Abstract P3-06-33: Effect of trastuzumab-based therapy on serum activin A levels in metastatic breast cancer

Background: Only half of HER2-positive metastatic breast cancer patients will respond to first-line trastuzumab-containing therapy, but of these, most will progress within a year. Trastuzumab resistance remains a continuing clinical problem, and better biomarkers and therapies are needed. Activin A is a TGF-beta superfamily member that regulates cell proliferation, apoptosis, differentiation, and immune response. We have previously reported that higher pretreatment serum activin A level predicted reduced progression-free survival (PFS) and overall survival (OS) to first-line trastuzumab, independent of age, line of therapy, CA 15–3, and hormone receptor status (ASCO Ab ID 607, 2012).

Methods: Serum activin A was measured using ELISA (R&D Systems, Minneapolis, MN) in 60 metastatic breast cancer patients before and 1 month after starting first-line trastuzumab-containing therapy. PFS and OS were analyzed using the Kaplan-Meier method and Cox modeling with both continuous and dichotomous (median) serum activin A analyses.

Results: Pretreatment serum activin A levels had a median of 629 pg/mL and an inter-quartile range of 406 to 1791 pg/mL. There was no significant change in activin A levels between pretreatment and one month after starting trastuzumab therapy. Median activin A level at one month was 655 pg/mL, with an inter-quartile range of 405 to 1517 pg/mL. 83% of patients who had low pretreatment activin A levels (below median) had low activin levels at one month, and 83% who had high activin levels (above median) at baseline had high activin A levels at one month. Patients who had high activin A levels at baseline and one month had the worst outcome for both PFS (HR 3.9; median 134 days vs.776 days; p < 0.0001) and OS (HR 6.7; p < 0.0001) when compared to patients with low activin A levels which remained low at one month.

Conclusions: Higher pretreatment and 1 month post-treatment serum activin A predicted for reduced PFS and overall survival in metastatic breast cancer patients treated with first-line trastuzumab-containing therapy. Trastuzumab-based therapy did not have a significant effect on activin A levels at one month. Patients with persistently high activin A levels had significantly worsened outcomes compared to those with low activin A levels. Serum activin A deserves further study to select patients most likely to respond to activin A-targeted therapy.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P3-06-33.

Abstract P5-20-03: A phase 2, double-blind, randomized, placebo-controlled, dose-finding study of sotatercept for the treatment of patients with chemotherapy-induced anemia and metastatic breast cancer

Background: Sotatercept is a recombinant activin receptor IIA (ActRIIA) ligand trap and is comprised of the extracellular domain of ActRIIA linked to the Fc domain of human IgG1 (ActRIIA-IgG1). Results of preclinical and early clinical studies provide evidence that sotatercept increases the concentration of hemoglobin (Hb) in blood and may constitute a novel treatment for chemotherapy-induced anemia (CIA), a condition that results in significant morbidity.

Methods: This study evaluated the safety of, and hematopoietic response to, sotatercept in patients with CIA and metastatic breast cancer (MBC). Response was defined as increase in Hb ≥1 g/dL for ≥28 consecutive days during treatment or ≤2 months following the last dose, in the absence of red blood cell (RBC) transfusion or treatment with an erythropoiesis stimulating agent (ESA). If RBC transfusion or treatment with an ESA was required, no Hb measurements within 28 days of the RBC transfusion or administration of ESA were used to determine the Hb response. Subjects were randomized to subcutaneous injection of sotatercept (0.1, 0.3, or 0.5 mg/kg) or placebo and were treated on day 1 of each of four 28-day cycles.

Results: Thirty (30) subjects were enrolled and treated (5 placebo, 25 sotatercept). Increases in mean Hb in the 0.3 and 0.5 mg/kg groups were greater than in 0.1 mg/kg and placebo groups. Increases peaked approximately 15 days following treatment and declined over the remaining interval between treatments. Among 23 subjects with confirmed CIA and administered ≥1 dose and followed for ≥57 days (per-protocol analysis), 5/18 (28%) administered sotatercept responded (0/5 [0%] at 0.1 mg/kg; 3/9 [33%] at 0.3 mg/kg; 2/4 [50%] at 0.5 mg/kg) vs 1/5 [20%] administered placebo. Among 13 nonresponders administered sotatercept, 5 (39%) experienced ≥1 dose interruption/reduction, as per protocol, due to elevated Hb. The incidence of adverse events (AEs) was consistent with that reported in patients with MBC. No dose-limiting or dose-related toxicity was observed.

