Delayed 68Ga-FAPI-46 PET/MR imaging confirms ongoing fibroblast activation in patients after acute myocardial infarction

Purpose of the Report

Combined cardiac 68Ga-Fibroblast-Activation Protein-alpha inhibitor (FAPI) positron-emission tomography (PET) and cardiac magnetic resonance imaging (MRI) constitute a novel diagnostic tool in patients for the assessment of myocardial damage after an acute myocardial infarction (AMI). Purpose of this pilot study was to evaluate simultaneous Ga-68-FAPI-46-PET/MR imaging in the delayed phase after AMI.

Material and Methods

Eleven patients underwent hybrid 68Ga-FAPI-46 PET/MRI post AMI. Standardized uptake values and fibroblast activation volume (FAV) were calculated and correlated with serum biomarkers and MRI parameters.

Results

Significant 68Ga-FAPI-46 uptake could be demonstrated in 11 (100 %) patients after a mean period of 30.9 ± 22.0 days. FAV significantly exceeded the infarction size in MRI and showed a good correlation to MRI parameters as well as to serum biomarkers of myocardial damage.

Conclusions

68Ga-FAPI-46 PET/MRI offers molecular and morphological imaging of affected myocardium after AMI. This study demonstrates ongoing fibroblast activation in a delayed phase after AMI and generates hypotheses for future studies while aiming for a better understanding of myocardial remodeling following ischemic tissue damage.

Delphi consensus project on prostate-specific membrane antigen (PSMA)-targeted surgery-outcomes from an international multidisciplinary panel

PURPOSE

Prostate-specific membrane antigen (PSMA) is increasingly considered as a molecular target to achieve precision surgery for prostate cancer. A Delphi consensus was conducted to explore expert views in this emerging field and to identify knowledge and evidence gaps as well as unmet research needs that may help change practice and improve oncological outcomes for patients.

METHODS

One hundred and five statements (scored by a 9-point Likert scale) were distributed through SurveyMonkey®. Following evaluation, a consecutive second round was performed to evaluate consensus (16 statements; 89% response rate). Consensus was defined using the disagreement index, assessed by the research and development project/University of California, Los Angeles appropriateness method.

RESULTS

Eighty-six panel participants (72.1% clinician, 8.1% industry, 15.1% scientists, and 4.7% other) participated, most with a urological background (57.0%), followed by nuclear medicine (22.1%). Consensus was obtained on the following: (1) The diagnostic PSMA-ligand PET/CT should ideally be taken < 1 month before surgery, 1-3 months is acceptable; (2) a 16-20-h interval between injection of the tracer and surgery seems to be preferred; (3) PSMA targeting is most valuable for identification of nodal metastases; (4) gamma, fluorescence, and hybrid imaging are the preferred guidance technologies; and (5) randomized controlled clinical trials are required to define oncological value. Regarding surgical margin assessment, the view on the value of PSMA-targeted surgery was neutral or inconclusive. A high rate of "cannot answer" responses indicates further study is necessary to address knowledge gaps (e.g., Cerenkov or beta-emissions).

CONCLUSIONS

This Delphi consensus provides guidance for clinicians and researchers that implement or develop PSMA-targeted surgery technologies. Ultimately, however, the consensus should be backed by randomized clinical trial data before it may be implemented within the guidelines.

Visualization of fibroblast activation using 68Ga-FAPI PET/CT after pulmonary vein isolation with pulsed field compared with cryoballoon ablation

BACKGROUND

Pulsed-field ablation (PFA) is a novel ablation modality for atrial fibrillation (AF) ablating myocardium by electroporation without tissue-heating. With its different mechanism of tissue ablation, it is assumed that lesion creation is divergent to thermal energy sources. 68Ga-fibroblast-activation protein inhibitor (FAPI) PET/CT targets FAP-alpha expressed by activated fibroblasts. We aimed to assess 68Ga-FAPI uptake in pulmonary veins as surrogate for ablation damage after PFA and cryoballoon ablation (CBA).

METHODS

26 patients (15 PFA, 11 CBA) underwent 68Ga-FAPI-PET/CT after ablation. Standardized uptake values (SUV) and fibroblast-activation volumes of localized tracer uptake were assessed.

RESULTS

Patient characteristics were comparable between groups. In PFA, focal FAPI uptake was only observed in 3/15 (20%) patients, whereas in the CBA cohort, 10/11 (90.9%) patients showed atrial visual uptake. We observed lower values of SUVmax (2.85 ± 0.56 vs 4.71 ± 2.06, P = 0.025) and FAV (1.13 ± 0.84 cm3 vs 3.91 ± 2.74 cm3, P = 0.014) along with a trend towards lower SUVpeak and SUVmean in PFA vs CBA patients, respectively.

CONCLUSION

Tissue response with respect to fibroblast activation seems to be less pronounced in PFA compared to established thermal ablation systems. This functional assessment might contribute to a better understanding of lesion formation in thermal and PFA ablation potentially contributing to better safety outcomes.

