Predicting and Quantifying Antagonistic Effects of Natural Compounds Given with Chemotherapeutic Agents: Applications for High-Throughput Screening

Natural products have been used for centuries to treat various human ailments. In recent decades, multi-drug combinations that utilize natural products to synergistically enhance the therapeutic effects of cancer drugs have been identified and have shown success in improving treatment outcomes. While drug synergy research is a burgeoning field, there are disagreements on the definitions and mathematical parameters that prevent the standardization and proper usage of the terms synergy, antagonism, and additivity. This contributes to the relatively small amount of data on the antagonistic effects of natural products on cancer drugs that can diminish their therapeutic efficacy and prevent cancer regression. The ability of natural products to potentially degrade or reverse the molecular activity of cancer therapeutics represents an important but highly under-emphasized area of research that is often overlooked in both pre-clinical and clinical studies. This review aims to evaluate the body of work surrounding the antagonistic interactions between natural products and cancer therapeutics and highlight applications for high-throughput screening (HTS) and deep learning techniques for the identification of natural products that antagonize cancer drug efficacy.

Neurofibromatosis -1 diagnosed from an intraoral swelling - a case series

The neurofibromatoses [NF 1, NF 2 and schwannomatosis] are a group of genetic disorders that lead to the development of nervous system tumours and have diverse dermatologic, neurologic, ophthalmic, skeletal and vascular effects. The most common is NF 1 (Neurofibromatosis 1) also known as von Recklinghausen's disease, which is one of the most common human genetic diseases. Oral manifestations of NF 1 are reported in 72% of cases and in one of our cases precipitated attendance at a general dental practitioner (GDP), subsequent diagnosis and genetic screening for family members. This disease may go undiagnosed due to its variable expressivity of symptoms. The pivotal importance of a GDP in the discovery and early referral to an oral or oral and maxillofacial surgeon for further investigation and diagnosis of this condition is highlighted. Knowledge of the most common features of neurofibromatosis can facilitate the speedy referral and subsequent diagnosis of generalized neurofibromatosis, local surgical management of benign neoplasms and long term management of its other clinical features. Dentists should be aware of the classic symptoms of this condition and of their role in long-term care in view of the risk of local recurrence and malignant transformation.

Evolving healthcare; nurses’ attitudes towards complementary therapies

Background

Integration of complementary therapies alongside conventional medical treatment is common and affects health behaviour and outcomes. Nurses frequently interact with patients and their attitudes to these therapies may play a significant role in decision-making. This mixed-method study investigated nurses' attitudes and behaviour towards complementary therapies.

Methods

A sequential exploratory design was utilised. Qualitative data were collected via interviews with nurses working in primary and tertiary settings, in all states of Australia. Interview data underwent thematic analysis. Findings from the interviews informed the development of a questionnaire, which was used to conduct a national online survey. Survey data were descriptively analysed using frequency distributions and percentages.

Results

Nineteen nurses were interviewed and 614 responded to the survey. Themes that emerged from the qualitative data were; Promoting safe care, Seeking complementary therapies knowledge; Supporting holistic health care and Integrating complementary therapies in practice. Survey responses revealed most nurses (77.5%) discussed complementary therapies with patients. More than one half (55.5%) would 'sometimes' recommend complementary therapies and 12.0% would 'almost always/always' do so. The majority (91.8%) believed nurses should have some understanding of complementary therapies. There was a lack of agreement regarding integration of these therapies into nursing practice.

Conclusions

Nurses were generally supportive of patients' interest in complementary therapies and want basic education about these therapies.

Key messages

Nurses working in Australia often engage with patients about complementary therapies. Increasing nurses’ complementary therapy knowledge is likely to promote informed decision-making and improve patient safety.

