Internet-based randomised controlled trials for the evaluation of complementary and alternative medicines: probiotics in spondyloarthropathy

<b>Background</b> The clinical effectiveness of complementary and alternative medicines (CAMs) is widely debated because of a lack of clinical trials. The internet may provide an effective and economical approach for undertaking randomised controlled trials (RCTs) of low-risk interventions. We investigated whether the internet could be used to perform an internet-based RCT of a CAM fulfilling the revised CONSORT (Consolidated Standards of Reporting Trials) statement quality checklist for reporting of RCTs. A secondary aim was to examine the effect of probiotics compared to placebo in terms of well-being over 12 weeks.<p></p> <b>Methods</b> People aged ≥18 years with confirmed spondyloarthropathy living in the United Kingdom with internet access were invited to participate in an internet-based RCT of probiotic compared to placebo for improving well-being and bowel symptoms. The intervention was a probiotic containing 4 strains of live bacteria or identical placebo taken by mouth daily for 3 months. The primary outcome measure was the performance of the trial according to the revised CONSORT statement.<p></p> <b>Results</b> 147 people were randomised into the trial. The internet-based trial of the CAM fulfilled the revised CONSORT statement such as efficient blinding, allocation concealment, intention to treat analysis and flow of participants through the trial. Recruitment of the required number of participants was completed in 19 months. Sixty-five percent (96/147) completed the entire 3 months of the trial. The trial was low cost and demonstrated that in an intention to treat analysis, probiotics did not improve well-being or bowel symptoms.<p></p> <b>Conclusion</b> The internet-based RCT proved to be a successful and economical method for examining this CAM intervention. Recruitment, adherence and completion rate were all similar to those reported with conventional RCTs but at a fraction of the cost. Internet-based RCTs can fulfil all the criteria of the revised CONSORT statement and are an appropriate method for studying low-risk interventions

BHPR research: qualitative1. Complex reasoning determines patients' perception of outcome following foot surgery in rheumatoid arhtritis

Background: Foot surgery is common in patients with RA but research into surgical outcomes is limited and conceptually flawed as current outcome measures lack face validity: to date no one has asked patients what is important to them. This study aimed to determine which factors are important to patients when evaluating the success of foot surgery in RA Methods: Semi structured interviews of RA patients who had undergone foot surgery were conducted and transcribed verbatim. Thematic analysis of interviews was conducted to explore issues that were important to patients. Results: 11 RA patients (9 ♂, mean age 59, dis dur = 22yrs, mean of 3 yrs post op) with mixed experiences of foot surgery were interviewed. Patients interpreted outcome in respect to a multitude of factors, frequently positive change in one aspect contrasted with negative opinions about another. Overall, four major themes emerged. Function: Functional ability & participation in valued activities were very important to patients. Walking ability was a key concern but patients interpreted levels of activity in light of other aspects of their disease, reflecting on change in functional ability more than overall level. Positive feelings of improved mobility were often moderated by negative self perception ("I mean, I still walk like a waddling duck”). Appearance: Appearance was important to almost all patients but perhaps the most complex theme of all. Physical appearance, foot shape, and footwear were closely interlinked, yet patients saw these as distinct separate concepts. Patients need to legitimize these feelings was clear and they frequently entered into a defensive repertoire ("it's not cosmetic surgery; it's something that's more important than that, you know?”). Clinician opinion: Surgeons' post operative evaluation of the procedure was very influential. The impact of this appraisal continued to affect patients' lasting impression irrespective of how the outcome compared to their initial goals ("when he'd done it ... he said that hasn't worked as good as he'd wanted to ... but the pain has gone”). Pain: Whilst pain was important to almost all patients, it appeared to be less important than the other themes. Pain was predominately raised when it influenced other themes, such as function; many still felt the need to legitimize their foot pain in order for health professionals to take it seriously ("in the end I went to my GP because it had happened a few times and I went to an orthopaedic surgeon who was quite dismissive of it, it was like what are you complaining about”). Conclusions: Patients interpret the outcome of foot surgery using a multitude of interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than other factors in the overall outcome of the surgery. Future research into foot surgery should incorporate the complexity of how patients determine their outcome Disclosure statement: All authors have declared no conflicts of interes

