When infection mimics cauda equina syndrome: a cautionary tale

A 63-year-old man presented to the emergency department with low back pain, perineal and genital numbness, together with bilateral lower limb paraesthesia and urinary retention. He was admitted under the orthopaedic service for investigation of suspected cauda equina syndrome. Magnetic resonance imaging of his spine did not reveal any evidence of cauda equina compression. Magnetic resonance imaging of his brain demonstrated nonspecific multiple hyperintensities in the right frontotemporal and left temporo-occipital regions. Computed tomography of his chest, abdomen, and pelvis did not identify any evidence of malignancy. Cerebrospinal fluid from a lumbar puncture showed a high leucocyte count (predominantly lymphocytes). Viral cerebrospinal fluid polymerase chain reaction was positive for varicella zoster virus. A diagnosis of varicella zoster virus myeloradiculitis (Elsberg syndrome) was established and the patient was treated with intravenous aciclovir. Unfortunately, the patient succumbed to a devastating intracerebral haemorrhage during his inpatient stay, probably due to vasculopathy from the underlying varicella zoster virus infection. This case describes a rare infectious mimic of cauda equina syndrome. Elsberg syndrome is an infectious syndrome characterised by bilateral lumbosacral myeloradiculitis, with varicella zoster virus being a well-recognised aetiological agent. We discuss the relevant literature in detail and identify the key, cautionary lessons learned from this case.

Anti-tumor effects of an ID antagonist with no observed acquired resistance

ID proteins are helix-loop-helix (HLH) transcriptional regulators frequently overexpressed in cancer. ID proteins inhibit basic-HLH transcription factors often blocking differentiation and sustaining proliferation. A small-molecule, AGX51, targets ID proteins for degradation and impairs ocular neovascularization in mouse models. Here we show that AGX51 treatment of cancer cell lines impairs cell growth and viability that results from an increase in reactive oxygen species (ROS) production upon ID degradation. In mouse models, AGX51 treatment suppresses breast cancer colonization in the lung, regresses the growth of paclitaxel-resistant breast tumors when combined with paclitaxel and reduces tumor burden in sporadic colorectal neoplasia. Furthermore, in cells and mice, we fail to observe acquired resistance to AGX51 likely the result of the inability to mutate the binding pocket without loss of ID function and efficient degradation of the ID proteins. Thus, AGX51 is a first-in-class compound that antagonizes ID proteins, shows strong anti-tumor effects and may be further developed for the management of multiple cancers.

496 The Use of Virtual Trauma Clinics (VTC) In the Assessment of Acute Hand Trauma; A Service Evaluation

As a UK tertiary referral centre for hand trauma the current COVID outbreak has led to the reconfiguration of trauma services. We evaluate the impact of our newly introduced VTC on our hand trauma service, comparing a cohort of patients who were managed pre-COVID, with our current revised pathway.

We carried out a service evaluation of all those patients processed by the VTC over 14 days in April 2020 (n = 184). We collected prospective data on timing of referral to assessment and surgery. This data was compared to a matched period in April 2019 (n = 162).

Post VTC there has been a significant reduction in time to clerking and time to surgery (p = < 0.001), with 98.1% being clerked within 1 day of referral. Post VTC 12.9% of patients were discharged directly from VTC, all other patients had definitive treatment in a single trip.

VTC has shown a clear benefit to patients with definitive management provided in a single trip in all cases. Whilst we have been able to clerk patients earlier any improvement in time to surgery depends on theatre staffing and availability, which differed in the two cohorts and certainly will as we move forward into normal services.

533 The Use of Virtual Reality Simulation to Facilitate Surgical Ward-Based Learning in Medical Students During the Covid-19 Pandemic

Introduction

The Covid-19 pandemic quickly resulted in the removal of all non-essential personnel from surgical wards. It also resulted in suspending medical student placements which are heavily relied upon to provide the students with necessary “hands-on” experience. Virtual Reality (VR) simulation was employed in order to ensure that the students had a comparable experience.

