Associations between the stanford integrated psychosocial assessment for transplant and one-year lung transplant medical and psychosocial outcomes

The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) is a standardized measure of the psychosocial risk profile of solid organ transplant candidates. While studies have found associations between this measure and transplant outcomes, to date this has not been examined in lung transplant recipients. We examined relations between pre-transplant SIPAT scores and 1-year lung transplant medical and psychosocial outcomes in a sample of 45 lung transplant recipients. The SIPAT was significantly associated with 6-minute walk test (χ2(1) = 6.47, p = .010), number of readmissions (χ2(1) = 6.47, p = .011), and mental health services utilization (χ2(1) = 18.15, p < .001). It was not a significantly associated with the presence of organ rejection or mortality (ps > 0.10). Results suggest that the SIPAT can help identify patients who are at an elevated risk for transplant complications and thus would benefit from services to mitigate risk factors and improve outcomes.

Characterization of the Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) in Lung Transplant Candidates

The SIPAT is a standardized measure for pre-transplant psychosocial evaluation. Previous SIPAT studies utilized a relatively small lung transplant sample and only included listed patients. This study characterized the SIPAT in 147 lung transplant candidates to better elucidate its utility. The average score corresponded to a minimally acceptable rating and nearly half of the patients had relative or absolute contraindications. Interstitial Lung Disease (ILD) patients scored more favorably than non-ILD patients (U = 7.69, p < .05). The Total (β = - .05, SE = .018, p < .01), Social Support Subscale (β = - .133, SE = .058, p < .05), and Psychosocial Stability and Psychopathology Subscale (β = - .103, SE = .040, p < .05) significantly predicted listing status. The SIPAT has a unique profile in lung transplant candidates and demonstrated utility for guiding transplant decisions. Future research should examine which lung transplant outcomes are significantly associated with SIPAT scores.

Practice Issues for Evaluation and Management of the Suicidal Left Ventricular Assist Device Patient

There is a high prevalence of depression among left ventricular assist device patients, who present with an increased risk of suicidality given access to means via the device either with nonadherence or disconnection. Suicidality via device nonadherence/disconnection is an underresearched clinical issue, as paradoxically this life-saving procedure can also provide a method of lethal means to patients with significant mental health concerns. A case study is used to highlight the course of an attempted suicide by ventricular assistive device nonadherence. Clinical implications and recommendations for practice include a thorough psychological evaluation presurgery, monitoring quality of life and coping styles before and after placement, psychological testing, outlining specific suicide protocols, psychiatric care considerations for patients with highly specialized medical devices, and related ethical concerns.

An Investigation of Dosimetric Correlates of Acute Toxicity in Prostate Stereotactic Body Radiotherapy: Dose to Urinary Trigone is Associated with Acute Urinary Toxicity

AIMS

There are limited data on dosimetric correlates of toxicity in stereotactic body radiotherapy (SBRT) for prostate cancer. We aimed to identify potential relationships between dose and toxicity using conventional dose-volume histograms (DVHs) and dose-surface maps (DSMs).

MATERIALS AND METHODS

Urinary bladder trigone and rectum DSMs were produced for a single-institution service evaluation cohort of 50 patients receiving SBRT for localised prostate cancer, together with conventional DVHs for bladder and rectum. Patients had been prospectively recruited to this cohort and treated according to a pre-defined protocol to a dose of 36.25 Gy in five fractions. Radiation Therapy Oncology Group (RTOG) and International Prostate Symptom Score (IPSS) toxicity data were recorded prospectively. Logistic regression was used to identify dosimetric predictors of acute IPSS+10 (rise of 10 points or more above baseline) and grade 2+ RTOG toxicity.

RESULTS

On univariate analysis, trigone area receiving 40 Gy and trigone Dmax were associated with IPSS+10 (odds ratio 1.06 [1.02-1.11], P = 0.007 and odds ratio 1.54 [1.06-2.25], P = 0.024, respectively). These two variables were highly correlated. In a multivariate model, including all baseline variables, trigone Dmax remained associated with IPSS+10 (odds ratio 1.91 [1.13-3.22], P = 0.016). These findings were not significant with Holm-Bonferroni correction for multiple testing (corrected P value threshold 0.006). No associations were seen between rectal toxicity and DVH or DSM parameters.

CONCLUSIONS

Our study suggests a potential relationship between high doses to the urinary bladder trigone and patient-reported urinary toxicity in prostate SBRT, and is consistent with previous studies in conventionally fractionated radiotherapy, justifying further evaluation in larger cohorts.

Children with 7q11.23 duplication syndrome: psychological characteristics

To begin to delineate the psychological characteristics associated with classic 7q11.23 duplication syndrome (duplication of the classic Williams syndrome region; hereafter classic Dup7), we tested 63 children with classic Dup7 aged 4-17 years. Sixteen toddlers aged 18-45 months with classic Dup7 and 12 adults identified by cascade testing also were assessed. For the child group, median General Conceptual Ability (similar to IQ) on the Differential Ability Scales-II was 85.0 (low average), with a range from severe disability to high average ability. Median reading and mathematics achievement standard scores were at the low average to average level, with a range from severe impairment to high average or superior ability. Adaptive behavior was considerably more limited; median Scales of Independent Behavior-Revised Broad Independence standard score was 62.0 (mild impairment), with a range from severe adaptive impairment to average adaptive ability. Anxiety disorders were common, with 50.0% of children diagnosed with Social Phobia, 29.0% with Selective Mutism, 12.9% with Separation Anxiety Disorder, and 53.2% with Specific Phobia. In addition, 35.5% were diagnosed with Attention Deficit/Hyperactivity Disorder and 24.2% with Oppositional Defiant Disorder or Disruptive Behavior Disorder-Not Otherwise Specified. 33.3% of the children screened positive for a possible Autism Spectrum Disorder and 82.3% were diagnosed with Speech Sound Disorder. We compare these findings to previously reported results for children with Williams syndrome and argue that genotype/phenotype studies involving the Williams syndrome region offer important opportunities to understand the contribution of genes in this region to common disorders affecting the general population.

