Economic impact of a nationwide interoperable e-Health system using the PENG evaluation tool

OBJECTIVE

The aim of this paper is to evaluate the costs and benefits of the Estonian interoperable health information exchange system. In addition, a framework will be built for follow-up monitoring and analysis of a nationwide HIE system.

METHODS

PENG evaluation tool was used to map and quantify the costs and benefits arising from type II diabetic patient management for patients, providers and the society. The analysis concludes with a quantification based on real costs and potential benefits identified by a panel of experts.

RESULTS

Setting up a countrywide interoperable eHealth system incurs a large initial investment. However, if the system is working seamlessly, benefits will surpass costs within three years. The results show that while the society stands to benefit the most, the costs will be mainly borne by the healthcare providers. Therefore, new government policies should be devised to encourage providers to invest to ensure society wide benefits.

Abstract C221: Glycoengineered anti-EGFR (GA201) elicits enhanced ADCC responses by NK cells from colorectal cancer patients despite tumor-associated impairments to natural cytotoxicity

Background: One component of the therapeutic efficacy of IgG1 monoclonal antibodies (mAb) is their ability to induce antibody dependent cellular cytotoxicity (ADCC) by NK cells and other immune effectors bearing the low-affinity Fc RIIIa (CD16) receptor. Clinical studies establish the relevance of ADCC finding widespread polymorphisms that encode a very low affinity CD16 (158F/F) predict limited clinical responses to Cetuximab or Rituximab. Now, mAbs with increased affinity for CD16 can be produced using GlycoMab technology. The altered glycosylation pattern in the Fc domain of these antibodies enhances CD16-binding and ADCC irrespective of genotype. Yet, the potential for enhanced ADCC in patients with advanced colorectal carcinoma (CRC) has not been demonstrated. Considering the potential for tumor-associated immune impairments and treatments-associated leukopenia, we enumerated and characterized NK cells from patients prior to chemotherapy, on active therapy, or following two-lines of standard treatment and compared responsiveness to standard and glycoengineered anti-EGFR mAbs. Methodology: PBMCs were isolated from blood of age-matched healthy donors and 100 patients: either at presentation with metastatic disease; during chemotherapy with FOLFOX, FOLFIRI, or Irinotecan; or at disease progression >4 weeks following second line failure. Laboratory tests included: immunophenotyping for CD3,CD8,CD45,CD4 and CD3,CD56/16,CD45,CD19 markers; measurements of CD16- and NKG2D-expressing NK cells; CD16 158 genotype; and assessment of K562-killing (natural cytotoxicity) and degranulation (CD107+) of NK cells among cryopreserved PBMC in response to K562 or EGFR+ A431 cells with 10 g/ml GlycoMAb anti-EGFR (GA201), wild-type GA201, Panitumumab or Cetuximab.

Results: For each group of patients, the proportion of NK cells among lymphocytes remained similar to controls. However, NK cells counts were reduced about half in patients (affected primarily by disease and only slightly by treatment). Per NK cell killing capacity of K562 was substantially impaired in patients prior to therapy and most profoundly among the post-chemotherapy group. ADCC responses were similarly impaired but to lesser degrees. In all cohorts tested, GlycoMAb anti-EGFR was superior to cetuximab in activating more NK cells. The superior ADCC activation of NK cells by GlycoMAb was most pronounced in the patients with chemotherapy-resistant disease.

Conclusion: Chemotherapy does not induce gross alterations in the immune phenotype of CRC patients. At all stages of treatment, patients retain CD16+ NK cells capable of ADCC. The impairments in the NK functional responses tested are likely due to host/tumor interaction and not a consequence of treatment. Despite impairments, the best activation of NK cells was always in response to GlycoMAb GA201 for all individuals tested. These findings support testing for enhanced ADCC by GA201 in clinical trials of CRC patients following two lines of chemotherapy or in combination with chemotherapy.

Acknowledgements: Simon Hollingsworth, current affiliation Astra Zeneca UK

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C221.

