Tracing MYC Expression for Small Molecule Discovery

Our inability to effectively "drug" targets such as MYC for therapeutic purposes requires the development of new approaches. We report on the implementation of a phenotype-based assay for monitoring MYC expression in multiple myeloma cells. The open reading frame (ORF) encoding an unstable variant of GFP was engineered immediately downstream of the MYC ORF using CRISPR/Cas9, resulting in co-expression of both proteins from the endogenous MYC locus. Using fluorescence readout as a surrogate for MYC expression, we implemented a pilot screen in which ∼10,000 compounds were prosecuted. Among known MYC expression inhibitors, we identified cardiac glycosides and cytoskeletal disruptors to be quite potent. We demonstrate the power of CRISPR/Cas9 engineering in establishing phenotype-based assays to identify gene expression modulators.

Critical care usage after major gastrointestinal and liver surgery: a prospective, multicentre observational study

BACKGROUND

Patient selection for critical care admission must balance patient safety with optimal resource allocation. This study aimed to determine the relationship between critical care admission, and postoperative mortality after abdominal surgery.

METHODS

This prespecified secondary analysis of a multicentre, prospective, observational study included consecutive patients enrolled in the DISCOVER study from UK and Republic of Ireland undergoing major gastrointestinal and liver surgery between October and December 2014. The primary outcome was 30-day mortality. Multivariate logistic regression was used to explore associations between critical care admission (planned and unplanned) and mortality, and inter-centre variation in critical care admission after emergency laparotomy.

RESULTS

Of 4529 patients included, 37.8% (n=1713) underwent planned critical care admissions from theatre. Some 3.1% (n=86/2816) admitted to ward-level care subsequently underwent unplanned critical care admission. Overall 30-day mortality was 2.9% (n=133/4519), and the risk-adjusted association between 30-day mortality and critical care admission was higher in unplanned [odds ratio (OR): 8.65, 95% confidence interval (CI): 3.51-19.97) than planned admissions (OR: 2.32, 95% CI: 1.43-3.85). Some 26.7% of patients (n=1210/4529) underwent emergency laparotomies. After adjustment, 49.3% (95% CI: 46.8-51.9%, P<0.001) were predicted to have planned critical care admissions, with 7% (n=10/145) of centres outside the 95% CI.

CONCLUSIONS

After risk adjustment, no 30-day survival benefit was identified for either planned or unplanned postoperative admissions to critical care within this cohort. This likely represents appropriate admission of the highest-risk patients. Planned admissions in selected, intermediate-risk patients may present a strategy to mitigate the risk of unplanned admission. Substantial inter-centre variation exists in planned critical care admissions after emergency laparotomies.

A systematic review of the use, quality and effects of pelvic examination in primary care for the detection of gynaecological cancer

AIM

This three part systematic review gathered all the current evidence on the use, quality and effects of pelvic examination (abdominal palpation, bimanual vaginal examination ± visualisation of the cervix) in primary care in diagnosing gynaecological cancer. Research questions • Do primary care practitioners perform pelvic examination during the assessment of symptoms, which are potentially indicative of gynaecological cancer? (RQ1) • What is the quality of pelvic examination performed in primary care, in terms of technical competence and interpretation of findings? (RQ2) • Is pelvic examination associated with the referral of patients with gynaecological cancer, and if so, in what way? (RQ3) Methods: PRISMA guidelines were followed. MEDLINE, EMBASE and Cochrane databases were searched using a combination of four terms, their MeSH terms and synonyms: pelvic examination; primary care; competency and gynaecological cancer. Inclusion and exclusion criteria were defined. Citation lists of all identified papers were searched. Two authors (PW and PM or CMB or CB) independently screened titles, abstracts and the full texts of publications. Data extraction was performed by PW and duplicated in all papers by a second reviewer (PM, CMB or CB). Paper quality was assessed using CASP methodology.

RESULTS

Nine hundred fifty four references were identified: 21 met the inclusion criteria: 5 RQ1; 6 RQ2; 10 RQ3. Examination rates prior to referral were generally low: one paper identified pre-referral PE in 52% of the patients; remaining papers demonstrated examination in less than half of the patients with suspicious symptoms. No papers explored GPs' competence at performing PE directly; but one paper identified 39% of 'clinically suspicious' cervices referred for colposcopy as having no abnormality. Pre-referral PE was associated with reduced diagnostic delay and early stage diagnosis.

