Regulatory T Cell Biomarkers Identify Patients at Risk of Developing Acute Cellular Rejection in the First Year Following Heart Transplantation

BACKGROUND

Acute cellular rejection (ACR), an alloimmune response involving CD4+ and CD8+ T cells, occurs in up to 20% of patients within the first year following heart transplantation. The balance between a conventional versus regulatory CD4+ T cell alloimmune response is believed to contribute to developing ACR. Therefore, tracking these cells may elucidate whether changes in these cell populations could signal ACR risk.

METHODS

We used a CD4+ T cell gene signature (TGS) panel that tracks CD4+ conventional T cells (Tconv) and regulatory T cells (Treg) on longitudinal samples from 94 adult heart transplant recipients. We evaluated combined diagnostic performance of the TGS panel with a previously developed biomarker panel for ACR diagnosis, HEARTBiT, while also investigating TGS' prognostic utility.

RESULTS

Compared with nonrejection samples, rejection samples showed decreased Treg- and increased Tconv-gene expression. The TGS panel was able to discriminate between ACR and nonrejection samples and, when combined with HEARTBiT, showed improved specificity compared with either model alone. Furthermore, the increased risk of ACR in the TGS model was associated with lower expression of Treg genes in patients who later developed ACR. Reduced Treg gene expression was positively associated with younger recipient age and higher intrapatient tacrolimus variability.

CONCLUSIONS

We demonstrated that expression of genes associated with CD4+ Tconv and Treg could identify patients at risk of ACR. In our post hoc analysis, complementing HEARTBiT with TGS resulted in an improved classification of ACR. Our study suggests that HEARTBiT and TGS may serve as useful tools for further research and test development.

IMplementing Predictive Analytics towards efficient COPD Treatments (IMPACT): protocol for a stepped-wedge cluster randomized impact study

INTRODUCTION

Personalized disease management informed by quantitative risk prediction has the potential to improve patient care and outcomes. The integration of risk prediction into clinical workflow should be informed by the experiences and preferences of stakeholders, and the impact of such integration should be evaluated in prospective comparative studies. The objectives of the IMplementing Predictive Analytics towards efficient chronic obstructive pulmonary disease (COPD) treatments (IMPACT) study are to integrate an exacerbation risk prediction tool into routine care and to determine its impact on prescription appropriateness (primary outcome), medication adherence, quality of life, exacerbation rates, and sex and gender disparities in COPD care (secondary outcomes).

METHODS

IMPACT will be conducted in two phases. Phase 1 will include the systematic and user-centered development of two decision support tools: (1) a decision tool for pulmonologists called the ACCEPT decision intervention (ADI), which combines risk prediction from the previously developed Acute COPD Exacerbation Prediction Tool with treatment algorithms recommended by the Canadian Thoracic Society's COPD pharmacotherapy guidelines, and (2) an information pamphlet for COPD patients (patient tool), tailored to their prescribed medication, clinical needs, and lung function. In phase 2, we will conduct a stepped-wedge cluster randomized controlled trial in two outpatient respiratory clinics to evaluate the impact of the decision support tools on quality of care and patient outcomes. Clusters will be practicing pulmonologists (n ≥ 24), who will progressively switch to the intervention over 18 months. At the end of the study, a qualitative process evaluation will be carried out to determine the barriers and enablers of uptake of the tools.

DISCUSSION

The IMPACT study coincides with a planned harmonization of electronic health record systems across tertiary care centers in British Columbia, Canada. The harmonization of these systems combined with IMPACT's implementation-oriented design and partnership with stakeholders will facilitate integration of the tools into routine care, if the results of the proposed study reveal positive association with improvement in the process and outcomes of clinical care. The process evaluation at the end of the trial will inform subsequent design iterations before largescale implementation.

TRIAL REGISTRATION

NCT05309356.

P11 Evaluation of in vitro activity of double β-lactam therapy and relationship with PBP activity in Escherichia coli isolates

Background

PBPs are involved in the construction of peptidoglycan, which is the major constituent of bacterial cell walls and the target of β-lactam antibiotics. There is little published research analysing the relationship between β-lactams with differing bacterial PBP targets and how they can be manipulated in combinations with respect to clinical or microbiological (e.g. resistance) outcomes (i.e. does expanded PBP activity via a combination lead to better in vitro/in vivo outcomes).

Objectives

To systematically explore the relationship between double β-lactam therapy (with and without at least one partner being a β-lactamase inhibitor antibiotic such as co-amoxiclav) and in vitro activity against susceptible Escherichia coli strains.

Methods

We systematically explored the relationship between double β-lactam therapy combinations against seven E. coli strains of variable resistance in vitro. This included fully susceptible isolates, ESBL producers and carbapenemase producers (CPEs). For each of 10 antibiotics, the MIC was determined individually, and subsequently in combination with 9 further antibiotics, using the MTS™ ‘cross’ synergy method (Liofilchem, 2012).

Results

Overall, 86/630 (13.6%) of all combinations tested showed synergy and 408/630 (64.8%) were additive; 136/630 (21.6%) combinations showed indifference. Of the 86 ‘bug–drug’ combinations that showed synergy, 42/86 (49%) included ceftazidime/avibactam, representing 42/126 (33%) of all ceftazidime/avibactam-based combinations tested, and 56/86 (65%) of synergistic combinations covered PBP2. Synergy was most commonly detected in ESBL producers (58/86; 67% of combinations) and less frequently seen in CPEs (2/86; 2% of combinations) and fully susceptible isolates (8/86; 9% of combinations). Additive effects were seen in 92/180 (51%) combinations versus ESBLs, compared with 18/90 (20%) in CPEs, versus 154/180 (86%) in fully susceptible isolates. No antagonism was identified with any antibiotic combination.

