POS1472-HPR CONSTRUCT VALIDITY OF THE PROMIS PHYSICAL FUNCTION 10-ITEM SHORT FORM IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASES AND SEVERE LIMITATIONS IN PHYSICAL FUNCTIONING

Background

Physical functioning in patients with inflammatory arthritis (IA) can be severely affected and is often measured using the disease-specific questionnaires Health Assessment Questionnaire-Disability Index (HAQ-DI) or Bath Ankylosing Spondylitis Functional Index (BASFI). Also, the Patient Reported Outcome Measurement Information System (PROMIS) Physical Function Item Bank1 has been increasingly used. This is a generic instrument to assess physical functioning and compare health status across conditions. Several short forms can be derived, including the PROMIS PF 10-Item Short Form (PROMIS PF-10). To date, experience with this PROMIS PF-10 in research with IA is limited and more insight is needed in its construct validity in specific IA populations.

Objectives

To assess the construct validity of the PROMIS PF-10 in patients with rheumatoid arthritis (RA) or axial spondyloarthritis (axSpA) and severe limitations in physical functioning.

Methods

Baseline data from patients with RA or axSpA and severe limitations in physical functioning participating in two randomized controlled trials on the effectiveness of longstanding physical therapy2 were used. Patients completed the PROMIS PF-10 (score range 13.5-61.9 worst-best, standardized to the Dutch population) and several measures of physical functioning and quality of life: i.e. the 36-item Short Form Health Survey (SF-36) (Physical and Mental Component summary Scores (PCS and MCS) were calculated), the EuroQol 5-dimensions 5-levels (EQ5D5L; index and VAS) and the 6 Minute Walk Test (6MWT). In addition, RA patients completed the HAQ-DI and axSpA patients the BASFI. Spearman rho correlation coefficients were computed between the PROMIS PF-10 and the other measures. Correlations were considered 0.3<r<0.5 weak, 0.5 <r<0.75 moderate to good, r >0.75 good to excellent. The PROMIS PF-10 was expected to correlate moderately to good with instruments measuring physical functioning and weak with other instruments (e.g. SF-36 MCS). All analyses were stratified for RA and axSpA.

Results

Data from 181 patients with RA and 139 with axSpA (92% and 48% female, mean (SD) age 59 (13.1) and 54 (11.4) years, respectively) were analyzed. The mean score of the measures of physical functioning and quality of life are summarized in the Table 1. The PROMIS PF-10 correlated moderately to good with HAQ-DI, BASFI, SF-36 PCS and EQ5D5L-index (Spearman r >0.5, all p-values <0.001). The PROMIS PF-10 correlated weak with the 6MWT, EQ-VAS and the SF-36 MCS (Spearman r <0.5).

Table 1.

Mean score and Spearman r correlation coefficients of PROMIS PF-10 with measures of physical functioning and quality of life

PROMIS PF-10HAQ-DI (RA) BASFI (axSpA)SF-36 PCSSF-36 MCSEQ5D5L indexEQ-VAS6MWTRA Mean(SD)34.1 (5.0)1.6 (0.5)39.4 (19.7)46.8 (12.0)0.5 (0.3)56.4 (18.7)300 (100)Spearman r--0.724*0.611*0.1010.617*0.450*0.469*AxSpA Mean(SD)35.4 (4.2)6.2 (1.8)44.4 (17.6)45.5 (11.6)0.5 (0.3)54.5 (19.0)390 (108)Spearman r--0.686*0.539*-0.0140.598*0.438*0.434**Correlation is significant at <0.001 level

Conclusion

The moderately to good correlations of the PROMIS PF-10 with measures of physical functioning support the construct validity in RA and axSpA patients with severe limitations in physical functioning. However, the correlation of the quality of life questionnaire EQ5D5L was also moderately to good. Future research is needed to better understand this relatively high correlation. Also clinimetric properties (responsiveness to change and ability to discriminate between intervention and control conditions) in this population should be determined in future.

References

[1]Gershon RC, et al. J Appl Meas. 2010;11(3):304-314.

[2]van Wissen MAT, et al. Physiother Res Int. 2021;e1933.

Funding:

The Netherlands Organisation for Health Research and Development [ZonMw: 852004018 and 852004019]; Ministry of Health, Welfare and Sport [VWS]; the Dutch Arthritis Society [ReumaNederland] and the Royal Dutch Society for Physical Therapy [KNGF].

Disclosure of Interests

None declared

POS1508-HPR USE OF PHYSICAL THERAPY IN PATIENTS WITH RHEUMATOID ARTHRITIS OR AXIAL SPONDYLOARTHRITIS: THE PATIENT´S PERSPECTIVE

Background

In national and international management guidelines physical therapy (PT) is a recommended treatment for people with inflammatory arthritis (IA). Based on multiple systematic reviews, concluding that supervised exercise therapy and exercise promotion is an effective and safe PT treatment option in patients with IA, recommendations in particular endorse active PT treatment. In order to monitor and enhance the quality of PT in clinical practice, knowledge about its delivery, including its active content, is needed.

Objectives

To assess the use, frequency, duration and content of PT in patients with IA.

Methods

In this cross-sectional, national study a link to an electronic questionnaire addressing people with rheumatic and musculoskeletal diseases was published between December 2020-July 2021 by the Dutch Arthritis Foundation via their website, newsletter and various social media. It comprised questions on demographic and health characteristics, the EuroQol 5-Dimensions 5-Levels (EQ5D5L) and 29 questions on the usage of PT currently and/or in the past 12 months and, if applicable, the duration, frequency and content of the PT treatment. The content of PT was categorized into exercises (active aerobic, muscle strengthening, range of motion and/or functional exercises), manual treatment, physical modalities and counseling/education. Only data from patients self-identifying as diagnosed with rheumatoid arthritis (RA) and/or axial spondyloarthritis (axSpA) were used for the current study.

Results

A total of 267 people with RA (mean (SD) age 54 (12) years, 96% female) and 104 people with axSpA (age 47 (13) years, 88% female) (10 patients with both diagnoses) completed the questionnaire. More than 90% were treated by a rheumatologist; the mean (SD) EQ5D5L of people with RA was 0.62 (0.2) and of axSpA 0.59 (0.2). 172 RA respondents (64%) reported the use of PT related to their RA (162 individual PT, 1 group PT, 9 both individual and group PT). In axSpA, the rate was 87 (84%; 77 individual PT, 2 group PT, 8 both individual and group PT).

Of those reporting individual PT treatment, the duration was long-term (> 3 months) in 134 (89%) and 70 (89%) of the respondents with RA and axSpA respectively, with a duration of more than 2 years in 67 (44%) and 38 (48%). In all users of individual PT, the mean frequency was once per week or less in 116 (77%) of the RA and 63 (80%) of the axSpA patients. Proportions were based on number of respondents to questions on individual PT.

Concerning the content of individual PT, and taking into account both short-term and long-term use, for active exercises, the proportion of patients reporting aerobic, muscle strengthening, range of motion or functional exercises ranged from 40-66% in RA and 24-73% in axSpA patients. Regarding manual treatment, the proportions were 61% and 58%, in RA and 73% and 72% in axSpA for massage and passive mobilizations, respectively. With respect to physical modalities (passive), the modality most frequently mentioned were kinesiotaping and dry needling (40 and 25% and 43 and 32% in RA and axSpA). For counseling/education, exercises to perform at home (70 and 78%) and physical activity (PA) promotion (48 and 49%) were most often reported in both RA and AxSpA.

Conclusion

Long-term use of PT is common in patients with RA and AxSpA. Apart from active treatment modalities (exercises) and promoting recommended PA, passive treatment options appear to be relatively often used. The results must be interpreted with caution, as the respondents may not constitute a representative sample of the IA population, yet warrant further research.

