Dual islet transplantation modeling of the instant blood-mediated inflammatory reaction.

Islet xenotransplantation is a potential treatment for diabetes without the limitations of tissue availability. Although successful experimentally, early islet loss remains substantial and attributed to an instant blood-mediated inflammatory reaction (IBMIR). This syndrome of islet destruction has been incompletely defined and characterization in pig-to-primate models has been hampered by logistical and statistical limitations of large animal studies. To further investigate IBMIR, we developed a novel in vivo dual islet transplant model to precisely characterize IBMIR as proof-of-concept that this model can serve to properly control experiments comparing modified xenoislet preparations. WT and α1,3-galactosyltransferase knockout (GTKO) neonatal porcine islets were studied in nonimmunosuppressed rhesus macaques. Inert polyethylene microspheres served as a control for the effects of portal embolization. Digital analysis of immunohistochemistry targeting IBMIR mediators was performed at 1 and 24 h after intraportal islet infusion. Early findings observed in transplanted islets include complement and antibody deposition, and infiltration by neutrophils, macrophages and platelets. Insulin, complement, antibody, neutrophils, macrophages and platelets were similar between GTKO and WT islets, with increasing macrophage infiltration at 24 h in both phenotypes. This model provides an objective and internally controlled study of distinct islet preparations and documents the temporal histology of IBMIR.

Belatacept and sirolimus prolong nonhuman primate islet allograft survival: adverse consequences of concomitant alefacept therapy.

Calcineurin inhibitors (CNI) and steroids are known to promote insulin resistance, and their avoidance after islet transplantation is preferred from a metabolic standpoint. Belatacept, a B7-specific mediator of costimulation blockade (CoB), is clinically indicated as a CNI alternative in renal transplantation, and we have endeavored to develop a clinically translatable, belatacept-based regimen that could obviate the need for both CNIs and steroids. Based on the known synergy between CoB and mTOR inhibition, we studied rhesus monkeys undergoing MHC-mismatched islet allotransplants treated with belatacept and the mTOR inhibitor, sirolimus. To extend prior work on CoB-resistant rejection, some animals also received CD2 blockade with alefacept (LFA3-Ig). Nine rhesus macaques were rendered diabetic with streptozotocin and underwent islet allotransplantation. All received belatacept and sirolimus; six also received alefacept. Belatacept and sirolimus significantly prolonged rejection-free graft survival (median 225 days compared to 8 days in controls receiving basiliximab and sirolimus; p = 0.022). The addition of alefacept provided no additional survival benefit, but was associated with Cytomegalovirus reactivation in four of six animals. No recipients produced donor-specific alloantibodies. The combination of belatacept and sirolimus successfully prevents islet allograft survival in rhesus monkeys, but induction with alefacept provides no survival benefit and increases the risk of viral reactivation.

Nondepleting anti-CD40-based therapy prolongs allograft survival in nonhuman primates.

Costimulation blockade of the CD40/CD154 pathway has been effective at preventing allograft rejection in numerous transplantation models. This strategy has largely depended on mAbs directed against CD154, limiting the potential for translation due to its association with thromboembolic events. Though targeting CD40 as an alternative to CD154 has been successful at preventing allograft rejection in preclinical models, there have been no reports on the effects of CD40-specific agents in human transplant recipients. This delay in clinical translation may in part be explained by the presence of cellular depletion with many CD40-specific mAbs. As such, the optimal biologic properties of CD40-directed immunotherapy remain to be determined. In this report, we have characterized 3A8, a human CD40-specific mAb and evaluated its efficacy in a rhesus macaque model of islet cell transplantation. Despite partially agonistic properties and the inability to block CD40 binding of soluble CD154 (sCD154) in vitro, 3A8-based therapy markedly prolonged islet allograft survival without depleting B cells. Our results indicate that the allograft-protective effects of CD40-directed costimulation blockade do not require sCD154 blockade, complete antagonism or cellular depletion, and serve to support and guide the continued development of CD40-specific agents for clinical translation.

Use of clinical risk factors to identify postmenopausal women with vertebral fractures.

