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

Background

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

Methods

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

Results

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

Conclusion

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

Insulin-like growth factor axis parameters in sick hospitalized neonates

The circulating insulin-like growth factor (IGF) axis consists of the IGF peptides, the IGF binding proteins (IGFBPs), and the IGFBP proteases. Little is known about the IGF axis in newborns, its possible perturbations in sick neonates, and the effect of nutrition on the IGF axis of such patients. The aims of this study were to define IGF axis parameters in the sera of hospitalized newborns and to correlate these parameters with the nutritional status of the infants. Serum samples obtained from twenty four hospitalized infants in the intensive care nursery were analyzed for IGF axis parameters. Insulin-like growth factor-I and IGFBP-3 by RIA were mostly within the normal range for age and were only minimally affected by gestational age. In comparison, 8 newborn infants with congenital growth hormone deficiency had IGFBP-3 levels which were below the normal range. Two infants on ECMO had elevated levels of IGFBP-3 by RIA. Western ligand blotting (WLB) demonstrated that IGFBP-2 was the major binding protein in infant serum and the 44 kDa IGFBP-3 in critically ill neonatal serum was approximately 10% of adult serum levels. IGFBP-3 by RIA in neonatal serum averaged approximately 25% of adult serum levels. Compatible with this discrepancy, a number of sick neonates had detectable levels of IGFBP-3 proteolytic activity and higher levels of IGFBP-3 fragments compared to normal adult serum in both the protease assays and Western immunoblotting. There was no correlation between any IGF axis parameter and nutritional status. In summary, sick hospitalized neonates display mostly normal IGF and IGFBP-3 levels, which are not correlated to nutritional intake. Thus serum IGFBP-3 levels maintain their diagnostic utility for growth hormone deficiency in critically ill neonates.

Purine metabolism and inhibition of xanthine oxidase in severely hypoxic neonates going onto extracorporeal membrane oxygenation

The effect of allopurinol to inhibit purine metabolism via the xanthine oxidase pathway in neonates with severe, progressive hypoxemia during rescue and reperfusion with extracorporeal membrane oxygenation (ECMO) was examined. Twenty-five term infants meeting ECMO criteria were randomized in a double-blinded, placebo-controlled trial. Fourteen did not receive allopurinol, whereas 11 were treated with 10 mg/kg after meeting criteria and before cannulation, in addition to a 20-mg/kg priming dose to the ECMO circuit. Infant plasma samples before cannulation, and at 15, 30, 60, and 90 min, and 3, 6, 9, and 12 h on bypass were analyzed (HPLC) for allopurinol, oxypurinol, hypoxanthine, xanthine, and uric acid concentrations. Urine samples were similarly evaluated for purine excretion. Hypoxanthine concentrations in isolated blood-primed ECMO circuits were separately measured. Hypoxanthine, xanthine, and uric acid levels were similar in both groups before ECMO. Hypoxanthine was higher in allopurinol-treated infants during the time of bypass studied (p = 0.022). Xanthine was also elevated (p < 0.001), and uric acid was decreased (p = 0.005) in infants receiving allopurinol. Similarly, urinary elimination of xanthine increased (p < 0.001), and of uric acid decreased (p = 0.04) in treated infants. No allopurinol toxicity was observed. Hypoxanthine concentrations were significantly higher in isolated ECMO circuits and increased over time during bypass (p < 0.001). This study demonstrates that allopurinol given before cannulation for and during ECMO significantly inhibits purine degradation and uric acid production, and may reduce the production of oxygen free radicals during reoxygenation and reperfusion of hypoxic neonates recovered on bypass.

