Prospective cohort study of long-term neurological outcomes in retired elite athletes: the Advanced BiomaRker, Advanced Imaging and Neurocognitive (BRAIN) Health Study protocol

INTRODUCTION

Although limited, recent research suggests that contact sport participation might have an adverse long-term effect on brain health. Further work is required to determine whether this includes an increased risk of neurodegenerative disease and/or subsequent changes in cognition and behaviour. The Advanced BiomaRker, Advanced Imaging and Neurocognitive Health Study will prospectively examine the neurological, psychiatric, psychological and general health of retired elite-level rugby union and association football/soccer players.

METHODS AND ANALYSIS

400 retired athletes will be recruited (200 rugby union and 200 association football players, male and female). Athletes will undergo a detailed clinical assessment, advanced neuroimaging, blood testing for a range of brain health outcomes and neuropsychological assessment longitudinally. Follow-up assessments will be completed at 2 and 4 years after baseline visit. 60 healthy volunteers will be recruited and undergo an aligned assessment protocol including advanced neuroimaging, blood testing and neuropsychological assessment. We will describe the previous exposure to head injuries across the cohort and investigate relationships between biomarkers of brain injury and clinical outcomes including cognitive performance, clinical diagnoses and psychiatric symptom burden.

ETHICS AND DISSEMINATION

Relevant ethical approvals have been granted by the Camberwell St Giles Research Ethics Committee (Ref: 17/LO/2066). The study findings will be disseminated through manuscripts in clinical/academic journals, presentations at professional conferences and through participant and stakeholder communications.

Computerised cognitive assessment in patients with traumatic brain injury: an observational study of feasibility and sensitivity relative to established clinical scales

Background

Online technology could potentially revolutionise how patients are cognitively assessed and monitored. However, it remains unclear whether assessments conducted remotely can match established pen-and-paper neuropsychological tests in terms of sensitivity and specificity.

Methods

This observational study aimed to optimise an online cognitive assessment for use in traumatic brain injury (TBI) clinics. The tertiary referral clinic in which this tool has been clinically implemented typically sees patients a minimum of 6 months post-injury in the chronic phase. Between March and August 2019, we conducted a cross-group, cross-device and factor analyses at the St. Mary's Hospital TBI clinic and major trauma wards at Imperial College NHS trust and St. George's Hospital in London (UK), to identify a battery of tasks that assess aspects of cognition affected by TBI. Between September 2019 and February 2020, we evaluated the online battery against standard face-to-face neuropsychological tests at the Imperial College London research centre. Canonical Correlation Analysis (CCA) determined the shared variance between the online battery and standard neuropsychological tests. Finally, between October 2020 and December 2021, the tests were integrated into a framework that automatically generates a results report where patients' performance is compared to a large normative dataset. We piloted this as a practical tool to be used under supervised and unsupervised conditions at the St. Mary's Hospital TBI clinic in London (UK).

Findings

The online assessment discriminated processing-speed, visual-attention, working-memory, and executive-function deficits in TBI. CCA identified two significant modes indicating shared variance with standard neuropsychological tests (r = 0.86, p < 0.001 and r = 0.81, p = 0.02). Sensitivity to cognitive deficits after TBI was evident in the TBI clinic setting under supervised and unsupervised conditions (F (15,555) = 3.99; p < 0.001).

Interpretation

Online cognitive assessment of TBI patients is feasible, sensitive, and efficient. When combined with normative sociodemographic models and autogenerated reports, it has the potential to transform cognitive assessment in the healthcare setting.

Funding

This work was funded by a National Institute for Health Research (NIHR) Invention for Innovation (i4i) grant awarded to DJS and AH (II-LB-0715-20006).

ADVANCE-TBI study protocol: traumatic brain injury outcomes in UK military personnel serving in Afghanistan between 2003 and 2014 - a longitudinal cohort study

INTRODUCTION

Outcomes of traumatic brain injury (TBI) are highly variable, with cognitive and psychiatric problems often present in survivors, including an increased dementia risk in the long term. Military personnel are at an increased occupational risk of TBI, with high rates of complex polytrauma including TBI characterising the UK campaign in Afghanistan. The ArmeD SerVices TrAuma and RehabilitatioN OutComE (ADVANCE)-TBI substudy will describe the patterns, associations and long-term outcomes of TBI in the established ADVANCE cohort.

