A holistic molecular modelling approach to design novel indole-2-carboxamide derivatives as potential inhibitors of MmpL3

Tuberculosis is an infectious air-borne disease and one of the leading causes of death globally among all infectious diseases. There is an urgent need to develop antitubercular drugs that would be highly efficient and less toxic than the presently available marketed drugs. Mycobacterium membrane protein large 3 (MmpL3) is an emerging drug target in tuberculosis with various classes of molecules that have been known to inhibit it. In this study, a dataset of indole-2-carboxamides showing antitubercular activity by inhibiting MmpL3 was utilized. Initially, a chimera-based homology model was developed and docking was performed with the filtered dataset to analyse the interactions. Thereafter, molecular dynamics simulations were run with representative molecules to gain a better insight on the binding patterns. To attain a more quantitative correlation, an atom-based 3D QSAR model was developed which complemented the results from the previous models. A library of novel indole-2-carboxamides was then generated using core hopping-based ligand enumeration and upon screening on our workflow model it predicted three molecules as potent antitubercular compounds. This work not only helps to gain new insights on the interactions at the MmpL3 binding site but also provides novel indole-2-carboxamides having the potential to become antitubercular drugs in future.

Protocol design and preliminary evaluation of the REAL-Health Triple Aim, an open-cohort CVD-care optimisation initiative

Introduction

Effective treatment of cardiovascular disease (CVD) in primary care could be improved. We aim to assess the efficacy of a scalable treatment optimisation programme in unselected community populations in South East England, with the triple aim of improved blood pressure control in people with hypertension, increased high-intensity statin use in people with CVD and reduced gastrointestinal bleeding in patients on antithrombotic medication.

Method

This observational study comprises an open cohort of approximately 200,000 adults at high cardiovascular risk registered with general practitioners in five South East England Clinical Commissioning Groups (CCGs). An intervention programme is planned in four of these CCGs with a further non-intervention CCG acting as a control group. The intervention will consist of: clinical guidelines and educational outreach; virtual patient-reviews software; peer-performance “dashboards” and, where available, financial incentives.

The study will examine 3 primary outcomes: 1. Diagnosed hypertension with a blood pressure <140/90mmHg; 2. Diagnosed CVD on a high-intensity statin; 3. A cardiovascular indication for antithrombotic therapy with one or more factors for increased risk of gastrointestinal bleeding (e.g. age ≥65) on gastroprotection. A further 17 secondary outcomes related to these three aims will be assessed.

Analysis

We will use an interrupted time series analysis over 18 months, representing the pre-implementation, implementation and the post-implementation phases with comparison to the control CCG and applicable national Quality and Outcomes Framework and national prescribing statistics (e.g. OpenPrescribing). Secondary outcomes include an equity impact analysis with results stratified by age, gender, ethnic group and index of deprivation.

Preliminary data

We present preliminary data on Key Performance Indicators (KPIs) collected from 191 GP practices including [percentage achievement on 01/09/2019, on 01/09/2020]: 1. Patients with hypertension and most recent blood pressure ≤140/90mmHg [68.7%, 60.6%]. 2. Patients eligible for treatment with a high-intensity statin on such treatment [53.8%, 55.8%]. 3. Patients on antithrombotics with ≥1 risk factors for gastrointestinal bleeding on gastroprotection [59.0%, 60.1%]. We also present our virtual patient-review software tool and outcome visualisation dashboard.

Conclusion

The REAL-Health Triple Aim initiative is a large-scale primary care cardiovascular risk reduction initiative which was launched almost contemporaneously with the United Kingdom's first SARS-CoV-2 related lockdown. Preliminary data justify the need for the Triple Aim initiative and give us an insight on the impact of the pandemic on its implementation.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Barts CharityBritish Heart Foundation

Integrated quality assessment for diabetes care in Portuguese primary health care using prevention quality indicators

AIMS

This study evaluates the prevention quality indicators (PQI) for Diabetes Mellitus (DM) in Portugal using contemporary data and explores their variability according to Primary Health Care (PHC) quality indicators.

METHODS

We conducted a retrospective observational analysis of secondary data comprising Portuguese PHC indicators by health centres group (ACES) and the National Hospital Morbidity Database. We calculated and analysed age-sex-adjusted rates for each PQI. Worse-performing ACES were identified using the 2017 median PQI values as an assessment cut-off. A multivariate logistic analysis was carried to find variables associated with the likelihood of being a worse-performing ACES for the biennium.

RESULTS

The median values of the indicator PQI93 - Prevention Quality Diabetes Composite were 79 and 65.2 hospitalizations per 100 000 pop, in 2016 and 2017 respectively. Diabetes long term complications (PQI 03) accounted for most of the hospitalizations. The quality indicator in PHC with greater influence on PQI93 was the proportion of DM patients with <65 years with test results for HbA1c < = 6.5%.

