Mortality and HRQoL in ICU patients with delirium: Protocol for 1-year follow-up of AID-ICU trial

BACKGROUND

Intensive care unit (ICU)-acquired delirium is frequent and associated with poor short- and long-term outcomes for patients in ICUs. It therefore constitutes a major healthcare problem. Despite limited evidence, haloperidol is the most frequently used pharmacological intervention against ICU-acquired delirium. Agents intervening against Delirium in the ICU (AID-ICU) is an international, multicentre, randomised, blinded, placebo-controlled trial investigates benefits and harms of treatment with haloperidol in patients with ICU-acquired delirium. The current pre-planned one-year follow-up study of the AID-ICU trial population aims to explore the effects of haloperidol on one-year mortality and health related quality of life (HRQoL).

METHODS

The AID-ICU trial will include 1000 participants. One-year mortality will be obtained from the trial sites; we will validate the vital status of Danish participants using the Danish National Health Data Registers. Mortality will be analysed by Cox-regression and visualized by Kaplan-Meier curves tested for significance using the log-rank test. We will obtain HRQoL data using the EQ-5D instrument. HRQoL analysis will be performed using a general linear model adjusted for stratification variables. Deceased participants will be designated the worst possible value.

RESULTS

We expect to publish results of this study in 2022.

CONCLUSION

We expect that this one-year follow-up study of participants with ICU-acquired delirium allocated to haloperidol vs. placebo will provide important information on the long-term consequences of delirium including the effects of haloperidol. We expect that our results will improve the care of this vulnerable patient group.

Agents intervening against delirium in the intensive care unit (AID-ICU) - Protocol for a randomised placebo-controlled trial of haloperidol in patients with delirium in the ICU

BACKGROUND

Delirium among patients in the intensive care unit (ICU) is a common condition associated with increased morbidity and mortality. Haloperidol is the most frequently used pharmacologic intervention, but its use is not supported by firm evidence. Therefore, we are conducting Agents Intervening against Delirium in the Intensive Care Unit (AID-ICU) trial to assess the benefits and harms of haloperidol for the treatment of ICU-acquired delirium.

METHODS

AID-ICU is an investigator-initiated, pragmatic, international, randomised, blinded, parallel-group, trial allocating adult ICU patients with manifest delirium 1:1 to haloperidol or placebo. Trial participants will receive intravenous 2.5 mg haloperidol three times daily or matching placebo (isotonic saline 0.9%) if they are delirious. If needed, a maximum of 20 mg/daily haloperidol/placebo is given. An escape protocol, not including haloperidol, is part of the trial protocol. The primary outcome is days alive out of the hospital within 90 days post-randomisation. Secondary outcomes are number of days without delirium or coma, serious adverse reactions to haloperidol, usage of escape medication, number of days alive without mechanical ventilation; mortality, health-related quality-of-life and cognitive function at 1-year follow-up. A sample size of 1000 patients is required to detect a 7-day improvement or worsening of the mean days alive out of the hospital, type 1 error risk of 5% and power 90%.

PERSPECTIVE

The AID-ICU trial is based on gold standard methodology applied to a large sample of clinically representative patients and will provide pivotal high-quality data on the benefits and harms of haloperidol for the treatment ICU-acquired delirium.

Abstract P6-01-03: Exploring the relationship between an in vitro model of breast cancer cell mineralisation and the cancer grade specific composition of ex vivo microcalcifications

Background: Microcalcifications resulting from calcium deposition in the mammary gland play a central role in the early detection of breast cancer [1]. However, the relationship between their occurrence in the breast and cancer progression remains poorly understood. Our approach is to use vibrational spectroscopy and imaging, which is non-invasive, non-destructive, label-free and chemically specific, to assess the composition and distribution of the deposits in an in vitro cancer cell model of mineralisation [2]. In parallel we will utilise the same methods to measure the biochemical composition of microcalcifications found in breast biopsies from different grades of cancer. The ultimate aim of the study is to link the changes identified during the in vitro mineralisation process with the different stages of breast cancer. Vibrational spectroscopic methods can provide incredibly detailed biomolecular fingerprints enabling us to elucidate both the compositional changes with advancing pathology and the spatial distribution of those changes within the calcification and the surrounding tissue.

