Klippel-Trenaunay syndrome or not? An exploration of atypical presentations

Klippel-Trenaunay syndrome (KTS) is a rare, congenital disorder typically emerging in early infancy or childhood. The classic presentation of KTS is distinguished by a triad of clinical features: a port-wine stain, early-onset varicosities and limb overgrowth. However, a notable variant of KTS has been documented, characterised by limb shortening rather than lengthening, occasionally referred to as 'inverse KTS'. This report details two cases that display this unusual presentation-both patients had classical features of port-wine stain and varicose veins but both experienced shortening of the affected limb. Whether these cases represent a variant of KTS or a new clinical syndrome altogether is uncertain. They however offer valuable insights into the nuances and breadth of clinical manifestations associated with this syndrome.

Identical anatomy, different symptoms: a comparative case study of median arcuate ligament syndrome in monozygotic twins

Median arcuate ligament syndrome (MALS) is a rare clinical entity arising from the extrinsic compression of the coeliac axis by the median arcuate ligament. In this report, we detail a unique presentation involving monozygotic twins, both of whom demonstrated anatomical extrinsic compression of the coeliac axis by the median arcuate ligament. Intriguingly, only one twin manifested clinical symptoms consistent with MALS, despite comparable anatomical compression of the coeliac axis observed in both. This case highlights the potential interplay of a genetic or anatomical predisposition to coeliac axis compression and secondary, possibly environmental, factors that lead to the development of clinical symptoms. In this report, we explore various determinants potentially influencing symptomatology in MALS and advocate for the publication of similar case studies to further elucidate this rare condition.

Trends in AAA Repair in Australia Over Twenty Years

Background

The advent of endovascular techniques has revolutionised the treatment of abdominal aortic aneurysms (AAA). Many countries have seen a transition from open AAA repair (OAR) to endovascular AAA repair (EVAR) over the past 25 years. The only study done in Australia that describes this change was done in the private sector. Majority of healthcare in Australia is delivered through the public, universal healthcare system. The aim of this study was to evaluate the trends in AAA repair in the Australian public sector over the past two decades.

Methods

The Australian Institute of Health and Welfare (AIHW) Procedures Data Cubes from the National Hospitals Data Collection was used to extract data pertaining to AAA repairs from 2000 to 2021. Population data from the Australian Bureau of Statistics was used to calculate incidence of each type of repair per 100,000 population.

Results

There were 65,529 AAA repairs performed in the Australian public sector from 2000 to 2021. EVARs accounted for 64.4% (42,205) and OARs accounted for 35.6% (23, 324) of them. EVAR surpassed OAR as the preferred method of AAA repair in 2006. This trend was observed in both males and females and across all age groups.

Conclusion

There was a consistent and steady transition from OAR to EVAR over the 21 year period with EVAR surpassing OAR as the preferred method of AAA repair relatively early in Australia compared to other countries. Further research that investigates medium- and long-term outcomes of newer stent grafts is needed to further ascertain the continued viability and effectiveness of this trend in AAA treatment.

The Indirect Impact of COVID-19 Pandemic on Lower Extremity Amputations - An Australian Study

Background

The COVID-19 pandemic has had indirect and deleterious effects on patient health due to interruptions to routine provision of healthcare. This is particularly true for patients with chronic conditions like peripheral vascular disease (PVD). This study aims to evaluate the impact of the pandemic on patients with PVD in Australia by analysing rates of amputation, indications for amputation and urgency of surgery in the pre-pandemic and pandemic periods.

Methods

The Australian Vascular Audit was used to capture lower extremity amputation data in Victoria, Australia, in the 22 months before and after the start of the pandemic.

