Drug-induced Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and SJS-TEN overlap: a multicentric retrospective study

BACKGROUND

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare immune-mediated severe cutaneous adverse reactions with incidence rate of 0.05 to 2 persons per million populations per year. Drugs are the most commonly implicated in 95% of cases.

AIMS

To audit the causative drugs, clinical outcome, and cost of management in SJS, TEN, and SJS-TEN overlap.

SETTING AND DESIGN

Tertiary care hospitals-based multicentric retrospective study (case series).

MATERIALS AND METHODS

Indoor case papers of SJS, TEN, and SJS-TEN overlap admitted between January 2006 and December 2009 in four tertiary care hospitals of Gujarat were scrutinized. Data were collected for demographic information, causative drugs, investigations, treatment given, duration of hospital stay, time interval between onset of symptoms and drug intake, clinical outcome, and complications. Data were analyzed to find out proportion of individual drugs responsible, major complications, and clinical outcome in SJS, TEN, and SJS-TEN overlap. Total cost of management was calculated by using cost of drugs, investigations, and consumables used during entire hospital stay.

STATISTICAL ANALYSIS

One-way Analysis of Variance followed by Tukey-Kramer multiple comparison test was used for comparison of incubation period, duration of hospital stay, and cost of management.

RESULTS

Antimicrobials (50%), nonsteroidal anti-inflammatory drugs (22.41%), and antiseizure drugs (18.96%) were the most commonly associated groups. Nevirapine (28.12%) was the most common drug. Antiseizure drugs were more often associated with serious form of adverse reaction (TEN: 81.8%) than other drugs. Duration of hospital stay (20.6 vs 9.7 days) and cost of management (7,910/- vs 2,460/-) were significantly higher in TEN than SJS (P=0.020 and P<0.001, respectively). Time duration between drug intake and onset of symptoms (17.7 vs 27.5 days) was nonsignificantly lower in TEN as compared with SJS. Secondary infection (28.12%) was the most common complication noted. Mortality rate was 15.6% among all cases; 9% in SJS and 26.7% in TEN.

CONCLUSION

Antimicrobial drugs are the most commonly implicated drugs and cost of managing these adverse drug reactions is higher than other serious ADRs.

Study on the antibacterial potential of physalis minima linn

Physalis minima is an important medicinal plant of Indian System of Medicine. This plant is reported for its diuretic, laxative and antiinflammatory activities. However, the plant is not well scrutinized for its antimicrobial potential. The major chemical constituents reported from the plant are phenolics and alkaloids, which suggest that the plant may turn out to be a potent antiinfective agent. The aim of the study was to find out the antibacterial potential of mature berries of P. minima using streak plate, well diffusion, determination of minimum inhibitory concentration and bioautographic methods against a battery of Gram positive and Gram negative bacterial strains. Results of the study showed that methanol and chloroform extracts of P. minima exhibited potent inhibitory activity against all the bacterial strains tested. Minimum inhibitory concentration found out was 100 μg in both the extracts. Bioautography assay showed polar compounds present in the crude extract are responsible for the antimicrobial action.

microRNA-29 can regulate expression of the long non-coding RNA gene MEG3 in hepatocellular cancer

The human genome is replete with long non-coding RNAs (lncRNA), many of which are transcribed and likely to have a functional role. Microarray analysis of >23,000 lncRNAs revealed downregulation of 712 (~3%) lncRNA in malignant hepatocytes, among which maternally expressed gene 3 (MEG3) was downregulated by 210-fold relative to expression in non-malignant hepatocytes. MEG3 expression was markedly reduced in four human hepatocellular cancer (HCC) cell lines compared with normal hepatocytes by real-time PCR. RNA in situ hybridization showed intense cytoplasmic expression of MEG3 in non-neoplastic liver with absent or very weak expression in HCC tissues. Enforced expression of MEG3 in HCC cells significantly decreased both anchorage-dependent and -independent cell growth, and induced apoptosis. MEG3 promoter hypermethylation was identified by methylation-specific PCR and MEG3 expression was increased with inhibition of methylation with either 5-Aza-2-Deoxycytidine, or siRNA to DNA Methyltransferase (DNMT) 1 and 3b in HCC cells. MiRNA-dependent regulation of MEG3 expression was studied by evaluating the involvement of miR-29, which can modulate DNMT 1 and 3. Overexpression of mir-29a increased expression of MEG3. GTL2, the murine homolog of MEG3, was reduced in liver tissues from hepatocyte-specific miR-29a/b1 knock-out mice compared with wild-type controls. These data show that methylation-dependent tissue-specific regulation of the lncRNA MEG3 by miR-29a may contribute to HCC growth and highlight the inter-relationship between two classes of non-coding RNA, miRNAs and lncRNAs, and epigenetic regulation of gene expression.

Effect of the ultraconserved noncoding RNA uc.338 on cellular growth of hepatocarcinoma

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Background: The role of non-protein coding (nc)RNAs in cancer is unknown but emerging evidence suggests that deregulated expression of ncRNA may contribute to cancer pathogenesis. We sought to examine the role of ultraconserved ncRNA (ucRNA) that are 100% conserved across the human, rat and mouse genomes in hepatocellular cancers (HCC).

