Glucocorticoid treatment in rheumatoid arthritis: low-dose therapy does not reduce responsiveness to higher doses

BACKGROUND

Despite low-dose gluco-corticoid (GC) treatment, many patients with rheumatoid arthritis (RA) require additional flare therapy with GC at higher doses. Since low dose GC has been suggested to confer resistance to higher doses, we aimed to assess if resistance was detectable on the clinical level in patients with active RA.

METHODS

Eighty-nine patients with active RA (Disease Activity Score 28, DAS28>3.2; mean age 54.5 years, mean duration of RA 9.7 years) were consecutively enrolled into a one-week trial of a total of 250 mg prednisolone. We compared improvement of the DAS28 and the Simplified Disease Activity Index (SDAI) in groups of patients with (n=41) and without (n=48) low-dose GC at baseline (by t-test). In addition, we analyzed changes of all individual core set measures of disease activity using multivariate statistics.

RESULTS

All clinical, serological and functional measures improved significantly over one week (p<0.001). Baseline RA activity of patients with and without low-dose GC was on average +/- standard deviation similar among the two groups (DAS28: 4.8+/-1.2 and 4.9+/-1.1; mean SDAI: 26.1+/-14.0 and 25.9+/-13.0, respectively), and likewise there was no difference between the two groups in the final disease activity reached, for both the DAS28 (1.4+/-1.1 vs. 1.1+/-1.0; p=0.14) and the SDAI (11.1+/-13.4 vs. 11.1+/-11.4; p=0.99). Improvement in all individual measures was also not different using a multivariate model (p=0.26).

CONCLUSION

Pre-treatment with low-dose GC does not appear to portend GC resistance at least clinically, since the responsiveness to GC boosts is unaffected.

Prevailing therapeutic regimes and predictive factors for prandial insulin substitution in 26 687 children and adolescents with Type 1 diabetes in Germany and Austria

AIMS

To analyse current therapeutic strategies for prandial insulin substitution in a large number of children and adolescents with Type 1 diabetes in Germany and Austria, along with changes in therapeutic habits and outcome.

METHODS

We classified the data of 26 687 patients, treated from 1995 to 2005 in 152 paediatric clinics, using a database established for quality control and scientific surveys in paediatric diabetology (DPV).

RESULTS

Seventy-three per cent of all patients (mean age 13.6 years., mean duration of diabetes 5.4 years.) were treated with > or = 4 daily injections (intensified conventional treatment; ICT), 14% with continuous subcutaneous insulin infusion (CSII), 13% with 1-3 injections per day (conventional treatment). Frequency of daily injections increased with age, duration of diabetes and insulin dose. The insulin dose at breakfast was higher than for the evening meal or lunch, from diagnosis onwards. Individuals using insulin analogues received up to 11% higher insulin doses per day compared with patients treated with human insulin. The time of day, age, duration of diabetes, female gender, insulin analogues and ICT all had a significant influence on prandial insulin doses. Although the number of patients treated with ICT or CSII increased over the period of observation, mean glycated haemoglobin (HbA(1c)) was approximately 8.0% each year, and decreased by only 0.01%.

CONCLUSIONS

Eighty-seven per cent of patients were treated with ICT or CSII. However, while this percentage increased over the observation period, mean HbA(1c) was almost constant. Longer duration of diabetes, increasing age, female gender, insulin analogues and ICT were associated with higher prandial insulin doses.

Impact of RYR1 genotype of Piétrain boars on litter traits of Czech Large White x Czech Landrace crossbred sows

Piétrain boars of different ryanodine receptor (RYR1) genotypes (NN, Nn and nn, three boars each) were mated with approximately 10 Czech Large White x Czech Landrace sows (genotype NN) each to produce one litter per sow. The progeny of nn boars had a significantly higher individual weaning weight (7.31 kg versus 6.86 kg) and average daily gain from birth to weaning (252 g/day versus 240 g/day) than the progeny of NN boars. Furthermore, piglets from nn boars differed statistically significant also from piglets of boars with the Nn genotype for these two traits. The litters of the NN boars were greater by 0.5 piglets than the litters of the nn boars for the total number of piglets born, piglets born alive and piglets weaned, but the differences were not significant. The Nn genotype showed for all litter size traits and the number of stillborn piglets the best values. The difference between the genotypes Nn and nn was statistically significant at the 0.05 level for the number of piglets born alive and the number of piglets weaned.

[MRI screening before stem cell transplantation--necessary?]

PURPOSE

In the context of stem cell transplantation (SCT), we often observe neurological complications as a consequence of immune system suppression, conditioning therapy or prophylaxis and treatment of graft-versus-host disease. Furthermore, cerebral lesions in existence prior to transplantation can be found. The aim of this study was to evaluate the benefit of cerebral magnetic resonance imaging (MRI) prior to stem cell transplantation.

