Efficacy and safety of tirbanibulin 1% ointment in actinic keratoses: Data from two phase-III trials and the real-life clinical practice presented at the European Academy of Dermatology and Venereology Congress 2022

BACKGROUND

The 31st European Academy of Dermatology and Venereology (EADV) Congress took place between 7th and 10th of September 2022 in Milan, Italy.

OBJECTIVES

We report presented clinical data on the efficacy/effectiveness, safety and tolerability of tirbanibulin 1% ointment that has recently been licensed for actinic keratosis (AK) of the face or scalp in adults.

METHODS

Summary of presentations given at the EADV Congress.

RESULTS

Prof. Pellacani presented two post hoc analyses from two phase-III trials with AK patients (NCT03285477 [N = 351] and NCT03285490 [N = 351]): A descriptive analysis of medical history, concomitant medications, and safety results confirming a favourable profile for tirbanibulin showing that number of baseline AK lesions was not correlated to severity of local skin reactions. The latter analysis showed that cases of tirbanibulin application site pain or pruritus were few, and most were found to be mild. Prof. Kunstfeld reported six real-life clinical cases in Austria showing good tirbanibulin effectiveness, safety and tolerability for the treatment of new or recurring AK lesions. Results demonstrated that after 2- to 4-month follow-up, tirbanibulin was well tolerated and effective in AK patients. Presentations by Dr. Patel confirmed good outcomes and tolerability of tirbanibulin in Olsen grade 1-2 AK (N = 12) and porokeratosis patients (N = 4) treated once daily for 5 consecutive days in the United Kingdom. Furthermore, real-world experience in solid organ transplant recipients (N = 2) demonstrated effectiveness of tirbanibulin in skin field cancerization treatment. A symposium sponsored by Almirall was conducted during the congress in which Dr. Hadshiew and Dr. Lear brought together their clinical experience in Germany and the United Kingdom respectively. Interesting clinical cases of 5 consecutive days of tirbanibulin treatment compared to other treatments were discussed with attendees, as well as current treatment needs of AK patients.

CONCLUSIONS

This article provides an overview of presentations and symposium discussions, summarizing key phase-III results and real-life clinical experience with tirbanibulin shared by dermatologists across Europe.

Medicinal Aspects of PTP 1B Inhibitors as Anti-Breast Cancer Agents: An Overview

Protein tyrosine phosphatase 1B (PTP1B) has gained interest as a therapeutic target for type 2 diabetes and obesity. Besides metabolic signalling, PTP1B is a positive regulator of signalling pathways linked to ErbB2-induced breast tumorigenesis. Substantial evidence proves that its overexpression is involved in breast cancer, which suggests that selective PTP1B inhibition might be effective in breast cancer treatment. Therefore, huge research is being carried out on PTP1B inhibitors and their activity against breast cancer development. To date, only two PTP1B inhibitors, viz. ertiprotafib and trodusquemine, have entered clinical trials. The discovery of selective inhibitors of PTP1B could open a new avenue in breast cancer treatment. In this review, we provide an extensive overview on the involvement of PTP1B in breast cancer, its pathophysiology, with special attention on the discovery and development of various natural as well as synthetic PTP1B inhibitors. This study will provide significant information to the researchers developing PTP1B inhibitors for breast cancer treatment.

Interspersed expression of CUP-SHAPED COTYLEDON2 and REDUCED COMPLEXITY shapes Cardamine hirsuta complex leaf form

How genetically regulated growth shapes organ form is a key problem in developmental biology. Here, we investigate this problem using the leaflet-bearing complex leaves of Cardamine hirsuta as a model. Leaflet development requires the action of two growth-repressing transcription factors: REDUCED COMPLEXITY (RCO), a homeodomain protein, and CUP-SHAPED COTYLEDON2 (CUC2), a NAC-domain protein. However, how their respective growth-repressive actions are integrated in space and time to generate complex leaf forms remains unknown. By using live imaging, we show that CUC2 and RCO are expressed in an interspersed fashion along the leaf margin, creating a distinctive striped pattern. We find that this pattern is functionally important because forcing RCO expression in the CUC2 domain disrupts auxin-based marginal patterning and can abolish leaflet formation. By combining genetic perturbations with time-lapse imaging and cellular growth quantifications, we provide evidence that RCO-mediated growth repression occurs after auxin-based leaflet patterning and in association with the repression of cell proliferation. Additionally, through the use of genetic mosaics, we show that RCO is sufficient to repress both cellular growth and proliferation in a cell-autonomous manner. This mechanism of growth repression is different to that of CUC2, which occurs in proliferating cells. Our findings clarify how the two growth repressors RCO and CUC2 coordinate to subdivide developing leaf primordia into distinct leaflets and generate the complex leaf form. They also indicate different relationships between growth repression and cell proliferation in the patterning and post-patterning stages of organogenesis.

Developing our knowledge of the quinolone scaffold and its value to anticancer drug design

INTRODUCTION

The quinolone scaffold is a bicyclic benzene-pyridinic ring scaffold with nitrogen at the first position and a carbonyl group at the second or fourth position. It is endowed with a diverse spectrum of pharmacological activities, including antitumor activity, and has progressed into various development phases of clinical trials for their target-specific anticancer activity.

AREAS COVERED

The present review covers both classes of quinolones, i.e. quinolin-2(H)-one and quinolin-4(H)-one as anticancer agents, along with their possible mode of binding. Furthermore, their structure-activity relationships, molecular mechanisms, and pharmacokinetic properties are also covered to provide insight into their structural requirements for their rational design as anticancer agents.

EXPERT OPINION

Synthetic feasibility and ease of derivatization at multiple positions, has allowed medicinal chemists to explore quinolones and their chemical diversity to discover newer anticancer agents. The presence of both hydrogen bond donor (-NH) and acceptor (-C=O) functionality in the basic scaffold at two different positions, has broadened the research scope. In particular, substitution at the -NH functionality of the quinolone motif has provided ample space for suitable functionalization and appropriate substitution at the quinolone's third, sixth, and seventh carbons, resulting in selective anticancer agents binding specifically with various drug targets.

