Emergency Department Management of Low Back Pain: A Comparative Review of Guidelines and Practices

This narrative review examines the current best practices and guidelines for integrating pharmacologic interventions, imaging, and physiotherapy in the management of low back pain. The review also explores how patient factors such as age, sex, comorbidities, and prevalent pathologies/diagnoses influence the choice and effectiveness of these treatment approaches.

Total Reference Air Kerma (TRAK) is Associated with Dosimetric Parameters in Template-Based High Dose-Rate (HDR) Interstitial Brachytherapy in Advanced Gynecologic Cancers

PURPOSE/OBJECTIVE(S)

To study TRAK and its association with dosimetric parameters in template-based high dose-rate interstitial brachytherapy in advanced gynecologic cancers.

MATERIALS/METHODS

Brachytherapy treatment plans of 53 patients treated between 2012 and 2022 at our institution with template-based Iridium-192 HDR brachytherapy, post-external beam RT, for locally advanced cancers of the cervix and vagina were retrospectively reviewed. Brachytherapy dose ranged from 25 to 30-Gy delivered in 4 to 6 fractions. The median number of flexi-guide catheters implanted was 18 (range 10-30). Clinical Target Volume (CTV) values were mean (±SD): 72.2 (±40.4) cm3 (high-risk, HR) and 182.2 (±73.7) cm3 (intermediate-risk, IR) respectively. TRAK per fraction (cGy at 1m), dose-volume information for the implant, target, and organ-at-risk (OAR) were recorded. Indices for dose coverage (CI), homogeneity (DHI), non-uniformity (DNR), overdose volume (ODI) were computed. Regression and correlation tests were used to study the TRAK relationship with various dosimetric parameters. The false discovery rate at a 5% level was corrected using the Benjamini-Hochberg procedure.

RESULTS

The average TRAK per fraction was 0.365 (±0.12) cGy. Mean and range values of plan quality indices were - CI 0.92 (0.7- 1.0), DHI 0.57 (0.41 - 0.77), DNR 0.43 (0.23 - 0.59) and ODI 0.22 (0.11 - 0.38), respectively Correlation results for TRAK with various dosimetric indices are presented in Table 1. TRAK showed a weak correlation with the number of flexi-guide catheters implanted (r = 0.35, p = 0.013). TRAK correlated strongly with target volumes (CTV_HR and CTV_IR and CTV_HR V100%) and with isodose volumes at both high (V300, V200, V150), and low dose levels (V90, V85, V50) (p<0.00001). TRAK correlated moderately with OAR 2-cm3 doses (p<0.00001). A weak correlation was observed between TRAK and plan quality indices.

CONCLUSION

TRAK correlates positively with target volume and volumes enclosed by isodoses at various dose levels in interstitial HDR brachytherapy of advanced Gynecologic Cancers. Interestingly, our study observed a comparatively stronger positive correlation between TRAK and Sigmoid 2-cm3 dose, equated to TRAK correlation with bladder, rectum, and small bowel 2-cm3 doses. This finding could interest future studies utilizing TRAK as a surrogate for treatment outcome and toxicity.

Evaluation of An Aerial Application of Duet Hd® Against Aedes Dorsalis and Culex Tarsalis in Rural Habitats of the Great Salt Lake, Utah

The Salt Lake City Mosquito Abatement District (SLCMAD) has been conducting aerial applications using an organophosphate insecticide against adult mosquitoes for several decades. In order to evaluate a potential rotation product, aerial applications of Duet HD™, a pyrethroid, were conducted under operational conditions against wild populations of Aedes dorsalis and Culex tarsalis and against colony strains of Cx. pipiens and Cx. quinquefasciatus. The erratic wind patterns of the greater Salt Lake area did not prevent sufficient droplet deposition flux at 9 monitoring locations spread across a 5,120-acre (2,072 ha) spray block within rural habitats. Three separate aerial application trials showed great efficacy against Ae. dorsalis. In contrast, Cx. tarsalis exhibited inconsistent treatment-associated mortalities, suggesting the presence of less susceptible or resistant field populations as a result of spillover from agricultural or residential pyrethroid usage. Bottle bioassays to diagnose pyrethroid resistance using field-collected Cx. tarsalis indicated that some populations of this species, especially those closest to urban edges, failed to show adequate mortality in resistance assays. Despite challenging weather conditions, Duet HD worked reasonably well against susceptible mosquito species, and it may provide a crucial role as an alternative for organophosphate applications within specific and sensitive areas. However, its area-wide adoption into control applications by the SLCMAD could be problematic due to reduced impacts on the most important arboviral vector species, Cx. tarsalis, in this area. This study demonstrates the importance of testing mosquito control products under different operational environments and against potentially resistant mosquito populations by municipal mosquito control districts.

Post-COVID Conditions and Burden of Disease

Post-COVID condition (PCC), also known as long COVID, is a multi-systemic illness estimated to affect 10% to 20% of those infected, regardless of age, baseline health status, or initial symptom severity. PCC has affected millions of lives, with long-lasting debilitating effects, but unfortunately it remains an underrecognized and therefore poorly documented condition. Defining and disseminating the burden of PCC is essential for developing effective public health strategies to address this issue in the long term.

