Role of microsomal metabolism in bromfenac-induced cytotoxicity

This study delves into the intricate mechanisms underlying drug-induced liver injury (DILI) with a specific focus on bromfenac, the withdrawn nonsteroidal anti-inflammatory drug. DILI is a pervasive concern in drug development, prompting market withdrawals and posing significant challenges to healthcare. Despite the withdrawal of bromfenac due to DILI, the exact role of its microsomal metabolism in inducing hepatotoxicity remains unclear. Herein, employing HepG2 cells with human liver microsomes and UDP-glucuronic acid (UDPGA), our investigation revealed a substantial increase in bromfenac-induced cytotoxicity in the presence of UDPGA, pointing to the significance of UDP-glucuronosyltransferase (UGT)-dependent metabolism in augmenting toxicity. Notably, among the recombinant UGTs examined, UGT2B7 emerged as a pivotal enzyme in the metabolic activation of bromfenac. Metabolite identification studies disclosed the formation of reactive intermediates, with bromfenac indolinone (lactam) identified as a potential mediator of hepatotoxic effects. Moreover, in cytotoxicity experiments, the toxicity of bromfenac lactam exhibited a 34-fold increase, relative to bromfenac. The toxicity of bromfenac lactam was mitigated by nicotinamide adenine dinucleotide phosphate-dependent metabolism. This finding underscores the role of UGT-dependent metabolism in generating reactive metabolites that contribute to the observed hepatotoxicity associated with bromfenac. Understanding these metabolic pathways and the involvement of specific enzymes, such as UGT2B7, provides crucial insights into the mechanisms of bromfenac-induced liver injury. In conclusion, this research sheds light on the metabolic intricacies leading to cytotoxicity induced by bromfenac, especially emphasizing the role of UGT-dependent metabolism and the formation of reactive intermediates like bromfenac lactam. These findings offer insight into the mechanistic basis of DILI and emphasize the importance of understanding metabolism-mediated toxicity.

Synthesis of 2,3-Benzotropones via Palladium(II)-Catalyzed Aerobic Dehydrogenation from 1-Benzosuberones and Sequential Diels-Alder Reaction to Yield Benzobicyclo[3.2.2]nonenones

An approach to 2,3-benzotropone from 1-benzosuberone via palladium(II)-catalyzed aerobic dehydrogenation was developed. This method first provided a catalytic route to various 2,3-benzotropones from their corresponding 1-benzosuberones in good yields. In addition, the reaction could be applied to a one-pot Diels-Alder reaction with maleimide, providing a complex benzobicyclo[3.2.2]nonenone in ≤90% yield. Kinetic analysis supporting our proposed mechanism was also performed, underscoring the robustness of the developed synthetic pathway.

A remote-controlled automatic chest compression device capable of moving compression position during CPR: A pilot study in a mannequin and a swine model of cardiac arrest

BACKGROUND

Recently, we developed a chest compression device that can move the chest compression position without interruption during CPR and be remotely controlled to minimize rescuer exposure to infectious diseases. The purpose of this study was to compare its performance with conventional mechanical CPR device in a mannequin and a swine model of cardiac arrest.

MATERIALS AND METHODS

A prototype of a remote-controlled automatic chest compression device (ROSCER) that can change the chest compression position without interruption during CPR was developed, and its performance was compared with LUCAS 3 in a mannequin and a swine model of cardiac arrest. In a swine model of cardiac arrest, 16 male pigs were randomly assigned into the two groups, ROSCER CPR (n = 8) and LUCAS 3 CPR (n = 8), respectively. During 5 minutes of CPR, hemodynamic parameters including aortic pressure, right atrial pressure, coronary perfusion pressure, common carotid blood flow, and end-tidal carbon dioxide partial pressure were measured.

RESULTS

In the compression performance test using a mannequin, compression depth, compression time, decompression time, and plateau time were almost equal between ROSCER and LUCAS 3. In a swine model of cardiac arrest, coronary perfusion pressure showed no difference between the two groups (p = 0.409). Systolic aortic pressure and carotid blood flow were higher in the LUCAS 3 group than in the ROSCER group during 5 minutes of CPR (p < 0.001, p = 0.008, respectively). End-tidal CO2 level of the ROSCER group was initially lower than that of the LUCAS 3 group, but was higher over time (p = 0.022). A Kaplan-Meier survival analysis for ROSC also showed no difference between the two groups (p = 0.46).

CONCLUSION

The prototype of a remote-controlled automated chest compression device can move the chest compression position without interruption during CPR. In a mannequin and a swine model of cardiac arrest, the device showed no inferior performance to a conventional mechanical CPR device.

Real-time x-ray abnormality alerts for emergency departments using a radiographer comment model - a multisite pilot study

INTRODUCTION

The timely communication of clinically significant image appearances to Emergency Department (ED) referrers is necessary for optimum patient care. Australian reliance on verbal communication only is time-limited, open to misinterpretation and lacks transparency. A combined radiographer alert and comment model was designed to reliably communicate image abnormalities to ED referrers in real-time.