Basic science232. Certolizumab pegol prevents pro-inflammatory alterations in endothelial cell function

Background: Cardiovascular disease is a major comorbidity of rheumatoid arthritis (RA) and a leading cause of death. Chronic systemic inflammation involving tumour necrosis factor alpha (TNF) could contribute to endothelial activation and atherogenesis. A number of anti-TNF therapies are in current use for the treatment of RA, including certolizumab pegol (CZP), (Cimzia ®; UCB, Belgium). Anti-TNF therapy has been associated with reduced clinical cardiovascular disease risk and ameliorated vascular function in RA patients. However, the specific effects of TNF inhibitors on endothelial cell function are largely unknown. Our aim was to investigate the mechanisms underpinning CZP effects on TNF-activated human endothelial cells. Methods: Human aortic endothelial cells (HAoECs) were cultured in vitro and exposed to a) TNF alone, b) TNF plus CZP, or c) neither agent. Microarray analysis was used to examine the transcriptional profile of cells treated for 6 hrs and quantitative polymerase chain reaction (qPCR) analysed gene expression at 1, 3, 6 and 24 hrs. NF-κB localization and IκB degradation were investigated using immunocytochemistry, high content analysis and western blotting. Flow cytometry was conducted to detect microparticle release from HAoECs. Results: Transcriptional profiling revealed that while TNF alone had strong effects on endothelial gene expression, TNF and CZP in combination produced a global gene expression pattern similar to untreated control. The two most highly up-regulated genes in response to TNF treatment were adhesion molecules E-selectin and VCAM-1 (q 0.2 compared to control; p > 0.05 compared to TNF alone). The NF-κB pathway was confirmed as a downstream target of TNF-induced HAoEC activation, via nuclear translocation of NF-κB and degradation of IκB, effects which were abolished by treatment with CZP. In addition, flow cytometry detected an increased production of endothelial microparticles in TNF-activated HAoECs, which was prevented by treatment with CZP. Conclusions: We have found at a cellular level that a clinically available TNF inhibitor, CZP reduces the expression of adhesion molecule expression, and prevents TNF-induced activation of the NF-κB pathway. Furthermore, CZP prevents the production of microparticles by activated endothelial cells. This could be central to the prevention of inflammatory environments underlying these conditions and measurement of microparticles has potential as a novel prognostic marker for future cardiovascular events in this patient group. Disclosure statement: Y.A. received a research grant from UCB. I.B. received a research grant from UCB. S.H. received a research grant from UCB. All other authors have declared no conflicts of interes

Maternal variants in NLRP and other maternal effect proteins are associated with multilocus imprinting disturbance in offspring

Background: Genomic imprinting results from the resistance of germline epigenetic marks to reprogramming in the early embryo for a small number of mammalian genes. Genetic, epigenetic or environmental insults that prevent imprints from evading reprogramming may result in imprinting disorders, which impact growth, development, behaviour and metabolism. We aimed to identify genetic defects causing imprinting disorders, by whole-exome sequencing in families with one or more members affected by multi-locus imprinting disturbance. Methods: Whole-exome sequencing was performed in 38 pedigrees where probands had multi-locus imprinting disturbance, in five of whom, maternal variants in NLRP5 have previously been found. Results: We now report 15 further pedigrees in which offspring had disturbance of imprinting, while their mothers had rare, predicted-deleterious variants in maternal-effect genes, including NLRP2, NLRP7 and PADI6. As well as clinical features of well-recognised imprinting disorders, some offspring had additional features including developmental delay, behavioural problems and discordant monozygotic twinning, while some mothers had reproductive problems including pregnancy loss. Conclusion: The identification of 20 putative maternal-effect variants in 38 families affected by multi-locus imprinting disorders adds to the evidence that maternal genetic factors affect oocyte fitness and thus offspring development. Testing for maternal-effect genetic variants should be considered in families affected by atypical imprinting disorders.<br/

