Antiangiogenic-immune-checkpoint inhibitor combinations: lessons from phase III clinical trials

Antiangiogenic agents, generally antibodies or tyrosine-kinase inhibitors that target the VEGF-VEGFR pathway, are currently among the few combination partners clinically proven to improve the efficacy of immune-checkpoint inhibitors (ICIs). This benefit has been demonstrated in pivotal phase III trials across different cancer types, some with practice-changing results; however, numerous phase III trials have also had negative results. The rationale for using antiangiogenic drugs as partners for ICIs relies primarily on blocking the multiple immunosuppressive effects of VEGF and inducing several different vascular-modulating effects that can stimulate immunity, such as vascular normalization leading to increased intratumoural blood perfusion and flow, and inhibition of pro-apoptotic effects of endothelial cells on T cells, among others. Conversely, VEGF blockade can also cause changes that suppress antitumour immunity, such as increased tumour hypoxia, and reduced intratumoural ingress of co-administered ICIs. As a result, the net clinical benefits from antiangiogenic-ICI combinations will be determined by the balance between the opposing effects of VEGF signalling and its inhibition on the antitumour immune response. In this Perspective, we summarize the results from the currently completed phase III trials evaluating antiangiogenic agent-ICI combinations. We also discuss strategies to improve the efficacy of these combinations, focusing on aspects that include the deleterious functions of VEGF-VEGFR inhibition on antitumour immunity, vessel co-option as a driver of non-angiogenic tumour growth, clinical trial design, or the rationale for drug selection, dosing and scheduling.

Green synthesis of silver nanoparticles by using Allium sativum extract and evaluation of their electrical activities in bio-electrochemical cell

An electrical application of green synthesized silver nanoparticles (Ag NPs) by developing a unique bio-electrochemical cell (BEC) has been addressed in the report. Here, garlic extract (GE) has been used as a reducing agent to synthesize Ag NPs, and as a bio-electrolyte solution of BEC. Ag NPs successfully formed into face-centered cubic structures with average crystallite and particle sizes of 8.49 nm and 20.85 nm, respectively, according to characterization techniques such as the UV-vis spectrophotometer, XRD, FTIR, and FESEM. A broad absorption peak at 410 nm in the UV-visible spectra indicated that GE played a vital role as a reducing agent in the transformation of Ag+ions to Ag NPs. After that four types of BEC were developed by varying the concentration of GE, CuSO4. 5H2O, and Ag NPs electrolyte solution. The open circuit voltage and short circuit current of all cells were examined with the time duration. Moreover, different external loads (1 Ω, 2 Ω, 5 Ω, and 6 Ω) were used to investigate the load voltage and load current of BEC. The results demonstrated that the use of Ag NPs on BEC played a significant role in increasing the electrical performance of BEC. The use of GE-mediated Ag NPs integrated the power, capacity, voltage efficiency, and energy efficiency of BEC by decreasing the internal resistance and voltage regulation. These noteworthy results can take a frontier forward to the development of nanotechnology for renewable and low-cost power production applications.

Immunomodulatory and anti-cancer potential of cloves (Syzygium aromaticum) bud extract and its phytogenic silver nanoparticles

Clove plant (Syzygium aromaticum) is one of the Myrtaceae family. It's a common flavor in food and the traditional medicine. The study's objective was to ascertain whether the clove bud aqueous extract (CAE) and CAE + nanosilver have any biological effects on immune cells and HT-29 colon cancer cell line. Nanosilver was produced through green synthesis approach using CAE. Produced nanosilver was characterized via electron microscope (scanning, SEM) and ultraviolet-visible spectroscopy. CAE and CAE + nanosilver were examined for their active biomolecules using FTIR analysis, p53 contents using real-time PCR, apoptosis and cell cycle arrest power on HT-29 cancer cell line via flow cytometerty and immunomodulatory potential utilizing MTT assay. Results cleared that a spherical nanosilver with a diameter range of 53 nm was formed by CAE. There were several active biomolecules in CAE and CAE + nanosilver. CAE and CAE + nanosilver increased the p53 protein expression and apoptotic cell number in HT-29 colon cancer cells. CAE and CAE + nanosilver could arrest HT-29 cells at the phase G2/M. CAE and CAE + nanosilver stimulated quiescent and PHA-pre-treated splenic cells at higher concentrations, and CAE suppressed quiescent splenic cell when diluted. In conclusion, the safe edible Syzygium aromaticum plant can be utilized to make anti-tumor agent, essentially for colon tumor. As Syzygium aromaticum plant could stimulate immune cells, it can be used as immune-stimulatory agent that can help fight tumor and tumor development.

Tumors resurrect an embryonic vascular program to escape immunity

[Figure: see text].

Genetic similarities and phylogenetic analysis of Muntjac (Muntiacus spp.) by comparing the nucleotide sequence of 16S rRNA and cytochrome B genome

This study aimed to identify the phylogenetic similarities among the muntjac (Muntiacus spp.). The phylogenetic similarities among seven major muntjac species were studied by comparing the nucleotide sequence of 16s rRNA and cytochrome b genome. Nucleotide sequences, retrieved from NCBI databases were aligned by using DNASTAR software. A phylogenetic tree was created for the selected species of muntjac by using the maximum likelihood method on MEGA7 software. The results of nucleotide sequences (16s rRNA) showed phylogenetic similarities between, the M. truongsonensis and M. rooseveltorum had the highest (99.2%) while the lowest similarities (96.8%) found between M. crinifrons and M. putaoensi. While the results of nucleotide sequences (Cty b) showed the highest similarity (100%) between M. muntjak and M. truongsonensis and the lowest s (91.5%) among M. putaoensis and M. crinifrons. The phylogenetic tree of muntjac species (16s rRNA gene) shows the main two clusters, the one including M. putaoensis, M. truongsonensis, M. rooseveltorum, and M. muntjak, and the second one including M. crinifrons and M. vuquangensis. The M. reevesi exists separately in the phylogenetic tree. The phylogenetic tree of muntjac species using cytochrome b genes shows that the M. muntjak and M. truongsonensis are clustered in the same group.

