Deviations From Best Practice: Findings From a Certified Patient Safety Organization Remote-Verification Observational Study of Intravenous Compounding of Chemotherapeutic and Ancillary Drugs.

Background: Chemotherapeutic and immunomodulatory medications can pose a serious risk to patient and healthcare provider safety because of complex processes, cytotoxicity, and prevalent medication use. Objective: To evaluate chemotherapeutic and ancillary medication compounding in hospital pharmacies using a remote verification system, focusing on pharmaceutical deviations from best practice, compounding time, medication waste, and cost. Methods: This retrospective, blinded observational study used a remote intravenous (IV) workflow verification system to examine IV chemotherapeutic compounding errors in large hospital systems. A Patient Safety Organization securely obtained >5000 compounding records and photos from the IV workflow system. Blinded pharmacists evaluated IV chemotherapy preparations using picture slide viewers to assess any deviations from best practice. Time variables, medication waste, STAT vs non-STAT orders, and cost were also evaluated. Results: The most frequently reported deviations from best practice included medications exceeding the >10% additive volume guideline (35.9%) and inaccurate dose labels (28.3%). Time flow analyses demonstrated a substantial increase in total compounding time per vial for 1 vs 2 vials. Most medications in this analysis had an average waste ranging from 0-.36 vials. STAT orders, accounting for 38.4% of all orders, wasted more medication than non-STAT orders. Gemcitabine cost analyses showed an association for number of vials and compounding time with overall cost per dose. Conclusion: Substantial inconsistencies between workflow stations were observed-highlighting the lack of standardization across chemotherapeutics, volume of medication waste during preparation, and the need to establish improved quality controls to safeguard patient and health care provider safety.

Top-down regulation of hemlock woolly adelgid (Adelges tsugae) in its native range in the Pacific Northwest of North America.

The density of insect herbivores is regulated by top-down factors (e.g., natural enemies), bottom-up effects (e.g., plant defenses against herbivory), or a combination of both. As such, understanding the relative importance of these factors can have important implications for the establishment of effective management options for invasive species. Here, we compared the relative importance of top-down and bottom-up factors on the abundance of hemlock woolly adelgid (HWA), Adelges tsugae. HWA is invasive in eastern North America, but its native range includes the Pacific Northwest of North America where it has co-evolved with western hemlock, Tsuga heterophylla. Eastern hemlock, Tsuga canadensis, can also be found planted in city and park settings in the Pacific Northwest and the presence of both host species allowed us to directly compare the importance of predators (top-down) and host plant resistance (bottom-up) on HWA abundance by placing mesh exclusion bags on branches of both species and monitoring HWA abundance over two years. We found no evidence for bottom-up control of HWA on western hemlock (a native host). HWA established more readily on that species than on eastern hemlock on which it is a major pest in eastern North America. We found strong evidence for top-down control in that both summer and winter-active predators significantly reduced HWA densities on the branches of both tree species where predators were allowed access. These findings support the validity of the biological control program for HWA, the goal of which is to reduce outbreak populations of HWA in eastern North America.

Evolved resistance to a novel cationic peptide antibiotic requires high mutation supply.

Background and Objectives: A key strategy for resolving the antibiotic resistance crisis is the development of new drugs with antimicrobial properties. The engineered cationic antimicrobial peptide WLBU2 (also known as PLG0206) is a promising broad-spectrum antimicrobial compound that has completed Phase I clinical studies. It has activity against Gram-negative and Gram-positive bacteria including infections associated with biofilm. No definitive mechanisms of resistance to WLBU2 have been identified. Methodology: Here, we used experimental evolution under different levels of mutation supply and whole genome sequencing (WGS) to detect the genetic pathways and probable mechanisms of resistance to this peptide. We propagated populations of wild-type and hypermutator Pseudomonas aeruginosa in the presence of WLBU2 and performed WGS of evolved populations and clones. Results: Populations that survived WLBU2 treatment acquired a minimum of two mutations, making the acquisition of resistance more difficult than for most antibiotics, which can be tolerated by mutation of a single target. Major targets of resistance to WLBU2 included the orfN and pmrB genes, previously described to confer resistance to other cationic peptides. More surprisingly, mutations that increase aggregation such as the wsp pathway were also selected despite the ability of WLBU2 to kill cells growing in a biofilm. Conclusions and implications: The results show how experimental evolution and WGS can identify genetic targets and actions of new antimicrobial compounds and predict pathways to resistance of new antibiotics in clinical practice.