Results

The number of total amputations increased from 1770 pre-pandemic to 1850 during the pandemic, a 4.3% increase. This was largely driven by a statistically significant, 19% increase in major amputations. The number of minor amputations remained relatively similar in the two time periods. Amputations due to tissue loss secondary to arterial insufficiency increased from 474 to 526, an 11% increase, potentially indicating disruptions to revascularisation procedures contributing to the rise in amputations. Elective and emergency surgeries fell by 14% and 18%, respectively, while semi-urgent amputations increased by 32%.

Conclusion

This study found an increase in the number of amputations overall and a significant increase in major amputations during the pandemic compared to pre-pandemic times. Tissue loss secondary to arterial insufficiency was an increasingly common indication for amputation that was observed in the pandemic group, indicating that disruption to revascularisation likely contributed to this increase in amputations. These findings can inform and direct future vascular surgery service delivery to prepare for the post-pandemic recovery. Additionally, this study further confirms that patients with chronic diseases are often disproportionately disadvantaged when global crises affect routine provision of healthcare and calls for better systems to be developed that can be used in such crises in the future.

The indirect impact of COVID-19 pandemic on limb preservation care- a retrospective analysis of trends in lower limb revascularisation

BACKGROUND

Disruptions caused by COVID-19 pandemic have profoundly influenced the management of many conditions, especially vascular pathologies including limb preservation care. The aim of this study is to evaluate the impact of the pandemic on patients with peripheral arterial disease (PAD) focusing on lower limb revascularisation procedure volume, their indication and urgency of surgery.

METHODS

The Australian Vascular Audit (AVA) was used to capture data on revascularisation procedures before and after the onset of the pandemic in Victoria, Australia. Information on patient demographics, procedures performed, their indication and urgency of surgery were collected.

RESULTS

There was a significant 22.7% increase in revascularisations for PAD during the COVID-19 pandemic, driven solely by a 31.9% increase in endovascular revascularisation procedures. Revascularisation procedures for all indications of PAD, namely claudication, rest pain and tissue loss, increased by 14.8%, 39.2% and 27.4% respectively, during the pandemic compared to pre-pandemic times. Open procedures declined by 10.2% during the pandemic. There were significant 13.9% and 62.2% increases in elective and semi-urgent revascularisations respectively during the pandemic while emergency revascularisations for PAD fell by 4.2%. There were no significant increases in toe, forefoot or below knee amputations during the pandemic compared to pre-pandemic times.

CONCLUSIONS

This study found that the volume of revascularisation for PAD increased significantly during the pandemic indicating that patients with PAD had significant deterioration of their condition during the pandemic. This is likely multifactorial; due to disruptions to standard provision of podiatry, vascular surgery and endocrinology services to these patients, a decline in overall health and changes in health-related behaviours due to restrictions and infection control methods imposed during the pandemic. The number of elective and semi-urgent procedures also increased during the pandemic which reflects the significant deterioration of PAD patients during the pandemic. This study highlights a concerning trend of worsening PAD when routine care of these patients is disrupted. Such data should be instrumental in contingency planning and resource allocation for managing the ongoing pandemic.

Effect of Psychosocial, Behavioral, and Disease Characteristics on Health-Related Quality of Life (HRQoL) After Breast Cancer Surgery: A Cross-Sectional Study of a Regional Australian Population

BACKGROUND

 Increasing long-term breast cancer survivorship has highlighted the importance of patient-reported outcomes such as health-related quality of life (HRQoL) in addition to traditional outcomes that were used to define successful operative management. This study aimed to describe HRQoL in patients who underwent breast cancer resection in a regional Australian setting and identify the psychosocial, demographic, and operative characteristics associated with poor HRQoL.

METHODS

 Consecutive patients who underwent breast cancer resection between 2015 and 2022 were included. Patients were asked to complete a survey instrument that included validated measures of HRQoL, emotional distress, fear of cancer recurrence (FCR), and social support. Demographic, disease, and operative data were collected from the medical record of the respondents.

