Intraoperative radiation therapy for pediatric sarcomas and other solid tumors

PURPOSE

To evaluate local failure (LF) and toxicity after intraoperative radiation therapy (IORT) in pediatric solid tumors (ST).

METHODS

A single-institution retrospective study of 96 pediatric patients (108 applications) with ST treated from 1995 to 2022 with IORT. LF was calculated via cumulative incidence function and overall survival (OS) by Kaplan-Meier method, both from the day of surgery.

RESULTS

Median age at time of IORT was 8 years (range: 0.8-20.9 years). Median follow-up for all patients and surviving patients was 16 months and 3 years, respectively. The most common histologies included rhabdomyosarcoma (n = 42), Ewing sarcoma (n = 10), and Wilms tumor (n = 9). Most (95%) received chemotherapy, 37% had prior external beam radiation therapy to the site of IORT, and 46% had a prior surgery for tumor resection. About half (54%) were treated with upfront IORT to the primary tumor due to difficult circumstances such as very young age or challenging anatomy. The median IORT dose was 12 Gy (range: 4-18 Gy), and median area treated was 24 cm2 (range: 2-198 cm2). The cumulative incidence of LF was 17% at 2 years and 23% at 5 years. Toxicity from IORT was reasonable, with postoperative complications likely related to IORT seen in 15 (16%) patients.

CONCLUSION

Our study represents the largest and most recent analysis of efficacy and safety of IORT in pediatric patients with ST. Less than one quarter of all patients failed locally with acceptable toxicities. Overall, IORT is an effective and safe technique to achieve local control in patients with challenging circumstances.

Intraoperative Radiation Therapy for Relapsed or Refractory High-Risk Neuroblastoma: A 27-Year Experience

PURPOSE

To evaluate outcomes after intraoperative radiation therapy (IORT) in high-risk neuroblastoma (NB), including local control, overall survival, and toxicity.

METHODS AND MATERIALS

This was a single institution retrospective study of 92 pediatric patients with NB treated with IORT from 1995 to 2022. Each IORT application was considered a separate event for a total of 110 sites treated. Local failure was calculated using the cumulative incidence function and survival by Kaplan-Meier method from the day of surgery.

RESULTS

All patients had high-risk relapsed or treatment refractory disease. Median age was 6 years (range, 2-34 years). Median follow-up for all patients and surviving patients was 16 months and 4 years, respectively. All patients previously received chemotherapy, 93% had prior external beam radiation therapy to the site of IORT (median dose, 21.6 Gy; range, 10-36 Gy), and 94% had a prior surgery for tumor resection. The median IORT dose was 12 Gy (range, 8-18 Gy) and median area treated was 18 cm2 (range, 2.5-60 cm2). The cumulative incidence of local failure was 23% at 2 years and 29% at 5 years. The overall survival (OS) was 44% at 2 years and 29% at 5 years. Local failure after IORT was associated with worse OS (hazard ratio, 1.74; 95% CI, 1.07-2.84; P = .0267). Toxicity from IORT was rare, with postoperative complications likely related to IORT seen in 7 (8%) patients.

CONCLUSIONS

Our study represents the largest, most recent analysis of the efficacy and safety of IORT in patients with relapsed or refractory NB. Less than one-third of patients failed locally at 5 years, and achieving local control affected overall survival. Minimal toxicities directly related to IORT were observed. Overall, IORT is an effective and safe technique to achieve local control in high-risk relapsed or refractory neuroblastoma.

Long-Term Outcomes After Abdominal Radiation for Wilms Tumor: A 20-Year Experience

BACKGROUND

As radiation therapy (RT) for Wilms tumor (WT) evolves with more conformal techniques, it is necessary to evaluate patterns of failure and toxicity. We sought to determine the rate of local failure (LF) after abdominal RT in WT, specifically focusing on those with contained rupture treated with whole abdominal and pelvic RT (WAPRT) vs flank RT. Secondary objectives were to determine overall survival (OS), distant failure (DF), and late toxicities.

METHODS

A single institution retrospective study of 54 pediatric patients with WT treated with abdominal RT between May 2000 and October 2022. LF and DF were calculated through cumulative incidence function and OS by Kaplan-Meier method.

RESULTS

The median age was 4.5 years and the median follow-up was 6 years. Most patients (91%) had favorable histology. Only 1 patient experienced LF, 15 months from completion of RT (cumulative incidence 2% at 5 y). All patients who received unilateral flank radiation for contained rupture/spillage (n=13) experienced long-lasting intra-abdominal tumor control. A total of 5 patients experienced a DF at a median of 7 months, all in the lung. No patient relapsed in the lungs after upfront whole lung irradiation (n=16). OS was 96% at 5 years. Among 28 patients who followed through puberty, 4 female patients with prior WAPRT experienced hormonal irregularities/infertility.

CONCLUSIONS

Unilateral flank radiation may be a viable alternative to WAPRT for contained rupture/spillage and should be further explored prospectively. Our results may also be utilized in the future for outcome and toxicity comparison as conformal radiation techniques evolve.

Post-Mastectomy Implant Complications in the Hispanic Breast Cancer Patient Population

BACKGROUND/AIM

The purpose was to analyze the impact of post-mastectomy radiation therapy (PMRT) on implant-based breast reconstruction (IBR) in self-identified Hispanic patients compared to non-Hispanic counterparts.

PATIENTS AND METHODS

We retrospectively reviewed patients who underwent IBR between January 1, 2017 and December 31, 2019 at a single hospital system. Patients were cisgender women, assigned female at birth, 18 years or older, and underwent mastectomy with immediate IBR +/- PMRT. We compared characteristics between Hispanic and non-Hispanic patients, assessing capsular contracture and implant loss rates. Multivariable analysis was performed to identify factors associated with complications.

RESULTS

A total of 317 patients underwent mastectomy and reconstruction. Of these patients, 302 underwent a total of 467 mastectomies with IBR, and these 467 procedures were included in the analysis of complications. Complications occurred in 175 breasts (37.5%), regardless of PMRT. Seventy-two of the 302 patients (24%) received PMRT to one breast. The overall rates of capsular contracture, implant loss, and overall complications did not vary significantly between Hispanic and non-Hispanic patients (p=0.866, 0.974, and 0.761, respectively). When comparing only irradiated patients, there was a trend towards increased implant loss and overall complication rates in Hispanic versus non-Hispanic patients (p=0.107 and 0.113, respectively). Following PMRT the rate of any complication was 71% in Hispanic women and 53% in non-Hispanic women.

CONCLUSION

Our study illuminates a trend towards higher complication rates after PMRT in Hispanic versus non-Hispanic patients. Further studies are needed to understand why Hispanic patients may have more side effects from radiation therapy.

