Randomised clinical trial: faecal microbiota transplantation for recurrent Clostridum difficile infection - fresh, or frozen, or lyophilised microbiota from a small pool of healthy donors delivered by colonoscopy

BACKGROUND

Faecal microbiota transplantation (FMT) has become routine in managing recurrent C. difficile infection (CDI) refractory to antibiotics.

AIM

To compare clinical response and improvements in colonic microbiota diversity in subjects with recurrent CDI using different donor product.

METHODS

Seventy-two subjects with ≥3 bouts of CDI were randomised in a double-blind study to receive fresh, frozen or lyophilised FMT product via colonoscopy from 50 g of stool per treatment from eight healthy donors. Recipients provided stools pre- and 7, 14 and 30 days post-FMT for C. difficile toxin and, in a subset, microbiome composition by 16S rRNA gene profiling.

RESULTS

Overall resolution of CDI was 87% during 2 months of follow-up after FMT. Stool samples before FMT had significantly decreased bacterial diversity with a high proportion of Proteobacteria compared to donors. Cure rates were highest for the group receiving fresh product seen in 25/25 (100%), lowest for the lyophilised product 16/23 (78%; P = 0.022 vs. fresh and 0.255 vs. frozen) and intermediate for frozen product 20/24 (P = 0.233 vs. fresh). Microbial diversity was reconstituted by day 7 in the subjects receiving fresh or frozen product. Improvement in diversity was seen by day 7 in those randomised to lyophilised material with reconstitution by 30 days.

CONCLUSIONS

Comparative efficacy in faecal microbiota transplantation was observed in subjects receiving fresh or frozen faecal product from the same donors. The lyophilised product had a slightly lowered efficacy compared with fresh product, but it resembled other treatments in microbial restoration 1 month after faecal microbiota transplantation.

Abstract P4-07-10: Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers

Background: MicroRNA mediated molecular alterations are involved in the initiation and progression of cancer. Altered expression of multiple microRNAs is associated with endocrine resistance in hormone receptor positive HER2 negative (HR+/HER2-ve) cancer. The role of miR-221 in inducing epithelial to mesenchymal transition (EMT) is well documented especially in cell line model systems. However, the detailed mechanism of specific microRNAs in intrinsic and acquired resistance to endocrine therapy needs to be worked out. In addition, more needs to be done in the documentation of these mechanisms in human breast cancer specimens with complete clinical documentation and long-term follow-up. In this study, we have evaluated the clinical significance of miR-221 and its mechanistic role in EMT using human specimens and cell line models.

Materials and Methods: Formalin fixed paraffin embedded tumor from 129 HR+/HER2-ve breast cancer patients with a median follow up of 63 months were used for estimation of miR-221 by quantitative real time PCR. Expression levels of genes which are direct targets of miR-221 and related genes in EMT were analysed from these tumors. Survival between miR-221 high and low groups was compared by Kaplan Meier survival curves and prognostic relevance was estimated by Cox proportional hazard model.

Cell line experiments to investigate the role of miR-221 in inducing EMT through integrin β6 are underway in both wild type and tamoxifen resistant MCF-7 cell lines (A gift from Prof Ben Ho Park, Johns Hopkins University School of Medicine).

Results: A significant elevated level of miR-221 was observed in small proportion (14%) of HR+/HER2-ve tumors. miR-221 expression had an inverse correlation with both ER protein and ESR1 mRNA levels within HR+/HER2-ve tumors. Tumors with high levels of miR-221 showed significantly higher expression of integrin β6 which is a robust marker of EMT. Patients with high expression of miR-221 had a poorer survival in Kaplan Meier analysis.

Results of interrogation of EMT mediated through integrin related pathways involving miR-221 in cell line models will be presented.

Discussion: The association between miR-221 and integrin β6 in HR+/HER2-ve breast cancer with endocrine resistance suggests a potential link between an epigenetic regulator and a mediator of tumor-stromal interaction. The other mediators involved in this pathway are being investigated. miR-221 could be potentially used as a marker for identification of a poor prognostic subtype within HR+/HER2-ve breast cancers.

