Full-mouth Tooth Extraction Lowers Systemic Inflammatory and Thrombotic Markers of Cardiovascular Risk

Prior studies of a link between periodontal and cardiovascular disease have been limited by being predominantly observational. We used a treatment intervention model to study the relationship between periodontitis and systemic inflammatory and thrombotic cardiovascular indicators of risk. We studied 67 adults with advanced periodontitis requiring full-mouth tooth extraction. Blood samples were obtained: (1) at initial presentation, immediately prior to treatment of presenting symptoms; (2) one to two weeks later, before all teeth were removed; and (3) 12 weeks after full-mouth tooth extraction. After full-mouth tooth extraction, there was a significant decrease in C-reactive protein, plasminogen activator inhibitor-1 and fibrinogen, and white cell and platelet counts. This study shows that elimination of advanced periodontitis by full-mouth tooth extraction reduces systemic inflammatory and thrombotic markers of cardiovascular risk. Analysis of the data supports the hypothesis that treatment of periodontal disease may lower cardiovascular risk, and provides a rationale for further randomized studies.

Teaching Patients about Kidney Transplantation: Documentation

Increasing demands are being placed on transplant nurse coordinators for more precise documentation of their teaching of kidney transplant patients, but the amount of time nurses have for this added documentation remains unchanged or has diminished. After a thorough review of the literature, our transplant team found no patient teaching documentation format that assisted us in overcoming the problem of increased demands. Consequently, following the Joint Commission on Accreditation of Healthcare Organization standards, we developed a Renal Transplant Patient Teaching Record that has assisted our team in documenting the pre- and post-transplant patient teaching that we complete.

Multidimensional severity assessment in bronchiectasis: an analysis of seven European cohorts

INTRODUCTION

Bronchiectasis is a multidimensional disease associated with substantial morbidity and mortality. Two disease-specific clinical prediction tools have been developed, the Bronchiectasis Severity Index (BSI) and the FACED score, both of which stratify patients into severity risk categories to predict the probability of mortality.

METHODS

We aimed to compare the predictive utility of BSI and FACED in assessing clinically relevant disease outcomes across seven European cohorts independent of their original validation studies.

RESULTS

The combined cohorts totalled 1612. Pooled analysis showed that both scores had a good discriminatory predictive value for mortality (pooled area under the curve (AUC) 0.76, 95% CI 0.74 to 0.78 for both scores) with the BSI demonstrating a higher sensitivity (65% vs 28%) but lower specificity (70% vs 93%) compared with the FACED score. Calibration analysis suggested that the BSI performed consistently well across all cohorts, while FACED consistently overestimated mortality in 'severe' patients (pooled OR 0.33 (0.23 to 0.48), p<0.0001). The BSI accurately predicted hospitalisations (pooled AUC 0.82, 95% CI 0.78 to 0.84), exacerbations, quality of life (QoL) and respiratory symptoms across all risk categories. FACED had poor discrimination for hospital admissions (pooled AUC 0.65, 95% CI 0.63 to 0.67) with low sensitivity at 16% and did not consistently predict future risk of exacerbations, QoL or respiratory symptoms. No association was observed with FACED and 6 min walk distance (6MWD) or lung function decline.

CONCLUSION

The BSI accurately predicts mortality, hospital admissions, exacerbations, QoL, respiratory symptoms, 6MWD and lung function decline in bronchiectasis, providing a clinically relevant evaluation of disease severity.

Pulmonary atresia with intact ventricular septum and hypoplastic right ventricle in an Arabian foal

Pulmonary atresia with intact ventricular septum, rudimentary tricuspid valve, hypoplastic right ventricle, and right-to-left atrial shunting were identified in a four-day-old, male Arabian foal with clinical signs of cyanotic heart disease. Pulmonary blood flow was apparently derived from a ductus arteriosus. Echocardiographic evaluation revealed the majority of cardiac abnormalities and also findings compatible with right-sided congestive heart failure. Congenital cardiac defects have a high incidence in this breed, and this is the first description of this combination of congenital cardiac defects.

