Novel mTORC1 Inhibitors Kill Glioblastoma Stem Cells.

Glioblastoma (GBM) is an aggressive tumor of the brain, with an average post-diagnosis survival of 15 months. GBM stem cells (GBMSC) resist the standard-of-care therapy, temozolomide, and are considered a major contributor to tumor resistance. Mammalian target of rapamycin Complex 1 (mTORC1) regulates cell proliferation and has been shown by others to have reduced activity in GBMSC. We recently identified a novel chemical series of human-safe piperazine-based brain-penetrant mTORC1-specific inhibitors. We assayed the piperazine-mTOR binding strength by two biophysical measurements, biolayer interferometry and field-effect biosensing, and these confirmed each other and demonstrated a structure-activity relationship. As mTORC1 is altered in human GBMSC, and as mTORC1 inhibitors have been tested in previous GBM clinical trials, we tested the killing potency of the tightest-binding piperazines and observed that these were potent GBMSC killers. GBMSCs are resistant to the standard-of-care temozolomide therapy, but temozolomide supplemented with tight-binding piperazine meclizine and flunarizine greatly enhanced GBMSC death over temozolomide alone. Lastly, we investigated IDH1-mutated GBMSC mutations that are known to affect mitochondrial and mTORC1 metabolism, and the tight-binding meclizine provoked 'synthetic lethality' in IDH1-mutant GBMSCs. In other words, IDH1-mutated GBMSC showed greater sensitivity to the coadministration of temozolomide and meclizine. These data tend to support a novel clinical strategy for GBM, i.e., the co-administration of meclizine or flunarizine as adjuvant therapy in the treatment of GBM and IDH1-mutant GBM.

Cetylpyridinium chloride is a potent AMP-activated kinase (AMPK) inducer and has therapeutic potential in cancer.

AMP-activated protein kinase (AMPK) is a eukaryotic energy sensor and protector from mitochondrial/energetic stress that is also a therapeutic target for cancer and metabolic disease. Metformin is an AMPK inducer that has been used in cancer therapeutic trials. Through screening we isolated cetylpyridinium chloride (CPC), a drug known to dose-dependently inhibit mitochondrial complex 1, as a potent and dose-dependent AMPK stimulator. Mitochondrial biogenesis and bioenergetics changes have also been implicated in glioblastoma, which is the most aggressive form of brain tumors. Cetylpyridinium chloride has been administered in humans as a safe drug-disinfectant for several decades, and we report here that under in vitro conditions, cetylpyridinium chloride kills glioblastoma cells in a dose dependent manner at a higher efficacy compared to current standard of care drug, temozolomide.

Idebenone is a cytoprotective insulin sensitizer whose mechanism is Shc inhibition.

When insulin binds insulin receptor, IRS1 signaling is stimulated to trigger the maximal insulin response. p52Shc protein competes directly with IRS1, thus damping and diverting maximal insulin response. Genetic reduction of p52Shc minimizes competition with IRS1, and improves insulin signaling and glucose control in mice, and improves pathophysiological consequences of hyperglycemia. Given the multiple benefits of Shc reduction in vivo, we investigated whether any of 1680 drugs used in humans may function as Shc inhibitors, and thus potentially serve as novel anti-diabetics. Of the 1680, 30 insulin sensitizers were identified by screening in vitro, and of these 30 we demonstrated that 7 bound Shc protein. Of the 7 drugs, idebenone dose-dependently bound Shc protein in the 50-100 nM range, and induced insulin sensitivity and cytoprotection in this same 100 nM range that clinically dosed idebenone reaches in human plasma. By contrast we observe mitochondrial effects of idebenone in the 5,000 nM range that are not reached in human dosing. Multiple assays of target engagement demonstrate that idebenone physically interacts with Shc protein. Idebenone sensitizes mice to insulin in two different mouse models of prediabetes. Genetic depletion of idebenone's target eliminates idebenone's ability to insulin-sensitize in vivo. Thus, idebenone is the first-in-class member of a novel category of insulin-sensitizing and cytoprotective agents, the Shc inhibitors. Idebenone is an approved drug and could be considered for other indications such as type 2 diabetes and fatty liver disease, in which insulin resistance occurs.

Small molecules bind human mTOR protein and inhibit mTORC1 specifically.