Acknowledgements:

This work was supported by the Dutch Arthritis Society [ReumaNederland], the Royal Dutch Society for Physical Therapy [KNGF] and The Netherlands Organisation for Health Research and Development [ZonMw].

Disclosure of Interests

None declared

Web-based system to capture consistent and complete real-world data of physical therapy interventions following total knee replacement Methods to define and test structured data to accelerate comparative effectiveness research (Preprint)

Background

Electronic health records (EHRs) have the potential to facilitate consistent clinical data capture to support excellence in patient care, quality improvement, and knowledge generation. Despite widespread EHR use, the vision to transform health care system and its data to a "learning health care system" generating knowledge from real-world data is limited by the lack of consistent, structured clinical data.

Objective

The purpose of this paper was to demonstrate the design of a web-based structured clinical intervention data capture system and its evaluation in practice. The use case was ambulatory physical therapy (PT) treatment after total knee replacement (TKR), one of the most common and costly procedures today.

Methods

To identify the PT intervention type and intensity (or dose) used to treat patients with knee arthritis following TKR, an iterative user-centered design process refined an initial list of PT interventions generated during preliminary chart reviews. Input from practicing physical therapists and national and international experts refined and categorized the interventions. Next, a web-based, hierarchical structured system for intervention and intensity documentation was designed and deployed.

Results

The PT documentation system was implemented by 114 physical therapists agreeing to record all interventions at patient visits. Data for 161 patients with 2615 PT visits were entered by 83 physical therapists. No technical problems with data entry were reported, and data entry required less than 2 minutes per visit. A total of 42 (2%) interventions could not be categorized and were recorded using free text.

Conclusions

The use of user-centered design principles provides a road map for developing clinically feasible data capture systems that employ structured collection of uniform data for use by multiple practitioners across institutions to complement and augment existing EHRs. Secondarily, these data can be analyzed to define best practices and disseminate knowledge to practice.

Point-of-care testing and treatment of sexually transmitted and genital infections during pregnancy in Papua New Guinea (WANTAIM trial): protocol for an economic evaluation alongside a cluster-randomised trial

INTRODUCTION

Left untreated, sexually transmitted and genital infections (henceforth STIs) in pregnancy can lead to serious adverse outcomes for mother and child. Papua New Guinea (PNG) has among the highest prevalence of curable STIs including syphilis, chlamydia, gonorrhoea, trichomoniasis and bacterial vaginosis, and high neonatal mortality rates. Diagnosis and treatment of these STIs in PNG rely on syndromic management. Advances in STI diagnostics through point-of-care (PoC) testing using GeneXpert technology hold promise for resource-constrained countries such as PNG. This paper describes the planned economic evaluation of a cluster-randomised cross-over trial comparing antenatal PoC testing and immediate treatment of curable STIs with standard antenatal care in two provinces in PNG.

METHODS AND ANALYSIS

Cost-effectiveness of the PoC intervention compared with standard antenatal care will be assessed prospectively over the trial period (2017-2021) from societal and provider perspectives. Incremental cost-effectiveness ratios will be calculated for the primary health outcome, a composite measure of the proportion of either preterm birth and/or low birth weight; for life years saved; for disability-adjusted life years averted; and for non-health benefits (financial risk protection and improved health equity). Scenario analyses will be conducted to identify scale-up options, and budget impact analysis will be undertaken to understand short-term financial impacts of intervention adoption on the national budget. Deterministic and probabilistic sensitivity analysis will be conducted to account for uncertainty in key model inputs.

ETHICS AND DISSEMINATION

This study has ethical approval from the Institutional Review Board of the PNG Institute of Medical Research; the Medical Research Advisory Committee of the PNG National Department of Health; the Human Research Ethics Committee of the University of New South Wales; and the Research Ethics Committee of the London School of Hygiene and Tropical Medicine. Findings will be disseminated through national stakeholder meetings, conferences, peer-reviewed publications and policy briefs.

TRIAL REGISTRATION NUMBER

ISRCTN37134032.

AB0873-HPR EFFECTIVENESS AND COST-EFFECTIVENESS OF LONGSTANDING EXERCISE THERAPY VERSUS USUAL CARE IN PATIENTS WITH AXIAL SPONDYLOARTHRITIS OR RHEUMATOID ARTHRITIS: THE PROTOCOLS OF TWO PARALLEL RANDOMIZED CONTROLLED TRIALS

Background:

Axial SpondyloArthritis (axSpA) and Rheumatoid Arthritis (RA) are chronic rheumatic diseases with an often progressive course, defined by chronic inflammation. With respect to exercise therapy, in axSpA and RA, multiple systematic reviews concluded that supervised exercise therapy is an effective and safe treatment option, resulting in small to modest improvements in pain, disease activity, functional ability and axial mobility. In general, most of the studies included in these reviews concerned programs of a relatively short duration (<12 weeks) and the studies mostly concerned patients with stable disease, without co-morbid conditions and relatively favorable functional ability (1-5). The group of patients with active disease, irreversible joint damage, multiple joint replacements and/or severe comorbidity hampering participation in exercise therapy programs and in need for individualized, longstanding therapy is therefore likely to be underrepresented in research so far. Consequently, cost-effectiveness studies on longstanding physical therapy are also lacking in these specific subgroups.

Objectives:

We aim to evaluate the effectiveness and cost-effectiveness of longstanding exercise therapy compared to usual care in the subgroup of patients with axSpA or RA and severe limitations in functioning.

Methods:

In two separate, parallel randomized controlled trials, the effectiveness and cost-effectiveness of longstanding, active exercise therapy (52 weeks) compared with usual care (1:1) will be evaluated (Figure 1). The longstanding, active exercise therapy will focus on improving individual limitations in daily activities and participation, and will be given by a trained physical therapist in the vicinity of the participant. For each diagnosis, 215 patients with severe limitations in activities and participation will be included. Assessments are performed at baseline, 12, 26, and 52 weeks. The primary outcome measure of effectiveness is the individual level of functioning (activities and participation), as measured with the Patient-Specific Complaints instrument at 52 weeks. For cost-effectiveness analyses, the EuroQol (EQ-5D-5L) and questionnaires on healthcare use and productivity will be administered. The economic evaluation will be a cost-utility analysis from a societal perspective. After 52 weeks, the patients in the usual care group are offered longstanding, active exercise therapy as well. Follow-up assessments are done at 104, 156 and 208 weeks.

Figure 1.

Study flowchart

Results:

The results of these studies will provide insights in the effectiveness and cost-effectiveness of longstanding exercise therapy in the subgroup of axSpA and RA patients with severe functional limitations.

References:

[1]Mewes J, de Bekker P, Bossen D, Steuten L. 2016. Systematic review of supervised physical exercise therapy for patients with rheumatoid arthritis. Panaxea.

[2]Mewes J, de Bekker P, Bossen D, Steuten L. 2016. Systematic review of supervised phyiscal exercise therapy for patients with ankylosing spondylitis. Panaxea.

[3]Swardh E, Brodin N. 2016. Effects of aerobic and muscle strengthening exercise in adults with rheumatoid arthritis: a narrative review summarising a chapter in Physical activity in the prevention and treatment of disease (FYSS 2016). Br J Sports Med 50: 362-7.

[4]Sveaas SH, Smedslund G, Hagen KB, Dagfinrud H. 2017. Effect of cardiorespiratory and strength exercises on disease activity in patients with inflammatory rheumatic diseases: a systematic review and meta-analysis. Br J Sports Med 51: 1065-72.

