Correlation between improved leptin signaling and cognitive function post bariatric surgery

Determining whether changes in leptin signaling plays a role in the improvement of cognitive function post-bariatric surgery may aid in the understanding and development of novel therapeutic approaches targeting cognitive dysfunction through the greater understanding of processes connecting obesity and brain health. Several studies have explored the effects of cognition post bariatric surgery, and others have studied leptin and its changes post surgery. However the amalgamation of the effects of leptin signaling in relation to cognition post bariatric surgery have yet to be considered as key tools in the understanding of cognitive dysfunction in obese subjects with leptin resistance or insensitivity. This review serves to highlight the potential correlations, to further elucidate the effect of improved leptin signaling on cognition post bariatric surgery, and to propose a direct cause for the improvement of cognitive function via the amelioration of the leptin Janus kinase/Signal transducer and activator of transcription (JAK/STAT) signaling pathway as a result of the reversal of inflammatory processes involved in diseased individuals.

Development of an 18F-labeled anti-human CD8 VHH for same-day immunoPET imaging

PURPOSE

Cancer immunotherapies (CITs) have revolutionized the treatment of certain cancers, but many patients fail to respond or relapse from current therapies, prompting the need for new CIT agents. CD8⁺ T cells play a central role in the activity of many CITs, and thus, the rapid imaging of CD8⁺ cells could provide a critical biomarker for new CIT agents. However, existing ⁸⁹Zr-labeled CD8 PET imaging reagents exhibit a long circulatory half-life and high radiation burden that limit potential applications such as same-day and longitudinal imaging.

METHODS

To this end, we discovered and developed a 13-kDa single-domain antibody (VHH5v2) against human CD8 to enable high-quality, same-day imaging with a reduced radiation burden. To enable sensitive and rapid imaging, we employed a site-specific conjugation strategy to introduce an ¹⁸F radiolabel to the VHH.

RESULTS

The anti-CD8 VHH, VHH5v2, demonstrated binding to a membrane distal epitope of human CD8 with a binding affinity (K_D) of 500 pM. Subsequent imaging experiments in several xenografts that express varying levels of CD8 demonstrated rapid tumor uptake and fast clearance from the blood. High-quality images were obtained within 1 h post-injection and could quantitatively differentiate the tumor models based on CD8 expression level.

CONCLUSION

Our work reveals the potential of this anti-human CD8 VHH [¹⁸F]F-VHH5v2 to enable rapid and specific imaging of CD8⁺ cells in the clinic.

Mental health mobile apps for patients: Psychiatrists’ concerns

Introduction

The use of mobile apps aimed at supporting patients with a mental illness is rapidly increasing.

Objectives

The presented results explore psychiatrists’ concerns about mobile apps for patients with a mental illness. These results are part of a larger study that examines psychiatrists’ attitudes regarding the use and development of mobile apps.

Methods

In the qualitative exploratory study, semi-structured interviews were conducted with 18 psychiatrists in Czech Republic, Austria, and Slovakia. Psychiatrists were recruited via snowball sampling. The interviews were digitally recorded, transcribed verbatim, translated into English, and content analyzed using deductive and inductive category development.

Results

There were mixed feelings regarding mobile apps for patients with mental illness. While psychiatrists emphasized certain benefits (e.g. increasing patients’ treatment motivation and engagement), several concerns were also expressed, especially by psychiatrists who were generally unfamiliar with mobile apps. They feared being replaced; were afraid that patients would act as their own doctors, thereby damaging their health; stressed that mobile apps could not respond or be tailored to an individual the same way psychiatrists could tailor treatment to a patient.

Conclusions

The psychiatrists who were more likely to have concerns about mental health apps were those who were generally unfamiliar with the apps and/or thought the apps aim to replace, rather than support, face-to-face treatment. Thus, clinicians and patients should be familiarized with the use of such mobile apps and educated on how they could support the face-to-face treatment.

Head-to-head comparison of DFO* and DFO chelators: selection of the best candidate for clinical 89Zr-immuno-PET

Purpose

Almost all radiolabellings of antibodies with ⁸⁹Zr currently employ the hexadentate chelator desferrioxamine (DFO). However, DFO can lead to unwanted uptake of ⁸⁹Zr in bones due to instability of the resulting metal complex. DFO*-NCS and the squaramide ester of DFO, DFOSq, are novel analogues that gave more stable ⁸⁹Zr complexes than DFO in pilot experiments. Here, we directly compare these linker-chelator systems to identify optimal immuno-PET reagents.

Methods

Cetuximab, trastuzumab and B12 (non-binding control antibody) were labelled with ⁸⁹Zr via DFO*-NCS, DFOSq, DFO-NCS or DFO*Sq. Stability in vitro was compared at 37 °C in serum (7 days), in formulation solution (24 h ± chelator challenges) and in vivo with N87 and A431 tumour-bearing mice. Finally, to demonstrate the practical benefit of more stable complexation for the accurate detection of bone metastases, [⁸⁹Zr]Zr-DFO*-NCS and [⁸⁹Zr]Zr-DFO-NCS-labelled trastuzumab and B12 were evaluated in a bone metastasis mouse model where BT-474 breast cancer cells were injected intratibially.

Results

[⁸⁹Zr]Zr-DFO*-NCS-trastuzumab and [⁸⁹Zr]Zr-DFO*Sq-trastuzumab showed excellent stability in vitro, superior to their [⁸⁹Zr]Zr-DFO counterparts under all conditions. While tumour uptake was similar for all conjugates, bone uptake was lower for DFO* conjugates. Lower bone uptake for DFO* conjugates was confirmed using a second xenograft model: A431 combined with cetuximab. Finally, in the intratibial BT-474 bone metastasis model, the DFO* conjugates provided superior detection of tumour-specific signal over the DFO conjugates.

