Anorexia Nervosa in vivo cytokine production: a systematic review

INTRODUCTION

The underlying psychobiology that contributes to Anorexia Nervosa (AN) onset and disease progression remains unclear. New research is emerging suggesting a possible link between inflammation and a variety of mental illnesses. Alterations of cytokines may play a role in the pathogenesis of AN. Some studies have found differences in the cytokine profile of those with AN compared to healthy controls, but results are heterogeneous. The aim of this work was to systematically review existing studies investigating in-vivo cytokine production in those with AN before and after weight restoration compared to controls.

METHODS

A comprehensive literature search of four electronic databases (PubMed, PsychInfo, EMBASE and CINAH) was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines to identify human in-vivo studies investigating the relationship between AN and cytokine production. Data extracted from included studies related to population characteristics (e.g. age, gender, mean mBMI/%IBW), cytokine measurement and relevant findings. Confounding factors (e.g. smoking status, co-morbid mental illness, menstruation status) were also collected.

RESULTS

36 studies were eligible for this systematic review of which the majority were conducted in Europe (77.8%) and involved female subjects (97.2%). Those with AN ranged in age from 13 to 47 years and had an illness duration of 3 months to 24 years. 15 candidate cytokines and 3 receptors were identified (TNF-alpha, IL-6, IL-1B, CRP, IL-2, IL-7, IL-10, IFN-γ, TNF-R2, IL-1 α, IL-15, TNF-R1, IL-17, IL-18, TGF-B1, IL-12, IL-6R and TGF-B2) exploring in-vivo levels in patients with AN and comparing to controls. TNF-alpha and IL-6 were the most extensively studied with IL-6 being significantly elevated in 4 out of 8 (50%) of longitudinal studies when comparing AN patients at baseline compared to post weight restoration. Following weight restoration, there was no difference in IL-6 levels when comparing to HC in 7 of 8 (87.5%) longitudinal studies examined.

CONCLUSIONS

The most promising cytokine potentially involved in the pathogenesis of AN appears to be IL-6, and possibly TNF-alpha pathways. The heterogeneity of clinical and methodology factors impedes the generalizability of results. Future studies may wish to address these methodological shortcomings as alterations in cytokine levels in AN could act as therapeutic targets assisting with weight restoration and psychopathology and may offer diagnostic potential.

Intercomparison of bidirectional reflectance distribution function measurements at in- and out-of-plane geometries

In recent years, there has been a growing interest in the measurements of the bidirectional reflectance distribution function (BRDF) in industry and research and development. However, there is currently no dedicated key comparison to demonstrate the scale conformity. To date, scale conformity has been proved only for classical in-plane geometries, in comparisons between different national metrology institutes (NMIs) and designated institutes (DIs). This study aims at expanding that with nonclassical geometries, including, for the first time, to the best of our knowledge, two out-of-plane geometries. A total of four NMIs and two DIs participated in a scale comparison of the BRDF measurements of three achromatic samples at 550 nm in five measurement geometries. The realization of the scale of BRDF is a well-understood procedure, as explained in this paper, but the comparison of the measured values presents slight inconsistencies in some geometries, most likely due to the underestimation of measurement uncertainties. This underestimation was revealed and indirectly quantified using the Mandel-Paule method, which provides the interlaboratory uncertainty. The results from the presented comparison allow the present state of the BRDF scale realization to be evaluated, not only for classical in-plane geometries, but also for out-of-plane geometries.

POS1216 SYMPTOM RATES, ATTITUDES AND MEDICATION ADHERENCE OF RHEUMATIC AND MUSCULOSKELETAL DISEASE PATIENTS DURING THE SARS-CoV2 PANDEMIC

Background:

SARS-CoV2 has caused over two million deaths globally. The relationship between rheumatic and musculoskeletal disease (RMDs), immunosuppressive medications and COVID-19 is unclear.

Objectives:

This study explores the rates of COVID-19 symptoms and positive tests, DMARD adherence and attitudes to virtual clinics. amongst RMD patients.

Methods:

An online population survey was disseminated via the Arthritis Ireland website and social media channels.