[5]Regel A, Sepriano A, Baraliakos X, van der Heijde D, Braun J, Landewe R, Van den Bosch F, Falzon L, Ramiro S. 2017. Efficacy and safety of non-pharmacological and non-biological pharmacological treatment: a systematic literature review informing the 2016 update of the ASAS/EULAR recommendations for the management of axial spondyloarthritis. RMD Open 3: e000397.

Disclosure of Interests:

None declared

Static cold storage compared with normothermic machine perfusion of the liver and effect on ischaemic-type biliary lesions after transplantation: a propensity score-matched study

BACKGROUND

Given the susceptibility of organs to ischaemic injury, alternative preservation methods to static cold storage (SCS), such as normothermic machine perfusion (NMP) are emerging. The aim of this study was to perform a comparison between NMP and SCS in liver transplantation with particular attention to bile duct lesions.

METHODS

The outcomes of 59 consecutive NMP-preserved donor livers were compared in a 1 : 1 propensity score-matched fashion to SCS control livers. Postoperative complications, patient survival, graft survival and bile duct lesions were analysed.

RESULTS

While patients were matched for cold ischaemia time, the total preservation time was significantly longer in the NMP group (21 h versus 7 h, P < 0.001). Patient and graft survival rates at 1 year were 81 versus 82 per cent (P = 0.347) and 81 versus 79 per cent (P = 0.784) in the NMP and SCS groups, respectively. The postoperative complication rate was comparable (P = 0.086); 37 per cent NMP versus 34 per cent SCS patients had a Clavien-Dindo grade IIIb or above complication. There was no difference in early (30 days or less) (NMP 22 versus SCS 19 per cent, P = 0.647) and late (more than 30 days) (NMP 27 versus SCS 36 per cent, P = 0.321) biliary complications. However, NMP-preserved livers developed significantly fewer ischaemic-type bile duct lesions (NMP 3 versus SCS 14 per cent, P = 0.047).

CONCLUSION

The use of NMP allowed for a significantly prolonged organ preservation with a lower rate of observed ischaemic-type bile duct lesions.

THU0653-HPR BARRIERS FOR THE UPTAKE OF EULAR POSTGRADUATE EDUCATION FOR HEALTH PROFESSIONALS IN RHEUMATOLOGY IN EASTERN EUROPEAN COUNTRIES: RESULTS FROM 3 NATIONAL SURVEYS

Background:

Health professionals play an important role in the care for people with rheumatic and musculoskeletal diseases. In order to improve and maintain the quality of their work, appropriate professional education is needed. EULAR has developed several educational products and activities specifically targeted at Health Professionals in Rheumatology (HPR), but particularly in Eastern European countries, their uptake is limited. The overarching aim of a EULAR project (named HEE4ALL: Health professionals Education in Eastern European countries for All) is to develop and execute implementation strategies for EULAR educational activities in 3 eastern European countries.

Objectives:

The aim of the present analysis was to identify barriers and facilitators for the uptake of EULAR educational activities among HPR in Eastern European countries.

Methods:

First, a questionnaire was sent to representatives of national health professionals’ or patients’ organization in 17 Eastern European countries, in order to determine their eligibility to participate in the implementation project. Eligibility criteria were: Having a national HPR organization; Willing and able to compose a team with HPR, Patients, and Rheumatologists; and Interested to participate in the project. Selected countries (minimum 3) were requested to set up a national implementation team, and conduct a national, electronic survey among HPR on anticipated barriers and needs regarding educational activities. The survey included the following elements: a. characteristics of the responding HPRs; b. Familiarity with EULAR educational offerings; c. Anticipated barriers and facilitators (score 0=no barrier at all to10 very important barrier); d. Ability to pay for the HPR online course.

Results:

Representatives from 10/17 Eastern European countries responded to the first questionnaire, with 3 countries meeting the selection criteria: Hungary, Serbia and Turkey. Subsequently, 216 (H:106, S:42 and T:68) HPR completed the 3 national surveys. In all 3 countries, the majority of the respondents was female (93.1%), and nurse (70.8%) or physical therapist (19.0). Familiarity with EULAR educational offerings was poor, with the lowest proportions of HPR being familiar with postgraduate face-to-face courses (13.9%), educational visits (19.0%) and the EULAR online course for HPR (25.0%). The highest ranked barriers in all 3 countries included the costs of EULAR annual congress, the costs of the EULAR HPR online course and a lack of mastery of English language.The maximum amount of money HPR were able to pay for the EULAR online course was on average €66, €29 and €83 in Hungary, Serbia and Turkey, respectively.

Conclusion:

Based on a survey in 3 Eastern European countries, it appears that familiarity with EULAR educational offerings is suboptimal. However, when HPR are aware of the educational offerings, their costs and a lack of mastery of the English language seem to be the most important barriers for participation. Based on these results, the 3 national teams developed implementation plans during a 2-day meeting (October 2019). The implementation plans are now executed and a process and effect evaluation is planned by November, 2020.

Acknowledgments:

Supported by EULAR; Project HPR 042

Disclosure of Interests:

Leti van Bodegom-Vos: None declared, T.P.M. Vliet Vlieland: None declared, Loreto Carmona Grant/research support from: Novartis Farmaceutica, SA, Pfizer, S.L.U., Merck Sharp & Dohme España, S.A., Roche Farma, S.A, Sanofi Aventis, AbbVie Spain, S.L.U., and Laboratorios Gebro Pharma, SA (All trhough institution), Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andrea Domjan: None declared, Alzbeta Goehmann: None declared, Annamaria Iagnocco Grant/research support from: Abbvie, MSD and Alfasigma, Consultant of: AbbVie, Abiogen, Alfasigma, Biogen, BMS, Celgene, Eli-Lilly, Janssen, MSD, Novartis, Sanofi and Sanofi Genzyme, Speakers bureau: AbbVie, Alfasigma, BMS, Eli-Lilly, Janssen, MSD, Novartis, Sanofi, Marija Kosanovic: None declared, Rikke Helene Moe: None declared, Wilfred Peter: None declared, Marija Segrt: None declared, Eda Tonga: None declared, Codruta Zabalan: None declared

Comparison of a video versus paper questionnaire on functional limitation in lower limb osteoarthritis

INTRODUCTION

The video Animated Activity Questionnaire (AAQ) was developed to assess the impact of lower limb osteoarthritis (OA) on daily functional activities. The objective of the study was to compare the video and the HOOS/KOOS paper questionnaires and to assess the effect of order of administration.

MATERIAL AND METHODS

Patients recruited in the KHOALA cohort were randomized in two groups: AAQ questionnaire first (AAQ-first group) and HOOS (hip)/KOOS (knee) questionnaire first (H/KOOS-first group). Within group differences between AAQ and HOOS/KOOS scores were compared using a Student t-test. The Spearman correlation coefficient between AAQ score and HOOS/KOOS score was calculated in each group then compared, using Fisher z-transformation.

RESULTS

Among 200 randomized patients, 188 (65.8 years, 66.0% women) completed the questionnaires: 99 in the AAQ-first group and 89 in the H/KOOS-first group. The AAQ score was 85.9 (SD: 13.7) in the AAQ-first versus 87.8 (SD: 13.1) in the H/KOOS-first group (p = 0.34). The H/KOOS score was 72.5 (SD: 21.2) in the AAQ-first versus 73.5 (SD: 18.4) in the H/KOOS-first group (p = 0.71). The Spearman correlation coefficient between AAQ and H/KOOS in the AAQ-first was 0.84[0.77-0.89] and 0.73[0.61-0.81] in H/KOOS-first group. These correlations differed between groups significantly (p = 0.02).

