Bevacizumab beginning concurrently with a sequential regimen of doxorubicin and cyclophosphamide followed by docetaxel and capecitabine as neoadjuvant therapy followed by postoperative bevacizumab alone for women with HER2-negative locally advanced breast cancer (LABC): A phase II trial of the NSABP Foundation Research Group

584

Background: Bevacizumab with chemotherapy improves outcomes in patients with metastatic breast cancer. The purpose of this trial was to determine the activity and safety profile of bevacizumab with chemotherapy in women with LABC. Methods: Between November 2006 and August 2007, 45 women with HER-2 negative LABC initiated preoperative standard AC x 4 followed by docetaxel 75 mg/m2 IV and capecitabine 825 mg/m2 BID days 1–14 (TX) every 21 days for 4 cycles. Bevacizumab 15 mg/kg IV was given concurrently with chemotherapy every 21 days for a total of 6 preoperative doses. Postoperatively, bevacizumab was resumed for a total of 10 doses. Primary endpoint was pathologic complete response rate (pCR) in the breast. The secondary endpoints include clinical response rates and toxicity. Results: The median age was 50 yrs (range 30–78). 30 patients had stage IIIA (67%), 12 stage IIIB (27%), and 3 stage IIIC (7%) disease. Of these, 10 (22%) had inflammatory breast cancer. 27 patients (60%) had ER-positive disease. A pCR in the breast was documented in 4/44 (9%) patients, which included negative axillary nodes. A complete clinical response was noted in 14/45 (31%). One patient did not have surgery due to progression. Toxicities included hand-foot (grade 2/3–33%/22%), mucositis (grade 2/3–49%/27%), and febrile neutropenia (grade 3–24%). Conclusions: This regimen demonstrated only modest activity with substantial toxicity, and does not appear to warrant further evaluation. This clinical trial is being conducted through the support of Genentech and Roche.

[Table: see text]

Epirubicin plus cyclophosphamide followed by docetaxel plus trastuzumab and bevacizumab as neoadjuvant therapy for HER2-positive locally advanced breast cancer (LABC) or as adjuvant therapy for HER2-positive pathologic stage III breast cancer (PS3BC): A phase II trial of the NSABP Foundation Research Group

580

Background: A previous phase II study evaluating the combination of trastuzumab (tras) and bevacizumab (bev) as first-line therapy in HER2 + MBC showed a response rate of 54%. The purpose of this trial is to determine the cardiac safety profile of these agents with docetaxel (T) following epirubicin plus cyclophosphamide (EC) in women with LABC and PS3BC and the activity in those with LABC. Methods: Since June 2007, 75 women with HER-2 + LABC or PS3BC have begun epirubicin 90 mg/m2 IV plus cyclophosphamide 600 mg/m2 IV q3wks x 4 followed by docetaxel 100 mg/m2 IV q3wks x 4. Targeted therapy: Cohort A (neoadjuvant), bev 15 mg/kg IV with Cycle 4 of EC, continued with the first 3 cycles of T. Standard weekly tras with 4 cycles of T. Postop, bev 15 mg/kg IV and tras 6 mg/kg IV q3wks to complete 1 yr of targeted therapy. Cohort B (adjuvant), bev 15 mg/kg q3wks for 4 cycles and weekly tras with T. After chemotherapy, bev and tras q3wks to complete 1 yr of therapy. Primary endpoints were the rate of cardiac events in both cohorts and pCR rate in breast/axillary lymph nodes in Cohort A. Results: Median age was 50 yrs. In Cohort A, 28 (53%) patients (pts) were stage IIIA, 20 (38%) stage IIIB, and 5 (9%) stage IIIC. 13 (25%) had inflammatory BC. A pCR occurred in 19 of the first 36 pts (53%). Toxicity information on the first 73 pts in both cohorts showed that grade 2 LVEF dysfunction has developed in 5 pts and grade 3 LVEF dysfunction in 2, 1 with NYHA Class II and 1 with Class III symptoms. The latter met criteria for a cardiac event. Conclusions: The regimen is active with an acceptable preliminary rate of cardiac toxicity. Updated results will be presented. This trial is conducted with the support of Genentech.