Conclusions

In the combinations tested, synergy or additive effects were common (78%); similar to our previous work with fosfomycin/β-lactam combinations (89%), but higher than we found with fosfomycin/non-β-lactam combinations (28%). Many of the synergistic bug–drug combinations identified contained a β-lactam inhibitor as a partner and/or provided PBP2 activity. This provisionally suggests a role for PBP2 (also targeted by avibactam) in synergy, although the presence of a β-lactamase inhibitor may also be important. Confirmation using an alternative method and mechanistic elucidation is required. The clinical/microbiological importance of such effects remains unclear.

Experiences of the SARS-CoV-2 pandemic amongst Australian healthcare workers: from stressors to protective factors

BACKGROUND

The SARS-CoV-2 pandemic has critically challenged healthcare systems globally. Examining the experiences of healthcare workers (HCWs) is important for optimizing ongoing and future pandemic responses.

OBJECTIVES

In-depth exploration of Australian HCWs' experiences of the SARS-CoV-2 pandemic, with a focus on reported stressors vis-à-vis protective factors.

METHODS

Individual interviews were performed with 63 HCWs in Australia. A range of professional streams and operational staff were included. Thematic analysis was performed.

RESULTS

Thematic analysis identified stressors centred on paucity of, or changing, evidence, leading to absence of, or mistrust in, guidelines; unprecedented alterations to the autonomy and sense of control of clinicians; and deficiencies in communication and support. Key protective factors included: the development of clear guidance from respected clinical leaders or recognized clinical bodies, interpersonal support, and strong teamwork, leadership, and a sense of organizational preparedness.

CONCLUSIONS

This study provides insights into the key organizational sources of emotional stress for HCWs within pandemic responses and describes experiences of protective factors. HCWs experiencing unprecedented uncertainty, fear, and rapid change, rely on clear communication, strong leadership, guidelines endorsed by recognized expert groups or individuals, and have increased reliance on interpersonal support. Structured strategies for leadership and communication at team, service group and organizational levels, provision of psychological support, and consideration of the potential negative effects of centralizing control, would assist in ameliorating the extreme pressures of working within a pandemic environment.

Occurrence of bacteria with technological and probiotic potential in Argentinian human breast-milk

Breast milk can be a source of potential probiotic bacteria, but the technological capacity of isolates obtained from this source is not always guaranteed. We aimed at isolating lactobacilli from breast milk samples collected in Argentina, focusing on isolates with functional and technological potential as probiotics. Fourteen Lactobacillus and one Bifidobacterium isolates were obtained from 164 samples donated by 104 mothers. The isolates preliminarily identified by MALDI-TOF, and then the identity was confirmed by partial 16S rRNA gene sequencing. Hydrophobicity was determined (hexadecane and xylene partition). The strains were also co-cultured with murine RAW 264.7 macrophages for screening the capacity to induce the anti-inflammatory cytokine interleukin (IL)-10. Hydrophobicity ranged from 7.4 and 95.9%. The strains Lactobacillus gasseri (70a and 70c) and Lactobacillus plantarum (73a and 73b) were the strains with a higher capacity to induce IL-10 production by macrophages. The technological application was evaluated by freezing dried in 10% lactose or 10% polydextrose. The survival was assessed after accelerated (37 °C, 4 weeks) or long-term (5 and 25 °C, 12 months) storage. Except for Lactobacillus gallinarum 94d, strains lost less than 1 Log10 order cfu/g after long-term (12 months) storage at 5 °C in lactose and polydextrose as protectants. A low correlation between survival to accelerated and long-term storage tests was observed. L. gasseri (70a and 70c) and L. plantarum (73a and 73b) deserve further studies as potential probiotics due to their capacity to induce IL-10 from murine macrophages and their hydrophobicity. In special, L. plantarum 73a was able to confer enhanced protection against Salmonella infection by promoting the immunity of the small intestine.

Happy Hookers: findings from an international study exploring the effects of crochet on wellbeing

AIMS

With rising rates of mental health disorders being reported globally, it is imperative that we investigate economical and accessible ways to increase relaxation and reduce stress. While there is a plethora of anecdotal evidence as to the positive effects of domestic crafts on mental wellbeing, there is little empirical research in this area. As such, we aimed to explore perceived links between crochet and wellbeing.

METHODS

An online survey was developed and piloted, based on an existing tool that explored knitting and wellbeing. The final survey was promoted through social media, over a 6-week period, resulting in valid responses from 8391 individuals.

RESULTS

Most respondents were female (99.1%), aged between 41 and 60 years (49.5%) and living in 87 different countries. Many respondents reported crocheting for between 1 and 5 years (42.6%). The three most frequent reasons reported for crocheting were: to be creative (82.1%), to relax (78.5%) and for a sense of accomplishment (75.2%). Respondents reported that crochet made them feel calmer (89.5%), happier (82%) and more useful (74.7%). There was a significant improvement in reported scores for mood before crocheting (M = 4.19, SD = 1.07) and mood after crocheting (M = 5.78, SD = 0.82); z = -69.86, p < .001, r = -0.56. Content analysis of free-text responses identified five major themes: (1) health benefits, (2) process of crochet, (3) personal connection, (4) crochet as contribution and (5) online crochet communities.

