Central generators of migraine and autonomic cephalalgias as targets for personalized pain management: Translational links

BACKGROUND AND OBJECTIVE

Migraine oscillates between different states in association with internal homeostatic functions and biological rhythms that become more easily dysregulated in genetically susceptible individuals. Clinical and pre-clinical data on migraine pathophysiology support a primary role of the central nervous system (CNS) through 'dysexcitability' of certain brain networks, and a critical contribution of the peripheral sensory and autonomic signalling from the intracranial meningeal innervation. This review focuses on the most relevant back and forward translational studies devoted to the assessment of CNS dysfunctions involved in primary headaches and discusses the role they play in rendering the brain susceptible to headache states.

METHODS AND RESULTS

We collected a body of scientific literature from human and animal investigations that provide a compelling perspective on the anatomical and functional underpinnings of the CNS in migraine and trigeminal autonomic cephalalgias. We focus on medullary, hypothalamic and corticofugal modulation mechanisms that represent strategic neural substrates for elucidating the links between trigeminovascular maladaptive states, migraine triggering and the temporal phenotype of the disease.

CONCLUSION

It is argued that a better understanding of homeostatic dysfunctional states appears fundamental and may benefit the development of personalized therapeutic approaches for improving clinical outcomes in primary headache disorders.

SIGNIFICANCE

This review focuses on the most relevant back and forward translational studies showing the crucial role of top-down brain modulation in triggering and maintaining primary headache states and how these central dysfunctions may interact with personalized pain management strategies.

Pembrolizumab versus placebo as post-nephrectomy adjuvant therapy for clear cell renal cell carcinoma (KEYNOTE-564): 30-month follow-up analysis of a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial

BACKGROUND

The first interim analysis of the KEYNOTE-564 study showed improved disease-free survival with adjuvant pembrolizumab compared with placebo after surgery in patients with clear cell renal cell carcinoma at an increased risk of recurrence. The analysis reported here, with an additional 6 months of follow-up, was designed to assess longer-term efficacy and safety of pembrolizumab versus placebo, as well as additional secondary and exploratory endpoints.

METHODS

In the multicentre, randomised, double-blind, placebo-controlled, phase 3 KEYNOTE-564 trial, adults aged 18 years or older with clear cell renal cell carcinoma with an increased risk of recurrence were enrolled at 213 hospitals and cancer centres in North America, South America, Europe, Asia, and Australia. Eligible participants had an Eastern Cooperative Oncology Group performance status of 0 or 1, had undergone nephrectomy 12 weeks or less before randomisation, and had not received previous systemic therapy for advanced renal cell carcinoma. Participants were randomly assigned (1:1) via central permuted block randomisation (block size of four) to receive pembrolizumab 200 mg or placebo intravenously every 3 weeks for up to 17 cycles. Randomisation was stratified by metastatic disease status (M0 vs M1), and the M0 group was further stratified by ECOG performance status and geographical region. All participants and investigators involved in study treatment administration were masked to the treatment group assignment. The primary endpoint was disease-free survival by investigator assessment in the intention-to-treat population (all participants randomly assigned to a treatment). Safety was assessed in the safety population, comprising all participants who received at least one dose of pembrolizumab or placebo. As the primary endpoint was met at the first interim analysis, updated data are reported without p values. This study is ongoing, but no longer recruiting, and is registered with ClinicalTrials.gov, NCT03142334.

FINDINGS

Between June 30, 2017, and Sept 20, 2019, 994 participants were assigned to receive pembrolizumab (n=496) or placebo (n=498). Median follow-up, defined as the time from randomisation to data cutoff (June 14, 2021), was 30·1 months (IQR 25·7-36·7). Disease-free survival was better with pembrolizumab compared with placebo (HR 0·63 [95% CI 0·50-0·80]). Median disease-free survival was not reached in either group. The most common all-cause grade 3-4 adverse events were hypertension (in 14 [3%] of 496 participants) and increased alanine aminotransferase (in 11 [2%]) in the pembrolizumab group, and hypertension (in 13 [3%] of 498 participants) in the placebo group. Serious adverse events attributed to study treatment occurred in 59 (12%) participants in the pembrolizumab group and one (<1%) participant in the placebo group. No deaths were attributed to pembrolizumab.

INTERPRETATION

Updated results from KEYNOTE-564 support the use of adjuvant pembrolizumab monotherapy as a standard of care for participants with renal cell carcinoma with an increased risk of recurrence after nephrectomy.

FUNDING

Merck Sharp & Dohme LLC, a subsidiary of Merck & Co, Inc, Rahway, NJ, USA.

Altered Cortical Trigeminal Fields Excitability by Spreading Depolarization Revealed with in Vivo Functional Ultrasound Imaging Combined with Electrophysiology

Spreading depolarization, usually termed cortical spreading depression has been proposed as the pathophysiological substrate of migraine aura and as an endogenous trigger of headache pain. The links between neurovascular coupling and cortical craniofacial nociceptive activities modulated by SD were assessed by combining in vivo local field potential (LFP) recordings in the primary somatosensory cortex (S1) with functional ultrasound imaging of S1 and caudal insular (INS) cortices of anesthetized male rats. A single SD wave triggered in the primary visual cortex elicited an ipsilateral, quadriphasic hemodynamic and electrophysiological response in S1 with an early phase consisting of concomitant increases of relative cerebral blood volume (rCBV) and LFPs. A transient hypoperfusion was then correlated with the beginning of the neuronal silence, followed by a strong increase of rCBV, whereas synaptic activities remained inhibited.LFPs and rCBV recovery period was followed by a progressive increase in S1 and INS baseline activities and facilitation of cortical responses evoked by periorbital cutaneous receptive field stimulation. Sensitization of cortical ophthalmic fields by SD was bilateral, occurred with precise spatiotemporal profiles, and was significantly reduced by pretreatment with an NMDA antagonist. Combined high-resolution assessing of neurovascular coupling and electrophysiological activities has revealed a useful preclinical tool for deciphering central sensitization mechanisms involved in migraine attacks.SIGNIFICANCE STATEMENT A crucial unsolved issue is whether visual aura and migraine headache are parallel or sequential processes. Here, we show that a single spreading depolarization wave triggered from the primary visual cortex is powerful enough to elicit progressive, sustained increases of hemodynamic and sensory responses to percutaneous periorbital noxious stimuli recorded in S1 and insular ophthalmic fields. Sensitization of cortical ophthalmic fields by SD was bilateral, occurred with precise spatiotemporal profiles, and was significantly reduced by pretreatment with an NMDA antagonist. Combined high-resolution assessing of neurovascular coupling and electrophysiological activities has revealed a useful preclinical tool for deciphering central sensitization mechanisms involved in migraine attacks.