Microbiological profiles of sputum and gastric juice aspirates in Cystic Fibrosis patients

Gastro-Oesophageal Reflux (GOR) is a key problem in Cystic Fibrosis (CF), but the relationship between lung and gastric microbiomes is not well understood. We hypothesised that CF gastric and lung microbiomes are related. Gastric and sputum cultures were obtained from fifteen CF patients receiving percutaneous endoscopic gastrostomy feeding. Non-CF gastric juice data was obtained through endoscopy from 14 patients without lung disease. Bacterial and fungal isolates were identified by culture. Molecular bacterial profiling used next generation sequencing (NGS) of the 16S rRNA gene. Cultures grew bacteria and/or fungi in all CF gastric juice and sputa and in 9/14 non-CF gastric juices. Pseudomonas aeruginosa(Pa) was present in CF sputum in 11 patients, 4 had identical Pa strains in the stomach. NGS data from non-CF gastric juice samples were significantly more diverse compared to CF samples. NGS showed CF gastric juice had markedly lower abundance of normal gut bacteria; Bacteroides and Faecalibacterium, but increased Pseudomonas compared with non-CF. Multivariate partial least squares discriminant analysis demonstrated similar bacterial profiles of CF sputum and gastric juice samples, which were distinct from non-CF gastric juice. We provide novel evidence suggesting the existence of an aerodigestive microbiome in CF, which may have clinical relevance.

Restructuring Care Teams Within a Neonatal Intensive Care Unit

BACKGROUND: Organizing care teams in a large neonatal intensive care unit (NICU) is a challenge. In our pod-based model, babies were assigned a care team based on acuity and bed location. They were frequently moved between teams to accommodate nursing assignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team.

OBJECTIVES: The objective of this project was to improve consistency of patient care and to balance the workload across the three care teams in the NICU.

DESIGN/METHODS: The setting is a 69 bed tertiary teaching NICU with approximately 1300 admissions a year. Three clinical teams share day to day assignment of a combination of these level III and level II pods. A multidisciplinary subgroup conducted a two hour Kaizen (brain storming) event with a larger group of stake-holders during which the decision was made to assign babies to a care team based on current workload of each team. The care teams follow each patient from admission to discharge, regardless of the baby’s location within the unit instead of moving babies between teams. Education communication, feedback strategies regarding the process change were formulated and executed by the sub-group. The new method was piloted for a period of three months. Objective data was collected regarding patient movement, patient acuity, census balance, and rounds time. Qualitative data was collected through staff and family surveys. ignments, causing an imbalance in patient census and acuity across teams. As part of a larger process improvement project, we implemented and studied an alternate model for assigning patients to a care team.

RESULTS: Forty percent of babies admitted to the NICU crossed care teams during their stay prior to the process change while 0.3% changed teams after the change. The number of moves per patient decreased from 1.4 to 1.27. The variability in both census and acuity was diminished following implementation of the changes. The daily average number of man-hours to complete daily rounds decreased from 47.5 before the change to 40.5 after the change. There was a 35% response rate to the staff survey with an overall positive response to the changes with regards to improving the patient and family experience. The family satisfaction survey showed a trend toward increased satisfaction following the change.

CONCLUSION: Process improvement methods can be used to successfully change how care teams are structured in a tertiary NICU.

Cord Blood Methylmercury and Fetal Growth Outcomes in Baltimore Newborns: Potential Confounding and Effect Modification by Omega-3 Fatty Acids, Selenium, and Sex

BACKGROUND

Methylmercury (MeHg) may affect fetal growth; however, prior research often lacked assessment of mercury speciation, confounders, and interactions.

OBJECTIVE

Our objective was to assess the relationship between MeHg and fetal growth as well as the potential for confounding or interaction of this relationship from speciated mercury, fatty acids, selenium, and sex.

