Immunological classification of renal cell carcinoma patients based on phenotypic analysis of immune check-point molecules

Abstract

Objectives

To clarify comprehensive immunological signature patterns of tumour tissue-infiltrating lymphocytes in patients with renal cell carcinoma and show its clinical significance.

Materials and methods

We investigated the surface marker expressions of tumour tissue-infiltrating lymphocytes quantitatively and classified them based on their functional populations. We extracted 109 sets of tumour tissue-infiltrating lymphocytes from 80 patients who underwent surgical resection of renal cell carcinoma, of which 44 tumour tissue-infiltrating lymphocytes were multiply extracted from 15 patients. Each tumour tissue-infiltrating lymphocyte was characterised on the basis of functional T-cell populations using ten surface marker expressions measured by flow cytometry.

Results

All sets of the tumour tissue-infiltrating lymphocytes were classified into three groups, which correlated significantly with Fuhrman grade (OR 0.253, 95% CI 0.094–0.678, P = 0.006). Importantly, both overall metastasis-free survival (HR 0.449, 95% CI 0.243–0.832, P = 0.011) and recurrence-free survival (HR 0.475, 95% CI 0.238–0.948, P = 0.035) of the patients with the higher marker expressions were significantly inferior to those of the patients with the lower marker expressions by multivariate analysis. Six specific genes for this classification identified by microarray analysis verified our results using the TCGA KIRC data set. In addition, we discovered the presence of intra-tumoural diversity in the classification of 3 (20%) of the 15 patients.

Conclusions

This study showed that the presence of classable diversity in the immunological signature of tumour tissue-infiltrating lymphocytes correlated with prognosis and tumour aggressiveness that was observed even within individual tumours in some patients with renal cell carcinoma.

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PET Molecular Imaging Research of Levodopa-Induced Dyskinesias in Parkinson’s Disease

Abstract

Purpose of Review

To review the current status of positron emission tomography (PET) molecular imaging research of levodopa-induced dyskinesias (LIDs) in Parkinson's disease (PD).

Recent Findings

Recent PET studies have provided robust evidence that LIDs in PD are associated with elevated and fluctuating striatal dopamine synaptic levels, which is a consequence of the imbalance between dopaminergic and serotonergic terminals, with the latter playing a key role in mishandling presynaptic dopamine release. Long-term exposure to levodopa is no longer believed to solely induce LIDs, as studies have highlighted that PD patients who go on to develop LIDs exhibit elevated putaminal dopamine release before the initiation of levodopa treatment, suggesting the involvement of other mechanisms, including altered neuronal firing and abnormal levels of phosphodiesterase 10A.

Summary

Dopaminergic, serotonergic, glutamatergic, adenosinergic and opioid systems and phosphodiesterase 10A levels have been shown to be implicated in the development of LIDs in PD. However, no system may be considered sufficient on its own for the development of LIDs, and the mechanisms underlying LIDs in PD may have a multisystem origin. In line with this notion, future studies should use multimodal PET molecular imaging in the same individuals to shed further light on the different mechanisms underlying the development of LIDs in PD.

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Henry’s retirement blues

Late in his career, 'our Henry' has established a glowing reputation on the international stage both as a riveting storyteller with Do No Harm and as an eloquent performer on YouTube and TV (Your Life in their Hands and The English Surgeon). Both Ian McEwan and The Economist ventured that neurosurgery had found its Boswell. In his new book Admissions, Henry is in reflective mode as he struggles with retirement, loss of professional identity, lost opportunities to put matters right and post-retirement blues. The book starts with his suicide kit and ends with his ambition not to wait for the end, but to be ready to leave, booted and spurred, when it comes. In between, there is a compelling mix of poignant patient vignettes interspersed with laments about his own clinical failings, the state of medicine at home and abroad, and fleeting observations on consciousness and the hereafter.

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Pharmacological targeting of apelin impairs glioblastoma growth

Abstract

Glioblastoma are highly aggressive brain tumours that are associated with an extremely poor prognosis. Within these tumours exists a subpopulation of highly plastic self-renewing cancer cells that retain the ability to expand ex vivo as tumourspheres, induce tumour growth in mice, and have been implicated in radio- and chemo-resistance. Although their identity and fate are regulated by external cues emanating from endothelial cells, the nature of such signals remains unknown. Here, we used a mass spectrometry proteomic approach to characterize the factors released by brain endothelial cells. We report the identification of the vasoactive peptide apelin as a central regulator for endothelial-mediated maintenance of glioblastoma patient-derived cells with stem-like properties. Genetic and pharmacological targeting of apelin cognate receptor abrogates apelin- and endothelial-mediated expansion of glioblastoma patient-derived cells with stem-like properties in vitro and suppresses tumour growth in vivo. Functionally, selective competitive antagonists of apelin receptor were shown to be safe and effective in reducing tumour expansion and lengthening the survival of intracranially xenografted mice. Therefore, the apelin/apelin receptor signalling nexus may operate as a paracrine signal that sustains tumour cell expansion and progression, suggesting that apelin is a druggable factor in glioblastoma.

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Resveratrol attenuates bone cancer pain through regulating the expression levels of ASIC3 and activating cell autophagy

Abstract

Bone cancer pain (BCP) is one of the most common pains in patients with malignant cancers. The mechanism underlying BCP is largely unknown. Our previous studies and the increasing evidence both have shown that acid-sensing ion channels 3 (ASIC3) is an important protein in the pathological pain state in some pain models. We hypothesized that the expression change of ASIC3 might be one of the factors related to BCP. In this study, we established the BCP model through intrathecally injecting rat mammary gland carcinoma cells (MRMT-1) into the left tibia of Sprague-Dawley female rats, and found that the BCP rats showed bone destruction, increased mechanical pain sensitivities and up-regulated ASIC3 protein expression levels in L4–L6 dorsal root ganglion. Then, resveratrol, which was intraperitoneally injected into the BCP rats on post-operative Day 21, dose-dependently increased the paw withdrawal threshold of BCP rats, reversed the pain behavior, and had an antinociceptive effect on BCP rats. In ASIC3-transfected SH-SY5Y cells, the ASIC3 protein expression levels were regulated by resveratrol in a dose- and time-dependent manner. Meanwhile, resveratrol also had an antinociceptive effect in ASIC3-mediated pain rat model. Furthermore, resveratrol also enhanced the phosphorylation of AMPK, SIRT1, and LC3-II levels in ASIC3-transfected SH-SY5Y cells, indicating that resveratrol could activate the AMPK-SIRT1-autophagy signal pathway in ASIC3-transfected SH-SY5Y cells. In BCP rats, SIRT1 and LC3-II was also down-regulated. These findings provide new evidence for the use of resveratrol as a therapeutic treatment during BCP states.

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Whole-Genome and Epigenomic Landscapes of Etiologically Distinct Subtypes of Cholangiocarcinoma [Research Articles]

Cholangiocarcinoma (CCA) is a hepatobiliary malignancy exhibiting high incidence in countries with endemic liver-fluke infection. We analyzed 489 CCAs from 10 countries, combining whole-genome (71 cases), targeted/exome, copy-number, gene expression, and DNA methylation information. Integrative clustering defined 4 CCA clusters—fluke-positive CCAs (clusters 1/2) are enriched in ERBB2 amplifications and TP53 mutations; conversely, fluke-negative CCAs (clusters 3/4) exhibit high copy-number alterations and PD-1/PD-L2 expression, or epigenetic mutations (IDH1/2, BAP1) and FGFR/PRKA-related gene rearrangements. Whole-genome analysis highlighted FGFR2 3' untranslated region deletion as a mechanism of FGFR2 upregulation. Integration of noncoding promoter mutations with protein–DNA binding profiles demonstrates pervasive modulation of H3K27me3-associated sites in CCA. Clusters 1 and 4 exhibit distinct DNA hypermethylation patterns targeting either CpG islands or shores—mutation signature and subclonality analysis suggests that these reflect different mutational pathways. Our results exemplify how genetics, epigenetics, and environmental carcinogens can interplay across different geographies to generate distinct molecular subtypes of cancer.

Significance: Integrated whole-genome and epigenomic analysis of CCA on an international scale identifies new CCA driver genes, noncoding promoter mutations, and structural variants. CCA molecular landscapes differ radically by etiology, underscoring how distinct cancer subtypes in the same organ may arise through different extrinsic and intrinsic carcinogenic processes. Cancer Discov; 7(10); 1116–35. ©2017 AACR.

This article is highlighted in the In This Issue feature, p. 1047

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Osimertinib May Be an Effective First-Line Therapy in EGFR-Mutant NSCLC [Clinical Trials]

Osimertinib achieved objective responses in 77% of patients with treatment-naïve NSCLC.

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ADC Approval Likely to Spur More Research [News in Brief]

The FDA's decision to approve inotuzumab ozogamicin for patients with relapsed or refractory acute lymphoblastic leukemia could open up further uses for the drug. It is being tested as a first-line treatment in combination with chemotherapy. The decision could also stimulate research into other antibody–drug conjugates.

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Local Delivery of IFN{alpha} Has Antitumor Activity in Bladder Cancer [Clinical Trials]

Intravesical delivery of rAd-IFNα/Syn3 is safe and achieves durable responses in high-grade NMIBC.

http://ift.tt/2yTYiH4

Soils and Seeds That Initiate Pancreatic Cancer Metastasis [In the Spotlight]

Summary: Pathways that stimulate metastasis of pancreatic cancer cells are critical for understanding tumor evolution and can serve as potential therapeutic targets. The microenvironment produces a host of metabolic perturbations and tropic factors that may play a formative role in this process. Cancer Discov; 7(10); 1067–8. ©2017 AACR.

See related article by Chiou et al., p. 1184.

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Surrogate Endpoint ID'd for Prostate Cancer Trials [News in Brief]

Metastasis-free survival is a strong surrogate for overall survival for men with localized prostate cancer, a meta-analysis shows. The intermediate outcome measure could help accelerate the evaluation of novel adjuvant therapies in this patient population.

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Resistance Genes Identified [News in Brief]

A CRISPR-based screen of all 19,050 genes in the genome has revealed around 100 genes that cancer cells must express in order for T cells—and, thus, immunotherapies—to effectively recognize and kill tumors.

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TERT Promoter Mutations Promote Immortalization and Genomic Instability [Telomerase]

TERT promoter mutations may induce early and late tumorigenesis by separate mechanisms.

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EWS-FLI1 Retargets BAF Chromatin Remodeling Complexes in Ewing Sarcoma [Ewing Sarcoma]

BAF recruitment to GGAA microsatellites activates the Ewing sarcoma transcriptional program.

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MAGE-A3-Targeted Autologous CD4+ T Cells May Target Metastatic Cancer [Clinical Trials]

Adoptive transfer of MAGE-A3–targeted CD4⁺ T cells is safe and achieves responses in several tumor types.

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More T Cells versus Better T Cells in Patients with Breast Cancer [In the Spotlight]

Summary: Characterization of intratumoral leukocyte populations may help in estimating patients' prognosis and predictions. A new study shows remarkable differences between the in situ and invasive breast cancer stages and highlights that cell number analyses should be complemented with characterization of T-cell functions, increasing the likelihood that immune competent antitumor T cells and further biomarkers are identified for guiding therapy choices. Cancer Discov; 7(10); 1062–4. ©2017 AACR.

See related article by Gil Del Alcazar et al., p. 1098.

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Veliparib With Temozolomide or Carboplatin/Paclitaxel Versus Placebo With Carboplatin/Paclitaxel in Patients With BRCA1/2 Locally Recurrent/Metastatic Breast Cancer: Randomized Phase II Study

Abstract

Background

Homologous recombination defects in BRCA1/2-mutated tumors result in sensitivity to poly(ADP-ribose) polymerase (PARP) inhibitors, which interfere with DNA damage repair. Veliparib, a potent PARP inhibitor, enhanced the antitumor activity of platinum agents and temozolomide in early phase clinical trials. This phase II study examined the safety and efficacy of intermittent veliparib with carboplatin/paclitaxel (VCP) or temozolomide (VT) in patients with BRCA1/2-mutated breast cancer.