CONCLUSIONS

Pre-referral pelvic examination in symptomatic women appears to be under-performed, despite urgent suspected cancer referral guideline recommendation to do so (Healthcare Improvement Scotland 2014 ; National Institute for Health and Care Excellence 2015 ). While no evidence was found to confirm GPs' competence for performing PE, there was an association with shorter diagnostic delay and better outcomes in those women where it was performed.

Newborn and infant physical examination standards in a dedicated clinic for developmental dysplasia of the hip

Introduction In 2014 our centre started a dedicated clinic for developmental dysplasia of the hip (DDH). The aim of the clinic was to streamline DDH referrals, enabling timely review, imaging and multidisciplinary treatment. Ongoing audit has been carried out based on the UK National Screening Committee newborn and infant physical examination (NIPE) guidelines, first published in 2008. Methods A three-year prospective audit was undertaken between 2014 and 2016 assessing compliance with NIPE standards (ST2b and ST2d) relating to timeliness of expert consultation following positive ultrasonography findings of DDH with positive examination or risk factors. Results A total of 257 babies born between January 2014 and December 2016 were seen in our dedicated DDH clinic, with 106 with abnormalities on ultrasonography and 54 requiring treatment. Compliance with 'expert consultation within 4 weeks of age for babies with an abnormality detected on clinical examination and positive ultrasonography' improved from 50% in 2014 to 53% in 2015 and 71% in 2016. Compliance with 'expert consultation within 8 weeks of age for babies with positive risk factors, negative examination and positive ultrasonography' improved from 65% in 2014 to 93% in 2015 and 100% in 2016. Conclusions This prospective audit assessing timeliness of expert consultation has demonstrated ongoing improvements between 2014 and 2016. A greater proportion of babies with ultrasonography evidence of DDH have been seen at the appropriate time. In the majority of cases, this has enabled timely non-invasive treatment with a Pavlik harness rather than surgery.

Oscillatoria sp. LPS activates human monocytes in a manner that is distinct from E. coli LPS

Within the gut-associated lymphoid tissue (GALT) reside monocyte/macrophages that sample products from normal flora and pathogens. After consumption of the pathogen cyanobacteria, toxins and lipopopolysaccharide (LPS) from this bacterium can induce fever, gastro-intestinal illness, and even death. The toxicity of one species of cyanobacteria, Oscillatoria sp. (Osc-sp.), is not well understood. Previous studies from our laboratories demonstrate that Osc-sp. LPS activates murine B cells, but to a lesser extent than E. coli LPS, due to a decrease in NF-kB and a loss of IRF-3 activation. Since ingestion of Osc-sp. exposes resident GALT monocyte/macrophages to the LPS of Osc-sp., we tested the effects of this cyanobacteria’s LPS on human monocytes. Due to our previous findings we hypothesized that Osc-sp. LPS would activate human monocytes, but may change the predominant functions and cytokines produced in comparison to E. coli LPS. Therefore, we purified monocytes from purchased human buffy coats and activated the cells in the absence or presence of Osc-sp. LPS or E. coli LPS. Our data indicate that Osc-sp. LPS activates monocytes to proliferate and upregulate markers important for T cell activation to a lesser extent that E. coli LPS. In contrast, Osc-sp. LPS was able to induce greater phagocytosis of FITC-Dextran and produce a different cytokine environment when compared to E. coli LPS. These findings indicate that Osc-sp. may be more effective in activating certain functions of human monocytes than E. coli LPS, in contrast to its effects on murine B cells. As cyanobacteria, such as Osc-sp., continue to contaminate our fresh water sources, our understanding of the toxic effects of these bacteria on humans and animals will be critical.

eHealth readiness of dietitians

BACKGROUND

The present study aimed to determine the eHealth readiness and changes over time of dietitians in Australia.

METHODS

Two cross-sectional analyses of Australian dietitians were conducted in 2013 and 2016, using a survey adapted from one conducted in 2011 by the US Academy of Nutrition and Dietetics. The survey encompassed 30 questions on eHealth readiness across five dimensions: access, standards, attitude, aptitude and advocacy. Descriptive statistics, independent t-tests, chi-squared tests and Z-tests were computed to compare responses from the 2013 and 2016 surveys.

