Minocycline and Diacetyl Minocycline Eye Drops Reduce Ocular Neovascularization in Mice

Purpose

To evaluate the efficacy of minocycline and a novel, modified minocycline analogue that lacks antimicrobial action, diacetyl minocycline (DAM), on choroidal neovascularization (CNV) in mice of both sexes.

Methods

CNV was induced via laser injury in female and male C57BL/6J mice. Minocycline, DAM, or saline was administered via topical eye drops twice a day for 2 weeks starting the day after laser injury. CNV volume was measured using immunohistochemistry labeling and confocal microscopy.

Results

Minocycline reduced lesion volume by 79% (P ≤ 0.0004) in female and male mice. DAM reduced lesion volume by 73% (P ≤ 0.001) in female and male mice. There was no significant difference in lesion volume between minocycline and DAM treatment groups or between female and male mice.

Conclusions

Both minocycline and DAM eye drops significantly reduced laser-induced CNV lesion volume in female and male mice. While oral tetracyclines have been shown to mitigate pathologic neovascularization in both preclinical studies and clinical trials, the present data are the first to suggest that tetracycline derivatives may be effective to reduce pathologic CNV when administered via topical eye drops. However, the action is unrelated to antimicrobial action. Targeted delivery of these medications via eye drops may reduce the potential for systemic side effects.

Translational Relevance

Topical administration of minocycline and/or DAM via eye drops may represent a novel therapeutic strategy for disorders involving pathologic CNV.

Neoadjuvant nivolumab plus chemotherapy versus chemotherapy for resectable NSCLC: subpopulation analysis of Chinese patients in CheckMate 816

BACKGROUND

Neoadjuvant nivolumab plus chemotherapy significantly improved event-free survival (EFS) and pathologic complete response (pCR) versus chemotherapy alone in patients with resectable non-small-cell lung cancer (NSCLC) in the global phase III CheckMate 816 study. Here, we report post hoc exploratory efficacy, safety, and surgical outcomes in the Chinese subpopulation of this study.

METHODS

Adults with stage IB-IIIA resectable NSCLC were randomized to receive nivolumab 360 mg plus chemotherapy or chemotherapy alone every 3 weeks for three cycles followed by surgery. Primary endpoints included EFS and pCR (both per blinded independent review). EFS and pCR results were from 14 October 2022, and 16 September 2020, database locks, respectively.

RESULTS

The Chinese subpopulation comprised 97 patients (nivolumab plus chemotherapy, 44; chemotherapy, 53). At 38.2 months of minimum follow-up, median EFS was not reached [95% confidence interval (CI) 23.4 months-not reached] in the nivolumab plus chemotherapy arm and 13.9 months (95% CI 8.3-34.3 months) in the chemotherapy arm (hazard ratio 0.47, 95% CI 0.25-0.88). pCR rates were 25.0% (95% CI 13.2% to 40.3%) and 1.9% (95% CI 0.0% to 10.1%), respectively (odds ratio 11.05; 95% CI 1.41-86.49). Of 97 Chinese patients, 36 (82%) in the nivolumab plus chemotherapy arm and 41 (77%) in the chemotherapy arm underwent definitive surgery. Grade 3-4 treatment-related adverse events occurred in 18/43 patients (42%) treated with nivolumab plus chemotherapy and 22/53 patients (42%) treated with chemotherapy.

CONCLUSIONS

Consistent with findings in the global study population of CheckMate 816, neoadjuvant nivolumab plus chemotherapy improved EFS and pCR versus chemotherapy in the Chinese subpopulation without impacting treatment tolerability or the feasibility of surgery. These findings support the use of nivolumab plus chemotherapy as a standard neoadjuvant treatment option for Chinese patients with resectable NSCLC.

Antimicrobial Coatings for Medical Textiles via Reactive Organo-Selenium Compounds

Bleached and cationized cotton fabrics were chemically modified with reactive organoselenium compounds through the nucleophilic aromatic substitution (SNAr) reaction, which allowed for organo-selenium attachment onto the surface of cotton fabrics via covalent bonds and, in the case of the cationized cotton fabric, additional ionic interactions. The resulting textiles exhibited potent bactericidal activity against S. aureus (99.99% reduction), although only moderate activity was observed against E. coli. Fabrics treated with reactive organo-selenium compounds also exhibited fungicidal activities against C. albicans, and much higher antifungal activity was observed when organo-selenium compounds were applied to the cationized cotton in comparison to the bleached cotton. The treatment was found to be durable against rigorous washing conditions (non-ionic detergent/100 °C). This paper is the first report on a novel approach integrating the reaction of cotton fabrics with an organo-selenium antimicrobial agent. This approach is attractive because it provides a method for imparting antimicrobial properties to cotton fabrics which does not disrupt the traditional production processes of a textile mill.

Long-term survival with first-line nivolumab plus ipilimumab in patients with advanced non-small-cell lung cancer: a pooled analysis

BACKGROUND

First-line nivolumab plus ipilimumab prolongs survival versus chemotherapy in advanced non-small-cell lung cancer (NSCLC). We further characterized clinical benefit with this regimen in a large pooled patient population and assessed the effect of response on survival.

PATIENTS AND METHODS

Data were pooled from four studies of first-line nivolumab plus ipilimumab in advanced NSCLC (CheckMate 227 Part 1, 817 cohort A, 568 Part 1, and 012). Overall survival (OS), progression-free survival (PFS), objective response rate, duration of response, and safety were assessed. Landmark analyses of OS by response status at 6 months and by tumor burden reduction in responders to nivolumab plus ipilimumab were also assessed.

