Abstract P4-06-04: Gamma-secretase inhibitors suppress the activation of NFκB and the expression of TNFα, IL-6 and IL-8 in triple negative breast cancer cells

Background: Inflammation mediators, such as NF-kappa B (NFκB) and tumor necrosis factor alpha (TNFα), play major role in breast cancer pathogenesis, progression, and relapse. Triple negative breast cancer (TNBC) is a heterogeneous group of aggressive breast cancers and often has a poor outcome, in which Notch pathways are highly activated. However, role of crosstalk between Notch and inflammation mediators in TNBC progression and recurrence is poorly understood. The present study determines: 1) whether NFκB is highly activated in TNBC cells such as MDA-MB-231 (claudin-low-like) and MDA-MB-468 (basal-like), compared to ER-positive cells (MCF-7); 2) whether TNFα, IL-6 and IL-8 are highly expressed in TNBC cells, compared to MCF-7 cells; 3) whether Notch inhibition by gamma-secretase inhibitors (GSIs) significantly decrease NFκB activation and the expression of TNFα, IL-6 and IL-8 in TNBC cells; 4) whether GSI inhibits TNBC cell migration.

Material and Methods: MDA-MB-231, MDA-MB-468, MCF-7 cells were cultured using RPMI 1640 media with 10% FBS. The cells were exposed to GSIs such as DAPT and RO4929097 for 18 hours. Nuclear NFκB activation was determined by using the TransAM NFκB p65 kit (Active Motif). The expressions of TNFα, IL-6, IL-8, and IFNγ were determined by the ELISA kits (R&D Systems). Migration was determined using BD BioCoat Matrigel Invasion Chamber (BD Bioscience Discovery Labware, Sedford, MA).

Results: Nuclear NFκB p65 activations (A450) were 0.292±0.015, 0.222±0.005, and 0.132±0.004 in cultured MDA-MB-231, MDA-MB-468, and MCF-7 cells, respectively, in which the negative control was 0.125±0.008 and the difference between the groups were significant (P < 0.01, n=6). TNFα protein level was 266±14 pg/mg in MDA-MB-468 cells, but it was not detected in MCF-7 and MDA-MB-231 cells. IL-8 protein levels were 42.8±3, 30.3±2, and 0.23±0.01 ng/mg in MDA-MB-468, MDA-MB-231, and MCF-7 cells, respectively (P < 0.01 between groups, n=6). IL-6 protein levels were 17.1±0.9, 13.9±0.7, and 0.11±0.02 ng/mg in MDA-MB-468, MDA-MB-231, and MCF-7 cells, respectively (P < 0.01 between groups, n=6). IFNγ was not detected in these three cell lines. DAPT (20 µmol/L) or RO4929097 (10 µmol/L) caused 47.7% or 30.6% reduction in NFκB activation, 34.6% or 32.1% reduction in TNFα expression, and 22.2% or 16.4% reduction in IL-8 expression in MDA-MB-468 cells, compared to DMSO group (P < 0.01, n=6). GSIs had no effect on IL-6 expression. DAPT (20 µmol/L) significantly reduced migration of MDA-MB-468 cells by 23%, compared to DMSO group (P < 0.01, n=6).

Discussion: The novel findings are 1) NFκB is highly activated in TNBC cells, compared to ER-positive cells, which is associated with significantly increased the expression of inflammation mediators such as IL-6 and IL-8 in TNBC cells and TNFα in MDA-MB-468; and 2) Notch inhibition by GSIs significantly decrease NFκB activation and the expression of TNFα, and IL-8 in TNBC cells. These results support the hypothesis that the crosstalk between Notch and NFκB lead to activation of inflammation mediators such as TNFα and IL 8, which contribute to TNBC progression and recurrence.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P4-06-04.

