A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma.

BACKGROUND: There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy. METHODS: CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%. RESULTS: Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2. CONCLUSIONS: The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC. CLINICAL TRIAL REGISTRATION: NCT04953962.

In vivo growth and genomic characterization of rickettsia-like organisms isolated from farmed Chinook salmon (Oncorhynchus tshawytscha) in New Zealand.

A rickettsia-like organism, designated NZ-RLO2, was isolated from Chinook salmon (Oncorhynchus tshawytscha) farmed in the South Island, New Zealand. In vivo growth showed NZ-RLO2 was able to grow in CHSE-214, EPC, BHK-21, C6/36 and Sf21 cell lines, while Piscirickettsia salmonis LF-89T grew in all but BHK-21 and Sf21. NZ-RLO2 grew optimally in EPC at 15°C, CHSE-214 and EPC at 18°C. The growth of LF-89 T was optimal at 15°C, 18°C and 22°C in CHSE-24, but appeared less efficient in EPC cells at all temperatures. Pan-genome comparison of predicted proteomes shows that available Chilean strains of P. salmonis grouped into two clusters (p-value = 94%). NZ-RLO2 was genetically different from previously described NZ-RLO1, and both strains grouped separately from the Chilean strains in one of the two clusters (p-value = 88%), but were closely related to each other. TaqMan and Sybr Green real-time PCR targeting RNA polymerase (rpoB) and DNA primase (dnaG), respectively, were developed to detect NZ-RLO2. This study indicates that the New Zealand strains showed a closer genetic relationship to one of the Chilean P. salmonis clusters; however, more Piscirickettsia genomes from wider geographical regions and diverse hosts are needed to better understand the classification within this genus.

The first reported outbreak of equine herpesvirus myeloencephalopathy in New Zealand.

CASE HISTORY AND CLINICAL FINDINGS: On 9 January 2014 (Day 0) a mare from a stud farm in the Waikato region presented with urinary incontinence without pyrexia. Over the following 33 days 15 mares were clinically affected with neurological signs. All but one mare had a foal at foot. The most commonly observed clinical signs were hind limb paresis and ataxia. In some cases recumbency occurred very early in the course of disease and seven mares were subject to euthanasia for humane reasons. LABORATORY FINDINGS: Equid herpesvirus (EHV) type 1 was detected using PCR in various tissues collected post mortem from two mares with neurological signs. DNA sequencing data from the DNA polymerase gene of the virus showed a nucleotide transition at position 2254, a mutation encoding amino acid D752 that is highly associated with the neuropathogenic genotype of EHV-1. In total 12/15 mares were confirmed positive for EHV-1 on PCR. Results from a virus neutralisation test and ELISA on paired serum samples, and PCR on whole blood and nasal swabs, indicated that of four paddocks in a high-risk area where a cluster of cases had occurred, 20/21 (95%) horses were likely to have been exposed or were confirmed infected with EHV-1. Subsequent to the outbreak two mares aborted, one at 9 months and one at 10 months of gestation. The cause of abortion was confirmed as EHV-1 with the same genotype as that involved in the outbreak. DIAGNOSIS: Equine herpesvirus myeloencephalopathy. CLINICAL RELEVANCE: The outbreak described shows the considerable impact that can occur in outbreaks of equine herpesvirus myeloencephalopathy in New Zealand. Early biosecurity controls not only reduced the effect on the farm but mitigated the potential for the virus to spread to other horse enterprises.

Congenital-infantile fibrosarcoma of the foot--avoidance of amputation.

Congenital-infantile fibrosarcoma is a rare entity with a five year survival rate of over 90%. Surgery is still the most common treatment modality with amputation often necessary. There have been reports supporting the use of neoadjuvant chemotherapy to debulk the tumour in an effort to facilitate limb sparing surgery. We report a case of a newborn who presented with a life threatening haemorrhage from a fibrosarcoma of the foot, successfully treated with Vincristine, Actinomycin and Cyclophosphamide (VAC) chemotherapy alone.

Socioeconomic deprivation does not affect prescribing of secondary prevention in patients with peripheral arterial disease.

