Cerebral aspergillosis: tissue penetration is the key

Cerebral aspergillosis is increasingly recognized in severely immunocompromised patients and, until recently, this type of fungal infection was associated with a mortality approaching 100%. The central nervous system is a protected environment and penetration of drugs across the blood-brain barrier is mainly limited by their molecular size and physicochemical properties, as well as drug interaction with transporter systems (e.g., P-glycoprotein) at the blood-brain barrier. Most antifungal agents are large molecules (>700 Da), which makes sufficient penetration into the central nervous system unlikely. In fact, the available data indicate low levels of most antifungal agents in cerebrospinal fluid and brain tissue, except for fluconazole and voriconazole. Concentrations of voriconazole exceeding inhibitory concentrations for Aspergillus species were found repeatedly in cerebrospinal fluid and brain tissue, including brain abscess material. A recent retrospective study confirmed that voriconazole treatment resulted in improved response and survival rates in patients with cerebral aspergillosis. Data from animal models, which explored escalated doses or combinations of antifungal agents in experimental neuroaspergillosis, suggest that selected combination or dose-escalated therapies might further improve the still unsatisfactory prognosis in this particular type of Aspergillus infection.

Targeting the pathophysiology of type 2 diabetes: rationale for combination therapy with pioglitazone and exenatide

OBJECTIVE

The objectives of this article are to review the pathophysiology of type 2 diabetes mellitus (T2DM), present the rationale for a pathophysiologically based treatment approach for patients with T2DM and discuss the role of the therapeutic combination of pioglitazone and exenatide in the management of T2DM.

METHODS

References were identified from searches of the PubMed database that were conducted in May 2007, October 2007 and March 2008 and updates to product labeling that occurred between May 2007 and December 2007. Information was selected for inclusion on the basis of its relevance to the pathophysiology of T2DM or the clinical use of thiazolidinediones or exenatide. Discussion of other anti-diabetic treatment strategies is not included.

RESULTS

T2DM results from a combination of insulin resistance and beta-cell dysfunction. The combination of a thiazolidinedione and an incretin mimetic offers a combination of characteristics (e.g., glycemic control, reduced insulin resistance, decreased weight, potential cardiovascular benefits, beta-cell preservation) that addresses many of the pathophysiologic underpinnings of T2DM. A recent small placebo-controlled study assessed the effects of exenatide used with a thiazolidinedione (TZD; pioglitazone or rosiglitazone) with or without metformin. Exenatide demonstrated a greater incidence of glycosylated hemoglobin (HbA(1c)) < 7%; greater reductions in fasting blood glucose, postprandial plasma glucose and body weight; and improved beta-cell function versus the TZD/placebo group. However, exenatide was associated with a high dropout rate, and the 16-week duration of treatment in this study precluded evaluation of the long-term effects of the exenatide/pioglitazone combination. Furthermore, exenatide/pioglitazone has not been compared with any other anti-diabetic combination in a head-to-head clinical study.

CONCLUSIONS

Dual effects on insulin sensitivity (TZD) and insulin secretion (exenatide) make the TZD/exenatide combination a rational treatment option for patients who do not attain glycemic control with a single agent. Studies undertaken to evaluate the effects on cardiovascular outcomes and the potential for prevention of T2DM with impaired glucose tolerance may reveal additional advantages of this combination approach.

Loss of confidence in diabetes management

Using current treatment approaches, many patients with type 2 diabetes do not achieve glycemic goals--and do experience macrovascular complications that contribute to morbidity and mortality. It's time to consider other options.

IMPLICATIONS

Aggressive therapeutic interventions aimed at insulin resistance and cell dysfunction may alter outcomes. Managed care organizations may need to modify the way they look at diabetes and should consider changing their focus from drug costs to wellness. Value-based insurance design may provide opportunities to optimize diabetes management, resulting in improved outcomes for patients and economic benefits for managed care organizations.

Proteomic profiling of the effect of prostate-specific antigen on prostate cancer cells

BACKGROUND

Prostate-specific antigen (PSA) is a well-known biomarker for diagnosis and management of prostate cancer. PSA has been shown to have anti-angiogenic activity. We used the emerging proteomic research technology to identify proteins in prostate cancer cells whose expression is regulated by enzymatically active PSA.

