A phase I-II study of paclitaxel, ifosfamide, and vinorelbine with filgrastim (rhG-CSF) support in advanced non-small-cell lung cancer

PURPOSE

We designed a phase I-II trial of three active agents, paclitaxel, ifosfamide, and vinorelbine, in advanced non-small-cell lung cancer (NSCLC) to: 1) define the dose-limiting toxicities (DLT) and maximum tolerated dose (MTD) of paclitaxel with filgrastim (G-CSF) support; and 2) determine the overall response rate and median survival of patients treated on this regimen.

PATIENTS AND METHODS

We treated cohorts of patients with stage IIIB or IV NSCLC with ifosfamide 1.2-1.6 g/m2/day x 3 and vinorelbine 20-25 mg/m2/day x 3 and escalating doses of paclitaxel at 100-175 mg/m2 on day 2 with G-CSF support on a 21-day cycle. One prior experimental single-agent chemotherapy regimen was allowed.

RESULTS

Fifty-six patients, were enrolled on this trial: 27 on the phase I portion of the study and an additional 29 at the recommended phase II dose (RPTD). Thirteen patients had received prior chemotherapy. Paclitaxel doses of 175 mg/m2 and 150 mg/m2 produced dose-limiting myelosuppression, and the RPTD was determined to be paclitaxel 135 mg/m2 with ifosfamide 1.2 g/m2/day on days 1-3 and vinorelbine 20 mg/m2/ day on days 1-3 with G-CSF support. The overall response rate was 18%, with a median survival of 6.1 months. Six of 35 patients (17%) treated at the RPTD achieved a partial response to therapy. Grade IV neutropenia was observed in 19 of 35 patients at this dose, with eight patients suffering febrile neutropenia.

CONCLUSIONS

This non-cisplatin-containing three-drug regimen has substantial toxicity and low activity in advanced NSCLC, and does not seem to improve on prior regimens. It is unclear whether the lack of efficacy relates to an antagonistic reaction between the specific drugs, administration schedule, or to subtherapeutic doses of the individual agents.

Enhancing motivation for change in treatment-resistant eating disorders

Denial and resistance to change are prominent features in most patients with anorexia nervosa. The egosyntonic quality of symptoms can contribute to inaccuracy in self-report, avoidance of treatment, difficulties in establishing a therapeutic relationship, and high rates of attrition and relapse. Individuals with bulimia nervosa are typically more motivated to recover, but often ambivalent about forfeiting the ideal of slenderness and the protective functions of binge-purge behavior. Few attempts have been made to assess denial and resistance in the eating disorders, or to examine alternative strategies for enhancing motivation to change. Review of the clinical literature indicates a striking convergence of recommendations across conceptually distinct treatment approaches. Clinicians are encouraged to acquire a frame of reference that can help them understand the private experience of individuals with eating disorders, empathize with their distress at the prospect of weight gain, and acknowledge the difficulty of change. The Socratic method seems particularly well-suited to work with this population because of its emphasis on collaboration, openness, curiosity, patience, focused and systematic inquiry, and individual discovery. Four themes are crucial in engaging reluctant eating-disordered clients in therapy: the provision of psychoeducational material, an examination of the advantages and disadvantages of symptoms, the explicit use of experimental strategies, and an exploration of personal values.

Ifosfamide-based three-drug combination regimens in non-small cell lung cancer

The role of chemotherapy in the treatment of non-small cell lung cancer (NSCLC) has expanded in recent years, resulting in increased median survival and higher 5-year survival rates in some studies. Few patients with NSCLC can be cured, however, and the median survival time is still modest. Research strategies are aimed at identifying new active single agents, testing their combination in non-cisplatin- and non-carboplatin-containing regimens, and their incorporation into regimens containing more than two drugs, in efforts to improve response and survival and/or reduce toxicity. Several trials of triplet chemotherapy combinations for the treatment of NSCLC have been conducted at the University of Chicago. The three-drug regimen of vinorelbine, paclitaxel, and ifosfamide with granulocyte colony-stimulating factor was evaluated in a phase I trial. Doses of all three drugs were reduced from their standard doses so that toxicity would be manageable, although toxicity was still high. The low response rate (<20%) at the recommended phase II doses led to early closure of this trial. The University of Chicago is also assessing the three-drug combination of carboplatin, paclitaxel, and ifosfamide in patients with stage IIIB and IV NSCLC. The carboplatin and paclitaxel doses are being maintained within their active single-agent range, with the goal of identifying the maximum tolerated dose of ifosfamide when added to this combination. Additional end points include response rates, survival time, and dose-limiting toxicities. This study is ongoing.

