Qatar Foundation Annual Research Conference Proceedings Volume 2016 Issue 1

Background

Systemic inflammation is the continuous phenomenon of inflammatory response which can promote tissue damage. Systemic inflammation is characterized by circulatory elevation of many inflammatory mediators such as (CRP, IL-6 and TNF-α). This state plays a pivotal role in all stages of type 2 diabetes. Stages include pathogenicity and progression and chronic complication development. This study aimed at investigating the risk of systemic inflammation among type 2 diabetic patients according to glycemic control.

Objectives

This work aimed to investigate the risk of systemic inflammation among type 2 diabetic patients in relation to body fat accumulation and distribution among patients with controlled glycaemia versus poorly controlled patients.

Subjects/Methods

Study protocol and tools were approved by the research ethics committee; Institutional Review Board (IRB) at Jordan University of Science and Technology (JUST). Patients were recruited from out-patient endocrinology unit at King Abdullah University Hospital (KAUH), Jordan University of Science and Technology Health Center and major private endocrinology clinics in North of Jordan. Initial screening included 1500 patients diagnosed with type 2 diabetes. Due to the multiple co-variation nature of the relationship of interest, about 75% of the initially screened patients were excluded from the study. A total of 198 male and female patients diagnosed with type 2 diabetes participated in this cross-sectional. Patients’ weight, height, waist circumference, total body fat and truncal fat percent were measured. Venous blood specimen were collected and levels of HbA1c, serum hs-CRP, serum IL-6 were determined. A 10-ml sample of venous blood was collected from each patient by a registered nurse. HbA1c blood samples collected in Ethylene-Diamine-Tetra-Acetic acid (EDTA) tubes and measured in whole blood using the Immuno-inhibition test for the quantitative determination of glycosylated hemoglobin (Beckman Coulter AU analyzers). Blood samples of hs-CRP and IL-6 collected in Z-Clot activator tubes. Samples were allowed to clot before centrifugation for 15 minutes at 1000 × g. Aliquot of serum stored at ≤  -22°C in a sterile small tubes prior to biochemical assay. Immuno-turbidimetric test was used to determine hs-CRP levels (Beckman Coulter AU analyzers). IL-6 was measured using a human immunoassay kit from R&D SYSTEMS through sandwich-type enzyme-linked immunosorbent assay (ELISA). Absorbance Microplate reader was used to measure the optical density of IL-6 (BioTek ELx800). Anthropometrics (weight, height) were measured following World Health Organization procedures. 18 Body weight was measured with the individuals wearing no shoes and light clothing. Height was measured using measuring rod (Seca, Germany).Body Mass Index (BMI) was calculated using the ratio of weight (kilograms) to the square of height (meters) kg/m². Waist circumference (WC) was measured to the nearest centimeter using non-stretchable circumference measuring tape (SECA 203, Germany). The site of tape placing was determined according to World Health Organization (WHO) description of middle way between the iliac crest and lower rib border. The WHO BMI cutoff points were used to classify patients based on their BMI and WC. Patients’ total body fat and truncal fat percent were determined using bioelectrical impedence technique (TANITA, BC-418). The Segmental body composition analyzer (TANITA, BC-418) used in this study was previously validated against hydro-densitometry in the assessment of body composition in healthy young adults. Body fat and percentage cut-off points used were gender and age specific based on which patients were classified into healthy, over-fat, and obese. Cut-off points for truncal fat % were gender specific based according to which patients were classified into three levels of truncal fat: low, average, and high. A P-value of <  0.05 was considered the cut-off level for statistical significance. Multivariate analysis of variance (MANOVA) was used to examine the relationship between serum levels of hs-CRP, IL-6 and glycemic control and body fatness, Least Significant Difference (LSD) post-hoc MANOVA was conducted to determine the difference between patients in different categories.

Results

Poorly controlled females had higher levels of hs-CRP as compared to poorly controlled males (P = 0.004). However, no differences were noticed in the CRP serum levels in good glycemic control group. At the same time, older patients with poor glycemia had higher serum IL-6 levels as compared to younger patients. In poor glycemic control group and after adjusting for age, gender, lipid lowering drugs and diabetes duration, the (hs-CRP) serum levels of patients with high BMI (obese) was significantly higher than that observed in the normal, and overweight patients (P-value =  0.02). Body fat percentage was significantly associated with hs-CRP serum levels inpoor glycemic control group; patients with healthy body fat percentages had lower hs-CRP (6.30 ±  0.66) compared to patients with obese patients (11.89 ±  1.30). Trunk fat mean seems to be significantly associated with patients’ hs-CRP serum levels regardless of the glycemic control groups (P-value =  0.05). Among patients with poor glycemic control, higher levels of serum IL-6 were detected in obese patients (6.10 ±  0.93) compared to those with normal body weight patients (4.06 ± 1.82). Similar trend is found with regard to WC where patients with poor glycemic control continue to have higher levels of IL-6 with higher WC (P =  0.018). Positive relationship was found between IL-6 serum levels and trunk fat percentage among all patients regardless of glycemic control.