METHODS AND ANALYSIS

The ADVANCE cohort comprises 579 military personnel exposed to major battlefield trauma requiring medical evacuation, and 566 matched military personnel without major trauma. TBI exposure has been captured at baseline using a standardised interview and registry data, and will be refined at first follow-up visit with the Ohio State Method TBI interview (a National Institute of Neurological Disorders and Stroke TBI common data element). Participants will undergo blood sampling, MRI and detailed neuropsychological assessment longitudinally as part of their follow-up visits every 3-5 years over a 20-year period. Biomarkers of injury, neuroinflammation and degeneration will be quantified in blood, and polygenic risk scores calculated for neurodegeneration. Age-matched healthy volunteers will be recruited as controls for MRI analyses. We will describe TBI exposure across the cohort, and consider any relationship with advanced biomarkers of injury and clinical outcomes including cognitive performance, neuropsychiatric symptom burden and function. The influence of genotype will be assessed. This research will explore the relationship between military head injury exposure and long-term outcomes, providing insights into underlying disease mechanisms and informing prevention interventions.

ETHICS AND DISSEMINATION

The ADVANCE-TBI substudy has received a favourable opinion from the Ministry of Defence Research Ethics Committee (ref: 2126/MODREC/22). Findings will be disseminated via publications in peer-reviewed journals and presentations at conferences.

Assessing prospective and retrospective metacognitive accuracy following traumatic brain injury remotely across cognitive domains

The ability to monitor one's behaviour is frequently impaired following TBI, impacting on patients' rehabilitation. Inaccuracies in judgement or self-reflection of one's performance provides a useful marker of metacognition. However, metacognition is rarely measured during routine neuropsychology assessments and how it varies across cognitive domains is unclear. A cohort of participants consisting of 111 TBI patients [mean age = 45.32(14.15), female = 29] and 84 controls [mean age = 31.51(12.27), female = 43] was studied. Participants completed cognitive assessments via a bespoke digital platform on their smartphones. Included in the assessment were a prospective evaluation of memory and attention, and retrospective confidence judgements of task performance. Metacognitive accuracy was calculated from the difference between confidence judgement of task performance and actual performance. Prospective judgment of attention and memory was correlated with task performance in these domains for controls but not patients. TBI patients had lower task performance in processing speed, executive functioning and working memory compared to controls, maintaining high confidence, resulting in overestimation of cognitive performance compared to controls. Additional judgments of task performance complement neuropsychological assessments with little additional time-cost. These results have important theoretical and practical implications for evaluation of metacognitive impairment in TBI patients and neurorehabilitation.

Detecting axonal injury in individual patients after traumatic brain injury

Poor outcomes after traumatic brain injury (TBI) are common yet remain difficult to predict. Diffuse axonal injury is important for outcomes, but its assessment remains limited in the clinical setting. Currently, axonal injury is diagnosed based on clinical presentation, visible damage to the white matter or via surrogate markers of axonal injury such as microbleeds. These do not accurately quantify axonal injury leading to misdiagnosis in a proportion of patients. Diffusion tensor imaging provides a quantitative measure of axonal injury in vivo, with fractional anisotropy often used as a proxy for white matter damage. Diffusion imaging has been widely used in TBI but is not routinely applied clinically. This is in part because robust analysis methods to diagnose axonal injury at the individual level have not yet been developed. Here, we present a pipeline for diffusion imaging analysis designed to accurately assess the presence of axonal injury in large white matter tracts in individuals. Average fractional anisotropy is calculated from tracts selected on the basis of high test-retest reliability, good anatomical coverage and their association to cognitive and clinical impairments after TBI. We test our pipeline for common methodological issues such as the impact of varying control sample sizes, focal lesions and age-related changes to demonstrate high specificity, sensitivity and test-retest reliability. We assess 92 patients with moderate-severe TBI in the chronic phase (≥6 months post-injury), 25 patients in the subacute phase (10 days to 6 weeks post-injury) with 6-month follow-up and a large control cohort (n = 103). Evidence of axonal injury is identified in 52% of chronic and 28% of subacute patients. Those classified with axonal injury had significantly poorer cognitive and functional outcomes than those without, a difference not seen for focal lesions or microbleeds. Almost a third of patients with unremarkable standard MRIs had evidence of axonal injury, whilst 40% of patients with visible microbleeds had no diffusion evidence of axonal injury. More diffusion abnormality was seen with greater time since injury, across individuals at various chronic injury times and within individuals between subacute and 6-month scans. We provide evidence that this pipeline can be used to diagnose axonal injury in individual patients at subacute and chronic time points, and that diffusion MRI provides a sensitive and complementary measure when compared to susceptibility weighted imaging, which measures diffuse vascular injury. Guidelines for the implementation of this pipeline in a clinical setting are discussed.

