Predictors of adjuvant chemotherapy (AT) decision-making in referred patients (pts) with stage II and III colon cancer (CC)

e15070

Background: Randomized clinical trials have demonstrated a robust survival benefit of AT for node positive (stage III) CC patients; similar evidence for node-negative (stage II) patients is lacking. While guidelines recommend AT for stage III colon cancer but AT is not a routine recommendation for stage II. Actual practice of the evidence varies and suggests the interplay of additional variables. We sought to identify factors associated with practice patterns which vary from conventional AT guidelines, ie no AT in stage III CC and receipt of AT in.stage II CC. Methods: Data pertaining to pt demographics, tumor characteristics, and treatment for pts with resected stage II (n=176) and III CC (n=235) referred to the British Columbia Cancer Agency in 2004 was collected by retrospective chart review. One-sided Fisher's exact test was used to assess statistical significance (p<0.05) by univariate analysis. Results: 28% (n=49) of stage II pts received AT. Compared to untreated pts, stage II pts who received AT were significantly more often younger than 66 years (57% vs 21%), lived in a city with a regional cancer center (71% vs 51%), had T4 disease (33% vs 9%), vascular invasion (22% vs 5%), perineural invasion (10% vs 2%) and high grade (26% vs 2%). Marital status, ethnicity, lymphatic invasion and high CEA were not associated with AT in stage II. 29% (n=69) of stage III pts did not receive AT. Compared to treated pts, stage III pts who did not receive AT were significantly more often older than 65 years (91% vs 51%), had low grade disease (96% vs 84%) and presented for oncology consultation greater than 42 days from surgery (29% vs 11%). Marital status, ethnicity, residence, T4 status or N2 status were not associated with no AT in stage III. Conclusions: For pts with stage II CC, subgroups associated with high risk for relapse were more likely to receive AT although the majority of stage II pts in this cohort remained untreated. For stage III disease, almost one-third of referred pts did not receive AT. Older age and delayed presentation were strongly associated with failure to receive AT. Within the limitations of a retrospective review, these data highlight the significant and commonly observed implications of factors other than stage in AT decision-making for high risk resected CC.

No significant financial relationships to disclose.

Analysis of prognostic (prog) Web-based models for stage II and III colon cancer (CC): A population-based validation of Numeracy (NUM) and ADJUVANT! Online (ADJ!)

4044

Background: To aid in decisions regarding adjuvant therapy (AT) for resected high-risk CC, two prog models are in common use: the Mayo Clinic NUM calculator developed from a pooled data analysis of 7 randomized 5FU-based AT trials, and ADJ! developed using SEER data. This study examines the accuracy of NUM and ADJ! utilizing a cohort of patients (pts) referred to the BC Cancer Agency (BCCA). Methods: Demographic, disease and treatment data for pts with stage II/III CC referred to the BCCA from 1995–1996 + 1999–2003 were collected. Observed (obs) 5-year relapse free survival (RFS) and overall survival (OS) were compared to predicted estimates (pred) using NUM and ADJ!, both overall and for all prog subgroups with ≥ 10pts, as stratified by T stage, N stage, tumor grade and age. Data are presented in a descriptive manner and using confidence intervals. Results: Median follow-up was 5.6 yrs for 2,033 pts - 53% male, median age 68y, 40% N0. The mean percentages of 5 year pred outcomes for each of the two models and the actual Kaplan Meier mean survivals are presented in the table . The percentage correct predictions of 5 y status is also presented, with correctness deemed accurate if the pt was alive and predicted to be alive by ≥ 50% as determined by each model or dead while the respective tool predicted < 50% possibility of being alive. For surgery alone pts, ADJ!pred were more often closer to what was observed, as compared to NUMpred, in the prog subgroups (for RFS 56%, OS 88%). For surgery + 5-FU pts, within these subgroups, NUMpred were more often closer to what was observed, as compared to ADJ!pred, for RFS (62%) and for OS (55%). Conclusions: In this independent population-based validation, NUM and ADJ! have acceptable and similar reliability with modest over-estimations of 5y RFS and OS. Both models thus appear to be useful adjuvant decision-aids.

[Table: see text]

No significant financial relationships to disclose.

Impact of bevacizumab (bev) on overall survival (OS) in patients (pts) with metastatic colorectal cancer (MCRC): A population-based study

4114

Background: As of 2003, irinotecan or oxaliplatin in combination with fluorouracil was standard treatment for MCRC in British Columbia (BC). The addition of bev to chemotherapy (CT) was approved in BC in 2006. We compared OS between referred pts diagnosed with MCRC in 2003/2004 (pre-bev era) and 2006 (bev era). Methods: All pts diagnosed with MCRC in 2003/04 and 2006, and referred to the BC Cancer Agency (BCCA) were included. The BCCA is a cancer network with centers throughout BC, ≈60% of MCRC pts in BC are referred to the BCCA. Systemic therapy (ST) is centrally funded and treatment data was obtained from the pharmacy database. The primary endpoint was OS of all pts within each cohort. Secondary endpoints were OS in pts treated with ST, and in those not treated. Kaplan Meier method was used for survival analysis. Subgroup analysis based on age was performed. Results: 1417 pts were included: 969 from 2003/04, and 448 from 2006. Median age at diagnosis of MCRC was 68y in 2003/04 and 69y in 2006. Median follow up time was 47.3 and 21.4 mos respectively. Between 2003/04 and 2006 the proportion of pts treated with ST for MCRC increased from 61.1% to 67.6% (p= 0.02). Proportion of pts who received irinotecan, oxaliplatin and fluorouracil did not change (24.7% to 23.7%, p=0.68). Proportion of pts who received bev increased (5.9% to 30.6%, p<0.001). Median OS significantly improved for the entire cohort (13.8 to 17.3 mos, p<0.001). Median OS for pts who received ST for MCRC improved (18.6 to 23.6 mos, p=0.001). Median OS for pts who did not receive ST did not change (6.1 to 5.9 mos, p=0.65). Of pts who received ST, the proportion who received bev increased in pts <70 (12.7% to 58%, p<0.001) and in pts ≥70 (3.6% to 22.7%, p<0.001). Median OS for pts <70 who received ST for MCRC improved (20.3 to 26.5 mos, p = 0.002). Median OS for pts ≥70 who received ST for MCRC improved (16.5 to 19.9 mos), but this was not significant (p=0.16). Conclusions: In this population based study, median OS for MCRC significantly increased between 2003/04 and 2006. The improvement in survival appears to be limited to pts treated with ST for metastatic disease. The main difference in ST has been the addition of bev. On a population basis, the addition of bev to CT is associated with a significant improvement in OS in MCRC.