Conclusion

Findings of the current study indicate that high subcutaneous intraperitoneal fat induces the risk of systemic inflammation regardless of glycemic control. General obesity is associated with systemic inflammation only among patients with poor glycemic control. This study had several strengths including the tough selection procedure of the participants to rule out any response to acute response to inflammation. Several blood measurements were performed on the patients including HbA1c, CRP, and IL-6 which add to the validity of our hypothesis testing. Moreover, the study operationalized obesity in different ways BMI, WC, total and truncal fat%. However, findings of this study is limited due to the cross-sectional nature of the study design.

Obtaining Reliable Evidence on the Determinants of NCDs in the UAE: The Abu Dhabi Cohort Study Cardiovascular disease and diabetes are extremely common in Abu Dhabi and throughout the Arab World. While cohort studies have made tremendous contributions to scientific knowledge of the epidemiology and determinants of cardiovascular disease, few have been done in Arab populations. To study the causes of these diseases and other diseases common to the Abu Dhabi, we are establishing a prospective cohort study (the Abu Dhabi Cohort Study) for epidemiologic research. In Phase I of the study, we will recruit 20,000 adult subjects from multiple sites including ambulatory care centers, universities, workplaces and blood collection centers. After providing informed consent, participants will complete a 30–45 minute survey, administered via tablet computer. The questionnaire will cover lifestyle, health habits (tobacco use, diet, physical activity), health status and other factors. Biological samples will be collected, including blood, urine and an oral wash. Physical measurements will also be carried out (blood pressure, grip strength, and anthropometric measures including weight, height, waist size and percent body fat). In Phase II, a subsample (approximately 2,000) of Phase I participants will be invited to return for non-invasive testing, which will include determinants of cardiovascular disease (carotid artery intima medial thickness and brachial artery flow-mediated vasodilation) and pulmonary function (spirometry). Study subjects will also provide consent for long-term follow-up for the adult lifespan to determine health outcomes and related health determinants through brief quarterly surveys and a longer annual questionnaire. Study design and progress is guided by an International Advisory Committee and a local Steering Committee. In order to finalize cohort study procedures, we carried out a pilot study on 500 participants in 2015. As this was the first time such a study was being done in the UAE, and following best practice from similar studies internationally and in the region, it was essential to do a pilot study first to establish both the study feasibility and to ensure that all protocols and participant materials were appropriate for the local population. The pilot study had five main objectives and the results in relation to each of these objectives are summarized below:

1. Development of participant materials (participant information leaflet, consent form and questionnaires.) The first stage of the pilot study (September to December 2014) was a series of focus groups with potential participants to develop and optimise the participant information material and study protocols. These were conducted at UAE University, Zayed University and NYUAD. Participants provided feedback on the study design, approaches to recruitment and the design of the participants’ materials including the participant information leaflet (PIL) and consent form; the questionnaire and all aspects of the assessment visit. Particular focus was given to aspects of the study which participants were unfamiliar with, such as genetic testing. In general, participants were happy with the study design and recruitment approaches, but some changes were made to the PIL in response to feedback (mainly making it shorter).

2. Assessment of participation rates for various recruitment strategies Making use of modifications suggested from the focus groups, the second stage of the pilot involved recruitment of 500 participants into the cohort study from January to May 2015, at facilities licensed by HAAD with authorisation for medical research (Zayed Military Hospital's Primary Health Care Clinic and clinic at Zayed Military City and the Abu Dhabi blood bank.) The response rate was 68% (522/769). The main reasons for not taking part were: Lack of time (60% of non-respondents)Not interested (20%) Not convinced (10%) Other (10%) Responders and non-responders were similar with respect to age and gender. No monetary or non-monetary gifts were given to participants.

3. Evaluation of baseline assessment visit. In each location, HAAD- licensed nurses carried out physical measurements including waist, hip, and neck circumferences, as well as height, weight, handgrip, blood pressure, and body composition (impedance). The nurse also assisted participants to complete a questionnaire using an iPad, and collected blood, an oral wash and urine samples. The assessment visit took most participants between 40 to 60 minutes. Completion rates for the various components of the study were approximately: Questionnaire – 70% Physical measurements – 80% Blood 95% Urine 80% Mouthwash 80% Based on the pilot study experience, one nurse and one research assistant are required to recruit, consent and collect materials from about 10 people daily.

4. Assessment of procedures for biological sample collection, transport and processing. Blood, urine and mouthwash samples were transferred to NYUAD laboratories; aliquots of which were stored at – 80°C for analyses. Samples will be analysed for a battery of routine and specialized biochemical markers from May 2015 to December 2015.

5. Assessment of acceptability of various parts of the study A brief post-visit questionnaire was sent to all participants by email/SMS to assess their understanding of key components of the consent (as well seeking opinions on the assessment visit and highlighting any areas for improvement). Of 330 questionnaires sent by email, 34 were completed (10% response rate). In response to the question ‘How would you answer if a close friend or family member were to ask you “should I participate in the Abu Dhabi Cohort study?”, 80% said they would definitely take part. Analyses of data collected in the pilot study Simple descriptive analyses of questionnaire and physical measurements data collected in the pilot study were carried out to help inform sample size calculations for the main study. Crude (not age-adjusted) prevalence for selected characteristics are shown below: Selected baseline characteristics Men Women Number of participants 325 150 Mean age 32 30 Self–reported Diabetes 8 9 Self-reported Hypertension 11 12 Self-reported Hypercholesterolemia 19 11 Overweight 34 25 Obese 23 18 Cigarette smoking 18 1 Midwakh smoking 17 1 Shisha smoking 13 2

Introduction

Stroke, a neurological disorder that continues to be considerable burden on health systems due to high fatality rates and a major disability in survivors. Despite a decline in stroke incidence in the developed world, developing nations are still facing the problem at its eminent peak. Over 80% of all stroke deaths in the world occur in developing countries. This includes the MENA region, which not only comprises of the hugely populated and lesser developed countries in the world but some nations also has varied ethnic group due to prominent immigration predominantly from South Asia and South-east Asia.