Stratifying drug treatment of cognitive impairments after traumatic brain injury using neuroimaging

Cognitive impairment is common following traumatic brain injury. Dopaminergic drugs can enhance cognition after traumatic brain injury, but individual responses are highly variable. This may be due to variability in dopaminergic damage between patients. We investigate whether measuring dopamine transporter levels using 123I-ioflupane single-photon emission computed tomography (SPECT) predicts response to methylphenidate, a stimulant with dopaminergic effects. Forty patients with moderate-severe traumatic brain injury and cognitive impairments completed a randomized, double-blind, placebo-controlled, crossover study. 123I-ioflupane SPECT, MRI and neuropsychological testing were performed. Patients received 0.3 mg/kg of methylphenidate or placebo twice a day in 2-week blocks. Subjects received neuropsychological assessment after each block and completed daily home cognitive testing during the trial. The primary outcome measure was change in choice reaction time produced by methylphenidate and its relationship to stratification of patients into groups with normal and low dopamine transporter binding in the caudate. Overall, traumatic brain injury patients showed slow information processing speed. Patients with low caudate dopamine transporter binding showed improvement in response times with methylphenidate compared to placebo [median change = -16 ms; 95% confidence interval (CI): -28 to -3 ms; P = 0.02]. This represents a 27% improvement in the slowing produced by traumatic brain injury. Patients with normal dopamine transporter binding did not improve. Daily home-based choice reaction time results supported this: the low dopamine transporter group improved (median change -19 ms; 95% CI: -23 to -7 ms; P = 0.002) with no change in the normal dopamine transporter group (P = 0.50). The low dopamine transporter group also improved on self-reported and caregiver apathy assessments (P = 0.03 and P = 0.02, respectively). Both groups reported improvements in fatigue (P = 0.03 and P = 0.007). The cognitive effects of methylphenidate after traumatic brain injury were only seen in patients with low caudate dopamine transporter levels. This shows that identifying patients with a hypodopaminergic state after traumatic brain injury can help stratify the choice of cognitive enhancing therapy.

Neuropsychological outcomes following traumatic brain injury

This review examines the clinical and neuroradiological features of traumatic brain injury that are most frequently associated with persistent cognitive complaints. Neuropsychological outcomes do not depend solely on brain injury severity but result from a complex interplay between premorbid factors, the extent and nature of the underlying structural damage, the person's neuropsychological reserve and the impact of non-neurological factors in the recovery process. Brain injury severity is only one of these factors and has limited prognostic significance with respect to neuropsychological outcome. We examine the preinjury and postinjury factors that interact with the severity of a traumatic brain injury to shape outcome trajectories. We aim to provide a practical base on which to build discussions with the patient and their family about what to expect following injury and also to plan appropriate neurorehabilitation.

Post-traumatic amnesia and confusional state: hazards of retrospective assessment

Retrospective assessment of post-traumatic amnesia (PTA) must take into account factors other than traumatic brain injury (TBI) which may impact on memory both at the time of injury and subsequent to the injury. These include analgesics, anaesthesia required for surgery, and the development of acute or post-traumatic stress disorder. This is relevant in clinical and medicolegal settings. Repeated assessments of the post-injury state, involving tests for continuing amnesia, risk promoting recall of events suggested by the examiner, or generating confabulations. The PTA syndrome affects the categorical autobiographical memory, and is accompanied by confusion as an essential component; this should be suspected from the initial or early Glasgow Coma Scale score (13-14/15) if not directly recorded by clinical staff. PTA by itself is only one of several indices of severity of TBI. The nature of the head injury, including observers' accounts, clinical and neuroimaging data, the possible role of other external injuries, blood loss, acute stress disorder and the potential for hypoxic brain injury, must be taken into account as well as concomitant alcohol or substance abuse, and systemic shock. A plausible mechanism for a TBI must be demonstrable, and other causes of amnesia excluded.

