Single-institution experience using transarterial chemoembolization (TACE) with carboplatinum (carbo) and doxorubicin in patients (pts) with hepatocellular carcimona (HCC) awaiting liver transplantation (LTx)

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Background: LTx is the best treatment option for multinodular HCC and those with advanced liver dysfunction. Tumor progression occurs in 20-50% of pts on liver transplant list. TACE is increasingly used as locoregional therapy and as a bridge to LTx. We report here our single institutional experience with TACE using carbo and doxorubicin in pts with HCC awaiting LTx.

Methods: Retrospective chart review was performed in all pts who had TACE between 2008 and June 2010. Our institutional protocol uses a fixed dose of carbo 300mg, doxorubicin 50mg, in 10ml of lipoidol solution. We analyzed pt demographics, etiologies of liver disease, Child-Pugh status, CLIP scores, size of tumor, alpha-fetoprotein (AFP), toxicity, length of stay, and transplantation statistics.

Results: 32 pts (28 men) were treated with 39 TACE procedures. The median age was 57 (32-83). 28 of 32 had cirrhosis with Child's A/B/C 36/51/18% respectively. The major etiologies of cirrhosis were hepatitis C (HCV) 8, alcohol and HCV 19, alcohol 7; portal vein thrombosis in 8 pts. The median tumor size was 6.2 cm (range 2-12 cm) and 81% were multifocal CLIP score 0,1/2,>3 were 5/62/38%. There were no mortality within 30 days of TACE procedure. The majority of the pts were discharged after 24 hr observation; 6 pts require readmissions within 30days. There was no systemic hematologic toxicity. 11 pts had elevated AFP at baseline and 6/11 (54%) had >50 % reduction in AFP value. 11pts (34%) received Ltx; 3 pts came off the LTx list due to disease progression, 2 pts are still on transplant list, and 16pts not able to be listed. 42% of pts received sorafenib in addition to TACE. The median time from last TACE to LTx was 55 days and 4 pts received transplantation within 30days. Very good pathological treatment effect was observed in 8/11 explanted liver.

Conclusions: Our regimen of TACE with carbo/doxorubicin appears to be a safe and tolerable approach for localized treatment as a bridge to liver transplantation. It has acceptable toxicity and is associated with good AFP and pathological responses. We plan to evaluate different baseline parameters for better pt selection.

No significant financial relationships to disclose.

An analysis of three opportunistic infections in an outpatient HIV clinic in Jamaica

OBJECTIVES

To determine the occurrence of opportunistic infection (OI) in HIV-positive patients and to identify any risk factors which may be associated with such.

METHODS

A cross-sectional study of all patients attending the HIV out-patient clinic was conducted. Their hospital notes were examined between January 1 and December 31, 2007 inclusive, to identify any occurrence of opportunistic infection. In addition, the patient list was also cross-referenced with all patients hospitalized on the medical wards during the same time period. Clinical and demographic data were collected for all participants. The occurrence of opportunistic infections and the variables of age, gender CD4 counts and viral loads: (first ever last in 2007 and at diagnosis of OI [or within six months]), the use of primary and secondary prophylaxis, the discontinuation of prophylactic regimens and the HAART regime at diagnosis of an OI and the diagnostic and treatment protocols of these infections were calculated.

RESULTS

Six hundred and three patients participated in the study and 4.7% (n = 28) were found to have experienced at least one opportunistic infection in 2007. Significant associations were found between first and last CD4 cell count, viral load in 2007, year of entry into the clinic and death (p < 0.05).

CONCLUSIONS

Opportunistic infections continue to cause significant morbidity and mortality in the HIV-patient population in this study. Earlier entry to treatment facilities and the use of HAART and appropriate prophylaxis can reduce this impact and lead to improved quality of life for HIV-positive individuals.