"I realised it weren't about spending the money. It's about doing something together:" the role of money in a community empowerment initiative and the implications for health and wellbeing

Community initiatives aiming to reduce health inequalities are increasingly common in health policy. Though diverse many such initiatives aim to support residents of disadvantaged places to exercise greater collective control over decisions/actions that affect their lives - which research suggests is an important determinant of health - and some seek to achieve this by giving residents control over a budget. Informed by theoretical work in which community capabilities for collective control are conceptualised as different forms of power, and applying a relational lens, this paper presents findings on the potential role of money as a mechanism to enhance these capabilities from an on-going evaluation of a major place-based initiative being implemented in 150 neighbourhoods across England:The Big Local (BL). The research involved semi-structured interviews with 116 diverse stakeholders, including residents and participant observation in a diverse sample of 10 BL areas. We took a thematic constant comparative approach to the analysis of data from across the sites. The findings suggest that the money enabled the development of capabilities for collective control in these communities primarily by enhancing connectivity amongst residents and with external stakeholders. However, residents had to engage in significant 'relational work' to achieve these benefits and tensions around the money could hinder communities' 'power to act'. Greater social connectivity has been shown to directly affect individual and population health by increasing social cohesion and reducing loneliness. Additionally, supporting enhanced collective control of residents in these disadvantaged communities has the potential to improve population health and reduce health inequalities.

Barriers to the Use of Assistive Technology with Children: A Survey

This article reports on the responses of 120 teachers and habilitative specialists of multiply handicapped blind and deaf-blind children in Massachusetts to a survey on their use of assistive technology. The respondents reported problems in all areas covered by the survey: knowledge of electronic mobility aids and communication devices; the availability, maintenance, and funding of devices; and adequate information about devices. They especially mentioned the need for resources to assess and match students to appropriate devices and to generate more training for themselves.

Achieving good-quality consent: review of literature, case law and guidance

Background

Informed consent is an integral part of clinical practice. There is widespread agreement amongst health professionals that obtaining procedural consent needs to move away from a unidirectional transfer of information to a process of supporting patients in making informed, self‐determined decisions. This review aimed to identify processes and measures that warrant consideration when engaging in consent‐based discussions with competent patients undergoing elective procedures.

Methods

Formal written guidance from the General Medical Council and Royal College of Surgeons of England, in addition to peer‐reviewed literature and case law, was considered in the formulation of this review.

Results

A framework for obtaining consent is presented that is informed by the key tenets of shared decision‐making (SDM), a model that advocates the contribution of both the clinician and patient to the decision‐making process through emphasis on patient participation, analysis of empirical evidence, and effective information exchange. Moreover, areas of contention are highlighted in which further guidance and research are necessary for improved enhancement of the consent process.

Conclusion

This SDM‐centric framework provides structure, detail and suggestions for achieving meaningful consent.

THU0382 ARTICULAR MANIFESTATIONS IN PATIENTS WITH INFLAMMATORY BOWEL DISEASES TREATED WITH ANTI-TNFΑ

Background:

Articular manifestations are the most frequent extra-digestive manifestations of Inflammatory Bowel Disease (IBD). Anti-TNF have proved to be as effective on articular symptoms as on IBD’s ones, but have been suspected to induce paradoxical articular manifestations.

Objectives:

The aims of this study were to describe the frequency, the type and the management of all articular manifestations occurring in patients treated with anti-TNF for IBD and to look for factors associated with their occurrence.

Methods:

In this retrospective monocentric study, we included all patients who received an anti-TNF for an IBD in our tertiary hospital referent for inflammatory rheumatic and bowel diseases. We searched for all incident articular manifestations occurring during treatment with anti-TNF, including new or recurrent articular manifestations. Characteristics of patients with paradoxical articular manifestations (defined as inflammatory articular symptoms occurring while IBD was in remission, without immunization against anti-TNF) were compared to that of patients without articular manifestations to identify factors associated with their occurrence.

