CPL-01, an investigational long-acting ropivacaine, demonstrates safety and efficacy in open inguinal hernia repair

BACKGROUND

There is an unmet medical need for effective nonopioid analgesics that can decrease pain while reducing systemic opioid use. CPL-01, an extended-release injectable formulation of ropivacaine, is designed to safely provide analgesia and reduce or eliminate opioid use in the postoperative period.

METHODS

Subjects undergoing open inguinal hernia with mesh were prospectively randomized to 1 of 3 doses of CPL-01 (10, 20, or 30 ml of 2% CPL-01, n = 14, 12, and 14, respectively), Naropin (150 mg, n = 40), or saline placebo (n = 13) infiltrated into the surgical site prior to closure. Pain and rescue medication usage was assessed, and Numeric Rating Scale (NRS) pain scores were adjusted for opioid usage using windowed worst observation carried forward (wWOCF) imputation. The primary efficacy endpoint was the mean area under the curve (AUC) of the NRS pain intensity scores with activity.

RESULTS

Ninety-three subjects were treated, and 91 subjects completed 72 h of post-operative monitoring. Subjects who received the highest dose of CPL-01 in Cohort 3 showed a clinically meaningful reduction in postoperative pain intensity scores, which was the lowest value for any treatment in all cohorts, showing a trend towards statistical significance as compared to the pooled placebo group (p = 0.08), and numerically better than the 40 subjects who received Naropin. Opioid use through 72 h in subjects who received CPL-01 in Cohort 3 was approximately half of that shown in the placebo and Naropin groups; approximately 2/3 of the CPL-01 subjects (9/14) required no opioids at all through the first 72 h after the operation. More CPL-01 subjects avoided severe pain and were ready for discharge earlier than other groups. CPL-01 was safe and well-tolerated, with no clinically meaningful safety signals, and showed predictable and consistent extended-release pharmacokinetics.

CONCLUSION

Results suggest that CPL-01 may be the first long-acting ropivacaine to address postoperative pain while reducing the need for opioids.

Generation of precision preclinical cancer models using regulated in vivo base editing

Although single-nucleotide variants (SNVs) make up the majority of cancer-associated genetic changes and have been comprehensively catalogued, little is known about their impact on tumor initiation and progression. To enable the functional interrogation of cancer-associated SNVs, we developed a mouse system for temporal and regulatable in vivo base editing. The inducible base editing (iBE) mouse carries a single expression-optimized cytosine base editor transgene under the control of a tetracycline response element and enables robust, doxycycline-dependent expression across a broad range of tissues in vivo. Combined with plasmid-based or synthetic guide RNAs, iBE drives efficient engineering of individual or multiple SNVs in intestinal, lung and pancreatic organoids. Temporal regulation of base editor activity allows controlled sequential genome editing ex vivo and in vivo, and delivery of sgRNAs directly to target tissues facilitates generation of in situ preclinical cancer models.

A functional genomics screen identifying blood cell development genes in Drosophila by undergraduates participating in a course-based research experience

Undergraduate students participating in the UCLA Undergraduate Research Consortium for Functional Genomics (URCFG) have conducted a two-phased screen using RNA interference (RNAi) in combination with fluorescent reporter proteins to identify genes important for hematopoiesis in Drosophila. This screen disrupted the function of approximately 3500 genes and identified 137 candidate genes for which loss of function leads to observable changes in the hematopoietic development. Targeting RNAi to maturing, progenitor, and regulatory cell types identified key subsets that either limit or promote blood cell maturation. Bioinformatic analysis reveals gene enrichment in several previously uncharacterized areas, including RNA processing and export and vesicular trafficking. Lastly, the participation of students in this course-based undergraduate research experience (CURE) correlated with increased learning gains across several areas, as well as increased STEM retention, indicating that authentic, student-driven research in the form of a CURE represents an impactful and enriching pedagogical approach.

GO: a functional reporter system to identify and enrich base editing activity

Base editing (BE) is a powerful tool for engineering single nucleotide variants (SNVs) and has been used to create targeted mutations in cell lines, organoids and animal models. Recent development of new BE enzymes has provided an extensive toolkit for genome modification; however, identifying and isolating edited cells for analysis has proven challenging. Here we report a 'Gene On' (GO) reporter system that indicates precise cytosine or adenine base editing in situ with high sensitivity and specificity. We test GO using an activatable GFP and use it to measure the kinetics, efficiency and PAM specificity of a range of new BE variants. Further, GO is flexible and can be easily adapted to induce expression of numerous genetically encoded markers, antibiotic resistance genes or enzymes, such as Cre recombinase. With these tools, GO can be exploited to functionally link BE events at endogenous genomic loci to cellular enzymatic activities in human and mouse cell lines and organoids. Thus, GO provides a powerful approach to increase the practicality and feasibility of implementing CRISPR BE in biomedical research.

