Variations of the extensor pollicis brevis tendon and its insertion: a study of 44 cadaveric hands

The aim of this study was to describe the anatomy of the extensor pollicis brevis tendon, in particular its insertion, in 44 preserved hands from 23 cadavers. We found that only 25% of the tendons were inserted in the conventional way, viz, into the base of the proximal phalanx, and confirmed that the course and insertion of the extensor pollicis brevis tendon varies widely. The importance of these findings to the practice of hand surgery is discussed.

Rediscovering dignity at the bedside

It is possible to teach the ABCD of preserving patients' dignity

Randomized trial of active cellular immunotherapy with sipuleucel-T in androgen dependent prostate cancer (ADPC)

5059

Background: Sipuleucel-T is an investigational, active cellular immunotherapy product for prostate cancer. To explore the potential benefit in ADPC, sipuleucel-T was studied in a randomized, double blind, multicenter, placebo controlled study, P-11. Methods: ADPC patients with a rise in serum prostate specific antigen (PSA) as the only sign of disease recurrence after prostatectomy were randomized (2:1) to sipuleucel-T or placebo, administered in weeks 0, 2, and 4, following 3-months of hormonal therapy. PSA kinetics were evaluated by time to biochemical failure (BF), defined as any PSA = 3 ng/mL (primary endpoint), as well as PSA doubling time (PSADT). Clinical endpoints included time to distant metastases (DF) and survival. The effect of a single booster infusion of sipuleucel-T on the immune system was also evaluated. Results: 176 patients were randomized (117 sipuleucel-T:59 placebo) and analyzed by intent to treat. Median time to BF was 18.0 months for sipuleucel-T and 15.4 months for placebo (hazard ratio (HR)=0.94 [95% confidence interval (CI): 0.64, 1.38]; p>0.05, log rank). The hazard ratio for BF was 0.80 in favor of sipuleucal-T ([95%CI: 0.53, 1.20], p>0.05) when the analysis was restricted to patients with a confirmed BF. An analysis of PSADT calculated from 90 days following randomization to BF or the initiation of systemic therapy demonstrated that patients randomized to sipuleucel-T had a 35% increase in PSADT (125 vs 91 days; p=0.046, F-test). PSADT calculated after testosterone recovery to baseline levels demonstrated a 48% increase in PSADT for the sipuleucel-T arm (155 vs 105 days; p=0.038). Only 16% of patients developed distant metastases. The hazard ratio for time to DF was 0.78 (95%CI: 0.34, 1.58, p>0.05, log rank). Patients are still being followed for DF and survival. The most common treatment-associated adverse events were chills, fatigue, headache, and pyrexia, which were primarily Grade 1–2. Conclusions: Time to BF was not different between the two study arms. The effect on PSADT, an important prognostic indicator in ADPC, may suggest the biologic activity of sipuleucel-T in this population. Additional follow-up for clinical endpoints of DF and survival is of interest.

No significant financial relationships to disclose.

A phase I dose escalation trial of the VEGFR tyrosine kinase inhibitor, PTK787/ ZK222584 (PTK/ZK), used in combination with paclitaxel in patients with advanced solid tumors with pharmacokinetic (PK) analysis

14012

Background: The aim of this study was to define the maximum tolerated dose (MTD) for weekly paclitaxel administered in combination with daily PTK/ZK and assess for a potential PK drug interaction. Methods: 17 patients (pts) with refractory metastatic solid tumors, were enrolled. During cycle 1 (C1) paclitaxel was given on days 1 and 15 in combination with PTK/ZK on days 3 to 28. PTK/ZK was administered once daily each night. During cycle 2 (C2) and beyond, paclitaxel was given on days 1, 8 and 15 every 28 days. PTK/ZK was taken orally each night. A “3+3” design was used. In addition to the standard definitions of dose limiting toxicity (DLT) occurring in C1 and C2, the inability to give day 8 or 15 of paclitaxel or > 7 days of missed PTK/ZK due to toxicity was also deemed dose limiting. Therapy was given until disease progression. Results: 60 cycles (range: 1 to 8) have been administered to 16 evaluable pts. No DLTs were observed when 75 mg/m2 of paclitaxel was combined with PTK/ZK doses of 250 mg, 500 mg and 750 mg. Two of 5 pts treated with paclitaxel 85 mg/m2 and PTK/ZK 1,000 mg had Grade 3 transaminase elevation (defined DLT) in C1 after day 15. The MTD was therefore 75 mg/m2 paclitaxel and 750 mg PTK/ZK. Paclitaxel PK was obtained in 14 patients: 13 of 14 patients had a faster clearance (L/hr) of paclitaxel on C1 day 15 versus day 1 (average % increase: 79%, range 14–256%, SD: 69). Only one patient had a slower clearance: 26% decrease. Activity included 2 partial responses (prostate and esophageal cancer), and 8 pts had stable disease lasting 2–9+ months, including ovarian cancer pts previously treated with paclitaxel. Conclusion: The MTD for weekly paclitaxel plus daily PTK/ZK is 75 mg/m2 and 750 mg. DLTs were liver transaminase elevation. This combination was well tolerated, and responses and prolonged disease stabilization were seen. PK analysis revealed an increase in rate of paclitaxel clearance in most patients.

