The conundrum of total neoadjuvant therapy in rectal cancer.

Total neoadjuvant therapy (TNT) has fast become the paradigm in the management of rectal cancer. The widespread adoption of this approach across the world, not only for locally advanced cancers but even for cancers that otherwise would not merit chemotherapy, leads both to an increase in treatment-related toxicity for patients and burdens the healthcare services of the country. It is important to tailor treatment to each patient based not only on the tumour but, even more importantly, on the patient's expectations and goals. The intent of treatment while prescribing TNT needs to be clear, understanding that not all patients are suitable for an organ preservation (watch and wait) approach and that the survival benefits of TNT are not as obvious as most proponents believe.

Colon cancer: feeling the imbalance?

While neoadjuvant chemotherapy has become the standard of care for rectal cancers in most centres, there is much interest in neoadjuvant chemotherapy in colon cancer after the recent publication of the FOxTROT trial. The management of colon cancers seems to be heading down the same path as rectal cancer, where the radicality of surgery is replaced by chemotherapy intensification. The role of demanding procedures such as complete mesocolic excision with central venous ligation in this new paradigm of upfront chemotherapy remains uncertain and uninvestigated.

Design and synthesis of imidazo[1,2-a]pyridine-chalcone conjugates as antikinetoplastid agents.

A library of imidazo[1,2-a]pyridine-appended chalcones were synthesized and characterized using 1 H NMR, 13 C NMR and HRMS. The synthesized analogues were screened for their antikinetoplastid activity against Trypanosoma cruzi, Trypanosoma brucei brucei, Trypanosoma brucei rhodesiense and Leishmania infantum. The analogues were also tested for their cytotoxicity activity against human lung fibroblasts and primary mouse macrophages. Among all screened derivatives, 7f was found to be the most active against T. cruzi and T. b. brucei exhibiting IC50 values of 8.5 and 1.35 µM, respectively. Against T. b. rhodesiense, 7e was found to be the most active with an IC50 value of 1.13 µM. All synthesized active analogues were found to be non-cytotoxic against MRC-5 and PMM with selectivity indices of up to more than 50.

Prospective Study of the Multisite Spread of a Medication Safety Intervention: Factors Common to Hospitals With Improved Outcomes.

Context and implementation approaches can impede the spread of patient safety interventions. The objective of this article is to characterize factors associated with improved outcomes among 9 hospitals implementing a medication safety intervention. Nephrotoxic Injury Negated by Just-in-Time Action (NINJA) is a pharmacist-driven intervention that led to a sustained reduction in nephrotoxic medication-associated acute kidney injury (NTMx-AKI) at 1 hospital. Using qualitative comparative analysis, the team prospectively assessed the association between context and implementation factors and NTMx-AKI reduction during NINJA spread to 9 hospitals. Five hospitals reduced NTMx-AKI. These 5 had either (1) a pharmacist champion and >2 pharmacists working on NINJA (Scon 1.0, Scov 0.8) or (2) a nephrologist-implementing NINJA with minimal competing organizational priorities (Scon 1.0, Scov 0.2). Interviews identified ways NINJA team leaders obtained pharmacist support or successfully implemented without that support. In conclusion, these findings have implications for future spread of NINJA and suggest an approach to study spread of safety interventions more broadly.

Splenic flexure cancer: is right extended hemicolectomy better than left hemicolectomy?

INTRODUCTION: There is no consensus on the optimal surgery for splenic flexure cancers. METHODS: Review of a prospectively maintained database of patients with splenic flexure cancer undergoing either a right extended hemicolectomy or left hemicolectomy at a tertiary care cancer hospital from 14.5.2010 to 16.9.2021. The primary outcome measures were postoperative morbidity and hospital stay with secondary outcomes being overall survival, disease-free survival, and long-term patient reported functional and quality of life outcomes. RESULTS: The demographic variables were evenly distributed between groups, and median follow-up was 44 months. The groups were comparable in terms of postoperative morbidity (Clavien-Dindo complication ≥ 3a 10.6% vs 10%, p = 0.322) and hospital stay (8 days vs 7 days, p = 0.316). Oncological outcomes were similar in both groups (3-year disease-free survival 71.8% vs 67.8%, p = 0.877, and 3-year overall survival 83.9% vs 75.8%, p = 0.787), and long-term patient-reported functional outcomes were excellent in both groups. CONCLUSION: Oncological outcomes, post operative morbidity, and long-term patient reported functional outcomes are comparable in patients undergoing either a right extended or left hemicolectomy for splenic flexure cancer.

Steroid-triazole conjugates: A brief overview of synthesis and their application as anticancer agents.

