Resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with high-risk melanoma

The Toll-like receptor (TLR) 7/8 agonist resiquimod has been used as an immune adjuvant in cancer vaccines. We evaluated the safety and immunogenicity of the cancer testis antigen NY-ESO-1 given in combination with Montanide (Seppic) with or without resiquimod in patients with high-risk melanoma. In part I of the study, patients received 100 μg of full-length NY-ESO-1 protein emulsified in 1.25 mL of Montanide (day 1) followed by topical application of 1,000 mg of 0.2% resiquimod gel on days 1 and 3 (cohort 1) versus days 1, 3, and 5 (cohort 2) of a 21-day cycle. In part II, patients were randomized to receive 100-μg NY-ESO-1 protein plus Montanide (day 1) followed by topical application of placebo gel [(arm A; n = 8) or 1,000 mg of 0.2% resiquimod gel (arm B; n = 12)] using the dosing regimen established in part I. The vaccine regimens were generally well tolerated. NY-ESO-1-specific humoral responses were induced or boosted in all patients, many of whom had high titer antibodies. In part II, 16 of 20 patients in both arms had NY-ESO-1-specific CD4⁺ T-cell responses. CD8⁺ T-cell responses were only seen in 3 of 12 patients in arm B. Patients with TLR7 SNP rs179008 had a greater likelihood of developing NY-ESO-1-specific CD8⁺ responses. In conclusion, NY-ESO-1 protein in combination with Montanide with or without topical resiquimod is safe and induces both antibody and CD4⁺ T-cell responses in the majority of patients; the small proportion of CD8⁺ T-cell responses suggests that the addition of topical resiquimod to Montanide is not sufficient to induce consistent NY-ESO-1-specific CD8⁺ T-cell responses.

Phase I/II study of resiquimod as an immunologic adjuvant for NY-ESO-1 protein vaccination in patients with melanoma

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Background: The TLR 7/8 agonist, Resiquimod has been shown to induce local activation of immune cells, production of cytokines, and antigen-presentation by dendritic cells, features desirable for cancer vaccine adjuvants. In this study, we evaluated the safety and immunogenicity of vaccination with NY-ESO-1 protein emulsified in Montanide ISA-51 VG when given with or without Resiquimod in patients with surgically resected stage IIB-IV melanoma patients. Methods: This is a two-part study design. Part I represents an open-label dose-escalation with Resiquimod using 2 cohorts treated with 100ug NY-ESO-1 protein emulsified in 1.25mL Montanide (day1) followed by topical application of 1000mg of the 0.2% Resiquimod gel on days 1 and 3 for cohort-1 (N=3) or days 1, 3, and 5 for cohort-2 (N=3). The cycles were repeated every 3 weeks, total of 4 cycles. Part II of the study is blinded. Patients were randomized to receive 100ug NY-ESO-1 protein emulsified in 1.25mL Montanide (day1) followed by topical application of placebo gel (Arm-A; N=8) or 1000mg of 0.2% Resiquimod gel (Arm-B; N=12) using the dosing regimen established in Part I. Blood samples were collected at baseline, one week after each cycle of vaccination, and at follow-up visit for the assessment of NY-ESO-1-specific humoral and cellular immune responses. Results: Enrollment has been completed. 25/26 patients received all 4 vaccinations. The treatment was generally well-tolerated, with no grade 4 adverse events or study-related deaths. The most common toxicities were mild to moderate and included local injection site reactions (granuloma, pruritus, induration) and systemic flu-like symptoms. One patient experienced a grade 3 syncopal episode that was deemed unrelated to the drug. Another patient experienced a grade 3 injection site necrosis that was possibly related to the study drug and was removed from the study prior to receiving the 4th vaccine. Conclusions: This study demonstrates the safety of Resiquimod as an adjuvant for NY-ESO-1 protein vaccination. The study will remain blinded until all immune monitoring assays have been completed. An updated abstract will be submitted once the study is unblinded.

The "two-week wait" referral pathway allows prompt treatment but does not improve outcome for patients with oesophago-gastric cancer

INTRODUCTION

The Two Week Wait Referral Service (2WW) has been implemented as a means of fast-tracking patients with suspected upper gastrointestinal cancers for endoscopy. Whether or not it impacts on the outcome of these patients is unclear. The aim of this study was to compare the outcome of patients referred through 2WW with that of patients with oesophago-gastric cancer identified through alternate referral pathways (routine, emergency).