A comprehensive response to the HIV/AIDS epidemic in Jamaica: a review of the past 20 years

Jamaica has a well-established, comprehensive National Human Immunodeficiency Virus (HIV) programme that has slowed the HIV epidemic and mitigated its impact. Adult HIV prevalence has been stable at approximately 1.5% since 1996. HIV rates are high among those most at risk such as sex-workers (9%) and men who have sex with men [MSM] (31.8%). Risk behaviour among adults with AIDS includes multiple sexual partners (80%), a history of a sexually transmitted infection [STI] (51.1%), commercial sex (23.9%) and crack/cocaine (8.0%). Approximately 20% of all reported AIDS cases, mainly women, give no history of any of the usual risk factors for HIV infection. The national programme is based in the Ministry of Health. Since 1988, Jamaica has had a national plan to guide its HIV response. A National AIDS Committee was established in 1988 to lead the multi-sectoral response. Prevention approaches have included information, education and communication campaigns, condom promotion, sexually transmitted infections (STI) control, targeted interventions, cultural approaches, outreach and peer education, workplace programmes and HIV counselling and testing. Concerted efforts have been made to reduce HIV stigma and discrimination. Antiretroviral therapy (ARV) was introduced for prevention of mother-to-child transmission in 2001 and a public access treatment programme introduced in 2004. A national HIV/AIDS Policy was adopted unanimously in parliament in 2005. The National Strategic plan 2007-2012 commits Jamaica to achieving universal access to HIVprevention, treatment and care. Awareness of HIV and how to prevent it is near universal though belief in myths remains strong. The condom market has increased from approximately 2.5 million in 1985 to 12 million in 2006 while condom use has grown significantly with nearly 75% of men and 65% of women reporting condom use at last sex with a non-regular partner The proportion of women 15-24 years reporting ever having a HIV test increased from 29.8% in 2004 to 48.9% in 2008. HIV transmission from mother-to-child has declined from 25% prior to 2000 to less than 8% in 2007. As of September 2008, 4450 persons or an estimated 68.5% of persons with advanced HIV and AIDS have been placed on ARV treatment resulting in a significant decline in mortality and morbidity due to HIV

Paediatric and perinatal HIV/AIDS in Jamaica an international leadership initiative, 2002-2007

BACKGROUND

Paediatric and Perinatal HIV/AIDS remain significant health challenges in the Caribbean where the HIV seroprevalence is second only to Sub-Saharan Africa.

METHOD

We describe a collaborative approach to the prevention, treatment and care ofHIVin pregnant women, infants and children in Jamaica. A team of academic and government healthcare personnel collaborated to address the paediatric and perinatal HIV epidemic in Greater Kingston as a model for Jamaica (population 2.6 million, HIV seroprevalence 1.5%). A five-point plan was utilized and included leadership and training, preventing mother-to-child transmission (pMTCT), treatment and care of women, infants and children, outcomes-based research and local, regional and international outreach.

RESULTS

A core group of paediatric/perinatal HIV professionals were trained, including paediatricians, obstetricians, public health practitioners, nurses, microbiologists, data managers, information technology personnel and students to serve Greater Kingston (birth cohort 20,000). During September 2002 to August 2007, over 69 793 pregnant women presented for antenatal care. During these five years, significant improvements occurred in uptake of voluntary counselling (40% to 91%) and HIV-testing (53% to 102%). Eight hundred and eighty-three women tested HIV-positive with seroprevalence rates of 1-2% each year The use of modified short course zidovudine or nevirapine in the first three years significantly reduced mother-to-child transmission (MTCT) of HIV from 29% to 6% (RR 0.27; 95%0 CI--0.10, 0.68). During 2005 to 2007 using maternal highly active antiretroviral therapy (HAART) with zidovudine and lamivudine with either nevirapine, nelfinavir or lopinavir/ritonavir and infant zidovudine and nevirapine, MTCT was further reduced to an estimated 1.6% in Greater Kingston and 4.75% islandwide. In five years, we evaluated 1570 children in four-weekly paediatric infectious diseases clinics in Kingston, St Andrew and St Catherine and in six rural outreach sites throughout Jamaica; 24% (377) had HIV/AIDS and 76% (1193) were HIV-exposed. Among the infected children, 79% (299 of 377) initiated HAART resulting in reduced HIV-attributable childhood morbidity and mortality islandwide. An outcomes-based research programme was successfully implemented.

