Flexible tape-drive target system for secondary high-intensity laser-driven sources

We present the development of a flexible tape-drive target system to generate and control secondary high-intensity laser-plasma sources. Its adjustable design permits the generation of relativistic MeV particles and x rays at high-intensity (i.e., ≥1 × 1018 W cm-2) laser facilities, at high repetition rates (>1 Hz). The compact and robust structure shows good mechanical stability and a high target placement accuracy (<4 μm RMS). Its compact and flexible design allows for mounting in both the horizontal and vertical planes, which makes it practical for use in cluttered laser-plasma experimental setups. The design permits ∼170° of access on the laser-driver side and 120° of diagnostic access at the rear. A range of adapted apertures have been designed and tested to be easily implemented to the targetry system. The design and performance testing of the tape-drive system in the context of two experiments performed at the COMET laser facility at the Lawrence Livermore National Laboratory and at the Advanced Lasers and Extreme Photonics (ALEPH) facility at Colorado State University are discussed. Experimental data showing that the designed prototype is also able to both generate and focus high-intensity laser-driven protons at high repetition rates are also presented.

P-031 AN UNUSUAL CASE OF AN INCARCERATED 5MM PORT SITE HERNIA FOLLOWING LAPAROSCOPIC FUNDOPLICATION

Aim

Port site hernias are a rare, but recognised risk of laparoscopic surgery. Literature supports fascial closure at port sites of 10mm or greater. However, there are few reported cases of herniation through 5mm port sites.

Methods

This case report focuses on a 67-year-old female who underwent an uncomplicated primary laparoscopic Toupet's fundoplication. 11 days post procedure she presented with an incarcerated port site hernia. CT scan demonstrated high grade small bowel obstruction with a transition point at the site of the 5mm right sided port. A laparotomy was performed, the hernia reduced, small bowel was viable, and the port site hernia was closed internally using vicryl sutures.

Results

The incidence of 5mm trocar-site hernias is rare. A recent literature review found only 10 such cases related to general surgery (cholecystectomy:6; appendicectomy: 2; right hemicolectomy: 1; paraesophageal hernia:1). Risk factors for port-site hernias include: high BMI, midline position, size, number and type of trocar tip. The limited current literature identifies excessive trocar manipulation as the major risk factor for developing 5mm port-site hernias, yet routine fascial closure is not supported.

Conclusion

Herniation at 5mm port sites is rare but attention should be paid when patients present with symptoms suggesting its occurrence.

969 ACUTE FRAILTY MODEL: A DISTRICT GENERAL HOSPITAL EXPERIENCE OF DELIVERING COMPREHENSIVE GERIATRIC ASSESSMENT

Introduction

Under the NHS Long Term Plan1, every hospital with a Type 1 Emergency Department (ED) has been asked to provide Acute Frailty Services for at least 70 hours a week. We have adopted a liaison model to ensure Comprehensive Geriatric Assessment at the front door. The Frailty Team now includes two Frailty Practitioners, a Specialist Registrar based in ED and the Acute Medical Unit (AMU) with Consultant Physician of the Week support.

Method

The team attend multi-disciplinary meetings in ED and AMU on a daily basis. Frail patients are reviewed and Comprehensive Geriatric Assessments are undertaken together with appropriate signposting. The aim being, to enhance the care of frail patients at the earliest opportunity.

Results

High bed utilisation comes at a cost and a longer length of stay (LOS) is associated with an increased risk of deconditioning. Since introducing incremental changes to our working model, the average LOS of patients on AMU has been reduced from a mean of 1.33 days to 0.82 days. This represents a 38.3% reduction from September 2020 to August 2021. This reduction has been sustained, while 30-day readmission rates have not increased. Feedback has been very positive from all the other teams involved.

Conclusion

Our service has established a more positive working culture to efficiently manage frail patients. The AMU team now feel empowered to make patient-centric decisions regarding patient flow and discharges. Since this data was analysed we have implemented a further change to help enhance the care of frail patients. A list of appropriate patients is emailed to the hospital site team every afternoon to aid getting the right patients into the right beds. The impact of LOS on the frailty wards will then be reviewed following this introduction.

Reference

1. nhs-long-term-plan-june-2019.pdf (longtermplan.nhs.uk).

Small-molecule inhibitors of P-Rex guanine-nucleotide exchange factors

P-Rex1 and P-Rex2 are guanine-nucleotide exchange factors (GEFs) that activate Rac small GTPases in response to the stimulation of G protein-coupled receptors and phosphoinositide 3-kinase. P-Rex Rac-GEFs regulate the morphology, adhesion and migration of various cell types, as well as reactive oxygen species production and cell cycle progression. P-Rex Rac-GEFs also have pathogenic roles in the initiation, progression or metastasis of several types of cancer. With one exception, all P-Rex functions are known or assumed to be mediated through their catalytic Rac-GEF activity. Thus, inhibitors of P-Rex Rac-GEF activity would be valuable research tools. We have generated a panel of small-molecule P-Rex inhibitors that target the interface between the catalytic DH domain of P-Rex Rac-GEFs and Rac. Our best-characterized compound, P-Rex inhibitor 1 (PREX-in1), blocks the Rac-GEF activity of full-length P-Rex1 and P-Rex2, and of their isolated catalytic domains, in vitro at low-micromolar concentration, without affecting the activities of several other Rho-GEFs. PREX-in1 blocks the P-Rex1 dependent spreading of PDGF-stimulated endothelial cells and the production of reactive oxygen species in fMLP-stimulated mouse neutrophils. Structure-function analysis revealed critical structural elements of PREX-in1, allowing us to develop derivatives with increased efficacy, the best with an IC₅₀ of 2 µM. In summary, we have developed PREX-in1 and derivative small-molecule compounds that will be useful laboratory research tools for the study of P-Rex function. These compounds may also be a good starting point for the future development of more sophisticated drug-like inhibitors aimed at targeting P-Rex Rac-GEFs in cancer.

