Abstract B192: The EPR effect of CDP-tubulysin in the recurrence of lung and pancreatic cancers

Tubulysins, a tubulin-targeted class of natural compounds, are highly active in multidrug-resistant cells and potential agents to overcome clinical drug resistance in recurrent tumors. Unfortunately, the extraordinary activity of the potent tubulysins poses considerable complications for chemotherapeutic applications due to toxicity against normal cells and tissues. Nanoparticle drug delivery systems provide the potential to increase the intracellular concentration of drugs in cancer cells while avoiding toxicity in normal cells through the enhanced permeability and retention (EPR) effect. In this study, the efficacy of β-cyclodextrin-based polymeric tubulysin (CDP-tubulysin) administered by intravenous injection was tested on subcutaneous lung and pancreatic xenograft models. The single-dose pharmacokinetic study and tumor distribution of CDP-tubulysin and tubulysin alone were also determined in tumor-bearing mice. Our data demonstrated that CDP-tubulysin showed potent efficacy in treating lung and pancreatic cancers. The recurrent lung and pancreatic tumors were also regressed by treating with CDP-tubulysin but not gemcitabine. Moreover, the conjugation of CDP to tubulysin showed control-release behavior in the blood resulting in increased distribution of tubulysin in tumors. In conclusion, CDP conjugation was an effective delivery of tubulysins to avoid toxicity and provide potency in recurrent tumors through the EPR effect.

Citation Format: Pei-Yi Tsai, Huei-Lin Jheng, Yen-Ju Hsieh, Yung-Jen Tsai, Michael Ahrweiler, Wolfgang Richter, Muhammad Abbas, Gianfranco Pasut, Jia-Ming Chang. The EPR effect of CDP-tubulysin in the recurrence of lung and pancreatic cancers [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B192.

A novel ventricular restraint device (ASD) repetitively deliver Salvia miltiorrhiza to epicardium have good curative effects in heart failure management

A novel ventricular restraint is the non-transplant surgical option for the management of an end-stage dilated heart failure (HF). To expand the therapeutic techniques we design a novel ventricular restraint device (ASD) which has the ability to deliver a therapeutic drug directly to the heart. We deliver a Traditional Chinese Medicine (TCM) Salvia miltiorrhiza (Danshen Zhusheye) through active hydraulic ventricular support drug delivery system (ASD) and we hypothesize that it will show better results in HF management than the restraint device and drug alone. SD rats were selected and divided into five groups (n=6), Normal, HF, HF+SM (IV), HF+ASD, HF+ASD+SM groups respectively. Post myocardial infarction (MI), electrocardiography (ECG) showed abnormal heart function in all groups and HF+ASD+SM group showed a significant therapeutic improvement with respect to other treatment HF, HF+ASD, and HF+SM (IV) groups on day 30. The mechanical functions of the heart such as heart rate, LVEDP, and LVSP were brought to normal when treated with ASD+SM and show significant (P value<0.01) compared to other groups. BNP significantly declines in HF+ASD+SM group animals compared with other treatment groups. Masson's Trichrome staining was used to study histopathology of cardiac myocytes and quantification of fibrosis was assessed. The large blue fibrotic area was observed in HF, HF+ASD, and HF+SM (IV) groups while HF+ASD+SM showed negligible fibrotic myocyte at the end of study period (30days). This study proves that novel ASD device augments the therapeutic effect of the drug and delivers Salvia miltiorrhiza to the cardiomyocytes significantly as well as provides additional support to the dilated ventricle by the heart failure.

