The use of faecal microbiota transplant as treatment for recurrent or refractory Clostridioides difficile infection and other potential indications: second edition of joint British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS) guidelines

The first British Society of Gastroenterology (BSG) and Healthcare Infection Society (HIS)-endorsed faecal microbiota transplant (FMT) guidelines were published in 2018. Over the past 5 years, there has been considerable growth in the evidence base (including publication of outcomes from large national FMT registries), necessitating an updated critical review of the literature and a second edition of the BSG/HIS FMT guidelines. These have been produced in accordance with National Institute for Health and Care Excellence-accredited methodology, thus have particular relevance for UK-based clinicians, but are intended to be of pertinence internationally. This second edition of the guidelines have been divided into recommendations, good practice points and recommendations against certain practices. With respect to FMT for Clostridioides difficile infection (CDI), key focus areas centred around timing of administration, increasing clinical experience of encapsulated FMT preparations and optimising donor screening. The latter topic is of particular relevance given the COVID-19 pandemic, and cases of patient morbidity and mortality resulting from FMT-related pathogen transmission. The guidelines also considered emergent literature on the use of FMT in non-CDI settings (including both gastrointestinal and non-gastrointestinal indications), reviewing relevant randomised controlled trials. Recommendations are provided regarding special areas (including compassionate FMT use), and considerations regarding the evolving landscape of FMT and microbiome therapeutics.

A111 CLINICAL AND PATHOLOGICAL OUTCOMES BETWEEN WATER EXCHANGE AND AIR INSUFFLATION USING NON-SEDATED EXTENDED FLEXIBLE SIGMOIDOSCOPY FOR AVERAGE RISK COLORECTAL CANCER SCREENING: PRELIMINARY FINDINGS FROM A RANDOMIZED CONTROL TRIAL

Background

Colorectal cancer (CRC) is Canada's third most common cancer type and represents approximately 11% of all cancer deaths. While sedated colonoscopy or flexible sigmoidoscopy (FS) continues to be considered for CRC screening, these modalities have limitations and risks. Another unevaluated screening modality, known as an extended FS (EFS), attempts to capitalize on the benefits of a FS while minimizing the risks involved with a sedated colonoscopy. EFS provides a scope-based examination up to the splenic flexure and then attempts to examine beyond, often to the point of the caecum. Providing the option for EFS may produce improvements in the patient experience and performance, which may improve the feasibility of using scope-based screening more broadly in screening programs.

Purpose

To determine the extent non-sedated EFS using the water exchange method (WE) is associated with a complete colon examination compared to the traditional air insufflation (AI) method using CO2 in an average-risk screening population.

Method

This randomized control trial included 90 non-sedated participants, screened by trained general surgery and gastroenterology clinicians at Kelowna General Hospital, British Columbia, Canada, using two different scope insufflation techniques, WE and AI. The primary outcome of interest was the cecal intubation rates (CIR), while secondary outcomes included the adenoma detection rate (ADR) and reported pain scores. Other metrics, such as patient satisfaction rates, sessile serrated adenoma detection rates (SSADR), and serrated lesion detection rates (SLDR) were also recorded.

Result(s)

The demographic characteristics between the WE and AI groups were statistically similar, with the mean age of participants being 58 and 57, respectively. During the study period, four endoscopists performed the EFS. There were higher initial satisfaction rates in the WE group vs the AI (95% vs 77%, satisfaction of ≥ 9/10 p = 0.028). CIR and ADR were similar between the WE and AI group (CIR = 93% vs 91%, p = 0.710), (ADR = 40% vs 34%, p = 0.660). The SSADR and SLDR were also similar between the WE and AI group (SSADR = 21% vs 14%, p = 0.408), (SLDR = 42% vs 36%, p = 0.528).

Conclusion(s)

EFS without sedation using either technique exceeds quality benchmarks recommended for sedated screening colonoscopy while maintaining adequate patient safety and comfort. The WE method optimizes a patient's overall experience making a strategy of average risk colorectal cancer screening with non-sedated WE EFS feasible.

Please acknowledge all funding agencies by checking the applicable boxes below

CAG, Other

Please indicate your source of funding;

Kelowna General Hospital, Interior Health

Disclosure of Interest

None Declared

TNFR2 blockade of regulatory T cells unleashes an antitumor immune response after hematopoietic stem-cell transplantation

Background

Targeting immune checkpoints that inhibit antitumor immune responses has emerged as a powerful new approach to treat cancer. We recently showed that blocking the tumor necrosis factor receptor-type 2 (TNFR2) pathway induces the complete loss of the protective function of regulatory T cells (Tregs) in a model of graft-versus-host disease (GVHD) prevention that relies on Treg-based cell therapy. Here, we tested the possibility of amplifying the antitumor response by targeting TNFR2 in a model of tumor relapse following hematopoietic stem-cell transplantation, a clinical situation for which the need for efficient therapeutic options is still unmet.