Conclusions: Sotatercept demonstrated dose-dependent hematopoietic activity in subjects with CIA and MBC. The safety findings were generally consistent with the known safety profile of sotatercept. These data suggest that a greater dose of sotatercept or a dose interval <28 days might result in a more sustained, and greater rate of, hematopoietic response.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P5-20-03.

Clinical studies with tumour necrosis factor

The mechanism of tumour necrosis factor (TNF) cytotoxicity remains unknown. The in vivo antitumour effects of TNF may be related to direct cytotoxicity, immunomodulatory effects or endothelial effects on tumour vasculature. Phase I and early Phase II clinical trials of human recombinant TNF are under way in Japan, the USA, the UK and Germany. The maximum Phase II dose for TNF has not been established. The clinical toxicity of TNF is generally similar to that of other biological agents. Systemic toxicity, including fever, chills, anorexia and nausea, has been seen in most patients treated with TNF and has not been clearly related to dose. Other toxicities have included liver function abnormalities, hypotension, transient neurological changes and haematological abnormalities. Few clinical responses have been reported but organized Phase II testing remains to be completed. Combination trials with interferons have recently been initiated. Phase II efficacy studies of TNF as a single agent and in combination are needed for an assessment of the value of this agent in cancer therapy.

Two phase I studies of low dose recombinant human IL-12 with Melan-A and influenza peptides in subjects with advanced malignant melanoma

Preclinical studies have shown that low dose IL-12 can potentiate cytotoxic lymphocyte responses. Since previous trials have demonstrated significant toxicity from high dose recombinant human IL-12 (rhIL-12), we sought to determine an optimal biological dose for rhIL-12 at lower doses when combined with peptide antigens. Two studies were undertaken. The rhIL-12 was administered at doses of 0 (placebo), 10, 30 and 100 ng/kg, subcutaneously in one study and intravenously in the other. Apart from IL-12 dosing, the studies were identical. Subjects had evaluable stage III or IV melanoma which expressed Melan-A by RT-PCR or immunohistochemistry. Melan-A (26-35) (EAAGIGILTV) and influenza matrix (58-66) (GILGFVFTL) peptides were administered intradermally on weeks 1, 2, 3, 4 and 9. Twenty-eight subjects were enrolled, of whom 24 were evaluable for clinical and immunological responses. Therapy was well tolerated, the main adverse event being influenza-like symptoms. Immunological monitoring included the evaluation of cutaneous reactions and assays for antigen-specific T-cells. Clinical responses included a complete response in a subject with small volume subcutaneous disease, a partial response in a subject with hepatic metastases, and mixed responses in pulmonary, pleural and nodal disease. Biopsies of accessible tumors showed infiltration with CD4+ and CD8+ lymphocytes capable of lysing Melan-A peptide-pulsed targets in vitro. No clear dose-dependent effect of rhIL-12 could be determined. The rhIL-12 given either s.c. or i.v. was well tolerated at doses of 10-100 ng/kg. Clinical and immunological activity has been observed in this study where peptides were administered either with or without low dose rhIL-12.

Chemical orientation of brown bullheads, Ameiurus nebulosus, under different flow conditions

The spatiotemporal information in chemical signals provides critical information for organisms during chemical orientation. Information in chemical signals is influenced by the hydrodynamic conditions of the environment. Hydrodynamically distinct environments will contain different types of information, which will influence how organisms orient. This study was designed to examine how the orientation behavior of the brown bullhead (Ameiurus nebulosus) is influenced by flow regime. The experiment was conducted in a flume under two different flow conditions. Treatments consisted of control (no odor) and plain gelatin (odor). Percent success, swimming speed, turning angle, heading angle, heading angle upstream, and net-to-gross ratio were analyzed. Brown bullheads were 100% successful in finding the odor source under no flow and 57% successful in flow. Bullheads swam differently in the no-flow condition when compared to the flow condition. Since, these fish did not orient the same under different flow conditions, it appears that hydrodynamics plays a role in shaping their behavior.

