Abstract P6-03-02: Budesonide and colesevelam reduce neratinib-induced diarrhea in a rat model

Background: Neratinib (Puma Biotechnology Inc.) is an irreversible pan-HER tyrosine kinase inhibitor approved for use as extended adjuvant therapy in women with early-stage HER2+ breast cancer. Diarrhea is the main adverse event of neratinib; grade 3 events are common in the absence of antidiarrheal prophylaxis (40%) [Chan et al. Lancet Oncol 2016]. To investigate the underlying pathogenic mechanisms and to explore possible targets for its prevention, we developed a reproducible rat model of neratinib-induced diarrhea. Findings from the model indicated that neratinib-induced diarrhea is multifactorial, involving anatomical disruption and mucosal inflammation in the ileum and colon [Secombe et al. Asia Pac J Clin Oncol 2017]. We investigated the effects of budesonide, a locally-acting corticosteroid used for gastrointestinal conditions, and colesevelam, a bile acid sequestrant, on neratinib-associated diarrhea and intestinal changes in this model.

Methods: Male albino Wistar rats were randomly allocated to vehicle control (5% DMSO/1% carboxymethyl cellulose), neratinib 50 mg/kg alone or combined with budesonide 1 mg/kg or colesevelam 300 mg/kg by oral gavage for 14 or 28 days. Diarrhea severity was graded daily [0, no diarrhea; 1, mild; 2, moderate; 3, severe]. A tissue injury score was assigned based on validated histological criteria (villus fusion and atrophy, disruption of brush border and enterocytes, crypt losses/architectural disruption, crypt cell disruption, infiltration of polymorphonuclear cells/lymphocytes, dilation of lymphatics/capillaries, edema). Inflammation was assessed using multiplex cytokine/chemokine ELISA.Fecal bile acids were measured in pooled fecal samples over an 8-hour period.

Results: Findings at 28 days:

VariableControl (n=16)Neratinib (n=16)Neratinib + budesonide (n=16)Neratinib + colesevelam (n=16)Incidence of diarrhea, %Grade 137.5000Grade 212.587.5100100Grade 3012.500Mean±SEM days with grade 2 diarrhea0.1±0.115.8±2.710.0±1.0*10.0±2.1*Median (range) tissue injury scoreDistal ileum0.5 (0–2.0)4.0 (3.0–5.0)††3.0 (2.0–4.0)3.0 (2.0–4.0)†Proximal colon2.0 (0–3.0)5.0 (4.0–6.0)††3.0 (2.0–5.0)*3.0 (2.0–5.0)Distal colon0.5 (0–2.0)2.5 (2.0–4.0)††1.0 (0–2.0)*1.5 (0–2.0)Median (range) cytokine levelsaIleumIFN-γ27 (15–48)49 (39–67)†43 (29–55)–IL-463 (15–111)223 (109–318)464 (309–559)**–IL-1021 (14–54)32 (10–84)60 (52–89)*–ColonIFN-γ22 (6–32)16 (12–22)16 (6–19)–IL-4147 (88–270)165 (15–327)345 (170–433)*–IL-1054 (18–128)55 (37–96)47 (43–60)–Mean±SEM total fecal bile acids, umol/mg3.5±0.43.9±0.2–5.5±0.4††*ang/ml (IFN-γ); pg/ml (IL-4, IL-10); *p<0.05, **p<0.005 vs neratinib; †p<0.05, ††p<0.005 vs control; IFN, interferon; IL, interleukin; SEM, standard error of the mean

Conclusions: Budesonide and colesevelam reduced duration of neratinib-induced diarrhea and prevented severe diarrhea. Budesonide also reduced histopathological injury and inflammation via preservation of intestinal morphology and upregulation of anti-inflammatory cytokines in the ileum and colon. The phase II CONTROL study (Clinicaltrials.gov NCT02400476) is currently investigating the effects of adding budesonide or colestipol to loperamide prophylaxis in the prevention of neratinib-induced diarrhea and will help to determine the clinical relevance of our observations.