Acute intestinal schistosomiasis among school-aged children presented to King Abdullah Hospital, Bisha province, Saudi Arabia: A Case Series

Acute intestinal schistosomiasis is one of the clinical manifestations of infection with S. mansoni fluke. School aged-children are most at risk for this infection. To present cases of acute intestinal schistosomiasis among school-aged children attending the pediatric unit at King Abdullah Hospital, Bisha province, southwest of Saudi Arabia. This was a retrospective case study of nine school aged-children who were diagnosed with intestinal schistosomiasis in 2015. Data regarding clinical presentation, development of infections, diagnosis and management were recorded. Direct microscopical examination of stool sample for detection of S. mansoni egg's had been applied as a diagnostic tool. Laboratory findings were obtained to assess the severity of the infection. Nine children (7 boys and 2 girls) having acute intestinal schistosomiasis were reviewed. The age of the children were between six to 13 years old [mean 8.8 ± 2.17 years (SD)]. The duration of signs and symptoms prior to admission ranged from three to 21 days [mean 9.0 ± 5.8 days (SD)]. Most of the patients (n=7) presented with fever associated with abdominal pain followed by vomiting and cough. Four patients have a family history of intestinal schistosomiasis. Children had history of water contact for playing and swimming purposes. Infected children were treated with praziquantel (PZQ) oral dose of 20 mg/kg every eight hours for a day. None of the children presented late complications of schistosomiasis after three months follow up. The existence of intestinal schistosomiasis among school aged-children in Bisha suburb is alarming. The severity of the clinical manifestations of acute intestinal schistosomiasis were non-specific and varied that need of high expectation of physicians to diagnosis such disease. Obtaining of patients travelling history to endemic areas and visiting of infested water resources are necessary for detection of schistosomiasis cases.

Good epidemiological practice: a narrative review of appropriate scientific methods to evaluate the impact of antimicrobial stewardship interventions

AIMS

In this narrative review, we provide a framework for assessing the quality of evidence provided by studies investigating antimicrobial stewardship (AMS) interventions, and inform the design and planning stage for future AMS evaluation studies to determine the best strategies to keep antimicrobial resistance at bay.

SOURCES

Cochrane/Pubmed.

CONTENT

As AMS is mostly applied in a complex, real-world setting, bias and random time effects can jeopardize the validity of causal inference. The most important risks include simultaneously implemented infection prevention strategies and regression to the mean. Inclusion of homogeneous intervention and control arms, through randomization of the intervention, can limit these risks. However, contamination can play an important role for AMS; therefore, randomization at cluster-level, instead of randomization at individual-level, is recommended. It can be challenging to identify enough representative clusters, and implementation of a cluster-RCT (cRCT) can be costly. Controlled interrupted time series (ITS) design has a high validity as well, and is relatively straightforward to implement, although time-varying confounding should be considered. Independent of the study design, it is crucial to include multiple process, clinical outcome, microbiological and financial measures, to be able to detect possible, unintended consequences.

IMPLICATIONS

Future studies assessing the impact of new AMS strategies should produce compelling evidence by opting for cRCTs, or ITS including a control arm. Furthermore, a holistic view of intended and unintended consequences should be reported, and a detailed process evaluation should be provided to adequately inform implementation of successful AMS strategies to battle the rising burden of AMR.

Aflatoxin, proximate composition and mineral profile of stored broiler feed treated with medicinal plant leaves

OBJECTIVES

In the present investigation, the Morus alba (M. alba), Vitis vinifera (V. vinifera), Ficus religiosa (F. religiosa) and Citrus paradisi (C. paradisi) leaves anti-aflatoxigenic activities were evaluated in Aspergillus flavus (A. flavus) inoculated feed.

METHODS

The broiler feed inoculated with A. flavus was treated with selected medicinal plant leaf powder (5%, 10% and 15% w/w) and stored for the period of six months at 28°C and 16% moisture. The aflatoxins (AFTs) were estimated at the end of each month by Reversed Phase High Performance Liquid Chromatography (RP-HPLC) method along with proximate composition and mineral contents.

RESULTS

Plant leaves controlled AFTs efficiently without affecting the feed proximate composition and mineral contents. The M. alba leaves completely inhibition (100%) the AFTs (B₁ and B₂) in feed at very low concentration (5%). Other plants also showed significant (P<0.05) inhibition of AFTs production without affecting the feed quality over the storage period of six months.