Smartphone technology: Gentle reminders of everyday tasks for those with prospective memory difficulties post-brain injury

BACKGROUND

Prospective memory is a common deficit following brain injury that can reduce an individuals' ability to complete everyday tasks. The smartphone is a device that may compensate for these difficulties using the calendar's prompting function. Reminders can be programmed remotely using email to phone synchronization.

OBJECTIVE

To explore whether smartphone reminders help people complete pre-identified tasks as compared to when reminders are not provided.

METHODS

An ABAB case series design compared reminder present vs. reminder absent phases with regards completion of pre-set tasks. Six participants aged 24-55 with Acquired Brain Injury (ABI) and five caregivers participated in the study. Both completed a series of questionnaires looking at the impact of the smartphone reminders on everyday memory functioning at pre, post and follow-up. A 3-month follow-up questionnaire assessed continued use of the system.

RESULTS

There was a significant improvement in task completion rates when smartphone reminders were provided. A thematic analysis identified that smartphone reminders improved independence, confidence in coping with memory difficulties and general mood. All participants were still using the system at 3-month follow-up.

CONCLUSIONS

Smartphone reminders may provide a cost-effective, accessible and non-stigmatizing tool for participants to compensate for prospective memory difficulties.

How do experts reporting for the legal process validate symptoms? The results of a survey

This article examines the views of experts from a range of disciplines and how they view symptoms given to them by claimants in matters of personal injury or medical negligence assessments. The survey was carried out in 2009 and looks at current practice and attitudes from a number of different disciplines. The survey included questions looking at what percentage of cases were thought to be genuine, symptoms most likely to be elaborated, methods for assessing symptom validity, and documentary evidence required for a report. This article highlights the importance of looking at symptom validation in the legal process.

A multicenter phase II study of cetuximab in combination with chest radiotherapy and consolidation chemotherapy in patients with stage III non-small cell lung cancer

BACKGROUND

Cetuximab has demonstrated improved efficacy in combination with chemotherapy and radiotherapy. We evaluated the integration of cetuximab in the combined modality treatment of stage III non-small cell lung cancer (NSCLC).

METHODS

Patients with surgically unresectable stage IIIA or IIIB NSCLC were treated with chest radiotherapy, 73.5 Gy (with lung and tissue heterogeneity corrections) in 35 fractions/7 weeks, once daily (63 Gy without heterogeneity corrections). Cetuximab was given weekly during radiotherapy and continued during consolidation therapy with carboplatin and paclitaxel up to a maximum of 26 weekly doses. The primary endpoint was overall survival. Baseline tumor tissue was analyzed for EGFR by fluorescence in situ hybridization (FISH).

RESULTS

Forty patients were enrolled in this phase II study. The median overall survival was 19.4 months and the median progression-free survival 9.3 months. The best overall response rate in 31 evaluable patients was 67%. No grade 3 or 4 esophagitis was observed. Three patients experienced grade 3 rash; 16 patients (69%) developed grade 3/4 neutropenia during consolidation therapy. One patient died of pneumonitis, possibly related to cetuximab. EGFR gene copy number on baseline tumor tissues, analyzed by FISH, was not predictive of efficacy outcomes.

CONCLUSIONS

The addition of cetuximab to chest radiotherapy and consolidation chemotherapy was tolerated well and had modest efficacy in stage III NSCLC. Taken together with the lower incidence of esophagitis, our results support evaluation of targeted agents instead of chemotherapy with concurrent radiotherapy in this setting.

Phase II study of RAD001 (everolimus) in previously treated small cell lung cancer (SCLC)