METHODS

This cross-sectional study includes 271 singletons born in Baltimore, Maryland, 2004-2005. Umbilical cord blood was analyzed for speciated mercury, serum omega-3 highly unsaturated fatty acids (n-3 HUFAs), and selenium. Multivariable linear regression models controlled for gestational age, birth weight, maternal age, parity, prepregnancy body mass index, smoking, hypertension, diabetes, selenium, n-3 HUFAs, and inorganic mercury (IHg).

RESULTS

Geometric mean cord blood MeHg was 0.94 μg/L (95% CI: 0.84, 1.07). In adjusted models for ponderal index, βln(MeHg) = -0.045 (g/cm(3)) × 100 (95% CI: -0.084, -0.005). There was no evidence of a MeHg × sex interaction with ponderal index. Contrastingly, there was evidence of a MeHg × n-3 HUFAs interaction with birth length [among low n-3 HUFAs, βln(MeHg) = 0.40 cm, 95% CI: -0.02, 0.81; among high n-3 HUFAs, βln(MeHg) = -0.15, 95% CI: -0.54, 0.25; p-interaction = 0.048] and head circumference [among low n-3 HUFAs, βln(MeHg) = 0.01 cm, 95% CI: -0.27, 0.29; among high n-3 HUFAs, βln(MeHg) = -0.37, 95% CI: -0.63, -0.10; p-interaction = 0.042]. The association of MeHg with birth weight and ponderal index was affected by n-3 HUFAs, selenium, and IHg. For birth weight, βln(MeHg) without these variables was -16.8 g (95% CI: -75.0, 41.3) versus -29.7 (95% CI: -93.9, 34.6) with all covariates. Corresponding values for ponderal index were -0.030 (g/cm(3)) × 100 (95% CI: -0.065, 0.005) and -0.045 (95% CI: -0.084, -0005).

CONCLUSION

We observed an association of increased MeHg with decreased ponderal index. There is evidence for interaction between MeHg and n-3 HUFAs; infants with higher MeHg and n-3 HUFAs had lower birth length and head circumference. These results should be verified with additional studies.

Abstract P5-04-05: Targeting the pH regulatory mechanisms of breast cancer cells

Background:

The abnormal regulation of H+ ions, leading to a reversed pH gradient in tumor cells in comparison to normal cells, is considered to be one of the hallmarks of cancer. This feature, however, has yet to be exploited as a therapeutic target. The aim of this study was to assess whether targeting proteins (CAIX, NHE1 and V-ATPase) that permit hypoxic cancer cell adaptation to acidosis in the tumor microenvironment can produce an effective therapeutic response in breast cancer, using 2D and 3D models.

Method:

Western blotting and gene expression analysis were performed on MCF-7, MDA-MB-231 and HBL-100 cancer cells to assess target protein expression in differing O2 conditions in 2D, while IHC was used to measure protein levels in 3D using multicellular tumor spheroids. Sulforhodamine B assays were executed to analyze the effects of inhibitors targeting CAIX, NHE1 and V-ATPase on breast cancer cell proliferation in 2D. 3D invasion assays were performed with MDA-MB-231 spheroids and explant tissue derived from human patients to see if CAIX inhibition had any effect on cancer cell invasion. An MDA-MB-231 xenograft model was used to investigate the effects of CAIX inhibition in vivo. Clonogenic assays were performed with MDA-MB-231 spheroids to evaluate whether any of the drugs combined effectively with irradiation.