CONCLUSION

Working collaboratively, our mission of pMTCT of HIV and improving the quality of life for families living and affected by HIV/AIDS in Jamaica is being achieved.

A review of instruments developed to measure outcomes for carers of people with mental health problems

OBJECTIVE

Community-based care for mental disorders places considerable burden on families and carers. Measuring their experiences has become a priority, but there is no consensus on appropriate instruments. We aimed to review instruments carers consider relevant to their needs and assess evidence for their use.

METHOD

A literature search was conducted for outcome measures used with mental health carers. Identified instruments were assessed for their relevance to the outcomes identified by carers and their psychometric properties.

RESULTS

Three hundred and ninety two published articles referring to 241 outcome measures were identified, 64 of which were eligible for review (used in three or more studies). Twenty-six instruments had good psychometric properties; they measured (i) carers' well-being, (ii) the experience of caregiving and (iii) carers' needs for professional support.

CONCLUSION

Measures exist which have been used to assess the most salient aspects of carers outcome in mental health. All require further work to establish their psychometric properties fully.

A comparison of the use of Trachlight and Eschmann multiple-use introducer in simulated difficult intubation

BACKGROUND AND OBJECTIVE

The Eschmann multiple-use introducer is widely used in the management of difficult intubations. Transillumination of the neck is less commonly used. We conducted a randomized crossover study comparing the Trachlight lightwand and Eschmann multiple-use introducer in simulated difficult intubation.

METHODS

Sixty-four healthy patients were studied using a standard anaesthetic and full muscle relaxation assessed by train of four. A Macintosh laryngoscope was then inserted and then lowered to simulate a Grade 3 view. Tracheal placement was attempted with both Trachlight lightwand and Eschmann multiple-use introducer in a randomized order. Anaesthetists placing the devices had extensive experience with the Eschmann multiple-use introducer, but only 15 previous uses of the Trachlight. Success rates and time for tracheal placement were recorded.

RESULTS

The Eschmann multiple-use introducer and Trachlight were successfully placed in 96.8% and 93.7%, respectively (n.s.). Mean (SD) time to intubation for Eschmann multiple-use introducer and Trachlight were 15(6) and *21(13), respectively (*P < 0.001).

CONCLUSION

The Trachlight is a potentially useful alternative to the Eschmann multiple-use introducer in difficult intubation.

The influence of superficial venous surgery and compression on incompetent calf perforators in chronic venous leg ulceration

OBJECTIVES

Previous studies have suggested that perforating vein incompetence is reduced by surgery to superficial veins. This study analysed the effect in a randomised clinical trial.

DESIGN

Retrospective analysis of duplex data.

METHODS

Patients in this study were part of the ESCHAR randomised controlled trial. All patients had chronic venous leg ulceration with superficial venous reflux. Patients were treated with compression bandaging alone or compression plus superficial venous surgery. Legs were assessed using colour venous duplex prior to treatment and at 3 and 12 months.

RESULTS

Of 500 patients recruited to the ESCHAR trial, 261 were included in this study. One hundred and forty six of 261 legs were treated with compression alone and 115/261 underwent compression and superficial venous surgery. In the compression group, more legs had incompetent perforators at 12 months (77/131) compared to baseline (61/146, p =0.010, Wilcoxon Signed Ranks test for paired data in 131 legs). Following surgery, significantly fewer legs had incompetent calf perforators (59/115 vs 44/104 at 12 months, p =0.001, Wilcoxon Signed Ranks test for paired data in 104 legs). In addition, significantly fewer legs in the compression and surgery group developed new perforator incompetence in comparison to the group treated with compression alone (12/104 vs 36/131, p =0.003, Chi-Squared test).