METHODS

A multidisciplinary steering group designed the model for all ED general imaging. Protocols were developed to document radiographer comments (critical, urgent and clinically significant) in patients' medical records. Critical findings were communicated directly to ED. Five NSW hospitals varying in size, complexity and population demographics piloted the model between three to twelve months during 2021-2022. Site auditors compared comments with the radiology report and designated each as True Positive (TP), False Positive (FP), indeterminate and clinically significant. Indeterminate cases were analysed by an external radiologist. Inter-observer consensus was obtained for all classifications via two independent auditors. The Positive Predictive Value (PPV), or precision of the comment, was calculated for each site.

RESULTS

Radiographers (n = 69) provided comments for 1102 cases. The pooled average PPV for TP was 0.96; (0.947-0.971; 95% CI). The weighted mean error (FP comments) was 3.9%; (2.9% - 5.3%.; 95% CI).

CONCLUSION

The Radiographer Comment model provided consistent levels of commenting precision and reproducibility across a range of sites with a pooled average PPV (0.96). The False Positive rate or weighted mean error (FP) of 3.9% (2.9% - 5.3%.; 95% CI) was low.

IMPLICATIONS FOR FUTURE PRACTICE

A strategic, interprofessional approach in the implementation of an image alert combined with a Radiographer Comment can be adapted across a variety of hospital settings for ED and other departments.

Australian radiographer roles in the emergency department; evidence of regulatory compliance to improve patient safety - A narrative review

OBJECTIVES

Using a narrative approach, this paper aims to determine the extent of Australian radiographers' regulatory compliance to improve patient safety when performing appendicular X-ray and non-contrast brain computed tomography (CT) in the Emergency Department (ED).

KEY FINDINGS

A narrative review explored relevant literature and key regulatory policy. Ten documents were identified, three main themes were developed related to the radiographer roles in X-ray request justification, dose optimisation and preliminary image evaluation (PIE). Radiographers were equally aware of justification and optimisation pre and post the introduction of a Medical Code of Practice. The collective PIE accuracy of radiographers remained unaffected by changes in mode of PIE delivery and regulatory factors but varied based on the anatomical region.

CONCLUSION

While current Australian regulations mandate radiographer request justification, dose optimisation and PIE, the degree of compliance by Australian radiographers remains uncertain. Current literature provides evidence that radiographers can improve patient care and safety through justification, optimisation, and PIE delivery. Change in workplace practice, supported by key stakeholders including radiologists, is essential to integrate radiographers' functions into routine ED clinical practice. Further research is required to audit radiographers' regulatory compliance to improve patient safety.

IMPLICATIONS FOR PRACTICE

Patient safety in ED can be improved with timely and accurate diagnosis provided by radiographers. Radiographers have a professional obligation to adhere to the capabilities and standards for safe medical radiation practice defined by Australian regulations. Therefore, radiographers must justify the X-ray request, optimise the radiation dose where appropriate and communicate urgent or unexpected findings to the referrer.

Enhancement of the therapeutic efficacy of the MAP regimen using thiamine pyrophosphate-decorated albumin nanoclusters in osteosarcoma treatment

Recent studies on osteosarcoma regimens have mainly focused on modifying the combination of antineoplastic agents rather than enhancing the therapeutic efficacy of each component. Here, an albumin nanocluster (NC)-assisted methotrexate (MTX), doxorubicin (DOX), and cisplatin (MAP) regimen with improved antitumor efficacy is presented. Human serum albumin (HSA) is decorated with thiamine pyrophosphate (TPP) to increase the affinity to the bone tumor microenvironment (TME). MTX or DOX (hydrophobic MAP components) is adsorbed to HSA-TPP via hydrophobic interactions. MTX- or DOX-adsorbed HSA-TPP NCs exhibit 20.8- and 1.64-fold higher binding affinity to hydroxyapatite, respectively, than corresponding HSA NCs, suggesting improved targeting ability to the bone TME via TPP decoration. A modified MAP regimen consisting of MTX- or DOX-adsorbed HSA-TPP NCs and free cisplatin displays a higher synergistic anticancer effect in HOS/MNNG human osteosarcoma cells than conventional MAP. TPP-decorated NCs show 1.53-fold higher tumor accumulation than unmodified NCs in an orthotopic osteosarcoma mouse model, indicating increased bone tumor distribution. As a result, the modified regimen more significantly suppresses tumor growth in vivo than solution-based conventional MAP, suggesting that HSA-TPP NC-assisted MAP may be a promising strategy for osteosarcoma treatment.

Non-Animal Stabilized Hyaluronic Acid (NASHA) Gel Marker vs. Surgical Clips for Tumor Bed Delineation in Breast Cancer Using MR-Simulation

PURPOSE/OBJECTIVE(S)

Consistent delineation of the tumor bed (TB) after breast conserving surgery (BCS) is critical and remains a challenge with increasing prevalence of oncoplastic surgeries. Clips are generally used to help TB identification on CT-simulation but they are not well identified on MR-simulation. The aim of this study is to assess whether the use of NASHA gel with MR-simulation yields similar interobserver variability (inter-OV) compared to clips with CT-simulation.