NEK Family Review and Correlations with Patient Survival Outcomes in Various Cancer Types

The Never in Mitosis Gene A (NIMA)–related kinases (NEKs) are a group of serine/threonine kinases that are involved in a wide array of cellular processes including cell cycle regulation, DNA damage repair response (DDR), apoptosis, and microtubule organization. Recent studies have identified the involvement of NEK family members in various diseases such as autoimmune disorders, malignancies, and developmental defects. Despite the existing literature exemplifying the importance of the NEK family of kinases, this family of protein kinases remains understudied. This report seeks to provide a foundation for investigating the role of different NEKs in malignancies. We do this by evaluating the 11 NEK family kinase gene expression associations with patients’ overall survival (OS) from various cancers using the Kaplan–Meier Online Tool (KMPlotter) to correlate the relationship between mRNA expression of NEK1-11 in various cancers and patient survival. Furthermore, we use the Catalog of Somatic Mutations in Cancer (COSMIC) database to identify NEK family mutations in cancers of different tissues. Overall, the data suggest that the NEK family has varying associations with patient survival in different cancers with tumor-suppressive and tumor-promoting effects being tissue-dependent.

SAFETY AND EFFICACY OF THYMIC PEPTIDES IN THE TREATMENT OF HOSPITALIZED COVID-19 PATIENTS IN HONDURAS

Coronavirus disease 2019 (Covid-19) active cases continue to demand the development of safe and effective treatments. This is the first clinical trial to evaluate the safety and efficacy of oral thymic peptides. ; We conducted a nonrandomized phase 2 trial with a historic control group to evaluate the safety and efficacy of a daily 250-mg oral dose of thymic peptides in the treatment of hospitalized Covid-19 patients. Comparisons based on standard care from registry data were performed after propensity score matching. The primary outcomes were survival, time to recovery, and number of participants with treatment-related adverse events or side effects by day 20. ; A total of 44 patients were analyzed in this study: 22 in the thymic peptide group and 22 in the standard care group. There were no deaths in the intervention group compared to 24% mortality in standard care by day 20 (log-rank P=0.02). Kaplan-Meier analysis showed a significantly shorter time to recovery by day 20 in the thymic peptide group than in the standard care group (median, 6 days vs. 12 days; hazard ratio for recovery, 2.75 [95% confidence interval, 1.34 to 5.62]; log-rank P=0.002). No side effects or adverse events were reported. ; In patients hospitalized with Covid-19, the use of thymic peptides resulted in no side effects, adverse events, or deaths by day 20. Compared with the registry data, a significantly shorter time to recovery and mortality reduction were measured.

Expression of Novel Kinase MAP3K19 in Various Cancers and Survival Correlations

Mitogen Activated Protein (MAP) kinases are a category of serine/threonine kinases that have been demonstrated to regulate intracellular events including stress responses, developmental processes, and cancer progression Although many MAP kinases have been extensively studied in various disease processes, MAP3K19 is an understudied kinase whose activities have been linked to lung disease and fibroblast development. In this manuscript, we use bioinformatics databases starBase, GEPIA, and KMPlotter, to establish baseline expressions of MAP3K19 in different tissue types and its correlation with patient survival in different cancers.

MAP3K Family Review and Correlations with Patient Survival Outcomes in Various Cancer Types

The mitogen-activated protein kinase (MAPK) pathways are ubiquitous in cellular signaling and are essential for proper biological functions. Disruptions in this signaling axis can lead to diseases such as the development of cancer. In this review, we discuss members of the MAP3K family and correlate their mRNA expression levels to patient survival outcomes in different cancers. Furthermore, we highlight the importance of studying the MAP3K family due to their important roles in the larger, overall MAPK pathway, relationships with cancer progression, and the understudied status of these kinases.

Extremely long-range, high-temperature Josephson coupling across a half-metallic ferromagnet

The Josephson effect results from the coupling of two superconductors across a spacer such as an insulator, a normal metal or a ferromagnet to yield a phase coherent quantum state. However, in junctions with ferromagnetic spacers, very long-range Josephson effects have remained elusive. Here we demonstrate extremely long-range (micrometric) high-temperature (tens of kelvins) Josephson coupling across the half-metallic manganite La_0.7Sr_0.3MnO₃ combined with the superconducting cuprate YBa₂Cu₃O₇. These planar junctions, in addition to large critical currents, display the hallmarks of Josephson physics, such as critical current oscillations driven by magnetic flux quantization and quantum phase locking effects under microwave excitation (Shapiro steps). The latter display an anomalous doubling of the Josephson frequency predicted by several theories. In addition to its fundamental interest, the marriage between high-temperature, dissipationless quantum coherent transport and full spin polarization brings opportunities for the practical realization of superconducting spintronics, and opens new perspectives for quantum computing.