No significant financial relationships to disclose.

Patients with IgA nephropathy have increased serum galactose-deficient IgA1 levels

Immunoglobulin A (IgA) nephropathy is the most prevalent form of glomerulonephritis worldwide. A renal biopsy is required for an accurate diagnosis, as no convenient biomarker is currently available. We developed a serological test based upon the observation that this nephropathy is characterized by undergalactosylated IgA1 in the circulation and in mesangial immune deposits. In the absence of galactose, the terminal saccharide of O-linked chains in the hinge region of IgA1 is terminal or sialylated N-acetylgalactosamine. A lectin from Helix aspersa, recognizing N-acetylgalactosamine, was used to develop an enzyme-linked immunosorbent assay that measures galactose-deficient IgA1 in serum. The median serum lectin-binding IgA1 level was significantly higher for 153 Caucasian adult patients with IgA nephropathy without progression to end-stage renal disease as compared with that for 150 healthy Caucasian adult controls. As the lectin-binding IgA1 levels for the controls were not normally distributed, the 90th percentile was used for determination of significant elevation. Using a value of 1076 U/ml as the upper limit of normal, 117 of the 153 patients with IgA nephropathy had an elevated serum lectin-binding IgA1 level. The sensitivity as a diagnostic test was 76.5%, with specificity 94%; the positive predictive value was 88.6% and the negative predictive value was 78.9%. We conclude that this lectin-binding assay may have potential as a noninvasive diagnostic test for IgA nephropathy.

Delivery of cancer genetics services: The Royal Marsden telephone clinic model

We have conducted a telelink telephone-led cancer genetic counselling model at The Royal Marsden NHS Foundation Trust. The study commenced in March 2004 and evaluation of the clinic was conducted over 17 months from March 2005 to the end of July 2006. A total of 612 patients had telephone consultations during this time, 228 of whom were referred from primary care with a median of 30 patients counselled per month (range of 19-63, depending on staff availability with average of two staff per clinic). Waiting times were measured for General Practitioner referrals and all 228 were counselled within the national target-stipulated 13 weeks (median 6 weeks, range 1-12). An additional 132 patients who were sent appointment letters after receipt of their family history questionnaires did not attend their appointments (18% of all potential referrals) and required recontacting by letter. After telephone counselling, 42% of patients were able to be discharged from the telephone clinic without a subsequent face-to-face appointment, thereby saving resources. The telephone clinic also had a short set-up time with flexibility on timing and day of administration, which would be an advantage in centres where outreach clinic facilities are scarce. The telelink telephone counselling model is highly efficient in triaging high risk individuals for face-to-face counselling as per the Kenilworth model, in effecting concentration of resources and in providing a flexible individual-centred approach to cancer genetic counselling delivery.

A review of the effect of tap water versus normal saline on infection rates in acute traumatic wounds

This review seeks to determine whether using tap water rather than normal saline to irrigate acute traumatic wounds in the community has any effect on the rate of infection. The evidence suggests there is no such association.

Brief smoking cessation advice from practice nurses during routine cervical smear tests appointments: a cluster randomised controlled trial assessing feasibility, acceptability and potential effectiveness

The aim of this study is to assess the potential effectiveness, acceptability and feasibility of a brief smoking cessation intervention delivered as part of cervical screening. A cluster randomised controlled trial was conducted with clinic week as the unit of randomisation, comparing a group (n=121) receiving brief smoking cessation advice supplemented with written information given by practice nurses during cervical smear test appointments, with a group (n=121) not receiving this advice. Outcomes were intention to stop smoking (potential effectiveness); intention to attend for future cervical screening (acceptability); duration of intervention (feasibility). 172/242 (71%) and 153/242 (63%) participants completed 2-week and 10-week follow-ups, respectively. Compared to women in the control group, those in the intervention group had higher intentions to stop smoking at 2-weeks (adjusted mean difference 0.51, 95% CI: -0.02 to 1.03, P=0.06) and 10-weeks (adjusted mean difference 0.80, 95% CI 0.10 to 1.50, P=0.03). The two groups had similarly high intentions to attend for future screening. Consultations in the intervention arm took a mean of 4.98 min (95% CI: 3.69 to 6.27; P<0.001) longer than the control arm. In conclusion, brief smoking cessation advice given by practice nurses as part of cervical screening seems acceptable, feasible and potentially effective. Evidence is lacking on the effectiveness and cost effectiveness of this intervention in achieving biochemically validated smoking cessation.

