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We have investigated the basis of the lack of activity of a natural variant human peroxisome proliferator-activated receptor alpha, hPPARalpha6/29. A subcloning approach was used to change the four variant amino acids in the hPPARalpha6/29 sequence, individually and in combination, to those found in an active human PPARalpha. Individual amino acid "back mutations" were unable to confer on hPPARalpha6/29 the ability to be activated by peroxisome proliferators in a transient transfection assay. Although hPPARalpha6/29 was able to bind specifically to DNA in the presence of the retinoid X receptor alpha (RXRalpha), the complete restoration of receptor transcriptional activity required two separate back mutations of the hPPARalpha6/29 sequence, namely amino acid 123 in the DNA binding domain, and amino acid 444 close to the C-terminus. This suggests that sequences in the PPARalpha DNA binding domain influence other receptor functions besides DNA binding.

The authors of this paper are the three General Lighthouse Authorities (GLAs) of the United Kingdom and the Republic of Ireland. It was presented on their behalf at the RIN-96 conference by Captain Turner. The paper gives a brief overview of the policy of the GLAs (i.e. the Corporation of Trinity House, the Northern Lighthouse Board and the Commissioners of Irish Lights) regarding the provision of an aids to navigation service with emphasis on the future prospects of traditional aids to navigation over the next 25 years. The three GLAs have recently carried out a consultation exercise on marine aids to navigation into the 21st century. The results of this consultation exercise are discussed. It should be noted that, for clarity, the General Lighthouse Authorities (GLAs) refer to the systems that they provide as ‘aids to navigation’ (AtoN), to differentiate their provision from the equipment carried on board ships for navigational purposes which are referred to by the GLAs as ‘navigational aids’. This paper therefore in the main deals with AtoN.The coastlines within the GLAs' areas of responsibility rank with the most heavily trafficked and dangerous in the world. The coastlines vary from isolated rocks and the steep, Atlantic coastline, to the low-lying relatively featureless coastline of south-east England, off which are shifting sandbanks and channels. The tidal range in GLA waters is significant and tidal streams can reach 10 knots or more in a number of places.

peer-reviewed Context. Delirium occurs commonly in settings of palliative care (PC), in which patient vulnerability in the unique context of end-of-life care and delirium-associated impairment of decision-making capacity may together present many ethical challenges.Objectives. Based on deliberations at the Studies to Understand Delirium in Palliative Care Settings (SUNDIPS) meeting and an associated literature review, this article discusses ethical issues central to the conduct of research on delirious PC patients.Methods. Together with an analysis of the ethical deliberations at the SUNDIPS meeting, we conducted a narrative literature review by key words searching of relevant databases and a subsequent hand search of initially identified articles. We also reviewed statements of relevance to delirium research in major national and international ethics guidelines.Results. Key issues identified include the inclusion of PC patients in delirium research, capacity determination, and the mandate to respect patient autonomy and ensure maintenance of patient dignity. Proposed solutions include designing informed consent statements that are clear, concise, and free of complex phraseology; use of concise, yet accurate, capacity assessment instruments with a minimally burdensome schedule; and use of PC friendly consent models, such as facilitated, deferred, experienced, advance, and proxy models.Conclusion. Delirium research in PC patients must meet the common standards for such research in any setting. Certain features unique to PC establish a need for extra diligence in meeting these standards and the employment of assessments, consent procedures, and patient-family interactions that are clearly grounded on the tenets of PC. (C) 2014 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved. peer-reviewed

Purpose Emerging evidence suggests muscle depletion predicts survival of patients with cancer. Patients and Methods At a cancer center in Alberta, Canada, consecutive patients with cancer (lung or GI; N = 1,473) were assessed at presentation for weight loss history, lumbar skeletal muscle index, and mean muscle attenuation (Hounsfield units) by computed tomography (CT). Univariate and multivariate analyses were conducted. Concordance (c) statistics were used to test predictive accuracy of survival models. Results Body mass index (BMI) distribution was 17% obese, 35% overweight, 36% normal weight, and 12% underweight. Patients in all BMI categories varied widely in weight loss, muscle index, and muscle attenuation. Thresholds defining associations between these three variables and survival were determined using optimal stratification. High weight loss, low muscle index, and low muscle attenuation were independently prognostic of survival. A survival model containing conventional covariates (cancer diagnosis, stage, age, performance status) gave a c statistic of 0.73 (95% CI, 0.67 to 0.79), whereas a model ignoring conventional variables and including only BMI, weight loss, muscle index, and muscle attenuation gave a c statistic of 0.92 (95% CI, 0.88 to 0.95; P < .001). Patients who possessed all three of these poor prognostic variables survived 8.4 months (95% CI, 6.5 to 10.3), regardless of whether they presented as obese, overweight, normal weight, or underweight, in contrast to patients who had none of these features, who survived 28.4 months (95% CI, 24.2 to 32.6; P < .001). Conclusion CT images reveal otherwise occult muscle depletion. Patients with cancer who are cachexic by the conventional criterion (involuntary weight loss) and by two additional criteria (muscle depletion and low muscle attenuation) share a poor prognosis, regardless of overall body weight.