Survival impact among occidental patients with metastatic gastric cancer (mGC) treated with ramucirumab as second line treatment (2L): Local experience of a teaching hospital in Chile

e16007

Background: GC is frequent in Chile, with an incidence of 7.8% and a mortality rate of 11.6% in 2020. Late diagnosis continues to be one of the most important problems, although treatments in advanced stages have experienced important advances in the last 6 years. REGARD and RAINBOW trials showed an increase in median OS when using Ramucirumab alone or in combination with Paclitaxel of 5,2 and 9,4 mths respectively. Although this therapy is not covered by our Public Health Insurance, there are some patients that they can access. Also, there are not too many reports in LATAM pts so we present our local real world data. Methods: We conducted a retrospective study of local data from patients diagnosed with mGC who progressed with standard first-line treatment and were treated with ramucirumab-based regimens from January 2015 to January 2021. Clinical factors were recorded baseline, characteristics of therapy and AE related to toxicity. Toxicity was assessed by CTCAE v5.0 and response to treatment by RECIST 1.1. Results were analyzed by measuring time to progression and survival. Results: The search resulted in 9 pts, 6 men and 3 women between 38 and 72 years (median 59 years). 66% were in ECOG 1 performance status and 33% in ECOG 2, with a median BMI of 23 kg / m2. 33% were smokers and all had some other comorbidity as a medical history. All tumors were adenocarcinomas and 33% had a signet ring cell component on histology. Only one tumor was HER2 +++ and all were MSS (by IHC). The most common first-line treatment received before progression was FOLFOX; 4 to 12 cycles; 8 cycle average. All patients were treated with paclitaxel-ramucirumab as 2L (4 to 19 cycles, mean of 5 cycles). 67% of patients achieved stable disease with the best response. During the follow-up period, 8 patients experienced disease progression in an average of 6.7 months, who switched to 3L with Nivolumab. Relapses during 2L were in the peritoneum and 55% in other sites as well. Only two patients discontinued paclitaxel treatment after 4 cycles due to intolerance and continued to receive Ramucirumab. 44% developed grade 3 toxicities: 50% of them due to taxane-related peripheral neuropathy. Grade 4 or 5 toxicity was not reported. 50% of patients were alive at 6 months of treatment. Conclusions: In our country and LATAM, GC still has a significant medical and socioeconomic burden. Its incidence is still one of the highest in the world, most patients are diagnosed in the metastatic stage and face treatment in deficient PS. In this context, our local real-world data showed consistency with what the literature says, although more data remains to accumulate and describe.

Lenvatinib plus pembrolizumab for patients with previously treated biliary tract cancers in the multicohort phase 2 LEAP-005 study

4080

Background: Second-line treatment options for patients with biliary tract cancers (BTC) are limited. Lenvatinib, an anti-angiogenic multikinase inhibitor, in combination with the programmed death-1 immune checkpoint inhibitor pembrolizumab, has demonstrated promising antitumor activity with a manageable safety profile in patients with select advanced solid tumors. LEAP-005 (NCT03797326) is evaluating the efficacy and safety of lenvatinib plus pembrolizumab in patients with previously treated advanced solid tumors; here we present results from the BTC cohort of LEAP-005. Methods: In this nonrandomized, open-label, phase 2 study, eligible patients were aged ≥18 years with histologically or cytologically documented advanced (metastatic and/or unresectable) BTC with disease progression after 1 prior line of therapy, measurable disease per RECIST v1.1, ECOG PS of 0‒1, and tissue sample evaluable for PD-L1 expression. Patients received lenvatinib 20 mg once daily plus pembrolizumab 200 mg Q3W for up to 35 cycles (approximately 2 years) or until confirmed disease progression, unacceptable toxicity, or withdrawal of consent. Treatment with lenvatinib could continue beyond 2 years in patients experiencing clinical benefit. Primary endpoints were ORR (per RECIST v1.1 by blinded independent central review) and safety. Secondary endpoints were the disease control rate (DCR; comprising CR, PR, and SD), duration of response (DOR), PFS, and OS. Tumor imaging was performed Q9W from treatment initiation for 54 weeks, then Q12W to week 102, and Q24W thereafter. Results: 31 patients were enrolled in the BTC cohort (ECOG PS 1, 55%; 84% ex-US). As of April 10, 2020, median time from first dose to data cutoff (DCO) was 9.5 months (range, 3.1‒11.9), with 8 patients on treatment at DCO. There were 3 (10%) PRs and 18 (58%) SDs. ORR was 10% (95% CI, 2‒26), and DCR was 68% (95% CI, 49‒83). Median DOR was 5.3 months (range, 2.1+ to 6.2). Median PFS was 6.1 months (95% CI, 2.1‒6.4). Median OS was 8.6 months (95% CI, 5.6 to NR). Treatment-related AEs occurred in 30 patients (97%), including 15 (48%) who had grade 3 AEs; there were no grade 4 or 5 treatment-related AEs. 2 (6%) discontinued treatment due to treatment-related AEs (myocarditis, pyrexia; n = 1 each). The most frequent treatment-related AEs were hypertension (42%), dysphonia (39%), diarrhea (32%), fatigue (32%), and nausea (32%). 14 patients (45%) had immune-mediated AEs and 1 patient (3%) had an infusion-related reaction. Conclusions: Lenvatinib plus pembrolizumab demonstrated encouraging efficacy and manageable toxicity in patients with advanced BTC who had received 1 line of prior therapy. Based on these data, enrollment in the BTC cohort has been expanded to 100 patients. Clinical trial information: NCT03797326.

Lenvatinib plus pembrolizumab for patients with previously treated biliary tract cancers in the multicohort phase II LEAP-005 study

321

Background: Second-line treatment options for patients with biliary tract cancers (BTC) are limited. Lenvatinib, an anti-angiogenic multikinase inhibitor, in combination with the programmed death-1 immune checkpoint inhibitor pembrolizumab, has demonstrated promising antitumor activity with a manageable safety profile in patients with select advanced solid tumors. LEAP-005 (NCT03797326) is evaluating the efficacy and safety of lenvatinib plus pembrolizumab in patients with previously treated advanced solid tumors; here we present results from the BTC cohort of LEAP-005. Methods: In this nonrandomized, open-label, phase II study, eligible patients were aged ≥18 years with histologically or cytologically documented advanced (metastatic and/or unresectable) BTC with disease progression after 1 prior line of therapy, measurable disease per RECIST v1.1, ECOG PS of 0‒1, and tissue sample evaluable for PD-L1 expression. Patients received lenvatinib 20 mg once daily plus pembrolizumab 200 mg Q3W for up to 35 cycles (approximately 2 years) or until confirmed disease progression, unacceptable toxicity, or withdrawal of consent. Treatment with lenvatinib could continue beyond 2 years in patients experiencing clinical benefit. Primary endpoints were ORR (per RECIST v1.1 by blinded independent central review) and safety. Secondary endpoints were the disease control rate (DCR; comprising CR, PR, and SD), duration of response (DOR), PFS, and OS. Tumor imaging was performed Q9W from treatment initiation for 54 weeks, then Q12W to week 102, and Q24W thereafter. Results: 31 patients were enrolled in the BTC cohort (ECOG PS 1, 55%; 84% ex-US). As of April 10, 2020, median time from first dose to data cutoff (DCO) was 9.5 months (range, 3.1‒11.9), with 16 patients on treatment at DCO. There were 3 (10%) PRs and 18 (58%) SDs. ORR was 10% (95% CI, 2‒26), and DCR was 68% (95% CI, 49‒83). Median DOR was 5.3 months (range, 2.1+ to 6.2). Median PFS was 6.1 months (95% CI, 2.1‒6.4). Median OS was 8.6 months (95% CI, 5.6 to NR). Treatment-related AEs occurred in 30 patients (97%), including 15 (48%) who had grade 3‒4 AEs; there were no treatment-related deaths. 2 (6%) discontinued treatment due to treatment-related AEs (myocarditis, pyrexia; n = 1 each). The most frequent treatment-related AEs were hypertension (42%), dysphonia (39%), diarrhea (32%), fatigue (32%), and nausea (32%). 14 patients (45%) had immune-mediated AEs and 1 patient (3%) had an infusion-related reaction. Conclusions: Lenvatinib plus pembrolizumab demonstrated encouraging efficacy and manageable toxicity in patients with advanced BTC who had received 1 line of prior therapy. Based on these data, enrollment in the BTC cohort has been expanded to 100 patients. Clinical trial information: NCT03797326.

