POS0013 SJÖGREN-LIKE SYNDROME, MULTIPLE AUTOIMMUNE DISEASES, THYMOMA AND GENETIC VARIANTS IN AIRE

Background

The autoimmune regulator gene AIRE is the main controlling factor for developing central immunotolerance. Variants in AIRE lead to autoimmunity and underly the autoimmune polyendocrine syndrome type 1 (APS-1 or APECED), defined by the clinical triad chronic mucocutaneous candiasis hypoparathyroidism and adrenal insufficiency.(1, 2) Manifold additional manifestation have been described, including Sjögren-like disease lacking the typical serology.(3) Furthermore, serological abnormalities, e.g. antibodies against IL-22, IL-17F and IFNώ are a hallmark of the disease. Due to the diversity in clinical manifestations and the genetic variants in AIRE, diagnosis is often delayed.

Objectives

Case report of a patient with 2 new variants in AIRE with diverse rheumatological and autoimmune disorders as well as thymoma.

Methods

Case report.

Results

The 38-year-old male patient was transferred to our clinic for immunoglobuline therapy, from his treating neurologist. His medical history included diabetes mellitus type 1, diagnosed in 1996, followed by Grave’s disease in 2000, culminating in a thyroidectomy in 2017. In 2009 he underwent a thymectomy for a thymoma. He had been treated with a series of immunosuppressive therapies including prednisolone, rituximab and mycophenolate, as well as plasmapheresis and immunopheresis for his atypical, seronegative myasthenia gravis. Due to the limited effect of the previous therapeutic regimen a trial with intravenous immunoglobulin had been initiated inducing clinical stabilization.

We diagnosed Sjogren-like syndrome based on sicca symptoms and a suspicious submandibular salivary gland in sonography, without typical serology. Family history was negative for autoimmune diseases. The clinical findings pointed towards immunodysregulation, prompting cytokine examination, lymphocyte phenotyping and genetic testing. Cytokines (IFNγ, IL-2, IL-4, IL-10, IL-17) under immunosuppression with 20 mg prednisolone and 2 g of mycophenolate were all low/below detection threshold. Flow cytometry showed no abnormalities except for a low CD20 (after Rituximab) and a slightly elevated T-reg count. Genetic testing revealed heterozygous variants in exon three (c.354C>G) and eight (c.927C>G) of AIRE. The patient´s mother showed the same genotype - indicating that the variants in the patient are in cis - but is asymptomatic. (Figure 1)

Figure 1.

Electropherograms of the heterozygous patient, his heterozygous, asymptomatic mother and his asymptomatic father, who has a wildtype of AIRE.

Conclusion

To our knowledge this is the first report of a patient with thymoma and genetic variant(s) in the AIRE gene displaying several autoimmune diseases. Although clinical similarities between thymoma patients and APECED / APS1 are known (4), a genetic link between these 2 diseases has not yet been described. As rheumatic autoimmunity can be induced by either, rheumatologists should be aware of these potentially underlying causes.

An additional point of interest is the lack of autoimmunity in the mother with the same genetic variants, which suggests an additional environmental trigger (e.g. smoking, viral infection) in the patient.

References

[1]Aaltonen J, Björses P, Perheentupa J, Horelli–Kuitunen N, Palotie A, Peltonen L, et al. An autoimmune disease, APECED, caused by mutations in a novel gene featuring two PHD-type zinc-finger domains. Nature Genetics. 1997;17(4):399-403.

[2]Ahonen P, Myllärniemi S, Sipilä I, Perheentupa J. Clinical variation of autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED) in a series of 68 patients. N Engl J Med. 1990;322(26):1829-36.

[3]Ferre EM, Rose SR, Rosenzweig SD, Burbelo PD, Romito KR, Niemela JE, et al. Redefined clinical features and diagnostic criteria in autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy. JCI Insight. 2016;1(13).

[4]Wolff AS, Kärner J, Owe JF, Oftedal BE, Gilhus NE, Erichsen MM, et al. Clinical and serologic parallels to APS-I in patients with thymomas and autoantigen transcripts in their tumors. J Immunol. 2014;193(8):3880-90.

Disclosure of Interests

None declared

Multipartite Entanglement Generation and Contextuality Tests Using Nondestructive Three-Qubit Parity Measurements

We report on the realization and application of nondestructive three-qubit parity measurements on nuclear spin qubits in diamond. We use high-fidelity quantum logic to map the parity of the joint state of three nuclear spin qubits onto an electronic spin qubit that acts as an ancilla, followed by a single-shot nondestructive readout of the ancilla combined with an electron spin echo to ensure outcome-independent evolution of the nuclear spins. Through the sequential application of three such parity measurements, we demonstrate the generation of genuine multipartite entangled states out of the maximally mixed state. Furthermore, we implement a single-shot version of the Greenberger-Horne-Zeilinger experiment that can generate a quantum versus classical contradiction in each run. Finally, we test a state-independent noncontextuality inequality in eight dimensions. The techniques and insights developed are relevant for fundamental tests as well as for quantum information protocols such as quantum error correction.

Tunable long-distance spin transport in a crystalline antiferromagnetic iron oxide

Spintronics relies on the transport of spins, the intrinsic angular momentum of electrons, as an alternative to the transport of electron charge as in conventional electronics. The long-term goal of spintronics research is to develop spin-based, low-dissipation computing-technology devices. Recently, long-distance transport of a spin current was demonstrated across ferromagnetic insulators1. However, antiferromagnetically ordered materials, the most common class of magnetic materials, have several crucial advantages over ferromagnetic systems for spintronics applications2: antiferromagnets have no net magnetic moment, making them stable and impervious to external fields, and can be operated at terahertz-scale frequencies3. Although the properties of antiferromagnets are desirable for spin transport4-7, indirect observations of such transport indicate that spin transmission through antiferromagnets is limited to only a few nanometres8-10. Here we demonstrate long-distance propagation of spin currents through a single crystal of the antiferromagnetic insulator haematite (α-Fe2O3)11, the most common antiferromagnetic iron oxide, by exploiting the spin Hall effect for spin injection. We control the flow of spin current across a haematite-platinum interface-at which spins accumulate, generating the spin current-by tuning the antiferromagnetic resonance frequency using an external magnetic field12. We find that this simple antiferromagnetic insulator conveys spin information parallel to the antiferromagnetic Néel order over distances of more than tens of micrometres. This mechanism transports spins as efficiently as the most promising complex ferromagnets1. Our results pave the way to electrically tunable, ultrafast, low-power, antiferromagnetic-insulator-based spin-logic devices6,13 that operate without magnetic fields at room temperature.