Methods: Whole genome ucRNA expression profiling was performed using a custom microarray, and verified by real time PCR in cell lines and by in situ hybridization in a tissue microarray comprising of 221 human HCC, 72 non cirrhotic (NC) and 97 cirrhotic (C) liver tissues. ucRNA expression was manipulated with siRNA or plasmid-over-expressing ucRNA, and the effects on anchorage-dependent and independent growth, and cell cycle assessed using cell viability, soft agar assays and flow cytometry. Gene ontology analysis was performed by evaluating uc338-dependent changes on mRNA expression using Affymetrix chips.

Results: 56 ucRNAs were aberrantly expressed with 33 increased and 23 decreased in HepG2 cells compared to non-malignant hepatocytes. The greatest change was observed with uc.338 (6.9-fold increase). uc.338 expression was significantly increased in several HCC cell lines. uc.338 expression was detected in 170 cases (77%) of HCC, with 62% of these showing a moderate to strong expression. Compared to non- malignant adjacent tissue, uc.338 expression was increased in 97/156 of HCC. The mean % of cells expressing uc.338 was 4% in NC liver, 15% in C and 24% in HCC. Inhibition of uc.338 reduced anchorage dependent and independent growth, and cell cycle progression in both human and murine malignant hepatocytes. Gene annotation enrichment analysis of mRNAs that were altered by inhibition of uc.338 expression identified the top over-represented GenMAPP pathways as: cell cycle, mRNA processing, RNA transcription, G1 to S cell cycle. Moreover, enforced expression of uc.338 increased cell growth in nonmalignant hepatocytes.

Conclusions: These data showing that uc.338 is selectively overexpressed in HCC and promotes cell growth provides new insights into the role of RNA genes in HCC.

No significant financial relationships to disclose.

Search for quark compositeness with the dijet centrality ratio in pp collisions at √s=7 TeV

A search for quark compositeness in the form of quark contact interactions, based on hadronic jet pairs (dijets) produced in proton-proton collisions at √s=7 TeV, is described. The data sample of the study corresponds to an integrated luminosity of 2.9 pb(-1) collected with the CMS detector at the LHC. The dijet centrality ratio, which quantifies the angular distribution of the dijets, is measured as a function of the invariant mass of the dijet system and is found to agree with the predictions of the standard model. A statistical analysis of the data provides a lower limit on the energy scale of quark contact interactions. The sensitivity of the analysis is such that the expected limit is 2.9 TeV; because the observed value of the centrality ratio at high invariant mass is below the expectation, the observed limit is 4.0 TeV at the 95% confidence level.

Bladder cancer: a review of clinical management and prognostic factors

Bladder cancer is a heterogeneous disease that offers a unique challenge for the patient and the physician as treatment paradigms are continually evolving. There are multiple factors that can influence how each individual is treated, including lymphovascular invasion, micropapillary histology, and p53 nuclear accumulation which have demonstrated a worse prognosis in patients with bladder cancer. They can influence the use of neoadjuvant and adjuvant chemotherapy, which in itself can affect the timing of extirpative surgery. This review will focus on the contemporary management and treatment of bladder cancer focusing on areas of clinical decision making.

Search for dijet resonances in 7 TeV pp collisions at CMS

A search for narrow resonances in the dijet mass spectrum is performed using data corresponding to an integrated luminosity of 2.9 pb⁻¹ collected by the CMS experiment at the Large Hadron Collider. Upper limits at the 95% confidence level are presented on the product of the resonance cross section, branching fraction into dijets, and acceptance, separately for decays into quark-quark, quark-gluon, or gluon-gluon pairs. The data exclude new particles predicted in the following models at the 95% confidence level: string resonances, with mass less than 2.50 TeV, excited quarks, with mass less than 1.58 TeV, and axigluons, colorons, and E6 diquarks, in specific mass intervals. This extends previously published limits on these models.

Food allergy in patients with eczema: immediate symptoms are usual, with nuts and tomatoes the major allergens

BACKGROUND

Food intolerance is a popular notion in the general population but limited data are available on the presence of food allergy in adult patients with eczema.

OBJECTIVE

We wanted to characterize food hypersensitivity in this group of patients.

METHOD

A retrospective study was carried out on all patients with food related symptoms attending a cutaneous allergy clinic.

RESULTS AND CONCLUSION

Our study showed that while the reported prevalence of food allergy in adult patients with eczema is low (10%), more than half of these will show immunological evidence of a food allergy which support the clinical history. Immediate symptoms are usual, with nuts and tomatoes the major allergens. Demographic factors such as age, gender and duration of eczema did not significantly correlate with number of foods or an allergen-specific IgE of ≥grade 2. Food-related symptoms were associated with significant anxiety in all our patients leading to a profound effect on their behaviour.

SABRE-B: an evaluation of paclitaxel and bevacizumab with or without sunitinib as first-line treatment of metastatic breast cancer

BACKGROUND

The vascular endothelial growth factor (VEGF) pathway can be targeted through VEGF neutralization or VEGF receptor (VEGFR) blockade using tyrosine kinase inhibition. Because laboratory models suggest that combining these approaches might be synergistic, we sought to evaluate the feasibility and efficacy of combining sunitinib with paclitaxel + bevacizumab (PB).