Total neoadjuvant chemotherapy with FLOT scheme in resectable adenocarcinoma of the gastro-oesophageal junction or gastric adenocarcinoma: impact on pathological complete response and safety

Background

Gastric cancer is the fifth cause of cancer incidence worldwide. Multidisciplinary approaches that improve the survival are needed. Perioperative chemotherapies show improvement in pathological complete remission (pCR) and overall survival (OS), but less than 50% of the patients completed the chemotherapeutic regimen. The recent 5-fluorouracil, leucovorin, oxaliplatin, docetaxel-4 (FLOT4) study shows OS 50 months and pCR 16.6%, but only 46% of the patients completed pre- and postoperative treatment. This case series report evaluated pCR and safety in patients that received complete preoperative chemotherapeutic with FLOT.

Methods

Patients received eight cycles FLOT regimen before surgery. Each cycle comprised 50 mg/m² docetaxel intravenous (iv) on day 1, 85 mg/m² oxaliplatin iv on day 1, 200 mg/m² leucovorin iv on day 1 and 2,600 mg/m² 5-fluorouracil iv in a 24-hour infusion on day 1, every 2 weeks.

Results

Fifty-nine patients were evaluated, 58 patients received preoperative cycles. Thirty-one patients received all eight cycles of preoperative therapy. 65.5% patients presented any major adverse event. Thirty-nine patients underwent surgery. Thirty-three biopsy reports were obtained. Six patients (18.2%) presented pCR, 13 patients (39.4%) had no lymph node involvement. OS was 21.32 months. Patients with histology of signet ring carcinoma cells had a shorter survival than other histologies.

Conclusion

Total neoadjuvant with FLOT chemotherapy presents an adequate safety profile, a similar pathologic regression rate, and a slightly higher rate of completing treatment to report in perioperative FLOT regimen studies. A prospective clinical study with suitable diagnostic, staging tools and an adequate follow-up may prove total neoadjuvant chemotherapy’s efficacy.

Efficacy and Safety of Pembrolizumab or Pembrolizumab Plus Chemotherapy vs Chemotherapy Alone for Patients With First-line, Advanced Gastric Cancer: The KEYNOTE-062 Phase 3 Randomized Clinical Trial

Importance

Safe and effective therapies for untreated, advanced gastric/gastroesophageal junction (G/GEJ) cancer remain an unmet need.

Objective

To evaluate the antitumor activity of pembrolizumab, pembrolizumab plus chemotherapy, or chemotherapy alone in patients with untreated, advanced G/GEJ cancer with programmed cell death ligand 1 (PD-L1) combined positive score (CPS) of 1 or greater.

Design, Setting, and Participants

The phase 3 KEYNOTE-062 randomized, controlled, partially blinded interventional trial enrolled 763 patients with untreated, locally advanced/unresectable or metastatic G/GEJ cancer with PD-L1 CPS of 1 or greater from 200 centers in 29 countries between September 18, 2015, and May 26, 2017.

Interventions

Patients were randomized 1:1:1 to pembrolizumab 200 mg, pembrolizumab plus chemotherapy (cisplatin 80 mg/m2/d on day 1 plus fluorouracil 800 mg/m2/d on days 1 to 5 or capecitabine 1000 mg/m2 twice daily), or chemotherapy plus placebo, every 3 weeks.

Main Outcomes and Measures

Primary end points were overall survival (OS) and progression-free survival (PFS) in patients with PD-L1 CPS of 1 or greater or 10 or greater.

Results

A total of 763 patients were randomized to pembrolizumab (n = 256), pembrolizumab plus chemotherapy (n = 257), or chemotherapy (n = 250). The median (range) age of all patients in the study cohort was 62 (20-87) years; 554 of 763 (72.6%) were men. At final analysis, after a median (range) follow-up of 29.4 (22.0-41.3) months, pembrolizumab was noninferior to chemotherapy for OS in patients with CPS of 1 or greater (median, 10.6 vs 11.1 months; hazard ratio [HR], 0.91; 99.2% CI, 0.69-1.18). Pembrolizumab monotherapy was not superior to chemotherapy in patients with CPS of 1 or greater. Pembrolizumab prolonged OS vs chemotherapy in patients with CPS of 10 or greater (median, 17.4 vs 10.8 months; HR, 0.69; 95% CI, 0.49-0.97), but this difference was not statistically tested. Pembrolizumab plus chemotherapy was not superior to chemotherapy for OS in patients with CPS of 1 or greater (12.5 vs 11.1 months; HR, 0.85; 95% CI, 0.70-1.03; P = .05) or CPS of 10 or greater (12.3 vs 10.8 months; HR, 0.85; 95% CI, 0.62-1.17; P = .16) or for PFS in patients with CPS of 1 or greater (6.9 vs 6.4 months; HR, 0.84; 95% CI, 0.70-1.02; P = .04). Grade 3 to 5 treatment-related adverse event rates for pembrolizumab, pembrolizumab plus chemotherapy, and chemotherapy were 17%, 73%, and 69%, respectively.

Conclusions and Relevance

This phase 3 randomized clinical trial found that among patients with untreated, advanced G/GEJ cancer, pembrolizumab was noninferior to chemotherapy, with fewer adverse events observed. Pembrolizumab or pembrolizumab plus chemotherapy was not superior to chemotherapy for the OS and PFS end points tested.

Trial Registration

ClinicalTrials.gov Identifier: NCT02494583.

Management of cancer patients during COVID-19 pandemic at developing countries

Cancer patient care requires a multi-disciplinary approach and multiple medical and ethical considerations. Clinical care during a pandemic health crisis requires prioritising the use of resources for patients with a greater chance of survival, especially in developing countries. The coronavirus disease 2019 crisis has generated new challenges given that cancer patients are normally not prioritised for admission in critical care units. Nevertheless, the development of new cancer drugs and novel adjuvant/neoadjuvant protocols has dramatically improved the prognosis of cancer patients, resulting in a more complex decision-making when prioritising intensive care in pandemic times. In this context, it is essential to establish an effective and transparent communication between the oncology team, critical care, and emergency units to make the best decisions, considering the principles of justice and charity. Concurrently, cancer treatment protocols must be adapted to prioritise according to oncologic response and prognosis. Communication technologies are powerful tools to optimise cancer care during pandemics, and we must adapt quickly to this new scenario of clinical care and teaching. In this new challenging pandemic scenario, multi-disciplinary work and effective communication between clinics, technology, science, and ethics is the key to optimising clinical care of cancer patients.

