Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: results of a 48-month longitudinal cohort study

Sims KB, Pastores GM, Weinreb NJ, Barranger J, Rosenbloom BE, Packman S, Kaplan P, Mankin H, Xavier R, Angell J, Fitzpatrick MA, Rosenthal D. Improvement of bone disease by imiglucerase (Cerezyme) therapy in patients with skeletal manifestations of type 1 Gaucher disease: results of a 48-month longitudinal cohort study. Clin Genet 2008: 73: 430–440. © Blackwell Munksgaard, 2008

Progressive skeletal disease accounts for some of the most debilitating complications of type 1 Gaucher disease. In this 48-month, prospective, non-randomized, open-label study of the effect of enzyme replacement therapy on bone response, 33 imiglucerase-naïve patients (median age 43 years with one or more skeletal manifestations such as osteopenia, history of bone crisis, or other documented bone pathology) received imiglucerase 60 U/kg/2 weeks. Substantial improvements were observed in bone pain (BP), bone crises (BC), and bone mineral density (BMD). Improvements in BP were observed at 3 months (p < 0.001 vs baseline) and continued progressively throughout the study, with 39% of patients reporting pain at 48 months vs 73% at baseline. Eleven of the 13 patients with a pre-treatment history of BC had no recurrences. Biochemical markers for bone formation increased; markers for bone resorption decreased. Steady improvement of spine and femoral neck BMD, measured using dual-energy X-ray absorptiometry was noted. Mean Z score for spine increased from −0.72 ± 1.302 at baseline to near-normal levels (−0.09 ± 1.503) by month 48 (p = 0.042) and for femoral neck from −0.59 ± 1.352 to −0.17 ± 1.206 (p = 0.035) at month 36. This increase was sustained at 48 months. With imiglucerase treatment, patients should anticipate resolution of BC, rapid improvement in BP, increases in BMD, and decreased skeletal complications.

Effect of a low-dose ketamine regimen on pain, mood, cognitive function and memory after major gynaecological surgery

BACKGROUND AND OBJECTIVE

Major gynaecological abdominal surgery is associated with moderate to severe postoperative pain, hyperalgesia and the need for multimodal analgesia to reduce high morphine consumption. A low-dose ketamine regimen appears to prevent postoperative hyperalgesia. We examined the potential beneficial effect of ketamine on postoperative pain management and cognitive function.

METHODS

Ninety patients were included in this double-blind, randomized, placebo-controlled study to test the efficacy and adverse effects of ketamine (as an intraoperative bolus of 0.15 mg kg-1, followed postoperatively by ketamine 0.5 mg per morphine 1 mg in a patient-controlled analgesia device). All patients received additionally ketoprofen. The main end-point was morphine consumption over the first 24 h. Secondary efficacy and safety end-points were morphine consumption during the titration period and during the patient-controlled analgesia period (48 h), the number of morphine-related adverse effects and the results of psychometric tests.

RESULTS

Ketamine, in combination with morphine and ketoprofen, did not improve postoperative pain scales and did not reduce morphine consumption and the incidence of morphine-related adverse effects. Ketamine did not modify mood, cognitive and memory functioning.

CONCLUSION

Adding a low dose of ketamine to an efficacious multimodal analgesic regimen did not improve analgesia after gynaecological surgery. Although this combination appears to be safe, the lack of benefit suggests that a low dose of ketamine should not be used for routine care.

A phase II trial of ZD 1869 for advanced cutaneous squamous cell carcinoma of the head and neck

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Background: Advanced HN CSSC carries a 30–40% risk of death by 2 years with standard therapies. A number of patients (pts) with clinically aggressive CSCC tend to have a poor prognosis when treated with standard approaches using surgery and radiation (RT), thus novel therapies are needed. CSSC over expresses the epidermal growth factor receptor (EGFR) and these compounds have activity in head and neck cancers. We are studying the use of gefitinib as an induction therapy in a high-risk patient group prior to definitive therapy to determine the overall efficacy, toxicity and feasibility. Methods: Eligible pts must have HN CSSC >2cm, regional nodal metastases, peri-neural invasion, or deep invasion into cartilage, muscle or bone and must be candidates for definitive local-regional therapy with surgery and/or radiation. Two 30-day cycles of gefitinib 250mg administered orally are given daily prior to definitive therapy. Pts are assessed clinically after the first 30-day cycle. If a response is noted, gefitinib is continued. For patients with stable disease, the dose is escalated to 500mg daily. Pts with progressive disease go off study. Biomarker evaluations including EGFR and Akt expression prior to and after induction are planned. Results: To date, 14 pts have been enrolled. 10 are evaluable for response and 13 for toxicity. A complete clinical response (CR) was noted in 3 pts (30%, one pathological CR), partial response in 2 patients (20%), stable disease in 2 (20%) and progressive disease in 3 (30%). Therapy was well tolerated with 2 patients having grade 3 toxicity (rash, diarrhea, or elevated liver enzymes). Conclusions: Standard definitive surgery and RT are inadequate for patients with advanced HN CSSC. The emergence of targeted therapies has given new hope for many patients with high-risk cancers. The preliminary results from our study suggest that gefitinib is an active agent for HN CSCC, and is well tolerated. Correlative studies may help identify patients most likely to respond to anti- EGFR therapy.