Abstract OT3-4-02: MINT I: Multi-Institutional Neo-adjuvant Therapy, MammaPrint Project I

Background: Women with locally advanced breast cancer (LABC) are often treated with neo-adjuvant chemotherapy to reduce the size of the tumor prior to surgery, to enable breast conserving surgery and to observe the clinical effect of therapy in real time. Studies have shown that the 25–27% of individuals who have a pathologic complete response (pCR) to neoadjuvant therapy have a survival advantage of 80% in 5 years, which is double the expected survival of the remaining patients without pCR. If patients who are likely to show a pCR could be identified prior to initiation of therapy, it would enable more informed treatment decisions – patients likely to respond would be served well by current neoadjuvant chemotherapy protocols, while those unlikely to respond may be better suited to innovative new strategies for drug discovery [von Minckwitz et al. JCO 2006]. Genomics assays, which are widely used to provide prognostic and predictive information in early breast cancer, have the potential to provide information on the likelihood of a patient with LABC responding to neo-adjuvant therapy [Glück et al. ASCO 2012].

Trial design: MINT I is a prospective study designed to test the ability of molecular profiling, as well as traditional pathologic and clinical prognostic factors, to predict responsiveness to neo-adjuvant chemotherapy in patients with LABC. MammaPrint risk profile, BluePrint molecular subtyping profile, TargetPrint estrogen receptor (ER), progesterone receptor (PR) and HER2 single gene readout, and the 56-gene TheraPrint Research Gene Panel will be analyzed on a fresh tumor specimen using the whole genome array. Patients will receive neo-adjuvant chemotherapy pre-specified in the protocol. Response will be measured centrally. pCR is defined as the absence of invasive carcinoma in both the breast and axilla at microscopic examination of the resection specimen, regardless of the presence of carcinoma in situ.

Eligibility: The study will include women ≥18 years with histologically-proven invasive breast cancer T2 (≥3.5cm)-T4, N0M0 or T2-T4N1M0, adequate bone marrow reserves and normal renal and hepatic function who signed an IRB approved informed consent.

Objectives: The objectives of the study are to: 1. Determine the predictive power of MammaPrint and BluePrint for sensitivity to neo-adjuvant chemotherapy as measured by pCR.2. Compare TargetPrint ER, PR and HER2 with local and centralized IHC and/or CISH/FISH assessment.3. Identify correlations between TheraPrint and response to neo-adjuvant chemotherapy.4. Identify and/or validate predictive gene expression profiles of clinical response or resistance to neo-adjuvant chemotherapy.5. Compare BluePrint with IHC-based subtype classification.

Statistical methods: Standard statistical tests such as the Pearson Chi-square test will be used to characterize and evaluate the relationship between chemoresponsiveness and gene expression patterns.

Accrual: A total of 226 eligible patients will be enrolled from multiple institutions. To date (June 06, 2012), 31 patients have been enrolled.

Clinical trial registry number: NCT01501487.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-4-02.

Promoting rehabilitation for stroke survivors

Stroke does not only affect physical health; it also has an impact on psychological health and many other aspects of survivors' lives. Nurses have a central role in stroke rehabilitation. This article discusses rehabilitation, the role of the nurse, psychological care, secondary prevention and life after stroke. It focuses on resuming driving and returning to work as these are particularly important for the one-quarter of stroke patients who are aged under 65.

Medical student rankings of proposed sanction for unprofessional behaviours relating to academic integrity: results from a Scottish medical school

The General Medical Council emphasizes the cultivation of professional behaviours among medical students from early undergraduate years. Learning professional behaviours, however, is a progression and is constituted of several developmental stages. Behaving with academic integrity may be the first stage. In an educational setting, academic integrity is represented by a collection of diverse behaviours. Although there is consensus within the medical community that the absence of (or lapses in) academic integrity is unacceptable, the level of sanctions recommended for medical students is controversial. In the main, these punitive decisions over students are taken by teachers and clinicians. What sanctions would students suggest for a colleague who is academically unprofessional? This study reports the sanctions recommended by 375/700 (54%) of the students of one Scottish medical school in relation to lapses in academic integrity.