Results:

There were 1381 respondents with RMD, 74.8% were on immunosuppressive medication. COVID-19 symptoms were reported by 3.7% of respondents of which 0.46% tested positive, no different from the general population at that timepoint. The frequency of COVID-19 symptoms was higher for respondents with spondyloarthropathy [odds ratio (OR) 2.06, 95% CI: 1.14, 3.70] and lower in those on immunosuppressive medication (OR 0.48, 95% CI: 0.27, 0.88), and those compliant with health authority (HSE) guidance (OR 0.47, 95% CI: 0.25, 0.89). Adherence to RMD medications was reported in 84.1%, with 57.1% using health authority guidelines for information on medication use. Importantly, adherence rates were higher amongst those who cited guidelines (89.3% vs 79.9%, P <0.001), and conversely lower in those with COVID-19 symptoms (64.0% vs 85.1%, P =0.009). Finally, the use of virtual clinics was supported by 70.4% of respondents.

Conclusion:

The rate of COVID-19 positivity in RMD patients was similar to the general population. COVID-19 symptoms were lower amongst respondents on immunosuppressive medication and those adherent to medication guidelines. Respondents were supportive of HSE advice and virtual rheumatology clinics.

Disclosure of Interests:

Kieran Murray Grant/research support from: Bresnihan Molloy and Newman fellowships, Sean Quinn: None declared, Matthew Turk: None declared, Anna O’Rourke: None declared, Eamonn Molloy: None declared, Lorraine O’Neill: None declared, Anne Barbara Mongey: None declared, Ursula Fearon: None declared, Douglas Veale: None declared.

POS0964 CHARACTERISTICS AND BURDEN OF DISEASE IN PATIENTS WITH RADIOGRAPHIC VERSUS NON-RADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN THE ANKYLOSING SPONDYLITIS REGISTRY OF IRELAND COHORT

Background:

Axial spondyloarthritis (axSpA) is an umbrella term for types of inflammatory arthritis that primarily affect the spine and the sacroiliac joints. It is comprised of patients with both radiographic (r-axSpA) and non-radiographic features (nr-axSpA). R-axSpA was historically known as Ankylosing Spondylitis. Previous studies have shown the burden of disease to be largely similar in patients with radiographic versus non-radiographic axial spondyloarthritis in cohorts both in the US and Europe [1]. The Ankylosing Spondylitis Registry of Ireland (ASRI) was formed with the objective to measure the burden of axial spondyloarthritis in the population and identify early predictors of a poor outcome. All patients in the registry are 18 years or older and meet Assessment of Spondyloarthritis International Society (ASAS) criteria for a diagnosis of SpA.

Objectives:

To compare the characteristics and burden of disease in patients with radiographic versus non-radiographic axial spondyloarthritis in the ASRI cohort.

Methods:

Patients with radiographic axial spondyloarthritis (r-axSpA) were defined as those with x-ray evidence of sacroiliitis. Patients with non-radiographic axial spondyloarthritis (nr-axSpA) were defined as having MRI evidence of sacroiliitis but no x-ray evidence of sacroiliitis. A standardised clinical assessment was performed on each patient and structured interviews provided patient-reported data. For each patient the following scores were captured: Bath Ankylosing Spondylitis Disease Activity Index (BASDAI), Bath Ankylosing Spondylitis Functional Index (BASFI), Bath Ankylosing Spondylitis Metrology Index (BASMI), Health Assessment Questionnaire (HAQ) assesses the self-reported functional status for performing activities of daily living, and the Ankylosing Spondylitis Quality of Life (ASQoL) questionnaire. Categorical variables were summarized as percentages with frequency counts, and continuous variables with a mean and standard deviation. Statistical comparisons between subgroups were evaluated using 2 sample t-tests for continuous variables and chi-square tests for categorical variables.

Results:

764 patients were available for analysis. Analysis of radiographic status showed 88.1% (n=673) of patients with r-axSpA and 11.9% (n=91) with nr-axSpA. Patients with nr-axSpA were younger (41.3 vs. 46.6 years, p<0.01), had shorter disease duration (14.8 vs. 20.2 years, p<0.01), lower proportion of males (66.6% vs. 78.4%, p=0.02) with lower rates of HLA-B27 positivity (73.6% vs. 90.5%, p<0.01). The nr-axSpA group had lower BASDAI (3.37 vs. 4.05, p=0.01), BASFI (2.46 vs. 3.88, p<0.01), BASMI (2.33 vs. 4.34, p<0.01), ASQoL (5.2 vs. 6.67, p=0.02), and HAQ scores (0.38 vs. 0.57, p<0.01). There were no significant differences in the prevalence of extra-articular manifestations.

