Adjustment of creatinine clearance for carboplatin dosing in Calvert's formula and clinical efficacy for lung cancer

BACKGROUND

The Cockcroft-Gault formula is commonly used as a substitute for glomerular filtration rate (GFR) in Calvert's formula for carboplatin dosing, where adjusting serum creatinine measured using the enzymatic method with 0.2 mg/dL has been suggested in Japan. However, the effects of these adjustments on efficacy in patients with non-small-cell lung cancer remain unknown.

METHODS

We conducted a post hoc analysis of the PREDICT1 study (CJLSG1201), a multicenter prospective observational trial of carboplatin-pemetrexed. Glomerular filtration rate values in Calvert's formula were back-calculated from the administered dosages of carboplatin and the reported value of the target area under the curve. We estimated the serum creatinine adjustments and divided the patients into crude and adjusted groups.

RESULTS

Patients in the crude group (N = 169) demonstrated similar efficacy to those in the adjusted group (N = 104) in progression-free survival (PFS) and overall survival (OS) (hazard ratio [HR], 1.02; 95% confidence interval [CI], 0.76-1.35; p = 0.916 vs. HR, 0.87; 95% CI, 0.65-1.17; p = 0.363), with higher grade 3-4 hematologic toxicity. Among patients aged ≥75 years, the crude group (N = 47) showed superior efficacy compared with the adjusted group (N = 17) in PFS and OS (HR, 0.37; 95% CI, 0.20-0.69; p = 0.002 vs. HR, 0.43; 95% CI, 0.23-0.82; p = 0.010).

CONCLUSIONS

Serum creatinine adjustment may be associated with similar efficacy compared to the crude serum creatinine value. In older patients, the adjustment should be cautiously applied owing to the potential for reduced efficacy.

PREDICT1: An observational study for identifying blood biomarkers associated with clinical benefit from carboplatin and pemetrexed (CbP) treatment in patients with non-squamous (NS) non-small cell lung cancer (NSCLC) (CJLSG1201)

9524

Background: At present, platinum-doublet chemotherapy or in combination with an immune check point inhibitor are standard treatment for patients with metastatic or recurrent NSCLC which lacks somatic gene alterations. Although CbP is one of the commonly used treatment options for NS-NSCLC, its clinical utility is limited due to lack of optimal biomarkers. Methods: Chemotherapy-naïve patients with pathologically proven advanced or recurrent NS-NSCLC received carboplatin (area under the curve = 5-6, at investigator’s discretion) plus pemetrexed (500 mg/m2) every 3 weeks followed by maintenance pemetrexed until disease progression. Blood samples were collected before treatment for proteomic analysis using mass spectrometry (MS). A classifier was constructed based on both an objective response assessed by radiologist independent of attending physicians in accordance with RECIST v1.1 and expression profiles of protein in a training cohort. The constructed classifier was then assessed with a validation cohort evaluating prediction accuracy of good responder, progression free survival (PFS) and overall survival (OS). Results: Of 244 patients with NS-NSCLC in a training cohort, proteomic profiles in blood from 96 patients who responded or progressed after treatment with CbP were analyzed to develop a classifier based on weighted voting. Details of the classifier will be presented at the 2020 ASCO Annual Meeting. The classifier was then applied to validation cohort (n = 94), and we successfully identified patients who benefit from the treatment (55 in good MS group) or not (39 in poor MS group). The objective response rate of the good MS group was significantly higher than that of the poor MS group (30.9% vs. 5.1%; p = 0.0018). The good MS group showed a significantly improved survival compared to the poor MS group (median PFS, 6.0 m vs. 2.3 m; hazard ratio [HR], 0.15; 95% confidence interval [CI], 0.09-0.27; p < 0.001; median OS, 25.7 m vs. 5.1 m; HR, 0.18; 95% CI, 0.1-0.34; p < 0.001). Conclusions: In the present study, we successfully developed and validated a predictive classifier using proteomic analyses with blood samples collected from patients before treatment with CbP, suggesting the clinical utility of the classifier in selecting NS-NSCLC patients for treatment with CbP. Clinical trial information: UMIN000008476 .

[Utility of the Predictive Score for Cisplatin-Induced Nephrotoxicity in Patients with Chemotherapy for Lung Cancer]

BACKGROUND

Cisplatin(CDDP)-induced nephrotoxicity(CIN)is a critical complication of chemotherapy. Among patients undergoing chemotherapy with CDDP, short-hydration, and magnesium supplementation for lung cancer, this study was conducted to evaluate the frequency of CIN and utility of the predictive score.

METHODS

Patients who underwent chemotherapy with CDDP for lung cancer were retrospectively investigated. A multiple logistic regression analysis to detect the risk factors for CIN and receiver operating characteristic analysis to examine the discrimination of the predictive score were performed.

RESULTS

A total of 111 patients were included, with a total count of chemotherapy courses of 402 and a median count of chemotherapy courses of 4. CIN occurred in 9.9% of the patients, with grade 2 and higher in 7.2% and 87% of the CIN cases detected in the initial course, respectively. The significantly independent risk factors for CIN included the number of chemotherapy courses, female gender, and predictive score. The discriminative power of the predictive score was moderate.

CONCLUSION

The predictive score for CIN was simple and useful in patients undergoing chemotherapy for lung cancer with CDDP, short-hydration, and magnesium supplementation, even in late courses.

