In-depth knowledge of the low-temperature hydrothermal synthesis of nanocrystalline hydroxyapatite from waste green mussel shell (Perna Viridis)

ABSTRACTThis study presents the use of a low-temperature hydrothermal method for extracting calcium sources from green mussel shell (P. Viridis) wastes and converting them into synthetic nanosized hydroxyapatite (HA). In this study, raw mussel shells were washed, pulverised, and sieved to start producing a fine calcium carbonate-rich powder. XRD quantitative analysis confirmed that the powder contains 97.6 wt. % aragonite. This powder was then calcined for 5 h at 900 °C to remove water, salt, and mud, yielding a calcium-rich feedstock with major minerals of calcite (68.7 wt.%), portlandite (24.7 wt.%), and minor aragonite (6.5 wt.%). The calcined powders were dissolved in aqueous stock solutions of HNO3 and NH4OH before hydrothermally reacting with phosphoric acid [(NH4)2HPO4], yielding pure, nanoscale (16-18 nm) carbonated HA crystals, according to XRD, FT-IR, and SEM analyses. The use of a low-temperature hydrothermal method for a feedstock powder produced by the calcination of low-cost mussel shell wastes would be a valuable processing approach for the industry's development of large-scale hydroxyapatite nanoparticle production.

Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Practical insights into the recycling of green mussel shells (Perna Viridis) for the production of precipitated calcium carbonate

The study presented a powder processing method involving calcination and subsequent carbonation in the synthesis of precipitated calcium carbonate (PCC) for recycling green mussel shells, which contain a high calcium carbonate content. The purity of portlandite [Ca(OH)2] as a result of calcination and subsequent moisture absorption during storage was verified using the XRD-Rietveld method. Further quantitative XRD Rietveld analysis of the PCC product confirmed the presence of vaterite (55.20 wt.%) and calcite (44.80 wt.%) minerals after carbonation process of the calcined powder product. The SEM examination of this product revealed particle aggregates of non-uniform polyhedral and cubical grains of varying small and large sizes. The FTIR analysis also confirmed that calcination and subsequent hydration of mussel shell powder yielded pure portlandite, whereas the carbonation yielded PCC polymorphism. As a result, this powder processing method is simple to scale and reduces the cost of PCC synthesis, which is critical for practical applications. The current study demonstrated that the powder processing method for recycling green mussel shells as starting materials in biomedical applications is technically feasible.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

Methylene blue versus vasopressin analog for refractory septic shock in the preterm neonate: A randomized controlled trial

BACKGROUND

Refractory septic shock in neonates is still associated with high mortality, necessitating an alternative therapy, despite all currently available treatments. This study aims to assess the vasopressor effect of methylene blue (MB) in comparison to terlipressin (TP) as adjuvant therapy for refractory septic shock in the preterm neonate.

METHODS

A double-blinded randomized controlled trial was conducted in the Neonatal Intensive Care Units at Ain Shams University, Egypt. Thirty preterm neonates with refractory septic shock were randomized to receive either MB or TP as an adjuvant to conventional therapy. Both MB and TP were administered as an intravenous loading dose followed by continuous intravenous infusion. The hemodynamic variables, functional echocardiographic variables, and oxidant stress marker were assessed over a 24 h period together with the side effects of MB.

RESULTS

MB causes significant improvement in mean arterial blood pressure with a significant decrease of the norepinephrine requirements (1.15±0.21μm/kg/min at baseline vs. 0.55±0.15μm/kg/min at 24 h). MB infusion causes an increase of the pulmonary pressure (44.73±8.53 mmHg at baseline vs. 47.27±7.91 mmHg after 24 h) without affecting the cardiac output. Serum malonaldehyde decreased from 5.45±1.30 nmol/mL at baseline to 4.40±0.90 nmol/mL at 24 h in the MB group.

CONCLUSION

Administration of MB to preterm infants with refractory septic shock showed rapid increases in systemic vascular resistance and arterial blood pressure with minimal side effects.

