Reactive oxygen species and p21Waf1/Cip1 are both essential for p53-mediated senescence of head and neck cancer cells

Treatment of head and neck squamous cell carcinoma, HNSCC, often requires multimodal therapy, including radiation therapy. The efficacy of radiotherapy in controlling locoregional recurrence, the most frequent cause of death from HNSCC, is critically important for patient survival. One potential biomarker to determine radioresistance is TP53 whose alterations are predictive of poor radiation response. DNA-damaging reactive oxygen species (ROS) are a by-product of ionizing radiation that lead to the activation of p53, transcription of p21(cip1/waf1) and, in the case of wild-type TP53 HNSCC cells, cause senescence. The expression of p21 and production of ROS have been associated with the induction of cellular senescence, but the intricate relationship between p21 and ROS and how they work together to induce senescence remains elusive. For the first time, we show that persistent exposure to low levels of the ROS, hydrogen peroxide, leads to the long-term expression of p21 in HNSCC cells with a partially functional TP53, resulting in senescence. We conclude that the level of ROS is crucial in initiating p53's transcription of p21 leading to senescence. It is p21's ability to sustain elevated levels of ROS, in turn, that allows for a long-term oxidative stress, and ensures an active p53-p21-ROS signaling loop. Our data offer a rationale to consider the use of either ROS inducing agents or therapies that increase p21 expression in combination with radiation as approaches in cancer therapy and emphasizes the importance of considering TP53 status when selecting a patient's treatment options.

Utilizing the multidisciplinary team for planning and monitoring care and quality improvement

Multidisciplinary team management of patients with rectal cancer requires a dedicated group of surgeons, medical and radiation oncologists, pathologists, radiologists, and mid-level providers who meet to discuss every patient with rectal cancer. The data from that meeting is collected prospectively, recommendations made for case, follow-up obtained, and quality issues monitored. Improved case is the result.

Factors associated with low bone mineral density in patients with cystic fibrosis

Osteoporosis associated with cystic fibrosis is becoming more important as the life expectancy of patients continues to improve. This study was done to determine the prevalence of osteoporosis and osteopenia in CF patients and to identify risk factors. We reviewed the medical charts of 103 adults and adolescents with Cystic Fibrosis who had undergone a dual energy X-ray absorptiometry (DEXA) scan to measure the bone mineral content of the lumbar spine (L1-L4). Disease severity was assessed by lung function and body mass index (BMI) was calculated from weight and height at the time of the DEXA. None of the patients were being treated for low BMD. Random blood samples were analyzed for biochemical markers. The relationship between all these variables and BMD measurements was analyzed. Of 103 patients, ten (9.7%) patients (9 males, 1 female) were diagnosed with osteoporosis. An additional 36 (35%) patients (26 males, 10 females) were identified as having osteopenia. BMI, gender, weight, lung functions (FVC, FEV1, and FEF 25-75), and alkaline phosphatase, and 25-OH vitamin D levels were significantly correlated with Z-scores (p < 0.05). Stepwise linear regression revealed that a low Z-score was best predicted with low FEV1, male gender, low weight, and low 25-OH vitamin D levels (p < 0.05) for each variable. Osteopenia and osteoporosis are common in adults with CF, especially in male patients and in patients with low lung function, body weight, and 25-OH vitamin D levels.

Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE): a physiological method of increasing apnoea time in patients with difficult airways

Emergency and difficult tracheal intubations are hazardous undertakings where successive laryngoscopy-hypoxaemia-re-oxygenation cycles can escalate to airway loss and the 'can't intubate, can't ventilate' scenario. Between 2013 and 2014, we extended the apnoea times of 25 patients with difficult airways who were undergoing general anaesthesia for hypopharyngeal or laryngotracheal surgery. This was achieved through continuous delivery of transnasal high-flow humidified oxygen, initially to provide pre-oxygenation, and continuing as post-oxygenation during intravenous induction of anaesthesia and neuromuscular blockade until a definitive airway was secured. Apnoea time commenced at administration of neuromuscular blockade and ended with commencement of jet ventilation, positive-pressure ventilation or recommencement of spontaneous ventilation. During this time, upper airway patency was maintained with jaw-thrust. Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) was used in 15 males and 10 females. Mean (SD [range]) age at treatment was 49 (15 [25-81]) years. The median (IQR [range]) Mallampati grade was 3 (2-3 [2-4]) and direct laryngoscopy grade was 3 (3-3 [2-4]). There were 12 obese patients and nine patients were stridulous. The median (IQR [range]) apnoea time was 14 (9-19 [5-65]) min. No patient experienced arterial desaturation < 90%. Mean (SD [range]) post-apnoea end-tidal (and in four patients, arterial) carbon dioxide level was 7.8 (2.4 [4.9-15.3]) kPa. The rate of increase in end-tidal carbon dioxide was 0.15 kPa.min(-1) . We conclude that THRIVE combines the benefits of 'classical' apnoeic oxygenation with continuous positive airway pressure and gaseous exchange through flow-dependent deadspace flushing. It has the potential to transform the practice of anaesthesia by changing the nature of securing a definitive airway in emergency and difficult intubations from a pressured stop-start process to a smooth and unhurried undertaking.

