Understanding the safety of the new ultra long acting basal insulin

Hypoglycaemia is a key safety concern in diabetes management. It is potentially dangerous and the fear of hypoglycaemia may lead to sub-optimal dosing and inadequate glycaemic control. On the other hand, hypoglycaemia may generate adverse effects and disease complications, will compromise the quality of life and will substantially increase the economic burden of treatment budged. Today, treat to target clinical trial designs are mandate for clinical development of any newer anti-diabetic medication. While similar glycaemic targets are expected to be achieved by test and comparator, the newer molecules are definitely expected to show advantage over standard comparator in terms of reduction in frequency and severity of hypoglycaemia. An ultra-long acting basal analogue insulin degludec (IDeg), has been recently approved for the treatment of type 2 and type 1 diabetes mellitus (T2DM and T1DM). The pooled patient-level data for self-reported hypoglycaemia from seven phase 3a trials with IDeg has shown significantly lower episodes of nocturnal confirmed and numerical low overall confirmed hypoglycaemia with IDeg, compared to Insulin glargine (IGlar), which was more pronounced during maintenance phase of treatment in all populations. The most plausible explanation being that, the flat peakless profile of IDeg with least glycaemic variability leads to less hypoglycaemia and adds to the safety profile of this ultra-long acting insulin. The real life practice will further validate the findings of clinical trials.

Coexistence of Extended Spectrum Beta-Lactamases, AmpC Beta-Lactamases and Metallo-Beta-Lactamases in Acinetobacter baumannii from burns patients: a report from a tertiary care centre of India

Multidrug-resistant Acinetobacter baumanii is a major pathogen encountered in pyogenic infections, especially from burns patients in hospital settings. Often there is also coexistence of multiple beta-lactamase enzymes responsible for beta-lactam resistance in a single isolate, which further complicates treatment options. We conducted a study on burn wound pus samples obtained from the burns unit of our hospital. Phenotypic tests were used to determine the Extended Spectrum Beta-Lactamase, AmpC Beta-Lactamase and Metallo-Beta-Lactamase producing status of the isolates. Almost half of the samples from the burn wounds yielded Acinetobacter baumanii as the predominant pathogen (54.05%). Coexistence of the three resistance mechanisms was seen in 25 of the 100 (25%) isolates of Acinetobacter baumanii. This study emphasizes the need for the detection of isolates that produce these enzymes to avoid therapeutic failures and nosocomial outbreaks.

Abstract P1-04-05: Subpopulation heterogeneity demonstrated in circulating tumor cells isolated from breast cancer patients using ApoStream™, an antibody-independent cancer cell recovery device

Background: Current established methods of circulating tumor cell (CTC) isolation and identification rely on antibodies against epithelial specific markers such as epithelial cell adhesion molecule (EpCAM) and cytokeratin (CK). The classical phenotypic definition of a CTC is a CK positive, CD45 negative, nucleated cell, yet several reports have shown that EpCAM and CK detect only a fraction of CTCs and are not sufficient to detect the heterogeneous subpopulations of CTCs. Moreover, subsets of primary tumor cells acquire features of invasiveness and transform into an aggressive phenotype. During this process, EpCAM and CK are down regulated or lost leaving a lethal population of CTCs undetectable and unstudied using antibody dependent CTC technologies. It is imperative to isolate CTCs in an unbiased, EpCAM independent manner and expand the phenotypic characterization of CTCs to elucidate the subpopulation heterogeneity. Here we used ApoStream™, a novel, antibody-independent device which exploits differences in the dielectric properties between cancer cells and normal blood cells to enrich CTCs from the blood of cancer patients. We demonstrate device performance and integration with additional methods to perform subsequent phenotyping and molecular marker analysis. Methods: The performance of ApoStream™ was assessed using SKOV3 (ovarian cancer) and MDA-MB-231 (breast cancer) cell lines that have a high and low expression level of EpCAM, respectively, to demonstrate linearity and precision of recovery independent of EpCAM receptor levels. A side-by-side comparison of CellSearch® and ApoStream™ was performed on 10 metastatic breast cancer patients. A multiplexed immunofluorescent assay and laser scanning cytometry (LSC) analyses were applied to identify multiple combinations of positive and/or negative staining for CK/CD45/DAPI cells, expression of EpCAM and vimentin. Results: In system precision performance studies, the average recovery of SKOV3 and MDA-MB-231 cancer cells spiked into approximately 12 million peripheral blood mononuclear cells obtained from 7.5 mL normal donor blood was 75.4 ± 3.1% (n = 12) and 71.2 ± 1.6% (n = 6), respectively. The intra-day and inter-day precision coefficients of variation (CVs) of the device were both less than 3%. Linear regression analysis yielded a correlation coefficient (R2) of more than 0.99 for a spiking range of 4-2600 cells. ApoStream™ consistently recovered significantly higher numbers of CTCs compared to CellSearch® (p = 0.024). ApoStream™ recovered varying numbers of CK+/CD45−/DAPI+, CK+/CD45+/DAPI+, CK−/CD45−/DAPI+ cells from each cancer patient sample tested. ApoStream™ recovered both EpCAM+ and EpCAM− CTCs in 50% and 90% of patients, respectively. Vimentin+ CTCs were isolated from 90% of patients. Conclusions: The ApoStream™ technology circumvents dependence on expression of EpCAM and recovers CTCs in high percentage of patients. ApoStream™ coupled with LSC analysis is a sensitive method for phenotyping and detecting biomarker expression in CTCs. These results demonstrate the broad applicability of ApoStream™ for enrichment and molecular characterization of CTCs as a foundation for improved clinical applications of CTCs.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-04-05.

