Ethnic and racial differences in self-reported symptoms, health status, activity level, and missed work at 3 and 6 months following SARS-CoV-2 infection

Introduction

Data on ethnic and racial differences in symptoms and health-related impacts following SARS-CoV-2 infection are limited. We aimed to estimate the ethnic and racial differences in symptoms and health-related impacts 3 and 6 months after the first SARS-CoV-2 infection.

Methods

Participants included adults with SARS-CoV-2 infection enrolled in a prospective multicenter US study between 12/11/2020 and 7/4/2022 as the primary cohort of interest, as well as a SARS-CoV-2-negative cohort to account for non-SARS-CoV-2-infection impacts, who completed enrollment and 3-month surveys (N = 3,161; 2,402 SARS-CoV-2-positive, 759 SARS-CoV-2-negative). Marginal odds ratios were estimated using GEE logistic regression for individual symptoms, health status, activity level, and missed work 3 and 6 months after COVID-19 illness, comparing each ethnicity or race to the referent group (non-Hispanic or white), adjusting for demographic factors, social determinants of health, substance use, pre-existing health conditions, SARS-CoV-2 infection status, COVID-19 vaccination status, and survey time point, with interactions between ethnicity or race and time point, ethnicity or race and SARS-CoV-2 infection status, and SARS-CoV-2 infection status and time point.

Results

Following SARS-CoV-2 infection, the majority of symptoms were similar over time between ethnic and racial groups. At 3 months, Hispanic participants were more likely than non-Hispanic participants to report fair/poor health (OR: 1.94; 95%CI: 1.36-2.78) and reduced activity (somewhat less, OR: 1.47; 95%CI: 1.06-2.02; much less, OR: 2.23; 95%CI: 1.38-3.61). At 6 months, differences by ethnicity were not present. At 3 months, Other/Multiple race participants were more likely than white participants to report fair/poor health (OR: 1.90; 95% CI: 1.25-2.88), reduced activity (somewhat less, OR: 1.72; 95%CI: 1.21-2.46; much less, OR: 2.08; 95%CI: 1.18-3.65). At 6 months, Asian participants were more likely than white participants to report fair/poor health (OR: 1.88; 95%CI: 1.13-3.12); Black participants reported more missed work (OR, 2.83; 95%CI: 1.60-5.00); and Other/Multiple race participants reported more fair/poor health (OR: 1.83; 95%CI: 1.10-3.05), reduced activity (somewhat less, OR: 1.60; 95%CI: 1.02-2.51; much less, OR: 2.49; 95%CI: 1.40-4.44), and more missed work (OR: 2.25; 95%CI: 1.27-3.98).

Discussion

Awareness of ethnic and racial differences in outcomes following SARS-CoV-2 infection may inform clinical and public health efforts to advance health equity in long-term outcomes.

Effectiveness of a Messenger RNA Vaccine Booster Dose Against Coronavirus Disease 2019 Among US Healthcare Personnel, October 2021-July 2022

Background

Protection against symptomatic severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (coronavirus disease 2019 [COVID-19]) can limit transmission and the risk of post-COVID conditions, and is particularly important among healthcare personnel. However, lower vaccine effectiveness (VE) has been reported since predominance of the Omicron SARS-CoV-2 variant.

Methods

We evaluated the VE of a monovalent messenger RNA (mRNA) booster dose against COVID-19 from October 2021 to June 2022 among US healthcare personnel. After matching case-participants with COVID-19 to control-participants by 2-week period and site, we used conditional logistic regression to estimate the VE of a booster dose compared with completing only 2 mRNA doses >150 days previously, adjusted for multiple covariates.

Results

Among 3279 case-participants and 3998 control-participants who had completed 2 mRNA doses, we estimated that the VE of a booster dose against COVID-19 declined from 86% (95% confidence interval, 81%-90%) during Delta predominance to 65% (58%-70%) during Omicron predominance. During Omicron predominance, VE declined from 73% (95% confidence interval, 67%-79%) 14-60 days after the booster dose, to 32% (4%-52%) ≥120 days after a booster dose. We found that VE was similar by age group, presence of underlying health conditions, and pregnancy status on the test date, as well as among immunocompromised participants.

Conclusions

A booster dose conferred substantial protection against COVID-19 among healthcare personnel. However, VE was lower during Omicron predominance, and waning effectiveness was observed 4 months after booster dose receipt during this period. Our findings support recommendations to stay up to date on recommended doses of COVID-19 vaccines for all those eligible.

Neuronal response to high negative affective stimuli in major depressive disorder: An fMRI study

BACKGROUND

Disturbed emotion processing underlies depression. We examined the neuronal underpinnings of emotional processing in patients (PAT) with major depressive disorder (MDD) compared to healthy volunteers (HV) using functional magnetic resonance (fMRI) scan.

METHODS

Thirty-six MDD patients and 30 HV underwent T2-weighted fMRI assessments during the presentation of an implicit affective processing task in three conditions. They differed regarding their affective quality (=valence, high negative, low negative and neutral stimuli) and regarding the arousal based on stimuli from the International Affective Picture System.

RESULTS

Group contrasts showed lower left-sided activation in dorsolateral prefrontal cortex (DLPFC), anterior PFC, precentral and premotor cortex in PAT compared with HV (Cluster-level threshold, 5000 iterations, p<0.01). We found a significant interaction effect of valence and group, a significant effect of emotional valence and a significant effect of group. All effects were shown in brain regions within the emotional network (Cluster-level threshold, 5000 iterations, p<0.01). Higher arousal (rho=-0.33, p<0.01) and higher valence (rho=-0.33, p<0.01) during high negative stimuli presentation as well as more severe depression (Beck Depression Inventory II [BDI II]; r = 0.39, p = 0.01) were significantly negatively associated with left DLFPC activity in patients.

LIMITATIONS

Potential influence of psychopharmacological drugs on functional activation is one of the most discussed source of bias in studies with medicated psychiatric patients.

CONCLUSIONS

The results highlight the importance of left DLPFC during the processing of negative emotional stimuli in MDD. The integration of a neurophysiological model of emotional processing in MDD may help to clarify and improve therapeutic options.

POS0460 ASSOCIATION OF ANTI-CITRULLINATED PROTEIN ANTIBODIES OF IgA SUBCLASSES WITH SUSTAINED REMISSION AND FLARE IN RHEUMATOID ARTHRITIS

Background:

Understanding key mechanisms of flare development and sustained remission is one of the acute goals in modern rheumatology. Anti-citrullinated protein antibodies (ACPA) are the most abundant and specific autoantibodies in rheumatoid arthritis (RA) patients. However, the impact of ACPA of IgA isotype is poorly defined. IgA ACPA were previously shown to have a higher percentage of IgA2 in comparison to total IgA; and a correlation between IgA2% ACPA with the DAS28 score was observed in a previous study [1]. Of note, IgA1 and IgA2 were shown to exhibit different effector functions, with IgA2 being pro-inflammatory, which might be the background for its role in RA [1].

Objectives:

We aimed to investigate, whether IgA ACPA could be used as a predictive factor for flare development in RA; and to look further into the changes in IgA ACPA levels in patients remaining in stable remission versus patients developing flare.

Methods:

We analysed serum of 111 patients from a multicentre randomized controlled trial ‘RETRO’. The study observational period was 12 months. Patients in the trial had to be in stable remission (DAS28-ESR<2.6) for a minimum of 6 months and were randomized into 3 different treatment arms: continuation of treatment, tapering by 50% or a gradual tapering until discontinuation [2]. IgA ACPA concentrations were measured with an enzyme-linked immunosorbent assay on CCP2-pre-coated plates.

Results:

60% of patients had IgG-ACPA. IgA ACPA levels were higher among the IgG-ACPA-positive patients (median 4.7 versus 2.24 µg/ml, p<0.0001). Baseline IgA1 and 2 ACPA levels were not different between patients who had a flare later on in the study period and those remaining in remission, showing no predictive value for flare development. However, the percentage of IgA2 in ACPA was correlating with the first registered DAS28 after flare (r=0.36, p=0.046). After the 12 months study period, IgA2 ACPA as well as IgA2% ACPA decreased significantly in patients who remained in stable remission by 17.5% (median, p<0.0001) and 13.6% (p=0.0006), respectively. By contrast, there was no significant change in IgA2 ACPA levels over time in patients who developed a flare. IgA1 ACPA levels remained stable over time. Disease management strategies did not seem to influence IgA ACPA levels in a specific way, as baseline levels were similar between patients on biological and conventional DMARDs and changes in levels after 12 months did not depend on the assignment to either of the study arms.