MATERIALS/METHODS

This prospective single arm feasibility study included patients eligible for BCS. After lumpectomy, the surgeon placed both clips (>5) and NASHA gel drops as markers to define the TB. Patients underwent CT and MRI simulation scans. Five radiation oncologists and one radiologist delineated the TB aided by clips on CT, and gel on MRI. The observers also assessed the visibility and utility of the gel (scale from 1 to 10), as well as the cavity visualization score (CVS, scale from 1 to 5). The primary endpoint was the inter-OV of the delineated TB using the overlap difference of contours using clips and CT versus gel and MRI, with the conformity index measured according to the pair definition of the Dice Similarity Coefficient (DSC).

RESULTS

Of the 35 patients recruited, 30 were eligible for inter-OV analysis of TB delineation and 5 patients required further breast surgery for positive margins. One third of the eligible patients underwent an oncoplastic procedure. There were no significant differences between inter-OV of delineated TB using clips and CT versus gel and T2-weighted MRI with the mean DSC (0.60 vs 0.62, p = 0.364). The observers reported higher usefulness of gel in patients with an oncoplastic procedure than not (median US 8.2 vs 6.6, p = 0.024), and higher visibility of gel in patients who had their scans within 6 weeks than beyond post-op (median VS 8.1 vs 6.1, p = 0.013). When the CVS was higher (3-5), the median US of gel was lower (5.9 vs 7.8, p = 0.004), and the conformity index of clip and CT delineated TB was higher (median DSC 0.72 vs 0.53, p <0.001). Interestingly, a higher CVS did not lead to significantly higher conformity index of gel and T2-weighted MR delineated TB (mean DSC 0.67 vs 0.58, p = 0.073). NASHA gel injection added a median of 3 minutes to the operating theatre (OT) time and was rated as 'easy' in 89% of cases by surgeons. There were no immediate adverse events (AE) in OT, while 2 of 35 patients later experienced a grade 3 AE - hematoma which required evacuation in OT day 1 post-BCS, and infected seroma which required drainage and washout in OT 2 months post-BCS and axillary dissection. These reflect common risks with standard BCS and are not clearly attributed to gel injection alone.

CONCLUSION

Use of NASHA gel leads to similar inter-OV of BC TB delineation compared to >5 clips. NASHA gel is hence a reliable alternative to clips when MR-simulation is used.

Chemical Glycosylation with p-Methoxyphenyl (PMP) Glycosides via Oxidative Activation

A novel persulfate-mediated oxidative glycosylation system using p-methoxyphenyl (PMP) glycosides as bench-stable glycosyl donors is developed. This study shows that both K₂S₂O₈ as an oxidant and Hf(OTf)₄ as a Lewis acid catalyst play important roles in the oxidative activation of the PMP group into a potential leaving group. This convenient glycosylation protocol proceeds under mild conditions and delivers a wide range of biologically and synthetically valuable glycoconjugates, including glycosyl fluorides.

Photoredox-Catalyzed Oxidative Radical-Polar Crossover Enables the Alkylfluorination of Olefins

The three-component alkylfluorination of olefins via an oxidative radical-polar crossover under visible light-induced photocatalysis is disclosed. A key feature of this reaction is the incorporation of two synthetically meaningful components involving a three-dimensional alkyl group and a fluorine atom using easily preparable N-hydroxyphthalimide esters as the alkyl donors and a low-cost hydrogen fluoride as the fluorine source. Furthermore, a one-step procedure using commercially available carboxylic acids demonstrated the versatility of this new method.

Ligand-controlled regiodivergent direct arylation of indoles via oxidative boron Heck reaction

Ligand-controlled direct arylation of indoles via Pd(ii) catalyzed oxidative boron Heck reaction under aerobic conditions is reported.

COVID-19 vaccination acceptability in the UK at the start of the vaccination programme: a nationally representative cross-sectional survey (CoVAccS - wave 2)

Objectives

Investigate factors associated with the intention to have the COVID-19 vaccination following initiation of the UK national vaccination programme.

Study design

An online cross-sectional survey completed by 1500 adults (13th–15th January 2021).

Methods

Linear regression analyses were used to investigate associations between intention to be vaccinated for COVID-19 and sociodemographic factors, previous influenza vaccination, attitudes and beliefs about COVID-19 and COVID-19 vaccination and vaccination in general. Participants’ main reasons for likely vaccination (non-)uptake were also solicited.

Results

73.5% of participants (95% CI 71.2%, 75.7%) reported being likely to be vaccinated against COVID-19, 17.3% (95% CI 15.4%, 19.3%) were unsure, and 9.3% (95% CI 7.9%, 10.8%) reported being unlikely to be vaccinated. The full regression model explained 69.8% of the variance in intention. Intention was associated with: having been/intending to be vaccinated for influenza last winter/this winter; stronger beliefs about social acceptability of a COVID-19 vaccine; the perceived need for vaccination; adequacy of information about the vaccine; and weaker beliefs that the vaccine is unsafe. Beliefs that only those at serious risk of illness should be vaccinated and that the vaccines are just a means for manufacturers to make money were negatively associated with vaccination intention.

Conclusions

Most participants reported being likely to get the COVID-19 vaccination. COVID-19 vaccination attitudes and beliefs are a crucial factor underpinning vaccine intention. Continued engagement with the public with a focus on the importance and safety of vaccination is recommended.

