24 REVERSING FRAILTY AND ENHANCING RESILIENCE WITH EXERCISE AND DIETARY EDUCATION (REFEREE): A PRIMARY CARE RANDOMISED CONTROLLED TRIAL

Background

There is a need for effective primary-care interventions that help older people combat frailty and build resilience. This study aims to test the effectiveness of a co-designed exercise and dietary protein intervention.

Methods

This was a multicentre, randomised-controlled, parallel-arm trial in six Irish primary-care practices. We enrolled adults aged 65+ with Clinical Frailty Scale score ≤5 from December 2020 to April 2021. Participants were randomised to intervention or usual care with allocation concealed until enrolment with a GP. Intervention comprised exercises, emphasising strength, and dietary protein guidance. At three-month follow-up, effectiveness was measured by comparing SHARE-Frailty Instrument between groups, on intention-to-treat basis. Secondary outcomes included muscle mass, bone mass and biological age measured by Bioelectrical Impedance Analysis (BIA). Ease of intervention and health difference were measured on Likert scales.

Results

359 adults were assessed for eligibility and 168 enrolled. 156 (92.9%) attended follow-up (mean age 77.1; 67.3% women; 79 intervention, 77 control). At baseline, frailty proportions were 17.7% in the intervention and 16.9% in the control group. At follow-up, they were 6.3% and 18.2%, respectively. The odds ratio (OR) of being frail for the intervention group was 0.23 times that of the control group (95% confidence interval: 0.07-0.72; P=0.011), adjusting for age, gender and site. Absolute risk reduction was 11.9% (CI: 0.8%-22.9%; P=0.018). Number needed to treat was 8.4. BIA parameters improved, bone mass significantly (P=0.040). 66.2% found the intervention easy, 69.0% reported feeling better.

Conclusion

A combination of exercises and dietary protein significantly reduced frailty and improved self-reported health. Frailty was reversed in more than 1 in 9 participants.

Additive Manufacturing of Personalized Pharmaceutical Dosage Forms via Stereolithography

The introduction of three-dimensional printing (3DP) has created exciting possibilities for the fabrication of dosage forms, paving the way for personalized medicine. In this study, oral dosage forms of two drug concentrations, namely 2.50% and 5.00%, were fabricated via stereolithography (SLA) using a novel photopolymerizable resin formulation based on a monomer mixture that, to date, has not been reported in the literature, with paracetamol and aspirin selected as model drugs. In order to produce the dosage forms, the ratio of poly(ethylene glycol) diacrylate (PEGDA) to poly(caprolactone) triol was varied with diphenyl(2,4,6-trimethylbenzoyl)phosphine oxide (Irgacure TPO) utilized as the photoinitiator. The fabrication of 28 dosages in one print process was possible and the printed dosage forms were characterized for their drug release properties. It was established that both drugs displayed a sustained release over a 24-h period. The physical properties were also investigated, illustrating that SLA affords accurate printing of dosages with some statistically significant differences observed from the targeted dimensional range, indicating an area for future process improvement. The work presented in this paper demonstrates that SLA has the ability to produce small, individualized batches which may be tailored to meet patients’ specific needs or provide for the localized production of pharmaceutical dosage forms.

Mass-customization of oral tablets via the combination of 3D printing and injection molding

The new frontier of medicine is the personalization of treatment to match a patient's individual needs. Fused-filament fabrication (FFF) offers a platform for the personalization of drug dosage forms, but one of its chief shortcomings compared to other tablet production methods such as dry compression and wet granulation is relatively low throughput. Conversely, injection molding (IM) is a manufacturing technique for the high-volume production of parts, but in which individual part customization is both expensive and slow requiring the modification of expensive mold tooling. Mass-customization is the manufacture of custom products that match the needs of individual consumers but which are produced at the low unit cost associated with high-volume production. We successfully integrated for the first time FFF with IM in a multi-step manufacturing process for the production of custom bilayer tablets loaded with two active pharmaceutical ingredients used in the treatment of cardiovascular disease. The FFF layer was loaded with the diuretic hydrochlorothiazide, while the IM layer was loaded with lovastatin. Infill percentage was varied for the FFF layer as a means to modify drug release. The IM injection pressure was evaluated for its effect on drug release and layer-layer adhesion. The bilayer tablets obtained offered different combinations of drug release profiles, which were governed by a combination of factors, including surface area to volume ratio; IM injection volume penetration into the FFF layer; FFF infill percentage; layer tortuosity and porosity. These different parameters could be utilized to modify the individual release of both drugs from the bilayer tablet. Thus for the first time, we have demonstrated a viable method for the mass-customization of oral tablets which could hasten the rollout of personalized medicine.