METHODS

Patients with human epidermal growth factor receptor 2 (HER2)-negative, metastatic breast cancer receiving first-line chemotherapy were randomized to PB or PB with sunitinib (PBS), with planned escalation of the sunitinib dose.

RESULTS

Forty-six patients were randomized to PB or PBS with sunitinib dosed at 25 mg p.o. daily. Patients receiving PBS encountered substantial toxicity that precluded adequate treatment. The percentage of patients with grade ≥3 adverse events was greater in the PBS arm than the PB arm (83% versus 57%), and sunitinib dosing was modified in 78% of patients, most often due to neutropenia, febrile neutropenia, and fatigue. In addition, 44% of patients had sunitinib dose reduction to 12.5 mg, and 39% required discontinuation. Patients receiving PBS had more bevacizumab treatment interruptions and discontinuations because of toxicity. Median treatment duration was longer in the PB arm compared with the PBS arm (14.1 versus 11.1 weeks), reflecting early treatment discontinuation of PBS. Because of poor tolerability of the addition of sunitinib to PB, the planned sunitinib dose escalation was halted and the study accrual was terminated.

CONCLUSION

Adding sunitinib to standard doses of bevacizumab plus paclitaxel for metastatic breast cancer is not feasible. Different strategies will be required to evaluate whether there is additional clinical benefit to combining VEGF/VEGFR-targeted agents.

A Retrospective Review of Patients with Adenoid Cystic Breast Cancer Treated at Mayo Clinic

Background: Adenoid cystic carcinoma of the breast is a rare type of breast cancer accounting for approximately 0.1% of all breast cancer and less than 200 cases are reported in the literature. Hence, data for treatment and outcome are limited. This retrospective review reports the Mayo Clinic's experience.Methods: We identified 30 patients between 1971 and 2009 who were diagnosed with adenoid cystic breast cancer at Mayo Clinic Rochester, Arizona or Florida. Median follow-up was 62 months with a range of 1 to 424 months. Data regarding demographics (age, gender, and race), tumor characteristics (size, grade, and margin status), biological features (Estrogen receptor (ER), Progesterone receptor (PR) status, HER2 status) and clinical course (recurrence, secondary treatment) were collected. Disease free survival was calculated using Kaplan Meier estimates.Results: The median age of all patients was 58 (range, 22 – 78 years). All were female. Median tumor size was 1.3 cm (range, 0.6 – 8.5cm). Axillary lymph node sampling (sentinel or complete dissection) was performed in 15 patients. No patient had lymph node positive disease on presentation. The majority of patients had hormone receptor negative disease. Only 3 patients (10%) had weak hormone receptor (1-10%) positivity. No tumors were HER2 positive. Only two patients had high grade disease. Initial surgical data only available in twenty one patients: fifteen (50%) were treated with lumpectomy and adjuvant radiation, and 6 (20%) were treated with mastectomy. There were no local recurrences. Only one patient was treated with adjuvant chemotherapy (with cyclophosphamide, methotrexate and fluorouracil (CMF) followed by tamoxifen) but still suffered a distant recurrence within 5 years. There were a total of five patients that recurred. The 5-year disease free survival (DFS) rate for the entire cohort was 90%, and 10 year DFS was 83%. Median time to recurrence was 47.5 months (Range, 23-77 months). Recurrence occurred almost exclusively in patients with ≥ T2 disease. The primary site of metastases was lung (80%) and bone (20%) but subsequent liver and brain metastases were also seen. Treatments at relapse included surgical resection, radiosurgery and chemotherapy.Conclusion: Adenoid cystic carcinomas of the breast are rare but have overall good prognosis. This review confirms that the majority of these patients present with node negative disease, low to intermediate histologic grade and endocrine unresponsive tumors. Primary treatment is surgery (mastectomy or lumpectomy plus radiation) and there seems to be no role of any adjuvant therapy at the present time. In general, recurrences (80%) occurred with tumors larger than 2 cm and adjuvant chemotherapy and/or targeted therapy could be explored for selected patients in the context of a clinical trial. Overall mortality after recurrence was 50% but median overall survival was variable in years (1-14 years).

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2055.

Paclitaxel-Related Peripheral Neuropathy Associated with Improved Outcome of Patients with Early Stage HER2+ Breast Cancer Who Did Not Receive Trastuzumab in the N9831 Clinical Trial

