High-Volume, High-Acuity, and High-Impact Learning: Tips and Tricks for Infectious Diseases Training Programs

The Infectious Diseases Society of America Training Program Directors Committee met in October 2022 and discussed an observed increase in clinical volume and acuity on infectious diseases (ID) services, and its impact on fellow education. Committee members sought to develop specific goals and strategies related to improving training program culture, preserving quality education on inpatient consult services and in the clinic, and negotiating change at the annual IDWeek Training Program Director meeting. This paper outlines a presentation of ideas brought forth at the meeting and is meant to serve as a reference document for infectious diseases training program directors seeking guidance in this area.

A phase IIb, open-label, randomized controlled dose ranging multi-centre trial to evaluate the safety, tolerability, pharmacokinetics and exposure-response relationship of different doses of delpazolid in combination with bedaquiline delamanid moxifloxacin in adult subjects with newly diagnosed, uncomplicated, smear-positive, drug-sensitive pulmonary tuberculosis

BACKGROUND

Linezolid is an effective, but toxic anti-tuberculosis drug that is currently recommended for the treatment of drug-resistant tuberculosis. Improved oxazolidinones should have a better safety profile, while preserving efficacy. Delpazolid is a novel oxazolidinone developed by LegoChem Biosciences Inc. that has been evaluated up to phase 2a clinical trials. Since oxazolidinone toxicity can occur late in treatment, LegoChem Biosciences Inc. and the PanACEA Consortium designed DECODE to be an innovative dose-ranging study with long-term follow-up for determining the exposure-response and exposure-toxicity relationship of delpazolid to support dose selection for later studies. Delpazolid is administered in combination with bedaquiline, delamanid and moxifloxacin.

METHODS

Seventy-five participants with drug-sensitive, pulmonary tuberculosis will receive bedaquiline, delamanid and moxifloxacin, and will be randomized to delpazolid dosages of 0 mg, 400 mg, 800 mg, 1200 mg once daily, or 800 mg twice daily, for 16 weeks. The primary efficacy endpoint will be the rate of decline of bacterial load on treatment, measured by MGIT liquid culture time to detection from weekly sputum cultures. The primary safety endpoint will be the proportion of oxazolidinone class toxicities; neuropathy, myelosuppression, or tyramine pressor response. Participants who convert to negative liquid media culture by week 8 will stop treatment after the end of their 16-week course and will be observed for relapse until week 52. Participants who do not convert to negative culture will receive continuation phase treatment with rifampicin and isoniazid to complete a six-month treatment course.

DISCUSSION

DECODE is an innovative dose-finding trial, designed to support exposure-response modelling for safe and effective dose selection. The trial design allows assessment of occurrence of late toxicities as observed with linezolid, which is necessary in clinical evaluation of novel oxazolidinones. The primary efficacy endpoint is the change in bacterial load, an endpoint conventionally used in shorter dose-finding trials. Long-term follow-up after shortened treatment is possible through a safety rule excluding slow-and non-responders from potentially poorly performing dosages.

TRIAL REGISTRATION

DECODE was registered in ClinicalTrials.gov before recruitment start on 22 October 2021 (NCT04550832).

Inclusion, Diversity, Access, and Equity in Infectious Diseases Fellowship Training: Tools for Program Directors

The Infectious Diseases Society of America (IDSA) has set clear priorities in recent years to promote inclusion, diversity, access, and equity (IDA&E) in infectious disease (ID) clinical practice, medical education, and research. The IDSA IDA&E Task Force was launched in 2018 to ensure implementation of these principles. The IDSA Training Program Directors Committee met in 2021 and discussed IDA&E best practices as they pertain to the education of ID fellows. Committee members sought to develop specific goals and strategies related to recruitment, clinical training, didactics, and faculty development. This article represents a presentation of ideas brought forth at the meeting in those spheres and is meant to serve as a reference document for ID training program directors seeking guidance in this area.

