Effect of acute testosterone on myocardial ischemia in men with coronary artery disease

The effect of acute testosterone administration on exercise-induced myocardial ischemia was assessed in 14 men with coronary artery disease and low plasma testosterone concentrations in a study of randomized, double-blind, crossover design. Testosterone increased time to 1-mm ST-segment depression compared with placebo by 66 (15 to 117) seconds (p = 0.016), suggesting a beneficial effect of testosterone on myocardial ischemia in these patients.

SERCA2A overexpression decreases the incidence of aftercontractions in adult rabbit ventricular myocytes

K. Davia, E. Bernobich, H. K. Ranu, F. del Monte, C. M. N. Terracciano, K. T. MacLeod, D. L. Adamson, B. Chaudhri, R. J. Hajjar and S. E. Harding. SERCA2a Overexpression Decreases the Incidence of Aftercontractions in Adult Rabbit Ventricular Myocytes. Journal of Molecular and Cellular Cardiology (2001) 33, 1005-1015. Slow relaxation and poor contractile response to increasing stimulation frequency in failing human heart have been strongly linked to a decrease in the activity of the sarcoplasmic reticulum (SR) Ca(2+)-ATPase (SERCA2a). Restoration of SERCA2a levels using gene transfer has beneficial effects on contractile function but, like beta -adrenoceptor stimulation, could potentially produce excess SR Ca(2+), arrhythmias and cell death. We have examined the effects of SERCA2a overexpression in adult rabbit cardiac myocytes, and compared changes in relaxation with those following beta -adrenoceptor stimulation. Myocytes were infected with an adenovirus carrying both SERCA2a and green fluorescent protein (GFP) for positive identification of infected cells. Myocyte survival was significantly enhanced in the infected cultures. There was a reduction in both time-to-peak contraction and time-to-50% relaxation (R50) 48 h after infection. Time-to-90% relaxation (R90) was particularly improved (non-infected 516+/-41 ms, AD.SERCA2a-GFP 230+/-23 ms, n=7 preparations, P<0.001). There was also a decreased incidence of aftercontractions in Ad.SERCA2a-GFP infected myocytes (21+/-5%v 41+/-4% in controls, P<0.01). This contrasts with beta -adrenoceptor stimulation, which reduced R50 but prolonged R90 by 158+/-76 ms (P<0.02, n=16). At higher stimulation frequencies (2-3 Hz) contraction amplitude and SR calcium content were increased and diastolic contracture was reduced following SERCA2a overexpression. Overall, increasing levels of SERCA2a resulted in an improvement in systolic and diastolic function and a reduction in cell death and arrhythmic aftercontractions. SERCA2a overexpression therefore lacks the detrimental effects associated with some other inotropic interventions.

Use of vasopressin after Caesarean section in idiopathic pulmonary arterial hypertension

We report the successful use of vasopressin in the management of hypotension in association with severe right ventricular (RV) failure in two patients with advanced idiopathic pulmonary arterial hypertension. Both patients were pregnant and developed systemic hypotension after delivery by Caesarean section. Placental autotransfusion and possibly oxytocin use were thought to be the major contributing factors in worsening RV function. After the use of vasopressin in both patients, cardiovascular variables improved without untoward effect on RV function, and provided rescue therapy for systemic hypotension in this setting. Vasopressin, a direct vasopressor acting via V1 receptors on the vascular endothelium, has been shown to cause pulmonary vasodilatation experimentally and in animal models of pulmonary hypertension. Its synthetic analogue, terlipressin, has been shown to reduce pulmonary vascular resistance in humans with cirrhosis. Vasopressin may therefore have differential effects on the pulmonary and systemic circulations, allowing systemic pressure to be supported without detrimental effects on the pulmonary circulation.