Background: Microtubules are crucial for spindle formation during mitosis and for cellular proliferation. The antineoplastic effect of paclitaxel is mainly related to its ability to bind the beta subunit of tubulin, thus preventing tubulin chain depolarization and inducing apoptosis. Tubulins are expressed in human peripheral nerves and the binding of paclitaxel to tubulin may lead to neuropathy. Peripheral neuropathy is a common dose limiting toxicity of paclitaxel. We hypothesized that the occurrence of peripheral neuropathy may correlate with outcome (disease-free survival; DFS).Methods: This analysis sought to describe incidence of peripheral neuropathy following paclitaxel and its association to outcome (DFS) in patients who received paclitaxel (weekly x 12) in the adjuvant HER2+ intergroup trial N9831. Only eligible pts who initiated paclitaxel and did not have peripheral neuropathy at initiation of paclitaxel that were randomized to arms A (955 pts; chemotherapy alone) and C (889 pts; chemotherapy plus concurrent trastuzumab) of N9831 were included. Cox regression analysis stratified by ER/PR status and nodal status was used to compare DFS within arm between patients with and without peripheral neuropathy.Results: Out of 1844 eligible pts, 379 developed neuropathy (20.5%). For pts in arm A, those who developed neuropathy had better DFS than pts who did not (3 yr DFS: 86.2% vs 81.8%; HR 0.65; p=0.01), despite lower doses of paclitaxel in the pts with neuropathy. Grade of neuropathy did not appear to impact DFS. No statistical difference was noted for pts treated in the trastuzumab-containing arm (3 yr DFS: 92.8% vs 91.1% for pts with neuropathy vs not; HR 0.79; p=0.34). There were no differences in paclitaxel dose intensity between arms A and C.Conclusion: Patients with early stage HER2+ breast cancer who received adjuvant paclitaxel-containing chemotherapy in arm A and developed peripheral neuropathy had a better DFS than pts who did not develop neuropathy. This effect was possibly abrogated by the use of trastuzumab in Arm C. This side effect may represent effective bindings of paclitaxel to the target tubulin, lack of point mutations in tubulin at the paclitaxel binding site and/or lack of selective overexpression of β-III tubulin. This is a hypothesis generating study and additional analysis needs to be conducted from other large taxane-based trials.Partial support from Genentech and the Breast Cancer Research Foundation

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2100.

Lung cancer symptoms with cetuximab/taxane/carboplatin in first-line advanced NSCLC: Analysis of the BMS099 trial

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Background: The phase III BMS099 trial investigated cetuximab (C) added to taxane/carboplatin (TC) for 1st line treatment of advanced NSCLC. Progression-free survival (PFS) was not significantly different with C; response rate (RR) was significantly higher. Median overall survival (OS) was longer, with a difference not statistically significant, but similar in magnitude to the significant OS improvement from the FLEX trial (cisplat/vinorelb±C). A secondary objective of the BMS099 study was to assess the effect of C on Lung Cancer Symptoms (LCS). Methods: Chemonaïve patients (pts) with stage IIIB/IV NSCLC (any histology or EGFR expression status) were randomized to TC±C. LCS were measured using the functional assessment of cancer treatment-lung cancer subscale questionnaire (FACT-LCS), given at baseline and before each therapy cycle until disease progression (scoring 7 symptoms: breath loss, weight loss, clear thinking, coughing, appetite, chest tightness, breath ease, on a 0–4 scale). The main endpoints were rates of symptom response/progression (≥ 2 point improvement/decrease from baseline in 2 consecutive assessments), compared between arms with a stratified Cochran-Mantel-Haenszel (CMH) test; a stratified log-rank test was used to compare time to symptomatic progression. A Wei-Lachin test was used to compare between arms the changes from baseline in LCS score, and a longitudinal model was constructed to measure treatment effect on those score changes. Results: With 676 patients randomized, the baseline compliance rates for the FACT-LCS questionnaire were 99.4% and 99.1% for CTC and TC respectively, decreasing by week 18 to 74.0% and 66.4%. Baseline FACT-LCS scores were similar across treatment arms (median, 19.0). Symptom response rates were similar with CTC vs TC (32.6% vs 28.5%, CMH P=0.26), and time to symptomatic progression was not significantly different (log-rank P=0.58). Changes from baseline in FACT-LCS scores did not differ significantly between arms (Wei Lachin P=0.912; longitudinal model P=0.81). Conclusions: The addition of C to TC for the 1st treatment of advanced NSCLC resulted in similar symptom response/progression rates and did not affect trends in LCS score changes throughout treatment.

[Table: see text]

Resuscitation room blood alcohol concentrations: one-year cohort study

OBJECTIVE

To clarify the relationship between presenting clinical condition and blood alcohol concentration (BAC) among adult patients admitted to a resuscitation room (RR) of an emergency department (ED) in order to help guide clinical practice.

METHOD

Single-site prospective cohort study of all patients admitted to the RR of an inner-city hospital over a one-year period. The study sample comprised all those aged 16 years and over from whom a blood sample was taken, with BAC (results not known to ED staff), pathology by International Classification of Diseases (ICD) version 10 coding, injury severity score for trauma, return visit to hospital and mortality during the subsequent 6-month period, being recorded.

RESULTS

291 (15%) of 1908 presentations had a positive BAC (ie, BAC >10 mg/100 ml) ranging from 11 to 574 mg/100 ml, of which almost 40% were over 240 mg/100 ml (ICD-10 code Y90.8). In addition to collapse from alcohol/drugs, almost half of those presenting following self-harm or assault had a positive BAC. Those with a positive BAC had a higher rate of ED re-attendance in the following 6 months. 10% of all presentations were due to trauma.

CONCLUSION

The following five presentations to the RR are associated with a positive BAC: collapse from alcohol/drugs, self-harm, trauma, gastrointestinal bleeding (ICD-10 code K92.2) and non-cardiac chest pain (ICD-10 code R07). Patients with a positive BAC demonstrate a very wide range of pathology, some with severe levels of misuse. This highlights the opportunity for prompt feedback when sober, to ensure all is done to encourage patients to contemplate change in order to reduce re-attendance.