RESULTS

 Forty-six patients completed the survey (100% female, mean age = 62.68 years). Most HRQoL domains were significantly lower than an Australian reference population. HRQoL was more strongly associated with psychosocial factors (emotional distress, FCR, and social support) but was also associated with socioeconomic status, stage of cancer at presentation, and surgical complications. HRQoL was not related to breast conservation, management of the Axilla, or time since operation.

CONCLUSION

 Long-term changes in HRQoL should be considered during the management and surveillance of breast cancer patients in regional Australia.

Trends in Incisional and Ventral Hernia Repair: A Population Analysis From 2001 to 2021

Background Incisional and ventral hernias are highly prevalent, with primary ventral hernias occurring in approximately 20% of adults and incisional hernias developing in up to 30% of midline abdominal incisions. Recent data from the United States have shown an increasing incidence of elective incisional and ventral hernia repair (IVHR) and emergency repair of complicated hernias. This study examines Australian population trends in IVHR over a two-decade study period. Methods This retrospective study was performed using procedure data from the Australian Institute of Health and Welfare and population data from the Australian Bureau of Statistics captured between 2000 and 2021 to calculate incidence rates per 100,000 population by age and sex for selected subcategories of IVHR operations. Trends over time were evaluated using simple linear regression. Results There were 809,308 IVHR operations performed in Australia during the study period. The cumulative incidence adjusted for population was 182 per 100,000; this increased by 9.578 per year during the study period (95%CI = 8.431-10.726, p<.001). IVHR for primary umbilical hernias experienced the most significant increase in population-adjusted incidence, 1.177 per year (95%CI = 0.654-1.701, p<.001). Emergency IVHR for incarcerated, obstructed, and strangulated hernias increased by 0.576 per year (95%CI = 0.510-0.642, p<.001). Only 20.2% of IVHR procedures were performed as day surgery. Conclusions Australia has seen a significant increase in IVHR operations performed in the last 20 years, particularly those for primary ventral hernias. IVHR for hernias complicated by incarceration, obstruction, and strangulation also increased significantly. The proportion of IVHR operations performed as day surgery is well below the target set by the Royal Australasian College of Surgeons. With the increasing incidence of IVHR operations and an increasing proportion of these being emergent, elective IVHR should be performed as day surgery when it is safe.

Search for Electron Antineutrino Appearance in a Long-Baseline Muon Antineutrino Beam

Electron antineutrino appearance is measured by the T2K experiment in an accelerator-produced antineutrino beam, using additional neutrino beam operation to constrain parameters of the Pontecorvo-Maki-Nakagawa-Sakata (PMNS) mixing matrix. T2K observes 15 candidate electron antineutrino events with a background expectation of 9.3 events. Including information from the kinematic distribution of observed events, the hypothesis of no electron antineutrino appearance is disfavored with a significance of 2.40σ and no discrepancy between data and PMNS predictions is found. A complementary analysis that introduces an additional free parameter which allows non-PMNS values of electron neutrino and antineutrino appearance also finds no discrepancy between data and PMNS predictions.

Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital

BACKGROUND

There is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards.

OBJECTIVES

The objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors.

METHODS, DESIGN, SETTING, AND PARTICIPANTS

This was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital.

MAIN OUTCOME MEASURES

The main outcome measures were knowledge of post-intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors.

RESULTS

The overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care.

CONCLUSION

There are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

IN VITRO CHEMOTHERAPY PROFILING OF WELL-DIFFERENTIATED MIDGUT NEUROENDOCRINE TUMORS (NETS) BASED ON INDIVIDUAL PATIENT TUMOR BIOMARKERS ANALYSIS

BACKGROUND

Midgut neuroendocrine tumors (NETs) are rare malignancies with indolent clinical courses. In general, they are well-differentiated with most tumor cells in the G0 phase of the cell cycle, consistent with the poor response rate of NETs to chemotherapy in vivo. We hypothesize that insults, such as surgery, can drive NET cells from G0 into S phase and that biomarker analysis of individual patient tumors harvested and grown in the lab will provide useful practical guide for future intra and post-operative adjuvant therapy.