An impedance cardiography system: a new design

An IBM compatible impedance cardiac output monitoring prototype system has been developed for use at the bedside on patients in the ICU, CCU, ER, Cath. Lab, and OR, etc. This impedance cardiographic (ICG) system, whose operation is completely technician-free, provides a continuous display with digital results and four channel color waveforms on an Enhanced Graphics Display screen. The software is written in C language with several special segments in assembly code where speed is essential. In this prototype system, a real-time algorithm was introduced to modify the ensemble averaging technique so that it averages nonperiodic signals such as: ECG, dZ/dT, delta Z, etc. Also, a real-time algorithm was developed to adaptively detect R spikes from conventional ECG signals. A signal preprocessor was developed to process signals digitally before any further work is done. This procedure reduces muscle noise, 60 Hz interference, and ventilatory movement. A special digital filter was designed to cope with the cases in which pacemakers are used. A special algorithm was also developed to further reduce the ventilation artifacts so that a period of apnea is unnecessary during the performance of the measurements. An anatomically specified electrode configuration has been defined enabling precise and reproducible positioning of the electrodes--hopefully leading to electrode standardization. At the present time, this prototype system has been compared with standard hand calculation and correlated with the clinical "gold standard," the Swan-Ganz thermodilution cardiac output. Using 144 sets of data from 10 healthy volunteers, 4 critically ill patients, and 8 healthy exercising volunteers, calculations of cardiac output were made using our system and the standard hand calculation of stroke volume, based upon Kubicek's equation; there was a relatively high and stable correlation: r = 0.93, p less than 0.005 (healthy); r = 0.94, p less than 0.002 (ill), r = 0.95, p less than 0.002 (exercise). From 20 patients at two different hospitals all with Swan-Ganz catheters in their hearts, 65 correlation studies between our system and the standard thermodilution technique were performed; the results were encouraging in terms of accuracy and consistency (r1 = 0.84, p less than 0.01, n = 10 CCU patients), and (r2 = 0.93, p less than 0.01, n = ICU patients). These results along with a growing body of data from other investigators indicate that this noninvasive and technician-free system for measuring cardiac output could have a significant role in patient care.

Completeness of cause of injury coding in healthcare administrative databases in the United States, 2001

OBJECTIVES

To determine the completeness of external cause of injury coding (E-coding) within healthcare administrative databases in the United States and to identify factors that contribute to variations in E-code reporting across states.

DESIGN

Cross sectional analysis of the 2001 Healthcare Cost and Utilization Project (HCUP), including 33 State Inpatient Databases (SID), a Nationwide Inpatient Sample (NIS), and nine State Emergency Department Databases (SEDD). To assess state reporting practices, structured telephone interviews were conducted with the data organizations that participate in HCUP.

RESULTS

The percent of injury records with an injury E-code was 86% in HCUP's nationally representative database, the NIS. For the 33 states represented in the SID, completeness averaged 87%, with more than half of the states reporting E-codes on at least 90% of injuries. In the nine states also represented in the SEDD, completeness averaged 93%. Twenty two states had mandates for E-code reporting, but only eight had provisions for enforcing the mandates. These eight states had the highest rates of E-code completeness.

CONCLUSIONS

E-code reporting in administrative databases is relatively complete, but there is significant variation in completeness across the states. States with mandates for the collection of E-codes and with a mechanism to enforce those mandates had the highest rates of E-code reporting. Nine statewide ED data systems demonstrate consistently high E-coding completeness.

Endometriosis fertility index predicts live births following surgical resection of moderate and severe endometriosis

STUDY QUESTION

Can live birth be accurately predicted following surgical resection of moderate-severe (Stage III-IV) endometriosis?

SUMMARY ANSWER

Live births can accurately be predicted with the endometriosis fertility index (EFI), with adnexal function being the most important factor to predict non-assisted reproductive technology (non-ART) fertility or the requirement for ART (www.endometriosisefi.com).

WHAT IS KNOWN ALREADY

Fertility prognosis is important to many women with severe endometriosis. Controversy persists regarding optimal post-operative management to achieve pregnancy and the counselling of patients regarding duration of conventional treatments before undergoing ART. The EFI is reported to correlate with expectant management pregnancy rate, although external validation has been performed without specifically addressing fertility in women with moderate and severe endometriosis.

STUDY DESIGN, SIZE, DURATION

Retrospective cohort study of 279 women from September 2001 to June 2016.

PARTICIPANTS/MATERIALS, SETTINGS, METHODS

We included women undergoing laparoscopic resection of Stage III-IV endometriosis who attempted pregnancy post-operatively. The EFI was calculated based on detailed operative reports and surgical images. Fertility outcomes were obtained by direct patient contact. Kaplan-Meier model, log rank test and Cox regression were used for analyses.