Intraoperative Radiation Therapy for Pediatric Patients: A 25 Year Experience

PURPOSE/OBJECTIVE(S)

To assess outcomes after intra-operative radiation therapy (IORT) in pediatric patients, including local control, overall survival, and toxicity.

MATERIALS/METHODS

Single institution retrospective study of 184 pediatric patients treated with IORT from 1995-2022. Each IORT application was considered a separate event for a total of 213 sites treated. Local failure was calculated using the cumulative incidence function and survival by Kaplan-Meier method from the day of surgery. Median follow up for all patients was 14 months while median follow up for surviving patients was 3 years.

RESULTS

Median patient age was 6 years (range 9 months to 21 years) and half were male. Patients were generally high risk with 76% having relapsed or refractory disease. Tumor types included neuroblastoma (n = 88), soft tissue sarcoma (n = 69), Wilms tumor (n = 11), and other solid tumors (n = 24). The majority (97%) of patients had prior chemotherapy, 69% had at least one prior attempt at resection, and 65% had prior external beam radiation to the site of IORT. Location of IORT included the retroperitoneum (n = 99), anterior abdominal wall (n = 14), pelvic region (n = 49), chest and thorax (n = 36), head (n = 5), neck (n = 7), and axilla/shoulder (n = 3), with a median dose of 12 Gy (range 4 to 18 Gy). Overall survival was 47% and 32% at 2 and 5 years respectively. Rates of local failure were 20% and 26% at 2 and 5 years. Local failure had a significant impact on overall survival (p = 0.009). Analyzing specific tumor types at 2 years, the rate of local failure and overall survival were 22% and 57% for soft tissue sarcomas, 23% and 39% for neuroblastoma, and 10% and 60% for Wilms tumor. Direct toxicity from IORT was rare, however there were several cases of surgical complications where a potential contribution from IORT could not be ruled out. The most common complications included abscesses in the surgical field, fistula or stricture development, and hydronephrosis. There were no post-operative mortalities related to IORT.

CONCLUSION

Our study represents the largest scale analysis of efficacy and safety of IORT in patients with pediatric solid tumors. Less than one third of patients failed locally at 5 years. Achieving local control impacted overall survival, emphasizing the importance of local control in these patients. Minimal radiation related toxicities were observed. Overall, IORT is an effective technique to achieve local control in children with high-risk solid tumors.

Orthopedic Surgery Residencies: The Leap to Social Media

Social media has been previously shown to influence applicants' perception of plastic surgery residencies and increase their likelihood to apply, interview, and rank the program. We wanted to analyze this hypothesized trend in the context of orthopedic surgery residency while also characterizing the content of orthopedic surgery residency program accounts. A current list of US orthopedic residency programs was acquired from the American Orthopaedic Association and cross-referenced with the Accreditation Council for Graduate Medical Education webpage of all orthopedic surgery residencies. Forty-five of 185 (24%) residencies had residency-specific Instagram accounts. We analyzed the number of followers, the number of posts, and the date of the first post for each account. We characterized content by categories including science education, recruitment or hospital promotion, resident highlight, news coverage, events, and community building posts. We analyzed the "social currency" of each post and program, tracking the number of likes, comments, and followers. Twenty-seven of 45 (60%) active residency Instagram pages were created in 2020, with 13 of 45 (29%) pages created in June 2020 alone. Residency programs are increasingly turning to Instagram to showcase the residents at their programs, their lifestyles, and program strengths. Sixty percent of all orthopedic residency Instagram accounts were created in 2020 alone, likely precipitated by travel concerns from COVID-19 forcing programs to conduct online interviews and cancel away rotations this application cycle. Going forward, residency programs will continue using Instagram to recruit potential residents, leaving programs without social media accounts at a relative disadvantage in terms of visibility and their ability to recruit qualified applicants. [Orthopedics. 2023;46(5):e281-e286.].

Prognostic value of intrinsic subtypes in hormone-receptor-positive metastatic breast cancer: systematic review and meta-analysis

BACKGROUND

In hormone receptor-positive (HoR+) breast cancer (BC), gene expression analysis identifies luminal A (LumA), luminal B (LumB), human epidermal growth factor receptor 2 (HER2)-enriched (HER2-E), basal-like (BL) intrinsic subtypes and a normal-like group. This classification has an established prognostic value in early-stage HoR+ BC. Here, we carried out a trial-level meta-analysis to determine the prognostic ability of subtypes in metastatic BC (MBC).

MATERIALS AND METHODS

We systematically reviewed all the available prospective phase II/III trials in HoR+ MBC where subtype was assessed. The primary endpoint was progression-free survival (PFS)/time to progression (TTP) of the LumA subtype compared to non-LumA. Secondary endpoints were PFS/TTP of each individual subtype, according to treatment, menopausal and HER2 status and overall survival (OS). The random-effect model was applied, and heterogeneity assessed through Cochran's Q and I². Threshold for significance was set at P < 0.05. The study was registered in PROSPERO (ID: CRD42021255769).

RESULTS

Seven studies were included (2536 patients). Non-LumA represented 55.2% and was associated with worse PFS/TTP than LumA [hazard ratio (HR) 1.77, P < 0.001, I² = 61%], independently of clinical HER2 status [P_{subgroup difference} (P_sub) = 0.16], systemic treatment (P_sub = 0.96) and menopausal status (P_sub = 0.12). Non-LumA tumors also showed worse OS (HR 2.00, P < 0.001, I² = 65%), with significantly different outcomes for LumB (PFS/TTP HR 1.46; OS HR 1.41), HER2-E (PFS/TTP HR 2.39; OS HR 2.08) and BL (PFS/TTP HR 2.67; OS HR 3.26), separately (PFS/TTP P_sub = 0.01; OS P_sub = 0.005). Sensitivity analyses supported the main result. No publication bias was observed.

CONCLUSIONS

In HoR+ MBC, non-LumA disease is associated with poorer PFS/TTP and OS than LumA, independently of HER2, treatment and menopausal status. Future trials in HoR+ MBC should consider this clinically relevant biological classification.