Citation Format: Prabhu JS, Kaul R, Korlimarla A, Desai K, Gangadharan C, Rajarajan S, Nair MG, Alexander A, Kaluve R, Manjunath S, Correa M, Prasad MSN, Patil S, Srinath BS, Sridhar TS. Epithelial mesenchymal transition associated with high miR-221 and integrin β6 leads to poor prognosis in hormone receptor positive HER2 negative breast cancers [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-07-10.

Survey of veterinary clients' perceptions of informed consent at a referral hospital

This retrospective questionnaire study evaluates the perceptions of veterinary clients of the informed consent process and the consent form in a veterinary referral hospital. Replicating a validated perception survey from human medicine, 470 clients at the Queen Mother Hospital for Animals were surveyed on their perceptions during the consenting process through postal survey examining their understanding, experience and recall of informed consent. Of the 165 responses (35 per cent response rate), the majority of clients recalled the process and signing the form; however, half of the clients did not feel in control (51 per cent) or reassured (53 per cent) by the process. There was limited understanding of the purpose of consent, with 45 per cent thinking it removed their right to compensation for negligence and 31 per cent thought the veterinarian could do something different from the agreed procedure. Sixty per cent of clients did not read the form, as they trusted their veterinarian, but 33 per cent of clients felt frightened by the process. This survey highlights the need to understand the process of consent from the client's perspective, and adapt the consenting process to incorporate this into professional communication to ensure that the professional and contractual objectives of consent are met fully.

Organization and control of epileptic circuits in temporal lobe epilepsy

When studying the pathological mechanisms of epilepsy, there are a seemingly endless number of approaches from the ultrastructural level-receptor expression by EM-to the behavioral level-comorbid depression in behaving animals. Epilepsy is characterized as a disorder of recurrent seizures, which are defined as "a transient occurrence of signs and/or symptoms due to abnormal excessive or synchronous neuronal activity in the brain" (Fisher et al., 2005). Such abnormal activity typically does not occur in a single isolated neuron; rather, it results from pathological activity in large groups-or circuits-of neurons. Here we choose to focus on two aspects of aberrant circuits in temporal lobe epilepsy: their organization and potential mechanisms to control these pathological circuits. We also look at two scales: microcircuits, ie, the relationship between individual neurons or small groups of similar neurons, and macrocircuits, ie, the organization of large-scale brain regions. We begin by summarizing the large body of literature that describes the stereotypical anatomical changes in the temporal lobe-ie, the anatomical basis of alterations in microcircuitry. We then offer a brief introduction to graph theory and describe how this type of mathematical analysis, in combination with computational neuroscience techniques and using parameters obtained from experimental data, can be used to postulate how microcircuit alterations may lead to seizures. We then zoom out and look at the changes which are seen over large whole-brain networks in patients and animal models, and finally we look to the future.

Surgical manifestations of gastrointestinal cytomegalovirus infection in children: Clinical audit and literature review

INTRODUCTION

Gastrointestinal sequelae of cytomegalovirus are rare, usually associated with significant immune compromise, and carry a high morbidity and mortality. Gastrointestinal disease frequently requires surgical intervention for diagnosis and management.

AIM

The aim of the study is to evaluate the incidence, presentation and management of gastrointestinal cytomegalovirus disease in a pediatric population.

METHOD

Between January 2003 and June 2011, a retrospective folder review was conducted of all symptomatic children with proven CMV disease, presenting to the surgical service. Eligible patients were identified using the surgical, histopathology and serology databases.

RESULTS

Thirty-eight patients (1.8/1000 surgical admissions) were identified with a median presenting age of 5months (range 3days-12years). Esophagitis (n=18) and small bowel disease (n=16) predominated, but CMV was seen throughout the gastrointestinal tract. Risk factors included HIV infection (n=21, 55%) and recent gastrointestinal surgery or infection (n=10, 26%). Characteristic multiple jejunoileal perforations were seen in six patients. Compared to upper GIT disease, intestinal involvement was associated with younger age and doubled mortality. In HIV-infected children, median CD4 (%) was lower in intestinal compared to upper gastrointestinal disease. Morbidities included anastomotic breakdowns (5), anastomotic strictures (3), relook laparotomies (10), resistant esophageal strictures (5) and prolonged parenteral nutrition (5). Anti-CMV drugs were given in 63%. Overall mortality was 32% (12/38) and was associated with lower GIT disease.