The role for interleukin-12 therapy of cutaneous T cell lymphoma

Recent phase I and phase II trials using recombinant human interleukin-12 (rhIL-12) for cutaneous T cell lymphoma (CTCL) have been completed. Observations on 32 evaluable patients revealed an overall response rate approaching 50 percent. Biopsy of regressing lesions revealed an increase in numbers of CD8+ and/or TIA-1+ T cells. These results suggest that rhIL-12 may induce lesion regression by augmenting antitumor cytotoxic T cell responses. Future trials will be focused on strategies for further immune enhancement by the concomitant use of additional immune augmenting cytokines with rhIL-12.

Efficacy and safety of gemtuzumab ozogamicin in patients with CD33-positive acute myeloid leukemia in first relapse

PURPOSE

Three open-label, multicenter trials were conducted to evaluate the efficacy and safety of single-agent Mylotarg (gemtuzumab ozogamicin; CMA-676; Wyeth Laboratories, Philadelphia, PA), an antibody-targeted chemotherapy agent, in patients with CD33-positive acute myeloid leukemia (AML) in untreated first relapse.

PATIENTS AND METHODS

The study population comprised 142 patients with AML in first relapse with no history of an antecedent hematologic disorder and a median age of 61 years. All patients received Mylotarg as a 2-hour intravenous infusion, at a dose of 9 mg/m(2), at 2-week intervals for two doses. Patients were evaluated for remission, survival, and treatment-emergent adverse events.

RESULTS

Thirty percent of patients treated with Mylotarg obtained remission as characterized by 5% or less blasts in the marrow, recovery of neutrophils to at least 1,500/microL, and RBC and platelet transfusion independence. Although patients treated with Mylotarg had relatively high incidences of myelosuppression, grade 3 or 4 hyperbilirubinemia (23%), and elevated hepatic transaminase levels (17%), the incidences of grade 3 or 4 mucositis (4%) and infections (28%) were relatively low. There was a low incidence of severe nausea and vomiting (11%) and no treatment-related cardiotoxicity, cerebellar toxicity, or alopecia. Many patients received Mylotarg on an outpatient basis (38% and 41% of patients for the first and second doses, respectively). Among the 142 patients, the median total duration of hospitalization was 24 days; 16% of patients required 7 days of hospitalization or less.

CONCLUSION

Administration of the antibody-targeted chemotherapy agent Mylotarg to patients with CD33-positive AML in first relapse induces complete remissions with what appears to be a favorable safety profile.

Bilateral eventration of the diaphragm with perforated gastric volvulus in an adolescent

Bilateral congenital eventration of the diaphragm almost uniformly presents in infancy with respiratory compromise and is associated with a high mortality rate. Delayed presentation of diaphragmatic eventration in older children and adults may be associated with acute gastric volvulus. Thus, any patient with abdominal pain, vomiting, or nonspecific gastrointestinal symptoms in association with abnormal diaphragmatic findings on chest x-ray should undergo further diagnostic workup with upper gastrointestinal series or computed tomography (CT) scan. Treatment of gastric volvulus requires immediate surgical repair to prevent subsequent necrosis and perforation. The authors describe a case report of bilateral congenital diaphragmatic eventration complicated by a perforated gastric volvulus in a 13-year-old boy. Emergent reduction of the volvulus, closure of the perforated stomach, plication of the diaphragm, and placement of gastrostomy was performed successfully.

Interleukin-12 therapy of cutaneous T-cell lymphoma induces lesion regression and cytotoxic T-cell responses

Progression of cutaneous T-cell lymphoma (CTCL) is associated with profound defects in cell-mediated immunity and depressed production of cytokines, which support cell-mediated immunity. Because we have observed marked defects in interleukin-12 (IL-12) production in CTCL and because IL-12 is critical for antitumor cytotoxic T-cell responses, we initiated a phase I dose escalation trial with recombinant human IL-12 (rhIL-12) where patients received either 50, 100, or 300 ng/kg rhIL-12 twice weekly subcutaneously or intralesionally for up to 24 weeks. Ten patients were entered: 5 with extensive plaque, 3 with Sezary syndrome, and 2 with extensive tumors with large cell transformation. One patient with Sezary syndrome dropped out after 1 week for personal reasons. Subcutaneous dosing resulted in complete responses (CR) in 2 of 5 plaque and partial responses (PR) in 2 of 5 plaque, and 1 of 2 Sezary syndrome (overall response rate CR+PR 5 of 9, 56%). A minor response also occurred in 1 of 5 plaque patients. Intralesional dosing resulted in individual tumor regression in 2 of 2 patients. Biopsy of regressing lesions showed a significant decrease in the density of the infiltrate in all cases and complete resolution of the infiltrate among those with clinical lesion resolution. An increase in numbers of CD8-positive and/or TIA-1-positive T cells were observed on immunohistochemical analysis of skin biopsy specimens obtained from regressing skin lesions. Adverse effects of rhIL-12 on this regimen were minor and limited and included low-grade fever and headache. One patient discontinued rhIL-12 at week 6 because of depression. These results suggest that rhIL-12 may augment antitumor cytotoxic T-cell responses and may represent a potent and well-tolerated therapeutic agent for CTCL.

