Clinical characteristics with inflammation profiling of long COVID and association with 1-year recovery following hospitalisation in the UK: a prospective observational study

BACKGROUND

No effective pharmacological or non-pharmacological interventions exist for patients with long COVID. We aimed to describe recovery 1 year after hospital discharge for COVID-19, identify factors associated with patient-perceived recovery, and identify potential therapeutic targets by describing the underlying inflammatory profiles of the previously described recovery clusters at 5 months after hospital discharge.

METHODS

The Post-hospitalisation COVID-19 study (PHOSP-COVID) is a prospective, longitudinal cohort study recruiting adults (aged ≥18 years) discharged from hospital with COVID-19 across the UK. Recovery was assessed using patient-reported outcome measures, physical performance, and organ function at 5 months and 1 year after hospital discharge, and stratified by both patient-perceived recovery and recovery cluster. Hierarchical logistic regression modelling was performed for patient-perceived recovery at 1 year. Cluster analysis was done using the clustering large applications k-medoids approach using clinical outcomes at 5 months. Inflammatory protein profiling was analysed from plasma at the 5-month visit. This study is registered on the ISRCTN Registry, ISRCTN10980107, and recruitment is ongoing.

FINDINGS

2320 participants discharged from hospital between March 7, 2020, and April 18, 2021, were assessed at 5 months after discharge and 807 (32·7%) participants completed both the 5-month and 1-year visits. 279 (35·6%) of these 807 patients were women and 505 (64·4%) were men, with a mean age of 58·7 (SD 12·5) years, and 224 (27·8%) had received invasive mechanical ventilation (WHO class 7-9). The proportion of patients reporting full recovery was unchanged between 5 months (501 [25·5%] of 1965) and 1 year (232 [28·9%] of 804). Factors associated with being less likely to report full recovery at 1 year were female sex (odds ratio 0·68 [95% CI 0·46-0·99]), obesity (0·50 [0·34-0·74]) and invasive mechanical ventilation (0·42 [0·23-0·76]). Cluster analysis (n=1636) corroborated the previously reported four clusters: very severe, severe, moderate with cognitive impairment, and mild, relating to the severity of physical health, mental health, and cognitive impairment at 5 months. We found increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate with cognitive impairment clusters compared with the mild cluster, including IL-6 concentration, which was increased in both comparisons (n=626 participants). We found a substantial deficit in median EQ-5D-5L utility index from before COVID-19 (retrospective assessment; 0·88 [IQR 0·74-1·00]), at 5 months (0·74 [0·64-0·88]) to 1 year (0·75 [0·62-0·88]), with minimal improvements across all outcome measures at 1 year after discharge in the whole cohort and within each of the four clusters.

INTERPRETATION

The sequelae of a hospital admission with COVID-19 were substantial 1 year after discharge across a range of health domains, with the minority in our cohort feeling fully recovered. Patient-perceived health-related quality of life was reduced at 1 year compared with before hospital admission. Systematic inflammation and obesity are potential treatable traits that warrant further investigation in clinical trials.

FUNDING

UK Research and Innovation and National Institute for Health Research.

How people living with motor neurone disease and their carers experience healthcare decision making: a qualitative exploration

PURPOSE

Healthcare decision making in motor neurone disease (MND) focuses on symptom management and quality of life. Decision making may be affected by personal approach to receiving information, decision making style, and disease symptoms. This study explored decision making from the perspectives of people living with motor neurone disease (plwMND). The issues impacting engagement and involvement in healthcare decisions were investigated.

METHODS

Semi-structured interviews were conducted with 19 plwMND and 15 carers. Interview data was inductively analysed to identify and describe patterns and themes.

RESULTS

Data analysis identified six overarching themes: Dimensions of decision making; Window of opportunity for choice; Intrinsic influences on decision making; Extrinsic influences impacting decision making; Planning in uncertainty; and, Communication is core. Many participants did not identify a process of "decision-making" except if considering early gastrostomy placement. Information provision requires a balance between ensuring patients are informed but not overwhelmed. Communication impairment impacts involvement. Healthcare professionals' communication style influences engagement in decision making.

CONCLUSION

PlwMND perceive a lack of clinical decisions to make because disease symptoms and clinical phenotypes dictate necessary interventions. PlwMND describe communication impairment as a barrier to involvement in decision making and extra support is required to ensure they maintain engagement.IMPLICATIONS FOR REHABILITATIONPeople living with MND (plwMND) perceive they have few clinical decisions to make and viewed this process as "accepting a recommendation", rather than "making a decision" although early gastrostomy placement is the exception with considerable deliberation evident.Specialist multidisciplinary clinic advice is especially helpful for plwMND without dysphagia (swallowing problems) when considering early gastrostomy placement.Communication impairment may be a barrier to involvement in healthcare decisions and extra support to remain engaged is required.Some plwMND choose not to involve others in their decisions, and patients/families with medical or scientific backgrounds are more likely to collaborate with each other outside the context of clinic appointments.

1096. Reducing Unnecessary Postoperative Antibiotic Prophylaxis

Background

National guidelines for the prevention of surgical site infections (SSI) recommend against antibiotic prophylaxis following wound closure for clean and clean-contaminated surgical procedures. Prolonged antibiotic prophylaxis can lead to antibiotic resistance and adverse drug events without reducing SSI rates. The objective was to reduce the rate of antibiotic prophylaxis following surgical incision closure for specified procedures in the Divisions of Neurosurgery (NRS), Otolaryngology (OTO), and General Surgery (GS) at Children’s Hospital of Philadelphia (CHOP).

Methods

We identified all NRS, OTO, and GS procedures conducted at CHOP from July 1, 2016 to June 20, 2017. Collaborative meetings between surgical quality improvement team leads and the antimicrobial stewardship program (ASP) were convened to identify procedures most suitable for the intervention, including Chiari decompressions and tethered cord repair (NRS); tympanoplasty and tracheostomy (OTO); and laparoscopic and thoracoscopic procedures (GS). The intervention, started in March 2018, included (1) education of surgeons on perioperative prescribing guidelines, (2) order set modification, and (3) individualized monthly audit with feedback reports of inappropriate postoperative prescribing (via email copying all surgeons within the division). We monitored rates utilizing SPC charts of postoperative antibiotic use (defined as administration within 24 hours of procedure end) and evaluated SSI rates pre and post-intervention with a Poisson regression.

