Risks associated with oral deferiprone in the treatment of infratentorial superficial siderosis

Objective

Deferiprone is an iron chelator that has recently been used to treat patients with infratentorial superficial siderosis (iSS). It is considered to have a generally favourable safety profile but concerns have been raised due to the risk of agranulocytosis. We aimed to evaluate the safety and tolerability of oral deferiprone as a treatment for patients with iSS.

Methods

We present a case series of 10 consecutive patients presenting with classical iSS treated with deferiprone.

Results

Ten patients were followed up for a mean period of 2.3 years (range 0.5–5.5 years). Four patients (40%) were withdrawn from treatment because of treatment-related side effects. The reasons for treatment discontinuation were neutropenic sepsis (n = 3) and fatigue (n = 1). In 2 out of the 3 cases of neutropenic sepsis, patients initially developed neutropenia without sepsis. The mean time to neutropenic sepsis following deferiprone was 1.2 years (range 0.3–2.5) with mean neutrophil count of 0.4 (range 0.3–0.5). Six patients (60%) reported no change in neurological function while on treatment, and four patients (40%) reported that their condition deteriorated.

Conclusions

Deferiprone was poorly tolerated, with 40% of patients withdrawing from treatment, most commonly due to neutropenic sepsis, after an average of 2 years on treatment. This study increases the number of reported cases of agranulocytosis in patients with iSS treated with deferiprone. Clinicians treating iSS patients with deferiprone should be aware that this drug has a potentially life-threatening side effect of neutropenic sepsis, and should ensure that appropriate haematological monitoring is in place.

Patient blood management: A solution for South Africa

For more than 70 years the default therapy for anaemia and blood loss was mostly transfusion. Accumulating evidence demonstrates a significant dose-dependent relationship between transfusion and adverse outcomes. This and other transfusion-related challenges led the way to a new paradigm. Patient blood management (PBM) is the application of evidence-based practices to optimise patient outcomes by managing and preserving the patient's own blood. 'Real-world' studies have shown that PBM improves patient outcomes and saves money. The prevalence of anaemia in adult South Africans is 31% in females and 17% in males. Improving the management of anaemia will firstly improve public health, secondly relieve the pressure on the blood supply, and thirdly improve the productivity of the nation's workforce. While high-income countries are increasingly implementing PBM, many middle- and low-income countries are still trying to upscale their transfusion services. The implementation of PBM will improve South Africa's health status while saving costs.

Did school characteristics affect the uptake of meningococcal quadrivalent vaccine in Greater Manchester, United Kingdom?

OBJECTIVES

The objective of this study was to assess if school characteristics were associated with the uptake of the meningococcal ACWY (MenACWY) vaccine in Greater Manchester in 2017/18.

STUDY DESIGN

This is an ecological cross-sectional study.

METHODS

We analysed data on all 129 schools in seven local authorities in Greater Manchester from the Department for Education and from local child health information systems to determine whether school characteristics, including school type and Ofsted effectiveness score, were associated with vaccine uptake. Schools with no eligible pupils were excluded. We undertook single-variable and multivariable analysis and considered key interactions.

RESULTS

The overall uptake rate was 80.7%, with a median uptake per school of 80.6% (interquartile range, 69.0%-87.4%). Lower vaccination rates were associated with lower overall effectiveness scores (odds ratio [OR]: 3.54, 95% confidence interval [CI]: 3.00-4.19) and lower numbers of pupils eligible for vaccination (OR: 1.39, 95% CI: 1.28-1.51). Schools with a lower percentage of pupils for whom English is a second language and high deprivation were associated with lower uptake (OR: 1.58, 95% CI: 1.41-1.78). In addition, community schools (the schools with the most local authority oversight) had lower vaccination rates than other categories of schools.

CONCLUSIONS

In this study, uptake rates of the MenACWY vaccine were associated with all five school characteristics considered. Effectiveness scores for schools had the largest association with vaccine uptake, with poorer schools having lower uptake. These characteristics should be used by vaccination providers to prioritise their interventions to increase immunisation rates.

Spores of Bacillus coagulans GBI-30, 6086 show high germination, survival and enzyme activity in a dynamic, computer-controlled in vitro model of the gastrointestinal tract