CONCLUSIONS

This study shows that some PHC quality indicators are closely related to DM care, and so their monitoring is of high importance. Diabetes long term complications (PQI 03) demand greater attention from PHC professionals.

Primary care organizational model mix and avoidable hospitalization: an ecological study in Portugal

Background

In Portugal, there are different organizational models in primary health care (PHC), mainly regarding the payment scheme. USF-B is the only type with financial incentives to the professional (pay-for-performance). Our goal was to assess the relationship between groups of primary healthcare centres (ACES) with higher proportion of patients within USF-B model and the rate of avoidable hospitalizations, as proxy of primary care quality.

Methods

We conducted a cross-sectional study considering the 55 ACES from mainland Portugal, in 2017. We used data from public hospitalizations to calculate the prevention quality indicator (avoidable hospitalizations) adjusted for age and sex, using direct standardization. The main independent variable was the proportion of patients in one ACES registered in the USF-B model. Unemployment rate, proportion of patients with family doctor and presence of Local Health Unit (different organization model) within ACES were also considered. The association was assessed by means of a linear regression model.

Results

Age-sex adjusted PQI value varied between 490 and 1715 hospitalizations per 100,000 inhabitants across ACES. We observed a significant effect of the proportion of patients within USF-B in the crude PQI rate (p = 0.001). However, using the age-sex adjusted PQI, there was not a statistical significant association (p = 0.504). This last model was also adjusted for confounding variables and the association remains non-significant (p = 0.865).

Conclusions

Our findings suggest that, when adjusting for age and sex, there is no evidence that ACES with more patients enrolled in a pay-for-performance model is associated with higher quality of PHC (using avoidable hospitalizations as proxy). Further studies addressing individual data should be performed.

This work was financed by FEDER funds through the COMPETE 2020 - POCI, and by Portuguese funds through FCT in the framework of the project POCI-01-0145-FEDER-030766 “1st.IndiQare”.

Key messages

Adjusting PQI to sex and age seems to influence its value more than the type of organizational model of primary health care. Groups of primary healthcare centres with more units under the pay-for-performance scheme was not associated with different rate of avoidable hospitalizations.

Time trends of primary care quality across Portuguese regions: using prevention quality indicators

Background

Primary care quality is one of the main dimensions of primary care performance and can be evaluated by several methods, e.g. studying hospitalizations for conditions that could be treated, or less severe, if appropriately managed in primary care. Accordingly, the Agency for Healthcare Research and Quality (AHRQ) developed prevention quality indicators (PQIs). In this study, we aimed to compare PQIs and their time trends across Portuguese regions.

Methods

We performed a retrospective study, using all adult public hospital discharges in mainland Portugal, between 2011 and 2015. PQI rates for the overall (PQI 90) and composite indicators (i.e. 91 - acute, 92 - chronic, 93 - diabetes) were computed using AHRQ specifications. These rates were compared between the 5 Portuguese NUTS 2 regions of residence.

Results

From the total of 407,792 hospital discharges in mainland Portugal (2011-2015) 11.9% comprised the selected PQIs, the majority related the acute composite PQI, followed by the chronic composite PQI. The hospitalization rate of the overall PQI increased from 999.5 hospitalizations (2011) to 1231,0 hospitalizations/100,000 inhabitants (2015), with an increase in all NUTS 2 regions. In 2015, while Algarve and North had the lowest PQI rates, Centro and Alentejo showed the highest ones.

Conclusions

Between 2011 and 2015, there was an increasing trend of overall and composite PQI rates. Also, important differences between Portuguese regions were found that must be further studied.

The authors thank the support given by the Project ’POCI-01-0145-FEDER-030766’ (1st.IndiQare - Quality indicators in primary health care: validation and implementation of quality indicators as an assessment and comparison tool), funded by Fundação para a Ciência e a Tecnologia (FCT) and co-funded by Fundo de Desenvolvimento Regional (FEDER) through Operacional Competitividade e Internacionalização (COMPETE 2020).

Key messages

Between 2011 and 2015, overall prevention quality indicator rate increased in Portugal. There are great differences between Portuguese NUTS 2 regions regarding prevention quality indicators.