METHODS

The study population was 340 patients with oesophago-gastric carcinoma (gastric 154) diagnosed during the time period 01/2006-12/2007 at University Hospitals of Leicester NHS Trust. Data were collected prospectively by the MDT co-ordinator and analysed retrospectively.

RESULTS

135 of the 340 patients with oesophago-gastric cancer were diagnosed through the 2WW, 115 patients through routine referral pathways, and 90 patients were admitted on an emergency basis. Patients referred through 2WW had a median referral to 1st treatment time of 47 days (routine 79, emergency 28, p < 0.001 all group comparisons). The number of patients treated with potentially curative intent was 37 of 135 for the 2WW, 42 of 115 for the routine referrals and 10 of 90 for patients admitted as emergencies. The corresponding median survivals for the groups were 239 days (2WW), 405 days (routine) and 121 days (emergency), p < 0.001 (log rank).

CONCLUSIONS

Referral by 2WW resulted in more rapid treatment than routine referral but this did not translate into an improvement in survival. This suggests that the targeting of endoscopy to patients with alarm symptoms is flawed and a less selective approach should be promoted if curable cancers are to be detected.

A framework for integrating interprofessional education curriculum in the health sciences

CONTEXT

Traditionally, the structures of health professional education in Canada and elsewhere have been largely based on "silos" in which health professionals are educated in relative isolation to one another. The curriculum content and structure has followed strict disciplinary lines. Recent commissions, committees and policy documents in Canada have identified the importance of reshaping educational preparation and the professional training of health care professionals (Commission on the Future of Health Care in Canada, 2002; Health Council of Canada, 2005).

OBJECTIVES

This brief communication describes an interprofessional curricular approach that combines characteristics of Barr et al.'s (2005) extracurricular and crossbar models of interprofessional education curriculum.

METHODS

An interprofessional education curriculum that combines principles of an integrative, continuous, early-to-late and blended learning approach.

DISCUSSION

The curricular approach supports exposing students to interprofessional education at an early stage in their training and then to continue with regular reinforcement. Another guiding principle is that interprofessional education is integrative rather than supplementary to the existing core curriculum. Early evaluation results suggest favourable satisfaction amongst students and faculty as well as significant effect on attitudes toward interprofessional teamwork and education. An ongoing evaluation is continuing based upon the various levels of Freeth et al.'s (2002) interprofessional education evaluation framework.

Gaseous ozone treatment inactivates Listeria innocua in vitro

AIMS

To investigate the effects of ozone on inactivation of Listeria innocua on solid media.

METHODS AND RESULTS

Suspensions of L. innocua ranging from 4.5 x 10(4 )- 6.4 x 10(4) CFU ml(-1) were inoculated onto potato dextrose agar (PDA, pH 5.6 and 6.8) and nutrient agar (NA, pH 6.0 and 6.8), then exposed to gaseous ozone. Variable factors included postinoculation standing time at 20 degrees C before exposure to ozone, ozone concentration, treatment duration and treatment temperature (5 or 20 degrees C). The interaction among ozone concentration, treatment duration, media and temperature in effecting changes in colony-forming units (CFU) was significant. The 100 nl l(-1) ozone treatment for 2 h reduced the microbial populations by 2-3 log CFU ml(-1). Cell viability decreased more rapidly on PDA than on NA. The average time to obtain a 2 log CFU ml(-1) reduction was 1.3 h at 20 degrees C and 2.5 h at 5 degrees C (P < 0.001).

CONCLUSIONS

Gaseous ozone effectively inactivates L. innocua at concentrations of 50 and 100 nl l(-1) during short exposure times at both 5 and 20 degrees C. The Gompretz model can be utilized for determining the response of L. innocua to ozone over time.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study provides useful information on ozone inactivating Listeria spp., which may be imposed on ensuring quality and safety of horticultural produce and food products.