Elacestrant: a new FDA-approved SERD for the treatment of breast cancer

Elacestrant (RAD-1901), a selective estrogen receptor degrader, was approved by USFDA on January 27, 2023, for the treatment of breast cancer. It has been developed by Menarini Group under the brand name Orserdu®. Elacestrant showed anticancer activity both in vitro and in vivo in ER+ HER2-positive breast cancer models. The present review delebrates the development stages of Elacestrant, with its medicinal chemistry, synthesis, mechanism of action, and pharmacokinetic studies. Clinical data and safety profile has also been discussed, including data from randomized trials.

Selective Estrogen receptor degraders (SERDs) for the treatment of breast cancer: An overview

Discovery of SERDs has changed the direction of anticancer research, as more than 70% of breast cancer cases are estrogen receptor positive (ER+). Therapies such as selective estrogen receptor modulators (SERM) and aromatase inhibitors (AI's) have been effective, but due to endocrine resistance, SERDs are now considered essential therapeutics for the treatment of ER+ breast cancer. The present review deliberates the pathophysiology of SERDs from the literature covering various molecules in clinical trials. Estrogen receptors active sites distinguishing characteristics and interactions with currently available FDA-approved drugs have also been discussed. Designing strategy of previously reported SERDs, their SAR analysis, in silico, and the biological efficacy have also been summarized along with appropriate examples.

Molecular docking, 3D-QSAR and simulation studies for identifying pharmacophoric features of indole derivatives as 17β-hydroxysteroid dehydrogenase type 5 (17β-HSD5) inhibitors

Excess of androgens leads to various diseases such as Poly-Cystic Ovarian Syndrome, Prostate Cancer, Hirsutism, Obesity and Acne. 17β-Hydroxysteroid Dehydrogenase type 5 (17β-HSD5) converts androstenedione into testosterone peripherally, thereby significantly contributing to the development of these diseases. Indole-bearing scaffolds are reported as potential 17β-HSD5 inhibitors for the manifestation of diseases arising due to androgen excess. In the present work, we have extensively performed a combination of molecular docking, Gaussian field-based 3D-QSAR, Pharmacophore mapping and MD-simulation studies (100 ns) to identify the pharmacophoric features of indole-based compounds as potent 17β-HSD5 inhibitors. Molecular simulation studies of the most potent compound in the binding pocket of enzyme revealed that the compound 11 was stable in the binding pocket and showed good binding affinity through interactions with various residues of active site pocket. The Molecular mechanics Generalized Born surface area continuum solvation (MM/GBSA) and Molecular mechanics Poisson-Boltzmann surface area (MM/PBSA) calculations revealed that the compound 11 possessed a free binding energy of -36.36 kcal/mol and -7.00 kcal/mol, respectively, which was better as compared to reference compound Desmethyl indomethacin (DES). The developed pharmacophore will be helpful to design novel indole-based molecules as potent 17β-HSD5 inhibitors for the treatment of various androgenic disorders.Communicated by Ramaswamy H. Sarma.

Recent Advancements in the Discovery of MDM2/MDM2-p53 Interaction Inhibitors for the Treatment of Cancer

Abstract:

Discovery of MDM2 and MDM2-p53 interaction inhibitors changed the direction of anticancer research as it is involved in about 50% of cancer cases globally. Not only the inhibition of MDM2 but also its interaction with p53 proved to be an effective strategy in anticancer drug design and development. Various molecules of natural as well as synthetic origin have been reported to possess excellent MDM2 inhibitory potential. The present review discusses the pathophysiology of the MDM2-p53 interaction loop and MDM2/MDM2-p53 interaction inhibitors from literature covering recent patents. Focus has also been put on characteristic features of the active site of the target and its desired interactions with the currently FDA-approved inhibitor. The designing approach of previously reported MDM2/MDM2-p53 interaction inhibitors, their SAR studies, in silico studies, and the biological efficacy of various inhibitors from natural as well as synthetic origins are also elaborated. An attempt is made to cover recently patented MDM2/MDM2-p53 interaction inhibitors.

PIN-FORMED1 polarity in the plant shoot epidermis is insensitive to the polarity of neighboring cells

At the Arabidopsis shoot apex, epidermal cells are planar-polarized along an axis marked by the asymmetric localization patterns of several proteins including PIN-FORMED1 (PIN1), which facilitates the directional efflux of the plant hormone auxin to pattern phyllotaxis. While PIN1 polarity is known to be regulated non-cell autonomously via the MONOPTEROS (MP) transcription factor, how this occurs has not been determined. Here, we use mosaic expression of the serine threonine kinase PINOID (PID) to test whether PIN1 polarizes according to the polarity of neighboring cells. Our findings reveal that PIN1 is insensitive to the polarity of PIN1 in neighboring cells arguing against auxin flux or extracellular auxin concentrations acting as a polarity cue, in contrast to previous model proposals.

Novel electrogram featurization reveals a spectrum of response to ablation from atrial tachycardia to types of atrial fibrillation

Background

Although atrial tachycardia (AT) may interconvert with fibrillation (AF) in many patients, it is undefined if this represents a pathophysiological spectrum of organization, or whether it indicates that AF will respond better to ablation.

Objective

To test the hypothesis that the spatial area within which electrograms (EGMs) repeat in synchronized fashion over time indicates a spectrum from AT, in which areas span the entire atria, to AF, in which areas are limited. We further hypothesized that repetitive areas would be larger in AF patients with acute termination than in those with poor response to ablation.

Methods

We studied N=234 patients (47% women, 64±10Y), of whom (i) N=10 had AT, (ii) N=120 had AF that terminated with ablation (“Term”), (ii) N=104 had AF that did not terminate (“Non-term”). All patients had global left atrial mapping by 64 pole baskets (Abbott, IL). Spatial areas of repetitive activity (REACT) were calculated by correlating unipolar EGMs in 2x2 grids for 4 sec, repeated for the entire atria (Figure 1A, B). We quantified global organization by averaging the REACT map for each patient.