CONCLUSION

The data suggests that crochet offers positive benefits for personal wellbeing with many respondents actively using crochet to manage mental health conditions and life events such as grief, chronic illness and pain. Crochet is a relatively low-cost, portable activity that can be easily learnt and seems to convey all of the positive benefits provided by knitting. This research suggests that crochet can play a role in promoting positive wellbeing in the general population, adding to the social prescribing evidence base.

Novel bifidobacteria strains isolated from nonconventional sources. Technological, antimicrobial and biological characterization for their use as probiotics

AIM

To characterize four novel autochthonous bifidobacteria isolated from monkey faeces and a Bifidobacterium lactis strain isolated from chicken faeces by evaluating their technological and biological/functional potential to be used as probiotics. Different stressors, including food process parameters and storage, can affect their viability and functionality.

METHODS AND RESULTS

The resistance to frozen storage, tolerance to lyophilization and viability during storage, thermal, acidic and simulated gastric resistance, surface hydrophobicity and antimicrobial activity against pathogens were studied. Bifidobacterium lactis Bb12 and INL1 were used as reference strains. The results obtained demonstrated that the new isolates presented strain-dependent behaviour. Good results were obtained for thermal resistance, frozen storage at -80°C and lyophilized powders maintained at 5°C. Cell viability during refrigerated storage was higher when the strains were resuspended in milk at pH 5·0 than at 4·5. The surface hydrophobicity ranged between 7 and 98% depending on the strain. The simulated gastric resistance was improved for the strains incorporated in cheese. Regarding antimicrobial activity, bifidobacteria isolated from monkey presented higher inhibitory capacity than the reference strains.

CONCLUSION

This research provides a deeper insight into new strains of bifidobacteria isolated from primates and chicken that have not been previously characterized for their potential use in dairy products and confirm the most robust stress tolerance of B. lactis.

SIGNIFICANCE AND IMPACT OF THE STUDY

The possibility of expanding the available bifidobacteria with the potential to be added to a probiotic food necessarily implies characterizing them from different points of view, especially when considering unknown species. For monkey isolates (which showed higher antimicrobial activity against pathogens), more in-depth knowledge is needed before applying strategies to improve their performance. On the contrary, the chicken isolate B. lactis P32/1 showed similar behaviour to the references B. lactis strains; therefore, it could be considered as a potential probiotic candidate.

A Double-Blind Trial of Intramuscular Stanozolol in the Prevention of Postoperative Deep Vein Thrombosis Following Elective Abdominal Surgery

Fibrinolytic shutdown may be important in the development of postoperative deep vein thrombosis (DVT). We have previously shown that stanozolol 50 mg, given intramuscularly 24 hr before surgery, prevents the decrease in plasminogen activator activity (PA) seen on the first postoperative day in patients at high risk of DVT. To investigate the role of fibrinolytic shutdown in causation of DVT, sixty patients were randomised in a double-blind controlled trial to receive stanozolol or placebo intramuscularly, and DVT was detected by leg scanning and confirmed by venography. Scan positive DVT occurred in IT of 31 placebo patients (35%) and 12 of 29 who received stanozolol (41%). A significant decrease in PA was confirmed in the placebo group, while stanozolol caused a significant increase in PA on the first postoperative day. Patients in either group who did not develop DVT showed minimal changes in PA. We conclude that prevention of fibrinolytic shutdown by this regimen of stanozolol does not prevent postoperative DVT, and that further studies are required to clarify the relationships of postoperative fibrinolysis and DVT.

The Effects of Acute Smoking on Platelet Behaviour, Fibrinolysis and Haemorheology in Habitual Smokers

There is an increased frequency of arterial thrombosis in cigarette smokers. The changes in blood coagulation seen in these subjects have been studied by many workers but results have not always been in agreement. We wished to study the effects of acute .smoking on platelet behaviour, fibrinolysis and haemorheology in ten habitual smokers, and to compare these results with nonsmoking controls. Results show that the smoking group had higher plasma fibrinogen (p <0.04), lower plasminogen (p <0.02) and plasminogen activator (p <0.05), and higher plasma viscosity (p <0.003). The changes seen in cigarette smokers after smoking three cigarettes were an increase in the rate of platelet aggregation to ADP (p <0.02), an increase in α2M, (p <0.02), and factor VIII RAG (p <0.05). Plasma viscosity was decreased (p <0.02) as was red cell deformability (p >0.02).

We confirm an increased tendency to hypercoagulability in smokers compared to controls which becomes more pronounced immediately after smoking three cigarettes.

Non-invasive acquisition of fetal ECG from the maternal xyphoid process: a feasibility study in pregnant sheep and a call for open data sets

OBJECTIVE

The utility of fetal heart rate (FHR) monitoring can only be achieved with an acquisition sampling rate that preserves the underlying physiological information on the millisecond time scale (1000 Hz rather than 4 Hz). For such acquisition, fetal ECG (fECG) is required, rather than the ultrasound to derive FHR. We tested one recently developed algorithm, SAVER, and two widely applied algorithms to extract fECG from a single-channel maternal ECG signal recorded over the xyphoid process rather than the routine abdominal signal.

APPROACH

At 126dG, ECG was attached to near-term ewe and fetal shoulders, manubrium and xyphoid processes (n  =  12). fECG served as the ground-truth to which the fetal ECG signal extracted from the simultaneously-acquired maternal ECG was compared. All fetuses were in good health during surgery (pH 7.29  ±  0.03, pO₂ 33.2  ±  8.4, pCO₂ 56.0  ±  7.8, O₂Sat 78.3  ±  7.6, lactate 2.8  ±  0.6, BE  -0.3  ±  2.4).