Most studies of Rapid-Response Teams (RRTs) assess their effect on outcomes of all hospitalised patients. Little information exists on RRT activation patterns or why RRT calls are needed. Triage error may necessitate RRT review of ward patients shortly after hospital admission. RRT diurnal activation rates may reflect the likely frequency of caregiver visits.To study the timing of RRT calls in relation to time of day and day of week, and their frequency and outcomes in relation to days after hospital admission.We prospectively studied RRT calls over 1 month in seven hospitals during 2009, collecting data on patient age, sex, admitting unit, admission source, limitations of medical therapy (LOMTs), and admission and discharge dates. We assessed the timing of RRT calls in relation to hospital admission and circadian variation; and differences in characteristics and outcomes of calls occurring early (Days 0 and 1) versus late (after Day 7) after hospital admission.There were 652 RRT calls for 518 patients. Calls were more likely on Mondays (P=0.018) and during work hours (P0.0001) but less likely on weekends (P=0.003) or overnight (P0.001). There were 177 early calls (27.1%) and 198 late calls (30.4%). Early calls involved younger patients (median ages, 67.5 years [early calls] v 73 years [late calls]; P= 0.01), fewer LOMTs (P=0.029), and lower in hospital mortality (12.8% [early calls] v 32.3% [late calls]; P0.0001). The mortality difference remained in patients without LOMTs (5.6% [early calls] v 19.6% [late calls]; P=0.003).About one-quarter of RRT calls occurred shortly after hospital admission, and were more common when caregivers were around. Early calls may partially reflect suboptimal triage, though the associated mortality appeared low. Late calls may reflect suboptimal end-of-life care planning, and the associated mortality was high. There is a need to further assess the epidemiology of RRT calls at different phases of the hospital stay.

The estimation of return periods for floods likely to have significant societal impact is challenging unless suitably long records exist. Relatively few sites across the UK provide a continuous record of river level or discharge over 50 years, whilst records extending back to the nineteenth century are rare. This represents a significant problem in providing robust and reliable estimates of flood risk, as relatively short records often fail to include an adequate sample of large floods. The inclusion of historical flood levels/magnitudes prior to instrumental river flow recording presents a valuable opportunity to extend this dataset. This paper examines the value of using historical data (both documentary and epigraphic) to augment existing gauged records for the River Trent in Central England, as part of a multi-method approach to assessing flood risk. Single station and pooled methods are compared with flood risk estimates based on an augmented historical series (1795–2008) using the generalised logistic and generalised Pareto distributions. The value of using an even longer, but less reliable, extended historical series (1320–2008) is also examined. It is recommended that modelling flood risk for return periods >100 years should incorporate historical data, where available, and that a multi-method approach increases confidence in flood risk estimates.

A 39-year-old woman with breast cancer metastatic to bone presented with acute hip pain marginally responsive to escalating doses of opioid analgesics. Pathologic pelvic fractures were present and there were minimal clinical indicators of infection, but the severity and intractable nature of the pain prompted further investigation. Computed tomography revealed a pelvic abscess. Antibiotic therapy and drainage of the abscess resulted in markedly improved pain control, decreased analgesic requirements, and improved quality of life. We suggest that, in patients with malignancy, the diagnosis of occult infection should be aggressively pursued as a potentially reversible cause of intractable pain.

The National Cancer Institute (Canada) sponsored a workshop on symptom control in Banff, Alberta, in October 1993. This article reports on the workshop recommendations for research on one symptom complex, the cachexia-anorexia-asthenia syndrome. In addition to encouraging study generation, the recommendations provide a baseline for assessing the scope and strength of future Canadian research initiatives on cachexia-anorexia-asthenia.

Palliative care is now an integral part of the undergraduate medical curriculum. Medical education across the board is adopting a case-based approach. This book uses a series of cases to illustrate critical points in palliative medicine. The case-studies have been carefully chosen to reflect real life clinical practice. The chapters illustrate, through the case studies, the desired skills, attitudes, and knowledge required in this field of medicine. Since publication of the second edition, many approaches to palliative care have been further refined and developed. Ongoing research has led to the improved use of existing medications, and the development of several new treatments. More is known about the psychosocial existential distress experienced by patients and their families resulting in an improved understanding by health care providers of how best to approach and assist those affected by advanced illness, and more is known about methadone and other medications with emerging uses. The third edition of this book continues to offer a panoramic view of palliative care. It introduces a number of new topics including neurological disorders, the last days, and palliative sedation.