Method

VR simulations were used to simulate the ward environments and the students were able to gain valuable experience with common scenarios encountered on surgical wards. Each student was allocated a 1-hour time slot per session with a debriefing session after each. The digital immersive environment allowed students to build upon their didactic preparation and previously acquired knowledge base.

Results

Feedback was given at the end of each simulation by the simulation facilitator. Using the technical proficiency that they had acquired in the first scenario; the students went on to employ these skills directly in their next scenarios thereby capitalising on the repetition of core skills to maximize their learning.

Conclusions

In this instance, VR was successfully used to enhance both knowledge acquisition and experience. Feedback from the participating students was overwhelmingly positive with many suggesting that they were more comfortable learning in a simulated environment.

Real-world bone turnover marker use: impact on treatment decisions and fracture

The use of bone turnover marker (BTM) testing for patients with osteoporosis in the USA has not been well characterized. This retrospective US-based real-world data study found BTM testing has some association with treatment decision-making and lower fracture risk in patients with presumed osteoporosis, supporting its use in clinical practice.

INTRODUCTION

The purpose of this study was to characterize bone turnover marker (BTM) testing patterns and estimate their clinical utility in treatment decision-making and fragility fracture risk in patients with osteoporosis using a retrospective claims database.

METHODS

Data from patients aged ≥ 50 years with newly diagnosed osteoporosis enrolled in the Truven MarketScan^® Commercial Claims and Encounters and Medicare Supplemental and Co-ordination of Benefits databases from January 2008 to June 2018 were included. Osteoporosis was ascertained by explicit claims, fragility fracture events associated with osteoporosis, or prescribed anti-resorptive or anabolic therapy. BTM-tested patients were 1:1 propensity score matched to those untested following diagnosis. Generalized estimating equation models were performed to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for testing versus no testing on both treatment decision-making and fragility fracture.

RESULTS

Of the 457,829 patients with osteoporosis, 6075 were identified with ≥ 1 BTM test following diagnosis; of these patients, 1345 had a unique treatment decision made ≤ 30 days from BTM testing. The percentage of patients receiving BTM tests increased significantly each year (average annual % change: + 8.1%; 95% CI: 5.6-9.0; p = 0.01). Patients tested were significantly more likely to have a treatment decision (OR: 1.14; 95% CI: 1.13-1.15), and testing was associated with lower odds of fracture versus those untested (OR: 0.87; 95% CI: 0.85-0.88).

CONCLUSION

In this large, heterogeneous population of patients with presumed osteoporosis, BTM testing was associated with treatment decision-making, likely leading to fragility fracture reduction following use.

Identification and diagnosis of Secondary Progressive Multiple Sclerosis during the clinical encounter: Results from a physician survey

BACKGROUND

It is difficult to characterize the transition from relapsing-remitting multiple sclerosis (RRMS) to secondary progressive MS (SPMS), due to symptomatic variability across patients. Diagnosis of SPMS is prolonged and often established retrospectively, as it is based on patient clinical history and symptoms. This cross-sectional study aimed to identify MS neurologist reported clinical indicators deemed important in diagnosing SPMS in clinical practice.

METHODS

A web-based quantitative survey was conducted among MS-treating neurologists across the United States in January 2019. The questionnaire comprised of 17 questions evaluating primary clinical indicators used by neurologists in assessing patient progression to SPMS. Treatment approach and factors influencing treatment decision-making following SPMS diagnosis were also analyzed in the survey.

RESULTS

Overall, 300 neurologists completed the survey; most of the respondents were general MS-treating neurologists (63%) and from private care setting (58%). The overall respondents as well as MS-focused neurologists ranked patient history (45% and 42%, respectively) and patients' neurological exam (39% and 44%, respectively) as -primary clinical indicators of SPMS diagnosis. 57% of neurologists always or mostly switched disease modifying therapies after progression to SPMS, and mostly considered 3-6 months' assessment interval to diagnose SPMS.