MAIN RESULT

In all animals, single lead fECG extraction algorithm could not extract fECG from the maternal ECG signal over the xyphoid process with the F1 less than 50%.

SIGNIFICANCE

The applied fECG extraction algorithms might be unsuitable for the maternal ECG signal over the xyphoid process, or the latter does not contain strong enough fECG signal, although the lead is near the mother's abdomen. Fetal sheep model is widely used to mimic various fetal conditions, yet ECG recordings in a public data set form are not available to test the predictive ability of fECG and FHR. We are making this data set openly available to other researchers to foster non-invasive fECG acquisition in this animal model.

Prenatal Factors Associated with Postnatal Brain Injury in Infants with Congenital Diaphragmatic Hernia

BACKGROUND AND PURPOSE

Approximately 60% of infants with congenital diaphragmatic hernia have evidence of brain injury on postnatal MR imaging. It is unclear whether any brain injury is present before birth. In this study, we evaluated fetal MR imaging findings of brain injury and the association of congenital diaphragmatic hernia severity with postnatal brain injury.

MATERIALS AND METHODS

Fetal MR imaging and postnatal brain MR imaging were retrospectively evaluated in 36 cases of congenital diaphragmatic hernia (from 2009 to 2014) by 2 pediatric neuroradiologists. Brain injury on postnatal MR imaging and brain injury and congenital diaphragmatic hernia severity on fetal MR imaging were recorded. Correlations between brain abnormalities on fetal and postnatal brain MR imaging were analyzed. Postnatal brain injury findings correlating with the severity of congenital diaphragmatic hernia were also assessed.

RESULTS

On fetal MR imaging, enlarged extra-axial spaces (61%), venous sinus distention (21%), and ventriculomegaly (6%) were identified. No maturational delay, intracranial hemorrhage, or brain parenchymal injury was identified on fetal MR imaging. On postnatal MR imaging, 67% of infants had evidence of abnormality, commonly, enlarged extra-axial spaces (44%). Right-sided congenital diaphragmatic hernia was associated with a greater postnatal brain injury score (P = .05). Low observed-to-expected lung volume was associated with postnatal white matter injury (P = .005) and a greater postnatal brain injury score (P = .008). Lack of liver herniation was associated with normal postnatal brain MR imaging findings (P = .03).

CONCLUSIONS

Fetal lung hypoplasia is associated with postnatal brain injury in congenital diaphragmatic hernia, suggesting that the severity of lung disease and associated treatments affect brain health as well. We found no evidence of prenatal brain parenchymal injury or maturational delay.

RNAseq profiling of primary microglia and astrocyte cultures in near-term ovine fetus: A glial in vivo-in vitro multi-hit paradigm in large mammalian brain

BACKGROUND

The chronically instrumented fetal sheep is a widely used animal model to study fetal brain development in health and disease, but no methods exist yet to interrogate dedicated brain cell populations to identify their molecular and genomic phenotype. For example, the molecular mechanisms whereby microglia or astrocytes contribute to inflammation in the brain remain incompletely understood.

NEW METHOD

Here we present a protocol to derive primary pure microglial or astrocyte cultures from near-term fetal sheep brain, after the animals have been chronically instrumented and studied in vivo. Next, we present the implementation of whole transcriptome sequencing (RNAseq) pipeline to deeper elucidate the phenotype of such primary sheep brain glial cultures.

RESULTS

We validate the new primary cultures method for cell purity and test the function of the glial cells on protein (IL-1β) and transcriptome (RNAseq) levels in response to a lipopolysaccharide (LPS) challenge in vitro.

COMPARISON WITH EXISTING METHODS

This method represents the first implementation of pure microglial or astrocytes cultures in fetal sheep brain.

CONCLUSIONS

The presented approach opens new possibilities for testing not only supernatant protein levels in response to an in vitro challenge, but also to evaluate changes in the transcriptome of glial cells derived from a large mammalian brain bearing high resemblance to the human brain. Moreover, the presented approach lends itself to modeling the complex multi-hit paradigms of antenatal and perinatal cerebral insults in vivo and in vitro.

Correlation of MRI Brain Injury Findings with Neonatal Clinical Factors in Infants with Congenital Diaphragmatic Hernia

BACKGROUND AND PURPOSE

Infants with congenital diaphragmatic hernia are reported to have evidence of brain MR imaging abnormalities. Our study aimed to identify perinatal clinical factors in infants with congenital diaphragmatic hernia that are associated with evidence of brain injury on MR imaging performed before hospital discharge.

MATERIALS AND METHODS

MRIs performed before hospital discharge in infants with congenital diaphragmatic hernia were scored for brain injury by 2 pediatric neuroradiologists. Perinatal variables and clinical variables from the neonatal intensive care unit stay were analyzed for potential associations with brain MR imaging findings.

RESULTS

Fifty-three infants with congenital diaphragmatic hernia (31 boys) were included. At least 1 abnormality was seen on MR imaging in 32 infants (60%). The most common MR imaging findings were enlarged extra-axial spaces (36%), intraventricular hemorrhage (23%), ventriculomegaly (19%), white matter injury (17%), and cerebellar hemorrhage (17%). The MR imaging brain injury score was associated with extracorporeal membrane oxygenation (P = .0001), lack of oral feeding at discharge (P = .012), use of inotropes (P = .027), and gastrostomy tube placement before hospital discharge (P = .024). The MR imaging brain injury score was also associated with a large diaphragmatic defect size (P = .011).

