Intensive care in a general hospital: demographics, utilization and outcomes

INTRODUCTION

Intensive care units (ICU) in Irish academic centres are known to fare as well as their international counterparts. Our aim in this study was to characterise the role and outcomes of an ICU in a smaller Irish hospital and to compare these to international best practice.

METHODS

We reviewed admissions of patients to the ICU of St. Luke's Hospital, Kilkenny. Patient demographics, indications for admission, and outcomes were all recorded and analysed. Sequential organ failure assessment (SOFA) scores were calculated.

RESULTS

Forty-three patients were included in our study, 33 (76.7 %) of which were emergency admissions. Median length of stay was 2 days. The observed mortality rate in our cohort was 20.9 %. The median SOFA score in patients admitted was 7. Higher median SOFA scores on admission were predictive of mortality. The ICU occupancy rate during the duration of our study was 98 %, with only 15 (35.7 %) of admissions to ICU occurring within core working hours.

CONCLUSION

Critical care can be provided safely and in line with current best practice in smaller Irish hospitals. There is a cohort of patients for whom care may be best provided in a tertiary centre, how best to provide for these patients will likely be achieved by early identification (e.g. with SOFA score). Bed capacity issues remain problematic.

Long-term outcome of the anal fistula plug for anal fistula of cryptoglandular origin

AIM

This study aimed to evaluate the long-term outcome of the anal fistula plug in the treatment of anal fistula of cryptoglandular origin.

METHOD

A review of all patients who had at least one anal fistula plug inserted from March 2007 to August 2008 was performed. Only anal fistulae of cryptoglandular origin were included. Success was defined as the closure of the external opening with no further purulent discharge or collection.

RESULTS

Thirty anal fistula plugs were inserted in 26 patients [median age 40 (26-70) years]. Twenty-six of the fistulae were transsphincteric and three were suprasphincteric. One patient had a high intersphincteric fistula, which was the only fistula that did not have a seton inserted. The median duration between seton insertion and the plug procedure was 12 (4-28) weeks. The median length of the fistula tract was 3 (1-7.5) cm. After a median follow-up of 59 (13-97) weeks, 26 (86.7%) fistulae recurred. Of the 26 failures, the median time to failure was 8 (2-54) weeks. Subsequent surgical interventions were performed in 20 of the failures.

CONCLUSION

The role of the fistula plug in the management of anal fistula of cryptoglandular origin remains debatable and warrants further evaluation.

Abstract C106: Screening small cell lung cancer lines against approved oncology drugs and investigational agents elucidates patterns of sensitivity

Small cell lung cancer (SCLC) is an aggressive cancer with a 5-year survival rate of <5% that frequently recurs after conventional cytotoxic chemotherapy. We have undertaken a systematic large-scale screening of approved oncology drugs and investigational agents for activity against SCLC in an effort to provide new leads to effective treatment of this disease. Our laboratory compiled a panel of >75 human SCLC lines and is screening approximately 60 (well characterized) lines against 103 agents from the Approved Oncology Drugs (AOD) library) and 420 agents from the Investigational Agents library. Compounds are evaluated at 9 concentrations (10uM to 1.5nM) in comparison with vehicle controls using cell viability 96h post drug exposure as the endpoint - allowing a direct comparison between the IC50, anticipated compound molecular target and the breadth of activity across the cell lines. These cells represent a broad coverage of those available as representatives of SCLC with an array of growth behaviors. Cell lines grow as adherent cultures, in single cell suspension, in suspension as spheres and /or clumps, or mixed cultures. Despite these varied phenotypes, the screen was robust (Z’ score > 0.5) in all of the lines studied to date. Interestingly, SHP77 (an unusual undifferentiated large cell morphological variant with biochemical properties of SCLC) consistently showed lower sensitivity to the drugs than other cell lines tested. Trends emerging from the early data indicate that: 1) Comparing compound activity (IC50 value) by cell line and clustering the compounds based on their reported targets, we could readily observe the target classes that produced the greatest cell growth inhibition across the widest set of the SCLC cell lines; and 2) from these data it appears that discrete HDAC inhibitors and HSP90 inhibitors produce potent growth inhibition across a wide array of SCLC lines (including SHP77). We are expanding the number of SCLC lines under study. Each cell line will be examined for gene expression patterns, miRNA expression patterns and sensitivity to the approved and investigational agents (IC50). These data will allow correlations to be made regarding sensitivity of the cells to agents with discrete cellular targets versus the genomic background in these cells. Data from the drug screens combined with genomic profiling of the cells may allow clinical trials to select therapeutic agents to maximize benefit in patients presenting with SCLC. Further analyses and findings from the data will be presented.