PATIENTS AND METHOD

Cerebral MR examinations of 116 children and adolescents were performed before SCT. Patients ranged in age from 1.1 to 21.4 years (mean 12.6 years). All MR images were obtained by a 1.5 T system. The predefined short protocol included an axial T 1-weighted SE sequence and a coronary T 2-weighted TSE sequence. We evaluated existing cerebral lesions, the diameter of the ventricular system, and the paranasal sinuses. In the case of pathological findings, the short examination protocol was expanded.

RESULTS

In 5 of 116 children (4.3 %) we observed prior to SCT findings requiring immediate treatment although the patients did not show any clinical symptoms (1 x aspergilloma, 1 x hemorrhage of vascular anomaly). An increased risk of bleeding caused by cavernoma or another vascular anomaly without hemorrhage also had to be taken into account. 32 of 116 patients (37.1 %) showed atrophic lesions. In 42 children (36.2 %), we observed affections of the paranasal sinuses.

CONCLUSION

The imaging findings requiring immediate treatment even though the children did not show any clinical signs, justify cerebral MR examinations prior to stem cell transplantation.

Optimum storage conditions for cord blood-derived hematopoietic progenitor cells prior to isolation

Optimum storage conditions of cord blood-derived hematopoietic progenitor cells before isolation remain unknown. We therefore evaluated CD34+ cells isolated from cord blood units (n=57) within 1 h after collection and following storage for 24, 48 and 72 h at either room temperature (RT) or 4 degrees C. Isolated CD34+ cells were analyzed for their cell count, immunophenotype, apoptosis rate, clonogenicity and transmigration capacity in response to stroma-derived factor 1alpha using direct-paired comparisons (n=27). CD34+, CD133+ and CD45+ positivity after isolation remained the same under all conditions. After 24 h, CD34+ cell counts and numbers of CFU-GM colonies dropped regardless of the storage temperature. After 48 h, the number of CD34+ cells increased compared to 24 h, if the cord blood had been stored at RT resulting in almost three times more CD34+ cells than at 4 degrees C. These cells had a lower early apoptosis rate and formed four times more BFU-E than those stored at 4 degrees C with equivalent plating efficiencies. CD34+ cells kept at RT for 48 h had the highest transmigration capacities, which paralleled an increased CXCR-4 expression. Cord blood should be stored at RT before CD34+ isolation and a storage time for 48 h should be preferred to 24 h.

Impact of milk pricing system on the economic response to selection on milk components

The impact of various milk pricing systems on the economic weights and the resulting selection responses for milk yield and fat and protein contents in Holstein and Czech Fleckvieh were investigated. The calculations were done for the situations with and without quotas on milk yield and fat content. There was a substantial influence of the milk pricing system on the selection response. The use of index weights based on a 'wrong' pricing system reduced the total economic selection response by up to 51% of the selection response expected for an index based on the 'correct' pricing system. Financial losses in the selection response were greater with quotas than without quotas. Higher losses were also calculated for Holstein compared with Czech Fleckvieh. Incorrect assumptions on the output limitation (absence or presence of milk quotas) led only to minor reductions in the total selection response (mostly <2%) if the other parameters were correct. The results indicate that customized subindices for milk production traits would increase farmers' profit from sire selection when selling milk on the basis of different pricing systems.

A phase I study of imatinib mesylate and paclitaxel in patients with advanced (stage IIIC/IV) or recurrent uterine papillary serous carcinoma (UPSC)

16025

Background: Uterine serous carcinoma (USC) is a rare, aggressive uterine tumor biologically distinct from typical endometrial cancers. Imatinib mesylate (IM)-associated kinases (kit, abl, PDGFR-B) are overexpressed and activated in most tumors from patients (pts) with USC. Single agent paclitaxel (TAX) has a good response rate but short duration of response in pts with USC. The purpose of this study was to determine the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) of escalated doses of IM with a fixed dose of TAX. Methods: Pts with newly diagnosed (stage IIIC/IV) or recurrent USC were eligible (pts were required to have tumors that expressed at least one of the IM-targeted kinases by immunohistochemistry). Measurable disease was not required. TAX was administered at 175 mg/m2 every three weeks. One dose reduction to 135 mg/m2 was allowed. IM was given daily (400 mg, 500 mg or 600 mg). A 3+3 design was implemented. Pts with measurable disease were treated until progression or treatment associated toxicity. Pts with no measurable disease were treated for six cycles. Results: 11 pts were enrolled. The median age was 62 years (47–79). A total of 50 cycles were administered. Three pts were treated at the first dose level (400 mg), 6 pts treated at the second dose level (500 mg), and 2 pts were treated at the highest dose level (600 mg). Three DLTs were observed (1 at 500 mg level and 2 at 600 mg level) including: rash, neutropenia, and fatigue. IM 500 mg daily and TAX 175 mg/m2 every three weeks was the MTD. There were 3 serious adverse events not related to treatment (infection, dyspnea, pain). Neutropenia was the most common grade 3 or 4 toxicity but only one patient required TAX dose reduction. 8 pts were evaluated for efficacy (2 with measurable disease, 6 with no measurable disease). 1 (of 2) pts with measurable disease had a partial response and was treated for 13 cycles. Of the 6 pts with no measurable disease, 2 recurred (5 and 10 months). The median disease free interval for the pts without recurrent disease was 22 months (6–30). Conclusion: Combination therapy of IM and TAX is well tolerated with minimal side effects in pts with advanced or recurrent USC. Initiation of the phase II component of this study is warranted to better evaluate efficacy.