CONCLUSIONS

Most infants with congenital diaphragmatic hernia have at least 1 abnormality identified on MR imaging of the brain performed before discharge. The main predictors of brain injury in this population are a requirement for extracorporeal membrane oxygenation, large diaphragmatic defect size, and lack of oral feeding at discharge.

Effects of circuit resistance training and timely protein supplementation on exercise-induced fat oxidation in tetraplegic adults

BACKGROUND

Substrate utilization during exercise in persons with spinal cord injury (SCI) remains poorly defined.

PURPOSE

To investigate effects of circuit resistance training (CRT) and timing of protein supplementation (PS) on fuel utilization in persons with tetraplegia.

METHODS

Eleven individuals with chronic tetraplegia underwent 6 months of CRT 3 times weekly. Five randomly assigned participants received immediate PS (iPS) administered in split doses prior to and following all exercise sessions. Other participants consumed a matched dose of PS that was delayed until 24 hours post-exercise (dPS). Participants underwent a maximal graded exercise test (GXT) to volitional exhaustion at 4 conditioning time points: 3 months before (-3mo), at the beginning of (0mo), 3 months into (3mo), and 6 months following (6mo) the CRT conditioning program. Respiratory measures were continuously obtained throughout the GXT via open-circuit spirometry. Fuel utilization and energy expenditure were computed from the respiratory data.

RESULTS

The differences in changes in substrate utilization between the PS groups were not significant as determined by the interaction of PS group and conditioning time point, F (3, 27) = 2.32, P = .098, η(2) P = .205. Maximal absolute fat oxidation did not change significantly from 0 to 6mo (mean difference, 0.014 ± 0.031 g/min; P = .170), and fat oxidation remained low never exceeding an average of 0.10 ± 0.09 g/min for any given exercise intensity.

CONCLUSION

Maximum fat utilization during exercise and fat utilization at matched exercise intensities were not increased in persons with tetraplegia, independent of PS, and levels of fat oxidation remained low after training.

Emerging outbreaks associated with equine coronavirus in adult horses

The purpose of this study was to describe clinical, hematological and fecal PCR results from 161 horses involved in outbreaks associated with ECoV. The outbreaks happened at four separate boarding facilities between November 2011 and April 2012 in the States of CA, TX, WI and MA. Following the molecular detection of ECoV in the feces from the initial index cases, the remaining herdmates were closely observed for the development of clinical signs. Fecal samples were collected from sick and healthy horses for the PCR detection of ECoV. All four outbreaks involved primarily adult horses. Fifty-nine horses developed clinical signs with 12–16 sick horses per outbreak. The main clinical signs reported were anorexia, lethargy and fever. Four horses from 3 different outbreaks were euthanized or died due to rapid progression of clinical signs. The cause of death could not be determined with necropsy evaluation in 2 horses, while septicemia secondary to gastrointestinal translocation was suspected in 2 horses. Blood work was available from 10 horses with clinical disease and common hematological abnormalities were leucopenia due to neutropenia and/or lymphopenia. Feces were available for ECoV testing by real-time PCR from 44 and 96 sick and healthy horses, respectively. 38/44 (86%) horses with abnormal clinical signs tested PCR positive for ECoV, while 89/96 (93%) healthy horses tested PCR negative for ECoV. The overall agreement between clinical status and PCR detection of ECoV was 91%. The study results suggest that ECoV is associated with self-limiting clinical and hematological abnormalities in adult horses.

Percutaneous lumbar discectomy with a working endoscope and laser assistance

The authors describe percutaneous disc surgery performed via the unilateral monoportal method with a C-arm image intensifier, a working endoscope, and an yttrium-aluminum-garnet laser in 300 patients at three community hospitals over a 6-year period. Visualizing the area of the annulus to be fenestrated, verifying the status of the nerve root, inspecting the cavity created, and monitoring laser hemostasis and vaporization all contributed to patient safety. Fewer than 2% of the cases required a second surgery. The only postoperative sequelae recorded were one psoas hematoma, which resolved, and sympathetic mediated pain in 5% of the patients who responded to appropriate treatment. For treatment of a prolapsed lumbar disc, a 1-hour endoscopic procedure performed while the patient receives a neuroleptanalgesic continues to be a significant surgical alternative.

Asthma and ageing: an end user's perspective--the perception and problems with the management of asthma in the elderly

Despite the high prevalence of asthma in the elderly, its development, diagnosis, and treatment are under-researched. This paper provides a comprehensive review of the current state of knowledge in relation to management of asthma in the elderly - focusing on barriers to diagnosis and treatment and the central role of self-management. Asthma prevalence increases with age, as does the risk of dying from asthma, and with the ageing of the population and increasing life expectancy, the prevalence of (diagnosed and undiagnosed) asthma in older adults is expected to increase drastically, placing an increasing burden on sufferers, the community and health budgets. Asthma sufferers are more likely to be psychologically distressed and at a higher risk of anxiety and depression, more likely to experience a sense of lack of control over their health and to have lower self-reported quality of life. Asthma is under-diagnosed, and under-treated, in the elderly, further exacerbating these negative consequences. The review concludes, among other things, that there is a need to better understand the development and impact of asthma in the elderly, to increase community awareness of asthma in the elderly, to improve both 'medical management' and 'self-management' in this population and to develop more effective tools for diagnosis and treatment of asthma in the elderly. The paper concludes with key recommendations for future research and practice in this area.