Nerve growth factor-regulated properties of sensory neurones in Oct-2 null mutant mice

The POU-domain transcription factor Oct-2 is expressed in both B lymphocytes and sensory neurones, where its expression is regulated by nerve growth factor (NGF). In order to define a possible role for Oct-2 in neurotrophin signalling, we examined the expression of an NGF-regulated channel (capsaicin-evoked ion fluxes), neuropeptides (substance P, calcitonin gene-related peptide), structural proteins (neurofilaments and peripherin) and receptors (trks) in dorsal root ganglion neurones derived from perinatal transgenic mice containing a defective Oct-2 structural gene. Northern blots show that central nervous tissue contains a larger than normal (> 10 kb) mRNA transcript corresponding in size to an Oct-2 transcript encoding a defective protein. PCR analysis shows the absence of normal Oct-2 transcripts in dorsal root ganglia. In null mutants, capsaicin sensitivity, and neuropeptide and cytoskeletal protein expression were unaffected by the loss of Oct-2 expression. The number of sensory neurones and the gross morphology of CNS tissues that normally express high levels of Oct-2 were also examined and found to be normal in the null mutant. Heterozygous animals show normal thresholds of sensitivity to noxious heat and normal inflammatory responses. Oct-2 does not therefore play an essential role in the NGF responsiveness of sensory neurones in these animals.

Cytokine elevations in infants with bacterial and aseptic meningitis

We sought to determine whether the detection of cytokines, produced during the inflammatory response, would aid in the diagnosis of meningitis in young infants. We measured cerebrospinal fluid (CSF) and plasma levels of interleukin-6 (IL-6) and tumor necrosis factor (TNF) in 62 infants less than 6 months of age whose condition was evaluated for meningitis. Twenty infants had culture-proved meningitis, 22 had aseptic meningitis, and 20 control infants had no evidence of meningitis. The CSF IL-6 levels were elevated in all 20 infants with bacterial meningitis and in 9 of 22 infants with aseptic meningitis but were undetectable in all control subjects. Furthermore, CSF IL-6 levels were 10 times greater in infants with bacterial versus aseptic meningitis (p < 0.001). Levels of TNF in CSF were detected in 12 of 20 infants with bacterial meningitis and were undetectable in infants with aseptic meningitis and in control infants (p < 0.02). Plasma IL-6 and TNF levels were unreliable for the detection of meningitis in this patient population. We conclude that the presence of IL-6 in the CSF reliably identifies infants with meningitis and that the presence of CSF TNF is a highly specific indicator of bacterial meningeal inflammation.

Prospective analysis of coagulase-negative staphylococcal infection in hospitalized infants

Coagulase-negative staphylococci are the major cause of late-onset nosocomial neonatal sepsis. We prospectively examined all infants less than 6 months of age hospitalized at Children's Hospital of Philadelphia from whom at least one of two or more blood cultures grew coagulase-negative staphylococci. We considered as infections only those episodes in which multiple blood cultures grew identical isolates. Among 59 episodes that yielded specimens meeting study criteria, 25 were considered infection and 34 contamination. Cultures from infected infants yielded significantly higher numbers of coagulase-negative staphylococci than cultures representing contamination (p = 0.001). Infected infants were more likely to have central venous lines (p = 0.009), and to have received any parenteral nutrition (p = 0.002) or lipids (0.017). Hematologic values were not helpful in distinguishing between infected and uninfected infants. Isolates representing true infection were not different from contaminants in the frequency of positivity for putative virulence phenotypes. Our data corroborate previous studies indicating risk factors and predictors of coagulase-negative staphylococcal infection.

Plasmodium falciparum: mapping the membrane-binding domain in the ring-infected erythrocyte surface antigen

The ring-infected erythrocyte surface antigen (RESA) associates with spectrin in the erythrocyte membrane (Foley, M., Tilley, L., Sawyer, W. H., and Anders, R. F., 1991, Mol. Biochem. Parasitol. 46, 137-148). In this study, we have used deletion mutagenesis combined with an in vitro binding assay to identify a region of the RESA polypeptide that is involved in the attachment of this parasite protein to the host membrane skeleton. It was found that the tandem repeat sequences of RESA do not appear to be involved in the association of this protein with the erythrocyte membrane and that large deletions of the N-terminal region of RESA did not affect binding. The membrane-binding domain has been mapped to a 48-amino-acid region of RESA located between the two blocks of repetitive amino acid sequence. This binding domain does not overlap the region of RESA that shares homology with the Escherichia coli molecular chaperone, DnaJ. Identification of the amino acid sequence which is critical for the binding of RESA to erythrocyte spectrin may provide important clues to the functional consequences of RESA attachment to the host membrane.