Hydrodynamic treatment of wastewater effluent flocs for improved disinfection

Hydrodynamic forces generated by an orifice plate under low pressure were examined as a means of disrupting flocs, in order to improve disinfection of treated wastewater effluents. Changes in cavitation conditions were found to have little impact on the extent of particle breakage in this experimental setup. The rate of strain (flow rate divided by the hole radius cubed), however, was found to be the best predictor of floc breakage. Floc breakage was not affected by changes in floc concentration, but was very sensitive to differences between flocs collected from different sources. Larger flocs (90 to 106 microm) were broken apart to a greater extent than smaller ones (53 to 63 microm). Hydrodynamic treatment decreased the viability of bacteria associated with large flocs, and also increased the ultraviolet dose response by up to one log unit (i.e., a factor of ten). Subjecting final effluent wastewaters to hydrodynamic treatment, therefore, provides a treatment strategy for conditions in which the presence of flocs limits the level of disinfection that can be achieved.

CMRF44+ Dendritic Cells from Peripheral Blood Stem Cell Harvests of Patients with Myeloma as Potential Cellular Vectors for Idiotype Vaccination

The optimal conditions required to harvest dendritic cells (DC) for immunotherapy were investigated in a series of preliminary investigations using peripheral blood stem cell (PBSC) harvests and blood from patients with myeloma. There was no difference in the number of DC (CMRF44+, CD19-, CD14-) in PBSC mobilized with G-CSF (mean 0.28%, n = 7) compared with GM-CSF (mean 0.24%, n = 6) and apheresis itself did not concentrate DC. In longitudinal studies (n = 10), the peak DC count (day 12 post PBSC harvest) did not correlate with the peak CD34+ cell count or white cell count. A simple affinity purification of DC resulted in a mean 63-fold purification. Affinity enriched suspensions from normal blood contained more DC (mean = 18.8%; n = 5) than those from patients with myeloma (mean = 9.9%; n = 13). The percentage of DC with a lymphoid phenotype (CD11c-, CDw123hi+) was significantly higher in G-CSF mobilized PBSC harvests (22.7%; n = 6) than in peripheral blood samples from patients with myeloma (7.0%; n = 13; p = 0.01). DC endocytosis was normal and did not change throughout the course of the disease. Neither DC numbers nor subsets changed significantly between days 1 and 3 of culture. Current mobilization procedures, optimized for PBSC, need to be altered when harvesting DC.

Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland - a curriculum

The technical aspects of dentistry need to be practised with insight into the spectrum of human diseases and illnesses and how these impact upon individuals and society. Application of this insight is critical to decision-making related to the planning and delivery of safe and appropriate patient-centred healthcare tailored to the needs of the individual. Provision for the necessary training is included in undergraduate programmes, but in the United Kingdom and Ireland there is considerable variation between centres without common outcomes. In 2009 representatives from 17 undergraduate dental schools in the United Kingdom and Ireland agreed to move towards a common, shared approach to meet their own immediate needs and that might also be of value to others in keeping with the Bologna Process. To provide a clear identity the term 'Clinical Medical Sciences in Dentistry' was agreed in preference to other names such as 'Human Disease' or 'Medicine and Surgery'. The group was challenged to define consensus outcomes. Contemporary dental education documents informed, but did not drive the process. The consensus curriculum for undergraduate Clinical Medical Sciences in Dentistry teaching agreed by the participating centres is reported. Many of the issues are generic and it includes elements that are likely to be applicable to others. This document will act as a focus for a more unified approach to the outcomes required by graduates of the participating centres and act as a catalyst for future developments that ultimately aim to enhance the quality of patient care.

Variation in complement component C1 inhibitor in age-related macular degeneration

This study assessed variation in plasma levels of the complement regulatorC1 inhibitor (C1inh) in patients with age related macular degeneration (AMD) and controls. Plasma from391 AMD cases and 370 controls was assayed by rate nephelometry to determine C1inh protein levels. Protein levels were analysed for relationships with age, gender, smoking, AMD disease status and genetic variation in the SERPING1 gene, which encodes C1inh, using a multivariate analysis. t-Tests show a significant difference in C1inh levels in AMD cases compared with controls (p=2.340E-6), smokers compared to non-smokers (p=1.022E-4) and females compared to males (p=1.661E-7). Multivariate analysis shows that after accounting for gender and smoking AMD status remained significant. Age was included in the model but was not significant. Including genetic variation in the model shows that one significant SNP (rs2649663) 5' of the SERPING1 gene is associated with C1inh levels though this SNP is not associated with AMD. This suggests that genetic variation in the promoter region of the SERPING1 gene may influence expression of the gene.

