Composite tissue allotransplantation: past, present and future-the history and expanding applications of CTA as a new frontier in transplantation

Composite tissue allotransplantation (CTA) transplantation is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed in over 40 successful hand transplants, 3 facial reconstructions, and vascularized knee, esophageal, abdominal wall, and tracheal allografts. The toxicity of chronic, nonspecific immunosuppression remains a major limitation to the widespread availability of CTA and is associated with opportunistic infections, nephrotoxicity, end-organ damage, and an increased rate of malignancy. Methods to reduce or eliminate the requirement for immunosuppression would represent a significant step forward in the field. Mixed chimerism induces tolerance to solid organ and tissue allografts, including CTA. This overview focuses on the history and expanding applications of CTA as a new frontier in transplantation, and considers the important hurdles that must be overcome through research to allow widespread clinical application.

Risk of bleeding in cancer patients treated with the angiogenesis inhibitor bevacizumab: A meta-analysis

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Background: Bleeding is a serious adverse event associated with bevacizumab, a humanized monoclonal antibody against vascular endothelial growth factor (VEGF) used extensively in the treatment of cancer. Currently the overall risk of bleeding remains unclear. This study was conducted to determine the overall risk of bleeding associated with bevacizumab in cancer patients by a meta-analysis of randomized controlled trials (RCT). Methods: Databases from PUBMED and the Web Science from January 1966 until July 2008 and abstracts presented at the American Society of Clinical Oncology (ASCO) conferences from January 2000 to through July 2008 were searched to identify relevant studies. Eligible studies included prospective RCTs in which standard anti-neoplastic therapy was administered with and without the use of bevacizumab with available data of bleeding. Summary incidence rate, relative risk (RR), and 95% confidence interval (CI) were calculated employing fixed- or random-effect models based upon the heterogeneity of the included studies. Results: A total of 13048 patients with a variety of solid tumors from 20 RCTs were included for analysis. Among patients receiving bevacizumab, the incidence of all-grade bleeding was 36.3% (95% CI: 28.0 - 45.5), and the RR was 3.1 (95% CI: 2.4 - 4.1) as compared to controls. The incidence of high grade (grade 3 or above) bleeding with bevacizumab was 2.7% (95% CI: 2.0 - 3.6%), and the RR was 1.8 (95% CI: 1.2 - 2.7). The risk of bleeding varied with the dose of bevacizumab, with RR of 3.0 (95% CI: 2.4 - 3.6) at 5mg/kg/week and 1.6 (95% CI: 1.3 - 2.0) at 2.5mg/kg/week. The risk of bleeding with bevacizumab may vary with tumor type, with higher risk seen in patients with colorectal cancer (RR=6.6, 95% CI: 3.6–12.2) and renal cell cancer (RR=3.7, 95% CI: 2.6–5.5). Bevacizumab is associated with different patterns of bleeding, with epistaxis being the most common. The incidence of all grade epistaxis with bevacizumab was 33.8% (95% CI 24.5–44.6) with a RR of 3.1 (95% CI 2.4 - 4.0). Conclusions: There is a significant increase in the risk of bleeding in cancer patients receiving bevacizumab. The risk may vary with the dose of bevacizumab and tumor type.

No significant financial relationships to disclose.

Risk of bevacizumab-associated gastrointestinal perforation in patients with colorectal cancer and noncolorectal cancer

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Background: Bevacizumab is a recombinant humanized monoclonal antibody that inhibits vascular endothelial growth factor. It is a widely used angiogenesis inhibitor in the treatment of colorectal cancer (CRC) and other solid tumors. Gastrointestinal (GI) perforation is a potentially fatal adverse event associated with bevacizumab, but the risk unclear. This study was conducted to determine the risk of developing GI perforation among CRC and non-CRC patients receiving bevacizumab. Methods: Databases from PUBMED and the Web Science from January 1966 until July 2008 and abstracts presented at the American Society of Clinical Oncology conferences from January 2000 to through July 2008 were searched to identify relevant studies. Eligible studies included prospective phase III clinical trials in which standard anti-neoplastic therapy was administered with and without the use of bevacizumab with available data for GI perforation. Summary incidence rate, relative risk (RR), and 95% confidence interval (CI) were calculated using fixed or random effect models based upon the heterogeneity of the included studies. Results: A total of 12084 patients with various solid tumors from 14 phase III trials were included for analysis. Among patients receiving bevacizumab, the incidence of GI perforation was 0.8% (95% CI: 0.6–1.1%), and RR was 2.0 (95% CI: 1.1–3.8, p = 0.028) in compared with controls. The risk of GI perforation was significantly increased in patients receiving bevacizumab at 5 mg/kg/week (RR 2.6, 95% CI: 1.0–6.6, p=0.04), but not at 2.5 mg/kg/week (RR=1.5, 95%CI: 0.7–3.3, p=0.3). Among 2151 patients with CRC, the incidence of GI perforation was 0.8% (95% CI: 0.5–1.6%); while for 2.999 patients with non-CRC malignancies, the incidence of GI perforation was 0.7% (95% CI: 0.5–1.1%); The relative risk of GI perforation varied with tumor type, with significantly increased risk observed in patients with CRC (RR = 3.1, 95% CI: 1.2–8.2, p<0.023), but not non-CRC (RR=1.5, 95% CI: 0.67–3.4, p=0.3). Conclusions: There is a significant difference in the risk of developing GI perforation in CRC and non-CRC patients receiving bevacizumab with a higher relative risk in patients with CRC. Further investigation into the etiology of this difference is recommended.

