Parenteral support and micronutrient deficiencies in children with short bowel syndrome: A comprehensive retrospective study

BACKGROUND & AIMS

Short bowel syndrome (SBS) is the leading cause of chronic intestinal failure. The duration of parenteral support (PS) and the long-term micronutrient needs in children with SBS vary, based on their clinical and anatomical characteristics. Our study aimed to review the clinical course and identify high risk patient groups for prolonged PS and long-term micronutrient supplementation.

METHODS

A retrospective review was conducted on electronic medical records of children with SBS and chronic intestinal failure who were enrolled in the multidisciplinary intestinal rehabilitation program at Manchester Children's Hospital, UK. Children were included in the review if they required PN for more than 60 days out of 74 consecutive days and had at least 3 years of follow-up. Statistical analysis was performed using IBM SPSS Statistics 24.0.

RESULTS

40 children with SBS achieved enteral autonomy (EA) and 14 remained dependent on PS after 36 months of follow up. Necrotizing enterocolitis was the most common cause for intestinal resection (38.9%) followed by gastroschisis (22.2%), malrotation with volvulus (20.4%), segmental volvulus (9.3%) and long segment Hirschsprung disease (1.9%). Those who achieved EA had significantly longer intestinal length 27.5% (15.0-39.3) than those who remained on PS 6.0% (1.5-12.5) (p < 0.001). Type I SBS was only found in the PS cohort. Median PN dependence was 10.82 months [IQR 5.73-20.78]. Congenital diagnosis was associated with longer PN dependence (21.0 ± 20.0) than acquired (8.7 ± 7.8 months), (p = 0.02). The need for micronutrient supplementation was assessed after the transition to EA; 87.5% children had at least one micronutrient depletion, most commonly Vitamin D (64.1%), followed by iron (48.7%), Vitamin B12 (34.2%), and vitamin E (28.6%). Iron deficiency and vitamin A depletion were correlated with longer PS after multivariate analysis (OR: 1.103, 1.006-1.210, p = 0.037 and OR: 1.048, 0.998-1.102, p = 0.062 respectively).

CONCLUSION

In our cohort, small bowel length was the main predictor for EA. Children on longer PS, had more often a congenital cause of resection and were at risk for micronutrient deficiencies in EA.

Energetic Electron Precipitation Driven by Electromagnetic Ion Cyclotron Waves from ELFIN's Low Altitude Perspective

We review comprehensive observations of electromagnetic ion cyclotron (EMIC) wave-driven energetic electron precipitation using data collected by the energetic electron detector on the Electron Losses and Fields InvestigatioN (ELFIN) mission, two polar-orbiting low-altitude spinning CubeSats, measuring 50-5000 keV electrons with good pitch-angle and energy resolution. EMIC wave-driven precipitation exhibits a distinct signature in energy-spectrograms of the precipitating-to-trapped flux ratio: peaks at >0.5 MeV which are abrupt (bursty) (lasting ∼17 s, or Δ L ∼ 0.56 ) with significant substructure (occasionally down to sub-second timescale). We attribute the bursty nature of the precipitation to the spatial extent and structuredness of the wave field at the equator. Multiple ELFIN passes over the same MLT sector allow us to study the spatial and temporal evolution of the EMIC wave - electron interaction region. Case studies employing conjugate ground-based or equatorial observations of the EMIC waves reveal that the energy of moderate and strong precipitation at ELFIN approximately agrees with theoretical expectations for cyclotron resonant interactions in a cold plasma. Using multiple years of ELFIN data uniformly distributed in local time, we assemble a statistical database of ∼50 events of strong EMIC wave-driven precipitation. Most reside at L ∼ 5 - 7 at dusk, while a smaller subset exists at L ∼ 8 - 12 at post-midnight. The energies of the peak-precipitation ratio and of the half-peak precipitation ratio (our proxy for the minimum resonance energy) exhibit an L -shell dependence in good agreement with theoretical estimates based on prior statistical observations of EMIC wave power spectra. The precipitation ratio's spectral shape for the most intense events has an exponential falloff away from the peak (i.e., on either side of ∼ 1.45 MeV). It too agrees well with quasi-linear diffusion theory based on prior statistics of wave spectra. It should be noted though that this diffusive treatment likely includes effects from nonlinear resonant interactions (especially at high energies) and nonresonant effects from sharp wave packet edges (at low energies). Sub-MeV electron precipitation observed concurrently with strong EMIC wave-driven >1 MeV precipitation has a spectral shape that is consistent with efficient pitch-angle scattering down to ∼ 200-300 keV by much less intense higher frequency EMIC waves at dusk (where such waves are most frequent). At ∼100 keV, whistler-mode chorus may be implicated in concurrent precipitation. These results confirm the critical role of EMIC waves in driving relativistic electron losses. Nonlinear effects may abound and require further investigation.