Citation Format: Bowen JM, Secombe KR, Ball IA, Shirren J, Wignall AD, Finnie JW, Olek E, Martin D, Lalani AS, Keefe D. Budesonide and colesevelam reduce neratinib-induced diarrhea in a rat model [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-03-02.

Joint European Society of Paediatric Radiology (ESPR) and International Society for Forensic Radiology and Imaging (ISFRI) guidelines: paediatric postmortem computed tomography imaging protocol

Postmortem CT for investigating childhood deaths is increasingly utilised as a noninvasive adjunct or alternative to standard autopsy; however there are no standardised published imaging protocols. This article describes a standardised imaging protocol that has been developed based on current practices of international postmortem imaging practitioners and experts. This recommendation is expected to be useful for postmortem imaging centres wishing to update their existing practices and for those starting paediatric postmortem CT as a new service.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

Weight loss interventions for adults with overweight/obesity and chronic musculoskeletal pain: a mixed methods systematic review

Worldwide prevalence of adult overweight and obesity is a growing public health issue. Adults with overweight/obesity often have chronic musculoskeletal pain. Using a mixed-methods review, we aimed to quantify the effectiveness and explore the appropriateness of weight loss interventions for this population. Electronic databases were searched for studies published between 01/01/90 and 01/07/16. The review included 14 randomized controlled trials that reported weight and pain outcomes and three qualitative studies that explored perceptions of adults with co-existing overweight/obesity and chronic musculoskeletal pain. The random-effects pooled mean weight loss was 4.9 kg (95%CI:2.9,6.8) greater for intervention vs control. The pooled mean reduction in pain was 7.3/100 units (95%CI:4.1,10.5) greater for intervention vs control. Study heterogeneity was substantial for weight loss (I²  = 95%, tau = ±3.5 kg) and pain change (I²  = 67%, tau = ±4.1%). Meta-regression slopes for the predictors of study quality, mean age and baseline mean weight on mean study weight reduction were shallow and not statistically significant (P > 0.05). The meta-regression slope between mean pain reduction and mean weight lost was shallow, and not statistically significant, -0.09 kg per unit pain score change (95%CI:-0.21,0.40, P = 0.54). Meta-synthesis of qualitative findings resulted in two synthesized findings; the importance of healthcare professionals understanding the effects of pain on ability to control weight and developing management/education programmes that address comorbidity.

[The management of unruptured intracranial aneurysms]

The rupture of an intracranial aneurysm is a sudden, unpredictable and potentially severe event. The responsible aneurysm has to be excluded from the cerebral circulation to avoid recurrence. More and more commonly, intracranial aneurysms are detected by coincidence. How to react to these fortuitous discoveries is unclear, because the risk of rupture is difficult to estimate. We present our approach to patients facing this situation and the decision-making process.

Linking Inuit Knowledge and Public Health for Improved Child and Youth Oral Health in NunatuKavut

The oral health of Inuit children in Canada has been identified as a public health crisis. Although efforts are being made to identify and address ways to deal with this crisis, current policy and program approaches are largely entrenched within the prevailing paradigm of dental science to the exclusion of Indigenous people's understandings of health. This article reports qualitative findings of a larger study aimed at identifying, understanding, and addressing rates of oral disease among children living in NunatuKavut, a cluster of small, coastal Inuit communities located in southern Labrador, Canada. Through 18 focus groups with youth (n = 86), caregivers (n = 22), and interviews with key informant (n = 13), this study begins to elucidate southern Inuit understandings of oral health. Theorized using Two-Eyed Seeing, an Indigenous approach to balancing both Indigenous and non-Indigenous understandings of the world, the findings reported here reveal 3 themes, each of which is crosscut by historical and contemporary dimensions: 1) (w)holistic conceptualizations of health are essential to good oral health, 2) achieving optimal oral health is prohibitive for Inuit communities, and 3) community-engaged oral health service delivery is needed. Our recommendations have implications for improved oral public health service delivery for Inuit communities, in that the inclusion of Inuit perspectives on oral health should form an instrumental element of oral public health service delivery. Knowledge Transfer Statement: The results of this study may be used by clinicians and oral health educators to inform approaches to oral health service delivery within the context of Indigenous communities. It may also be used by policymakers to recognize how historical and contemporary issues of colonization relate to the formation of oral health-related policies.

