Functional host-specific adaptation of the intestinal microbiome in hominids

Fine-scale knowledge of the changes in composition and function of the human gut microbiome compared that of our closest relatives is critical for understanding the evolutionary processes underlying its developmental trajectory. To infer taxonomic and functional changes in the gut microbiome across hominids at different timescales, we perform high-resolution metagenomic-based analyzes of the fecal microbiome from over two hundred samples including diverse human populations, as well as wild-living chimpanzees, bonobos, and gorillas. We find human-associated taxa depleted within non-human apes and patterns of host-specific gut microbiota, suggesting the widespread acquisition of novel microbial clades along the evolutionary divergence of hosts. In contrast, we reveal multiple lines of evidence for a pervasive loss of diversity in human populations in correlation with a high Human Development Index, including evolutionarily conserved clades. Similarly, patterns of co-phylogeny between microbes and hosts are found to be disrupted in humans. Together with identifying individual microbial taxa and functional adaptations that correlate to host phylogeny, these findings offer insights into specific candidates playing a role in the diverging trajectories of the gut microbiome of hominids. We find that repeated horizontal gene transfer and gene loss, as well as the adaptation to transient microaerobic conditions appear to have played a role in the evolution of the human gut microbiome.

Dynamic Prediction of Toxicities in Head and Neck Cancer Radiotherapy by 3D Convolutional Neural Network Using Daily Cone-Beam CTs

PURPOSE/OBJECTIVE(S)

Radiotherapy (RT) is essential in head and neck cancer (HNC) treatments, but often causes significant toxicity. Different machine learning models have shown promise in predicting RT-induced toxicity, but none have yet integrated the fluctuating anatomical changes. By integrating daily cone-beam CTs (CBCT) allowing sequential anatomical views, our aim is to build a dynamic predictive model for three major HNC RT toxicities: reactive feeding tube placement, hospitalization and radionecrosis (RN).

MATERIALS/METHODS

292 HNC cases treated with curative RT between 2017 and 2019 at our institution were retrospectively analyzed for clinical and radiological data. VoxelMorph, a deep deformable registration model, integrated the daily anatomical deformations between each CBCT and the planning CT, then converted them to Jacobian determinant matrix (Jf). Resnet, a convolutional neural network with multiple layers was trained using a 5-fold cross validation to integrate both radiological and clinical data. Each toxicity was classified as a binary decision using the cross-entropy loss to account for a class imbalance. Its predictive performance was compared to the baseline model using only clinical data.

RESULTS

The cohort included 78% men and 22% women, with a median age of 63 years (range 35-84). Primary cancer sites were 46% oropharynx, 19% larynx, 14% oral cavity, 7.5% nasopharynx, 5% hypopharynx, 4% unknown primary and 5% others; and stage ranged between Tx-4b N0 and 3b M0 (AJCC 8th Ed). Induction chemotherapy, concurrent chemotherapy, and adjuvant RT was used in 9%, 57% and 20% of patients, respectively. The incidence of feeding tube, hospitalization and RN was 19.9%, 7.2%, and 3.8%, respectively. Integrating Jf from the 10th RT CBCT showed better accuracy for each toxicity prediction: feeding tube (69.1% > 57.2%), hospitalization (75.3% > 63.1%) and RN (85.8% > 75.7%). Integrating both the raw CBCT and Jf improved hospitalization prediction (79.0% > 73.6%). Substituting Jf for the raw CBCT improved the prediction for RN (79.7% > 74.7%) and hospitalization (73.6% > 64.4%). For feeding tube, predictive performance of the Jf model trained against deformations showed a positive correlation between its performance and the RT received (r2 > 0.9) with increasing RT fractions, with a maximum accuracy of 83.1% at the 25th fraction. No such correlation was found for RN or hospitalization prediction.

CONCLUSION

To our knowledge, this is the first study showing promising results to predict HNC RT toxicities using daily per-treatment CBCT. Next steps involve integrating both the radiomic and the dosimetric inputs to build a more powerful model. This could expand to predict therapeutic outcomes and, ultimately, could guide decisions in individualized RT.