Results

Following the intervention, postoperative antibiotic use reached special cause resulting in a mean decline for laparoscopy (19.6% to 11.7%), thoracoscopy (35.6% to 17.9%), tympanoplasty (90.5% to 11.4%), tethered cord repair (95% to 25.5%), and Chiari decompression (97% to 45.9%). There was no mean shift in postoperative antibiotic use for tracheostomy (25.5%). 30-day SSI rates did not change pre- and post-intervention (P = 0.36).

Conclusion

A quality improvement initiative conducted to implement national guidelines recommending against postoperative antibiotic prophylaxis showed a significant reduction in postoperative antibiotic prophylaxis without a concomitant rise in SSI rates.

Disclosures

All authors: No reported disclosures.

The prevalence of faecal incontinence in myotonic dystrophy type 1

Faecal incontinence is recognised as a feature of myotonic dystrophy along with other symptoms of bowel dysfunction, but its prevalence is poorly defined. We have surveyed 152 unselected myotonic dystrophy patients. We identified issues with bowel control in 104 (68% of the study population). Forty-eight (32%) reported faecal incontinence in the 4 weeks prior to completion of the questionnaire. Fifty-six patients (37%) reported having to change their lifestyle because of incontinence issues at some point in the prior 4 weeks. This study shows a high frequency of life-changing symptoms in a large unselected, cohort of patients with myotonic dystrophy type 1, and highlights lower gastrointestinal symptoms as an important issue for further research.

Dissolution kinetics of quicklime in various organic solvents and solutions

The rate of the dissolution of quicklime was measured in different organic solvents and solutions of methanol, ethylene glycol, glycerol and sucrose. It was found that the rate of dissolution in methanol, glycerol and sucrose was dramatically reduced compared with that in deionized water. However, little difference was measured in a solution of ethylene glycol compared with aqueous solutions. The presence of chloride ions increases the rate of dissolution in all solvents and solutions, except for ethylene glycol, where a decrease was actually observed. It was also found that the presence of sulphate ions decreases the rate in all organic solvents and solutions tested.

The primary structure of human urogastrone

Urogastrone is a potent inhibitor of gastric acid secretion which is present in human urine. Its existence has been known for over 30 years but it has only recently been isolated in a sufficiently pure form for detailed structural studies to be undertaken. Two separate polypeptides beta- and gamma-urogastrone were isolated. The structures were established by carrying out enzymic degradations of S-carboxymethyl and S-carboxamidomethyl derivatives with trypsin, chymotrypsin, thermolysin and a protease derived from the fungus Armillaria mellea. Sequences of the smaller peptides thus obtained were determined by the dansyl Edman method. Partial acid hydrolysis of urogastrone itself gave fragments containing single intact disulphide bonds, and oxidation then allowed the direction of individual bonds to be established. Beta-Urogastrone was shown to be a 53-amino acid residue polypeptide containing three disulphide bonds, and gamma-urogastrone had an identical sequence but lacked the C-terminal arginine residue. Urogastrone was subsequently found to be structurally related to mouse epidermal growth factor in that 37 of the 53 residues were commonly located in each polypeptide. Furthermore, as both peptides has similar effects upon gastric acid secretion and upon epidermal growth, urogastrone was also a human epidermal growth factor. The 16 variable residues were spread across the molecule, all apart from two were compatible with single base changes in the triplet condons, and the overall effect was to make uorgastrone more acidic than EGF. The smallest biologically active unit has not been defined but at least six residues can be removed from the C-terminus without causing a reduction in potency.

Prospective surveillance of women with a family history of breast cancer: auditing the risk threshold

To evaluate current guidelines criteria for inclusion of women in special ‘breast cancer family history’ surveillance programmes, records were reviewed of women referred to Scottish breast cancer family clinics between January 1994 and December 2003 but discharged as at ‘less than ‘moderate’ familial risk’. The Scottish Cancer Registry was then interrogated to determine subsequent age-specific incidence of breast cancer in this cohort and corresponding Scottish population figures. Among 2074 women, with an average follow-up of 4.0 years, 28 invasive breast cancers were recorded up to December 2003, where 14.4 were expected, a relative risk (RR) of 1.94. Eleven further breast cancers were recorded between January 2004 and February 2006 (ascertainment incomplete for this period). The overall RR for women in the study cohort exceeded the accepted ‘cutoff’ level (RR=1.7) for provision of special counselling and surveillance. The highest RR was found for the age group 45–59 years and this group also generated the majority of breast cancers. The National Institute for Clinical Excellence (‘NICE’) guidelines appear to be more accurate than those of the Scottish Intercollegiate Guidelines Network (‘SIGN’) in defining ‘moderate’ familial risk, and longer follow-up of this cohort could generate an evidence base for further modification of familial breast cancer services.

The evolution and refinements of the distally based dorsal metacarpal artery (DMCA) flaps

Distally based DMCA flaps are well established in reconstructive hand surgery. They comprise the dorsal flap described by Quaba and the DMCA flaps described by Earley, Milner and others. The most frequent indications for these flaps are soft tissue defects of the dorsum of the proximal phalanx and the total length of the finger. Since its introduction several modifications have been developed to match specific defect requirements; these include: the development of pure fascial DMCA flaps, the use of DMCA flaps in dorsally grafted burned hands and modifications in design to avoid 'tunnelling' and to permit skin-skin defect closure. The purpose of this article is to provide an overview of the evolution and refinements of the DMCA flaps based on the experience of a single centre. The DMCA flaps provide one stage coverage of excellent quality with independent vascularisation and permit primary closure of the recipient site without sacrificing relevant arteries (e.g. proper digital artery). However, the DMCA flaps also possess drawbacks, for example, apart from the fact that this technique is quite demanding, possible hair growth and a visible scar on the exposed dorsal part of the hand present aesthetic problems for some patients. Despite these limitations, DMCA flaps are considered to be extremely useful.

