Sunitinib in BCG-refractory non-muscle-invasive transitional cell carcinoma of the bladder

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Background: Treatment options for pts with BCG-refractory NMITCC are limited and there is no established role for systemic chemotherapy in this setting. While cystectomy remains the gold standard, the vast majority of pts are unable or unwilling to have surgery. Sunitinib is an oral tyrosine kinase inhibitor of VEGFR-2, PDGFR, KIT and FLT3 with demonstrated antitumor activity in advanced TCC. To determine the clinical and biologic effects of sunitinib in BCG-refractory NMITCC pts a prospective phase II study was conducted.

Methods: Pts with biopsy proven BCG- refractory NMITCC received three 28-day cycles of continuous sunitinib (37.5 mg PO). Subsequently, pts underwent cystoscopic evaluation. If no tumor was found, pts continued with standard cystoscopic surveillance. A single stage design was employed to test the hypothesis of a 25% improvement in the 12-month CR rate over the 20% CR historically observed in this setting. Overall response rate (ORR), disease-free recurrence (DFR) and safety were recorded. Exploratory endpoints included treatment effect on CTCs, type-1 response and immunosuppressive Treg cells.

Results: To date 17 of a planned 31 pts are enrolled. Median age is 72 years (range, 54-82); 94% of pts were ECOG 0; 6 pts had received additional intravesical therapy other than BCG. Fourteen pts have already completed 3 cycles of treatment and 13 pts had at least once cystoscopic assessment. Among these, 8 pts (62%) were NED in their first cystoscopic evaluation. Most common treatment-related toxicity observed in both studies included fatigue, HTN, stomatitis, PPE, diarrhea and thrombocytopenia. Treatment with sunitinib also resulted in a sustained increase (compared to pre-treatment) in CD3+ and CD4+ IFN-g producing T-cells (p < 0.07). In addition there was a significant decrease in CD33+ MDSC following 2 and 3 cycles of therapy (p < 0.04). There was also a significant decrease in T regulatory cells following 2 cycles of therapy (p = 0.04); however it was not maintained during cycle 3 (p = 0.36).

Conclusions: Sunitinib has modest clinical activity in pts with BCG-refractory NMITCC. Early immune studies also denote the ability of sunitinib to restore the balance of type-1 and type-2 immune response in bladder cancer.

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Relationship between gastrointestinal transit time and anesthetic fasting protocols in the captive chimpanzee, Pan troglodytes

BACKGROUND

Lengthy social separation and prolonged fasting time contribute to increased risks associated with anesthesia in captive primates. This study is an initial attempt to identify a safe pre-anesthetic fasting procedure by identifying gastric emptying time (GET) and gastrointestinal transit time (GTT) of captive chimpanzees, Pan troglodytes.

METHODS

Seven adult chimpanzees at the North Carolina Zoo immobilized for annual physical examinations were fed barium-impregnated polyethylene spheres to measure GET. Eleven animals were individually fed a color dye marker and fecal passage was observed to determine GTT.

RESULTS

Gastric emptying time (GET) was approximated to be >3 hours but <16 hours. The mean GTT was 16.5 hours.

CONCLUSIONS

This study indicates that a fasting time of 3 hours would allow for complete gastric emptying and could potentially replace the current overnight fast (≥16 hour) to help minimize complications associated with pre-anesthetic fasting in captive primates.

Observed Properties and Electronic Structure of RNiSb Compounds (R = Ho, Er, Tm, Yb and Y). Potential Thermoelectric Materials

The RNiSb compounds (R=Ho, Er, Tm, Yb and Y) and some selected solid solution members such as (Zr1-xErx)Ni(Sn1-xSbx) and ErNiSb1-xPnx (Pn=As, Sb, Bi) have been studied. They all crystallize in the MgAgAs structure type, which can be considered as a NaCI structure type in which half of the interstitial tetrahedral sites are occupied by Ni atoms. The measured values of the Seebeck coefficients, at room temperature, are positive for RNiSb (R=Ho, Er, Yb and Y) compounds and ErNiSb1-xPnx (Pn=As, Sb, Bi) solid solutions, but for (Zr1-xErx)Ni(Sn1-xSbx) members vary from negative to positive values when 0 < x < 1. Some of these compounds show metallic conductivity while others exhibit thermally activated charge transport. Solid solutions of these materials have lower thermal conductivities than the pure members, RNiSb (R=Ho, Er, Yb and Y) and ZrNiSn. The electronic structures of RNiSb compounds, where R is Y, La, Lu, and Yb, have been studied with density functional theory. The results of the calculations for these systems, except for the Yb compound, indicate narrow gap semiconductors with large effective masses near the conduction band extrema. The Yb system is expected to show heavy fermion characteristics.

