Use of subatmospheric pressure to prevent doxorubicin extravasation ulcers in a swine model

Application of subatmospheric pressure to sites injected with doxorubicin prevented ulcer formation in treated sites (0 ulcers/16 sites) compared to control wounds (10 ulcers/16 sites) in a pig model.

BACKGROUND AND OBJECTIVES

Extravasation of doxorubicin hydrochloride (Adriamycin) frequently causes chronic ulcers, which usually progress and expose underlying structures such as tendons and bone. The exact mechanism of action that causes cell death and the chronic ulcers is unknown.

METHODS

Eight sites were injected intradermally with doxorubicin on each of 4 pigs. Four sites on each animal served as untreated controls. The remaining four sites were exposed to 125 mm Hg subatmospheric pressure applied 1 h after injection. The sites were observed on a three times per week schedule. Sites that did not develop ulcers were re-injected up to a total of four injections. The animals were observed for 5 weeks.

RESULTS

Ten of sixteen control sites developed ulcers. No subatmospheric pressure treated sites developed ulcers. The incidence of ulcer formation was significantly less for treated wounds compared to control wounds at P < 0.001 by Fisher's exact test.

CONCLUSIONS

This physical modality appears to successfully prevent ulcer formation after doxorubicin injection.

An effective and more convenient drug regimen for prophylaxis against paclitaxel-associated hypersensitivity reactions

"Standard" prophylaxis for paclitaxel-associated hypersensitivity reactions has included the systemic administration of H1 and H2 histamine antagonists, along with oral dexamethasone taken both the night prior to, and the morning of, each paclitaxel treatment. To improve patient convenience and compliance with steroid delivery, the Gynecologic Cancer Program of the Cleveland Clinic Foundation has treated patients with an all-intravenous prophylaxis regimen (diphenhydramine 50 mg, famotidine 20 mg, dexamethasone 20 mg) given 30 min prior to paclitaxel (without any earlier oral steroid dosing). To date, we have treated more than 200 patients who received all courses of paclitaxel with this simplified prophylactic regimen, of whom approximately 9% developed hypersensitivity reactions (major or minor). This incidence is comparable to our previously reported experience with hypersensitivity reactions in a similar number of patients receiving the standard prophylaxis (including oral dexamethasone) with their initial course of paclitaxel, and subsequent cycles employing this all-intravenous program. We conclude that this "modified" regimen for paclitaxel-associated hypersensitivity reactions (with all drugs administered approximately 30 min prior to the delivery of paclitaxel) is as effective as, and more convenient than, the standard regimen, and avoids delaying chemotherapy as a result of a patient failing to remember to take one or both oral steroid doses.

Persistent chemosensitivity to platinum and/or paclitaxel in metastatic endometrial cancer

It has long been recognized that individuals with ovarian cancer who initially respond to a platinum-containing chemotherapeutic regimen may exhibt a second response to platinum (cisplatin or carboplatin) at the time of recurrence. In this report, we describe three individuals with metastatic endometrial cancer who demonstrated secondary responses to platinum/paclitaxel-based regimens. Endometrial cancer should be added to the list of malignancies for which platinum and/or paclitaxel are considered as second-line treatment options in patients previously responding to the agents.

The expression of inhibin/activin subunits in the human adrenal cortex and its tumours