RESULTS

The survey completion rate represented 14.5% (747) of the Dietitians Association of Australia members in 2013 and 8% (417) in 2016. The survey responses in relation to access and standards suggest that dietitians are well positioned for eHealth. For attitude and aptitude, there is a moderate level of preparedness, with minor improvements over time. Although showing significant improvement (P < 0.05), advocacy highlights the area requiring the most development because the majority of dietitians (61%) reported 'no role' in eHealth solutions.

CONCLUSIONS

Dietitians are progressing in relation to access, attitudinal and aptitudinal readiness for eHealth, although they rate poorly with respect to advocacy readiness. It was concluded that dietitians are not yet ready, and also that valuable opportunities to achieve the benefits that eHealth can deliver will be missed, if dietitians do not take the lead in guiding the development, selection and implementation of nutrition-related technologies. Strengthening the dimension of advocacy and ensuring collaboration across the profession, drawing on the varying expertise demonstrated across the practice areas and by the different generations, will be central to improving dietitian eHealth readiness.

Improving patient experiences of mental health inpatient care: a randomised controlled trial

BACKGROUND

Poorer patient views of mental health inpatient treatment predict both further admissions and, for those admitted involuntarily, longer admissions. As advocated in the UK Francis report, we investigated the hypothesis that improving staff training improves patients' views of ward care.

METHOD

Cluster randomised trial with stepped wedge design in 16 acute mental health wards randomised (using the ralloc procedure in Stata) by an independent statistician in three waves to staff training. A psychologist trained ward staff on evidence-based group interventions and then supported their introduction to each ward. The main outcome was blind self-report of perceptions of care (VOICE) before or up to 2 years after staff training between November 2008 and January 2013.

RESULTS

In total, 1108 inpatients took part (616 admitted involuntarily under the English Mental Health Act). On average 51.6 staff training sessions were provided per ward. Involuntary patient's perceptions of, and satisfaction with, mental health wards improved after staff training (N582, standardised effect -0·35, 95% CI -0·57 to -0·12, p = 0·002; interaction p value 0·006) but no benefit to those admitted voluntarily (N469, -0.01, 95% CI -0.23 to 0.22, p = 0.955) and no strong evidence of an overall effect (N1058, standardised effect -0.18 s.d., 95% CI -0.38 to 0.01, p = 0.062). The training costs around £10 per patient per week. Resource allocation changed towards patient perceived meaningful contacts by an average of £12 (95% CI -£76 to £98, p = 0.774).

CONCLUSION

Staff training improved the perceptions of the therapeutic environment in those least likely to want an inpatient admission, those formally detained. This change might enhance future engagement with all mental health services and prevent the more costly admissions.

Areca nut extracts mobilize calcium and release pro-inflammatory cytokines from various immune cells

Betel nut consumption has significant implications for the public health globally, as the wide-spread habit of Areca chewing throughout Asia and the Pacific is associated with a high prevalence of oral carcinoma and other diseases. Despite a clear causal association of betel nut chewing and oral mucosal diseases, the biological mechanisms that link Areca nut-contained molecules, inflammation and cancer remain underexplored. In this study we show that the whole Areca nut extract (ANE) is capable of mobilizing Ca²⁺ in various immune cell lines. Interestingly, none of the four major alkaloids or a range of other known constituents of Areca nut were able to induce such Ca²⁺ signals, suggesting that the active components might represent novel or so far unappreciated chemical structures. The separation of ANE into aqueous and organic fractions has further revealed that the calcium-mobilizing molecules are exclusively present in the aqueous extract. In addition, we found that these calcium signals are associated with the activation of several immune cell lines as shown by the release of pro-inflammatory cytokines and increased cell proliferation. These results indicate that calcium-mobilizing molecules present in the aqueous fraction of the Areca nut may critically contribute to the inflammatory disorders affecting betel nut chewers.

The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study

The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.

Follow-up after curative treatment for colorectal cancer: longitudinal evaluation of patient initiated follow-up in the first 12 months

PURPOSE

To compare patient-triggered follow-up (PTFU) for curatively treated colorectal cancer against traditional outpatient follow-up (OPFU).

