Classifying the unclassifiable-a Delphi study to reach consensus on the fibrotic nature of diseases

BACKGROUND

Traditionally, clinical research has focused on individual fibrotic diseases or fibrosis in a particular organ. However, it is possible for people to have multiple fibrotic diseases. While multi-organ fibrosis may suggest shared pathogenic mechanisms, yet there is no consensus on what constitutes a fibrotic disease and therefore fibrotic multimorbidity.

AIM

A Delphi study was performed to reach consensus on which diseases may be described as fibrotic.

METHODS

Participants were asked to rate a list of diseases, sub-grouped according to eight body regions, as 'fibrotic manifestation always present', 'can develop fibrotic manifestations', 'associated with fibrotic manifestations' or 'not fibrotic nor associated'. Classifications of 'fibrotic manifestation always present' and 'can develop fibrotic manifestations' were merged and termed 'fibrotic'. Clinical consensus was defined according to the interquartile range, having met a minimum number of responses. Clinical agreement was used for classification where diseases did not meet the minimum number of responses (required for consensus measure), were only classified if there was 100% consensus on disease classification.

RESULTS

After consulting experts, searching the literature and coding dictionaries, a total of 323 non-overlapping diseases which might be considered fibrotic were identified; 92 clinical specialists responded to the first round of the survey. Over three survey rounds, 240 diseases were categorized as fibrotic via clinical consensus and 25 additional diseases through clinical agreement.

CONCLUSION

Using a robust methodology, an extensive list of diseases was classified. The findings lay the foundations for studies estimating the burden of fibrotic multimorbidity, as well as investigating shared mechanisms and therapies.

Pregnancy and contraception in women with Pre-Gestational diabetes in secondary Care- A questionnaire study

AIMS

To establish the knowledge of women with pre-gestational diabetes about of the risks of diabetes in pregnancy, and investigate their pregnancy plans, contraceptive choices, and preparedness for pregnancy.

METHODS

Women of reproductive age attending diabetes clinics across a single busy metropolitan NHS Trust were invited to fill in a questionnaire about pregnancy and contraception. The electronic health records of those women were also reviewed.

RESULTS

Ninety-six women completed the questionnaire. The majority of respondents (94%) had Type 1 Diabetes. Only 3% of women met the criteria of 'prepared for pregnancy'. Low efficacy contraception was used by 32% of women. Most women were only aware of a few risks to the mother and fetus in pregnancy, though the majority of women were aware of the importance of good glycaemic control before pregnancy. Previous pregnancies, or attendance at pre-conception counselling, did not improve participant knowledge.

CONCLUSIONS

Many women with diabetes of reproductive age are poorly prepared for pregnancy, but many are also using less effective contraceptive methods. These areas should be addressed if the poor pregnancy outcome in women with diabetes are to be improved, possibly through the development of an evidenced-based structured education course to target pre-conception and contraception.

804 Using Simulation as A Platform to Prepare for ENT Emergencies in The COVID-19 Era

Introduction

At the onset of COVID-19 crisis, our ENT department was allocated five interim foundation (FiY1) doctors to help support the clinical team at a time of extreme pressure within the NHS. An ENT emergency simulation programme was-established in order to improve the skills, knowledge and confidence of the new doctors, with the course being subsequently incorporated into departmental induction for the new first-on-call-ENT-doctors.

Method

Five FiY1 doctors attended a simulation study day, comprised of a “skills and drills” workshop followed by two interactive scenarios. An interactive SimMan3G-mannequin, technician utilizing a Mask-Ed™, trained confederate nurse and a video flexible laryngoscope trainer were used to provide high-fidelity simulation. Participants rated how prepared-they felt in managing the relevant condition before and after on a Likert scale (1–strongly disagree, 5–strongly agree). The session was repeated for the new nine first-on-call ENT doctors.

Results

Participants in the pilot session felt more prepared in managing both tracheostomy emergencies (1.2vs4.2)-and-epistaxis (2.0vs5.8). Participants in the subsequent session also felt-more-prepared in managing stridor (2.1vs4.6) -and-epistaxis-(3.1vs4.7). All-14-attendants stated that they would recommend the session to others.

Conclusions

Despite-the-simulation-course-being-originally-established-to help support newly qualified-FiY1 doctors during COVID-19, the success of the programme has resulted in its formal incorporation-into departmental ENT induction.

Case management: a critical review of the outcome literature

Case management has been an integral part of psychiatric practice in the United States for over a decade and has generated a large body of literature. The application of case management principles to the care of people suffering from psychiatric disorders is becoming increasingly popular in the United Kingdom and Europe and literature is now beginning to be published. However, no definitive statements about the efficacy of case management have been made due to a range of conceptual and methodological problems. The present paper is a critical review of the case management outcome literature. Reported outcomes are reviewed in the context of study design and service characteristics. The authors conclude that case management practice can have at least some impact on patients' use of services (including marked decrease in in-patient bed days); satisfaction with services; engagement with services; and social networks and relationships when it is delivered as a direct, clinical service with high staff: patient ratios. A set of recommendations are suggested for the future practice and presentation of research into case management.

Is it possible to constantly and accurately monitor blood sugar levels, in people with Type 1 diabetes, with a discrete device (non-invasive or invasive)?