Studies have shown that different ethnic groups have different pre-disposing factors, epidemiological patterns and outcomes of stroke. These variations can be due to lifestyle, demographic, and/or socioeconomic factors. These differences can not only significantly change the course of treatment and management of stroke, but also change the methods applied towards the prevention of stroke, which is shown to be significant in order to reduce the incidence of stroke in a region. In the absence of significant global public health response the morbidity and mortality rates will only go higher.

The MENA region comprises of a unique mix of low to middle income countries and high-income countries. But the common elements in all these countries include increase urbanization, unchecked population growth, increased consumption of western diet, obesity and inactivity. Moreover, the health services and public health response is not at par with the growing problem in hand.

Methods

Data sources and search strategy

We conducted a systematic review of the prevalence and incidence of Stroke in the 23 countries of MENA region (Sudan, Somalia, Djibouti, Pakistan, Afghanistan, Algeria, Bahrain, Egypt, Jordan, Kuwait, Lebanon, Libya, Iran, Iraq, Morocco, Oman, Qatar, Saudi Arabia, Syria, Tunisia, United Arab Emirates, Palestine and Yemen). The review was conducted following the PRISMA guidelines and the PRISMA checklist can be found on Figure S1 in Supporting Information (SI). Our search criteria can be found in Figure S2 in SI. Briefly, PubMed and EMBASE databases were used for this review. The databases were searched using text terms and MeSH/Emtree terms exploded to cover all sub-heading. We used a broad search criterion with no restrictions for language, or year of publication.

Study selection

The search results were imported to a reference manager, Endnote, and screened for duplicate papers. After exclusion of duplicates the titles and abstracts of the final set of distinctive papers was exported to Microsoft Excel. All the extracted articles were screened for relevance by two authors (SA and DD). The process of Screening was conducted in two separate steps: First level of screening involved screening titles and abstracts of all papers to exclude all non-relevant articles; second level involved screening the full-text of all relevant or potentially relevant articles thus, excluding all non-eligible articles. Any paper reporting the incidence or prevalence of stroke based on primary data were included in this review. All forms study designs except literature reviews, case reports, case series editorials, and letters to editors were included in the review. A publication is included in the review if it had a data point on either the prevalence of acute stroke, or the incidence of acute stroke, or both.

Data extraction and data synthesis

Data from relevant articles was extracted by two authors, SA and DD, for the following indicators: author, year of publication, year of study, country of study,study design, sampling technique, population, sample size, stroke incidence and stroke prevalence. Though the articles were not search for mortality and risk factors, this information was extracted from relevant reports when available. Data was extracted from abstracts when the full text is unavailable. Any studies in Arabic or French were screened by author DD.

Results

Conclusion

Figure 1

Reasons for exclusion

Full-text did not include data on relevant indicators (n = 191)

Article is an editorial/commentary/letter to editor (n = 4)

Full-text could not be retrieved and abstract does not have data on relevant outcomes (n = 15)

Reasons for exclusion

Same dataset as another included relevant publication (n = 5)

Paper presents contradictory/unclear numbers that could not be verified (n = 0)

References

Objectives

Metabolic syndrome is a cluster of conditions—increased blood pressure, a high blood sugar level, abdominal fat accumulation and abnormal cholesterol levels—that occur together, increasing the risk of heart disease, stroke and type 2 diabetes mellitus (T2DM). Mitochondria play a central role in the energy metabolism. Mitochondrial dysfunction contributes to the pathogenesis of metabolic disorders. Abnormality in mitochondrial function is a leading cause for development of insulin resistance and is promoted, at least partly, through lipid accumulation in ectopic tissues, including liver and skeletal muscle. Many growth and transcription factors involved in the regulation of mitochondrial gene expression also contribute to the pathophysiology of obesity, insulin resistance and type-2 diabetes. The role of mitochondria as functional organelles, and the signaling molecules produced by them are critical in the regulation of cellular energy metabolism and homeostasis. MOTS-c (mitochondrial open reading frame of the 12S rRNA type-c) encoding a 16-amino-acid peptide is a recently identified peptide. The skeletal muscle appears to be the main target organ for MOTS-c and its cellular actions inhibit the folate cycle and its tethered de novo purine biosynthesis, leading to AMPK activation. MOTS-c increases glucose utilization, promotes insulin sensitivity and metabolic homeostasis through activation of AMPK dependent mechanisms in skeletal muscle. In rodent studies MOTS-c has been demonstrated to protect against insulin resistance induced by diet and ageing. However the role of MOTS-c in adipocytes is largely unknown. In this current study we aimed to study the effect of MOTS-c on adipocyte development and metabolism in cultured mouse adipocytes.

