AB1452 EVALUATION OF HEPATITIS E VIRUS INFECTION DURING JAK INHIBITOR THERAPY IN AUTOIMMUNE INFLAMMATORY RHEUMATIC DISEASES

Background

Although impacting hundreds of thousands of people in Western nations each year, hepatitis E virus (HEV) is an under-reported health problem (1). HEV usually is a self-limiting disease, but especially immunocompromised individuals are at risk to develop a chronic course of infection, with rapid progression to fibrosis, cirrhosis or even the development of liver failure. Janus kinase (JAK) inhibitors are a novel drug class for the treatment of autoimmune inflammatory rheumatic disease (AIRD). As JAKs play a key role in innate immunity, viral infections and reactivation are frequently reported during JAK inhibitor treatment in AIRD patients (2).

Objectives

To characterize the influence of JAK inhibitors on HEV replication ex vivo and assess the risk for the development of symptomatic HEV infection during JAK Inhibitor therapy in vivo.

Methods

To determine the effect of JAK inhibitors on HEV replication we performed infection experiments with primary human hepatocytes (PHH) followed by immunofluorescence analysis and RNAseq. To evaluate the risk of HEV infection during JAK Inhibitor therapy, we monitored HEV RNA and HEV IgG/IgM of 111 AIRD patients, receiving JAK inhibitors. Moreover, we conducted a retrospective analysis of liver enzymes of patients which were anti-HEV IgG/IgM positive.

Results

Transcriptomic analysis of PHH revealed an upregulation of innate immunity components during HEV infection. This induction was perturbed in the presence of a JAK inhibitor, concomitant with strong elevation of HEV RNA levels. In line, infection experiments displayed an up to 50-fold increase of progeny virus production during JAK inhibitor treatment indicating that JAK signaling is critical to control HEV infection. Monitoring of seroprevalence identified 17 patients which were anti-HEV IgG and/or IgM positive, while no patient hat detectable HEV RNA levels. Five patients had detectable anti-HEV IgM levels suggesting a recent HEV infection. Three of 17 had a period with elevated liver enzymes (f.e. GGT> 200 U/L) during time of retrospective analysis (ranging from 10 to 23 months).

Conclusion

Obtained ex vivo data suggest that JAK inhibition facilitates HEV life cycle progression. Considering that JAK inhibitors are routinely applied for the treatment of AIRD, these patients may be at higher risk for a symptomatic course and outcome of HEV infection. In addition to established protocols, screening for HEV seroprevalence and HEV RNA should be considered prior starting JAK inhibitor treatment and in case of elevated liver enzymes during JAK inhibitor therapy.

References

[1]Faber M., Willrich N., Schemmerer M., Rauh C., Kuhnert R., Stark K., Wenzel J.J. Hepatitis E virus seroprevalence, seroincidence and seroreversion in the German adult population. J. Viral Hepat. 2018;25:752–758.

[2]Winthrop KL. The emerging safety profile of JAK inhibitors in rheumatic disease. Nat Rev Rheumatol. 2017;13:234–243.

Disclosure of Interests

None declared

A probable cause of paradoxical thrombosis in zygomycosis. Eine wahrscheinliche Ursache paradoxer Thrombose bei Zygomykose

Invasive zygomycoses (syn. mucormycoses) are rather rare but life-threatening diseases which often take a peracute course. Particularly endangered are diabetics and patients suffering from siderophilia. Zygomycosis is regularly complicated by thrombosis and subsequent necrosis. Usually it evolves from sinusitis in a rhinocerebral form. With the use of a clinical isolate (Rhizopus microsporus) and sera of the same female survivor, we investigated possible sources of the typical blood clotting. The results suggest that coagulation is probably initiated in a bimodal manner by an extracellular serine proteinase of the fungus and by elastase from the patients' leukocytes. The former causes a partial hydrolysis of fibrinogen, while the latter activates coagulation factor XIII (fibrin stabilizing factor). Both proteinases were present in the patient at the site of infection, and in vitro they jointly bring about regular clotting of fibrinogen.