MAIN RESULTS AND THE ROLE OF CHANCE

The follow-up rate was 84% with a mean duration of 4.1 years. A total of 147 women (63%) had a live birth following surgery, 94 of them (64%) without ART. The EFI was highly associated with live births (P < 0.001): for women with an EFI of 0-2 the estimated cumulative non-ART live birth rate at five years was 0% and steadily increased up to 91% with an EFI of 9-10, while the proportion of women who attempted ART and had a live birth, steadily increased from 38 to 71% among the same EFI strata (P = 0.1). A low least function score was the most significant predictor of failure (P = 0.003), followed by having had a previous resection (P = 0.019) or incomplete resection (P = 0.028), being older than 40 compared to <35 years of age (P = 0.027), and having leiomyomas (P = 0.037).

LIMITATIONS REASONS FOR CAUTION

The main limitation of this study is its retrospective design. Imprecision was higher with low EFI due to smaller sample size in this subgroup. Finally, the EFI is somewhat subjective and could be prone to intra- and inter-observer variations.

WIDER IMPLICATIONS OF THE FINDINGS

Women with a high EFI score have excellent fertility prognosis and may be advised to try to become pregnant with timed intercourse compared to women with a low score, for which prompt referral to ART seems more reasonable. Other prognostic factors can be used to guide the management of women with an intermediate EFI score. These data follow women over many years post-resection and represent longitudinal fertility data rarely demonstrated in such a cohort. The location and impact of lesions on the ability of the adnexa to function seems crucial for the fertility prognosis and should be further investigated.

STUDY FUNDING/COMPETING INTEREST(S)

This study was funded by the GRACE Research funds. S.M.-L. is the recipient of a Training Award from the Fonds de Recherche Quebec-Sante. D.A. is the primary author of the Endometriosis Fertility Index. All authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Esterified estrogens combined with methyltestosterone improve emotional well-being in postmenopausal women with chest pain and normal coronary angiograms

OBJECTIVE

The cardiac syndrome X is described as the triad of angina pectoris, a positive exercise test for myocardial ischemia, and angiographically smooth coronary arteries. Although syndrome X does not result in an increased risk of cardiovascular mortality, the symptoms are often troublesome and unresponsive to conventional antianginal therapy. The majority of patients are postmenopausal, and estrogen therapy can alleviate anginal symptoms. We investigated the effect of esterified estrogens combined with methyltestosterone (Estratest) on quality of life in postmenopausal women with syndrome X.

DESIGN

Patients were withdrawn from antianginal therapy. Sublingual nitrates were allowed for treatment of anginal episodes. Patients underwent treadmill testing, and quality of life was assessed by using the Short Form-36 and Cardiac Health Profile questionnaires after the women had received 8 weeks of Estratest or identical placebo in a randomized, double-blind, cross-over study.

RESULTS

Nineteen patients were randomized, and 16 patients completed the protocol. Plasma 17beta-estradiol concentrations were significantly increased by Estratest; however, total testosterone levels were not. The "emotional" score of the Cardiac Health Profile questionnaire was significantly improved after Estratest use compared with placebo (p = 0.03); however, there was no significant change in the Short Form-36 questionnaire for any variable. Estratest significantly increased systolic blood pressure and rate pressure product at rest but had no effect on exercise parameters. Time to onset of chest pain during exercise was also unaffected.

CONCLUSIONS

We have demonstrated a beneficial effect of Estratest on emotional well-being in postmenopausal women with cardiological syndrome X. There was no significant treatment effect on exercise parameters, including time to onset of chest pain.

A randomised trial of secondary prophylaxis using granulocyte colony-stimulating factor ('SPROG' trial) for maintaining dose intensity of standard adjuvant chemotherapy for breast cancer by the Anglo-Celtic Cooperative Group and NCRN

BACKGROUND

Guidelines on the use of haematopoietic colony-stimulating factors for patients having adjuvant chemotherapy for breast cancer are designed to minimise the risk of neutropaenic infection (Smith TJ, Khatcheressian J, Lyman GH et al. Update of recommendations for the use of white blood cell growth factors: an evidence-based clinical practice guideline. J Clin Oncol 2006; 3: 187-205; Aapro MS, Bohlius J, Cameron DA et al. Effect of primary prophylactic G-CSF use on systemic therapy administration for elderly breast cancer patients. Breast Cancer Res Treat 2011; 47: 8-32; Carlson RW, Allred DC, Anderson BO et al. Breast cancer. Clinical practice guidelines in oncology. J Natl Compr Canc Netw 2009; 7: 122-192). Non-randomised data suggest that the achievement of planned dose intensity (DI) may have an important effect on survival. This trial compared the effects of granulocyte colony-stimulating factor, GCSF, against standard management following a first neutropaenic event (NE) in achieving planned DI.

