[Catecholamine levels in plasma and cerebrospinal fluid of neurosurgical patients with normal and elevated intracranial pressure]

OBJECTIVE

Catecholamine levels in the plasma and cerebrospinal fluid of 21 neurosurgical patients with hydrocephalus and with normal and elevated intracranial pressure were determined prospectively in a clinical study.

METHODS

The study comprised 11 patients with normal intracranial pressure (8 female, 3 male, group 1) and 10 patients with elevated intracranial pressure (6 female, 4 male, group 2). The patients underwent a ventriculo-peritoneal shunt operation, external ventricular drainage or ventriculocisternostomy. The measuring times were set as follows: time 1: pre-operative; time 2: intra-operative; time 3: post-operative. The anaesthetic for the operations was administered as a total intravenous anaesthesia with propofol and alfentanil, muscle relaxation being achieved with rocuronium bromide or cis-atracurium.

RESULTS

Measurements of the catecholamine levels (adrenaline, noradrenaline and dopamine) at the three set times revealed an intra-operative fall compared to the initial pre-operative value and a rise in the catecholamine level again after the operation. It is likely that this largely reflects the course of the anaesthetic. The fall in the plasma catecholamine level was much slighter in group with elevated intracranial pressure. But in the group of patients with elevated intracranial pressure the catecholamine levels found in the plasma were much higher than those of the patients without elevated pressure. In the case of adrenaline, it was possible to demonstrate a statistically significant difference at the three measuring times. This suggests that especially the analyzed adrenaline level in the plasma could take on the role of a marker in cases of elevated intracranial pressure. In group 2, with elevated intracranial pressure, the catecholamine levels in the cerebrospinal fluid (CSF) were considerably higher than those in group 1, but the difference did not reach the significance level. The lack of correlation between the catecholamine values in the plasma and CSF described in the literature (comparison of the corresponding values at time 2) was confirmed for noradrenaline and dopamine in patients with elevated intracranial pressure (group 2). In both groups of patients there was a CSF plasma gradient for dopamine at time 2, i. e. the dopamine level was higher in cerebrospinal fluid than in the plasma.

CONCLUSION

The study shows that even a slight rise in intracranial pressure without clinically detectable ischaemia may result in elevated plasma and CSF catecholamine levels. Although catecholamine values are not routine parameters, they can be used in developing procedures to protect the brain in neurosurgical patients.

Treatment of non-small cell lung cancer (NSCLC) patients with the trifunctional antibody catumaxomab (anti-EpCAM x anti-CD3): Results of a phase I/II study

2540

Background: Catumaxomab is a trifunctional monoclonal antibody with binding specificities to human EpCAM, human CD3 and Fc gamma receptor I/III-positive accessory cells leading to induction of cell mediated, tumor specific cytotoxicity. As EpCAM is overexpressed in NSCLC patients (pts.) the present study was conducted in order to evaluate safety and tolerability of intravenous (i.v.) treatment with catumaxomab. Methods: Patients with NSCLC (UICC stage IB - IV) with at least one prior therapy were included into this trial. Escalating doses of 2–7,5 μg catumaxomab were given as a single i.v. infusion. Various doses of dexamethasone premedication (10 and 40 mg) were investigated at five different dose levels (level: catumaxomab (μg)/dexamethasone (mg)/number of pts. treated: I: 2/40/3, II: 2/0/1, III: 5/40/4, IV: 5/10/5, V: 7,5/40/2, respectively). Primary objectives were toxicity and definition of the maximum tolerated dose (MTD). In addition, time to progression (TTP) and survival were evaluated. Results: 24 pts. were included into this trial; 15 pts. were evaluable for safety analysis, 13 pts. for follow up. 13/15 pts. experienced a total of 68 AEs, of which 55 were reported as drug related and 9 defined as critical AEs. The majority (77%) of AEs were mild (CTC grade 1 and 2), 19% were grade 3 and 4% grade 4. 73% of the AEs were elevation of liver enzymes (gamma-GT, AST and ALT). Other toxicities were increase of blood ALP, dizziness, lymphopenia and pyrexia. Dose limiting toxicity (DLT) was a transient grade 3 and 4 elevation of ALT, AST and gamma-GT, observed at dose levels IV and V. Maximum tolerated dose (MTD) was defined at dose level III. Remarkably, follow up data showed 4/4 pts. stage IIIB and 1/4 pts. stage IV still alive at 26–28 months after catumaxomab treatment. Conclusion: 5 μg of catumaxomab can safely be administered intravenously with 40 mg dexamethasone as premedication. Based on the current results we recommend this regimen as first dose in a future study consisting of multiple catumaxomab infusions in pts. with locally advanced NSCLC.

[Table: see text]

Treatment of malignant pleural effusion with the trifunctional antibody catumaxomab (anti-EpCAM x anti-CD3): Results of a phase I/II study