Major threats and habitat use status of Demoiselle crane (Anthropoides virgo), in district Bannu, Pakistan

Cranes are the large and attractive Creatures of nature with long necks, legs, and life-span. Adults of both sexes are the same with similar color patterns. Demoiselle cranes spend most of their lifespan on dry grasses. They are also found around the stream, rivers, shallow lakes, natural wetlands, and depressions. To evaluate the current status of habitat use and major threats a study was conducted in tehsil Domel district Bannu. Line transect method and water quality tests (temperature, PH, contamination of E-coli bacteria) were used. To determine the major threats questionnaire method was used. The whole data was analyzed by using SPSS 21 version. Based on the distribution four study sites were selected and four water samples from each study site were taken. Most sites were moderate to highly degraded except Kashoo and kurram river mixing point which was low degraded with livestock grazing and human activities. Water quality tests showed PH ranges from 7-9, temperature 6.5-8.5, and contamination of E-coli in all samples. The social survey revealed that hunting, habitat degradation, and pollution as major threats. Effective long-term conservation and management in the study area are needed to focus on the protection of disturbance-free habitat.

Ang2 inhibitors and Tie2 activators: potential therapeutics in perioperative treatment of early stage cancer

Anti-angiogenic drugs targeting the VEGF pathway are most effective in advanced metastatic disease settings of certain types of cancers, whereas they have been unsuccessful as adjuvant therapies of micrometastatic disease in numerous phase III trials involving early-stage (resectable) cancers. Newer investigational anti-angiogenic drugs have been designed to inhibit the Angiopoietin (Ang)-Tie pathway. Acting through Tie2 receptors, the Ang1 ligand is a gatekeeper of endothelial quiescence. Ang2 is a dynamically expressed pro-angiogenic destabilizer of endothelium, and its upregulation is associated with poor prognosis in cancer. Besides using Ang2 blockers as inhibitors of tumor angiogenesis, little attention has been paid to their use as stabilizers of blood vessels to suppress tumor cell extravasation and metastasis. In clinical trials, Ang2 blockers have shown limited efficacy in advanced metastatic disease settings. This review summarizes preclinical evidence suggesting the potential utility of Ang2 inhibitors or Tie2 activators as neoadjuvant or adjuvant therapies in the prevention or treatment of early-stage micrometastatic disease. We further discuss the rationale and potential of combining these strategies with immunotherapy, including immune checkpoint targeting antibodies.

Identification and crop damage assessment of indian crested porcupine (Hystrix indica) in selected zones of Abbottabad, Pakistan

Indian crested porcupine is the largest rodent pest that damages a wide variety of crops, vegetables, and tree species which ultimately causes huge economic loss in Pakistan, which is an agricultural country. It prefers to live in hilly terrain but common in temperate and tropical forests, shrublands, and grasslands. This study focused on the identification and assessment of crops damaged along with the main precautionary measures used by the local farmers. The data was collected from twenty-four villages of two union councils i.e. Chamhad and Slahad of district Abbottabad. Two types of data (primary and secondary) were collected from the study area. Primary data was collected for identification and estimation calculation of total crop damaged through direct field observation by taking random quadrates in each village of the study area. The damage in the crop was assessed by randomly selecting a quadrate of 1x1 m2 for the wheat, pearl millet, and Sorghum fields. While 4x4 m2 quadrates were taken for maize and vegetables. At least three quadrate samples were taken from each field including one quadrate taken from the center of the field area. In union council Chamhad, damage to maize (11.31%) and wheat (0.73%) by the Indian crested porcupine while in union council Salhad, damage of maize (6.95%) and wheat (1.6%) was observed. In the entire study area, overall damage to maize crop (8.01%) and wheat (0.88%) was calculated. Based on information obtained from the farmers, the Indian porcupine inflicted damage to potato, tomato, cauliflower, chili pepper, turnip, radish, pea, and onion, etc. Secondary data obtained through a questionnaire survey to explore the human porcupine conflict and precautionary measures used by the farmers and landowners. Open and close-ended questionnaires (159) highlighted the presence of Indian crested porcupine in the study area and 96% of the respondents have seen porcupine directly. Many types of precautionary measures were used by the farmers such as fencing, night stay, night firing, and dogs to decrease the crop damage, respondents (63.91%) use guns for hunting. however, due to the largely agricultural area and nocturnal behavior of Indian crested porcupine majority of the respondents (51.57%) did not use any precautionary measure. Biological control of Indian porcupine is recommended in the study area. Farmers should be encouraged and provide incentives and killing through current should be banned while proper hunting license should be issued to overcome overhunting. Scientific studies are required to control the reproduction of porcupine specifically in the more damaged areas.

Seasonal distribution and habitat use preference of Barking deer (Muntiacus vaginalis) in Murree-Kotli Sattian-Kahuta National Park, Punjab Pakistan

Microhabitat factors associated with the habitat of barking deer (Muntiacus vaginalis) were examined and compared between summer and winter seasons. Habitat characteristics and preferred habitat were measured by locating direct and indirect signs. To quantify the habitat utilization of barking deer, each selected study site was sampled for floral diversity from 2015 to 2017. Quadrats were deployed along transect lines to determine seasonal distribution. Barking deer were not evenly distributed across vegetation types in the study area; they occurred more often in the broad-leaved forest than in Chir pine forest, at an elevational range of 550-850 m, in thick vegetation on steep slopes. The most preferred habitat included trees and shrubs with 30% and 69% cover, respectively. Barking deer avoided thicker tree cover, possibly as it hinders movement and escape from predators. No significant difference (χ2 = 6.37, df = 3, p = 0.19) in seasonal vegetation cover was recorded.