No significant financial relationships to disclose.

Phase II study of postoperative chemoradiotherapy for esophageal carcinoma

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Background: Esophageal squamous cell carcinoma is still a virulent disease diagnosed at late stage and remains a major cause of carcinoma mortality in China. The preoperative chemoradiotherapy had been applied to patients with esophageal carcinoma in an effort to reduce the relapse and improve survival. However, randomized controlled trails have shown conflicting results. Intergroup study 0116 demonstrated that postoperative chemoradiotherapy significantly improved overall survival in gastric carcinoma patients. The question remains whether postoperative chemoradiotherapy can improve overall survival in patients with esophageal carcinoma. Our planning study was to investigate the role of postoperative chemoradiotherapy in the multimodality treatment for locally advanced esophageal carcinoma. Methods: From October 2000 to October 2007, Fifty-two patients who underwent esophagectomy with stage II-III esophageal carcinoma were enrolled. All patients received 50Gy of postoperative radiotherapy over 25 fractions in 5 weeks. Two cycles of chemotherapy (Paclitaxel 135mg/m2 d1,cisplatin 20mg/m2d1–3) were administered concurrently on days 1–3 and days 29–31 of radiotherapy. Results: Of the total 52 patients, 28 (54%) developed grade 3 or 4 toxicity.At the time of analysis, 23 patients died. The median follow-up for surviving patients was 23.5 months. The median survival time was 37.2 months. Incidences of tumor recurrence were 53.8 % (28/52) of patients. As expected, distant metastasis was predominant. The 2-year local-regional control survival, distant metastasis-free survival and relapse-free survival were 60.01%, 71.38% and 42.01%, respectively. 1-year and 3-year overall survival were 82.19% and 47.13%, respectively. Conclusions: This novel postoperative chemoradiation regimen for treatment of patients with stage II-III esophageal cancer has a tolerable toxicity and promising 3-year overall survival.

No significant financial relationships to disclose.

Phase II study of cetuximab plus weekly cisplatin and 24-hour infusion of high-dose 5-fluorouracil and leucovorin for the first-line treatment of advanced gastric cancer

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Background: Cisplatin-HDFL regimen, using weekly 24-hour infusions of cisplatin and high-dose 5-fluorouracil (5-FU) and leucovorin, is commonly used in Taiwan for patients with advanced gastric cancer (GC), showing an overall response rate of approximately 60% (95% CI: 45%-76%) [J Clin Oncol (Suppl) 2006; 24(18S): A14063 ]. We have demonstrated that cetuximab is cytotoxic to human GC cells, and has a chemosensitizing effect for cisplatin and 5-FU in GC cells [Proc AACR 2006; 47: A1233]. Methods: All patients had pathologically confirmed metastatic/ recurrent chemonaive GC, at least 1 measurable lesion, a fasting serum triglyceride level > 70 mg/dl, WHO PS 0/1/2, adequate hepatic, renal, and bone marrow functions. Cetuximab 400 mg/m2 was given as 2h infusion, initially (i.e., D1 of cycle 1); and followed by weekly 1h infusion of 250 mg/m2 (i.e., D8, D15, D22 of cycle 1, and D1, D8, D15, D22 of cycle 2). Cisplatin 35 mg/m2 was given as a 24h infusion, admixing with 5-FU 2,000 mg/m2 and leucovorin 300 mg/m2 (HDFL), D1, D8. A 24h infusion of HDFL was given on D15. Cycles were repeated every 28 days, and response evaluation was performed every 2 cycles & at the end of protocol treatment. The primary end-point was confirmed objective response rate (RR) by RECIST. Results: Between Dec. 2005 and Nov. 2008, 35 patients (M:19, F:16) with a median age of 56 (40–74) were enrolled and evaluable for response assessment. The overall RR was 68.6% (51–83%, 95% C.I.) with 1 CR and 23 PRs. Among a total of 269 cycles (median: 7, range: 2 to 22+ cycles) given, Gr3/4 neutropenia, infection, and hepatic toxicity developed in 6.0%, 4.8%, and 0.74% of 269 cycles, respectively. Two patients have developed acute hepatitis B flare-up among seven HBsAg (+) carriers, and were well controlled by lamivudine. Gr1, Gr2, and Gr3 acne- like rashes have developed in 57.1%, 31.4%, 5.7%; and Gr1, Gr2, Gr3 paronychia have developed in 40.0%, 8.6%, and 2.9% of 35 patients, respectively. Median PFS (range: 3 to 22+ months) and median OS (range: 3 to 35+ months) was11.0 and 14.5 months, respectively. Conclusions: Cetuximab plus infusional cisplatin-HDFL is a highly effective regimen with low toxicity and favourable survival in the first-line treatment of advanced GC.