2548

Background: The trifunctional antibody catumaxomab specifically binds EpCAM+ tumor cells, CD3+ T lymphocytes and accessory cells via the Fcγ RI/III. Thus the antibody induces tumor specific cell mediated cytotoxicity in vitro and in vivo. Its intraperitoneal administration has demonstrated safety and led to efficient tumor cell killing and reduction of malignant ascites in ovarian cancer patients (pts.). The present study was conducted to evaluate safety, tolerability and preliminary efficacy of catumaxomab administered intrapleurally (i.pl.) into pts. with EpCAM+ malignant pleural effusion. Methods: This phase I/II trial was a multi-center uncontrolled, dose-escalating study. Pts. (ECOG ≤3) with recurrent malignant pleural effusion containing EpCAM+ tumor cells were included. Three escalating doses from 5–200 μg catumaxomab were administered i.pl. Primary objectives were toxicity and definition of the maximum tolerated dose (MTD). In addition, preliminary data on efficacy (reduction of pleural fluid and tumor cell killing) were generated. Results: 13/24 pts. received 3 infusions as planned. Reasons for early termination of infusions were 3 deteriorations of performance status, 2 exanthemas, 2 dyspnoea, 2 others. The dose regimen of 20–50–100 μg catumaxomab was defined as MTD. Most frequent drug related AEs were symptoms of cytokine release syndrome. 32 SAEs were reported in 18 pts., 4 SAEs were possibly drug related (1 death due to pleural empyema, 1 pneumonia, 1 erythema, 1 increase of liver enzymes). 8/9 deaths were not drug related but due to underlying disease. Induction of human-anti-mouse (HAMA) or human-anti-rat (HARA) antibodies after treatment was found in 8/11 pts. 8/13 fully treated pts. were defined as responders (1 complete, 4 partial, 3 NA) showing reduction of effusion and of drainage necessity. 5/13 were non-responders. A reduction of tumor cells up to log 5 was seen in 10/13 pts. Conclusions: 20–50–100 μg of catumaxomab can safely be administered i. pl. This regimen will further be investigated in a randomized phase II trial comparing catumaxomab to talcum-based pleurodesis.

[Table: see text]

The glutathione S-transferase M1 (GSTM1) null genotype and benzidine-associated bladder cancer, urine mutagenicity, and exfoliated urothelial cell DNA adducts

Multiple studies in the general population have suggested that subjects with the glutathione S-transferase M1 (GSTM1)-null genotype, who lack functional GSTM1, are at higher risk for bladder cancer. To evaluate the impact of the GSTM1-null genotype on bladder cancer caused by occupational exposure to benzidine and to determine its influence on benzidine metabolism, we carried out three complementary investigations: a case-control study of bladder cancer among workers previously exposed to benzidine in China, a cross-sectional study of urothelial cell DNA adducts and urinary mutagenicity in workers currently exposed to benzidine in India, and a laboratory study of the ability of human GSTM1 to conjugate benzidine and its known metabolites in vitro. There was no overall increase in bladder cancer risk for the GSTM1-null genotype among 38 bladder cancer cases and 43 controls (odds ratio, 1.0; 95% confidence interval, 0.4-2.7), although there was some indication that highly exposed workers with the GSTM1-null genotype were at greater risk of bladder cancer compared to similarly exposed workers without this allele. However, the GSTM1 genotype had no impact on urothelial cell DNA adduct and urinary mutagenicity levels in workers currently exposed to benzidine. Furthermore, human GSTM1 did not conjugate benzidine or its metabolites. These results led us to conclude that the GSTM1-null genotype does not have an impact on bladder cancer caused by benzidine, providing a contrast to its association with elevated bladder cancer risk in the general population.

[An unusual protodiastolic bruit: the click of an aberrant mitral cord]

An asymptomatic adult woman without clinical cardiac disease had an unusual early diastolic heart sound. All usual causes of this finding were excluded: it was not a delayed pulmonary component of the second heart sound, a mitral or tricuspid opening snap, an early diastolic third heart sound or a pericardial vibration. The only apparent cause was a left ventricular false tendon extending from the septal endocardium to the left ventricular free wall, demonstrated by 2D echocardiography. This type of aberrant intracardiac band has already been described but the possibility of early diastolic stretching of this structure giving rise to an abnormal early diastolic sound does not seem to have been previously reported.

[Inquiry of the Swiss Cardiology Society on long-term pacemakers in Switzerland in 1976 and 1977]

The Swiss Society of Cardiology has conducted a national inquiry into the state of pacing in Switzerland for the years 1976 and 1977. With a total of 1250 pacemakers implanted each year and a rate of first implantation of 146 per year and per million inhabitants, this study illustrates the methods of Swiss cardiologists and the problems which they meet in the field. It is generally agreed, as in other countries, that stimulation of the right ventricle by endocavitary approach with demand pacemakers generated by lithium batteries appears to be excellent for the moment. Pacemakers which can be programmed were not in widespread use during the period of this study. The incidence of various complications is considered.

[Value of sonography in the diagnosis of obscure cholestasis]

A retrospective study has been conducted in 36 cholestatic patients to determine the diagnostic accuracy of ultrasonography in preliminary differentiation of obstructive from non-obstructive hepato-biliary disease. Due to the high rate of correct biliary duct caliber evaluation, ultrasonography has proved itself an excellent screening method in patients with cholestasis of uncertain origin. The choice of the subsequent more invasive diagnostic examinations (ERC, PTC, laparoscopy) depends on the ultrasonic findings.

[Heart and sports in the daily life of a heart patient]

Everyone should practice regular physical activity through life, with the aim of slowing down arterial damage due to aging. In cardiac patients, especially with coronary insufficiency, exercise is also a suitable method of rehabilitation and can thus be considered a complementary treatment when the situation has been restored by medication. Sport should be practised discriminately in quantity and quality to prevent its major complication, sudden death during effort. The arrhythmias that may be precursors of sudden death should be looked for in the stress test in particular. Pathologies involving a risk of sudden death should likewise be detected. Care should be taken to avoid anything in these patients that could predispose to onset of arrhythmia, which is very often the trigger for ventricular fibrillation.