Results:

Through a systematic search of all IBD patients seen in our tertiary hospital between February 2013 and May 2017, we identified 442 patients (36.2±15 years, 50.5% men) who had ever received an anti-TNF for IBD: Crohn’s disease (n=277), ulcerative colitis (154) and undetermined colitis (n=11). 74 (16.7%) had already a history of inflammatory articular manifestations including 37 patients with a diagnosis of spondyloarthritis (SpA) made before anti-TNF’s beginning.

Among them, 115 (26%) patients developed a new articular manifestation after a mean of 20 (±22) months of treatment: mechanical in 56 (12.6%) and inflammatory in 59 (13.3%). Within patients with new inflammatory articular manifestations: 39% were paradoxical, 27% were concomitant of an IBD flare, 27% were associated to an immunization against anti-TNF, 3% were induced lupus, 2% were chondrocalcinosis and 2% were polymyalgia rheumatic. Articular manifestations associated to an immunization were linked to a loss of efficiency of the treatment for 62%, with (42%) or without (20%) associated digestive symptoms and 38% were due to delayed hypersensitivity reaction. Among paradoxical articular manifestations, 83% were new articular symptoms, including 35% of SpA de novo, and 17% were recurrence of known articular manifestations. The only predictive factor of paradoxical articular manifestation was a previous diagnosis of SpA (21.7% vs 6.8%; p=0.02). Paradoxical manifestations improved in 17 patients despite continuation of anti-TNF, methotrexate was added in 2 and anti-TNF was discontinued in only 4 patients.

Conclusion:

Inflammatory articular manifestations occurred in about 13% of patients treated with anti-TNF for IBD. More than a quarter were linked to an immunization against anti-TNF, which has to be searched in this situation. Less than half of them (39%) were paradoxical. In most of cases, they were transitory and did not require anti-TNF’s discontinuation. The only predictive factor of paradoxical articular manifestations was having a history of SpA.

References:

[1]Thiebault H, et al. Paradoxical articular manifestations in patients with inflammatory bowel diseases treated with infliximab. Eur J Gastroenterol Hepatol, 2016.

[2]Fiorino G et al. Paradoxical immune-mediated inflammation in inflammatory bowel disease patients receiving anti-TNF-α agents. Autoimmun Rev, 2014.

Disclosure of Interests:

Laurie Cachen: None declared, Gaetane Nocturne: None declared, Michael Collins Consultant of: Abbvie, Takeda, MSD, Celgene, Antoine Meyer: None declared, Franck Carbonnel Consultant of: Msd Abbvie Amgen, Xavier Mariette Consultant of: BMS, Gilead, Medimmune, Novartis, Pfizer, Servier, UCB, Raphaèle Seror Consultant of: BMS UCB Pfizer Roche

0929 Caregiver-Reported Versus Clinician-Documented Child Sleep Problems and Sleep-Related Health Behaviors in Primary Care

Introduction

Sleep problems are highly prevalent in early childhood but often under-identified in pediatric primary care. This study identified the prevalence of caregiver-reported versus primary care provider (PCP)-documented sleep problems and sleep-related health behaviors in young children presenting to well child visits (WCVs).

Methods

Caregivers (85.4% mothers) of 198 young children (2-5 years, M = 3.3, 53.7% female, 62.9% Black) presenting to urban (74.1%) and suburban (25.9%) primary care sites for well child visits (WCVs) completed research surveys on child behavioral sleep problems, snoring, and sleep-related health behaviors (e.g., caffeine consumption) on the day of their child’s WCV. Electronic medical record review was used to identify the rate of PCP-documented sleep problems and related recommendations in the WCV progress note.