METHODS

97 well-differentiated midgut NET patients underwent cytoreductive surgery at our institution between May/2012 and October/2012. 148 surgical specimens were collected and submitted to a single commercial lab for processing. Primary tumors, lymph nodes and liver metastases were harvested and cultured. Their ribonucleic acids (RNA) were then extracted to analyze the expressivity, a total of 88 different biomarkers. Based on our patients' specific tumor biomarker expressivity and known correlations between 36 anti-neoplastic agents with their linked biomarkers, recommendations were reported as clinically beneficial or non-beneficial.

RESULTS

A total of 148 specimens from 97 patients were tested. In four of the 97 patients, no clinically beneficial chemotherapy agent could be identified. Among the remaining 93 patients, the top three agents that are most likely to be clinically beneficial are: fluorouracil, cisplatin and carboplatin. These were reported to be clinically beneficial in 135/148 (91.2%), 103/148 (69.6%), and 103/148 (69.6%) patients respectively.

CONCLUSIONS

Midgut NETs are slow growing tumors which are chemotherapeutically inert owing to the fact that most of the tumor cells are in G0 cell cycle. Surgical insult drives NET cells into active synthetic phase where they begin to express biomarkers specific to their tumor cells. Analysis of these biomarkers guides further potential beneficial therapy based on the current known associations among biomarkers and chemotherapy agents. These results must then be compared and confirmed against a direct in-vitro chemo sensitivity assessment conducted simultaneously on the same patients.

A phase II study of UFT with leucovorin administered as a twice daily schedule in the treatment of patients with metastatic colorectal cancer

Prolonged infusions have been shown to be safer and potentially more effective than bolus regimens of 5-fluorouracil (5-FU) as treatment for metastatic colorectal cancer (mCRC). However, infusional 5-FU requires central venous access and costly infusion pumps. Oral fluoropyrimidines enable longer exposures to 5-FU with increased convenience. Tegafur–uracil (UFT) with leucovorin (LV) given thrice daily has improved safety plus comparable survival and response rates to bolus 5-FU/LV. We conducted a phase II clinical study in 98 patients with mCRC to evaluate if UFT with LV given twice daily provided comparable time to progression (TTP), efficacy and tolerability to that reported for thrice daily in two phase III clinical studies. Secondary objectives included overall response rate (ORR) and overall survival (OS). Median TTP was 3.8 months, when compared with 3.5 months for thrice daily. The ORR (11%) and median OS (12.8 months) with twice daily administration were similar to that of thrice daily administration (12% and 12.4 months). The incidence of grade 3/4 treatment-related diarrhoea was 30% on the twice daily and 21% on the thrice daily schedule. These results suggest that twice daily administration has similar efficacy and tolerability to thrice daily administration and is an acceptable alternative for patients who would benefit from UFT with LV therapy.

A phase III randomized controlled study comparing iron sucrose intravenously (IV) to no iron treatment of anemia in cancer patients undergoing chemotherapy and erythropoietin stimulating agent (ESA) therapy