Immunological effects of interleukin 12 administered by bolus intravenous injection to patients with cancer

The immunological effects of recombinant human interleukin 12 (rhIL-12) administration were examined during the conduct of a Phase I clinical trial. Forty patients with advanced cancer received bolus i.v. injections of rhIL-12 in doses ranging between 3 and 1000 ng/kg. Dose-dependent increases in serum IFN-gamma levels were seen during rhIL-12 therapy. Significant lymphopenia was observed 24 h after single i.v. injections of rhIL-12 at each dose level. The degree of lymphopenia was dose dependent, and a plateau effect was seen with rhIL-12 doses of 100 ng/kg and higher. Lymphocyte counts reached nadir levels at approximately 10 h after rhIL-12 injection and returned to baseline within 14 days postinjection. Rebound lymphocytosis, as seen after interleukin 2 therapy, was not observed after recovery from rhIL-12-induced lymphopenia. rhIL-12-induced lymphopenia involved all major lymphocyte subsets, although natural killer (NK) cell numbers were the most profoundly affected, and CD4 T-cell numbers were the least affected. CD2, LFA-1, and CD56 were transiently up-regulated on the surface of NK cells exposed to rhIL-12 in vivo. Peripheral blood mononuclear cells obtained from cancer patients before rhIL-12 therapy exhibited defective NK cell cytotoxicity and T-cell-proliferative responses. Peripheral blood mononuclear cells obtained after lymphocyte recovery following the administration of a single 500 ng/kg dose of rhIL-12 displayed augmented NK cell cytolytic activity in four of four patients tested and enhanced T-cell proliferation in three of four patients tested. These studies confirm that doses of rhIL-12 resulting in significant immunological activity can be administered with acceptable toxicity to cancer patients. Furthermore, rhIL-12 therapy can reverse defects in NK cell and T-cell function that are associated with advanced cancer in humans.

Effects of single-dose interleukin-12 exposure on interleukin-12-associated toxicity and interferon-gamma production

Interleukin-12 (IL-12) is a key regulator of cell-mediated immunity that has therapeutic potential in cancer and infectious disease. In a previous Phase 1 dose escalation study of a single test dose of recombinant human IL-12 (rhIL-12) followed 14 days later by cycles of five consecutive daily intravenous injections every 3 weeks, we showed that a dose level up to 500 ng/kg could be administered with acceptable levels of safety. Based on these results, a Phase 2 study was conducted. In the Phase 2 study, however, administration of rhIL-12 at this same dose level resulted in severe toxicities with some patients unable to tolerate more than two successive doses. Of the 17 patients receiving rhIL-12 in the Phase 2 study, 12 patients were hospitalized and two patients died. A thorough scientific investigation to determine the cause of this unexpected toxicity failed to identify any difference in the drug products used or the patient populations enrolled in the Phase 1 and Phase 2 studies that could have accounted for the profound difference in toxicity. The focus of the investigation therefore shifted to the schedule of rhIL-12 administration. We determined that a single injection of rhIL-12 2 weeks before consecutive dosing included in the Phase 1 study, but not in the schedule of administration in the Phase 2 study, has a profound abrogating effect on IL-12-induced interferon-gamma (IFN-gamma) production and toxicity. This observation of schedule-dependent toxicity of IL-12 has been verified in mice, as well as nonhuman primates. In this regard, a single injection of IL-12 before consecutive daily dosing protected mice and cynomolgus monkeys from acute toxicity including mortality and was associated with an attenuated IFN-gamma response. Because of this unique biologic response, careful attention to the schedule of administration is required to assure safe and effective clinical development of this highly promising cytokine.

