POS0844 EFFECTS OF SERIAL LOCALLY APPLIED WATER-FILTERED INFRARED A RADIATION IN PATIENTS WITH SYSTEMIC SCLEROSIS WITH SEVERE RAYNAUD’S SYNDROME RECEIVING PROSTAGLANDINE TREATMENT – A RANDOMIZED CONTROLLED TRIAL

Background:

More than 95% of patients with systemic sclerosis (SSc) suffer from Raynaud’s syndrome (RS) leading to digital ulcerations (DU). In severe RS, intravenous application of prostaglandins is required. Moreover, these patients profit from an additional non-pharmacological treatment using hyperthermia to increase vasodilatation and perfusion, and to reduce pain.

Serial locally applied water-filtered infrared A radiation (sl-wIRAR) is a hyperthermia treatment modality using infrared heat radiation in the range of 780-1400nm with high tissue penetration and low thermal load on the skin surface [1]. wIRAR has both, temperature-dependent and non-dependent effects, which do not inherit thermal energy transfer and/or relevant temperature changes [1]. It is therefore not only used in acute and chronic wound healing as it promotes perfusion, alleviates pain and has anti-infectious effects [2], but is also used in oncology [3] and rheumatology [4].

Objectives:

We conducted a randomized controlled trial with a follow-up visit after 2 weeks to evaluate the value of a high-frequent hyperthermia treatment using sl-wIRAR in comparison to a low-frequent hyperthermia treatment (our standard) in SSc patients with severe RS receiving Iloprost treatment.

Methods:

Eligible patients had SSc according to the 2013 ACR/EULAR classification criteria, were 18 to 80 years old and had RS requiring treatment with Iloprost in an in-patient setting. Key exclusion criteria were contraindications to any hyperthermia treatment such as infection or heat insensitivity. The trial was conducted at Campus Kerckhoff of Justus-Liebig University Giessen. Eligible patients were equally randomized to the intervention group (IG) receiving additional sl-wIRAR treatment (2 treatments for 30 min per day for 8 days) plus the standard of care (Iloprost treatment over 8 days plus daily carbon dioxide hand baths of 20 min) and the control group (CG) receiving only the standard of care. Primary outcome was the between-group difference in pain measured on a numeric rating scale (NRS) after intervention. Key secondary outcomes included a change in RS frequency, RS duration, and a change in Interleukin (IL) -6 and VEGF levels.

Results:

From 01.03.2020 to 31.12.2020 49 SSc patients met the inclusion criteria. 42 patients were enrolled (IG: 21, CG: 21). 38 patients (IG:19, CG: 19) completed the full trial period and were analyzed. There was no statistically significant between-group difference in pain levels (NRS) (p=0.284, Z -1.082 (Mann-Whitney U Test)) and thus the primary outcome was not met. Therefore, all p values for secondary outcomes are nominal. Intensity (Visual analogue scale 0-100mm) and duration (min) of RS were reduced in the IG (mean ± standard error) -14.579 ± 7.214 mm (p=0.058) and -2.917 ± 1.510 min (p=0.08), respectively. Intra- and inter-group comparison of IL-6 and VEGF levels showed no relevant change.

Conclusion:

The additive and frequent use of sl-wIRAR in the treatment of SSc patients with RS requiring Iloprost treatment does not improve outcomes regarding pain levels, RS intensity or frequency nor IL-6 and VEGF levels when compared to Iloprost treatment and low-frequent hyperthermia application.

References:

[1]Hoffmann G. Clinical applications of water-filtered infrared-A (wIRA) – a review. Phys Med Rehab Kuror. 2017;27(05):265–274.

[2]Hoffmann G, Harte M, Mercer JB. Heat for wounds – water-fil- tered infrared-a (wIRA) for wound healing – a review. GMS Ger Med Sci. 2016;14:Doc08.

[3]Notter M, Thomsen AR, Nitsche M, et al. Combined wIRA-hyperthermia and hypofractionated re-irradiation in the treatment of locally recurrent breast cancer: evaluation of therapeutic outcome based on a novel size classification. Cancers (Basel). 2020;12(3): 606.

[4]Klemm P, Eichelmann M, Aykara I et al. Serial locally applied water-filtered infrared a radiation in axial spondyloarthritis – a randomized controlled trial, International Journal of Hyperthermia, 37:1, 965-970.

Acknowledgements:

We acknowledge the help of Carina Schreiyäck.

This study was in part supported by the Dr. med. h.c. Erwin Braun Foundation, Basel, a charitable, nonprofit Swiss scientific foundation approved by the Swiss Federal Administration. The foundation supports clinical investigation of waterfiltered infrared-A. The foundation was not involved in any content- or decision-related aspect of the study.

This study was prospectively registered at www.drks.de (German Registry of Clinical Studies): DRKS00021098

Disclosure of Interests:

None declared

POS1492-HPR EVALUATION OF A VIRTUAL REALITY-BASED APPLICATION TO EDUCATE HEALTHCARE PROFESSIONALS AND MEDICAL STUDENTS ABOUT INFLAMMATORY ARTHRITIS

Background:

Inflammatory arthritides (IA), such as rheumatoid arthritis or psoriatic arthritis, are disorders that can be difficult to comprehend for health professionals and students in terms of the heterogeneity of clinical symptoms and pathologies. New didactic approaches using innovative technologies such as Virtual Reality (VR) applications could be helpful to demonstrate disease manifestations as well as joint pathologies in a more comprehensive way. However, the potential of using a VR education concept in IA has not yet been evaluated.

Objectives:

We evaluated the feasibility of a VR application to educate healthcare professionals and medical students about IA.

Methods:

We developed a VR application using IA patients data as well as two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images (1). This VR application (called Rheumality) allows the user to interact with representative arthritic joint and bone pathologies of IA patients (Figure 1 A, B). In a consensus meeting an online questionnaire was designed to collect basic demographic data (age, sex), profession of the participants, and their feedback on the general impression, knowledge gain and potential areas of application of the VR application. The VR application was subsequently tested and evaluated by healthcare professionals (physicians, researchers, and other healthcare professionals) and medical students at predefined events (two annual rheumatology conferences and academic teaching seminars at two sites in Germany).

Results:

125 individuals participated in this study (56% female, 43% male, 1% non-binary). 59% of the participants were between 18-30 years of age, 18% between 31-40, 10% between 41-50, 8% between 51-60 and 5% were between 61-70. Of the participants, 50 were physicians, five researchers and four other health care professionals, the remaining were medical students (66). The participants rated the application as excellent (Figure 1 C, D), the mean rating of the VR application was 9.0/10 (SD 1.2) and many participants would recommend the use of the application, with a mean recommendation score of 3.2/4 (SD 1.1). A large majority stated that the presentation of pathological bone formation improves the understanding of the disease (120 out of 125 (96%)).

Conclusion:

The data show that IA-targeting innovative teaching approaches based on VR technology are feasible. The use of VR applications enables a disease-specific knowledge visualization and may add a new educational pillar to conventional educational approaches.

References:

[1]Kleyer A et al. Z Rheumatol 78, 112–115 (2019)

Figure 1.