Ethnography and medicine: the utility of positivist methods in research

This commentary discusses the methodological utility of ethnography within the medical space. Whilst a general consensus affirms that ethnography aligns with qualitative approaches, as identified within the existing medical literature, here, we demonstrate how quantitative [positivist] methods can also be incorporated. This paper begins by contextualising ethnographic approaches within medical contexts by demonstrating its empirical value within the existing literature. Next, we discuss the interconnection between the practice of 'doctoring' and ethnographic research, whereby doctors themselves use forms of inductive and deductive reasoning to treat and manage patients in their everyday context. This philosophical discussion not only links to the everyday practice of medical practitioners, but also critically reflects on the role of the first author, as a diagnostic radiographer. Lastly, this paper identifies the virtues of ethnographic research for medical students and/or medical doctors whereby the combination of qualitative and quantitative methods (within an ethnographic methodology) can lead to new empirical and methodological insights, enabling the creation of alternate research strategies and evidence. This methodological strategy may be best considered amongst medical students and/or early career medical researchers, but we also anticipate it to resonate and open further discussion with experienced medical practitioners and researchers transnationally.

Evaluation of Anti-Melanogenesis Activity of Enriched Pueraria lobata Stem Extracts and Characterization of Its Phytochemical Components Using HPLC-PDA-ESI-MS/MS

The root of Pueraria lobata (Willd.) is a widely used herbal medicine worldwide, whereas the stem of the plant is discarded or used as feed for livestock. To reuse and exploit the stem of P. lobata as a resource, we investigated its potential as a skin-whitening agent. We found that the developed, enriched P. lobata stem (PLS) extract significantly inhibited melanin production in the 3-isobutyl-1-methylxanthine-induced B16/F10 cells at a concentration of 50 μg/mL. To further confirm the mechanism of the antimelanogenic effect of the enriched PLS extracts, we examined the mRNA expression of tyrosinase, which was suppressed by the extracts. To standardize and implement effective quality control of the enriched PLS extracts, its major chemical constituents were identified by high-performance liquid chromatography-photodiode array-electrospray ionization-mass spectrometry. In total, 12 constituents were identified. In silico analysis showed that the main constituents, puerarin and daidzin, had excellent binding affinities for human tyrosinase. Collectively, our results suggest that the PLS extracts could be used as anti-pigmentation agents.

POS0161-HPR BARRIERS AND FACILITATORS RELATED TO SELF-MANAGEMENT OF SHOULDER PAIN: A SYSTEMATIC REVIEW AND QUALITATIVE SYNTHESIS

Background:

Shoulder pain is a significant cause of pain and disability in the general population.1 Current research suggests that shoulder pain can be resistant to treatment and is often recurrent.2 Systematic review-level evidence shows modest short-term benefits for most current treatments.3 Effective self-management strategies that equip patients with the necessary tools to self-manage their condition are urgently required. However, engagement with self-management is poor, potentially compromising treatment outcomes and contributing to ongoing disability.4

Objectives:

The objectives of this review were to:

•Systematically identify and appraise relevant qualitative evidence on barriers and facilitators relating to self-management from the perspectives of people with shoulder pain and healthcare professionals.

•Collate and synthesise this evidence, to gain an understanding of factors that influence self-management of shoulder pain.

•Develop evidence-based recommendations to inform the implementation and delivery of self-management programmes for shoulder pain.

Methods:

A meta-aggregative approach to the synthesis of qualitative evidence was used. Twelve databases were searched, from inception to 13 July 2020, to identify studies exploring barriers and facilitators related to self-management of shoulder pain from the perspectives of people with shoulder pain and clinicians involved in the care of such patients. Two independent reviewers identified eligible articles, extracted the data and conducted critical appraisal. Two reviewers independently identified and developed categories, with validation by two further researchers. Categories were discussed among the wider research team and a comprehensive set of synthesized findings was derived.

Results:

Sixteen studies were included in the review, exploring several shoulder conditions: shoulder instability; rotator cuff-related pain; dysfunction post rotator cuff surgery; and degenerative rotator cuff tears. From the perspective of patients, three synthesized findings were identified that influenced self-management: (1) support for self-management, including subthemes related to patient-centred support, knowledge, time, access to equipment, and patient digital literacy; (2) personal factors, including patient beliefs, patient expectations, patient motivation, pain, and therapeutic response; and (3) external factors, including influence of the clinician and therapeutic approach. From the perspective of clinicians, two synthesized findings were identified that influenced adherence to self-management: (1) support for self-management, including education, patient-centred support, patient empowerment, time, and clinician digital literacy; and (2) preferred management approach, including clinician beliefs, expectations, motivation, therapeutic approach, and therapeutic response.

Conclusion:

Patients and clinicians identified several barriers and facilitators that influenced self-management of shoulder pain. Clinicians’ awareness of these factors could positively influence patient management, enhance patients’ ability to self-manage, and improve treatment outcomes.

References:

[1]Walker-Bone K, Palmer KT, Reading I, Coggon D, Cooper C. Prevalence and impact of musculoskeletal disorders of the upper limb in the general population. Arthritis and Rheumatism. 2004;51(4): 642-651.

[2]Croft P, Pope D, Silman A. The clinical course of shoulder pain: prospective cohort study in primary care. Primary Care Rheumatology Society Shoulder Study Group. British Medical Journal. 1996;313(7057): 601-602.