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Positive cross-match living donor kidney transplantation: longer-term outcomes

The long-term graft outcomes after positive cross-match (PXM) living donor kidney transplantation (LDKT) are unknown and the descriptive published data present short-medium term results. We conducted a retrospective cohort study of LDKT with PXM by flow cytometry performed at our center during February 1999 to October 2006, compared to a control group, matched 1:1 for age, sex, race, retransplantation and transplant year. The PXM group was treated with a course of plasmapheresis/low-dose intravenous immunoglobulin (IVIg) preoperatively, and OKT3 or thymoglobulin induction. Both groups (n = 41 each) were comparable except for duration of end-stage renal disease (ESRD), induction, HLA mismatch and panel-reactive antibody (PRA). During the period of up to 9 years, 14 PXM and 7 controls lost their grafts (p < 0.04). Graft survival rates at 1 and 5 years were 89.9% and 69.4% for PXM group and 97.6% and 80.6% for the controls, respectively. PXM was associated with higher risk of graft loss (HR 2.6, p = 0.04; 95%CI 1.03-6.4) (t(1/2)= 6.8 years), but not with patient survival (HR 1.96, p = 0.29; 95%CI 0.6-7.0) or 1-year serum creatinine (beta= 0.06, p = 0.59 for ln (SCr); 95% CI -0.16 to 0.28). These results suggest that despite the favorable short-term results of PXM LDKT after PP/IVIg conditioning, medium-long-term outcomes are notably worse than expected, perhaps comparable to non-ECD deceased donor kidney transplantation (KT).

Insulin receptors and insulin receptor antibodies: structure-function relationships

The insulin receptor has been purified by affinity chromatography and studied by affinity-labelling techniques. It appears to be a disulphide-linked heterotetramer, (alpha beta)2, composed of two copies of a 135,000 Mr subunit (alpha), and two copies of a 90,000 Mr subunit (beta). Beta is readily proteolysed to generate a 45,000 Mr fragment (beta 1). Alpha, beta and beta 1 all contain sialic acid and are, therefore, probably all exposed on the external surface of the membrane. Although alpha is predominantly labelled in affinity-labelling studies, beta and beta 1 can also be labelled. Therefore, alpha, beta and beta 1 are all in proximity to the insulin-binding site and may contain part of the binding site. Antibodies have been prepared against the intact, purified receptor and against the isolated alpha subunit. Both antibodies directly interact with the insulin receptor as indicated by their ability to immunoprecipitate the receptor. Neither antibody, however, directly competes with insulin binding. Therefore, they are probably directed against regions of the receptor distinct from the insulin-binding site. In spite of this, these antibodies have a wide range of insulin-like activities.

Cooling for newborns with hypoxic ischaemic encephalopathy

BACKGROUND

Newborn animal studies and pilot studies in humans suggest that mild hypothermia following peripartum hypoxia-ischaemia in newborn infants may reduce neurological sequelae without adverse effects.

OBJECTIVES

To determine the effect of therapeutic hypothermia in encephalopathic asphyxiated newborn infants on mortality, long-term neurodevelopmental disability and clinically important side effects.

SEARCH STRATEGY

The standard search strategy of the Neonatal Review Group as outlined in The Cochrane Library (Issue 2, 2007) was used. Randomised controlled trials evaluating therapeutic hypothermia in term newborns with hypoxic ischaemic encephalopathy were identified by searching the Oxford Database of Perinatal Trials, the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2007), MEDLINE (1966 to June 2007), previous reviews including cross-references, abstracts, conferences, symposia proceedings, expert informants and journal hand searching.

SELECTION CRITERIA

Randomised controlled trials comparing the use of therapeutic hypothermia with standard care in encephalopathic newborn infants with evidence of peripartum asphyxia and without recognisable major congenital anomalies were included. The primary outcome measure was death or long-term major neurodevelopmental disability. Other outcomes included adverse effects of cooling and 'early' indicators of neurodevelopmental outcome.

DATA COLLECTION AND ANALYSIS

Three review authors independently selected, assessed the quality of and extracted data from the included studies. Authors were contacted for further information. Meta-analyses were performed using relative risk and risk difference for dichotomous data, and weighted mean difference for continuous data with 95% confidence intervals.