Illustration of the VR application and evaluation results

Two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images in a patient with long-standing (inadequately treated) RA (A) and a patient with early RA (B). Overall rating (range 0-10) on the VR application divided into four different professional subgroups (C); recommendations of VR application in the four different professional subgroups (D). HC, health care professionals; Boxplot explanation: Crossbars represent medians, whiskers represent 5-95 percentiles (points below the whiskers are drawn as individual points), box always extends from the 25th to 75th percentiles (hinges of the plot).

Disclosure of Interests:

Philipp Klemm Consultant of: Lilly Deutschland GmbH, Arnd Kleyer Speakers bureau: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, Koray Tascilar: None declared, Louis Schuster: None declared, Timo Meinderink: None declared, Florian Steiger: None declared, Uwe Lange: None declared, Ulf Müller-Ladner: None declared, Johannes Knitza Speakers bureau: Lilly Deutschland GmbH, Philipp Sewerin Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Johanna Mucke Consultant of: Lilly Deutschland GmbH, Alexander Pfeil Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Georg Schett: None declared, Fabian Hartmann Consultant of: Lilly Deutschland GmbH, Axel Hueber Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH, David Simon Speakers bureau: Lilly Deutschland GmbH, Paid instructor for: Lilly Deutschland GmbH, Consultant of: Lilly Deutschland GmbH, Grant/research support from: Lilly Deutschland GmbH

POS1458-HPR DIGITAL RHEUMATOLOGY IN THE ERA OF COVID-19: RESULTS OF A NATIONAL PATIENT AND PHYSICIAN SURVEY

Background:

Digital health applications (DHAs) are gaining influence and promise great potential for the monitoring and management of rheumatic and musculoskeletal diseases (RMDs).

Objectives:

To analyse the impact of the COVID-19 pandemic on RMD patients’ and rheumatologists’ usage, preferences, and perception of digital health applications (DHAs) in Germany.

Methods:

A web-based national survey was developed by the Working Group Young Rheumatology of the German Society for Rheumatology and the German League against Rheumatism. The prospective survey was distributed via social media, QR-code, and email. Descriptive statistics were calculated, and regression analyses were performed to show correlations.

Results:

We analysed the responses of 299 patients and 129 rheumatologists. Most patients (74%) and rheumatologists (76%) believed that DHAs are useful in the management of RMDs and felt confident in their own usage thereof (90%; 86%). 38% of patients and 71% of rheumatologists reported that their attitude had changed positively towards DHAs and that their usage had increased due to COVID-19 (29%; 48%).

Usage and recommendation of DHAs for both groups are shown in Figure 1:

Figure 1.

Usage or recommendation of digital health applications. Patients and rheumatologists were asked to indicate the specific digital health applications (DHAs) they used or were recommended.

The majority in both groups agreed on implementing virtual visits for follow-up appointments in stable disease conditions. The most reported advantages of DHAs were usage independent of time and place (76.6%; 77.5%). The main barriers were a lack of information on suitable, available DHAs (58.5%; 41.9%), poor usability (42.1% of patients) and a lack of evidence supporting the effectiveness of DHAs (23.2% of rheumatologists) (Table 1).

Table 1.

Advantages and Barriers of DHA, n (%).

AdvantagesBarriersPatientsRheumatologistsPatientsRheumatologistsLocation-Independence229 (76.6)100 (77.5)Too little information175 (58.5)54 (41.9)Time-independence223 (74.6)94 (72.9)Too little evidence of benefits36 (12.0)30 (23.3)Detailed documentation97 (32.4)47 (36.4)Poor quality of current apps47 (15.7)29 (22.5)Cost saving95 (31.8)37 (28.7)Concernsabout data protection52 (17.4)25 (19.4)More information88 (29.4)38 (29.5)Lack of usability126 (42.1)17 (13.2)Independenceof doctors+36 (12.0)-Lack of accessibility4 (1.3)-More flexibility107 (36.8)77 (59.7)High costs4 (1.3)23 (17.8)Preparationfor discussion+46 (15.4)-No suitable equipment17 (5.7)11 (8.5)No advantages at all18 (6.0)1 (0.8)Lack of user competenceNo Need9 (3.0)39 (13.0)-12 (9.3)

Patients and rheumatologists were asked about the advantages and barriers of DHAs. Multiple answers were allowed. Patients had two additional potential advantages and potential barriers to choose from*.

Only a minority (<10% in both groups) believed that digitalisation has a negative impact on the patient-doctor relationship.

Conclusion:

The COVID-19 pandemic instigated an increase in patients’ and rheumatologists’ acceptance and usage of DHAs, possibly introducing a permanent paradigm shift in the management of RMDs.

Acknowledgements:

The authors thank the following persons and societies for their great effort, distributing the online survey: P.Aries, A.Hueber, E.Feist, C.Fiehn, P.Korsten, I.Kötter, F.Mühlensiepen, A.Pfeil, M.Rudwaleit, M.Welcker, S.Zinke, Deutsche Vereinigung Morbus Bechterew e.V., Deutsche Rheuma-Liga Bundesverband e. V., Sklerodermie Selbsthilfe e.V.

Disclosure of Interests:

Anna Kernder: None declared, Harriet Morf: None declared, Philipp Klemm: None declared, Diana Vossen Speakers bureau: Novartis, Abbvie, Amgen, Consultant of: Abbvie Deutschland GmbH & Co. KG, Bristol-Myer Squibb, Celgene GmbH, Gilead Sciences Inc., Lilly Deutschland GmbH, Medac GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH, UCB Pharma GmbH, Grant/research support from: Pfizer, Abbvie, Marco Meyer Consultant of: Medac, Isabell Haase Speakers bureau: Medac, Consultant of: Medac, Grant/research support from: UCB, Abbvie, BMS, Johanna Mucke Speakers bureau: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Consultant of: AbbVie Deutschland GmbH & Co. KG, Amgen, Bristol-Myers Squibb, Chugai Pharma Germany GmbH, Celgene GmbH, Gilead Sciences Inc., GlaxoSmithKline, Janssen-Cilag GmbH, Lilly Deutschland GmbH, Novartis Pharma GmbH, Pfizer Deutschland GmbH and UCB Pharma GmbH., Arnd Kleyer Shareholder of: yes, Speakers bureau: Lilly, Novartis, Consultant of: Abbvie, Lilly, Novartis BMS, Gilead,Janssen, Grant/research support from: Lilly, Novartis, Gilead,, Philipp Sewerin Consultant of: AbbVie, Amgen, Axiom Health, Biogen, Bristol-Myers Squibb, Celgene, Chugai Pharma Marketing Ltd./Chugai Europe, Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Johnson & Johnson, Lilly, Medi-login, Mediri GmbH, Novartis Pharma, Onkowissen GmbH, Pfizer, Roche Pharma, Rheumazentrum Rhein-Ruhr, Sanofi-Genzyme, Swedish Orphan Biovitrum, and UCB, Grant/research support from: AbbVie, Amgen, Biogen, Bristol-Myers Squibb, Bundesministerium fuer Bildung und Forschung (BMBF), Deutsche Forschungsgesellschaft (DFG), Deutscher Psoriasis-Bund, Fresenius Kabi, Gilead Sciences, Hexal Pharma, Janssen-Cilag, Lilly, Novartis Pharma, Pfizer, Rheumazentrum Rhein-Ruhr, Roche Pharma, Sanofi-Genzyme, and UCB, Gerlinde Bendzuck: None declared, Sabine Eis: None declared, Johannes Knitza Consultant of: Abbvie, Novartis, Lilly, Medac, BMS, Sanofi, Amgen, Gilead, UCB, ABATON, GSK, Grant/research support from: Novartis, UCB, Thermofisher, Sanofi, Martin Krusche Speakers bureau: Lilly, Medac, Novartis, Roche/Chugai, Consultant of: Abbvie, Lilly, Gilead, Medac, Novartis, Sobi, BMS, Amgen, GSK, Grant/research support from: Sanofi

OP0075 EVALUATION OF A VIRTUAL REALITY TEACHING CONCEPT FOR MEDICAL STUDENTS DURING THE SARS-COV-2 PANDEMIC

Background:

The ongoing COVID-19 pandemic has disrupted face-to-face teaching of medical students and forced efforts in finding alternative approaches. In order to help maintain high-quality education, a new virtual reality (VR)-based concept for training medical students in rheumatic and musculoskeletal diseases (RMD) has been developed. This VR training concept is based on the integration of real patient data with two- and three-dimensional visualized pathological joints from X-ray and computed tomography generated images.