Funded by NCI Contract No. HHSN261200800001E.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):C106.

Citation Format: David M. Evans, Rene Delosh, Julie Laudeman, Chad Ogle, Russell Reinhart, Michael Selby, Thomas Silvers, Anne Monks, Gurmeet Kaur, Joel Morris, Beverly A. Teicher. Screening small cell lung cancer lines against approved oncology drugs and investigational agents elucidates patterns of sensitivity. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr C106.

Analyses of the combination of 6-MP and dasatinib in cell culture

A major tenet of cancer therapeutics is that combinations of anticancer agents with different mechanisms of action and different toxicities may be effective treatment regimens. Evaluation of additivity/synergy in cell culture may be used to identify drug combination opportunities and to assess risk of additive/synergistic toxicity. The combination of 6-mercaptopurine and dasatinib was assessed for additivity/synergy using the combination index (CI) method and a response surface method in six human tumor cell lines including MCF-7 and MDA-MB‑468 breast cancer, NCI-H23 and NCI-H460 non‑small cell lung cancer, and A498 and 786-O renal cell cancer, based on two experimental end‑points: ATP content and colony formation. Clonal colony formation by human bone marrow CFU-GM was used to assess risk of enhanced toxicity. The concentration ranges tested for each drug were selected to encompass the clinical Cmax concentrations. The combination regimens were found to be additive to sub‑additive by both methods of data analysis, but synergy was not detected. The non-small cell lung cancer cell lines were the most responsive among the tumor lines tested and the renal cell carcinoma lines were the least responsive. The bone marrows CFU-GM were more sensitive to the combination regimens than were the tumor cell lines. Based upon these data, it appears that the possibility of enhanced efficacy from combining 6-mercaptopurine (6-MP) and dasatinib would be associated with increased risk of severe bone marrow toxicity, so the combination is unlikely to provide a therapeutic advantage for treating solid tumor patients where adequate bone marrow function must be preserved.

Antibacterial efficacy of Nisin, Pediocin 34 and Enterocin FH99 against Listeria monocytogenes and cross resistance of its bacteriocin resistant variants to common food preservatives

Antilisterial efficiency of three bacteriocins, viz, Nisin, Pediocin 34 and Enterocin FH99 was tested individually and in combination against Listeria mononcytogenes ATCC 53135. A greater antibacterial effect was observed when the bacteriocins were combined in pairs, indicating that the use of more than one LAB bacteriocin in combination have a higher antibacterial action than when used individually. Variants of Listeria monocytogenes ATCC 53135 resistant to Nisin, Pediocin 34 and Enterocin FH99 were developed. Bacteriocin cross-resistance of wild type and their corresponding resistant variants were assessed and results showed that resistance to a bacteriocin may extend to other bacteriocins within the same class. Resistance to Pediocin 34 conferred cross resistance to Enterocin FH 99 but not to Nisin. Similarly resistance to Enterocin FH99 conferred cross resistance to Pediocin 34 but not to Nisin. Also, the sensitivity of Nisin, Pediocin 34 and Enterocin FH99 resistant variants of Listeria monocytogenes to low pH, salt, sodium nitrite, and potassium sorbate was assayed in broth and compared to the parental wild-type strain. The Nisin, Pediocin 34 and Enterocin FH99 resistant variants did not have intrinsic resistance to low pH, sodium chloride, potassium sorbate, or sodium nitrite. In no case were the bacteriocin resistant Listeria monocytogenes variants examined were more resistant to inhibitors than the parental strains.

Zirconium-89 labeled panitumumab: a potential immuno-PET probe for HER1-expressing carcinomas

INTRODUCTION

Anti-HER1 monoclonal antibody (mAb), panitumumab (Vectibix) is a fully human mAb approved by the FDA for the treatment of epidermal growth factor receptor (EGFR, HER1)-expressing colorectal cancers. By combining the targeted specificity of panitumumab with the quantitative in vivo imaging capabilities of PET, we evaluated the potential of (89)Zr-DFO-panitumumab PET/CT imaging and performed non-invasive, in vivo imaging of HER1 expression and estimated human dosimetry.

