Corticosteroid effects on blood gene expression in Duchenne muscular dystrophy

Though Deflazacort and prednisone improve clinical endpoints in Duchenne muscular dystrophy (DMD) patients, Deflazacort produces fewer side effects. As mechanisms of improvement and side effect differences remain unknown, we evaluated effects of corticosteroid administration on gene expression in blood of DMD patients. Whole blood was obtained from 14 children and adolescents with DMD treated with corticosteroids (DMD-STEROID) and 20 DMD children and adolescents naïve to corticosteroids (DMD). The DMD-STEROID group was further subdivided into Deflazacort and prednisone groups. Affymetrix U133 Plus 2.0 expression microarrays were used to evaluate mRNA expression. Expression of 524 probes changed with corticosteroids, including genes in iron trafficking and the chondroitin sulfate biosynthesis pathway. Deflazacort compared with prednisone yielded 508 regulated probes, including many involved in adipose metabolism. These genes and pathways help explain mechanisms of efficacy and side effects of corticosteroids, and could provide new treatment targets for DMD and other neuromuscular disorders.

Initial experience with transvaginal incisional hernia repair

INTRODUCTION

Natural orifice surgery has evolved from a preclinical setting into a common occurrence at the University of California San Diego (UCSD). With close to 40 transvaginal cases, we have become comfortable with this technique and are exploring other indications. One of the perceived advantages in natural orifice surgery is the potential reduction in the incidence of hernia formation. Patients with abdominal wall hernias may be at increased risk of forming additional hernias at incision sites. In addition, patients with recurrent incisional hernias may, likewise, be at increased risk. We believe that reducing or eliminating abdominal wall incisions may be of benefit in the repair of abdominal wall hernias. Here, we describe what we believe to be the first natural orifice transluminal endoscopic surgical (NOTES) approach to the repair of an abdominal wall hernia.

METHODS

The patient is a 38-year-old female with a painful recurrent umbilical hernia, previously repaired 8 years prior with a polypropylene-based mesh. The patient underwent a transvaginal recurrent umbilical hernia repair with one other 5-mm port in the abdomen for safety.

RESULTS

The patient had no intraoperative or postoperative complications. At 5 months follow up, the patient had no complaints, no evidence of hernia recurrence, and was very pleased with her result.

CONCLUSIONS

The repair of primary and incisional hernias of the ventral abdominal wall via a transvaginal approach is technically feasible, and the result of our initial case was exceptional. However, there are still significant obstacles which must be addressed before this approach can be widely utilized. These obstacles include safe entrance into the abdominal cavity via a transvaginal approach, the proper mesh to be placed during the repair, and the risk of infection.

Infantile cardiomyopathy caused by a mutation in the overlapping region of mitochondrial ATPase 6 and 8 genes

BACKGROUND

Infantile cardiomyopathy is a genetically heterogeneous disorder with significant morbidity and mortality.

METHODS

This study aimed to identify the mutation present in four unrelated patients who presented as infants with isolated hypertrophic cardiomyopathy.

RESULTS

In all four, a novel mitochondrial m.8528T-->C mutation was identified. This results in a change of the initiation codon in ATPase 6 to threonine and a concurrent change from a highly conserved hydrophobic amino acid, tryptophan, at position 55 of ATPase 8 to a highly basic arginine. To our knowledge, this is the first report of a mutation affecting both mitochondrial genome-encoded complex V subunit proteins. Testing of the relatives of one patient indicated that the mutation is heteroplasmic and correlated with disease.

CONCLUSION

Mitochondrial genome sequencing should be considered in patients with infantile hypertrophic cardiomyopathy.

Monitoring and treatment practices of childhood asthma in Singapore: a questionnaire study

INTRODUCTION

Asthma is the most common chronic disease in children in Singapore. More than 20 percent of children will have been diagnosed with asthma by the age of 15 years. Most children are seen in the primary care setting, thus it is of value to study the management practices, especially of general practitioners, with comparison to gold standards. The aims of the study were to investigate: (a) Methods of monitoring asthma control; (b) Practices in managing acute exacerbations; and (c) Choice of therapy in maintenance treatment.

