[The question of surgical therapy for necrolytic migratory erythema, a cutaneous disease]

Necrolytic migratory erythema (NME) is a rare paraneoplastic dermatologic condition. Its underlying cause is usually a pancreatic islet cell tumour with marked glucagon secretion. The glucagonoma syndrome is characterised by pancreatic neuroendocrine neoplasm, NME, and diabetes mellitus. We present a case of glucagonoma syndrome in a 58-year-old woman with a history of recurrent cutaneous manifestations who was referred for surgical resection of a pancreatic neoplasm after the NME was finally diagnosed. We discuss diagnostic methods, differential diagnosis, and therapeutic management of this disease.

Left ventricular performance after mitral reconstruction for mitral regurgitation

Depressed left ventricular performance is often observed after mitral valve replacement for mitral regurgitation and is generally attributed to increased impedance to left ventricular ejection. We analyzed preoperative and postoperative catheterization data in 10 of 18 patients who underwent mitral reconstruction with preservation of the native valves and found a significant (p less than 0.05) fall in left ventricular end-diastolic volume index (from 143 +/- 39 to 84 +/- 21 ml/m2) and end-systolic volume index (from 50 +/- 24 to 32 +/- 12 ml/m2), with no significant change in ejection fraction (0.66 +/- 0.1 versus 0.62 +/- 0.1). These findings contrast with studies reported by others in comparable patients who had mitral valve replacement with no improvement in volume indices and a decline in ejection fraction postoperatively. We suggest that some of the left ventricular dysfunction observed after mitral replacement may be due simply to excision of the native valve. Mitral repair retains the tethering effect of chordal attachments and may thus prevent postoperative left ventricular dilatation and moderate the increase in wall stress that results from increased impedance to left ventricular ejection.

Transesophageal echocardiographic assessment of pulmonary venous flow after single lung transplantation

Transesophageal echocardiography was used to evaluate pulmonary venous flow velocity and pulmonary venous diameter of both the transplanted and native lungs in six single lung transplant recipients. Mean pulmonary venous velocity (50 +/- 10 versus 27 +/- 8 cm/sec) and pulmonary venous diameter (1.39 +/- 0.16 versus 0.98 +/- 0.18 cm) were significantly greater in the transplanted lung than in the native contralateral lung. An index of allograft perfusion, QD-transesophageal echocardiography (pulmonary venous velocity x pulmonary venous diameter), correlated highly with previously measured technetium 99m-labeled macroaggregated albumin quantitative lung perfusion studies (r = 0.94). A pressure gradient in pulmonary venous flow velocity across the left atrial anastomosis was detected in two patients (8 and 12 mm Hg). Analysis of previous resting supine and upright incremental hemodynamic exercise testing showed no significant differences in these two patients with respect to maximum oxygen uptake, mean pulmonary arterial pressure, pulmonary capillary wedge pressure, cardiac index, or pressure-flow relationships. Therefore these left atrial anastomotic gradients did not appear to adversely affect the pulmonary vascular response to incremental exercise. Transesophageal echocardiography may be an invaluable technique in the expedient evaluation of cardiac function and allograft perfusion after lung transplantation.

Patients who die awaiting heart transplantation

In the United States, heart donor availability has increasingly failed to keep pace with rising demand. Transplant data were obtained from the United Network for Organ Sharing for 1988, 1989, and 1990 and by survey of 50 heart transplantation centers, which performed 1932 transplantations between 1983 and 1989. According to the United Network for Organ Sharing, 512 patients on the waiting list died in 1988; 527, in 1989; 650, in 1990, and if present trends continue more than 800 will have died in 1991. Similar numbers of patients were inactivated or removed from the list each year. Only 49% of patients (1647 of 3390) on the heart transplant waiting list at some time in 1988 underwent the procedure in that year. For 1989 the figure fell to 42% (1630 of 3915 patients). Survey data revealed a threefold increase in the ratio of the number of patients who died/number of patients who underwent transplantation from 0.07 in 1983 to 0.21 in 1989 and in the ratio (number of patients who died+number of patients who were removed from the list)/number of patients who underwent transplantation from 0.12 in 1983 to 0.38 in 1989. The major causes of death among waiting patients were congestive heart failure (46%) and arrhythmia (29%). From 1983 to 1989, 55% (134 of 243) of those patients with documented urgency status died in the intensive care unit; 45% (109 of 243) died elsewhere. Waiting time for patients dying in the intensive care unit rose from 10.7 days in 1985 to 50.3 days in 1989; patients dying out of the intensive care unit waited 103.7 days in 1985 and 85.6 days in 1989. In conclusion, the number and proportion of potential recipients who die awaiting heart transplantation is increasing every year. Congestive heart failure and arrhythmia are the major causes of death, and similar numbers of patients die in and out of the intensive care unit.