Left atrial systolic force in hypertensive patients with left ventricular hypertrophy predicts atrial fibrillation

Background

Recently increased left atrial systolic force (LASF), a measure of left atrial function, has been associated with left ventricular hypertrophy (LVH) in hypertensive patients. Impaired left ventricular relaxation is often seen in hypertensive patients and because of the correlated left ventricular filling impairment the atrial contribution to ventricular filling is important. LASF may increase as a compensatory response to preserve a sufficient stroke volume, which partly could explain the association between age-related prolonged left ventricular relaxation and increased LASF. Reduced left atrial function has also been shown to be associated with poor prognosis in patients with atrial fibrillation. It remains unknown whether LASF can be used as a predictor of new-onset atrial fibrillation (NOAF). Furthermore, the influence of treatment with atenolol and losartan on LASF is unclear.

Purpose

We aimed to determine whether LASF correlates to incident atrial fibrillation and whether the preservation of LASF reduces the risk of new onset atrial fibrillation (NOAF).

Methods

N=758 patients without atrial fibrillation at baseline were enrolled from the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiography sub study. Participants of the LIFE-study were randomized to either atenolol- or losartan-based treatment. Mean follow-up was 59 month. LASF was calculated using average mitral orifice area and mitral peak A velocity obtained by Doppler echocardiography.

Results

At baseline 25% of patients had a LASF≤10.3kdyn. Compared to other quartiles this quartile had a higher proportion of men, lower heart rate, body mass index and age. After controlling for these variables patients in the first quartile had lower stroke volume compared to other quartiles. New-onset AF occurred in 29 (8.1/1,000 patients-years of follow-up) patients. In multivariable Cox regression analyses with backwards elimination increasing LASF was associated with lower risk of NOAF (HR=0.90 [95% confidence interval 0.85–0.96], p=0.001). Integrated discrimination improvement was 0.054 (p=0.004) and there was a borderline significant net reclassification improvement of 19.2% (p=0.075). Over time LASF decreased more in the atenolol-based than the losartan-based treatment group (p<0.001).

Conclusions

Low left atrial systolic force (LASF) was associated with higher risk of NOAF. Losartan-based treatment was associated with better preservation of LASF compared to atenolol-based treatment. Our data thus suggest that hypertensive patients with LVH and low LASF identifies a patient group with progressed left atrial dysfunction and with high risk of NOAF. Because of the preserving effect of losartan on the function and structure of the left atrium, treating hypertensive patients with LVH with losartan might decrease their risk of incident atrial fibrillation.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The LIFE study originally received support from Merck & Co., Inc.

Incident atrial fibrillation and heart failure in treated hypertensive patients with left ventricular hypertrophy

Background

Hypertension and left ventricular hypertrophy (LVH) are predictors of atrial fibrillation (AF) and heart failure (HF). The incidence rates of AF and HF and especially the combination of these two complications in hypertensive patients with LVH receiving antihypertensive treatment are unknown, and so are the association with risk levels of other cardiovascular diseases and death in hypertensive patients with LVH who develop new onset AF and HF.

Purpose

We aimed to investigate the appearance and severity of AF and HF in 8,702 hypertensive patients aged 55–80 years with LVH receiving antihypertensive treatment in a prospective and randomized clinical trial primarily designed to investigate the preventive effect on a composite endpoint of myocardial infarction, stroke and cardiovascular death.

Methods

Included were patients who had sinus rhythm in ECG and no history of AF or HF when they were randomly allocated to blinded study medication with losartan or atenolol. Additional medication was given with hydrochlorothiazide and calcium antagonist if needed to gain blood pressure control. Incident AF was detected by annual ECGs and from adverse event reports submitted by the 930 clinical investigators. Incident HF was diagnosed according to Framingham criteria. Endpoints including incident HF, myocardial infarction, stroke and cardiovascular death were reported with relevant documentation by the investigators, and adjudicated by an expert endpoint committee.

Results

Incident AF occurred in 679 patients (7.8%) and HF in 246 patients (2.8%) during 4.7±1.1 years mean follow-up. Incident AF was associated with a >4-fold increased risk of developing subsequent HF (HR=4.7; 95% CIs, 3.1–7.0; P<0.001) in multivariable Cox analyses adjusting for age, sex, race, randomized treatment, standard cardiovascular risk factors and incident myocardial infarction. The development of HF as a time-dependent variable was associated with a multivariable-adjusted 3-fold increase of the primary study endpoint (HR=3.11; 95% CIs, 1.52 to 6.39; P<0.001) which was the composite of myocardial infarction, stroke or cardiovascular death.

