents (4 boys, 4 girls) participated in an 8-wk program of supervised exercise, and 8 matched controls were encouraged to exercise on their own without supervision. All 16 subjects were asked to follow a standard ADA diet plan, kept a self-reported log of caloric intake, and met with a dietitian weekly to review their diets. Exercise for the supervised subjects was scheduled between the routine afternoon snack and the evening meal, and subjects were asked not to consume additional food on exercise days. After the 8-wk program, glycemic control, as measured by glycosylated serum albumin and blood glucose values (but not by glycosylated hemoglobin), improved in the supervised-exercise group despite reduced daily insulin dosage. Cardiorespiratory fitness, as measured by voluntary maximum treadmill time (Bruce protocol) and submaximal exercise heart rates, also improved. No changes were observed in the unsupervised control group.

Correlates of biopsy-studied nephropathy in young patients with insulin-dependent diabetes mellitus

We have correlated pathologic findings in kidney biopsies from 12 adolescents with proteinuria or hypertension with severity of limited joint mobility (LJM) and retinopathy. We compared mean glucosylated hemoglobin (GHB) and clinical findings in these patients with those in patients without proteinuria or hypertension. Severity of LJM correlated with basement membrane thickening. Protein excretion correlated with degree of mesangial matrix increase and basement membrane changes. Retinal changes were related to basement membrane thickness and duplication. Despite treatment, blood pressures were significantly higher in patients with nephropathy than in the comparison group. Glycemic control status was generally poor and did not correlate with pathologic changes. The narrow spectrum of control did not permit assessment of possible effects of milder metabolic derangement. However, the similarity of GHB values in the groups with and without nephropathy implicates other factors. The group with clinical nephropathy had more LJM than did the comparison group, reaffirming LJM as a risk factor for early microvascular disease. Biopsy changes of nephropathy may begin relatively early in the course of diabetes (less than 7 years in three of our patients) and is already advanced when proteinuria appears.