Arachidonic acid inhibition of the NLRP3 inflammasome is a mechanism to explain the anti-inflammatory effects of fasting

Elevated interleukin (IL)-1β levels, NLRP3 inflammasome activity, and systemic inflammation are hallmarks of chronic metabolic inflammatory syndromes, but the mechanistic basis for this is unclear. Here, we show that levels of plasma IL-1β are lower in fasting compared to fed subjects, while the lipid arachidonic acid (AA) is elevated. Lipid profiling of NLRP3-stimulated mouse macrophages shows enhanced AA production and an NLRP3-dependent eicosanoid signature. Inhibition of cyclooxygenase by nonsteroidal anti-inflammatory drugs decreases eicosanoid, but not AA, production. It also reduces both IL-1β and IL-18 production in response to NLRP3 activation. AA inhibits NLRP3 inflammasome activity in human and mouse macrophages. Mechanistically, AA inhibits phospholipase C activity to reduce JNK1 stimulation and hence NLRP3 activity. These data show that AA is an important physiological regulator of the NLRP3 inflammasome and explains why fasting reduces systemic inflammation and also suggests a mechanism to explain how nonsteroidal anti-inflammatory drugs work.

hcHCR: High-Throughput Single-Cell Imaging of RNA in Human Primary Immune Cells

Functional genomics and chemical screens can identify and characterize novel cellular factors regulating signaling networks and chemical tools to modulate their function for the treatment of disease. Screening methods have relied primarily on immortalized and/or transformed cancer cell lines, which can limit the generalization of results to more physiologically relevant systems. Most have also relied on immunofluorescence, or on stably expressed recombinant fluorescent proteins, to detect specific protein markers using high-content imaging readouts. In comparison, high-throughput methods to visualize and measure RNA species have been less explored. To address this, we have adapted an isothermal signal amplification chemistry for RNA FISH known as hybridization chain reaction (HCR) to an automated, high-content imaging assay format. We present a detailed protocol for this technique, which we have named high-content HCR (hcHCR). The protocol focuses on the measurement of changes in mRNA abundance at the single-cell level in human primary cells, but it can be applied to a variety of primary cell types and perturbing agents. We anticipate that hcHCR will be most suitable for low- to medium-throughput screening experiments in which changes in transcript abundance are the desired output measure.

Background levels of body fluids and DNA on the shaft of the penis and associated underpants in the absence of sexual activity

This study examines the background of blood, saliva, semen and autosomal DNA on penile swabs and underpants from males in the absence of recent sexual activity. Based on the data collected by the AFSP Body Fluid Forum, the results of this study show that; there is a very low expectation of detecting blood on penile swabs and male underpants; a low expectation of detecting saliva on penile swabs and male underpants; and spermatozoa would be expected in less than a quarter of penile swabs and three quarters of male underpants. As none of the samples had detectable levels of DNA which were suitable for meaningful comparison that did not match the donor or their partner, the expectation of detecting a DNA profile from the cellular background on penile swabs or underpants from a male who has not been involved in recent sexual intercourse is very low. The results of this study are extremely informative when evaluating the significance of blood, saliva, semen and DNA detected on the penile swabs and underpants of males in cases of alleged sexual assault.

2161. Posoleucel, an Allogeneic, Off-the-Shelf Multi-Virus Specific T Cell Therapy, for Severe, Drug-Refractory Viral Infections in Pediatric Patients Following HCT: Results from a Phase 2 Trial

Background

Serious viral infections are a leading cause of morbidity and mortality in pediatric recipients of allogeneic hematopoietic cell transplant (allo-HCT). Most available antivirals have significant toxicities and suboptimal efficacy. Posoleucel (PSL) is an allogeneic, off-the-shelf multi-virus specific T cell investigational product to prevent or treat 6 viral infections (AdV, BKV, CMV, EBV, HHV-6, and JCV). In the phase 2 CHARMS trial of PSL in allo-HCT recipients with intractable viral infections, 95% of patients had a clinical response. Here we present the efficacy and safety data in pediatric patients (< 18 years) enrolled in CHARMS.

