Deregulation and epigenetic modification of BCL2-family genes cause resistance to venetoclax in hematologic malignancies.

The BCL2 inhibitor venetoclax has been approved to treat different hematological malignancies. Because there is no common genetic alteration causing resistance to venetoclax in chronic lymphocytic leukemia (CLL) and B-cell lymphoma, we asked if epigenetic events might be involved in venetoclax resistance. Therefore, we employed whole-exome sequencing, methylated DNA immunoprecipitation sequencing, and genome-wide clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 screening to investigate venetoclax resistance in aggressive lymphoma and high-risk CLL patients. We identified a regulatory CpG island within the PUMA promoter that is methylated upon venetoclax treatment, mediating PUMA downregulation on transcript and protein level. PUMA expression and sensitivity toward venetoclax can be restored by inhibition of methyltransferases. We can demonstrate that loss of PUMA results in metabolic reprogramming with higher oxidative phosphorylation and adenosine triphosphate production, resembling the metabolic phenotype that is seen upon venetoclax resistance. Although PUMA loss is specific for acquired venetoclax resistance but not for acquired MCL1 resistance and is not seen in CLL patients after chemotherapy-resistance, BAX is essential for sensitivity toward both venetoclax and MCL1 inhibition. As we found loss of BAX in Richter's syndrome patients after venetoclax failure, we defined BAX-mediated apoptosis to be critical for drug resistance but not for disease progression of CLL into aggressive diffuse large B-cell lymphoma in vivo. A compound screen revealed TRAIL-mediated apoptosis as a target to overcome BAX deficiency. Furthermore, antibody or CAR T cells eliminated venetoclax resistant lymphoma cells, paving a clinically applicable way to overcome venetoclax resistance.

"I'll meet you at our bench": adaptation, innovation and resilience among VCSE organisations who supported marginalised and minoritised communities during the Covid-19 pandemic in Northern England - a qualitative focus group study.

BACKGROUND: The Covid-19 pandemic has exacerbated pre-existing inequalities and increased adversity and challenges for vulnerable and marginalised communities worldwide. In the UK, the Voluntary Community and Social Enterprise (VCSE) sector play a vital role in supporting the health and wellbeing of people who are marginalised or experiencing multiple complex needs. However, only a small number of studies have focused on the impact that Covid-19 had on the VCSE sector. METHODS: As part of a Health Inequalities Impact Assessment (HIIA), we conducted qualitative focus groups with staff and volunteers from five organisations to examine short, medium and longer-term impacts of Covid-19 upon the VCSE sector in Northern England. Nine online focus groups were conducted between March and July 2021. FINDINGS: Focus group transcripts were analysed using Framework Analysis and yielded three central themes: (1) exacerbation of pre-existing inequalities, adversity and challenges for vulnerable and marginalised populations; (2) the 'price' of being flexible, innovative and agile for VCSE staff and volunteers; and (3) the voluntary sector as a 'lifeline' - organisational pride and resilience. CONCLUSIONS: While the voluntary sector 'adapted at pace' to provide support during Covid-19 and in its continued aftermath, this resilience has potentially come at the cost of workforce and volunteer wellbeing, compounded by political obstacles and chronic shortage in funding and support. The VCSE sector has a vital role to play in the post-lockdown 'levelling up' agenda. The expertise, capacity and resilience of VCSE organisations, and their ability to respond to Covid-19, should be celebrated, recognised and supported adequately to maintain its resilience. To not do so threatens the sector's sustainability and risks jeopardising attempts to involve the sector in addressing the social determinants of health.

A systematic review of risk of HIV transmission through biting or spitting: implications for policy.