Whole-food plant-based diet reduces daytime sleepiness in patients with OSA

Consumption of a diet high in saturated fat has been associated with daytime sleepiness. A whole-food plant-based (WFPB) dietary pattern, which is low in saturated fat, has been shown to be beneficial in a variety of health conditions. We assessed the effect of a short-term (21 days) WFPB diet intervention on daytime sleepiness in 14 patients with obstructive sleep apnea (OSA). We found a mean decrease of 3.8 points (SD = 3.3, p = 0.003) on the Epworth Sleepiness Scale (ESS) after switching from a standard Western diet to a WFPB diet. Our results suggest that a WFPB diet could be a viable dietary intervention to reduce symptom of daytime sleepiness.

Identifying and Understanding Microbial Methanogenesis in CO2 Storage

Carbon capture and storage (CCS) is an important component in many national net-zero strategies. Ensuring that CO₂ can be safely and economically stored in geological systems is critical. To date, CCS research has focused on the physiochemical behavior of CO₂, yet there has been little consideration of the subsurface microbial impact on CO₂ storage. However, recent discoveries have shown that microbial processes (e.g., methanogenesis) can be significant. Importantly, methanogenesis may modify the fluid composition and the fluid dynamics within the storage reservoir. Such changes may subsequently reduce the volume of CO₂ that can be stored and change the mobility and future trapping systematics of the evolved supercritical fluid. Here, we review the current knowledge of how microbial methanogenesis could impact CO₂ storage, including the potential scale of methanogenesis and the range of geologic settings under which this process operates. We find that methanogenesis is possible in all storage target types; however, the kinetics and energetics of methanogenesis will likely be limited by H₂ generation. We expect that the bioavailability of H₂ (and thus potential of microbial methanogenesis) will be greatest in depleted hydrocarbon fields and least within saline aquifers. We propose that additional integrated monitoring requirements are needed for CO₂ storage to trace any biogeochemical processes including baseline, temporal, and spatial studies. Finally, we suggest areas where further research should be targeted in order to fully understand microbial methanogenesis in CO₂ storage sites and its potential impact.

Rapid microbial methanogenesis during CO2 storage in hydrocarbon reservoirs

Carbon capture and storage (CCS) is a key technology to mitigate the environmental impact of carbon dioxide (CO₂) emissions. An understanding of the potential trapping and storage mechanisms is required to provide confidence in safe and secure CO₂ geological sequestration^1,2. Depleted hydrocarbon reservoirs have substantial CO₂ storage potential¹,³, and numerous hydrocarbon reservoirs have undergone CO₂ injection as a means of enhanced oil recovery (CO₂-EOR), providing an opportunity to evaluate the (bio)geochemical behaviour of injected carbon. Here we present noble gas, stable isotope, clumped isotope and gene-sequencing analyses from a CO₂-EOR project in the Olla Field (Louisiana, USA). We show that microbial methanogenesis converted as much as 13-19% of the injected CO₂ to methane (CH₄) and up to an additional 74% of CO₂ was dissolved in the groundwater. We calculate an in situ microbial methanogenesis rate from within a natural system of 73-109 millimoles of CH₄ per cubic metre (standard temperature and pressure) per year for the Olla Field. Similar geochemical trends in both injected and natural CO₂ fields suggest that microbial methanogenesis may be an important subsurface sink of CO₂ globally. For CO₂ sequestration sites within the environmental window for microbial methanogenesis, conversion to CH₄ should be considered in site selection.

Abstract P6-07-03: A live tissue platform allows dynamic measurement of neovascularization and prediction of clinical response in human breast cancer samples, ex vivo

Background: Outgrowth of new blood vessels (neovascularization) allows tumors to supply themselves with oxygen and nutrients, and to rapidly metastasize throughout the body. Triple negative breast cancer (TNBC) is particularly susceptible to neovascularization. However, success with anti-angiogenics is highly variable and often patient-specific. This is particularly true as anti-angiogenics are being combined with immunotherapies. Thus, there is a huge unmet need for clinicians to test and predict clinical efficacy of anti-angiogenics at the individual patient level, prior to treatment.

Methods: Here, we characterize a patient-autologous, ex-vivo tumor model, termed CANscript, as a platform to study the intratumor microvascular density (iMVD) of breast cancer samples (N=15). To profile iMVD we used immunohistochemical (IHC) analysis of CD34, an early biomarker of neovascularization. We then introduced anticancer and anti-angiogenic agents (e.g. Avastin) for 72 hours, and subsequently quantified phenotypic response to drugs by testing viability, cell death, proliferation and morphology. These quantitative data were then fed into a machine learning algorithm that provides a clinical response prediction (M-Score).