Large intrinsic anomalous Hall effect in SrIrO3 induced by magnetic proximity effect

The anomalous Hall effect (AHE) is an intriguing transport phenomenon occurring typically in ferromagnets as a consequence of broken time reversal symmetry and spin-orbit interaction. It can be caused by two microscopically distinct mechanisms, namely, by skew or side-jump scattering due to chiral features of the disorder scattering, or by an intrinsic contribution directly linked to the topological properties of the Bloch states. Here we show that the AHE can be artificially engineered in materials in which it is originally absent by combining the effects of symmetry breaking, spin orbit interaction and proximity-induced magnetism. In particular, we find a strikingly large AHE that emerges at the interface between a ferromagnetic manganite (La_0.7Sr_0.3MnO₃) and a semimetallic iridate (SrIrO₃). It is intrinsic and originates in the proximity-induced magnetism present in the narrow bands of strong spin-orbit coupling material SrIrO₃, which yields values of anomalous Hall conductivity and Hall angle as high as those observed in bulk transition-metal ferromagnets. These results demonstrate the interplay between correlated electron physics and topological phenomena at interfaces between 3d ferromagnets and strong spin-orbit coupling 5d oxides and trace an exciting path towards future topological spintronics at oxide interfaces.

Evaluation of liver kinase B1 downstream signaling expression in various breast cancers and relapse free survival after systemic chemotherapy treatment

LKB1-signaling has prominent roles in cancer development and metastasis. This report evaluates LKB1-signaling pathway gene expression associations with patient survival in overall breast cancer, specific subtypes, as well as pre- and post-chemotherapy. Subtypes analyzed were based on intrinsic molecular subtyping and traditional biomarker classifications. Intrinsic molecular subtypes included were Luminal-A, Luminal-B, HER2-enriched, and Basal-like. The biomarker subtypes assessed were Estrogen-Receptor Positive (ER+) and Negative (ER-), Wild-Type TP53 (WT-TP53) & Mutant-TP53, and Triple-Negative Breast Cancer (TNBC). Additionally, comparisons were made between these subtypes and breast cancer overall, and analyses between LKB1 signaling to patient survival before and after chemotherapy were made. We used the Kaplan-Meier Online Tool (KM Plotter) to correlate the relationship between mRNA expression of known LKB1 scaffolding proteins (CAB39 and LYK5), and downstream signaling targets (AMPK, MARK1, MARK2, MARK3, MARK4, NUAK1, NUAK2, PAK1, SIK1, SIK2, BRSK1, BRSK2, SNRK, and QSK), and patient survival across each subtype and treatment group. Our findings provide evidence that LKB1-signaling is associated with improved survival in overall breast cancer. Stratification into breast cancer subtypes show a more complicated relationship; NUAK2, for example, is correlated with improved survival in ER- but is worse in ER+ breast cancer. In evaluating the association of LKB1-signaling pathway expression with relapse free survival of varying breast cancer tumors exposed to chemotherapy or treatment-naive tumors, our data provides baseline knowledge for understanding the pathway dynamics that affect survival and therefore are linked to pathology. This establishes a foundation for studying LKB1 targets with the goal of identifying druggable targets.

Abstract PS18-47: Use of the published kinase inhibitor set to identify therapeutic targets in TNBC

Breast cancer (BC) is the second leading cause of cancer associated deaths in women globally (1). Broadcategorization of BC is based on protein receptor expression: triple negative breast cancer (TNBC) lacksexpression of estrogen receptors, progesterone receptors, and exhibits non-amplification of HER2/Neu. Due tothe receptor status in TNBC, hormone-based targeted therapies are not effective; systemic chemotherapy is theprimary treatment which results in significant adverse effects for patients (2). TNBC would benefit significantlyfrom the development of novel targeted therapeutics and in this study, we describe a small molecule inhibitor-based approach to identify candidate targets.We screened TNBC cells using the Published Kinase Inhibitor Set (PKIS), a highly annotated set of kinaseinhibitors (6) and demonstrated the utility of screening chemogenomic sets for target vulnerability identification. Ahigher rate of metastasis is a defining characteristic of the TNBC subtype; a proposed mechanism for acquisitionof a metastatic phenotype is a cellular process known as epithelial-mesenchymal transition (EMT). In an initialadherent cell culture screen of the PKIS library using established TNBC cell lines (MDA-MB-231, BT-549) andprimary patient-derived TNBC cells (TU-BCX-4IC, TU-BCX-49S), we identified three compounds that had themost dramatic effects on reversing the mesenchymal cell phenotype such as an increase in cell size and cellularproliferation/death: GSK907232A, GSK1440913, and GW494601. Following cell culture studies, molecular andbiochemical assays were performed to analyze known EMT-related cancer pathways. Results showed an overalldecrease in mesenchymal gene expression (Vimentin, FOXC2, SNAIL, SMAD2, TGF- β) and an increase inepithelial expression (E-Cadherin) in all four tested cell lines. In addition to EMT analysis, we investigated therole of our three hits in breast cancer stem cell populations. These inhibitors showed a reduction in breast cancerstem cell marker ganglioside GD2, a population that is strongly associated with tumorigenesis, metastasis, anddrug resistance. These data suggest these inhibitors reverse EMT and inhibit the cancer stem cell effects,attributes linked to poor prognoses in cancer (3,4,7).Because these three PKIS compounds are non-selective and affect diverse kinases, we then examined kinomewide activity of the selected inhibitors using the KINOMEscanâ assay to discover candidate kinase targets topursue. Some kinases identified as targets of these inhibitors, such as NEK5 and MAP3K19 (5) are understudiedboth in and out of the field of breast oncology and warrant further exploration in TNBC. In conclusion, our primaryobjective was to demonstrate the utility of the PKIS library as a primary screening tool for target discoveryapplications. Ongoing work focuses on validation of the identified understudied kinases as druggable therapeutictargets for TNBC.