Inhibitory Effects of Essential Oils of Cinnamon zeylanicum and Myristica fragrans against Brucella abortus 544 Inoculated in Fresh Baladi Cheese

Background: Essential Oils (EOs) are natural metabolic products of plants that contain a condensed chemical hydrophobic liquid compounds. The aim of this study was to evaluate inhibitory effects of EOs of Cinnamon zeylanicum and Myristica fragrans against Brucella abortus 544 inoculated in fresh Baladi cheese. Methods: Fresh Baladi cheese was manufactured from experimentally contaminated milk with B. abortus 544 in combination of EOs of C. zeylanicum or M. fragrans. Cheese samples were periodically subjected to further microbiological surveys at different storage times (0, 1, 24, 48, 72, and 96 h). The inhibition zone diameter and Minimum Inhibitory Concentration (MIC) against tested strain were also determined. Statistical analyses were conducted by GraphPad Prism Statistical Software. Results: The inhibition zone diameter of the paper disk were 9.5±0.5 and 16±0.57 mm at 1% concentration of M. fragrans and C. zeylanicum EOs, respectively; and 15±0.28 and 21±0.76 mm at 5% concentration of M. fragrans and C. zeylanicum EOs, respectively. The values of inhibition zone diameters were significantly (p<0.0001) different between the two selected concentrations of 1% and 5% for the studied EOs. Also, anti-Brucella activity of C. zeylanicum was significantly (p<0.0001) more than that of M. fragrans EO. Conclusion: Due to the appropriate anti-Brucella activity, C. zeylanicum EO could be applied as an effective natural preservative in the production of fresh Baladi cheese. Conversely, using M. fragrans EO could not protect the fresh Baladi cheese against Brucella.

Detection and distribution of anti-leptospiral antibody among dogs and their handlers

The incidence of leptospirosis seems to be on the rise and could be an alarming indirect indication of a global re-emergence. It is a potential public health threat when dogs are speculated to be involved in the transmission of leptospirosis through possible subclinical harbouring of Leptospira spp. and subsequent shedding into the environment. This study aimed to detect anti-leptospiral antibodies among dogs and their handlers using the microscopic agglutination test (MAT). Blood samples from 266 apparently healthy dogs and 194 dog handlers were collected at four working dog organisations and four dog shelters. Serum samples were tested using MAT against 20 leptospiral serovars with a cut-off titre >=1:100 (dog) and >=1:50 (dog handlers). Seventy dogs (70/266; 26.3%) were seropositive mainly against serovars Icterohaemorrhagiae, Ballum, Bataviae and Javanica (titres ranged: 1:100-1:800). Sixty-seven dog handlers (67/194; 34.5%) were seropositive mainly against serovars Grippotyphosa, Icterohaemorrhagiae and Malaysia (titres ranged: 1:50-1:200). Dogs were seropositive due to exposure, vaccination or active infection. Seropositive dog handlers could indicate exposure or active infection. This shows the potential of dogs in maintaining and spreading the infection in Malaysia. Due to the occupational risk as a result of frequent contact with dogs and exposure to contaminated environments, dog handlers should be made aware of the presence of this zoonotic disease.

Observational study of talimogene laherparepvec use in the anti-PD-1 era for melanoma in the US (COSMUS-2)

AIM

Talimogene laherparepvec (T-VEC) is an intralesional therapy for unresectable, metastatic melanoma. T-VEC real-world use in the context of anti-PD1-based therapy requires further characterization.

MATERIALS & METHODS

A retrospective review of T-VEC use from 1 January 2017 and 31 March 2018 for melanoma patients was conducted at seven US institutions.

RESULTS

Among 83 patients, three categories of T-VEC and anti-PD-1 therapy were identified: T-VEC used without anti-PD-1 (n = 29, 35%), T-VEC after anti-PD-1-based therapy (n = 22, 27%) and concurrent T-VEC and anti-PD-1-based therapy (n = 32, 39%). 25% of patients discontinued T-VEC therapy due to no remaining injectable lesions, 37% discontinued T-VEC due to progressive disease. Discontinuation of T-VEC did not differ by anti-PD-1-based therapy use or timing.

CONCLUSION

In real-world settings, T-VEC may be used concurrently with or after anti-PD-1-based therapy.