Intermittent hypoxia suppresses adiponectin secretion by adipocytes

Obstructive sleep apnea (OSA), characterized by cyclic intermittent hypoxia (IH) during sleep, is an independent risk factor for cardiovascular disease. Adiponectin (APN), an adipocytokine secreted exclusively by adipocytes, possesses antiatherogenic properties. Low levels of APN, particularly the high-molecular-weight (HMW) form, are associated with an increased risk of cardiovascular disease. Here, we hypothesized that IH would result in the dysregulation of APN expression and secretion. 3T3-L1 adipocytes were exposed to IH at 12 cycles/h for 6 h/d to simulate the IH condition similar to that encountered in OSA. Control adipocytes were exposed to 21% O(2) under identical conditions. After 48 h of incubation, IH caused a decrease in the secretion of total and HMW APN in spite of a significant upregulation of APN mRNA expression by adipocytes. This study suggested a novel mechanism of how the cyclic hypoxemia in OSA predisposes OSA patients to cardiovascular disease through the dysregulation of secretion of APN by adipocytes. Further studies are needed to determine the exact molecular mechanism how IH reduces the release of APN by adipocytes.

Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents

BACKGROUND

Classical crush has a lower rate of final kissing balloon inflation (FKBI) immediately after percutaneous coronary intervention (PCI). The double kissing (DK) crush technique has the potential to increase the FKBI rate, and no prospective studies on the comparison of classical with DK crush techniques have been reported.

MATERIALS AND METHODS

Three hundred and eleven patients with true bifurcation lesions were randomly divided into classical (n = 156) and DK crush (n = 155) groups. Clinical and angiographic details at follow-up at 8 months were indexed. The primary end point was major adverse cardiac events (MACE) including myocardial infarction, cardiac death and target lesion revascularization (TLR) at 8 months.

RESULTS

FKBI was 76% in the classical crush group and 100% in the DK group (P < 0.001). The incidence of stent thrombosis was 3.2% in the classical crush group (5.1% in without- and 1.7% in with-FKBI) and 1.3% in the DK crush group. Cumulative 8 month MACE was 24.4% in the classical crush group and 11.4% in the DK crush group (P = 0.02). The TLR-free survival rate was 75.4% in the classical crush group and 89.5% in the DK crush group (P = 0.002).

CONCLUSIONS

DK crush technique has the potential of increasing FKBI rate and reducing stent thrombosis, with a further reduction of TLR and cumulative MACE rate at 8 months.

The efficiency of gravity distribution devices for on-site wastewater treatment systems

A detailed analysis of different types of gravity distribution devices, designed to split on-site wastewater effluent equally between percolation trenches, has been carried out both in the laboratory and also in the field under realistic loading conditions. Five different types of distribution device have been compared: a V-notch distribution box, stilling chamber box, T-splitters with and without baffles and tipping bucket device. The trials carried out in the laboratory with clean water showed that flow distribution for all devices was sensitive to both the off-level installation angles and variable flow rates, with the most stable performance achieved using the T-splitters with baffles and tipping bucket devices. In parallel to this, the on-site flow regime experienced at two sites was continuously monitored using a tipping bucket and data-logger over eighteen month periods, finding that the most common flow rates at the distribution unit were in the range of 0.1-2.5 L/min. The on-site performance of these devices receiving both septic tank and secondary treated effluent showed that significant solid deposition and biofilm development had severely affected the equal distribution between the trenches, hence highlighting the need for regular maintenance to ensure efficient performance over time after installation.

Nitrogen loading on groundwater from the discharge of on-site domestic wastewater effluent into different subsoils in Ireland

The performance of six separate percolation areas has been intensively monitored to ascertain the attenuation effects of the unsaturated subsoil with respect to on-site wastewater effluent. Septic tank effluent on three sites and secondary treated effluent on the other three sites was discharged into subsoils of varying percolation values. Samples of the percolating effluent were taken using suction lysimeters installed to nominal depths of 0.3, 0.6 and 1.0 m below the invert of the percolation trenches. The results clearly showed that the development of a biomat across the percolation areas receiving secondary treated effluent was muted on these sites compared to the sites receiving septic tank effluent. Significant differences were found between the sites receiving septic tank and secondary treated effluent in terms of the potential nitrogen loading to groundwater. The average nitrogen loading after 1.0 m depth of unsaturated subsoil per capita equated to 5.5, 3.3 and 3.2 gTotal-N/d for the sites receiving secondary treated effluent compared to 4.2, 1.7 and 0.3 gTotal-N/d for the sites receiving septic tank effluent. The noticeably higher nitrogen loading on one of the septic tank sites corresponded to the effluent percolating through highly permeable subsoil that counteracted any significant denitrification.