A biomechanical analysis of an instrumented spinal fixator under torsional loads

The effect of design features of an internal spinal fixator on the loading of its individual components is paramount to the understanding of the interaction between the fixator and the instrumented spine. Using a corpectomy injury model, a strain gauge instrumented spinal fixation device was employed to investigate the role of clamp tightening torque and the inclusion of transverse bars on the distribution of bending and torsional moments acting on the fixator under torsional loading. The increase in clamp torque from 5 to 10 Nm caused a marked decrease (40%) in torsional moments acting on the vertical rods, an increase of 24% in torsional moments acting on the screws and an increase of 44% in bending moments acting on the rods along the sagittal plane of the fixator. The inclusion of transverse elements significantly increased (132%) the bending moment acting on the rods and decreased (92%) the bending moments acting on the screws along the sagittal plane. The change in both design parameters significantly reduced the response hysteresis and decreased the asymmetry of loading. A theoretical model, developed to elucidate the load path mechanisms underlying this response, successfully predicted the external response of the fixator. This model suggested both design parameters would affect the internal force and moment distribution across the fixator and the relative role of each load response mechanism in effecting this response. The changes in load patterns across the fixator will influence both its ability to augment the process of spinal fusion and the long-term performance of its components.

Tentorium cerebelli subdural haematoma complicating subarachnoid haemorrhage

Acute subdural haematoma (SDH) as a result of aneurysmal rupture is a rare event. We report a tentorium cerebelli SDH, secondary to a ruptured aneurysm which we believe is unique in the literature. This report also gives further support to the theory that a sentinel bleed causes inflammation and adhesion between the aneurysm and arachnoid as the underlying pathology in these unusual subdural haematomas. Since the first report of acute SDH from a ruptured aneurysm by Hasse in 1855, only about 150 further cases have been reported in the literature. We describe a further case, but at an as yet unreported site with radiological evidence of a sentinel bleed.

Reasoning about apparent contradictions: resolution strategies and positive-negative asymmetries

Apparent contradictions, e.g. Did Susan like her supper?--Yes and no, involve asserting and denying the same proposition. They therefore violate the classical law of non-contradiction, suggesting the use of non-classical interpretive structures in natural language and reasoning. Experiment 1 explores the range of such interpretive structures available to adults (n = 24) in their reasoning about an apparent contradiction. Experiment 2 uses a similar task to study the emergence of these interpretive structures in young children's reasoning (3;6 to 8;4, n = 48). Results suggest an early facility with resolution strategies relating to object structure (as in, Maybe Susan liked one part of supper but didn't like another part) and an initial tendency to focus on the negative by referring to it first (as in, Maybe Susan didn't like one part of supper but did like another part). We discuss the results in terms of the natural logic of objects and their properties, and the logical resources available to young children.

The effects of design and configuration on the biomechanical response of an internal spinal fixator

This study examines the biomechanical performance of an internal spinal fixator and the effects of specific design features under a range of loading modes. The commercial device was mounted on plastic vertebrae in a corpectomy injury model and attached by a series of experimental jigs to an appropriate material testing machine and tested under axial compression, torsion and flexion and extension moments. Results from the torsional tests indicated that increasing the clamp tightening torque from 5 to 15 N m significantly increased the rigidity of the fixation system. The inclusion of the transverse elements resulted in a significant increase in the torsional stiffness, with the increase largely overriding the effect of clamp tightening torque. By contrast, under compressive and both flexion and extension loads, neither of the design features of the fixator had a marked effect on the overall measured stiffness of the system. However, under extension loads, there were specific interactions between the two design parameters. The present study clearly indicates the need for the optimization of the design of the clamps and for alternative configurations of the transverse elements to enhance their performance under sagittal loads.

Neuropsychological aspects of multiple sclerosis: a quantitative review

Neuropsychological studies of multiple sclerosis (MS) from a 20-year period were reviewed using meta-analytic and vote-count techniques. Mean effect sizes comparing MS and healthy control groups on variables categorized by neuropsychological domain were small to moderate in magnitude; all were statistically significant (M(r) = .22 (.13) to .46 (.15), rW = .23 to .43, all p < .05). Interhemispheric transfer, general cognitive ability, and learning/memory were more highly related to MS than were visuoperceptual, visuospatial, and visuoconstructional ability, language and conceptual ability (all p < .05); other domains were generally intermediate. Despite previous reports to the contrary, disease subtype was not shown to be consistently related to neuropsychological status independently of other potential explanatory variables. Findings were interpreted with regard to future research and clinical activities involving patients with MS, including selection of tests for brief neuropsychological screening examinations.