Association between complete response and survival in advanced melanoma treated with talimogene laherparepvec (T-VEC) plus ipilimumab (ipi)

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Background: This is the first randomized trial testing the addition of an oncolytic virus to an immune checkpoint inhibitor for advanced melanoma. At the 3-year (yr) follow-up, the combination (combo) of T-VEC and ipi demonstrated durable and statistically superior objective response rate (ORR) over ipi alone (36.7% vs. 16.0%; odds ratio, 3.0; 95% Cl, 1.6–6.0; P = 0.002). Complete response (CR) rate was 21.4% with the combo and 6.0% with ipi. Median overall survival (OS) was not reached in either arm. In this post hoc analysis, we utilized the 3-yr landmark data to explore the relationship between CR and OS in the combo arm. Methods: Pts with unresectable, stage IIIB-IV melanoma were randomized 1:1 to receive combo or ipi alone. T-VEC was administered intratumorally on day 1 of week (wk) 1 at 106 plaque-forming units (PFU)/mL followed by subsequent doses at 108 PFU/mL on day 1 of wk 4, and every 2 wks thereafter. Ipi (3 mg/kg) was given every 3 wks starting on day 1 of wk 6 for up to 4 doses. Response was assessed by investigators per immune-related response criteria every 12 wks until disease progression. The primary endpoint was ORR; key secondary endpoints were OS, progression-free survival, and safety. Results: 198 pts were randomized (98 to combo; 100 to ipi). As of February 25, 2019, the median follow-up time was 40.0 mos (range: 0.2–63.7) for the combo arm. Among 98 pts who received combo, 21 (21.4%) had a best overall response of CR including 8 who converted from an initial partial response (PR), 15 (15.3%) had PR, 19 (19.4%) had stable disease, 30 (30.6%) had progressive disease, and 13 (13.2%) were unevaluable. Of 21 pts achieving CR, 17 (81%) had ECOG status of 0, 16 (76.2%) had stage IIIB-IVM1a disease, and 16 (76.2%) had no visceral metastases. Median duration of CR was not reached (range: 5.4[+]–58.2[+] mos); 19 of 21 CRs lasted more than 6 months. The baseline tumor burden was lower in pts with CR than in those with non-CR. Median OS was not reached in pts with CR (range: 25.1[+]–63.7[+] mos) and was 47.6 mos (range: 0.2[+]– 63.7[+] mos) in pts with non-CR (Log-rank P = 0.0005). The Kaplan–Meier estimated 3-year OS rate was 100.0% for patients with CR and 52.3% for those with non-CR. Conclusions: CR rate was higher with T-VEC plus ipi than with ipi alone in pts with advanced melanoma (21.4% vs. 6.0%). In the combo arm, CR was associated with prolonged OS, and pts with CR tended to have better ECOG performance status, earlier-stage disease, and lower baseline tumor burden, as compared with those with non-CR. Clinical trial information: NCT01740297.

Intratumoral Immunotherapy-Update 2019

Intratumoral immunotherapies aim to trigger local and systemic immunologic responses via direct injection of immunostimulatory agents with the goal of tumor cell lysis, followed by release of tumor‐derived antigens and subsequent activation of tumor‐specific effector T cells. In 2019, a multitude of intratumoral immunotherapies with varied mechanisms of action, including nononcolytic viral therapies such as PV‐10 and toll‐like receptor 9 agonists and oncolytic viral therapies such as CAVATAK, Pexa‐Vec, and HF10, have been extensively evaluated in clinical trials and demonstrated promising antitumor activity with tolerable toxicities in melanoma and other solid tumor types. Talimogene laherparepvec (T‐VEC), a genetically modified herpes simplex virus type 1–based oncolytic immunotherapy, is the first oncolytic virus approved by the U.S. Food and Drug Administration for the treatment of unresectable melanoma recurrent after initial surgery. In patients with unresectable metastatic melanoma, T‐VEC demonstrated a superior durable response rate (continuous complete response or partial response lasting ≥6 months) over subcutaneous GM‐CSF (16.3% vs. 2.1%; p < .001). Responses were seen in both injected and uninjected lesions including visceral lesions, suggesting a systemic antitumor response. When combined with immune checkpoint inhibitors, T‐VEC significantly improved response rates compared with single agent; similar results were seen with combinations of checkpoint inhibitors and other intratumoral therapies such as CAVATAK, HF10, and TLR9 agonists. In this review, we highlight recent results from clinical trials of key intratumoral immunotherapies that are being evaluated in the clinic, with a focus on T‐VEC in the treatment of advanced melanoma as a model for future solid tumor indications.