Tankyrase inhibition sensitizes cells to CDK4 blockade

Tankyrase (TNKS) 1/2 are positive regulators of WNT signaling by controlling the activity of the ß-catenin destruction complex. TNKS inhibitors provide an opportunity to suppress hyperactive WNT signaling in tumors, however, they have shown limited anti-proliferative activity as a monotherapy in human cancer cell lines. Here we perform a kinome-focused CRISPR screen to identify potential effective drug combinations with TNKS inhibition. We show that the loss of CDK4, but not CDK6, synergizes with TNKS1/2 blockade to drive G1 cell cycle arrest and senescence. Through precise modelling of cancer-associated mutations using cytidine base editors, we show that this therapeutic approach is absolutely dependent on suppression of canonical WNT signaling by TNKS inhibitors and is effective in cells from multiple epithelial cancer types. Together, our results suggest that combined WNT and CDK4 inhibition might provide a potential therapeutic strategy for difficult-to-treat epithelial tumors.

The TFAP2C-Regulated OCT4 Naive Enhancer Is Involved in Human Germline Formation

Human primordial germ cells (hPGCs) are the first embryonic progenitors in the germ cell lineage, yet the molecular mechanisms required for hPGC formation are not well characterized. To identify regulatory regions in hPGC development, we used the assay for transposase-accessible chromatin using sequencing (ATAC-seq) to systematically characterize regions of open chromatin in hPGCs and hPGC-like cells (hPGCLCs) differentiated from human embryonic stem cells (hESCs). We discovered regions of open chromatin unique to hPGCs and hPGCLCs that significantly overlap with TFAP2C-bound enhancers identified in the naive ground state of pluripotency. Using CRISPR/Cas9, we show that deleting the TFAP2C-bound naive enhancer at the OCT4 locus (also called POU5F1) results in impaired OCT4 expression and a negative effect on hPGCLC identity.

Combining genomics and functional studies, Chen et al. identify the open chromatin state of human primordial germ cells (hPGCs), leading to the discovery that TFAP2C regulates hPGC development through the opening of naive enhancers.

Identical and Nonidentical Twins: Risk and Factors Involved in Development of Islet Autoimmunity and Type 1 Diabetes

OBJECTIVE

There are variable reports of risk of concordance for progression to islet autoantibodies and type 1 diabetes in identical twins after one twin is diagnosed. We examined development of positive autoantibodies and type 1 diabetes and the effects of genetic factors and common environment on autoantibody positivity in identical twins, nonidentical twins, and full siblings.

RESEARCH DESIGN AND METHODS

Subjects from the TrialNet Pathway to Prevention Study (N = 48,026) were screened from 2004 to 2015 for islet autoantibodies (GAD antibody [GADA], insulinoma-associated antigen 2 [IA-2A], and autoantibodies against insulin [IAA]). Of these subjects, 17,226 (157 identical twins, 283 nonidentical twins, and 16,786 full siblings) were followed for autoantibody positivity or type 1 diabetes for a median of 2.1 years.

RESULTS

At screening, identical twins were more likely to have positive GADA, IA-2A, and IAA than nonidentical twins or full siblings (all P < 0.0001). Younger age, male sex, and genetic factors were significant factors for expression of IA-2A, IAA, one or more positive autoantibodies, and two or more positive autoantibodies (all P ≤ 0.03). Initially autoantibody-positive identical twins had a 69% risk of diabetes by 3 years compared with 1.5% for initially autoantibody-negative identical twins. In nonidentical twins, type 1 diabetes risk by 3 years was 72% for initially multiple autoantibody-positive, 13% for single autoantibody-positive, and 0% for initially autoantibody-negative nonidentical twins. Full siblings had a 3-year type 1 diabetes risk of 47% for multiple autoantibody-positive, 12% for single autoantibody-positive, and 0.5% for initially autoantibody-negative subjects.

CONCLUSIONS

Risk of type 1 diabetes at 3 years is high for initially multiple and single autoantibody-positive identical twins and multiple autoantibody-positive nonidentical twins. Genetic predisposition, age, and male sex are significant risk factors for development of positive autoantibodies in twins.