Objectives:

To evaluate the practicability and acceptance of the VR training application in the digital curricular education of medical students during the COVID-19 pandemic.

Methods:

A short refresher lecture on rheumatic diseases (duration 60 minutes) was followed by presenting the VR training concept to the students. The VR training concept included the demonstration of three virtual patients with early rheumatoid arthritis, rheumatoid arthritis psoriatic arthritis regarding the symptoms, current medical problems, disease patterns at the imaging (conventional radiographs and high-resolution computed tomography) and therapy options. The practicability and acceptance of the VR was evaluated by medical students using a survey.

Results:

The study encompassed 237 medical students (163 female, 73 male, one diverse, age range 20 to 40 years). 72 % of the participants rated the virtual teaching as good or very good. 87 % presented an expanded knowledge for rheumatoid arthritis and psoriatic arthritis through the VR. Moreover, 91 % reported that the lecture provided a deeper understanding of RMD. Furthermore, 60 % of the students asked for additional courses by VR.

Conclusion:

The study highlighted the usefulness of innovative VR tools for teaching medical students digitally about RMD. VR applications can be a complementary educational modality for medical students, especially during the COVID-19 pandemic, to provide students with the best possible clinical experience while ensuring that patient, student, and staff safety is not compromised.

Figure 1.

A Screen view of virtual reality included three virtual patients with early rheumatoid arthritis (RA), RA, and psoriatic arthritis (PsA) and B demonstration of structural damage in RA and PsA using hand X-ray and high-resolution quantitative computed tomography images.

Disclosure of Interests:

Alexander Pfeil Speakers bureau: Lilly Pharma Deutschland GmbH, Franz Marcus: None declared, Tobias Hoffmann: None declared, Philipp Klemm Consultant of: Lilly Pharma Deutschland GmbH, Peter Oelzner: None declared, Ulf Müller-Ladner Consultant of: Lilly Pharma Deutschland GmbH, Axel Hueber Consultant of: Lilly Pharma Deutschland GmbH, Uwe Lange: None declared, Gunter Wolf: None declared, Georg Schett: None declared, David Simon Consultant of: Lilly Pharma Deutschland GmbH, Arnd Kleyer Consultant of: Lilly Pharma Deutschland GmbH

Maternal high-fat diet during lactation reprograms the dopaminergic circuitry in mice

The maternal perinatal environment modulates brain formation, and altered maternal nutrition has been linked to the development of metabolic and psychiatric disorders in the offspring. Here, we showed that maternal high-fat diet (HFD) feeding during lactation in mice elicits long-lasting changes in gene expression in the offspring's dopaminergic circuitry. This translated into silencing of dopaminergic midbrain neurons, reduced connectivity to their downstream targets, and reduced stimulus-evoked dopamine (DA) release in the striatum. Despite the attenuated activity of DA midbrain neurons, offspring from mothers exposed to HFD feeding exhibited a sexually dimorphic expression of DA-related phenotypes, i.e., hyperlocomotion in males and increased intake of palatable food and sucrose in females. These phenotypes arose from concomitantly increased spontaneous activity of D1 medium spiny neurons (MSNs) and profoundly decreased D2 MSN projections. Overall, we have unraveled a fundamental restructuring of dopaminergic circuitries upon time-restricted altered maternal nutrition to induce persistent behavioral changes in the offspring.

[Paget's disease of bone-a current review of clinical aspects, diagnostics and treatment]

Paget's disease is a monostotic or polyostotic progressive skeletal disease with a genetic predisposition. The affected bone areas show osseous swelling and often grotesque deformation, chronic pain and fractures. Many cases are asymptomatic for a long time resulting in a late diagnosis. The pathogenesis is still unknown. In addition to a genetic predisposition, viral factors are also discussed. Laboratory tests and imaging are used for diagnosis. The effective principle of medicinal bisphosphonate treatment is to inhibit osteoclastic bone resorption and should be initiated early to prevent secondary complications. This article presents the current knowledge about this rare osteological disease.

THU0625-HPR ELECTRONIC PATIENT-REPORTED OUTCOMES: A SURVEY ABOUT ACCEPTANCE, USAGE AND BARRIERS AMONG GERMAN RHEUMATOLOGISTS

Background:

The use of patient-reported outcomes (PROs) allows for patient-centered, measurable and transparent care. Electronic PROs (ePROs) have many benefits and hold great potential to improve current usage of PROs; yet, limited evidence exists regarding acceptance, usage and barriers among rheumatologists.

Objectives:

This study aimed to evaluate the current level of acceptance, usage, and barriers among German rheumatologists regarding the utilization of ePROs. The importance of different ePRO features for rheumatologists was investigated. Additionally, the most frequently used PROs for patients with rheumatoid arthritis (RA) were identified

Methods:

Data was collected via an online survey consisting of 18 questions. The survey was completed by members of the Working Group Young Rheumatologists of the German Society for Rheumatology (Deutsche Gesellschaft für Rheumatologie (DGRh)) at the annual 2019 DGRh conference. Only members currently working in clinical rheumatology were eligible to complete the survey.

Results:

A total of 119 rheumatologists completed the survey. 90% reported collecting PROs in routine practice and 25.5% already used ePROs. 44.3% were planning to switch to ePROs in the near future.The main reason for collecting PROs was for clinical decision making (66.4%), followed by research (39.5%), reimbursement (23.5%), internal quality management (21.9%) and patient satisfaction (16.8%). The most commonly cited reason for not switching to ePROs was the unawareness of suitable software solutions (figure 1).Respondents were asked to rate the features for ePROs on a scale of 0-100 (0 = unimportant, 100 = important). The most important features were automatic score calculation and display (score: 77.5), as well as the simple data transfer to medical reports (76.9) (table 1).When asked about PROs in RA, the respondents listed pain, morning stiffness and physician global assessment (PGA) as the most frequently used PROs (figure 2).

Table 1.

Ratings for features of ePRO on a scale of 0-100 (0 = unimportant, 100 = important))

QuestionmeanSDHow important would the graphic display be to you for ePROs?63.531.19How important would the automatic score calculation and display of ePROs be to you?77.527.64How important would the simple transfer of the ePROs in medical report be to you?76.930.07How important would an automatic alarm of yourself be for you if a critical threshold is exceeded by an ePRO?51.6533.5How important would an automatic alarm of the patient be for you if a critical threshold is exceeded by an ePRO?34.5530.61Figure 1.