Results

Figure 1C shows progressively decreasing areas of repetitive EGM from AT to AF Term to AF Non-term (p<0.001, ANOVA). Figure 1D shows a case of AT in a 71 YO male and global REACT >0.90, a case of AF REACT 0.45 in a 65 YO male with termination by ablation, and a case of AF with REACT 0.19 in an 85 YO male that did not terminate. Further, ROC analysis of REACT analysis in AF cases predicted termination with an AUC of 0.71.

Conclusion

Spatial areas of repeating electrogram shapes indicates a spectrum from AT to AF with good and AF with poor acute response to ablation. Future studies should investigate whether REACT areas can be identified non-invasively, such as by body surface ECG, to guide ablation or prognosis.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

Spatiotemporal signatures of response to atrial fibrillation ablation

Background

Atrial fibrillation (AF) can have organized regions, in the form of consistent dominant frequency sites, focal or reentrant sites, but it is unclear how these overlap with or differ from focal atrial tachycardias (AT) or potential drivers. We set out to develop an intuitive method based on fundamental electrogram shape and timing to separate types of AF.

Objective

To test the hypothesis that spatial regions of electrogram (EGM) in AF that show similar shapes over time based on cross-correlation analysis may separate patients with differing response to ablation.

Methods

We recruited N=133 patients (63.8±12.1 Y, 32% women), (i) N=10 had AT, (ii) N=122 AF that was or was not terminated by ablation, and (iii) N=1 pacing. All patients had left atrial mapping by 64 pole baskets. We applied repetitive activity (REACT) mapping that correlates EGMs in contiguous 2x2 regions (Fig. 1A) over 4sec. To calibrate REACT, we introduced simulated variations in shape (gaussian noise) and timing (gaussian delay) to pacing EGMs and computed nomograph over 100 random trials (Fig. 1C).

Results

Fig. 1B shows that REACT in a 71-year-old man with AT is more organized than in a 65 YO man with AF (100% vs 40% mapped field). Overall, REACT was higher in AT than AF (0.63±0.15 vs 0.36±0.22, p<0.001). There were 24 cases in which global REACT between AF and AT groups had the overlapping range of values, indicating organized “islands” in AF analogous to AT. From nomograph in Fig. 1C we identified that this overlap reflects 15 ms variation in cycle length and 20% variation in EGM shape (labelled “x” in Fig. 1C).

Conclusion

Basic electrogram properties in AF of similar shapes in spatial areas over time can separate response to ablation and may represent “islands” of AT. Future studies should investigate the mechanisms for such islands and whether they may be targeted for therapy.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

High threshold efficacy responses in moderate‐to‐severe atopic dermatitis are associated with additional quality of life benefits: pooled analyses of abrocitinib monotherapy studies in adults and adolescents

Background

Once‐daily abrocitinib treatment provided meaningful improvements in signs and symptoms of moderate‐to‐severe atopic dermatitis (AD) in randomized controlled studies.

Objective

To evaluate proportions of patients with responses meeting higher threshold efficacy responses than commonly used efficacy end points and to determine if these responses were associated with quality‐of‐life (QoL) benefits.

Methods

Data from a phase 2b (NCT02780167) and two phase 3 studies (NCT03349060/JADE MONO‐1; NCT03575871/JADE MONO‐2) in adult and adolescent patients (N = 942) with moderate‐to‐severe AD receiving once‐daily abrocitinib 200 mg, abrocitinib 100 mg or placebo were pooled. Commonly used (Eczema Area and Severity Index [EASI]‐75 and ≥4‐point improvement in Pruritus Numerical Rating Scale [PP‐NRS4]) and higher threshold efficacy end points (EASI‐90 to <EASI‐100, EASI‐100 or PP‐NRS0/1 response) were evaluated. Proportions of patients across Children's Dermatology Life Quality Index/Dermatology Life Quality Index (CDLQI/DLQI) band descriptors who achieved various efficacy end points were analysed.

Results

More abrocitinib‐treated patients achieved commonly used or higher threshold efficacy end points at week 12 vs. placebo. More abrocitinib‐treated patients who achieved higher threshold efficacy end points reported ‘no effect’ of AD on QoL (by CDLQI/DLQI) at week 12 vs. those who achieved commonly used but not higher threshold efficacy end points (PP‐NRS0/1 vs. PP‐NRS4 but not PP‐NRS0/1 responders [200 mg: 66.3% vs. 17.5%; 100 mg: 62.1% vs. 20.0%]; EASI‐100, EASI‐90 to <EASI‐100 vs. EASI‐75 to <EASI‐90 responders [200 mg: 67.6%, 48.9% vs. 28.8%; 100 mg: 63.2%, 48.1% vs. 36.7%]).

Conclusions

Substantial proportions of patients with moderate‐to‐severe AD receiving abrocitinib met higher threshold efficacy end points, and this was associated with meaningful additional QoL benefits compared with those who did not meet these higher efficacy thresholds. Not only do a substantial proportion of abrocitinib‐treated patients achieve higher threshold efficacy end points but they also do so in a similar timeframe as the more commonly used thresholds for efficacy end points.

Clinical trials

NCT02780167, NCT03349060 and NCT03575871.

The Social and Emotional Learning and Orientation Scale - Development and Validation of a Brief Measure in Hindi

Accumulating evidence of the impact of social and emotional learning (SEL) on student well-being as well as academic performance has led to an increased interest in understanding and measuring SEL in students. However, most existing measures have been developed in English and there is a paucity of culturally relevant measures in other languages. In this study, we present a short, culturally sensitive 8-item scale in Hindi entitled the Social and Emotional Learning and Orientation Scale (SELOS). Factor structure of SELOS was established through exploratory ( N=2844; Mage=14.65 years) and confirmatory factor analysis ( N=1508; Mage=14.50 years) with responses from 4352 Hindi-speaking students in India. The scale demonstrated a two-factor structure, with good reliability, discriminant validity and partial measurement invariance across gender. These results provide encouraging evidence for conducting culturally sensitive studies of SEL in India and in other Hindi-speaking parts of the world.