No significant financial relationships to disclose.

Phase II trial of erlotinib in advanced pancreatic cancer (PC)

4609

Background: The epidermal growth factor receptor (EGFR) is a potentially important target in PC. Benefit from erlotinib (Tarceva), an oral EGFR tyrosine kinase inhibitor has been associated with the presence of a skin rash. The purpose of this study was to determine the efficacy of erlotinib, dosed to achieve a rash, in patients (pts) with PC. Methods: Erlotinib was given at an initial dose of 150 mg/day to eligible pts with locally advanced (LA) or metastatic PC who had progressed or were unable to tolerate gemcitabine-based chemotherapy. The dose of erlotinib was increased by 50mg every 2 weeks (maximum 300 mg/day) until > grade 1 rash (CTCAE v 3.0) or other dose-limiting toxicities occurred. Erlotinib pharmacokinetic (PK) studies were performed. Baseline tumor tissue was collected for analysis of Kras mutations, EGFR by IHC and FISH. The primary endpoint of this two- stage phase II trial was prolonged disease control (PR + SD > 8 wks) with a rate of >20% assumed to be significant . Results: Fifty pts were accrued (median age 61, M:F = 25:25, ECOG 0:1:2 = 5:41:4, LA:Metastatic = 5:45, prior gemcitabine none:adjuvant:palliative = 2:16:35). 47 and 40 pts were evaluable for toxicity and response, respectively. Dose-escalation to 200–300 mg of erlotinib was possible in 9 pts. Most common treatment adverse events (TAEs) of any grade were: rash (35 pts, 74.5%), diarrhea (18 pts, 38.3 %), and fatigue (8 pts, 17%). Grade 3+ TAEs were rash in 2 pts and diarrhea in 2 pts. Best response was SD in 14 pts, 0.35 (95% CI: 0.2–0.5). Prolonged disease control (SD > 8 wks) was observed in 10/40 evaluable pts, 0.25 (95% CI: 0.12–0.38), which met the primary study endpoint. Median TTP was 1.6 mo (95% CI:1.6–2.1), mOS 4.1 mo (95% CI:3.2–7.3), and 6 mo OS rate was 39% (95%CI: 24–61%). PK and correlative data are being analyzed and will be presented. Conclusions: Erlotinib is associated with prolonged stable disease in a subset of pts with advanced refractory PC. Dose escalation in the absence of toxicity is feasible and safe.

[Table: see text]

Characterization of a degenerative cardiomyopathy associated with domoic acid toxicity in California sea lions (Zalophus californianus)

Domoic acid, produced by marine algae, can cause acute and chronic neurologic sequela in California sea lions (Zalophus californianus) from acute toxicity or sublethal exposure. Eight sea lions, representing acute and chronic cases, both sexes, and all age classes, were selected to demonstrate a concurrent degenerative cardiomyopathy. Critical aspects of characterizing the cardiomyopathy by lesion distribution and morphology were the development of a heart dissection and tissue-trimming protocol and the delineation of the cardiac conducting system by histomorphology and immunohistochemistry for neuron-specific protein gene product 9.5. Histopathologic features and progression of the cardiomyopathy are described, varying from acute to chronic active and mild to severe. The cardiomyopathy is distinguished from other heart lesions in pinnipeds. Based on histopathologic features, immunopositive staining for cleaved caspase-3, and comparison with known, similar-appearing cardiomyopathies, the proposed pathogenesis for the degenerative cardiomyopathy is the primary or at least initial direct interaction of domoic acid with receptors that are suspected to exist in the heart. l-Carnitine, measured in the heart and skeletal muscle, and troponin-I, measured in serum collected at the time of death from additional animals (n = 58), were not predictive of the domoic acid-associated cardiomyopathy. This degenerative cardiomyopathy in California sea lions represents another syndrome beyond central neurologic disease associated with exposure to domoic acid and may contribute to morbidity and mortality.

Liver biochemistry abnormalities in a quaternary care lipid clinic database

BACKGROUND

The metabolic syndrome and non-alcoholic fatty liver disease are increasing at alarming rates.

AIMS

To determine the effect of HMG-CoA reductase inhibitors (statins) on elevated liver enzymes in patients with hyperlipidemia.

PATIENTS

Patients with AST above 60 U/L prior to or during treatment with statin therapy at a quaternary care lipid clinic were reviewed.

METHODS

A retrospective analysis was conducted. Patients were separated into two groups: Group 1--elevated AST prior to statin therapy; and Group 2--elevated AST during statin therapy.

RESULTS

Forty six patients with one or more measurements of AST >60 U/L remained after exclusion criteria were applied. Ten of 13 (77%) group 1 patients had reduced AST levels after initiation of statin therapy. Thirty two of 33 patients (97%) in group 2 had transient AST elevations while on statin therapy; one patient had persistently elevated AST after initiation of treatment. There were no significant adverse events reported.

CONCLUSION

Use of HMG-CoA reductase inhibitors in patients with elevated AST resulted in normalization of AST levels. HMG-CoA reductase inhibitors were safe in patients with mildly elevated AST. This may translate to use of HMG-CoA reductase inhibitors in diseases such as non-alcoholic fatty liver disease and non-alcoholic steatohepatitis.

The pregnancy-induced increase in baseline circulating growth hormone in rats is not induced by ghrelin

The elevation in baseline circulating growth hormone (GH) that occurs in pregnant rats is thought to arise from increased pituitary GH secretion, but the underlying mechanism remains unclear. Distribution, Fourier and algorithmic analyses confirmed that the pregnancy-induced increase in circulating GH in 3-week pregnant rats was due to a 13-fold increase in baseline circulating GH (P < 0.01), without any significant alteration in the parameters of episodic secretion. Electron microscopy revealed that pregnancy resulted in a reduction in the proportion of mammosomatotrophs (P < 0.01) and an increase in type II lactotrophs (P < 0.05), without any significant change in the somatotroph population. However, the density of the secretory granules in somatotrophs from 3-week pregnant rats was reduced (P < 0.05), and their distribution markedly polarised; the granules being grouped nearest the vasculature. Pituitary GH content was not increased, but steady-state GH mRNA levels declined progressively during pregnancy (P < 0.05). In situ hybridisation revealed that pregnancy was accompanied by a suppression of GH-releasing hormone mRNA expression in the arcuate nuclei (P < 0.05) and enhanced somatostatin mRNA expression in the periventricular nuclei (P < 0.05), an expression pattern normally associated with increased GH feedback. Although gastric ghrelin mRNA expression was elevated by 50% in 3-week pregnant rats (P < 0.01), circulating ghrelin, GH-secretagogue receptor mRNA expression and the GH response to a bolus i.v. injection of exogenous ghrelin were all largely unaffected during pregnancy. Although trace amounts of 'pituitary' GH could be detected in the placenta with radioimmunoassay, significant GH-immunoreactivity could not be observed by immunohistochemistry, indicating that rat placenta itself does not produce 'pituitary' GH. Although not excluding the possibility that the pregnancy-associated elevation in baseline circulating GH could arise from alternative extra-pituitary sources (e.g. the ovary), our data indicate that this phenomenon is most likely to result from a direct alteration of somatotroph function.