Patients and methods

Eligible patients ≥18 years with locally recurrent or metastatic breast cancer and a deleterious BRCA1/2 germline mutation were randomized 1:1:1 to VCP, VT, or placebo plus carboplatin/paclitaxel (PCP). Primary endpoint was progression-free survival (PFS); secondary endpoints included overall survival (OS) and overall response rate (ORR).

Results

Of 290 randomized patients, 284 were BRCA+, confirmed by central laboratory. For VCP versus PCP, median PFS was 14.1 and 12.3 months, respectively (hazard ratio [HR], 0.789; 95% CI, 0.536–1.162; P=0.227), interim median OS 28.3 and 25.9 months (HR, 0.750; 95% CI, 0.503–1.117; P = 0.156), and ORR 77.8% and 61.3% (P = 0.027). For VT (versus PCP), median PFS was 7.4 months (HR, 1.858; 95% CI, 1.278–2.702; P=0.001), interim median OS 19.1 months (HR, 1.483; 95% CI, 1.032–2.131; P=0.032), and ORR 28.6% (P<0.001). Safety profile was comparable between carboplatin/paclitaxel arms. Adverse events (all grades) of neutropenia, anemia, alopecia, and neuropathy were less frequent with VT versus PCP.

Conclusion

Numerical but not statistically significant increases in both PFS and OS were observed in patients with BRCA1/2-mutated recurrent/metastatic breast cancer receiving VCP compared to PCP. The addition of veliparib to carboplatin/paclitaxel significantly improved ORR. There was no clinically meaningful increase in toxicity with VCP versus PCP. VT was inferior to PCP. An ongoing phase III trial is evaluating VCP versus PCP, with optional continuation single-agent therapy with veliparib/placebo if chemotherapy is discontinued without progression, in this patient population.Clinical trial information: NCT01506609.

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Randomized controlled trial of S-1 versus docetaxel in patients with non-small-cell lung cancer previously treated with platinum-based chemotherapy (East Asia S-1 Trial in Lung Cancer)

Abstract

Background

Chemotherapy remains a viable option for the management of advanced non-small-cell lung cancer (NSCLC) despite recent advances in molecular targeted therapy and immunotherapy. We evaluated the efficacy of oral 5-fluorouracil-based S-1 as second- or third-line therapy compared with standard docetaxel therapy in patients with advanced NSCLC.

Patients and methods

Patients with advanced NSCLC previously treated with ≥1 platinum-based therapy were randomized 1:1 to docetaxel (60 mg/m² in Japan, 75mg/m² at all other study sites; day 1 in a 3-week cycle) or S-1 (80–120 mg/day, depending on body surface area; days 1–28 in a 6-week cycle). The primary endpoint was overall survival. The non-inferiority margin was a hazard ratio (HR) of 1.2.

Results

A total of 1154 patients (577 in each arm) were enrolled, with balanced patient characteristics between the two arms. Median overall survival was 12.75 and 12.52 months in the S-1 and docetaxel arms, respectively (HR 0.945; 95% confidence interval [CI] 0.833–1.073; P=0.3818). The upper limit of 95% CI of HR fell below 1.2, confirming non-inferiority of S-1 to docetaxel. Difference in progression-free survival between treatments was not significant (HR 1.033; 95% CI 0.913–1.168; P=0.6080). Response rate was 8.3% and 9.9% in the S-1 and docetaxel arms, respectively. Significant improvement was observed in the EORTC QLQ-C30 global health status over time points in the S-1 arm. The most common adverse drug reactions were decreased appetite (50.4%), nausea (36.4%), and diarrhea (35.9%) in the S-1 arm, and neutropenia (54.8%), leukocytopenia (43.9%), and alopecia (46.6%) in the docetaxel arm.

Conclusion

S-1 is equally as efficacious as docetaxel and offers a treatment option for patients with previously treated advanced NSCLC.

Clinical trial number

Japan Pharmaceutical Information Center, JapicCTI-101155

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Surgery for patients with ‘lower grade’ glioma: putting assumptions, beliefs and convictions into perspective

Annals of Oncology 2017:00:1-2. doi:10.1093/annonc/mdx295

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TMPRSS2-ERG Alters the cis-Regulatory Landscape and Activates NOTCH [Prostate Cancer]

In TMPRSS2–ERG-positive prostate tumors, ERG establishes new clusters of regulatory elements (CORE).

http://ift.tt/2xctoYx

Equipping NK Cells with CARs [News in Brief]

Adding a chimeric antigen receptor (CAR) to natural killer (NK) cells is garnering interest as a therapeutic strategy because this immune cell type doesn't cause graft-versus-host disease, making its widespread, off-the-shelf use feasible. Based on promising preclinical data, a phase I/II trial of one such CAR NK-cell therapy is under way, targeting CD19 in hematologic malignancies.

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Superenhancer Analysis Defines Novel Epigenomic Subtypes of Non-APL AML, Including an RAR{alpha} Dependency Targetable by SY-1425, a Potent and Selective RAR{alpha} Agonist [Research Articles]

We characterized the enhancer landscape of 66 patients with acute myeloid leukemia (AML), identifying 6 novel subgroups and their associated regulatory loci. These subgroups are defined by their superenhancer (SE) maps, orthogonal to somatic mutations, and are associated with distinct leukemic cell states. Examination of transcriptional drivers for these epigenomic subtypes uncovers a subset of patients with a particularly strong SE at the retinoic acid receptor alpha (RARA) gene locus. The presence of a RARA SE and concomitant high levels of RARA mRNA predisposes cell lines and ex vivo models to exquisite sensitivity to a selective agonist of RARα, SY-1425 (tamibarotene). Furthermore, only AML patient-derived xenograft (PDX) models with high RARA mRNA were found to respond to SY-1425. Mechanistically, we show that the response to SY-1425 in RARA-high AML cells is similar to that of acute promyelocytic leukemia treated with retinoids, characterized by the induction of known retinoic acid response genes, increased differentiation, and loss of proliferation.

Significance: We use the SE landscape of primary human AML to elucidate transcriptional circuitry and identify novel cancer vulnerabilities. A subset of patients were found to have an SE at RARA, which is predictive for response to SY-1425, a potent and selective RARα agonist, in preclinical models, forming the rationale for its clinical investigation in biomarker-selected patients. Cancer Discov; 7(10); 1136–53. ©2017 AACR.

See related commentary by Wang and Aifantis, p. 1065..

This article is highlighted in the In This Issue feature, p. 1047

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Mapping Out Cancer Dependencies [News in Brief]

Through large-scale RNAi screens, two groups of researchers have documented, in depth, the molecular players essential for tumor cell viability. Their cancer "dependency maps," which are publicly accessible, should aid drug discovery efforts by pinpointing therapeutic targets that merit developmental focus.

http://ift.tt/2wuhPME

CMTM6 Regulates PD-L1 Expression and Antitumor Immunity [Immunotherapy]

CMTM6 binds to PD-L1 on the plasma membrane to promote its stability and inhibitory activity.

http://ift.tt/2xcmpPf

Enasidenib Approved for AML, but Best Uses Unclear [News in Brief]

The FDA approved the targeted therapy enasidenib for patients with refractory or relapsed acute myeloid leukemia with mutant IDH2. The drug produces remissions in some patients and may reduce the need for blood transfusions, although researchers acknowledge that the FDA's approval came with less supporting evidence than usual.

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Gilead Buying Kite for $11.9 Billion [News in Brief]

Gilead Sciences will buy Kite Pharma—and its autologous CAR T-cell technology—for $11.9 billion. The acquisition will help Gilead build its oncology portfolio and boost its revenues.

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$10M Gift Supports "Data Recycling" at UCSF [News in Brief]

The University of California, San Francisco's Institute for Computational Health Sciences has received a $10 million gift to support "data recycling" investigations. The approach to medical research involves mining existing data to potentially uncover new uses for existing drugs and help improve clinical care.

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Ascorbate Depletion Reduces TET2 Activity to Accelerate Leukemogenesis [Leukemia]

Elevated ascorbate levels maintain TET2 activity in HSCs and decline with differentiation.

http://ift.tt/2xcfwO3

CAR T Cells Drive CLL Remissions [News in Brief]

A new study shows that chimeric antigen receptor T cells produce objective responses in 71% of patients with chronic lymphocytic leukemia whose disease progressed despite receiving ibrutinib or who are unable to tolerate the drug. Cancer cells were undetectable in the bone marrow in 81% of tested patients, and 64% of tested patients showed complete lymph node responses. Most patients experienced adverse effects, however.

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How Ribosomes Translate Cancer [Review]

A wealth of novel findings, including congenital ribosomal mutations in ribosomopathies and somatic ribosomal mutations in various cancers, have significantly increased our understanding of the relevance of ribosomes in oncogenesis. Here, we explore the growing list of mechanisms by which the ribosome is involved in carcinogenesis—from the hijacking of ribosomes by oncogenic factors and dysregulated translational control, to the effects of mutations in ribosomal components on cellular metabolism. Of clinical importance, the recent success of RNA polymerase inhibitors highlights the dependence on "onco-ribosomes" as an Achilles' heel of cancer cells and a promising target for further therapeutic intervention.

Significance: The recent discovery of somatic mutations in ribosomal proteins in several cancers has strengthened the link between ribosome defects and cancer progression, while also raising the question of which cellular mechanisms such defects exploit. Here, we discuss the emerging molecular mechanisms by which ribosomes support oncogenesis, and how this understanding is driving the design of novel therapeutic strategies. Cancer Discov; 7(10); 1069–87. ©2017 AACR.

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Trastuzumab Biosimilar on Track for Approval [News in Brief]

An FDA expert panel recommended approval of Mylan's MYL-14010, a biosimilar candidate for Genentech's trastuzumab, putting it on track to become the first approved biosimilar for cancer. Experts predict that biosimilars will lead to lower drug prices, but caution that the savings won't be as dramatic as that seen with generics.

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First-Ever CAR T-cell Therapy Approved in U.S. [News in Brief]

The first chimeric antigen receptor T-cell therapy, tisagenlecleucel, received FDA approval for the treatment of patients up to 25 years of age with B-cell precursor acute lymphoblastic leukemia who haven't responded to standard therapy or who have relapsed at least twice.

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Z-endoxifen Is Active in Endocrine-Refractory Metastatic Breast Cancer [Clinical Trials]

The tamoxifen metabolite Z-endoxifen has acceptable tolerability and antitumor activity.

http://ift.tt/2wuhuJS

Noted [News in Brief]

A collection of recently published news items.

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VEGFR Inhibitor-Resistant Thyroid Cancer Responds to Cabozantinib [Clinical Trials]

Cabozantinib achieved partial responses in 40% of patients with differentiated thyroid cancer (DTC).

http://ift.tt/2wvfXmI

PON2 Promotes Glucose Uptake to Support PDAC Growth and Metastasis [Pancreatic Cancer]

PON2 promotes GLUT1-mediated glucose transport, is upregulated in PDAC, and is required for PDAC growth.

http://ift.tt/2xc9aOG

New bone formation and trabecular bone microarchitecture of highly porous tantalum compared to titanium implant threads: A pilot canine study

Abstract

Aim

This study evaluated new bone formation activities and trabecular bone microarchitecture within the highly porous region of Trabecular Metal™ Dental Implants (TM) and between the threads of Tapered Screw-Vent® Dental Implants (TSV) in fresh canine extraction sockets.