OBJECTIVES: The perceived threat of HIV transmission through spitting and biting is evidenced by the increasing use of "spit hoods" by Police Forces in the UK. In addition, a draft parliamentary bill has called for increased penalties for assaults on emergency workers, citing the risk of communicable disease transmission as one justification. We aimed to review literature relating to the risk of HIV transmission through biting or spitting. METHODS: A systematic literature search was conducted using Medline, Embase and Northern Lights databases and conference websites using search terms relating to HIV, AIDS, bite, spit and saliva. Inclusion and exclusion criteria were applied to identified citations. We classified plausibility of HIV transmission as low, medium, high or confirmed based on pre-specified criteria. RESULTS: A total of 742 abstracts were reviewed, yielding 32 articles for full-text review and 13 case reports/series after inclusion and exclusion criteria had been applied. There were no reported cases of HIV transmission related to spitting and nine cases identified following a bite, in which the majority occurred between family (six of nine), in fights involving serious wounds (three of nine), or to untrained first-aiders placing fingers in the mouth of someone having a seizure (two of nine). Only four cases were classified as highly plausible or confirmed transmission. None related to emergency workers and none were in the UK. CONCLUSIONS: There is no risk of transmitting HIV through spitting, and the risk through biting is negligible. Post-exposure prophylaxis is not indicated after a bite in all but exceptional circumstances. Policies to protect emergency workers should be developed with this evidence in mind.

Surgical management of complicated and medically refractory inflammatory bowel disease during pregnancy.

AIM: The medical management of inflammatory bowel disease (IBD) in pregnancy and the puerperium is well defined. Data on surgical management of complicated IBD in this setting are lacking. This study aimed to determine the optimal surgical strategy for medically refractory IBD during pregnancy and the puerperium. METHOD: Three databases were systematically reviewed to identify all published series or case reports of women undergoing surgery for Crohn's disease (CD) or ulcerative colitis (UC) while pregnant or during the puerperium. RESULTS: Thirty-two papers were identified, including 86 patients. Nearly one-fifth (18%) of cases were de novo presentations and intervention was required at all stages of pregnancy. UC refractory to medical treatment and perforated small bowel CD were the commonest indications for surgery. Operations used included colectomy, colectomy with mucous fistula and Turnbull-blowhole colostomy for complicated UC and open or laparoscopic small bowel resection with stoma formation for CD. Surgical intervention during the third trimester universally resulted in the onset of labour. Endoscopic and radiological interventions were rarely employed. In studies after 1980 there was no maternal or foetal mortality but there was an almost 50% preterm delivery rate. CONCLUSION: Surgical management of complicated IBD during pregnancy and the puerperium needs to be tailored to disease severity, the type of complications and foetal status. It should involve gastroenterologists, colorectal surgeons, obstetricians and neonatal specialists in a multidisciplinary manner within a single unit.

The adaptation and translation of the PEACH™ RCT intervention: the process and outcomes of the PEACH™ in the community trial.

OBJECTIVE: To describe the process and report selected outcomes of translating an effective child weight management initiative (PEACH™) from a randomised controlled trial intervention to a community health programme. STUDY DESIGN AND METHODS: Pre-post study design utilising the reach, effectiveness, adoption, implementation and maintenance (RE-AIM) evaluation framework. Adaptation of PEACH™ required significant promotional activity and consideration of legal, ethical and financial issues. PEACH™ components were revised and an evaluation design based on the RE-AIM framework was developed. Facilitator training workshops were made available to South Australian health or education professionals initially, then opened up to new graduates, interstate dietitians and others interested in professional development. Facilitators completed pretraining and post-training questionnaires and a third questionnaire following programme delivery. Data were collected from families by facilitators and returned to university staff for assessment of change (baseline to programme end) in body mass index (BMI) and waist circumference (WC) z-scores. RESULTS: Changes to organisational and political environments prevented maximum programme reach and adoption. Nonetheless, data indicated that PEACH™ was effective at improving facilitators' confidence (P < 0.05) and children's (n = 37) BMI z-score (-0.17, 95% confidence interval [CI]: 0.03:0.30, P = 0.016), WC z-score (-0.14, 95% CI: -0.02:0.30, P = 0.09) and lifestyle behaviours. Collection of maintenance data was prevented due to time and financial constraints. CONCLUSIONS: Translational research needs to develop ways to effectively and efficiently bridge the gap between behavioural research and practice to improve the adoption of evidence-based approaches to child weight management. Nutrition educators and researchers can drive these nutrition-focussed translational research efforts forward. Funding bodies and health service organisations are encouraged to provide financial and structural support for such activity.