Immunostimulatory and anti-tumor metronomic cyclophosphamide regimens assessed in primary orthotopic and metastatic murine breast cancer

The impressive successes of immune checkpoint blockade antibodies to treat various types of cancer are limited to minor subsets of patients. Combination therapy strategies, including with chemotherapy, are being explored to possibly improve the efficacy of immunotherapies. Here we report results regarding the use of an immunostimulatory regimen of metronomic cyclophosphamide (CTX). We show that in orthotopic models of syngeneic murine triple-negative breast cancer (EMT6), CTX administered at 140 mg/kg every 6 days (CTX140 1q6d) is superior at inhibiting primary tumor growth when compared to maximum tolerated dose or daily oral (continuous) low-dose CTX. In SCID or SCID beige mice, anti-tumor effects of CTX140 1q6d are reduced, reinforcing the therapeutic contribution of the adaptive and innate immune systems. In a second breast cancer model (SP1-AC2M2), CTX140 1q6d again showed clear superiority in anti-tumor effects, causing complete tumor regressions; however, these mice were not protected from subsequent tumor re-challenge, suggesting absence of immune memory. We also show that in an aggressive and metastatic cisplatin-resistant variant (EMT6-CDDP), CTX140 1q6d is superior and invokes an influx of intra-tumoral CD4+ and CD8+ T cells. CTX increases expression of tumor cell PD-L1; however, when combined with concomitant PD-L1 antibody therapy none of the CTX regimens showed increased benefit. This work sheds light on the potential use of metronomic CTX for the treatment of breast cancer, in particular using the quasi-weekly regimen, but also underscores the complexity of the anti-tumor mechanisms and potential to improve immune checkpoint therapy efficacy.

A new Tie1 targeted antibody blocks tumor cell extravasation and metastasis

Targeting the metastatic process is a critical pursuit in the treatment of malignant disease. There are currently no specific anti‐metastatic drugs approved for clinical use, despite metastasis being the leading cause of death for cancer patients. Targeting the Tie1 receptor was shown as a possible strategy for selective anti‐metastasis therapies based on previous gene deletion studies. This current study is the first description of a human antibody against Tie1 with the potential for clinical use in targeting extravasation of tumor cells into organs such as the lung, without having a detrimental effect on immune cell infiltration.

51 Working Collaboratively: Geriatrician Input in Older Patients Undergoing Emergency Laparotomy Reduces Overall Length of Stay - A Complete Audit Loop

Background

Great Western Hospital is a busy district general hospital with a catchment population of 340,000. Target population of this study was elderly patients aged >70 undergoing Emergency Laparotomy (EL).

Introduction

Approximately 8% of the population is aged over 75 years and operations in this patient group account for 23% of all surgical procedures. The 2010 National Confidential Enquiry into Patient Outcome and Death report “An Age Old Problem”, suggested routine daily input from Geriatrics should be available to elderly patients undergoing surgery.

This study focuses at the impact of Geriatrician input for EL patients with primary outcome of reduction in Length of Stay (LoS).

Methods

The service was designed with allocation of 4 hours per week of Consultant Geriatrician and 2.5 days per week of a Clinical Innovation Fellow (CIF) time. The existing team of surgical junior doctors, nursing and allied health professionals carried out plans suggested by the geriatrician.

Retrospective data (Prior to service initiation) for the emergency laparotomy patients >70 years, was collected from December 2015-May 2016.

Prospective data collected from February 2018 – July 2018 for EL patients aged > 70, patients with inpatient stay > 7 days, patients with delirium/ inpatient falls.

Length of stay and Inpatient mortality were compared between the two cohorts.

Intervention

Prior to the establishment of this service the medical support was provided on ad-hoc basis. Funding was obtained from local postgraduate medical education for CIF and twice weekly consultant led ward rounds were carried out.

Patients were recruited from hospital database and from a referrals book kept at surgical ward.

Results

45 patients were included in prospective study and Mean LoS was 17.8 days, which was reduced from 22.5 days prior to Geriatrician involvement (N=56).

Average 4.7 days per patient were saved.

IP mortality was 8.8% (2/4 deaths were palliative resections) after geriatrician input compared to 8.9% previously.

6.6% of patients had a new medical diagnosis, 24.4% patients were followed up in prospective cohort.

Conclusions

This study suggests the regular geriatrician input reduces the inpatient LoS. A day stay at surgical ward costs roughly £250, for 45 patients in last six months it saved approximately £52,875.

C-type lectin domain group 14 proteins in vascular biology, cancer and inflammation

The C‐type lectin domain (CTLD) group 14 family of transmembrane glycoproteins consist of thrombomodulin, CD93, CLEC14A and CD248 (endosialin or tumour endothelial marker‐1). These cell surface proteins exhibit similar ectodomain architecture and yet mediate a diverse range of cellular functions, including but not restricted to angiogenesis, inflammation and cell adhesion. Thrombomodulin, CD93 and CLEC14A can be expressed by endothelial cells, whereas CD248 is expressed by vasculature associated pericytes, activated fibroblasts and tumour cells among other cell types. In this article, we review the current literature of these family members including their expression profiles, interacting partners, as well as established and speculated functions. We focus primarily on their roles in the vasculature and inflammation as well as their contributions to tumour immunology. The CTLD group 14 family shares several characteristic features including their ability to be proteolytically cleaved and engagement of some shared extracellular matrix ligands. Each family member has strong links to tumour development and in particular CD93, CLEC14A and CD248 have been proposed as attractive candidate targets for cancer therapy.

Pre- and post-operative anti-PD-L1 plus anti-angiogenic therapies in mouse breast or renal cancer models of micro- or macro-metastatic disease

BACKGROUND

There are phase 3 clinical trials underway evaluating anti-PD-L1 antibodies as adjuvant (postoperative) monotherapies for resectable renal cell carcinoma (RCC) and triple-negative breast cancer (TNBC); in combination with antiangiogenic VEGF/VEGFR2 inhibitors (e.g., bevacizumab and sunitinib) for metastatic RCC; and in combination with chemotherapeutics as neoadjuvant (preoperative) therapies for resectable TNBC.

METHODS

This study investigated these and similar clinically relevant drug combinations in highly translational preclinical models of micro- and macro-metastatic disease that spontaneously develop after surgical resection of primary kidney or breast tumours derived from orthotopic implantation of murine cancer cell lines (RENCA^luc or EMT-6/CDDP, respectively).

RESULTS

In the RENCA^luc model, adjuvant sunitinib plus anti-PD-L1 improved overall survival compared to either drug alone, while the same combination was ineffective as early therapy for unresected primary tumours or late-stage therapy for advanced metastatic disease. In the EMT-6/CDDP model, anti-PD-L1 was highly effective as an adjuvant monotherapy, while its combination with paclitaxel chemotherapy (with or without anti-VEGF) was most effective as a neoadjuvant therapy.