Cytokine elevations in critically ill infants with sepsis and necrotizing enterocolitis

We hypothesized that plasma levels of cytokines such as interleukin-6 and tumor necrosis factor (TNF) are elevated in critically ill infants with sepsis and necrotizing enterocolitis (NEC) and that the magnitude of their elevation is correlated with mortality rate. We measured plasma levels of interleukin-6 and TNF in 62 newborn infants with suspected sepsis or NEC. Eighteen infants had bacterial sepsis, 9 had bacterial sepsis plus NEC, and 15 had NEC but negative culture results. Twenty comparably ill infants with negative results on culture of systemic specimens served as study control subjects. Interleukin-6 levels were five- to tenfold higher in infants with bacterial sepsis plus NEC at the onset of disease than in infants with bacterial sepsis alone, in infants with NEC but negative culture results, and in control infants (p < 0.01). These differences persisted throughout the 48-hour study period. Interleukin-6 levels were also significantly higher in nonsurvivors than in survivors (p < 0.001). In contrast, plasma TNF values were not consistently increased in any of the groups. We conclude that plasma interleukin-6 is a more reliable indicator of bacterial sepsis and NEC than plasma TNF and may identify infants who might benefit from immunotherapeutic strategies.

Sodium restriction versus daily maintenance replacement in very low birth weight premature neonates: a randomized, blind therapeutic trial

To test the hypothesis that restriction of sodium intake during the first 3 to 5 days of life will prevent the occurrence of hypernatremia and the need for administration of large fluid volumes, we prospectively and randomly assigned 17 babies (mean +/- SD: 850 +/- 120 gm; 27 +/- 1 weeks of gestation) to receive in blind fashion either daily maintenance sodium or salt restriction with physician-prescribed parenteral fluid intake. Maintenance-group infants received 3 to 4 mEq of sodium per kilogram per day; restricted infants received no sodium supplement other than with such treatments as transfusion. Sodium balance studies conducted for 5 days demonstrated that maintenance salt intake resulted in a daily sodium balance near zero, whereas sodium-restricted infants continued to excrete urinary sodium at a high rate, which promoted a more negative balance (average daily sodium balance -0.30 +/- 1.78 SD in maintenance group vs -3.71 +/- 1.47 mEq/kg per day in restriction group; p less than 0.001). Care givers tended to prescribe daily increases in parenteral fluids for the salt-supplemented infants, perhaps because serum sodium concentrations were elevated in these infants after the first day of the study (p less than 0.001). Hypernatremia developed in two sodium-supplemented infants (greater than 150 mEq/L), and hyponatremia developed in two sodium-restricted infants (less than 130 mEq/L); however, the restricted infants were more likely to have normal serum osmolality (p less than 0.05). Both groups of infants produced urine that was neither concentrated nor dilute, with a high fractional excretion of sodium; renal failure was not observed. The mortality rate was not affected, but the incidence of bronchopulmonary dysplasia was significantly less in the sodium-restricted babies (p less than 0.02). We conclude that in tiny premature infants, a fluid regimen that restricts sodium may simplify parenteral fluid therapy targeted to prevent hypernatremia and excessive administration of parenteral fluids.

