196 AN AUDIT OF PROTON-PUMP INHIBITOR PRESCRIBING IN PATIENTS ATTENDING A RAPID ACCESS FRAILTY ASSESSMENT UNIT

Background

Proton-Pump Inhibitor (PPI) usage has revolutionised gastroenterology practice with clinical indications for conditions such as Gastro-Oesophageal Reflux Disease (GORD), gastric and duodenal ulceration and Barrett's Oesophagus. However, these drugs are inappropriately prescribed, particularly among patients with an already heavy polypharmacy burden. PPI usage has been linked with electrolyte disturbances, most commonly hypomagnesaemia, resulting in higher rates of osteoporosis. It has also been shown to have adverse effects on renal function, an increased correlation with clostridium difficile and most recently, a deleterious impact on cognitive function. The purpose of this audit was to assess the appropriateness and clinical indication of PPI prescribing among patients attending Rapid Access Frailty Assessment Unit (RAFAU) in 2022.

Methods

A database of patients attending RAFAU in an Irish regional hospital was accessed. Records from years 2021-2022 were searched and documents citing patients’ medical history and clinical indication for prescribed medications included hospital discharge letters, outpatient clinic letters and GP referral letters. NICE guidelines from the UK NHS were used as comparison for prescribing guidelines.

Results

120 patients’ records were assessed. 63 (52.5%) patients were found to be prescribed a PPI among this cohort. Of those taking PPIs, only 15 (23.8%) patients were prescribed a PPI with a documented clinical indication in accordance with NICE Guidelines. Although several patients were taking gastro-erosive drugs including antiplatelets, anticoagulants and steroids, only one patient record mentioned PPIs being prescribed for iatrogenic gastritis. No records mentioned deprescribing or cessation of PPIs.

Conclusion

Most patients prescribed PPIs were without documented appropriate clinical indication and without clear duration of use. This is of particular importance among a frailty population where de-prescribing medications associated with significant co-morbidities should be prioritised.

Survey of Patient Knowledge and Awareness of "Sick Day Rules" in Rheumatology Patients on Long Term Glucocorticoid Therapy

Aims Rheumatic disease (RMD) patients treated with long-term glucocorticoids (GC) are at risk of developing tertiary adrenal insufficiency. With this survey we aimed to assess the knowledge of RMD patients taking long-term glucocorticoid therapy regarding risk of adrenal insufficiency and understanding of the "steroid sick day rules". Methods RMD patients taking ≥2.5 mg prednisolone daily for ≥3 months were recruited from the Rheumatology outpatient department in Beaumont Hospital, Dublin. Patient knowledge and previous counselling of steroid sick day rules was determined using an 8-point questionnaire carried out face-to-face or via phone call. Results 51 RMD patients on GC therapy were recruited. 3/51 (5.9%) of patients reported that they had been counselled on the Sick Day Rules. 2/51 (3.9%) carried a steroid emergency card or MedicAlert bracelet. Few patients would increase their steroid dose appropriately in response to infection, vomiting or peri-procedure [14/51 (27.5%); 9/51 (17.7%) and 5/51 (7.2%), respectively]. Conclusion We demonstrate a significant deficit of patient knowledge around the precautions for long-term GC use in rheumatic diseases. We suspect that our results may be generalisable to many other RMD units. We are currently reviewing our procedures around healthcare professional and patient education, issuing of information leaflets, emergency cards or MedicAlert bracelets etc. to at risk patients.

Zinc Gluconate Induces Potentially Cancer Chemopreventive Activity in Barrett's Esophagus: A Phase 1 Pilot Study

BACKGROUND

Chemopreventive effects of zinc for esophageal cancer have been well documented in animal models. This prospective study explores if a similar, potentially chemopreventive action can be seen in Barrett's esophagus (BE) in humans.

AIMS

To determine if molecular evidence can be obtained potentially indicating zinc's chemopreventive action in Barrett's metaplasia.

METHODS

Patients with a prior BE diagnosis were placed on oral zinc gluconate (14 days of 26.4 mg zinc BID) or a sodium gluconate placebo, prior to their surveillance endoscopy procedure. Biopsies of Barrett's mucosa were then obtained for miRNA and mRNA microarrays, or protein analyses.