Fractionated stereotactic radiotherapy for acoustic neuromas: long-term outcomes

AIMS

Acoustic neuromas are rare, benign intracranial tumours. There are a variety of treatment options, with no clear optimal management strategy and wide variation in treated outcomes. We report the outcomes from a 15 year cohort of patients treated at our centre using fractionated stereotactic radiotherapy (52.5 Gy in 25 fractions).

MATERIALS AND METHODS

We analysed a retrospective case series. Patients were identified from patient records and a retrospective review of case notes and imaging reports was undertaken. We assessed tumour response using RECIST criteria and recorded toxicity. Progression-free survival was estimated using the Kaplan-Meier method. The study was conducted according to the STROBE guidelines.

RESULTS

In total, 93 patients were identified; 83 patients had follow-up data, with a median follow-up period of 5.7 years. The overall control rate using RECIST criteria was 92%. Data on complications were available for 90 patients, with six (7%) experiencing a reduction in hearing, one (1%) developing trigeminal nerve dysfunction and one (1%) a deterioration in facial nerve function. Other toxicities included four (4%) patients who developed hydrocephalus, requiring the placement of a shunt and one (1%) patient who developed radiation brainstem necrosis. After further evaluation this patient was deemed to have been treated within acceptable dose constraints.

CONCLUSION

These data suggest that a good control rate of acoustic neuromas is achievable using fractionated stereotactic radiotherapy to a dose of 52.5 Gy in 25 fractions. Toxicity is considered acceptable but the episode of radiation brainstem necrosis remains of concern and is the subject of further work.

Longitudinal course of anxiety in children and adolescents with Williams syndrome

The longitudinal course of anxiety disorders in 45 children and adolescents with Williams syndrome (WS) was examined. Children were ages 4-13 years at the initial assessment. To assess their child's DSM-IV diagnoses, parents completed a structured diagnostic interview 3-9 times at intervals of at least 1 year. At the first assessment, 60% of the sample presented with at least one anxiety diagnosis; 82.2% received an anxiety diagnosis at some time during the study. Chronic, persistent anxiety within the period 5 years after their initial diagnosis was shown by 62.2% of those with an anxiety diagnosis (51.1% of the entire sample). The most common diagnoses were specific phobias and generalized anxiety disorder. Multilevel logistic regression models were estimated for the presence of any anxiety disorder, specific phobia, and specific phobia of loud noises. Developmental trajectories, expressed as the probability of a positive diagnosis, suggested that the odds of a positive diagnosis did not change with age. IQ was not significantly related to the presence of an anxiety disorder. However, there was a significant relation between executive functioning and anxiety such that the presence of an anxiety diagnosis was associated with increased scores on behavioral regulation, indicative of increased difficulty with inhibitory control of affect and behavior. These findings are discussed in terms of persistence of anxiety over time and the need to develop and test interventions to address the high levels of anxiety experienced by children and adolescents with WS.

Spinal serotonin receptor activation modulates the exercise ventilatory response with increased dead space in goats

Small increases in respiratory dead space (VD) augment the exercise ventilatory response by a serotonin-dependent mechanism known as short-term modulation (STM). We tested the hypotheses that the relevant serotonin receptors for STM are in the spinal cord, and are of the 5-HT2-receptor subtype. After preparing adult female goats with a mid-thoracic (T6-T8) subarachnoid catheter, ventilation and arterial blood gases were measured at rest and during treadmill exercise (4.8 km/h; 5% grade) with and without an increased VD (0.2-0.3 L). Measurements were made before and after spinal or intravenous administration of a broad-spectrum serotonin receptor antagonist (methysergide, 1-2mg total) and a selective 5-HT2-receptor antagonist (ketanserin, 5-12 mg total). Although spinal methysergide had no effect on the exercise ventilatory response in control conditions, the augmented response with increased VD was impaired, allowing Pa(CO)(2) to increase from rest to exercise. Spinal methysergide diminished both mean inspiratory flow and frequency responses to exercise with increased VD. Spinal ketanserin impaired Pa(CO)(2) regulation with increased VD, although its ventilatory effects were less clear. Intrathecal dye injections indicated CSF drug distribution was caudal to the upper cervical spinal cord and intravenous drugs at the same total dose did not affect STM. We conclude that spinal 5-HT2 receptors modulate the exercise ventilatory response with increased VD in goats.