The aim of this study was to assess the germination, survival and metabolic activity of the probiotic Bacillus coagulans GBI-30, 6086 [GanedenBC³⁰] (BC30) in a dynamic, computer controlled in vitro model of the gastrointestinal (GI) tract, simulating human adults. Experiments were performed in the presence of a meal to maximise germination, due to the presence of germination-triggers. Both an upper GI tract (stomach and small intestine; TIM-1) and a colon model (TIM-2) were used, where material exiting TIM-1 was added to TIM-2. Spores of BC30 were introduced in the gastric compartment of TIM-1 and samples were taken immediately after the pylorus. Moreover, for 6 h, every hour the ileal efflux was collected and a subsample was plated for viable counts (spores and germinated cells). The remainder of the sample was fed to TIM-2, and after 24 h another sample was taken and tested for viable counts. In addition, samples were taken from the dialysates of the model and analysed using LC-MS/MS to determine bacterial metabolites and digestion products. Survival after transit through the gastric compartment was high (97%) and most cells were still in the spore form (76%). Survival after transit through TIM-1 was on average 51%, meaning that on average half of the orally provided spores was found back as cfu on the agar plates. Of these on average 93% were germinated cells and only 7% were spores. 24 h after the start of the experiments germination had increased in TIM-2 to 97% vegetative cells, and only 3% spores. No further loss of viability was observed in TIM-2. In terms of metabolic activity, increased levels of amino acids, dipeptides and citric acid cycle metabolites were found compared to experiments in the absence of BC30. In conclusion, BC30 spores germinate to a large extent (>90%) in the presence of germination triggers in the small intestine in a model that closely mimics the physiological conditions of human adults. Of the oral dose, as much as half of the cells survived transit through the upper GI tract, and based on the metabolite profile, these cells were metabolically active. Either these cells or the enzymes released from the dead cells aided in digestion of the meal. These insights help explain some of the observations in previous experiments, and support the understanding of the mechanism of action of the probiotic BC30.

Bacillus coagulans GBI-30, 6086 increases plant protein digestion in a dynamic, computer-controlled in vitro model of the small intestine (TIM-1)

The aim of this study was to assess the potential of the probiotic Bacillus coagulans GBI-30, 6086 [GanedenBC30] (BC30) to aid in protein digestion of alimentary plant proteins. To test this, three plant proteins, from pea, soy and rice, were digested in a validated in vitro model of the stomach and small intestine (TIM-1) in the absence and in the presence of BC30. Samples were taken from the TIM-1 fractions that mimic uptake of amino acids by the host and analysed for α-amino nitrogen (AAN) and total nitrogen (TN). Both were increased by BC30 for all three plant proteins sources. The ratio of TN/AAN indicated that for pea protein digestion was increased by BC30, but the degree of polymerisation of the liberated small peptides and free amino acids was not changed. For soy and rice, however, BC30 showed a 2-fold reduction in the TN/AAN ratio, indicating that the liberated digestion products formed during digestion in the presence of BC30 were shorter peptides and more free amino acids, than those liberated in the absence of BC30. As BC30 increased protein digestion and uptake in the upper gastrointestinal (GI) tract, it consequently also reduced the amount of protein that would be delivered to the colon, which could there be fermented into toxic metabolites by the gut microbiota. Thus, the enhanced protein digestion by BC30 showed a dual benefit: enhanced amino acid bioavailability from plant proteins in the upper GI tract, and a healthier environment in the colon.

Bone mineral density and microarchitecture in patients with essential thrombocythemia and polycythemia vera

In this cross-sectional study of 45 patients with myeloproliferative neoplasms, we found no evidence of secondary osteoporosis.

INTRODUCTION

Patients with essential thrombocythemia (ET) and polycythaemia vera (PV) are at increased risk of fractures but the underlying mechanisms have not been settled. We conducted a study to assess bone mineral density, microarchitecture, estimated bone strength and global bone turnover in 45 patients with ET or PV.

METHODS

Patients were evaluated in a cross-sectional study with dual energy X-ray absorptiometry (DXA) at the hip and spine; high-resolution peripheral quantitative computed tomography (HR-pQCT) at the distal radius and distal tibia; and biochemical markers of bone turnover including pro-collagen type 1 N-terminal pro-peptide, osteocalcin, C-terminal cross-linking telopeptide of type 1 collagen and bone-specific alkaline phosphatase. Also, 45 healthy comparisons, matched on age, height and weight with each patient were included as control subjects.

RESULTS

Patients and comparisons had almost identical BMDs: 0.96 (IQR: 0.85-1.07) g/cm² and 0.96 g/cm² (IQR: 0.86-1.05 g/cm²), respectively. As well all microarchitecture and estimated bone strength measures were highly similar in the two groups. Levels of bone turnover markers were within reference values in patients.

CONCLUSION

These results reveal no evidence of secondary osteoporosis among patients with ET or PV. The mechanism behind the increased fracture risk in ET or PV patients remains unknown.

Randomized in vivo trial evaluating plaque inhibition benefits of an advanced stannous-containing sodium fluoride dentifrice used in conjunction with power brush technology

OBJECTIVE

To compare the plaque inhibition efficacy of a novel stannous-containing sodium fluoride test dentifrice to a standard anticavity negative control dentifrice, when both were used in conjunction with an advanced oscillating-rotating (O/R) power toothbrush.

METHODS

This was a randomized, two-treatment, three-period, double-blind crossover study conducted in a population using an O/R power brush. Subjects brushed twice per day with their assigned dentifrice during the three-treatment periods, each lasting for 17 consecutive days. Each period was separated by a 4-day washout period during which subjects continued to use their O/R power toothbrush. Plaque levels were assessed and averaged amongst three assessments taken on days 15, 16 and 17 at the end of each treatment period using digital plaque imaging analysis. Assessments were carried out on the facial anterior tooth surfaces in the morning before brushing (A.M. prebrush) following whole-mouth brushing (30 s per quadrant) with the assigned dentifrice (A.M. post-brush) and in the afternoon (P.M.).

