Andexanet alfa in acute aortic syndrome: first UK experience

Andexanet alfa was employed to reverse the anticoagulant effect of direct oral anticoagulants in 3 patients who required emergent surgery for repair of type A aortic dissection. Its use was instrumental in securing haemostasis. However, we caution against the administration of Andexanet alfa prior to cardiopulmonary bypass as it can induce heparin resistance and complicate the perioperative monitoring of anticoagulation during cardiopulmonary bypass.

Multidisciplinary paper on patient blood management in cardiothoracic surgery in the UK: perspectives on practice during COVID-19

The coronavirus (COVID-19) pandemic disrupted all surgical specialties significantly and exerted additional pressures on the overburdened United Kingdom (UK) National Health Service. Healthcare professionals in the UK have had to adapt their practice. In particular, surgeons have faced organisational and technical challenges treating patients who carried higher risks, were more urgent and could not wait for prehabilitation or optimisation before their intervention. Furthermore, there were implications for blood transfusion with uncertain patterns of demand, reductions in donations and loss of crucial staff because of sickness and public health restrictions. Previous guidelines have attempted to address the control of bleeding and its consequences after cardiothoracic surgery, but there have been no targeted recommendations in light of the recent COVID-19 challenges. In this context, and with a focus on the perioperative period, an expert multidisciplinary Task Force reviewed the impact of bleeding in cardiothoracic surgery, explored different aspects of patient blood management with a focus on the use of haemostats as adjuncts to conventional surgical techniques and proposed best practice recommendations in the UK.

24 REVERSING FRAILTY AND ENHANCING RESILIENCE WITH EXERCISE AND DIETARY EDUCATION (REFEREE): A PRIMARY CARE RANDOMISED CONTROLLED TRIAL

Background

There is a need for effective primary-care interventions that help older people combat frailty and build resilience. This study aims to test the effectiveness of a co-designed exercise and dietary protein intervention.

Methods

This was a multicentre, randomised-controlled, parallel-arm trial in six Irish primary-care practices. We enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to April 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment with a GP. Intervention comprised exercises, emphasising strength, and dietary protein guidance. At three-month follow-up, effectiveness was measured by comparing SHARE-Frailty Instrument between groups, on intention-to-treat basis. Secondary outcomes included muscle mass, bone mass and biological age measured by Bioelectrical Impedance Analysis (BIA). Ease of intervention and health difference were measured on Likert scales.

Results

359 adults were assessed for eligibility and 168 enrolled. 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, frailty proportions were 17.7% in the intervention and 16.9% in the control group. At follow-up, they were 6.3% and 18.2%, respectively. The odds ratio (OR) of being frail for the intervention group was 0.23 times that of the control group (95% confidence interval: 0.07-0.72; P=0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%; P=0.018). Number needed to treat was 8.4. BIA parameters improved, bone mass significantly (P=0.040). 66.2% found the intervention easy, 69.0% reported feeling better.

Conclusion

A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health. Frailty was reversed in more than 1 in 9 participants.

23 CO-DESIGNING A PRIMARY-CARE INTERVENTION TO REVERSE FRAILTY AND BUILD RESILIENCE THROUGH PUBLIC AND PATIENT INVOLVEMENT WITH OLDER PEOPLE

Background

An essential consideration in health research is to conduct research with members of the public rather than for them. Public and Patient Involvement (PPI) of older people in research can improve enrolment, relevance and impact. However, few studies with PPI in frailty research have been identified. PPI has fallen during the Covid-19 pandemic. We aimed to involve older people in co-designing a Randomised-Control Trial (RCT) intervention to reverse frailty and build resilience. We also wished to encourage wider use of PPI with older people by outlining our approach.

Methods

Involvement of older people was undertaken in three stages. Eighteen over 65-year-olds helped co-design an exercise intervention in two group discussions using the Socratic education method. Ninety-four contributed intervention feedback in one-on-one telephone interviews over nine months. Ten contributors helped optimise the intervention in three online workshops. Multidisciplinary team input and systematic review supported co-design.