Recombinant bacteriophage lysins as antibacterials

With the increasing worldwide prevalence of antibiotic resistant bacteria, bacteriophage endolysins (lysins) represent a very promising novel alternative class of antibacterial in the fight against infectious disease. Lysins are phage-encoded peptidoglycan hydrolases which, when applied exogenously (as purified recombinant proteins) to Gram-positive bacteria, bring about rapid lysis and death of the bacterial cell. A number of studies have recently demonstrated the strong potential of these enzymes in human and veterinary medicine to control and treat pathogens on mucosal surfaces and in systemic infections. They also have potential in diagnostics and detection, bio-defence, elimination of food pathogens and control of phytopathogens. This review discusses the extensive research on recombinant bacteriophage lysins in the context of antibacterials, and looks forward to future development and potential.

High-throughput sequence-based analysis of the bacterial composition of kefir and an associated kefir grain

Lacticin 3147 is a two-peptide broad spectrum lantibiotic produced by Lactococcus lactis DPC3147 shown to inhibit a number of clinically relevant Gram-positive pathogens. Initially isolated from an Irish kefir grain, lacticin 3147 is one of the most extensively studied lantibiotics to date. In this study, the bacterial diversity of the Irish kefir grain from which L. lactis DPC3147 was originally isolated was for the first time investigated using a high-throughput parallel sequencing strategy. A total of 17 416 unique V4 variable regions of the 16S rRNA gene were analysed from both the kefir starter grain and its derivative kefir-fermented milk. Firmicutes (which includes the lactic acid bacteria) was the dominant phylum accounting for > 92% of sequences. Within the Firmicutes, dramatic differences in abundance were observed when the starter grain and kefir milk fermentate were compared. The kefir grain-associated bacterial community was largely composed of the Lactobacillaceae family while Streptococcaceae (primarily Lactococcus spp.) was the dominant family within the kefir milk fermentate. Sequencing data confirmed previous findings that the microbiota of kefir milk and the starter grain are quite different while at the same time, establishing that the microbial diversity of the starter grain is not uniform with a greater level of diversity associated with the interior kefir starter grain compared with the exterior.

Late presentation of sorafenib-associated rash: a case report

Introduction

Sorafenib, an oral multitargeted tyrosine kinase inhibitor, is licensed for the treatment of hepatocellular carcinoma. Rash is one of the most common side effects of its use, generally appearing within days to a few weeks of commencing treatment. We report the first case of rash appearing nine months after starting treatment with sorafenib.

Case presentation

A 75-year-old Caucasian man initially presented with asymptomatic transient jaundice. He was diagnosed with Barcelona Clinic Liver Cancer stage B hepatocellular carcinoma after extensive investigation. He tolerated sorafenib 400 mg twice a day before presenting nine months later with a rash, confirmed to be drug-induced.

Conclusions

Sorafenib is a drug of choice in Barcelona Clinic Liver Cancer stage B hepatocellular carcinoma. It can cause protracted rash quite late into treatment. Successful management of the rash could contribute to achieving stable disease in hepatocellular carcinoma over a significant period of time.

An unusual guanyl oligonucleotide regulates cellulose synthesis in Acetobacter xylinum

The mechanism of GTP-specific activation of the membrane-bound cellulose synthase system of Acetobacter xylinum has been further elucidated. The supernatant fraction derived from washed membranes of this organism contains an enzyme which reacts with GTP to form a low molecular mass, heat-stable compound,tentatively characterized as a cyclic oligonuleotide composed of GMP residues, which is the immediate activator of the cellulose synthase. This activation is reversed by a membrane-bound enzyme that degrades the activator; the latter enzyme is inhibited by Ca (2+). It is suggested that the interaction between these enzymes and nucleotide derivatives, mediated by Ca (2+), may regulate cellulose synthesis in VIVO.

Colorectal cancer treatment

INTRODUCTION

Colorectal cancer is the third most common malignancy in the developed countries, and about a quarter of people present with intestinal obstruction or perforation. Risk factors for colorectal cancer are mainly dietary and genetic. Overall 5-year survival is about 50%, with half of people having surgery experiencing recurrence of the disease.

METHODS AND OUTCOMES

We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for colorectal cancer? We searched: Medline, Embase, The Cochrane Library, and other important databases up to August 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS

We found 57 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS

In this systematic review we present information relating to the effectiveness and safety of the following interventions: adjuvant systemic chemotherapy, preoperative radiotherapy, and routine intensive follow-up.