INTRODUCTION AND HYPOTHESIS: Previous studies have been unable to identify risk factors for prevalent vertebral fractures (VF), which are suitable for use in selection strategies intended to target high-risk sub-groups for diagnostic assessment. However, these studies generally consisted of large epidemiology surveys based on questionnaires and were only able to evaluate a limited number of risk factors. Here, we investigated whether a stronger relationship exists with prevalent VF when conventional risk factors are combined with additional information obtained from detailed one-to-one assessment. METHODS: Women aged 65-75 registered at four geographically distinct GP practices were invited to participate (n=1,518), of whom 540 attended for assessment as follows: a questionnaire asking about risk factors for osteoporosis such as height loss compared to age 25 and history of non-vertebral fracture (NVF), the get-up-and-go test, Margolis back pain score, measurement of wall-tragus and rib-pelvis distances, and BMD as measured by the distal forearm BMD. A lateral thoraco-lumbar spine X-ray was obtained, which was subsequently scored for the presence of significant vertebral deformities. RESULTS: Of the 509 subjects who underwent spinal radiographs, 37 (7.3%) were found to have one or more VF. Following logistic regression analysis, the four most predictive clinical risk factors for prevalent VF were: height loss (P=0.006), past NVF (P=0.004), history of back pain (P=0.075) and age (P=0.05). BMD was also significantly associated with prevalent VF (P=0.002), but its inclusion did not affect associations with other variables. Factors elicited from detailed one-to-one assessment were not related to the risk of one or more prevalent VFs. The area under ROC curves derived from these regressions, which suggested that models for prevalent VF had modest predictive accuracy, were as follows: 0.68 (BMD), 0.74 (four clinical risk factors above) and 0.78 (clinical risk factors + BMD). Analyses were repeated in relation to the subgroup of 13 patients with two or more VFs, which revealed that in this instance, the Margolis back pain score and rib-pelvis distance were associated with the presence of multiple VFs (P=0.022 and 0.026, respectively). Moreover, the predictive value as reflected by the ROC curve area was improved: 0.80 (BMD), 0.88 (the four most predictive clinical risk factors consisting of the height loss, past NVF, Margolis back pain score and rib-pelvis distance) and 0.91 (clinical risk factors + BMD). CONCLUSIONS: Evaluation of additional risk factors from detailed one-to-one assessment does not improve the predictive value of risk factors for one or more prevalent vertebral deformities in postmenopausal women. However, the use of factors such as the Margolis back pain score and rib-pelvis distance may be helpful in identifying postmenopausal women at high risk of multiple prevalent VFs.

Factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis: a cross-sectional survey.

OBJECTIVE: To determine the factors associated with adherence and persistence to bisphosphonate therapy in osteoporosis. DESIGN: Cross-sectional survey. SETTING: National survey in the UK. PARTICIPANTS: Participants were recruited through the National Osteoporosis Society and advertisements in the press and on the radio and included 533 women over age 50 with osteoporosis who were currently taking or had taken bisphosphonate therapy within the previous 12 months. MAIN OUTCOME MEASURES: Self-reported factors influencing adherence and persistence to bisphosphonate therapy in osteoporosis: fracture history, pain, practical difficulties taking medication (frequency of dosing, dealing with comedications, impact on daily routine), perceptions of therapy, and concerns about bisphosphonate therapy. RESULTS: Adherence to bisphosphonate therapy was 48% and was associated with previous fracture [odds ratio (OR) 1.62, 95% confidence interval (CI) 1.14-3.02], concerns about medication (OR 1.49, 95% CI 1.01-2.20), and less dissatisfaction with medication (OR 0.65, 95% CI 0.44-0.97). Nonpersistence was associated with dissatisfaction with medication (hazard ratio (HR) 1.83, 95% CI 1.38-2.43), side effects (HR 3.69, 95% CI 2.74-4.97), and concerns about bisphosphonate therapy (HR 2.21, 95% CI 1.48-3.30). For both daily (HR 1.53, 95% CI 1.1-2.33) and weekly bisphosphonates (HR 1.90, 95% CI 1.17-3.07), practical difficulties taking bisphosphonate medication-in particular, too frequent dosing-were associated with nonpersistence. CONCLUSIONS: Self-reported nonadherence to daily and weekly bisphosphonates is independent of the decision to stop taking treatment (nonpersistence). Nonpersistence is associated with side effects and other factors that could be modified in clinical practice through education, information, and concordant partnerships.

Long-term NSAID use in primary care: changes over a decade and NICE risk factors for gastrointestinal adverse events.