ASPM and microcephalin expression in epithelial ovarian cancer correlates with tumour grade and survival

BACKGROUND

The clinico-pathological and molecular heterogeneity of epithelial ovarian cancer (EOC) complicates its early diagnosis and successful treatment. Highly aneuploid tumours and the presence of ascitic fluids are hallmarks of EOC. Two microcephaly-associated proteins, abnormal spindle-like microcephaly-associated protein (ASPM) and microcephalin, are involved in mitosis and DNA damage repair. Their expression is deregulated at the RNA level in EOC. Here, ASPM and microcephalin protein expression in primary cultures established from the ascites of patients with EOC was determined and correlated with clinical data to assess their suitability as biomarkers.

METHODS

Five established ovarian cancer cell lines, cells derived from two benign ovarian ascites samples and 40 primary cultures of EOC derived from ovarian ascites samples were analysed by protein slot blotting and/or immunofluorescence to determine ASPM and microcephalin protein levels and their cellular localisation. Results were correlated with clinico-pathological data.

RESULTS

A statistically significant correlation was identified for ASPM localisation and tumour grade, with high levels of cytoplasmic ASPM correlating with grade 1 tumours. Conversely, cytoplasmic microcephalin was only identified in high-grade tumours. Furthermore, low levels of nuclear microcephalin correlated with reduced patient survival.

CONCLUSION

Our results suggest that ASPM and microcephalin have the potential to be biomarkers in ovarian cancer.

Effect of an individualized dose/schedule strategy for sunitinib in metastatic renal cell cancer (mRCC) on progression-free survival (PFS): Correlation with dynamic microbubble ultrasound (DCE-US) data

356

Background: Sunitinib area under the curve (AUC) correlates with response and PFS (Houk et al). Current recommendations for dose modification do not take this into account.

Methods: A single center retrospective review identified mRCC patients (pts) where individualized (individ) sunitinib dose/schedule modifications (DSM) were used to maximize dose and minimize time off therapy (Rx). Pts were started on 50 mg 28 days (d) on/14 d off. DSM were done to keep toxicity (fatigue, skin, GI) at ≤ grade-2. DSM-1 was 50 mg 14 d/7 d with individ increases in d on Rx based on toxicity. DSM-2 was 50 mg 7 d/7 d with individ increases in d on Rx. DSM-3 was 37.5 mg continuously with individ 7 d breaks. DSM-4 was 25 mg continuously with individ 7 d breaks.

Results: In 171 pts; median age was 60y; 20% good, 60% intermediate, 20% poor prognosis by Heng criteria; 80% had nephrectomy; 79% clear cell histology; 60% were previously untreated. At a median follow-up of 10.7 months (mo), overall median PFS was 7.9 mo. Of 39 pts still on therapy, 37 were on a DSM Rx. Pts were allocated to three groups based on the dose/schedule used for the longest time. The PFS/response% (PR+SD) for each group was 4.4 mo/65.6% (standard 50 mg 28 d/14 d; 43 pts), 8.0 mo/78.2% (DSM-1/DSM-2; 69 pts) and 10.4 mo/81.3% (DSM-3/DSM-4; 59 pts) with improved PFS (p=0.001) in both DSM groups vs. the standard schedule but no difference in response. 30 pts were studied by DCE-US at baseline, and after 7 d and 14 d on Rx or after 14 d and 28 d on Rx. In responding pts, tumor blood volume decreased at d 7 and again at d 14 vs. baseline but was stable or increased at d 28 vs. d 14. A rebound was seen after 14 d off Rx.

Conclusions: Based on the U.S. data, previous pharmacokinetic data (steady state at 10-14 d) and this clinical data, starting pts on 50 mg 14 d/7 d followed by individ DSM may be safe and active. This DSM strategy, was associated with a favorable toxicity profile, apparent improvement in PFS and a good PR+SD rate in a group of unselected mRCC pts, warranting confirmation in a prospective trial. Pts that tolerate 50 mg 28 d/14 d with minimum toxicity may need dose escalation and/or less time off therapy to optimize PFS.

[Table: see text]

Supervised step-down of inhaled corticosteroids in the community--an observational study

INTRODUCTION

Current asthma guidelines recommend step-down of inhaled corticosteroids (ICS) to the minimum dose required for control of symptoms.

AIM

To determine if supervised step-down of (ICS) in the community has any effect on asthmatic inflammation.

METHODS

119 Community based asthmatics underwent progressive step-down of therapy until they became unstable or reached an (ICS) dose of ≤200 μg beclomethasone dipropionate (BDP) or equivalent. Once unstable, participants stepped back up to the last stable dose of ICS. Exhaled nitric oxide (NO) and mannitol challenge were performed at the start and end of step-down. Asthma Quality of Life Questionnaire (AQLQ) and spirometry were recorded at each step-down visit.

RESULTS

The median (interquartile range) BDP equivalent dose was significantly higher pre vs. post step-down: 400 μg (400-800) and 250 μg (200-400) per day respectively (P < 0.05). Examination of change in PD(10) in individual patients revealed that 34% had an improvement (>+1 dd), 47% had no change (±-1 dd), and 19% had a worsening (<-1 dd). The geometric mean fold ratio in NO for pre vs. post was 0.96 (95% CI 0.87 to 1.06, P = 0.43). Mean (SEM) values for FEV(1) were 86.2% (1.51) vs. 84.5% (1.46) (P = 0.04). There was a significant improvement in AQLQ.