Differential release of cell-signaling metabolites by male and female bovine embryos cultured in vitro

Male and female early bovine embryos show dimorphic transcription that impacts metabolism. Individual release of metabolites was examined in a 24h single culture medium from Day-6 male and female morulae that developed to Day-7 expanded blastocysts. Embryos were produced in vitro, fertilized with a single bull and cultured in SOFaaci+6  g/L BSA. The embryonic sex was identified (amelogenin gene amplification). Embryos (N = 10 males and N = 10 females) and N = 6 blank samples (i.e. SOFaaci+6  g/L BSA incubated with no embryos) were collected from 3 replicates. Metabolome was analyzed by UHPLC-TOF-MS in spent culture medium. After tentative identification, N = 13 metabolites significantly (P < 0.05; ANOVA) differed in their concentrations between male and female embryos, although N = 10 of these metabolites showed heterogeneity (Levene's test; P > 0.05). LysoPC(15:0) was the only metabolite found at higher concentration in females (fold change [FC] male to female = 0.766). FC of metabolites more abundant in male culture medium (N = 12) varied from 1.069 to 1.604. Chemical taxonomy grouped metabolites as amino-acids and related compounds (DL-2 aminooctanoic acid, arginine, 5-hydroxy-l-tryptophan, and palmitoylglycine); lipids (2-hexenoylcarnitine; Lauroyl diethanolamide; 5,6 dihydroxyprostaglandin F1a; LysoPC(15:0); DG(14:0/14:1(9Z)/0:0) and triterpenoid); endogenous amine ((S)-N-Methylsalsolinol/(R)-N-Methylsalsolinol); n-acyl-alpha-hexosamine (N-acetyl-alpha-d-galactosamine 1-phosphate); and dUMP, a product of pyrimidine metabolism. Among the compounds originally contained in CM, female embryos significantly depleted more arginine than males and blank controls (P < 0.001). Male and female embryos induce different concentrations of metabolites with potential signaling effects. The increased abundance of metabolites released from males is consistent with the higher metabolic activity attributed to such blastocysts.

Treatment with proton pump inhibitors is associated with increased mortality in patients with pyogenic liver abscess

BACKGROUND

Proton pump inhibitors (PPI) are often used in patients with gastro-esophageal reflux and peptic ulcer disease. A higher risk for infectious diseases and for pyogenic liver abscess has been reported in patients with prolonged PPI intake. Although many patients have ongoing PPI treatment after diagnosis of liver abscess, there are no data available that focus on the prognostic impact of PPI treatment in these patients.

AIM

To analyse the effect of PPI treatment on mortality in patients with pyogenic liver abscesses.

METHODS

Between January 2005 and March 2017, one hundred and eighty-one patients with pyogenic liver abscess were retrospectively included in this analysis. Medical records including PPI treatment, microbiological and imaging data were reviewed. The primary endpoint was index mortality and predictive factors were analysed using uni- and multivariate logistic regression models.

RESULTS

One hundred patients with pyogenic liver abscess (55.2%) were treated with PPI compared to 81 patients (44.8%) without PPI treatment. In both patient cohorts, enterococcus spp. and streptococcus of the anginous group were the most common pathogens identified. Patients with PPI treatment had significantly higher index mortality compared to patients without PPI treatment (30.0% vs 11.1%, P = 0.003). After adjusting for comorbidities PPI remained an independent predictive factor with an OR of 2.56 (1.01-6.46, P = 0.036).