Thermoelectric Properties of the Cubic Family of Compounds AgPbBiQ3 (Q = S, Se, Te). Very Low Thermal Conductivity Materials

The AgPbBiQ3 class of compounds and their solid solution members are related to the NaCl structure type, where Ag, Pb and Bi atoms are statistically disordered on the Na site and Q atoms occupy the Cl site. These compounds were synthesized by combining the elements in the appropriate ratio and heating under static vacuum at 900° C for 3 days. They are narrow gap semiconductors with band gaps in the range of 0.6 to 0.28 eV. The charge-transport properties were measured on ingots as a function of temperature. The compounds AgPbBiTe3, AgPbBiSe3, AgPbBiTe2.75Se0.25and AgPbBiTe2Se, undoped, possess an electrical conductivity in the range of 70 S/cm to 400 S/cm. These materials exhibit negative thermopower ranging from -40 μV/K to -160 μV/K at room temperature and thermal conductivity less than 1.30 W/mK.

Perceptions and beliefs in sarcoidosis

BACKGROUND

Sarcoidosis is a chronic multisystem disease with a high prevalence of depression although this is often not recognised. It is not known how patients perceive their disease or the medications required for treatment. We hypothesised that perceptions of illness and beliefs about medications may relate to psychological distress in this condition.

METHODS

81(42 female) patients with sarcoidosis completed the following: Hospital Anxiety and Depression Scale, Illness Perception Questionnaire, Beliefs about Medications Questionnaire. Demographic and clinical data were collected and the physician's perception of symptom severity and relationship to sarcoidosis recorded.

RESULTS

The prevalence of depression (23%) and anxiety (33%) was high and related to self reported symptoms of sarcoidosis. Those on current treatment reported different illness perceptions than those not, and illness perceptions related to anxiety and depression scores. The majority of the sample felt that sarcoid medications were unnecessary but few patients reported concerns about potential adverse consequences of taking them. Beliefs about medications were related to illness perceptions but not associated with anxiety or depression scores or with clinical perception of disease state. There were significant gender differences in perceptions of illness and beliefs about medications.

CONCLUSIONS

These data confirm earlier reports that anxiety and depression are common in patients with sarcoidosis and in turn perceptions of illness impact on emotional wellness in this disorder. Use of the Illness Perceptions Questionnaire in clinical practice may help to identify those patients who would benefit from interventions to change their perceptions of illness.

"Choice" and place of delivery: a qualitative study of women in remote and rural Scotland

OBJECTIVE

To explore women's perceptions of "choice" of place of delivery in remote and rural areas where different models of maternity services are available.

SETTING AND METHODS

Remote and rural areas of the North of Scotland. A qualitative study design involved focus groups with women who had recent experience of maternity services.

RESULTS

Women had varying experiences and perceptions of choice regarding place of delivery. Most women had, or perceived they had, no choice, though some felt they had a genuine choice. When comparing different places of birth, women based their decisions primarily on their perceptions of safety. Consultant-led care was associated with covering every eventuality, while midwife-led care was associated with greater quality in terms of psycho-social support. Women engaged differently in the choice process, ranging from "acceptors" to "active choosers." The presentation of choice by health professionals, pregnancy complications, geographical accessibility and the implications of alternative places of delivery in terms of demands on social networks were also influential in "choice."

CONCLUSIONS

Provision of different models of maternity services may not be sufficient to convince women they have "choice." The paper raises fundamental questions about the meaning of "choice" within current policy developments and calls for a more critical approach to the use of choice as a service development and analytical concept.

A translational phase II trial of celecoxib plus interferon-alpha (IFN-α2b) in metastatic renal cell carcinoma (RCC) patients (pts) with 3+ COX-2 tumor immunostaining

