[Autism spectrum disorder: the impact of an online training strategy on the knowledge of the healthcare staff of a tertiary care hospital]

INTRODUCTION

Autism spectrum disorder (ASD) often presents related medical disorders that require specialised healthcare. Professionals in the health sector therefore face difficulties that require specific training in the healthcare needs of this population.

AIM

The aim of this study is to quantify paediatric healthcare professionals' knowledge about ASD and to assess the impact of online training.

SUBJECTS AND METHODS

It is a quasi-experimental, longitudinal, prospective before-and-after study; study subjects: health professionals; independent variable: online training in ASD; dependent variable: knowledge about ASD. An online training course was held for paediatric professionals to address the core characteristics of diagnosis, as well as the needs they present in the hospital context and the adaptations it is recommended that should be carried out. Fifty-eight healthcare professionals took part.

RESULTS

An increase in knowledge about ASD was observed at the end of the intervention (from 73.9% to 85% according to the ASD background knowledge questionnaire), which showed that more than 90% of the participants had the highest level of knowledge about ASD.

CONCLUSIONS

Online training courses are a useful and effective way to increase knowledge about ASD and the adaptations that are recommended in the hospital setting. More training in ASD should be made available in these settings.

Incidence and predictors of hepatocellular carcinoma in patients with autoimmune hepatitis

BACKGROUND AND AIMS

Autoimmune hepatitis (AIH) is a rare chronic liver disease of unknown aetiology; the risk of hepatocellular carcinoma (HCC) remains unclear and risk factors are not well-defined. We aimed to investigate the risk of HCC across a multicentre AIH cohort and to identify predictive factors.

METHODS

We performed a retrospective, observational, multicentric study of patients included in the International Autoimmune Hepatitis Group Retrospective Registry. The assessed clinical outcomes were HCC development, liver transplantation, and death. Fine and Gray regression analysis stratified by centre was applied to determine the effects of individual covariates; the cumulative incidence of HCC was estimated using the competing risk method with death as a competing risk.

RESULTS

A total of 1,428 patients diagnosed with AIH from 1980 to 2020 from 22 eligible centres across Europe and Canada were included, with a median follow-up of 11.1 years (interquartile range 5.2-15.9). Two hundred and ninety-three (20.5%) patients had cirrhosis at diagnosis. During follow-up, 24 patients developed HCC (1.7%), an incidence rate of 1.44 cases/1,000 patient-years; the cumulative incidence of HCC increased over time (0.6% at 5 years, 0.9% at 10 years, 2.7% at 20 years, and 6.6% at 30 years of follow-up). Patients who developed cirrhosis during follow-up had a significantly higher incidence of HCC. The cumulative incidence of HCC was 2.6%, 4.6%, 5.6% and 6.6% at 5, 10, 15, and 20 years after the development of cirrhosis, respectively. Obesity (hazard ratio [HR] 2.94, p = 0.04), cirrhosis (HR 3.17, p = 0.01), and AIH/PSC variant syndrome (HR 5.18, p = 0.007) at baseline were independent risk factors for HCC development.

CONCLUSIONS

HCC incidence in AIH is low even after cirrhosis development and is associated with risk factors including obesity, cirrhosis, and AIH/PSC variant syndrome.

IMPACT AND IMPLICATIONS

The risk of developing hepatocellular carcinoma (HCC) in individuals with autoimmune hepatitis (AIH) seems to be lower than for other aetiologies of chronic liver disease. Yet, solid data for this specific patient group remain elusive, given that most of the existing evidence comes from small, single-centre studies. In our study, we found that HCC incidence in patients with AIH is low even after the onset of cirrhosis. Additionally, factors such as advanced age, obesity, cirrhosis, alcohol consumption, and the presence of the AIH/PSC variant syndrome at the time of AIH diagnosis are linked to a higher risk of HCC. Based on these findings, there seems to be merit in adopting a specialized HCC monitoring programme for patients with AIH based on their individual risk factors.

Treatment responses and outcomes in patients with autoimmune hepatitis and concomitant features of non-alcoholic fatty liver disease

Background & Aims

Non-alcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH) affect 17-46% of Western countries, making coexistence with other liver diseases inevitable. We investigated the prevalence and clinical significance of NAFLD/NASH or the components of metabolic syndrome (MetS) in a large multicentric cohort of patients with autoimmune hepatitis (AIH).

Methods

Data from six academic centres (Greece, Canada, Japan, Germany, The Netherlands, and Spain) were evaluated. The presence of NAFLD/NASH in liver biopsy, MetS components, and clinical and laboratory parameters were recorded.