Multispectral imaging of the ocular fundus using light emitting diode illumination

We present an imaging system based on light emitting diode (LED) illumination that produces multispectral optical images of the human ocular fundus. It uses a conventional fundus camera equipped with a high power LED light source and a highly sensitive electron-multiplying charge coupled device camera. It is able to take pictures at a series of wavelengths in rapid succession at short exposure times, thereby eliminating the image shift introduced by natural eye movements (saccades). In contrast with snapshot systems the images retain full spatial resolution. The system is not suitable for applications where the full spectral resolution is required as it uses discrete wavebands for illumination. This is not a problem in retinal imaging where the use of selected wavelengths is common. The modular nature of the light source allows new wavelengths to be introduced easily and at low cost. The use of wavelength-specific LEDs as a source is preferable to white light illumination and subsequent filtering of the remitted light as it minimizes the total light exposure of the subject. The system is controlled via a graphical user interface that enables flexible control of intensity, duration, and sequencing of sources in synchrony with the camera. Our initial experiments indicate that the system can acquire multispectral image sequences of the human retina at exposure times of 0.05 s in the range of 500-620 nm with mean signal to noise ratio of 17 dB (min 11, std 4.5), making it suitable for quantitative analysis with application to the diagnosis and screening of eye diseases such as diabetic retinopathy and age-related macular degeneration.

Health Heritage© a web-based tool for the collection and assessment of family health history: initial user experience and analytic validity

A detailed family health history is currently the most potentially useful tool for diagnosis and risk assessment in clinical genetics. We developed and evaluated the usability and analytic validity of a patient-driven web-based family health history collection and analysis tool. Health Heritage(©) guides users through the collection of their family health history by relative, generates a pedigree, completes risk assessment, stratification, and recommendations for 89 conditions. We compared the performance of Health Heritage to that of Usual Care using a nonrandomized cohort trial of 109 volunteers. We contrasted the completeness and sensitivity of family health history collection and risk assessments derived from Health Heritage and Usual Care to those obtained by genetic counselors and genetic assessment teams. Nearly half (42%) of the Health Heritage participants reported discovery of health risks; 63% found the information easy to understand and 56% indicated it would change their health behavior. Health Heritage consistently outperformed Usual Care in the completeness and accuracy of family health history collection, identifying 60% of the elevated risk conditions specified by the genetic team versus 24% identified by Usual Care. Health Heritage also had greater sensitivity than Usual Care when comparing the identification of risks. These results suggest a strong role for automated family health history collection and risk assessment and underscore the potential of these data to serve as the foundation for comprehensive, cost-effective personalized genomic medicine.

A systematic review of studies validating the Edinburgh Postnatal Depression Scale in antepartum and postpartum women

OBJECTIVE

The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for postpartum depression (PPD). We systematically reviewed the published evidence on its validity in detecting PPD and antepartum depression (APD) up to July 2008.

METHOD

Systematic review of validation studies of the EPDS included 1987-2008. Cut-off points of 9/10 for possible PPD, 12/13 for probable PPD and 14/15 for APD were used.

RESULTS

Thirty-seven studies met the inclusion criteria. Sensitivity and specificity of cut-off points showed marked heterogeneity between different studies. Sensitivity results ranged from 34 to 100% and specificity from 44 to 100%. Positive likelihood ratios ranged from 1.61 to 78.

CONCLUSION

Heterogeneity among study findings may be due to differences in study methodology, language and diagnostic interview/criteria used. Therefore, the results of different studies may not be directly comparable and the EPDS may not be an equally valid screening tool across all settings and contexts.

Comparing the effects of entertainment media and tobacco marketing on youth smoking

OBJECTIVES

To examine the concurrent effects of exposure to movie smoking and tobacco marketing receptivity on adolescent smoking onset and progression.

METHODS

Cross-sectional study of 4524 northern New England adolescents aged 10-14 in 1999 with longitudinal follow-up of 2603 baseline never-smokers. Cross-sectional outcomes included ever tried smoking and higher level of lifetime smoking among 784 experimenters. The longitudinal outcome was onset of smoking among baseline never-smokers two years later. Movie smoking exposure was modelled as four population quartiles, tobacco marketing receptivity included two levels-having a favourite tobacco advert and wanting/owning tobacco promotional items. All analyses controlled for sociodemographics, other social influences, personality characteristics of the adolescent and parenting style.