Increased sensitivity to platinum drugs of cancer cells with acquired resistance to trabectedin.

BACKGROUND: In order to investigate the mechanisms of acquired resistance to trabectedin, trabectedin-resistant human myxoid liposarcoma (402-91/T) and ovarian carcinoma (A2780/T) cell lines were derived and characterised in vitro and in vivo. METHODS: Resistant cell lines were obtained by repeated exposures to trabectedin. Characterisation was performed by evaluating drug sensitivity, cell cycle perturbations, DNA damage and DNA repair protein expression. In vivo experiments were performed on A2780 and A2780/T xenografts. RESULTS: 402-91/T and A2780/T cells were six-fold resistant to trabectedin compared with parental cells. Resistant cells were found to be hypersensitive to UV light and did not express specific proteins involved in the nucleotide excision repair (NER) pathway: XPF and ERCC1 in 402-91/T and XPG in A2780/T. NER deficiency in trabectedin-resistant cells was associated with the absence of a G2/M arrest induced by trabectedin and with enhanced sensitivity (two-fold) to platinum drugs. In A2780/T, this collateral sensitivity, confirmed in vivo, was associated with an increased formation of DNA interstrand crosslinks. CONCLUSIONS: Our finding that resistance to trabectedin is associated with the loss of NER function, with a consequent increased sensitivity to platinum drugs, provides the rational for sequential use of these drugs in patients who have acquired resistance to trabectedin.

No evidence of transfusion transmission of Adenovirus and Epstein-Barr virus infections in paediatric recipients post-bone marrow transplant.

Adenovirus and Epstein-Barr virus can cause significant morbidity and mortality in paediatric patients post-bone marrow transplant. The source of infection is thought to be either reactivation of latent viruses or primary infection. We have investigated whether transfusion of blood components from viraemic donors could provide a route of primary infection in these patients and sought the prevalence of viraemia in the blood donor population from England. In 32 linked donor/recipient samples and 300 unselected blood donors, we found no evidence to suggest that these infections in paediatric bone marrow transplant recipients had been acquired from transfused blood components.

WHITE COATS AND NO TROUSERS: NARRATING THE EXPERIENCES OF WOMEN TECHNICIANS IN MEDICAL LABORATORIES, 1930-90.

Laboratory technicians are a vital part of any working lab. Not only is their knowledge and expertise important for the success of research, but they also often maintain the lab's intellectual and social life. Despite the importance of their work, they are rarely acknowledged in publications, and leave only a few traces within the historical recordthe voices of women laboratory technicians are even harder to uncover. This paper attempts to correct this imbalance by presenting the narratives of women who worked as laboratory technicians at places such as the National Institute for Medical Research (NIMR), the Wellcome Research Laboratories, and established hospital and university labs in Cambridge, Oxford and London. The data were collected though narrative interviews. Specifically, the paper looks at the roles of these women within the lab, their experiences of the social and gender dynamics of the lab, and the development of expertise in regard to the work they carried out and the extent to which they received credit for their contributions to science.

Service evaluation to establish the sensitivity, specificity and additional value of broad-range 16S rDNA PCR for the diagnosis of infective endocarditis from resected endocardial material in patients from eight UK and Ireland hospitals.

Infective endocarditis (IE) can be diagnosed in the clinical microbiology laboratory by culturing explanted heart valve material. We present a service evaluation that examines the sensitivity and specificity of a broad-range 16S rDNA polymerase chain reaction (PCR) assay for the detection of the causative microbe in culture-proven and culture-negative cases of IE. A clinical case-note review was performed for 151 patients, from eight UK and Ireland hospitals, whose endocardial specimens were referred to the Microbiology Laboratory at Great Ormond Street Hospital (GOSH) for broad-range 16S rDNA PCR over a 12-year period. PCR detects the causative microbe in 35/47 cases of culture-proven IE and provides an aetiological agent in 43/69 cases of culture-negative IE. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the 16S rDNA PCR assay were calculated for this series of selected samples using the clinical diagnosis of IE as the reference standard. The values obtained are as follows: sensitivity = 67 %, specificity = 91 %, PPV = 96 % and NPV = 46 %. A wide range of organisms are detected by PCR, with Streptococcus spp. detected most frequently and a relatively large number of cases of Bartonella spp. and Tropheryma whipplei IE. PCR testing of explanted heart valves is recommended in addition to culture techniques to increase diagnostic yield. The data describing the aetiological agents in a large UK and Ireland series of culture-negative IE will allow future development of the diagnostic algorithm to include real-time PCR assays targeted at specific organisms.