RESULTS

In the pooled population (N = 1332) with a minimum follow-up of 29.1-58.9 months, median OS was 18.6 months, with a 3-year OS rate of 35%; median PFS was 5.4 months (3-year PFS rate, 17%). Objective response rate was 36%; median duration of response was 23.7 months, with 38% of responders having an ongoing response at 3 years. In patients with tumor programmed death-ligand 1 (PD-L1) <1%, ≥1%, 1%-49%, or ≥50%, 3-year OS rates were 30%, 38%, 30%, and 48%. Three-year OS rates were 30% and 38% in patients with squamous or non-squamous histology. Efficacy outcomes in patients aged ≥75 years were similar to the overall pooled population (median OS, 20.1 months; 3-year OS rate, 34%). In the pooled population, responders to nivolumab plus ipilimumab at 6 months had longer post-landmark OS than those with stable or progressive disease; 3-year OS rates were 66%, 22%, and 14%, respectively. Greater depth of response was associated with prolonged survival; in patients with tumor burden reduction ≥80%, 50% to <80%, or 30% to <50%, 3-year OS rates were 85%, 72%, and 44%, respectively. No new safety signals were identified in the pooled population.

CONCLUSION

Long-term survival benefit and durable response with nivolumab plus ipilimumab in this large patient population further support this first-line treatment option for advanced NSCLC.

The in vitro efficacy of betadine antiseptic solution and colloidal silver gel combination in inhibiting the growth of bacterial biofilms

INTRODUCTION

Betadine (Povidone-Iodine) solution is a topically applied antiseptic, which has been used routinely used in wound care and general surgery to prevent skin and wound infections. However, several studies have documented the ineffectiveness of betadine. Other topical antimicrobial dressings, including those that contain silver, have been used in the management of infected wounds. The present study was undertaken to determine if the combination of 5% betadine solution and silver colloidal gel (Ag-gel) is more effective than either substance alone in inhibiting the growth gram-negative and gram-positive bacteria.

METHODS

The effectiveness of 5% betadine solution and Ag-gel as anti-microbial agents were assessed using both colony forming unit (CFU) assay and confocal laser scanning microscopy (CLSM).

RESULTS

Ag-gel showed complete inhibition on all the bacteria species examined except the Klebsiella pneumoniae clinical isolate (CL) strain while 5% betadine concentrations did not completely kill any of the tested bacteria. In contrast, K. pneumoniae was completely eliminated in the presence of both 5% betadine solution and Ag-gel together. The CLSM showed similar findings to the CFU results examining the 5% betadine solution and Ag-gel combination.

CONCLUSIONS

This study demonstrated that while the individual treatments using either 5% betadine solution and Ag-gel alone were infective antimicrobial agents, the combination of 5% betadine solution and Ag-gel was superior at eliminating all tested bacteria, including K. pneumoniae CL.

Heart failure with preserved ejection fraction (HFpEF) pathophysiology study (IDENTIFY-HF): rise in arterial stiffness associates with HFpEF with increase in comorbidities

Background

There has been a shift in paradigm proposing that comorbidities play a significant role towards the pathophysiology of the heart failure with preserved ejection fraction (HFpEF) syndrome. Further, HFpEF patients have abnormal macrovascular function, potentially contributing significantly in altered ventricular-vascular coupling in these patients. However, our full understanding of the role of comorbidities, arterial stiffness and it relationship with HFpEF remains incomplete.

Purpose

The IDENTIFY-HF study aims to shed light on the HFpEF pathophysiology and investigates whether gradually increase in arterial stiffness (in addition to ageing) due to increasing common comorbidities, such as hypertension and diabetes, is associated with HFpEF.

Methods

Arterial compliance was assessed in five groups (Groups A to E) matched for age, (≥70 years), sex and renal function: Group A; normal healthy volunteers without major comorbidities (control). Group B; patients with hypertension only. Group C; patients with hypertension and diabetes mellitus only. Group D; patients with HFpEF. Group E; patients with heart failure and reduced ejection fraction (HFrEF); the parallel group. Arterial compliance was assessed using pulse wave velocity (PWV), as the primary outcome measure and was compared between Group A to D. A separate comparison was made between Groups D and E. To avoid confounding factors, participants were asked to omit their morning blood pressure medication and abstain from caffeine for 12 hours prior to the study.

Results

From the 95 volunteers recruited, PWV was obtained in 94 subjects. The mean PWV in group A, B, C, D and E was 10.2-, 12.2-, 13.0-, 13.7- and 10.0 m/s respectively. After adjusting for covariance (age, sex, BMI and renal function), the mean difference between Group A (healthy volunteers) and D (HFpEF) was 2.14 m/s (p=0.023). Whilst the mean difference between the HFpEF and HFrEF group D and E respectively was 2.68 m/s (p=0.003).

Conclusion

Rise in comorbidities increases arterial stiffness, as measured by pulse wave velocity, which in turn significantly associates with HFpEF (p=0.023). It is therefore possible that the HFpEF syndrome may not be due to a primary cardiac pathology but rather an end-result of non-cardiac comorbidities affecting vascular resistance with perhaps some secondary cardiac involvement.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): 1)West Midlands Clinical Research Network, National Institute of Health Research, UK2)Research, Development & Innovation department of the University Hospitals Coventry & Warwickshire NHS Trust (RDI, UHCW), UK.

Real-world evaluation of follow up strategies after implantable cardiac-defibrillator therapies in patients with ventricular tachycardia (REFINE-VT)

Introduction

Implantable cardiac-defibrillators (ICD) can prevent sudden cardiac death but the risk of recurrent ventricular arrhythmia (VA) and ICD therapies persists. Established strategies to minimize such risks include medication optimization, device reprogramming or ventricular tachycardia (VT) catheter ablation (CA). However, the timing and choice of these strategies at ICD follow-up may not be as consistent in the real-world as the regulated conditions of clinical trials. Furthermore, whether these decisions at follow-up are influenced by the type of arrhythmia, ICD therapy or patient characteristics remain unclear.