Results

Eleven home-based resistance exercises were co-designed by group discussion contributors (mean age 75, 61% female). Frailty intervention format, gender balance and GP follow-up were shaped in telephone interviews (mean age 77, 63% female). Dietary guidance and patient communication were co-designed in workshops (mean age 71, 60% female). Technology proved no barrier to PPI. The co-designed frailty intervention is being evaluated in a definitive RCT.

Conclusion

We enabled meaningful involvement of 112 older people in co-design of an intervention to reverse frailty and build resilience in diverse ways. Inclusive involvement can be achieved during a pandemic. Feedback enhanced intervention feasibility for real-world primary-care.

IL-33 is induced in undifferentiated, non-dividing esophageal epithelial cells in eosinophilic esophagitis

The molecular and cellular etiology of eosinophilic esophagitis (EoE), an emerging tissue-specific allergic disease, involves dysregulated gene expression in esophageal epithelial cells. Herein, we assessed the esophageal expression of IL-33, an epithelium-derived alarmin cytokine, in patients with EoE. IL-33 protein was markedly overexpressed within the nuclei of a subpopulation of basal layer esophageal epithelial cells in patients with active EoE compared to control individuals. IL-33 exhibited dynamic expression as levels normalized upon EoE remission. IL-33–positive basal epithelial cells expressed E-cadherin and the undifferentiated epithelial cell markers keratin 5 and 14 but not the differentiation marker keratin 4. Moreover, the IL-33–positive epithelial cells expressed the epithelial progenitor markers p75 and p63 and lacked the proliferation markers Ki67 and phospho-histone H3. Additionally, the IL-33–positive cells had low expression of PCNA. IL-33 expression was detected in ex vivo–cultured primary esophageal epithelial cells in a subpopulation of cells lacking expression of proliferation markers. Collectively, we report that IL-33 expression is induced in an undifferentiated, non-dividing esophageal epithelial cell population in patients with active EoE.

Eosinophils in mucosal immune responses

Eosinophils, multifunctional cells that contribute to both innate and adaptive immunity, are involved in the initiation, propagation, and resolution of immune responses, including tissue repair. They achieve this multifunctionality by expression of a diverse set of activation receptors, including those that directly recognize pathogens and opsonized targets, and by their ability to store and release preformed cytotoxic mediators that participate in host defense, to produce a variety of de novo pleotropic mediators and cytokines, and to interact directly and indirectly with diverse cell types, including adaptive and innate immunocytes and structural cells. Herein, we review the basic biology of eosinophils and then focus on new emerging concepts about their role in mucosal immune homeostasis, particularly maintenance of intestinal IgA. We review emerging data about their development and regulation and describe new concepts concerning mucosal eosinophilic diseases. We describe recently developed therapeutic strategies to modify eosinophil levels and function and provide collective insight about the beneficial and detrimental functions of these enigmatic cells.

Childhood asthma and GOLD-defined chronic obstructive pulmonary disease

BACKGROUND

Current understanding of chronic obstructive pulmonary disease (COPD) is that it results from an interaction of genetic and environmental factors. This study aimed to investigate the strength of association of various known risk factors for COPD.

METHODS

Detailed written questionnaires, full pulmonary function tests and atopy testing were completed in 749 people, aged 25-75 years, recruited from a random population sample. COPD was defined, using Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, as a post-bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV(1) /FVC) ratio <0.7.

RESULTS

The prevalence of COPD was higher in men (OR 1.7 (95% CI 1.1-2.7)) and increased with increasing age (OR per decade older 2.1 (95% CI 1.7-2.7)). COPD was more frequent in current and ex-smokers and increased with increasing pack years (OR per 10 pack years 1.3 (95% CI 1.1-1.5)). On a logit scale, a diagnosis of asthma as a child conferred a similar risk as an increase in age of 22 years or 62 pack years of cigarette smoking.