Conclusion

DFO*-mAb conjugates provide lower bone uptake than their DFO analogues; thus, DFO* is a superior candidate for preclinical and clinical ⁸⁹Zr-immuno-PET.

Electronic supplementary material

The online version of this article (10.1007/s00259-020-05002-7) contains supplementary material, which is available to authorized users.

Molecular Interaction Characterization Strategies for the Development of New Biotherapeutic Antibody Modalities

The characterization of target binding interactions is critical at each stage of antibody therapeutic development. During early development, it is important to design fit-for-purpose in vitro molecular interaction characterization (MIC) assays that accurately determine the binding kinetics and the affinity of therapeutic antibodies for their targets. Such information enables PK/PD (pharmacokinetics/pharmacodynamics) modeling, estimation of dosing regimens, and assessment of potency. While binding kinetics and affinities seem to be readily obtained, there is little discussion in the literature on how the information should be generated and used in a systematic manner along with other approaches to enable key drug development decisions. The introduction of new antibody modalities poses unique challenges to the development of MIC assays and further increases the need to discuss the impact of developing context-appropriate MIC assays to enable key decision making for these programs. In this paper, we discuss for the first time the challenges encountered when developing MIC assays supporting new antibody modalities. Additionally, through the presentation of several real case studies, we provide strategies to overcome these challenges to enable investigational new drug (IND) filings.

The Production, Quality Control, and Characterization of ZED8, a CD8-Specific 89Zr-Labeled Immuno-PET Clinical Imaging Agent

Immuno-PET is a molecular imaging technique utilizing positron emission tomography (PET) to measure the biodistribution of an antibody species labeled with a radioactive isotope. When applied as a clinical imaging technique, an immuno-PET imaging agent must be manufactured with quality standards appropriate for regulatory approval. This paper describes methods relevant to the chemistry, manufacturing, and controls component of an immuno-PET regulatory filing, such as an investigational new drug application. Namely, the production, quality control, and characterization of the immuno-PET clinical imaging agent, ZED8, an ⁸⁹Zr-labeled CD8-specific monovalent antibody as well as its desferrioxamine-conjugated precursor, CED8, is described and evaluated. PET imaging data in a human CD8-expressing tumor murine model is presented as a proof of concept that the imaging agent exhibits target specificity and comparable biodistribution across a range of desferrioxamine conjugate loads.

Total-Body PET and Highly Stable Chelators Together Enable Meaningful 89Zr-Antibody PET Studies up to 30 Days After Injection

The use of ⁸⁹Zr-antibody PET imaging to measure antibody biodistribution and tissue pharmacokinetics is well established, but current PET systems lack the sensitivity needed to study ⁸⁹Zr-labeled antibodies beyond 2-3 isotope half-lives (7-10 d), after which a poor signal-to-noise ratio is problematic. However, studies across many weeks are desirable to better match antibody circulation half-life in human and nonhuman primates. These studies investigated the technical feasibility of using the primate mini-EXPLORER PET scanner, making use of its high sensitivity and 45-cm axial field of view, for total-body imaging of ⁸⁹Zr-labeled antibodies in rhesus monkeys up to 30 d after injection. Methods: A humanized monoclonal IgG antibody against the herpes simplex viral protein glycoprotein D (gD) was radiolabeled with ⁸⁹Zr via 1 of 4 chelator-linker combinations (benzyl isothiocyanate-DFO [DFO-Bz-NCS], where DFO is desferrioxamine B; DFO-squaramide; DFO*-Bz-NCS, where DFO* is desferrioxamine*; and DFO*-squaramide). The pharmacokinetics associated with these 4 chelator-linker combinations were compared in 12 healthy young male rhesus monkeys (∼1-2 y old, ∼3 ± 1 kg). Each animal was initially injected intravenously with unlabeled antibody in a peripheral vessel in the right arm (10 mg/kg, providing therapeutic-level antibody concentrations), immediately followed by approximately 40 MBq of one of the ⁸⁹Zr-labeled antibodies injected intravenously in a peripheral vessel in the left arm. All animals were imaged 6 times over a period of 30 d, with an initial 60-min dynamic scan on day 0 (day of injection) followed by static scans of 30-45 min on approximately days 3, 7, 14, 21, and 30, with all acquired using a single bed position and images reconstructed using time-of-flight list-mode ordered-subsets expectation maximization. Activity concentrations in various organs were extracted from the PET images using manually defined regions of interest. Results: Excellent image quality was obtained, capturing the initial distribution phase in the whole-body scan; later time points showed residual ⁸⁹Zr mainly in the liver. Even at 30 d after injection, representing approximately 9 half-lives of ⁸⁹Zr and with a total residual activity of only 20-40 kBq in the animal, the image quality was sufficient to readily identify activity in the liver, kidneys, and upper and lower limb joints. Significant differences were noted in late time point liver uptake, bone uptake, and whole-body clearance between chelator-linker types, whereas little variation (±10%) was observed within each type. Conclusion: These studies demonstrate the ability to image ⁸⁹Zr-radiolabeled antibodies up to 30 d after injection while maintaining satisfactory image quality, as provided by the primate mini-EXPLORER with high sensitivity and long axial field of view. Quantification demonstrated potentially important differences in the behavior of the 4 chelators. This finding supports further investigation.