9109

Background: The effect of using IV iron sucrose in managing cancer chemotherapy-related anemia has not been previously reported. To investigate this issue, we conducted a randomized study of IV iron sucrose in patients (pts) with cancer chemotherapy-related anemia who completed 8 prior wks of ESA therapy. Methods: This prospective, multicenter, randomized, open label, Phase III clinical trial enrolled 375 pts with chemotherapy induced anemia (Hgb levels = 10.0 g/dL) and was conducted in 2 stages. During Stage I (8-wk duration), pts received treatment with fixed ESA doses (100-mcg of darbepoetin or 40,000 units epoetin wkly or 200 mcg of darbepoetin every other wk). Pts were classified as either ESA responders (= 1 g/dL increase in Hgb) or ESA non-responders with each group randomized (Stage 2) separately to receive either 12 wks of fixed doses of ESA plus up to 1,500 mg of iron sucrose (given in 3 divided doses of up to 500mg) or 12 wks of fixed doses of ESA alone. Laboratories (including iron indices and acute phase reactants), quality of life and adverse events were assessed at baseline and throughout. Results: Iron sucrose plus ESA compared to ESA alone resulted in greater mean maximum Hgb levels and greater number of pts who achieved Hgb increases = 2.0 and ≥ 3.0 g/dl in both prior ESA responders and non-responders. There was also a statistically significant improvement in fatigue and iron stores in the iron sucrose treated pts. Baseline iron status did not predict responsiveness to iron sucrose therapy. Three serious but non-life threatening iron sucrose related adverse events were observed including one case of significant, transient hypotension in a female weighing 50 kg. Conclusions: IV iron sucrose increased Hgb levels and iron stores significantly and is well tolerated in doses up to 500 mg increments in ESA treated patients with cancer chemotherapy- related anemia. IV iron sucrose should be considered in combination with erythropoietic therapy in anemic cancer patients receiving chemotherapy.

[Table: see text]

The effects of pasireotide (SOM230) on health-related quality of life in patients with metastatic carcinoid tumors refractory or resistant to octreotide LAR

4558

Background: Pasireotide is a novel multi-ligand somatostatin analogue with high affinity binding for four of the five somatostatin receptor subtypes (sst1,2,3 and sst5). This Phase II clinical trial showed that pasireotide is effective in controlling the symptoms of diarrhea and flushing in 27% of patients with metastatic carcinoid tumors refractory or resistant to octreotide LAR. The impact of pasireotide therapy on health-related quality of life (HRQL) was also evaluated. Methods: Patients in this open-label, multicenter study initially received pasireotide 300 μg sc bid which was escalated to a maximum dose of 1,200 μg sc bid until clinical response was achieved. Data are reported for the Functional Assessment of Chronic Illness Therapy-Diarrhea (FACIT-D) instrument. FACIT-D comprises the Functional Assessment of Cancer Therapy-General (FACT-G) score, which measures physical, social, emotional and functional well-being, plus a symptom-specific sub-scale which measures HRQL specific to diarrhea. FACIT-D baseline assessment was obtained on day 1 immediately before dosing, and then monthly thereafter. FACIT-D sub-scale and total scores at baseline and after 1, 2, and 3 months of pasireotide treatment are described by categories of clinical response. Results: 45 patients (mean age 61 years; range 40–83) received treatment, and 44 were eligible for the efficacy and HRQL analyses. Functional well-being scores, symptom-specific scores and total FACIT-D scores of non-responders tended to be lower at baseline and during treatment than those of responders. The three sub-scale and summary FACIT-D scores exhibited relatively stable mean HRQL scores and similar patterns of variability in clinical responders and non- responders through the third month of pasireotide treatment. Conclusions: HRQL was stable during treatment with pasireotide in patients with advanced metastatic disease refractory or resistant to octreotide LAR. Additional work in HRQL study design and evaluation of HRQL endpoints in patients with carcinoid disease is indicated, and will further improve our understanding of quality of life in patients with this disease.

[Table: see text]

Safety and efficacy of pasireotide (SOM230) in patients with metastatic carcinoid tumors refractory or resistant to octreotide LAR: Results of a phase II study