8107

Background: Everolimus (E) is an oral inhibitor of mammalian target of rapamycin (mTOR), a novel target for anti-cancer therapy that plays a central role in the PI3K/AKT signaling pathway and other pathways that mediate tumor growth, proliferation, and angiogenesis. E has shown preclinical activity in SCLC cell lines and xenograft models. Methods: Eligibility included SCLC with disease progression after up to 2 prior chemotherapy regimens, ECOG performance status (PS) 0–2, and adequate bone marrow, liver, and kidney function. Patients (pts) were treated with E 10 mg, orally, once daily. Primary endpoint was the disease control rate (DCR), i.e. complete response (CR), partial response (PR) and stable disease (SD), after 2 cycles of E (6 weeks) in pts who received at least 1 cycle. A 2-stage design was followed. PI3K/AKT signaling pathway molecular biomarkers (AKT, pAKT, PTEN, P-S6, p-4E- BP1) will be evaluated on baseline tumor tissue. Results: 40 pts were enrolled; 14 males/26 females; median age 64 years (44–80); PS 0: 17, PS 1: 23; prior chemotherapy status: 1 prior regimen/sensitive relapse (i.e. relapse >60 days from completion of first-line chemotherapy): 23 pts; 1 prior regimen/refractory: 4 pts; 2 prior regimens: 13 pts. 28 pts (70%) received ≥ 2 cycles of E, 7 (18%) 1 cycle and 5 (12%) did not complete the first cycle of E due to adverse events or early progression. Best response in 35 evaluable patients: 1 (3%) PR, 8 (23%) SD and 26 (74%) progression; DCR at 6 weeks was 26% with a duration of disease control of 2.7–6.3 months; median progression-free survival 1.4 months; and median overall survival 5.5 months. No grade 4 toxicity was seen. Grade 3 toxicities included thrombocytopenia (2), neutropenia (2), infection (1), pneumonitis (1), fatigue (1), elevated transaminases (1), hyperglycemia (1), diarrhea (1), and acute renal failure due to dehydration from diarrhea and poor oral intake (1). Conclusions: E is well tolerated but has limited single-agent antitumor activity in unselected patients with pretreated SCLC.

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Phase II trial of oral imatinib in combination with every-three-week intravenous docetaxel in patients with metastatic, hormone- refractory prostate cancer

15603

Background: Imatinib is a small molecule tyrosine kinase inhibitor specific for Bcr-Abl, platelet-derived growth factor receptor (PDGFR) and c-Kit. Inhibition of PDGFR abrogates pericyte migration and perturbs regulation of interstitial fluid pressure, suggesting potential anti-tumor effect in combination with chemotherapy. Docetaxel is a microtubule-stabilizing cytotoxic agent shown to prolong survival in men with androgen-refractory prostate cancer (AIPC) when administered at 75 mg/m2 every 21 days. We have previously established that imatinib 400 mg daily plus docetaxel 60 mg/m2 every 21 days is well tolerated and now hypothesize that this combination will prolong time to disease progression (TTP) in patients with AIPC. Methods: Subjects with progressive AIPC received docetaxel 60 mg/m2 intravenously every 21 days (day 1; up to 8 cycles) plus imatinib 400 mg by mouth daily starting on day -3. After the first 6 subjects, the study treatment was modified so that subjects receive oral imatinib 400 mg only on days -3 thru +7 of each 21-day cycle. The primary endpoint is TTP. The sample size is 43 patients, providing 90% power to detect an increase in TTP from 5 to 8 months. Results: Nineteen subjects have enrolled in the study between August 2005 and October 2006. Age range of subjects was 54 to 84 years (median 69 years). Serious adverse events (=Grade (G) 3) were principally hematologic: neutropenia (G4=5, G3=2); thrombocytopenia (G4=1, G3=1), hemoglobin (G4=1). There was one G4 myocardial infarction and one incident of G5 sepsis associated with methicillin-resistant S. aureus bacteremia and normal neutrophil count. One instance each of the following G3 toxicities were observed: fatigue, myalgia, dyspnea, nausea/vomiting, diarrhea, chest pain, dizziness, urinary retention. Five subjects had >50% decrease in serum PSA. Eight subjects received 4 or more cycles of docetaxel, and 4 subjects continued on imatinib maintenance after completing 6–8 cycles of docetaxel plus imatinib. Conclusions: Intravenous docetaxel on day 1 plus oral imatinib on days -3 thru +7 of a 21-day cycle is generally well- tolerated in men with AIPC. Prolonged stable disease and/or serum PSA response was observed in several subjects.