Mucinous cystic neoplasms of the pancreas associated with pregnancy: Two case reports

RATIONALE

Although rare, pancreatic neoplasms can occur during pregnancy, both in benign and malignant forms. Mucinous cystic neoplasms (MCNs) of the pancreas, a type of these neoplasms, are precursor lesions to invasive pancreatic cancer. The presence of the ovarian-type stroma is a defining feature.

PATIENT CONCERNS

The first case was a 38-year-old woman in her 18th week of pregnancy with abdominal pain that worsens a few weeks later. The second case was a 30-year-old woman in her 17th week of pregnancy with abdominal pain in the left hypochondrium.

DIAGNOSIS

The patients were under clinical examination and laboratory test including carbohydrate antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA). Both patients had magnetic resonance imaging (MRI). The diagnosis of a MCNs of the pancreas was done preoperatively in the 2 cases.

INTERVENTIONS

Both patients underwent distal pancreatectomy during pregnancy. One of them was an emergency laparotomy because of a ruptured MCN.

OUTCOMES

Both patients were completely recovered from distal pancreatectomy and continued to full term, delivering a healthy baby by Caesarean section. After 6 years of follow-up, the first patient underwent a total gastrectomy, because of a gastric cancer with carcinomatosis. Currently the 2 patients are still alive after 8 years and 5 years of follow-up, respectively.

LESSONS

Surgical resection of MCNs during pregnancy should be considered during the second trimester given common distal pancreas location, rapid growth, risk of spontaneous rupture, and malignant potential.

A real-world evidence analysis of periampullary cancers in an academic hospital in Chile

663

Background: Periampullary cancers can originate in the pancreas, duodenum, bile duct or structures of the ampullary complex. The treatment of choice in early stages is pancreatoduodenectomy. The management post-surgery can depend on the histology pattern, and the overall survival can vary in different subgroups. Methods: A retrospective cohort study. We examined patients (pts) with invasive periampullary cancer undergoing pancreatoduodenectomy at the Hospital Clinico Universidad de Chile between 2002 to 2018. We analyzed epidemiological, clinical, surgical, and histological data. OS and the hazard ratio (HR) were established by GraphPad Prism 8.0. Results: Thirty-seven cases were registered. Twenty-two (59%) pts were men. The mean age was 62.5 (43-83 years). The histological subtypes were: 15 pts (40.5%) intestinal group (IN), 20 pts (54%) pancreatobiliary group (PB), 1 pt (2.7%) mixed and 1 pt (2.7%) signet ring cell type. A full concordance between histology and immunohistochemistry (CK20, CK7, CDX2, MUC1, and MUC2) patterns was 66% of the PB group, and 0% of the IN group. The stage IB was most frequent in all of the group (36,4%). The most frequent stages were IB (66,6%) in the IN type and IIIA (46%) in the PB type. The level of Ca19-9 was higher the PB group than IN group (629.7 versus 41.5 U/ml, respectively). Seven pts received postoperative adjuvant treatment such as FOLFOX, capecitabine, and gemcitabine. The median OS was 133,5 months (mo) in the intestinal group and 32,6 mo in PB group (P-value = 0.021). The HR was 0.38 (95% CI of ratio 0.1332 to 1.084). The 5-year OS was 75,2% and 45,7% in the IN and PB group, respectively. Conclusions: Periampullary cancer remains very challenging because it is a rare malignancy and present diverse histological pattern. These factors influence the behavior and OS of the disease. Our results showed clinically and statistically relevant differences in the staging, levels of Ca19-9, and OS of the IN and PB subtypes. Our patients received few post-operatory therapies such as chemotherapy; this factor could influence the OS in the high-risk group. According to our data, a personalized treatment by histological type should consider in this disease.

Predictive Validity of the YLS/CMI in a Sample of Spanish Young Offenders of Arab Descent

This study was conducted to assess the predictive validity of the Youth Level of Service/Case Management Inventory (YLS/CMI) in young offenders of Arab descent, living in Spain. To address this subject, the Inventory was administered to a sample of Arab minor offenders (N = 116), and results were compared to a sample of non-Arab minor offenders (N = 140), who were all aged between 14 and 17 years. The charges filed after the date of the first assessment carried out by the Youth Offending Team were coded during the follow-up period (2012-2017). The Inventory showed a similar predictive validity for both groups. However, the values were always slightly higher in the non-Arab group than in the Arab group. With subtle cultural differences, the YLS/CMI seems to be a risk instrument capable of predicting recidivism among Arab young offenders.

[Brain network dysfunctions as substrates of primary headaches]

A large body of clinical and pre-clinical evidence has shown complex interactions between bottom-up and top-down mechanisms that are essential for the discrimination of noxious information and pain perception. These endogenous systems, mainly originating from the brainstem, hypothalamus and cerebral cortex, are strongly influenced by behavioral, cognitive and emotional factors that are relevant for the survival of the individual. Under pathological conditions, however, dysfunctional engagement of these descending pathways certainly contributes to the transformation from acute into chronic pain states. In disorders such as primary headaches, dysfunctions affecting brain regulation mechanisms contribute to the generation of episodic painful states in susceptible individuals, and to the evolution from acute to chronic migraine or cluster headache. Taken together, these studies support the concept that CNS mechanisms that process trigemino-vascular pain do not consist only of a bottom-up process, whereby a painful focus modifies the inputs to the next higher level. Indeed, several CNS regions mediate subtle forms of plasticity by adjusting neural maps downstream and, consequently, altering all the modulatory mechanisms as a result of sensory, autonomic, endocrine, cognitive and emotional influences. Disturbances in normal sensory processing within these loops could lead to maladaptive changes and impaired craniofacial functions at the origin of primary headaches.

Burst-Like Subcutaneous Electrical Stimulation Induces BDNF-Mediated, Cyclotraxin B-Sensitive Central Sensitization in Rat Spinal Cord

Intrathecal administration of brain derived neurotrophic factor (BDNF) induces long-term potentiation (LTP) and generates long-lasting central sensitization in spinal cord thus mimicking chronic pain, but the relevance of these observations to chronic pain mechanisms is uncertain. Since C-fiber activation by a high-frequency subcutaneous electrical stimulation (SES) protocol causes spinal release of BDNF and induces spinal cord LTP, we propose that application of such protocol would be a sufficient condition for generating long-lasting BDNF-mediated central sensitization. Results showed that application of burst-like SES to rat toes produced (i) rapid induction of hyperalgesia that lasted for more than 3 weeks, (ii) early increase of C-reflex activity followed by increased wind-up scores lasting for more than 1 week, and (iii) early increase followed by late decrease in BDNF protein levels and phosphorylated TrkB that lasted for more than 1 week. These changes were prevented by the TrkB antagonist cyclotraxin-B administered shortly before SES, while hyperalgesia was reversed by cyclotraxin-B administered 3 days after SES. Results suggest that mechanisms underlying central sensitization first involve BDNF release of probably neuronal origin, followed by brief increased expression of likely glial BDNF and pTrkB that could switch early phase sensitization into late one.