Inhibins and activins are dimeric proteins of the transforming growth factor-beta superfamily which have been shown to be expressed in the adrenal cortex. Recent studies have suggested a role for these peptides in the pathogenesis and/or function of adrenal tumours. To investigate further their physiological and pathological roles, we have documented immunoreactivity for inhibin alpha, betaA and betaB subunits in normal adult and fetal human adrenals, in hyperplastic adrenals and in adrenal tumours. In the normal and hyperplastic adult gland, diffuse immunopositivity was demonstrated for beta subunits, suggesting that activins (beta beta dimers) can be expressed in all zones. Inhibin alpha was limited to the zona reticularis and the innermost zona fasciculata in the normal gland, extending centripetally into the zona fasciculata in hyperplasia, supporting a role for ACTH in the regulation of expression, and suggesting that expression of inhibins (alpha beta dimers) is restricted. Immunopositivity for all three subunits was seen in both fetal and definitive zones of the fetal cortex, indicating that both inhibins and activins could be expressed in both. Immunopositivity for all three subunits was seen in most adrenocortical tumours. Loss of immunopositivity for inhibin alpha in a subgroup of carcinomas might indicate a role in tumour progression. The greater intensity of staining for inhibin alpha in tumours associated with Cushing's syndrome again suggests a link with cortisol production.

Clinical features of hypersensitivity reactions to carboplatin

PURPOSE

To characterize the clinical features of carboplatin-associated hypersensitivity reactions.

PATIENTS

Patients with gynecologic malignancies treated at the Cleveland Clinic Foundation from June 1995 through July 1998 who experienced a carboplatin-associated hypersensitivity reaction were the subjects of this evaluation.

RESULTS

Of the 205 patients treated with carboplatin during this time period, 24 (12%) developed a carboplatin hypersensitivity reaction. The median number of platinum (carboplatin plus cisplatin) courses for the first episode was eight (range, six to 21). Only three patients (13%) developed this toxicity during their initial chemotherapy regimen, with the remainder experiencing a reaction during their second (n = 15) or third (n = 6) carboplatin treatment program for recurrent disease. Thirteen patients (54%) developed at least moderately severe symptoms (diffuse erythroderma, tachycardia, chest tightness, wheezing, facial swelling, dyspnea, hypertension, or hypotension). In approximately one half of patients, the reaction developed after more than 50% of the carboplatin had been infused. Only one of three patients was successfully treated with the agent upon rechallenge.

CONCLUSION

Carboplatin hypersensitivity reactions develop in patients who have been extensively pretreated with the agent. The clinical features are highly variable, but they are sufficiently different from those noted after the administration of paclitaxel that it should not be difficult to distinguish between reactions to the two agents. As carboplatin is increasingly used as initial and second-line chemotherapy of ovarian cancer and other malignancies, it can be anticipated that hypersensitivity reactions to the drug will become a more common and difficult clinical management issue.

Use of low-dose oral prednisone to prevent paclitaxel-induced arthralgias and myalgias

OBJECTIVES

The aim of this study was to examine the clinical utility of low-dose oral prednisone in preventing severe paclitaxel-associated arthralgias and myalgias.

METHODS

Patients treated with paclitaxel in the gynecologic oncology program of the Cleveland Clinic Foundation who developed arthralgias/myalgias which were uncontrolled through the use of nonsteroidal anti-inflammatory medications received low-dose oral prednisone (10 mg B.I.D. starting 24 h after the completion of chemotherapy and continuing for a total of 5 days) with their next paclitaxel course.

RESULTS

Of 46 patients meeting the criteria for treatment with the oral prednisone regimen (i.e., subjective feeling of unacceptable discomfort despite the use of nonsteroidal anti-inflammatory agents), 39 (85%) experienced substantial relief of symptoms. All but one of the responding patients requested continuation of the oral prednisone regimen with subsequent paclitaxel treatment cycles. There were no significant toxicities noted in any patient receiving prednisone.

CONCLUSION

This low-dose oral prednisone regimen results in substantial improvement in the majority of patients experiencing significant paclitaxel-associated arthralgias/myalgias.