Characterization of Female Reproductive Proteases in a Butterfly from Functional and Evolutionary Perspectives.

Molecules that mediate reproductive interactions are some of the most rapidly evolving traits. Researchers have often suggested that this is due to coevolution at key physiological interfaces. However, very few of these interfaces are well understood at the functional level. One such interface is the digestion of the spermatophore in Lepidoptera. Female Lepidoptera have a specialized reproductive organ called the bursa copulatrix that receives and processes the male spermatophore, a complex proteinaceous ejaculate. In the cabbage white butterfly, Pieris rapae, the bursa secretes a mixture of proteases hypothesized to digest the spermatophore. However, these proteases remain biochemically uncharacterized. Using a zymogram approach, we identified six proteases in bursal extracts at sufficiently high concentrations to characterize their in vitro activity. We assessed the modes of action of these bursal enzymes by quantifying their activity following exposure to diagnostic protease inhibitors. A serine protease-specific inhibitor failed to reduce bursal protease digestion of casein. However, a cysteine protease-specific inhibitor did decrease the activity of some proteases. To explore the possible molecular mechanisms responsible for these responses, we created protease homology models. The models mirrored the results of our in vitro experiments, indicating that protease homology models may offer insight into underlying functional mechanisms. Whether the observed bursal protease resistance to known inhibitors is important in the context of spermatophore digestion remains to be tested. However, our results suggest the exciting possibility that bursal protease specificity may have evolved in response to interactions with various proteins and inhibitors present within the female tract during the reproductive process.

Development and validation of an assay to measure cannabidiol and Δ9-tetrahydrocannabinol in human EDTA plasma by UHPLC-MS/MS.

The therapeutic use of cannabinoids has increased with providers often recommending cannabinoid-containing products with limited pre-clinical and clinical pharmacokinetic studies. An ultra-performance liquid chromatography with triple quadrupole mass spectrometry method was developed and validated for the determination of cannabidiol and Δ9-tetrahydrocannabinol in human ethylenediaminetetraacetic acid (EDTA) plasma. The cannabinoids are extracted from plasma with a liquid-liquid procedure utilizing methyl tert-butyl ether. UHPLC Separation was achieved with a Waters Acquity HSS T3 column (100 × 2.1 mm, 1.8 µm) under isocratic conditions (18:82:0.02 water:methanol:formic acid v/v/v). The run time was 8.5 min. Detection of analytes was achieved using electrospray ionization and triple quadrupole selected reaction monitoring. Standard curve concentrations ranged from 0.5 to 250 ng/mL for cannabidiol and Δ9-tetrahydrocannabinol. The intra- and inter-day accuracy (% bias) and precision (relative standard deviation) were <9.20% in low, medium, and high quality control samples. The validated method was applied to the analysis of donated human EDTA plasma. The assay provides an important patient monitoring capability to determine variability in clinical pharmacokinetics during use of cannabinoid-containing products.

Environmental adaptation in an asexual invasive insect.

