Stroke service: how can we improve and measure outcomes? Consensus summary from a global stroke forum

The success of acute stroke treatment is first and foremost time-dependent, and the need for improvement in acute stroke management is demonstrated by the fact that only a minority of patients gain access to treatment - in particular, intravenous recombinant tissue plasminogen activator (IV tPA) - within the necessary time window. Standards of acute stroke care vary widely both regionally and nationally; consequently, various healthcare organizations have undertaken initiatives to measure and improve quality of care. To date, most quality measures have been process-based, focusing primarily on metrics of patient care in the acute hospital-based setting (e.g., time to recombinant tPA administration). Therefore, there remains a need for metrics designed to assess how improvements in process translate into patient outcomes. A global forum was convened to share best practice and provide consensus recommendations on core metrics for measuring improvements in access to care and patient outcomes. Recommendations for core metrics of patient outcomes include hospital-based outcomes (e.g., neurological status at 24 h, ambulatory status at discharge) and post-discharge outcomes (e.g., modified Rankin Scale score at 30 and/or 90 days). Recommendations for best practice relating to aspects of people, process, and technology involved in the stroke treatment pathway that may help provide improvements in these core outcome measures are also outlined.

Disruption of the temporally regulated cloaca endodermal β-catenin signaling causes anorectal malformations

The cloaca is temporally formed and eventually divided by the urorectal septum (URS) during urogenital and anorectal organ development. Although congenital malformations, such as anorectal malformations (ARMs), are frequently observed during this process, the underlying pathogenic mechanisms remain unclear. β-Catenin is a critical component of canonical Wnt signaling and is essential for the regulation of cell differentiation and morphogenesis during embryogenesis. The expression of β-catenin is observed in endodermal epithelia, including URS epithelia. We modulated the β-catenin gene conditionally in endodermal epithelia by utilizing tamoxifen-inducible Cre driver line (Shh^CreERT2). Both β-catenin loss- and gain-of-function (LOF and GOF) mutants displayed abnormal clefts in the perineal region and hypoplastic elongation of the URS. The mutants also displayed reduced cell proliferation in the URS mesenchyme. In addition, the β-catenin GOF mutants displayed reduced apoptosis and subsequently increased apoptosis in the URS epithelium. This instability possibly resulted in reduced expression levels of differentiation markers, such as keratin 1 and filaggrin, in the perineal epithelia. The expression of bone morphogenetic protein (Bmp) genes, such as Bmp4 and Bmp7, was also ectopically induced in the epithelia of the URS in the β-catenin GOF mutants. The expression of the Msx2 gene and phosphorylated-Smad1/5/8, possible readouts of Bmp signaling, was also increased in the mutants. Moreover, we introduced an additional mutation for a Bmp receptor gene: BmprIA. The Shh^CreERT2/+; β-catenin^flox(ex3)/+; BmprIA^flox/− mutants displayed partial restoration of URS elongation compared with the β-catenin GOF mutants. These results indicate that some ARM phenotypes in the β-catenin GOF mutants were caused by abnormal Bmp signaling. The current analysis revealed the close relation of endodermal β-catenin signaling to the ARM phenotypes. These results are considered to shed light on the pathogenic mechanisms of human ARMs.

Dextromethorphan for neuropathic pain with Churg-Strauss syndrome

Abstract A 48-year old man who had been treated with prednisolone, aminophylline, and pranlukast, a leukotriene-receptor antagonist, was diagnosed with Churg-Strauss syndrome based on the findings of asthma, eosinophilia, mononeuropathy, and extravascular eosinophils. Intractable neuropathic pain of the legs was successfully controlled with an N-methyl-d-aspartate receptor antagonist, dextromethorphan. We suggest that dextromethorphan receptor antagonists may be a useful treatment for the pain of neuropathy caused by vasculitis syndrome.

Abstract P5-01-13: Poly(I:C), an innate adjuvant receptor ligand, can induce the antitumor effects on human breast cancer cells

[Background] Innate adjuvant receptors are expressed in immune cells and some types of cancers. If antitumor therapies targeting adjuvant receptors in cancer cells are established, it could be therapeutically useful because antitumor effects and activation of the immune system can be induced simultaneously.

[Objective]Poly(I:C) is one of innate adjuvant receptors ligands and triggers signaling through not only endosome Toll-like receptor (TLR) 3 but also cytoplasmic melanoma differentiation-associated gene (MDA) 5. In this study, we investigated antitumor effects of poly(I:C) on human breast cancer cell lines, and then elucidated the mechanisms.