Expression of mRNAs encoding uncoupling proteins in human skeletal muscle: effects of obesity and diabetes

To explore the potential role of the uncoupling protein (UCP) family in human obesity and diabetes, we have used the reverse transcription-polymerase chain reaction to quantify UCP mRNA expression in human skeletal muscle. Levels of mRNA for UCP2, and for both short (UCP3S) and long (UCP3L) forms of UCP3, were highly correlated in individuals, indicating that gene transcription of these UCPs may be coordinately regulated by common mechanisms. In normal glucose-tolerant individuals, muscle UCP2 mRNA levels were positively correlated with percentage of body fat and with BMI (r = 0.6 and P < 0.05 for both). UCP3S mRNA levels were also positively correlated with percentage of body fat (r = 0.52, P < 0.05), and UCP3L mRNA tended to increase as a function of obesity (0.05 < P < 0.1). UCP mRNA levels, however, were not correlated with resting metabolic rate. UCP3S and UCP3L mRNA levels (P < 0.05) and the UCP2 mRNA level (P = 0.09) were increased by 1.8- to 2.7-fold in type 2 diabetes, an effect that could not be explained by obesity. No significant difference was found for UCP2, UCP3S, or UCP3L mRNA levels between insulin-sensitive and insulin-resistant nondiabetic subgroups. We conclude that 1) skeletal muscle mRNA levels encoding UCP2 and UCP3 are correlated among individuals and may be coordinately regulated; 2) UCP3 expression is not regulated by differential effects on UCP3L and UCP3S forms of the mRNA; and 3) UCP mRNA expression tends to increase in muscle as a function of obesity but not of resting metabolic rate or insulin resistance, and is increased in patients with type 2 diabetes.

Paclitaxel administration to gynecologic cancer patients with major cardiac risk factors

PURPOSE

To examine the safety of administering paclitaxel to patients with preexisting significant cardiac risk factors.

PATIENTS AND METHODS

The medical records of gynecologic cancer patients with major cardiac risk factors who had been treated with paclitaxel (single-agent or combination regimen with cisplatin or carboplatin) at The Cleveland Clinic Foundation from 1993 through February 1998 were examined to determine the acute toxicity of therapy.

RESULTS

A total of 15 patients were found who met these criteria, of whom none were found to have suffered a worsening of cardiac function following treatment with paclitaxel. A single patient developed a severe paclitaxel-associated hypersensitivity reaction, but no cardiac sequela.

CONCLUSION

This series suggests that paclitaxel can be safely administered as a single agent or in a combination regimen with a platinum agent to some patients with significant cardiac risk factors, such as those associated with ischemic heart disease. However, since few patients had baseline severe conduction defects before paclitaxel treatment, the safety of this drug in this clinical setting remains to be determined.

Low-dose oral granisetron (1 mg) plus intravenous dexamethasone: efficacy in gynecologic cancer patients receiving carboplatin-based chemotherapy

OBJECTIVE

The objective of this study was to determine the efficacy of a low-dose oral granisetron plus intravenous dexamethasone prophylactic antiemetic regimen in patients receiving carboplatin-based chemotherapy.

PATIENTS AND METHODS

Patients with gynecologic malignancies being treated with either single-agent carboplatin or a carboplatin-paclitaxel regimen received a single 1-mg oral dose of granisetron 30 min prior to chemotherapy plus intravenous dexamethasone (20 mg) as prophylaxis for emesis. Patients either had not previously been treated with chemotherapy or had not received any cytotoxic drugs for >/=4 months prior to study entry. Effectiveness was evaluated based on the degree of control of nausea and vomiting during the 24 h following treatment.

RESULTS

Of the 32 patients participating in this phase 2 trial, only 2 (6%) experienced any degree of nausea or vomiting within the first 24 h of chemotherapy administration. Both of these individuals had carcinomatosis and were experiencing emesis prior to chemotherapy. One patient developed mild delayed nausea >24 h after treatment. No major or minor toxic effects of the antiemetic regimen observed.

CONCLUSION

A 1-mg dose of oral granisetron plus intravenous dexamethasone (20 mg) is a safe, effective, and relatively inexpensive prophylactic antiemetic regimen for patients receiving single-agent carboplatin or combination carboplatin-paclitaxel chemotherapy.