Non-uptake of predictive genetic testing for BRCA1/2 among relatives of known carriers: attributes, cancer worry, and barriers to testing in a multicenter clinical cohort

BRCA1/2 test decliners/deferrers have received almost no attention in the literature and this is the first study of this population in the United Kingdom. The aim of this multicenter study is to examine the attributes of a group of individuals offered predictive genetic testing for breast/ovarian cancer predisposition who did not wish to proceed with testing at the time of entry into this study. This forms part of a larger study involving 9 U.K. centers investigating the psychosocial impact of predictive genetic testing for BRCA1/2. Cancer worry and reasons for declining or deferring BRCA1/2 predictive genetic testing were evaluated by questionnaire following genetic counseling. A total of 34 individuals declined the offer of predictive genetic testing. Compared to the national cohort of test acceptors, test decliners are significantly younger. Female test decliners have lower levels of cancer worry than female test acceptors. Barriers to testing include apprehension about the result, traveling to the genetics clinic, and taking time away from work/family. Women are more likely than men to worry about receiving less screening if found not to be a carrier. The findings do not indicate that healthy BRCA1/2 test decliners are a more vulnerable group in terms of cancer worry. However, barriers to testing need to be discussed in genetic counseling.

Teaching undergraduates about familial breast cancer: comparison of a computer assisted learning (CAL) package with a traditional tutorial approach

We have developed a computer assisted learning package for teaching clinical medical students about familial breast cancer. It explains the principles of genetic predisposition to breast cancer, the association with other cancers, the principles of family history taking and confirmation, risk assessment and possible interventions. Clinical medical students were randomised to either conventional teaching or CAL, 48 students attended the evaluation session. Students randomised to conventional teaching received a 20 min mini-lecture, those randomised to CAL completed the package with technical, but not academic support available. At the end of the intervention both groups of students completed a short written assessment of acceptability and knowledge and understanding of breast cancer genetics. There was no significant difference between the CAL and mini-lecture groups in terms of marks or acceptability. Thus CAL appears to be an acceptable and effective method of teaching clinical medical students about familial breast cancer. Although time consuming to develop, CAL can be used in a variety of settings to increase curriculum flexibility. Methods of motivating students to complete the CAL, and of providing educational support are being explored.

Routine antenatal Rhesus D immunoglobulin prophylaxis: the results of a prospective 10 year study

OBJECTIVE

To assess the clinical and financial impact, and identify the problems, of providing routine antenatal RhD immunoglobulin prophylaxis for Rhesus D negative nulliparae.

DESIGN

A retrospective (1980-1986) and prospective (1987-1996) comparison between two similar populations, one population with nulliparae offered routine RhD immunoglobulin 500 IU prophylaxis at 28 and 34 weeks of gestation part way through the study period, and the other population not offered prophylaxis at any time.

SETTING

Obstetric units in two counties (three health districts) with similar annual numbers of maternities and the Regional Blood Transfusion Service antenatal serology laboratory.

PARTICIPANTS

Non-sensitised Rhesus D negative pregnant nulliparae.

INTERVENTIONS

Intramuscular RhD immunoglobulin 500 IU at 28 and 34 weeks of gestation to eligible women booked for confinement in one county; the intervention not offered in the other county.

MAIN OUTCOME MEASURES

1. Rhesus D sensitised second pregnancy rate; 2. success in providing prophylaxis to eligible women; 3. serology laboratory activity changes; 4. potential savings from the prophylaxis programme.

RESULTS

Prophylaxis significantly reduced iso-immunisation in the next pregnancy when compared with historical (OR 0.28, CI 0.14-0.53; P < 0.0001) and contemporary controls (OR 0.43, CI 0.22-0.86; P = 0.02). However, success at achieving comprehensive prophylaxis was disappointing, with only 89% of eligible women receiving the first injection, 74% both injections, and for only 29% were both at the correct gestation. Fifty-two percent of women delivered after 40 weeks of gestation, beyond the period of adequate prophylaxis protection. The savings in antenatal interventions, neonatal care and possible long term ill-health that result from very preterm birth should be considerable.

CONCLUSION

Routine prophylaxis for nulliparae significantly reduces the incidence of sensitised next pregnancies with consequent savings, and its adoption nationwide should be encouraged. A programme offering antenatal prophylaxis for all Rhesus D negative women is unlikely to be economic. Improvement in uptake of prophylaxis is needed; alternative administration strategies should be explored.

Guidelines for follow-up of women at high risk for inherited breast cancer: consensus statement from the Biomed 2 Demonstration Programme on Inherited Breast Cancer

Protocols for activity aiming at early diagnosis and treatment of inherited breast or breast-ovarian cancer have been reported. Available reports on outcome of such programmes are considered here. It is concluded that the ongoing activities should continue with minor modifications. Direct evidence of a survival benefit from breast and ovarian screening is not yet available. On the basis of expert opinion and preliminary results from intervention programmes indicating good detection rates for early breast cancers and 5-year survival concordant with early diagnosis, we propose that women at high risk for inherited breast cancer be offered genetic counselling, education in ‘breast awareness’ and annual mammography and clinical expert examination from around 30 years of age. Mammography every second year may be sufficient from 60 years on. BRCA1 mutation carriers may benefit from more frequent examinations and cancer risk may be reduced by oophorectomy before 40–50 years of age. We strongly advocate that all activities should be organized as multicentre studies subjected to continuous evaluation to measure the effects of the interventions on long-term mortality, to match management options more precisely to individual risks and to prepare the ground for studies on chemoprevention.

Efficacy of early diagnosis and treatment in women with a family history of breast cancer. European Familial Breast Cancer Collaborative Group

BACKGROUND

Surveillance programmes for women at increased genetic risk of breast cancer are being established worldwide but little is known of their efficacy in early detection of cancers and hence reduction in mortality.