[3]Littlewood C, May S, Walters S. A review of systematic reviews of the effectiveness of conservative interventions for rotator cuff tendinopathy. Shoulder & Elbow. 2013;5(3): 151-167.

[4]Littlewood C, Malliaras P, Mawson S, May S, Walters S. Patients with rotator cuff tendinopathy can successfully self-manage, but with certain caveats: a qualitative study. Physiotherapy. 2014;100(1): 80-85.

Disclosure of Interests:

Aidan O’Shea: None declared, Jonathan Drennan: None declared, Chris Littlewood: None declared, Helen Slater Speakers bureau: AbbVie PTY LTD 2018, Julius Sim: None declared, Joseph McVeigh: None declared

Effect of citric acid and heat treatment on the content of less-polar ginsenosides in flower buds of Panax ginseng

Ginseng flower bud (GFB), as an inexpensive part of Panax ginseng, attracted significant attention as a beneficial functional food with medicinal potentials due to its high content of ginsenosides. A few studies focused on the utilization of heat treatment and citric acid treatment to process ginseng flowers, converting its polar ginsenosides into rare ginsenosides to improve its biological activities. Thus, in this study, we compared the changes of ginsenosides in GFB after citric acid and heat treatment by HPLC method. The results revealed that less-polar ginsenoside, Rg₆ and F₄, increased to 1.01 and 0.27% by heat treatment, respectively. Further, ginsenoside F₂ increased to 1.13% with 1 M citric acid treatment. Furthermore, based on the combination of these two processing methods for the first time, the conversion rate of less-polar ginsenosides surged to 80%. The content of ginsenoside Rg3(s) and Rg₅ increased to 1.509 and 1.871%, respectively, by simultaneous heat and citric acid treatment. Therefore, a processing approach that simultaneously performs heat and citric acid treatments has been proposed, and this considerably inexpensive and convenient processing method could be applied to the processing of GFBs and produce less-polar ginsenosides.

An analysis of the continuing professional development needs of radiographers and radiation therapists in Singapore

INTRODUCTION

Continuing Professional development (CPD) is deemed essential for the Radiographers (DR) and Radiation Therapists (RT) after Singapore commenced state registration. Diagnostic imaging and radiotherapy treatment services are constantly revolutionizing and those working in this field requires sufficient knowledge of the uptrends for training and development. The purpose of this survey is to identify the current training needs of the registered DR and RT in Singapore, and to understand their views about CPD activities.

METHODS

An online questionnaire was disseminated by the Singapore Society of Radiographers (SSR) to all registered DR and RT in Singapore, and all practicing in restructured and private hospitals were included. Data collection took place from January 2018 to April 2018.

RESULTS

102 responses were analysed, where 89 were DR and 13 were RT. CPD was provided in 72.5% (n = 74) of the participants' institutions, and 69.6% (n = 71) of participants were aware of CPD. Interestingly, participants were significantly more likely to be unaware of CPD when working in an institution which do not offer CPD. Training programme objective was the most important factor for selecting a programme. 93.1% (n = 95) preferred SSR to support them for CPD. There were a few constraints to CPD engagements identified such as financial factors, lack of time, and institution availability.

CONCLUSION

There was significant intrinsic motivation in a quality CPD activity. CPD activities should be current, accessible and relevant for the healthcare professionals to increase participation, which directly contributes to high standards of clinical care.

IMPLICATIONS FOR PRACTICE

Local healthcare institutions should be aware and address needs, gaps and aspirations of the local DR and RT community to ensure adequate preparation has been made upon initiation of mandatory CPD.

A Review of the Pharmacological Activities and Recent Synthetic Advances of γ-Butyrolactones

γ-Butyrolactone, a five-membered lactone moiety, is one of the privileged structures of diverse natural products and biologically active small molecules. Because of their broad spectrum of biological and pharmacological activities, synthetic methods for γ-butyrolactones have received significant attention from synthetic and medicinal chemists for decades. Recently, new developments and improvements in traditional methods have been reported by considering synthetic efficiency, feasibility, and green chemistry. In this review, the pharmacological activities of natural and synthetic γ-butyrolactones are described, including their structures and bioassay methods. Mainly, we summarize recent advances, occurring during the past decade, in the construction of γ-butyrolactone classified based on the bond formation in γ-butyrolactone between (i) C5-O1 bond, (ii) C4-C5 and C2-O1 bonds, (iii) C3-C4 and C2-O1 bonds, (iv) C3-C4 and C5-O1 bonds, (v) C2-C3 and C2-O1 bonds, (vi) C3-C4 bond, and (vii) C2-O1 bond. In addition, the application to the total synthesis of natural products bearing γ-butyrolactone scaffolds is described.

A194 A POSSIBLE ASSOCIATION BETWEEN SECUKINUMAB AND NEW-ONSET INFLAMMATORY BOWEL DISEASE: A CASE SERIES

Background

Secukinumab is a monoclonal antibody targeting interleukin-17A and is commonly used for managing autoimmune diseases such as, psoriasis, psoriatic arthritis, and ankylosing spondylitis. Prior studies have suggested that anti-IL17 therapy may worsen symptoms in patients with pre-existing inflammatory bowel disease (IBD). However, it remains unclear if secukinumab is associated with new-onset IBD or in provoking a flare of previously quiescent IBD.

