Neuroprotection with amifostine in the first-line treatment of advanced ovarian cancer with carboplatin/paclitaxel-based chemotherapy--a double-blind, placebo-controlled, randomized phase II study from the Arbeitsgemeinschaft Gynäkologische Onkologoie (AGO) Ovarian Cancer Study Group

GOALS OF WORK

Neurotoxicity is a common side effect of platinum/taxane-based therapy of ovarian cancer. We performed a double-blind randomized placebo-controlled trial to evaluate the influence of the cytoprotectant amifostine on the neurotoxicity of first-line therapy of ovarian cancer with paclitaxel/carboplatin with or without epirubicin.

PATIENTS AND METHODS

Of 72 patients randomized, 71 were treated with paclitaxel 175 mg/m2 and carboplatin AUC5 with or without epirubicin 60 mg/m2 (q21 x 6) and randomized for i.v. premedication with amifostine 740 mg/m2 or placebo. Assessment included a questionnaire, NCI-CTC, tendon reflex activity (TRA), two-point discrimination (2-PD), measurement of vibration perception threshold (VPT) and vibration disappearance threshold (VDT), and quality of life.

RESULTS

The majority of neurotoxicity criteria showed a significant impairment during therapy in both treatment arms. A significant protective effect of amifostine was observed for 2-PD, TRA, VPT and VDT. Amifostine failed to improve the 'global health status quality of life' score significantly. Toxicities according to NCI-CTC showed improved sensory neuropathy (P = 0.0046) but a worsening in terms of nausea (P = 0.0005) and vomiting (P = 0.0083). No significant differences were observed for single sensory and motor symptoms, except for a better skilfulness in the amifostine group (P = 0.0404).

CONCLUSION

Amifostine improved sensory neuropathy according to NCI-CTC and with regard to objective neurological assessment, but there were almost no differences in self-estimated specific sensory or motor symptoms. Disadvantages with regard to non-neurological toxicities and inconsistent results for quality of life demand further evaluation of neuroprotection with amifostine as well as alternative approaches to prevent platinum-taxane induced neurotoxicity.

Navigationsgeführtes Operieren beim subtemporalen Zugang von intrameatalen Kleinhirnbrückenwinkeltumoren?

BACKGROUND

Computer assisted surgery (CAS) permits the visualization of hidden bony covered structures invisible for the human eye with radiological 3d data sets. The surgeon might be able to orientate anatomically during surgery without having to prepare the according landmarks. This would mean less surgical traumatization and a shorter and smaller operation corridor.

METHOD

We determined the use of CAS in a quality assurance analysis with the subtemporal approach in 8 patients with supra-meatal tumors type A of the cerebellopontine angle. Various navigation systems and methods for referencing for the registration of the patients' heads were used. The question was whether it is possible intraoperatively without preparation of known anatomical landmarks to define the borders of an optimal positioned temporary bone cap and to identify the bony covered inner auditory canal and its neuronal structures without orienting neurostimulation.

RESULT

It was possible with CAS to assess intraoperatively the borders of a temporary bone cap above the cranially positioned mastoid cell. However, the objective inaccuracy of 2 to 28 mm observed during surgery did not allow a secure identification of the inner auditory canal.

CONCLUSIONS

CAS with the subtemporal approach cannot replace the conventional preparation of known anatomical landmarks nor neurostimulation to identify neural structures, due to the expected high inaccuracy with the non-invasive referencing systems that are available today.

A phase II study of paclitaxel, carboplatin, and gemcitabine in previously untreated patients with epithelial ovarian cancer FIGO stage IC-IV (AGO-OVAR protocol OVAR-8)

PURPOSE

A multicenter, nonrandomized, phase II study was initiated to evaluate the tolerability, toxicity, and activity of paclitaxel, carboplatin, and gemcitabine combination in previously untreated ovarian cancer.

PATIENTS AND METHODS

Chemonaive patients who had radical debulking surgery for primary epithelial ovarian cancer International Federation of Gynecology and Obstetrics (FIGO) IC-IV received sequentially paclitaxel 175 mg/m(2), carboplatin AUC 5, and gemcitabine 800 mg/m(2) on day 1 and gemcitabine 800 mg/m(2) on day 8, every 3 weeks.