METHODS

Data were contributed from seven centres participating in the EU Demonstration Programme on Clinical Services for Familial Breast Cancer. All breast tumours (n = 161) detected prospectively, from the time of enrolment of women in a screening programme, were recorded. Analysis took account of age at diagnosis, whether tumours were screen-detected or not, their pathological stage and outcome by Kaplan-Meier survival plots.

RESULTS

Mean age at diagnosis was 48.6 years. Overall, 75% of tumours were detected in the course of planned examinations. For women under age 50 at diagnosis, this figure was 68%. Eighteen percent were mammographically negative, (23% in patients under age 50). At first ("prevalence") round and at follow-up screening, 16% and 22% of tumours respectively were carcinoma in situ (CIS) while 27% and 22% respectively had evidence of nodal or distant spread (CaN+). Comparison of screen-detected and other tumours showed that the latter were more frequently mammogram-negative and CaN+. Overall five-year survival was 89% and five-year event-free survival 86%. Five-year event-free survival was 100% for CIS, 88% for invasive cancer without nodal or distant spread and 67% for CaN+.

CONCLUSIONS

The majority of cancers arising in women at increased genetic risk of breast cancer can be detected by planned screening, even in those under age 50. Surveillance should include regular expert clinical examination and teaching of "breast awareness" as well as mammography. Attention to the logistics of screening programmes may improve still further the proportion of tumours that are screen-detected. The trend towards earlier pathological stage in tumours detected during follow-up rounds and the preliminary findings on survival analysis suggest that this approach will prove to be of long-term benefit for breast cancer families.

Ascertainment of familial ovarian cancer in the Aberdeen Genetic Clinic

Ovarian cancer is the fifth most common malignancy in women in the UK. Patients with a family history including ovarian cancer make up nearly 15% of family cancer referrals to the Genetic Clinic in Aberdeen. To date, only one pedigree has been suitable for linkage studies, which has enabled us to target screening more accurately at those people at highest risk. Following discovery of a strong candidate for the BRCA1 gene, direct mutation testing may soon be possible. People who seek testing will require further counselling. Therefore we anticipate an increased demand on both clinical and laboratory resources, but more accurate ascertainment of high risk subjects should lead to more appropriate targeting of screening services.

The complete cDNA derived sequence of the rat prolyl 4-hydroxylase alpha subunit

A rat cDNA encoding the prolyl 4-hydroxylase alpha subunit (P4H alpha) was isolated and sequenced. The primary aa sequence deduced from the nucleotide sequence reveals a 534-aa protein that shows extensive aa identity with the human (88%) and chick (77%) P4H alpha.

Evolution of bereavement counselling in sudden infant death syndrome, neonatal death and stillbirth

There have been changing attitudes to death and grief in Western society in recent centuries. During the twentieth century complex medical and social changes have resulted in changing attitudes to and experiences with death. Specifically, the impact of death in childhood is reviewed. In recent decades sudden and unexpected death associated with stillbirth, the newborn and infants appears to have a more profound affect on the bereaved parents than in the past when the overall death rates in childhood were higher. The evolution of parent support groups developed since the 1960s to alleviate the psychological trauma of unexpected and sudden death in childhood has been traced. These groups were founded initially for support with sudden infant death syndrome and later extended to include families with stillbirth and neonatal death.

Neutrophil-activating proteins in psoriasis

Neutrophil accumulation in the epidermis is a histologic characteristic of psoriasis. We addressed the question: What is the major protein-like chemotactic principle responsible for neutrophil accumulation? Purification of proteinaceous neutrophil chemoattractants from extracts obtained from psoriatic scales by multistep high-performance liquid chromatography (HPLC) yielded three biochemically distinct polypeptides with potent neutrophil chemotactic activity. Aminoterminal amino acid sequence analysis of the quantitatively major neutrophil attractant revealed the sequence ELRXQXIKTYSK, which is identical to that of a 69 residue form of neutrophil-activating peptide-1/interleukin 8 (NAP-1/IL-8). The second major attractant showed the sequence XXVATELRXQXL . . ., which is identical to that of the gene product of the oncogene "gro" as well as "melanoma growth stimulatory activity, MGSA," whereas the third and minor neutrophil chemotaxin has an NH2-terminal sequence identical with NAP-1/IL-8. Estimation of NAP-1/IL-8-related proteins and gro/MGSA by HPLC combined with bioassay revealed a mean of 3.3 +/- 1.7 ng NAP-1/IL-8-related proteins (n = 11) and 3.2 +/- 1.9 ng gro/MGSA (n = 11) per 1 mg psoriatic scales. In normal heel callus (n = 8), these neutrophil attractants were found at concentrations below 0.02 +/- 0.01 ng/mg. The finding of more than 150-times increased amounts of both NAP-1/IL-8 and gro/MGSA in lesional psoriasis material suggest that these mitogenic as well as neutrophil- and lymphocyte-chemotactic compounds may play an important role in the pathogenesis of psoriasis.

Elafin: an elastase-specific inhibitor of human skin. Purification, characterization, and complete amino acid sequence

A potent inhibitor of human leukocyte elastase (EC 3.4.21.37) and porcine pancreatic elastase (EC 3.4.21.36) was purified to homogeneity from human horny layers. It inhibits human leukocyte elastase and porcine pancreatic elastase in a 1:1 molar ratio and shows equilibrium dissociation constants of 6 x 10(-10) M and 1 x 10(-9) M, respectively. Inhibition of plasmin, trypsin, alpha-chymotrypsin, and cathepsin G was not observed. This inhibitor proved to be an acid stable basic peptide with an isoelectric point of 9.7. The complete amino acid sequence appears to be unique with 38% homology to the C-terminal half of antileukoprotease. The sequence shows that the inhibitor is composed of 57 amino acids and predicts a Mr of 7017. The high affinity as well as the apparent specificity for elastases suggests a functional role in preventing elastase-mediated tissue proteolysis. It is suggested that the term "elafin" be used to designate this inhibitor.

