A comprehensive evaluation of hemodynamic energy production and circuit loss using four different ECMO arterial cannulae.

OBJECTIVE: Pulsatile-flow veno-arterial extracorporeal membrane oxygenation (V-A ECMO) has shown encouraging results for microcirculation resuscitation and left ventricle unloading in patients with refractory cardiogenic shock. We aimed to comprehensively assess different V-A ECMO parameters and their contribution to hemodynamic energy production and transfer through the device circuit. METHODS: We used the i-cor® ECMO circuit, which composed of Deltastream DP3 diagonal pump and i-cor® console (Xenios AG), the Hilite 7000 membrane oxygenator (Xenios AG), venous and arterial tubing and a 1 L soft venous pseudo-patient reservoir. Four different arterial cannulae (Biomedicus 15 and 17 Fr, Maquet 15 and 17 Fr) were used. For each cannula, 192 different pulsatile modes were investigated by adjusting flow rate, systole/diastole ratio, pulsatile amplitudes and frequency, yielding 784 unique conditions. A dSpace data acquisition system was used to collect flow and pressure data. RESULTS: Increasing flow rates and pulsatile amplitudes were associated with significantly higher hemodynamic energy production (both p < 0.001), while no significant associations were seen while adjusting systole-to-diastole ratio (p = 0.73) or pulsing frequency (p = 0.99). Arterial cannula represents the highest resistance to hemodynamic energy transfer with 32%-59% of total hemodynamic energy generated being lost within, depending on pulsatile flow settings used. CONCLUSIONS: Herein, we presented the first study to compare hemodynamic energy production with all pulsatile ECLS pump settings and their combinations and widely used yet previously unexamined four different arterial ECMO cannula. Only increased flow rate and amplitude increase hemodynamic energy production as single factors, whilst other factors are relevant when combined.

Evaluation of an innovative mobile health programme for the self-management of chronic obstructive pulmonary disease (MH-COPD): protocol of a randomised controlled trial.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death globally. In outpatient care, the self-management of COPD is essential, but patient adherence to this remains suboptimal. The objective of this study is to examine whether an innovative mobile health (mHealth)-enabled care programme (MH-COPD) will improve the patient self-management and relevant health outcomes. METHODS AND ANALYSIS: A prospective open randomised controlled trial has been designed. In the trial, patients with COPD will be recruited from The Prince Charles Hospital, Brisbane, Australia. They will then be randomised to participate in either the MH-COPD intervention group (n=50 patients), or usual care control group (UC-COPD) (n=50 patients) for 6 months. The MH-COPD programme has been designed to integrate an mHealth system within a clinical COPD care service. In the programme, participants will use a mHealth application at home to review educational videos, monitor COPD symptoms, use an electronic action plan, modify the risk factors of cigarette smoking and regular physical activity, and learn to use inhalers optimally. All participants will be assessed at baseline, 3 months and 6 months. The primary outcomes will be COPD symptoms and quality of life. The secondary outcomes will be patient adherence, physical activity, smoking cessation, use of COPD medicines, frequency of COPD exacerbations and hospital readmissions, and user experience of the mobile app. ETHICS AND DISSEMINATION: The clinical trial has been approved by The Prince Charles Hospital Human Research Ethics Committee (HREC/16/QPCH/252). The recruitment and follow-up of the trial will be from January 2019 to December 2020. The study outcomes will be disseminated according to the Consolidated Standards of Reporting Trials statement through a journal publication, approximately 6 months after finishing data collection. TRIAL REGISTRATION NUMBER: ACTRN12618001091291.

Acute surgical unit safely reduces unnecessary after-hours cholecystectomy.

INTRODUCTION: The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care. METHODS: A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm - 8am), length of stay and surgical complications. RESULTS: A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar. CONCLUSIONS: Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.

Phase I and pharmacodynamic study of an orally administered novel inhibitor of histone deacetylases, SB939, in patients with refractory solid malignancies.