Effect of pulmonary rehabilitation with assistive use of short-acting β2 agonist in COPD patients using long-acting bronchodilators

Background: Assistive use of short-acting β2 agonists (SABAs) reportedly improves exercise tolerance, activities of daily living, and health-related quality of life (HRQOL) in patients with chronic obstructive pulmonary disease (COPD). However, the effect of SABA on physical activity (PA) is unclear.Objective: This study aimed to determine whether assistive use of SABA increases PA and whether additional pulmonary rehabilitation (PR) can aid further improvement.Methods: Twelve outpatients with COPD and dyspnea during daily activities despite regular use of long-acting bronchodilators were enrolled. This study comprised a 2-week pre-intervention investigation, a 12-week investigation of SABA effects, and an 8-week investigation of the additional effects of PR. Assistive use of SABA was allowed up to 4 times per day after the pre-intervention period. PA was measured for 14 consecutive days using an accelerometer sensor. Dyspnea, exercise tolerance, and HRQOL were evaluated at entry, at 4 and 12 weeks after initiating SABA use, and after completing PR.Results: Assistive use of SABA improved breathlessness during daily activities and increased PA (p < .001). PA and HRQOL were also improved following PR (p < .001 and p = .013, respectively).Conclusions: Combined therapy of SABA and PR can increase PA and HRQOL in COPD patients.

Comparison between stereotactic radiosurgery and whole-brain radiotherapy for 10-20 brain metastases from non-small cell lung cancer

The efficacy and safety of stereotactic radiosurgery (SRS) in comparison with whole brain radiotherapy (WBRT) for brain metastases (BMs) remains unclear. The present study retrospectively reviewed 44 patients who received SRS or WBRT as an initial treatment for 10-20 BMs from non-small cell lung cancer between 2009 and 2016. Of the patients, 24 (54.5%) were treated with SRS and 20 (45.5%) were treated with WBRT. Overall survival (OS), time to intracranial progression (TTIP), neurological survival (NS), and prognostic factors were examined. OS did not significantly differ between the two groups: 7.3 months in the SRS group vs. 7.2 months in the WBRT group (P=0.502). Median TTIP was significantly shorter in the SRS group than in the WBRT group (7.1 vs. 19.1 months, P=0.009). In contrast, there were no significant differences in NS between the two groups (14.5 months in the SRS group vs. 12.9 months in the WBRT group, P=0.346). Univariate and multivariate analysis revealed that the type of initial treatment for BMs (WBRT or SRS) was not a significant prognostic factor (hazard ratio=0.80, 95% confidence interval: 0.42-1.52, P=0.502). However, histology, performance status, subsequent molecular targeted drugs, subsequent chemotherapy and salvage treatment were independent prognostic factors. There were no significant differences in OS and NS between treatment with SRS and treatment with WBRT in patients with 10-20 BMs, although TTIP was improved with WBRT. As an upfront treatment for 10-20 BMs, SRS may delay WBRT and the adverse events associated with WBRT.

Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101)

BACKGROUND

Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness.

SUBJECTS, MATERIALS, AND METHODS

In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective.

RESULTS

Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness.

CONCLUSION

Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine.

IMPLICATIONS FOR PRACTICE

This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.

Factors influencing the physical activity in daily life of male patients with different levels of severity of chronic obstructive pulmonary disease

[Purpose] Physical activity influences the prognosis of chronic obstructive pulmonary disease and is influenced by exercise tolerance, and environmental, psychological, and many other factors, but the influence of these factors on physical activity levels in each stage of chronic obstructive pulmonary disease is unknown. This study aimed to clarify this matter. [Participants and Methods] Seventy-one male patients with chronic obstructive pulmonary disease (aged 72.2 ± 4.5 years) participated in this study. We compared physical activity levels (determined as daily steps), presence or absence of daily routine (e.g., housework or hobby), 6-minute walking distance, psychological factors (using the Hospital Anxiety and Depression Scale), and health-related quality of life (Physical and Mental component summary of the 36-item short-form health survey) between patients in different stages of chronic obstructive pulmonary disease. [Results] When examined at each stage of chronic obstructive pulmonary disease, physical activity levels correlated with the presence or absence of daily routine, 6-minute walking distance, and Physical component summary in all stages, but the scores in the anxiety and depression components of the Hospital Anxiety and Depression Scale and Mental component summary correlated only with stage 4. [Conclusion] Physical functioning was related to physical activity levels at any stage of chronic obstructive pulmonary disease, although psychological functioning was related to the progress of disease severity. The approach to promote an active lifestyle must be selected depending on the stage of chronic obstructive pulmonary disease.

Physician cooperation in outpatient cancer care. An amplified secondary analysis of qualitative interview data

The importance of outpatient cancer care services is increasing due to the growing number of patients having or having had cancer. However, little is known about cooperation among physicians in outpatient settings. To understand what inter- and multidisciplinary care means in community settings, we conducted an amplified secondary analysis that combined qualitative interview data with 42 general practitioners (GPs), 21 oncologists and 21 urologists that mainly worked in medical practices in Germany. We compared their perspectives on cooperation relationships in cancer care. Our results indicate that all participants regarded cooperation as a prerequisite for good cancer care. Oncologists and urologists mainly reported cooperating for tumour-specific treatment tasks, while GPs' reasoning for cooperation was more patient-centred. While oncologists and urologists reported experiencing reciprocal communication with other physicians, GPs had to gather the information they needed. GPs seldom reported engaging in formal cooperation structures, while for specialists, participation in formal spaces of cooperation, such as tumour boards, facilitated a more frequent and informal discussion of patients, for instance on the phone. Further research should focus on ways to foster GPs' integration in cancer care and evaluate if this can be reached by incorporating GPs in formal cooperation structures such as tumour boards.