C1 Posterior Arch Flare Point: A Useful Landmark for Fluoroscopically Guided C1-2 Puncture

BACKGROUND AND PURPOSE

The C1-2 intrathecal puncture is routinely performed when lumbar puncture is not feasible. Usage has steadily decreased in part because of the perceived high risk of injury to the cervical cord. Up to this point, vague fluoroscopic guidelines have been used, creating uncertainty about the actual needle location relative to the spinal cord. We present a novel osseous landmark to aid in C1-2 intrathecal puncture, corresponding to the posterior spinal cord margin on lateral fluoroscopic views. This landmark, which we have termed the "flare point," represents the triangular "flaring" of the posterior C1 arch at its junction with the anterior arch.

MATERIALS AND METHODS

Cervical spine CT myelograms were reviewed. High-resolution axial images were reformatted into the sagittal plane, and maximum-intensity-projection images were created to simulate a lateral fluoroscopic view. Tangential lines were drawn along the superior cortices of the anterior and posterior C1 arches, with the point of intersection used to approximate the flare point. Chart review was performed for all C1-2 punctures using the flare point technique in the past 3 years.

RESULTS

Forty-two cervical myelograms were reviewed. The average flare point was 0.2 ± 0.5 mm posterior to the dorsal spinal cord margin. In 37/42 subjects, the flare point was localized posterior to the spinal cord. Targeting by means of the flare point was used in 16 C1-2 punctures without complications.

CONCLUSIONS

The C1 posterior arch flare point accurately approximates the dorsal spinal cord margin on myelography. Targeting between the flare point and the spinolaminar line, at the mid-C1-2 interspace, allows safe and optimal needle positioning.

One-second coherence for a single electron spin coupled to a multi-qubit nuclear-spin environment

Single electron spins coupled to multiple nuclear spins provide promising multi-qubit registers for quantum sensing and quantum networks. The obtainable level of control is determined by how well the electron spin can be selectively coupled to, and decoupled from, the surrounding nuclear spins. Here we realize a coherence time exceeding a second for a single nitrogen-vacancy electron spin through decoupling sequences tailored to its microscopic nuclear-spin environment. First, we use the electron spin to probe the environment, which is accurately described by seven individual and six pairs of coupled carbon-13 spins. We develop initialization, control and readout of the carbon-13 pairs in order to directly reveal their atomic structure. We then exploit this knowledge to store quantum states in the electron spin for over a second by carefully avoiding unwanted interactions. These results provide a proof-of-principle for quantum sensing of complex multi-spin systems and an opportunity for multi-qubit quantum registers with long coherence times.

In Vitro Evaluation of Novel Nitazoxanide Derivatives against Mycobacterium tuberculosis

Nitazoxanide has antiparasitic and antibiotic activities including activity against Mycobacterium tuberculosis. We prepared and evaluated a set of its analogues to determine the structure-activity relationship, and identified several amide- and urea-based analogues with low micromolar activity against M. tuberculosis in vitro. Pharmacokinetics in the rat suggested a path forward to obtain bioavailable compounds. The series had a good microbiological profile with bactericidal activity in vitro against replicating and nonreplicating M. tuberculosis. Analogues had limited activity against other Gram-positive bacteria but no activity against Gram-negative bacteria. Our studies identified the key liability in this series as cytotoxicity. Future work concentrating on identifying the target(s) could assist in removing activity against eukaryotic cells.

The synthesis and evaluation of triazolopyrimidines as anti-tubercular agents

We identified a di-substituted triazolopyrimidine with anti-tubercular activity against Mycobacterium tuberculosis. Three segments of the scaffold were examined rationally to establish a structure-activity relationship with the goal of improving potency and maintaining good physicochemical properties. A number of compounds displayed sub-micromolar activity against Mycobacterium tuberculosis with no cytotoxicity against eukaryotic cells. Non-substituted aromatic rings at C5 and a two-carbon chain connecting a terminal aromatic at C7 were preferred features; the presence of NH at C7 and a lack of substituent at C2 were essential for potency. We identified compounds with acceptable metabolic stability in rodent and human liver microsomes. Our findings suggest that the easily-synthesized triazolopyrimidines are a promising class of potent anti-tubercular agents and warrant further investigation in our search for new drugs to fight tuberculosis.

Experimental creation of quantum Zeno subspaces by repeated multi-spin projections in diamond

Repeated observations inhibit the coherent evolution of quantum states through the quantum Zeno effect. In multi-qubit systems this effect provides opportunities to control complex quantum states. Here, we experimentally demonstrate that repeatedly projecting joint observables of multiple spins creates quantum Zeno subspaces and simultaneously suppresses the dephasing caused by a quasi-static environment. We encode up to two logical qubits in these subspaces and show that the enhancement of the dephasing time with increasing number of projections follows a scaling law that is independent of the number of spins involved. These results provide experimental insight into the interplay between frequent multi-spin measurements and slowly varying noise and pave the way for tailoring the dynamics of multi-qubit systems through repeated projections.

Repeated observations of quantum states inhibit coherent evolution through the Zeno effect, providing opportunities for controlling multi-qubit systems. Here the authors demonstrate that projecting joint observables of three spins in diamond creates quantum Zeno subspaces that suppress dephasing.

Abstract 4635: Relative bioavailability of dovitinib (TKI258) formulations

Background: Dovitinib (TKI258) is a potent oral tyrosine kinase inhibitor of FGFR as well as VEGFR, PDGFR, cKIT, and FLT3. Early clinical trials used an oral solution or a clinical service form (CSF) capsule of a lactate anhydrous formulation, which was challenging to produce on a large scale. Thus, a lactate monohydrate salt was developed as the final market image (FMI) and has been tested in both capsule and tablet form.