Methods: The breast cancer cell line MDA-MB-231 has the ability to produce mineralisation. This mineralisation was assessed over a 14-day period in the presence of different osteogenic cocktails: one composed of ascorbic acid, β-glycerophosphate (βG) and dexamethasone (Dex), and another one composed of inorganic phosphate (Pi). Fixed cells were analysed using Raman spectroscopy and micro-FTIR imaging at different time points (3, 7, 11 and 14 days). Tissue sections from patients with microcalcifications identified in histopathology will be sectioned to 3 mm and imaged with infrared (Agilent 670 FTIRinterferometer and Focal Plane Array imaging microscope) and Raman (Renishaw inVia) microspectrometers.

Results: We observed distinct and specific phosphate peak (PO43-) at 960 and 1020 cm-1 in Raman and FTIR spectra, respectively, corresponding to hydroxyapatite crystal and indicating the presence of microcalcification formation. Treatment with Pi induced a faster mineralisation (day 3) compared to cells treated with βG (day 11) and different spectral profiles during this development phase. In addition, there are changes in both the relative DNA and protein concentrations in the cells following 11 days exposure to the osteogenic agents.

It has been shown that the level of carbonate substitution in the calcium hydroxyapatite crystal correlates directly with the pathology of the tissue surrounding the microcalcification. Here we compare the mineral composition found ex vivo versus the in vitro model.

Conclusion: It could be possible to link the progressive biophysical changes associated with mineralisation to distinct stages of breast cancer pathology based on protein, lipid and carbonated apatite contents of the mineralised cells.

Support:This work was conducted as part of the Marie Curie Innovative Training Network Mid-TECH [H2020-MSCA-ITN-2014-642661]

References:

[1] R. Baker, KD. Rogers, N. Shepherd and N. Stone. British Journal of Cancer. 103, 1034-1039 (2010)

[2] RF. Cox, A. Hernandez-Santana, S. Ramdass, G. McMahon, JH. Harmey and MP. Morgan. British Journal of Cancer. 106, 525–537 (2012)

Citation Format: Bouzy P, O'Grady S, Palombo F, Morgan MP, Stone N. Exploring the relationship between an in vitro model of breast cancer cell mineralisation and the cancer grade specific composition of ex vivo microcalcifications [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-01-03.

Microcalcifications in breast cancer: From pathophysiology to diagnosis and prognosis

The implementation of mammographic screening programmes in many countries has been linked to a marked increase in early detection and improved prognosis for breast cancer patients. Breast tumours can be detected by assessing several features in mammographic images but one of the most common are the presence of small deposits of calcium known as microcalcifications, which in many cases may be the only detectable sign of a breast tumour. In addition to their efficacy in the detection of breast cancer, the presence of microcalcifications within a breast tumour may also convey useful prognostic information. Breast tumours with associated calcifications display an increased rate of HER2 overexpression as well as decreased survival, increased risk of recurrence, high tumour grade and increased likelihood of spread to the lymph nodes. Clearly, the presence of microcalcifications in a tumour is a clinically significant finding, suggesting that a detailed understanding of their formation may improve our knowledge of the early stages of breast tumourigenesis, yet there are no reports which attempt to bring together recent basic science research findings and current knowledge of the clinical significance of microcalcifications. This review will summarise the most current understanding of the formation of calcifications within breast tissue and explore their associated clinical features and prognostic value.

Derivatisation of buforin IIb, a cationic henicosapeptide, to afford its complexation to platinum(ii) resulting in a novel platinum(ii)-buforin IIb conjugate with anti-cancer activity

Herein we report the synthesis of buforin IIb, its novel malonate derivative malBuf and its Pt(ii) complex cis-[Pt(NH3)2(malBuf-2H)]. We decided to harness the cell targeting, cell-penetrating and anti-proliferative effects of buforin IIb to help target a cytotoxic dose of a Pt DNA binding species, {Pt(NH3)2} to cancer cells whilst also delivering a peptide with potent anti-cancer properties. Preliminary in vitro data shows cis-[Pt(NH3)2(malBuf-2H)] to be more cytotoxic against the cisplatin resistant ovarian cancer cell line (A2780cisR) relative to buforin IIb, cisplatin and cis-[Pt(NH3)2(malonate)].