Conclusion:

This study provides evidence that the burden of disease is less in patients with non-radiographic axial spondyloarthritis than radiographic axial spondyloarthritis, as demonstrated by better BASDAI, BASFI, BASMI, HAQ and ASQoL scores.

References:

[1]López-Medina C, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open, 2019. 5(2) p1108.

Table 1.r-axSpAnr-axSpAp valuen67391Age (years)46.6 (+/-12.4)41.3 (+/-12.4)<0.01Disease duration (years)20.2 (+/-12.4)14.8 (+/-11.7)<0.01Delay to diagnosis (years)8.41 (+/-8.6)6.34 (+/-7.2)0.03Males78.8% (528)65.9% (60)0.02Females21.5% (145)34.1% (31)0.02HLA-B27+90.50%(440 of 486 available results)73.60%(53 of 72 available results)<0.01BASDAI4.05 (+/-2.39)3.37 (+/-2.31)0.01BASFI3.88 (+/-3.00)2.46 (+/-2.39)<0.01BASMI4.34 (+/-2.08)2.33 (+/-1.42)<0.01ASQoL6.67 (+/-5.55)5.2 (+/-5.53)0.02HAQ0.57 (+/-0.54)0.38 (+/-0.44)<0.01Psoriasis17.8% (120)15.4% (14)0.31IBD11% (74)8.8% (8)0.58Uveitis33.9% (228)34.1% (31)0.54

Disclosure of Interests:

Sean Quinn: None declared, Sinead Maguire: None declared, Finbar Barry O’Shea: None declared, Lorraine O’Neill: None declared, Eamonn Molloy: None declared, Ursula Fearon Speakers bureau: Abbvie, Grant/research support from: Janssen, Abbvie, Pfizer, UCB, Phil Gallagher: None declared, Douglas Veale Speakers bureau: AbbVie, BMS, Celgene, Pfizer, MSD, Roche, Consultant of: AbbVie, Actelion, BMS, Novartis, Pfizer, MSD, Roche, Regeneron/Sanofi, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Roche, Janssen.

AB0370 UTILITY OF CRP AND ESR IN THE DIAGNOSIS OF GIANT CELL ARTERITIS RELAPSE IN A PHASE 2 TRIAL OF MAVRILIMUMAB

Background:

No universally accepted definition of flare currently exists in giant cell arteritis (GCA). Although relapses are defined mostly on clinical grounds (recurrence of GCA-related signs/symptoms), C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) help clinicians assess disease activity. In fact, >70% of patients on glucocorticoids (GCs) alone have increased CRP or ESR when the disease is active. In contrast, tocilizumab, given its IL-6-blockade effect in the liver, rapidly reduces CRP and ESR levels, rendering them unreliable for disease activity monitoring. Mavrilimumab – a GM-CSF receptor α inhibitor with demonstrated efficacy in a Phase 2 GCA trial1 – downregulates inflammation upstream of IL-6. We hypothesized that mavrilimumab would not interfere with the utility of CRP and ESR in monitoring disease activity and in identifying GCA relapse.

Objectives:

To analyze the relationship between CRP/ESR and clinical disease activity in GCA patients treated with mavrilimumab.

Methods:

New-onset and relapsing GCA patients with active disease were recruited. GC-induced remission (no GCA symptoms and CRP <1 mg/dL or ESR <20 mm/hr) was required by baseline. Patients were randomized 3:2 to mavrilimumab 150 mg or placebo subcutaneously every 2 weeks plus a protocol-defined 26-week prednisone taper. The primary efficacy endpoint was time to relapse by Week 26. Relapse (adjudicated) was defined as recurrent GCA-related signs/symptoms, including new/worsening vasculitis on imaging, concurrent with CRP ≥1 mg/dL and/or ESR ≥30 mm/hr. CRP and ESR were also measured periodically during the trial.

This post hoc analysis assessed the association of recurrent GCA-related signs/symptoms with concurrent CRP or ESR elevation post-randomization by treatment arm. We also assessed the proportion of patients with CRP or ESR elevation without GCA-related signs/symptoms up to Week 26.