Method

We developed appropriate experimental conditions that mimic patients that relapsed from their initial hematological malignancy after hematopoietic stem-cell transplantation. This consisted of defining in allogeneic bone marrow transplantation models developed in mice, the maximum number of required tumor cells and T cells to infuse into recipient mice to develop a model of tumor relapse without inducing GVHD. We next evaluated whether anti-TNFR2 treatment could trigger alloreactivity and consequently antitumor immune response. In parallel, we also studied the differential expression of TNFR2 on T cells including Treg from patients in post-transplant leukemia relapse and in patients developing GVHD.

Results

Using experimental conditions in which neither donor T cells nor TNFR2-blocking antibody per se have any effect on tumor relapse, we observed that the coadministration of a suboptimal number of T cells and an anti-TNFR2 treatment can trigger alloreactivity and subsequently induce a significant antitumor effect. This was associated with a reduced percentage of activated CD4⁺ and CD8⁺ Tregs. Importantly, human Tregs over-expressed TNFR2 relative to conventional T cells in healthy donors and in patients experiencing leukemia relapse or cortico-resistant GVHD after hematopoietic stem cell transplantation.

Conclusions

These results highlight TNFR2 as a new target molecule for the development of immunotherapies to treat blood malignancy relapse, used either directly in grafted patients or to enhance donor lymphocyte infusion strategies. More widely, they open the door for new perspectives to amplify antitumor responses against solid cancers by directly targeting Tregs through their TNFR2 expression.

Radiation Therapy Department Reorganization during the Coronavirus Disease 2019 (COVID-19) Outbreak: Keys to Securing Staff and Patients During the First Weeks of the Crisis and Impact on Radiation Therapy Practice from a Single Institution Experience

PURPOSE

During the first weeks of the coronavirus disease 2019 (COVID-19) outbreak in France, it was necessary to clearly define organizational priorities in the radiation therapy (RT) departments. In this report, we focus on the urgent measures taken to reduce risk for both our staff and patients by reducing the number of patients receiving treatment.

METHODS AND MATERIALS

We reviewed the fractionation schemes for all patients in our department, including those receiving treatment and those soon to start treatment. Our goals were to (1) decrease the number of patients coming daily to the hospital for RT, (2) adapt our human resources to continue patients' care in the department, and (3) help to cover understaffed COVID-19 sectors of the hospital.

RESULTS

We identified 50 patients who were receiving treatment (n = 6), were going to start radiation after CT scan simulation (n = 41), or for whom the CT scan was pending (n = 3). The majority were women (64%) treated for breast cancer (54%). RT was delayed for 22 (44%) patients. The majority were offered hormone therapy as "waiting therapy." Hypofractionation was considered in 21 (42%) patients mainly with breast cancer (18 of 21, 86%). The number of courses initially planned and replanned as a result of the COVID-19 outbreak during the period of March 15 to May 31, 2020, were 1383 and 683, respectively, which represented a reduction of 50% (including delayed sessions) that allowed our reorganization process.

CONCLUSIONS

To conserve resources during the pandemic, we successfully reduced the number of patients receiving treatment in a proactive fashion and adapted our organization to minimize the risk of COVID-19 contamination. Departments across the world may benefit from this same approach.

Probability-driven 3D pharmacophore mapping of antimycobacterial potential of hybrid molecules combining phenylcarbamoyloxy and N-arylpiperazine fragments

The current study examines in silico characterization of the structure-inhibitory potency for a set of phenylcarbamic acid derivatives containing an N-arylpiperazine scaffold, considering the electronic, steric and lipophilic properties. The main objective of the ligand-based modelling was the systematic study of classical comparative molecular field analysis (CoMFA)/comparative molecular surface analysis (CoMSA) performance for the modelling of in vitro efficiency observed for these phenylcarbamates, revealing their inhibitory activities against a virulent Mycobacterium tuberculosis H₃₇R_v strain. We compared the findings of efficiency modelling produced by a standard 3D methodology (CoMFA) and its neural counterparts (CoMSA) regarding multiple training/test subsets and variables used. Moreover, systematic space inspection, splitting values into the analysed training/test subsets, was performed to monitor statistical estimator performance while mapping the probability-driven pharmacophore pattern. Consequently, a 'pseudo-consensus' 3D-quantitative structure-activity relationship (3D-QSAR) approach was applied to retrieve an 'average' pharmacophore hypothesis by the investigation of the most densely populated training/test subpopulations to specify the potentially important factors contributing to the inhibitory activity of phenylcarbamic acid analogues. In addition, examination of descriptor-based similarity with a principal component analysis (PCA) procedure was employed to visualize noticeable variations in the performance of these molecules with respect to their structure and activity profiles.