Purpose

We evaluated ICD follow-up strategies in patients with ischaemic (ICM) and non-ischaemic cardiomyopathy (NICM) to refine the outpatient management of these complex patients and ultimately improve overall patient outcome.

Methods

REFINE-VT is a retrospective study of 514 patients with ICD/CRT-D who attended ICD follow-up between June 2018 to September 2019 at the University Hospital Coventry & Warwickshire (UHCW) tertiary cardiology department. All follow-ups were face-to-face. Patients were divided into 2 groups according to the absence or presence of sustained VA (e.g. &gt;30 seconds of VT and/or appropriate ICD therapy), described as “negative event” and “positive event” groups respectively. The type of strategy employed in response to a positive event were categorized into 4 groups: (1) Medication change only (2) Device programming +/− medication (3) Referral for VT CA (4) No intervention

Results

514 consecutive patients with ICD (52%) or CRT-D (48%) were analysed. Overall mean age was 67±14 years with 79% male patients. ICM was diagnosed in 329 (64%) patient and NICM in 185 (36%). 437 (85%) patients had no significant VA and/or ICD therapy referred to as the negative group. A total of 77 patients (15%) suffered VA and/or ICD therapies, of whom 22 patients (26%) experienced a second event. 31% (n=24) of this positive event group received no preventative strategy (Table 1). We observed an inconsistent approach to the choice of strategies across different types of arrhythmias and ICD therapies. E.g. the odds of intervening were significantly higher if ICD shock was detected compared to anti-tachycardia pacing (OR 8.4, 95% CI 1.7–39.6, p=0.007). Even in patients with two events, the rate of referral for VT ablation and escalation of antiarrhythmics were similarly as low as patients with a single event (Table 2).

Conclusion

This is the first contemporary study that has evaluated how strategies that reduce the risk of recurrent ICD events are executed in a real-world population. We have demonstrated that the decision to intervene and choices of strategy remain inconsistent and partially biased by the type of arrhythmia and ICD therapy at follow-up. This supports the need for an evidence-driven multi-disciplinary VT clinic to refine and standardize our approach to this heterogeneous population.

Funding Acknowledgement

Type of funding sources: None.

First-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone (four cycles) in advanced non-small-cell lung cancer: CheckMate 9LA 2-year update

BACKGROUND

To further characterize survival benefit with first-line nivolumab plus ipilimumab with two cycles of chemotherapy versus chemotherapy alone, we report updated data from the phase III CheckMate 9LA trial with a 2-year minimum follow-up.

PATIENTS AND METHODS

Adult patients were treatment naïve, with stage IV/recurrent non-small-cell lung cancer, no known sensitizing EGFR/ALK alterations, and an Eastern Cooperative Oncology Group performance status ≤1. Patients were randomized 1 : 1 to nivolumab 360 mg every 3 weeks plus ipilimumab 1 mg/kg every 6 weeks with two cycles of chemotherapy, or four cycles of chemotherapy. Updated efficacy and safety outcomes are reported, along with progression-free survival (PFS) after next line of treatment (PFS2), treatment-related adverse events (TRAEs) by treatment cycle, and efficacy outcomes in patients who discontinued all treatment components in the experimental arm due to TRAEs.

RESULTS

With a median follow-up of 30.7 months, nivolumab plus ipilimumab with chemotherapy continued to prolong overall survival (OS) versus chemotherapy. Median OS was 15.8 versus 11.0 months [hazard ratio 0.72 (95% confidence interval 0.61-0.86)]; 2-year OS rate was 38% versus 26%. Two-year PFS rate was 20% versus 8%. ORR was 38% versus 25%, respectively; 34% versus 12% of all responses were ongoing at 2 years. Median PFS2 was 13.9 versus 8.7 months. Improved efficacy outcomes in the experimental versus control arm were observed across most subgroups, including by programmed death-ligand 1 and histology. No new safety signals were observed; onset of grade 3/4 TRAEs was mostly observed during the first two treatment cycles in the experimental arm. In patients who discontinued all components of nivolumab plus ipilimumab with chemotherapy treatment due to TRAEs (n = 61) median OS was 27.5 months; 56% of responders had an ongoing response ≥1 year after discontinuation.

CONCLUSIONS

With a 2-year minimum follow-up, nivolumab plus ipilimumab with two cycles of chemotherapy provided durable efficacy benefits over chemotherapy with a manageable safety profile and remains an efficacious first-line treatment of advanced non-small-cell lung cancer.

Long-term Survival with 18-Fluorodeoxyglucose Positron Emission Tomography-directed Therapy in Non-small Cell Lung Cancer with Synchronous Solitary Brain Metastasis

AIMS

At diagnosis, <1% of patients with non-small cell lung cancer (NSCLC) have synchronous solitary brain metastasis (SSBM). In prior cohorts without 18-fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) staging, definitive treatment to intracranial and intrathoracic disease showed a 5-year overall survival (OS) of 11-21%. We investigated the long-term survival outcomes for patients with SSBM NSCLC, diagnosed in the FDG-PET/CT era and treated definitively with local therapies to both intracranial and intrathoracic sites of disease.

MATERIALS AND METHODS

This retrospective study assessed patients staged with FDG-PET/CT who received definitive lung and SSBM treatment from February 1999 to December 2017. A lung-molecular graded prognostic assessment (lung-molGPA) score was assigned for each patient using age, performance status score, and, where carried out, molecular status. Overall survival and progression-free survival (PFS) were calculated using Kaplan-Meier methods. Cox proportional hazard models determined OS and PFS prognostic factors.