Materials and methods

Eight partially edentulated dogs received four implants (4.1 mmD × 13 mmL) bilaterally in mandibular fresh extraction sockets (32 TM, 32 TSV implants), and allowed to heal for 2, 4, 8, and 12 weeks. Calcein was administered to label mineralizing bone at 11 and 4 days before euthanasia for dogs undergoing all four healing periods. Biopsies taken at each time interval were examined histologically. Histomorphometric assay was conducted for 64 unstained and 64 stained slides at the region of interest (ROI) (6 mm long × 0.35 mm deep) in the midsections of the implants. Topographical and chemical analyses were also performed.

Results

Histomorphometry revealed significantly more new bone in the TM than in the TSV implants at each healing time (p = .0014, .0084, .0218, and .0251). Calcein-labeled data showed more newly mineralized bone in the TM group than in the TSV group at 2, 8, and 12 weeks (p = .045, .028, .002, respectively) but not at 4 weeks (p = .081). Histologically TM implants exhibited more bone growth and dominant new immature woven bone at an earlier time point than TSV implants. The parameters representing trabecular bone microarchitecture corroborated faster new bone formation in the TM implants when compared to the TSV implants. TM exhibited an irregular faceted topography compared to a relatively uniform microtextured surface for TSV. Chemical analysis showed peaks associated with each implant's composition material, and TSV also showed peaks reflecting the elements of the calcium phosphate blasting media.

Conclusions and clinical implications

Results suggest that the healing pathway associated with the highly porous midsection of TM dental implant could enable faster and stronger secondary implant stability than conventional osseointegration alone; however, prospective clinical studies are needed to confirm these potential benefits in patients with low bone density, compromised healing, or prior implant failure.

http://ift.tt/2xc0HuQ

Role of in-situ simulation for training in healthcare: opportunities and challenges.

Purpose of review: Simulation has now been acknowledged as an important part of training in healthcare, and most academic hospitals have a dedicated simulation center. In-situ simulation occurs in patient care units with scenarios involving healthcare professionals in their actual working environment. The purpose of this review is to describe the process of putting together the components of in-situ simulation for training programs and to review outcomes studied, and challenges with this approach. Recent findings: In-situ simulation has been used to 'test-drive' new centers, train personnel in new procedures in existing centers, for recertification training and to uncover latent threats in clinical care areas. It has also emerged as an attractive alternative to traditional simulations for institutions that do not have their own simulation center. Summary: In-situ simulation can be used to improve reliability and safety especially in areas of high risk, and in high-stress environments. It is also a reasonable and attractive alternative for programs that want to conduct interdisciplinary simulations for their trainees and faculty, and for those who do not have access to a fully functional simulation center. Further research needs to be done in assessing effectiveness of training using this method and the effect of such training on clinical outcomes. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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NonOperating Room Anesthesia: distancing from invasive surgery, embracing the era of interventional medicine.

No abstract available

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Recent advances of simulation in obstetric anesthesia.

Purpose of review: Simulation training in obstetric anesthesia has become widespread in recent years. Simulations are used to train staff and trainees, assess and improve team performance, and evaluate the work environment. This review summarizes current research in these categories. Recent findings: Simulation to improve individual technical skills has focused on induction of general anesthesia for emergent cesarean delivery, an infrequently encountered scenario by anesthesia trainees. Low- and high-fidelity simulation devices for the learning and practicing neuraxial and non-neuraxial procedures have been described, and both are equally effective. The use of checklists in obstetric emergencies has become common as and post-scenario debriefing techniques have improved. Although participant task performance improves, whether participants retain learned skills or whether simulation improves patient outcomes has not yet been established. Tools to assess teamwork during simulation have been developed, but none have been rigorously validated. In-situ vs. offsite simulations do not differ in effectiveness. Summary: Simulation allows for practice of tasks and teamwork in a controlled manner. There is little data whether simulation improves patient outcomes and metrics to predict the long-term retention of skills by simulation participants have not been developed. Copyright (C) 2017 YEAR Wolters Kluwer Health, Inc. All rights reserved.

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Correction to: Tripeptides Restore the Number of Neuronal Spines under Conditions of In Vitro Modeled Alzheimer’s Disease

Abstract

On the page 553 Acknowledgements should be as follows: The study was supported by the Russian Science Foundation (grant 14-25-00024-P).

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Correction to: Possibility of Aggravation of Tissue Sclerosis after Injection of Multipotent Mesenchymal Stromal Cells Near the Forming Cicatrix in the Experiment

Abstract

The author name G. A. Chastikina should read G. A. Chastikin.

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Targeting NSG Mice Engrafting Cells with a Clinically Applicable Lentiviral Vector Corrects Osteoclasts in Infantile Malignant Osteopetrosis

Human Gene Therapy , Vol. 0, No. 0.


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Gene Therapy with an Adeno-Associated Viral Vector Expressing Human Interleukin-2 Alters Immune System Homeostasis in Humanized Mice

Human Gene Therapy , Vol. 0, No. 0.


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ZP2 heterozygous mutation in an infertile woman

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Correction to: Comparison of neuropsychiatric symptoms and diffusion tensor imaging correlates among patients with subcortical ischemic vascular disease and Alzheimer’s disease

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Inhibiting PI3K{beta} with AZD8186 regulates key metabolic pathways in PTEN-null tumours

Purpose: PTEN null tumours become dependent on the PI3Kb isoform and can be targeted by molecules such as the selective PI3Kb inhibitor AZD8186. However beyond the modulation of the canonical PI3K pathway, the consequences of inhibiting PI3Kb are poorly defined. Experimental Design: To determine the broader impact of AZD8186 in PTEN null tumours we performed a genome wide RNAseq analysis of PTEN null triple negative breast tumour xenografts treated with AZD8186. Mechanistic consequences of AZD8186 treatment were examined across a number of PTEN null cell lines and tumour models. Results: AZD8186 treatment resulted in modification of transcript and protein biomarkers associated with cell metabolism. We observed down regulation of cholesterol biosynthesis genes and upregulation of markers associated with metabolic stress. Down regulation of cholesterol biosynthesis proteins such as HMGCS1 occurred in PTEN null cell lines and tumour xenografts sensitive to AZD8186. Therapeutic inhibition of PI3Kb also up-regulated PDHK4 and increased PDH phosphorylation, indicative of reduced carbon flux into the TCA cycle. Consistent with this metabolomic analysis revealed a number of changes in key carbon pathways, nucleotide and amino acid biosynthesis. Conclusions: This study identifies novel mechanistic biomarkers of PI3Kb inhibition in PTEN null tumours supporting the concept that targeting PI3Kb may exploit a metabolic dependency that contributes to therapeutic benefit in inducing cell stress. Considering these additional pathways will guide biomarker and combination strategies for this class of agents.

http://ift.tt/2xNv5jC

A complex network of tumor microenvironment in human high grade serous ovarian cancer

Purpose: Most high grade serous ovarian cancer (HGSOC) patients develop recurrent disease after first line treatment, frequently with fatal outcome. This work aims at studying the molecular biology of both primary and recurrent HGSOC. Experimental design: Gene expression profiles of matched primary and recurrent fresh frozen tumor tissues from 66 HGSOC patients were obtained by RNA sequencing. Clustering analyses and pairwise comparison of the profiles between matched samples and subsequent functional alignment were used for the identification of molecular characteristics of HGSOC. Results: Both primary and recurrent HGSOC samples presented predominant gene expression differences in their microenvironment, determined by a panel of genes covering all major pathways of immune activation together with a number of genes involved in the remodeling of extracellular matrix and adipose tissues. Stratifying tumor tissues into immune active and silent groups, we further discovered that while some recurrent tumors shared the same immune status as their primary counterparts, others switched the immune status, either from silent to active or active to silent. Interestingly, genes belonging to the B7-CD28 immune checkpoint family, known for their major role as negative regulators of the immune response, were overexpressed in the immune active tumors. Searching for potential tumor antigens, CEACAM21, a member of the carcinoembryonic antigen family, was found to be significantly overexpressed in immune active tissues in comparison to the silent ones. Conclusion: The results illustrate the complexity of the tumor microenvironment in HGSOC and reveal the molecular relationship between primary and recurrent tumors, which have multiple therapeutic implications.

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Pharmacogenetic analysis of the UK MRC MAGIC trial: association of polymorphisms with toxicity and survival in patients treated with perioperative ECF chemotherapy

Purpose: Germline polymorphisms may affect chemotherapy efficacy and toxicity. We examined the effect of polymorphisms in drug metabolism and DNA repair genes on pathological response rates, survival, and toxicity for patients randomised to surgery alone or perioperative ECF chemotherapy in the MRC MAGIC trial. Experimental design: DNA was extracted from non-tumor resection FFPE blocks. ERCC1, ERCC2, XRCC1, DYPD, and OPRT SNPs were evaluated using Sequenom, GSTP1, GSTT1 deletion and TYMS (TS) 5' 2R/3R using multiplex PCR. Post PCR amplification TS 2R/3R and GSTT1 samples underwent gel electrophoresis. Results: Polymorphism data was available for 289/456 (63.4%) operated patients. No polymorphism was statistically significantly associated with pathological response to chemotherapy. Median overall survival (OS) for patients treated with surgery alone with any TS genotype was not different (1.76 years 2R/2R, 1.68 years 2R/3R, 2.09 years 3R/3R). Median OS for patients with a TS 2R/2R genotype treated with chemotherapy was not reached, whereas median OS for 2R/3R and 3R/3R patients were 1.44 and 1.60 years respectively (log rank p value 0.0053). The p value for the interaction between treatment arm and genotype (3R/3R and 3R/2R vs 2R/2R) was 0.029. No polymorphism was statistically significantly associated with chemotherapy toxicity. Conclusions: In MAGIC, patients with a TS 2R/2R genotype appeared to derive a larger benefit from perioperative ECF chemotherapy than patients with 3R containing genotypes. Further exploration of this potential predictive biomarker in this patient population is warranted.

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Diversity of mosaic pbp2x families of penicillin-resistant Streptococcus pneumoniae from Iran and Romania [PublishAheadOfPrint]

High rates of penicillin-resistant Streptococcus pneumoniae occur in Romania and the Iran. The mosaic structure of PBP2x was investigated in nine Iranian strains and in 15 strains from Romania to understand their evolutionary history. Mutations potentially important for β-lactam resistance were identified by comparison with related PBP2x of penicillin-sensitive reference S. mitis strains. Two main PBP2x mosaic gene families were recognized. Eight Iranian strains belonged to group 1 PBP2x with a mosaic block highly related to PBP2x of the clone Spain^23F-1 which is widespread among international penicillin-resistant S. pneumoniae clones. A second unique PBP2x group was observed in Romanian strains; furthermore, three PBP2x represented single mosaic variants. Sequence blocks of the penicillin-sensitive S. mitis 658 were common among PBP2x of strains from both countries. Each PBP2x group contained specific signature mutations within the transpeptidase domain, documenting distinct mutational pathways for the development of penicillin resistance.

http://ift.tt/2fFXGfL

Neuroblastoma Patients' KIR and KIR-ligand Genotypes Influence Clinical Outcome for Dinutuximab-based Immunotherapy: A Report from the Children's Oncology Group

