Improving the use of G-CSF during chemotherapy using physiological mathematical modelling : a quantitative systems pharmacology approach

La diminution des doses administrées ou même la cessation complète d'un traitement chimiothérapeutique est souvent la conséquence de la réduction du nombre de neutrophiles, qui sont les globules blancs les plus fréquents dans le sang. Cette réduction dans le nombre absolu des neutrophiles, aussi connue sous le nom de myélosuppression, est précipitée par les effets létaux non spécifiques des médicaments anti-cancéreux, qui, parallèlement à leur effet thérapeutique, produisent aussi des effets toxiques sur les cellules saines. Dans le but d'atténuer cet impact myélosuppresseur, on administre aux patients un facteur de stimulation des colonies de granulocytes recombinant humain (rhG-CSF), une forme exogène du G-CSF, l'hormone responsable de la stimulation de la production des neutrophiles et de leurs libération dans la circulation sanguine. Bien que les bienfaits d'un traitement prophylactique avec le G-CSF pendant la chimiothérapie soient bien établis, les protocoles d'administration demeurent mal définis et sont fréquemment déterminés ad libitum par les cliniciens. Avec l'optique d'améliorer le dosage thérapeutique et rationaliser l'utilisation du rhG-CSF pendant le traitement chimiothérapeutique, nous avons développé un modèle physiologique du processus de granulopoïèse, qui incorpore les connaissances actuelles de pointe relatives à la production des neutrophiles des cellules souches hématopoïétiques dans la moelle osseuse. À ce modèle physiologique, nous avons intégré des modèles pharmacocinétiques/pharmacodynamiques (PK/PD) de deux médicaments: le PM00104 (Zalypsis®), un médicament anti-cancéreux, et le rhG-CSF (filgrastim). En se servant des principes fondamentaux sous-jacents à la physiologie, nous avons estimé les paramètres de manière exhaustive sans devoir recourir à l'ajustement des données, ce qui nous a permis de prédire des données cliniques provenant de 172 patients soumis au protocol CHOP14 (6 cycles de chimiothérapie avec une période de 14 jours où l'administration du rhG-CSF se fait du jour 4 au jour 13 post-chimiothérapie). En utilisant ce modèle physio-PK/PD, nous avons démontré que le nombre d'administrations du rhG-CSF pourrait être réduit de dix (pratique actuelle) à quatre ou même trois administrations, à condition de retarder le début du traitement prophylactique par le rhG-CSF. Dans un souci d'applicabilité clinique de notre approche de modélisation, nous avons investigué l'impact de la variabilité PK présente dans une population de patients, sur les prédictions du modèle, en intégrant des modèles PK de population (Pop-PK) des deux médicaments. En considérant des cohortes de 500 patients in silico pour chacun des cinq scénarios de variabilité plausibles et en utilisant trois marqueurs cliniques, soient le temps au nadir des neutrophiles, la valeur du nadir, ainsi que l'aire sous la courbe concentration-effet, nous avons établi qu'il n'y avait aucune différence significative dans les prédictions du modèle entre le patient-type et la population. Ceci démontre la robustesse de l'approche que nous avons développée et qui s'apparente à une approche de pharmacologie quantitative des systèmes (QSP). Motivés par l'utilisation du rhG-CSF dans le traitement d'autres maladies, comme des pathologies périodiques telles que la neutropénie cyclique, nous avons ensuite soumis l'étude du modèle au contexte des maladies dynamiques. En mettant en évidence la non validité du paradigme de la rétroaction des cytokines pour l'administration exogène des mimétiques du G-CSF, nous avons développé un modèle physiologique PK/PD novateur comprenant les concentrations libres et liées du G-CSF. Ce nouveau modèle PK a aussi nécessité des changements dans le modèle PD puisqu’il nous a permis de retracer les concentrations du G-CSF lié aux neutrophiles. Nous avons démontré que l'hypothèse sous-jacente de l'équilibre entre la concentration libre et liée, selon la loi d'action de masse, n'est plus valide pour le G-CSF aux concentrations endogènes et mènerait en fait à la surestimation de la clairance rénale du médicament. En procédant ainsi, nous avons réussi à reproduire des données cliniques obtenues dans diverses conditions (l'administration exogène du G-CSF, l'administration du PM00104, CHOP14). Nous avons aussi fourni une explication logique des mécanismes responsables de la réponse physiologique aux deux médicaments. Finalement, afin de mettre en exergue l’approche intégrative en pharmacologie adoptée dans cette thèse, nous avons démontré sa valeur inestimable pour la mise en lumière et la reconstruction des systèmes vivants complexes, en faisant le parallèle avec d’autres disciplines scientifiques telles que la paléontologie et la forensique, où une approche semblable a largement fait ses preuves. Nous avons aussi discuté du potentiel de la pharmacologie quantitative des systèmes appliquées au développement du médicament et à la médecine translationnelle, en se servant du modèle physio-PK/PD que nous avons mis au point.