CONCLUSION

Childhood asthma emerged with the strongest association for GOLD-defined COPD. Possible explanations for this are suggested, including limitations of the current GOLD spirometric definition of COPD, a chance observation because of the high prevalence of both disorders in this population, or alternatively childhood asthma is a risk factor for COPD.

Distinct clinical phenotypes of airways disease defined by cluster analysis

Airways disease is currently classified using diagnostic labels such as asthma, chronic bronchitis and emphysema. The current definitions of these classifications may not reflect the phenotypes of airways disease in the community, which may have differing disease processes, clinical features or responses to treatment. The aim of the present study was to use cluster analysis to explore clinical phenotypes in a community population with airways disease. A random population sample of 25-75-yr-old adults underwent detailed investigation, including a clinical questionnaire, pulmonary function tests, nitric oxide measurements, blood tests and chest computed tomography. Cluster analysis was performed on the subgroup with current respiratory symptoms or obstructive spirometric results. Subjects with a complete dataset (n = 175) were included in the cluster analysis. Five clusters were identified with the following characteristics: cluster 1: severe and markedly variable airflow obstruction with features of atopic asthma, chronic bronchitis and emphysema; cluster 2: features of emphysema alone; cluster 3: atopic asthma with eosinophilic airways inflammation; cluster 4: mild airflow obstruction without other dominant phenotypic features; and cluster 5: chronic bronchitis in nonsmokers. Five distinct clinical phenotypes of airflow obstruction were identified. If confirmed in other populations, these findings may form the basis of a modified taxonomy for the disorders of airways obstruction.

Quality of life measured by the St George's Respiratory Questionnaire and spirometry

The present authors aimed to determine if the criteria for the diagnosis of chronic obstructive pulmonary disease (COPD) and its classification by severity as recommended by the Global Initiative for Chronic Obstructive Lung Disease are supported by measurements of respiratory health-related quality of life. A community-based sample of adults aged 25-75 yrs had pre- and post-bronchodilator spirometry and completed the St George's Respiratory Questionnaire (SGRQ). Loess scatter plot smoothers of the SGRQ versus post-bronchodilator forced expiratory volume in one second (FEV(1))/forced vital capacity (FVC) ratio and post-bronchodilator FEV(1) % predicted together with receiver operating characteristic (ROC) curve analysis were used to determine the relationship between spirometric variables and clinically important differences in the SGRQ score. The scatter plot smoother and ROC curve analyses supported the value of 0.7 for post-bronchodilator FEV(1)/FVC ratio, which was approximately 4 units higher than the nadir of the SGRQ. To represent a distance of 8 units on the SGRQ, the cut-off points for post-bronchodilator FEV(1) that delimit COPD severity stages were 80, 60 and 40% pred for mild, moderate and severe COPD, respectively. To diagnose chronic obstructive pulmonary disease the use of post-bronchodilator forced expiratory volume in one second/forced vital capacity ratio of 0.7 is supported by health-related quality of life measurements. There may be advantages in using forced expiratory volume in one second cut-off points of 80, 60 and 40% predicted for the classification of mild, moderate and severe chronic obstructive pulmonary disease, respectively, similar to the approach recommended for asthma.

Proportional classifications of COPD phenotypes

BACKGROUND

Chronic obstructive pulmonary disease (COPD) encompasses a group of disorders characterised by the presence of incompletely reversible airflow obstruction with overlapping subsets of different phenotypes including chronic bronchitis, emphysema or asthma. The aim of this study was to determine the proportion of adult subjects aged >50 years within each phenotypic subgroup of COPD, defined as a post-bronchodilator ratio of forced expiratory volume in 1 s/forced vital capacity (FEV(1)/FVC) <0.7, in accordance with current international guidelines.

METHODS

Adults aged >50 years derived from a random population-based survey undertook detailed questionnaires, pulmonary function tests and chest CT scans. The proportion of subjects in each of 16 distinct phenotypes was determined based on combinations of chronic bronchitis, emphysema and asthma, with and without incompletely reversible airflow obstruction defined by a post-bronchodilator FEV(1)/FVC ratio of 0.7.