RESULTS

Forty-nine patients newly diagnosed with NSCLC and SSBM had a median age of 63 years (range 34-76). The median follow-up of all patients was 3.9 years. Thirty-three patients (67%) had ≥T2 disease, 23 (47%) had ≥N2. At 2 years, 45% of first failures were intracranial only (95% confidence interval 30-59). At 3 and 5 years, OS was 45% (95% confidence interval 32-63) and 30% (95% confidence interval 18-51), respectively. In ≥N1 disease, 5-year OS was 34% (95% confidence interval 18-63). The 3- and 5-year PFS was 8% (95% confidence interval 3-22) and 0%, respectively. Higher lung-molGPA was associated with longer OS (hazard ratio 0.26, 95% confidence interval 0.11-0.61, P = 0.002). Higher lung-molGPA (hazard ratio 0.33, 95% confidence interval 0.15-0.71, P = 0.005) and lower N-stage (hazard ratio 1.56, 95% confidence interval 1.13-2.15, P = 0.007) were associated with longer PFS.

CONCLUSIONS

Definitive treatment of patients with NSCLC and SSBM staged with FDG-PET/CT can result in 5-year survivors, including those with ≥N1 disease.

Organo-Selenium-Containing Polyester Bandage Inhibits Bacterial Biofilm Growth on the Bandage and in the Wound

The dressing material of a wound plays a key role since bacteria can live in the bandage and keep re-infecting the wound, thus a bandage is needed that blocks biofilm in the bandage. Using an in vivo wound biofilm model, we examined the effectiveness of an organo-selenium (OS)-coated polyester dressing to inhibit the growth of bacteria in a wound. Staphylococcus aureus (as well as MRSA, Methicillin resistant Staph aureus), Stenotrophomonas maltophilia, Enterococcus faecalis, Staphylococcus epidermidis, and Pseudomonas aeruginosa were chosen for the wound infection study. All the bacteria were enumerated in the wound dressing and in the wound tissue under the dressing. Using colony-forming unit (CFU) assays, over 7 logs of inhibition (100%) was found for all the bacterial strains on the material of the OS-coated wound dressing and in the tissue under that dressing. Confocal laser scanning microscopy along with IVIS spectrum in vivo imaging confirmed the CFU results. Thus, the dressing acts as a reservoir for a biofilm, which causes wound infection. The same results were obtained after soaking the dressing in PBS at 37 °C for three months before use. These results suggest that an OS coating on polyester dressing is both effective and durable in blocking wound infection.

P3629Invasive versus medical management of non-ST elevation myocardial infarction in cancer patients: knowledge is bliss

Background

Cancer patients with non-ST elevation myocardial infarction (NSTEMI) frequently present with comorbidities (e.g., anaemia, thrombocytopenia) that discourage invasive treatment.

Purpose

To compare outcomes of cancer patients with NSTEMI treated with optimal medical therapy (OMT) + percutaneous coronary intervention (PCI) versus OMT alone and to identify variables associated with overall survival (OS).

Methods

All cancer patients diagnosed with NSTEMI between March 2016 and December 2018 at our institution were included. Patients were classified based on treatment of NSTEMI into 2 groups: invasive strategy or OMT alone. The invasive group was further classified into early (PCI≤72 hours since presentation) or delayed strategy (PCI>72 hours). Clinical and laboratory data, oncologic history, major adverse cardiovascular events, and survival were collected. Univariate Cox proportional hazards regression analyses were conducted to identify variables associated with OS.

Results

We included 201 patients with a mean age of 68±11 years, 136 (68%) of which were women. Median OS was 13 months. Factors influencing OS are presented in Table I. Patients receiving PCI had better OS compared to patients treated with OMT only (Figure 1, p<0.0001). Procedure-related complications were non-fatal and present in 2 (1.85%) cases.

Table I Covariate Hazard Ratio (95% confidence interval) p-value Early invasive treatment (≤72 hours) 0.327 (0.207–0.516) <0.0001 Delayed invasive treatment (>72 hours) 0.496 (0.252–0.977) 0.0426 Presenting symptom: chest pain 0.406 (0.254–0.649) 0.0002 Presenting symptom: others 1.869 (1.223–2.855) 0.0039 Single agent antiplatelet therapy 0.434 (0.263–0.716) 0.0011 Dual agent antiplatelet therapy 0.294 (0.174–0.496) <0.0001 Statins 0.440 (0.276–0.703) 0.0006 Active cancer 4.487 (1.646–12.234) 0.0033 Prior chemotherapy 2.312 (1.328–4.023) 0.0030 Prior chest radiation 1.752 (1.065–2.884) 0.0272 Active chemotherapy 1.931 (1.271–2.934) 0.0021

Figure 1

Conclusions

An invasive management of NSTEMI in cancer patients, especially within 72 hours, appears to be associated with improved OS. Patients presenting with symptoms other than chest pain were less likely to undergo PCI and had worse outcomes. Active cancer, a history of chest radiation, and active or prior chemotherapy were also associated with decreased OS.

Acknowledgement/Funding

None

Process measure of FAST tuberculosis infection control demonstrates delay in likely effective treatment

SETTING

The tuberculous infection control strategy, FAST (Find cases Actively, Separate safely and Treat effectively), recommends prompt initiation of likely effective anti-tuberculosis treatment informed by Xpert^® MTB/RIF results.OBJECTIVE: To describe FAST implementation at Quang Nam Provincial TB and Lung Disease Hospital (QNH), Tam Ky, Viet Nam, using time to initiation of effective TB treatment as a process measure.