A demonstration of mobile phone deployment to support the treatment of acutely ill children under five in Bushenyi district, Uganda.

Background: Benefits of mobile phone deployment for children <5 in low-resource settings remain unproven. The target population of the current demonstration study in Bushenyi District, Uganda, presented with acute fever, pneumonia, or diarrhoea and were treated by community health workers (CHWs) providing integrated community case management (iCCM). Methods: An observational study was conducted in five parishes (47 villages) served by CHWs well versed in iCCM with supplemental training in mobile phone use. Impact was assessed by quantitative measures and qualitative evaluation through household surveys, focus group discussions, and key informant interviews. Results: CHWs in targeted sites improved child healthcare through mobile phone use coupled with iCCM. Of acutely ill children, 92.6% were correctly managed. Significant improvements in clinical outcomes compared to those obtained by CHWs with enhanced iCCM training alone were unproven in this limited demonstration. Nonetheless, qualitative evaluation showed gains in treatment planning, supply management, and logistical efficiency. Provider confidence and communications were enhanced as was ease and accuracy of record keeping. Conclusion: Mobile phones appear synergistic with iCCM to bolster basic supportive care for acutely ill children provided by CHWs. The full impact of expanded mobile phone deployment warrants further evaluation prior to scaling up in low-resource settings.

Is facility based neonatal care in low resource setting keeping pace? A glance at Uganda’s National Referral Hospital.

Objectives: To identify reasons for neonatal admission and death with the aim of determining areas needing improvement. Method: A retrospective chart review was conducted on records for neonates admitted to Mulago National Referral Hospital Special Care Baby Unit (SCBU) from 1st November 2013 to 31st January 2014. Final diagnosis was generated after analyzing sequence of clinical course by 2 paediatricians. Results: A total of 1192 neonates were admitted. Majority 83.3% were in-born. Main reasons for admissions were prematurity (37.7%) and low APGAR (27.9%).Overall mortality was 22.1% (Out-born 33.6%; in born 19.8%). Half (52%) of these deaths occurred in the first 24 hours of admission. Major contributors to mortality were prematurity with hypothermia and respiratory distress (33.7%) followed by birth asphyxia with HIE grade III (24.6%) and presumed sepsis (8.7%). Majority of stable at risk neonates 318/330 (i.e. low APGAR or prematurity without comorbidity) survived. Factors independently associated with death included gestational age <30 weeks (p 0.002), birth weight <1500g (p 0.007) and a 5 minute APGAR score of < 7 (p 0.001). Neither place of birth nor delayed and after hour admissions were independently associated with mortality. Conclusion and recommendations: Mortality rate in SCBU is high. Prematurity and its complications were major contributors to mortality. The management of hypothermia and respiratory distress needs scaling up. A step down unit for monitoring stable at risk neonates is needed in order to decongest SCBU.

Danger theory: the link between AIS and IDS?

We present ideas about creating a next generation Intrusion Detection System (IDS) based on the latest immunological theories. The central challenge with computer security is determining the difference between normal and potentially harmful activity. For half a century, developers have protected their systems by coding rules that identify and block specific events. However, the nature of current and future threats in conjunction with ever larger IT systems urgently requires the development of automated and adaptive defensive tools. A promising solution is emerging in the form of Artificial Immune Systems (AIS): The Human Immune System (HIS) can detect and defend against harmful and previously unseen invaders, so can we not build a similar Intrusion Detection System (IDS) for our computers? Presumably, those systems would then have the same beneficial properties as HIS like error tolerance, adaptation and self-monitoring. Current AIS have been successful on test systems, but the algorithms rely on self-nonself discrimination, as stipulated in classical immunology. However, immunologist are increasingly finding fault with traditional self-nonself thinking and a new ‘Danger Theory’ (DT) is emerging. This new theory suggests that the immune system reacts to threats based on the correlation of various (danger) signals and it provides a method of ‘grounding’ the immune response, i.e. linking it directly to the attacker. Little is currently understood of the precise nature and correlation of these signals and the theory is a topic of hot debate. It is the aim of this research to investigate this correlation and to translate the DT into the realms of computer security, thereby creating AIS that are no longer limited by self-nonself discrimination. It should be noted that we do not intend to defend this controversial theory per se, although as a deliverable this project will add to the body of knowledge in this area. Rather we are interested in its merits for scaling up AIS applications by overcoming self-nonself discrimination problems.

