PROTACs, molecular glues and bifunctionals from bench to bedside: Unlocking the clinical potential of catalytic drugs.

The vast majority of currently marketed drugs rely on small molecules with an 'occupancy-driven' mechanism of action (MOA). Therefore, the efficacy of these therapeutics depends on a high degree of target engagement, which often requires high dosages and enhanced drug exposure at the target site, thus increasing the risk of off-target toxicities (Churcher, 2018 [1]). Although small molecule drugs have been successfully used as treatments for decades, tackling a variety of disease-relevant targets with a defined binding site, many relevant therapeutic targets remain challenging to drug due, for example, to lack of well-defined binding pockets or large protein-protein interaction (PPI) interfaces which resist interference (Dang et al., 2017 [2]). In the quest for alternative therapeutic approaches to address different pathologies and achieve enhanced efficacy with reduced side effects, ligand-induced targeted protein degradation (TPD) has gained the attention of many research groups both in academia and in industry in the last two decades. This therapeutic modality represents a novel paradigm compared to conventional small-molecule inhibitors. To pursue this strategy, heterobifunctional small molecule degraders, termed PROteolysis TArgeting Chimeras (PROTACs) have been devised to artificially redirect a protein of interest (POI) to the cellular protein homeostasis machinery for proteasomal degradation (Chamberlain et al., 2019 [3]). In this chapter, the development of PROTACs will first be discussed providing a historical perspective in parallel to the experimental progress made to understand this novel therapeutic modality. Furthermore, common strategies for PROTAC design, including assays and troubleshooting tips will be provided for the reader, before presenting a compendium of all PROTAC targets reported in the literature to date. Due to the recent advancement of these molecules into clinical trials, consideration of pharmacokinetics and pharmacodynamic properties will be introduced, together with the biotech landscape that has developed from the success of PROTACs. Finally, an overview of subsequent strategies for targeted protein degradation will be presented, concluding with further scientific quests triggered by the invention of PROTACs.

Impact of the environment on the health: From theory to practice.

The Erice 56 Charter titled "Impact of the environment on the health: from theory to practice" was unanimously approved at the end of the 56th course of the "International School of Epidemiology and Preventive Medicine G. D'Alessandro" held from 3rd to November 7, 2019 in Erice - Sicily (Italy) and promoted by the Study Group of "Environment and Health" of the Italian Society of Hygiene, Preventive Medicine and Public Health. The course, that included lectures, open discussions and guided working groups, was aimed to provide a general training on epidemiological and toxicological aspects of the environmental health impact, to be used by public health professionals for risk assessment, without forgetting the risk communications. At the end of the course 12 key points were agreed among teachers and students: they underlined the need of specific training and research, in the perspective of "One Health" and "Global Health", also facing emerging scientific and methodological issues and focusing on communication towards stakeholders. This Discussion highlight the need to improve knowledge of Health and Environment topic in all sectors of health and environmental prevention and management.

Impact of vaccination on invasive pneumococcal disease in Italy 2007-2017: surveillance challenges and epidemiological changes.

Surveillance of new cases of invasive pneumococcal disease (IPD) in Italy was started in 2007 by the Ministry of Health (MoH). In 2012, pneumococcal childhood vaccination was introduced at the national level and, in 2017, for citizens aged 65 years and over. We describe here IPD epidemiology in Italy over the past 10 years investigating the impact of the vaccine programme on disease burden. Reports of IPD cases, data on serotype and vaccination coverage (VC) data were obtained from MoH annual reports, for the period 2007-2017. IPD notification rate and proportion by year, region, age and serotype were calculated. In 2007, 525 cases were reported (rate 0.88/100 000), rising to 1703 cases (rate 2.82/100 000) in 2017. The distribution of IPD cases by age group over time registered the largest share among individuals aged 65 years and over. A decreasing trend in notification rate was observed among those aged 0-4 years. During the same period, the 24-month VC increased, ranging from 80.9% to 96.7% in 2017. Molecular data indicated re-emergence of PPSV23-specific serotypes and non-vaccine serotypes. We observed an increase in IPD notifications during 2007-2017, likely due to an improved surveillance system, at least in some regions, with the relative quota of IPD notifications decreasing among vaccinated children cohorts. Further strengthening of IPD surveillance system, including molecular and vaccine coverage data, would be needed to assess and inform pneumococcal vaccination strategies in Italy.

A Phospholipid Profile at 4 Months Predicts the Onset of Celiac Disease in at-Risk Infants.