AIM: Aim of the study was to assess the effect of socioeconomic deprivation on prescribing of cardiovascular secondary prevention medications in patients referred with peripheral arterial disease (PAD). METHODS: A retrospective review of vascular clinic referrals was performed. All patients referred from primary care with suspected PAD over a two month period were included. The deprivation score, prescription of cardiovascular secondary prevention medications, smoking status and the presence of cardiovascular co-morbidities (coronary artery or cerebrovascular disease--CAD/CVD) were assessed. Comparison was made between socioeconomic groups using the Carstairs Deprivation (DepCat) Score and between patients with and without a history of currently existing cardiovascular co-morbidities. RESULTS: The study included 391 patients. Almost two thirds of patients (253) were from the most deprived socioeconomic groups and were significantly younger at presentation (median age DepCat 7: 63 yrs, DepCat 1-2: 74.5 yrs, P<0.0001). The majority of patients with a prior history of CAD/CVD were prescribed secondary preventative medications at the time of referral with suspected PAD whereas those with no prior history of CAD/CVD, (212 patients, 54%) were significantly less likely to be prescribed antiplatelets (47% vs. 83%), statins (45% vs. 86%) or ACEi/ARBs (29% vs. 68%) (all P<0.05). Secondary prevention prescribing did not differ between socioeconomic groups. CONCLUSION: Secondary prevention prescribing is inadequate in patients with suspected PAD regardless of socioeconomic group and is significantly lower in those without previously diagnosed CAD/CVD. There remains a lack of appreciation of the high cardiovascular risk associated with PAD.

Evidence for absence of equine arteritis virus in the horse population of New Zealand.

AIM: To summarise investigation and laboratory data collected between 2001 and 2011 to provide evidence that equine arteritis virus is not present in the horse population of New Zealand. METHODS: Analysis was carried out on results from laboratory tests carried out at the Ministry for Primary Industries Animal Health Laboratory (AHL) for equine arteritis virus from horses tested prior to being imported or exported, testing of stallions as part of the New Zealand equine viral arteritis (EVA) control scheme and testing as part of transboundary animal disease (TAD) investigations for exclusion of EVA. Horse breeds were categorised as Thoroughbred, Standardbred or other. RESULTS: A total of 7,157 EVA serological test records (from import and export testing, EVA control scheme testing and TAD investigations) were available for analysis between 2005 and 2011. For the three breed categories a seroprevalence of ≤1.6% at the 95% confidence level was determined for each category. Between 2001 and 2011, as part of the EVA control scheme, the EVA status of 465 stallions was determined to be negative. During 2005-2011 EVA was excluded from 84 TAD investigations. CONCLUSIONS: There was no evidence of equine arteritis virus being present in the general horse population outside of carrier stallions managed under the EVA control scheme. CLINICAL RELEVANCE: Equine arteritis virus is absent from the general horse population of New Zealand.

Daily bathing with octenidine on an intensive care unit is associated with a lower carriage rate of meticillin-resistant Staphylococcus aureus.

Routine daily bathing of intensive care (ICU) patients with topical chlorhexidine reduces meticillin-resistant Staphylococcus aureus (MRSA) acquisition. The aim of this study was to investigate whether repeated five-day cycles of daily topical octenidine could result in a similar effect. This was a two-year retrospective, uncontrolled study in a mixed medical and surgical ICU/high dependency unit, demonstrating a 76% reduction in MRSA acquisition but no significant reduction in all ICU-acquired bacteraemias. Chlorhexidine use is increasing but resistance is being reported. This pilot study found a similar reduction in MRSA acquisition with octenidine as an alternative to chlorhexidine. Further study is required to establish causality.

Laparoscopic management of small bowel obstruction with associated intestinal ischemia.

Obstruction is the most common surgical disorder of the small bowel. Complete small bowel obstruction (SBO) is usually treated surgically because bowel strangulation cannot be excluded with certainty. Acute SBO has been previously considered a relative contraindication for laparoscopic management especially due to the laparotomy conversion rate. We present a case of SBO for which laparoscopic management resulted in earlier return of bowel function, shorter hospital stay, faster overall recovery, and decreased morbidity when compared to laparotomy.

Implementing Surviving Sepsis guidelines in a district general hospital.

We describe efforts made at Blackpool Victoria Hospital to implement the well-established international Surviving Sepsis guidelines. These included posters, pocket guides and stickers inserted in patient notes. All doctors and nurses in acute areas received specific information and education. Sepsis teams comprising both doctors and nurses were formed to encourage implementation and to audit and disseminate data. Data collection occurred from February to November 2009. Cases were considered prospectively at the time of initial assessment and 198 patients were identified; 169 (85%) had blood cultures taken; 146 (74%) had lactate levels measured; and 145 (74%) received antibiotics within the target time. We believe these results demonstrate relatively effective implementation of guidelines in the challenging environment of a district general hospital. Our results could be replicated easily and provide a good way of reducing patient mortality at minimal financial cost.

Is closure of entire wards necessary to control norovirus outbreaks in hospital? Comparing the effectiveness of two infection control strategies.