Incident HF was associated with a >3-fold increased risk of developing subsequent AF (HR=3.3; 95% CIs, 2.3–4.9; P<0.001). This development of AF was associated with more than a 2-fold increase of the composite of myocardial infarction, stroke or cardiovascular death in multivariable Cox analysis (HR=2.26; 95% CIs, 1.09–4.67; P=0.028).

Conclusions

Incident atrial fibrillation and heart failure are associated with increased risk of the other in treated hypertensive patients with left ventricular hypertrophy. These hypertensive patients who subsequently develop both atrial fibrillation and heart failure during antihypertensive treatment have particularly high risk of an additional composite endpoint consisting of myocardial infarction, stroke or cardiovascular death.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): The study originally received support from Merck & Co., Inc.

Patient reported symptoms in emergency health care service in patients with complete atrioventricular block

Aim

To examine initial symptoms in emergency and medical helpline calls of patients prior to hospital admission and pacemaker implantation due to recent onset of complete atrioventricular block.

Methods

In the capital region of Denmark, Copenhagen, citizens who require medical assistance can contact either the regional 24h non-urgent medical helpline 1813 or the emergency number 1–1-2 (equivalent to 9–1–1). In both services, the symptoms/purposes of the calls are registered by health professionals. We identified calls from patients who received a pacemaker due to recent onset complete AV block. Prior to analysis, symptoms were categorized as fainting, dizziness, other CNS symptoms, chest pain, other cardiac symptoms, breathing problems, trauma/exposure, unconsciousness, unclear problems, and other atypical symptoms.

Results

We identified 451 calls (261 emergency calls and 190 non-emergency calls) which included information on symptom presentation prior to hospital admission due to first time diagnosis of complete atrioventricular block, that resulted in pacemaker implantation (Figure). Typical symptoms such as fainting and dizziness accounted for only 12.6% (57/451) and 13.3% (60/451), respectively. Chest pain (13.6%, 61/451) and other cardiac symptoms (5.3%, 24/451) accounted for roughly one in five patient complaints. Across both service types, patients >80 years (median age) was more likely to call for help due to trauma/exposure, while complaints of fainting trended towards younger patients and the 1-1-2 emergency number. Median time from first call to pacemaker implantation was 2–3 days for fainting, dizziness, and chest pain, compared to 6–8 days for other CNS symptoms and other atypical symptoms (Table).

Conclusion

Typical symptoms such as fainting and dizziness accounted for only 13% in patients with complete atrioventricular block. Instead, these patients presented with a wide variety of initial symptoms, including chest pain, breathing problems, unclear problems, or trauma. Finally, symptom presentation seemed to affect the time to pacemaker implantation.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Foundation

Opioid administered prior to onset of myocardial infarction is associated with atypical symptoms of acute coronary ischemia in emergency calls

Background

Acute identification and treatment of myocardial infarction (MI) is crucial for survival. MI symptom presentation is typically characterized by chest pain. Regular use of opioids to relief pain of chronic diseases is common. However, it has not been investigated whether opioid administered prior to onset of MI is associated more with atypical presentation of ischemia compared to non-opioid users.

Purpose

To investigate if opioid therapy is associated with atypical symptoms of MI.

Methods

The study is registry-based. MI is defined as patients with the ICD-10 discharge diagnoses I20.0 and I21 as primary diagnosis <24 hours after a call to the Capital Emergency Medical Services, including the Emergency Number (1–1-2) and Out-of-hours Service (OOHS). MI patients with opioid treatment prior to onset of MI are compared with a control group of MI patients without opioid treatment. The primary symptom of MI is registered in calls to the Capital Emergency Medical Services, from 2014 to 2018. Opioid treatment includes opioid prescribed and picked up <30 days prior to onset of MI.

Results

In total, 866 MI patients with opioid treatment and 10,061 MI patients without opioid treatment were included. The median age was 72.0 vs 67.8 years, 50.5% vs 34.5% were women, 61.0% vs 54.7% called the Emergency Number (1–1-2), ischemic heart disease was present in 48.5% vs 34.3% and type 2 diabetes in 23.1% vs. 16.2%. Atypical symptoms of MI were associated with opioid treatment and most prevalent in calls to OOHS, in women and by higher age. Acute symptoms of MI are visualized in Figure 1 and 2.