CONCLUSION

Based on promising efficiency of selected medicinal plant leaves, A. flavus produced AFTs could possibly be controlled in stored poultry feed.

Application of Large-Scale Inversion Algorithms to Hydraulic Tomography in an Alluvial Aquifer

Large-scale inversion methods have been recently developed and permitted now to considerably reduce the computation time and memory needed for inversions of models with a large amount of parameters and data. In this work, we have applied a deterministic geostatistical inversion algorithm to a hydraulic tomography investigation conducted in an experimental field site situated within an alluvial aquifer in Southern France. This application aims to achieve a 2-D large-scale modeling of the spatial transmissivity distribution of the site. The inversion algorithm uses a quasi-Newton iterative process based on a Bayesian approach. We compared the results obtained by using three different methodologies for sensitivity analysis: an adjoint-state method, a finite-difference method, and a principal component geostatistical approach (PCGA). The PCGA is a large-scale adapted method which was developed for inversions with a large number of parameters by using an approximation of the covariance matrix, and by avoiding the calculation of the full Jacobian sensitivity matrix. We reconstructed high-resolution transmissivity fields (composed of up to 25,600 cells) which generated good correlations between the measured and computed hydraulic heads. In particular, we show that, by combining the PCGA inversion method and the hydraulic tomography method, we are able to substantially reduce the computation time of the inversions, while still producing high-quality inversion results as those obtained from the other sensitivity analysis methodologies.

Cefepime plasma concentrations and clinical toxicity: a retrospective cohort study

OBJECTIVES

Cefepime remains an important antibiotic for severe bacterial infections, yet some meta-analyses have shown elevated mortality among patients randomized to it. Therapeutic drug monitoring (TDM) of β-lactam antibiotics is increasing, but optimal plasma concentrations remain unknown. We examined clinical outcomes of patients undergoing cefepime TDM in an initial effort to define the drug's toxicity threshold.

METHODS

In this single-centre retrospective cohort study, we enrolled all adult hospitalized patients receiving cefepime and undergoing TDM from January 2013 through July 2016. The primary outcome was the incidence of clinical toxicity; a secondary outcome was clinical failure. Plasma samples were analysed via high-performance liquid chromatography with ultraviolet detection.

RESULTS

A total of 161 cefepime concentrations were drawn from 93 patients. Roughly half (82/161, 51%) and one-third (49/161, 30%) were trough and steady-state levels from patients receiving intermittent and continuous infusions, respectively; median concentrations were 17.6 mg/L (IQR 9.7-35.2) and 29.2 mg/L (IQR 18.9-45.9). Ten patients (11%) experienced a neurologic event considered at least possibly related to cefepime; neurotoxicity was associated with poorer renal function (median creatinine clearance 54 (IQR 39-97) vs. 75 mL/min/1.73² (IQR 44-104)) and longer cefepime durations (mean 8.3 (SD±6.7) vs. 13.3 days (± 14.2), p = 0.071). Patients with trough levels >20 mg/L had a fivefold higher risk for neurologic events (OR 5.05, 95% CI 1.3-19.8).

CONCLUSIONS

Neurotoxicity potentially related to cefepime occurred at plasma concentrations >35 mg/L. For those receiving intermittent infusions, trough concentrations >20 mg/L should be avoided until further information is available from prospective studies.

Neglected orthopedic oncology--Causes, epidemiology and challenges for management in developing countries

BACKGROUND

Management of malignant bone and soft tissue tumors remains an overwhelming confront to orthopedic surgeons. The challenge is discriminating in developing countries due to inadequate diagnostic and therapeutic amenities and unawareness. A lot has been discussed about the neglected orthopedic trauma, but the published literature on the causes and management of neglected bone and soft tissue tumors is sparse. Hence, current study was undertaken to highlight the causes of neglect and therapeutic challenges for managing these neglected tumors in developing countries.