Abstract P4-07-36: Chest-Wall and Nodal Irradiation in Non-Metastatic, Node Positive Breast Cancer Patients with Pathologic Complete Response After Neoadjuvant Chemotherapy and Surgery, in A Retrospective Cohort of Women Aged 45 Years and Younger

Purpose/Objective(s): Several randomized clinical trials and non-randomized studies have consistently shown that achievement of pathologic complete response (pCR) in the breast with negative axillary nodes is associated with excellent long-term outcomes. NSABP B-511 is a phase III trial aimed to determine if chest wall and regional nodal irradiation (CWRNI) post-op reduces invasive breast cancer recurrence-free interval in patients (pts) with positive axillary lymph nodes (LN) who achieve pCR after neoadjuvant chemotherapy (NAC). However, physicians might be biased towards avoiding enrollment of young patients (≤ 45 years) in this trial. Which in turn, could give way to this population becoming under-represented at the time of determining the standard of care. Our primary objective is to determine if the omission of CWRNI is associated with an increased risk of recurrence in a young patient population. Materials/Methods: Data were obtained from two institutions in South Florida. Patients aged ≤ 45 years, with non-metastatic invasive breast cancer, and positive clinical (LN) involvement, diagnosed between 2010 to 2017 and treated with NAC were identified through retrospective chart review. Disease recurrence including local and distant recurrence data were collected. The Kaplan-Meier survival function was used for plotting patients treated with CWRNI vs no CWRNI and the log-rank test was used to evaluate the recurrence-free survival according to groups. We reported recurrence probabilities at 5 years. Additionally, we also estimated hazard ratios (HRs) of patients treated with CWRNI vs no CWRNI using Cox proportional hazards regression analysis. Results: A total of 154 patients were identified. Median age was 39 years (24-45). Patients were 57% ER+, 33% HER2+, 29% triple negative and 59.1% were stage 3, with only 1 male patient in the cohort. PCR was achieved in 22.1% (34/154) of pts, and CWRNI frequency in these patients was 81.3%. Overall, 79.9% of pts received post-op CWRNI. Recurrence frequency in patients with a pCR who received CWRNI was 4/26 vs 2/6 in pts that did not receive CWRNI. The Kaplan-Meier survival curves indicated an overall probability of recurrence at 5 years of 31.9% (95%CI 3.8% – 51.8%) in patients that did not receive CWRNI vs 27.49% (95%CI 18.42% – 35.56%) in patients that received CWRNI (log rank p=0.55) however, statistical significance was not met. Cox regression indicated that omission of CWRNI was not associated with an increased risk of recurrence (HR 1.3, 95%CI 0.54 – 3.11, p=0.55). In patients that had a pCR after NAC, omission of CWRNI was not associated with an increased risk of recurrence (HR 2.004, 95%CI 0.36 – 10.9, p=0.42). However, the sample size for these analyses was too small to achieve significance. Conclusion: This data highlights the tendency of giving CWRNI to younger patients with clinically node-positive disease at diagnosis regardless of response to NAC. Overall, absolute recurrence in this cohort was very low. Although an absolute number of recurrences favored CWRNI in the setting of pCR, this was not statically significant given the small sample size.

Citation Format: Danielle Cerbon, Alex Sanchez-Covarrubias, Brianna Conte, Cristiane Takita, Lora Freedman, Jessica Meshman, Stuart Samuels, Caroline Shermoen, Neha Goel, Ruben Carmona, Lora Wang. Chest-Wall and Nodal Irradiation in Non-Metastatic, Node Positive Breast Cancer Patients with Pathologic Complete Response After Neoadjuvant Chemotherapy and Surgery, in A Retrospective Cohort of Women Aged 45 Years and Younger. [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P4-07-36.

Abstract P6-05-03: Post-Mastectomy Implant Complications in a Hispanic Breast Cancer Patient Population

Introduction: Breast cancer is the most common cancer diagnosed in women in the United States with primary treatment consisting of a combination of surgery, systemic therapy, and radiation. Breast reconstruction has been shown to improve quality of life in women and utilization is increasing with time. There is a large amount of evidence demonstrating the complications of radiation therapy on implant-based breast reconstruction including but not limited to, capsular contracture, infection, and reoperation. However, the majority of these studies have examined populations consisting primarily of non-Hispanic white patients with breast cancer. In general, hispanic populations are not well represented in research studies or Phase II/III clinical trials. Therefore, the goal of this study was to analyze the impact of radiation therapy on post mastectomy implant-based breast reconstruction complications in self-identified Hispanic patients.

Methods: We retrospectively reviewed patients who underwent mastectomy with implant reconstruction between January 1, 2017 and December 1, 2019. The inclusion criteria included female patients 18 years or older who self-reported as Hispanic or Latino. Exclusion criterias included patients who did not undergo mastectomy, did not undergo tissue-expander or implant reconstruction, or did not self identify as Hispanic descent. Outcomes infection needing antibiotics, capsular contracture Baker grade II-IV, and implant loss. Statistical analysis was performed using Chi-squared analysis.

Results: A total of 258 patients of Hispanic or Latino women were included in the study. This included 343 total number of breasts, with 228 breasts that underwent mastectomy with reconstruction due to breast cancer and 115 breasts that underwent prophylactic mastectomy with reconstruction. The median age at time of initial mastectomy was 49 years (range 19-86). 46 total breasts received adjuvant postoperative radiation and 296 breasts did not receive radiation. Median radiation dose to the chest wall was 50 Gy (range 42.56 - 60) in 2Gy (range 1.8 - 2.66) fractions. All patients who received postoperative radiation had at least 1 complication. The rate of complications and comparison between radiated breast compared to non-radiated breasts is demonstrated in table 1.

Conclusion: The goal of this study was to analyze the impact of radiation therapy complications on post-mastectomy implant-based breast reconstruction surgeries in patients of Hispanic descent. We demonstrate that the rate of capsular contracture is significantly higher after radiation therapy and the rate of overall complication after radiation therapy is higher (even though non statistically significant) compared with patients who do not undergo radiation. While these results are comparable to similar studies done in non-Hispanic groups, this is the first study to our knowledge that has looked at post-mastectomy complications focusing specifically on a Hispanic population. Mastectomy and subsequent implant reconstruction, radiation, and complications can have negative psychological effects on patients and can manifest differently with varying cultural backgrounds. It is imperative to understand the complications associated with race to better allow practitioners to cater treatment and support for a diverse patient population with breast cancer.

Table 1. Complications.

Citation Format: Brianna Conte, Caroline Shermoen, Danielle Cerbon, Susan Kesmodel, Caroline Fiser, sophia liu, Cristiane Takita, Jessica Meshman, John Oeltjen, Lora Wang. Post-Mastectomy Implant Complications in a Hispanic Breast Cancer Patient Population [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-05-03.

P-463 Anti-Müllerian hormone levels in breast cancer patients receiving chemotherapy with or without concurrent luteinizing hormone-releasing hormone agonist: results from the PROMISE phase III trial

Study question

How (neo)adjuvant chemotherapy and concurrent administration of luteinizing hormone-releasing hormone agonist (LHRHa) affect Anti-Mullerian hormone (AMH) and estradiol level dynamics in premenopausal breast cancer patients.