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Background: Cyclooxygenase-2 (COX-2) has been correlated with RCC stage and grade, and overexpression can lead to dysregulation of dendritic cells (DC) and CD4+/CD25+/FOXP3+ regulatory T cells (Treg). A previous trial of celecoxib in combination with IFNα2b in RCC (Rini et al, Cancer. 2006) demonstrated an association between more intense COX-2 RCC tumor staining and clinical response. Methods: Pts with cytokine-naïve mRCC with at least 10% maximal COX-2 tumor staining received IFNα2b MU five times/week plus celecoxib 400 mg BID continuously. Baseline tumor tissue was stained for COX-2, CD4+ and CD8+ T cells, Treg and DC (s100 and CD208). Peripheral blood prostaglandin E2 (PGE2), DC and Treg number/function and intracellular T cell cytokine production were measured at baseline, at the end of cycles 2 and 4 and at end of treatment. Activation of DC was assessed by IL-12 and IL-10 mRNA and protein production by ELISA. The primary endpoint was objective response rate (ORR). Secondary endpoints were DC / Treg number and cytokine production changes with therapy. The trial tested a null hypothesis of ORR <20% vs. alternative hypothesis of ORR >40%; beta = 0.8 and alpha = 0.05 (n = 34). Immune parameters were analyzed using non-parametric methods. Results: Fourteen pts have been enrolled; 79% male, median age 62 (range, 43–74) and 64% ECOG performance status 0. All pts had prior nephrectomy and 36% had received prior tyrosine kinase inhibitors (TKI); MSKCC Risk Group was favorable 14%, intermediate 71%, and unfavorable 14%. The ORR was 21% and 69% of pts experienced tumor shrinkage. Median PFS is 4.4 months. Toxicity was as expected for IFN therapy. Baseline 3+ COX-2 staining was associated with elevated peripheral blood PGE2 levels (p = 0.02), reduced DC IL-12 expression (p = 0.04) and reduction in IFN gamma-producing CD3+CD4+ T-cells (p = 0.04) compared to a control group of RCC pts with <10% 3+ COX-2 staining (n = 21). No significant changes in immunomodulatory cells were observed with therapy. Conclusions: COX-2 inhibition in combination with IFNα2b in maximal COX-2-expressing mRCC pts has clinical activity. COX-2 RCC tumor expression promotes an immunosuppressive phenotype.

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Models of intrapartum care and women’s trade-offs in remote and rural Scotland: a mixed-methods study

OBJECTIVE

To explore women's preferences for, and trade-offs between, key attributes of intrapartum care models.

DESIGN

Mixed-methods study using discrete choice experiments (DCEs) and focus groups.

SETTING

The North of Scotland.

POPULATION

Women from the catchment areas of eight rural maternity units in the North of Scotland.

METHODS

Based on current policy, 'model of care' and 'time travelled' were selected as key attributes of intrapartum care in remote and rural settings. A DCE questionnaire explored women's preferences for and trade-offs between these attributes. Focus groups validated the DCE attributes and provided valuable information about the drivers of women's preferences for place of delivery.

MAIN OUTCOME MEASURES

Preferences for attributes of intrapartum care.

RESULTS

Eight focus groups were conducted, and 877 eligible women completed the questionnaire. Overall, the DCE results found women preferred delivery in a unit to home birth and consultant-led care (CLC) to midwife-managed care (MMC). Women preferring CLC associated it with covering every eventuality and increased safety. Although women preferred shorter travel times, trade-offs indicated a willingness to travel for approximately 2 hours to get one's preferred choice. Focus group findings and subgroup DCE analysis showed heterogeneity of preferences related to experience, risk status, geographic location, perception of care and family circumstances.

CONCLUSIONS

In contrast to service redesign offering local midwife-managed intrapartum care, most rural women in our study expressed a preference to give birth in hospital and have CLC because they felt safer. Women were willing to travel for this but within limits. Qualitative results showed that women's preferences were influenced by their home and family context, beliefs and previous pregnancy experiences. Challenges for service redesign are to provide comprehensive obstetric services within acceptable travel time, while responding to the heterogeneity of women's preferences.

The EPIC nutrient database project (ENDB): a first attempt to standardize nutrient databases across the 10 European countries participating in the EPIC study

OBJECTIVE

This paper describes the ad hoc methodological concepts and procedures developed to improve the comparability of Nutrient databases (NDBs) across the 10 European countries participating in the European Prospective Investigation into Cancer and Nutrition (EPIC). This was required because there is currently no European reference NDB available.

DESIGN

A large network involving national compilers, nutritionists and experts on food chemistry and computer science was set up for the 'EPIC Nutrient DataBase' (ENDB) project. A total of 550-1500 foods derived from about 37,000 standardized EPIC 24-h dietary recalls (24-HDRS) were matched as closely as possible to foods available in the 10 national NDBs. The resulting national data sets (NDS) were then successively documented, standardized and evaluated according to common guidelines and using a DataBase Management System specifically designed for this project. The nutrient values of foods unavailable or not readily available in NDSs were approximated by recipe calculation, weighted averaging or adjustment for weight changes and vitamin/mineral losses, using common algorithms.