Could an endoneurial endothelial crosstalk between Wnt/β-catenin and Sonic Hedgehog pathways underlie the early disruption of the infra-orbital blood-nerve barrier following chronic constriction injury?

Background

Blood–nerve barrier disruption is pivotal in the development of neuroinflammation, peripheral sensitization, and neuropathic pain after peripheral nerve injury. Activation of toll-like receptor 4 and inactivation of Sonic Hedgehog signaling pathways within the endoneurial endothelial cells are key events, resulting in the infiltration of harmful molecules and immunocytes within the nerve parenchyma. However, we showed in a previous study that preemptive inactivation of toll-like receptor 4 signaling or sustained activation of Sonic Hedgehog signaling did not prevent the local alterations observed following peripheral nerve injury, suggesting the implication of another signaling pathway.

Methods

Using a classical neuropathic pain model, the infraorbital nerve chronic constriction injury (IoN-CCI), we investigated the role of the Wnt/β-catenin pathway in chronic constriction injury-mediated blood–nerve barrier disruption and in its interactions with the toll-like receptor 4 and Sonic Hedgehog pathways. In the IoN-CCI model versus control, mRNA expression levels and/or immunochemical detection of major Wnt/Sonic Hedgehog pathway (Frizzled-7, vascular endothelial-cadherin, Patched-1 and Gli-1) and/or tight junction proteins (Claudin-1, Claudin-5, and Occludin) readouts were assessed. Vascular permeability was assessed by sodium fluorescein extravasation.

Results

IoN-CCI induced early alterations in the vascular endothelial-cadherin/β-catenin/Frizzled-7 complex, shown to participate in local blood–nerve barrier disruption via a β-catenin-dependent tight junction protein downregulation. Wnt pathway also mediated a crosstalk between toll-like receptor 4 and Sonic Hedgehog signaling within endoneurial endothelial cells. Nevertheless, preemptive inhibition of Wnt/β-catenin signaling before IoN-CCI could not prevent the downregulation of key Sonic Hedgehog pathway readouts or the disruption of the infraorbital blood–nerve barrier, suggesting that Sonic Hedgehog pathway inhibition observed following IoN-CCI is an independent event responsible for blood–nerve barrier disruption.

Conclusion

A crosstalk between Wnt/β-catenin- and Sonic Hedgehog-mediated signaling pathways within endoneurial endothelial cells could mediate the chronic disruption of the blood–nerve barrier following IoN-CCI, resulting in increased irreversible endoneurial vascular permeability and neuropathic pain development.

[Pancreaticoduodenectomy for a solid pseudopapillary tumor of the pancreas in children]

The solid pseudopapillary tumor of the pancreas (SPT) is a rare neoplasm with low malignant potential in children. We report the case of a 9 years old child with a SPT localized in the pancreatic head. She underwent a pancreaticoduodenectomy (PD) with favorable evolution. The PD in high-volume centers is safe in both adults and children.

Cancer of the gallbladder-Chilean statistics

Chile has the world's highest rate of incidence as well as death from cancer of the gallbladder and biliary ducts. The problem is most acute in the southern provinces. These areas constitute the low average income associated with low educational attainment and a high rate of obesity compared with the rest of Chile. We could also include genetic factors related to processes of lithogenesis to these elements which are more common among the Mapuche. This population sub-group could benefit from special government programmes for early diagnosis and treatment of lithiasic disease and for the management of risk factors such as obesity. In this way, we could reduce the mortality rate of gallbladder cancer.

Hedgehog Pathway-Mediated Vascular Alterations Following Trigeminal Nerve Injury

Whereas neurovascular interactions in spinal neuropathic pain models have been well characterized, little attention has been given to such neurovascular interactions in orofacial neuropathic pain models. This study investigated in male Sprague-Dawley rats the vascular changes following chronic constriction injury (CCI) of the infraorbital nerve (IoN), a broadly validated preclinical model of orofacial neuropathic pain. Following IoN-CCI, an early downregulation of tight junction proteins Claudin-1 and Claudin-5 was observed within the endoneurium and perineurium, associated with increased local accumulation of sodium fluorescein (NaFlu) within the IoN parenchyma, as compared with sham animals. These events were evidence of local blood-nerve barrier disruption and increased vascular permeability. A significant upregulation of immunocytes (CD3, CD11b) and innate immunity (TLR2, TLR4) mRNA markers was also observed, suggestive of increased local inflammation. Finally, a significant downregulation of Hedgehog pathway readouts Patched-1 and Gli-1 was observed within the IoN after CCI and local injections of cyclopamine, a Hedgehog pathway inhibitor, replicated in naïve rats the molecular, vascular, and behavioral changes observed following IoN-CCI. These results suggest a major role of Hedgehog pathway inhibition in mediating local increased endoneurial and perineurial vascular permeability following trigeminal nerve injury, thus facilitating immunocytes infiltration, neuroinflammation development, and neuropathic pain-like aversive behavior.

Microglial Janus kinase/signal transduction and activator of transcription 3 pathway activity directly impacts astrocyte and spinal neuron characteristics

After peripheral nerve injury microglial reactivity change in the spinal cord is associated with an early activation of Janus kinase (JAK)/STAT3 transduction pathway whose blockade attenuates local inflammation and pain hypersensitivity. However, the consequences of microglial JAK/STAT3-mediated signaling on neighboring cells are unknown. Using an in vitro paradigm we assessed the impact of microglial JAK/STAT3 activity on functional characteristics of astrocytes and spinal cord neurons. Purified rat primary microglia was stimulated with JAK/STAT3 classical activator interleukin-6 in the presence or absence of a selective STAT3 inhibitor and rat primary astrocytes or spinal cord neurons were exposed to microglia conditioned media (CM). JAK/STAT3 activity-generated microglial CM modulated both astrocyte and neuron characteristics. Beyond inducing mRNA expression changes in various targets of interest in astrocytes and neurons, microglia CM activated c-Jun N-terminal kinase, STAT3 and NF-κB intracellular pathways in astrocytes and promoted their proliferation. Without modifying neuronal excitability or survival, CM affected the nerve processes morphology and distribution of the post-synaptic density protein 95, a marker of glutamatergic synaptic contacts. These findings show that JAK/STAT3 activity in microglia impacts the functional characteristics of astrocytes and neurons. This suggests its participation in spinal cord tissue plasticity and remodeling occurring after peripheral nerve injury. We show that the activity of JAK/STAT3 pathway in microglial cells confers them a specific signaling modality toward neighboring cells, promoting astrocyte proliferation and changes in neuronal morphology. These in vitro data suggest that the early JAK/STAT3 activation in spinal cord microglia, associated with peripheral nerve injury, participates in functional alteration of various cell populations and in spinal tissue remodeling.