Leaf Shape Diversity: From Genetic Modules to Computational Models

Plant leaves display considerable variation in shape. Here, we introduce key aspects of leaf development, focusing on the morphogenetic basis of leaf shape diversity. We discuss the importance of the genetic control of the amount, duration, and direction of cellular growth for the emergence of leaf form. We highlight how the combined use of live imaging and computational frameworks can help conceptualize how regulated cellular growth is translated into different leaf shapes. In particular, we focus on the morphogenetic differences between simple and complex leaves and how carnivorous plants form three-dimensional insect traps. We discuss how evolution has shaped leaf diversity in the case of complex leaves, by tinkering with organ-wide growth and local growth repression, and in carnivorous plants, by modifying the relative growth of the lower and upper sides of the leaf primordium to create insect-digesting traps.

Extent of atrium with 1:1 electrogram activation predicts response to ablation of atrial fibrillation

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

Background

Mechanisms associated with successful termination of persistent atrial fibrillation (AF) are still under debate. We sought to study the association between spatial extent of atrium with organized conduction and AF ablation success. We hypothesized that patients with large areas of atrium having 1:1 electrogram activation akin to ‘atrial tachycardia’ may have a higher likelihood of AF termination by ablation.

Methods

In n = 40 AF patients, n = 20 had termination by ablation ("Term"), and the remaining did not have AF termination by ablation ("Non-term"). Basket catheters (64 poles) were used to record unipolar electrograms (EGMs) in one or both atrium. Ablation targeted localized rotational/focal regions, after which pulmonary vein isolation was performed. Unipolar EGMs of 4sec duration at each 2x2 electrode neighborhood within 8x8 catheter grid were processed using a statistical correlation technique to identify the duration of 1:1 activations. Any EGM activation cycle that had a correlation above 80% was considered to be 1:1. Duration of contiguous 1:1 cycles was determined as percentage of total duration (4 sec).

Results

Spatial area of atrium (percentage of mapping field) and the corresponding 1:1 durations were assessed for patients in Term and Non-term groups. Fig A shows spatial 1:1 maps of a Term and a Non-term patient. Fig B shows examples of 1:1 and non-1:1 EGMs. Patients in Term group had higher average 1:1 atrial area than non-term group for any 1:1 duration (Fig C, 15 ± 22% vs 2 ± 4% with ≥70% 1:1 duration, p = 0.03). Positive and negative predictive values of duration≥70% for AF termination were 64.7%, and 75%, with specificity 60% and sensitivity 78.6%, exceeding clinical risk scores.

Conclusion

Persistent AF atrium shows areas of organized 1:1 conduction. Larger 1:1 atrial areas were identified in patients in whom AF terminated by ablation. Future studies should investigate mechanistic bases of organized conduction in AF. Abstract Figure.

Molecular dissection of TNFR-TNFα bidirectional signaling reveals both cooperative and antagonistic interactions with p75 neurotrophic factor receptor in axon patterning

During neural development, complex organisms rely on progressive and regressive events whereby axons, synapses, and neurons are overproduced followed by selective elimination of a portion of these components. Tumor necrosis factor α (TNFα) together with its cognate receptor (Tumor necrosis factor receptor 1; TNFR1) have been shown to play both regressive (i.e. forward signaling from the receptor) and progressive (i.e. reverse signaling from the ligand) roles in sympathetic neuron development. In contrast, a paralog of TNFR1, p75 neurotrophic factor receptor (p75NTR) promotes mainly regressive developmental events in sympathetic neurons. Here we examine the interplay between these paralogous receptors in the regulation of axon branch elimination and arborization. We confirm previous reports that these TNFR1 family members are individually capable of promoting ligand-dependent suppression of axon growth and branching. Remarkably, p75NTR and TNFR1 physically interact and p75NTR requires TNFR1 for ligand-dependent axon suppression of axon branching but not vice versa. We also find that p75NTR forward signaling and TNFα reverse signaling are functionally antagonistic. Finally, we find that TNFα reverse signaling is necessary for nerve growth factor (NGF) dependent axon growth. Taken together these findings demonstrate several levels of synergistic and antagonistic interactions using very few signaling pathways and that the balance of these synergizing and opposing signals act to ensure proper axon growth and patterning.

Autoregulation of RCO by Low-Affinity Binding Modulates Cytokinin Action and Shapes Leaf Diversity

Mechanisms through which the evolution of gene regulation causes morphological diversity are largely unclear. The tremendous shape variation among plant leaves offers attractive opportunities to address this question. In cruciferous plants, the REDUCED COMPLEXITY (RCO) homeodomain protein evolved via gene duplication and acquired a novel expression domain that contributed to leaf shape diversity. However, the molecular pathways through which RCO regulates leaf growth are unknown. A key question is to identify genome-wide transcriptional targets of RCO and the DNA sequences to which RCO binds. We investigate this question using Cardamine hirsuta, which has complex leaves, and its relative Arabidopsis thaliana, which evolved simple leaves through loss of RCO. We demonstrate that RCO directly regulates genes controlling homeostasis of the hormone cytokinin to repress growth at the leaf base. Elevating cytokinin signaling in the RCO expression domain is sufficient to both transform A. thaliana simple leaves into complex ones and partially bypass the requirement for RCO in C. hirsuta complex leaf development. We also identify RCO as its own target gene. RCO directly represses its own transcription via an array of low-affinity binding sites, which evolved after RCO duplicated from its progenitor sequence. This autorepression is required to limit RCO expression. Thus, evolution of low-affinity binding sites created a negative autoregulatory loop that facilitated leaf shape evolution by defining RCO expression and fine-tuning cytokinin activity. In summary, we identify a transcriptional mechanism through which conflicts between novelty and pleiotropy are resolved during evolution and lead to morphological differences between species.

The oral Janus kinase/spleen tyrosine kinase inhibitor ASN002 demonstrates efficacy and improves associated systemic inflammation in patients with moderate-to-severe atopic dermatitis: results from a randomized double-blind placebo-controlled study

BACKGROUND

ASN002 is an oral dual inhibitor of Janus kinase and spleen tyrosine kinase, which are involved in the pathogenesis of atopic dermatitis (AD) through their regulatory role on T helper (Th)1, Th2 and Th17/Th22 pathways.