Parthenogenetic reproduction is generally associated with low genetic variance and therefore reduced ability for environmental adaptation, and this could limit the potential invasiveness of introduced species that reproduce asexually. However, the hemlock woolly adelgid is an asexual invasive insect that has spread across a large geographic temperature gradient in its introduced range. Consequently, this insect has shown significant variation in cold hardiness among populations. We hypothesized that the increased cold hardiness of northern populations represents an adaptation to the colder temperatures. To test this, we collected individual adelgid from populations spanning their invaded range and inoculated them into a common thermal environment. We then experimentally sampled the supercooling point of the progeny of these adelgids and compared these results with tests of the supercooling point of adelgid sampled directly from their source populations. The results showed that the same significant differences in supercooling that was found among geographically distinct populations existed even when the adelgid was reared in a common environment, indicating a genetic basis for the variation in cold hardiness. These findings support the hypothesis that the adelgid has adapted to the colder environment as it has expanded its distribution in its invaded range.

Three-dimensional microstructural imaging of sulfur poisoning-induced degradation in a Ni-YSZ anode of solid oxide fuel cells.

Following exposure to ppm-level hydrogen sulfide at elevated temperatures, a section of a solid oxide fuel cell (SOFC) Ni-YSZ anode was examined using a combination of synchrotron-based x-ray nanotomography and x-ray fluorescence techniques. While fluorescence measurements provided elemental identification and coarse spatial mapping, x-ray nanotomography was used to map the detailed 3-D spatial distribution of Ni, YSZ, and a nickel-sulfur poisoning phase. The nickel-sulfur layer was found to form a scale covering most of the exposed nickel surface, blocking most fuel reformation and hydrogen oxidation reaction sites. Although the exposure conditions precluded the ability to develop a detailed kinetic description of the nickel-sulfur phase formation, the results provide strong evidence of the detrimental effects of 100 ppm hydrogen sulfide on typical Ni-YSZ anode materials.

Host use patterns by the European woodwasp, Sirex noctilio, in its native and invaded range.

Accelerating introductions of forest insects challenge decision-makers who might or might not respond with surveillance programs, quarantines, eradication efforts, or biological control programs. Comparing ecological controls on indigenous vs. introduced populations could inform responses to new introductions. We studied the European woodwasp, Sirex noctilio, which is not a pest in its native forests, is a serious invasive pest in the southern hemisphere, and now has an uncertain future in North America after its introduction there. Indigenous populations of S. noctilio (in Galicia, Spain) resembled those in New York in that S. noctilio were largely restricted to suppressed trees that were also dying for other reasons, and still only some dying trees showed evidence of S. noctilio: 20-40% and 35-51% in Galicia and New York, respectively. In both areas, P. sylvestris (native to Europe) was the species most likely to have attacks in non-suppressed trees. P. resinosa, native to North America, does not appear dangerously susceptible to S. noctilio. P. radiata, which sustains high damage in the southern hemisphere, is apparently not innately susceptible because in Galicia it was less often used by native S. noctilio than either native pine (P. pinaster and P. sylvestris). Silvicultural practices in Galicia that maintain basal area at 25-40 m(2)/ha limit S. noctilio abundance. More than 25 species of other xylophagous insects feed on pine in Galicia, but co-occurrences with S. noctilio were infrequent, so strong interspecific competition seemed unlikely. Evidently, S. noctilio in northeastern North America will be more similar to indigenous populations in Europe, where it is not a pest, than to introduced populations in the southern hemisphere, where it is. However, S. noctilio populations could behave differently when they reach forests of the southeastern U.S., where tree species, soils, climate, ecology, management, and landscape configurations of pine stands are different.

Three-dimensional microstructural imaging methods for energy materials.

Advances in the design of materials for energy storage and conversion (i.e., "energy materials") increasingly rely on understanding the dependence of a material's performance and longevity on three-dimensional characteristics of its microstructure. Three-dimensional imaging techniques permit the direct measurement of microstructural properties that significantly influence material function and durability, such as interface area, tortuosity, triple phase boundary length and local curvature. Furthermore, digital representations of imaged microstructures offer realistic domains for modeling. This article reviews state-of-the-art methods, across a spectrum of length scales ranging from atomic to micron, for three-dimensional microstructural imaging of energy materials. The review concludes with an assessment of the continuing role of three-dimensional imaging in the development of novel materials for energy applications.