P5999Heart failure rescue by high fat diet in a porcine model of hibernated myocardium

Background

Extensive coronary artery disease without revascularization options results in ischemic hibernated myocardium and ultimately heart failure (HF). A metabolic reprogramming of the heart characterized by a shift from fatty acids (FFA) to glucose as the preferential metabolic substrate is frequent in HF and hibernated myocardium. Previous studies in mouse models of HF have shown that high fat diet (HFD) is able to reverse the metabolic reprogramming of the heart and improve cardiac function. Here we used a translational large animal model of ischemic HF evaluated by state-of-the-art imaging modalities

Methods

IHM was generated in Yucatan minipigs (N=50) by progressive stenosis of the proximal left anterior descending (LAD) after surgical insertion of a casein ameroid around the artery. Pigs underwent a serial multimodality imaging study including magnetic resonance imaging (MRI), multi-tracer PET/CT (18FDG & 14(R,S)-[18F]Fluoro-6-thia-heptadecanoic acid (18F-FTHA) 19F-palmitate in-house synthetized), and invasive coronary angiography (ICA). Once hibernated myocardium with metabolic switch was documented (complete occlusion of LAD, LVEF<50% on MRI, viable myocardium with dobutamine/MRI- evaluated contractile reserve, and metabolic substrate utilization shift towards glucose on PET/CT), animals were randomized to HFD or regular diet for 3 months

Results

The first part of the study was dedicated to establish the model in 42 pigs. Pigs were followed-up for 170±24 days with monthly ICA, MRI and PET/CT. Severe LAD stenosis was documented in all pigs 3–4 weeks after surgery. Mortality during follow-up was 57% (n=24) (15 peri-procedure, 2 between day 1 and 7, seven between day 7 and 45). Among those surviving beyond the sixth week, 90% (16/18) developed hibernated myocardium (mean LVEF 36±10%, absence of transmural delayed enhancement, contractile reserve and metabolic switch on PET/CT).

In the second part of the study, 5 long-term survivors were allocated to receive HFD (20% extra lard), while 3 pigs served as controls. Mean LVEF before HFD initiation was 35±8%, and 36±5% in controls. Three months HFD was associated with a LVEF improvement in all treated animals (mean LVEF at the end of follow-up was 45±9%). Control animals on regular diet did not show any change in LVEF (35±5% at the end of follow-up)

Conclusions

We present a large animal model of HF due hibernated myocardium by placing an ameroid around the LAD. Mortality of this model is high (approx. 55%) but long-term survivors resemble all features seen in patients: LAD progressive stenosis with final occlusion but viable myocardium, LVEF deterioration and metabolic switch

Feeding pigs with HFD to force cardiac reutilization of FFA, results in a consistent and large LVEF improvement in all animals

Cardiac metabolic switch might be implicated in the pathogenesis of systolic dysfunction in hibernated myocardium and is a potential target for nutritional approaches

Association between non-HDL-C/HDL-C ratio and carotid atherosclerosis in postmenopausal middle-aged women

Background: A novel lipid relation, the non-high-density lipoprotein cholesterol to high-density lipoprotein cholesterol (non-HDL-C/HDL-C) ratio gathers information on all atherogenic and antiatherogenic particles on a single date. The relationship between this lipid marker and the presence of carotid atherosclerotic plaque (CAP) in postmenopausal women is unknown. Methods: Postmenopausal women in primary prevention up to 70 years of age were recruited. Association between the non-HDL-C/HDL-C ratio and presence of CAP, assessed by ultrasonography, was analyzed. Receiver operating characteristic (ROC) curve analysis was performed. Results: A total of 440 females with a mean age of 58.1 ± 5.3 years were recruited. The mean non-HDL-C/HDL ratio was 3.1 ± 1.2 and 28.2% of woman had CAP. A positive relationship was seen between quintiles of the non-HDL-C/HDL-C ratio and prevalence of CAP (p < 0.001). Regardless of other risk factors, women with higher non-HDL-C/HDL-C ratios had a greater chance of having CAP (odds ratio 1.30, 95% confidence interval: 1.07-1.58, p = 0.009). In the ROC curve analysis, the area under the curve of the non-HDL-C/HDL ratio for detecting CAP was 0.703 (95% confidence interval: 0.640-0.765) and the optimal cut-off point was 3.0 (Youden index 0.395). Conclusion: The present study suggests that the non-HDL-C/HDL-C ratio might be a strong marker for predicting the risk of CAP in postmenopausal women.