Methods

Allo-HCT patients who had failed antiviral therapy or were unable to tolerate antivirals to control BKV, CMV, AdV, EBV, HHV-6, and/or JCV infection received a single PSL infusion of 2×107 cells/m2. Patients with a response could receive up to 4 more doses after 4 weeks, at 2-week intervals. The primary endpoint of the study was safety and feasibility. Other endpoints included complete and partial clinical response, with complete response (CR) as return to normal range and resolution of signs/symptoms and partial response (PR) defined as ≥50% decrease in viral load and/or ≥50% improvement of clinical signs/symptoms assessed by 6 weeks post infusion.

Results

18 pediatric patients received PSL (1 was treated for 2 infections separately). Of the 13 with 1 viral infection, 6 (46%) had BKV, 3 (23%) CMV, 2 (15%) AdV, 2 (15%) HHV-6, and none EBV or JCV. Five (38%) had >1 infection: 3 had 2 infections, 1 had 3 infections, and 1 had 1 viral infection at each of 2 enrollments. 56% of patients received one infusion. PSL was generally well tolerated. Besides fever in 7 patients, we observed no toxicities or symptoms of CRS. Five cases of acute graft-versus-host disease (aGVHD) were observed; 3 in patients with history of aGVHD (2 had aGVHD at baseline). Both de novo cases of GVHD were Grade 1. 100% of patients achieved a clinical response (CR or PR) by 6 weeks including all 5 patients infected with multiple target viruses. Four of 6 patients with AdV infection had CR.

Conclusion

PSL treatment was well tolerated. All pediatric patients receiving PSL had a clinical response. Phase 3 studies including pediatric patients are in progress.

Disclosures

Ifigeneia Tzannou, MD, AlloVir: Advisor/Consultant Carlos Ramos, MD, Novartis: Advisor/Consultant Swati Naik, MD, Bellicum: Travel, Accomodation, Expenses Iain Fraser, MD, DPhil, AlloVir: Employee|AlloVir: Stocks/Bonds Marshelle Warren, MD, AlloVir: Advisor/Consultant Badrish Patel, MD, AlloVir: Employee|AlloVir: Stocks/Bonds Dany Ward, RN, AlloVir: Employee|AlloVir: Stocks/Bonds Ann Leen, PhD, AlloVir: Advisor/Consultant|AlloVir: Stocks/Bonds Bilal Omer, MD, AlloVir: Grant/Research Support.

TurboID biotin-tagging mass spectrometry identifies specific caspase-11-associated proteins regulating non-canonical inflammasome activation

While it has been demonstrated that cytosolic LPS can directly activate caspase11, the cellular processes regulating the non-canonical inflammasome response remain poorly defined. Caspase11 and caspase1 show substantial structural similarity, however, unlike the activation of caspase1 by NLR inflammasomes, there are no sensor or adaptor proteins known to be involved in transmitting cytosolic LPS signal to caspase11. Also, while caspase11 has been shown to associate with LPS, it lacks a characteristic LPS binding domain as observed in many other LPS binding proteins such as MD2 and LBP. Thus, we hypothesized that other effectors may be required to facilitate cytosolic LPS recognition. Moreover, the pathway is likely to be tightly regulated as caspase11 activation leads to highly inflammatory cell death.

To identify novel regulators of caspase11, we generated immortalized macrophages expressing a caspase11-TurboID-DHFR chimeric protein. The destabilizing domain was included to avoid cell death induced by caspase11 over-expression. We used a TurboID biotin-tagging MS assay to detect proteins in close proximity to caspase11 pre and post cytosolic LPS introduction. Importantly, the TurboID assay permits recognition of transient interactions, typically missed by traditional IP. To validate relevance of putative hits, we used siRNA knockdown in BMDM.

We’ve identified novel regulators specific for cytosolic LPS triggering. Several proteins interact with caspase11 only in the resting state, suggesting negative regulation to prevent pyroptosis. Among the identified regulators are kinases and proteins with pyrin and LRR domains, both common NLR features.

This work was supported by the Intramural Research Program of NIAID, NIH.

Assessment of drug interaction potential between the HCV direct-acting antiviral agents elbasvir/grazoprevir and the HIV integrase inhibitors raltegravir and dolutegravir

BACKGROUND

Elbasvir/grazoprevir is a once-daily fixed-dose combination therapy for the treatment of chronic HCV infection, including HCV/HIV coinfection.

