Identification of highly selective SIK1/2 inhibitors that modulate innate immune activation and suppress intestinal inflammation

The salt-inducible kinases (SIK) 1-3 are key regulators of pro- versus anti-inflammatory cytokine responses during innate immune activation. The lack of highly SIK-family or SIK isoform-selective inhibitors suitable for repeat, oral dosing has limited the study of the optimal SIK isoform selectivity profile for suppressing inflammation in vivo. To overcome this challenge, we devised a structure-based design strategy for developing potent SIK inhibitors that are highly selective against other kinases by engaging two differentiating features of the SIK catalytic site. This effort resulted in SIK1/2-selective probes that inhibit key intracellular proximal signaling events including reducing phosphorylation of the SIK substrate cAMP response element binding protein (CREB) regulated transcription coactivator 3 (CRTC3) as detected with an internally generated phospho-Ser329-CRTC3-specific antibody. These inhibitors also suppress production of pro-inflammatory cytokines while inducing anti-inflammatory interleukin-10 in activated human and murine myeloid cells and in mice following a lipopolysaccharide challenge. Oral dosing of these compounds ameliorates disease in a murine colitis model. These findings define an approach to generate highly selective SIK1/2 inhibitors and establish that targeting these isoforms may be a useful strategy to suppress pathological inflammation.

Computed tomographic analysis of the prevalence of International Frontal Sinus Anatomy Classification cells and their association with frontal sinusitis

OBJECTIVES

To determine the radiological prevalence of frontal cells according to the International Frontal Sinus Anatomy Classification in patients undergoing computed tomography of the paranasal sinuses for clinical symptoms of chronic rhinosinusitis, and to examine the association between cell classification and frontal sinusitis development.

METHODS

A total of 180 (left and right) sides of 90 patients were analysed. The prevalence of each International Frontal Sinus Anatomy Classification cell was assessed. Logistic regression analysis was used to compare the distribution of various cells in patients with and without frontal sinusitis.

RESULTS

The agger nasi cell was the most commonly occurring cell, seen in 95.5 per cent of patients. The prevalence rates for supra agger cells, supra agger frontal cells, supra bullar frontal cells, supra bullar cells, supra-orbital ethmoid cells and frontal septal cells were 33.3 per cent, 22.2 per cent, 21.1 per cent, 36.1 per cent, 39.4 per cent and 21.1 per cent, respectively. There was no significant difference in the occurrence of any of the cell types in patients with frontal sinusitis compared to those without (p > 0.05).

CONCLUSION

The presence of any of the International Frontal Sinus Anatomy Classification cells was not significantly associated with frontal sinusitis.

Opioid Analgesics Do Not Improve Abdominal Pain or Quality of Life in Crohn's Disease

BACKGROUND

Abdominal pain and opioid analgesic use are common in Crohn's disease (CD).

AIMS

We sought to identify factors associated with abdominal pain in CD and evaluate the impact of opioid analgesics on pain and quality-of-life scores in this setting.

METHODS

We performed a longitudinal cohort study using a prospective, consented IBD natural history registry from a single academic center between 2009 and 2013. Consecutive CD patients were followed for at least 1 year after an index visit. Data were abstracted regarding pain experience (from validated surveys), inflammatory activity (using endoscopic/histologic findings), laboratory studies, coexistent psychiatric disorders, medical therapy, opioid analgesic, and tobacco use.

RESULTS

Of 542 CD patients (56.6% women), 232 (42.8%) described abdominal pain. Individuals with pain were more likely to undergo surgery and were more frequently prescribed analgesics and/or antidepressants/anxiolytics. Elevated ESR (OR 1.79; 95%CI 1.11-2.87), coexistent anxiety/depression (OR 1.87; 95%CI 1.13-3.09), smoking (OR 2.08; 95%CI 1.27-3.40), and opioid use (OR 2.46; 95%CI 1.33-4.57) were independently associated with abdominal pain. Eighty patients (14.8%) were prescribed opioids, while 31 began taking them at or after the index visit. Patients started on opioids demonstrated no improvement in abdominal pain or quality-of-life scores on follow-up compared to patients not taking opioids.

