Venous thromboembolism in cancer patients - magnitude of problem, approach, and management

Cancer is hypercoagulable state. Patients with cancer are at high risk to develop venous thromboembolism (VTE). Relative risk of developing VTE is approximately seven times higher in patients with active cancer. The incidence of occult malignancy is 7%-12% in patients with idiopathic deep vein thrombosis (DVT). However, little research has been focused on cancer with thromboembolism. Lowmolecularweight heparin most frequently used pharmacologic agents as recommended by established guidelines. The aim was to evaluate the magnitude of problem in cancer patients and treatment option as per established guidelines. EMBASE, MEDLINE, and PubMed search of the literature were done to evaluate the association of DVT with various malignancy, magnitude of problem, approach, and various guidelines for the management of DVT. References of all publication were also searched to enrich this article for recent update. Thromboprophylaxis in cancer patient is gray zone area. This need lot of investigational work to find highrisk patients who would benefit from primary thromboprophylaxis.

Medical education in difficult circumstances: analysis of the experience of clinical medical students following the new innovative medical curriculum in Aksum, rural Ethiopia

BACKGROUND

In 2012, 12 medical schools were opened in Ethiopia to tackle the significant shortage of doctors. This included Aksum School of Medicine situated in Aksum, a rural town in Northern Ethiopia. The new Innovative Medical Curriculum (NIMC) is a four-year programme designed by the Ethiopian Federal Ministries of Health and Education. The curriculum is designed to train biomedical science graduates to become doctors in 4 years, with a focus on the healthcare needs of rural people living in poverty.

METHODS

This research was conducted at Aksum School of Medicine and included two hospitals (Aksum Referral Hospital and St Mary's District Hospital). This study focused on medical students during their clinical years across multiple specialities (61 Clerkship 1 students and 13 Clerkship 2 students). We used primarily qualitative research methods supplemented with quantitative measures. There were 3 stages of data collection over a 1 month period, this included qualitative group interviews, direct observation of students in a clinical setting and direct observation of skills sessions followed by a questionnaire on the sessions. We analysed the data by reconstructing the student experience and comparing it with the NIMC.

RESULTS

The proposed typical week set out in the NIMC tended to differ from the real clinical experience of these students. Through qualitative group interview and direct observation of teaching, the main theme that was consistent throughout was the lack of doctors with specialist postgraduate training. Clinical need often took priority over education. However, students enjoyed taking early responsibility and gaining practical experience. Through direct observation of skills sessions and short questionnaires, these sessions were highly valuable to the students and they felt confident in carrying out the taught procedures in the future.

CONCLUSIONS

The combination of poorly resourced hospitals and lack of specialist doctors provides a challenging environment for medical students to learn. However, it is a unique clinical experience that is rarely seen in developed countries and facilitates the acquirement of skills from an early stage. Supervision and specialist input is fundamental in enabling students to learn and this is a key area that was lacking in the students' clinical experience.

Genetically engineered two-warhead evasins provide a method to achieve precision targeting of disease-relevant chemokine subsets

Both CC and CXC-class chemokines drive inflammatory disease. Tick salivary chemokine-binding proteins (CKBPs), or evasins, specifically bind subsets of CC- or CXC-chemokines, and could precisely target disease-relevant chemokines. Here we have used yeast surface display to identify two tick evasins: a CC-CKBP, P1243 from Amblyomma americanum and a CXC-CKBP, P1156 from Ixodes ricinus. P1243 binds 11 CC-chemokines with Kd < 10 nM, and 10 CC-chemokines with Kd between 10 and 100 nM. P1156 binds two ELR + CXC-chemokines with Kd < 10 nM, and four ELR + CXC-chemokines with Kd between 10 and 100 nM. Both CKBPs neutralize chemokine activity with IC50 < 10 nM in cell migration assays. As both CC- and CXC-CKBP activities are desirable in a single agent, we have engineered "two-warhead" CKBPs to create single agents that bind and neutralize subsets of CC and CXC chemokines. These results show that tick evasins can be linked to create non-natural proteins that target subsets of CC and CXC chemokines. We suggest that "two-warhead" evasins, designed by matching the activities of parental evasins to CC and CXC chemokines expressed in disease, would achieve precision targeting of inflammatory disease-relevant chemokines by a single agent.

The N-terminal domain of a tick evasin is critical for chemokine binding and neutralization and confers specific binding activity to other evasins

Tick chemokine-binding proteins (evasins) are an emerging class of biologicals that target multiple chemokines and show anti-inflammatory activities in preclinical disease models. Using yeast surface display, we identified a CCL8-binding evasin, P672, from the tick Rhipicephalus pulchellus We found that P672 binds CCL8 and eight other CC-class chemokines with a Kd < 10 nm and four other CC chemokines with a Kd between 10 and 100 nm and neutralizes CCL3, CCL3L1, and CCL8 with an IC50 < 10 nm The CC chemokine-binding profile was distinct from that of evasin 1 (EVA1), which does not bind CCL8. We also show that P672's binding activity can be markedly modulated by the location of a StrepII-His purification tag. Combining native MS and bottom-up proteomics, we further demonstrated that P672 is glycosylated and forms a 1:1 complex with CCL8, disrupting CCL8 homodimerization. Homology modeling of P672 using the crystal structure of the EVA1 and CCL3 complex as template suggested that 44 N-terminal residues of P672 form most of the contacts with CCL8. Replacing the 29 N-terminal residues of EVA1 with the 44 N-terminal residues of P672 enabled this hybrid evasin to bind and neutralize CCL8, indicating that the CCL8-binding properties of P672 reside, in part, in its N-terminal residues. This study shows that the function of certain tick evasins can be manipulated simply by adding a tag. We conclude that homology modeling helps identify regions with transportable chemokine-binding functions within evasins, which can be used to construct hybrid evasins with altered properties.