Implications for Practice

This review provides oncologists with the latest information on the development of key intratumoral immunotherapies, particularly oncolytic viruses. Currently, T‐VEC is the only U.S. Food and Drug Administration (FDA)‐approved oncolytic immunotherapy. This article highlights the efficacy and safety data from clinical trials of T‐VEC both as monotherapy and in combination with immune checkpoint inhibitors. This review summarizes current knowledge on intratumoral therapies, a novel modality with increased utility in cancer treatment, and T‐VEC, the only U.S. FDA‐approved oncolytic viral therapy, for medical oncologists. This review evaluates approaches to incorporate T‐VEC into daily practice to offer the possibility of response in selected melanoma patients with manageable adverse events as compared with other available immunotherapies.

This review highlights recent results from clinical trials of key intratumoral immunotherapies that are being evaluated in the clinic, with a focus on talimogene laherparepvec in the treatment of advanced melanoma as a model for future solid tumor indications.

Experimental data for effect of carbon black loading on tensile, hardness and rebound of magnetic iron filled natural rubber composites

Generally, a base isolator is made up of alternate layers of steel and rubber. The idea of adopting magnetoreological elastomers (MREs) in base isolator systems was introduced in the past few years in order to improve the efficiency of base isolator systems. The article provides information on the mechanical corresponding to different carbon black loading loadings of 20 parts per hundred rubber (pphr), 40 pphr and 60 pphr in natural rubber compound. The mechanical dataset described the data from tensile, hardness and rebound test.

Checkpoint inhibitor (CPI) experienced patients (pts) from COSMUS-1: A clinical observational study of talimogene laherparepvec (T-VEC) in United States practice

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Background: T-VEC, a modified oncolytic herpes virus, is an intralesional therapy for unresectable advanced melanoma. COSMUS-1, a recently presented observational chart review study from 7 US academic sites, described metastatic melanoma treatment (tx) patterns and safety of T-VEC in the real-world setting (Perez et al, SMR 2018). In this analysis, we evaluated T-VEC use in pts after prior CPI use or with CPI from COSMUS-1. Methods: Of 76 pts treated with T-VEC (first dose 27Nov2015-15Dec2016), 33 pts had received pembrolizumab, nivolumab and/or ipilimumab (ie, CPI) prior to or with T-VEC and were analyzed for demographics, clinicopathologic characteristics, outcomes, and adverse events. Two groups were identified: Group A, CPI then T-VEC only and Group B, CPI with T-VEC. Results: There were 21 pts in A and 12 pts in B; in B, all received TVEC + CPI with (1) prior CPI, n = 5, (2) prior CPI and additional CPI after combination, n = 1, (3) as combination only, n = 4, or (4) as combination followed by CPI only, n = 2. In A and B, respectively, mean age was 72 yrs and 63 yrs; 12 (57%) and 9 (75%) were men; 17 (81%) and 9 (75%) had ECOG 0-1,10 (48%) and 4 (33%) had Stage IIIB-IVM1a, and 11 (52%) and 7 (58%) had Stage IVM1b/c. Two pts (both in B) remained on T-VEC by study end. 21 (100%) pts in A and 10 (83%) pts in B discontinued T-VEC (most common, respectively: 10 pts and 3 pts due to disease progression, 4 pts and 2 pts due to physician decision). 2 pts had no injectable lesions left (in A) and 1 pt (in A) had pathologic complete response (CR). Adverse events of interest were reported in 7 pts (33%) in A and 6 pts (50%) in B; most common events in A and B, respectively, were immune-mediated events (n = 3 and 6) which included flu-like symptoms (fever, chills, rigor; n = 2 and 5) and injection site complications (n = 5 and 2). No herpetic infections were reported in pts. Conclusions: These real-world data suggest that T-VEC is well tolerated and can be administered in pts previously treated with a CPI, both those who switched to T-VEC or those where T-VEC was added on. One pt achieved a pathologic CR.