Results

A total of 640 patients (474 females, age 49 [4-87] years; follow-up 78 [1-521] months) were included. NAFLD was present in 146 (22.8%) patients (AIH/non-alcoholic fatty liver [NAFL] 115 [18%], AIH/NASH 31 [4.8%]). AIH/NAFL patients were older (p = 0.017), more frequently overweight or obese (p = 0.002), had hypertension (p = 0.001), and had diabetes (p = 0.016), whereas they less frequently had acute presentation (p = 0.002) and soluble liver antigen/liver pancreas positivity (p <0.05), lower transaminases (p <0.001), ALP (p = 0.028) and IgG (p = 0.004) and higher albumin (p <0.001) than patients with AIH only. Patients with AIH/NASH more frequently had cirrhosis at diagnosis (p = 0.036) and higher IgG (p = 0.009). Response to treatment did not differ between groups. Patients with cirrhosis with AIH/NAFL had higher frequency of decompensation compared with patients with AIH only (p <0.05). Patients with type 2 diabetes mellitus and dyslipidaemia had increased hazard of disease progression (p <0.05 for each).

Conclusions

The prevalence of NAFLD in AIH is similar to the general population. Concurrence of NASH in patients with AIH signifies a more severe disease, whereas that of NAFL may indicate a worse prognosis in patients with cirrhosis. T2DM and dyslipidaemia in AIH patients are associated with dismal parameters of outcome. Our findings suggest that NAFLD presence or even components of MetS in patients with AIH may affect prognosis, so closer follow-up of such patients is warranted.

Impact and implications

Non-alcoholic fatty liver disease (NAFLD) and steatohepatitis (NASH) affect many people, making coexistence with other liver diseases inevitable. We investigated the prevalence and clinical significance of NAFLD/NASH or the components of metabolic syndrome (MetS) in patients with autoimmune hepatitis (AIH). NAFLD and NASH presence in patients with AIH is as frequent as in the general population. The concurrence of NASH in patients with AIH seems to signify a more severe disease, whereas that of non-alcoholic fatty liver may indicate a worse prognosis in a specific subgroup of patients who already have cirrhosis at diagnosis. Diabetes or dyslipidaemia in patients with AIH were associated with worse prognosis. Therefore, it seems that closer follow-up of patients with concurrent AIH and NAFLD or AIH and components of MetS is needed.

Radiological Structured Report Integrated with Quantitative Imaging Biomarkers and Qualitative Scoring Systems

The benefits of structured reporting (SR) in radiology are well-known and have been widely described. However, there are limitations that must be overcome. Radiologists may be reluctant to change the conventional way of reporting. Error rates could potentially increase if SR is used improperly. Interruption of the visual search pattern by keeping the eyes focused on the report rather than the images may increase reporting time. Templates that include unnecessary or irrelevant information may undermine the consistency of the report. Last, the lack of support for multiple languages may hamper the adaptation of the report to the target audience. This work aims to mitigate these limitations with a web-based structured reporting system based on templates. By including field validators and logical rules, the system avoids reporting mistakes and allows to automatically calculate values and radiological qualitative scores. The system can manage quantitative information from imaging biomarkers, combining this with qualitative radiological information usually present in the structured report. It manages SR templates as plugins (IHE MRRT compliant and compatible with RSNA's Radreport templates), ensures a seamless integration with PACS/RIS systems, and adapts the report to the target audience by means of natural language extracts generated in multiple languages. We describe a use case of SR template for prostate cancer including PI-RADS 2.1 scoring system and imaging biomarkers. For the time being, the system comprises 24 SR templates and provides service in 37 hospitals and healthcare institutions, endorsing the success of this contribution to mitigate some of the limitations of the SR.

Clinical utility of comprehensive circulating tumor DNA genotyping compared with standard of care tissue testing in patients with newly diagnosed metastatic colorectal cancer

BACKGROUND

Comprehensive biomarker testing is essential in selecting optimal treatment for patients with metastatic colorectal cancer (mCRC); however, incomplete genotyping is widespread, with most patients not receiving testing for all guideline-recommended biomarkers, in part due to reliance on burdensome sequential tissue-based single-biomarker tests with long waiting times or availability of only archival tissue samples. We aimed to demonstrate that liquid biopsy, associated with rapid turnaround time (TAT) and lower patient burden, effectively identifies guideline-recommended biomarkers in mCRC relative to standard of care (SOC) tissue testing.

PATIENTS AND METHODS

Prospectively enrolled patients with previously untreated mCRC undergoing physician discretion SOC tissue genotyping submitted pretreatment blood samples for comprehensive circulating tumor DNA (ctDNA) analysis with Guardant360 and targeted RAS and BRAF analysis with OncoBEAM.