METHODS

Differentially expressed proteins in PC-3M cells treated with PSA were analyzed by 2D-DIGE analysis and identified by HPLC-MS/MS and SEQUEST data mining. Biological network analysis was carried out using MetaCore integrated software designed for functional analysis of experimental data. Gene expression data for several regulated proteins were confirmed by real-time, quantitative PCR.

RESULTS

A total of 41 proteins were significantly (P < 0.05) changed in abundance in PC-3M cells in response to PSA treatment. Proteins from 26 gel-spots were identified. Many of the down-regulated proteins including N8 gene product long isoform, laminin receptor, vimentin, DJ-1 and Hsp60 are known to be involved in tumor progression.

DISCUSSION

The relevance of the level of PSA in prostate tissue microenvironment and its relation to tumor progression has not been elucidated. PSA has been shown to down-regulate several proteins that are known to have involvement in tumor progression. This suggests that normal physiological levels of PSA in prostate tissue microenvironment may be promoting non-angiogenic environment and its down-regulation may promote tumor growth.

A pilot study to examine the feasibility of insulin glargine in subjects with impaired fasting glucose, impaired glucose tolerance or new-onset type 2 diabetes

OBJECTIVE

People with early type 2 diabetes and pre-diabetes (impaired glucose tolerance [IGT] and/or impaired fasting glucose [IFG]) are at risk of hyperglycaemia-related complications, including cardiovascular disease. Insulin, traditionally reserved as late treatment in type 2 diabetes, may also be a useful therapy in this population. We examined the short-term efficacy and tolerability of insulin glargine (glargine) in individuals with early or pre-type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this multicentre, double-blind, placebo-controlled, randomized, parallel group, 12-day study, subjects with IGT/IFG (n=9), newly diagnosed type 2 diabetes (n=9) or normal glucose tolerance (n=3) (confined to a clinical research unit taking a prescribed diet) were randomized to once-daily glargine (n=16) or placebo (saline; n=5) at bedtime. Dose was titrated to achieve target fasting blood glucose (FBG) 80-95 mg/dL.

RESULTS

Over the treatment period, mean FBG decreased in glargine-treated subjects (from 100.0+/-18.8 to 85.6+/-18.4 mg/dL), but was unchanged in placebo-treated subjects (from 112.5+/-10.6 to 111.3+/-17.5 mg/dL). Mean eight-point blood glucose value decreased by 9.7 mg/dL in the glargine group, but increased by 8.1 mg/dL in the placebo group. Mean post-exercise blood glucose was similar before and after glargine treatment, but increased after placebo treatment. Five subjects receiving glargine experienced 16 mild symptomatic hypoglycaemia episodes; however, no hypoglycaemia occurred during exercise. Mean body weight decreased in both the glargine (-0.44 kg) and placebo (-0.25 kg) groups, in line with dietary restrictions.

CONCLUSIONS

The results of this pilot study suggest that glargine can be used by people with IFG, IGT or new-onset type 2 diabetes for management of hyperglycaemia with low risk of hypoglycaemia. However titration of insulin in people on dietary restrictions should be more cautious as they may be more prone to hypoglycaemia. Further studies are warranted to determine the clinical benefits of this approach.

Preparation of amniocytes for interphase fluorescence in situ hybridization (FISH)

Although FISH has been used to clarify deletions or structural rearrangements, recent work has focused increasingly on its applications to interphase analysis. This unit describes preparation of uncultured amniotic fluid cells for FISH analysis. Cells are swollen, then slides are prepared using either a cytocentrifuge or standard methods. These are then fixed and permeabilized for subsequent FISH. An Alternate Protocol describes attachment of amniocytes to a glass or plastic surface followed by hypotonic swelling, fixation, and permeabilization for subsequent FISH. Interphase FISH analysis of amniotic fluid cells is also described.

Effects of an endurance and resistance exercise program on persistent cancer-related fatigue after treatment

BACKGROUND

Fatigue is a relevant problem of cancer patients during and after treatment. Several studies have shown that exercise can improve quality of life and functional status of cancer patients undergoing chemo- or radiotherapy. However, there is a lack of information about the effects of this intervention on persistent cancer-related fatigue. Therefore, we assessed the effects of an exercise program on cancer-related fatigue after treatment.