Real-time continuous glucose monitors using subcutaneous needle-type sensors continue to develop. The limitations of currently available systems, however, include time lag behind changes in blood glucose, the invasive nature of such systems, and in some cases, their accuracy. Non-invasive techniques have been developed, but, to date, no commercial device has been successful. A key research priority for people with Type 1 diabetes identified by the James Lind Alliance was to identify ways of monitoring blood glucose constantly and accurately using a discrete device, invasive or non-invasive. Integration of such a sensor is important in the development of a closed-loop system and the technology must be rapid, selective and acceptable for continuous use by individuals. The present review provides an update on existing continuous glucose-sensing technologies, and an overview of emergent techniques, including their accuracy and limitations.

A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia

AIM

Hypoglycaemia in Type 1 diabetes is associated with mortality and morbidity, especially where awareness of hypoglycaemia is impaired. Clinical pathways for access to continuous glucose monitoring (CGM) and flash glucose monitoring technologies are unclear. We assessed the impact of CGM and flash glucose monitoring in a high-risk group of people with Type 1 diabetes.

METHODS

A randomized, non-masked parallel group study was undertaken. Adults with Type 1 diabetes using a multiple-dose insulin-injection regimen with a Gold score of ≥ 4 or recent severe hypoglycaemia were recruited. Following 2 weeks of blinded CGM, they were randomly assigned to CGM (Dexcom G5) or flash glucose monitoring (Abbott Freestyle Libre) for 8 weeks. The primary outcome was the difference in time spent in hypoglycaemia (below 3.3 mmol/l) from baseline to endpoint with CGM versus flash glucose monitoring.

RESULTS

Some 40 participants were randomized to CGM (n = 20) or flash glucose monitoring (n = 20). The participants (24 men, 16 women) had a median (IQR) age of 49.6 (37.5-63.5) years, duration of diabetes of 30.0 (21.0-36.5) years and HbA_1c of 56 (48-63) mmol/mol [7.3 (6.5-7.8)%]. The baseline median percentage time < 3.3 mmol/l was 4.5% in the CGM group and 6.7% in the flash glucose monitoring. At the end-point the percentage time < 3.3 mmol/l was 2.4%, and 6.8% respectively (median between group difference -4.3%, P = 0.006). Time spent in hypoglycaemia at all thresholds, and hypoglycaemia fear, were different between groups, favouring CGM.

CONCLUSION

CGM more effectively reduces time spent in hypoglycaemia in people with Type 1 diabetes and impaired awareness of hypoglycaemia compared with flash glucose monitoring. (Clinical Trial Registry No: NCT03028220).

Consistency properties of chaotic systems driven by time-delayed feedback

Consistency refers to the property of an externally driven dynamical system to respond in similar ways to similar inputs. In a delay system, the delayed feedback can be considered as an external drive to the undelayed subsystem. We analyze the degree of consistency in a generic chaotic system with delayed feedback by means of the auxiliary system approach. In this scheme an identical copy of the nonlinear node is driven by exactly the same signal as the original, allowing us to verify complete consistency via complete synchronization. In the past, the phenomenon of synchronization in delay-coupled chaotic systems has been widely studied using correlation functions. Here, we analytically derive relationships between characteristic signatures of the correlation functions in such systems and unequivocally relate them to the degree of consistency. The analytical framework is illustrated and supported by numerical calculations of the logistic map with delayed feedback for different replica configurations. We further apply the formalism to time series from an experiment based on a semiconductor laser with a double fiber-optical feedback loop. The experiment constitutes a high-quality replica scheme for studying consistency of the delay-driven laser and confirms the general theoretical results.

Testosterone therapy for sexual dysfunction in men with Type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials

AIM

To evaluate the effectiveness of testosterone therapy on a range of sexual function domains in men with Type 2 diabetes.

METHOD

Electronic databases were searched for studies investigating the effect of testosterone therapy on sexual function in men with Type 2 diabetes. All randomized controlled trials were considered for inclusion if they compared the efficacy of testosterone therapy with that of placebo and reported sexual function outcomes. Statistical analysis was performed using a random-effects model, and heterogeneity was expressed using the I² statistic.

RESULTS

A total of 611 articles were screened. Six randomized control trials, in a total of 587 men with Type 2 diabetes, were eligible for inclusion. The pooled data suggested that testosterone therapy improves sexual desire (random-effects pooled effect size 0.314; 95% CI 0.082-0.546) and erectile function (random-effects pooled effect size 0.203; 95% CI 0.007-0.399) when compared with control groups. Testosterone therapy had no significant effect on constitutional symptoms or other sexual domains compared with control groups. No studies have investigated the incidence of prostate cancer, fertility and cardiovascular disease after testosterone therapy in men with Type 2 diabetes.

CONCLUSION

Testosterone therapy may moderately improve sexual desire and erectile function in men with Type 2 diabetes; however, available data are limited, and the long-term risks of testosterone therapy are not known in this specific patient group. We conclude that testosterone therapy is a potential treatment for men with Type 2 diabetes non-responsive to phosphodiesterase-5 inhibitors. Testosterone therapy could be considered for men with Type 2 diabetes when potential risks and benefits of therapy are carefully considered and other therapeutic options are unsuitable.