The Influence of Low Shear Microbore Extrusion on the Properties of High Molecular Weight Poly(l-Lactic Acid) for Medical Tubing Applications

Biodegradable polymers play a crucial role in the medical device field, with a broad range of applications such as suturing, drug delivery, tissue engineering, scaffolding, orthopaedics, and fixation devices. Poly-l-lactic acid (PLLA) is one of the most commonly used and investigated biodegradable polymers. The objective of this study was to determine the influence low shear microbore extrusion exerts on the properties of high molecular weight PLLA for medical tubing applications. Results showed that even at low shear rates there was a considerable reduction in molecular weight (M_n = 7–18%) during processing, with a further loss (M_n 11%) associated with resin drying. An increase in melt residence time from ~4 mins to ~6 mins, translated into a 12% greater reduction in molecular weight. The degradation mechanism was determined to be thermal and resulted in a ~22-fold increase in residual monomer. The differences in molecular weight between both batches had no effect on the materials thermal or morphological properties. However, it did affect its mechanical properties, with a significant impact on tensile strength and modulus. Interestingly there was no effect on the elongational proprieties of the tubing. There was also an observed temperature-dependence of mechanical properties below the glass transition temperature.

Prognostic significance of neuroepithelial transforming gene 1 in adenocarcinoma of the oesophagogastric junction

Background

Neuroepithelial transforming gene 1 (NET1) mediates tumour invasion and metastasis in a number of cancers, including gastric adenocarcinoma. It is an indicator of poor prognosis in breast cancer and glioma. This study examined NET1 expression and its prognostic significance in patients with adenocarcinoma of the oesophagogastric junction (AOG).

Methods

NET1 expression was measured by immunohistochemistry in a tissue microarray, constructed from biobanked tissue collected over a 10-year interval, and linked to a prospectively maintained clinical database.

Results

Using the Siewert classification for AOG, type I tumours expressed significantly higher levels of NET1, with lowest expression in type III and intermediate levels in type II (P = 0·001). In patients with AOG type III, NET1-positive patients were more likely to be female (P = 0·043), have advanced stage cancer (P = 0.035), had a higher number of transmural cancers (P = 0·006) and had a significantly higher median number of positive lymph nodes (P = 0·029). In this subgroup, NET1-positive patients had worse median overall (15 versus 23 months; P = 0·025) and disease-free (11 versus 36 per cent; P = 0·025) survival compared with NET1-negative patients.

Conclusion

Although existing data show differences in clinical and prognostic indices across AOG subtypes, there are no studies showing differences in tumour biology. These data suggest NET1, a known mediator of an aggressive tumour phenotype in a number of gastrointestinal cancers, is expressed differentially across AOG subtypes and may be of prognostic significance in the clinical management of this condition.

Venous thromboembolism risk and prophylaxis in the acute hospital care setting: the Irish results of the ENDORSE study

ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), is a multinational, cross-sectional survey of venous thromboembolism (VTE) risk prevalence and effective prophylaxis in the acute hospital care setting. Three Irish hospitals enrolled in the study. The American College of Chest Physicians (ACCP) guidelines were employed to evaluate VTE risk and prophylaxis. Of 552 patients, 297 (53.8%) and 255 (46.2%) were categorised as surgical or medical, respectively, with 175 (59%) surgical and 109 (43%) medical patients deemed to be at risk for VTE. Of these, only 112 (64%) and 51 (47%) received recommended VTE prophylaxis, respectively. The results are consistent with those observed in other countries and demonstrate a high prevalence of risk for VTE and a low rate of prophylaxis use, particularly in medical patients. Awareness of VTE guidelines should be an integral component of health policy.

