Genetic prediction of long-term survival after neoadjuvant chemoradiation in locally advanced esophageal cancer

Candidate genes involved in DNA repair, 5-fluorouracil metabolism and drug detoxification were genotyped in 124 patients receiving neoadjuvant chemoradiation treatment for locally advanced esophageal cancer and their predictive role for long-term relapse-free survival (RFS) and cancer-specific survival (CSS) were evaluated. A panel including MTHFR 677TT, MDR1 2677GT, GSTP1 114CC, XPC 499CC and XPC 939AC+CC, defined as high-risk genotypes, discriminated subgroups with significantly different outcomes. When the panel was combined with histology, patients split into two subsets with 5-year RFS and CSS rates of 65% vs 27% (hazard ratio (HR) 3.0, P<0.0001) and 69% vs 31% (HR 2.9, P<0.0001), respectively. Combining the 5-single-nucleotide polymorphism (5-SNP) panel with pathological response defined two major informative risk classes with 5-year PFS and CSS rates of 79.4% vs 17.7% (HR 6.71, P<0.0001) and 79.3% vs 26.3% (HR 6.25, P<0.0001), respectively. This classification achieved a sensitivity of 79%, a specificity of 85.4% and an accuracy of 81.8%.

Predictive markers in elderly patients with estrogen receptor-positive breast cancer treated with aromatase inhibitors: an array-based pharmacogenetic study

So far, no reliable predictive clinicopathological markers of response to aromatase inhibitors (AIs) have been identified, and little is known regarding the role played by host genetics. To identify constitutive predictive markers, an array-based association study was performed in a cohort of 55 elderly hormone-dependent breast cancer (BC) patients treated with third-generation AIs. The array used in this study interrogates variants in 225 drug metabolism and disposition genes with documented functional significance. Six variants emerged as associated with response to AIs: three located in ABCG1, UGT2A1, SLCO3A1 with a good response, two in SLCO3A1 and one in ABCC4 with a poor response. Variants in the AI target CYP19A1 resulted associated with a favourable response only as haplotype; haplotypes with increased response association were also detected for ABCG1 and SLCO3A1. These results highlight the relevance of host genetics in the response to AIs and represent a first step toward precision medicine for elderly BC patients.

In vitro hemocompatibility and vascular endothelial cell functionality on titania nanostructures under static and dynamic conditions for improved coronary stenting applications

The usefulness of nanoscale topography in improving vascular response in vitro was established previously on hydrothermally modified titanium surfaces. To propose this strategy of surface modification for translation onto clinically used metallic stents, it is imperative that the surface should be also hemocompatible: an essential attribute for any blood-contacting device. The present in vitro study focuses on a detailed hemocompatibility evaluation of titania nanostructures created through an alkaline hydrothermal route on metallic Ti stent prototypes. Direct interactions of TiO2 nanocues of various morphologies with whole blood were studied under static conditions as well as using an in vitro circulation model mimicking arterial flow, with respect to a polished Ti control. Nanomodified stent surfaces upon contact with human blood showed negligible hemolysis under constant shear and static conditions. Coagulation profile testing indicated that surface roughness of nanomodified stents induced no alterations in the normal clotting times, with insignificant thrombus formation and minimal inflammatory reaction. Endothelialized nanomodified Ti surfaces were found to inhibit both activation as well as aggregation of platelets compared with the control surface, with the endothelium formed on the nanosurfaces having an increased expression of anti-thrombogenic genes. Such a nanotextured Ti surface, which is anti-thrombogenic and promotes endothelialization, would be a cost-effective alternative to drug-eluting stents or polymer-coated stents for overcoming in-stent restenosis.

Cerebrovascular reactivity during hypothermia and rewarming

BACKGROUND

Experimental evidence from a murine model of traumatic brain injury (TBI) suggests that hypothermia followed by fast rewarming may damage cerebral microcirculation. The effects of hypothermia and subsequent rewarming on cerebral vasoreactivity in human TBI are unknown.

METHODS

This is a retrospective analysis of data acquired during a prospective, observational neuromonitoring and imaging data collection project. Brain temperature, intracranial pressure (ICP), and cerebrovascular pressure reactivity index (PRx) were continuously monitored.