BACKGROUND: The objective of this study was to assess the safety, maximum tolerated dose (MTD), pharmacokinetics, pharmacodynamics, and preliminary efficacy of SB939, a novel histone deacetylase (HDAC) inhibitor, in patients with advanced solid malignancies. PATIENTS AND METHODS: Dose-escalating cohorts of three to six patients received SB939 orally thrice weekly for 3 weeks in a 4-week cycle. Acetylated histone H3 (acH3) was measured in peripheral blood mononuclear cells (PBMCs). RESULTS: Thirty patients treated at one of five doses (10-80 mg/day) received 79 cycles of SB939 (range, 1-12 cycles). Dose-limiting toxic effects were fatigue, hypokalemia, troponin T elevation, and QTc prolongation. Peak plasma concentration (C(max)) and area under the concentration-time curve extrapolated to infinity increased dose proportionally. The MTD of SB939 was 80 mg/day. The mean elimination half-life and oral clearance of SB939 were 7.2 ± 0.6 h and 53.0 ± 8.5 l/h, respectively, with no substantial accumulation on day 15. An increase in acH3 was observed at hour 3 and correlated with dose and C(max). Stable disease was seen in several tumor types treated at ≥40 mg. HDAC inhibition was consistently observed at 60 mg, the recommended dose. CONCLUSIONS: SB939 can be safely administered at the recommended dose and reaches plasma levels that strongly inhibit HDAC in PBMCs. These data support further efficacy studies of SB939.

Lean, nondiabetic Asian Indians have decreased insulin sensitivity and insulin clearance, and raised leptin compared to Caucasians and Chinese subjects.

OBJECTIVE: To study and compare the insulin sensitivity of healthy, nondiabetic Asian Indians with that of two other ethnic groups (Caucasian and Chinese) living in Singapore. DESIGN: Study of insulin sensitivity using euglycaemic hyperinsulinaemic glucose clamp. SUBJECTS: A total of 10 healthy, lean, young male subjects of each ethnic group, matched for age, body mass index (BMI) and physical activity. They all had normal glucose tolerance and had no family history of diabetes. MEASUREMENTS: Anthropometric parameters (BMI, waist-hip ratio (WHR) and percentage body fat (PBF)), fasting lipid profile and leptin concentration, insulin sensitivity index, and insulin clearance. RESULTS: Healthy lean (BMI 22.1+/-1.5 kg/m(2) (mean+/-s.d.)) Indians had significantly higher fasting serum leptin (5.1+/-2.5 vs Chinese 1.0+/-0.9 vs Caucasian 2.3+/-1.2 ng/ml; P<0.001), lower insulin sensitivity index (9.9+/-3.3 vs Chinese 14.1+/-3.5 vs Caucasian 18.8+/-9.2 mg/min kg fat-free mass/microU/ml; P<0.002), and lower insulin clearance (461.4+/-54.8 vs Chinese 621.0+/-99.3 vs Caucasian 646.9+/-49.2 ml/min m(2); P<0.001). Indians also had a higher PBF (26.5+/-5.2 vs Chinese 19.5+/-2.2 vs Caucasians 22.9+/-1.4%; P<0.001), diastolic blood pressure (P=0.036), fasting insulin (P<0.006) and fasting triglyceride (P=0.022). Stepwise regression analysis showed that ethnicity was the only significant independent determinant variable for the differences in insulin sensitivity index (P=0.008). CONCLUSION: Healthy lean nondiabetic Indians were more insulin resistant compared to other ethnic groups despite the similarity in living environment. These findings may warrant preventive health-care strategies for type II diabetes and coronary artery disease to target Indians at an earlier stage compared to other ethnic groups.

Pharmacogenetics: the molecular genetics of CYP2D6 dependent drug metabolism.