No significant financial relationships to disclose.

A phase II study of RAD001 (R) (everolimus) monotherapy in patients (pts) with advanced non-small cell lung cancer (NSCLC) failing prior platinum-based chemotherapy (C) or prior C and EGFR inhibitors (EGFR-I)

7589

Background: R is an oral inhibitor of mammalian target of rapamycin (mTOR) with anti-tumor activity. Single-agent R and in combination with other anticancer agents showed efficacy in in vitro and in vivo NSCLC models. In a phase I study, 4 disease stabilizations (SD) and 1 partial response (PR) were reported from 14 NSCLC pts treated with R monotherapy. Methods: Advanced NSCLC pts with adequate organ function, performance status ≤ 2, failing either ≤ 2 C (arm 1) or ≤ 2 C and an EGFR-I (arm 2) were treated with R at 10 mg qd if tolerable until progression (PD). Study applied a Simon-2-stage design with primary endpoint of objective tumor response rate (RR) according to RECIST. CT scans were performed every 28 days until month 4 and then every 2 months thereafter. Adverse events (AE) were assessed using NCI CTC v. 2.0. Results: This analysis is based on data acquired up to 20 Sep 2006. 85 pts were enrolled between 08/2005 and 05/2006. Demographics and patient disposition were (arm 1/arm 2): 42/43 (7 pts ongoing), female 38.1%/51.2%, never smoker 14.3%/44.2%, adenoca. 57.1%/62.8%, squamous cell ca. 21.4%/14.0%, BAC 2.4%/16.3%, others 19.1%/6.9%. Median age was 60 years (range 21–74). R was given on arm 1 as 2nd line therapy in 64.3% of pts., as 3rd line in 35.7% and on arm 2 as 3rd line in 58.1%, as 4th line in 41.9%. 90.6% pts had stage IV disease. The trial did not proceed to stage 2 based on RR for 74 pts in the efficacy population. Best overall tumor response (arm 1/2 in %): confirmed PR (5.3/2.8), SD (44.7/44.4); SD ≥ 12 weeks (34.2/41.7), duration of SD in days arm 1 (58 –267) and arm 2 (68 –231). Median PFS on arm 1 is 11.3 weeks (95% CI: 8.1; 12.4) and on arm 2 is 9.7 weeks (7.3; 13.0). Most frequent AEs (pts, all grades/grade 3 and 4): stomatitis/mucositis (43/5), cough (27/1), dyspnea (33/8), rash (26/0), fatigue (25/10), anorexia (25/1), nausea (20/0), anemia (18/3), epistaxis (18/0), diarrhea (17/2). Analyses of molecular markers in tumor tissue samples are ongoing. Conclusions: 10 mg qd R monotherapy is well tolerated and shows limited activity in pretreated advanced NSCLC pts. Combination trials with both standard chemotherapy and targeted agents are in progress.

No significant financial relationships to disclose.

Vandetanib with pemetrexed in patients with previously treated non-small cell lung cancer (NSCLC): An open-label, multicenter phase I study

