Autologous tumor-derived HSPPC-96 vs. physician’s choice (PC) in a randomized phase III trial in stage IV melanoma

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Background: Vitespen (Oncophage; formerly HSPPC-96) is an autologous, tumor-derived, heat shock protein (gp96)-peptide complex vaccine that has shown signals of clinical activity in patients (pts) with metastatic melanoma, and colon and renal cancers. Methods: This phase 3 trial compares vitespen v. PC in AJCC stage IV melanoma. Pts had ECOG PS 0/1 and ≥7 g tumor tissue for vaccine production. Randomization was 2:1 favoring vitespen, and stratified by ECOG PS and AJCC substage (M1a, -b, -c). Vitespen was administered s.c. weekly for 4 weeks, then biweekly until vaccine depletion or disease progression (DP). PC treatment was any regimen including IL-2 and/or dacarbazine/temozolomide and/or tumor resection. Pts were evaluated every 3 months for 1st year, every 6 months for 2nd year, then annually until DP. Primary endpoint was overall survival (OS). OS data, based on ITT, were analyzed using 1-sided log-rank tests. Results: From Jan 2002-Sept 2004, 322 pts at 76 centers (US, Europe, Russia/Ukraine, Australia) were enrolled. 215 pts were randomized to vitespen, 107 pts to PC. Mean age was 55 y; 59% were male; ECOG was 0 in 71% of pts; 19% of pts were M1a, 24% M1b, 57% M1c. 62% of pts in vaccine arm received vitespen; median number of vaccines was 6 (range, 0–74). As of Sept 2005, 18 pts were in tumor evaluation phase, 53 in survival follow-up, 251 off-study (death, withdrew consent, lost to follow-up). Median follow-up time for vaccine and PC arms was 250 and 289 d, respectively. Estimated median survival for vaccine and PC arms was 281 and 322 d, respectively (P = .078). M1a pts in the vaccine arm survived longer than those in the PC arm (626 v. 383 d, P = .177). Survival was comparable in both arms for M1b pts (297 v. 320 d, P = .478), and longer in the PC arm for M1c pts (299 v. 226 d, P = .015). Impact of number of doses was examined using landmark analyses to correct potential biases. Pts who received ≥10 doses of vaccine survived longer than those who received PC (377 v. 478 d, P = .072). Conclusions: Vitespen confers qualitative survival benefit over PC for M1a melanoma pts. If 10 doses of vaccine can be administered, vitespen also appears to confer survival benefit over PC for M1b pts. A phase 3 trial evaluating vitespen in M1a and M1b pts is planned.

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Measures to Counter Fatigue Failure in Railway Axles

This paper reviews the experience in London Transport of fatigue cracking in railway axles, and presents the results of laboratory fatigue tests on full-scale axle specimens under simulated rotating bending. The investigation was undertaken with the aim of entirely eliminating fatigue cracking and fretting under the press fits of wheel-axle sets. Whilst cold rolling of wheel seats, which is standard L.T. practice, strongly inhibits the propagation of such fatigue cracks, it does not prevent their initiation. The introduction of a stress-relieving groove, such that the edge of the press fit overhangs the groove, leads to a marked reduction in fretting and increase in life of test specimens, and the results of a limited service test suggest that the presence of such a groove reduces the stresses under the wheel hubs to a level at which cracking is eliminated. Since the presence of a press fit near to a groove increases the stress level at the root of the groove it is desirable to cold-roll the grooves, and a suitable rolling technique employing three rollers of slightly different profile radii has been developed.

Characterisation and internalisation of recombinant humanised HMFG-1 antibodies against MUC1

The humanised HMFG-1 immunoglobulin has been extensively developed as a clinical immunotherapeutic agent for MUC1 expressing tumours. We have constructed a single-chain Fv (scFv) and Fab fragment from this antibody and shown that both these species retain their specificity for MUC1. The scFv was less stable and less soluble than the Fab. Detailed analyses of the binding kinetics of the whole IgG and Fab fragment show that the affinity for MUC1 synthetic peptides is low (approximately 100 nM for the IgG and 10 μM for the Fab), with particularly low but similar dissociation rate constants (0.031–0.095 s⁻¹). Binding to native antigen on the cell surface is over two orders of magnitude better. Confocal immunofluorescence microscopy shows that both the IgG and Fab are internalised rapidly (the IgG is internalised within 15 min) and colocalise to early endosomes. This work provides an appreciation of the binding, internalising and trafficking kinetics, important for the development of future therapeutics based on this antibody.