Aims

We evaluated patients referred to our IBD clinic who developed intestinal inflammation after starting secukinumab for the management of autoimmune diseases.

Methods

We performed a retrospective, observational study at a single tertiary care center between 2017 and 2020. Patients referred to our IBD clinic who developed intestinal inflammation after starting secukinumab were included. We excluded patients with an established pre-existing diagnosis of IBD and patients who had positive stool testing for infectious organisms. Patient demographics, disease characteristics, distribution of intestinal inflammation and clinical outcomes were assessed. The pathology slides were reinterpreted by a single pathologist with a specialty in gastroenterology to determine the histologic characteristics of the inflammation.

Results

A total of 8 patients developed gastrointestinal symptoms after starting secukinumab: 4 (50%) males with a median age of 42.5 (IQR: 35–50 years old). Secukinumab was initiated for psoriasis in 3 (37.5%) patients, psoriatic arthritis in 2 (25%) patients, ankylosing spondylitis in 2 (25%) patients and juvenile idiopathic arthritis in 1 (12.5%) patient. The median time of onset for gastrointestinal symptoms after starting secukinumab was 7 months (IQR: 4–15 months). Of the patients who underwent testing for inflammatory biomarkers, the median CRP was 25.5 (IQR 25.4–34.2). Endoscopic disease distribution involved the colon in 5 (62.5%) patients and the ileum and colon in 3 (37.5%) patients. In this series of patients, the histologic characteristics demonstrated three patterns of colitis: IBD-like (ulcerative colitis or Crohn’s disease) in 6 (75%) patients based on mucosal granulomas and/or chronic inflammatory changes, MMF-like histology in 1 (12.5%) patient, characterized by an abundance of intraepithelial eosinophils in the lamina propria and numerous crypt apoptotic bodies, and finally active colitis in 1 (12.5%) patient characterized by an absence of chronic mucosal injury or granulomas. The treatment for these patients was cessation of secukinumab and initiating alternative therapies with close clinical monitoring.

Conclusions

In this small case series, Secukinumab was temporally associated with the development of gastrointestinal inflammation. Further larger studies are required to confirm this association and to determine if IL-17 contributes to the pathogenesis of IBD.

Funding Agencies

None

Recent advances in development of hetero-bivalent kinase inhibitors

Identifying a pharmacological agent that targets only one of more than 500 kinases present in humans is an important challenge. One potential solution to this problem is the development of bivalent kinase inhibitors, which consist of two connected fragments, each bind to a dissimilar binding site of the bisubstrate enzyme. The main advantage of bivalent (type V) kinase inhibitors is generating more interactions with target enzymes that can enhance the molecules' selectivity and affinity compared to single-site inhibitors. Earlier type V inhibitors were not suitable for the cellular environment and were mostly used in in vitro studies. However, recently developed bivalent compounds have high kinase affinity, high biological and chemical stability in vivo. This review summarized the hetero-bivalent kinase inhibitors described in the literature from 2014 to the present. We attempted to classify the molecules by serine/threonine and tyrosine kinase inhibitors, and then each target kinase and its hetero-bivalent inhibitor was assessed in depth. In addition, we discussed the analysis of advantages, limitations, and perspectives of bivalent kinase inhibitors compared with the monovalent kinase inhibitors.

Collective Syntheses of Guaiane Sesquiterpenes: Stereoselective Syntheses of (+)-Dysodensiol F, (+)-10β,14-Dihydroxy-allo-aromadendrane, and (-)-Dendroside C Aglycon

A collective synthetic route for tricyclic guaiane sesquiterpenes and total syntheses of (+)-dysodensiol F, (+)-10β,14-dihydroxy-allo-aromadendrane, and (-)-dendroside C aglycon starting from a versatile hydroazulene intermediate were accomplished. The key features of these syntheses involve late-stage carbene-mediated diastereoselective cyclopropanation, construction of an unusual cis-fused-hydroazulene skeleton via intramolecular Dieckmann condensation, and highly stereoselective tandem conjugate addition/intramolecular allylic alkylation to afford a 5/7/3 tricyclic skeleton of guaiane natural products. The synthesis of (-)-dendroside C aglycon and the first total synthesis of (+)-dysodensiol F and (+)-10β,14-dihydroxy-allo-aromadendrane are described in detail. Activation of the Nrf2/ARE signaling pathway by (-)-dendroside C aglycon is also disclosed via our synthesis.

Peroneal neuropathy caused by an extraneural ganglion cyst in the supracondylar area of the femur: A case report

RATIONALE

Peroneal neuropathy is the most common type of peripheral neuropathy in the lower extremities. The peroneal nerve is usually compressed at the lateral aspect of the fibular head. Compression by ganglion cysts are one of the numerous underlying etiologies for peroneal nerve neuropathy and are most frequently located around the fibular neck and proximal tibiofibular joint. To the best of our knowledge, this is the first report of an extraneural ganglion cyst located at the level of the distal thigh that resulted in compressive peroneal neuropathy.

PATIENT CONCERNS

We report a case of a 56-year-old man with sudden onset of left foot drop and gait disturbance caused by an extraneural ganglion cyst located in the popliteal fossa.