Enzymatic hydrolysis and production of bioethanol from common macrophytic green alga Ulva fasciata Delile

The green seaweed Ulva which proliferates fast and occurs abundantly worldwide was used as a feedstock for production of ethanol following enzymatic hydrolysis. Among the different cellulases investigated for efficient saccharification, cellulase 22119 showed the highest conversion efficiency of biomass into reducing sugars than Viscozyme L, Cellulase 22086 and 22128. Pre-heat treatment of biomass in aqueous medium at 120°C for 1h followed by incubation in 2% (v/v) enzyme for 36 h at 45°C gave a maximum yield of sugar 206.82±14.96 mg/g. The fermentation of hydrolysate gave ethanol yield of 0.45 g/g reducing sugar accounting for 88.2% conversion efficiency. These values are substantially higher than those of reported so far for both agarophytes and carrageenophytes. It was also confirmed that enzyme can be used twice without compromising on the saccharification efficiency. The findings of this study reveal that Ulva can be a potential feedstock for bioethanol production.

Spectrum of imaging findings on MDCT enterography in patients with small bowel tuberculosis

Abdominal tuberculosis (TB) is the sixth most common extrapulmonary site of involvement. The sites of involvement in abdominal tuberculosis, in descending order of frequency, are lymph nodes, genitourinary tract, peritoneal cavity, and gastrointestinal tract. The radiological armamentarium for evaluating tuberculosis of the small bowel (SBTB) includes barium studies (small bowel follow-through, SBFT), CT (multidetector CT, CT enterography, and CT enteroclysis), ultrasound (sonoenteroclysis), and magnetic resonance imaging (MRI; enterography and enteroclysis). In this review, we illustrate the abnormalities at MDCT enterography in 20 consecutive patients with SB TB and also describe extraluminal findings in these patients. MDCT enterography allows non-invasive good-quality assessment of well-distended bowel loops and the adjacent soft tissues. It displays the thickness and enhancement of the entire bowel wall in all three planes and allows examination of all bowel loops, especially the ileal loops, which are mostly superimposed. The terminal ileum and ileocaecal junction are the most common sites of small bowel involvement in intestinal TB. The most common abnormality is short-segment strictures with symmetrical concentric mural thickening and homogeneous mural enhancement. Other findings include lymphadenopathy, ascites, enteroliths, peritoneal thickening, and enhancement. In conclusion, MDCT enterography is a comprehensive technique for the evaluation of SB TB.

A comparative analysis of nasogastric and intravenous fluid resuscitation in patients with malignant obstructive jaundice prior to endoscopic biliary drainage

Background:

An alternative to intravenous is nasogastric fluid administration through normal functioning gut. Though not common, this practice has significance in mass causalities and elective situations.

Aim:

The study was designed to compare nasogastric and intravenous fluid resuscitation in malignant obstructive jaundice (OJ) and their effect on endotoxemia.

