Physical and Psychosocial Factors in the Prevention of Chronic Pain in Older Age

Chronic pain is recognized as a major challenge as people age. Yet, despite growing research on chronic pain management, there is little research into chronic pain prevention. Thus there is a clear need to identify multimodal activities that could be encouraged among older adults as part of a healthy lifestyle to decrease the incidence risk of chronic pain. Using data from the English Longitudinal Study of Ageing we tracked 2,631 adults aged ≥50 years who were free from chronic pain at baseline across a decade and explore whether physical or psychosocial factors reduced the risk of developing chronic pain. In relation to physical factors, engaging in vigorous weekly activity was protective against the development of chronic pain (odds ratio 0.74, standard error 0.07, 95% confidence interval 0.62–0.89) when controlling for all identified socioeconomic, health, and social confounders. However, no effects were found for moderate weekly activity. In relation to psychosocial factors, cultural engagement was also protective against the development of chronic pain (odds ratio 0.75, standard error 0.07, 95% confidence interval 0.63–0.91), but community group participation was not. These findings extend previous work showing that physical activity and psychosocial factors such as positive affect are key factors in the long-term success of chronic pain self-management. Future interventional studies for chronic pain are encouraged.

Ruxolitinib in Aicardi-Goutières syndrome

Metabolic Brain Disease - Aicardi-Goutières Syndrome (AGS) is a monogenic leukodystrophy with pediatric onset, clinically characterized by a variable degree of neurologic impairment. It...     

Granulomatous hepatitis associated with glyburide

Summary A wide variety of diseases and injuries can cause granulomatous hepatitis, and drug-induced granulomatous hepatitis is a well-described entity. Sulfonylurea derivatives, which are commonly used oral hypoglycemic agents in the treatment of non-insulin-dependent diabetes mellitus, have been implicated in liver disease. However, glyburide, a second-generation sulfonylurea and a potent hypoglycemic drug, is considered to have less hepatic side effects than chlorpropamide. It has been reportedly associated with cholestatic jaundice and hepatitis and with hypersensitivity angiitis. A case of necrotizing granuloma has been reported. We present a second case of granulomatous hepatitis occurring in a patient who had been taking glyburide for approximately three years, and we review the literature for glyburide-associated hepatitis.     

Comparison of inflammatory cytokine profiles in plasma of patients undergoing otorhinological surgery with propofol or isoflurane anesthesia

Objective and design

The effects of anesthetics on cytokine release in patients without comorbidities who undergo minor surgery are not well defined. We compared inflammatory cytokine profiles in adult patients undergoing minimally invasive surgery who received isoflurane or propofol anesthesia.

Methods

Thirty-four patients without comorbidities undergoing minor surgery were randomly assigned to receive an inhaled anesthetic (isoflurane; n = 16) or an intravenous anesthetic (propofol; n = 18). Blood samples were drawn before premedication and anesthesia (T1), 120 min after anesthesia induction (T2), and on the first post-operative day (T3). Plasma concentrations of interleukins (IL-) 1β, 6, 8, 10 and 12 and tumor necrosis factor (TNF)-α were measured using flow cytometry.

Results

The pro-inflammatory cytokine IL-6 was increased in the isoflurane group at T2 and T3 compared to T1 (P < 0.01). In the propofol group, IL-6 and IL-8 were significantly increased at T3 compared to T1. However, there were no significant differences in cytokine concentrations between the isoflurane and propofol groups.

Conclusion

An inflammatory response occurred earlier in patients who received an inhaled agent compared with an intravenous anesthetic, but no differences in plasma cytokine profiles were evident between isoflurane and propofol anesthesia in patients without comorbidities undergoing minimally invasive surgeries.     