CONCLUSIONS

Our preclinical data suggest that anti-PD-L1 plus sunitinib may warrant further investigation as an adjuvant therapy for RCC, while anti-PD-L1 may be improved by combining with chemotherapy in the neoadjuvant but not the adjuvant setting of treating breast cancer.

Predicting Neonatal Hyperbilirubinemia Using First Day Serum Bilirubin Level in Late Preterm and Term Healthy Newborn

Hyperbilirubinemia is a common problem during the neonatal period and is the most common reason for readmission after early hospital discharge of the healthy near term and term infants. This early discharge policy along with limited follow-up facilities in developing countries and inadequate communication between physicians and parents necessitates a prognostic test to predict hyperbilirubinemia in these newborns; for early and effective management and prevention of potential complication before it occurred. This observational analytical study was done to determine the predictability of day1 total serum bilirubin (TSB) level as a screening test and identify the best cutoff value which would predict neonates likely to develop significant hyperbilirubinemia. The study was carried out in the Department of Neonatology and Department of Gynecology and Obstetrics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from 1st April 2013 to 31st March 2014. A TSB level of ≥17mg/dl after 72 hours was defined as significant hyperbilirubinemia. By purposive sampling method, 100 healthy late preterm and term neonates fulfilling the inclusion criteria were enrolled and 89 were finally analyzed. Among 89 neonates 14(15.74%) developed significant hyperbilirubinemia (Group II) and 75(84.26%) did not develop hyperbilirubinemia (Group I). Mean time of sample collection was similar in both groups. Mean TSB level on day1 was significantly higher in Group II (5.97±1.74mg/dl) than Group I (3.19±1.4mg/dl). By using ROC (Receiver Operating Characteristic) analysis, TSB level of 5.65mg/dl on day 1 has the best combination of sensitivity (86%) and specificity (91%) to predict neonates at risk of significant hyperbilirubinemia (AUC-0.880, p=0.001). At this cut-off PPV was 63% and NPV 97%. Total serum bilirubin level on first day of life predicts neonates at risk of subsequent significant hyperbilirubinemia and late preterm and term babies with TSB level of ≥5.65mg/dl on day 1 of life should be followed up strictly either in the hospital or in the outpatient department on day 5.

Comparison of Serum Bilirubin with Transcutaneous Bilirubinometry in Late Preterm and Term Newborn

Neonatal jaundice or hyperbilirubinemia is a common occurrence in newborns. It can progress to develop kernicterus unless intervention is initiated. Severity and decision for management are usually based on serum bilirubin which needs blood sampling. Transcutaneous bilirubin measurement is a noninvasive technique and correlates closely with serum bilirubin. This Cross sectional study was done in the Department of Neonatology, Bangabandhu Sheikh Mujib Medical University from March 2013 to August 2014 to evaluate the transcutaneous bilirubin in comparison to serum bilirubin. Total 160 infants with ≥35 weeks were purposively included over a period of 16 months. Neonates with less than 35 weeks, previously exposed to phototherapy, serious illness which leads to impaired circulation, who have had exchange transfusion, having major congenital malformation were excluded. Transcutaneous bilirubin measurement was performed within 30 minutes of obtaining sample for total serum bilirubin measurements. Of the enrolled infants, mean birth weight was 2631±520 grams, postnatal age was 4.99±3.02 days ranging from 2 to 25 days and mean transcutaneous bilirubin and serum bilirubin value was 14.59±2.55 and 13.62±2.86mg/dl respectively. Mean difference of transcutaneous bilirubin and serum bilirubin was 0.97±1.01mg/dl. In the total enrolled infant, transcutaneous bilirubin and serum bilirubin values showed significant correlation (r = 0.93, r2 = 0.876, p<0.001) and this was not affected by sex, gestational age, postnatal age, and birth weight. The area under ROC curve for transcutaneous bilirubin was 87% (p value <0.001). If the cut off value of transcutaneous bilirubin was set at 15 mg/dl, then a sensitivity of 77%, specificity of 88% and accuracy of 82% were obtained. Use of transcutaneous bilirubin can reduce need for serum bilirubin in assaying neonatal jaundice; as it showed significantly high correlation with serum bilirubin. Predictive accuracy of transcutaneous bilirubin was found to be statistically significant in comparison to serum bilirubin.

A CD276 Antibody Guided Missile with One Warhead and Two Targets: The Tumor and Its Vasculature

In this issue of Cancer Cell, Seaman et al. demonstrate that antibody drug conjugates (ADCs) against CD276 expressed by tumor cells and tumor vasculature have promising anti-tumor activity while showing little toxicity. Importantly, these agents have the potential to target both angiogenic vessels and non-angiogenic vessels co-opted by tumor cells.

Salt Losing Variety of Congenital Adrenal Hyperplasia--A Case Report

Congenital adrenal hyperplasia is a genetic endocrinologic disorder. The severe classic form occurs in one in 15,000 births worldwide. Twenty-one-hydroxylase deficiency (21-OHD) is the most common cause in this autosomal recessive disease. It can cause virilization, ambiguous genitalia at birth and severe life threatening condition due to salt wasting. In this report we describe the clinical course of a male neonate presenting with lethargy, failure to thrive (FTT), genital pigmentation, electrolytes imbalance and high serum 17-hydroxy-progesterone (17-OHP) level and subsequently diagnosed as Congenital Adrenal Hyperplasia. After the initial crises management, the child was continued on replacement therapy. During the follow up, he was found to grow appropriately and achieving normal milestones for age.

Anti-angiogenic alternatives to VEGF blockade

Angiogenesis is a major requirement for tumour formation and development. Anti-angiogenic treatments aim to starve the tumour of nutrients and oxygen and also guard against metastasis. The main anti-angiogenic agents to date have focused on blocking the pro-angiogenic vascular endothelial growth factors (VEGFs). While this approach has seen some success and has provided a proof of principle that such anti-angiogenic agents can be used as treatment, the overall outcome of VEGF blockade has been somewhat disappointing. There is a current need for new strategies in inhibiting tumour angiogenesis; this article will review current and historical examples in blocking various membrane receptors and components of the extracellular matrix important in angiogenesis. Targeting these newly discovered pro-angiogenic proteins could provide novel strategies for cancer therapy.