Reasons why ePROs are currently not used (multiple answers were possible for question)

Figure 2.

PROs being used in clinical practice and their respective frequency

Conclusion:

The potential of ePROs is widely seen, and there is a great interest in ePROs. Despite this, a minority of physicians only uses ePROs, and the main reason for not implementing was cited as the unawareness of suitable software solutions.

Developers, patients and rheumatologists should work closely together to help realize the full potential of ePROs and ensure a seamless integration into clinical practice.

Disclosure of Interests:

Martin Krusche Consultant of: Sanofi, Novartis and Medac, Speakers bureau: Roche/Chugai, Novartis, Sobi,, Philipp Klemm Consultant of: Lilly, Medac, Manuel Grahammer Shareholder of: MG is MD and shareholder of Abaton GmbH, Johanna Mucke: None declared, Diana Vossen Consultant of: Medac, Novartis, Abvie, Speakers bureau: Abvie, BMS, Arnd Kleyer Consultant of: Lilly, Gilead, Novartis,Abbvie, Speakers bureau: Novartis, Lilly, Philipp Sewerin Grant/research support from: AbbVie Deutschland GmbH & Co. KG

Bristol-Myers Squibb Celgene GmbH

Lilly Deutschland GmbH

Novartis Pharma GmbH Pfizer Deutschland GmbH

Rheumazentrum Rhein-Ruhr, Consultant of: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Speakers bureau: AMGEN GmbH AbbVie Deutschland GmbH & Co. KG Biogen GmbHBristol-Myers Squibb Celgene GmbH Chugai Pharma arketing Ltd. / Chugai Europe GmbHHexal Pharma Janssen-CilagGmbH Johnson & Johnson Deutschland GmbHLilly Deutschland GmbH / Lilly Europe / Lilly Global Novartis Pharma GmbH Pfizer Deutschland GmbH Roche Pharma Rheumazentrum Rhein-Ruhr Sanofi-Genzyme Deutschland GmbH Swedish Orphan Biovitrum GmbH UCB Pharma GmbH, Johannes Knitza Grant/research support from: Research Grant: Novartis

THU0350 LOGOPEDIC TESTING IN SSC PATIENTS REVEALS HIGH FREQUENCY OF OROPHARYNGEAL DYSFUNCTION: A MONOCENTRIC EXPERIENCE

Background:

Up to 98% of patients with systemic sclerosis (SSc) show involvement of the gastrointestinal system (GI) [1]. While meteorism, heartburn and GI dysmotility are very common and accessible to pharmacologic treatment on an evidence based level [1–3], checking for oropharyngeal dysfunction is usually not part of the standard diagnostic algorithm. However, in a survey of the German Network for Systemic Sclerosis (DNSS) patients reported coughing and/or a sore voice in up to 78% [1]. As impairment in speaking or swallowing for example does not only substantially reduce quality of life, it can also be very stigmatizing. In addition, the usual prokinetic therapy of GI-involvement, e.g. metoclopramide, does not appear to improve these symptoms. As the first step to approach this problem is the qualitative and quantitative description, we evaluated the oropharyngeal function in our cohort of SSc patients by detailed logopedic assessment.

Objectives:

To evaluate the frequency and type of oropharyngeal dysfunction, e.g. swallowing or speaking, in patients with SSc and to elucidate the correlating and associated factors, e.g. disease duration or modified Rodnan Skin Score.

Methods:

After obtaining written consent, oropharyngeal function using a standardized assessment protocol was evaluated in patients with SSc fulfilling the ACR/EULAR criteria by a speech therapist. Furthermore, we investigated whether oropharyngeal dysfunction is associated with patients’ characteristics. In addition, all patients received instruction for a training program to treat their individual oropharyngeal dysfunction.

Results:

37 patients with d/lSSc were assessed for eligibility. 34 patients met the inclusion criteria (3 patients did not speak German) and written consent was obtained.

Oropharyngeal dysfunction (impairment of speaking, swallowing, breathing or oropharyngeal muscle function) was found in 29 of 34 (85%) of both l/dSSc patients. Neither the subtype of SSc, disease duration nor mRSS were significantly correlated with oropharyngeal dysfunction in general. Only GI involvement in general was associated with oropharyngeal dysfunction.

After logopedic therapy, 28 of the 34 (82%) patients with oropharyngeal dysfunction reported a benefit after 3 days of training and were motivated to continue logopedic training at home.

Oropharyngeal dysfunctionPresent(n=29)absent(n=5)p-values (x2-test)dcSSc800,027lcSSc2240,027disease duration (mean)12,7 y12 y0,462mRSS<4920,322mRSS>42030,322Raynauds syndrom2950,673digital ulcers1920,812lung fibrosis1120,596eosophageal dilatation1520,566eosophageal dysmotility1900,015GI-involvement2310,007

Conclusion:

Logopedic assessment revealed a high incidence of oropharyngeal dysfunction in our cohort of SSc patients. Oropharyngeal dysfunction was not associated with disease duration, skin- or lung-involvement or dcSSc/lcSSc differentiation. A logopedic training program seems to be of benefit for this currently not pharmacologically treatable problem.

References:

[1]Schmeiser T, Saar P, Jin D, Noethe M, Müller A, Soydan N, et al. Profile of gastrointestinal involvement in patients with systemic sclerosis. Rheumatol Int 2012;32:2471–8.doi:10.1007/s00296-011-1988-6.

[2]Boeckxstaens GE, Bartelsman JFWM, Lauwers L, Tytgat GNJ. Treatment of GI dysmotility in scleroderma with the new enterokinetic agent prucalopride. Am J Gastroenterol 2002;97:194–7.doi:10.1016/S0002-9270(01)03958-2.

[3]Mercado U, Arroyo de Anda R, Avendaño L, Araiza-Casillas R, Avendaño-Reyes M. Metoclopramide response in patients with early diffuse systemic sclerosis. Effects on esophageal motility abnormalities. Clin Exp Rheumatol 2005;23:685–8.

Disclosure of Interests:

Miriam Wirths: None declared, Ole Hudowenz: None declared, Ulrike Hoffmann: None declared, Ulf Müller-Ladner Speakers bureau: Biogen, Uwe Lange: None declared, Philipp Klemm Consultant of: Lilly, Medac

Mechanical stress enhances CD9 expression in cultured podocytes

Elevated glomerular pressure represents a high risk for the development of severe kidney diseases and causes an increase in mechanical load to podocytes. In this study, we investigated whether mechanical stress alters gene expression in cultured podocytes using gene arrays. We found that tetraspanin CD9 is significantly upregulated in cultured podocytes after mechanical stress. The differential expression of CD9 was confirmed by RT-PCR and Western blotting under stretched and unstretched conditions. Furthermore, mechanical stress resulted in a relocalization of CD9. To get an insight into the functional role of CD9, podocytes were transfected with pEGFP-CD9. The expression of CD9 induced the formation of substratum-attached thin arborized protrusions. Ca(2+) depletion revealed that podocytes overexpressing CD9 possess altered adhesive properties in contrast to the control transfected cells. Finally, elevated CD9 expression increased migration of podocytes in a wound assay. In summary, our results suggest that upregulation of CD9 may play an important role in podocyte morphology, adhesion, and migration.