METHODS

2,100 questionnaires consisting of 35 questions were sent by post to general practitioners and various paediatric doctors throughout Singapore. 173 valid responses were received and results were compared to the 2006 Global Initiative for Asthma guidelines.

RESULTS

76.3 percent of respondents were general practitioners. 89.1 percent did not use symptom score cards / diaries. 37.6 percent did not use peak-flow meters / spirometers. 83.8 percent used a short-acting beta-agonist in acute exacerbations, but only 41.0 percent used oral corticosteroids in outpatients. A significant number used long-acting beta-agonists (LABA) in combination with inhaled steroids (29.5-41.6 percent) or as monotherapy (5.8-8.7 percent) for maintenance treatment. 91.3 percent never used immunotherapy in practice.

CONCLUSION

Greater usage of diaries / score cards can be encouraged along with objective peak flow / spirometry measurements. Management of acute exacerbations is appropriate but corticosteroids are under-prescribed by most doctors. LABA continues to be prescribed for maintenance despite a lack of established safety profile for infants, along with recommendations that they only be used selectively in patients poorly-controlled by medium-dosage inhaled corticosteroids.

Expression of claudin-2 in the multistage process of gastric carcinogenesis

OBJECTIVE

Claudin-2 is an important component of the tight junction (TJ) of epithelial cells, and its protein expression between many tumours is significantly different. It is unclear if Claudin-2 overexpression is a trigger or a consequence during carcinogenesis. The multistage tissues of gastric carcinogenesis provides us a valuable model for determining tumourigenicity.

METHODS

This paper investigated, for the first time, claudin-2 expression in the pathological paraffin tissues of sinus ventriculi from gastroscopic biopsy. To determine claudin-2 expression in gastric carcinogenesis by immunochemical ABC technique.

RESULTS

Altogether, 108 chronic superficial gastritis, 55 chronic atrophic gastritis, 109 intestinal-type metaplasia, 93 dysplasia and 52 gastric intestinal-type adenocarcinoma samples were analyzed. Results indicated that the percentage of claudin-2-positive cases was 0% for chronic superficial gastritis (0/108), 0% for chronic atrophic gastritis (0/55), 0% for intestinal-type metaplasia (0/109), 35.87% for dysplasia (33/92), and 73.47% for gastric intestinal-type adenocarcinoma (36/49) respectively, primarily in the cell membrane, and gradually increased in the multistage process of gastric carcinogenesis (P<0.001).

CONCLUSIONS

This suggests that claudin-2 protein overexpression may be closely correlated to gastric carcinogenesis.

The impact of psychological abuse by an intimate partner on the mental health of pregnant women

Objective

The objective of this first population-based study in Hong Kong was to assess the impact of psychological abuse by an intimate partner on the mental health of pregnant women.

Design

Survey.

Setting

Antenatal clinics in seven public hospitals in Hong Kong.

Population

Three thousand two hundred and forty-five pregnant women.

Methods

The Abuse Assessment Screen (AAS) and demographic questionnaires were administered face-to-face at 32–36 weeks of gestation. At 1 week postpartum, the AAS, Edinburgh Postnatal Depression Scale and SF-12 Health Survey were administered by telephone.

Main outcome measures

Intimate partner violence, postnatal depression and health-related quality of life.

Results

Two hundred and ninety six (9.1%) of the participants reported abuse by an intimate partner in the past year. Of those abused, 216 (73%) reported psychological abuse only and 80 (27%) reported physical and/or sexual abuse. Forty six (57.5%) in the physical and/or sexual abuse group also reported psychological abuse. Women in the psychological abuse only group had a higher risk of postnatal depression compared with nonabused women (adjusted OR: 1.84, 95% CI: 1.12–3.02). They were also at a higher risk of thinking about harming themselves (adjusted OR: 3.50, 95% CI: 1.49–8.20) and had significantly poorer mental health-related quality of life (P < 0.001). The higher risks of postnatal depression and thinking of harming themselves were not observed in the physical and/or sexual abuse group although significantly poorer mental health-related quality of life (P < 0.001) was observed.