CONCLUSION

The survey indicated that neurologists are able to recognize signs of SPMS within six months of symptomatic assessment. The diagnosis is primarily based on patient history among MS-treating neurologists. Therefore, continued education to neurologists may facilitate early diagnosis and timely introduction of effective treatment to manage the progression of SPMS.

Direct-drive laser fusion: status, plans and future

Laser-direct drive (LDD), along with laser indirect (X-ray) drive (LID) and magnetic drive with pulsed power, is one of the three viable inertial confinement fusion approaches to achieving fusion ignition and gain in the laboratory. The LDD programme is primarily being executed at both the Omega Laser Facility at the Laboratory for Laser Energetics and at the National Ignition Facility (NIF) at Lawrence Livermore National Laboratory. LDD research at Omega includes cryogenic implosions, fundamental physics including material properties, hydrodynamics and laser-plasma interaction physics. LDD research on the NIF is focused on energy coupling and laser-plasma interactions physics at ignition-scale plasmas. Limited implosions on the NIF in the 'polar-drive' configuration, where the irradiation geometry is configured for LID, are also a feature of LDD research. The ability to conduct research over a large range of energy, power and scale size using both Omega and the NIF is a major positive aspect of LDD research that reduces the risk in scaling from OMEGA to megajoule-class lasers. The paper will summarize the present status of LDD research and plans for the future with the goal of ultimately achieving a burning plasma in the laboratory. This article is part of a discussion meeting issue 'Prospects for high gain inertial fusion energy (part 2)'.

Complement promotes endothelial von Willebrand factor and angiopoietin-2 release in obstructive sleep apnea

STUDY OBJECTIVE

Obstructive sleep apnea (OSA) is highly prevalent and triples vascular thromboembolic risk. Intermittent hypoxia (IH) during transient cessation of breathing in OSA impairs endothelial protection against complement. Complement activation stimulates the endothelial release of a pro-thrombotic von Willebrand factor (vWF). We investigated whether increased complement activity in OSA promotes the endothelial release of vWF and pro-inflammatory angiopoietin-2. We further investigated whether improving complement protection with statins reverses these changes.

METHODS

Using endothelial cells (ECs) and blood collected from OSA patients (n = 109) and controls (n = 67), we assessed whether altered cellular localization of complement inhibitor CD59 in OSA modulates exocytosis of Weibel-Palade bodies (WPB), secretory granules that store vWF and angiopoietin-2. These interactions were also assessed in vitro in ECs exposed to normoxia or IH with or without recombinant complement C9 and with or without atorvastatin.

RESULTS

Circulating levels of angiopoietin-2 were greater in OSA than controls and levels of vWF cleavage products correlated with OSA severity. In cultured ECs, IH enhanced complement-stimulated angiopoietin-2 and vWF release by reducing EC surface and increasing intracellular expression of complement inhibitor CD59. Intracellular CD59 co-localized with WPB in OSA. IH increased binding of intracellular CD59 to syntaxin-3, which dissociated syntaxin-3 from voltage-sensitive calcium channel Cav1.2, and activated WPB exocytosis in a calcium-dependent manner. Atorvastatin reversed IH-enhanced endothelial release of vWF and angiopoietin-2.

CONCLUSIONS

IH promotes the complement-mediated release of vWF and angiopoietin-2, which may contribute to pro-thrombotic and pro-inflammatory conditions in OSA. Statin reversed these effects, suggesting a potential approach to reduce cardiovascular risk in OSA.

A Rare Case of Retroperitoneal Isolated Enteric Duplication Cyst with Malignant Transformation

Introduction/Objective

Isolated enteric duplication cysts (IEDC) are rare congenital abnormalities that do not have a communication with the normal intestinal lumen. They are usually recognized before the age of 2 years. They are rarely encountered in adults and very seldom undergo malignant change. These cysts are predominantly located within the abdominal cavity. They histologically demonstrate gastrointestinal mucosal lining and smooth muscle in the wall.