Citation Format: Andrew Rivera, Matthew Burow, Khoa Nguyen. Use of the published kinase inhibitor set to identify therapeutic targets in TNBC [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS18-47.

Clostridioides difficile carriage in animals and the associated changes in the host fecal microbiota

The relationship between the gut microbiota and Clostridioides difficile, and its role in the severity of C. difficile infection in humans is an area of active research. Intestinal carriage of toxigenic and non-toxigenic C. difficile strains, with and without clinical signs, is reported in animals, however few studies have looked at the risk factors associated with C. difficile carriage and the role of the host gut microbiota. Here, we isolated and characterized C. difficile strains from different animal species (predominantly canines (dogs), felines (cats), and equines (horses)) that were brought in for tertiary care at North Carolina State University Veterinary Hospital. C. difficile strains were characterized by toxin gene profiling, fluorescent PCR ribotyping, and antimicrobial susceptibility testing. 16S rRNA gene sequencing was done on animal feces to investigate the relationship between the presence of C. difficile and the gut microbiota in different hosts. Here, we show that C. difficile was recovered from 20.9% of samples (42/201), which included 33 canines, 2 felines, and 7 equines. Over 69% (29/42) of the isolates were toxigenic and belonged to 14 different ribotypes including ones known to cause CDI in humans. The presence of C. difficile results in a shift in the fecal microbial community structure in both canines and equines. Commensal Clostridium hiranonis was negatively associated with C. difficile in canines. Further experimentation showed a clear antagonistic relationship between the two strains in vitro, suggesting that commensal Clostridia might play a role in colonization resistance against C. difficile in different hosts.

Sex differences in patients with ischemia and no obstructive coronary disease subjected to intracoronary acetylcholine test in a multicenter registry

Background

Ischemia with no obstructive coronary disease (INOCA) is increasingly diagnosed because of wide performance of coronary angiography. Prevalence of INOCA is higher in women than in men, however the exact pathophysiological mechanisms which may explain this phenomenon are still not very well understood.

Objective

To evaluate differences in clinical and procedural characteristics between men and women with INOCA subjected to intracoronary acetylcholine test (Ach).

Methods

A total of 210 women and 148 men with INOCA diagnosed with coronary angiography, were prospectively enrolled in a multicenter, observational registry. Ach test was performed according to clinical indications in all included patients. After 1-year patients were re-evaluated for major cardiovascular events, angina symptoms and prescribed medical treatment.

Results

Mean age of 60.6±13.6 years old was similar in both populations, but differences were observed in the prevalence of risk factors: active smoking was more frequent among men (43% vs. 17%, p&lt;0.001), who had also a higher number of associated risk factors (≥3 risk factors were present in 31.2% of men vs. 20.2% of women, p&lt;0.01) and more frequent history of percutaneous coronary revascularization (14.2% vs. 6.7%, p=0.03). Women were more prone to have dyspnea than men (35.5% vs. 20.8%, p=0.01). Men had more coronary atherosclerosis in angiography (57.9% vs. 43.7%, p=0.01) and more slow flow in the left anterior descending artery (21.6% vs. 9.0%, p=0.001). Ach was positive in 36.5% of patients, similar in both sexes, with no differences in the type of induced coronary spasm. Among those with a positive Ach test, at one-year, 36% of women vs. 43.6% of men were on optimal medical treatment for vasospasm although the difference was not statistically significant. Importantly, 41.5% of women and 38.1% of men experienced severe symptoms of angina during follow-up.

Conclusions

Although men with INOCA have a higher risk profile than women and more coronary atherosclerosis, one third of patients present endothelial dysfunction, similar in both groups, indicating that probably other pathophysiological mechanisms are responsible for it in females. Treatment in these patients remains suboptimal and associated with highly impaired quality of life.

Funding Acknowledgement

Type of funding source: None

Clinical profile and predictors of positivity of acetylcholine test in patients with angina and no obstructive coronary artery disease. Results of a multi-center mediterranean registry

Background

Coronary endothelial dysfunction and vasospasm are potential causes of ischemia in no obstructive coronary disease (INOCA) and are now known to be associated with an increased risk of major cardiovascular events (MACE) and impaired quality of life. The recent guidelines recommend the use of intracoronary acetylcholine to unravel the underlying pathophysiology of INOCA, by identifying those with endothelial dysfunction, and to guide future treatment in these patients.

Objective

To evaluate the clinical profile and prevalence of endothelial dysfunction in patients with INOCA, and to identify the predictors of positivity of the acetylcholine test.

Methods

A total of 358 patients with INOCA were prospectively enrolled in a multicenter observational study. Coronary angiography and acetylcholine test were performed according to clinical indications in all included patients. Patients were followed-up for 1-year for MACE and clinical reevaluation of symptoms.

Results

Patients' mean age was 60.6±13.5 y.o. and 58.7% were females, with no previous history of coronary heart disease in 76% of cases. Regarding clinical presentation, 56.9% had angina at rest, 59.9% exertional angina, and 29.5% dyspnea. In 39% the EKG was abnormal, and in 10.9% there was a troponin rise.