RESULTS

The final ENDB contains about 550-1500 foods depending on the country and 26 common components. Each component value was documented and standardized for unit, mode of expression, definition and chemical method of analysis, as far as possible. Furthermore, the overall completeness of NDSs was improved (>or=99%), particularly for beta-carotene and vitamin E.

CONCLUSION

The ENDB constitutes a first real attempt to improve the comparability of NDBs across European countries. This methodological work will provide a useful tool for nutritional research as well as end-user recommendations to improve NDBs in the future.

Sustainable maternity services in remote and rural Scotland? A qualitative survey of staff views on required skills, competencies and training

OBJECTIVES

To explore staff views on their roles, skills and training to deliver high quality and local intrapartum services in remote and rural settings against national recommendations.

DESIGN

Interview and postal survey.

SETTING

A stratified representative sample of remote and rural maternity units in Scotland (December 2002 to May 2003).

PARTICIPANTS

Staff proportionally representative of professional groups involved in maternity care.

RESULTS

Staff interviews took place at 11 units (response rate 93%). A subsequent postal survey included the interview sample and staff in a further 11 units (response rate 78%). Medical specialisation, workforce issues, and proposed regulatory evaluation of competencies linked to throughput raised concerns about the sustainability and safety of services, particularly for "generalists" in rural maternity care teams and for medical cover in small district general hospitals with large rural catchments. Risk assessment and decision making to transfer were seen as central for effective rural practice and these were influenced by rural context. Staff self-reported competence and confidence varied according to procedure, but noted service change appeared to be underway ahead of their preparedness. Self-reported competence in managing obstetric emergencies was surprisingly high, with the caveat that they were not independently assessed in this study. Staff with access to video conference technology reported low actual use although there was enthusiasm about its potential use.

CONCLUSIONS

Considerable uncertainties remain around staffing models and training to maintain maternity care team skills and competencies. Further research is required to test how this will impact on safety, appropriateness, and access and acceptability to rural communities.

Giant ganglion formation in the quadriceps femoris tendon following total knee replacement

A case of giant ganglion cyst arising from the quadriceps femoris tendon, following total knee replacement is presented in this case report. The ganglion cyst was successfully excised. The formation of a ganglion cyst following total knee replacement has not been reported.

A clinical method for locating the femoral head centre during total knee arthroplasty

Localisation of the femoral head centre (FHC) during total knee arthroplasty (TKA) is necessary when assessing the overall alignment of the leg using an extramedullary guide for the femur. On-table radiographs for this purpose are time consuming and inconvenient. We describe a clinical method for estimating the FHC: it is marked 1.5 cm lateral to the point where the femoral artery crosses the line joining the pubic tubercle and the anterior superior iliac spine. Using this method the estimated FHC was within 15 mm of the anatomic centre in 84% of cases, and within 24 mm in 99%. This translates into possible knee alignment errors of 2 degrees and 3 degrees, respectively. As alignment error of up to +/-3 degrees is compatible with satisfactory clinical results of TKA, our method provides useful approximation of the FHC. For greater accuracy however, an on-table radiograph is recommended.

Evaluations of unformulated and formulated dendrimer-based microbicide candidates in mouse and guinea pig models of genital herpes

Prevention of sexually transmitted infections is a priority in developed and developing countries. One approach to prevention is the use of topical microbicides, and one promising approach is the use of dendrimers, highly branched macromolecules synthesized from a polyfunctional core. Three new dendrimer products developed to provide stable and cost-efficient microbicides were initially evaluated in vitro for anti-herpes simplex virus activity and then in vivo by using a mouse model of genital herpes. From these experiments one product, SPL7013, was chosen for further evaluation to define the dose and duration of protection. Unformulated SPL7013 provided significant protection from genital herpes disease and infection at concentrations as low as 1 mg/ml and for at least 1 h following topical (intravaginal) administration of 10 mg/ml. This compound was then formulated into three vehicles and further evaluated in mouse and guinea pig models of genital herpes infection. In the murine evaluations each of the formulations provided significant protection at concentrations of 10 and 50 mg/ml. Formulated compounds provided protection for at least 1 h at a concentration of 10 mg/ml. From these experiments formulation 2V was chosen for dose ranging experiments using the guinea pig model of genital herpes. The guinea pig evaluations suggested that doses of 30 to 50 mg/ml were required for optimal protection. From these studies a lead compound and formulation (2V of SPL7013) was chosen for ongoing evaluations in primate models of simian immunodeficiency virus and Chlamydia trachomatis infection.