SARS-CoV-2-specific immune responses and clinical outcomes after COVID-19 vaccination in patients with immune-suppressive disease

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immune responses and infection outcomes were evaluated in 2,686 patients with varying immune-suppressive disease states after administration of two Coronavirus Disease 2019 (COVID-19) vaccines. Overall, 255 of 2,204 (12%) patients failed to develop anti-spike antibodies, with an additional 600 of 2,204 (27%) patients generating low levels (&lt;380 AU ml−1). Vaccine failure rates were highest in ANCA-associated vasculitis on rituximab (21/29, 72%), hemodialysis on immunosuppressive therapy (6/30, 20%) and solid organ transplant recipients (20/81, 25% and 141/458, 31%). SARS-CoV-2-specific T cell responses were detected in 513 of 580 (88%) patients, with lower T cell magnitude or proportion in hemodialysis, allogeneic hematopoietic stem cell transplantation and liver transplant recipients (versus healthy controls). Humoral responses against Omicron (BA.1) were reduced, although cross-reactive T cell responses were sustained in all participants for whom these data were available. BNT162b2 was associated with higher antibody but lower cellular responses compared to ChAdOx1 nCoV-19 vaccination. We report 474 SARS-CoV-2 infection episodes, including 48 individuals with hospitalization or death from COVID-19. Decreased magnitude of both the serological and the T cell response was associated with severe COVID-19. Overall, we identified clinical phenotypes that may benefit from targeted COVID-19 therapeutic strategies

Physicochemical Evidence that Francisella FupA and FupB Proteins Are Porins

Responsible for tularemia, Francisella tularensis bacteria are highly infectious Gram-negative, category A bioterrorism agents. The molecular mechanisms for their virulence and resistance to antibiotics remain largely unknown. FupA (Fer Utilization Protein), a protein mediating high-affinity transport of ferrous iron across the outer membrane, is associated with both. Recent studies demonstrated that fupA deletion contributed to lower F. tularensis susceptibility towards fluoroquinolones, by increasing the production of outer membrane vesicles. Although the paralogous FupB protein lacks such activity, iron transport capacity and a role in membrane stability were reported for the FupA/B chimera, a protein found in some F. tularensis strains, including the live vaccine strain (LVS). To investigate the mode of action of these proteins, we purified recombinant FupA, FupB and FupA/B proteins expressed in Escherichia coli and incorporated them into mixed lipid bilayers. We examined the porin-forming activity of the FupA/B proteoliposomes using a fluorescent 8-aminonaphthalene-1,3,6-trisulfonic acid, disodium salt (ANTS) probe. Using electrophysiology on tethered bilayer lipid membranes, we confirmed that the FupA/B fusion protein exhibits pore-forming activity with large ionic conductance, a property shared with both FupA and FupB. This demonstration opens up new avenues for identifying functional genes, and novel therapeutic strategies against F. tularensis infections