Methods: The objective was to characterize the relative bioavailability of the CSF capsule, the FMI capsule, and the FMI tablet to the oral solution. Relative bioavailability was quantified via the area under the concentration time curve from time zero until the last time point sampled (AUClast) and by the maximum concentration (Cmax) following a single dose. First, population pharmacokinetic (PK) modeling from 2 phase 1 studies was used to characterize the relative bioavailability of the CSF capsule to the oral solution. Then, results from 2 formal relative bioavailability studies (FMI capsule vs CSF capsule and FMI tablet vs CSF capsule) were used to bridge the FMI formulations to the oral solution. The ratio of an FMI formulation's AUClast or Cmax to that of the oral solution was found as the product of the ratio of the FMI formulation to the CSF capsule times the ratio of the CSF capsule to the oral solution. In the 2 phase 1 studies, the oral solution was used in 9 patients (dose range, 50-600 mg), and the CSF capsule was used in 67 patients (dose range, 200-600 mg). The sample sizes of the 2 relative bioavailability studies for the CSF capsule were 20 and 21 for the FMI capsule and tablet, respectively.

Results: The population PK model showed that the ratios of PK parameters (90% CI) comparing the CSF capsule to the oral solution were 0.85 (range, 0.65-1.14) for AUClast and 0.85 (range, 0.64-1.12) for Cmax. Then using the bioavailability ratio of the FMI capsule to the CSF capsule (AUClast, 0.88 [range, 0.82-0.94]; Cmax, 0.97 [range, 0.89-1.06]), bridging found the AUClast ratio of the FMI capsule to the oral solution to be 0.75 (range, 0.56-1.02), and the Cmax ratio was 0.83 (range, 0.61-1.10). Similarly, the bioavailability ratio of the FMI tablet to the CSF capsule (AUClast, 0.97 [range, 0.88-1.07]; Cmax, 0.99 [range, 0.91-1.08]) was used to calculate the ratio of FMI tablet to the oral solution: 0.82 (range, 0.62-1.14) for AUClast and 0.85 (range, 0.62-1.13) for Cmax.

Conclusions: The relative bioavailabilities of dovitinib CSF capsules (≈ 0.85), FMI capsules (0.75-0.83) and FMI tablets (0.82-0.85) to oral solution were found to be similar to each other with respect to both AUClast and Cmax. This is consistent with the fact that the FMI capsule and CSF capsule as well as the FMI tablet and CSF capsule were similarly bioavailable.

Citation Format: Samira Garonzik, Jerry Nedelman, Jeffrey Scott, Jeffrey Cramer, Eugene Tan. Relative bioavailability of dovitinib (TKI258) formulations. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4635. doi:10.1158/1538-7445.AM2014-4635

[Muscular sarcocystosis after travel to Malaysia: a case series from Germany]

BACKGROUND

Since 2011, about 100 travellers to the island of Tioman, Malaysia, have been diagnosed worldwide with suspected muscular sarcocystosis, a previously only sporadically observed parasitic disease. Source of infection and therapy remain unclear. Final diagnosis requires microscopic identification of cysts in muscle biopsies. The study objective was a systematic description of characteristic symptoms, laboratory investigations and treatment response.

METHODS

Systematic case series.

RESULTS

The 26 cases of 5 centers for tropical medicine in Germany showed a characteristic biphasic development: symptoms began in general 2 weeks after mid-holidays (min. 7.5, max. 22 days) with unspecific fever and headaches lasting for almost 1 week. After an asymptomatic period of 2 weeks, severe myalgia (6.5, scale 0-10) and fever developed and lasted for about 6 weeks (min. 7, max. 207 days), accompanied by creatin-phosphokinase(CK)-elevation (up to 3.5 times), and eosinophilia (2.9 times). One out of two muscle biopsies revealed a cyst typical for sarcocystosis. In 6 out of 7 patients an increase in Sarcocystis-specific antibody concentration could be demonstrated by ELISA. Treatment with systemic steroids and albendazole, or ivermectin resulted in significant symptomatic improvement in most of the patients. One patient was treated early with cotrimoxazole and subsequently did not develop a second phase of the disease. All patients had stayed in the North-West of the island Tioman.

CONCLUSIONS

Muscular sarcocystosis develops in a biphasic pattern with initial fever and later prolonged myalgia, eosinophilia, and CK-elevation. Steroids achieve symptomatic relief in the late phase. Early cotrimoxazole-therapy could possibly prevent parasitic muscle invasion. In fever after travel to Malaysia differential diagnosis should include sarcocystosis. The source of infection appears to be located in North-West of Tioman. Further studies are needed, including addressing early diagnosis and treatment.

Universal control and error correction in multi-qubit spin registers in diamond

Quantum registers of nuclear spins coupled to electron spins of individual solid-state defects are a promising platform for quantum information processing. Pioneering experiments selected defects with favourably located nuclear spins with particularly strong hyperfine couplings. To progress towards large-scale applications, larger and deterministically available nuclear registers are highly desirable. Here, we realize universal control over multi-qubit spin registers by harnessing abundant weakly coupled nuclear spins. We use the electron spin of a nitrogen-vacancy centre in diamond to selectively initialize, control and read out carbon-13 spins in the surrounding spin bath and construct high-fidelity single- and two-qubit gates. We exploit these new capabilities to implement a three-qubit quantum-error-correction protocol and demonstrate the robustness of the encoded state against applied errors. These results transform weakly coupled nuclear spins from a source of decoherence into a reliable resource, paving the way towards extended quantum networks and surface-code quantum computing based on multi-qubit nodes.

Entanglement genesis by ancilla-based parity measurement in 2D circuit QED

We present an indirect two-qubit parity meter in planar circuit quantum electrodynamics, realized by discrete interaction with an ancilla and a subsequent projective ancilla measurement with a dedicated, dispersively coupled resonator. Quantum process tomography and successful entanglement by measurement demonstrate that the meter is intrinsically quantum nondemolition. Separate interaction and measurement steps allow the execution of subsequent data-qubit operations in parallel with ancilla measurement, offering time savings over continuous schemes.