Associations between single-nucleotide polymorphisms of ADIPOQ, serum adiponectin and increased type 2 diabetes mellitus risk in Bahraini individuals

This study aimed to estimate the frequency of the SNPs (+45T>G and +276G>T) genotypes and investigate the association between the two SNPs and adiponectin concentration, metabolic parameters and risk of T2DM in the Bahraini population. We genotyped the two ADIPOQ SNPs in 140 unrelated T2DM patients and 66 nondiabetic controls using the polymerase chain reaction-restriction fragment length polymorphism assay. Lipid profile was measured by enzymatic methods. Total serum adiponectin levels were measured by immunoassay. T2DM patients had reduced adiponectin levels compared with controls. +45T>G was more prevalent in patients than controls. The rare G allele of +45T>G occurred more frequently than the common T allele in T2DM patients compared with controls, and was associated with lower serum adiponectin levels. There was no significant difference in allele and genotype frequencies of +276G>T between type T2DM patients and controls. There was no association between both SNPs and metabolic parameters.

Microcalcifications in breast cancer: novel insights into the molecular mechanism and functional consequence of mammary mineralisation

BACKGROUND

Mammographic microcalcifications represent one of the most reliable features of nonpalpable breast cancer yet remain largely unexplored and poorly understood.

METHODS

We report a novel model to investigate the in vitro mineralisation potential of a panel of mammary cell lines. Primary mammary tumours were produced by implanting tumourigenic cells into the mammary fat pads of female BALB/c mice.

RESULTS

Hydroxyapatite (HA) was deposited only by the tumourigenic cell lines, indicating mineralisation potential may be associated with cell phenotype in this in vitro model. We propose a mechanism for mammary mineralisation, which suggests that the balance between enhancers and inhibitors of physiological mineralisation are disrupted. Inhibition of alkaline phosphatase and phosphate transport prevented mineralisation, demonstrating that mineralisation is an active cell-mediated process. Hydroxyapatite was found to enhance in vitro tumour cell migration, while calcium oxalate had no effect, highlighting potential consequences of calcium deposition. In addition, HA was also deposited in primary mammary tumours produced by implanting the tumourigenic cells into the mammary fat pads of female BALB/c mice.

CONCLUSION

This work indicates that formation of mammary HA is a cell-specific regulated process, which creates an osteomimetic niche potentially enhancing breast tumour progression. Our findings point to the cells mineralisation potential and the microenvironment regulating it, as a significant feature of breast tumour development.

Microsomal prostaglandin E2 synthase 1 expression in basic calcium phosphate crystal-stimulated fibroblasts: role of prostaglandin E2 and the EP4 receptor

OBJECTIVE

Basic calcium phosphate (BCP) crystals have been implicated in the pathogenesis of osteoarthritis (OA), in part because of their ability to upregulate cyclooxygenase and prostaglandin E(2) (PGE(2)) production. The aim of this work was to investigate the expression of terminal PGE(2) synthases and PGE(2) receptors (EP) in BCP crystal-stimulated fibroblasts.

METHODS

Cultured fibroblasts were stimulated with BCP crystals in vitro. mRNA expression was measured by real-time polymerase chain reaction, and protein production by western blotting.

RESULTS

Basal expression of microsomal prostaglandin E(2) synthase 1 (mPGES1) in osteoarthritic synovial fibroblasts (OASF) was found to be 30-fold higher than in human foreskin fibroblasts (HFF). BCP crystals increased mPGES1 expression fourfold in HFF, but not in OASF. EP4 expression was downregulated twofold by BCP crystals in OASF, but not in HFF. Exogenous PGE(2) also downregulated EP4 expression; this effect was blocked by co-administration of L-161,982, a selective EP4 antagonist. While administration of exogenous PGE(2) significantly upregulated mPGES1 expression in OASF, mPGES1 expression was threefold higher in the OASF treated with BCP crystals and PGE(2) as compared with OASF treated with PGE(2) alone.