PATIENTS AND METHODS

Adult patients receiving adjuvant or neoadjuvant chemotherapy were randomised following a first NE, defined as hospitalisation due to neutropaenic fever, an absolute neutrophil count (ANC) ≤1.5 × 10(9)/l requiring treatment delay or dose reduction of 15% or more of planned dose. The study was initially planned to enrol 816 patients to detect a difference of 10%. This was difficult to achieve in the timeframe and the trial size was amended. Thus, 407 patients were randomly assigned to filgrastim for 7 days or pegfilgrastim versus standard care. The amended study was designed to have 80% power to detect an absolute difference of 14% of planned DI between the two groups.

RESULTS

Most regimens were anthracycline-based many of which included a sequential taxane and/or were in clinical trials. Around 82.7% had an NE in the first three cycles. A total of 401 had calculable relative dose intensity (RDI) data. A target of 85% planned RDI was achieved in only 50% of patients in the control arm compared with 75% in the GCSF arm (P < 0.0001). A secondary end point revealed a reduction in post-randomisation NEs, 65.7% controls versus 18.2% with GCSF.

CONCLUSIONS

Secondary intervention with GCSF showed a statistically significant improvement in the achievement of adequate RDI in non-intensive regimens. This may have important clinical implications for outcome.

Ultrasonically determined kidney transplant hypertrophy

Increased renal transplant size is a criterion of acute rejection. Statistically significant increases in ultrasonically measured kidney graft dimensions were demonstrated in 8 recipients of living related donor kidneys who never had rejection crises. After an average followup of 4.9 +/- 3.8 months (range 2 to 12 months), anteroposterior, cross-sectional and pole-to-pole measurements were increased by 0.75, 1.9 and 0.58 cm., respectively. Some increase in kidney graft size is normal and should not be confused with acute rejection.

Fetal proinsulin and birth weight

In both diabetic and non-diabetic pregnancies fetal insulin is an important anabolic hormone. Fetal hyperinsulinaemia is associated with accelerated fetal growth and increased birth weight. Insulin and C-peptide concentrations in both umbilical cord and amniotic fluid reflect fetal beta-cell secretion and are correlated with birth weight. In the present study umbilical venous proinsulin and insulin concentrations were measured in 54 term infants born to women with and without mild disturbances of glucose tolerance. Umbilical venous cord proinsulin, assayed using a highly specific immunoradiometric assay, was independently correlated with infant birth weight (Rho = 0.53, p < 0.0001) and birth percentile (Rho = 0.65, p < 0.0001). The correlation between birth weight and birth percentile weight with umbilical venous insulin, measured using a non-specific insulin assay, was lost following correction for the influence of proinsulin. Umbilical venous cord proinsulin appears to be a good indicator of fetal beta-cell activity, and in this study, a superior marker to insulin assayed using a non-specific insulin radioimmunoassay. The longer half-life of proinsulin compared with insulin may contribute to proinsulin being a more robust marker of overall fetal beta-cell activity than insulin.

Functional evidence for a cyclic-AMP related mechanism of action of the beta(2)-adrenoceptor in human ventricular myocytes

The human ventricle contains both beta(1)- and beta(1)-adrenoceptors (AR) and both have been shown to be present on a single myocyte. In animal ventricular myocardium there is evidence that beta(1)ARs increase cardiac contraction by non-cAMP-dependent mechanisms. We have used the anti-adrenergic effects of carbachol and the cAMP antagonist Rp -cAMPS to investigate the functional contribution of cAMP to beta(2)AR responses in human ventricular myocytes isolated from cardiac biopsies or explants. Concentration-response curves to isoproterenol (Iso) were constructed in the absence and presence of a beta(1)AR antagonist, CGP 207 12A (300 nmol/l) to determine the contribution of the beta(2)AR to contraction. The cells were rechallenged with sub-maximal dose of Iso under beta(2)AR-specific conditions and Rp -cAMPS (100-200 micromol/l) or carbachol (1-3 microm/l) added. Rp -cAMPS significantly decreased contraction amplitude (% shortening; Iso 7.1+/-0.7, Iso+Rp -cAMPS 3.5+/-0.5, n=7, P<0.001) though not completely to the baseline (2.2+/-0.6, n=7). Rechallenge with Iso alone reversed the effects of Rp -cAMPS, and subsequent addition of the beta(1)AR antagonist ICI 118,551 reduced the response to baseline (1.6+/-0.3, n=4) confirming beta(2)AR involvement. Similarly, carbachol decreased Iso-stimulated contraction from 7.5+/-1.2% to 3.2+/-0.9% (P<0.05, n=4), but not completely to basal levels (1.6+/-0.3%). These results provide functional evidence for a predominantly cAMP-mediated mechanism of contractile stimulation by beta(1)ARs in human ventricular myocardium, although a small contribution from a non-cAMP dependent pathway may occur.