OBJECTIVES

To evaluate the pharmacokinetic interaction of elbasvir and grazoprevir with raltegravir or dolutegravir.

METHODS

Three open-label trials in healthy adult participants were conducted. In the raltegravir trials, participants received a single dose of raltegravir 400 mg, a single dose of elbasvir 50 mg or grazoprevir 200 mg, and raltegravir with either elbasvir or grazoprevir. In the dolutegravir trial, participants received a single dose of dolutegravir 50 mg alone or co-administered with once-daily elbasvir 50 mg and grazoprevir 200 mg.

RESULTS

The raltegravir AUC0-∞ geometric mean ratio (GMR) (90% CI) was 1.02 (0.81-1.27) with elbasvir and 1.43 (0.89-2.30) with grazoprevir. Dolutegravir AUC0-∞ GMR (90% CI) was 1.16 (1.00-1.34) with elbasvir and grazoprevir. The elbasvir AUC0-∞ GMR (90% CI) was 0.81 (0.57-1.17) with raltegravir and 0.98 (0.93-1.04) with dolutegravir. The grazoprevir AUC0-24 GMR (90% CI) was 0.89 (0.72-1.09) with raltegravir and 0.81 (0.67-0.97) with dolutegravir.

CONCLUSIONS

Elbasvir or grazoprevir co-administered with raltegravir or dolutegravir resulted in no clinically meaningful drug-drug interactions and was generally well tolerated. These results support the assertion that no dose adjustments for elbasvir, grazoprevir, raltegravir or dolutegravir are needed for co-administration in HCV/HIV-coinfected people.

Fine-Needle Aspiration for the Evaluation of Hepatic Pharmacokinetics of Vaniprevir: A Randomized Trial in Patients With Hepatitis C Virus Infection

Fine-needle aspiration (FNA) for serial hepatic sampling may be an efficient and less invasive alternative to core needle biopsy (CNB), the current standard for liver tissue sampling. In this randomized, open-label trial in 31 participants with hepatitis C virus genotype 1 infection (NCT01678131/Merck protocol PN048), we evaluated the feasibility of using FNA to obtain human liver tissue samples appropriate for measuring hepatic pharmacokinetics (PK), using vaniprevir as a tool compound. The primary end point was successful retrieval of liver tissue specimens with measurable vaniprevir concentrations at two of three specified FNA time points. Twenty-nine patients met the primary end point and, therefore, were included in the PK analyses. Hepatic vaniprevir concentrations obtained with FNA were consistent with known vaniprevir PK properties. The shape of liver FNA and CNB concentration-time profiles were comparable. In conclusion, FNA may be effective for serial tissue sampling to assess hepatic drug exposure in patients with liver disease.

Consumption of salt rich products: impact of the UK reduced salt campaign

This paper uses a leading UK supermarket's loyalty card database to assess the effectiveness and impact of the 2004 UK reduced salt campaign. We present an econometric analysis of purchase data to assess the effectiveness of the Food Standard Agency's (FSA) 'reduced salt campaign'. We adopt a general approach to determining structural breaks in the time series of purchase data, using unit root tests whereby structural breaks are endogenously determined from the data. We find only limited evidence supporting the effectiveness of the FSA's reduced salt campaign. Our results support existing findings in the literature that have used alternative methodologies to examine the impact of information campaigns on consumer choice of products with high salt content.

A sustained small increase in NOD1 expression promotes ligand-independent oncogenic activity