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Phase II trial of pemetrexed (P) and bevacizumab (B) in patients (pts) with recurrent or metastatic head and neck squamous cell carcinoma (HNSCC): An interim analysis

6049

Background: P is a multi-targeted antifolate with single-agent activity in recurrent or metastatic HNSCC (RR 26%, Pivot et al. Br J Cancer 2001;85:649–55) and a preferable toxicity profile compared with cisplatin or the taxanes. B is a monoclonal antibody against the vascular endothelial growth factor that has been successfully incorporated in the treatment of other advanced solid tumors. Methods: Eligible pts had pathologically documented HNSCC, ECOG performance status 0–1, measurable disease, no history of bleeding diathesis or hemoptysis, and were not on anticoagulation. Pts had no prior systemic therapy for recurrent or metastatic HNSCC; chemotherapy as part of initial potentially curative therapy, but without P or B, was allowed if completed >6 months earlier. Treatment consisted of P 500 mg/m2 and B 15 mg/Kg, both given intravenously every 21 days, until disease progression or intolerable toxicity. All patients received folic acid, vitamin B12, and corticosteroid prophylaxis. The primary endpoint was the time to progression (TTP) with a sample size of 40 pts (one stage design) with planned interim safety analysis after the first 6 and 12 pts. Results: 14 pts have been enrolled. Median age 64 years (35–84); male/female 13/1; PS 0/1: 7/7; prior chemotherapy: 8; primary site: oropharynx (7), larynx (4), oral cavity (3). Median number of cycles 5 (1–10). With a median follow up of 5.5 months, median TTP was 6 months (95% CI, 4–8). 11 pts were evaluable for response using RECIST. Best response was CR: 2, PR: 3, SD: 6, PD: 0, with ORR 45%. There were no grade 4 toxicities in 14 evaluable pts; 2 pts had grade 3 hemorrhagic events in the first cycle (1 tumor-related and 1 due to gastric ulcer post gastrostomy tube placement), and both discontinued treatment. 3 other pts had grade 1–2 hemorrhagic events. The relationship of these events to treatment was difficult to ascertain. Other grade 3 toxicities were stomatitis, dysphagia, and fatigue (all occurred in 1 pt). Conclusions: Preliminary results show that P plus B is a novel, highly active regimen that may represent a new treatment paradigm in HNSCC. However, bleeding complications were frequent in pts with susceptibility to such events. Study accrual continues.

No significant financial relationships to disclose.

Phase I and pharmacokinetic (PK) study of 17-allylamino-17 demethoxygeldanamycin (17-AAG) in combination with weekly paclitaxel for advanced solid malignancies

14028

Background: 17-AAG inhibits heat shock protein 90, promotes degradation of oncoproteins & exhibits synergy with paclitaxel in vitro. We conducted a phase I study in patients (pts) with advanced malignancies to determine the recommended phase II dose (RP2D) of the combination of 17-AAG & paclitaxel. Methods: Key eligibility criteria were: histologically confirmed malignancy; lack of standard or proven treatment options; age > 18 years; ECOG PS 0–2; adequate hepatic, renal & bone marrow function & willingness to sign informed consent. Patients with neuropathy > grade 1 and those on therapeutic anticoagulation were excluded. 17-AAG (80–225 mg/m2) was given on days 1, 4, 8, 11, 15 & 18 of each 4-week cycle to sequential cohorts of patients. Paclitaxel (80–100 mg/m2) was administered on days 1, 8 & 15. PK sampling was done on days 1, 4 & 8 of cycle 1. Dose-limiting toxicity (DLT) was assessed during cycle 1. 17-AAG & paclitaxel were quantitated with validated HPLC and LC/MS assays, respectively. Results: 25 pts were accrued to 5 dose levels. Patient demographics were: male 18; median age 61; PS 0–14 pts, 1–10 pts, 2–1 pt. Primary tumor sites were prostate (5), lung (4), esophagus (4), ovary (2), colon (2) & others (8). The median number of cycles was 2. Chest pain (Gr 3) & fatigue (Gr 4) were dose-limiting at dose level 4 (17-AAG 225 mg/m2, paclitaxel 80 mg/m2). Other toxicities included neutropenia, fatigue, neuropathy, nausea, arthralgia and myalgia. The RP2D for the regimen is 17-AAG (175 mg/m2 administered biweekly) & paclitaxel (80 mg/m2/wk.) for 3 weeks in a 4 wk. cycle. None of the 6 patients at this dose level experienced DLT. One patient with fibrosarcoma experienced a PR & 4 (esophageal, prostate, gall bladder cancer) had SD. Paclitaxel PK were compatible with previous reports in literature and were similar on days 1 & 8. 17-AAG PK were linear and similar when given alone and in combination with paclitaxel. Conclusions: The combination of biweekly 17-AAG (175 mg/m2) and weekly paclitaxel (80 mg/m2/week) is tolerated well and was associated with anti-cancer activity. There was no evidence of drug-drug PK interactions. Support: NCI U01 CA099168–01, NIH/NCCR/GCRC grant 5M01RR 00056

No significant financial relationships to disclose.