DIAGNOSIS

Electrodiagnosis (EDX) suggested a peroneal nerve lesion. Subsequently, diagnostic ultrasonography (USG) revealed a cystic mass located within the left side of the supracondylar area of femur. Further magnetic resonance imaging confirmed that the mass was located at the proximal of popliteal fossa.

INTERVENTIONS

Surgical excision was performed using a direct posterior approach. The cystic mass was compressing the common peroneal nerve, and was carefully and completely removed ensuring that all nerve branches were protected.

OUTCOMES

A histopathologic evaluation confirmed the diagnosis of a ganglion cyst. There were no postoperative complications. Two months after the surgery, follow-up USG revealed no evidence of cyst recurrence or residual lesions. Six months after the surgery, the ankle dorsiflexor motor power improved and he experienced less pain and hypoesthesia.

LESSONS

Physicians should bear in mind that the peroneal neuropathy can occur because of the ganglion cyst in the distal thigh. The thorough evaluation of EDX and USG is crucial for the early diagnosis and surgical intervention, although there is no abnormal finding around the fibular neck.

Usefulness of Goal Attainment Scaling in Intensive Stroke Rehabilitation During the Subacute Stage

OBJECTIVE

To investigate the usefulness of goal attainment scaling (GAS) in intensive stroke rehabilitation during the subacute stage.

METHODS

Medical records of subacute post-stroke patients who had undergone intensive rehabilitation under hospitalization, before and after the application of GAS, were collected. GAS was conducted at the initial evaluation of each patient. Specific goals were suggested by physical and occupational therapists and were determined by the responsible physiatrist. A 5-point scale was used for the GAS score after 4 weeks of rehabilitation according to the preset criteria of each goal. To evaluate the influence of GAS in rehabilitation practice, functional improvements were compared between two patient groups before (n=121) and after (n=141) GAS. To assess progress in GAS practice, the standard GAS score was calculated, and the changes were observed over a 3-year period. The standard GAS score converged to 50 points when the goal was achieved. The therapists who used GAS also completed a survey regarding its usefulness.

RESULTS

There were no statistical differences in the motor and cognitive outcomes of the patient groups before and after applying GAS scoring. Successive yearly changes in the standard GAS scores showed progressive convergence to 50 points, signaling that the patient's goal-setting abilities improved. According to the survey, most therapists felt that GAS enhanced the quality of therapies (84.6%).

CONCLUSION

GAS improved goal-setting for the rehabilitation of subacute post-stroke patients and might have a positive effect on rehabilitation.

Multifunctional Building Blocks Compatible with Photoredox-Mediated Alkylation for DNA-Encoded Library Synthesis

DNA-encoded library (DEL) technology has emerged as a novel interrogation modality for ligand discovery in the pharmaceutical industry. Given the increasing demand for a higher proportion of C(sp³)-hybridized centers in DEL platforms, a photoredox-mediated cross-coupling and defluorinative alkylation process is introduced using commercially available alkyl bromides and structurally diverse α-silylamines. Notably, no protecting group strategies for amines are necessary for the incorporation of a variety of amino-acid-based organosilanes, providing crucial branching points for further derivatization.

Assessment of Aspiration Risk Using the Mann Assessment of Swallowing Ability in Brain-Injured Patients With Cognitive Impairment

Objectives: The purposes of this study are to determine whether there is a correlation between the Mann Assessment of Swallowing Ability (MASA) and modified MASA (mMASA) according to various cognitive status and to investigate whether the cognitive status of patients with brain damage affects the prediction of aspiration using the MASA.

Methods: We retrospectively assessed 146 dysphagic patients with brain lesion due to various causes. Dysphagia was assessed using the MASA and mMASA. According to the videofluoroscopic swallowing study results, patients were divided into two groups: aspirators and non-aspirators. Patients were classified into four groups according to cognitive function according to the Korean version of Mini-mental State Examination scores: normal (>24), mild (21–24), moderate (10–20), and severe (<10) cognitive impairment. The correlation between the MASA and mMASA scores according to cognitive function were analyzed. The sensitivity, specificity, and positive and negative predictive values of the MASA scores for predicting aspiration were assessed.

Results: The MASA and mMASA scores showed a significant positive correlation in all cognition groups. In patients with more severe cognitive impairment MASA scores had high sensitivity and low specificity for prediction of aspiration. On the other hand, the MASA scores had low sensitivity and high specificity for prediction of aspiration in the normal and mild cognitive impairment groups.

Conclusions: The MASA and mMASA scores correlated with each other in patients with various levels of cognitive function. Interestingly, this study results demonstrated that patients with good cognitive function may have false negative results of MASA screening due to low sensitivity. Thus, when interpreting the MASA results, the impact of cognitive status should be taken into consideration.

Open-Air Alkylation Reactions in Photoredox-Catalyzed DNA-Encoded Library Synthesis

DNA-encoded library (DEL) technology is a powerful tool commonly used by the pharmaceutical industry for the identification of compounds with affinity to biomolecular targets. Success in this endeavor lies in sampling diverse chemical libraries. However, current DELs tend to be deficient in C(sp³) carbon counts. We report unique solutions to the challenge of increasing both the chemical diversity of these libraries and their C(sp³) carbon counts by merging Ni/photoredox dual catalytic C(sp²)-C(sp³) cross-coupling as well as photoredox-catalyzed radical/polar crossover alkylation protocols with DELs. The successful integration of multiple classes of radical sources enables the rapid incorporation of a diverse set of alkyl fragments.