Cirugía Laparoscópica Abdominal Experiencia 1991-1995 - Hospital Guillermo Almenara Irigoyen

Se presenta el desarrollo de la cirugía laparoscópica abdominal en el Hospital Guillermo Almenara desde su inicio, en setiembre de 1991, hasta el 31 de diciembre de 1995. Compromete la revisión de 2 750 historias clínicas de pacientes sometidos a esta técnica operatoria. La colecistectomía significó el 96% de los casos estudiados, le siguen en frecuencia la hernioplastía inguinofemoral con el 0.88%, la esplenectomía con el 0.85% y la colectomía con el 0.38%. Es importante relevar que progresivamente se han ido abordando otras técnicas que no sean colecistectomía, éstas significaron el 1.3% hasta 1993, el 2.6% al final de 1994 y el 4% al concluir la serie estudiada. La colecistectomía laparoscópica reune un total de 2 465 casos con un predominio del sexo femenino y una edad promedio de 44 años para las mujeres y 51 años para varones. El índice de conversión es de 4.9%. La morbilidad total significó el 9.36% de ésta, el 7% fueron problemas menores y solamente el 2.36% necesitaron reoperación. La mortalidad alcanzó el 0.24% causada por lesiones en las vías biliares. Debemos subrayar el importante avance logrado en nuestro hospital en la técnica de la esplenectomía, que ha sido modificada de su forma original de planteo por nuestros cirujanos con un índice de conversión que supera a las referencias internacionales, pues sólo alcanzó el 4.76%. Mención particular merece la cirugía de colon que en esta serie compromet nó el vólvulo como indicación de resección; hubieron 3 adenocarcinomas, 1 caso de adenoma velloso y un caso de divertículo. El presente estudio da fe de la madurez alcanzada en el manejo de la técnica laparoscópica que ha permitido resolver con solvencia la patología vesicular e iniciar el abordaje satisfactorio de las hernias, la patología esplénica y colónica.

Adrenalectomía laparoscópica

Objetivo: Evaluar la efectividad y resultados de la adrenalectomía laparoscópica en la patología adrenal benigna. Materiales y Métodos: Estudio retrospectivo de 15 adrenalectomías realizadas en 13 pacientes por el mismo equipo quirúrgico en el Hospital Nacional Guillermo Almenara Irigoyen EsSalud y en la Clínica San Pablo,. Lima – Perú, entre 1996 y 2005, evaluándose la efectividad y resultados con respecto al tamaño del tumor, técnica quirúrgica y otros aspectos. Resultados: Once adrenalectomías fueron unilaterales y dos bilaterales. Las indicaciones fueron: adenoma no funcionante (2), adenoma funcionante (6), feocromocitoma (3), teratoma (1), leiomiosarcoma (1), mielolipoma (2). No hubo mortalidad ni reoperaciones. Conclusión: La adrenalectomía laparoscópica es factible y segura para tumores menores de 7 cm.

Un caso de duplicación gástrica quística del adulto manejado por laparoscopia

El objetivo de este estudio fue evaluar las dificultades diagnósticas y las alternativas terapéuticas de esta rara enfermedad. Describimos un caso de duplicación gástrica en una paciente de 42 años de edad, que acudió por dolor abdominal inespecífico y que las imágenes mostraron una masa quística retrogástrica. Con el diagnóstico presuntivo de cistoadenoma o hidatidosis pancreática, la paciente fue sometida a exploración y manejo laparoscópico. Se extirpó una tumoración quística dependiente de la pared posterior gástrica, sin comunicación con su luz, la cual fue extraída completamente en una bolsa. El contenido fue verdoso y el informe de anatomía patológica fue duplicación gástrica. Concluimos que la duplicación gástrica debe ser resecada completamente y que la vía laparoscópica es una alternativa viable.

Manejo laparoscópico de un quiste de colédoco, incluyendo mucosectomía

El quiste de colédoco es una enfermedad poco frecuente de la vía biliar. Presentamos un caso de quiste de colédoco Todani I, tratado exitosamente por vía laparoscópica, incluyendo la reconstrucción con un asa desfuncionalizada, en Y de Roux. Además, se realizó una mucosectomía laparoscópica de la porción intrapancreática del quiste. La evolución del paciente fue muy satisfactoria. Se concluye que es factible el manejo laparoscópico del quiste de colédoco.

Spinal LTP induced by sciatic nerve electrical stimulation enhances posterior triangular thalamic nociceptive responses

Long-term potentiation (LTP) can be induced by electrical stimulation and gives rise to an increase in synaptic strength at the first relay. This phenomenon has been associated with learning and memory and also could be the origin of several pathological states elicited by an initial strong painful stimulus, such as some forms of neuropathic pain. We used high-frequency electrical stimulation of the sciatic nerve in anesthetized rats to produce spinal LTP. To evaluate the effect of spinal LTP on the activity of neurons in the posterior triangular nucleus of the thalamus (PoT), we applied an electrical stimulation (40 stimuli; 1ms; 0.5Hz; 1.5mA) to cutaneous tissues at 10-min intervals during at least 3h. In the majority of cases, PoT cells did not respond to cutaneous stimulation before LTP, but 50min after LTP induction PoT cells progressively began responding to the cutaneous stimulation. Furthermore, after 3h of LTP induction, PoT neurons could respond to cutaneous stimulation applied to different paws. Interestingly, the conduction velocities for the receptive field responses from the paw to the PoT cells were compatible with those of Aδ-fibers. Since PoT cells project to the insular cortex, the progressive increase in PoT activity and also the progressive unmasking of somatic receptive fields in response to LTP, place these cells in a key position to detect pain stimuli following central sensitization.

[Palliative treatment for locally advanced or metastatic gallbladder cancer: conclusions of the Latin American Consensus meeting for the management of gallbladder cancer]

Gallbladder cancer is a rare disease in Western developed countries, but it is a highly prevalent and lethal disease in Chile and other countries in Latin America. No randomized controlled trials have been performed in gallbladder cancer to establish standard treatments. We therefore performed the first Latin American consensus meeting for the management of gallbladder cancer. In this article we present the conclusions of the panel of experts for the palliative treatment of unresectable or metastatic gallbladder cancer based on a review of the literature, the discussion of the participating experts and the opinion of the assistants. The topics reviewed included: (1) Gallbladder cancer and cholangiocarcinoma--are they the same disease?; (2) Palliative chemotherapy: indications, drugs and schedules; (3) Palliative radiotherapy; (4) Palliative Surgery; (5) Management of malignant biliary obstruction.

[Solid pseudopapillary tumor of the pancreas: a neoplasm of low malignant potential?]

BACKGROUND

Solid pseudo papillary tumor of the pancreas is considered a neoplasm of low malignant potential. The radicality of surgical approach is controversial.

PATIENTS AND METHODS

We describe and analyze retrospectively the clinical, radiological, laboratory, operative report and pathology results of seven patients who were diagnosed and operated by solid pseudo papillary tumor of the pancreas in the period 2003 to 2010, in our institution.