Permanent pacemaker therapy before and after the reunification of Germany: 16 years of experience at an East German regional pacing center

The reunification of Germany had a significant influence on the management of patients with bradyarrhythmias. The current study was performed in a regional pacing center located in the former German Democratic Republic. It compares the situation of patients with critical bradyarrhythmias before and after the reunification of Germany in 1990 focusing on (1) indication for pacemaker implantation, (2) pacemaker modalities and function, (3) type of leads, (4) frequency of reintervention, and (5) early and late complications. The study covers 9 years before and 7 years after the reunification. A total of 1,125 patients were included, and the database was formed by the patients' files and the protocols of implantation. The situation before reunification was characterized by a nonavailability of modern physiological pacing devices and insufficient diagnostic equipment. Between 1981 and 1990, 384 patients underwent pacemaker implantation solely receiving single chamber devices with no or only minimal feasibility of programming. Between 1990 and 1996, 741 patients were treated, and they all received modern pacemakers having the capability of multiprogramming and telemetry. Regarding complications of pacemaker therapy, lead related problems significantly decreased after the reunification (dislocation, 5.3% vs 1.7%, P < 0.05; exit block, 6.7% vs 1.4%, P < 0.05) opposite to pacemaker infections, which significantly increasing after dual chamber pacemakers were implanted (2.2% vs 6.0%, P < 0.05). The reunification of Germany dramatically improved the situation of patients with critical bradyarrhythmias leading to free access to high-tech pacing equipment within a few months. However, the abrupt change from antiquated to modern pacemaker therapy created some new problems, especially regarding application and handling of modern physiological pacing devices.

Steep central islands after myopic photorefractive keratectomy

PURPOSE

To investigate the formation of steep central islands and their reduction under modified experimental conditions.

SETTING

University Eye Hospital Münster and Schwind Co., Kleinostheim, Germany.

METHODS

Corneas of enucleated intact bovine eyes were treated with the Schwind Keratom. All experimental conditions were repeated six times in six different corneas. Eight experimental groups were looked at. Fluence was 180 to 200 mJ/cm2. Ablation mode (phototherapeutic keratectomy ([PTK] and standard myopic photorefractive keratectomy [PRK]), internal repetition rate (3 to 30 Hz), and ablation diameter (5 to 8 mm) and depth (4 to 15 diopters [D] in PRK) were varied. Modifications to reduce or avoid steep central islands included blowing nitrogen gas and aerosol over the cornea, cleaning the cornea of fluid, and using an anti-central-island software program.

RESULTS

In PTK, an increase in the internal repetition rate resulted in a decrease in the height of the steep central island. In standard PRK, increasing refractive correction up to -8.0 D and increasing the ablation diameter resulted in an increase in steep central island power. The anti-central-island program, blowing aerosol, and cleaning the cornea reduced the formation of steep central islands and blowing nitrogen gas eliminated them.

CONCLUSION

Steep central islands are created by a wide-field ablation process and are probably caused by many factors. Both software and hardware modifications can be used to reduce their formation.

Electromyographic investigation of stretching: the effect of warm-up

OBJECTIVE

To compare the fine wire electromyographic (EMG) firing patterns during static stretches in the biceps femoris, soleus, and gastrocnemius before and after warm-up as well as over time.

DESIGN

Experimental single group pretest-posttest design.

SETTING

Biomechanics research laboratory.

PARTICIPANTS

Sixteen healthy volunteers 23 to 36 years of age with no history of lower extremity injury.

INTERVENTION

Subjects performed one hamstring stretch and four calf stretches for 90 seconds, bicycled for 30 minutes as a warm-up, and stretched again.

MAIN OUTCOME MEASURE

EMG was recorded at time 0, 30, 60, and 90 seconds during the stretches before and after warm-up. Recorded values were normalized to EMG during maximum manual muscle testing (MMT). A two-way analysis of variance with repeated measures (p < 0.05) was done to compare EMG activity during stretching before and after warm-up as well as over time.

RESULTS

Low EMG activity was seen for all muscles (< 20% MMT). It was constant over the time of the stretch for all muscles, but it increased in the soleus during the bent knee stretch position. There was a statistically significant decrease in the EMG activity after the warm-up for the gastrocnemius using the traditional and heel off stretching positions and for the soleus using the heel off stretching position (p < 0.05). The biceps femoris EMG activity showed no significant differences before and after warm-up.

CONCLUSIONS

EMG activity during static stretching was low. Overall, the EMG activity remained constant with time for a given stretch position. EMG of the soleus and gastrocnemius was significantly less after warm-up for some stretches, whereas the EMG activity of biceps femoris showed no differences before and after warm-up.

Human polyomavirus JC control region variants in persistently infected CNS and kidney tissue

The question of a possible role for JC virus (JCV) genomic rearrangements in the pathogenesis of progressive multifocal leukoencephalopathy (PML) was addressed by analysis of the genomic complexity and the transcriptional control region (TCR) of the JCV DNA population in persistently infected CNS and kidney tissue. After cloning of full-length viral DNA, no extensive changes were detected in the coding regions of the JCV genome by restriction analysis suggesting an intact JCV DNA population. For further analysis of the distribution of JCV subtypes, the non-coding region was amplified by PCR. Molecular analysis revealed homogeneous JCV TCR populations in almost 50% of the individuals. Heterogeneity was found in two CNS samples with three and five different JCV subtypes, respectively, and in four kidney specimens with two TCR subtypes. Altogether, seven TCR subtypes were identified. One in each group represented single promoter element TCRs without duplication of sequences. The TCR of the major variant JCV-W1 was comparable in sequence and structure to that of the PML prototype JCV Mad-1 DNA. The identification of dominant PML-derived JCV TCR subtypes in most persistently infected individuals suggests that rearrangements of the JCV TCR can be associated with the persistent state of infection. However, it appears unlikely that PML-associated JCV subtypes are generated anew in each individual host in the course of persistence. The findings rather suggest that a limited number of stable JCV subtypes circulate in different geographical regions of the world.