Magnetic resonance imaging of the pelvic floor in patients with obstructed defaecation

BACKGROUND

Evacuation proctography and measurements of anorectal physiology are frequently used to clarify the pathophysiology of obstructed defaecation. In some patients these tests are normal, despite convincing clinical evidence of defaecatory difficulty. The aim of this study was to determine whether magnetic resonance imaging (MRI) could reveal pelvic floor abnormality in patients with obstructed defaecation.

METHODS

Eleven women with obstructed defaecation, in whom evacuation proctography and anorectal physiology were normal, were examined by MRI, using a fast gradient echo sequence. Measurements of pelvic visceral and muscular descent were taken at rest and during straining, and compared with those obtained from 13 asymptomatic volunteers.

RESULTS

Patients with obstructed defaecation had significantly greater pelvic visceral descent (P < 0.05), levator muscle descent (P = 0.04), levator plate angle change (P = 0.003) and increase in the area of the pelvic floor hiatus (P = 0.0002) than asymptomatic volunteers.

CONCLUSION

MRI demonstrated marked pelvic visceral and levator muscle descent in women with obstructed defaecation, despite normal evacuation proctography and anorectal physiology. MRI should be considered if these examinations have been normal.

Dynamic MR imaging compared with evacuation proctography when evaluating anorectal configuration and pelvic floor movement

OBJECTIVE

The aim of this study was to determine the agreement between measurements of the anorectal configuration made with dynamic MR imaging and with evacuation proctography.

SUBJECTS AND METHODS

Ten women with constipation were examined sequentially using both standard evacuation proctography and dynamic MR imaging. Correlation and agreement between standard measurements of anorectal configuration at rest and during straining or evacuation of the rectum were evaluated.

RESULTS

Significant correlation existed for anorectal junction descent (r = .7, p = .023), change in the anorectal angle (r = .78, p = .008), the position of the rectal axis on straining (r = .62, p = .032), and rectocele depth (r = .82, p = .004). The mean of the measurement differences for anorectal junction descent as measured using the two techniques was -0.23 cm (SD, 1.40 cm). The mean of the measurement differences for change of the anorectal angle was +15.3 degrees (SD, 27.92 degrees).

CONCLUSION

Standard measurements of anorectal configuration made using evacuation proctography and dynamic MR imaging show significant correlation. However, in our study statistical agreement was poor for measurement of anorectal junction descent and anorectal angle change as seen on imaging obtained with the two techniques.

The effects of massage: an holistic approach to care

In this article the authors review the benefits of massage and its relationship and relevance to more orthodox therapies. Most studies of the effects of massage on patients' wellbeing have been undertaken by non-nursing researchers and the authors suggest that more nurse-based research would make an important contribution to an holistic approach to care. Interest in, and the use of, complementary therapies has been growing over recent years. Massage seems to be of particular interest to nurses, involving as it does the close, intimate contact which nurses are often engaged in as part of their day-to-day work with patients. The benefits, and some of the problems, associated with massage are explored below.

Paclitaxel/carboplatin plus ifosfamide in non-small cell lung cancer

Chemotherapy has a positive role in managing patients with stage IV non-small cell lung cancer. Randomized studies and meta-analyses comparing chemotherapy with best supportive care have confirmed a significant prolongation of survival for chemotherapy-treated patients. In recent years, several new active agents have been identified. These include the taxanes paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) and docetaxel, the antimetabolite gemcitabine, the mitotic spindle inhibitor vinorelbine, and (potentially) the topoisomerase I inhibitors. Combinations of either vinorelbine or paclitaxel with cisplatin have resulted in a significant increase in median survival times compared with both cisplatin and vindesine and cisplatin and etoposide. Paclitaxel combined with either carboplatin or ifosfamide also has been promising. Since even the best current combination regimens result in median survival times of less than 1 year, the identification of more active drugs and combinations remains a high priority. One possible strategy to identify more active regimens may be the combination of three rather than two active agents into a combination regimen. Although the three-drug regimens used in the 1980s appeared to be no more active than two-drug combinations, the advent of additional active compounds with novel mechanisms of action allows this question to be readdressed. Based on this background, we have initiated a phase I/II study of carboplatin and paclitaxel with escalating doses of ifosfamide. The study design and dosing schedule are discussed in this report.

Patterns of prolapse in women with symptoms of pelvic floor weakness: assessment with MR imaging

PURPOSE

To show the magnetic resonance (MR) imaging patterns of prolapse and to correlate them with symptoms in patients with constipation or fecal incontinence.

MATERIALS AND METHODS

Thirty women underwent MR imaging with fast spoiled gradient-recalled acquisition in the steady state. The women were divided into three groups: 10 were asymptomatic volunteers, 10 had constipation, and 10 had fecal incontinence. Visceral prolapse and the configuration of the pelvic floor muscles were identified at rest and during straining. Visceral descent was compared between the three groups.