Verbal fluency in elderly bilingual speakers: normative data and preliminary application to Alzheimer's disease

This study investigated verbal fluency abilities in 30 healthy elderly English-Afrikaans bilingual speakers, and 6 bilingual subjects with Alzheimer's disease. Three 1-min semantic verbal fluency tasks (animals) were obtained in the bilingual mode, Afrikaans and English. Results were analysed in terms of total correct, and semantic clusters. There was no significant difference between monolingual and bilingual performance. Some healthy bilingual subjects used code switching as a strategy but with no direct increase in the number of exemplars generated, and there was no relationship between age of acquisition, pattern of use and verbal fluency scores. In comparison, subjects with Alzheimer's disease did not make use of code switching strategies, and there was some relationship between age of acquisition, pattern of use and verbal fluency scores.

Lymphatic malformation: predictive factors for recurrence

OBJECTIVE

Although lymphatic malformations are often found to be well circumscribed when surgery is undertaken in early childhood, complete surgical excision can be difficult when the lesion is infiltrative. This study retrospectively evaluates these patients in an attempt to identify prognostic factors that may predict recurrence.

STUDY DESIGN AND SETTING

A retrospective chart review was conducted covering the years 1991 to 1998. Seventeen patients were identified having undergone 32 surgical resections of tumors described as lymphatic malformations. Data abstracted from the charts included the site of the lesion, surgical and histologic assessment of encapsulation, and status at follow-up examination.

RESULTS

Six of 17 patients developed a recurrence after surgery. Correlation between recurrence and histologic or operative impressions of encapsulation was significant by chi(2) analysis (P<0.01).

CONCLUSION

On the basis of the findings of this case series, lymphatic malformations that are found to be nonencapsulated and infiltrative by intraoperative or histologic assessment are more likely to recur.

Spread of the Spanish multi-resistant serotype 23F clone of Streptococcus pneumoniae to Seoul, Korea

Multi-resistant serotype 23F pneumococcal strains from an outbreak in a day-care centre in South Africa and strains from sporadic cases in Korea were analysed for their relatedness, by means of arbitrarily-primed PCR (AP-PCR), repetitive extragenic palindromic PCR (rep-PCR) and penicillin-binding protein (PBP) gene profiles. The South African strains previously shown to be identical to the 23F Spanish clone had identical AP-PCR and rep-PCR patterns to 13 Korean isolates. PBP gene analysis of strains from this cluster showed identical fingerprints, suggesting clonality. Isolates, identical genotypically to the 23F clone appeared to have acquired the type 19F and 14 capsular serotypes, respectively, a result that suggests horizontal transfer of capsular biosynthetic genes. These same techniques revealed three serotype 9V isolates not closely related to the 23F clone but which harbour PBP genes identical to the 23F clone. The data presented suggests that a clone of S. pneumoniae serotype 23F related to isolates from Spain and South Africa has become disseminated in Korea.

A phase II trial of docetaxel (Taxotere) in hormone-refractory prostate cancer: correlation of antitumor effect to phosphorylation of Bcl-2

Twenty-one patients with hormone refractory prostate cancer were enrolled to receive single-agent docetaxel (Taxotere; Rhône-Poulenc Rorer, Collegeville, PA) 75 mg/m2 intravenously every 21 days. Six patients consented to biopsies of the prostate tumor before and following the first cycle of chemotherapy and 11 patients underwent periodic blood collection for isolation of the mononuclear cell fraction. The toxicities of treatment were moderate but included eight episodes of grade III and two episodes of grade IV nonhematologic toxicity as well as seven episodes of grade III and 11 episodes of grade IV hematologic toxicity (primarily neutropenia, including four episodes of febrile neutropenia). An objective response of more than 50% reduction in prostate-specific antigen was observed in seven patients (38%) and more than half of the patients with symptomatic disease at the initiation of therapy had improvements on treatment. Radiographic or scintigraphic evidence of tumor regression was observed in six patients. Nine patients experienced a prolonged period of stable disease on treatment (median, six cycles). Tumor specimens are currently being analyzed for bcl-2 expression and phosphorylation. The current series confirms the substantial single-agent activity of docetaxel in hormone refractory prostate cancer and may help to further elucidate its mechanism of action at the molecular level.

