TSH-Secreting Pituitary Adenoma: Current Management and Review

The neurosurgical literature contains little information about the current management of patients with thyroid-stimulating hormone (TSH)-secreting pituitary adenomas or about the usefulness of the somatostatin analogue octreotide in such cases. While TSH-secreting pituitary adenomas are rare, our review and illustrative case demonstrate the effectiveness of pretreating patients with octreotide therapy not only to reduce tumor size prior to surgical resection but also to increase the possibility of clinical remission.A 52-year-old male presented with signs and symptoms of hyperthyroidism and elevated TSH, thyroxine, and triiodothyronine. Magnetic resonance imaging revealed a pituitary macroadenoma with extension into the suprasellar cistern. The patient was treated with octreotide for 6 months prior to surgery. Approximately 3 months after initiation of octreotide therapy, the patient exhibited excellent biochemical and clinical response. Tumor shrinkage of nearly 50% was associated with resolution of suprasellar extension and optic nerve compression. Subsequent transsphenoidal surgery for resection of residual adenoma was followed by symptomatic and hormonal remission without the need for reinstitution of octreotide therapy.Pretreatment with octreotide for TSH-secreting pituitary adenomas has a beneficial effect on disease symptoms and reduces tumor mass. We suggest that patients with these rare tumors can be managed with a combination of octreotide therapy and subsequent surgical removal of residual tumor. Although this combination treatment helps to facilitate clinical remission, only short-term follow-up has been reported and thus the optimal management of these patients remains to be determined.

Feasibility testing of an automated image-capture method to aid dietary recall

Background/Objectives

The accuracy of dietary recalls might be enhanced by providing participants with photo images of foods they consumed during the test period.

Subjects/Methods

We examined the feasibility of a system (Image-Diet Day) that is a user-initiated camera-equipped mobile phone that is programmed to automatically capture and transmit images to a secure website in conjunction with computer-assisted, multi-pass, 24-hour dietary recalls in 14 participants during 2007. Participants used the device during eating periods on each of the three independent days. Image processing filters successfully eliminated underexposed, over-exposed, and blurry images. Captured images were accessed by participants using the ImageViewer software while completing the 24-hour dietary recall on the following day.

Results

None of the participants reported difficulty using the ImageViewer. Images were deemed “helpful” or “sort of helpful” by 93% of participants. A majority (79%) of users reported having no technical problems, but 71% rated the burden of wearing the device as somewhat to very difficult, owing to issues such as limited battery life, self-consciousness about wearing the device in public, and concerns about the camera’s field of view.

Conclusion

Overall, these findings suggest that automated imaging is a promising technology to facilitate dietary recall. The challenge of managing the thousands of images generated can be met. Smaller devices with a broader field of view may aid in overcoming user’s self-consciousness with using or wearing the device

Safety of a non-viral plasmid-encoding dual isoforms of hepatocyte growth factor in critical limb ischemia patients: a phase I study

We aimed to evaluate in a phase I dose-escalation study, the safety of intramuscular injections of a novel non-viral plasmid DNA expressing two isoforms of human hepatocyte growth factor (HGF) (VM202) in patients with critical limb ischemia (CLI). In total, 12 patients with CLI and unsuitable for revascularization were consecutively assigned to increasing doses (2 to 16 mg) of VM202 administered into the ischemic calf muscle at days 1 and 15. Patients were evaluated for safety and tolerability, changes in ankle- and toe brachial index (ABI and TBI), and pain severity score using a visual analog scale (VAS) throughout a 12-month follow-up period. Median age was 72 years and 53% of the patients were male. VM202 was safe and well tolerated with no death during the 12-month follow-up. Median ABI and TBI significantly increased from 0.35 to 0.52 (P=0.005) and from 0.15 to 0.24 (P=0.01) at 12 months follow-up. Median VAS decreased from 57.5 to 16.0 mm at 6 months follow-up (P=0.03). In this first human clinical trial, VM202, which expresses two isoforms of human HGF, appear to be safe and well tolerated with encouraging clinical results and thus supports the performance of a phase II randomized controlled trial.