Evidence that a "treatment-free interval of less than 6 months" does not equate with clinically defined platinum resistance in ovarian cancer or primary peritoneal carcinoma

The standard definition of platinum-resistant ovarian cancer or primary peritoneal carcinoma commonly includes patients whose disease initially responded to a platinum-based combination regimen, but recurred less than 6 months after the completion of primary therapy. Recent experience with several patients with these malignancies treated in the Gynecologic Cancer Program of the Cleveland Clinic Foundation, whose disease recurred within this period but who subsequently responded to platinum therapy, calls into question the validity and clinical relevance of this commonly employed definition, both for the conduct of phase 2 trials of new agents in ovarian cancer and primary peritoneal carcinoma, and for the standard management of women in this clinical setting.

Phase 2 trial of single agent ifosfamide/mesna in patients with platinum/paclitaxel refractory ovarian cancer who have not previously been treated with an alkylating agent

Ifosfamide has been shown to possess modest activity in patients with platinum/cyclophosphamide refractory ovarian cancer. Current standard initial chemotherapy for ovarian cancer does not include an alkylating agent (paclitaxel substituting for cyclophosphamide). To evaluate the activity of ifosfamide in patients with refractory ovarian cancer who had not previously received an alkylating agent, 21 patients with platinum/paclitaxel refractory disease were treated with the drug as a single agent (1.8 g/m2/day x 3 days, with treatment repeated every 28 days). Treatment was reasonably well tolerated in most patients, although 1 individual was removed from study secondary to neurotoxicity. One patient exhibited an objective response of measurable disease, while a second individual had a major decrease in CA-125 levels (no measurable disease present) following therapy. An additional patient experienced disappearance of severe pelvic pain following treatment but failed to meet the criteria for a partial response. We conclude that ifosfamide has modest activity in platinum/paclitaxel refractory ovarian cancer. However, the level of effectiveness does not appear to be increased in individuals who are alkylating-agent naive, compared to previously reported experience in patients with prior exposure to this class of cytotoxic drugs (10-15% response rate).

Phase 2 trial of moderately high dose single agent mitoxantrone in platinum and paclitaxel-refractory ovarian cancer

In the human clonogenic assay, mitoxantrone possesses among the steepest dose-response curves of any cytotoxic agent against ovarian cancer. To test the potential clinical relevance of this observation, we conducted a phase 2 trial of moderately high dose single agent mitoxantrone (28 mg/m2 delivered every 3-4 weeks) along with granulocyte-macrophage colony stimulating factor (250 micrograms/m2/day beginning 24 h after mitoxantrone and continuing until neutrophil recovery) in 34 patients with clinically defined platinum and paclitaxel-refractory ovarian cancer. The major toxicity of treatment was severe neutropenia which was almost universal. However, there were no treatment-related infectious deaths. Significant cardiac toxicity was not observed. Five of 33 evaluable patients demonstrated objective evidence of a response to treatment (1 patient achieving a partial response of measurable tumor masses, 4 patients achieving a > or = 50% reduction in CA-125 antigen level), with a median duration of response of 3 months (range 2-5 months). We conclude that moderately high dose mitoxantrone has definite, although very limited, single agent activity in platinum and paclitaxel-refractory ovarian cancer. Unfortunately, as this regimen produces severe hematologic toxicity and response durations are short, it cannot be recommended for routine clinical use. The role of an even higher dose mitoxantrone schedule employed as a component of a high dose chemotherapy program with bone marrow or peripheral progenitor cell protection in the treatment of ovarian cancer remains to be defined.

Revision of the 1990 working formulation for cardiac allograft rejection: the Sheffield experience

OBJECTIVE

To audit the 1990 International Society for Heart and Lung Transplantation cardiac rejection criteria and to evaluate the impact on classification and clinical outcomes of a modification in which grade 2 is abolished and grades 1A and 1B are amalgamated into a single "grade 1."