RESULTS

From October 2001 to July 2002, 55 patients were treated and evaluated. Main toxicities were hematological with NCI-CTC grade 3/4 anemia 12.7%, leukopenia 70.9%, neutropenia 76.3%, and thrombocytopenia 45.5. However, febrile neutropenia occurred only in 1.8%. Grade 3/4 nonhematological toxicities were rare and occurred in less than 10% of patients. Toxicity-induced treatment delays occurred in 3.1% of cycles and resulted in early treatment cessation in four patients. Dose intensity reached 90.8% for carboplatin and paclitaxel, and 73.3% for gemcitabine. Objective response was observed in 10 of 14 patients with measurable disease.

CONCLUSIONS

The triplet combination of paclitaxel-carboplatin-gemcitabine is feasible and active, with manageable hematological toxicity and no unexpected nonhematological toxicity. This regimen has proceeded to phase III evaluation.

'Human' insulin versus animal insulin in people with diabetes mellitus

BACKGROUND

Human insulin was introduced for the routine treatment of diabetes mellitus in the early 1980s without adequate comparison of efficacy to animal insulin preparations. First reports of altered hypoglycaemia awareness after transfer to human insulin made physicians and especially patients uncertain about potential adverse effects of human insulin.

OBJECTIVES

To assess the effects of different insulin species by evaluating their efficacy (in particular glycaemic control) and adverse effects profile (mainly hypoglycaemia).

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on human versus animal insulin was performed using The Cochrane Library, MEDLINE and EMBASE. We also searched reference lists and databases of ongoing trials. Date of latest search: July 2004.

SELECTION CRITERIA

We included randomised controlled clinical trials with diabetic patients of all ages that compared human to animal (for the most part purified porcine) insulin. Trial duration had to be at least one month in order to achieve reliable results on the main outcome parameter glycated haemoglobin.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was performed by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and by Jadad.

MAIN RESULTS

Altogether 2156 participants took part in the 45 randomised controlled studies that were discovered through extensive search efforts. Though many studies had a randomised, double-blind design, most studies were of poor methodological quality. Purified porcine and semi-synthetic insulin were most often investigated. No significant differences in metabolic control or hypoglycaemic episodes between various insulin species could be elucidated. Insulin dose and insulin antibodies did not show relevant dissimilarities.

AUTHORS' CONCLUSIONS

A comparison of the effects of human and animal insulin as well as of the adverse reaction profile did not show clinically relevant differences. Many patient-oriented outcomes like health-related quality of life or diabetes complications and mortality were never investigated in high-quality randomised clinical trials. The story of the introduction of human insulin might be repeated by contemporary launching campaigns to introduce pharmaceutical and technological innovations that are not backed up by sufficient proof of their advantages and safety.

Methodik der Evaluation perimodiolärer CI-Elektrodenträger im Felsenbeinmodell

BACKGROUND

Cochlear implants (CI) are the established treatment for cochlear deafness. Recently, indications for cochlear implantation have been expanded to include severely hearing-impaired patients. The use of bilateral implants seems to provide additional benefit. Moreover, new electrode designs, i. e. perimodiolar electrode arrays, aim at improving benefit for patients. However, in addition to providing functional improvements, modern electrode array development must also address safety aspects, because damage to the cochlear morphology (especially the osseous spiral lamina) may lead to degeneration of residual neuronal structures and bony obliteration or scarring within the cochlear ducts.

METHODS

Therefore, insertion trauma of the newly developed electrode arrays in human temporal bones must be evaluated before applied to patients. Several methods for testing electrode location and intracochlear trauma are described.

RESULTS

Combining cross-sectional imaging, histological analysis and elements of risk-assessment valid information about trauma and possible consequences for use in patients can be determined, based on our experience in 57 temporal bones.

CONCLUSIONS

Following our results, safety studies with prototype electrode arrays should, in addition to radiological examination, always include careful histomorphological evaluation.

Evaluation des Insertionstraumas des Nucleus® Contour Advance™-Elektrodenträgers im humanen Felsenbeinmodell

BACKGROUND

The development of intracochlear electrode arrays is aiming at a placement close to the modiolus with an insertion as atraumatic as possible. A new perimodiolar electrode model the Nucleus Contour Advance was to be evaluated regarding the possible intracochlear trauma.

METHODS

The implantation of the Contour Advance electrode was performed in 11 frozen native temporal bones. Beneath a regular insertion in 5 temporal bones in 6 cases the insertion was carried out using the "advance-off-stylett" technique with a fixed stylett. The temporal bones were embedded in metacrylate based resin for histomorphological evaluation. The evaluation was performed regarding to the intracochlear placement close to the modiolus and the damage to intracochlear fine structures (basilar membrane, osseus spiral lamina).