Phase I clinical/pharmacokinetic and pharmacodynamic trial of the c-raf-1 antisense oligonucleotide ISIS 5132 (CGP 69846A)

PURPOSE

Raf-1 is a protein kinase that plays a broad role in oncogenic signaling and acts as a downstream effector of Ras in the mitogen-activated protein kinase pathway. The present study was designed to determine the maximum-tolerated dose (MTD), toxicity profile, pharmacokinetics, and antitumor activity of the c-raf-1 antisense oligodeoxynucleotide ISIS 5132 (CGP 69846A; ISIS Pharmaceuticals Inc, Carlsbad, CA). The effect of ISIS 5132 on c-raf-1 gene expression in peripheral-blood mononuclear cells (PBMCs) of treated patients was studied using a reverse transcriptase polymerase chain reaction assay.

PATIENTS AND METHODS

Patients with refractory malignancies received ISIS 5132 as a 2-hour intravenous infusion three times weekly for 3 consecutive weeks. Pharmacokinetic sampling was performed during the first cycle in all patients; PBMCs for c-raf-1 mRNA analysis were collected at baseline and on days 3, 5, 8, and 15 of cycle 1 and on day 1 of each cycle thereafter.

RESULTS

Thirty-one patients received ISIS 5132 at one of nine dose levels ranging from 0.5 mg/kg to 6.0 mg/kg. Clinical toxicities included fever and fatigue, but these were not dose limiting. A clinically defined MTD was not reached. The harmonic mean half-life of ISIS 5132 was 59.8 minutes (range, 35.5 to 107.3 minutes). The area under the concentration-time curve increased linearly with dose, and mean plasma clearance was 1.86 mL/kg/min (range, 1.21 to 2.41 mL/kg/min). Two patients experienced prolonged stable disease lasting more than 7 months, which was associated with persistent reduction in c-raf-1 expression in PBMCs. Significant decreases in c-raf-1 expression were identified at time points after the baseline value (P <.05) at doses >/= 2.5 mg/kg.

CONCLUSION

ISIS 5132 is well tolerated at doses up to 6.0 mg/kg when administered as a thrice weekly 2-hour infusion for 3 consecutive weeks. The pharmacokinetic behavior of the drug is reproducible, and suppression of target gene expression is observed in circulating PBMCs.

Conversation analysis of communication breakdown after closed head injury

This single case study investigated the use of Conversation Analysis (CA) in assessing pragmatic language difficulties after closed head injury (CHI). The aim was to see if CA captures the types of communication breakdown observed after CHI and whether results from CA can be directly related to scores on formal tests more typically applied after CHI. The results suggested that CA was a sensitive tool for identifying and investigating pragmatic deficits in this case. It facilitated an exploration of whether language impairments identified on formal tests manifest themselves in functional communication; it revealed how different interlocutors adapt to these language difficulties in conversation and also explained why some conversational partners were more successful than others. Considered together, formal test results and CA insights facilitated an in-depth analysis into the precise nature of the communicative impairments of the speaker in this exploratory study, suggesting that CA is a promising approach to the assessment of pragmatic impairments in the CHI population.

Phase II trial of all-trans retinoic acid in metastatic non-small cell lung cancer

The toxicity and marginal effectiveness of cytotoxic chemotherapy in metastatic non-small cell lung cancer (NSCLC) necessitates the search for new agents. Preliminary data in lung cancer and other malignant and premalignant disorders have identified retinoid compounds as potentially useful antitumor agents. Twenty-eight patients with metastatic NSCLC were treated with oral all-trans retinoic acid in a phase II trial. The study population consisted of patients with excellent performance status and minimal weight loss. Toxicities were generally mild and included cutaneous effects, headache, and myalgia. A significant number of patients developed elevations of hepatic transaminases or hyperlipidemia and 3 patients had treatment-related leukocytosis. Two patients (8%) achieved a partial response, and 1 had a mixed response. The duration of remission in the 2 responders was 7 and 13 months and the median survival of all patients 7 months. Therefore, all-trans retinoic acid has minimal activity as a single agent in NSCLC but warrants further study in combination with biological agents and chemotherapy.