Biokinetic model for nitrogen removal in free water surface constructed wetlands

In this article, a mechanistic biokinetic model for nitrogen removal in free water surface constructed wetlands treating eutrophic water was developed, including organic matter performance due to its importance in nitrogen removal by denitrification. Ten components and fourteen processes were introduced in order to simulate the forms of nitrogen and organic matter, the mechanisms of autotrophic and heterotrophic microorganisms in both aerobic and anoxic conditions, as well as macrophytes nitrogen uptake and release. Dissolved oxygen was introduced as an input variable with a time step of 0.5days for mimicking eutrophic environments: aerobic conditions were assigned during daylight hours and anoxic conditions during the night. The sensitivity analysis showed that the most influential parameters were those related to the growth of heterotrophic and autotrophic microorganisms. The model was properly calibrated and validated in two full scale systems working in real conditions for treating eutrophic water from Lake L'Albufera (València). In the studied systems, ammonium was mainly removed by the growth of autotrophic microorganisms (nitrification) whereas nitrate was removed by the anoxic growth of heterotrophic microorganisms (denitrification). Macrophyte uptake removed between 9 and 19% of the ammonium entering to the systems, although degradation of dead standing macrophytes returned a significant part to water column.

Abstract S1-01: Whole exome and transcriptome sequencing of resistant ER+ metastatic breast cancer

Background: While great strides have been made in the treatment of estrogen receptor-positive (ER+) metastatic breast cancer (MBC), therapeutic resistance invariably occurs. A better understanding of the underlying resistance mechanisms is critical to enable durable control of this disease.

Methods: We performed whole exome sequencing (WES) and transcriptome sequencing (RNA-seq) on metastatic tumor biopsies from 88 patients with ER+ MBC who had developed resistance to one or more ER-directed therapies. For 27 of these patients, we sequenced the treatment-naïve primary tumors for comparison to the resistant specimens. Tumors were analyzed for point mutations, insertions/deletions, copy number alterations, translocations, and gene expression. Detailed clinicopathologic data was collected for each patient and linked to the genomic information.

Results: WES of all metastatic samples demonstrated several recurrently altered genes whose incidence differed significantly from primary, treatment-naïve ER+ breast cancers sequenced in the TCGA study (TCGA). These include ESR1 mutations (n=17, 19.3%; 32.86 fold enrichment, q.value&lt;7.5e-12), CCND1 amplification (n=52, 59.1%; 2.3 fold enrichment, q.value&lt;0.0073), and MAP2K4 biallelic inactivation (n=14, 15.9%; 3.04 fold enrichment, q.value&lt; 0.054).

Comparing to matched primary samples from the same patient, many alterations were found to be acquired in several cases, including for ESR1, ERBB2, PIK3CA, PTEN, RB1, AKT1, and others. Initial analysis of RNA-seq data from metastatic samples (n=59) allowed classification of individual resistance mechanisms into broader resistance modes based on the observed transcriptional state.

Conclusions: We present a genomic landscape of resistant ER+ MBC using WES and RNA-seq. Multiple genes were recurrently altered in these tumors at significantly higher rates than in ER+ primary breast cancer. When compared with matched primary tumors from the same patient, alterations in these and other genes were often found to be acquired after treatment, suggesting a role in resistance to ER-directed therapies and/or metastasis. Potential resistance mechanisms appear to fall into several categories; integrating RNA-seq data may enhance the ability to identify these categories even when genomic alterations are not identified. Multiple clinically relevant genomic and molecular alterations are identified in metastatic biopsies– with implications for choice of next therapy, clinical trial eligibility, and novel drug targets.

Citation Format: Cohen O, Kim D, Oh C, Waks A, Oliver N, Helvie K, Marini L, Rotem A, Lloyd M, Stover D, Adalsteinsson V, Freeman S, Ha G, Cibulskis C, Anderka K, Tamayo P, Johannessen C, Krop I, Garraway L, Winer E, Lin N, Wagle N. Whole exome and transcriptome sequencing of resistant ER+ metastatic breast cancer [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 S1-01.

Hospitalizations for unintentional injuries among Canadian adults in areas with a high percentage of Aboriginal-identity residents

Introduction

Injuries are a leading cause of death and morbidity. While individual Aboriginal identifiers are not routinely available on national administrative databases, this study examines unintentional injury hospitalization, by cause, in areas with a high percentage of Aboriginal-identity residents.

Methods

Age-standardized hospitalization rates (ASHRs) and rate ratios were calculated based on 2004/2005-2009/2010 data from the Discharge Abstract Database.

Results

Responses from parents living in provinces with legislation (n = 640) and without legislation (n = 362) were as follows: concern for injury (63% vs. 68%, nonsignificant [NS]); believe helmets are effective (98% vs. 98%, NS); child always wears a helmet (74% vs. 69%, NS); support legislation for children (95% vs. 83%, p $lt; .001); support legislation for all ages (85% vs. 75%, p $lt; .001); support police enforcement (83% vs. 76%, p = .003); believe legislation decreases the amount of time their child bicycles (5% vs. 8%, NS).

Conclusion

Residents of high-percentage Aboriginal-identity areas also live in areas of lower socio-economic conditions, suggesting that the causes for rate differences among areas require further investigation.

