In vivo activity of the second-generation proteasome inhibitor ixazomib against pediatric T-cell acute lymphoblastic leukemia xenografts

The overall survival rate of patients with T-cell acute lymphoblastic leukemia (T-ALL) is now 90%, although patients with relapsed T-ALL face poor prognosis. The ubiquitin-proteasome system maintains normal protein homeostasis, and aberrations in this pathway are associated with T-ALL. Here we demonstrate the in vitro and in vivo activity of ixazomib, a second-generation orally available, reversible, and selective proteasome inhibitor against pediatric T-ALL cell lines and patient-derived xenografts (PDXs) grown orthotopically in immunodeficient NOD.Cg-PrkdcscidIL2rgtm1Wjl/SzJAusb (NSG) mice. Ixazomib was highly potent in vitro, with half-maximal inhibitory concentration (IC50) values in the low nanomolar range. As a monotherapy, ixazomib significantly extended mouse event-free survival of five out of eight T-ALL PDXs in vivo.

In vivo activity of the dual PI3Kδ and PI3Kγ inhibitor duvelisib against pediatric acute lymphoblastic leukemia xenografts

BACKGROUND

Acute lymphoblastic leukemia (ALL) remains one of the most common causes of cancer-related mortality in children. Phosphoinositide 3-kinases (PI3Ks) are a family of lipid kinases, and aberrations in the PI3K pathway are associated with several hematological malignancies, including ALL. Duvelisib (Copiktra) is an orally available, small molecule dual inhibitor of PI3Kδ and PI3Kγ, that is Food and Drug Administration (FDA) approved for the treatment of relapsed/refractory chronic lymphocytic leukemia and small lymphocytic lymphoma. Here, we report the efficacy of duvelisib against a panel of pediatric ALL patient-derived xenografts (PDXs).

PROCEDURES

Thirty PDXs were selected for a single mouse trial based on PI3Kδ (PIK3CD) and PI3Kγ (PIK3CG) expression and mutational status. PDXs were grown orthotopically in NSG (NOD.Cg-Prkdc^scid IL2rg^tm1Wjl /SzJAusb) mice, and engraftment was evaluated by enumerating the proportion of human versus mouse CD45⁺ cells (%huCD45⁺ ) in the peripheral blood. Treatment commenced when the %huCD45⁺ reached greater than or equal to 1%, and events were predefined as %huCD45⁺ greater than or equal to 25% or leukemia-related morbidity. Duvelisib was administered per oral (50 mg/kg, twice daily for 28 days). Drug efficacy was assessed by event-free survival and stringent objective response measures.

RESULTS

PI3Kδ and PI3Kγ mRNA expression was significantly higher in B-lineage than T-lineage ALL PDXs (p-values <.0001). Duvelisib was well-tolerated and reduced leukemia cells in the peripheral blood in four PDXs, but with only one objective response. There was no obvious relationship between duvelisib efficacy and PI3Kδ or PI3Kγ expression or mutation status, nor was the in vivo response to duvelisib subtype dependent.

CONCLUSIONS

Duvelisib demonstrated limited in vivo activity against ALL PDXs.

Conducting a conventional multi-casualty incident in COVID-19 personal protective equipment - a semi-structured interview

Background

The risk of COVID-19 transmission to healthcare professionals is likely to continue for the foreseeable future. The wearing of personal protective equipment (PPE) presents a number of potential challenges to responders that may impact upon the management of patients in a multi-casualty incident.

This report describes a multi-agency multi-casualty incident. It identifies learning points specifically related to the challenges of conducting a conventional multi-casualty incident in COVID-19 PPE.

Case

The multi casualty incident in Reading, UK on the 20 June 2020 involved six stab injury victims and was attended by four pre-hospital critical care teams. This was the first conventional multi-casualty incident that pre-hospital critical care teams had attended during the COVID-19 era and it was conducted in COVID-19 PPE (1). The scene was an urban park where three patients were confirmed to be in Traumatic Cardiac Arrest (TCA) from stab wounds and another three patients had also suffered stab injuries. By the time the incident had concluded three patients were pronounced dead at the scene. Two patients were transported to the local trauma unit and one patient was transported to the regional Major Trauma Centre depending on the severity of their injuries.