RESULTS

Zinc-induced mRNA changes were observed for a large number of transcripts. These included downregulation of transcripts encoding proinflammatory proteins (IL32, IL1β, IL15, IL7R, IL2R, IL15R, IL3R), upregulation of anti-inflammatory mediators (IL1RA), downregulation of transcripts mediating epithelial-to-mesenchymal transition (EMT) (LIF, MYB, LYN, MTA1, SRC, SNAIL1, and TWIST1), and upregulation of transcripts that oppose EMT (BMP7, MTSS1, TRIB3, GRHL1). miRNA arrays showed significant upregulation of seven miRs with tumor suppressor activity (-125b-5P, -132-3P, -548z, -551a, -504, -518, and -34a-5P). Of proteins analyzed by Western blot, increased expression of the pro-apoptotic protein, BAX, and the tight junctional protein, CLAUDIN-7, along with decreased expression of BCL-2 and VEGF-R2 were noteworthy.

CONCLUSIONS

When these mRNA, miRNA, and protein molecular data are considered collectively, a cancer chemopreventive action by zinc in Barrett's metaplasia may be possible for this precancerous esophageal tissue. These results and the extensive prior animal model studies argue for a future prospective clinical trial for this safe, easily-administered, and inexpensive micronutrient, that could determine if a chemopreventive action truly exists.

Applications of Functional Genomics for Drug Discovery

Many diseases, such as diabetes, autoimmune diseases, cancer, and neurological disorders, are caused by a dysregulation of a complex interplay of genes. Genome-wide association studies have identified thousands of disease-linked polymorphisms in the human population. However, detailing the causative gene expression or functional changes underlying those associations has been elusive in many cases. Functional genomics is an emerging field of research that aims to deconvolute the link between genotype and phenotype by making use of large -omic data sets and next-generation gene and epigenome editing tools to perturb genes of interest. Here we review how functional genomic tools can be used to better understand the biological interplay between genes, improve disease modeling, and identify novel drug targets. Incorporation of functional genomic capabilities into conventional drug development pipelines is predicted to expedite the development of first-in-class therapeutics.

Loss of BCAA Catabolism during Carcinogenesis Enhances mTORC1 Activity and Promotes Tumor Development and Progression

Tumors display profound changes in cellular metabolism, yet how these changes aid the development and growth of tumors is not fully understood. Here we use a multi-omic approach to examine liver carcinogenesis and regeneration, and find that progressive loss of branched-chain amino acid (BCAA) catabolism promotes tumor development and growth. In human hepatocellular carcinomas and animal models of liver cancer, suppression of BCAA catabolic enzyme expression led to BCAA accumulation in tumors, though this was not observed in regenerating liver tissues. The degree of enzyme suppression strongly correlated with tumor aggressiveness, and was an independent predictor of clinical outcome. Moreover, modulating BCAA accumulation regulated cancer cell proliferation in vitro, and tumor burden and overall survival in vivo. Dietary BCAA intake in humans also correlated with cancer mortality risk. In summary, loss of BCAA catabolism in tumors confers functional advantages, which could be exploited by therapeutic interventions in certain cancers.

The gold-standard genome of Aspergillus niger NRRL 3 enables a detailed view of the diversity of sugar catabolism in fungi

The fungal kingdom is too large to be discovered exclusively by classical genetics. The access to omics data opens a new opportunity to study the diversity within the fungal kingdom and how adaptation to new environments shapes fungal metabolism. Genomes are the foundation of modern science but their quality is crucial when analysing omics data. In this study, we demonstrate how one gold-standard genome can improve functional prediction across closely related species to be able to identify key enzymes, reactions and pathways with the focus on primary carbon metabolism.

Based on this approach we identified alternative genes encoding various steps of the different sugar catabolic pathways, and as such provided leads for functional studies into this topic. We also revealed significant diversity with respect to genome content, although this did not always correlate to the ability of the species to use the corresponding sugar as a carbon source.