Conclusion

Opioid treatment prior to onset of MI was associated with increased atypical symptoms of MI, especially dyspnea, and increased in calls to the OOHS, in women and by higher age. This might challenge the clinician in early diagnose of MI in patients with opioid treatment and thereby delay acute lifesaving treatment.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Danish Heart Foundation

Host traits, lifestyle and environment are associated with human skin bacteria

BACKGROUND

The human skin offers diverse ecosystems for microbial symbionts. However, the factors shaping skin-microbiome interactions are still insufficiently characterized. This contrasts with the broader knowledge about factors influencing gut microbiota.

OBJECTIVES

We aimed to investigate major patterns of association of host traits, lifestyle and environmental factors with skin bacteria in two German populations.

METHODS

This is a cross-sectional study with 647 participants from two population-based German cohorts, PopGen (n = 294) and KORA FF4 (n = 353), totalling 1794 skin samples. The V1-V2 regions of the 16S ribosomal RNA (rRNA) gene were sequenced. Associations were tested with two bacterial levels, community (beta diversity) and 16S rRNA gene amplicon sequence variants (ASVs).

RESULTS

We validated known associations of the skin microbiota with skin microenvironment, age, body mass index and sex. These factors were associated with beta diversity and abundance of ASVs in PopGen, which was largely replicated in KORA FF4. Most intriguingly, dietary macronutrients and total dietary energy were associated with several ASVs. ASVs were also associated with smoking, alcohol consumption, skin pH, skin type, transepidermal water loss, education and several environmental exposures, including hours spent outdoors. Associated ASVs included members of the genera Propionibacterium, Corynebacterium and Staphylococcus.

CONCLUSIONS

We expand the current understanding of factors associated with the skin bacterial community. We show the association of diet with skin bacteria. Finally, we hypothesize that the skin microenvironment and host physiology would shape the skin bacterial community to a greater extent compared with a single skin physiological feature, lifestyle and environmental exposure.

3304High sensitive cardiac troponin i at admission and 30 minutes later to rule-in or rule-out acute myocardial infarction - Preliminary results from the RACING-MI trial

Introduction

Current ESC guidelines have introduced a 0h/1h algorithm for accelerated rule-in or rule-out of acute myocardial infarction (MI) when using assay specific high-sensitive cardiac troponin I (hs-cTnI). Several studies have investigated the diagnostic performance and safety of this approach using different hs-cTnI assays. However, little is known of the diagnostic performance of a 0h/30min algorithm.

Purpose

To evaluate the diagnostic accuracy of early rule-in or rule-out of MI after 30 minutes by applying assay specific hs-cTnI cut-off values from a recently validated 0h/1h algorithm.

Methods

We prospectively enrolled chest pain patients suggestive of MI admitted to the Emergency Department. Patients underwent serial hs-cTnI measurements at admission (0 hour) and after 3 hours according to clinical practice. In addition, hs-cTnI measurements were performed after 30 minutes. The assay specific cut-off values from the 0h/1h algorithm were applied to the 30 minute cohort (figure 1). Final diagnosis was adjudicated independently by two physicians.

Results

In total, 943 patients were included. MI was the final diagnosis in 67 (7.1%) patients. Overall, absolute hs-cTnI values after 30 minutes were significantly higher in the MI group than in the non-MI group (19.2 (Q1:Q3) 2.7–75.3) ng/L versus 0.1 (0.2–0.7) ng/L, p<0.001). When applying the assay-specific hs-cTnI cut-off valuesfor the 0h/1h algorithmto the 30 minute patient cohort, 52.4% of patients were classified as rule-out with a negative predictive value of 100% (95% CI: 99.2–100). In total, 8.5% were classified as rule-in with a positive predictive value of 83.8% (95% CI: 74.2–90.3). Sensitivity was 100% (95% CI: 94.6–100) and specificity was 97.4% (95% CI: 95.7–98.6). Overall, 39.1% were assigned to the observational zone with a 3.5% prevalence of MI.

Conclusions

The use of assay specific hs-cTnI measurement at admission (0h) and 30 min later can be used to safely rule-out MI. This indicates that it might be safe to develop a 0h/30min algorithm and hereby reduce time to diagnosis even further. NCT03634384.

Acknowledgement/Funding

Randers Regional Hospital, A.P Møller Foundation, Boserup Foundation, Korning Foundation, Højmosegård Grant, Siemens Healthcare (TNIH assays), etc.