Conclusion:

Neither IgA1 nor IgA2 ACPA levels were predictive of flare development or associated with treatment strategies (though rituximab, JAK-inhibitors and abatacept were not amongst treatment options). However, in patients remaining in sustained remission after 1 year a decrease in IgA2 and IgA2% ACPA was observed and IgA2% ACPA was associated with DAS28 score registered after flare. This could be an indication towards ACPA of IgA2 isotype contributing to the severity of flare, alongside other factors, and its reduction being associated with a prolonged state of remission.

References:

[1]Steffen U, Koeleman CA, Sokolova MV, et al. IgA subclasses have different effector functions associated with distinct glycosylation profiles. Nat Commun 11, 120 (2020).

[2]Haschka J, Englbrecht M, Hueber AJ, et al. Relapse rates in patients with rheumatoid arthritis in stable remission tapering or stopping antirheumatic therapy: interim results from the prospective randomised controlled RETRO study. Ann Rheum Dis. 75:45-51 (2016).

Disclosure of Interests:

None declared

OP0318 TREATMENT TAPERING AND WITHDRAWAL IN RHEUMATOID ARTHRITIS WITH STABLE REMISSION - FINAL ANALYSIS OF THE RETRO STUDY

Background:

Due to better treatment strategies and higher remission rates the management of rheumatoid arthritis (RA) patients in sustained remission is of increasing interest (1). The Rheumatoid Arthritis in Ongoing Remission (RETRO) study investigated the possibility to taper and stop disease modifying anti-rheumatic drugs (DMARDs).

Objectives:

To compare one-year remission and relapse rates in rheumatoid arthritis patients randomized to continued treatment, reduced treatment or gradual treatment withdrawal after stable remission under routine care.

Methods:

Primary data of the phase III, randomized, controlled RETRO trial in RA patients with stable conventional synthetic and/or biologic DMARD treatment in sustained (>6 months) DAS28-ESR remission (<2.6 units). Patients were randomized 1:1:1 into three strategy arms (continuation of 100% DMARD dose, CONT; tapering to 50% DMARD dose, TAP; 50% tapering followed by withdrawal of DMARDs, STOP). The primary endpoint was the proportion of patients in sustained DAS28-ESR remission after 1 year.

Results:

316 RA patients in sustained remission were included, 303 were randomized (CONT: N=100; TAP: N=102; STOP: N=101) and 282 (93%) had complete data sets after 1 year (CONT:N=93; TAP: N=93; STOP: N=96; Table 1). After 1 year, 81.2%, 58.6%, 43.3% of patients, maintained their remission state over 1 year in the CONT, TAP and STOP arms, respectively (p=0.0004 with log rank test for trend; Figure 1). Hazard ratios for flare were 3.02 (95%CI 1.69 to 5.40) and 4.34 (95%CI 2.48 to 7.60) for the TAP and STOP arms. RA patients who flared were more likely to be female, have longer disease duration, RF/ACPA positivity and higher baseline DAS-28 scores with standardized mean differences >0.2. Serious adverse events were reported in 10.8%, 7.5%, and 13.5% in the CONT, TAP and STOP arms, respectively.

Table 1.

Baseline Characteristics

GroupControlReduceReduce/StopOverallN939396282Age, mean(SD)55.9 (12.7)56.9 (13.0)56.5 (13.3)56.5 (13.0)Female, n (%)53 (57.0)57 (62.0)57 (59.4)167 (59.4)RF, n (%)52 (55.9)58 (62.4)52 (54.2)162 (57.4)ACPA, n (%)53 (57.0)50 (54.9)55 (57.3)158 (56.4)Disease duration, years, mean(SD)7.6 (6.9)7.8 (6.9)6.8 (8.1)7.4 (7.3)Remission duration, months, mean(SD)20.6 (18.0)16.5 (15.9)22.7 (30.4)20.0 (22.6)Biologics, n (%)39 (41.9)44 (47.3)39 (40.6)122 (43.3)Methotrexate, n (%)71 (76.3)67 (72.0)75 (78.1)213 (75.5)Other DMARDs, n (%)24 (25.8)20 (21.5)16 (16.7)60 (21.3)Glucocorticoids, n (%)27 (29.0)23 (24.7)17 (17.7)67 (23.8)CRP, mg/L, mean(SD)0.3 (0.3)0.5 (0.5)0.5 (0.6)0.4 (0.5)ESR, mm/h, mean(SD)11.3 (8.4)12.2 (8.8)13.0 (10.0)12.2 (9.1)Tender joint count, mean(SD)0.2 (0.6)0.0 (0.2)0.1 (0.3)0.1 (0.4)Swollen joint count, mean(SD)0.1 (0.3)0.1 (0.3)0.1 (0.4)0.1 (0.3)Physician VAS,mm, mean(SD)1.8 (4.2)2.6 (4.4)2.0 (3.9)2.1 (4.2)Patient VAS,mm, mean(SD)6.4 (9.0)5.5 (8.3)4.5 (8.4)5.5 (8.6)HAQ, standard, mean(SD)0.2 (0.4)0.2 (0.3)0.2 (0.4)0.2 (0.4)HAQ, alternative, mean(SD)0.2 (0.4)0.1 (0.3)0.2 (0.3)0.2 (0.3)DAS-28, mean(SD)1.7 (0.7)1.7 (0.6)1.7 (0.6)1.7 (0.6)SDAI, mean(SD)1.4 (1.5)1.4 (1.5)1.3 (1.3)1.3 (1.4)DAS-28 remission, n (%)91 (97.8)93 (100.0)95 (99.0)279 (98.9)SDAI remission, n (%)79 (87.8)79 (84.9)88 (92.6)246 (88.5)Boolean remission, n (%)69 (75.8)71 (76.3)76 (79.2)216 (77.1)

Conclusion:

This randomized controlled study shows that half of RA patients in sustained remission relapse when tapering/stopping their DMARDs. Presence of autoantibodies, higher baseline DAS28-ESR and female sex are predictors for flares.

References:

[1]Schett G et al. Tapering biologic and conventional DMARD therapy in rheumatoid arthritis: current evidence and future directions. Ann Rheum Dis. 2016 Aug;75(8):1428-37.

Disclosure of Interests:

Melanie Hagen Speakers bureau: advisory boards, Koray Tascilar Speakers bureau: advisory board, Michaela Reiser: None declared, Larissa Valor: None declared, Judith Haschka Speakers bureau: advisory board, Arnd Kleyer Speakers bureau: advisory board, Axel Hueber Speakers bureau: advisory boards, Bernhard Manger Speakers bureau: advisory boards, Jayme Cobra Speakers bureau: advisory boards, Camille Figuereido Speakers bureau: advisory boards, Stephanie Finzel Speakers bureau: advisory boards, Hans-Peter Tony Speakers bureau: advisory boards, Joerg Wendler Speakers bureau: advisory boards, Stefan Kleinert Speakers bureau: advisory boards, Florian Schuch Speakers bureau: advisory boards, Monika Ronneberger: None declared, Martin Feuchtenberger Speakers bureau: advisory boards, Martin Fleck Speakers bureau: advisory boards, Karin Manger: None declared, Wolfgang Ochs: None declared, Matthias Schmitt-Haendle: None declared, Hanns-Martin Lorenz Speakers bureau: advisory boards, Rieke Alten Speakers bureau: advisory boards, Jörg Henes Speakers bureau: advisory boards, Klaus Krueger Speakers bureau: advisory boards, Jürgen Rech Speakers bureau: advisory boards, Georg Schett Speakers bureau: advisory boards.

[Rheumatology in German MD curricula]

Transmitting a substantial amount of basic knowledge in Rheumatology to all medical students is essential for the future medical care of patients with rheumatic diseases for two reasons: on the one hand, future general practitioners will need to master the patterns of rheumatic diseases to recognize them fast enough in new-onset patients and to refer them in time and directly to rheumatologists. On the other hand, the shortage of rheumatologists can only then be relieved in the future when we are able to inspire enthusiasm for our specialty. Adequate rheumatological structures are established only in some of the German faculties of medicine. Structural improvements happen in small steps only but were achieved at several sites. The better the local structures, the higher the chances of committed university teachers in rheumatology to reach all medical students. Probably from 2026 onwards, the learning objectives relevant for examinations will be defined by the national competence-based catalogue of learning objectives in medicine (NKLM), which is currently in the final stages of completion together with the German Federal Institute for Medical and Pharmaceutical Examinations (IMPP). It now appears that systemic autoimmune diseases and inflammatory rheumatic diseases are adequately depicted in this catalogue. If this is achieved, students will know more about these diseases in the future and will diagnose them faster in patients. Work on the NKLM is therefore of highest importance. In addition to the work on the learning objectives, up to date learning materials are required, which have to be available throughout Germany. A Rheumatology script just finished by the committee for medical student education of the German Society of Rheumatology (DGRh) and now available on the DGRh homepage should close this gap.