Purpose: In 2010, a Children's Oncology Group (COG) phase III randomized trial for high-risk neuroblastoma patients (ANBL0032) demonstrated improved event-free survival (EFS) and overall survival (OS) following treatment with an immunotherapy regimen of dinutuximab, GM-CSF, IL-2, and isotretinoin compared to treatment with isotretinoin alone. Dinutuximab, a chimeric anti-GD2 monoclonal antibody, acts in part via NK cells. Killer Immunoglobulin-like Receptors (KIRs) on NK cells and their interactions with KIR-ligands can influence NK cell function. We investigated whether KIR/KIR-ligand genotypes were associated with EFS or OS in this trial. Experimental Design: We genotyped patients from COG study, ANBL0032, and evaluated the effect of KIR/KIR-ligand genotypes on clinical outcomes. Cox regression models and log-rank tests were used to evaluate associations of EFS and OS with KIR/KIR-ligand genotypes. Results: In this trial, patients with the "all KIR-ligands present" genotype, as well as patients with inhibitory KIR2DL2 with its ligand (HLA-C1) together with inhibitory KIR3DL1 with its ligand (HLA-Bw4) were associated with improved outcome if they received immunotherapy. In contrast, for patients with the complementary KIR/KIR-ligand genotypes, clinical outcome was not significantly different for patients that received immunotherapy vs. those receiving isotretinoin alone. Conclusions: These data show that administration of immunotherapy is associated with improved outcome for neuroblastoma patients with certain KIR/KIR-ligand genotypes, while this was not seen for patients with other KIR/KIR-ligand genotypes. Further investigation of KIR/KIR-ligand genotypes may clarify their role in cancer-immunotherapy, and may enable KIR/KIR-ligand genotyping to be utilized prospectively for identifying patients likely to benefit from certain cancer immunotherapy regimens.

http://ift.tt/2g658RV

Pharmacokinetic Interactions between Simeprevir and Ledipasvir in Treatment-naïve Hepatitis C virus Genotype 1-infected Patients without Cirrhosis Treated with a Simeprevir/Sofosbuvir/Ledipasvir Regimen [PublishAheadOfPrint]

Interactions between simeprevir (hepatitis C virus [HCV] NS3/4A protease inhibitor) and ledipasvir (HCV NS5A replication complex inhibitor) were investigated in treatment-naïve HCV genotype 1-infected patients without cirrhosis, treated with simeprevir/sofosbuvir/ledipasvir in a two-panel, Phase 2, open-label study (NCT02421211). Patients had stable background treatment with sofosbuvir (400 mg once daily [QD]). In Panel 1 (N=20), the effect of ledipasvir (90 mg QD) on simeprevir (150 mg QD) was studied. Patients received simeprevir and sofosbuvir from Days 1--14; steady-state pharmacokinetics (PK) of simeprevir were assessed (Day 14). On Day 15, ledipasvir was added and steady-state PK of simeprevir in the combination was evaluated (Day 28). In Panel 2 (N=20), the effect of simeprevir on ledipasvir was investigated. From Days 1--14, patients received ledipasvir and sofosbuvir and steady-state PK of ledipasvir was assessed (Day 14). On Day 15, simeprevir was added and a full PK profile was obtained (Day 28). The least squares mean maximum plasma concentration and area under the concentration--time curve (90% confidence interval) increased 2.3- (2.0-2.8) and 3.1- (2.4-3.8) fold for simeprevir, respectively, (Panel 1); and 1.6- (1.4-1.9) and 1.7- (1.6-2.0) fold for ledipasvir, respectively (Panel 2), in the presence versus the absence of the other drug. All patients achieved sustained virologic response 12 weeks after treatment end. Adverse events, mainly Grade 1/2, occurred in 80% of patients; the most common was photosensitivity (45%). Due to the magnitude of interaction and the limited amount of safety data available, the use of this treatment combination is not recommended.

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Risk factors that influence the empirical treatment of patients with acute pyelonephritis: a cohort study. [PublishAheadOfPrint]

Objectives. The aim of the current study is to compare community-acquired acute pyelonephritis (CA-APN) with healthcare-associated acute pyelonephritis (HCA-APN), describe outcomes and identify variables that could predict antimicrobial susceptibility.

Methods. We conducted an observational study that included all consecutive episodes of acute pyelonephritis (APN) in adults during 2014 at a Spanish university-hospital. From each episode demographic data, co-morbidities, clinical presentation, microbiological data, antimicrobial therapy, and outcome were recorded. A multivariable logistic regression model was performed to define variables associated to antimicrobial resistance.

Results. 607 patients were included in the study, 506 (83.4%) CA-APN and 101 (16.6%) HCA-APN. Patients with HCA-APN were older (70.4 vs. 50.6 y; p<0.001), had higher rates of previous urinary tract infections (UTI) (56.5% vs. 24.5%; p<0.001) and previous antibiotic use (56.8% vs. 22.8%; p<0.001). Escherichia coli was more frequently isolated in CA-APN than in HCA-APN (79.9% vs. 50.5%; p<0.001). Resistance rates of E. coli in CA-APN vs. HCA-APN were: amoxicillin-clavulanic acid (22.4% vs. 53.2%, p=0.001), cefuroxime (7.7% vs. 43.5%, p=0.001), ceftriaxone (4.3% vs. 32.6%, p<0.001), ciprofloxacin (22.8% vs. 74.5%, p<0.001), and cotrimoxazole (34.5% vs. 58.7%, p=0.003). Site of acquisition, recurrent UTI and previous antibiotic use were independent risk factors for antimicrobial resistance. Relapse rates were significantly higher when definitive antimicrobial treatment was not adequate (37.1% vs. 9.3%; p<0.001).

Conclusions. Our study reflects the rise of resistance to common used antibiotics in acute pyelonephritis. In order to choose the adequate empirical antibiotic therapy risk factors for resistance should be considered.

http://ift.tt/2fFBnqy

New Delhi metallo-{beta}-lactamase-1 catalyses avibactam and aztreonam hydrolysis [PublishAheadOfPrint]

Metallo-β-lactamases (MBLs) threaten the clinical utility of β-lactam antibiotics by hydrolysing penicillins, cephalosporins, and carbapenems....

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In Vitro Activity of the Novel Lactone Ketolide Nafithromycin (WCK 4873) When Tested against Contemporary Clinical Bacteria from a Global Surveillance Program [PublishAheadOfPrint]

Nafithromycin (WCK 4873), a novel antimicrobial agent of the lactone ketolide class, is currently in Phase 2 development for treatment of community-acquired bacterial pneumonia (CABP): A total of 4,739 non-duplicate isolates were selected from a 2014 global surveillance program from medical institutions located in 43 countries within the United States, Europe, Latin America, and Asia-Pacific. Nafithromycin and comparator agents were susceptibility tested by reference broth microdilution methods. Nafithromycin was active against Staphylococcus aureus (MIC_50/90, 0.06/>2 μg/mL), including erythromycin-resistant strains exhibiting an inducible clindamycin-resistance phenotype (MIC_50/90, 0.06/0.06 μg/mL) and telithromycin-susceptible strains (MIC_50/90, 0.06/0.06 μg/mL), but exhibited limited activity against most telithromycin-resistant and clindamycin-resistant isolates that were constitutively resistant to macrolides (MIC_50/90, >2/>2 μg/mL). Nafithromycin was very active (MIC_50/90, 0.015/0.06 μg/mL) against 1,911 Streptococcus pneumoniae, inhibiting all strains at MIC values ≤0.25 μg/mL. Telithromycin susceptibility was 99.9% against Streptococcus pneumoniae, and nafithromycin was up to 8-fold more potent than telithromycin. Overall, 37.9% of S. pneumoniae were resistant to erythromycin and 19.7% were resistant to clindamycin. Nafithromycin was highly active against 606 Streptococcus pyogenes (MIC_50/90, 0.015/0.015 μg/mL), inhibiting 100.0% of isolates at ≤0.5 μg/mL, and MIC_50/90 values (0.015/0.015-0.03 μg/mL) were similar for each of the 4 geographic regions. Nafithromycin and telithromycin demonstrated comparable in vitro activity against 1,002 Haemophilus influenzae isolates and 504 Moraxaxella catarrhalis. Overall, nafithromycin showed potent in vitro activity against a broad range of contemporary (2014) global pathogens. These results support the continued clinical development of nafithromycin for CABP.

http://ift.tt/2xbxmWa

Modified penicillin molecule with carbapenem-like stereochemistry specifically inhibits Class C {beta}-lactamases [PublishAheadOfPrint]

Bacterial β-lactamases readily inactivate most penicillins and cephalosporins by hydrolyzing and "opening" their signature β-lactam ring. In contrast, carbapenems resist hydrolysis by many serine-based Class A, C and D β-lactamases due to their unique stereochemical features. To improve the resistance profile of penicillins, we synthesized a modified penicillin molecule MPC-1 by "grafting" carbapenem-like stereochemistry onto the penicillin core. Chemical modifications include the trans conformation of hydrogen atoms at C5 and C6 instead of cis, and a 6-α hydroxyethyl moiety to replace the original 6-β aminoacyl group. MPC-1 selectively inhibits Class C β-lactamase such as P99 by forming a non-hydrolyzable acyl adduct and its inhibitory potency is ~2-5 times higher than that for clinically used β-lactamase inhibitors clavulanate and sulbactam. Crystal structure of MPC-1 forming acyl adduct with P99 reveals a novel binding mode for MPC-1 that resembles carbapenem bound in the active site of Class A β-lactamase. Furthermore, in this novel binding mode, the carboxyl group of MPC-1 blocks the deacylation reaction by occluding the critical catalytic water molecule and renders the acyl adduct non-hydrolyzable. Our results suggest that, by incorporating carbapenem-like stereochemistry, the current collection of over 100 penicillins and cephalosporins can be modified into candidate compounds for development of novel β-lactamase inhibitors.

http://ift.tt/2fGavqw

Role of alanine racemase mutations in Mycobacterium tuberculosis D-cycloserine resistance [PublishAheadOfPrint]

Screening of more than 1,500 drug-resistant strains of Mycobacterium tuberculosis revealed evolutionary patterns characteristic of positive selection for three alanine racemase (Alr) mutations. We investigated these mutations using molecular modeling, in vitro MIC testing, as well as direct measurements of enzymatic activity, which demonstrated that these mutations likely confer resistance to D-cycloserine.

http://ift.tt/2fGLdZq

ABCI3, a new mitochondrial ABC transporter from Leishmania major involved in susceptibility to antimonials and infectivity [PublishAheadOfPrint]

We have identified and characterized ABCI3 as a new mitochondrial ABC transporter from Leishmania major. Localization studies using confocal microscope, surface biotinylation assay and trypsin digestion after digitonin permeabilization suggested that ABCI3 presents a dual localization in both mitochondria and plasma membrane. Using single-knock out parasites for ABCI3 (ABCI3^+/-), we provided evidence that ABCI3 is directly involved in Sb^III and metal ions susceptibility. Attempts to obtain double knock-out parasites for ABCI3 were unsuccessful, suggesting that ABCI3 could be an essential gene in L. major. ABCI3^+/- promastigotes were 5-fold more resistant to Sb^III, while ABCI3^+/- amastigotes were approximately 2-fold more resistant to Sb^V. This resistant phenotype was associated with a decreased Sb^III accumulation due to a decreased Sb^III uptake. ABCI3^+/- parasites presented higher ATP levels and generated less mitochondrial superoxide after Sb^III incubation. Finally, we have observed that ABCI3^+/- parasites showed a slightly higher infection capacity than wild-type and add-back ABCI3^+/-:3xFABCI3 parasites; however, after 72 h the number of ABC3^+/- intracellular parasites per macrophage increased significantly. Our results show that ABCI3 is responsible for Sb^III transport inside mitochondria, where it would contribute to enhance the general toxic effects caused by Sb^III. To our knowledge, ABCI3 is the first ABC transporter which is involved in susceptibility towards antimony, conferring Sb^III resistance to parasites when partially deleted.

http://ift.tt/2xbxm8C

Risk Factors for Colonization or Infection with Carbapenem-Resistant Enterobacteriaceae in Children: a Multicenter Study [PublishAheadOfPrint]