A review of welfare indicators for sea turtles undergoing rehabilitation, with emphasis on environmental enrichment

For animals undergoing rehabilitation it is vital to monitor welfare in a way that is feasible, practical, and limits stress to the animal. The industry gold standard is to assess welfare under the Five Domains model, including nutrition, environment, physical health, and behaviour as the first four physical domains and mental domain as the fifth. Feasibility and effectiveness of these domains for assessing welfare of sea turtles undergoing rehabilitation were reviewed and it was determined that the mental state can be best assessed through behavioural changes. A scoping review of the literature was conducted using Scopus and Web of Science to investigate use of environmental enrichment devices (EEDs) as a measure of welfare in sea turtles. Behavioural assessments using EEDs were found to be well-documented; however, most EED studies pertained largely to livestock or zoo animals. Furthermore, studies rarely concentrated on reptiles, and specifically sea turtles. Results also showed that certain welfare assessment methods may be less appropriate for short-term captivity experienced during rehabilitation. Additionally, the hospital environment limits the ability to address some of the domains (ie biosecurity, feasibility, safety of turtle, etc, might be compromised). This review shows that only three of the nine environmental enrichment strategies described in the literature suit the specific requirements of sea turtles in rehabilitation: feeding, tactile, and structural. It is documented that turtles display behaviours that would benefit from EEDs and, therefore, more specific studies are needed to ensure the best welfare outcomes for sea turtles undergoing rehabilitation.

The Emperor's New Clothes: PRospective Observational Evaluation of the Association Between Initial VancomycIn Exposure and Failure Rates Among ADult HospitalizEd Patients With Methicillin-resistant Staphylococcus aureus Bloodstream Infections (PROVIDE)

BACKGROUND

Vancomycin is the most commonly administered antibiotic in hospitalized patients, but optimal exposure targets remain controversial. To clarify the therapeutic exposure range, this study evaluated the association between vancomycin exposure and outcomes in patients with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia.

METHODS

This was a prospective, multicenter (n = 14), observational study of 265 hospitalized adults with MRSA bacteremia treated with vancomycin. The primary outcome was treatment failure (TF), defined as 30-day mortality or persistent bacteremia ≥7 days. Secondary outcomes included acute kidney injury (AKI). The study was powered to compare TF between patients who achieved or did not achieve day 2 area under the curve to minimum inhibitory concentration (AUC/MIC) thresholds previously found to be associated with lower incidences of TF. The thresholds, analyzed separately as co-primary endpoints, were AUC/MIC by broth microdilution ≥650 and AUC/MIC by Etest ≥320.

RESULTS

Treatment failure and AKI occurred in 18% and 26% of patients, respectively. Achievement of the prespecified day 2 AUC/MIC thresholds was not associated with less TF. Alternative day 2 AUC/MIC thresholds associated with lower TF risks were not identified. A relationship between the day 2 AUC and AKI was observed. Patients with day 2 AUC ≤515 experienced the best global outcomes (no TF and no AKI).

CONCLUSIONS

Higher vancomycin exposures did not confer a lower TF risk but were associated with more AKI. The findings suggest that vancomycin dosing should be guided by the AUC and day 2 AUCs should be ≤515. As few patients had day 2 AUCs <400, further study is needed to define the lower bound of the therapeutic range.

Advances in 211At production at Texas A&M University

Alpha emitting radionuclides with medically relevant half-lives are interesting for treatment of tumors and other diseases because they deposit large amounts of energy close to the location of the radioisotope. Researchers at the Cyclotron Institute at Texas A&M University are developing a program to produce 211At, an alpha emitter with a medically relevant half-life. The properties of 211At make it a great candidate for targeted alpha therapy for cancer due to its short half-life (7.2 h). Astatine-211 has now been produced multiple times and reliability of this process is being improved.

1220. Impact of Mandatory Infectious Diseases Consultation on the Use of Core Measures and Mortality in Staphylococcus aureus Bacteremia (SAB) at an Academic Medical Center

Background

Multiple studies have shown that Infectious Diseases (ID) consultation significantly improves adherence to guidelines for patients with SAB and decreases mortality. Data from a prior retrospective study done at Hahnemann University Hospital showed that ID consultation improved the use of guideline-based core measures for SAB management. Based on these data, a mandatory ID consultation was established at our institution in November 2016.

Methods

A retrospective, observational study was conducted to evaluate patient characteristics, adherence to core measures for SAB, and in-hospital mortality. All patients with at least one documented blood culture positive for S. aureus were stratified into two groups: pre-mandatory consult (January 1, 2014–November 1, 2016) and post mandatory consult (November 2, 2016–February 1, 2018).

Results

Three hundred seventy-three discrete episodes of SAB were included in the final analysis, 238 episodes before mandatory consult, and 135 episodes after the mandatory consult policy was enacted. Mandatory consultation significantly improved the use of the following core measures for SAB: surveillance blood cultures (87.7% pre vs. 99.2% post, P < 0.001), echocardiography (81.9% vs. 96.9%, P < 0.001), early targeted antimicrobial therapy with nafcillin or cefazolin in MSSA (71.7% vs. 88.6%, P < 0.001), and appropriateness of final antibiotic choice (80.2% vs. 95.2%, P < 0.001). In addition, in-hospital mortality (15.4% vs. 6.2%, P = 0.011), and infection-related mortality (14.3% vs. 5.6%, P = 0.011) were found to be statistically significantly lower in the post mandatory consultation patients.