Effect of the CeZrNd mixed oxide synthesis method in the catalytic combustion of soot

Ce0.64Zr0.27Nd0.09Oδ mixed oxides have been prepared by three different methods (nitrates calcination, coprecipitation and microemulsion), characterized by N2 adsorption, XRD, H2-TPR, Raman spectroscopy and XPS, and tested for soot combustion in NOx/O2. The catalyst prepared by microemulsion method is the most active one, which is related to its high surface area (147 m2/g) and low crystallite size (6 nm), and the lowest activity was obtained with the catalyst prepared by coprecipitation (74 m2/g; 9 nm). The catalyst prepared by nitrates precursors calcination is slightly less active to that prepared by microemulsion, but the synthesis procedure is very straightforward and surfactants or other chemicals are not required, being very convenient for scaling up and practical utilization. The high activity of the catalyst prepared by nitrates calcination can be attributed to the better introduction of Nd cations into the parent ceria framework than on catalysts prepared by coprecipitation and microemulsion, which promotes the creation of more oxygen vacancies.

FOCUS : frailty management optimisation through EIPAHA commitments and utilisation of stakeholders’ input – an innovative European project in elderly care

The goal of FOCUS, which stands for Frailty Management Optimization through EIPAHA Commitments and Utilization of Stakeholders’ Input, is to reduce the burden of frailty in Europe. The partners are working on advancing knowledge of frailty detection, assessment, and management, including biological, clinical, cognitive and psychosocial markers, in order to change the paradigm of frailty care from acute intervention to prevention. FOCUS partners are working on ways to integrate the best available evidence from frailty-related screening tools, epidemiological and interventional studies into the care of frail people and their quality of life. Frail citizens in Italy, Poland and the UK and their caregivers are being called to express their views and their experiences with treatments and interventions aimed at improving quality of life. The FOCUS Consortium is developing pathways to leverage the knowledge available and to put it in the service of frail citizens. In order to reach out to the broadest audience possible, the FOCUS Platform for Knowledge Exchange and the platform for Scaling Up are being developed with the collaboration of stakeholders. The FOCUS project is a development of the work being done by the European Innovation Partnership on Active and Healthy Ageing (EIPAHA), which aims to increase the average healthy lifespan in Europe by 2020 while fostering sustainability of health/social care systems and innovation in Europe. The knowledge and tools developed by the FOCUS project, with input from stakeholders, will be deployed to all EIPAHA participants dealing with frail older citizens to support activities and optimize performance.

ARIA 2016: Care pathways implementing emerging technologies for predictive medicine in rhinitis and asthma across the life cycle

The Allergic Rhinitis and its Impact on Asthma (ARIA) initiative commenced during a World Health Organization workshop in 1999. The initial goals were (1) to propose a new allergic rhinitis classification, (2) to promote the concept of multi-morbidity in asthma and rhinitis and (3) to develop guidelines with all stakeholders that could be used globally for all countries and populations. ARIA—disseminated and implemented in over 70 countries globally—is now focusing on the implementation of emerging technologies for individualized and predictive medicine. MASK [MACVIA (Contre les Maladies Chroniques pour un Vieillissement Actif)-ARIA Sentinel NetworK] uses mobile technology to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group and by patients themselves. An app (Android and iOS) is available in 20 countries and 15 languages. It uses a visual analogue scale to assess symptom control and work productivity as well as a clinical decision support system. It is associated with an inter-operable tablet for physicians and other health care professionals. The scaling up strategy uses the recommendations of the European Innovation Partnership on Active and Healthy Ageing. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers, whatever their age, sex or socio-economic status, in order to reduce health and social inequalities incurred by the disease.