Coronary endothelial dysfunction –defined as a vasoconstriction over 30%– was observed in 129 (36%) patients, and severe vasoconstriction (&gt;70%) in 75 (21%). Of positive cases, 47 (36%) focal vasoconstriction, and 90 (70%) diffuse. On follow-up, patients with a positive Ach test were treated differently, with a lower prescription of betablockers (12% vs. 24%, p=0.01) and a higher use of vasodilators (47% vs. 28.5%, p=0.001). Guidelines-recommended optimal treatment was prescribed to 39.2% of patients with a positive acetylcholine test. Patients with positive acetylcholine test were more prone to having worsening angina (25.6% vs. 12.8%, p&lt;0.01) and minimal exertion angina (40% vs. 26.7%, p=0.03) on follow-up. Multivariable regression analysis showed that acetylcholine test positivity was predicted by the presence of diabetes (OR 1.7, p=0.04), exertional angina (OR 1.2, p=0.04), coronary atherosclerosis (OR 1.8, p=0.02) and coronary milking (OR 2.6, p=0.04).

Conclusions

Endothelial dysfunction detected by acetylcholine test was present in one third of patients with INOCA and was associated with more severe and worsening symptoms. Although Ach test positivity influenced the pharmacological treatment at discharge, a large room for optimization still remained.

Funding Acknowledgement

Type of funding source: None

AB0472 INFECTIOUS PROFILE IN PATIENTS WITH ANCA-ASSOCIATED VASCULITIS: RETROSPECTIVE ANALYSIS IN A REFERRAL CENTRE

Background:

The antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) are rare multisystem autoimmune diseases of unknown cause, characterised by inflammatory cell infiltration causing necrosis of blood vessels. The treatment of AAV requires prolonged immunosuppressive therapy. Infections remain a major cause of morbidity and mortality.

Objectives:

The aim of our study was to investigate the prevalence and characteristics of infection, and analyse the factors associated with infection in patients with AAV from Northern of Spain.

Methods:

Retrospective, descriptive study of patients with AAV followed in a specific Systemic Autoimmune Diseases and Thrombosis Unit from January 2000 to December 2019. Demographic, laboratory, microbiology, treatment and clinical data were collected from the medical records. AAV was diagnosed according to the definitions of the Chapel Hill nomenclature and designated as granulomatosis with polyangiitis (GPA), eosinophilic granulomatosis with polyangiitis (EGPA), microscopic polyangiitis (MPA) or pauci-immune necrotizing and/or crescentic glomerulonephritis without systemic vasculitis (renal-limited vasculitis, RLV). Disease activity of AAV was evaluated by Birmingham Vasculitis Activity score (BVAS). The infection episode was considered on the basis of clinical, laboratory, microbiology, radiology information, and response to therapy. Different episodes of infection in one patient were independently reflected. Data were analysed using SPSS 25.0

Results:

Thirty-six patients of which 20 (55.6%) were males. Median follow-up was 42 months. The mean age at the diagnosis was 61.14 ± 17.49 years and mean BVAS was 18.81 ± 5.96. 15 patients were diagnosed of GPA, 13 of MPA, 5 of EGPA and 3 of RLV. 72.2% MPO, 11.1% PR3. Lung involvement occurred in 75% of patients, upper airways was detected in 41.7%, skin involvement in 16.7%, Nervous system affectation occurred in 33.3%. 30 patients (83.3%) had renal affectation with a mean of 1.93± 1.66 gr/dl of Proteinuria and 2.9±2.17mg/dl of creatinine. We detected hypocomplementemia in 27.8% of patients (C3 in 19.4% and C4 in 16.7%). Regarding induction treatments, all patients received corticoids at high doses, 21 (58.3%) Cyclophosphamide, 3 (20%) Rituximab and 2 (13.3%) patients, Azathioprine. When we analyse infections, we detected 15 patients (41.66%) who presented any infection after the diagnosis of AAV, with a total of 71 episodes of infection. The most frequent were bacterial infections (29 episodes), specifically gram negative pathogens. The most frequent location was the respiratory (56.3%) followed by urinary (22.5%) and Skin (8.5%). Also opportunistic infections were described: 3 patients with Aspergillus fumigatus and one patient with Cryptococcus neoformans. 41 of these episodes needed hospitalisation with a median stay of 11 days. 6 episodes warranted intensive care unit (ICU) admission. Infection related mortality was 2.82%. We made latent tuberculosis screening and Pneumocystis prophylaxis in all our patients. No cases of Tuberculosis or Pneumocystis were recorded. Factors associated with increased risk of hospitalisation with statistical signification in univariated study were MPA, Hypocomplementemia and increased BVAS. But in the logistical regression study, only the value of the BVAS maintained statistical significance. The only factor associated with elevated risk of ICU admission was IgG deficit in the multivariate analysis. Neither immunosuppressive therapy nor age was associated with increased risk of infection in our study.

Conclusion:

More than 50% of the episodes of infection needed hospitalisation in patients with AAV. Risk factors for hospitalisation and ICU admission were BVAS and IgG deficit respectively. Bacterial infections were the most frequent but fungal infections were the most severe.