Consensus generation of a minimum set of outcome measures for auditing glaucoma surgery outcomes-a Delphi exercise

PURPOSE

To identify the key set of glaucoma surgery outcome measures considered most important and practical to collect by glaucoma specialists.

METHODS

One hundred two glaucoma specialists (57 members of the UK and Eire Glaucoma Society (UKEGS) and 45 members of the European Glaucoma society (EGS)) took part in an Online Delphi exercise. The RAND/UCLA appropriateness method was used analyse data from each round and generate a disagreement index.

RESULTS

Participants agreed on 13 baseline data points and 12 outcomes that were considered important and practical to collect. For intraocular pressure (IOP) percentage reduction in IOP from baseline (last three IOP readings pre-op) and reduction below a specified target were considered important. For visual fields, change in a global visual field index, e.g. MD, and development of progression as assessed by linear regression were considered important. From a safety perspective, any visual loss resulting in a doubling of the minimal angle of resolution, loss of 5 dB or more of visual field or development of advanced field loss (Hodapp Parrish Anderson Stage 4) was considered important. The importance of routinely using patient reported outcome measures (PROMs) was highlighted. Consensus suggested that outcomes of glaucoma treatments should be reported at 1, 5 and 10 years.

CONCLUSIONS

There was broad consensus on a minimum dataset for reporting the outcomes of glaucoma surgery and outcome measurement intervals.

Aedes albopictus in urban and forested areas of Malaysia: A study of mitochondrial sequence variation using the CO1 marker

This study explores the use of a long fragment of the mitochondrial cytochrome oxidase subunit 1 (CO1) marker to elucidate the genetic diversity of Aedes albopictus sampled from urban and forested regions in Peninsular and East Malaysia. A total of 36 samples were collected from 5 localities from which its genetic variability was analysed. 33 distinct mtDNA haplotypes were identified following the amplification and sequencing of the concatenated CO1 gene. The analysed region of the CO1 gene identified substantial levels of genetic diversity among mosquitoes in urban populations and revealed unique genealogical relationships between local isolates as revealed in the haplotype network. This study highlights the reliability of the long CO1 fragment to identify genetic divergence of Aedes albopictus which can be utilized in forthcoming studies.

Initial Risk Assessment as part of the Quality by Design in peptide drug containing formulation development

Risk Assessment (RA) is the key element of the Quality by Design (QbD) approach recommended by the pharmaceutical regulatory bodies. This research paper aimed to implement the regulatory requirements, the QbD thinking and the RA from the first steps of the oral peptide formulation development. The authors intended to give a general recommendation about the application possibilities of this methodology, to demonstrate the risk factors and the required decision points. Later, this paper presents a concrete development in practice. This case study shows the QbD and RA based early phase development of the GLP 1 analog, Liraglutide, an antidiabetic peptide drug mainly used in the treatment of type 2 Diabetes Mellitus. The objective here was to design Liraglutide encapsulated polymeric nanoparticles for oral delivery and the progress of their RA based development is presented. In this case, the particle size, the encapsulation efficiency, and the drug loading were found as the most critical quality attributes, the polymer concentration, the drug concentration, the w2/o ratio, the stabilizer concentration and polymer type were identified by the criticality rating as having the greatest impact on the product quality among the critical material attributes, finally the sonication time and sonication power were selected as the most critical elements of the production process. The results showed the importance of the risk factor-focused development in the oral peptide pharmaceutical formulations, and underlined the importance of the profound planning phase even in such cases. The formulation of an oral peptide delivery system is associated with several risks, but their priority ranking helps to focus on the resources (human, financial, time) related to the final product quality aimed at.

Effects of herbal preparations on symptom clusters during the menopausal transition

AIMS

To determine the effects of herbal therapies on hot flushes and at least one other symptom including, sleep, mood, cognition, and pain that women experience during the menopausal transition and early postmenopause.