In silico estimation of basic activity-relevant parameters for a set of drug absorption promoters

Finding a balance between a desired drug's potency and its physicochemical properties that are important for its molecule pharmacokinetic or pharmacodynamics profile is still a challenging issue in rational drug discovery. Quantitative assessment of the lipophilic characteristics of potential drug molecules is indispensable for efficient development of Absorption, Distribution, Metabolism, Excretion, Toxicity-tailored structure-activity models; therefore reliable procedures for deriving log P from molecular structure are desirable. In the current work a range of various software log P predictors for estimation of the numerical lipophilic values for a set of cholic acid derivatives were employed and subsequently cross-compared with the experimental parameters. Thus, the empirical lipophilicity (R_M) was compared with the corresponding log P characteristics calculated using alternative methods for deducing the lipophilic features. The mean values of the selected molecular descriptors that were averaged over the chosen calculation methods (consensus clog P) were subsequently correlated with the R_M parameter. As an additional experiment, the iterative variable elimination partial least squares (IVE-PLS) methodology for an ensemble of descriptors retrieved from Dragon 6.0 software was applied for a set of drug transporters. To investigate the variations within the ensemble of cholic acid derivatives principal component analysis (PCA) and self-organizing neural network (SOM) procedures were used to visualize the major differences in the performance of drug promoters with respect to their lipophilic profile.

Patient radiation doses and reference levels in pediatric interventional radiology

OBJECTIVES

To describe, in a multicentric paediatric population, reference levels (RLs) for three interventional radiological procedures.

METHODS

From January 2012 to March 2015, children scheduled for an interventional radiological procedure in two French tertiary centres were retrospectively included and divided into four groups according to age: children younger than 2 years (A1), aged 2-7 years (A5), 8-12 years (A10) and 13-18 years (A15). Three procedures were identified: cerebral digital subtraction angiography (DSA), brain arteriovenous malformation (bAVM) embolization, and head and neck superficial vascular malformation (SVM) percutaneous sclerotherapy. Demographic and dosimetric data, including dose area product (DAP), were collected.

RESULTS

550 procedures were included. For DSA (162 procedures), the proposed RL values in DAP were 4, 18, 12 and 32 Gy∙cm² in groups A1, A5, A10 and A15, respectively. For bAVM embolization (258 procedures), values were 33, 70, 105 and 88 Gy∙cm² in groups A1, A5, A10 and A15, respectively. For SVM sclerotherapy (130 procedures), values were 350, 790, 490 and 248 mGy∙cm² in groups A1, A5, A10 and A15, respectively.

CONCLUSION

Consecutive data were available to permit a proposal of reference levels for three major paediatric interventional radiology procedures.

KEY POINTS

• We determined reference levels (RLs) for bAVM embolization, DSA and SVM sclerotherapy. • The proposed RLs will permit benchmarking practice with an external standard. • The proposed RLs by age may help to develop paediatric dose guidelines.

Multidimensional (3D/4D-QSAR) probability-guided pharmacophore mapping: investigation of activity profile for a series of drug absorption promoters

A hybrid approach that combines 3D and 4D-QSAR methods based on grid and neural paradigms with automated IVE-PLS procedure was examined to identify the pharmacophore pattern for cholic acid derivatives as potential drug absorption promoters.