Selection of a food classification system and a food composition database for future food consumption surveys

OBJECTIVE

To harmonize food classification and food composition databases, allowing comparability of consumption at both food and nutrient levels in Europe.

DESIGN

To establish the level of comparability at the food level, the EFCOSUM group benefited from the work already carried out within other European projects, which established a Euro Food Groups (EFG) classification system. Four food groups, ie bread, vegetables (excluding potatoes), fruits (excluding fruit juice) and fish and seafood, were judged on their applicability for making food consumption data comparable across countries at the food level.

CONCLUSIONS

It was concluded that the EFG system could be used but that still much work has to be done. For food consumption data to be collected in the future, the software that will be used should enable conversion of foods 'as consumed' to foods at the 'raw edible' level. With respect to comparability of nutrient intake estimations, EFCOSUM advises waiting for the European Nutrient Composition Database (ENDB) currently being prepared by the EPIC group. Until this is available, comparison of consumption data at the nutrient level cannot be carried out between countries.

Improvement of comparability of dietary intake assessment using currently available individual food consumption surveys

BACKGROUND

Food consumption data are used for monitoring dietary indicators of health. In this context, there is a need for comparable (individual) data at the European level. The preference is to perform a pan-European survey able to generate data collected on the same basis. Until this can be realized, the existing data have to be made as comparable as possible.

OBJECTIVE

To identify solutions; to make existing food consumption data from nationally representative databases more comparable.

METHODS

General guidelines for the comparison of food intake data using currently available data were discussed and agreed upon in the EFCOSUM project team.

RESULTS AND CONCLUSIONS

Criteria were assessed with regard to the population involved, age of the survey, method of data collection, duration of the survey, the food classification system and the food composition tbl Based on these criteria, a maximum of 15 countries could provide food consumption data that can be made comparable at the individual level for the adult population. It is recommended to make data comparable at the food level, starting with vegetables (excluding potatoes), fruits (excluding fruit juices), fish (including shellfish) and bread. Comparability of foods is only possible at the 'raw edible' ingredient level. To achieve this, a large amount of work has to be undertaken. The approach of the EFG (Euro Food Groups) system is considered to be the best compromise between the different classification systems. Comparability at the nutrient level has to wait for the availability of a European Nutrient Database, like the one that is being developed within the EPIC context.

Gait adaptations in patients with chronic posterior instability of the knee

OBJECTIVE

A retrospective analysis was performed to assess gait in individuals with a long history of posterior knee instability.

DESIGN

Descriptive study.

BACKGROUND

There are few studies in the literature concerning evaluation of the biomechanics of the knee in patients with knee posterior instability.

METHODS

Nine individuals with posterior knee instability and a matched control group of uninjured subjects were tested in regards to knee kinematics and kinetics while walking and ascending and descending stairs. The mean follow up time for the individuals with posterior instability was 11.1 years. Individual satisfaction with the knee was measured by having participants complete the Flandry (also known as Hughston Clinic) self-assessment questionnaire.

RESULTS

It was found that patients with knee posterior instability who indicated a higher level of satisfaction on the Flandry score walked in a manner that demonstrated greater peak knee extensor torque during stance phase, while less satisfied patients with knee posterior instability demonstrated lower peak knee extensor torque. There was a significant correlation between the self-assessment score and the peak knee extensor torque during level walking (P=0.003). During stair ascent and descent, patients with posterior instability averaged lower knee extensor torque and power than the control subjects, but those differences were only statistically significant in power while descending stairs (P=0.048).

CONCLUSIONS

Individuals with chronic knee posterior instability modify their gait, and the adaptation can be predicted based upon the individuals self-assessment of their knee using the Flandry questionnaire.

RELEVANCE

These data suggest that gait retraining may be a valuable addition to the traditional muscle strengthening programs, which are commonly used during conservative management of knee posterior instability.

Pseudo-aneurysm of the anterior tibial artery complicating high tibial osteotomy--a case report

The anterior recurrent branch of the anterior tibial artery is vulnerable during high tibial osteotomy. It may be injured during subperiosteal elevation of soft tissue from the lateral tibia--necessary for visualisation of the osteotomy or for placing the fixation device; or during excision of the infero-medial aspect of the fibular head--necessary to facilitate closure of the osteotomy. Recurrent bleeding from the operation site should draw attention to the possibility of a pseudo-aneurysm. Angiography helps in making an accurate diagnosis. Ligation of the feeding vessels provides effective treatment.