PATIENTS AND METHODS

A consecutive series of 32 cancer patients with mild to severe persistent fatigue [scores on the Brief Fatigue Inventory (BFI) > 25] participated in a 3-week exercise program consisting of endurance (30 min walking on a treadmill) and resistance/coordination exercises for the major muscle groups. Fatigue, mood, and anxiety were assessed with questionnaires and physical performance with a stress test before and after the program.

RESULTS

At the end of the program, we observed a significant increase of physical performance (workload at the anaerobic threshold pre 61 +/- 26 W, post 78 +/- 31 W, P < 0.0001) and reduction of global fatigue (Functional Assessment of Cancer Therapy: pre 45.7 +/- 13.4, post 52.6 +/- 12.4, P < 0.0001; BFI: pre 37.9 +/- 18.3, post 31.2 +/-17.1, P < 0.001). However, no significant improvement of cognitive fatigue or reduction of anxiety was observed.

CONCLUSIONS

A 3-week exercise program leads to a substantial improvement of physical performance and reduction of mental and physical fatigue in cancer patients after treatment. However, this intervention does not affect depression, anxiety, or cognitive fatigue.

Thymic adult T-cell acute lymphoblastic leukemia stratified in standard- and high-risk group by aberrant HOX11L2 expression: experience of the German multicenter ALL study group

Adult T-cell acute lymphoblastic leukemia (T-ALL) continues to represent an unfavorable disease. Molecularly based treatment stratifications could help improve outcome. The prognostic impact of HOX11 and HOX11L2 expression has been an area of controversy. We have investigated 286 adult T-ALL patients enrolled into the German Multicenter ALL (GMALL) therapy protocols by comparative real-time RT-PCR. High HOX11 expression and HOX11L2 expression were predominantly seen in thymic T-ALL (P<or=0.031). In a multivariate analysis HOX11L2 expression proved to be an independent adverse risk factor for relapse-free survival (RFS) with a hazard ratio (HR) of 2.02 (P=0.023) and an HR for overall survival (OS) of 1.81 (P=0.021), both adjusted for the immunophenotype. HOX11 expression was found to have a favorable impact on RFS (HR 0.51; P=0.048) but did not exhibit a significant impact on OS. A subgroup analysis for thymic T-ALL revealed a more pronounced negative correlation of HOX11L2 expression with RFS (HR 3.26; P=0.002) and OS (HR 2.38; P=0.009). Although the prognostic impact of HOX11 in T-ALL is less clear, HOX11L2 expression identifies a small subset of high-risk patients, who are so far classified as standard-risk group. Thus, patients with aberrant HOX11L2 expression should be considered early as candidates for intensified treatment regimes.

Transforming pathways unleashed by a HDAC2 mutation in human cancer

Although disruption of histone modification patterns is a common hallmark of human cancer, our knowledge of the mechanistic role of histone-modifying enzymes in its generation is very limited. We have recently identified an inactivating mutation in the histone deacetylase-2 (HDAC2) in sporadic carcinomas with microsatellite instability and in tumors arising in individuals with hereditary nonpolyposis colorectal cancer syndrome. Since HDAC2 seems to be a central player in epigenetic gene repression, we wondered whether HDAC2-truncating mutations conferred a particular expression signature on these cancer cells. Using unsupervised clustering analysis in microsatellite-unstable colorectal cancer cell lines, we have found that HDAC2 mutant cells (RKO and Co115) show a characteristically different expression microarray signature from HDAC2 wild-type cells (HCT-116, SW48, HCT-15 and LoVo). HDAC2 mutant cells exhibit upregulation of tumor-promoting genes, such as those of tyrosine kinases, mediators of cell cycle progression and angiogenic factors. The overexpression of these genes is associated with a loss of HDAC2 recruitment and a gain of histone H4 hyperacetylation in their particular 5'-end promoters, as observed by chromatin immunoprecipitation. Transfection of wild-type HDAC2 in mutant cells reverted this epigenetic pattern by repressing the transforming genes in association with HDAC2 promoter occupancy. These results suggest a role for HDAC2 mutations in human tumorigenesis through the derepression of key genes from multiple cellular transformation pathways.