Carbapenem-resistant Enterobacteriaceae (CRE) are increasingly identified in children in the United States, but data on the epidemiology of CRE in this population are limited. The objectives of this study were to characterize risk factors for colonization or infection with CRE and describe the microbiologic characteristics of pediatric CRE isolates. We performed a multicenter matched case-control study from January 2011 to October 2015 at three tertiary care pediatric centers. Case patients were hospitalized children with CRE isolated from clinical cultures and were matched in a 2:1 ratio to control patients with carbapenem-susceptible Enterobacteriaceae (CSE). Risk factors for colonization or infection with CRE were then evaluated using multivariable conditional logistic regression. Additionally, we comprehensively reported the antimicrobial susceptibility pattern for CRE isolates. Sixty-three case patients were identified and matched to 126 control patients. On multivariable analysis, anti-pseudomonal antibiotic exposure within the previous 3 months (odds ratio [OR], 5.20; 95% confidence interval [CI], 1.71-15.9, P=0.004), prior surgery (OR, 6.30; 95% CI, 1.83-21.6, P=0.003), and mechanical ventilation (OR, 12.4; 95% CI, 1.26-122, P=0.031) were identified as risk factors for colonization or infection with CRE. Pediatric CRE isolates demonstrated relatively low rates of resistance to amikacin (5%) and ciprofloxacin (25%). Our findings support an important role for antibiotic stewardship interventions limiting the unnecessary use of anti-pseudomonal antibiotics as a strategy to prevent widespread emergence of CRE in children. Future studies should further characterize molecular determinants of antibiotic resistance among pediatric CRE isolates.

http://ift.tt/2xblwLC

Kinetics of sulbactam hydrolysis by {beta}-lactamases, and their inhibition [PublishAheadOfPrint]

Sulbactam is one of 4 β-lactamase inhibitors in current clinical use to counteract drug resistance caused by degradation of β-lactam antibiotics by these bacterial enzymes. As a β-lactam itself, sulbactam is susceptible to degradation by β-lactamases. We investigated the Michaelis-Menten kinetics of sulbactam hydrolysis by 14 β-lactamases representing clinically widespread groups within all 4 Ambler classes: CTX-M-15, KPC-2, SHV-5, and TEM-1 for class A; IMP-1, NDM-1, and VIM-1 for class B; Acinetobacter baumannii ADC-7, Pseudomonas aeruginosa AmpC and Enterobacter cloacae P99 for class C; and OXA-10, OXA-23, OXA-24, and OXA-48 for class D. All of the β-lactamases were able to hydrolyze sulbactam, although they varied widely in their kinetic constants for the reaction, even within each class. We also investigated the inactivation kinetics of inhibition of these enzymes by sulbactam. The class A β-lactamases varied widely in their susceptibility to inhibition, the class C and D enzymes were very weakly inhibited, and the class B enzymes were essentially or completely unaffected. In addition, we measured the sulbactam turnover number, the sulbactam:enzyme molar ratio required for complete inhibition of each enzyme. Class C enzymes had the lowest turnover numbers, class A enzymes varied widely, and class D enzymes had very high turnover numbers. These results are valuable for understanding which β-lactamases ought to be well-inhibited by sulbactam. Moreover, since sulbactam has intrinsic antibacterial activity against Acinetobacter species pathogens, these results contribute to understanding β-lactamase-mediated sulbactam resistance in Acinetobacter, especially due to the action of the widespread class D enzymes.

http://ift.tt/2fFBliq

Concentration and variety of carbapenemase producers in recreational coastal waters showing distinct levels of pollution [PublishAheadOfPrint]

Carbapenemase-producing bacteria cause difficult-to-treat infections related to increased mortality in healthcare settings. Their occurrence has been reported in raw sewage, sewage-impacted rivers, and polluted coastal waters, which may indicate their spread to the community. We assessed variety and concentration of carbapenemase producers in coastal waters with distinct pollution levels during one year. We describe a variety of bacterial species producing distinct carbapenemases, not only in unsuitable, but also in waters considered suitable for primary contact.

http://ift.tt/2xcnXO8

The gastrointestinal tract is a major source of echinocandin drug resistance in a murine model of Candida glabrata colonization and systemic dissemination [PublishAheadOfPrint]

Candida species are a part of the human microbiome and can cause systemic infection upon immune suppression. C. glabrata infections are increasing and have greater rates of antifungal resistance compared to other species. Here, we present a C. glabrata gastrointestinal (GI) colonization model to explore whether colonized yeast exposed to caspofungin, an echinocandin antifungal, develop characteristic resistance mutations, and upon immunosuppression, breakthrough causing systemic infection. Daily therapeutic dosing (5 mg/kg) of caspofungin resulted in no reduction in fecal burdens, organ breakthrough rates similar to control groups, and resistance rates (0-10%) similar to those reported clinically. Treatment with 20 mg/kg caspofungin initially reduced burdens, but a rebound following 5-9 days of treatment was accompanied by high levels of resistance (FKS1/2 mutants). Although breakthrough rates decreased in this group, the same FKS mutants were recovered from organs. In an attempt to negate drug tolerance critical for resistance development, we co-treated mice with daily caspofungin and the chitin synthase inhibitor nikkomycin Z. The largest reduction (3-log) in GI burdens was obtained within 3-5 days of 20 mg/kg caspofungin plus nikkomycin treatment. Yet, echinocandin resistance, characterized by a novel Fks1-L630R substitution, was identified following 5-7 days of treatment. Therapeutic caspofungin plus nikkomycin treatment left GI burdens unchanged, but significantly reduced organ breakthrough rates (20%; p<0.05). Single dose pharmacokinetics demonstrated low levels of drug penetration into the GI lumen post caspofungin treatment. Overall, we show that C. glabrata echinocandin resistance can arise within the GI tract and that resistant mutants can readily disseminate upon immunosuppression.

http://ift.tt/2fFjLen

Pharmacokinetic properties of micafungin in critically ill patients diagnosed with invasive candidiasis [PublishAheadOfPrint]

Background: The estimated attributable mortality rate for invasive candidiasis (IC) in the Intensive Care Unit (ICU) setting varies from 30-40%. Physiological changes in critically ill patients may affect the distribution and elimination of micafungin and therefore dosing adjustments might be mandatory. Objective: To determine the pharmacokinetic parameters of micafungin in critically ill patients and assess the probability of target attainment (PTA). Methods: Micafungin plasma concentrations were measured to estimate the pharmacokinetic properties of micafungin. MIC values were determined for Candida isolates to assess the PTA for the patients. Results: Data from 19 patients with suspected or proven invasive candidiasis were available for analysis. The median (IQR) AUC_0-24h was 89.6 mg*h/L (75.4-113.6); this was significantly lower than the median (IQR) micafungin AUC_0-24h 152.0 mg*h/L (136.0-162.0) and 134.0 mg*h/L (118.0-148.6) in healthy volunteers (P = <0.0001 and P = <0.001, respectively). All Candida isolates were susceptible to micafungin with a median (IQR) MIC of 0.016 mg/L (0.012-0.023). The median (IQR) AUC_0-24h/MIC ratio was 5684 (4325-7578) and three of the 17 evaluable patients (17.6%) diagnosed with proven invasive candidiasis did not meet the AUC/MIC target of 5000. Conclusions: The micafungin exposure was lower in critically ill patients than in healthy volunteers. The variability in micafungin exposure in this ICU population could be explained by the patient's bodyweight. Our findings suggest that healthier patients (SOFA score <10) weighing more than 100 kg and receiving 100 mg micafungin daily are at risk for inappropriate micafungin exposure and potentially inadequate antifungal treatment.

http://ift.tt/2xaL6jL

Functional characterization of CTX-M-14 and CTX-M-15 {beta}-lactamase by in vitro DNA shuffling [PublishAheadOfPrint]

This work investigated the molecular events driving the evolution of the CTX-M-type β-lactamases by DNA shuffling of fragments of the bla_CTX-M-14 and bla_CTX-M-15 genes. Analysis of a total of 51 hybrid enzymes showed that enzymatic activity could be maintained in most cases, yet active hybrids possessed fewer amino acid substitutions than those that were inactive, suggesting that point mutations in the constructs, rather than re-shuffling fragments of the two target genes, would more likely cause disruption of CTX-M activity. For example, the P⁶⁷L and L²⁶¹P changes in a CTX-M-14 fragment could completely abolish the activity of the enzyme on all antibiotics tested. Structural analysis showed that L²¹⁶ was located in the active site β sheet, and might interact with the adjacent hydrophobic residues to stabilize the active site β sheet and maintain the integrity of the enzyme active site. Likewise, a single amino acid substitution E⁶⁴K was found to exhibit significant suppressive effect on CTX-M-15 activity. Structural analysis showed that E⁶⁴ might form a salt bridge with R⁴⁴, disruption of which might affect CTX-M-15 activity. Further analysis of the structure/function relationship of a range of mutant enzymes confirmed that, as can be expected, unstable enzymes lose their activity and avoid selective events. These findings suggest that the distal pockets could also contribute to the activity of the enzymes and may be regarded as alternative targets for inhibitor development.

http://ift.tt/2fGLHhY

Immunohistochemical investigations of treatment with Ro 13-3978, praziquantel, oxamniquine and mefloquine in Schistosoma mansoni-infected mice [PublishAheadOfPrint]

To date there is only one drug in use, praziquantel, to treat more than 250 million people afflicted with schistosomiasis, a debilitating parasitic disease. The aryl hydantoin Ro 13-3978 is a promising drug candidate with superior in vivo activity to praziquantel against both adult and juvenile Schistosoma mansoni. Given the drugs' contrasting low activity in vitro, and the timing of its onset of action in vivo, it was postulated that immune-assisted parasite clearance could contribute to the drug's in vivo activity. We undertook histopathological studies to investigate this hypothesis. Infected mice were treated with an effective dose of Ro 13-3978 (100 mg/kg) and were dissected before and after the drugs in vivo onset of action. The veins and livers were excised, paraffin-embedded, sectioned and macrophages (IBA-1), neutrophils (Neutro), B-cells (CD45R) and T-cells (CD3) were stained by immunohistochemistry. For comparison, samples from infected-untreated mice and mice treated with effective doses of praziquantel (400 mg/kg), oxamniquine (200 mg/kg) and mefloquine (100 mg/kg) were examined. At 24 h after treatment with Ro 13-3978, significant macrophage recruitment to the veins was observed, along with a modest increase in circulating B cells and at 48 h, neutrophils and T cells are also present. Treatment with praziquantel and oxamniquine showed a similar pattern of recruitment but with comparatively higher cellular levels, whereas mefloquine treatment resulted in minimal cell recruitment until 3 d post-treatment. Our study sheds light on the immediate immune responses to antischistosomal treatment in mice and provides further insight into immune effector mechanisms of schistosome clearance.

http://ift.tt/2xcOfj4

Sustained ex vivo susceptibility of Plasmodium falciparum to artemisinin derivatives but increasing tolerance to ACT partner quinolines in The Gambia [PublishAheadOfPrint]

Antimalarial interventions have yielded significant decline in malaria prevalence in The Gambia, where Artemether-Lumefantrine (AL) has been used as first line antimalarial for a decade. Clinical Plasmodium falciparum isolates collected from 2012 to 2015 were analysed ex vivo for antimalarial susceptibility and genotyped for drug resistance markers (pfcrt K76T, pfmdr1-86-184 and 1246 and pfk13) and microsatellite variation. Additionally, allele frequencies of SNPs from other drug resistance-associated genes were compared from genomic sequence datasets from 2008 (n=79) and 2014 (n=168). No artemisinin resistance associated pfk13 mutation was found and only 4% of isolates tested in 2015 showed significant growth after exposure to dihydroartemisinin. Conversely, the IC₅₀ concentrations of Amodiaquine and Lumefantrine increased within this period. pfcrt 76T and pfmdr1 184F mutants remained above 80%. pfcrt 76T was positively associated with higher IC₅₀ values to chloroquine. pfmdr1 NYD increased in frequency between 2012 and 2015 due to Lumefantrine selection. The TNYD (pfcrt 76T and pfmdr1 NYD wild type haplotype) also increased in frequency following AL implementation in 2008. These results suggest selection for pfcrt and pfmdr1 genotypes that enable tolerance to Lumefantrine. Increased tolerance to Lumefantrine calls for sustained chemotherapeutic monitoring in The Gambia to minimise complete ACT failure in the future.