Results:

2D and 3D expression analysis showed that CAIX levels were extremely responsive to changes in O2 conditions in each of the cell lines, with HBL100 cells exhibiting the largest changes in both mRNA (42-fold increase) and protein (78-fold increase) levels at low (0.5%) O2 concentrations. NHE1 and V-ATPase mRNA/protein levels were, however, much more consistently expressed across the cell lines in different O2 conditions. Drugs targeting CAIX, NHE1 and V-ATPase had anti-proliferative effects on the breast cancer cells in 2D. Normoxic cancer cells were the most sensitive to drug treatment, acute hypoxic cancer cells showed increased resistance to the anti-proliferative effects of these drugs, while chronic hypoxic cells had IC50 values more similar to the normoxic cells. The results for the CAIX inhibitor were unexpected, as we had predicted that the increased levels of CAIX in the acute hypoxic cells would make them more sensitive to treatment. CAIX inhibition did, however, significantly reduce the invasion of cancer cells from both MDA-MB-231 spheroids (p≤0.01) and explant tissue (p≤0.001). Targeting pH regulation was also shown to have an effect in vivo on MDA-MB-231 xenografts, with CAIX inhibition significantly reducing the growth (p≤0.05) and proliferation (p≤0.05) of tumors within mice. Finally, clonogenic assays showed that drugs targeting both CAIX and NHE1 led to a significant reduction in colony number when combined with radiation (p≤0.05), compared to either drug individually or radiation treatment alone.

Conclusions:

This study shows that drugs targeting pH regulation molecules have potential in the treatment of breast cancer. This is highlighted by their ability to affect the proliferation and invasion of breast cancer cells, along with their ability to be combined with radiation. Of the 3 pH regulatory molecules, CAIX represents the target with the most promise.

Citation Format: Meehan J, Ward C, Jarman E, Xintaropoulou C, Martinez-Perez C, Turnbull A, Supuran C, Dixon M, Kunkler I, Langdon SP. Targeting the pH regulatory mechanisms of breast cancer cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-04-05.

Abstract P4-08-06: Modulation of hypoxia-inducible factors and the HIF transcriptional response to hypoxia by ERBB2 overexpression in the MCF7 breast cancer cell line

Objective: To explore the role of HIF2α in growth factor receptor-driven HIF modulation and investigate the relationship between growth factor- and hypoxia-driven HIF activation. HIF-mediated transcriptional activity is known to drive genes involved in various processes which are associated with cancer pathology such as glycolysis, angiogenesis and metastasis. Therefore, understanding the implications of hypoxia-independent HIF regulation for both HIF1α and HIF2α, may give new insight into the mechanisms by which HIF drives cancer pathology in vivo and a greater understanding of when HIF inhibitory agents may be effective therapies.

Methods: We used an ERBB2 overexpressing MCF7 cell line (MCF7-HER2) to investigate the effect of ERBB2 on the HIF-axis. Western blotting was used to assess protein level in these cell lines. HIF protein expression was compared with and without ERBB stimulation by ERBB3 ligand neuregulin 1β. Illumina BeadChip analysis was used to compare mRNA levels between these cell lines in normoxia (20% oxygen), acute hypoxia (0.5% oxygen for 24 hours) and chronic hypoxia (0.5% oxygen for 10 weeks). Differentially expressed genes were identified using rank products analysis with a cut-off P-value of 0.01. This allowed an in-depth comparison of hypoxia responses at the level of transcription between the cell lines to ascertain the effect of ERBB2 overexpression on hypoxia driven transcriptional changes.

Results: Immunoblotting shows that HIF1α protein level is comparable between MCF7 and MCF7-HER2 cell lines, and is inducible in normoxia by stimulation with neuregulin 1β. Conversely, HIF2α protein is unaffected, but is constitutively expressed in MCF7-HER2 only. This suggests that both HIF isoforms can be up-regulated in normoxia but by different mechanisms. Microarray data suggests that the constitutively higher HIF2α levels in the MCF7-HER2 cell line may be due, at least in part, to the increased transcription of the HIF2A gene which is higher in normoxia and in response to hypoxia when compared to wild-type MCF7. Overexpression of ERBB2 in MCF7-HER2 cells appears to prime cells for their response to hypoxia, as 14% (N= 591) of the genes which are induced in acute hypoxia are also expressed at significantly higher levels in normoxic MCF7-HER2 cells. However, only 1% are more highly expressed in wild-type MCF7 cells. For chronic hypoxic genes, 18% (N= 514) were more highly expressed in normoxic MCF7-HER2 cells and just 8% in wild-type MCF7 cells. These up-regulated genes include both HIF1 and HIF2 target genes which may have important consequences for glycolysis (ALDOC, PFKFB), tumour cell survival (E4BP4, STC2) and proliferation (FOS, KDM5B).

