Should individuals choose their definition of death?

Alireza Bagheri supports a policy on organ procurement where individuals could choose their own definition of death between two or more socially accepted alternatives. First, we claim that such a policy, without any criterion to distinguish accepted from acceptable definitions, easily leads to the slippery slope that Bagheri tries to avoid. Second, we suggest that a public discussion about the circumstances under which the dead donor rule could be violated is more productive of social trust than constantly moving the line between life and death.

[Elderly patients with Chronic Kidney Disease: what is their course at one year?]

INTRODUCTION

Aging is associated to several structural and functional kidney changes. Recently, there is a great interest in the detection of Chronic Kidney Disease (CKD) in the general population. A classification of CKD, based on several stages of the estimated glomerular filtration rate (eGFR), has been established. In this study we followed up, clinically and biochemically, during one year eighty patients older than 65 years so as to ascertain the applicability and utility of such classification to those patients.

PATIENTS AND METHODS

80 clinically stable patients, with a median age of 83 years, recruited within January and April 2006, were followed up during one year. We separated them in two groups: Group 1: 38 patients with serum creatinine pound sterling 1,1 mg/dl (range 0,7-1,1) and with no proteinuria; and Group 2: 42 patients with serum creatinine > or =1.1 mg/dl (range 1,2-3) and with proteinuria <3 grs/24 hours. Clinically we registered morbimortality and treatments received, and biochemically we measured serum creatinine and eGFR at the time of recruitment and after one year of follow up using two equations: Cockroft and abbreviated MDRD. Statistical comparisons were made using the general lineal model for repeated measures of the SPSS 11.0 program.

RESULTS

10% of the patients died during the follow up. Cardiac problems were the kind of morbidity more frequently found. Only a small proportion (23%) of group 2 patients were receiving erythropoietin (EPO) treatment. Estimated GFR and proteinuria remained stable at the end of one year independently of basal GFR; we found no significant differences between groups in the rest of analytical parameters.

CONCLUSION

in old patients with no significant proteinuria, the similarity of their clinical evolution and the stability of their eGFR (independently of its basal value), as well as the lack of differences in other analytical parameters, appears not to confer any advantages to the use of mathematical formulae to classified them according to their eGFR.

Random regression model of growth during the first three months of age in Spanish Merino sheep1,2

A total of 88,727 individual BW records of Spanish Merino lambs, obtained from 30,214 animals between 2 and 92 d of age, were analyzed using a random regression model (RRM). These animals were progeny of 546 rams and 15,586 ewes raised in 30 flocks, between 1992 and 2002, with a total of 45,941 animals in the pedigree. The contemporary groups (animals of the same flock, year, and season, with 452 levels), the lambing number (11 levels), the combination sex of lambs with type of litter (4 levels), and a fixed regression coefficient of age on BW were included as fixed effects. A total of 7 RRM were compared, and the best fit was obtained for a model of order 3 for the direct and maternal genetic effects and for the individual permanent environmental effect. For the maternal permanent environmental effect the best model had an order 2. The residual variance was assumed to be heterogeneous with 10 age classes; the covariance between both genetic effects was included. According to the results of the selected RRM, the heritability for both genetic effects (h(a)2 and h(m)2) increased with age, with estimates of 0.123 to 0.186 for h(a)2 and of 0.059 to 0.108 for h(m)2. The correlations between direct and genetic maternal effects were -0.619 to -0.387 during the first 45 d of age and decreased as age increased, until reaching values from -0.366 to -0.275 between 45 to 75 d of age. Important changes in ranking of the animals were found based on the breeding value estimation with the current method and with the random regression procedure. The use of RRM to analyze the genetic trajectory of growth in this population of Merino sheep is highly recommended.

Square Wave Voltcoulometry: A Tool for the Study of Strongly adsorbed Redox Molecules

A new multipotential pulse technique called square wave voltcoulometry (SWVC), based on the analysis of the difference of converted charge signals obtained between two successive half-cycles when a square wave potential is applied, is developed to study charge-transfer processes taking place in electroactive monolayers. The use of SWVC presents the advantage of giving rise to a peak-shaped response, which evolves to a charge plateau at high square wave pulse amplitudes, from which the total surface excess and the formal potential can be immediately measured for quasi-reversible and reversible processes. This characteristic represents its main advantage versus other multipotential step techniques, which lead to a negligible current under reversible conditions. The formal potential of the electroactive systems can be measured from the peak potential of the SWVC curves, even for quasi-reversible behavior. Moreover, the non-faradic effects on the response can be easily evaluated and avoided as is demonstrated in this paper. Experimental verification of the theoretical predictions is given for reversible and quasi-reversible systems.