Role of low-dose, noncontrast computed tomography from integrated positron emission tomography/computed tomography in evaluating incidental 2-deoxy-2-[F-18]fluoro-D-glucose-avid colon lesions

PURPOSE

To assess the contribution of concurrent low-dose, noncontrast CT in the assessment of the malignant potential of incidental focal 2-deoxy-2-[F-18]fluoro-D-glucose (FDG)-avid colonic lesions on positron emission tomography/computed tomography (PET/CT).

PROCEDURES

Routine FDG-PET/CT scans were reviewed for identification of focal FDG-avid colon lesions, and the CT component was independently reviewed for an anatomical lesion and malignant potential based on CT criteria. Clinical, endoscopic, and histopathology follow-up was obtained.

RESULTS

A total of 85/2,916 (3%) oncology FDG-PET/CT scans had incidental focal colon lesions. Clinical and/or endoscopic follow-up was available in 83/85 (98%) patients. Focal, corresponding CT lesions were found in 44/83 (53%) patients, but features of malignancy were not assessable. Of the 44 patients with a final diagnosis, 32/44 (73%) were FDG-PET/CT true positives; 5/44 (11%) were false positives; and 7/44 (16%) had inconclusive FDG-PET/CT findings.

CONCLUSIONS

Concurrent low-dose, noncontrast CT improves localization, but does not provide independent information on the malignant potential of incidental focal colonic activity on FDG-PET/CT.

Trends in chemotherapy (CT) utilization for colorectal cancer: A provincial population-based analysis

17014

Background: Significant advances have been made in the treatment of colorectal cancer in both the adjuvant and metastatic setting. The purpose of this study is to examine CT prescribing patterns for adjuvant therapy of colon cancer and metastatic colorectal cancer over the last 15 years in British Columbia, Canada. Methods: All patients (pts) with stage 2 or 3 colon cancer, or stage 4 colorectal cancer at presentation referred to the BC Cancer Agency during a one year period for three time cohorts: 1990, 2000 and 2004, were reviewed. A pt was considered to be treated with CT if they received a cycle of CT within 6 months of referral. Results: A total of 1421 pts were included: stage 2/3 n=915, stage 4 n=506. Chemotherapy utilization increased significantly from 1990 to 2004 for adjuvant CT (1990: 49 (29%), 2000: 129 (45%), 2004: 235 (52%), p<0.001) and for palliative CT (1990: 41(35%), 2000: 100 (51%), 2004 120 (63%), p<0.001). The proportion of pts with stage 2 disease treated with adjuvant CT dramatically increased (1990: 3(4%), 2000: 38 (26%), 2004: 50 (30%), p<0.001). CT utilization was associated with a later time cohort and younger age of presentation ( Table 1 ). The use of palliative CT was significantly associated with male gender (p=0.025). This gender bias was not observed in the adjuvant setting. Among pts >70y, only 25% (99/394) received adjuvant CT [1990: 5(8%), 2000:38 (28%), 2004: 57 (28%] and 31% (50/162) received palliative CT [1990:4 (15%), 2000:17 (24%), 2004:30 (45%)]. Conclusions: In this population-based cohort, adjuvant and palliative CT utilization has increased since 1990 however there is room for improvement. Despite the lack of conclusive evidence, the use of adjuvant CT for stage II disease has increased significantly. Female pts appear less likely to receive palliative CT. Despite evidence that the elderly can accrue similar proportional benefits, the majority of referred pts >70y did not receive adjuvant or palliative CT. Such discrepancies in CT utilization require further investigation.

[Table: see text]

No significant financial relationships to disclose.

Targeted chemoradiation for metastatic colorectal cancer: A phase I trial of oral capecitabine combined with 131I- huA33

4078

Background: HuA33 is a humanized antibody that targets the A33 antigen, which is highly expressed in intestinal epithelium and >95% of human colon cancers, but not other normal tissues. Previous studies have shown huA33 can target and be retained in a metastatic tumor for 6 weeks, but eliminated from normal colonocytes within days. This phase 1 study used radio-labeled huA33 in combination with capecitabine chemotherapy to target chemoradiation to metastatic colorectal cancer. Methods: The primary objective was safety and tolerability of the combination of capecitabine and 131I-huA33. Pharmacokinetics, biodistribution, immunogenicity, and tumor response were also assessed. Eligibility included measurable metastatic colorectal cancer, adequate hematological and biochemical function, and informed consent. An outpatient scout 131I-huA33 dose was followed by a single therapy infusion one week later, when capecitabine was commenced. Dose escalation occurred over 5 dose levels. Patients were evaluated weekly, with tumor response assessment at the end of the12 week trial. Tumor targeting was assessed using gamma camera and single photon emission computerized tomography (SPECT) imaging. Results: 16 patients have enrolled with 2 currently on treatment, including one in the final dose cohort. Accrual will be completed by March 2007. The dose escalation protocol was amended following 2 dose limiting toxicities in the second cohort, but subsequent cohorts demonstrated good tolerability. Biodistribution analysis demonstrated excellent tumor targeting of the known tumor sites, expected transient bowel uptake, but no other normal tissue uptake. Maximal duration of stable disease is currently 3 years. Conclusions: 131I-huA33 achieves specific targeting of radiotherapy to sites of metastasis and can be safely combined with chemotherapy. This provides an opportunity to deliver chemoradiation specifically to metastatic disease in colorectal cancer patients.

[Table: see text]

No significant financial relationships to disclose.