OBJECTIVES

The objectives of this study were to evaluate the efficacy, safety, pharmacokinetics and effects on systemic biomarkers of ASN002 in patients with moderate-to-severe AD. Methods A total of 36 patients with moderate-to-severe AD were randomized (3 : 1) to ASN002 or placebo in the phase Ib study. Three dosage cohorts were studied over a 28-day period (20 mg, 40 mg and 80 mg once daily).

RESULTS

ASN002 was superior to placebo for the proportion of patients achieving Eczema Area and Severity Index (EASI) 50 (20 mg 20%, P = 0·93; 40 mg 100%, P = 0·003; 80 mg 83%, P = 0·03; placebo 22%), EASI 75 (20 mg 0%, P = 0·27; 40 mg 71%, P = 0·06; 80 mg 33%, P = 0·65; placebo 22%) and in change from baseline in pruritus (20 mg -1·3 ± 2·1, P = 0·81; 40 mg -3·1 ± 2·7, P = 0·27; 80 mg -4·7 ± 2·1, P = 0·01; placebo -1·6 ± 1·8). Adverse events were generally mild and similar across all groups. ASN002 showed dose-dependent plasma exposure with low interpatient variability, significantly downregulated several serum biomarkers involved in Th1, Th2 and Th17/Th22 immunity, and decreased the atherosclerosis-associated biomarker E selectin/SELE.

CONCLUSIONS

In patients with moderate-to-severe AD, ASN002 showed strong efficacy with rapid onset of action and associated improvements in systemic inflammation.

Questionnaire-based Evaluation of Factors Leading to Patient-physician Distrust and Violence against Healthcare Workers

BACKGROUND

Rising incidents of aggression and violence against healthcare workers (HCWs) is widening the rift between the patients and their caregivers. So, aim of the study was to evaluate the perceptions of healthcare workers (HCWs) and patient's attendants about factors responsible for widespread violence and patient-physician distrust.

MATERIALS AND METHODS

An anonymous, questionnaire-based, cross-sectional study was conducted over a period of one year in a tertiary care teaching institute. Performas, adapted from WHO published questionnaire and translated to local language, were administered separately to HCWs and attendants. Responses generated were collected and analyzed.

RESULTS

Out of 295 HCWs, 11 (3.7%) HCWs faced physical violence, whereas verbal abuse was faced by 147 (50%) HCWs. A higher number of incidents of physical violence (91%) and verbal abuse (64%) were faced by HCWs in the age group of 20-30 years. Verbal abuse was faced by 49.3% of nurses, 53% of junior residents, 61% of senior residents and 36% of consultants. Out of 158 incidents of workplace violence (WPV), maximum occurred in ICUs (62.0%) and emergency (21%). Unexpected death, unexpected complication, extended hospital stay, staff shortage and unexpected bill were some of the factors perceived to be responsible for WPV.

CONCLUSION

HCWs commonly face violence from patient's attendants resulting in stressful and fearful environment at the healthcare facility. Dedicated sessions on good communication and counseling for HCWs and better security arrangements at the hospitals are the need of the hour and also in the best interest of HCWs and patients.

HOW TO CITE THIS ARTICLE

Sharma S, Gautam PL, Sharma S, Kaur A, Bhatia N, Singh G, et al. Questionnaire-based Evaluation of Factors Leading to Patient-physician Distrust and Violence against Healthcare Workers. Indian J Crit Care Med 2019;23(7):302-309.

Quantitative analysis of auxin sensing in leaf primordia argues against proposed role in regulating leaf dorsoventrality

Dorsoventrality in leaves has been shown to depend on the pre-patterned expression of KANADI and HD-ZIPIII genes within the plant shoot apical meristem (SAM). However, it has also been proposed that asymmetric auxin levels within initiating leaves help establish leaf polarity, based in part on observations of the DII auxin sensor. By analyzing and quantifying the expression of the R2D2 auxin sensor, we find that there is no obvious asymmetry in auxin levels during Arabidopsis leaf development. We further show that the mDII control sensor also exhibits an asymmetry in expression in developing leaf primordia early on, while it becomes more symmetric at a later developmental stage as reported previously. Together with other recent findings, our results argue against the importance of auxin asymmetry in establishing leaf polarity.

ANP-MOORA-based approach for the analysis of selected issues of green supply chain management

Purpose

Industries start focusing on the green concept in supply chain management (SCM) to reduce waste and emission, preserve the quality of natural resources and decrease the consumption of hazardous/harmful materials for better product life cycle, which not only improve environmental performance but also economic performance. But, for industries, it is still very difficult to understand and analyze the effect of individual activities and their corresponding contribution. The purpose of this paper is to identify and analyze selected issues in green supply chain management for the implementation of the green concept in industries.

Design/methodology/approach

To fulfill the objectives of this paper, analytical network process-multi-objective optimization using rational analysis (ANP-MOORA) techniques are used. In the proposed methodologies, different issues, sub-issues, and alternatives are identified for the selection of the best supply chain using ANP which is being followed by the MOORA method.

Findings

Findings of this paper are highly valuable for the Indian manufacturing industries for the management of green supply chain (GSC) issues.

Research limitations/implications

In this research, only selected issues are identified and analyzed for the management of GSCs. Further, it is believed that an ANP-based framework helps to take up the explicit account of multi-criteria decision making (MCDM) approaches in decision making and for improving and selecting the best supply chain. Other issues in GSC can be analyzed and further extended by other MCDM approaches.

Originality/value

This paper identified different type of supply chains and their issues. The systematic way of analyzing the green concept in supply chain helps the researchers and managers to implement green management practices for improving economic and environmental performance.