RESULTS

Among 155 patients, physician discretion SOC tissue genotyping identified a guideline-recommended biomarker in 82 patients, versus 88 identified with comprehensive ctDNA (52.9% versus 56.8%, noninferiority demonstrated down to α = 0.005) and 69 identified with targeted PCR ctDNA analysis (52.9% versus 44.5%, noninferiority rejected at α = 0.05). Utilizing ctDNA in addition to tissue increased patient identification for a guideline-recommended biomarker by 19.5% by rescuing those without tissue results either due to tissue insufficiency, test failure, or false negatives. ctDNA median TAT was significantly faster than tissue testing when the complete process from sample acquisition to results was considered (median 10 versus 27 days, P < 0.0001), resulting in accelerated biomarker discovery, with 52.0% biomarker-positive patients identified by ctDNA versus 10.2% by SOC tissue 10 days after sample collection (P < 0.0001).

CONCLUSIONS

Comprehensive ctDNA genotyping accurately identifies guideline-recommended biomarkers in patients with mCRC at a rate at least as high as SOC tissue genotyping, in a much shorter time. Based on these findings, the addition of ctDNA genotyping to clinical practice has significant potential to improve the care of patients with mCRC.

Pregnancy and placental development in horses: an update

Horses have been domesticated by man and historical information mostly associates horses with men. Nowadays, however, horse riding is essentially by women. Women are also very much involved in equine sciences, with a large contribution to the understanding of fetoplacental development. While highlighting the work of female scientists, this review describes the recent advances in equine fetoplacental studies, focusing on data obtained by new generation sequencing and progress on the understanding of the role of placental progesterone metabolites throughout gestation. A second emphasis is made on fetal programming, a currently very active field, where the importance of maternal nutrition, mare management or the use of embryo technologies has been shown to induce long term effects in the offspring that might affect progeny's performance. Finally, new perspectives for the study of equine pregnancy are drawn, that will rely on new methodologies applied to molecular explorations and imaging.

Boosting mitochondria activity by silencing MCJ overcomes cholestasis-induced liver injury

BACKGROUND & AIMS

Mitochondria are the major organelles for the formation of reactive oxygen species (ROS) in the cell, and mitochondrial dysfunction has been described as a key factor in the pathogenesis of cholestatic liver disease. The methylation-controlled J-protein (MCJ) is a mitochondrial protein that interacts with and represses the function of complex I of the electron transport chain. The relevance of MCJ in the pathology of cholestasis has not yet been explored.

METHODS

We studied the relationship between MCJ and cholestasis-induced liver injury in liver biopsies from patients with chronic cholestatic liver diseases, and in livers and primary hepatocytes obtained from WT and MCJ-KO mice. Bile duct ligation (BDL) was used as an animal model of cholestasis, and primary hepatocytes were treated with toxic doses of bile acids. We evaluated the effect of MCJ silencing for the treatment of cholestasis-induced liver injury.

RESULTS

Elevated levels of MCJ were detected in the liver tissue of patients with chronic cholestatic liver disease when compared with normal liver tissue. Likewise, in mouse models, the hepatic levels of MCJ were increased. After BDL, MCJ-KO animals showed significantly decreased inflammation and apoptosis. In an in vitro model of bile-acid induced toxicity, we observed that the loss of MCJ protected mouse primary hepatocytes from bile acid-induced mitochondrial ROS overproduction and ATP depletion, enabling higher cell viability. Finally, the in vivo inhibition of the MCJ expression, following BDL, showed reduced liver injury and a mitigation of the main cholestatic characteristics.

CONCLUSIONS

We demonstrated that MCJ is involved in the progression of cholestatic liver injury, and our results identified MCJ as a potential therapeutic target to mitigate the liver injury caused by cholestasis.

LAY SUMMARY

In this study, we examine the effect of mitochondrial respiratory chain inhibition by MCJ on bile acid-induced liver toxicity. The loss of MCJ protects hepatocytes against apoptosis, mitochondrial ROS overproduction, and ATP depletion as a result of bile acid toxicity. Our results identify MCJ as a potential therapeutic target to mitigate liver injury in cholestatic liver diseases.