RESULTS

Twenty-seven subjects were randomized and completed the study. During the 17-day usage period, the stannous-containing test NaF dentifrice demonstrated a statistically significant lower mean plaque area versus the negative control dentifrice at each assessment timepoint; overnight A.M. prebrush was 33.8% lower (P < 0.0001), A.M. post-brush was 21.8% lower (P < 0.01), and P.M. was 29.2% lower (P < 0.0001).

CONCLUSION

A population of O/R power toothbrush users had significantly less plaque coverage for all three measurements when using a stannous-containing NaF dentifrice than when using a negative control (fluoride) dentifrice.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

An ongoing large outbreak of measles in Merseyside, England, January to June 2012

From 1 January to 30 June 2012, 359 confirmed and 157 probable cases of measles were reported in Merseyside, England. The most affected age groups were children under five years and young adults from 15 years of age. Most cases have been sporadic. There have been few outbreaks in nurseries; however, no outbreaks have been reported in schools. Of the cases eligible for vaccination, only 3% of the confirmed cases were fully immunised.

Randomized digital plaque imaging trial evaluating plaque inhibition efficacy of a novel stabilized stannous fluoride dentifrice compared with an amine fluoride/stannous fluoride dentifrice

OBJECTIVE

To assess the plaque inhibition efficacy ofa novel 0.454% stabilized stannous fluoride test dentifrice (SnF2) to an amine fluoride/stannous fluoride marketed control dentifrice (AmF/SnF2) using digital plaque imaging analysis (DPIA).

METHODS

The 10-week study was a randomized, two-treatment, three-period, double-blind crossover design. Subjects brushed twice daily with their assigned dentifrice (SnF2 or AmF/SnF2) using a standard manual toothbrush during three treatment periods each lasting 17 days, separated by four-day washout periods. DPIA was used to analyze plaque coverage on facial surfaces of the 12 anterior teeth (canine to canine) by three assessments on Days 15, 16, and 17 at the end of each treatment period. Assessments were conducted the morning following no overnight brushing of facial surfaces (A.M. pre-brush), after 40 seconds of full mouth brushing with the assigned dentifrice (A.M. post-brush), and during the afternoon (P.M.).

RESULTS

Twenty-seven subjects were randomized and completed the study. At each assessment time point, plaque levels for the SnF2 dentifrice were statistically significantly lower compared to those for the AmF/SnF2 dentifrice (21.4%, 22.6%, 24.3%, respectively; p < 0.0001 for all).

CONCLUSION

Plaque coverage, as assessed by DPIA, was significantly lower with a novel SnF2 dentifrice than with the AmF/SnF2 dentifrice. The plaque control benefits of the SnF2 dentifrice seen at the morning and afternoon time points indicated significantly better inhibition of plaque re-growth.

Clinical comparison of plaque inhibition effects of a novel stabilized stannous fluoride dentifrice and a chlorhexidine digluconate dentifrice using digital plaque imaging

OBJECTIVE

To compare the plaque inhibition efficacy of a novel 0.454% stannous fluoride (SnF2) test dentifrice with sodium hexametaphosphate and stannous chloride to a chlorhexidine digluconate (0.05%), aluminium lactate (0.8%), and aluminium fluoride marketed control dentifrice (Lacalut Aktiv or AlF3/Chx).

METHODS

This was a randomized, two-treatment, two-period, double-blind crossover study that compared the SnF2 test dentifrice to the AlF3/Chx control dentifrice. Each of the two treatment periods lasted for 17 consecutive days of product use, during which subjects were required to brush twice per day with their assigned dentifrice using a standard manual toothbrush (Oral-B P35 Indicator). The two periods of the crossover were separated by a four-day washout period. Plaque levels on the facial anterior tooth surfaces were evaluated and averaged among three assessment days at the end of each treatment period using digital plaque imaging analysis (DPIA). The evening prior to assessments, subjects only brushed lingual surfaces. Assessment time points were carried out in the morning following no morning brushing (A.M. pre-brush), following 40 seconds of brushing with the assigned dentifrice (A.M. post-brush), and in the afternoon (P.M.). The DPIA captured images were used to calculate and analyze visible plaque coverage.

RESULTS

Twenty-eight subjects were randomized and completed the study. At each assessment time point, the SnF2 test dentifrice demonstrated a statistically significant lower plaque level compared to the AlF3/Chx dentifrice: A.M. mean pre-brush 15.9% lower, p < 0.05; A.M. mean post-brush 22.2% lower, p < 0.05; P.M. mean 24.3% lower, p < 0.005.

CONCLUSION

Compared to the AlF3/Chx control dentifrice, the novel SnF2 test dentifrice significantly inhibited plaque regrowth overnight and during the day. Immediately after brushing there was also significantly less plaque coverage with the SnF2 test dentifrice.