OBJECTIVES: To examine prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) in general practice and to compare the results with a 1993 study. To assess numbers at risk of gastrointestinal adverse events using the National Institute for Clinical Excellence (NICE) guidance on the use of cyclo-oxygenase (Cox) II selective drugs. METHODS: Patients currently prescribed a NSAID for 2 months or more were identified from practice records. Demographic information, indications, previous gastrointestinal disease, serious co-morbidity and concomitant prescriptions were recorded. Data were compared with the 1993 survey and the NICE guidance. RESULTS: Seven thousand nine hundred and fifty-eight patients were registered with the practice in 2003. Two hundred and four patients were receiving repeat prescriptions for conventional NSAIDs and 63 for Cox II selective drugs. As in 1993 diclofenac (38%) and ibuprofen (24%) were the commonest individual agents and the main indication was regional pain. Seventy-three per cent of patients prescribed Cox II selective drugs and 64% of patients prescribed conventional NSAIDs had at least one NICE risk factor for gastrointestinal adverse events. Frequency of co-prescription of aspirin or antacids was similar for conventional NSAIDs and Cox II selective drugs, but prescription of antacids was higher with NICE risk factors. CONCLUSION: The indications for NSAIDs have not changed since 1993. Cox II selective drug prescribing was within the NICE guidance but a substantial proportion of patients taking other NSAIDs had risk factors for gastrointestinal adverse events. Discussion with the GPs highlighted the difficulties of balancing perceived risk of gastrointestinal adverse events with cardioprotection and further guidance is urgently needed.

Familial neurofibromatosis microdeletion syndrome complicated by rhabdomyosarcoma.

Neurofibromatosis type 1 with dysmorphism and developmental delay is reported in a mother and two children. The son required treatment for a prostatic rhabdomyosarcoma. His sister has an optic pathway glioma. Fluorescence in situ hybridisation confirmed a submicroscopic deletion at 17q11.2. New evidence suggests an increased malignancy frequency in microdeletion cases.

A fracture risk profile using single-site bone density assessment and clinical risk factors.

The Risk Factor Profile combines single-site bone density assessment and selected clinical risk factors to help estimate the risk of osteoporotic fracture for Caucasian postmenopausal women over the next 5 years. The bone density assessment uses T score cut-off values equivalent to the WHO definitions of osteoporosis and osteopenia at the hip that would identify 16-17% of women over 50 years of age as "high" risk. The clinical risk factors are defined as "major" producing about a doubling of fracture risk independent of bone density, and "minor" where the predictive power is less certain. The indications for a risk factor assessment using the Profile are the same as for any bone density assessment with the exception of monitoring response to treatment. In practice the clinical risk factors can be measured at the time of the bone density estimation taking only a few minutes. The decision to treat, or not to treat, a postmenopausal woman at high or medium risk will ultimately depend on the overall assessment of risks and benefits, costs of treatment and the desires of the patient. The Risk Factor Profile aims to supply the clinician with a simple tool to aid treatment decision-making.

A randomized, double-blind, placebo-controlled trial of sclerosing injections in patients with chronic low back pain.

OBJECTIVE: To determine the clinical efficacy of sclerosing injections in patients with chronic low back pain. METHODS: Randomized, double-blind, placebo-controlled trial of three, once weekly injections of dextrose-glycerine-phenol with lignocaine vs saline plus lignocaine in patients with mechanical back pain of more than 6 months' duration. All patient assessments were performed blind by an experienced physiotherapist. The injections to the ligaments of the L4-5 and L5-S1 lumbar motion segments were given by an orthopaedic physician experienced in the technique, blinded to the nature of the injection solution according to a standard protocol. Demographic and clinical data, the short-form McGill Pain Questionnaire, the modified Somatic Pain Questionnaire, the Zung Depression Inventory, Oswestry Disability Scale and the modified Schober method of measuring spinal flexion were undertaken at 0, 1, 3 and 6 months. RESULTS: Seventy-four patients [mean (S.D.) age 45(11) yr, female:male ratio 1:1, median pain duration >10 yr] were recruited and there were no drop-outs over the study period. There were no statistically significant differences in patient characteristics between the placebo and treatment groups at baseline or for any measure at follow-up. CONCLUSIONS: Three, weekly sclerosant injections alone may not be effective treatment in many patients with undifferentiated chronic back pain. Patient selection and combination with other treatment modalities may be factors in determining treatment success.