89 Effect of embryo transfer and recipient breed on offspring performance in equine show jumping

Maternal preconceptional, gestational, and postnatal environments alter offspring phenotype in humans and animals. In particular, embryo technologies were shown in horses and other species to affect offspring growth and metabolism. Quantitative genetic calculations in a database containing genealogy and a measured trait (performance) of individuals enable geneticists to estimate the respective contribution of (A) genetic aptitude for the trait (inherited from all parents), (B) genetic maternal aptitude (additional contribution of the mother and her ancestors, acting through pregnancy, lactation, and nursing), and (C) the permanent maternal environment (similarities between the offspring of a dam that are not attributed to genetics) to the variability of this trait in this population. Additionally, fixed effects can be introduced and estimated to take into account additional factors acting on individual performance. The aim of this project was to apply this method to estimate the respective contributions of A, B, and C as well as the fixed effects of maternal parity (D), age at foaling (E), foaling interval (F), embryo transfer (G), and breed of recipient mare (for ET recipients) on the adult offspring sport performance in show jumping horses. The data came from the French Horse Database established in 1976 for genealogy and performance; calculation was done using WOMBAT® software. The performance of 207,984 horses (4.5 years per horse), born to 90,438 dams (of which 4187 were ET recipients, the others being bred by AI or natural service), were studied. Performance was expressed as follows. For each event, points were distributed depending on the horse’s rank within the event and the event’s difficulty. The logarithm of the sum of points of the year has a Gaussian distribution and is then normalised to mean=0 and standard deviation=1. The genetic maternal aptitude and permanent maternal environment showed a small but significant contribution to the variance of performance (1.4 and 1.5%, respectively) compared to a direct genetic contribution of 24.4%. Within each age class of dam, offspring of primiparous mares have a handicap (−0.04 to −0.06) compared to multiparous mares. Within multiparous mares, a foaling interval of 1 year only provided a small advantage (+0.01, nonsignificant) compared to longer intervals (&gt;2 years). The effect of embryo transfer was strong and significant (+0.24), which could reflect the better management of the horses produced by embryo transfer because of their genetic and financial value rather than a physiologic effect. The performance of offspring born to draft and warmblood recipients (+0.27v. +0.24, nonsignificant) were not different. In conclusion, although jumping performance occurs several years after birth, maternal effects are still measurable and embryo transfer is associated with a strongly increased performance independent of genetic value, probably due to better management of these horses. No effect of recipient mare’s breed was found.

Maternal obesity increases insulin resistance, low-grade inflammation and osteochondrosis lesions in foals and yearlings until 18 months of age

INTRODUCTION

Obesity is a growing concern in horses. The effects of maternal obesity on maternal metabolism and low-grade inflammation during pregnancy, as well as offspring growth, metabolism, low-grade inflammation, testicular maturation and osteochondrotic lesions until 18 months of age were investigated.

MATERIAL AND METHODS

Twenty-four mares were used and separated into two groups at insemination according to body condition score (BCS): Normal (N, n = 10, BCS ≤4) and Obese (O, n = 14, BCS ≥4.25). BCS and plasma glucose, insulin, triglyceride, urea, non-esterified fatty acid, serum amyloid A (SAA), leptin and adiponectin concentrations were monitored throughout gestation. At 300 days of gestation, a Frequently Sampled Intravenous Glucose Tolerance Test (FSIGT) was performed. After parturition, foals' weight and size were monitored until 18 months of age with plasma SAA, leptin, adiponectin, triiodothyronine (T3), thyroxine (T4) and cortisol concentrations measured at regular intervals. At 6, 12 and 18 months of age, FSIGT and osteoarticular examinations were performed. Males were gelded at one year and expression of genes involved in testicular maturation analysed by RT-qPCR.

RESULTS

Throughout the experiment, maternal BCS was higher in O versus N mares. During gestation, plasma urea and adiponectin were decreased and SAA and leptin increased in O versus N mares. O mares were also more insulin resistant than N mares with a higher glucose effectiveness. Postnatally, there was no difference in offspring growth between groups. Nevertheless, plasma SAA concentrations were increased in O versus N foals until 6 months, with O foals being consistently more insulin resistant with a higher glucose effectiveness. At 12 months of age, O foals were significantly more affected by osteochondrosis than N foals. All other parameters were not different between groups.

CONCLUSION

In conclusion, maternal obesity altered metabolism and increased low-grade inflammation in both dams and foals. The risk of developing osteochondrosis at 12 months of age was also higher in foals born to obese dams.

65 Placental Function at Term is Altered in Broodmares Fed with Cereals from Mid Gestation

Recent data obtained in our laboratory suggest that feeding pregnant broodmares with cereal concentrates may affect both mare and foal metabolism in the short and long term. Here, we investigated feto-placental biometry and placental function at term in mares fed with cereals and forage or forage only. Twenty-two multiparous mares inseminated with the same stallion were allocated to 1 of 2 groups from 7 months of gestation: group F (n = 10) were fed forage only, whereas group B (n = 12) received forage and cracked barley until foaling. At 3 and 9 months of gestation, a glucose tolerance test (IVGTT) was performed to evaluate the insulin resistance of pregnant mares. At birth, placentas and foals were weighed and measured. Placental samples were collected above the umbilical cord insertion and snap frozen. An RNA sequencing (RNAseq) analysis was performed on 9 placentas of each group. After normalization, gene levels were analysed using the DESEqn 2 package of R software (https://www.r-project.org/). Enrichment of gene sets was analysed using the Gene Set Enrichment Analysis (GSEA) software using the Kyoto Encyclopaedia of Genes and Genomes (KEGG) and Gene Ontology [GO, biological processes (bp), molecular function (mf) and cellular components (cc)] databases. Gene analysis statistical results were considered significant for P-values < 0.05 after false rate discovery (fdr) correction. The IVGTT results were analysed using a type 3 ANOVA on a mixed linear model with group as fixed effect and age of the mare as random effect. At 3 months of gestation, maternal glucose metabolism was not different between groups. At 9 months, B mares had a higher insulin area under the curve (AUC) after glucose injection than F mares (P < 0.01), without any difference in glucose AUC, suggesting that B mares were more insulin resistant than F mares. At birth, no difference was observed for feto-placental biometry between groups. Gene-level analysis could not discern differences in gene expression between groups after fdr correction. The GSEA analysis, however, showed that 8 gene sets were down-regulated in C placentas (2 KEGG, 2 GObp, 3 GOmf, 1 GOcc) and 193 gene sets were up-regulated (15 KEGG, 144 GObp, 12 GOmf, 22 GOcc) in B placentas. The down-regulated gene sets were involved in neutral amino acids and anion transport, fatty acid oxidation, acetyl coA synthesis, cholesterol and folate degradation, and the up-regulated gene sets were involved in RNA expression, inflammation (activation and recruitment of immune cells, MAPK signalling, complement and coagulation cascades, pro-inflammatory cytokine production and signalling) and in vascularisation (vasculogenesis, angiogenesis and smooth muscle cells development). The results are consistent with the altered function observed in term placentas of women who suffer from gestational diabetes. In conclusion, feeding pregnant mares with cereal from mid gestation alters the placental function at term. The authors thank the GeT platform (Toulouse, France) for the sequencing of the samples.