Results: We determined that ex-vivo culture reliably retains baseline heterogeneity of iMVD based on expression of CD34+ nodes per visual field by IHC. Furthermore, we show that anticancer and anti-angiogenic agents will dynamically alter iMVD, ex-vivo, in a patient-specific manner. Finally, we show that prediction of clinical response using the 'M-Score' algorithm associates with diminished expression of CD34 per visual field of IHC after drug pressure.

Summary: Neovascularization and iMVD are features of aggressive cancers, such as TNBC. CANscript provides a rapid assessment of clinical response to anticancer drugs, many of which induce their antitumor effect by targeting the tumor vasculature. We show that pharmacodynamics of antiangiogenics can be captured during acute ex-vivo culture under drug pressure, which associate to clinical response prediction. Therefore, we highlight the ability of CANscript as a platform to predict clinical response to anti-angiogenic drugs, and may therefore be a logical 'testing ground' to predict clinical efficacy of antiangiogenic drugs combined with immunotherapies.

Citation Format: Smalley M, Alam N, Murmu N, Somashekhar S, Ulaganathan B, Thayakumar A, Maciejko L, Ganesh J, Lawson M, Gertje H, Shanthappa BU, Goldman A. A live tissue platform allows dynamic measurement of neovascularization and prediction of clinical response in human breast cancer samples, ex vivo [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-07-03.

A Type 1 Diabetes Genetic Risk Score Predicts Progression of Islet Autoimmunity and Development of Type 1 Diabetes in Individuals at Risk

OBJECTIVE

We tested the ability of a type 1 diabetes (T1D) genetic risk score (GRS) to predict progression of islet autoimmunity and T1D in at-risk individuals.

RESEARCH DESIGN AND METHODS

We studied the 1,244 TrialNet Pathway to Prevention study participants (T1D patients' relatives without diabetes and with one or more positive autoantibodies) who were genotyped with Illumina ImmunoChip (median [range] age at initial autoantibody determination 11.1 years [1.2-51.8], 48% male, 80.5% non-Hispanic white, median follow-up 5.4 years). Of 291 participants with a single positive autoantibody at screening, 157 converted to multiple autoantibody positivity and 55 developed diabetes. Of 953 participants with multiple positive autoantibodies at screening, 419 developed diabetes. We calculated the T1D GRS from 30 T1D-associated single nucleotide polymorphisms. We used multivariable Cox regression models, time-dependent receiver operating characteristic curves, and area under the curve (AUC) measures to evaluate prognostic utility of T1D GRS, age, sex, Diabetes Prevention Trial-Type 1 (DPT-1) Risk Score, positive autoantibody number or type, HLA DR3/DR4-DQ8 status, and race/ethnicity. We used recursive partitioning analyses to identify cut points in continuous variables.

RESULTS

Higher T1D GRS significantly increased the rate of progression to T1D adjusting for DPT-1 Risk Score, age, number of positive autoantibodies, sex, and ethnicity (hazard ratio [HR] 1.29 for a 0.05 increase, 95% CI 1.06-1.6; P = 0.011). Progression to T1D was best predicted by a combined model with GRS, number of positive autoantibodies, DPT-1 Risk Score, and age (7-year time-integrated AUC = 0.79, 5-year AUC = 0.73). Higher GRS was significantly associated with increased progression rate from single to multiple positive autoantibodies after adjusting for age, autoantibody type, ethnicity, and sex (HR 2.27 for GRS >0.295, 95% CI 1.47-3.51; P = 0.0002).

CONCLUSIONS

The T1D GRS independently predicts progression to T1D and improves prediction along T1D stages in autoantibody-positive relatives.

Case Report: Spontaneous Hemorrhage of a Rare Renal Tumor in the Native Kidney of a Renal Transplant Recipient

Renal cancers are some of the most common solid organ malignancies found during follow-up of patients who have undergone renal transplantation (RT). In this case report, we describe a life-threatening spontaneous hemorrhage of a rare subtype of renal cell carcinoma in the native kidney of a 27-year-old man, 4 years after RT. After fluid resuscitation and stabilization, the patient underwent emergent open radical nephrectomy with the final histopathology reporting T1bN0Mx mucinous tubular and spindle cell (MTSC) carcinoma. This case report highlights the need to consider an underlying malignancy in patients who presents with spontaneous hemorrhage of native kidneys after RT.

Uniaxial strain control of spin-polarization in multicomponent nematic order of BaFe2As2

The iron-based high temperature superconductors exhibit a rich phase diagram reflecting a complex interplay between spin, lattice, and orbital degrees of freedom. The nematic state observed in these compounds epitomizes this complexity, by entangling a real-space anisotropy in the spin fluctuation spectrum with ferro-orbital order and an orthorhombic lattice distortion. A subtle and less-explored facet of the interplay between these degrees of freedom arises from the sizable spin-orbit coupling present in these systems, which translates anisotropies in real space into anisotropies in spin space. We present nuclear magnetic resonance studies, which reveal that the magnetic fluctuation spectrum in the paramagnetic phase of BaFe₂As₂ acquires an anisotropic response in spin-space upon application of a tetragonal symmetry-breaking strain field. Our results unveil an internal spin structure of the nematic order parameter, indicating that electronic nematic materials may offer a route to magneto-mechanical control.