Methods

3T3L1 cells were grown in DMEM media containing 10% FBS. Cells were stimulated with various concentrations of MOTS-c (100 nM to 50 μM) to study the effect of MOTS-c on cell viability. For differentiation pre-adipocytes were grown in differentiation induction medium containing dexamethasone, IBMX and insulin for two days. The media was replaced with medium containing insulin only for the next six days. About 60–70% differentiation was achieved by day 8. For treatment group pre-adipocytes were pre-treated with MOTS-c for 24 hours, and then differentiated into adipocytes for eight days. Quantitative real-time PCR was used to investigate the effect of MOTS-c on adipogenic genes expression:, Peroxisome Proliferator-Activated Receptor Gamma (PPARg), AP2, adiponectin and leptin in mouse 3T3-L1 pre-adipocytes.

Result

MOTS-c treatment did not induce any significant changes in cell viability at 24h following treatment. Pretreatment with MOTS-c prior to induction of differentiation down regulated expression of adipogenic markers including leptin, adiponectin, PPARg and PPARg-coactivator 1-alpha (PGC1a) mRNA levels, compared to differentiated adipocyte controls.

Conclusion

Our primary result indicates that MOTS-c inhibits adipogenesis through down-regulation of multiple genes involved in development of adipocytes, and this inhibition could contribute to the reduced abdominal adiposity. Future studies are currently in progress to further assess the effects of MOTS-c on adipocytes lipolysis, glucose uptake, glucose transporter (GLUT) family and other insulin-signaling pathway protein including GSK3B, IGF1R, IGF2R, and PIK3K are needed to understand the role of MOTS-c in mouse 3T3-L1 adipocytes.

Introduction

Our long term goal is to develop a visual prosthesis which interfaces with the thalamic visual center of the brain to restore vision to patients who have lost sight through glaucoma, the leading cause of blindness for which no satisfactory medical treatment exists. Glaucoma is a group of neurodegenerative disorders that affects the retinal ganglion cell (RGC) layer of the eye in 60 million people worldwide [1] and is a disease especially prevalent among peoples of the Gulf region. RGCs link the early visual signal processing of the eye with subsequent visual processing centers of the brain. Of these structures, the lateral geniculate nucleus (LGN) located in the thalamus is the primary target for RGC signals. Many groups are seeking to combat vision loss through use of prostheses; currently, two retinal prostheses are approved clinical devices. Because these retinal prostheses require intact RGCs, they have merit for patients with diseases like age–related macular degeneration (AMD) and retinitis pigmentosa, but not for patients who face blindness through glaucoma. Our proposal that seeks to address all people rendered blind, either through diseases of photoreceptor degeneration (e.g., AMD) or through loss of RGCs (i.e., glaucoma) is to develop a high density multi–electrode array (MEA) that can be used to electrically stimulate many neurons of the human LGN (Fig. 1). Figure 1. Visual processing begins in the eye then data are relayed into the brain via the optic nerve to the LGN and subsequently to the visual cortex. Although each of these structures has been a target for visual prostheses, we propose that MEA stimulation of the LGN is a promising technique to address all forms of blindness.

Objectives

The primary objective of the current study has been to determine the optimum electrode materials and stimulus parameters to safely and efficiently stimulate LGN neurons electrically using a multielectrode array (MEA).

Methods

Retina preparation

The retina is a displaced part of the central nervous system that develops like the thalamus from the embryonic diencephalon. RGCs therefore provide for a convenient and advantageous target, because they can be both stimulated visually and electrically in vitro, for early stage testing of electrode performance for LGN stimulation. Retinal tissue was taken from 3–6 month old C57BL/6 wild–type mice. To maintain normal visual–evoked responses from RGCs and be assured that the retina is undamaged before testing the electrodes, mice were sacrificed without drugs and retinas were isolated in darkness. Briefly, mice were first dark–adapted for 1 hr to retain light sensitivity then euthanized by cervical dislocation. Eyes were immediately removed and the retinas were excised in artificial cerebrospinal fluid (ACSF) within 15–20 min using an IR stereomicroscope. The retina was flattened on the MEA with the ganglion cell layer adjacent to the electrodes. The retina was maintained at room temperature (21°C) and perfused with oxygenated ACSF (95% O2, 5% C02) at 3–5 ml/min. Visual and electrical stimulation The MEAs (Multichannel Systems, Reutlingen, Germany) used in experiments consisted of 60 electrodes (30 μm in diameter, separated by 200 μm) arranged in a 2–D planar 8 × 8 rectangular array with a glass ring fixed to the surface to create a chamber for the perfusion medium. The three electrode coatings tested were titanium nitride (TiN), iridium oxide (IrOx), and poly (3,4–ethylenedioxythiophene)–carbon nanotubes (PEDOT–CNT). Visual stimulation of the retina with Gaussian white noise light patterns for 30 min at a 15 Hz refresh rate was performed utilizing a lens to focus the image of a LCD microdisplay (Kopin Ruby SVGA Microdisplay, Edmund Optics, Barrington, NJ, USA) onto the same plane as the MEA electrodes [2]. Electrical stimulation and recording of neurons was performed in a MEA system (STG1002 and MEA1060–Inv–BC, Multichannel Systems, Reutlingen, Germany). The STG1002 stimulator was programmed to deliver current–controlled biphasic symmetrical waveforms with positive or negative phase first, square or sine waveforms, current amplitude ± 1–500 μA, single phase pulse width 40–1000 μs, and frequency 1–200 Hz. Spike Sorting RGC spike trains were processed using a combination of MC Rack to record raw spike records (Multichannel Systems, Reutlingen, Germany), Offline Sorter to identify individual unit spike waveforms (v3 spike sorter, Plexon Inc., Dallas, TX, USA), Matlab for further sorting of units (Mathworks Inc., Natick, MA, USA), and Neuroexplorer for data analysis (v3, Nex Technologies, Madison, AL, USA). The records were sampled at 10 kHz after high pass filtering at 200 Hz. The inherent noise of the system was 5–20 μV depending upon the electrode material, and the voltage threshold for a spike event was set at 20–24 μV to ensure all spikes were at or above the noise level.

