ABC; An AGITG trial of fixed dose rate (FDR) gemcitabine (gem) and cisplatin for patients (pts) with advanced biliary tract cancer (ABC)

15015

Background: No standard regimen exists for pts with ABC. Previous studies suggest that FDR optimises gem activity. This study evaluated the activity of FDR gem with low dose cisplatin using a previously identified schedule. Methods: Single arm, multi- centre phase II trial, planned to enrol 45 pts > 18 years, ECOG PS = 2, with previously untreated histologically / cytologically confirmed, inoperable locally advanced or metastatic ABC. Treatment consisted of FDR gem 1000 mg/m2 (10 mg/m2/min) and cisplatin 20 mg/m2 days 1& 8 q21 days until progression or intolerable toxicity. The primary end point was response rate (RR) by RECIST. Secondary end points included tolerability and safety, progression free and overall survival (PFS, OS) and response duration (RD). Results: 50 pts were enrolled from Feb 05 to Oct 06. Mean age was 60y (39–78); 88% had ECOG PS 0–1; 54% were female. Primary sites were gall bladder 45%, biliary tree 51%, ampulla 4%. Distant metastases were present in 63%. Past treatments included biliary stent in 29%, bypass in 6%, and an external drain in 4%. With a minimum follow-up of 12 weeks, best response was a confirmed PR in 11 pts (RR 22%, 95% CI 11 - 36) and SD (after 4 cycles) in 11 pts (22%), 1 (2%) unevaluable. CA19–9 responses occurred in 6 of 33 pts (18%). Median OS was 7 mo (0.3–13), PFS 4.4 mo (0.3–13), and RD 8 mo (5–12). One year survival rate was 30%. The median number of cycles was 4 (1–16). Treatment was delayed at least once in 45% of pts; mean delay 9d. Grade 3/4 (NCI/CTC) toxicities included infection 9%, fatigue 9%, anorexia/nausea 11%, vomiting 9%, anaemia 9%, neutropenia 28%, thrombocytopenia 15%, abnormal ALP 25%, GGT 47%, AST 6%. There was 1 treatment related death (hematemesis with grade 4 thrombocytopenia). Exploratory analysis of CA 19–9 and its association with response assessment and overall survival will be presented in June. Conclusions: This combination was well tolerated. The observed response rate is consistent with the expected 35% rate and may be superior to that expected with gem monotherapy. Further testing of this dose and scheduling is warranted. The authors thank Lilly for an unrestricted grant to conduct this study.

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The Role of Glucagon in Regulating Chicken Hepatic Malic Enzyme and Histidase Messenger Ribonucleic Acid Expression In Response to an Increase in Dietary Protein Intake

Increased dietary protein intake rapidly (3 h) decreases hepatic malic enzyme and increases hepatic histidase mRNA expression in broiler chicks. A series of experiments was conducted to determine the role that glucagon or a specific mixture of dietary amino acids might have in regulating the rapid changes in mRNA expression of these enzymes, when dietary protein intake is increased. Three hours after the injection of glucagon (240 microg/kg of BW) into the brachial vein of broiler chicks, hepatic malic enzyme mRNA expression was significantly lower and hepatic histidase mRNA expression was significantly greater than the level detected in saline-injected chicks. In addition, broiler chicks fed a high (40 g/ 100 g of diet) protein diet had significantly higher plasma glucagon levels at 1 and 3 h after initial access to this diet than broiler chicks fed a basal (22 g/100 g of diet) protein diet. The plasma glucagon concentration, however, was not different between the chicks fed the 2 dietary protein levels at 2 h after the initial access to the 2 diets. When a mixture of indispensable or dispensable amino acids was added to the basal diet to equal the concentrations of the individual indispensable or dispensable amino acids in the high protein diet, hepatic mRNA expression of malic enzyme and histidase were intermediate to the expression found in chicks fed the basal and high protein diet. The results indicate that glucagon may mediate the changes in the mRNA expression of malic enzyme and histidase in response to dietary protein intake and that total amino acid intake rather than the ingestion of specific amino acids regulates the mRNA expression of malic enzyme and histidase in chicks.