RESULTS

In the full cross-sectional sample, 17.5% had tried smoking; both exposure to movie smoking and receptivity to tobacco marketing were associated with having tried smoking. Among experimental smokers, the majority (64%) were receptive to tobacco marketing, which had a multivariate association with higher level of lifetime smoking (movie smoking did not). In the longitudinal study 9.5% of baseline never-smokers tried smoking at follow-up. Fewer never-smokers (18.5%) were receptive to tobacco marketing. Movie smoking had a multivariate association with trying smoking (receptivity to tobacco marketing did not).

CONCLUSIONS

The results suggest separate roles for entertainment media and tobacco marketing on adolescent smoking. Both exposures deserve equal emphasis from a policy standpoint.

A computerized expert system for handling the output of the Technicon H1 haematology analyser

A computer-based expert system is described which handles the output of the Technicon H1 in the haematology laboratory of a large teaching hospital. Using patient request data, analyser results, error and morphology flags, the expert system decides; whether to validate the main indices plus differential; whether a blood film is required for manual review; and which abnormal results require phoning to the requesting doctor. The results of this computer-assisted analysis are sent to a printer adjacent to the analyser. The print-out details any further action required of the operator before release of results to the main hospital computer, and serves as a log of all samples run on that analyser. Benefits of the expert system include greatly simplified interpretation of the large array of analyser flags, and consistency in sample handling for all operators over all shifts.

Interval timing in genetically modified mice: a simple paradigm

We describe a behavioral screen for the quantitative study of interval timing and interval memory in mice. Mice learn to switch from a short-latency feeding station to a long-latency station when the short latency has passed without a feeding. The psychometric function is the cumulative distribution of switch latencies. Its median measures timing accuracy and its interquartile interval measures timing precision. Next, using this behavioral paradigm, we have examined mice with a gene knockout of the receptor for gastrin-releasing peptide that show enhanced (i.e. prolonged) freezing in fear conditioning. We have tested the hypothesis that the mutants freeze longer because they are more uncertain than wild types about when to expect the electric shock. The knockouts however show normal accuracy and precision in timing, so we have rejected this alternative hypothesis. Last, we conduct the pharmacological validation of our behavioral screen using d-amphetamine and methamphetamine. We suggest including the analysis of interval timing and temporal memory in tests of genetically modified mice for learning and memory and argue that our paradigm allows this to be done simply and efficiently.

In vitro development of embryos from Sinclair miniature pigs: a preliminary report

The goal of this project was to identify conditions that result in development from the zygote or the 2-cell stage Sinclair miniature pig embryos to the blastocyst stage. Four media were selected, 2 that have been shown to result in in vitro development in domestic pigs (Hepes buffered Tyrode's medium and Whitten's medium), 1 that is compatible with similar development in the cow (CR-1), and 1 that is compatible with development in the mouse (CZB). One- and two-cell stage embryos from Sinclair miniature pigs were flushed from oviducts in Hepes buffered Tyrode's medium, allocated to 1 of the 4 media and cultured for 120 h. At the end of the culture period, embryos were morphologically scored and nuclei were counted. Morphology scores were lowest for Hepes buffered Tyrode's medium but were not different for Whitten's medium, CZB or CR-1. The highest (P < 0.07) number of nuclei was present in the oocytes cultured in Whitten's medium (21.3), with CR-1 (15.7) and CZB (16.5) not differing significantly. Similar to the morphology scores, Hepes buffered Tyrode's medium resulted in the lowest number nuclei (5.5). In a parallel experiment, domestic pig embryos were cultured in Hepes buffered Tyrode's medium versus Whitten's medium. The domestic pig embryos, while also developing better in Whitten's Medium, developed better in the Hepes buffered Tyrode's medium than did the embryos from Sinclair pigs. Thus, the Sinclair pig embryo develops best if placed in Whitten's Medium.