Results

Electrode material sensitivity for recording neural spikes Filtered recordings from the three electrode materials were compared to determine their sensitivities for stimulation of RGCs. Several steps were used to ensure recordings obtained were real spikes and not noise or artifacts from the delivered electrical stimulation. Firstly, stimulation signals are biphasic, meaning the charge delivered is equal to the charge returned, eliminating residual charge in the area. The MEA system employs a blanking circuit by which the recording electrodes become disconnected from the MEA during stimulation and do not reconnect until 640 μs has passed in order to avoid electrical artifacts. Through MC Rack software, a 200 Hz high pass filter was implemented so all slow–rising spikes are removed and spike thresholds were set above the noise level for each material. Finally, spikes were sorted with Offline Sorter to separate spikes that are neuronal units from artificial “neuronal like” spikes. The graphs in Fig. 2 illustrate the filtered analog recordings (raw data without threshold, before sorting) of the three electrode materials when stimulating retinas with a 1 μA, 200 μs, 50 Hz biphasic square pulse. The data indicate that recordings with TiN electrodes recorded more noise (noise level around 10–12 μV) than IrOx or PEDOT–CNT electrodes (noise level 5–8 μV). Although the higher noise might suggest that TiN electrodes may be a more sensitive material for recording neural spikes, in fact the signal–to–noise ratio (SNR) was worse than for electrodes of the other two materials, making it less desirable for use as a recording electrode. TiN appeared to record more spikes in the analog data (Fig. 2), however further analysis (as shown later) identified the spikes as being stimulus artifacts. Because TiN delivers stimuli through capacitive charging, it is possible that the blanking time is insufficient and residual charge results in false spikes. IrOx and PEDOT–CNT provided better recording performance with stronger SNR and more reliable spikes. Figure 2. The plots above show representative examples of the raw records obtained from the MEA system for stimulation through different electrode materials. The records come from an electrode 600 μm from the stimulating electrode. The y–axis is the recorded signal amplitude (μV) and the x–axis is a section of time during a stimulus train (0–350 ms). The timing of electrical stimulation pulses (50 Hz) is shown as black bars above the plots. Stimulation efficacy for different electrode materials Tests were conducted on two mouse retinas for each electrode material. Electrode 55 (column 5, row 5) was assigned to be the stimulation electrode and a ground electrode was placed in the media above the MEA. Electrical stimuli were delivered with either a rectangular or a sine wave shape while changing one stimulus parameter at a time; the standard stimulus was a constant 50 μA, 200 μs, 100 Hz. Each stimulus waveform was delivered to the retina 2000 times. Recordings were analyzed for each electrode from − 2 to ?8 ms surrounding a stimulus. The heatmap (Fig. 3) displays the total number of cell spikes recorded during this time window arranged in an 8 × 8 array corresponding to the MEA. Results for two electrode materials are shown (PEDOT–CNT and TiN). The results for IrOx were similar to those for TiN. For the same stimulus conditions, we found that stimulation with PEDOT–CNT electrodes was considerably more effective in evoking spike responses from mouse RGCs than was the case with either stimulation with IrOx or TiN electrodes. Increasing the amplitude of the current used for stimulation through PEDOT–CNT electrodes increased spike responses but not for stimulation with TiN or IrOx electrodes in the range that we tested. Waveform shape, frequency, and pulse width did not appear to affect the number of spikes after stimulation much. The fact that evoked responses were insensitive to increases in stimulus amplitude through IrOx or TiN electrodes suggests that we may have failed to reach the threshold to drive many RGCs for stimulation with these materials. In any event, the key result is quite clear – PEDOT–CNT electrodes provide a far superior interface for electrical stimulation of RGCs and, by inference, LGN neurons. Figure 3. Heat maps showing the total number of spikes recorded within − 2 to ?8 ms of an electrical stimulus at each position in an 8 × 8 array correlating to the MEA electrode layout. Dark blue ? 0 spikes and Red–brown ? 3000 spikes recorded during a period of 2000 stimuli. By increasing the current amplitude from 50–500 μA, more spikes were recorded when stimulation was fed through PEDOT–CNT electrodes, but no significant increase was observed when stimulation was through TiN or IrOx (not shown) electrodes. Square or sine wave shape did not appear to affect the degree of RGC stimulation much. Comparing visual and electrical stimulation Both visual and electrical stimulation can evoke responses from RGCs (Fig. 4) but there are some differences. The main difference we observed was that multi–unit responses were more frequent during visual stimulation. This is likely because axonal units with receptive fields and thus axon initial segments (the point of low threshold spike activation) distant from the electrical stimulation site could be activated by visual but not electrical stimulation and recorded on the electrode of interest. This hypothesis does however require further investigation. Current results suggest that somal units recorded on an electrode can be equally activated by either electrical or visual stimulation, as shown in the plots below where the average waveform shape are nearly identical. Figure 4. The plots above show the set of spike shapes recorded 600 μm from the stimulating electrode. The green lines represent all the waves recorded from a single channel. Red is the average waveform (template) and blue is ± 3 standard deviations. (A) Waveforms were recorded during (A) visual stimulation and (B) electrical stimulation. There are fewer spikes recorded during electrical stimulation but the population averages are not significantly different.