Conclusions: We have demonstrated that both HIF1α and HIF2α can be regulated independently of hypoxia, however these appear to be controlled through distinct mechanisms. Whilst the implications of HIF1 in breast cancer pathology have been appreciated for some time, relatively little is known about the impact of HIF2. Here we show that ERBB2 overexpression can not only increase HIF2α protein levels in normoxia, but may also prime cells for hypoxia by allowing the constitutively higher expression of HIF1 and HIF2 target genes.

Citation Format: Jarman EJ, Turnbull AK, Martinez-Perez C, Meehan J, Xintralopoulou C, Ward C, Langdon SP. Modulation of hypoxia-inducible factors and the HIF transcriptional response to hypoxia by ERBB2 overexpression in the MCF7 breast cancer cell line. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-08-06.

From gastric aspiration to airway inflammation

The airways are poorly protected from potentially damaging agents contained within gastric contents. While digestive factors are obvious damaging agents, gastric aspiration may also deliver microbial agents, cytokines or food antigens to airway tissues. Direct damage or the triggering of the inflammatory cascade by gastric aspiration is believed to drive airways disease onset and/or progression. Evidence exists from experimental models demonstrating direct instillation of damaging factors to a range of airways epithelia causes damage and/or an inflammatory response. Clinical longitudinal studies have also noted an association between the presence of biomarkers of reflux in airways samples and disease progression. A shared pathophysiology of many chronic airways diseases is a more negative intrathoracic pressure. Such changes would drive an increased abdominothoracic pressure gradient. These changes in respiratory mechanics mean that chronic lung disease patients may be predisposed to reflux and subsequent aspiration. Therefore, it appears that gastric aspiration and airways disease progression may be linked not solely as cause and effect, but seemingly within a vicious cycle. A range of physiological factors govern both occurrence of gastric reflux into the pharynx/larynx and could also increase the susceptibility of certain individuals to disease progression. A range of long-term surgical and pharmacological intervention studies are necessary to test the benefit of such therapies in reducing disease progression or driving symptom improvement. Such studies may be hampered by the reliability of available therapies in halting gastric aspiration and the difficulty in the clinical or biochemical assessment of gastric aspiration.

Care in the home for seriously ill children with complex needs: A narrative literature review

This article reviews contemporary literature on home care of the seriously ill child with complex care needs and the sick child/parent dyad. The literature search revealed three major themes, namely the increasing acuity of child illness, the evolving role of the parent as care provider, and the health professional as care provider. While there is much known about the complexity of care of children and the role of family in that care, little is known about what families require in terms of support and sustenance during the long years of care provision.

Successful treatment of a cat with primary hypoadrenocorticism and severe hyponatremia with desoxycorticosterone pivalate (DOCP)

A 6-year-old, castrated male Siamese cat was diagnosed with primary hypoadrenocorticism, confirmed by an adrenocorticotopic hormone (ACTH) stimulation test documenting both hypocortisolism and hypoaldosteronism. The cat was successfully treated using a combination of prednisolone and desoxycorticosterone pivalate (DOCP). This case demonstrates that DOCP can be used successfully as mineralocorticoid supplementation in cats with hypoadrenocorticism and may have a longer therapeutic duration than that in dogs.