A fundamental understanding of nematic order is one of the most important issues to explore in the high temperature superconductors. Here, the authors unveil an internal spin structure of the nematic order in BaFe₂As₂ by using nuclear magnetic resonance under precisely controlled tunable strain.

Abstract P5-11-04: Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications

Background: Predicting patient-specific clinical response to anticancer therapy is the holy grail of treatment-selection. It is now clear that response or resistance to therapy depends on the heterogeneous tumor microenvironment, which is comprised of malignant cells, normal stroma, soluble ligands, and tumor-immune contexture; attributes that are unique to each individual patient. This is particularly true for emerging anticancer drugs, such as immune checkpoint inhibitors, which recalibrate the body's own immune defense largely by modulating exhaustion of cytotoxic lymphocytes including T cells and natural killer (NK) cells. However, clinical response to therapy varies enormously. There is a critical gap in our understanding for the mechanisms that drive response or resistance to conventional drugs and immunotherapies at the individual patient level.

Methods: Here, we used a fully patient-autologous, clinically-validated ex-vivo tumor model that recreates and preserves the native, patient tumor microenvironment (CANscriptTM), which incorporates an algorithm-driven method to predict clinical response to therapy (M-Score). Utilizing tissue from patients diagnosed with luminal, HER2 positive, and triple-negative (ER- PR- HER2-) breast cancers (N=10), we studied phenotypic alterations to the tumor-immune contexture under pressure of conventional standard-of-care regimens and immunotherapies including immune-checkpoint inhibitors, ex-vivo. To do this, we used a comprehensive panel of immunological assays to evaluate changes in cytotoxic lymphocytes by flow cytometry and multiplex immunohistochemistry (i.e. CD56, MHC class 1A/B, NKG2D/C, CD8, CD3, PD-1, CTLA-4, TIM-3, LAG-3, 4-1BB, granzyme A/B). In addition, we used multiplex cytokine analysis to study the soluble components of the tumor microenvironment.

Results: We identified that tumor response, predicted by M-Score, correlates to increased infiltration of NK cells, which associated a pro-inflammatory cytokine signature from the tumor microenvironment. Interestingly, these evidences were concordant with induction of the tumor-expressing biomarker MICA/B, which is known to attract and recruit active NK cells. Furthermore, we determined that therapy-induced expression of protein biomarkers associated with NK cell exhaustion inversely correlated to the expression of cytotoxic granzyme B in the tumor microenvironment.

Conclusions: Taken together, these data demonstrate an integral role that NK cells contribute to the antitumor effect of therapy including conventional and immuno-modulatory drugs. It further demonstrates how a novel ex-vivo platform can be harnessed to study the mechanisms of response and resistance, which couldn't otherwise be known in a drug naïve state. Such an advance in our preclinical methods to study anticancer drugs at the individual patient level can help guide treatment decisions for clinicians while simultaneously functioning as a platform to study clinical efficacy of novel and emerging agents.

Citation Format: Smalley M, Shanthappa BU, Gertje H, Lawson M, Ulaganathan B, Thayakumar A, Maciejko L, Radhakrishnan P, Biswas M, Thiyagarajan S, Majumder B, Gopinath KS, K GB, Goldman A. Therapy-induced priming of natural killer cells predicts patient-specific tumor rejection in multiple breast cancer indications [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-11-04.

Abstract PD4-04: Combined inhibition of mTOR and CDK4/6 is required for optimal blockade of E2F function and long term growth inhibition in estrogen receptor positive breast cancer

