The "atheroprotective" mediators apolipoprotein A-I and Foxp3 are over-abundant in unstable carotid plaques

OBJECTIVE

Inflammation is important in plaque vulnerability but the role of atheroprotective mediators in unstable plaques is not defined. The apolipoproteinA-I (apoA-I) component of HDL, and CD4+/CD25+ regulatory T cells (with their major transcription factor, Foxp3), have been implicated in the suppression of vascular inflammation. Our aim was to characterise the presence of these novel "protective" markers (apoA-I and Foxp3) in carotid plaques from symptomatic and asymptomatic subjects.

METHODS AND RESULTS

Plaques from 57 patients (25 symptomatic, 32 asymptomatic) were stained immunohistochemically for macrophages (CD68), T cells (CD3), monocyte chemotactic protein-1 (MCP-1), matrix metalloproteinase-2 (MMP-2), myeloperoxidase (MPO), apoA-I and Foxp3. Twelve randomly selected plaques (6 asymptomatic, 6 symptomatic) were immunostained for interleukin-10 (IL-10) and interleukin-17 (IL-17). Staining was quantified using Image-Pro Plus software. Significantly greater areas of positive immunostaining for CD68, CD3, MCP-1, MMP-2, IL-17 and MPO were found in plaques from symptomatic patients compared with asymptomatic patients (p<0.05 for all). Furthermore, significantly greater areas of positive immunostaining for apoA-I, Foxp3 and IL-10 were found in symptomatic versus asymptomatic plaques (p<0.05 for all). The presence of apoA-I was correlated significantly and co-localised with CD3, CD68, MCP-1, MMP-2 and MPO immunostaining (R=0.70, 0.63, 0.52, 0.55 and 0.79, respectively; p<0.01 for all). Foxp3 immunostaining also correlated significantly with CD3 (R=0.42), CD68 (R=0.47), MCP-1 (R=0.55) and MMP-2 (R=0.44) immunostaining (p<0.05 for all).

CONCLUSIONS

ApoA-I and Foxp3 are over-abundant in plaques from symptomatic subjects and co-localise with key inflammatory mediators. These data suggest ineffective/insufficient protection against atherosclerosis-mediated inflammation by these "atheroprotective" moieties.

A SARC global collaborative phase II trial of R1507, a recombinant human monoclonal antibody to the insulin-like growth factor-1 receptor (IGF1R) in patients with recurrent or refractory sarcomas

10503

Background: The IGF1 system has been implicated in sarcoma development and inhibition of IGF1R function has been shown to induce clinical responses in select sarcomas. Methods: Objectives included response rate (RR) and progression-free survival (PFS) to R1507 in patients with recurrent or refractory Ewing's (ES, 2 cohorts- primary refractory vs. others) osteo (OS), synovial (SS), rhabdomyosarcoma (RMS), and other sarcomas. Eligibility included recurrent/refractory measurable disease, age ≥ 12 yrs, life expectancy ≥ 6 weeks, Karnofsky PS ≥ 70, adequate renal, hepatic and bone marrow function. R1507 was administered i.v. at 9 mg/kg over one hour weekly. Response was assessed by WHO criteria every 6 wks X 4 and every 12 wks thereafter. A two-stage design (Green and Dahlberg) was used. The endpoint for the primary refractory ES cohort was PFS at week 18 (planned n=65). RR was the primary endpoint for the remaining cohorts (planned n=240). Results: From 12/07–12/08, 203 eligible patients from 29 centers across the US, Europe and Australia were enrolled. Age ranged from 12–85 yrs (median=27 yrs) and 126 were male. Verified histologic subtypes were ES (n=71), OS (n=43), RMS (n=28), SS (n=25), and others (n=25). 15 severe adverse events were reported in 9 patients, the most common being fatigue (n=2), thrombocytopenia (n=2), dehydration (n=2), and hyperglycemia (n=2). Clinically significant activity has been observed in ES, RMS and OS with several dramatic responses seen in ES and RMS. Independent radiologic review is currently ongoing and updated data will be presented. Conclusions: The rapid accrual amongst many centers in diverse geographical locations demonstrates the feasibility of collaborative research in sarcomas. R1507 is well tolerated and a promising new agent for the treatment of various sarcomas. SARC and Roche are collaborating in additional clinical trials to better define the role of R1507 in the treatment of selected sarcomas.

