Updated remission duration and survival results of single-agent clofarabine in previously untreated older adult patients with acute myelogenous leukemia (AML) unlikely to benefit from standard induction chemotherapy due to unfavorable baseline risk factor(s)

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Background: The CLASSIC II trial has previously reported an independently confirmed overall remission rate of 46% (38% CR and 8% CRp) and 30- and 60-day mortality rates of 9.8% and 16.1%, respectively (Blood 112: 558, 2008). We now report updated duration of remission (DOR), disease-free survival (DFS), and overall survival (OS). Methods: Single arm, multi-center, phase II, open-label, 2-stage study of patients with untreated AML, ≥60 years old, and at least one adverse prognostic factor: age ≥70 years, antecedent hematologic disorder (AHD), PS = 2, and/or intermediate/unfavorable risk karyotype. Clofarabine (CLO) administered days 1–5 at 30 mg/m2 during induction and 20 mg/m2 during re-induction/consolidation for maximum 6 cycles. Patients were followed for at least 6 months past remission (CR/CRp). Results: 116 patients enrolled and 112 in full analysis set. Median age 71 years. Median DOR (censored at alternative therapy) for CR/CRp was 56 weeks (95% CI, 33 weeks - not yet estimable [n/e]) and for CR 65 weeks (95% CI, 41 weeks - n/e). Median DFS (not censored at alternative therapy) for CR/CRp was 34 weeks (95% CI, 24 - 65 weeks). Median OS was 41 weeks (95% CI 28 - 53 weeks), for CR/CRp 59 weeks (95% CI, 50 weeks - n/e ), and for CR was 72 weeks (95% CI, 53 weeks - n/e) after median follow-up of 36 weeks (range, 1 - 85 weeks). Thirty-day mortality was 9.8% for all patients with 4.7% and 13% for age <70 and age ≥70 years, respectively. Conclusions: These data expand on the previously reported efficacy and safety data of single agent CLO in adult AML. Complete remissions appear durable (median >1 yr), and DFS and OS compare favorably to historical experience, particularly in patients with these adverse prognostic factors. These results suggest that single agent CLO is an effective and tolerable treatment option for older adult patients with untreated AML and 1 or more unfavorable baseline prognostic factor(s).

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[Cardiovascular protection in diabetic patients with heart disease in the doctor's office]

The long-term care of diabetic patients with heart disease poses a particular challenge. Various combinations of risk factors, progression of the coronary heart disease, and complications with further organic damage by the underlying diabetes, frequently necessitate a differentiated diagnostic work-up and management. This can be implemented only by close cooperation between the various specialities. Structured processes may be useful provided they are correctly applied and implemented. Guideline-based treatment of detected cardiovascular risk factors can improve quality of life, reduce morbidity and cardiovascular mortality and thus save costs over the long term.

[Glucose metabolism]

The markedly increased peri-interventional risk (PCI and CABG) in patients with type-2 diabetes mellitus may be reduced by adjusting blood glucose values to a near-normal level. This adjustment should be realized acutely by glucose-insulin-potassium infusions. In long-term therapy, the target value should be achieved independent of the pharmacological principle of blood glucose reduction. Among the available oral antidiabetic agents, metformin, acarbose and glitazones seem to be cardioprotective via pleotropic effects. Given an optimal stent implantation and administration of GP IIb/IIIa inhibitors during coronary interventions, results are similar to those of non-diabetics.

Outcomes for patients with dementia from the Cleveland Alzheimer's Managed Care Demonstration

This investigation evaluates effects of care consultation delivered within a partnership between a managed health care system and Alzheimer's Association chapter. Care consultation is a multi-component telephone intervention in which Association staff work with patients and caregivers to identify personal strengths and resources within the family, health plan, and community. The primary hypothesis is that care consultation will decrease utilization of managed care services and improve psychosocial outcomes. A secondary modifying-effects hypothesis posits benefits will be greater for patients with more severe memory impairment. The sample is composed of managed care patients whose medical records indicate a diagnosis of dementia or memory loss. Patients were randomly assigned to an intervention group, which was offered care consultation in addition to usual managed care services, or to a control group, which was offered only usual managed care services. Data come from two in-person interviews with patients, and medical and administrative records. Results supporting the primary hypothesis show intervention group patients feel less embarrassed and isolated because of their memory problems and report less difficulty coping. Findings consistent with the modifying-effects hypothesis show intervention group patients with more severe impairment have fewer physician visits, are less likely to have an emergency department visit or hospital admission, are more satisfied with managed care services, and have decreased depression and strain.