Extended Telemedical Consultation using Arden Syntax Based Decision Support, Hypertext and WWW Technique

There is an obvious need for geographic distribution of expert knowledge among several health care units without increasing the cost of on-site expertise in locations where health care is provided. This paper describes the design of a knowledge-based decision-support system for extended consultation in clinical medicine. The system is based on Arden Syntax for Medical Logic Modules and hypertext using World Wide Web technology. It provides advice and explanations regarding the given advice. The explanations are presented in a hypertext format allowing the user to browse related information and to verify the relevance of the given advice. The system is intended to be used in a closed local network. With special precautions regarding issues of safety and patient security, the system can be used over wider areas such as in rural medicine. A prototype has been developed in the field of clinical microbiology and infectious diseases regarding infective endocarditis.

A Decision Support System for Diabetes Care: Ethical Aspects

In this paper the design and implementation of a decision support system for diabetes care is examined from an ethical perspective. It is noted that the system creates potential for enhancing the realization of the principle of autonomy through improved information to patients and participation by patients. However, there is also potential for using the system in a way that is contrary to good health care. It may provide patients with information they are unable to interpret and handle, and it may be used by healthcare authorities for controlling their personnel in ways contrary to good quality working conditions. In order for a decision support system to function as a well-integrated element in ethically based health care, different ethical aspects have to be taken into account during the design of the system. The ethical aspects also constitute one perspective of a systematic re-evaluation and re-design process.

Evaluation of a semi-automated software program for the identification of vertebral fractures in children

AIM

To assess observer reliability and diagnostic accuracy in children, of a semi-automated six-point technique developed for vertebral fracture (VF) diagnosis in adults, which records percentage loss of vertebral body height.

MATERIALS AND METHODS

Using a semi-automated software program, five observers independently assessed T4 to L4 from the lateral spine radiographs of 137 children and adolescents for VF. A previous consensus read by three paediatric radiologists using a simplified algorithm-based qualitative technique (i.e., no software involved) served as the reference standard.

RESULTS

Of a total of 1,781 vertebrae, 1,187 (67%) were adequately visualised according to three or more observers. Interobserver agreement in vertebral readability for each vertebral level for five observers ranged from 0.05 to 0.47 (95% CI: -0.19, 0.76). Intra-observer agreement using the intraclass correlation coefficient (ICC) ranged from 0.25 to 0.61. The overall sensitivity and specificity were 18% (95% CI: 14-22) and 97% (95% CI: 97-98), respectively.

CONCLUSION

In contrast to adults, the six-point technique assessing anterior, middle, and posterior vertebral height ratios is neither satisfactorily reliable nor sensitive for VF diagnosis in children. Training of the software on paediatric images is required in order to develop a paediatric standard that incorporates not only specific vertebral body height ratios but also the age-related physiological changes in vertebral shape that occur throughout childhood.

The PARP inhibitor ABT-888 potentiates dacarbazine-induced cell death in carcinoids

Monoagent DNA-alkylating chemotherapies like dacarbazine are among a paucity of medical treatments for advanced carcinoid tumors, but are limited by host toxicity and intrinsic chemoresistance through the base excision repair (BER) pathway via poly (ADP-ribose) polymerase (PARP). Hence, inhibitors of PARP may potentiate DNA-damaging agents by blocking BER and DNA restoration. We show that the PARP inhibitor ABT-888 (Veliparib) enhances the cytotoxic effects of dacarbazine in carcinoids. Two human carcinoid cell lines (BON and H727) treated with a combination of ABT-888 and dacarbazine resulted in synergistic growth inhibition signified by combination indices <1 on the Chou-Talalay scale. ABT-888 administered prior to varying dacarbazine doses promoted the suppression of neuroendocrine biomarkers of malignancy ASCL1 and CgA, shown by Western analysis. ATM phosphorylation and p21^Waf1/Cip1 activation, indicative of DNA damage, were increased by ABT-888 when combined with dacarbazine treatment, suggesting BER pathway attenuation by ABT-888. PE Annexin V/7-AAD staining and sorting revealed a profound induction of apoptosis following combination treatment, which was further confirmed by increased PARP cleavage. These results demonstrate that ABT-888 synergizes dacarbazine treatment in carcinoids. Therefore, ABT-888 may help treat carcinoids unresponsive or refractory to mainstay therapies.

Next-generation sequencing with a myeloid gene panel in core-binding factor AML showed KIT activation loop and TET2 mutations predictive of outcome

Clinical outcome and mutations of 96 core-binding factor acute myeloid leukemia (AML) patients 18–60 years old were examined. Complete remission (CR) after induction was 94.6%. There was no significant difference in CR, leukemia-free-survival (LFS) and overall survival (OS) between t(8;21) (N=67) and inv(16) patients (N=29). Univariate analysis showed hematopoietic stem cell transplantation at CR1 as the only clinical parameter associated with superior LFS. Next-generation sequencing based on a myeloid gene panel was performed in 72 patients. Mutations in genes involved in cell signaling were associated with inferior LFS and OS, whereas those in genes involved in DNA methylation were associated with inferior LFS. KIT activation loop (AL) mutations occurred in 25 patients, and were associated with inferior LFS (P=0.003) and OS (P=0.001). TET2 mutations occurred in 8 patients, and were associated with significantly shorter LFS (P=0.015) but not OS. Patients negative for KIT-AL and TET2 mutations (N=41) had significantly better LFS (P<0.001) and OS (P=0.012) than those positive for both or either mutation. Multivariate analysis showed that KIT-AL and TET2 mutations were associated with inferior LFS, whereas age ⩾40 years and marrow blast ⩾70% were associated with inferior OS. These observations provide new insights that may guide better treatment for this AML subtype.