Celiac disease (CeD) is a multifactorial disease influenced by both genetic and environmental risk factors. CeD genetic components are mainly due to HLA class II genes, which account for approximately 40% of the disease heritability. The environmental factor is linked to gliadin ingestion. Despite genetic and epigenetic studies, the pathological molecular mechanism remains unclarified. The strong genetic component does not explain more than half of the hereditability; we identified several epigenetic features that contribute to the understanding of the missing hereditability. The lipid profile of infants has been proposed as a potential biomarker of CeD metabolism that can be measured before they exhibit developmental disorders and clinical symptoms. We suggest that the state of the host is a main factor for the abnormal immune response to gluten. Long before any exposure to the offending agent or any production of specific antibodies, several molecular mechanisms are differentially expressed in infants who will develop CeD compared to their peers matched for the same genetic profile. The present study explored the serum phospholipid profile of a group of infants at risk for celiac disease, followed up to 8 years to monitor the onset of CeD. We compared 30 patients who developed the disease with 20 age- and sex-matched peers with similar genetic profiles who did not develop the disease within 8 years. Serum phospholipids were analysed at 4 months, before exposure to gluten, and at 12 months of age, when none showed any marker of disease. In the 30 CeD patients, we also analysed the serum at the time of diagnosis (>24 months). The serum phospholipid profile was fairly constant across 4 and 12 months of age and, in CeD, up to 24-36 months. The phospholipid signature was dramatically different in infants who developed CeD when compared to that of control NY-CeD (Not Yet developing Celiac Disease) peers. We identified a specific serum phospholipid signature that predicts the onset of celiac disease in HLA at-risk infants years before the appearance of antibodies specific for CeD in the serum and before any clinical symptoms, even before gluten introduction into the diet at 4 months. Specifically, lysophosphatidylcholine, phosphatidylcholine, alkylacyl-phosphatidylcholine, phosphoethanolamines, phosphatidylserines, phosphatidylglycerol and phosphatidylinositol were found to be differentially represented in CeD versus NY-CeD. A set constituted by a limited number of alkylacyl-phosphatidylcholine and lyso-phosphatidylcholine, together with the duration of breast-feeding, allows the discrimination of infants who develop celiac disease before 8 years of age from those at a similar genetic risk who do not develop the disease. In addition to recent discovery, our paper unveiled a specifc phopholipid profile, able to discriminate infants who eventually develop celiac disease years before antibodies or clinical symptoms ensue.

A visual quality control scale for clinical arterial spin labeling images.

BACKGROUND: Image-quality assessment is a fundamental step before clinical evaluation of magnetic resonance images. The aim of this study was to introduce a visual scoring system that provides a quality control standard for arterial spin labeling (ASL) and that can be applied to cerebral blood flow (CBF) maps, as well as to ancillary ASL images. METHODS: The proposed image quality control (QC) system had two components: (1) contrast-based QC (cQC), describing the visual contrast between anatomical structures; and (2) artifact-based QC (aQC), evaluating image quality of the CBF map for the presence of common types of artifacts. Three raters evaluated cQC and aQC for 158 quantitative signal targeting with alternating radiofrequency labelling of arterial regions (QUASAR) ASL scans (CBF, T1 relaxation rate, arterial blood volume, and arterial transient time). Spearman correlation coefficient (r), intraclass correlation coefficients (ICC), and receiver operating characteristic analysis were used. RESULTS: Intra/inter-rater agreement ranged from moderate to excellent; inter-rater ICC was 0.72 for cQC, 0.60 for aQC, and 0.74 for the combined QC (cQC + aQC). Intra-rater ICC was 0.90 for cQC; 0.80 for aQC, and 0.90 for the combined QC. Strong correlations were found between aQC and CBF maps quality (r = 0.75), and between aQC and cQC (r = 0.70). A QC score of 18 was optimal to discriminate between high and low quality clinical scans. CONCLUSIONS: The proposed QC system provided high reproducibility and a reliable threshold for discarding low quality scans. Future research should compare this visual QC system with an automatic QC system.

Errors in Medicine: perception of healthcare professionals in the Lazio Region.