This chapter contains a case study to present the valuable skills, attitudes, and knowledge needed to diagnose and manage anorexia-cachexia. It addresses several questions such as: What are the definitions of anorexia and cachexia? What are the clinical characteristics of patients with anorexia-cachexia syndrome? Are some cancers more likely than others to cause cachexia? How does a chronic inflammatory state cause cachexia? What is the framework for your anorexia-cachexia therapeutic platform?

Background The short elimination half-life of metoclopramide necessitates frequent administration for optimal relief of nausea. This study compares a newly developed controlled release preparation of metoclopramide (CRM) and immediate release metoclopramide (IRM) with respect to efficacy, safety, and pharmacokinetics in patients with chronic nausea associated with advanced cancer. Methods Thirty-four patients with advanced cancer with nausea lasting more than 1 month and with no evidence of involvement of the gastrointestinal tract, peptic ulcer or gastritis, brain metastases, or metabolic abnormalities were randomized, in a double-blind cross-over study, to receive 40 mg of CRM every 12 hours or 20 mg of IRM every 6 hours for 3 days. Nausea, food intake, and side effects were assessed four times daily. On Day 3, sequential venous samples were taken (12 patients) to determine plasma metoclopramide concentrations. Results In 29 evaluable patients, the intensity of nausea on Day 3, measured by a 0-100-mm visual analogue scale and 0-3 categoric scale was 15 +/- 17 and 0.6 +/- 0.6 after IRM, versus 8 +/- 9 (P = 0.033) and 0.4 +/- 0.5 (P = 0.055) after CRM, respectively. Visual analogue scale nausea scores recorded by time of day and by day for the 3 treatment days were significantly lower for patients who received CRM compared with those who received IRM (P = 0.047 and P = 0.043, respectively), but categoric nausea scores were not significantly different between treatments by time of day and by day across the 3 treatment days. No differences were observed in caloric intake or side effects between treatments. In a pharmacokinetic analysis, the CRM/IRM ratio for area under the curve0-12 (microgram x hours x L-1), Cmax (microgram/L), and Tmax (hours) was 100%, 98%, and 2.3 fold, respectively. Conclusion Controlled release metoclopramide is safe and effective in managing chronic nausea in patients with advanced cancer. Future studies should focus on characterizing this syndrome more clearly and on determining the optimal dose of metoclopramide and the effects of drug combinations that have proven to be useful in managing chemotherapy-induced emesis (i.e., metoclopramide plus corticosteroids).

Summary To develop a framework for the definition and classification of cancer cachexia a panel of experts participated in a formal consensus process, including focus groups and two Delphi rounds. Cancer cachexia was defined as a multifactorial syndrome defined by an ongoing loss of skeletal muscle mass (with or without loss of fat mass) that cannot be fully reversed by conventional nutritional support and leads to progressive functional impairment. Its pathophysiology is characterised by a negative protein and energy balance driven by a variable combination of reduced food intake and abnormal metabolism. The agreed diagnostic criterion for cachexia was weight loss greater than 5%, or weight loss greater than 2% in individuals already showing depletion according to current bodyweight and height (body-mass index [BMI] 2 ) or skeletal muscle mass (sarcopenia). An agreement was made that the cachexia syndrome can develop progressively through various stages—precachexia to cachexia to refractory cachexia. Severity can be classified according to degree of depletion of energy stores and body protein (BMI) in combination with degree of ongoing weight loss. Assessment for classification and clinical management should include the following domains: anorexia or reduced food intake, catabolic drive, muscle mass and strength, functional and psychosocial impairment. Consensus exists on a framework for the definition and classification of cancer cachexia. After validation, this should aid clinical trial design, development of practice guidelines, and, eventually, routine clinical management.

Previous surveys have revealed wide variations in the management by radiation oncologists of non-small-cell lung cancer (nsclc) in Canada. The aim of the present study was to determine the current patterns of practice for locally advanced and metastatic nsclc among Canadian radiation oncologists. An online survey was distributed electronically to all members of the Canadian Association of Radiation Oncologists. Those who treat lung cancer were invited to participate. The survey consisted of three scenarios focusing on areas of nsclc treatment in which the radiotherapy (rt) regimen that provides the best therapeutic ratio is unclear. Replies from 41 respondents were analyzed. For an asymptomatic patient with stage iiib nsclc unsuitable for radical treatment, 22% recommended immediate rt, and 78% recommended rt only if the patient were to become symptomatic. Those who believed that immediate rt prolongs survival were more likely to recommend it (p = 0.028). For a patient with a bulky stage iiib tumour and good performance status, 39% recommended palliative treatment, and 61% recommended radical treatment (84% concurrent vs. 16% sequential chemoradiation at 60&ndash, 66 Gy in 30&ndash, 33 fractions). Those who believed that chemoradiation has a greater impact on survival were more likely to recommend it (p < 0.001). For a symptomatic patient with stage iv nsclc, 54% recommended external-beam rt (ebrt) alone, 41% recommended other modalities (brachytherapy, endobronchial therapy, or chemotherapy) with or without ebrt, and 5% recommended best supportive care. A majority (76%) prescribed 20 Gy in 5 fractions for ebrt. Compared with previous surveys, more radiation oncologists now offer radical treatment for locally advanced nsclc. Management of nsclc in Canada may be evidence-based, but perception by radiation oncologists of the treatment&rsquo, s impact on survival also influences treatment decisions.