Assessment of the Risk of Introduction of H5N1 HPAI Virus from Affected Countries to the U.K

The Department for Environment, Food and Rural Affairs (Defra) has monitored epidemiologic developments following outbreaks of H5N1 in Asia since the beginning of 2004 and publishes risk assessments as the situation evolves. The U.K. applies safeguard measures that reflect EU rules to enable imports to continue when they present negligible risk. Defra risk assessments (RA) identify possible pathways by which the H5N1 virus may be introduced to the U.K. These assessments provide a basis for identifying appropriate surveillance activities to ensure early detection, should the virus be introduced, and disease control measures to be taken, should the virus be detected in the U.K. Nevertheless, these assessments have highlighted that many fundamental uncertainties still remain. These uncertainties center on the geographic and species distribution of infection outside Asia and the means of dissemination of the virus. However, the evolving developments demonstrated that regulatory decisions had to be made despite these uncertainties. Improvements in our current RA abilities would greatly benefit from systematic studies to provide more information on the species susceptibility, dynamics of infection, pathogenesis, and ecology of the virus along with possible pathways by which the H5N1 virus may be disseminated. Such an approach would assist in reducing uncertainties and ensuring that regulatory risk management measures are regularly reviewed by taking into account the most recent scientific evidence. The likelihood of the persistence of H5N1 outside Asia in the coming years and the effects of control programs in Asia and other affected regions to reduce the prevalence of infection are also important factors.

Intercessory prayer for the alleviation of ill health

BACKGROUND

Prayer is an ancient and widely used intervention for alleviating illness and promoting good health. Whilst the outcomes of trials of prayer cannot be interpreted as 'proof/disproof' of God's response to those praying, there may be an effect of prayer not dependent on divine intervention. This may be quantifiable; which makes this investigation of a widely used health care intervention both possible and important.

OBJECTIVES

To review the effectiveness of intercessory prayer as an additional intervention for those with health problems already receiving standard medical care.

SEARCH STRATEGY

We systematically searched ten databases (June 2005).

SELECTION CRITERIA

We included any randomised trial of personal, focused, committed and organised intercessory prayer with those interceding holding some belief that they are praying to a God. This prayer should be offered on behalf of anyone with health problems.

DATA COLLECTION AND ANALYSIS

We extracted data independently and analysed on an intention to treat basis calculating, for binary data, the fixed effect relative risk (RR), their 95% confidence intervals (CI), and the number needed to treat or harm (NNT or NNH).

MAIN RESULTS

Ten studies are now included (n=7646). We found a slight difference between groups, favouring prayer for death (6 RCTs, N=6782, RR 0.88 CI 0.80 to 0.97, NNT 42 CI 25 to 167, I(2 )83%) but no differences between groups for clinical state, complications or leaving the study early. Individual studies did find some effects. One trial separated death data into 'high' and 'low' risk and found prayer had a positive effect on those at 'high' risk of death (1 RCT, N=445, RR 0.3 CI 0.2 to 0.46, NNT 8 CI 7 to 11). A second study found a positive effect of prayer on women undergoing IVF treatment with significantly more successful implantations in the prayer group compared with standard care (1 RCT, n=169, RR 0.68 CI 0.53 to 0.86, NNT 5 CI 3 to 10). A larger study assessed the effect of awareness of prayer and found those aware of receiving prayer had significantly more post operative complications than those not receiving prayer (1 RCT, n=1198, RR 1.15 CI 1.04 to 1.28, NNH 14 CI 8 to 50) and those uncertain if they were receiving prayer (1 RCT, n=1205, RR 1.12 CI 1.01 to 1.24, NNH 17 CI 9 to 201)

AUTHORS' CONCLUSIONS

It is not sensible to interpret any of the interesting results with great confidence. However, for women hoping for successful IVF treatment there are some data suggesting a favourable outcome of prayer but these data are derived from only one of the smaller trials. On the other hand, one of the larger studies suggests that those undergoing operations may not wish to know of the prayer that is being offered on their behalf. Most data are equivocal. The evidence presented so far is interesting enough to justify further study into the human aspects of the effects of prayer. However it is impossible to prove or disprove in trials any supposed benefit that derives from God's response to prayer.