[Methods] Three breast cancer cell lines (MCF-7, MDA-MB-231, and BT-549) were used in this study. Poly(I:C) was transfected into these cancer cells, and cell viability and apoptosis were evaluated by WST8 assay and flow cytometry, respectively. The expression of adjuvant receptors and cell cycle-related molecules were examined by immunobotting. Autophagy was evaluated by immunoblotting and confocal imaging. In vivo antitumor effect was determined using a xenograft mouse model.

[Results] All three cell lines were positive for both TLR3 and MDA5. Poly(I:C) transfection drastically reduced their cell viabilities in a partially MDA5-dependent manner. Poly(I:C)-transfected cancer cells showed caspase-dependent apoptosis and growth arrest as a result of suppression of c-Myc and cyclinD1. Interestingly, poly(I:C) transfection was accompanied by autophagy, which is known to work cytoprotectively under starvation and stress, and knockdown of beclin-1, an essential molecule for autophagy, by RNA interference promoted poly(I:C) transfection-induced apoptosis. In vivo poly(I:C) transfection exerted the antitumor effect on xenografted MDA-MB-231 in nude mice.

[Conclusions] These results suggest that the innate adjuvant receptors are promising targets in human breast cancer and that autophagy plays a protective role in this treatment modality.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P5-01-13.

Nanometer-scale water droplet free from the constraint of reverse micelles at low temperatures

Temperature dependence of the configurational fluctuation of water confined in a reverse micellar solution has been studied by absorption spectroscopy of a probe molecule. We have found that the configurational fluctuation is liquidlike below the homogeneous nucleation temperature. This is proposed to be due to a large reduction in the confinement of water, and is explained in terms of water shedding from the reverse micelle. Further, the configurational fluctuation is frozen at ~210 K. A reverse micellar solution is considered to be a promising candidate for studies of supercooled water.

PBSC collection from family donors in Japan: a prospective survey

Severe adverse events (SAE) and late hematological malignancies have been reported after PBSC donation. No prospective data on incidence and risk factors have been available for family donors so far. The Japan Society for Hematopoietic Cell Transplantation (JSHCT) introduced therefore in 2000 a mandatory registration system. It defined standards for donor eligibility and asked harvest centers to report any SAE immediately. All donors were examined at day 30 and were to be contacted once each year for a period of 5 years. Acute SAEs within day 30 were reported from 47/3264 donations (1.44%) with 14 events considered as unexpected and severe (0.58%). No donor died within 30 days. Late SAEs were reported from 39/1708 donors (2.3%). The incidence of acute SAEs was significantly higher among donors not matching the JSHCT standards (P=0.0023). Late hematological malignancies in PBSC donors were not different compared with a retrospective cohort of BM donors (N:1/1708 vs N:2/5921; P=0.53). In conclusion, acute and late SAEs do occur in PBSC donors at relatively low frequency but risk factors can be defined.

Updated overall survival results from a randomized phase III trial comparing gefitinib with carboplatin-paclitaxel for chemo-naïve non-small cell lung cancer with sensitive EGFR gene mutations (NEJ002)

BACKGROUND

NEJ002 study, comparing gefitinib with carboplatin (CBDCA) and paclitaxel (PTX; Taxol) as the first-line treatment for advanced non-small cell lung cancer (NSCLC) harboring an epidermal growth factor receptor (EGFR) mutation, previously reported superiority of gefitinib over CBDCA/PTX on progression-free survival (PFS). Subsequent analysis was carried out mainly regarding overall survival (OS).

MATERIALS AND METHODS

For all 228 patients in NEJ002, survival data were updated in December, 2010. Detailed information regarding subsequent chemotherapy after the protocol treatment was also assessed retrospectively and the impact of some key drugs on OS was evaluated.

RESULTS

The median survival time (MST) was 27.7 months for the gefitinib group, and was 26.6 months for the CBDCA/PTX group (HR, 0.887; P=0.483). The OS of patients who received platinum throughout their treatment (n=186) was not statistically different from that of patients who never received platinum (n=40). The MST of patients treated with gefitinib, platinum, and pemetrexed (PEM) or docetaxel (DOC, Taxotere; n=76) was around 3 years.

CONCLUSIONS

No significant difference in OS was observed between gefitinib and CBDCA/PTX in the NEJ002 study, probably due to a high crossover use of gefitinib in the CBDCA/PTX group. Considering the many benefits and the risk of missing an opportunity to use the most effective agent for EGFR-mutated NSCLC, the first-line gefitinib is strongly recommended.