Anti-interleukin-5 antibody treatment (mepolizumab) in active eosinophilic oesophagitis: a randomised, placebo-controlled, double-blind trial

OBJECTIVE

Eosinophilic oesophagitis (EoO) is a clinicopathological condition defined by proton pump inhibitor-refractory oesophageal symptoms combined with oesophageal eosinophilia. The pharmacodynamic effect of mepolizumab (a humanised anti-interleukin-5 monoclonal antibody) in EoO was evaluated.

METHODS

Eleven adults with active EoO (>20 peak eosinophil number/high power field (hpf) and dysphagia) were randomised to 750 mg of mepolizumab (n = 5) or placebo (n = 6) and received two intravenous infusions, 1 week apart. Those not in complete remission (<5 peak eosinophil number/hpf) after 8 weeks received two further doses 4 weeks apart, 1500 mg of mepolizumab or placebo. The effect of mepolizumab was assessed clinically, endoscopically, histologically, and via blood and tissue biomarkers.

RESULTS

As assessed by immunofluorescence, a marked reduction of mean oesophageal eosinophilia (p = 0.03) was seen in the mepolizumab group (-54%) compared with the placebo group (-5%) 4 weeks after initiation of treatment. No further reduction of eosinophil numbers was observed in response to the two additional infusions in either group. Mepolizumab reduced tenascin C (p = 0.033) and transforming growth factor beta1 (p = 0.05) expression in the oesophageal epithelial layer 13 weeks after initiation of treatment. Clinically, limited improvement of symptoms was seen, although a trend was seen between 4 and 13 weeks after initiation of mepolizumab treatment. Mepolizumab was well tolerated.

CONCLUSIONS

Mepolizumab significantly reduced eosinophil numbers in oesophageal tissues in adult patients with active EoO, and changes in the expression of molecules associated with oesophageal remodelling were reversed. Minimal clinical improvement was achieved in a subgroup of patients with EoO. Mepolizumab had an acceptable safety profile, even at the high 1500 mg dose level.

TRIAL REGISTRATION NUMBER

NCT00274703.

Long-term activation of the pro-coagulant response after neoadjuvant chemoradiation and major cancer surgery

Background:

The association between cancer, major surgery and venous thromboembolism (VTE) is well established. Multimodal therapy is increasingly being used as standard treatment for localised gastrointestinal cancer. The aim of this study was to examine the markers of pro-coagulation response and VTE risk in an exemplar multimodal model of pre-operative combination chemotherapy and radiation therapy, followed by complex cancer surgery.

Methods:

Consecutive patients (n=36) with localised oesophageal cancer were studied at baseline after the first and second cycles of chemoradiation, and on post-operative days 1–28, and at 3, 6 and 9 months. Factors regulating the pro- and anti-coagulant response, as well as pro-inflammatory markers including NFκB activation in peripheral blood mononuclear cells, were examined. All patients received enoxaparin 40 mg s.c. postoperatively up to discharge, and underwent pulmonary CT-pulmonary angiography and venography on day 10 postoperatively.

Results:

Four (11%) non-fatal thromboembolic events were documented, all after hospital discharge. Neoadjuvant therapy before surgery activated factor VIII (FVIII) and pro-inflammatory NFκB, and increased D-dimers, pro-thrombin fragment 1+2 (F1+2) and the thrombin-anti-thrombin complex (TAT). Surgery significantly (P<0.05) increased pro-thrombin time (PT), activated partial thromboplastin time, fibrinogen, D-dimers, TAT, F1+2 and FVIII up to 6 months.

Conclusion:

These data highlight the linked pro-coagulant and immunoinflammatory pathways in the multimodal management of oesophageal cancer, and suggest that the duration of current standard thromboprophylaxis regimens warrants further study.

Effect of tailored practice and patient care plans on secondary prevention of heart disease in general practice: cluster randomised controlled trial

OBJECTIVE

To test the effectiveness of a complex intervention designed, within a theoretical framework, to improve outcomes for patients with coronary heart disease.

