Low alanine aminotransferase levels and higher number of cardiovascular events in people with Type 2 diabetes: analysis of the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study

AIMS

To determine whether alanine aminotransferase or gamma-glutamyltransferase levels, as markers of liver health and non-alcoholic fatty liver disease, might predict cardiovascular events in people with Type 2 diabetes.

METHODS

Data from the Fenofibrate Intervention and Event Lowering in Diabetes study were analysed to examine the relationship between liver enzymes and incident cardiovascular events (non-fatal myocardial infarction, stroke, coronary and other cardiovascular death, coronary or carotid revascularization) over 5 years.

RESULTS

Alanine aminotransferase measure had a linear inverse relationship with the first cardiovascular event occurring in participants during the study period. After adjustment, for every 1 sd higher baseline alanine aminotransferase measure (13.2 U/l), the risk of a cardiovascular event was 7% lower (95% CI 4-13; P = 0.02). Participants with alanine aminotransferase levels below and above the reference range 8-41 U/l for women and 9-59 U/l for men, had hazard ratios for a cardiovascular event of 1.86 (95% CI 1.12-3.09) and 0.65 (95% CI 0.49-0.87), respectively (P = 0.001). No relationship was found for gamma-glutamyltransferase.

CONCLUSIONS

The data may indicate that in people with Type 2 diabetes, which is associated with higher alanine aminotransferase levels because of prevalent non-alcoholic fatty liver disease, a low alanine aminotransferase level is a marker of hepatic or systemic frailty rather than health.

Genetic markers for resilience and susceptibility to Johne's disease In red deer (Cervus elaphus) (VET1P.1120)

Mycobacterium avium subspecies paraturberculosis is the causative agent of Johne’s disease, an enteritis infection that affects ruminants.This disease has been studied in deer, but there is little information regarding immunity or disease immunopathology. There is evidence that host genetics contribute to resilience or susceptibility to the disease. This study sought to identify genes in the innate and adaptive immune systems as biomarkers for resilient (R) or susceptible (S) phenotypes in red deer. We have bred over 60 animals from sires with a confirmed R or S phenotype. Animals were bled routinely and monocyte derived macrophages (MDMs) or whole PBMCs were obtained and cultured in vitro. Gene expression was determined using qPCR. The 15 most informative gene targets were chosen from a panel of 60 using GenEx software MDMs showed higher levels of expression of immune genes such as IL1A, TNFA, IL23A and IL12A in S animals, as well as genes not typically associated with the immune system, such as PKLR that exhibit this pattern. Conversely, PBMC samples from these animals exhibit higher levels of expression of immune genes such as IFNY, IL17A and IL2 in R animals. These results have been reproduced in animals bred from different sires over several years. We intend to incorporate these gene markers into diagnostic tests to identify R and S animals at an early age. These genes may also provide deeper insights into immune parameters that determine disease outcome in an animal.

Attitudes towards involuntary incarceration for tuberculosis: a survey of Union members

BACKGROUND

Policies involving the use of involuntary incarceration for tuberculosis (TB) are highly ethically controversial. To encourage ethical reflection within the International Union Against Tuberculosis and Lung Disease (The Union), the Ethics Advisory Group (EAG) surveyed members regarding their attitudes and values relating to involuntary incarceration for TB.

METHODS

Members of the Union TB section were invited to respond to an anonymous web-based survey. The survey included both multiple choice questions describing a range of scenarios regarding involuntary incarceration, and free-text fields inviting respondents to provide general comments on ethical issues.

RESULTS

The survey was completed by 194 participants, 33 (17%) of whom were opposed to involuntary incarceration on principle. The age and sex of the respondents was not associated with likelihood of principled opposition; respondents from North America were least likely to be opposed to involuntary incarceration (P = 0.02). Respondents were most likely to consider involuntary incarceration for persons with known multidrug-resistant TB or a history of previous treatment default, and least likely where people lived alone, were university-educated or the main income provider for their families.

CONCLUSION

This survey found a wide range of viewpoints regarding involuntary incarceration, and highlights a number of key elements in ethical engagement with the tensions surrounding involuntary incarceration. We provide commentary on approaches to ethical policy making in the light of these findings.

Research ethics in The Union: an 8-year review of the Ethics Advisory Group

SETTING

The Ethics Advisory Group (EAG) of the International Union Against Tuberculosis and Lung Disease (The Union) was established in 2004 to provide ethical guidance and promote ethical standards within The Union, including reviews of proposed research projects associated with The Union.