Oral arsenic trioxide-based regimen as salvage treatment for relapsed or refractory mantle cell lymphoma

BACKGROUND

Mantle cell lymphoma (MCL) is aggressive, and relapsed/refractory disease has poor outcomes.

PATIENTS AND METHODS

Thirty-nine patients (men = 34, women = 5) at 64 (41-82) years of age with relapsed/refractory MCL, ineligible for high-dose chemotherapy and had received 2 (1-5) prior regimens, were treated with a continuous oral regimen, comprising oral arsenic trioxide (oral-As2O3), chlorambucil and ascorbic acid.

RESULTS

Overall response rate was 49% (complete response, CR = 28%; partial response, PR = 21%). Only grade 1/2 toxicities were observed (hematologic: 56%, hepatic: 8%). Response was maintained in 11 patients (CR = 8; PR = 3), after a median of 24 (2-108) months. Independent prognostic factors for response were increased lactate dehydrogenase (P = 0.04) and unfavorable MCL international prognostic index (P = 0.04). At a median follow-up of 21 (1-118) months, the median progression-free survival (PFS) was 16 months, and overall survival (OS) 38 months. Independent prognostic factors for PFS were female gender (P = 0.002), and Eastern Cooperative Oncology Group (ECOG) performance score of 2 (P = 0.009). Independent prognostic factors for OS were female gender (P < 0.001), ECOG performance score of 2 (P = 0.03), non-response (P < 0.001), and disease progression after initial response (P = 0.05).

CONCLUSION

An oral regimen of oral-As2O3, chlorambucil and ascorbic acid was active with minimal toxicity in relapsed/refractory MCL, achieving durable responses in ∼30% of cases.

A case of isolated cutaneous Rosai-Dorfman-Syndrome

Rosai-Dorfman Syndrome (RDD) is a rare, benign, self-limiting disorder which is characterized by the non-malignant proliferation of distinctive histiocytic cell within lymphatic system. RDD has been described as a dynamic entity in the spectrum of histiocytosis with non-Langerhans cell histiocytosis at one end and Langerhans cell histiocytosis at the other. The exact etiology of this disease is uncertain despite widespread search for infectious or immunological reasons. We present a case of purely cutaneous Rosai-Dorfman Syndrome presenting as abdominal wall swelling.

KEYWORDS

Rosai-Dorfman Disease, Lymphoma.

An integrated approach to identify normal tissue expression of targets for antibody-drug conjugates: case study of TENB2

BACKGROUND AND PURPOSE

The success of antibody-drug conjugates (ADCs) depends on the therapeutic window rendered by the differential expression between normal and pathological tissues. The ability to identify and visualize target expression in normal tissues could reveal causes for target-mediated clearance observed in pharmacokinetic characterization. TENB2 is a prostate cancer target associated with the progression of poorly differentiated and androgen-independent tumour types, and ADCs specific for TENB2 are candidate therapeutics. The objective of this study was to locate antigen expression of TENB2 in normal tissues, thereby elucidating the underlying causes of target-mediated clearance.

EXPERIMENTAL APPROACH

A series of pharmacokinetics, tissue distribution and mass balance studies were conducted in mice using a radiolabelled anti-TENB2 ADC. These data were complemented by non-invasive single photon emission computed tomography - X-ray computed tomography imaging and immunohistochemistry.

KEY RESULTS

The intestines were identified as a saturable and specific antigen sink that contributes, at least in part, to the rapid target-mediated clearance of the anti-TENB2 antibody and its drug conjugate in rodents. As a proof of concept, we also demonstrated the selective disposition of the ADC in a tumoural environment in vivo using the LuCaP 77 transplant mouse model. High tumour uptake was observed despite the presence of the antigen sink, and antigen specificity was confirmed by antigen blockade.

CONCLUSIONS AND IMPLICATIONS

Our findings provide the anatomical location and biological interpretation of target-mediated clearance of anti-TENB2 antibodies and corresponding drug conjugates. Further investigations may be beneficial in addressing the relative contributions to ADC disposition from antigen expression in both normal and pathological tissues.

Cytokine profile and induction of T helper type 17 and regulatory T cells by human peripheral mononuclear cells after microbial exposure

The immunomodulatory effects of probiotics were assessed following exposure of normal peripheral blood mononuclear cells (PBMC), cord blood cells and the spleen-derived monocyte/macrophage cell line CRL-9850 to Lactobacillus acidophilus LAVRI-A1, Lb. rhamnosus GG, exopolysaccharides (EPS)-producing Streptococcus thermophilus St1275, Bifidobacteriun longum BL536, B. lactis B94 and Escherichia coli TG1 strains. The production of a panel of pro- and anti-inflammatory cytokines by PBMC following bacterial stimulation was measured, using live, heat-killed or mock gastrointestinal tract (GIT)-exposed bacteria, and results show that (i) all bacterial strains investigated induced significant secretion of pro- and anti-inflammatory cytokines from PBMC-derived monocytes/macrophages; and (ii) cytokine levels increased relative to the expansion of bacterial cell numbers over time for cells exposed to live cultures. Bifidobacteria and S. thermophilus stimulated significant concentrations of transforming growth factor (TGF)-β, an interleukin necessary for the differentiation of regulatory T cells (T(reg) )/T helper type 17 (Th17) cells and, as such, the study further examined the induction of Th17 and T(reg) cells after PBMC exposure to selected bacteria for 96 h. Data show a significant increase in the numbers of both cell types in the exposed populations, measured by cell surface marker expression and by cytokine production. Probiotics have been shown to induce cytokines from a range of immune cells following ingestion of these organisms. These studies suggest that probiotics' interaction with immune-competent cells produces a cytokine milieu, exerting immunomodulatory effects on local effector cells, as well as potently inducing differentiation of Th17 and T(reg) cells.