Synthesis of α-Fluoro-α-Amino Acid Derivatives via Photoredox-Catalyzed Carbofluorination

A mild, metal-free, regioselective carbofluorination of dehydroalanine derivatives has been developed. Alkyl radicals resulting from visible-light photoredox catalysis engage in a radical conjugate addition to dehydroalanine, with subsequent fluorination of the newly generated radical to afford an α-fluoro-α-amino acid. By using a highly oxidizing organic photocatalyst, this process incorporates non-stabilized primary, secondary, and tertiary alkyl radicals derived from commercially available alkyltrifluoroborates to furnish a wide range of fluorinated unnatural amino acids.

Novel Hypoxia-Inducible Factor 1α (HIF-1α) Inhibitors for Angiogenesis-Related Ocular Diseases: Discovery of a Novel Scaffold via Ring-Truncation Strategy

Ocular diseases featuring pathologic neovascularization are the leading cause of blindness, and anti-VEGF agents have been conventionally used to treat these diseases. Recently, regulating factors upstream of VEGF, such as HIF-1α, have emerged as a desirable therapeutic approach because the use of anti-VEGF agents is currently being reconsidered due to the VEGF action as a trophic factor. Here, we report a novel scaffold discovered through the complete structure-activity relationship of ring-truncated deguelin analogs in HIF-1α inhibition. Interestingly, analog 6i possessing a 2-fluorobenzene moiety instead of a dimethoxybenzene moiety exhibited excellent HIF-1α inhibitory activity, with an IC₅₀ value of 100 nM. In particular, the further ring-truncated analog 34f, which showed enhanced HIF-1α inhibitory activity compared to analog 2 previously reported by us, inhibited in vitro angiogenesis and effectively suppressed hypoxia-mediated retinal neovascularization. Importantly, the heteroatom-substituted benzene ring as a key structural feature of analog 34f was identified as a novel scaffold for HIF-1α inhibitors that can be used in lieu of a chromene ring.

Conformation-Enabled Total Syntheses of Ohmyungsamycins A and B and Structural Revision of Ohmyungsamycin B

The first total syntheses of the bioactive cyclodepsipeptides ohmyungsamycin A and B are described. Key features of our synthesis include the concise preparation of a linear cyclization precursor that consists of N-methyl amides and non-proteinogenic amino acids, and its macrolactamization from a bent conformation. The proposed structure of ohmyungsamycin B was revised based on its synthesis. The cyclic core of the ohmyungsamycins was shown to be responsible for the excellent antituberculosis activity, and ohmyungsamycin variants with truncated chains were evaluated for their biological activity.

Asymmetric Total Synthesis of (+)-(3E)-Pinnatifidenyne via Abnormally Regioselective Pd(0)-Catalyzed Endocyclization

The asymmetric total synthesis of the marine natural product (+)-(3E)-pinnatifidenyne was accomplished. The key features of the synthesis involve the construction of an eight-membered cyclic ether by the abnormally regioselective Pd(0)-catalyzed cyclization, the installation of a double bond in the oxocene skeleton by sequential in situ deconjugative isomerization, and the efficient introduction of the crucial chloride mediated by the substrate-controlled diastereoselective reduction.

Stereoselective Synthesis of 1,4,5-Tri-cis-guaiane Sesquiterpene: First Total Synthesis of (-)-Dendroside C Aglycon

The first total synthesis of (-)-dendroside C aglycon, consisting of a 1,4,5-tri-cis-guaiane skeleton, from a versatile hydroazulene intermediate has been accomplished. The key features of the syntheses include the stereoselective preparation of the unusual cis-hydroazulene core via a sequence of a unique Dieckmann condensation of the bicyclic lactone system, which was concisely prepared by the tandem conjugate addition and intramolecular allylic alkylation of a butenolide precursor, and construction of the characteristic tricyclic skeleton by a carbene-mediated cyclopropanation.

Total synthesis of (+)-brasilenyne via concise construction of an oxonane framework containing a 1,3-cis,cis-diene

The enantioselective total synthesis of (+)-brasilenyne, which has a unique oxonane framework containing a 1,3-cis,cis-diene, has been accomplished.

Nicrophorusamides A and B, Antibacterial Chlorinated Cyclic Peptides from a Gut Bacterium of the Carrion Beetle Nicrophorus concolor

Nicrophorusamides A and B (1 and 2) were discovered from a rare actinomycete, Microbacterium sp., which was isolated from the gut of the carrion beetle Nicrophorus concolor. The structures of the nicrophorusamides were established as new chlorinated cyclic hexapeptides bearing uncommon amino acid units mainly based on 1D and 2D NMR spectroscopic analysis. The absolute configurations of the amino acid residues 5-chloro-l-tryptophan, d-threo-β-hydroxyasparagine/d-asparagine, l-ornithine, l-allo-isoleucine, d-leucine, and d-valine were determined using Marfey's method and chemical derivatization with 2,3,4,6-tetra-O-acetyl-β-d-glucopyranosyl isothiocyanate followed by LC/MS analysis. Nicrophorusamide A (1) showed antibacterial activity against several Gram-positive bacteria.