The cyclin dependent kinase (CDK) –retinoblastoma (RB) -E2F pathway plays a critical role in the control of cell cycle in estrogen receptor positive (ER+) breast cancer. Small molecule inhibitors of CDK4/6 have shown promise in this tumour type in combination with hormonal therapies, reflecting the particular dependence of this subtype of cancer on cyclin D1 and E2F transcription factors. mTOR inhibitors have also shown potential in clinical trials in this disease setting. Recent data has suggested cooperation between the phosphatidylinositol 3-kinase (PI3K) pathway and CDK4/6 inhibition in preventing early adaptation and eliciting growth arrest, but the mechanisms of the interplay between these pathways have not been fully elucidated. Here we show that profound and durable inhibition of ER+ breast cancer growth is likely to require multiple hits on E2F mediated transcription. We demonstrate that inhibition of mTOR using the mTORC1/2 inhibitor vistusertib at 300nM causes a &gt;50% decrease in cyclin D1 protein levels and RB phosphorylation in three cell lines. At these concentrations, vistusertib treatment also elicits marked effects on E2F mediated transcription, causing changes in the mRNA levels of 28 out of 43 (65%) of a selected set of E2F target genes.Combined inhibition of mTOR, CDK4/6 and ER delivers profound and durable regressions in breast cancer cell lines and xenografts (110.2% tumour growth inhibition at day 48). In vivo data show, that over a period of 58 days, tumours failed to re-grow in the presence of the triplet combination compared to either agent alone, suggesting, that the triplet is necessary to maintain growth inhibition. Furthermore, we show that CDK4/6 inhibitor resistant cell lines re-activate the CDK-RB-E2F pathway, but remain sensitive to mTOR inhibition (EC50 52.7 nM in parental cells vs 39.6-73.3 nM in a number of palbociclib resistant cell populations), suggesting that mTORC1/2 inhibitors may represent an option for patients that have relapsed on CDK4/6 therapy. A Phase I study (PASTOR) combining the dual TOR kinase inhibitor Vistusertib with Palbociclib, and Fulvestrant is underway to explore safety and efficacy of the triplet combination in patients with metastatic breast cancer.

Citation Format: Oelmann E, Michaloglou C, Crafter C, Siersbaek R, Delpuech O, Curven J, Carnevalli L, Staniszweska A, Polanska U, Cheraghchi-Bashi A, Lawson M, Chernukhin I, McEwen R, Carroll J, Cosulich S. Combined inhibition of mTOR and CDK4/6 is required for optimal blockade of E2F function and long term growth inhibition in estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD4-04.

Nuclear magnetic resonance probe head design for precision strain control

We present the design and construction of an NMR probe to investigate single crystals under strain at cryogenic temperatures. The probe head incorporates a piezoelectric-based apparatus from Razorbill Instruments that enables both compressive and tensile strain tuning up to strain values on the order of 0.3% with a precision of 0.001%.   ⁷⁵As NMR in BaFe₂As₂ reveals large changes to the electric field gradient and indicates that the strain is homogeneous to within 16% over the volume of the NMR coil.

Indomethacin and Protein Binding of Methotrexate

Indomethacin, a non-steroidal anti-inflammatory drug is known to increase the efficacy and toxicity of methotrexate, the widely used anti-cancer drug in man. The mechanism for this interaction has not been clearly established. However, since these drugs bind with albumin, a possible displacement of methotrexate by indomethacin from albumin might explain this interaction. To investigate the possible interaction an in-vitro protein-binding displacement study was carried out in 17 normal volunteers and in two groups of eight cancer patients. One group of patients had active disease and the other was in complete clinical remission. Serum samples were obtained and protein levels estimated. The protein binding of methotrexate was measured alone and with indomethacin using equilibrium dialysis. Statistical analysis of results suggested that the binding of methotrexate is not influenced by indomethacin, confirming that methotrexate is not displaced by indomethacin.

Characteristics of AZD9708, a novel, selective β2-adrenoceptor agonist with rapid onset and long duration of action

Here we describe the pre-clinical pharmacological profile of AZD9708, a novel long-acting β(2)-adrenoceptor agonist that has potential as a once-daily therapy for asthma and chronic obstructive pulmonary disease (COPD). AZD9708 is a potent and selective agonist at the human β(2)-adrenoceptor, with selectivity over human β(1)- and β(3)-adrenoceptors of >500 and >24 fold, respectively. AZD9708 relaxes carbachol-induced contraction of human bronchial rings with a time to 90% of maximal relaxation of 13-20 min, similar to that seen with formoterol and quicker than salmeterol. In anesthetized guinea pigs, AZD9708 provides significant protection against histamine-induced airway constriction at 24 h after intratracheal and nebulized doses. This is longer than with intratracheal salmeterol, which is bronchoprotective for approximately 8 h, and formoterol, which is bronchoprotective for 8 and 12 h following nebulized and intratracheal dosing, respectively. AZD9708 also shows the potential for a greater therapeutic margin than widely used β(2)-adrenoceptor agonists such as formoterol. At a defined efficacy dose that provides 80% bronchoprotection (ED(80)), formoterol leads to a decrease in blood potassium levels in guinea pigs, whilst AZD9708 is not associated with significant reductions in potassium levels at doses up to 7 times the ED(80). [(14)C]AZD9708 is associated with extensive protein binding in both human (mean 1.0% free) and rat (mean 2.6% free) plasma. This pharmacological profile indicates the potential of AZD9708 to become an important addition to the range of bronchodilators available for the treatment of patients with obstructive airways disease.