Intensified strategies to control vancomycin-resistant enterococci in immunocompromised patients

Increasing colonization and infection with vancomycin-resistant enterococci (VRE) in immunocompromised patients are associated with increased mortality. Despite contact precautions for VRE control, rapid limitation of its spread is often impossible. We report on a VRE outbreak in a hematologic/oncologic unit including 33 patients. Although 28 of the patients had only VRE colonization, VRE-related infection was probable in 4 patients, and VRE infection of the bloodstream occurred in 1 case. Two patients were identified by VRE screening on admission, 20 were identified by weekly routine VRE screening, and 6 were identified from specimens taken to clarify infections (eg, urine, bronchoalveolar lavage). Five individuals acquired VRE colonization as inpatients (contact patients). Multiple-locus variable-number tandem repeat analysis (MLVA) proved that the outbreak was caused by VanA gene-positive Enterococcus faecium belonging to MLVA genogroup C1(MLVA types 1, 7, 12). The outbreak strains exhibited the potential virulence factor esp(enterococcus surface protein). The outbreak was terminated within 2 months by intensified infection-control measures, including quarantine and the cohorting of patients who tested positive for VRE; however, VRE spread recurred after the measures were discontinued but was again limited by resuming the measures. We conclude that intensive infection-control strategies enable the timely termination of VRE outbreaks, even those involving VRE strains with high epidemic potential on "high-risk wards" (eg, hematologic/oncologic units). Premature discontinuation of infection-control measures may cause recurrence of the VRE spread.

Looking at human eyes affects contralesional stimulus processing after right hemispheric stroke

Human eyes are a powerful social cue that may automatically attract the attention of an observer. Here we tested whether looking toward open human eyes, as often arises in standard clinical "confrontation" tests, may affect contralesional errors in a group of right brain-damaged patients showing visual extinction. Patients were requested to discriminate peripheral shape-targets presented on the left, right, or bilaterally. On each trial they also saw a central task-irrelevant stimulus, comprising an image of the eye sector of a human face, with those seen eyes open or closed. The conditions with central eye stimuli open (vs closed) induced more errors for contralesional peripheral targets, particularly for bilateral trials. These results suggest that seeing open eyes in central vision may attract attentional resources there, reducing attention to the periphery, particularly for the affected contralesional side. The seen gaze of the examiner may thus need to be considered during confrontation testing and may contribute to the effectiveness of that clinical procedure.

A phase II trial of weekly cisplatin and docetaxel in advanced non-small cell lung cancer (NSCLC)

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Background: Every 3-week cisplatin doublets used to treat advanced NSCLC carry a significant risk of renal and other toxicities and can be difficult for patients with co-morbidities. To reduce these toxicities, we conducted a phase II study to evaluate the efficacy and toxicity of weekly cisplatin and docetaxel in advanced NSCLC. Methods: Eligibility included patients with advanced or recurrent NSCLC, ECOG PS of 0–1, and no prior chemotherapy for metastatic disease. This Cancer Institute of New Jersey network, single stage phase II clinical trial was designed to give 3 weekly doses of cisplatin at 25 mg/m2 and docetaxel at 35 mg/m2, followed by 1 week of rest, for a total of 6 cycles of therapy. Toxicity was monitored weekly, and disease evaluation was performed every 2 cycles. The primary endpoint was response rate (RR); secondary endpoints included time to progression (TTP), median and 1-year survival. Results: From 12/03 to 11/06, 36 patients were enrolled so far. The median age of patients is 63 (range 47–78), the majority is white (n=33), 29 have stage IV disease, and half (n=18) are women. Fourteen have an ECOG PS=0 and 22 with PS=1. Histologic subtypes are: adenocarcinoma (n=24), NSCLC NOS (n=7), squamous (n=5). Eleven patients received = 4 cycles of therapy; median number of cycles delivered is 2.5. Reasons for treatment discontinuation include completion of therapy (n=5), progression of disease (n=16), adverse events (n=8), and patient preference (n=4). Three patients continue on therapy at this time. No complete responses were yet observed; 8 patients (22%) achieved a partial response; 10 patients had stable disease, 10 patients progressed, and 8 came off study before first disease evaluation. Median TTP was 3.1 months (mo) (95% CI 2, 5.5), median survival is 8.3 mo (95% CI 5,16.2) and 1-year survival is 39% (95% CI 20, 57). Most toxicities were mild but also included neutropenia (grade 3, n=1; grade 4, n=1), neutropenic fever (n=1), renal toxicity (grade 3, n=2), nausea (grade 3, n=1), fatigue (grade 3, n=3), diarrhea (grade 3, n=4) and metabolic abnormalities (grade 3, n=3). Conclusion: Weekly cisplatin and docetaxel is well tolerated with a low incidence of toxicity and demonstrates activity similar to every 3-week treatment in patients with advanced NSCLC.