Conclusion

Implementation of a mandatory ID consultation for patients with SAB at our institution was associated with increased adherence to guideline-based core measures for management of SAB, and decreased in-hospital and infection-related mortality. Our results suggest that mandatory ID consultation for SAB should be considered at all institutions.

Disclosures

All authors: No reported disclosures.

The Emperor’s New Clothes: Prospective Observational Evaluation of the Association between the Day 2 Vancomycin Exposure and Failure Rates among Adult Hospitalized Patients with MRSA Bloodstream Infections (PROVIDE)

Background

Current guidelines recommend vancomycin (VAN) dosing to achieve AUC/MIC ratio ≥400 for patients (pts) with serious MRSA bloodstream infections (BSI), but supporting data were largely derived in single center retrospective studies. A recent study using a Bayesian approach to estimate the VAN AUC found that patients with MRSA BSI who had an AUC_DAY2/MIC_BMD ≥ 650 or an AUC_DAY2/MIC_ETEST ≥ 320 had lower incidences of failure (Clin Infect Dis 59:666, 2014). This study prospectively evaluated if these VAN AUC_DAY2/MIC targets were associated with lower incidences of failure (PROVIDE, Award number UM1AI104681, Antibacterial Resistance Leadership Group).

Methods

Prospective, multi-center (n = 14), observational study (2014–2106) of hospitalized adults with confirmed MRSA BSI treated with VAN ≥ 72h. Exclusion: (1) neutropenia; (2) cystic fibrosis; (3) renal replacement therapy; (4) APACHE-II score > 25; (5) previous MRSA BSI within 60 days. VAN exposures were estimated using maximum a posteriori probability procedure in ADAPT 5. MIC_BMD and MIC_ETEST were performed at a central laboratory. Outcomes: failure (30-day mortality or MRSA BSI ≥ 7 days); acute kidney injury (AKI), ≥1.5 × increase in serum creatinine (S_cr) among patients with a baseline S_CR < 2.0mg/dl. The study was powered at 80% to detect a 17.5% difference in failure between AUC_DAY2/MIC groups.

Results

Among the 265 evaluable patients, mean (SD) age was 61 (17) and APACHE-II was 12 (6). Endocarditis was definite/possible in 29%. The MIC_50/90 by BMD and ETEST were 1/1 and 1.5/1.5mg/l, respectively. Failure occurred in 18%; 26% had AKI. Mean (SD) VAN duration was 18 (14) days. Mean (SD) AUC_DAY2 was 586.9 (235.5) and 44% and 73% of patients achieved an AUC_DAY2/MIC_BMD ≥ 650 and AUC_DAY2/MIC_ETEST ≥ 320. In the multivariate analyses (Figure 1), failure was not significantly different between AUC_DAY2/MIC groups. In contrast, AKI was significantly more common in patients with an AUC_DAY2/ MIC_ETEST > = 320.

Conclusion

Achievement of higher VAN AUC_DAY2/MIC exposures for patients with MRSA BSIs were not associated with better outcomes and were found to result in increased AKI. Clinicians should assess the benefits vs. risks of using VAN regimens that confer high AUC_DAY2/MIC exposures for patients with MRSA BSIs.

Disclosures

T. P. Lodise Jr., allergan: Consultant, Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee and Speaker honorarium; medicines company: Consultant, Grant Investigator, Scientific Advisor and Speaker’s Bureau, Consulting fee, Research support and Speaker honorarium; melinta: Consultant, Consulting fee; motif: Consultant and Scientific Advisor, Consulting fee; paratek: Consultant and Scientific Advisor, Consulting fee; nabriva: Consultant, Consulting fee; M. J. Zervos, Merck, Inc.: Investigator, Research grant; M. Scheetz, Bayer: Scientific Advisor, Consulting fee; V. Fowler Jr., Pfizer, Novartis, Galderma, Novadigm, Durata, Debiopharm, Genentech, Achaogen, Affinium, Medicines Co., Cerexa, Tetraphase, Trius, MedImmune, Bayer, Theravance, Cubist, Basilea, Affinergy, Janssen, xBiotech, Contrafect: Consultant, Consulting fee; NIH, Basilea, MedImmune, Cerexa/Forest/Actavis/Allergan, Pfizer, Advanced Liquid Logics, Theravance, Novartis, Cubist/Merck; Medical Biosurfaces; Locus; Affinergy; Contrafect; Karius: Grant Investigator, Research grant; Green Cross, Cubist, Cerexa, Durata, Theravance; Debiopharm: Consultant, Consulting fee; UpToDate: author on several chapters, Royalties