The Lakagígar eruption in Iceland during 1783 was followed by the severe winter of 1783/1784, which was characterised by low temperatures, frozen soils, ice-bound watercourses and high rates of snow accumulation across much of Europe. Sudden warming coupled with rainfall led to rapid snowmelt, resulting in a series of flooding phases across much of Europe. The first phase of flooding occurred in late December 1783–early January 1784 in England, France, the Low Countries and historical Hungary. The second phase at the turn of February–March 1784 was of greater extent, generated by the melting of an unusually large accumulation of snow and river ice, affecting catchments across France and Central Europe (where it is still considered as one of the most disastrous known floods), throughout the Danube catchment and in southeast Central Europe. The third and final phase of flooding occurred mainly in historical Hungary during late March and early April 1784. The different impacts and consequences of the above floods on both local and regional scales were reflected in the economic and societal responses, material damage and human losses. The winter of 1783/1784 can be considered as typical, if severe, for the Little Ice Age period across much of Europe.

The purpose of this double-blind crossover study was to determine whether a sustained-release morphine sulfate (SRMS) tablet given orally every 12 hours could adequately replace immediate-release morphine sulfate solution (IRMS) given orally every 4 hours in hospitalized patients with chronic pain from advanced cancer. Of 33 patients entered, 27 completed the study and were included in the efficacy and safety analysis. Patients were initially randomized to receive either 30-mg SRMS tablets every 12 hours or IRMS at the same mg/24 hours dose, every 4 hours. After 2 days, a crossover was performed, and patients received the alternate treatment for 3 days. Pain and side effects were assessed using a standard 100 mm visual analogue scale (VAS). There were no statistically significant differences between the two treatment groups for mean VAS pain scores or scores for sleepiness, nausea, depression, and anxiety. The incidence of breakthrough pain was similar for both treatment groups, as was the incidence of confusion and constipation. The results demonstrated that SRMS is a safe, effective analgesic preparation for patients who require oral opioids for cancer pain. The data also support the conclusion that sustained-release morphine tablets administered every 12 hours can replace an immediate-release morphine solution administered every 4 hours.

After a baseline symptom and laboratory assessment, 24 patients with metastatic bone disease and pain were randomized to receive either a 4-hr intravenous infusion of 2-dichloromethylene bisphosphonate (Cl2MDP), 600 mg in 500 mL of normal saline, or a 4-hr placebo infusion, 500 mL of normal saline. The administration was double blind. After 1 wk, the assessment was repeated and the patients were crossed over to the alternate treatment. After 1 more wk, a final assessment and blinded choice by the patient and investigator took place. Of the 21 evaluable patients, 12 (57%) chose the Cl2MDP and 4 (19%) chose the placebo; 5 (24%) patients did not have a specific preference (p = NS). The investigator chose the Cl2MDP in 14 (67%) cases, placebo in 6 (29%) cases and was unable to discern a difference in 1 (5%) case (p less than 0.05). The patients and investigator made similar selections in 16 (76%) instances. On the visual analogue scale assessments, a significant decrease in pain scores was observed following the Cl2MDP infusion (p less than 0.01) and an increase in activity scores was also demonstrated (p less than 0.01). No significant difference in the daily oral morphine equivalent analgesic requirement was demonstrated for either arm. No difference in clinical and laboratory parameters of toxicity was evident between the placebo and Cl2MDP arms of the trial. Our preliminary findings suggest that Cl2MDP is safe, and has analgesic properties that may prove to be useful in the management of metastatic bone pain.

In this paper, a sensitivity analysis and the numerical optimization of an initial design for a fast foil-assisted catamaran ferry are described, with the goal of both reducing wakes and increasing fuel efficiency. The procedure is split into two phases: 1. Starting from an initial design, a set of new hull shapes was automatically generated and evaluated, via a potential flow solver. These results were successively used to derive information about the influence of each design parameter. 2. A multi-objective design problem, with 3 objective functions, was formulated and solved and the best trade-off solutions (belonging to the Pareto optimal set) were identified. The potential flow optimization lead to a new hull geometry that was optimized in terms of bow shape, foil thickness, foil position, and demi-hull spacing providing a basis for improvements by the naval architect and the starting point for a more detailed optimization with a RANS solver.