Impact of irinotecan and oxaliplatin on overall survival in patients with metastatic colorectal cancer (MCRC): A population- based study

4077

Background: Over the past 10 years, chemotherapeutic options for MCRC has significantly expanded from 5-FU based therapy, to include irinotecan and oxaliplatin. The effect of the availability of these treatments on overall survival is evaluated among patients in 3 time cohorts referred to the British Columbia Cancer Agency (BCCA). Methods: Patients with newly diagnosed or relapsed metastatic colorectal cancer referred to the BCCA in 1995/96, 2000 and 2003/04 were included. In 1995/96, 5-FU was the only palliative chemotherapy agent available at BCCA and irinotecan and oxaliplatin were available in 2000 and 2003, respectively. A one year period was used for the irinotecan cohort to minimize overlap between groups. Overall survival estimates were generated using the Kaplan Meier method. Survival was calculated from time of diagnosis of distant metastatic disease to either death or last contact date. Results: Cohorts were generally similar, however, a significantly higher proportion of patients received chemotherapy in more recent eras ( Table 1 ). Only 25% of patients received both irinotecan and oxaliplatin in 2003/4 and only 10 % received biologic therapies. An improvement in median survival of 3.6 months was observed. The improvement in the treated subgroup was 4.2 months. Outcomes of patients untreated with chemotherapy were unchanged between cohorts. Conclusions: In this population based study, the proportion of patients with MCRC treated with chemotherapy significantly increased between 1995/6 and 2000/2003/4. Patients treated with chemotherapy experienced a 4.2 month increase in median survival in 2003/4 compared to 1995/6. Survival improvements were only significant in the time period when all three effective chemotherapies (5FU, irinotecan and oxaliplatin) were available. As bevacizumab was not available until 2006, its survival impact in this population is not yet known.

[Table: see text]

No significant financial relationships to disclose.

Surgical treatment of pulmonary aspergilloma: a series of 72 cases

BACKGROUND

The objective of this study was to evaluate the immediate and long-term result of resectional surgery in pulmonary aspergilloma.

METHODS

Seventy-two patients who underwent pulmonary resectional surgery for symptomatic aspergilloma between 1990 to 2002 were studied. Seventy-nine definitive operations were carried out, including one bilateral lobectomy for recurrent lesions and six thoracoplasties to deal with post-operative complications, besides 21 pneumonectomies and 51 lobectomies. There were 10 bilobectomies as well, included in the lobectomy group.

RESULTS

At a mean follow-up of 3.5 years, there were two post-operative deaths and a few complications occurred in 20 cases translating into a morbidity of 28.57% and a mortality of 2.77 percent. Major complications included were persistent air leak, persistent pleural space, empyema, bronchopleural fistula and massive haemorrhage. All events were seen in cases of complex aspergilloma; cases of simple aspergillomas had an uneventful course.

CONCLUSIONS

Surgery offers definitive and long-term symptom-free survival in cases of pulmonary aspergilloma at a negligible risk; though almost one-third of those undergoing surgery develop some complications, these are largely manageable.

Role of VraSR in antibiotic resistance and antibiotic-induced stress response in Staphylococcus aureus

Exposure of Staphylococcus aureus to cell wall inhibitors induces massive overexpression of a number of genes, provided that the VraSR two-component sensory regulatory system is intact. Inactivation of vraS blocks this transcriptional response and also causes a drastic reduction in the levels of resistance to beta-lactam antibiotics and vancomycin. We used an experimental system in which the essential cell wall synthesis gene of S. aureus, pbpB, was put under the control of an isopropyl-beta-d-thiogalactopyranoside-inducible promoter in order to induce reversible perturbations in cell wall synthesis without the use of any cell wall-active inhibitor. Changes in the level of transcription of pbpB were rapidly followed by parallel changes in the vraSR signal, and the abundance of the pbpB transcript was precisely mirrored by the abundance of the transcripts of vraSR and some additional genes that belong to the VraSR regulon. Beta-lactam resistance in S. aureus appears to involve a complex stress response in which VraSR performs the critical role of a sentinel system capable of sensing the perturbation of cell wall synthesis and allowing mobilization of genes that are essential for the generation of a highly resistant phenotype. One of the sites in cell wall synthesis "sensed" by the VraSR system appears to be a step catalyzed by PBP 2.

Outcomes of patients with metastatic colorectal carcinoma (MCRC) treated with first and second line chemotherapy at a multicenter cancer clinic

13529

Background: In British Columbia (BC), FOLFIRI and FOLFOX were approved for the treatment of MCRC in 2002. The effect on survival of various treatment and patient related factors was determined for patients with MCRC treated with sequential doublet chemotherapy. Methods: Eligible patients received either FOLFOX or FOLFIRI first-line with a cross over to the alternative regimen for second-line therapy. Patient records were retrospectively reviewed for patient and disease characteristics, treatment, toxicity and survival. Analysis of survival was performed by the Kaplan-Meier method. Results: Between March 2002 and June 2004, 106 new patients met the criteria above. Sixty five patients were treated with a sequence of FOLFOX-FOLFIRI (Group A): 67% M, median age 57y, rectal 20%. Forty-one were treated with the sequence FOLFIRI-FOLFOX (Group B): 64% M, median age 58y, 27% rectal. Survival was statistically similar in both groups. Progression requiring second line chemotherapy within 4 weeks of a first line treatment was associated with inferior survival (13 months vs. 21 months (p<0.018). Grade 3 or 4 toxicity was experienced in 27.5% of the patients treated with FOLFOX and 22% of the patients treated with FOLFIRI. Conclusions: In the general population with MCRC, the median survival achieved with sequential doublet therapy is consistent with that reported in clinical trials. A superior sequence was not identified. The median number of first line chemotherapy cycles with FOLFOX and FOLFIRI was similar, reflecting the general clinical practice in BC to give 10 - 12 cycles of therapy followed by a planned break. Patients who required initiation of second line chemotherapy within 4 weeks of stopping the first line therapy experienced an inferior prognosis. Univariate and multivariate analysis showed no significance of sex, age, site (colon versus rectal), and ECOG status as predictive factors. [Table: see text]

No significant financial relationships to disclose.

A phase II trial of oblimersen sodium (G3139) in combination with doxorubicin (DOX) in advanced hepatocellular carcinoma (HCC). NCI protocol # 5798