Survival and metabolic activity of the GanedenBC30 strain of Bacillus coagulans in a dynamic in vitro model of the stomach and small intestine

We have investigated the survival and activity of GanedenBC30 during passage through the upper gastro-intestinal tract. GanedenBC30 was tested in a dynamic, validated, in vitro model of the stomach and small intestine (TIM-1) on survival and its potential to aid in digestion of milk protein, lactose and fructose. The survival of GanedenBC30 was high (70%), although germination of the spores was minimal (<10%) under the conditions tested. Survival of the strain in the presence of lactose and fructose was markedly lower (56-59%) than in the absence of the sugars. The amount of digested milk protein available for absorption was somewhat higher (+0.2 g) when GanedenBC30 was added to the milk. When GanedenBC30 was tested with lactose or fructose added to the meal, the cumulative amount of lactate produced was slightly higher (+0.12-0.18 mmol) compared to the GanedenBC30 alone. In conclusion, although the differences in survival of GanedenBC30 are small, these results show the potential of GanedenBC30 to aid in protein digestion and in the digestion of lactose and fructose. If a larger fraction of the Bacillus coagulans cells had germinated, the influence on protein and carbohydrate digestion would probably have been much greater. Importance of the findings: the potential of GanedenBC30 to aid in the digestion of lactose and fructose could be used to prevent occurrence of intestinal symptoms in individuals sensitive to these carbohydrates.

Patient blood management - a new paradigm for transfusion medicine?

The saving of many lives in history has been duly credited to blood transfusions. What is frequently overlooked is the fact that, in light of a wealth of evidence as well as other management options, a therapy deemed suitable yesterday may no longer be the first choice today. Use of blood has not been based upon scientific evaluation of benefits, but mostly on anecdotal experience and a variety of factors are challenging current practice. Blood is a precious resource with an ever limiting supply due to the aging population. Costs have also continually increased due to advances (and complexities) in collection, testing, processing and administration of transfusion, which could make up 5% of the total health service budget. Risks of transfusions remain a major concern, with advances in blood screening and processing shifting the profile from infectious to non‐infectious risks. Most worrying though, is the accumulating literature demonstrating a strong (often dose‐dependent) association between transfusion and adverse outcomes. These include increased length of stay, postoperative infection, morbidity and mortality. To this end, a recent international consensus conference on transfusion outcomes (ICCTO) concluded that there was little evidence to corroborate that blood would improve patients’ outcomes in the vast majority of clinical scenarios in which transfusions are currently routinely considered; more appropriate clinical management options should be adopted and transfusion avoided wherever possible. On the other hand, there are patients for whom the perceived benefits of transfusion are likely to outweigh the potential risks. Consensus guidelines for blood component therapy have been developed to assist clinicians in identifying these patients and most of these guidelines have long advocated more conservative ‘triggers’ for transfusion. However, significant variation in practice and inappropriate transfusions are still prevalent. The ‘blood must always be good philosophy’ continues to permeate clinical practice. An alternative approach, however, is being adopted in an increasing number of centres. Experience in managing Jehovah’s Witness patients has shown that complex care without transfusion is possible and results are comparable with, if not better than those of transfused patients. These experiences and rising awareness of downsides of transfusion helped create what has become known as ‘patient blood management’. Principles of this approach include optimizing erythropoiesis, reducing surgical blood loss and harnessing the patient’s physiological tolerance of anaemia. Treatment is tailored to the individual patient, using a multidisciplinary team approach and employing a combination of modalities. Results have demonstrated reduction of transfusion, improved patient outcomes and patient satisfaction. Significant healthcare cost savings have also followed. Despite the success of patient blood management programmes and calls for practice change, the potential and actual harm to patients caused through inappropriate transfusion is still not sufficiently tangible for the public and many clinicians. This has to change. The medical, ethical, legal and economic evidence cannot be ignored. Patient blood management needs to be implemented as the standard of care for all patients.

International community health networking project: two year follow-up of graduates

AIM

This paper presents the perceptions of graduates 2 years post-exchange in a USA-European Union funded programme. The primary goal of this 8-week exchange programme was to increase cultural knowledge and sensitivity by teaching a common module of community health assessment and planning to multi-national groups of undergraduate students in four countries.

BACKGROUND

Cultural diversity and globalization are among the factors that encourage faculty in nursing to develop programmes of international exchange for students. The challenge is to combine the exchange with the teaching of other courses required by the home institution during the same semester.

METHODS

Twenty-one graduates of participating USA schools responded to an open-ended interview by telephone or email 2 years after graduation. Bennett's continuum (1993) of intercultural sensitivity was used to assess cultural development.

FINDINGS

Graduates overwhelmingly supported international education and described its continued impact personally and professionally. Gains in cultural sensitivity were perceived as the greatest benefit and influence on their practice. The majority of graduates were believed to be in Bennett's ethnorelative categories of acceptance and adaptation. The depth and breadth of previous cultural experiences, specific host and home schools, and previous travel were found to be related to development on the intercultural sensitivity continuum.