Joint EANM/SNMMI procedure guideline for the use of 177Lu-labeled PSMA-targeted radioligand-therapy (177Lu-PSMA-RLT)

Prostate-specific membrane antigen (PSMA) is expressed by the majority of clinically significant prostate adenocarcinomas, and patients with target-positive disease can easily be identified by PSMA PET imaging. Promising results with PSMA-targeted radiopharmaceutical therapy have already been obtained in early-phase studies using various combinations of targeting molecules and radiolabels. Definitive evidence of the safety and efficacy of [177Lu]Lu-PSMA-617 in combination with standard-of-care has been demonstrated in patients with metastatic castration-resistant prostate cancer, whose disease had progressed after or during at least one taxane regimen and at least one novel androgen-axis drug. Preliminary data suggest that 177Lu-PSMA-radioligand therapy (RLT) also has high potential in additional clinical situations. Hence, the radiopharmaceuticals [177Lu]Lu-PSMA-617 and [177Lu]Lu-PSMA-I&T are currently being evaluated in ongoing phase 3 trials. The purpose of this guideline is to assist nuclear medicine personnel, to select patients with highest potential to benefit from 177Lu-PSMA-RLT, to perform the procedure in accordance with current best practice, and to prepare for possible side effects and their clinical management. We also provide expert advice, to identify those clinical situations which may justify the off-label use of [177Lu]Lu-PSMA-617 or other emerging ligands on an individual patient basis.

[New treatment approaches for and ongoing trials in metastatic hormone-sensitive prostate cancer]

BACKGROUND

For many years, therapy for metastatic hormone-sensitive prostate cancer (mHSPC) was dominated by monotherapy using androgen deprivation therapy (ADT). With the demonstration of survival benefit with intensified systemic therapy from the CHAARTED and STAMPEDE trials, this has fundamentally changed. We analyzed the phase III trials that led to the change in therapy in mHSPC. In addition, we summarized ongoing trials in mHSPC.

OBJECTIVES

The ongoing studies and current data on systemic therapy in mHSPC were analyzed.

RESULTS

Monotherapy with ADT is no longer considered the standard therapy for mHSPC. Combination therapy with ADT and novel androgen receptor targeting agents (ARTAs: abiraterone, apalutamide, enzalutamide) is now the established standard option. The added value of further intensification of therapy was demonstrated in the first trials of triple therapy with ADT + docetaxel + darolutamide or abiraterone in mHSPC. Current studies are also investigating new forms of therapy. Lutetium177-PSMA radioligand therapy is an established standard in metastatic castration-resistant prostate cancer (mCRPC) and is currently being evaluated in combination with ADT + ARTA in mHSPC. The use of PARP inhibitors (PARPi) have been established in mCRPC. Current studies are showing early evidence of benefit from novel combination therapies of PARPi + ARTA, which represent a further expansion of the therapeutic landscape. Experimental therapies are testing another combination, such as an AKT inhibitor with ARTA in patients with PTEN (phosphatase and tensin homolog) loss. Based on the proof of principle in mCRPC, this combination is now being evaluated in earlier stage mHSPC. Other experimental therapies in clinical testing include inhibitors of cyclin dependent kinases (CDK).

CONCLUSIONS

Combination therapies are the current standard of care for mHSPC, with the combination of ADT + ARTA dominating. Preliminary results underline the importance of further intensification of therapy by means of triple therapy. However, novel combinations with radioligand therapy or PARP inhibitors are also promising in the treatment of mHSPC. Preliminary results show the principle efficacy of AKT inhibitors in patients with PTEN loss, which similar to therapy with CDK4/6 inhibitors still have to prove their clinical relevance in randomized trials.

Preoperative PET-SUVmax and volume based PET parameters of the primary tumor fail to predict nodal upstaging in early-stage lung cancer

OBJECTIVES

Accurate nodal staging is of utmost importance in patients with lung cancer. FDG-PET/CT imaging is now part of the routine staging. Despite thorough preoperative staging nodal upstaging still occurs in early-stage lung cancer. However, the predictive value of preoperative PET metrics of the primary tumor on nodal upstaging remains to be unexplored. Our aim was to assess the association of these preoperative PET-parameters with nodal upstaging in histologically confirmed lung adenocarcinoma and squamous cell carcinoma.

METHODS

From January 2016 to November 2018, 500 patients with pT1-T2/cN0 lung cancer received an anatomical resection with curative intent. 171 patients with adenocarcinoma and squamous cell carcinoma and available PET-CTs were retrospectively included. We analyzed the the association of nodal upstaging with preoperative PET-SUVmax and metabolic PET metrics including total lesion glycolysis (TLG) and metabolic tumor volume (MTV) with different defined thresholds.

RESULTS

High values of preoperative PET-SUVmax of the primary tumor were associated with squamous cell carcinoma (p < 0.0001) and with larger tumors (p < 0.0001). Increased preoperative C-reactive protein levels (<1mg/dL) correlated significantly with high preoperative PET-SUVmax values (p < 0.0001). No significant relationship between PET-SUVmax and lactate dehydrogenase activity (p = 0.6818), white blood cell count (p = 0.7681), gender (p = 0.1115) or age (p = 0.9284) was observed. Nodal upstaging rate was 14.0 % with 8.8 % N1 and 5.3 % N2 upstaging. Tumor size (p = 0.0468) and number of removed lymph nodes (p = 0.0461) were significant predictors of nodal upstaging but no significant association was found with histology or PET parameters. Of note, increased MTV - regardless of the threshold - tended to associate with nodal upstaging.