RESULTS

Visceral prolapse was seen at multiple sites, most frequently in constipated patients. There was significantly greater bladder base descent (P < .01), uterocervical descent (P < .001), and puborectalis muscle ballooning (P < .05) in the group of constipated patients when compared with the group with fecal incontinence or the asymptomatic group. The degree of anorectal junction descent was significantly greater (P < .05) in the group of incontinent patients when compared with the asymptomatic group.

CONCLUSION

MR imaging clearly shows pelvic visceral prolapse and pelvic floor configuration on straining. Prolapse frequently involves multiple sites in constipated patients, which is suggestive of global pelvic floor weakness. In contrast, the weakness is frequently posterior in fecally incontinent patients.

The effect of circulating antigen on the biodistribution of the engineered human antibody hCTM01 in a nude mice model

Clinical studies are currently underway to assess the biodistribution and therapeutic potential of the genetically engineered human antibody hCTM01 directed against polymorphic epithelial mucin (PEM) in patients with ovarian carcinoma. The present study was undertaken to assess the effect of circulating PEM antigen on the biodistribution of the anti-PEM antibody in mice bearing MUC-1 transfected adenocarcinoma cell lines. Tumour xenografts were established from three cell lines: 413-BCR, which expressed antigen on the cell surface and also shed antigen into the circulation, E3P23, which expressed the antigen but did not shed into the circulation, and a negative control (410.4 MUCI). Groups of five mice were injected with 1.0 mg/kg antibody, imaged after 72 h and then sacrificed, followed by assay of tissue uptake. The results showed a clear difference in the tumour and liver uptake, with the non-secreting cell line showing almost twice the tumour uptake and approximately 20% of the liver uptake of the secreting cell line.

Statistical analysis of data for three British ethnic groups from a new STR multiplex

Data have been collected from 602 Caucasians, 190 Afro-Caribbeans and 257 Asians of Indo/Pakistani descent who have been profiled using a new six locus short tandem repeat (STR) multiplex. The data have been analysed by conventional significance testing methods: the exact test, homozygosity, and conventional goodness of fit to Hardy-Weinberg proportions. Frequency tables are given and the expected performance in British forensic casework is discussed.

Comparative performance of disposable soft contact lenses

A short-term clinical study was undertaken to compare and evaluate the fit and clinical behaviour of eight disposable hydrogel contact lenses. Thirty subjects were enrolled in a 1-day, randomised, double-masked study. The lenses compared were Vistakon Acuvue (8.80), Vistakon Surevue (8.80), Aspect Frequency-55, Bausch & Lomb Medalist (SeeQuence 2), Ciba Focus (8.90), Lunelle Rythmic, Pilkington Barnes Hind Precision-Wand Wesley Jessen Freshlook. Three of the eight designs, Acuvue (86.7%), Precision-UV (86.7%) and Frequency-55 (90%), achieved relatively high levels of fitting success. The Rythmic lenses achieved the lowest success rate (70%) showing significantly greater downward decentration than the other designs. Although all the lenses were designed to fit a wide variety of eyes, they exhibited widely varying fitting characteristics. Some were more successful than others. The study shows that it is necessary for practitioners to utilise a range of lens designs in order to fit satisfactorily the typical contact lens population.

A hypervariable region in VP1 of chicken infectious anemia virus mediates rate of spread and cell tropism in tissue culture

Chicken infectious anemia virus (CIAV) is a unique infectious agent with an amino acid composition that has been found to be remarkably conserved even in isolates from different parts of the world. We have characterized field isolates of CIAV which vary significantly in terms of their abilities to replicate in culture, demonstrating a biological difference between isolates. Two sublines of MDCC-MSB1 cells that differ in their abilities to support CIAV were identified. In the MSB1(S) subline the CIA-1 isolate of CIAV was found to be less cytopathogenic than the prototype Cux-1(C) isolate; the MSB1(L) subline, which supports Cux-1(C) replication, was found to be nonpermissive for CIA-1. Alignments of the VP1 sequences of previously examined isolates with those of the field isolates CIA-1 and L-028 and the culture-adapted ConnB isolate revealed a previously unreported hypervariable region spanning amino acid positions 139 to 151. Chimeras of Cux-1(C) and CIA-1 were constructed to examine the potential for this region to affect cytopathogenicity. Transfer of a 316-bp region of Cux-1(C) open reading frame 1 into CIA-1 produced a virus with a cytopathogenic profile typical of Cux-1(C), indicating that one or both of the amino acid differences at positions 139 and 144 affect the rate of replication or the spread of infection. Transfection experiments with additional chimeras indicated that the inability of CIA-1 to replicate in MSB1(L) cells is mediated by a larger region of the genome which contains the hypervariable region in addition to upstream amino acid differences. Analysis of chimeras excluding the entire region of open reading frame 1 suggested the presence of a secondary mediator in the progression of infection in culture that was localized to a region containing a single nucleotide difference which results in amino acid differences in both VP2 (V-153) and the nuclear localization signal of VP3 (C-118). Immunofluorescence assays indicated an increased cytoplasmic distribution of VP3 and a general lack of VP3-associated apoptotic bodies in infections of CIA-1 and chimeras containing V-153 or C-118, as opposed to a primarily nuclear distribution and association with well-formed apoptotic bodies in Cux-1(C)-infected cells.