Bactericidal activity of an imidazo[1, 2-a]pyridine using a mouse M. tuberculosis infection model

Tuberculosis remains a global threat due in part to the long treatment regimen and the increased prevalence of drug resistant M. tuberculosis strains. Therefore, new drug regimens are urgently required to combat this deadly disease. We previously synthesized and evaluated a series of new anti-tuberculosis compounds which belong to the family of imidazo[1,2-a]pyridines. This family of compounds showed low nM MIC (minimal inhibitory concentration) values against M. tuberculosis in vitro. In this study, a derivative of imidazo[1,2-a]pyridines, (N-(4-(4-chlorophenoxy)benzyl)-2,7-dimethylimidazo[1,2-a]pyridine-3-carboxamide) (ND-09759), was selected as a promising lead compound to determine its protective efficacy using a mouse infection model. Pharmacokinetic analysis of ND-09759 determined that at a dosage of 30 mg/kg mouse body weight (PO) gave a maximum serum drug concentration (C_max) of 2.9 µg/ml and a half-life of 20.1 h. M. tuberculosis burden in the lungs and spleens was significantly decreased in mice treated once daily 6 days per week for 4-weeks with ND-09759 compared to untreated mice and this antibiotic activity was equivalent to isoniazid (INH) and rifampicin (RMP), two first-line anti-TB drugs. We observed slightly higher efficacy when using a combination of ND-09759 with either INH or RMP. Finally, the histopathological analysis revealed that infected mice treated with ND-09759 had significantly reduced inflammation relative to untreated mice. In conclusion, our findings indicate ND-09759 might be a potent candidate for the treatment of active TB in combination with current standard anti-TB drugs.

Partial-measurement backaction and nonclassical weak values in a superconducting circuit

We realize indirect partial measurement of a transmon qubit in circuit quantum electrodynamics by interaction with an ancilla qubit and projective ancilla measurement with a dedicated readout resonator. Accurate control of the interaction and ancilla measurement basis allows tailoring the measurement strength and operator. The tradeoff between measurement strength and qubit backaction is characterized through the distortion of a qubit Rabi oscillation imposed by ancilla measurement in different bases. Combining partial and projective qubit measurements, we provide the solid-state demonstration of the correspondence between a nonclassical weak value and the violation of a Leggett-Garg inequality.

Advancement of Imidazo[1,2-a]pyridines with Improved Pharmacokinetics and Nanomolar Activity Against Mycobacterium tuberculosis

A set of fourteen imidazo[1,2-a]pyridine-3-carboxamides was synthesized and screened against Mycobacterium tuberculosis H₃₇Rv. The minimum inhibitory concentrations of twelve of these agents were ≤ 1 μM against replicating bacteria and five compounds (9, 12, 16, 17 and 18) had MIC values ≤ 0.006 μM. Compounds 13 and 18 were screened against a panel of MDR and XDR drug resistant clinical Mtb strains with the potency of 18 surpassing that of clinical candidate PA-824 by nearly 10 fold. The in vivo pharmacokinetics of compounds 13 and 18 were evaluated in male mice by oral (PO) and intravenous (IV) routes. These results indicate that readily synthesized imidazo[1,2-a]pyridine-3-carboxamides are an exciting new class of potent, selective anti-TB agents that merit additional development opportunities.

Effects of corticotropin-releasing factor 1 receptor antagonism on the hypothalamic-pituitary-adrenal axis of rodents

Corticotropin-releasing factor (CRF) is the major hypothalamic neuropeptide responsible for stimulation of the hypothalamic-pituitary-adrenal axis (HPAA), resulting in the synthesis and release of glucocorticoids from the adrenal cortex. In a recent study, we reported the discovery of the CRF1 receptor antagonist, 3-(4-chloro-2-morpholin-4-yl-thiazol-5-yl)-8-(1-ethylpropyl)-2,6-dimethyl-imidazo[1,2-b]pyridazine (MTIP), which has efficacy in preclinical models of stress-induced alcohol consumption. Because CRF1 is important in HPAA activation, we evaluated the effects of MTIP administration on rodent HPAA function. Initial studies established the MTIP doses required for brain and pituitary CRF1 occupancy and those associated with the inhibition of intracerebroventricular CRF on the HPAA in mice. Then, rat basal plasma corticosterone (CORT) concentrations were measured hourly by radioimmunoassay for 24 h after three daily doses of MTIP or vehicle. In these studies, the early phase of the nocturnal CORT surge was reduced; however, the area under the CORT curve was identical for the 24-h period. In subsequent studies, increases in plasma CORT due to direct pharmacological manipulation of the HPAA axis or by stressors were evaluated after MTIP treatment in mice. MTIP attenuated CORT responses generated by immediate bolus administration of insulin or ethanol; however, MTIP did not affect activation of the HPAA by other stressors and pharmacological agents. Therefore, MTIP can modulate basal HPAA activity during the CORT surge and reduced activation after a select number of stressors but does not produce a lasting suppression of basal CORT. The ability of MTIP to modulate plasma CORT after hyperinsulinemia may provide a surrogate strategy for a target occupancy biomarker.

Haemolysis and sublethal injury of RBCs after routine blood bank manipulations

OBJECTIVES

To determine the extent of RBC sublethal injury in male donor units as measured by both the mechanical fragility index (MFI) and percentage haemolysis after RBCs underwent leucoreduction (LR), irradiation (IRRAD), and washing.

BACKGROUND

RBCs frequently undergo post-collection processing to meet certain recipient's special needs. The extent of haemolysis and sublethal injury following these interventions has not been fully characterised.

METHODS

Eight to ten day old male, AS-5 RBCs underwent either LR, IRRAD or washing. A control group of male, AS-5 RBCs were unmanipulated. The MFI, percent haemolysis, and plasma free haemoglobin (PFHb) were measured immediately after manipulation and, for a series of irradiated RBCs, 28 days after irradiation (IRRAD28).

RESULTS

The MFI of the washed units was significantly higher than unmanipulated, LR, IRRAD, IRRAD28 units (P < 0·0001). The percent haemolysis was highest in the IRRAD28 units (1·4%) followed by the washed units (0·74%); the other three units demonstrated significantly less haemolysis (P < 0·0001). The largest mean total amount of PFHb per unit was found in the IRRAD28 units (500·5 mg/unit) followed by the washed units (149·8 mg/unit); the mean total amount of PFHb in the three other types of units was significantly less than that found in both the IRRAD28 and washed units (P at least < 0·001).