CONCLUSIONS

The differing effects of BCP crystals on mPGES1 expression in HFF and OASF may be explained by BCP crystal-induced EP4 downregulation in OASF, likely mediated via PGE(2). These data underline the complexity of the pathways regulating PGE(2) synthesis and suggest the existence of a compensatory mechanism whereby mPGES1 expression can be diminished, potentially reducing the stimulus for further PGE(2) production.

Mechanism of basic calcium phosphate crystal-stimulated matrix metalloproteinase-13 expression by osteoarthritic synovial fibroblasts: inhibition by prostaglandin E2

OBJECTIVE

To determine the mechanism of matrix metalloproteinase (MMP)-13 upregulation in osteoarthritic synovial fibroblasts (OASF) in response to stimulation with basic calcium phosphate (BCP) crystals and to investigate the effect of prostaglandin (PG)E2 on BCP crystal-stimulated MMP expression.

METHODS

Primary OASF were stimulated with BCP crystals; mRNA expression was measured by real-time reverse transcription-polymerase chain reaction and protein levels were assessed by Western blotting.

RESULTS

BCP crystals upregulated MMP-13 mRNA expression over 20-fold and increased MMP-13 protein production in OASF. BCP crystal-stimulated MMP-13 mRNA expression was blocked by inhibition of the extracellular regulated kinase (ERK1/2) and p38 mitogen activated protein kinase (MAPK) pathways and inhibition of the activation of nuclear factor kappaB. Addition of exogenous PGE2 downregulated BCP crystal-stimulated MMP-13 expression. In contrast, PGE2 upregulated, and had no effect, on BCP crystal stimulated MMP-3 and MMP-1 mRNA expression, respectively. These effects of PGE2 were diminished by L-161,982, a selective EP4 receptor antagonist, and mimicked by CAY10399, a selective EP2 receptor agonist, and forskolin, an adenylate cyclase activator.

CONCLUSIONS

These data suggest that BCP crystal induction of MMP-13 expression may involve the ERK1/2 and p38 MAPK pathways and activation of nuclear factor kappaB; this upregulation of MMP-13 may contribute to the accelerated cartilage breakdown in BCP crystal-associated osteoarthritis. PGE2 had contrasting effects on BCP crystal-stimulated MMP-3 and MMP-13 mRNA expression, mediated in an EP2/EP4/cAMP-dependent manner, suggesting that PGE2 may have beneficial as well as deleterious effects in BCP crystal-associated osteoarthritis.

BCP crystals increase prostacyclin production and upregulate the prostacyclin receptor in OA synovial fibroblasts: potential effects on mPGES1 and MMP-13

OBJECTIVE

To investigate the potential involvement of prostacyclin in basic calcium phosphate (BCP) crystal-induced responses in osteoarthritic synovial fibroblasts (OASF).

METHODS

OASF grown in culture were stimulated with BCP crystals. Prostacyclin production was measured by enzyme immunoassay. Expression of messenger RNA (mRNA) transcripts was assessed by real-time polymerase chain reaction (PCR). Expression of prostacyclin synthase (PGIS) and the prostacyclin (IP) receptor was measured. The effects of iloprost, a prostacyclin analogue, on expression of genes implicated in osteoarthritis such as microsomal prostaglandin E2 synthase 1 (mPGES1) and matrix metalloproteinases (MMPs) were also studied. FPT inhibitor II, a farnesyl transferase inhibitor, was used to antagonize iloprost-induced responses.

RESULTS

BCP crystal stimulation led to a five-fold increase in prostacyclin production in OASF compared to untreated cells. This induction was attenuated by cyclooxygenase (COX)-2 and COX-1 inhibition at 4 and 32h, respectively. PGIS and IP receptor transcripts were constitutively expressed in OASF. BCP crystals upregulated IP receptor expression two-fold. While iloprost diminished BCP crystal-stimulated IP receptor upregulation, the inhibitory effect of iloprost was blocked by the farnesyl transferase inhibitor. In addition, iloprost upregulated mPGES1 and downregulated MMP-13 expression in BCP crystal-stimulated OASF, effects that were not influenced by the farnesyl transferase inhibitor.