Steroids are biomolecules that play pivotal roles in various physiological and drug discovery processes. Abundant research has been fuelled towards steroid-heterocycles conjugates over the last few decades as potential therapeutic agents against various diseases especially as anticancer agents. In this context various steroid-triazole conjugates have been synthesized and studied for their anticancer potential against various cancer cell lines. A thorough search of the literatures revealed that a concise review pertaining the present topic is not compiled. Therefore, in thus review we summarize the synthesis, anticancer activity against various cancer cell lines and structure activity relationship (SAR) of various steroid-triazole conjugates. This review can lay down the path towards the development of various steroid-heterocycles conjugates with lesser side effects and profound efficacy.

Bile-Acid-Appended Triazolyl Aryl Ketones: Design, Synthesis, In Vitro Anticancer Activity and Pharmacokinetics in Rats.

A library of bile-acid-appended triazolyl aryl ketones was synthesized and characterized by detailed spectroscopic techniques such as 1H and 13C NMR, HRMS and HPLC. All the synthesized conjugates were evaluated for their cytotoxicity at 10 µM against MCF-7 (human breast adenocarcinoma) and 4T1 (mouse mammary carcinoma) cells. In vitro cytotoxicity studies on the synthesized conjugates against MCF-7 and 4T1 cells indicated one of the conjugate 6cf to be most active against both cancer cell lines, with IC50 values of 5.71 µM and 8.71 µM, respectively, as compared to the reference drug docetaxel, possessing IC50 values of 9.46 µM and 13.85 µM, respectively. Interestingly, another compound 6af (IC50 = 2.61 µM) was found to possess pronounced anticancer activity as compared to the reference drug docetaxel (IC50 = 9.46 µM) against MCF-7. In addition, the potent compounds (6cf and 6af) were found to be non-toxic to normal human embryonic kidney cell line (HEK 293), as evident from their cell viability of greater than 86%. Compound 6cf induces higher apoptosis in comparison to 6af (46.09% vs. 33.89%) in MCF-7 cells, while similar apoptotic potential was observed for 6cf and 6af in 4T1 cells. The pharmacokinetics of 6cf in Wistar rats showed an MRT of 8.47 h with a half-life of 5.63 h. Clearly, these results suggest 6cf to be a potential candidate for the development of anticancer agents.

Folate-Targeted Cholesterol-Grafted Lipo-Polymeric Nanoparticles for Chemotherapeutic Agent Delivery.

Docetaxel (DTX), an FDA approved chemotherapeutic agent, is used as a first-line treatment for triple-negative breast cancer (TNBC). Its poor aqueous solubility, rapid metabolism, short half-life, and effective targeting to the cancer cells limits its optimal therapeutic use. Herein, we report folate targeted amphiphilic lipopolymer grafted with cholesterol conjugated carbonate and DL-lactide prepared by microwave assisted ring opening polymerization, for the efficient actively targeted delivery of DTX. The DTX-loaded folate-targeted lipopolymeric nanoparticles (F-DTX-LPNs) prepared by the emulsion solvent evaporation method exhibited a smaller size of ∼115.17 nm with a PDI of 0.205 and encapsulation efficiency of >80%. Further, these lipopolymeric nanoparticles (F-DTX-LPNs) showed a good on-bench stability and sustained DTX release for 7 days. Cell-based assays in MDA-MB-231 cells revealed a significant enhancement in the intracellular uptake of folate-targeted lipopolymeric nanoparticles compared to non-targeted nanoparticles. Further, methyl beta-cyclodextrin (Mß-CD) completely inhibited the uptake of these nanoparticles in the cells, indicating a lipid raft-mediated uptake mechanism. The developed F-DTX-LPNs showed improved cytotoxicity, apoptosis, and significant fold-change in expression levels of Bcl-2, BAX and Ki-67 as compared to non-targeted DTX-LPNs and free DTX. Further, F-DTX-LPNs showed an improved in vivo pharmacokinetic profile in Sprague Dawley rats as compared to the free DTX. The bio-imaging of ex vivo tissues demonstrated that the DiR loaded folate targeted LPNs exhibited intense signals after 24 h because of slow release of DiR dye from the nanoparticles.

The Improving Renal Outcomes Collaborative: Blood Pressure Measurement in Transplant Recipients.