P2673Challenging time limits: Using a single high-sensitive troponin I to rule-out acute myocardial infarction in early presenters

Introduction

According to ESC guidelines, an acute myocardial infarction (MI) can be excluded without serial troponin measurements in patients presenting with a single high-sensitive troponin below the 99th percentile and chest pain starting >6 hours prior to admission. However, it is unclear if single-testing of high-sensitive troponin can rule-out MI in early presenters.

Purpose

To investigate the diagnostic performance of a single value of high-sensitive cardiac troponin I (hs-cTnI) at presentation for ruling-out MI in patients presenting with chest pain to the Emergency Department irrespective of chest pain onset.

Methods

We conducted a substudy of preliminary data from the RACING-MI trial. We included patients presenting with chest pain suggestive of MI to the Emergency Department of a Regional Hospital. We used the Siemens hs-cTnI (Siemens Healthcare, TNIH, Limit of detection: 2.21 ng/L) and a diagnostic cut-off value <3 ng/L to rule-out MI at presentation. Two physicians independently adjudicated the final diagnosis based on all clinical information. Patients were stratified based on time from chest pain onset to hospital admission as very early (0–3 hours), early (3–6 hours) and late presenters (>6 hours).

Results

We included 989 patients with available hs-cTnI results at admission. MI was confirmed in 82 (8.3%) patients. Using hs-cTnI <3 ng/L as diagnostic cut-off value at presentation, 302 (30.5%) patients without MI were classified as rule-out. Overall, the negative predictive value (NPV) for MI was 100% (95% CI 98.7–100).

Based on chest pain onset, 33.8% of patients were classified as very early, 12.8% as early, and 42.7% as late presenters, with 10.7% patients with unreported/unknown onset. NPV was 100% (95% CI 96.5–100) for very early, 100% (95% CI 88.3–100) for early and 100% (95% CI 97.3–100) for late presenters.

Conclusions

Using a single hs-cTnI value <3ng/L as diagnostic cut-off to rule-out MI seems to be safe and to allow rapid rule-out of MI in patients presenting with chest pain to the emergency department, even in very early presenters.

ClinicalTrials.gov Identifier: NCT03634384.

Acknowledgement/Funding

Randers Regional Hospital, A.P Møller Foundation, Boserup Foundation, Korning Foundation, Højmosegård Grant, Siemens Healthcare (TNIH assays), etc.

Circulating long-non coding RNAs as biomarkers of left ventricular diastolic function and remodelling in patients with well-controlled type 2 diabetes

Contractile dysfunction is underdiagnosed in early stages of diabetic cardiomyopathy. We evaluated the potential of circulating long non-coding RNAs (lncRNAs) as biomarkers of subclinical cardiac abnormalities in type 2 diabetes. Forty-eight men with well-controlled type 2 diabetes and 12 healthy age-matched volunteers were enrolled in the study. Left ventricular (LV) parameters were measured by magnetic resonance imaging. A panel of lncRNAs was quantified in serum by RT-qPCR. No differences in expression levels of lncRNAs were observed between type 2 diabetes patients and healthy volunteers. In patients with type 2 diabetes, long intergenic non-coding RNA predicting cardiac remodeling (LIPCAR) was inversely associated with diastolic function, measured as E/A peak flow (P < 0.050 for all linear models). LIPCAR was positively associated with grade I diastolic dysfunction (P < 0.050 for all logistic models). Myocardial infarction-associated transcript (MIAT) and smooth muscle and endothelial cell-enriched migration/differentiation-associated long noncoding RNA (SENCR) were directly associated with LV mass to LV end-diastolic volume ratio, a marker of cardiac remodelling (P < 0.050 for all linear models). These findings were validated in a sample of 30 patients with well-controlled type 2 diabetes. LncRNAs are independent predictors of diastolic function and remodelling in patients with type 2 diabetes.

Randomised clinical trial: a comparison between a GerdQ-based algorithm and an endoscopy-based approach for the diagnosis and initial treatment of GERD

BACKGROUND

The diagnosis of gastro-oesophageal reflux disease (GERD) remains challenging. An algorithm, facilitated by a questionnaire, may provide a more structured and cost-effective care of patients.

AIM

To compare symptom control achieved with empirical therapy for GERD, in an algorithm based on the GerdQ (new structured pathway, NSP), with that of current care after endoscopy (ordinary clinical pathway, OCP).