RESULTS

Six patients were female and one male. The median age was 35 years (range: 15-49). The most common symptom was abdominal pain (100%). Jaundice in one patient (14.3%). The radiological appearance mixed solid-cystic was the most common. We performed four Whipple procedures (57.1%), 2 distal pancreatectomy with splenectomy (28.6%), one by laparoscopy and the other by local resection. Morbidity presented in four patients. There was no postoperative mortality or reoperation. Five tumors were located in the pancreatic head (71.4%) and two in the tail (28.6%). The median tumor size was 93 mm (range: 20-150). Two (28.6%) were R1 resections. Four tumors showed malignant behavior (57.1%): splenic capsule and infiltration of metachronous liver metastases (1), infiltration of superior mesenteric artery (1), lymphatic metastasis (1) and synchronous liver metastases, and lymphovascular invasion duodenal infiltration (1). There was no mortality from the disease during the average follow-up of 26 months (range 6-70 months).

CONCLUSION

Solid pseudo papillary tumor is a neoplasm with high malignant potential in our experience. We recommend an aggressive surgical approach with radical resection including lymphadenectomy.

Changes of meningeal excitability mediated by corticotrigeminal networks: a link for the endogenous modulation of migraine pain

Alterations in cortical excitability are implicated in the pathophysiology of migraine. However, the relationship between cortical spreading depression (CSD) and headache has not been fully elucidated. We aimed to identify the corticofugal networks that directly influence meningeal nociception in the brainstem trigeminocervical complex (Sp5C) of the rat. Cortical areas projecting to the brainstem were first identified by retrograde tracing from Sp5C areas that receive direct meningeal inputs. Anterograde tracers were then injected into these cortical areas to determine the precise pattern of descending axonal terminal fields in the Sp5C. Descending cortical projections to brainstem areas innervated by the ophthalmic branch of the trigeminal nerve originate contralaterally from insular (Ins) and primary somatosensory (S1) cortices and terminate in laminae I-II and III-V of the Sp5C, respectively. In another set of experiments, electrophysiological recordings were simultaneously performed in Ins, S1 or primary visual cortex (V1), and Sp5C neurons. KCl was microinjected into such cortical areas to test the effects of CSD on meningeal nociception. CSD initiated in Ins and S1 induced facilitation and inhibition of meningeal-evoked responses, respectively. CSD triggered in V1 affects differently Ins and S1 cortices, enhancing or inhibiting meningeal-evoked responses of Sp5C, without affecting cutaneous-evoked nociceptive responses. Our data suggest that "top-down" influences from lateralized areas within Ins and S1 selectively affect interoceptive (meningeal) over exteroceptive (cutaneous) nociceptive inputs onto Sp5C. Such corticofugal influences could contribute to the development of migraine pain in terms of both topographic localization and pain tuning during an attack.

Response of six strawberry (Fragaria x ananassa Duch.) cultivars to the root lesion nematode (Pratylenchus penetrans Filipjev and Schurmanns Stekhoven)

In the Philippines, strawberry is grown only in Benguet Province because of its unique climatic conditions. It has been a lucrative source of income for Benguet farmers and adds to the revenue of Benguet Province. The root lesion nematode, Pratylenchus penetrans is an economically important pest of strawberry in the area. It can cause substantial losses to strawberry growers, both by reducing vegetative plant growth and by reducing strawberry yields. The nematode has a very wide host range and hence, is not readily controlled by crop rotation. An alternative approach which growers may wish to consider trying is planting of strawberry varieties which are either resistant or tolerant to this nematode. The relative susceptibility/tolerance of six strawberry cultivars to the root lesion nematode, P. penetrans was evaluated under greenhouse and field conditions. Inoculation of 500 nematodes/pot did not significantly affect the fresh top weight, fresh root weight, and yield of strawberry cultivars Festival, Whitney, Winterdawn, Earlibrite, and Camarosa. The said cultivars had significantly higher number of nematodes recovered from the roots. On the other hand, the highest strawberry yield was recorded in cv Sweet Charlie, however, this was significantly reduced by nematode inoculation .Surprisingly, the number of nematodes recovered from the roots of this cultivar was significantly the lowest among the cultivars tested. Results of the field experiment showed that strawberry cv Sweet Charlie gave the highest marketable yield which was significantly different from the rest of the cultivars tested. This was followed by Festival, and Earlibrite. On the other hand, Camarosa and Whitney gave significantly lower yield than the above cultivars but significantly higher than Winterdawn. In terms of nematodes recovered from the roots, the highest was noted in Whitney, followed by Sweet Charlie and Earlibrite. The lowest was obtained from Camarosa, followed by Festival and Winterdawn. Based on the results of the greenhouse experiment, Festival, Whitney, Winterdawn, Earlibrite and Camarosa can be considered tolerant while Sweet Charlie was slightly susceptible to P. penetrans. However, based on the field trial, Sweet Charlie, Festival and Earlibrite were tolerant while Whitney, Camarosa and Winterdawn were slightly susceptible.

Management of root knot nematode, Meloidogyne incognita in cucumber (Cucumis sativus) using silicon

Silicon (Si) has been reported to effectively manage some pests and diseases of plants. This study was conducted to determine the effect of Si concentration, mode, and frequency of application in managing Meloidogyne incognita in cucumber. A susceptible cultivar of cucumber (cv. Cyclone) was planted in pots containing heat-sterilized soil. Three weeks after planting, the plants were inoculated with 1,000 juveniles/ pot. Uninoculated plants were provided to serve as control. Three concentrations of Si in the form of sodium metasilicate was applied on the leaves and roots alone and also on both the leaves and roots. Application was done once during the growing period and weekly until seven days before harvest. Leaf and root application of Si was found to significantly increase (p = 0.0029) the fresh top weight of inoculated and uninoculated plants. On the other hand, inoculation of root-knot nematode significantly increased the fresh root weight of cucumber which could be due to enlargement of roots or formation of galls. Interestingly, the inoculated plants gave significantly higher marketable yield than uninoculated ones. Application of Si at the rate of 200 ppm significantly increased the marketable yield compared to the higher rate of Si (400 ppm). At 200 ppm, one application of Si both on the leaves and roots significantly reduced the number of galls in inoculated plants. This was comparable to the same concentration applied continuously on the roots and at higher concentration (400 ppm) applied continuously on the leaves and on the roots. On the other hand, single root application of Si at the rate of 400 ppm gave the lowest number of eggmasses, however, it was comparable to the same Si concentration applied singly on the leaves and applied continuously both on the leaves and roots. These treatments, however, were at par with continuous application of the lower rate of Si (200 ppm) on the leaves and both leaves and roots.

[Results of adjuvant chemoradiation after curative surgery for gastric cancer: a retrospective study]

BACKGROUND

Survival rates after curative surgery for gastric cancer are disappointing. Therefore adjuvant therapeutic strategies are required.

AIM

To analyze survival and side effects of treatment among gastric cancer patients treated with adjuvant chemo radiotherapy after curative resection of gastric adenocarcinoma.

MATERIAL AND METHODS

Retrospective review of medical records of 74 patients aged 20 to 74 years, treated with complete resection of gastric adenocarcinoma followed by adjuvant chemo radiation. Survival analysis was based on the records and information from the National Mortality Registry.