The success of rectus and gracilis muscle flaps in the treatment of chronic pelvic sepsis and persistent perineal sinus: a systematic review.

AIM: Chronic pelvic sepsis is a challenging problem, which may require muscle flaps to fill the pelvic cavity. The aim of this systematic review was to determine the relative success of rectus and gracilis flaps used for this purpose. METHOD: A systematic review was conducted to identify papers that reported the outcome of rectus or gracilis myocutaneous flaps in the treatment of persistent perineal sinuses or chronic pelvic sepsis. Reports of muscle flaps used for reconstruction or treatment of fistula in the absence of chronic sepsis were excluded. A successful outcome was defined as complete perineal healing within 12 months of surgery. RESULTS: The review identified 19 studies reporting the outcome of 73 rectus and 87 gracilis flaps. Their respective success was 84% and 64%. Heterogeneity of the underlying cases did not allow for direct comparison of the flaps. Full healing of the flaps was generally achieved within 3 months. Donor site morbidity was minimal. CONCLUSION: The surgical treatment of chronic pelvic sepsis should be tailored to the individual, but the rectus flap has a reasonable success rate with little morbidity.

Central nervous system infection after Onyx embolisation of arterio-venous malformations in two paediatric patients.

BACKGROUND: Increasingly, Onyx is used for endovascular embolization of aneurysms and arterio-venous malformations. Although reports in the literature on the use of Onyx are favourable, there have been so far no reports on the central nervous system (CNS) infection rate after embolisation with Onyx and no recommendations as to the management of these infections. CASE REPORTS: We present two cases of paediatric patients who acquired CNS infection with Pseudomonas aeruginosa after Onyx embolisation of AVMs and describe their subsequent management. CONCLUSIONS: Presence of established infection after Onyx embolisation should be dealt with by removal of infected material, administration of appropriate antibiotic therapy and supportive treatment.

Lack of unique neuropathology in amyotrophic lateral sclerosis associated with p.K54E angiogenin (ANG) mutation.

AIMS: Five to 10% of cases of amyotrophic lateral sclerosis are familial, with the most common genetic causes being mutations in the C9ORF72, SOD1, TARDBP and FUS genes. Mutations in the angiogenin gene, ANG, have been identified in both familial and sporadic patients in several populations within Europe and North America. The aim of this study was to establish the incidence of ANG mutations in a large cohort of 517 patients from Northern England and establish the neuropathology associated with these cases. METHODS: The single exon ANG gene was amplified, sequenced and analysed for mutations. Pathological examination of brain, spinal cord and skeletal muscle included conventional histology and immunohistochemistry. RESULTS: Mutation screening identified a single sporadic amyotrophic lateral sclerosis case with a p.K54E mutation, which is absent from 278 neurologically normal control samples. The clinical presentation was of limb onset amyotrophic lateral sclerosis, with rapid disease progression and no evidence of cognitive impairment. Neuropathological examination established the presence of characteristic ubiquitinated and TDP-43-positive neuronal and glial inclusions, but no abnormality in the distribution of angiogenin protein. DISCUSSION: There is only one previous report describing the neuropathology in a single case with a p.K17I ANG mutation which highlighted the presence of eosinophilic neuronal intranuclear inclusions in the hippocampus. The absence of this feature in the present case indicates that patients with ANG mutations do not always have pathological changes distinguishable from those of sporadic amyotrophic lateral sclerosis.

Influence of enhanced recovery after surgery pathways and laparoscopic surgery on health-related quality of life.