Molecular characterization of F.tularensis resistance to fluoroquinolones

Dans des expériences récemment réalisées au laboratoire, des clones de F. tularensis ont été exposés à des concentrations croissantes d’antibiotiques. Au cours de cette expérience d’évolution expérimentale, les bactéries ont acquis un haut niveau de résistance aux FQ. Cette résistance s’est accompagnée de mutations sur la cible des FQ soient les topoisomérases de type II. Le séquençage du génome de ces souches, a montré que l’exposition aux FQ induisait également des mutations du gène fupA. Mon objectif est d’investiguer le rôle potentiel de FupA dans la résistance aux FQ à partir de deux axes : 1- Analyse phénotypique des mutants FupA : Cette analyse se fera via la complémentation des mutants des lignées d’évolution, l’évaluation des CMI et l’étude in vitro de la multiplication intracellulaire. Préalablement, les vecteurs de complémentation nécessaires seront clonés et séquencés. 2- Etude biochimique de la protéine : Cette étude consistera en la purification de la protéine recombinante suivie de la recherche des ligands potentiels. Outre des expériences de pull-down, la protéine sera utilisée pour générer des anticorps. L’étude cristallographique de cette protéine est également envisagée.In recent experiments performed in the lab, F. tularensis strains were exposed to increasing concentrations of antibiotics. During this evolution procedure, bacteria acquired a high-level fluoroquinolone (FQ) resistance. This resistance has been associated with mutations in the FQ target genes encoding DNA gyrase and topoisomerase IV. Interestingly, the sequencing of the genomes of these strains showed that exposure to FQ also induced mutations in the gene encoding the FupA protein. My goal is to investigate the putative role of FupA in FQ resistance, an effect never previously reported. Two main approaches will be carried out. 1- phenotypic analysis of fupA mutants: This analysis will consist in complementation of mutants, evaluation of MIC and in vitro study of intracellular multiplication. Previously, the complementation vectors required will be cloned and sequenced. FQ resistance will also be evaluated on a FupA KO Francisella strain to be constructed. 2- biochemical study of the protein: We will perform cloning and purification of the full-length recombinant protein or truncated forms. Recombinant target will be useful for further identification of potential ligands by pull-down experiments. It will also be used to generate antibodies to check expression of FupA in highly resistant clones as well as for IF or EM localisation of the protein. Crystallographic study of this protein is also envisaged

Recherche d’un nouveau marqueur de résistance aux fluoroquinolones chez F. tularensis

Mémoire de Diplôme d'Etudes Spécialisées (DES) tenant lieu de thèse d'exercice.Francisella tularensis, is a highly infectious Gram negative pathogen, causing the severe disease tularemia. Fluoroquinolones (FQ) represent the best alternative for the oral therapy of this disease. Over the past decade, the overuse of these antibiotics led to an increased prevalence of resistant bacteria and this is a major public-health problem. As a consequence, a better understanding of the mechanisms of FQ resistance and the identification of new targets is of high importance. Previous results obtained in the lab showed that the in vitro exposure of the LVS strain of F. tularensis to FQ generate highly resistant strains, among which 80% are sharing mutations on fupA/B. The aim of my thesis was thus to determine whether the FupA/B protein is involved in FQ resistance. The evaluation of MIC to ciprofloxacin of the evolved FQ-resistant mutants complemented or not with fupA/B confirmed that a FupA/B expression defect was indeed correlated with FQ resistance. These results were confirmed using a LVSΔfupA/B strain constructed in this work. In clinical strains, FupA/B is encoded by two distinct genes, fupA and fupB. The production of a specific antibody targeting FupA allowed to check expression of this protein from clinical isolates. We also looked for mutations within the corresponding gene from DNA extracted from samples of infected patients with treatment failure. To date, our results have not revealed any altered expression of FupA but several perspectives are envisaged including biofilm analyses.Francisella tularensis est une bactérie à Gram négatif, hautement pathogène, responsable de la tularémie, pathologie pour laquelle les fluoroquinolones (FQ) sont prescrites en première intention. L’utilisation excessive de ces antibiotiques est à l’origine d’une augmentation inquiétante de la prévalence des bactéries résistantes. De ce fait, la compréhension des mécanismes d’acquisitions de résistances aux FQ et l’identification de nouvelles cibles est d’un intérêt majeur. Des résultats préliminaires ont montré qu’in vitro, l’exposition aux FQ de la souche LVS de F. tularensis favorisait la génération de souches hautement résistantes dont 80% portent des mutations de fupA/B. L’objectif de mon travail de Thèse d’Exercice a donc été de caractériser le rôle de la protéine codée par ce gène dans la résistance aux FQ. L’évaluation de la CMI à la ciprofloxacine des mutants d’évolution résistants aux FQ complémentés ou non par fupA/B à confirmer qu’un défaut d’expression de FupA/B était associé à la résistance aux FQ. Ces résultats ont été confirmés avec une souche LVSΔfupA/B construite dans ce projet. Dans les souches cliniques, cette protéine est codée par deux gènes distincts, fupA et fupB. La production d’un anticorps spécifique a permis d’analyser l’expression de FupA dans des isolats cliniques. Nous avons également recherché des mutations du gène à partir d’ADN extrait de prélevements de patients infectés en échec thérapeutique. A ce jour, nos résulats n’ont pas révélé d’altération de l’expression de FupA mais un certain nombre de perspectives sont envisagées, dont l’analyse de biofilms