Combined use of a cytoprotectant and rehabilitation therapy after severe intracerebral hemorrhage in rats

After moderate intracerebral hemorrhage (ICH), both hypothermia (HYPO) and constraint-induced movement therapy (CIMT) improve recovery and reduce the volume of brain injury. We tested the hypothesis that more severe ICH requires both cytoprotection and rehabilitation to significantly improve recovery. Rats were subjected to a unilateral striatal ICH via collagenase infusion. Rats remained normothermic or were subjected to mild HYPO ( approximately 2 days) starting 12 h later. Fourteen days after ICH, half of the rats received CIMT (7 days of restraint of the less affected limb plus daily exercises); the remainder were untreated. Walking, limb use and skilled reaching were assessed up to 60 days, at which time animals were euthanized and the volume of tissue lost was determined. The HYPO treatment alone did not improve outcome, whereas CIMT alone provided significant benefit on the limb use asymmetry test. In the staircase test, the greatest benefit was achieved with the combination of HYPO and CIMT treatments. The volume of tissue lost after ICH was similar among groups arguing against cytoprotection as a mechanism of functional recovery. Finally, these findings suggest that, at least under the present circumstances (e.g., severe striatal ICH), CIMT provides superior benefit to HYPO and that combination therapy will sometimes further improve recovery.

Composition and distribution of pythium communities in wheat fields in eastern washington state

ABSTRACT Pythium spp. were isolated from a mixture of soil and roots collected from 80 wheat fields in eastern Washington in the summer of 2000 from an area encompassing approximately 27,000 km(2). These sites covered a range of soil textures (coarse to fine, silty loess), average annual precipitation (200 to 600 mm), and average annual temperatures (7 to 11 degrees C). Soil type and annual precipitation run in an east-west gradient, while temperature has a north-south gradient. Species were identified using classical methods and by sequencing the internal transcribed spacer (ITS)-1 region of the rDNA and comparing these sequences to a database from a worldwide collection of Pythium spp. The species with the highest frequency of occurrence among all the sites were P. abappressorium sp. nov. (A) (50%), P. rostratum (R) (40%), P. debaryanum (D) (37.5%), P. heterothallicum (H) (33.7%), P.oligandrum (O) (31.2%), an unidentified P. sp. (aff. echinulatum) (E) (25%), and P. ultimum (U) (18%). P. intermedium, P. irregulare, P. paroecandrum, P. sylvaticum, P. dissimile, and P. dissoticum were isolated at a low frequency. From one to six species were isolated at each site, and there were 46 different species combinations detected. The species presence/absence data from all sites were analyzed with Jaccard's similarity coefficient hierarchical cluster analysis. Six communities were identified (species within each community designation in order of frequency among the sites within the community)-AD, AOU, AR, DEH, HE, and RU. In general, P. abappressorium was evenly distributed over all zones. AOU was more prevalent in zones with lower precipitation and coarser soil, while DEH and HE were associated with zones with higher precipitation and finer-textured soils on the basis of comparison of frequency distributions with the expected distribution over all the sites. The RU community was more prevalent in higher temperature zones. Canonical correspondence analysis was performed to examine the relationship between species and environmental variables. Soil type and precipitation were highly correlated with each other and with axis 1, which separated P. ultimum and P. abappressorium (lower variable values) from P. heterothallicum (higher variable values). Axis 2 and 3 were most correlated with temperature, and these axes separated P. oligandrum (higher value) from P. debaryanum (lower value) and P. ultimum-P. rostratum from the other species. The results suggest that Pythium species composition, distributions, and associations on a given crop may be influenced by environmental factors at a mesoscale level (100 to 1,000,000 ha).