CONCLUSION

Surgical correction of superficial reflux may abolish incompetence in some calf perforators and offer protection against developing new perforator incompetence.

Effect of phosphatidic acid on human breast cancer cells exposed to doxorubicin

We previously demonstrated that phosphatidic acid (PA) induces chemotactic migration of highly metastatic breast cancer cells MDA-MB-231. The widely used anticancer drug doxorubicin was reported to induce apoptosis of cancer cells. Growth factors such as epidermal growth factor (EGF) and bioactive lipids such as lysophosphatidic acid (LPA) and sphingosine 1-phosphate (SPP) have been shown to enhance viability and to protect cancer cells against apoptosis. In this study, we investigated the effect of PA on MDA-MB-231 cells exposed to the anticancer drug doxorubicin. Cell migration toward PA was partially inhibited by doxorubicin treatment, and PA moderately diminished cell cycle arrest of cells exposed to doxorubicin. Although PA itself was not able to induce apoptosis of MDA-MB-231 cells, apoptosis of cells exposed to doxorubicin was markedly enhanced by PA treatment. Thus, PA is able to increase the apoptotic potential of doxorubicin, and may regulate the effects of doxorubicin used for chemotherapy.

Reducing violence in severe mental illness: randomised controlled trial of intensive case management compared with standard care

OBJECTIVES

To establish whether intensive case management reduces violence in patients with psychosis in comparison with standard case management.

DESIGN

Randomised controlled trial with two year follow up.

SETTING

Four inner city community mental health services.

PARTICIPANTS

708 patients with established psychotic illness allocated at random to intervention (353) or control (355) group.

INTERVENTION

Intensive case management (caseload 10-15 per case manager) for two years compared with standard case management (30-35 per case manager).

MAIN OUTCOME MEASURE

Physical assault over two years measured by interviews with patients and case managers and examination of case notes.

RESULTS

No significant reduction in violence was found in the intensive case management group compared with the control group (22.7% v 21.9%, P=0.86).

CONCLUSIONS

Intensive case management does not reduce the prevalence of violence in psychotic patients in comparison with standard care.

Relatives of patients with severe psychotic illness: factors that influence appraisal of caregiving and psychological distress

BACKGROUND

Research shows considerable variability in the effect on relatives of patients' mental illness but the determinants of relatives' experience remain unclear. We investigated the influence of demographic, social and clinical characteristics on relatives' experience when conceptualised using a stress-appraisal-coping paradigm.

METHODS

Our sample was drawn from relatives of patients recruited to the UK700 case management study (n = 154). Demographic, social and clinical data were collected from patients, and relatives completed the Experience of Caregiving Inventory and the General Health Questionnaire. We predicted that patients' symptomatology in particular would influence relatives' experience, and that relatives who appraised caregiving more negatively and less positively would experience greater psychological distress.

RESULTS

Linear regression analyses revealed that relatives' appraisal was not predicted by patients' symptomatology. Instead, relatives appraised caregiving more negatively if the patient was unemployed or younger, and less positively if the patient had been ill for longer or had poorer social functioning. Little of the variance in appraisal was explained by these variables, however. Consistent with the stress-coping model, relatives' negative appraisal was a strong predictor of psychological distress and accounted for a substantial proportion of its variance. Positive appraisal did not predict psychological distress, however. None of the demographic, social or clinical characteristics tested had any significant effect on relatives' psychological distress once appraisal was adjusted for. There was an unexpected positive correlation between the two appraisal scales, with relatives who appraised caregiving more negatively also appraising it more positively.

CONCLUSIONS

Our results support a stress-coping model of caregiving but further research is required to determine more influential predictors of relatives' appraisal. Our findings indicate that interventions aimed at patients' social functioning and relatives' negative appraisal of caregiving may assist in reducing relatives' psychological distress.

Child sexual abuse, poor parental care and adult depression: evidence for different mechanisms

BACKGROUND

Child sexual abuse (CSA) and poor parental care (neglect and institutional care) are associated with depression in adult life. Little is known about possible mechanisms underlying these associations.