The wake of high speed passenger only ferries that operated through Rich Passage, on the Seattle-Bremerton ferry route, caused beach erosion and damage to habitat. A task was initiated to design a low wake high speed vessel using multi-fidelity CFD based design optimization by using low-fidelity potential flow solvers for initial global design optimization and by using URANS solvers for high-fidelity tuning of the optimized design. This simulation based design process witnessed a close collaboration between ship designers, and hydrodynamics and CFD specialists, whose collective expertise guided the evolution of the design based on both hydrodynamic and structural aspects. The initial hull shape optimization using potential flow code was carried out by blending three different initial concepts provided by the designers. Subsequently, URANS was used to evaluate the potential flow optimized hull and to further optimize the hull configuration parameters, namely, the centre-of-gravity, demihull spacing, foil location, foil angle and slenderness ratio at different displacement conditions. The URANS based configuration optimization also took into account the far-field wakes' energy spectrum with an objective of reducing the energetic, low frequency far-field wakes which are associated with beach flattening on the mixed sand and gravel beaches. Calculation of the far-field wake using URANS would require an unfeasibly large domain size; therefore, a Havelock code with a source distribution matching the URANS calculated near field wave elevation was used to propagate the wakes into the far field. The end result of the optimization was a design with significantly reduced far field wake, which is currently being built for experimental testing.

Literature demonstrating the importance of social relationships for cancer survivorship is accumulating. Building on that literature, the term &ldquo, Healing Ties&rdquo, refers to the scientific and popular factors supporting the idea that relationships and community are essential for healing. However, difficulties arise in assessing the effect of social support for survivorship.

Richard J. Ablin, PhD, Research Professor of Immunobiology, University of Arizona College of Medicine and the Arizona Cancer Center, Tucson, Arizona, U.S.A., and Phil Gold, PhD MD, Professor of Medicine, Physiology, and Oncology, McGill University, Montreal, Quebec, Canada, Section Editors.

Chronic inflammation often acts as a tumor promoter, resulting in aggressive cancerous growth and spread. Many of the same inflammatory factors that promote tumor growth also are responsible for cancer cachexia/anorexia, pain, debilitation, and shortened survival. A compelling case may be made for mounting an attack on inflammation with other anticancer measures at initial diagnosis, with the consequent probability of improving both patient quality of life and survival. High serum levels of the inflammatory marker C-reactive protein or fibrinogen and an elevated white blood cell count correlate with poor prognosis and may be used as a prognostic index to establish the need for nutritional/metabolic intervention. At the author's institution, a concerted effort is being made to screen all newly diagnosed patients with non-small cell lung cancer for the presence of nutritional problems, inflammatory markers, and related symptoms. Interventions include dietary counseling; nutritional and, if warranted, vitamin supplementation; exercise concordant with the patient's physical condition; a prescription for omega 3 fatty acids if inflammation is present, and general symptom management. To establish the value of early nutritional/metabolic intervention, clinical trials are needed that combine measures that combat cachexia and inflammation with first-line chemotherapy in patients who present with weight loss, fatigue, and deteriorating function.

The Rich Passage Passenger Only Fast Ferry Study is investigating the feasibility of restoring passenger only fast ferry (POFF) service between Seattle and Bremerton in Puget Sound, Washington. The mixed sediment beaches respond to POFF and non-POFF wakes, large water level variations and currents, and wind waves. Beach response does not follow the high-energy coarse-grained beach model; rather, it is more consistent with the response expected for a low-energy mixed beach backed by a seawall. Despite small differences in wave height, POFF wakes are significantly more energetic because their periods are longer than wakes from slower and smaller vessels. The longer POFF waves result in greater swash and backwash excursion. Beach profile response to POFF operation is rapid, occurring over an interval of several weeks. POFF wakes mobilize and remove sand and coarse-grained sediments from the upper foreshore and deposit it on the middle and lower foreshore or move it alongshore. Smaller and shorter period wake wash from smaller and slower vessels result in net accretion of sand and gravel on the upper beach. The situation is further complicated by the apparent differential rates of erosion for gravel as opposed to sand and by the prevalence of alongshore transport resulting from wake wash approaching the shore at an angle. Gravel and cobble particles, once set in motion by turbulence and shear under breaking waves, are rolled preferentially downslope on the steep (1:5 to 1:7) beach face. Fines are removed from the coarse matrix, possibly by exfiltration at low tide. During recovery phase following slow-down or cessation of POFF operations, the waves do not have sufficient energy to transport the largest gravels and cobble back upslope. Therefore, an accumulation of coarse sediment occurs at the toe of the slope while finer gravel and sand accumulates higher on the beach.