A propensity score-matched comparison of the efficacies of OK-432 and talc slurry for pleurodesis for malignant pleural effusion induced by lung adenocarcinoma

BACKGROUND

The choice of an optimal sclerosant for pleurodesis for malignant pleural effusion remains controversial. This retrospective clinical study compared the efficacy and safety of two sclerosants; talc slurry (talc-s) and OK-432.

METHODS

We compared the characteristics, 30/90-day success rates, and adverse events in patients with lung adenocarcinoma who underwent pleurodesis by using either OK-432 or talc-s. Propensity score matching was used to compare the two scelrosants.

RESULTS

Ninety-four patients (mean age=71.6±9.6 years) were included in this retrospective study, of whom 64 received OK-432 and 30 received talc-s. Seventy-three patients (77.6%) were initially diagnosed with clinical stage IV lung cancer, with a 28.7% epidermal growth factor receptor mutation frequency. The propensity score-matched cohort included 26 patients from each group. The 30-day success rates for OK-432 and talc-s were 80.7% and 76.9%, respectively (odds ratio: 1.26, 95% confidence interval: 0.33-4.77, p=0.73). Neither the overall incidence of adverse events nor the 90-day success rates differed significantly. Multivariate logistic regression revealed that the predictors of 30-day success were lower drainage volume on the previous day, particularly <250mL/day, the presence of full lung expansion, and pre-therapy with an epidermal growth factor receptor-tyrosine kinase inhibitor. The median post-pleurodesis survival time was 6.9 months, which was not significantly different between the study groups.

CONCLUSIONS

Propensity score-matched analyses showed that pleurodesis using OK-432 and talc-s demonstrated comparable efficacy and safety profiles in patients with lung adenocarcinoma. This indicated that OK-432 could be a viable alternative to talc-s in this procedure.

Can we predict the development of serious adverse events (SAEs) and early treatment termination in elderly non-small cell lung cancer (NSCLC) patients receiving platinum-based chemotherapy?

PURPOSE

Predicting the feasibility of platinum-based chemotherapy remains an important issue in elderly (over 70 years) patients with non-small cell lung cancer (NSCLC). The aim of this study was to identify the risk factors for the early serious adverse events (SAEs) (during cycles 1-2) in elderly receiving platinum-based chemotherapy, and to explore the clinical characteristics of patients who require early treatment termination without progressive disease (PD).

METHODS

One hundred and ninety-eight consecutive elderly NSCLC patients receiving platinum-based chemotherapy were retrospectively reviewed.

RESULTS

The median age was 73 years (range 70-83). 161 (81 %) were males, and 190 (95 %) were PS 0-1. Fifty-one (29 %) and 39 (19 %) patients developed early non-hematological SAEs and hematological SAEs, respectively. Multivariate analysis identified low serum albumin (<3.0 g/dl) as an independent risk factor for non-hematological SAEs, while low creatinine clearance (<45 ml/min) for hematological SAEs. In all, 24 (12 %) patients needed early treatment termination without PD. The major reason for this event was the development of non-hematological SAEs (4.5 %), followed by grade 2 non-hematological adverse events (AEs) (3 %). In multivariate analysis, age over 75 years and low serum albumin were associated with this event. The median overall survival (OS) in patients with this event was only 6.0 months, while the development of early SAE was not associated with poor OS.

CONCLUSION

Baseline serum albumin might be useful for predicting the feasibility of platinum-based chemotherapy, and the risk estimation of early treatment termination without PD might be beneficial for the treatment selection in elderly NSCLC patients.

[A Case of Acute Arterial Occlusion of the Lower Limb during Chemotherapy for Lung Cancer]

A 69-year-old man visited a clinic for left leg weakness. With suspicions of lung cancer and a metastatic brain tumor, he was referred to our hospital and was diagnosed with large cell neuroendocrine carcinoma, cT1bN0M1b (BRA), stage IV. After stereotactic radiosurgery for his brain metastasis, he was treated with chemotherapy containing cisplatin and irinotecan. A week after initiating chemotherapy, he suddenly developed severe right leg pain and adynamia. A computed tomography angiogram revealed occlusion of the right common femoral artery, and percutaneous thrombectomy was performed. The symptoms resolved completely, and he was discharged without any sequelae or recurrence. Acute arterial occlusion of the limbs during chemotherapy is uncommon and requires prompt diagnosis and treatment; hence, caution should be paid when it is clinically suspected.

Phase II Study of Carboplatin and Pemetrexed in Advanced EGFR-wild-type Non-squamous Non-small Cell Lung Cancer: The Central Japan Lung Study Group Trial 0906

BACKGROUND

Several pre-clinical and clinical studies suggest a potential predictive role of epidermal growth factor receptor (EGFR) mutation in responsiveness to cytotoxic chemotherapy. The aim of this phase II study was to evaluate the efficacy and safety of pemetrexed-carboplatin combination as first-line chemotherapy in advanced non-squamous non-small cell lung cancer (NSCLC) limited to EGFR-wild-type cases.