Small genetically-determined differences in transcription are implicated in complex disease but the mechanisms by which small changes in gene expression impact the origin of complex disease are unknown. Recent GWAS fine-mapping studies show that many causal alleles for complex immune-related diseases lie in non-coding regions of genes, generating expression quantitative trait loci (eQTLs), with the extent of expression variation between susceptible and resistant genotypes often in the 1.5–3 fold range. Concurrently, systems-level studies across several cancer types suggest a regulatory organization in which disease-promoting genomic mutations lie upstream of functional master regulator proteins, a change in whose expression by 1.5–3 fold is responsible for propagating a tumor cell state. Here we show that a persistent small (~1.5 fold) increase in expression of the innate sensor NOD1 (Nucleotide-binding Oligomerization Domain-containing protein 1) precipitates large cancer-promoting changes in cell state in the absence of ligand-driven activity. A ~1.2–1.4-fold increase in NOD1 protein concentration by loss of microRNA regulation sensitizes cells to ligand-induced inflammation with an additional slight increase leading to ligand-independent NOD1 activation that upregulates the expression of proto-oncogenes and is linked to poor prognosis in gastric cancer. Our data show that tight expression regulation of NOD1 prevents this sensor from exceeding a physiological switching checkpoint that promotes persistent inflammation and oncogene expression and reveal the impact of a single small quantitative change in cell state on cancer.

No Pharmacokinetic Interactions Between Elbasvir or Grazoprevir and Buprenorphine/Naloxone in Healthy Participants and Participants Receiving Stable Opioid Agonist Therapy

The aims of these phase I trials were to evaluate the pharmacokinetic interaction between elbasvir (EBR) or grazoprevir (GZR) and buprenorphine/naloxone (BUP/NAL). Trial 1 was a single-dose trial in healthy participants. Trial 2 was a multiple-dose trial in participants on BUP/NAL maintenance therapy. Coadministration of EBR or GZR with BUP/NAL had minimal effect on the pharmacokinetics of BUP/NAL, EBR, and GZR. The geometric mean ratios (GMRs (90% CI)) for BUP, norbuprenorphine, and NAL AUC0-∞ were 0.98 (0.89-1.08), 0.97 (0.86-1.09), and 0.88 (0.78-1.00) in the presence/absence of EBR; 0.98 (0.81-1.19), 1.13 (0.97-1.32), and 1.10 (0.82-1.47) in the presence/absence of GZR. The GMRs (90% CI) for EBR and GZR AUC0-∞ in the absence/presence of BUP/NAL were 1.22 (0.98-1.52) and 0.86 (0.63-1.18). In conclusion, no dose adjustment for BUP/NAL, EBR, or GZR is required for patients with HCV infection receiving EBR/GZR and BUP/NAL maintenance therapy.

No Pharmacokinetic Interactions Between Elbasvir or Grazoprevir and Methadone in Participants Receiving Maintenance Opioid Agonist Therapy

We conducted two phase I trials to evaluate the pharmacokinetic interactions between elbasvir (EBR), grazoprevir (GZR), and methadone (MK‐8742‐P010 and MK‐5172‐P030) in non‐hepatitis C virus (HCV)‐infected participants on methadone maintenance therapy. Coadministration of EBR or GZR with methadone had no clinically meaningful effect on EBR, GZR, or methadone pharmacokinetics. The geometric mean ratios (GMRs) for R‐ and S‐methadone AUC_0‐24 were 1.03 (90% confidence interval (CI), 0.92–1.15) and 1.09 (90% CI, 0.94–1.26) in the presence/absence of EBR; and 1.09 (90% CI, 1.02–1.17) and 1.23 (90% CI, 1.12–1.35) in the presence/absence of GZR. The GMRs for EBR and GZR AUC_0‐24 in participants receiving methadone relative to a healthy historical cohort not receiving methadone were 1.20 (90% CI, 0.94–1.53) and 1.03 (90% CI, 0.76–1.41), respectively. These results indicate that no dose adjustment is required for individuals with HCV infection receiving stable methadone therapy and the EBR/GZR fixed‐dose regimen.

Benefits transfer and the aquatic environment: An investigation into the context of fish passage improvement

We present findings from a choice experiment investigating improvements in the aquatic environment from mitigation of barriers to fish passage. Implemented at a local and national level, results reveal positive preferences for increased numbers of fish species as well as fish abundance. In addition, we examine if in this case the willingness to pay estimates are suitable for direct transfer between national and local settings. For both samples, we consider the extent to which stated attribute non-attendance impacts estimates of willingness to pay and the potential ability of researchers to transfer values between contexts. Implications of the use of benefit transfer within this policy context are discussed in light of our findings.