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Novel immunologic mechanisms in eosinophilic esophagitis

Julie M Caldwell | Misu Paul | Marc E Rothenberg

http://ift.tt/2fMy0BU

Urinary biomarker CXCL10, identifying site specific allograft inflammation in renal transplantation.

No abstract available

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Altered Th17 pathway in tolerant kidney transplant patients: a 'chicken-or-the-egg' dilemma?.

No abstract available

http://ift.tt/2hHiIPi

Long-term effects of pancreas transplantation on diabetic retinopathy and incidence and predictive risk factors for early worsening.

Background: Limited data are available regarding the long-term effects of pancreas transplantation on the progression of diabetic retinopathy (DR) and the incidence of and associated risk factors for early worsening of DR. Methods: Patients who underwent successful pancreas transplantation between January 2007 and October 2015 and were followed for >= 1 year were consecutively enrolled. Variables regarding demographic, systemic, metabolic, and surgical factors were reviewed for each patient. DR progression was defined as i) development or aggravation of macular edema requiring intravitreal injections and/or ii) progression of DR severity requiring panretinal photocoagulation (PRP) and/or pars planar vitrectomy (PPV). Early worsening was defined as progression within 1 year of posttransplant. Results: Three hundred and 3 eyes of 153 patients were included in the analysis. At the pretransplant ocular evaluation, 221 eyes (72.9 %) showed advanced DR with history of PRP and/or PPV. During a mean follow-up period of 4.2 years, 62 eyes (20.5%) experienced DR progression, and early worsening was noted in 57 eyes (18.8%). DR with recent PRP within pretransplant 1 year and pancreas transplant alone were significant risk factors for early worsening. Conclusions: In 4 out 5 patients who received pancreas transplant, the degree of DR remained stable over time after transplantation. Meanwhile, early worsening of DR could occur in patients at risk, particularly within the first posttransplant year. We suggest that physicians should have a high index of suspicion and carefully monitor for early worsening of DR, and timely manage possible ocular deterioration. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Marked decrease in urgent listing for liver transplantation over time: evolution of characteristics and outcomes of Status-1 liver transplantation.

Background: Approximately 5% of liver transplants annually are performed urgently with "status-1" designation. This study aims to determine if the demand, characteristics and outcome for status-1 liver transplantation has changed over time. Methods: We utilized the Scientific Registry of Transplant Patients (2003-2015) to characterize 2352 adult patients who underwent 2408 status-1 liver transplants and compared them between Era1 (2003-6/2009) and Era2 (7/2009 -2015). Results: Overall, there were fewer liver transplants performed with the Status-1 designation in Era2 than Era1 (1099 vs 1309). Although the number of urgent liver transplants was relatively constant with successive years, the proportion transplanted with Status-1 designation decreased markedly over time. Era2 patients were older (43.2 vs 41.7 years, p=0.01) and less likely be ABO-incompatible (1.1% vs 2.4%, p=0.01) or re-transplant (77 vs 124, p=0.03). In terms of disease etiology, the largest group was "ALF, nonspecified" (43.4%). There was no difference in proportion with drug-induced liver injury (DILI), but the subset of herbal/dietary supplements increased in Era2 (1.3% vs 0.46 %, p=0.04). Survival was increased in Era2 in the overall cohort and for patients with autoimmune disease (p

http://ift.tt/2hHiJmk

Role of human CD200 overexpression in pig-to-human xenogeneic immune response compared with human CD47 overexpression.

Background: Macrophages play important roles in xenograft rejection. Here, we investigated whether overexpression of human CD200 or CD47 in porcine endothelial cells (PEC) can suppress macrophages activation in xenogeneic immune responses. Methods: PECs and human macrophages were incubated together, harvested and analyzed for in vitro macrophage phagocytic and cytotoxicity activity, and cytokine release. Next, PEC were injected into renal subcapsular space of humanized mice. On day 10 posttransplantation, we analyzed xenograft survival and perigraft inflammatory cell infiltrations in PEC-to-humanized mouse transplantation. Results: PECs highly expressing human CD200, CD47, or both CD47/CD200 were established by lentiviral vector transduction. Both CD200 and CD47 suppressed in vitro macrophage phagocytic and cytotoxic activity against PECs; decreased TNF-[alpha], IL-1[beta], and IL-6 secretion; and increased IL-10 secretion. However, simultaneous overexpression of CD200 and CD47 did not show additive effects. Next, PECs were transplanted into NSG mice, and human monocytes and lymphocytes were adoptively transferred 1 day after xenotransplantation. PEC xenograft cell death and apoptosis were decreased in the CD200-PEC and CD47/CD200-PEC groups. Perigraft infiltration of human T cells was suppressed by CD47; CD200 suppressed infiltration of human macrophages to a greater extent than CD47; and the CD47/CD200-PEC group exhibited the lowest level of leukocyte infiltration. In summary, overexpression of CD200 in PECs suppressed xenogeneic activation of human macrophages and improved survival of PEC xenografts in humanized mice; however, co-expression of CD200 and CD47 did not show additive effects. Conclusions: Therefore, overexpression of human CD200 in donor pigs could constitute a promising strategy for overcoming xenograft rejection. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Coexistence of Bilirubin >=10 mg/dL and Prothrombin Time-International Normalized Ratio >=1.6 on Day 7: A Strong Predictor of Early Graft Loss after Living Donor Liver Transplantation.

Background: Early allograft dysfunction (EAD) defined by serum total bilirubin (TB) >=10 mg/dL or prothrombin time-international normalized ratio (PT-INR) >=1.6 on postoperative day 7 (POD7) or aminotransferase >2000 IU/L within the first week, is associated with early graft loss after deceased-donor liver transplantation. We aimed to determine the prognostic impact of the EAD definition in living-donor liver transplantation (LDLT). Methods: We analyzed the validity of the EAD definition and its impact on early graft survival in 260 adult recipients who underwent primary LDLT. Results: Eighty-four (32.3%) patients met the EAD criteria; 59 (22.7%) and 46 (17.7%) patients had TB >=10 mg/dL and PT-INR >=1.6 on POD7, respectively, and 22 (8.5%) patients satisfied both criteria. Graft survival differed significantly when stratified according to TB >=10 mg/dL and PT-INR >=1.6 (p=1.6 resulted in higher graft mortality (RR=3.87, p<.0001 at rr="2.97," p as did tb>=10 mg/dL (RR=1.89, p=0.027 at 90-day; RR=1.91, p=0.006 at 180-day). Coexistence of TB >=10 mg/dL and PT-INR >=1.6 was strongly associated with early graft loss (59.1%, RR=6.97 at 90-day; 68.2%, RR=5.75 at 180-day). In Cox regression analysis, PT-INR >=1.6 and TB >=10 mg/dL on POD7 were significant risk factors for early graft loss (hazard ratio =4.10 [95% CI: 2.35-7.18], p=10 mg/dL and/or PT-INR >=1.6 on POD7 predicted early graft loss after LDLT, and their coexistence worsened patient outcomes. Copyright (C) 2017 Wolters Kluwer Health, Inc. All rights reserved.

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Clinical and molecular characteristics, risk factors and outcomes of Carbapenem-resistant Klebsiella pneumoniae bloodstream infections in the intensive care unit

To analyze the clinical characteristics and outcomes of carbapenem-resistant Klebsiella pneumoniae (CRKp) and carbapenem-susceptible K. pneumoniae (CSKp) bloodstream infections (BSIs), and to study the risk facto...

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Implementation of central line-associated bloodstream infection prevention bundles in a surgical intensive care unit using peer tutoring

Central line-associated bloodstream infections (CLABSIs) can be prevented through well-coordinated, multifaceted programs. However, implementation of CLABSI prevention programs requires individualized strategi...

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The Norwegian patient experiences with GP questionnaire (PEQ-GP): reliability and construct validity following a national survey

Objectives

The aim of this study was to test the reliability and validity of a new questionnaire for measuring patient experiences with general practitioners (PEQ-GP) following a national survey.

Setting

Postal survey among patients on any of 500 GPs patient lists in Norway. GPs were stratified by practice size and geographical criteria.

Participants

4964 patients who had at least one consultation with their regular GP in the foregoing 12 months were included in the study. The patients were randomly selected after the selection of GPs. 2377 patients (49%) responded to the survey.

Primary and secondary outcome measures

The items were assessed for missing data and ceiling effects. Factor structure was assessed using exploratory factor analyses. Reliability was tested with item–total correlation, Cronbach's alpha and test–retest correlations. Item discriminant validity was tested by correlating items with all scales. Construct validity was assessed through associations of scale scores with health status, the patients' general satisfaction with the services, whether the patient had been incorrectly treated by the GP and whether the patient would recommend the GP to others.

Results

Item missing varied from 1.0% to 3.1%, while ceiling effects varied from 16.1% to 45.9%. The factor analyses identified three factors. Reliability statistics for scales based on these three factors, and two theoretically derived scales, showed item–total correlations ranging from 0.63 to 0.85 and Cronbach's alpha values from 0.77 to 0.93. Test–retest correlation for the five scales varied from 0.72 to 0.88. All scales had the expected association with other variables.

Conclusions

The PEQ-GP has good evidence for data quality, internal consistency and construct validity. The PEQ-GP is recommended for use in local, regional and national surveys in Norway, but further studies are needed to assess the instrument's ability to detect differences over time and between different GPs.

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Preoperative next-generation sequencing of pancreatic cyst fluid is highly accurate in cyst classification and detection of advanced neoplasia

Objective

DNA-based testing of pancreatic cyst fluid (PCF) is a useful adjunct to the evaluation of pancreatic cysts (PCs). Mutations in KRAS/GNAS are highly specific for intraductal papillary mucinous neoplasms (IPMNs) and mucinous cystic neoplasms (MCNs), while TP53/PIK3CA/PTEN alterations are associated with advanced neoplasia. A prospective study was performed to evaluate preoperative PCF DNA testing.

Design

Over 43-months, 626 PCF specimens from 595 patients were obtained by endoscopic ultrasound (EUS)-fine needle aspiration and assessed by targeted next-generation sequencing (NGS). Molecular results were correlated with EUS findings, ancillary studies and follow-up. A separate cohort of 159 PCF specimens was also evaluated for KRAS/GNAS mutations by Sanger sequencing.

Results

KRAS/GNAS mutations were identified in 308 (49%) PCs, while alterations in TP53/PIK3CA/PTEN were present in 35 (6%) cases. Based on 102 (17%) patients with surgical follow-up, KRAS/GNAS mutations were detected in 56 (100%) IPMNs and 3 (30%) MCNs, and associated with 89% sensitivity and 100% specificity for a mucinous PC. In comparison, KRAS/GNAS mutations by Sanger sequencing had a 65% sensitivity and 100% specificity. By NGS, the combination of KRAS/GNAS mutations and alterations in TP53/PIK3CA/PTEN had an 89% sensitivity and 100% specificity for advanced neoplasia. Ductal dilatation, a mural nodule and malignant cytopathology had lower sensitivities (42%, 32% and 32%, respectively) and specificities (74%, 94% and 98%, respectively).

Conclusions

In contrast to Sanger sequencing, preoperative NGS of PCF for KRAS/GNAS mutations is highly sensitive for IPMNs and specific for mucinous PCs. In addition, the combination of TP53/PIK3CA/PTEN alterations is a useful preoperative marker for advanced neoplasia.

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A comparison of the resection rate for cold and hot snare polypectomy for 4-9 mm colorectal polyps: a multicentre randomised controlled trial (CRESCENT study)

Objective

To investigate the success rate of cold snare polypectomy (CSP) for complete resection of 4–9 mm colorectal adenomatous polyps compared with that of hot snare polypectomy (HSP).