OBJECTIVES

To describe research proposal reviews conducted by the EAG in the period 2005-2012 in terms of 1) annual numbers, 2) the Union departments in which the proposals originated, 3) study designs, 4) regions and countries where studies were to be conducted, 5) study topics, 6) problems encountered by the EAG, and 7) review outcomes.

DESIGN

Descriptive study of application records of the EAG.

RESULTS

A total of 292 applications were reviewed; 79% were proposals for operational research; 85% were from Africa and Asia, with 64% from India, South Africa, Malawi, Kenya and Zimbabwe. Tuberculosis was the topic in 68%; only three studies in the 8 years were on other lung diseases. Several problems encountered are highlighted. All applications were approved except six, either immediately or after modification.

CONCLUSION

The proposal review process of the EAG serves to maintain ethical standards of research within The Union. Ideas for expanding the scope of the EAG are discussed.

Global gene expression profiling of monocyte-derived macrophages from red deer (Cervus elaphus) genotypically resistant or susceptible to Mycobacterium avium subspecies paratuberculosis infection

Mycobacterium avium subspecies paratuberculosis (MAP) can cause a chronic inflammatory bowel disease, Johne's disease (JD), in ruminant animals. This study has explored the molecular basis of resistance and susceptibility to this disease in red deer breeds previously confirmed to express polarised phenotypes by experimental infection trials and following natural infection. Monocyte-derived macrophage cultures were obtained from uninfected red deer selected for either a resistant or susceptible phenotype. Cells were infected with MAP in vitro and gene expression analysed by RNA-Seq. Transcriptome analysis revealed a more disrupted gene expression profile in macrophages from susceptible animals compared with cells from resistant animals in terms of the number of genes up- or downregulated. Highly upregulated genes were related to chemotaxis (CXCL10, CSF3, and CCL8) and type 1 interferon signalling (RSAD2, IFIT1, IFIT2, ISG12, ISG15, USP18, and HERC6). Upregulation of these genes was observed to be greater in macrophages from susceptible animals compared to cells from resistant animals in response to in vitro MAP infection. These data support the use of transcriptomic approaches to enable the identification of markers associated particularly with susceptibility to MAP infection.

Composite testing for ante-mortem diagnosis of Johne's disease in farmed New Zealand deer: correlations between bacteriological culture, histopathology, serological reactivity and faecal shedding as determined by quantitative PCR

Background

In the absence of overt clinical signs of Johne’s Disease (JD), laboratory based tests have largely been limited to organism detection via faecal culture or PCR and serological tests for antibody reactivity. In this study we describe the application of quantitative faecal PCR for the detection of Mycobacterium avium subsp. paratuberculosis (MAP) in New Zealand farmed deer to quantify the bacterial load in cervine faecal samples as an adjunct to an existing serodiagnostic test (Paralisa™) tailored for JD diagnosis in deer. As ELISA has potential as a cheap, high throughput screening test for JD, an attempt was made to assess the sensitivity, specificity and positive/negative predictive (PPV/NPV) values of Paralisa™ for estimating levels of faecal shedding of MAP as a basis for JD management in deer.

Results

Correlations were made between diagnostic tests (ELISA, qPCR, culture and histopathology) to establish the precision and predictive values of individual tests. The findings from this study suggest there is strong correlation between bacterial shedding, as determined by faecal qPCR, with both culture (r = 0.9325) and histopathological lesion severity scoring (r = 0.7345). Correlation between faecal shedding and ELISA reactivity in deer was weaker with values of r = 0.4325 and r = 0.4006 for Johnin and Protoplasmic antigens, respectively. At an ELISA Unit (EU) cutoff of >50 (Johnin antigen) the PPV of Paralisa™ for significant faecal shedding in deer (>10⁴ organisms/g) was moderate (0.55) while the NPV was higher (0.89). At an EU cutoff of ≥150, the PPV for shedding >10⁵ organisms/g rose to 0.88, with a corresponding NPV of 0.85.

Conclusions

The evidence available from this study suggests that Paralisa™ used at a cutoff of 50EU could be used to screen deer herds for MAP infection with sequential qPCR testing used to cull all Paralisa™ positive animals that exhibit significant MAP faecal shedding.