Effectiveness of a multidisciplinary patient care bundle for reducing surgical-site infections

BACKGROUND

Surgical-site infection (SSI) is associated with significant healthcare costs. To reduce the high rate of SSI among patients undergoing colorectal surgery at a cancer centre, a comprehensive care bundle was implemented and its efficacy tested.

METHODS

A pragmatic study involving three phases (baseline, implementation and sustainability) was conducted on patients treated consecutively between 2013 and 2016. The intervention included 13 components related to: bowel preparation; oral and intravenous antibiotic selection and administration; skin preparation, disinfection and hygiene; maintenance of normothermia during surgery; and use of clean instruments for closure. SSI risk was evaluated by means of a preoperative calculator, and effectiveness was assessed using interrupted time-series regression.

RESULTS

In a population with a mean BMI of 30 kg/m² , diabetes mellitus in 17·5 per cent, and smoking history in 49·3 per cent, SSI rates declined from 11·0 to 4·1 per cent following implementation of the intervention bundle (P = 0·001). The greatest reductions in SSI rates occurred in patients at intermediate or high risk of SSI: from 10·3 to 4·7 per cent (P = 0·006) and from 19 to 2 per cent (P < 0·001) respectively. Wound care modifications were very different in the implementation phase (43·2 versus 24·9 per cent baseline), including use of an overlying surface vacuum dressing (17·2 from 1·4 per cent baseline) or leaving wounds partially open (13·2 from 6·7 per cent baseline). As a result, the biggest difference was in wound-related rather than organ-space SSI. The median length of hospital stay decreased from 7 (i.q.r. 5-10) to 6 (5-9) days (P = 0·002). The greatest reduction in hospital stay was seen in patients at high risk of SSI: from 8 to 6 days (P < 0·001). SSI rates remained low (4·5 per cent) in the sustainability phase.

CONCLUSION

Meaningful reductions in SSI can be achieved by implementing a multidisciplinary care bundle at a hospital-wide level.

Abstract PD2-07: Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence

Background)

Sentinel lymph node (SLN) biopsy using indocyanine green fluorescence (fICG) method showed equal or better identification rate compared with blue dye or radioisotope (RI) method. In the fICG method, lymphatic vessels which drain into the SLNs can be seen through skin or subcutaneous tissue using near infrared camera (Photodynamic Eye®: PDE), and we can easily find the SLNs. However, whenever we observe the fluorescence images, we have to hold the PDE, turn off the operating light, and look at a monitor because fluorescence images cannot be seen directly. Medical imaging projection system (MIPS) is a new device which detects fluorescent emission from the organ and projects their images on the location of the fluorescence emission (Panasonic Connected Solutions Company, Japan). Projected images can be adjusted following the body movement or deformation of the organ. Therefore, MIPS could provide an option for real-time navigation for the SLN biopsy. The aim of this study was to evaluate the clinical utility of the MIPS.

Patients and methods)

Patients with clinically node-negative primary breast cancer underwent the fICG SLN biopsy using MIPS. Primary endpoint was identification rate of the fICG method using MIPS. At first, the study was conducted as an interventional study because the MIPS was the unapproved medical device. After approval of the MIPS, this study was conducted as an observational study. The study protocol was approved by the institutional review board at Kyoto University Hospital. All patients provided informed consent to participate in this study.

Results)

Between March 2016 and May 2017, 39 patients (40 procedures) underwent the fICG method SLN biopsy using MIPS. The median age was 55 years (range 32–74 years), and the median body mass index was 20.4 kg/m2 (range 17.7–27.7 kg/m2). About half had tumor stage T1 (58%) and 8 (20.0%) had DCIS. 8 procedures (20%) were performed after preoperative systemic therapy (PST). As MIPS itself can illuminate the operating field, SLN biopsy using MIPS was successfully performed without operating light in all procedures. At least one SLN was detected using MIPS for all procedures and the identification rate was 100% (95% CI: 91–100%). Median number of SLNs detected by MIPS was 3 (range 1–9) for all procedures, and 3 (range 2–8) for procedures after PST. Two pathologically positive SLNs and one SLN which included isolated tumor cells were detected by MIPS. In 25 procedures, RI was also used. 62 of 97 SLNs detected by MIPS (64%) were also detected by RI. However, no SLNs were detected only by RI.