How strict is galactose restriction in adults with galactosaemia? International practice

Dietary management of 418 adult patients with galactosaemia (from 39 centres/12 countries) was compared. All centres advised lactose restriction, 6 restricted galactose from galactosides ± fruits and vegetables and 12 offal. 38% (n=15) relaxed diet by: 1) allowing traces of lactose in manufactured foods (n=13) or 2) giving fruits, vegetables and galactosides (n=2). Only 15% (n=6) calculated dietary galactose. 32% of patients were lost to dietetic follow-up. In adult galactosaemia, there is limited diet relaxation.

Prognostic Relevance of Circulating Tumor Cells in Molecular Subtypes of Breast Cancer

Circulating tumor cells (CTCs) can be detected in the peripheral blood of breast cancer patients with early and metastatic disease. Recent data suggest that immune pathologic characteristics between the primary tumor, metastatic colonies and CTCs are discordant and that CTCs possess an independent phenotype that is associated with prognosis and treatment efficacy. Large scale gene expression analysis has provided the possibility to stratify breast cancer according to the gene expression fingerprint of primary tumor tissue into five intrinsic molecular subtypes which can be associated with different clinical outcome. As a consequence of the different prognostic power of primary tumors' characteristics and CTCs several groups have started to investigate if CTCs might be disseminated differentially within these breast cancer subtypes. They determined the CTC number in immunohistochemical subtypes to validate if CTCs may provide differential and more specific prognostic information within each subtype. This review provides an overview of the outcome of some recently published data gathered from early and metastatic breast cancer.

Responsiveness of stem-like human glioma cells to all-trans retinoic acid and requirement of retinoic acid receptor isotypes α, β and γ

Retinoic acid (RA) is required for development and homeostasis of the normal mammalian brain and may play a role in the initiation and progression of malignant brain tumors, such as the glioblastoma multiforme (GBM) and the gliosarcoma (Gsarc). The subpopulation of stem-like glioma cells (SLGCs) was shown to resist standard glioma radio-/chemotherapy and to propagate tumor regrowth. We used phenotypically distinct, self-renewing SLGC lines from six human GBMs, two Gsarcs, and two subcloned SLGC derivatives in order to investigate their responsiveness to all-trans retinoic acid (atRA) and to identify the RA-receptor (RAR) isotypes involved. In general, atRA exerted a pro-proliferative and pro-survival effect on SLGCs, though the efficacy was distinct. By means of RAR isotype-selective retinoids we disclosed that these effects were mediated by RARα and RARγ, except for one SLGC line, in which the pro-proliferative signal was induced by the RARβ-selective retinoid. Only one GBM-derived cell line (T1338) and a subpopulation of another (T1389) displayed neural differentiation in response to atRA. Differentiation of T1338 was induced by RARα and RARγ isotype-selective retinoids, associated with down-regulation of Sox2, and the failure to induce orthotopic tumors in the brains of SCID mice. The differential responsiveness of the SLGC lines appeared unrelated to the expression of RARβ, as (i) atRA augmented RAR isotype mRNA expression and particularly rarβ mRNA in all SLGC lines, (ii) rarβ promoter hypomethylation in the SLGC lines was not related to differentiation and (iii) the induction of T1338 differentiation was by RARα- and RARγ-selective ligands.

Slab coupled optical fiber sensor calibration

This paper presents a method for calibrating slab coupled optical fiber sensors (SCOS). An automated system is presented for selecting the optimal laser wavelength for use in SCOS interrogation. The wavelength calibration technique uses a computer sound card for both the creation of the applied electric field and the signal detection. The method used to determine the ratio between the measured SCOS signal and the applied electric field is also described along with a demonstration of the calibrated SCOS involving measuring the dielectric breakdown of air.

Progestogens and membrane-initiated effects on the proliferation of human breast cancer cells

OBJECTIVES

Evidence is accumulating that progestogens may play a crucial role in the development of breast cancer under contraception and hormone therapy in reproductive and menopausal women. Progesterone receptor membrane component 1 (PGRMC1) expressed in breast cancer may be important in tumorigenesis and thus may increase breast cancer risk. The aim of this project was to investigate the influence of progesterone and nine synthetic progestins on MCF-7 breast cancer cells overexpressing PGRMC1.