[Table: see text]

A randomized phase II study of perifosine (P) plus imatinib for patients with imatinib-resistant gastrointestinal stromal tumor (GIST)

10563

Background: P inhibits activation of the Akt pathway which results in apoptosis and block cancer cell proliferation. Since AKT is a molecule downstream of Kit, its inhibition may overcome Kit-dependent imatinib resistance. We performed a phase II trial to assess antitumor activity of perifosine in patients with advanced GIST who were refractory to imatinib mesylate. Methods: Pts with Kit(+) advanced GIST who have PD on IM were eligible. Pts continued their current dose of IM and were randomized to one of two dosing schedules of P (Arm A: 100 mg p.o. qd x 28 + IM or Arm B: 900 mg [300 mg p.o tid] qweekly + qd IM). A Bayesian approach was utilized to assess a target response rate or 20% with an unacceptable toxicity rate of 15% or less. Response was measured at q8 wk intervals by RECIST and Choi criteria. The primary endpoint was to determine the efficacy of P with IM in pts with advanced GIST with PD while receiving IM. Results: From 8/2005 to 7/2008, 41 pts were accrued. After 1 pt exclusion and 2 cross-overs, 22 pts were in Arm A and 18 pts in Arm B. Median age was 58 (range, 32–82), 51% were male, and median ECOG PS was 1. The most common primary site of disease and metastasis was the stomach (29%) and liver (66%), respectively. KIT genotype was available for 22 pts(54%); 5(12%) WT, 13(32%) exon 11 mutations, and 4(10%) exon 9 mutations. The median number of cycles was 2 (range, 1–24). By Choi and RECIST, 30 pts(73%) and 36 pts(87%) were available for response, respectively. No CR was identified but the PR rate was 4/36 (11%) by Choi (4 PR, 9 SD) and 0/36 (0%) by RECIST (16 SD). 4/5 (80%) of pts with WT KIT appeared to benefit (Choi: 1 PR, 3 SD; RECIST: 4 SD). Median PFS and OS for 40 pts were 2.2 months and 18.3 months. No difference in PFS was noted for the 2 schedules. Toxicity was assessed in 39 pts; 46 grade 3 events and 4 grade 4 events (ALT elevation, blurred vision, fatigue, and mood alteration) were noted. The most common grade 3 event was fatigue (20%). Three pts (7%) were removed from the study for toxicity (Arm A:1 pt, Arm B:2 pts). Conclusions: The addition of P to IM has minimal activity in IM-refractory GIST although its activity in GIST with WT KIT may be further investigated.

No significant financial relationships to disclose.

Evaluation of AMG 531 in chemotherapy-induced thrombocytopenia (CIT): Results of a phase I/II study

e20616

Background: AMG 531 is a Fc-peptide fusion protein (peptibody) that increases platelet production by stimulating thrombopoietin (TPO) receptors. Prior studies have shown the importance of schedule of recombinant TPO to overcome cumulative thrombocytopenia (TCP) caused by high-dose chemotherapy with carboplatin (C), a late-nadir regimen, and doxorubicin and/or ifosfamide (AI), early-nadir regimen. Methods: The objectives of this study were to evaluate the safety and biologic activity of AMG 531 in CIT. Pts receiving high dose C (AUC=11) or AI received CT alone in the study cycle-1 and CT + AMG 531 in the study cycle-2 and subsequent cycles. At least 6 pts were enrolled at each dose level of AMG 531 (1, 3, and 10 mcg/kg). AMG 531 was administered SC as 2 doses given 2 days apart, starting from the day after CT (post-dosing schedule). An additional cohort of 6 pts received AMG 531 (10 mcg/kg) 2 doses administered as predose (day -5) and postdose given on day after CT (pre-/postdosing schedule). Results: Twenty-four of the 27 pts enrolled received the study drug and are evaluable. Treatment with AMG 531 was well tolerated; one pt experienced pulmonary embolism during cycle-6. In the 4 pts that received C with AMG 531 (1 mcg/kg) by post-dosing schedule, there was a reduction in duration of TCP (days < 100,000/mm3; 10 vs 7, p = 0.023, and days < 50,000mm3; 6 vs 2, p = 0.001, in cycles 1 and 2, respectively) and the PLT nadir count was stable (2 pts), increased < 2-fold (1 pt) or > 2-fold (1 pt) in C-2 as compared to C-1. In pts that received AI with AMG 531, there was a trend for increase in PLT nadir count with pre/post dosing schedule with a regimen known to cause cumulative thrombocytopenia from C-1 to C-2 ( Table ). Conclusions: AMG 531 is well tolerated and shows biologic activity in pts receiving CT. These findings suggest that postdosing may be effective with late-nadir regimen such as C. Ongoing study will determine if pre-/postdosing may be more effective with early-nadir regimens such as AI.