Economic costs associated with moderate and late preterm birth: a prospective population-based study

OBJECTIVE

We sought to determine the economic costs associated with moderate and late preterm birth.

DESIGN

An economic study was nested within a prospective cohort study.

SAMPLE

Infants born between 32(+0) and 36(+6)  weeks of gestation in the East Midlands of England. A sample of infants born at ≥37 weeks of gestation acted as controls.

METHODS

Data on resource use, estimated from a National Health Service (NHS) and personal social services perspective, and separately from a societal perspective, were collected between birth and 24 months corrected age (or death), and valued in pounds sterling, at 2010-11 prices. Descriptive statistics and multivariable analyses were used to estimate the relationship between gestational age at birth and economic costs.

MAIN OUTCOME MEASURES

Cumulative resource use and economic costs over the first two years of life.

RESULTS

Of all eligible births, 1146 (83%) preterm and 1258 (79%) term infants were recruited. Mean (standard error) total societal costs from birth to 24 months were £12 037 (£1114) and £5823 (£1232) for children born moderately preterm (32(+0) -33(+6)  weeks of gestation) and late preterm (34(+0) -36(+6)  weeks of gestation), respectively, compared with £2056 (£132) for children born at term. The mean societal cost difference between moderate and late preterm and term infants was £4657 (bootstrap 95% confidence interval, 95% CI £2513-6803; P < 0.001). Multivariable regressions revealed that, after controlling for clinical and sociodemographic characteristics, moderate and late preterm birth increased societal costs by £7583 (£874) and £1963 (£337), respectively, compared with birth at full term.

CONCLUSIONS

Moderate and late preterm birth is associated with significantly increased economic costs over the first 2 years of life. Our economic estimates can be used to inform budgetary and service planning by clinical decision-makers, and economic evaluations of interventions aimed at preventing moderate and late preterm birth or alleviating its adverse consequences.

TWEETABLE ABSTRACT

Moderate and late preterm birth is associated with increased economic costs over the first 2 years of life.

Blockade of BFA-mediated apoptosis in macrophages by the HIV-1 Nef protein

HIV-1 Nef protein has key roles at almost all stages of the viral life cycle. We assessed the role of Nef and of the translation elongation factor eEF1A in primary human macrophages. Nuclear retention experiments and inhibition of the exportin-t (Exp-t) pathway suggested that cytoplasmic relocalization of eEF1A, mediated by Exp-t occurs in Nef-treated monocyte-derived macrophages (MDMs). We observed the presence of tRNA in the Nef/eEF1A complexes. Nucleocytoplasmic relocalization of the Nef/eEF1A complexes prevented stress-induced apoptosis of MDMs treated with brefeldin A. Blockade of stress-induced apoptosis of MDMs treated with HIV-1 Nef resulted from enhanced nucleocytoplasmic transport of eEF1A with decreased release of mitochondrial cytochrome c, and from increased tRNA binding to cytochrome c, ultimately leading to an inhibition of caspase activation. Our results indicate that HIV-1 Nef, through the nucleocytoplasmic relocalization of eEF1A and tRNAs, enhances resistance to stress-induced apoptosis in primary human macrophages.

Fasciolopsiasis in a five year old girl

A 5 year old girl hailing from Keraniganj, presented with the complaints of fever, periumbilical pain and vomiting. In vomitus, Fasciolopsis buski worm in adult form was identified by naked eye examination. In stool, ova of Fasciolopsis buski were also observed under microscope. Clinically she was pale and had hepatomegaly. Microcytic hypochromic anaemia with normal liver function test was found on lab investigation. She was diagnosed as a case of Fasciolopsiasis and treated with Praziquantel and on follow up visit she was found to be free of symptom.

Inhibition of ER stress-mediated apoptosis in macrophages by nuclear-cytoplasmic relocalization of eEF1A by the HIV-1 Nef protein

HIV-1 Nef protein has key roles at almost all stages of the viral life cycle. We assessed the role of the Nef/eEF1A (eukaryotic translation elongation factor 1-alpha) complex in nucleocytoplasmic shuttling in primary human macrophages. Nuclear retention experiments and inhibition of the exportin-t (Exp-t) pathway suggested that cytoplasmic relocalization of eEF1A, mediated by Exp-t, occurs in Nef-treated monocyte-derived macrophages (MDMs). We observed the presence of tRNA in the Nef/eEF1A complexes. Nucleocytoplasmic relocalization of the Nef/eEF1A complexes prevented stress-induced apoptosis of MDMs treated with brefeldin-A. Blockade of stress-induced apoptosis of MDMs treated with HIV-1 Nef resulted from enhanced nucleocytoplasmic transport of eEF1A with decreased release of mitochondrial cytochrome c, and from increased tRNA binding to cytochrome c, ultimately leading to an inhibition of caspase activation. Our results indicate that HIV-1 Nef, through the nucleocytoplasmic relocalization of eEF1A and tRNAs, enhances resistance to stress-induced apoptosis in primary human macrophages.

The use of computerised tomography guided percutaneous fine needle aspiration in the evaluation of solitary pulmonary nodules

The evaluation of a solitary pulmonary nodule (SPN) has changed over the years with increased access to percutaneous computerised tomography (CT) guided fine needle aspiration (FNA), where bronchoscopy is unhelpful. The aim of our study was to evaluate the sample adequacy, diagnostic and complication rate of CT-FNA of a SPN at our academic teaching hospital over an 18 month period. CT-FNA was performed by a radiologist, with a cytopathologist in attendance to confirm the adequacy of the sample obtained. The size of the nodule, sample material and adequacy, diagnosis and complications were recorded. A total of 101 patients were included, 54 male and the mean age was 68 +/- 11 years. The mean size of the SPN was 2.3 cm (range 1-11 cm). 56 (56%) patients had a right SPN, 45 (45%) had a left SPN. CT-FNA was diagnostic in 80 (80%) patients and non-diagnostic in 21 (20%) patients. The sample was insufficient for immunocytochemistry, although the morphological appearance was diagnostic in 20 (25%) of the 80 patients. Pneumothorax occurred in 26/101 (26%) patients post CT-FNA, of these 7 (27%) required chest drain insertion, while 19 (73%) were managed conservatively. CT FNA is a useful tool for the diagnosis of a SPN, with our diagnostic accuracy comparable to that reported in the literature. However, CT-FNA may not provide adequate sample volume to perform ancillary testing and has a moderate complication rate.