Conclusions)

Although we still may not be able to avoid RI method because 25/40 (62.5%) procedures required the combined use of RI method, the fICG methods SLN biopsy using MIPS, which showed comparable identification rate of SLN with the conventional methods, could be useful tool with a view of allowing us to perform a real-time navigation surgery.

Acknowledgements)

This study was supported by Acceleration Transformative research for Medical innovation, Japan Agency for Medical Research and Development (AMED).

Citation Format: Takada M, Takeuchi M, Suzuki E, Sato F, Matsumoto Y, Torii M, Sakita-Kawaguchi N, Nakayama Y, Okuda T, Nishino H, Seo S, Hatano E, Toi M. Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-07.

Differential protein stability and clinical responses of EML4-ALK fusion variants to various ALK inhibitors in advanced ALK-rearranged non-small cell lung cancer

Background

Anaplastic lymphoma kinase (ALK) inhibition using crizotinib has become the standard of care in advanced ALK-rearranged non-small cell lung cancer (NSCLC), but the treatment outcomes and duration of response vary widely. Echinoderm microtubule-associated protein-like 4 (EML4)-ALK is the most common translocation, and the fusion variants show different sensitivity to crizotinib in vitro. However, there are only limited data on the specific EML4-ALK variants and clinical responses of patients to various ALK inhibitors.

Patients and methods

By multiplex reverse-transcriptase PCR, which detects 12 variants of known EML4-ALK rearrangements, we retrospectively determined ALK fusion variants in 54 advanced ALK rearrangement-positive NSCLCs. We subdivided the patients into two groups (variants 1/2/others and variants 3a/b) by protein stability and evaluated correlations of the variant status with clinical responses to crizotinib, alectinib, or ceritinib. Moreover, we established the EML4-ALK variant-expressing system and analyzed patterns of sensitivity of the variants to ALK inhibitors.

Results

Of the 54 tumors analyzed, EML4-ALK variants 3a/b (44.4%) was the most common type, followed by variants 1 (33.3%) and 2 (11.1%). The 2-year progression-free survival (PFS) rate was 76.0% [95% confidence interval (CI) 56.8-100] in group EML4-ALK variants 1/2/others versus 26.4% (95% CI 10.5-66.6) in group variants 3a/b (P = 0.034) among crizotinib-treated patients. Meanwhile, the 2-year PFS rate was 69.0% (95% CI 49.9-95.4) in group variants 1/2/others versus 32.7% (95% CI 15.6-68.4) in group variants 3a/b (P = 0.108) among all crizotinib-, alectinib-, and ceritinib-treated patients. Variant 3a- or 5a-harboring cells were resistant to ALK inhibitors with >10-fold higher half maximal inhibitory concentration in vitro.

Conclusion

Our findings show that group EML4-ALK variants 3a/b may be a major source of ALK inhibitor resistance in the clinic. The variant-specific genotype of the EML4-ALK fusion allows for more precise stratification of patients with advanced NSCLC.

Effects of Smartphone-based Memory Training for Older Adults with Subjective Memory Complaints

Introduction

Brain health has garnered increasing attention as a requisite condition for healthy aging. The rapid growth in mobile health and increasing smartphone ownership among older adults has paved the way for smartphones to be utilized as effective tools for improving mental fitness.

Objectives

There are few studies that have explored the efficacy of smartphone-based cognitive training. The present study examined the memory-enhancing effects of smartphone-based memory training for older adults.

Aims

We explored whether newly developed application “Smartphone-based brain Anti-aging and memory Reinforcement Training (SMART)” improved memory performance in older adults with subjective memory complaints.

Methods

A total of 53 adults (mean age: 59.3 years) were randomised into either one of two smartphone-based intervention groups (SMART vs. Fit Brains®) or a wait-list group. Participants in the intervention groups underwent 15–20 minutes of training per day, five days per week for 8 weeks. We used objective cognitive measures to evaluate changes with respect to four domains: attention, memory, working memory (WM), and executive function (inhibition, fluency, etc.). In addition, we included self-report questionnaires to assess levels of subjective memory complaints.

Results

The performance on WM test increased significantly in the SMART group (t[17] = 6.27, P < 0.0001) but not in the control groups. Self-reports of memory contentment, however, increased in the Fit Brains® group only (t[18] = 2.12, P = 0.048).