DESIGN

Hospital logs were used to calculate the time to likely effective treatment in patients with pulmonary TB (PTB) hospitalised during the study period.

RESULTS

Between 1 January and 31 December 2016, of 858 patients treated for PTB, 493 (57.5%) received likely effective treatment. The median time to likely effective treatment was 3 days (interquartile range 2.0-6.0), with 213 (43.2%) patients receiving likely effective treatment within 2 days. Of 81 patients receiving likely effective treatment for drug-susceptible TB with a positive Xpert result as their initial in-patient diagnostic test, 64 (79.0%) received likely effective treatment within 2 days compared with 10 (5.7%) who were initially smear-negative then found to be Xpert-positive (P < 0.0001).

CONCLUSIONS

A 'time to' process measure of the FAST tuberculous infection control strategy indicates delays in the initiation of likely effective anti-tuberculosis treatment in a resource-limited hospital. Expanding access to Xpert may speed time to likely effective treatment.

Utilization of Del Nido Cardioplegia in Adult Coronary Artery Bypass Grafting - A Retrospective Analysis

BACKGROUND

Studies assessing the safety and effectiveness of Del Nido cardioplegia for adult cardiac surgery remain limited. We investigated early outcomes after coronary artery bypass grafting (CABG) using single-dose Del Nido cardioplegia vs. conventional multi-dose blood cardioplegia. Methods and Results: The 81 consecutive patients underwent isolated CABG performed by a single surgeon. The initial 27 patients received anterograde blood cardioplegia, while the subsequent 54 patients received anterograde Del Nido cardioplegia. There were no differences in the baseline characteristics of each group nor any differences in the 30-day incidences of myocardial infarction, all-cause death, and readmission following surgery. The use of Del Nido cardioplegia was associated with shorter cardiopulmonary bypass time (98 vs. 115 min, P=0.011), shorter cross-clamp time (74 vs. 87 min, P=0.006), and decreased need for intraoperative defibrillation (13.0% vs. 33.3%, P=0.030) compared with blood cardioplegia. To control for the difference in cross-clamp time, we performed propensity score matching with a logistical treatment model and confirmed that Del Nido cardioplegia provided similar outcomes as blood cardioplegia and also reduced the need for defibrillation independent of cross-clamp time.

CONCLUSIONS

Compared with conventional blood cardioplegia, Del Nido cardioplegia provided excellent myocardial protection with reduced need for intraoperative defibrillation, shorter bypass and cross-clamp times, and comparable early clinical outcomes for adult patients undergoing CABG.

The Effect of Topical Substance-P Plus Insulin-like Growth Factor-1 (IGF-1) on Epithelial Healing After Photorefractive Keratectomy in Rabbits

Purpose

To determine whether topical Substance-P (SP) plus insulin-like growth factor-1 (IGF-1) can improve corneal healing after photorefractive surface ablation in a rabbit.

Methods

After a 9.0-mm corneal de-epithelialization using a combination of chemical (18% alcohol) and mechanical debridement, excimer photorefractive surface ablation was performed bilaterally in eight rabbits (16 eyes) with an 8.0-mm ablation zone and 70-μm depth. The right eye was treated with SP (250 μg/mL) and IGF-1 (25 ng/mL) in hyaluronic acid, one drop twice a day, and the other eye treated with only hyaluronic acid. The epithelial healing process was documented photographically twice a day until healing was complete. Six rabbits were sacrificed 6 weeks after photorefractive keratectomy (PRK) and corneas examined histologically.

Results

Seven of eight rabbit eyes treated with SP/IGF-1 healed in a shorter time than the untreated eye. For rabbit #6, both eyes healed at the same time. The average healing time (total time until wound closure) for the treated eyes was 99 hours, while the average healing time for the untreated eyes was 170 hours (P = 0.0490). A persistent epithelial defect was found in two of the nontreated eyes but none in the treated eyes. Corneal pathology showed some degree of epithelial separation in the central corneal wound in three out of six nontreated eyes and in just the treated eye of rabbit #6.

Conclusion

Topical SP plus IGF-1 increases the epithelial healing rate after PRK. There may have been beneficial effects upon cell adhesion as well.

Translational Relevance

Better and faster healing.

Synovasure 'quick test' is not as accurate as the laboratory-based α-defensin immunoassay: a systematic review and meta-analysis

AIMS

α-defensin is a biomarker which has been described as having a high degree of accuracy in the diagnosis of periprosthetic joint infection (PJI). Current meta-analyses are based on the α-defensin laboratory-based immunoassay rather than the quick on-table lateral flow test kit. This study is the first meta-analysis to compare the accuracy of the α-defensin laboratory-based immunoassay and the lateral flow test kit for the diagnosis of PJI.

MATERIALS AND METHODS

A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Inclusion criteria were all clinical studies where the diagnosis of PJI was uncertain. All studies selected used the Musculoskeletal Infection Society (MSIS) or modified MSIS criteria. Two independent reviewers reviewed the studies and extracted data. A meta-analysis of results was carried out: pooled sensitivity, specificity, positive and negative likelihood ratio, heterogeneity and areas under curves are reported.

RESULTS

Ten studies (759 patients) were included. Of these, seven studies (640 patients) evaluated the laboratory-based α-defensin immunoassay and three (119 patients) the lateral flow test. The pooled sensitivity and specificity of the qualitative α-defensin laboratory immunoassay was 0.953 (95% confidence interval (CI) 0.87 to 0.984) and 0.965 (95% CI 0.943 to 0.979) respectively. The pooled positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 34.86 (95% CI 19.34 to 62.85) and 0.02 (95% CI 0.00 to 0.11). The pooled sensitivity and specificity of the lateral flow test were 0.774 (95% CI 0.637 to 0.870) and 0.913 (95% CI 0.828 to 0.958), respectively. The pooled PLR and NLR were 8.675 (95% CI 4.229 to 17.794) and 0.248 (95% CI 0.147 to 0.418), respectively.