Conclusion

We have tested three different materials for recording and electrical stimulation of RGCs: TiN, IrOx, and PEDOT–CNT. The IrOx and PEDOT–CNT electrodes both have lower noise compared with the TiN electrode. Most significantly, the PEDOT–CNT electrode performed considerably better in stimulating RGCs electrically than both of the other two electrode materials. Changing the current amplitude elicited changes in spike recordings more so than any changes in duration, frequency, or waveform. We also found electrical stimulation can evoke spikes as readily as visual stimulation, indicating that electrical stimulation may indeed interface naturally with the visual system. The major result of this study is that electrodes coated with PEDOT–CNT are more likely than IrOx or TiN to permit effective stimulation of neurons. The search for a material with high sensitivity is critical for our goal of creating a high density MEA for stimulation of the LGN in blind patients. The next step for us in this project is to demonstrate that vision can be restored in a blind animals through electrical stimulation of the LGN in vivo.

Acknowledgment

All of the work reported here was funded by NPRP grant # NPRP 5-457-2-181 from the Qatar National Research Fund (a member of Qatar Foundation).

References

[1] Quigley HA and Broman AT. 2006. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthal 90(3):262–267.

[2] Inayat S, Rountree CM, Troy JB, and Saggere L. 2015. Chemical stimulation of rat retinal neurons: feasibility of an epiretinal neurotransmitter–based prosthesis. J Neur Eng 12(1).

Diabetes is the fifth-deadliest disease in the United States. Most diabetes patients die from diabetic complications, such as renal failure, heart attack or stroke. However, diabetic complications are still neither preventable nor curable. New strategies that can prevent, treat, or cure diabetic complications are needed. Increasing evidence has identified the formation of advanced glycation end products (AGEs) as a major pathogenic link between hyperglycemia and diabetes-related complications. In diabetes, formation of AGEs occurs at a higher rate when compared to non-diabetic normal individuals. Alpha-oxoaldehydes such as methylglyoxal (MGO) and glyoxal (GO), the reactive dicarbonyl intermediates generated during the non-enzymatic glycation between reducing sugars and amino groups of proteins, lipids, and DNA, are precursors of AGEs and exert direct toxicity to cells and tissues. Levels of MGO and GO were observed to be 2–6 times higher in diabetic patients' plasma as compared with healthy people's plasma. In addition, this is complicated by many food products and beverages representing exogenous sources of MGO and GO. It is likely that decreasing the levels of MGO and GO and inhibiting the formation of AGEs will form an important component of future therapy in patients with diabetes. Numerous studies have reported that bioactive components in ginger, tea and apple can prevent diabetes and its related complications. However, the underlying molecular mechanisms are still largely unknown. In this project, we investigated the effect of bioactive compounds in ginger ([6]-shogaol (6S) and [6]-gingerol (6G)), tea (epigallocatechin gallate (EGCG)) and apple (phloretin and phloridzin) to inhibit the formation of AGEs via trapping MGO. We demonstrated for the first time that both [6]-shogaol (6S) and [6]-gingerol (6G), the major active components in ginger, markedly trapped MGO in vitro and consequently formed mono-MGO adducts, 6S-MGO and 6G-MGO, which were purified from the respective chemical reaction and characterized as novel compounds by NMR experiments and LC-MS/MS approaches. We revealed that the α-carbon of carbonyl group in the side chain of 6S or 6G is the major active site for trapping MGO. We also demonstrated that 6S and 6G could effectively inhibit the formation of MGO-induced AGEs via trapping MGO in a time-dependent manner in the human serum albumin (HSA)-MGO system. Mono-MGO adducts, 6S-MGO and 6G-MGO, were determined to be the major conjugates in 6S- and 6G-treated HSA-MGO assays, respectively, using LC-ESI/MS techniques. These findings showed the potential effects of 6S and 6G on the prevention of protein glycation, suggesting regular consumption of ginger root extract may attenuate the progression of MGO-associated diabetic complications in patients. Similarly, we found that both EGCG and phloretin could inhibit the formation of AGEs through the same pathways. In addition, we also studied whether these compounds could inhibit the formation of AGEs via trapping MGO in high fat diet treated mice. Two different doses of 6G, EGCG and phloretin (25 mg/kg and 75 mg/kg) were given to mice through oral gavage for 16 weeks. Plasma and tissue samples were collected from control and treated mice. The formation of MGO adducts of each compound were analyzed using our established LC/MS methods. The levels of MGO and AGEs were also quantified.

Introduction

Sbar is a techinique that can be used to facilitate prompt and appropriate communication. It is a way for healthcare proffessionals to communicate effectively. The sbar tool is a memory prompt which helps the medical staff handover, prepare information just before handing over the required details/outcomes/result of the concerned patient from one shift to another shift duty incharge.