Serotonin elicits long-lasting enhancement of rhythmic respiratory activity in turtle brain stems in vitro

Brain stem preparations from adult turtles were used to determine how bath-applied serotonin (5-HT) alters respiration-related hypoglossal activity in a mature vertebrate. 5-HT (5-20 microM) reversibly decreased integrated burst amplitude by approximately 45% (P < 0.05); burst frequency decreased in a dose-dependent manner with 20 microM abolishing bursts in 9 of 13 preparations (P < 0.05). These 5-HT-dependent effects were mimicked by application of a 5-HT(1A) agonist, but not a 5-HT(1B) agonist, and were abolished by the broad-spectrum 5-HT antagonist, methiothepin. During 5-HT (20 microM) washout, frequency rebounded to levels above the original baseline for 40 min (P < 0.05) and remained above baseline for 2 h. A 5-HT(3) antagonist (tropesitron) blocked the post-5-HT rebound and persistent frequency increase. A 5-HT(3) agonist (phenylbiguanide) increased frequency during and after bath application (P < 0.05). When phenylbiguanide was applied to the brain stem of brain stem/spinal cord preparations, there was a persistent frequency increase (P < 0.05), but neither spinal-expiratory nor -inspiratory burst amplitude were altered. The 5-HT(3) receptor-dependent persistent frequency increase represents a unique model of plasticity in vertebrate rhythm generation.

A phase I trial of CV706, a replication-competent, PSA selective oncolytic adenovirus, for the treatment of locally recurrent prostate cancer following radiation therapy

CV706 is a prostate-specific antigen (PSA)-selective, replication-competent adenovirus that has been shown to selectively kill human prostate cancer xenografts in preclinical models. To study the safety and activity of intraprostatic delivery of CV706, a Phase I dose-ranging study for the treatment of patients with locally recurrent prostate cancer after radiation therapy was conducted. Twenty patients in five groups were treated with between 1 x 10(11) and 1 x 10(13) viral particles delivered by a real-time, transrectal ultrasound-guided transperineal technique using a three-dimensional plan. The primary end point was the determination of treatment-related toxicity. Secondary objectives included evaluation of the antitumor activity of CV706 and monitoring for other correlates of antineoplastic action. In this study, CV706 was found to be safe and was not associated with irreversible grade 3 or any grade 4 toxicity. No grade >1 alterations in liver function tests associated with CV706 administration were observed. Posttreatment prostatic biopsies and detection of a delayed "peak" of circulating copies of virus provided evidence of intraprostatic replication of CV706. The study defined the timing of CV706 shedding into blood and urine as well as the appearance of circulating Ad5 neutralizing antibodies. Finally, this study documents the serum PSA response of treated patients and reveals a dose response showing that all five patients who achieved a > or =50% reduction in PSA were treated with the highest two doses of CV706. This study represents the first clinical translation of a prostate-specific, replication-restricted adenovirus for the treatment of prostate cancer. Taken together, this study documents that intraprostatic delivery of CV706 can be safely administered to patients, even at high doses, and the data also suggest that CV706 possesses enough clinical activity, as reflected by changes in serum PSA, to warrant additional clinical and laboratory investigation.

A hepatocellular carcinoma-specific adenovirus variant, CV890, eliminates distant human liver tumors in combination with doxorubicin

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death in the world. Tumor resection remains the only curative treatment but is often not possible because of advanced stage and frequently unsuccessful because of intrahepatic or distant tumor recurrence. alpha-Fetoprotein (AFP), a tumor marker currently used for the diagnosis and management of HCC, is an oncofetal protein expressed in a majority of HCCs but rarely in normal hepatocytes. Because AFP gene expression is tightly regulated at the level of transcription, AFP transcriptional regulatory elements (TRE) are excellent candidates for generating HCC-specific oncolytic adenoviruses. We devised a new strategy for the AFP TRE to control an artificial E1A-IRES-E1B bicistronic cassette in an adenovirus 5 vector (Ad5) and constructed an HCC-specific oncolytic virus, CV890. In vitro, CV890 expression of the E1A and E1B genes, virus replication, and cytopathic effects were examined by Northern blot, Western blot, virus yield assay, and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay in AFP-producing cell lines (HepG2, Huh7, Hep3B, PLC/PRF/5, and SNU449), non-AFP-producing cell lines (Sk-Hep-1, Chang liver cell, LNCaP, HBL-100, PA-1, UM-UC-3, SW 780, Colo 201, and U118 MG), and non-AFP-producing human primary cells (lung fibroblast, bladder smooth muscle, and mammary epithelial). CV890 efficiently replicates in and destroys AFP-producing HCC cells as well as wild-type Ad5, but replication is highly attenuated in non-AFP-producing HCC cells or non-HCC cells. CV890 produced 5,000-100,000-fold less virus than wild-type Ad5 in non-AFP-producing cells. CV890 was attenuated 100-fold more than CV732, a virus containing the AFP TRE driving the E1A gene alone, in non-AFP-producing cells. These studies demonstrated that expression of both E1A and E1B genes under the control of a bicistronic AFP-E1A-IRES-E1B cassette yielded improvements in virus specificity equivalent to driving the E1A and E1B genes with two independent TREs yet requires only one TRE thereby conserving genomic space within the virus. Significantly, CV890 produced nearly the same yield of virus in cells that produced AFP over a 75-fold range, from a low of 60 ng AFP/10(6) cells/10 days to as high as 4585 ng AFP/10(6) cells/10 days. In vivo, antitumor efficacy of CV890 was examined in BALB/c-nu/nu mice containing large s.c. HepG2 or Hep3B tumor xenografts. Tumor volume of distant xenografts dropped below baseline 4 weeks after a single i.v. injection. Combination of CV890 with doxorubicin demonstrated synergistic antitumor efficacy, yielding complete elimination of distant Hep3B tumors 4 weeks after a single i.v. administration of both compounds. Our results support the clinical development of CV890 as an antineoplastic agent for the treatment of localized or metastatic HCC.