In response to a request from the World Health Organization (WHO), the International Association for Hospice and Palliative Care (IAHPC) developed a List of Essential Medicines for Palliative Care based on the consensus of palliative care workers from around the world. IAHPC designed a process of five steps, which included developing a set of ethical guidelines; identifying the most common symptoms in palliative care; identifying a list of medications to treat those symptoms; carrying out a survey using a modified Delphi process with participants from developed and developing countries; and convening a meeting of representatives from regional, international, and scientific organizations to develop the final list. Twenty-one symptoms were identified as the most common in palliative care, and an initial list of 120 medications resulted from the initial survey. Seventy-one participants from developing and developed countries responded to the Delphi survey and agreed on the effectiveness and safety of 48 medications for 18 of the 21 symptoms. The final step included discussions among representatives from 26 organizations, which led to the finalization of the list. The IAHPC List of Essential Medicines for Palliative Care includes 33 medications, of which 14 are already included in the WHO Model List. The participants agreed that there is too little evidence to recommend medications for five of the symptoms and suggested that further research be carried out to solve this need. The IAHPC and all the organizations involved in this process welcome suggestions on ways to continue to improve the List of Essential Medicines for Palliative Care and to improve access to medications for patients in need.

A statistical analysis of the largest weather-driven hazards in the UK contradicts the typical view that each predominates in distinct events that do not interact with those of other hazard types (i.e., are ‘primary’); this potentially has implications for any multi-hazard environments globally where some types of severe event are still thought to occur independently. By a first co-investigation of long (1884–2008) meteorological time-series and nationwide insurance losses for UK domestic houses (averaging £1.1 billion/yr), new systematic interactions within a 1 year timeframe are identified between temporally-distinct floods, winter wind storms, and shrink–swell subsidence events (P

The ACE System is a potent biological engineering system consisting of a mammalian artificial chromosome engineered with multiple site-specific integration sites, expression-optimized shuttle vectors to specifically transfer genes, and a proprietary integrase to catalyze specific incorporation of a payload onto the ACE. ACEs are promising gene delivery vehicles for gene-based cell therapies as they are stably maintained, non-integrating, autonomously replicating, and are easily isolated to high purities by flow sorting. We published the first reports of the transfer and stable transgene expression of a mammalian artificial chromosome into hMSCs and hHSCs (Stem Cells 22:324|[ndash]|33, 2004; Exp Hematol 33:1470|[ndash]|1476, 2005). We will update our progress, including an hMSCs enrichment strategy resulting in stable EPO transgene expression, more than 50 days post EPO-ACE transfer, at levels of 100|[ndash]|200 IU/cell/day.

The ACE System, consisting of a pre-engineered mammalian artificial chromosome containing multiple site-specific integration sites (acceptor sites); an ACE Targeting Vector containing a Platform ACE specific donor site and the gene(s) of interest; and the ACE Integrase, a proprietary integrase that catalyzes the site-specific recombination of the ACE Targeting Vector onto the Platform ACE, is a versatile biological engineering system for the genetic modification of cells for gene-based cell therapies, the generation of high expressing cell lines for the production of recombinant proteins, and the generation of transgenic animals. ACEs are promising gene delivery vehicles as they are stably maintained, autonomous, non-integrating chromosomes that are easily purified by flow cytometry and readily transfected into a variety of cell types. We developed and optimized a procedure for transfecting human cord blood CD34+ cells with ACEs using LipofectAMINE PLUS (Invitrogen) and iododeoxyuridine-labeled (IdU) ACEs and ACEs encoding genes for humanized Renilla green fluorescence protein (hrGFP) and zeomycin resistance (zeoR, which confers resistance to bleomycin). CD34+ positively selected cells were isolated from human umbilical cord blood using a Ficoll-Hypaque (Pharmacia) density gradient followed by two positive selection steps using magnetic beads (Miltenyi). Prior to transfection, the cells were stimulated with thrombopoietin, stem cell factor, flt-3 ligand, and IL-6, all at 100 ng/mL, for 1–3 days. We quantified the delivery of IdU-labeled ACEs, 24–48 hours post-transfection, by a screening technique that utilizes a FITC-conjugated anti-BrdU B44 clone antibody (Becton Dickinson) that cross-reacts with IdU, and flow cytometry. We detected IdU-labeled ACEs in 2.5–4.0 % of the cells 24–48 hours post-transfection. CD34+ positively selected cells transfected with hrGFP-zeoR-ACEs were plated into methycellulose culture with or without bleomycin. Using these conditions we were able to detect hrGFP expression in up to 3% of the total transfected cells grown without bleomycin. Untransfected negative control CD34+ positively selected cells did not grow in methycellulose culture with bleomycin; however there was significant CFU-GM colony growth with CD34+ positively selected cells transfected with hrGFP-zeoR-ACEs in the presence of bleomycin (3 to 12 cfu/10,000 cells plated, in 3 experiments). The bleomycin-resistant colonies (100% hrGFP+) were analyzed via fluorescent in situ hybridization (FISH) and contained autonomous ACEs (one ACE/cell). In recent gene-base cell therapy clinical trials, hematopoietic cells have been transduced with retroviral vectors, with at least two patients contracting leukemia due to viral insertional oncogenesis. ACEs may provide greater safety as an autonomous replicating non-integrating platform that can be loaded and characterized in vitro with multiple and/or large therapeutic genes and transferred ex vivo to hematopoietic cells to treat hematological, immunodeficiency, and genetic diseases. We believe that this is the first report of the transfer of a functioning mammalian artificial chromosome into human hematopoietic cells.