CONCLUSION

Early-stage lung cancer patients with squamous histology and T2 tumors presented increased preoperative PET-SUVmax values. Nevertheless, beyond tumor size and number of removed lymph nodes neither SUVmax nor metabolic PET parameters MTV and TLG were significant predictors of nodal upstaging.

Maize resistance to witchweed through changes in strigolactone biosynthesis

Maize (Zea mays) is a major staple crop in Africa, where its yield and the livelihood of millions are compromised by the parasitic witchweed Striga. Germination of Striga is induced by strigolactones exuded from maize roots into the rhizosphere. In a maize germplasm collection, we identified two strigolactones, zealactol and zealactonoic acid, which stimulate less Striga germination than the major maize strigolactone, zealactone. We then showed that a single cytochrome P450, ZmCYP706C37, catalyzes a series of oxidative steps in the maize-strigolactone biosynthetic pathway. Reduction in activity of this enzyme and two others involved in the pathway, ZmMAX1b and ZmCLAMT1, can change strigolactone composition and reduce Striga germination and infection. These results offer prospects for breeding Striga-resistant maize.

CTNI-43. COMBINATION OF TROFOSFAMIDE PLUS ETOPOSIDE IN RECURRENT ADULT-TYPE DIFFUSE GLIOMAS

Disease relapse almost inevitably occurs in patients with adult-type diffuse glioma. Standard of care treatment options at tumor relapse are still not well defined. Few studies indicate that the combination of trofosfamide plus etoposide (T/E) may be feasible in pediatric glioblastoma patients. We collected clinicopathological data from adult patients with adult-type diffuse glioma treated with the combination of Trofosfamide (100mg/m2/day) and Etoposide (25mg/m2/day) for a minimum of four weeks at the Division of Clinical Neurooncology at the University Hospital Essen. T/E was administered orally in a “one week on, one week off” scheme. A cohort of patients receiving empiric treatment at the investigators’ discretion balanced for tumor entity and canonical prognostic factors served as control. We collected toxicity data as it pertained to CTCAE (Common Terminology Criteria for Adverse Events, version 5.0) and survival data to explore putative efficacy.A total of 33 patients were eligible for this analysis. In the IDH wild-type glioblastoma (n = 18) subgroup, median progression-free survival (3.8 months versus 2.9 months, HR: 2.09, 95% CI: 1.010-4.312, p = 0.0227; PFS-6: 39% versus 6%) and median overall survival (10.4 months versus 5.7 months, HR: 3.05, 95% CI: 1.393-6.655, p = 0.0008) were significantly prolonged as compared to the control cohort. In a multivariable Cox regression analysis, treatment with T/E emerged as statistically significant prognostic marker regarding progression-free survival and overall survival. We observed high-grade adverse events (CTCAE grade III or higher) in 21 (64%) of all recurrent glioma patients with hematotoxicity comprising most adverse events (n = 18, 86%; Lymphopenia: n=13, 62%). This study provides first indication that the combination of T/E is safe in patients with adult-type diffuse gliomas and may be associated with prolonged survival in adult patients with recurrent IDH wildtype glioblastoma. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective controlled trial.

P17.04.B Combination of Trofosfamide and Etoposide in Recurrent Glioma

Background

Disease relapse almost inevitably occurs in patients with adult-type diffuse glioma. Standard of care treatment options at tumor relapse are still not well defined. Frequently used drugs for adult-type diffuse glioma recurrence include lomustine (CCNU) and bevacizumab. Few studies indicate that the combination of trofosfamide/etoposide, given their high lipid solubility with good blood-brain barrier penetrance, may be feasible in pediatric glioblastoma patients. In this retrospective analysis, we determined tolerability and feasibility of combined trofosfamide/etoposide treatment at disease recurrence of patients with adult-type diffuse glioma.

Material and Methods

We collected clinicopathological data from adult patients with adult-type diffuse glioma treated with the combination of trofosfamide/etoposide at the Division of Clinical Neurooncology at the University Hospital Essen. Only those patients were considered eligible who received trofosfamide/etoposide treatment for more than four weeks (one course). Trofosfamide (100mg/m2/day) and Etoposide (25mg/m2/day) was administered orally in a “one week on, one week off” scheme. A cohort of patients receiving empiric treatment at the investigators’ discretion balanced for tumor entity and canonical prognostic factors (number of previous treatments, MGMT promoter methylation, IDH mutation status, KPS, age, extent of resection) served as control. We collected toxicity data as it pertained to CTCAE (Common Terminology Criteria for Adverse Events, version 5.0) and survival data to explore putative efficacy.