Germline competency of human embryonic stem cells depends on eomesodermin

In humans, germline competency and the specification of primordial germ cells (PGCs) are thought to occur in a restricted developmental window during early embryogenesis. Despite the importance of specifying the appropriate number of PGCs for human reproduction, the molecular mechanisms governing PGC formation remain largely unexplored. Here, we compared PGC-like cell (PGCLC) differentiation from 18 independently derived human embryonic stem cell (hESC) lines, and discovered that the expression of primitive streak genes were positively associated with hESC germline competency. Furthermore, we show that chemical inhibition of TGFβ and WNT signaling, which are required for primitive streak formation and CRISPR/Cas9 deletion of Eomesodermin (EOMES), significantly impacts PGCLC differentiation from hESCs. Taken together, our results suggest that human PGC formation involves signaling and transcriptional programs associated with somatic germ layer induction and expression of EOMES.

Use of Oral Fluids for Detection of Virus and Antibodies in Pigs Infected with Swine Vesicular Disease Virus

The use of swine oral fluid (OF) for the detection of nucleic acids and antibodies is gaining significant popularity. Assays have been developed for this purpose for endemic and foreign animal diseases of swine. Here, we report the use of OF for the detection of virus and antibodies in pigs experimentally infected with swine vesicular disease virus (SVDV), a virus that causes a disease clinically indistinguishable from the economically devastating foot-and-mouth disease. Viral genome was detected in OF by real-time reverse transcription polymerase chain reaction (RRT-PCR) from 1 day post-infection (DPI) to 21 DPI. Virus isolation from OF was also successful at 1-5 DPI. An adapted competitive ELISA based on the monoclonal antibodies 5B7 detected antibodies to SVDV in OF starting at DPI 6. Additionally, using isotype-specific indirect ELISAs, SVDV-specific IgM and IgA were evaluated in OF. IgM response started at DPI 6, peaking at DPI 7 or 14 and declining sharply at DPI 21, while IgA response started at DPI 7, peaked at DPI 14 and remained high until the end of the experiment. These results confirm the potential use of OF for SVD surveillance using both established and partially validated assays in this study.

Intrinsic Metastabilities in the Charge Configuration of a Double Quantum Dot

We report a thermally activated metastability in a GaAs double quantum dot exhibiting real-time charge switching in diamond shaped regions of the charge stability diagram. Accidental charge traps and sensor backaction are excluded as the origin of the switching. We present an extension of the canonical double dot theory based on an intrinsic, thermal electron exchange process through the reservoirs, giving excellent agreement with the experiment. The electron spin is randomized by the exchange process, thus facilitating fast, gate-controlled spin initialization. At the same time, this process sets an intrinsic upper limit to the spin relaxation time.

Comparison of specimens for detection of porcine reproductive and respiratory syndrome virus infection in boar studs

Porcine reproductive and respiratory syndrome virus (PRRSV)-contaminated semen from boars is a route of transmission to females, and early detection of PRRSV infection in boars is a key component in sow farm biosecurity. The purpose of this study was to determine the optimum diagnostic specimen(s) for the detection of acute PRRSV infection in boars. Individually housed boars (n = 15) were trained for semen and oral fluid collection and then vaccinated with a commercial PRRSV modified live virus vaccine. Starting on the day of vaccination and for 14 days thereafter, oral fluid specimens were collected daily from all boars. The 15 boars were subdivided into three groups of 5, and serum, blood swabs and 'frothy saliva' were collected at the time of semen collection on a 3-day rotation. Frothy saliva, derived from the submandibular salivary gland, is produced by aroused boars. Semen was centrifuged, and semen supernatant and cell fractions were tested separately. All samples were randomly ordered and then tested by PRRSV real-time quantitative reverse-transcription polymerase chain reaction assay (rRT-PCR) and PRRSV antibody ELISA. In this study, a comparison of serum, blood swab, and oral fluid rRT-PCR results found no statistically significant differences in the onset of detection or proportion of positives, but serum was numerically superior to oral fluids for early detection. Serum and oral fluid provided identical rRT-PCR results at ≥ 5 day post-vaccination. Likewise, the onset of detection of PRRSV antibody in serum, oral fluid and frothy saliva was statistically equivalent, with serum results again showing a numerical advantage. These results showed that the highest assurance of providing PRRSV-negative semen to sow farms should be based on rRT-PCR testing of serum collected at the time of semen collection. This approach can be augmented with oral fluid sampling from a random selection of uncollected boars to provide for statistically valid surveillance of the boar stud.