CONCLUSION

There is a significant quantity of PFHb in IRRAD28 RBC units, and potentially in washed allogeneic RBC units. Clinical correlation is required to determine if this quantity of PFHb and the transfusion of potentially fragile RBCs causes adverse events.

Stress-related neuropeptides and alcoholism: CRH, NPY, and beyond

This article summarizes the proceedings of a symposium held at the conference on "Alcoholism and Stress: A Framework for Future Treatment Strategies" in Volterra, Italy, May 6-9, 2008. Chaired by Markus Heilig and Roberto Ciccocioppo, this symposium offered a forum for the presentation of recent data linking neuropetidergic neurotransmission to the regulation of different alcohol-related behaviors in animals and in humans. Dr. Donald Gehlert described the development of a new corticotrophin-releasing factor receptor 1 antagonist and showed its efficacy in reducing alcohol consumption and stress-induced relapse in different animal models of alcohol abuse. Dr. Andrey Ryabinin reviewed recent findings in his laboratory, indicating a role of the urocortin 1 receptor system in the regulation of alcohol intake. Dr. Annika Thorsell showed data supporting the significance of the neuropeptide Y receptor system in the modulation of behaviors associated with a history of ethanol intoxication. Dr. Roberto Ciccocioppo focused his presentation on the nociceptin/orphanin FQ (N/OFQ) receptors as treatment targets for alcoholism. Finally, Dr. Markus Heilig showed recent preclinical and clinical evidence suggesting that neurokinin 1 antagonism may represent a promising new treatment for alcoholism. Collectively, these investigators highlighted the significance of neuropeptidergic neurotransmission in the regulation of neurobiological mechanisms of alcohol addiction. Data also revealed the importance of these systems as treatment targets for the development of new medication for alcoholism.

3-(4-Chloro-2-morpholin-4-yl-thiazol-5-yl)-8-(1-ethylpropyl)-2,6-dimethyl-imidazo[1,2-b]pyridazine: a novel brain-penetrant, orally available corticotropin-releasing factor receptor 1 antagonist with efficacy in animal models of alcoholism

We describe a novel corticotropin-releasing factor receptor 1 (CRF1) antagonist with advantageous properties for clinical development, and its in vivo activity in preclinical alcoholism models. 3-(4-Chloro-2-morpholin-4-yl-thiazol-5-yl)-8-(1-ethylpropyl)-2,6-dimethyl-imidazo[1,2-b]pyridazine (MTIP) inhibited 125I-sauvagine binding to rat pituitary membranes and cloned human CRF1 with subnanomolar affinities, with no detectable activity at the CRF2 receptor or other common drug targets. After oral administration to rats, MTIP inhibited 125I-sauvagine binding to rat cerebellar membranes ex vivo with an ED50 of approximately 1.3 mg/kg and an oral bioavailability of 91.1%. Compared with R121919 (2,5-dimethyl-3-(6-dimethyl-4-methylpyridin-3-yl)-7-dipropylamino-pyrazolo[1,5-a]pyrimidine) and CP154526 (N-butyl-N-ethyl-4,9-dimethyl-7-(2,4,6-trimethylphenyl)-3,5,7-triazabicyclo[4.3.0]nona-2,4,8,10-tetraen-2-amine), MTIP had a markedly reduced volume of distribution and clearance. Neither open-field activity nor baseline exploration of an elevated plus-maze was affected by MTIP (1-10 mg/kg). In contrast, MTIP dose-dependently reversed anxiogenic effects of withdrawal from a 3 g/kg alcohol dose. Similarly, MTIP blocked excessive alcohol self-administration in Wistar rats with a history of dependence, and in a genetic model of high alcohol preference, the msP rat, at doses that had no effect in nondependent Wistar rats. Also, MTIP blocked reinstatement of stress-induced alcohol seeking both in postdependent and in genetically selected msP animals, again at doses that were ineffective in nondependent Wistar rats. Based on these findings, MTIP is a promising candidate for treatment of alcohol dependence.

[Diagnostic efficacy of gadodiamide-enhanced dynamic examination technique in comparison to conventional magnet resonance tomography in exacerbated chronic osteomyelitis]

PURPOSE

To evaluate the diagnostic effectiveness of dynamic gadodiamide-enhanced MRI in discriminating reparative tissue formation from florid inflammation in patients with chronic osteomyelitis.

MATERIALS AND METHODS

Subjects with chronic osteomyelitis and clinically suspected exacerbation were consecutively enrolled into a prospective trial. Following conventional contrast-enhanced MRI scanning, a dynamic contrast-enhanced SE sequence was carried out in all patients (acquisition interval 58 s, 11 repetitions with a total acquisition time of 11 minutes). The relative increase of the time-dependent signal intensity was assessed in representative circular regions of interest placed over bone marrow and surrounding soft tissues. As diagnostic reference standard, histologic and intraoperative findings were obtained independently from the result of the index test. The MRI studies were evaluated by two radiologists who were blinded to the findings of the reference test.

RESULTS

30 of 51 patients were subsequently scheduled for surgery (mean age 42.6 +/- 12.7 years, 27 males). 19 cases had a florid granulocytic infection, with 6 cases showing histologic signs of putrid liquefaction. Another 11 patients had chronic-granulating, fibrosing osteomyelitis. The course of the signal-time curves differed significantly between the different pathologic processes (multiple measures ANOVA, p < 0,001) in both bone marrow and soft tissue. The areas under the receiver operating characteristics (ROC) curves of the dynamic sequence as a performance measure to distinguish between acute and chronic infection were 0.73 (95 % confidence interval 0.41 - 1.00) and 0.82 (95 % confidence interval 0.59 - 1.00), respectively. Although no overall difference was found in diagnostic efficacy between conventional and dynamic MRI, the dynamic technique provided important additional information for equivocal conventional results.

CONCLUSION

Dynamic contrast-enhanced MRI scanning is a safe and potentially valuable tool to discriminate between florid and chronic inflammation in documented osteomyelitis.