CONCLUSION

The pooled sensitivity and specificity of the lateral flow test were lower than those of the α-defensin laboratory-based immunoassay test. Hence, care must be taken with interpretation of the lateral flow test when relying on its results for the intra-operative diagnosis of PJI. Cite this article: Bone Joint J 2018;100-B:66-72.

Freies Endothel des Magna-Krossenstumpfes und Neoreflux/Neoangiogenese

Ziel: Die Existenz eines postoperativ inguinalen Neorefluxes (iNR) bzw. einer Neoangiogense (NA) nach korrekter V.-saphena-magna-Krossektomie wird von vielen anerkannt. Als eine Ursache wird das Endothel des Krossenstumpfes gesehen. Die Frage wird jetzt überprüft, ob es durch eine Reduktion der Menge an freiem Stumpfendothel zu einer Verringerung der Rate an postoperativem iNR/NA kommen kann. Patienten, Methode: In einer prospektiven Studie wurde 65 Beine (55 Patienten) untersucht. In allen Fällen wurde nach korrekter Magna-Krossektomie (Farbduplexkontrolle) der Stumpf bewusst lang gelassen (ca. 2 cm) mit dem Ziel, dass das freie Stumpfendothel nicht nach außen zum Subkutangewebe gerichtet war sondern miteinander verkleben konnte. Nach neun Monaten erfolgte eine erneute Duplexkontrolle mit der Frage, ob sich ein inguinaler Neoreflux entwickelt hatte. Dieses Ergebnis wurde mit anderen Studien zur NA-Protektion verglichen. Ergebnisse: In drei Fällen (5%) konnte ein refluxtragender Venenast mit Ursprung aus der V. femoralis entdeckt werden (Durchmesser 1,0-2,6 mm). Unsere einfache Technik mit Reduktion der Menge an freiem Endothel ergibt eine Rate an postoperativer iNR/NA, die vergleichbar ist mit Literaturdaten (1-14%). Schlussfolgerung: Die Wirksamkeit unserer Technik unterstützt einmal mehr die Hypothese der Neoangiogenese. Dieses kleine Detail in der Operationstechnik mag zudem erklären, warum manche Chirurgen das Phänomen der Neoangiogenese nicht zu sehen scheinen. Wenn sie schon immer ihren Stumpf etwas länger gelassen haben, dann haben sie unbewusst eine Neoangiogenese-Protektion durchgeführt.

Reduzierung des Neorefluxes an der V. saphena magna Crosse durch extensive Crossektomie

Background: Neovascularisation (NV) at the saphenofemoral junction (SFJ) is an important cause of recurrent great saphenous varicose veins. Unfortunately up to now no surgical technique at the SFJ could prevent neoreflux completely. We present a new technique at the SFJ with the aim to reduce the rate of neoreflux.

Material and Methods: In a prospective study 100 patients (100 SFJ ligations) with extensive crossectomy were included. Extensive crossectomy means: Flush ligation of the SFJ, oversewing the endothelium stump with Prolene®(4 x 0), ligation of the side branches as far away as possible from the SFJ and electrocoagulation of the free endothelium of these side branches. Mean age 47 years (18–65), female/ male 69 %/31 %, ASA-classification I–II (100 %), CEAP-classification C2 59, C3 25, C4 16. All patients could be examined by colour duplex scan after two/three days, three months and one year and 68 patients after two years.

Results: Duplex imagines identified neoreflux at the SFJ in two patients (2 %) after one year and in only one patient (1.5 %/ 68 patients) after two years. This female patient was pregnant (31st week) and had recurrent varicose veins with origin mostly from an insufficient Dodd perforator vein. The other patient with reflux at the first examination showed no more reflux after two years.

Conclusion: Recurrent reflux in the groin by neovascularisation was strongly reduced by our technique of extensive crossectomy. Up to know no other technique to prevent NV (patch, barrier technique) has shown such favourable results. The technique is easily performed and has no further complication than a simple ligation of the SFJ.

Varicose vein surgery

Background: The incidence of deep vein thrombosis (DVT) after varicose vein surgery remains largely unknown because of problems with study design in many of the previous reports. Patients, methods: This was a prospective study of 2805 patients (3756 legs) who had standard varicose vein surgery. The operations were done on inpatients under heparin prophylaxis and under local anaesthesia in a sequential way that reduced the duration of each procedure to less than 45 minutes. Before hospital discharge, and again three months later the deep veins of the legs were investigated using duplex ultrasound imaging by an objective phlebologist to determine the incidence of postoperative DVT exclusively in the femoral and popliteal veins (not in the calf veins). Results: All patients were imaged before discharge and 2961 legs (79%) returned for investigation after three months. In none of these was any DVT detected. One patient presented elsewhere with a femoropopliteal DVT and was anticoagulated. This patient was asymptomatic three and twelve months postoperatively. Conclusion: The strategy of sequential short duration varicose vein surgery done under local anaesthesia as an inpatient might be responsible for the low rate of postoperative DVT (0.03 %) in this study.

Taking culture seriously: Can we improve the developmental health and well-being of Australian Aboriginal children in out-of-home care?

BACKGROUND

Children in out-of-home care have well-documented health and developmental needs. Research suggests that Aboriginal children in care have unmet health and intervention needs. In metropolitan Sydney, Kari Aboriginal Resources Inc. (KARI), an Aboriginal organization, provides support to indigenous children in care, including clinical assessment and intervention. We wanted to determine the health and developmental needs of a subset of children in out-of-home care with KARI, who had been in stable care for at least a year. We wanted to identify child, carer, and intervention characteristics that contributed to children doing well. We also wanted to identify enablers and barriers to providing culturally competent intervention.