METHODS

An extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized, controlled trials reported in English between January 2004 and July was conducted by an experienced reference librarian. There were 1193 abstracts identified but only 58 trials examined effectiveness of therapies for hot flushes and at least one additional co-occurring symptom.

RESULTS

Seventeen studies used herbal preparation including seven studies of black cohosh, two studies of black cohosh mixed with other herbals, and eight studies of other herbals. Of these, one study of black cohosh, two studies of black cohosh mixed with other herbals, and four other herbal studies had significant effects on hot flushes and at least one additional co-occurring symptom. The adverse events of herbal therapies were various, ranging from mild to moderate and women were generally tolerant of the preparations.

CONCLUSIONS

Black cohosh mixed with other herbals, Rheum rhaponticum, and French maritime pine bark had significant effects on hot flushes and at least one other symptom. These herbal therapies may be a promising alternative treatment to hormonal treatment. Future studies should classify women based on their menopausal stages, report each symptom separately, have adequate sample size, focus on multiple co-occurring symptoms, and target symptom management of menopausal symptoms.

Effects of mind-body therapies on symptom clusters during the menopausal transition

AIMS

Although most women experience symptom clusters during the menopausal transition and early postmenopause, investigators reporting clinical trial effects for hot flushes often omit co-occurring symptoms. Our aim was to review controlled clinical trials of mind-body therapies for hot flushes and at least one other co-occurring symptom from these groups: sleep, cognitive function, mood, and pain.

METHODS

An experienced reference librarian performed an extensive search of PubMed/Medline, CINAHL Plus, PsycInfo, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Web of Science, EMBASE, AMED, and Alt-Health Watch for randomized controlled trials reported in English between 2004 and July 2011. Of 1193 abstracts identified, 58 trials examining effectiveness of therapies for hot flushes and at least one additional co-occurring symptom of interest were identified.

RESULTS

Eight trials (ten publications) examined relaxation, yoga, or exercise. Physical activity/exercise trials (six) yielded mixed results; only one significantly reduced hot flushes and mood symptoms. Of two relaxation therapy trials, only mindfulness-based stress reduction training reduced sleep and mood symptoms and had within-group treatment effects on hot flushes. Yoga (one trial) significantly reduced hot flushes and improved cognitive symptoms more than exercise, and also had within-group effects on sleep and pain symptoms.

CONCLUSIONS

Studies of mind-body therapies for hot flushes increasingly measure multiple symptom outcomes, but few report treatment effects in ways that allow clinicians to consider symptom clusters when prescribing therapies. Future studies need to measure and report results for individual symptoms or group like symptoms together into subscales rather than use subscales with mixed dimensions. Trials with larger numbers of participants are essential to allow evaluation of these therapies on multiple co-occurring symptoms.

Effect of compositions in nanostructured lipid carriers (NLC) on skin hydration and occlusion

Purpose

To study the effects of varying lipid concentrations, lipid and oil ratio, and the addition of propylene glycol and lecithin on the long-term physical stability of nanostructured lipid nanocarriers (NLC), skin hydration, and transepidermal water loss.

Methods

The various NLC formulations (A1–A5) were prepared and their particle size, zeta potential, viscosity, and stability were analyzed. The formulations were applied on the forearms of the 20 female volunteers (one forearm of each volunteer was left untreated as a control). The subjects stayed for 30 minutes in a conditioned room with their forearms uncovered to let the skin adapt to the temperature (22°C ± 2°C) and humidity (50% ± 2%) of the room. Skin hydration and skin occlusion were recorded at day one (before treatment) and day seven (after treatment). Three measurements for skin hydration and skin occlusion were performed in each testing area.

Results

NLC formulations with the highest lipid concentration, highest solid lipid concentration, and additional propylene glycol (formulations A1, A2, and A5) showed higher physical stability than other formulations. The addition of propylene glycol into an NLC system helped to reduce the particle size of the NLC and enhanced its long-term physical stability. All the NLC formulations were found to significantly increase skin hydration compared to the untreated controls within 7 days. All NLC formulations exhibited occlusive properties as they reduced the transepidermal water loss within 7 days. This effect was more pronounced with the addition of propylene glycol or lecithin into an NLC formulation, whereby at least 60% reduction in transepidermal water loss was observed.