Methods

We report a case of a 45-year-old African American female who was evaluated for a pain in the left-sided abdomen and pelvis. Magnetic resonance imaging revealed a large multilocular cystic retroperitoneal mass, extending into the left iliac fossa and anteriorly displacing the colon. No other mass lesion was radiologically identified. The main radiologic impression was sarcoma. A biopsy was performed, and a pathologic diagnosis of adenocarcinoma was established with a consideration of primary retroperitoneal mucinous cystadenocarcinoma. An en bloc surgical resection of the retroperitoneal mass with adjacent segment of the descending colon was accomplished. Gross examination revealed an 11 x 5 x 4 cm cystic mass, containing a necrotic fluid and adherent to a 4 cm long segment of descending colon. Microscopically, the mass was lined by neoplastic cells arranged into tubules, villi and glands. Areas of necrosis were present. The wall of the cystic mass showed extensive hyalinized fibrosis and focal invasion. The neoplastic cells had positive immunoreactivity for CK7, CK20 and CDX2, but were negative for PAX8, PR and ER. Desmin immunostain and trichrome special stain highlighted a focus of smooth muscle bundle within the wall of the mass. These findings led to the pathologic diagnosis of adenocarcinoma arising in retroperitoneal IEDC.

Conclusion

In conclusion, we present this case because of its unusual presentation and location. Recognition of this entity and its rare malignant potential is important as it can pose a diagnostic challenge to pathologists.

Genome targeting by hybrid Flp-TAL recombinases

Genome engineering is a rapidly evolving field that benefits from the availability of different tools that can be used to perform genome manipulation tasks. We describe here the development of the Flp-TAL recombinases that can target genomic FRT-like sequences in their native chromosomal locations. Flp-TAL recombinases are hybrid enzymes that are composed of two functional modules: a variant of site-specific tyrosine recombinase Flp, which can have either narrow or broad target specificity, and the DNA-binding domain of the transcription activator-like effector, TAL. In Flp-TAL, the TAL module is responsible for delivering and stabilizing the Flp module onto the desired genomic FRT-like sequence where the Flp module mediates recombination. We demonstrate the functionality of the Flp-TAL recombinases by performing integration and deletion experiments in human HEK-293 cells. In the integration experiments we targeted a vector to three genomic FRT-like sequences located in the β-globin locus. In the deletion experiments we excised ~ 15 kilobases of DNA that contained a fragment of the integrated vector sequence and the neighboring genome sequence. On average, the efficiency of the integration and deletion reactions was about 0.1% and 20%, respectively.

Evaluation of Changes in Microbiology and Periodontal Parameters During and After Fixed Orthodontic Appliances

The objective of the study was to evaluate the changes in microbiology through quantitative analysis of aerobic and anaerobic colonies and periodontal measurements during and after 1 month of removal of fixed orthodontic appliances. This prospective study comprised 30 patients, aged 12-30 years seeking orthodontic treatment in the department of Orthodontics and Dentofacial Orthopaedics of People's College of Dental Sciences and Research Centre, Bhopal from May 2016 to November 2017. Microbiological samples (supra- and subgingival plaque) and periodontal measurements like bleeding on probing (BOP), periodontal pocket depth (PPD) with oral hygiene assessment indices {plaque index (PI), gingival index (GI)} were used at 2 time interval: when patient undergoing orthodontic treatment >12 month (baseline, T₁) and 1 month after the removal of appliance (T₂). Bacterial culture method used to detect aerobic and anaerobic colony forming units (CFU) and their ratio (aerobic/anaerobic). Data analyzed using paired t-test and chi-square test. There was a significant decrease in an aerobic and anaerobic CFU (both supra- and subgingivally) and increase in CFU ratio (relatively less anaerobes) (p≤0.05) at T₂. Supragingival plaque sampling showed greater diminution in the CFU count as compared to the subgingival CFU, as these sites are more accessible for maintaining hygiene. Also, periodontal measurements showed significant decrement (PI, GI, PPD and BOP) at T₂ (p≤0.05). Fixed orthodontic treatment has transient effect on periodontium as supra- and subgingival CFU count decreases and periodontal health was ameliorated after removal of appliances which was accompanied with periodontopathic bacteria and clinical periodontal signs of inflammation during treatment.