Purpose Studies suggest eicosapentaenoic acid (EPA), an omega-3 fatty acid, augments weight, appetite, and survival in cancer-associated wasting. This study determined whether an EPA supplement—administered alone or with megestrol acetate (MA)—was more effective than MA. Patients and Methods Four hundred twenty-one assessable patients with cancer-associated wasting were randomly assigned to an EPA supplement 1.09 g administered bid plus placebo; MA liquid suspension 600 mg/d plus an isocaloric, isonitrogenous supplement administered twice a day; or both. Eligible patients reported a 5-lb, 2-month weight loss and/or intake of less than 20 calories/kg/d. Results A smaller percentage taking the EPA supplement gained ≥ 10% of baseline weight compared with those taking MA: 6% v 18%, respectively (P = .004). Combination therapy resulted in weight gain of ≥ 10% in 11% of patients (P = .17 across all arms). The percentage of patients with appetite improvement (North Central Cancer Treatment Group Questionnaire) was not statistically different: 63%, 69%, and 66%, in EPA-, MA-, and combination-treated arms, respectively (P = .69). In contrast, 4-week Functional Assessment of Anorexia/Cachexia Therapy scores suggested MA-containing arms experienced superior appetite stimulation compared with the EPA arm, with scores of 40, 55, and 55 in EPA-, MA-, and combination-treated arms, respectively (P = .004). Survival was not significantly different among arms. Global quality of life was not significantly different among groups. With the exception of increased impotence in MA-treated patients, toxicity was comparable. Conclusion This EPA supplement, either alone or in combination with MA, does not improve weight or appetite better than MA alone.

OBJECTIVE: Much of what we know about ethical issues in palliative care comes from the perceptions of physicians and ethicists. In this study our goal was to hear other voices and to gain first-hand knowledge of the possibly contrasting views of patients, their families, nurses, volunteers, and other team members on end-of-life issues. DESIGN: Qualitative study using semistructured interviews. SETTING: Inpatient and consultation palliative care service of the Royal Victoria Hospital in Montreal, Que. PARTICIPANTS: Of 113 people interviewed, 13 were patients, 43 were family members, 32 were volunteers, 14 were nurses, and 11 were other staff. METHOD: Interviewers elicited subjects' perspectives on ethical issues. Content analysis was used to identify, code, and categorize themes in the data. MAIN FINDINGS: Communication difficulties and insufficient resources and staff were the most frequently mentioned problems in this palliative care setting. CONCLUSION: The findings of this study will help guide policy decisions and setting of educational priorities in end-of-life care, particularly regarding the importance of adequate communication.

Mammalian artificial chromosomes (MACs) provide a means to introduce large payloads of genetic information into the cell in an autonomously replicating, non-integrating format. Unique among MACs, the mammalian satellite DNA-based Artificial Chromosome Expression (ACE) can be reproducibly generated de novo in cell lines of different species and readily purified from the host cells' chromosomes. Purified mammalian ACEs can then be re-introduced into a variety of recipient cell lines where they have been stably maintained for extended periods in the absence of selective pressure. In order to extend the utility of ACEs, we have established the ACE System, a versatile and flexible platform for the reliable engineering of ACEs. The ACE System includes a Platform ACE, containing >50 recombination acceptor sites, that can carry single or multiple copies of genes of interest using specially designed targeting vectors (ATV) and a site-specific integrase (ACE Integrase). Using this approach, specific loading of one or two gene targets has been achieved in LMTK(-) and CHO cells. The use of the ACE System for biological engineering of eukaryotic cells, including mammalian cells, with applications in biopharmaceutical production, transgenesis and gene-based cell therapy is discussed.

Peroxisome proliferators (PPs) such as the hypolipidaemic drug, nafenopin and the phthalate plasticiser 2-diethylhexylphthalate induce rodent hepatocyte cell proliferation and suppress apoptosis leading to tumours. PPs act via the nuclear hormone receptor peroxisome proliferator activated receptor alpha (PPAR alpha) which directly regulates genes implicated in the response to PPs such as the peroxisomal gene acyl CoA oxidase. As expected for xenobiotics that perturb proliferation, PPs alter expression of cell cycle regulatory proteins. However, the ability to alter expression of cyclins and cyclin-dependent kinases is shared by physiological hepatic mitogens such as epidermal growth factor and is thus unlikely to be specific to the PP-induced aberrant growth associated with hepatocarcinogenesis. Recent evidence suggests that the response of hepatocytes to PPs is not only dependent upon PPAR alpha but also on the trophic environment provided by nonparenchymal cells and by cytokines such as tumour necrosis factor alpha. Additionally, the ability of PPs to suppress apoptosis and induce proliferation depends upon survival signalling mediated by p38 mitogen activated protein kinase. The cross talk between PPAR alpha-mediated transcription, survival signalling and cell cycle will be discussed with particular emphasis on relevance to toxicology.