Combining galiximab with the chemotherapeutic agents fludarabine or doxorubicin improves efficacy in animal models of lymphoma

3040

Background: Galiximab, a primatized monoclonal antibody that binds with high affinity to CD80 and mediates antibody- dependent, cell-mediated cytotoxicity in vitro, is currently under investigation for the treatment of follicular non-Hodgkin’s lymphoma (NHL). In a phase I/II monotherapy study, galiximab produced an overall response rate of 11%, and tumor reductions were observed in 46% of patients. Initial clinical trials also demonstrate that galiximab is well tolerated and suggest that combining galiximab with rituximab (anti-CD20) provides clinical benefit. These results are consistent with preclinical studies in murine lymphoma xenograft model systems, which demonstrate the superiority of combination therapy. Methods: To further define the therapeutic potential of galiximab, the Raji subcutaneous and the SKW disseminated lymphoma murine xenograft models were used to define the in vivo efficacy of galiximab alone or in combination with fludarabine or doxorubicin. Similar studies were performed with rituximab. Results: In the Raji model, both galiximab and rituximab exhibited maximal inhibition of the growth of preestablished (150-mg) tumors at a dose of 3 mg/kg/wk. Interestingly, higher doses of galiximab (but not rituximab) showed reduced inhibition. Galiximab (3 mg/kg/wk) inhibited tumor growth alone (P<0.0001 vs. control) and showed significantly enhanced activity when combined with fludarabine (50 or 100 mg/kg daily for 5 days; P<0.0002 vs. galiximab alone and P<0.003 vs. fludarabine alone). Similar results were observed with rituximab. In the SKW model, treatment with galiximab (5 mg/kg/wk for 6 doses) significantly enhanced survival compared with a control (P<0.0001) or doxorubicin (2.5 mg/kg/day for 3 doses; P<0.0001). Studies combining fludarabine or doxorubicin with both galiximab and rituximab are ongoing. Conclusions: Studies in animal models of lymphoma indicate that galiximab may provide clinical benefit when used in combination with chemotherapeutic agents such as fludarabine and doxorubicin, and provide a rationale for the investigation of these novel chemoimmunotherapy combinations in clinical trials.

No significant financial relationships to disclose.

Phase II study of clofarabine and cytosine arabinoside in adult patients with relapsed AML and in elderly patients with untreated AML who are at high risk of anthracycline toxicity

7064

Purpose: To evaluate the efficacy/safety of a novel AML regimen in elderly patients with heart disease or in patients with a contraindication to ‘standard‘ anthracycline-containing regimens. Patients and Methods: Phase II, open-label design. Eligible pts had elderly de-novo or relapsed AML or would not benefit from 7+3 or simlar therapy. Treatment was CLOF 40 mg/m2, Ara-C 1,000 mg/m2. (d1–5). Results: Patients were accrued and treated from April 2005 through Oct 2006. All pts signed IRB-approved consents. The median age was 67 years (range 38–82 years). Twenty (67%) subjects had received at least one prior cytoxic regimen (excluding 5-AZA). Significant cardiovascular (history of MI, bypass grafting, cardiomyopathy) was present in 43% (13/30) prior to therapy. Thirty pts were enrolled and all recieved at least one day of therapy. 1 pt died within 24 hours of starting treatment due to disease progression. Of the remaining, 29/30 received at least one complete cycle of therapy and 5 received 2 cycles. None received more than 2 cycles. Toxicities were greater in those receiving a second cycle. Grade 4 neutropenia developed in all patients. There were no cases of regimen-related cardiac toxicity. Most patients had some degree of edema and third-spacing syndrome. Several developed a significant but reversible acral rash. 25 patients survived >28 days and are evaluable for hematologic response. The histologic response rate (RR) is 68% (17/25) consisting of 14 (56%) complete remissions (marrow blasts <5%) and 3 (12%) partial responses (PR). There were 13 subjects with known cytogenetic abnormalities, 1 favorable and 12 unfavorable. Complete cytogenetic remissions (CytoCR) occurred in 4 of those patients, by chromosome analysis and/or FISH. Durable remissions and low toxicity allowed some patients to proceed to nonablative allogeneic stem cell transplantation. Conclusion: Clofarabine and Ara-C is an active and well tolerated regimen in myeloid malignancies including “elderly AML” a distinct entity usually associated with poor response rate and high treatment-related toxicities. Other drug combinations with clofarabine are ongoing in hematopoietic transplant and other high risk subgroups.

