Outcomes and predicting response in anaemic chemotherapy patients treated with epoetin alfa. A multicentre, 4-month, open-label study in Australia and New Zealand

BACKGROUND

The aim of the study was to evaluate the effectiveness, safety, and clinical outcomes of erythropoietin therapy in the treatment of anaemic cancer subjects receiving chemotherapy and to examine hypochromic red blood cell measurement as an indicator of functional iron sufficiency and as a predictor of responsiveness or non-responsiveness to erythropoietin therapy.

METHODS

Patients who had a non-myeloid malignancy, had Hb < or = 11.0 g/dL, had a life expectancy of more than 6 months, were 18 years or older, were receiving chemotherapy and would continue to be treated for at least 2 months were given s.c. epoetin alfa three times a week.

RESULTS

Haemoglobin levels increased significantly at all time periods compared with baseline and the number of transfusions received decreased significantly at all time periods compared with baseline. Quality of life as measured by Functional Assessment of Cancer Therapy-Anaemia showed significant increases at months 2 and 4 and there were significant improvements in the fatigue subscale at both time points (P < 0.05). Significant improvements at end-point were observed for the physical, emotional and functional well-being, and additional concern subscales (all P < 0.05). Haematocrit and reticulocytes increased significantly at end-point compared with at baseline (haematocrit 33.4 vs 28.3%, P < 0.001; reticulocytes 105.8 vs 78.6 x 10(9)/dL, P = 0.005). The percentage of hypochromic red blood cells did not show predictive value for response to treatment status.

CONCLUSION

Epoetin alfa improved haemoglobin levels and quality of life in anaemic cancer patients receiving chemotherapy.

A multi-centre survey of inpatient pharmacological management strategies for alcohol withdrawal

BACKGROUND

It is well recognized that alcohol is a growing problem in the UK with significant morbidity and mortality and associated resource implications for the National Health Service (NHS). The inpatient management of alcohol withdrawal is felt to be variable between hospitals. The aim of this study was to assess the variation in pharmacological management and acute inpatient alcohol services across NHS hospitals in the UK.

METHOD

A web-based survey was distributed to Society for Acute Medicine (SAM) members and others with an interest in Acute Medicine between January and March 2008.

RESULTS

The results suggest poor utilization of guidelines, variable drug regimens and differences in acute alcohol-related support services.

CONCLUSION

In response to these findings, we suggest that a simplified national approach is required for what is now recognized to be an epidemic problem.

Isomer-specific effects of CLA on gene expression in human adipose tissue depending on PPARgamma2 P12A polymorphism: a double blind, randomized, controlled cross-over study

BACKGROUND

Peroxisome proliferator-activated receptor (PPAR)gamma is a key regulator in adipose tissue. The rare variant Pro12Ala of PPARgamma2 is associated with a decreased risk of insulin resistance. Being dietary PPARgamma ligands, conjugated linoleic acids (CLAs) received considerable attention because of their effects on body composition, cancer, atherosclerosis, diabetes, obesity and inflammation, although some effects were only demonstrated in animal trials and the results in human studies were not always consistent. In the present study effects of CLA supplementation on genome wide gene expression in adipose tissue biopsies from 11 Ala12Ala and 23 Pro12Pro men were investigated. Subjects underwent four intervention periods (4 wk) in a randomized double blind cross-over design receiving 4.25 g/d of either cis-9, trans-11 CLA, trans-10,cis-12 CLA, 1:1 mixture of both isomers or a reference linoleic acid oil preparation. After each intervention biopsies were taken, whole genome expression microarrays were applied, and genes of interest were verified by realtime PCR.

RESULTS

The following genes of lipid metabolism were regulated by CLA: LDLR, FASN, SCD, FADS1 and UCP2 were induced, while ABCA1, CD36 and CA3 were repressed. Transcription factors PPARgamma, NFAT5, CREB5 and EBF1, the adipokine NAMPT, members of the insulin signaling cascade SORBS1 and IGF1 and IL6ST were repressed, while the adipokine THBS1 and GLUT4 involved in insulin signaling were induced. Compared to trans-10,cis-12 CLA and the CLA mixture the cis-9, trans-11 CLA isomer exerted weaker effects. Only CD36 (-1.2 fold) and THBS1 (1.5 fold) were regulated. The CLA effect on expression of PPARgamma and leptin genes depends on the PPARgamma2 genotype.

CONCLUSION

The data suggest that the isomer specific influence of CLA on glucose and lipid metabolism is genotype dependent and at least in part mediated by PPARgamma.

TRIAL REGISTRATION

http://www.controlled-trials.com: ISRCTN91188075.

Improvement in out-of-hours outcomes following the implementation of Hospital at Night

BACKGROUND

Hospital at Night (H@N) is a Department of Health (England) driven programme being widely implemented across UK. It aims to redefine how medical cover is provided in hospitals during the out-of-hours period.