Electron acceleration at oblique angles via stimulated Raman scattering at laser irradiance >10^{16}Wcm^{-2}μm^{2}

The generation of hot, directional electrons via laser-driven stimulated Raman scattering (SRS) is a topic of great importance in inertial confinement fusion (ICF) schemes. Little recent research has been dedicated to this process at high laser intensity, in which back, side, and forward scatter simultaneously occur in high energy density plasmas, of relevance to, for example, shock ignition ICF. We present an experimental and particle-in-cell (PIC) investigation of hot electron production from SRS in the forward and near-forward directions from a single speckle laser of wavelength λ_{0}=1.053μm, peak laser intensities in the range I_{0}=0.2-1.0×10^{17}Wcm^{-2} and target electron densities between n_{e}=0.3-1.6%n_{c}, where n_{c} is the plasma critical density. As the intensity and density are increased, the hot electron spectrum changes from a sharp cutoff to an extended spectrum with a slope temperature T=34±1keV and maximum measured energy of 350 keV experimentally. Multidimensional PIC simulations indicate that the high energy electrons are primarily generated from SRS-driven electron plasma wave phase fronts with k vectors angled ∼50^{∘} with respect to the laser axis. These results are consistent with analytical arguments that the spatial gain is maximized at an angle which balances the tendency for the growth rate to be larger for larger scattered light wave angles until the kinetic damping of the plasma wave becomes important. The efficiency of generated high energy electrons drops significantly with a reduction in either laser intensity or target electron density, which is a result of the rapid drop in growth rate of Raman scattering at angles in the forward direction.

A pilot study evaluating GSK1070806 inhibition of interleukin-18 in renal transplant delayed graft function

INTRODUCTION

Delayed graft function (DGF) following renal transplantation is a manifestation of acute kidney injury (AKI) leading to poor long-term outcome. Current treatments have limited effectiveness in preventing DGF. Interleukin-18 (IL18), a biomarker of AKI, induces interferon-γ expression and immune activation. GSK1070806, an anti-IL18 monoclonal antibody, neutralizes activated (mature) IL18 released from damaged cells following inflammasome activation. This phase IIa, single-arm trial assessed the effect of a single dose of GSK1070806 on DGF occurrence post donation after circulatory death (DCD) kidney transplantation.

METHODS

The 3 mg/kg intravenous dose was selected based on prior studies and physiologically based pharmacokinetic (PBPK) modeling, indicating the high likelihood of a rapid and high level of IL18 target engagement when administered prior to kidney allograft reperfusion. Utilization of a Bayesian sequential design with a background standard-of-care DGF rate of 50% based on literature, and confirmed via extensive registry data analyses, enabled a statistical efficacy assessment with a minimal sample size. The primary endpoint was DGF frequency, defined as dialysis requirement ≤7 days post transplantation (except for hyperkalemia). Secondary endpoints included safety, pharmacokinetics and pharmacodynamic biomarkers.

RESULTS

GSK1070806 administration was associated with IL18-GSK1070806 complex detection and increased total serum IL18 levels due to IL18 half-life prolongation induced by GSK1070806 binding. Interferon-γ-induced chemokine levels declined or remained unchanged in most patients. Although the study was concluded prior to the Bayesian-defined stopping point, 4/7 enrolled patients (57%) had DGF, exceeding the 50% standard-of-care rate, and an additional two patients, although not reaching the protocol-defined DGF definition, demonstrated poor graft function. Six of seven patients experienced serious adverse events (SAEs), including two treatment-related SAEs.

CONCLUSION

Overall, using a Bayesian design and extensive PBPK dose modeling with only a small sample size, it was deemed unlikely that GSK1070806 would be efficacious in preventing DGF in the enrolled DCD transplant population.

TRIAL REGISTRATION

NCT02723786.

Cost effectiveness of intraoperative laparoscopic ultrasound for suspected choledocholithiasis; outcomes from a specialist benign upper gastrointestinal unit

INTRODUCTION

Common bile duct stones are present in 10% of patients with symptomatic gallstones. One-third of UK patients undergoing cholecystectomy will have preoperative ductal imaging, commonly with magnetic resonance cholangiopancreatography. Intraoperative laparoscopic ultrasound is a valid alternative but is not widely used. The primary aim of this study was to assess cost effectiveness of laparoscopic ultrasound compared with magnetic resonance cholangiopancreatography.

MATERIALS AND METHODS

A prospective database of all patients undergoing laparoscopic cholecystectomy between 2015 and 2018 at a district general hospital was assessed. Inclusion criteria were all patients, emergency and elective, with symptomatic gallstones and suspicion of common bile duct stones (derangement of liver function tests with or without dilated common bile duct on preoperative ultrasound, or history of pancreatitis). Patients with known common bile duct stones (magnetic resonance cholangiopancreatography or failed endoscopic retrograde cholangiogram) were excluded. Ninety-day morbidity data were also collected.

RESULTS

A total of 420 (334 elective and 86 emergency) patients were suspected to have common bile duct stones and were included in the study. The cost of a laparoscopic ultrasound was £183 per use. The cost of using the magnetic resonance cholangiopancreatography unit was £365 per use. Ten postoperative magnetic resonance cholangiopancreatographies were performed for inconclusive intraoperative imaging. The estimated cost saving was £74,650. Some 128 patients had common bile duct stones detected intraoperatively and treated. There was a false positive rate of 4.7%, and the false negative rate at 90 days was 0.7%. laparoscopic ultrasound use saved 129 bed days for emergency patients and 240 magnetic resonance cholangiopancreatography hours of magnetic resonance imaging.

CONCLUSION

The use of laparoscopic ultrasound during laparoscopic cholecystectomy for the detection of common bile duct stone is safe, accurate and cost effective. Equipment and maintenance costs are quickly offset and hospital bed days can be saved with its use.

