Cryoballoon ablation of left atrial roof with a novel cryoballoon system

Introduction

A novel cryoballoon system (POLARx) has emerged and its efficacy regarding pulmonary vein isolation (PVI) has been already investigated. On the other hand, cryoballoon ablation of left atrial (LA) roof has been performed using a conventional cryoballoon system (Arctic Front Advance Pro [AFA-Pro]) in addition to PVI. However, cryoballoon ablation of LA roof with POLARx has not been investigated yet.

Methods

We performed cryoballoon ablation of LA roof with POLARx in 22 patients after we achieved PVI. After the cryoballoon ablation, complete conduction block at LA roof and isolation of all PVs were confirmed by creating an activation map during high right atrium pacing. If they could not be obtained with solely a cryoballoon, touch up ablation with radiofrequency ablation was permitted. The procedural data during ablation with POLARx was compared with those during ablation with AFA-Pro we had performed in a historical cohort of patients (n=46).

Results

Complete conduction block at LA roof without touch up ablation could be obtained in all the patients in POLARx group and 44 (95.7%) patients in AFA-Pro group. Total procedure time was almost similar in both groups (164.2±35.4 min for POLARx vs 180.3±35.4 min for AFA-Pro, p=0.10). During LA roof line ablation, nadir balloon temperature was significantly lower in POLARx group (right side: −53.6±4.4°C for POLARx vs −45.6±4.6°C for AFA-Pro, p<0.01, central part: −56.4±4.3°C for POLARx vs −46.0±3.7°C for AFA-Pro, p<0.01, left side: −55.1±3.5°C for POLARx vs −45.7±5.3°C for AFA-Pro, p<0.01), and balloon temperature reached −40°C earlier in POLARx (right side: 30.7±8.9 sec for POLARx vs 78.0±39.8 sec for AFA-Pro, p<0.01, central part: 30.6±9.3 sec for POLARx vs 65.9±33.3 sec for AFA-Pro, p<0.01, left side: 30.4±4.2 sec for POLARx vs 78.8±49.6 sec for AFA-Pro, p<0.01). Total freezing time required for LA roof line ablation was significantly shorter in POLARx group (589.3±163.6 sec for POLARx vs 877.5±191.7 sec for AFA-Pro, p<0.01).The scar area created after LA roof line ablation was similar in both groups (9.3±4.1 cm2 for POLARx vs 11.0±4.8 cm2 for AFA-Pro, p=0.23).

Conclusion

Complete conduction block at LA roof could be obtained after cryoballoon ablation with POLARx, in the same way as AFA-Pro. Lower nadir balloon temperature could be expected in shorter freezing time during LA roof line ablation in using POLARx compared with AFA-Pro.

Funding Acknowledgement

Type of funding sources: None.

How to perform effective cryoballooon ablation of left atrial roof: considerations after experiences of more than 1000 cases

Introduction

Although pulmonary vein isolation is the cornerstone of atrial fibrillation (AF) ablation, concomitant cryoballoon ablation of left atrial (LA) roof has been expected to improve clinical outcomes after ablation. We demonstrate characteristics and efficacy of cryoballoon ablation of LA roof through our experiences from a large volume of procedures.

Methods

We had performed cryoballoon ablation of LA roof in 1036 procedures including 202 redo procedures in AF patients since June 2016. Among these procedures, we analyzed 834 patients (309 paroxysmal AF) who had undergone de novo ablation for AF. We confirmed whether the complete conduction block of LA roof line was obtained after the ablation.