Major seminal plasma proteome of rabbits and associations with sperm quality

The present study was conducted to describe the major seminal plasma proteome of rabbits and potential associations between seminal proteins and semen criteria. Semen samples were collected from 18 New Zealand adult rabbits, and seminal plasma proteins were analyzed by 2-D SDS-PAGE and tandem mass spectrometry. Sperm motility, vigor, concentration, morphology and membrane sperm viability were evaluated. Rabbits ejaculated 364 ± 70 million sperm/ml, with 81 ± 6.1% motile cells, 3.8 ± 0.2 vigor and 66.7 ± 2.5% sperm with normal morphology. Based on the viability and acrosome integrity assay, there were 65.8 ± 2.5% live sperm with intact acrosome and most spermatozoa had both intact acrosome and functional membrane. On average, 2-D gels of rabbit seminal plasma had 232 ± 69.5 spots, as determined by PDQuest software (Bio Rad, USA). Mass spectrometry allowed the identification of 137 different proteins. The most abundant proteins in rabbit seminal plasma were hemoglobin subunit zeta-like, annexins, lipocalin, FAM115 protein and albumin. The intensity of the spots associated with these five proteins represented 71.5% of the intensity of all spots detected in the master gel. Multiple regression models were estimated using sperm traits as dependent variables and seminal plasma proteins as independent ones. Also, sperm motility had positive association with beta-nerve growth factor and cysteine-rich secretory protein 1-like and a negative one with galectin-1. The percentage of rabbit sperm with intact membrane was related to seminal plasma protein FAM115 complex and tropomyosin. Then, the population of morphologically normal sperm in rabbit semen was positively linked to carcinoembryonic antigen-related cell adhesion molecule 6-like and down regulated by seminal plasma isocitrate dehydrogenase. Based on another regression model, the variation in the percentage of live sperm with intact acrosome was partially explained by the amount of leukocyte elastase inhibitor and the peptidyl-prolyl cis-trans isomerase A in the rabbit seminal fluid. The current study reports the identification of 137 proteins of rabbit seminal plasma. Major proteins of seminal secretion relate primarily to prevention of damages caused by lipid peroxide radicals and oxidative stress, membrane functionality, transport of lipids to the sperm membrane and temperature regulation. Moreover, finding seminal plasma proteins as indicators of semen parameters will improve assisted reproductive technologies.

Plasma proprotein convertase subtilisin/kexin type 9 inhibitors and cataract risk: A systematic review and meta-analysis

BACKGROUND

The marked decrease in LDL-C levels produced by the inhibitors of the plasma proprotein convertase subtilisin/kexin type 9 (iPCSK9) could be associated with an increased risk of cataracts.

METHODS

A meta-analysis was performed that included randomised clinical trials controlled with iPCSK9, alone, or in combination with other lipid-lowering drugs, which reported new cases of cataracts, by searching PubMed/Medline, databases of EMBASE and Cochrane Clinical Trials. A fixed-effect model was used, and a meta-regression was carried out evaluating the relationship between intra-treatment LDL-C and the risk of developing cataracts.

RESULTS

Five eligible studies of iPCSK9 including 83,492 patients were taken into account for the analysis, and 531 new cases of cataracts in iPCSK9 group vs. 532 in placebo group were diagnosed. The iPCSK9 therapy was not associated with an increased risk of cataracts [OR: 0.96, 95% CI: 0.85-1.08; P=.86, I²: 0%]. Likewise, no significant association was found between on-treatment LDL-C levels, differences between study arms, and new cases of cataracts.

CONCLUSION

In this analysis, the use of iPCSK9 was not associated with an increased risk of cataracts.

Therapy with cholesteryl ester transfer protein (CETP) inhibitors and diabetes risk

BACKGROUND

Cholesteryl ester transfer protein (CETP) inhibitors are a class of drugs that targets the CETP enzyme to significantly increase serum high-density lipoprotein cholesterol (HDL-C) and decrease low-density lipoprotein cholesterol (LDL-C) levels. As HDL-C has potential antidiabetic properties, and the beneficial effects of CETP drugs on glucose homoeostasis have not been sufficiently studied, the aims of this study were: (1) to evaluate the effect of CETP inhibitors on the incidence of diabetes; and (2) to assess the association between CETP inhibitor-induced changes in HDL-C levels and incidence of diabetes.

METHODS

A meta-analysis was performed of randomized controlled clinical trials of CETP inhibitor therapy, either alone or combined with other lipid-lowering drugs, reporting data from new cases of diabetes with a minimum of 6 months of follow-up, after searching the PubMed/MEDLINE, Embase and Cochrane Controlled Trials databases. A fixed-effects meta-regression model was then applied.

RESULTS

Four eligible trials of CETP inhibitors, involving a total of 73,479 patients, were considered for the analyses, including 960 newly diagnosed cases of diabetes in the CTEP inhibitor group vs 1086 in the placebo group. CETP inhibitor therapy was associated with a significant 12% reduction in incidence of diabetes (OR: 0.88, 95% CI: 0.81-0.96; P=0.005). Assessment of the relationship between on-treatment HDL-C and the effect of CETP inhibitors showed a statistically non-significant trend (Z=-1.13, P=0.26).

CONCLUSION

CETP inhibitors reduced the incidence of diabetes. The improvement in glucose metabolism may have been related, at least in part, to the increase in HDL-C concentration.