CV706, a prostate cancer-specific adenovirus variant, in combination with radiotherapy produces synergistic antitumor efficacy without increasing toxicity

Radiation is an effective means of treating localized prostate cancer. However, up to 40% of men with certain risk factors will develop biochemical failure 5 years after radiotherapy. CV706, a prostate cell-specific adenovirus variant, is currently in clinical trials for the treatment of recurrent organ-confined prostate cancer. We demonstrated previously that a single administration of CV706 at 5 x 10(8) particles/mm3 of tumor eliminated established tumors within 6 weeks in nude mouse xenografts (Rodriguez et al., Cancer Res. 57: 2559-2563, 1997). We now demonstrate that CV706-mediated cytotoxicity is synergistic with radiation. In vitro, addition of radiation to CV706 resulted in a synergistic increase of cytotoxicity toward the human prostate cancer cell line LNCaP and a significant increase of virus burst size, with no reduction in specificity of CV706-based cytopathogenicity for prostate cancer cells. In vivo, prostate-specific antigen (+) LNCaP xenografts of human prostate cancer were treated with CV706 (1 x 10(7) particles/mm3 of tumor), 10 Gy of single fraction local tumor radiation, or both. Tumor volumes of the group treated with CV706 or radiation was 97% or 120% of baseline 6 weeks after treatment. However, when the same dose of CV706 was followed 24 h later with the same dose of radiation, the tumor volume dropped to 4% of baseline at this time point and produced antitumor activity that was 6.7-fold greater than a predicted additive effect of CV706 and radiation. Histological analyses of tumors revealed that, compared with CV706 or radiation alone, combination treatment with two agents increased necrosis by 180% and 690%, apoptosis by 330% and 880%, and decreased blood vessel number by 1290% and 600%, respectively. Importantly, no increase in toxicity was observed after combined treatment when compared with CV706 or radiation alone. These data demonstrate that CV706 enhances the in vivo radioresponse of prostate tumors and support the clinical development of CV706 as a neoadjuvant agent with radiation for localized prostate cancer.

Antitumor synergy of CV787, a prostate cancer-specific adenovirus, and paclitaxel and docetaxel

CV787, a PSA+ prostate cell-specific adenovirus variant, is currently in Phase I/II clinical trials for the treatment of prostate cancer. We have previously demonstrated that a single administration of CV787 at 1 x 10(11) particle/animal could eliminate established tumors within 6 weeks in nude mouse xenografts (Yu et al., Cancer Res., 59: 4200-4203, 1999). We now demonstrate that CV787-mediated replication-dependent cytotoxicity is synergistic with the chemotherapeutic agents paclitaxel (Taxol) or docetaxel (Taxotere) both in vitro and in vivo. In vitro, cells were pretreated with CV787 24 h before taxane, pretreated with taxane 24 h before CV787, or treated with both agents simultaneously. Cell viability was determined at various time points by 3-[4,5-dimethylthiazole-2-4]-2,5-diphenyl-2H-tetrazolium bromide assay, and virus yield was examined by plaque assay. Addition of taxane to CV787 resulted in a synergistic increase of cytotoxicity toward the human prostate cancer cell line LNCaP, regardless of the timing of administration. There was no reduction in virus replication or specificity of CV787-based cytopathogenicity for prostate cancer cells (approximately 10,000 to 1) with the taxanes. p53 expression was significantly elevated in the cells treated with CV787 and taxane. In vivo, using the PSA+ LNCaP xenograft model of prostate cancer, a single i.v. dose of 1 x 10(8) particles CV787 and docetaxel in combination eliminates large preexistent distant tumors. Toxicity studies do not show a synergistic increase of toxicity of CV787 and taxane. These experiments demonstrate a synergistic antitumor efficacy for CV787 when combined with taxane and demonstrate an in vivo single-dose curative therapeutic index for CV787 of over 1000:1.

Short-term modulation of the exercise ventilatory response in goats: effects of 8-OH-DPAT and MPPI

Increased respiratory dead space increases the exercise ventilatory response, a response known as short-term modulation (STM). We hypothesized that STM results from a spinal, serotonin (5-HT)-dependent mechanism. Because 5-HT(1A) autoreceptors on caudal brain stem raphe neurons inhibit 5-HT release, we hypothesized that 5-HT(1A)-receptor agonists would inhibit, whereas 5-HT(1A)-receptor antagonists would enhance, STM. Ventilatory and arterial blood-gas measurements were made at rest and during exercise (4.0-4.5 km/h, 5% grade) in goats with the respiratory mask alone or with increased dead space (0.20-0.25 liter), before and after intravenous administration of the 5-HT(1A)-receptor agonist 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT; 0.1 mg/kg) or the antagonist 4-iodo-N-(2-[4-(methoxyphenyl)-1-piperazinyl]ethyl)-N-2-pyridinylbenz amide (MPPI; 0.08 mg/kg). 8-OH-DPAT increased the slope of the arterial PCO(2) vs. metabolic CO(2) production relationship and decreased the ventilation vs. metabolic CO(2) production relationship during exercise with increased dead space (not with the mask alone), indicating an impairment of STM. In contrast, MPPI had minimal effects on any measured variable. Although nonspecific effects of 8-OH-DPAT cannot be ruled out, impaired STM is consistent with the hypothesis that STM requires active raphe serotonergic neurons and 5-HT release.