Caractérisation moléculaire de la résistance de F.tularensis aux fluoroquinolones

In recent experiments performed in the lab, F. tularensis strains were exposed to increasing concentrations of antibiotics. During this evolution procedure, bacteria acquired a high-level fluoroquinolone (FQ) resistance. This resistance has been associated with mutations in the FQ target genes encoding DNA gyrase and topoisomerase IV. Interestingly, the sequencing of the genomes of these strains showed that exposure to FQ also induced mutations in the gene encoding the FupA protein. My goal is to investigate the putative role of FupA in FQ resistance, an effect never previously reported. Two main approaches will be carried out. 1- phenotypic analysis of fupA mutants: This analysis will consist in complementation of mutants, evaluation of MIC and in vitro study of intracellular multiplication. Previously, the complementation vectors required will be cloned and sequenced. FQ resistance will also be evaluated on a FupA KO Francisella strain to be constructed. 2- biochemical study of the protein: We will perform cloning and purification of the full-length recombinant protein or truncated forms. Recombinant target will be useful for further identification of potential ligands by pull-down experiments. It will also be used to generate antibodies to check expression of FupA in highly resistant clones as well as for IF or EM localisation of the protein. Crystallographic study of this protein is also envisaged.Dans des expériences récemment réalisées au laboratoire, des clones de F. tularensis ont été exposés à des concentrations croissantes d’antibiotiques. Au cours de cette expérience d’évolution expérimentale, les bactéries ont acquis un haut niveau de résistance aux FQ. Cette résistance s’est accompagnée de mutations sur la cible des FQ soient les topoisomérases de type II. Le séquençage du génome de ces souches, a montré que l’exposition aux FQ induisait également des mutations du gène fupA. Mon objectif est d’investiguer le rôle potentiel de FupA dans la résistance aux FQ à partir de deux axes : 1- Analyse phénotypique des mutants FupA : Cette analyse se fera via la complémentation des mutants des lignées d’évolution, l’évaluation des CMI et l’étude in vitro de la multiplication intracellulaire. Préalablement, les vecteurs de complémentation nécessaires seront clonés et séquencés. 2- Etude biochimique de la protéine : Cette étude consistera en la purification de la protéine recombinante suivie de la recherche des ligands potentiels. Outre des expériences de pull-down, la protéine sera utilisée pour générer des anticorps. L’étude cristallographique de cette protéine est également envisagée

Influence of anesthesia on immune responses and its effect on vaccination in children: review of evidence

Anesthesia and surgery exert immunomodulatory effects and some authors argue that they may exert additive or synergistic influences on vaccine efficacy and safety. Alternatively, inflammatory responses and fever elicited by vaccines may interfere with the postoperative course. There is a lack of consensus approach among anesthesiologists to the theoretical risk of anesthesia and vaccination. Few studies have assessed the influence of anesthesia and surgery on pediatric vaccine responses. We have undertaken an extensive review of articles published in English between 1970 and 2006 meeting the criteria: measurement of immune parameters following general anesthesia in children. By searching the major medical databases (OVID Medline, PubMed, ISI Web of Science) and references cited in the articles themselves, among 277 articles obtained none examined directly the influence of anesthesia/surgery on vaccine responses. Only 16 original reports assessed the influence of several anesthetic agents on various markers of immunity including lymphocyte numbers and functions. These results are reinterpreted here in view of our current understanding of the immune mechanisms underlying vaccine efficacy and adverse events. We conclude that the immunomodulatory influence of anesthesia during elective surgery is both minor and transient (around 48 h) and that the current evidence does not provide any contraindication to the immunization of healthy children scheduled for elective surgery. However, respecting a minimal delay of 2 days (inactivated vaccines) or 14-21 days (live attenuated viral vaccines) between immunization and anesthesia may be useful to avoid the risk of misinterpretation of vaccine-driven adverse events as postoperative complications