Results

LA roof line block was obtained in 767 patients (92.0%) without touch up ablation with a radiofrequency catheter (Group A). LA diameter (LAD) was significantly smaller (43.6±6.6mm vs 47.4±7.5mm, p<0.01) and body mass index (BMI) was significantly lower (24.9±4.0kg/m2 vs 26.3±4.6kg/m2, p=0.01) in those in Group A compared with those without LA roof line block after cryoballoon ablation (Group B). Compared with those in Group B, cryoballoon application number of LA roof (4.1±1.2 vs 4.5±1.6, p<0.01) and mean nadir of cryoballoon temperature during cryoballoon ablation of LA roof (−44.5±5.6°C vs −40.5±7.5°C, p<0.01) were significantly lower in those in Group A. Regarding cryoballoon application number, the number of the cryoballoon application in which a cryoballoon was applied to LA roof with the guiding catheter located in a left superior pulmonary vein (LSPV) was significantly lower in patients in Group A (1.3±0.8 vs 1.6±1.0, p=0.02), and when the number was less than 2, mean nadir of cryoballoon temperature was significantly lower compared with when it was 2 or more than 2 (−44.8±5.8°C vs −42.8±5.6°C, p<0.01). Among those refer to first ablation procedures, one-year Kaplan-Meier atrial arrhythmias free rate estimates, 80.6% for those in Group A and 59.0% for those in Group B (p<0.01). Multivariate analysis identified LA roof line block without touch up ablation as one of the predictors of atrial arrhythmias recurrences. Atrial tachycardia depending on LA roof occurred after cryoballoon ablation of LA roof in 8 patients, although LA roof line block without touch up ablation could be obtained in the index ablation procedure in 6 patients among them.

Conclusion

LA roof line block could be obtained by solely cryoballoon with a reasonable success rate, especially in those with smaller LAD and lower BMI. To obtaine LA roof line block, cryoballoon ablation with the guiding catheter located in LSPV is preferable. LA roof line block without touch up ablation brings better clinical outcomes in those who underwent cryoballoon ablation of LA roof.

Funding Acknowledgement

Type of funding sources: None.

Nosocomial infection by human bocavirus and human rhinovirus among paediatric patients with respiratory risks

BACKGROUND

Nosocomial infections by respiratory viruses undetected by rapid tests are not often diagnosed. For paediatric patients with background diseases, nosocomial infection could be fatal.

AIM

To determine the relationship between developing symptoms by respiratory viruses undetectable by rapid tests and respiratory risks and to improve the management of infection control.

METHODS

Two episodes of nosocomial infection by human bocavirus (HBoV) and human rhinovirus (HRV) were retrospectively investigated in a tertiary hospital paediatric ward in Japan. Viruses were identified by polymerase chain reaction to determine infection control management. When viruses of the same species were detected from different patients, the virus homology was investigated. The relationship between respiratory risks and developing symptoms was statistically investigated.

FINDINGS

Three and four patients with respiratory risks in the HBoV and HRV outbreaks, respectively, developed respiratory symptoms. The nucleotide sequences of two patients in the HBoV outbreak and all four patients in the HRV outbreak were phylogenetically close. In both outbreaks, the patients with respiratory risks developed significantly more symptoms than those without any risk (P = 0.035 and 0.018, respectively). After the patients with respiratory infection were separated from those with respiratory risks, no additional nosocomial infection occurred.

CONCLUSION

Patients with respiratory risks easily develop respiratory symptoms and acquire severe symptoms of nosocomial infection by those viruses. In a paediatric ward, we should adopt not only standard precautions but also isolation management of the patients with respiratory symptoms, even if they have negative results in rapid tests.

Balance of Emission and Dynamical Controls on Ozone During the Korea-United States Air Quality Campaign From Multiconstituent Satellite Data Assimilation

Global multiconstituent concentration and emission fields obtained from the assimilation of the satellite retrievals of ozone, CO, NO2, HNO3, and SO2 from the Ozone Monitoring Instrument (OMI), Global Ozone Monitoring Experiment 2, Measurements of Pollution in the Troposphere, Microwave Limb Sounder, and Atmospheric Infrared Sounder (AIRS)/OMI are used to understand the processes controlling air pollution during the Korea-United States Air Quality (KORUS-AQ) campaign. Estimated emissions in South Korea were 0.42 Tg N for NO x and 1.1 Tg CO for CO, which were 40% and 83% higher, respectively, than the a priori bottom-up inventories, and increased mean ozone concentration by up to 7.5 ± 1.6 ppbv. The observed boundary layer ozone exceeded 90 ppbv over Seoul under stagnant phases, whereas it was approximately 60 ppbv during dynamical conditions given equivalent emissions. Chemical reanalysis showed that mean ozone concentration was persistently higher over Seoul (75.10 ± 7.6 ppbv) than the broader KORUS-AQ domain (70.5 ± 9.2 ppbv) at 700 hPa. Large bias reductions (>75%) in the free tropospheric OH show that multiple-species assimilation is critical for balanced tropospheric chemistry analysis and emissions. The assimilation performance was dependent on the particular phase. While the evaluation of data assimilation fields shows an improved agreement with aircraft measurements in ozone (to less than 5 ppbv biases), CO, NO2, SO2, PAN, and OH profiles, lower tropospheric ozone analysis error was largest at stagnant conditions, whereas the model errors were mostly removed by data assimilation under dynamic weather conditions. Assimilation of new AIRS/OMI ozone profiles allowed for additional error reductions, especially under dynamic weather conditions. Our results show the important balance of dynamics and emissions both on pollution and the chemical assimilation system performance.