DESIGN

Cluster randomised controlled multicentre trial.

SETTING

General practices in Northern Ireland and the Republic of Ireland, regions with different healthcare systems.

PARTICIPANTS

903 patients with established coronary heart disease registered with one of 48 practices.

INTERVENTION

Tailored care plans for practices (practice based training in prescribing and behaviour change, administrative support, quarterly newsletter), and tailored care plans for patients (motivational interviewing, goal identification, and target setting for lifestyle change) with reviews every four months at the practices. Control practices provided usual care.

MAIN OUTCOME MEASURES

The proportion of patients at 18 month follow-up above target levels for blood pressure and total cholesterol concentration, and those admitted to hospital, and changes in physical and mental health status (SF-12).

RESULTS

At baseline the numbers (proportions) of patients above the recommended limits were: systolic blood pressure greater than 140 mm Hg (305/899; 33.9%, 95% confidence interval 30.8% to 33.9%), diastolic blood pressure greater than 90 mm Hg (111/901; 12.3%, 10.2% to 14.5%), and total cholesterol concentration greater than 5 mmol/l (188/860; 20.8%, 19.1% to 24.6%). At the 18 month follow-up there were no significant differences between intervention and control groups in the numbers (proportions) of patients above the recommended limits: systolic blood pressure, intervention 98/360 (27.2%) v control, 133/405 (32.8%), odds ratio 1.51 (95% confidence interval 0.99 to 2.30; P=0.06); diastolic blood pressure, intervention 32/360 (8.9%) v control, 40/405 (9.9%), 1.40 (0.75 to 2.64; P=0.29); and total cholesterol concentration, intervention 52/342 (15.2%) v control, 64/391 (16.4%), 1.13 (0.63 to 2.03; P=0.65). The number of patients admitted to hospital over the 18 month study period significantly decreased in the intervention group compared with the control group: 107/415 (25.8%) v 148/435 (34.0%), 1.56 (1.53 to 2.60; P=0.03).

CONCLUSIONS

Admissions to hospital were significantly reduced after an intensive 18 month intervention to improve outcomes for patients with coronary heart disease, but no other clinical benefits were shown, possibly because of a ceiling effect related to improved management of the disease.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN24081411.

Characterization of polymorphic microsatellite DNA markers in Hakea oldfieldii Benth. (Proteaceae)

A genomic library was constructed and 13 polymorphic microsatellite markers were developed for Hakea oldfieldii, a woody shrub endemic to southwest Western Australia. Polymorphism was investigated for these markers in 28 individuals from a single population located in restricted habitat at the base of the Whicher Range south of Busselton. Expected heterozygosity ranged from 0.279 to 0.770 and averaged 0.633. Observed heterozygosity ranged from 0.321 to 0.786 and averaged 0.598. The number of alleles per locus ranged from 2.0 to 6.0 and averaged 4.5. These markers will be used to assay genetic diversity and pollen dispersal in this species.

Expanding the value of qualitative theories of illness experience in clinical practice: a grounded theory of secondary heart disease prevention

Qualitative theories of illness experience are about the individual interpretations of the psychosocial and cultural aspects of living with illness. Thus, they contribute to a better understanding of health and health care provision. In this paper, we examine how a grounded theory (GT) of heart disease experience can inform secondary prevention. In-depth interviews of individual experience of heart disease were conducted with 26 patients, using GT iterative data collection and analysis framework. A GT was compiled from data and examined within a sociocultural framework to ascertain how experience influenced health behaviour. Despite individual contextual variations, the theory of 'keeping it going' describes the study sample's common attitude to living with heart disease. The theory was adequate in explaining secondary cardiac behaviour, because it identified the aspects of patients' beliefs and attitudes which are key to effective secondary prevention. The assessment of the impact of illness experience on health behaviour within a sociocultural framework helped to articulate the strong influence of social and contextual factors. The study offers an appropriate explanatory framework for encouraging health behaviour change. It emphasizes the importance of interventions being relevant to individual perceptions and interpretations. It provides a framework for designing and evaluating cardiac interventions and the theoretical principles which underpin them.