Cost effectiveness of deferasirox compared to desferrioxamine in the treatment of iron overload in lower-risk, transfusion-dependent myelodysplastic syndrome patients

OBJECTIVE

The study evaluated the cost effectiveness of deferasirox (Exjade * ) compared to non-proprietary desferrioxamine (DFO) for the control of transfusional iron overload in lower risk myelodysplastic syndromes (MDS) patients. A UK National Health Service perspective was adopted.

METHODS

Recent clinical evidence has demonstrated the efficacy and safety of deferasirox in transfusion-dependent MDS patients with elevated serum ferritin levels. An economic model was used to extrapolate the clinical benefits of iron chelation therapy (ICT) in a cohort of lower risk MDS patients. Costs for drug acquisition, drug administration and monitoring, and quality of life (utility) outcomes associated with mode of drug administration were derived from a variety of sources. The incremental cost per QALY gained for deferasirox was estimated. Costs and outcomes were discounted at 3.5% in line with UK standards.

RESULTS

The base-case cost effectiveness of deferasirox versus DFO was estimated to be £20,822 per QALY gained, the key driver being the additional quality of life benefits associated with a simpler mode of administration for deferasirox. A mean survival benefit for both forms of ICT of 4.5 years was estimated. The results were sensitive to drug dose, days of DFO administration, and patient weight.

CONCLUSIONS

In the UK, a cost per QALY below £20,000-30,000 is considered cost effective. Hence, the results from this economic analysis suggest deferasirox is cost effective in lower risk, transfusion-dependent, MDS patients. Limitations with the analysis include a lack of comparative randomised controlled trial evidence, in particular to differentiate survival and clinical outcomes for deferasirox and DFO.

Conservative management of diabetic forefoot ulceration complicated by underlying osteomyelitis: the benefits of magnetic resonance imaging

AIMS

To assess efficacy of conservative management of neuropathic forefoot ulcers with underlying osteomyelitis in subjects with diabetes when magnetic resonance imaging (MRI) is used to confirm or establish diagnosis and to guide antibiotic duration.

METHODS

A retrospective cohort study over 6 years assessing rates of ulcer healing, relapse and amputation. Antibiotics were continued for 3-month cycles with interval MRI: if the lesion had healed and bone signal change resolved or improved, antibiotics were discontinued; if the lesion had not healed or there was no difference in bone signal change, antibiotics were continued for a further 3-month cycle; clinical or radiological deterioration resulted in endoluminal or open vascular surgical intervention where appropriate, or digital or more proximal amputation.

RESULTS

There were 53 episodes in 47 subjects (mean +/- sd age 62 +/- 13 years, duration of diabetes 19 +/- 13 years, glycated haemoglobin 8.4 +/- 1.6%; six with Type 1 diabetes and seven with end-stage renal failure). Successful healing without relapse was achieved in 40 episodes (75%) [median (range) duration of antibiotics 6 (3-12) months and follow-up post-cessation of antibiotics 15 (3-58) months]. Relapse occurred in six episodes (13%) at 31 (2-38) months post-cessation of antibiotics. There were one major (2%) and eight minor (15%) amputations. Five subjects have died (11%), all without foot ulcers.

CONCLUSIONS

High rates of healing and low rates of amputation were achieved. The use of MRI was associated with long courses of antibiotics, but particularly low relapse rate.

Connective tissue growth factor/CCN2 overexpression in mouse synovial lining results in transient fibrosis and cartilage damage

OBJECTIVE

Characteristics of osteoarthritis (OA) include cartilage damage, fibrosis, and osteophyte formation. Connective tissue growth factor (CTGF; also known as CCN2), is found in high levels in OA chondrocytes and is frequently involved in fibrosis, bone formation, and cartilage repair. The present study was therefore undertaken to investigate the potential role of CTGF in OA pathophysiology.

METHODS

We transfected the synovial lining of mouse knee joints with a recombinant adenovirus expressing human CTGF and measured synovial fibrosis and proteoglycan content in cartilage on days 1, 3, 7, 14, and 28. Messenger RNA (mRNA) expression in synovium and cartilage was measured on days 3, 7, and 21.

RESULTS

CTGF induced synovial fibrosis, as indicated by accumulation of extracellular matrix and an increase in procollagen type I-positive cells. The fibrosis reached a maximum on day 7 and had reversed by day 28. Levels of mRNA for matrix metalloproteinase 3 (MMP-3), MMP-13, ADAMTS-4, ADAMTS-5, tissue inhibitor of metalloproteinases 1 (TIMP-1), and transforming growth factor beta were elevated in the fibrotic tissue. TIMP-1 expression was elevated on day 3, while expression of other genes did not increase until day 7 or later. CTGF induced proteoglycan depletion in cartilage as early as day 1. Maximal depletion was observed on days 3-7. Cartilage damage was reduced by day 28. A high level of MMP-3 mRNA expression was found in cartilage. CTGF overexpression did not induce osteophyte formation.

CONCLUSION

CTGF induces transient fibrosis that is reversible within 28 days. Overexpression of CTGF in knee joints results in reversible cartilage damage, induced either by the high CTGF levels or via factors produced by the CTGF-induced fibrotic tissue.