[Terminology for classifying the porcine reproductive and respiratory syndrome virus (PRRSV) status of swine herds]

Standardized terminology for the porcine reproductive and respiratory syndrome virus (PRRSV) status of swine herds is necessary to facilitate communication between veterinarians, swine producers, genetic companies, and other industry participants. It is also required for implementation of regional and national efforts towards PRRSV control and elimination. The purpose of this paper is to provide a herd classification system for describing the PRRSV status of herds, based upon a set of definitions reflecting the biology and ecology of PRRSV. The herd classification system was developed by a definitions committee formed jointly by the American Association of Swine Veterinarians (AASV) and the United States Department of Agriculture PRRS-Coordinated Agricultural Project, and was approved by the AASV Board of Directors on March 9, 2010. The committee included veterinarians from private practice and industry, researchers, and representatives from AASV and the National Pork Board. Breeding herds, with or without growing pigs on the same premises, are categorized as Positive Unstable (Category I), Positive Stable (Category II), Provisional Negative (Category III), or Negative (Category IV) on the basis of herd shedding and exposure status. Growing-pig herds are categorized as Positive or Negative. Recommended testing procedures and decision rules for herd classification are detailed.

Effects of different delay of reinforcement procedures on variable-interval responding

Two experiments studied responding in the rat when the first bar press after a variable period of time produced a cue light that remained on for either 10, 30, or 100 sec and terminated with the delivery of food. In Experiment I, response rate decreased and time to the first response after reinforcement increased as the delay of reinforcement increased. Similar results were obtained whether the delay consisted of retracting the lever during the delay, a fixed delay with no scheduled consequence for responding, or every response during the delay restarted the delay interval. In Experiment II, fixed-delay and fixed-interval schedules of the same duration during the delay period had no differential effect on either response rate or time to the first response after reinforcement, but differentially controlled responding during the delay periods.

Differential effects of token reinforcement on instruction-following behavior in retarded students instructed as a group

This study was addressed to the problem of applying behavior modification techniques on a group basis to a class of retarded students with "attentional deficits". Seven boys, age 8 to 15 yr, characterized as showing severe "attentional" problems or disruptive behavior in their respective classrooms, participated daily for 30-min sessions in a special class over a 1.5-month period. In each session, verbal instructions were given to the class as a whole. In control sessions, each appropriate instruction-following response by a child produced praise for that child. In experimental sessions, appropriate responses also produced tokens exchangeable for tangible reinforcers after the session. Token reinforcement differentially maintained instruction-following behavior in four children while one responded appropriately to most instructions and a second improved continuously during the study. While the data suggest that the present approach can be successfully applied to the alteration of instruction-following behavior in retarded children, its major contribution may be that of providing objective quantitative information about such behavior.

A double-blind, multicentered study comparing the accuracy of diagnostic markers to predict short- and long-term clinical events and their utility in patients presenting with chest pain

BACKGROUND

Millions of patients present annually with chest pain, but only 10% have myocardial infarction (MI). We recently reported comparative sensitivity and specificity of available markers in the diagnosis of MI; however, optimum interpretation of marker results requires prognostic follow-up data.

HYPOTHESIS

The study was undertaken to study the accuracy of CK-MB subforms, troponin I and T, myoglobin, and CK-MB in predicting clinical events at 30 days and 6 months.

METHODS

In all, 955 consecutive patients with chest pain were enrolled in a prospective, multicenter, double-blind study to test the prognostic accuracy of these markers.

RESULTS

Myocardial infarction was diagnosed in 119 by CK-MB mass criteria and unstable angina (UA) in 203 patients by clinical criteria. Follow-up at 30 days and 6 months was available in 824 and 724 patients, respectively, with mortalities of 2.8 and 4.14%, respectively. Cumulative 6-month mortality was 5.6% in MI, 4.4% in UA, and 3.0% in others. Revascularization was reported in 9.3% of patients by 6 months. A positive test on each of the markers except myoglobin was predictive of revascularization. The composite endpoint of death or revascularization occurred in 107 patients by 6 months and a positive result on each of the markers was predictive of this composite endpoint (p < 0.05). The relative risk of death or revascularization for patients who did not have MI but tested positive on each of the markers was > 1.0 but did not reach statistical significance.

CONCLUSIONS

With the possible exception of myoglobin, each of the diagnostic markers displayed similar prognostic performance in patients with chest pain presenting to emergency departments. The most appropriate markers to triage patients with chest pain, which has both adequate early diagnostic sensitivity and prognostic accuracy, are the CK-MB subforms.