Role of microfinance to support agricultural climate change adaptations in Indonesia: Encouraging private sector participation in climate finance

The demands of mitigation and adaptation policies are important to understanding a country’s climate change preparation by providing microfinance in the agricultural sector. This could be seen as a strategy to fight against the challenges of future food security. In 2014, Indonesia established climate change adaptation policies. This legislation aims to pave the way for making actions on climate change adaptation mainstream in national and local development planning. Public and private finance have supported the implementation of the climate actions. However, most funding is still used for mitigation. Adaptation finance needs support, especially in agriculture. This research paper studies opportunities for microfinance to play a role together with existing resources in supporting climate change adaptation in Indonesia. The data was acquired and analysed through a literature review, analysis of case studies and interviews with stakeholders in the climate change-related financial sector. The central findings regarding the opportunity for microfinance to contribute to the existing schemes in Indonesian climate change adaptation finance for agriculture are worthy of the result. This study found that adaptation finance is mostly used for indirect activities. Meanwhile, local communities, and farmers in particular, need directly targeted measures to adapt to climate change. An alternative approach is providing microfinance, insurance and capacity development for farmers to produce high quality agricultural products. This would contribute to optimizing the agri-food value chain, which supports socio-economic development of stakeholders, especially farmers. Hence, microfinance appears to be one potential solution to support direct climate change adaptation actions for the agricultural sector. However, this may not be strong enough to finance the entire needs for agricultural climate actions. Adaptation is contextual, so it has to be grounded in the needs of local communities. Microfinance needs public sectors support as well as other resources from the private sector. In the case of rapid response to disasters, which often destroy the agricultural sector, microfinance should be advantageous in supporting adaptation. However, in reality, it does not work, as it is prevented by regulations. So, this can be an area the public sector can support as a risk-taker as well as by providing initial funds and resources for scaling up efforts.

Assessing the conservation status of Mediterranean temporary ponds using biodiversity: a new tool for practitioners

The assessment of the habitat condition is the first step of conservation actions and several tools are available to assess wetlands. However, only a few tools are adapted to the priority habitat Mediterranean temporary ponds. Thus, our objectives were (i) to identify biological indicators associated with the different conservation status of Mediterranean tem- porary ponds and (ii) to create an efficient evaluation tool for non-experts using indicators of conservation status. A total of 87 ponds were sampled in southwest Portugal to assess the presence of plants, large branchiopods, amphibians, threatened voles and bats. Ponds with favourable conservation status showed higher species richness of plants, large branchiopods and amphibians. We identified eighteen indicators for favourable ponds: 15 plants, one large branchiopod and two amphibian taxa. We propose a new tool to assess the conservation status of Mediterranean tem- porary ponds based on the presence of these indicators. This tool is an alternative to other common, but time- consuming, methods and can be readily used by trained practitioners. The replication and adaptation of this tool to other regions and habitats enables the collection of comparable data and the geographical scaling-up of the assessments.

Assessing the conservation status of Mediterranean temporary ponds using biodiversity: a new tool for practitioners

The assessment of the habitat condition is the first step of conservation actions and several tools are available to assess wetlands. However, only a few tools are adapted to the priority habitat Mediterranean temporary ponds. Thus, our objectives were (i) to identify biological indicators associated with the different conservation status of Mediterranean temporary ponds and (ii) to create an efficient evaluation tool for non-experts using indicators of conservation status. A total of 87 ponds were sampled in southwest Portugal to assess the presence of plants, large branchiopods, amphibians, threatened voles and bats. Ponds with favourable conservation status showed higher species richness of plants, large branchiopods and amphibians. We identified eighteen indicators for favourable ponds: 15 plants, one large branchiopod and two amphibian taxa. We propose a new tool to assess the conservation status of Mediterranean temporary ponds based on the presence of these indicators. This tool is an alternative to other common, but time consuming, methods and can be readily used by trained practitioners. The replication and adaptation of this tool to other regions and habitats enables the collection of comparable data and the geographical scaling-up of the assessments.

Biotechnological approaches to valorize alternative protein source, waste and by-products from food industries

The PhD research project was a striking example of the enhancement of milling by-product and alternative protein sources from house cricket (Acheta domesticus), conceived as sustainable and renewable sources, to produce innovative food products. During milling processing of wheat and rye, several by-products with high technological and functional potential, are produced. The use of selected microbial consortia, allowed to obtain a pre-fermented ingredient for use in the bakery. The pre-ferments obtained were characterized by a high technological, functional and nutritional value, also interesting from a nutraceutical point of view. Bakery products obtained by the addition of pre-fermented ingredients were characterized by a greater quantity of aromatic molecules and an increase in SCFA, antioxidant activity, total amino acids and total phenols resulting in positive effect on the functionality. Moreover, the industrial scaling-up of pre-ferment and innovative bakery goods production, developed in this research, underlined the technological applicability of pre-fermented ingredients on a large scale. Moreover, the identification of innovative protein sources, can address the request of new sustainable ingredients able to less impact on the environment and to satisfy the food global demand. To upscale the insect production and ensure food safety of insect-based products, biotechnological formulations based on Acheta domesticus powder were optimized. The use of Yarrowia lipolytica in the biotechnological transformation of cricket powder led to the achievement of a cricket-based food ingredient characterized by a reduced content of chitin and an increase of antimicrobial and health-promoting molecules. The innovative bakery products containing cricket-based hydrolysates from Y. lipolytica possessed specific sensory, qualitative and functional characteristics to the final product. Moreover, the combination of Y. lipolytica hydrolysis and baking showed promising results regarding a reduced allergenicity in cricket-based baked products. Thus, the hydrolysate of cricket powder may represent a versatile and promising ingredient in the production of innovative foods.