Elevated aqueous humour tissue inhibitor of matrix metalloproteinase-1 and connective tissue growth factor in pseudoexfoliation syndrome

BACKGROUND/AIMS

Pseudoexfoliation syndrome (PXF) was recently found to be associated with increased expression of transforming growth factor beta(1) (TGFbeta(1)) in the aqueous humour. As concern has been raised regarding anti-TGFbeta therapy, which can potentially disrupt the maintenance of anterior chamber associated immune deviation, the authors explored the levels of tissue inhibitor of matrix metalloproteinase-1 (TIMP-1), matrix metalloproteinase-9 (MMP-9), and connective tissue growth factor (CTGF) in aqueous humour to determine if these may represent alternative therapeutic targets.

METHODS

Aqueous humour samples were collected from patients who underwent routine cataract surgery. All patients were categorised into three main groups-PXF, uveitis, and control. The PXF group was further subcategorised into three grades based on the density of the exfoliative material observed on biomicroscopy, as well as the presence or absence of glaucoma. TIMP-1, MMP-9, and CTGF levels were measured using specific enzyme immunoassays (ELISA).

RESULTS

Eyes with PXF had significantly higher aqueous humour TIMP-1 concentration (n = 56, mean (SE), 9.76 (1.10) ng/ml) compared with controls (n = 112, 5.73 (0.43) ng/ml, p<0.01). Similarly, the CTGF level in PXF eyes (n = 36, 4.38 (0.65) ng/ml) was higher than controls (n = 29, 2.35 (0.46) ng/ml, p<0.05). Further, the CTGF concentration in the PXF glaucoma group is significantly higher compared with PXF eyes without glaucoma (6.03 (1.09) ng/ml v 2.73 (0.45) ng/ml, p<0.01). The MMP-9 levels were low and below detection limit in all PXF and control samples with no statistical difference between groups.

CONCLUSION

A raised TIMP-1 level and a low MMP-9 level in aqueous humour of PXF eyes may imply a downregulation in proteolytic activity. The increased CTGF concentration supports the proposed fibrotic pathology of PXF. Regulation of MMP/TIMP expression and anti-CTGF therapy may offer potential therapeutic avenues for controlling PXF associated ocular morbidity.

Differential expression of connective tissue growth factor in microglia and pericytes in the human diabetic retina

BACKGROUND/AIM

Connective tissue growth factor (CTGF) stimulates extracellular matrix formation, fibrosis, and angiogenesis. It has a role in the pathogenesis of diabetic nephropathy and possibly in diabetic retinopathy (DR): in cultured retinal vascular cells CTGF is induced by VEGF-A. To further characterise this role the authors investigated CTGF expression in normal and diabetic human retina.

METHODS

CTGF expression patterns were studied by immunohistochemistry in the retina of eyes of 36 diabetic persons and 18 non-diabetic controls and compared with markers of endothelial cells (CD31, PAL-E), pericytes (NG2), astrocytes (GFAP), and microglia (CD45).

RESULTS

In the retina, distinct and specific staining of CTGF was observed in microglia, situated around or in close vicinity of retinal capillaries. In the control cases, sporadic staining of pericytes was also observed within the vascular wall. In contrast, in the retina of people with diabetes, CTGF staining in microglia was decreased and staining in pericytes was increased. This pattern of predominantly pericyte staining was observed in 20 out of 36 diabetic cases and in one out of 18 controls. The altered CTGF staining patterns in the diabetic cases did not correlate to staining of PAL-E, a marker of retinal vascular leakage associated with DR.

CONCLUSIONS

The study shows that CTGF is expressed in microglia in the normal retina whereas in a large subset of diabetic persons, CTGF expression shifts to microvascular pericytes. This altered CTGF expression pattern appears unrelated to manifest DR and may therefore represent a preclinical retinal change caused by diabetes. The results suggest a distinct, but as yet unidentified, role of CTGF in the pathogenesis of diabetic retinopathy.

A series of heterocyclic inhibitors of phenylalanyl- t RNA synthetases with antibacterial activity

A series of novel heterocyclic analogues have been synthesized and evaluated for their ability to inhibit phenylalanyl-t-RNA synthetases and act as antibacterial agents. Several analogues have good antibacterial activity against Staphylococcus aureus.

A series of spirocyclic analogues as potent inhibitors of bacterial phenylalanyl- t RNA synthetases

We have identified a series of spirocyclic furan and pyrrolidine inhibitors of Enterococcus faecalis and Staphylococcus aureus phenylalanyl-tRNA synthetases. The most potent analogue 1b showed IC50=5 nM (E. faecalis PheRS) and IC50=2 nM (S. aureus PheRS) with high selectivity over the human enzyme. The crystal X-ray structure of analogue 1b was determined.

Resistance studies with daptomycin

We studied the in vitro emergence of resistance to daptomycin using three methods: spontaneous resistance incidence, serial passage in the presence of increasing drug concentrations, and chemical mutagenesis. No spontaneously resistant mutants were obtained for any organism tested (<10(-10) for Staphylococcus aureus, <10(-9) for Staphylococcus epidermidis, <10(-9) for Enterococcus faecalis, <10(-9) for Enterococcus faecium, <10(-8) for Streptococcus pneumoniae). Population analysis demonstrated that bacterial susceptibility to daptomycin is heterogeneous. Assay results were sensitive to calcium concentration and culture density, both of which can affect apparent resistance rates. Stable S. aureus mutants were isolated by both serial passage in liquid media and chemical mutagenesis. The daptomycin MICs for these isolates were 8- to 32-fold higher than for the parental strain. Many mutants with high MICs (>12.5 microg/ml) had significant growth defects but did not display phenotypes typical of S. aureus small colony variants. The voltage component (Delta psi) of the bacterial membrane potential was increased in three independent resistant isolates. In vivo data showed that some daptomycin-resistant mutants had lost significant virulence. For other mutants, the degree of in vitro resistance was greater than the change in in vivo susceptibility. These results suggest that infection with some daptomycin-resistant organisms may still be easily treatable.