14072

Background: Advanced HCC is refractory to most standard forms of chemotherapy, however responses to DOX are seen. The bcl-2 protein confers resistance to apoptosis in cancer cells and is important in tumor progression and resistance to chemotherapy. The bcl-2 antisense oligonucleotide, G3139 (G), has been shown to enhance the activity of DOX in tumor models by blocking bcl-2 synthesis. This argues for evaluating G + DOX in combination in HCC. By decreasing tumor bcl-2 protein levels, HCC may be sensitized to the apoptotic effects of DOX. Methods: We completed a phase II trial evaluating treatment with G at 7 mg/ kg for 7 days cont. i.v. infusion (d1–8) plus DOX at 45 mg/m2 i.v. bolus d5, every 28 d (as determined from our phase I HCC study). Eligible patients (pts) had path-confirmed, measurable, advanced HCC. Minimal eligibility included Childs-Pugh A cirrhosis, adequate hematological (hem) parameters and ECOG PS <2. Tumor biopsies for correlative studies were obtained at baseline and cycle 1 d 4 in consenting pts. Results: 19 patients were accrued, 1 was ineligible, 18 evaluable for toxicity, 17 evaluable for response; receiving a median (med) of 2 cycles (range 1,10). Risk for HCC was 39% HBV, 22% HCV, 17% alcohol, 22% other. Most common toxicities were hem and could be attributed to both G+DOX and to G alone. Overall grade 3–4 toxicities seen were: ANC- 67% (med nadir d 24–25), lymphopenia - 44%, thrombocytopenia - 6%, transaminitis - 33% and grade 1–2 G-fever - 67%. No responses were seen and the trial was stopped at stage 1. Six patients (35%) had stable disease, with one pt completing 10 cycles as per protocol (pt # 22). Med TTP is 1.8 months (1.7-NA) and 6-month PFS is 17.2% (5.3–56.4). 18 of 19 pts have died with med OS of only 5.4 months (2.7–11.6). Correlative studies on 3 available pts’ paired tumor biopsies showed absent baseline bcl-2 expression but moderate expression of both bcl-xl and BAX protein and with no change after exposure to G (includes pt #22). Conclusions: G + DOX is inactive in HCC at this dose and schedule. The overlap of hem toxicity may have resulted in suboptimal DOX dosing in HCC. Low baseline bcl-2 tumor expression relative to bcl-xl seen may suggest a relative insensitivity to the effects of bcl-2 inhibition in these HCC tumors.

[Table: see text]

Patterns of diagnosis for colorectal cancer (CRC): Screening detected versus symptomatic presentation

1023

Background: Colorectal cancer (CRC) is a leading cause of cancer death in North America; studies have shown that screening improves survival. Conducted in British Columbia, Canada, this study was conducted to identify the proportion of screening-eligible patients with sporadic CRC who are detected by screening tests versus symptomatic presentation,and to compare baseline patient and tumor characteristics of these two groups. Methods: This retrospective cohort study identified 571 cases via the BC Cancer Registry of patients age 50 years and older presenting with first diagnosis of invasive CRC between Nov. 2002 and Apr. 2003. Patients with non-adenocarcinoma histology, HNPCC or FAP were not included. Self completed questionnaires were mailed to all patients to capture: prior screening history, screening versus symptomatic presentation, and demographic information. All respondents charts were then reviewed to corroborate screening information, and to obtain pathological information including TNM stage, grade and site (proximal versus distal colon versus rectal). Results: Of 212 eligible respondents (37% response), only 14 of 212 (6.6%) patients with a new CRC were detected via screening versus 198 of 212 (93.4%) presenting with symptoms. Respondents were average age at diagnosis 69 years, 59% male, 91% Caucasian, 37%rectal, and 18% M1 at diagnosis. No significant differences in the age, gender, ethnicity, socioeconomic status, tumour stage and site were detected between the screened versus symptomatic groups. Only 33 of 212 patients (15.6%) reported ever having a screening test. 19 of 198 cancers (9.6%) were diagnosed by symptomatic presentation despite a compliant screening history. Conclusion: Despite universal health-care access in British Columbia, only 7% of patients with a new diagnosis of CRC were detected via a screening test. Furthermore, only 15% of screening-eligible respondents have ever been screened. There were no differences in patient demographics or stage of disease at presentation but numbers in the screening cohort were limited. Significant effort is required to increase knowledge and compliance for CRC screening.

No significant financial relationships to disclose.

First-line bolus IFL and second-line FOLFOX: A retrospective review of two hundred thirty patients

13555

Introduction: The IFL regimen (irinotecan, 5-fluorouracil bolus and leucovorin) is active in metastatic colorectal cancer. Early treatment-related deaths in N9741 led to the utilization of a dose-reduced schema. An infusional regimen (FOLFIRI) replaced IFL because of superior tolerability. FOLFOX can be used as second-line therapy in patients treated previously with IFL. Methods: A retrospective review was performed at the British Columbia Cancer Agency to evaluate both the safety and outcome of all patients given IFL as first-line treatment for metastatic colorectal cancer. Data on second-line FOLFOX was also collected. Between March 31/2002 and April 1/2004, 230 patients were treated. Results: The mean number of IFL cycles delivered was 4.6 (18 doses) for a mean duration of 7.1 months. Toxicity was manageable with only 1 treatment-related death. 17% of patients had grade 3/4 toxicities that included neutropenia and diarrhea. Only 6% of patients required hospitalization during IFL treatment. The median survival of the entire group was 16.6 months (95% CI 14.3–18.6). One hundred twelve patients received second-line therapy. Forty-nine of these patients (44%) received infusional oxaliplatin (mFOLFOX 6) as second-line therapy. 27% had grade 3/4 toxicities and 10% required hospitalization. The median survival of these patients was 25.2 months (95% CI 20.1–30.3). Conclusion: This population-based study demonstrated that bolus IFL played a significant role in the treatment of metastatic colorectal cancer and had a manageable toxicity profile. Lastly, the sequence of IFL followed by FOLFOX resulted in a very meaningful patient survival of over 25 months.

No significant financial relationships to disclose.

Metastatic Colorectal Cancer Treatment to progression or Not?

13511

Background: Treatment until progression or planned interruption of first line chemotherapy is common in the therapy for metastatic colorectal cancer and are upon the discretion of the oncologist. A retrospective analysis was performed to determine the impact of these differing therapeutic strategies on overall survival. Methods: Eligible patients were treated between 2002 to 2004 in British Columbia. All patients received chemotherapy with both FOLFOX and FOLFIRI, either first or second line. Records were retrospectively reviewed for treatment interruption, efficacy and toxicity. Overall survival was the primary endpoint. Results: 101 patients were identified. Twenty-three patients who progressed before receiving 8 cycles of chemotherapy and 9 patients who stopped their chemotherapy due to toxicity were excluded. The remaining patients were analyzed for survival. Twenty-three patients were treated to progression of whom 6 received first line FOLFIRI and 17 received first line FOLFOX. The mean number of cycles of first line therapy was was 11.5. Forty six patients received a planned break. Of these, 21pateints received first line FOLFIRI and 25 patients received first line FOLFOX. Mean number of cycles of first line therapy was 9.7. Median survival of patients treated to progression was 16 months compared to 22 months for patients with planned break of therapy (p=0.003). The Hazard ratio was 2.3 (p=0.01) in favor of patients who had a planned break. Uni-variate and multivariate analysis showed no significance of sex, age, site (colon versus rectal), sequence and ECOG status as predictive factors. Conclusion: In this study, patients who were treated until progression with first line chemotherapy with either FOLFOX or FOLFIRI had an inferior survival. Possible explanations for the detrimental hazard ratio for patients treated to progression are decreasing reserve for second line therapy when first line therapy is prolonged and increasing resistance to 5-FU based therapy with prolonged exposure. As this is a retrospective, observational study, other variables not captured by the modeled covariates that may have influenced results. This data suggests that treating to best response and then allowing a break does not detrimentally affect survival.