A multicentre randomised phase III trial comparing pembrolizumab versus single-agent chemotherapy for advanced pre-treated malignant pleural mesothelioma: the European Thoracic Oncology Platform (ETOP 9-15) PROMISE-meso trial

BACKGROUND

Malignant pleural mesothelioma (MPM) is an aggressive malignancy characterised by limited treatment options and a poor prognosis. At relapse after platinum-based chemotherapy, single-agent chemotherapy is commonly used and single-arm trials of immune-checkpoint inhibitors have demonstrated encouraging activity.

PATIENTS AND METHODS

PROMISE-meso is an open-label 1:1 randomised phase III trial investigating the efficacy of pembrolizumab (200 mg/Q3W) versus institutional choice single-agent chemotherapy (gemcitabine or vinorelbine) in relapsed MPM patients with progression after/on previous platinum-based chemotherapy. Patients were performance status 0-1 and unselected for programmed cell death ligand 1 (PD-L1) status. At progression, patients randomly assigned to receive chemotherapy were allowed to crossover to pembrolizumab. The primary end point was progression-free survival (PFS), assessed by blinded independent central review (BICR). Secondary end points were overall survival (OS), investigator-assessed PFS, objective response rate (ORR), and safety. Efficacy by PD-L1 status was investigated in exploratory analyses.

RESULTS

Between September 2017 and August 2018, 144 patients were randomly allocated (pembrolizumab: 73; chemotherapy: 71). At data cut-off [20 February 2019, median follow-up of 11.8 months (interquartile range: 9.9-14.5)], 118 BICR-PFS events were observed. No difference in BICR-PFS was detected [hazard ratio = 1.06, 95% confidence interval (CI): 0.73-1.53; P = 0.76], and median BICR-PFS (95% CI) for pembrolizumab was 2.5 (2.1-4.2), compared with 3.4 (2.2-4.3) months for chemotherapy. A difference in ORR for pembrolizumab was identified (22%, 95% CI: 13% to 33%), over chemotherapy (6%, 95% CI: 2% to 14%; P = 0.004). Forty-five patients (63%) assigned to chemotherapy received pembrolizumab at progression. With follow-up to 21 August 2019 [17.5 months: (14.8-19.7)], no difference in OS was detected between groups (HR = 1.12, 95% CI: 0.74-1.69; P = 0.59), even after adjusting for crossover. Pembrolizumab safety was consistent with previous observations. Exploratory efficacy analyses by PD-L1 status demonstrated no improvements in ORR/PFS/OS.

CONCLUSION

This is the first randomised trial evaluating the efficacy of pembrolizumab in MPM patients progressing after/on previous platinum-based chemotherapy. In biologically unselected patients, although associated with an improved ORR, pembrolizumab improves neither PFS nor OS over single-agent chemotherapy.

Retrospective analysis of EMR database to assess the effectiveness of Saccharomyces boulardii CNCM I-745 in children with acute diarrhoea during routine clinical practice

This study aimed to assess the efficacy of Saccharomyces boulardii, a yeast probiotic, in the management of acute diarrhoeal disorders in the paediatric population in outpatient settings. It was a multicentre retrospective analysis of medical records of children who were treated for acute diarrhoea by routine treatment (oral rehydration solution and zinc) with or without S. boulardii. Overall, 160 children presenting with acute diarrhoea at seven different outpatient paediatric settings were included in the study. Children were divided into two categories based on their treatment with S. boulardii (SB group) or without S. boulardii (Non-SB group). Baseline demographic, anthropometric and clinical variables were compared between the two groups. The median duration of diarrhoea post-treatment was significantly shorter in the S. boulardii group (3 days) than in the non-SB group (4 days). A significant reduction in the frequency of stools was observed post-treatment in the S. boulardii group (1.7 versus 2.5 in the non-SB group). There was a significant weight gain in the S. boulardii group post-treatment (300 g) in comparison with the non-SB group (mean loss of 400 g). This study established the positive role of S. boulardii in the management of acute diarrhoeal diseases in children. Moreover, the S. boulardii probiotic was seen to be effective in diarrhoeal diseases in children with dehydration.