Results

A total of 33 patients were eligible for this analysis. In the IDH wild-type glioblastoma (n=18) subgroup, median progression-free survival (3.8 months versus 2.9 months, HR: 2.09, 95% CI: 1.010-4.312, p=0.0227; PFS-6: 39% versus 6%) and median overall survival (10.4 months versus 5.7 months, HR: 3.05, 95% CI: 1.393-6.655, p=0.0008) were significantly prolonged as compared to the control cohort. In a multivariable Cox regression analysis, treatment with trofosfamide/etoposide emerged as statistically significant prognostic marker regarding progression-free survival and overall survival. We observed high-grade adverse events (CTCAE grade≥III ) in 21 (64%) of all recurrent glioma patients with hematotoxicity comprising most adverse events (n=18, 86%). Lymphopenia was by far the most observed hematotoxic adverse event (n=13, 62%). Among non-hematologic high-grade adverse events was transaminase elevation (n=3, 14%).

Conclusion

This study provides first indication that the combination of trofosfamide/etoposide is safe in patients with adult-type diffuse gliomas and may be associated with prolonged survival in adult patients with recurrent IDH wildtype glioblastoma. Our data provide a reasonable rationale for follow-up of a larger cohort in a prospective controlled trial.

Safety of PSMA-targeted molecular radioligand therapy with 177Lu-PSMA-617: results from the prospective multicenter phase 2 trial RESIST-PC NCT03042312

Purpose of the study: To report the safety evaluation of ¹⁷⁷Lu-PSMA-617 derived from the cohort of 64 patients exposed to ¹⁷⁷Lu-PSMA-617 in the RESIST-PC trial NCT03042312 Methods: RESIST-PC was a prospective multicenter phase 2 trial. Patients with progressive mCRPC after ≥1 novel androgen-axis drug, either chemotherapy naïve or post-chemotherapy, with sufficient bone marrow reserve, normal kidney function, sufficient PSMA expression by PSMA PET and no visceral PSMA-negative lesions were eligible. Patients were randomized (1:1) into two activity groups (6.0 or 7.4 GBq per cycle) and received up to 4 cycles every 8 weeks. The primary safety endpoint was assessed by collecting and grading Adverse Events (AE) using the CTCAE. Patients were followed until disease progression, death, serious or intolerable AE, study termination by sponsor, patient withdrawal, lost to follow-up or 24 months after the first cycle. Results: The study was closed at enrollment of 71/200 planned patients because of sponsorship transfer. A total of 64 (90.1%) patients received at least one cycle of ¹⁷⁷Lu-PSMA-617: 28 (36%) in Arm 1 (6.0 GBq) and 41 (64%) in Arm 2 (7.4GBq). There were 10 (43.5%), 19 (46.5%) and 29 (45.3%) patients who completed 4 cycles of ¹⁷⁷Lu-PSMA-617 in the 6.0 GBq arm, 7.4 GBq arm, and overall, respectively. The most common treatment-emergent adverse events (TEAEs) of any grade in the 6.0 GBq arm, the 7.4 GBq arm and overall, were dry mouth (47.8%; 63.4%; 57.8%, respectively), fatigue (56.5%; 51.2%; 53.1%), nausea (52.2%; 43.9%; 46.9%), and diarrhea (13.0%; 31.7%; 25.0%). Frequencies of all other TEAEs were comparable among the 2 groups (within 10% difference). Serious possibly drug-related TEAEs were reported for 5 (7.8%) patients overall (none were considered as probably or definitely related to treatment): one subdural hematoma Grade 4, one anemia grade 3, one thrombocytopenia grade 4, one gastrointestinal hemorrhage grade 3, and one acute kidney injury grade 3. There were no clinically significant changes in vital signs in ECGs in the 2 treatment groups. No trend to creatinine increase, or increasing frequency of shifts from normal to abnormal over time for any hematologic parameter was noted. Conclusion: ¹⁷⁷Lu-PSMA-617 was safe and well-tolerated at 6.0 and 7.4 GBq per cycle given at 8-week intervals with side effects easily managed with standard medical support. With established safety, further clinical trials applying individualized dosimetry and testing different ¹⁷⁷Lu-PSMA-617 administration schemes (activity levels, time intervals) are needed to optimize tumor dose delivery and treatment efficacy.

SAT0365 EFFECTS OF ANTI-TNF-THERAPY ON OSTEOBLASTIC ACTIVITY IN ANKYLOSING SPONDYLITIS – RESULTS FROM A PROSPECTIVE STUDY USING PET-MRI OF SIJ AND SPINE

Background:

The clinical efficacy of tumor necrosis factor inhibitors (TNFi) in patients with axial spondyloarthritis (axSpA) is well established but its effect on new bone formation is still unclear (1). Positron emission tomography (PET) using bone-seeking18F-Fluoride [18F]F in combination with magnetic resonance imaging ([18F]F /MRI) has been shown to depict not only bone marrow edema (BME) but also shows the quantity of tracer uptake in the late phase of perfusion suggestive of remodeling and osteoblastic activity, not only in radiographic axSpA (r-axSpA) (2).

Objectives:

Assess the effect of TNFi on bone remodeling processes in the axial skeleton of r-axSpA patients using [18F]F/MRI prior (baseline, BL) and 4 months after (follow-up, FU) treatment.