Characterization of polymorphic microsatellite DNA markers in Banksia nivea, formerly Dryandra nivea

A genomic library was constructed and 10 novel polymorphic microsatellite markers were developed for Banksia nivea subsp. uliginosa, a woody shrub endemic to the southwest of Western Australia. Polymorphism was investigated for these markers in 30 individuals from one population located in restricted habitat at the base of the Whicher Range east of Busselton. Expected heterozygosity ranged from 0.124 to 0.898 and averaged 0.570. Observed heterozygosity ranged from 0.133 to 0.933 and averaged 0.544. The number of alleles per locus ranged from 2.0 to 16.0 and averaged 7.3. These markers also produced amplification products in three other Banksia species and will be used to assay genetic diversity in these species.

Birth of a biome: insights into the assembly and maintenance of the Australian arid zone biota

The integration of phylogenetics, phylogeography and palaeoenvironmental studies is providing major insights into the historical forces that have shaped the Earth's biomes. Yet our present view is biased towards arctic and temperate/tropical forest regions, with very little focus on the extensive arid regions of the planet. The Australian arid zone is one of the largest desert landform systems in the world, with a unique, diverse and relatively well-studied biota. With foci on palaeoenvironmental and molecular data, we here review what is known about the assembly and maintenance of this biome in the context of its physical history, and in comparison with other mesic biomes. Aridification of Australia began in the Mid-Miocene, around 15 million years, but fully arid landforms in central Australia appeared much later, around 1-4 million years. Dated molecular phylogenies of diverse taxa show the deepest divergences of arid-adapted taxa from the Mid-Miocene, consistent with the onset of desiccation. There is evidence of arid-adapted taxa evolving from mesic-adapted ancestors, and also of speciation within the arid zone. There is no evidence for an increase in speciation rate during the Pleistocene, and most arid-zone species lineages date to the Pliocene or earlier. The last 0.8 million years have seen major fluctuations of the arid zone, with large areas covered by mobile sand dunes during glacial maxima. Some large, vagile taxa show patterns of recent expansion and migration throughout the arid zone, in parallel with the ice sheet-imposed range shifts in Northern Hemisphere taxa. Yet other taxa show high lineage diversity and strong phylogeographical structure, indicating persistence in multiple localised refugia over several glacial maxima. Similar to the Northern Hemisphere, Pleistocene range shifts have produced suture zones, creating the opportunity for diversification and speciation through hybridisation, polyploidy and parthenogenesis. This review highlights the opportunities that development of arid conditions provides for rapid and diverse evolutionary radiations, and re-enforces the emerging view that Pleistocene environmental change can have diverse impacts on genetic structure and diversity in different biomes. There is a clear need for more detailed and targeted phylogeographical studies of Australia's arid biota and we suggest a framework and a set of a priori hypotheses by which to proceed.

A randomized trial of capecitabine (C) given intermittently (IC) rather than continuously (CC) compared to classical CMF as first-line chemotherapy for advanced breast cancer (ABC)