RESULTS

A total of 469 subjects completed the investigative modules, 96 of whom (20.5%) had COPD. Diagrams were constructed to demonstrate the relative proportions of the phenotypic subgroups in subjects with and without COPD. 18/96 subjects with COPD (19%) had the classical phenotypes of chronic bronchitis and/or emphysema but no asthma; asthma was the predominant COPD phenotype, being present in 53/96 (55%). When COPD was defined as a post-bronchodilator FEV(1)/FVC less than the lower limit of normal, there were one-third fewer subjects with COPD and a smaller proportion without a defined emphysema, chronic bronchitis or asthma phenotype.

CONCLUSION

This study provides proportional classifications of the phenotypic subgroups of COPD which can be used as the basis for further research into the pathogenesis and treatment of this heterogeneous disorder.

Mechanisms of exertional dyspnea in patients with cancer

Exertional dyspnea is an important symptom in cancer patients, and, in many cases, its cause remains unexplained after careful clinical assessment. To determine mechanisms of exertional dyspnea in a variety of cancer types, we evaluated cancer outpatients with clinically important unexplained dyspnea (CD) at rest and during exercise and compared the results with age-, sex-, and cancer stage-matched control cancer (CC) patients and age- and sex-matched healthy control participants (HC). Participants (n = 20/group) were screened to exclude clinical cardiopulmonary disease and then completed dyspnea questionnaires, anthropometric measurements, muscle strength testing, pulmonary function testing, and incremental cardiopulmonary treadmill exercise testing. Dyspnea intensity was greater in the CD group at peak exercise and for a given ventilation and oxygen uptake (P < 0.05). Peak oxygen uptake was reduced in CD compared with HC (P < 0.05), and breathing pattern was more rapid and shallow in CD than in the other groups (P < 0.05). Reduced tidal volume expansion during exercise correlated with reduced inspiratory capacity, which, in turn, correlated with reduced inspiratory muscle strength. Patients with cancer had a relatively reduced diffusing capacity of the lung for carbon monoxide, reduced skeletal muscle strength, and lower ventilatory thresholds during exercise compared with HC (P < 0.05). There were no significant between-group differences in measurements of airway function, pulmonary gas exchange, or cardiovascular function during exercise. In the absence of evidence of airway obstruction or restrictive interstitial lung disease, the shallow breathing pattern suggests ventilatory muscle weakness as one possible explanation for increased dyspnea intensity at a given ventilation in CD patients.

Effect of tiotropium bromide on the cardiovascular response to exercise in COPD

INTRODUCTION

Exercise limitation and exertional dyspnea are important symptoms of chronic obstructive pulmonary disease (COPD), which may be partially relieved by tiotropium. Although the mechanism of relief is multifactorial, improved dynamic ventilatory mechanics appear to be important. It is not however known whether tiotropium may also act by improving cardiovascular function during exercise.

METHODS

We conducted a randomized, placebo-controlled crossover study in 18 COPD subjects with a FEV(1) 40+/-3% predicted (mean+/-SEM). Subjects inhaled either tiotropium 18 microg or placebo once daily for 7-10 days then the other intervention for a further 7-10 days after a 35-day washout period. Subjects performed constant work rate cycle exercise at 75% of maximum after each treatment period. Heart rate, blood pressure, oxygen uptake, operating lung volumes and breathing pattern were measured.

RESULTS

Heart rate was 7 beats/min lower at rest and throughout exercise with tiotropium compared to placebo (p=0.001). Oxygen uptake was unchanged throughout exercise. Oxygen pulse on exercise was greater by 7.4% (p<0.01) and systolic blood pressure was lower by 7 mmHg (p=0.03). The cardiac rate pressure product was reduced by 7.6% (p<0.01) with tiotropium. Exercise endurance tended to be greater with tiotropium. Reduction in heart rate on exercise correlated with an increase in inspiratory reserve volume (r=-0.50, p=0.04).