No significant financial relationships to disclose.

Adjuvant therapy (AT) with raltitrexed (RAL) in colorectal cancer (CRC) patients (pts) intolerant of 5-fluorouracil (5FU)

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Background: Severe 5FU toxicity in AT of CRC may require discontinuation or change of therapy. RAL, a TS inhibitor, has different toxicity but similar efficacy in metastatic CRC. Excess mortality from RAL in the PETACC trial has limited its role in CRC AT. RAL AT (3 mg/m2 IV q3w) was offered at BCCA to pts with demonstrated intolerance to bolus (Mayo) 5FU. We sought to explore retrospectively the safety & efficacy of RAL AT in these pts. Methods: A search of BCCA Pharmacy & Clinical Records from Oct. 1999 to June 2004 identified CRC pts who received 5FU AT and RAL AT. Data was collected on pt and disease characteristics, therapy & follow-up (FU) status. Kaplan-Meier survival proportions were compared with historical experience. Results: Of 1,456 CRC pts who received 5FU AT, 44 pts (3%) received RAL following 5FU intolerance (42 pts GI/hem toxicity, 2 pts due to angina). Median age was 62.3 y (range 39.8 - 83.2); 31 female; 31 colon primary. Stage III: 39 pts (88.6%); N2: 14 (31.8%). Median # 5FU cycles given prior to RAL was 2 (1 - 4). 21 pts (48%) had only 1 cycle of 5FU before RAL. Grade ≥3 toxicities from 5FU occurred in 39 pts; 17 pts were hospitalised for 2 - 29d (median 8). Twelve of 44 pts also received RT. Median # RAL cycles: 5 (1–8); 77% received >3 cycles; 84% completed all planned RAL. Gr 1, 2, 3 RAL toxicity rates: 55%, 27%, 7% respectively. 1 pt was hospitalised (4 days, FN); no deaths. Median FU of living pts is 4.2 yr (range 1.4 - 6.5). Median survival for all pts is not yet reached. 3 Year Relapse free (RFS) and Overall Survival (OS) proportions were 72% (95% CI 58.5% - 85.5%) and 83.2% (95% CI 71.8% - 94.6%) resp. Stage III 3 Year RFS was 70.8% (95% CI 56.1% - 85.5%) and 3 Year OS was 83.6% (95% CI 71.4% - 95.8%). For N1 & N2 pts, 3 Year RFS was 83.8% (95% CI 69.3% - 98.3%) and 49% (95% CI 22.3% - 75.7%), and OS 91.4% (95% CI 80% - 100%) & 70.7% (95% CI 46.4% - 95%) resp. Conclusions: Severe 5FU intolerance was seen in 3% of pts. RAL AT can be given safely if further 5FU is contraindicated. Outcomes appear similar to historical experience with 5FU AT.

[Table: see text]

No significant financial relationships to disclose.

A probabilistic screening model for evaluating pyrethroid surface water monitoring data

Synthetic pyrethroids have been detected in recent California surface water monitoring. Filtration is avoided during sample workup because pyrethroids are extremely hydrophobic, tending to sorb to most surfaces. The resultant analytical pyrethroid concentrations reflect both dissolved pyrethroid and pyrethroid associated with suspended sediment in the water column. Such "whole-water" analytical data are not directly comparable to aquatic acute toxicity effect concentrations measured in laboratory sediment-free water. Consequently, any potential aquatic toxicity risk is indeterminate. In this study a simple probabilistic model was developed to allow a screening-level assessment of pyrethroid whole-water monitoring data. The results suggest that water column toxicity of pyrethroids is possible in California's agriculturally-dominated tributaries, and indicate that additional monitoring to better characterize pyrethroid water-column concentrations are warranted. Model refinement will depend on future work that more firmly establishes the relationship between pyrethroid partitioning and bioavailability, and that addresses the potential influence of dissolved organic carbon on pyrethroid sorption and bioavailability.

PS-341 and gemcitabine in patients with metastatic pancreatic adenocarcinoma: a North Central Cancer Treatment Group (NCCTG) randomized phase II study

BACKGROUND

PS-341 is a proteasome inhibitor with preclinical activity in pancreatic cancer tumor models and synergistic activity with gemcitabine. This randomized phase II study determined the tumor response rate (RR) for PS-341 alone and the 6-month survival and RR for the combination of gemcitabine and PS-341 in patients with metastatic pancreatic adenocarcinoma.

PATIENTS AND METHODS

Patients were randomized to receive 3-week cycles of either arm A: PS-341 1.5 mg/m(2) i.v. bolus (over 3--5 s) on days 1, 4, 8 and 11 or arm B: PS-341 1.0 mg/m(2) (same as arm A otherwise) plus gemcitabine 1,000 mg/m(2) i.v. on days 1 and 8. Patients progressing on arm A were allowed to receive arm B treatment.

RESULTS

Arm A: 42 evaluable patients were enrolled with a confirmed RR of 0% (95% CI 0% to 8%), median survival of 2.5 months (95% CI 2.0-3.3), and median time to progression (TTP) of 1.2 months (95% CI 1.1--1.3). Twelve of 43 evaluable patients (28%) experienced at least one grade 4+ AE. Arm B: 39 evaluable patients yielded a 6-month survival rate of 41% (16/39, 95% CI 29.8% to 67.0%), median survival of 4.8 months (95% CI 2.4--7.4), median TTP of 2.4 months (95% CI 1.5--3.1), and confirmed RR of 10% (4 partial responses/0 complete responses, 95% CI 3% to 24%). Eleven of 43 evaluable patients (26%) experienced at least one grade 4+ AE. One patient had grade 5 hypotension.

CONCLUSION

The use of PS-341 alone or in combination with gemcitabine did not result in an overall survival and RR better than that expected for gemcitabine alone. Based on the lack of efficacy and the toxicity seen in our trial, there does not appear to be a role for PS-341 in pancreatic adenocarcinoma with either of the schedules used in this trial.