Results:

Seventy patients were enrolled (mavrilimumab, N=42; placebo, N=28). The association of CRP or ESR elevation with unequivocal GCA-related signs/symptoms post-randomization was consistent regardless of treatment arm: 8/8 in the mavrilimumab group and 13/13 in the placebo group (Table 1). During relapse, median (range) CRP was 1.8 (1.4 – 8.4) mg/dL (mavrilimumab group) and 1.8 (1.1 – 9.0) mg/dL (placebo group). Corresponding ESR values were 39.5 (30 – 102) mm/hr (mavrilimumab group) and 49 (31 – 101) mm/hr (placebo group). Four mavrilimumab recipients had self-limited, equivocal GCA-related signs/symptoms without concurrent CRP or ESR elevation; all 4 completed the prespecified GC taper by Week 26 without need for rescue GCs, so relapse was not confirmed. At least 1 elevated CRP or ESR value in the absence of GCA-related signs/symptoms was observed in 58.8% of mavrilimumab recipients and 93.3% of placebo recipients by Week 26.

Conclusion:

The observed association of CRP or ESR elevation with GCA-related signs/symptoms is consistent with the upstream mechanism and supports the utility of the stringent protocol definition of relapse. The frequency and magnitude of CRP and ESR elevations at relapse were similar in both treatment groups, suggesting that CRP and ESR remain useful in assessments of disease activity in mavrilimumab-treated patients. CRP and ESR elevations without GCA-related signs/symptoms occurred more often in placebo recipients.

References:

[1]Cid, Unizony et al. Arthritis Rheumatol. 2020; 72 (suppl 10)

Table 1.

CRP and ESR levels in patients with or without GCA relapse

Assessment§MavrilimumabPlaceboMavrilimumabPlaceboN=42N=28N=42N=28With RelapseWithout Relapse# of patients8 (19.1)13 (46.4)34 (81.0)15 (53.6) Elevated CRP* or ESR†8 (100.0)13 (100.0)20 (58.8)14 (93.3)  Elevated CRP*7 (87.5)10 (76.9)10 (29.4)11 (73.3)   Median (range) mg/dL1.8 (1.4 - 8.4)1.8 (1.1 - 9.0)2.6 (1.3 – 7.0)2.0 (1.0 – 6.6) Elevated ESR†6 (75.0)9 (69.2)16 (47.1)10 (66.7)  Median (range) mm/hr39.5 (30 - 102)49.0 (31 - 101)41.5 (30 - 110)53.5 (30 - 82)

§# (%), except where indicated otherwise.

*CRP ≥ 1 mg/dL

†ESR ≥ 30 mm/hr

Disclosure of Interests:

Sebastian Unizony Consultant of: Janssen and Kiniksa, Grant/research support from: Genentech, Maria C. Cid Speakers bureau: Roche and Kiniksa, Paid instructor for: GSK and Vifor, Consultant of: Janssen, GSK, and Abbvie, Grant/research support from: Kiniksa, Elisabeth Brouwer Speakers bureau: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Consultant of: Dr. E.Brouwer as an employee of the UMCG received speaker fees and consulting fees from Roche in 2017 2018 which were paid to the UMCG., Lorenzo Dagna Speakers bureau: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Consultant of: Abbvie, Amgen, Biogen, BMS, Celltrion, Galapagos, Glaxo SmithKline, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI; clinical trial for Kiniksa, Grant/research support from: Abbvie, Amgen, BMS, Celltrion, Galapagos, Novartis, Pfizer, Roche, Sanofi-Genzyme, SOBI, Merk Sharp &Dohme, Janssen, Kiniksa, Bhaskar Dasgupta Paid instructor for: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Consultant of: CI UK for the Kiniksa trial, Grant/research support from: Educational grant symposium/workshop for Roche-chugai, Sanofi, and Abbvie, Bernhard Hellmich Consultant of: Honoraria paid to the institution for participation in the clinical trial, Eamonn Molloy: None declared, Carlo Salvarani: None declared, Bruce C. Trapnell Consultant of: Consultant member of DSMB for Kiniksa., Kenneth J Warrington Consultant of: Clinical trial support from Eli Lilly and Kiniksa, Ian Wicks: None declared, Manoj Samant Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Teresa Zhou Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, Lara Pupim Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals, John F. Paolini Shareholder of: Kiniksa Pharmaceuticals, Employee of: Kiniksa Pharmaceuticals