[Cognitive functions and cerebral oxygenation of older patients after general and regional anaesthesia]

OBJECTIVE

The aim of the present study was to show the influence of cerebral oxygenation (regional cerebral oxygen saturation rSO(2) by near infrared spectroscopy) and of the nocturnal arterial oxygen saturation (SatO(2) by pulse oximetry) on the restitution of cognitive functions in patients aged between 40 and 85 years scheduled for elective hip arthroplasty.

METHODS

A total of 40 patients (ASA II) were randomized to be operated either in general anaesthesia or regional anaesthesia. The patients were additionally classified by age (40-64 years and 65-85 years). Cognitive functions were tested 14-16 h pre-operatively (t0), 1.5 h post-operatively (t1) and at the first and third postoperative days (t2 and t3). During testing, as well as during surgery and postoperatively until t1, rSO(2) was continuously measured. SatO(2) was measured in the night before surgery (N0) and for 3 nights after surgery (N1, N2, N3) between 22.00 p.m. and 5.00 a.m. These measurements were divided into interval groups (80-83%, 84-87%, 88-91%, 92-95%, 96-100%).

RESULTS

Almost all cognitive functions were significantly reduced at t1 in all groups compared to t0, but recovered up to the third postoperative day (t3). RSO(2) in contrast was significantly reduced in all groups compared to t0 at the third postoperative day (t3). The relative proportion of the intervals compared to the total measurement time for SatO(2) shifted in both anaesthesia procedures: before surgery (N0) the most frequented interval was 96-100%, after surgery (N1, N2) it was 88-91%. There was no correlation between rSO(2), the restitution of the tested cognitive functions and SatO(2).

CONCLUSIONS

Cognitive functions recovered completely during the first 3 postoperative days in patients scheduled for elective hip surgery under general or regional anaesthesia regardless of age and type of anaesthesia. This restitution of cognition occurred despite a significant decrease of cerebral oxygenation (rSO(2)) and despite an increase of nocturnal hypoxaemic intervals. Changes of the rsO(2) up to 3% below the baseline values (measured by NIRS) do not predict cognitive restitution. A minimal limiting value of the rSO(2) could not be defined.

[Severe mediastinal emphysema after temporal gunshot with a gas revolver]

Injuries after a close contact gunshot with clear or tear gas cartridges can lead to severe and life threatening complications. The high pressure of the gas may damage soft tissue, bones and organs. This mechanism is able to cause mediastinal emphysema, rupture of upper and lower pharyngeal, esophageal and tracheal structures far away from the initial trauma with diagnostic findings which are may be difficult to interpret. This case report presents a mediastinal emphysema in a 17 year old man following a temporal shot with a gas revolver. The diagnostics, focussed on CT and X-ray imaging, and the therapeutic concept of such cases will be discussed.

[Frozen shoulder--MRI-verified continuous block of suprascapular nerve]

Suprascapular nerve block may provide sufficient analgesia in painful immobilisation of the shoulder joint. In the following case report a 41 year old male presenting with adhesive capsulitis (frozen shoulder) has been treated successfully by performing continuous delivery of local anesthetics to the suprascapular nerve via catheter. The location of the catheter has been verified using MRI examination. Pain relief was quantified by using visual analog scale (VAS 1 - 10) and showed decretion from VAS 8 - 10 pre treatment to VAS 1 - 2 after insertion of the catheter and throughout five days of intensive physiotherapy, respectively. The technique of catheterization using a nerve stimulator and alternative peripheral nerve blocks are discussed. In summary, continuous suprascapular nerve block offers an advantageous alternative for pain relief in patients with frozen shoulder. It may provide better pain control and earlier discharge in the ambulatory setting than repetetive single dose blocks.

Indicators of lifetime estrogen exposure: effect on breast cancer incidence and interaction with raloxifene therapy in the multiple outcomes of raloxifene evaluation study participants

PURPOSE

To test the hypothesis that risk factors related to lifetime estrogen exposure predict breast cancer incidence and to test if any subgroups experience enhanced benefit from raloxifene.

PATIENTS AND METHODS

Postmenopausal women with osteoporosis (N = 7,705), enrolled onto the Multiple Outcomes of Raloxifene Evaluation (MORE) trial, were randomly assigned to receive placebo, raloxifene 60 mg/d, or raloxifene 120 mg/d for 4 years. Breast cancer risk was analyzed by the following baseline characteristics indicative of estrogen exposure: previous hormone replacement therapy, prevalent vertebral fractures, family history of breast cancer, estradiol level, bone mineral density (BMD), body mass index, and age at menopause. Therapy-by-subgroup interactions were assessed using a logistic regression model.