Development of Photoinitiated Nitric Oxide Releasing Polymer Films for Controlled Drug Delivery

Nitric Oxide (NO) is small, free radical gas that has been shown to have a wide variety of physiological functions, including the ability to hinder tumor angiogenesis at high, but non lethal, concentrations [1]. Previous work suggests that if NO could be effectively delivered in vivo to tumors of patients currently undergoing chemotherapy treatments at the appropriate levels, less damaging chemotherapy treatments could be used against cancer [2]. This could increase the overall survivability of cancer patients, especially in those prone to the harmful effects of chemotherapy: children, elderly, and those of weak immune systems. If NO is especially successful at preventing and eliminating tumor growth, angiogenesis, and carcinogenesis the need for stressful chemotherapy treatments could be eliminated altogether. This project is focused on developing novel photosensitive NO donors that can be incorporated into polymeric systems and used in a fiber optic drug delivery system. Development of these NO-releasing polymers will allow continued investigation of NO's role in tumor death by precisely controlling the surface flux of NO that cells are exposed to. Generating specific surface fluxes of NO from polymer films has been demonstrated by using polymer films that contain photoinitiated NO donors [3], prepared by synthesizing S-nitrosothiol (RSNO) derivitized polymer fillers that are blended into hydrophobic polymers and cast into a film. These films generate and sustain a surface flux of NO based on the wavelength and intensity of light used [3]. Polymers releasing NO are more promising as an NO donor than simply injecting NO into samples because they allow for spatial and temporal control of NO delivery. The specific concentration of NO needed to produce desirable effects on tumor cells (i.e., apoptosis) is not known. Data will be presented that show the synthesis and NO-release properties of novel RSNOs based on the nitrosation of benzyl mercaptan thiols. Specifically, UV-Vis spectrum of benzyl mercaptan in toluene and S-nitrosobenzyl mercaptan after the addition of t-butyl nitrite will be presented. We are currently investigating the effects of varying NO-surface fluxes generated from photolytic NO donating polymer films on aortic smooth muscle cell cultures obtained from mice. Once we have established that we can quantitatively determine the effects of different levels of NO on the proliferation of smooth muscle cell cultures, work will begin to apply this methodology and these novel NO-releasing polymeric systems to begin investigating what durations and surface fluxes of NO are necessary to have tumorcidal effects on specific cancer cells.

Phase I dose escalation trial (ARQ 197–111) evaluating combination of selective c-Met inhibitor ARQ 197 and erlotinib

3549

Background: ARQ197 (A) is a selective, non-ATP competitive inhibitor of c-Met, a receptor tyrosine kinase implicated in tumor cell migration, invasion, and proliferation. Phase I data for ARQ 197 monotherapy is previously reported. Recent evidence suggests c-Met promotes resistance to EGFR-inhibition by driving ERBB3 (HER3)-dependent PI3K activation. Dual EGFR-Met inhibition is now proposed as a strategy for overcoming resistance to EGFR-inhibition. Methods: Patients (pts) were enrolled in a sequential-cohort dose-escalation trial seeking to define safety, tolerability, pharmacokinetics (PK), and preliminary anti-tumor activity of A in combination with 150 mg daily oral erlotinib (E). Oral A was administered at escalating doses of 120, 240, and 360 mg bid. Intra-patient dose escalation was allowed in the absence of dose-limiting toxicity (DLT) through 1 cycle of therapy (21 days). Results: 25 pts (10 F/15 M; mean 60.5 yrs) received EA combination with starting A dose of 120 (8 pts), 240 (4 pts), and 360 (13 pts) mg bid. PK data reveal linear kinetics through 360 bid and no evidence of drug-drug interaction. Adverse events (AEs) considered related to combination therapy were reported in 13 (52%) of pts incl.sinus bradycardia (5 pts), fatigue (5 pts), rash (4 pts), itching (3 pts), and diarrhea (3 pts). 2 pts experienced related serious AEs incl. neutropenia (360 bid) and sinus bradycardia (240 bid). 1 death occurring on-study was considered unrelated to study drug. 9/10 evaluable pts demonstrated disease stabilization (SD) as their best RECIST response (5.9–27.1+ wks). Tumor regressions (2.3%-19.4%) were observed in 4/10 evaluable pts. Of note, 3/3 evaluable pts with NSCLC achieved SD for durations (14–32 wks) exceeding median PFS in BR.21 (9.7 wks). Conclusions: Continuous therapy with EA combination appears well tolerated and without drug-drug interaction. While no formal MTD was identified, a phase 2 combination dose (R2PD) of 360 mg bid A + 150 mg daily E is recommended. This RP2D is currently being investigated in an ongoing randomized trial comparing EA to E monotherapy in 2nd/3rd line NSCLC.