AIM: This study set out to compare the postoperative health related quality of life (HQoL) of patients undergoing elective open colorectal surgery using a well-established enhanced recovery after surgery (ERAS) pathway with those undergoing laparoscopic surgery without an established an ERAS pathway. METHOD: Using a power calculation, it was estimated that 40 patients would be required in each group. HQoL of the two groups was prospectively assessed using SF-12 (Short Form 12) and EORTC QLQ 30 (European Organisation of Research and Treatment of Cancer, Quality of Life Questionnaire) preoperatively, and at 2 and 6 weeks after discharge. RESULTS: Data were collected from 83 patients, 41 in the laparoscopic group and 42 in the open-ERAS group. There was a significant difference between the median length of stay of the open-ERAS (5 days) and laparoscopic (7 days, P = 0.028) groups. There were no significant differences between the HQoL score of the two groups at any stage. In both groups, the majority of HQoL scores had improved considerably by 6 weeks. CONCLUSION: Laparoscopic and open-ERAS surgery have a similar impact on postoperative HQoL. HQoL tends to improve by the 6-week stage.

Developing a national 'low risk' febrile neutropenia framework for use in children and young people's cancer care.

PURPOSE: A Delphi study was undertaken to develop a framework guidance that would rationalise and standardise the care of children with febrile neutropenia (FNP) across the UK. METHODS: A mailed Delphi survey was undertaken with health professionals working in children's cancer units. The survey employed two rounds of feedback on 22 practice statements drawn from a systematic review of clinical evidence. Consensus was assumed for any statement where 80+ % of respondents indicated that they "agreed" or "strongly agreed". RESULTS: Consensus was reached on 21 of the 22 practice statements in round 1 that were categorised into six areas: definition of fever and neutropenia, initial management and choice of antibiotic, defining low-risk patients, strategy in low-risk patients and alternative approaches. Consensus could not be reached on whether patients needed to be afebrile to be suitable for discharge and the required length of outpatient antibiotic treatment. CONCLUSIONS: A Delphi survey allowed the successful development of a national framework for identification and management of children with FNP. The use of an existing well-functioning professional network was key in this project's success.

Outcomes of asymptomatic anastomotic leaks found on routine postoperative water-soluble enema following anterior resection for cancer.

BACKGROUND: The incidence and consequence of an anastomotic leak associated with low anterior resection for cancer mandates covering stoma in most cases. A water-soluble enema is often performed to assess anastomotic integrity prior to stoma reversal. The functional outcome following reversal in patients with occult radiologically detected leaks is poorly defined. The goal of the present study was to determine the functional outcome in patients with a radiologically detected anastomotic leak who subsequently underwent stoma reversal. METHODS: This case control study used patients with and without radiologically detected occult anastomotic leak having undergone reversal of covering stomata. The study group was matched with controls for age, gender, procedure, tumor stage, and adjuvant/neoadjuvant therapy. Validated fecal incontinence quality of life (FIQL), Cleveland Clinic Fecal Incontinence Score (CCFIS), and the Memorial Sloan-Kettering Cancer Center (MSKCC) Bowel Function Index (BFI) were used. Patient satisfaction, medication use, and ancillary procedures prior to closure were also recorded. RESULTS: Thirteen patients with radiologically detected occult anastomotic leaks and 13 matched controls were identified from a prospectively maintained database. The FIQL, CCFIS, and MSKCC BFI scores were significantly reduced in those with occult leaks. The mean number of radiological and surgical interventions was significantly greater in the patients with occult leaks. Antidiarrheal and bulking agent use, as well as patient satisfaction, were the same for both groups. Only one patient in the occult leak group would not undergo stoma reversal again. CONCLUSIONS: Reversal of a defunctioning ileostomy in the presence of an occult radiological leak can be associated with poorer functional outcomes, but patient satisfaction is undiminished.

Open-reading-frame sequence tags (OSTs) support the existence of at least 17,300 genes in C. elegans.