Disclosure of Interests:

None declared

Development of a High-Throughput Fluorescence Polarization Assay to Detect Inhibitors of the FAK-Paxillin Interaction

Focal adhesion kinase (FAK) is a promising cancer drug target due to its massive overexpression in multiple solid tumors and its critical role in the integration of signals that control proliferation, invasion, apoptosis, and metastasis. Previous FAK drug discovery and high-throughput screening have exclusively focused on the identification of inhibitors that target the kinase domain of FAK. Because FAK is both a kinase and scaffolding protein, the development of novel screening assays that detect inhibitors of FAK protein-protein interactions remains a critical need. In this report, we describe the development of a high-throughput fluorescence polarization (FP) screening assay that measures the interactions between FAK and paxillin, a focal adhesion-associated protein. We designed a tetramethylrhodamine (TAMRA)-tagged paxillin peptide based on the paxillin LD2 motif that binds to the focal adhesion targeting (FAT) domain with significant dynamic range, specificity, variability, stability, and a Z'-factor suitable for high-throughput screening. In addition, we performed a pilot screen of 1593 compounds using this FP assay, showing its feasibility for high-throughput drug screening. Finally, we identified three compounds that show dose-dependent competition of FAT-paxillin binding. This assay represents the first described high-throughput screening assay for FAK scaffold inhibitors and can accelerate drug discovery efforts for this promising drug target.

Trends of maxillofacial trauma: An update from the prospective register of a multicenter study in emergency services of Chile

Background

Determine the behavior of the maxillofacial trauma of adults treated in 3 tertiary care centers in the central zone of Chile.

Material and Methods

Descriptive, cross-sectional, multicenter study, based on the prospective records of maxillofacial trauma cases attended between May 2016 and April 2017 by dental and maxillofacial clinical teams of Adult Emergency Units of hospitals Dr. Sótero del Río (metropolitan region), Carlos Van Buren and Dr. Gustavo Fricke (region V). Age, sex, date of occurrence, type of trauma according to ICD-10, etiology, legal medical prognosis and associated injuries were recorded, stratifying by sex and age. Chi square and unpaired Wilcoxon tests were used to compare by groups.

Results

2.485 cases and 3.285 injuries were investigated. The male: female ratio was 1.7: 1 with age under 30 predominant, followed by older adults. Variability was observed in the yearly, weekly and daily presentation. The highest frequencies were in January and September, weekends and at night. The main etiologies were violence (42.3%), falls (13.1%) and road traffic crashes (12.9%) with differences by age and sex (p<0.05). 31,9% of the injuries occurred in hard tissue, being fractures in nasal bones predominant (S02.2).

Conclusions

The profile of the maxillofacial trauma in Chile seems to be mixed by age, affecting young people and the elderly. The male sex predominates; the main cause, which varies by age group, is violence. Their surveillance is possible from hospital emergency records.

Key words:Maxillofacial trauma, emergency department, multicenter study.

High resolution crystal structure of the FAK FERM domain reveals new insights on the Druggability of tyrosine 397 and the Src SH3 binding site

Background

Focal Adhesion Kinase (FAK) is a major cancer drug target that is involved in numerous aspects of tumor progression and survival. While multiple research groups have developed ATP-competitive small molecule inhibitors that target the kinase enzyme, recent attention has been focused on the FAK FERM (Band 4.1, Ezrin, Radixin, Moesin) domain that contains key residue Y397 and contributes to many protein-protein interactions. Previous x-ray crystal structures of the FAK FERM domain gave conflicting results on the structure of the Y397 region and therefore the overall druggability.

Results

Here, we report the identification of a higher resolution crystal structure of the avian FAK FERM domain that shows conformational differences in Y397 and surrounding residues in the F1 lobe. In addition, we resolve the residues of the Src SH3 binding site, an area of the FERM domain that has previously shown limited electron density.

Conclusions

These crystallographic data suggest that the Y397 region is highly dynamic and question the druggability of a putative pocket on the F1 lobe. In addition, new electron density data around the Src SH3 binding site provide structural insight on the FAK-Src activation cascade through a putative auto-inhibitory conformation.

A single introduction of Yersinia pestis to Brazil during the 3rd plague pandemic

Yersinia pestis was introduced to Brazil during the third plague pandemic and currently exists in several recognized foci. There is currently limited available phylogeographic data regarding Y. pestis in Brazil. We generated whole genome sequences for 411 Y. pestis strains from six Brazilian foci to investigate the phylogeography of Y. pestis in Brazil; these strains were isolated from 1966 to 1997. All 411 strains were assigned to a single monophyletic clade within the 1.ORI population, indicating a single Y. pestis introduction was responsible for the successful establishment of endemic foci in Brazil. There was a moderate level of genomic diversity but little population structure among the 411 Brazilian Y. pestis strains, consistent with a radial expansion wherein Y. pestis spread rapidly from the coast to the interior of Brazil and became ecologically established. Overall, there were no strong spatial or temporal patterns among the Brazilian strains. However, strains from the same focus tended to be more closely related and strains isolated from foci closer to the coast tended to fall in more basal positions in the whole genome phylogeny than strains from more interior foci. Overall, the patterns observed in Brazil are similar to other locations affected during the 3rd plague pandemic such as in North America and Madagascar.