Effect of orally-administered epidermal growth factor on intestinal iron absorption and mucosal permeability

A progressive increase in intestinal 59Fe3+ absorption was observed on oral feeding of mice with physiological doses of EGF/UGO. Maximal changes were apparent after 3d and appeared to be dose-dependent. In addition to a small increase in intestinal cell proliferation, as reflected by increased ornithine decarboxylase activity, EGF/UGO-feeding increased mucosal permeability (evaluated with [51Cr]-EDTA): the latter could account for the increase in iron absorption. Sialoadenectomy, to remove the major source of endogenous EGF/UGO, had no appreciable effect on the intestinal absorption of iron.

Is polyamine synthesis involved in the proliferative response of the intestinal epithelium to urogastrone-epidermal growth factor?

1. Intestinal epithelial cell proliferation was measured in rats maintained on total parenteral nutrition (TPN), in TPN rats given 300 micrograms of recombinant human epidermal growth factor (urogastrone-epidermal growth factor, URO-EGF) day-1 kg-1, and in further groups given URO-EGF and difluoromethylornithine (DFMO), an inhibitor of the enzyme ornithine decarboxylase (ODC). 2. URO-EGF significantly increased intestinal cell proliferation throughout the gastrointestinal tract. The proliferative response of the colon was particularly pronounced. 3. DFMO reduced the proliferative effect of urogastrone in the stomach and small intestine. DFMO also reduced URO-EGF-stimulated intestinal cell proliferation in the colon, but to a lesser extent. 4. It is concluded that ODC is essential for effecting the proliferative response of the stomach and small intestine to URO-EGF, but this role may be less important in the colon.

The constitution and properties of phosphorylated and unphosphorylated C-terminal fragments of progastrin from dog and ferret antrum

Antibodies to the extreme C-terminal tryptic (nona-) peptide fragment of porcine progastrin have been used in radioimmunoassay to identify progastrin fragments in dog, ferret and pig antral mucosa extracts and to monitor their purification. In addition to previously characterised phosphorylated and unphosphorylated C-terminal tryptic peptides of porcine progastrin a minor form corresponding to the C-terminal octapeptide (i.e. des-Ser C-terminal nonapeptide) was isolated and characterised. The latter form together with phosphorylated and unphosphorylated forms of the nonapeptides were also isolated and chemically characterised from dog antrum, and the unphosphorylated nonapeptide was characterised from ferret antrum. The primary amino acid sequences of the dog, ferret and pig nonapeptides were identical. In ferret the unphosphorylated nonapeptide predominated, and in dog the phosphorylated form predominated; in pig both forms of the nonapeptide were well represented. Intact progastrin was identified in gel filtration eluates of extracts of all 3 species, but occurred only in relatively low concentrations. The nonapeptides did not stimulate acid secretion in the conscious gastric fistula rat and they did not modify the acid response to G17. Phosphorylation of progastrin-derived peptides is evidently well conserved across a range of species even though there appear to be differences in the relative proportions of phosphorylated and unphosphorylated forms.

Epidermal and transforming growth factor alpha in patients with breast tumours

Measurements of transforming growth factor alpha (TGF-alpha) in cancer patients have produced variable results. We have now used a specific radioimmunoassay (RIA) and a mitogenic assay to evaluate TGF-alpha content of tumour and urine samples separated by an analytical HPLC system. Urine samples from patients with breast tumours and from age matched controls gave TGF-alpha amounts ranging from 0 to 61.5 ng 24 h-1 compared to urogastrone epidermal growth factor figures of 3.0-26.2 micrograms 24 h-1. The quantities of TGF-alpha in patient and control groups were not significantly different. The majority of breast tumour extracts contained mitogenic material eluting from the HPLC system at the TGF-alpha calibration point. Measurement by RIA of combined samples from each group showed that steroid receptor positive tumours had a mean figure of 14.8 ng g-1 tissue and steroid receptor negative 7.4 ng g-1. Receptor positive tumours from patients treated with an antioestrogen, tamoxifen citrate (Nolvadex), had 0.16 ng g-1. Thus TGF-alpha is found in tumours as a biologically active entity and in quantities sufficient to promote cell division. In addition the observation that tamoxifen causes a significant reduction in the content of TGF-alpha may be an additional beneficial action.

Plasma enteroglucagon, peptide YY and gastrin in rats deprived of luminal nutrition, and after urogastrone-EGF administration. A proliferative role for PYY in the intestinal epithelium?

Intestinal tissue mass was significantly reduced throughout the gastrointestinal tract (p less than 0.001) of intravenously fed (TPN) rats. Urogastrone-epidermal growth factor, (URO-EGF), reversed these changes. Although plasma enteroglucagon and gastrin levels showed a small increase with URO-EGF, this was far less than the gut tissue weight change, suggesting that it was unlikely that they were involved in modulating the proliferative response of the intestine to URO-EGF. Peptide tyrosine tyrosine (PYY) levels were however significantly increased by URO-EGF, indicating that PYY may possibly have a role in the modulation of intestinal cell proliferation.

Human amniotic fluid urogastrone (epidermal growth factor) and fetal lung phospholipids

Urogastrone was measured by radioimmunoassay in amniotic fluid obtained from 186 complicated pregnancies at 22 to 40 weeks gestation. Amniocentesis was performed for a variety of indications to obtain information about fetal lung maturity or bilirubin levels before induction of labour or caesarean section in various obstetric conditions. In 114 specimens lung phospholipids extracted from amniotic fluid were also assayed using two-dimensional thin layer chromatography. Urogastrone concentrations became measurable at approximately 30 weeks gestation and thereafter there was a 10-fold rise in concentrations between 30 and 40 weeks gestation. This increase in urogastrone concentration was positively correlated with a rise in phosphatidylcholine and phosphatidylglycerol concentrations and the phosphatidylcholine (lecithin)/sphingomyelin ratio (L/S). These results are compatible with a role for urogastrone in human fetal lung maturation.