Placental structure and function in different breeds in horses

Ponies and sometimes draft horses are often used as experimental models for horses although size and metabolic parameters are known to vary between horse breeds. So far, there is little information about differences of placental structure and no information about differences of placental function between breeds. The aim of this study was to investigate differences in placental size, structure and function at birth in relation to foal size and weight in ponies, Saddlebred and draft horses. Pony, Saddlebred and draft horse pregnancies were obtained by artificial insemination over 2 successive breeding seasons. Foals and total fetal membranes (TFM) were weighed and placentas measured for surface area at term. Placentas were sampled above the umbilical cord insertion. Surface density and volume fraction of the different cellular components of the placenta were measured on histological sections using stereology. The expression of genes involved in growth and development, nutrient transfer and vascularization was compared between groups. Foals and TFM were lighter at birth in ponies than Saddlebred horses, and both were lighter compared to draft horses. The surface density and volume fraction of microcotyledonary vessels was increased in pony compared to Saddlebred placentas. The relative expression of genes involved in growth and development was different between breeds and increased with maternal, fetal and placental weight. Primiparous dams produced lighter foals and smaller placentas, associated with a decreased volume fraction of microcotyledonary vessels and genes involved in growth and development and vascularization. Foal sex had little effect on placental structure and function as the expression of only one gene differed according to sex, with EGFR expression being decreased in placentas of females compared to males. In conclusion, foal and placental weight, as well as placental expression of genes involved in growth and development were correlated with maternal size. Placental structure also differed between breeds, with a stronger difference between ponies and both breeds of horses.

67 MATERNAL OBESITY AT CONCEPTION AND INSULIN SENSITIVITY IN LATE GESTATION ALTERS PLACENTAL STRUCTURE BUT NOT FETAL BIOMETRY AT BIRTH IN THE HORSE

Obesity is a major health issue in the horse industry, often associated with insulin resistance. This study aimed to analyse effects of maternal obesity at insemination and insulin resistance during late gestation on term placenta and foals at term. A total of 24 multiparous saddlebred mares were allocated to 1 of 2 groups at insemination: group obese (O) had a body condition score (BCS, French scale 1–5) >4 (N = 15), and group normal (N) had a BCS = 4 (N = 9). From insemination until the sixth month of gestation, all the mares had access to pasture. From wintering, they were housed in box stalls and fed the same amount of energy, proteins, and fibre as a percentage of their body weight. During all the gestation, BCS, basal blood glucose, insulin, triglycerides, and nonesterified fatty acid plasma concentrations were measured each month. At 300 days of gestation, a frequent sampling glucose tolerance test, enabling the simultaneous evaluation of insulin sensitivity (IS) and glucose tolerance, was performed. At birth, placentas and foals were measured. Placentas were sampled around the umbilical cord to perform structural and functional analyses by stereology and RT-qPCR. Results were analysed using a type 3 ANOVA taking into account mare group and foal sex. Effects were considered significant when P < 0.05. At 300 days of gestation, the frequent sampling glucose tolerance test indicated that half of the O mares were insulin resistant (IS <1; N = 8), whereas the other half were insulin sensitive (IS >1; N = 7). Based on these results, O mares were subdivided in 2 groups: obese resistant and obese sensitive (OS). Obese resistant mares were 61% less insulin sensitive than N mares and 59% less insulin sensitive than OS mares (P < 0.0001, P < 0.01, respectively). There was no difference for IS between N and OS mares. All analyses were thus performed comparing the 3 groups. In the N group, 3 mares were insulin resistant (one-third of the mares of the N group). Feed intake during wintering was not different between groups. Mares of both O groups maintained a high BCS (>4) during pregnancy, whereas N mares lost BCS down 2.75 at birth (<0.001). Basal glucose, insulin, triglycerides, and nonesterified fatty acid plasma were not different during gestation. At birth, no difference was observed for placental weight, surface and volume, nor for foal weight and withers height. The volume of allantoic vessels was reduced in placentas of OS mares compared with those of OR (P = 0.03; 78%) and N mares (P = 0.005; 65%). Moreover, placentas from OS mares had an increased volume of haemotrophic trophoblast (P = 0.03) and microcotyledonary vessels (P = 0.03) compared with N mares. No difference of expression was observed for 11 genes related to nutrient transfer, vascularization, growth, and development. Mare that are obese at insemination and insulin sensitive in late gestation appear to develop placental structural adaptations during gestation, possibly to increase fetoplacental exchanges, compared with obese, insulin resistant mares and lean mares. The monitoring of foal development (growth, metabolism, and osteoarticular status) is ongoing.