Tödliches Dieulafoy-Ulkus

Nach einem Schlaganfall wurde ein 51 Jahre alter Mann in eine Rehaklinik verlegt. Gemäß klinischen Angaben soll sich dort eine Sepsis entwickelt haben. Aufgrund eines plötzlichen Bewusstseinsverlustes wurde der Patient umgehend in die nächstgelegene Klinik verbracht, wo er trotz umgehender Behandlung verstarb. Da die Ehefrau Vorwürfe gegen das Personal der Rehaklinik erhob, wurde eine rechtsmedizinische Obduktion in Auftrag gegeben.

Im Rahmen der Obduktion fielen große Mengen flüssigen Blutes im Magen sowie im oberen Gastrointestinaltrakt auf, sodass bereits autoptisch ein inneres Verbluten als Todesursache definiert wurde. Als Blutungsquelle kam ein makromorphologisch auffälliges, eröffnetes Gefäß im Magenfundus in Betracht. Die sichere Diagnose eines tödlichen Dieulafoy-Ulkus konnte jedoch erst nach histologischer Begutachtung erfolgen. Definierend für diesen Befund ist eine kaliberpersistente Arterie in der Submukosa ohne pathologische Veränderungen. Bei sicherer Diagnose kann dieser Befund einen plötzlichen Tod aus natürlicher Ursache darstellen. Da das Ulkus im gesamten gastrointestinalen Trakt vorkommen kann, ist bei relevantem Blutverlust und unklarer Blutungsquelle neben der genauen Inspektion eine histologische Aufarbeitung möglicher Blutungsquellen unerlässlich. Damit die Kriterien eines Dieulafoy-Ulkus beurteilt werden können, sollte neben einer HE(Hämatoxylin-Eosin)-Färbung mindestens eine EvG(Elastica-van-Gieson)-Färbung durchgeführt werden. Nur dann können alternative Entstehungsmöglichkeiten ausgeschlossen werden, welche aus forensischer Sicht möglicherweise hätten verhindert werden können.

International survey: real-world pain management strategies

Background

Pain is a nearly universal experience, but little is known about how people treat pain. This international survey assessed real-world pain management strategies.

Methods

From 13-31 January, 2020, an online survey funded by GSK Consumer Healthcare was conducted in local languages in Australia, Brazil, Canada, China, Colombia, France, Germany, India, Italy, Japan, Saudi Arabia, Malaysia, Mexico, Poland, Russia, Spain, Sweden, UK, and USA. Adults were recruited from online panels of people who agreed to participate in surveys. Quotas ensured nationally representative online populations based on age, gender, and region.

Results

Of 19,000 people (1000/country) who completed the survey, 18,602 (98%) had ever experienced physical pain; 76% said they would like to control their pain better. Presented with 17 pain-management strategies and asked to select the ones they use in the order of use, respondents chose an average of 4 strategies each. The most commonly selected strategies were pain medication (65%), rest/sleep (54%), consult a doctor (31%), physical therapy (31%), and nonpharmacologic action (eg, heat/cold application; 29%). Of those who use pain medication, 56% take some other action first. Only 36% of those who treat pain do so immediately; 56% first wait to see if it will resolve spontaneously. Top reasons for waiting include a desire to avoid medication (37%); willingness to tolerate less severe pain (33%); concerns about side effects (21%) or dependency (21%); and wanting to avoid a doctor's visit unless pain is severe or persistent (21%). Nearly half (42%) of those who take action to control pain have visited ≥1 healthcare professional (doctor 31%; pharmacist 18%; other 17%) about pain.

Conclusions

This large global survey shows that people employ a range of strategies to manage pain but still wish for better pain control. Although pain medication is the most commonly used strategy, many people postpone or avoid its use.

Key messages

More than three-quarters (76%) of respondents across countries seek better pain control. Pain medication and rest/sleep consultation are the most common pain management strategies. More than half of respondents (56%) wait to see if pain will resolve spontaneously before taking any action, and 56% of those who use pain medication try some other approach first.

SAT0055 PREDICTION OF FLARES FOR RHEUMATOID ARTHRITIS PATIENTS ON BIOLOGIC DMARDS USING MACHINE LEARNING AND SUBSETS OF VARIABLES AVAILABLE TO PHYSICIANS, PATIENTS AND PAYERS

Background:

Today approximately 50 percent of patients with RA reach sustained remission. In a specific subset of RA patients in stable remission, biological Disease Modifying Anti-Rheumatic Drugs (bDMARDs) may be successfully tapered. However, it remains challenging to predict the patients’ individual flare risk. As we have recently shown, machine learning based on extensive clinical and laboratory data could be used to estimate individual flare risk [1].

Objectives:

In this study we aimed to investigate the performance of machine learning models trained with variables that are typically (1) immediately available to a physician during patient visits (clinical and demographic variables without laboratory values and composite disease activity scores), (2) theoretically available to patients at home and (3) available to payers in large health-system databases.

Methods:

Longitudinal clinical data of RA patients on bDMARDs from the first interim analysis of the phase-3, multicentre, randomised, open, prospective, controlled, parallel-group RETRO study (EudraCT number 2009-015740-42) was used [2] to build a predictive model for estimating the flare probability within 3 months from the current patient visit. A flare was defined as a DAS-28 ESR score over 2.6. Four different models (log. regression, random forest, k-NN and naïve Bayes) were trained which output the flare probability at each patient visit. These probabilities were used as an input for a stacking logistic regression meta-classifier [3]. The final model performance expressed as the AUROC was assessed using nested cross-validation [4]. We applied this method to three variable subsets (physician, patient, payer, Table 1).

Table 1.

List of variables used in three subsets:

Variable / RolePhysicianPatientPayerGender (m/f)xxxDisease duration (years)xxxMethotrexate co-use (yes/no)xxxOther DMARDs co-use (yes/no)xxxDrug ATC codexxxIV-administration (yes/no)xxxDose percentagexxxAgexxxBody mass indexxxxDose percentage changexxxSwollen joint countxTender joint countxVAS_GH (pat. global disease activity)xxHAQ (health assessment questionnaire)xxSmoking status (yes/no/ex)xxAlcohol consumption (yes/no)xxPrevious flares (yes/no)x

Results:

Data from 135 follow-ups of 41 patients were used. The measured AUROC of the best performing model using all RETRO variables was 0.802 (95%CI 0.717 – 0.887) [1]. When a subset based on demographic and clinical variables is used that is available to a physician immediately during a patient visit the AUROC drops about 5 percent points. When only variables theoretically available to patients at home are used, the performance drops about 10 percent points comparing to the original model. Similar observation holds for the variable subset typically available to payers (Figure 1).

Conclusion:

This study shows that predictive models for flares have the potential to support physicians in making decisions immediately during the patient visit, even though laboratory values and respective activity scores are not yet available. In the future, machine learning applications may allow fast and reliable decisions on flare prediction in RA patients. These data can guide decisions about DMARD tapering at in real time during the physician-patient contact and allow to reduce costs not only by selective treatment tapering but also by sparing additional laboratory examinations.

References:

[1] Vodencarevic A. et al. Arthritis Rheumatol. 2019; 71

[2] Haschka J et al. Ann Rheum Dis 2016; 75:45-51.

[3] Tang J et al. CRC Press 2015; 498-500

[4] Cawley GC et al. J Mach Learn Res 2010; 11:2079-2107

Disclosure of Interests:

Asmir Vodencarevic Shareholder of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Employee of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Koray Tascilar: None declared, Fabian Hartmann: None declared, Michaela Reiser: None declared, Sara Bayat Speakers bureau: Novartis, Johannes Knitza Grant/research support from: Research Grant: Novartis, Larissa Valor: None declared, Melanie Hagen: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Marcus Zimmermann-Rittereiser Shareholder of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Employee of: Siemens Healthcare GmbH. Siemens Healthcare GmbH is a medical technology company (NOT a pharmaceutical company)., Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly

OP0117 LONGITUDINAL CHANGE IN THE CENTRAL NERVOUS SYSTEM PAIN RESPONSE AFTER TREATMENT WITH CERTOLIZUMAB OR PLACEBO. A POST-HOC ANALYSIS FROM THE PRECEPRA TRIAL

Background:

Tumor necrosis factor inhibitors have revolutionized the treatment of rheumatoid arthritis (RA). However, only about 50% of the patients respond well to TNF inhibitors. Therefore, markers that predict response to TNF inhibitors are valuable. Previously we demonstrated that central nervous system (CNS) response to nociceptive stimuli, measured by fMRI of the brain as blood oxygen level dependent (BOLD) signals, decreases already after 24 hours of anti-TNF administration a higher pre-treatment BOLD signal volume seems to predict clinical response to treatment with certolizumabpegol (CZP)1,2. We therefore hypothesized that the baseline volume of BOLD signal in the CNS could predict anti-TNF treatment response.