Pre-existent adenovirus antibody inhibits systemic toxicity and antitumor activity of CN706 in the nude mouse LNCaP xenograft model: implications and proposals for human therapy

Pre-existent humoral antibody to adenovirus potentially confounds human clinical trials involving intravascular administration of adenovirus. Using the LNCaP prostate cancer xenograft model in BALB/c nu/nu mice and the prostate-specific attenuated replication-competent adenovirus (ARCATM) CN706, we developed an animal model that systematically controls both the dose of intravascularly administered adenovirus and the titer of the pre-existent anti-Ad5 antibody, and then measures the virus-induced toxicity as well as antitumor activity. We prepared hyperimmune sera to adenovirus in rabbits, passively injected the purified rabbit anti-Ad5 antibody into tumor-bearing mice, and established measurable humoral anti-Ad5 antibody titers. CN706 was intravenously injected into the tail vein of animals 24 hr after passive anti-Ad5 antibody administration. In the absence of pre-existent antibody, the lethal dose (LD100) for BALB/c nu/nu mice was 2.5x10(11) CN706 particles, whereas 1x10(11) CN706 particles was not lethal. However, in the presence of a 1:80 pre-existent titer of Ad5 neutralizing antibody (NAb), intravenous injection of 5x10(11) CN706 particles was no longer lethal. In addition, pre-existent antibody also prevented antitumor activity in a dose-dependent manner: 1x 10(11) CN706 particles prevented LNCaP xenograft tumor progression, but antitumor activity was eliminated by a pre-existent 1:80 NAb titer. These results led us to propose transient removal of pre-existent adenovirus antibody by immunoapheresis. An affinity column of cloned virus capsid proteins was constructed that was able to specifically remove adenovirus antibody from human clinical serum samples. A 5-min disposable immunoassay was also developed to monitor the level of pre-existent antibody in sera before and after immunoapheresis. Clinically, this approach may enable controlled clinical studies of intravenously administered adenovirus in patients with pre-existent anti-adenovirus antibody.

Serotonin reuptake inhibition does not enhance short term modulation of the exercise ventilatory response

Increased respiratory dead space causes a serotonin (5-HT) dependent augmentation of the exercise ventilatory response known as short term modulation (STM). Contrary to predictions, 5-HT reuptake inhibition with fluoxetine failed to enhance, and even impaired STM with large dead space volumes (0.4-0.6 L). In this study, we tested the hypotheses that: (1) fluoxetine similarly impairs STM with smaller dead space volumes (0.2 L); whereas (2) acute 5-HT release and reuptake inhibition with fenfluramine would enhance STM. Ventilatory and blood gas measurements were made on five goats (37-58 kg) during rest and exercise, with the mask alone or with increased dead space (0.2 L). STM protocols were performed following chronic fluoxetine (>/=21 days, 1 mg/kg, SQ, SID) and acute fenfluramine administration (1 mg/kg, IV). Following fluoxetine, STM was partially impaired. Fenfluramine had no detectable effects on STM. The data suggest that: (1) chronic fluoxetine diminishes STM, possibly via down-regulation of relevant 5-HT receptors, and (2) drugs that release 5-HT acutely do not enhance STM.

The addition of adenovirus type 5 region E3 enables calydon virus 787 to eliminate distant prostate tumor xenografts

CV787, a novel highly prostate-specific replication-competent adenovirus with improved efficacy, was constructed. CV787 contains the prostate-specific rat probasin promoter, driving the adenovirus type 5 (Ad5) E1A gene, and the human prostate-specific enhancer/promoter, driving the E1B gene. To improve efficacy, we constructed CV787 such that it also contains the entire Ad5 E3 region. CV787 replicates in prostate-specific antigen (PSA)+ cells as well as wild-type adenovirus, but in PSA- cells, CV787 replicates 10(4)-10(5) times less efficiently. CV787 destroys PSA+ prostate cancer cells 10,000 times more efficiently than PSA- cells. Incorporation of the Ad5 E3 region significantly improves the target cell killing ability or efficacy of CV787. In nu/nu mice carrying s.c. LNCaP xenografts, a single i.v. tail vein injection of CV787 eliminates 300-mm3 tumors within 4 weeks. CV787 could be a powerful therapeutic for human metastatic prostate cancer.