STAT6 and IL-10 are required for the anti-arthritic effects of Schistosoma mansoni via different mechanisms

To investigate possible roles of T helper type 2 (Th2) cytokines in the anti-arthritic effects of a blood fluke, Schistosoma mansoni (Sm), for mouse collagen-induced arthritis (CIA), wild-type (WT), signal transducer and activator of transcription 6 (STAT6) knock-out (KO) and interleukin (IL)-10 KO mice were infected with Sm. Three weeks after infection, the mice were immunized with bovine type II collagen (IIC). Arthritis severity was monitored by scoring, measurement of paw thickness and the presence of ankylosis. Serum anti-IIC IgG levels, splenic cytokine production and cytokine gene expression in the popliteal lymph nodes (PLNs) were measured and compared among WT and gene-KO mice. Consistent with our previous findings, Sm infection reduced the arthritis severity in WT mice. Splenic production of IL-17A and tumor necrosis factor (TNF)-α was reduced by the infection. In contrast, Sm infection markedly exacerbated CIA in STAT6 KO mice. In the KO mice, IL-17A production was increased by the infection. Conversely, Sm infection did not affect the exacerbated arthritis in IL-10 KO mice, although IL-17A production was reduced by the helminth. Our results suggest that signaling via STAT6 (presumably IL-4 and/or IL-13) and IL-10 is required for the suppression of CIA by Sm infection, but through different mechanisms. STAT6 was essential for helminth-induced reduction of IL-17A, whereas regulation of the basal arthritis severity by IL-10 was needed in order for it to be sufficiently suppressed by the helminth.

Thy28 protects against anti-CD3-mediated thymic cell death in vivo

Apoptotic cell death plays a pivotal role in the development and/or maintenance of several tissues including thymus. Deregulated thymic cell death is associated with autoimmune diseases including experimental autoimmune encephalomyelitis (EAE), a prototype murine model for analysis of human multiple sclerosis. Because Thy28 expression is modulated during thymocyte development, we tested whether Thy28 affects induction of EAE as effectively as antigen-induced thymocyte deletion using Thy28 transgenic (TG) mice. Thy28 TG mice showed partial resistance to anti-CD3 monoclonal antibody (mAb)-induced thymic cell death in vivo, as assessed by annexin V-expression and loss of mitochondrial membrane potential. The resistance to anti-CD3 mAb-induced cell death in Thy28 TG mice appeared to correlate with a decreased c-Jun N-terminal kinase phosphorylation and reduced down-regulation of Bcl-xL. Moreover, thymic hyperplasia was detected in Thy28 TG mice, although thymocyte development was unaltered. Development of peripheral lymphoid tissues including spleen and lymph nodes was also unaltered. Thy28 TG spleen T cells showed an increased production of IFN-γ, but not IL-17, in response to both anti-CD3 and anti-CD28 mAbs. Finally, Thy28 TG mice displayed accelerated induction of EAE as assessed by disease incidence, clinical score, and pathology following immunization with myelin oligodendrocyte glycoprotein compared with control WT mice. These findings suggest that modulation of Thy28 expression plays a crucial role in the determination of thymic cell fate, which may contribute to the development of EAE through proinflammatory cytokine production.

Off-pump coronary artery bypass for a heparin-allergic patient

A 46-year-old man with no history of drug allergy developed acute myocardial infarction. Coronary angiographic findings revealed triple vessel disease. Serum hepatic enzymes were elevated due to heparin administered to control infarction, and an allergic reaction developed exclusively due to heparin. To avoid heparin use, we adopted heparin-free off-pump coronary artery bypass grafting through median sternotomy. The systemic anticoagulant agent argatroban was administered to maintain active clotting time over 200 seconds. The left internal thoracic artery was anastomosed to the left anterior descending artery, the radial artery to the diagonal branch, and the right gastroepiploic artery to the right coronary artery. Patency was confirmed by postoperative coronary angiography. No complications were noted. For patients with heparin allergy, off-pump coronary artery bypass grafting is a useful maneuver, because it can be conducted using anticoagulant agents other than heparin.