Materials and Methods:

Sixty patients with malignant OJ undergoing endoscopic biliary drainage were randomized into two groups. A total of 4 l of fluid (Ringer's lactate) was administered to Group A through nasogastric tube and to Group B through intravenous route for 48 h. Vital parameters, serum bilirubin, serum creatinine, creatinine clearance rate, electrolytes, and endotoxemia were monitored.

Results:

Significant improvement in blood pressure (Group A, P = 0.014; Group B, P = 0.020) and significant decrease in serum bilirubin level (Group A, P = 0.001; Group B, P > 0.0001) was observed in both groups after resuscitation. Significantly decreased (P = 0.036) post hydration endotoxin level was observed in Group A as compared to Group B. Febrile events were significantly higher (P = 0.023) in Group B as compared to Group A (6 vs 0). Electrolyte abnormalities were found more in Group B, however statistically insignificant.

Conclusion:

In OJ patient undergoing biliary drainage, preoperative fluid resuscitation through nasogastric tube may be helpful in reducing postoperative septic complications and endotoxemia.

Survival Differences between Organ Preservation Surgery and Definitive Radiotherapy in Early Supraglottic Squamous Cell Carcinoma

Objective

Single-modality treatment, either with organ preservation surgery (OPS) or definitive radiation (RT), is the treatment of choice for patients with early supraglottic squamous cell carcinoma (SGC). However, studies comparing the effectiveness of these 2 techniques are lacking. This study compares the survival outcomes in early SGC patients treated with OPS versus RT.

Study Design

Secondary data analysis.

Setting

Surveillance, Epidemiology and End Results database.

Subjects and Methods

This study included adult patients with early-stage (T1N0, T2N0) SGC undergoing single-modality treatment with either OPS (with or without neck dissection [ND]) or RT between 1988 and 2008. Survival analysis was used to compare the overall survival (OS) and disease-specific survival (DSS) between patients treated with OPS+ND, OPS alone, and RT.

Results

A total of 2631 T1/T2 N0 SGC patients were identified, of whom 167 (6%) were treated with OPS+ND, 186 (7%) with OPS only, and 2278 patients (87%) with definitive RT only. In stage I (T1N0) SGC patients, a significantly better 5-year DSS was noted for both OPS+ND (81% vs 68%, hazard ratio [HR] = 0.61, P = .03) and OPS only (82% vs 68%, HR = 0.70, P = .05) when compared with definitive RT. For stage II (T2N0) patients, only OPS+ND resulted in a significantly better 5-year DSS (86% vs 60%, HR = 0.31, P < .001) when compared with patients treated with RT.

Conclusions

Patients with early SGC who underwent OPS+ND had better OS and DSS than patients undergoing RT alone. OPS+ND may be considered a viable and preferred treatment option in these patients.

Effect of vehicle front end profiles leading to pedestrian secondary head impact to ground

Most studies of pedestrian injuries focus on reducing traumatic injuries due to the primary impact between the vehicle and the pedestrian. However, based on the Pedestrian Crash Data Study (PCDS), some researchers concluded that one of the leading causes of head injury for pedestrian crashes can be attributed to the secondary impact, defined as the impact of the pedestrian with the ground after the primary impact of the pedestrian with the vehicle. The purpose of this study is to understand if different vehicle front-end profiles can affect the risk of pedestrian secondary head impact with the ground and thus help in reducing the risk of head injury during secondary head impact with ground. Pedestrian responses were studied using several front-end profiles based off a mid-size vehicle and a SUV that have been validated previously along with several MADYMO pedestrian models. Mesh morphing is used to explore changes to the bumper height, bonnet leading-edge height, and bonnet rear reference-line height. Simulations leading up to pedestrian secondary impact with ground are conducted at impact speeds of 40 and 30 km/h. In addition, three pedestrian sizes (50th, 5th and 6yr old child) are used to enable us to search for a front-end profile that performs well for multiple sizes of pedestrians, not just one particular size. In most of the simulations, secondary ground impact with pedestrian head/neck/shoulder region occurred. However, there were some front-end profiles that promoted secondary ground impact with pedestrian lower extremities, thus avoiding pedestrian secondary head impact with ground. Previous pedestrian safety research work has suggested the use of active safety methods, such as 'pop up hood', to reduce pedestrian head injury during primary impact. Accordingly, we also conducted simulations using a model with the hood raised to capture the effect of a pop-up hood. These simulations indicated that even though pop-up hood helped reducing the head injury criterion during primary impact, it changed the overall pedestrian kinematics in some cases. The specific design with pop up hood evaluated in this study did not prevent pedestrian head secondary impact with the ground or actually led to more severe pedestrian secondary head impact with the ground.