[Table: see text]

Recommendations for a standard UK approach to incorporating umbilical cord blood into clinical transplantation practice: conditioning protocols and donor selection algorithms

Allogeneic haematopoietic cell transplantation is an established curative treatment modality for patients with malignant and non-malignant haematological disorders. Since the first related umbilical cord blood transplant (UCBT) in 1988, the use of UCB as a stem cell source for transplantation has become a standard practice in many countries, with approximately 8000 such transplants having been performed worldwide to date.

[Imatinib-induced DRESS]

BACKGROUND

Imatinib (Glivec) is a tyrosine kinase inhibitor used to treat certain cases of leukaemia. We report a case of a drug-induced reaction with eosinophilia and systemic symptoms (DRESS) caused by imatinib.

CASE-REPORT

A 77-year-old woman with a chronic myeloid leukaemia was treated with imatinib and allopurinol. Nineteen days after the start of treatment, the patient presented fever with a generalized polymorphous rash associated with oral erosions, facial oedema, diffuse lymphadenopathy and blood hypereosinophilia. Histological analysis of skin biopsy specimens suggested a drug-induced reaction. The outcome was favourable two weeks after discontinuation of treatment. Three months later, imatinib was reintroduced because of progression of the patient's chronic myeloid leukaemia, and recurrence of the skin rash and fever was observed within 12 hours.

DISCUSSION

Allopurinol was stopped definitively because of its more frequent imputability. Imatinib was reintroduced after considering the benefit-risk ratio and in full knowledge of the existence of cutaneous reactions to imatinib, despite there being only one recent report of DRESS following treatment with imatinib. According to the causality criteria of Bégaud et al. regarding imatinib, inherent causality of the drug in our patient was initially possible (I2) and appeared likely (I3) after the rechallenge test. This case clearly illustrates that imatinib is a potential cause of DRESS.

Interprofessional education: effects on professional practice and health care outcomes

BACKGROUND

Patient care is a complex activity which demands that health and social care professionals work together in an effective manner. The evidence suggests, however, that these professionals do not collaborate well together. Interprofessional education (IPE) offers a possible way to improve collaboration and patient care.

OBJECTIVES

To assess the effectiveness of IPE interventions compared to education interventions in which the same health and social care professionals learn separately from one another; and to assess the effectiveness of IPE interventions compared to no education intervention.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register, MEDLINE and CINAHL, for the years 1999 to 2006. We also handsearched the Journal of Interprofessional Care (1999 to 2006), reference lists of the six included studies and leading IPE books, IPE conference proceedings, and websites of IPE organisations.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time series (ITS) studies of IPE interventions that reported objectively measured or self reported (validated instrument) patient/client and/or healthcare process outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed the eligibility of potentially relevant studies, and extracted data from, and assessed study quality of, included studies. A meta-analysis of study outcomes was not possible given the small number of included studies and the heterogeneity in methodological designs and outcome measures. Consequently, the results are presented in a narrative format.

MAIN RESULTS

We included six studies (four RCTs and two CBA studies). Four of these studies indicated that IPE produced positive outcomes in the following areas: emergency department culture and patient satisfaction; collaborative team behaviour and reduction of clinical error rates for emergency department teams; management of care delivered to domestic violence victims; and mental health practitioner competencies related to the delivery of patient care. In addition, two of the six studies reported mixed outcomes (positive and neutral) and two studies reported that the IPE interventions had no impact on either professional practice or patient care.

AUTHORS' CONCLUSIONS

This updated review found six studies that met the inclusion criteria, in contrast to our first review that found no eligible studies. Although these studies reported some positive outcomes, due to the small number of studies, the heterogeneity of interventions, and the methodological limitations, it is not possible to draw generalisable inferences about the key elements of IPE and its effectiveness. More rigorous IPE studies (i.e. those employing RCTs, CBA or ITS designs with rigorous randomisation procedures, better allocation concealment, larger sample sizes, and more appropriate control groups) are needed to provide better evidence of the impact of IPE on professional practice and healthcare outcomes. These studies should also include data collection strategies that provide insight into how IPE affects changes in health care processes and patient outcomes.