METHODS

MCF-7 cells were stably transfected with PGRMC1 expression plasmid (WT-12). To test the effects of progestogerone (P) and the synthetic progestins chlormadinone acetate (CMA), desogestrel (DSG), drospirenone (DRSP), dydrogesterone (DYD), levonorgestrel (LNG), medroxyprogesterone acetate (MPA), nomegestrol (NOM) and norethisterone (NET) on cell proliferation, MCF-7 and WT-12 cells were stimulated with different concentrations (0.01-1 µmol/l).

RESULTS

In MCF-7 cells, DRSP, DSG, DYD, LNG and NET increased the proliferation at 1 µmol/l, the effect being highest for NET with about 20%. In WT-12 cells, the same progestins, but additionally MPA, showed a significant increase, which was much higher (30-245%) than in MCF-7 cells. Here again, NET showed the highest proliferative effect. No effect was found for CMA, NOM and P.

CONCLUSION

Some synthetic progestins trigger a proliferative response of PGRMC1-overexpressed MCF-7 cancer cells. The effect of progestogens on breast cancer tumorigenesis may clearly depend on the specific pharmacology of the various synthetic progestins.

Electrical responses to chemosensory stimulation recorded from the vomeronasal duct and the respiratory epithelium in humans

The physiological significance of the human vomeronasal duct (VND) is still unclear. The aim of the present study was to investigate the question whether mucosal responses obtained from the VND are different from those obtained from the respiratory epithelium. There were 15 healthy subjects (8 male, 7 female; age range 19-45 years; 14 normosmic subjects, 1 anosmic subject). All subjects participated in two sessions whereby the first session was used to acquaint them with the experimental conditions. For chemical stimulation, an olfactometer was used which delivered chemical stimulants without altering mechanical or thermal conditions at the stimulated nasal mucosa. For stimulation we used substances previously reported to produce vomeronasal activation ("estra"=estra-1,3,5(10),16-tetraen-3ol and "andro"=androsta-4,16-dien-3-on); in addition, gaseous CO(2) was used as a non-odorous, relatively specific stimulant of the trigeminal nerve. Placement of electrodes either in the VND or on the respiratory epithelium was performed under endoscopical guidance. Subjects rated the overall intensity of the stimuli, the strength of trigeminally mediated sensations, and the hedonic tone of the stimulants. Responses could not be recorded from all subjects. For the remaining 7 subjects, intensity was strongest for CO(2) stimuli (p<0.001), whereas no significant difference was observed between "andro" and "estra" (p=0.33). All three stimulants produced responses at the respiratory epithelium with largest responses obtained after stimulation with CO(2). Similar findings were made for recordings inside the VND. Due to the small sample size sexual dimorphisms could not be addressed. In summary, these results seem to indicate that the presently used stimulants produce similar responses at the respiratory epithelium and in the VND which argues against a specific responsiveness of the VND epithelium to chemosensory stimuli although it has to be kept in mind that the effective sample size was small.

Patterns of surgical care for uterine cancers in Ontario

OBJECTIVES

To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for uterine cancer.

METHODS

Women with an incident diagnosis of a uterine malignancy were identified from 1 April 2003 to 31 March 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan.

RESULTS

Uterine cancer affected 1,436 women. Disease specific rates of cancer were higher in rural areas and those from the highest income quintiles. Surgery occurred in 94.7% of women. Use of surgery did not appear to vary by SEC, urban/rural residence or LHIN. Gynecologists conducted 76.1% of the operations. Lymphadenectomy took place in 18.7% of women. Lymphadenectomy rates were highest in gynecologic oncologists (43.3%). All women were assessed by CXR. Radiation therapy consults were preformed in half of the women with uterine cancer but treatment was only delivered in half of those seen. Medical oncologists saw about 6.3% of women with uterine cancers.

CONCLUSIONS

There appear to be variations in incidence rates of uterine cancer with disease being more frequent in those of the highest SES. In two-thirds of the population, surgery is delivered in the region where the patient lives. Subspecialty care from gynecologic oncologists was provided to one-third of women. Rates of lymphadenectomy as part of a surgical attempt to assess disease spread appear low. These pilot data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Patterns of care for the initial management of cervical cancer in Ontario

OBJECTIVE

To facilitate the planning of resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for cervical cancer.