Anti-adhesive properties of fish tropomyosins

AIMS

We have recently found that preconditioning of stainless steel surfaces with an aqueous fish muscle extract can significantly impede bacterial adhesion. The purpose of this study was to identify and characterize the primary components associated with this bacteria-repelling effect.

METHODS AND RESULTS

The anti-adhesive activity was assayed against Escherchia coli K-12, and bacterial adhesion was quantified by crystal violet staining and sonication methods. Proteolytic digestion, elution and fractionation experiments revealed that the anti-adhesive activity of the extract was linked to the formation of a proteinaceous conditioning film composed primarily of fish tropomyosins. These fibrous proteins formed a considerable anti-adhesive conditioning layer on and reduced bacterial adhesion to several different materials including polystyrene, vinyl plastic, stainless steel and glass. The protein adsorption profiles obtained from the various materials did not differ significantly, but elution was often incomplete making minor qualitative/quantitative differences indiscernible.

CONCLUSIONS

The data highlights the significance of protein conditioning films on bacterial adhesion and emphasizes the importance of substratum's physiochemical properties and exposure time with regards to protein adsorption/elution efficiency and subsequent bacterial adhesion.

SIGNIFICANCE AND IMPACT OF THE STUDY

Fish tropomyosin-coatings could potentially offer a nontoxic and relatively inexpensive measure of reducing bacterial colonization of inert surfaces.

[Tracheal agenesis. A rare cause of respiratory insufficiency in neonates]

Tracheal agenesis is a very rare congenital anomaly that occurs isolated or in combination with other anomalies. It presents immediately after birth with an absolute respiratory insufficiency and lack of crying. The immediate precise anatomical classification of the anomaly is crucial in order to decide if surgical therapy is possible. This report describes a newborn boy with tracheal agenesis type II. The diagnosis was confirmed by spiral computed tomography and a selection of the pictures is presented. The treatment was discontinued due to a lack of therapeutical options. Based on this case report we discuss the special situation of this rare anomaly. Interesting information on tracheal agenesis was gathered, the differential diagnosis of respiratory insufficiency of the newborn is summarised and a modified algorithm of the current newborn resuscitation guidelines of the American Heart Association is presented.

Laparoscopic coagulation of the uterine blood supply in laparoscopic-assisted vaginal hysterectomy is associated with less blood loss

BACKGROUND

Does laparoscopic coagulation of the uterine blood supply decrease blood loss compared with transvaginal ligature of the uterine vessels?

METHODS

Intra- and postoperative data of 446 patients undergoing laparoscopic-assisted vaginal hysterectomy at the Department of Gynecology, University of Jena, between 1998 and 2001 were analysed. In 213 patients the uterine blood supply was transected laparoscopically at the origin of the uterine vessels (LAVH type II) and in 233 patients (LAVH type I) transvaginally.

RESULTS

Patients in both groups were comparable with respect to median age, Quetelet index, and parity. The drop of hemoglobin between the preoperative day and postoperative day 3 was 0.8 mmol/l or 0.6 mmol/l for LAVH type I without or with BSO vs 0.3 mmol/l or 0.4 mmol/l for LAVH type II without or with BSO (p = 0.001), respectively. Median operative time was similar for both techniques: LAVH type I 136 min or with BSO 128 min vs LAVH type II 126 min or with BSO 131 min. The weight of the removed uteri was significantly lower in LAVH type I vs type II (220 vs 270 grams), but similar when LAVH was combined with BSO (160 vs 178 grams). The rate of intraoperative complications was 2.2% vs 0.9% between LAVH type I or II (n.s.), but 9% vs 3.3% for overall postoperative complications (p = 0.01).

CONCLUSIONS

Laparoscopic coagulation of the uterine blood supply at the origin of uterine vessels is a safe technique which minimizes blood loss in LAVH. In patients with a low preoperative hemoglobin value this technique is indicated.

Resection of presacral ganglioneurofibroma by laparoscopy

BACKGROUND

Tumors of the retrorectal space are rare. They comprise a heterogeneous group of benign or malignant tumors that cause similar symptoms due to their location in presacral space. If possible, complete surgery excision is the therapy of choice mainly through a sacral, abdominal-sacral, or a pure abdominal or perineal axis.

CASE REPORT

A 15-year-old asymptomatic patient was diagnosed with a retrouterine tumor during her first gynecological examination. Magnetic resonance imaging of the pelvis showed a 10 x 8.5 x 7-cm encapsulated presacral tumor. Retrorectal ganglioneurofibroma was removed by laparoscopy with preservation of the sympathetic and parasympathetic nerves and the sacral roots of the ischiadic nerves. No sensory or motoric dysfunction of the legs, bladder, or rectum was observed postoperatively.

CONCLUSION

This is the first case report of a complete endoscopic removal of large presacral ganglioneurofibroma in an asymptomatic woman.

Laparoscopic-assisted vaginal hysterectomy with lateral transsection of the uterine vessels

BACKGROUND

Increased safety and diminished blood loss are achieved through laparoscopic-assisted vaginal hysterectomy by selective coagulation and transsection of the uterine vessels at their origin.

METHODS

Three laparoscopic steps are performed: coagulation and transsection of the round ligament, of the uterine artery at its origin, and of the fallopian tube and ovarian ligament or (in BSO) the infundibulopelvic ligament. The uterine vessels are identified from the pararectal space and, following the internal liliac artery, and the ureter. Hysterectomy is completed transvaginally.

RESULTS

Two hundred and sixty-seven patients underwent this procedure. Mean operation time was 121 min, and hemoglobin decreased to 0.6 g/dl by postoperative day 3. It took 8.4 min on average to identify and coagulate the uterine artery.

CONCLUSIONS

Lateral transsection of the uterine vessels is safe and blood sparing and can be used in patients in whom blood loss must be minimized.

DNA microarray analysis of fim mutations in Escherichia coli

Bacterial adhesion is often mediated by complex polymeric surface structures referred to as fimbriae. Type 1 fimbriae of Escherichia coli represent the archetypical and best characterised fimbrial system. These adhesive organelles mediate binding to D-mannose and are directly associated with virulence in the urinary tract. A typical type 1 fimbriated bacterium has up to 500 fimbriae on its surface, with each fimbria consisting of approximately 1000 individual subunits. This equates to approximately 8% of the total cellular protein and is potentially a significant resource drain for the cell. Here we have used DNA microarray analysis to examine the molecular events involved in response to fimbrial gene expression in E. coli K-12. Observed differential expression levels of the fim genes were in good agreement with our current knowledge of the stoichiometry of type 1 fimbriae. Changes in fim expression correlated directly with alterations in colony morphology. Deletion of the entire fim gene cluster resulted in the converse expression of another surface protein Antigen 43 (Ag43). Specific deletion of the fimH gene did not affect expression of other fim genes or Ag43, but did dramatically reduce the number of fimbriae expressed on the cell surface. The use of high-resolution oligonucleotide arrays for defining points of transcription initiation and termination is also demonstrated.