The standard approach for norovirus control in hospitals in the UK, as outlined by the Health Protection Agency guidance and implemented previously by Lancashire Teaching Hospitals, involves the early closure of affected wards. However, this has a major impact on bed-days lost and cancelled admissions. In 2008, a new strategy was introduced in the study hospital, key elements of which included closure of affected ward bays (rather than wards), installation of bay doors, enhanced cleaning, a rapid in-house molecular test and an enlarged infection control team. The impact of these changes was assessed by comparing two norovirus seasons (2007-08 and 2009-10) before and after implementation of the new strategy, expressing the contrast between seasons as a ratio (r) of expected counts in the two seasons. There was a significant decrease in the ratio of confirmed hospital outbreaks to community outbreaks (r = 0.317, P = 0.025), the number of days of restricted admissions on hospital wards per outbreak (r = 0.742, P = 0.041), and the number of hospital bed-days lost per outbreak (r = 0.344, P <0.001). However, there was no significant change in the number of patients affected per hospital outbreak (r = 1.080, P = 0.517), or the number of hospital staff affected per outbreak (r = 0.651, P = 0.105). Closure of entire wards during norovirus outbreaks is not always necessary. The changes implemented at the study hospital resulted in a significant reduction in the number of bed-days lost per outbreak, and this, together with a reduction in outbreak frequency, resulted in considerable cost savings.

The prevalence of the activating JAK2 tyrosine kinase mutation in chronic porto-splenomesenteric venous thrombosis.

BACKGROUND: Occult myeloproliferative disorders (MPD) are present in 25% of patients with chronic portal, splenic and mesenteric venous thrombosis (PSMVT). A somatic mutation of JAK2 (JAK2V617F) can be used to identify patients with latent MPD. AIM: We evaluated the prevalence and clinical significance of JAK2V617F in patients with chronic PSMVT. METHODS: Allele-specific polymerase chain reaction was performed to screen for JAK2V617F. RESULTS: Thirty-five patients were tested for JAK2V617F. The underlying pro-coagulant condition was MPD in seven of 35 (20.0%) patients; other aetiologies included hereditary thrombophilia (n = 5), chronic pancreatitis (n = 2), liver abscess (n = 1) and umbilical vein sepsis (n = 3). The remainder were labelled idiopathic, i.e. 17/35 (48.6%) patients. JAK2V617F was detected in 16/35 (45.7%) patients: seven of seven (100%) with MPD, two of 11 (18.1%) with non-MPD acquired conditions and seven of 17 (41.2%) with 'idiopathic' chronic PSMVT. Mean haemoglobin concentration (P = 0.04), haematocrit (P = 0.04), white cell count (P = 0.002) and platelet count (P = 0.05) were significantly higher in patients with JAK2V617F. None of the seven patients with latent MPD have progressed to overt MPD over median follow-up of 85 months. CONCLUSION: JAK2V617F occurs in 41% of patients with idiopathic chronic portal, splenic and mesenteric venous thrombosis, confirming the presence of latent myeloproliferative disorders, and should form part of the routine pro-coagulant screen.

Unnecessary inter-hospital referral of minor hand injuries: a continuing problem.

BACKGROUND: Trauma patients are a burden on resources in terms of personnel, operating time and bed occupancy. The plastic surgery trauma clinic was established in January 1999 and has been running Monday to Friday mornings from 9 am to 1 pm since its establishment. AIM: To analyse and compare referral patterns to the Plastic Surgery trauma clinic over three time periods. METHOD: Three time groups were analysed and compared: data from this initial study (2000-2001), a retrospective chart review (2002-2003), as well as a prospective study (2006-2007). RESULTS: Numbers of attendances at the Trauma Clinic seem to be increasing every year despite encouragement by letter after the initial study for local centres to treat many of the minor injuries not requiring plastic surgical skills. CONCLUSION: Admission rates have remained below 50% of the patients seen in the clinic; however 50% of patients required only local anaesthetic procedures performed in the clinic, or no treatment at all (27.6% of patients in 2003, 35.3% in 2006).

Occupational injuries in foreign-national workers presenting to St James's Hospital Plastic Surgery service.

This study was undertaken to investigate our impression that migrant foreign-national workers were more at risk of sustaining work place injuries requiring referral to our Plastic Surgery service than their indigenous Irish counterparts. Data were collected prospectively from August 2006 to February 2007 on all work-related injuries presenting to the Plastic Surgery service in St James's Hospital, Dublin. 201 work-related injuries were recorded during the six month study period. 40% (n = 81) of the study group were foreign-national workers. Foreign-national workers account for only nine percent of the total Irish workforce. 31% (n = 25) of the study group required a translator. Over half (55%) of all the foreign-national workers in the current study had been in their present job for less than six months at the time of injury compared to only nine percent of Irish workers. This study highlights that foreign-national workers in Ireland are at a disproportionately high risk of occupational injury when compared to their Irish colleagues and emphasises the need for targeted occupational health and safety measures in this vulnerable group.