Intraventricular hemorrhage and fetal heart rate in very low birth weight infants

OBJECTIVE

This study was designed to investigate the relationship between fetal heart rate patterns before delivery and periventricular-intraventricular hemorrhage in the very low birth weight infant.

STUDY DESIGN

The last 30 minutes of electronic fetal heart rate data preceding delivery were analyzed for 84 singleton infants weighing between 700 and 1500 gm. All these infants received serial cranial ultrasonographic examinations commencing within 24 to 48 hours of birth.

RESULTS

Thirty-three fetuses had normal heart rate patterns, and 51 had fetal heart rate abnormalities. Periventricular-intraventricular hemorrhage was not associated with fetal heart rate abnormalities. Univariate and multivariate regression analysis demonstrated that only gestational age < 28 weeks was a significant contributing factor to periventricular-intraventricular hemorrhage (odds ratio 2.2, 95% confidence interval [CI], 1.0 to 4.8).

CONCLUSION

Fetal heart rate patterns immediately preceding delivery are not predictive of periventricular-intraventricular hemorrhage in the very low birth weight infant.

Quality control for DNA contamination in laboratories using PCR-based class II HLA typing methods

Quality control (QC) in laboratories performing molecular histocompatibility class II typing often includes a polymerase chain reaction (PCR) approach for monitoring DNA contamination. An oligonucleotide primer set was designed, (RBQBf/RBQBr), which is specific for nonpolymorphic regions of the DR-B, DQ-B, and DP-B consensus sequences with an expected PCR product size of 81 bp. RBQBf/RBQBr detected genomic DNA from reference cell lines LWAGS and BM21 (50 to 100 picograms) as well as DR-B, DP-B, and DQ-B amplicon (1 copy). Additionally, RBQBf/RBQBr detected SSP products from routine DR-B and DQ-B typings. Validation studies employing controlled DNA contamination of laboratory surfaces revealed that increasing amounts of wipe test samples (5% to 20% v/v) were inhibitory to the wipe test PCR, whereas lower amounts (1% to 2%), or alternatively, a diluted wipe test sample, increased the sensitivity of the test and optimized the results. Collectively, this study describes a primer set, RBQBf/RBQBr, which detects both genomic DNA and DR-B, DQ-B, or DP-B amplicon and furthermore illustrates the necessity of routine testing for potential inhibitory factors that may be introduced into the wipe test PCR.

Phase I evaluation of intravenous recombinant human interleukin 12 in patients with advanced malignancies

A Phase I dose escalation trial of i.v. administered recombinant human interleukin 12 (rhIL-12) was performed to determine its toxicity, maximum tolerated dose (MTD), pharmacokinetics, and biological and potential antineoplastic effects. Cohorts of four to six patients with advanced cancer, Karnofsky performance >/=70%, and normal organ function received escalating doses (3-1000 ng/kg/day) of rhIL-12 (Genetics Institute, Inc.) by bolus i.v. injection once as an inpatient and then, after a 2-week rest period, once daily for five days every 3 weeks as an outpatient. Therapy was withheld for grade 3 toxicity (grade 4 hyperbilirubinemia or neutropenia), and dose escalation was halted if three of six patients experienced a dose-limiting toxicity (DLT). After establishment of the MTD, eight more patients were enrolled to further assess the safety, pharmacokinetics, and immunobiology of this dose. Forty patients were enrolled, including 20 with renal cancer, 12 with melanoma, and 5 with colon cancer; 25 patients had received prior systemic therapy. Common toxicities included fever/chills, fatigue, nausea, vomiting, and headache. Fever was first observed at the 3 ng/kg dose level, typically occurred 8-12 h after rhIL-12 administration, and was incompletely suppressed with nonsteroidal anti-inflammatory drugs. Routine laboratory changes included anemia, neutropenia, lymphopenia, hyperglycemia, thrombocytopenia, and hypoalbuminemia. DLTs included oral stomatitis and liver function test abnormalities, predominantly elevated transaminases, which occurred in three of four patients at the 1000 ng/kg dose level. The 500 ng/kg dose level was determined to be the MTD. This dose, administered by this schedule, was associated with asymptomatic hepatic function test abnormalities in three patients and an onstudy death due to Clostridia perfringens septicemia but was otherwise well tolerated by the 14 patients treated in the dose escalation and safety phases. The T1/2 elimination of rhIL-12 was calculated to be 5.3-9.6 h. Biological effects included dose-dependent increases in circulating IFN-gamma, which exhibited attenuation with subsequent cycles. Serum neopterin rose in a reproducible fashion regardless of dose or cycle. Tumor necrosis factor alpha was not detected by ELISA. One of 40 patients developed a low titer antibody to rhIL-12. Lymphopenia was observed at all dose levels, with recovery occurring within several days of completing treatment without rebound lymphocytosis. There was one partial response (renal cell cancer) and one transient complete response (melanoma), both in previously untreated patients. Four additional patients received all proposed treatment without disease progression. rhIL-12 administered according to this schedule is biologically and clinically active at doses tolerable by most patients in an outpatient setting. Nonetheless, additional Phase I studies examining different schedules and the mechanisms of the specific DLTs are indicated before proceeding to Phase II testing.