PATIENTS AND METHODS

In this single-arm, multicenter clinical trial, patients received pemetrexed (500 mg/m(2)) and carboplatin (area under the curve=6) intravenously on day 1 every 3 weeks for three to six cycles. The objective response rate (ORR) was the primary end-point; secondary end-points included the disease control rate (DCR), progression-free survival (PFS), overall survival (OS) and safety.

RESULTS

A total of 54 patients were enrolled and 53 patients received therapy. No complete response was observed and partial response was observed in 19 (35.8%) cases, resulting in an ORR of 35.8% [95% confidence interval (CI)=23.1-50.2%]. Stable disease was observed in 20 (37.7%) patients and therefore the DCR was 73.6% (95% CI=59.7-84.7%). The median PFS was 5.4 months (95% CI=4.1-6.8 months) and the median OS was 12.7 months (95% CI=9.3-16.1 months). Treatment-related grade 3 or 4 hematological toxicities were neutropenia, leukopenia, anemia and thrombocytopenia in 35.8%, 11.3%, 30.2%, and 32.1% of patients, respectively. No grade 3 febrile neutropenia was observed, and grade 3 or 4 non-hematological toxicities were mild. There was no treatment-related death.

CONCLUSION

The pemetrexed-carboplatin combination was effective and well-tolerated in patients with EGFR-wild-type non-squamous NSCLC (UMIN-CTR number: UMIN000003393).

Distinct features of distant metastasis and lymph node stage in lung adenocarcinoma patients with epidermal growth factor receptor gene mutations

BACKGROUND

The influence of epidermal growth factor receptor (EGFR) mutation status on distant and lymph node metastasis is not fully understood.

METHODS

Ninety-five consecutive patients with stage IV lung adenocarcinoma, who had been examined for the EGFR mutation status, were retrospectively analyzed with regard to numbers of distant metastasis and clinical stage of lymph node metastasis at the time of diagnosis.

RESULTS

While EGFR mutation status did not influence the presence or absence of distant metastasis in the lung, brain, or liver, patients with EGFR mutations demonstrated a significantly greater number of metastatic lesions in the lung (median: 85 vs. 4, P=0.01) and the brain (11 vs. 3.5, P=0.04). On the other hand, patients with EGFR mutations showed a significantly lower lymph node staging (P<0.01).

CONCLUSION

The presence of EGFR mutations in patients with lung adenocarcinoma correlates with lower lymph node stage and a greater number of metastatic lesions in the lung and brain.

Diagnostic management of patients with suspected ocular sarcoidosis

BACKGROUND

Ophthalmologists often refer patients with suspected ocular sarcoidosis to pulmonologists for diagnostic examination of sarcoidosis. However, no recommendation has been proposed for managing such patients. This study aims to prospectively evaluate the diagnostic values of examinations and propose the management of patients with suspected ocular sarcoidosis.

METHODS

Consecutive patients with suspected ocular sarcoidosis were prospectively investigated according to type of ocular lesions, measurement of serum ACE, and findings of chest radiography, chest CT, bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB). Diagnostic values were calculated on the basis of pathological results.

RESULTS

Forty-two patients were included (female, 71.4%; mean age, 56.2±14.8 years), of whom 64.3% was diagnosed with sarcoidosis. Patient characteristics and ocular lesions did not differ significantly, regardless of the presence of sarcoidosis. Chest CT had low specificity and very high sensitivity for detecting sarcoidosis; in contrast, chest radiography and direct findings of bronchofiberscopy had high specificity and low sensitivity. Serum ACE and BAL did not have high diagnostic value. A flow chart was proposed to diagnose sarcoidosis, and this chart reduced the requirement of TBLB to 50% in our population. During the median follow-up of 51 months, 7 patients in the sarcoidosis group (25.9%) developed new lesions.

CONCLUSIONS

Application of our flow chart appears to detect avoidable TBLB. Development of a more comprehensive flow chart including survey of ocular findings is warranted.

Re-expansion pulmonary edema: evaluation of risk factors in 173 episodes of spontaneous pneumothorax

BACKGROUND

The precise incidence and clinical features of re-expansion pulmonary edema (RPE) are unclear, and they vary among reports. In this study, we assessed the incidence, risk factors, and outcomes of patients with RPE over a 3-yr period in a general hospital, with the goal of proposing a primary intervention for pneumothorax.

METHODS

We retrospectively reviewed records of inpatients with spontaneous pneumothorax treated by tube thoracostomy between October 2007 and December 2010.

RESULTS

A total of 173 episodes of spontaneous pneumothorax occurred in 156 patients. The incidence of RPE was 27/173 (15.6%). Symptom duration and pneumothorax size were significant risk factors for RPE, and the occurrence of RPE was independent of primary treatment of spontaneous pneumothorax. Among the patients with RPE, 18 (67%) were symptomatic. Five patients (18.5%) were treated with temporary oxygen, however, 21 patients (78%) did not need any treatment. All patients survived and none required mechanical ventilation. The occurrence of RPE did not influence the clinical outcome.