Cost drivers of inpatient mental health care: a systematic review

Aims. New reimbursement schemes for inpatient mental health care are imminent in the UK and Germany. The shared intention is to reflect cost differences between patients in reimbursement rates. This requires understanding of patient characteristics that influence hospital resource use. The aim of this review was to show which associations between mental health care per diem hospital costs and patient characteristics are supported by current evidence. Methods. A systematic review of the literature published between 1980 and 2012 was carried out. The search strategy included electronic databases and hand-searching. Furthermore, reference lists, citing articles and related publications were screened and experts were contacted. Results. The search found eight studies. Dispersion in per diem costs was moderate, as was the ability to explain it with patient characteristics. Six patient characteristics were identified as the most relevant variables. These were (1) age, (2) major diagnostic group, (3) risk, (4) legal problems, (5) the ability to perform activities of daily living and (6) presence of psychotic or affective symptoms. Two non-patient-related factors were identified. These were (1) day of stay and (2) treatment site. Conclusions. Idiosyncrasies of mental health care complicated the prediction of per diem hospital costs. More research is required in European settings since transferability of results is unlikely.

Optimizing the high-resolution manometry (HRM) study protocol

BACKGROUND

Intolerance of the esophageal manometry catheter may prolong high-resolution manometry (HRM) studies and increase patient distress. We assessed the impact of obtaining the landmark phase at the end of the study when the patient has acclimatized to the HRM catheter.

METHODS

366 patients (mean age 55.4 ± 0.8 years, 62.0% female) undergoing esophageal HRM over a 1-year period were studied. The standard protocol consisted of the landmark phase, 10 5 mL water swallows 20-30 s apart, and multiple rapid swallows where 4-6 2 mL swallows were administered in rapid succession. The modified protocol consisted of the landmark phase at the end of the study after test swallows. Study duration, technical characteristics, indications, and motor findings were compared between standard and modified protocols.

KEY RESULTS

Of the 366 patients, 89.6% underwent the standard protocol (study duration 12.9 ± 0.3 min). In 10.4% with poor catheter tolerance undergoing the modified protocol, study duration was significantly longer (15.6 ± 1.0 min, p = 0.004) despite similar duration of study maneuvers. Only elevated upper esophageal sphincter basal pressures at the beginning of the study segregated modified protocol patients. The 95th percentile time to landmark phase in the standard protocol patients was 6.1 min; as many as 31.4% of modified protocol patients could not obtain their first study maneuver within this period (p = 0.0003). Interpretation was not impacted by shifting the landmark phase to the end of the study.

CONCLUSIONS & INFERENCES

Modification of the HRM study protocol with the landmark phase obtained at the end of the study optimizes study duration without compromising quality.

Exaggerated smooth muscle contraction segments on esophageal high-resolution manometry: prevalence and clinical relevance

BACKGROUND

Two smooth muscle contraction segments (S2, S3) on esophageal high-resolution manometry (HRM) demonstrate varying contraction vigor in symptomatic patients. Significance of isolated exaggerated smooth muscle contraction remains unclear.