Best practice in primary care pathology: review 1

This first best practice review examines four series of common primary care questions in laboratory medicine, namely: (i) measurement and monitoring of cholesterol and of liver and muscle enzymes in patients in the context of lipid lowering drugs, (ii) diagnosis and monitoring of vitamin B12/folate deficiency, (iii) investigation and monitoring of paraprotein bands in blood, and (iv) management of Helicobacter pylori infection. The review is presented in a question-answer format, referenced for each question series. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are not standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.

Clinician-led surgical site infection surveillance of orthopaedic procedures: a UK multi-centre pilot study

The UK Department of Health established the Healthcare-associated Infection (HAI) Surveillance Steering Group in 2000 to develop a strategy for implementing a national programme for HAI surveillance in National Health Service trusts. A subgroup of this committee examined the surveillance of surgical site infections following orthopaedic surgery. This group oversaw a pilot scheme that was set up in 12 hospitals around the UK to explore the feasibility of implementing a system of surveillance that engaged clinical staff in its operation, provided a process for continuous data collection and could be maintained as part of routine hospital operation over time. A minimum data set was established by the subgroup, and Centers for Disease Control and Prevention (CDC) definitions of infection were used. By March 2003, the surveillance had been undertaken continuously in 11 sites for one to two years, depending on the date of implementation. Only one hospital had ceased data collection. The information was collected mainly by clinical staff, with support and co-ordination usually provided by infection control teams. Data on more than 5400 procedures were available for analysis for four core procedures: arthroplasty of the hip and knee; hemi-arthroplasty of the hip; and internal fixation of trochanteric fractures of the femur. The data set permitted the calculation of risk-adjusted rates, allowing comparisons between hospitals and within a hospital over time. The methodology enhanced clinical ownership of the surveillance process, re-inforced infection control as the responsibility of all staff, and provided timely feedback and local data analysis. The use of CDC definitions permitted international comparisons of the data.

Convectively driven polymerase chain reaction thermal cycler

We have fabricated a low-cost disposable polymerase chain reaction thermal chamber that uses buoyancy forces to move the sample solution between the different temperatures necessary for amplification. Three-dimensional, unsteady finite element modeling and a simpler 1-D steady-state model are used together with digital particle image velocimetry data to characterize the flow within the device. Biological samples have been amplified using this novel thermal chamber. Time for amplification is less than 30 min. More importantly, an analysis of the energy consumption shows significant improvements over current technology.

Reproducibilty of partial weight bearing

OBJECTIVES

To find out whether partial weight bearing can be reproduced and retained.

DESIGN

In vivo experiment in normal subjects.

INTERVENTION

Training for partial weight bearing (25% of body weight) using bathroom scales.

MAIN OUTCOME MEASUREMENT

Reproducibility on force platform immediately after training and after 60 min.

RESULTS

Twelve subjects were asked to reproduce 25% of their body weight through either the dominant or non-dominant limb on force platform after three practice attempts on bathroom scales with concurrent visual feedback. No feedback was provided after the measurements on force plate. The process was repeated after 1h without any practice sessions in the interim period to find out if the weight practised could be retained. The mean 0-min reading was found to be 25.9% of body weight while the mean 60-min reading was found to be 24.4%. The p-value for the difference between the two means was found to be 0.3841.

CONCLUSIONS

This study indicates that partial weight bearing instructions can be quantified and graded. Simple bathroom scales are sufficient to educate the patients and this can be practised at home after an initial period of supervision.

Dairy augmentation of total and central fat loss in obese subjects

BACKGROUND AND OBJECTIVE

We have previously demonstrated an antiobesity effect of dietary Ca; this is largely mediated by Ca suppression of calcitriol levels, resulting in reduced adipocyte intracellular Ca2+ and, consequently, a coordinated increase in lipid utilization and decrease in lipogenesis. Notably, dairy Ca is markedly more effective than other Ca sources.

DESIGN

Obese subjects were placed on balanced deficit (-500 kcal/day) diets and randomized to control (400-500 mg Ca/day; n = 16) or yogurt (1100 mg Ca/day; n = 18) treatments for 12 weeks. Dietary macronutrients and fiber were held constant at the US average.

MEASUREMENTS

Body weight, body fat and fat distribution (by dual-energy X-ray absorptiometry), blood pressure and circulating lipids were measured at baseline and after 12 weeks of intervention.