CONCLUSIONS

We have demonstrated that a significant reduction in ICS dose may be achieved in a community setting without any worsening of airways inflammation or lung function, and with an associated improvement quality of life in the majority of patients. This apparent disconnect may reflect enhanced adherence due to supervision of step-down.

ICRP Publication 111 - Application of the Commission's recommendations to the protection of people living in long-term contaminated areas after a nuclear accident or a radiation emergency

In this report, the Commission provides guidance for the protection of people living in long-term contaminated areas resulting from either a nuclear accident or a radiation emergency. The report considers the effects of such events on the affected population. This includes the pathways of human exposure, the types of exposed populations, and the characteristics of exposures. Although the focus is on radiation protection considerations, the report also recognises the complexity of post-accident situations, which cannot be managed without addressing all the affected domains of daily life, i.e. environmental, health, economic, social, psychological, cultural, ethical, political, etc. The report explains how the 2007 Recommendations apply to this type of existing exposure situation, including consideration of the justification and optimisation of protection strategies, and the introduction and application of a reference level to drive the optimisation process. The report also considers practical aspects of the implementation of protection strategies, both by authorities and the affected population. It emphasises the effectiveness of directly involving the affected population and local professionals in the management of the situation, and the responsibility of authorities at both national and local levels to create the conditions and provide the means favouring the involvement and empowerment of the population. The role of radiation monitoring, health surveillance, and the management of contaminated foodstuffs and other commodities is described in this perspective. The Annex summarises past experience of longterm contaminated areas resulting from radiation emergencies and nuclear accidents, including radiological criteria followed in carrying out remediation measures.

Suitability of buttermilk for fermentation with Lactobacillus helveticus and production of a functional peptide-enriched powder by spray-drying

AIM

To ferment buttermilk, a low-cost by-product of the manufacture of butter, with a proteolytic strain of Lactobacillus helveticus, to enhance its value by the production of a functional peptide-enriched powder.

METHODS AND RESULTS

Buttermilk was fermented with Lact. helveticus 209, a strain chosen for its high proteolytic activity. To enhance the release of peptidic fractions, during fermentation pH was kept at 6 by using NaOH, Ca(CO)(3) or Ca(OH)(2). Cell-free supernatant was recovered by centrifugation, supplemented or not with maltodextrin and spray-dried. The profile of peptidic fractions released was studied by RP-HPLC. The lactose, Na and Ca content was also determined. The powder obtained was administered to BALB/c mice for 5 or 7 consecutive days, resulting in the proliferation of IgA-producing cells in the small intestine mucosa of the animals.

CONCLUSIONS

Buttermilk is a suitable substrate for the fermentation with Lact. helveticus 209 and the release of peptide fractions able to be spray-dried and to modulate the gut mucosa in vivo.

SIGNIFICANCE AND IMPACT OF THE STUDY

A powder enriched with peptides released from buttermilk proteins, with potential applications as a functional food additive, was obtained by spray-drying. A novel use of buttermilk as substrate for lactic fermentation is reported.

Papillary type thyroid carcinoma in an ovarian struma

BACKGROUND

Struma Ovarii are mature teratomas. In rare circumstances thyroid tissue is found as part of the histopathological makeup. Malignant transformation may occur in 1-2% of these rare cases.

AIM

To report a rare case of malignant thyroid carcinoma within a struma ovarii.

RESULT

A 22-year-old lady presented with a right pelvic mass. A right-sided laparoscopic salpingo-oophrectomy was performed which revealed a malignant struma ovarii neoplasm. A total thyroidectomy was performed with adjuvant I(131) therapy.

CONCLUSION

This is a rare tumour which necessitates surgical extirpation and removal of a normal thyroid gland to facilitate thyroglobulin monitoring.

Disconnect between standardized field-based testing and mannitol challenge in Scottish elite swimmers

BACKGROUND

Elite swimmers have high rates of rhinoconjunctivitis and exercise-induced bronchoconstriction. Moreover, exposure to chlorine and chlorine metabolites is known to induce bronchial hyper-reactivity.

OBJECTIVE

To assess the early and late effects of chlorine and exercise on the unified airway of elite swimmers, and to compare the response to mannitol and field-based exercise challenge.

METHODS

The Scottish national squad underwent exhaled tidal (FE(NO)) and nasal (N(NO)) nitric oxide measurement, peak nasal inspiratory flow (PNIF), and forced expiratory volume in 1 s before, immediately after, and 4-6 h post-swimming. A sport-specific exercise test was carried out during an intensive lactate set (8 min at >/=80% maximum hear rate). All swimmers underwent mannitol challenge, and completed a health questionnaire.

RESULTS

N=61 swimmers were assessed: 8/59 (14%) of swimmers had a positive mannitol challenge. Nine out of 57 (16%) of swimmers had a positive exercise test. Only one swimmer was positive to both. Swimmers with a positive mannitol had a significantly higher baseline FE(NO) (37.3 vs. 18.0 p.p.b., P=0.03) than those with a positive exercise challenge. A significant decrease in FE(NO) was observed pre vs. immediate and delayed post-chlorine exposure: mean (95% CI) 18.7 (15.9-22.0) p.p.b. vs. 15.9 (13.3-19.1) p.p.b. (P<0.01), and 13.9 (11.5-16.7) p.p.b. (P<0.01), respectively. There were no significant differences in N(NO.) Mean PNIF increased from 142.4 L/min (5.8) at baseline to 162.6 L/min (6.3) immediately post-exposure (P<0.01). Delayed post-exposure PNIF was not significantly different from pre-exposure.