Epigenetic regulation of microRNA-370 by interleukin-6 in malignant human cholangiocytes

Interleukin-6 (IL-6) is overexpressed and contributes to tumor cell growth in cholangiocarcinoma. Enforced IL-6 production can alter the expression of specific microRNAs (miRNAs) involved in tumor growth, and moreover can modulate expression of methylation-dependent genes. Thus, we assessed the methylation-dependent regulation of miRNA expression in human malignant cholangiocytes stably transfected to overexpress IL-6. The expression of the methyltransferases DNA methyltransferase enzyme-1 and HASJ4442 was increased by IL-6 overexpression, but was decreased by the methylation inhibitor 5-aza-2'-deoxycytidine (5-aza-CdR). Expression profiling identified seven miRNAs that were significantly downregulated by IL-6 overexpression (<0.4-fold) and upregulated (>2-fold) by 5-aza-CdR. One of these, miR-370, is embedded in a CpG island. Although 5-aza-CdR increased miR-370 expression by 2.1-fold in malignant cells, the expression in nonmalignant cells was unchanged. The oncogene mitogen-activated protein kinase kinase kinase 8 (MAP3K8) was identified as a target of miR-370, and its expression was decreased by 5-aza-CdR in cholangiocarcinoma cells. Overexpression of IL-6 reduced miR-370 expression and reinstated MAP3K8 expression in vitro as well as in tumor cell xenografts in vivo. Thus, IL-6 may contribute to tumor growth by modulation of expression of selected miRNAs, such as miR-370. These studies define a mechanism by which inflammation-associated cytokines can epigenetically modulate gene expression and directly contribute to tumor biology.

Improving medication management for patients: the effect of a pharmacist on post-admission ward rounds

PROBLEM

Medication management in the NHS has been highlighted by the UK Department of Health as an area for improvement. Pharmacist participation on post-take (post-admission) ward rounds was shown to reduce medication errors and reduced prescribing costs in the USA and in UK teaching hospitals, which can contribute to improved medication management. We sought to demonstrate the problem in our hospital by collecting data on prescribing practice from three consecutive general medical post-take ward rounds.

SETTING

Northwick Park Hospital, a district general hospital in north-west London, which provides acute medical services to a population of 300,000.

STRATEGY FOR CHANGE

A pharmacist was invited to become a member of the post-take ward round team that reviewed medical patients admitted within the preceding 24 hours. Patients also continued to receive care from a ward based pharmacist. Patient notes were analysed for cost of drugs on admission and discharge, discrepancies between admission drug history and pharmacist history, number of admission drugs stopped before discharge, and pharmacist recommendations. Pharmacist recommendations and actions were classified using a National Patient Safety Agency risk matrix.

EFFECTS OF CHANGE

Discrepancies between the admission and the pharmacist derived drug history were noted in 26 of 50 in the pre-intervention group and 52 of 53 in the intervention group. The annual drug cost per patient following discharge increased by pounds 181 in the pre-intervention group and by pounds 122 in the intervention group. Five pre-admission drugs were stopped in three pre-intervention patients saving pounds 276 per annum, while the 42 drugs stopped in 19 intervention patients saved pounds 4699 per annum. No ward based pharmacist recommendations were recorded in the pre-intervention group. Recommendations regarding drug choice, dose, and need for drug treatment were most common; 58 minor, 48 moderate and four major risks to patients were potentially avoided.

LESSONS LEARNT

The presence of a pharmacist on a post-take ward round improved the accuracy of drug history documentation, reduced prescribing costs, and decreased the potential risk to patients in our hospital. As a result of this work a full time pharmacist has now been funded to attend daily post-take ward rounds on a permanent basis.

Disseminated Mycobacterium tuberculosis infection due to interferon gamma deficiency. Response to replacement therapy

The case of a previously healthy HIV seronegative woman with disseminated Mycobacterium tuberculosis infection and markedly reduced interferon gamma production is reported here. Complete healing of her disseminated lesions was seen only after addition of subcutaneous interferon gamma to her tuberculosis treatment.

Noise pollution in residential areas of Jharsuguda Town, Orissa (India) and its impact

In this paper, an attempt has been made to study noise levels in different residential areas of Jharsuguda town in western Orissa (India). Minimum, maximum, L10, L50 and L90 noise levels have been computed. It was found that noise levels in the residential areas exceed the standards set by the Central Pollution Control Board, India. Vehicular traffic, with air horns of loud noise, was found to be the main reason for these high noise levels. Strict measures need to be taken to reduce and control the noise pollution.

The tumour necrosis factor-alpha inhibitor adalimumab rapidly reverses the decrease in epidermal Langerhans cell density in psoriatic plaques

BACKGROUND

The pathophysiology of psoriasis is poorly understood, and the mechanism of action of biological agents interfering with tumour necrosis factor (TNF)-alpha that improve psoriatic plaques is completely unknown.

OBJECTIVES

To begin to unravel the mechanism of action, cellular changes occurring in plaques following administration of adalimumab, a humanized monoclonal antibody against TNF-alpha, were investigated.

METHODS

Thirteen different patients underwent sequential biopsies as part of a clinical trial. Each biopsy was immunostained and evaluated to calculate the relative density of epidermal Langerhans cells (LCs) before and after treatment (days 2, 7, 28, 84). To explore the basis for reduced epidermal LC densities in plaques, a SCID-Hu animal model was utilized. Acute psoriatic lesions were created within 2 weeks by injection of superantigen-activated CD4+ T cells into engrafted symptomless skin.