1031

Background: Intensive treatment is not indicated for many women having first line chemotherapy for ABC. We sought to determine for such women whether oral C was preferable to classical CMF, and whether C given continuously (CC) was preferable to the same total dose given intermittently for 14 of every 21 days (IC). Methods: 325 women were randomized between June 01 and July 05 to either IC (2,000mg/m2/d for 14 of every 21d), or CC (1,300mg/m2/d for 21 of every 21d), or CMF (cyclophosphamide 100mg/m2/d p.o. d1–14; methotrexate 40mg/m2 and 5-FU 600mg/m2, IV d1&8, every 28d). Treatment was continued until disease progression (PD), unacceptable toxicity, or intolerance. Clinical and quality of life (QOL) assessments were 3–4 wkly, and imaging was 3 monthly, both until PD. The primary endpoint was quality adjusted progression-free survival (QAPFS). Overall survival (OS), PFS, response rates (RR=CR+PR), QOL, acceptability of chemotherapy and adverse events (AE) were secondary endpoints. The analysis plan was to first compare IC v CC, and if p>0.05, then to combine the two arms (C = IC + CC) for comparisons v CMF. Primary analyses were with the logrank test. Cox’s models were used to calculate hazard ratios (HR), 95% confidence intervals (CI), and to adjust for other factors. All p-values and CI are 2-sided. Results: OS was longer with C than CMF (HR .72, CI .55 to .94, p=.02, medians 22 v 18 mo). PFS was similar for C and CMF overall (HR .86, CI .67 to 1.1, p=.2, median 7 mo), and over the first 6 mo (HR 1.15, CI .81 to 1.6), but longer on C than CMF beyond 6 mo (HR .62, CI .44 to .87). Response rates were similar on C and CMF (21% v 18%, p=.8). Febrile neutropenia, infection, and sore mouth were more common on CMF; hand-foot syndrome was more common on C. Chemotherapy was continued beyond 6 mo in 40% on C but only 21% on CMF. PFS, OS, RR and AE were similar for IC and CC (p>0.4). Cox’s models adjusting for baseline factors corroborated all results and conclusions. Analyses of QAPFS, QOL, and acceptability of chemotherapy will be available in June 07. Conclusion: C improved overall survival with less toxicity and greater tolerability than classical CMF. C is a good first line option when more intensive treatment is not indicated.

[Table: see text]

Differential response of factor VIII and protein C expression following multimodal therapy for esophageal carcinoma

15106

Background: Tumour growth is associated with development of a hypercoaguable state and increased risk of thrombosis. Factor VIII plasma concentration has been shown to be an independent and dose-dependant risk factor for venous thromboembolism. Von Willebrand factor, the carrier molecule of circulating FVIII is expressed by vascular endothelial cells and in vitro observations indicate that chemotherapy induces endothelial damage with subsequent dysfunction. This study assessed FVIII, Protein C and Protein S response following multi modal therapy for oesophageal carcinoma. Methods: Fifty oesophageal cancer patients were studied, (multimodal n= 25, surgery only, n=25), at time points 0 (pre-operatively, following the first and final cycles of chemoradiation, and on days 1, 3, 7, 14, 21 and 28 days, and at 3 and 6 months postoperatively. Blood samples were collected and centrifuged at 3000g for 20 minutes to botain platelet poor plasmad. Factor VIII levels were measured by one stage clotting assay with factor VIII-deficient plasma. Automated functional assays for Protein C and Protein S in plasma were performed. Results: Factor FVIII levels were significantly elevated in the multimodal cohort following the 1st (p<0.008) and 2nd (p<0.001) cycles of chemoradiotherapy and at all time points following surgery, compared to baseline readings (p<0.001). Similar elevation was noted in the surgery only patients. No significant difference in factor FVIII levels between the multimodal group and surgery only patients was seen, except on day 21 (p < 0.04). Preliminary findings indicate a significant difference between the multimodal and surgery only cohorts in Protein C (0.74–1.32 IU/ml) levels (p < 0.05) at two timepoints. Conclusion: Factor VIII serum levels are significantly elevated following preoperative chemoradiotherapy. The pattern of response post oesophagectomy did not differ between the two cohorts. Elevated levels are a risk factor for both primary and recurrent venous thrombolism. The precise pathogenetic mechanism and cause of this elevation remains to be elucidated. Further studies investigating Protein C activity and, relating Factor VIII to thrombosis and inflammation in the oesophageal cancer patient are required.

No significant financial relationships to disclose.