Self-organizing periodicity in development: organ positioning in plants

Periodic patterns during development often occur spontaneously through a process of self-organization. While reaction-diffusion mechanisms are often invoked, other types of mechanisms that involve cell-cell interactions and mechanical buckling have also been identified. Phyllotaxis, or the positioning of plant organs, has emerged as an excellent model system to study the self-organization of periodic patterns. At the macro scale, the regular spacing of organs on the growing plant shoot gives rise to the typical spiral and whorled arrangements of plant organs found in nature. In turn, this spacing relies on complex patterns of cell polarity that involve feedback between a signaling molecule - the plant hormone auxin - and its polar, cell-to-cell transport. Here, we review recent progress in understanding phyllotaxis and plant cell polarity and highlight the development of new tools that can help address the remaining gaps in our understanding.

Circulating progenitor cells in patients with familial hypercholesterolemia

OBJECTIVE

Familial hypercholesterolemia (FH) is a genetic disease with very high levels of circulating low density lipoprotein cholesterol (LDL-C) levels that leads to accelerated atherosclerosis. Lipoprotein apheresis is an effective treatment option for patients with FH and results in reduced cardiovascular morbidity and mortality. Circulating progenitor cells (CPCs) are markers of overall vascular health and diminished levels have been associated with decreased reparative potential and worse outcomes. We assessed the short-term change in CPC levels following a single lipoprotein apheresis session in FH patients who are already on stable lipoprotein apheresis therapy. We hypothesized that in addition to a reduction in atherogenic lipids, the cardiovascular benefit from lipoprotein apheresis therapy is mediated by enhanced vascular reparative capacity through mobilization of CPCs.

METHODS

Eight FH patients (1 homozygous and 7 heterozygous) on stable lipoprotein apheresis therapy for at least three months had CPCs measured at baseline (prior to apheresis) and two hours after apheresis. Results were compared with data from age-matched hyperlipidemic (HLP) patients on statin therapy and healthy volunteers.

RESULTS

FH patients had higher baseline circulating levels of CD34+/CD133+ and CD34+/CD133+/CXCR4+ cells compared to HLP and healthy subjects. There was no significant change in CPCs after apheresis in FH patients.

CONCLUSIONS

FH patients had higher CPC counts at baseline compared to age-matched HLP and healthy controls, suggesting activation of reparative mechanism in this high risk population. Larger studies are needed to better characterize differences in CPC counts between FH subjects and HLP patients over time.

Cell type boundaries organize plant development

In plants the dorsoventral boundary of leaves defines an axis of symmetry through the centre of the organ separating the top (dorsal) and bottom (ventral) tissues. Although the positioning of this boundary is critical for leaf morphogenesis, how the boundary is established and how it influences development remains unclear. Using live-imaging and perturbation experiments we show that leaf orientation, morphology and position are pre-patterned by HD-ZIPIII and KAN gene expression in the shoot, leading to a model in which dorsoventral genes coordinate to regulate plant development by localizing auxin response between their expression domains. However we also find that auxin levels feedback on dorsoventral patterning by spatially organizing HD-ZIPIII and KAN expression in the shoot periphery. By demonstrating that the regulation of these genes by auxin also governs their response to wounds, our results also provide a parsimonious explanation for the influence of wounds on leaf dorsoventrality.

Auxin Acts through MONOPTEROS to Regulate Plant Cell Polarity and Pattern Phyllotaxis

The periodic formation of plant organs such as leaves and flowers gives rise to intricate patterns that have fascinated biologists and mathematicians alike for hundreds of years [1]. The plant hormone auxin plays a central role in establishing these patterns by promoting organ formation at sites where it accumulates due to its polar, cell-to-cell transport [2, 3, 4, 5, 6]. Although experimental evidence as well as modeling suggest that feedback from auxin to its transport direction may help specify phyllotactic patterns [7, 8, 9, 10, 11, 12], the nature of this feedback remains unclear [13]. Here we reveal that polarization of the auxin efflux carrier PIN-FORMED 1 (PIN1) is regulated by the auxin response transcription factor MONOPTEROS (MP) [14]. We find that in the shoot, cell polarity patterns follow MP expression, which in turn follows auxin distribution patterns. By perturbing MP activity both globally and locally, we show that localized MP activity is necessary for the generation of polarity convergence patterns and that localized MP expression is sufficient to instruct PIN1 polarity directions non-cell autonomously, toward MP-expressing cells. By expressing MP in the epidermis of mp mutants, we further show that although MP activity in a single-cell layer is sufficient to promote polarity convergence patterns, MP in sub-epidermal tissues helps anchor these polarity patterns to the underlying cells. Overall, our findings reveal a patterning module in plants that determines organ position by orienting transport of the hormone auxin toward cells with high levels of MP-mediated auxin signaling. We propose that this feedback process acts broadly to generate periodic plant architectures.

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Auxin-regulated MP expression and activity predict PIN1 polarity changes at the SAM

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Localized MP activity is necessary to mediate periodic organ formation

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MP orients PIN1 polarity non-cell autonomously to promote local auxin accumulation

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Sub-epidermal MP activity is required to stabilize auxin distribution patterns

End-tidal sevoflurane concentration for ProSeal(TM) versus Classic(TM) laryngeal mask airway insertion in unpremedicated anaesthetised adult females

The optimal end-tidal sevoflurane concentration for successful ProSealTM (Teleflex, Morrisville, NC, USA) laryngeal mask airway (PLMA) versus ClassicTM (Teleflex, Morrisville, NC, USA) laryngeal mask airway (CLMA) insertion in unpremedicated anaesthetised adults is unknown. We determined end-tidal sevoflurane concentrations for successful insertion in fifty percent of anaesthetised adults. This randomised, prospective, double-blind study was conducted in the operating theatre of a government tertiary care hospital. Forty-four unpremedicated American Society of Anesthesiologists physical status I and II women with cervical carcinoma (aged 30 to 60 years), scheduled for intracavity caesium implantation under general anaesthesia with a laryngeal mask airway (LMA) were included in the study. The participants were randomised to one of the two groups, to receive either a PLMA or CLMA. After anaesthetic induction with sevoflurane, a predetermined end-tidal sevoflurane concentration (starting at 2.5%) was sustained for 10 minutes before LMA insertion was attempted. End-tidal sevoflurane concentration was increased/decreased (step-size 0.25%) using Dixon and Massey's up-and-down method for the next patient based on the previous patient's response. Placement without clenching, movement, coughing or biting within one minute was considered successful insertion. The end-tidal sevoflurane concentration required for successful LMA insertion in fifty percent of anaesthetised adults was calculated as the mean of the crossover pairs' midpoints in each group and further confirmed by probit regression analysis. The end-tidal sevoflurane concentration (95% confidence interval) required for successful PLMA insertion in 50% of anaesthetised adults (3.15% [3.12% to 3.18%]) was significantly higher than that for CLMA insertion (2.71% [2.66% to 2.76%], P<0.001). These findings suggest that deeper anaesthesia is required for placement of a PLMA in comparison to a CLMA.