Objectives:

To perform a randomized placebo controlled trial in active RA patients to test the effect of TNF inhibition on arthritis induced pain activity in the brain and to test whether patients with high-level RA-related brain activation react differently to TNF-inhibitors than patients with low-level brain activation.

Methods:

Adult RA patients fulfilling the 2010 ACR/EULAR classification criteria with a DAS28>3.2 receiving stable DMARD treatment for at least 3 months were eligible. Patients underwent the first fMRI at screening measuring BOLD signal upon MCP joint compression and were stratified into low (< 700 units) and high (>700 units) voxel counts. Then patients were randomized to CZP or placebo with a 2:1 ratio. The second and third fMRI were performed after 12 and 24 weeks, respectively. Control stimulation was done by measuring brain activation after non-painful finger tapping.

Results:

156 RA patients with moderate-to-high disease activity participated in the study. In the finger tapping control, fMRI showed no significant changes in BOLD signal in the CZP-L and CZP-H arms, but a slight but significant decrease (p=0.043) was observed. After joint compression, the CZP-L group showed significant increase in the BOLD signal volume (p=0.043) in fMRI-2 as compared to fMRI-1 with no further significant changes. In contrast, in the CZP-H group, the BOLD signal volume significantly decreased (p=0.037) in fMRI-2 and continued to decrease further, p=0.007. No significant changes were observed in the placebo arm over time.

Conclusion:

TNF inhibition improves arthritis-related brain activity in the subgroup of RA patients with high baseline BOLD activity in the fMRI.

References:

[1]Hess, A.et al.PNAS (2011).

[2]Rech, J. et al. Arthritis & Rheumatism (2013).

Fig 1.

BOLD fMRI responses to painful stimulation

Acknowledgments:

The study was supported by an unrestricted grant of UCB Biopharma SPRL Brussels, Belgium

Disclosure of Interests:

Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Hannah Schenker: None declared, Melanie Hagen: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Verena Schönau: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis, Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

SAT0050 PREDICTION OF RESPONSE TO CERTOLIZUMAB PEGOL TREATMENT BY FUNCTIONAL MRI OF THE BRAIN: AN INTERNATIONAL, MULTI-CENTER, RANDOMIZED, DOUBLE-BLIND, PLACEBO-CONTROLLED TRIAL (PRECEPRA)

Background:

Personalization of RA treatment is not optimal due to lack of predictors. We previously demonstrated in RA patients that central nervous system (CNS) pain response to tender joint compression, measured by using functional MRI (fMRI) of the brain rapidly wanes after 24 hours of anti-TNF administration and that a higher pre-treatment BOLD signal volume seems to predict clinical response to treatment with certolizumab-pegol (CZP)1,2. We therefore hypothesized that the CNS pain response upon compression of a painful joint could predict subsequent anti-TNF treatment response.

Objectives:

To compare disease activity after 12-weeks of CZP treatment to that of placebo in DMARD-refractory RA patients based on pre-treatment baseline CNS pain response measured using BOLD fMRI.

Methods:

Adult RA patients fulfilling the 2010 ACR/EULAR classification criteria with a DAS28>3.2 under stable DMARD treatment for at least 3 months were eligible. Patients underwent fMRI scanning of the brain at screening for stratification by CNS pain response. Whole brain BOLD-signal-voxel-count of 700 units classifying between low and high, and were randomized to CZP or placebo (2:1) The primary outcome was low disease activity (LDA, DAS28 ≤3.2) after 12 weeks of treatment.

Results:

156 RA patients, inadequate responders to csDMARD, signed the informed consent. 139 patients (46/47, 46/49 and 42/43) (99 females, 71%) with moderate-high disease activity (mean (SD) DAS-28: 4.83 (1.03)) could be included respectively and completed the 12-week study treatment. Geometric mean (SD) numbers of baseline BOLD signal positive voxels were 559 (10), 81 (12) and 2498 (3) in the 3 arms respectively. The mean DAS28 (SD) scores after 12 weeks of study treatment were Placebo: 3.89 (1.29), CZP-L: 3.42 (1.06) and CZP-H: 3.06 (1.04). LDA was achieved in 12/47 patients (25.5 %) in placebo, 22/49 (44.9%) in the CZP-L, and 25/43, (58.1%) in the CZP-H arm. The linear effect term for the ordinal study group variable supported a linear trend of increasing CZP treatment effect with increasing baseline CNS pain response. RR (95% CI) for achieving LDA with each unit increase in treatment category over placebo was 1.79 (1.24 to 2.74, p=0.003).

Conclusion:

A higher pre-treatment brain activity in response to pain measured with fMRI predicts the chance of achieving low disease activity with CZP treatment.

References:

[1] Hess, A.et al.PNAS (2011)

[2] Rech, J.et al. Arthritis & Rheumatism(2013).

Acknowledgments :

The study was supported by an unrestricted grant from UCB Biopharma SPRL, Brussels, Belgium

Disclosure of Interests:

Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Hannah Schenker: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Melanie Hagen: None declared, Verena Schönau: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

AB1346-HPR REAL-WORLD EFFECTIVENESS AND PERCEIVED USEFULNESS OF SYMPTOM CHECKERS IN RHEUMATOLOGY: INTERIM REPORT FROM THE PROSPECTIVE MULTICENTER BETTER STUDY

Background:

Symptom checkers (SC) promise to reduce diagnostic delay, misdiagnosis and effectively guide patients through healthcare systems. They are increasingly used, however little evidence exists about their real-life effectiveness.

Objectives:

The aim of this study was to evaluate the diagnostic accuracy, usage time, usability and perceived usefulness of two promising SC, ADA (www.ada.com) and Rheport (www.rheport.de). Furthermore, symptom duration and previous symptom checking was recorded.

Methods:

Cross-sectional interim clinical data from the first of three recruiting centers from the prospective, real-world, multicenter bETTeR-study (DKRS DRKS00017642) was used. Patients newly presenting to a secondary rheumatology outpatient clinic between September and December 2019 completed the ADA and Rheport SC. The time and answers were recorded and compared to the patient’s actual diagnosis. ADA provides up to 5 disease suggestions, Rheport calculates a risk score for rheumatic musculoskeletal diseases (RMDs) (≥1=RMD). For both SC the sensitivity, specificity was calculated regarding RMDs. Furthermore, patients completed a survey evaluating the SC usability using the system usability scale (SUS), perceived usefulness, previous symptom checking and symptom duration.

Results:

Of the 129 consecutive patients approached, 97 agreed to participate. 38% (37/97) of the presenting patients presented with an RMD (Figure 1). Mean symptom duration was 146 weeks and a mean number of 10 physician contacts occurred previously, to evaluate current symptoms. 56% (54/96) had previously checked their symptoms on the internet using search engines, spending a mean of 6 hours. Rheport showed a sensitivity of 49% (18/37) and specificity of 58% (35/60) concerning RMDs. ADA’s top 1 and top 5 disease suggestions concerning RMD showed a sensitivity of 43% (16/37) and 54% (20/37) and a specificity of 58% (35/60) and 52% (31/60), respectively. ADA listed the correct diagnosis of the patients with RMDs first or within the first 5 disease suggestions in 19% (7/37) and 30% (11/37), respectively. The average perceived usefulness for checking symptoms using ADA, internet search engines and Rheport was 3.0, 3.5 and 3.1 on a visual analog scale from 1-5 (5=very useful). 61% (59/96) and 64% (61/96) would recommend using ADA and Rheport, respectively. The mean SUS score of ADA and Rheport was 72/100 and 73/100. The mean usage time for ADA and Rheport was 8 and 9 minutes, respectively.

Conclusion:

This is the first prospective, real-world, multicenter study evaluating the diagnostic accuracy and other features of two currently used SC in rheumatology. These interim results suggest that diagnostic accuracy is limited, however SC are well accepted among patients and in some cases, correct diagnosis can be provided out of the pocket within few minutes, saving valuable time.

Figure:

Acknowledgments:

This study was supported by an unrestricted research grant from Novartis.