CONCLUSION

This study found video AAQ and paper HOOS/KOOS questionnaire highly correlated, with a moderate but significant effect of order administration of video and paper questionnaires evidencing a stronger correlation when the videos were viewed first.

Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea)

Background: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and bacterial vaginosis have been associated with preterm birth and low birth weight, and are highly prevalent among pregnant women in many low- and middle-income settings. There is conflicting evidence on the potential benefits of screening and treating these infections in pregnancy. Newly available diagnostic technologies make it possible, for the first time, to conduct definitive field trials to fill this knowledge gap. The primary aim of this study is to evaluate whether antenatal point-of-care testing and immediate treatment of these curable sexually transmitted and genital infections (STIs) leads to reduction in preterm birth and low birth weight.

Methods: The Women and Newborn Trial of Antenatal Interventions and Management (WANTAIM) is a cluster-randomised crossover trial in Papua New Guinea to compare point-of-care STI testing and immediate treatment with standard antenatal care (which includes the WHO-endorsed STI ‘syndromic’ management strategy based on clinical features alone without laboratory confirmation). The unit of randomisation is a primary health care facility and its catchment communities. The primary outcome is a composite measure of two events: the proportion of women and their newborns in each trial arm, who experience either preterm birth (delivery <37 completed weeks of gestation as determined by ultrasound) and/or low birth weight (<2500 g measured within 72 hours of birth). The trial will also evaluate neonatal outcomes, as well as the cost-effectiveness, acceptability and health system requirements of this strategy, compared with standard care.

Conclusions: WANTAIM is the first randomised trial to evaluate the effectiveness, cost-effectiveness, acceptability and health system requirements of point-of-care STI testing and treatment to improve birth outcomes in high-burden settings. If the intervention is proven to have an impact, the trial will hasten access to these technologies and could improve maternal and neonatal health in high-burden settings worldwide.

Registration: ISRCTN37134032.

Point-of-care testing and treatment of sexually transmitted infections to improve birth outcomes in high-burden, low-income settings: Study protocol for a cluster randomized crossover trial (the WANTAIM Trial, Papua New Guinea)

Background: Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis and bacterial vaginosis have been associated with preterm birth and low birth weight, and are highly prevalent among pregnant women in many low- and middle-income settings. There is conflicting evidence on the potential benefits of screening and treating these infections in pregnancy. Newly available diagnostic technologies make it possible, for the first time, to conduct definitive field trials to fill this knowledge gap. The primary aim of this study is to evaluate whether antenatal point-of-care testing and immediate treatment of these curable sexually transmitted and genital infections (STIs) leads to reduction in preterm birth and low birth weight. Methods: The Women and Newborn Trial of Antenatal Interventions and Management (WANTAIM) is a cluster-randomised crossover trial in Papua New Guinea to compare point-of-care STI testing and immediate treatment with standard antenatal care (which includes the WHO-endorsed STI 'syndromic' management strategy based on clinical features alone without laboratory confirmation). The unit of randomisation is a primary health care facility and its catchment communities. The primary outcome is a composite measure of two events: the proportion of women and their newborns in each trial arm, who experience either preterm birth (delivery <37 completed weeks of gestation as determined by ultrasound) and/or low birth weight (<2500 g measured within 72 hours of birth). The trial will also evaluate neonatal outcomes, as well as the cost-effectiveness, acceptability and health system requirements of this strategy, compared with standard care. Conclusions: WANTAIM is the first randomised trial to evaluate the effectiveness, cost-effectiveness, acceptability and health system requirements of point-of-care STI testing and treatment to improve birth outcomes in high-burden settings. If the intervention is proven to have an impact, the trial will hasten access to these technologies and could improve maternal and neonatal health in high-burden settings worldwide. Registration: ISRCTN37134032.

Notizen: Hexa(isocyanato)disilan / Hexa(isocyanato)disilane

The new compound hexa(isothiocyanato)-disilane, Si2(NCO)6, is prepared by reaction of Si2Bre and AgNCO in toluene, and is characterized by mass, vibrational as well as UV spectra.

[Exercise therapy in hip or knee osteoarthritis]

"Exercise is medicine": exercise therapy reduces pain and activity limitations in osteoarthritis of the knee and is likely to have the same effects in osteoarthritis of the hip. Further research into exercise therapy is needed, since disease-modifying drugs are not available, pain medication can cause side effects, and surgical interventions are preferably applied in an advanced stage of disease. Classical exercise therapy is aimed at improving muscle strength, aerobic capacity, range of joint motion, and training of walking and activities of daily living. New modalities of targeted exercise therapy are currently being developed, aimed at the correction of low levels of activity and to correct instability of the knee. Weight loss, preferably combined with exercise therapy, reduces pain and activity limitations in osteoarthritis patients who are overweight. Modalities of exercise therapy adapted to comorbid conditions are currently being developed.

How good is fetal weight estimation using volumetric methods?

PURPOSE

Birth weight is an important predictive parameter for neonatal morbidity and mortality, and accurate estimation of fetal weight is therefore a valuable tool for determining the further obstetric management. Many sonographic weight formulas have been introduced. Most of these widely accepted formulas were derived from non-linear regression analysis. Only few formulas have been constructed using other methods, such as the physically based volumetric method based on routine two-dimensional biometric parameters in the fetus. The rationale for calculating fetal weight from volumetric measurements was that weight should to be directly proportional to fetal volume. In a recent review by Dudley, this method was considered to have some advantages in comparison with conventional regression formulas. However, to the best of our knowledge, none of the published volumetric formulas has ever been evaluated in a large population of fetuses. The aim of this study was to compare the volumetry-based formulas with widely accepted weight equations derived from regression analysis. We evaluated weight equations over the whole weight range and in specific weight groups in order to find out whether some equations were preferable in the groups tested.

MATERIALS AND METHODS

3975 pregnancies were included in order to evaluate four conventional formulas and four formulas based on volumetric models. The inclusion criteria were a singleton pregnancy, ultrasound examination with complete biometric parameters within 7 days before delivery, and an absence of structural or chromosomal malformations. The equations were compared over the whole weight range and in specific weight groups.

RESULTS

Over the whole weight range, no single formula was able to offer a substantial advantage. In the small fetus, the Hadlock formula was preferable due to its low level of systematic error. For mid-sized fetuses, the Schild formula should be considered. In macrosomic fetuses, all formulas tended to underestimate the actual birth weight. Here, the best accuracy was achieved using the Merz formula.

CONCLUSION

Neither a volumetric formula nor a conventional formula proved to be superior over the whole weight range. Within specific weight groups, some formulas showed improved accuracy. However, new approaches such as three-dimensional ultrasonography need to be pursued further in order to achieve better results in fetal weight estimation.

Influence of antihypertensive therapy and blood pressure control on left ventricular geometry and function in subjects with type II diabetes: The Augsburg Diabetes Family Study

Cross-sectional data often fail to show beneficial effects of antihypertensive therapy in patients with hypertension. We, therefore, examined the influence of hypertension control on left ventricular (LV) structure in diabetic persons separated into those having and not having any known cardiovascular disease (CVD) symptoms. The study population consisted of 394 subjects with type II diabetes. According to the presence of CVD, subjects were classified as symptomatic (N=181) or asymptomatic (N=213). In addition, three groups were differentiated: controlled hypertensives (CHs), that is, known hypertension with normal blood pressure (BP), uncontrolled hypertensives (UHs), that is, elevated BP regardless of antihypertensive medication, and normotensives (Ns). Symptomatic subjects showed a significantly higher prevalence of LV hypertrophy (LVH) (34.5 vs 23.4%, P<0.02). In contrast to symptomatic subjects where hypertension control status had no further significant impact on LV geometry, a considerable impact on preservation of normal LV geometry was observed in asymptomatic persons (LVH of 30, 15 and 18% in UH, CH and N, respectively, P<0.001). Control of hypertension in early diabetes seems especially to prevent the development of concentric hypertrophy (24 vs 11% in UH vs CH, P<0.04). In conclusion, in subjects with diabetes and CVD, the prevalence of LV structural abnormalities is very high. Although in this population-based study setting, in the latter group BP control does not seem to positively influence LV mass and function, hypertension control in still asymptomatic diabetic persons is beneficial and has a considerable impact on preservation of normal LV geometry.