Development and validation of a patient-based health-related quality of life questionnaire in schizophrenia: the S-QoL

We developed a self-administered instrument to assess health-related quality of life (HRQL) among people with schizophrenia. The S-QoL, based on Calman's approach to the subject's point of view, is a multidimensional instrument that is sensitive to change. The scale is a 41-item questionnaire with eight subscales (psychological well-being, self-esteem, family relationships, relationships with friends, resilience, physical well-being, autonomy and sentimental life) and a total score. In-depth interviews with patients determined the pertinent issues for item development. The validation study, performed with 207 patients, showed high internal consistency reliability, reproducibility and responsiveness. Construct validity was confirmed using established clinical and HRQL measures. S-QoL covers domains that differ from areas tapped in other measures, with greater responsiveness. The S-QoL is an efficient instrument for the measurement of the impact of schizophrenia on individuals' lives.

Within-gene interaction between c.135 G/A genotypes and RET proto-oncogene germline mutations in HSCR families

Hirschsprung disease (HSCR) is considered a model for a complex inheritance disorder. Several genes, including the major HSCR-susceptibility RET proto-oncogene, play an aetiological role in the development of HSCR. Genetic linkage analysis in familial HSCR with both long- and short-segment phenotypes has demonstrated a tight linkage to the RET locus, while the phenotype within a HSCR family is characterised by an incomplete penetrance or a variable extension of the aganglionosis. Therefore, additional genetic alterations of RET are postulated in the aetiology or modification of the HSCR phenotype. In this study, the coding region of all 21 exons of the RET proto-oncogene, including the flanking intronic sequences, were investigated by direct DNA sequencing in a HSCR population. We genotyped the c.135 G/A polymorphism and resolved haplotypes comprising the mutation locus and the c.135 G/A polymorphism. Twenty different mutations were detected in 18 of 76 HSCR patients. In ten families the mutations were inherited from the parents, while only four patients had a positive family history for the disease. Moreover, in all ten families an incomplete penetrance of the HSCR phenotype was observed. We have investigated the effect of the non-mutated wild-type allele as well as the c.135 G/A polymorphism on the phenotype within the HSCR families. Our findings support the notion that both RET alleles are involved in the pathogenesis of a subgroup of HSCR patients in a dose-dependent fashion. Additionally, we have shown a modifying effect of the c.135 G/A polymorphism on the HSCR phenotype within HSCR families.

Medicine partnerships

Partial medication compliance, where patients do not take enough of their prescribed medicine to achieve adequate outcomes, is common. Research using electronic monitoring to assess compliance has shown that people take approximately 75% of doses as prescribed, irrespective of the condition being treated or its severity. Erratic compliance often leads to discontinuation of therapy, as treatment is perceived to be ineffective. Compliance decreases as frequency of dosing increases. Inadequate compliance and treatment persistence results in poor outcomes, despite the best efforts of the medical team. It is important to develop and implement a strategy to improve compliance. Simple steps that can be taken include helping patients to select "cues" to remind them to take their tablets, use of dose reminder boxes, and visual feedback of compliance data from electronic monitors.

Effect of terbinafine on the pharmacokinetics and pharmacodynamics of desipramine in healthy volunteers identified as cytochrome P450 2D6 (CYP2D6) extensive metabolizers

Terbinafine-CYP2D6 inhibition was evaluated by assessing 48-hour concentration-time profiles of the tricyclic antidepressant desipramine in 12 healthy volunteers identified as extensive cytochrome P450 2D6 (CYP2D6) metabolizers by genotyping and phenotyping. Pharmacokinetics was evaluated at baseline (50 mg oral desipramine given alone), steady state (after 250 mg oral terbinafine for 21 days), and 2 and 4 weeks after terbinafine discontinuation. Pharmacodynamics was evaluated before and 2 hours after each desipramine administration, using Mini-Mental Status Examination (MMSE) and EGG. Terbinafine administration inhibited CYP2D6 metabolism, as indicated by the significant increase in desipramine C(max) (19 ng/ml vs. 36 ng/ml) and AUC0-infinity (482 ng.h/ml vs. 2383 ng.h/ml) and decrease in AUC0-24 and C(max) of the CYP2D6-mediated metabolite, 2-hydroxydesipramine. In addition, the C(max) and AGUC0-infinity of desipramine and metabolite were still elevated 4 weeks after terbinafine discontinuation. Caution should be exercised when coprescribing terbinafine and drugs metabolized by CYP2D6, particularly those with a narrow therapeutic index.

STR primer concordance study

Over 1500 population database samples comprising African Americans, Caucasians, Hispanics, Native Americans, Chamorros and Filipinos were typed using the PowerPlex 16 and the Profiler Plus/COfiler kits. Except for the D8S1179 locus in Chamorros and Filipinos from Guam, there were eight examples in which a typing difference due to allele dropout was observed. At the D8S1179 locus in the population samples from Guam, there were 13 examples of allele dropout observed when using the Profiler Plus kit. The data support that the primers used in the PowerPlex 16, Profiler Plus, and COfiler kits are reliable for typing reference samples that are for use in CODIS. In addition, allele frequency databases have been established for the STR loci Penta D and Penta E. Both loci are highly polymorphic.

Detecting improvement in quality of life and symptomatology in schizophrenia

Instrument-based scores are often used as outcome measures. However, little is known about what changes in scores mean in terms of a clinical assessment of improvement or deterioration. The purpose of this report was to determine how much change in standard instrument scores represents a clinically detectable improvement or deterioration. The Veterans Affairs (VA) Cooperative Study of Clozapine in Refractory Schizophrenia evaluated 423 patients on clozapine or haloperidol. Symptoms and quality of life scales were completed at baseline; 6 weeks; and 3, 6, and 12 months. Among patients judged as "improved" by clinicians, the average percentage changes were a 21 percent decrease in Positive and Negative Syndrome Scale (PANSS) scores and a 26 percent increase in Quality of Life Scale (QLS) scores across all followup periods. The change in mean seven-point item scores were -0.46 (PANSS) and 0.23 (QLS). A major gain in clinically assessed improvement to "much better" was associated with a 45 percent decline in PANSS scores and 50 percent increase in QLS scores (change in mean seven-point item scores -0.88 and 0.92, respectively). Thus, modest changes in psychometric scales assessing symptoms and quality of life reflect clinically detectable improvement.