Conclusions

We conducted a semi structured telephone interview with the critical care clinicians who were involved in the incident. The interviews focused specifically on the challenges of responding whilst wearing COVID-19 PPE, rather than the wider challenges of responding to such an incident. The key learning points identified were:

Improving the identifiability of clinicians in level 3 PPE

wearing identification tabards

using visible labelling on PPE suits

Improving communication by radio

using a belt to carry the radio

using an earpiece and push to talk system.

Training in conducting multi casualty incidents in level 3 PPE.

Soft X-ray microscopy for probing of topical tacrolimus delivery via micelles

The penetration of topically applied tacrolimus formulated in micelles into murine skin is reported, measured by X-ray microscopy. Tacrolimus and micelles are probed for the first time by this high spatial resolution technique by element-selective excitation in the C 1s- and O 1s-regimes. This method allows selective detection of the distribution and penetration depth of drugs and carrier molecules into biologic tissues. It is observed that small, but distinct quantities of the drug and micelles, acting as a drug carrier, penetrate the stratum corneum. A comparison is made with the paraffin-based commercial tacrolimus ointment Protopic^®, where local drug concentrations show to be low. A slight increase in local drug concentration in the stratum corneum is observed, if tacrolimus is formulated in micelles, as compared to Protopic^®. This underscores the importance of the drug formulations for effective drug delivery. Time-resolved penetration shows presence of drug in the stratum corneum 100 min after formulation application, with penetration to deeper skin layers at 1000 min. High resolution micrographs give indications for a penetration pathway along the lipid membranes between corneocytes, but also suggest that the compound may penetrate corneocytes.

Characterisation and management of concrete grinding residuals

Concrete grinding residue is the waste product resulting from the grinding, cutting, and resurfacing of concrete pavement. Potential beneficial applications for concrete grinding residue include use as a soil amendment and as a construction material, including as an additive to Portland cement concrete. Concrete grinding residue exhibits a high pH, and though not hazardous, it is sufficiently elevated that precautions need to be taken around aquatic ecosystems. Best management practices and state regulations focus on reducing the impact on such aquatic environment. Heavy metals are present in concrete grinding residue, but concentrations are of the same magnitude as typically recycled concrete residuals. The chemical composition of concrete grinding residue makes it a useful product for some soil amendment purposes at appropriate land application rates. The presence of unreacted concrete in concrete grinding residue was examined for potential use as partial replacement of cement in new concrete. Testing of Florida concrete grinding residue revealed no dramatic reactivity or improvement in mortar strength.

Coherent X-ray imaging: bridging the gap between atomic and micro-scale investigations

We present a review of state-of-the art X-ray imaging techniques based on partially coherent synchrotron radiation. Full-field X-ray tomography, X-ray ptychography, scanning small-angle X-ray scattering, and scanning transmission X-ray microscopy are imaging techniques that gather structural information at spatial resolution ranging from several microns to a few tens of nanometers in both real- and reciprocal space. These methods exploit contrast mechanisms based on absorption, phase, and spectroscopic signals. We provide examples of how these techniques can be applied to address scientific questions ranging from imaging of biological samples, to foam rheology, and cement composition.

Calibrated NEXAFS spectra of common conjugated polymers

Near edge x-ray absorption fine structure (NEXAFS) spectroscopy has evolved into a powerful characterization tool for polymeric materials and is increasingly being used to elucidate composition and orientation in thin films of relevance to organic electronic devices. For accurate quantitative compositional analysis, insight into the electronic structure and the ability to assess molecular orientation, reliable reference spectra with known energy resolution and calibrated energy scale are required. We report a set of such NEXAFS spectra from 23 semiconducting polymers and some related materials that are frequently used in organic device research.