Design

A prospective, multicentre, randomised controlled, parallel, non-inferiority trial conducted in 12 Japanese endoscopy units. Endoscopically diagnosed sessile adenomatous polyps, 4–9 mm in size, were randomly assigned to the CSP or HSP group. After complete removal of the polyp using the allocated technique, biopsy specimens from the resection margin after polypectomy were obtained. The primary endpoint was the complete resection rate, defined as no evidence of adenomatous tissue in the biopsied specimens, among all pathologically confirmed adenomatous polyps.

Results

A total of 796 eligible polyps were detected in 538 of 912 patients screened for eligibility between September 2015 and August 2016. The complete resection rate for CSP was 98.2% compared with 97.4% for HSP. The non-inferiority of CSP for complete resection compared with HSP was confirmed by the +0.8% (90% CI –1.0 to 2.7) complete resection rate (non-inferiority p<0.0001). Postoperative bleeding requiring endoscopic haemostasis occurred only in the HSP group (0.5%, 2 of 402 polyps).

Conclusions

The complete resection rate for CSP is not inferior to that for HSP. CSP can be one of the standard techniques for 4–9 mm colorectal polyps. (Study registration: UMIN000018328)

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Modifiable factors associated with patient-reported pain during and after screening colonoscopy

Objective

Pain associated with colonoscopy is a major burden for patients. We investigated modifiable factors associated with patient-reported pain during and after colonoscopy.

Design

This cross-sectional analysis included database records from 23 centres participating in a population-based colonoscopy screening programme in Poland. Colonoscopies were performed under three sedation modalities: none, benzodiazepine-opioid sedation or propofol sedation. We used Gastronet (a validated tool) to assess patients' pain during and after colonoscopy; pain was scored on a four-point scale (no, little, moderate or severe pain), with moderate to severe defined as painful. We used multivariate logistic regression models to estimate ORs for painful colonoscopy and calculated risk-adjusted ratios of painful colonoscopies per endoscopist and compared it to the mean rate.

Results

Of 35 216 screening colonoscopies in 2014 and 2015 included in our study, 22 725 (64.5%) patients returned valid Gastronet questionnaires. The proportion of examinations described as causing pain during (after) the procedure was 22.5% (14.2%) for unsedated, 19.9% (13.5%) for benzodiazepine-opioid sedation and 2.5% (7.5%) for propofol sedation. Propofol sedation, higher case volume of endoscopists, newest endoscope generation and adequate bowel preparation were significantly associated with lower odds of painful colonoscopy. Pain scores after colonoscopy showed similar associations. Adjusted pain rates during and after colonoscopy varied 11 and over 23-fold, respectively, between endoscopists.

Conclusion

We identified several independent, modifiable factors associated with pain during and after colonoscopy, of which individual endoscopist was the most important. Dedicated training should be considered to decrease variability among endoscopists.

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Covered TIPS versus endoscopic band ligation plus propranolol for the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis: a randomised controlled trial

Objective

Limited data are available on the prevention of variceal rebleeding in cirrhotic patients with portal vein thrombosis (PVT). This study aimed to compare transjugular intrahepatic portosystemic shunt (TIPS) with covered stents versus endoscopic band ligation (EBL) plus propranolol for the prevention of variceal rebleeding among patients with cirrhosis and PVT.

Design

Consecutive cirrhotic patients (94% Child-Pugh class A or B) with PVT who had variceal bleeding in the past 6 weeks were randomly assigned to TIPS group (n=24) or EBL plus propranolol group (EBL+drug, n=25), respectively. Primary endpoint was variceal rebleeding. Secondary endpoints included survival, overt hepatic encephalopathy (OHE), portal vein recanalisation and rethrombosis, other complications of portal hypertension and adverse events.

Results

During a median follow-up of 30 months in both groups, variceal rebleeding was significantly less frequent in the TIPS group (15% vs 45% at 1 year and 25% vs 50% at 2 years, respectively; HR=0.28, 95% CI 0.10 to 0.76, p=0.008), with a significantly higher portal vein recanalisation rate (95% vs 70%; p=0.03) and a relatively lower rethrombosis rate (5% vs 33%; p=0.06) compared with the EBL+drug group. There were no statistically significant differences in survival (67% vs 84%; p=0.152), OHE (25% vs 16%; p=0.440), other complications of portal hypertension and adverse events between groups.

Conclusion

Covered TIPS placement in patients with PVT and moderately decompensated cirrhosis was more effective than EBL combined with propranolol for the prevention of rebleeding, with a higher probability of PVT resolution without increasing the risk of OHE and adverse effects, but this benefit did not translate into improved survival.

Trial registration number

ClinicalTrials.gov: NCT01326949.

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International development and validation of a classification system for the identification of Barretts neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT)

Background

Barrett's oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett's neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use.

Objective

To develop and validate a simple classification system to identify Barrett's neoplasia using AAC.

Design

The study was conducted in four phases: phase 1—development of component descriptive criteria; phase 2—development of a classification system; phase 3—validation of the classification system by endoscopists; and phase 4—validation of the classification system by non-endoscopists.

Results

Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett's mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001).

Conclusion

We developed and validated a classification system known as PREDICT for the diagnosis of Barrett's neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett's neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

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An unusual gastric tumour with gastric outlet obstruction

Question

A 62-year-old male without significant medical history presented with intermittent epigastric pain and abdominal fullness for 2 months. He denied having bloody stool or weight loss. He visited the outpatient department, where the CT scan of abdomen was performed (figure 1). He then underwent oesophagogastroduodenoscopy (EGD), which revealed a subepithelial tumour at gastric antrum with obstruction of the pylorus (figure 2 and video in the online ). Endoscopic ultrasound sonography (EUS) was performed (figure 3).

What is your diagnosis?Answer

Gastric inflammatory fibroid polyp (IFP) with gastroduodenal intussusception and gastric outlet obstruction.

The EGD showed a subepithelial tumour at the posterior wall of antrum with gastric outlet obstruction and gastroduodenal intussusception, which was then reduced by air inflation. The EUS disclosed a hypoechoic tumour arising from the submucosal layer. He then received laparoscopic gastric tumour excision (figure 4). The histology revealed a 2.2x1.0 cm submucosal tumour composed...

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Different Effects of Screening on Prostate Cancer Death in Two Trials

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Accuracy of Cardiovascular Risk Prediction Varies by Neighborhood Socioeconomic Position A Retrospective Cohort Study

Background:

Inequality in health outcomes in relation to Americans' socioeconomic position is rising.

Objective:

First, to evaluate the spatial relationship between neighborhood disadvantage and major atherosclerotic cardiovascular disease (ASCVD)–related events; second, to evaluate the relative extent to which neighborhood disadvantage and physiologic risk account for neighborhood-level variation in ASCVD event rates.

Design:

Observational cohort analysis of geocoded longitudinal electronic health records.

Setting:

A single academic health center and surrounding neighborhoods in northeastern Ohio.

Patients:

109 793 patients from the Cleveland Clinic Health System (CCHS) who had an outpatient lipid panel drawn between 2007 and 2010. The date of the first qualifying lipid panel served as the study baseline.

Measurements:

Time from baseline to the first occurrence of a major ASCVD event (myocardial infarction, stroke, or cardiovascular death) within 5 years, modeled as a function of a locally derived neighborhood disadvantage index (NDI) and the predicted 5-year ASCVD event rate from the Pooled Cohort Equations Risk Model (PCERM) of the American College of Cardiology and American Heart Association. Outcome data were censored if no CCHS encounters occurred for 2 consecutive years or when state death data were no longer available (that is, from 2014 onward).

Results:

The PCERM systematically underpredicted ASCVD event risk among patients from disadvantaged communities. Model discrimination was poorer among these patients (concordance index [C], 0.70 [95% CI, 0.67 to 0.74]) than those from the most affluent communities (C, 0.80 [CI, 0.78 to 0.81]). The NDI alone accounted for 32.0% of census tract–level variation in ASCVD event rates, compared with 10.0% accounted for by the PCERM.

Limitations:

Patients from affluent communities were overrepresented. Outcomes of patients who received treatment for cardiovascular disease at Cleveland Clinic were assumed to be independent of whether the patients came from a disadvantaged or an affluent neighborhood.

Conclusion:

Neighborhood disadvantage may be a powerful regulator of ASCVD event risk. In addition to supplemental risk models and clinical screening criteria, population-based solutions are needed to ameliorate the deleterious effects of neighborhood disadvantage on health outcomes.

Primary Funding Source:

The Clinical and Translational Science Collaborative of Cleveland and National Institutes of Health.

http://ift.tt/2xsnB2t

Single-Payer Reform

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Patterns of Sedentary Behavior and Mortality in U.S. Middle-Aged and Older Adults A National Cohort Study

Background:

Excessive sedentary time is ubiquitous in Western societies. Previous studies have relied on self-reporting to evaluate the total volume of sedentary time as a prognostic risk factor for mortality and have not examined whether the manner in which sedentary time is accrued (in short or long bouts) carries prognostic relevance.

Objective:

To examine the association between objectively measured sedentary behavior (its total volume and accrual in prolonged, uninterrupted bouts) and all-cause mortality.

Design:

Prospective cohort study.

Setting:

Contiguous United States.

Participants:

7985 black and white adults aged 45 years or older.

Measurements:

Sedentary time was measured using a hip-mounted accelerometer. Prolonged, uninterrupted sedentariness was expressed as mean sedentary bout length. Hazard ratios (HRs) were calculated comparing quartiles 2 through 4 to quartile 1 for each exposure (quartile cut points: 689.7, 746.5, and 799.4 min/d for total sedentary time; 7.7, 9.6, and 12.4 min/bout for sedentary bout duration) in models that included moderate to vigorous physical activity.

Results:

Over a median follow-up of 4.0 years, 340 participants died. In multivariable-adjusted models, greater total sedentary time (HR, 1.22 [95% CI, 0.74 to 2.02]; HR, 1.61 [CI, 0.99 to 2.63]; and HR, 2.63 [CI, 1.60 to 4.30]; P for trend < 0.001) and longer sedentary bout duration (HR, 1.03 [CI, 0.67 to 1.60]; HR, 1.22 [CI, 0.80 to 1.85]; and HR, 1.96 [CI, 1.31 to 2.93]; P for trend < 0.001) were both associated with a higher risk for all-cause mortality. Evaluation of their joint association showed that participants classified as high for both sedentary characteristics (high sedentary time [≥12.5 h/d] and high bout duration [≥10 min/bout]) had the greatest risk for death.

Limitation:

Participants may not be representative of the general U.S. population.

Conclusion:

Both the total volume of sedentary time and its accrual in prolonged, uninterrupted bouts are associated with all-cause mortality, suggesting that physical activity guidelines should target reducing and interrupting sedentary time to reduce risk for death.

Primary Funding Source:

National Institutes of Health.

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Breast Cancer Screening in Denmark

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Low-Dose Intravenous Immunoglobulin Treatment for Long-Standing Complex Regional Pain Syndrome A Randomized Trial

Background:

Two small trials suggest that low-dose intravenous immunoglobulin (IVIg) may improve the symptoms of complex regional pain syndrome (CRPS), a rare posttraumatic pain condition.

Objective:

To confirm the efficacy of low-dose IVIg compared with placebo in reducing pain during a 6-week period in adult patients who had CRPS from 1 to 5 years.

Design:

1:1 parallel, randomized, placebo-controlled, multicenter trial for 6 weeks, with an optional 6-week open extension. Patients were randomly assigned to 1 of 2 study groups between 27 August 2013 and 28 October 2015; the last patient completed follow-up on 21 March 2016. Patients, providers, researchers, and outcome assessors were blinded to treatment assignment. (ISRCTN42179756)

Setting:

7 secondary and tertiary care pain management centers in the United Kingdom.