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Subclinical cardiac toxicity and health-related quality of life (hql) in childhood cancer survivors

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Background: Despite substantial information about late cardiotoxicity, little is known about its impact on the adolescent/young adult survivor's health-related quality of life (HQL). Using cross-sectional data, we assessed how HQL and New York Heart Association (NYHA) functional classification are related to survivors’ cardiac performance, cardiac risk factors, and treatment history. Methods: HQL indicators were examined in 164 long-term survivors of pediatric cancer (age 16–40 years), who had (n=132; 10 years (mean) after diagnosis of predominantly leukemia or lymphoma) or had not (n=32; 11 years (mean) after diagnosis of predominantly solid tumors) received anthracyclines and/or thoracic irradiation. Survivors underwent extensive noninvasive clinical and laboratory cardiac risk evaluation and completed a self-report questionnaire on selected subscales of the SF-36 (HQL). Results: Reported general health was lower in the cardiotoxic-therapy group (P = 0.05). Sex, current age, time since diagnosis, cardiac function, and cardiac risk factors were independent predictors of HQL subscales and NYHA class in multivariable analysis. Female sex and higher LDL cholesterol interacted to predict diminished reported vitality (P = 0.04) and physical health (P = 0.05) shown in table . Conclusions: Even in the absence of clinically evident cardiotoxicity, cardiac dysfunction and cardiac risk were strongly linked to decreased HQL and NYHA class, particularly among female survivors. Reduced HQL may be an indicator of unidentified sequelae that should be investigated and monitored.

No significant financial relationships to disclose.

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A study of complementary therapies in men receiving radiation therapy for prostate cancer: A randomized feasibility trial

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Background: Prostate-cancer patients suffer from substantial distress with both their diagnosis and treatment. Several studies have looked at the use of complementary and alternative medicine (CAM) in patients with prostate cancer to alleviate their stress and effects of therapy. We elected to study Reiki and Relaxation Response Therapy (RRT) in prostate-cancer patients. Methods: Patients receiving an eight-week course of radiation for prostate cancer were eligible. Consented participants were randomly assigned to RRT, to Reiki, or to no CAM therapy during radiotherapy. Reiki was given twice weekly, RRT once weekly. The feasibility of enrolling 60 patients, their compliance with physiologic and psychological testing, and preliminary assessment of the effect of CAM are the study endpoints. Statistical analysis of feasibility is based on the assumption that at least 80% of patients would complete 14/16 Reiki sessions or 7/8 RRT sessions. Patients were tested for outcome measures at baseline, at randomization, halfway through radiation, at completion of radiation and 2 months later. The psychosocial outcome measures used were the STAI, CES-D, FACT-G, FACIT: Fatigue Scale, and EPIC: Hormone Section. Physiological assessment included salivary cortisol, blood samples for interleukin-6, tumor necrosis factor alpha, CD8, natural killer cells, heat shock protein 70 and a validated bowel-and-bladder-symptom questionnaire. Results: We have enrolled 62 of 108 eligible patients (60%) within 18 months. The number of enrollment has been increased to 62 as two patients changed their treatment location. To date five patients dropped out short of completion, 1 became ineligible, 32 have completed the study, 20 are still receiving CAM therapy or are in active follow-up and 2 are awaiting randomization and radiotherapy. Conclusions: Complementary therapy appears to be of much interest to prostate-cancer patients. At the completion of the trial, we will have more data on feasibility, compliance and preliminary results on the effect of CAM intervention in this population.

No significant financial relationships to disclose.