Genomic and exoproteomic diversity in plant biomass degradation approaches among Aspergilli

We classified the genes encoding carbohydrate-active enzymes (CAZymes) in 17 sequenced genomes representing 16 evolutionarily diverse Aspergillus species. We performed a phylogenetic analysis of the encoding enzymes, along with experimentally characterized CAZymes, to assign molecular function to the Aspergilli CAZyme families and subfamilies. Genome content analysis revealed that the numbers of CAZy genes per CAZy family related to plant biomass degradation follow closely the taxonomic distance between the species. On the other hand, growth analysis showed almost no correlation between the number of CAZyme genes and the efficiency in polysaccharide utilization. The exception is A. clavatus where a reduced number of pectinolytic enzymes can be correlated with poor growth on pectin. To gain detailed information on the enzymes used by Aspergilli to breakdown complex biomass, we conducted exoproteome analysis by mass spectrometry. These results showed that Aspergilli produce many different enzymes mixtures in the presence of sugar beet pulp and wheat bran. Despite the diverse enzyme mixtures produced, species of section Nigri, A. aculeatus, A. nidulans and A. terreus, produce mixtures of enzymes with activities that are capable of digesting all the major polysaccharides in the available substrates, suggesting that they are capable of degrading all the polysaccharides present simultaneously. For the other Aspergilli, typically the enzymes produced are targeted to a subset of polysaccharides present, suggesting that they can digest only a subset of polysaccharides at a given time.

Lipids Reprogram Metabolism to Become a Major Carbon Source for Histone Acetylation

Cells integrate nutrient sensing and metabolism to coordinate proper cellular responses to a particular nutrient source. For example, glucose drives a gene expression program characterized by activating genes involved in its metabolism, in part by increasing glucose-derived histone acetylation. Here, we find that lipid-derived acetyl-CoA is a major source of carbon for histone acetylation. Using ¹³C-carbon tracing combined with acetyl-proteomics, we show that up to 90% of acetylation on certain histone lysines can be derived from fatty acid carbon, even in the presence of excess glucose. By repressing both glucose and glutamine metabolism, fatty acid oxidation reprograms cellular metabolism, leading to increased lipid-derived acetyl-CoA. Gene expression profiling of octanoate-treated hepatocytes shows a pattern of upregulated lipid metabolic genes, demonstrating a specific transcriptional response to lipid. These studies expand the landscape of nutrient sensing and uncover how lipids and metabolism are integrated by epigenetic events that control gene expression.

Designing a broad-spectrum integrative approach for cancer prevention and treatment

Targeted therapies and the consequent adoption of "personalized" oncology have achieved notable successes in some cancers; however, significant problems remain with this approach. Many targeted therapies are highly toxic, costs are extremely high, and most patients experience relapse after a few disease-free months. Relapses arise from genetic heterogeneity in tumors, which harbor therapy-resistant immortalized cells that have adopted alternate and compensatory pathways (i.e., pathways that are not reliant upon the same mechanisms as those which have been targeted). To address these limitations, an international task force of 180 scientists was assembled to explore the concept of a low-toxicity "broad-spectrum" therapeutic approach that could simultaneously target many key pathways and mechanisms. Using cancer hallmark phenotypes and the tumor microenvironment to account for the various aspects of relevant cancer biology, interdisciplinary teams reviewed each hallmark area and nominated a wide range of high-priority targets (74 in total) that could be modified to improve patient outcomes. For these targets, corresponding low-toxicity therapeutic approaches were then suggested, many of which were phytochemicals. Proposed actions on each target and all of the approaches were further reviewed for known effects on other hallmark areas and the tumor microenvironment. Potential contrary or procarcinogenic effects were found for 3.9% of the relationships between targets and hallmarks, and mixed evidence of complementary and contrary relationships was found for 7.1%. Approximately 67% of the relationships revealed potentially complementary effects, and the remainder had no known relationship. Among the approaches, 1.1% had contrary, 2.8% had mixed and 62.1% had complementary relationships. These results suggest that a broad-spectrum approach should be feasible from a safety standpoint. This novel approach has potential to be relatively inexpensive, it should help us address stages and types of cancer that lack conventional treatment, and it may reduce relapse risks. A proposed agenda for future research is offered.