Novel Zn(2+)-chelating peptides selected from a fimbria-displayed random peptide library

The display of peptide sequences on the surface of bacteria is a technology that offers exciting applications in biotechnology and medical research. Type 1 fimbriae are surface organelles of Escherichia coli which mediate D-mannose-sensitive binding to different host surfaces by virtue of the FimH adhesin. FimH is a component of the fimbrial organelle that can accommodate and display a diverse range of peptide sequences on the E. coli cell surface. In this study we have constructed a random peptide library in FimH. The library, consisting of approximately 40 million individual clones, was screened for peptide sequences that conferred on recombinant cells the ability to bind Zn(2+). By serial selection, sequences that exhibited various degrees of binding affinity and specificity toward Zn(2+) were enriched. None of the isolated sequences showed similarity to known Zn(2+)-binding proteins, indicating that completely novel Zn(2+)-binding peptide sequences had been isolated. By changing the protein scaffold system, we demonstrated that the Zn(2+)-binding seems to be uniquely mediated by the peptide insert and to be independent of the sequence of the carrier protein. These findings might be applied in the design of biomatrices for bioremediation purposes or in the development of sensors for detection of heavy metals.

[The extralobar sequestration of the fetal lung]

The extralobar sequestration is a rare pulmonary malformation. An accurate antenatal evaluation is required for a timely therapy and subsequently a good outcome. Here an unusual case of extralobar pulmonary sequestration in a male human fetus is reported. Antenatal ultrasound at 28th week of gestation has revealed a fetal hydrothorax in coexistence with pulmonary hypoplasia and an isolated pulmonary structure. Authors summarise their postnatal findings with special reference to the pathogenesis of an accessory lung. The aim of this report is to define the association of clinical, gross, and histological features of this rare congential malformation in order to improve the antenatal diagnosis. This case indicates that an extralobar pulmonary sequester is not connected to the tracheobronchial tree, and that the arterial as well as the venous blood supply is realised by aberrant systemic vessels. Moreover, histologically revealed dilatations of the normally differentiated terminal airways within the sequester suggest that hyperechogenity can not be a reliable diagnostic criterion. For the accurate assessment of a pulmonary sequestration a detailed antenatal evaluation of both, the arterial and the venous blood supply is essential.

FimH-mediated autoaggregation of Escherichia coli

Autoaggregation is a phenomenon thought to contribute to colonization of mammalian hosts by pathogenic bacteria. Type 1 fimbriae are surface organelles of Escherichia coli that mediate d-mannose-sensitive binding to various host surfaces. This binding is conferred by the minor fimbrial component FimH. In this study, we have used random mutagenesis to identify variants of the FimH adhesin that confer the ability of E. coli to autoaggregate and settle from liquid cultures. Three separate autoaggregating clones were identified, all of which contained multiple amino acid changes located within the N-terminal receptor-binding domain of FimH. Autoaggregation could not be inhibited by mannose, but was inhibited by growth at temperatures at or below 30 degrees C. Using green fluorescent protein (GFP) as a reporter, we show that the autoaggregating clones do not mix with wild-type fimbriated cells. Electron microscopy shows that autoaggregating cells produce fimbriae with a twisted and entangled appearance. We present evidence that autoaggregating versions of FimH also occur in nature. Our results stress the highly adaptive nature of the ubiquitous FimH adhesin.

Valency conversion in the type 1 fimbrial adhesin of Escherichia coli

FimH protein is a lectin-like adhesive subunit of type 1, or mannose-sensitive, fimbriae that are found on the surface of most Escherichia coli strains. All naturally occurring FimH variants demonstrate a conserved mannotriose-specific (i.e. multivalent) binding. Here, we demonstrate that replacement of residues 185-279 within the FimH pilin domain with a corresponding segment of the type 1C fimbrial adhesin FocH leads to a loss of the multivalent mannotriose-specific binding property accompanied by the acquisition of a distinct monomannose-specific (i.e. monovalent) binding capability. Bacteria expressing the monovalent hybrid adhesins were capable of binding strongly to uroepithelial tissue culture cells and guinea pig erythrocytes. They could not, however, agglutinate yeast or bind human buccal cells -- functions readily accomplished by the E. coli-expressing mannotriose-specific FimH variants. Based on the relative potency of inhibiting compounds of different structures, the receptor binding site within monovalent FimH-FocH adhesin has an extended structure with an overall configuration similar to that within the multivalent FimH of natural origin. The monomannose-only specific phenotype could also be invoked by a single point mutation, E89K, located within the lectin domain of FimH, but distant from the receptor binding site. The structural alterations influence the receptor-binding valency of the FimH adhesin via distal effects on the combining pocket, obviously by affecting the FimH quaternary structure.

Biofilm formation in a hydrodynamic environment by novel fimh variants and ramifications for virulence

Type 1 fimbriae are surface-located adhesion organelles of Escherichia coli that are directly associated with virulence of the urinary tract. They mediate D-mannose-sensitive binding to different host surfaces by way of the minor fimbrial component FimH. Naturally occurring variants of FimH that bind strongly to terminally exposed monomannose residues have been associated with a pathogenicity-adaptive phenotype that enhances E. coli colonization of extraintestinal locations such as the urinary tract. The FimH adhesin also promotes biofilm formation in a mannose-inhibitable manner on abiotic surfaces under static growth conditions. In this study, we used random mutagenesis combined with a novel selection-enrichment technique to specifically identify mutations in the FimH adhesin that confer on E. coli the ability to form biofilms under hydrodynamic flow (HDF) conditions. We identified three FimH variants from our mutant library that could mediate an HDF biofilm formation phenotype to various degrees. This phenotype was induced by the cumulative effect of multiple changes throughout the receptor-binding region of the protein. Two of the HDF biofilm-forming FimH variants were insensitive to mannose inhibition and represent novel phenotypes not previously identified in naturally occurring isolates. Characterization of our enriched clones revealed some similarities to amino acid alterations that occur in urinary tract infection (UTI) strains. Subsequent screening of a selection of UTI FimH variants demonstrated that they too could promote biofilm formation on abiotic surfaces under HDF conditions. Interestingly, the same correlation was not observed for commensal FimH variants. FimH is a multifaceted protein prone to rapid microevolution. In addition to its previously documented roles in adherence and invasion, we have now demonstrated its function in biofilm formation on abiotic surfaces subjected to HDF conditions. The study indicates that UTI FimH variants possess adaptations that enhance biofilm formation and suggests a novel role for FimH in UTIs associated with medical implants such as catheters.

Antigen 43 facilitates formation of multispecies biofilms

Antigen 43 (Ag43) is a surface-displayed autotransporter protein of Escherichia coli. By virtue of its self-association characteristics, this protein is able to mediate autoaggregation of E. coli cells in static cultures. Here, we show that Ag43 can be expressed in a functional form on the surface of Pseudomonas fluorescens. Ag43 expression dramatically enhances the biofilm-forming potential of both E. coli and P. fluorescens to abiotic surfaces in simple microtitre well assays and in flow chambers. Importantly, Ag43-expressing E. coli and P. fluorescens cells tagged with Gfp and Rfp were shown to form interwoven biofilms in flow chambers. The three-dimensional structures of the biofilms were analysed by laser-confocal microscopy. Heterogeneous expression of Ag43 induced interspecies cell-to-cell contact that generated multispecies biofilm formation. Our data indicate that this versatile molecular tool can be used for the rational design of multispecies biofilms. More specifically, this novel technology offers opportunities for the design of multispecies consortia in which the concerted action of several bacterial species is required, e.g. waste treatment and degradation of pollutants.