The human gastrin precursor. Characterization of phosphorylated forms and fragments

There is a potential phosphorylation site in the C-terminal region of the precursor for the acid-stimulating hormone gastrin, which is immediately adjacent to an important cleavage point. In the present study we have sought to identify, separate, quantify and characterize phosphorylated and unphosphorylated forms of human progastrin and its fragments. Identification was made by two radioimmunoassays: (a) a novel assay employing an antibody raised to intact human progastrin; and (b) an assay using antibody reacting with the C-terminal tryptic fragment of human progastrin, as well as progastrin itself. Two forms of human progastrin isolated from a gastrinoma were separated by ion-exchange h.p.l.c., and had similar elution positions on reverse-phase h.p.l.c. and on gel filtration. The more acidic peptide contained close to equimolar amounts of phosphate. On trypsinization, peptides were released that co-eluted on ion-exchange h.p.l.c. with, and had the immunochemical properties of, naturally occurring C-terminal fragments of progastrin. One of the latter was isolated and shown by Edman degradation after derivatization with ethanethiol to have the sequence Ser (P)-Ala-Glu-Asp-Glu-Asn. Similar peptides occur in antral mucosa resected from ulcer patients. The unphosphorylated forms of progastrin predominated, whereas the phosphorylated forms of the C-terminal fragments were predominant. This distribution could be explained by preferential cleavage of phosphorylated progastrin. We conclude that in human progastrin, Ser-96 can occur in the phosphorylated form; this residue immediately follows a pair of basic residues (Arg-Arg) that are cleaved during synthesis of the biologically active product.

Proenkephalin A processing in the upper digestive tract: isolation and characterisation of phosphorylated N-terminally extended Met-enkephalin Arg6Phe7 variants

Previous studies suggest the processing of proenkephalin A in the porcine upper digestive tract might differ from that in the brain. To characterise more precisely some of the products, we have used antibodies to Met-enkephalin Arg6Phe7 (MERF) in radioimmunoassay to monitor the isolation of immunoreactive peptides from extracts of porcine pyloric antral muscle, antral mucosa, and duodenum. Sephadex G50 gel filtration of each extract produced a single broad peak of high-molecular-weight MERF-immunoreactivity. On anion-exchange chromatography the antral muscle MERF-immunoreactivity fractionated into two major peaks, and that from the antral mucosa and duodenum each into four major peaks, suggesting tissue specific processing of proenkephalin A within the porcine gut. Reverse-phase HPLC and Edman degradation analysis revealed that the least acidic antral muscle peptide was a 31-residue N-terminally extended form of MERF that is equivalent to proenkephalin A 209-239. Alkaline phosphatase digestion of the N-terminally extended MERF variants indicated that some of these peptides were modified by phosphorylation. We conclude that there are complex patterns of proenkephalin A processing in the porcine gut, which in part are due to phosphorylation.

The contribution of the C-terminal undecapeptide sequence of urogastrone-epidermal growth factor to its biological action

Progressive enzymic degradation of human urogastrone-epidermal growth factor (URO-EGF) has given a series of fragments shortened at the C-terminus leading to removal of 20% of the structure. These peptides have been evaluated for their ability to bind to polyclonal antiserum and to isolated membrane receptors, to stimulate thymidine uptake by fibroblasts and to inhibit gastric acid secretion in rats. The related molecule human transforming growth factor-alpha, was also assayed and showed similar potency to URO-EGF in all systems. Reduced binding to the receptors of the fragments was paralleled by reduction in both biological activities indicating that this portion of the molecule was concerned entirely with receptor binding. After removal of 11 amino acids from the C-terminus the residue peptide was a full agonist although higher concentrations were necessary.

Does resection enhance the response of the intestine to urogastrone-epidermal growth factor in the rat?

1. The objective of this study was to see whether another proliferative stimulus could modify the marked proliferative effect of human epidermal growth factor (urogastrone-epidermal growth factor, URO-EGF) on the gastrointestinal epithelium. 2. The response of the gastrointestinal tract to URO-EGF was investigated in rats maintained on total parenteral nutrition (TPN) with or without 75% small bowel resection. 3. Continuous infusion of 60 micrograms of recombinant beta-urogastrone/day per rat increased proliferation in the stomach by over four times (P less than 0.01), doubled proliferation in the small intestine (P less than 0.001) and increased it by four and a half times in the colon (P less than 0.001) in the control group. No significant effect of urogastrone was observed in the stomach of the resected groups, but proliferation was also increased in the small intestine by one and a half times (P less than 0.001) and by nearly four times in the colon (P less than 0.001). 4. Two-way analysis of variance showed that resection had a significant effect (P less than 0.01) on proliferation below the anastomosis and in the ileum. However, the response of the ileum was only half that observed in orally fed rats, which confirms the importance of 'luminal nutrition' in the response to resection. 5. Intestinal resection in the TPN rat was associated with a small rise in plasma enteroglucagon levels, suggesting that this hormone may be implicated in the adaptive response of the small intestine to resection.(ABSTRACT TRUNCATED AT 250 WORDS)

Characterisation of N-terminally extended met-enkephalin Arg6Gly7Leu8 variants in the porcine upper digestive tract

Proenkephalin A-derived peptides are known to occur in the gut, but their precise identity is uncertain. We report here the isolation of N-terminally extended forms of Met-enkephalin Arg6Gly7Leu8 from porcine upper digestive tract monitored by radioimmunoassay. A single major form was identified in pyloric antral muscle and mucosa, but in the duodenum two major forms were detected. Microsequence analysis together with immunological data revealed that the antral mucosal peptide and the most acidic duodenal peptide had identical amino-acid sequences, corresponding to a 5.3 kDa peptide terminating in Met-enkephalin Arg6Gly7Leu8. The data indicate that high-molecular-weight peptides may constitute a major proportion of gut opioid peptide immunoactivity.