Basin-scale coherence in phenology of shrimps and phytoplankton in the North Atlantic Ocean.

Climate change could lead to mismatches between the reproductive cycles of marine organisms and their planktonic food. We tested this hypothesis by comparing shrimp (Pandalus borealis) egg hatching times and satellite-derived phytoplankton bloom dynamics throughout the North Atlantic. At large spatial and long temporal (10 years or longer) scales, hatching was correlated with the timing of the spring phytoplankton bloom. Annual egg development and hatching times were determined locally by bottom water temperature. We conclude that different populations of P. borealis have adapted to local temperatures and bloom timing, matching egg hatching to food availability under average conditions. This strategy is vulnerable to interannual oceanographic variability and long-term climatic changes.

Culture conditions affect the chemical composition of the exopolysaccharide synthesized by the fungus Aureobasidium pullulans.

AIMS: To identify if culture conditions affect the chemical composition of exopolysaccharide (EPS) produced by Aureobasidium pullulans. METHODS AND RESULTS: In batch airlift and continuously stirred tank (CSTR) reactors the EPS produced with low (0.13 g l(-1) N) initial NaNO(3) or (NH(4))(2)SO(4) levels contained pullulan, with maltotriose as its major component, similar to that synthesized in the airlift reactor with high (0.78 g l(-1) N) initial NaNO(3) levels. EPS produced by CSTR grown cultures with high (NH(4))(2)SO(4) levels contained little pullulan, possibly because of a population shift from unicells to mycelium. This chemical difference may explain why total EPS yields did not fall as they did with cultures grown under identical conditions with high NaNO(3) levels, where the pullulan component of the EPS disappeared. EPS synthesized in N-limiting chemostat cultures of A. pullulans changed little with growth rate or N source, being predominantly pullulan consisting of maltotriose units. CONCLUSIONS: While the EPS chemical composition changed little under N-limiting conditions, high initial medium N levels determined maltotriose content and/or pullulan content possibly by dictating culture morphology. SIGNIFICANCE AND IMPACT OF THE STUDY: These results emphasize the requirement of all studies to determine EPS chemical composition when examining the influence of culture conditions on EPS yields.

Epidemiology of major paediatric trauma.

In Europe injury is the leading cause of death in those aged between 1 and 14 years. In Ireland over 800,000 people are aged less than 14 years. There is currently no national trauma register to collect data on the morbidity and mortality associated with major trauma in the paediatric population in Ireland. We prospectively collected data on 153 patients admitted to our hospital with major trauma. There were 99 males and 54 females. The majority of patients were transported by ambulance (n= 138). Road traffic accidents (n=69) and thermal injuries (n=49) represented the majority of admissions. 68% (n=47) of the vehicle occupants in this study were either unrestrained or incorrectly restrained. Most patients (n=133) had an in patient stay of <50 days, with only 4 patients staying >100 days. 14 patients died. A paediatric trauma register as well as a level 1 paediatric trauma centre are required in Ireland.

Patterns of crystallin distribution in porcine eye lenses.

PURPOSE: To measure the protein distribution patterns in single young porcine lenses. METHODS: Twenty fresh porcine lenses from 5 to 6 months old animals were fractionated into 8-10 concentric fractions by controlled dissolution in phosphate buffer. Proportions of soluble and insoluble protein were determined by Bradford assay. Water-soluble proteins in all layers were separated into HMW, MMW, and LMW fractions by size-exclusion HPLC and constituents of each class further characterized by SDS gel electrophoresis, as were the water-insoluble proteins. Size-exclusion fractions were further separated by reverse-phase HPLC and the molecular masses of each peak determined by MALDI-TOF mass spectrometry. RESULTS: The major soluble proteins in the porcine lens are beta-crystallins. They comprise around 45% of the total protein in the outer lens decreasing gradually to 35% in the central region. Soluble alpha-crystallins vary from 35% to 22% from outer to inner lens. The proportion of soluble gamma-crystallin levels, substantially lower than that of the other protein classes, increases gradually with progression into the lens center. Insoluble protein levels also increase from outer to inner lens layers. CONCLUSIONS: In the young porcine lens, there is relative constancy in the levels of all three crystallin classes in the outer lens with alpha- and beta-crystallins representing the predominant protein classes. The increase in gamma-crystallin in the inner lens may contribute to the refractive index gradient.