Methods:

Patients (11 male, 5 female, mean age 38.6±12.0 years) with clinically active r-axSpA (BASDAI>4, failure of NSAIDs, no previous biologics) prospectively underwent 3-Tesla and [18F]F PET/MRI (40 minutes after injection of a mean activity of 157 MBq [18F]F). Images of the SIJ (n=16 patients) and the whole spine (n=10 patients) were performed at BL and FU. Three readers (1 for [18F]F/MRI and 2 for conventional MRI) evaluated all images independently and blinded to timepoint allocation. Only lesions on which all readers agreed on were used for further analyses. Inflammation (bone marrow edema, BME), structural lesions (fat deposition (FD), sclerosis, erosions and ankylosis) and focal [18F]F uptake were recorded on the level of SIJ (SIJ-Q) and vertebral quadrants (V-Q), with each SIJ or vertebral body consisting of 4 VQs (superior and inferior sacral and iliac for the SIJ, and superior and inferior, anterior and posterior for the vertebral bodies).

Results:

A total of 128 SIJ-Q and 920 VQs were analyzed at both BL and FU. In the SIJs, 75 (58.6%), 120 (93.8%), 69 (53.9%), 99 (77.3%) and 16 (12.5%) SIJ-Q showed BME, FD, sclerosis, erosions and ankylosis, while 111 (86.7%) SIJ-Q showed focal [18F]F-uptake at BL. Association with increased [18F]F-uptake was found most frequently in SIJ-Q with BME (70/75 SIJ-Q, 93.3%), sclerosis (65/69 SIJ-Q, 94.2%) and FD (105/120 SIJ-Q, 87.5%). At FU, 37 SIJ-Q still showed BME (improvement by 50.7%), while almost no changes were observed in chronic lesions. In comparison, improvement of focal [18F]F-uptake was found in all lesion combinations, with improvement of focal [18F]F-lesions associated with BME by 62.9%, with sclerosis by 33.8% and with FD by 22.9% of SIJ-Q.

In the spine, only 41 (4.5%), 61 (6.6%), 14 (1.5%) V-Q showed BME, FD and sclerosis, respectively, while 77 V-Q (8.4%) showed focal [18F]F-uptake. An association to increased [18F]F-uptake was found most frequently with sclerosis (7/14 V-Q, 50%) and FD (25/61 V-Q, 41%). At FU, 12 V-Q still showed BME (improvement by 70.7%), while, similar to SIJ, almost no changes were observed in the chronic lesions. The largest improvement was found in focal [18F]F-lesions associated with BME 81.8% and with FD by 22.9% of V-Q.

Conclusion:

In this first prospective study on whole spine and SIJ [18F]F/MRI in patients with r-axSpA, a significant decrease of osteoblastic activity was observed over 4 months of continuous anti-TNF treatment. The effect of treatment was observed not only at sites with inflammatory lesions (BME) but also at sites with pre-existing chronic structural lesions, while some osteoblastic activity remained visible at 4 months. These data support a short-term effect of anti-TNF treatment on osteoblastic activity, while the long-term effects need to be further studied.

References:

[1]Van der Heijde D et al, Ann Rheum Dis 2017

[2]Buchbender C et al, J Rheumatol 2015

This work was supported by an unrestricted Grant by MSD GmbH, Germany

Disclosure of Interests:

Xenofon Baraliakos Grant/research support from: Grant/research support from: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Consultant of: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Speakers bureau: AbbVie, BMS, Celgene, Chugai, Merck, Novartis, Pfizer, UCB and Werfen, Styliani Tsiami: None declared, Christoph Rischpler: None declared, Nils-Martin Bruckmann: None declared, Wolfgang Fendler: None declared, Julian Kirchner: None declared, Ken Hermann: None declared, Lino Sawicki: None declared, Juergen Braun Grant/research support from: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, Eli Lilly and Company, Medac, MSD (Schering Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi- Aventis, and UCB Pharma, Consultant of: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma, Speakers bureau: Abbvie (Abbott), Amgen, BMS, Boehringer, Celgene, Celltrion, Centocor, Chugai, EBEWE Pharma, Eli Lilly and Company, Medac, MSD (Schering-Plough), Mundipharma, Novartis, Pfizer (Wyeth), Roche, Sanofi-Aventis, and UCB Pharma

SAT0389 FREQUENCY OF DISEASE FLARES UNDER LONG-TERM ANTI-TNF THERAPY IN PATIENTS WITH EARLY AXIAL SPONDYLOARTHRITIS: RESULTS FROM THE ETANERCEPT VERSUS SULFASALAZINE IN EARLY AXIAL SPONDYLOARTHRITIS TRIAL

Background:

Disease flares in axial spondyloarthritis (axSpA) might occur even in patients with otherwise stable disease receiving highly effective anti-inflammatory therapy such as TNF inhibitors. The frequency of disease flares, especially in patients with axSpA receiving long-term stable therapy, and factors associated with flares are not sufficiently investigated.

Objectives:

The objective was to assess the frequency of disease flares and to identify factors associated with flares in patients with early axSpA receiving continuous long-tem (up to 10 years) treatment with a TNF inhibitor etanercept.