METHODS

We used mixed methods. From the KARI clinic database over the past 3 years, we identified children who had been in stable care with KARI for >12 months. We compared clinical measures and outcomes for these children with results from previous audits. We carried out a group discussion and key informant interviews with therapists and caseworkers to identify risk and resilience factors for each child, as well as enablers and barriers to culturally competent intervention.

RESULTS

The health and developmental profile of the 26 children identified as being in stable care was similar to that of previous audits. Most (88%) were getting speech pathology intervention; one third were getting occupational therapy and psychological intervention; most children and their carers attended cultural programmes. The majority of children (25/26) improved in their developmental health. Caseworkers and therapists identified risk and resilience factors related to child, carer, and home characteristics. They also identified elements of good practice; systemic issues prevented some interventions from being carried out.

CONCLUSIONS

There are challenges delivering a trauma-informed, culturally respectful service to Aboriginal children in out-of-home care in an urban setting, but it can be done if attention is paid to culture and the enablers and barriers are identified.

De novo hepatocellular carcinoma post-multivisceral transplantation in a child

De novo hepatocellular carcinoma (HCC) post-transplantation in patients without viral hepatitis is extremely rare, with only three reported adult cases in the English literature. Here, we present a case of de novo HCC that developed in a 7-year-old female, who at 8 months of age received a liver, small bowel, spleen, and pancreas transplantation 6.5 years ago for gastroschisis and total parenteral nutrition (TPN)-related cirrhosis. The post-transplant course was complicated by Epstein-Barr virus (EBV) infection, post-transplant lymphoproliferative disease, and subsequent development of multifocal EBV-associated post-transplant smooth muscle tumors (EBV-PTSMT) in the small bowel 1 year and 10 months after transplantation, respectively. This was managed by reducing immunosuppression with rituximab and EBV-specific cytotoxic T-cell therapy. She was noted to have a new lesion in her transplanted liver graft 6.5 years post-transplantation that was diagnosed as HCC. The HCC was resected, and the patient remained clinically stable for 7 months. At that time, recurrence of the HCC was discovered on MRI. She passed away 6 months after. To the best of our knowledge, this is the first reported occurrence of de novo HCC post-transplantation in the pediatric population that is unrelated to viral hepatitis in either recipient or donor.

Survey of dental clinic patients: smoking and preferences for cessation support

BACKGROUND

Smoking cessation interventions delivered by dental practitioners can be as effective as those delivered by general medical practitioners. However, concern that addressing smoking may cause offence to their patients is a reason cited by dental practitioners for not regularly addressing patient smoking behaviours, despite believing they should play a role in smoking cessation. This study aimed to elicit the smoking behaviour and smoking cessation preferences of dental patients to determine if these concerns accurately reflect patient attitudes.

METHODS

We surveyed 726 adult dental patients attending The University of Queensland's School of Dentistry dental clinics, Brisbane Dental Hospital and four private dental practices in South-East Queensland.

RESULTS

Most (80%) current daily smokers had tried to quit smoking. Smokers and non-smokers both agreed that dentists should screen for smoking behaviour and are qualified to offer smoking cessation advice (99% and 96% respectively). Almost all participants (96%) said they would be comfortable with their dentist asking about their smoking and that if their smoking was affecting their oral health their dentist should advise them to quit.

CONCLUSIONS

Patients are receptive to dental practitioners inquiring about smoking behaviour and offering advice on quitting. Smoking patients showed considerable motivation and interest in quitting smoking, particularly in the context of health problems related to smoking being identified. These results should encourage dentists to raise the issue with their patients.

Organo-Selenium Coatings Inhibit Gram-Negative and Gram-Positive Bacterial Attachment to Ophthalmic Scleral Buckle Material

Purpose

Biofilm formation is a problem for solid and sponge-type scleral buckles. This can lead to complications that require removal of the buckle, and result in vision loss due to related ocular morbidity, primarily infection, or recurrent retinal detachment. We investigate the ability of a covalent organo-selenium coating to inhibit biofilm formation on a scleral buckle.

Methods

Sponge and solid Labtican brand scleral buckles were coated with organo-selenium coupled to a silyation reagent. Staphylococcus aureus biofilm formation was monitored by a standard colony-forming unit assay and the confocal laser scanning microscopy, while Pseudomonas aeruginosa biofilm formation was examined by scanning electron microscopy. Stability studies were done, by soaking in phosphate buffer saline (PBS) at room temperature for 2 months. Toxicity against human corneal epithelial cell was examined by growing the cells in the presence of organo-selenium–coated scleral buckles.

Results

The organo-selenium coating inhibited biofilm formation by gram-negative and gram-positive bacteria. The buckle coatings also were shown to be fully active after soaking in PBS for 2 months. The organo-selenium coatings had no effect on the viability of human corneal epithelial cells.

Conclusions

Organo-selenium can be used to covalently coat a scleral buckle, which is stable and inhibits biofilm formation for gram-negative and gram-positive bacteria. The organo-selenium buckle coating was stable and nontoxic to cell culture.

Translational Relevance

This technology provides a means to inhibit bacterial attachment to devices attached to the eye, without damage to ocular cells.