Chromosome 22qII deletions. An under-recognised cause of idiopathic learning disability.

BACKGROUND: Velo-cardio-facial syndrome (VCFS), a syndrome of multiple congenital abnormalities including characteristic dysmorphology, congenital heart defects and learning disability, is associated with small interstitial deletions of chromosome 22qII. We tested the hypothesis that VCFS may be significantly under-diagnosed by screening a learning disabled population for chromosome 22qII deletions. METHOD: Two hundred and sixty-five people with learning disability residing in two learning disability hospitals in South Wales were reviewed. They were selected for inclusion in the study if they fulfilled any of the following criteria: psychotic disorder (schizophrenia or affective disorder), family history of psychotic disorder, cleft palate and/or lip, congenital heart disease, broadly defined facial dysmorphism or a history of hypocalcaemia. Fluorescence in situ hybridisation studies were performed on 74 selected individuals. RESULTS: Cytogenetic analysis revealed that two people demonstrated a previously undetected chromosome 22qII deletion. A third person demonstrated a previously undetected cytogenetically visible deletion on chromosome 15. CONCLUSIONS: VCFS appears to be aetiologically significant in a proportion of individuals with idiopathic learning disability, especially in those where psychosis is associated with mild learning disability. We suggest that clinicians should consider a chromosome 22qII deletion in people who meet selection criteria.

Quantitative ultrasound (QUS) of the heel predicts wrist and osteoporosis-related fractures in women age 45-75 years.

This study was designed to determine the ability of quantitative ultrasound (QUS) of the heel to predict fracture risk at different sites in postmenopausal women between the ages of 45 and 75 years. Heel QUS was measured at baseline using a Lunar Achilles scanner, and subsequent fractures were identified over 3 yr. The results were analyzed graphically after age adjustment and using Cox's proportional regression to estimate odds ratios for fracture risk; 3180 women were scanned (79% of sample). Sixty-three wrist, 12 hip, 4 vertebral, 7 proximal humerus, 3 pelvic, and 61 other fractures were identified over a mean followup of 31 mo. There was a fivefold difference in numbers of wrist and osteoporosis-related fractures (hip, vertebra, pelvis, and humerus combined) between the lowest and highest quartiles of QUS results adjusted for age. The odds ratios per 1 SD decline in QUS parameters adjusted for age were: wrist fractures BUA = 1.6, SOS = 1.5, stiffness = 1.8, osteoporosis-related fractures BUA = 1.9, speed of sound (SOS) = 1.6, stiffness = 2.2, and other fractures, BUA = 1.0, SOS = 1.1, stiffness = 1.1. When analyzed for each 10-yr age group, the odds ratios were generally higher in the 56-65 yr group than the other decades. In women between 45 and 75 yr, heel QUS can predict wrist and osteoporosis- related fractures at about the same level that dual-energy X-ray absorptiometry (DXA) of various sites can predict wrist fractures. This extends the current evidence that heel QUS can predict hip fracture risk in women over 75 yr to include other fracture sites in younger women. Heel QUS may be useful in the primary care assessment of osteoporotic fracture risk in women after the menopause.

Isochromosomes of both short and long arms of chromosome 12 resulting in an additional copy of chromosome 12 in a case of splenic lymphoma with villous lymphocytes.

We report a case of splenic lymphoma with villous lymphocytes showing a karyotype with an isochromosome for both the long arm and the short arm of chromosome 12, i(12)(p10) and i(12)(q10), effectively resulting in trisomy 12. This is, apparently, the first documented case of an additional copy of chromosome 12 resulting from isochromosome formation in a neoplastic disorder.

Randomized placebo-controlled trial of brisk walking in the prevention of postmenopausal osteoporosis.