No significant financial relationships to disclose.

High-grade proteinuria associated with bevacizumab in patients with renal cell cancer and non-renal cell cancer

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Background: Bevacizumab is a humanized monoclonal antibody that inhibits vascular endothelial growth factor. It is a widely used angiogenesis inhibitor in the treatment of renal cell cancer (RCC) and other solid tumors. Proteinuria is associated with significant morbidity and treatment interruptions. The overall risk for proteinuria is unclear. This study was conducted to determine the risk of developing proteinuria among RCC and non-RCC patients receiving bevacizumab. Methods: Databases from PUBMED and Web Science from January 1966 until July 2008 and abstracts presented at ASCO from January 2000 to July 2008 were searched to identify relevant studies. Studies included randomized controlled clinical trials in which standard anti-neoplastic therapy was administered with and without bevacizumab with available data for proteinuria. Summary incidence rate, relative risk (RR), and 95% confidence interval (CI) were calculated employing fixed or random effect models based upon the heterogeneity of included studies. Results: A total of 6,702 patients from 14 randomized controlled studies were included for analysis. The incidence of all-grade proteinuria in patients receiving bevacizumab was 19.3% (95% CI: 11.9–29.6%) with 2.3% (95% CI: 1.2–4.1%) being high-grade (grade 3 or 4). Patients treated with bevacizumab had an increased risk of developing high-grade proteinuria with RR of 6.3 (95% CI: 4.0–9.9) compared with controls. Risk may vary with dose of bevacizumab; significant difference may exist in patients receiving bevacizumab at 5 mg/kg/week (RR 9.1, 95% CI: 4.3–19.6, p < 0.001) and 2.5 mg/kg/week (RR = 5.1, 95%CI: 3.0–8.8, p < 0.001). The risk of high-grade proteinuria may also depend on tumor type; the incidence of high-grade proteinuria was 10.0% (95% CI: 4.3–22.4%) with a RR 48.7 (95% CI: 9.7–244.3) among 703 RCC patients compared with an incidence of 1.7% (95% CI: 0.09–3.2%) and RR of 5.2 (95% CI: 3.3–8.4) among 5,999 non-RCC patients. Conclusions: There is a significant risk for high-grade proteinuria in patients receiving bevacizumab. The risk may vary with bevacizumab dose and tumor type. RCC patients may have higher risk than non-RCC patients. Close monitoring and management are recommended for patients at high risk.

No significant financial relationships to disclose.

Effect of chemotherapy on the risk of erlotinib-induced skin rash in cancer patients: A meta-analysis

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Background: Erlotinib, an inhibitor of epidermal growth factor receptor (EGFR) tyrosine kinase, is effective in the treatment of non-small cell lung cancer (NSCLC) as a single agent and pancreatic cancer when combined with chemotherapy. Its application in other types of cancer is also undergoing extensive clinical assessment. Skin rash is a major side effect of erlotinib. This study aims to gain a better understanding of skin toxicity with erlotinib through a systematic review and meta-analysis of randomized controlled clinical trials. Methods: Relevant studies were identified from Medline (1966 to October 2008), Web of Science, and abstracts presented at the American Society of Clinical Oncology Conferences between January, 2004 and October, 2008. Eligible studies included prospective randomized controlled clinical trials in which cancer patients were treated with erlotinib at 150 mg daily as single agent or in combination with other agents. Incidence, relative risk (RR), and 95% confidence intervals were calculated using random-effects or fixed-effects models based on the heterogeneity of included studies. Results: A total of 3,562 patients with a variety of solid tumors from 12 randomized controlled clinical trials were included for analysis. The overall incidence of all-grade skin rash associated with erlotinib was 68.7% (95% CI: 63.0–73.8%) with 8.9% (95% CI: 7.7–10.3%) being high-grade (grade 3 or above). There was a significantly increased risk of skin toxicity with erlotinib in comparison with controls (all-grade: RR 3.1, 95% CI: 2.2–4.3, p < 0.001; high-grade: RR 10.1, 95% CI: 5.5–18.5, p < 0.001). Interestingly, chemotherapy may decrease the risk of skin rash associated with erlotinib. RR of all-grade skin rash was 4.7 (95% CI: 3.6–6.2) for single-agent erlotinib and 2.3 (95% CI: 2.0–2.7) for erlotinib in combination with chemotherapy; RR of high-grade skin rash was 17.3 (95% CI: 3.3–90.5) for single-agent erlotinib and 9.3 (95% CI: 4.8–17.8) for erlotinib in combination. Conclusions: Erlotinib was associated with significantly increased risk of skin toxicity among cancer patients. Its combination with chemotherapy may decrease the risk of skin rashes.