Publisher Summary Proteomics is an evolving group of technologies that harness the power of genomics data to identify and quantify functional changes in protein expression and posttranslational modification associated with cellular processes, toxicant treatment, or disease states. By combining the new technology with classical cell biology and protein biochemistry, it is possible to use proteomics to profile changes in specific organelles or subgroups of proteins within the total proteome. By applying these technologies to systems such as peroxisome proliferator (PP)-induced rodent hepatocarcinogenesis, ones will increase understanding of the molecular mechanisms underlying their effects and the species specificity of those effects. In rodents, PPs induce the expression of hepatic genes such as β-oxidative enzymes and cytochrome P4504A members, cause increased hepatic DNA replication, and suppress hepatic apoptosis, leading to the formation of tumors. The chapter discusses the molecular mechanism of the response to peroxisome proliferators (PPs) and used protein profiling because of the additional functional information that may be revealed.

Three cases are reported where patients experienced severe central nervous system adverse effects on high-dose hydromorphone. These effects were rapidly alleviated following a change in therapy to morphine at 20–25% of the usually accepted potency equivalent dose. We recommend caution in using equivalent dose tables when changing opioid therapy in patients receiving high-dose opioid treatment.

In Reply Drs Saugel and Reuter challenge the description of the OPTIMISE trial as a pragmatic trial. As applied to clinical trials, the term pragmatic has a particular meaning. Pragmatic trials are designed to evaluate the clinical effectiveness of a treatment in the context of routine clinical practice.1 This distinguishes them from explanatory trials, which are designed to evaluate the efficacy of a treatment under ideal conditions.

Importance: small trials suggest that postoperative outcomes may be improved by the use of cardiac output monitoring to guide administration of intravenous fluid and inotropic drugs as part of a hemodynamic therapy algorithm. Objective: to evaluate the clinical effectiveness of a perioperative, cardiac output–guided hemodynamic therapy algorithm. Design, setting, and participants: OPTIMISE was a pragmatic, multicenter, randomized, observer-blinded trial of 734 high-risk patients aged 50 years or older undergoing major gastrointestinal surgery at 17 acute care hospitals in the United Kingdom. An updated systematic review and meta-analysis were also conducted including randomized trials published from 1966 to February 2014. Interventions: patients were randomly assigned to a cardiac output–guided hemodynamic therapy algorithm for intravenous fluid and inotrope (dopexamine) infusion during and 6 hours following surgery (n=368) or to usual care (n=366). Main outcomes and measures: the primary outcome was a composite of predefined 30-day moderate or major complications and mortality. Secondary outcomes were morbidity on day 7; infection, critical care–free days, and all-cause mortality at 30 days; all-cause mortality at 180 days; and length of hospital stay. Results: baseline patient characteristics, clinical care, and volumes of intravenous fluid were similar between groups. Care was nonadherent to the allocated treatment for less than 10% of patients in each group. The primary outcome occurred in 36.6% of intervention and 43.4% of usual care participants (relative risk [RR], 0.84 [95% CI, 0.71-1.01]; absolute risk reduction, 6.8% [95% CI, ?0.3% to 13.9%]; P?=?.07). There was no significant difference between groups for any secondary outcomes. Five intervention patients (1.4%) experienced cardiovascular serious adverse events within 24 hours compared with none in the usual care group. Findings of the meta-analysis of 38 trials, including data from this study, suggest that the intervention is associated with fewer complications (intervention, 488/1548 [31.5%] vs control, 614/1476 [41.6%]; RR, 0.77 [95% CI, 0.71-0.83]) and a nonsignificant reduction in hospital, 28-day, or 30-day mortality (intervention, 159/3215 deaths [4.9%] vs control, 206/3160 deaths [6.5%]; RR, 0.82 [95% CI, 0.67-1.01]) and mortality at longest follow-up (intervention, 267/3215 deaths [8.3%] vs control, 327/3160 deaths [10.3%]; RR, 0.86 [95% CI, 0.74-1.00]). Conclusions and relevance: in a randomized trial of high-risk patients undergoing major gastrointestinal surgery, use of a cardiac output–guided hemodynamic therapy algorithm compared with usual care did not reduce a composite outcome of complications and 30-day mortality. However, inclusion of these data in an updated meta-analysis indicates that the intervention was associated with a reduction in complication rates