Assessing the image quality of pelvic MR images acquired with a flat couch for radiotherapy treatment planning

OBJECTIVES

To improve the integration of MRI with radiotherapy treatment planning, our department fabricated a flat couch top for our MR scanner. Setting up using this couch top meant that the patients were physically higher up in the scanner and, posteriorly, a gap was introduced between the patient and radiofrequency coil.

METHODS

Phantom measurements were performed to assess the quantitative impact on image quality. A phantom was set up with and without the flat couch insert in place, and measurements of image uniformity and signal to noise were made. To assess clinical impact, six patients with pelvic cancer were recruited and scanned on both couch types. The image quality of pairs of scans was assessed by two consultant radiologists.

RESULTS

The use of the flat couch insert led to a drop in image signal to noise of approximately 14%. Uniformity in the anteroposterior direction was affected the most, with little change in right-to-left and feet-to-head directions. All six patients were successfully scanned on the flat couch, although one patient had to be positioned with their arms by their sides. The image quality scores showed no statistically significant change between scans with and without the flat couch in place.

CONCLUSION

Although the quantitative performance of the coil is affected by the integration of a flat couch top, there is no discernible deterioration of diagnostic image quality, as assessed by two consultant radiologists. Although the flat couch insert moved patients higher in the bore of the scanner, all patients in the study were successfully scanned.

Cost-effectiveness of gastrostomy placement for children with neurodevelopmental disability

INTRODUCTION

Malnutrition and growth deficiency are common in neurologically impaired children. Gastrostomy placement has been shown to result in significant catch-up growth, improved health of the child and reduction in family stress; its cost-effectiveness has not been investigated.

AIMS

Costs related to gastrostomy placement are estimated here from a prospective controlled study of children referred to a tertiary paediatric centre in the UK.

METHODS

Costs of inpatient stay, medication, tests, general practitioner consultations, community healthcare, equipment, and parents' indirect costs were estimated at baseline and follow-up. Costs of the different types of gastrostomy surgery are given.

RESULTS

Results for both time periods were available for 54 of the 76 children recruited to the study. Five-day food diaries were kept at baseline and follow-up. Costs of food increased slightly but not significantly post surgery from pound sterling 33 to pound sterling 40 (Euro 44 to Euro 54, US$65 to US$78) per week. Variation in cost between cases was considerable but the mean net cost difference of pound sterling 20.80 (CI - pound sterling 43.79 to pound sterling 85.35) (Euro 28 (CI Euro-59 to Euro 115), US$41 (CI US$-86 to US$167)) per week per child including for food and surgery, was also not significant. Community service costs were significantly lower post surgery. Few parents reported personal costs at either time point, although many had reduced or stopped paid work to care for the child.

CONCLUSION

As gastrostomy placement for these children resulted in significant clinical benefit at no significant extra cost, it is concluded that the procedure is cost-effective.

Validation of weekly-dose cisplatin combined with radiation therapy in locally advanced head and neck cancer

6076

Background: Impressive outcomes have been achieved using multiagent neoadjuvant and concomitant chemotherapy combined with radiation in definitive treatment of head and neck cancer; these are associated with significant toxicities. The purpose of this study was to determine the efficacy and toxicities of single-agent weekly (CDDP) during curative-intent radiation therapy. Methods: 36 patients with AJCC Stage II (3%), Stage III (14%), Stage IV (83%) squamous cell carcinoma of the larynx, hypopharynx, oropharynx and oral cavity treated from 6/2000 to 11/2003 were retrospectively reviewed. Subjects received 72 Gy irradiation given either by hyperfractionation or IMRT technique with CDDP 30 mg/m2/wk throughout the radiation course. Cisplatin was held for Grade III/IV toxicities. The endpoints were best response, percentage of Grade III/IV toxicities, disease-free survival (DFS), overall survival (OS). Results: The median number of cycles of CDDP administered was 6. Grade III/IV toxicities: 11% of patients had anemia, 6% thrombocytopenia, 33% leukopenia, 0% renal failure, and 25% developed Grade III/IV mucositis; 1 patient (3%) died due to complications directly related to therapy. Responses to therapy included 72% CR, 17% PR, and 5% SD. Median follow-up for all patients was 19 months (34.5 months for living patients), DFS at 3 years (yrs.) was 59%, and OS at 3 yrs, was 40%. Nine patients died of disease up to 2.6 (median, 0.7) yrs. after treatment, while 11 died of intercurrent diseases up to 5.1 (median, 1.8) yrs. later. Fifteen are alive (2 with recurrence) at median 2.7 yrs. after treatment. Conclusion: Concomitant weekly CDDP with full-course radiation is feasible, tolerable, highly active, and comparable to more complex, costly and toxic regimens. Intercurrent disease was a significant contributor to mortality in our population. Our regimen is an attractive alternative to sequential chemoradiotherapy programs.