Impact of drug conjugation on pharmacokinetics and tissue distribution of anti-STEAP1 antibody-drug conjugates in rats

Antibody-drug conjugates (ADCs) are designed to combine the exquisite specificity of antibodies to target tumor antigens with the cytotoxic potency of chemotherapeutic drugs. In addition to the general chemical stability of the linker, a thorough understanding of the relationship between ADC composition and biological disposition is necessary to ensure that the therapeutic window is not compromised by altered pharmacokinetics (PK), tissue distribution, and/or potential organ toxicity. The six-transmembrane epithelial antigen of prostate 1 (STEAP1) is being pursued as a tumor antigen target. To assess the role of ADC composition in PK, we evaluated plasma and tissue PK profiles in rats, following a single dose, of a humanized anti-STEAP1 IgG1 antibody, a thio-anti-STEAP1 (ThioMab) variant, and two corresponding thioether-linked monomethylauristatin E (MMAE) drug conjugates modified through interchain disulfide cysteine residues (ADC) and engineered cysteines (TDC), respectively. Plasma PK of total antibody measured by enzyme-linked immunosorbent assay (ELISA) revealed ∼45% faster clearance for the ADC relative to the parent antibody, but no apparent difference in clearance between the TDC and unconjugated parent ThioMab. Total antibody clearances of the two unconjugated antibodies were similar, suggesting minimal effects on PK from cysteine mutation. An ELISA specific for MMAE-conjugated antibody indicated that the ADC cleared more rapidly than the TDC, but total antibody ELISA showed comparable clearance for the two drug conjugates. Furthermore, consistent with relative drug load, the ADC had a greater magnitude of drug deconjugation than the TDC in terms of free plasma MMAE levels. Antibody conjugation had a noticeable, albeit minor, impact on tissue distribution with a general trend toward increased hepatic uptake and reduced levels in other highly vascularized organs. Liver uptakes of ADC and TDC at 5 days postinjection were 2-fold and 1.3-fold higher, respectively, relative to the unmodified antibodies. Taken together, these results indicate that the degree of overall structural modification in anti-STEAP1-MMAE conjugates has a corresponding level of impact on both PK and tissue distribution.

Fetal ventricular tachycardia secondary to long QT syndrome treated with maternal intravenous magnesium: case report and review of the literature

Ventricular tachycardia is a very rare fetal arrhythmia accounting for fewer than 2% of fetal tachycardias. We describe a fetus presenting at 30 weeks' gestation with ventricular tachycardia at a rate of 220 beats per min and fetal hydrops. The tachycardia was unresponsive to flecainide but was controlled within 12 h by an intravenous infusion of magnesium to the mother. Despite rapid control of the arrhythmia the fetus developed severe periventricular leukomalacia before birth for which a poor neurological prognosis was given. The baby was delivered preterm at 32 weeks' gestation and died on the sixth day after birth. Long QT syndrome was identified postnatally on the electrocardiogram, and was confirmed by genetic testing which showed a mutation in the KCNH2 gene (p.T613M).

Administration of melatonin mixed with soft food and liquids for children with neurodevelopmental difficulties

It is sometimes necessary for the contents of medication capsules to be mixed with certain foods and drinks because children are not always able to swallow the capsules. The compatibility and short-term stability (6h) of melatonin capsules mixed in a variety of liquids and foodstuffs (water, orange juice, semi-skimmed milk, strawberry yogurt, and strawberry jam) were analyzed for degradation. Extraction of melatonin from these common administration vehicles and an analytical assay for the drug and its potential degradation products were developed and validated. The results showed good recovery of melatonin from low- and high-strength capsules for all administration vehicles (between 89% minimum and 111% maximum). The drug was found to be stable in the common liquids and foods tested for up to 6 hours at room temperature (no degradation peak); hence it is unlikely to compromise the results of the Use of Melatonin in Children with Neurodevelopmental Disorders and Impaired Sleep trial.

Low antibiotic resistance rates in Staphylococcus aureus, Escherichia coli and Klebsiella spp but not in Enterobacter spp and Pseudomonas aeruginosa: a prospective observational study in 14 Swedish ICUs over a 5-year period

BACKGROUND

Intensive care units (ICUs) are hot zones for emergence and spread of antibiotic resistance because of frequent invasive procedures, antibiotic usage and transmission of bacteria. We report prospective data on antibiotic use and bacterial resistance from 14 academic and non-academic ICUs, participating in the ICU-STRAMA programme 1999-2003.

METHODS

The quantity of antibiotics delivered to each ICU was calculated as defined daily doses per 1,000 occupied bed days (DDD(1,000)). Specimens for culture were taken on clinical indications and only initial isolates were considered. Species-related breakpoints according to the Swedish Reference Group for Antibiotics were used. Antibiotic resistance was defined as the sum of intermediate and resistant strains.