Equation of state and critical point behavior of hard-core double-Yukawa fluids

A theoretical study on the equation of state and the critical point behavior of hard-core double-Yukawa fluids is presented. Thermodynamic perturbation theory, restricted to first order in the inverse temperature and having the hard-sphere fluid as the reference system, is used to derive a relatively simple analytical equation of state of hard-core multi-Yukawa fluids. Using such an equation of state, the compressibility factor and phase behavior of six representative hard-core double-Yukawa fluids are examined and compared with available simulation results. The effect of varying the parameters of the hard-core double-Yukawa intermolecular potential on the location of the critical point is also analyzed using different perspectives. The relevance of this analysis for fluids whose molecules interact with realistic potentials is also pointed out.

Implementation of an Execution Engine for SNOMED CT Expression Constraint Language

The need to achieve high levels of semantic interoperability in the health domain is regarded as a crucial issue. Nowadays, one of the weaknesses when working in this direction is the lack of a coordinated use of information and terminological models to define the meaning and content of clinical data. IHTSDO is aware of this problem and has recently developed the SNOMED CT Expression Constraint Language to specify subsets of concepts. In this paper, we describe an implementation of an execution engine of this language. Our final objective is to allow advanced terminological binding between archetypes and SNOMED CT as a fundamental pillar to get semantically interoperable systems. The execution engine is available at http://snquery.veratech.es.

110 BARLEY SUPPLEMENTATION AT MID-GESTATION IN BROODMARES DOES NOT AFFECT FETAL DEVELOPMENT AND IS ACCOMPANIED BY MINIMAL PLACENTAL ADAPTATIONS

Modifications of maternal environment could alter fetal growth and development through the placenta and thus health in adulthood. The developmental origins of health and disease suggest that maternal nutrition during pregnancy may affect offspring development and subsequent energy metabolism. To understand the effect of common feeding practices during gestation, 24 saddlebred mares were allocated to 1 of 2 groups: group B was supplemented twice a day with barley (B) and group F was fed only with fodder (F) between month 7 of gestation and foaling. B mares maintained an optimal body condition score through gestation, with an increase in glycaemia and insulinemia after each meal and insulin resistance in month 9 of gestation. F mares lost condition as assessed by body condition score in the last part of gestation, leading to a moderate undernutrition and a transitional increase in nonesterified fatty acid plasma concentrations. Diets had no effect on feto-placental biometry or on placental structure. In contrast, an increase in microcotyledonary vessel volume was observed in F placentas, indicating placental adaptation, possibly to increase fetomaternal exchanges. There was no overall difference in the expression of genes involved in vascularization, nutrient transfer, growth, and development between placentas from B and F mares. Nevertheless, as seen in other species, sex-specific effects of maternal nutrition were observed in placentas from female foals, with differences in the expression of endogline, kinase insert domain receptor, insulin-like growth factor 2 and insulin-like growth factor 1 receptor genes. This study demonstrates that breeding practices such as supplementation in concentrate at mid-gestation do not seem to affect fetal development. More work is ongoing to evaluate postnatal health.