The promoter of the human interleukin-2 gene contains two octamer-binding sites and is partially activated by the expression of Oct-2

The gene encoding interleukin-2 (IL-2) contains a sequence 52 to 326 nucleotides upstream of its transcriptional initiation site that promotes transcription in T cells that have been activated by costimulation with tetradecanoyl phorbol myristyl acetate (TPA) and phytohemagglutinin (PHA). We found that the ubiquitous transcription factor, Oct-1, bound to two previously identified motifs within the human IL-2 enhancer, centered at nucleotides -74 and -251. Each site in the IL-2 enhancer that bound Oct-1 in vitro was also required to achieve a maximal transcriptional response to TPA plus PHA in vivo. Point mutations within either the proximal or distal octamer sequences reduced the response of the enhancer to activation by 54 and 34%, respectively. Because the murine T-cell line EL4 constitutively expresses Oct-2 and requires only TPA to induce transcription of the IL-2 gene, the effect of Oct-2 expression on activation of the IL-2 promoter in Jurkat T cells was determined. Expression of Oct-2 potentiated transcription 13-fold in response to TPA plus PHA and permitted the enhancer to respond to the single stimulus of TPA. Therefore, both the signal requirements and the magnitude of the transcription response of the IL-2 promoter can be modulated by Oct-2.

Serum myoinositol concentrations in premature infants fed human milk, formula for infants, and parenteral nutrition

Myoinositol concentration was studied in serum of 65 neonates and their mothers at the time of birth, in samples of various types of feedings for infants, and in serial serum samples of 15 premature infants receiving human milk, formulas for infants, or parenteral nutrition over a 3-wk period. At birth the serum concentration of myoinositol was greater in neonates than in their mothers (108 +/- 10 vs 52 +/- 6 mumol/L, respectively, means +/- SEM, p less than 0.01). In feedings for infants, the concentrations of myoinositol were significantly greater in human milk than in formulas or parenteral nutrition solutions (1840 +/- 451 vs 420 +/- 110 vs 100 +/- 8 mumol/L, respectively, p less than 0.001). Over a 3-wk period the serum concentration of myoinositol increased in infants receiving human milk but not in those receiving formulas or parenteral nutrition. Serum concentrations of myoinositol in neonates are greater than in adults and are directly influenced by myoinositol intake.

Class II restriction in mice to the malaria candidate vaccine ring infected erythrocyte surface antigen (RESA) as synthetic peptides or as expressed in recombinant vaccinia

The immune response to three peptides corresponding to the repeat regions of the malaria candidate vaccine ring infected E surface Ag (RESA) were studied. Both antibody responses and lymphocyte stimulation in mice injected with these peptides without carrier were found to be restricted to certain MHC class II haplotypes. Mice bearing IAk were strong responders to all three peptides. Mice bearing IAd were strong responders only to the 3' repeat peptides, the octamer and tetramer. Mice bearing Is or Iq did not respond to any repeat peptides. Remarkably, the pattern of genetic restriction of the antibody response to the entire RESA as expressed in vaccinia indicated that there were no other epitopes besides the three repeats. Because only one class II haplotype (i.e., k) out of five tested responded strongly to this peptide and only two out of five (i.e., k and d) responded to the octamer or tetramer, it may be difficult to achieve a good immune response against RESA in most or all humans.

Class II restriction in mice to the malaria candidate vaccine ring infected erythrocyte surface antigen (RESA) as synthetic peptides or as expressed in recombinant vaccinia

The immune response to three peptides corresponding to the repeat regions of the malaria candidate vaccine ring infected E surface Ag (RESA) were studied. Both antibody responses and lymphocyte stimulation in mice injected with these peptides without carrier were found to be restricted to certain MHC class II haplotypes. Mice bearing IAk were strong responders to all three peptides. Mice bearing IAd were strong responders only to the 3' repeat peptides, the octamer and tetramer. Mice bearing Is or Iq did not respond to any repeat peptides. Remarkably, the pattern of genetic restriction of the antibody response to the entire RESA as expressed in vaccinia indicated that there were no other epitopes besides the three repeats. Because only one class II haplotype (i.e., k) out of five tested responded strongly to this peptide and only two out of five (i.e., k and d) responded to the octamer or tetramer, it may be difficult to achieve a good immune response against RESA in most or all humans.