The effects of vagus nerve stimulation on cognitive performance in patients with treatment-resistant depression

BACKGROUND

Chronic vagus nerve stimulation (VNS) is effective in the management of treatment-resistant epilepsy. Open-trial evidence suggests that VNS has clinically significant antidepressant effects in some individuals who experience treatment-resistant major depressive episodes. However, limited information regarding the effects of VNS on neurocognitive performance exists.

OBJECTIVE

The primary aim of this study was to determine whether VNS leads to neurocognitive deterioration.

METHOD

A neuropsychological battery was administered to 27 patients with treatment-resistant depression before and after 10 weeks of VNS. Thirteen neurocognitive tests sampled the domains of motor speed, psychomotor function, language, attention, memory, and executive function.

RESULTS

No evidence of deterioration in any neurocognitive measure was detected. Relative to baseline, improvement in motor speed (finger tapping), psychomotor function (digit-symbol test), language (verbal fluency), and executive functions (logical reasoning, working memory, response inhibition, or impulsiveness) was found. For some measures, improved neurocognitive performance correlated with the extent of reduction in depressive symptoms, but VNS output current was not related to changes in cognitive performance.

CONCLUSIONS

Vagus nerve stimulation in treatment-resistant depression may result in enhanced neurocognitive function, primarily among patients who show clinical improvement. Controlled investigation is needed to rule out the contribution of practice effects.

Improvement of depression following transcranial magnetic stimulation

Psychiatry as a field was transformed by the discovery and introduction of electroconvulsive therapy (ECT) as a treatment in the early part of this century. ECT demonstrated that depression was a disease of the brain and that it could be treated with a direct brain intervention. Psychiatry's evolution continued in 1958 with the discovery of the antidepressant activity of the monoamine oxidase inhibitors. Interestingly, although the area of neuropsychopharmacology has continued to advance, the realm of physical somatic interventions in psychiatry has lagged behind. With perhaps the exception of light therapy, there were no advances in somatic interventions in psychiatry. However, in 1985, Barker et al. developed a brief high intensity electromagnet capable of depolarizing cortical neurons, called transcranial magnetic stimulation (TMS). There has been much interest in the past 10 years in whether TMS might have antidepressant actions, similar to ECT but without causing a seizure and with no apparent cognitive side effects. This review examines the basic principles underlying TMS, and describes how TMS differs from electrical stimulation and the other uses of magnets.

Increased release of matrix metalloproteinase-9 in bronchoalveolar lavage fluid and by alveolar macrophages of asthmatics

In order to determine whether matrix metalloproteinases (MMPs) contribute to inflammation in asthma, we have examined the release of MMPs in bronchoalveolar lavage (BAL) fluids and their production and regulation by alveolar macrophages (AM), in short-term culture. BAL was collected from 38 asthmatic subjects (24 untreated and 14 treated with inhaled corticosteroids), 26 healthy nonsmokers, and 18 patients with chronic bronchitis used as a control group for another inflammation. The profile of MMPs present in BAL fluid and AM supernatant, determined by zymographic analysis, was found to be similar in all populations. The main enzyme released was identified immunologically as MMP-9, a potent collagenolytic and elastolytic enzyme. Its release, measured using enzyme immunoassay, was significantly enhanced in fluids and in AM supernatants from untreated asthmatics compared with those from the other populations. Enhanced MMP-9 levels, in asthma, could not be explained by a different sensitivity of AM to interleukin-4, interferon-gamma, or dexamethasone, compounds that have been shown to inhibit MMP-9. The phorbol ester phorbol 12-myristate 13-acetate (PMA), a protein kinase C (PKC) activator, significantly increased MMP-9 in AM from healthy control subjects but not in those from untreated asthmatics. Calphostin C and H7, PKC inhibitors, significantly reduced PMA-stimulated MMP-9 release in AM from healthy control subjects and spontaneous MMP-9 release in AM from untreated asthmatics. H8, a PKA inhibitor, was inactive in both populations. These data suggest that the stimulation of MMP-9 release in AM from untreated asthmatic patients occurs, at least partly, via signals activating PKC.

Case management: a week in the life of a clinical case management team

This paper describes the work of a clinical case management core team (four nurses and an occupational therapist) during the course of a week. Information was gathered through non-participant observation of the team by two independent researchers. Transcripts produced from the data recorded were examined. From this, seven categories of activity were identified: planned client contact; unplanned client contact; family/carer contact; liaison; administration; team information sharing and supervision, training and personal development. These categories were felt to encompass the range of activities practised by the team. The amount of time that case managers spent engaged in these core functions was calculated. Detailed examples are presented. Results are discussed with reference to Kanter's components and principles of clinical case management.