Impact of change in bedtime variability on body composition and inflammation: secondary findings from the Go Red for Women Strategically Focused Research Network

Variability in daily sleep patterns is an emerging factor linked to metabolic syndrome. However, whether reducing bedtime variability improves markers of disease risk has not been tested. Here, we assessed whether body composition and inflammation were impacted by changes in bedtime variability over a 6-week period, during which, women were instructed to maintain healthy, habitual sleep (HS) patterns (one arm of a randomized trial). Data were available for 37 women (age 34.9 ± 12.4 years, BMI 24.7 ± 2.9 kg/m2, sleep duration 7.58 ± 0.49 h/night). Body composition and leukocyte platelet aggregates (LPA) were measured at baseline and endpoint using magnetic resonance imaging and flow cytometry, respectively. Sleep data were collected daily using wrist actigraphy. Change in bedtime variability was calculated as the difference in the standard deviation (SD) of bedtimes measured during the 2-week screening period and the 6-week intervention period. Results showed that women who reduced their bedtime variability (n = 29) during the intervention had reductions in total (P < 0.001) and subcutaneous adipose tissue (P < 0.001) relative to women who increased/maintained (n = 8) bedtime variability. Similar effects were observed for LPA levels between women who reduced vs increased/maintained bedtime variability (P = 0.011). Thus, reducing bedtime variability, without changing sleep duration, could improve cardiometabolic health by reducing adiposity and inflammation.

Gastric point-of-care ultrasound (PoCUS) during pregnancy and the postpartum period: a systematic review

Personalised risk assessment of the likelihood of pulmonary aspiration is recommended for pregnant women undergoing general anaesthesia and gastric point-of-care ultrasound (PoCUS) may help to achieve this. Traditionally, risk assessment is based upon adherence to fasting times, but gastric emptying may vary during pregnancy and surgery often needs to be expedited. We systematically reviewed the evidence for gastric PoCUS up to August 2018 in pregnant and postpartum women to determine whether it can identify and quantify stomach contents, provide aspiration risk assessment via qualitative or quantitative means, and determine how gastric emptying is affected by pregnancy. Twenty-two articles comprising 1050 participants were included and studies were classified by qualitative or quantitative findings. The evidence suggests that gastric PoCUS is a reliable and feasible method of imaging the stomach in pregnancy in clinical practice. Qualitative assessment via the Perlas grading system can provide rapid assessment of gastric volume states. If fluid is visible, identification of patients at high risk of pulmonary aspiration requires measurement of antral cross-sectional area. Cut-off values of 608 mm² and 960 mm² are recommended in the semi-recumbent and right lateral semi-recumbent positions, respectively. Validated methods to quantify stomach volumes are available, however their usefulness is currently restricted to research. Gastric PoCUS also provides evidence that gastric emptying of ingested food is delayed by term pregnancy, labour and during the early postpartum period. However, the passage of fluids through the stomach appears unaffected throughout the peripartum period.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Are the tubular bones of the hand really the commonest site for an enchondroma?

AIM

To investigate whether the long-held view that the hand is the commonest site for an enchondroma is actually correct in light of more sensitive imaging techniques that are able to demonstrate small enchondromas at other skeletal sites.