Disclosure of Interests:

Johannes Knitza Grant/research support from: Research Grant: Novartis, Jacob Mohn: None declared, Christina Bergmann: None declared, Eleni Kampylafka Speakers bureau: Novartis, BMS, Janssen, Melanie Hagen: None declared, Daniela Bohr: None declared, Elizabeth Araujo Speakers bureau: Novartis, Lilly, Abbott, Matthias Englbrecht Grant/research support from: Roche Pharma, Chugai Pharma Europe, Consultant of: AbbVie, Roche Pharma, RheumaDatenRhePort GbR, Speakers bureau: AbbVie, Celgene, Chugai Pharma Europe, Lilly, Mundipharma, Novartis, Pfizer, Roche Pharma, UCB, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Timo Meinderink: None declared, Wolfgang Vorbrüggen: None declared, Cay-Benedict von der Decken: None declared, Stefan Kleinert Shareholder of: Morphosys, Grant/research support from: Novartis, Consultant of: Novartis, Speakers bureau: Abbvie, Novartis, Celgene, Roche, Chugai, Janssen, Andreas Ramming Grant/research support from: Pfizer, Novartis, Consultant of: Boehringer Ingelheim, Novartis, Gilead, Pfizer, Speakers bureau: Boehringer Ingelheim, Roche, Janssen, Jörg Distler Grant/research support from: Boehringer Ingelheim, Consultant of: Boehringer Ingelheim, Paid instructor for: Boehringer Ingelheim, Speakers bureau: Boehringer Ingelheim, Peter Bartz-Bazzanella: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, Martin Welcker Grant/research support from: Abbvie, Novartis, UCB, Hexal, BMS, Lilly, Roche, Celgene, Sanofi, Consultant of: Abbvie, Actelion, Aescu, Amgen, Celgene, Hexal, Janssen, Medac, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: Abbvie, Aescu, Amgen, Biogen, Berlin Chemie, Celgene, GSK, Hexal, Mylan, Novartis, Pfizer, UCB

OP0218 CENTRAL NERVOUS SYSTEM PAIN RESPONSE AND COMPONENTS OF DISEASE ACTIVITY IN RA PATIENTS AFTER TREATMENT WITH CERTOLIZUMAB OR PLACEBO: A POST-HOC ANALYSIS FROM THE PRECEPRA TRIAL

Background:

We have previously observed in RA patients that central nervous system (CNS) response to compression of a painful joint, measured using functional MRI (fMRI) of the brain as the number of blood oxygen level dependent (BOLD) signal positive voxels, is rapidly ameliorated, much earlier than any clinical response with anti-TNF treatment and a high baseline CNS pain response could predict better response to certolizumab pegol (CZP) treatment. Pre-CePRA was designed and conducted to test this effect in a randomized, placebo controlled trial of CZP and showed an incremental linear trend of DAS28 low disease activity (LDA) across study groups treated with placebo, and two CZP arms stratified as low or high pre-treatment CNS pain response.

Objectives:

To explore and describe pre-treatment CNS pain response associations with post treatment course of RA disease activity components and patient-physician discrepancy in global disease assessment.

Methods:

Patients fulfilling the 2010 ACR/EULAR classification criteria with moderate-severe disease activity (DAS-28>3.2) under stable DMARD treatment were recruited. Patients underwent an fMRI scan, stratified by a whole-brain BOLD positive voxel count threshold of 700 units and randomized to treatment with CZP or placebo in a 2:1 ratio. We descriptively assessed components of RA disease activity (Table 1 + 2). We summarized the mean results and 95% confidence intervals of these measurements at study timepoints and compared the 3 study groups at week 12 using one-way ANOVA and post-hoc Tukey tests.

Results:

156 eligible patients were screened and 139 (99 females, 71%) patients with moderate-high disease activity were randomized. ANOVA and pairwise comparisons showed that PGA-VAS improvement was larger in the CZP-H group whereas more similar to that in placebo in the CZP-L group. PhysGA-VAS however was similarly reduced in both CZP groups. Patients in the CZP-L group constantly rated their pain numerically higher than physicians whereas in the CZP-H group an initially higher discrepancy numerically reduced over time.

Conclusion:

These results suggest that improved patient global disease activity assessment could be the main driver of improved DAS-28 LDA rates with CZP treatment in patients with a high CNS pain response. Our findings indicate a potential role of fMRI imaging of the brain to further understand disease activity perception in RA patients.

Figure 1.

Course of disease activity components through trial timepoints. *indicates log-transformed y axis. *#x002A; Discrepancy equals Patient global minus physician global assessment.

Disclosure of Interests:

Hannah Schenker: None declared, Jürgen Rech Consultant of: BMS, Celgene, Novartis, Roche, Chugai, Speakers bureau: AbbVie, Biogen, BMS, Celgene, MSD, Novartis, Roche, Chugai, Pfizer, Lilly, Koray Tascilar: None declared, Melanie Hagen: None declared, Verena Schönau: None declared, Marina Sergeeva: None declared, Mageshwar Selvakumar: None declared, Laura Konerth: None declared, Jutta Prade: None declared, Sandra Strobelt: None declared, Larissa Valor: None declared, Axel Hueber Grant/research support from: Novartis, Lilly, Pfizer, EIT Health, EU-IMI, DFG, Universität Erlangen (EFI), Consultant of: Abbvie, BMS, Celgene, Gilead, GSK, Lilly, Novartis, Speakers bureau: GSK, Lilly, Novartis, David Simon Grant/research support from: Else Kröner-Memorial Scholarship, Novartis, Consultant of: Novartis, Lilly, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Frank Behrens Grant/research support from: Abbvie, Pfizer, Roche, Chugai, Janssen, Consultant of: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, Speakers bureau: Abbvie, Pfizer, Roche, Chugai, UCB, BMS, Celgene, MSD, Novartis, Biotest, Janssen, Genzyme, Lilly; Boehringer; Sandoz, José Antonio P. da Silva Grant/research support from: Pfizer, Abbvie, Consultant of: Pfizer, AbbVie, Roche, Lilly, Novartis, Christoph Baerwald Consultant of: CGB received speaker or consulting fees from AbbVie, Paid instructor for: CGB received speaker or consulting fees from AbbVie, Speakers bureau: CGB received speaker or consulting fees from AbbVie, Stephanie Finzel: None declared, Reinhard Voll: None declared, Eugen Feist Consultant of: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Speakers bureau: Novartis, Roche, Sobi, Lilly, Pfizer, Abbvie, BMS, MSD, Sanofi, Arnd Doerfler: None declared, Nemanja Damjanov Grant/research support from: from AbbVie, Pfizer, and Roche, Consultant of: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Speakers bureau: AbbVie, Gedeon Richter, Merck, Novartis, Pfizer, and Roche, Andreas Hess: None declared, Georg Schett Speakers bureau: AbbVie, BMS, Celgene, Janssen, Eli Lilly, Novartis, Roche and UCB

Identification of N-Hydroxamic Acid and N-Hydroxyimide Compounds that Inhibit the Influenza Virus Polymerase

The RNA-dependent RNA polymerase of influenza virus transcribes messenger RNA through a unique cap-scavenging mechanism. The polymerase binds to the cap structure at the 5′ ends of host mRNAs, which are then cleaved and used as primers for viral mRNA synthesis. In an effort to discover antiviral compounds against this target, an in-vitro transcription assay was utilized to screen a proprietary chemical collection. Results of this screening effort identified an N-hydroxamic acid structure as an inhibitor of the capped RNA-dependent transcriptase activity. Subsequent sub-structure searching and screening based upon this pharmacophore identified two related N-hydroxyimide compounds as specific inhibitors. These compounds were found to inhibit the cap-scavenging mechanism through inhibition of the endonuclease function of the polymerase.

Decommissioning and rehabilitation of uranium and thorium production facilities

The use of nuclear energy for military as well as for peaceful purposes was and remains closely connected with the mining and processing of uranium ore and, to a lesser extent, of thorium ore. Mining and processing of radioactive ores are characterised by the generation of huge amounts of radioactive residues, massive impacts upon ecosystems, landscape reshaping (or devastation in some places), and the monostructural socio-economic orientation of human settlement areas. However, a great number of the mines and mills commissioned during the cold war have been already closed, either for deposits being depleted of economically recoverable resources or on political grounds. The specifics of uranium/thorium mining and milling make high demands on the decommissioning and rehabilitation of the facilities which in addition to radiological aspects would have to address issues such as water pollution control and soil conservation, future site re-use, landscaping, and infrastructure development. The present paper gives an overview of the state of decommissioning and rehabilitation. Radiological specifics and their integration into the decommissioning and rehabilitation management are demonstrated for the rehabilitation of uranium mining legacies in Saxony and Thuringia.

Three-dimensional vision enhances task performance independently of the surgical method

BACKGROUND

Within the next few years, the medical industry will launch increasingly affordable three-dimensional (3D) vision systems for the operating room (OR). This study aimed to evaluate the effect of two-dimensional (2D) and 3D visualization on surgical skills and task performance.