Some electrophysiological properties of developing rat skeletal myotubes grown in serum-free, chemically defined medium

Serum-free, chemically defined media have been reported to provide suitable conditions for growth and proliferation of mammalian skeletal muscle, but there is no information regarding the ability of myotubes to develop normal electrophysiological properties in these media. We have recorded transmembrane resting and action potentials from rat skeletal myotubes grown in both serum-containing (GM) and serum-free chemically defined (CDM) growth media. Muscle cells in CDM do not develop as high resting Em as their counterparts in conventional growth media. CDM myotubes also had a lower incidence and frequency of spontaneously occurring action potentials. Treatment with ouabain or decrease in temperature of the recording medium reduced resting Em of both GM and CDM cells to the same level. We found that the sensitivity of CDM cells to ouabain was about 10-fold higher than that of GM cells. An increase in temperature of the recording medium increased Em of GM myotubes but not of CDM myotubes. The change in resting Em in response to a 10-fold change in extracellular K(+)-ion concentration was the same for both groups of cells thus indicating that there was no difference in membrane permeability to K(+)-ion. We conclude that the difference in Em can be accounted for largely, if not entirely, by differences in activity or amount of electrogenic Na(+)-K(+) ATPase.

epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England

National evidence-based guidelines for preventing healthcare-associated infections (HCAI) in National Health Service (NHS) hospitals in England were originally commissioned by the Department of Health and developed during 1998-2000 by a nurse-led multi-professional team of researchers and specialist clinicians. Following extensive consultation, they were first published in January 2001(1) and updated in 2007.(2) A cardinal feature of evidence-based guidelines is that they are subject to timely review in order that new research evidence and technological advances can be identified, appraised and, if shown to be effective for the prevention of HCAI, incorporated into amended guidelines. Periodically updating the evidence base and guideline recommendations is essential in order to maintain their validity and authority. The Department of Health commissioned a review of new evidence and we have updated the evidence base for making infection prevention and control recommendations. A critical assessment of the updated evidence indicated that the epic2 guidelines published in 2007 remain robust, relevant and appropriate, but some guideline recommendations required adjustments to enhance clarity and a number of new recommendations were required. These have been clearly identified in the text. In addition, the synopses of evidence underpinning the guideline recommendations have been updated. These guidelines (epic3) provide comprehensive recommendations for preventing HCAI in hospital and other acute care settings based on the best currently available evidence. National evidence-based guidelines are broad principles of best practice that need to be integrated into local practice guidelines and audited to reduce variation in practice and maintain patient safety. Clinically effective infection prevention and control practice is an essential feature of patient protection. By incorporating these guidelines into routine daily clinical practice, patient safety can be enhanced and the risk of patients acquiring an infection during episodes of health care in NHS hospitals in England can be minimised.

Pharmacophore-based database mining for probing fragmental drug-likeness of diketo acid analogues

A number of the structurally diverse chemical compounds with functional diketo acid (DKA) subunit(s) have been revealed by combined online and MoStBiodat 3D pharmacophore-guided ZINC and PubChem database screening. We used the structural data available from such screening to analyse the similarities of the compounds containing the DKA fragment. Generally, the analysis by principal component analysis and self-organizing neural network approaches reveals four families of compounds complying with the chemical constitution (aromatic, aliphatic) of the compounds. From a practical point of view, similar studies may reveal potential bioisosteres of known drugs, e.g. raltegravir/elvitegravir. In this context, it seems that mono-halogenated aryl substructures with para group show the closest similarity to these compounds, in contrast to structures where the aromatic ring is halogenated in both ortho- and para-locations.

Analogues of the styrylquinoline and styrylquinazoline HIV-1 integrase inhibitors: design and synthetic problems

In our work, leading to new styrylquinoline and styrylquinazoline inhibitors of HIV integrase, we analyzed virtual combinatorial library that includes these compounds. Using this method we were able to find interesting synthetic targets. We optimized synthetic procedure yielding such compounds and obtained a couple of new analogues. Their activity will be evaluated in the near future.

Activation of protein kinase C zeta induces serine phosphorylation of VAMP2 in the GLUT4 compartment and increases glucose transport in skeletal muscle

Insulin stimulates glucose uptake into skeletal muscle tissue mainly through the translocation of glucose transporter 4 (GLUT4) to the plasma membrane. The precise mechanism involved in this process is presently unknown. In the cascade of events leading to insulin-induced glucose transport, insulin activates specific protein kinase C (PKC) isoforms. In this study we investigated the roles of PKC zeta in insulin-stimulated glucose uptake and GLUT4 translocation in primary cultures of rat skeletal muscle. We found that insulin initially caused PKC zeta to associate specifically with the GLUT4 compartments and that PKC zeta together with the GLUT4 compartments were then translocated to the plasma membrane as a complex. PKC zeta and GLUT4 recycled independently of one another. To further establish the importance of PKC zeta in glucose transport, we used adenovirus constructs containing wild-type or kinase-inactive, dominant-negative PKC zeta (DNPKC zeta) cDNA to overexpress this isoform in skeletal muscle myotube cultures. We found that overexpression of PKC zeta was associated with a marked increase in the activity of this isoform. The overexpressed, active PKC zeta coprecipitated with the GLUT4 compartments. Moreover, overexpression of PKC zeta caused GLUT4 translocation to the plasma membrane and increased glucose uptake in the absence of insulin. Finally, either insulin or overexpression of PKC zeta induced serine phosphorylation of the GLUT4-compartment-associated vesicle-associated membrane protein 2. Furthermore, DNPKC zeta disrupted the GLUT4 compartment integrity and abrogated insulin-induced GLUT4 translocation and glucose uptake. These results demonstrate that PKC zeta regulates insulin-stimulated GLUT4 translocation and glucose transport through the unique colocalization of this isoform with the GLUT4 compartments.