Summary answer

Breast cancer chemotherapy has a major negative impact on patients’ ovarian function and reserve. Women receiving LHRHa showed higher probability of long-term ovarian function recovery.

What is known already

The risk of developing treatment-induced premature ovarian insufficiency (POI) and infertility following chemotherapy is among the most important concern in premenopausal breast cancer patients.

AMH is a promising biomarker for assessing treatment-induced gonadotoxicity in patients receiving anticancer therapies.

Concurrent administration of LHRHa with chemotherapy is associated with a lower risk of treatment-induced ovarian failure and higher rates of menstrual function recovery. However, data on the impact of LHRHa during chemotherapy on patients’ ovarian reserve are still insufficient.

Study design, size, duration

Between 2003 and 2008, the PROMISE-GIM6 trial randomized 281 premenopausal early breast cancer women to receive chemotherapy alone (control group) or chemotherapy plus triptorelin (LHRHa group). Primary endpoints were incidence of early menopause and long-term ovarian function. For exploratory purposes in a subset of patients, AMH and estradiol levels were measured at baseline, &lt;3 months after last cycle of chemotherapy, 1 year after last cycle of chemotherapy, and at the end of adjuvant endocrine treatment.

Participants/materials, setting, methods

The main results of the trial showed that use of concurrent LHRHa significantly reduced the risk of early menopause, increased the chances of long-term ovarian function recovery and did not influence survival outcomes (JAMA 2011, JAMA 2015, JNCI 2022). The present exploratory analysis reports on dynamics of ovarian biomarkers (AMH and estradiol) at baseline and following (neo)adjuvant chemotherapy.

Main results and the role of chance

Out of 281 enrolled patients, 48 enrolled at the coordinating centers had at least one measurement of AMH and estradiol levels at baseline and after (neo)adjuvant chemotherapy. Baseline patient characteristics were similar between treatment arms, with median age being 41 and 39 years, and median AMH levels being 3.9 and 4.9 mcg/L in the control and LHRHa groups, respectively.

In the overall population, estradiol levels showed a significant decrease at the end of chemotherapy, a significant increase after one year, and a return to baseline values at the end of endocrine therapy. By contrast, AMH levels showed a constant decrease over time.

As compared to patients in the control group, those in the LHRHa group had a significant reduction in the risk of early menopause (p = 0.02) and significantly higher estradiol levels at the end of chemotherapy and 1 year after chemotherapy (p &lt; 0.001), suggesting a higher probability of ovarian function recovery. By contrast, no significant differences were observed in the AMH level dynamics between patients receiving LHRHa and those who did not.

Limitations, reasons for caution

Relatively small number of included patients (n = 48) and small number of patients with AMH and estradiol levels determined at each timepoint.

Wider implications of the findings

This biomarker analysis within a phase III randomized trial confirmed that patients receiving LHRHa had a higher probability of ovarian function recovery also supported by estradiol dynamics. However, both patients in the LHRHa and control group showed a major decline in AMH levels after chemotherapy that persisted over time.

Trial registration number

NCT00311636

T-DM1 versus pertuzumab, trastuzumab and a taxane as first-line therapy of early-relapsed HER2-positive metastatic breast cancer: an Italian multicenter observational study

Background

The current standard first-line treatment of human epidermal growth factor receptor 2 (HER2)-positive (+) metastatic breast cancer is the combination of pertuzumab, trastuzumab and a taxane (P + T + taxane), while standard second-line is ado-trastuzumab-emtansine (T-DM1). The registration trial of pertuzumab, however, did not include early-relapsing patients, defined as patients experiencing tumor relapse ≤12 months from the end of (neo)adjuvant anti-HER2 therapy. Conversely, the pivotal trial of T-DM1 included some patients relapsing ≤6 months after the end of (neo)adjuvant trastuzumab. Thus, a proportion of early-relapsing patients are currently eligible to receive T-DM1 as first-line treatment. Nevertheless, no direct comparison exists between the two regimens in this clinical setting.

Patients and methods

We retrospectively compared T-DM1 versus P + T + taxane as first-line treatment in two cohorts of early-relapsing patients in an Italian ‘real-world’ setting, involving 14 public health care institutions. The primary endpoint was progression-free survival. Secondary endpoints included patients' characterization, overall survival and post-progression survival. Univariate and multivariate analyses were carried out. All tests were two-sided and a P ≤ 0.05 was considered statistically significant.

Results

Among 1252 screened patients, 75 met the inclusion criteria. Forty-four (58.7%) received P + T + taxane and 31 (41.3%) received T-DM1. The two cohorts showed similar characteristics of aggressiveness and no significant differences in treatment history. T-DM1, compared with P + T + taxane was associated with worse progression-free survival (adjusted hazard ratio: 2.26, 95% confidence interval: 1.13-4.52, P = 0.021) and overall survival (adjusted hazard ratio: 3.95, 95% confidence interval: 1.38-11.32, P = 0.010), irrespective of previous (neo)adjuvant treatment, age, hormone receptors status, time-to-relapse (≤6 months or within 6-12 months) and presence of visceral/brain metastases. No differences were observed in post-progression survival (P = 0.095).

Conclusions

Our study suggests superiority for P + T + taxane over T-DM1 as up-front treatment of early-relapsing HER2+ metastatic breast cancer, which merits further assessment in larger and prospective trials.

•

This is the first study comparing pertuzumab + trastuzumab + taxane (P + T + taxane) with T-DM1 in early-relapsing HER2+ MBC.

•

The majority of early-relapsing HER2+ MBC have high-grade, node-positive, large primary tumors.

•

First-line T-DM1 compared with P + T + taxane is associated with worse progression-free survival.

•

First-line T-DM1 compared with P + T + taxane is associated with worse overall survival.

•

Post-progression survival does not differ between the two treatments cohorts.

Implementation of a medical student-run telemedicine program for medications for opioid use disorder during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic led to the closure of the IDEA syringe services program medical student-run free clinic in Miami, Florida. In an effort to continue to serve the community of people who inject drugs and practice compassionate and non-judgmental care, the students transitioned the clinic to a model of TeleMOUD (medications for opioid use disorder). We describe development and implementation of a medical student-run telemedicine clinic through an academic medical center-operated syringe services program.

METHODS

Students advertised TeleMOUD services at the syringe service program on social media and created an online sign-up form. They coordinated appointments and interviewed patients by phone or videoconference where they assessed patients for opioid use disorder. Supervising attending physicians also interviewed patients and prescribed buprenorphine when appropriate. Students assisted patients in obtaining medication from the pharmacy and provided support and guidance during home buprenorphine induction.