Heparinized saline versus normal saline in maintaining patency of the radial artery catheter

OBJECTIVE

To compare the ability of normal versus heparinized saline infusion to maintain patency of the radial artery catheter used for monitoring or multiple blood sampling.

DESIGN

Randomized double-blind trial.

SETTING

A university-affiliated hospital.

PATIENTS

All 108 patients admitted to the surgical intensive care unit who required radial arterial line catheters. Excluded were patients who required emergency admission, those who refused to give consent, those who needed anticoagulants, thrombolytic or platelet therapy, those whose cannulation site was other than the radial artery, inadvertent discontinuation of the arterial line or incomplete data collection. This resulted in a sample of 78 adults, randomized according to date of admission.

INTERVENTIONS

Forty patients admitted on odd-numbered dates received heparinized normal saline (2 units/mL), and 38 patients admitted on even dates received normal saline, both as continuous flush solutions.

MAIN OUTCOME MEASURES

Measurement of radial artery flow and pressure before and after cannulation, and catheter patency during cannulation.

RESULTS

The type of flush solution did not adversely affect the radial artery or the hand in any measurable way. Catheter blockage occurred in three patients receiving heparinized saline and seven patients receiving normal saline as the flush solution (p = 0.06). At 96 hours of cannulation, 92% of the catheters in the heparinized saline group were patent compared with 74% in the normal saline group. Intra-arterial blood pressure was inaccurate compared with the brachial cuff pressure in 6 patients in the heparinized saline group compared with 14 patients in the normal saline group (p < 0.03).

CONCLUSIONS

There is no significant difference between flushing with normal saline and heparinized saline in the maintenance of radial arterial line patency. However, the use of a continuous heparinized flush solution in pressurized arterial lines is beneficial in that it results in greater accuracy of blood pressure monitoring than normal saline infusion.

Evidence of human polyomavirus BK and JC infection in normal brain tissue

Infection with the polyomaviruses JC and BK is ubiquitous in the human population and JCV is the only virus associated with the central nervous system disease progressive multifocal leukoencephalopathy. In the attempt to analyze the pathogenesis of polyomavirus infections we asked whether human polyomaviruses invade the brain during persistence. Brain autopsy material from 67 individuals with disorders other than PML was examined for the presence of polyomavirus DNA. Southern blot analysis demonstrated JCV-specific full-length virus genomes in healthy brain tissue in about 20% of the patients. Type-specific analysis with polymerase chain reaction and sequencing confirmed these data. Additionally, the presence of BKV DNA sequences covering an early gene fragment and the control region with flanking early and late protein coding sequences was detected. Cloning of the complete BKV genome from two cases supported the assumption that not only full-length JCV DNA was present in those tissue specimens but also BKV genomes. The data obtained demonstrate that dual infection of the brain with the polyomaviruses JCV and BKV is a common event and give strong evidence that both viruses frequently establish a latent CNS infection.

Poor implantation of cryopreserved reinsemination-fertilized human embryos

OBJECTIVE

To investigate whether a poor rate of implantation after in vitro fertilization (IVF) was due to poor embryonic/endometrial synchrony during the original IVF cycle, we have cryopreserved reinseminated-fertilized embryos for later more synchronous replacement after thawing. The chance of implantation of fresh reinseminated fertilized human oocytes is approximately one tenth that of timely fertilized embryos. STUDY DESIGN AND DATA: Retrospective study of 35 original oocyte collections in which initial normal fertilization was 47.3% (129/273 oocytes), with 49.6% fertilization (67/135) upon reinsemination. Of these, 70 initially fertilized and 67 reinsemination-fertilized embryos were cryopreserved, and 50 initially fertilized and all 67 reinsemination-fertilized embryos were subsequently thawed with 72% and 63% cryosurvival, respectively, (not significant).

SETTING

Private infertility clinic.