Inhibition of mTOR activity (mechanistic target of rapamycin) is an anti-cancer therapeutic strategy. mTOR participates in two functional complexes, mTORC1 and mTORC2. Since mTORC1 is specifically activated in multiple tumors, novel molecules that inhibit mTORC1 could be therapeutically important. To identify potentially novel modulators of mTOR pathways, we screened 1600 small molecule human drugs for mTOR protein binding, using novel biolayer interferometry technology. We identified several small molecules that bound to mTOR protein in a dose-dependent manner, on multiple chemical scaffolds. As mTOR participates in two major complexes, mTORC1 and mTORC2, the functional specificities of the binders were measured by S6Kinase and Akt phosphorylation assays. Three novel 'mTOR general' binders were identified, carvedilol, testosterone propionate, and hydroxyprogesterone, which inhibited both mTORC1 and mTORC2. By contrast, the piperazine drug cinnarizine dose-dependently inhibited mTORC1 but not mTORC2, suggesting it as a novel mTORC1-specific inhibitor. Some of cinnarizine's chemical analogs also inhibited mTORC1 specifically, whereas others did not. Thus we report the existence of a novel target for some related piperazines including cinnarizine and hydroxyzine, i.e. specific inhibition of mTORC1 activity. Since mTOR inhibition is a general anti-cancer strategy, and mTORC1 is specifically activated in some tumors, we suggest the piperazine scaffold, including cinnarizine and hydroxyzine, could be proposed for rational therapy in tumors in which mTORC1 is specifically activated. Related piperazines have shown toxicity to cancer cells in vitro as single agents and in combination chemotherapy. Thus piperazine-based mTOR inhibitors could become a novel chemotherapeutic strategy.

Nurses' experiences assessing the spirituality of terminally ill patients in acute clinical practice.

AIM: To explore and describe how nurses define spirituality and incorporate spiritual care into their clinical practice. METHOD: A two-phase, mixed-methods, explanatory descriptive design was adopted. Sixteen nurses working in an acute medical ward completed a purpose-designed questionnaire. This was followed by unstructured focus group interviews. The data generated was analysed using a thematic coding process. FINDINGS: Four themes were identified: understanding spirituality, assessment of spirituality, difficulties in meeting spiritual needs, and education. The exploration of the nurses' experiences showed that they did not clearly define or recognize the concept of spirituality, but they did recognize an aspect of patient care that required a transition away from a technical to a humane response. CONCLUSION: Despite the lack of a clear definition of spirituality and application of an established spiritual assessment tool, nurses do assess spirituality and incorporate spiritual care into their clinical practice, even in acute care settings.

Detection of rapidly growing mycobacteria in routine cultures of samples from patients with cystic fibrosis.

Rapidly growing mycobacteria (RGM) are respiratory pathogens in patients with cystic fibrosis (CF), but detection generally requires specialized cultures for acid-fast bacilli (AFB; AFB cultures). We determined that RGM could be recovered from routine cultures of samples from patients with CF by extending incubation of the Burkholderia cepacia selective agar (BCSA) from 5 to 14 days. To explore the impact of this modification, we compared results from routine and AFB cultures of samples from CF patients for 2 years before (4,212 samples by routine culture, 1,810 samples by AFB culture, 670 patients) and 2 years after (4,720 samples by routine culture, 2,179 samples by AFB culture, 695 patients) the change. Clinical relevance was assessed with samples from a subgroup of 340 patients followed regularly throughout both periods. Extending incubation of BCSA enhanced RGM recovery from routine cultures (0.7% before, 2.8% after; P < 0.001); recovery from AFB cultures was unchanged (5.5% before, 5.7% after). Estimates of RGM detection sensitivity by culture or patient-based methods ranged from ∼65 to 75% for routine cultures (nonsignificantly lower than the ∼80 to 85% for AFB cultures) and were adversely affected by coculture with mold or nonpseudomonal, nonfermenting Gram-negative rods. In the after period, 16 CF patients met the criteria for RGM infection by routine culture, including 4 who did not meet the criteria for RGM infection by AFB culture. We conclude that a simple methodological change enhanced recovery of RGM from routine cultures. The modified culture method could be utilized to improve screening for RGM in CF patients or as a simpler method to follow patients with known RGM infection. However, this method should be used cautiously in patients with certain coinfections.

The evolution of palliative care and the relevance to residential aged care: understanding the past to inform the future.

Improving the experience of dying in residential aged care units became a significant project of the Australian Government's National Palliative Care Program in 2004. This initiative resulted in an expectation that residential aged care facilities would adopt the recommended palliative approach to underpin service delivery. Recognising palliative care as a specialist area of health care practice is a recent development which has influenced the expectations of community and government. This paper traces the global history of palliative care and how historical factors influenced its development in Australia. This discussion presents an overview of the positioning of dying and death within society, explaining how with the shifting emphasis on care of the dying accordingly has been the focus on palliative care specialists. Care of the dying in residential aged care units has largely been overlooked in the context of specialist involvement. This paper acknowledges dying and death as occurring in residential aged care facilities, illuminating the advantages of adopting a palliative approach and offers recommendations.