Expression of type 1 and P fimbriae in situ and localisation of a uropathogenic Escherichia coli strain in the murine bladder and kidney

Adhesion is an important aspect of bacterial colonisation and induction of human disease. Escherichia coli which infects and causes disease of the urinary tract expresses several adherence factors including type 1 and P fimbriae. Their expression has been implicated in the virulence of E. coli strains infecting the urinary tract, however, the evidence for the expression of these fimbriae in situ has been implied rather than proven. Here we describe in situ detection of E. coli and of fimbrial expression in urinary tract tissue. Kidneys and bladders were isolated from mice infected with the uropathogenic isolate E. coli AD110. The tissue was sectioned and subjected to DNA-rRNA hybridization and indirect immunofluorescent staining with antibodies against type 1 and P fimbriae. Sections of both kidney and bladder stained positive for bacterial cells using a Cy3-labelled E. coli-specific rRNA probe. The same cells in these sections also stained positive for type 1 or P fimbriae using fluorescein-labelled antibodies. Tissue taken from several different time points (2, 6, and 24 hours post infection) showed the presence of bacterial cells which stained positive for fimbrial expression. Bacteria in kidney and bladder sections were observed either as individual cells associated with the mucosa or as members of microcolonies.

Antigen 43 from Escherichia coli induces inter- and intraspecies cell aggregation and changes in colony morphology of Pseudomonas fluorescens

Antigen 43 (Ag43) is a surface-displayed autotransporter protein of Escherichia coli. By virtue of its self-association characteristics, this protein is able to mediate autoaggregation and flocculation of E. coli cells in static cultures. Additionally, surface display of Ag43 is associated with a distinct frizzy colony morphology in E. coli. Here we show that Ag43 can be expressed in a functional form on the surface of the environmentally important Pseudomonas fluorescens strain SBW25 with ensuing cell aggregation and frizzy colony types. Using green fluorescence protein-tagged cells, we demonstrate that Ag43 can be used as a tool to provide interspecies cell aggregation between E. coli and P. fluorescens. Furthermore, Ag43 expression enhances biofilm formation in P. fluorescens to glass surfaces. The versatility of this protein was also reflected in Ag43 surface display in a variety of other gram-negative bacteria. Display of heterologous Ag43 in selected bacteria might offer opportunities for rational design of multispecies consortia where the concerted action of several bacterial species is required, e.g., waste treatment and degradation of pollutants.

An inpatient cervical cancer screening program to reach underserved women

Underserved women (e.g., African American, older women of all races) are less likely to be screened than other groups. The Johns Hopkins Hospital began the Cervical Cancer Screening Program (CCSP) to provide direct Papanicolaou (Pap) test screening to inpatient females. Over a 1-year period, 256 women received Pap tests as part of the CCSP. Of these, 56% (n = 144) were African American, 36% (n = 92) received medical assistance benefits, and only 47% (n = 120) had health insurance. The CCSP is an effective way to screen low-income and underserved females who otherwise may not be screened.

Expression and purification of the mannose recognition domain of the FimH adhesin

Type 1 fimbriae have been shown to be specifically required for Escherichia coli colonisation and pathogenesis of the urinary tract. These structural organelles mediate specific adhesion to alpha-D-mannosides by virtue of the FimH adhesin. FimH is a two-domain protein in which the N-terminal domain contains the receptor-binding site and the C-terminal domain is required for organelle integration. To date, FimH has only been isolated as a complex with the system-specific chaperone FimC. Here we report that a functional form of the FimH receptor-binding domain can be readily isolated and characterised by replacing the C-terminal domain with a histidine tag.

Fimbriae-assisted bacterial surface display of heterologous peptides

The display of peptide segments on the surface of bacteria offers many new and exciting applications in biotechnology and medical research. Fimbria-assisted display of heterologous sequences is a paradigm for chimeric organelle display on bacteria. Fimbriae are particularly attractive candidates for epitope display for several reasons: (1) they are present in extremely high numbers at the cell surface, (2) they are strong immunogens, (3) they possess inherent adhesive properties, and (4) they can be easily purified. The majority of work dealing with fimbria-assisted peptide display has been focused on the development of recombinant vaccines. A number of different fimbrial types have been used to display immune-relevant sectors of various foreign proteins. Chimeric fimbrial vaccines can be used in the context of purified proteins, however the potential also exists to exploit this technology for the development of live recombinant vaccines. Work has also been performed demonstrating the amenability of fimbriae towards the powerful technology of random peptide display. This review summarises the current state of research in this field.

Functional flexibility of the FimH adhesin: insights from a random mutant library

Type 1 fimbriae are surface organelles of Escherichia coli which mediate D-mannose-sensitive binding to different host surfaces. This binding is conferred by the minor fimbrial component FimH. Naturally occurring variants of the FimH protein have been selected in nature for their ability to recognize specific receptor targets. In particular, variants that bind strongly to terminally exposed monomannose residues have been associated with a pathogenicity-adaptive phenotype that enhances E. coli colonization of extraintestinal locations such as the urinary bladder. In this study we have used random mutagenesis to specifically identify nonselective mutations in the FimH adhesin which modify its binding phenotype. Isogenic E. coli clones expressing FimH variants were tested for their ability to bind yeast cells and model glycoproteins that contain oligosaccharide moieties rich in either terminal monomannose, oligomannose, or nonmannose residues. Both the monomannose- and the oligomannose-binding capacity of type 1 fimbriae could be altered by minor amino acid changes in the FimH protein. The monomannose-binding phenotype was particularly sensitive to changes, with extensive differences in binding being observed in comparison to wild-type FimH levels. Different structural alterations were able to cause similar functional changes in FimH, suggesting a high degree of flexibility to target recognition by this adhesin. Alteration of residue P49 of the mature FimH protein, which occurs within the recently elucidated carbohydrate-binding pocket of FimH, completely abolished its function. Amino acid changes that increased the binding capacity of FimH were located outside receptor-interacting residues, indicating that functional changes relevant to pathogenicity are likely to be due to conformational changes of the adhesin.

Demands of illness in people treated for colorectal cancer

PURPOSE/OBJECTIVES

To describe the most common and most intense demands of illness in people with colorectal cancer.

DESIGN

Descriptive, comparative.

SETTING

People with colorectal cancer were accrued through weekly online computer postings.

SAMPLE

121 people (68 men and 53 women) from 35 states (n = 106) and six other countries (n = 15) who were treated for colon, rectal, or anal cancer.

METHODS

Mailed questionnaires included a 125-item, self-report instrument with seven subscales (Demands of Illness Inventory (DOII) and a 14-item demographic form.

MAIN RESEARCH VARIABLES

Demands of illness, time since treatment, perception of illness state, activity level, and age.

FINDINGS

Demands of illness were greatest in the personal meaning domain, with more than 93% of subjects reporting that they thought about the value of life and how long they might live. More than 85% reported uncertainty in six similar areas. The 10 most intense demands were predominately psychosocial and existential concerns. Respondents in the youngest age group (< 45 years) reported significantly greater demands in six of seven domains of the DOII than the middle and older groups. Three variables (time since treatment, perception of illness, activity level) accounted for 45% of the variance in DOII scores.

CONCLUSIONS

Colorectal cancer imposed significant psychosocial and existential concerns on respondents, especially the youngest age group.