Successful treatment of pulmonary lymphangiomyomatosis with oophorectomy and progesterone

A 35-yr-old woman, with profound dyspnea at rest and failure to thrive, asked to be evaluated at Stanford Medical Center. She requested a second opinion after entering death counseling in another institution because of an unrelenting, deteriorating course caused by pulmonary lymphangiomyomatosis. Her recurring right chylous pleural effusion was drained by chest tube, a LaVeen shunt was placed to decompress her severe chylous ascites, an oophorectomy was performed, large dose progesterone (medroxyprogesterone acetate) was initiated intramuscularly, and during her hospitalization she was fed by total parenteral nutrition. She was discharged mildly improved after 2 months. Now, 3 yr later, her pulmonary function tests and chest radiographs are improved, and she walks 2 miles per day and teaches school full time. Extensive hormonal analysis did not reveal an endocrinologic abnormality that could explain the pathophysiology of her disease. However, the patient had multiple human chorionic gonadotropin injections before becoming ill, as have a number of other patients who have developed this disease. This report is an example of successful treatment of severe pulmonary lymphangiomyomatosis.

The Lag Period in Auxin-Induced Expansion of Storage Tissue and Coleoptiles

Auxin caused a rapid shift in the point of incipient plasmolysis of a number: of tissues which showed auxin-induced expansion. The plasmolysis shift was not caused by dilution of the cell sap and might be due to an effect of auxin on the adhesion between cytoplasm and cell wall.

A sequential response to growth substances in coleoptiles from γ-irradiated wheat

γ-irradiated wheat seed (500 kr) produces coleoptiles that grow without cell division or DNA synthesis. Apart from an initial 24-hr delay in growth, intact γ coleoptiles have a pattern of cell elongation similar to normal coleoptiles. The elongation of coleoptiles excised at a size of 2 mm, when the cells are small and just prior to entering a rapid elongation phase, is promoted by kinetin and gibberellic acid (GA3). Elongation of coleoptiles excised at 8 mm, when the cells are larger and in the rapid elongation phase, is promoted by indoleacetic acid (IAA). This sequential response to growth substances in γ coleoptiles is remarkably similar to that in normal coleoptiles. The GA3 response in excised γ coleoptiles is not inhibited by FUDR, confirming that DNA synthesis is not required for GA3-induced elongation in γ coleoptiles.

Use of endoscopic biopsies and microelectrodes to study human gastric acid secretion in vitro

We have investigated the possibility of measuring acid secretion from human gastric mucosa in vitro as a potential pharmacological preparation. We used open-ended 10 microns-tip, lix-based glass microelectrodes to measure the pH of the mucus layer of gastric biopsies superfused with a HEPES buffered solution in an organ bath. With no drugs added the pH of the mucus layer of biopsies from the body of the stomach stayed constant but the pH of antral biopsies fell slightly by a median of 0.12 pH units over 80 min (P < 0.05). Stimulation of the biopsies with 1-100 microM histamine produced a dose-dependent decrease in pH which was significantly greater in biopsies from the gastric body than from the antrum. 500 pM pentagastrin produced a median fall in pH of 1.20 (P < 0.01) which was prevented by the prior addition of 100 microM omeprazole or 10 microM ranitidine. Omeprazole or ranitidine alone produced slight rises in the median pH of 0.47 (P < 0.05) and 0.26 (P < 0.05) units respectively. Those biopsies which were infected with Helicobacter pylori had a slightly elevated initial pH of about 0.2 of a pH unit (P < 0.05). This novel system provides a means to study human gastric acid secretion in vitro and may be valuable in the testing of new drugs on the stomach.