Conclusions

Psychological abuse by an intimate partner against pregnant women has a negative impact on their mental health postdelivery. Furthermore, psychological abuse in the absence of physical and/or sexual abuse can have a detrimental effect on the mental health of abused women. The findings underscore the importance of screening pregnant women for abuse by an intimate partner and the need for developing, implementing and evaluating interventions to address psychological abuse.

Please cite this paper as: Tiwari A, Chan K, Fong D, Leung W, Brownridge D, Lam H, Wong B, Lam C, Chau F, Chan A, Cheung K, Ho P. The impact of psychological abuse by an intimate partner on the mental health of pregnant women. BJOG 2008;115:377–384.

Immunoreactivity profile of peripheral blood mononuclear cells from patients with ragweed-induced allergic rhinitis

BACKGROUND

Seasonal rhinitis is manifested by a series of nasal symptoms in response to exposure to seasonal allergens including ragweed pollen. Understanding its immunological mechanisms may help to better manage the disease.

OBJECTIVE

We sought to determine comprehensively ragweed-induced cytokine and chemokine production by peripheral blood mononuclear cells from normal individuals and patients with seasonal rhinitis sensitized to ragweed pollen, and to assess its regulation by exogenous IL-10.

METHODS

Cells were cultured in the presence or absence of a purified ragweed pollen extract with or without exogenous IL-10. Cytokines and chemokines were measured in the supernatant. Gene expression was evaluated using real-time quantitative reverse transcription PCR.

RESULTS

Ragweed stimulation significantly increased the production of the Th2-associated cytokines IL-5, IL-9 and IL-13, the chemokines CCL17 and CCL22 and the regulatory cytokine IL-10 in allergic patients, whereas transforming growth factor-beta (TGF-beta) production was increased only in normal individuals. No difference was detected between groups in the production of the Th1 cytokine IFN-gamma or the Th1-affiliated chemokines CXCL10 and CXCL11. Exogenous IL-10 significantly suppressed spontaneous and induced production of both Th1- and Th2-associated cytokines and chemokines.

CONCLUSION

Our work demonstrated that locally manifested allergic rhinitis is underlined by a systemic Th2 immune response specific to allergens. The molecular pathogenesis of allergic rhinitis may be linked to a compromised allergen-specific immune regulation, e.g., reduced spontaneous and allergen-induced TGF-beta production in patients compared with healthy controls. Our data also show that IL-10 inhibits both the effector and directional mechanisms of allergen-specific immune response, further supporting its potential therapeutic benefit in preventing and treating allergic diseases.

Hypercytokinemia and hyperactivation of phospho-p38 mitogen-activated protein kinase in severe human influenza A virus infection

BACKGROUND

We postulate that hypercytokinemia plays a role in immunopathogenesis of severe human influenza.

METHODS

We prospectively studied 39 consecutive patients who were hospitalized with severe influenza A virus infection. On laboratory confirmation of the diagnosis, paired acute-phase (obtained at hospital admission) and convalescent-phase (obtained >10 days after hospital admission) plasma samples were collected for assay of 11 cytokines and chemokines (interleukin [IL] 1 beta; IL-6; IL-10; IL-12p70; tumor necrosis factor alpha; IL-8; monokine induced by interferon [IFN]-gamma; IFN-inducible protein 10; monocyte chemoattractant protein 1; regulated upon activation, normal T cell-expressed and secreted; and IFN-gamma) using cytometric bead-array analysis and enzyme-linked immunosorbent assay. Simultaneously, virus concentration in the acute-phase nasopharyngeal aspirate was determined using real-time quantitative reverse-transcriptase polymerase chain reaction. Intracellular signaling molecules regulating lymphocyte activation, phospho-p38 mitogen-activated protein kinase and phospho-extracellular signal-regulated protein kinase in CD4+ and CD8+ T lymphocytes were studied in the acute-phase samples using flow cytometric analysis and were compared with results for samples from healthy control subjects.