Phase I study of continuous-infusion recombinant macrophage colony-stimulating factor in patients with metastatic melanoma

Macrophage colony-stimulating factor (M-CSF) is a lineage-specific, homodimeric growth factor that supports the proliferation and maturation of bone marrow progenitors and the survival and function of mononuclear/macrophage cells. In vitro studies have demonstrated antitumor activity of macrophage colony-stimulating factor-treated monocytes against melanoma target cells. A Phase I study was conducted by administering the glycosylated form of the protein to patients with metastatic melanoma as two 7-day continuous i.v. infusions separated by a 2-week rest. Cohorts of three patients per dose level received escalating doses of 10-160 microgram/kg/day. Safety, clinical, and biological effects were evaluated. The infusions were well tolerated with occasional maximum grade 2 nonhematological toxicity. Rapidly reversible thrombocytopenia was the major hematological adverse effect. Its etiology may in part be explained by proliferation and activation of monocyte/macrophage cells in bone marrow samples. Evidence for a biological effect on tumors was suggested by the delayed, complete disappearance of multiple lesions in one patient and a decrease in the size of one marker lesion in a second patient with a mixed response. Fasting serum cholesterol levels decreased during the infusions and may represent an additional therapeutic application for this growth factor.

Randomized investigation of antimicrobials for the prevention of preterm birth

OBJECTIVE

Occult amniotic fluid infection has emerged as a possible cause of many heretofore unexplained preterm births. We sought to determine whether antimicrobial therapy is effective in preventing preterm delivery.

STUDY DESIGN

A double-blind, placebo-controlled, randomized trial was conducted to study the efficacy of ampicillin-sulbactam and amoxicillin-clavulanic acid in women hospitalized for preterm labor between 24 and 34 weeks' gestation. During this investigation no tocolytics or steroids were used.

RESULTS

Thirty-nine women with preterm labor received antimicrobial therapy and 39 received placebos. The mean gestational ages at study entry were 29.8 +/- 0.4 weeks (SEM) and 30.6 +/- 0.3 weeks in the antimicrobial and placebo groups, respectively (not significant). Similarly, the mean gestational ages at delivery were 34.2 +/- 0.7 and 34.1 +/- 0.6 weeks, respectively (not significant). Other index values of pregnancy outcome, for example, birth weight, neonatal morbidity, and prenatal death, were not significantly improved by antimicrobial therapy given to the mother in preterm labor.

CONCLUSION

We find that antimicrobial therapy given to women in preterm labor is ineffective in the prevention of preterm birth.

Association between workers' compensation and outcome following multidisciplinary treatment for chronic pain: roles of mediators and moderators

OBJECTIVE

To determine whether the tendency for chronic pain patients who receive Workers' Compensation to show a poorer response than non-compensated patients to pain treatment can be accounted for by mediating factors; to assess whether moderating factors can distinguish subgroups of Workers' Compensation recipients who react very poorly to treatment from compensated patients who respond well.

DESIGN

Outcome study based on archives.

SETTING

Multidisciplinary pain treatment center.

PATIENTS

Of 214 patients, 158 had complete data.

OUTCOME MEASURE

Blind ratings of narrative discharge summaries written by the Pain Treatment Center staff.