Peripheral-type benzodiazepine receptor overexpression and knockdown in human breast cancer cells indicate its prominent role in tumor cell proliferation

The peripheral-type benzodiazepine receptor (PBR), an 18-kDa high affinity drug and cholesterol binding protein, is expressed at high levels in various cancers. Its expression is positively correlated with aggressive metastatic behavior in human breast cancer cells. To determine the role of PBR in tumor progression, two human mammary carcinoma cell lines were utilized: the non-aggressive MCF-7 cell line, which expresses extremely low PBR levels, and the highly aggressive MDA-MB-231 cell line, which has much higher PBR levels. We have generated stably transfected lines of the tetracycline-repressible MCF-7 cell line (MCF-7 Tet-Off) with inducible human PBR cDNA. Induction of PBR expression in MCF-7 Tet-Off cells increased PBR ligand binding and cell proliferation. Transfection of MDA-MB-231 cells with multiple siRNAs complementary to PBR (PBR-siRNAs) led to different levels of PBR mRNA knockdown. Lentiviral-mediated PBR RNA interference in MDA-MB-231 cells decreased PBR levels by 50%. Decreased PBR expression was associated with cell cycle arrest at G2 phase, decreased cell proliferation, and significant increases in the protein levels of the cyclin-dependent kinase inhibitor p21(WAF/CIP1). These changes were accompanied by p53 activation seen as increased p53 phosphorylation (Ser15). In parallel, increased proteolytic activation of caspase-3 was also observed. Taken together these results suggest that PBR protein expression is directly involved in regulating cell survival and proliferation in human breast cancer cells by influencing signaling mechanisms involved in cell cycle control and apoptosis.

Effects of a loading dose of morphine before i.v. morphine titration for postoperative pain relief: a randomized, double-blind, placebo-control study

BACKGROUND

I.V. morphine titration (MT) allows adjustment of the dose needed for pain relief in the post-anaesthesia care unit (PACU). However, MT has limitations such as a delay to achieve pain relief. We thus assessed the effect of a fixed intraoperative loading dose of morphine administered before titration.

METHODS

One hundred patients who were undergoing major orthopaedic surgery were included in a double-blind, randomized study comparing a loading dose of morphine (0.15 mg kg(-1)) with placebo administered intraoperatively. MT was then administered in the PACU followed by patient-controlled analgesia (PCA) over 24 h. Data are expressed as mean (sd).

RESULTS

The initial VAS [41 (36) vs 52 (35), NS] was not decreased in the morphine group. The VAS was lower in the morphine group in the PACU and PCA periods. The time to achieve effective pain relief was not decreased in the morphine group. The total dose of morphine administered in the PACU (including the loading dose) was significantly increased in the morphine group (+31% in mg kg(-1), P<0.05). Morphine requirements during the PCA period were not different between groups. The incidence of sedation was increased and a severe episode of ventilatory depression occurred in the morphine group.

CONCLUSIONS

A loading dose of morphine administered at the end of surgery slightly decreased the VAS but did not reduce the time to pain relief or morphine consumption within the first 24 h. This slight improvement in analgesia was obtained at the expense of morphine-related adverse events.

Remote superficial femoral artery endarterectomy and distal aSpire stenting: results of a multinational study at three-year follow-up

AIM

The aim of this study was to examine the results of remote superficial femoral artery endarterectomy (RSFAE) in conjunction with distal aSpire stenting in a multinational study.

METHODS

RSFAE is a minimally invasive procedure performed through a limited groin incision. A total of 210 patients were included in this study. The indications for the procedure were claudication in 158 (75%) patients and limb salvage in 52 (25%). After RSFAE the outflow tract atheromatous plaque was ''tacked'' with the aSpire stent, which is an expanded polytetrafluoroethylene (ePTFE) covered nitinol stent with high radial strength, yet it is flexible enough to withstand the compressive forces at the knee joint. Prior to stent deployment, if the stent position is not in optimal position, it can be ''wrapped down'', repositioned and re-expanded. Therefore, not only is the plaque end point tacked, but the collaterals are preserved as well. All patients underwent follow-up examination with serial color-flow duplex ultrasound scanning.

RESULTS

The mean length of endarterectomized superficial femoral arteries (SFAs) was 28.2+/-6.2 cm (range 15-43 cm). The primary cumulative patency rate by means of life-table analysis was 60.6+/-4.8% (SE) at 33 months, (mean 17.1 months; range 1-33 months). During follow-up percutaneous transluminal balloon and/or stent angioplasty was necessary in 50 patients for a primary assisted patency of 70.2+/-4.8% at 33 months. The locations of the restenosis after RSFAE were evenly distributed along the endarterectomized artery. There were 2 deaths (myocardial infarctions), 12 (5.7%) wound complications (7 hematomas, 5 skin edge sloughs) and the mean hospital length of stay was only 1.3+/-0.5 days.

CONCLUSION

RSFAE with distal aSpire stenting is a minimally invasive, safe durable procedure for the treatment of long-segment SFA occlusive disease.