CONCLUSIONS

PPI treatment is associated with higher index mortality in patients with pyogenic liver abscess. Therefore, critical evaluation of the indication for PPI treatment is particularly important in patients at high risk for pyogenic liver abscess.

In vitro cultured bovine endometrial cells recognize embryonic sex

Endometrial cell co-culture (ECC) with single embryo may reflect endometrium responses in vivo. Bovine Day-6 in vitro-produced morulae were cultured until Day-8 in modified synthetic oviductal fluid (mSOF), or on the epithelial side of ECC. Expression of epithelial- and stromal-cell transcripts was analyzed by RT-PCR in ECC with one male (ME) or female embryo (FE). Concentrations of ARTEMIN (ARTN) and total protein were determined in epithelial cell-conditioned medium. ECCs yielded embryos with more cells in the inner cell mass than embryos cultured in mSOF. Embryos altered transcript expression only in epithelial cells, not in stromal ones. Thus, ME induced larger reductions than FE and controls (i.e., no embryos cultured) in hexose transporter solute carrier family 2 member 1 (SLC2A1) and member 5 (SLC2A5), connective tissue growth factor (CTGF), artemin (ARTN), and interferon alpha and beta receptors subunit IFNAR1 and IFNAR2. FE reduced SLC2A1 and SLC2A5, and increased ARTN expression with respect to controls. ME tended to reduce total protein concentration (P < 0.082) in ECC-conditioned medium, while ARTN protein and gene expressions strongly correlated (R > 0.90; P < 0.05) in the group of ME or FE, but not in controls (without embryo). Isolated male and female embryos may differentially release signaling factors that induce sexually dimorphic responses in endometrial cells.

Test of the Brink-Axel Hypothesis for the Pygmy Dipole Resonance

The gamma strength function and level density of 1^{-} states in ^{96}Mo have been extracted from a high-resolution study of the (p[over →], p[over →]^{'}) reaction at 295 MeV and extreme forward angles. By comparison with compound nucleus γ decay experiments, this allows a test of the generalized Brink-Axel hypothesis in the energy region of the pygmy dipole resonance. The Brink-Axel hypothesis is commonly assumed in astrophysical reaction network calculations and states that the gamma strength function in nuclei is independent of the structure of the initial and final state. The present results validate the Brink-Axel hypothesis for ^{96}Mo and provide independent confirmation of the methods used to separate gamma strength function and level density in γ decay experiments.

Review article: the role of the microcirculation in liver cirrhosis

BACKGROUND

Intrahepatic microvascular derangements and microcirculatory dysfunction are key in the development of liver cirrhosis and its associated complications. While much has been documented relating to cirrhosis and the dysfunction of the microcirculation in the liver parenchyma, far less is known about the state of the extrahepatic microcirculation and the role this may have in the pathogenesis of multiple organ failure in end stage liver cirrhosis.

AIM

To provide an update on the role of the microcirculation in the pathophysiology of cirrhosis and its associated complications and briefly discuss some of the imaging techniques which may be used to directly investigate the microcirculation.

METHODS

A Medline literature search was conducted using the following search terms: 'cirrhosis', 'microcirculation', 'circulation', 'systemic', 'inflammation', 'peripheral', 'hepatorenal' and 'hepatopulmonary'.

RESULTS

Significant heterogeneous microvascular alterations exist in patients with cirrhosis. Data suggest that the systemic inflammation, associated with advanced cirrhosis, induces microcirculatory dysregulation and contributes to haemodynamic derangement. The resultant vasoconstriction and hypoperfusion in the systemic extrahepatic microvasculature, is likely to be instrumental in the pathophysiology of organ failure in decompensated cirrhosis, however the mechanistic action of vasoactive agents used to correct the circulatory disturbance of advanced cirrhosis is poorly understood.

CONCLUSIONS

Further research into the role of the microcirculation in patients with liver cirrhosis, will improve physicians understanding of the pathophysiology of cirrhosis, and may provide a platform for real time evaluation of an individual's microcirculatory response to vasoactive mediators, thus guiding their therapy.