The Expansion of Heterotopic Bone in Fibrodysplasia Ossificans Progressiva Is Activin A-Dependent

Fibrodysplasia ossificans progressiva (FOP) is a rare autosomal dominant disorder that is characterized by episodic yet cumulative heterotopic ossification (HO) in skeletal muscles, tendons, and ligaments over a patient's lifetime. FOP is caused by missense mutations in the type I bone morphogenetic protein (BMP) receptor ACVR1. We have determined that the formation of heterotopic bone in FOP requires activation of mutant ACVR1 by Activin A, in part by showing that prophylactic inhibition of Activin A blocks HO in a mouse model of FOP. Here we piece together a natural history of developing HO lesions in mouse FOP, and determine where in the continuum of HO Activin A is required, using imaging (T2-MRI, μCT, ¹⁸ F-NaF PET/CT, histology) coupled with pharmacologic inhibition of Activin A at different times during the progression of HO. First, we show that expansion of HO lesions comes about through growth and fusion of independent HO events. These events tend to arise within a neighborhood of existing lesions, indicating that already formed HO likely triggers the formation of new events. The process of heterotopic bone expansion appears to be dependent on Activin A because inhibition of this ligand suppresses the growth of nascent HO lesions and stops the emergence of new HO events. Therefore, our results reveal that Activin A is required at least up to the point when nascent HO lesions mineralize and further demonstrate the therapeutic utility of Activin A inhibition in FOP. These results provide evidence for a model where HO is triggered by inflammation but becomes "self-propagating" by a process that requires Activin A. © 2017 The Authors. Journal of Bone and Mineral Research Published by Wiley Periodicals Inc.

Abstract P4-20-01: Implications of financial modeling in breast cancer clinical research from 1990 to 2010

SUMMARY: Over the past two decades significant progress has been made in breast cancer treatment resulting in a substantial improvement in patients' outcome. But we have to think about who promotes all this research and the consequences of the type of fundingThis project aims to evaluate the implication of finance in clinical research and the variance according to the type of funding.

OBJETIVES: To evaluate the financial evolvement of breast cancer clinical trials in the past two decades, regarding the phase of development design of the studies, the collaboration between Academy (Acad) and Industry (Ind), the sample size, the study results and the statistical analyses conducted.

METHODS: A systematic review was performed using MEDLINE to identify breast cancer randomized clinical trials published between January1990 and December2010. Studies that involved chemotherapy, endocrine and/or targeted therapies, wherethe primary endpoint was considered adequate to support a drug approval in oncology according to the FDA and EMA (U.S. Food and Drug Administration and European Medicines Agency, respectively), were included.

RESULTS:Data were evaluated 2,211 and 472 met selection criteria comprised in the methodology During the first decade the Acad was the main breast cancer research promoter being replaced by the Inv. throughout the second decade (p &lt;0.0001). Thirty nine percent of the studies evaluated were phase III (39% Acad, 61% Ind), 15% were phase II (30% Acad, 70% Ind) and the remaining 47% were not classified by authors (65% Acad 35% Ind). As for the primary endpoint, 25% of the phase III trials evaluated progression free survival, 15% overall response rate, 1% time to progression and only 5% examined overall survival. Sixty five percent of the trials were national (60% Acad 40% Ind) and 35% international (25% Acad 75% Ind). Single-center studies accounted for 11% of the trial (65% Acad 35% Ind). Most of the national trials were developed by the US. Fifty four percent of the studies were conducted by research groups (67% supported by Ind. and 33% Acad.). The Ind sponsored 26% of the studies in the first decade and 50% during the second. The median number of patients enrolled by research groups was 892 in contrast with 409 included by other organizations. The primary endpoint was achieved in 19% of the Acad trials and 21% of the Ind trials. Only 53% of the studies declared intention to treat based analysis in their statistical workout.

RESULTS  ACADEMY(%)INDUSTRY (%)PPROMOTION OF THE STUDY1990-2000121(26)68(14)0,0001 2001-2010105(22)178(38)0,0001STUDY DESIGNUNICENTRIC TRIALS34(7)18(4)0,007 MULTICENTRIC TRIALS191(40)228(48)  NATIONAL TRIALS183(39)122(26)0,0001 INTERNATIONAL TRIALS42(9)124(26)  COOPERATIVE GROUP95(20)160(34)  NOT COOPERATIVE GROUP130(28)86(18) STATISTICAL ANALYSISINTENT OF TREAT86(18)163(35)  NOT DECLARATED140(30)83(18) 

CONCLUSIONS:There is a significant tendency towards the promotion of research by the pharmaceutical industries during the last two decades, leading a change in the clinical trials design and the endpoints.

Citation Format: Jerez Y, Lopez-Tarruella S, Marquez-Rodas I, Perez S, Ocaña A, Echavarria I, Lobo M, Gallego I, Torres G, Ortega L, Garcia G, Palomero I, Gonzalez Del Val R, Massarrah T, Esteban M, Del Monte-Millan M, Martin M. Implications of financial modeling in breast cancer clinical research from 1990 to 2010 [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-20-01.

Five Years of Multidisciplinary Care in Hereditary Cancer: Our Experience in a Spanish University Hospital

OBJECTIVE

To analyse the evolution of a multidisciplinary heredofamilial cancer unit (HFCU) in a university hospital.

METHODS

This was a retrospective analysis of the activity of our HFCU in its first 5 years of existence.