ALDH-1 expression levels predict response or resistance to preoperative chemoradiation in resectable esophageal cancer patients

PURPOSE

Operable thoracic esophageal/gastroesophageal junction carcinoma (EC) is often treated with chemoradiation and surgery but tumor responses are unpredictable and heterogeneous. We hypothesized that aldehyde dehydrogenase-1 (ALDH-1) could be associated with response.

METHODS

The labeling indices (LIs) of ALDH-1 by immunohistochemistry in untreated tumor specimens were established in EC patients who had chemoradiation and surgery. Univariate logistic regression and 3-fold cross validation were carried out for the training (67% of patients) and validation (33%) sets. Non-clinical experiments in EC cells were performed to generate complimentary data.

RESULTS

Of 167 EC patients analyzed, 40 (24%) had a pathologic complete response (pathCR) and 27 (16%) had an extremely resistant (exCRTR) cancer. The median ALDH-1 LI was 0.2 (range, 0.01-0.85). There was a significant association between pathCR and low ALDH-1 LI (p ≤ 0.001; odds-ratio [OR] = 0.432). The 3-fold cross validation led to a concordance index (C-index) of 0.798 for the fitted model. There was a significant association between exCRTR and high ALDH-1 LI (p ≤ 0.001; OR = 3.782). The 3-fold cross validation led to the C-index of 0.960 for the fitted model. In several cell lines, higher ALDH-1 LIs correlated with resistant/aggressive phenotype. Cells with induced chemotherapy resistance upregulated ALDH-1 and resistance conferring genes (SOX9 and YAP1). Sorted ALDH-1+ cells were more resistant and had an aggressive phenotype in tumor spheres than ALDH-1- cells.

CONCLUSIONS

Our clinical and non-clinical data demonstrate that ALDH-1 LIs are predictive of response to therapy and further research could lead to individualized therapeutic strategies and novel therapeutic targets for EC patients.

Results of the baseline positron emission tomography can customize therapy of localized esophageal adenocarcinoma patients who achieve a clinical complete response after chemoradiation

BACKGROUND

Patients with localized esophageal adenocarcinoma (EAC) who achieve a clinical complete response (clinCR) after preoperative chemoradiation (trimodality therapy; TMT) or definitive chemoradiation (bimodality therapy; BMT) live longer than those who achieve a <clinCR (Suzuki A, Xiao LC, Hayashi Y et al. Prognostic significance of baseline positron emission tomography and importance of clinical complete response in patients with esophageal or gastroesophageal junction cancer treated with definitive chemoradiotherapy. Cancer 2011; 117: 4823-4833; Cheedella NK, Suzuki A, Xiao L et al. Association between clinical complete response and pathological complete response after preoperative chemoradiation in patients with gastroesophageal cancer: analysis in a large cohort. Ann Oncol 2013; 24: 1262-1266; Ajani JA, Correa AM, Hofstetter WL et al. Clinical parameters model for predicting pathologic complete response following preoperative chemoradiation in patients with esophageal cancer. Ann Oncol 2012; 23: 2638-2642). We hypothesized that the initial standardized uptake value (iSUV) of positron emission tomography will define novel subsets of clinCR patients.

METHODS

We analyzed 323 EAC patients, from our prospective database, who achieved a clinCR. Various statistical methods were used to assess the influence of iSUV on patient outcome.

RESULTS

The median follow-up of 323 patients was 40.8 months [95% confidence interval (CI) 35.6-47.3 months]. Two hundred six (63.8%) patients had TMT and 117 (36.2%) had BMT. If iSUV was ≥6, TMT patients had a longer median OS (94.8 months; 95% CI 66.07-NA) than BMT patients (31.4 months; 95% CI 21.7-42.1; P ≤ 0.001). However, if iSUV was <6, the median OS of TMT and BMT patients was similar (P = 0.62). iSVU did not influence the pathologic complete response rate in TMT patients (P = 0.85).