Spill-over of European Bat Lyssavirus Type 1 into a Stone Marten (Martes foina) in Germany

European bat lyssavirus type 1 (EBLV-1, genotype 5) is known to endemically circulate in insectivorous bat populations in Germany. In August 2001, a rabies suspect stone marten (Martes foina) was found in the city of Burg (Saxony-Anhalt, Germany) and was sent to the regional veterinary laboratory for routine rabies diagnosis. Whereas brain samples repeatedly tested negative in the fluorescent antibody test for classical rabies virus (genotype 1), the mouse inoculation test and the rabies tissue culture inoculation test yielded positive results. Rabies viral RNA was also detected in the stone marten brain sample both by nested and heminested RT-PCR specific for the nucleoprotein gene and for the nucleoprotein phosphoprotein junction of rabies virus. The amplification products were sequenced to genotype the isolate. Sequence data obtained from the first-round RT-PCR products were analysed and the suspect stone marten isolate was confirmed as a rabies related virus (EBLV-1a). Phylogenetic comparison with sequences from recent genotype five isolates from Germany and Denmark showed that it was closely related to a previous isolate of EBLV-1 from a serotine bat in Saxony-Anhalt obtained in the same year in an area adjacent to the place where the EBLV-1 infected stone marten was found. Both EBLV-1 isolates share a 99.5% identity. This is the first report of an EBLV-1a spill-over from an insectivorous bat into wildlife in Europe.

Human immunodeficiency virus and other sexually transmitted infections among female sex workers in two major cities in Papua New Guinea

BACKGROUND

Treatable sexually transmitted infections are very common in developing countries and quite often are inadequately treated or remain untreated despite the fact that they enhance the transmission of human immunodeficiency virus (HIV).

GOAL

To estimate the prevalence of HIV, syphilis, chlamydial infection, gonorrhea, and trichomoniasis among female sex workers in Port Moresby and Lae, Papua New Guinea, and to collect data on associated behaviors.

STUDY DESIGN

Self-identified female sex workers recruited through our peer-mediated sexually transmitted disease (STD)/HIV risk-reduction community outreach program were invited to participate in the study. Participants underwent pretest counseling, were interviewed, and were asked to self-collect vaginal swab specimens for the detection of STDs and to provide 10 mL of blood for HIV and syphilis testing.

RESULTS

A total of 407 female sex workers, 207 in Port Moresby and 200 in Lae, were enrolled in the study. The overall prevalence rates of HIV, syphilis, genital chlamydial infection, gonorrhea, and trichomoniasis among these women were estimated to be 10%, 32%, 31%, 36%, and 33%, respectively. The sex workers in Port Moresby had a significantly higher HIV infection rate (17%) than those in Lae (3%) and a significantly lower trichomoniasis rate (21%) than those in Lae (44%). Mixed infections were common, occurring in 45% of the cases. Despite a high rate of symptoms, the rate of treatment-seeking was low. Condom use among the sex workers was very inconsistent; 85% reported that they did not use condoms at all times when having sex with their clients. Common reasons cited were dislike by clients, unavailability, alcohol use, and familiarity with a client.

CONCLUSIONS

STDs are very common among female sex workers in Port Moresby and Lae and very often present as multiple infections. Despite STD/HIV awareness campaigns, unsafe sex-particularly irregular use of condoms-continues among sex workers and their clients. Barriers to safer sexual behavior need to be addressed, as do improvements in provision of STD services.

Tumor progression of skin carcinoma cells in vivo promoted by clonal selection, mutagenesis, and autocrine growth regulation by granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor

Tumor microenvironment is crucial for cancer growth and progression as evidenced by reports on the significance of tumor angiogenesis and stromal cells. Using the HaCaT/HaCaT-ras human skin carcinogenesis model, we studied tumor progression from benign tumors to highly malignant squamous cell carcinomas. Progression of tumorigenic HaCaT-ras clones to more aggressive and eventually metastatic phenotypes was reproducibly achieved by their in vivo growth as subcutaneous tumors in nude mice. Their enhanced malignant phenotype was stably maintained in recultured tumor cells that represented, identified by chromosomal analysis, a distinct subpopulation of the parental line. Additional mutagenic effects were apparent in genetic alterations involving chromosomes 11 and 2, and in amplification and overexpression of the H-ras oncogene. Importantly, in vitro clonal selection of benign and malignant cell lines never resulted in late-stage malignant clones, indicating the importance of the in vivo environment in promoting an enhanced malignant phenotype. Independently of their H-ras status, all in vivo-progressed tumor cell lines (five of five) exhibited a constitutive and stable expression of the hematopoietic growth factors granulocyte colony-stimulating factor and granulocyte-macrophage colony-stimulating factor, which may function as autocrine/paracrine mediators of tumor progression in vivo. Thus, malignant progression favored by the in vivo microenvironment requires both clonal selection of subpopulations adapted to in vivo growth and mutational events leading to stable functional alterations.

Two mutations in the IV/S4-S5 segment of the human skeletal muscle Na+ channel disrupt fast and enhance slow inactivation

Fast and slow inactivation (FI, SI) of the voltage-gated Na+ channel are two kinetically distinct and structurally dissociated processes. The voltage sensor IV/S4 and the intracellular IV/S4-S5 loop have been shown to play an important role in FI mediating the coupling between activation and inactivation. Two mutations in IV/S4-S5 of the human muscle Na+ channel, L1482C/A, disrupt FI by inducing a persistent Na+ current, shifting steady-state inactivation in the depolarizing direction and accelerating its recovery. These effects were more pronounced for L1482A. In contrast, SI of L1482C/A channels was enhanced showing a more complete SI and a 3-fold slowing of its recovery. Effects on SI were more pronounced for L1482C. The results indicate an important role of the IV/S4-S5 loop not only in FI but also in SI of the Na+ channel.

A human muscle Na+ channel mutation in the voltage sensor IV/S4 affects channel block by the pentapeptide KIFMK

1. Whole cell patch clamping of transfected HEK293 cells was used to examine the effects of a pentapeptide (KIFMK) containing the proposed inactivation particle of the Na+ channel on two mutations causing myotonia. One mutation (R1448P) is located in the voltage sensor IV/S4, and the other one (G1306E) near the postulated inactivation gate within the III-IV linker. 2. In the absence of peptide, currents of wild-type (WT) and mutant human muscle Na+ channels decayed monoexponentially with inactivation time constants that were 5-fold (R1448P) and 3-fold (G1306E) larger for the mutants. Upon intracellular application of KIFMK (0.3-1 mM) the current decay became biexponential with an additional fast decaying component that increased in amplitude with depolarization. 3. Furthermore, the peptide induced large tail currents upon repolarization, indicating that KIFMK prevents inactivation by blocking open Na+ channels. The peak of this tail current decreased only slowly with depolarizations of increasing duration. The voltage dependence of this decline indicated that the dissociation rate of the charged peptide decreased with depolarization. Increased external [Na+] ([Na+]e) antagonized block by KIFMK, consistent with a pore-blocking mechanism. 4. The results are discussed with regard to a three-state model for one open, an absorbing inactivated and one blocked state with voltage-dependent on- and off-rates for peptide binding. The peptide had qualitatively similar effects on WT and both mutants, indicating that the freely diffusible peptide accelerates the current decay in all three clones. However, for the R1448P mutation the affinity for KFIMK was decreased and the voltage dependence of peptide block was changed in a similar way to the voltage dependence of inactivation. These data suggest that the mutation R1448P affects the voltage-dependent formation of a receptor site for both the inactivation particle and KIFMK.