DNA binding proteins from keloid fibroblasts form unique complexes with the human fibronectin promoter

Keloids are pathological lesions characterized by enhanced expression of extracellular matrix molecules including fibronectin. A molecular dissection of the human fibronectin promoter was performed to identify DNA-protein interactions that correlate with altered fibronectin gene expression by keloid fibroblasts. DNA mobility shift patterns generated by nuclear extracts from skin, scar, and keloid fibroblasts were identical at a consensus CRE at -170 of the human fibronectin promoter whereas extracts from keloid fibroblasts formed complexes at a CRE/AP-1-like sequence at -415 that differed from those generated by skin and scar fibroblast extracts. The DNA-protein interactions identified at -415 were sensitive to altered serum concentrations in skin and scar but not keloid fibroblast cultures. The effects of forskolin and TGF-beta on fibronectin expression correlated with changes in the DNA-protein complexes assembled on the -170 and -415 cis elements, respectively. Oligonucleotides containing consensus CRE and AP-1 sequences did not compete for binding of nuclear proteins to the CRE/AP-1-like domain at -415, suggesting that this is a unique cis element. These studies indicate that the human fibronectin promoter contains two cis elements on which related but nonidentical complexes form. Alterations in the complexes interacting with the sequence at -415 may be responsible for the differences in fibronectin gene expression among quiescent skin, mature scar, and keloid fibroblasts.

Stress and its relationship to expressed emotion in community mental health workers

A small opportunistic study of Stress and Expressed Emotion was undertaken with community mental health workers, who were all case managers or keyworkers to clients with severe mental illness. It was hypothesised that a range of EE ratings would be found in staff, and that they would have high levels of burnout and stress. Job satisfaction was also measured. Ten staff were interviewed about 28 clients. Thirty nine percent of interviewees were rated as high EE (7/10 staff were high EE about at least one client), with low EE interviews showing significantly more warmth. Emotional exhaustion, depersonalisation and GHQ levels were above norms for the general population, and were similar to those found in other inner city community teams, but were not related to EE levels. Nevertheless personal accomplishment and job satisfaction were high. High EE interviews were related to increased client symptomatology. Implications for long term community care are discussed.

Transcriptional repression of fibronectin gene expression in v-src transformation

V-src-dependent and -independent alterations in the steady-state content, rates of synthesis, and turnover of fibronectin protein and mRNA were identified using rat fibroblasts which are temperature sensitive for p60v-src activity. Activation of p60v-src caused a fivefold reduction in the rate of fibronectin biosynthesis. The v-src-dependent decrease in fibronectin biosynthesis resulted from a similar reduction in the steady-state content of fibronectin mRNA. This change was reversible and required more than 24 h, implying an indirect effect of p60v-src on fibronectin gene expression. The rate of fibronectin mRNA turnover and pattern of alternative splicing were unchanged following p60v-src activation, indicating that these regulatory steps are insensitive to v-src transformation. A v-src-specific reduction of at least threefold was measured for the rate of fibronectin gene transcription, and gene transfer studies using fibronectin promoter-CAT reporter genes indicated that transcriptional repression occurs at the level of initiation. When p60v-src was inactive, CAT reporter genes controlled by 4.9 or 3.2 kb of the rat fibronectin promoter exhibited relatively increased CAT activity (approximately twofold) compared to another CAT reporter construction controlled by only 880 bp of the fibronectin promoter. In contrast, CAT activity was relatively reduced (approximately twofold) for the reporter constructions containing 4.9 or 3.2 kb of the promoter when p60v-src was active. These findings indicate that the distal portion of the fibronectin promoter contains a v-src-sensitive element(s) which mediates a decrease in the rate of fibronectin transcription initiation by negative control.

Gene expression of tenascin is altered in normal scars and keloids

Tenascin is an extracellular matrix molecule with structural similarity to fibronectin. An increase in extracellular matrix content of both tenascin and fibronectin is associated with early wound healing and with various skin fibroses. However, the relationship of tenascin and fibronectin expression during scar remodeling and the formation of pathologic scars such as keloids is unknown. Expression of tenascin in normal and abnormal human scars was examined and compared with that of fibronectin by immunohistochemistry and in situ hybridization. Tenascin and fibronectin protein and messenger RNA contents were elevated in normal, mature scars relative to quiescent skin, similar to the situation during earlier stages of healing. Tenascin and fibronectin expression was further enhanced in keloids relative to normal skin and scar, and, as has been shown for fibronectin, tenascin expression in uninjured skin adjacent to keloids was indistinguishable from that in quiescent skin from unaffected individuals. These data suggest that tenascin and fibronectin gene expression are coordinated during later stages of normal wound healing and that a defect involving common regulatory elements for these genes is associated with the formation of keloids.

Technique Integration: THERAPEUTIC TOUCH AND THEORY-BASED MENTAL HEALTH NURSING

Acceptance of therapeutic touch (TT) by the nursing community has become widespread. Nurses are advancing the pioneering work of Krieger (1973) through practice, research, education, and, most recently, through the development of theory-based nursing practice. The purpose of this article is to contribute to the development of theory-based nursing practice by introducing integration of TT with mental health nursing approaches. The Science of Unitary Human Beings (Rogers, 1986) is used to explain the relationship between TT and mental health nursing practice. The use of TT in practice is demonstrated through case examples from experiences with students and clients.