METHODS

High-resolution manometry studies were reviewed in 272 consecutive patients (56.4 ± 0.8 years, 62% F) and compared to 21 healthy controls (27.6 ± 0.6 years, 52% F), using HRM tools (distal contractile integral, DCI; distal latency, DL; integrated relaxation pressure, IRP), Chicago Classification (CC) and multiple rapid swallows (MRS). Segments were designated merged when the trough between S2 and S3 was ≥150 mmHg, and exaggerated S3 when peak S3 amplitude was ≥150 mmHg without merging with S2. Presenting symptoms and global symptom severity (on 100 mm visual analog scale) were recorded. Prevalence of merged and exaggerated segments was determined, and characteristics compared to symptomatic patients with normal HRM, and to healthy controls.

KEY RESULTS

Merged segments were identified in 5.6%, and exaggerated S3 in another 12.5%, but only 17-50% had a CC diagnosis; one healthy control had merged segments. DCI with wet swallows was similar in cohorts with merged and exaggerated segments (p = 0.7), significantly higher than symptomatic patients with normal HRM and healthy controls (p ≤ 0.003 for each comparison). Incomplete inhibition and prominent DCI augmentation on MRS (p ≤ 0.01), and presenting symptoms (chest pain and dysphagia, p = 0.04) characterized exaggerated segments, but not demographics or symptom burden.

CONCLUSIONS & INFERENCES

Merged esophageal smooth muscle segments and exaggerated S3 may represent hypermotility phenomena from abnormal inhibition and/or excitation, and are not uniformly identified by the CC algorithm.

Impact of Different Methods of Feedback to Clinicians After Postprescription Antimicrobial Review Based on the Centers for Disease Control and Prevention's 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults

Objectives.

To evaluate (1) the framework of the 12 Steps to Prevent Antimicrobial Resistance Among Hospitalized Adults that is part of the Centers for Disease Control and Prevention (CDC) Campaign to Prevent Antimicrobial Resistance in Healthcare Settings, with regard to steps addressing antimicrobial use; and (2) methods of feedback to clinicians regarding antimicrobial use after postprescription review.

Design.

Prospective intervention to identify and modify inappropriate antimicrobial therapy.

Setting.

A 1,000-bed, tertiary care teaching hospital.

Patients.

Inpatients in selected medicine and surgery units receiving broad-spectrum antimicrobials for 48-72 hours.

Interventions.

We created a computer-based clinical-event detection system that automatically identified inpatients taking broad-spectrum and “reserve” antimicrobials for 48-72 hours. Although prior approval was required for initial administration of broad-spectrum and reserve antimicrobials, once approval was obtained, therapy with the antimicrobials could be continued indefinitely at the discretion of the treating clinician. Therapy that was ongoing at 48-72 hours was reviewed by an infectious diseases pharmacist or physician, and when indicated feedback was provided to clinicians to modify or discontinue therapy. Feedback was provided via a direct telephone call, a note on the front of the medical record, or text message sent to the clinician's pager. The acceptance rate of feedback was recorded and recommendations were categorized according to the 12 steps recommended by the CDC.

Results.

Interventions were recommended for 334 (30%) of 1,104 courses of antimicrobial therapy reviewed. A total of 87% of interventions fit into one of the CDC's 12 steps of prevention: 39% into step 3 (“target the pathogen”), 1% into step 4 (“access experts”), 3% into steps 7 and 8 (“treat infection, not colonization or contamination”), 18% into step 9 (“say ‘no’ to vancomycin”), and 26% into step 10 (“stop treatment when no infection”). The rate of compliance with recommendations to improve antimicrobial use was 72%. No differences in compliance were seen with the different methods of feedback.

Conclusions.

Nearly one-third of antimicrobial courses did not follow the CDC's recommended 12 steps for prevention of antimicrobial resistance. Clinicians demonstrated high compliance with following suggestions made after postprescription review, suggesting that it is a useful approach to decreasing and improving antimicrobial use among inpatients.

MRI scanning and orthodontics

Magnetic Resonance Imaging (MRI) plays an important role in diagnosis for many head and neck lesions. Both clinical and experimental studies have shown that orthodontic appliances may produce image distortion on MRI scans of the head and neck. A case is presented in which the patient complained of unexplained right-sided facial paraesthesia, whilst undergoing fixed appliance orthodontic treatment. This was a serious symptom, which warranted investigation including a MRI scan. The compatibility of fixed appliances with MRI is discussed.