Direct current cardioversion in pregnancy: a multicentre study

OBJECTIVE

Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld.

DESIGN

Retrospective cohort study.

SETTING

Seventeen UK and Ireland specialist maternity centres.

SAMPLE

Twenty-seven pregnant women requiring DCCV in pregnancy.

MAIN OUTCOME MEASURES

Maternal and fetal outcomes following DCCV.

RESULTS

Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV.

CONCLUSIONS

Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Acquisition of resistance to the bont tick Amblyomma hebraeum (Acarina: Ixodidae) by goats

Goats acquired resistance to larvae of Amblyomma hebraeum following three repeated infestations. Resistance was associated with immediate Type I hypersensitivity reactions following intradermal skin tests using crude egg extracts. In a separate experiment, the inoculation of tick-naive goats with extracts of the larvae of A. hebraeum failed to induce observable effects on feeding larvae despite the development of anti-larval antibodies.

Abstract P6-21-01: Xentuzumab (BI 836845), an insulin-like growth factor (IGF)-neutralizing antibody (Ab), combined with exemestane and everolimus in hormone receptor-positive (HR+) locally advanced/metastatic breast cancer (LA/mBC): Randomized phase 2 results

Background:

Xentuzumab (Xen), an IGF-1/-2-neutralizing Ab, binds IGF-1 and IGF-2, inhibits their growth-promoting signaling, and suppresses AKT activation by everolimus (Ev). This Phase 1b/2 trial evaluates Xen in combination with Ev and exemestane (Ex) in HR+/HER2− LA/mBC.

Methods:

The two-arm, open-label, randomized Phase 2 part enrolled female patients (pts) with HR+/HER2− LA/mBC not amenable to curative therapy and refractory to nonsteroidal aromatase inhibitors. Pts were randomized (1:1) to: oral Ev (10 mg/d) + Ex (25 mg/d); or Xen (1000 mg/wk iv) + Ev (10 mg/d) + Ex (25 mg/d). Randomization was stratified by visceral metastases (VM; Y vs N). Treatment continued in 28-day cycles until progression, intolerable adverse events (AEs) or other reasons for discontinuation. Primary endpoint was progression-free survival (PFS), with an interim futility analysis incorporated in the study design.

Results:

Following the results of the interim analysis, the Data Monitoring Committee (DMC) advised early termination of the trial and discontinuation of Xen treatment. Thus, Xen treatment exposure time and time-to-event data for the Xen+Ev+Ex arm are limited. Of the 139 women treated (Xen+Ev+Ex 70; Ev+Ex 69), 77% had VM. Median PFS was not significantly different between arms (Xen+Ev+Ex vs Ev+Ex, 7.3 vs 5.6 months; HR [95% CI] 0.97 [0.57–1.65]; p=0.91). In a pre-specified subgroup of pts without VM, Xen+Ev+Ex showed favorable PFS vs Ev+Ex (HR 0.21 [0.05–0.98]; Pint=0.0141). Pint values &lt;0.05 were also observed for ad hoc subgroups: measurable disease at baseline; bone-only metastases. Rates of total AEs/grade ≥3 AEs/drug-related AEs were similar between arms (Xen+Ev+Ex, 100/60/96%; Ev+Ex, 99/58/96%). The most common AEs overall were diarrhea (44 vs 33%), mucosal inflammation (39 vs 32%), rash (34 vs 33%) and stomatitis (34 vs 38%); most were grade 1/2. 6% of pts in the Xen+Ev+Ex arm discontinued Xen due to AEs. Ev/Ex discontinuations (Xen+Ev+Ex vs Ev+Ex) occurred in 13/6% vs 23/6%; 1 pt each in the Xen+Ev+Ex arm died from pneumonitis and liver injury and 1 pt each in the Ev+Ex arm died from Burkitt's lymphoma, acute kidney injury and metastases to the peritoneum.

Conclusion:

In the overall population, PFS did not improve with the addition of Xen to Ev+Ex and the trial was therefore discontinued early. Nevertheless, a favorable signal was observed in the pre-specified subgroup of pts without VM when treated with Xen+Ev+Ex, which warrants additional investigation. The safety profile was comparable between arms.