CONCLUSIONS

The risk of developing RPE increases with an increased duration or size of pneumothorax. Our results suggest that the methods of primary intervention, including prompt suction, do not affect the onset of RPE. Close observation is always required regardless of the intervention because of the potentially fatal complications.

Paradoxical infarct in tuberculous meningitis: a case report

We describe a case of 78-year-old woman with a 1-week history of fever and left hemiparesis. Head magnetic resonance imaging showed a small infarct. After admission, she showed altered consciousness and another small infarct. She finally had diagnoses of miliary tuberculosis (miliary-TB) and tuberculous meningitis (TBM). She recovered after receiving anti-tuberculous therapy (ATT) with prednisolone. However, 5 weeks later, we found another infarct. This is a rare case of TBM with recurrent infarcts in atypical lesions in spite of ATT. We suggest the possibility that the new infarct after ATT was due to a paradoxical reaction.

[A case of six metachronous primary malignancies]

Recently, the early detection and the advances in therapy for malignant diseases have contributed to prolonged survival of patients, resulting in an increment of multiple primary malignancies. We describe a 55-year-old man, at the first presentation, with six malignancies over 14 years(malignant lymphoma, gastric cancer, ureteral cancer, small cell lung cancer, bladder cancer, and squamous cell lung cancer). A case of six primary malignancies is extremely rare and, as far as we know, this is the 16th case of its kind reported in Japan. The overlapping of many malignant diseases resulted in some difficulties with treatment. Whereas the ureteral cancer and small cell lung cancer were synchronous, considering the therapeutic duration of lung cancer, we proceeded with the operation for ureteral cancer and had to delay the start of chemotherapy for small cell lung cancer for more than one month. Moreover, dose intensity of the chemotherapy for the small cell lung cancer was limited by expectancy of augmented myelosuppression, due to the effect of prior chemotherapy for malignant lymphoma. However, a strong neutropenia-induced postoperative abdominal infection necessitated discontinuation of chemotherapy and treatment with radiotherapy alone. In addition, the therapies for the newly developed squamous cell lung cancer, the sixth malignancy, were also limited because of reduced lung function and myelopoiesis. In treatment or follow-up of patients with multiple primary malignancies, as opposed to those with a single malignant disease, the characteristics of other malignancies and the morbidities by preceding therapies must be considered.

[A case of fulminant community-acquired Acinetobacter pneumonia in a healthy woman]

We describe a case of fulminant community-acquired Acinetobacter baumannii pneumonia. A 68-year-old woman, who had no past medical history, was admitted with septic shock and pneumonia of left lower lobe. Despite intensive treatment she died on day 3 after admission. To the best of our knowledge, this is the 4th report of community-acquired Acinetobacter pneumonia in Japan and the 1st report in a healthy patient. We report a case of Acinetobacter pneumonia and discuss the clinical characteristics of the community-acquired type compared with the hospital-acquired type.

[Relationship between chronic obstructive pulmonary disease and gastroesophageal reflux disease defined by the Frequency Scale for the Symptoms of gastroesophageal reflux disease]

Little is known about gastroesophageal reflux disease (GERD) in chronic obstructive pulmonary disease (COPD) patients. The aim of this study was to investigate the prevalence, clinical characteristics and risk factors for GERD in COPD patients, based on the Frequency Scale for the Symptoms of GERD (FSSG). In 228 COPD patients, the prevalence of GERD was 26.7%, independent of COPD stage. Logistic regression multivariate analysis revealed significant risk factors for accompanying GERD were age (p = 0.009; odds ratio (OR), 0.933; 95% confidence interval (CI) 0.885 to 0.983) and number of COPD exacerbation within one year (p = 0.043; OR, 1.675; 95% CI, 1.075 to 2.764). The risk factors of COPD exacerbation were total FSSG score (p = 0.031; OR, 1.079; 95% CI, 1.007 to 1.156) and inhaled corticosteroid use (p = 0.003; OR, 3.238; 95% CI, 1.482 to 7.076). Moreover, the Spearman rank correlation test showed that FSSG score was weakly but significantly correlated with the number of COPD exacerbations (rs = 0.317, p < 0.001). In conclusion, the incidence of GERD in COPD patients is high, and the incidence of GERD is closely related to COPD exacerbation.

Spontaneous pneumomediastinum: an algorithm for diagnosis and management

Spontaneous pneumomediastinum (SPM) is a rare disorder most often affecting young males which is generally self-limiting. Despite the benign prognosis with few complications and little morbidity, it frequently confuses clinicians in primary settings, who may have difficulty differentiating SPM from other serious organ ruptures, especially oesophageal rupture (the so-called Boerhaave syndrome), which may lead to mediastinitis and may be fatal, even with appropriate interventions. An overview of adult SPM is provided, reviewing 17 studies (414 patients), including our clinical experience, and finally an algorithm for diagnosis and management of SPM is proposed, based on the characteristics of SPM.