A rare late complication of traumatic diaphragmatic hernia repair

We report a case of sudden cardiovascular collapse several weeks following surgical repair of a traumatic diaphragmatic hernia. The patient presented with features of circulatory shock without a clear diagnosis, therefore an urgent computed tomography scan of the chest and abdomen was undertaken, which revealed a pericardial effusion with evidence of cardiac tamponade. Ultrasound-guided needle pericardiocentesis with aspiration of blood from the pericardial sac in the Emergency Department provided an immediate response and her cardiac output improved. On review of the imaging, it is likely a surgically-placed permanent metallic fixation device, sitting near the pericardium, caused bleeding into the pericardial sac due to local trauma as a delayed postoperative complication.

DNA methylation and mRNA expression of imprinted genes in blastocysts derived from an improved in vitro maturation method for oocytes from small antral follicles in polycystic ovary syndrome patients

STUDY QUESTION

Does imprinted DNA methylation or imprinted gene expression differ between human blastocysts from conventional ovarian stimulation (COS) and an optimized two-step IVM method (CAPA-IVM) in age-matched polycystic ovary syndrome (PCOS) patients?

SUMMARY ANSWER

No significant differences in imprinted DNA methylation and gene expression were detected between COS and CAPA-IVM blastocysts.

WHAT IS KNOWN ALREADY

Animal models have revealed alterations in DNA methylation maintenance at imprinted germline differentially methylated regions (gDMRs) after use of ARTs. This effect increases as more ART interventions are applied to oocytes or embryos. IVM is a minimal-stimulation ART with reduced hormone-related side effects and risks for patients. CAPA-IVM is an improved IVM system that includes a pre-maturation step (CAPA), followed by an IVM step, both in the presence of physiological compounds that promote oocyte developmental capacity.

STUDY DESIGN, SIZE, DURATION

For DNA methylation analysis 20 CAPA-IVM blastocysts were compared to 12 COS blastocysts. For RNA-Seq analysis a separate set of 15 CAPA-IVM blastocysts were compared to 5 COS blastocysts.

PARTICIPANTS/MATERIALS, SETTING, METHODS

COS embryos originated from 12 patients with PCOS (according to Rotterdam criteria) who underwent conventional ovarian stimulation. For CAPA-IVM 23 women were treated for 3-5 days with highly purified hMG (HP-hMG) and no hCG trigger was given before oocyte retrieval. Oocytes were first cultured in pre-maturation medium (CAPA for 24 h containing C-type natriuretic peptide), followed by an IVM step (30 h) in medium containing FSH and Amphiregulin. After ICSI, Day 5 or 6 embryos in both groups were vitrified and used for post-bisulphite adaptor tagging (PBAT) DNA methylation analysis or RNA-seq gene expression analysis of individual embryos. Data from specific genes and gDMRs were extracted from the PABT and RNA-seq datasets.

MAIN RESULTS AND THE ROLE OF CHANCE

CAPA-IVM blastocysts showed similar rates of methylation and gene expression at gDMRs compared to COS embryos. In addition, expression of major epigenetic regulators was similar between the groups.

LIMITATIONS, REASONS FOR CAUTION

The embryos from the COS group were generated in a range of culture media. The CAPA-IVM embryos were all generated using the same sperm donor. The DNA methylation level of gDMRs in purely in vivo-derived human blastocysts is not known.

WIDER IMPLICATIONS OF THE FINDINGS

A follow-up of children born after CAPA-IVM is important as it is for other new ARTs, which are generally introduced into clinical practice without prior epigenetic safety studies on human blastocysts. CAPA-IVM opens new perspectives for patient-friendly ART in PCOS.

STUDY FUNDING/COMPETING INTEREST(S)

IVM research at the Vrije Universiteit Brussel has been supported by grants from the Institute for the Promotion of Innovation by Science and Technology in Flanders (Agentschap voor Innovatie door Wetenschap en Technologie-IWT, project 110680), the Fund for Research Flanders (Fonds voor Wetenschappelijk Onderzoek-Vlaanderen-FWO-AL 679 project, project G.0343.13), the Belgian Foundation Against Cancer (HOPE project, Dossier C69Ref Nr 2016-119) and the Vrije Universiteit Brussel (IOF Project 4R-ART Nr 2042). Work in G.K.'s laboratory is supported by the UK Biotechnology and Biological Sciences Research Council and Medical Research Council. The authors have no conflicts of interest.

ANTI-DIABETIC EFFECT OF ETHANOL EXTRACT OF Costus spicatus JACQ. IN RHIZOME EXTRACT IN STREPTOZOTOCIN-INDUCED DIABETIC RATS –HISTOLOGICAL STUDY

Objective: The rats were randomly divided into 5 groups and each group consisted of 6 rats and the duration of treatment was 45 days. Body weight, fasting plasma glucose levels, SGOT, SGPT and ALP levels were measured. Methods: Albino Wistar male rats; 10- weeks old with a bodyweight ranged between 180-250 g were used. Anti-diabetic effect of plant Costus spicatus. In rhizome extract of ethanol extract. Result: The present study clearly indicates in the form of administration of C. spicatus rhizome extract towards glucose fed mice normalizes blood glucose level. Recent studies have revealed induced diabetic rats caused anti-diabetic effects. Histopathological studies of Pancreasin diabetic and treated groups are determined to show the protective action of the ECS. The administration of STZ resulted in a significant increase in plasma glucose level, SGOT, SGPT and ALP along with a reduction in body weight. Conclusion: All these effects were observed on 45th day. ECS and Glibenclamide of STZ induced diabetic animals restored the normal plasma glucose levels and SGOT, SGPT and ALP levels without damaging the pancreas. Keywords:Anti-hypolipidemic, diabetes mellitus, peripheral insulin resistance, pancreatic, STZ.