CONCLUSIONS

Abdominal pain is common in CD and is associated with significant opioid analgesic utilization and increased incidence of anxiety/depression, smoking, and elevated inflammatory markers. Importantly, opioid use in CD was not associated with improvement in pain or quality-of-life scores. These findings reinforce the limitations of currently available analgesics in IBD and support exploration of alternative therapies.

Primary uterine angiosarcoma with "rhabdoid morphology": A case report

INTRODUCTION

Primary uterine angiosarcoma is a very rare tumour, with only 23 cases described till now. It is a malignant tumour with cells variably recapitulating the morphologic features of an endothelium and expressing immunohistochemical markers of endothelial cells. In general, it is a bulky neoplasm and frequently is at advance stage of disease at presentation. In general, patients with uterine angiosarcoma tend to have a poorer prognosis, mostly related to the aggressive nature and the metastatic potential of these tumours.

CASE REPORT

We report a rare case of primary uterine angiosarcoma with unusual rhabdoid morphology in a 41-year-old female, who underwent radical hysterectomy and died of disease after 4 months of treatment.

DISCUSSION

We described the differential diagnosis of primary angiosarcoma of the uterus that can pose a diagnostic challenge.

Unusual presentation of hydatid cyst - ruptured intraventricular hydatid

Echinococcosis in humans occurs as a result of infection by the larval stages of taenid cestodes of the genus Echinococcus. Most of the intracranial hydatids develop in brain parenchyma. Hydatid cyst within the cerebral ventricle is quite unusual. Literature review showed few case reports of childhood as well as adult intraventricular hydatid cysts. None of these cases presented for the first time with features of ruptured intraventricular cyst. This is a very rare presentation of a common disease. The possibility of infestation with E. granulosus should be included in the differential diagnosis of raised intracranial tension in patients reporting from endemic areas, because the prognosis following surgical intervention is excellent, especially in the pediatric age group.

Robotic assistants in personal care: A scoping review

The aim of this study is to present an overview of the technological advances in the field of robotics developed for assistance with activities of daily living (ADL), and to present areas where further research is required. Four databases were searched for articles presenting either a novel design of one of these personal care robotic system or trial results relating to these systems. Articles presenting nine different robotic personal care systems were examined, six of which had been developed after 2005. These six also all have publications relating to their trials. In the majority of trials, patient independence was improved with operation of the robotic device for a specific subset of ADL. A map of the current state of the field of personal care robotics is presented in this study. Areas requiring further research include improving feedback and awareness, as well as refining control methods and pre-programmed behaviors. Developing an affordable, easy to use system would help fill the current gap in the commercial market.

Modeling the clinical phenotype of BTK inhibition in the mature murine immune system

Inhibitors of Bruton's tyrosine kinase (BTK) possess much promise for the treatment of oncologic and autoimmune indications. However, our current knowledge of the role of BTK in immune competence has been gathered in the context of genetic inactivation of btk in both mice and man. Using the novel BTK inhibitor PF-303, we model the clinical phenotype of BTK inhibition by systematically examining the impact of PF-303 on the mature immune system in mice. We implicate BTK in tonic BCR signaling, demonstrate dependence of the T3 B cell subset and IgM surface expression on BTK activity, and find that B1 cells survive and function independently of BTK. Although BTK inhibition does not impact humoral memory survival, Ag-driven clonal expansion of memory B cells and Ab-secreting cell generation are inhibited. These data define the role of BTK in the mature immune system and mechanistically predict the clinical phenotype of chronic BTK inhibition.