Measurement of the nucleon strange-antistrange asymmetry at next-to-leading order in QCD from NuTeV Dimuon data

We present a new measurement of the difference between the nucleon strange and antistrange quark distributions from dimuon events recorded by the NuTeV experiment at Fermilab. This analysis is the first to use a complete next to leading order QCD description of charm production from neutrino scattering. Dimuon events in neutrino deep inelastic scattering allow direct and independent study of the strange and antistrange content of the nucleon. We find a positive strange asymmetry with a significance of 1.6sigma. We also report a new measurement of the charm mass.

Amyloid imaging in distinguishing atypical prion disease from Alzheimer disease

OBJECTIVE

To compare the in vivo uptake of two amyloid-binding PET agents, PIB and FDDNP, in human subjects with a prion protein (PrP) gene (PRNP) mutation that produces a clinical syndrome similar to Alzheimer disease (AD).

BACKGROUND

Amyloid imaging with specific PET ligands offers great promise for early detection and differential diagnosis of AD. Genetic forms of prion disease can present with clinical features that resemble AD, and at autopsy may show deposition of mutant PrP-amyloid. FDDNP binds to PrP-amyloid in postmortem human specimens, but has not been reported in vivo in prion disease. The ability of PIB to bind PrP-amyloid is not known.

METHODS

Two brothers with a 6 octapeptide repeat insertion mutation (6-OPRI) in the PRNP gene underwent clinical, structural MRI, and FDG-PET evaluations. One brother received a PIB-PET evaluation, while the other received an FDDNP-PET scan. PET results were compared with five normal subjects and five individuals with AD scanned with either agent.

RESULTS

PIB uptake was similar to controls in one brother, while FDDNP uptake was intermediate between AD and controls in the other brother.

CONCLUSIONS

Different amyloid-binding agents may have differential sensitivity to prion-related brain pathology. A combination of amyloid imaging agents may be useful in the diagnosis of early-onset dementia.

Rationale for the recommendations for harmonizing current methodology for detecting BCR-ABL transcripts in patients with chronic myeloid leukaemia

Molecular monitoring for patients with chronic myeloid leukaemia (CML) has become an important practice in the era of imatinib therapy. For successful widespread introduction into the mainstream patient monitoring schedule, many procedural aspects of the complex real-time quantitative polymerase chain reaction (RQ-PCR) technique for measuring BCR-ABL transcripts require optimization. Recommendations for harmonizing the differing methodologies have recently been proposed. These recommendations were designed to maximize reliability of analysis for clinical decision making and proposed the adoption of an International Scale of measurement. The purpose of this review is to present the evidence and supporting data for specific recommendations. These recommendations include use of the same source of cells, either blood or marrow, for analysis; for validation of equal PCR amplification efficiencies of cDNA and standards when using a plasmid to construct standard curves and for ensuring ongoing high-level performance by undertaking a quality assurance programme. Clinicians must know the measurement reliability of an RQ-PCR assay to be able to determine the significance of a change in BCR-ABL level. An assay with poor precision limits the clinical usefulness of results. International harmonization should establish RQ-PCR measurement of BCR-ABL as the best method for monitoring treatment response for patients with CML.

Search for the invisible decay of neutrons with KamLAND

The Kamioka Liquid scintillator Anti-Neutrino Detector is used in a search for single neutron or two-neutron intranuclear disappearance that would produce holes in the -shell energy level of (12)C nuclei. Such holes could be created as a result of nucleon decay into invisible modes (inv), e.g., n--> 3v or nn--> 2v. The deexcitation of the corresponding daughter nucleus results in a sequence of space and time-correlated events observable in the liquid scintillator detector. We report on new limits for one- and two-neutron disappearance: tau(n--> inv) > 5.8 x 10(29) years and tau (nn--> inv) > 1.4 x 10(30) years at 90% C.L. These results represent an improvement of factors of approximately 3 and >10(4) and over previous experiments.

Executive dysfunction in hyperhomocystinemia responds to homocysteine-lowering treatment

An elevated serum homocysteine level is a risk factor for the development of cognitive impairment. Reported is a late-onset case of hyperhomocystinemia due to a vitamin B12 metabolic deficit (cobalamin C) with cognitive impairment, primarily in frontal/executive function. After homocysteine-lowering therapy, the patient's functional and neuropsychological status improved in conjunction with a decrease in leukoariosis on his MRI scan. These findings suggest that homocysteine-related cognitive impairment may be partially reversible.