No significant financial relationships to disclose.

Lumiliximab (anti-CD23 antibody) mediates apoptosis and antitumor activity in chronic lymphocytic leukemia (CLL) cells and CD23+ lymphoma cell lines

3039

Background: Given the success of treating CLL with antibody therapies, interest in those directed at alternative B-cell antigens remains high. Lumiliximab is a chimeric macaque and human anti-CD23 monoclonal antibody whose antigen is expressed on almost all CLL cells. Methods: We examined lumiliximab’s ability to mediate direct apoptosis, antibody-dependent cellular cytotoxicity (ADCC), and complement-dependent cytotoxicity (CDC) against primary CLL cells and CD23+ B-cell lines. Apoptosis was measured with a flow-cytometry based assay for active caspase-3. ADCC was determined by 51Cr-release assay. CDC assays were performed in the presence of 30% autologous plasma from patients and quantified by propidium iodide staining. Western blotting analysis was used to monitor protein expression before and after treatment with lumiliximab. The CD23+ human lymphoma SKW6.4 cell line was used for in vivo evaluation of lumiliximab in a disseminated human lymphoma model. Results: Lumiliximab mediates apoptosis, ADCC, and CDC in CD23+ B-cell lines. However, in primary CLL cells, the primary mechanism of cell killing appears to be mediated via apoptosis. Apoptosis induced by lumiliximab occurs mainly through the intrinsic pathway used by other CLL therapies. Lumiliximab decreased expression of Bcl-2 and XIAP and inhibited Akt activation in CLL cells. Lumiliximab when combined in vitro or in vivo with rituximab or fludarabine effectively mediates synergistic cytotoxicity against primary CLL cells and CD23+ B-cell lines. Significant antitumor activity was also observed with lumiliximab vs a control antibody in a SCID mouse model of human B-cell lymphoma (P <.01). More importantly, lumiliximab + rituximab or lumiliximab + fludarabine results in prolonged survival vs lumiliximab, rituximab, or fludarabine single-agent treatment. Conclusions: These results indicate that lumiliximab induces apoptosis by activating caspases and downregulating antiapoptotic proteins, and suggest that in combination with rituximab or chemotherapy, lumiliximab synergistically enhances antitumor activity in CLL or other B-cell malignancies in which this antigen is overexpressed.

No significant financial relationships to disclose.

[Patient satisfaction with the process of computerisation, consent and decision making during hospitalisation]

The health organisations have moved from being centred on the professionals and are now centred on users and their expectations. The new health institutions want to know patients' perception of the quality of the care received, with particular respect to the information received, consent and decision making. It is necessary to have available measuring instruments that explore the different components of the process of information, consent and decision making.

BACKGROUND

To identify the dimensions related to the process of information, consent and decision making of most importance to patients and susceptible to evaluation by questionnaire.

SUBJECTS AND METHODS

Adult persons who have been hospitalised for at least two days. Qualitative study using semi-structured interviews.

RESULTS

The participants wish to be informed and to participate in decision making; they do not know the meaning of the charter of patients' rights; they wish to share the whole care process with their family; written information is incomprehensible to them; and they feel that their pain and discomfort do not receive appropriate attention.

CONCLUSION

It would be convenient to include the following dimensions in the questionnaires on satisfaction: a) the possibility of clarifying doubts; b) real knowledge of the rights and duties of patients; c) participation by the family in the care process; d) continuity of the same informer throughout hospitalisation; d) degree of understanding of the written information; e) involvement in decision making; and f) attention to pain and discomfort.

A phase I/II study of galiximab (an anti-CD80 monoclonal antibody) in combination with rituximab for relapsed or refractory, follicular lymphoma

BACKGROUND

Galiximab is a monoclonal antibody that targets CD80, a costimulatory molecule constitutively expressed on follicular and other lymphomas. Modest single-agent clinical activity and tolerability were demonstrated in a phase I study in relapsed or refractory, follicular non-Hodgkin's lymphoma (NHL). A phase I/II study was conducted to evaluate galiximab in combination with a standard course of rituximab. Safety, pharmacokinetics, and efficacy were evaluated.