Effect of anaesthetic technique on oestrogen receptor-negative breast cancer cell function in vitro

BACKGROUND

Metastatic recurrence is the main cause of breast cancer-related deaths. Tumour cell proliferation and migration are crucial steps in the metastatic process. Several perioperative factors, including general anaesthesia and opioid analgesia, adversely affect immune function, potentially increasing metastatic recurrence. Regional anaesthesia-analgesia has been consistently shown to attenuate the stress response to surgery, and also reduce opioid and general anaesthesia requirements, thereby attenuating this perioperative immunosuppression. We investigated the effect of serum from breast cancer surgery patients who received different anaesthetic techniques on breast cancer cell function in vitro.

METHODS

Patients were randomized to receive propofol/paravertebral anaesthesia-analgesia (propofol/paravertebral, n=11) or sevoflurane general anaesthesia with opioid analgesia (sevoflurane/opioid, n=11). The ER-negative MDA-MB-231 cell line was treated with patient serum from both groups. The effects on proliferation and migration were measured.

RESULTS

Treatment groups were well balanced for age, weight, surgical procedure, and cancer pathology. Pain scores were lower at 1 and 2 h in the propofol/paravertebral analgesia group. Compared with preoperative values, proliferation of MDA-MB-231 cells treated with postoperative patient serum at 10% concentration from the propofol/paravertebral group was significantly reduced compared with the sevoflurane/opioid group (-24% vs 73%, P=0.01). There was no significant change in MDA-MB-231 cell migration after treatment with patient serum between the two groups.

CONCLUSIONS

Serum from patients receiving propofol/paravertebral anaesthesia for breast cancer surgery inhibited proliferation, but not migration, of ER-MDA-MB-231 cells in vitro, to a greater extent than that from patients receiving sevoflurane/opioid anaesthesia-analgesia. This implies that anaesthetic technique alters the serum molecular milieu in ways that may affect breast cancer cell function, possibly by altering anaesthetic and opioid drug administration and resultant pain scores.

An outbreak of tuberculosis affecting cattle and people on an Irish dairy farm, following the consumption of raw milk

Bovine tuberculosis is an ongoing problem in Ireland, and herd incidence has remained at approximately 5% for some years. Spillover of infection from cattle to people remains an ever-present possibility, given the ongoing pool of infection in the Irish cattle population. This paper describes an outbreak of tuberculosis affecting cattle and people on a dairy farm in southeastern Ireland following the consumption of milk from a seven-year-old cow with tuberculous mastitis. Twenty-five of 28 calves born during autumn 2004 and spring 2005 were subsequently identified as TB reactors, and five of six family members were positive on the Mantoux test. During 2005, milk from this cow had mainly been used to feed calves, and was added only occasionally to the bulk tank. Therefore, the calves each received infected milk on an almost continuous basis between birth and weaning. The family collected milk from the bulk milk tank, and consumed it without pasteurisation. This case highlights the risks associated with the consumption of raw milk. In this family, TB has had a very significant impact on the health of two young children. These risks are well recognised, and relevant information for farmers is available. It is of concern, therefore, that raw milk consumption remains prevalent on Irish farms. New strategies are needed, in partnership with industry, to address this important issue. Keywords: bovine tuberculosis, Ireland, mastitis, milk, Mycobacterium bovis, pasteurisation, TB, zoonosis

Net1 and Myeov: computationally identified mediators of gastric cancer

Gastric adenocarcinoma (GA) is a significant cause of mortality worldwide. The molecular mechanisms of GA remain poorly characterised. Our aim was to characterise the functional activity of the computationally identified genes, NET 1 and MYEOV in GA. Digital Differential Display was used to identify genes altered expression in GA-derived EST libraries. mRNA levels of a subset of genes were quantitated by qPCR in a panel of cell lines and tumour tissue. The effect of pro- and anti-inflammatory stimuli on gene expression was investigated. Cell proliferation and invasion were measured using in an in-vitro GA model following inhibition of expression using siRNA. In all, 23 genes not previously reported in association with GA were identified. Two genes, Net1 and Myeov, were selected for further analysis and increased expression was detected in GA tissue compared to paired normal tissue using quantitative PCR. siRNA-mediated downregulation of Net1 and Myeov resulted in decreased proliferation and invasion of gastric cancer cells in vitro. These functional studies highlight a putative role for NET1 and Myeov in the development and progression of gastric cancer. These genes may provide important targets for intervention in GA, evidenced by their role in promoting invasion and proliferation, key phenotypic hallmarks of cancer cells.