Conclusion

NLCs with high lipid content, solid lipid content, phospholipid, and lecithin are a highly effective cosmetic delivery system for cosmetic topical applications that are designed to boost skin hydration.

Kisspeptin and seasonal control of reproduction in male European sea bass (Dicentrarchus labrax)

In the present study, we developed and validated real-time quantitative RT-PCR assays for a suite of genes involved in the brain-pituitary gonadal axis in fish including kisspeptin genes and its receptor (Kiss1, kiss2, kissr4) and gonadotropin-releasing hormone genes (sbGnRH, sGnRH, cGnRHII) in the brain, and gonadotropin genes (fshβ and lhβ) in the pituitary. Sex steroid profiles (T and 11-KT) and gonadal development were also studied over a full annual reproductive cycle in adult male sea bass. The cDNA partial sequence of sea bass kissr4 encoding 185 amino acids showed a high degree of conservation with other fish kissr4 subtype. Results clearly showed a seasonal profile for Kiss1, kiss2 and kissr4 mRNAs. Kissr4, fshβ and lhβ levels increased gradually and peaked during spermatogenesis (January) while Kiss1, kiss2, cGnRH-II as well as steroids showed peaks during early spawning (March). No significant seasonal changes were observed for sbGnRH and sGnRH expression. These results support the possible involvement of the kiss genes and their receptor (kissr4) in the seasonal control sea bass reproduction. However, a lack of correlation between kiss genes and sbGnRH expression and the mismatch between kisspeptin and the onset of gonadotropin surge contrast with previous findings.

Cathodic stripping voltammetric determination at a hanging mercury drop electrode of the environmental heavy metal precipitant trimercapto-s-triazine (TMT)

Trimercapto-s-triazine (TMT) is available commercially for precipitating heavy metals in effluents prior to discharge and for recovering silver and copper. The TMT content of an effluent for discharge is normally monitored down to about 2 ppm by means of its UV absorption at 285 nm. Indirect cathodic-stripping voltammetric methods of determining TMT at sub-ppb levels in standard solutions are reported here. These methods might prove suitable for the determination of TMT in effluent at levels lower than is currently possible. TMT can be accumulated and determined indirectly at pH 9.0 as its mercury salt down to sub-ppb levels. Accumulation is made at 0 V and the mercury TMT reduction peak is at -0.47 V. Alternatively, by adding nickel(II), TMT can be determined optimally at pH 7.8, using the catalytic nickel peak at -0.73 V and accumulating between -0.10 and -0.60 V: at this pH the HgTMT peak at -0.47 V is small. At slightly higher pH (pH 8.6) the nickel TMT complex can be accumulated directly at -0.40 V, but at this pH, however, a slightly increased sensitivity can be achieved by accumulating TMT as its mercury salt, at -0.1 V in the presence of nickel(II), the nickel TMT complex being formed during the potential sweep on the release of the TMT when the mercury salt is reduced. Unlike many other thiols TMT is not accumulated as its copper(I) salt on addition of copper(II) to the solution.

Allantoic cyst - an unusual umbilical cord swelling

We report a baby with an unusual umbilical cord swelling. On the antenatal scans, a cystic area within the umbilical cord near its insertion onto the abdominal wall was detected. Postnatally an unusually thick umbilical cord with a yellow fluid filled cyst at the base was noted. The fluid from the cyst was confirmed as urine and ultrasound confirmed patent urachus. The baby underwent a cystoscopy and excision of patent urachus with associated allantoic cyst. Allantoic cyst is a rare swelling formed at the base of umbilicus associated with a patent urachus which results from an allantoic remnant. Paediatricians need to be aware about this condition as investigation is required to differentiate allantois cysts from umbilical pseudocysts. A patent urachus with allantoic cyst requires surgical excision.