AIMS

To examine the role of adult intimate-love relationships as differential mediators or moderators of the associations between CSA, poor parental care and adult depression.

METHOD

Sampling was carried out in two phases. In the first, questionnaires were sent to women aged 25-36 years in five primary care practices. Second-phase subjects for interview (n=198) were drawn from three strata defined on the basis of childhood adversities. Recalled childhood experiences and recent adult relationships and depression were assessed and rated independently. Frequencies of predictor and response variables, effect estimates and their confidence intervals were weighted back to the general population questionnaire sample.

RESULTS

The risk for depression associated with CSA was unaffected by quality of adult relationships, while the risk associated with poor parental care was substantially altered.

CONCLUSIONS

There may be different pathways linking CSA and poor parental care to adult depression.

Relatives of patients with severe psychotic disorders: factors that influence contact frequency. Report from the UK700 trial

BACKGROUND

The isolation experienced by many patients with severe psychotic disorders is generally assumed to be due to their social withdrawal. An alternative possibility is that relatives avoid frequent contact with patients because they find the situation distressing.

AIMS

To examine the predictors of frequent patient-relative contact, in particular the role of relatives' experience.

METHOD

UK700 trial data were used to determine baseline predictors of frequent contact and establish whether relatives' experience at baseline predicted continued frequent contact 2 years later.

RESULTS

Neither characteristics associated in the literature with relatives' 'burden' nor relatives' experience predicted patient-relative contact frequency. Instead, the predictors were mainly demographic.

CONCLUSIONS

Many relatives experience considerable distress, but the evidence does not suggest that they avoid frequent contact with the patient as a consequence.

Suicidal behaviour in psychosis: prevalence and predictors from a randomised controlled trial of case management: report from the UK700 trial

BACKGROUND

It is unclear whether intensive case management influences the prevalence of suicidal behaviour in patients with psychosis.

AIMS

To compare the effect of intensive case management and standard care on prevalence of suicidal behaviour in patients with chronic psychosis.

METHOD

Patients with established psychosis (n = 708) were randomised either to intensive case management or to standard care. The prevalence of suicidal behaviour was estimated at 2-year follow-up and compared between treatment groups. Suicide attempters and non-attempters were compared on multiple socio-demographic and clinical variables to identify predictors of suicidal behaviour.

RESULTS

There was no significant difference in prevalence of suicidal behaviour between treatment groups. Recent attempts at suicide and multiple recent hospital admissions best predicted future attempts.

CONCLUSIONS

Intensive case management does not appear to influence the prevalence of suicidal behaviour in chronic psychosis. Predictors identified in this study confirm some previous findings.

Intellectual functioning and outcome of patients with severe psychotic illness randomised to intensive case management. Report from the UK700 trial

BACKGROUND

Little research has been carried out on the benefits of intensive case management (ICM) for people with borderline IQ and severe mental illness.

AIMS

To compare outcome and costs of care of patients with severe psychotic illness with borderline IQ to patients of normal IQ and to assess whether ICM is more beneficial for the former than for the latter.

METHOD

The study utilises data from the UK700 multi-centre randomised controlled trial of case management. The main outcome measure was the number of days spent in hospital for psychiatric reasons. Secondary outcomes were costs of care and clinical outcome.

RESULTS

ICM was significantly more beneficial for borderline-IQ patients than those of normal IQ in terms of reductions in days spent in hospital, hospital admissions, total costs and needs and increased satisfaction.

CONCLUSIONS

ICM appears to be a cost-effective strategy for a subgroup of patients with severe psychosis with cognitive deficits.