Results

Fifteen percent of caregivers reported a child sleep problem according to questionnaire data, which did not significantly differ from the 12.0% of children with a PCP-documented sleep problem in the WCV progress note (p = .31). However, significantly more caregivers (28.3%) reported bedtime difficulties (resistance; tantrums) on questionnaires (p <.001), which were not captured in the 12.0% of WCVs noting sleep problems. A total of 8% of WCVs included child sleep recommendations. Child snoring was reported by 17.0% of caregivers, but was less frequently documented in WCVs (4.5%, p <.001). Although many caregivers reported poor child sleep-related health behaviors, including daily child caffeine consumption (21.1%) and bedroom electronics (62.9%), significantly fewer PCPs documented these issues (caffeine: 2.0%; electronics: 6.6%) or related recommendations (decrease caffeine: 1.0%; eliminate electronics: 3.5%) in the progress note (all p-values <.001).

Conclusion

Although caregiver-endorsed child sleep problems on surveys did not differ from PCP-documented concerns, there are gaps in documenting other problematic sleep-related health behaviors, such as caffeine consumption and electronics use. More resources to address sleep-related health behaviors, as well as sleep problems, in pediatric primary care are needed.

Support

Sleep Research Society Foundation and K23HD094905 (AAW)

0947 Parent-Perceived Sleep Problems and Sleep Goals in Infants and Toddlers: A Global Sample

Introduction

The aim of this study was to assess parent perceptions of sleep problems in young children and parent-identified areas of change in a global sample.

Methods

Caregivers (95.6% mothers) of 1555 infants/toddlers (birth-37 mos; M=12.2 mos; 49.5% male) completed an online survey, representing Indonesia (n=187), Japan (n=718), New Zealand (n=231), Singapore (n=199), and Thailand (n=221). The survey included an abbreviated version of the Brief Infant Sleep Questionnaire, and a list of potential sleep-related areas of change.

Results

36.9% reported a perceived sleep-problem, whereas 92.9% indicated an area of desired change related to their child’s sleep. In terms of areas of change, 82.5% endorsed bedtime/how child falls asleep, 70.0% nighttime sleep, and 57.8% related to the morning. As expected, 99.7% of parents who endorsed a problem indicated a desired change compared to 88.9% who did not perceive a problem, p < .001. Those who noted a problem were more likely to endorse a change at bedtime (92.5%) and during the night (90.1%), compared to the morning (68.8%). There were country-based differences, with caregivers in New Zealand (47.0%) and Singapore (44.2%) more likely to report a child sleep problem compared to Thailand (35.3%), Japan (34.1%) and Indonesia (29.4%), p < .001. No differences were noted in parent-report of desired change across Japan, New Zealand, Singapore, and Thailand (94-96%) but were significantly higher than Indonesia (83.4%).

Conclusion

Although one-third of parents of young children in a global sample indicate a perceived sleep problem, almost all parents wish to change something about their child’s sleep, primarily relate to bedtime and during the night. Sleep education and assessment delivered by health care providers should focus not only on what families consider to be “problematic,” but also what families would like to modify, or improve, about their child’s sleep within a developmentally appropriate framework.

Support

Johnson & Johnson Consumer Inc., Skillman, NJ, USA.

Identification of a synergistic combination of dimethylaminoparthenolide and shikonin alters metabolism and inhibits proliferation of pediatric precursor-B cell acute lymphoblastic leukemia

Exploiting metabolic vulnerabilities of cancer cells with nontoxic, plant derived compounds constitutes a novel strategy for both chemoprevention and treatment. A high-throughput screening approach was used to evaluate a library of natural products to determine the most synergistic combination in precursor-B cell acute lymphoblast leukemia. Dimethylaminoparthenolide and shikonin effectively inhibited proliferation resulting in cell death in primary and immortalized leukemia cells, while having negligible effects on normal cells. Dimethylaminoparthenolide and shikonin have been shown separately to inhibit cell survival and proliferative signaling and activate tumor suppressors and proapoptotic pathways. Untargeted metabolomics and metabolic flux analysis with stable isotopically labeled glucose and glutamine exhibited a global shift in metabolism following treatment. Pathway analysis indicated significant differences in amino acid, antioxidant, tricarboxylic acid cycle, and nucleotide metabolism. Together, dimethylaminoparthenolide and shikonin reduced the shunting of glycolytic intermediates into the pentose phosphate pathway for biosynthetic purposes. Similarly, the incorporation of glutamine and glutamine-derived metabolites into purine and pyrimidine synthesis was inhibited by the combination of dimethylaminoparthenolide and shikonin, effectively impeding biosynthetic pathways critical for leukemia cell survival. This approach demonstrates that a synergistic pair of compounds with malignant cell specificity can effectively target metabolic pathways crucial to leukemia cell proliferation and induce apoptosis.