Using molecular tools to assess biofilms in onsite systems

Onsite sewage treatment is growing in diversity, and in regulatory control across Australia. This is occurring for both blackwater and greywater treatment, as the drought impact deepens and more of the community are exposed to options for 'managing' their own water. Regulators in each State are drafting and implementing Guidelines to cover a range of on-site system scenarios. In addition, more and more decentralised options are being tendered for sewage management in the commercial world. In this project we aim to use novel molecular tools, in combination with traditional physical/chemical/biological methods, to understand onsite treatment in a more detailed manner. The system tested is a new peat based biofilter which can be used for greywater or blackwater application, and can be retrofitted to current sewage systems. This project has been based on the AquaReuse greywater system for demonstration purposes, showing the strength of the information gained from the use of novel tools. The two systems investigated are installed at a caravan park in New South Wales (NSW) and a domestic residence in Tamborine, Queensland (OLD). A 20-week intensive sampling and analysis program was followed. The project monitored standard analytes such as biochemical oxygen demand (BOD5), suspended solids (SS) and thermotolerant coliforms (TC). Additionally, we studied the biological community using fluorescent in situ hybridisation (FISH) on a monthly basis and full-cycle ribosomal RNA analysis (rRNA) for one sample to assess the biological community inhabitants. rRNA analysis at the NSW facility demonstrated a highly diverse biological community, in keeping with its long established operating period. In contrast, FISH analysis at the OLD installation showed a less diverse and younger community. rRNA and FISH identified organisms that are mostly associated with nutrient removing functions.

Harmful algal bloom toxins alter c-Fos protein expression in the brain of killifish, Fundulus heteroclitus

The immediate early gene c-fos, and its protein product c-Fos, are known to be induced in neurons of mammals and fish as a result of neuronal stimulation. The purpose of this study was to quantitatively examine CNS alterations in killifish, Fundulus heteroclitus, in relation to harmful algal bloom (HAB) toxin exposure. c-Fos expression was visualized using immunocytochemistry in the brains of killifish exposed to the excitatory neurotoxins domoic acid (DA) and brevetoxin (PbTx-2), and a paralytic neurotoxin, saxitoxin (STX), released from HABs. In addition, a simulated transport stress experiment was conducted to investigate effects of physical stress on c-Fos induction. Groups of fish were exposed to the different stress agents, brain sections were processed for c-Fos staining, and expression was quantified by brain region. Fish exposed to DA, STX, and transport stress displayed significant alterations in neuronal c-Fos expression when compared to control fish (p< or = 0.05). DA, PbTx-2, and transport stress increased c-Fos expression in the optic tecta regions of the brain, whereas STX significantly decreased expression. This is the first study to quantify c-Fos protein expression in fish exposed to HAB toxins. General alterations in brain activity, as well as knowledge of specific regions within the brain activated in association with HABs or other stressors, provides valuable insights into the neural control of fish behavior as well as sublethal effects of specific stressors in the CNS.

A novel, selective, orally active, potent small molecule inhibitor of Hsp90

13067

Background: The preclinical and clinical data evaluating derivatives of the natural product geldanamycin, including 17-AAG and 17-DMAG, reveal that inhibition of the molecular chaperone HSP90 results in multiple anti-tumor effects. SNX-5422 and SNX-5542 are potent, novel, highly specific, water soluble and orally active small molecule inhibitors of Hsp90. Here we describe the preclinical efficacy and toxicity evaluation of these compounds. Methods: The PK profile of SNX-5422 and SNX-5542 was determined following oral and iv dosing in mice and rats. HT29 xenografts were performed oral doses of SNX-5542 on a schedule of Q2DX3,2 for 2 weeks or 17-DMAG on the previously reported regimen of bid×5,2 for 2 weeks, with tumor progression and body weight monitored. Plasma, tumor and other tissues were harvested for evaluation of HSP70 induction and levels of HSP90 client proteins. Rats were treated with varying oral doses on a schedule of Q2DX3,2 for two weeks. Clinical observations were noted and standard hematology and clinical chemistry parameters were monitored. Results: SNX-5542 exhibited 37% oral BA in rats and >75% in mice, with t½ >7h in each species. SNX-5542 was well tolerated in normal and tumor-bearing mice at 300 mg/m2 Q2DX3,2 for 2 weeks, 0.9% weight gain. 17-DMAG at 30 mg/m2 bid×5,2 for 2 weeks caused 3.3% body weight loss. At these doses, SNX-5542 exhibited 78% median tumor growth inhibition of HT29 tumors while 17-DMAG exhibited 23% inhibition. Mechanistic indicators of HSP90 inhibition correlated with efficacy across multiple dosing levels. At 120 mg/m2 Q2DX3,2 for 2 weeks SNX-5422 was well tolerated in rats, with no significant effect on any clinical, hematology or clinical chemistry parameter with the exception of a slight increase in blood urea nitrogen levels. Histopathological evaluation of liver, thymus, spleen and kidneys revealed no significant treatment-related effects. At 120 mg/m2 Q2DX3,2 for 13 days SNX-5422 does not exhibit any of the toxicities reported for 17-DMAG (bidX5,2 for 8 days at 24 mg/m2). Conclusions: SNX small-molecule HSP90 inhibitors have favorable pharmacokinetic profiles, oral bioavailability, tolerability and superior anti-tumor activity compared to the natural product derivative 17-DMAG.

[Table: see text]