RESULTS

Between July 2010 and July 2015, 1,518 patients from 1,318 families attended our HFCU. Genetic testing was offered to 862 patients. Of those, 833 (96.6%) accepted testing, with available results for 636 (76.4%). Pathogenic mutations in BRCA1 and BRCA2 were found in 175 patients. Lynch syndrome and adenomatous polyposis were the most frequent syndromes diagnosed (151/175, 86.3%) among 17 different syndromes studied. Of the 404 patients without a previous genetic diagnosis in the family, 62 (15.3%) were found to have mutations in disease-causing genes. Prophylactic surgery and follow-up (33.7%) or follow-up only (66.3%) was proposed for mutation carriers according to international guidelines and patients' preferences.

CONCLUSION

We have a high mutation detection rate, genetic test acceptance, and compliance with risk reduction strategies. However, there is room for improvement, especially in genetic testing timing, considering that an increase in the indications for genetic testing is expected.

Serratia liquefaciens Infection of a Previously Excluded Popliteal Artery Aneurysm

Introduction

Popliteal artery aneurysms (PAAs) are rare in the general population, but they account for nearly 70% of peripheral arterial aneurysms. There are several possible surgical approaches including exclusion of the aneurysm and bypass grafting, or endoaneurysmorrhaphy and interposition of a prosthetic conduit. The outcomes following the first approach are favorable, but persistent blood flow in the aneurysm sac has been documented in up to one third of patients in the early post-operative setting. Complications from incompletely excluded aneurysms include aneurysm enlargement, local compression symptoms, and sac rupture. Notably infection of a previously excluded and bypassed PAA is rare. This is the third reported case of PAA infection after exclusion and bypass grafting and the first due to Serratia liquefaciens.

Methods

Relevant medical data were collected from the hospital database.

Results

This case report describes a 54 year old male patient, diagnosed with acute limb ischaemia due to a thrombosed PAA, submitted to emergency surgery with exclusion and venous bypass. A below the knee amputation was necessary 3 months later. Patient follow-up was lost until 7 years following surgical repair, when he was diagnosed with aneurysm sac infection with skin fistulisation. He had recently been diagnosed with alcoholic hepatic cirrhosis Child–Pugh Class B. The patient was successfully treated by aneurysm resection, soft tissue debridement and systemic antibiotics.

Conclusion

PAA infection is a rare complication after exclusion and bypass procedures but should be considered in any patient with evidence of local or systemic infection. When a PAA infection is diagnosed, aneurysmectomy, local debridement, and intravenous antibiotic therapy are recommended. The “gold standard” method of PAA repair remains controversial. PAA excision or endoaneurysmorrhaphy avoids complications from incompletely excluded aneurysms, but is associated with a high risk of neurological damage.

•

Popliteal artery aneurysms (PAAs) are the most common cause of non-traumatic leg amputation.

•

Potential complications from PAA exclusion are aneurysm enlargement, local compression symptoms, sac rupture, and infection.

•

Infection of a previously excluded and bypassed popliteal artery aneurysm is exceedingly rare.

•

This is the third case of excluded aneurysm infection, and the first by the Serrate genus.

Psycho-Oncology in Portugal: It is Different from the Rest of the World?

Introduction

Psycho-Oncology (PO) is a specific psychiatric approach to cancer patients. The main psychiatric disorders observed are delirium and adjustment disorders (AD) and the most frequent treatments used are pharmacologic and psychotherapeutic.

With regard to the type of cancer, the most frequent in Portugal are breast, digestive and prostate.

Objective

Analyze the activity of PO in a district general hospital in Portugal.

Aims

Demonstrate that the main core in PO is similar in the world.

Methods

Prospective longitudinal study, during one year.

Results

The sample had 130 patients (369 evaluations), mainly male, with the mean age of 64.22 years. The most frequent psychiatric diagnoses were delirium (56 cases; 43%) and AD (44; 34%) and the main interventions used were pharmacologic and psycho-education. The most common frequent cancers were digestive (54; 42%), urologic (16; 12%) and breast (15; 11%). This high frequency of urologic cancer was interpreted as a consequence of the sample and its geographic location, but it was also a reflection of the large number of requests made by this specialty. The majority of cancers had an advanced stage (84% vs 16%) that can be explained by the sample but also by health culture in Portugal, which is reflected in the inpatient services: Oncology (51; 39%) and Palliative Care (25; 19%).