AIMS AND OBJECTIVES

To determine the causes of neglect of malignant bone and soft tissue tumors, their epidemiology (including their relative frequencies, age, gender discrimination, anatomical sites of occurrence and histological characteristics) and difficult aspect of management due to neglect or delayed presentation.

MATERIALS AND METHODS

This was an appraisal of the neglected malignant bone and soft tissue tumors presented to J. N. Medical College and Hospital from June 2008 to May 2013. Criteria for labeling the tumor as neglected malignant bone and soft tissue tumor was delayed presentation (>3 months), locally advanced disease, ulceration, sepsis, fungating mass or metastasis at the time of presentation. All the cases were reviewed and analyzed for age, gender, histological types, educational status and socioeconomic status of the family, any prior treatment by traditional bone setters or registered medical practitioner, cause of delay for seeking medical advice. We have also analyzed the treatment given at our institute and the outcome of the tumor.

OBSERVATIONS AND RESULTS

Eighteen patients fulfilled the criteria for neglected malignant bone and soft tissue tumors, hence were included in study. Eight cases were of osteosarcoma, five cases were of Ewing's sarcoma, three cases were of chondrosarcoma and 1 case each was of pleomorphic liposarcoma and primary lymphoma of bone. According to Enneking staging system 11 cases were of stage III (distant metastasis) and 7 were stage II-B. Seven were females, and 11 were males. Age range was 5-68 years. 15 patients (83.3%) belonged to low socioeconomic status with 17 patients (94.4%) belonged to uneducated background. Cause of delay in seeking medical advice was neglect by the patient and family due to financial constraints, cultural and religious believes, lack of access to health care facilities, consultation with traditional bone setters and even misdiagnosis by qualified orthopedic surgeons. The tumors included were all unresectable and of huge sizes, hence were managed with amputation/dis-articulation, chemotherapy or radiation.

CONCLUSION

The current study tries to highlight the causes and quantity of neglect of malignant bone and soft tissue tumors prevalent in our country, which poses a therapeutic challenge for management and consequent mutilating surgeries with poor outcome resulting in loss of extremity and existence.

A comparison of airborne bacterial fallout between orthopaedic and vascular surgery

INTRODUCTION The objective of the study was to compare bacterial fallout during vascular prosthesis insertion and orthopaedic major joint replacement performed in conventional and laminar flow ventilation, respectively. MATERIALS AND METHODS A prospective single-centre case control study of 21 consecutive elective vascular procedures involving prosthetic graft insertion and 24 consecutive elective orthopaedic major joint replacements were tested for degree of bacterial fallout using agar settle plates. Preparation time, waiting time and total procedure duration were collected at the time of surgery, and bacterial colony counts on the agar settle plates from airborne bacterial fallout were counted after an incubation period. RESULTS Bacterial fallout count in vascular prosthetic graft insertion was 15-fold greater than in orthopaedic prosthetic joint insertion (15, (IQR 15) vs 1, (IQR 3) respectively, P < 0.0001, Wilcoxon). Waiting time and patient transfer did not significantly increase bacterial fallout counts during the procedure (P = 0.9). CONCLUSIONS Vascular surgical theatres have significantly higher bacterial fallout compared with orthopaedic theatres. This may be partly explained by orthopaedic surgery being routinely performed in laminar flow ventilation, a practice which has not been widely adopted for vascular surgery, in which prosthetic infection may also result in significant mortality and morbidity.

Ovarian Small Cell Carcinoma Hypercalcemic Type: A Case Report >

A 31-year-old female was diagnosed with small cell carcinoma of the ovary hypercalcaemic type (OSCCHT) post left oophorectomy. This is a rare aggressive ovarian tumour of which less than 300 cases were reported.