Identification of the transcriptional regulatory sequences of human kallikrein 2 and their use in the construction of calydon virus 764, an attenuated replication competent adenovirus for prostate cancer therapy

Human glandular kallikrein (hK2) and prostate-specific antigen (PSA) are related members of the human kallikrein gene family. The genes for hK2 and PSA are expressed predominately in the prostate, are transcriptionally up-regulated by androgens, and share 78% homology. Previously, one functional androgen response element was identified within the proximal promoter (-324 to +33 relative to the cap site) of the hK2 gene. To detect additional upstream regulatory elements, the 12.3 kbp between the PSA gene and 5' to the hK2 gene were amplified by PCR and linked to a promoterless firefly luciferase reporter gene. Transient transfection experiments showed an androgen-dependent enhancer, located between -3.4 and -5.2 kb upstream of the transcription start site of the hK2 gene. This hK2 enhancer increased luciferase expression 100-fold in the presence of the testosterone analogue R1881. The hK2 enhancer contains an androgen response element that lost activity when mutated. The hK2 enhancer/promoter demonstrated activity in PSA(+) LNCaP cells whereas the enhancer/promoter was inactive in PSA(-) 293, A549, HBL100, HUH-7, LoVo, MCF-7, OVCAR-3, and PC-3 cells. Insertion of the hK2 enhancer/promoter into adenovirus to drive the E1A genes of adenovirus type 5 (Ad5) created an attenuated replication competent adenovirus variant Calydon virus (CV) 763, which replicates similarly to wild-type adenovirus in prostate tumor cells but is attenuated in nonprostate tumor cells. In addition, CV764, an adenovirus variant containing the previously cloned prostate-specific enhancer (to drive the Ad5 E1A genes) and the hK2 enhancer/promoter (to drive the Ad5 E1B genes) was constructed. CV764 is significantly attenuated and has a high therapeutic index with a cell specificity of 10,000:1 for PSA(+) LNCaP cells, compared to ovarian cancer OVCAR-3 cells and SK-OV-3 cells and PA-1 cells. CV764 is also highly attenuated in primary human microvascular endothelial cells.

Effects of serotonin re-uptake inhibition on ventilatory control in goats

Fluoxetine (Prozac) inhibits serotonin (5-HT) re-uptake. thereby enhancing serotonergic effects. Since serotonin is known to affect ventilation in a variety of circumstances, we investigated the effects of chronic serotonin re-uptake inhibition with fluoxetine on selected ventilatory responses including: (1) eupnea; (2) the hypercapnic ventilatory response at rest; (3) the exercise ventilatory response and (4) repeated trials of hypercapnic exercise. Ventilatory and arterial blood gases were measured in goats (n = 5) at rest, during steady-state treadmill exercise, and during successive rest/exercise trials with increased respiratory dead space (0.4-0.6 L). Fluoxetine was administered (> or = 4 weeks, 1 mg/kg, SQ, SID) and protocols were repeated. Following fluoxetine, PaCO2 was increased in most conditions studied; however, no differences were seen in exercise PaCO2 regulation or ventilatory responses pre- versus post-fluoxetine. We conclude that chronic fluoxetine slightly depresses respiratory control at rest, but, has minimal effects during exercise or with mild hypercapnia during rest or exercise in goats.

CO2 and heat have different effects on directed ventilation behavior of grasshoppers Melanoplus differentialis

We tested the hypothesis that CO2 and heat have different effects on the ventilatory pattern of grasshoppers Melanoplus differentialis. Eight grasshoppers were sealed between rostral (inspiratory) and caudal (expiratory) spiracles in separated, airtight, chambers and pressure changes were measured. Normal breathing patterns decreased pressure in the rostral chamber and increased pressure in the caudal chamber (i.e. unidirectional pumping rostral to caudal). Insects exposed to ventilatory stimulation by CO2 or heat significantly increased pumping frequency from 26+/-2 (+/-S.E.M.) at 0% CO2 to 54+/-6 breaths/min at 8% CO2 (at 30 degrees C), and from 27+/-3 at 30 degrees C to 44+/-4 breaths/min at 45 degrees C. Unidirectional pumping failed to change with increased CO2 concentration and increased significantly with heat exposure. Thus, while CO2 only increased pumping frequency, heat increased pumping frequency and unidirectional pumping.

Prostate attenuated replication competent adenovirus (ARCA) CN706: a selective cytotoxic for prostate-specific antigen-positive prostate cancer cells

Prostate-specific antigen (PSA) is a widely used marker for the diagnosis and management of prostate cancer. Minimal enhancer/promoter constructs derived from the 5' flank of the human PSA gene (prostate-specific enhancer) were inserted into adenovirus type 5 DNA so as to drive the E1A gene, thereby creating a prostate-specific enhancer-containing virus, CN706. E1A was expressed at high levels in CN706-infected human PSA-producing LNCaP cells but not in CN706-infected DU145 cells, which are human prostate cells that do not express PSA. The titer of CN706 was significantly higher in LNCaP cells compared to several human cell lines that do not produce PSA (HBL100, PANC-1, MCF-7, DU145, and OVCAR3). Furthermore, in LNCaP cells, the yield of CN706 was dependent on exogenous androgen (R1881). CN706 destroyed large LNCaP tumors (1 x 10(9) cells) and abolished PSA production in nu/nu mouse xenograft models with a single intratumoral injection.

Prostate-specific antigen expression is regulated by an upstream enhancer

Prostate cancer can be detected using assays for blood-borne prostate-specific antigen (PSA), which is the clinically most useful diagnostic marker of malignant disease. This paper characterizes the 5 -flanking prostate-specific enhancer which controls expression of the human PSA gene This enhancer, located between -5824 and -3738, is androgen-responsive and requires a promoter for activity. Inductions of 12-100-fold activity occur at 1 nM concentrations of the testosterone analog R1881. The enhancer demonstrated tissue specificity as judged by transfections of several human cell lines. Electrophoretic mobility shift assays comparing nuclear extracts from breast cancer cells MCF-7, and prostate cancer cells LNCaP, showed three regions of prostate-specific binding. These three regions are -4168 to -4797 (region I), -4710 to 4479 (region II), and -4168 to -3801 (region III). Region III contained a putative androgen response element at -4136 that markedly affected activity if mutated. These data suggest that prostate-specific gene expression may involve interaction of prostate-specific proteins or protein complexes with the enhancer in addition to binding of the androgen receptor to androgen response elements.