INTRODUCTION: The error in medicine is always the subject of debate in the scientific debates. The purpose of this study is to evaluate the degree knowledge, attitudes and behaviors of health workers towards the error in the health sector. METHODS: A survey was carried out involving 435 health profes- sionals working in health facilities of the Lazio region, of which 312 females (71%) and 123 males (28%) with an age between 21 and 68 years. A structured questionnaire was administered for investigating the experiences and opinions about the errors found in medical prac- tice, the causes underlying them and the mistakes that should never be committed. Data were collected, stratified by sex, age, marital status, year of graduation, years of service and the workplace (medical or surgical). The statistical significance was set at p≤0.05. RESULTS: The 5 errors found more frequently in the clinical prac- tice by health professionals were as follows: errors related to the request for examination (60.9%); errors in the collection of samples (37.5%); errors relating to the delivery of the reports (35.2%); errors due to reporting of examinations (31.7%); errors of history (29.2%). The five cases considered to be the most frequently responsible for such errors were: disorganization (52%); fast (46.4%); tiredness due to excessive workloads, stress (44.6%); negligence and carelessness (41.6%); inattention (41.1). With regard to the errors that you should never commit they were more frequently: exchange of patient or misidentification of the patient (49.2%); administration errors of therapies or medications (47.6%); errors related to surgery (41.6%); errors of prescription therapies or medications (39.3); errors in the reporting of exams (33.6%). CONCLUSIONS: The results of this study shows the importance of a culture of error in medicine among healthcare professionals, those who have already gained practical experience in health care and therefore better able to perform a critical analysis and evaluation of the errors that occur every day. The continuous training of health professionals is fundamental for promoting patient safety and quality in the healthcare sector.

Multiparameter MR imaging in the 6-OPRI variant of inherited prion disease.

BACKGROUND AND PURPOSE: Inherited prion diseases represent over 15% of human prion cases and are a frequent cause of early onset dementia. The purpose of this study was to define the distribution of changes in cerebral volumetric and microstructural parenchymal tissues in a specific inherited human prion disease mutation combining VBM with VBA of cerebral MTR and MD. MATERIALS AND METHODS: VBM and VBA of cerebral MTR and MD were performed in 16 healthy control participants and 9 patients with the 6-OPRI mutation. An analysis of covariance consisting of diagnostic grouping with age and total intracranial volume as covariates was performed. RESULTS: On VBM, there was a significant reduction in gray matter volume in patients compared with control participants in the basal ganglia, perisylvian cortex, lingual gyrus, and precuneus. Significant MTR reduction and MD increases were more anatomically extensive than volume differences on VBM in the same cortical areas, but MTR and MD changes were not seen in the basal ganglia. CONCLUSIONS: Gray matter and WM changes were seen in brain areas associated with motor and cognitive functions known to be impaired in patients with the 6-OPRI mutation. There were some differences in the anatomic distribution of MTR-VBA and MD-VBA changes compared with VBM, likely to reflect regional variations in the type and degree of the respective pathophysiologic substrates. Combined analysis of complementary multiparameter MR imaging data furthers our understanding of prion disease pathophysiology.

Relationship between waist circumference and cholesterol in Central Africans with congestive heart failure.

BACKGROUND: There are controversies as to what the traditional risk factors for coronary heart disease should be in sub-Saharan Africa. OBJECTIVE: To assess the relationship between cholesterol and cardiovascular disease risk factors including Helicobacter pylori infection in black Africans with congestive heart failure. METHOD: A cross-sectional and observational study of 48 men and 52 women. RESULTS: Congestive heart failure was associated with abdomal obesity, hypertension, chronic renal failure, moderate levels of low HDL-C, excessive alcohol intake and hyperuricaemia, but low levels of cholesterol and triglycerides. TC was related by Univariate analysis with red cells, glucose, weight, waist circumference with HDL-C, CRP, fibrinogen and IgG antibodies against H pylori. Multivariate analysis revealed that waist circumference (B=0.688) and HDL-C (B=0.826) were the significant determinants of TC. There was a respective U-shaped relationship between CVD (P>0.05), chronic renal failure (P<0.05) H. pylori-induced chronic gastritis (P<0.05) and the HDL-categories. Ischemic stroke and myocardial infarction were significantly (p<0.05) associated with low HDL-C, respectively. Clinical insulin resistance (P<0.01) was predominantly more commonin the intermediate HDL-C category than in low and high HDL-categories. There was an inverse relation between lower TC: HDL-C ratio, high HDL-C and abdominal obesity/ insulin resistance in men. H. pylori gastritis was positively related to higher TC: HDL-C ratio in both men and women. CONCLUSION: Preventive measures, more studies on the interplay between HDL-C level and its function and a specific ethnic dfinition of metabolic syndrome in the African are needed.