Understanding patient access patterns for primary health-care services for Aboriginal and Islander people in Queensland: a geospatial mapping approach

This paperexplores the patterns ofpatients'accessingsix Aboriginal and Islander CommunityControlled Health Services (AICCHSs) in Queensland. Between August 2011 and February 2014, 26199 patients made at least one visit over a 2-year period prior to at least one of six Queensland AICCHS - one urban service (RA 1) in south-east Queensland, and five services in regional towns (RA 3) in Far North Queensland. Geospatial mapping of addresses for these registered patients was undertaken. The outcomes analysed included travel times to, the proportion of catchment populations using each AICCHS and an assessment of alternative mainstream general practice availability to these patients was made. In brief, the use of AICCHS was higher than Australian Bureau of Statistics census data would suggest. Approximately 20% of clients travel more than 30min to seek Aboriginal Health services, but only 8% of patients travelled longer than 60min. In the major city site, many other general practitioner (GP) services were bypassed. The data suggest Aboriginal and Islander patients in Queensland appear to value community-controlled primary care services. The number of Indigenous clients in regional locations in the Far North Queensland registered with services is often higher than the estimated resident population numbers.

Selective RET kinase inhibition for patients with RET-altered cancers

Background

Alterations involving the RET kinase are implicated in the pathogenesis of lung, thyroid and other cancers. However, the clinical activity of multikinase inhibitors (MKIs) with anti-RET activity in RET-altered patients appears limited, calling into question the therapeutic potential of targeting RET. LOXO-292 is a selective RET inhibitor designed to inhibit diverse RET fusions, activating mutations and acquired resistance mutations.

Patients and methods

Potent anti-RET activity, high selectivity, and central nervous system coverage were confirmed preclinically using a variety of in vitro and in vivo RET-dependent tumor models. Due to clinical urgency, two patients with RET-altered, MKI-resistant cancers were treated with LOXO-292, utilizing rapid dose-titration guided by real-time pharmacokinetic assessments to achieve meaningful clinical exposures safely and rapidly.

Results

LOXO-292 demonstrated potent and selective anti-RET activity preclinically against human cancer cell lines harboring endogenous RET gene alterations; cells engineered to express a KIF5B-RET fusion protein -/+ the RET V804M gatekeeper resistance mutation or the common RET activating mutation M918T; and RET-altered human cancer cell line and patient-derived xenografts, including a patient-derived RET fusion-positive xenograft injected orthotopically into the brain. A patient with RET M918T-mutant medullary thyroid cancer metastatic to the liver and an acquired RET V804M gatekeeper resistance mutation, previously treated with six MKI regimens, experienced rapid reductions in tumor calcitonin, CEA and cell-free DNA, resolution of painful hepatomegaly and tumor-related diarrhea and a confirmed tumor response. A second patient with KIF5B-RET fusion-positive lung cancer, acquired resistance to alectinib and symptomatic brain metastases experienced a dramatic response in the brain, and her symptoms resolved.

Conclusions

These results provide proof-of-concept of the clinical actionability of RET alterations, and identify selective RET inhibition by LOXO-292 as a promising treatment in heavily pretreated, multikinase inhibitor-experienced patients with diverse RET-altered tumors.

Laparoscopic common bile duct exploration; a preferential pathway for elderly patients

Background

Laparoscopic common bile duct exploration (LCBDE) has emerged as a recommended alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis. However, its use in the elderly has been limited, and evidence of its safety and efficacy in these patients is yet to be established. This study describes our experience of LCBDE in elderly patients, analysing the safety and efficacy of this technique in comparison to younger patients.

Methods

All patients undergoing laparoscopic cholecystectomy (LC) with LCBDE for choledocholithiasis in our unit between January 2015 and January 2017 were included. Data pertaining to patient demographics, comorbidities, investigations, operative technique and outcomes were analysed. Patients were divided into 2 groups based on age (Group A:<65 years vs Group B: >/ = 65 years) for comparative analysis.

Results

124 patients (Group A: 65, Group B: 59) were included. Group B were more co-morbid and had a higher ASA grade than Group A. However, there was no significant difference between groups in rates of conversion to open or complications, including bile leak (3.1% vs 5.1%, p = 0.67), retained stone (4.6% vs 1.7%, p = 0.62), or complications according to Clavien-Dindo classification (p = 0.78). Re-intervention rates were also similar between groups (7.7% vs 3.4%, p = 0.44 and 3.1% vs 3.4%, p = 1.0 respectively), as was length of stay.

Conclusion

Despite higher frequency of comorbidities and ASA grade, LCBDE in elderly patients is safe and effective, and has similar outcomes to younger patients. Therefore elderly patients with choledocholithiasis should be offered LCBDE as an alternative to ERCP.