Recommendations and outcomes from a geriatric assessment guided multidisciplinary clinic prior to autologous stem cell transplant in older patients

BACKGROUND

Autologous hematopoietic stem cell transplant (autoHCT) is a mainstay of treatment for multiple myeloma and non-Hodgkin lymphoma but is underutilized in older adults. We investigated the association of vulnerabilities identified by a geriatric assessment (GA)-guided multidisciplinary clinic (MDC) on the receipt of autoHCT and evaluated its ability to predict outcomes in older autoHCT candidates.

METHODS

Patients 50+ years received GA-informed optimization recommendations: 'decline' if unlikely to realize benefits of autoHCT, 'defer' if optimization necessary before autoHCT, and 'proceed' if autoHCT could proceed without delay. We compared characteristics and outcomes of autoHCT recipients (n = 62) to non-autoHCT patients (n = 29) and evaluated GA deficits on outcomes.

RESULTS

91 patients were evaluated; the MDC recommendation was 'decline' for 5 (6%), 'defer' for 25 (27%), and 'proceed' for 61 (67%). AutoHCT recipients had fewer GA-rated impairments relative to non-autoHCT patients, as did patients with a 'proceed' recommendation relative to 'defer'. Among autoHCT recipients, 1-year and 3-year non-relapse morality (NRM) was 0% and 5%, and there was no difference in length of hospitalization, readmission rate, or mortality after transplant by MDC recommendation. Frail grip strength and poor performance status were associated with inferior post-autoHCT progression-free survival and overall survival.

CONCLUSIONS

Patients pursuing autoHCT after MDC-directed optimization achieved excellent outcomes, including patients deferred but ultimately receiving autoHCT. GA-identified functional deficits, especially frail grip strength, may improve risk stratification in older autoHCT candidates. Employing a GA earlier in the disease trajectory to inform early referral to an MDC may increase autoHCT safety and utilization in older patients.

Methodologies to assess paediatric adiposity

INTRODUCTION

Childhood obesity is associated with increased risk of adult obesity, cardiovascular disease, diabetes and cancer. Appropriate techniques for assessment of childhood adiposity are required to identify children at risk. The aim of this review was to examine core clinical measurements and more technical tools to assess paediatric adiposity.

METHODS

The online databases PubMed, CINALH and EMBASE were searched and the abstracts identified were reviewed to determine appropriate studies. Their reference lists were also searched to identify further eligible studies. Publications were included if they described childhood measurement techniques or involved validation.

RESULTS AND DISCUSSION

There are many body composition assessment tools available, none of which are direct. Each technique has limitations and a combination of methods may be used. The main clinical techniques are weight, height, body mass index (BMI) and circumferences which provide sufficient information to enable classification of overweight or obesity when growth centile charts and ratios are employed. Further investigation depends on resources available and examiner skill. Skinfold thicknesses are cost-effective but require technical training and only measure subcutaneous fat. Dual energy X-ray absorptiometry (DEXA), air displacement plethysmography (ADP), magnetic resonance imaging (MRI) and computed tomography (CT) are more costly and intensive, requiring the child to remain still for longer periods. DEXA and ADP are capable of accurately measuring adiposity but are unable to distinguish between fat depots. MRI and CT can distinguish intra-abdominal from subcutaneous adiposity and are considered gold standards, but CT is unsuitable for adiposity measurement in children due to high levels of radiation exposure. Ultrasound is a promising technique capable of measuring intra-abdominal adiposity in children but requires further validation.

CONCLUSION

The core clinical measurements of weight, height, BMI and circumferences are sufficient to enable diagnosis of paediatric overweight and obesity while more technical tools provide further insight.