METHODS

Patients with symptoms of GERD, but without alarm features, were randomised in an open, parallel-group study and followed for 4-8 weeks. In the NSP, GerdQ score was used as a basis for both diagnosis and a treatment algorithm. Patients with high likelihood of GERD were treated empirically with a PPI whereas patients with low likelihood of GERD received therapy chosen by the clinician. In the OCP, diagnosis and treatment were based on endoscopy or pH-metry findings. The statistical hypothesis was non-inferiority of NSP to OCP.

RESULTS

A total of 147 patients (86.5%) in the NSP and 133 patients (80.1%) in the OCP arm were responders. Overall, NSP was non-inferior to OCP, but not superior (P = 0.14). Patients with high likelihood of GERD had significantly better symptom relief in the NSP (P = 0.03), whereas those with low likelihood of GERD showed a numerical difference in favour of an endoscopy-based approach (OCP). NSP saved 146 € per patient.

CONCLUSIONS

A symptom-based approach using GerdQ reduced health care costs without loss in efficacy. Patients with high likelihood GERD benefited from empirical treatment. An algorithm based on GerdQ may provide physicians with a tool for a more structured care of patients (ClinicalTrials.gov NCT00842387).

Novel techniques and targets in cardiovascular microRNA research

MicroRNAs (miRNAs) are highly conserved, tiny (∼22 nucleotides) non-coding RNAs that have emerged as potent regulators of mRNA translation. miRNAs exhibit fine-tuning of the control of proteins involved in cell signalling (AE) pathways and in vital cellular and developmental processes. miRNAs are expressed in cardiovascular tissues, and multiple functional aspects of miRNAs underscore their key role in cardiovascular (patho)physiology. The development and increasing use of novel molecular biology tools have contributed to the recent success in miRNA research. In the present review, we discuss current updates on important and novel miRNA techniques, including: (i) miRNA screening tools; (ii) bioanalytical target prediction tools; (iii) target validation tools; and (iv) manipulative miRNA expression tools. We also present an update about recently identified miRNA targets that play a key role in cardiovascular development and disorders.

A double-blind, placebo-controlled, randomized study to evaluate the efficacy, safety and tolerability of tegaserod in patients with irritable bowel syndrome

BACKGROUND

Tegaserod has been shown to be an effective therapy for the multiple symptoms of irritable bowel syndrome (IBS) in Western and Asia-Pacific populations. This study evaluated the efficacy, safety and tolerability of tegaserod versus placebo in patients with IBS.

METHODS

Patients with IBS (excluding those whose primary bowel symptom was diarrhoea) were randomized to receive either tegaserod 6 mg b.i.d. (n = 327) or placebo (n = 320) for a 12-week double-blind treatment period. The primary efficacy variable (over weeks 1 to 4) was the response to the question: 'Over the past week do you consider that you have had satisfactory relief from your IBS symptoms?' Secondary efficacy variables assessed overall satisfactory relief over 12 weeks and the individual IBS symptoms.

RESULTS

Overall satisfactory relief was greater in the tegaserod group than in the placebo group. Over weeks I to 4, the odds ratio was 1.54, that is, the odds of satisfactory relief were 54% higher in the tegaserod group than in the placebo group (95% confidence interval for odds ratio (CI) (1.14, 2.08), P = 0.0049). Over weeks 1 to 12, the odds ratio was 1.78, that is, the odds of satisfactory relief were 78% higher in the tegaserod group than in the placebo group (95% CI (1.35, 2.34), P < 0.0001). A statistically significant therapeutic gain over placebo was observed for the majority of weeks from week 1 to week 12 (except weeks I and 4), with a mean therapeutic gain of 7.3 and 10.6 percentage points over weeks 1-4 and weeks 1-12, respectively. Headache was the most commonly reported adverse event (8.0% tegaserod versus 4.7% placebo). Diarrhoea was reported by 9.2% of patients on tegaserod (1.3% on placebo) and led to discontinuation in 2.8% of tegaserod patients.

CONCLUSION

Tegaserod 6 mg b.i.d. is an effective, safe and well-tolerated treatment in patients suffering from IBS without diarrhoea as primary bowel symptom.

