FcMBL magnetic bead-based MALDI-TOF MS rapidly identifies paediatric blood stream infections from positive blood cultures.

Rapid identification of potentially life-threatening blood stream infections (BSI) improves clinical outcomes, yet conventional blood culture (BC) identification methods require ~24-72 hours of liquid culture, plus 24-48 hours to generate single colonies on solid media suitable for identification by mass spectrometry (MS). Newer rapid centrifugation techniques, such as the Bruker MBT-Sepsityper® IVD, replace culturing on solid media and expedite the diagnosis of BCs but frequently demonstrate reduced sensitivity for identifying clinically significant Gram-positive bacterial or fungal infections. This study introduces a protocol that utilises the broad-range binding properties of an engineered version of mannose-binding lectin linked to the Fc portion of immunoglobulin (FcMBL) to capture and enrich pathogens combined with matrix-assisted laser desorption-ionisation time-of-flight (MALDI-TOF) MS for enhanced infection identification in BCs. The FcMBL method identified 94.1% (64 of 68) of clinical BCs processed, with a high sensitivity for both Gram-negative and Gram-positive bacteria (94.7 and 93.2%, respectively). The FcMBL method identified more patient positive BCs than the Sepsityper® (25 of 25 vs 17 of 25), notably with 100% (3/3) sensitivity for clinical candidemia, compared to only 33% (1/3) for the Sepsityper®. Additionally, during inoculation experiments, the FcMBL method demonstrated a greater sensitivity, identifying 100% (24/24) of candida to genus level and 9/24 (37.5%) top species level compared to 70.8% (17/24) to genus and 6/24 to species (25%) using the Sepsityper®. This study demonstrates that capture and enrichment of samples using magnetic FcMBL-conjugated beads is superior to rapid centrifugation methods for identification of BCs by MALDI-TOF MS. Deploying the FcMBL method therefore offers potential clinical benefits in sensitivity and reduced turnaround times for BC diagnosis compared to the standard Sepsityper® kit, especially for fungal diagnosis.

Long-Term Report of a Comprehensive Molecular and Genomic Analysis in NRG Oncology/RTOG 0424: A Phase II Study of Radiation and Temozolomide in High-Risk Grade II Glioma.

PURPOSE: This study sought to determine the prognostic significance of the WHO-defined glioma molecular subgroups along with additional alterations, including MGMT promoter methylation and mutations in ATRX, CIC, FUBP1, TERT, and TP53, in NRG/RTOG 0424 using long-term follow-up data. METHODS: Mutations were determined using an Ion Torrent sequencing panel. 1p/19q co-deletion and MGMT promoter methylation were determined by Affymetrix OncoScan and Illumina 450K arrays. Progression-free survival (PFS) and overall survival (OS) were estimated using the Kaplan-Meier method and tested using the log-rank test. Hazard ratios were calculated using the Cox proportional hazard model. Multivariable analyses (MVAs) included patient pretreatment characteristics. RESULTS: We obtained complete molecular data to categorize 80/129 eligible patients within the WHO subgroups. Of these, 26 (32.5%) were IDHmutant/co-deleted, 28 (35%) were IDHmutant/non-co-deleted, and 26 (32.5%) were IDHwild-type. Upon single-marker MVA, both IDHmutant subgroups were associated with significantly better OS and PFS (P values < .001), compared with the IDHwild-type subgroup. MGMT promoter methylation was obtained on 76 patients, where 58 (76%) were methylated and 18 (24%) were unmethylated. Single-marker MVAs demonstrated that MGMT promoter methylation was statistically significant for OS (P value < .001) and PFS (P value = .003). In a multimarker MVA, one WHO subgroup comparison (IDHmutant/co-deleted v IDHwild-type) was significant for OS (P value = .045), whereas MGMT methylation did not retain significance. CONCLUSION: This study reports the long-term prognostic effect of the WHO molecular subgroups, MGMT promoter methylation, and other mutations in NRG/RTOG 0424. These results demonstrate that the WHO molecular classification and MGMT both serve as strong prognostic indicators, but that MGMT does not appear to add statistically significant prognostic value to the WHO subgrouping, above and beyond IDH and 1p/19q status.

In-Flight Medical Emergencies: A Review.