No significant financial relationships to disclose.

Oestrogen confers cardioprotection by suppressing Ca2+/calmodulin-dependent protein kinase II

BACKGROUND AND PURPOSE

Oestrogen confers cardioprotection by down-regulating the beta(1)-adrenoceptor and suppressing the expression and activity of protein kinase A. We hypothesized that oestrogen may also protect the heart by suppressing Ca(2+)/calmodulin-dependent protein kinase II (CaMKII), another signalling messenger activated by the beta(1)-adrenoceptor, that enhances apoptosis.

EXPERIMENTAL APPROACH

We first determined the expression of CaMKII in the heart from sham and ovariectomized rats with and without oestrogen replacement. We then determined the effects of CaMKII inhibition (KN93, 2.5 micromolxL(-1)) in the presence or absence of 10(-7) molxL(-1) isoprenaline, a non-selective beta-adrenoceptor agonist. We also determined the percentage apoptosis in myocytes from rats in each group with or without beta-adrenoceptor stimulation.

KEY RESULTS

Both CaMKIIdelta and phosphorylated CaMKII were up-regulated in the hearts from ovariectomized rats, and they were restored to normal by oestrogen replacement. The infarct size and lactate dehydrogenase release were significantly greater after ovariectomy. Similarly, cardiac contractility, the amplitude of the electrically induced intracellular Ca(2+) transient and the number of apoptotic cells were also greater in ovariectomized rats upon ischaemia/reperfusion in the presence or absence of isoprenaline. Most importantly, the responses to ischaemic insult in ovariectomized rats were reversed not only by oestrogen replacement, but by blockade of CaMKII with KN93.

CONCLUSIONS AND IMPLICATIONS

Oestrogen confers cardioprotection at least partly by suppressing CaMKIIdelta. This effect of oestrogen on CaMKII is independent of the beta-adrenoceptor and occurs in addition to down-regulation of the receptor.

Factors associated with bed and room sharing in Chinese school-aged children

BACKGROUND AND OBJECTIVES

Co-sleeping (bed or room sharing) has potential implications for children's development. Previous studies showed that co-sleeping was more prevalent in non-Western countries than in Western countries, which demonstrated that co-sleeping was marked with ethnic and socio-cultural background characteristics. The purpose of this study was to survey the prevalence of bed and room sharing and to examine related factors among school-aged children in an Asian country - China.

METHODS

A cross-sectional questionnaire survey was conducted in 10 districts of Shanghai, China from November to December 2005. A total of 4108 elementary school children, 49.2% boys and 50.8% girls with a mean age of 8.79 years, participated. Parent-administered questionnaires were used to collect information about children's sleeping arrangements and socio-demographic characteristics.

RESULTS

The prevalence of routine bed sharing, room sharing and sleeping alone in Chinese school-aged children was 21.0%, 19.1% and 47.7%, respectively. Bed and room sharing didn't show significant gender difference but gradually decreased with increasing age. Multivariate logistic regression identified those factors associated with bed and room sharing: younger age, large family, children without their own bedroom and parents' approval of a co-sleeping arrangement.

CONCLUSION

Co-sleeping arrangement was a common practice in Chinese school-aged children. Associated factors were characterized by intrinsic socio-cultural values and socio-economic status in China.

Efficient human growth hormone gene expression in the milk of non-transgenic goats

Heterogenous expression of recombinant proteins in milk of livestock at a large scale is very labour-intensive to be achieved with current transgenic animals, and usually seen as time-consuming, expensive and technically most challenging. Here we describe a convenient system for transient production of recombinant human growth hormone and its extensive use in recombinant protein production for therapeutic purposes. In this study, an adenoviral vector containing the GFP gene and hGH gene was constructed for direct infusion into the epithelium of mammary glands of goats via the teat canal during the period of natural lactation. Western-blot analysis of milk samples obtained from all of the viral-treated founders indicated that the recombinant hGH (rhGH) was secreted into the milk of the goats. The concentrations of rhGH in milk ranged from 0.6 to 2.4 mg/ml and lasted for more than 10 days during lactation. These data suggest that it is possible to produce larger amounts of recombinant human growth hormone in the milk of livestock animals by using replication-defective adenoviruses.