RESULTS

Compared with symptomless skin, untreated plaques had a significantly reduced density of epidermal LCs. There was a rapid increase in density of epidermal LCs in plaques following treatment with adalimumab beginning as early as day 7. The paucity of epidermal LCs in plaques was contrasted to the prominent density of LCs in other skin disorders with chronic inflammation and alterations in keratinization, including lichen planus and inflamed seborrhoeic keratosis. Rapid creation of plaques using the SCID-Hu model was accompanied by loss of epidermal LCs, indicating that diminished LC density occurs at an early stage of lesion formation.

CONCLUSIONS

These data shed light on a new immunopathological perspective highlighting a rapid loss of epidermal LCs in acute psoriatic lesions, with sustained decreased density of LCs in chronic plaques. Furthermore, an unexpected insight into the mechanism of action was uncovered for adalimumab, in which rapid restoration of epidermal LC density was observed.

The clinical importance of axillary lymphadenopathy detected on screening mammography: revisited

AIM

The aim of this study was to re-evaluate our protocol for the management of isolated axillary lymphadenopathy (ALP) on mammographic screening.

METHODS

In a retrospective review of 200,716 women screened at the South West London Breast Screening Service (SWLBSS) over 7 years, 72 women with ALP with an otherwise normal mammogram were identified. Thirteen patients were not recalled, nine of who had a known underlying diagnosis and the remainder had longstanding unchanged mammograms. Fifty-nine patients were recalled for further clinical assessment and investigations, including ultrasound, further mammographic views, fine-needle aspiration cytology (FNAC), blood tests and a chest radiograph. Those with a definite diagnosis were referred for appropriate management and those with benign reactive cytology on FNAC reviewed at 6 weeks with subsequent referral for excision of persisting abnormal nodes.

RESULTS

The ultimate diagnosis was benign in 45 cases: 26 benign reactive changes, 11 arthritides, five with dermatological and viral conditions and three with tuberculosis. Malignancy was diagnosed in 13 cases: four with metastatic breast carcinoma and nine with lymphoma/leukaemia. The total number of newly diagnosed malignancies was 20% of women recalled. Another 5% of patients had active tuberculosis. Of the 22 patients with benign reactive cytology, one had significant pathology on excision biopsy: tuberculosis. Over 95% of the results from excision biopsy in these patients did not alter management.

CONCLUSION

In the majority of patients, the FNAC results were representative of the final excision pathology. The present study suggests that excision biopsy could be omitted for those patients whose FNAC and culture are negative.

Structure-affinity relationships in the gp41 ELDKWA epitope for the HIV-1 neutralizing monoclonal antibody 2F5: effects of side-chain and backbone modifications and conformational constraints

The human monoclonal antibody, mAb 2F5, has broad HIV-1 neutralizing activity and binds a conserved linear epitope within the envelope glycoprotein gp41 having a core recognition sequence ELDKWA. In this study, the structural requirements of this epitope for high-affinity binding to mAb 2F5 were explored using peptide synthesis and competitive enzyme-linked immunosorbant assay (ELISA). Expansion of the minimal epitope to an end-capped, linear nonapeptide, Ac-LELDKWASL-amide, was sufficient to attain maximal affinity within the set of native gp41-sequence peptides assayed. Scanning single-residue alanine and d-residue substitutions then confirmed the essential recognition requirements of 2F5 for the central DKW sequence, and also established the importance of the terminal leucine residues in determining high-affinity binding of the linear nonapeptide. Further studies of side-chain and backbone-modified analogs revealed a high degree of structural specificity for the DK sequence in particular, and delineated the steric requirements of the Leu(3) and Trp(6) residues. The nine-residue 2F5 epitope, flanked by pairs of serine residues, retained a high affinity for 2F5 when it was conformationally constrained as a 15-residue, disulfide-bridged loop. However, analogs with smaller or larger loop sizes resulted in lower 2F5 affinities. The conformational effects of the gp41 C-peptide helix immediately adjacent to the N-terminal end of the ELDKWA epitope were examined through the synthesis of helix-initiated analogs. Circular dichroism (CD) studies indicated that the alpha-helical conformation was propagated efficiently into the LELDKWASL epitope, but without any significant effect on its affinity for 2F5. This study should guide the design of a second generation of conformationally constrained ELDKWA analogs that might elicit an immune response that mimics the HIV-neutralizing actions of 2F5.

Monthly docetaxel and weekly gemcitabine in metastatic breast cancer: a phase II trial

BACKGROUND

Docetaxel and gemcitabine are active against breast cancer. The purpose of this phase II study was to evaluate the efficacy and safety of monthly docetaxel combined with weekly gemcitabine in patients with chemotherapy-pretreated metastatic breast cancer.

PATIENTS AND METHODS

Thirty-nine patients were enrolled, of whom thirty had received prior chemotherapy in the adjuvant setting, seven for metastatic disease, and two for both, including prior anthracycline in 33 patients. Treatment was gemcitabine 800 mg/m2 days 1, 8, 15 and docetaxel 100 mg/M2 on day 1, with cycles repeated every four weeks.