Keloid fibroblasts exhibit an altered response to TGF-beta

Treatment with transforming growth factor beta 1 (TGF-beta 1) results in stimulation of total protein synthesis in normal dermal fibroblasts but not in keloid fibroblasts, suggesting that the TGF-beta regulatory program is altered in keloid fibroblasts. However, both keloid and normal fibroblasts treated with TGF-beta 1 exhibit accelerated fibronectin biosynthesis, indicating that keloid cells can respond to TGF-beta 1. In the absence of serum, the TGF-beta 1-induced increase in fibronectin biosynthesis occurs more rapidly in keloid fibroblasts, also suggesting modification of this regulatory pathway. The TGF-beta 1-mediated increase in keloid fibronectin production is independent of the steroid regulatory pathway for fibronectin, which accelerates synthesis by means of a post-transcriptional mechanism. Thus, TGF-beta 1 stimulation of fibronectin production in keloid cells is likely to involve a transcriptional mechanism and keloid overproduction of extracellular matrix components may be due to an inherent modification of the TGF-beta regulatory program.

Fibronectin gene transcription is enhanced in abnormal wound healing

Abnormal wound healing in susceptible individuals can result in the formation of keloids that have an elevated content of extracellular matrix material compared to normal scars. Keloid-derived fibroblasts exhibit as much as a four-fold increase in the rate of fibronectin biosynthesis compared to fibroblasts from normal dermis and normal scars. Altered biosynthesis is due to an increase in the steady-state level of fibronectin mRNA, and in this investigation we have identified the level of fibronectin gene expression that is responsible for this increase. The rate of fibronectin gene transcription was found to be increased as much as threefold in keloid fibroblasts when compared to normal fibroblasts. Other possible changes that could account for the elevated level of fibronectin mRNA in keloids, such as increased copy number of the fibronectin gene or decreased turnover of fibronectin mRNA were also examined. The possibility of altered gene dosage was eliminated because chromosome content, G-banding patterns, and fibronectin gene content of keloid fibroblasts were all found to be normal. Analysis of fibronectin mRNA degradation revealed a half-life of approximately 13 h, and the residual fibronectin mRNA was observed to remain full length during this time period in both keloid and normal fibroblasts. Thus, altered degradation of fibronectin mRNA is unlikely to contribute to overproduction of fibronectin in keloids. Increased translational competence of fibronectin mRNA in keloids was also eliminated as a contributing factor because fibronectin mRNA remaining after one half-life were equally available for translation in both cell types. Although stimulation of transcription may not entirely account for the increase in fibronectin biosynthesis in keloids, this mechanism is best able to account for the majority of the change.

Uterine fibronectin mRNA content and localization are modulated during implantation

Fibronectin mRNA and protein content were examined during embryonic implantation in the rat uterus. Content of total fibronectin mRNA at day 6 of pregnancy increased relative to the non-pregnant uterus. In contrast, fibronectin protein content of the subepithelial stroma was relatively decreased except in the region directly surrounding the lumen, and this fibronectin immunoreactivity was sensitive to hyaluronidase treatment. These changes are likely to reflect the degradation and subsequent remodeling of the previously stable uterine extracellular matrix in preparation for embryonic implantation. A+, B-, V + fibronectin mRNAs were present in both the non-pregnant and day 6 pregnant uterus with increased content of A+ and V+ fibronectin mRNAs in the latter. A + fibronectin mRNA was distributed throughout the endometrial stroma of the non-pregnant uterus and content of the subepithelial stroma increased by day 4 of pregnancy, coincident with progesterone action on the endometrium. On day 6 of pregnancy, fibronectin mRNAs encoding the V95 and A regions were preferentially localized to the mesometrial zone of the subepithelial stroma. Accumulation of these mRNA splicing variants at the mesometrial zone was dependent upon decidualization, but the embryo was not required. Thus, there are two major changes in uterine fibronectin gene expression as a result of pregnancy: increased fibronectin mRNA content and mesometrial localization. These changes suggest a key function for fibronectin in implantation and imply the operation of a regulatory program of fibronectin gene expression which depends on hormonal sensitization and a nidatory stimulus.

Fibronectin is overproduced by keloid fibroblasts during abnormal wound healing

Wound healing in certain individuals leads to the development of keloid tumors which exhibit abnormal collagen metabolism and an increased abundance of extracellular matrix components. Comparison of fibronectin levels in fibroblasts derived from keloids and normal dermis revealed a relative increase in intracellular and extracellular fibronectin in the keloid-derived cells. While fibronectin was similarly processed, compartmentalized, and degraded by both cell types, fibronectin biosynthesis was found to be accelerated as much as fourfold in keloid fibroblasts due to a corresponding increase in the amount of accumulated fibronectin mRNA. These changes account for the elevated steady-state level of the molecule in keloid fibroblasts and suggest that increased fibronectin in keloid lesions is due to overproduction by the wound-healing fibroblasts. Glucocorticoid treatment stimulated fibronectin biosynthesis in both normal and keloid fibroblasts. However, the amount of stimulation was less for the keloid-derived cells, indicating a limitation on maximal rates of fibronectin biosynthesis. These observations suggest that separate mechanisms act to control basal and maximal rates of fibronectin production. Biosynthesis of the 140-kilodalton fibronectin receptor was also found to be increased in keloid fibroblasts, suggesting some level of coordinate regulation for fibronectin and fibronectin receptor expression.