Strategies to hijack MTs dysfunction in neurodegenerative tauopathies: Design and synthesis of novel CNS-disease-modifying tools

Neuronal microtubules assembly and dynamics are regulated by several proteins including (MT)-associated protein tau, whose aberrant hyperphosphorylation promotes its dissociation from MTs and its abnormal deposition into neurofibrillary tangles, a common neurotoxic hallmarks of neurodegenerative tauopathies. To date, no disease-modifying drugs have been approved to combat CNS tau-related diseases. The multifactorial etiology of these conditions represents one of the major limits in the discovery of effective therapeutic options. In addition, tau protein functions are orchestrated by diverse post-translational modifications among which phosphorylation mediated by PKs plays a leading role. In this context, conventional single-target therapies are often inadequate in restoring perturbed networks and fraught with adverse side-effects. This thesis reports two distinct approaches to hijack MT defects in neurons. The first is focused on the rational design and synthesis of first-in-class triple inhibitors of GSK-3β, FYN, and DYRK1A, three close-related PKs, which act as master regulators of aberrant tau hyperphosphorylation. A merged multi-target pharmacophore strategy was applied to simultaneously modulate all three targets and achieve a disease-modifying effect. Optimization of ARN25068 by a computationally and crystallographic driven SAR exploration, allowed to rationalize the key structural modifications to maintain a balanced potency against all three targets and develop a new generation of quite well-balanced analogs exhibiting improved physicochemical properties, a good in vitro ADME profile, and promising cell-based anti-tau phosphorylation activity. In Part II, MT-stabilizing compounds have been developed to compensate MT defects in tau-related pathologies. Intensive chemical effort has been devoted to scaling up BL-0884, identified as a promising MT-normalizing TPD, which exhibited favorable ADME-PK, including brain penetration, oral bioavailability, and brain pharmacodynamic activity. A suitable functionalization of the exposed hydroxyl moiety of BL-0884 was carried out to generate corresponding esters and amides possessing a wide range of applications as prodrugs and active targeting for cancer chemotherapy.

Clinical and Microbiologic Follow-Up Evaluations After Non-Surgical Periodontal Treatment With Erbium:YAG Laser and Scaling and Root Planing

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Effect of smoking on the results of a chlorhexidine digluconate treatment extended up to 3 months after scaling and root planing-a pilot study

The aim of the study was to evaluate the impact of smoking on a prolongated chlorhexidine digluconate regimen after scaling and root planing. Forty-two smokers (test group) and 85 nonsmoking patients (control group) with generalized chronic periodontitis were examined for clinical attachment level (CAL), probing depth (PD), bleeding on probing (BoP), and Plaque Index (Pl) at baseline and after 1 and 3 months. During scaling and root planing, a 0.2% chlorhexidine digluconate solution and a 1% chlorhexidine digluconate gel were used. The subjects used a 0.2% chlorhexidine digluconate solution twice daily for 3 months. The Mann-Whitney U and Wilcoxon tests were used for statistical analysis. There were significant improvements of all studied variables after 1 and 3 months in both groups. After 3 months, the mean improvement in the test group was 1.62 mm for CAL, 2.85 mm for PD, and 48% for BoP; in the control group, the values were 2.18 mm for CAL, 2.81 mm for PD, and 47% for BoP. Only the maximum changes of CAL between 1 and 3 months (test group, 0.32 mm vs 0.69 mm in the control group) and PD (test group, 0.47 mm vs 0.76 mm in the control group) were significantly different between the groups (P < .05 and P = .05, respectively). The present data appear to suggest that the use of chlorhexidine digluconate twice daily during a period of 3 months following nonsurgical periodontal therapy may result in significant clinical improvements in smokers and nonsmokers.