Impact of weekly iron folic acid supplementation with and without vitamin B12 on anaemic adolescent girls: a randomised clinical trial

BACKGROUND/OBJECTIVES

In India, approx. 70% of the adolescent girls are anaemic (haemolgobin <120 g/l). The present study was a supervised randomised double-blind clinical trial conducted among adolescent girls (11-18 years) to assess and compare the impact of weekly iron folic acid (IFA) supplementation with or without vitamin B12 on reduction in the prevalence of anaemia and on blood/serum levels of haemoglobin, serum ferritin, folic acid and vitamin B12.

SUBJECTS/METHODS

Community-based randomized controlled trial was carried out in Kirti Nagar slums of West Delhi. A total of 446 mild (100-119 g/l) and moderate (70-99 g/l) anaemic volunteer adolescent girls were identified and randomised into two groups. Weekly supervised supplementation was given for 26 weeks: Group A (n=222): iron (100 mg), folic acid (500 mcg) and placebo; Group B (n=224): iron (100 mg), folic acid (500 mcg) and cyanocobalamin (500 mcg for 6 weeks and 15 mcg for 20 weeks). Haemoglobin, serum ferritin, folic acid and vitamin B12 levels were assessed at baseline and after intervention. A total of 373 subjects completed 26 weeks of supplementation successfully.

RESULTS

The mean haemoglobin increased from 106.7±11.2 g/l and 108.9±8.91 g/l in Group A and Group B at baseline to 116.4±10.8 g/l (P<0.001) and 116.5±10.26 g/l (P<0.001) at post-intervention, respectively, with the reduction in the prevalence of anaemia by 35.9% in Group A and 39.7% in Group B (P>0.05). A total of 63.3% participants had deficient vitamin B12 levels (<203 pg/ml) at baseline, which reduced to 40.4% after intervention with cyanocobalamin, whereas no change was observed in vitamin B12 status in the other group. Significant reduction (P=0.01) in the prevalence of serum ferritin deficiency (<15 ng/ml) was observed in the group supplemented with vitamin B12 (from 36.5 to 6.4%) as compared with the other group supplemented with only IFA (from 39.1 to 15.2%).

CONCLUSIONS

IFA supplementation with or without vitamin B12 is an effective measure to cure anaemia. Although addition of vitamin B12 had similar impact on improving haemoglobin status as IFA alone, it resulted in better ferritin status. Hence, more multi-centre studies with a longer duration of supplementation or higher dose of vitamin B12 may be undertaken to assess the possible impact of vitamin B12 on improving haemoglobin levels in the population.

Federal public health strategies to minimize the importation of communicable diseases into Canada

BACKGROUND

The global spread of communicable diseases is a growing concern largely as a result of increased international travel. In Canada, although most public health management of communicable diseases occurs at the front line, the federal government also takes actions to prevent and mitigate their importation.

OBJECTIVE

To describe the role of the Public Health Agency of Canada (PHAC) in minimizing the importation of communicable diseases through preventive measures taken before travellers leave Canada and through early detection and prompt containment measures taken when travellers arrive in the country with a potential communicable disease.

INTERVENTIONS

PHAC works to minimize the importation of communicable diseases into Canada by developing evidence-based travel health advice and targeted outreach activities geared to the public and to health care professionals. On the basis of the Quarantine Act and the International Health Regulations (2005), PHAC also conducts inspections of conveyances such as aircraft and boats and works with partners to conduct border screening to assess ill travellers entering the country.

CONCLUSION

PHAC plays an important role in preventing and minimizing the importation of communicable diseases into Canada in conjunction with clinicians, public health authorities at all levels of government and other federal government departments.

Anterior septal chondroma

The cartilaginous tumours of the nasal septum are very rare and almost always arise from the posterior part. Considering the extremely rare occurrence of chondroma arising from anterior part of septum we report such a case. The tumour was well defined, homogenous in appearance and was widely excised through lateral rhinotomy approach. The least accepted traumatic etiology seems to be most appropriate for the oncogenesis in this case. We advocate a thorough histopathological examination of the tumour in to-to in order to appreciate early sarcomatous changes. This report also reviews the relevant literature.

Association of white matter hyperintensity measurements on brain MR imaging with cognitive status, medial temporal atrophy, and cardiovascular risk factors

BACKGROUND AND PURPOSE

White matter hyperintensities (WMHs) are frequently characterized as markers of cerebrovascular disease, whereas medial temporal atrophy (MTA) is a recognized marker of Alzheimer disease (AD). Our purpose was to test the reliability of a visual rating system (VRS) in evaluating WMHs and MTA and in distinguishing healthy from cognitively impaired subjects.

MATERIALS AND METHODS

Subjects (n = 192) enrolled in the Florida Alzheimer's Disease Research Center were diagnosed with no cognitive impairment, nonamnestic mild cognitive impairment (na-MCI), amnestic MCI (a-MCI), or probable AD. The severity of WMHs was assessed on T2-weighted fluid-attenuated inversion recovery axial MR images, and the severity of MTA was evaluated on 1.5-mm-thick coronal MR images by using a computer-based visual rating system. Cardiovascular risk factor scores were calculated as the sum of 10 independent cardiovascular risk factors.