METHODS

1652 heart biopsies were reviewed over a four year period. The initial 1348 biopsies (group 1), using the original 1990 criteria, were analysed in terms of diagnostic grade and compared with the 304 biopsies analysed with the modified scheme (group 2). Differences in grading with the 1990 scheme were compared between two groups (1.1 and 1.2) reflecting early and late experience with grading. Subsequently all the grade 2 and grade 1B biopsies were rescored in terms of the modified scheme. Clinical results in terms of actuarial patient survival at one year and freedom from 3A rejection were similarly audited.

RESULTS

The relative ratios of potentially significant rejection (grade 3A, 3B, 4) remained constant over the entire study in groups 1.1, 1.2, and 2. A 50% reduction in grade 2 biopsy reporting was noted comparing early and late parts of group 1. At subsequent review of the group 1 grade 2 biopsies, 97% could be reassigned to grades 0 or 1 in the modified scheme, with the majority of these diagnoses reflecting Quility effect/biopsy site reactions. Two cases (3%) of the 77 grade 2 biopsies were regraded as grade 3A rejection, with both occurring within three months of transplantation. None of the grade 1B biopsies had high grade cardiac rejection on review, most of these biopsies similarly showing pronounced Quility effect and biopsy site reactions. Actuarial survival at one year rose from 86% to 90% during the study, with freedom from 3A rejection remaining unchanged at 80%.

CONCLUSIONS

The original working formulation produces consistent grading except at grade 2, which is judged to be a misnomer resulting from Quility effect and other non-rejection phenomena. While acceptable standardisation can be achieved with the 1990 scheme, the modified scheme has advantages in that it appears to encourage clear discrimination between significant and non-significant cardiac rejection. Overall, elimination of grade 2 did not produce an increase in higher grades of cardiac rejection, and thus the value of this diagnostic grade is questioned.

Ninety-six-hour infusional paclitaxel as salvage therapy of ovarian cancer patients previously failing treatment with 3-hour or 24-hour paclitaxel infusion regimens

PURPOSE

To test the hypothesis that prolonged infusion of paclitaxel (96 hours) might overcome resistance to shorter infusion schedules (3 or 24 hours) in ovarian cancer.

PATIENTS AND METHODS

A total of 30 patients with advanced ovarian cancer (24 patients), primary carcinoma of the peritoneum (four patients), or fallopian tube cancer (two patients) who previously had received paclitaxel administered on either a 3-hour or 24-hour schedule were treated with the agent delivered as a 96-hour infusion (30 to 35 mg/m2/d x 4 days) on an every 3-week program.

RESULTS

Although the regimen generally was well tolerated, no objective responses were observed.

CONCLUSION

In patients with ovarian cancer who have shown resistance to shorter paclitaxel infusion schedules, ninety-six hour infusional paclitaxel is an inactive treatment strategy. This makes it less likely that protracted infusion of paclitaxel will improve outcome when used as part of primary therapy of ovarian cancer. An ongoing randomized study will answer that question.

Reduced quality of clot formation with gelatin-based plasma substitutes

We have studied, over a wide range of dilutions using techniques of clot weight, thrombelastography and scanning electron microscopy, the physical properties of a blood clot formed in vitro when fresh blood was diluted with gelatin-based colloid solutions compared with crystalloid controls. The colloid solutions tested (3.5% polygeline (Haemaccel) and 4% succinylated gelatin (Gelofusine)) produced clots that had reduced median weight (P < 0.001 and P = 0.018, respectively) and reduced mean shear modulus (P < 0.001) compared with crystalloid controls. Scanning electron microscopy showed that the fibrin formed a less extensive mesh in the presence of the gelatin-based colloids compared with crystalloid. Reduction in clot quality with gelatin-based colloids has not been noted previously and further work is needed to ascertain if this occurs in vivo as these solutions are used frequently in patients who require full haemostatic competence.