RESULTS

Statistically significant increases in plasma IL-6 (3.7-fold increase), IL-8 (2.6-fold increase), IFN-induced protein 10 (4.9-fold increase), and monokine induced by IFN-gamma (2.3-fold increase) concentrations were detected during acute illness (P < .01 for all, by Wilcoxon signed-rank test); the highest concentrations were observed on symptom days 3 and 4. Corresponding plasma cytokine and chemokine concentrations and nasopharyngeal viral loads showed statistically significant correlations (rho = 0.41, 0.49, 0.54, and 0.46, respectively; P < or = .01). Phospho-p38 mitogen-activated protein kinase expression in CD4+ lymphocytes was increased, correlating with cytokine concentrations (e.g., for IFN-induced protein 10, rho = 0.78; P < .01); phospho-extracellular signal-regulated protein kinase was suppressed. Advanced age and comorbidity were associated with aberrant IL-6, IL-8, and monokine induced by IFN-gamma responses (P < .05, by Mann-Whitney U test). An elevated IL-6 concentration was independently associated with prolonged hospitalization (hospitalization for >5 days; P = .02), adjusted for age, comorbidity, and virus load.

CONCLUSIONS

Hypercytokinemia (of proinflammatory and T helper 1 cytokines) is detected in severe influenza, correlating with clinical illness and virus concentration. Hyperactivation of phospho-p38 mitogen-activated protein kinase (in T helper cells) is possibly involved. Early viral suppression may attenuate these potentially deleterious cytokine responses.

Pharmacodynamic and safety study of reolysin in patients with advanced solid tumors

14004

Background: Reolysin is an intravenous formulation of reovirus serotype 3 - Dearing strain which is a double stranded RNA non-enveloped icosahedral virus capable of inducing cytopathic effects in cancer cells that have an activating mutation in the ras protooncogene. Pre clinical testing has identified cancer cell lines as being susceptible to reovirus infection. Methods: This was an open- label single center phase I safety and dose escalation trial of reolysin administered intravenously over 1 hour on day 0 in a 28 day cycle. Dose escalations were in half log increments. Serum for neutralizing antibody (NA) was drawn at baseline, and days (d) 1, 7, 14, 21, and 28, and serum, stool, saliva, and urine for viral shedding (by RT-PCR) were sampled on d 1,7,14,21, and 28. Response was assessed by imaging studies after 1, 3, 5, and 7 cycles. Results: 18 patients (pt); median age 57 (40–72) years; performance status 0–1; diagnoses - ovarian (6), colorectal (5), and others (7) received 27 cycles of reolysin (median 1, range 1–7) in 6 dose cohorts of 1x108, 3x108, 1x109, 3x109, 1x1010, and 3x1010 tissue culture infective dose (TCID)50. No protocol defined dose limiting toxicities were observed. Drug related grade 2 toxicities included chills (2 pt), and fatigue (3 pt). The only grade 3 event was fever in cycle 7 in a 57 year old woman with progressive breast cancer, treated at a dose of 1x1010 TCID50. She was noted to have 28.5% shrinkage in objective tumor volume. An additional 7 pt had stable disease (SD). No NA was detectable in the serum in any pt at baseline; however all pt developed NA (on d 5 in 5 pt, d 8 in 11 pt, d 14 in 1 pt, and d 28 in 1 pt) during the course of the study. Viral shedding was observed in serum - 5 pt, stool - 3 pt, saliva - 3 pt, and urine - 4 pt. Of interest, 4 of 5 pt with viral shedding had SD as their best response. However, there was no observed relationship between NA formation and SD. Conclusion: Reolysin administered as a one hour infusion on a monthly schedule is safe and well-tolerated even in multiple doses. This preliminary data suggests there is anti-tumor activity of reolysin as a single agent, and warrants further studies either alone or in combination with cytotoxic chemotherapy.