CONCLUSION

Tiotropium may improve cardiac as well as pulmonary function during exercise in COPD. We suggest that this effect may be due, in part, to improved cardiopulmonary interaction as a result of mechanical unloading of the ventilatory muscles however further study is required.

A chemical inhibitor of PPM1D that selectively kills cells overexpressing PPM1D

The PPM1D gene is aberrantly amplified in a range of common cancers and encodes a protein phosphatase that is a potential therapeutic target. However, the issue of whether inhibition of PPM1D in human tumour cells that overexpress this protein compromises their viability has not yet been fully addressed. We show here, using an RNA interference (RNAi) approach, that inhibition of PPM1D can indeed reduce the viability of human tumour cells and that this effect is selective; tumour cell lines that overexpress PPM1D are sensitive to PPM1D inhibition whereas cell lines with normal levels are not. Loss of viability associated with PPM1D RNAi in human tumour cells occurs via the activation of the kinase P38. To identify chemical inhibitors of PPM1D, a high-throughput screening of a library of small molecules was performed. This strategy successfully identified a compound that selectively reduces viability of human tumour cell lines that overexpress PPM1D. As expected of a specific inhibitor, the toxicity to PPM1D overexpressing cell lines after inhibitor treatment is P38 dependent. These results further validate PPM1D as a therapeutic target and identify a proof-of-principle small molecule inhibitor.

Evidence for the involvement of the NADPH oxidase enzyme complex in the optimal accumulation of Platelet-activating factor in the human cell line PLB-985

Platelet-activating factor (PAF) is an early product of the inflammatory environment, influencing development and resolution of inflammation. Its production is greater in neutrophils and macrophages, which predominantly synthesize 1-alkyl sn-2 acetyl glycerophosphocholine (GPC) than in nongranulocytes (B cells and endothelial cells), which lack a respiratory burst and synthesize 1-acyl sn-2 acetyl GPC as their major PAF species. This study investigated whether the respiratory burst was responsible for the quantitative and qualitative differences in sn-2 acetyl GPC species generation by neutrophils and macrophages versus those cells lacking the NADPH oxidase complex. The myeloid cell line PLB-985 (capable of differentiation into neutrophils) was used to test this hypothesis, since these cells had previously been generated with a non-functional respiratory burst (X-CGD PLB-985). Differentiated PLB-985 cells underwent a large respiratory burst in response to PMA (phorbol ester), and smaller respiratory bursts in response to A23187 (calcium ionophore), and the bacterial polypeptide fMLP (receptor mediated activation). Concurrently, treated cells were assessed for production of 1-hexadecyl and 1-palmitoyl sn-2 acetyl GPC species by gas chromatography/mass spectrometry. Neither cell type generated these lipid species in response to PMA, but both cell types generated equal levels of sn-2 acetyl GPC in response to A23187, with five times more 1-hexadecyl than 1-palmitoyl species. Upon fMLP activation, X-CGD PLB-985 cells produced significantly less 1-hexadecyl and 1-palmitoyl sn-2 acetyl GPC in comparison to the wild-type PLB-985 cells. These findings suggest phagocytic oxidant production by NADPH oxidase is not essential for sn-2 acetyl GPC generation, but appears important for optimal production of PAF in response to some stimuli.

Antiinflammatory activity of the platelet-activating factor receptor antagonist A-85783

Accumulating evidence suggests an important role for the lipid mediator, platelet-activating factor (PAF), in cutaneous inflammation. In these studies the antiinflammatory effects of the potent and selective lipophilic PAF receptor antagonist A-85783 topically applied to the ventral ears of male Wistar rats were assessed. Intradermal injections of PAF into rat ears resulted in cutaneous inflammation as assessed by both ear thickness measurements and histological evaluation. Pretreatment of the ears with A-85783 resulted in an inhibition of subsequent PAF-induced inflammation. A-85783 treatment also inhibited phorbol myristic acetate-induced cutaneous inflammation, suggesting that the PAF receptor is involved in the etiology of this experimental dermatitis. These findings demonstrate that epicutaneous A-85783 is an appropriate tool to study the role of the PAF receptor in cutaneous inflammation, and suggest the possible clinical utility of this new class of antiinflammatory agents.