Intratumoral expression of programmed death ligand 1 (PD-L1) in patients with clear cell renal cell carcinoma (ccRCC)

The immunological checkpoints of programmed death 1 and its ligand (PD-L1) are currently in focus as novel therapeutic targets in renal cell carcinoma (RCC). The aim of this study was to evaluate the prognostic association of PD-L1 expression in clear cell (cc) RCC with clinical parameters, tumor aggressiveness and overall survival (OS). Patients who underwent renal surgery due to RCC between 1994 and 2003 were retrospectively evaluated. Tumor specimens were analyzed for PD-L1 expression by immunohistochemistry. One hundred and seventy-seven ccRCC patients were eligible for analysis, in which 140 (79.1 %) were negative and 37 (20.9 %) were positive for PD-L1 expression. PD-L1 positivity was associated with female gender (p = 0.001), lymph node metastasis (p = 0.004), distant metastasis (p = 0.002), higher AJCC stage (p = 0.004), as well as advanced disease (pT3/4 and/or N+ and/or M1) (p < 0.001). Kaplan-Meier analysis revealed a significantly diminished 5- and 10-year overall survival of 46.7 and 28.3 % for PD-L1(+) compared to PD-L1(-) tumors with 66 and 53.4 % (p = 0.005), respectively. Univariate analysis showed a significant negative association of OS with PD-L1 positivity [p = 0.005; HR: 2 (95 % CI 1.2-3.3)], even though PD-L1 positivity only tends to predict independently the OS using multivariate analyses [p = 0.066; HR: 1.6 (95 % CI 0.98-2.7)]. PD-L1 expression in ccRCC is associated with parameters of aggressiveness, as well as with poor OS, even though PD-L1 status was not identified as a significant independent prognostic parameter. However, further studies in larger cohorts are warranted.

Outcome of babies admitted with hypoxic-ischemic encephalopathy in Neonatal Unit of Services Hospital, Lahore

Objectives: To determine the outcome of newborns, admitted with different stages of HIE in Neonatal Unit, Services Hospital, Lahore. Study design: Descriptive Study. Place and duration of study: Neonatology Section, Pediatrics Department, Services Institute of Medical Sciences (SIMS) / Services Hospital, Lahore. Over a period of Six months, from 1st August 2005 to 31st January 2006. Material & methods: A total of 170 newborns having Apgar score less than 7 were included in the study. Babies with any congenital anomaly were excluded. Results: 80% were males. 17.64% had weight less than 1.5 Kg, 37.06% weight between 1.5 Kg to 2.5 Kg and 45.29% had weight more than 2.5 Kg. 90.5% of our babies were delivered in Services Hospital, Lahore. 77.64% babies were full term. Babies were divided into three groups; Group-I had Apgar score 0-3, Group-II between 4 & 5 and Group-III had Apgar score 6-7. In Group-I, 65% babies died, whereas 100% had any one of the complications, in Group-II, there were 22% deaths and no baby died from Group-III. Conclusions: Despite advanced technology, a high number of babies have HIE and its complications. It is better to prevent babies from HIE, because once HIE occur, you cannot save babies completely from its complications.

Benefit of rectal washout for anterior resection and left sided resections

PURPOSE

To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer.

MATERIALS AND METHODS

A best evidence topic was constructed according to a structured protocol. Medline 1948-2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched.

OUTCOMES

Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses.

CONCLUSIONS

On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question.

Benefit of rectal washout for anterior resection and left sided resections

PURPOSE

To assess the effectiveness of rectal wash out in preventing local recurrence for patients who undergo anterior resection for recto-sigmoid cancer.

MATERIALS AND METHODS

A best evidence topic was constructed according to a structured protocol. Medline 1948-2015 and EMBASE 1980 to 2015 using the OVID interface: ( Rectal) AND (Washout) AND (Anterior Resection). In addition, the reference lists of the relevant papers were searched.

OUTCOMES

Eight papers among the 17 relevant articles were identified as representing the best evidence including 3 prospective non-randomized studies, 1 retrospective non randomized study and 4 meta-analyses.

CONCLUSIONS

On the basis of current evidence, rectal washout does not stop local recurrence of cancer after anterior resection or left sided colonic resection, but it may reduce the rate of local recurrence. A randomised controlled trial to address this issue would formally answer this question.