Extensive pollen dispersal in a bird-pollinated shrub,Calothamnus quadrifidus, in a fragmented landscape

Pollen dispersal was investigated in six populations of Calothamnus quadrifidus, a bird-pollinated shrub in the fragmented agricultural region of southern Western Australia. Paternity analysis using six microsatellite loci identified a pollen source within populations for 67% of seedlings, and the remainder were assumed to have arisen from pollen sources outside the populations. Outcrossing was variable, ranging from 5% to 82%, and long-distance pollen dispersal was observed in all populations with up to 43% of pollen sourced from outside the populations over distances of up to 5 km. This extensive pollen immigration was positively associated with population size but not isolation. Comparison of two populations of similar size but different density showed greater internal pollination and less selfing in the denser population, suggesting an influence of density on pollinator behaviour. The study revealed extensive long-distance pollen dispersal for C. quadrifidus within this fragmented agricultural landscape and highlighted the interaction between reserve populations and isolated road verge remnants in maintaining genetic connectivity at the landscape scale.

The active evolutionary lives of echinoderm larvae

Echinoderms represent a researchable subset of a dynamic larval evolutionary cosmos. Evolution of echinoderm larvae has taken place over widely varying time scales from the origins of larvae of living classes in the early Palaeozoic, approximately 500 million years ago, to recent, rapid and large-scale changes that have occurred within living genera within a span of less than a million years to a few million years. It is these recent evolutionary events that offer a window into processes of larval evolution operating at a micro-evolutionary level of evolution of discrete developmental mechanisms. We review the evolution of the diverse larval forms of living echinoderms to outline the origins of echinoderm larval forms, their diversity among living echinoderms, molecular clocks and rates of larval evolution, and finally current studies on the roles of developmental regulatory mechanisms in the rapid and radical evolutionary changes observed between closely related congeneric species.

Phase II study of vinflunine in patients with metastatic renal cell carcinoma

PURPOSE

An open-label, multicentre, non-comparative phase II trial to determine the response rate of intravenous vinflunine as first line chemotherapy in patients with metastatic renal cell carcinoma (RCC).

PATIENTS AND METHODS

Patients with metastatic RCC were treated with vinflunine 350 mg/m2 (n = 11) or 320 mg/m2 (n = 22) administered intravenously every 21 days.

RESULTS

Out of 33 patients included in this study, one partial response was observed in the group treated at 350 mg/m2 and none in the group receiving 320 mg/m2 resulting in a response rate in this population of 9.1% (95% CI: 0.2-41.3). Median progression free survival was 5.6 months (95% CI: 2.8-14.4) for patients treated at 350 mg/m2, and 3.3 months (95% CI: 1.6-6.4) for those treated at 320 mg/m2.The median survival time was 10.4 months (95% CI: 6.8-12.4) for the whole study population. The principal toxicities were grade 3/4 neutropaenia -90.9% at 350 mg/m2 and 68.1% at 320 mg/m2, febrile neutropaenia was recorded in 3 patients (27.3%) at 350 mg/m2 and in 5 patients (22.7%) at 320 mg/m2. One episode of thromboembolic event was reported in 1 patient at each dose level.

CONCLUSION

Vinflunine given intravenously once every 3 weeks has not shown any clinically relevant activity in the management of patients with metastatic renal cell carcinoma; tolerance of the treatment was better at a dose of 320 mg/m2 than at 350 mg/m2.

Secondhand smoke exposure and risk following the Irish smoking ban: an assessment of salivary cotinine concentrations in hotel workers and air nicotine levels in bars

OBJECTIVE

To investigate whether the Irish smoking ban has had an impact on secondhand smoke (SHS) exposures for hospitality workers.

DESIGN, SETTING, AND PARTICIPANTS

Before and after the smoking ban a cohort of workers (n = 35) from a sample of city hotels (n = 15) were tested for saliva cotinine concentrations and completed questionnaires. Additionally, a random sample (n = 20) of city centre bars stratified by size (range 400-5000 square feet), were tested for air nicotine concentrations using passive samplers before and after the ban.

MAIN OUTCOME MEASURES

Salivary cotinine concentrations (ng/ml), duration of self reported exposures to secondhand smoke, air nicotine (microg/cubic metre).