CONCLUSION

Invasive CMV gastrointestinal disease in our children was predominantly HIV-associated, or followed a major lower gastrointestinal inflammatory insult in infants younger than 6months. Successful therapy requires a high index of suspicion of active CMV disease to allow early implementation of CMV viral load control and aggressive treatment of the underlying immune impairment. Multiple surgical interventions are often required for both tissue diagnosis and management of acute and chronic complications. CMV-viral-load-tailored anti-CMV therapy is supported by recent literature.

Patient-specific compensation for Co-60 TBI treatments based on Monte Carlo design: A feasibility study

PURPOSE

To develop an AP-PA treatment technique for the delivery of total body irradiation (TBI) at extended SSD using a modified Co-60 unit equipped with flattening filter and patient-specific compensators supported by Monte Carlo (MC) simulations and measurements.

METHODS

An existing Eldorado-78 Co-60 teletherapy unit was stripped of its original collimator and equipped with two beam-defining cerrobend blocks. An acrylic flattening filter was numerically designed based on detailed mapping of the dose distribution of the large open field at a 10 cm depth in water using a primary radiation attenuation calculation. An EGSnrc/BEAMnrc MC model of the resulting unit was developed and experimentally validated and was used to calculate MC dose distributions in whole-body supine and prone CT images of a patient. AP-PA patient-specific compensators were designed based on the supine and prone mid-plane dose distributions.

RESULTS

The designed flattening filter flattens the beam to within ±2% over a 200 cm × 70 cm area at 10 cm depth in water. Experimental validation of the calculated dose profiles in the open and flattened beams shows agreement of better than 2% and 1%, respectively. Patient MC dose calculations in the flattened, uncompensated beam showed dose deviations from prescription dose most notably in lung, neck and extremities ranging from -5% to +25%. The use of patient-specific compensators reduced inhomogeneities to within -5% to +10%.

CONCLUSIONS

This work demonstrates that a Co-60 TBI setup upgraded with patient-specific compensators, numerically designed using MC patient dose calculations, is feasible and considerably improves the dose homogeneity.

Hydrocephalus decreases arterial spin-labeled cerebral perfusion

BACKGROUND AND PURPOSE

Reduced cerebral perfusion has been observed with elevated intracranial pressure. We hypothesized that arterial spin-labeled CBF can be used as a marker for symptomatic hydrocephalus.

MATERIALS AND METHODS

We compared baseline arterial spin-labeled CBF in 19 children (median age, 6.5 years; range, 1-17 years) with new posterior fossa brain tumors and clinical signs of intracranial hypertension with arterial spin-labeled CBF in 16 age-matched controls and 4 patients with posterior fossa tumors without ventriculomegaly or signs of intracranial hypertension. Measurements were recorded in the cerebrum at the vertex, deep gray nuclei, and periventricular white matter and were assessed for a relationship to ventricular size. In 16 symptomatic patients, we compared cerebral perfusion before and after alleviation of hydrocephalus.

RESULTS

Patients with uncompensated hydrocephalus had lower arterial spin-labeled CBF than healthy controls for all brain regions interrogated (P < .001). No perfusion difference was seen between asymptomatic patients with posterior fossa tumors and healthy controls (P = 1.000). The median arterial spin-labeled CBF increased after alleviation of obstructive hydrocephalus (P < .002). The distance between the frontal horns inversely correlated with arterial spin-labeled CBF of the cerebrum (P = .036) but not the putamen (P = .156), thalamus (P = .111), or periventricular white matter (P = .121).

CONCLUSIONS

Arterial spin-labeled-CBF was reduced in children with uncompensated hydrocephalus and restored after its alleviation. Arterial spin-labeled-CBF perfusion MR imaging may serve a future role in the neurosurgical evaluation of hydrocephalus, as a potential noninvasive method to follow changes of intracranial pressure with time.