Nondigestive symptoms in non-erosive reflux disease: nature, prevalence and relation to acid reflux

BACKGROUND

Nondigestive symptoms are frequent in the irritable bowel syndrome (IBS).

AIM

To characterize nondigestive symptoms in non-erosive gastro-oesophageal reflux disease (NERD) patients, as features of IBS are common in patients with NERD.

METHODS

A prospective, case-control study. NERD was defined in patients with reflux symptoms, a normal oesophageal mucosa and oesophageal pH < 4 for > or = 5% of the time during 24-h pH monitoring. Nondigestive symptoms were scored on validated scales of somatic pain, urinary, sleep and neurasthenia. IBS was defined by the Rome I criteria.

RESULTS

pH-positive NERD patients (n = 326) scored significantly higher than controls (nonpatient hospital visitors; n = 174) on all scales. The scores of pain, sleep and neurasthenia were highly specific in the discrimination of NERD patients from controls. In patients, nondigestive symptoms were independently associated with age, reflux symptoms severity and IBS status, but not with oesophageal acid exposure. NERD patients who met diagnostic criteria for IBS (49%) scored significantly higher on all the nondigestive symptoms scales than those had not met [IBS(-)]. Yet, IBS(-) patients scored significantly higher than controls on all scales.

CONCLUSIONS

Nondigestive symptoms were highly prevalent in NERD patients and were specific in their discrimination from controls. Nondigestive symptoms correlated with reflux symptoms and were predicted by IBS status.

Functional heartburn vs. non-erosive reflux disease: similarities and differences

BACKGROUND

Bowel symptoms have been associated with non-erosive reflux disease (NERD). However, their role in functional heartburn (FH) has not been established.

AIMS

To characterize bowel symptoms in FH and NERD patients, and investigate their role as predictors of severity of reflux symptoms.

METHODS

A prospective study of patients with normal upper endoscopy undergoing a 24-h oesophageal pH monitoring for the evaluation of reflux symptoms. Patients with oesophageal acid exposure <3.1% and a symptom index <50% were classified as FH (n = 60), while those with oesophageal acid exposure >4% were defined as NERD (n = 160). Symptom severity was scored on validated scales.

RESULTS

In FH, a female predominance was noted (P < 0.001). Reflux symptoms were scored higher in NERD patients (P < 0.001) while bowel symptoms were similarly scored in the two groups. In both groups, severity of reflux symptoms was independently associated with a composite score on the bowel scales (P < 0.001) and was not predicted by oesophageal acid exposure. In FH, reflux symptom severity was inversely related to age (P = 0.03), while in NERD, the opposite was true (P = 0.01).

CONCLUSIONS

In both FH and NERD, bowel symptoms were the strongest predictors of reflux symptoms severity. A female preponderance, and an opposite relationship between reflux symptom severity and age, indicate that FH and NERD may be distinct entities.

Potential of information technology in dental education

The use of information technology (IT) in dentistry is far ranging. In order to produce a working document for the dental educator, this paper focuses on those methods where IT can assist in the education and competence development of dental students and dentists (e.g. e-learning, distance learning, simulations and computer-based assessment). Web pages and other information-gathering devices have become an essential part of our daily life, as they provide extensive information on all aspects of our society. This is mirrored in dental education where there are many different tools available, as listed in this report. IT offers added value to traditional teaching methods and examples are provided. In spite of the continuing debate on the learning effectiveness of e-learning applications, students request such approaches as an adjunct to the traditional delivery of learning materials. Faculty require support to enable them to effectively use the technology to the benefit of their students. This support should be provided by the institution and it is suggested that, where possible, institutions should appoint an e-learning champion with good interpersonal skills to support and encourage faculty change. From a global prospective, all students and faculty should have access to e-learning tools. This report encourages open access to e-learning material, platforms and programs. The quality of such learning materials must have well defined learning objectives and involve peer review to ensure content validity, accuracy, currency, the use of evidence-based data and the use of best practices. To ensure that the developers' intellectual rights are protected, the original content needs to be secure from unauthorized changes. Strategies and recommendations on how to improve the quality of e-learning are outlined. In the area of assessment, traditional examination schemes can be enriched by IT, whilst the Internet can provide many innovative approaches. Future trends in IT will evolve around improved uptake and access facilitated by the technology (hardware and software). The use of Web 2.0 shows considerable promise and this may have implications on a global level. For example, the one-laptop-per-child project is the best example of what Web 2.0 can do: minimal use of hardware to maximize use of the Internet structure. In essence, simple technology can overcome many of the barriers to learning. IT will always remain exciting, as it is always changing and the users, whether dental students, educators or patients are like chameleons adapting to the ever-changing landscape.