Histiocytic necrotising lymphadenitis in systemic lupus erythematosus

Histiocytic necrotising lymphadenitis is the pathognomonic histological appearance of lymph nodes in Kikuchi's disease, a condition characterised by a brief systemic illness and lymphadenopathy. The case is described of a young man, originally diagnosed as having Kikuchi's disease by lymph node histology, who subsequently developed systemic lupus erythematosus with symmetrical polyarthritis, Coombs' positive haemolytic anaemia and haemorrhagic pneumonitis. The case emphasises that a range of diseases is associated with histiocytic necrotising lymphadenitis, belying the unitary impression given by the term Kikuchi's disease.

Bilateral pleural and pericardial effusions because of mediastinal placement of a central venous catheter

Pneumothorax, hydrothorax, hydromediastinum, and cardiac tamponade are uncommon, although not unusual, complications of central venous catheter placement. We report a case of hydromediastinum with bilateral pleural and pericardial effusions, occurring in a patient after placement of a Silastic double-lumen central venous catheter for hyperalimentation.

Endoscopic sphincterotomy in the management of benign and malignant extrahepatic biliary obstruction

One hundred twenty-one patients with extrahepatic biliary obstruction underwent endoscopic sphincterotomy (EST). This was followed by balloon occlusion catheter or dormia basket stone extraction in 106 patients with choledocholithiasis, and by transpapillary biliary endoprosthesis placement in 15 patients with malignant distal common bile duct obstruction. All patients had excellent biliary decompression. Complications not requiring surgical intervention were seen in six patients. This article shows that EST is a low-risk, effective therapy for benign and malignant extrahepatic biliary obstruction.

Percutaneous transluminal angioplasty of stenosis at the common iliac artery origin using a single-balloon technique

The "kissing balloon" technique has been recommended for percutaneous transluminal angioplasty of common iliac stenoses located at or near the aortic bifurcation, because of the theoretical risk of contralateral embolization or stenosis if a single balloon is used. A single-balloon technique was used to dilate 20 atherosclerotic stenoses at this site in 19 patients. Technical success was achieved in 18. No complications occurred. Follow-up studies at intervals ranging from three to 51 months showed a patency rate similar to that achieved with the kissing balloon method. We believe that the use of kissing balloons is unnecessary since single-balloon angioplasty is safe and effective.

Early gastric cancer in clinical practice

A description of four patients with early gastric cancer diagnosed by endoscopy is reported. All patients presented with type III (excavated or ulcerative) early gastric cancer. Early gastric cancer appeared to be slow growing in three patients, and was difficult to diagnose in two cases, especially when associated with large gastric ulcers. Endoscopic biopsy of nonhealing or recurrent gastric ulcers and endoscopic follow-up to complete ulcer healing are recommended.

Pancreatic abscess associated with pancreas divisum

Pancreas divisum has been implicated as a cause of pancreatitis. Pseudocyst development in association with chronic pancreatitis has also been observed in a few patients with this anomaly. The association of pancreatic abscess with pancreas divisum has not been observed previously. The case herein reported illustrates a coincidental finding of pancreas divisum in a patient who presented with a pancreatic abscess.

IgG (kappa) paraproteinaemia and arthritis

Three patients with IgG (kappa) paraproteinaemia in association with inflammatory polyarthritis are described. Two of the patients had an erosive deforming arthritis, and the third had a non-erosive arthritis and necrotizing vasculitis. Possible aetiological relationships between the paraproteinaemia, arthritis and vasculitis are discussed.

Swing beds: an approach to hospital utilization

The need to use every available space for productive purposes is becoming a major concern for hospitals, especially rural hospitals. This need, coupled with the decline in the building of nursing homes, has given rise to the concept of the swing bed, a hospital bed that can be used to provide care to either acute or long-term care patients. This ability allows an acute care hospital to provide care to patients who might traditionally receive care in a nursing home.

CEDIA, a new homogeneous immunoassay system

Genetic engineering of beta-galactosidase (EC 3.2.1.23) has led to the development of a new homogeneous assay system, CEDIA. The Z gene of the lac operon of Escherichia coli encodes a large enzymatically inactive polypeptide that spontaneously aggregates and folds to form active beta-galactosidase. Using recombinant DNA techniques, we have been able to engineer beta-galactosidase protein into a large polypeptide (an enzyme acceptor, EA) and a small polypeptide (an enzyme donor, ED). The EAs and EDs are both enzymatically inactive, but spontaneously associate to form enzymatically active tetramers. In the assay, hapten or analyte is attached to an ED, and an analyte-specific antibody is used to inhibit the spontaneous assembly of active enzyme. Analyte in a patient's serum competes with the analyte in the analyte-ED conjugate for antibody, modulating the amount of beta-galactosidase formed. The signal generated by enzyme substrates is directly proportional to the analyte concentrations in the patient's serum. We describe quick (5-15 min) colorimetric tests for digoxin, requiring no serum pretreatments or predilutions and suitable for use with centrifugal and random-access analyzers.