METHODS

Panitumumab was radiolabeled with (89)Zr using a derivative of desferrioxamine (DFO-Bz-NCS) and with (111)In using CHX-A" DTPA as bifunctional chelators. Comparative biodistribution/dosimetry of both radiotracers was performed in non-tumor bearing athymic nude mice (n=2 females and n=2 males) over 1-week following i.v. injection of either using (89)Zr-DFO-panitumumab or (111)In-CHX-A"-DTPA-panitumumab. Micro-PET/CT imaging of female athymic nude mice bearing human breast cancer tumors (n=5 per tumor group) with variable HER1-expression very low (BT-474), moderate (MDA-MB-231), and very high (MDA-MB-468) was performed at over 1 week following i.v. injection of (89)Zr-DFO-panitumumab.

RESULTS

Radiochemical yield and purity of (89)Zr-Panitumumab was >70% and >98% respectively with specific activity 150 ± 10 MBq/mg of panitumumab in a ~4 hr synthesis time. Biodistribution of (111)In-CHX-A" DTPA -panitumumab and (89)Zr-DFO-panitumumab in athymic non-tumor bearing nude mice displayed similar percent injected dose per gram of tissue with prominent accumulation of both tracers in the lymph nodes, a known clearance mechanism of panitumumab. Also exhibited was prolonged blood pool with no evidence of targeted accumulation in any organ. Human radiation dose estimates showed similar biodistributions with estimated human effective doses of 0.578 and 0.183 mSv/MBq for (89)Zr-DFO-panitumumab and (111)In-CHX-A"-DTPA-panitumumab, respectively. Given the potential quantitative and image quality advantages of PET, imaging of tumor bearing mice was only performed using (89)Zr-DFO-panitumumab. Immuno-PET imaging of (89)Zr-DFO-panitumumab in mice bearing breast cancer xenograft tumors with variable HER1 expression showed high tumor uptake (SUV >7) in the MDA-MB-468 high HER1-expressing mice and a strong correlation between HER1-expression level and tumor uptake (R(2)= 0.857, P < .001).

CONCLUSIONS

(89)Zr-DFO-panitumumab can prepared with high radiochemical purity and specific activity. (89)Zr-DFO-panitumumab microPET/CT showed uptake corresponding to HER-1 expression. Due to poor clearance, initial dosimetry estimates suggest that only a low dose (89)Zr-DFO-panitumumab shows favorable human dosimetry; however due to high tumor uptake, the use of (89)Zr-DFO-panitumumab is expected to be clinically feasible.

Abstract 4361: Target and drug discovery for recalcitrant, rare and neglected cancers

Efforts are underway to improve the treatment of recalcitrant, rare and neglected cancers through the discovery of potential therapeutic targets, the identification of possible therapeutic combinations, and the identification of genomic vulnerabilities, using state-of-the-art drug discovery, molecular characterization, and mechanism-of-action techniques. Our current focus is on sarcoma and small cell lung cancer. Sarcoma comprises approximately 1% of cancers inclusive of 50 subtypes and occurs in patients of all ages with a frequency spread evenly over the human age range. Small cell lung cancer (SCLC) constitutes approximately 15% of lung cancers, is extremely aggressive, has a high mortality rate and frequently recurs after conventional cytotoxic chemotherapy. We have established comprehensive panels of human sarcoma and small cell lung cancer cell lines (approximately 80 per tumor type). Cell lines are being screened for response to all of the FDA approved anticancer agents and to a library of investigational agents with a goal of identifying existing agents that may be suitable for novel clinical trials, plus identifying potential points of vulnerability for drug discovery. Analysis of selected somatic mutations showed that ATM is frequently mutated in both soft tissue and bone sarcoma. In addition, gene expression profiles were measured in sarcoma cell lines using Affymetrix Exon 1.0 ST arrays in an effort to facilitate identification of splice variants and fusion genes. The gene-level data from the Exon ST1 array compares well with published U133plus 2 expression profiles. Principal components analysis of genes in 48 sarcoma lines indicates that expression varies primarily by disease subtype. For instance, Ewing's Sarcoma overexpressed genes including PRKCB, NPY5R and NPY1R, ITM2A plus adrenergic receptors B1, B3 and A1D, while ACTC1, IGF2 and CHRNA1 were dysregulated in rhabdomyosarcoma. Predicted associations between gene and miRNA expression included CSF1 with miR-128, thioredoxin reductase with miR-324-5p, MDM4 with miR-152, and PODXL with miR-199a-5p, suggesting potential regulatory relationships that might be exploited as cancer targets. In these lines, exome expression was found to be altered more than 10% in 232 genes, including known splice variant genes such as KLK11, UBE2C and sarcoma related fusion genes EWSR1 and ETV. Calculated fusion scores based on EWSR1-FLI1 expression profiles successfully segregated Ewing's sarcoma from all other sarcoma cell lines. Association analysis between gene and microRNA expression and sensitivity to specific anticancer agents is ongoing. Our mission is to improve the treatment of these neglected cancers by providing a comprehensive public database of molecular signatures and sensitivities that can be leveraged by the scientific community at large. Funded by NCI Contract no. HHSN261200800001E.