Androstane and withanolides from Physalis cinerascens.

Two new withanolides, cinerolide and 24,25-dihydrowithanolide S, together with the new androstane, cinedione, and the known withanolides, visconolide, physalactone, withanolide S and 4beta-hydroxywithanolide E were isolated from the EtOAc extract of leaves, flowers and stems of Physalis cinerascens. The structures of these compounds were established by spectroscopic methods and that of cinerolide was confirmed by X-ray diffraction analysis.

High resolution MRI of the brain at 4.7 Tesla using fast spin echo imaging.

Over recent years, high field MR scanners (3 T and above) have become increasingly widespread due to potential advantages such as higher signal-to-noise ratio. However, few examples of high resolution images covering the whole brain in reasonable acquisition times have been published to date and none have used fast spin echo (FSE), a sequence commonly employed for the acquisition of T(2) weighted images at 1.5 T. This is mostly due to the increased technical challenges associated with uniform signal generation and the increasingly restrictive constraints of current safety guidelines at high field. We investigated 10 volunteers using an FSE sequence optimized to the 4.7 T environment. This sequence allows the acquisition of 17- and 34-slice data sets with an in-plane resolution of approximately 500 microm x 500 microm and a slice thickness of 2 mm, in 5 min 40 s and 11 min 20 s, respectively. The images appear T(2) weighted, although the contrast is due to the combined effects of chosen echo time, magnetization transfer, direct radio frequency saturation and diffusion as well as the T(1) and T(2) relaxation times of the tissue. The result is an excellent detailed visualization of anatomical structures, demonstrating the great potential of 4.7 T MRI for clinical applications. This paper shows that, with careful optimization of sequence parameters, FSE imaging can be used at high field to generate images with high spatial resolution and uniform contrast across the whole brain within the prescribed power deposition limits.

Spectral editing in (13)C MAS NMR under moderately fast spinning conditions.

Novel procedures for the spectral assignment of peaks in high-resolution solid-state (13)C NMR are discussed and demonstrated. These methods are based on the observation that at moderate and already widely available rates of magic-angle spinning (10--14 kHz MAS), CH and CH(2) moieties behave to a large extent as if they were effectively isolated from the surrounding proton reservoir. Dipolar-based analogs of editing techniques that are commonly used in liquid-state NMR such as APT and INEPT can then be derived, while avoiding the need for periods of homonuclear (1)H--(1)H multipulse decoupling. The resulting experiments end up being very simple, essentially tuning-free, and capable of establishing unambiguous distinctions among CH, CH(2), and --C--/-CH(3) carbon sites. The principles underlying such sequences were explored using both numerical calculations and experimental measurements, and once validated their editing applications were illustrated on a number of compounds.

Is hyperuricemia a risk factor of stroke and coronary heart disease among Africans?

BACKGROUND: Uric acid stabilizes platelet aggregation and enhances thrombotic tendency. OBJECTIVE: To examine the relationship between raised serum uric acid and subsequent cardiovascular events (mortality, myocardial infarction, stroke). METHODS: This is a longitudinal study in a small random number (418) of patients in Kinshasa, Congo. In this hospital-based study, uricemia was determined with respect to gender, obesity and hypertension as well correlated with traditional cardiovascular risk factors. A univariate regression model was used to investigate the association of serum uric acid with the incidence of mortality, stroke and myocardial infarction. RESULTS: Serum uric acid was higher (P<0.05) in obese women and men as well in hypertensives, than in their controls. The significant (P<0.05 and 0.001) highest frequency of hyperuricemia was observed in both diabetic and hypertensive patients. Blood pressure (BP) was higher (P<0.001) in patients with hyperuricemia than in those with normal serum uric acid. Serum uric acid was significantly correlated with body weight, BP, glucose, fibrinogen, urea, creatinin and total cholesterol. In men, hyperuricemia was significantly (P<0.01) associated with a twofold increased risk of both myocardial infarction and stroke incidence. However, hyperuricemia was significantly related to a double risk of all mortality and stroke onset. CONCLUSION: Our results indicate that hyperuricemia among african patients is a strong predictor of myocardial infarction in men, stroke in both sexes and all causes of mortality in women.

Low birth weight and risk of hypertension in African school children.