CEDIA, a new homogeneous immunoassay system

Genetic engineering of beta-galactosidase (EC 3.2.1.23) has led to the development of a new homogeneous assay system, CEDIA. The Z gene of the lac operon of Escherichia coli encodes a large enzymatically inactive polypeptide that spontaneously aggregates and folds to form active beta-galactosidase. Using recombinant DNA techniques, we have been able to engineer beta-galactosidase protein into a large polypeptide (an enzyme acceptor, EA) and a small polypeptide (an enzyme donor, ED). The EAs and EDs are both enzymatically inactive, but spontaneously associate to form enzymatically active tetramers. In the assay, hapten or analyte is attached to an ED, and an analyte-specific antibody is used to inhibit the spontaneous assembly of active enzyme. Analyte in a patient's serum competes with the analyte in the analyte-ED conjugate for antibody, modulating the amount of beta-galactosidase formed. The signal generated by enzyme substrates is directly proportional to the analyte concentrations in the patient's serum. We describe quick (5-15 min) colorimetric tests for digoxin, requiring no serum pretreatments or predilutions and suitable for use with centrifugal and random-access analyzers.

Endoscopic sphincterotomy in clinical practice

Endoscopic sphincterotomy was performed in 22 patients with biliary obstruction. Nineteen patients had obstructing choledocholithiasis and three patients had distal common-bileduct obstruction due to malignant disease. All patients had excellent biliary decompression. Three patients had complications that responded to medical management. Endoscopic sphincterotomy is a safe and effective procedure for the nonsurgical management of obstructive-biliary-tract disease.

Calcium pyrophosphate dihydrate deposition disease and familial hypomagnesemia

A 40-year-old woman presented with calcium pyrophosphate synovitis and chondrocalcinosis. She was subsequently found to have hypomagnesemia, as did her 22-year-old son. Metabolic studies demonstrated normal gastrointestinal absorption of magnesium, and impaired renal conservation of magnesium without other evidence of renal tubular dysfunction. It seems likely that a genetically determined abnormality of magnesium metabolism was responsible for the occurrence of chondrocalcinosis in this patient.

Longterm follow-up of posterior cervical fusion for atlanto-axial subluxation in rheumatoid arthritis

Surgical fusion of the upper cervical spine was used to treat atlanto-axial subluxation in 7 patients with rheumatoid arthritis. Postsurgical follow-up was 3 to 16 yr. Despite progressive and often severe radiological changes in the cervical spine, no patient has had a clinical recurrence of neck symptoms requiring further surgery. These results suggest that surgical fusion is successful in the longterm, despite the often dramatic radiological changes which occur in the cervical spine with the passage of time.

Spontaneous osteonecrosis of the medial femoral condyle

Six patients with osteonecrosis of the medial femoral condyle were seen during a 3 1/2-year period in a rheumatology unit. This condition, which may not be rare, is characterized by the sudden onset of pain in the knee of elderly people (usually women) without significant trauma. Physical signs include effusion and tenderness at the medial margin of the knee joint. Radiographic changes may not be evident for weeks or even months. The later appearances are characteristic and the site of the lesion is remarkably constant.

Synovitis in polymyalgia rheumatica

Synovitis was observed in 13 out of 88 consecutive patients with polymyalgia rheumatica. It is described in detail in five patients, on the basis of clinical radiological observations, joint aspiration, arthroscopy and biopsy. The synovitis of polymyalgia rheumatica cannot be distinguished histologically or at arthroscopy from the appearance seen in mild rheumatoid arthritis. Clinically, however, the synovitis of polymyalgia rheumatica is mild, transient and confined to one or two joints or tendon sheaths. It is not followed by joint deformity or by radiological erosive changes in the bone ends. It may occur at any stage of the disease but particularly at its onset, or when the dose of corticosteroid treatment is reduced.

Vertical atlanto-axial subluxation in rheumatoid arthritis

In a prospective survey of 476 hospital in-patients with rheumatoid arthritis, vertical atlanto-axial subluxation (AAL) was found in 13 patients (3.7 per cent). All were women with severe rheumatoid arthritis. Neurological signs were found in ten patients, and in seven they appeared to be due to vertical AAL. The signs caused by vertical AAL were diminished pain and temperature sensation in the upper divisions of the trigeminal nerve, sensory loss in the areas supplied by C2, nystagmus and pyramidal lesions. Disabling involvement due to vertical AAL was not found although it may occur and the lesion may be fatal. The lower cervical spine was involved in all patients and severe lesions were seen in nine. The most severe neurological lesions appeared to be due to subaxial subluxation. Corticosteroid therapy may have been a contributing factor in four patients.

Lack of correlation of synovial histology with joint damage in rheumatoid arthritis

Twenty-two patients with rheumatoid arthritis (RA) involving the knee were studied. The systemic features of the disease were graded and the extent of knee involvement was quantified in terms of the clinical, radiological, and arthroscopic appearances. Adequate synovial biopsies were obtained from 21 patients. In these patients no correlation could be found between the severity of any of the features on histological examination nor between any of these features and the extent of local joint damage, inflammation, or the severity of the systemic disease.