Suppressors of cytokine signalling (SOCS): putative modulators of cytokine bioactivity in health and disease

Cytokines are important modulators of homeostatic processes such as development, haematopoiesis and host defence. A recently identified family of proteins, the supressors of cytokine signalling (SOCS) act as negative regulators of the key cytokine-activated signalling pathway, the Janus kinase/signal transducers and activators of transcription (JAK/STAT) cascade. In the current review, the discovery, structural features, regulation of expression, mechanisms of JAK/STAT inhibition and putative role in health and disease of the SOCS family are discussed.

A preliminary comparison of two perennially ice-covered lakes in Antarctica: analogs of past Martian lacustrine environments

Perennially ice-covered lakes in the Antarctic have been suggested as analogs to lakes which may have existed on the surface of Mars 3.5 billion years ago. During the 1991-1992 austral summer, a joint Russian/American research effort was directed at studies of ice-covered lakes in the Bunger Hills Oasis, Antarctica (66 degrees S, 100 degrees E). The primary objective of the expedition was to investigate this ice-free area for features analogous to ancient martian environments that may have been capable of supporting life and to compare the ice-covered lakes of the Bunger Hills with those in the McMurdo Dry Valleys of southern Victoria Land (77 degrees S, 166 degrees E) as part of the continuing studies of Antarctic-Mars analogs.

Macrophage production of basic fibroblast growth factor in the fibroproliferative disorder of alveolar fibrosis after lung injury

In organ repair following injury, macrophages accumulate and granulation tissue, comprised of fibroblasts and endothelial cells, develops in the injured area. Basic fibroblast growth factor (bFGF), a potent stimulator of fibroblast and endothelial cell growth, has been linked to the fibroproliferative process. Macrophages are thought to play a central role in the fibroproliferative response, and prior studies indicate that they produce bFGF. Whereas it is plausible that macrophages produce bFGF in a fibroproliferative process, currently no data exists that directly identifies the macrophage as a source of bFGF in a fibroproliferative disorder. We used the model of acute intraalveolar granulation tissue formation following lung injury to determine if the macrophage was a cellular source of bFGF in a naturally occurring fibroproliferative process. To examine this hypothesis, patients with severe acute lung injury underwent bronchoalveolar lavage during the phase of lung repair. Polymerase chain reaction and Northern analysis of macrophage RNA revealed the presence of two species of bFGF messenger RNA (4.4 kb and 1.9 kb). Metabolic labeling studies of recovered macrophages revealed a newly synthesized 18-kd protein with antigenic similarity to bFGF. Immunohistochemical evaluation of lung tissue from patients who died following acute lung injury, showed numerous bFGF immunoreactive macrophages present within airspaces containing fibroblastic and vascular tissue proliferation. This investigation has identified the alveolar macrophage as a cellular source of bFGF in the fibroproliferative disorder of intraalveolar fibrosis following acute lung injury.

Retinal pigment epithelial correlates of avian retinal degeneration: electron microscopic analysis

The delayed amelanotic (DAM) strain of domestic chicken is characterized by an early, developmental onset of choroidal inflammation and destruction of both feather and choroidal melanocytes. Secondarily, retinal pigment epithelial (RPE) cells in the peripapillary region develop abnormalities, and a series of progressive histopathological changes ensues which includes reduction and ultimate loss of RPE-melanin granules and RPE-cell atrophy. The earliest sign of RPE-cell abnormality is a dramatic alteration in the distribution of intracellular melanin granules. Apical processes also show a lessening of contact with photoreceptor outer segments, leading in more advanced stages to their retraction and development of retinal detachments. Other progressive alterations in RPE cells include disorganization and loss of basal infoldings; size reductions and density increases in both mitochondria and myeloid bodies from early to advanced stages; appearance of large macrophages in the subretinal space; Loss of intercellular junctional complexes; and progressive reduction in the density of melanin granules. These abnormalities appear to spread in a cell-by-cell, radial pattern, until widespread areas of the retina become severely pathologic and atrophic. The DAM chorioretinal disorder appears to show many of the histopathologic features which characterize experimentally induced uveitis and other ocular diseases which may result from hypersensitivity to, or autoimmune reaction against, pigments of the uveal tract.