The μPIVOT: an integrated particle image velocimeter and optical tweezers instrument for microenvironment investigations

A novel instrument to manipulate and characterize the mechanical environment in and around microscale objects in a fluidic environment has been developed by integrating two laser-based techniques: micron-resolution particle image velocimetry (μPIV) and optical tweezers (OT). This instrument, the μPIVOT, enables a new realm of microscale studies, yet still maintains the individual capabilities of each optical technique. This was demonstrated with individual measurements of optical trap stiffness (∼70 pN μm(-1) for a 20 μm polystyrene sphere and a linear relationship between trap stiffness and laser power) and fluid velocities within 436 nm of a microchannel wall. The integrated device was validated by comparing computational flow predictions to the measured velocity profile around a trapped particle in either a uniform flow or an imposed, gravity-driven microchannel flow (R(2) = 0.988, RMS error = 13.04 μm s(-1)). Interaction between both techniques is shown to be negligible for 15 μm to 35 μm diameter trapped particles subjected to fluid velocities from 50 μm s(-1) to 500 μm s(-1) even at the highest laser power (1.45 W). The integrated techniques will provide a unique perspective toward understanding microscale phenomena including single-cell biomechanics, non-Newtonian fluid mechanics and single particle or particle-particle hydrodynamics.

Pilot study of the combination of EGFR and mTOR inhibitors in recurrent malignant gliomas

Malignant gliomas are frequently characterized by amplification of the epidermal growth factor receptor (EGFR) and loss of PTEN tumor suppressor gene. Twenty-eight heavily pretreated patients with recurrent malignant gliomas were administered EGFR inhibitors (gefitinib or erlotinib) in combination with the mTOR (mammalian target of rapamycin) inhibitor sirolimus. The regimens were reasonably well tolerated. Nineteen percent of patients experienced a partial response and 50% had stable disease. Six-month progression-free survival for glioblastoma patients was 25%.

The alteration of behavior in a special classroom situation

Unproductive classroom behavior was eliminated in two emotionally disturbed boys by removing social consequences of the behavior. Behavior which was more adequate and efficient with respect to social and scholastic adjustment was shaped and maintained with social reinforcers.

Selected growth of cubic and hexagonal GaN epitaxial films on polar MgO(111)

Selected molecular beam epitaxy of zinc blende (111) or wurtzite (0001) GaN films on polar MgO(111) is achieved depending on whether N or Ga is deposited first. The cubic stacking is enabled by nitrogen-induced polar surface stabilization, which yields a metallic MgO(111)-(1 x 1)-ON surface. High-resolution transmission electron microscopy and density functional theory studies indicate that the atomically abrupt semiconducting GaN(111)/MgO(111) interface has a Mg-O-N-Ga stacking, where the N atom is bonded to O at a top site. This specific atomic arrangement at the interface allows the cubic stacking to more effectively screen the substrate and film electric dipole moment than the hexagonal stacking, thus stabilizing the zinc blende phase even though the wurtzite phase is the ground state in the bulk.

Irritable bowel, smoking and oesophageal acid exposure: an insight into the nature of symptoms of gastro-oesophageal reflux

BACKGROUND

In gastro-oesophageal reflux disease, oesophageal acid exposure correlates with symptoms but explains only a small fraction of their variance.

AIMS

To elucidate the effects of irritable bowel syndrome and smoking on gastro-oesophageal reflux disease symptoms and to clarify whether they modulate the relationship between oesophageal acid exposure and symptoms.

METHODS

The relationship between oesophageal acid exposure, irritable bowel syndrome (Rome I criteria), smoking status and symptoms was investigated in patients with a normal gastroscopy who underwent a 24-h oesophageal pH monitoring.

RESULTS

Of 256 patients with gastro-oesophageal reflux disease, 16% were smokers and 50% met the criteria for irritable bowel syndrome (irritable bowel syndrome+). The extent of oesophageal acid exposure was unrelated to smoking or irritable bowel syndrome status. Oesophageal acid exposure, irritable bowel syndrome status and current smoking independently predicted symptoms. Irritable bowel syndrome and smoking modulated the effect of oesophageal acid exposure on symptoms: oesophageal acid exposure was predictive of symptoms only in non-smokers. However, irritable bowel syndrome was a significant predictor of symptoms both in smokers and in non-smokers. Smoking was associated with symptoms only in irritable bowel syndrome+, while oesophageal acid exposure was associated with symptoms irrespective of irritable bowel syndrome status.