Participants:

111 patients with moderate or severe CRPS of 1 to 5 years' duration.

Intervention:

IVIg, 0.5 g/kg of body weight, or visually indistinguishable placebo of 0.1% albumin in saline on days 1 and 22 after randomization.

Measurements:

The primary outcome was 24-hour average pain intensity, measured daily between days 6 and 42, on an 11-point (0- to 10-point) rating scale. Secondary outcomes were pain interference and quality of life.

Results:

The primary analysis sample consisted of 108 eligible patients, 103 of whom had outcome data. Mean (average) pain scores were 6.9 points (SD, 1.5) for placebo and 7.2 points (SD, 1.3) for IVIg. The adjusted difference in means was 0.27 (95% CI, −0.25 to 0.80; P = 0.30), which excluded the prespecified, clinically important difference of −1.2. No statistically significant differences in secondary outcomes were found between the groups. In the open extension, 12 of the 67 patients (18%) who received 2 IVIg infusions had pain reduction of at least 2 points compared with their baseline score. Two patients in the blinded phase (1 in the placebo and 1 in the IVIg group) and 4 in the open IVIg phase had serious events.

Limitations:

Results do not apply to patients who have had CRPS for less than 1 year or more than 5 years and do not extend to full-dose treatment (for example, 2 g/kg). The study was inadequately powered to detect subgroup effects.

Conclusion:

Low-dose immunoglobulin treatment for 6 weeks was not effective in relieving pain in patients with moderate to severe CRPS of 1 to 5 years' duration.

Primary Funding Source:

Medical Research Council/National Institute for Health Research Efficacy and Mechanism Evaluation Program, Pain Relief Foundation, and Biotest United Kingdom.

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Someone's Son

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Should We Screen This Patient for Carotid Artery Stenosis? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

In July 2014, the U.S. Preventive Services Task Force (USPSTF) published a clinical guideline on screening for asymptomatic carotid artery stenosis. The guideline recommended against screening in asymptomatic adults, based primarily on the results of 3 large randomized trials (grade D recommendation). The principal screening test was carotid ultrasonography, and the intervention in the 3 trials was carotid endarterectomy for patients with stenosis exceeding 50% to 60%. In a meta-analysis, carotid endarterectomy reduced rates of 1) perioperative stroke, death, or subsequent ipsilateral stroke and 2) perioperative stroke, death, or any subsequent stroke. The corresponding absolute risk differences were –2.0% (95% CI, –3.3% to –0.7%) and –3.5% (CI, –5.1% to –1.8%), respectively. However, perioperative stroke and death were substantially less common among the 3 randomized trials than in contemporaneous cohort studies (1.9% vs. 3.3%). In addition to stroke or death in patients receiving carotid endarterectomy, a harm of screening included the risk for angiography prompted by abnormal results on carotid ultrasonography. In this article, 2 discussants address the risks and benefits of screening for carotid artery disease as well as how to apply the guideline to an individual patient who is deciding whether to be screened.

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Reconciling the Effects of Screening on Prostate Cancer Mortality in the ERSPC and PLCO Trials

Background:

The ERSPC (European Randomized Study of Screening for Prostate Cancer) found that screening reduced prostate cancer mortality, but the PLCO (Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial) found no reduction.

Objective:

To evaluate whether effects of screening on prostate cancer mortality relative to no screening differed between the ERSPC and PLCO.

Design:

Cox regression of prostate cancer death in each trial group, adjusted for age and trial. Extended analyses accounted for increased incidence due to screening and diagnostic work-up in each group via mean lead times (MLTs), which were estimated empirically and using analytic or microsimulation models.

Setting:

Randomized controlled trials in Europe and the United States.

Participants:

Men aged 55 to 69 (ERSPC) or 55 to 74 (PLCO) years at randomization.

Intervention:

Prostate cancer screening.

Measurements:

Prostate cancer incidence and survival from randomization; prostate cancer incidence in the United States before screening began.

Results:

Estimated MLTs were similar in the ERSPC and PLCO intervention groups but were longer in the PLCO control group than the ERSPC control group. Extended analyses found no evidence that effects of screening differed between trials (P = 0.37 to 0.47 [range across MLT estimation approaches]) but strong evidence that benefit increased with MLT (P = 0.0027 to 0.0032). Screening was estimated to confer a 7% to 9% reduction in the risk for prostate cancer death per year of MLT. This translated into estimates of 25% to 31% and 27% to 32% lower risk for prostate cancer death with screening as performed in the ERSPC and PLCO intervention groups, respectively, compared with no screening.

Limitation:

The MLT is a simple metric of screening and diagnostic work-up.

Conclusion:

After differences in implementation and settings are accounted for, the ERSPC and PLCO provide compatible evidence that screening reduces prostate cancer mortality.

Primary Funding Source:

National Cancer Institute.

http://ift.tt/2x66nuQ

Treatment of Type 1 Diabetes: Synopsis of the 2017 American Diabetes Association Standards of Medical Care in Diabetes

Description:

The American Diabetes Association (ADA) annually updates Standards of Medical Care in Diabetes to provide clinicians, patients, researchers, payers, and other interested parties with evidence-based recommendations for the diagnosis and management of patients with diabetes.

Methods:

For the 2017 Standards of Care, the ADA Professional Practice Committee did MEDLINE searches from 1 January 2016 to November 2016 to add, clarify, or revise recommendations on the basis of new evidence. The committee rated the recommendations as A, B, or C, depending on the quality of evidence, or E for expert consensus or clinical experience. The Standards of Care were reviewed and approved by the Executive Committee of the ADA Board of Directors, which includes health care professionals, scientists, and laypersons. Feedback from the larger clinical community informed revisions.

Recommendation:

This synopsis focuses on recommendations from the 2017 Standards of Care about monitoring and pharmacologic approaches to glycemic management for type 1 diabetes.

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E-Cigarettes and Toxin Exposure

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Reimagining Halfway Technologies With Behavioral Science

Investment in discovering transformative health care interventions favors future generations that might realize its large but distant benefits, but it shortchanges current generations who could immediately benefit from the "halfway technologies" that get us pretty far but not to the moon.

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Correction: In the Clinic—Osteoporosis

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Diagnostic Reasoning: An Endangered Competency in Internal Medicine Training

In this essay, the authors describe several initiatives at their institution to foster the development of diagnostic reasoning skills among internal medicine residents.

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Evaluation of Intrathecal Routes of Administration for Adeno-Associated Viral Vectors in Large Animals

Human Gene Therapy , Vol. 0, No. 0.


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Steerable Induction of the Thymosin β4/MRTF-A Pathway via AAV-Based Overexpression Induces Therapeutic Neovascularization

Human Gene Therapy , Vol. 0, No. 0.


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Biochemical and Structural Characterization of the Carbohydrate Transport Substrate-binding-protein SP0092

A streamlined protocol for performing an extensive biochemical and structural characterization of a carbohydrate substrate binding protein from Streptococcus pneumoniae is presented.

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EMCrit Podcast 209 – GTD Redux – Opportunities, Time, & Future Selves

More on GTD

EMCrit by Scott Weingart.

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Live-cell Measurement of Odorant Receptor Activation Using a Real-time cAMP Assay

Characterizing the function of odorant receptors serves an indispensable part in the deorphanization process. We describe a method to measure the activation of odorant receptors in real time using a cAMP assay.

http://ift.tt/2g5zX9o

Sequential Salt Extractions for the Analysis of Bulk Chromatin Binding Properties of Chromatin Modifying Complexes

Sequential salt extraction of chromatin bound proteins is a useful tool for determining the binding properties of large protein complexes. This method can be employed to evaluate the role of individual subunits or domains in the overall affinity of a protein complex to bulk chromatin.

http://ift.tt/2xasm4e

Use of a Rat Model to Study Ventral Abdominal Hernia Repair

This manuscript describes methods associated with creation and repair of a ventral abdominal wall defect (hernia). This model can be used to study repair strategies such as those that use implanted materials. In this manuscript, repair of the experimental hernia with porcine small intestinal submucosa is presented as an example.

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Correlation of 99m Tc-sestamibi uptake in renal masses with mitochondrial content and multi-drug resistance pump expression

Abstract

Background

^99mTc-sestamibi single-photon emission computed tomography/computed tomography (SPECT/CT) has recently been explored for the characterization of indeterminate renal masses. As judged by increased intra-tumoral radiotracer uptake, we have previously reported the excellent diagnostic performance characteristics of this test for identifying benign/indolent oncocytomas and hybrid oncocytic/chromophobe tumors (HOCTs). In this study, we investigated potential molecular mechanisms underlying the discriminatory ability of ^99mTc-sestamibi SPECT/CT for renal masses.

Fifty renal masses imaged with ^99mTc-sestamibi SPECT/CT prior to surgical resection were evaluated by immunohistochemistry for mitochondrial content and expression of the multi-drug resistance pump 1 (MDR1/P-gp). Immunohistochemical staining was scored semi-quantitatively, and results were compared across renal tumor histologies and correlated with ^99mTc-sestamibi uptake.

Results

In total, 6/6 (100%) and 2/2 (100%) HOCTs demonstrated strong mitochondrial content staining combined with low MDR1 staining. Clear cell renal cell carcinoma showed an opposite pattern with the majority having low mitochondrial (14/26, 54%) and high MDR1 staining (18/26, 69%). Other tumor types were more variable in staining pattern, although the staining pattern reliably predicted ^99mTc-sestamibi uptake in almost all tumors except chromophobe renal cell carcinoma.

Conclusions

Our findings confirm that renal tumors with high mitochondrial content and relatively low MDR pump expression activity accumulate ^99mTc-sestamibi and allow for the accurate diagnosis of the benign/indolent tumor class that includes oncocytomas and HOCTs. For masses in which MDR activity outweighs the presence of mitochondria, the tumors appear cold on ^99mTc-sestamibi SPECT/CT, allowing for high confidence in the diagnosis of renal cell carcinoma.

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Effects of protein supplementation combined with resistance exercise on body composition and physical function in older adults: a systematic review and meta-analysis [Nutritional support]

Background: Overweight and obese older people face a high risk of muscle loss and impaired physical function, which may contribute to sarcopenic obesity. Resistance exercise training (RET) has a beneficial effect on muscle protein synthesis and can be augmented by protein supplementation (PS). However, whether body weight affects the augmentation of muscular and functional performance in response to PS in older people undergoing RET remains unclear.

Objective: This study was conducted to identify the effects of PS on the body composition and physical function of older people undergoing RET.

Design: We performed a comprehensive search of online databases to identify randomized controlled trials (RCTs) reporting the efficacy of PS for lean mass gain, strength gain, and physical mobility improvements in older people undergoing RET.

Results: We included 17 RCTs; the overall mean ± SD age and body mass index (BMI; in kg/m²) in these RCTs were 73.4 ± 8.1 y and 29.7 ± 5.5, respectively. The participants had substantially greater lean mass and leg strength gains when PS and RET were used than with RET alone, with the standard mean differences (SMDs) being 0.58 (95% CI: 0.32, 0.84) and 0.69 (95% CI: 0.39, 0.98), respectively. The subgroup of studies with a mean BMI ≥30 exhibited substantially greater lean mass (SMD: 0.53; 95% CI: 0.19, 0.87) and leg strength (SMD: 0.88; 95% CI: 0.42, 1.34) gains in response to PS. The subgroup of studies with a mean BMI <30 also exhibited relevant gains in response to PS.

Conclusions: Compared with RET alone, PS combined with RET may have a stronger effect in preventing aging-related muscle mass attenuation and leg strength loss in older people, which was found in studies with a mean BMI ≥30 and in studies with a mean BMI <30. Clinicians could use nutrition supplement and exercise strategies, especially PS plus RET, to effectively improve the physical activity and health status of all older patients.

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