METHODS

Women with an incident diagnosis of cervical cancer were identified from 1 April, 2003 to 31 March, 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan.

RESULTS

There were 513 incident cases. Disease-specific rates of cancer were higher in rural areas and those from lower income quintiles. Forty-three percent of women had no surgery. Use of surgery did not appear to vary by SEC, urban/rural residence or LHIN. Women of younger age were more like to receive surgery for cervical cancer. Gynecologists conducted 63% of the operations. Gynecologics were most likely to complete a lymphadenectomy (70.3%). All women were assessed by CXR. Only 22% of women had a CT scan of the abdomen and pelvis. Radiation consults were performed in half of the women with cervix cancer but treatment was only delivered to half of those seen. Medical oncologists saw about 10% of women with cervical cancers.

CONCLUSIONS

There appear to be variations in incidence rates of cervical cancer, with cancers being more frequent in rural areas. In two-thirds of the population, surgery is performed in the region where the patient lives. Subspecialty care from gynecologic oncologists was provided to one-third of women. These preliminary data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Patterns of care in the initial management of women with vulvar cancers in Ontario

BACKGROUND

To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for vulvar cancer.

METHODS

Women with an incident diagnosis of vulvar malignancy were identified from 1, April 2003 to 31 March, 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan.

RESULTS

Vulvar cancers affected 148 women. Disease specific rates of cancer were higher in rural areas and in women in the lower income quintiles. No surgery occurred in 17.6% of women. Use of surgery did not appear to vary by urban/rural residence or LHIN. Ontario's 17 gynecologic oncologists performed 75% of the surgeries. Groin lymphadenectomy rate was 52.8%. Surgery was performed in the LHIN of residence for 41% of women. All women were assessed by CXR. CT scan of the abdomen and pelvis occurred in 77%. MRIs were done infrequently. Radiation consults were preformed in half of the women with vulvar cancer but treatment was only delivered in half of those seen. Medical oncologists saw about 10% of women with gynecologic cancers.

CONCLUSIONS

There appear to be variations in incidence rates of vulvar cancer with disease being more frequent in rural areas. Subspecialty care from gynecologic oncologists was provided to 75% of women. Rates of lymphadenectomy as part of a surgical attempt occurred in 52.8% of women. These data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage.

Patterns of care in the initial management of women with ovarian cancer in Ontario

BACKGROUND

To facilitate the planning of future resources for cancer services in Ontario, Cancer Care Ontario commissioned an evaluation of operative services delivered for ovarian cancers. The affected population was characterized in terms of age, location of residence, and SES. Operative care delivery was described in terms of inpatient verses outpatient access, LHIN of treatment, surgical specialist providing treatment, and specific operative procedures. The investigations and consults around the time of diagnosis are described.

METHODS

Women with an incident diagnosis of an ovarian malignancy were identified from 1 April 2003 to 31 March 2004 using the Ontario Cancer Registry. Record linkages were created to other provincial health databases such as the Ontario Health Insurance Plan.

RESULTS

We report on 963 women with ovarian cancer. The incidence of disease was related to increasing age. Access to surgery correlated with the highest income quintile, urban residence and LHIN. Twenty-seven percent of women did not have surgery for their ovarian cancer. Women of younger age were more like to receive surgery for ovarian cancer. Use of a laparotomy for biopsy was most common in community hospital (40%). Lymphadenectomy rates were low overall; rates for gynecologic oncologists were 13.2%. All women were assessed by CXR. CT scan of abdomen and pelvis occurred in 77% of women. MRIs were done infrequently. Medical oncology were involved in 26.6% of the patients.

CONCLUSIONS

These pilot data would be enhanced with further information such as comorbidity, treatment intent (palliative/curative), histology, grade and stage. However, there are clear referral patterns to academic centres which means a need for manpower and hospital resources to deal with this population.

Elderly patients with dementia-related symptoms of severe agitation and aggression: consensus statement on treatment options, clinical trials methodology, and policy

OBJECTIVE

Atypical antipsychotic drugs have been used off label in clinical practice for treatment of serious dementia-associated agitation and aggression. Following reports of cerebrovascular adverse events associated with the use of atypical antipsychotics in elderly patients with dementia, the U.S. Food and Drug Administration (FDA) issued black box warnings for several atypical antipsychotics titled "Cerebrovascular Adverse Events, Including Stroke, in Elderly Patients With Dementia." Subsequently, the FDA initiated a metaanalysis of safety data from 17 registration trials across 6 antipsychotic drugs (5 atypical antipsychotics and haloperidol). In 2005, the FDA issued a black box warning regarding increased risk of mortality associated with the use of atypical antipsychotic drugs in this patient population.

