Cardiac safety of docetaxel/cyclophosphamide/trastuzumab (DCH) as adjuvant therapy for HER-2 (+) early stage breast cancer

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Background: The addition of trastuzumab to adjuvant chemotherapy is standard for Her2(+) breast cancer. In our practice, adjuvant docetaxel/cyclophosphamide (DC) + 1 yr of trastuzumab is offered to pts with low-risk Her2(+) disease. Although the HERA trial allowed the use of a variety of chemotherapy regimens to combine with trastuzumab, it predates the acceptance of DC as an adjuvant care-standard and therefore the safety profile of DCH has not been reported. Methods: We conducted a two-center, retrospective cohort study including all pts treated with adjuvant DCH between 12/06 and 3/08 to assess its safety profile. Using the CTCAE criteria, records were screened for toxicity from DCH initiation to the present. The primary outcome was cardiac toxicity defined as clinical CHF or a confirmed significant LVEF decline (≥ 16% decrease in EF from baseline or EF < 50% + ≥ 10% decrease from baseline). Results: 27 pts, mean age 54, were identified with a median follow-up of 23.4 months (range 12.2- 42.0 months). The mean tumor size was 1.4 cm (0.5–4.3 cm) with 84% hormone receptor(+), 96% node(-) and 100% Her2(+) by FISH or IHC. 52% of pts received DCH concurrently and 48% received trastuzumab following DC. Baseline mean EF was 65% (53–86%). EF assessments were performed every 3 months/pt. 7.4% and 11.1% of pts had a prior history of anthracycline exposure or cardiac disease respectively. 11.1% of pts experienced a significant LVEF decline occurring on ≥ 2 sequential EF measurements. The trastuzumab discontinuation rate was 3.7% (1 pt). No pt developed clinical CHF. 88% of pts have now completed trastuzumab therapy. 33% of pts received pegfilgrastim with chemotherapy. 25% of pts experienced grade III-IV neutropenia. Grade III-IV anemia and thrombocytopenia were not observed. Trastuzumab-related infusion reactions were observed in 1 pt and did not warrant drug discontinuation. At this time all pts are alive and no patient has experienced disease recurrence. Conclusions: The DCH regimen, given in sequence or concomitantly, appears to be a safe and effective adjuvant treatment for women with Her2(+) disease. Along with docetaxel/carboplatin/trastuzumab, DCH represents another acceptable non-anthracycline containing regimen for low-risk, Her2(+) pts.

No significant financial relationships to disclose.

Undergraduate requirements in restorative dentistry in the UK and Ireland

OBJECTIVES

To ascertain the requirements in restorative dentistry that undergraduate dental students have to fulfil in order to sit the finals examinations in dental schools in the UK and Ireland and to compare those requirements with the competencies stipulated by the GDC in The first five years.

METHODS

Fifteen anonymised questionnaires, of open and closed question design, were sent by post to academics in the university departments of restorative dentistry in each of the undergraduate dental schools in the UK and Ireland. The first section concerned numerical information regarding total numbers of procedures that were required to be completed in undergraduate restorative dentistry. The second section was designed to ascertain information as to how decisions are made with respect to an undergraduate's readiness to sit the finals examination in restorative dentistry (such as continual assessment and/or competency assessments).

RESULTS

A total of 15 replies were received for analysis, a 100% response rate. Several institutions emphasised that they do not have 'requirements', but provide guidelines as to what should be achieved. Six institutions did not have set numerical requirements for direct placement restorations or bridges. The number of direct placement restorations required at the other nine institutions ranged from 50 to 160. Five institutions did not have numerical requirements for dentures; four institutions did not set numerical targets for crowns, veneers, inlays/onlays or endodontics. In institutions where numerical requirements were not used, forms of competency assessments were completed. The requirements across all institutions for periodontology, integrated treatment planning and completed cases were ill-defined.

CONCLUSIONS

This study shows that there is a wide disparity amongst institutions in the UK and Ireland with regards to finals requirements in restorative dentistry. Ideally, such requirements should be similar between institutions and should be closely mapped to the GDC's required learning outcomes (The first five years) for the UK institutions.

Plasticity in the development of neocortical areas

Heterotopic transplantation analysis suggests that individual areas of the developing neocortex have the capacity to differentiate many of the architectural and connectional features normally characteristic of other neocortical areas. Many studies indicate a pivotal role for thalamocortical afferents in the differentiation of the area-specific features that distinguish neocortical areas. Both activity-dependent and activity-independent mechanisms contribute to the patterning of thalamocortical afferent terminations. The available evidence suggests that positional information is established in the cortical subplate and that this information controls the precise targeting of developing thalamocortical axons. In this way appropriate thalamocortical relationships can be established that allow these afferents to promote the differentiation of the functionally specialized and anatomically distinct areas of the adult neocortex.