IMPORTANCE: In-flight medical emergencies (IMEs) are common and occur in a complex environment with limited medical resources. Health care personnel are often asked to assist affected passengers and the flight team, and many have limited experience in this environment. OBSERVATIONS: In-flight medical emergencies are estimated to occur in approximately 1 per 604 flights, or 24 to 130 IMEs per 1 million passengers. These events happen in a unique environment, with airplane cabin pressurization equivalent to an altitude of 5000 to 8000 ft during flight, exposing patients to a low partial pressure of oxygen and low humidity. Minimum requirements for emergency medical kit equipment in the United States include an automated external defibrillator; equipment to obtain a basic assessment, hemorrhage control, and initiation of an intravenous line; and medications to treat basic conditions. Other countries have different minimum medical kit standards, and individual airlines have expanded the contents of their medical kit. The most common IMEs involve syncope or near-syncope (32.7%) and gastrointestinal (14.8%), respiratory (10.1%), and cardiovascular (7.0%) symptoms. Diversion of the aircraft from landing at the scheduled destination to a different airport because of a medical emergency occurs in an estimated 4.4% (95% CI, 4.3%-4.6%) of IMEs. Protections for medical volunteers who respond to IMEs in the United States include a Good Samaritan provision of the Aviation Medical Assistance Act and components of the Montreal Convention, although the duty to respond and legal protections vary across countries. Medical volunteers should identify their background and skills, perform an assessment, and report findings to ground-based medical support personnel through the flight crew. Ground-based recommendations ultimately guide interventions on board. CONCLUSIONS AND RELEVANCE: In-flight medical emergencies most commonly involve near-syncope and gastrointestinal, respiratory, and cardiovascular symptoms. Health care professionals can assist during these emergencies as part of a collaborative team involving the flight crew and ground-based physicians.

A phase II study of temozolomide in patients with advanced aerodigestive tract and colorectal cancers and methylation of the O6-methylguanine-DNA methyltransferase promoter.

Responses of patients with gliomas to temozolomide are determined by O(6)-methylguanine-DNA methyltransferase (MGMT) and mismatch repair (MMR) pathways. This phase II study (NCT00423150) investigated whether MGMT promoter methylation predicts response in patients with advanced aerodigestive tract and colorectal cancers (CRC). Tumor and serum samples were screened for MGMT promoter methylation. In methylation-positive patients, 150 mg/m(2) temozolomide was administered daily on a seven-day-on, seven-day-off schedule for each 28-day cycle. The primary efficacy endpoint was response rate (RR). MMR status was determined by a microsatellite instability assay. Among 740 patients screened, 86 were positive for MGMT promoter methylation and enrolled. Nineteen percent of the screened population (137/740) had confirmed tissue and/or serum MGMT promoter methylation, including 25% (57 of 229) for CRC, 36% (55 of 154) for esophageal cancer, 11% (12 of 113) for head and neck cancer, and 5% (13 of 242) for non-small cell lung carcinoma. Among patients with valid methylation results in both tissue and serum samples, concordance was 81% (339 of 419). The majority of enrolled patients (69 of 86; 80%) had microsatellite stable cancer. Overall RR was 6% (5 of 86 partial responses); all responders had microsatellite stable cancer. Temozolomide resulted in low RRs in patients enriched for MGMT methylation. MGMT methylation status varied considerably in the patient population. Although serum methylation assay is an option for promoter methylation detection, tissue assay remains the standard for methylation detection. The low RR of this cohort of patients indicates that MGMT methylation as a biomarker is not applicable to heterogeneous tumor types, and tumor-specific factors may override validated biomarkers.

Phase I/II dose escalation trial of concurrent temozolomide and whole brain radiation therapy for multiple brain metastasis.

This study sought to establish the recommended phase II dose and efficacy of temozolomide (TMZ) with concurrent radiotherapy in patients with brain metastases. Patients were stratified by prior systemic therapy (≤1 vs. ≥2) and enrolled in cohorts of escalating doses of daily TMZ for 14 days (group A: 75, 95, 115, 135, or 150 mg/m(2), group B: 75, 90, 105, 120, or 135 mg/m(2)). Endpoints included safety and clinical activity. For group A (≤1 prior chemotherapy) no dose limiting toxicity was seen at 75 and 95 mg/m(2). Five of eight patients experienced dose limiting toxicities at 115 mg/m(2), thus the recommended phase II dose was 95 mg/m(2). Arm B (≥2 prior chemotherapy regimens) was closed due to poor enrollment. In the phase II portion, 17 patients in group A were treated. There were 0 patients with complete radiographic response, three with a partial response, ten remained stable, and four demonstrated early progression. The 3 and 6 month progression-free survival (PFS) rates were 41 and 18% with a median PFS time of 2.4 months. Overall survival at 3 and 6 months was 53 and 41%, respectively, with a median survival time of 4.1 months. The maximum tolerated dose of daily TMZ with concurrent WBRT was 95 mg/m(2). Despite dose escalation, outcomes did not appear to be improved in the sample treated.