Cost-effectiveness of physical fitness training for stroke survivors

Background Physical fitness is impaired after stroke, yet fitness training after stroke reduces disability. Several international guidelines recommend that fitness training be incorporated as part of stroke rehabilitation. However, information about cost-effectiveness is limited. Methods A decision tree model was used to estimate the cost-effectiveness of a fitness programme for stroke survivors vs. relaxation (control group). This was based on a published randomised controlled trial, from which evidence about quality of life was used to estimate Quality Adjusted Life Years. Costs were based on the cost of the provision of group fitness classes within local community centres and a cost per Quality Adjusted Life Year was calculated. Results The results of the base case analysis found an incremental cost per Quality Adjusted Life Year of £2,343. Conclusions Physical fitness sessions after stroke are a cost-effective intervention for stroke survivors. This information will help make the case for the development of new services.

Marine plastics threaten giant Atlantic Marine Protected Areas

There has been a recent shift in global perception of plastics in the environment, resulting in a call for greater action. Science and the popular media have highlighted plastic as an increasing stressor [1,2]. Efforts have been made to confer protected status to some remote locations, forming some of the world's largest Marine Protected Areas, including several UK overseas territories. We assessed plastic at these remote Atlantic Marine Protected Areas, surveying the shore, sea surface, water column and seabed, and found drastic changes from 2013-2018. Working from the RRS James Clark Ross at Ascension, St. Helena, Tristan da Cunha, Gough and the Falkland Islands (Figure 1A), we showed that marine debris on beaches has increased more than 10 fold in the past decade. Sea surface plastics have also increased, with in-water plastics occurring at densities of 0.1 items m^-3; plastics on seabeds were observed at ≤ 0.01 items m^-2. For the first time, beach densities of plastics at remote South Atlantic sites approached those at industrialised North Atlantic sites. This increase even occurs hundreds of meters down on seamounts. We also investigated plastic incidence in 2,243 animals (comprising 26 species) across remote South Atlantic oceanic food webs, ranging from plankton to seabirds. We found that plastics had been ingested by primary consumers (zooplankton) to top predators (seabirds) at high rates. These findings suggest that MPA status will not mitigate the threat of plastic proliferation to this rich, unique and threatened biodiversity.

Non-isothermal drying kinetics of human feces

The non-isothermal drying behavior and kinetics of human feces (HF) were investigated by means of thermogravimetric analysis to provide data for designing a drying unit operation. The effect of heating rate and blending with woody biomass were also evaluated on drying pattern and kinetics. At low heating rate (1 K/min), there is effective transport of moisture, but a higher heating rate would be necessary at low moisture levels to reduce drying time. Blending with wood biomass improves drying characteristics of HF. The results presented in this study are relevant for designing non-sewered sanitary systems with in-situ thermal treatment.

Preliminary Examinations of Concussion in Older Adults

Purpose

This study sought to investigate whether concussion in older adults improves through evaluating their performance on the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) and Vestibular/Ocular-Motor Screen (VOMS) across visits and to describe and better characterize concussion in this at-risk population.

Methods

We conducted a retrospective review of medical records for 69 older adult patients (40 females, 29 males) that presented to a concussion specialty clinic. Participants averaged 64.71 (SD=4.1) years in age and presented within 6-998 days of injury (SD=170.9). Demographics and clinical data were recorded at intake through last appointment. Descriptive analysis, including frequencies, means, and standard deviations were performed as well as paired T-test to compare mean scores for first and last visit. Statistical significance was determined by two-sided p-values <.05.