RESULTS

Over the first 9 weeks in operation, 31 appointments were requested, and 22 initial telehealth appointments were completed by a team of students and attending physicians. Fifteen appointments were for MOUD and 7 for other health issues. All patients seeking MOUD were prescribed buprenorphine and 12/15 successfully picked up medications from the pharmacy. The mean time between appointment request and prescription pick-up was 9.5 days.

CONCLUSIONS

TeleMOUD is feasible and successful in providing people who inject drugs with low barrier access to life-saving MOUD during the COVID-19 pandemic. This model also provided medical students with experience treating addiction during a time when they were restricted from most clinical activities.

How do we fight COVID-19? Military medical actions in the war against the COVID-19 pandemic in France

'We are at war', French President Emmanuel Macron said in an address to the nation on 16 March 2020. As part of this national effort, the French Military Medical Service (FMMS) is committed to the fight against COVID-19. This original report aimed to describe and detail actions that the FMMS has carried out in the nationwide fight against the COVID-19 pandemic in France, as well as overseas. Experts in the field reported major actions conducted by the FMMS during the COVID-19 pandemic in France. In just few weeks, the FMMS developed ad hoc medical capabilities to support national health authorities. It additionally developed adaptive, collective en route care via aeromedical and naval units and deployed a military intensive care field hospital. A COVID-19 crisis cell coordinated the French Armed Forces health management. The French Military Centre for Epidemiology and Public Health provided all information needed to guide the decision-making process. Medical centres of the French Armed Forces organised the primary care for military patients, with the widespread use of telemedicine. The Paris Fire Brigade and the Marseille Navy Fire Battalion emergency departments ensured prehospital management of patients with COVID-19. The eight French military training hospitals cooperated with civilian regional health agencies. The French military medical supply chain supported all military medical treatment facilities in France as well as overseas, coping with a growing shortage of medical equipment. The French Armed Forces Biomedical Research Institute performed diagnostics, engaged in multiple research projects, updated the review of the scientific literature on COVID-19 daily and provided expert recommendations on biosafety. Finally, even students of the French military medical academy volunteered to participate in the fight against the COVID-19 pandemic. In conclusion, in an unprecedented medical crisis, the FMMS engaged multiple innovative and adaptive actions, which are still ongoing, in the fight against COVID-19. The collaboration between military and civilian healthcare systems reinforced the shared objective to achieve the goal of 'saving the greatest number'.

In situ remediation of contaminated marinesediment: an overview

Sediment tends to accumulate inorganic and persistent hydrophobic organic contaminants representing one of the main sinks and sources of pollution. Generally, contaminated sediment poses medium- and long-term risks to humans and ecosystem health; dredging activities or natural resuspension phenomena (i.e., strongly adverse weather conditions) can remobilize pollution releasing it into the water column. Thus, ex situ traditional remediation activities (i.e., dredging) can be hazardous compared to in situ techniques that try to keep to a minimum sediment mobilization, unless dredging is compulsory to reach a desired bathymetric level. We reviewed in situ physico-chemical (i.e., active mixing and thin capping, solidification/stabilization, chemical oxidation, dechlorination, electrokinetic separation, and sediment flushing) and bio-assisted treatments, including hybrid solutions (i.e., nanocomposite reactive capping, bioreactive capping, microbial electrochemical technologies). We found that significant gaps still remain into the knowledge about the application of in situ contaminated sediment remediation techniques from the technical and the practical viewpoint. Only activated carbon-based technologies are well developed and currently applied with several available case studies. The environmental implication of in situ remediation technologies was only shortly investigated on a long-term basis after its application, so it is not clear how they can really perform.

Effects of heavy metals on ultrastructure and Hsp70 induction in Lemna minor L. exposed to water along the Sarno River, Italy

The effects of freshwater pollution in the highly contaminated river Sarno (Campania, Southern Italy) have been evaluated using bags containing the aquatic plant Lemna minor (Lemnacee, Arales), in order to determine morpho-physiological modifications as a response to pollutants. The exposition of Lemna bags for 7 days on three different sites along the river path showed alterations in chloroplasts and vacuoles shape and organization. Moreover, some specimens were exposed in vitro at the same heavy metal (HM) concentrations measured in the polluted sites of the river, and compared with data from the bag experiment; to verify the dose and time dependent effects, samples were exposed to HM in vitro at concentrations ranging from 10(-6) to 10(-4)M up to 7 days. Transmission electron microscopy (TEM) observations on in vitro plants confirmed that ultrastructural alterations affected most of plastids and the shape of different subcellular structures, namely vacuoles; in in vitro stressed specimens, Heat Shock Proteins 70 (Hsp70) levels changed, in dependence of changing levels of HM measured in different sites along the river path. Thus L. minor exhibited a possible correlation between the levels of HM pollution and Hsp70 occurrence; interestingly, the data presented showed that copper specifically increased Hsp70 levels at concentrations detected in polluted river waters, whereas cadmium and lead did not; on the other side, the latter represent highly toxic elements when specimens were exposed to higher levels in vitro. The effects of specific elements in vitro are compared to those observed in bags exposed along the river path; thus results are examined in order to propose L. minor as an organism able to be utilized to monitor heavy metals pollution; the possibility of using Hsp70s as specific markers of HM pollution is discussed.

Toxicity, accumulation, and removal of heavy metals by three aquatic macrophytes

A comprehensive understanding of the uptake, tolerance, and transport of heavy metals by plants will be essential for the development of phytoremediation technologies. In the present paper, we investigated accumulation, tissue and intracellular localization, and toxic effects of cadmium (Cd), lead (Pb), zinc (Zn), and copper (Cu) in three aquatic macrophytes (the angiosperms Lemna minor and Elodea canadensis, and the moss Leptodictyum riparium). We also tested and compared their capacity to absorb heavy metal from water under laboratory conditions. Our data showed that all the three species examined could be considered good bioaccumulators for the heavy metals tested. L. riparium was the most resistant species and the most effective in accumulating Cu, Zn, and Pb, whereas L. minor was the most effective in accumulating Cd. Cd was the most toxic metal, followed by Pb, Cu, and Zn. At the ultrastructural level, sublethal concentrations of the heavy metals tested caused induced cell plasmolysis and alterations of the chloroplast arrangement. Heavy metal removal experiments revealed that the three macrophytes showed excellent performance in removing the selected metals from the solutions in which they are maintained, thus suggesting that they could be considered good candidates for wastewaters remediation purpose.