Detection of karyotypic aberrations in acute myeloblastic leukaemia: a prospective comparison between PCR/FISH and standard cytogenetics in 140 patients with de novo AML

In 140 patients with de novo acute myeloid leukaemia (AML) standard cytogenetics were compared with RT-PCR for the detection of t(8;21), t(15;17) and inv(16) and fluorescence in situ hybridization (FISH) for numerical aberrations of chromosomes 7, 8, X and Y. RT-PCR detected 18 cases with t(8;21), 12 with t(15;17) and seven with inv(16). In two cases with t(8;21), two with t(15;17) and four with inv(16) these aberrations had not been detected by standard cytogenetics. There were no false negative PCR results. In 12 patients with these chromosomal changes, standard cytogenetics revealed additional chromosomal aberrations. In 16 patients sole numerical aberrations of the chromosomes 7, 8, X or Y were found by FISH. In these patients the sensitivity of FISH and standard cytogenetics was comparable. In 87 patients no aberrations could be found by PCR and FISH whereas in 24 of these patients standard cytogenetics revealed an abnormal karyotype. These data recommend the combination of standard cytogenetics and molecular techniques to improve the sensitivity for the detection of genetic lesions in AML. Once chromosomal markers have been identified by combined analysis these markers could be used to monitor residual disease during/after chemotherapy, by RT-PCR and/or FISH.

Measurement of ovalocyte frequency in peripheral blood smears in defining ovalocytosis in Papua New Guinea

Red cell oval morphology is still the only accepted basis for the clinical or epidemiological diagnosis of ovalocytosis. Therefore it is important to know the errors when detecting and counting morphological ovalocytes. In all previous studies of ovalocytosis there was no assessment of the variation which may have occurred in classification due to smearing and staining techniques or the criteria for the diagnosis of ovalocyte morphology; nor was inter or intraobserver variation assessed. We report how different peripheral blood smear methods influence the diagnosis of ovalocytosis in populations in the Madang and East Sepik Provinces in Papua New Guinea. We also examined within and between observer variation in the quantitative assessment of ovalocytosis at x 40 and x 100 microscopy powers. A modified method of making a thin malaria blood smear gave the best preservation of red cell morphology and was adopted for the quantitative ovalocytosis studies. A special haematology smear is unnecessary. Ovalocyte frequency estimations were similar when x 40 and x 100 lenses were used, but x 40 was preferable for assessing morphology. Two observers were consistent in their findings and produced very similar results for the high-quality smears from the planned Madang survey, and rather different results for the smears from the unplanned routine Sepik survey. We conclude that measurement error for ovalocytosis assessment can be quite small and unimportant, minimized by careful planning and quality control. Otherwise measurement error is substantial and threatens validity of classification and grading of ovalocytosis.

The correlation between microscopical examination and erythrocyte band 3 (AE1) gene deletion in South-east Asian ovalocytosis

South-east Asian ovalocytosis status was determined by microscopical examination of peripheral blood samples collected from 137 individuals in Papua New Guinea. The examination was performed separately by 2 microscopists, one of whom was very experienced in examining peripheral blood films for the diagnosis of south-east Asian ovalycytosis and the other was recently trained. The samples were also analysed by polymerase chain reaction (PCR) to determine ovalocytosis status by demonstrating a 27 base pair deletion in erythrocyte band 3 protein of the affected individuals. The microscopists were unaware of each other's results and of those obtained by PCR. Generally, there was very good agreement between the results obtained by both microscopists and the PCR. Although there was considerable inter-observer variation in the final ovalocyte count between the 2 microscopists, this did not affect their ability to discriminate between ovalocytic and normocytic individuals. Taking the PCR results as the standard, for the first, more experienced observer, the most efficient ovalocyte count cut-off point was around 50%. At this ovalocyte count the sensitivity and specificity of microscopical examination were 93.6% and 92.2%, and the positive and negative predictive values 86.3% and 96.5%, respectively. The second microscopist generally underscored the ovalocyte counts and his most efficient cut-off point was 20%, with sensitivity and specificity of 85.1% and 93.3% and positive and negative predictive values of 87.0% and 92.3%, respectively.

Role in fast inactivation of the IV/S4-S5 loop of the human muscle Na+ channel probed by cysteine mutagenesis

1. In order to investigate the role in fast inactivation of the cytoplasmic S4-S5 loop of the fourth domain (IV/S4-S5) within the alpha-subunit of the adult human muscle Na+ channel, every single amino acid from R1469 to G1486 was substituted by a cysteine and the mutants were studied by functional expression in human embryonic kidney cells (tsA201) using whole-cell patch clamping. Effects following intracellular application of the sulfhydryl reagents MTSET and MTSES on the mutants were investigated. 2. Sixteen of eighteen mutants resulted in the formation of functional channels. For P1480C and N1484C, no Na+ currents could be detected in transfected cells. In the absence of sulfhydryl reagents, F1473C and A1481C slowed fast Na+ channel inactivation by 2- and 1.5-fold, respectively, and L1482C induced a steady-state Na+ current (Iss) of 3% of peak current (Ipeak) (1% for wild-type). 3. Upon application of MTSET and MTSES, changes in fast inactivation gating occurred for most of the mutants. The most dramatic destabilizing effects on fast inactivation were observed for M1476C (9-fold slowing of inactivation; Iss/Ipeak, 3.6%; +15 mV shift in steady-state inactivation; 2- to 3-fold acceleration of recovery from inactivation), A1481C (3-fold; 14%; +20 mV; no change) and F1473C (2.5-fold; 2.4%; +8 mV; 1.5-fold). Less pronounced destabilizing effects were observed for M1477C and L1479C. Strongly stabilizing effects on the inactivated state, that is a 20-30 mV hyperpolarizing shift of the inactivation curve associated with a 3- to 4-fold decrease in the rate of recovery from inactivation, occurred for T1470C, L1471C and A1474C. Almost all effects were independent of the membrane potential; however, A1474C only reacted when cells were depolarized. Significant effects on activation were not observed. 4. We conclude that the IV/S4-S5 loop plays an important role in fast inactivation of the muscle Na+ channel and may contribute to the formation of a receptor for the putative inactivation particle. The effects of sulfhydryl reagents on the various mutations suggest an alpha-helical structure of IV/S4-S5 (up to P1480) with destabilizing effects on inactivation for one cluster of amino acids (1473/76/77/79) and a stabilized inactivation at the opposite side of the helix (1470/71/74).