RNASEH1 gene variants are associated with autoimmune type 1 diabetes in Colombia

BACKGROUND

In a previous work, we found linkage and association of type 1 diabetes (T1D) to a 12 known gene region at chromosome 2p25 in Colombian families. Here, we present further work on this candidate region.

MATERIALS AND METHODS

Seventeen SNPs located on the 12 candidate genes, in 100 familial trios set, were tested by ARMS-tetraprimer-PCR or PCR-RFLP. Five extra SNPs in the vicinity of rs10186193 were typed. A replica phase included 97 novel familial trios, in whom diabetes-related auto-antibodies (AABs) were tested in sera of the patients. In addition to transmission disequilibrium tests, haplotype analyses were carried out using the unphased software.

RESULTS

SNP rs10186193 (at RNASEH1 gene) showed association with T1D (P = 0.005). The additional five SNPs revealed that rs7607888 (P = 2.03 × 10^-7), rs55981318 (P = 0.018), and rs1136545 (P = 1.93 × 10^-9) were also associated with T1D. Haplotype analysis showed association for rs55981318-rs10186193 (P = 0.0005), rs7563960-rs7607888 (P = 0.0007), rs7607888-rs1136545 (P = 9.21 × 10^-10), and rs1136545-rs11538545 (P = 6.67 × 10^-8). In contrast, the new set of 97 familial trios tested for SNPs rs55981318, rs10186193, and rs7607888 did not support the previous finding; however, by combining the sample (197 trios), evidence of association of T1D with rs55981318 and rs7607888 was conclusive. In addition, a two-loci haplotype analysis of the combined sample showed significant association of RNASEH1 with T1D (P = 3.1 × 10^-5).

CONCLUSION

In conclusion, our analyses suggest that RNASEH1 gene variants associate with susceptibility/protection to T1D in Colombia.

Alcohol Intake and Risk of Incident Melanoma: A Pooled Analysis of Three Prospective Studies in the United States

BACKGROUND

Alcohol consumption is associated with increased risk of numerous cancers, but existing evidence for an association with melanoma is equivocal. No study has evaluated the association with different anatomic locations of melanoma.

METHODS

We used data from three large prospective cohort studies to investigate whether alcohol intake was associated with risk of melanoma. Alcohol intake was assessed repeatedly by food-frequency questionnaires. A Cox proportional hazards model was used to calculate multivariate-adjusted hazard ratios (HRs).

RESULTS

A total of 1,374 cases of invasive melanoma were documented during 3,855,706 person-years of follow-up. There was an association between higher alcohol intake and incidence of invasive melanoma (pooled multivariate HR 1.14 [95% confidence interval (CI), 1.00-1.29] per drink/day; P_trend = 0.04). Among alcoholic beverages, white wine consumption was associated with an increased risk of melanoma (pooled multivariate HR 1.13 [95% CI, 1.04-1.24] per drink/day; P_trend <0.01) after adjusting for other alcoholic beverages. The association between alcohol consumption and melanoma risk was stronger for melanoma in relatively UV-spared sites (trunk) versus more UV-exposed sites (head, neck, or extremities). Compared with nondrinkers, the pooled multivariate-adjusted HRs for ≥20 g/day of alcohol were 1.02 (95% CI, 0.64-1.62; P_trend = 0.25) for melanomas of the head, neck, and extremities and 1.73 (95% CI, 1.25-2.38; P_trend = 0.02) for melanomas of the trunk.

CONCLUSIONS

Alcohol intake was associated with a modest increase in the risk of melanoma, particularly in UV-protected sites.

IMPACT

These findings further support American Cancer Society Guidelines for Cancer Prevention to limit alcohol intake. Cancer Epidemiol Biomarkers Prev; 25(12); 1550-8. ©2016 AACR.

"It Ruined My Life": The effects of the War on Drugs on people who inject drugs (PWID) in rural Puerto Rico

BACKGROUND

The War on Drugs has raised the incarceration rates of racial minorities for non-violent drug-related crimes, profoundly stigmatized drug users, and redirected resources from drug prevention and treatment to militarizing federal and local law enforcement. Yet, while some states consider shifting their punitive approach to drug use, to one based on drug treatment and rehabilitation, nothing suggests that these policy shifts are being replicated in Puerto Rico.

METHODS

This paper utilizes data from 360 PWID residing in four rural towns in the mountainous area of central Puerto Rico. We initially recruited 315 PWID using respondent-driven sampling (RDS) and collected data about risk practices and conducted HIV and HCV testing. During a second phase, we conducted 34 micro-ethnographic assays, in which we randomly recruited 34 participants from the first phase and included their ego networks in this phase. Our ethnographic inquiry produced significant data regarding the effects of the war on drugs on the local drug trade, drug availability, and injectors' social networks.

RESULTS

Findings suggest that repressive policing has been ineffective in preventing drug distribution and use among those in our study. This type of law enforcement approach has resulted in the disproportionate incarceration of poor drug users in rural Puerto Rico, and mainly for nonviolent drug-related crimes. In addition, incarceration exposes PWID to a form of a cruel and unusual punishment: having to quit heroin "cold turkey" while the prison environment also represents a HIV/HCV risk. In turn, the war on drugs not only diverts resources from treatment but also shapes treatment ideologies, punishing non-compliant patients.