Conclusions

Use of an 8-week smartphone-based memory training program may improve working memory function in older adults. However, objective improvement in performance does not necessarily lead to decreased subjective memory complaints.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Label-free cell-substrate adhesion imaging on plasmonic nanocup arrays

Cell adhesion is a crucial biological and biomedical parameter defining cell differentiation, cell migration, cell survival, and state of disease. Because of its importance in cellular function, several tools have been developed in order to monitor cell adhesion in response to various biochemical and mechanical cues. However, there remains a need to monitor cell adhesion and cell-substrate separation with a method that allows real-time measurements on accessible equipment. In this article, we present a method to monitor cell-substrate separation at the single cell level using a plasmonic extraordinary optical transmission substrate, which has a high sensitivity to refractive index changes at the metal-dielectric interface. We show how refractive index changes can be detected using intensity peaks in color channel histograms from RGB images taken of the device surface with a brightfield microscope. This allows mapping of the nonuniform refractive index pattern of a single cell cultured on the plasmonic substrate and therefore high-throughput detection of cell-substrate adhesion with observations in real time.

RraAS1 inhibits the ribonucleolytic activity of RNase ES by interacting with its catalytic domain in Streptomyces coelicolor

RraA is a protein inhibitor of RNase E, which degrades and processes numerous RNAs in Escherichia coli. Streptomyces coelicolor also contains homologs of RNase E and RraA, RNase ES and RraAS1/RraAS2, respectively. Here, we report that, unlike other RraA homologs, RraAS1 directly interacts with the catalytic domain of RNase ES to exert its inhibitory effect. We further show that rraAS1 gene deletion in S. coelicolor results in a higher growth rate and increased production of actinorhodin and undecylprodigiosin, compared with the wild-type strain, suggesting that RraAS1-mediated regulation of RNase ES activity contributes to modulating the cellular physiology of S. coelicolor.

Exogenous β-mannanase improves feed conversion efficiency and reduces somatic cell count in dairy cattle

Exogenous fibrolytic enzymes have been shown to be a promising way to improve feed conversion efficiency (FCE). β-Mannanase is an important enzyme digesting the polysaccharide β-mannan in hemicellulose. Supplementation of diets with β-mannanase to improve FCE has been more extensively studied in nonruminants than in ruminants. The objective of this study was to investigate the effects of β-mannanase supplementation on nutrient digestibility, FCE, and nitrogen utilization in lactating Holstein dairy cows. Twelve post-peak-lactation multiparous Holstein cows producing 45.5±6.6kg/d of milk at 116±19.0d in milk were randomly allotted to 1 of 3 treatments in a 3×3 Latin square design with 3 periods of 18d (15d for adaptation plus 3d for sample collection). All cows were fed the same basal diet and the 3 treatments differed only by the β-mannanase dose: 0% dry matter (DM; control), 0.1% of DM (low supplement, LS), and 0.2% of DM (high supplement, HS) supplemented to the basal diet. Supplementation of β-mannanase enzyme at the LS dose reduced dry matter intake (DMI) but did not affect milk yield or milk composition. Cows receiving LS produced 90g more milk per kg of DMI compared with control cows. Somatic cell count (SCC) in milk was lower for cows fed the LS diet compared with cows fed control diets. Cows fed LS diet had lower DM, organic matter and crude protein digestibility compared with cows fed control diets. Starch, neutral detergent fiber, and acid detergent fiber digestibility were not affected by LS. Milk yield, DMI, SCC, and nutrient digestibility did not change for HS. Despite the reduced crude protein digestibility, reduced N intake led to similar fecal N excretions in LS cows and control cows (234 vs. 235g/cow per day). Urinary N excretions remained similar between enzyme-fed and control cows (~190g/cow per day), although the percentage of N intake partitioned to urinary N tended to be greater in LS than in control cows (31 vs. 27%). Cows fed LS significantly improved the percentage of apparently absorbed N partitioned to milk protein N (42 vs. 38%). When supplemented at 0.1% of dietary DM, β-mannanase can improve FCE and lower the SCC of dairy cows without affecting milk yield, milk composition, or total manure N excretions of dairy cows.