The SQUIRE (Standards for QUality Improvement Reporting Excellence) guidelines for quality improvement reporting: explanation and elaboration

As the science of quality improvement in health care advances, the importance of sharing its accomplishments through the published literature increases. Current reporting of improvement work in health care varies widely in both content and quality. It is against this backdrop that a group of stakeholders from a variety of disciplines has created the Standards for QUality Improvement Reporting Excellence, which we refer to as the SQUIRE publication guidelines or SQUIRE statement. The SQUIRE statement consists of a checklist of 19 items that authors need to consider when writing articles that describe formal studies of quality improvement. Most of the items in the checklist are common to all scientific reporting, but virtually all of them have been modified to reflect the unique nature of medical improvement work. This "Explanation and Elaboration" document (E & E) is a companion to the SQUIRE statement. For each item in the SQUIRE guidelines the E & E document provides one or two examples from the published improvement literature, followed by an analysis of the ways in which the example expresses the intent of the guideline item. As with the E & E documents created to accompany other biomedical publication guidelines, the purpose of the SQUIRE E & E document is to assist authors along the path from completion of a quality improvement project to its publication. The SQUIRE statement itself, this E & E document, and additional information about reporting improvement work can be found at http://www.squire-statement.org.

Evolution of the nanomorphology of photovoltaic polyfluorene blends: sub-100 nm resolution with x-ray spectromicroscopy

We investigate the influence of annealing on the morphology of intimately mixed blends of the conjugated polymers poly(9,9'-dioctylfluorene-co-bis-N,N'-(4-butylphenyl)-bis-N,N'-phenyl-1,4-phenylene-diamine) (PFB) and poly(9,9'-dioctylfluorene-co-benzothiadiazole) (F8BT) with scanning transmission x-ray microscopy (STXM). Through the use of a zone plate with theoretical Rayleigh resolution of 30 nm, we are able to resolve sub-100 nm bulk structure in these films. Surprisingly, for unannealed films spin-coated from chloroform we observe features with an average diameter of 85 nm. The high degree of photoluminescence quenching in these as-spun films (>95%) implies that there is significant intermixing within the 85 nm structures, indicating that a hierarchy of phase separation exists even on the length scale of less than 100 nm. With annealing up to 160 °C, close to the T(g) of the components, there is little change in the feature sizes observed by STXM, although an increase in variation of the composition is observed. With annealing above 160 °C the imaged features begin to evolve in size, increasing to 225 nm in extent, alongside large changes in composition with annealing to 200 °C. Comparing the evolution of morphology imaged by STXM with the change in photoluminescence quenching with annealing, we propose that phase separation first evolves via the evolution of relatively pure phases on the length scale of a few to tens of nanometres within the larger 85 nm structures. Once the length scale of compositional fluctuations exceeds 85 nm (for anneal temperatures above 160 °C) the hierarchy of phase separation is lost and the subsequent morphological evolution is readily imaged by STXM. Applying the results of an exciton diffusion and quenching model, we find good agreement between the size of the domains measured by STXM (above 180 °C) and the results of the model for an exciton diffusion length of 15 nm. The growth in domain size and towards purer structures has also been observed with resonant soft x-ray scattering.

Regulating plant/insect interactions using CO2 enrichment in model ecosystems

The greenhouse environment is a challenging artificial ecosystem in which it is possible to study selected plant/insect interaction in a controlled environment. Due to a combination of "direct" and "indirect" effects of CO2 enrichment on plant photosynthesis and plant development, canopy productivity is generally increased. In this paper, we discuss the effects of daytime and nighttime CO2 enrichment protocols on gas exchange of pepper plants (Capsicum annuum L, cv Cubico) grown in controlled environments. In addition, we present the effects of thrips, a common Insect pest, on the photosynthetic and respiratory activity of these plant canopies. Carbon dioxide has diverse effects on the physiology and mortality of insects. However, our data indicate that thrips and whiteflies, at least, are not killed "directly" by CO2 levels used to enhance photosynthesis and plant growth. Together the data suggest that the insect population is affected "indirectly" by CO2 and that the primary effect of CO2 is via its effects on plant metabolism.

Effect of hemodialysis and antiretroviral therapy on plasma viral load in HIV-1 infected hemodialysis patients

BACKGROUND

Plasma viral load has become an important test in predicting the progress of HIV-1 infected patients. The higher the viral load the faster is the progression to AIDS. As HIV-1 infected hemodialysis (HD) patients have higher mortality and morbidity than HIV-1 infected non-dialysis patients, and as all the blood tests in the HD patients are drawn during HD, we measured the effect of HD and antiretroviral therapy on viral load in HIV-1 infected HD patients.