AIM

To investigate whether the implementation of H@N is associated with significant change in system or clinical outcomes.

DESIGN

An observational study for 14 consecutive nights before, and 14 consecutive nights after the implementation of H@N. Data were collected from the Combined surgical and medical Assessment Unit (CAU), the 18 medical/surgical wards (The Ward Arc) and the four High Dependency Units (The Critical Care corridor) within the Royal Infirmary of Edinburgh.

METHODS

Following an overnight episode of clinical concern, data were gathered on response time, seniority of reviewing staff, patient outcome and the use of Standardized Early Warning Score (SEWS).

RESULTS

Two hundred and nine episodes of clinical concern were recorded before the implementation of H@N and 216 episodes afterwards. There was no significant change in response time in the CAU, Ward Arc or Critical Care corridor. However, significant inter-speciality differences in response time were eradicated, particularly in the Critical Care corridor. Following the implementation of H@N, patients were reviewed more frequently by senior medical staff in CAU (28% vs. 4%, P < 0.05) and the Critical Care corridor (50% vs. 22%, P < 0.001). Finally there was a reduction in adverse outcome (defined as unplanned transfer to critical care/cardiac arrest) in the Ward Arc and CAU from 17% to 6% of patients reviewed overnight (P < 0.01). SEWS was more frequently and accurately recorded in CAU.

CONCLUSION

This is the first study that we are aware of directly comparing out-of-hours performance before and after the implementation of H@N. Significant improvements in both patient and system outcomes were observed, with no adverse effects noted.

Angiography postclipping and coiling of cerebral aneurysms

Postclipping cerebral angiography is generally not practised in the UK. The International Subarachnoid Trial (ISAT) data show that coiling compared favourably with clipping in the early posttreatment phase. We present a 4-year, single unit experience comparing cerebral angiography at 6 months postclipping and postcoiling, defining the proportion of aneurysms in either group, which were incompletely excluded from the cerebral circulation after treatment. There were 4 'dog-ear' remnants (4.6%) in the clipping group of 86 aneurysms, one of which required further surgery. Thirty-one out of 82 (37.8%) coiled aneurysms that underwent check angiography were inadequately excluded from the cerebral circulation at 6 months. Of these, to date, four patients have undergone re-coiling. Although the immediate complications of coiling may be less than those of clipping (ISAT), it seems that the degree and permanence of exclusion of an aneurysm from the cerebral circulation may be more secure with surgery. In summary, the rates of incomplete aneurysmal exclusion from the cerebral circulation, the requirement for reintervention and the requirement for continuing surveillance were all higher in the coiled population than in the clipped population.

Posterolateral spinal fusion in a rabbit model using a collagen-mineral composite bone graft substitute

Choosing the appropriate graft material to participate in the healing process in posterolateral spinal fusion continues to be a challenge. Combining synthetic graft materials with bone marrow aspirate (BMA) and autograft is a reasonable treatment option for surgeons to potentially reduce or replace the need for autograft. FormaGraft, a bone graft material comprising 12% bovine-derived collagen and 88% ceramic in the form of hydroxyapatite (HAp) and beta tricalcium phosphate (beta-TCP) was evaluated in three possible treatment modalities for posterior spinal fusion in a standard rabbit model. These three treatment groups were FormaGraft alone, FormaGraft soaked in autogenous BMA, and FormaGraft with BMA and iliac crest autograft. No statistically demonstrable benefits or adverse effects of the addition of BMA were found in the current study based on macroscopic, radiology or mechanical data. This may reflect, in part, the good to excellent results of the collagen HA/TCP composite material alone in a well healing bony bed. Histology did, however, reveal a benefit with the use of BMA. Combining FormaGraft with autograft and BMA achieved results equivalent to autograft alone. The mineral and organic nature of the material provided a material that facilitated fusion between the transverse processes in a standard preclinical posterolateral fusion model.

Inhibition of androstenediol-dependent LNCaP tumour growth by 17alpha-ethynyl-5alpha-androstane-3alpha, 17beta-diol (HE3235)

Androst-5-ene-3β, 17β-diol (AED) is an adrenal hormone that has been reported to sustain prostate cancer growth after androgen deprivation therapy (ADT). LNCaP cells express a mutated androgen receptor that confers the ability to respond not only to androgen but also to oestrogen and adrenal hormones such as AED, and thus provide a cell line useful for identifying compounds capable of inhibiting AED-stimulated cell growth. We sought to determine whether structurally related steroids could inhibit AED-stimulated LNCaP cell growth in vitro and tumour growth in vivo. We report here the identification of a novel androstane steroid, HE3235 (17α-ethynyl-5α-androstan-3α, 17β-diol), with significant inhibitory activity for AED-stimulated LNCaP proliferation. This inhibitory activity is accompanied by an increase in the number of apoptotic cells. Animal studies have confirmed the cytoreductive activity of HE3235 on LNCaP tumours. The results suggest that this compound may be of clinical use in castration-resistant prostate cancer.