Sharp dissection of the Weiss ring to induce a posterior vitreous detachment

Removal of the posterior hyaloid is an important aspect of pars plana vitrectomy surgery in cases including but not limited to macular holes. A surgical technique is described in which the Weiss ring can be easily detached from the optic nerve with little to no trauma.

Oyster mushroom reduced blood glucose and cholesterol in diabetic subjects

It has been postulated that mushroom has beneficial effect of lowering blood glucose and cholesterol in diabetic subjects. The literature so far searched and found that there was no published data in this regard. This study was undertaken to assess the effect of reducing blood glucose, cholesterol and triglycerides in diabetic patients. Additionally, this study addressed whether there was any hepatic and renal toxicity of mushroom. This clinical investigation was conducted in BIRDEM hospital from July 2005 to January 2006. Eighty-nine subjects were recruited. Baseline investigations included height, weight, blood pressure (SBP, DBP), plasma glucose for fasting (FPG) and 2-h after-breakfast (2hPG), total cholesterol (T-chol), triglycerides (TG) and high-density lipoprotein (HDL-c). Twenty- four days' study constitutes 7-days mushroom, 7-days no mushroom and then 7-days mushroom. Investigations were done at the start and each after every 7-days. Thirty subjects (M / F = 17 / 13) followed to ensure full compliance with the designed protocol for 24 days. The mean (SD) age of the participants was 46.3 (10) years. Mushroom significantly reduced systolic and diastolic blood pressure (SBP, p<0.01; DBP, p<0.05). It also lowered both plasma glucose significantly (FPG & 2-hPG, p<0.001). Mushroom also lowered total cholesterol and TG significantly; whereas, there was no significant change in weight and HDL-c. When mushroom was withdrawn, there were significant increases of DBP, FPG, 2hPG, T-cholesterol and TG, whereas, no significant change was observed in weight, SBP and HDL-c. Restarting mushroom there was again significant reduction of blood glucose, TG and cholesterol. We conclude that mushroom significantly reduced blood glucose, blood pressure, TG and cholesterol of diabetic subjects without any deleterious effect on liver and kidney. The effect of mushroom may be investigated in a large sample for a longer duration to evaluate its efficacy and toxicity.

Viral anti-inflammatory reagents: the potential for treatment of arthritic and vasculitic disorders

Inflammatory and immune responses are inherent in the development of progressive arthritic or vasculitic disorders. Arthritis is frequently associated with accelerated forms of vasculitis; atherosclerosis being one form of accelerated vasculitis that blocks blood flow causing heart attacks and strokes. The arterial supply is central to maintaining normal articular function and acts as a conduit for inflammatory (innate) and immune (antigen dependent) cell trafficking in joints. The vasculature in some cases can become inflamed in the disease process. While treatment of severely debilitating arthritic disorders has improved, some current treatments are limited to reducing symptoms while others act as disease modifying drugs (DMARDs), but may have limited success. Many current treatments also have reported adverse side effects. Vasculitic disorders are similarly debilitating with high associated morbidity and mortality and current therapy for these disorders is only partially successful. Immune-modifying agents, which alter vascular inflammation, thus have potential for application in rheumatologic diseases. Viral immune modulating proteins reduce early arterial inflammatory responses with associated reductions in atherosclerotic plaque development and transplant rejection in a wide range of animal models. A clinical trial utilizing one such viral reagent, a secreted myxomaviral serpin, is currently in progress, assessing treatment of acute coronary syndrome, a vascular syndrome with marked up-regulation of systemic inflammatory responses. In this review we examine viral anti-inflammatory proteins as potential therapeutic reagents for arthritic and vasculopathic disorders.

Spinal cord stimulation modulates intraspinal colorectal visceroreceptive transmission in rats

Previous studies have shown that spinal cord stimulation (SCS) of upper lumbar segments decreases visceromotor responses to mechanical stimuli in a sensitized rat colon and reduces symptoms of irritable bowel syndrome in patients. SCS applied to the upper cervical spinal dorsal column reduces pain of chronic refractory angina. Further, chemical stimulation of C1-C2 propriospinal neurons in rats modulates the responses of lumbosacral spinal neurons to colorectal distension. The present study was designed to compare the effects of upper cervical and lumbar SCS on activity of lumbosacral neurons receiving noxious colorectal input. Extracellular potentials of L6-S2 spinal neurons were recorded in pentobarbital anesthetized, paralyzed and ventilated male rats. SCS (50 Hz, 0.2 ms) at low intensity (90% of motor threshold) was applied to the dorsal column of upper cervical (C1-C2) or upper lumbar (L2-L3) ipsilateral spinal segments. Colorectal distension (CRD, 20 mmHg, 40 mmHg, 60 mmHg, 20s) was produced by air inflation of a latex balloon. Results showed that SCS applied to L2-L3 and C1-C2 segments significantly reduced the excitatory responses to noxious CRD from 417.6+/-68.0 to 296.3+/-53.6 imp (P<0.05, n=24) and from 336.2+/-64.5 to 225.0+/-73.3 imp (P<0.05, n=18), respectively. Effects of L2-L3 and C1-C2 SCS lasted 10.2+/-1.9 and 8.0+/-0.9 min after offset of CRD. Effects of SCS were observed on spinal neurons with either high or low-threshold excitatory responses to CRD. However, L2-L3 or C1-C2 SCS did not significantly affect inhibitory neuronal responses to CRD. C1-C2 SCS-induced effects were abolished by cutting the C7-C8 dorsal column but not by spinal transection at cervicomedullary junction. These data demonstrated that upper cervical or lumbar SCS modulated responses of lumbosacral spinal neurons to noxious mechanical stimulation of the colon, thereby, proved two loci for a potential therapeutic effect of SCS in patients with irritable bowel syndrome and other colonic disorders.