Increased IGFR activity and glucose transport in cultured skeletal muscle from insulin receptor null mice

We have studied the role of the insulin receptor (IR) in metabolic and growth-promoting effects of insulin on primary cultures of skeletal muscle derived from the limb muscle of IR null mice. Cultures of IR null skeletal muscle displayed normal morphology and spontaneous contractile activity. Expression of muscle-differentiating proteins was slightly reduced in myoblasts and myotubes of the IR null skeletal muscle cells, whereas that of the Na+/K+ pump appeared to be unchanged. Insulin-like growth factor receptor (IGFR) expression was higher in myoblasts from IR knockout (IRKO) than from IR wild-type (IRWT) mice but was essentially unchanged in myotubes. Expression of the GLUT-1 and GLUT-4 transporters appeared to be higher in IRKO than in IRWT myoblasts and was significantly greater in myotubes from IRKO than from IRWT cultures. Consistent with GLUT expression, both basal and insulin or insulin-like growth factor I (IGF-I)-stimulated glucose uptakes were higher in IR null skeletal myotubes than in wild-type skeletal myotubes. Interestingly, autophosphorylation of IGFR induced by insulin and IGF-I was markedly increased in IR null skeletal myotubes. These results indicate that, in the absence of IR, there is a compensatory increase in basal as well as in insulin- and IGF-I-induced glucose transport, the former being mediated via increased activation of the IGF-I receptor.

Na(+)/K(+) pump expression in the L8 rat myogenic cell line: effects of heterologous alpha subunit transfection

We have characterized the physiological and biochemical properties of the Na(+)/K(+) pump and its molecular expression in L8 rat muscle cells. Pump properties were measured by [(3)H]ouabain binding and (86)Rb uptake. Scatchard plot analysis of specific ouabain binding indicated the presence of a single family of binding sites with a B(max) of approximately 135 fmol/ mg P and a K(D) of 3.3 x 10(-8). (86)Rb uptake due to specific pump activity was found to be 20% of the total in L8 cells. The results indicated lower affinity of L8 cells for ouabain and lower activity of the pump than that reported for chick or rat skeletal muscle in primary culture. Both the alpha(1) and beta(1) protein and mRNA isoforms were expressed in myoblasts and in myotubes, while the alpha(2), alpha(3), and beta(2) isoforms were not detectable. We attempted to overcome low physiological expression of the Na(+)/K(+) pump by employing a vector expressing an avian high affinity alpha subunit. This allowed identification of the transfected subunit separate from that endogenously expressed in L8 cells. Successful transfection into L8 myoblasts and myotubes was recognized by anti-avian alpha subunit monoclonal antibodies. Fusion index, Na(+)/K(+) pump activity, and the level of the transmembrane resting potential were all significantly greater in transfected L8 (tL8) cells than in non-tL8. The total amount of alpha subunit (avian and rat) in tL8 cells was greater than that (only rat) in non-tL8 cells. This relatively high abundance of the Na(+)/K(+) pump in transfected cells may indicate that avian and rat alpha subunits hybridize to form functional pump complexes.

[Arteriovenous communication of the retina--case report]

In this paper I have described a rare case of typical arteriovenous communication of the retina (ACVR), also called racemose haemangioma, but with some atypical traits. A case of a young white 22-year-old woman is presented. AVCR was recognised in her left eye, II stage according to Archer's classification, therefore neither intracranial haemangioma nor vascular decompensation of retina was observed. In the standard ophthalmic examination, including automated perymetry and fluorescein angiography, the following phenomena were not seen yet or they were rarely described: pigmented muffs on some changed vessels, mainly nasal location of AVCR, parallel AVCR existed between both great and precapillar vessels and macular changes: yellowish ring surrounded the central fovea. Visual acuity of the affected eye was 1.0 and the patient did not complain about it.