[Predictors of survival in patients with chronic hypercapnic respiratory failure receiving domiciliary NPPV]

Fifty-four cases (36 men) with chronic hypercapnic respiratory failure were prescribed domiciliary NPPV during 9 years. COPD (26 patients) and sequelae of tuberclosis (16 patients) were the major primary diseases. At the initiation of NPPV, the age was 71.2 +/- 7.3 years-old (mean +/- standard deviation) and PaCO2 was 76.7 +/- 16.2Torr. Overall, the 1-year and 5-year survival rates were 63.8% and 26.0%, respectively. Multivariate analysis identified BMI (body mass index) (hazzard ratio : 0.837, p = 0.020) and the number of days of hospitalization during 1 year before NPPV (hazzard ratio: 1.013, p = 0.016) as predictors of survival. Patients with frequent hospitalization for exacerbation or with malnutrition had poor prognosis, so comprehensive supports aimed to improve general status are needed for patients with chronic respiratory failure received domiciliary NPPV.

Management of spontaneous pneumomediastinum based on clinical experience of 25 cases

STUDY OBJECTIVES

Spontaneous pneumomediastinum (SPM) is a rare disorder that usually occurs in young individuals and has a self-limiting course and no recurrence in most cases. But actually in many cases, patients are undergo some examinations or some limitations. The purpose of this study was to evaluate the clinical characteristics and recommend appropriate management of SPM.

DESIGN

Retrospective research of clinical records of a single institution.

RESULTS

Over 11 years, we diagnosed 25 patients (18 males) with SPM. Their average age was 20.1 years (range 13-28 years). Chest pain or neck symptoms were most frequent, and 17 patients (68%) had subcutaneous emphysema. In all cases, blood counts and C-reactive protein (CRP) were measured, and their mean values were 10,100+/-4600/mm(3) and 1.0+/-1.5 mg/dL, respectively. In 20 patients (80%), either leucocytosis or elevated CRP was observed. Twenty-four patients (96%) were admitted (average 7.8+/-4.1 days) and 20 of them were prescribed antibiotics or limited oral intake. The symptoms were self-limiting in all cases and disappeared on average 1.8+/-0.9 days after diagnosis. No recurrence was noted in the approximately 2 years follow-up period.

CONCLUSION

SPM is a self-limiting disease with mild inflammatory signs. For patients suspicious of SPM, shortened hospitalization for about 2 days with observation alone may be feasible, if their symptoms improve gradually. Otherwise, less invasive procedures, such as esophagram, should be performed immediately. Long-term follow-up is usually unnecessary. We propose a new algorithm for management of SPM based on clinical experience.

[Purpura fulminans due to pneumococcal pneumonia in a healthy adult: a case report]

We report a case of infectious purpura fulminans due to pneumococcal pneumonia in a 61-year-old man presenting multiple organ failure and pneumococcal bacteremia secondary to pneumonia on admission. His lower limbs showed rapidly progressive purpura and symmetrical dry gangrene. He had no history of or apparent immunodeficiency, including asplenia, in abdominal ultrasonography. Despite of therapy, he died on day 15 after admission. Infectious purpura fulminans involves skin lesions with severe infection often accompanied by disseminated intravascular coagulation and septic shock. Although it occurs mainly in childhood, especially as a complication of Neisseria meningitis or Varicella virus infection, it has also been reported in adult, as a rare complication of invasive pneumococcal infection. Most had immunodeficiency such as asplenia or postsplenectomy. Purpura fulminans in a previously healthy adult is very rare and this is insofar as we know, the first report in Japan detailing the development from pneumococcal pneumonia.

GADD34 induces p53 phosphorylation and p21/WAF1 transcription

Recently, others and we have shown that one of the functions of GADD34 is a recovery from a shutoff of protein synthesis induced by endoplasmic reticulum stress. GADD34 has been shown to induce growth arrest and apoptosis. Main protein of apoptosis is p53, especially phosphorylation of p53. And one of the main proteins of growth arrest is p21/WAF1. Here we analyzed the effects of GADD34 on p53 phosphorylation and p21/WAF1 transcription. Transfected Myc-tagged p53 was dose-dependently phosphorylated at Ser15 by increasing the amount of GADD34. Transfection of GADD34 also induced the endogenous phosphorylation of p53 and enhanced p21 protein expression. Transfection of GADD34 induced p21/WAF1 promoter activity. This activity was dependent on p53, because GADD34 transfection to p53-deficient cells produced only a slight increase of p21/WAF1 promoter activity. The p21/WAF1 promoter activity was greatly enhanced by the transfection of p53. Both GADD34 and p53 transfection induced much higher p21/WAF1 promoter activity. The promoter activity of p21/WAF1 was very low in GADD34 deficient MEF. The transfection of GADD34 increased the p21/WAF1 promoter activity in GADD34 deficient MEF.

Protein phosphatase 1, but not protein phosphatase 2A, dephosphorylates DNA-damaging stress-induced phospho-serine 15 of p53

Okadaic acid (OA) is a protein phosphatase (PP) inhibitor and induces hyperphosphorylation of p53. We investigated whether the inhibition of PP1 by OA promotes the phosphorylation of the serine 15 of p53. In vitro dephosphorylation assay showed that PP1 dephosphorylated ultraviolet C (UVC)-induced phospho-ser15 of p53, and that OA treatment inhibited it. One of the PP1 regulators, growth arrest and DNA damage 34 (GADD34), disturbed PP1 binding with p53, interfered with the dephosphorylation of p53 and increased the amount of phospho-p53 after UVC-treatment. This report provides the first evidence that PP1, but not PP2A, dephosphorylates phospho-serine 15 of p53.