No significant financial relationships to disclose.

Identification of a new subgroup of adult acute T-lymphoblastic leukemia (T-ALL) with a very favorable outcome using low ERG and BAALC expression

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Background: High expression of the oncogenic ETS transcription factor ERG is an independent adverse prognostic factor in T-ALL and acute myeloid leukemia (AML). The gene BAALC similarly shows high expression in hematopoietic progenitors, downregulation with onset of differentiation, and prognostic significance in AML. Therefore, we assessed whether combined expression of ERG and BAALC would better predict outcome in T-ALL. Methods: ERG and BAALC mRNA expression was determined by realtime RT-PCR in pretherapy bone marrow of 152 adults with newly diagnosed T-ALL treated on German ALL protocols (05/93, 06/99). Patients (pts) were designated low (n=76) or high (n=76) ERG expressers based on median ERG expression and as low (n=111) or high (n=37) BAALC grouping the lower quartiles 1–3 vs. quartile 4. HOX11 and HOX11L2 expression was determined and immunophenotyping differentiated 3 T-ALL groups (early, thymic, mature). Results: High BAALC expression correlated with immature T-ALL with a higher frequency of early T-ALL (P<0.0001), CD34 positivity (P<0.0001), co-expression of myeloid markers (CD13 and/or CD33; P=0.03), and high ERG expression (P=0.02). Pts with high BAALC had fewer complete remissions (73% vs. 89%, P=0.03) and a higher relapse rate (67% vs. 32%, P=0.01) than low BAALC pts. Excluding 33 pts that had received stem cell transplantation (SCT), high expression of ERG (P=0.002) and of BAALC (P=0.0004) was associated with inferior relapse-free survival (RFS) and overall survival (OS, ERG: P=0.004; BAALC: P=0.0001) compared to low expression of ERG and BAALC, respectively. In contrast, pts with low expression of both ERG and BAALC had the most favorable outcome (5y-RFS: low ERG/low BAALC 81% vs. high ERG and/or high BAALC 33%, P<0.0001; 5y-OS: low ERG/low BAALC 69% vs. high ERG and/or high BAALC 26%, P=0.0001). On multivariable analysis low ERG/low BAALC expression was of independent favorable prognostic significance (RFS, HR: 0.18, P=0.0003; OS, HR: 0.3, P=0.001); the only other prognostic factor was the immunophenotype. Conclusions: Low expression of both ERG and BAALC identifies T-ALL pts with a distinctly favorable long term outcome, thus detecting pts that may not benefit from further treatment intensification including SCT.

No significant financial relationships to disclose.

Medication safety in cancer clinical trials: An analysis of medication error reports at a comprehensive cancer center