The short-term impact of adjunctive tiagabine on health-related quality of life

Combinations of tiagabine (TGB), carbamazepine (CBZ), and phenytoin (PHT) were compared for their impact on health-related quality of life (HRQOL) and adverse effects related to treatment efficacy for people with frequent complex partial seizures. Two independent, randomized, double-blind clinical trials for efficacy and safety were conducted simultaneously with treatment groups: CBZ+PHT versus CBZ+TGB, and PHT+CBZ versus PHT+TGB. Treatment was initiated at week 0 and continued through week 16. HRQOL was evaluated with the QOLIE-89. Treatment success was defined as > or =50% reduction in complex partial seizures. Among patients who achieved a > or =50% reduction in seizures, addition of TGB to baseline PHT enhanced patient perceptions of attention/concentration (13%; p = 0.002), memory (17%; p = 0.042), and language subscales (22%; p = 0.004). Addition of CBZ to PHT led to positive change in the work/driving/social relations subscale (14%; p = 0.004). These improvements were significantly different only between visits, not between the two treatment groups. Seizure worry subscale scores showed improvement among all treatment groups and was probably related to participation in the clinical trial. These exploratory analyses suggest a possible early positive effect of TGB on patient-perceived cognitive domains using the QOLIE-89. These findings are limited by the small sample size and could be related to reduction in seizures.

Refill patterns of atypical and conventional antipsychotic medications at a national retail pharmacy chain

This study examined whether patients who received prescriptions for conventional and atypical antipsychotics in routine outpatient care continued medication therapy. Prescription refill records of more than 25,000 patients from a national retail pharmacy chain were surveyed during a full eight-month period. At the start of the ninth month, 48 percent of the patients taking conventional agents were continuing therapy. The overall rate for those taking atypical agents was 44 percent; however, the rate for those taking clozapine was 71 percent. Atypical agents, despite their improved side effect profile, were not associated with higher rates of continued treatment. A highly supervised medication administration process, frequent patient-provider contact, and favorable patient selection may help explain the higher rate among patients taking clozapine.

A systematic review of the associations between dose regimens and medication compliance

BACKGROUND

Previous reviews of the literature on medication compliance have confirmed the inverse relationship between number of daily doses and rate of compliance. However, compliance in most of these studies was based on patient self-report, blood-level monitoring, prescription refills, or pill count data, none of which are as accurate as electronic monitoring (EM).

OBJECTIVE

In this paper, we review studies in which compliance was measured with an EM device to determine the associations between dose frequency and medication compliance.

METHODS

Articles included in this review were identified through literature searches of MEDLINE, PsychInfo, HealthStar, Health & Psychosocial Instruments, and the Cochrane Library using the search terms patient compliance, patient adherence, electronic monitoring, and MEMS (medication event monitoring systems). The review was limited to studies reporting compliance measured by EM devices, the most accurate compliance assessment method to date. Because EM was introduced only in 1986, the literature search was restricted to the years 1986 to 2000. In the identified studies, data were pooled to calculate mean compliance with once-daily, twice-daily, 3-times-daily, and 4-times-daily dosing regimens. Because of heterogeneity in definitions of compliance, 2 major categories of compliance rates were defined: dose-taking (taking the prescribed number of pills each day) and dose-timing (taking pills within the prescribed time frame).

RESULTS

A total of 76 studies were identified. Mean dose-taking compliance was 71% +/- 17% (range, 34%-97%) and declined as the number of daily doses increased: 1 dose = 79% +/- 14%, 2 doses = 69% +/- 15%, 3 doses = 65% +/- 16%, 4 doses = 51% +/- 20% (P < 0.001 among dose schedules). Compliance was significantly higher for once-daily versus 3-times-daily (P = 0.008), once-daily versus 4-times-daily (P < 0.001), and twice-daily versus 4-times-daily regimens (P = 0.001); however, there were no significant differences in compliance between once-daily and twice-daily regimens or between twice-daily and 3-times-daily regimens. In the subset of 14 studies that reported dose-timing results, mean dose-timing compliance was 59% +/- 24%; more frequent dosing was associated with lower compliance rates.

CONCLUSIONS

A review of studies that measured compliance using EM confirmed that the prescribed number of doses per day is inversely related to compliance. Simpler, less frequent dosing regimens resulted in better compliance across a variety of therapeutic classes.

[The infected endoprosthesis with the example of the hip joint endoprosthesis. An increasing danger to patient and society]

Because of demographic factors there is an increase in the numbers of total joint replacement operations each year. Deep infection after joint replacement remains one of the major complications in orthopedic surgery. The economic consequences for society are enormous. The treatment of such infections usually means a long and difficult course for the patient. In most cases multiple operations, including removal or exchange of the prosthesis are required. Concepts of treatment are very different and vary from debridement and keeping the prosthesis, resection arthroplasty to one- and second-stage exchange procedures. It is essential to know the special advantages and disadvantages of each concept to be able to choose the right strategy of treatment. Even getting the right diagnosis may be difficult since only about 2/3 of all cases go along with a positive microbiology. By the example of the infected hip prosthesis, the aim of the article is to give recommendations on the bases of current literature and our own experience. The strategy of treatment of infections used in our hospital is reported.

[Knee joint endoprosthesis]

Total knee replacement is increasing in number due to increased life expectancy and improved implants. [figure: see text] Degenerative changes (arthritis) and joint destruction based on polyarthritis and posttraumatic deformities are the common indications. There are basically four modes for knee replacement: Unicompartimental prosthesis, non-constrained, semi-constrained (posterior stabilized) and constrained total knee arthroplasty. Of major importance in knee alloarthoplasty are restitution of the correct limb axis, sufficient lateral ligaments and the restoration of the patellofemoral joint. Therefore particularly in cases with deformities an extensive soft tissue release is mandatory. A meticulous operative technique and versatile implants lead to good clinical outcome. Possible complications are still septic and aseptic implant loosening as well as wound infections.