RESULTS

Overall, women with the highest one-third estradiol levels (> or = 12 pmol/L) had a 2.07-fold increased invasive breast cancer risk compared with women with lower levels. Raloxifene significantly reduced breast cancer risk in both the low- and high-estrogen subgroups for all risk factors examined (P <.05 for each comparison). The women with the highest BMD and those with a family history of breast cancer experienced a significantly greater therapy benefit with raloxifene, compared with the two thirds of patients with lower BMD or those without a family history, respectively; the subgroup-by-therapy interactions were significant (P =.005 and P =.015, respectively).

CONCLUSION

The MORE trial confirms that increased lifetime estrogen exposure increases breast cancer risk. Raloxifene therapy reduces breast cancer risk in postmenopausal osteoporotic women regardless of lifetime estrogen exposure, but the reduction is greater in those with higher lifetime exposure to estrogen.

Digitized mammography: a clinical trial of postmenopausal women randomly assigned to receive raloxifene, estrogen, or placebo

BACKGROUND

High mammographic density is associated with increased breast cancer risk. Previous studies have shown that estrogens increase breast density on mammograms, but the effect on mammographic density of selective estrogen receptor modulators, such as raloxifene, is unknown. We assessed changes in mammographic density among women receiving placebo, raloxifene, or conjugated equine estrogens in an osteoporosis prevention trial.

METHODS

In a 5-year multicenter, double-blind, randomized, placebo-controlled osteoporosis prevention trial, healthy postmenopausal women who had undergone hysterectomy less than 15 years before the study and had no history of breast cancer received placebo, raloxifene (at one of two doses), or conjugated estrogens (ERT). Women from English-speaking investigative sites who had baseline and 2-year craniocaudal mammograms with comparable positioning (n = 168) were eligible for this analysis. Changes in mammographic density were determined by digital scanning and computer-assisted segmentation of mammograms and were analyzed with the use of analysis of variance. All statistical tests were two-sided.

RESULTS

Among the four treatment groups after 2 years on study, the mean breast density (craniocaudal view) was statistically significantly greater in the ERT group than it was in the other three groups (P<0.01 for all three comparisons). Within treatment groups, the mean breast density from baseline to 2 years decreased statistically significantly in women receiving the placebo or either the higher or lower raloxifene dose (P = 0.003, P = 0.002, and P<0.001, respectively) and showed a nonstatistically significant increase in women receiving ERT.

CONCLUSIONS

In an osteoporosis prevention trial, raloxifene did not increase breast density after 2 years of treatment. Raloxifene administration should not interfere with, and could even enhance, mammographic detection of new breast cancers.

17beta-estradiol, gender independently, reduces atheroma development but not neointimal proliferation after balloon injury in the rabbit aorta

The aim of the present study was to investigate anti-proliferative and anti-atherogenic properties of 17beta-estradiol in balloon injured female and male rabbit aortae. Thirty-two female and 32 male New Zealand White rabbits where gonadectomised. Vascular injury was performed with a balloon catheter in the lower abdominal aorta. Male and female rabbits were randomised into four groups of eight animals each. Only two of four groups received a 0.5% cholesterol-enriched diet. One cholesterol-diet group and one normal-diet group received intramuscular injections of estradiol valerate (1 mg/kg body weight/week). After 28 days, the denuded part of the abdominal aorta was excised and analysed by morphometry and immunohistochemistry. Estrogen treatment did not show an inhibitory effect on neointimal proliferation in normo-cholesterolemic male or female rabbits. A gender independent inhibitory effect of 17beta-estradiol was seen on atheroma development in cholesterol-fed female and male rabbits, while plasma total cholesterol levels were significantly reduced in male rabbits only. The 17beta-estradiol treatment was associated with a significantly decreased number of luminal endothelial cells in normo and hyper-cholesterolemic female rabbits, as evaluated by immunohistochemical staining for 'von Willebrand factor'. Staining for Ki-67-positive proliferating cells after 28 days showed a statistically significant increased proliferative activity in the neointima of hyper-cholesterolemic female rabbits. The neointimal content of macrophages increased significantly in all hyper-cholesterolemic rabbits. Under 17beta-estradiol treatment, the number of macrophages was increased in female and decreased in male rabbits by tendency. Additionally, the 'classical' vascular estrogen receptor was present in both female and male rabbit aortae without statistically significant differences. In conclusion, 17beta-estradiol did not reduce post-injury neointima formation in normo-cholesterolemic rabbits. However, in hyper-cholesterolemic rabbits, 17beta-estradiol reduced atheroma development gender independently. This effect cannot be explained by lowering of plasma cholesterol levels or endothelium-mediated pathways, and requires further investigation on, for example, antioxidative, antiproliferative or estrogen receptor mediated effects.