DISCUSSION

Most important are the findings from this evaluation that provide insight into the factors enhancing growth of intercultural sensitivity. Previous travel, characteristics of the home and host institutions, and the opportunity and willingness to be a cultural outsider were important influences.

Herpes simplex encephalitis: an audit of the use of laboratory diagnostic tests

BACKGROUND

The combination of both PCR and intrathecal antibody studies is recommended to confirm or refute the diagnosis of herpes simplex encephalitis (HSE).

AIM

To investigate the pattern of use of laboratory tests in the diagnosis of suspected cases of HSE, and to determine the final diagnosis in cases proven not to be HSE.

DESIGN

Structured audit.

METHODS

We reviewed the case-notes of all patients who, over a five-year time period, presented with suspected encephalitis; and/or were prescribed aciclovir. Clinical and laboratory criteria were used to categorize the likelihood of HSE.

RESULTS

We identified 222 patients: 10 (5%) had definite HSE, 24 (10%) possible HSE, and 144 (65%) a definite alternative diagnosis. In 44 (20%), no final diagnosis was made, but the diagnosis of HSE was excluded. PCR was performed in 68 (31%), intrathecal antibody studies in 24 (11%), and brain biopsy in 17 (8%). A wide range of diseases mimicked HSE, but most common were inflammatory diseases and other infections of the central nervous system.

DISCUSSION

Laboratory tests, particularly intrathecal antibody assays, are under-used in the diagnosis of HSE. Although early empirical treatment of suspected HSE is essential, confirmation or exclusion of the diagnosis is equally important to avoid overlooking alternative diagnoses. Identification of the aetiology of encephalitis is of particular importance, given the current concerns of emerging infections and bioterrorism.

Intrinsic AHR in IL-5 transgenic mice is dependent on CD4(+) cells and CD49d-mediated signaling

Overexpression of interleukin (IL)-5 by the airway epithelium in mice using the rat CC10 promoter (NJ.1726 line) leads to several histopathologies characteristic of human asthma, including airway hyperreactivity (AHR). We investigated the contribution of B and T cells, as well as CD4 expression, to the development of AHR in IL-5 transgenic mice. NJ.1726 mice on a T cell or CD4 knockout background, but not on a B cell knockout background, lost intrinsic AHR. These effects occurred without decreases in IL-5 or eosinophils. We further investigated the contribution of alpha(4)-integrin signaling to the development of AHR in IL-5 transgenic mice through the administration of anti-CD49d (alpha(4)-integrin) antibody (PS/2). Administration of PS/2 resulted in immediate (16-h) inhibition of AHR. The inhibition of AHR was not associated with a decrease in airway eosinophils. These studies demonstrate that, despite the presence of increased levels of IL-5 and eosinophils in the lungs of NJ.1726 mice, CD4(+) cells and alpha(4)-integrin signaling are necessary for the intrinsic AHR that develops in IL-5 transgenic mice.

Traumatic stress and ways of coping of community residents exposed to a train disaster

OBJECTIVES

The aims of this study were to examine the degree of traumatic stress and the coping strategies employed by community residents who lived on both sides of a rail track where a train collision occurred in 1996 in Stafford, UK. The hypothesis was that there would be a high level of traumatic stress and that emotion-focused coping would be the predictor to distress.

METHOD

This was a cross-sectional survey with a retrospective design in which 66 community residents, who lived between 30 and 100 feet away from the crash site, were interviewed. The study began approximately 7 months after the disaster. The Impact of Event Scale (IES), the General Health Questionnaire (GHQ-28) and the Ways of Coping Checklists (WOC) were administered to the residents.

RESULTS

On the whole, the results did not entirely support the hypothesis. The residents were found to have experienced some intrusive thoughts and avoidance behaviour but their mean scores were significantly lower than those of standardized samples. Thirty-five per cent scored at 4 or above on the GHQ-28. Traumatic stress was predicted by both emotion-focused and problem-focused coping strategies.

CONCLUSION

Although community residents were not on the train or related to the dead or injured in any way, they could, after being exposed to a train disaster, manifest traumatic stress symptoms which had long-lasting effects. Such traumatic stress was found to be associated with coping strategies of community residents characterized by their efforts to manage or alter the source of stress, and by their efforts to regulate stressful emotions.

Effect of oral Bacillus coagulans administration on the density of vancomycin-resistant enterococci in the stool of colonized mice

AIMS

A mouse model of vancomycin-resistant enterococcus (VRE) stool colonization was used to study the effect of Bacillus coagulans, a biotherapeutic agent, on the density of colonization.

METHODS AND RESULTS

VRE-colonized mice received orally administered B. coagulans (107 cfu) or saline daily for four days. For one VRE strain, the density of VRE at one and four days after treatment was 1.4 log10cfu x g(-1) lower in experimental vs. control mice (P=0.03), and 35% of experimental vs. 0% of control mice had no detectable VRE four days after treatment (P=0.03). For two additional strains, there was no statistically significant reduction of VRE density in the B. coagulans groups.