[Table: see text]

[Table: see text]

A phase II study of gefitinib in patients with metastatic melanoma

9057

Background: Gefitinib is an inhibitor of epidermal growth factor receptor (EGFR), which is frequently expressed on both choroidal and non-choroidal melanoma cells. We evaluated the clinical efficacy of gefitinib in patients (pts) with metastatic melanoma. Methods: Pts with stage IV or unresectable or recurrent stage III melanoma and Zubrod performance status of 0 to 2 were eligible. For non-choroidal melanoma, pts must have received systemic cytotoxic therapy, but no more than 2 regimens; for choroidal melanoma, pts could be either chemo-naïve or have received up to 2 systemic cytotoxic therapies. The dose of oral gefitinib was 250 mg daily, and tumor response was evaluated every 6 weeks per RECIST. Ten patients with cutaneous disease were also consented for paired biopsies and blood collection for correlative studies at baseline and after 3 weeks of treatment. Results: Fifty-two pts (46 non-choroidal; 6 choroidal primay) were treated and evaluated for toxicity, and 50 pts were evaluable for response. Median age of pts was 62.5 years, with median Zubrod PS Score of 1. The median number of prior systemic treatments was 1. Forty-one pts (79%) had stage M1c disease. There were no drug-related grade 4 or 5 adverse events (AEs), and fatigue was the only grade 3 AEs in >5% of the patients. There were 2 (4%) partial responses, including a pt with metastatic choroidal melanoma, and 13 pts (26%) had disease stabilization. A median duration of response was 9.5 months among the responders. Median time to progression was 6 weeks, and median overall survival was 4.6 months. Among 7 pts with sufficient tissue on paired biopsies, there were no notable trends in the changes of the expression of pERK1/2, pAKT, or pPAK1 with treatment. Additionally, no trends were identified in serum VEGF or IL-8 levels after treatment. Conclusions: Gefitinib was well tolerated, but had minimal clinical efficacy as a single-agent therapy for metastatic melanoma of cutaneous origin. There were no consistent changes in the expressions of downstream kinase proteins with gefitinib treatment.

No significant financial relationships to disclose.

IL2- and IL4-dependent proliferation of T-cell clones derived early after allogeneic bone marrow transplantation: Studies of patients with chronic myelogenous leukaemia

In an attempt to explore T-cell functions shortly after allogeneic bone marrow transplantation more fully, IL2- and IL4-dependent proliferation was assessed on CD4+ TCR alpha beta+ T-cell clones derived 4-6 weeks after transplantation. Both allogeneic pooled peripheral blood mononuclear cells and Epstein-Barr virus-transformed B-cell lines (BCL) could function as accessory cells (AC) for PHA activation of T-cell clones. Although minimal clonal proliferation was seen when the T-cell activation signal was BCL+PHA+IL4, a majority of the clones could undergo IL4-dependent proliferation after previous activation with AC+PHA+IL2. For certain clones, IL4 also showed an additive effect with IL2. Thus, IL4 was a growth factor for a majority of the investigated posttransplant T-cell clones, and in vivo modulation of IL4-dependent T-cell functions may thus become a future therapeutic possibility to enhance graft-versus-leukaemia effects in bone marrow transplant recipients.

New dimensions in endodontic imaging: part 1. Conventional and alternative radiographic systems

Conventional radiographs used for the management of endodontic problems yield limited information because of the two-dimensional nature of images produced, geometric distortion and anatomical noise. These factors often act in combination. This review paper assesses the limitations of periapical radiographs and seeks to clarify three-dimensional imaging techniques that have been suggested as adjuncts to conventional radiographs. These include tuned aperture computed tomography, magnetic resonance imaging, ultrasound, computed tomography and cone beam computed tomography (CBCT). Of these techniques, CBCT appears to be an effective and safe way to overcome some of the problems associated with conventional radiographs.

Mycotic aneurysm of the posterior tibial artery -- a rare complication of bacterial endocarditis: a case report

Introduction

Distal arterial embolisation and subsequent aneurysm formation are rare occurrences and most are secondary to trauma. We have found no case reports that describe posterior tibial aneurysm formation secondary to bacterial endocarditis.