152 SPECIES-SPECIFIC DIFFERENCES IN THE METHYLATION REPROGRAMMING DURING EARLY PRE-IMPLANTATION DEVELOPMENT

Studies in mouse and human have shown extensive DNA methylation reprogramming in pre-implantation development followed by remethylation from implantation. However, the extent to which such reprogramming is conserved in mammals and the timing of demethylation and remethylation are unknown. As part of a major objective to characterise methylation dynamics in the bovine and porcine species from the oocyte to the blastocyst stage, we aimed here to compare the distribution of methylation at single-base resolution in both species at Day 7.5 of development. The DNA methylation profiles were obtained from individual blastocysts at Day 7.5 [pig: 3 in vivo, 3 in vitro; cow: 3 in vivo, 3 in vitro, 3 inner cell mass (ICM) and 3 trophoectoderm (TE) dissected from in vitro blastocysts] using the post-bisulphite adaptor tagging method and Illumina sequencing. For oocytes, data (GEO: GSE63330) from Schroeder et al. 2015 were analysed. Raw sequences were mapped, methylation calls made using Bismark and data analysis and visualisation was done within the SeqMonk platform. Gene expression profiles from individual blastocysts (3 pig, 3 cow) were obtained by RNA-seq. Annotated mRNA features were quantitated in SeqMonk and these were fed into DESeq2 for differential expression analysis (P < 0.05) as previously reported (Love et al. 2014 Genome Biol. 15, 550). Global methylation levels in whole blastocysts differed substantially between porcine and bovine embryos (in vivo: 12.33 ± 3.6 v. 28.33 ± 3.5%; in vitro: 15.02 ± 3.3 v. 24.41 ± 4.1%). In addition, the distribution of methylation differed: the pattern of cytosine methylated seemed random in the porcine genome, but was highly structured in the bovine genome, with methylation predominantly over gene bodies, resembling the profile previously reported in oocytes (Schroeder et al. 2015 PLoS Genet. 11, e1005442). Regarding correlation analysis, gene expression versus methylation were plotted. It suggested that gene body methylation reflected gene expression pattern in oocytes as well as in bovine blastocysts. Pair-wise comparison of isolated ICM and TE was filtered to require 5% change, and replicate set statistics were applied. This revealed very similar total and regional methylation levels in the 2 compartments, indicating that remethylation does not initiate preferentially in one compartment in bovine pre-implantation embryos. This confirms, from a viewpoint of the genome-wide DNA methylation, what has been observed in mouse for specific genes: the trophoblast-specific DNA methylation occurs after the segregation of the TE and ICM (Nakanishi et al. 2012 Epigenetics 7, 173–183). Our study is the first to provide whole genome methylation profiles from single blastocysts of economically important livestock species. Our data demonstrate that methylation reprogramming in early pre-implantation development is species specific. Knowledge of these specific patterns may have high importance when decisions are taken regarding the use of assisted reproductive technologies, cloning, or generation of transgenic animals. This work was funded by AGL2015–66341-R (MINECO-FEDER), PRX14/00348 (MECD), 19595/EE/14 (F. Séneca).

Gene Clustering Using Metaheuristic Optimization Algorithms

Gene clustering is a familiar step in the exploratory analysis of high dimensional biological data. It is the process of grouping genes of similar patterns in the same cluster and aims at analyzing the functions of gene that leads to the development of drugs and early diagnosis of diseases. In the recent years, much research has been proposed using nature inspired meta-heuristic algorithms. Cuckoo Search is one such optimization algorithm inspired from nature by breeding strategy of parasitic bird, the cuckoo. This paper proposes cuckoo search clustering and clustering using levy flight cuckoo search for grouping brain tumor gene expression dataset. A comparative study is made with genetic algorithm, PSO clustering, cuckoo search clustering and clustering using levy flight cuckoo search. Levy flight is an important property of levy distribution which covers the entire search space. Breeding pattern of cuckoo is associated with the genes that cause tumor to grow and affect other organs gradually. Clusters generated by these algorithms are validated to find the closeness among the genes in a cluster and separation of genes between clusters. Experimental results carried out in this paper show that cuckoo search clustering outperforms other clustering methods used for experimentation.

Improving student nurses' aged care understandings through a supported placement

AIM

The study aimed to identify the potential for aged care placements to deliver benefits for second year nursing students when conducted within a supportive framework with debriefing and critical reflection opportunities.

BACKGROUND

Given the ageing population and complex care needs of aged care facility residents, exacerbated by the high prevalence of dementia, the healthcare workforce's ability to meet older people's care needs is paramount. Yet research shows that nursing students are disengaged from aged care.

METHODS

Using a quasi-experimental mixed method design within an action research framework, 40 students were allocated a 3-week supported placement in 2011-2012 at one of the two intervention residential aged care facilities in Tasmania, Australia. Staff formed mentor action research groups in each facility and participated in a pre-placement capacity-building programme. Thirty-nine students were placed across 14 control facilities. Data were collected via meetings with students and pre-post placement questionnaires on placement experiences, attitudes and dementia knowledge.

RESULTS

The intervention facility placement programme led to mentors and students being well prepared for the placement and to students experiencing enhanced teaching and learning derived from high levels of mentor support and increased autonomy. Students' knowledge, understanding and attitudes around aged care and dementia improved.

DISCUSSION

Mentors working together within an action research framework can provide a supported residential aged care placement for nursing students that improves students' aged care attitudes and understandings.

CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY

Provision of quality, supported aged care student placements is vital to prepare a new generation of nurses who will have to deal with the complex chronic healthcare needs associated with an ageing population.

GSK2374697, a novel albumin-binding domain antibody (AlbudAb), extends systemic exposure of exendin-4: first study in humans--PK/PD and safety

GSK2374697 is a genetically engineered fusion protein of a human domain antibody to exendin-4. This molecule binds with a high affinity to human serum albumin, creating a long-duration glucagon-like peptide-1 (GLP-1) receptor agonist. This study is the first evaluation of the albumin-binding domain antibody (AlbudAb) drug delivery platform in humans. The aim of this randomized clinical study was to determine the pharmacokinetics, pharmacodynamics, safety, and tolerability of GSK2374697. The pharmacokinetic profile was prolonged, with estimated half-lives ranging from 6 to 10 days. Postprandial glucose and insulin were reduced, and gastric emptying was delayed in healthy subjects, confirming anticipated GLP-1 receptor agonist pharmacology. The safety and tolerability were as expected for a potent GLP-1 agonist. Gradual titration of doses greatly improved tolerability. Rapid tolerance to nausea was observed. Study results support further investigation in type 2 diabetes and for weight loss.

Harmony Search PSO Clustering for Tumor and Cancer Gene Expression Dataset

Enormous quantity of gene expression data from diverse data sources are accumulated due to the modern advancement in microarray technology that leads to major computational challenges. The foremost step towards addressing this challenge is to cluster genes which reveal hidden gene expression patterns and natural structures to find the interesting patterns from the underlying data that in turn helps in disease diagnosis and drug development. Particle Swarm Optimization (PSO) technique is extensively used for many practical applications but fails in finding the initial seeds to generate clusters and thus reduces the clustering accuracy. One of the meta-heuristic optimization algorithms called Harmony Search is free from divergence and helps to find out the near-global optimal solutions by searching the entire solution space. This paper proposes a novel Harmony Search Particle Swarm Optimization (HSPSO) clustering algorithm and is applied for Brain Tumor, Colon Cancer, Leukemia Cancer and Lung Cancer gene expression datasets for clustering. Experimental results show that the proposed algorithm produces clusters with better compactness and accuracy, in comparison with K-means clustering, PSO clustering (swarm clustering) and Fuzzy PSO clustering.