OBJECTIVE: to evaluate the effects of brisk walking on bone mineral density in women who had suffered an upper limb fracture. DESIGN: randomized placebo-controlled trial. Assessments of bone mineral density were made before and at 1 and 2 years after intervention. Standardized and validated measures of physical capacity, self-rated health status and falls were used. SETTING: district general hospital outpatient department. SUBJECTS: 165 women drawn from local accident and emergency departments with a history of fracture of an upper limb in the previous 2 years. Women were randomly allocated to intervention (self-paced brisk walking) or placebo (upper limb exercises) groups. INTERVENTION: both groups were seen at 3-monthly intervals to assess progress, measure physical capacity and maintain enthusiasm. The brisk-walking group were instructed to progressively increase the amount and speed of walking in a manner that suited them. The upper limb exercise placebo group were asked to carry out a series of exercises designed to improve flexibility and fine hand movements, appropriate for a past history of upper limb fracture. RESULTS: drop-outs from both intervention and placebo groups were substantial (41%), although there were no significant differences in bone mineral density, physical capacity or health status between drop-outs and participants. At 2 years, among those completing the trial, bone mineral density at the femoral neck had fallen in the placebo group to a greater extent than in the brisk-walking group [mean net difference between intervention and placebo groups 0.019 g/cm2, 95% confidence interval (CI) -0.0026 to +0.041 g/cm2, P = 0.056]. Lumbar spine bone mineral density had increased to a similar extent (+0.017 g/cm2) in both groups. The cumulative risk of falls was higher in the brisk-walking group (excess risk of 15 per 100 person-years, 95% CI 1.4-29 per 100 person-years, P < 0.05). There were no significant differences in clinical or spinal x-ray fracture risk or self-rated health status between intervention and placebo groups. CONCLUSION: the promotion of exercise through brisk-walking advice given by nursing staff may have a small, but clinically important, impact on bone mineral density but is associated with an increased risk of falls. Self-paced brisk walking is difficult to evaluate in randomized controlled trials because of drop-outs, placebo group exercise, limited compliance and lack of standardization of the duration and intensity of walking. Further work is needed to evaluate the best means of safely achieving increased activity levels in different groups, such as older women and those at high risk of fractures.

Handicap in inflammatory arthritis.

Two instruments measuring handicap were evaluated and compared with clinical, laboratory and disability measures. Participants were 133 patients attending a rheumatology follow-up clinic in a district general hospital, of whom 102 were followed up after 3 months. Measurements included acute-phase response, early morning stiffness, pain, wellbeing, joint involvement (impairments), the Stanford Health Assessment Questionnaire (disability), the Disease Repercussion Profile and the London Handicap Scale (handicap). A substantial burden of disability and handicap was recorded. There were moderate correlations between impairments (0.4 < rho < 0.6), and moderate to strong correlations between disability and handicap measures (0.4 < rho < 0.8). Correlations between impairment and disability/handicap were weak (rho < 0.4). Mean changes in all variables over 3 months were small, and none was statistically significant. A comprehensive description of the impact of disease and treatment requires measurements to be made of impairments, disabilities and handicaps. The use of clinical and laboratory variables alone may be misleading.

Carpal tunnel syndrome: evaluation of a new method of assessing median nerve conduction at the wrist.

OBJECTIVE: To compare median nerve conduction velocity measured using a new, portable electroneurometer with measurements made using conventional hospital nerve conduction apparatus. METHODS: Twenty five patients were studied who were consecutively referred to a hospital neurophysiology department with a clinical diagnosis of carpal tunnel syndrome. Sensory and motor latencies for the median nerve at the wrist were measured bilaterally using the portable electroneurometer and a Medilec MS 92 hospital apparatus operated by a trained technician. RESULTS: There was strong agreement between motor latency values obtained by the two techniques (r = 0.89, p < 0.001; mean difference -0.03 ms, limits of agreement -0.33 to 0.27 ms). Sensory latencies were less easy to detect with the electroneurometer, and correlated less well with the hospital apparatus (r = 0.78, p < 0.001; mean difference -0.16 ms, limits of agreement -0.50 to 0.18 ms). CONCLUSION: The portable electroneurometer provides a convenient, rapid, and inexpensive means of assessing median nerve conduction velocity at the wrist. Measurements of motor latency obtained with this new instrument agree more strongly with those made by conventional apparatus than do measurements of sensory latency. Although the utility of the instrument in clinical practice will be limited, it provides a helpful tool in epidemiological studies of carpal tunnel syndrome.

Quality of life measures.

Quality of life measures have become increasingly popular as outcome measures despite the lack of consensus on a definition of quality of life. This review describes the most frequently used measures, and discusses the conceptual and measurement issues surrounding quality of life measurement. Finally, it tries to place quality of life in the World Health Organization's model of disease impact.