CONCLUSIONS

These data showed for the first time that BCP crystals can increase prostacyclin production and upregulate expression of the IP receptor in OASF. The potential of prostacyclin to influence BCP crystal-stimulated responses was supported by the effects of iloprost on the expression of the IP receptor, mPGES1 and MMP-13. These data demonstrate the potential involvement of prostacyclin in BCP crystal-associated osteoarthritis (OA) and suggest that inhibition of PG synthesis with non-steroidal anti-inflammatory drugs may have both deleterious and beneficial effects in BCP crystal-associated OA.

Calcium hydroxyapatite promotes mitogenesis and matrix metalloproteinase expression in human breast cancer cell lines

Radiographic mammary microcalcifications are one of the most pertinent diagnostic markers of breast cancer. Breast tissue calcification in the form of calcium hydroxyapatite (HA) is strongly associated with malignant disease. We tested the hypothesis that calcium HA may exert biological effects on surrounding cells, thereby facilitating breast cancer progression. Our findings showed that HA crystals enhanced mitogenesis in breast cancer cell lines MCF-7 and Hs578T and also in normal human mammary epithelial cells. HA crystals were also found to upregulate the production of a variety of matrix metalloproteinases (MMPs), including MMP-2, -9, and -13 in MCF-7 and MMP-9 in human mammary epithelial cell lines. HA crystals were found to greatly augment prostaglandin E(2) levels in Hs578T cells, and treatment with a cyclooxygenase inhibitor, aspirin, abrogated the HA-induced mitogenesis. These results suggest that calcium HA crystals may play an active role in amplifying the pathological process involved in breast cancer.

Development of a shortened version of the Breathing Problems Questionnaire suitable for use in a pulmonary rehabilitation clinic: a purpose-specific, disease-specific questionnaire

One hundred and thirty-eight chronic obstructive pulmonary disease (COPD) patients completed the Breathing Problems Questionnaire (BPQ) before and after a comprehensive programme of rehabilitation. Examination of the changes on individual items showed improvement on 22 items, of which four items were significant at p < 0.05 and deterioration on nine items, of which two were significant at p < 0.01. All deteriorating items were consistent with lifestyle adaptations encouraged as part of the rehabilitation programme. We examined the psychometric properties of a reduced ten item version of the BPQ limited to the items most sensitive to change. We recommend the purpose-specific, disease-specific COPD scale for measuring change in pulmonary rehabilitation assessment in contrast to the longer 33 item questionnaire, which, however, may be more useful for cross-sectional assessment.

Treatment of posttraumatic stress disorder with eye movement desensitization

This case report describes the successful treatment of a posttraumatic stress disorder (PTSD) using eye movement desensitization (EMD). The client, a 40-year-old male, presented with an 8-year history of PTSD following an incident in which he was shot with a hand gun and left dying. Using EMD treatment, this trauma was quickly desensitized. Two earlier traumas with similar themes then emerged and they too were desensitized. Test results, taken pre-treatment and posttreatment, along with the client's verbatim account of cognitive and behavioral changes 8 months later, converged to document the successful treatment outcome.

Human ciliary body epithelium in culture

Human ciliary body epithelial cells have been maintained in vitro and have been partially characterized by the determination of growth rate, morphology, and ultrastructural parameters. The dissection technique employed allows the separation of pure ciliary body epithelium with a predominance of cells being from the nonpigmented layer. Growth curves indicate this cell population follows a prolonged rate of growth compared to other primary cell cultures. Loss of pigment granules noted by light microscopy were documented by morphometric analysis of electron micrographs. Thirty-two percent of the cultures attempted were successful. Maintenance of these cells in vitro may provide a means for studying their enzyme systems, growth factors, reactions to various stimuli, and the effects of this cell population on other intraocular tissues.