The effects of intermittent illumination on a visual inspection task

Two experiments are described in which eye movements were monitored as subjects performed a simple target-spotting task under conditions of intermittent illumination produced by varying the display-screen frame rate on a computer VDU. In Experiment 1, subjects executed a saccade from a fixation point to a target which appeared randomly at a fixed eccentricity of 14 character positions to the left or right. Saccade latency did not differ reliably as a function of screen refresh rate, but average saccade extent at 70 Hz and 110 Hz was reliably shorter than at 90 Hz and 100 Hz. Experiment 2 examined the same task using a range of target eccentricities (7, 14, and 28 character positions to the left and right) and across a wider range of screen refresh rates. The results confirmed the curvilinear relationship obtained in Experiment 1, with average saccade extent reliably shorter at refresh rates of 50 Hz and 125 Hz than at 75 Hz and 100 Hz. While the effect was greater for remote targets, analyses of the proportional target error failed to show a reliable interaction between target eccentricity and display refresh rate. In contrast to Experiment 1, there was a pronounced effect of refresh rate on saccade latency (corrected for time to write the screen frame), with shorter latencies at higher refresh rates. It may be concluded that pulsation at frequencies above fusion disrupts saccade control. However, the curvilinear functional relationship between screen refresh rate and saccade extent obtained in these studies differs from previously reported effects of intermittent illumination on the average size of "entry saccades" (the first saccade to enter a given word) in a task involving word identification (Kennedy & Murray, 1993a, 1996). This conflict of data may arise in part because within-word adjustments in viewing position, which are typical of normal reading, influence measures of average saccade extent.

Exercise and heart disease: cardiac findings in fatal cycle accidents

BACKGROUND

Regular cyclists have been found to have a lower incidence of coronary events (CHD) than the general public. Non-invasive studies have found that competitive cyclists develop a cardiac hypertrophy that is physiological and reversible.

METHODS

To obtain pathological support for these observations, the postmortem findings of 32 cyclists killed in accidents have been compared with those in a control group of 32 other road traffic accidents, which were matched with the cyclists by sex, age, and year of death.

FINDINGS

Large myocardial scars and complete blockage of a coronary artery were only found in the controls; serious stenoses of coronary arteries (> 50%) were found in eight controls but in only one of the cyclists. Of the cyclists, 25 had normal coronary arteries as compared with 14 of the controls. The mean age of the cyclists with evidence of CHD was greater than that of similarly affected controls. The heart weights of the two groups were almost the same but heart weight varied with the degree of CHD. The heart weight of the healthy cyclists (389 g) was greater than that of the healthy controls (371 g) but this was not statistically significant.

INTERPRETATION

The results are in keeping with the concept that regular exercise provides some protection from the development of CHD and that cycling may be a valuable form of exercise in this respect. This may be of importance as the number of physically active occupations declines.

Split tibialis posterior tendon transfer in the treatment of spastic equinovarus foot

Sixteen patients with cerebral palsy causing equinovarus deformity were treated surgically. All of these patients underwent preoperative gait analysis by using a CODA-3 motion analyzer. The equinus deformity was assessed by using sagittal kinematics, and in particular, the range of movement of the ankle during stance phase and the maximal dorsiflexion during swing. The varus deformity was assessed by the degree of varus of the foot at prepositioning. The degree of varus was obtained by measuring the angle generated between the plane of progression and a line joining a marker on the heel to a marker on the fifth metatarsal in the transverse plane. All patients underwent split tibialis posterior tendon transfer and, in 13, this was combined with tendo calcaneus lengthening. Clinical assessment and gait analysis repeated 1 year postoperatively confirmed good outcome after split tibialis posterior tendon transfer in combination with gastrocnemius lengthening. This was confirmed by using sagittal kinematic analysis and quantitative assessment of the degree of varus of the foot at the time of prepositioning.