Field evaluation of the CATT/Trypanosoma brucei gambiense on blood-impregnated filter papers for diagnosis of human African trypanosomiasis in southern Sudan

Most Human African Trypanosomiasis (HAT) control programmes in areas endemic for Trypanosoma brucei gambiense rely on a strategy of active mass screening with the Card Agglutination Test for Trypanosomiasis (CATT)/T. b. gambiense. We evaluated the performance, stability and reproducibility of the CATT/T. b. gambiense on blood-impregnated filter papers (CATT-FP) in Kajo-Keji County, South-Sudan, where some areas are inaccessible to mobile teams. The CATT-FP was performed with a group of 100 people with a positive CATT on whole blood including 17 confirmed HAT patients and the results were compared with the CATT on plasma (CATT-P). The CATT-FP was repeated on impregnated filter papers stored at ambient and refrigerated temperature for 1, 3, 7 and 14 days. Another 82 patients with HAT, including 78 with a positive parasitology, were tested with the CATT-FP and duplicate filter paper samples were sent to a reference laboratory to assess reproducibility. The CATT-FP was positive in 90 of 99 patients with HAT (sensitivity: 91%). It was less sensitive than the CATT-P (mean dilution difference: -2.5). There was no significant loss of sensitivity after storage for up to 14 days both at ambient and cool temperature. Reproducibility of the CATT-FP was found to be excellent (kappa: 0.84). The CATT-FP can therefore be recommended as a screening test for HAT in areas where the use of CATT-P is not possible. Further studies on larger population samples in different endemic foci are still needed before the CATT-FP can be recommended for universal use.

Induction of Hsp60 by Photofrin-mediated photodynamic therapy

Photodynamic therapy (PDT) invokes a number of cellular responses. Other studies have shown that PDT induces transcription and translation of heat shock proteins (Hsps). The expression of mitochondrial heat shock protein, Hsp60, was measured following in vitro Photofrin-mediated PDT in the colon cancer cell line HT29 and its PDT-induced resistant variant HT29-P14 as well as the radiation-induced fibrosarcoma cells RIF-1 and its PDT-induced resistant variant, RIF-8A. Basal levels of Hsp60 were found to be similar in the two murine cell lines. In the human model, the resistant HT29-P14 cell line showed a small increase in basal levels relative to its parental population. Incubation with Photofrin (PII) alone or photosensitization caused a significant increase in Hsp60 levels in all cell lines as determined by flow cytometry. A dose-dependent and temporal relationship for PDT response was observed, maximum levels were detected 6-8 h post PDT, at which time, Hsp60 induction was found to be significantly greater in the two resistant variants. Induction in the RIF cells was also found to be greater after incubation with PII alone at the highest doses tested. These results indicate that the presence of PII and the subsequent oxidative stress of PDT can induce Hsp60 and implicated it as a common factor that may contribute to the resistance observed in the induced resistant cells.

Hereditary nonpolyposis colorectal cancer in 95 families: differences and similarities between mutation-positive and mutation-negative kindreds

Hereditary nonpolyposis colorectal cancer (HNPCC) describes the condition of a disparate group of families that have in common a predisposition to colorectal cancer in the absence of a premalignant phenotype. The genetic basis of this disease has been linked to mutations in genes associated with DNA mismatch repair. A large proportion of families harbor changes in one of two genes, hMSH2 and hMLH1. Approximately 35% of families in which the diagnosis is based on the Amsterdam criteria do not appear to harbor mutations in DNA-mismatch-repair genes. In this report we present data from a large series of families with HNPCC and indicate that there are subtle differences between families that harbor germline changes in hMSH2 and families that harbor hMLH1 mutations. Furthermore, there are differences between the mutation-positive group (hMSH2 and hMLH1 combined) of families and the mutation-negative group of families. The major findings identified in this study focus primarily on the extracolonic disease profile observed between the mutation-positive families and the mutation-negative families. Breast cancer was not significantly overrepresented in the hMSH2 mutation-positive group but was overrepresented in the hMLH1 mutation-positive group and in the mutation-negative group. Prostate cancer was not overrepresented in the mutation-positive groups but was overrepresented in the mutation-negative group. In age at diagnosis of colorectal cancer, there was no difference between the hMSH2 mutation-positive group and the hMLH1 mutation-positive group, but there was a significant difference between these two groups and the mutation-negative group.