SIRT3 regulates progression and development of diseases of aging

The mitochondrial sirtuin SIRT3 is a protein deacylase that influences almost every major aspect of mitochondrial biology, including nutrient oxidation, ATP generation, reactive oxygen species (ROS) detoxification, mitochondrial dynamics, and the mitochondrial unfolded protein response (UPR). Interestingly, mice lacking SIRT3 (SIRT3KO), either spontaneously or when crossed with mouse models of disease, develop several diseases of aging at an accelerated pace, such as cancer, metabolic syndrome, cardiovascular disease, and neurodegenerative diseases, and, thus, might be a valuable model of accelerated aging. In this review, we discuss functions of SIRT3 in pathways involved in diseases of aging and how the lack of SIRT3 might accelerate the aging process. We also suggest that further studies on SIRT3 will help uncover important new pathways driving the aging process.

Immunologic targeting of FOXP3 in inflammatory breast cancer cells

The forkhead transcription factor FOXP3 is necessary for induction of regulatory T lymphocytes (Tregs) and their immunosuppressive function. We have previously demonstrated that targeting Tregs by vaccination of mice with murine FOXP3 mRNA-transfected dendritic cells (DCs) elicits FOXP3-specific T cell responses and enhances tumor immunity. It is clear that FOXP3 expression is not restricted to T-cell lineage and herein, using RT-PCR, flow cytometry, and western immunoblot we demonstrate for the first time that FOXP3 is expressed in inflammatory breast cancer (IBC) cells, SUM149 (triple negative, ErbB1-activated) and SUM190 (ErbB2-overexpressing). Importantly, FOXP3-specific T cells generated in vitro using human FOXP3 RNA-transfected DCs as stimulators efficiently lyse SUM149 cells. Interestingly, an isogenic model (rSUM149) derived from SUM149 with an enhanced anti-apoptotic phenotype was resistant to FOXP3-specific T cell mediated lysis. The MHC class I cellular processing mechanism was intact in both cell lines at the protein and transcription levels suggesting that the resistance to cytolysis by rSUM149 cells was not related to MHC class I expression or to the MHC class I antigen processing machinery in these cells. Our data suggest that FOXP3 may be an effective tumor target in IBC cells however increased anti-apoptotic signaling can lead to immune evasion.

Oxygen flux analysis to understand the biological function of sirtuins

The sirtuins are a family of highly conserved NAD(+)-dependent lysine deacylases with important roles in metabolic regulation. Of the seven mammalian sirtuins, three localize to the mitochondria: SIRT3, SIRT4, and SIRT5. Mitochondrial sirtuins are crucial regulators of the metabolic network that controls energy homeostasis and impacts cancer, obesity, diabetes, mitochondrial diseases, metabolic disorders, and many other human diseases of aging. To best study the mitochondrial function of the sirtuins, we have employed an oxygen flux analyzer as a tool to track and record the extracellular oxygen consumption rate and acidification rate that reflects mitochondrial respiration and glycolysis, respectfully. Here we described the methods using this assay to study the substrate utilization and mitochondrial function in a human hepatocellular carcinoma cell line, Huh7. Additionally, we have generated a stable SIRT4 knocked-down Huh7 cell line. With this cell line, we evaluated how the absence of SIRT4 affects mitochondrial function, glucose utilization, glutamine oxidation, and fatty acid oxidation in these cells.

Acceptability of routine enquiry regarding domestic violence in the antenatal clinic

Domestic Violence poses a significant health risk for the woman and her baby. We wished to determine the acceptability of routine questioning for domestic violence in the maternity hospital setting. A non-anonymised questionnaire was completed by 481 women attending for booking antenatal appointment in a maternity hospital antenatal clinic. The doctor asked four questions regarding experience of partner abuse, The acceptability of these questions was determined. 468 (99%) patients found the questions acceptable and said it would be helpful to ask all patients. Sixty-one (12.9%) women gave a history of at least one form of partner abuse. We concluded that routine enquiry about domestic violence during hospital antenatal visits is acceptable to women and perceived by them to be worthwhile.