Prompt laparoscopic cholecystectomy would reduce morbidity and save hospital resources

INTRODUCTION

Limited resources and organisational problems often result in significant waiting times for patients presenting with an indication for cholecystectomy. This study investigated the potential false economy of such practice.

METHODS

Retrospective analysis of all patients on a waiting list for cholecystectomy between July 2007 and October 2010 was performed. The hospital computer document management system and patients' notes were used to collect data.

RESULTS

A total of 1,021 patients were included in the study; 701 were listed from clinic and 320 were listed following an emergency admission. The median time on a waiting list before surgery was 96 days (range: 5-381 days). Eighty-seven patients (8.5%) had an emergency admission with a gallstone related problem while on a waiting list. This resulted in 488 cumulative inpatient days. There was a significant correlation between increased time spent on the waiting list and increased chance of an emergency admission (p=0.01). Patients added to the waiting list from emergency admissions were more likely to be admitted with complications than those listed from clinic (15.3% vs 5.4%, p<0.01). There was no association between age (p=0.53) or sex (p=0.23) and likelihood of emergency admission while on a waiting list.

CONCLUSIONS

Prompt elective surgery and same-admission emergency laparoscopic cholecystectomy can reduce waiting list patient morbidity and is likely to save resources in the long term.

The Role of Within-Person Variability in Forming Stable Face Representations

We are usually able to recognise novel instances of familiar faces with little difficulty; yet unfamiliar face recognition can be dramatically impaired by natural within-person variability. Unless otherwise prompted, naturally varying instances of an unfamiliar face are often perceived as belonging to multiple different people (Jenkins, White, Van Montford & Burton, 2011). In Experiment 1 participants sorted naturally varying images of unfamiliar faces into their separate identities; half were told that only two target identities were present (constrained), while half were given no indication of the number of targets (unconstrained). Results indicate that unconstrained participants sorted images into 7.5 identities (mean 5 images per pile). On a subsequent matching test, participants who had performed a constrained sort were more accurate than unconstrained sorters, although matching task accuracy was greater for identities seen in the sorting task than for completely novel faces. To investigate this form of learning, Experiment 2 replicated the design using equally complex non-face stimuli (photographic negative faces from Experiment 1). Results indicate that while sorting and matching accuracy was generally poorer, matching task accuracy was greater for learnt than novel negatives. The implications of these findings are discussed with regards to the importance of within-person variability in developing stable face representations.

Does concentration of surgical expertise improve outcomes for laparoscopic cholecystectomy? 9 year audit cycle

BACKGROUND

Evidence from surgery shows that high volume is often associated with better outcomes. The aim of this study was to investigate this principle related to elective laparoscopic cholecystectomy practice.

METHODS

A retrospective analysis of all conversions and complications for patients undergoing elective laparoscopic cholecystectomy was performed. Data was collected and then repeated after restrictions were implemented to concentrate practice. Hospital databases and patient notes were used to collect data.

RESULTS

Between January 1999 and March 2004, 1605 laparoscopic cholecystectomies were performed by 8 surgeons. Case load varied from an average of <1 to 104 procedures per annum. Only 1 surgeon was an upper gastrointestinal specialist. Overall rates for conversion to open surgery were 4.9%, common bile duct injury was 0.31%, bile leak 0.75%, bowel injury 0.25%, haemorrhage 0.44% and death 0.06%, which met guidelines. Significant correlation between conversion and procedure number was identified (p=0.033) Between April 2006 and March 2010, 1820 laparoscopic cholecystectomies were performed by 4 surgeons. Case load varied from 23 to 268 procedures per annum, 2 surgeons were upper gastrointestinal specialists. Overall rates for conversion to open surgery were 3.5%, common bile duct injury 0.1%, bile leak 0.9%, bowel injury 0.21%, haemorrhage 0.16% and death 0.1%. Conversion rates were significantly lower in re-audit data (p=0.027), but remained lowest for the highest volume sub-specialist surgeons (p=0.016).

CONCLUSIONS

Concentrating expertise to those surgeons with interest and commitment to laparoscopic cholecystectomy service led to standardisation and reduction in conversion rates. There is correlation between volume of surgery and outcomes.

Differential gene body methylation and reduced expression of cell adhesion and neurotransmitter receptor genes in adverse maternal environment

Early life adversity, including adverse gestational and postpartum maternal environment, is a contributing factor in the development of autism, attention deficit hyperactivity disorder (ADHD), anxiety and depression but little is known about the underlying molecular mechanism. In a model of gestational maternal adversity that leads to innate anxiety, increased stress reactivity and impaired vocal communication in the offspring, we asked if a specific DNA methylation signature is associated with the emergence of the behavioral phenotype. Genome-wide DNA methylation analyses identified 2.3% of CpGs as differentially methylated (that is, differentially methylated sites, DMSs) by the adverse environment in ventral-hippocampal granule cells, neurons that can be linked to the anxiety phenotype. DMSs were typically clustered and these clusters were preferentially located at gene bodies. Although CpGs are typically either highly methylated or unmethylated, DMSs had an intermediate (20-80%) methylation level that may contribute to their sensitivity to environmental adversity. The adverse maternal environment resulted in either hyper or hypomethylation at DMSs. Clusters of DMSs were enriched in genes that encode cell adhesion molecules and neurotransmitter receptors; some of which were also downregulated, indicating multiple functional deficits at the synapse in adversity. Pharmacological and genetic evidence links many of these genes to anxiety.