Quantitative RT-PCR assessment of melanoma cells in peripheral blood during immunotherapy for metastatic melanoma

Circulating malignant cells in peripheral blood are thought to be precursors and surrogate markers of distant metastases and hence markers of a poor clinical outcome. In this study, we used the detection of MART-1 and tyrosinase (TYR) mRNA with a quantitative reverse transcription-polymerase chain reaction (RT-PCR) assay to identify circulating melanoma cells. Blood samples were obtained from 35 patients with metastatic melanoma before, during and after treatment with interleukin-2, interferon-alpha and cisplatin. In addition, MART-1 and TYR protein was identified by immunohistochemistry in consecutive biopsies from 15 of the patients. Analysis of three daily blood samples for 3 days demonstrated that four out of 11 patients examined were negative for both markers on all occasions, and two patients were positive for both markers on all occasions but one. The remaining five patients showed sporadic low positive results for one or the other of the two markers. By comparing the immunohistochemistry results from consecutive biopsies with the RT-PCR results, we demonstrated that patients with MART-1 and TYR protein in their tumour cells had circulating MART-1 and TYR mRNA in 77% and 54% of the cases, respectively. During treatment, the majority of patients who were positive for MART-1 and TYR mRNA converted to being negative. However, these conversions did not significantly correlate with objective response. The presence of TYR mRNA in one of the first two samples showed a trend towards being an independent prognostic factor for poor survival.

Esomeprazole 20 mg maintains symptom control in endoscopy-negative gastro-oesophageal reflux disease: a controlled trial of 'on-demand' therapy for 6 months

BACKGROUND

Most patients with gastro-oesophageal reflux disease (GERD), regardless of endoscopic status, suffer symptomatic relapse within 6 months of stopping acid suppressant therapy.

AIM

To assess the efficacy of 'on-demand' treatment of GERD with esomeprazole, the first proton pump inhibitor developed as an optical isomer.

METHODS

In this multicentre, double-blind study, 342 endoscopy-negative GERD patients demonstrating complete resolution of heartburn during the final week of a 4-week treatment period with esomeprazole 20 mg or omeprazole 20 mg once daily were randomized to receive esomeprazole 20 mg or placebo on demand (maximum of one dose per day) for a further 6 months. Use of rescue antacids was permitted.

RESULTS

All 342 patients (191 males), aged 19-79 (mean 49) years, were evaluable in the intention-to-treat analysis. The proportion of patients who discontinued treatment due to insufficient control of heartburn was significantly higher among placebo compared to esomeprazole recipients (51% vs. 14%; P < 0.0001). Patients randomized to esomeprazole on-demand therapy remained in the study longer than those in the placebo group (mean 165 vs. 119 days). Over 50% took the study medication for periods of 1--3 consecutive days (esomeprazole) or 4--13 consecutive days (placebo). Use of antacids was > 2-fold higher among placebo recipients. The frequency of adverse events was similar in the two groups, when adjusted for time spent in the study, as were the clinical laboratory profiles.

CONCLUSIONS

On-demand therapy with esomeprazole 20 mg is effective and well tolerated in maintaining symptom control in endoscopy-negative GERD.

Dual-plane lipoplasty for the superficial and deep layers

Two embryologically and histologically distinct layers of the subcutaneous adipose tissue were treated individually by different modalities. The authors performed ultrasound-assisted lipoplasty at the superficial layer and traditional suction-assisted lipectomy in the deep subcutaneous tissue. The ultrasound procedure allowed tissue-specific destruction of the superficial layer supported by dense fibrous networks without disrupting them. Skin retractions caused by this procedure could diminish the necessity of surgical dermolipectomy such as an abdominoplasty in moderately deformed cases. On the other hand, the traditional liposuction was performed to remove the excessive deep fat contained in the loose fibrous network in a limited area. Although the advancement of ultrasound devices and regimens has now reduced their operating times significantly, the ultrasonic lipoplasty was slower than traditional liposuction at the beginning of our procedure. In the abdominal wall, the procedure was performed only in a confined area, because the skin retractions made over the locally managed areas created a circumferential tightness around the trunk, using the nontreated area as a bridge. Confinement on the managed area prevented unnecessary blood loss and tissue destruction. It was less a matter of fat volume to remove in the superficial layer; rather, a precise application to the exact target area was required to get a more natural result. Dual-plane lipoplasty was performed for 2 years in 35 patients, mostly for the abdomen. No serious complication such as seromas or skin loss was observed in our series of patients.