Suppression of autoimmune diabetes by soluble galectin-1

Type 1 diabetes (T1D) is a T cell-mediated autoimmune disease that targets the beta-cells of the pancreas. We investigated the ability of soluble galectin-1 (gal-1), an endogenous lectin that promotes T cell apoptosis, to down-regulate the T cell response that destroys the pancreatic beta-cells. We demonstrated that in nonobese diabetic (NOD) mice, gal-1 therapy reduces significantly the amount of Th1 cells, augments the number of T cells secreting IL-4 or IL-10 specific for islet cell Ag, and causes peripheral deletion of beta-cell-reactive T cells. Administration of gal-1 prevented the onset of hyperglycemia in NOD mice at early and subclinical stages of T1D. Preventive gal-1 therapy shifted the composition of the insulitis into an infiltrate that did not invade the islets and that contained a significantly reduced number of Th1 cells and a higher percentage of CD4(+) T cells with content of IL-4, IL-5, or IL-10. The beneficial effects of gal-1 correlated with the ability of the lectin to trigger apoptosis of the T cell subsets that cause beta-cell damage while sparing naive T cells, Th2 lymphocytes, and regulatory T cells in NOD mice. Importantly, gal-1 reversed beta-cell autoimmunity and hyperglycemia in NOD mice with ongoing T1D. Because gal-1 therapy did not cause major side effects or beta-cell toxicity in NOD mice, the use of gal-1 to control beta-cell autoimmunity represents a novel alternative for treatment of subclinical or ongoing T1D.

Expansion and contraction of HIV-specific CD4 T cells with short bursts of viremia, but physical loss of the majority of these cells with sustained viral replication

Chronic infection with the HIV results in poor HIV-specific CD4 T cell proliferation, but more recent analyses using intracellular cytokine staining demonstrated that IFN-gamma-producing, HIV-specific CD4 T cells can be detected for years in HIV-infected subjects. Because it is not known whether the majority of HIV-specific T cells are lost or become dysfunctional, we examined the kinetics of the T cell response over an extended period of time using a panel of 10 HLA-DR tetramers loaded with HIV p24 peptides. Tetramer+ CD4 T cells were present at a relatively high frequency during acute infection, but the size of these populations substantially contracted following suppression of viral replication. Short-term cessation of antiretroviral therapy resulted in a burst of viral replication and concomitant expansion of tetramer+ CD4 T cells, and these populations again contracted following reinitiation of therapy. The kinetics with which these cell populations contracted were characteristic of effector T cells, a conclusion that was supported by their phenotypic (CCR7-CD45RA-) and functional properties (IFN-gamma+). Continued high-level viremia resulted in the physical loss of the majority of tetramer+ CD4 T cells, and the decline of HIV p24-specific CD4 T cells occurred more rapidly and was more substantial than the reduction of total CD4 T cell numbers. We conclude that the population of HIV p24-specific CD4 T cells is initially responsive to changes in the levels of viral Ags, but that the majority of these cells are lost in a setting of chronic viremia.

Diagnosis of tubular colonic duplication by barium follow-through study

Barium enema studies are considered essential for the diagnosis of tubular colonic duplication with opacification of two colons being the diagnostic sign. Yet in certain cases, barium enema apparently does not show positive findings. A case is reported in which a barium follow-through study established the complete diagnosis of duplication of colon and terminal ileum. The findings were confirmed on laparotomy.

Clinical signs of infection during continuous postoperative epidural analgesia in children: the value of catheter tip culture

BACKGROUND

Infection arising from the use of epidural catheters for postoperative analgesia is a major source of anxiety.

METHODS

The routine culture of epidural catheter tips were studied in 100 consecutive children aged 1 day to 15 years. Epidural catheters were inserted aseptically in accordance with an agreed protocol. The catheter site was inspected regularly and the tip sent for microbiological culture following removal.

RESULTS

Local signs of inflammation at the epidural site were seen in 16% of children, and bacteria were isolated from catheter tip culture in 32%. Positive catheter tip culture was found in 43% of children with local signs of inflammation and of the remaining children with no local signs, organisms were isolated from the catheter tip in 30%. Culture of skin swabs and catheter tips in two patients with purulent discharge at the epidural site yielded the same organism. No correlation between the number of attempts at catheter insertion and either local signs of inflammation or positive catheter tip cultures were found.