RESULTS

Fat loss was markedly increased on the yogurt diet (-4.43+/-0.47 vs -2.75+/-0.73 kg in yogurt and control groups; P<0.005) while lean tissue loss was reduced by 31% on the yogurt diet. Trunk fat loss was augmented by 81% on the yogurt vs control diet (P<0.001), and this was reflected in a markedly greater reduction in waist circumference (-3.99+/-0.48 vs -0.58+/-1.04 cm, P<0.001). Further, the fraction of fat lost from the trunk was higher on the yogurt diet vs control (P<0.005).

CONCLUSION

Isocaloric substitution of yogurt for other foods significantly augments fat loss and reduces central adiposity during energy restriction..

Impact of antibody framework residue VH-71 on the stability of a humanised anti-MUC1 scFv and derived immunoenzyme

Anti-MUC1 single-chain Fv (scFv) fragments generated from the humanised antibody huHMFG1 had adequate antigen-binding properties but very poor stability irrespective of the applied linker or domain orientation. Mutagenesis of heavy-chain framework residue V_H-71, previously described as a key residue for maintaining the CDR-H2 main-chain conformation and thus important for antigen binding, markedly stabilised the scFv while having only a minor effect on the binding affinity of the molecule. Because of its improved stability, the engineered fragment exhibited immunoreactivity with tumour cells even after 7 days of incubation in human serum at 37°C. It also showed, in contrast to the wild-type scFv, a concentration-dependent binding to the target antigen when displayed on phage. When fusing the scFv to the recombinant ribonuclease rapLRI, only the fusion protein generated with the stable mutant scFv was able to kill MUC1⁺ tumour cells with an IC₅₀ of 80 nM. We expect this novel immunoenzyme to become a promising tool for the treatment of MUC1⁺ malignancies.

A new biomechanical model for the functional assessment of knee osteoarthritis

The severity of symptoms in osteoarthritis (OA) of the knee can be difficult to assess. A new method for assessing medial compartment OA of the knee is proposed. The purpose of this study was to determine if a relationship exists between the severity of OA and single limb stance knee adduction moment (SSKAM). Fourteen patients with medial compartment OA of the knee were tested and compared with 14 age-matched volunteers. WOMAC OA index scores were documented. Biomechanical data were collected from a single Kistler force platform and a six-camera ProReflex motion analysis system, and the knee adduction moments were calculated. A significant difference in the maximum, minimum and mean adduction moments was found between the two groups, and a correlation of r=0.66 for WOMAC physical function subscale, r=0.63 for the WOMAC pain subscale and r=0.63 for the sum of the subscales and mean SSKAM was found. Single limb stance adduction moments provide additional, objective information in the assessment of medial compartment OA of the knee. It may be useful in the selection of patients for surgery and for evaluating various treatment modalities for medial compartment OA of the knee.

Sex-steroid derived compounds induce sex-specific effects on autonomic nervous system function in humans

The physiological and psychological effects of 2 human sex-steroid derived compounds, 4.16-androstadien-3-one (AND) and l,3,5(10),16-estratetraen-3-ol(EST) were measured in 24 subjects who participated in a within-subjects, double-blind experiment. A dissociation was evident in the physiological effects of AND, in that it increased physiological arousal in women but decreased it in men. EST did not significantly affect physiological arousal in women or men. Neither compound significantly affected mood. AND is an androgen derivative that is the most prevalent androstene in human male sweat, male axillary hair, and on the male axillary skin surface. The authors argue that AND's opposite effects on physiology in men and women further implicate this compound in chemical communication between humans.

Agreement between physiotherapists on quality of movement rated via videotape

BACKGROUND

Although achieving quality of movement after stroke is an important aim of physiotherapy it is rarely measured objectively or described explicitly.

OBJECTIVE

To test whether physiotherapists agree on a composite measure of quality of movement. SETTING; A movement analysis laboratory

SUBJECTS

Ten stroke patients and 10 healthy age-matched volunteers.

DESIGN

Prospective correlational.

PROCEDURE

All subjects were videofilmed performing three trials of six standardized functional tasks. Two videotapes were made, each with a different randomized order of appearance of the trials. Ten senior physiotherapists independently rated the videotapes twice using a 100-mm visual analogue scale.

ANALYSIS

Analysis of variance models were fitted to transformed data. Estimates of components of variance were calculated and presented as a percentage of the total variance for differences, within subjects (intra-subject), between raters (inter-rater) and within raters (intra-rater). An acceptable percentage was set at less than 10%.

RESULTS

The percentage of intra-subject variance ranged from 1% (pick up box and walking) to 9% (step on block). The percentage of inter-rater variance ranged from 18% (pick up pencil) to 38% (sit to stand). The percentage of intra-rater variance was less than 1% for all tasks.