Influence of barefoot, barefoot inspired and conventional shoes on tibial accelerations and loading kinetics during running in natural rearfoot strikers

Running barefoot and in footwear designed to mimic barefoot locomotion, has received considerable attention in footwear research. This study examined the differences in impact force and tibial acceleration parameters. Ten male participants completed 10 trials when running barefoot, in vibram five-fingers and in conventional footwear at three locomotion velocities: walk, jog and run (1.25, 3.5 and 5.0 m/s, respectively). Impact force and tibial acceleration parameters were synchronously obtained and contrasted between footwear and velocities using 3 (footwear) x 3 (velocity) repeated measures ANOVA's. Significant main effects were obtained for both footwear and velocity which suggest that barefoot running at higher velocities is associated with increases in impact loading magnitude. This leads to the conclusion that barefoot locomotion may be associated with increased risk of injury regardless of running velocity and that more specifically running barefoot at higher velocities should be undertaken with caution.

Tumour cell responses to new fibroblast growth factor receptor tyrosine kinase inhibitors and identification of a gatekeeper mutation in FGFR3 as a mechanism of acquired resistance

Fibroblast growth factor receptors (FGFRs) can act as driving oncoproteins in certain cancers, making them attractive drug targets. Here we have characterized tumour cell responses to two new inhibitors of FGFR1-3, AZ12908010 and the clinical candidate AZD4547, making comparisons with the well-characterized FGFR inhibitor PD173074. In a panel of 16 human tumour cell lines, the anti-proliferative activity of AZ12908010 or AZD4547 was strongly linked to the presence of deregulated FGFR signalling, indicating that addiction to deregulated FGFRs provides a therapeutic opportunity for selective intervention. Acquired resistance to targeted tyrosine kinase inhibitors is a growing problem in the clinic but has not yet been explored for FGFR inhibitors. To assess how FGFR-dependent tumour cells adapt to long-term FGFR inhibition, we generated a derivative of the KMS-11 myeloma cell line (FGFR(Y373C)) with acquired resistance to AZ12908010 (KMS-11R cells). Basal phosphorylated FGFR and FGFR-dependent downstream signalling were constitutively elevated and refractory to drug in KMS-11R cells. Sequencing of FGFR3 in KMS-11R cells revealed the presence of a heterozygous mutation at the gatekeeper residue, encoding FGFR3(V555M); consistent with this, KMS-11R cells were cross-resistant to AZD4547 and PD173074. These results define the selectivity and efficacy of two new FGFR inhibitors and identify a secondary gatekeeper mutation as a mechanism of acquired resistance to FGFR inhibitors that should be anticipated as clinical evaluation proceeds.

Testing children of mothers with HIV infection: experience in three south-west London HIV clinics

OBJECTIVE

There are several reported cases of vertically infected children presenting with advanced HIV infection in the UK. The children of women with HIV infection are at increased risk of being infected. There are few data available on the number of such children that are yet to be tested for HIV. This study looked at the HIV testing status of children whose mothers attend HIV services at three south-west London clinics.

METHODS

Case notes of women attending the clinics from 1 January to 30 June 2009 were reviewed. When data were incomplete, women were prospectively interviewed.

RESULTS

Case notes of 605 women were reviewed; 478 women had 1107 children. The majority of women (386; 81%) were of Black African ethnicity. Sixty-one per cent (675 of 1107) of the children were known to have been tested for HIV. The children resident abroad were more likely to be untested compared with those resident in the UK; 186 of 255 (73%) vs. 246 of 852 (29%). A quarter (106 of 432) of the untested children were ≤ 18 years old; 49 (46%) of these were resident in the UK. The most common reason given by the mothers for not testing was a perceived 'unlikely risk'.

CONCLUSIONS

A significant number of children at risk of vertically transmitted HIV infection, including 49 children ≤ 18 years and resident in the UK, were identified through this study. The mothers are being encouraged to have these children tested and a multidisciplinary team involving adult and paediatric HIV healthcare professionals has been set up to negotiate and facilitate testing.

Plantar fasciitis and impaired vision: A case report

We report a case of acute bilateral central serous chorioretinopathy in a patient who received a local injection of triamcinolone for the treatment of plantar fasciitis. Central serous chorioretinopathy is a serious, though rare, ocular complication of steroid treatment and it may occur even when the steroid is administered at a site as remote from the eye as the foot. This case report highlights the need for greater awareness of this complication amongst all medical personnel who prescribe steroids. It is advisable that patients, undergoing steroid treatment for any cause, be alerted to the risk of sudden visual impairment.

Phase II trial of sagopilone, a novel epothilone analog in metastatic melanoma

BACKGROUND

Sagopilone is a novel fully synthetic epothilone with promising preclinical activity and a favourable toxicity profile in phase I testing.

METHODS

A phase II pharmacokinetic and efficacy trial was conducted in patients with metastatic melanoma. Patients had measurable disease, Eastern Cooperative Oncology Group performance status 0-2, adequate haematological, and organ function, with up to 2 previous chemotherapy and any previous immunotherapy regimens. Sagopilone, 16 mg m⁻², was administered intravenously over 3 h every 21 days until progression or unacceptable toxicity.

RESULTS

Thirty-five patients were treated. Sagopilone showed multi-exponential kinetics with a mean terminal half-life of 64 h and a volume of distribution of 4361 l m⁻² indicating extensive tissue/tubulin binding. Only grade 2 or lower toxicity was observed: these included sensory neuropathy (66%), leukopenia (46%), fatigue (34%), and neutropenia (31%). The objective response rate was 11.4% (one confirmed complete response, two confirmed partial responses, and one unconfirmed partial response). Stable disease for at least 12 weeks was seen in an additional eight patients (clinical benefit rate 36.4%).

CONCLUSION

Sagopilone was well tolerated with mild haematological toxicity and sensory neuropathy. Unlike other epothilones, it shows activity against melanoma even in pretreated patients. Further clinical testing is warranted.

Tribal ethnicity and CYP2B6 genetics in Ugandan and Zimbabwean populations in the UK: implications for efavirenz dosing in HIV infection

OBJECTIVES

To determine differences in CYP2B6 loss of function (LoF) single nucleotide polymorphisms (SNPs) and haplotypes between Zimbabweans and Ugandans, and within Ugandan populations (Bantu and Nilotic).