Methods:

In the ESTHER (etanercept versus sulfasalazine in early axial spondyloarthritis trial), patients with early axSpA (symptom duration ≤5 years) were treated with ETN (n=40) versus sulfasalazine (n=36) for 48 weeks [2]. After one year all patients were treated continuously with etanercept (n=17 patients temporarily interrupted treatment in the 2nd year to assess time to flare and were then (re-)treated with etanercept, except 4 patients who completed the study in sustained remission) for up to 10 years in total. Only patients who were continuously treated with etanercept for at least 6 months were included in the current analysis. The disease flare was defined as a worsening of the ASDAS by ≥0.9 as compared to the value obtained at the previous visit. Univariate and multivariable cox-regression analyses were performed to analyze the predictors of flares.

Results:

Out of 76 patients who entered the study at baseline, 62 patients (n=32 with radiographic (r-) axSpA and n=30 with non-radiographic (nr-) axSpA) fulfilled the criterion of the continuous etanercept treatment. A total of 22 patients (35%) experienced at least one flare over the entire treatment period 10 patients (31.3%) in the r-axSpA and 12 patients (40%) in the nr-axSpA subgroup) - figure. A total of 81 flares occurred (33 and 48 in the r- and nr-axSpA subgroups, respectively) in the 10 years of follow-up. None of the documented disease flares resulted in a direct study withdrawal. The majority of flares occurred within first 4 years of treatment (figure). There were also no statistically significant differences between nr- and r-axSpA in the time until the first flare (p=0.4, Log-rank test). In the multivariable Cox regression analysis normal CRP values (≤5mg/l), HLA-B27 negativity, higher physician global assessment, a longer symptom duration at study entry, higher spinal ankylosis and higher fatty degeneration in the sacroiliac joints but lower spinal osteitis scores and lower ankylosis scores in the sacroiliac joints at baseline MRI were associated with a higher risk for flares.

Conclusion:

Disease flares according to the ASAS definition of clinically important worsening in axSpA based on ASDAS occurred ~1/3 of patients with early axSpA who received a treatment with etanercept for up to 10 years without major differences between r- and nr- forms of axSpA. HLA-B27 negativity, normal CRP, higher spinal ankylosis scores, higher fatty degeneration scores but lower ankylosis scores in the SIJ´s at baseline MRI were associated with a higher risk for flares.

Figure 1.

Baseline characteristics of all patients with with continous ETC treatment.

all≥1 flareno flarepatientsn (%)62 (100)22 (35.5)40 (64.5)malen (%)38 (61.3)16 (72.7)22 (55)agemean (SD)34.1 (8.3)32.6 (7.8)35 (8.6)BASDAImean (SD)2.7 (2)1.8 (1.8)3.2 (1.9)ASDASmean (SD)1.6 (0.8)1.3 (0.7)1.7 (0.8)Figure 2.

Kaplan-Meier curves indicating time to first flare and flare free survival propability.

Acknowledgments:

The ESTHER study was supported by an unrestricted research grant from Pfizer. Murat Torgutalp’s (MT) work at Charité - Universitätsmedizin was supported by an award from the Scientific and Technological Research Council of Turkey (TUBITAK).

Disclosure of Interests:

Fabian Proft Grant/research support from: Novartis Pharma GmbH, Consultant of: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: Consultancy / speaker fees from: Abbvie, BMS, Celgene, Lilly, MSD, Novartis, Pfizer, Roche, UCB, Murat Torgutalp: None declared, Anja Weiß: None declared, Mikhail Protopopov Consultant of: Novartis, Valeria Rios Rodriguez Consultant of: Abbvie, Novartis, Hildrun Haibel Consultant of: Abbvie, Jansen, MSD, and Novartis, Speakers bureau: Abbvie, Jansen, MSD, and Novartis, Kay Hermann: None declared, Christian Althoff: None declared, Olaf Behmer Employee of: Pfizer Pharma GmbH, Joachim Sieper Consultant of: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Speakers bureau: AbbVie, Boehringer Ingelheim, Eli Lilly and Company, Janssen, Merck, Novartis, Pfizer, Roche, and UCB Pharma, Denis Poddubnyy Grant/research support from: AbbVie, MSD, Novartis, and Pfizer, Consultant of: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB, Speakers bureau: AbbVie, Bristol-Myers Squibb, Eli Lilly, MSD, Novartis, Pfizer, Roche, UCB

Evaluation of the BAX® System for Detection of Salmonella in Selected Foods: Collaborative Study

A multilaboratory study was conducted to compare the automated BAX® System to the standard cultural methods for detection of Salmonella in selected foods. Five food types—frankfurters, raw ground beef, mozzarella cheese, raw frozen tilapia fish, and orange juice—at 3 inoculation levels, were analyzed by each method. A sixth food type, raw ground chicken, was tested using 3 naturally contaminated lots. A total of 16 laboratories representing government and industry participated. In this study, 1386 samples were analyzed, of which 1188 were paired samples and 198 were unpaired samples. Of the 1188 paired samples, 461 were positive by both methods and 404 were negative by both methods. Thirty-seven samples were positive by the BAX System but negative by the standard reference method, and 11 samples were positive by standard cultural method and negative by the BAX System. Of the 198 unpaired samples, 106 were positive by the BAX System and 60 were positive by the standard cultural method. A Chi square analysis of each of the 6 food types, at the 3 inoculation levels tested, was performed. For all foods, the BAX System demonstrated results comparable to those of the standard reference methods based on the Chi square results.