Continued breast cancer risk reduction in postmenopausal women treated with raloxifene: 4-year results from the MORE trial. Multiple outcomes of raloxifene evaluation

Raloxifene, a selective estrogen receptor modulator approved for the prevention and treatment of postmenopausal osteoporosis, has shown a significant reduction in breast cancer incidence after 3 years in this placebo-controlled, randomized clinical trial in postmenopausal women with osteoporosis. This article includes results from an additional annual mammogram at 4 years and represents 3,004 additional patient-years of follow-up in this trial. Breast cancers were ascertained through annual screening mammograms and adjudicated by an independent oncology review board. A total of 7,705 women were enrolled in the 4-year trial; 2,576 received placebo, 2,557 raloxifene 60 mg/day, and 2,572 raloxifene 120 mg/day. Women were a mean of 66.5-years old at trial entry, 19 years postmenopause, and osteoporotic (low bone mineral density and/or prevalent vertebral fractures). As of 1 November 1999, 61 invasive breast cancers had been reported and were confirmed by the adjudication board, resulting in a 72% risk reduction with raloxifene (relative risk (RR) 0.28, 95% confidence interval (CI) 0.17, 0.46). These data indicate that 93 osteoporotic women would need to be treated with raloxifene for 4 years to prevent one case of invasive breast cancer. Raloxifene reduced the risk of estrogen receptor-positive invasive breast cancer by 84% (RR 0.16, 95% CI 0.09, 0.30). Raloxifene was generally safe and well-tolerated, however, thromboembolic disease occurred more frequently with raloxifene compared with placebo (p=0.003). We conclude that raloxifene continues to reduce the risk of breast cancer in women with osteoporosis after 4 years of treatment, through prevention of new cancers or suppression of subclinical tumors, or both. Additional randomized clinical trials continue to evaluate this effect in postmenopausal women with osteoporosis, at risk for cardiovascular disease, and at high risk for breast cancer.

The effect of three broad-spectrum antimicrobials on mononuclear cell responses to encapsulated bacteria: evidence for down-regulation of cytokine mRNA transcription by trovafloxacin

The effect of trovafloxacin, ciprofloxacin and ceftriaxone on cytokine production of human peripheral blood mononuclear cells (PBMCs) was examined. PBMC responses were measured after stimulation with lipopolysaccharide (LPS), lipoteichoic acid (LTA) or killed or viable Streptococcus pneumoniae and Haemophilus influenzae. Trovafloxacin inhibited the production of tumour necrosis factor alpha (TNF-alpha), interleukin-1beta (IL-1beta), IL-6 and IL-8 by PBMCs after stimulation with either LPS or LTA by 83%. Similar inhibition occurred in PBMCs incubated with killed or live bacteria and trovafloxacin, but not with ciprofloxacin or ceftriaxone. The relevance of this in vitro observation was explored by examining TNF-alpha and IL-6 responses in trovafloxacin-treated mice. Serum concentrations of both cytokines 1 h after LPS challenge were 95% less than serum concentrations in mice that were not given trovafloxacin. Reverse transcription- polymerase chain reaction studies of the mechanisms determining cytokine down-regulation demonstrated that trovafloxacin reduced TNF-alpha, IL-1beta and IL-6 mRNA to levels similar to those of unstimulated cells. These observations indicate that trovafloxacin can consistently and significantly reduce production of cytokines that play an important role in sepsis. In vitro, this effect can occur in the presence of bacteriolysis and is associated with inhibition of transcription of cytokine genes.

[Perioperative treatment of a patient with hereditary angioedema (HAE) in a case of a young patient with osteosynthesis from a femoral fracture]

The following case report describes hereditary angioedema (HAE) in a juvenile male patient presenting with femoral fracture. The clinical characteristics, pathophysiological changes, diagnostics and management of anaesthesia for patients with hereditary angioedema will be discussed. Hereditary angioedema (HAE) is a rare autosomal dominant disorder, which is caused by congenital deficiency of functional C1-inhibitor (C1-INH). Patients are suffering from episodic and painless edema of the skin (face and limbs) and mucous membranes of the respiratory and gastrointestinal tracts (the latter causing abdominal cramps due to edema of the intestine). Life-threatening airway obstruction may occur when patients develop laryngeal edema. It is important to differentiate HAE from the more frequent allergic angioedema because of differences in the pharmacological treatment of acute attacks of HAE. C1-INH-concentrate is effective in both treatment of acute attacks and prevention of edema, especially in children, juveniles and young women.