Multitargeted Flavonoid Inhibition of the Pathogenic Bacterium Staphylococcus aureus: A Proteomic Characterization

Growth inhibition of the pathogen Staphylococcus aureus with currently available antibiotics is problematic in part due to bacterial biofilm protection. Although recently characterized natural products, including 3',4',5-trihydroxy-6,7-dimethoxy-flavone [1], 3',4',5,6,7-pentahydroxy-flavone [2], and 5-hydroxy-4',7-dimethoxy-flavone [3], exhibit both antibiotic and biofilm inhibitory activities, the mode of action of such hydroxylated flavonoids with respect to S. aureus inhibition is yet to be characterized. Enzymatic digestion and high-resolution MS analysis of differentially expressed proteins from S. aureus with and without exposure to antibiotic flavonoids (1-3) allowed for the characterization of global protein alterations induced by metabolite treatment. A total of 56, 92, and 110 proteins were differentially expressed with bacterial exposure to 1, 2, or 3, respectively. The connectivity of the identified proteins was characterized using a search tool for the retrieval of interacting genes/proteins (STRING) with multitargeted S. aureus inhibition of energy metabolism and biosynthesis by the assayed flavonoids. Identifying the mode of action of natural products as antibacterial agents is expected to provide insight into the potential use of flavonoids alone or in combination with known therapeutic agents to effectively control S. aureus infection.

Shear-mediated platelet activation in the free flow: Perspectives on the emerging spectrum of cell mechanobiological mechanisms mediating cardiovascular implant thrombosis

Shear-mediated platelet activation (SMPA) is central in thrombosis of implantable cardiovascular therapeutic devices. Despite the morbidity and mortality associated with thrombosis of these devices, our understanding of mechanisms operative in SMPA, particularly in free flowing blood, remains limited. Herein we present and discuss a range of emerging mechanisms for consideration for "free flow" activation under supraphysiologic shear. Further definition and manipulation of these mechanisms will afford opportunities for novel pharmacologic and mechanical strategies to limit SMPA and enhance overall implant device safety.

Targeting the MET Pathway in Gastric and Oesophageal Cancers: Refining the Optimal Approach

Gastric and oesophageal cancers are a major cause of global cancer-related morbidity and mortality. Improvements in treatment for locoregional and metastatic gastric and oesophageal cancer have been incremental and the overall prognosis remains poor. Increasingly, molecular classification has identified recurrent, therapeutically relevant, somatic alterations in gastroesophageal malignancies. However, other than ERBB2 amplification, molecularly directed therapies have not translated to improved survival. Amplification of the receptor tyrosine kinase MET is found in about 5% of gastroesophageal cancers and represents an oncogenic driver and therapeutic target. Small series have shown activity of MET-directed tyrosine kinase inhibitors, but the clinical benefit of anti-MET antibodies has been disappointing. Here we discuss the MET pathway in gastroesophageal cancers, the clinical data for MET small molecule tyrosine kinase inhibitors, anti-MET antibodies and future clinical directions for targeting MET in gastric and oesophageal cancers. To our knowledge, this is the most comprehensive review of the clinical experience with MET-directed therapies in gastric and oesophageal cancers.

Shear-mediated platelet activation in patients implanted with continuous flow LVADs: A preliminary study utilizing the platelet activity state (PAS) assay

Left ventricular assist devices (LVADs) have emerged as vital life-saving therapeutic systems for patients with advanced and end-stage heart failure (HF). Despite their efficacy, VAD systems remain limited by post-implantation thrombotic complications. Shear-mediated platelet activation is the major driver of such complications in these devices. Nowadays few platelet function assays are routinely utilized in assessing the degree of platelet activation in VAD implanted patients. No assays exist that specifically target shear-mediated platelet activation. The platelet activity state (PAS) is a novel assay that has been well validated in vitro, measuring thrombin release as a surrogate for shear-mediated platelet activation. To date limited data exist as to the utility of this assay in the clinical setting. In the present study we evaluated eight LVAD patients' platelet activation level using the PAS assay. Simultaneous measurements of conventional prothrombotic and hemolysis markers, - i.e. fibrinogen and lactate dehydrogenase (LDH) - were also performed. Trends as to alteration from baseline were studied. We observed that the PAS assay allowed detection of an abnormal level of platelet activation in one patient in our series who suffered from an overt thrombosis. Interestingly in the same patient no signal of major abnormality in fibrinogen or LDH was detected. Further for 7/8 patients who were free of thrombosis, no significant level of platelet activation was detected via PAS assay, while elevation in fibrinogen and LDH were observed. As such, from our observational series it appears that the PAS assay is a sensitive and specific indicator of shear-mediated platelet activation. Further patients' experience will help elucidate the role of this promising assay in the management of LVAD implanted patients.

Survey of Australian oral health practitioners and their smoking cessation practices

BACKGROUND

Smoking is a significant health and economic burden in Australia. Studies of smoking cessation practices in dental settings have primarily concentrated on dentists rather than other oral health practitioner (OHP) groups (dental hygienists, dental therapists and oral health therapists). The aim of this study was to measure Australian OHPs' attitudes, behaviours, interest and barriers to delivering smoking cessation interventions.

METHODS

Members of the two peak professional bodies representing Australian OHPs were invited to participate in an anonymous online questionnaire.

RESULTS

There were discrepancies between practitioner attitudes and current smoking cessation practices. While the majority of practitioners (90.1%) frequently screened for smoking behaviour, fewer (51.1%) assisted patients to quit smoking. The principal form of assistance was referral to Quitline (45.7%) or to a general medical practitioner (44.4%). The most prevalent barriers identified were lack of knowledge of pharmacological treatments (45.8%) and lack of access to smoking cessation resources (44.2%). Contrary to international studies, time and financial incentive were not commonly cited barriers to delivering smoking cessation interventions.

CONCLUSIONS

This survey identifies a need for continuing education in smoking cessation practice. Dissemination of policies, guidelines and resources may assist OHPs to become more engaged and confident in delivering smoking cessation interventions as part of their routine practice.