Practical consensus recommendations on management of triple-negative metastatic breast cancer

Patients with breast cancer along with metastatic estrogen and progesterone receptor (ER/PR)- and human epidermal growth factor receptor 2 (HER2)-negative tumors are referred to as having metastatic triple-negative breast cancer (mTNBC) disease. Resistance to current standard therapies such as anthracyclines or taxanes limits the available options for previously treated patients with metastatic TNBC to a small number of non-cross-resistant regimens, and there is currently no preferred standard chemotherapy. Clinical experience suggests that many women with triple-negative metastatic breast cancer (MBC) relapse quickly. Expert oncologist discussed about new chemotherapeutic strategies and agents used in treatment of mTNBC and the expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

A prospective randomized trial comparing capecitabine-based chemoradiotherapy with 5-FU-based chemoradiotherapy in neoadjuvant setting in locally advanced carcinoma rectum

INTRODUCTION

Fluorouracil (FU)based chemoradiotherapy is regarded as a standard perioperative treatment in locally advanced rectal cancer. Capecitabine is an oral fluoropyrimidine that generates 5FU preferentially at the tumor site by exploiting the higher activity of the enzyme thymidine phosphorylase in tumor tissue compared with healthy tissue. As an oral agent, capecitabine can be administered in the outpatient setting, potentially providing FU exposure similar to a lowdose continuous infusion of 5FU.

AIMS AND OBJECTIVES

To compare capecitabine with 5FU, with regard to efficacy and toxicity when used in neoadjuvant setting along with radiotherapy for locally advanced carcinoma rectum.

MATERIALS AND METHODS

Thirty patients were enrolled, 14 in 5FU and 16 in capecitabine arm. All patients were planned for 45 Gy/25#/5 weeks pelvic radiotherapy followed by a boost of 5.4 Gy/3#/3 days. 5FU was prescribed at a dose of 500 mg/m2 #1-#5 and #21-#25 of RT and capecitabine was given at 1650 mg/m2 on RT days throughout the course of radiotherapy. A magnetic resonance imaging/computerized tomography scan was done at the start of treatment and 1 month after completion of treatment, followed by surgery. Toxicity was assessed weekly during treatment and on the first followup.

RESULTS

Response rates and toxicity profile of capecitabinebased cathode ray tube (CRT) was similar to 5FUbased CRT with nonsignificant P values.

CONCLUSION

Capecitabine may be used as an alternative in patients who do not tolerate 5FU.

Activated carbon from sugarcane bagasse ash for melanoidins recovery

This work investigates the value added utilization of two sugar-distillery wastes: (i) melanoidins, which are complex Maillard reaction products in molasses distillery wastewater, and (ii) unburnt carbon in sugarcane bagasse ash. Activated unburnt carbon (AUC), prepared by deashing and steam activation, had properties comparable to commercial activated carbon (CAC). Both carbons are suitable for melanoidins adsorption followed by desorption using 25% pyridine solution. For AUC, the equilibrium adsorption data is well described by Langmuir isotherm up to 35 °C while Freundlich model fits better at higher temperature. Adsorption using CAC followed Freundlich isotherm at all temperatures. Both carbons followed pseudo second order kinetics and displayed endothermic physisorption. Recovery of melanoidins from AUC (78%) was close to that observed with CAC (80%).

Molecular Response to Imatinib and Its Correlation with mRNA Expression Levels of Imatinib Influx Transporter (OCT1) in Indian Chronic Myeloid Leukemia Patients

Background and objectives:

Imatinib mesylate is approved for the treatment of Chronic Myeloid Leukemia (CML). About 20% of patients with CML do not respond to treatment with Imatinib either initially or because of acquired resistance. In addition to mutated BCR-ABL1 kinase, the organic cation transporter1 (OCT1, encoded by SLC22A1) has been considered to contribute to Imatinib resistance in patients with chronic myeloid leukemia (CML). OCT1 has been reported to be the main influx transporter involved in Imatinib uptake into CML cells. To date, only a few studies have been reported on involvement of influx transporters in development of Imatinib resistance. Therefore this study was aimed to determine the expression level of Imatinib uptake transporter (OCT1) in CML patients and to correlate this level with molecular response.

Methods:

One hundred fifty eight patients on Imatinib were considered for gene expression analysis study for OCT1 gene. Total RNA was extracted from peripheral blood mononuclear cells. Complementary DNAs (cDNAs) were synthesized and Real Time Polymerase Chain Reaction (RQ-PCR) was performed.

Results:

High OCT1 expression was present in 81 (51.8%) patients and low OCT1 expression was in 77 (48.7%) patients. Low Sokal risk score group have a significantly high OCT1 expression (p=0.048). The rate of molecular response was higher in those with high OCT1 expression than in those with low OCT1 expression (p=0.05). Both event-free survival and median overall survival were significantly shorter in patients with low OCT1 expressions when compared to the patients with high OCT1 expression (p=0.03 and p=0.05).

Conclusions:

Our findings demonstrated that the mRNA expression level of OCT1 was significantly correlated with molecular response in CML patients. Based on these findings, present study believes that the pre-therapeutic higher expression of OCT1 may help to predict response to imatinib therapy in CML patients.