RESULTS

A significant negative relationship between receiving Workers' Compensation and outcome was mediated by a pessimistic belief in the ability to return to former occupation. Moderator effects showed that Workers' Compensation recipients with high initial pain and a history of pain-related surgery fared worse than any other group. Moreover, Workers' Compensation recipients not characterized by high pain and a history of surgery responded as well as noncompensated patients.

CONCLUSIONS

The inadequate response to pain programs shown by Workers' Compensation recipients may be partly understood in terms of well-defined mediating factors, which may admit to amelioration via clinical intervention. Moreover, Workers' Compensation patients should not be considered high risks for failure by sole virtue of their compensation status. Multifactor assessment methods may be needed to identify that portion of compensation recipients who are actually at appreciable risk for treatment failure so that appropriate adjustments in treatment regimen may be made.

Maternal youth and pregnancy outcomes: middle school versus high school age groups compared with women beyond the teen years

OBJECTIVE

We sought to measure and compare pregnancy complications in middle school versus high school versus older maternal age groups.

STUDY DESIGN

From January 1988 through December 31, 1991, maternal and infant data from 16,512 consecutive nulliparous women were collected and electronically stored. These women were divided into three study groups: middle school (11 to 15 years old), high school (16 to 19 years old), and women 20 to 22 years old at delivery. Statistical analysis included logistic regression to control for potentially confounding demographic variables.

RESULTS

Middle school-aged mothers were disproportionately black (50% vs 36% Hispanic vs 14% white), and very low birth weight (4% vs. 2%, p = 0.003) was increased in these youthful mothers. First births to high school-aged mothers were not found to be compromised compared with those of women 20 to 22 years old, and, indeed, cesarean birth was less frequent in these women compared with those > or = 20 years old.

CONCLUSIONS

We conclude that the health hazard associated with school-age pregnancy is predominantly prematurity and is increased only in middle school-aged mothers. High school-aged mothers do not experience excess medical complications of pregnancy compared with older women. We suggest that middle school pregnancy, particularly for inner-city teenagers, should be a special focus for pregnancy prevention and intervention.

Meconium: a 1990s perspective on an old obstetric hazard

OBJECTIVE

To quantify the current perinatal consequences associated with intrapartum detection of meconium in the amniotic fluid (AF).

METHODS

We compared retrospectively the outcomes in 8136 term singleton cephalic pregnancies with meconium and 34,573 similar pregnancies with clear AF.

RESULTS

Virtually all measures of adverse fetal-neonatal outcomes were significantly increased with meconium. For example, perinatal mortality increased from 0.3 per 1000 births with clear AF to 1.5 deaths per 1000 with meconium (P < .001). Most of these deaths resulted from meconium aspiration. Other unwanted outcomes also increased; eg, severe fetal acidemia at birth (umbilical artery blood pH 7.00 or less) increased from three per 1000 to seven per 1000 when meconium was diagnosed (P < .001). Delivery by cesarean also increased with meconium, from 7 to 14% (P < .001).

CONCLUSION

Meconium in the AF is an obstetric hazard with small but significantly increased risks of adverse fetal-neonatal outcomes.

High-dose oxytocin: 20- versus 40-minute dosage interval

OBJECTIVE

To determine whether an increase in the oxytocin dosing interval would decrease the incidence of uterine hyperstimulation.

METHODS

This study included 1801 consecutive pregnancies receiving high-dose oxytocin. Oxytocin was used for labor augmentation in 1167 and induction in 634 women. Twenty- and 40-minute dosage intervals were compared. The study period was based on an 80% likelihood of detecting 5 and 10% differences in the cesarean and hyperstimulation rates, respectively. Statistics were analyzed with chi 2, Fisher, and Wilcoxon rank-sum tests where appropriate. Multivariate logistic regression and analysis of covariance were used to control for confounding demographic variables.

RESULTS

Comparison of the 20- and 40-minute regimens for labor induction yielded no differences in the rates of cesarean delivery for dystocia (16 versus 19%) or fetal distress (5 versus 6%). The 20-minute regimen for augmentation was associated with a significant reduction in cesarean for dystocia (8 versus 12%; P = .05). The incidence of uterine hyperstimulation was greater with the 20-minute than the 40-minute regimen for induction (40 versus 31%; P = .02), but not for augmentation (31 versus 28%). Neonatal outcomes were unaffected by the dosage interval for both augmentation and induction.