Reproductive measurements in Sinclair and NIH miniature pigs: a retrospective analysis

The data presented here represent a retrospective analysis of information gathered while collecting data for other studies on miniature pigs. Two different breeds of miniature pigs, NIH and Sinclair, were used in this study. The NIH females were gilts, while Sinclair females included both gilts and sows. The pigs were checked twice a day for estrus and were mated at 12 and 24 h after the onset of estrus. One- and 2-cell stage embryos were collected on Day 2; while 4-cell, 8-cell, compact morula and blastocyst stage embryos were collected on Days 2.7, 3.5, 4.3 and 6.0, respectively. The percentage of recovery of these embryos was dependent upon the surgeon (P = 0.002) and the stage of development (P = 0.018). The number of ovulations was higher (P < 0.04) in the Sinclair sows (10.4 +/- 0.60) than in the Sinclair gilts (8.9 +/- 0.67) and in the NIH gilts (8.3 +/- 0.67). When the NIH gilts were divided into swine leukocyte antigen (SLA) haplotypes, it was found that SLA(dd) gilts (8.5 +/- 0.43) had more ovulations (P = 0.02) than SLA(ad) gilts (6.8 +/- 0.57). Some animals were treated with Regumate to synchronize estrus. The Sinclair gilts (7.8 +/- 0.28) and NIH gilts (7.7 +/- 0.27) took more days (P < 0.07) to show estrus than the Sinclair sows (6.3 +/- 0.58) after the removal of Regumate. Four of the animals had reproductive tract abnormalities; more specifically, a blind uterine horn or oviduct that was not patent with the other horn. All 4 were NIH gilts with the SLA(dd) haplotype.

The role of high-dose therapy and stem cell rescue in the management of T-cell malignant lymphomas: a BSBMT and ABMTRR study

Peripheral T-cell lymphomas (PTCL) are a rare and heterogeneous subset of lymphomas with a poorer prognosis compared with B-cell lymphomas. We conducted a retrospective study of 82 patients who received high-dose therapy for PTCL (autologous SCT (ASCT) N=64; allogeneic SCT (Allo-SCT) N=18). With a median follow-up from ASCT of 37 months from transplant, 33 patients were alive; 20 died of progressive disease, 10 died from non-relapse mortality (NRM) with 1 unknown cause. Three-year overall survival (OS) and progression-free survival (PFS) were 53% (95% confidence interval (CI) 42, 67) and 50% (95% CI 39, 64), respectively. Factors significantly affecting OS and PFS on univariate analysis were histological subtype and chemotherapy sensitivity. In a multivariate analysis, the only factor with significant impact was chemotherapy sensitivity. After a median follow-up from Allo-SCT of 57 months, five patients were alive; five died of progressive disease and eight died from NRM. The 3-year OS and PFS were 39% (95% CI 22, 69) and 33% (95% CI 17, 64), respectively, and the 3-year relapse rate was 28% (95% CI 6, 50). These results demonstrate that high-dose chemotherapy with autologous stem cell rescue has a substantial role in the management of T-cell lymphoma. The use of full-intensity allogeneic transplantation is limited by high transplant-related mortality, and exploration of reduced intensity regimens is warranted.

A prospective multicenter trial of peripheral blood stem cell sibling allografts for acute myeloid leukemia in first complete remission using fludarabine-cyclophosphamide reduced intensity conditioning

The role of allogeneic transplantation in patients with de novo acute myeloid leukemia in first complete remission (AML-CR1) is controversial. Aiming to preserve a graft-versus-leukemia effect, but minimize morbidity and mortality from conditioning-related toxicity and graft-versus-host disease (GVHD), we conducted a prospective multicenter study of reduced-intensity conditioning (RIC) as preparation for peripheral blood stem cell sibling allografts in patients with intermediate or poor risk AML-CR1. Conditioning consisted of fludarabine 125 mg/m(2) and cyclophosphamide 120 mg/kg. Thirty-four patients were transplanted with a median age of 45 years; 85% had intermediate risk cytogenetics. Early toxicity was minimal. The overall incidence of grade II-IV acute GVHD was low (21%), but the 3 patients (9%) who developed grade IV GVHD died. Donor T cell chimerism was rapid and generally complete, but complete myeloid chimerism was delayed. Thirteen patients (38%) relapsed, 12 within a year of transplant. The estimated disease-free survival (DFS) and overall survival at 2 years was 56% (95% confidence interval [CI] 39%-71%) and 68% (95% CI 50%-81%), respectively. The incidence of extensive chronic GVHD (cGVHD) was low (24% of surviving patients at 12 months) and most survivors had an excellent performance status. These observations justify a prospective comparison of RIC versus myeloablative conditioning allografts for AML-CR1.