Citation Format: Crown J, Sablin M-P, Cortés J, Bergh J, Im S-A, Lu Y-S, Martínez N, Neven P, Lee KS, Morales S, Pérez-Fidalgo JA, Adamson D, Goncalves A, Prat A, Jerusalem G, Schlieker L, Espadero R-M, Bogenrieder T, Chin-Lun Huang D, Schmid P. Xentuzumab (BI 836845), an insulin-like growth factor (IGF)-neutralizing antibody (Ab), combined with exemestane and everolimus in hormone receptor-positive (HR+) locally advanced/metastatic breast cancer (LA/mBC): Randomized phase 2 results [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-21-01.

The importance of fixed costs in animal health systems

In this paper, the authors detail the structure and optimal management of health systems as influenced by the presence and level of fixed costs. Unlike variable costs, fixed costs cannot be altered, and are thus independent of the level of veterinary activity in the short run. Their importance is illustrated by using both single-period and multi-period models. It is shown that multi-stage veterinary decision-making can often be envisaged as a sequence of fixed-cost problems. In general, it becomes clear that, the higher the fixed costs, the greater the net benefit of veterinary activity must be, if such activity is to be economic. The authors also assess the extent to which it pays to reduce fixed costs and to try to compensate for this by increasing variable costs. Fixed costs have major implications for the industrial structure of the animal health products industry and for the structure of the private veterinary services industry. In the former, they favour market concentration and specialisation in the supply of products. In the latter, they foster increased specialisation. While cooperation by individual farmers may help to reduce their individual fixed costs, the organisational difficulties and costs involved in achieving this cooperation can be formidable. In such cases, the only solution is government provision of veterinary services. Moreover, international cooperation may be called for. Fixed costs also influence the nature of the provision of veterinary education.

Rp-cAMPS has no effect on adenosine A1 receptors in guinea-pig cardiomyocytes

Rp-cAMPS, a protein kinase A inhibitor, is used in the investigation of the cAMP-dependent systems. A report by Musgrave et al. has suggested that Rp-cAMPS may also act on adenosine receptors. To determine whether this occurs in guinea-pig ventricular myocytes, Rp-cAMPS was applied in the presence and absence of DCPCX, an adenosine A receptor antagonist. The isoprenaline-induced response was significantly decreased by Rp-cAMPS and the effect was not altered by the presence of DCPCX. Therefore Rp-cAMPS has no effect on cell contraction via adenosine A1 receptors and can reliably be used to investigate cyclic AMP-dependent systems in isolated cardiac myocytes.

The pros and cons of animal health harmonisation

It has been argued that the global harmonisation of animal health procedures, regulations and responses will improve animal health and provide economic benefits. Harmonisation of regulations can be driven by trade reform, such as multilateral or bilateral agreements, or as a response to private quality assurance programmes. At an international level, trade reform is currently focused on reducing the costs of trading between countries. To achieve this, bilateral agreements, where possible, are harmonising regulations throughout all sectors of the economy. However, as with any new developments, there are both positive and negative outcomes that should be explored to understand the net effect of these changes on animal health, the economy and society. In this article, the authors debate the economic foundations of harmonisation, explore alternative methods to achieve it, and discuss its pros and cons to more fully understand the opportunity costs from countries adopting the same level of risk to animal health.

The effect of altering airway tone on the sensitivity of the cough reflex in normal volunteers

Cough is frequently the presenting symptom of bronchial asthma, although cough can result from a wide variety of other respiratory disease. Treatment of chronic cough has proved extremely difficult. It has been suggested that treatment with bronchodilators may reduce the symptom of cough. In this study the effect of altering airway tone on the sensitivity of the cough reflex was determined. Twelve normal, healthy volunteers took part. The number of coughs following inhalations of single breaths of doubling concentrations of capsaicin (1.95-500 microM) was recorded before and after doses of salbutamol, methacholine and saline which altered forced expiratory volume in one second (FEV1) by 6.2 +/- 2.6%, -8.8 +/- 3.2% and -0.18 +/- 1.38%, respectively. In a further study the cough response was recorded before and after doses of salbutamol and ipratropium bromide, both of which reduced baseline respiratory resistance and resistance measured after capsaicin. Ipratropium bromide, salbutamol and methacholine, despite having significant effects on airway tone, did not change the sensitivity of capsaicin-induced cough. Thus, if bronchodilator drugs are antitussive in non-asthmatic patients, then this is unlikely to be due to an effect on the sensitivity of the cough reflex.