BACKGROUND: In accordance with Baker's programming hypothesis, many studies have demonstrated a relationship between low birth weight (LBW) and high risk of hypertension in adulthood. The present study examines a possible association between LBW and the risk of a child having hypertension later in life. METHODS: The study was a cross-sectional, semi-urban survey. Information on the perinatal characteristics of 2648 randomly sampled school children was collected retrospectively in Kinshasa town, Democratic Republic of Congo. RESULTS: High risk of hypertension in these African school children was related to LBW (<2.500 g); the odds ratio was 2 (95% confidence interval 0.9-8.2, P<0.01) and 2.3 (95% confidence interval 0.6-11.5, P<0.01) for systolic and diastolic hypertension respectively. Birth weight was inversely related with both blood pressure and heart rate; the strongest association was shown in females and adolescents. CONCLUSIONS: Antenatal stress leading to LBW may be associated with programming induced by foetal undernutrition, which in turn leads to the emergence of cardiovascular disease and increased risk of hypertension.

The spin coherence relaxation in the rotating frame as a microscopy parameter for strongly coupled spin systems.

The transverse relaxation time in the rotating frame T2rho is proposed as an effective parameter to get specific contrast in solid state imaging. Several peculiarities make T2rho an interesting candidate to map dynamics and structure in solids: the effect of the secular spin interaction can be controlled by the experimenter and therefore the relaxation associated with the nonsecular terms, which is particularly sensitive to very slow dynamics, can be observed. In this paper we present preliminary results obtained on polymers and prove the capability of the MARF Imaging, enhanced by a filter based on rotary echo refocusing, to produce images of solids contrasted by T2rho.

Assessment of ventricular diastolic function in AIDS patients from Congo: a Doppler echocardiographic study.

OBJECTIVE: To investigate the prevalence of left ventricular dysfunction in African patients infected with the human immunodeficiency virus (HIV). The hypothesis was that HIV infected patients with left ventricular dysfunction are asymptomatic. METHODS: M mode, cross sectional, and Doppler echocardiography were performed in 49 consecutive patients (30 HIV positive (HIV+) carriers and 19 AIDS patients). None of the patients or 58 controls had a medical history of cardiovascular abnormalities. RESULTS: Cardiac abnormalities were not suspected on physical, electrocardiographic, and radiological examination. Forty-two of the HIV infected patients had left ventricular diastolic dysfunction; this was more pronounced in AIDS patients than in HIV+ carriers. Systolic function was normal in both stages of HIV infection. Left ventricular isovolumic relaxation time (mean SD)) increased from 87.2 (12.4) ms in the carrier state to 103.9 (19.3) ms in AIDS (p < 0.05, Bonferoni correction), peak early filling velocity declined from 0.54 (0.1) to 0.44 (0.1) m/s (p < 0.05), and late velocity increased from 0.64 (0.1) to 0.69 (0.2) m/s. A restrictive filling pattern was explained by concentric hypertrophy in 23 HIV infected patients, and by systemic amyloidosis with left ventricular dilatation in 12 of 49 HIV infected patients. CONCLUSIONS: Echocardiography is a useful technique for detecting left ventricular diastolic dysfunction in HIV infected patients with clinically unsuspected cardiac lesions. Systolic function was normal despite the presence of such cardiac abnormalities.

[The effect of HIV infection on high incidence of heart diseases in Kinshasa (Zaire). Echocardiographic study]. / Influence de l'infection par le VIH sur la fréquence elevée des cardiopathies a Kinshasa (Zaïre). Etude echocardiographique.

Invasion of the heart by HIV has become a clinical problem over the last decade. The objective of the present study was to systematically detect the excess HIV-related cardiac lesions in Kinshasa by performing echocardiography. The study population consisted of 166 HIV-infected patients and 166 HIV-seronegative patients with heart disease (control group). 69% of patients were at stage A of HIV infection and 31% were at stage AIDS C3 according to CDC 1993 criteria. A higher incidence of echocardiographic abnormalities was observed in HIV-seropositive subjects (28.3%) than in control subjects (13%) (p = 0.035). Systolic function was very severely impaired at the stage of AIDS (%R = 21,6 +/- 8.7) showing a highly significant difference (p < 0.01) compared to HIV-seropositive patients at stage A (% R = 29.2 +/- 11.9) and control subjects (%R = 28.9 +/- 5). One patient (0.6%) developed Salmonella enteritidis infectious endocarditis. Echocardiography, a noninvasive technique, contributes to the diagnosis of cardiac lesions associated with HIV infection. HIV has a predominant role in the severity of dilatation and alteration of the left ventricular systolic function in black Africans compared to Caucasian populations.