Assessment of clinical risk in the out of hours hospital prior to the introduction of Hospital at Night

Overnight medical cover in hospital is less than during daylight hours. We aimed to quantify the numbers of patients deteriorating overnight and their clinical outcome. Data was collected in real time on use of the Standardised Early Warning Score (SEWS), 'time to doctor', seniority of medical review and clinical outcome. 136 incidents of clinical concern were noted on the general wards with a median response time of 5 minutes for SEWS>4 and 10 minutes if SEWS<4. 159 incidents were recorded in critical care. There was significant inter-speciality variation in median response times and seniority of responding staff, particularly within critical care, which recorded the slowest times across the hospital. This will be reassessed following the establishment of Hospital at Night.

Providing better care for patients with complex needs in acute medicine

Patients with complex needs are commonly admitted on the acute medical take and comprise a significant proportion of the workload for an acute physician. An innovative multi-professional approach to the assessment of this group of patients has been developed in Edinburgh; this paper summarises the results of a 4 week review of data collected on patients assessed by the multiprofessional team on the Medical Assessment Unit at Edinburgh Royal Infirmary.

Intermedin (adrenomedullin-2): a novel counter-regulatory peptide in the cardiovascular and renal systems

Intermedin (IMD) is a novel peptide related to calcitonin gene-related peptide (CGRP) and adrenomedullin (AM). Proteolytic processing of a larger precursor yields a series of biologically active C-terminal fragments, IMD(1-53), IMD(1-47) and IMD(8-47). IMD shares a family of receptors with AM and CGRP composed of a calcitonin-receptor like receptor (CALCRL) associated with one of three receptor activity modifying proteins (RAMP). Compared to CGRP, IMD is less potent at CGRP(1) receptors but more potent at AM(1) receptors and AM(2) receptors; compared to AM, IMD is more potent at CGRP(1) receptors but less potent at AM(1) and AM(2) receptors. The cellular and tissue distribution of IMD overlaps in some aspects with that of CGRP and AM but is distinct from both. IMD is present in neonatal but absent or expressed sparsely, in adult heart and vasculature and present at low levels in plasma. The prominent localization of IMD in hypothalamus and pituitary and in kidney is consistent with a physiological role in the central and peripheral regulation of the circulation and water-electrolyte homeostasis. IMD is a potent systemic and pulmonary vasodilator, influences regional blood flow and augments cardiac contractility. IMD protects myocardium from the deleterious effects of oxidative stress associated with ischaemia-reperfusion injury and exerts an anti-growth effect directly on cardiomyocytes to oppose the influence of hypertrophic stimuli. The robust increase in expression of the peptide in hypertrophied and ischaemic myocardium indicates an important protective role for IMD as an endogenous counter-regulatory peptide in the heart.

NPY and cardiac diseases

Hypertension-induced left ventricular hypertrophy (LVH), along with ischemic heart disease, result in LV remodeling as part of a continuum that often leads to congestive heart failure. The neurohormonal model has been used to underpin many treatment strategies, but optimal outcomes have not been achieved. Neuropeptide Y (NPY) has emerged as an additional therapeutic target, ever since it was recognised as an important mediator released from sympathetic nerves in the heart, affecting coronary artery constriction and myocardial contraction. More recent interest has focused on the mitogenic and hypertrophic effects that are observed in endothelial and vascular smooth muscle cells, and cardiac myocytes. Of the six identified NPY receptor subtypes, Y(1), Y(2) and Y(5) appear to mediate the main functional responses in the heart. Plasma levels of NPY become elevated due to the increased sympathetic activation present in stress-related cardiac conditions. Also, NPY and Y receptor polymorphisms have been identified that may predispose individuals to increased risk of hypertension and cardiac complications. This review examines what understanding exists regarding the likely contribution of NPY to cardiac pathology. It appears that NPY may play a part in compensatory or detrimental remodeling of myocardial tissue subsequent to hemodynamic overload or myocardial infarction, and in angiogenic processes to regenerate myocardium after ischemic injury. However, greater mechanistic information is required in order to truly assess the potential for treatment of cardiac diseases using NPY-based drugs.

Invasive Cryptococcus neoformans infection in an asplenic patient

Individuals who are asplenic or have impaired splenic function are at increased risk of developing life-threatening infections, especially due to encapsulated bacteria. This risk is higher in children, but adults can also develop fulminant infection or "post splenectomy sepsis" (PSS). Cryptococcus neoformans is an encapsulated yeast usually causing infection in immunocompromised patients. In a recent review of cryptococcal infection in HIV-negative patients, splenectomy was reported to be a risk factor for infection in 3% of cases. Detailed case reports are lacking. Here we report a case of disseminated C. neoformans infection in a patient who had a splenectomy performed for warm autoantibody haemolytic anaemia some months before he presented with signs and symptoms of meningitis. This report aims to raise awareness of the possibility of C. neoformans infection in asplenic patients.