Clinical experience with insulin detemir, biphasic insulin aspart and insulin aspart in people with type 2 diabetes: Results from the Mumbai cohort of the A1chieve study

BACKGROUND

The A1chieve, a multicentric (28 countries), 24-week, non-interventional study evaluated the safety and effectiveness of insulin detemir, biphasic insulin aspart and insulin aspart in people with T2DM (n = 66,726) in routine clinical care across four continents.

MATERIALS AND METHODS

Data was collected at baseline, at 12 weeks and at 24 weeks. This short communication presents the results for patients enrolled from Mumbai, India.

RESULTS

A total of 2112 patients were enrolled in the study. Four different insulin analogue regimens were used in the study. Patients had started on or were switched to biphasic insulin aspart (n = 1561), insulin detemir (n = 313), insulin aspart (n = 144), basal insulin plus insulin aspart (n = 53) and other insulin combinations (n = 41). At baseline glycaemic control was poor for both insulin naïve (mean HbA1c: 8.7%) and insulin user (mean HbA1c: 9.2%) groups. After 24 weeks of treatment, both the groups showed improvement in HbA1c (insulin naïve: -1.4%, insulin users: -1.8%). SADRs including major hypoglycaemic events or episodes did not occur in any of the study patients.

CONCLUSION

Starting or switching to insulin analogues was associated with improvement in glycaemic control with a low rate of hypoglycaemia.

Evaluation of diuretic activity of different extracts of Mimosa pudica Linn

In that study, Mimosa pudica linn was tested for diuretic activity using the lipschitz test. The ethanolic and aqoues extract of Mimosa pudica Linn. was studied at two dose level 100 and 200 mg kg(-1) b.wt. Furosemide (20 mg kg(-1) b.wt.) was used as standard drug in a 0.9% saline solution. Urine volumes were measured for all the groups up to 5 h. The ethanolic extract of Mimosa pudica linn was exhibited significant diuretic activity at doses of 100 and 200 mg kg(-1) b.wt. by increasing total urine volume and ion concentration of Na+ k+ and Cl-.

Abstract A079: Subpopulation heterogeneity demonstrated in circulating tumor cells isolated from breast cancer patients using ApoStream, an antibody-independent cancer cell recovery device

Background: Current established methods of circulating tumor cell (CTC) isolation and identification rely on antibodies against epithelial specific markers such as epithelial cell adhesion molecule (EpCAM) and cytokeratin (CK). The classical phenotypic definition of a CTC is a CK positive, CD45 negative, nucleated cell, yet several reports have shown that EpCAM and CK detect only a fraction of CTCs and are not sufficient to detect the heterogeneous subpopulations of CTCs. Moreover, subsets of primary tumor cells acquire features of invasiveness and transform into an aggressive phenotype. During this process, EpCAM and CK are down regulated or lost leaving a lethal population of CTCs undetectable and unstudied using antibody dependent CTC technologies. It is imperative to isolate CTCs in an unbiased, EpCAM independent manner and expand the phenotypic characterization of CTCs to elucidate the subpopulation heterogeneity. Here we used ApoStream™, a novel, antibody-independent device which exploits differences in the dielectric properties between cancer cells and normal blood cells to enrich CTCs from the blood of cancer patients. We demonstrate device performance and integration with additional methods to perform subsequent phenotyping and molecular marker analysis. Methods: The performance of ApoStream™ was assessed using SKOV3 (ovarian cancer) and MDA-MB-231 (breast cancer) cell lines that have a high and low expression level of EpCAM, respectively, to demonstrate linearity and precision of recovery independent of EpCAM receptor levels. A side-by-side comparison of CellSearch® and ApoStream™ was performed on 10 metastatic breast cancer patients. A multiplexed immunofluorescent assay and laser scanning cytometry (LSC) analyses were applied to identify multiple combinations of positive and/or negative staining for CK/CD45/DAPI cells, expression of EpCAM and vimentin. Results: In system precision performance studies, the average recovery of SKOV3 and MDA-MB-231 cancer cells spiked into approximately 12 million peripheral blood mononuclear cells obtained from 7.5 mL normal donor blood was 75.4 ± 3.1% (n=12) and 71.2 ± 1.6% (n=6), respectively. The intra-day and inter-day precision coefficients of variation (CVs) of the device were both less than 3%. Linear regression analysis yielded a correlation coefficient (R2) of more than 0.99 for a spiking range of 4-2600 cells. ApoStream™ consistently recovered significantly higher numbers of CTCs compared to CellSearch® (p=0.024). ApoStream™ recovered varying numbers of CK+/CD45–/DAPI+, CK+/CD45+/DAPI+, CK–/CD45–/DAPI+ cells from each cancer patient sample tested. ApoStream™ recovered both EpCAM+ and EpCAM– CTCs in 50% and 90% of patients, respectively. Vimentin+ CTCs were isolated from 90% of patients. Conclusions: The ApoStream™ technology circumvents dependence on expression of EpCAM and recovers CTCs in high percentage of patients. ApoStream™ coupled with LSC analysis is a sensitive method for phenotyping and detecting biomarker expression in CTCs. These results demonstrate the broad applicability of ApoStream™ for enrichment and molecular characterization of CTCs as a foundation for improved clinical applications of CTCs.