CONCLUSION

clinCR patients with iSUV of <6 are identified as a new subset that fared equally well when treated with TMT or BMT. Future esophageal preservation strategy may be best suited for this newly identified subset of EAC patients.

Association between clinical complete response and pathological complete response after preoperative chemoradiation in patients with gastroesophageal cancer: analysis in a large cohort

BACKGROUND

Chemoradiation followed by surgery is the preferred treatment of localized gastroesophageal cancer (GEC). Surgery causes considerable life-altering consequences and achievement of clinical complete response (clinCR; defined as postchemoradiation [but presurgery] endoscopic biopsy negative for cancer and positron emission tomographic (PET) scan showing physiologic uptake) is an enticement to avoid/delay surgery. We examined the association between clinCR and pathologic complete response (pathCR).

PATIENTS AND METHODS

Two hundred eighty-four patients with GEC underwent chemoradiation and esophagectomy. The chi-square test, Fisher exact test, t-test, Kaplan-Meier method, and log-rank test were used.

RESULTS

Of 284 patients, 218 (77%) achieved clinCR. However, only 67 (31%) of the 218 achieved pathCR. The sensitivity of clinCR for pathCR was 97.1% (67/69), but the specificity was low (29.8%; 64/215). Of the 66 patients who had less than a clinCR, only 2 (3%) had a pathCR. Thus, the rate of pathCR was significantly different in patients with clinCR than in those with less than a clinCR (P < 0.001).

CONCLUSIONS

clinCR is not highly associated with pathCR; the specificity of clinCR for pathCR is too low to be used for clinical decision making on delaying/avoiding surgery. Surgery-eligible GEC patients should be encouraged to undergo surgery following chemoradiation despite achieving a clinCR.

Single- and Multiple-dose Pharmacokinetics of Nefiracetam, a New Nootropic Agent, in Healthy Volunteers

The pharmacokinetic profile of nefiracetam (N-(2,6-dimethylphenyl)-2-(2-oxo-l-pyrrolidinyl)acetamide), a new nootropic agent, was studied in healthy Japanese male volunteers. Nefiracetam was administered orally at doses of 10–200 mg in the single-dose studies, and at doses of 200 mg three times a day for seven days in the multiple-dose study. An HPLC method was used to determine the concentrations of nefiracetam in serum, urine and faecal samples. Linear kinetic behaviour was obtained after single oral administration. Serum concentrations of nefiracetam reached maximum values (Cmax) within 2 h for all dosage groups, and declined monophasically after Cmax with half-lives of 3–5 h. The area under the concentration-time curve (ALTC∞) and Cmax were linearly related to the dose. The apparent clearance (CL) values were 94·4–140·3 mL min−1. Urinary excretion of nefiracetam was independent of the administered dose, and less than 10% of the dose was recovered in urine as the unchanged form within 24 h after administration. Renal clearance (CLR) did not change significantly as dose increased from 10 to 1200 mg. Faecal excretion of nefiracetam was less than 0·1% of the dose up to 24 h after a 300 mg oral dose. Food intake delayed the absorption of nefiracetam but did not significantly modify its pharmacokinetics. No clinically significant accumulation of nefiracetam in the body was observed during and after multiple doses.

Left-sided approach for cardiac procedure and thoracoplasty in a patient with Marfan syndrome

We present a case of a 20-year-old female in whom we successfully performed a simultaneous Bentall procedure and thoracoplasty by initially removing only the left side of the costal cartilages. This modified sternal elevation technique offered chest stability and an excellent surgical view, and the postoperative course was satisfactory.

A phase II trial of oral S-1 combined with gemcitabine in patients with unresectable biliary tract cancer