Effects of heavy metals on ultrastructure and HSP70s induction in the aquatic moss Leptodictyum riparium Hedw

The effects of heavy metals, both toxic (Pb, Cd) and essential (Cu, Zn) on the ultrastructure and the induction of Heat Shock Protein 70 (HSP70) have been studied in the aquatic moss Leptodictyum riparium Hedw. In vitro cultured L. riparium was treated with different heavy metals, both toxic, as cadmium or lead; and essential microelements such as Copper or Zinc concentrations ranging from 10(-3) to 10(-6) M to investigate both ultrastructural damage and HSP induction. TEM observations showed that sub-lethal concentrations of heavy metals caused only slight changes, largely localized in the chloroplasts. Among all the heavy metals tested, cadmium caused the most severe modifications. Heavy metals caused the decrease of the soluble protein content and the enhancement of proteins reacting versus HSP70 antibodies, suggesting that molecular chaperons might be involved in the resistance to toxic effects of lead, cadmium, copper and zinc. Therefore, the induction of HSP70 in L. riparium would confer a higher resistance to pollutants under stressful conditions lethal for other mosses and higher plant species. These results suggest that the moss L. riparium can tolerate heavy metals stress without incurring severe cellular/subcellular damage. Therefore it can be used as a useful indicator of heavy metals accumulation.

Heavy metal deposition in the Italian "triangle of death" determined with the moss Scorpiurum circinatum

In this study, a biomonitoring project using the moss Scorpiurum circinatum was carried out to evaluate the deposition and biological effects of heavy metals in the area of Acerra (Naples, S Italy), one of the vertices of the sadly called "Italian triangle of death" owing to the dramatic increase in tumours. The results clearly indicated that the study area is heavily polluted by heavy metals, a large proportion of which is likely present in the atmosphere in particulate form. The ultrastructural organization of exposed samples was essentially preserved, but cell membrane pits, cytoplasm vesicles and concentric multilamellar/multivesicular bodies, probably induced by pollution, were found, which may be involved in the tolerance mechanisms to metal pollution in this moss species. Although severe biological effects were not found at the ultrastructural level in the exposed moss, effects on humans, especially after long-term exposure, are to be expected.

Comparison of the heavy metal bioaccumulation capacity of an epiphytic moss and an epiphytic lichen

This study compared the heavy metal bioaccumulation capacity in the epiphytic moss Scorpiurum circinatum and the epiphytic lichen Pseudevernia furfuracea, exposed in bags for 3 months in the urban area of Acerra (S Italy). The content of Al, As, Cd, Co, Cr, Cu, Fe, Mn, Mo, Ni, Pb, Ti, V, and Zn was measured by ICP-MS. The results showed that both species accumulated all the heavy metals assayed. The moss had the highest bioaccumulation capacity for all metals and showed a more constant and linear accumulation trend than the lichen. Intra-tissue heavy metal bioaccumulation was assessed by X-ray microanalysis applied to ESEM operated in high and low vacuum and ESEM modes.

Pharmacology of MEN 11467: a potent new selective and orally- effective peptidomimetic tachykinin NK(1) receptor antagonist

We have investigated the pharmacological properties of MEN 11467, a novel partially retro-inverse peptidomimetic antagonist of tachykinin NK(1) receptors. MEN 11467 potently inhibits the binding of [(3)H] substance P (SP) to tachykinin NK(1) receptors in the IM9 limphoblastoid cell line (pK(i) = 9.4 +/- 0.1). MEN 11467 is highly specific for the human tachykinin NK(1) receptors, since it has negligible effects (pK(i) <6) on the binding of specific ligands to tachykinin NK(2) or NK(3) receptors and to a panel of 30 receptors ion channels unrelated to tachykinin receptors. The antagonism exerted by MEN 11467 at tachykinin NK(1) receptors is insurmountable in saturation binding experiments, both K(D) and B(max) of SP were significantly reduced by MEN 11467 (0.3-10 nM). In the guinea-pig isolated ileum, MEN 11467 (0.03-1 nM) produced a nonparallel rightward shift of the concentration-response curve to SP methylester with a concomitant reduction of the Emax to the agonist (pK(B) = 10.7 +/- 0.1). Moreover the antagonist activity of MEN 11467 was hardly reversible despite prolonged washout. In vivo, MEN 11467 produced a long lasting (> 2-3h) dose-dependent antagonism of bronchoconstriction induced by the selective tachykinin NK(1) receptor agonist, [Sar(9), Met(O(2))(11)]SP in anaesthetized guinea-pigs (ID(50)s' = 29+/-5, 31+/-12 and 670+/-270 microg/kg, after intravenous, intranasal and intraduodenal administration, respectively), without affecting bronchoconstriction induced by methacholine. After oral administration MEN 11467 produced a dose-dependent inhibition of plasma protein extravasation induced in guinea-pig bronchi by [Sar(9), Met(O(2))(11)] (ID(50) = 6.7 +/- 2 mg/kg) or by antigen challenge in sensitized animals (ID(50) = 1.3 mg/kg). After i.v. administration MEN 11467 weakly inhibited the GR 73632-induced foot tapping behaviour in gerbil (ED(50) = 2.96 +/- 2 mg/kg), indicating a poor ability to block central tachykinin NK(1) receptors. These results demonstrate that MEN 11467 is a potent, highly selective and orally effective insurmountable pseudopeptide antagonist of peripheral tachykinin NK(1) receptors with a long duration of action.

Protective effect of the tachykinin NK2 receptor antagonist nepadutant in acute rectocolitis induced by diluted acetic acid in guinea-pigs

We have evaluated the potential protective activity of nepadutant, a selective tachykinin NK2 receptor antagonist, in a model of acute rectocolitis induced by an enema with 7.5% acetic acid in guinea-pigs. The injury was quantified visually by using a macroscopic injury score, and histologically by using a necrosis score. In addition, changes in myeloperoxidase activity, a marker for neutrophil infiltration, and plasma protein extravasation were evaluated. The injury caused by 7.5% acetic acid was mild, affecting the superficial layers and producing a strong edema of the submucosa. A single administration of nepadutant (0.3-10 mg/kg s.c., 1 h before acetic acid) markedly reduced the macroscopic damage and necrosis score and the increase in plasma protein extravasation induced by 7.5% acetic acid in the early phase of the injury. Single administration of nepadutant (3 mg/kg s.c.) reduced the macroscopic score and myeloperoxidase activity at the top (24 h) of inflammation. Repeated administration (3 mg/kg s.c. three times during 24 h) or co-administration of the tachykinin NK1 receptor antagonist MEN 11467 (3 mg/kg s.c.) did not enhance the antiulcer effect obtained with the single treatment with nepadutant. These data suggest the involvement of tachykinin NK2 receptors in the first phases of inflammation induced by acetic acid.