Assessment of nutritional and metabolic status of paraplegics

Nutritional and metabolic assessment using anthropometric, biochemical, immunological, and indirect calorimetric techniques was performed on 17 healthy paraplegic males with a mean age of 44.2 +/- 14.6 years and mean duration of injury of 17.8 +/- 12.3 years. Significant differences in energy expenditure were observed; only 29.4 percent were normometabolic [measured resting energy expenditure: (MREE) 90-110 percent of predicted resting energy expenditure (PREE)], 35.3 percent were hypermetabolic (MREE greater than 110 percent of PREE) and 35.3 percent were hypometabolic (MREE less than 90 percent of PREE). Obesity (weight greater than 110 percent ideal body weight) was maximum in hypometabolic patients (83.3 percent) due to the imbalance between caloric intake and energy expenditure (p less than 0.05). None of the patients had normal values for all four objective measurements of nutritional assessment (albumin, transferrin, total lymphocyte count, and cutaneous hypersensitivity). Mild malnutrition was evidenced in 47 percent of patients; 53 percent of patients demonstrated some index of moderate malnutrition. We conclude that nutritional therapy based on measurements of energy expenditure instead of predictive equations will benefit these patients. A larger long-term study is needed to determine the ideal predictive measurements of nutritional assessment with their optimal cutoff values applicable to the spinal cord-injured patient.

Variant (6;15) translocations in murine plasmacytomas involve a chromosome 15 locus at least 72 kb from the c-myc oncogene

The variant (6;15) translocations in murine plasmacytomas join the myc oncogene-bearing band of chromosome 15 and the immunoglobulin kappa band of chromosome 6. We recently cloned a region from chromosome 15 linked to C kappa and have now used probes from that region to define the major locus of plasmacytoma variant translocations, which we denote pvt-1. In five of nine plasmacytomas we analysed, the 6;15 translocation resulted from reciprocal recombination between the C kappa locus and a 4.5-kb region of pvt-1. Moreover, nearby we located the region shown by others to have undergone a complex (15;12;6) translocation in plasmacytoma PC7183. All the chromosome 6 breakpoints fell between 1 and 3 kb 5' to C kappa but only two were near J kappa genes. Thus the J kappa -C kappa region appears to be a recombination 'hot spot' in lymphocytes, but the breaks are unlikely to be mediated via V/J recombination enzymes. Comparison of a cloned 108-kb region across pvt-1 and another of 52 kb across c-myc established that the pvt-1 breakpoints lie at least 72 kb from the c-myc promoters. Since c-myc is expressed at a substantial level, the 6;15 translocation apparently activates c-myc. Activation may occur directly, at a remarkable distance along the chromosome, or indirectly, via a putative pvt-1 gene product.

Legionella micdadei (Pittsburgh pneumonia agent): direct fluoresent-antibody examination of infected human lung tissue and characterization of clinical isolates

Legionella micdadei (Pittsburgh pneumonia agent) was identified by direct fluorescent-antibody (DFA) examination of lung tissue in six of seven persons diagnosed previously as having L. micdadei pneumonia only by histopathology and in four persons who also had positive cultures of the organism. No cross-reactions occurred with monospecific DFA conjugates prepared against Legionella pneumophila serogroups 1 to 6, Legionella bozemanii, Legionella dumoffii, and Legionella gormanii. One person had L. pneumophila serogroup 6 identified by DFA examination of lung tissue and subsequent culture of stored pulmonary secretions. Characterization of the four strains of L. micdadei revealed specific DFA reactions, bacteriological behavior, and cellular fatty acid composition that allow identification of the organism. DFA testing appears to be a sensitive method for identifying L. micdadei prescent in human lung tissue or cultured on artificial media.

Detection of Candida vaginitis by a dipstick method

A media impregnated polystyrene strip was tested for its ability to detect Candida in vaginal secretions. Of 230 patients with vaginitis, 20 were positive for Candida when the gram stain, routine culture, and Microstix-Candida (M-C) were used. Routine culture alone detected 17 cases, while the M-C alone detected 14 cases. Although this test system should not be used as a primary laboratory diagnostic tool, its use as an office or clinic screening test for vaginal candidiasis is recommended.