Idiosyncratic drug hepatotoxicity: a 2008 update

Pharmaceutical preparations, and also herbal products and dietary supplements, are emerging contributors to severe forms of liver disease. Although acetaminophen intoxication is still the reason for many cases of drug-induced liver injury (DILI) in Western countries, the bulk of hepatic reactions to drugs are idiosyncratic. Only a small fraction of individuals exposed to a drug associated with liver injury will develop hepatotoxicity. Indeed, the rarity of this serious adverse event prevents its detection in clinical trials. The pathogenesis of idiosyncratic DILI is not well known because of a lack of reliable animal models, although it probably involves the metabolism of the drug and/or activation of the immune system. Different databases have described antibiotics, NSAIDs and anticonvulsants as the main group of drugs incriminated in DILI. Clinical presentation of DILI includes predominantly a hepatocellular type of damage, yet cholestatic and mixed types are also common; the determinants of the type of damage induced by a given drug are poorly understood. Analysis of pooled data has recently underlined the influence of older age in the cholestatic/mixed expression of liver injury, as well as the independent association of female gender, older age, aspartate aminotransferase levels with hepatocellular type of damage and high bilirubin levels with the risk of fulminant liver failure/death. In the long term (providing the patient survives the initial episode), persistent damage may occur in at least 6% of patients, with the cholestatic mixed type of damage more prone to becoming chronic, while in the hepatocellular pattern the severity is greater, with further likelihood of evolution to cirrhosis. Cardiovascular and CNS drugs are the main groups leading to chronic liver damage. The diagnosis of hepatotoxicity remains a difficult task owing to the lack of reliable markers for use in general clinical practice. Diagnostic algorithms may add consistency to clinical judgment by translating a suspicion into a quantitative score. Currently, the Council for International Organizations of Medical Sciences/Roussel Uclaf Causality Assessment Method instrument is considered the gold standard in causality assessment of hepatotoxicity, although there is probably room for improvement. Current efforts in collecting bona fide cases will make refinements of existing scales feasible. Efforts should also be directed towards the development of an abridged instrument for use in evaluating suspected drug-induced hepatotoxicity at the very beginning of the diagnosis and treatment process when clinical decisions need to be taken. The treatment of idiosyncratic DILI is largely supportive. Early suspicion and withdrawal of the offending agent is the most important therapeutic measure.

Sustained disease remission and inhibition of radiographic progression in methotrexate-naive patients with rheumatoid arthritis and poor prognostic factors treated with abatacept: 2-year outcomes

OBJECTIVE

To assess the efficacy and safety of abatacept plus methotrexate versus methotrexate alone in early erosive rheumatoid arthritis (RA).

METHODS

The AGREE was a 2-year phase IIIb multinational study in early (≤ 2 years) RA. During the double-blind period (year 1), patients were randomly assigned 1:1 to receive abatacept+methotrexate or methotrexate alone; all patients received open-label abatacept+methotrexate during year 2. Clinical outcomes assessed included 28-joint disease activity score (DAS28) defined remission, low disease activity score (LDAS), American College of Rheumatology (ACR) responses and physical function. Radiographic outcomes were assessed using the Genant-modified Sharp total score (TS). Safety was monitored throughout.

RESULTS

Of the 459 patients completing year 1, 433 patients (94.3%) completed year 2. DAS28-defined remission, LDAS, ACR and physical function were sustained through year 2 in the original abatacept+methotrexate group, with 55.2% in remission at 2 years. Upon introduction of abatacept in the methotrexate-alone group, additional patients achieved DAS28-defined remission (44.5% vs 26.9%), LDAS (60.4% vs 43.2%) and improved ACR 70 (49.8% vs 31.7%) for year 2 versus year 1. Less radiographic progression was observed at 2 years in the original abatacept+methotrexate group than the methotrexate-alone group (change in TS 0.84 vs 1.75, p<0.001). No new safety issues were seen. Similar rates of serious adverse events, serious infections and autoimmune events were observed in years 1 and 2.

CONCLUSIONS

The AGREE trial was the first to examine the impact of T-cell co-stimulation modulation with abatacept in patients with early erosive RA. Early treatment with abatacept+methotrexate resulted in greater sustainable clinical, functional and radiographic benefits than methotrexate alone, with acceptable safety and tolerability.

TRIAL REGISTRATION

NCT00122382.

Kinking of carotid arteries is not a mechanism of cerebral ischemia: a functional evaluation by Doppler echography

AIM

The aim of this paper was to evaluate the hemodynamic behavior of carotid kinking, as assessed by color Doppler ultrasonography at baseline and during neck movements, and their relation to neurological symptoms.

METHODS

In this cross-sectional study, 60 consecutive patients with non-atheromatous carotid kinking in whom diagnostic color Doppler ultrasonography investigation of neck vessels had been requested for clinical suspicion of atherosclerotic disease were evaluated. To evaluate if there were significant changes of blood velocities as a consequence of kinking, for each carotid artery we recorded systolic and diastolic velocities both in the segments proximal to kinking, as well as intra-kinking. The effects of postural changes and neck movements on carotid blood flow were also studied.

RESULTS

Flow in carotid arteries with kinking was always normal, and no differences were found between flow velocity measured at the level of kinking compared to the normal tract of the vessel. During head rotation tests, flow remained largely unaffected, a substantial reduction in the velocities in the ophthalmic artery was found in 13.5% of the cases, while an increase was recorded in 27%; and no symptoms or events were recorded during the study. None of the patients referred symptoms, nor were neurological events or signs detected during the maneuvers.