Dose-response study of the effect of growth hormone on mechanical properties of skin graft wounds

The aim of the study was to investigate the effect of growth hormone on compromised wound healing in a model without exogenously applied metabolic disturbances, e.g., diabetes mellitus. Female Wistar rats were injected with biosynthetic human growth hormone (b-hGH) at 2.0, 4.0, 8.0, and 16.0 mg/kg/day from 7 days before operation to 7 days after. Controls were given saline. On the left side of the dorsal skin a 35 x 20-mm full-thickness skin graft was raised and replaced in situ. After 7 days of healing the wound between the graft and the skin was tested mechanically. The maximum load and maximum stiffness showed a positive correlation with dose of b-hGH, being increased by 40 and 47% in the 8.0 mg group and 34 and 48% in the 16.0 mg group compared with the saline group. During the 7 days of injection before operation serum insulin-like growth factor I (IGF-I) decreased in the saline group, was unchanged in the group given 2.0 and 4.0 mg b-hGH, and was increased in the groups given 8.0 and 16.0 mg b-hGH. Postoperatively, no changes in se-IGF-I were seen in any of the groups when compared to the values at operation. Blood glucose was unaffected by b-hGH treatment. Postoperatively the saline-treated rats showed an 8% weight loss and the 2.0 mg b-hGH group a 3% weight loss, whereas no significant changes were seen postoperatively in the 4.0, 8.0, and 16.0 mg b-hGH groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Gastrointestinal diseases--the place of endoscopy in examination, treatment and control]

Dyspepsia, defined as discomfort in the upper abdomen after a meal, is the most frequent indication for gastroscopy. Such dyspepsia was earlier considered to be an element of the ulcer disease, Moynihan's disease. Whether examination showed an ulcer or not was of minor importance as long as the treatment was the same. Similar opinions still contribute to a negative attitude towards the need to obtain a more specific diagnosis, especially in young patients where risk of cancer is low. We are of the opinion that dyspepsia is a non-specific symptom of several different diseases, and that curative therapy is often available today provided the diagnosis is correct. It is therefore necessary to make an active effort to diagnose the cause of the dyspepsia, also in younger persons. In practice, this means that there are many different indications for gastroscopy. We try, however, to practice a restrictive policy with respect to control gastroscopy.

Mechanical properties of skin graft wounds

In female Wistar rats the mechanical strength development of the wound between a skin graft and the neighbouring intact skin (graft wound) was compared with that of ordinary incisional wounds after 4, 7, 14 and 21 days of healing. In one group of rats a 35 x 20 mm skin graft including the subcutaneous muscle was raised and replaced in situ on the left side of the back and a 35 mm incisional wound was made on the right side. In another group a 35 mm incisional wound was made on the right side of the back only. After 4 days the maximum load, maximum stiffness and relative failure energy of the graft wounds were 49, 43 and 40% less respectively than those of the incisional wounds from the same animals and after 7 days the maximum load and maximum stiffness of the graft wounds were reduced by 26 and 29%. However, after 14 and 21 days no differences in mechanical properties were found between these two types of wounds. Compared with the incisional wound from rats without graft the maximum load, maximum stiffness and relative failure energy of the graft wound were reduced by 57, 58 and 44% after 4 days, 59, 62 and 54% after 7 days, 37, 38 and 29% after 14 days and for maximum load and maximum stiffness a reduction of 33 and 31% was found after 21 days of healing.

[Endoscopic hemostasis in hemorrhagic peptic ulcer. A review and pilot study of local thrombin injection combined with systemic fibrinolysis inhibition (with tranexamic acid)]

Today, most upper GI-haemorrhages can be handled without surgery. We discuss the available endoscopic haemostatic methods. Injection therapy seems to be as effective as laser-, heater probe- and bipolar electrocoagulation, and is often preferred because the equipment is inexpensive. In a pilot study of 37 patients with haemorrhage from peptic ulcer (13 with active bleeding and 24 with stigmata of recent hemorrhage) we injected thrombin in the ulcer base and treated the patients systemically with an antifibrinolytic drug (tranexamic acid) for five days. Endoscopic follow-up revealed stigmata of recent haemorrhage in 23 patients on day 1 and in eight patients on day 5. "Blood in stomach" was seen in eight patients on day 1 and in two patients on day 5. Four patients had clinical signs of rebleeding, but only one of them needed operation (definite hemostasis 97%). There were no obvious side effects of the treatment. Contrary to other endoscopic methods, local injection of thrombin does not damage the normal mucosa. However, the method has not been sufficiently explored as yet, and cannot be recommended without strict control and follow-up measures. Early control endoscopy seems to be a sensitive way of monitoring haemostasis.