METHODS

In this study, 34 individuals with varying laparoscopic experience (18 inexperienced individuals) performed three tasks to test spatial relationships, grasping and positioning, dexterity, precision, and hand-eye and hand-hand coordination. Each task was performed in 3D using binocular vision for open performance, the Viking 3Di Vision System for laparoscopic performance, and the DaVinci robotic system. The same tasks were repeated in 2D using an eye patch for monocular vision, conventional laparoscopy, and the DaVinci robotic system.

RESULTS

Loss of 3D vision significantly increased the perceived difficulty of a task and the time required to perform it, independently of the approach (P < 0.0001-0.02). Simple tasks took 25 % to 30 % longer to complete and more complex tasks took 75 % longer with 2D than with 3D vision. Only the difficult task was performed faster with the robot than with laparoscopy (P = 0.005). In every case, 3D robotic performance was superior to conventional laparoscopy (2D) (P < 0.001-0.015).

CONCLUSIONS

The more complex the task, the more 3D vision accelerates task completion compared with 2D vision. The gain in task performance is independent of the surgical method.

[Scarless surgery: myth or reality through NOTES?]

Natural orifice translumenal endoscopic surgery (NOTES) is an exciting concept bringing scarless surgery a reality consisting in body cavity and organs approach through natural orifices (digestive, female genital, urinary tracts). While new instrumentation necessitated by NOTES is still developing, multiple surgical procedures have been performed with success in human. Whenever this approach combining surgical and endoscopic expertise needs technical improvement and clinical validation, it will have a large impact on the future of surgery related to population demand for scarless surgery. The next decade, will show us if surgery will be performed through NOTES or if minimally invasive surgery will be positively influenced by the technical progress of NOTES to be the most minimally traumatic.

Management of sexual dysfunction due to antipsychotic drug therapy

BACKGROUND

Psychotropic drugs are associated with sexual dysfunction. Symptoms may concern penile erection, lubrication, orgasm, libido, sexual arousal or overall sexual satisfaction.

OBJECTIVES

To determine the effects of different strategies (e.g. dose reduction, drug holidays, adjunctive medication, switching to another drug) for treatment of sexual dysfunction due to antipsychotic therapy.

SEARCH STRATEGY

We searched the Cochrane Schizophrenia Group's Register (June 2006), the Cochrane Library (Issue 2, 2005), MEDLINE (1966-8/2005), PsycLIT (1974-8/2005), EMBASE (1980-8/2005) and references of all identified studies for further trials. We contacted relevant pharmaceutical companies and authors of trials.

SELECTION CRITERIA

We included all relevant randomised controlled trials involving people with schizophrenia and sexual dysfunction.

DATA COLLECTION AND ANALYSIS

Working independently, we extracted data. For dichotomous data we calculated random effects odds ratios (OR) with 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) on an intention-to-treat basis. For continuous data we calculated weighted mean differences on the basis of a random effects model. We analysed crossover trials under consideration of correlation of paired measures.

MAIN RESULTS

Currently this review includes two pioneering crossover studies (total n=42 men, duration 2-3 weeks). They reported significantly more erections sufficient for penetration when receiving sildenafil compared with when receiving placebo (n=32, WMD 3.20 CI 1.83 to 4.57), a greater mean duration of erections (n=32, WMD 1.18 CI 0.52 to 1.84) and frequency of satisfactory intercourse (n=32, WMD 2.84 CI 1.61 to 4.07). The second trial found no evidence for selegiline as symptomatic treatment for antipsychotic-induced sexual dysfunction compared with placebo (n=10, WMD change on Aizenberg's sexual functioning scale -0.40 CI -3.95 to 3.15).

AUTHORS' CONCLUSIONS

We are not confident that crossover studies are appropriate for this participant group. Sildenafil may be a useful option in the treatment of antipsychotic-induced sexual dysfunction in men with schizophrenia, but this conclusion is based only on one small short trial. Further well designed, conducted and reported trials are urgently needed.

Mice deficient in galectin-1 exhibit attenuated physiological responses to chronic hypoxia-induced pulmonary hypertension

Pulmonary hypertension (PH) is characterized by sustained vasoconstriction, with subsequent extracellular matrix (ECM) production and smooth muscle cell (SMC) proliferation. Changes in the ECM can modulate vasoreactivity and SMC contraction. Galectin-1 (Gal-1) is a hypoxia-inducible beta-galactoside-binding lectin produced by vascular, interstitial, epithelial, and immune cells. Gal-1 regulates SMC differentiation, proliferation, and apoptosis via interactions with the ECM, as well as immune system function, and, therefore, likely plays a role in the pathogenesis of PH. We investigated the effects of Gal-1 during hypoxic PH by quantifying 1) Gal-1 expression in response to hypoxia in vitro and in vivo and 2) the effect of Gal-1 gene deletion on the magnitude of the PH response to chronic hypoxia in vivo. By constructing and screening a subtractive library, we found that acute hypoxia increases expression of Gal-1 mRNA in isolated pulmonary mesenchymal cells. In wild-type (WT) mice, Gal-1 immunoreactivity increased after 6 wk of hypoxia. Increased expression of Gal-1 protein was confirmed by quantitative Western analysis. Gal-1 knockout (Gal-1(-/-)) mice showed a decreased PH response, as measured by right ventricular pressure and the ratio of right ventricular to left ventricular + septum wet weight compared with their WT counterparts. However, the number and degree of muscularized vessels increased similarly in WT and Gal-1(-/-) mice. In response to chronic hypoxia, the decrease in factor 8-positive microvessel density was similar in both groups. Vasoreactivity of WT and Gal-1(-/-) mice was tested in vivo and with use of isolated perfused lungs exposed to acute hypoxia. Acute hypoxia caused a significant increase in RV pressure in wild-type and Gal-1(-/-) mice; however, the response of the Gal-1(-/-) mice was greater. These results suggest that Gal-1 influences the contractile response to hypoxia and subsequent remodeling during hypoxia-induced PH, which influences disease progression.

Asymptomatic cytomegalovirus infection is associated with increased risk of new-onset diabetes mellitus and impaired insulin release after renal transplantation

AIMS/HYPOTHESIS

The human cytomegalovirus (CMV) may increase the risk of diabetes mellitus, but the literature is scarce. The present study was designed to test the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset diabetes after renal transplantation, and to assess the impact of asymptomatic CMV infection on OGTT-derived estimates of insulin release and insulin action.

METHODS

A total of 160 consecutive non-diabetic renal transplant recipients on cyclosporine (Sandimmun Neoral)-based immunosuppression were closely monitored for CMV infection during the first 3 months after transplantation. All patients underwent a 75-g OGTT at 10 weeks. Excluded from the analyses were 36 patients with symptomatic CMV infection (disease).

RESULTS

The incidence of new-onset diabetes was 6% in a control group of recipients without CMV infection (4/63) and 26% in the group with asymptomatic CMV infection (16/61). Asymptomatic CMV infection was associated with a significantly increased risk of new-onset diabetes (adjusted odds ratio: 4.00; 95% CI: 1.19 to 13.43, p=0.025). The group of patients with CMV infection had a significantly lower median insulin release than controls.

CONCLUSIONS/INTERPRETATION

Our findings support the hypothesis that asymptomatic CMV infection is associated with increased risk of new-onset post-transplant diabetes mellitus, and suggest that impaired insulin release may involve one pathogenetic mechanism.

[Detection of genetically modified soy (Roundup-Ready) in processed food products]

In this study, the application of a qualitative and a quantitative method of analysis to detect genetically modified RR-Soy (Roundup-Ready Soy) in processed foods is described. A total of 179 various products containing soy such as baby food and diet products, soy drinks and desserts, tofu and tofu products, soy based meat substitutes, soy protein, breads, flour, granules, cereals, noodles, soy bean sprouts, fats and oils as well as condiments were investigated following the pattern of the section 35 LMBG-method L 23.01.22-1. The DNA was extracted from the samples and analysed using a soybean specific lectin gene PCR as well as a PCR, specific for the genetic modification. Additional, by means of PCR in combination with fluorescence-detection (TaqMan 5'-Nuclease Assay), suspicious samples were subjected to a real-time quantification of the percentage of genetically modified RR-Soy. The methods of analysis proved to be extremely sensitive and specific in regard to the food groups checked. The fats and oils, as well as the condiments were the exceptions in which amplifiable soy DNA could not be detected. The genetic modification of RR-Soy was detected in 34 samples. Eight of these samples contained more than 1% of RR-Soy. It is necessary to determine the percentage of transgenic soy in order to assess whether genetically modified ingredients were deliberately added, or whether they were caused by technically unavoidable contamination (for example during transportation and processing).