Conclusions

The type of psychiatric disorders and treatments offered in PO is preserved around the world. The authors propose to do more studies, namely if the relation with others specialties affects psychiatric treatment of the patient.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Dynamic dual-isotope molecular imaging elucidates principles for optimizing intrathecal drug delivery

The intrathecal (IT) dosing route offers a seemingly obvious solution for delivering drugs directly to the central nervous system. However, gaps in understanding drug molecule behavior within the anatomically and kinetically unique environment of the mammalian IT space have impeded the establishment of pharmacokinetic principles for optimizing regional drug exposure along the neuraxis. Here, we have utilized high-resolution single-photon emission tomography with X-ray computed tomography to study the behavior of multiple molecular imaging tracers following an IT bolus injection, with supporting histology, autoradiography, block-face tomography, and MRI. Using simultaneous dual-isotope imaging, we demonstrate that the regional CNS tissue exposure of molecules with varying chemical properties is affected by IT space anatomy, cerebrospinal fluid (CSF) dynamics, CSF clearance routes, and the location and volume of the injected bolus. These imaging approaches can be used across species to optimize the safety and efficacy of IT drug therapy for neurological disorders.

Abstract 1679: Combined efficacy of Cediranib and Quinacrine in glioma is enhanced by hypoxia and is associated with autophagic vacuole accumulation

Despite robust vascularity of malignant gliomas, anti-angiogenic therapy largely fails to induce durable responses. We have previously reported that efficacy with Cediranib (Ced), a VEGF/PDGF receptor tyrosine kinase inhibitor, is synergistically enhanced via combination with late-stage autophagy inhibitor quinacrine (Quin), in intracranial 4C8 mouse glioma, resulting in decreased tumor vascularization and growth, increased tumor necrosis and improved mouse survival (#1905, AACR 2012). Our present study was aimed at investigating the role of autophagy (a cellular catabolic pathway that promotes tumor cell survival under hypoxic/nutrient stress), in this synergistic efficacy. MTS assays revealed dose-dependent reductions in cell viability for Ced and Quin under normal (Nrm) and hypoxic (0.5%O2, Hyp) conditions: IC50s(μM) under Nrm and Hyp were 2.7±0.1 and 2.4±0.2 for Ced, and 3.2±0.2 and 2.4±0.04 for Quin, respectively. Greater than additive combined efficacy for Ced+Quin occurred only under Hyp (cell viability reductions for 1μM C + 2.5μM Q: 78±7%(Hyp) vs. 31±3%(Nrm), p&lt;0.05). Western blotting for cleaved caspase 3 also indicated a marked increase in apoptosis with Ced+Quin/Hyp versus all other groups. Western blotting for autophagic vacuole (AV) associated LC3-II protein, which increases with increased autophagic flux and/or late stage autophagic inhibition, not only indicated increases with Quin, but also with Ced, suggesting that Ced may increase autophagic flux. Hypoxia potentiated LC3-II increases in the presence of either Quin or Ced, with the largest increases occurring with Ced+Quin/Hyp, suggesting that hypoxia-induced autophagic flux stimulation combined with late stage autophagic inhibition can trigger AV accumulation and cell death. Bafilomycin A1 (Baf), another late-stage autophagy inhibitor, also decreased cell viability. However, the efficacy of combined Baf and Ced was only additive and lacked substantial potentiation by Hyp (cell viability reductions for 1μM Ced/5ηM Baf: 54±8% (Hyp) vs 37±11% (Nrm)). LC3-II accumulation with Baf was substantially lower than with Quin, either with Hyp or Nrm, suggesting that in addition to inhibiting late-stage autophagy, Quin may also stimulate autophagic flux, consistent with its reported inhibition of PI3K/Akt/mTOR signaling. Thus, a key role for AV accumulation is consistent with its increase with Quin versus Baf in tandem with the improved efficacy of Quin over Baf, in combination with Ced. Our results suggest that the unique cytotoxic efficacy of Ced+Quin we previously reported in vivo, could be associated with increased AV accumulation within hypoxic tumor cells, induced by Ced and possibly Quin, in combination with late-stage autophagic inhibition by Quin. These findings provide a rationale for a careful evaluation of a Ced+Quin combination therapy in patients with malignant gliomas.

Citation Format: Merryl Lobo, Peter Kurre, Matthias Schabel, Yancey Gillespie, Randall Woltjer, Martin Pike. Combined efficacy of Cediranib and Quinacrine in glioma is enhanced by hypoxia and is associated with autophagic vacuole accumulation. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 1679. doi:10.1158/1538-7445.AM2013-1679

Effect of different carbon sources on proteases secreted by the fungal pathogen Sclerotinia sclerotiorum during Phaseolus vulgaris infection

Sclerotinia sclerotiorum (Sclerotiniaceae) is a plant pathogenic fungus that causes white mold disease in vegetable crops, including the common bean (Phaseolus vulgaris). Proteases produced by fungi are normally an important part of the pathogenic process in the host. We examined the effect of different carbon sources--pectin, glucose, and cell wall of P. vulgaris on the production of proteases in cultures of S. sclerotiorum. These proteases were also assayed in infected P. vulgaris plants. Enzyme activity was increased with all carbon sources, but the highest levels were found when pectin was added. Based on real-time quantitative reverse transcription-PCR analyses, protease induction in S. sclerotiorum was found to occur at the level of gene transcription. The finding of increased expression of acid phosphatase 1 and aspartyl protease in vivo in infected P. vulgaris plants supports the role of these enzymes in the invasion process of S. sclerotiorum.