Effects of ageing and pharmacological hypothyroidism on pituitary?thyroid axis of Dutch-Miranda and Wistar rats

To evaluate the ability of the aged rat pituitary to increase TSH secretion in response to major decreases in serum thyroid hormones, hypothyroidism was induced by methimazole in young and old, male and female, Dutch-Miranda and Wistar rats. Before MMI-treatment there were no differences in serum TSH of young and old rats, but serum T(4) was significantly decreased in aged rats from both genders and strains, while serum T(3) was significantly decreased in aged male rats from both strains, and in old Wistar females. MMI treatment significantly decreased serum T(4) and T(3) in all treated animals, and progressively increased serum TSH in both male and female rats, but the increase was significantly smaller in the elder rats. The pituitary TSH content was higher in Wistar than in Dutch-Miranda rats, of both genders, and was not significantly affected by age. MMI treatment decreased the pituitary TSH in both young and old Dutch-Miranda rats, but in the Wistar strain only the old females had a significant decrease. Our results show that the ability of the pituitary thyrotrophs to increase hormonal secretion in response to decreased levels of thyroid hormones is impaired in the old rat, even when the thyroid hormone levels are dramatically reduced.

Retrievable inferior vena cava filters: early clinical experience

AIM

Multiple-trauma patients often have injuries that prevent the use of anticoagulant or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism (PE) during the early, highest-risk perioperative and immediate injury period, while avoiding potential long-term sequelae of a permanent IVCF. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit (ICU) bedside under real-time intravascular ultrasound (IVUS) guidance in multiple-trauma patients.

METHODS

One hundred and three multiple-trauma patients between July 1, 2002, and July 1, 2004, under-went placement of Günther-Tulip (n=38), Recovery (n=30) or OptEase (n=35) retrievable IVCFs under real-time IVUS guidance. The mean+/-SD injury severity score of the patients was 27.7 (+/-2.2). All patients had abdominal X-rays to verify filter location. Before IVCF retrieval, all patients underwent femoral vein color-flow ultrasonography to rule out deep vein thrombosis (DVT) and pre and postprocedure vena-cavography for possible IVCF thrombus entrapment and postretrieval IVC injury.

RESULTS

Twenty-four patients died of their injuries; no deaths were related to IVCF placement. One PE occurred during follow-up after filter retrieval, and 2 insertion site femoral vein DVT occurred. As verified by abdominal X-rays, 97.1% (100/103) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 3 groin hematomas (2.9%) and 3 IVCFs misplaced in the right iliac vein early in our experience; these filters were uneventfully retrieved and replaced in the IVC within 24 h. Forty-four patients underwent uneventful retrieval of IVCFs after DVT or PE anticoagulation prophylaxis was initiated. Thirty-five filters were not removed, including 32 because severity of injury prevented DVT or PE prophylaxis and 3 because of thrombus trapped with the filter.

CONCLUSIONS

Prophylactic, temporary IVCFs placed at the ICU bedside under IVUS guidance in multiple-trauma patients serves as an effective bridge to anticoagulation until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in these patients is warranted.

Different levels of γ-synuclein mRNA in the cerebral cortex of dominant, neutral and submissive rats selected in the competition test

Synucleins are small proteins regulating the filamentous network that in turn influences the release of dopamine and glutamate neurotransmitters involved in mood and motivation processes. We have studied the pattern of synuclein expression in animal models for mania and depression. Dominant behavior, as defined in a food competition test with dyads of rats, can serve as a model of mania and submissive behavior as a model of depression. The expression of alpha-, beta- and gamma-synuclein was analyzed in four regions of cortex from dominant, neutral and submissive rats using TaqMan reverse transcription-polymerase chain reaction technology. The expression levels of gamma-synuclein were elevated consistently in all regions of cerebral cortex of dominant rats (P <0.05; 23.5 +/- 1.1, normalized units) in contrast to the submissive rat group (10.3 +/- 1.2). Neutral rats had intermediate cerebral cortex levels of gamma-synuclein expression (15.7 +/- 1.4) that were significantly lower than that in dominant rats (P <0.05). No changes in alpha- or beta-synuclein expression were observed among the groups. These studies indicate that gamma-synuclein levels in the cerebral cortex were differentially associated with dominant and submissive behavior.

Remote superficial femoral artery endarterectomy

The advent of minimally invasive procedures such as percutaneous transluminal angioplasty with or without stent, laser-assisted balloon angioplasty, and atherectomy, whose results have proven disappointing in the treatment of long-segment (> more than 15 cm) superficial femoral artery (SFA) occlusive disease, stimulated a reassessment of SFA endarterectomy. With the evolution of remote superficial femoral artery endarterectomy (RSFAE) a minimally invasive technique became available which could be performed through a single incision, allowed, debulking of the arterial plaque, and placement of an endovascular stent. We report results of RSFAE in an initial trial, results of RSFAE in concert with the aSpire Covered Stent which is a flexible ePTFE covered Nitinol stent with significant radial strength to withstand torsional stresses at the knee joint, and RSFAE and distal vein bypass for limb salvage.