Molecular Epidemiology of Two Fowl Cholera Outbreaks on a Free-Range Chicken Layer Farm

Two outbreaks of fowl cholera on a multiage free-range egg farm were investigated. The outbreaks occurred in 1994 and 2002. A total of 22 strains of Pasteurella multocida were available for study, 11 from the 1994 outbreak and 11 from the 2002 outbreak. Lesions typical of acute fowl cholera were seen in the 1994 outbreak, whereas both acute and chronic fowl cholera occurred in the 2002 outbreak. The isolates were examined in an extended phenotypic typing methodology, by a P. multocida–specific polymerase chain reaction (PCR), by the Heddleston somatic serotyping scheme, and by restriction endonuclease analysis (REA) typing using the enzyme HpaII. All 22 strains had the same phenotypic properties, all were confirmed as P. multocida by PCR, all were Heddleston serovar 4, and all had the same REA pattern. The results indicate that these 2 outbreaks were caused by the same clone of P. multocida–-despite the 8-year time period between the outbreaks.

Comprehensive RNAi-based screening of human and mouse TLR pathways identifies species-specific preferences in signaling protein use

Toll-like receptors (TLRs) are a major class of pattern recognition receptors, which mediate the responses of innate immune cells to microbial stimuli. To systematically determine the roles of proteins in canonical TLR signaling pathways, we conducted an RNA interference (RNAi)–based screen in human and mouse macrophages. We observed a pattern of conserved signaling module dependencies across species, but found notable species-specific requirements at the level of individual proteins. Among these, we identified unexpected differences in the involvement of members of the interleukin-1 receptor–associated kinase (IRAK) family between the human and mouse TLR pathways. Whereas TLR signaling in mouse macrophages depended primarily on IRAK4 and IRAK2, with little or no role for IRAK1, TLR signaling and pro inflammatory cytokine production in human macrophages depended on IRAK1, with knockdown of IRAK4 or IRAK2 having less of an effect. Consistent with species-specific roles for these kinases, IRAK4 orthologs failed to rescue signaling in IRAK4-deficient macrophages from the other species, and only mouse macrophages required the kinase activity of IRAK4 to mediate TLR responses. The identification of a critical role for IRAK1 in TLR signaling in humans could potentially explain the association of IRAK1 with several autoimmune diseases. Furthermore, this study demonstrated how systematic screening can be used to identify important characteristics of innate immune responses across species, which could optimize therapeutic targeting to manipulate human TLR-dependent outputs.

Predictors of weight loss at 1 year after laparoscopic adjustable gastric banding and the role of presurgical quality of life

BACKGROUND

There is uncertainty regarding preoperative predictors of a successful outcome for bariatric surgery (BarSurg), on which to determine appropriateness for such a procedure. Our aims were to identify preoperative clinical and psychosocial predictors of success following BarSurg and to explore the influence of body mass index (BMI) on these parameters.

METHODS

Preoperative data, including Impact of Weight on Quality of Life-Lite (IWQOL-Lite) scores transformed to Health-Related Quality of Life (HRQOL) scores, were accrued from 76 morbidly obese adults awaiting BarSurg. Pre- and postoperative data were also accrued for 26 patients who had completed 1-year follow-up post-bariatric surgery (laparoscopic adjustable gastric banding-LAGB). Statistical analysis was performed to assess the relationships between preoperative HRQOL scores, preoperative BMI and excess weight loss 1 year following BarSurg (EWL-1 year).

RESULTS

Preoperative BMI showed a significant independent, negative linear correlation with the public distress domain of preoperative quality of life (QOL) (r = -0.368, p = 0.001; β = -0.245, p = 0.009). Preoperative BMI had a significant, positive and independent association with EWL-1 year (r = 0.499, p = 0.009; β = 0.679, p = 0.015). Preoperative QOL scores had no association with EWL-1 year.

CONCLUSIONS

Preoperative BMI appears to predict EWL-1 year following restrictive bariatric surgery (LAGB). Preoperatively, patients with higher BMI appear to manifest greater public distress. Preoperative QOL scores, however, do not appear to have any predictive value for EWL-1 year post-LAGB. Preoperative BMI should therefore be employed as a predictor of EWL-1 year post-LAGB. Other measures of successful outcomes of bariatric surgeries (such as effects on QOL scores at 1 year) should be explored in future, larger and longer term studies.