Citation Format: Kenna L. Anderes, Vladislava O. Melnikova, Vishal Gupta, Dave K. Hasegawa, Darren W. Davis. Subpopulation heterogeneity demonstrated in circulating tumor cells isolated from breast cancer patients using ApoStream, an antibody-independent cancer cell recovery device. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Breast Cancer Research: Genetics, Biology, and Clinical Applications; Oct 3-6, 2013; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2013;11(10 Suppl):Abstract nr A079.

Summary of the British Thoracic Society guideline for diagnostic flexible bronchoscopy in adults

Flexible bronchoscopy is an essential, established and expanding tool in respiratory medicine. Its practice, however, needs to be safe, effective and for the right indications to maximise clinical utility. This guideline is based on the best available evidence and is a revised update of the British Thoracic Society guideline on diagnostic flexible bronchoscopy.

Early detection of recurrent disease by FDG-PET/CT leads to management changes in patients with squamous cell cancer of the head and neck

OBJECTIVE

The objective of this study was to compare the efficacy of surveillance high-resolution computed tomography (HRCT) and physical examination/endoscopy (PE/E) with the efficacy of fluorodeoxyglucose (FDG)-positron emission tomography (PET)/HRCT for the detection of relapse in head and neck squamous cell carcinoma (HNSCC) after primary treatment.

METHODS

This is a retrospective analysis of contemporaneously performed FDG-PET/HRCT, neck HRCT, and PE/E in 99 curatively treated patients with HNSCC during post-therapy surveillance to compare performance test characteristics in the detection of early recurrence or second primary cancer.

RESULTS

Relapse occurred in 19 of 99 patients (20%) during a median follow-up of 21 months (range: 9-52 months). Median time to first PET/HRCT was 3.5 months. The median time to radiological recurrence was 6 months (range: 2.3-32 months). FDG-PET/HRCT detected more disease recurrences or second primary cancers and did so earlier than HRCT or PE/E. The sensitivity, specificity, and positive and negative predictive values for detecting locoregional and distant recurrence or second primary cancer were 100%, 87.3%, 56.5%, and 100%, respectively, for PET/HRCT versus 61.5%, 94.9%, 66.7%, and 93.8%, respectively, for HRCT versus 23.1%, 98.7%, 75%, and 88.6%, respectively, for PE/E. In 19 patients with true positive PET/HRCT findings, a significant change in the management of disease occurred, prompting either salvage or systemic therapy. Of the 14 curatively treated patients, 11 were alive with without disease at a median follow-up of 31.5 months.

CONCLUSION

FDG-PET/HRCT has a high sensitivity in the early detection of relapse or second primary cancer in patients with HNSCC, with significant management implications. Given improvements in therapy and changes in HNSCC biology, appropriate modifications in current post-therapy surveillance may be required to determine effective salvage or definitive therapies.