Effectiveness of a multidisciplinary team approach to the prevention of readmission for acute glycaemic events

AIMS

To describe the effect of a combined diabetes specialist/mental health team approach to prevent readmissions for acute glycaemic events among patients with diabetes.

METHODS

Consecutive patients with diabetes, readmitted to a single hospital for an acute glycaemic condition, were offered one or more diabetes (including assessment, education, medication, technology use and intensive support) and mental health (including assessment, training and therapies) interventions. The pilot service took place over 11 months, with the preceding 24 months and subsequent 8 months serving as control periods.

RESULTS

Of the 58 patients admitted, 50 had Type 1 diabetes and were from within the hospital catchment area, and were discharged home. Of these, 32 (64%) had a pre-existing mental health issue and 14 (28%) had a complex social situation. In all, 96% of patients were met as an inpatient by a team member, and 94% accepted at least one intervention. The mean ±sd number of admissions per patient/month dropped from 0.12 ± 0.10 to 0.05 ± 0.10 (P < 0.001) during the intervention, increasing, once the intervention ended, to 0.16 ± 0.36 (P = 0.002). The mean ± sd length of stay similarly decreased and increased (0.6 ± 0.9 to 0.2 ± 0.7 days; P < 0.001 to 0.006) to 0.6 ± 1.4 days (P = 0.003) per patient/month) across the three periods, as did the mean ±sd tariff paid per patient/month (₤258.0 ± 374.0 vs ₤92.1 ± 245.0 vs ₤287.3 ± 563.8; P < 0.001 and P = 0.018, respectively). The mean ± sd HbA1c level dropped from 99 ± 22 to 92 ± 24 mmol/mol (11.2 ± 4.2% vs 10.6 ± 4.3%; P = 0.014) but did not increase after the intervention [89 ± 26 mmol/mol (10.4 ± 4.5%)].

CONCLUSIONS

The cost and long-term risks of hospitalization among patients with Type 1 diabetes and recurrent admissions can be reduced by a combined specialist diabetes/mental health team approach.

Dietary sources of methylated arsenic species in urine of the United States population, NHANES 2003-2010

BACKGROUND

Arsenic is an ubiquitous element linked to carcinogenicity, neurotoxicity, as well as adverse respiratory, gastrointestinal, hepatic, and dermal health effects.

OBJECTIVE

Identify dietary sources of speciated arsenic: monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA).

METHODS

Age-stratified, sample-weighted regression of NHANES (National Health and Nutrition Examination Survey) 2003-2010 data (∼8,300 participants ≥6 years old) characterized the association between urinary arsenic species and the additional mass consumed of USDA-standardized food groups (24-hour dietary recall data), controlling for potential confounders.

RESULTS

For all arsenic species, the rank-order of age strata for median urinary molar concentration was children 6-11 years > adults 20-84 years > adolescents 12-19 years, and for all age strata, the rank-order was DMA > MMA. Median urinary molar concentrations of methylated arsenic species ranged from 0.56 to 3.52 µmol/mol creatinine. Statistically significant increases in urinary arsenic species were associated with increased consumption of: fish (DMA); fruits (DMA, MMA); grain products (DMA, MMA); legumes, nuts, seeds (DMA); meat, poultry (DMA); rice (DMA, MMA); rice cakes/crackers (DMA, MMA); and sugars, sweets, beverages (MMA). And, for adults, rice beverage/milk (DMA, MMA). In addition, based on US (United States) median and 90th percentile consumption rates of each food group, exposure from the following food groups was highlighted: fish; fruits; grain products; legumes, nuts, seeds; meat, poultry; and sugars, sweets, beverages.

CONCLUSIONS

In a nationally representative sample of the US civilian, noninstitutionalized population, fish (adults), rice (children), and rice cakes/crackers (adolescents) had the largest associations with urinary DMA. For MMA, rice beverage/milk (adults) and rice cakes/crackers (children, adolescents) had the largest associations.