A controlled release pilocarpine buccal insert in the treatment of Sjögren's syndrome

OBJECTIVES

To assess the efficacy of a novel hydrogel polymer buccal insert containing 5 mg pilocarpine in releasing the pilocarpine in a controlled fashion over a three hour period, and to assess the effects of this on quantitative tear and saliva production and the acceptability of the insert to the patient.

DESIGN

This was an open, uncontrolled pilot study for which Ethics Committee approval was obtained prior to starting. Hydrogel buccal inserts containing 5 mg pilocarpine were used three times a day for seven days.

SETTING

The Department of Oral Medicine, Glasgow Dental Hospital & School.

SUBJECTS

Eight patients with Sjögren's syndrome.

MAIN OUTCOME MEASURES

Changes over baseline in (1) Schirmer test, (2) whole saliva flow rate, (3) oral comfort score (VAS), (4) ocular comfort score (VAS), (5) patient acceptability.

RESULTS

The buccal inserts successfully released in excess of 85% of their 5 mg pilocarpine load over three hours. There was a general improvement in oral and ocular comfort scores assessed by visual linear analogue scale, and saliva and tear production generally increased. The inserts were well tolerated by all patients except one (who wore dentures). Adverse events were few and none was serious.

CONCLUSION

This novel form of buccal pilocarpine delivery demonstrated potential for use in treating patients with Sjögren's syndrome.

Awareness in retrieval medicine

Awareness is the spontaneous recall of an event(s) that occurred during general anaesthesia and surgery. The incidence of awareness is approximately 0.2% of cases where neuromuscular blockers are used and half that where they are omitted. The majority of data relating to awareness is from anaesthetic practice. We report a case of awareness associated with an out-of-hospital transportation of a critically ill patient requiring a medical escort (retrieval). We discuss the risk factors associated with awareness during retrieval, in particular the trend toward excessive administration of neuromuscular blockers, and the unique challenges for the prevention of awareness within the retrieval environment.

Gene expression profiling in a mouse model for African trypanosomiasis

This study aimed to provide the foundation for an integrative approach to the identification of the mechanisms underlying the response to infection with Trypanosoma congolense, and to identify pathways that have previously been overlooked. We undertook a large-scale gene expression analysis study comparing susceptible A/J and more tolerant C57BL/6 mice. In an initial time course experiment, we monitored the development of parasitaemia and anaemia in every individual. Based on the kinetics of disease progression, we extracted total RNA from liver at days 0, 4, 7, 10 and 17 post infection and performed a microarray analysis. We identified 64 genes that were differentially expressed in the two strains in non-infected animals, of which nine genes remained largely unaffected by the disease. Gene expression profiling at stages of low, peak, clearance and recurrence of parasitaemia suggest that susceptibility is associated with high expression of genes coding for chemokines (e.g. Ccl24, Ccl27 and Cxcl13), complement components (C1q and C3) and interferon receptor alpha (Ifnar1). Additionally, susceptible A/J mice expressed higher levels of some potassium channel genes. In contrast, messenger RNA levels of a few immune response, metabolism and protease genes (e.g. Prss7 and Mmp13) were higher in the tolerant C57BL/6 strain as compared to A/J.

Pragmatic, observational study of bupropion treatment for smoking cessation in general practice

BACKGROUND

Cigarette smoking remains the single largest cause of premature death in the United Kingdom. As part of the government's national service framework for coronary heart disease, smoking cessation forms a key part of the strategy.

OBJECTIVES

To determine the effectiveness of bupropion treatment for smoking cessation in a general practice setting, measuring continuous abstinence from smoking, from 8 weeks to 52 weeks.