[Relative bioavailability of glucosamine after oral, intramuscular and transdermal administration of hondroxid maximum preparation in experiment]

A comparison of the relative bioavailability and intensity of penetration of glucosamine sulfate in oral, injection and topical administration of the dosage form Hondroxid Maximum as a cream containing micellar system for transdermal delivery of glucosamine in the experiment by Sprague-Dawley rats was carried out. On the base on the pharmacokinetic profiles data of glucosamine in rat blood plasma with daily administration in 3 times a day for 1 week by cream Hondroxid Maximum 400 mg/kg and the single injection solution of 4% Glucosamine sulfate 400 mg/kg was found that the relative bioavailability was 61.6%. Calculated penetration rate of glucosamine in the plasma through the rats skin in 4 hours, equal to 26.9 μg/cm2 x h, and the penetration of glucosamine through the skin into the plasma after a single dose of cream in 4 hours was 4.12%. Comparative analysis of literature and experimental data and calculations based on them suggest that medicine Hondroxid Maximum, cream with transdermal glucosamine complex in the treatment in accordance with the instructions can provide an average concentration of glucosamine in the synovial fluid of an inflamed joint in the range (0.7 - 1.5) μg/ml, much higher than the concentration of endogenous glucosamine human synovial joint fluid (0.02 - 0.07 μg/ml). By theoretical calculations taking into account experimental data it is shown that the medicine Hondroxid Maximum can reach the bioavailability level of the modern injection forms and exceed the bioavailability level of modern oral forms of glucosamine up to 2 times.

Abstract P6-12-09: Targeting deregulated cyclin E in inflammatory breast cancer via sequential combination therapy

Inflammatory breast cancer (IBC) is a rare, highly aggressive form of breast cancer, accounting for 2-5% of all breast cancers in the US and 10% of breast cancer deaths. Unfortunately, until recently this disease has not been studied extensively at the molecular/cellular level despite the compelling unmet need to develop more effective therapies. In spite of receiving aggressive multidisciplinary therapy (anthracycline-taxane-based neoadjuvant chemotherapy, modified-radical-mastectomy and adjuvant radiation therapy), only about 40% of IBC patients survive 5 years. The goal of this project is to identify new targets that can be exploited pharmacologically either in combination with current therapies or with other novel agents.

Previous work has identified tumor-specific low molecular weight forms of cyclin E, termed LMW-E, that are preferentially found in triple negative breast cancers (TNBC) and serve as a poor prognostic biomarker. As a result of cleavage, LMW-E preferentially accumulates in the cytoplasm where it exerts its pleiotropic oncogenic functions including deregulating the cell cycle. Furthermore, we have shown that TNBC cells harboring LMW-E are sensitive to CDK inhibitors.

To establish the clinical relevance of targeting the cyclin E/CDK2 axis in IBC, a pilot study was performed to determine the incidence of LMW-E. We performed IHC on 11 post-chemotherapy surgical specimens from MDACC. All tumors expressed cyclin E, 8 of which had predominantly cytoplasmic staining, indicative of LMW-E expression. These results are now being validated in a larger cohort of samples. These promising preliminary results led us to perform in vitro experiments to determine sensitivity to CDK2 inhibitors and characterize cell cycle profiles.

Similar to non-IBC breast cancers, IBC tumors can be ER-positive, TNBC or HER2-overexpressing; however, there are only TN-IBC or HER2+ cell lines. We utilized 2 cell lines for these studies, one of which is TN-IBC, the other of which is ER-negative and HER2-overexpressing. These cell lines were treated with a panel of CDK inhibitors to evaluate their sensitivity in both short-term and long-term assays. The long-term assay we developed called the high-throughput survival assay was used to examine combinations of agents for potential synergies using isobologram analysis. We have demonstrated chemotherapy-specific synergistic cell death when cells are first treated with CDK inhibitor in IBC and non-IBC cell lines.

Using flow cytometry, we have demonstrated that CDK inhibitors induce a G2/M arrest, which is further increased by sequential treatment with chemotherapy. Furthermore, combination treatment leads to cell death, as measured by sub-G1 DNA content.

Taken together, these studies provide solid evidence that targeting CDK2 is a promising strategy in treating IBC tumors that express cyclin E. Beyond these early pre-clinical advances, however, we demonstrated clear sequence-specificity for certain pairs of drugs, implying that future clinical studies should be designed taking into account the mechanism of action of cell cycle targeting drugs.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-12-09.

Abstract P6-08-12: Gains in women’s education has not led to commensurate gains in seeking health-care early in breast cancer patients in urban India

Introduction:

Breast cancer is the leading cancer diagnosed in urban Indian women. Historically the proportion of women presenting with advanced disease has been in excess of 50% at most regional cancer centres. The past 20 years has witnessed rapid economic growth and urbanization with significant gains in women's education and access to health. However, it is not clear if this has translated to earlier seeking of care in the educated.