Effect of MEN 11467, a new tachykinin NK1 receptor antagonist, in acute rectocolitis induced by acetic acid in guinea-pigs

The aim of this study was to evaluate the effect of MEN 11467 (1R,2S)-2-N[1(H)indol-3-yl-carbonyl]-1-N{N-(p-tolylacetyl)-N-(meth yl)-D-3(2-Naphthyl)alanyl}diaminocyclohexane), a new potent tachykinin NK1 receptor antagonist, in an experimental model of acute rectocolitis induced by an enema with 7.5% acetic acid in guinea-pigs. This effect was compared to that of mesalazine (5-amino-2-hydroxybenzoic acid). The injury was quantified visually by using a macroscopic injury score and histologically by using a necrosis score. In addition, changes in myeloperoxidase activity, a marker for neutrophil infiltration, and plasma protein extravasation were evaluated. The injury caused by 7.5% acetic acid was mild, affecting the superficial layers and producing a strong edema of the submucosa. A single administration of MEN 11467 (0.3-10 mg/kg s.c., I h before acetic acid) reduced the macroscopic damage and necrosis score and the increase in plasma protein extravasation induced by 7.5% acetic acid in the early acute phase of the injury (death at 2.5 h). Mesalazine (100 mg/kg p.o., 1 h before) reduced the macroscopic score but not the plasma protein extravasation. Repeated administration of MEN 11467 (1-3 mg/kg s.c., -1, +6 and +23 h after 7.5% acetic acid) reduced the macroscopic score and myeloperoxidase activity but not the plasma protein extravasation induced in the late phase of acute injury (death at 24 h). At this time mesalazine markedly reduced the macroscopic score, myeloperoxidase activity and plasma protein extravasation induced by 7.5% acetic acid. These results suggest a greater involvement of tachykinin NK1 receptors in the early phase than in the late phase of colonic inflammation in response to chemical injury.

Inflammatory and motor responses by tachykinins in the guinea-pig oesophageal sphincter

1. The aim of this study was to characterize the tachykinin receptors involved in producing plasma protein extravasation and contractile responses of the guinea-pig oesophageal sphincter. 2. In anaesthetized guinea-pigs, the selective tachykinin NK-1 receptor agonist [Sar9,Met(O2)11]substance P produced plasma protein extravasation (PPE) which was not affected by the treatment with the tachykinin NK-2 receptor antagonist MEN 10627 (1 micromol kg(-1) i.v.) or the histamine H1-receptor antagonist, diphenhydramine (34.5 micromol kg(-1) i.v.). However, the [Sar9,Met(O2)11]substance P-induced PPE was blocked by the previous administration of the peptide tachykinin NK-1 receptor antagonist FK 888 or by the non-peptide antagonist SR 140333, yielding ED50 values of 1.1 +/- 0.2 and 0.01 +/- 0.004 micromol kg(-1) i.v., respectively. 3. The tachykinin NK-2 or NK-3 receptor agonists [beta-Ala8]neurokinin A (4-10) or [MePhe7]neurokinin B, respectively, produced a weak PPE at high doses. The effect of [MePhe7]neurokinin B-induced PPE was inhibited by SR 140333. 4. In the guinea-pig isolated oesophageal sphincter, [Sar9,Met(O2)11]substance P did not exert any contractile effect up to 10 microM. The selective tachykinin NK-2 receptor agonist ([beta-Ala8]neurokinin A (4-10), produced concentration-dependent contractions (pD2 = 7.6 +/- 0.03) which were inhibited by the selective tachykinin NK-2 receptor antagonist, MEN 10627 (pA2 = 8.6 +/- 0.1). Also, the tachykinin NK-3 receptor selective agonist [MePhe7]neurokinin B induced concentration-dependent contractile responses, but these responses were inhibited by MEN 10627. 5. Altogether, these data indicate that the stimulation of tachykinin NK-1 receptor produces a vascular inflammatory response, while activation of tachykinin NK-2 receptors mediate the contraction of the guinea-pig oesophageal sphincter.

Tortuosity, kinking, and coiling of the carotid artery: expression of atherosclerosis or aging?

The etiology of carotid abnormalities is both congenital than acquired. The aim of this study was to clarify the role of aging and atherosclerosis in the acquired cases, and the role of these abnormalities in hemodynamic alterations and neurologic symptoms. Over a 1-year period the authors studied all the subjects undergoing carotid examination by continuous-wave and color-coded Doppler sonography at an Angiology Unit. They evaluated neurologic symptoms; risk factors for atherosclerosis; number, sites, and kinds of carotid abnormalities; atherosclerotic lesions; stenosis; hemodynamic alterations of the carotid; and other localizations of atherosclerotic diseases. There were 469 subjects: 272 (58%) with abnormalities (group 1) and 197 (42%) without abnormalities (group 2). The total number of abnormalities was 479 (104 tortuosities, 262 kinkings, and 113 coilings). The abnormalities were more prevalent in the elderly (P<0.001) and in women (P<0.001). In group 1 they found significant prevalences of hyperlipemia (P<0.001), hypertension (P<0.01), chronic cigarette smoking (P<0.01), and ischemic heart disease (P<0.05). Carotid atherosclerotic lesions were more prevalent in group 1 than in group 2 (P<0.001); among the patients with atherosclerotic carotid lesions, those in group 1 were older than those in group 2 (P<0.001). Tortuosity seemed to be associated with fewer hemodynamic alterations. The authors conclude that atherosclerosis, hypertension, and aging may play an important role in producing carotid abnormalities. The aging seemed more important than atherosclerosis. Only a prospective study of patients with carotid abnormalities and no atherosclerotic lesion will clarify the role of hemodynamics and neurologic symptomatology.

Pharmacology of the peptidomimetic, MEN 11149, a new potent, selective and orally effective tachykinin NK1 receptor antagonist