Safety and efficacy of standard and new antiepileptic drugs

Knowledge about the comparative safety and efficacy of standard and new antiepileptic drugs (AEDs) is limited. Medications are selected on the basis of seizure type and epilepsy syndrome, adverse effect profiles, and cost. However, there are few data comparing the efficacy of the new AEDs for the treatment of recent-onset versus refractory partial seizures, simple versus complex partial seizures, frontal versus temporal lobe seizures, or other relevant clinical types. Few studies compare new AEDs. The next best approach has been the use of meta-analyses and compilation of data from clinical trials, which allow interstudy comparisons to define broad and rough comparative estimates. These analyses, however, do not define clear differences in the safety and efficacy of the new AEDs because of differences in study populations. The new AEDs have expanded our arsenal against seizures. As a group, they have favorable safety and efficacy profiles. The challenge is to define the differences in terms of clinical significance.

Photomodulation of conformational states. II. Mono- and bicyclic peptides with (4-aminomethyl)phenylazobenzoic acid as backbone constituent

It has been reported that backbone cyclization of octapeptides with the photoresponsive (4-aminomethyl)phenylazobenzoic acid imparts sufficient restraints to induce and stabilize ordered conformations of the peptide backbone in both the cis- and trans-azo-isomers (L. Ulysse, J. Cubillos, and J. Chmielewski, Journal of the American Chemical Society, 1995, Vol. 117, pp. 8466-8467). Correspondingly, the active-site octapeptide fragment H-Ala-Cys-Ala-Thr-Cys-Asp-Gly-Phe-OH [134-141] of thioredoxin reductase, with its high preference for a 3(10)-helix turn conformation centered on the Thr-Cys sequence, was backbone cyclized with this azobenzene moiety in the attempt to design a photoresponsive system where the conformational states of the peptide backbone are dictated by the configuration of the azobenzene and can be further modulated by the disulfide bridge. Nuclear magnetic resonance conformational analysis of the monocyclic compound clearly revealed the presence of two conformational families in both the cis- and trans-azo configuration. Of the higher populated conformational families, the structure of the trans-isomer seems like a pretzel-like folding, while the cis-isomer relaxes into a significantly less defined conformational state that does not exhibit any regular structural elements. Further restrictions imparted by disulfide bridging of the peptide moiety leads to an even better defined conformation for the trans-azo-isomer, whereas the cis-isomer can be described as a frustrated system without pronounced energy minima and thus with little conformational preferences. Our findings would suggest that this photoresponsive peptide template may not be of general usefulness for light-induced conformational transitions between two well-defined conformational states at least under the experimental conditions employed, even in the bicyclic form. However, trans --> cis isomerization of the bicyclic peptide is accompanied by a switch from a well-defined conformation to an ensemble of possible conformations.

Clinical and psychopharmacologic factors influencing family burden in refractory schizophrenia. The Department of Veterans Affairs Cooperative Study Group on Clozapine in Refractory Schizophrenia

BACKGROUND

This study compares the effect of clozapine and haloperidol and identifies other factors related to family burden as experienced by relatives of patients with refractory schizophrenia (DSM-III-R).

METHOD

Of 423 patients participating in a multisite randomized clinical trial, 221 identified a family member who was actively involved in their care and who agreed to complete a standardized measure of family burden at 6 weeks and 3, 6, 9, and 12 months after randomization, simultaneous with comprehensive patient assessments.

RESULTS

Patient factors most consistently correlated with greater family burden were symptom severity, days living in the community (i.e., not in the hospital), and frequency of family contact. Among family members, clozapine was associated with significantly (p = .048) greater reduction in feelings of dissatisfaction related to providing support to the patient, but not in objective measures of support, amount of worry the patient engendered, or days of missed employment or household activity. Although clozapine reduces symptoms, thus lowering family burden, it also increases days living in the community, which tends to increase family burden, perhaps canceling out the benefit to families of reduced symptoms.

CONCLUSION

Clozapine has a small but significant effect on the experience of families of patients. This is the first study to demonstrate that effective pharmacotherapy may be of some benefit to families as well as to patients.

Synthesis and conformational analysis of apamin analogues with natural and non-natural cystine/selenocystine connectivities

By replacing two cysteine residues in apamin with selenocysteine, the three possible isomers related to the side-chain connectivities of a bis-cystinyl-peptide were synthesized in regioselective manner exploiting the low redox potential of the diselenide bond. Nuclear magnetic resonance conformational analysis of monoselenocystine analogue apamin with the natural diselenide/disulfide network confirmed the highly isomorphous character of the sulfur replacement with selenium despite its slightly larger atomic radius and increased bond lengths. The comparative conformational analysis of the apamin analogues containing the non-natural side-chain links with wild type apamin clearly revealed retention of the main structural fold and thus the high propensity of these small molecules to adopt the secondary structure elements present in natural apamin. These findings offered interesting hints for a better understanding of the oxidative refolding pathway of the bis-cystinyl peptide that leads exclusively to the correct natural isomer.

How long to wait for a response to clozapine: a comparison of time course of response to clozapine and conventional antipsychotic medication in refractory schizophrenia

This study compared the time course to clinical improvement with clozapine and with conventional antipsychotic medications. A double-blind trial compared clozapine and haloperidol in patients with schizophrenia who were refractory to conventional antipsychotic medication and were hospitalized for 30 to 364 days at 15 Veteran Affairs medical centers during the year before study entry. Patients in the original study were randomly assigned to haloperidol or clozapine and followed for 12 months, at maximum tolerable doses. Patients who completed a full year of treatment with clozapine (n = 122), or with either haloperidol or another conventional antipsychotic medication (n = 123) and who also completed the 9- or 12-month assessment were included. Response to treatment was defined as 20 percent improvement on standard scales of symptoms and quality of life at the latter of the 9- or 12-month interviews. More patients assigned to clozapine achieved 20 percent improvement in symptoms at each followup. Among patients who did not improve at 6 weeks, 3 months, or 6 months, there were no significant differences between clozapine and comparison patients in outcomes at 1 year. Among patients who did improve, maintenance of that improvement also did not differ between the groups at 1 year on symptom measures. Maintenance of improvement in quality of life at 1 year was significantly greater for clozapine patients who had improved at 6 months (p < 0.04). Significant differential symptom response to clozapine occurred exclusively during the first 6 weeks of treatment.