RESULTS

Five years survival fluctuated from 50% among patients in stage IB to 25% among those is stage IV. Significant acute toxicity was observed in 23 patients (31%). No patients died due to acute toxicity. Eleven patients (16.4%) developed significant late toxicity, with two possible deaths related to treatment.

CONCLUSIONS

Postoperative chemo radiotherapy is feasible in our experience. Continues infusion of 5-fluoruracil is recommended to reduce toxicity.

Central nervous system networks involved in the processing of meningeal and cutaneous inputs from the ophthalmic branch of the trigeminal nerve in the rat

This study analysed the organization of central nervous system networks involved in the processing of meningeal inputs in the male, Sprague-Dawley rat. We injected the anterograde tracer, biotin dextran, into areas of the medullary trigeminal nucleus caudalis (Sp5C), which receive inputs from the ophthalmic division of the trigeminal nerve. Double-labelling immunohistochemical studies were then performed to compare calcitonin gene-related peptide (CGRP) or serotonin 1D (5HT1(D)) receptor distributions in the areas innervated by Sp5C neurons. Dense, topographically organized intratrigeminal connections were observed. Sp5C neurons projected to the commissural subnucleus of the solitary tract, A5 cell group region/superior salivatory nucleus, lateral periaqueductal grey matter, inferior colliculus and parabrachial nuclei. Trigeminothalamic afferents were restricted to the posterior group and ventroposteromedial thalamic nuclei. Some of these areas are also immunoreactive for 5HT1(D) and CGRP and thus remain potential central targets of triptan molecules and other antimigraine drugs.

Chemotherapy in gallbladder cancer: Improving survival

15140

Background: Since 1999 we had been studying the effect of chemotherapy in gallbladder cancer, a disease frequent in low economical income area of the world, orphan of research, traditionally considered chemotherapy-resistant. Previous studies included 5- FU regimen and communicated response rate of 10–26 %, and no changes on survival. We first conducted a phase II study with gemcitabine (Gem), and later, another study (with support of GOCCHI) using Gem and cisplatin (C). Since 2001 we had treated patients out of clinical trial. We compare median survival observed in all series. Methods: Patients file of both 2 phase II studies and clinical record of all patients treated out of clinical trial were retrieved and median survival was calculated. The both phase two trials had a similar population, and inclusion criteria, both were multicenters. The third cohort is a one center experience. The regimens used were: Gem 1,000 mg/m2 on days 1,8 and 15 every 28 days (first trial), Gem 1,250 mg/m2+C 35 mg/m2 on the 1 and 8 days every 21 days (second trial), only maximum 6 courses were planned. The third group, most frequently, received Gem 1.000 mg/m2 (10mg/m2/min)+C 40 mg/m2 days 1 and 8 every 21 days, until disease progression and/or toxicity; second line chemotherapy was allowed. Among whole group 7 pts, who had significant response, underwent a surgical resection. Survival was also calculated and comparison is included. The toxicity was evaluated every 2 weeks and response was assessed every two cycles using CT scan. Overall survival was calculated from beginning of chemotherapy until death or last follow up. Survival analysis was also done using Kaplan Meier’s tables Results: For Gem monotherapy (26 pts) median survival was 30 weeks, for Gem+C (44 pts) median survival was 28 weeks. For third group (29 pts) median survival was 56 weeks. Until now, for the 7 pts who underwent a surgical resection median survival is 92 weeks, with one pt alive, without evidence of disease, at 112 weeks of follow up Conclusions: Both regimens showed better efficacy than 5-FU based chemotherapy, the combination did not show better survival. The third group has better median survival, probable due to the use of second line therapies. Combining chemotherapy + surgical resection may be a better treatment for some few, well selected patients.

No significant financial relationships to disclose.

Tumour necrosis factor (TNF)alpha -308 G/G promoter polymorphism and TNFalpha levels correlate with a better response to adalimumab in patients with rheumatoid arthritis

OBJECTIVE

To investigate the influence of -308 tumour necrosis factor-alpha (TNFalpha) promoter polymorphism and circulating TNFalpha levels in the clinical response to adalimumab treatment in patients with rheumatoid arthritis (RA).

METHODS

Eighty-one patients with active RA were genotyped for the -308 TNFalpha polymorphism by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) analysis and subdivided into two groups for each polymorphism (G/A and G/G genotype). All received 40 mg of adalimumab subcutaneously every other week. We compared the groups' clinical responses to adalimumab at 8, 16, and 24 weeks using the Disease Activity Score in 28 joints (DAS28).

RESULTS

Both groups showed a significant improvement from baseline. A significant difference between groups was found at week 24. We found that 88.2% of G/G versus 68.4% of G/A for the -308 polymorphism were DAS28 responders (p = 0.05). The score improvement at week 24 was 2.5 +/- 1.3 in the G/G group and 1.8 +/- 1.3 in the G/A group for the -308 polymorphism (p = 0.04). The median of serum TNFalpha levels of the G/A group were lower than those of the G/G group, and statistically different at weeks 8 and 24 (p < 0.039 and p < 0.043). When comparing baseline levels to those achieved at 8, 16, and 24 weeks for the whole group, only responder patients showed a statistically significant overall increase in TNFalpha over time (p < 0.000001).

CONCLUSION

A relationship between DAS28 improvement, the -308 G/G polymorphism, and increased circulating TNFalpha levels was found in Chilean RA patients treated with adalimumab.

Corticofugal output from the primary somatosensory cortex selectively modulates innocuous and noxious inputs in the rat spinothalamic system

Sensory maps for pain can be modified by deafferentation or injury, and such plasticity has been attributed mainly to changes in the convergence of projections in "bottom-up" mechanisms. We addressed the possible contribution of "top-down" mechanisms by investigating the functional significance of corticofugal influences from the primary somatosensory cortex (S1) to the ventroposterolateral thalamic nucleus (VPL). The strong convergence of spinal and lemniscal afferents to the VPL and the close correspondence between afferents and efferents within the VPL-S1 network suggest the existence of functionally related thalamocortical circuits that are implicated in the detection of innocuous and noxious inputs. Functional characterization of single nociceptive, wide dynamic range, and non-nociceptive VPL neurons and labeling the axons and terminal fields with the juxtacellular technique showed that all three types of cells project to a restricted area, within S1. The convergence of the terminal trees of axons from VPL neurons activated by innocuous, noxious, or both inputs suggests that their inputs are not segregated into anatomically distinct regions. Microinjections within S1 were performed for pharmacological manipulation of corticofugal modulation. Glutamatergic activation of corticofugal output enhanced noxious-evoked responses and affected in a biphasic way tactile-evoked responses of VPL cells. GABA(A)-mediated depression of corticofugal output concomitantly depressed noxious and enhanced innocuous-evoked responses of VPL neurons. Microinjections of a GABA(A) antagonist on corticofugal cells enhanced noxious-evoked responses of VPL cells. Our findings demonstrate that corticofugal influences from S1 contribute to selectively modulate somatosensory submodalities at the thalamic level.