CONCLUSIONS

Although physiotherapists disagreed with each other on quality of movement they were more consistent in their own scoring.

High average power, all-solid-state external resonator Raman laser

As much as 3 W of average power at 1064 nm from a diode-pumped Nd:YAG laser, Q switched at 4 kHz, was used to pump an external-resonator, crystalline Ba(NO3)2 Raman laser generating a maximum of 1.3-W output at the first Stokes wavelength of 1197 nm. The slope efficiency was 63% with respect to the fundamental power incident on the Ba(NO3)2 crystal. A reduction in the beam quality of the Stokes output from M2 approximately 1.4 at lower Stokes powers to M2 approximately 3.4 at higher powers is attributed to thermal loading of the Raman-active crystal.

Effects of extracts from the cyanobacterium Microcystis aeruginosa on ion regulation and gill Na+,K+-ATPase and K+-dependent phosphatase activities of the estuarine crab Chasmagnathus granulata (Decapoda, Grapsidae)

Recent discoveries indicate that microcystins affect enzymes, such as Na(+),K(+)-ATPase, involved in ion regulation of aquatic animals, through K(+)-dependent phosphatase inhibition. In vitro studies showed the inhibitory effect of Microcystis aeruginosa extracts on Na(+),K(+)-ATPase and K(+)-dependent phosphatase activities in gills of Chasmagnathus granulata (Decapoda, Grapsidae). Extracts of M. aeruginosa were prepared from lyophilized or cultures cells of the cyanobacterium. For lyophilized cells, IC(50) values were estimated as 0.46 microg/L (95% confidence interval [CI]=0.40-0.52 microg/L) and 1.31 microg/L (95% CI=1.14-1.51 microg/L) for Na(+),K(+)-ATPase and K(+)-dependent phosphatase, respectively. However, extracts prepared from cultured cells presented a much lower inhibitory potency against both enzymes. Gas chromatography revealed long-chain fatty acids in the lyophilized cell extracts, indicating that they are in part responsible for the enzyme inhibition. In vivo studies showed that the toxin inhibited Na(+),K(+)-ATPase activity in anterior gills, whereas an increased augmented activity of glutathione-S-transferase was observed in both kind of gills, indicating that the crab has increased its ability to conjugate the toxin. No significant differences in hemolymph sodium or chloride concentration were detected. This result is in agreement with the lack of effects of microcystin on Na(+),K(+)-ATPase activity of posterior (osmoregulating) gills.

Treatment requirements of infants with rhesus isoimmunisation within a geographically defined area

OBJECTIVE

To provide population based data on the treatment requirements of infants with rhesus isoimmunisation.

SETTING

Twenty nine hospitals in South Thames in which 81 119 deliveries occurred between February 1999 and January 2000.

DESIGN

Every month, a clinician identified in each of the hospitals sent back a postcard indicating whether or not an infant with RhD had required treatment in their institution. Antenatal and postnatal information was then requested from all those who gave positive responses.

MAIN OUTCOME MEASURES

Requirement for postnatal treatment for rhesus isoimmunisation.

RESULTS

During the one year study period, only 26 infants required treatment for rhesus isoimmunisation. The median duration of phototherapy of the 26 infants was five days (range 1-12). Seven infants required at least one exchange transfusion (two required two exchange transfusions), and seven infants received one "top up" transfusion. None received erythropoietin and no infant died.

CONCLUSION

The results suggest that few infants require treatment for rhesus isoimmunisation.

Monitoring antibiotic resistance in urinary isolates from the community--a spotter practice model

Awareness of the rise in antimicrobial resistance has led to recommendations for better prescribing guidelines, based on accurate laboratory sensitivity data. However, concerns have been raised of possible biases in sampling leading to skewed resistance rates results, and so a range of different enhanced surveillance models have been proposed. This study compared the differences between routine results from unselected primary care urine samples with results from samples from spotter practices. Five hundred and eighty-eight out of 2,288 urine samples received from three spotter practices were culture positive. Of the 510 isolates tested against a panel of commonly prescribed antibiotics, levels of resistance to ampicillin were 32.5%, and to trimethoprim 18.0% (p < 0.05). By comparison, of 40,026 urine specimens submitted by other practices, 9,382 were culture positive and the percentage antibiotic resistant was higher--36.3% to ampicillin and 22.6% to trimethoprim. Routinely submitted laboratory samples may overestimate the true levels of antibiotic resistance in the community. A spotter practice-model is an effective and viable way of collecting unbiased data.