Perinatal Treponema pallidum: evidence based guidelines to reduce mother to child transmission

Universal antenatal screening for T. pallidum is standard in Irish maternity units. The prevalence of adult syphilis has increased in Ireland. We audited the neonatal management of infants exposed to T. pallidum in utero. A cross sectional retrospective analysis of all pregnancies with confirmed positive serology for T. pallidum from January 2005 to December 2010 was conducted at the National Maternity Hospital, Holles St. Data were analysed using SPSS 14.0. Ethical approval was obtained. There were 55,058 live births during the study period. Fifty-eight women had positive serology and 41 met inclusion criteria. Infant evaluation and follow up was decided by allocation to an evidence based algorithm. Twenty-one infants (51%) were accurately allocated and assessed, 5 (12%) had a partial assessment and the algorithm was incorrectly applied in 15 (36%) of cases. Failure to adhere to evidence based neonatal guidelines is common and undermines efficacy of the screening program.

An epidemiological study of factors associated with preterm infant in-hospital mortality

Nationally representative in-hospital mortality rates among preterm infants are essentially unknown in Ireland. We examined preterm infants born in hospital and admitted to intensive care unit (ICU) between 2005 and 2008. Unadjusted incidence rates and risk ratios were derived. Overall, 6,599 preterm infants were admitted to ICU of whom 256 (3.9%) died prior to hospital discharge. Infants with a birthweight less than 1,000 g were 18.1 (95% CI 12.1-27.1) times more likely to die in hospital. Mortality was high among preterm infants diagnosed with Grade 3/4 intra-ventricular haemorrhage (43.6 deaths per 100 cases; 95% CI 31.0-56.7). Congenital anomaly diagnosis was associated with a five-fold increased risk (RR 5.1; 95% CI 4.0-6.6) of in-hospital mortality. Our population-based study provides reliable estimates of in-hospital mortality among preterm infants admitted to Irish ICUs.

Neonatal respiratory extracorporeal membrane oxygenation (ECMO) referrals

Extracorporeal membrane oxygenation (ECMO) is a complex technique for providing life support in neonatal respiratory failure. T UK Collaborative ECMO trial demonstrated cost-effectiveness and substantial improvements in neurological morbidity and mortality. Currently, infants requiring ECMO in Ireland are referred to one of various centres in the UK and Scandinavia. We aimed to review the number of infants referred from Ireland for respiratory ECMO. All infants with a non-cardiac condition referred from Ireland for ECMO were reviewed for diagnosis and outcomes. Eleven infants required ECMO between June 2006 and January 2009 and were referred to the Scandinavian team for ECMO transport although one infant improved and did not require ECMO following the arrival of the team. Four infants died: one infant died prior to arrival of the ECMO team, 3 infants had fatal diagnoses and one infant with congenital diaphragmatic hernia received pre-op ECMO. The median (inter-quartile range) gestational age was 39.7 (38.3-40.7) weeks and birth weight of 3.7 (3.2-4.0) kg. The median age at the decision to transfer for ECMO was 13h (4-123) and the team arrived at 23 h (12-132). All infants had a normal cranial ultrasound and echo prior to ECMO and 2 infants had an abnormal MRI post-ECMO. The time on ECMO was 9 days (3-17) and total length of hospital stay was 32 d (23-36). There were no pre-ECMO clinical or biochemical

Pharmacological characterization of PF-00547659, an anti-human MAdCAM monoclonal antibody

BACKGROUND AND PURPOSE

The adhesion molecule mucosal addressin cell adhesion molecule (MAdCAM) plays an essential role in the recruitment of lymphocytes to specialized high endothelial venules of the gastrointestinal tract and in their excessive tissue extravasation observed in inflammatory conditions, such as Crohn's disease. We have characterized the in vitro pharmacological properties of two monoclonal antibodies blocking MAdCAM, MECA-367 and PF-00547659, and determined their pharmacokinetic/pharmacodynamic profiles in vivo.

EXPERIMENTAL APPROACH

Functional adhesion assays and surface plasmon resonance were used to characterize, in vitro, the pharmacological properties of MECA-367 and PF-00547659. The in vivo effects of MECA-367 and PF-00547659 on restriction of beta(7) (+) memory T lymphocytes were determined in mice and macaques, respectively, over the pharmacological dose range to confirm pharmacokinetic/pharmacodynamic relationships.