Of apples and oranges, file drawers and garbage: why validity issues in meta-analysis will not go away

This paper examines how threats to the validity of meta-analysis have been dealt with by clinical researchers employing this approach to literature review. Three validity threats were identified--mixing of dissimilar studies, publication bias, and inclusion of poor quality studies. Approaches to addressing these threats were evaluated for their effectiveness and popularity by surveying 32 published meta-analyses in clinical psychology. Distrust of meta-analysis, however, was found to transcend these validity threats. Other explanations for why this popular research strategy continues to receive widespread criticism were considered. Suggestions were made for how meta-analysis might better address these concerns.

Microemulsions with Didodecyldimethylammonium Bromide Studied by Neutron Contrast Variation

The structure of water-in-oil microemulsion droplets, stabilized by didodecyldimethylammonium bromide (DDAB), has been investigated by small-angle neutron scattering (SANS). Detailed information about the curved surfactant film has been obtained by selectively deuterating the water, DDAB, and cyclohexane components. For each surfactant h -DDAB and d -DDAB and concentration, three sets of complementary neutron contrast data were analyzed together in terms of a Schultz distribution of core-shell particles. The modeling was consistent with a simple liquid-like surfactant layer, of density 0.80 g cm-3 , with no evidence for any solvent penetration. This film thickness was found to be 11-12 A, about 70% of an all-trans C12 chain length. At the water interface the area per head was 56-61 A2 , while for the alkyl chains at the outer surface it was 90-125 A2 (15-30% lower than that for a truncated cone molecular configuration). The cyclohexane-water interfacial tensions gammao/w , measured by surface light scattering, were used along with the droplet polydispersities to find that the rigidity of the DDAB film, 2K + K ; is close to 1.0k B T . This means that rather than acting as an effective parameter in the SANS analysis, the polydispersity is a natural consequence of the film rigidity. These results show that the film bending energy model accounts well for the behavior of such DDAB microemulsions.

A new surgical technique to treat refractory labial fusion in the elderly

An elderly woman with refractory labial fusion was treated by labial separation. The subsequent raw area was covered by a rotational skin flap from the thigh. The flap was deroofed of epithelium proximally and tunnelled subcutaneously. The distal portion emerged to cover the raw clitoral area and this successfully prevented contraction and scarring.

Eosinophilic gastroenteritis

Eosinophilic gastroenteritis is a rare condition, characterized by diffuse infiltration of the gastrointestinal tract by eosinophils. This involves mainly the stomach, duodenum and small bowel and rarely the esophagus, colon, pancreas, gallbladder, prostate and urinary bladder. Most reported cases have occurred in adults in the third decade of life. The authors report on a 15-day-old infant who initially presented with rectal bleeding and a scan that indicated a Meckel's diverticulum was present. At laparotomy, however, a Meckel's diverticulum was not found. The appendix was slightly distended and there was a mild inflammatory reaction. Appendectomy was performed. Microscopically the appendix showed diffuse eosinophilic infiltration. The blood eosinophil count was elevated. The patient recovered well, but had several minor episodes of rectal bleeding following ingestion of milk. He remained asymptomatic on a milk-free diet. The etiology of eosinophilic gastroenteritis is unknown and there is no specific treatment. In uncomplicated cases, diet, corticosteroids and adrenocorticotropic hormone are used. Operation is reserved for cases of obstruction and hemorrhage.

Urinary retention and intervertebral disc protrusion

The case histories of 17 patients in whom urinary retention was associated with an intervertebral disc protrusion which occurred, most commonly, centrally at the lumbar 4/5 level are presented. Strong pleas are made for consideration of this entity in patients with unexplained urinary retention.

Amine metabolites in the cerbrospinal fluid in Huntington's chorea

The amine metabolites HVA and 5-HIAA in the lumbar CSF of 15 patients with Huntington's chorea were determined. A negative correlation was found between the severity of symptoms and the CSF HVA, but not 5-HIAA levels. The mean HVA concentration was lower than that of a group of patients with miscellaneous neurological disorders, similar to that of a group with miscellaneous psychiatric disorders and higher than that of a group with Parkinson's disease. The mean 5-HIAA concentration was similar to that of the neurological group and higher than those of the groups with psychiatric disorders or Parkinson's disease. CSF HVA and 5-HIAA concentrations of a single patient with severe akinetic rigid Huntington's chorea were similar to those found in Parkinson's disease. The findings are discussed in relation to previous neuropathological observations and to reported effects of drugs on the choreic symptoms.