4082

Background: Pasireotide is a novel multiligand somatostatin analogue that exhibits high binding affinity to 4 of 5 somatostatin receptor subtypes: sst1,2,3 and sst5. Compared with octreotide, pasireotide has 30, 5 and 40 times greater affinity for sst1,3 and sst5 receptors respectively and a comparable affinity for sst2. Methods: This was a Phase II, open-label, multicenter study in patients with metastatic carcinoid tumors whose symptoms (diarrhea and flushing) were inadequately controlled by octreotide LAR. Patients had histopathologically confirmed disease, elevated 5-HIAA and/or CgA levels and at least one measurable lesion (excluding bone). Patients initially received pasireotide 300 μg sc bid and escalated to a maximum dose of 1200 μg sc bid every 3 days until clinical response was achieved. Partial response (PR) was defined as a mean of <4 bowel movements (BM)/day with no more than 6 BM on any given day, and a mean of <2 flushing episodes/day for 15 consecutive days on a fixed dose of pasireotide. Complete response (CR) was defined as a mean of ≤3 BM/day, with no more than 3 BM on any given day, and no flushing episodes. Results: Safety data are reported from 45 patients as of September 2005; 44 patients (mean age 61 years) qualified for efficacy assessment. Carcinoid tumors were predominantly of midgut origin. Preliminary efficacy data in controlling symptoms of carcinoid syndrome showed PR in 9 patients (20%) at 600–1200 μg sc bid doses and CR in 2 patients (5%) at the 600 and 900 μg sc bid doses. Objective tumor response in 11 patients showed 9 with stable disease and 2 with progressive disease at 6 months. Adverse events (AEs) were primarily gastrointestinal (GI): abdominal pain (31%) and nausea (27%). Weight loss (22%) and fatigue (22%) were also reported. Most AEs were mild or moderate. Glucose-related AEs (predominantly CTC grade 1–2) were observed in 24% of patients. Most discontinuations were due to GI AEs (n = 6) or lack of therapeutic response. Conclusions: Pasireotide 600–1200 μg sc bid was effective in controlling symptoms of diarrhea and flushing in 25% of patients with metastatic carcinoid tumors inadequately controlled by octreotide LAR. The safety profile of pasireotide is similar to octreotide LAR.

[Table: see text]

[Pathological findings in pigs affected by the postweaning multisystemic wasting syndrome in Argentina]

Postweaning multisystemic wasting syndrome was first described in Canada in 1991 and at present an increasing number of cases has been diagnosed worldwide. In Argentina the first cases of PMWS were reported recently. Forty eight 5 to 12 week old pigs with signs characteristic of PMWS from 19 farms were studied. Although the real distribution of the virus in our country is not known it was observed an increasing number of farms with PMWS distributed in the major producing provinces. The histopathology was an important tool in diagnosis of suspicious cases of PMWS with the observation of different degrees of lesion. In the studied animals, the secondary infections, either by opportunistic pathogens or secondary bacteria could be important.

How sigma docks to RNA polymerase and what sigma does

It is clear that multiple sites of interaction exist between sigmas and core subunits, likely reflecting the changing pattern of interactions that occur sequentially during the complex process of holoenzyme formation, open promoter formation, and initiation of transcription. Recent studies have revealed that a major site of interaction of Escherichia coli sigma factors is the amino acid 260-309 coiled-coil region of the beta' subunit of core RNA polymerase. This region of beta' interacts with region 2.1-2.2 of sigma(70). Binding of this region of beta' to sigma(70) triggers a conformational change in sigma that allows it to bind to a -10 nontemplate promoter DNA strand oligonucleotide.

RNA polymerases from Bacillus subtilis and Escherichia coli differ in recognition of regulatory signals in vitro

Adaptation of bacterial cells to diverse habitats relies on the ability of RNA polymerase to respond to various regulatory signals. Some of these signals are conserved throughout evolution, whereas others are species specific. In this study we present a comprehensive comparative analysis of RNA polymerases from two distantly related bacterial species, Escherichia coli and Bacillus subtilis, using a panel of in vitro transcription assays. We found substantial species-specific differences in the ability of these enzymes to escape from the promoter and to recognize certain types of elongation signals. Both enzymes responded similarly to other pause and termination signals and to the general E. coli elongation factors NusA and GreA. We also demonstrate that, although promoter recognition depends largely on the sigma subunit, promoter discrimination exhibited in species-specific fashion by both RNA polymerases resides in the core enzyme. We hypothesize that differences in signal recognition are due to the changes in contacts made between the beta and beta' subunits and the downstream DNA duplex.