RESULTS

WMH and MTA scores were greater in subjects with probable AD, relative to those with no cognitive impairment and na-MCI. MTA scores differentiated subjects with a-MCI from those with no cognitive impairment and na-MCI. The total WMH score was significantly related to MTA (r = 0.39; P < .001) but not to cardiovascular risk factor scores (r = 0.07; P = not significant). The overall correct classification rate of probable AD versus no cognitive impairment by using MTA scores was 81.8%, improving to 86.5% when combined with WMH scores.

CONCLUSIONS

Both MTA and WMH scores distinguished subjects with no cognitive impairment and probable AD. Combining MTA and WMH scores improved the correct classification rate, whereas WMH scores were significantly related to MTA scores, but not to cardiovascular risk factor scores. This finding suggests that among subjects with a-MCI and probable AD, WMHs on MR images are primarily associated with neurodegenerative disease.

Effect of rehabilitation facility location on outcomes in head and neck surgical patients

The objective of this study was to determine the significance of in-hospital rehabilitation facility vs. distant rehabilitation facilities in the outcomes and complications of post-operative head and neck surgical patients. Retrospective review of head and neck surgical patients was conducted over a 5-year period at a tertiary care medical centre. Fifty patients met criteria for this study (35 males, 15 females). Forty-two patients had a primary squamous cell carcinoma and eight patients had other primary malignancies of the head and neck. Thirty-two patients were placed in an in-hospital rehabilitation facility and 18 patients were placed in distant rehabilitation facilities (average distance 40.9 miles). Seventeen patients (34%) had complications including infection/drainage (seven patients), fistula (six patients), pneumonia (two patients), wound dehiscence (two patients) and other minor complications. The difference complication rate among the two groups was not statistically significant (37.5% in-hospital rehabilitation, 27.8% distant rehabilitation; P=0.496). The rate of hospital re-admission was not statistically significant (25% in-hospital rehabilitation patients, 16.7% distant rehabilitation patients; P=0.505). The average length of stay of patients without complications was 18.5 days (SD=5.8) for in-hospital rehabilitation and 12.9 days (SD=17) for distant rehabilitation. This difference was not statistically significant (P=0.346). In summary, one-third of post-operative head and neck surgical patients developed complications while in a rehabilitation facility. The length of stay, hospital re-admission rate and frequency of complications does not correlate with the proximity of the rehabilitation facility to the hospital where the patients received their surgery.

Green tea polyphenol EGCG suppresses cigarette smoke condensate-induced NF-kappaB activation in normal human bronchial epithelial cells

Cigarette smoke is a powerful inducer of inflammatory responses resulting in disruption of major cellular pathways with transcriptional and genomic alterations driving the cells towards carcinogenesis. Cell culture and animal model studies indicate that (-)-epigallocatechin-3-gallate (EGCG), the major polyphenol present in green tea, possesses potent anti-inflammatory and antiproliferative activity capable of selectively inhibiting cell growth and inducing apoptosis in cancer cells without adversely affecting normal cells. Here, we demonstrate that EGCG pretreatment (20-80 microM) of normal human bronchial epithelial cells (NHBE) resulted in significant inhibition of cigarette smoke condensate (CSC)-induced cell proliferation. Nuclear factor-kappaB (NF-kappaB) controls the transcription of genes involved in immune and inflammatory responses. In most cells, NF-kappaB prevents apoptosis by mediating cell survival signals. Pretreatment of NHBE cells with EGCG suppressed CSC-induced phosphorylation of IkappaBalpha, and activation and nuclear translocation of NF-kappaB/p65. NHBE cells transfected with a luciferase reporter plasmid containing an NF-kappaB-inducible promoter sequence showed an increased reporter activity after CSC exposure that was specifically inhibited by EGCG pretreatment. Immunoblot analysis showed that pretreatment of NHBE cells with EGCG resulted in a significant downregulation of NF-kappaB-regulated proteins cyclin D1, MMP-9, IL-8 and iNOS. EGCG pretreatment further inhibited CSC-induced phosphorylation of ERK1/2, JNK and p38 MAPKs and resulted in a decreased expression of PI3K, AKT and mTOR signaling molecules. Taken together, our data indicate that EGCG can suppress NF-kappaB activation as well as other pro-survival pathways such as PI3K/AKT/mTOR and MAPKs in NHBE cells, which may contribute to its ability to suppress inflammation, proliferation and angiogenesis induced by cigarette smoke.

Oxidant, vitamin A and angiogenic markers in laryngeal cancer patients

In this study the status of oxidant stress, vitamin A and angiotensin-converting enzyme (ACE) levels were evaluated in cases of laryngeal carcinoma patients from Northern India. In control subjects the levels of malondialdehyde (MDA), vitamin A and ACE were 0.23 ± 0.07 nmole/ml, 2515 ± 84 IU, and 1.4 ± 0.8 U/ml respectively. Thirty laryngeal cancer patients were divided into three groups according to the TNM classification (American Joint Committee on Cancers). In laryngeal cancer patients according to tumour size, MDA and ACE levels increased to 0.32 ± 0.04 nmole/ml and 4.7 ± 0.5 U/ml respectively and the effect was statistically significant (p<0.01). The correlation coefficient between different subgroups was also highly significant (r =0.96, p<0.01). However, serum vitamin A levels decreased to 621 ± 20 IU and the effect was statistically significant (p<0.01). In another two groups of laryngeal cancer patients, a similar pattern of various markers was obtained. Thirty patients with laryngeal carcinoma were divided into four different groups according to nodal involvement and it was observed that in laryngeal cancer patients with no nodal involvement, ACE levels were low 3.6 ± 1.4 U/ml while patients with maximum nodal involvement had the highest levels of ACE 7.1 ± 0.18 U/ml. The correlation coefficient between different groups is highly statistically significant (r = 0.95, p<0.01). In patients with laryngeal cancer the serum MDA and vitamin A levels correlation coefficient between different groups was not significant. It is thus concluded that serum ACE might be a specific test marker for laryngeal cancer disease burden. The use of this marker enzyme for therapeutics is being planned.