RESULTS

In 11 cycles, 23 thawed initially fertilized embryos (group A) were replaced with a 21.7% implantation rate per embryo; in 10 cycles, 13 initially fertilized and 12 reinsemination-fertilized embryos (group B) were replaced together with an 8% implantation rate; finally, in 16 cycles, 30 reinsemination-fertilized embryos (group C) were replaced with a 3.3% implantation rate (group A versus group C: P = 0.076). Comparison of clinical pregnancies between these groups was significantly different (6/11 versus 1/16; P = 0.0427).

CONCLUSION

Reinsemination-fertilized embryos survive freezing as well as initially fertilized embryos, but better embryonic/endometrial synchrony does not improve chances of their implantation.

Immunosuppression supports implantation of zona pellucida dissected human embryos

The effect of low dose immunosuppression with methylprednisolone during the first 4 days after oocyte retrieval on potential immune cell invasion of partially zona dissected embryos in utero was investigated in alternate in vitro fertilization patients (n = 32). The incidence of pregnancy was significantly higher in patients receiving methylprednisolone (7 of 18, 39%) than in control patients (1 of 14, 7%). Twenty-eight percent (11 of 39) of the embryos replaced in the corticosteroid treated patients implanted, whereas only 7% (2 of 31) of embryos in control patients had a fetal heart beat. There were no side effects reported in any of the patients receiving corticosteroids. It can be concluded that methylprednisolone supports implantation of embryos with small holes in their zonae. However, the actual mechanisms of corticosteroid support on the interaction between immune cells and micromanipulated embryos are not well understood.

Observations on the morphology of pronuclei and nucleoli in human zygotes and implications for cryopreservation

The effects of cryopreservation on human zygotes at various stages between the appearance of pronuclei and their close association were investigated. Pronuclear zygotes (n = 233) from 101 patients were frozen using propanediol 21-35 h following egg collection. The incidence of implantation of thawed pronuclear zygotes frozen 29-35 h following oocyte collection was significantly higher than that of younger pronuclear zygotes (28 versus 10%, respectively). Zygote age did not affect cell survival following cryostorage. The diameter and association of pronuclei and the number and distribution of nucleoli were determined from video tape recordings of 140 fresh zygotes. Pronuclear migration continued after pronuclear enlargement. The number of nucleoli remained constant during pronuclear migration, but their random distribution within the pronucleus diminished. Strongly adhered pronuclei had significantly more aligned nucleoli on adjacent sides than pronuclei which were still visually separated by ooplasm. This equatorial distribution of nucleoli was noted in the majority of zygotes older than 26 h. The findings suggest that zygote cryopreservation should be initiated when pronuclear migration is completed. This moment can be determined accurately by studying pronuclear association and nucleolar alignment.

[Pemphigus vulgaris with involvement of duodenum and colon]

Pemphigus vulgaris should be numbered among the many causes of gastrointestinal hemorrhage. In our present case, the lesions of the intestinal mucosa occurred some time before those of the oral mucous membranes which finally led to the diagnosis. At the beginning of our century, the possibility of intestinal involvement in pemphigus vulgaris was well-known among dermatologists. We suggest that patients with pemphigus vulgaris should be endoscopically examined in order to confirm the clinical observations made in former times by modern scientific methods.

Time trend analysis of plasma unconjugated and sulfoconjugated estrone and 3 beta-delta 5-steroids in fetal and maternal sheep plasma in relation to spontaneous parturition at term

Parturition in the sheep is preceded by a complex series of changes in both fetal and maternal plasma-steroid hormone concentrations. Using the chronically catheterized fetal sheep preparation, we measured unconjugated and sulfoconjugated pregnenolone, 17 alpha-hydroxypregnenolone, dehydroepiandrosterone, and estrone in fetal and maternal plasma over the final 20 days before spontaneous vaginal delivery at term. Where appropriate, third degree polynomial functions were fitted to the changing plasma hormone concentration profile. Fetal and maternal plasma pregnenolone and pregnenolone sulfate both fell from maximum values in the last 4 days of gestation. Fetal and maternal plasma estrone and estrone sulfate concentrations underwent a terminal rise over the last 4 days of gestation that was a mirror image of the fall in plasma pregnenolone and pregnenolone sulfate. Maternal 17 alpha-hydroxypregnenolone rose over the last 4 days of gestation. Fetal 17 alpha-hydroxypregnenolone, maternal and fetal plasma dehydroepiandrosterone sulfate, and fetal plasma dehydroepiandrosterone sulfate, and fetal plasma dehydroepiandrosterone showed no trend during the period of study. Maternal plasma dehydroepiandrosterone rose over the last 4 days of gestation. These results support the view that increased activity of placental 17 alpha-hydroxylase and 17-20-desmolase is responsible for the conversion of C-21 steroids to estrogens at term. delta 5-Steroids are present in very high plasma concentrations in fetal sheep plasma and may constitute a more important precursor pool for estrogen biosynthesis than does circulating plasma progesterone.