New route to alpha-adducts of homoallylic alcohols by an acid-catalyzed stereospecific allyl-transfer reaction from gamma-adducts

Allylation of aldehydes by an allyl-transfer reaction from the gamma-adducts of homoallylic alcohols has been successfully carried out to give the corresponding alpha-adducts regiospecifically. The reaction proceeds via a hemiacetal (11), derived from an aldehyde and the homoallylic alcohol, followed by a six-membered cyclic transition state (2-oxonia[3.3]-sigmatropic rearrangement) in the presence of a Lewis acid. Moreover, the gamma-adducts are restructured into the corresponding alpha-adducts via a similar transition state by an acid catalyst, in which chirality in both anti- and syn-gamma-adducts is stereospecifically transferred to the corresponding E- and Z-alpha-adducts, respectively, with > 98% ee.

Octreotide acetate long-acting formulation versus open-label subcutaneous octreotide acetate in malignant carcinoid syndrome

PURPOSE

Subcutaneous (SC) octreotide acetate effectively relieves the diarrhea and flushing associated with carcinoid syndrome but requires long-term multiple injections daily. A microencapsulated long-acting formulation (LAR) of octreotide acetate has been developed for once-monthly intramuscular dosing.

PATIENTS AND METHODS

A randomized trial compared double-blinded octreotide LAR at 10, 20, and 30 mg every 4 weeks with open-label SC octreotide every 8 hours for the treatment of carcinoid syndrome. Seventy-nine patients controlled with treatment of SC octreotide 0.3 to 0.9 mg/d whose symptoms returned during a washout period and who returned for at least the week 20 evaluation constituted the efficacy-assessable population.

RESULTS

Complete or partial treatment success was comparable in each of the four arms of the study (SC, 58.3%; 10 mg, 66.7%; 20 mg, 71.4%; 30 mg, 61.9%; P> or =.72 for all pairwise comparisons). Control of stool frequency was similar in all treatment groups. Flushing episodes were best controlled in the 20-mg LAR and SC groups; the 10-mg LAR treatment was least effective in the control of flushing. Treatment was well tolerated by patients in all four groups.

CONCLUSION

Once octreotide steady-state concentrations are achieved, octreotide LAR controls the symptoms of carcinoid syndrome at least as well as SC octreotide. A starting dose of 20 mg of octreotide LAR is recommended. Supplemental SC octreotide is needed for approximately 2 weeks after initiation of octreotide LAR treatment. Occasional rescue SC injections may be required for possibly 2 to 3 months until steady-state octreotide levels from the LAR formulation are achieved.

The cost-effectiveness of octreotide acetate in the treatment of carcinoid syndrome and VIPoma

Markov modeling was used to evaluate the cost-effectiveness of octreotide in treating carcinoid syndrome and VIPoma. For each condition, using octreotide was associated with doubled survival time. Octreotide was cost-effective for treating carcinoid tumor ($752 per additional year of life, two additional years on average), and cost saving for VIPoma.

Differential scanning calorimetric and X-ray study of the binding of the water of primary hydration to calf-thymus DNA

Differential scanning calorimetry has been used to study the thermal properties of hydrated films of calf-thymus Na-, K- and CsDNA between 20 and 320 degrees C. A broad endothermic transition near 75 degrees C and a sharp exothermic transition near 240 degrees C are observed. The broad transition is due to the dehydration of the DNA, while the exothermic transition is due to pyrolysis of the sample. the peak temperatures of both transitions increase as the scan rate is increased. Based on a Kissinger analysis, the net activation energy for the desorption of the primary water of hydration is about 0.6 eV while that for the pyrolysis is about 1.9 eV. X-ray diffraction patterns suggest that heating the DNA films to 180 degrees C once does not, but thrice does, destroy their structural ordering.