No significant financial relationships to disclose.

Characterization of a selective and potent antagonist of human P2X(7) receptors, AZ11645373

BACKGROUND AND PURPOSE

The ATP-gated P2X(7) receptor has been shown to play a role in several inflammatory processes, making it an attractive target for anti-inflammatory drug discovery. We have recently identified a novel set of cyclic imide compounds that inhibited P2X(7) receptor-mediated dye uptake in human macrophage THP-1 cells. In this study the actions and selectivity of one of these compounds, AZ11645373, were characterized.

EXPERIMENTAL APPROACH

We measured membrane currents, calcium influx, and YOPRO-1 uptake from HEK cells expressing individual P2X receptors, and YOPRO1 uptake and interleukin-1beta release from THP-1 cells in response to ATP and the ATP analogue benzoylbenzoyl ATP (BzATP).

KEY RESULTS

AZ11645373 up to 10 microM, had no agonist or antagonist actions on membrane currents due to P2X receptor activation at human P2X(1), rat P2X(2), human P2X(3), rat P2X(2/3), human P2X(4), or human P2X(5) receptors expressed in HEK cells. AZ11645373 inhibited human P2X(7) receptor responses in HEK cells in a non-surmountable manner with K (B) values ranging from 5 - 20 nM, with mean values not significantly different between assays. K (B) values were not altered by removing extracellular calcium and magnesium. ATP-evoked IL-1beta release from lipopolysaccharide-activated THP-1 cells was inhibited by AZ11645373, IC(50) = 90 nM. AZ11645373 was > 500-fold less effective at inhibiting rat P2X(7) receptor-mediated currents with less than 50% inhibition occurring at 10 microM.

CONCLUSIONS AND IMPLICATIONS

AZ11645373 is a highly selective and potent antagonist at human but not rat P2X(7) receptors and will have much practical value in studies of human cells.

[Gangrene with pyocyanic infection and osteitis in a patient presenting endemic Kaposi's sarcoma: case report from Benin]

Infectious complications involving chronic skin ulcers have been well document but superinfection of ulcerated Kaposi's sarcoma nodules by multiresistant germs has rarely been reported. The purpose of this report is to describe a case in a 57-year-old HIV-negative black African man. Kaposi's sarcoma nodules appeared suddenly and spread rapidly on the right leg with pain and fever. Onset was associated with a laboratory-documented inflammatory syndrome and two metatarsal bone defects. Amputation of the leg was required due to the presence of multiresistant germs: Pseudomonas aeruginosa, multiresistant Staphylococus aureus and Candida albicans. Occurrence of bone lesions beneath superinfected Kaposi's sarcoma nodules poses a challenge for differential diagnosis of the underlying cause, i.e. either Kaposi's sarcoma or infectious osteitis. Since etiologic diagnosis of bone defects requires facilities that are rarely available in an African hospital, surgical treatment is the only alternative if antimicrobial therapy fails.

Medical, surgical, and health outcomes of gastrostomy feeding

A prospective controlled study with repeated measures before and after surgery examined the medical, surgical, and health outcomes of gastrostomy for children with disabilities at a tertiary paediatric referral centre in the North Thames area, UK. Anthropometric measures included weight, mid-upper-arm and head circumference. Five-day prospective food diaries were completed and data on physical health and surgical outcomes recorded. Seventy-six children participated and underwent gastrostomy (44 males, 32 females; median age 3 y 4 mo, range 4 mo-17 y 5 mo), and 35/76 required an anti-reflux procedure. Categories of disability were: cerebral palsy (32/76), syndrome of chromosomal or other genetic origin (25/76), slowly progressive degenerative disease (11/76), and unconfirmed diagnosis (8/76). Most children had gross motor difficulties (99%) and were non-ambulant (83%). Oromotor problems were identified in 78% of children, 69% aspirated, and 65% were fed nasogastrically before surgery. The mean weight before surgery was -2.84 standard deviation score (SDS; SD 2.21, range -9.8 to 3.4). Two-thirds of children achieved catch-up growth postoperatively: weight-for-age (mean difference 0.51 SDS, 95% CI 0.23-0.79, p=0.001) and mid-upper arm circumference (mean difference 1.12 cm, 95% confidence interval 0.50-1.75, p=0.001). Health gains included a reduction in drooling, secretions, vomiting, and constipation. Major surgical complications were found in 13/74 children. The study provides evidence that catch-up growth and health gains are possible following gastrostomy.