INTRODUCTION: Genetic variation of drug metabolising enzymes has been recognised as one of the major causes of the inter-individual variability to drug response. The vast majority of drugs are degraded via a small number of metabolic pathways, mainly by microsomal P-450 enzymes localised in the liver and, to a minor extent, in the small intestine. Of these, CYP3A4 is the isozyme involved in the metabolism of most of the clinically useful drugs (50%). This is followed by CYP2D6 (20%), CYP2C9 and CYP2C19 (15%). In addition, minor pathways are catalysed by CYP2E1, CYP1A2, CYP2A6 and unidentified P-450s. Almost 40% of human P-450 dependent drug metabolism is carried out by genetically polymorphic enzymes. Polymorphisms generated by mutations in the genes for these enzymes cause quantitatively or qualitatively altered enzyme expression or activity through multiple molecular mechanisms. While CYP3A4 genetic polymorphisms are just beginning to be unraveled, extensive studies on the CYP2D6 gene over the last decade have identified at least 53 alleles. Of these, more than 20 of them are known to significantly alter the metabolism of CYP2D6 substrates. METHODS: This article reviews the information derived from various studies over the past decade and explains the molecular basis of functional differences in CYP2D6 variants, especially with respect to inter-ethnic differences and their clinical implications. RESULTS: CYP2D6 activity ranges from complete absence to ultra-rapid metabolism. Large inter-individual and inter-ethnic variability exists in the activity of the enzyme, and consequently in the disposition of drugs undergoing oxidative metabolism. CONCLUSIONS: Pharmacokinetic differences resulting from these polymorphisms show potentially important clinical consequences.

Open reading frame 1 of the Norwalk-like virus Camberwell: completion of sequence and expression in mammalian cells.

The ORF1 sequence was determined for Camberwell virus, a genogroup 2 Norwalk-like virus, completing the full genome of 7,555 nucleotides. ORF1 cDNA was cloned into a simian virus 40-based expression vector, and the viral proteins synthesized following transfection into COS cells were analyzed. By using antisera directed against the helicase, protease, or polymerase regions, eight polypeptides ranging in size from 19 to 117 kDa were detected by radioimmunoprecipitation. The cleavage sites determining the amino and carboxy termini of the 3C-like protease were identified at E(1008)/A and E(1189)/G, respectively.

Variation in ORF3 of genogroup 2 Norwalk-like viruses.

The nucleotide sequences of the 3'-terminal open reading frame (ORF3) and 3' untranslated region (3'UTR) were determined for four Norwalk-like viruses (NLVs) belonging to genogroup 2. Three of the viruses, isolated in 1995 and 1996, were closely related to Mexico virus (92-93% nucleotide identity in ORF3). The fourth virus, isolated in 1984, was unique, showing only 49-58% nucleotide identity with other NLVs. The variation in sequence of the 3'-terminal ORF of NLVs was greater than that observed for other caliciviruses. This variation was partly due to repeated sequences and frameshifting. To investigate the properties of the ORF3 encoded polypeptide, a signal sequence and N-linked glycosylation sites predicted for Camberwell virus were tested for function by in vitro translation in the presence of microsomes. Membrane insertion, cleavage of an N-terminal signal sequence, or glycosylation were not detected.

Primary non-Hodgkin's lymphoma of the uterine cervix: case report of long-term survival of two patients treated with surgery and radiotherapy.

Two patients with Stage 1EA primary non-Hodgkin's lymphoma of the uterine cervix were treated by surgery and radiotherapy in 1986 and 1987. On follow-up, over a period of 10 years, both are well and remain free of recurrence.

Developmental expression of N-methyl-D-aspartate (NMDA)-induced neurotoxicity, NMDA receptor function, and the NMDAR1 and glutamate-binding protein subunits in cerebellar granule cells in primary cultures.