MATERIALS AND METHODS

A two-part retrospective study was undertaken. Part 1 comprised a review of the hand radiographs obtained in two major teaching hospitals over a 10-year period to establish the incidence of enchondroma in the hand. Part 2 was a review of a series of enchondromas of the proximal humerus, distal femur, and proximal tibia <4 cm in length on magnetic resonance imaging (MRI) to see which cases were visible or not on corresponding radiographs.

RESULTS

Part 1: 84 enchondromas were identified on 116,354 trauma radiographs to give an incidence of 0.07%. Part 2: 157 patients with an enchondroma on MRI <4 cm were reviewed. Only 17% of lesions <2 cm in length were visible on the contemporaneous radiographs. In lesions that were 2-2.9 and 3-3.9 cm the percentage visible on the radiographs increased to 58 and 77%, respectively.

CONCLUSION

It is well recognised from existing studies that incidental enchondromas can be seen in approximately 2.5% of routine shoulder and knee MRI scans. This figure is 35 times higher than the incidence found in the series of hand trauma radiographs. This infers that the hand should no longer be considered as the commonest site for an enchondroma. This is because radiographs are relatively insensitive to the detection of small lesions in larger bones, such as the proximal humerus and around the knee, when compared with MRI.

Mediterranean diet components are linked to greater endothelial function and lower inflammation in a pilot study of ethnically diverse women

The Mediterranean Diet, characterized by higher intakes of plant foods including plant proteins, monounsaturated fat, fish, and lower consumption of animal products and saturated fat, has long been associated with reduced cardiovascular risk, but the molecular mechanisms underlying these associations have not been fully elucidated. We conducted a pilot study to evaluate associations of an Alternate Mediterranean Diet Score, reflective of adherence to this diet pattern and adapted for US populations, and its components, with markers of endothelial inflammation directly measured in endothelial cells harvested from a diverse sample of women (n = 25, mean ± SD age 33 ± 10.5y, 68% racial/ethnic minorities). Cardiovascular risk markers including nuclear factor kappa B (NF-κB)-a marker of inflammation, as well as oxidative stress and endothelial nitric oxide synthase (eNOS) gene expression-markers of endothelial function, were evaluated in harvested endothelial cells. We hypothesized that the Mediterranean diet pattern would be associated with lower inflammation and oxidative stress and higher eNOS expression in endothelial cells. Results showed that lower oxidative stress was associated with higher plant-based protein (Exp(β) = 0.96; P = .007), overall protein (Exp(β) = 0.99; P = .007), and red and processed meat intake (Exp(β) = 0.93; P = .012). Lower NF-κB was associated with higher legume (Exp(β) = 0.79; P = .045) intake, and higher eNOS was associated with higher red and processed meat intake (Exp(β) = 1.13; P = .005). Our findings suggest potential novel mechanisms through which certain Mediterranean dietary components may influence pre-clinical vascular alterations that may be associated with cardiovascular risk through lower endothelial oxidative stress, lower inflammation, and greater endothelial functioning. These findings warrant confirmation, prospectively in a larger sample.

A Small-Molecule Pan-Id Antagonist Inhibits Pathologic Ocular Neovascularization

Id helix-loop-helix (HLH) proteins (Id1-4) bind E protein bHLH transcription factors, preventing them from forming active transcription complexes that drive changes in cell states. Id proteins are primarily expressed during development to inhibit differentiation, but they become re-expressed in adult tissues in diseases of the vasculature and cancer. We show that the genetic loss of Id1/Id3 reduces ocular neovascularization in mouse models of wet age-related macular degeneration (AMD) and retinopathy of prematurity (ROP). An in silico screen identifies AGX51, a small-molecule Id antagonist. AGX51 inhibits the Id1-E47 interaction, leading to ubiquitin-mediated degradation of Ids, cell growth arrest, and reduced viability. AGX51 is well-tolerated in mice and phenocopies the genetic loss of Id expression in AMD and ROP models by inhibiting retinal neovascularization. Thus, AGX51 is a first-in-class compound that antagonizes an interaction formerly considered undruggable and that may have utility in the management of multiple diseases.