The validation of a 7-locus multiplex STR test for use in forensic casework. (I). Mixtures, ageing, degradation and species studies

We have evaluated a multiplex STR system for routine forensic use, which co-amplifies six short tandem repeat (STR) loci; HUMTH01, D21S11, D18S51, D8S1179, HUMVWF31/A and HUMFIBRA (FGA), in conjunction with the X-Y homologous gene Amelogenin. Analysis of PCR products employs denaturing polyacrylamide gels coupled with fluorescent labelled primers and detection is undertaken on ABD 373A automated sequencers. The technique was shown to be robust and reproducible when samples were analysed under conditions consistent with those encountered in a forensic environment. The system was demonstrated to be human specific and is suitable for use with both aged and degraded material. Somatic stability was proven with a wide range of tissue types and we were able to detect mixtures at ratios between 1:10 and 10:1. During this study no incidence of sample mis-typing due to allelic or locus drop-out was observed. Furthermore, although additional artefact bands were occasionally encountered these did not interfere with the interpretation of results. The performance of the system with poor quality samples demonstrated its suitability as a powerful tool in forensic investigation.

Dopaminergic transmission in the rat retina: evidence for volume transmission

The study was designed to determine whether dopaminergic neurotransmission in the retina can operate via volume transmission. In double immunolabelling experiments, a mismatch as well as a match was demonstrated in the rat retina between tyrosine hydroxylase (TH) and dopamine (DA) immunoreactive (ir) terminals and cell bodies and dopamine D2 receptor-like ir cell bodies and processes. The match regions were located in the inner nuclear and plexiform layers (D2 ir cell bodies plus processes). The mismatch regions were located in the ganglion cell layer, the outer plexiform layer, and the outer segment of the photoreceptor layer, where very few TH ir terminals can be found in relation to the D2 like ir processes. In similar experiments analyzing D1 receptor like ir processes versus TH ir nerve terminals, mainly a mismatch in their distribution could be demonstrated, with the D1 like ir processes present in the outer plexiform layer and the outer segment where a mismatch in D2 like receptors also exists. The demonstration of a mismatch between the localization of the TH terminal plexus and the dopamine D2 and D1 receptor subtypes in the outer plexiform layer, the outer segment and the ganglion cell layer (only D2 immunoreactivity (IR)) suggests that dopamine, mainly from the inner plexiform layer, may reach the D2 and D1 mismatch receptors via diffusion in the extracellular space. After injecting dopamine into the corpus vitreum, dopamine diffuses through the retina, and strong catecholamine (CA) fluorescence appears in the entire inner plexiform layer and the entire outer plexiform layer, representing the match and mismatch DA receptor areas, respectively. The DA is probably bound to D1 and D2 receptors in both plexiform layers, since the DA receptor antagonist chlorpromazine fully blocks the appearance of the DA fluorescence, while only a partial blockade is found after haloperidol treatment which mainly blocks D2 receptors. These results indicate that the amacrine and/or interplexiform DA cells, with sparse branches in the outer plexiform layer, can operate via volume transmission in the rat retina to influence the outer plexiform layer and the outer segment, as well as other layers of the rat retina such as the ganglion cell layer.

Quantitative urinary excretion of unmetabolised N tau-[Me-14C] methylhistidine by the common ringtail possum (Pseudocheirus peregrinus) marsupialia

Six common ringtail possums (Pseudocheirus peregrinus) were intravenously injected with a standard dose of radioactive 3-Methylhistidine (N tau-[Me-14C]MeH). The dose was rapidly and quantitatively excreted by the possums. More than 90% of radioactivity was recovered within 3 days. Thin layer chromatography and mass spectroscopy showed that 97% of recovered radioactivity was associated with unmetabolised N tau-[Me-14C]MeH. These data satisfy two key requirements for the validity of urinary 3-Methylhistidine (N tau-3MeH) excretion as an index of muscle protein catabolism, in P. peregrinus.