Efavirenz modulation of sleep spindles and sleep spectral profile

Non-nucleoside reverse transcriptase inhibitors are important antiretroviral agents for the treatment of human immunodeficiency virus. Some non-nucleoside reverse transcriptase inhibitors, in particular efavirenz, have prominent effects on sleep, cognition and psychiatric variables that limit their tolerability. To avoid confounds due to drug-drug and drug-disease interactions, we assessed the effects of efavirenz in healthy volunteers on sleep, cognition and psychological endpoints during the first week of treatment. Forty healthy male subjects were randomized to receive placebo or efavirenz 600 mg nightly for 7 days after completion of a 3-day placebo run-in period. Treatment with efavirenz was associated with reduced time to sleep onset in the Maintenance of Wakefulness Test, an increase in non-rapid eye movement sleep, a large exposure-related decrease in sigma band spectral density and sleep spindle density during non-rapid eye movement sleep, and reduced performance on an attention switching task. Because efavirenz has been shown to have serotonin 2A receptor partial-agonist properties, we reasoned that antagonism of serotonin 2A receptor signalling in the thalamic reticular nucleus, which generates sleep spindles and promotes attention, may be responsible. Consistent with predictions, treatment of healthy volunteers with a single dose of a serotonin 2A receptor antagonist was found to significantly suppress sigma band spectral density in an exposure-related manner and modulated the overall spectral profile in a manner highly similar to that observed with efavirenz, consistent with the notion that efavirenz exhibits serotonin 2A receptor partial-agonist pharmacology in humans.

Investigating the mechanism of TLR signaling crosstalk in mouse macrophages (IRM5P.702)

It is well established that the TRIF- and MyD88-dependent signaling branches in the TLR4 pathway cooperate to induce a strong innate immune response. It is also known that certain toll-like receptor (TLR) ligand combinations can induce synergistic production of some cytokines. However, the molecular mechanisms underlying this signaling pathway cooperation remain elusive. We conducted a microarray analysis of mouse bone marrow-derived macrophages stimulated with all pairwise combinations of the TLR ligands LPS, Pam3CSK4, R848 and poly I:C to characterize synergy in transcript induction. We find that the crosstalk between the different TLR pathways is most prevalent in combinations which induce both the TRIF and the MyD88 pathways, which is essentially a mimic of the TLR4 pathway. Genes synergistically induced under dual TLR stimulation are mainly cytokines and immune effectors, including IL-6, IL-10, IL-1α, IL-1β, haptoglobin, lipocalin 2, and SOCS3. Based on these data, over 200 synergy factor candidates were picked and targeted using RNAi screening, with IL-6 and IL-12p40 secretion as read outs. A total of 32 hits were identified in the primary screening, including well-known regulators of secondary response gene transcription such as Nfkbiz, Irak2, Tnfaip3 and Tnip1. Secondary screening is ongoing to verify what role the 32 identified genes play in the MyD88/TRIF-dependent synergistic induction of immune regulators.

Using a systematic approach to select flagship species for bird conservation

Conservation marketing campaigns that focus on flagship species play a vital role in biological diversity conservation because they raise funds and change people's behavior. However, most flagship species are selected without considering the target audience of the campaign, which can hamper the campaign's effectiveness. To address this problem, we used a systematic and stakeholder-driven approach to select flagship species for a conservation campaign in the Serra do Urubu in northeastern Brazil. We based our techniques on environmental economic and marketing methods. We used choice experiments to examine the species attributes that drive preference and latent-class models to segment respondents into groups by preferences and socioeconomic characteristics. We used respondent preferences and information on bird species inhabiting the Serra do Urubu to calculate a flagship species suitability score. We also asked respondents to indicate their favorite species from a set list to enable comparison between methods. The species' traits that drove audience preference were geographic distribution, population size, visibility, attractiveness, and survival in captivity. However, the importance of these factors differed among groups and groups differed in their views on whether species with small populations and the ability to survive in captivity should be prioritized. The popularity rankings of species differed between approaches, a result that was probably related to the different ways in which the 2 methods measured preference. Our new approach is a transparent and evidence-based method that can be used to refine the way stakeholders are engaged in the design of conservation marketing campaigns.