Tragal perichondrium and cartilage in reconstructive tympanoplasty

The objective of study was to assess the efficacy of tragal perichondrium and cartilage, the functional capacity in restoring hearing acuity, it's mechanical survival, it's extrusion rate and it's functional integrity in tympanomastoid reconstruction. The study was conducted at K.E.M. Hospital, ENT department during 1980 to 2000. The study presents six hundred ear operations of varied middle ear pathology using tragal cartilage and perichondrium as a choice graft. The technical advantages of tragal perichondrium graft in myringoplasty, ossiculoplasty, osseusplasty, and mastoid cavity obliteration are discussed. We have recorded our observations and results and concluded that tragal perichondrium and cartilage is an ideal graft material for reconstructive tympanoplasty.

Herbal creams used for atopic eczema in Birmingham, UK illegally contain potent corticosteroids

AIMS

To determine whether "herbal creams" reported as being effective for the treatment of childhood atopic eczema contained corticosteroids.

METHODS

Patients attending the paediatric dermatology clinic at Birmingham Children's Hospital, April 2001 to March 2002, and who reported using "herbal creams" with good effect for atopic eczema were asked to submit the cream for analysis. Hydrocortisone, clobetasone butyrate, betamethasone valerate, and clobetasol propionate were analysed by HPLC.

RESULTS

Twenty four creams from 19 patients, median (interquartile range) age 3.82 (0.69-7.98) years were analysed. All five creams labelled Wau Wa and the two labelled Muijiza cream contained clobetasol propionate. Thirteen of 17 unnamed creams contained corticosteroids: clobetasol proprionate (n = 4), clobetasol proprionate + hydrocortisone (n = 1), betamethasone valerate (n = 2), clobetasone butyrate (n = 3), and hydrocortisone (n = 2); there was an unidentified peak in one. Further analysis suggested Wau Wa cream contained approximately 20% proprietary Dermovate Cream in a paraffin base. No parents were aware that the creams contained steroid.

CONCLUSIONS

The majority of herbal creams analysed illegally contained potent or very potent topical steroids. There is an urgent need for tighter regulation of herbal creams and for increased public education about the potential dangers of alternative therapies.

A pilot randomized trial in primary care to investigate and improve knowledge, awareness and self-management among South Asians with diabetes in Manchester

AIMS

To investigate whether a secondary-primary care partnership education package could improve understanding of diabetes care among South Asians.

METHODS

In a pilot randomized controlled trial, in the setting of eight general practices randomized to intervention or control, patients were invited to four or more rotating visits per year by one of a diabetes specialist nurse, dietician or chiropodist working with general practice staff. Participants were from lists of South Asian patients with known Type 2 diabetes in each (general) practice.

RESULTS

Patients and practice scores at baseline and 1-year follow-up, from an interview using a questionnaire on knowledge, awareness and self-management of diabetes. Responses were developed into educational packages used during intervention. Of the 411 patients listed at baseline only 211 were traced for interview (refusal only 4%). Mean age was 55.4 years, age of diabetes onset 47.1 years. Fourteen percent were employed and 35% were able to communicate in English fluently. Only 118 could be traced and interviewed at 1 year, although there was no significant difference in demography between those who completed the study and those who did not. Despite a mean of four visits/patient, intervention had no impact on scores for diabetes knowledge, or awareness [score change 0.14, 95% confidence interval (CI) -0.20, 0.49] or self-management (-0.05, 95% CI -0.48, 0.39) between baseline and 1 year.

CONCLUSIONS

This form of secondary/primary care support did not transfer information effectively, and we suspect similar problems would arise in other similar communities. Different methods of clinician/patient information exchange need to be developed for diabetes in this South Asian group.

Review article: colorectal cancer chemotherapy

Colorectal cancer is a leading cause of cancer death world-wide. There have been important advances in the chemotherapeutic management of colorectal cancer as a result of a deliberate collaborative process of well-designed clinical trials. From the earlier standard of 5-fluorouracil-based therapy alone, the recent availability of newer agents, including capecitabine, irinotecan and oxaliplatin, has significantly expanded the options available for the management of patients with advanced colorectal cancer, with consequent improvements in survival. For patients with resected, high-risk, localized disease, adjuvant systemic chemotherapy improves survival. The identification of new chemotherapy regimens, the use of predictive testing and the integration of novel targeted therapies with cytotoxic chemotherapies are areas of active clinical investigation. A review of the chemotherapeutic management of colorectal cancer is presented.

Descriptive epidemiology of adult critical care transfers from the emergency department

AIMS

To describe the nature, frequency, and characteristics of adult critical care transfers originating from the emergency department (ED).

METHODS

A one year prospective regional descriptive study using multiple data sources of all critically ill adults transferred from an ED or a minor injuries unit (MIU) within the former Yorkshire Regional Health Authority Area or into a regional critical care facility if originating from an ED or MIU elsewhere.

RESULTS

29 EDs transferred 349 adults into the regional critical care facilities. The median number of transfers per department within the region was 18 (range 1 to 42). Seventeen were transferred from outside the region. A total of 263 (75%) patients were transferred for specialist care and 76 (22%) for non-clinical reasons. Altogether 294 (84%) were admitted to intensive care or a high dependency unit at the receiving hospital. The in-hospital documented mortality rate was 26%. A total of 170 patients (49%) had traumatic pathology of which 101 were principally transferred for management of a head injury. Median time in the ED was 3 hours 5 minutes (range 11 minutes to 17 hours 47 minutes). In 146 (42%) patients the decision to transfer was primarily made by the emergency medicine clinician. A total of 251 (72%) patients were intubated. The documented critical incident rate was 15%.

CONCLUSION

Trauma is the most common reason for transfer of the critically ill adult from the ED. A significant number of patients are transferred, however, with medical and surgical conditions and for non-clinical reasons. There continues to be problems with the quality of care that these patients receive. Emergency medicine clinicians must be actively involved in the development of regional critical care systems as a significant proportion of all critically ill adults transferred originate from the ED.

Male breast cancer

OBJECTIVE

To review cases of male breast cancer.

SETTINGS

Histopathology Section, Department of Pathology, The Aga Khan University, Karachi.

METHOD

Fifty one cases of male breast cancer specimens, received during a period of 10 years, routinely processed and stained with Haematoxylin and Eosin were analyzed. Special stains and Immunohistochemistry were used in difficult cases.

RESULTS

Male breast cancer affected individuals in the sixth and seventh decades of life with a mean age of 56.2 years. Infiltrating ductal carcinoma (IDC) was the predominant type. Skin involvement was seen in 27.45% of the cases. Breast lump was the most common presenting symptom followed by skin ulceration. At the time of presentation 43.13% patients had a tumour size of more than 3 cm.

CONCLUSION

Male breast cancer is a rare disease. Most of our findings correspond to the published local and international data.