DESIGN

Prospective observational study.

SETTING

One general practice (six whole time equivalent doctors, 11,070 patients) in rural Northumberland.

SUBJECTS

Of the 243 patients who presented to the practice over a one year period for smoking cessation, a total of 227 motivated people, who were appropriate for bupropion treatment as a pharmacological aid for smoking cessation, entered the study. Continuous smoking cessation at one year was validated by an exhaled carbon monoxide level of 10 ppm or less.

RESULTS

Fifty patients successfully gave up smoking, giving a one year smoking cessation prevalence with bupropion of 22% (95% confidence intervals (CI) 17% to 28%). There was no difference in success rate for sex, number of cigarettes smoked, the number of years smoking, or whether there were other smokers in the household or not.

CONCLUSION

Bupropion treatment in this general practice helped 22% of motivated people to quit and remain stopped smoking at one year. Mainly nurses, whose prescribing rights are restricted and currently exclude bupropion, deliver smoking cessation services in primary care.

Mid term results of PlantTan plate in the treatment of proximal humerus fractures

This prospective study evaluates the clinical efficacy of a special implant, PlantTan plate used for fixation of displaced proximal humerus fractures. The PlantTan plate was used for internal fixation of closed displaced proximal humeral fractures in 68 patients from September 1999 to June 2002, in a University Hospital. One of the surgeries was for a non-union, and five patients were lost to follow-up. The patients' ages ranged from 19 to 76 years (mean 61 years and median 66 years). Of the remaining 62 patients, 42 were female and 20 were male. As defined using the Neer classification 19 patients had two part, 37 three part and 6 had four part fractures. Median follow-up was 19 months (11-38). The outcome was assessed using radiographs, American Shoulder and Elbow Surgeons (ASES) score and Hospital for Special Surgery (HSS) scoring system. Fifty-two patients achieved union in a median of 8 weeks. The median cumulative score of activities of daily living of ASES was 20.4/30 (13-27). According to HSS, 11 scored excellent, 26 good, 14 fair and 11 scored poor. Eight patients had fixation failure and two developed avascular necrosis. Eleven patients developed an infection. Six patients developed an infection resulting in implant removal. One had a transient and one permanent axillary nerve palsy. Since the PlantTan plate provides stability, early active rehabilitation can be instituted. The implant is distally placed reducing impingement symptoms. However, the implant requires wide surgical exposure, is bulky and has an unacceptable infection rate. The fixation failure is high in patients with osteoporosis. In view of the above encountered problems, the implant has been discontinued in our hospital.

Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study*

OBJECTIVE

To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation.

DESIGN

Prospective longitudinal observational study.

SETTING

Medical-surgical intensive care unit.

PARTICIPANTS

Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit.

INTERVENTIONS

Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period.

MEASUREMENTS AND MAIN RESULTS

Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001).

CONCLUSIONS

After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.

A map of the human genome in linkage disequilibrium units

Two genetic maps with additive distances contribute information about recombination patterns, recombinogenic sequences, and discovery of genes affecting a particular phenotype. Recombination is measured in morgans (w) over a single generation in a linkage map but may cover thousands of generations in a linkage disequilibrium (LD) map measured in LD units (LDU). We used a subset of single nucleotide polymorphisms from the HapMap Project to create a genome-wide map in LDU. Recombination accounts for 96.8% of the LDU variance in chromosome arms and 92.4% in their deciles. However, deeper analysis shows that LDU/w, an estimate of the effective bottleneck time (t), is significantly variable among chromosome arms because (i) the linkage map is approximated from the Haldane function, then adjusted toward the Kosambi function that is more accurate but still exaggerates w for all chromosomes, especially shorter ones; (ii) the non-pseudoautosomal region of the X chromosome is subject to hemizygous selection; and (iii) at resolution less than approximately 40,000 markers per w, there are indeterminacies (holes) in the LD map reflecting intervals of very high recombination. Selection and stochastic variation in small regions must have effects, which remain to be investigated by comparisons among populations. These considerations suggest an optimal strategy to eliminate holes quickly, greatly enhance the resolution of sex-specific linkage maps, and maximize the gain in association mapping by using LD maps.