Development of the BELANA questionnaire for the analysis of economic burdens of food allergy and intolerance

INTRODUCTION

Patients affected by food allergies and intolerance need to apply dedicated avoidance strategies and also prevent the consequences of unbalanced diets. In most countries, the health economic costs for these patients are unknown.

METHODS

To measure temporal and financial burdens of the patients in multinational settings, the BELANA questionnaire (Burdens and Expenses of Living as an Adult with Nutrition based Allergy or Intolerance) has been developed. For the complementary measurement of Health Related Quality of Life (HR-QoL), a combined appliance of the disease-specific FAQLQ-AF (Food Allergy Quality of Life Questionnaire - Adult Form) and the generic SF-12v1 (Short Form-12 Health Survey) has been chosen.

RESULTS

BELANA collects six economic items while avoiding questions, which are already included in the HR-QoL questionnaires or could lead to denial tendencies. In a web-based pilot survey with 51 patients, the practicability of using BELANA together with the complementary quality of life instruments was investigated. The electronic data collection offers real time plausibility checks and limits the workload for completion and data evaluation.

DISCUSSION

The response rates at BELANA health-economic items (76 - 100%) and the high amount of completed questionnaires (50 of 51) confirm the patients acceptance of the chosen methodology. Within the web-based survey, the combination of BELANA, FAQLQ-AF and SF-12v1 was completed in an average of 22 minutes. An age-related selection bias was not been confirmed in this pilot application. The median age in the pilot trial was 37.9 years (minimum age to participate was 18 years, range from 19 to 72 years, Standard Deviation (SD) = 12.4 years). Most of the participants were female (44 of 50).

CONCLUSION

It is assumed that the BELANA questionnaire should be a useful tool for the evaluation of health-economic burden for patients with food allergy and intolerance.

Oligodendrogliomas: A comparison of CT and MR imaging features with histological malignancy grading in 20 cases: A pathoradiological study

Purpose: To study the pattern of contrast enhancement in MR and CT of oligodendrogliomas and to compare this with other imaging findings and with histopathological grading criteria.

Material and Methods: 20 patients with oligodendrogliomas (12 low-grade WHO II and 8 anaplastic WHO III) were reviewed. 20 complete MR investigations, 20 non-enhanced CT studies and 16 CTs after contrast enhancement were estimated blindly without knowledge of the tumour histological grades.

Results: All anaplastic oligodendrogliomas showed tumour contrast enhancement on MR and CT images. Also in 6/12 low-grade oligodendrogliomas the contrast was enhanced on MR imaging. In 5 of these, tumour calcifications were detected by CT. The remaining 6/12 WHO grade II cases showed no significant MR contrast enhancement. Of the oligodendrogliomas grade II, CT showed contrast uptake in 3 cases and no enhancement in 6, while in 3 cases postcontrast CT was not available. A comparison of contrast enhancement with tumour grade resulted in a p-value of 0.042 for MR and of 0.011 for CT. A combined statistical test of tumour grade and calcifications detected by CT compared with MR contrast enhancement showed a significant correlation ( p=0.014).

Conclusion: These data demonstrated that a clear grading of oligodendrogliomas based on the image criterion MR contrast enhancement was not possible. We suppose that, besides tumour neovascularisation, additional factors such as calcifications may disturb the blood-brain barrier.

[Patient care in an out-of-hours care practice - a descriptive study of the CONTENT project]

BACKGROUND

Little published research is available about the content of out of hours care (OOHC) in Germany. CONTENT is a project of the University Hospital Heidelberg to build up a morbidity registry for ambulatory health care. One of the participating practices of the network is a rural OOHC centre. The study reports exemplarily on the work of this practice.

METHODS

The design of the study is cross-sectional. One of the 2 available CONTENT practice-softwares was used for data retrieval. The softwares allow for classifying reasons for encounter (RFE), health problems (diagnoses) and processes of care with the International Classification of Primary Care (ICPC-2). Furthermore the softwares allow for pseudonymised data export.

RESULTS

A 3-year period with 15 886 patient contacts of 9 542 patients (65.9% female) is described. Close to 8% of the population in the catchment area visited the practice at least once in a year. Medium age of the patients was 42 years (range 0-104). The groups of the 25-44-year-old and the 45-64-year-old patients formed together 43% of all contacts. The most frequent RFE were: fever (5.8%), sore throat (4.8%), cough (4.8%), earache (3.9%) and insect bites (3.6%). Frequencies of these RFEs differed considerably between the age groups. With the help of the data, resulting diagnoses and care processes can be described in detail.

CONCLUSION

This study describes, for the first time in Germany, the work of an OOHC practice. Data capture to accomplish this was feasible within existing practice software and without much extra work. If more OOHC practices would participate in the CONTENT project a more representative picture of OOHC in Germany could be established.