RESULTS

Mean antibiotic use increased from 1,245 DDD(1,000) in 1999 to 1,510 DDD(1,000) in 2003 (P = 0.11 for trend). Of Staphylococcus aureus, 0-1.8% were methicillin resistant (MRSA). A presumptive extended spectrum beta-lactamase (ESBL) phenotype was found in <2.4% of Escherichia coli, based on cefotaxime susceptibility, except a peak in 2002 (4.6%). Cefotaxime resistance was found in 2.6-4.9% of Klebsiella spp. Rates of resistance among Enterobacter spp. to cefotaxime (20-33%) and among Pseudomonas aeruginosa to imipenem (22-33%) and ciprofloxacin (5-21%) showed no time trend.

CONCLUSION

MRSA and cefotaxime-resistant E. coli and Klebsiella spp strains were few despite high total antibiotic consumption. This may be the result of a slow introduction of resistant strains into the ICUs, and good infection control. The cause of imipenem and ciprofloxacin resistance in P. aeruginosa could reflect the increased consumption of these agents plus spread of resistant clones.

Impact of consumption of different levels of Bifidobacterium lactis HN019 on the intestinal microflora of elderly human subjects

BACKGROUND

Age-related changes in the physiology and intestinal function of the elderly render them more susceptible to gut-related illnesses. Probiotic dietary supplementation has been shown to enhance the health indices in the elderly.

OBJECTIVE

To determine the effect of three different doses [5 x 109 CFU/day (high), 1.0 x 109 CFU/day (medium) and 6.5 x 107 CFU/day (low)] of Bifidobacterium lactis HN019 (DR10TM) on the intestinal flora of elderly human subjects and the dose response effect.

DESIGN

Randomised, double-blind and placebo-controlled human dietary intervention study consisting of four groups of 20 elderly (over 60 years old) volunteers. Each volunteer consumed 250 mL per day of reconstituted skim milk (RSM) which either did not contain any probiotic supplement (placebo group) or contained B. lactis HN019 at different levels (low, medium and high dose groups). The study comprised three stages: a 2-week pre-intervention (without any supplement), followed by 4 weeks of test feeding (dietary intervention) and then a 2-week washout period.

RESULTS

After dietary intervention, statistically significant increases in bifidobacteria, lactobacilli and enterococci were observed. At the end of the 4-week feeding period the mean number of bifidobacteria recorded in the placebo group were 9.31 +/- 0.01 log CFU/g of faeces. In the high, medium and low dose groups the bifidobacteria levels were significantly (p < 0.006) higher (9.88 +/- 0.1, 9.75 +/- 0.14 and 9.74 +/- 0.11 log CFU/g of faeces, respectively), when compared to the respective pre-intervention levels. There were no significant differences (p superior 0.05) between the responses of the different dose groups, indicating that even the lowest dose tested augmented the changes in bifidobacteria. Similar trends were observed for lactobacilli and enterococci. In contrast, the counts of enterobacteria were reduced in all the probiotic dose groups.

CONCLUSION

The present study showed that dietary supplementation with B. lactis HN019 significantly increased the number of resident bifidobacteria and reduced the enterobacteria counts. In addition, enterococci and lactobacilli were also increased. Based on this study and already published clinical evidence (4, 5, 8, 9) we conclude that, B. lactis HN019 is a suitable probiotic for elderly human subjects and even the lowest dose (6.5 x 107 CFU/day) tested is able to confer desired changes in the intestinal microflora.

Time components of circulatory transport from the lungs to a peripheral artery in humans

Blood gas changes occurring in the lung undergo delay and damping on their way to a peripheral artery sampling site. Knowledge of the time components of circulatory transfer is important for the understanding of respiratory control and cardiovascular reflexes in response to blood gas transients. Providing steady state with regard to VA/Q distribution, cardiac output and peripheral blood flow, the relationship between the time courses of small end-tidal and peripheral PO2 changes is determined by the transfer function of the interposed vascular segment. This transfer function, expressed as delay time TD and mean transit time (MTT), was measured in six well-trained subjects, allowing the calculation of arterial time-courses from end-tidal to the reverse. They were studied at rest and during four different dynamic leg exercise intensities in the supine posture. TD and MTT amounted to 15.8 +/- 1.7 (mean +/- SEM) and 18.3 +/- 2.1 s at rest and were shortened to 7.7 +/- 0.6 and 11.5 +/- 1.8 s during exercise at 170 W. The shortening of TD and MTT did not appear to be simply an inverse function of cardiac output, suggesting that the shortening occurs in the central circulatory segment but not in the arm segment.

Phene Plate (PhP) biochemical fingerprinting. A screening method for epidemiological typing of enterococcal isolates

Pulsed-field gel electrophoresis (PFGE) is currently considered the gold standard for genotyping of enterococci. However, PFGE is both expensive and time-consuming. The purpose of this study was to investigate whether the PhP system can be used as a reliable clinical screening method for detection of genetically related isolates of enterococci. If so, it should be possible to minimize the number of isolates subjected to PFGE typing, which would save time and money. Ninety-nine clinical enterococcal isolates were analysed by PhP (similarity levels 0.90-0.975) and PFGE (similarity levels < or =3 and < or =6 bands) and all possible pairs of isolates were cross-classified as matched or mismatched. We found that the probability that a pair of isolates (A and B) belonging to the same type according to PhP also belong to the same cluster according to PFGE, i.e. p(A(PFGE)=B(PFGE) * A(PhP)=B(PhP)), and the probability that a pair of isolates of different types according to PhP also belong to different clusters according to PFGE, i.e. p(A(PFGE) not equalB(PFGE) * A(PhP) not equalB(PhP)), was relatively high for E. faecalis (0.86 and 0.96, respectively), but was lower for E. faecium (0.51 and 0.77, respectively). The concordance which shows the probability that PhP and PFGE agree on match or mismatch was 86%-93% for E. faecalis and 54%-66% for E. faecium, which indicates that the PhP method may be useful for epidemiological typing of E. faecalis in the current settings but not for E. faecium.