RESULTS

Cotinine concentrations reduced by 69%, from 1.6 ng/ml to 0.5 ng/ml median (SD 1.29; p < 0.005). Overall 74% of subjects experienced decreases (range 16-99%), with 60% showing a halving of exposure levels at follow up. Self reported exposure to SHS at work showed a significant reduction from a median 30 hours a week to zero (p < 0.001). There was an 83% reduction in air nicotine concentrations from median 35.5 microg/m3 to 5.95 microg/m3 (p < 0.001). At baseline, three bars (16%) were below the 6.8 microg/m3 air nicotine significant risk level for lung cancer alone; at follow up this increased to 10 (53%).

CONCLUSIONS

Passive smoking and associated risks were significantly reduced but not totally eliminated. Exposure to SHS is still possible for those working where smoking is still allowed and those working where smoke may migrate from outdoor areas. Further research is required to assess the true extent and magnitude of these exposures.

A comparative study on attitudes, towards the provision of out-of-hours care, of the spouses of general practitioners participating, or not, in a rural out-of-hours co-op

Qualitative research has suggested that the stress of general practice, and that of out-of-hours care in particular, has an impact on general practitioners' (GPs') spouses. The effects on the families of practitioners, of the introduction of out-of-hours co-operatives has not been extensively studied. Our objective was to compare, between the spouses of GPs participating or not in a rural co-op, the effects of out-of-hours commitments on personal and family life. The spouses of all 125 GPs in a rural region in Ireland were sent questionnaires; 59 GPs were members of an out-of-hours co-op, 66 were engaged in traditional on-call rotas. Most questions were in statement form, to which participants were required to respond on a five point Likert rating scale. The response rate was 67%. Non-co-op spouses were significantly older than co-op spouses (48.3 years versus 42.6, t(68)=-3.02, p=0.04). 80% of the co-op group favoured a co-op for on-call cover as compared to 46% of the non-co-op group. The majority of respondents from both groups agreed that they dislike when their spouse is on call and that time spent on-call placed a strain on family life and was detrimental to their spouse's health. Spouses of non-co-op general practitioners were more likely to agree that their home life was interrupted by patients telephoning the house (z=-3.06, p=0.002) and by patients calling to the door without a prior appointment (z=2.9, p=0.004). They were also more likely to worry about the safety of their spouse on call (z=-2.07, p=0.038). The general provision of out-of-hours care has a significant impact on the spouses and families of GPs participating, or not, in a rural co-op. Spouses of participants in co-ops had significantly less interruptions to their home life from patients and worried less about the safety of their spouse. The implications of these findings on the recruitment and retention of rural practitioners merits further discussion.

Evolution of abbreviated development in the ophiuroid Ophiarachnella gorgonia involves heterochronies and deletions

The ophiuroid Ophiarachnella gorgonia Müller and Troschel, 1842 has the Type II mode of ophiuroid development through a short-lived (lecithotrophic) vitellaria larva that settles 3 days after fertilization. Development in O. gor gonia is characterized by a reduction in larval structures and settlement of a precocious juvenile. In comparison with other ophiuroid vitellariae, the larva of O. gorgonia has reduced ciliated bands that lack prominent epithelial ridges. Ab breviated development in O. gorgonia is achieved through prompt formation of a radial hydrocoel and radial juvenile skeleton. Newly settled juvenile O. gorgonia also lack the feeding and locomotory structures found in the settlement stage of species with ophioplutei. Juveniles of O. gorgonia settle with one pair of buccal podia, and the mouth is not functional. The first arm segment forms before the mouth opens. In comparison, in species with ophioplutei the first two pairs of buccal podia and the first two arm segments develop before the mouth opens and before settlement occurs. Comparison of development of O. gorgonia and that of other species with vitellariae suggests that hetero chron ies and deletions in the metamorphic and settlement programs may be involved in the evolution of abbreviated development.