Trans-Tenon's retrobulbar triamcinolone infusion for the treatment of uveitis

AIM

To assess efficacy and complications of trans-Tenon's retrobulbar infusion of triamcinolone acetonide for posterior uveitic inflammation.

METHODS

Non-randomised, uncontrolled, retrospective study of 51 eyes of 37 patients who underwent triamcinolone infusion for vitritis, cystoid macular oedema (CMO), or posterior retinal vasculitis using a long blunt cannula via an incision made through conjunctiva and Tenon's capsule.

RESULTS

Overall clinical efficacy was 86%; 96% for vitritis, 82% for CMO, and 33% for posterior retinal vasculitis. Mean visual acuity improved within 1 month after triamcinolone infusion (p <0.05). Cataract progression and intraocular pressure elevation were observed in 31% and 27% of eyes, respectively.

CONCLUSION

Trans-Tenon's retrobulbar triamcinolone infusion may be a safe and effective treatment for posterior uveitic inflammation.

The function of GADD34 is a recovery from a shutoff of protein synthesis induced by ER stress: elucidation by GADD34-deficient mice

GADD34 is a protein that is induced by stresses such as DNA damage. The function of mammalian GADD34 has been proposed by in vitro transfection, but its function in vivo has not yet been elucidated. Here we generated and analyzed GADD34 knockout mice. Despite their embryonic stage- and tissue-specific expressions, GADD34 knockout mice showed no abnormalities at fetal development and in early adult life. However, in GADD34-/- mouse embryonic fibroblasts (MEFs), recovery from a shutoff of protein synthesis was delayed when MEFs were exposed to endoplasmic reticulum (ER) stress. The phosphorylation of eukaryotic translation initiation factor 2 alpha (eIF2alpha) at Ser51 induced by thapsigargin or DTT was prolonged in GADD34-/- MEF, although following treatment with tunicamycin, the eIF2alpha phosphorylation level did not change in either GADD34+/+ or GADD34-/- cells. ER stress stimuli induced expressions of Bip (binding Ig protein) and CHOP (C/EBP homologous protein) in MEF of wild-type mice. These expressions were strongly reduced in GADD34-/- MEF, which suggests that GADD34 up-regulates Bip and CHOP. These results indicate that GADD34 works as a sensor of ER stress stimuli and recovers cells from shutoff of protein synthesis.

Heterozygosity with respect to Zfp148 causes complete loss of fetal germ cells during mouse embryogenesis

Zfp148 belongs to a large family of C2H2-type zinc-finger transcription factors. Zfp148 is expressed in fetal germ cells in 13.5-d-old (E13.5) mouse embryos. Germ-line transmission of mutations were not observed in chimeric Zfp148(+/-) mice, and some of these mice completely lacked spermatogonia. The number of primordial germ cells in Zfp148(+/-) tetraploid embryos was normal until E11.5, but declined from E11.5 to E13.5 and continued to decline until few germ cells were present at E18.5. This phenotype was not rescued by wild-type Sertoli or stromal cells, and is therefore a cell-autonomous phenotype. These results indicate that two functional alleles of Zfp148 are required for the normal development of fetal germ cells. Recent studies have shown that Zfp148 activates p53, which has an important role in cell-cycle regulation. Primordial germ cells stop proliferating at approximately E13.5, which correlates with induction of phosphorylation of p53 and its translocation to the nucleus. Phosphorylation of p53 is impaired in Zfp148(+/-) embryonic stem cells and in fetal germ cells from chimeric Zfp148(+/-) embryos. Thus, Zfp148 may be required for regulating p53 in the development of germ cells.

A day care program and evaluation of animal-assisted therapy (AAT) for the elderly with senile dementia

We conducted a survey to clarify the evaluation methods of animal-assisted therapy (AAT) for the elderly with senile dementia in an adult day care center. AAT was implemented for a total of six biweekly sessions. The AAT group consisted of seven subjects and the control group numbered 20 subjects. In a comparison between Mini-Mental State Exam (MMSE) scores at baseline and those measured three months later, the average MMSE score before AAT (baseline) was 11.43 (+/- 9.00), and three months later it was 12.29(+/- 9.69). In the AAT group, the average score on Nishimura's Activities of Daily Living (N-ADL) at baseline was 28.43(+/- 14.00), and after ATT it was 29.57(+/- 14.47). In the AAT group, the average baseline score on behavioral pathology of Alzheimer's disease (Behave-AD) was 11.14(+/- 4.85), and three months after AAT it was 7.29(+/- 7.11) (p < 0.05). In the control group, the average baseline score was 5.45(+/- 3.27) and three months later it was 5.63(+/- 3.59). The evaluation of salivary CgA, as a mental stress index, showed a decreasing tendency in the AAT group. Our findings demonstrate the usefulness of using several methods for evaluation of the changes in patients given AAT.