Subchronic exposure of cardiomyocytes to low concentrations of tumor necrosis factor alpha attenuates the positive inotropic response not only to catecholamines but also to cardiac glycosides and high calcium concentrations

The main purpose of this study was to determine the subchronic effects of low concentrations of tumor necrosis factor alpha (TNF alpha) on the inotropic response and on the cellular level of high energy phosphates of cardiomyocytes. Therefore, the inotropic response of cultured neonatal rat heart cells to 10(-5) M isoproterenol-, 10(-6) M ouabain-, 10(-5) M forskolin- and 2,4 mM calcium-perfusion was studied 24 h after exposure to TNF alpha (0.01/0.1/1/10/100 U/ml). In parallel experiments high energy phosphates (CP, ATP, ADP, AMP) were determined by high performance liquid chromatography. Furthermore, the reversibility of TNF alpha-induced changes was studied after washout of TNF alpha or after administration of anti-TNF alpha-antibody. Whereas control cells showed an increase of cell wall motion to 150 +/- 5% of baseline value during 10(-5) M isoproterenol-perfusion respectively 180 +/- 7% during 2,4 mM calcium-perfusion, 24 h exposure of the cells to 1 U/ml up to 100 U/ml TNF alpha resulted in an inhibition of the inotropic response. Almost complete inhibition was observed 12 h after exposure to TNF alpha and was reversible 12 h after administration of the anti-TNF alpha-antibody. If the cells were perfused with 10(-6) M ouabain or 10(-5) M forskolin, a similar inhibition of the inotropic response was observed 24 h after TNF alpha-exposure. Determination of high energy phosphates showed that 24 h TNF alpha-exposure resulted in a reversible decrease of ATP, ADP, AMP and CP by 30-40% (p < 0.05). However, a similar reduction of cellular high energy phosphate levels using a TNF alpha independent mechanism (2,5 mM 2-deoxy-D-glucose) did not inhibit the inotropic response of the cardiomyocytes. From our results we conclude that subchronic exposure to low concentrations of TNF alpha resulted in an almost complete but reversible inhibition of the response of cardiomyocytes to different inotropic agents suggesting that a common final step of the inotropic cascade might be altered by TNF alpha. Though energy metabolism of TNF alpha exposed cells was affected also, reduction of high energy phosphate levels alone did not explain the observed inhibition of the inotropic response of the cardiomyocytes.

Step-wise progression in human skin carcinogenesis in vitro involves mutational inactivation of p53, rasH oncogene activation and additional chromosome loss

Two mechanisms relevant for skin carcinogenesis in man are mutational inactivation of p53 and oncogenic activation of c-rasH gene. Previously, we transfected c-rasH oncogene into human skin keratinocytes (HaCaT) with u.v.-typic mutations in both p53 alleles, which produced benign and malignant tumorigenic clones, expressing similar amounts of mutant Ras protein. Here we show that neither the ras integration site nor the karyotypic changes affects the formation of the benign or malignant tumorigenic phenotype. From the original malignant HaCaT-ras clone we took single human chromosomes, carrying the c-rasH oncogene and transferred them by microcell mediated chromosome transfer into genetically different untransfected nontumorigenic HaCaT cells. This novel approach identified the genetic background of the recipient cell as a critical determinant for the resulting tumor phenotype. Exhibiting similar oncogene expression, microcell hybrids from early passage cells remained nontumorigenic or formed benign tumors, while those with more cytogenetic aberrations (later passages) and loss of > 1 copy of chromosome 15 became malignant. Since aberrations in chromosome 15 were also detected in three of five human skin carcinoma lines this study provides evidence that p53 and c-rasH mutations are early events of human skin carcinogenesis, while loss of gene(s) on chromosome 15 is a late event.

Oct-4 transcription factor is differentially expressed in the mouse embryo during establishment of the first two extraembryonic cell lineages involved in implantation

Oct-4 is the earliest expressed gene known to encode a transcription factor which is developmentally regulated during mammalian embryogenesis. In order to understand the role of Oct-4 in early murine embryogenesis, we carried out an analysis of the temporal and spatial pattern of protein expression. We report the presence of Oct-4 protein in cultured cells and murine embryos as determined by immunohistochemistry using confocal microscopy. Oct-4 protein is present in both embryonic stem cells and embryonal carcinoma cells, but is down-regulated following differentiation of these cells by culture in the absence of leukemia inhibitory factor or in the presence of retinoic acid, respectively. In embryos, the protein is found at low levels in unfertilized eggs and is localized predominantly to the pro-nuclei upon their formation following fertilization. The protein is present in the nuclei in all cleavage stages, but following differentiation of the trophectoderm at the blastocyst stage, Oct-4 protein is only expressed in the inner cell mass. The pattern of protein expression to this stage correlates well with previously reported in situ hybridization results; however, a striking difference was seen in primitive endoderm cells which had begun to differentiate and migrate along the inner surface of the trophectoderm. In direct contrast to RNA localization studies which demonstrate that there are only low levels of Oct-4 transcripts in primitive endoderm cells, protein expression in these early migrating cells is higher than in the inner cell mass.

Differentiation ability and oncogenic potential of HPV-33- and HPV-33 + ras-transfected keratinocytes

Five HPV-33-immortalized and 5 HPV-33 + ras-transfected cell lines were characterized in terms of growth in soft agar, tumorigenic potential in nude mice, p21 expression, morphology and expression of differentiation markers in organotypic cultures. No striking differences were observed between the HPV-33-immortalized cell lines and their corresponding ras-transfected counterparts as regards their tumorigenicity in nude mice (only one cell line was able to develop tumors in nude mice) or their behavior on lifted collagen gels. However, all the ras-transfected cell lines gave rise to colonies in soft agar while only 2 HPV-33-transfected lines (CK1 and CK4) displayed this property. The 10 cell lines could be divided into 2 groups with respect to their phenotype in monolayer and in organotypic cultures. Lines from group I (CK2, 3, 5 and their ras-transfected homologous lines) shared a typical epithelial phenotype in monolayer and the ability (a) to form an epithelium similar to a CIN-III lesion and (b) to strongly express keratins K1-K10 and involucrin in organotypic cultures. On the other hand, for the lines from group II (CK1, CK4, CK1EJ7 and CK4EJ5), there was a correlation between an elongated phenotype in monolayer and the property (a) to form a structure similar to a microinvasive carcinoma and (b) to express vimentin and keratins K8-K18. These cell lines, exhibiting various transformation-associated alterations, can be considered as an in vitro model representing various stages of HPV-33-associated cervical carcinogenesis.

Preservation of regional myocardial function and myocardial oxygen tension during acute ischemia in pigs: comparison of selective synchronized suction and retroinfusion of coronary veins to synchronized coronary venous retroperfusion

OBJECTIVES

The efficacy of selective synchronized suction and retroinfusion of coronary veins was compared with synchronized coronary venous retroperfusion in preventing ischemic reduction of regional myocardial function and myocardial oxygen tension.

BACKGROUND

Because incomplete protection by synchronized coronary venous retroperfusion during ischemia might result from nonselective retroinfusion and only passive drainage of the veins, a suction device was added to a retroinfusion system.

METHODS

Regional myocardial function (ultrasonic crystals) and myocardial oxygen tension (polarographic electrodes) were studied in 30 pigs during 10-min occlusion of the left anterior descending coronary artery (ischemia), followed by reperfusion. During ischemia, group A (n = 10) was supported by selective synchronized suction and retroinfusion; group B (n = 10) was supported by synchronized coronary venous retroperfusion, and group C (n = 10) was not supported by retroinfusion.

RESULTS

In group A, subendocardial segment shortening decreased from 21 +/- 4% (mean +/- SD) before ischemia to 11 +/- 5% during ischemia. In contrast, systolic dyskinesia was observed in group B (-2 +/- 4%, p < 0.001) and group C (-2 +/- 5%, p < 0.001). During ischemia, the decrease in intramyocardial oxygen tension was less pronounced in group A (41 +/- 15 vs. 27 +/- 12 mm Hg) than in group B (40 +/- 10 vs. 19 +/- 10 mm Hg, p = 0.1) or group C (33 +/- 11 vs. 12 +/- 8 mm Hg, p = 0.002). During ischemia, myocardial surface oxygen tension was preserved > 0 mm Hg only in group A.