In vitro modulation of naturally occurring flavonoids on cytochrome P450 2A6 (CYP2A6) activity

1. The effect of flavonoids on coumarin 7-hydroxylation, an activity marker of an important human liver cytochrome P450 isoform, cytochrome P450 2A6 (CYP2A6), was investigated in this study. 2. Coumarin 7-hydroxylase activity was measured fluorometrically in reaction mixtures containing cDNA-expressed CYP2A6, nicotinamide adenine dinucleotide phosphate generating system and 10 uM coumarin, at various concentrations of flavonoids. 3. Among the 23 compounds tested, most of the active members were from flavonol group of hydroxylated flavonoids, with myricetin being the most potent inhibitor followed by quercetin, galangin, and kaempferol. 4. Further exploration of the inhibition mechanism of these compounds revealed that myricetin, galangin, and kaempferol exhibited mixed-type of inhibition pattern while quercetin was observed to exhibit competitive mode of inhibition. 5. Structure-function analyses revealed that degree of inhibition was closely related to the number and location of hydroxyl groups, glycosylation of the free hydroxyl groups, degree of saturation of the flavane nucleus as well as the presence of the alkoxylated function.

Tumour necrosis factor haplotypes associated with sensory neuropathy in Asian and Caucasian human immunodeficiency virus patients

In human immunodeficiency virus (HIV) patients, neuropathy is a common adverse side effect to some antiretroviral treatments, particularly stavudine. As stavudine is cheap, it is widely used in Asia and Africa. We showed that increasing age and height moderately predict the development of neuropathy. This was improved by the inclusion of tumour necrosis factor (TNF)-1031 (rs1799964). To investigate this association, Malay (n = 64), Chinese (n = 74) and Caucasian patients (n = 37) exposed to stavudine were screened for neuropathy. DNA samples were genotyped for polymorphisms in the central major histocompatibility complex (MHC) near TNF, and haplotypes were derived. The haplotype group FVa6,7,8 (incorporating TNF-1031) was found to be associated with neuropathy in Chinese patients in bivariate analyses (P = 0.03), and in Malays and Chinese in a multivariate analysis correcting for age and height (P = 0.02, P = 0.03, respectively). This trend was also confirmed in Caucasians.

CYP2C9 polymorphism: prevalence in healthy and warfarin-treated Malay and Chinese in Malaysia

INTRODUCTION

Genetic polymorphisms of CYP2C9 among different populations in different geographical regions could be different. CYP2C9 has been reported to be the enzyme responsible for the metabolism of many drugs, including warfarin and other drugs with a narrow therapeutic index. Realising the importance of inter-individual differences in the genetic profile in determining the outcome of a drug therapy, this study was conducted to explore the types and frequencies of CYP2C9 alleles in healthy and warfarin-treated Malays and Chinese, the two major ethnic groups in Malaysia. We aimed to evaluate the prevalence of the types and frequencies of common CYP2C9 alleles (*1, *2, *3 and *4) among the healthy unrelated individuals and diseased patients prescribed with warfarin.

METHODS

A total of 565 Malay and Chinese subjects, including 191 patients prescribed warfarin, were recruited into the study. The healthy unrelated volunteers were also blood donors and they were confirmed to be physically fit before participating in the study. For the patients group, their medical records were reviewed for the relevant clinical data. 5 ml of blood was taken from each subject, and DNA was isolated and used for identification of the CYP2C9 allele *1, *2, *3 and *4 using nested-allele-specific-multiplex-polymerase chain reaction.

RESULTS

CYP2C9*1,*2 and *3 were detected among the healthy unrelated individuals but only CYP2C9*1 and *3 were found in the diseased patients. Among the healthy Malays, 92.8 percent had CYP2C9*1/*1, 2.6 percent had CYP2C9*1/*2 and 4.6 percent had CYP2C9*1/*3 genotypes. Among the Chinese, 92.3 percent had CYP2C9*1/*1 and 7.7 percent had CYP2C9*1/*3, but CYP2C9*2 and *4 were not found in the Chinese. Among the warfarin-treated group, only CYP2C9*1 and *3 were detected. Even though some alleles were not detected among the patients, suggesting the possible role of CYP2C9 in certain disorders, the sample size of the current study is too small to be able to arrive at any conclusive results.

CONCLUSION

Based on the above-observed genotypes, the prevalence of CYP2C9*2 and *3 was low in healthy and warfarin-treated Malays and Chinese in Malaysia. Further studies are required to support the clinical effectiveness of pharmacogenomics testing.