e15527

Background: Optimal chemotherapy for unresectable biliary tract cancer is yet to be defined. We have conducted the phase II trial of Gemcitabine (GEM) with S-1, oral fluorouracil prodrug tegafur combined with two modulators, 5-chloro-2, 4-dihydropridine and potassium oxonate to evaluate the activity and toxicity of such combination in patients with unresectable biliary tract cancer. Methods: Eligibility criteria were pathologically-proven biliary tract cancer, appropriate performance status 0 to 2, age 20 to 79 years, adequate hematological, renal and liver functions, no prior chemotherapy, and written informed consent. S-1 was given orally (30mg/m2) bid for 14 consecutive days and GEM (1000mg/m2) was given on day 8 and 15. Cycle was repeated every 21 days. Results: 30 patients with unresectable biliary tract cancer (Gall-bladder: intrahepatic bile ducts: extrahepatic bile ducts=7:16:7) were enrolled from March 2007 to December 2008. Patients characteristics were: median age; 67 (46–79), male/female; 20/10, PS 0/1/2; 16/13/1. Median number of cycles was 8 (range 1 to 14). Out of total 26 evaluable patients, objective responses were observed in 9 patients (30%); 16 patients achieved stable disease and 1 patients showed disease progression. Median survival was 390 days (95% c.i.: 290 - 490 days). The grade 3–4 toxicities observed were leucopenia (20%), neutropenia (40%), anemia (17%), thrombocytopenia (37%), anorexia (7%), fever (10%), rash (7%) and interstitial pneumonia (7%). Conclusions: The combination chemotherapy with GEM and S-1 was well tolerated and high response rate has been observed. This result is very promising but survival benefit against GEM monotherapy should be demonstrated in future phase 3 studies.

No significant financial relationships to disclose.

[Tricuspid annuloplasty, pulmonary valve replacement, ventricular septal defect (VSD) patch closure, and right-sided maze procedure 23-years after corrective repair of tetralogy of Fallot]

Postoperative pulmonary valve regurgitation, stenosis of the right ventricular outflow tract, conduit failure, ventricular septal patch leak, secondary tricuspid valve regurgitation, and various arrhythmias are the major complications that develop after surgical repair of tetralogy of Fallot in adults. A 27-year-old male with pulmonary regurgitation, tricuspid regurgitation, residual ventricular septal defect (VSD), low left ventricular function, and chronic atrial fibrillation underwent tricuspid annuloplasty, pulmonary valve replacement with a stentless aortic valve, VSD patch closure, and right-sided maze procedure, and the postoperative course was uneventful. The cardiothoracic ratio decreased, sinus rhythm was restored, and the patient's complaints were relieved. Reoperation at the optimal time after corrective repair of tetralogy of Fallot in adults may improve the outcome.

Phase II trial of oral S-1 combined with gemcitabine in metastatic pancreatic cancer

We conducted a phase II trial of gemcitabine with S-1, oral fluorouracil (5-FU) prodrug tegafur combined with two modulators, 5-chloro-2, 4-dihydroxypyridine and potassium oxonate, to evaluate the activity and toxicity of such a combination in metastatic pancreatic cancer (MPC) patients. Patients who had pathologically proven pancreatic cancer with metastatic lesions were eligible candidates for entry into the study. S-1 was given orally (30 mg m⁻²) b.i.d. for 14 consecutive days and gemcitabine (1000 mg m⁻²) was given on days 8 and 15. The cycle was repeated every 21 days. We enrolled 33 MPC patients. The median number of cycles was eight (range 1–20). Grade 3–4 toxicities were leucopenia (33%), neutropenia (55%), anaemia (9%), thrombocytopenia (15%), anorexia (6%), fever (9%), and interstitial pneumonia (6%). Objective responses were obtained in 16 patients (one complete response and 15 partial responses; response rate, 48%; 95% confidence interval (CI), 33–65). Median survival and 1-year survival rate were 12.5 months (95% CI, 5.9–19.1) and 54% (95% CI, 36–72), respectively. Combination chemotherapy with GEM and S-1 was well tolerated and yielded a significantly high response rate.

Phase II study of S-1 in patients with gemcitabine resistant advanced pancreatic carcinoma