Quantitative x-ray phase imaging at the nanoscale by multilayer Laue lenses.

For scanning x-ray microscopy, many attempts have been made to image the phase contrast based on a concept of the beam being deflected by a specimen, the so-called differential phase contrast imaging (DPC). Despite the successful demonstration in a number of representative cases at moderate spatial resolutions, these methods suffer from various limitations that preclude applications of DPC for ultra-high spatial resolution imaging, where the emerging wave field from the focusing optic tends to be significantly more complicated. In this work, we propose a highly robust and generic approach based on a Fourier-shift fitting process and demonstrate quantitative phase imaging of a solid oxide fuel cell (SOFC) anode by multilayer Laue lenses (MLLs). The high sensitivity of the phase to structural and compositional variations makes our technique extremely powerful in correlating the electrode performance with its buried nanoscale interfacial structures that may be invisible to the absorption and fluorescence contrasts.

Zone-doubled Fresnel zone plates for high-resolution hard X-ray full-field transmission microscopy.

Full-field transmission X-ray microscopy is a unique non-destructive technique for three-dimensional imaging of specimens at the nanometer scale. Here, the use of zone-doubled Fresnel zone plates to achieve a spatial resolution better than 20 nm in the hard X-ray regime (8-10 keV) is reported. By obtaining a tomographic reconstruction of a Ni/YSZ solid-oxide fuel cell, the feasibility of performing three-dimensional imaging of scientifically relevant samples using such high-spatial-resolution Fresnel zone plates is demonstrated.

Focused ion beam preparation of samples for X-ray nanotomography.

The preparation of hard material samples with the necessary size and shape is critical to successful material analysis. X-ray nanotomography requires that samples are sufficiently thin for X-rays to pass through the sample during rotation for tomography. One method for producing samples that fit the criteria for X-ray nanotomography is focused ion beam/scanning electron microscopy (FIB/SEM) which uses a focused beam of ions to selectively mill around a region of interest and then utilizes a micromanipulator to remove the milled-out sample from the bulk material and mount it on a sample holder. In this article the process for preparing X-ray nanotomography samples in multiple shapes and sizes is discussed. Additionally, solid-oxide fuel cell anode samples prepared through the FIB/SEM technique underwent volume-independence studies for multiple properties such as volume fraction, average particle size, tortuosity and contiguity to observe the characteristics of FIB/SEM samples in X-ray nanotomography.

Growth, metastasis, and expression of CCL2 and CCL5 by murine mammary carcinomas are dependent upon Myd88.

Previously we reported that lipopolysaccharide (LPS) treatment of murine mammary carcinomas resulted in decreased growth of the tumors. Here we show the decreased growth following LPS treatment was mediated through effects downstream of TLR4 and Myd88. Perhaps more notably, simply reducing TLR4 or Myd88 levels was sufficient to slow tumor growth rates. Moreover, reduced levels of Myd88 correlated with a significant reduction in lung metastasis as well as decreased CCL2 and CCL5 expression. To determine whether inhibiting Myd88 function could also alter tumor growth and chemokine expression we used a Myd88 homodimerization inhibitory peptide. Indeed, inhibiting Myd88 function in four different murine mammary carcinomas as well as the human breast cancer cell line MDA-MB-231 led to decreased growth as well as CCL2 and CCL5 expression. These data imply that Myd88 is important for growth and metastasis of breast cancer, and expression of at least two proinflammatory chemokines.

High-dose octreotide acetate for management of gastroenteropancreatic neuroendocrine tumors.