An intracellular nanobody targeting T4SS effector inhibits Ehrlichia infection

Infection with obligatory intracellular bacteria is difficult to treat, as intracellular targets and delivery methods of therapeutics are not well known. Ehrlichia translocated factor-1 (Etf-1), a type IV secretion system (T4SS) effector, is a primary virulence factor for an obligatory intracellular bacterium, Ehrlichia chaffeensis. In this study, we developed Etf-1–specific nanobodies (Nbs) by immunizing a llama to determine if intracellular Nbs block Etf-1 functions and Ehrlichia infection. Of 24 distinct anti–Etf-1 Nbs, NbD7 blocked mitochondrial localization of Etf-1–GFP in cotransfected cells. NbD7 and control Nb (NbD3) bound to different regions of Etf-1. Size-exclusion chromatography showed that the NbD7 and Etf-1 complex was more stable than the NbD3 and Etf-1 complex. Intracellular expression of NbD7 inhibited three activities of Etf-1 and E. chaffeensis: up-regulation of mitochondrial manganese superoxide dismutase, reduction of intracellular reactive oxygen species, and inhibition of cellular apoptosis. Consequently, intracellular NbD7 inhibited Ehrlichia infection, whereas NbD3 did not. To safely and effectively deliver Nbs into the host cell cytoplasm, NbD7 was conjugated to cyclized cell-permeable peptide 12 (CPP12-NbD7). CPP12-NbD7 effectively entered mammalian cells and abrogated the blockade of cellular apoptosis caused by E. chaffeensis and inhibited infection by E. chaffeensis in cell culture and in a severe combined-immunodeficiency mouse model. Our results demonstrate the development of an Nb that interferes with T4SS effector functions and intracellular pathogen infection, along with an intracellular delivery method for this Nb. This strategy should overcome current barriers to advance mechanistic research and develop therapies complementary or alternative to the current broad-spectrum antibiotic.

Human monocytic ehrlichiosis (HME), one of the most prevalent, life-threatening, and emerging tick-borne diseases in the United States (1, 2) is caused by infection with Ehrlichia chaffeensis, an obligatory intracellular bacterium in the order Rickettsiales. E. chaffeensis replicates within human monocytes-macrophages and causes severe flu-like symptoms accompanied by hematologic abnormalities and hepatitis. Currently, the only HME therapy is the broad-spectrum antibiotic doxycycline, which is effective only if initiated early because delayed initiation (e.g., because of misdiagnosis can lead to severe complications or death). In addition, doxycycline is contraindicated for pregnant women and children or those with drug allergies. The presence of underlying illness or injury, immunosuppression, and coinfection with other tick-borne pathogens can similarly lead to severe complications or death (3). No vaccine exists for HME. Tick-borne diseases have risen dramatically in the past 20 y and continue to rise, underscoring the importance of developing new therapeutic approaches and preventive measures (4).The type IV secretion system (T4SS) is conserved among all rickettsial organisms. The recent elucidation of critical roles of T4SS for E. chaffeensis and Anaplasma phagocytophilum infection (5) may provide potential targets for new approaches against rickettsial diseases. For example, the T4SS effectors Ehrlichial translocated factors 1 and 2 (Etf-1 and Etf-2) are critical E. chaffeensis proteins secreted via T4SS into the host cell cytoplasm, as knockdown of Etf-1 or Etf-2 by transfection of E. chaffeensis with specific antisense peptide nucleic acids significantly inhibits E. chaffeensis infection (6, 7). Secreted Etf-1 localizes to mitochondria and blocks mitochondria-mediated host cell apoptosis to keep the infected host cell alive for bacterial intracellular replication (8). A subpopulation of Etf-1 molecules that are not localized to mitochondria interacts with Beclin 1 (ATG6) and active Rab5 (Rab5-GTP), and induces Rab5-regulated autophagy for E. chaffeensis to acquire catabolites as nutrients (9). Etf-2 directly binds Rab5-GTP on Ehrlichia-containing inclusion membranes and blocks Rab5 GTPase activating protein (RabGAP-5) engagement with Rab5-GTP to prevent Ehrlichia-containing inclusions from maturing into late endosomes and fusing with lysosomes (7).Camelidae produce two types of antibodies: conventional antibodies and heavy-chain–only antibodies (10). The variable domain of the heavy chain of heavy-chain–only antibodies (VHHs) of camelids is the smallest (11 to 15 kDa) antigen-binding fragment relative to conventional antibodies. VHHs are soluble and display long surface loops, which are often larger than those of conventional murine and human antibodies (11, 12). The VHHs can be cloned into bacterial or mammalian expression plasmids (13) to produce a nanobody (Nb), a monomeric variable antibody. VHHs cloned into mammalian expression vectors can produce intracellular Nbs within mammalian cells that are superior to conventional antibodies for modulating intracellular functions because they can operate in the reducing intracellular environment, are proteolytically stable, can target subcellular sites, can penetrate cavities in target antigens, and can bind efficiently to antigens, such as enzyme catalytic sites (13–16). Although the therapeutic potential of Nbs has been investigated for several infectious diseases (14, 17–19), the use of Nbs as a therapeutic agent against intracellular bacteria such as E. chaffeensis has not been reported. In the present study, we developed an intracellular Nb approach to block T4SS effectors within mammalian cells, thereby inhibiting intracellular pathogen infection.Progress in developing effective therapy and investigative approach for obligatory intracellular pathogens has been hindered by many factors, not the least of which is the lack of safe and efficient intracellular delivery methods of macromolecules. Although cyclic peptides are generally unable to cross the cell membrane, some naturally occurring cyclic peptides (e.g., cyclosporine A) possess the unusual ability of crossing the cell membrane by passive diffusion and are orally bioavailable (20). Cyclized Arg-rich cell-permeable peptides (CPPs)—such as cyclo(FΦRRRRQ) or cFΦR4, where Φ is l-2-naphthylalanine—or newer and more effective CPPs, such as CPP9 and CPP12, that include d-arginine or d-phenylalanine, provide rapid and efficient cytosolic delivery of their linked cargo proteins into >95% of cells (21–23). They are not cytotoxic at effective concentrations and have oral and intravenous bioavailability based on preliminary pharmacokinetics in mice (22). The cyclic CPPs (and the CPP-cargo conjugates) bind directly to plasma membrane phospholipids and enter cells by endocytosis (22). They then efficiently escape from the early endosome into the cytosol unlike Tat, which escapes only from late endosomes (22–24).In the present study, we have developed anti–Etf-1 Nbs. We obtained a Nb that blocks Etf-1 functions and demonstrated its effectiveness in combination with a cyclic CPP for inhibition of E. chaffeensis infection in cell culture and in a mouse model. These findings represent a significant advance in developing therapeutic and investigative strategy of obligatory intracellular pathogens.     