[Table: see text]

Clinical trial accrual rates in prostate cancer: Prospective experience from a single institution

15611

Background: Clinical trial (CT) participation is a key to better cancer therapy. The Nevada Cancer Institute (NVCI), the official cancer center of NV, is committed to CT participation. We hypothesized that CT accrual at the NVCI should exceed the national average of 3–5%. Methods: Patient (pt) visits began in 3/05 and by 12/31/07 1363 pts had been seen. Prostate cancer (PC) was the largest group (N=270; 50 with 1 visit only). All records are electronic and entered into a cancer registry. A relatively robust portfolio of PC CTs has been available, thus the cancer registry data base was compared to the CT data base for the 16 PC CTs (8 phase III, 1 phase II, 7 phase I) that accrued pts. The data base records all accruals, screen failures, consent withdrawals, and subsequent treatments (on or off CT). Results: 101 consents were signed by 68 PC pts (25 consented to 2 or more CTs). 31 consents lead to screen failures/consent withdrawal (5 pts were screen failures for 2 CTs while 1 pt was a screen failure for 3 CTs). Screen failure was less common in phase II/III CTs (18/74 =24%) than in phase I CTs (10/27=37%). Most of the phase I screen failures were due to rapid decreases in performance status or organ function dysfunction. Among the 68 unique pts who consented, 35 pts were treated on 1 CT and 16 pts were treated on 2 or more CTs resulting in a total of 51 PC pts being treated on at least 1 CT. Conclusions: CT accrual at the NVCI of PC pts (51/270=19%) exceeds the national average. Reports of CT activity should specify the denominator and include both consent and accrual rates. Screen failure/consent withdrawal was common in this older male population with advanced disease. This analysis has limitations; Phase I CTs were activated only after 10/05, only 1 phase II CT was open during this period and CTs for radiation and surgery alone for PC pts were not open. Thus, the percent of pts on CT should rise as more CTs are activated.

No significant financial relationships to disclose.

Preclinical and clinical investigation of histone deacetylase inhibitor valproic acid given orally in androgen independent prostate cancer

14614

Background: Considerable preclinical data suggests that histone deacetylase inhibitors (HDAIs) can cause differentiation and apoptosis of prostate cancer cell lines and inhibit prostate cancer xenografts in vivo. There is evidence that valproic acid (VPA) is a HDAI and can be administered safely to cancer patients intravenously (Atmaca et al J Clin Oncol 2004). Methods: In the current investigation, 6 cell lines of a variety of solid tumors including prostate cancers were treated with escalating concentrations of VPA (0.5, 1, 2 and 4 mM) over 24–144 hours. Cell growth inhibition was studied by a modified MTS assay. Simultaneously, patients with androgen independent prostate cancers were treated with dose escalations of oral VPA every week or as tolerated (10, 15, 20, 25 mg/kg). Weekly total and free serum VPA, PSA and serum testosterone levels were obtained. In addition, lymphocytes were collected for histone H3 acetylation. Results: VPA inhibited all solid tumor cell lines in a dose-dependent and time-dependent fashion. Optimal (>50% over control) inhibition of most cell lines required 2–4 mM exposure over at least 72–96 hours. Prostate and lung cancer lines were more sensitive to inhibition after VPA administration. A total of 5 patients (Median age 71, Range 48–78) were treated with VPA. Major adverse events included Gr 1 confusion (1 pt), Gr 1 fatigue (3 pts), Gr 1 Dizziness (2 patients) and Gr 1 nausea and vomiting (1 pt). When PSA levels were normalized for simultaneously drawn serum testosterone (Median 20, Range 16–281 ng/dl), all patients had transient drops in PSA. In 3 of 4 evaluable patients, normalized PSA increased after patients were discontinued from VPA because of side effects or co-morbid conditions. In 1 patient, normalized PSA declined after re-challenge with VPA. Conclusions: In this study, VPA has demonstrable activity in cell lines and in patients as measured by lowered PSA levels. Normalization of PSA to serum testosterone might be important to detect clinical effects of HDAIs. Updated clinical data and a correlation between PSA, serum levels of VPA and histone acetylation will be presented.

No significant financial relationships to disclose.