Citation Format: Anne Monks, Annamaria Rapisarda, Kazimierz O. Wrzeszczynski, E. Michael August, Eric C. Polley, Sudhir B. Kondapaka, Gurmeet Kaur, Dianne Newton, Beverley A. Teicher. Target and drug discovery for recalcitrant, rare and neglected cancers. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 4361. doi:10.1158/1538-7445.AM2013-4361

Change in structural morphology on addition of ZnO and its effect on fluorescence of Yb³⁺/Er³⁺ doped Y₂O₃

Yb(3+)/Er(3+) codoped Y(2)O(3) phosphor and its composite with ZnO have been synthesized by combustion method. Morphology of the materials has been investigated using X-ray diffraction pattern (XRD) and scanning electron microscopy (SEM) techniques. XRD confirms the constituents as Y(2)O(3) and ZnO, with average crystallite size of 112 nm. On addition of ZnO, a small shifting in XRD pattern of Y(2)O(3) is observed. SEM pattern suggests that the average particle size lies in micro-range (0.5 μm). A dumble like structure is observed for hybrid material on annealing at 1473 K. A strong green (525, 546 nm) with weak blue (411 nm) and red (657 nm) emissions through upconversion has been observed from the phosphor on excitation with 976 nm diode laser. The observed emissions involve (2)H(9/2)→(4)I(15/2), (2)H(11/2)→(4)I(15/2), (4)S(3/2)→(4)I(15/2) and (4)F(9/2)→(4)I(15/2) electronic transitions, respectively. The upconversion process has been confirmed by power dependence measurements and its slope value was found to be 1.85, 1.72 for green and red emissions, respectively. On addition of ZnO, the intensity of these emissions is enhanced several times. The reason behind the enhancement is discussed with the help of the emitting level lifetime. An interesting dual mode property (upconversion and downconversion) to the same material has been observed on excitation with 532 nm laser source.

Testisimmune privilege - Assumptions versus facts

The testis has long enjoyed a reputation as an immunologically privileged site based on its ability to protect auto-antigenic germ cells and provide an optimal environment for the extended survival of transplanted allo- or xeno-grafts. Exploration of the role of anatomical, physiological, immunological and cellular components in testis immune privilege revealed that the tolerogenic environment of the testis is a result of the immunomodulatory factors expressed or secreted by testicular cells (mainly Sertoli cells, peritubular myoid cells, Leydig cells, and resident macrophages). The blood-testis barrier/Sertoli cell barrier, is also important to seclude advanced germ cells but its requirement in testis immune privilege needs further investigation. Testicular immune privilege is not permanent, as an effective immune response can be mounted against transplanted tissue, and bacterial/viral infections in the testis can be effectively eliminated. Overall, the cellular components control the fate of the immune response and can shift the response from immunodestructive to immunoprotective, resulting in immune privilege.

Flavopiridol (L86 8275; NSC 649890), a new kinase inhibitor for tumor therapy

Flavopiridol is a new synthetic flavone, structurally related to a natural alkaloid, originally purified from Dysoxylum binectariferum, a plant indigenous to India and used in Indian folk medicine. Flavopiridol was detected by a tandem screening system consisting in inhibition of the EGF-receptor Tyrosine phosphokinase and cytotoxicity. As a cytostatic mechanism, however, Flavopiridol strongly inhibits the cyclin-dependent kinases (cdk1, cdk2, cdk4, cdk7), with the potential to cause inhibition of cell cycle progression in G(1) and G(2) by multiple mechanisms relatable to cdk inhibition. In certain cell types, Flavopiridol induces apoptosis. The antitumor activity of that compound on human xenograft tumors is similar to standard cytostatic drugs and superior to them at least in prostate carcinoma. The dose limiting toxicity is diarrhea. Compared with other flavonoids or other kinase inhibitors Flavopiridol can be regarded as unique as no other compound is yet known that as specifically and potently inhibits nearly all the main cyclin dependent kinases and by that mechanisms can arrest cell cycle progression in G(1) as well as in G(2) and no other specific kinase inhibitor is known, which after i.v. or oral application reduces the growth of subcutaneous or subrenal xenografts of human tumors of different types. Initial results of a phase I study at the National Cancer Institute (NCI), USA, (Investigational New Drug Application no. 46211) provided some clinical and laboratory evidence for antineoplastic effect at nontoxic doses (no grade IV toxicities encountered). Thus, Flavopiridol is clearly in need of further clinical evaluation of its tumor therapeutic potential. In this review the chemical profile, tumorpharmacology (in vitro activity, inhibition of cdk's and preclinical in vivo activity), preclinical toxicology and pharmacokinetic of Flavopiridol are reviewed to provide a comprehensive source to aid further developmental efforts.