RESULTS

Response rate was 79% (95% confidence interval (CI): 63%-91%), with 2 complete and 29 partial responses. Twenty-five of the responders remained progression-free for more than six months. Median survival was 24.5 months. Delivered dose intensity of gemcitabine was lower than expected (63% of planned). The predominant hematologic toxicity was grade 4 neutropenia in 36 patients, complicated by fever in three patients. With the exception of asthenia, severe non-hematological toxicities were infrequent.

CONCLUSIONS

Monthly docetaxel, combined with weekly gemcitabine, has significant but manageable hematologic toxicity. Despite frequent dose adjustments, this doublet is very active in metastatic breast cancer, producing a high proportion of durable responses associated with favorable survival.

Proteomic comparison of human and great ape blood plasma reveals conserved glycosylation and differences in thyroid hormone metabolism

Most blood plasma proteins are glycosylated. These glycoproteins typically carry sialic acid-bearing sugar chains, which can modify the observed molecular weights and isoelectric points of those proteins during electrophoretic analyses. To explore changes in protein expression and glycosylation that occurred during great ape and human evolution, we subjected multiple blood plasma samples from all these species to high-resolution proteomic analysis. We found very few species-specific differences, indicating a remarkable degree of conservation of plasma protein expression and glycosylation during approximately 12 million years of evolution. A few lineage-specific differences in protein migration were noted among the great apes. The only obvious differences between humans and all great apes were an apparent decrease in transthyretin (prealbumin) and a change in haptoglobin isoforms (the latter was predictable from prior genetic studies). Quantitative studies of transthyretin in samples of blood plasma (synthesized primarily by the liver) and of cerebrospinal fluid (synthesized locally by the choroid plexus of the brain) confirmed approximately 2-fold higher levels in chimpanzees compared to humans. Since transthyretin binds thyroid hormones, we next compared plasma thyroid hormone parameters between humans and chimpanzees. The results indicate significant differences in the status of thyroid hormone metabolism, which represent the first known endocrine difference between these species. Notably, thyroid hormones are known to play major roles in the development, differentiation, and metabolism of many organs and tissues, including the brain and the cranium. Also, transthyretin is known to be the major carrier of thyroid hormone in the cerebrospinal fluid, likely regulating delivery of this hormone to the brain. A potential secondary difference in retinoid (vitamin A) metabolism is also noted. The implications of these findings for explaining unique features of human evolution are discussed.

Increasing incidence and mortality of primary intrahepatic cholangiocarcinoma in the United States

Clinical observations suggest a recent increase in intrahepatic biliary tract malignancies. Thus, our aim was to determine recent trends in the epidemiology of intrahepatic cholangiocarcinoma in the United States. Reported data from the Surveillance, Epidemiology, and End Results (SEER) program and the United States Vital Statistics databases were analyzed to determine the incidence, mortality, and survival rates of primary intrahepatic cholangiocarcinoma. Between 1973 and 1997, the incidence and mortality rates from intrahepatic cholangiocarcinoma markedly increased, with an estimated annual percent change (EAPC) of 9.11% (95% CI, 7.46 to 10.78) and 9.44% (95%, CI 8.46 to 10.41), respectively. The age-adjusted mortality rate per 100,000 persons for whites increased from 0.14 for the period 1975-1979 to 0.65 for the period 1993-1997, and that for blacks increased from 0.15 to 0.58 over the same period. The increase in mortality was similar across all age groups above age 45. The relative 1- and 2-year survival rates following diagnosis from 1989 to 1996 were 24.5% and 12.8%, respectively. In conclusion, there has been a marked increase in the incidence and mortality from intrahepatic cholangiocarcinoma in the United States in recent years. This tumor continues to be associated with a poor prognosis.

Comparison of short and long-term renal function in liver transplant patients receiving cyclosporin or FK 506

Long-term renal function was compared in 49 liver recipients [25 patients received cyclosporin (CyA) and 24 patients received FK 506] followed for a period of 1 year. Creatinine (CR) and glomerular filtration rate (GFR) pretransplantation (pre-Tx) and at 1, 3, 5, and 12 months post-Tx were recorded, as well as incidences of hyperkalemia, post-Tx hypertension, and insulin-dependent diabetes mellitus (IDDM) in the two groups. At 1 year post-Tx, the mean Cr had risen from baseline by 56% and 60% in the FK and CyA groups, respectively; the mean GFR had dropped by 32% in FK patients and by 27% in CyA patients. Acute nephrotoxicity occurred in 7/25 CyA patients (2/7 required dialysis) and 9/26 FK patients (7/9 required dialysis; 2/7 were switched to CyA). None remained on dialysis at 3 months. Renal insufficiency persisted at 1 year in 7/16 patients with early toxicity (CyA, 4; FK, 3) and in 3 of the remaining 36 pts (P < 0.001). Hyperkalemia occurred in 4/25 CyA, and in 12/24 FK patients (P < 0.025), post-Tx hypertension occurred in 15 CyA, and 7 FK patients (P < 0.05), and IDDM occurred in 4 CyA and 7 FK patients (P = ns). FK 506 and CyA, thus, exerted similar chronic renal effects. Although acute renal insufficiency improved upon dose reduction, renal impairment was permanent in some cases.