BACKGROUND AND OBJECTIVES: Hypertension is highly prevalent in pediatric kidney transplant recipients and contributes to cardiovascular death and graft loss. Improper blood pressure (BP) measurement limits the ability to control hypertension in this population. Here, we report multicenter efforts from the Improving Renal Outcomes Collaborative (IROC) to standardize and improve appropriate BP measurement in transplant patients. METHODS: Seventeen centers participated in structured quality improvement activities facilitated by IROC, including formal training in quality improvement methods. The primary outcome measure was the proportion of transplant clinic visits with appropriate BP measurement according to published guidelines. Prospective data were analyzed over a 12-week pre-intervention period and a 20-week active intervention period for each center and then aggregated as of the program-specific start date. We used control charts to quantify improvements across IROC centers. We applied thematic analysis to identify patterns and common themes of successful interventions. RESULTS: We analyzed data from 5392 clinic visits. At baseline, BP was measured and documented appropriately at 11% of visits. Center-specific interventions for improving BP measurement included educating clinic staff, assigning specific team member roles, and creating BP tracking tools and alerts. Appropriate BP measurement improved throughout the 20-week active intervention period to 78% of visits. CONCLUSIONS: We standardized appropriate BP measurement across 17 pediatric transplant centers using the infrastructure of the IROC learning health system and substantially improved the rate of appropriate measurement over 20 weeks. Accurate BP assessment will allow further interventions to reduce complications of hypertension in pediatric kidney transplant recipients.

Fabrication of deoxycholic acid tethered α-cyanostilbenes as smart low molecular weight gelators and AIEE probes for bio-imaging.

Four novel deoxycholic acid tethered α-cyanostilbenes were designed, synthesized and characterized using detailed spectroscopic analysis. The synthesized deoxycholic acid tethered α-cyanostilbene derivatives formed stable gels with a variety of solvents, such as xylene, toluene, mesitylene, decane, dodecane etc. The stable gels showed lamellar sheet type structures stacked over each other, consisting of entangled fibres as evident from SEM, TEM and Fluorescence Microscopy images; The synthesized compounds exhibited AIEE behaviour in H2O/THF mixture, with the maximum emission observed in 70% H2O/THF fraction along with a bathochromic shift. A solvent thickening experiment was perform to establish the mechanism of AIEE and the AIEE property was explored for bacterial bio-imaging. The synthesized derivatized steroids proved their potential as multifunctional organic materials.

Ruthenium Catalyzed C-H Acylmethylation of N-Arylphthalazine-1,4-diones with α-Carbonyl Sulfoxonium Ylides: Highway to Diversely Functionalized Phthalazino-fused Cinnolines.

A direct ortho-Csp2 -H acylmethylation of 2-aryl-2,3-dihydrophthalazine-1,4-diones with α-carbonyl sulfoxonium ylides is achieved through a RuII -catalyzed C-H bond activation process. The protocol featured high functional group tolerance on the two substrates, including aryl-, heteroaryl-, and alkyl-substituted α-carbonyl sulfoxonium ylides. Thereafter, 2-(ortho-acylmethylaryl)-2,3-dihydrophthalazine-1,4-diones were used as potential starting materials for the expeditious synthesis of 6-arylphthalazino[2,3-a]cinnoline-8,13-diones and 5-acyl-5,6-dihydrophthalazino[2,3-a]cinnoline-8,13-diones under Lawesson's reagent and BF3 ⋅OEt2 mediated conditions, respectively. Of these, the BF3 ⋅OEt2 -mediated cyclization proceeded in DMSO as a solvent and a methylene source via dual C-C and C-N bond formations.

Reduction in Nephrotoxic Antimicrobial Exposure Decreases Associated Acute Kidney Injury in Pediatric Hematopoietic Stem Cell Transplant Patients.