PATIENTS AND METHODS

We measured plasma viral load pre-dialysis and post-dialysis in 10 HIV-1 infected HD patients. The viral load was measured using an in vitro quantitative nucleic acid amplification test. We also compared viral load in 8 HIV-1 infected HD patients on one antiretroviral drug with 8 HIV-1 patients on two (6) or three (2) antiretroviral drugs.

RESULTS

There was a small reduction in plasma viral load postdialysis in all HIV-1 infected HD patients (45% +/- 5.4, 0.3 log +/- 0.05, p < 0.0004). However, HIV-1 RNA could not be detected in the ultrafiltrate. The patients who were on two or three antiretroviral drugs had lower viral load (8915 +/- 3702 vs. 351440 +/- 101237, p < 0.004) and higher CD4 count (355 +/- 81 vs 82 +/- 39, p < 0.009) than patients on only one antiretroviral drug.

CONCLUSION

We conclude that there is a small reduction in plasma viral load in HIV-1 infected hemodialysis patients post-dialysis. As no viral RNA could be detected in the ultrafiltrate, the reduction could be due to nonspecific adsorption of the viral RNA to the dialysis membrane. HIV-1 infected hemodialysis patients who are on two or three antiretroviral drugs had significantly lower viral load and higher CD4 count than patients on only single antiretroviral drug. Therefore a single antiretroviral drug should not be used in treating HIV-1 infected HD patients.

Continuing professional development in public health medicine

BACKGROUND

A survey of public health doctors was undertaken in the South Thames region to support coordination of continuing professional development (CPD) and to guide appropriate provision of educational activities for those working in the specialty.

METHODS

A postal survey of 130 public health doctors in service, academic and military posts in the South Thames region of the UK.

RESULTS

The response rate was 79% with good representation of grades and geographical areas. Public health doctors preferred personal and small group learning particularly focused on problem solving. Epidemiology as a basic discipline was rated highly by respondents, but senior doctors also showed preferences for topics beyond the textbooks. Respondents demonstrated that they had acquired such knowledge and skills, which could be shared in CPD sessions with colleagues. There was support for learning with and from non-medical colleagues. In the service posts structural change was ongoing, expectations of performance by management were high, and appropriate CPD was an expressed need, although time was seriously limited for this activity.

CONCLUSIONS

Appropriate CPD could support the effectiveness of public health physicians in challenging circumstances. However, a critical evaluation of the relevance of CPD programmes to public health practice is essential if CPD is to support doctors in delivering the public health agenda in the changing structures within which they work.

Case report: percutaneous drainage of periappendiceal actinomycosis

Abdominal actinomycosis is a disorder which often complicates a chronic perforation of the gastrointestinal (GI) tract, such as at the appendix (Wyngaarden and Smith, 1988). Delayed diagnosis characterizes abdominal actinomycosis. Multiple abscesses and draining sinuses are frequently present. Treatment has consisted of long-term oral antibiotic therapy coupled with surgery, including incision and drainage of abscesses with removal of persistent sinuses (Berardi, 1979). We present a patient with abdominal actinomycosis complicating a chronically ruptured appendix who was managed by percutaneous catheter drainage and antibiotic therapy.

Computed tomography in patients with psychiatric illnesses: advantage of a "rule-in" approach

Computed tomography (CT) is used commonly to "rule-out" disease. In 123 consecutive patients with psychiatric diseases in three institutions, 105 CT scans (85.4%) interpreted as normal or normal except for atrophy did not influence management, only reassured clinicians and patients. Incidental and false positive findings were more numerous than true positive findings. All six true positive findings occurred in patients with focal findings on neurologic examination; four led to management changes. The lower 954% confidence limit of the cost of case finding by CT only was estimated to be $2931 for all patients; $603 for patients with focal findings; and at least $7083 for patients without focal findings. Computed tomography is a sensitive diagnostic method that may detect more false and incidental positive findings when used somewhat unselectively to "rule-out" disease. In these patients, a examination suggesting structural intracranial abnormalities would have been less expensive and more effective.