7654

Background: Vandetanib (ZD6474) is a once-daily oral anticancer drug that selectively inhibits VEGF-dependent tumor angiogenesis and EGFR- and RET-dependent tumor cell proliferation and survival. Methods: Eligible patients had locally advanced or metastatic NSCLC (stage IIIB/IV) after failure of 1st-line chemotherapy. An initial cohort of 10 patients received once- daily oral vandetanib (100 mg) with pemetrexed (500 mg/m2 i.v. infusion every 21 days). If <2 patients experienced a vandetanib- related dose-limiting toxicity (DLT), an additional cohort received vandetanib 300 mg + pemetrexed. The planned duration of treatment was =6 weeks. The primary objective of the study was to establish the safety and tolerability of vandetanib + pemetrexed. Secondary objectives included an assessment of pharmacokinetic (PK) interaction and preliminary assessment of efficacy (RECIST). Results: Twenty- one patients (14 male, 7 female; mean age 60 years, range 44–77) received vandetanib 100 mg + pemetrexed (n=10) or vandetanib 300 mg + pemetrexed (n=11). One DLT was reported in each cohort: QTc prolongation (>100 ms from baseline, but absolute QTc <500 ms) in a male patient who had electrolyte imbalance and short baseline QTc interval of 318 ms (100 mg cohort); and interstitial lung disease, which resolved after steroid therapy, in a Caucasian female patient with bronchoalveolar carcinoma and a long smoking history (300 mg cohort). The most common adverse events (AEs) were rash, anorexia, fatigue and diarrhea (all n=10; 48%). The most frequent CTC grade 3/4 AEs were increased gamma-glutamyltransferase (n=4), anorexia (n=3) and dyspnea (n=3), which are generally consistent with previous experience with vandetanib and pemetrexed as monotherapies. There was no apparent PK interaction between vandetanib and pemetrexed. In 18 patients evaluable for efficacy, there was one confirmed partial response (female; 100 mg cohort) and 13 stable disease =6 weeks. Conclusions: In patients with advanced NSCLC, vandetanib + pemetrexed was generally well tolerated, with no apparent PK interaction. A Phase III trial of vandetanib 100 mg + pemetrexed in 2nd-line NSCLC has begun.

No significant financial relationships to disclose.

Selection for Profit in Cattle: II. Economic Weights for Dairy and Beef Sires in Crossbreeding Systems

The relative economic importance (economic weights) of 18 traits was determined for Holstein and Charolais sires used in a dairy production system applying cross-breeding with beef sires and in a cow-calf pasture cross-breeding system with integrated fattening of surplus animals. A bioeconomic model containing a profit function was used for the calculations in both systems. Discounted expressions for direct and maternal components of the traits during an investment period of 25 yr were calculated using the gene-flow technique. The relative economic weights for some traits or trait components of the dairy sires differed substantially between the purebred and crossbred dairy systems. There were also meaningful differences among the relative economic weights of traits for beef sires, depending on whether these bulls were used for terminal crossing with F1 females in the cow-calf pasture system (back-crossing), for crossing in dairy herds producing slaughter animals, or for crossing in dairy herds producing F1 females for the cow-calf pasture system. We therefore recommend construction of specific sets of subindices for dairy and beef sires to allow users to rank the bulls according to expected merit of their progeny in specific production systems.

Selection for Profit in Cattle: I. Economic Weights for Purebred Dairy Cattle in the Czech Republic

A bioeconomic model for dairy cattle production was used to estimate economic values of 18 traits for dairy sires in purebred Holstein and Czech Fleckvieh populations. Economic values were defined as partial derivatives of the profit function with respect to each trait in a closed production system with dairy cow herds and integrated fattening of bulls. All revenues and costs associated with cows calving in the herds within one year and with their progeny were discounted at 5% per annum back to the date of calving. Calculations were carried out for the situation in the Czech Republic in 2005 (scenario 1: market quotas for milk yield and fat percentage) and for the expected situation in 2015 (scenario 2: free market). The relative economic importance of each trait was expressed as a ratio of the standardized economic value of that trait (its marginal economic value multiplied by its genetic standard deviation) to the standardized economic value of 305-d milk yield, with average fat and protein percentages. In addition to milk yield, somatic cell score was the second most important trait, achieving 32% to 43% of the value for milk yield in both scenarios. The relative importance of milk components differed notably between scenarios. The relative importance was approximately zero for protein and from -14 to -23% for fat percentage in scenario 1, but changed to 38% for protein and 27 to 31% for fat percentage in scenario 2. In both scenarios and for both breeds, the relative economic values for somatic cell score and length of productive life of cows were similar to those for fat and protein percentages in scenario 2. The smallest relative economic values (less than 4% of the relative importance of milk yield) were for birth weight, conception rate of heifers, and carcass traits. In conclusion, relative emphasis among traits in the breeding objective for Czech dairy cattle should be reassessed according to the expected situation after shifting to a free market economy in 2015.

Hyperprolactinemia and amenorrhea associated with olanzapine normalized after addition of aripiprazole

Hyperprolactinemia is a frequent side-effect in the use of atypical antipsychotics. The propensity to induce hyperprolactinemia is highly substance dependent and hyperprolactinemia is not always associated with clinical side-effects. We report a case in which hyperprolactinemia and amenorrhea under the treatment with olanzapine gets normalized after the addition of aripiprazole.