RESULTS

In 2 out of 11 cases we found a perforation from the scala tympani to the scala vestibuli independent of the insertion-technique. A severe intracochlear trauma was observed in one case with fracture of osseus spiral lamina using the AOS-technique. A close position to the modiolus could be achieved by insertion the scala tympani without perforation of the basilar membrane.

CONCLUSIONS

The Nucleus Contour Advance electrode array showed minimal trauma in human temporal bones by using a standard insertion technique. By using the freehand AOS-technique a severe cochlear trauma is possible. Therefore further development in electrode design and the use of an insertion-tool is recommended.

National Bioterrorism Syndromic Surveillance Demonstration Program

The National Bioterrorism Syndromic Surveillance Demonstration Program identifies new cases of illness from electronic ambulatory patient records. Its goals are to use data from health plans and practice groups to detect localized outbreaks and to facilitate rapid public health follow-up. Data are extracted nightly on patient encounters occurring during the previous 24 hours. Visits or calls with diagnostic codes corresponding to syndromes of interest are counted; repeat encounters are excluded. Daily counts of syndromes by zip code are sent to a central data repository, where they are statistically analyzed for unusual clustering by using a model-adjusted SaTScan approach. The results and raw data are displayed on a restricted website. Patient-level information stays at the originating health-care organization unless required by public health authorities. If a cluster surpasses a threshold of statistical aberration chosen by the corresponding public health department, an electronic alert can be sent to that department. The health department might then call a clinical responder, who has electronic access to records of cases contributing to clusters. The system is flexible, allowing for changes in participating organizations, syndrome definitions, and alert thresholds. It is transparent to clinicians and has been accepted by the health-care organizations that provide the data. The system's data are usable by local and national health agencies. Its software is compatible with commonly used systems and software and is mostly open-source. Ongoing activities include evaluating the system's ability to detect naturally occurring outbreaks and simulated terrorism events, automating and testing alerts and response capability, and evaluating alternative data sources.

Cluster core-level binding-energy shifts: the role of lattice strain

Our combined experimental and theoretical analysis of the shifts, with particle size, of core-level binding energies (BE's) of metal nanoparticles on insulating supports, shows that these shifts have an important initial state contribution arising, in large part, because of lattice strain. This contribution of BE shifts has not been recognized previously. Lattice strain changes the chemical bonding between the metal atoms and this change induces BE shifts.

Outcome of critical foot ischaemia in longstanding diabetic patients: a retrospective cohort study in a specialised tertiary care centre

Background: We sought to establish risk factors predicting the outcome of foot lesions in longstanding diabetic patients with critical foot ischaemia (CFI). Patients and methods: We investigated retrospectively 98 consecutive diabetic patients with ischaemic foot lesions. The patients (mean age 70 years, duration of diabetes 21 years) were jointly cared for by specialised diabetologists and vascular surgeons; 75 patients were treated by arterial revascularisation. Results: Good outcome (lesions healing) was observed in 53 patients (54%). Bad outcome was observed in 45 patients: not healing lesions (n = 5), major amputation(n = 19), and death in relation to the foot lesion (n = 21). Patients with good and bad outcome did not differ regarding age, sex, smoking status, type, duration and treatment of diabetes mellitus, presence of neuropathy, coronary heart disease, stroke, previous amputations, current revascularization, and localization of the foot lesion. The risk of bad outcome was increased 8.9 times in patients on dialysis for end-stage renal disease; 7.0 times if surgical complications were present; and 5.4 times with C-reactive protein (CRP) above the second quintile (cut-off value 8 mg/dl). Conclusion: Management of longstanding diabetic patients with ischaemic foot lesions leaves room for improvement. Dialysis treatment, elevated CRP levels and surgical complications were strongly predictive of non-healing lesions, major amputation and death.

'Human' insulin versus animal insulin in people with diabetes mellitus

BACKGROUND

Human insulin was introduced for the routine treatment of diabetes mellitus in the early 1980s without adequate comparison of efficacy to animal insulin preparations. First reports of altered hypoglycaemia awareness after transfer to human insulin made physicians and especially patients uncertain about potential adverse effects of human insulin.

OBJECTIVES

To assess the effects of different insulin species by evaluating their efficacy (in particular glycaemic control) and adverse effects profile (mainly hypoglycaemia).

SEARCH STRATEGY

A highly sensitive search for randomised controlled trials combined with key terms for identifying studies on human versus animal insulin was performed using the Cochrane Library (issue 2, 2002), Medline (1966 to May, 2002) and Embase (1974 to February, 2002). We also searched reference lists and databases of ongoing trials. Date of latest search: May 2002.