Docosahexaenoic acid induces apoptosis in Jurkat cells by a protein phosphatase-mediated process

Docosahexaenoic acid (DHA) is an omega-3 fatty acid under intense investigation for its ability to modulate cancer cell growth and survival. This research was performed to study the cellular and molecular effects of DHA. Our experiments indicated that the treatment of Jurkat cells with DHA inhibited their survival, whereas similar concentrations (60 and 90 microM) of arachidonic acid and oleic acid had little effect. To explore the mechanism of inhibition, we used several measures of apoptosis to determine whether this process was involved in DHA-induced cell death in Jurkat cells. Caspase-3, an important cytosolic downstream regulator of apoptosis, is activated by death signals through proteolytic cleavage. Incubation of Jurkat cells with 60 and 90 microM DHA caused proteolysis of caspase-3 within 48 and 24 h, respectively. DHA treatment also caused the degradation of poly-ADP-ribose polymerase and DNA fragmentation as assayed by flow cytometric TUNEL (terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling) assay. These results indicate that DHA induces apoptosis in Jurkat leukemic cells. DHA-induced apoptosis was effectively inhibited by tautomycin and cypermethrin at concentrations that affect protein phosphatase 1 (PP1) and protein phosphatase 2B (PP2B) activities, respectively, implying a role for these phosphatases in the apoptotic pathway. Okadaic acid, an inhibitor of protein phosphatase 2A, had no effect on DHA-induced apoptosis. These results suggest that one mechanism through which DHA may control cancer cell growth is through apoptosis involving PP1/PP2B protein phosphatase activities.

Monocytes harbour replication-competent, non-latent HIV-1 in patients on highly active antiretroviral therapy

OBJECTIVE

To determine whether HIV-1 can be recovered from blood monocytes as well as resting, memory CD4 T lymphocytes of patients on highly active antiretroviral therapy (HAART) with undetectable plasma viraemia and whether infection is active or latent.

DESIGN

Five patients with plasma HIV-1-RNA levels of less than 500 copies/ml for at least 3 months and less than 50 copies/ml at the time of sampling were initially selected, followed by an additional five patients with viral loads of less than 50 copies/ml for 3 months or more.

METHODS

Monocytes were isolated from blood by plastic adherence, then further purified by a second adherence step or CD3 depletion before co-culture with CD8-depleted donor peripheral blood mononuclear cells. Virus isolates were examined for mutations conferring resistance to reverse transcriptase or protease inhibitors and for genotype. The highly purified monocytes were also analysed for the presence of proviral and unintegrated viral DNA and multiply spliced (MS) viral mRNA by polymerase chain reaction.

RESULTS

Virus was recovered from monocytes of five patients. Sequencing of the recovered viruses did not reveal multiple drug resistance, and was consistent with a non-syncytium-inducing/CCR5 phenotype. Proviral DNA was detectable in monocytes from all subjects, and unintegrated HIV-1 DNA and MS RNA was found in four out of five populations examined.

CONCLUSION

Recovery of replication-competent virus from some HAART patients indicates that monocytes can also harbour HIV-1. Detection of circular, viral DNA and spliced RNA, albeit at very low levels, in these cells suggests that their infection is recent and transcriptionally active rather than latent.

Sphingosine 1-phosphate released from platelets during clotting accounts for the potent endothelial cell chemotactic activity of blood serum and provides a novel link between hemostasis and angiogenesis

Recent studies have identified factors responsible for angiogenesis within developing tumors, but mediators of vessel formation at sites of trauma, injury, and wound healing are not clearly established. Here we show that sphingosine 1-phosphate (S1P) released by platelets during blood clotting is a potent, specific, and selective endothelial cell chemoattractant that accounts for most of the strong endothelial cell chemotactic activity of blood serum, an activity that is markedly diminished in plasma. Preincubation of endothelial cells with pertussis toxin inhibited this effect of S1P, demonstrating the involvement of a Galphai-coupled receptor. After S1P-induced migration, endothelial cells proliferated avidly and differentiated forming multicellular structures suggestive of early blood vessel formation. S1P was strikingly effective in enhancing the ability of fibroblast growth factor to induce angiogenesis in the avascular mouse cornea. Our results show that blood coagulation initiates endothelial cell angiogenic responses through the release of S1P, a potent endothelial cell chemoattractant that exerts its effects by activating a receptor-dependent process.