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Background: Although medication errors comprise 10–25% of all medical errors, little is known concerning the occurrence or types of medication errors occurring while treating patients on a clinical trial. Therefore, we retrospectively reviewed the medication errors reported in patients enrolled on clinical trials at our center. Methods: As part of a multidisciplinary continuous quality improvement project, from January 2003 through December 2006, we collected voluntary reports of medication errors in adult and pediatric patients on clinical trials involving both oral and intravenous chemotherapy. All reports were classified prospectively regarding clinical trial involvement, severity category (A to I) per the National Coordination Council on Medical Error Reporting and Prevention, type, cause, and where in the medication use process the error occurred. Results: There were 163 reports involving patients treated on clinical trials. The most common errors were those corrected prior to reaching the patient in 68% of events (Category A&B), while 31% reached the patient but did not result in harm (Category C&D), with 1% resulting in temporary patient harm (Category E&F). The most common type of errors were prescribing (66%), improper dose (42%), and omission errors (9%). Not following an institutional procedure or the protocol was the primary cause for these errors (39%), followed by the written order (30%), and poor communication involving both the healthcare team and the patient (26%). The processes where the errors initiated were in prescribing 47%, administration 10%, dispensing 6%, and monitoring 5%. Conclusion: Medication errors do occur in clinical trials, however the majority of these are corrected prior to reaching the patient or do not result in harm. Not following an institutional procedure or the protocol was the most common cause of error. This is most likely due to the protocol procedures differing from existing standards of care. Protocol-specific education through the Centralized Education and Training Service, a shared resource within our cancer center, addresses this issue enhancing the quality and safety of clinical trials through the education and training of healthcare professionals.

No significant financial relationships to disclose.

Safety and efficacy of s-citalopram in patients with co-morbid major depression and diabetes mellitus

OBJECTIVE

The presence of co-morbid depressive symptoms may have a negative impact on the management of diabetes mellitus. Moreover, some antidepressants may adversely affect glycemic control. Selective serotonin reuptake inhibitors (SSRIs) may improve glycemic control and may be beneficial for patients with co-morbid depression and diabetes. We examined the safety and efficacy of s-citalopram therapy in patients with co-morbid depression and diabetes, and its ability to improve glycemic control.

RESEARCH DESIGN AND METHODS

17 patients were enrolled into the trial and 14 patients received open-label s-citalopram therapy for up to 16 weeks. Clinical outcome measures included the 17-item Hamilton depression rating (HAM-D 17) and the clinical global impressions severity (CGI/S) and change (CGI/C) ratings. In addition, fasting glucose, fructosamine, and glycosylated hemoglobin-A(1C) measures were obtained before and during s-citalopram therapy.

RESULTS

We observed a significant reduction in mean HAM-D 17 (p<0.001), CGI/S (p=0.001) and CGI/C (p=0.001) ratings during s-citalopram therapy. We also observed a modest, non-significant reduction in fasting glucose, fructosamine, and glycosylated hemoglobin-A(1C) levels during s-citalopram therapy.

LIMITATION

Limitations of this study include a modest patient sample size and a 16-week treatment duration which may have been insufficient to demonstrate the full effect of SSRI therapy on glycemic control.

CONCLUSION

We observed a significant reduction in depressive symptoms and modest, non-significant reductions in fasting glucose, fructosamine, and glycosylated hemoglobin-A(1C) levels during SSRI therapy of co-morbid depression and diabetes.

Redefining the risks of prenatally ascertained supernumerary marker chromosomes: a collaborative study

BACKGROUND

A marker chromosome is defined as a structurally abnormal chromosome that cannot be identified by routine cytogenetics. The risk for phenotypic abnormalities associated with a marker chromosome depends on several factors, including inheritance, mode of ascertainment, chromosomal origin, and the morphology, content, and structure of the marker.

METHODS

to understand the karyotype-phenotype relationship of prenatally ascertained supernumerary de novo marker chromosomes, we combined data from prenatal cases obtained from 12 laboratories with those from studies in the literature. We were able to obtain cytogenetic and phenotypic data from 108 prenatally ascertained supernumerary de novo marker chromosomes to refine the phenotypic risk associated with these markers. Because of the growing number of cases and because more techniques are available to delineate marker morphology, we have been able to group risk estimates into subcategories, such as by marker type and whether there are ultrasound abnormalities.

RESULTS

If a de novo supernumerary marker chromosome is found prenatally, our data suggest there is a 26% risk for phenotypic abnormality when there is no other information defining the marker (such as chromosomal origin or information about the existing phenotype). However, if high resolution ultrasound studies are normal, this risk reduces to 18%.

CONCLUSIONS

Our findings strongly support the value of additional genetic studies for more precisely defining the risk in individual cases involving marker chromosomes.