RESULTS

Twenty-four TBI patients with refractory intracranial hypertension were cooled from 36.0 (0.9) to 34.2 (0.5) degrees C [mean (sd), P < 0.0001] in 3.9 (3.7) h. Induction of hypothermia [average duration 40 (45) h] significantly reduced ICP from 23.1 (3.6) to 18.3 (4.8) mm Hg (P < 0.05). Hypothermia did not impair cerebral vasoreactivity as average PRx changed non-significantly from 0.00 (0.21) to -0.01 (0.21). Slow rewarming up to 37.0 degrees C [rate of rewarming, 0.2 (0.2) degrees C h(-1)] did not increase ICP [18.6 (6.2) mm Hg] or PRx [0.06 (0.18)]. However, in 17 (70.1%) out of 24 patients, rewarming exceeded the brain temperature threshold of 37 degrees C. In these patients, the average brain temperature was allowed to increase to 37.8 (0.3) degrees C (P < 0.0001), ICP remained stable at 18.3 (8.0) mm Hg (P = 0.74), but average PRx increased to 0.32 (0.24) (P < 0.0001), indicating significant derangement in cerebrovascular reactivity. After rewarming, PRx correlated independently with brain temperature (R = 0.53; P < 0.05) and brain tissue O2 (R = 0.66; P < 0.01).

CONCLUSIONS

After moderate hypothermia, rewarming exceeding the 37 degrees C threshold is associated with a significant increase in average PRx, indicating temperature-dependent hyperaemic derangement of cerebrovascular reactivity.

Validation of physiological scoring systems in the accident and emergency department

BACKGROUND

Scoring systems that weigh the degree of abnormality of bedside observations might be able to identify patients at risk of catastrophic deterioration.

OBJECTIVES

To establish a frequency distribution for typical physiological scoring systems and to establish the potential benefit of adding these to an existing triage system in accident and emergency departments.

METHODS

Physiological data were collected from 53 unselected emergency department admissions, from 50 patients admitted from the emergency department to intensive care, and from 50 patients admitted from emergency department to general wards and then to intensive care. Three different physiological scores were calculated from the data. Identification of sick patients by the scores was compared with triage information from the Manchester Triage System (MTS).

RESULTS

Most patients admitted to the emergency department would not be identified as critically ill with the aid of physiological scoring systems. This was true even for patients who were admitted to intensive care. Only in 0-8% of unselected patients did the scores indicate increased risk. In 100 patients admitted to the intensive care, adding of medical emergency team call-out criteria, Modified Early Warning Score or Assessment Score for Sick patient Identification and Step-up in Treatment would identify none, seven or one patient in addition to those triaged as orange and red by the MTS.

CONCLUSIONS

Introduction of a physiological scoring system would have identified only a small number of additional patients as critically ill and added little to the triage system currently in use.

Pharmacokinetic and demographic markers of 5-fluorouracil toxicity in 181 patients on adjuvant therapy for colorectal cancer

BACKGROUND

The relationship between 5-fluorouracil (5-FU) pharmacokinetics and toxicity following i.v. bolus administration has not been extensively studied.

PATIENTS AND METHODS

One hundred and eighty-one patients on adjuvant therapy with 5-FU plus leucovorin for colorectal cancer were the study population. 5-FU pharmacokinetics was determined on day 2 of the first, third, and fifth cycles; type and the grade of adverse reactions were recorded on the next cycle.

RESULTS

The 5-FU area under the curve (AUC) measured at the first cycle ranged between 146 and 1236 mg x min/l and was significantly correlated with drug dose, patients' body weight (BW) and gender, females having higher AUCs. These covariates explained only 23% of AUC variability. AUC and age were the only covariates which discriminated between toxic (grade > or =2) and nontoxic cycles (grade <2), with an optimal AUC cut-off value of 596 mg x min/l. Such a correlation was lost during the next cycles following dose reduction because of toxicity in 80 patients.

CONCLUSIONS

A method for calculating the initial 5-FU dose is proposed which takes into account patient BW, gender and a target AUC of 596 mg x min/l. Nevertheless, it appears that a substantial part of 5-FU toxicity is not linked to pharmacokinetic factors and dose adjustments must still be on the basis of careful clinical surveillance.

Cerebral protection devices for use during carotid artery stenting

(1) Cerebral protection devices offer a new approach to reducing the risk of stroke and death in patients undergoing carotid angioplasty with stenting (CAS). (2) Nine studies have examined the efficacy of cerebral protection devices, by comparing the incidence of procedure related stroke and death to that of CAS without protection, and to surgical endarterectomy. Few of the studies were of high quality. (3) Overall, the differences in the incidence of procedure-related stroke and death were not statistically significant among patients who underwent CAS without protection, compared to those who received CAS with protection, or to those who underwent endarterectomy. (4) Complications reported with the use of cerebral protection devices are minor and transient. (5) CAS with cerebral protection may offer a safe and efficacious alternative to endartectomy in symptomatic, high risk patients with severe carotid artery disease. Evidence to support the use of CAS with cerebral protection devices in asymptomatic patients who have severe carotid artery stenosis, is unavailable.