14070

Background: S-1 is an oral fluoropyrimidine derivative with reported response rate of 21.1∼37.5% for advanced pancreatic carcinoma (Ueno, Oncology 2005; Furuse, ASCO 2005). The primary objective of this study was to assess the efficacy and safety of S-1 in patients with gemcitabine resistant advanced pancreatic carcinoma. Methods: Patients with histologically or cytologically proven, metastatic pancreatic carcinoma who had failed prior chemotherapy with gemcitabine were eligible for this study. Other eligibility criteria included an ECOG performance status (PS) of 2 or less; an age of at least 20 years; adequate organ function; and written informed consent. S-1 was administered orally at a dose of 40 mg/m2 twice daily for 28 days, followed by a 14-day rest period. Treatment was repeated every 6 weeks until disease progression. Results: Seventeen patients were enrolled with the following characteristics: median age 67 (range 40–75); male/female = 9/8; ECOG PS 0/1/2 = 1/8/8. All patients were included in analysis. Treatment was generally well tolerated and no life threatening toxicity was observed. Grade 3–4 toxicities were anorexia (17.6%) and fatigue (5.9%). Common grade 1–2 toxicities were anorexia (35.3%), anemia (35.3%), leukocytopenia (29.4%) and diarrhea (23.5%). Three patients were discontinued S-1 because of toxicities. Out of the 17 eligible patients, 3 patients (17.6%) achieved a partial response and 5 patients (29.4%) had stable disease. A marked decrease (≥50%) in tumor markers was observed in 5 (29.4%) of the patients. (CA 19–9 in 3 patients, CEA in 1 patient, DUPAN-2 in 1 patient) The median progression-free survival and the median survival time from the date of initiation of S-1 were 4.1 months (95% CI, 2.0 to 6.2 months) and 5.7 months (95% CI, 2.6 to 8.7 months), respectively. Conclusions: S-1 is well tolerated and active in patients with gemcitabine resistant advanced pancreatic carcinoma. Further investigation of this treatment appears warranted.

No significant financial relationships to disclose.

The global atmospheric environment for the next generation

Air quality, ecosystem exposure to nitrogen deposition, and climate change are intimately coupled problems: we assess changes in the global atmospheric environment between 2000 and 2030 using 26 state-of-the-art global atmospheric chemistry models and three different emissions scenarios. The first (CLE) scenario reflects implementation of current air quality legislation around the world, while the second (MFR) represents a more optimistic case in which all currently feasible technologies are applied to achieve maximum emission reductions. We contrast these scenarios with the more pessimistic IPCC SRES A2 scenario. Ensemble simulations for the year 2000 are consistent among models and show a reasonable agreement with surface ozone, wet deposition, and NO2 satellite observations. Large parts of the world are currently exposed to high ozone concentrations and high deposition of nitrogen to ecosystems. By 2030, global surface ozone is calculated to increase globally by 1.5 +/- 1.2 ppb (CLE) and 4.3 +/- 2.2 ppb (A2), using the ensemble mean model results and associated +/-1 sigma standard deviations. Only the progressive MFR scenario will reduce ozone, by -2.3 +/- 1.1 ppb. Climate change is expected to modify surface ozone by -0.8 +/- 0.6 ppb, with larger decreases over sea than over land. Radiative forcing by ozone increases by 63 +/- 15 and 155 +/- 37 mW m(-2) for CLE and A2, respectively, and decreases by -45 +/- 15 mW m(-2) for MFR. We compute that at present 10.1% of the global natural terrestrial ecosystems are exposed to nitrogen deposition above a critical load of 1 g N m(-2) yr(-1). These percentages increase by 2030 to 15.8% (CLE), 10.5% (MFR), and 25% (A2). This study shows the importance of enforcing current worldwide air quality legislation and the major benefits of going further. Nonattainment of these air quality policy objectives, such as expressed by the SRES-A2 scenario, would further degrade the global atmospheric environment.

Phase I trial of oral S-1 combined with gemcitabine in metastatic pancreatic cancer

The objective of this study was to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of S-1, an oral fluorouracil derivative, combined with gemcitabine, the current standard treatment for advanced pancreatic cancer (APC). The subjects were histopathologically proven APC patients with distant metastasis. S-1 was administered orally twice daily each day for 14 days and gemcitabine on days 8 and 15 of each cycle, and this was repeated every 21 days. Doses of each drug were planned as follows: level 1: 800/60, level 2a: 800/80, level 2b: 1000/60, level 3: 1000/80 (gemcitabine (mg m⁻²)/S-1 (mg m⁻² day⁻¹)). In all, 21 patients with APC were enrolled. The main grade 3–4 toxicities observed during first cycle were neutropenia (33%), anaemia (10%), thrombocytopenia (14%) and anorexia (10%). There were no DLT observed in level 1. Three of six patients in level 2a had DLT and this level was considered the MTD. In all, 12 patients in level 2b had no DLT and this level was selected as the recommended dose. Applicable responses were one complete response and nine partial responses (48%). As toxicities were well tolerated and antitumour activities seem to be promising, this combination can be recommended for further phase II studies with APC.