Marked elevations in pro-inflammatory polyunsaturated fatty acid metabolites in females with irritable bowel syndrome

Irritable bowel syndrome (IBS) is the most common functional gastrointestinal disorder referred to gastroenterologists. Although the pathophysiology remains unclear, accumulating evidence points to the presence of low-level immune activation both in the gut and systemically. Circulating polyunsaturated fatty acids (PUFA) have recently attracted attention as being altered in a variety of disease states. Arachidonic acid (AA), in particular, has been implicated in the development of a pro-inflammatory profile in a number of immune-related disorders. AA is the precursor of a number of important immunomodulatory eicosanoids, including prostaglandin E(2) (PGE(2)) and leukotriene B(4) (LTB(4)). We investigated the hypothesis that elevated plasma AA concentrations in plasma contribute to the proposed pro-inflammatory profile in IBS. Plasma AA and related PUFA were quantified by gas chromatography analysis in IBS patients and controls. Both PGE(2) and LTB(4) were measured in serum using commercially available ELISA assays. AA concentrations were elevated in our patient cohort compared with healthy controls. Moreover, we demonstrated that this disturbance in plasma AA concentrations leads to downstream elevations in eicosanoids. Together, our data identifies a novel proinflammatory mechanism in irritable bowel syndrome and also suggests that elevated arachidonic acid levels in plasma may serve as putative biological markers in this condition.

The effect of hand dominance on recurrent idiopathic paediatric epistaxis

OBJECTIVES

No published data exists to support the belief that nose picking contributes to recurrent idiopathic paediatric epistaxis. If nose picking is implicated then there may be a higher incidence of epistaxis on the side of the dominant hand. The objective of the study was to determine whether nose picking has a significant role in paediatric epistaxis by comparing hand dominance and side of epistaxis.

DESIGN AND SETTING

A prospective, consecutive cohort of new epistaxis referrals to a tertiary paediatric centre over a 14-month period were assessed for hand dominance and reported side of the epistaxis. The presence of septal excoriation, crusting and prominent blood vessels was also recorded.

PARTICIPANTS

One hundred and forty-eight new epistaxis referrals.

MAIN OUTCOME MEASURES

Dominant hand, side of epistaxis history and side of positive examination findings.

RESULTS

No statistically significant association between hand dominance and either epistaxis history or examination findings was identified. A statistically significant association between epistaxis history and examination findings was identified P < 0.001, K = 0.614, SE 0.571.

CONCLUSIONS

The study does not provide evidence to support the belief that paediatric epistaxis is influenced by nose picking. The study provides evidence that patients' epistaxis history and positive examination findings are a consistent marker of previous epistaxis.

Investigating the inflammatory phenotype of major depression: focus on cytokines and polyunsaturated fatty acids

There is evidence that increased inflammatory activity contributes to treatment non-response in depression and studies suggest that omega-3 fatty acid supplementation is effective in antidepressant non-responders. We tested the hypotheses that in major depression (1) the plasma omega-6:omega-3 fatty acid ratio is greater in antidepressant non-responders than responders and (2) higher omega-6:omega-3 ratios are associated with a pro-inflammatory cytokine profile. Twenty DSM-IV major depressives who had failed a six week course of an SSRI, 14 subjects who responded to a six week course of an SSRI and were currently euthymic and 24 healthy comparison subjects took part in the study. Six millilitres of whole blood was collected in ethylenediaminetetraacetic acid (EDTA) tubes for determination of fatty acids together with IL-6 and TNF-alpha. Arachidonic acid (AA) levels were elevated in both the responders and the non-responders. IL-6 was elevated in a similar manner but differences in TNF-alpha did not reach statistical significance. The eicosapentaenoic acid (EPA):AA ratio in the three groups was as follows: controls 0.08+/-0.01; responders 0.08+/-0.01; non-responders 0.04+/-0.01. These differences are significant (p<0.001). AA and IL-6 were highly correlated in both responders and non-responders but not in healthy volunteers. The findings of this study provide further support for the view that major depression is associated with a pro-inflammatory phenotype which at least partially persists when patients become normothymic.