The aim of this study was to examine if higher education (College) was a determinant in the time of seeking first medical consultation, and whether there were significant differences between women under the age of 40 versus women over 60 years old at the time of diagnosis.

Methods:

The data for analysis were obtained from a prospective longitudinal observational study conducted between 2008-2013 at a medical teaching hospital and a tertiary specialized cancer care centre. A total of 460 patients have been enrolled so far. All patients provided informed consent and the study has been reviewed and approved by the institutional ethics committees at these institutions. We have collected from the patients and their medical records information about their age at diagnosis, educational level, stage of disease, histopathology reports and clinical details.

Results:

Data from 194 patients have been used for the analysis. Patients were divided into one group of &lt; = 40Y of age (Group I, N = 58) and the second of &gt; = 60 years of age (Group II, N = 136). Mean age at presentation for the groups was 35 and 68 years respectively. As expected almost 1.5 times as many women under the age of 40 (36%) were college educated compared to the women over 60 (22%) (p = 0.05). The proportion of LABC in the two groups was not different with group I having 27% and group II 25%. The proportion of older women with LABC and a college degree was 20%. However, rather than the expected decrease in proportion of women with high education and LABC, 31% of young women with LABC had a college degree. LABC in the college educated was not different in the group I when compared to group II. (p = 0.39).

Conclusion:

The determinants of seeking health care are complex and influenced by a variety of factors including socio-economic status, access to health care, education, cultural beliefs, and personal preferences. While urban India's steady economic growth has been highlighted by the scholarly as well as the lay press, the data presented here suggest that there is not an automatic and linear transfer between education, economics and healthcare seeking behaviours. We suggest that while a lot of attention has been paid to awareness and screening, we may need to focus on local cultural factors, and perhaps provide support from female counsellors and care providers as critical components of attempting to bring our women to the hospital at the earliest.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-08-12.

Sustained Release of Diltiazem Hydrochloride from Cross-linked Biodegradable IPN Hydrogel Beads of Pectin and Modified Xanthan Gum

Interpenetrating polymer network hydrogel beads of pectin and sodium carboxymethyl xanthan were prepared by ionotropic gelation with Al(+3) ions and covalent cross-linking with glutaraldehyde for sustained delivery of diltiazem hydrochloride. Fourier transform infrared spectroscopy, X-ray diffraction, differential scanning colorimetry and scanning electron microscopy were used to characterise the hydrogel beads. The swelling of the hydrogel and the release of drug were relatively low in pH 1.2 buffer solutions. However, higher swelling and drug release were observed in pH 6.8 buffer solutions. The carboxyl functional groups of hydrogels undergo ionisation and the osmotic pressure inside the beads increases resulting in higher swelling and drug release in higher pH. The release of drug depends on concentration of polymer, amount and exposure time of cross-linker and drug content in the hydrogel matrices. The present study indicated that the hydrogel beads minimised the drug release in pH 1.2 buffer solutions and to prolong the drug release in pH 6.8 buffer solutions.

In situ liver transection with portal vein ligation for rapid growth of the future liver remnant in two-stage liver resection

Background

Portal vein embolization (PVE) has become a standard procedure to increase the future liver remnant (FLR) and enable curative resection of initially unresectable liver tumours. This study investigated the safety and feasibility of a new two-stage liver resection technique that uses in situ liver transection (ISLT) and portal vein ligation before completion hepatectomy.

Methods

A consecutive series of patients undergoing ISLT and extended right hepatectomy between 2009 and 2011 were compared with consecutive patients undergoing extended right hepatectomy after PVE. All patients had initially unresectable primary or secondary liver tumours, owing to an insufficient FLR (liver segments II/III).

Results

Fifteen patients who had PVE and seven who underwent ISLT before extended right hepatectomy were evaluated. ISLT induced rapid growth of the FLR within 3 days, particularly after insufficient PVE, from a mean(s.d.) of 293(58) ml to 477(85) ml, corresponding to a volume increase of 63(29) per cent. All patients who had ISLT underwent completion extended right hepatectomy within 8 days (range 4–8 days).

Conclusion

ISLT is an effective and reliable technique to induce rapid growth of the FLR, even in patients with insufficient volume increase after PVE.