Cellular automata and its advances to drug therapy for HIV infection

This paper gives an over view of the use of cellular automata (CA) model of drug therapy for HIV infection. Nonuniform CA is employed to simulate drug treatment of HIV infection, where each computational domain may contain different CA rules, in contrast to normal uniform CA models. Ordinary (or partial) differential equation models are insufficient to describe the two extreme time scales involved in HIV infection (days and decades), as well as the implicit spatial heterogeneity. Zorzenon and Coutinho [Phy Rev Lett, 16 (2001) 1] reported a cellular automata approach to simulate three-phase patterns of human immunodeficiency virus (HIV) infection consisting of primary response, clinical latency and onset of acquired immunodeficiency syndrome (AIDS). But here we present a related model, based on non-uniform CA to study the dynamics of drug therapy of HIV infection. The main aim in this model is to simulate the four phases (acute, chronic, drug treatment responds and onset of AIDS). The results shown here indicate that both simulations (with and without treatments) evolve to the relatively same steady state (characteristics of Wolfram's class II behavior). Different kinds of drug therapies can also be simulated in this model, which can be found useful for developing a proper drug therapy.

Surface-reconstruction-switched adsorbate photofragmentation dynamics

Energy-resolved angular distributions of neutral fragments ejected during photoinduced electron transfer reaction of CH3Br on GaAs(100) exhibit three distinct methyl-radical ejection channels. These undergo marked changes when the termination is switched from the Ga-rich c(8 x 2) to the As-rich c(2 x 8). Our observations are consistent with a strong adsorption-site dependence of the dynamics.

Hepatitis B vaccination among health care workers and students of a medical college

OBJECTIVE

To study the vaccination status against Hepatitis B among health care workers and students of a medical school.

MATERIALS AND METHODS

It is a descriptive study done at Allama Iqbal Medical College, Lahore. The participants comprised of 206 health care workers of various categories and 327 medical students. The main outcome measure was vaccination status and reasons for non-vaccination.

RESULTS

Only 49% health care workers and 42.20% medical students were vaccinated. The main reasons for non-vaccination (47.7%) among health care workers was the high cost of vaccination, while the most often cited reason (33.7%) among medical student was the belief that they were not at risk. This belief was also prevalent among nurses (36.4%), laboratory workers (38.6%) and paramedics (33.2%).

CONCLUSION

In a low-income country like Pakistan the health institutions should bear the cost for vaccinating their staff. Efforts should also be made to impart appropriate health education regarding hepatitis B infection.

Pulmonary function profile in chronic congestive heart failure and the effect of ipratropium bromide

Twenty-five symptomatic patients of chronic heart failure were subjected to spirometry to detect abnormalities of pulmonary function and to assess the effect of ipratropium bromide in reversing or minimising these abnormalities. All the patients exhibited abnormal pulmonary function manifesting as obstructive (15/25) or restrictive (10/25) ventilatory defect. There was overall improvement in lung functions with ipratropium bromide especially in those with obstructive ventilatory defects and mostly comprised of smokers. Forced expiratory volume in one second increased by 47.7 percent (p < 0.02), forced expiratory volume in one second/forced vital capacity ratio by 14.1 percent (p < 0.001) and maximal voluntary ventilation by 40.6 percent (p < 0.05) in these patients. It is concluded that ipratropium bromide can prove as a promising adjunctive therapeutic intervention in improving quality of life in patients of chronic congestive heart failure who are incapacitated by dyspnoea and have clearly documented ventilatory defects.

Development and evaluation of a multiple-unit oral sustained release dosage form for S(+)-ibuprofen: preparation and release kinetics

Mini-matrix tablets containing S(+)-ibuprofen have been prepared by the wet granulation method. The hydrophilic matrix was formed with either xanthan gum, karaya gum or hydroxymethylcellulose (HPMC) together with a choice of additives from lactose, Encompress(R), Avicel(R) PH101, talc and Lubritab(R). Multiple unit dosage forms (MUDFs) were subsequently obtained by encapsulating the mini-matrix tablets into hard gelatin capsules. Preparation, in vitro release profiles and release kinetics are presented.

Silent myocardial ischemia and cardiac autonomic neuropathy in diabetics

OBJECTIVE

To evaluate the association of silent myocardial ischemia (SMI) with cardiac autonomic neuropathy in asymptomatic diabetic patients.

MATERIAL AND METHODS

Two hundred asymptomatic patients of diabetes mellitus were assessed for evidence of cardiac autonomic neuropathy. Of these, 30 (15 males, 15 females; mean age 44.7 +/- 8.8 years) were found to have cardiac autonomic neuropathy. Thirty (30) age and sex matched diabetic patients (mean age 42.4 +/- 7.6 years) who had no evidence autonomic neuropathy were included in the study as control group. Both the groups of patients were evaluated for SMI by 24 hour ambulatory electrocardiographic (ECG) monitoring.

RESULTS

Incidence of SMI was significantly higher in patients with autonomic neuropathy 12/30 (40%) compared to those without 3/30 (10%) p < 0.001. Duration of diabetes was more (13 +/- 1.59 years) in patients with autonomic neuropathy compared to the control group (8.66 +/- 1.55 years) p < 0.001. Serum cholesterol and triglyceride levels were significantly higher in patients with autonomic neuropathy in comparison to control group < 0.05 and < 0.01, respectively. There was no difference in the pattern of SMI in the two groups (p = N.S).

CONCLUSION

Cardiac autonomic neuropathy predisposes patients with diabetes mellitus to SMI. Twenty four hour ambulatory ECG monitoring provides useful diagnostic information in early detection and evaluation of SMI in asymptomatic diabetic patients.

Comparative mutagenic and genotoxic effects of three antimalarial drugs, chloroquine, primaquine and amodiaquine

Comparative mutagenic and genotoxic effects of three antimalarial drugs, chloroquine, primaquine and amodiaquine, were assessed in the Ames mutagenicity assay (in strains TA97a, TA100, TA102 and TA104) and in vivo sister chromatid exchange (SCE) and chromosome aberration (CA) assays in bone marrow cells of mice. These are the most commonly used antimalarial drugs available at present throughout the world. The results of the bacterial mutagenicity assays showed a very weak mutagenic effect of all three drugs in Salmonella strains TA97a and TA100 both with and without S9 mix and in TA104 only with S9 mix. The results of the in vivo SCE and CA assays indicate that these three drugs are genotoxic in bone marrow cells of mice.