Results

Twenty out of 69 participants (29%) reported a previous concussion. Concussion symptom severity scores at participants’ first clinic visit averaged 56.19 (SD=26.56) compare with 39.51 (SD=25.53) at their final clinic visit. When comparing ImPACT data, all scores improved comparatively from Visit 1 to Last Visit (P values =0.000-0.014); all VOMS total scores improved as well (P =0.00-0.047). The most frequent primary profile among participants was Vestibular (31.9%).

Conclusion

Older adults diagnosed with concussion showed improvement on ImPACT scores and their symptom severity scores decreased. The most frequent primary concussion profile at initial visit was Vestibular. Further research with this at-risk population is needed.

Comparison of Clinical Outcomes Following Patients' First and Second Concussions

Purpose

The objective of this study was to examine differences in self-reported symptoms, neurocognitive performance, and vestibular-ocular insufficiencies between patients’ first and second concussions. A secondary purpose was to explore the role of risk factors on recovery.

Methods

We conducted a retrospective medical chart review of 73 (32-M/41-F) patients aged 15.69 (SD=1.67) years from a concussion specialty clinic with two separate concussions (84.9% of 1st and 79.5% of 2nd sport-related) that occurred between August 2010 and April 2018. Clinical outcomes included the PCSS, ImPACT, and the Vestibular/Ocular Motor Screening (VOMS). A series of paired samples t-tests were used to compare clinical outcomes along with chi-square analyses for risk factor associations.

Results

Verbal memory scores were higher following the second (M=80.67, SD=15.3) (M=76.32, SD=15.65) (t[73]=–2.18, p=.03) concussion. Visual motor processing speed was faster following the second concussion (M=35.04, SD= 7.90) (M=31.35, SD=7.63) (t[73]=–5.72, p<.001). There were no other significant differences observed. Recovery time was similar for the first (61.07, SD=58.41.5) and second (67.91 SD=70.10) respectively, t(70)=–.91, p=.37. There was no relationship between any risk factors, and recovery time for either injury with the exception a significant association between gender and recovery time (>21 days) with the 1st injury for females (χ2, N=73)=10.58, p=.001.

Conclusion

Findings suggest that a second concussion does not result in more pronounced symptoms, worse neurocognitive performance, or increased deficits on vestibular/ocular performance and/or longer recovery time. The only significant risk factor to a recovery over 21 days included gender.

Reliability and Consistency of the Vestibular/Ocular Motor Screening (VOMS) Assessment Near Point of Convergence (NPC) Trials

Purpose

To examine the reliability of near point of convergence (NPC) across three trials and determine if one trial of NPC is adequate to identify receded NPC post-concussion.

Methods

Participants included 263 concussed patients (64.3% male; age=16.92±3.49 years) evaluated within 21 days of injury. NPC was measured in centimeters from the tip of the nose using a fixation stick and a Gulick anthropometric tape measure. A two-way, mixed effect, absolute agreement intraclass correlation coefficient (ICC 3,1) was conducted to evaluate reliability across the three trials. A chi-square analysis examined consistency of NPC classification (normal/abnormal) on the initial trial compared to average across three trials.

Results

Reliability of the three trials was high (.91 [95%CI, .89–.93]). Agreement between Trial 1 classification and classification based on average of all three trials was high (96.2%). Of the 10 participants who were classified differently for Trial 1 compared to average trials, 8 had borderline (e.g., 4–6 cm) measurements on the first trial.

Conclusion

NPC measurement across trials is reliable for the overall sample, but those who fell well below (i.e. 0–1cm) or well above (>8cm) clinical cutoffs on the first trial were almost always below or above respective cutoffs on the average convergence (>99%). Results suggest it is important to measure NPC across multiple trials for patients with initial borderline measurement.