Abstract 3713: Comparison of endpoints and data analysis methods for exposure of human tumor cells to dasatinib (NSC732517) and 6-MP (NSC755) in culture

Previous research using the NCI60 cell line combination screen suggested that dasatinib (NSC732517) and 6-mercaptopurine (6-MP; NSC755) may have greater than additive cytotoxicity in selected cell lines. We have conducted a detailed combination study using 6-MP and dasatinib in p53 wild type (MCF-7, H460, A498) and p53 mutant (MDA-MB-468, H23, 786-O) breast, lung and renal cell lines. These studies were performed measuring ATP as the endpoint using Cell Titer Glo after 72h exposure to 6-MP and dasatinib alone or in combination and measuring survival using colony formation after 72hr exposure to the compounds alone or in combination. As a single agent, the lung and renal mutant cell lines (H23, 786-O) were 2-10 fold more sensitive to 6-MP than wild type (H460, A498) with the exception of MDA-MD-468 (mutant), which was more resistant to 6-MP than MCF-7 (wild type). On the other hand all cell lines were sensitive to dasatinib with the IC50 ranging from 0.2-2 μM. For the combination studies, additivity/synergy was calculated using CompuSyn Software (Chou and Martin) or MacSynergy (Prichard and Shipman). Combination index (CI) analysis of the single agent and combination data for 6-MP and dasatinib was additive or antagonist in most of the cell lines. In A498, 786-0, MCF-7 and H460 cell lines a synergistic effect was observed at &gt;10 fold the clinical plasma levels of 6-MP (0.59 μM) or dasatinib (0.19 μM). NCI-H23 cell line demonstrated an additive effect at 0.3 μM of 6-MP and 0.2 μM of dasatinib (CI = 0.94). MDA-MB-468 cell lines demonstrated a strong synergy (CI = 0.2-0.4) for 6-MP (0.03-1 μM) and dasatinib (0.05 μM) at concentrations less than the clinical plasma levels. In a single agent colony formation assay, the H460 cells were sensitive to 6-MP (IC50= 0.21 μM) and resistant to dasatinib (IC50= &gt;10 μM). In a combination study, a synergistic effect (CI = 0.59-0.8) was observed in H460 cell line at concentrations below the clinical plasma level of 6-MP (0.2 μM-0.6 μM) and dasatinib (0.1 μM). These drug effects will be further evaluated in all cell lines by the determination of survival using colony formation assay.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 3713. doi:1538-7445.AM2012-3713

Genomics and transcriptomics across the diversity of the Nematoda

The diversity of biology in nematodes is reflected in the diversity of their genomes. Parasitic species in particular have evolved mechanisms to invade and outwit their hosts, and these offer opportunities for the development of control measures. Genomic analyses can reveal the molecular underpinnings of phenotypes such as parasitism and thus, initiate and support research programmes that explore the manipulation of host and parasite physiologies to achieve favourable outcomes. Wide sampling across nematode diversity allows phylogenetically informed formulation of research hypotheses, identification of core features shared by all species or important evolutionary novelties present in isolated clades. Many nematode species have been investigated through the use of the expressed sequence tag approach, which samples from the transcribed genome. Gene catalogues generated in this way can be explored to reveal the patterns of expression associated with parasitism and candidates for testing as drug targets or vaccine components. Analysis environments, such as NEMBASE facilitate exploitation of these data. The development of new high-throughput DNA-sequencing technologies has facilitated transcriptomic and genomic approaches to parasite biology. Whole genome sequencing offers more complete catalogues of genes and assists a systems approach to phenotype dissection. These efforts are being coordinated through the 959 Nematode Genomes initiative.