Self-splicing of the Tetrahymena intron from mRNA in mammalian cells

The Tetrahymena pre-rRNA self-splicing intron is shown to function in the unnatural context of an mRNA transcribed by RNA polymerase II in mammalian cells. Mutational analysis supports the conclusion that splicing in cells occurs by the same RNA-catalyzed mechanism established for splicing in vitro. Insertion of the intron at five positions spanning the luciferase open reading frame revealed 10-fold differences in accumulation of ligated exons and in luciferase activity; thus, the intron self-splices in many exon contexts, but the context can have a significant effect on activity. In addition, even the best self-splicing constructs, which produced half as much mRNA as did an uninterrupted luciferase gene, gave approximately 100-fold less luciferase enzyme activity, revealing an unexpected discontinuity between mRNA production and translation in cells. The finding that production of accurately spliced mRNA in cells does not guarantee a corresponding level of protein production is surprising, and may have implications for the development of trans-splicing ribozymes as therapeutics.

A regulatory role for Fc gamma receptors (CD16 and CD32) in hematopoiesis

Progenitor cells of the T- and B-lineages in mice express (CD32) and Fc gamma RIII (CD16) but as the developing lymphocytes begin to express clonal antigen receptors, CD16 and CD32 are downregulated in T-cells, and CD16 is downregulated in B-cells. Considering that counter-receptors for Fc gamma R occur on thymic and bone marrow stromal cells, the possibility exists that Fc gamma R might participate in some aspect of T- and B-lineage development prior to the stage of antigen receptor expression. Previous studies provided evidence that Fc gamma R can influence murine T-lineage development. In the present studies we found that anti-Fc gamma RII/III mAb accelerated B-lineage development in bone marrow cultures from normal mice, but not in cultures from CD16-/- or CD32-/- mice. Similar results were observed when FACS-purified B-progenitor cells were co-cultured with BMS2, a bone marrow stromal cell line. Fresh bone marrow from CD32-/- mice contained about two-fold more B-lineage cells compared to bone marrow from normal or CD16-/- mice. These studies indicate that the Fc gamma R on B-lineage progenitor cells can influence their further development and add to a growing body of evidence that implicates Fc gamma R as regulatory elements in hematopoiesis.

Survival after in-hospital cardiopulmonary resuscitation. A meta-analysis

OBJECTIVE

To determine the rates of immediate survival and survival to discharge for adult patients undergoing in-hospital cardiopulmonary resuscitation, and to identify demographic and clinical variables associated with these outcomes.

MEASUREMENTS AND MAIN RESULTS

The MEDLARS database of the National Library of Medicine was searched. In addition, the authors' extensive personal files and the bibliography of each identified study were searched for further studies. Two sets of inclusion criteria were used, minimal (any study of adults undergoing in-hospital cardiopulmonary resuscitation) and strict (included only patients from general ward and intensive care units, and adequately defined cardiopulmonary arrest and resuscitation). Each study was independently reviewed and abstracted in a nonblinded fashion by two reviewers. The data abstracted were compared, and any discrepancies were resolved by consensus discussion. For the subset of studies meeting the strict criteria, the overall rate of immediate survival was 40.7% and the rate of survival to discharge was 13.4%. The following variables were associated with failure to survive to discharge: sepsis on the day prior to resuscitation (odds ratio [OR] 31.3; 95% confidence interval [CI] 1.9, 515), metastatic cancer (OR 3.9; 95% CI 1.2, 12. 6), dementia (OR 3.1; 95% CI 1.1, 8.8), African-American race (OR 2. 8; 95% CI 1.4, 5.6), serum creatinine level at a cutpoint of 1.5 mg/dL (OR 2.2; 95% CI 1.2, 3.8), cancer (OR 1.9; 95% CI 1.2, 3.0), coronary artery disease (OR 0.55; 95% CI 0.4, 0.8), and location of resuscitation in the intensive care unit (OR 0.51; 95% CI 0.4, 0.8).

CONCLUSIONS

When talking with patients, physicians can describe the overall likelihood of surviving discharge as 1 in 8 for patients who undergo cardiopulmonary resuscitation and 1 in 3 for patients who survive cardiopulmonary resuscitation.

Atypical pulmonary eosinophilia is mediated by a specific amino acid sequence of the attachment (G) protein of respiratory syncytial virus

We analyzed the immune responses evoked by a series of overlapping peptides to better understand the molecular basis for respiratory syncytial virus (RSV) G protein-induced eosinophilia in BALB/c mice. In vitro stimulation of spleen cells from natural G protein-primed mice showed dominant proliferative and cytokine (interferon [IFN]-gamma and interleukin [IL]-5) responses to a peptide encompassing amino acids 184-198. Mice vaccinated with peptide 184- 198 conjugated to keyhole limpet hemocyanin showed significant pulmonary eosinophilia (39.5%) after challenge with live RSV. In contrast, mice immunized with a peptide (208-222) conjugate associated with induction of IFN-gamma secreting spleen cells did not exhibit pulmonary eosinophilia after challenge. The in vivo depletion of CD4(+) cells abrogated pulmonary eosinophilia in mice vaccinated with the peptide 184-198 conjugate, whereas the depletion of CD8(+) cells had a negligible effect. Therefore, we have identified an association between peptide 184- 198 of natural G protein and the CD4(+) T cell-mediated induction of pulmonary eosinophilia after live RSV challenge. Out of 43 human donors, 6 provided peripheral blood mononuclear cells that showed reactivity to G protein from RSV A2, 3 of which responded to peptide 184- 198. The results have important implications for the development of a vaccine against RSV.

Homing of transgenic gammadelta T cells into murine vaginal epithelium

The vaginal epithelium of normal mice contains lymphocytes of fetal thymic origin that express an invariant Vgamma4/Vdelta1 TCR. The apparent lack of other gammadelta TCR species suggests that a selection mechanism might operate to regulate the localization of gammadelta T cells at this anatomical site. Selection might be connected to the Vgamma4/Vdelta1 TCR or to some homing characteristic of the fetal thymic lineage that appears at day 17-18 of embryonic life. In the present studies, we investigated whether transgenic gammadelta cells expressing a TCR species characteristic of the subpopulation of gammadelta T cells found in the blood, spleen and lymph would translocate to the vaginal epithelium. We found that the transgenic Vgamma2 TCR+ cells did accumulate in the vagina of transgenic mice. Furthermore, like normal vaginal gammadelta T cells, the transgenic vaginal gammadelta T cells expressed the phenotype of recently activated memory/effector T cells (CD44(hi), CD62L-, CD45RB(lo), CD69+). Vaginal gammadelta T cells in normal mice do not express the CD2 and CD28 antigens, but both of these markers are present on transgenic vaginal gammadelta T cells. We observed that a small fraction of splenic transgenic gammadelta T cells had the same surface phenotype as the vaginal transgenic gammadelta T cells, raising the possibility that the gammadelta T cells present in the vaginal epithelium of transgenic mice originated from the peripheral lymphoid organs. Data in support of this possibility came from experiments in which co-incubation of splenic transgenic gammadelta T cells with vaginal epithelial cell suspensions induced the vaginal gammadelta phenotype on the splenic gammadelta T cells. The finding of transgenic gammadelta T cells in the vaginal epithelium suggests that homing of gammadelta T cells to this site is not restricted to gammadelta T cells that express the V4/NS1 invariant TCR. Furthermore, these findings imply that retention of gammadelta T cells in the vaginal epithelium of normal mice is affected by a Vgamma4/Vdelta1-specific mechanism. The finding of a significant level of apoptosis in the transgenic vaginal gammadelta T cells, but not in the normal vaginal gammadelta T cells, could reflect that the mechanism of retention of Vgamma4/Vdelta1 + in the vaginal epithelium involves selective survival at the site.

Characterization of thyroid hormone sulfotransferases

Sulfation is an intriguing pathway of thyroid hormone metabolism since it facilitates the degradation of the hormone by the type I deiodinase (D1). This study reports the preliminary characterization of iodothyronine sulfotransferase activities of rat and human liver cytosol and recombinant rSULT1C1 and hSULT1A1 isoenzymes. All these enzyme preparations catalyzed the sulfation of--in decreasing order of efficiency--3,3'-diiodothyronine (3,3'-T2) > 3,3',5-triiodothyronine (T3) approximately 3,3',5'-triiodothyronine (rT3) > thyroxine (T4). 3,3'-T2 sulfotransferase activity was found to be higher in male than in female rat liver, which has also been shown by others for the expression of rSULT1A1 and rSULT1C1. No sulfation of iodothyronines was observed with rSULT1A1. Different phenol derivatives were found to be potent inhibitors of the sulfation of 3,3'-T2 by native and recombinant sulfotransferases, with pentachlorophenol and 2,4,6-tribromophenol being the most potent. The inhibitions exerted by the different phenols on 3,3'-T2 sulfation by rSULT1C1 correlated better with the effects observed in male than with those in female liver. A strong correlation was also observed between the inhibition profiles of human liver cytosol and hSUL1T1A1. These results suggest that: (1) rSULT1C1 is an important isoenzyme for the sulfation of thyroid hormone in male rat liver; (2) another isoenzyme with similar properties, perhaps rSULT1B1, is responsible for thyroid hormone sulfation in female rat liver and may also contribute to this process in male rat liver; and (3) hSULT1A1 is an important isoenzyme for thyroid hormone sulfation in human liver.