Prion infectivity in variant Creutzfeldt-Jakob disease rectum

BACKGROUND

Disease-related prion protein (PrP(Sc)) is readily detectable in lymphoreticular tissues in variant Creutzfeldt-Jakob disease (vCJD), but not in other forms of human prion disease. This distinctive pathogenesis, with the unknown population prevalence of asymptomatic vCJD infection, has led to significant concerns that secondary transmission of vCJD prions will occur through a wide range of surgical procedures. To date PrP(Sc):prion infectivity ratios have not been determined in vCJD, and it is unknown whether vCJD prions are similar to experimental rodent prions, where PrP(Sc) concentration typically reflects infectious prion titre.

AIM

To investigate prion infectivity in vCJD tissue containing barely detectable levels of PrP(Sc).

METHODS

Transgenic mice expressing only human PrP (Tg(HuPrP129M(+/+)Prnp(o/o))-35 and Tg(HuPrP129M(+/+)Prnp(o/o))-45 mice) were inoculated with brain or rectal tissue from a previously characterised patient with vCJD. These tissues contain the maximum and minimum levels of detectable PrP(Sc) that have been observed in vCJD.

RESULTS

Efficient transmission of prion infection was observed in transgenic mice inoculated with vCJD rectal tissue containing PrP(Sc) at a concentration of 10(4.7)-fold lower than that in vCJD brain.

CONCLUSIONS

These data confirm the potential risks for secondary transmission of vCJD prions via gastrointestinal procedures and support the use of PrP(Sc) as a quantitative marker of prion infectivity in vCJD tissues.

Undergraduate training as preparation for vocational training in England: a survey of vocational dental practitioners' and their trainers' views

AIMS

To compare the views of new vocational dental practitioners (VDPs) and their trainers regarding how undergraduate dental education has prepared them for their vocational training (VT) in England. This study also aims to identify areas of relative weakness in dental undergraduate education that could influence the future training needs of vocational trainees.

METHOD

Structured postal questionnaires were completed by VDPs and trainers from five Deaneries in England. The usable response rate was 71% (n = 186 VDPs and 186 trainers).

RESULTS

The vast majority of VDPs and trainers perceived the undergraduate training in history taking, diagnosis and treatment planning for general practice to have been covered 'well' or even 'very well'. Undergraduate training in routine restorative dentistry, oral pathology and paediatric dentistry was also perceived to have been covered well. However, a large proportion of VDPs and trainers reported that they felt that undergraduate training in orthodontics, molar endodontics, surgical endodontics and surgical extraction of teeth had not adequately prepared them for VT.

CONCLUSIONS

Newly qualified dentists appear to lack certain competencies recommended by the General Dental Council in The First Five Years. This has implications for dental undergraduate education, but also highlights current training needs during VT.

Phase II study of gemcitabine (Gem) and trastuzumab (T) combination therapy in first line metastatic breast cancer (MBC) patients (pts) with HER2 overexpression

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Background: Phase III studies have demonstrated that the addition of T to chemo is associated with higher response rates (RR), improved time-to-progression (TTP) and improved overall survival in pts with metastatic HER2+ tumors. The greatest benefit from T-based therapy is found in women with pronounced HER2 overexpression (FISH+ or IHC 3+). Preclinical models suggest that Gem+T appear to be additive or synergistic. The present study was designed to determine overall RR (primary endpoint), TTP, OS and the toxicity profile of the combination of Gem+T as first-line therapy for MBC pts. Methods: Pts with measurable HER2-overexpressing (IHC 3+ or FISH+) MBC, no prior chemo in the metastatic setting (adjuvant was allowed), adequate end-organ function and PS 0–2, received Gem 1,250 mg/m2 on days 1 and 8 and T on day 1 (8 mg/kg over 90 min on cycle 1, then 6 mg/kg over 30 min on subsequent cycles) of a 21-day cycle, until progressive disease or undue toxicity. A Simon’s optimal two-stage design was used with a total sample size of 66 (25 patients treated in the first stage and 41 additional patients in the second stage). Results: Sixty-six patients have been treated and results are available for sixty-four patients. Median age: 53 years (range 34–83); Race: Caucasian/Other 88%/12%. ER status positive/negative: 53%/47%. HER2 status IHC 3+/FISH+: 58/20 pts.; ECOG PS 0/1/2: 66%/30%/3%; Prior adjuvant therapy: Chemo 39 pts (prior anthra 31, prior taxane 21), Hormonal 32 pts (6 adj, 18 met, 8 both). Total number of cycles = 396; median = 6 (range 1–21). Toxicity was generally modest. Grade 3/4 neutropenia occurred in 11 pts (17%)/7 pts (11%); thrombocytopenia 3pts (5%)/1pt (2%), anemia 3 pts (4.7%)/ 0 pts, and 2 pts with grade 4 transaminase elevation, grade 3 elevated ALT 6 pts (9.4%); no other grade 4 toxicities were recorded. One pt with prior anthra exposure had a grade 2 decrease in left ventricular ejection fraction; no symptomatic cardiac toxicity was recorded. Best Overall RR assessment (N = 64): CR 8 (12.5%), PR 26 (40.6%) for an overall RR of 53.1% (95% CI: 40%-66%). TTP median 6 mo (95% CI: 4.4 -9.7 mo). Survival data not mature at this time. Conclusions: The combination of Gem+T in front-line MBC shows a high response rate with modest toxicity.