MAIN RESULTS

Eight randomised controlled trials were included in this review, comprising 638 term infants with moderate/ severe encephalopathy and evidence of intrapartum asphyxia. Therapeutic hypothermia resulted in a statistically significant and clinically important reduction in the combined outcome of mortality or major neurodevelopmental disability to 18 months of age [typical RR 0.76 (95% CI 0.65, 0.89), typical RD -0.15 (95% CI -0.24, -0.07), NNT 7 (95% CI 4, 14)]. Cooling also resulted in statistically significant reductions in mortality [typical RR 0.74 (95% CI 0.58, 0.94), typical RD -0.09 (95% CI -0.16, -0.02), NNT 11 (95% CI 6, 50)] and in neurodevelopmental disability in survivors [typical RR 0.68 (95% CI 0.51, 0.92), typical RD -0.13 (95% CI -0.23, -0.03), NNT 8 (95% CI 4, 33)]. Some adverse effects of hypothermia included an increase in the need for inotrope support of borderline significance and a significant increase in thrombocytopaenia.

AUTHORS' CONCLUSIONS

There is evidence from the eight randomised controlled trials included in this systematic review (n = 638) that therapeutic hypothermia is beneficial to term newborns with hypoxic ischaemic encephalopathy. Cooling reduces mortality without increasing major disability in survivors. The benefits of cooling on survival and neurodevelopment outweigh the short-term adverse effects. However, this review comprises an analysis based on less than half of all infants currently known to be randomised into eligible trials of cooling. Incorporation of data from ongoing and completed randomised trials (n = 829) will be important to clarify the effectiveness of cooling and to provide more information on the safety of therapeutic hypothermia, but could also alter these conclusions. Further trials to determine the appropriate method of providing therapeutic hypothermia, including comparison of whole body with selective head cooling with mild systemic hypothermia, are required.

Anastomotic devices for coronary artery bypass grafting: Technological options and potential pitfalls

With the advent of off-pump coronary artery bypass grafting and minimally invasive coronary artery bypass grafting, significant efforts have been made to facilitate construction of the graft to coronary anastomosis. As a result, a number of anastomotic devices have been developed. While the ideal anastomotic device should be easy to use, to produce a geometrically optimal anastomosis with minimal endothelial damage and minimal blood-exposed non-intimal surface, a number of design constraints apply. This review collects the available pre-clinical and clinical data for some of the devices with special regard for surgical outcome, patency rate and the need for additional perioperative anticoagulation treatment.

Influence of intraoperative opioid on postoperative pain and pulmonary function after laparoscopic gastric banding: remifentanil TCI vs sufentanil TCI in morbid obesity

BACKGROUND

Choice of opioid may influence postoperative pain, recovery, and respiratory homeostasis in morbid obesity. The aim of this study was to compare the effects of target-controlled infusions (TCIs) of remifentanil or sufentanil on postoperative analgesia, recovery, and pulmonary function after laparoscopic gastric banding.

METHODS

Forty morbidly obese patients undergoing laparoscopic gastric banding received BIS-guided desflurane anaesthesia combined with remifentanil TCI (Group R) or sufentanil TCI (Group S). Intraoperative haemodynamic stability, BIS controllability, and immediate recovery in the operating room were measured. Pulmonary function, modified Aldrete score, modified Observers Assessment of Alertness and Sedation score, blood gas analysis, and visual analogue score for pain and postoperative nausea and vomiting were measured on admission to the post-anaesthesia care unit and 30, 60, 120 min afterwards. After operation, patients received patient-controlled analgesia with morphine.

RESULTS

During the first two postoperative hours, cumulative morphine consumption was higher in the remifentanil group compared with the sufentanil group, but was equal values after that time. Recovery profiles and spirometry showed no significant differences. During maintenance, remifentanil gave a better haemodynamic stability.

CONCLUSIONS

As few differences occurred in the postoperative period, the theoretical advantage of remifentanil over the longer acting sufentanil can be questioned when using TCI technology.

Is wheezing associated with decreased sleep quality in Sri Lankan children? A questionnaire study

AIM

To investigate the association between wheezing and impaired sleep in Sri Lankan children, aged 6-12 years; and, to report the prevalence of asthma-related symptoms in these subjects.

METHODS

The International Study of Asthma and Allergies in Childhood questionnaire and a separate sleep questionnaire were completed.

RESULTS

Of 800 originally distributed questionnaires, 652 were analyzed. Wheezing was present in 89 children (14%). Within this group, 66% reported wheezing in the last 12 months. Wheezing children had a significantly higher presence of snoring, restless sleep, nocturnal awakenings and daytime tiredness. Wheezing was found to be independently associated with restless sleep (odds ratio (OR) = 2.4). There was no association between wheezing and difficulties falling asleep, nocturnal awakenings, apneas, and daytime sleepiness and tiredness. After adjusting for possible confounders, the following significant associations were present: snoring and apneas (OR = 1.6), chronic rhinitis and apneas (OR = 1.6), snoring and restless sleep (OR = 3.2), chronic rhinitis and restless sleep (OR = 2.1), and hayfever and daytime tiredness (OR = 4.3). Wheezing was related to an increased risk of snoring (OR = 2.8) and subjects with chronic rhinitis had also an increased risk of snoring (OR = 1.7), adjusting for possible confounders.