Exposure to nephrotoxic medications is a common risk factor for acute kidney injury (AKI) in pediatric stem cell transplantation (SCT). We hypothesized that reducing nephrotoxic antimicrobial exposure for SCT patients would be associated with lower nephrotoxin-associated AKI (NTMx-AKI) rates and no increase in infection treatment failures. We conducted a prospective cohort analysis of all inpatient SCT patients at Cincinnati Children's Hospital Medical Center between January 2014 and December 2017. In January 2016, first line fever coverage was changed from piperacillin-tazobactam to cefepime, acknowledging that the change resulted in a loss of enterococcal coverage, and the duration of antimicrobial exposures was limited, specifically including vancomycin. We collected data using prospective NTMx-AKI and antimicrobial utilization monitoring platforms within the electronic health record. AKI days and severity were extracted for patients exposed to 3+ nephrotoxins, 3+ days of IV aminoglycosides, or 3+ days of IV vancomycin. AKI was identified using KDIGO serum creatinine criteria. We assessed rates of nephrotoxin exposure and NTMx-AKI in all SCT inpatients for 2 years pre- and post-intervention. Data were grouped and analyzed by calendar month, normalized to a denominator of 1000 patient-days. Statistical process control methods were used to monitor adherence to the intervention and identify changes in mean rate of nephrotoxin exposure and NTMx-AKI. Infection rates, alternate antimicrobial usage rates, and the fraction of repeat positive cultures were used to identify treatment failures. PTZ usage decreased from 196 to 33 days/1000 patient days, cefepime usage increased from 62 to 290 days/1000 patient days, and vancomycin usage decreased from 62 to 41 days/1000 patient days. High nephrotoxin exposure decreased by 33% (143 to 96 days/1000 patient days), and NTMx-AKI decreased by 74% (24 to 6 days/1000 patient days). Rates of all KDIGO stages of NTMx-AKI decreased ≥50% after the intervention. Stage 3, the most severe, decreased by >80%. The fraction of repeat positive cultures remained stable between the two eras at .1 (standard deviation 0.21) and .07 (standard deviation 0.17), respectively. There were no increases in infection rates, alternate antimicrobial usage rates, or treatment failures. Reduction of nephrotoxic antimicrobial exposure can decrease the amount and severity of NTMx-AKI in SCT patients without an increase in treatment failures.

Iridium-catalyzed [4 + 2] annulation of 1-arylindazolones with α-diazo carbonyl compounds: access to indazolone-fused cinnolines.

An efficient one-pot Ir-catalyzed method was developed for the synthesis of indazolone-fused cinnolines by [4 + 2] annulation of 1-arylindazolones with α-diazo carbonyl compounds via sequential C-H activation/carbene insertion/cyclization in a tandem manner. This method has excellent tolerance towards electron-withdrawing and electron-donating functional groups on 1-arylindazolone. This method was also found to be applicable to cyclic α-diazo carbonyl compounds.

Clickable conjugates of bile acids and nucleosides: Synthesis, characterization, in vitro anticancer and antituberculosis studies.

A series of clickable bile acid-nucleosides conjugates linked directly or via amino acid linker were synthesized, and characterized by spectroscopic techniques such as 1H NMR, 13C NMR, FT-IR, HRMS and HPLC. The synthesized compounds 6a-p were screened for their in vitro anticancer property against a panel of three cancer cell lines (PC-3, MCF-7, IMR-32). In addition, the synthesized derivatives were also tested for their antimycobacterial activity against Mycobacterium tuberculosis H37Rv (ATCC 27294 strain). Among the screened compounds, cholic acid-uridine clicked conjugate (6c), and cholic acid-uridine clicked conjugate liked via phenylalanine moiety (6m) were found to be most active against MCF-7 and IMR-32 exhibiting an IC50 value of 8.084 and 8.71 µM, respectively. The antimycobacterial study of the synthesized conjugates revealed all the conjugates to be active with MIC values in the range of 4.09-15.41 µM. Deoxycholic acid-adenosine clicked conjugate (6b) showed most promising antituberculosis property with MIC value of 4.09 µM. Most of the synthesized conjugates were found to be safe at 50 µM against normal human embryonic kidney (HEK 293 T) cell line.

Additive-Driven Rhodium-Catalyzed [4+1]/[4+2] Annulations of N-Arylphthalazine-1,4-dione with α-Diazo Carbonyl Compounds.

A Rh(III)-catalyzed strategy involving the [4+1] annulation of 2-arylphthalazine-1,4-diones with α-diazo carbonyl compounds was developed, accessing a series of unprecedented hydroxy-dihydroindazolo-fused phthalazines in good to excellent yields. By varying the additive, phthalazino-fused cinnolines were synthesized under Rh-catalyzed conditions via [4+2] annulation between the same starting materials. Notably, such two strategies showed a good functional group tolerance and high atom efficiency.

Aziridine based electrophilic handle for aspartic acid ligation.

A one-pot ligation strategy at aspartic acid junctions has been developed by successfully incorporating aziridin-2,3-dicarboxylate to the N-side of a peptide fragment, affording N-aziridine appended peptides, which were ligated in solution phase with a variety of small peptide thio acids to afford native peptides, following a ring-opening/peptidyl migration/desulfurization strategy. The reaction proceeds in a highly regiospecific manner, and provides short native peptides in good isolable yields. A variety of aspartame based peptides were synthesized to showcase the generality of this aziridine based ligation. Computational studies have also been performed to obtain insight about the reaction pathway.

Synthesis and evaluation of bile acid amides of [Formula: see text]-cyanostilbenes as anticancer agents.