CONCLUSIONS

Minor local signs of inflammation and infection are common in pediatric patients during continuous epidural infusion. Epidural catheter tips are also frequently culture positive in patients with and without local signs and who may not go on to develop further signs or symptoms of infection. Routine culture of catheter tips is unnecessary as it is not a good predictor of epidural space infection.

Prevention of type 1 diabetes by gene therapy

The autoimmune disease type 1 diabetes in humans and NOD mice is determined by multiple genetic factors, among the strongest of which is the inheritance of diabetes-permissive MHC class II alleles associated with susceptibility to disease. Here we examined whether expression of MHC class II alleles associated with resistance to disease could be used to prevent the occurrence of diabetes. Expression of diabetes-resistant MHC class II I-Abeta chain molecules in NOD mice following retroviral transduction of autologous bone marrow hematopoietic stem cells prevented the development of autoreactive T cells by intrathymic deletion and protected the mice from the development of insulitis and diabetes. These data suggest that type 1 diabetes could be prevented in individuals expressing MHC alleles associated with susceptibility to disease by restoration of protective MHC class II expression through genetic engineering of hematopoietic stem cells.

Parental opinions regarding the route of administration of analgesic medication in children

Parents were asked about the acceptability of different routes of administration of analgesia for their children. Their opinions were also sought regarding the need for consent and of the sources and quality of information provided to them perioperatively. Questionnaires before and after surgery were administered to 150 consecutively recruited parents. The majority (58%) of parents considered the rectal route to be the most unpleasant way of giving medication, compared to 19% for intramuscular and 11% and 9% for intravenous and oral, respectively. Over 70% thought additional consent, either verbal or written, is not necessary for administering medication by any route. The best information was received verbally in the opinion of 90%. Contrary to expectations, the rectal route was the most unpopular of all in this study. Parents' limited knowledge and experience may be important determining factors. Despite their negative opinions, parents did not consider separate consent necessary for the rectal or any other route.

Soluble fibrin augments platelet/tumor cell adherence in vitro and in vivo, and enhances experimental metastasis

There is considerable evidence for a relationship between hemostasis and malignancy. Since platelet adhesion to tumor cells has been implicated in the metastatic process and plasma levels of fibrinogen (Fg) and soluble fibrin (sFn) monomer are increased in cancer, we hypothesized that these molecules might enhance tumor-platelet interaction. We therefore studied binding of sFn monomer to tumor cells in a static microplate adhesion assay and determined the effect of pre-treating tumor cells with sFn on tumor cell-induced thrombocytopenia and experimental metastasis. Soluble fibrin (produced by adding thrombin to FXIII- and plasminogen-free Fg in the presence of Gly-Pro-Arg-Pro-amide (GPRP-NH2) significantly increased platelet adherence to tumor cells. This effect was primarily mediated by the integrins alphaIIb beta3 on the platelet and CD 54 (ICAM-1) on the tumor cells. Platelets adhered to untreated A375 cells (28 +/- 8 platelets/tumor cell) and this was not significantly affected by pre-treatment of the tumor cells with fibrinogen or GPRP-NH2. Although thrombin treatment increased adherence, pre-incubation of the tumor cells with sFn resulted in a further increase in platelet binding to tumor cells. In contrast to untreated tumor cells, intravenous injection of sFn-treated A 375 cells reduced the platelet count in anticoagulated mice, supporting the in vitro finding that sFn enhanced tumor cell-platelet adherence. In a more aggressive model of experimental metastasis, treating tumor cells with sFn enhanced lung seeding by 65% compared to untreated cells. Extrapolation of our data to the clinical situation suggests that coagulation activation, and subsequent increase in circulating Fn monomer, may enhance platelet adhesion to circulating tumor cells and thereby facilitate metastatic spread.