PARTICIPANTS

Geriatric mental health experts participating in a 2006 consensus conference (Bethesda, Md., June 28-29) reviewed evidence on the safety and efficacy of antipsychotics, as well as nonpharmacologic approaches, in treating dementia-related symptoms of agitation and aggression. EVIDENCE/CONSENSUS PROCESS: The participants concluded that, while problems in clinical trial designs may have been one of the contributors to the failure to find a signal of drug efficacy, the findings related to drug safety should be taken seriously by clinicians in assessing the potential risks and benefits of treatment in a frail population, and in advising families about treatment. Information provided to patients and family members should be documented in the patient's chart. Drugs should be used only when nonpharmacologic approaches have failed to adequately control behavioral disruption. Participants also agreed that there is a need for an FDA-approved medication for the treatment of severe, persistent, or recurrent dementia-related symptoms of agitation and aggression (even in the absence of psychosis) that are unresponsive to nonpharmacologic intervention.

CONCLUSIONS

This article outlines methodological enhancements to better evaluate treatment approaches in future registration trials and provides an algorithm for improving the treatment of these patients in nursing home and non-nursing home settings.

Down-regulation of CD55 and CD46 expression by anti-sense phosphorothioate oligonucleotides (S-ODNs) sensitizes tumour cells to complement attack

Overexpression of one or more membrane-bound complement regulatory proteins (mCRPs) protects tumour cells against complement-mediated clearance by the autologous humoral immune response and is also considered as a barrier for successful immunotherapy with monoclonal anti-tumour antibodies. Neutralization of mCRPs by blocking antibodies, enzymatic removal or cytokine-mediated down-regulation has been shown to sensitize tumour cells to complement attack. In our study we applied, for the first time, anti-sense phosphorothioate oligonucleotides (S-ODNs) to knock down the expression of the mCRPs CD55 and CD46 with the aim of exploiting complement more effectively for tumour cell damage. Potent anti-sense oligonucleotides against CD55 and CD46 were identified by screening various target sequences (n = 10) for each regulator. S-ODN anti-CD55(687) reduced CD55 protein expression up to 84% and CD46 protein expression was inhibited up to 76% by S-ODN anti-CD46(85). Reverse transcription-polymerase chain reaction (RT-PCR) analysis revealed a similar reduction of the CD55 and CD46 mRNA levels, which argues for an RNAse H-dependent anti-sense mechanism. T47D, A549 and PC3 cells, representing breast, lung and prostate carcinoma, were used for functional studies. Dependent on the particular cell line, anti-sense-based inhibition of mCRP expression enhanced complement-dependent cytolysis (CDC) up to 42% for CD55 and up to 40% for CD46, and the combined inhibition of both regulators yielded further additive effects in T47D cells. C3 opsonization of CD55/CD46-deficient tumour cells was also clearly enhanced upon mCRP suppression. Due to the clinical applicability of S-ODNs, the anti-sense approach described in this study may offer an additional alternative to improve the efficacy of antibody- and complement-based cancer immunotherapy.

Expression of VACM-1/cul5 mutant in endothelial cells induces MAPK phosphorylation and maspin degradation and converts cells to the angiogenic phenotype

Vasopressin-activated calcium mobilizing receptor (VACM-1) is a member of the cullin gene family involved in ubiquitin-proteosome dependent regulation of cellular functions. Expression of VACM-1 cDNA in cos-1 cells in vitro decreases basal cAMP levels and inhibits growth. The expression of (S730A)VACM-1 mutant cDNA, which removes PKA-dependent phosphorylation site in the VACM-1 cDNA sequence, reverses this phenotype. Since the expression of VACM-1 protein in vivo localizes largely to the vascular endothelial cells, in this study, we examined the effects of (S730A)VACM-1 cDNA expression on cellular signaling in the rat endothelial cell line RAMEC. Our results indicate that expression of (S730A)VACM-1 cDNA in RAMEC promotes cellular proliferation and induces angiogenic growth patterns. Western blot analyses indicate that (S730A)VACM-1 cDNA transfected cells express increased levels of Nedd8 modified VACM-1 and have higher levels of phosphorylated MAPK protein when compared to controls. Furthermore, expression of (S730A)VACM-1 cDNA induces translocation of the endogenous early response gene, egr-1, to the nucleus and leads to morphological changes that involve actin rearrangement. Finally, expression of (S730A)VACM-1 cDNA in RAMEC decreases concentration of maspin, a putative anti-angiogenic factor with a tumor suppressor activity. These results show that VACM-1 protein regulates endothelial cell growth and may modulate angiogenesis by a mechanism that involves MAPK phosphorylation, nuclear localization of egr-1, maspin expression, and actin polymerization.