METHODS

Questionnaires were mailed at four time points over one-year post-treatment to two prospectively-recruited cohorts: A, patients entering follow-up and receiving OPFU pre-implementation of PTFU; B, patients entering follow-up (FU) and receiving either OPFU (B1) or PTFU (B2) post-implementation of PTFU. Bi-variate tests were used to compare patient characteristics and outcomes eight months after entering follow-up (generic and cancer-specific quality of life (QoL), satisfaction). Regression analysis explored associations between follow-up model and outcomes. Resource implications and costs of models were compared.

RESULTS

Patients in Cohort B1 were significantly more likely to have received chemotherapy (p < 0.001), radiotherapy (p < 0.05), and reported poorer QoL (p = 0.001). Having a longstanding co-morbid condition was the most important determinant of QoL (p < 0.001); model of care was not significant. Patients were satisfied with their follow-up care regardless of model. Health service costs were higher in PTFU over the first year CONCLUSIONS: PTFU is acceptable to patients with colorectal cancer and can be considered to be a realistic alternative to OPFU for clinically suitable patients. The initial costs are higher due to provision of a self-management (SM) programme and remote surveillance. Further research is needed to establish long-term outcomes and costs.

Coordinated protein co-expression in plants by harnessing the synergy between an intein and a viral 2A peptide

A novel approach is developed for coordinated expression of multiple proteins from a single transgene in plants. An Ssp DnaE mini-intein variant engineered for hyper-N-terminal autocleavage is covalently linked to the foot-and-mouth disease virus 2A (F2A) peptide with unique ribosome skipping property, via a peptide linker, to create an 'IntF2A' self-excising fusion protein domain. This IntF2A domain acts, in cis, to direct highly effective release of its flanking proteins of interest (POIs) from a 'polyprotein' precursor in plants. This is successfully demonstrated in stably transformed cultured tobacco cells as well as in different organs of transgenic tobacco plants. Highly efficient polyprotein processing mediated by the IntF2A domain was also demonstrated in lettuce and Nicotiana benthamiana based on transient expression. Protein constituents released from the polyprotein precursor displayed proper function and accumulated at similar levels inside the cells. Importantly, no C-terminal F2A extension remains on the released POIs. We demonstrated co-expression of as many as three proteins in plants without compromising expression levels when compared with those using single-protein vectors. Accurate differential cellular targeting of released POIs is also achieved. In addition, we succeeded in expressing a fully assembled and functional chimeric anti-His Tag antibody in N. benthamiana leaves. The IntF2A-based polyprotein transgene system overcomes key impediments of existing strategies for multiprotein co-expression in plants, which is particularly important for gene/trait stacking.

Effects of cyanobacteria Oscillatoria sp. lipopolysaccharide on B cell activation and Toll-like receptor 4 signaling

Cyanobacteria ("blue-green algae"), such as Oscillatoria sp., are a ubiquitous group of bacteria found in freshwater systems worldwide that are linked to illness and in some cases, death among humans and animals. Exposure to cyanobacteria occurs via ingestion of contaminated water or food-products. Exposure of the gut to these bacteria also exposes their toxins, such as lipopolysaccharide (LPS), to B cells in the gut associated lymphoid tissue. However, the effect of Oscillatoria sp. LPS on B cell activation is unknown. To test the hypothesis that Oscillatoria sp. LPS exposure to murine B cells would result in B cell activation, murine B cells were incubated in the absence or presence of Oscillatoria sp. LPS or E. coli LPS as a positive control. The data indicate that Oscillatoria sp. LPS induces B cells to proliferate, upregulate MHC II and CD86, enhance antigen uptake and induce IgM production at low levels. Additional studies demonstrate that this low level of stimulation may be due to incomplete TLR4 signaling induced by Oscillatoria sp. LPS, since IRF-3 is not induced in B cells after stimulation with Oscillatoria sp. LPS. These findings have important implications for the mechanisms of toxicity of cyanobacteria in both humans and animals.

Endoscopic cystic duct stent as primary treatment for intrahepatic gallbladder perforation with abscess formation

Intrahepatic gallbladder perforation with abscess formation is an uncommon presentation of biliary disease. There is no consensus on how to treat this condition, with strategies varying from percutaneous drainage to open cholecystectomy and washout. We present a case of a novel, minimally invasive treatment, using endoscopic retrograde cholangiopancreatography to place a transcystic drain as a bridge to laparoscopic cholecystectomy.