The implications of policy on delivering a palliative approach in residential aged care: rhetoric or reality?

This critical ethnographic study aimed to understand policy and documentation in relationship to guiding nursing practice in delivering a palliative approach to residents of an aged care unit of a Multi-purpose Service (MPS). A thematic analysis was undertaken that searched the text for cultural determinants of practice, and similarities and differences between the data sets. Where discrepancies occurred, key informants were revisited and questioned regarding anomalies. Using a critical lens this interpreted data formed the substantive findings of this research. The Guidelines for a Palliative Approach in Residential Aged Care (RAC) were not known or understood by management or nurses employed in this MPS. This paper supports the need for research to be conducted into evaluating the Guidelines as the current premise of this research is that policy is rhetoric not reality in providing a planned trajectory of care for residents and their family members.

Examining the methods used for a critical ethnographic enquiry.

Methodology articulates the broad theoretical and philosophical framework which researchers employ when conducting an inquiry. Methods are the procedural rules by which research inquiry is conducted; giving authority to articulate and communicate information as reliable and accurate in nature. Critical ethnography delves beneath the surface to examine the power relations and influences affecting phenomena by using field methods to identify not only culture, the 'consciousness' or the 'lived experiences' of others, but also exposing the political, social and material disempowerment of individuals and disadvantaged groups in order to elicit change. Fieldwork is central to all ethnographies and in this critical ethnography it forms the platform from which the delivery of palliative care to aged residents in a multi-purpose centre can be scrutinised. This paper explicates the fieldwork adopted in conducting such a study.

Gaining human ethics approval: a strategy for refining research studies.

We argue that developing a human ethics application is an effective method for refining the intent and design of research studies. Our study aimed to investigate the delivery of end-of-life and palliative care nursing to residents of an aged care unit in a Multi-purpose Service/Centre in rural Victoria. We used the ethics application process as a strategy to focus the study, and to refine the data collection and analysis techniques. It is our contention that the process of completing the application and gaining ethics approval is laborious; however, the intellectualising that occurs provides researchers with an opportunity to reflect upon and refine their studies, thus ensuring the ultimate success and timely completion of research investigations.

The importance of language for nursing: does it convey commonality of meaning and is it important to do so.

OBJECTIVE: Language is the medium by which communication is both conveyed and received. To understand and communicate meaning it is necessary to examine the theoretical basis of word conceptualisation. The determinants of understanding language however are somewhat elusive and idiosyncratic by nature. This paper will examine briefly the development of language and how language is used in the health care setting, while recognising that nursing is an internationally recognised profession. SETTING: In nursing, language is used to facilitate quality care and inform and educate recipients of that care. In today's somewhat litigious society, it is essential that what is transmitted is commonly interpreted by nurses and patients alike. Questions are posed relating to an elitist language for nurses and its placement for communicating with other health care professionals. PRIMARY ARGUMENT: Through exploring language with a small group of nurses, this paper alludes to consumer expectations; how nurses use a common language; and where and when they move toward a more elitist communication. The paper examines consumer expectations of health care communication and how it facilitates consumer choice and the quality care agenda. CONCLUSION: Communication for the nursing profession poses a challenge as there are differing requirements for specific situations. Nurses acknowledge that language facilitates commonality of understanding and hence meaning. An elitist language when communicating with other health professionals does exist within specialist units, though where commonality of language ends and an elite language begins is difficult to determine. Language does elicit power and authority when educating and communicating with patients while proving difficult in the context of international global nursing requirements.

Research an exciting journey and a career statement: a means to an end, putting rurality on the nursing research agenda.

Two issues were of importance to nurses in rural areas considering postgraduate studies. The first was the need for part-time study and what this entails. The second was a request that there be no research component within the postgraduate courses they identified. It is this second issue that I wish to address. I was a nonbeliever in the merit of research studies being integrated into nursing specialist programs. Following a long career in rural clinical nursing and management I have come full circle and now acknowledge the need to understand the role to base practice evidence that is generated through empirical research.

Prevalence of vancomycin-resistant enterococcus in prenatal screening cultures.

Recommendations for the perinatal treatment of women colonized with Streptococcus agalactiae include vancomycin prophylaxis for those with severe penicillin allergies and antibiotic-resistant organisms. Because of potential postpartum infections due to vancomycin-resistant enterococci (VRE) and the possible spread of vancomycin resistance, the prevalence of VRE in prenatal screening cultures was determined.