Outpatient management of biliary colic: a prospective observational study of prescribing habits and analgesia effectiveness

BACKGROUND

Uncomplicated biliary colic presents a significant health and financial burden to hospitals and primary care services alike. There is little guidance on the correct analgesia to use on an outpatient basis. This study aimed to evaluate the effectiveness of oral analgesics on biliary colic pain and to explore the prescribing habits of community doctors.

METHODS

Consecutive patients with ultrasound proven symptomatic gallstones completed a questionnaire recording demographics and symptomatology. Pain was assessed using a visual analogue scale (VAS) based on the Biliary Symptom Score (BSS) to evaluate the effectiveness of various analgesic agents. Local General Practitioners were also surveyed to establish prescribing practices.

RESULTS

Co-Codamol had the highest mean effectiveness VAS score (6.5/10). Patients with increased BMI, short symptom duration and a BSS >70 were most likely to suffer from severe pain. Patients in a subgroup with severe pain were most likely to have their pain reduced by NSAID analgesia compared to no NSAID (OR 2.20, p = 0.027). This effect remained significant upon multivariable regression (OR 2.52, p = 0.018) in a model containing age and NSAIDs. There was wide variation in the prescribing practice of GPs and hospital doctors.

CONCLUSIONS

The range of drugs prescribed for biliary colic is extensive with little evidence base. In this study NSAIDs were the most effective analgesia for patients with severe pain. In the absence of contraindications to their use, physician education or guidance emphasizing the benefits of NSAIDs may potentially reduce symptomatic hospital presentation and admissions for biliary colic.

An unusual case of pancreatic fistula

We report an unusual case of a pancreatic fistula communicating with an appendicectomy wound. This occurred following an episode of acute haemorrhagic pancreatitis. The patient was initially admitted with signs and symptoms indicating appendicitis and went to theatre for an open appendicectomy. However, this did not resolve his symptoms and a laparotomy was performed the next day revealing haemorrhagic pancreatitis. He endured a stormy post-operative course, the cause of which was found to be an external pancreatic fistula with discharge of amylase-rich fluid from the Lanz incision. A trial of conservative management failed despite multiple percutaneous drainage procedures and treatment with broad-spectrum antibiotics. After a second opinion was sought, it was decided to fit a roux loop anastomosis between the head of the pancreas and the duodenum to divert the fistulous fluid. This procedure was a success and the patient remains well 2 years later.

Ablation of the regulatory IE1 protein of murine cytomegalovirus alters in vivo pro-inflammatory TNF-alpha production during acute infection

Little is known about the role of viral genes in modulating host cytokine responses. Here we report a new functional role of the viral encoded IE1 protein of the murine cytomegalovirus in sculpting the inflammatory response in an acute infection. In time course experiments of infected primary macrophages (MΦs) measuring cytokine production levels, genetic ablation of the immediate-early 1 (ie1) gene results in a significant increase in TNFα production. Intracellular staining for cytokine production and viral early gene expression shows that TNFα production is highly associated with the productively infected MΦ population of cells. The ie1- dependent phenotype of enhanced MΦ TNFα production occurs at both protein and RNA levels. Noticeably, we show in a series of in vivo infection experiments that in multiple organs the presence of ie1 potently inhibits the pro-inflammatory cytokine response. From these experiments, levels of TNFα, and to a lesser extent IFNβ, but not the anti-inflammatory cytokine IL10, are moderated in the presence of ie1. The ie1- mediated inhibition of TNFα production has a similar quantitative phenotype profile in infection of susceptible (BALB/c) and resistant (C57BL/6) mouse strains as well as in a severe immuno-ablative model of infection. In vitro experiments with infected macrophages reveal that deletion of ie1 results in increased sensitivity of viral replication to TNFα inhibition. However, in vivo infection studies show that genetic ablation of TNFα or TNFRp55 receptor is not sufficient to rescue the restricted replication phenotype of the ie1 mutant virus. These results provide, for the first time, evidence for a role of IE1 as a regulator of the pro-inflammatory response and demonstrate a specific pathogen gene capable of moderating the host production of TNFα in vivo.