Comparative analysis of in vivo and in vitro AAV vector transduction in the neonatal mouse retina: effects of serotype and site of administration.

The specificity of retinal cells transduced by AAV serotype 1, 2 or 5 vectors was determined in vivo versus in vitro in the normal P7 mouse in order to develop a rapid and accurate way to anticipate the behavior of AAV vectors in the retina. In vivo results confirm that AAV1 transduces retinal pigment epithelial cells, while AAV2 and AAV5 transduce both RPE and photoreceptor cells by subretinal injection. AAV2 was the only serotype to efficiently transduce inner retinal cells by intravitreal injection. Parallel analysis employing in vitro retinal organ culture showed qualitatively similar AAV-mediated GFP expression as seen in vivo suggesting that organ culture substitute is a useful method to screen new vector transduction patterns, particular in retinal cells in neonatal mice.

Integrating simulation training into the nursing curriculum.

The use of simulation is gaining momentum in nurse education across the UK. The Nursing and Midwifery Council is currently investigating the use of simulation in pre-registration nursing. This article gives a brief history of simulation, discusses competence issues and why simulation is best placed to teach nurses in today's health service. An innovative approach to implementing simulation into the nursing curriculum is introduced.

Causes for the undertreatment of elderly breast cancer patients: tailoring treatments to individual patients.

BACKGROUND: Ageism has been suggested as a cause for the undertreatment of elderly breast cancer patients. The purpose of this study was to determine the rate and causes of elderly patients not receiving standard therapy. STUDY DESIGN: A random sample of 500 patients was reviewed for age, cancer stage, surgical, radiation, cytotoxic or hormonal chemotherapy, number and type of comorbidities, type of therapeutic deficiencies, and their causes. RESULTS: The average age was 59.9+/-13.6 years. Of the patients less than 65 years old, 6.0% did not receive standard treatment, compared with 22.2% of patients 65 years or older. Treatment omitted in the less than 65-year-old group: 16.7%, no tumor extirpation; 38.9%, no axillary dissection; 33.3%, no radiation therapy; and 33.3% no chemotherapy. Treatment omitted in the 65-year and older group: 11.4%, no tumor extirpation; 39.1%, no axillary dissection; 47.7%, no radiation therapy; and 18.2%, no chemotherapy. Causes in the less than 65-year-old group were: prohibitive associated medical conditions, 27.8%; favorable primary tumor pathology, 16.7%; and patient treatment refusal, 55.6%. Causes in the 65-year and older group were: prohibitive associated medical conditions, 40.9%; favorable tumor pathology, 13.6%; patient treatment refusal, 31.8%; and unexplainable, 13.6%. The median number of concomitant medical conditions in patients receiving standard therapy was one compared with three in the undertreated patients from prohibitive associated medical conditions or unexplained causes. CONCLUSION: Population-based studies of breast cancer treatment do not adequately assess the complex decision making associated with breast cancer in the elderly. Patients do not receive standard care for specific reasons.

Exponential-phase expression of spvA of the Salmonella typhimurium virulence plasmid: induction in intracellular salts medium and intracellularly in mice and cultured mammalian cells.

The spv genes of Salmonella typhimurium and other non-typhoidal Salmonella serovars are essential for efficient systemic infection beyond the intestines in orally inoculated mice as a model for enteric fever. These virulence genes are not significantly expressed by salmonellae during exponential growth in L broth but are induced when the bacteria enter the stationary phase of growth. Using RNase protection analysis to directly measure spvA mRNA from the virulence plasmid of S. typhimurium, we found that spvA was maximally induced in an SpvR- and RpoS-dependent manner during exponential growth in intracellular Salts Medium, which mimics the intracellular environment of mammalian cells. A cloned spvA-lacZ operon fusion in S. typhimurium was induced intracellularly in periotoneal cells of mice, correlating in vivo intracellular gene expression with intracellular function of the spv genes in infected mice. spvA was also induced intracellularly in vitro within both Henle-407 intestinal epithelial cells and J774.A1 macrophage-like cells when the bacteria were replicating with exponential kinetics. Prevention of invasion of salmonellae with cytochalasin D inhibited spvA induction within tissue culture cells, indicating that salmonellae must be internalized for spvA to be induced. The spvA-lacZ fusion was not induced by salmonellae in extracellular fluid of the peritoneal cavity or in serum. Since induction of the spv genes occurs intracellularly during exponential growth of salmonellae, cessation of growth may not be the most relevant inducing signal for spv gene expression.