CONCLUSION

B. coagulans therapy reduced the density of colonization for one of three VRE strains tested.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study suggests a potential role for biotherapeutic agents as a means to reduce the density of VRE intestinal colonization.

Blockade of CD49d inhibits allergic airway pathologies independent of effects on leukocyte recruitment

Lymphocyte and/or eosinophil recruitment is dependent on the sequential interactions between adhesion molecules expressed on activated endothelial cells and both leukocyte subtypes. Endothelial P- and E-selectins mediate tethering and rolling of leukocytes through interactions with P-selectin glycoprotein ligand-1 (PSGL-1), and diapedesis subsequently occurs by engagement of endothelial vascular cell adhesion molecule-1 and CD49d (alpha(4)-integrins). The anti-inflammatory potential of interfering with these adhesive interactions was assessed with an ovalbumin challenge mouse model of asthma. Administration of a soluble form of PSGL-1 reduced eosinophils (80%) and lymphocytes (50%) in bronchoalveolar lavage fluid without affecting epithelial changes or airway hyperreactivity (AHR). In contrast, although administration of anti-CD49d monoclonal antibodies (PS/2) resulted in similar reductions in eosinophils (75%) and lymphocytes (50%), PS/2 reduced and abolished mucous cell metaplasia and AHR, respectively. Administration of both PSGL-1 and PS/2 had the additive effect of eliminating eosinophils from the airways (96% decrease), with few or no additional reductions (relative to PS/2 administration alone) in lymphocyte recruitment, mucous cell metaplasia, or AHR. These data show that eosinophils and lymphocytes differentially utilize adhesive interactions during recruitment and that the inhibition of AHR is independent of this recruitment.

Interactions of bacterial cationic peptide antibiotics with outer and cytoplasmic membranes of Pseudomonas aeruginosa

Polymyxins B and E1 and gramicidin S are bacterium-derived cationic antimicrobial peptides. The polymyxins were more potent than gramicidin S against Pseudomonas aeruginosa, with MICs of 0.125 to 0. 25 and 8 microg/ml, respectively. These peptides differed in their affinities for binding to lipopolysaccharide, but all were able to permeabilize the outer membrane of wild-type P. aeruginosa PAO1 strain H103, suggesting differences in their mechanisms of self-promoted uptake. Gramicidin S caused rapid depolarization of the bacterial cytoplasmic membrane at concentrations at which no killing was observed within 30 min, whereas, conversely, the concentrations of the polymyxins that resulted in rapid killing resulted in minimal depolarization. These data indicate that the depolarization of the cytoplasmic membrane by these peptides did not correlate with bacterial cell lethality.

The effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in multiple sclerosis

We investigated the effect of oral and intravenous methylprednisolone treatment on subsequent relapse rate in patients with multiple sclerosis. Following a double blind trial designed to compare the effect of oral and intravenous methylprednisolone treatment on promoting recovery from acute relapses of multiple sclerosis, 80 patients were followed for two years with six-monthly assessments during which all subsequent relapses were recorded. The annual relapse rate was slightly higher in the oral compared with the intravenous methylprednisolone-treated patients (1.06 vs. 0.78), but the adjusted difference between the two groups was not statistically significant (0.18; 95% CI -0.19 to 0.55, P=0.3). The time to onset and the severity of the first relapse after treatment, the number of relapse free patients at the end of the follow-up period, and the severity of the relapses during the follow-up period were similar in the two groups. This trial did not show a statistically significant difference in relapse rate during the first two years following oral compared with intravenous methylprednisolone treatment.

Fast eye movement initiation of ocular torsion in mesodiencephalic lesions

Three patients with episodic ocular torsion and skew deviation due to mesodiencephalic lesions were studied by using binocular three-dimensional scleral search coils. The conjugate ocular torsion (upper pole of each eye rotating toward the side of the brainstem lesion) was initiated by a torsional fast eye movement. During prolonged episodes, torsional nystagmus was also present. Cessation of the ocular torsion and skew deviation occurred by slow eye movements with exponentially decreasing velocities in 2 patients, and by multiple fast torsional movements in 1 patient. In 1 patient, the abnormal eye movements were temporally linked to dystonic movements in the limbs on the side opposite the brainstem lesion. The occurrence of skew deviation with conjugate ocular torsion in brainstem lesions has been attributed to functional asymmetry in vestibular pathways responsible for the slow-phase compensatory eye movement response to roll. In comparison, the findings in our patients show that in mesodiencephalic lesions conjugate ocular torsion with skew deviation may be generated by torsional fast eye movements, indicating activation of the burst cells of the rostral interstitial nucleus of the medial longitudinal fasciculus.

Randomised trial of oral and intravenous methylprednisolone in acute relapses of multiple sclerosis

BACKGROUND

An intravenous rather than oral course of methylprednisolone is often prescribed for treating acute relapses in multiple sclerosis (MS) despite the lack of evidence to support this route of administration. Our double-blind placebo-controlled randomised trial was designed to compare the efficacy of commonly used intravenous and oral steroid regimens in promoting recovery from acute relapses in MS.