KEY RESULTS

MECA-367 and PF-00547659 bound with high affinity to mouse and human MAdCAM with K(d) values of 5.1 and 16.1 pmol.L(-1) respectively and blocked the adhesion of alpha(4)beta(7) (+) leukocytes to MAdCAM with similar potency. MECA-367 and PF-00547659 induced a similar, dose-dependent two- to threefold increase in circulating populations of beta(7) (+) memory T-cells in the mouse and macaque; without affecting the beta(7) (-) populations.

CONCLUSIONS AND IMPLICATIONS

PF-00547659 has potential utility in the treatment of inflammatory conditions by blocking tissue homing of activated alpha(4)beta(7) (+) leukocytes. The characterization of a rodent cross-reacting antibody as a surrogate for PF-00547659 in the search for potential pharmacological biomarkers and the determination of efficacious doses was effective in addressing the restricted orthologous cross-reactivity of PF-00547659 and the challenges this poses with respect to efficacy and safety testing.

Unravelling referrals to medical outpatients

Little is known about the process of referral to Irish hospital outpatient medical clinics. We analysed pre-referral management, information quality and communication to a general medical outpatient clinic. 100 consecutive attendee referral letters were prospectively assessed for information, appropriateness, legibility and pre-referral management. Patients underwent a questionnaire. We documented the final diagnosis and management patterns. 16% of letters were largely illegible, Only 47% of letters gave examination findings and of those, 40% omitted significant details. Appropriate pre-referral investigations were performed in 55%. Where performed, results were not enclosed in 32%. In 61% of cases therapy could have been instituted prior to referral, of these treatment was not started in 36%. 16% of patients did not understand the reason for referral. 10% of referrals were inappropriate. In this limited study there were substantial communication deficiencies in patient referral. If standard criteria were set (e.g. by proforma) before a referral is accepted perhaps the quality of patient care might improve especially if treatment could be initiated earlier by referring doctors.

Cerebral venous sinus thrombosis precipitated by Graves' disease and Factor V Leiden mutation

We report a case of simultaneous presentation of cerebral venous sinus thrombosis and thyrotoxicosis in a 28 year-old female subsequently found to have the Factor V Leiden mutation. She made an excellent neurological recovery with anticoagulation. The mode of presentation of the case was surprising, as she had no thrombotic episodes in two previous pregnancies. This suggests that thyrotoxicosis may give rise to a hypercoagulable state.

Brain imaging of attention deficit/hyperactivity disorder

Advances in imaging technology allow unprecedented access to the anatomy and physiology of the living, growing human brain. Anatomical imaging studies of individuals with attention deficit/hyperactivity disorder (ADHD) consistently point to involvement of the frontal lobes, basal ganglia, corpus callosum, and cerebellum. Imaging studies of brain physiology also support involvement of right frontal-basal ganglia circuitry with a powerful modulatory influence from the cerebellum. Although not currently of diagnostic utility, further extension and refinement of these findings may offer hope for greater understanding of the core nature of ADHD and possible subtyping to inform treatment interventions.

Intensive enteral nutrition support in paediatric bone marrow transplantation

This study retrospectively analyses the experience with an intensive enteral feeding protocol in children undergoing BMT at the National Paediatric BMT Centre, Our Lady's Hospital for Sick Children, Crumlin, Dublin. Fifty-three patients were transplanted between January 1996 and December 1998; 42 patients received allogeneic transplants, (19 unrelated) and 11 were autologous. Indications included ALL (21), ANLL (3), CML (3), JCML (1), MPS (5), WAS (2), AA/FA (6), NHL/HD (3) and solid tumours (9). Nasogastric (NG) tubes were inserted electively either during conditioning or within the first week when voluntary oral intake had decreased. Nineteen patients were commenced on a whole protein-based formula, 28 on a semi-elemental preparation and two were commenced on an elemental feed. All were maintained on an elemental formula during the period of maximal gut toxicity. Tubes which were vomited were promptly replaced and morphine infusions were routinely employed until mucositis had resolved. Of 49 evaluable patients, 42 (86%) were maintained exclusively on enteral nutrition and seven required parenteral nutrition. Seven patients weighed <85% ideal body weight (IBW) at discharge (range 75-84), only one of whom was <85% IBW at 3 months. Twenty-two patients continued on NG feeds following discharge (median 41 days). No patient had veno-occlusive disease. The programme was overwhelmingly endorsed by patients and/or parents but required intensive multidisciplinary counselling to ensure success.