CONCLUSION

Shifting the emphasis from repression to treatment and rehabilitation is likely to have a positive impact on the health and overall quality of life of PWID and their communities.

The effect of n-acetyl-cysteine on recovery of the facial nerve after crush injury

Objective

Facial nerve dysfunction can vary in severity and recovery is dependent on the character of the injury. N‐acetyl‐cysteine prevents oxidative stress and cellular damage, and its use in the setting of nerve dysfunction from crush injury has not yet been established. In this study, rats with facial nerve crush injury will be treated with n‐acetyl‐cysteine or control and functional recovery and electrophysiologic outcome will be compared.

Study Design

Prospective, randomized animal study

Methods

Twenty‐four Wistar rats underwent unilateral facial nerve crush injury. Rats were implanted with a subcutaneous osmotic pump filled with saline (n = 12) or n‐acetyl‐cysteine 50 mg/kg/day (n = 12). Functional and electromyographic recovery was recorded at two and four weeks postoperatively.

Results

When compared to untreated rats, n‐acetyl‐cysteine treated rats had a greater electromyography amplitude recovery at 2 weeks with regard to eye blink (p=0.006) but not vibrissae function. At four weeks, the electromyography amplitude recovery of the vibrissae function was greater in n‐acetyl‐cysteine treated rats (P=0.001), but the amplitude recovery difference in eye blink was only marginally significant between groups (p=0.07). The functional score was higher in n‐acetyl‐cysteine‐treated rats than in untreated rats at all of the time points.

Conclusion

This study demonstrated that n‐acetyl‐cysteine facilitated facial nerve recovery with improved functional and electromyography outcomes in the setting of crush injury.

Level of Evidence

NA

Antarctic ice sheet discharge driven by atmosphere-ocean feedbacks at the Last Glacial Termination

Reconstructing the dynamic response of the Antarctic ice sheets to warming during the Last Glacial Termination (LGT; 18,000–11,650 yrs ago) allows us to disentangle ice-climate feedbacks that are key to improving future projections. Whilst the sequence of events during this period is reasonably well-known, relatively poor chronological control has precluded precise alignment of ice, atmospheric and marine records, making it difficult to assess relationships between Antarctic ice-sheet (AIS) dynamics, climate change and sea level. Here we present results from a highly-resolved ‘horizontal ice core’ from the Weddell Sea Embayment, which records millennial-scale AIS dynamics across this extensive region. Counterintuitively, we find AIS mass-loss across the full duration of the Antarctic Cold Reversal (ACR; 14,600–12,700 yrs ago), with stabilisation during the subsequent millennia of atmospheric warming. Earth-system and ice-sheet modelling suggests these contrasting trends were likely Antarctic-wide, sustained by feedbacks amplified by the delivery of Circumpolar Deep Water onto the continental shelf. Given the anti-phase relationship between inter-hemispheric climate trends across the LGT our findings demonstrate that Southern Ocean-AIS feedbacks were controlled by global atmospheric teleconnections. With increasing stratification of the Southern Ocean and intensification of mid-latitude westerly winds today, such teleconnections could amplify AIS mass loss and accelerate global sea-level rise.

Long-range dispersal moved Francisella tularensis into Western Europe from the East

For many infections transmitting to humans from reservoirs in nature, disease dispersal patterns over space and time are largely unknown. Here, a reversed genomics approach helped us understand disease dispersal and yielded insight into evolution and biological properties of Francisella tularensis, the bacterium causing tularemia. We whole-genome sequenced 67 strains and characterized by single-nucleotide polymorphism assays 138 strains, collected from individuals infected 1947-2012 across Western Europe. We used the data for phylogenetic, population genetic and geographical network analyses. All strains (n=205) belonged to a monophyletic population of recent ancestry not found outside Western Europe. Most strains (n=195) throughout the study area were assigned to a star-like phylogenetic pattern indicating that colonization of Western Europe occurred via clonal expansion. In the East of the study area, strains were more diverse, consistent with a founder population spreading from east to west. The relationship of genetic and geographic distance within the F. tularensis population was complex and indicated multiple long-distance dispersal events. Mutation rate estimates based on year of isolation indicated null rates; in outbreak hotspots only, there was a rate of 0.4 mutations/genome/year. Patterns of nucleotide substitution showed marked AT mutational bias suggestive of genetic drift. These results demonstrate that tularemia has moved from east to west in Europe and that F. tularensis has a biology characterized by long-range geographical dispersal events and mostly slow, but variable, replication rates. The results indicate that mutation-driven evolution, a resting survival phase, genetic drift and long-distance geographical dispersal events have interacted to generate genetic diversity within this species.

Water as Source of Francisella tularensis Infection in Humans, Turkey

Francisella tularensis DNA extractions and isolates from the environment and humans were genetically characterized to elucidate environmental sources that cause human tularemia in Turkey. Extensive genetic diversity consistent with genotypes from human outbreaks was identified in environmental samples and confirmed water as a source of human tularemia in Turkey.