Role of epidermal growth factor in healing of chronic gastroduodenal ulcers in rats

The healing of acetic acid-induced gastric and duodenal ulcers was examined together with biochemical indices of growth in gastric and duodenal mucosa in rats with intact or removed salivary glands after treatment with epidermal growth factor (EGF) or somatostatin, or both. After the extirpation of salivary glands, the healing rate of gastric and duodenal ulcerations was delayed and gastric content of immunoreactive EGF was reduced. This was accompanied by a significant decrease in the contents of deoxyribonucleic acid and ribonucleic acid in the gastric and duodenal mucosa. Repeated administration of EGF either subcutaneously or orally accelerated the healing of gastroduodenal ulcers in rats with intact salivary glands and completely reversed the delay in ulcer healing in sialoadenectomized animals. These effects were also accompanied by a significant increase in the growth parameters of gastric and duodenal mucosa. Administration of somatostatin, which prevented the growth-promoting action of subcutaneous EGF, resulted in a significant decrease in the EGF-stimulated healing of gastric and duodenal ulcerations in both intact and sialoadenectomized rats. Our findings suggest that cell proliferation is an important factor in healing of gastric and duodenal ulcerations and that EGF plays an important role in ulcer healing due to its mitogenic action.

Effects of urogastrone (epidermal growth factor) on the intestinal epithelium

Recombinant urogastrone (human epidermal growth factor) was infused into rats in which intestinal cell proliferation was reduced to a steady state basal level by feeding them intravenously. Urogastrone elevated the augmented metaphase index and weight of all sections of the gastrointestinal tract in a dose-related manner. Infusion of urogastrone at a dose which has a minimal effect on gastric acid secretion significantly increased crypt cell production and tissue weights throughout the gastrointestinal tract. Intravenous urogastrone was also effective in restoring cell proliferation after the intestine had become hypoproliferative. Urogastrone administered luminally had no significant effect on either intestinal weight, crypt cell production rate, or metaphase collection.

Structure determination of a human lymphocyte derived neutrophil activating peptide (LYNAP)

Phytohemagglutinin or Concanavalin A-stimulated human T-lymphocytes produce a factor (LYNAP) with potent chemotactic and enzyme degranulating activity in peripheral human neutrophils. Sequence analysis of LYNAP established an apparently novel 72 residue polypeptide structure. Examination of protein data bases showed that LYNAP had about 30% sequence homology with recently characterised connective tissue activating proteins produced by platelets. Furthermore, it was subsequently found that the amino acid sequence is largely the same as that predicted from a cDNA clone derived from mRNA elevated in peripheral human leukocytes stimulated by mitogens.

Post-translational processing of the porcine gastrin precursor by phosphorylation of the COOH-terminal fragment

The gene sequence encoding porcine preprogastrin is known; in order to clarify pathways of post-translational processing of the predicted precursor peptide we have characterized material reacting with antibodies to a synthetic peptide corresponding to the expected extreme COOH-terminal portion of the precursor. Radioimmunoassay was used to identify and monitor the purification of peptides in porcine antral mucosa. Two peptides (I and II) were isolated to homogeneity by steps involving gel filtration, ion exchange, and reversed-phase high performance liquid chromatography. The two co-eluted on gel filtration but were separated on anion-exchange chromatography. The more acidic peptide (II) was less hydrophobic on high performance liquid chromatography. Automated gas-phase microsequencing revealed the less acidic peptide (I) to have the sequence of porcine preprogastrin 96-104 (SAEEGDQRP); it would be produced by tryptic-like cleavage of Arg95-Ser96. The second peptide did not yield a phenylthiohydantoin-derivative on the first cycle but thereafter it sequenced as the first peptide (i.e. -AEEGDQRP). Incubation in alkali liberated almost equimolar amounts of phosphate from peptide II but not from I. In addition, alkaline phosphatase liberated phosphate and converted the acidic peptide to the less acidic one. The results suggest that serine in the first position is phosphorylated in peptide II but not I. The tripeptide -Ser(P)-Ala-Glu- also occurs in adrenocorticotropic hormone; this tripeptide is a substrate for physiological casein kinase. Potential phosphorylation sites occur at comparable positions in the precursors of a number of regulatory peptides.

The solution structure of human epidermal growth factor

The epidermal growth factors (EGFs) are powerful mitogens for a wide variety of cells in culture; human EGF (hEGF), known as urogastrone, also inhibits gastric acid secretion in vivo. The transforming growth factors (TGF-alpha) are related to the EGF family both in sequence and activity and EGF-like sequences are often observed in a wide range of functionally unrelated proteins. Attempts to examine the structure of EGF by diffraction methods have not yet succeeded because of difficulties with crystallization. We report here a three-dimensional structure of a biologically active derivative (residues 1-48) of the 53-residue human EGF. An analysis of high resolution 1H nuclear magnetic resonance (NMR) spectra was used together with a combination of distance geometry, restrained energy minimization and restrained molecular dynamics methods. The three-dimensional structure provides a basis for understanding the properties of EGFs and for predicting the structures of homologous sequences in other proteins.

Intravenous but not intragastric urogastrone-EGF is trophic to the intestine of parenterally fed rats

The effects of beta-urogastrone/human epidermal growth factor (URO-EGF) on intestinal epithelial cell proliferation were studied in rats in which intestinal cell proliferation had been reduced to a steady state basal level, by maintaining the rats on total parenteral nutrition. The accumulation of arrested metaphases over a two hour time period was determined in a dose response study. Increasing doses of URO-EGF progressively raised the two hour collection of metaphases and intestinal weights. Intravenous infusion of URO-EGF was also effective in restoring cell proliferation when it was infused after the intestine had become hypoproliferative. beta-urogastrone/human epidermal growth factor administered through an intragastric cannulae thrice daily had no significant effect on intestinal weight or crypt cell production rate or metaphase collection. It is proposed that one of the in vivo actions of urogastrone-epidermal growth factor is the maintenance of gastrointestinal growth and that this occurs through a systemic rather than a luminal mechanism.

Isolation and characterization of the intact gastrin precursor from a gastrinoma

Antibodies to the extreme C-terminal region of human progastrin have been used to monitor the isolation of high-Mr immunoreactive material in a gastrinoma extract. Microsequence analysis of the product revealed amino acid residues in the first 18 positions corresponding to those predicted from the cDNA sequence for preprogastrin starting at position 22; the sequence and immunochemical data together allow the identification of this material as intact progastrin. Implications for gastrin biosynthesis are discussed.