Resistant geriatric depressions and therapeutic response to monoamine oxidase inhibitors

Elderly depressed patients who met the research diagnostic criteria (RDC) for major depressive illness, resistant to other types of treatment, were treated with phenelzine, a nonselective monoamine oxidase (MAO) inhibitor, for a period of 2 to 7 weeks, following 2 weeks of placebo washout period. Dosage ranged from 15-75 mg daily. Clinical status of patients as well as vital signs, EKG, and platelet MAO inhibition were measured weekly. All responders at the end of this period were followed for 1 to 2 years. Analysis of the results showed a 65% response rate as measured by Hamilton, Global, and Self-rating Scales. No significant drug effect in cognitive functioning, as measured by objective cognitive tests, was observed. Clinical improvement was sustained for all participants throughout the follow-up period with no side effects. A direct relationship between platelet MAO inhibition and clinical response was found. The majority of the responders (70%) had achieved high platelet MAO inhibition values (greater than 80%), while most of the nonresponders had platelet MAO inhibition values of less than 80%. These findings have potential clinical and research implications for treating geriatric depression, especially the ones resistant to other forms of treatment.

A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy.

METHODS

CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%.

RESULTS

Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2.

CONCLUSIONS

The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC.

CLINICAL TRIAL REGISTRATION

NCT04953962.

How short can courses be in lower respiratory tract infections?

Prospective clinical studies conducted over the last 10 years provide data on which to base decisions regarding the treatment of community-acquired pneumonia (CAP), including the need for hospitalization, optimal timing of the switch from intravenous to oral antibiotic therapy and the discharge of patients. Validated treatment algorithms, such as the classification of community-acquired pneumonia, now enable decisions to be made on which patients with CAP require hospitalization, as well as identifying those who will benefit from early switch therapy. Generally, unstable CAP patients are suitable candidates for early switch therapy, which consists of rapid initiation of 1 - 2 days' intravenous therapy followed by 5 days' oral therapy, with early discharge from hospital after the receipt of one or two doses of oral antibiotic. Studies with intravenous cefuroxime and followed by oral cefuroxime axetil suggest this regimen is both effective and well tolerated as rapid switch therapy, and has the potential to reduce overall healthcare costs and improve patient satisfaction.

Hamartomatous malformation of the left ventricle associated with sudden death

We describe unusual left ventricular cardiac lesions in a 17 year old boy who died suddenly during exertion. These consisted of two grossly evident regions of deficient myocardium, containing cavernous spaces which represented exaggerated intertrabecular regions of the left ventricular cavity. Dense fibro-elastotic tissue was deposited around these spaces along with a variable admixture of mature adipose tissue, fibrous tissue and blood vessels. The etiology of these presumably congenital developmental abnormalities is obscure. The lesions most probably represent a hamartomatous malformation, which is a poorly documented pathological entity.

Stable expression of cloned human antibody genes in murine myeloma cells

Human monoclonal antibodies (MAbs) offer potential advantages over murine MAbs for therapy because they are not likely to elicit immune responses and are expected to interact more efficiently with the human immune system to activate therapeutically useful functions. Traditional methods for obtaining human MAbs (i.e., immortalization of B cells by cell fusion or transformation) can result in low and unstable antibody secretion. Recently, methods have been devised for direct cloning of human variable region genes via polymerase chain reaction and phage combinatorial libraries. Both types of human MAb production can benefit from expression systems that support the stable, high-level antibody secretion required for therapeutic use. Using an existing human-derived hybridoma that secretes a human IgM antibody as a convenient source of antibody genes, we have demonstrated that cloned human antibody genes can be efficiently expressed in murine myeloma cells and that cell lines with properties suitable for large-scale economical production can be obtained. We were unable to detect any differences between the antibodies produced by the original hybridoma and the engineered cell line. In addition, we were able to express an IgG form of the antibody, showing that expression of a recombinant human antibody need not be limited to the original antibody class.