Notl-Msell methylation-sensitive amplied fragment length polymorhism for DNA methylation analysis of human cancers

We have applied a methylation-sensitive restriction endonuclease, NotI, to the existing amplified fragment length polymorphism (AFLP) method and developed NotI-MseI methylation-sensitive-AFLP (MS-AFLP). NotI-MseI MS-AFLP allows the analysis of DNA methylation alterations at the NotI sites scattered over the genome. Hypermethylation and hypomethylation are visualized by the decrease and increase in the band intensity of DNA fingerprints. Identification of consistent changes can be facilitated through parallel electrophoresis of multiple samples. DNA fragments exhibiting alterations can be cloned from fingerprint bands by amplification of gel-eluted DNA with the same pair of primers used for radioactive fingerprint presentation. Fluorescent NotI-MseI MS-AFLP offers a safer method of studying the alterations in DNA methylation, and may be applied to the hybridization of DNA microarrays in the future. Using NotI-MseI MS-AFLP, we observed frequent hypomethylation of a satellite DNA repeat sequence in a majority of breast tumors.

Characterization of semen collected from beagles and captive Japanese black bears (Ursus thibetanus japonicus)

This study characterized semen collected from the Japanese black bear, Ursus thibetanus aponicus, to provide information on semen cryopreservation for artificial breeding. Preliminary studies using a beagle dog as the model species showed that sperm concentration and total sperm count were lower in semen collected by electroejaculation than in semen collected by digital manipulation, but that sperm motility, viability and morphology were similar. Characterization of semen obtained from Japanese black bears by electroejaculation under general anesthesia revealed that semen volume and total number of spermatozoa collected were lower; but that sperm concentration, motility, viability and morphology were equivalent to those reported in other ursids. When semen was collected via a catheter inserted into the urethra during the stimulation for ejaculation, the sperm concentration, total sperm count and motility were relatively higher than when semen was collected directly in a test tube. Specific normal semen characteristics (mean +/- SEM) were pH, 7.6 +/- 0.0; volume, 0.212 +/- 0.038 mL; sperm concentration, 361 +/- 100 x 10(6)/mL; total sperm count, 84.0 +/- 32.2 x 106; +++ motility, 30 +/- 5%; motility, 77 +/- 3%; viability 77 +/- 2%; and abnormal morphology, 11+/- 2%. These results suggest that semen can be collected from Japanese black bears by electroejaculation.

Phosphatidylglycerol participates in syncytium formation induced by HTLV type 1-bearing cells

We previously reported that 71-kDa heat shock cognate protein (HSC70) was expressed on the cell surface of human T cell lymphotropic virus type 1 (HTLV-1)-susceptible cells and that HSC70, beta-actin, and a lipid-like component on the target cell membrane participated in syncytium formation by HTLV-1. We have now identified this lipid-like component to be palmitoyl (16:0)-oleoyl (18:1)-phosphatidylglycerol (POPG), using preparative thin-layer chromatographic fractionation and tandem mass spectrometric analysis. In the syncytium formation assay, exogenously added PG inhibited cell-to-cell transmission of HTLV-1 in a dose-dependent manner. Other phospholipids showed less (PE) or no effect (PC, PS, PI, PA, lysoPC, lysoPE, and CL). Binding experiments showed that PG interacted with three synthetic peptides, gp46--111, gp46--197, and gp21--400, which correspond to regions Lys111--Asp138 and Asp197--Leu216 on the gp46 surface glycoprotein, and to region Cys400--Leu429 on the gp21 transmembrane glycoprotein, respectively, as well as with intact gp46 and gp21 proteins of HTLV-1. On the other hand, HSC70 and beta-actin interacted with gp46--197 and gp46, not with gp46--111. However, the eluate from an affinity column coupled with gp46--111 contained not only PG but also HSC70 and beta-actin, despite the lack of direct interaction between gp46--111 and these proteins. In the in vitro binding assay, HSC70 showed interaction with both PG and beta-actin, while there was no evidence of any interaction between PG and beta-actin. These results suggest that HSC70 molecules on target cell surface interact with both PG in lipid bilayers and intracellular beta-actin and that these three cellular components form a receptor complex that plays a critical role in syncytium formation induced by HTLV-1-bearing cells.

HTLV type 1 envelope glycoprotein gp46 evokes necrosis by binding to receptor complex

In syncytium formation induced by HTLV-1-bearing cells, 71-kDa heat shock cognate protein (HSC70) functions as a receptor molecule and the receptor complex with beta-actin and palmitoyl(16:0)-oleoyl(18:1)-phosphatidylglycerol (PG) is thus formed. We now have evidence that the molecular association between HTLV-1 gp46 envelope protein and HSC70 led to pore formation on the surface of target cell membrane and cell death followed. The peptide segment corresponding to the region from Asp-197 to Leu-216 (gp46-197), and which serves as a binding site to both HSC70 and PG for syncytium formation, also had cytotoxic effects on target cell MOLT-4. This cytotoxicity was due to necrosis, not apoptosis. On the other hand, two other receptor-binding sites, Lys-111 to Asp-138 on gp46 (gp46-111) and Cys-400 to Leu-429 on gp21 (gp21-400), and which bound only with PG, had no cytotoxic effects on MOLT-4 cells. The HTLV-2 peptide (gp46-194; Glu194 to Leu-213) corresponding to the region of HTLV-1 gp46-197 showed no cytotoxicity, and interacted only with PG, not with either HSC70 or beta-actin. Amino acid alterations between HTLV-1 gp46-197 and HTLV-2 gp46-194 were significant on the hydrophilic face of the amphipathic structure. Taken together, the interaction between HSC70 and gp46 of HTLV-1 through the hydrophilic face of gp46-197 may lead to pore formation in lipid bilayers to be followed by membrane fusion or cell death.