Sulfotransferase-mediated activation of mutagens studied using heterologous expression systems

Sulfation is a common final step in the biotransformation of xenobiotics and is traditionally associated with inactivation. However, the sulfate group is electron-withdrawing and may be cleaved off heterolytically in some molecules leading to electrophilic cations which may form adducts with DNA and other important cellular structures. Since endogenous sulfotransferases do not appear to be expressed in indicator cells of standard mutagenicity tests, rat and human sulfotransferases have been stably expressed in his- Salmonella typhimurium strain TA1538 and Chinese hamster V79 cells. Using these recombinant indicator cells, sulfotransferase-dependent genotoxic activities were detected with N-hydroxy-2-acetylaminofluorene, 2-acetylaminofluorene (in the presence of co-expressed rat cytochrome P450 1A2), hycanthone, 1'-hydroxysafrole, alpha-hydroxytamoxifen and various benzylic alcohols derived from polycyclic aromatic hydrocarbons. In several cases, it was critical that the reactive sulfuric acid conjugates were formed directly within the indicator cells, owing to the inefficient penetration of cell membranes. In other cases, spontaneous benzylic substitution reactions with medium components, such as halogenide ions or amino acids, led to secondary, membrane-penetrating reactive species. Different sulfotransferases, including related forms from rat and human, substantially differed in their substrate specificity towards the investigated promutagens. It is known that some sulfotransferases are expressed with high tissue and cell type specificities. This site-dependent expression together with the limitations in the distribution of reactive sulfuric acid conjugates may explain organotropic effects of compounds activated by this metabolic pathway.

Expression of human estrogen sulfotransferase in Salmonella typhimurium: differences between hHST and hEST in the enantioselective activation of 1-hydroxyethylpyrene to a mutagen

Various human sulfotransferases (hP-PST, hM-PST, hHST) and rat sulfotransferases (rPST-IV, rHSTa) have already been expressed in Ames' Salmonella strains (in particular in TA1538). Now a further strain, TA1538-hEST, which expresses the human estrogen sulfotransferase (hEST), has been constructed. This strain activated the primary benzylic alcohol 1-hydroxymethylpyrene (1-HMP) and the secondary benzylic alcohol 1-hydroxyethylpyrene (1-HEP) to mutagens. Human sulfotransferases hEST and hHST both activated 1-HEP, but they differed substantially in their enantioselectivity for this compound.

The effect of structure in a long target RNA on ribozyme cleavage efficiency

Inhibition of gene expression by catalytic RNA (ribozymes) requires that ribozymes efficiently cleave specific sites within large target RNAs. However, the cleavage of long target RNAs by ribozymes is much less efficient than cleavage of short oligonucleotide substrates because of higher order structure in the long target RNA. To further study the effects of long target RNA structure on ribozyme cleavage efficiency, we determined the accessibility of seven hammerhead ribozyme cleavage sites in a target RNA that contained human immunodeficiency virus type 1 (HIV-1) vif - vpr . The base pairing-availability of individual nucleotides at each cleavage site was then assessed by chemical modification mapping. The ability of hammerhead ribozymes to cleave the long target RNA was most strongly correlated with the availability of nucleotides near the cleavage site for base pairing with the ribozyme. Moreover, the accessibility of the seven hammerhead ribozyme cleavage sites in the long target RNA varied by up to 400-fold but was directly determined by the availability of cleavage sites for base pairing with the ribozyme. It is therefore unlikely that steric interference affected hammerhead ribozyme cleavage. Chemical modification mapping of cleavage site structure may therefore provide a means to identify efficient hammerhead ribozyme cleavage sites in long target RNAs.

Lack of Fc-epsilon receptors on murine eosinophils: implications for the functional significance of elevated IgE and eosinophils in parasitic infections

Chronic infection with Schistosoma mansoni induces in humans and mice a Th2-dominant immune response in which eosinophils and IgE are conspicuously elevated. Human eosinophils express IgE receptors that participate in an IgE-dependent eosinophil-mediated ADCC reaction against Schistosomula larvae in vitro. To investigate the expression of IgE receptors on murine eosinophils, they were purified (>95% pure by Giemsa-stained cytospin preparations) from liver granulomas of Schistosoma-infected mice. Flow cytometric analysis showed the absence of the low-affinity IgE receptor Fc-epsilon RII (CD23) and Mac-2 and the absence of binding of murine IgE. Reverse transcription-polymerase chain reaction (RT-PCR) analysis of granuloma eosinophil mRNA did not detect transcripts for Fc-epsilon RII or the alpha-chain of the high-affinity IgE receptor Fc-epsilon RI, but did detect transcripts that encode Mac-2 and the low-affinity IgG receptors Fc-gamma RIIb2, Fc-gamma RIII, and the FcR-associated gamma-chain. In vitro stimulation of granuloma eosinophils with interleukin-4 (IL-4) did not induce IgE binding, surface expression of Mac-2, or the transcription of Fc-epsilon receptors (Fc-epsilon RI, Fc-epsilon RII/CD23). To investigate normal murine eosinophils, we cultured normal mouse bone marrow cells with recombinant IL-3, recombinant IL-5, and recombinant granulocyte-macrophage colony-stimulating factor, conditions that promote eosinophil differentiation. Flow cytometric analysis of bone marrow-derived eosinophils failed to detect IgE binding or cell surface expression of Fc-epsilon RII and Mac-2, and RT-PCR analysis of fluorescence-activated cell sorted bone marrow-derived eosinophils failed to detect transcripts that encode Fc-epsilon RI or Fc-epsilon RII. These findings show that, in contrast to human eosinophils, murine eosinophils do not express cell surface receptors that bind IgE. However, because IgG receptors (Fc-gamma RIIb2, Fc-gamma RII) were present on eosinophils purified from granulomas, we investigated whether they might be involved in eosinophil activation. We found that an oxidative burst in eosinophils could be triggered through their IgG receptors.

Gamma delta T cells of the murine vagina: T cell response in vivo in the absence of the expression of CD2 and CD28 molecules

While little is known about their activation requirements and function, the intraepithelial T cells of the murine vagina express TCR complexes in which the antigen recognition components and the signaling components have unusual features. These vaginal T cells express an invariant V gamma 4/V delta 1 TCR and appear to be the only intraepithelial gamma delta T cells that exclusively use FcR gamma chains in their TCR complex. To further characterize the vaginal gamma delta T cells we isolated them from normal mice and from mice injected systemically with an activation-inducing dose of anti-TCR mAb. The isolated gamma delta T cells were examined by flow cytometry for their surface expression of a panel of adhesion, proteins, activation antigens and cellular interaction molecules (CD44, CD62L, CD45RB, LFA-1, CD2 and CD28). The patterns of expression observed indicate that the vaginal gamma delta T cells of normal mice show the phenotype of effector T cells. The adhesion/co-stimulatory molecules CD28 and CD2 were not detected on vaginal gamma delta T cells, an interesting finding since the absence of CD2 from other T cells has been suggested to result in anergy. However, vaginal gamma delta T cells are responsive to TCR-mediated signals since injection of normal mice with pan-anti-TCR antibody or stimulating anti-gamma delta TCR antibody resulted in an increase in cell number and increased expression of transferrin and IL-2 receptors. These results indicate that vaginal gamma delta T cells might utilize other co-stimulatory molecules, if any, in connection with TCR-induced activation and differentiation. While the physiological function of vaginal gamma delta T cells remains unknown, the expression of an invariant V gamma 4/V delta 1 TCR, their exclusive use of gamma chain homodimers in their TCR, and the absence of CD2 and CD28 co-stimulatory molecules are a novel combination of properties that suggests specialized functional properties. Although vaginal gamma delta T cells share some features in common with gamma delta T cells that reside in other epithelial tissues, such as skin and intestine, the present studies provide additional evidence that vaginal gamma delta T cells are a highly specialized and distinct T cell population.