Proliferative effects of urogastrone-EGF on the intestinal epithelium

The effects of B-urogastrone/human epidermal growth factor on intestinal epithelial cell proliferation were studied in rats in which intestinal cell proliferation was reduced to a steady state basal level (by maintaining the rats on total parenteral nutrition). Increasing doses of urogastrone progressively raised the two hour collection of metaphases and intestinal weights. The crypt cell production rate was measured in animals maintained parenterally with or without urogastrone, and in rats fed a standard laboratory ration. Continuous infusion of 15 micrograms per rat per day of recombinant beta urogastrone (a dose which has a minimal effect on gastric acid secretion) significantly increased cell proliferation and intestinal tissue weights throughout the gastrointestinal tract. Intravenous infusion of urogastrone was also effective in restoring cell proliferation when it was infused after the intestine had become hypoproliferative. Urogastrone administered through an intragastric cannula thrice daily had no significant effect on either intestinal weight, crypt cell production rate, or metaphase collection.

Epidermal growth factor in blood

The presence of receptors for epidermal growth factor (EGF) in a wide variety of human tissues and also some tumours indicates an as yet undefined role for EGF and it is therefore necessary to know precise concentrations in blood and other fluids. We have investigated the occurrence of EGF in the circulation and found that in platelet rich plasma, EGF levels were 51 +/- 5 pmol/l (mean +/- S.E.M., n = 6) while in platelet poor plasma levels were 2.9 +/- 0.9 pmol/1. In contrast, serum EGF was 37 +/- 7 pmol/l if separated at 30 min and rose to 117 +/- 5 pmol/l if separated at 270 min. Gel chromatography showed that all residual EGF immunoreactivity in platelet poor plasma resided in the high molecular weight form thought to be non biologically active. In serum, delay in separation resulted in an increase in the proportion of EGF immunoreactivity co-eluting with EGF standard. These results suggest that EGF in the circulation is associated with platelets and that the process of blood coagulation leads to release of free EGF.

Urinary excretion of epidermal growth factor in the newborn

Urinary epidermal growth factor (EGF) excretion was studied serially in 36 newborn infants, from 26 to 40 weeks gestation, from birth to three months of age. All infants excreted EGF from birth. Excretion was significantly higher in term infants than in preterm infants at birth; in term infants excretion rose steadily in early infancy and there was a similar but delayed rise in EGF excretion by preterm infants. Urinary EGF excretion appears to be related to age from conception and birth does not influence it. There was no correlation between urinary EGF excretion and the rapid maturation of the lungs and skin which occurs in preterm infants in the early neonatal period.

Identification of surface-exposed segments of apolipoprotein B-100 in the LDL particle

The isolation and amino acid sequence of eleven peptides liberated by tryptic treatment from surface-exposed regions of apolipoprotein B-100 in the native low-density lipoprotein particle are described. These peptides represent eight segments in the sequence of the B-100 protein, one of which was localised to the amino-terminal thrombolytic fragment T4 (1297 amino acids), four to the T3 fragment (2052 residues) and three to the carboxylterminal fragment T2 (1287 residues). An exposed segment was identified on each side of the T2/T3 cleavage site, in close proximity to two segments enriched in basic amino acids (residues 3147-3157 and 3359-3367 respectively). The surface exposure of this region is consistent with its contribution to the putative apo-B,E receptor binding domain. Four of the eight tryptic segments contribute to regions of proline-rich clusters. Homology between the sequence of the tryptic peptides and those predicted by cDNA cloning was complete.

Isolation from chicken antrum, and primary amino acid sequence of a novel 36-residue peptide of the gastrin/CCK family

A peptide that cross-reacted with C-terminal gastrin/CCK antisera was isolated from chicken antral extracts by a combination of gel filtration and reversed-phase HPLC. The sequence was: Phe-Leu-Pro-His- Val-Phe-Ala-Glu-Leu-Ser-Asp-Arg-Lys-Gly-Phe-Val-Gln-Gly-Asn-Gly-Ala- Val-Glu-Ala-Leu-His-Asp-His-Phe-Tyr-Pro-Asp-Trp-Met-Asp-Phe(NH2). Aside from the C-terminal tetrapeptide and the Tyr residue, the molecule does not resemble other known forms of gastrin or CCK. The peptide was a potent stimulus of avian gastric acid but not pancreatic secretion. The results have important implications for the structure-activity and evolutionary relationships of the gastrin/CCK family.

Inhibition of acid formation by epidermal growth factor in the isolated rabbit gastric glands

The effects of epidermal growth factor (EGF) on basal and stimulated (with histamine, dibutyryl cyclic AMP, and high concentrations of K+) acid formation have been studied in isolated glands from the rabbit gastric mucosa. The changes in the accumulation of [14C]aminopyrine [14C]AP have been used as an indirect measurement of acid production in the glands. Unstimulated gastric glands accumulated [14C]AP indicating the existence of basal acid production in these glands, and EGF caused a small but significant reduction in basal [14C]AP uptake. A similar reduction of basal [14C]AP uptake was observed after exposure to omeprazole but not after ranitidine or prostaglandin E2 (PGE2). Histamine, dibutyryl cyclic AMP and K+ caused a strong and dose-dependent stimulation of acid formation by the glands. EGF, like omeprazole, reduced dose-dependently the [14C]AP accumulation stimulated by both histamine and dibutyryl cyclic AMP, while ranitidine and PGE2 reduced histamine- but not dibutyryl-cyclic-AMP-stimulated accumulation of [14C]AP. In the absence of other external stimuli, an increased K+ concentration enhanced [14C]AP accumulation to levels similar to those produced by histamine and this effect was not changed by EGF, ranitidine or PGE2 but was inhibited by omeprazole. We conclude that EGF interferes with the final steps of acid production between cyclic nucleotides and proton pump of the parietal cells.