SELECTION CRITERIA

We included randomised controlled clinical trials with diabetic patients of all ages that compared human to animal (for the most part purified porcine) insulin. Trial duration had to be at least one month in order to achieve reliable results on the main outcome parameter glycated haemoglobin.

DATA COLLECTION AND ANALYSIS

Trial selection as well as evaluation of study quality was performed by two independent reviewers. The quality of reporting of each trial was assessed according to a modification of the quality criteria as specified by Schulz and by Jadad.

MAIN RESULTS

Altogether 2156 participants took part in the 45 randomised controlled studies that were discovered through extensive search efforts. Though many studies had a randomised, double-blind design, most studies were of poor methodological quality. Purified porcine and semi-synthetic insulin were most often investigated. No significant differences in metabolic control or hypoglycaemic episodes between various insulin species could be elucidated. Insulin dose and insulin antibodies did not show relevant dissimilarities.

REVIEWER'S CONCLUSIONS

A comparison of the effects of human and animal insulin as well as of the adverse reaction profile did not show clinically relevant differences. Many patient-oriented outcomes like health-related quality of life or diabetes complications and mortality were never investigated in high-quality randomised clinical trials. The story of the introduction of human insulin might be repeated by contemporary launching campaigns to introduce pharmaceutical and technological innovations that are not backed up by sufficient proof of their advantages and safety.

Reliability of causes of death in persons with Type I diabetes

AIMS/HYPOTHESIS

To compare causes of death assessed by a clinical review committee, the information given on death certificates, and ICD-codes provided by the State Documentation Office in deceased persons with Type 1 (insulin-dependent) diabetes mellitus.

METHODS

A cohort of 3674 patients were monitored for 10+/-3 (mean +/- SD) years. Vital status and end-stage diabetic complications were documented for 97%; 251 patients had died. Causes of death were assessed by a clinical review committee and compared to the information provided by death certificates and ICD-9 codes.

RESULTS

The review committee defined a leading cause of death in 94% of cases, whereas death certificates were available for 73% and ICD-codes for 79% of patients; 10% of death certificates could not be evaluated due to insufficient information. Diabetes was mentioned on 71% of death certificates, and renal disease in 75% of cases with renal replacement therapy. There was acceptable agreement between the committee, death certificates and ICD-codes only for deaths due to neoplasma, and between the committee and death certificates for deaths due to acute myocardial infarction, cerebrovascular events and accidents. In only one out of four deaths due to hypoglycaemia and in four of seven deaths due to ketoacidosis was this diagnosis mentioned on the death certificate. No death due to hypoglycaemia or ketoacidosis and 41% due to suicide were identifiable by ICD-codes.

CONCLUSION/INTERPRETATION

Reliance on death certificates or ICD-codes as the only sources of information on the cause of specific mortality does not provide data of sufficient reliability for evaluation of clinical outcome in Type I diabetes.

Chemotherapy versus hormonal treatment in platinum- and paclitaxel-refractory ovarian cancer: a randomised trial of the German Arbeitsgemeinschaft Gynaekologische Onkologie (AGO) Study Group Ovarian Cancer

BACKGROUND

The majority of patients with ovarian cancer are not cured by first-line treatment. Until now, no study could demonstrate any substantial benefit when exposing ovarian cancer patients to second-line chemotherapy. However, most treatment regimens induce toxicity, thus negatively influencing the quality of rather limited life spans. Here we evaluate whether a second-line chemotherapy can offer any benefit compared with a less toxic hormonal treatment.

PATIENTS AND METHODS

Patients with ovarian cancer progressing during platinum-paclitaxel containing first-line therapy or experiencing relapse within 6 months were eligible. Patients were stratified for response to primary treatment (progression versus no change/response), and measurable versus non-measurable disease. Treatment consisted of either treosulfan 7 g/m5 infused over 30 min or leuprorelin 3.75 mg injected subcutaneously or intramuscularly. Both regimens were repeated every 4 weeks.

RESULTS

This study began in late 1996, and after 2.5 years accrual an interim analysis was performed when several investigators reported their concern about a suspected lack of efficacy. Following this analysis the recruitment was stopped early and the 78 patients already enrolled were followed up. The majority of patients received treatment until progressive disease was diagnosed or death occurred. Treatment delay was observed rarely and dose reduction was performed only in the treosulfan arm in 5% of 150 courses. Overall, both treatment arms were well tolerated. No objective responses were observed. The median survival time was 36 and 30 weeks in the treosulfan and leuprorelin arms, respectively. Overall survival did not differ between patients with relapse 3-6 months after first-line chemotherapy compared with patients with progressive disease within 3 months.