Aim/objectives

To increase and starndardize the usage of sbar as a communication tool among the clinical staff in the emergency department of hamad general hospital to 100% by feb 2016.

Methods

The project was done in an iterative four-step continuos improvement method through careful monitoring in various areas of ed to collect the baseline data. Sbar champ were chosen from each area to facilitate & coordinate the project to most of emergency dept. Sbar endorsement form was introduced for the nurses between shifts to notify information. Champion docs, nurse educators & quality reviewers decided on educational sessions to the ed-nurses & physicians. Educational sessions consisted of role play, scenario based and simulation training for the nurses & doctorsto make them understand the relevance of sbar. A monitoring tool was developed for “secret audit” on sbar usage.

Results/outcomes

There has been a spike in the usage of sbar by the nurses & doctors during the endorsement time and between the work schedule. With the help of the charge nurses and sbar champions who regularly change from day to day, careful monitoring has been placed in various areas of the emergency department which has led to such significant achievement. As of now the measurement and the testing has been done with the nurses, physicians, ecg technicians, respiratory therapists and also the quality reviewers. We are soon planning to include ems for the same training and by end of june, we will make sure the whole emergency dept will be talking & reporting in sbar.

Conclusions

Interproffesional communication activity is needed at the entry level for all proffesionals.Sbar is a teachable skill that is recognized by all healthcare workers as a safe effective method of communicating among providers. We will soon spread this communication between units & during transfers also.

Background

Vasoactive intestinal peptide (VIP) is a neuropeptide that controls the proliferation, differentiation, and survival of various normal and cancer cells. Elevated expression of VIP receptors has been found in prostate and breast cancer; and antagonists of VIP inhibit the growth of cancer xenografts. We previously reported the cytoprotective mechanisms activated by VIP in differentiated cancer cells that form the bulk of tumor, however, the signaling mechanisms activated in cancer stem cells (CSC) have not been identified.

Objectives

The objectives of this study are to unravel the anti-apoptotic mechanisms activated by VIP in CSC, and examine if these pathways converge on a pro-apoptotic protein BAD. Identification of mechanisms responsible for survival of CSC will help design new therapeutic strategies that target and eliminate CSC.

Methods

Sphere formation assay and Fluorescent Activated Cell Sorter (FACS) were used to enrich and purify CSC (CD44+/CD24 −  and/or CD133+) from prostate and breast cancer cells. Apoptosis of CSC was induced by inhibiting the survival kinase PI3K/Akt using pharmacological inhibitor LY294002. Caspase assay, FACS and soft agar colony formation assays were used to measure the cytoprotective effects of VIP. Western blot was used to address the phosphorylation and quantification of various signaling proteins.

Results and conclusion

Cancer stem cells were sorted to a purity of 95% and characterized for their stemness phenotype. While LY induced apoptosis in CSC by dephosphorylating BAD, VIP rescued by restoring the BAD phosphorylation at Ser112. VIP activated two non-redundant antiapoptotic signaling pathways that converge on BAD. One signaling pathway operate via activation of protein kinase A (PKA), whereas the other pathway predominately relies on MEK/MAPK pathway. Both pathways partially control BAD phosphorylation at Ser112. Either of these pathways is sufficient to protect CSC from apoptosis, thus both have to be inhibited to block cytoprotective effects of VIP. Using phosphorylation deficient mutant BAD, we show that the BAD phosphorylation is essential for the VIP-induced survival of CSC. Taken together, our findings suggest the potential usefulness of VIP receptor inhibition, and that BAD plays a critical role in CSC and thus targeting BAD might be an attractive strategy for development of novel therapeutics.

Purpose

Statins selection for the largest hospital formulary in Qatar is not systematic, not comparative, not cost saving, and does not consider the multi-indication nature of statins. There are no literature reports of multi-indication based comparative scoring models of statins, or reports of statins selection criteria weights that are primarily based on local clinicians' preference and experiences. The study sought to comparatively evaluate statins for first-line therapy in Qatar, and to evaluate the economic impact of this.

Methods

An evidence-based, multi-indication, multi-criteria pharmacotherapeutic model was developed for the scoring of statins. This was from the perspective of the main healthcare provider in Qatar, the Hamad Medical Corporation (HMC). Literature and an expert panel informed the selection criteria of statins. Relative weighting of selection criteria was based on the input of the relevant local clinician population. The targeted clinician population was of all specialists and consultants in the departments of cardiology, internal medicine, and nephrology in HMC. Statins were comparatively evaluated according to their total pharmacotherapeutic selection scores, with only the statins that score more than 95% of the highest scoring statin getting recommended for formulary inclusion. Remaining statins that score more than 90% of the highest scoring statin will also be considered, but as non-formulary alternative. The remaining did not progress. Sensitivity analyses were conducted to investigate the robustness of the study outcomes against variations in study inputs. These included deterministic, probabilistic as well as scenario analyses, via @Risk-5.5 Palisade, USA.

