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.

Distal myopathy in multi-minicore disease

A 52-year-old man noted distal dominant slowly progressive muscle weakness at age 36 years. On muscle CT, the red muscles of the soleus, anterior tibial and paraspinal muscles, where type 1 fiber is known to predominate, were almost totally replaced by fat tissue while quadriceps femoris, gastrocnemius and upper extremity muscles were relatively spared. Quadriceps muscle biopsy revealed multi-minicores in addition to occasional larger cores, in about 70% of the type 1 fibers. A novel heterozygous nucleotide change c.5869T > A (p.S1957T) was identified in RYR1. Although pathogenicity was not confirmed, this nucleotide change was absent in 100 control DNA. We did not find a mutation in either multi-minicore disease-associated gene, SEPN1, or major distal myopathy-related genes, including GNE, ZASP, MYOT, exons 32-36 of MYH7, and the last exon of TTN. This is probably a unique form of distal myopathy characterized by the presence of multi-minicores with preferential involvement of type 1 fibers.

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.

Efficacy, safety and tolerability of rivastigmine capsules in patients with probable vascular dementia: the VantagE study

OBJECTIVE

The aim was to evaluate the efficacy, safety and tolerability of rivastigmine capsules in patients diagnosed with probable vascular dementia (VaD).

METHODS

VantagE (Vascular Dementia trial studying Exelon) was a 24-week, multicentre, double-blind study. VaD patients aged 50-85 years were randomized to rivastigmine capsules (3-12 mg/day) or placebo. Efficacy assessments included global and cognitive performances, activities of daily living and neuropsychiatric symptoms. Adverse events were recorded. Additional exploratory analyses determined whether heterogeneity in pathologies and symptoms extended to differential treatment effects.

TRIAL REGISTRATION

NCT00099216.

RESULTS

710 patients were randomized. Rivastigmine demonstrated superiority over placebo on three measures of cognitive performance (Vascular Dementia Assessment Scale, Alzheimer's Disease Assessment Scale cognitive subscale, Mini-Mental State Examination; all p< or = 0.05, intent-to-treat population [ITT]), but not other outcomes. Predominant adverse events were nausea and vomiting. Exploratory analyses indicated that older patients (> or =75 years old), assumed more likely to also have Alzheimer's disease (AD) pathology, demonstrated significant cognitive responses to rivastigmine and a safety profile similar to that seen in AD patients. Younger patients, assumed less likely to have concomitant AD pathology, showed no efficacy response and were associated with slight elevations of blood pressure, cerebrovascular accidents and mortality. Rivastigmine-placebo differences in patients with, versus those without, medial temporal atrophy (also suggestive of concomitant AD) showed a numerical difference similar to that seen between the older versus younger patients, but did not attain statistical significance.

CONCLUSION

Consistent with trials evaluating other cholinesterase inhibitors, rivastigmine did not provide consistent efficacy in probable VaD. The efficacy apparent on cognitive outcomes was derived from effects in older patients likely to have concomitant Alzheimer pathology. This is supportive of an existing argument that the putative cholinergic deficit in VaD reflects the presence of concomitant Alzheimer pathology.

It takes a village to prevent falls: reconceptualizing fall prevention and management for older adults

Systematic evidence reviews support the efficacy of physical activity programs and multifactorial strategies for fall prevention. However, community settings in which fall prevention programs occur often differ substantially from the research settings in which efficacy was first demonstrated. Because of these differences, alternative approaches are needed to judge the adequacy of fall prevention activities occurring as part of standard medical care or community efforts. This paper uses the World Health Organization Innovative Care for Chronic Conditions (ICCC) framework to rethink how fall prevention programs might be implemented routinely in both medical and community settings. Examples of innovative programs and policies that provide fall prevention strategies consistent with the ICCC framework are highlighted, and evidence where available is provided on the effects of these strategies on processes and outcomes of care. Finally, a "no wrong door" approach to fall prevention and management is proposed, in which older adults who are found to be at risk of falls in either a medical or community setting are linked to a standard fall risk evaluation across three domains (physical activity, medical risks, and home safety).

Composite tissue transplantation: a rapidly advancing field

Composite tissue allotransplantation (CTA) is emerging as a potential treatment for complex tissue defects. It is currently being performed with increasing frequency in the clinic. The feasibility of the procedure has been confirmed through 30 hand transplantation, 3 facial reconstructions, and vascularized knee, esophageal, and tracheal allografts. A major drawback for CTA is the requirement for lifelong immunosuppression. The toxicity of these agents has limited the widespread application of CTA. Methods to reduce or eliminate the requirement for immunosuppression and promote CTA acceptance would represent a significant step forward in the field. Multiple studies suggest that mixed chimerism established by bone marrow transplantation promotes tolerance resulting in allograft acceptance. This overview focuses on the history and the exponentially expanding applications of the new frontier in CTA transplantation: immunology associated with CTA; preclinical animal models of CTA; clinical experience with CTA; and advances in mixed chimerism-induced tolerance in CTA. Additionally, some important hurdles that must be overcome in using bone marrow chimerism to induce tolerance to CTA are also discussed.