BACKGROUND: Long-acting sandostatin (S-LAR; octreotide acetate) is well tolerated and effective for symptom control and possibly disease control in gastroenteropancreatic neuroendocrine tumors (GEP-NETs). We undertook a retrospective analysis to study the efficacy and tolerability of higher doses (more than 20-30 mg/month) of S-LAR in GEP-NETs. PATIENTS AND METHODS: With IRB approval, charts of all patients with GEP-NET who received S-LAR between June 2002 to September 2007 at Roswell Park Cancer Institute were reviewed and their data analyzed. RESULTS: Fifty-four patients with GEP-NET received S-LAR; thirty required dose escalation. Patients received a median of 5 doses of S-LAR at conventional dose followed by up-titration of the dose for symptom control (20) and radiological progression (17). Median high dose of S-LAR was 40 mg (range: 40-90 mg) with a median of 8.5 high doses received. No treatment related toxicities were seen. The estimated 1-year survival for patients on conventional dose alone was 0.77 (95% CI of 0.50 to 0.91) and those on high-dose was 0.88 (95% CI of 0.68 to 0.96) (p=0.4777) while median time to any other intervention was 2.9 months versus 17.7 months (p=0.12). CONCLUSION: Dose escalation of S-LAR is well tolerated and may provide longer disease control.

Adjuvant FOLFOX chemotherapy and splenomegaly in patients with stages II-III colorectal cancer.

BACKGROUND: The impact of adjuvant chemotherapy on hepatic function and portal hypertension in patients with stages II-III colon cancer has not been previously described. We conducted a retrospective study to assess the effects of adjuvant FOLFOX chemotherapy on the splenic index (SI) as a surrogate marker for portal hypertension. METHODS: Stage II-III colorectal cancer patients treated with adjuvant FOLFOX or fluorouracil/leucovorin (5-FU/LV) at Roswell Park Cancer Institute between 2002 and 2006 were identified. Computerizedt omography (CT) scans obtained prior to and at completion of chemotherapy, and every 6 months thereafter were reviewed. Splenic size was evaluated using the SI (SI = length x width x height of the spleen). RESULTS: 40 patients were identified in the FOLFOX group and 23 in the 5-FU/LV group. After 6 months of adjuvant chemotherapy, the mean increase in SI was 45.7 and 16.3% in the FOLFOX and 5-FU/LV groups, respectively (p = 0.0069). SI increased by >100% in 6 patients (15%) in the FOLFOX group versus none in the 5-FU/LV group (p = 0.16). The mean SI at completion of adjuvant chemotherapy was significantly higher in the FOLFOX group than in the 5-FU/LV group (p = 0.007). The mean SI decreased steadily over a period of 2 years after discontinuation of FOLFOX, suggesting potential reversibility of oxaliplatin-induced hepatic injury in this setting. CONCLUSIONS: Adjuvant FOLFOX significantly increases the SI in patients with resected colorectal cancer in comparison to adjuvant 5-FU/LV. The increase in SI may be a marker of oxaliplatin-induced hepatic injury and should be investigated further in prospective longitudinal studies of oxaliplatin-based adjuvant chemotherapy.

Hypertension secondary to anti-angiogenic therapy: experience with bevacizumab.

BACKGROUND: Hypertension (HT) is a common complication of anti-angiogenic therapy. Its incidence, treatment and complications are undefined. PATIENTS AND METHODS: Retrospective review of patients treated with bevacizumab (BV) from 2003-5. Common toxicity criteria (CTC) for adverse events version 3.0 were used. RESULTS: Fifty-five out of the 154 patients treated with BV (35%) experienced HT. Eleven (20%) developed a new onset HT and 44 (80%) experienced an exacerbation of pre-existing HT. HT developed after a median of 11 weeks at a median BV dose of 10 mg/kg. HT severity was grade 1 (n =1), grade 2 (n=29) or grade 3 (n=22); 3 experienced hypertensive complications. HT was controlled in 47 (85%); BV was discontinued in 3. The angiotensin-converting enzyme inhibitor (ACE-I), quinapril was commonly used and resulted in better HT control than ACE-II, calcium channel or beta antagonists. CONCLUSION: HT associated with bevacizumab therapy is a manageable toxicity with the use of ACE-I.