CONCLUSIONS

In patients with non-erosive gastro-oesophageal reflux disease, smoking and irritable bowel syndrome independently predicted symptoms, without affecting the extent of oesophageal acid exposure. The relationship between oesophageal acid exposure and symptoms was affected significantly, and in opposite directions, by smoking and irritable bowel syndrome.

The effect of short-term estradiol therapy on cognitive function in older men receiving hormonal suppression therapy for prostate cancer

OBJECTIVES

To determine the effect of estrogen (E) alone (without the influence of testosterone (T)) on cognitive function in older men, using 17-beta micronized estradiol versus placebo in older men rendered hypogonadal (low T and E) by treatment for prostate cancer.

DESIGN

Short-term double-blind, randomized, controlled trial.

SETTING

An outpatient General Clinical Research Center.

PARTICIPANTS

Twenty-seven community-dwelling men aged 65 and older receiving neoadjuvant or established therapy with luteinizing-hormone releasing-hormone agonists for treatment of prostate cancer enrolled in a short-term randomized, controlled trial of 17-beta micronized estradiol versus placebo on the effect on biochemical markers of bone turnover.

MEASUREMENTS

Hormone levels, including E, T, and sex hormone-binding globulin; standardized neurocognitive tests, including measures of sustained attention, executive function, and memory; and questionnaires to assess subjects' perception of cognitive deficits and symptoms of depression.

RESULTS

There were no significant differences between patients receiving E or placebo on 15 of 17 neurocognitive measures and no significant differences in self-reported cognitive deficits or number of depressive symptoms.

CONCLUSION

Although studies have suggested that E replacement therapy may improve cognitive function, most notably memory performance in postmenopausal woman, there was no evidence in the present study that the addition of short-term E therapy was more beneficial than placebo in tests of cognitive performance in hypogonadal men.

Validation of a brief inventory for diagnosis and monitoring of symptomatic gastro-oesophageal reflux

BACKGROUND

This article presents a brief inventory for the diagnosis and monitoring of GORD symptoms.

METHODS

The inventory consists of five items pertaining to different aspects of GORD to be graded for frequency on a 5-point Likert scale. It was validated on a consecutive group of GORD patients diagnosed either by endoscopy (n = 25) or by 24-h ambulatory pH monitoring (acid exposure time > or = 5%; n = 233) and control subjects (n = 300).

RESULTS

Each of the inventory items was significantly associated with GORD (P < 0.001). Factor analysis indicated that all items loaded on a single scale with a high reliability (Cronbach alpha 0.88). Each item was weighted by its respective odds ratio in favour of GORD and a total score for the scale was then calculated as the sum of weighted scores on the five individual items. Receiver-operator (ROC) curve analysis implemented on a random sample comprising 67% of the group indicated that a total weighted score of 31.6 (percentage of the maximal possible weighted score) was 91% sensitive and 92% specific in the diagnosis of GORD. This score was then validated on the rest of the sample, where it correctly classified patients and controls with a sensitivity of 89% and specificity of 94%. The score proved stable on repeated administration in controls and in patients with stable symptoms, and decreased by 66% (P < 0.001) after 1 month of treatment with omeprazole in patients who reported symptom relief.

CONCLUSIONS

The scale described in this article is a brief, simple and accurate measure, for the diagnosis of GORD as well as for monitoring its symptoms.

The effect of micronized estradiol on bone turnover and calciotropic hormones in older men receiving hormonal suppression therapy for prostate cancer