Ten-year in vivo wear measurement of a fully congruent mobile bearing unicompartmental knee arthroplasty

Polyethylene particulate wear debris continues to be implicated in the aetiology of aseptic loosening following knee arthroplasty. The Oxford unicompartmental knee arthroplasty employs a spherical femoral component and a fully congruous meniscal bearing to increase contact area and theoretically reduce the potential for polyethylene wear. This study measures the in vivo ten-year linear wear of the device, using a roentgenstereophotogrammetric technique. In this in vivo study, seven medial Oxford unicompartmental prostheses, which had been implanted ten years previously were studied. Stereo pairs of radiographs were acquired for each patient and the films were analysed using a roentgen stereophotogrammetric analysis calibration and a computer-aided design model silhouette-fitting technique. Penetration of the femoral component into the original volume of the bearing was our estimate of linear wear. In addition, eight control patients were examined less than three weeks post-insertion of an Oxford prosthesis, where no wear would be expected. The control group showed no measured wear and suggested a system accuracy of 0.1 mm. At ten years, the mean linear wear rate was 0.02 mm/year. The results from this in vivo study confirm that the device has low ten-year linear wear in clinical practice. This may offer the device a survival advantage in the long term.

Effects of azinphos-methyl on cholinergic responses and general health in zebra finches (Taeniopygia guttata) after previous treatment with p,p'-DDE

Although organochlorine (OC) pesticides were replaced with organophosphates (OPs) in the early 1970s, they continue to persist in orchard environments today. Extensive research has been conducted to determine the effects of currently used OPs on cholinesterase (ChE) activity; however, although OCs continue to be prevalent in areas of previous use, few studies have looked at the toxicity of a combination of residual OC compounds with currently used OP pesticides. The focus of our study was to determine the effects of azinphos-methyl (a common OP used in apple orchards today) on ChE activity and general health in zebra finches (Taeniopygia guttata) previously exposed to p,p'-DDE (a commonly detected metabolite of DDT). The main results of our study were as follows: (1) azinphos-methyl alone caused a dose-dependent inhibition of plasma and brain ChE activity; (2) p,p'-DDE in combination with azinphos-methyl did not change azinphos-methyl inhibition of ChE activity; and (3) there were suggestions of immunostimulation in birds dosed 1 year previously to p,p'-DDE and of anemia when p,p'-DDE was combined with azinphos-methyl; however, there was no dose-response for these parameters in birds subsequently dosed with p,p'-DDE.

Multiple loci are linked with anti-red blood cell antibody production in NZB mice -- comparison with other phenotypes implies complex modes of action

The New Zealand Black (NZB) mouse strain is a model of autoimmune haemolytic anaemia (AHA) and systemic lupus erythematosus (SLE), characterized by the production of anti-red blood cell (RBC) antibodies and anti-nuclear antibodies (ANA), respectively. A linkage analysis was carried out in an (NZB x BALB/c) F(2) cross in order to identify loci involved in the production of both anti-RBC IgM and IgG antibodies. These regions of linkage were compared with linkage data to ANA from the same cohort and other linkage analyses involving New Zealand mice. Four previously described NZB loci linked to anti-RBC antibodies were confirmed, and eight novel loci linked to this trait were also mapped: five of which were of NZB origin, and three derived from the non-autoimmune BALB/c background. A comparison between loci linked with anti-RBC antibodies and ANA demonstrated many that co-localize, suggesting the presence of genes that result in the general breaking of tolerance to self-antigen. Furthermore, the observation that some loci were associated only with the anti-RBC response suggests an antigen specific mechanism in addition to a general breaking of tolerance. A locus linked with anti-RBC antibodies and ANA on distal chromosome 7 in this cohort is orthologous to one on the q arm of human chromosome 11, a region linked to AHA and ANA in human SLE.

Molecular interfacial reactions between Pu(VI) and manganese oxide minerals manganite and hausmannite

The sorption of Pu(VI) onto manganite (MnOOH) and hausmannite (Mn3O4) was studied as a function of time, solution pH, and initial plutonium concentration. Kinetic experiments indicate that the surface complexation of plutonium occurs over the first 24 h of contact with the mineral surface. The sorption increases with pH beginning at pH 3 until it reaches a maximum value of 100% at pH 8 (0.0011-0.84 micromol of Pu/m2 of manganite and 0.98-1.2 micromol of Pu/m2 of hausmannite) and then decreases over the pH range from 8 to 10. The ratio of solid to solution was 10 mg/mL for manganite experiments and 4 mg/mL for hausmannite samples. Carbonate was not excluded from the experiments. The amount of plutonium removed from the solution by the minerals is determined by a combination of factors including the plutonium solution species, the surface charge of the mineral, and the mineral surface area. X-ray absorption fine structure taken at the Pu L(III) edge were compared to plutonium standard spectra and showed that Pu(VI) was reduced to Pu(IV) after contact with the minerals. Plutonium sorption to the mineral surface is consistent with an inner-sphere configuration, and no evidence of PuO2 precipitation is observed. The reduction and complexation of Pu(VI) by manganese minerals has direct implications on possible migration of Pu(VI) species in the environment.