Release and toxicity comparison between industrial- and sunscreen-derived nano-ZnO particles

Many consumer products containing ZnO have raised concern for safety in regard to environmental impact and the public health. Widely used sunscreens for protecting against UV and avoiding sunburns represent a great exposure to nano-ZnO, one of the ingredients commonly applied in sunscreens. Applying nanoproducts on beaches may release nanoparticles unintentionally into the ocean. Despite the accumulation of such nanoproducts in the ocean harming or being detrimental to critical marine organisms, few studies have investigated the release and potential toxicity of nanoparticles extracted from products and compared them with those from industrial-type nanoparticles. Results show that the cytotoxicity of both industrial- and sunscreen-derived nano-ZnO to the marine diatom algae, Thalassiosira pseudonana, increased as exposure increases over time, as measured by growth inhibition (%) of the algae at a constant concentration of nano-ZnO (10 mg/L). The extent of toxicity appeared to be higher from industrial-type nano-ZnO compared with sunscreen-extracted nano-ZnO, though the extent becomes similar when concentrations increase to 50 mg/L. On the other hand, at a fixed exposure time of 48 h, the cytotoxicity increases as concentrations increase with the higher toxicity shown from the industrial-type compared with sunscreen-induced nano-ZnO. Results indicate that while industrial-type nano-ZnO shows higher toxicity than sunscreen-derived nano-ZnO, the release and extent of toxicity from nano-ZnO extracted from sunscreen are not trivial and should be monitored for the development of safe manufacturing of nanomaterials-induced products.

RraAS2 requires both scaffold domains of RNase ES for high-affinity binding and inhibitory action on the ribonucleolytic activity

RraA is a protein inhibitor of RNase E (Rne), which catalyzes the endoribonucleolytic cleavage of a large proportion of RNAs in Escherichia coli. The antibiotic-producing bacterium Streptomyces coelicolor also contains homologs of RNase E and RraA, designated as RNase ES (Rns), RraAS1, and RraAS2, respectively. Here, we report that RraAS2 requires both scaffold domains of RNase ES for high-affinity binding and inhibitory action on the ribonucleolytic activity. Analyses of the steady-state level of RNase E substrates indicated that coexpression of RraAS2 in E. coli cells overproducing Rns effectively inhibits the ribonucleolytic activity of full-length RNase ES, but its inhibitory effects were moderate or undetectable on other truncated forms of Rns, in which the N- or/and C-terminal scaffold domain was deleted. In addition, RraAS2 more efficiently inhibited the in vitro ribonucleolytic activity of RNase ES than that of a truncated form containing the catalytic domain only. Coimmunoprecipitation and in vivo cross-linking experiments further showed necessity of both scaffold domains of RNase ES for high-affinity binding of RraAS2 to the enzyme, resulting in decreased RNA-binding capacity of RNase ES. Our results indicate that RraAS2 is a protein inhibitor of RNase ES and provide clues to how this inhibitor affects the ribonucleolytic activity of RNase ES.

Does response rate of chemotherapy with molecular target agents correlate with the conversion rate and survival in patients with unresectable colorectal liver metastases?: A systematic review

PURPOSE

This study aimed to evaluate whether the response rate of chemotherapy with molecular target agents correlates with the conversion rate, R0 resection rate, and survival in patients with initially unresectable colorectal liver metastases (CRLM).

METHODS

We reviewed the literature of prospective, controlled trials of systemic chemotherapy for patients with unresectable liver-only CRLM, including resectable extrahepatic metastases. Pearson's correlation coefficients were calculated.

RESULTS

A total of 26 patient groups from 18 studies were reviewed. The response rate was significantly correlated with the conversion rate (r = 0.66) and R0 resection rate (r = 0.43) in overall patients. In subgroup analysis, only the conversion rate in patients with chemotherapy only (r = 0.75) and anti-EGFR therapy (r = 0.78) were significantly strongly correlated with the response rate. A non-significant strong trend toward correlation between response and conversion rates was observed in patients with bevacizumab (r = 0.73, p = 0.10). The regression line in the scatter plot of patients using bevacizumab showed a less steep slope. This indicated that conversion rates were relatively less affected by response rates under anti-VEGF therapy compared with the other patient groups. The response rate in chemotherapy-only patients was significantly correlated with median progression-free survival (r = 0.61) and overall survival (r = 0.66).

CONCLUSIONS

Chemotherapy without molecular target agents and with anti-EGFR agents shows similar results of correlation between response and conversion/R0 resection rates. Under anti-VEGF therapy, conversion would be expected, even with a relatively lower response rate.