Case presentation

We report the case of a 47-year-old Caucasian man who, 2 years after an episode of subacute bacterial endocarditis, presented with signs and symptoms consistent with posterior tibial aneurysm formation.

Conclusion

Posterior tibial aneurysm formation is a rare occurrence, most commonly occurring after trauma and, although other causes have been described, to our knowledge, endocarditis has not been implicated before, and as such should therefore be borne in mind when dealing with cases where no obvious aetiology is evident.

Auditing orthopaedic audit

INTRODUCTION

Clinical audit plays an important role in the drive to improve the quality of patient care and thus forms a cornerstone of clinical governance. Assurance that the quality of patient care has improved requires completion of the audit cycle. A considerable sum of money and time has been spent establishing audit activity in the UK. Failure to close the loop undermines the effectiveness of the audit process and wastes resources.

PATIENTS AND METHODS

We analysed the effectiveness of audit in trauma and orthopaedics at a local hospital by comparing audit projects completed over a 6-year period to criteria set out in the NHS National Audit and Governance report.

RESULTS

Of the 25 audits performed since 1999, half were presented to the relevant parties and only 20% completed the audit cycle. Only two of these were audits against national standards and 28% were not based on any standards at all. Only a third of the audits led by junior doctors resulted in implementation of their action plan compared to 75% implementation for consultant-led and 67% for nurse-led audits.

CONCLUSIONS

A remarkably large proportion of audits included in this analysis failed to meet accepted criteria for effective audit. Audits completed by junior doctors were found to be the least likely to complete the cycle. This may relate to the lack of continuity in modern medical training and little incentive to complete the cycle. Supervision by permanent medical staff, principally consultants, and involvement of the audit department may play the biggest role in improving implementation of change.

The fate of deoxynivalenol and fumonisins in wheat and maize during commercial breakfast cereal production

A study of the changes undergone by Fusarium mycotoxins present in maize and wheat at intake during the processing of commercial grain samples into breakfast cereals was carried out. Natural concentrations of deoxynivalenol and zearalenone in wheat were mostly low although higher levels of fumonisins occurred in maize. An exhaustive cleaning regime was used for wheat received from UK farms that reduced deoxynivalenol levels by about 50%, although this varied considerably between consignments. During processing to manufacture two commercial breakfast cereals, further loss of deoxynivalenol was minimal. However, this was significantly greater in a product from which excess aqueous cooker effluent was drained, suggesting that loss was due to solution of the mycotoxin in the cooking liquor rather than to hydrolysis. It is estimated that deoxynivalenol present at the EC maximum limit of 1,250 µg/kg in intake wheat would be reduced to about 700 and 400 µg/kg respectively for the 2 types of whole-wheat breakfast cereals examined during processing. Maize flaking grits were inherently low in mycotoxin concentrations compared to the raw maize so that the mycotoxin levels in the cereal ingredient for cornflakes used in this manufacturing process were unlikely to approach EC regulatory levels. In processing these grits, fumonisins were reduced further by at least 93% although no reduction of deoxynivalenol occurred. It is estimated that fumonisins and deoxynivalenol at the EC maximum limits in raw maize of 4,000 µg/kg and 1,750 µg/kg would be reduced to about 17 µg/kg and 288 µg/kg respectively in corn flakes made by the traditional cooking process used in the UK.

Burden of neuroinfectious diseases on the neurology service in a tertiary care center

BACKGROUND

Neurologic infections have the potential to cause death and suffering. These disorders often go unrecognized or are misdiagnosed. There has yet not been a census of neurologic infections conducted in a hospital setting. We aimed to determine the burden of neurologic infections on the neurology service in a tertiary care center and identify challenges in the diagnosis and treatment of these infections.

METHODS

We reviewed retrospectively all inpatients diagnosed with any neuroinfectious disease evaluated at Johns Hopkins Medical Institutions between October 2004 and December 2005. We recorded information on hospital admission, clinical features, microbiologic analysis, neuroimaging, EEG, pathology, treatment, and outcome.

RESULTS

A total of 116 of 4,225 patients admitted to or consulted on by the neurology service were identified. Eighty percent of patients were aged between 18 and 65 years. Fifty-two patients were immunocompromised, of which 28 patients had HIV infection. Overall, 86 microbiologic agents were identified in 80 patients. The commonest causes were viral, followed by bacterial and fungal infections. However, 31% of patients remained without an identifiable microbiologic etiology. Hospitalization periods were long, with 43% of patients staying beyond 2 weeks. There was significant morbidity: 28% of patients required rehabilitation or long-term care, and 12% died.