IMPLICATIONS FOR NURSING PRACTICE

Nurses should address these concerns with patients while continuing to identify and scientifically test creative strategies to minimize psychosocial morbidity.

Bacterial adhesins: function and structure

Specific adhesion to host tissue cells is an essential virulence factor of most bacterial pathogens. The fundamental processes that determine bacterial attachment to host tissue surfaces are mediated by microbial adhesins. Host specificity and tissue tropism are characteristics exhibited by different bacteria and are determined (at least in part) by the interaction between adhesins and their complementary receptors on host cell surfaces. A detailed picture of how bacteria are able to target to various receptors is emerging. A large number of bacterial adhesins with individual receptor specificities have been identified. Furthermore, recent research has shown that individual adhesins are prone to rapid microevolution that results in changes in the receptor specificity of individual adhesins. Microbial adhesins are often assembled into complex polymeric organelle structures, however non-organelle adhesins linked to the cell surface as monomers or simple oligomers also exist. This review gives an overview of bacterial adhesins and focuses on some general aspects of their biogenesis and role in bacterial colonization of host cell surfaces and as virulence factors.

Antigen 43 and type 1 fimbriae determine colony morphology of Escherichia coli K-12

Colony morphology has been used as an important identification and characterization criterion in bacteriology for many decades. However, the molecular mechanisms underlying the appearance of different colony types have been given little attention. The synthesis of O antigen is defunct in Escherichia coli K-12, and colonies should accordingly only appear to be rough. However, previous reports have noted the presence of different interchangeable colony morphology types. In this study we have addressed the influence of two phase-variable surface structures, antigen 43 and type 1 fimbriae, on colony morphology. Due to differential expression of these structures, four different colony phenotypes could be distinguished. By creating and studying defined mutants of the respective loci, i.e. , flu and fim, we conclude that the presence or absence of the corresponding gene products on the cells correlates with the observed colony morphology forms. Interestingly, the habitat specificity of bacteria under static liquid conditions seems to correlate with the colony phenotypes.

FimE-catalyzed off-to-on inversion of the type 1 fimbrial phase switch and insertion sequence recruitment in an Escherichia coli K-12 fimB strain

We have investigated the capacity of a well-defined Escherichia coli fimB strain, AAEC350 (a derivative of MG1655), to express type 1 fimbriae under various growth conditions. The expression of type 1 fimbriae is phase-variable due to the inversion of a 314-bp DNA segment. Two tyrosine recombinases, FimB and FimE, mediate the inversion of the phase switch. FimB can carry out recombination in both directions, whereas the current evidence suggests that FimE-catalyzed switching is on-to-off only. We show here that AAEC350 is in fact capable of off-to-on phase switching and type 1 fimbrial expression under aerobic static growth conditions. The phase switching is mediated by FimE, and allows emerging fimbriate AAEC350 to outgrow their non-fimbriate counterparts by pellicle formation. Following inversion of the phase switch, this element can remain phase-locked in the on orientation due to integration of insertion sequence elements, viz. IS1 or IS5, at various positions in either the fimE gene or the phase switch.

Sequestration of zinc oxide by fimbrial designer chelators

Type 1 fimbriae are surface organelles of Escherichia coli. By engineering a structural component of the fimbriae, FimH, to display a random peptide library, we were able to isolate metal-chelating bacteria. A library consisting of 4 x 10(7) independent clones was screened for binding to ZnO. Sequences responsible for ZnO adherence were identified, and distinct binding motifs were characterized. The sequences selected exhibited various degrees of affinity and specificity towards ZnO. Competitive binding experiments revealed that the sequences recognized only the oxide form of Zn. Interestingly, one of the inserts exhibited significant homology to a specific sequence in a putative zinc-containing helicase, which suggests that searches such as this one may aid in identifying binding motifs in nature. The zinc-binding bacteria might have a use in detoxification of metal-polluted water.

Type 1 fimbriation and phase switching in a natural Escherichia coli fimB null strain, Nissle 1917

Escherichia coli Nissle 1917 has been used as a probiotic against intestinal disorders for many decades. It is a good colonizer of the human gut and has been reported to be able to express type 1 fimbriae. Type 1 fimbriae are surface organelles which mediate alpha-D-mannose-sensitive binding to various host cell surfaces. The expression is phase variable, and two tyrosine recombinases, FimB and FimE, mediate the inversion of the fimbrial phase switch. Current evidence suggests that FimB can carry out recombination in both directions, whereas FimE-catalyzed switching is on to off only. We show here that under liquid shaking growth conditions, Nissle 1917 did not express type 1 fimbriae, due to a truncation of the fimB gene by an 1,885-bp insertion element. Despite its fimB null status, Nissle 1917 was still capable of off-to-on switching of the phase switch and expressing type 1 fimbriae when grown under static conditions. This phase switching was not catalyzed by FimE, by truncated FimB, or by information residing within the insertion element. No further copies of fimB seemed to be present on the chromosome of Nissle 1917, suggesting that another tyrosine recombinase in Nissle 1917 is responsible for the low-frequency off-to-on inversion of the phase switch that is strongly favored under static growth conditions. This is the first report documenting the non-FimB- or non-FimE-catalyzed inversion of the fim switch.

Antigen-43-mediated autoaggregation of Escherichia coli is blocked by fimbriation

Antigen 43 (Ag43), the product of the flu gene, is a surface-displayed autotransporter protein of Escherichia coli. Ag43 is responsible for the autoaggregation and flocculation of static liquid cultures of many E. coli strains. The expression of Ag43 has been reported to be phase variable and controlled by the product of the oxyR gene. Type 1 fimbriae are thin adhesive thread-like surface organelles responsible for bacterial receptor recognition and tissue colonization. Like that of Ag43, the expression of type 1 fimbriae is phase variable. Interestingly, previous results have suggested that the expression of type 1 fimbriae and the expression of Ag43 are mutually exclusive. In the present report, we show, by use of well-defined mutants, that fimbriation abolishes Ag43-mediated autoaggregation but does not affect Ag43 expression. Autoaggregation is shown to require an intercellular Ag43-Ag43 interaction, and the physical presence of fimbriae on the cells seems to abrogate this interaction. The Ag43 or OxyR status does not appear to influence fimbria expression, and our results suggest that the expression of Ag43 and the expression of fimbriae are independent processes.

Spiritual well-being and demands of illness in people with colorectal cancer

The purpose of this descriptive correlational study was to identify the relationship between subjects' spiritual well-being and the demands of illness (DOI) imposed by colorectal cancer. Potential subjects were notified about the study through computer networks. Those who met the criteria and wished to participate in the study used e-mail to request a study packet, which included an explanation of the study, the Demands of Illness Inventory (DOII), the Spiritual Well-Being Scale (SWBS), a demographic form, and a stamped return-reply envelope. Of the 170 packets requested, 121 (71%) were returned complete. More than half of the respondents were men and were of a Christian faith. Most respondents reported physical symptoms, but were able to carry on normal activity. Demands of illness were greater among men, the youngest subjects, those who received treatment in the previous 2 months, and those who reported decreased activity, metastatic disease, and/or terminal status. Women reported significantly greater spiritual well-being than men. Subjects who reported higher levels of spiritual well-being indicated significantly lower DOI related to physical symptoms, monitoring symptoms, and treatment issues. Findings indicate that a greater degree of spiritual well-being may help to mitigate the DOI imposed by colorectal cancer.