METHODS

Genetic epidemiological study enrolling adult black African Ugandan and Zimbabwean patients attending a UK HIV-1 clinic, irrespective of antiretroviral therapy status. Genomic DNA was extracted from whole blood and the presence of CYP2B6 alleles was determined by direct sequencing of all nine exons of the CYP2B6 gene. Blood was also collected, where appropriate, for determination of efavirenz concentrations. Frequency of SNPs in all patients and LoF haplotype frequencies were calculated. The relationship between the number of LoF haplotype alleles possessed and efavirenz trough concentration (ETC) was determined.

RESULTS

Thirty-six Zimbabweans and 74 Ugandans (58 Bantu and 16 Nilotic) were recruited. The definite haplotypes determined were *6, *18, *20 and *27 as LoF and *4 as gain of function. Among those with definite genotypes, the frequency of LoF alleles was 65% [95% confidence interval (95% CI): 51-80] of Zimbabweans versus 22% (95% CI: 12-31) of Ugandan Bantus (P = 10(-6)) and versus 39% (95% CI: 14-64) of Ugandan Nilotics (P = 0.09). Among the 19 patients with definite genotype and with available ETCs, log ETCs were associated with a greater number of LoF haplotype alleles [848 ng/mL (n = 12), 1069 ng/mL (n = 4) and 1813 ng/mL (n = 3) for 0, 1 or 2 LoF haplotypes, respectively (P = 0.016)].

CONCLUSIONS

Among Zimbabweans, LoF haplotypes constitute the majority of CYP2B6 alleles and are significantly higher in prevalence compared with Ugandans. Frequencies of LoF haplotypes and SNPs in Ugandan Nilotics appear to lie between those of Zimbabweans and Ugandan Bantus. These findings may have relevance to pharmacokinetics and dosing of efavirenz in African populations.

Pharmacokinetic/pharmacodynamic analysis of adjuvant pegylated interferon α-2b in patients with resected high-risk melanoma

Purpose

High-dose pegylated interferon α-2b (peginterferon α-2b) significantly decreased disease recurrence in patients with resected stage III melanoma in a clinical study. We investigated the pharmacokinetics (PK) and safety of high-dose peginterferon α-2b in patients with high-risk melanoma.

Methods

For PK analysis, 32 patients received peginterferon α-2b 6 μg/(kg week) subcutaneously for 8 weeks (induction) then 3 μg/(kg week) for 4 weeks (maintenance). PK profiles were determined at weeks 1, 8, and 12. Exposure–response relationships between peginterferon α-2b and absolute neutrophil count (ANC) and alanine aminotransferase (ALT) level were also studied.

Results

Peginterferon α-2b was well-absorbed following SC administration, with a median T_max of 24 h. Mean half-life estimates ranged from 43 to 51 h. The accumulation factor was 1.69 after induction therapy. PK parameters showed moderate interpatient variability. PK profiles were described by a one-compartmental model with first-order absorption and first-order elimination. Toxicity was profiled and was acceptable; observed side effects were similar to those previously described. Dose reduction produced proportional decreases in exposure and predictable effects on ANC in an Imax model; however, a PK/pharmacodynamic (PK/PD) relationship between peginterferon α-2b and ALT could not be established with high precision.

Conclusions

Peginterferon α-2b was well-absorbed and sustained exposure to peginterferon α-2b was achieved with the doses tested. These data confirm and extend previous PK observations of peginterferon α-2b in melanoma and solid tumors. Our PK/PD model of exposure and ANC effect provides useful information for prediction of peginterferon α-2b-related hematologic toxicity.

Electronic supplementary material

The online version of this article (doi:10.1007/s00280-010-1326-9) contains supplementary material, which is available to authorized users.

Phase II trial of sagopilone (ZK-EPO), a novel synthetic epothilone, with significant activity in metastatic melanoma

9031

Background: Sagopilone (ZK-Epothilone) is a novel, fully synthetic epothilone with promising preclinical activity in several cancer models. This phase II study aims to define the efficacy and safety of sagopilone in patients with metastatic melanoma, as well as perform pharmacokinetic evaluation of this dose and schedule. Methods: Patients with unresectable stage III or IV malignant melanoma, with up to 2 prior chemotherapy and any prior immunotherapy regimens with measurable disease were eligible. Sagopilone was administered at 16 mg/m2 as a 3-hour IV infusion every 21 days. The primary end point of the trial was response rate, and secondary endpoints included time to progression, overall survival, and tolerability. Pharmacokinetic analysis was done on the first 10 patients. A total of 37 patients were to be accrued to have 33 evaluable patients. The trial had a 0.90 power and assumed α of 0.03. Results: Thirty four patients have been enrolled to date. Sagopilone appears to be well tolerated: The most common side effects seen have been sensory neuropathy, (55%, 19/34, 5 Grade 2, 14Grade 1) motor neuropathy (23%, 8/34, All Grade 1); anemia (26 %, 9/34) neutropenia (14%, 5/34 1 Grade 2, 4 Grade 1) thrombocytopenia (14%, 5/34) and fatigue (38%, 13/34). Two patients have shown grade 3 events (syncope and mental status changes, respectively, possibly related to therapy), both of which resolved and an additional patient had a pulmonary embolism which was considered unlikely to be related to therapy. Responses have been seen in 4 patients (3 RECIST confirmed PR, 1 unconfirmed PR). Stable disease was seen for at least 12 weeks in an additional 10 patients for a clinical benefit rate (CR+PR+SD) of 44%. No grade 4 events have been reported. Conclusions: Unlike the epothilone analogs patupilone or ixabepilone, sagopilone appears to be an active drug in advanced melanoma. The side effect profile seen to date at 16 mg/m2 given over 3 hours repeated every 3 weeks appears to be notably free of myelosuppression indicating that it could be combined with other drugs active in melanoma. Pharmacokinetic studies show a prolonged terminal half life, probably due to release from deep tissue compartments.

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