To examine the effect of estradiol (E(2)) without the confounding effect of hypothalamic-pituitary feedback, we studied men with prostate cancer in whom gonadotropin secretion was suppressed by LH-releasing hormone agonists (LHRH-A). Fourteen men over 65 yr of age and receiving established LHRH-A treatment (EST group) without bony metastases and 12 men who received LHRH-A as neoadjuvant therapy for locally advanced prostate cancer (NEO group) were randomized (double blind) to receive either 1 mg/d micronized E(2) (n = 12) or placebo (PL; n = 13) for 9 wk. E(2), estrone, testosterone, SHBG, PTH, and 25-hydroxy- and 1,25-dihydroxyvitamin D levels as well as markers of bone resorption [N- and C-telopeptide cross-links (NTX and CTX) and deoxypyridinoline] and bone formation (bone-specific alkaline phosphatase, osteocalcin, and N-terminal type I collagen) were measured before LHRH-A in the NEO group, before [baseline (BL)] and after 9 wk of E(2) or PL in all patients, and 6 wk after E(2) treatment in the EST group. In the NEO group, hormone levels fell 3 wk after the initial LHRH-A injection, and deoxypyridinoline increased significantly (P = 0.006). At BL, the EST group had higher bone turnover due to the longer duration of LHRH-A treatment. With E(2) treatment, E(2) levels rose into the normal male range, and two resorption markers decreased significantly from BL by 33% for NTX (P < 0.001) and 28% for CTX (P = 0.009). Bone formation markers did not change. PTH increased by 43% from BL (P < 0.01) in the E(2) group and decreased 16% from BL in the PL group (P < 0.01). Ionized calcium did not change in the E(2) group, but increased in the PL group by 2.3% (P < 0.01). NTX and CTX increased 6 wk after E(2) withdrawal in the EST group. We conclude that E(2) inhibits bone resorption in hypogonadal men through a direct skeletal effect that is independent of PTH. Low dose estrogen may be an option for the prevention and/or treatment of bone loss in this population.

[Severity assessment by APACHE III system in Spain]

BACKGROUND

To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain.

PATIENTS AND METHOD

Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality.

RESULTS

Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level.

CONCLUSIONS

The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

Dyspepsia as a somatic expression of guilt: a case report

A 58-year-old woman developed chronic, severe symptoms of heartburn, epigastric pain, and regurgitation that persisted for 2 years. She underwent a thorough evaluation and no organic cause was identified. Therefore, a diagnosis of dyspepsia was made. Her symptoms were refractory to pharmacological treatment. Upon further probing, the patient reported that the onset of her symptoms coincided with the death of her son of cancer 2 years earlier. She blamed herself for the death of her son and admitted to a need for self-punishment. A brief course of treatment using metaphors and hypnosis resulted in a complete resolution of her symptoms, which did not recur during a follow-up of 12 years. This is the first published report of the treatment of dyspepsia using hypnotic methods.

Basal insulin glargine (HOE 901) versus NPH insulin in patients with type 1 diabetes on multiple daily insulin regimens. U.S. Insulin Glargine (HOE 901) Type 1 Diabetes Investigator Group

OBJECTIVE

Insulin glargine (HOE 901, 21(A)-Gly-30(B)a-L-Arg-30(B)b-L-Arg human insulin) is a novel recombinant analog of human insulin with a shift in the isoelectric point producing a retarded absorption rate and an increased duration of action that closely mimics normal basal insulin secretion. It recently received approval from the Food and Drug Administration. The aim of this study was to evaluate 2 formulations of insulin glargine for safety and efficacy in the treatment of patients with type 1 diabetes.

RESEARCH DESIGN AND METHODS

In a 4-week trial, 256 patients with type 1 diabetes received either NPH insulin or insulin glargine containing 30 microg/ml zinc (insulin glargine[30]) or 80 microg/ml zinc (insulin glargine[80]). Insulin glargine was given subcutaneously once daily at bedtime. NPH insulin was given either once daily (at bedtime) or twice daily (before breakfast and at bedtime), according to the patient's prestudy regimen. The initial doses of insulin glargine and NPH were based on the previous NPH total daily dose.

RESULTS

At study end point, insulin glargine-pooled groups had significantly lower fasting plasma glucose (FPG) levels than the NPH insulin group, with adjusted mean FPG levels reduced by 2.2 mmol/l (P = 0.0001). Insulin glargine was superior to NPH insulin in reducing FPG levels in patients who had previously received NPH insulin twice daily but not in patients who had previously received NPH once daily. FPG levels were more stable in patients using insulin glargine than in patients using NPH insulin. A subset of patients (n = 71) underwent hourly overnight plasma glucose measurements. Insulin glargine patients exhibited lower FPG levels after 5:00 A.M.; the difference was significant by 8:00 A.M. The adjusted mean FPG for insulin glargine[30] was 7.8 mmol/l; for insulin glargine[80], 7.3 mmol/l; and for NPH, 10.7 mmol/l. Both formulations of insulin glargine were well tolerated, similar to NPH insulin.

CONCLUSIONS

Basal insulin glargine administered once daily for 4 weeks as part of a basal-bolus multiple daily insulin regimen was safe and more effective in lowering fasting plasma glucose levels than NPH in patients with type 1 diabetes.