Cerebellar granule cells maintained in vitro as primary cultures are a relatively homogeneous neuronal population that can be used to evaluate the developmental expression of neurotransmitter receptors and to assess their role in cell survival and degeneration. The toxicity induced by N-methyl-D-aspartate (NMDA) in granule cells maintained under partially depolarizing conditions and in the presence of physiologic extracellular concentrations of Mg2+ was greatest for the neurons maintained for 14 days in vitro (DIV). However, following NMDA receptor activation neurons as young as 5 DIV exhibited increases in the concentration of intracellular free Ca2+ which were as large as those achieved with cells at 8-9 or 13-14 DIV. The less mature neurons exhibited a "down-regulation" of responses to increasing concentrations of NMDA and the more mature cells maintained elevated intracellular Ca2+ levels during the inter-stimulus periods. Immunochemical analyses of the expression of the NMDA receptor-associated proteins NMDAR1 and glutamate-binding protein (GBP) in granule cells indicated a developmental increase in both proteins, albeit the pattern of expression of NMDAR1 was the more complex. No definite correlation has yet been established between toxicity induced by NMDA and the expression of these two proteins. Finally, although the developmental expression of nitric oxide synthase, an enzyme that catalyzes the formation of the potentially neurotoxic radicals nitric oxide and superoxide anion, increased progressively with the maturation of neurons in culture, an inhibitor of this enzyme did not protect neurons from NMDA-induced toxicity. Therefore, the developmental changes in granule cells that lead to increased vulnerability following excessive activation of NMDA receptors are not yet completely defined.

Purification and characterization of a low molecular weight endogenous glutamate binding inhibitor (LGBI) in porcine brain.

One of the endogenous substances which modulate glutamate receptor binding was isolated and highly purified from porcine brain. The purification involved extraction of brain tissue with doubled distilled water, followed by gel filtration, anion exchange, cation exchange, and several steps of C18 reverse-phase high performance liquid chromatography (HPLC). A low molecular weight glutamate binding inhibitor (LGBI) was purified to apparent homogeneity as judged from the elution profile of an HPLC column, in which a symmetrical peak was obtained when the eluate was monitored at 220 nm. The LGBI appears to be a small molecule (< 2 kD) that is heat- and acid/base-stable. The highly purified LGBI has no effect on GABAA and benzodiazepine receptor binding. The LGBI is not L-glutamate, L-aspartate or other negatively charged endogenous substances, since they are clearly separated from the LGBI in anion exchange chromatography. The inhibitory effect of the LGBI on [3H]L-glutamate binding is reversible, and it only changes the Bmax while the Kd remains the same. Since the membrane preparations used for [3H]L-glutamate binding assays for the detection of LGBI activity were enriched with quisqualate (QA)-sensitive subtypes, it was suggested that the LGBI could be a modulator of the QA receptor. Some amino acids which produce significant inhibition of glutamate binding activity were also compared with the LGBI, and they all showed no resemblance to the LGBI. The chemical structure of the LGBI remains to be determined.

Isolation of endogenous modulators for the GABAA and taurine receptors.

Several endogenous brain substances which inhibit [3H]muscimol binding were isolated, and one of them has been purified to apparent homogeneity. The purification involved the extraction of brain tissue with water, followed by several steps of gel filtration column chromatography and high performance liquid chromatography (HPLC). The muscimol binding inhibitor (MBI) thus obtained appeared to be homogeneous as judged from the elution profile of an HPLC column, in which a symmetrical peak was obtained when the eluate was monitored at either 220 or 280 nm. Furthermore, the MBI activity coincided with the absorption peak. The purified MBI is not gamma-amino butyric acid (GABA), beta-alanine or taurine since these amino acids are clearly separated from the MBI in the purification procedures. The MBI has no effect on benzodiazepine (BZ) binding or glutamate binding to their respective receptors. However, the MBI is a more potent inhibitor for [3H]taurine binding than that of [3H]muscimol binding. The MBI appears to be a small molecule (< 2000 Da) that is heat and acid/base stable. The chemical nature of the MBI is currently under investigation.