In this study we investigated the pharmacological properties of MEN 11149, 2-(2-naphthyl)-1-N-[(1R,2S)-2-N-[1(H)indol-3-ylcarbonyl]aminocy clohexanecarbonyl]-1-[N'-methyl-N'-(4-methylphenylacetyl)]di aminoethane, a novel partially retro-inverse pseudo peptide antagonist of tachykinin NK1 receptors. MEN 11149 potently inhibits the binding of [3H]substance P to tachykinin NK1 sites in IM9 cells (pKi = 8.5 +/- 0.1). The compound is highly specific for the human tachykinin NK1 receptors, since it has negligible effects (pKi < 6) on the binding of specific ligands to tachykinin NK2, NK3 receptors and a battery of central and peripheral receptors or ion channels. The tachykinin NK1 receptor antagonism of MEN 11149 appears to be insurmountable since, in saturation binding experiments, both K(D) and Bmax are significantly affected by incubation with the compound (1-30 nM). In isolated guinea-pig ileum, MEN 11149 (0.1-100 nM) shifts to the right in a non-parallel way the substance P methyl ester-induced cumulative concentration-response curve with progressive inhibition of the maximal response (pK(B) = 9.6 +/- 0.1). When tested for reversibility at 5 nM in the same preparation, the compound displays a slow dissociation rate compared to the fast dissociation rate with FK888 (N2-[(4R)-4-hydroxy-1-(1-methyl-1H-indol-3-yl)carbonyl-L-prolyl]-N-methy l-N-phenylmethyl-L-3-(2-naphthyl)alaninamide) at 5 nM. In the same preparation, MEN 11149 (10 microM) did not affect the cumulative concentration-response curve to acetylcholine. In vivo, MEN 11149 dose dependently antagonizes [Sar9,Met(O2)11]substance P-induced bronchoconstriction in anaesthetized guinea-pigs (ID50 = 83 +/- 31 nmol/kg i.v.). The duration of the effect exceeds 3 h. MEN 11149 does not affect the bronchoconstriction induced by neurokinin A. The compound dose dependently inhibits [Sar9,Met(O2)11]substance P-induced plasma protein extravasation in guinea-pig bronchi whether administered intravenously (ID50 = 0.22 +/- 0.02 micromol/kg) or orally (ID50 = 0.97 +/- 0.21 micromol/kg). These results demonstrate that MEN 11149 is a potent, highly selective and orally effective insurmountable antagonist of tachykinin NK1 receptors with a long duration of action.

Characterization of tachykinin NK2 receptor on dog proximal colon. Antagonism by MEN 10,627 and SR 48,968

The nature of the tachykinin receptors involved in the contraction of the circular muscle of dog colon has been investigated. The following rank order of potency for agonists was obtained: [Sar9,Met(O2)11]substance P > or = neurokinin A > [beta-Ala8]neurokinin A-(4-10) >> [MePhe7]neurokinin B. The efficacy of the tachykinin NK2 receptor agonists was significantly greater than that of the tachykinin NK1 receptor agonists and of carbachol. A concentration-dependent rightward shift of the motor response to neurokinin A (obtained in the presence of (+/-)-CP 96,345) was induced by peptide and non-peptide tachykinin NK2 receptor antagonists with this rank order: MEN 10,627 = SR 48,968 >> L 659,877 > MEN 10,376 > MDL 28,564. MEN 10,627 and SR 48,968 affinities were similar to those measured in human tissues. In conclusion, the tachykinin NK2 receptor plays a predominant role in tachykinin-induced contraction of the canine colonic circular muscle and this tissue could be useful to predict the pharmacological actions of MEN 10,627 and SR 48,968 in human colon.

Afferent and efferent branching axons from the rat lumbo-sacral spinal cord project both to the urinary bladder and the urethra as demonstrated by double retrograde neuronal labeling

A double retrograde axonal tracing technique has been used to ascertain the localization of neuronal cell bodies which give rise to branching axons innervating both the urinary bladder and the urethra in male rat. Application of fluorescent tracers Fast blue (FB) and Diamidino yellow (DY) to postganglionic fibers to the urinary bladder and to the urethra (penile nerve), respectively, produced the double-labeling of neurons located in the dorsal root ganglia and in the 'intermediolateral nucleus'.

Electrocorticographic desynchronization after application of visceral and somatic noxious stimuli in urethane-anesthetized rats: effect of intrathecal administration of tachykinin (NK 1 or NK 2) receptor antagonists

We investigated the electrocortical (E.Co.G) correlates of visceral (topical capsaicin application or overdistension of the urinary bladder) and somatic (perineal pinching) painful stimulation in urethane-anesthetized rats and their modulation by intrathecal application of selective tachykinins receptors (NK 1 and NK 2) antagonists. Vesical overdistension or topical capsaicin on the bladder serosal surface produced an immediate and lasting E.Co.G. desynchronization resembling a cortical arousal. A second application of capsaicin was ineffective. Bladder contraction induced by topical acetylcholine did not alter E.Co.G. A desynchronized E.Co.G. was also induced by pinching of the perineal area of the rat. Intrathecal administration of lidocaine at lumbosacral level abolished the E.Co.G. desynchronization induced by both visceral and somatic noxious stimulation. On the other hand capsaicin-induced or over-distension (but not pinching-induced) E.Co.G. desynchronization disappeared in animals systemically pretreated with capsaicin or after intrathecal administration of NK 1 tachykinin receptor antagonists such as the peptide GR 82334 or the nonpeptide RP 67580, whereas the inactive enantiomer RP 68651 or the nonpeptide NK 2 antagonists SR 48968 were ineffective. In conclusion, the experimental model described herein, allowing a quantitative analysis of the E.Co.G. correlates of visceral and somatic noxious stimulation in urethane-anesthetized rats, provides evidence for a specific neural pathway carrying bladder-arising visceral (both mechanical and chemical) nociception that uses pelvic capsaicin-sensitive afferents projecting to NK 1 (but not NK 2) bearing spinal neurons and that ultimately leads to activation of cortical areas.

Opposite modulation by tachykinin (NK1) and CGRP receptors of sympathetic control of mouse vas deferens motility

Electrical field stimulation of isolated mouse vas deferens elicited sympathetic twitch whose amplitude was transiently enhanced by the selective tachykinin NK1 receptor agonist, [Sar9,Met(O2)11]substance P (0.3-30 nM), but not by selective NK2 and NK3 receptor agonists. Potentiation by [Sar9,Met(O2)11]substance P was antagonized by (+/-)-CP 96,345 [(2S,3S)-cis-2-(diphenylmethyl)-N- [(2-methoxyphenyl)-methyl]-1-azabicyclo[2.2.2]octan-3-amine] (IC50 = 0.1 microM). On the other hand, electrical field stimulation-induced contractions were inhibited by calcitonin gene-related peptide, CGRP (0.1-30 nM), and this action was reduced by its antagonist, human CGRP-(8-37) (3 microM). [Sar9,Met(O2)11]substance P (3 nM) did not affect either high-K+ or noradrenaline-induced contraction, while CGRP (3 nM) significantly reduced the noradrenaline-induced motor response. Capsaicin (1 microM) inhibited sympathetic twitches, and this effect was partially antagonized by human CGRP-(8-37). In the presence of this antagonist, capsaicin induced a short-living and (+/-)-CP 96,345-sensitive twitch enhancement. These data suggest that the sympathetic control of mouse vas deferens motility can be modulated in an opposite manner by tachykinin NK1 (prejunctionally located) and by CGRP (pre- and/or postjunctionally located) receptors.