Is religion really important?

Introduction

Knowing the impact that religious beliefs can have on the etiology, diagnosis and course of psychiatric disorders will help psychiatrists better understand their patients, assessing when the religious or spiritual beliefs are used to cope with mental illness and when they may be exacerbating this disease.

Objectives

Alert to the importance of religion in clinical practice.

Methods

Relevant literature review.

Results

Several studies have demonstrated the influence of spirituality on physical, mental and health. In 1988, the World Health Organization (WHO) has given rise to the interest in further investigations in this area, with the inclusion of a spiritual aspect of the multidimensional concept of health. The spiritual well-being can be considered a protective factor for psychiatric disorders.

Although it is not possible to determine with accuracy, the mechanisms of interaction of spirituality on health, especially mental health, several studies suggest that exercise can influence the spiritual activities, psychodynamically, through positive emotions. Furthermore, these emotions may be important for mental health in terms of possible psychophysiological and psychoneuroimmunological mechanisms.

Anthropological sources suggest that beliefs in demons, black magic and evil spirits as cause of mental illness and distress are common. They may be less prevalent in western countries but even in Europe it's possible to see patients thought that their condition have been caused by evil and occult possession.

Conclusions

Clinicians should understand the negative and positive roles that religion plays in those with mental disorders and use this in clinical practice.

Functional outcome after surgical reconstruction of posterior tibial tendon insufficiency in patients under 50 years

BACKGROUND

Procedures utilized to address the flatfoot in this study included medializing calcaneal osteotomy, posterior tibial tendon reconstruction with flexor digitorum longus tendon transfer, and in patients with more severe deformity, lateral column lengthening. We evaluated patients age 50 and less at the time of surgery, who underwent surgical reconstruction for Stage 2 posterior tibial tendon dysfunction. Pre- and postoperative activity levels were evaluated to assess the effect of surgical reconstruction in the younger patient.

MATERIALS AND METHOD

Thirty-four feet in 30 patients (11 male, 19 female) with an average age of 41.2 (range, 17 to 50) years had surgery between 1997 and 2004. All feet were examined at an average followup of 44.5 (range, 24 to 65) months and were evaluated with the American-Orthopaedic-Foot and Ankle Society (AOFAS) Hindfoot-Score and SF-36 score.

RESULTS

The average preoperative AOFAS-Score was 53.1 +/- 14.5 points and 83.2 +/- 12.2 points at final postoperative followup. The mean improvement was 29.5. The difference between the preoperative and postoperative AOFAS score was significant (p < 0.0001) using a two-tailed t-test. The difference in the AOFAS pain and alignment subscales was also significant (p < 0.0001). The function subscale improvement was also significant (p = 0.018). The mean physical function component of the postoperative SF-36 score was 79.2. A correlation was found between the SF-36 physical component score and the post operative AOFAS score (r(2) = 0.754).

CONCLUSION

While some lateral discomfort or pain occurred in patients with or without a lateral column lengthening, the posterior tibial tendon reconstruction utilizing medial calcaneal displacement osteotomy with flexor digitorum longus transfer and a lateral column lengthening with more deformity was successful in the higher-functioning, younger patients.

Cellular characterisation of magnetic resonance imaging bone oedema in rheumatoid arthritis; implications for pathogenesis of erosive disease

Objectives:

Magnetic resonance imaging (MRI) bone oedema is an important predictor of bone erosion in rheumatoid arthritis (RA). This study aimed to determine the cellular components of MRI bone oedema, and clarify the relationship between bone erosion and MRI bone oedema.

Methods:

Twenty-eight bones from 11 patients with RA undergoing orthopaedic surgery were analysed by quantitative and semi-quantitative immunohistochemistry. Pre-operative contrast-enhanced MRI scans were analysed for bone oedema.

Results:

The density of osteoclasts was higher in those samples with MRI bone oedema than those without MRI bone oedema (p = 0.01). Other cells identified within bone marrow included macrophages and plasma cells, and these were more numerous in samples with MRI bone oedema (p = 0.02 and 0.05 respectively). B cells were present in lower numbers, but B cell aggregates were identified in some samples with MRI bone oedema. There was a trend to increased RANKL expression in samples with MRI bone oedema (p = 0.09). Expression of RANKL correlated with the number of osteoclasts (r = 0.592, p = 0.004).

Conclusions:

The increased number of osteoclasts and RANKL expression in samples with MRI bone oedema supports the hypothesis that bone erosion in RA occurs through activation of local bone resorption mechanisms within subchondral bone as well as through synovial invasion into bone.