Forced use of the upper extremity in cerebral palsy: a single-case design

OBJECTIVE

Muscle imbalance and poor control of movement can have an impact on the daily occupational functioning of children with cerebral palsy. When one side of the body functions better than the other, children will often prefer to use the less-involved upper extremity for completion of play and self-care activities because they have learned that the other hand does not function as effectively. This study examined a method purported to overcome this learned nonuse of the affected upper extremity by directing the child's attention to this extremity and increasing his or her motivation to use it. The research hypothesis was that restriction of the less-involved hand with a resting splint would result in increased use of the more-involved hand in a child with spastic cerebral palsy.

METHOD

Initially, two children with cerebral palsy participated in this single-subject, ABA design study, but only one subject complied with the splint-wearing schedule and completed the study. This subject was a 2-year-old girl with greater involvement of the right side than the left. During the experimental phase, she wore a resting splint on her less-involved hand for most of the waking hours of the day to restrict its use. Data were collected over a 7-week period (2 weeks presplinting, 3 weeks splinting, 2 weeks postsplinting) and at a 6-month follow-up. Use of the more-involved extremity was measured through analysis of her performance during 15-min videotaped sessions of free play, administration of items from the Peabody Developmental Fine Motor Scales, and completion of a daily finger-feeding task.

RESULTS

An improvement in quality, quantity, and variety of use of the more-involved extremity after splinting, with some continuing improvement evident at follow-up, was found. The subject had increased voluntary control of her more-involved arm and hand and used them more spontaneously for completion of daily occupations.

CONCLUSIONS

Although the results of this single-case design are encouraging, further research with a randomized, controlled design is necessary to determine the effectiveness of the forced-use technique with a larger population.

Role of the theatre nurse in minimal access surgery

Operating department nursing practice involves a diversity of skills in conjunction with a specialist and multidisciplinary knowledge base. This article explores the emergence of minimal access surgery (MAS) and what occurs during the perioperative period. The authors argue that perioperative care of the MAS patient requires not only technical competence but also a high order of interpersonal skill allied to specialist nursing knowledge.

How to put the Food Guide Pyramid into practice

The Food Guide Pyramid represents changes and challenges for nutrition educators. Nutrition educators will have to change the focus, content, and teaching expectations for lessons. Use of the Pyramid will also require changes in the way the concepts of good nutrition are related to different audiences. In contrast to previous food guides, which represented a foundation diet, the Food Guide Pyramid represents the total diet, addressing overnutrition as well as undernutrition. The Food Guide Pyramid is a graphic representation of the Dietary Guidelines for Americans, and illustrates the key concepts of variety, moderation, and proportionality. For practitioners, one challenge is to find ways to effectively use the Food Guide Pyramid to teach clients how to put the Dietary Guidelines into action. Another challenge involves designing materials that adapt the messages of the Food Guide Pyramid to a variety of audiences. Teaching materials and instructions should emphasize the key concepts of the Food Guide Pyramid and should be clear, consistent, motivational, and culturally sensitive. Few educational materials are available to help practitioners with these challenges. In this article we outline the key changes that the Food Guide Pyramid embodies, and provide ideas and suggestions for using the Pyramid in a practice setting.

Are we meeting their needs

The aim of this pilot study is to discover the student nurses' learning needs and perceptions during their operating department allocation and whether we are meeting those needs. Also, what influence their perceptions have had upon selecting perioperative nursing as a career. The study focuses upon semi-structured interviews with student nurses and their accounts of their experiences of being learners in the operating department. During their allocation, students are able to view surgery and to assist in the recovery of patients and to understand what a surgical patient experiences. They are exposed to the roles and responsibilities of operating department nurses. However, little is known about how students perceive these experiences. In this study two groups of students from the same year were interviewed to determine their perceptions and needs during the allocation and whether their learning needs had been met.

A Comparison of the Intensity of Play in Squash and Running

In brief: Ten recreational runners and squash players were monitored with telemetry to determine their heart rate response to the two activities. The authors found that even though squash is a discontinuous exercise, the mean heart rate intensity in the squash sessions was very similar to the mean heart rate intensity while running. Therefore, health professionals can indicate that squash play with a partner of equal ability and fitness level has aerobic benefits similar to running.

Skeletal muscle analysis of wheelchair athletes

The present study reports the results of using the biopsy technique with members of the Canadian Wheelchair Internation Team. The results demonstrate that these athletes possess muscles with large fibre areas than seen in Olympic athletes.