CONCLUSION

Our results show that carotid kinks are not a mechanism of acute cerebral ischemia, and therefore are unlikely to be a cause of neurological events or symptoms.

[Magnetic resonance imaging postprocessing techniques in the study of brain connectivity]

Brain connectivity is a key concept for understanding brain function. Current methods to detect and quantify different types of connectivity with neuroimaging techniques are fundamental for understanding the pathophysiology of many neurologic and psychiatric disorders. This article aims to present a critical review of the magnetic resonance imaging techniques used to measure brain connectivity within the context of the Human Connectome Project. We review techniques used to measure: a) structural connectivity b) functional connectivity (main component analysis, independent component analysis, seed voxel, meta-analysis), and c) effective connectivity (psychophysiological interactions, causal dynamic models, multivariate autoregressive models, and structural equation models). These three approaches make it possible to combine and use different statistical techniques to elaborate mathematical models in the attempt to understand the functioning of the brain. The findings obtained with these techniques must be validated by other techniques for analyzing structural and functional connectivity. This information is integrated in the Human Connectome Project where all these approaches converge to provide a representation of all the different models of connectivity.

Impact of Acute Hepatitis A Virus (HAV) Infection on HIV Viral Load in HIV-Infected Patients and Influence of HIV Infection on Acute HAV Infection

Purpose: To assess the effect of hepatitis A virus (HAV) infection on HIV viral load (VL) and the influence of HIV on the clinical expression of HAV infection. Methods: Single-center study of 23 HIV-positive patients and 41 HIV-negative patients diagnosed with acute HAV infection during 2008-2009. The impact of HAV on HIV VL was defined as an increase of >0.5 log10 during the event, or a detectable VL for those previously suppressed patients. Results: The impact of acute HAV on VL was observed in 37.5% patients. HIV-negative patients were younger (27 vs 34 years, P < .0001), and serum transaminases levels normalized earlier than in the HIV-positive patients (121 vs 178 days, P < .05). Conclusions: Acute HAV infection may have an impact on HIV VL. The interactions between the 2 viruses may not only prolong the HAV viremia, with a potential increase in the transmission of infection, but the impact on HIV may increase the risk of HIV transmission. Studies with higher sample size are needed to confirm our results.

Antibiotic-induced liver toxicity: mechanisms, clinical features and causality assessment

Antibiotics are the therapeutic agents most often associated with hepatotoxicity. However, this is mainly due to the widespread prescription of these drugs. The relative risk of antibiotic-related hepatotoxicity is low. Causality assessment of suspected drug-induced liver injury (DILI) related to antibiotics can be difficult, particularly because some cases occur long after the drug has been stopped. Among the penicillins, amoxicillin clavulanate is the most associated with hepatotoxicity and is the most frequent cause of DILI-related hospitalisations. Flucloxacillin ranks as the second highest cause of DILI in many countries. The severity of antibiotic-induced DILI varies widely, with the hepatitis-like (hepatocellular) damage tending to be more severe that than cholestatic/mixed type. The pattern is strongly influenced by age. Recently telithromycin (a new generation macrolide) has been linked with DILI, with a typical pattern, which includes abrupt commencement of fever, abdominal pain, jaundice and, in some cases, ascites. Antibiotic-induced DILI appears, in most instances, to be idiosyncratic. Genetic-association studies have recently identified genotypes related to flucloxacillin and possibly to amoxicillin-clavulanate hepatotoxicity.

[Tuberculous peritonitis in HIV-infected patients]

In order to describe the clinical and laboratory findings of Mycobacterium tuberculosis peritonitis M. tuberculosis in HIV+ patients, we conducted a retrospective analysis of the medical records of HIV+ patients with isolation of M. tuberculosis from ascitic fluid (AF), assisted at Hospital Muñiz, Buenos Aires, Argentina (1996-2005).

RESULTS

21 patients were included. Median age: 33, male sex: 52%; peripheral blood CD4-T lymphocyte count (median): 85/mm3; prior history of tuberculosis: 40%; cirrhosis: 65%; enolism: 45%; HCV coinfection: 85%. The most frequent symptoms were abdominal distension (71%), fever (62%) and abdominal pain (19%). The chemical characteristics of the AF were (median): leukocyte count: 751/mm3 (mononuclear predominance: 79%), protein: 3.1 g/dl, LDH: 351 IU/l. AF samples positive for acid fast bacilli at direct microscopic examination: 14%. Infection with multidrug resistant M. tuberculosis (TB-MR): 20%. M. tuberculosis was isolated from other clinical samples in 79%. Fifteen patients received treatment for tuberculosis; in 30% of cases, it was not appropriate due to the susceptibility of the isolated strain. Overall mortality was 66.4%.

CONCLUSION

high mortality was observed, which may be attributable to the high frequency of TB-MR, the level of immunosuppression and the prevalence of cirrhosis secondary to enolism and/or HCV coinfection.