METHODS

42 patients with clinically definite relapse in MS received oral, and 38 intravenous, methylprednisolone. Clinical measurements at entry and at 1 week, 4 weeks, 12 weeks, and 24 weeks included Kurtzke's expanded disability status scale (EDSS), Hauser's Ambulatory Index, and an arm-function index. The primary outcome criterion was a difference between the two treatment groups of one or more EDSS grades at 4 weeks.

FINDINGS

There were no significant differences between the two groups at any stage of the study in any measurement taken: the mean difference in EDSS at 4 weeks (adjusted for baseline level) was 0.07 grades more in those taking oral steroids (95% CI -0.46 to 0.60). The most optimistic outcome for intravenous therapy is an average benefit of less than half a grade improvement on EDSS over oral treatment.

INTERPRETATION

Since our study did not show any clear advantage of the intravenous regime we conclude that it is preferable to prescribe oral rather than intravenous steroids for acute relapses in MS for reasons of patient convenience, safety, and cost.

Purification and partial characterization of the OmpA family of proteins of Pasteurella haemolytica

This study was conducted to partially characterize and identify the purity of two major outer membrane proteins (OMPs) (with molecular weights of 32,000 and 35,000 [32K and 35K, respectively]) of Pasteurella haemolytica. The 35K and 32K major OMPs, designated Pasteurella outer membrane proteins A and B (PomA and PomB, respectively), were extracted from P. haemolytica by solubilization in N-octyl polyoxyl ethylene. The P. haemolytica strain used was a mutant serotype A1 from which the genes expressing the 30-kDa lipoproteins had been deleted. PomA and PomB were separated and partially purified by anion-exchange chromatography. PomA but not PomB was heat modifiable. The N-terminal amino acid sequences of the two proteins were determined and compared with reported sequences of other known proteins. PomA had significant N-terminal sequence homology with the OmpA protein of Escherichia coli and related proteins from other gram-negative bacteria. Moreover, polyclonal antiserum raised against the E. coli OmpA protein reacted with this protein. PomA was surface exposed, was conserved among P. haemolytica biotype A serotypes, and had porin activity in planar bilayers. No homology between the N-terminal amino acid sequence of PomB and those of other known bacterial proteins was found. Cattle vaccinated with live P. haemolytica developed a significant increase in serum antibodies to partially purified PomA, as shown by enzyme-linked immunosorbent assays, and to purified PomA and PomB, as detected on Western blots and by densitometry.

Contribution of host-derived growth factors to in vivo growth of a transplantable murine mammary carcinoma

The contribution of host-derived growth factors to tumour growth in vivo was studied using the transplantable murine mammary carcinoma, MT1, grown in syngeneic mice. Promotion of growth of the mammary carcinoma by a factor(s) from the host was evident in experiments in which the carcinoma cells were inoculated intraperitoneally. In this environment, tumours develop as multiple solid nodules, each probably arising from an individual cell or a small cluster of cells. Tumour growth was found to occur in the peritoneal cavity following inoculation of 10(3) cells, but an inoculum of as few as ten cells grew if a leucocyte-rich exudate had first been induced. To determine which host-derived growth factors might contribute to growth of MT1, extracts of the tumour were first examined for growth factor activity. Fractionation of tumour extracts by either ion-exchange chromatography or gel filtration revealed several peaks of mitogenic activity, but none of this could be attributed to epidermal growth factor (EGF). Accordingly, an anti-EGF antibody was tested as a putative inhibitor of tumour growth as any effect of this antibody could be ascribed to removal of EGF derived from the host. The antibody was found to have potent anti-tumour activity when tested against MT1 tumours that had been inoculated into the peritoneal cavity. In contrast, the antibody had little effect on growth of the discrete tumour mass which formed when MT1 was transplanted subcutaneously. The results suggest that host-derived EGF contributes to establishment of microcolonies of MT1 carcinoma within the peritoneal cavity. This may be directly, by providing growth factors to supplement those produced by the tumour until it reaches a certain critical mass to sustain autocrine growth, or indirectly, by affecting the production of other growth-stimulatory factors or cytokines.

Antimicrobial constituents of Rhus glabra

The antimicrobial activity of the methanol extract and isolated constituents of Rhus glabra (Anacardiaceae), a species used in folk medicine by North American native people, was evaluated against 11 microorganisms, including gram-positive and gram-negative bacteria. The extract was subsequently fractionated and monitored by bioassays leading to the isolation of three antibacterial compounds, the methyl ester of 3,4,5-trihydroxybenzoic acid (methyl gallate) (minimal inhibition concentration (MIC) 12.5 micrograms/ml), 4-methoxy-3,5-dihydroxybenzoic acid (MIC 25 micrograms/ml) and gallic acid (MIC > 1000 micrograms/ml). The first two compounds are reported here for the first time from Rhus glabra. Their structures were established using spectroscopic and chemical methods.