CONCLUSIONS

No association was found between mannitol and standardized field-based testing in elite swimmers. Mannitol was associated with a high baseline FE(NO); however, exercise/chlorine challenge was not. Thus, mannitol may identify swimmers with a 'traditional' inflammatory asthmatic phenotype, while field-based exercise/chlorine challenge may identify a swimmer-specific bronchoconstrictor response. A sustained fall in FE(NO) following chlorine exposure suggests that a non-cellular, perhaps neurogenic, response may be involved in this group of athletes.

Methylation Status of Promoters 0K, 0N and a Newly Identified Promoter Regulate ERβ1 Expression in Breast Cancer

Gene expression is regulated at multiple levels, including transcriptional silencing by methylation. ERβ1 is downregulated in breast cancer compared to normal breast and mechanisms surrounding this are unclear. Two novel ERβ mRNA isoforms with distinct 5'-UTRs have been identified, ERβ-0K-1 and ERβ-0N-1. The aim of study was to examine whether methylation at these promoter regions plus a novel promoter identified by our group were involved in ERβ1 regulation (figure 1).Bisulfite modification and direct sequencing analysis were performed for promoters 0K, 0N, and a novel mini CpG island upstream of ERβ exon1 in two ERβ1- and one ERβ1+ breast cancer cell lines. Distinct methylation patterns were observed. Promoter 0N was completely methylated in BT20, partially methylated in MDAMB453 and unmethylated in T47D, while the mini CpG island was methylated in all 3 cell lines. In contrast, promoter 0K was unmethylated. Furthermore, a negative correlation between ERβ1 mRNA expression and the methylation status of promoter 0N was observed in breast cells. To further investigate whether methylation of the ERβ1 promoter was responsible for the loss of ERβ1 expression, BT20 and MDAMB453 cells were treated with either 5-aza-dC, TSA or both, concentrations of which had been previously optimised for each cell line. In BT20 cells which had complete methylation of 0N, both agents were required for induction of ERβ1 and ERβ-0N-1 but not ERβ-0K-1 expression, both of which are part of the 5'UTR region. However in MDAMB453 treatment with 5-aza-dC was sufficient to induce ERβ1 and ERβ-0N-1 expression with no additional re-expression seen with TSA and no effects on ERβ-0K-1. This suggests that promoter 0N is responsible for driving the transcription of ERβ1. On going work is confirming these observations in clinical samples. Our results suggest that promoter 0N plays an important role in regulation of ERβ1 mRNA expression in breast cancer. Our results add to growing literatures which demonstrate ERβ1 is regulated at multiple levels in breast cancer and that DNA methylation is an important mechanism for silencing ERβ1 gene expression.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1148.

miR-92 Is a Novel Regulator of ERβ1 Expression in Breast Cancer

Down-regulation of ERβ1 expression is thought to contribute to carcinogenesis in the breast and consequently is seen in many breast cancers. The molecular mechanisms responsible for the down-regulation of ERβ1 remain unclear. microRNAs are a novel family of regulators of gene expression that have been shown to act on the expression of many critical cancer genes but their relationship with ERβ1 has not so far been demonstrated. The aims of this study were to establish whether miR-92 regulates ERβ1 expression, and whether this regulation plays a role in defining ERβ1 expression levels in breast cancers.Using a bioinformatics approach we initially identified potential binding sites for miR-92 within the 3' untranslated regions of ERβ transcripts using RNAhybrid software (http://bibiserv.techfak.uni-bielefeld.de/rnahybrid/). Two conserved target-sites for miR-92 were identified within the ERβ1 3'-UTR sequence contained within Genebank. We confirmed the expression of these UTRs in MCF7 cells. Next, we performed 3' RACE reactions to determine the 3'-UTR sequence of ERβ1 in MCF7 cellsWe used qPCR analyses of expression in paired normal breast and breast tumour samples (n=6) to examine the relative expression of miR-92 and ERβ1. Upregulation of miR-92 expression was observed in breast tumours compared with normal breast. An inverse relationship with ERβ1 expression was observed in these samples. In a separate cohort of breast tumours (n=36), a significant negative correlation between ERβ1 mRNA and miR-92 was observed (Spearman's correlation coefficient, r = -0.5, p=0.001). Elevated ratios of ERβ1 mRNA /miR92 were also observed in ERβ1 positive compared to ERβ1 negative cells lines.Inhibition of miR-92 in MCF-7 cells increased ERβ1 expression in a dose–dependent manner at RNA levels. Enhanced GFP reporter constructs containing miR-92 binding sites from the 3'-UTR of ERβ1 were used to determine whether miR-92 downregulates ERβ1 via the direct targeting of this 3'-UTR. Inhibition of miR-92 increased the translational efficiency (protein produced per unit of mRNA) of the GFP reporter, confirming that the miR-92 binding sites are a critical regulatory region. Finally, we showed that miR-92 expression was upregulated by 17β-estradiol and downregulated by tamoxifen in MCF7 cells (ERα+ ERβ+) but not in ERβ negative cells (BT20 and MDAMB453), suggesting ERs can mediate miR-92 regulation. Our results demonstrate that ERβ1 expression in breast cancer is regulated by miRNA-92.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4139.