CONCLUSIONS

The selected patient population represents a subgroup with extremely poor prognosis. Accordingly, results were not impressive. Both treatment arms showed favourable toxicity data, but failed to show remarkable activity, thus adding only limited evidence to the issue of whether patients with refractory ovarian cancer might benefit from second-line chemotherapy. Even stratified analysis did not identify any subgroup of patients in whom the administration of second-line chemotherapy could demonstrate a clinically relevant survival benefit.

cAMP-dependent phosphorylation of CYP2B1 as a functional switch for cyclophosphamide activation and its hormonal control in vitro and in vivo

An important feature of cytochrome P450 (CYP) 2B1 is its high ability to convert the prodrug cyclophosphamide (CPA) to therapeutically cytotoxic metabolites, resulting in interstrand DNA-cross-linking and cell death. We have examined whether and how the phosphorylation of CYP2B1 influences CPA metabolic activation in vitro and in vivo. We found first that only part of the total CYP2B1 pool undergoes phosphorylation. This part is fully inactivated. Second, phosphorylation of CYP2B1 in intact hepatocytes reduced by up to 75% toxification of CPA to mutagenic metabolites (totally dependent on the same preferentially CYP2B-catalyzed 4-hydroxylation of CPA as is the generation of highly cytotoxic species). Third, the phosphoacceptor-serine 128 of CYP2B1 in the consensus sequence for interaction with the protein kinase A represents an on/off switch for the activation of CPA depending on the phosphorylation conditions in the cell. Fourth, evidence is presented that the above-described events also occur in vivo. In conclusion, a successful therapy with CPA, helped by forced expression of CYP2B1 in tumor cells (as recently proposed) will, in addition, be profoundly modified by its phosphorylation status.

The integration of anthracyclines in the treatment of advanced ovarian cancer

Since the publication of the Gynecologic Oncology Group (GOG) protocol 111 in 1996, and the results of the Arbeitgemeinschaft Gyna kologische Onkologie (AGO) trial Ovar-3 and the GOG protocol 158, the combination of platinum and paclitaxel has been adopted as the standard therapy in advanced ovarian cancer. One option for achieving further progress in the first-line treatment of advanced ovarian cancer might be the addition of noncross-resistant drugs to the two-drug regimen. Meta-analysis showed a survival benefit for platinum-anthracycline based combinations as compared to platinum-based combinations without anthracyclines. An AGO phase I/II trial compared epirubicin in combination with carboplatin and paclitaxel in untreated patients with gynecological malignancies. Based on the results of this study a randomized phase III trial together with the French GINECO group was conducted. The trial started 11/97 and was closed 11/99. All 1281 patients were randomized. Currently, 1132 end-of-therapy reports have been issued. Nine hundred eighty nine (87%) patients completed six cycles of treatment. Treatment and toxicity data are available for these patients. Three hundred thirty five patients had a measurable residual tumor after initial debulking surgery. Response data of 228 patients (111 ET-Carbo, 117 Carbo-T) are available.

Saliva testing after single and chronic administration of dihydrocodeine

In the present study, concentrations of dihydrocodeine and its metabolites in saliva and serum were compared after single low-dose and chronic high-dosage administration of the drug. In the first investigation, blood and saliva were collected periodically from six subjects after oral administration of 60 mg dihydrocodeine. In the second study, 20 subjects on oral dihydrocodeine maintenance provided single samples of blood and saliva simultaneously. Serum protein binding of salivary analytes and their recovery from the adsorbing material of the collection device as well as pH values of saliva samples were determined. The fluids were analyzed for dihydrocodeine and the major metabolites by high-performance liquid chromatography. In the single dose study dihydrocodeine was the only analyte found in saliva for up to 12-24 h post-dose. The half-life of dihydrocodeine in saliva was about twice that found in blood. The ratios of saliva/serum concentrations ranged from 1.2 to 17.0. After chronic high-dosage use, dihydrocodeine was the main salivary analyte and N-nordihydrocodeine was present in a few samples. Saliva/serum concentration ratios of dihydrocodeine were strongly dependent on the pH value of saliva and, to a lesser extent, on serum-protein binding. The saliva/serum ratios were more similar after chronic administration. The data suggest a passive diffusion process as the underlying mechanism for the transport of dihydrocodeine into saliva. After both single and chronic use, the presence of the drug in saliva can be used as evidence of recent substance administration.