CONCLUSIONS

Preservation of regional myocardial function and myocardial oxygen tension was substantially higher by selective synchronized suction and retroinfusion of coronary veins than by synchronized coronary venous retroperfusion in pigs.

Mouse Oct-1 contains a composite homeodomain of human Oct-1 and Oct-2

Members of the Oct family of transcription factors specifically interact with the octamer motif, ATGC-AAAT, a regulatory element important for tissue- and cell-specific transcription as well as for the expression of housekeeping genes. Except for Oct-1, all Oct factors are expressed in a temporally and spatially restricted mode during murine development and their number varies in a given cell type. Despite its ubiquitous expression pattern Oct-1 may play a role in murine development. As a first step towards elucidating the role of Oct-1 we report the complementary DNA cloning of the mouse Oct-1 gene. Two large transcripts of 5 and 14 kb are derived from a single gene. The expression patterns of three splicing products of Oct-1 are similar in a number of cells and tissues. In the POU region murine Oct-1 differs in four amino acids from the human homologue and these differences are restricted to helices 1 and 2. Interestingly, two of the four variant amino acids are identical to those in human and mouse Oct-2 and thus the murine Oct-1 homeodomain is intermediary in sequence between human Oct-1 and Oct-2. These two amino acids together with a third one have been shown to be relevant for the interaction between human Oct-1 and herpes simplex virus transactivator VP16. Nevertheless, VP16 interacts albeit weakly with murine Oct-1. We speculate that the differences in the human and mouse Oct-1 homeodomains reflect host-specific differences in protein-protein interactions.

Interchain cysteine bridges control entry of progesterone to the central cavity of the uteroglobin dimer

The progesterone-binding protein uteroglobin has been expressed in Escherichia coli in an unfused, soluble form. Like mature uteroglobin from rabbit endometrium (UG), the E.coli produced uteroglobin (UG1) dimerizes in vitro, forms an antiparallel dimer with Cys3-Cys69' and Cys69-Cys3' disulfide bonds and binds progesterone under reducing conditions. In order to analyze the dimerization and the reduction dependence of progesterone binding in more detail, we separately replaced cysteine 3 and cysteine 69 by serines. Under reducing conditions, both uteroglobin variants (UG1-3Ser and UG1-69Ser) bind progesterone with the same affinity as the wild-type suggesting that both cysteine residues are not directly involved in progesterone binding. In contrast to the wild-type protein, both cysteine variants also bind progesterone with high affinity in the absence of reducing agents. In addition, UG1-3Ser and UG1-69Ser both form covalently linked homodimers. Thus, unnatural Cys69-69' and Cys3-3' disulfide bonds exist in UG1-3Ser and UG1-69Ser, respectively. These data together with computer models based on X-ray diffraction data strongly support the idea that progesterone reaches its binding site located in an internal hydrophobic cavity via a hydrophobic tunnel along helices 1 and 4. Under non-reducing conditions the tunnel is closed by two disulfide bridges (Cys3-Cys69' and Cys69-Cys3') that lie in the most flexible region of the dimer. Reduction or replacement of a cysteine residue enables conformational changes that open the channel allowing progesterone to enter.

Expression of the uteroglobin promoter in epithelial cell lines from endometrium

To understand the molecular mechanism of endometrial differentiation we have initiated an analysis of the uteroglobin promoter. Uteroglobin is normally expressed in endometrial tissues under the control of ovarian hormones. In gene transfer experiments with the Ishikawa cell line, derived from a human endometrial adenocarcinoma, we have identified several regions in the promoter of the uteroglobin gene that are responsible for its endometrium-specific expression. To evaluate the generality of these findings, we have begun cloning the promoter regions of potential endometrial markers, including the rat, mouse, and human uteroglobin gene. In the rat, expression of the uteroglobin-like gene, CC10, is dominant in the lung but is also observed in the endometrium of progesterone treated animals. A comparison of the 5'-flanking sequence of the rat and rabbit uteroglobin gene resulted in the detection of similarities and differences that could explain their differential expression in vivo. To substantiate these findings we have established several cell lines from rat endometrium using murine retroviral vectors containing a positive selection marker and various viral oncogenes, such as SV40 large T antigen, adenovirus E1A, and Ha-ras. Cell lines immortalized by SV40 T-antigen were subsequently transformed with the Ha-ras oncogene. Several cell lines exhibit properties of epithelial endometrial cells. Two cell lines generated with a temperature sensitive mutant of the SV40 large T-antigen grow as transformed cells at the permissive temperature, but differentiate upon shifting to the non-permissive temperature. These rat endometrial cell lines should be useful for the analysis of endometrium-specific gene expression and as model systems for endometrial carcinoma.

Identification of residues essential for progesterone binding to uteroglobin by site-directed mutagenesis

In order to identify amino acids directly involved in progesterone binding to rabbit uteroglobin we have mutated Phe 6, Tyr 21 and Thr 60 by site-directed mutagenesis of the uteroglobin cDNA. These residues have been postulated previously to participate in progesterone binding. High-level expression of the mutated uteroglobin cDNAs in Escherichia coli yields recombinant protein mutants that, like natural uteroglobin, form stable dimers, suggesting that the tertiary structure of the protein has not been altered. Substitution of Phe 6 by Ser or Ala does not change the progesterone binding characteristics. In contrast, replacement of Tyr 21 by Phe or Ala, drastically decreases progesterone binding. In addition, replacement of Thr 60 by Ala reduces the affinity for progesterone by a factor of three. These data suggest a direct interaction of progesterone with these two amino acids and support the idea of direct hydrogen bonding of the carbonyl (C3 and C20) of progesterone with the hydroxyl groups of Tyr 21 and Thr 60, respectively.

Karyotypic characterization of established cell lines derived from a squamous cell carcinoma and an adenocarcinoma of human lung cancers

Two non-small cell carcinoma cell lines from the major histopathologic groups of human lung cancers have been karyotyped: HS-24 was established from a squamous cell carcinoma, and SB-3 was obtained from a metastasis of a poorly differentiated adenocarcinoma. Endoreduplication is characteristic for both cell lines. Subsequent loss of chromosomes led finally to hypotetraploid karyotypes with modal chromosome numbers of 66-68 and 70-72 for HS-24 and SB-3, respectively. The structural analysis was performed by G- and C-banding. Stable overrepresentation of chromosomes 7, 8, 12, and 16 was found. Both cell lines developed a characteristic set of disomic and stable markers. Chromosomes involved in markers were 1, 2, 5, 6, 10, 11, 16, and 17. Consistent numerical and structural normality for chromosomes 4, 18, and 21 was observed.

Recombinant rabbit uteroglobin expressed at high levels in E. coli forms stable dimers and binds progesterone

In order to express uteroglobin in Escherichia coli we have constructed a DNA coding for complete mature rabbit uteroglobin by fusing genomic sequences from the second exon of the gene to an incomplete cDNA. This DNA was inserted into various positions of the polylinker cloning region of pDS expression vectors and the uteroglobin gene was expressed in E. coli by IPTG induction. Four different uteroglobin-derived proteins were produced containing 1, 3, 5 and 7 more N-terminal amino acids than the naturally occurring mature protein. The yield of soluble protein strongly increased with increasing length of the N-terminal additions. Protein and RNA analysis showed that this variation is most likely due to progressively higher translation efficiencies of the larger recombinants. UG7, the most efficiently synthesized recombinant protein, carrying seven additional N-terminal amino acids, was purified and further characterized. Like natural uteroglobin, UG7 forms a dimer and binds progesterone with an affinity indistinguishable to the natural protein. This bacterially produced protein can be used for detailed structure-function investigations of uteroglobin.