Obstacles to cancer immunotherapy: expression of membrane complement regulatory proteins (mCRPs) in tumors

Monoclonal antibodies (mAbs) are being increasingly used in cancer therapy owing to their ability to recognize specifically cancer cells and to activate complement- and cell-mediated cytotoxicity and/or to induce growth arrest or apoptosis. The therapeutic potential of anticancer antibodies is significantly limited due to the ability of cancer cells to block killing by complement. Of the multiple resistance strategies exploited by cancer cells, the expression of membrane complement regulatory proteins (mCRPs), such as CD46 (membrane cofactor protein (MCP)), CD55 (decay-accelerating factor (DAF)), CD35 (complement receptor type-1 (CR1)) and CD59, has received most attention. CD46, CD55 and CD35 block the complement cascade at the C3 activation stage and CD59 prevents assembly of the membrane attack complex of complement (MAC). These proteins protect normal tissues from accidental injury by activated complement, but also confer resistance on cancer cells, thereby limiting the effect of complement-fixing monoclonal antibodies. Expression of mCRPs on malignant cells is highly variable, yet there is clear indication that certain tumors express higher mCRP levels than the normal tissue from which they have evolved. mCRP level of expression and cellular location may also vary during malignant transformation and between differentiated and undifferentiated tumors. Neutralizing anti-mCRP mAbs have been used in vitro to elucidate the significance of mCRP expression to the tumor complement resistance phenotype. In general, CD59 appears to be the most effective mCRP protecting tumor cells from complement-mediated lysis. Nevertheless, it acts additively, and in certain tumors even synergistically, with CD55 and CD46. It is envisaged that treatment of cancer patients with mCRP blocking antibodies targeted specifically to cancer cells in combination with anticancer complement-fixing antibodies will improve the therapeutic efficacy.

Complement resistance of human carcinoma cells depends on membrane regulatory proteins, protein kinases and sialic acid

Nucleated cells employ several strategies to evade killing by homologous complement. We studied complement resistance in the human carcinoma cell lines (CA) T47D (mammary), SKOV3 (ovarian), and PC-3 (prostate) with emphasis on the following mechanisms of defense: 1. Expression and shedding of the membrane complement regulatory proteins (mCRP) CD46, CD55 and CD59; 2. Resistance based on protein phosphorylation; 3. Cell surface expression of sialic acid residues; 4. Desensitization to complement upon exposure to sublytic complement doses. Anti-mCRP antibody blocking experiments demonstrated that CD59 is the main mCRP protecting these CA from complement. Soluble CD59 was also found in supernates of PC-3> SKOV3 > T47D cells. Second, inhibitors of PKC, PKA and MEK sensitized the CA to lysis, thus implicating these protein kinases in CA complement resistance. Third, removal of sialic acid residues with neuraminidase also sensitized CA to lysis. Finally, exposure of CA to sublytic doses of complement conferred on them enhanced resistance to lytic complement doses in a PKC-dependent process. Combined treatment of CA with anti-CD59 antibodies, PD98059 (a MEK inhibitor) and neuraminidase produced a large enhancement in CA sensitivity to complement. Our results show that CD59 and sialic acid residues present on the cell surface, and intracellular processes involving protein phosphorylation act additively to secure CA resistance to complement-mediated lysis. Therefore, the effectiveness of antibody- and complement-based cancer immunotherapy will markedly improve by suppression of the various complement resistance mechanisms.

A gene expression screen in zebrafish embryogenesis

A screen for developmentally regulated genes was conducted in the zebrafish, a system offering substantial advantages for the study of the molecular genetics of vertebrate embryogenesis. Clones from a normalized cDNA library from early somitogenesis stages were picked randomly and tested by high-throughput in situ hybridization for restricted expression in at least one of four stages of development. Among 2765 clones that were screened, a total of 347 genes with patterns judged to be restricted were selected. These clones were subjected to partial sequence analysis, allowing recognition of functional motifs in 163 among them. In addition, a portion of the clones were mapped with the aid of the LN54 radiation hybrid panel. The usefulness of the in situ hybridization screening approach is illustrated by describing several new markers for the characteristic structure in the fish embryo named the yolk syncytial layer, and for different regions of the developing brain.