Beta-oxidation of 12(S)-hydroxy-5,8,10,14-eicosatetraenoic acid by MOLT-4 lymphocytes

MOLT-4 lymphocytes metabolize 12-hydroxy-5,8,10,14-eicosatetraenoic acid (12(S)-HETE via beta-oxidation with retention of the hydroxyl group at the omega 9 carbon atom. The isolation of 6-hydroxy-4,8-tetradecadienoic acid documents that these cells have the capacity to catabolize the conjugated diene system. 12(S)-HETE was also metabolized to 3,12-dihydroxy-8,10,14-eicosatrienoic acid and 1,9-dihydroxy-5,7,11-heptadecatriene as well as to 17- and 19-carbon aldehydes. When MOLT-4 cells were incubated with the beta-oxidation product, 10-hydroxy-6,8,12-octadecatrienoic acid, it was in part further catabolized but in addition it served as an anabolic precursor as defined by the accumulation 3,12-dihydroxy-8,10,14-eicosatrienoic acid as well as 1,11-dihydroxy-7,9,13-nonadecatriene. Neither 10-hydroxy-6,8,12-octadecatrienoic acid nor 13-hydroxy-5,8,11-octadecatrienic acid was as potent in inhibiting phytohemagglutin-induced lymphocyte mitogenesis as were their parent compounds--i.e., 12(S)- and 15(S)-HETE. These findings argue against the hypothesis that beta-oxidation products of 12(S)- and 15(S)-HETE are the potential modulators of lymphocyte function. However, neither the pathway for synthesis, nor the role of odd chain aldehydes and diols as potential lipid mediators was determined in this study.

The evaluation of child behavior during dental examination and treatment using predmedication and placebo

The purpose of this study were to determine the association of scores on the North Carolina Behavior Rating Scale (NCBRS) to those of the Frankl scale during restorative visits; and to quantify and compare rated behavior of children during an oral examination and restorative visits involving either a placebo or a combination of chloral hydrate (CH) and hydroxyzine. Fifteen patients 21-37 months old participated in this institutionally approved study. The study was a double-blind, crossover design. Following an examination using a mirror, explorer, and prophylaxis cup, the child received either a placebo or a combination of chloral hydrate (CH) and hydroxyzine. Fifteen patients 21-37 months old participated in this institutionally approved study. The study was a double-blind, crossover design. Following an this institutionally approved study. The study was a double-blind, crossover design. Following an examination using a mirror, explorer, and prophylaxis cup, the child received either a placebo or a combination of chloral hydrate and hydroxyzine. The sequence was reversed at the next appointment. All exam and treatment visits were videotaped and analyzed using the NCBRS. In addition, all treatment visits were rated with the Frankl scale. The data were analyzed using a repeated ANOVA and correlation coefficients. The results showed a high interrater reliability (> 86% agreement) and a significant correlation between the NCBRS and Frankl scale (P < 0.001). No significant difference was found for the amount of disruptive behavior among oral examination, placebo, and medication visits (P < or = 0.097), although a consistent decrease in mean disruptive behavior for that order of visits was observed most frequently.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolism of 13-hydroxy-9,11-octadecadienoic acid by MOLT-4 lymphocytes

MOLT-4 lymphocytes metabolize 13-hydroxy-9,11-octadecadienoic acid, via the beta-oxidation pathway with retention of the omega 6 hydroxyl group and the conjugated diene system. The products which accumulate include 11-hydroxy-7,9-hexadecadienoic acid and 9-hydroxy-5,7-tetradecadienoic acid. In addition, it was possible to isolate two beta-hydroxy acids which were shown to be 3,13-dihydroxy-9,11-octadecadienoic acid and 3,11-dihydroxy-7,9-hexadecadienoic acid. The odd chain aldehyde, 12-hydroxy-8,10-heptadecadien-1-al, also was detected. However, neither the pathway nor the immediate precursor for the synthesis of this compound was established.