CONCLUSIONS

Neurologic infections have a major socioeconomic impact because they result in prolonged hospitalizations, expensive diagnostic tests and treatments, and long-term debilitation or death in young patients. Though potentially curable conditions, the burden of undiagnosed infections remains high.

Quantitative PCR for Epstein–Barr virus DNA and RNA in multiple sclerosis

Background

Epstein–Barr virus (EBV) is associated with MS, but it is not clear whether EBV plays a role in the pathogenesis of MS.

Hypothesis

We hypothesized that the immune control of EBV might be defective in MS, and that reactivation of EBV might drive the immune response in MS.

Methods

We collected blood from controls and patients with MS, and measured the amounts of EBV DNA and RNA using quantitative PCR.

Results

We found that EBV DNA and RNA were frequently detectable in peripheral blood leukocytes from both patients with MS and normal controls. There was no significant difference between patients with MS or controls. Paired samples from a small number of subjects suggest that EBV DNA may increase before and during clinical relapse.

Conclusions

We conclude that the immune control of EBV infection is similar in MS and controls, and that reactivation of EBV may correlate with MS disease activity.

Helicobacter pylori-induced peptic ulcer disease is associated with inadequate regulatory T cell responses

BACKGROUND AND AIMS

Helicobacter pylori infection is the major cause of peptic ulceration and gastric adenocarcinoma. To address the hypothesis that the human acquired immune response to H. pylori influences pathogenesis, we characterised the gastric T helper (Th) and regulatory T cell (Treg) response of infected patients.

METHODS

The human gastric CD4(+) T cell response of 28 donors who were infected with H. pylori and 44 who were not infected was analysed using flow cytometry. The T cell associated mucosal cytokine response was analysed by real-time polymerase chain reaction assay of samples from 38 infected and 22 uninfected donors. Recombinant interleukin 10 (IL10) was added to co-cultures of H. pylori and AGS cells and its suppressive effects upon inflammatory responses were measured.

RESULTS

We found that the H. pylori-specific response consists of both T helper 1 and 2 subsets with high levels of IL10-secreting Tregs. People with peptic ulcer disease had a 2.4-fold reduced CD4(+)CD25(hi)IL10(+) Treg response (p = 0.05) but increased Th1 and Th2 responses (Th1: 3.2-fold, p = 0.038; Th2: 6.1-fold, p = 0.029) compared to those without ulcers. In vitro studies showed that IL10 inhibited IL8 expression and activation of nuclear factor kappa B induced by H. pylori in gastric epithelial cells, and enhanced H. pylori growth in a bacterial-cell co-culture model.

CONCLUSIONS

Together our data suggest that H. pylori induces a regulatory T cell response, possibly contributing to its peaceful coexistence with the human host, and that ulcers occur when this regulatory response is inadequate.

Endovascular interventions following intravenous thrombolysis may improve survival and recovery in patients with acute ischemic stroke: a case-control study

BACKGROUND AND PURPOSE

Since the introduction of recombinant tissue plasminogen activator (rtPA) into clinical practice in the mid 1990s, no adjunctive treatment has further improved clinical outcomes in patients with ischemic stroke. The safety, feasibility, and efficacy of combining intravenous (IV) rtPA with endovascular interventions has been described; however, no direct comparative study has yet established whether endovascular interventions after IV rtPA are superior to IV rtPA alone. A retrospective case-control study was designed to address this issue.

MATERIALS AND METHODS

Between 2003 and 2006, 33 consecutive patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores >/=10 were treated with IV rtPA in combination with endovascular interventions (IV plus intervention) at a tertiary care facility. Outcomes were compared with a control cohort of 30 consecutive patients treated with IV rtPA (IV only) at a comparable facility where endovascular interventions were not available.

RESULTS

Baseline parameters were similar between the 2 groups. We found that the IV-plus-intervention group experienced significantly lower mortality at 90 days (12.1% versus 40.0%, P = .019) with a significantly greater improvement in NIHSS scores by the time of discharge or follow-up (P = .025). In the IV-plus-intervention group, patients with admission NIHSS scores between 10 and 15 and patients </=80 years of age showed the greatest improvement, with a significant change of the NIHSS scores from admission (P = .00015 and P = .013, respectively).

CONCLUSIONS

In this small case-control study of patients with acute ischemic stroke and admission NIHSS scores >/=10, there was a suggestion of incremental clinical benefit among patients receiving endovascular interventions following standard administration of IV rtPA.