CONCLUSION

A 40-minute dosing interval for high-dose oxytocin offers no clear advantage over a 20-minute interval. Both regimens were safe and efficient, with no differences in perinatal outcome. The 20-minute interval was associated with fewer cesareans for dystocia when used for labor augmentation, whereas the 40-minute interval resulted in less hyperstimulation when used for labor induction.

Down-regulation of tumor necrosis factor expression by pentoxifylline in cancer patients: a pilot study

The wasting syndrome (cachexia) characterized by anorexia, malaise, and weight loss is observed in many patients with cancer or chronic infection. The excessive levels of tumor necrosis factor-alpha (TNF)/cachectin reported in 50% of cancer patients exhibiting clinically active disease may therefore mediate, at least in part, the cachexia associated with malignancy. Pentoxifylline, a substituted methylxanthine approved for treatment of intermittent claudication, has been shown in preclinical studies to down-regulate TNF RNA expression as well as TNF activity. We report that pentoxifylline suppressed TNF RNA levels on all three occasions in patients with initially elevated levels of TNF RNA. Pentoxifylline did not suppress TNF RNA to subnormal levels in all five patients with initially normal TNF RNA levels. Four patients reported an increased sense of well-being, improved appetite and ability to perform the activities of daily living. Two of these five patients with normal TNF levels each had a weight gain of more than 5% after 3 weeks of pentoxifylline therapy suggesting that, although TNF may be important in the pathogenesis of cancer cachexia, other anorexia-producing cytokines that are potentially affected by pentoxifylline may also be involved. No severe adverse effects were observed. Taken together these findings suggest that pentoxifylline can down-regulate TNF expression and improve the sense of well-being in cancer patients. A larger study with a randomized, double-blind, placebo-controlled design and more sophisticated estimates of quality of life will be needed to confirm these observations.

Birth weight threshold for postponing preterm birth

OBJECTIVE

The study was designed to determine the birth weight threshold at which obstetric efforts intended to delay delivery might potentially improve rates of neonatal morbidity and mortality among pregnancies delivered after spontaneous preterm labor or rupture of the membranes.

STUDY DESIGN

We studied 1147 singleton infants with birth weights between 1000 and 2499 gm and whose only complication was spontaneous preterm labor or preterm rupture of the membranes. The Mantel-Haenszel chi 2 statistic was used to evaluate trends for neonatal mortality and several indexes of morbidity.

RESULTS

The birth weight threshold for neonatal mortality was 1600 gm (p < 0.001). For neonatal morbidity the threshold was between 1600 and 1900 gm (p < 0.008).

CONCLUSION

Aggressive obstetric attempts to prevent preterm birth for infants whose weights exceed 1900 gm offers few apparent potential benefits.

Involvement of reactive oxygen intermediates in the induction of c-jun gene transcription by ionizing radiation

Previous work has demonstrated that the cellular response to ionizing radiation includes transcriptional activation of the c-jun gene. The signaling events responsible for this response, however, remain unclear. The present studies have examined the effects of ionizing radiation on c-jun expression in a variant of HL-60 cells, designated HL-525, which is deficient in protein kinase C (PKC)-mediated signal transduction. The results demonstrate that these cells express low levels of PKC alpha and PKC beta transcripts and exhibit an attenuated induction of c-jun expression following treatment with 12-O-tetradecanoylphorbol-13-acetate (TPA). In contrast, HL-525 cells respond to ionizing radiation with an increase in c-jun mRNA which is more pronounced than that in wild-type HL-60 cells. These cells similarly respond to ionizing radiation with increased expression of the jun-B, jun-D, c-fos, and fos-B genes. Nuclear run-on assays demonstrate that X-ray-induced c-jun expression in HL-525 cells is regulated by increases in the rate of c-jun gene transcription. Moreover, mRNA stability studies in irradiated HL-525 cells demonstrate that the half-life of c-jun transcripts is prolonged compared to that in wild-type cells. Studies with N-acetyl-L-cysteine (NAC), an antioxidant, suggest that X-ray-induced transcriptional activation of the c-jun gene is mediated at least in part through the formation of reactive oxygen intermediates (ROIs). In this context, H2O2 also induced c-jun expression in HL-525 cells, and this effect was inhibited by NAC.(ABSTRACT TRUNCATED AT 250 WORDS)