Double-blind, randomized comparison of the antiemetic efficacy of intravenous dolasetron mesylate and intravenous ondansetron in the prevention of acute cisplatin-induced emesis in patients with cancer. Dolasetron Comparative Chemotherapy-induced Emesis Prevention Group

PURPOSE

To assess the comparative antiemetic efficacy of single-dose intravenous (IV) dolasetron mesylate and ondansetron in preventing cisplatin-induced nausea and vomiting.

PATIENTS AND METHODS

Cancer patients (n = 609) receiving first-course cisplatin chemotherapy were randomized to one of three treatments: 1.8 or 2.4 mg/kg dolasetron mesylate salt (equivalent to 1.3 and 1.8 mg/kg dolasetron base, respectively) or 32 mg ondansetron. Each treatment was infused over 15 minutes, 30 minutes before cisplatin administration. Patients were stratified to cisplatin doses of > or = 70 and less than 91 mg/m2 (n = 368) or > or = 91 mg/m2 (n = 241), administered over < or = 3 hours. Protocol-defined efficacy criteria included complete response (zero emetic episodes and no rescue medication), major response (1 to 2 emetic episodes and no rescue medication), and patients' report of nausea severity and satisfaction recorded on a 100-mm visual analog scale (VAS).

RESULTS

The three treatments met protocol-specified criteria for equivalence. Complete response rates for dolasetron mesylate 1.8 mg/kg, 2.4 mg/kg, and ondansetron, respectively, were 49.2%, 45.6%, and 50.4% for patients in the lower cisplatin stratum (mean, 74.7 mg/m2) and 36.8%, 31.3%, and 31.8% in the higher cisplatin stratum (mean, 100.6 mg/m2). No significant differences were observed in the extent of nausea with either dolasetron dose compared with ondansetron. Less nausea was noted with 1.8 mg/kg dolasetron compared with the 2.4 mg/kg dose (P = .044) All three antiemetic treatments were well tolerated. Asymptomatic electrocardiogram changes were recorded with both dolasetron and ondansetron.

CONCLUSION

A single IV dose of dolasetron mesylate (1.8 or 2.4 mg/kg) has comparable safety and efficacy to a single 32-mg IV dose of ondansetron in patients receiving cisplatin chemotherapy.

Somatostatin analogue phase I trials in neuroendocrine neoplasms

To further investigate the antineoplastic efficacy and safety of somatostatin analogues, 2 trials were performed. Octreotide, SMS 201-995 (Sandostatin), was escalated in doses ranging from 1,500 micrograms to 6,000 micrograms daily in 14 patients with carcinoid. Somatuline, (BIM 23014C, Angiopeptin, Lanreotide) was given in doses ranging from 2,250 micrograms to 9,000 micrograms daily to 13 neuroendocrine patients (6 carcinoid, 2 atypical carcinoid, 3 pancreatic islet cell and 2 small cell lung cancer patients). All patients successfully completed dose escalations without significant adverse effects and were evaluable for toxicity. The dose limiting side-effect of octreotide was the injection volume. No dose limiting adverse effects have been observed with somatuline. Carcinoid syndrome symptoms were better controlled with higher octreotide doses. Thirteen patients were evaluable for octreotide's antitumor efficacy with a partial response observed in 4 (31%), stable disease in 2 and progressive disease in 7 patients. Radiographic changes of increased tumor necrosis occurred in 5 patients and was independent of response. Somatuline resulted in a partial response in 4 patients (2 carcinoids, 1 gastrinoma and 1 small cell lung cancer) (31%), stable disease in 1 atypical carcinoid, and progressive disease in 8 (4 carcinoid, 1 atypical carcinoid, 2 islet cell and 1 multi-drug resistant small cell lung cancer). Six of the 8 carcinoid patients had radiographic changes of increased necrosis. Dose escalation of somatostatin analogues is well tolerated and may be associated with antitumor activity in some neuroendocrine neoplasms.