Fulminant onset of acute leukemia from normal hematopoiesis within 3 months of follow up for multiple myeloma treated with total therapy protocols

Assiduous surveillance for genetic aberrations is necessary in patients on cytotoxic therapies to detect therapy‐related myeloid neoplasms (t‐MN). Current modalities include metaphase cytogenetics and FISH. Since t‐MN may develop abruptly in cytogenetically normal patients, a discussion exploring additional methods such as SNP‐array and targeted‐deep‐sequencing to detect subchromosomal abnormalities is needed.     

Bilateral bifid ureter with unilateral renal vasculature variations

During routine dissection of 82-year-old female cadaver with no known unfavorable medical history, we observed bilateral bifid ureter and variation in arterial supply of left kidney only. Careful examination revealed that there were bifid ureters on both sides enclosed in single facial sheath. It was also observed that both the ureter have different pattern of origin. On the right side, both the ureters were seen to be emerging from the hilum, one below another and joined together at the brim of the lesser pelvis just before crossing the right external iliac artery. Right kidney was supplied by single renal artery lying anterior to both the ureters. On the left side one ureter emerged from the hilum while the second one exited the kidney from a prominent lobule present below the inferior pole.     

Matrix production and remodeling capacity of cardiomyocyte progenitor cells during in vitro differentiation

Cell-based therapy has emerged as a treatment modality for myocardial repair. Especially cardiac resident stem cells are considered a potential cell source since they are able to differentiate into cardiomyocytes and have improved heart function after injury in a preclinical model for myocardial infarction. To avoid or repair myocardial damage it is important not only to replace the lost cardiomyocytes, but also to remodel and replace the scar tissue by "healthy" extracellular matrix (ECM). Interestingly, the role of cardiac stem cells in this facet of cardiac repair is largely unknown. Therefore, we investigated the expression and production of ECM proteins, matrix metalloproteinases (MMPs) and their inhibitors (TIMPs) in human cardiomyocyte progenitor cells (CMPCs) undergoing differentiation towards the cardiomyogenic lineage. Our data suggest that CMPCs have the capacity to synthesize and modulate their own matrix environment, especially during differentiation towards the cardiomyogenic lineage. While undifferentiated CMPCs expressed collagen I, III, IV and fibronectin, but no elastin, during the process of differentiation the expression of collagen I, III, IV and fibronectin increased and interestingly also elastin expression was induced. Furthermore, undifferentiated CMPCs express MMP-1 -2 and -9 and upon differentiation the expression of MMP-1 decreased, while the expression of MMP-2 and MMP-9, although the latter only in the early stage of differentiation, increased. Additionally, the expression of TIMP-1, -2 and -4 was induced during differentiation. This study provides new insights into the matrix production and remodeling capacity of human CMPCs, with potential beneficial effects for the treatment of cardiac injury.