The suppression of the production rather than the blockage of action of the potent inflammatory mediator TNFα is a particular hallmark of anti-TNFα mechanisms associated with microbial and parasitic infections. Whether this mode of counter-regulation is an important feature of infection by viruses is not clear. Also, it remains to be determined whether a specific pathogen gene in the context of an infection in vivo is capable of modulating levels of TNFα production. In this study we disclose a virus-mediated moderation of TNFα production, dependent on the ie1 gene of murine cytomegalovirus (MCMV). The ie1 gene product IE1 is a well-characterized nuclear protein capable of altering levels of host and viral gene expression although its biological role in the context of a natural infection is to date unknown. We provide evidence showing that ie1 is associated with a moderated pro-inflammatory cytokine response, in particular with TNFα production. Further, we show that the viral moderation of this cytokine is not only readily apparent in vitro but also in the natural host. The identification of a viral gene responsible for this mode of regulation in vivo may have therapeutic potential in the future in both anti-viral and anti-inflammatory strategies.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

Emergency presentation of retrograde intussusception as a late complication of gastric bypass

Retrograde intussusception is a rare complication of a Roux-en-Y gastric bypass. With the rising number of gastric bypass operations being performed in the UK, the incidence of retrograde intussusception is likely to increase. We report the first case in the UK and highlight its insidious presentation and the importance of considering intussusception in any patient with a history of a Roux-en-Y gastric bypass.

The pitfalls of treating anorectal conditions after radiotherapy for prostate cancer

We present a salutary lesson learned from three cases with significant complications that followed anorectal intervention in the presence of radiation proctitis due to prior radiotherapy for adenocarcinoma of the prostate. After apparent routine rubber band ligation for painful haemorrhoids, one patient developed a colo-cutaneous fistula. Following laser coagulation for radiation proctitis, one patient required a pelvic exenteration for a fistula, while another developed a rectal stenosis. Those diagnosing and treating colonic conditions should be mindful of the increased prevalence of patients who have had radiotherapy for prostate cancer and the potential for complications in treating these patients.

Host gene targets for novel influenza therapies elucidated by high-throughput RNA interference screens

Influenza virus encodes only 11 viral proteins but replicates in a broad range of avian and mammalian species by exploiting host cell functions. Genome-wide RNA interference (RNAi) has proven to be a powerful tool for identifying the host molecules that participate in each step of virus replication. Meta-analysis of findings from genome-wide RNAi screens has shown influenza virus to be dependent on functional nodes in host cell pathways, requiring a wide variety of molecules and cellular proteins for replication. Because rapid evolution of the influenza A viruses persistently complicates the effectiveness of vaccines and therapeutics, a further understanding of the complex host cell pathways coopted by influenza virus for replication may provide new targets and strategies for antiviral therapy. RNAi genome screening technologies together with bioinformatics can provide the ability to rapidly identify specific host factors involved in resistance and susceptibility to influenza virus, allowing for novel disease intervention strategies.

Activation by interferon-gamma of expression of ICAM-1 and MHC class II antigens in tumour cells from colorectal carcinomas

Aims-To determine whether lack of MHC class II antigen and intercellular adhesion molecule-1 (ICAM-1) expression in some tumours is due to the inability of the tumour cells to respond to the cytokine interferon-gamma (IFN-gamma), an important activator of these surface molecules.Methods-Cells from 40 colorectal tumours which did not constitutively express class II MHC antigens or ICAM-1 were kept in short term culture after disaggregation for a few days to two weeks without significant loss of viability. These were treated with IFN-gamma. Expression of class II MHC antigens and ICAM-1 was determined using immunohistological techniques.Results-There was clear induction in vitro of both MHC class II antigens and ICAM-1 in cells from eight of the tumours, with between 50 and 80% of the tumour cells in the cultures staining positively. The staining was apparent within 24 hours, appeared maximal at about three days, and declined thereafter. There were no obvious differences in cell morphology or viability between the cultures which were inducible and those which were not, nor were there obvious differences between the tumours from which they were derived.Conclusions-Expression of MHC class II antigens and ICAM-1 may be induced by IFN-gamma in a small proportion of colorectal tumours which do not constitutively express these antigens, showing that only a minority of tumours are capable of responding to this cytokine.