The genome sequences of Caenorhabditis elegans, Drosophila melanogaster and Arabidopsis thaliana have been predicted to contain 19,000, 13,600 and 25,500 genes, respectively. Before this information can be fully used for evolutionary and functional studies, several issues need to be addressed. First, the gene number estimates obtained in silico and not yet supported by any experimental data need to be verified. For example, it seems biologically paradoxical that C. elegans would have 50% more genes than Drosophilia. Second, intron/exon predictions need to be tested experimentally. Third, complete sets of open reading frames (ORFs), or "ORFeomes," need to be cloned into various expression vectors. To address these issues simultaneously, we have designed and applied to C. elegans the following strategy. Predicted ORFs are amplified by PCR from a highly representative cDNA library using ORF-specific primers, cloned by Gateway recombination cloning and then sequenced to generate ORF sequence tags (OSTs) as a way to verify identity and splicing. In a sample (n=1,222) of the nearly 10,000 genes predicted ab initio (that is, for which no expressed sequence tag (EST) is available so far), at least 70% were verified by OSTs. We also observed that 27% of these experimentally confirmed genes have a structure different from that predicted by GeneFinder. We now have experimental evidence that supports the existence of at least 17,300 genes in C. elegans. Hence we suggest that gene counts based primarily on ESTs may underestimate the number of genes in human and in other organisms.

The use of a two-gene sequencing approach to accurately distinguish between the species within the Mycobacterium abscessus complex and Mycobacterium chelonae.

Mycobacterium abscessus [M. abscessus (sensu lato) or M. abscessus complex] comprises three closely related species: M. abscessus (sensu stricto), hereafter referred to as M. abscessus, M. bolletii and M. massiliense. We describe here an accurate and robust method for distinguishing M. chelonae from M. abscessus, M. bolletii and M. massiliense, using polymerase chain reaction (PCR) and the sequencing of house-keeping gene targets (hsp65 and rpoB). Sequencing of the sodA gene is of little additional value in discriminating between species, but M. massiliense can be rapidly identified by amplification of the truncated erm(41) gene without the need for amplicon sequencing. We have applied the method to 81 isolates from 40 patients from two hospitals, the majority of whom were cystic fibrosis (CF) patients. Of these patients, 21 had previously been identified as M. chelonae and 59 as M. abscessus complex using commercial line probe assays. We identified these as 46 M. abscessus isolates, 20 M. massiliense isolates, five M. bolletii isolates and nine M. chelonae isolates and confirmed the one M. fortuitum isolate. This is the first study that has identified the individual members of the M. abscessus complex in a UK cohort of mainly CF patients.

Balloon dilatation of benign rectal anastomotic strictures -- a review.

BACKGROUND: The occurrence of anastomotic stricture at the level of the rectum gives rise to three broad therapeutic options, namely major pelvic and abdominal revisional surgery, faecal diversion (stoma), or local revision by transanal approaches (including endoscopic and fluoroscopic). This article updates the current evidence and focuses on the results of the balloon dilatation technique. METHODS: A Medline search was carried out using the search terms (dilatation OR dilatation) AND (stricture OR strictures OR stenosis OR stenotic) AND (rectum OR rectal). In an effort to lessen publication bias, articles included at least 10 patients who were consecutively referred for treatment. RESULTS/CONCLUSION: This review would suggest that probably relatively short strictures have been chosen for balloon dilatation and that the results have had a very low major morbidity (0.45%) and mortality (0%) rate.

Prognostic significance of lymph node ratio in patients undergoing abdominoperineal resection of rectum.

BACKGROUND: Lymph node ratio (LNR) has been shown to be an independent prognostic factor in stage III colorectal cancer. Abdominoperineal resection (APR) of rectum is historically associated with poorer oncological outcomes compared to other colorectal resections, and significance of LNR in this group of patients has not been studied. OBJECTIVE: Our aim was to determine impact of LNR on oncological outcomes in a series of patients with rectal cancers undergoing APR. PATIENTS AND METHODS: A series of patients who had undergone APR and had lymph node metastasis were identified from a prospectively maintained clinical, histopathological and radiological database. LNR was calculated, and Cox regression was used to determine the impact of factors affecting local recurrence, distal metastases and overall survival. RESULTS: Fifty-eight (42 males) patients were identified to have rectal cancer with lymph node involvement. LNR was an independent predictor of distal metastasis and overall survival at cutoff levels of 0.17, 0.41 and 0.69. CONCLUSION: Lymph node ratio is an independent predictor of survival outcomes in patients with stage III tumours undergoing APR. LNR may help improve stratification of this group of patients.