Antibiotic prescription practices, consumption and bacterial resistance in a cross section of Swedish intensive care units

BACKGROUND

The purpose of this work was to study usage of antibiotics, its possible determinants, and patterns of bacterial resistance in Swedish intensive care units (ICUs).

METHODS

Prospectively collected data on species and antibiotic resistance of clinical isolates and antibiotic consumption specific to each ICU in 1999 were analyzed together with answers to a questionnaire. Antibiotic usage was measured as defined daily doses per 1000 occupied bed days (DDD1000).

RESULTS

Data were obtained for 38 ICUs providing services to a population of approximately 6 million. The median antibiotic consumption was 1257 DDD1000 (range 584-2415) and correlated with the length of stay but not with the illness severity score or the ICU category. Antibiotic consumption was higher in the ICUs lacking bedside devices for hand disinfection (2193 vs. 1214 DDD1000, p=0.05). In the ICUs with a specialist in infectious diseases responsible for antibiotic treatment the consumption pattern was different only for use of glycopeptides (58% lower usage than in other ICUs: 26 vs. 11 DDD1000,P=0.02). Only 21% of the ICUs had a written guideline on the use of antibiotics, 57% received information on antibiotic usage at least every 3 months and 22% received aggregated resistance data annually. Clinically significant antimicrobial resistance was found among Enterbacter spp. to cephalosporins and among Enterococcus spp. to ampicillin.

CONCLUSIONS

Availability of hand disinfection equipment at each bed and a specialist in infectious diseases responsible for antibiotic treatment were factors that correlated with lower antibiotic consumption in Swedish ICUs, whereas patient-related factors were not associated with antibiotic usage.

Superficial and deep sternal wound complications: incidence, risk factors and mortality

OBJECTIVES

Sternal wound complications often have a late onset and are detected after patients are discharged from the hospital. In an effort to catch all sternal wound complications, different postdischarge surveillance methods have to be used. Together with this long-term follow-up an analysis of risk factors may help to identify patients at risk and can lead to more effective preventive and control measures.

METHODS

This retrospective study of 3008 adult patients who underwent consecutive cardiac surgery from January 1996 through September 1999 at Linköping University Hospital, Sweden, evaluated 42 potential risk factors by univariate analysis followed by backward stepwise multivariate logistic regression analysis.

RESULTS

Two-thirds of the 291 (9.7%) sternal wound complications that occurred were identified after discharge. Of the 291 patients, 47 (1.6%) had deep sternal infections, 50 (1.7%) had postoperative mediastinitis, and 194 (6.4%) had superficial sternal wound complications. Twenty-three variables were selected by univariate analysis (P<0.15) and included in a multivariate analysis where eight variables emerged as significant (P<0.05). Preoperative risk factors for deep sternal infections/mediastinitis were obesity, insulin-dependent diabetes, smoking, peripheral vascular disease, and high New York Heart Association score. An intraoperative risk factor was bilateral use of internal mammary arteries, and a postoperative risk factor was prolonged ventilator support. Risk factors for superficial sternal wound complications were obesity, and an age of <75 years. The 30 day mortality was 2.7% for patients without sternal wound complications and 2/291 (0.7%) for all patients with sternal wound complications, 0.5% for superficial sternal wound complications, and 1.0% for deep sternal infections/mediastinitis. The 1 year mortality rate was 4.8% for patients without sternal wound complications and 11/291 (3.8%) for patients with sternal wound complications, 2.1% for superficial sternal wound complications, and 7.2% for deep sternal infections/mediastinitis.

CONCLUSIONS

The risk factors found in this study have been detected and reported in previous studies. The predictive ability was stronger though for deep sternal infections/mediastinitis (those needing surgical revisions) than for superficial sternal wound complications. Earlier recognition of sternal wound complications and aggressive treatment have probably contributed to the relatively low mortality rate seen in this study.

Diagnosis and nonoperative management of cervical radiculopathy

STUDY DESIGN

Qualitative, comprehensive literature review.

OBJECTIVE

To discuss and summarize the current peer-reviewed literature related to the management of patients with cervical radiculopathy.

BACKGROUND

Cervical radiculopathy is a lesion of the cervical spinal nerve root with a reported prevalence of 3.3 cases per 1000 people; peak annual incidence is 2.1 cases per 1000 and occurs in the fourth and fifth decades of life. Nerve root injury has the potential to produce significant functional limitations and disability.

METHODS AND MEASURES

A search of the MEDLINE, CINAHL, and Web of Science databases for the periods 1966, 1982, and 1996, respectively, to December 1999 was conducted using selected keywords and MeSH headings. The bibliography of all retrieved articles were searched and pertinent articles were obtained. The Cochrane Database of Systematic Reviews was also searched. Literature related to the diagnosis, prognosis, and treatment of cervical radiculopathy were thoroughly reviewed and summarized using a critical appraisal approach.

RESULTS

Although cervical radiculopathy remains largely a clinical diagnosis, the true diagnostic accuracy of the clinical examination for cervical radiculopathy is unknown. Imaging and electrophysiologic tests are capable of detecting clinically significant problems in many patients and each modality has inherent strengths and weaknesses; technical as well as practical factors affect the choice of procedure. The natural course of cervical radiculopathy appears to be generally favorable but no prognostic or risk factors have been firmly established and the efficacy of various nonoperative treatments for the condition is unknown.

CONCLUSION

A clear definition of terms and further research are required to establish definitive diagnostic criteria and effective treatment for the management of patients with cervical radiculopathy.