Concurrent oxaliplatin, 5-fluorouracil, and radiotherapy in the treatment of locally advanced esophageal carcinoma.

PURPOSE: The combination of oxaliplatin, 5-fluorouracil, and leucovorin with concurrent radiotherapy was demonstrated to be a safe regimen for locally advanced esophageal carcinoma in a prior phase I study. We now report the efficacy data for 42 patients treated with this regimen. METHODS: Each chemotherapy cycle lasted 29 days and consisted of 5-fluorouracil, 180 mg/m2 protracted-infusion from days 1 to 29, and oxaliplatin, 85 mg/m2 on days 1, 15, and 29. The first cycle was administered concurrently with radiation. The radiation field included regional lymph nodes as well as the primary tumor or tumor bed to a dose of 50.4 Gy in 28 fractions. After concurrent chemoradiotherapy, 1 to 2 additional cycles of chemotherapy were administered. If esophagectomy was indicated, it occurred 4 weeks after completion of concurrent chemoradiotherapy. In the adjuvant group, concurrent chemoradiotherapy was initiated 4 weeks after surgery. RESULTS: Median age was 61 years (range 38-78 years); 30 (71%) of the patients were male. Thirty-three patients had adenocarcinoma, and 9 had squamous cell carcinoma. Concurrent chemoradiotherapy was administered preoperatively (group 1) in 24 patients, definitively (group 2) in 13 patients, and as adjuvant treatment (group 3) in 5 patients. In group 1, 16 patients were down-staged including 1 patient with minimal residual disease and 5 with a complete pathologic response; 4 patients were not down-staged, and 4 did not undergo esophagectomy (2 progressed, 1 died of unrelated causes, and 1 refused). In group 2, 1 patient had a complete clinical response, 4 others were down-staged, 2 had stable disease, and 6 progressed. Four patients in group 3 progressed. Median survival was 28 months for group 1, 12 months for group 2, and not reached at 14 months for group 3. There was one grade 4 toxicity (anaphylaxis) in group 2. Grade 3 toxicities were reported for 5 patients in group 1 and 1 patient in group 2. They consisted of hypotension (n=1), fatigue (n=2), diarrhea (n=2), neuropathy (n=1), mucositis (n=1), pneumonitis (n=1), dehydration (n=1), emesis (n=1), and weight loss (n=1). CONCLUSIONS: Our study supports the incorporation of oxaliplatin into a multimodal concurrent chemoradiotherapy protocol for locally advanced esophageal cancer.

Cetuximab-induced hypomagnesemia in patients with colorectal cancer.

BACKGROUND: Cetuximab treatment has been associated with severe hypomagnesemia, but the predisposing factors and management of this toxicity have been poorly characterized. PATIENTS AND METHODS: The charts of 114 patients with colorectal cancer treated with cetuximab were reviewed. Forty-eight evaluable patients had normal magnesium levels before initiation of cetuximab and >or=1 repeat magnesium level during cetuximab treatment. The incidence, grade, and management of hypomagnesemia were described in the evaluable population. RESULTS: Among the evaluable population, 13 patients developed grade 3/4 hypomagnesemia (27%). The incidence of grade 3/4 hypomagnesemia was 6%, 23%, and 47% in patients receiving < 3 months, 3-6 months, and > 6 months of cetuximab therapy, respectively. Grade 3/4 hypomagnesemia was refractory to oral supplementation and required daily to 3-times-weekly intravenous magnesium sulfate supplementation at 6-10 g per dose. Recovery or amelioration in hypomagnesemia occurred approximately 4 weeks after cetuximab discontinuation. CONCLUSION: Severe hypomagnesemia is a frequent side effect of cetuximab therapy. Treatment of hypomagnesemia requires frequent intravenous magnesium supplementation and can be associated with significant patient inconvenience and an increased risk of venous access-related complications. Intermittent cetuximab schedules need to be investigated in order to reduce the frequency and severity of hypomagnesemia.