A series of amino-substituted [Formula: see text]-cyanostilbene derivatives and their bile acid (cholic and deoxycholic acid) amides were designed and synthesized. A comparative study on the anticancer and antibacterial activity evaluation on the synthesized analogs was carried against the human osteosarcoma (HOS) cancer cell line, and two gram -ve (E. coli and S. typhi) and two gram [Formula: see text]ve (B. subtilis and S. aureus) bacterial strains. All the cholic acid [Formula: see text]-cyanostilbene amides showed an [Formula: see text] in the range 2-13 [Formula: see text] against human osteosarcoma cells (HOS) with the most active analog (6g) possessing an [Formula: see text] of [Formula: see text]. One of the amino-substituted [Formula: see text]-cyanostilbene, 4e, was found to possess an [Formula: see text] of [Formula: see text]. An increase in the number of cells at the sub-[Formula: see text] phase of the cell was observed in the in vitro cell cycle analysis of two most active compounds in the series (4e, 6g) suggesting a clear indication toward induction of apoptotic cascade. With respect to antibacterial screening, amino-substituted [Formula: see text]-cyanostilbenes were found to be more active than their corresponding bile acid amides. The synthesized compounds were also subjected to in silico study to predict their physiochemical properties and drug-likeness score.

Solvent-Driven Iodine-Mediated Oxidative Strategies for the Synthesis of Bis(imidazo[1,2-a]pyridin-3-yl)sulfanes and Disulfanes.

Two efficient iodine-mediated strategies, which are economical and one-pot, are described to access bis(imidazo[1,2-a]pyridin-3-yl)sulfanes and bis(imidazo[1,2-a]pyridin-3-yl)disulfanes in chloroform and acetic acid, respectively, by a direct oxidative homocoupling of imidazo-heterocycles using inexpensive sodium sulfide as a sulfur source. These strategies are scalable, and an array of substrates delivered their corresponding stable sulfur-bridged imidazo-heterocycles in excellent yields.

A Comparative Study of CSF Viral RNA Loads between HIV Positive Patients with Neurological Manifestations and Neurologically Asymptomatic HIV Patients.

INTRODUCTION: There are conflicting reports in literature about correlation of CSF viral RNA levels with neurological manifestations in HIV positive patients. Many studies in animals and human subjects have shown that CSF HIV-1 RNA can be useful as a specific marker of HIV induced neuropathology. To the contrary there are studies which show that neurological disease states can occur in absence of significant increase of CSF HIV RNA. MATERIALS AND METHODS: This was a prospective study conducted at Base hospital Delhi Cantt, New Delhi, a tertiary care hospitals for HIV patients. The study period was from 16 May 2006 to16 Jun 2011. The current study included forty (40) patients (Twenty HIV positive patients with neurological manifestations and twenty HIV positive patients clinically without any neurological manifestation). All potential study subjects and controls were explained the nature of this study and enrolled thereafter with written consent. RESULTS: In our study all the cases (HIV/AIDS patients with Neuro AIDS) and controls (HIV/AIDS patients without Neuro manifestations) were males only. 45% of the cases and 60% of controls were in the age group of 25 to 35 yrs and 35 % of cases and 40% of controls were in age group of 36 to 45 yrs. Among cases (HIV patients with neurological manifestations), The neurological manifestations in our 20 patients included; dementia-5, cryptococcal meningitis-4, Tubercular meningitis-4, CVA-3, Headache-3, (without CSF abnormality), 1 case each of pyogenic meningitis, Candida meningitis, Tremors and Herpes Zoster. Among the 20 cases fourteen patients had abnormal CSF (70%) whereas only one patient among the controls showed CSF abnormality (5%). Out of 20 cases, radio-imaging (CT Scan/ MRI) of brain was done in 18 cases. Twelve cases (66.66) had some abnormality on CT/ MRI. Various abnormalities seen were as under Calcified granuloma-1, Infarcts-5, Hydrocephalus-2, TBM (meningeal enhancement)-2, Candidiasis (Focal hypodensities in subcortical white matter of cerebral hemispheres)-1, Cryptococcoma-1, Cerebral atrophy-1, Focal enhancing lesions-2. In our study, mean CSF viral load in cases was 5236.3 copies/ml and in controls 502.4 copies/ml. Viral load in CSF among cases was significantly higher than viral load in CSF among controls. CONCLUSIONS: CSF HIV-1 RNA viral load estimation can be a useful tool for clinicians in confirming neurological involvement in HIV infected patients. Hence, in HIV positive patients suspected to have neurological involvement, CSF viral load studies should be done. Serial estimations of CSF HIV-1 RNA levels can be of prognostic significance. Estimation of CSF HIV-1 RNA level before and serially during administration of HAART can be useful to judge the efficacy of HAART.