Identification of microsatellite markers linked to Russian wheat aphid resistance genes Dn4 and Dn6

The Russian wheat aphid (RWA), Diuraphis noxia (Mordvilko), is a serious economic pest of wheat worldwide. Host plant resistance is the preferred method to control RWA infestations. The identification and mapping of RWA-resistant genes and the development of resistant wheat cultivars can be facilitated through the use of molecular markers. In the present study, microsatellite (SSR) markers linked to the RWA-resistant genes Dn4 and Dn6 were identified using several F(2) mapping populations derived from crosses of susceptible wheat cultivars and resistant sources. Two flanking microsatellite markers Xgwm106 and Xgwm337 are linked in coupling phase with Dn4 on the short arm of wheat chromosome 1D at 7.4 cM and 12.9 cM, respectively. Two other microsatellite markers Xgwm44 and Xgwm111 are linked to Dn6 in coupling phase near the centromere on the short arm of chromosome 7D at 14.6 cM and 3.0 cM, respectively. This is the first report on the chromosomal location of Dn6, which proved to be either allelic or tightly linked to Dn1, Dn2 and Dn5. This result of Dn6 location contradicts previous reports that Dn6 was independent of Dn1, Dn2 and Dn5. The linked markers can be conveniently used for marker-assisted selection in wheat breeding programs for the identification and/or pyramiding of Dn4 and Dn6 genes.

Expression of prolactin receptors in normal, benign, and malignant breast tissue: an immunohistological study

AIMS

Prolactin plays an important role in the proliferation and differentiation of normal breast epithelium, and possibly in the development of breast carcinoma. The effects of prolactin are mediated by its receptor; thus, alteration in the expression of this receptor could be important in studying the biology of breast cancer. This investigation was aimed at comparing the expression of prolactin receptors in normal, benign, and malignant breast tissue.

MATERIAL/METHODS

The expression of prolactin receptors was studied in paraffin wax embedded sections of 102 breast biopsies (93 female and nine male), using the monoclonal antibody B6.2, and the avidin-biotin immunoperoxidase technique. Six biopsies were normal, 34 had benign lesions, and 62 were malignant.

RESULTS

In normal cases, prolactin receptor positivity was seen only on the luminal borders of the epithelial cells lining ducts and acini. In most benign lesions, variable degrees of luminal and cytoplasmic staining were seen. Cells showing apocrine metaplasia and florid regular ductal epithelial hyperplasia were mostly negative. In malignant cases, the staining pattern was mostly cytoplasmic and heterogeneous. Forty one of the 59 carcinomas in women showed a degree of positivity involving 10-100% of the tumour cells. A significant direct correlation was found between prolactin receptor and oestrogen receptor staining when only cases that scored more than 100/300 for the latter receptor, using the H scoring system, were considered (p = 0.0207). No correlation was found between prolactin receptors and progesterone receptors, patient's age, tumour size, tumour grade, or axillary lymph node status.

CONCLUSIONS

Prolactin receptors seem to be expressed at different cellular sites in normal, benign, and malignant breast epithelial cells. The receptor is expressed in more than two thirds of female breast carcinomas, suggesting that it may play a role in the pathogenesis of the disease. The positivity is correlated with moderate and strong staining for oestrogen receptors in tissue sections, but not with other prognostic factors.

Neuroendocrine aspects of aging in women

In women, the loss of ovarian function at menopause is associated with marked changes in hypothalamic and pituitary function. In addition, the steady decline in serum levels of LH, FSH, and FAS with age following menopause provides clear evidence for age-related neuroendocrine changes independent of the changes occurring owing to loss of ovarian feedback on the hypothalamic and pituitary components of the reproductive axis. An increase in the overall amount of GnRH secreted occurs despite a 30% decrease in GnRH pulse frequency with aging. This observation implies that the amount of GnRH secreted with each secretory bolus is greater in older postmenopausal women when compared with younger postmenopausal women. Thus, there may be a prominent pituitary component to the age-related decline in gonadotropin secretion. Recent studies indicate that the response to estrogen negative feedback at the hypothalamic level is preserved with aging, whereas the response to estrogen positive feedback may decrease with reproductive aging; however, the response to estrogen positive feedback in women has not been investigated with respect to aging, per se. It will be important to determine whether these age-related changes in hypothalamic-pituitary function contribute to reproductive senescence in normal women, as has been suggested for similar changes in animal models.

SarT, a repressor of alpha-hemolysin in Staphylococcus aureus

In searching the Staphylococcus aureus genome, we found several homologs to SarA. One of these genes, sarT, codes for a basic protein with 118 residues and a predicted molecular size of 16,096 Da. Northern blot analysis revealed that the expression of sarT was repressed by sarA and agr. An insertion sarT mutant generated in S. aureus RN6390 and 8325-4 backgrounds revealed minimal effect on the expression of sarR and sarA. The RNAIII level was notably increased in the sarT mutant, particularly in postexponential-phase cells, while the augmentative effect on RNAII was less. SarT repressed the expression of alpha-hemolysin, as determined by Northern blotting, Western blotting, and a rabbit erythrocyte hemolytic assay. This repression was relieved upon complementation. Similar to agr and sarA mutants, which predictably displayed a reduction in hla expression, the agr sarT mutant exhibited a lower level of hla transcription than the sarT mutant. In contrast, hla transcription was enhanced in the sarA sarT mutant compared with the single sarA mutant. Collectively, these results indicated that the sarA locus, contrary to the regulatory action of agr, induced alpha-hemolysin production by repressing sarT, a repressor of hla transcription.

Biochemical markers of ischaemia for the early identification of acute myocardial infarction without St segment elevation

Blood was collected on admission and after 1-2 h in 130 consecutive patients admitted with typical chest pain in order to assess the capacity of myoglobin, fatty-acid-binding protein (FABP), CK-MB mass, and troponin I (TnI) in the early identification of acute myocardial infarction (AMI) without ST elevation. Using the maximum value within 6 h of onset of symptoms, AMI was detected with a 90-95% sensitivity and a 81-94% specificity by FABP at a cut-off level 8-12 midrog/l, or 81-86% and 89-93%, respectively, by myoglobin at a cut-off level 70-90 microg/l. CK-MB mass and TnI had low sensitivity, albeit very high specificity. As almost all AMI patients were identified within 6 h, serial measurements of FABP or myoglobin ruled out AMI with a very high degree of certainty. Due to the low prevalence of AMI (16%), the positive predictive values were modest (47-73%), yet increasing the probability of AMI by a factor 3-4. Myoglobin and FABP are very useful markers in the early triage of chest pain patients.