Comparison of bone marrow cell growth on 2D and 3D alginate hydrogels

Calcium cross-linked sodium alginate hydrogels have several advantageous features making them potentially suitable as tissue engineering scaffolds and this material has been previously used in many biomedical applications. 3D cell culture systems are often very different from 2D petri dish type cultures. in this study the effect of alginate hydrogel architecture was investigated by comparing rat bone marrow cell proliferation and differentiation on calcium cross linked sodium alginate discs and 1mm internal diameter tubes. It was found that bone marrow cell proliferation was diminished as the concentration of alginate in the 2D hydrogel substrates increased, yet proliferation was extensive on tubular alginate constructs with high alginate contents. Alginate gel thickness was found to be an important parameter in determining cell behaviour and the different geometries did not generate significant alterations in BMC differentiation profiles.

Novel P2X7 receptor antagonists

The synthesis and pharmacological evaluation of a new series of potent P2X(7) receptor antagonists is disclosed. The compounds inhibit BzATP-mediated pore formation in THP-1 cells. The distribution of the P2X(7) receptor in inflammatory cells, most notably the macrophage, mast cell and lymphocyte, suggests that P2X(7) antagonists have a significant role to play in the treatment of inflammatory disease.

Demographic, familial and trait predictors of fruit and vegetable consumption by pre-school children

OBJECTIVE

To examine the contribution to fruit and vegetable eating in children of potential predictive variables within the domains of demographics, parental feeding practices and personality traits.

DESIGN

Cross-sectional survey.

SETTING

Questionnaires were distributed to parents through 22 London nursery schools.

SUBJECTS

Questionnaires were completed and returned by 564 parents or principal caregivers of 2-6-year-old children.

RESULTS

Significant predictors of children's fruit and vegetable intake emerged from all three domains examined. Demographic variables associated with child's vegetable consumption were mother's education and child's age and gender. Only ethnicity was significantly associated with fruit consumption. Parental consumption, breast-feeding and early introduction to fruit and vegetables were related to intake of both. Family meal times were associated with higher intake of vegetables, but not of fruit. Two characteristics of children themselves (food neophobia and enjoyment of food) were strongly related to the consumption of fruit and vegetables. Subsequent multivariate analyses revealed that parental intake and child food neophobia independently predicted intake of both foods. In the presence of these, fruit consumption was affected by breast-feeding and early introduction to fruit, whereas vegetable consumption was related only to child's gender and enjoyment of food.

CONCLUSIONS

These findings may be used to inform future interventions aimed at increasing children's consumption of fruit and vegetables. Parents should be made aware of the possible impact of their own behaviour on the eating habits of their children.

Evaluation of sodium alginate for bone marrow cell tissue engineering

Sodium alginate has applications as a material for the encapsulation and immobilisation of a variety of cell types for immunoisolatory and biochemical processing applications. It forms a biodegradable gel when crosslinked with calcium ions and it has been exploited in cartilage tissue engineering since chondrocytes do not dedifferentiate when immobilised in it. Despite its attractive properties of degradability, ease of processing and cell immobilisation, there is little work demonstrating the efficacy of alginate gel as a substrate for cell proliferation, except when RGD is modified. In this study we investigated the ability of rat bone marrow cells to proliferate and differentiate on alginates of differing composition and purity. The mechanical properties of the gels were investigated. It was found that high purity and high G-type alginate retained 27% of its initial strength after 12 days in culture and that comparable levels of proliferation were observed on this material and tissue culture plastic. Depending on composition, calcium crosslinked alginate can act as a substrate for rat marrow cell proliferation and has potential for use as 3D degradable scaffold.

Meeting the challenge of prescribing and administering medicines safely: structured teaching and assessment for final year medical students

OBJECTIVES

To promote safe prescribing and administration of medicines in the pre-registration house officer (PRHO) year through a programme of structured teaching and assessment for final year medical students.

DESIGN

Forty final year medical students from two medical schools were randomly allocated either to participate in a pharmacist facilitated teaching session or to receive no additional teaching. Teaching comprised five practical exercises covering seven skills through which students rotated in small groups. One month later, a random sample of 16 taught and 16 non-taught students participated in a nine-station objective structured clinical examination (OSCE) to assess the impact of the teaching.

SETTING

Manchester School of Medicine (MSM), and Kings College School of Medicine and Dentistry (KCSMD).

PARTICIPANTS

Final year medical student volunteers.

MAIN OUTCOME MEASURES

The need for teaching as indicated by student prior experience; questionnaire rating of student acceptability of teaching and assessment; self-rating of student confidence post-assessment, and student performance assessed by OSCE.

RESULTS

The study demonstrated that the taught group achieved higher scores in eight OSCE stations. Four of these were statistically significant (P < or= 0.005). Taught students felt more confident performing the skills on five stations. From 0 to 47.5% students had prior experience of the skills taught. The post-teaching questionnaire evaluated exercises positively on several criteria, including provision of new information and relevance to future work.

CONCLUSIONS

Structured teaching provided an effective and acceptable method of teaching the medicines management skills needed in the PRHO year. The structured approach complemented variable precourse clinical experience.