Synthesis of bulky beta-lactams for inhibition of cell surface beta-lactamase activity

Procedures are described for the preparation of a series of compounds consisting of methicillin linked to beta-cyclodextrin through variable hydrophilic linkers. beta-Cyclodextrin was coupled to the antibiotic methicillin to prevent the antibiotic from permeating the outer membranes of bacteria. Stoichiometric oxidation of the beta-cyclodextrin with sodium metaperiodate provided a functional group for coupling to the linker. Methicillin was coupled to the linker via its carboxyl group. These compounds were tested for activity toward purified beta-lactamase. The length of the spacer arm between beta-cyclodextrin and methicillin was crucial in binding beta-lactamase and inhibiting activity. Compounds with longer spacers were effective inhibitors of beta-lactamase. We have deduced that the length of the spacer should be greater than 16 A for optimum inhibition of beta-lactamase.

Cellular localization and hormonal regulation of pancreatic intrinsic factor secretion in dogs

Gastric mucosal cells are considered to be the principal site of intrinsic factor (IF) production in most mammals. Recent observations in dogs suggest that the pancreas is the major site of IF production in this species. The present study was undertaken to determine the cellular origins of canine pancreatic IF by combining in situ hybridization with immunocytochemistry and to examine the potential role of physiological pancreatic secretagogues, cholecystokinin octapeptide (CCK-8) and secretin, as mediators of canine pancreatic IF secretion. A human IF cDNA probe (J. Hewitt et al., Genomics 10: 432-440, 1991), validated for use in the dog, identified IF mRNA in parietal cells in the gastric fundus, gastric gland cells in the pyloric antrum, and in secretory duct cells of the pancreas. Immunocytochemistry using antibody against rat IF confirmed that these cells, as well as secretory ducts of salivary glands, synthesized an immunoreactive protein. In stimulated secretions of anesthetized dogs, mean 45-min outputs of IF, haptocorrin, and trypsinogen were 13-, 8-, and 16-fold greater during stimulation with CCK-8 than with secretin. No synergistic effects of combined stimulation were observed for IF or haptocorrin, although a synergistic effect was observed for trypsinogen. These findings demonstrate that IF is synthesized in the canine stomach, pancreas, and probably salivary glands and that CCK-8 mediates IF secretion from pancreatic duct cells.

Dopamine D2 receptor gene Taq I 'A' locus map including 'A4' variant: relevance for alcoholism and drug abuse

The D2 dopamine receptor gene (DRD2) displays Taq I restriction fragment length polymorphisms (RFLPs) at two different loci, termed A and B. One of the three different Taq I A 'alleles' described at this site, the A1 allele (size = 6.6 kb), has been found to be associated with alcoholism and with drug abuse in the majority of studies reported to date. A complete map of the Taq I A RFLP site has been constructed, through hybridization with different fragments of the 3' flanking region and polymerase chain reaction (PCR). When screening 432 unrelated individuals to establish possible A1 allelic association with drug abuse or dependence, we have encountered a novel Taq I A RFLP, which we have named 'A4' (size = 8.6 kb). This sequence variant displays a frequency of approximately 1% in our sample and shows a Mendelizing genetic pattern in an Italian nuclear family. Primers suitable for detecting A4 using PCR have been designed. The A4, but not the A3 'allele', displays substantial overlap with the A1. In particular, A2 and A3 share the presence of a Taq I restriction site, whose absence in A1 and A4 is apparently associated with substance abuse vulnerability. Therefore, in association studies it is proper to contrast individuals displaying A1 and A4 RFLP patterns, with individuals displaying A2 and A3 RFLPs.

Switching from differentiation to growth in hepatocytes: control by extracellular matrix

Studies were carried out to analyze how different extracellular matrix (ECM) molecules regulate hepatocyte growth and differentiation. Freshly isolated rat hepatocytes were cultured on non-adhesive plastic dishes that were pre-coated with defined densities of either laminin, fibronectin, type I collagen, or type IV collagen. Sparse cell plating densities were used to minimize cell-cell contact formation and all studies were carried out in chemically defined medium that contained a saturating amount of soluble growth factors. Dishes coated with a low ECM density (1 ng/cm2) supported hepatocyte attachment, but did not promote cell spreading or growth. Computerized image analysis confirmed that over 80% of cells remained free of contact with other cells under these conditions. Yet, these round cells maintained high levels of albumin gene expression as well as elevated secretion rates for multiple liver-specific proteins (albumin, transferrin, and fibrinogen), regardless of the type of ECM molecule used for cell attachment. When ECM coating densities were raised from 1 to 1,000 ng/cm2, cell spreading, expression of histone mRNA, DNA synthesis, and cell proliferation all increased in parallel. Activation of growth by high ECM densities was also accompanied by a concomitant down-regulation of differentiated functions and again, dishes coated with all four types of ECM molecules produced similar effects. Thus, the ability to switch hepatocytes from differentiation to growth (i.e., between different genetic programs) is not limited to a single ECM molecule, a distinct three dimensional ECM geometry, or due to alteration of cell-cell interactions. Rather, the regulatory signals conveyed by immobilized ECM molecules depend on the density at which they are presented and thus, on their ability to either prohibit or support cell spreading.