CONCLUSION

The sleep of wheezing children was impaired compared with their non-wheezing peers, resulting in an increased prevalence of daytime tiredness. Upper airway symptoms, such as chronic rhinitis or hayfever, should be carefully considered in these children, as they might be responsible for these sleep problems.

Exposure to pets and the risk of allergic symptoms during the first 2 years of life

BACKGROUND

Currently, there is a lack of consensus regarding the influence of household pets on the development of allergic diseases in childhood.

OBJECTIVE

The aim of this birth cohort study was to analyze the relationship between pet ownership at time of birth and the prevalence of atopic diseases approximately 2 years later.

METHODS

A few days after the delivery of their babies, we asked 3132 mothers of German nationality whether they kept household pets like dogs, cats, or birds. Two years later, we asked whether their children had developed bronchial asthma, eczema, or hay fever. We then used logistic regression models to analyze whether there was an association between the development of allergic reactions among the children and pet ownership at the time of birth.

RESULTS

In families without a history of atopic disease, the prevalence of asthma and eczema among 2-year-old children was significantly lower in those families that owned a dog at the time the children were born (odds ratio [OR], 0.52; 95% confidence interval [CI], 0.33-0.83). In contrast, in families with a history of atopic disease, early dog exposure was associated with a higher prevalence of asthma and eczema in 2-year-old children (OR, 1.43; 95% CI, 0.95-2.15). Comparable analyses assessing the influence of cats and birds in the home showed no effect on the development of atopic diseases in early childhood.

CONCLUSIONS

This study confirms the findings of several earlier studies suggesting a negative association between dog ownership and the development of atopic diseases in early childhood, although the effect was only observed in families without a history of atopic disorders.

Regulation of pri-microRNA BIC transcription and processing in Burkitt lymphoma

BIC is a primary microRNA (pri-miR-155) that can be processed to mature miR-155. In this study, we show the crucial involvement of protein kinase C (PKC) and nuclear factor-kappaB (NF-kappaB) in the regulation of BIC expression upon B-cell receptor triggering. Surprisingly, Northern blot analysis did not reveal any miR-155 expression upon induction of BIC expression in the Burkitt lymphoma-derived Ramos cell line, whereas other microRNAs were clearly detectable. Ectopic expression of BIC in Ramos and HEK293 cells resulted in miR-155 expression in HEK293, but not in Ramos cells, suggesting a specific block of BIC to miR-155 processing in Ramos. In line with the results obtained with Ramos, lack of miR-155 expression after induction of BIC expression was also observed in other Burkitt lymphoma cell lines, indicating a generic and specific blockade in the processing of BIC in Burkitt lymphoma. In contrast, induction of BIC expression in normal tonsillar B cells resulted in very high levels of miR-155 expression and induction of BIC expression in Hodgkin's lymphoma cell lines. It also resulted in elevated levels of miR-155. Our data provide evidence for two levels of regulation for mature miR-155 expression: one at the transcriptional level involving PKC and NF-kappaB, and one at the processing level. Burkitt lymphoma cells not only express low levels of BIC, but also prevent processing of BIC via an, as yet, unknown mechanism.

Outcome after three years of laronidase enzyme replacement therapy in a patient with Hurler syndrome

Enzyme replacement therapy (ERT) with laronidase, recombinant alpha-L-iduronidase, for mucopolysaccharidosis type I (MPS I) has been clinically available since April 2003. Pre-approval studies were performed on patients with the more attenuated forms of MPS I, Hurler-Scheie and Scheie syndromes. The clinical efficacy of laronidase on the severe form of MPS I, Hurler syndrome, is not well known. We present a patient with Hurler syndrome who has been treated with laronidase for 3 years. Clinically, the patient demonstrated improvement in urinary glycosaminoglycan (GAG) levels and hepatomegaly, but continued to experience decline in respiratory status, musculoskeletal and spinal involvement, and developmental skills. Overall, the benefit of ERT with laronidase in advanced Hurler syndrome appeared to be minimal in this patient.