Vaccine-associated varicella and rubella infections in severe combined immunodeficiency with isolated CD4 lymphocytopenia and mutations in IL7R detected by tandem whole exome sequencing and chromosomal microarray

In areas without newborn screening for severe combined immunodeficiency (SCID), disease-defining infections may lead to diagnosis, and in some cases, may not be identified prior to the first year of life. We describe a female infant who presented with disseminated vaccine-acquired varicella (VZV) and vaccine-acquired rubella infections at 13 months of age. Immunological evaluations demonstrated neutropenia, isolated CD4 lymphocytopenia, the presence of CD8(+) T cells, poor lymphocyte proliferation, hypergammaglobulinaemia and poor specific antibody production to VZV infection and routine immunizations. A combination of whole exome sequencing and custom-designed chromosomal microarray with exon coverage of primary immunodeficiency genes detected compound heterozygous mutations (one single nucleotide variant and one intragenic copy number variant involving one exon) within the IL7R gene. Mosaicism for wild-type allele (20-30%) was detected in pretransplant blood and buccal DNA and maternal engraftment (5-10%) demonstrated in pretransplant blood DNA. This may be responsible for the patient's unusual immunological phenotype compared to classical interleukin (IL)-7Rα deficiency. Disseminated VZV was controlled with anti-viral and immune-based therapy, and umbilical cord blood stem cell transplantation was successful. Retrospectively performed T cell receptor excision circle (TREC) analyses completed on neonatal Guthrie cards identified absent TREC. This case emphasizes the danger of live viral vaccination in severe combined immunodeficiency (SCID) patients and the importance of newborn screening to identify patients prior to high-risk exposures. It also illustrates the value of aggressive pathogen identification and treatment, the influence newborn screening can have on morbidity and mortality and the significant impact of newer genomic diagnostic tools in identifying the underlying genetic aetiology for SCID patients.

Effect of Liverubin™ on hepatic biochemical profile in patients of alcoholic liver disease: a retrospective study

Liverubin™ is an available drug in the Indian market that contains silymarin, the major active complex extracted from the medicinal plant milk thistle (Silybum marianum L.). The study retrospectively tracked and analyzed the data of 602 patients, out of which 230 were alcohol induced; 131 with alcohol-induced liver damage (ALD), 13 with liver cirrhosis, and 86 with fatty liver; to assess the effects of water soluble Silymarin (Liverubin™) on important hepatic biochemical parameters. The data was collected from 32 major cities treated by 72 physicians across India who were observed for the specified treatment duration of 11 months. Data was analyzed by using descriptive statistics. At the end of the treatment the hepatic biochemical profile was appreciably improved: the mean % of change in the levels of important hepatic biochemical parameters was observed as follows: total bilirubin 63.48% (direct bilirubin: 64.96%; indirect bilirubin: 61.63%). The serum SGOT and SGPT changed at a mean % of 65.43 and 69.31 respectively while serum alkaline phosphatase was changed at a mean % rate of 39.81. Liverubin™ proved to be safe & well-tolerated among the studied population and no significant treatment related adverse events were reported during the study. Liverubin™ treatment is found to bring about effective lowering of abnormally elevated hepatic biochemical parameters. Liverubin™, water soluble active Silymarin, in the popularly prescribed doses of 140-mg tid is observed to be a promising safe and effective drug in cases of alcoholic liver disease.

What are the significant factors associated with burnout in doctors?

BACKGROUND

Burnout syndrome is well established as a condition that affects a significant proportion of practising doctors. Although much literature exists on the prevalence of burnout, only specific variables associated with this condition have been analysed.

AIMS

To identify and categorize key factors that are associated with burnout across various medical specialities and geographical locations.

METHODS

Three electronic databases were searched for literature on the factors associated with burnout published in the past 5 years. Inclusion and exclusion criteria were applied in three stages. We analysed and critically appraised each paper individually, identifying the common themes.

RESULTS

Forty-seven papers were included from the 395 identified by our primary search. Younger age, female sex, negative marital status, long working hours and low reported job satisfaction were found to be predictive of burnout syndrome across the literature. Participation in 'wellness programmes' was related to lower burnout incidence. Causation could not be established however, due to the limited number of longitudinal studies.

CONCLUSIONS

More prospective studies are required to assess causation. Despite this, our thematic analysis revealed consistent findings across many papers. This information can be used to inform prevention and interventions to tackle burnout. The associated factors should not be addressed individually, as they are inter-related.