PATIENTS AND METHODS

Patients with follicular NHL who had relapsed or failed primary therapy were enrolled. Rituximab-refractory patients (no response or a response with time to progression <6 months) were excluded. Patients received 4 weekly i.v. infusions of galiximab (125, 250, 375, or 500 mg/m(2)) and rituximab (375 mg/m(2)). International Workshop Response Criteria (IWRC) were used to evaluate response.

RESULTS

Seventy-three patients received treatment. All had received at least one prior lymphoma therapy; 40% were rituximab naive. Infusions were delivered in an outpatient setting and were well tolerated. The most common study-related adverse events (AE) were lymphopenia, leukopenia, neutropenia, fatigue, and chills. The overall response rate at the recommended phase II dose of galiximab (500 mg/m(2)) was 66%: 19% complete response, 14% unconfirmed complete response, and 33% partial response. The median progression free survival was 12.1 months. Combination therapy did not appear to alter pharmacokinetics.

CONCLUSION

These results indicate that galiximab can be safely combined with a standard course of rituximab. This doublet biologic approach offers the potential to avoid or delay chemotherapy or to integrate with other lymphoma therapies. A phase III, randomized study evaluating clinical benefit of rituximab versus the combination has been initiated.

Differential pulse voltammetry and additive differential pulse voltammetry with solvent polymeric membrane ion sensors

The ion transfer across the water-solvent polymeric membrane interface is investigated by using a new device based on a modification of a commercial ion-selective electrode body that permits the accommodation of a platinum counter electrode inside the inner filling solution compartment and, therefore, use of a four-electrode potentiostat with ohmic drop compensation. This device is used here to apply two different double potential pulse techniques--differential pulse voltammetry and additive differential pulse voltammetry--which are more advantageous than other voltammetric techniques, such as normal pulse voltammetry or cyclic voltammetry, for the determination of the characteristic electrochemical parameters of the system. This is due to the concurrence of two factors in these double potential pulse techniques, the peak-shaped response together with a considerable reduction of undesirable current contributions.

[Sclerosing encapsulating peritonitis: a latent threat. Changes of posture in surgery treatment]

Sclerosing Encapsulating Peritonitis (SEP) is a rare but serious complication of continuous ambulatory peritoneal dialysis (CAPD) with a high morbi-mortality. We describe our experience with patients was diagnostic of SEP, their characteristics in CAPD and their clinic evolution after diagnosis. 190 CAPD patients were follow-up during 17 years. Eight patients (4.2%) developed SEP. Average age 45+/-14 years (range 29-64 years), four was male. Time in CAPD was 72+/-29 months (range 24-120 months). All patients have peritonitis previously (mean 3+/-1). We observe a change in peritoneum characteristics (D/P Cr 4), with an average of 0.6+/-0.1 at one year of CAPD, versus 0.82+/-0.08 at the end of CAPD, with statistic significance (p<0.001). There are increases in use of hypertonic bags: 53%+/-28 at beginning versus 91%+/-27 at end, with statistic significance (p<0.009). All patients show tendency to hyperphosphoremia (mean 6.7+/-0.7 mg/dl), with product calcium-phosphorus 68.4+/-8.3. Five patients (62.5%) have a previous renal transplant, one lost due to early graft thrombosis and two lost due to acute rejection. Six patients (75%) have a previous abdominal surgery, although was extra peritoneal in all cases. The diagnosis of SEP was clinic suspicion in all cases, suggestive radiological data (intestinal handle group) and laparoscopy showing SEP (cocoon) with histological confirmation (fibrosis and peritoneal calcification) in four cases. The treatment was medical in six cases associated with surgery in four of them. The medical treatment was tamoxifen and/or corticosteroids, associated with total parenteral nutrition in two patients and enteral nutrition in one. Surgery in six patients: three as urgent surgery (all died) and three as programme surgery (two live still). Etiology of died was: three for sepsis, one for peritonitis after bowel perforation, one for severe problems of nutrition. The average survival of three patients alive was 38+/-17 months, two of them had programme surgery, and one with functioning transplant we opt for conservative treatment. The actuarial survival at 24 months was 51%.

CONCLUSION

The SEP is a serious entity with high mortality. Although our short experience doesn't can indicate a concrete treatment, our personal impression is that early surgery associated with corticosteroids treatment may improve the prognostic.