A DNase I hypersensitive site near the murine gamma1 switch region contributes to insertion site independence of transgenes and modulates the amount of transcripts induced by CD40 ligation

Several cis-acting elements regulate the expression of germline transcripts of heavy chain constant region genes and their subsequent switch recombination. To study such elements in the murine gamma1 gene, we have utilized a transgenic approach. In this study we focused on a DNase I hypersensitive site (termed 'Site II') that lies about 2 kb 3' of the gamma1 promoter region and I exon, just 5' to the gamma1 switch region. We have reported that gamma1 transgenes with Site II display the characteristics of a locus control region (LCR) in that they are insertion site independent and copy number dependent. For the present study we prepared six lines of transgenic mice that have the promoter region and I exon, but lack Site II. Expression of RNA from gamma1 transgenes that lack Site II is not correlated with transgene copy number; expression is insertion site dependent. This result indicates that DNase hypersensitive Site II is an important part of the LCR-like elements in the murine gamma1 gene. RNA expression from the gamma1 transgenes that lack Site II is inducible by IL-4 and by CD40 ligation. However, the induction of transgenic RNA expression by CD40 ligation is greater than expected, suggesting that elements within Site II participate in negative regulation of the amount of germline transcripts after CD40 ligation.

Getting nutrition education into medical schools: a computer-based approach

Despite awareness of the importance of nutrition as part of medical student's education, numerous barriers exist to incorporating nutrition education into the medical school curriculum. Chief among such barriers is that most medical schools do not have faculty trained specifically in nutrition. A curriculum is needed that can deliver comprehensive nutrition information that is consistent across medical schools. One way to deliver this information is to use computer-assisted instruction (CAI). To meet the different needs of medical schools and provide a consistent base of nutrition information, we developed a series of interactive, multimedia educational programs (Nutrition in Medicine) that teach the basic principles of nutritional science and apply those principles in a case-oriented approach. Curriculum content is derived from the American Society for Clinical Nutrition consensus guidelines. These modules offer the advantages of accessibility, self-paced study, interactivity, immediate feedback, and tracking of student performance. Modules are distributed free to all US medical schools. Preliminary data from surveys gathered by our team at the University of North Carolina at Chapel Hill indicate that 73 US medical schools use, or are planning to use, these modules; more schools are currently evaluating the programs. Successful implementation of CAI requires easy program access, faculty training, adequate technical support, and faculty commitment to the programs as a valuable resource. CAI fails when the program is just placed in the library and students are told to use it when they can find the time.

Association of a polymorphism in the TNFR2 gene with low bone mineral density

Previous genetic linkage data suggested that a gene on chromosome 1p36.2-36.3 might be linked to low bone mineral density (BMD). Here, we examine the gene for tumor necrosis factor receptor 2 (TNFR2), a candidate gene within that interval, for association with low BMD in a group of 159 unrelated individuals. We assess two polymorphic sites within the gene, a microsatellite repeat within intron 4, and a three-nucleotide variation in the 3' untranslated region (UTR) of the gene. The latter has five alleles of which the rarest allele is associated with low spinal BMD Z score (p = 0.008). Lowest mean spinal BMD Z scores were observed for individuals having genotypes that were heterozygous for the rarest allele. No homozygotes for the rarest allele were observed. Preliminary analysis suggests that there is a difference in the genotype frequency distribution between the group with low BMD and a control group.

Direct control of a computer from the human central nervous system

We describe an invasive alternative to externally applied brain-computer interface (BCI) devices. This system requires implantation of a special electrode into the outer layers of the human neocortex. The recorded signals are transmitted to a nearby receiver and processed to drive a cursor on a computer monitor in front of the patient. Our present patient has learned to control the cursor for the production of synthetic speech and typing.