Clinical spectrum of infective endocarditis: 15 years experience

Four hundred and sixty-six patients (277 males, 189 females; mean age 23.2 years) diagnosed as cases of infective endocarditis during the past 15 years were retrospectively analysed. Two-thirds of patients belonged to the 15 to 35 years age group. The most common predisposing cardiac lesion was rheumatic heart disease seen in 73.4 percent patients. Mitral valve prolapse and right-sided endocarditis were infrequent, seen in four patients each. Blood culture positivity was 28.7 percent in adults and 61 percent in children. Commonest organism isolated was staphylococcus aureus in adults (39.3%) and streptococcus viridans in children (48%). Salmonella typhi was detected in 17 patients and showed excellent response to ciprofloxacin and gentamycin. Overall mortality was 13.9 percent and resistant heart failure was the leading cause of death. Our study presents the clinical spectrum of infective endocarditis and highlights the comparison with western studies.

Relationship between swelling, erosion and drug release in hydrophillic natural gum mini-matrix formulations

The swelling, erosion and solvent front penetration properties of mini-matrices containing xanthan (X), locust bean (LB) and karaya (K) gums were examined, analysed and related to the overall in vitro release kinetics of diclofenac sodium, used as a model drug. Mini-matrices were produced with drug:gum ratios of 1:1 as well as formulations of drug and X in combinations of 2:1, 2:3 and 1:2. The rank order of decreasing swelling index (SI) in both axial and radial dimensions was X?K?LB and each gum showed almost Fickian swelling behaviour. The solvent front penetration rates were consistent with the rates of swelling. However, the order of decreasing drug release and erosion rates was LB>X>K and all formulations demonstrated anomalous (non-Fickian) drug release kinetics. Therefore Fickian drug diffusion and polymer erosion were both occurring simultaneously. The dominant mechanism depended on the nature and content of the gum, as well as the stage in the dissolution time period. There was a loss of matrix integrity in formulations containing a high drug:gum ratio.

Comparative mutagenic and genotoxic effects of three propionic acid derivatives ibuprofen, ketoprofen and naproxen

The mutagenicity of three propionic acid derivatives, namely ibuprofen, ketoprofen and naproxen, was tested in the Ames mutagenicity assay (in strains TA97a, TA100 and TA102) and in vivo genotoxicity was tested by sister chromatid exchange (SCE) in bone marrow cells of mice. These are the anti-inflammatory drugs frequently used in different parts of the world. Mutagenicity results showed no mutagenic effects in strains TA97a, TA100 and TA102 for all three drugs. Results of in vivo SCE assays indicate that these three drugs are weakly genoxic in bone marrow cells of mice. This is the first report of the Ames mutagenicity assay for ketoprofen and in vivo SCE assay for three drugs.

Acetates and benzoates of alkyl catechols and evaluation of their antibacterial activity

Potential biologically active alkyl catechol esters were prepared and their antibacterial activity was determined against 12 Gram-positive and 16 Gram-negative bacteria. Esterification (acetylation and benzoylation) of mono-, di- and tetra- substituted alkyl catechols afforded the di-acetyl and di-benzoyl derivatives in each case. In the primary screening it was observed that the substitution of hydroxyl group in alkyl catechol with an acyl group generally resulted in a decrease of antibacterial activity. A number of acetyl and benzoyl derivatives inhibited the growth of Salmonella typhi. In case of Gram-positive bacteria only di-O-benzoyl-3,5,6,-tetra-(3-hexyl) catechol (26) showed a significant activity.

Comparative study of 18 gauge and 20 gauge intravenous catheters during transcranial Doppler ultrasonography with saline solution contrast

A formal technical protocol has not been established for transcranial Doppler ultrasonography in the detection of venous to arterial shunts; techniques have been adapted from contrast echocardiography. We evaluated the effect of different diameter indwelling intravenous catheters on the detection of right-to-left shunts by transcranial Doppler ultrasonography. Fifteen patients underwent transcranial Doppler sonographic evaluation with saline solution contrast using both 18 gauge and 20 gauge indwelling intravenous catheters. The larger bore intravenous catheter delivered a greater number of signals in a shorter time to the insonated middle cerebral artery. We recommend that a standardized method for transcranial Doppler sonographic contrast studies include an 18 gauge intravenous catheter.

Chemistry and biological activity of a tryptamine and beta-carboline series of bases

Twenty-six derivatives of harmaline and tetrahydroharmine were prepared and characterized by UV, IR, MS, and NMR spectroscopy. They were tested for their antimicrobial, antiplatelet aggregation and cytotoxic activity. Their effect on central nervous system was also studied.

Transcranial Doppler ultrasonography in the detection of venous to arterial shunting in acute stroke and transient ischaemic attacks

OBJECTIVES

To prospectively evaluate the prevalence of venous to arterial shunting in patients with acute stroke and transient ischaemic attacks (TIAs) using transcranial Doppler ultrasonography (TCD) with saline contrast.

METHODS

A consecutive series of patients with stroke or TIA underwent contrast TCD. Patients were subsequently divided into groups according to causative factors for stroke or TIA. The prevalence of right to left shunt was assessed within these groups.

RESULTS

A total of 210 patients underwent contrast TCD. A right to left shunt was detected in 28.6% of patients (60 of 210). Among the patients with cryptogenic stroke or TIA, 37.1% (43 of 116) had a positive contrast TCD whereas only 18% (17 of 94) with another identifiable cause had a positive test (P = 0.0024). When age was used to further classify those patients with cryptogenic stroke, TCD was positive in 59.3% patients (16 of 27) of < or = 50 years of age versus 30.3% of patients (27 of 89) > 50 years of age (P = 0.0058).

CONCLUSIONS

There was a significantly higher prevalence of venous to arterial shunting in patients with stroke or TIA of undetermined cause than in stroke patients with identifiable aetiologies, as detected by contrast TCD. The prevalence of a venous to arterial shunt was significantly higher in the younger group with cryptogenic stroke. Saline contrast TCD is a relatively non-invasive bedside procedure useful in the detection of venous to arterial shunting.