Findings

This is the first literature report to inform formulary inclusion in Qatar or the Middle Eastern region, and the first in literature that comparatively score statins based on multiple indications, as compared to the typical pharmacoeconomics evaluation method, comparing differences in cost and effect between two statins for an indication of interest to guide the formulary inclusion decisions. With 95% confidence interval and 5% margin of error, the scoring model was successfully developed. Selection criteria comprised 28 sub-criteria, under the following main criteria: clinical efficacy, best publish evidence and experience, adverse effects, drug interaction, dosing time, and fixed dose combination availability. Outcome measures of multiple indications related to effects on LDL-cholesterol, HDL-cholesterol, triglyceride, total cholesterol, and c-reactive protein. Atorvastatin, pravastatin and rosuvastatin exceeded defined pharmacotherapeutic thresholds. Atorvastatin and pravastatin were suggested for first-line use in HMC, followed by rosuvastatin as a non-formulary alternative. Fluvastatin and simvastatin were recommended for exclusion from any hospital drug lists. This was estimated to produce 17.6% in cost savings, reducing the annual statins expenditure from QAR 152, 118, 200 to QAR 125, 367, 620;. Sensitivity analyses confirmed the robustness of the evaluation outcomes. The comparative criterion that affected the study conclusion was the availability of fixed dose combination. The possibility of 30% non-formulary drug utilization scenario resulted in an annual expenditure of QAR 129, 654, 180, still associated with up to 14.8% cost saving.

Implications

Incorporating a comparative evaluation of statins in Qatari practices, based on a locally-developed, transparent, multi-indication, multi-criteria scoring model, has the potential to considerably reduce the expenditure on statins. Atorvastatin and pravastatin should be the first-line statin therapies in the main Qatari healthcare provider, with rosuvastatin as an alternative. Important, is that the study results are consistent with published clinical guidelines, as well as with practices in overseas.

Purpose

The purpose of our study is to determine indications for the use of an IMRT technique for large volume size left breast cancers.

Materials/methods

We ran a retrospective review of Stage 0-III left breast cancers with large volumes treated with conservation therapy from April 2011 to January 2012 at the Radiation Oncology Department at the National Center for Cancer Care and Research in Doha, Qatar. Computer tomography simulation was used to design fields. Patients were treated supine and received 2 Gray (Gy) fractions to 50 Gy to the whole breast followed by an electron or 3D boost of 16 Gy using 6, 15 or mixed 6/15 megavoltage photons. A variety of techniques including electronic compensation (E-comp), field in field (FinF), and 3D with wedges (3DW) were compared. Dosimetric evaluations were made of the breast planning target volume (PTV), lung, heart and contralateral breast for each technique. RTOG skin toxicity grades, treatment data, and breast volumes were obtained by chart and treatment plan review. We further continued dose volume data evaluation using the following dosimetric parameters: uniformity index (UI), conformity index (CI) and homogeneity index (HI) parameters and radiobiological models to further assess our results.

Results

A total of 30 patients were treated, and all patients received chemotherapy. Volumes ranged from 718–3296 cc (ave.1483.33 cc). Separations ranged from 20–35 cm (ave. 23.87 cm). During treatment there were 63% Grade 1, 37% Grade 2, 0% grade 3/ 4 RTOG skin toxicity; no treatment breaks recorded. E-comp plans resulted in better coverage of the 95% volume (V95) coverage with improved dose homogeneity of the PTV. This was seen especially in breast volumes > 2400 cc. Also, there was a reduction in V110 and V115 in the FinF and Ecomp plans compared to conventional 3DW technique. In terms of dose to the contralateral breast Ecomp had a slight advantage (1%). No significant difference seen in the LT lung V20 and Heart V25 and Contralateral Breast V5 between Ecomp and FinF which was better than 3DW. The average dose coverage values of PTV with ecomp and FinF plans were comparable, and achieved an overall better target coverage than 3D plans. Forward planning IMRT gave higher conformity index values of 0.66 ± 0.07 and 0.67 ± 0.07 for ecomp and FinF plans respectively as compared to 0.65 ± 0.07 for 3D-CRT plans. The Homogeneity (HI) and Uniformity Index (UI) values favored ecomp and FinF values compared to 3DCRT with average HI values of 0.27 ± 0.16 for ecomp, 0.31 ± 0.14 for FinF, and 0.38 ± 0.33 for 3D-CRT. And uniformity index values of 1.11 ± 0.04, 1.13 ± 0.05 and 1.26 ± 0.39 for ecomp, FinF, and 3D respectively.

Conclusions

For women with large breast size Ecomp planning significantly improved dose homogeneity decreased acute skin toxicity and less hot spot value. These factors grow more important in women with large breasts, who may experience more Grade 3/4 skin toxicity and increased pain resulting in a lower quality of life with standard tangential fields. Therefore, we suggest using an Ecomp technique for left-sided breast cancer in the following situations: 1) breast volume >1500cc 2) separation of >25 cm or 4) combination of large volume/cup size with separation > 22 cm or vice versa, 5) the use of mixed beams. For patients with large breast volumes supine IMRT treatments can provide good dose homogeneity, spare dose to critical structures, and may be preferable to the prone breast irradiation. Conformity Index, Homogeneity Index and Uniformity Index are objective tools for evaluating dose coverage for breast planning. This study showed that a better target coverage for ecomp and FinF plans over 3D-CRT with a slight advantage of ecomp over FinF with large breast volumes. Furthermore, we will assess the potential advantage of IMRT over 3D planning using radiobilogical models.