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Estimating population served by sewage treatment works from readily available GIS data

Environmental risk assessment of household chemicals at the catchment scale requires an estimate of the load at individual Sewage Treatment Works (STWs). This can be achieved based upon population served and market consumption data. Although the population served is difficult to obtain, this paper shows that reasonable estimates can be made using readily available spatially referenced data. A new method is developed using STW data from the Exe and the Aire and Calder catchments and validated using 193 STWs within the Environment Agency's Anglian region. The estimated populations served were compared with available estimates of Population Equivalents (PEs). The population estimates were broadly similar to PEs for small works but agreement was lower for larger plants. The discrepancy for larger works is consistent with trade influent inclusion in the PE. The method is suitable for application to both rural areas and large urbanised areas, although the interpretation of corroborating data becomes increasingly difficult in very large urban areas serving more than one STW.

Economic evaluation of the impact of nicorandil in angina (IONA) trial

OBJECTIVE

To estimate the net cost of adding nicorandil to usual treatment for patients with angina and to compare this with indicators of health benefit.

DESIGN

Cost effectiveness analysis.

SETTING

Based on results of the IONA (impact of nicorandil on angina) trial.

PATIENTS

Patients with angina fulfilling the entry criteria for the IONA trial.

INTERVENTIONS

In one arm of the trial nicorandil was added to existing antianginal treatment and compared with existing treatment alone.

MAIN OUTCOME MEASURES

Costs were for use of hospital resources (for cardiovascular, cerebrovascular, and gastrointestinal reasons), nicorandil, and care after hospital discharge. Benefits were assessed in three ways: (1) IONA trial primary outcome (coronary heart disease (CHD) death, non-fatal myocardial infarction, or hospital admission for cardiac chest pain); (2) acute coronary syndrome (CHD death, non-fatal myocardial infarction, or unstable angina); and (3) event-free survivors at the end of the trial.

RESULTS

The net cost for each additional IONA trial end point averted was -5 pounds sterling (-7 euros). The net cost for each case of acute coronary syndrome averted was -8 pounds sterling (-12 euros). The net cost for each event-free survivor was -5 pounds sterling (-7 euros). These figures are based on gastrointestinal events that were judged definitely or probably related to nicorandil. When all gastrointestinal events were included these three ratios rose to 567 pounds sterling (835 euros), 886 pounds sterling (1305 euros), and 516 pounds sterling (760 euros), respectively.

CONCLUSIONS

A substantial amount of the additional cost of nicorandil is offset by reduced use of hospital services. The limited comparisons possible with other CHD interventions suggest that nicorandil compares favourably.

Pleiotropic role of VEGF-A in regulating fetal pulmonary mesenchymal cell turnover

Tight regulation of VEGF-A production and signaling is important for the maintenance of lung development and homeostasis. VEGF null mice have provided little insight into the role of VEGF during the later stages of lung morphogenesis. Therefore, we examined the in vitro effects of autocrine and paracrine VEGF-A production and the inhibition of VEGF-A signaling on a Flk-1-negative subset of fetal pulmonary mesenchymal cells (pMC). We hypothesized that VEGF-A receptor signaling regulates turnover of fetal lung mesenchyme in a cell cycle-dependent manner. VEGF receptor blockade with SU-5416 caused cell spreading and decreased proliferation and bcl-2 localization. Nuclear expression of the cell cycle inhibitory protein, p21, was increased with SU-5416 treatment, and p27 was absent. Autocrine VEGF production by pMC resulted in proliferation and p21/p27-dependent contact inhibition. In contrast, exogenous VEGF-A increased cell progression through the cell cycle. Selective activation of Flt by placental growth factor demonstrated the importance of this receptor/kinase in the VEGF-A responsiveness of pMC. The expression and localization of the survival factor bcl-2 was dependent on VEGF. These results provide evidence that VEGF-A plays a critical role in the regulation of fetal pulmonary mesenchymal proliferation, survival, and the subsequent development of normal lung architecture through bcl-2 and p21/p27-dependent cell cycle control.