Effect of diagnostic X-rays on somatic chromosomes of occupationally exposed workers

Investigations were carried out to estimate the level of radiation exposure effect of X-ray machines on 40 male personnel handling diagnostic X-ray machines and compared to 38 matched, unexposed, normal controls. The actual accumulated radiation doses were not disclosed. As compared to controls the exposed persons showed highly significantly increased levels (P < 0.01) of chromosome aberrations (0.68%-2.67%). Frequencies of sister chromatid exchanges (5.80-6.20) and the levels of aneuploidy (2.27-2.37) were also increased a little, but did not show statistically significant effect of exposure. Satellite associations (7.84-16.25) and mitotic index (5.14-6.07) showed a significant increase (P < 0.05) in exposed individuals. The statistically significant increase in the frequencies of chromosomal aberrations and satellite associations in X-ray personnel underscores the need of adopting measures to avoid or at least minimiZe overexposure to X-irradiation.

Foreign body in vagina--an uncommon cause of vaginitis in children

An intravaginal foreign body of long duration can pose diagnostic dilemma in children. We present a case of eight and a half years old girl who was suffering from blood stained vaginal discharge for 3 years for which she was treated by few gynaecologists. A vaginal examination performed under general anaesthesia revealed a foreign body (lead pencil). In cases of pediatric vaginitis one should always look for foreign body in vagina.

Effect of polycyclic aromatic hydrocarbons on somatic chromosomes of coal tar workers

The genotoxic effect of polycyclic aromatic hydrocarbons (PAHs) on somatic human chromosomes obtained from lymphocytes of 49 coal tar workers exposed to 26 micrograms/m3 benzo(a)pyrene, 16 mg/m3 benzene and 0.04 mg/m3 H2S in the ambient air, compared to equal numbers of matched controls breathing air containing 1 microgram/m3 benzo(a)pyrene, 1.5 mg/m3 benzene and 0.02 mg/m3 H2S, was investigated. The mitotic index (MI), chromosome aberrations (CAs), sister chromatid exchanges (SCEs) and satellite associations (SAs) were analysed. All the parameters showed a significant increase (p < 0.01 and 0.05) in the exposed individuals compared with the controls: viz MI, 4.59-7.92; CAs, 0.77-3.0; SCEs, 5.89-6.80; and SAs, 8.18-14.26. The occurrence of the DG type of satellite associations were highest and the 3D type lowest. The frequency of SCEs was highest in coal tar workers with an exposure period of 6-10 years. It is suggested that these results show PAH is genotoxic for humans.

Effect of NOx on the somatic chromosomes of goldsmiths

The genotoxic effect of NOx was investigated on somatic human chromosomes obtained from lymphocytes of 45 goldsmiths exposed to 1770.5 mg/m3 NOx in ambient air at normal temperature and pressure and compared to an equal number of matched controls breathing air containing 50 microgram/m3 NOx. Short-term lymphocyte cultures were set up from blood collected from both exposed and control individuals by venipuncture in heparinized sterile syringes. Mitotic index (MI), chromosome aberrations (CAs), sister chromatid exchanges (SCEs), and satellite associations (SAs) were analyzed. All the parameters showed a significant increase (p<0.01 and p<0.05) in the exposed individuals as compared to the controls: MI (9.57 vs. 5.01), CAs (3. 48 vs. 0.711), SCEs (10.56 vs. 7.02), and SAs (25.97 vs. 12.84), respectively. Occurrence of DG-type SAs (one D-group chromosome and one G-group chromosome) was highest and 3 D-type (three D-group chromosomes) lowest. NOx was thus found to be genotoxic for humans.

Synergy and healing: a perspective on Western health care

There is a crisis in health care resulting from the scarcity of resources and the inequitable distribution of those resources toward those most able to pay. Two paradigms for the generation and distribution of resources are discussed. The scarcity paradigm, in which individuals must compete for scarce resources, dominates Western care and expresses and supports that crisis. The synergy paradigm, in which individuals share resources which are renewable and expanding, is rare in the West but could help alleviate that crisis. Three case studies of synergy in Western health care are presented, illustrating the nature and functioning of "synergistic community". Dilemmas remaining in the introduction and maintenance of synergy within Western care are discussed.