Comparison of intubation skills between interfacility transport team members

OBJECTIVE

To compare intubation skill level and success rate between interfacility transport team members.

DESIGN

Prospective collection of data.

SETTING

University affiliated children's hospital interfacility transport team.

PATIENTS

One hundred thirty-two pediatric patients (age range 4 days to 11 years) intubated prior to transport by a specialized team.

INTERVENTIONS

None.

METHODS

Prospective data was gathered from June 1992 November 1996. In 3616 transports reviewed, 132 intubations were performed by the team at the referring facility. Patient ages ranged from 4 days to 11 years with a mean age of 23 months. We compared resident physicians and respiratory care practitioners (RCPs) to a standard threshold of 1 attempt per successful intubation. An attempt was defined as passage of the endotracheal tube into the oropharynx in an effort to pass it through the vocal cords. Patients were sedated and paralyzed for the procedures. The physicians were 2nd and 3rd year pediatric or emergency medicine residents. They received intubation training in Pediatric Advanced Life Support (PALS), Neonatal Resuscitation Program (NRP), and during rotations through neonatal and pediatric intensive care units. RCPs had an average of 3.5 years of experience overall on the transport team. They received training primarily on mannequins and written tests while in school. They were certified in PALS and NRP and required to participate in annual skill laboratories, which consisted of mannequin intubations and a written examination.

RESULTS

The results showed the RCPs to have greater overall success as well as greater success of intubation on first attempt compared to the resident physicians.

CONCLUSION

In our experience, RCPs on the interfacility transport team were very successful in performing endotracheal intubations and were more successful than resident physicians. RCPs are established members of not only the transport team, but also the intensive care units and, therefore, should be considered qualified to routinely perform endotracheal intubations in those settings as well.

High-dose therapy with autologous bone marrow support as consolidation of remission in follicular lymphoma: long-term clinical and molecular follow-up

PURPOSE

To evaluate the long-term results of high-dose therapy (HDT) in follicular lymphoma, with specific emphasis on the prognostic significance of polymerase chain reaction (PCR)-detectable Bcl-2/IgH rearrangements.

PATIENTS AND METHODS

Between June 1985 and October 1995, 99 patients with follicular lymphoma received HDT as consolidation of second or subsequent remission. Bone marrow was treated in vitro with anti-B-cell antibodies and complement.

RESULTS

Sixty-five patients remained alive, 49 treatment-failure free, with a median follow-up of 5.5 years (range, 1.5 to 12.5 years). Four "early" and 10 "late" deaths occurred from treatment-related causes; seven of the latter were due to secondary myelodysplasia (s-MDS) or secondary acute myeloblastic leukemia. Overall, 12 (12%) of the 99 patients developed s-MDS or acute myeloblastic leukemia. Kaplan-Meier estimates of freedom from recurrence (FFR) and survival rates at 5 years were 63% (95% confidence interval [CI], 52% to 72%) and 69% (95% CI, 58% to 78%), respectively. For all 99 patients, in multivariate analysis, absence of the Bcl-2/IgH rearrangement at the time of diagnosis (hazards ratio [HR], 0.39; P =.04) and three or fewer treatment episodes before HDT (HR, 0.03; P =.001) were significant prognostic factors for improved survival. For patients bearing Bcl-2/IgH rearrangements, in univariate and multivariate analyses, absence of a PCR-detectable Bcl-2/IgH rearrangement during follow-up was associated with a significantly lower risk of recurrence (adjusted HR, 0.13; P <.001) and death (HR, 0.25; P =.02), whereas the PCR status of the reinfused bone marrow did not correlate with outcome.

CONCLUSION

Prolonged FFR can be achieved in patients with follicular lymphoma after HDT, but as yet there is no survival advantage compared with conventional treatment. These results confirm that elimination of cells bearing the Bcl-2/IgH rearrangement is highly desirable and should be attempted. The incidence of s-MDS is of increasing concern in this setting.