Elementary steps of the catalytic NO(x) reduction with NH3: cluster studies on reactant adsorption at vanadium oxide substrate

Extended cluster models together with density-functional theory are used to evaluate geometric, energetic, and electronic properties of different adsorbate species that can occur at a vanadium oxide surface where the selective catalytic reduction (SCR) of NO in the presence of ammonia proceeds. Here, we focus on atomic hydrogen, nitrogen, and oxygen, as well as molecular NO and NHx, x = 1, 4, adsorption at a model V2O5(010) surface. Binding sites, oxygen and vanadium, at both the perfect and reduced surface are considered where reduction is modeled by (sub-) surface oxygen vacancies. The reactants are found to bind overall more strongly at oxygen vacancy sites of the reduced surface where they stabilize in positions formerly occupied by the oxygen (substitutional adsorption) compared with weaker binding at the perfect surface. In particular, ammonia, which interacts only weakly with vanadium at the perfect surface, binds quite strongly near surface oxygen vacancies. In contrast, surface binding of the NH4 adsorbate species differs only little between the perfect and the reduced surface which is explained by the dominantly electrostatic nature of the adsorbate interaction. The theoretical results are consistent with experimental findings and confirm the importance of surface reduction for the reactant adsorption forming elementary steps of the SCR process.

[What do medical students think of family medicine? Results of an online cross-sectional study in the federal state of Baden-Wuerttemberg]

BACKGROUND

In the context of physician shortages, critical factors influencing career choice need to be better understood. The aim of this study was to explore experiences students have had with family medicine in order to develop additional strategies for recruiting family medicine trainees.

METHODS

Students from the five medical faculties in the federal state of Baden-Wuerttemberg were invited to participate in an online-survey via email. A purpose-built questionnaire was used. In addition to descriptive statistics, analysis included linear partial correlations controlled for age, gender, and semester, which were calculated between the variable "I believe family medicine is an attractive job" and the 31 variables of the survey. Linear regression was used to analyze the influence of experiences with family medicine and statements about family medicine to the perception of family medicine as an attractive specialty.

RESULTS

1299 students participated in the survey. About half of the participants (49.7 %) considered working as a primary care physician to be attractive or partly attractive. 49.6 % of students reported positive experiences with family medicine as a patient and 33.1 % as a family member. 24.3 % reported positive experiences during the compulsory 1-2 weeks general practice internship and 18.1 % during a four weeks elective placement. For 302 participants (23.3 %), family medicine is presented positively in the media. 178 (13.7 %) consider family medicine to have high importance in both undergraduate and postgraduate education. Positive influences on judging attractiveness of family medicine were: own experience with family medicine as a clinical elective (rpart= + 0.450), own experience with family medicine as a patient (rpart= + 0.218), perception that family medicine offers a diversified working day (rpart= + 0.259), and perception that family medicine offers a good salary (rpart= + 0.242).

CONCLUSION

To enable students during undergraduate studies to have practical experience with family medicine seems to be an important influence on judging family medicine attractive.

Color and scent: how single genes influence pollinator attraction

A major function of angiosperm flowers is the recruitment of animal pollinators that serve to transfer pollen among conspecific plants. Distinct sets of floral characteristics, called pollination syndromes, are correlated with visitation by specific groups of pollinators. Switches among pollination syndromes have occurred in many plant families. Such switches must have involved coordinated changes in multiple traits and multiple genes. Two well-studied floral traits affecting pollinator attraction are petal color and scent production. We review current knowledge about the biosynthetic pathways for floral color and scent production and their interaction at the genetic and biochemical levels. A key question in the field concerns the genes that underlie natural variation in color and scent and how such genes affect pollinator preference, reproductive isolation, and ultimately speciation.

X-ray absorption from large molecules at metal surfaces: theoretical and experimental results for Co-OEP on Ni(100)

Metal octaethylporphyrins (M-OEP), M-N(4)C(20)H(4)(C(2)H(5))(8), adsorbed at a metallic substrate are promising candidates to provide spin dependent electric transport. Despite these systems having been studied extensively by experiment, details of the adsorbate geometry and surface binding are still unclear. We have carried out density functional theory calculations for cobalt octaethyl porphyrin (Co-OEP) adsorbate at clean and oxygen-covered Ni(100) surfaces as well as for the free Co-OEP molecule where equilibrium structures were obtained by corresponding energy optimizations. These geometries were then used in calculations of Co-OEP carbon and nitrogen 1s core excitations yielding theoretical excitation spectra to be compared with corresponding K-edge x-ray absorption fine structure (NEXAFS) measurements. The experimental NEXAFS spectra near the carbon K-edge of Co-OEP bulk material show large intensity close to the ionization threshold and a triple-peak structure at lower energies, which can be reproduced by the calculations on free Co-OEP. The experimental nitrogen K-edge spectra of adsorbed Co-OEP layers exhibit always a double-peak structure below ionization threshold, independent of the layer thickness. The peaks are shifted slightly and their separation varies with adsorbate-substrate distance. This can be explained by hybridization of N 2p with corresponding 3d contributions of the Ni substrate in the excited final state orbitals as a result of adsorbate-substrate binding via N-Ni bond formation.

[Experiences and attitudes regarding practice-based clinical trials: results of a survey among German primary care physicians]

OBJECTIVE

Clinical trials are regarded as complex due to the high demands on quality and patient safety and are still exceptional in German primary care. To optimise future trial planning, this study aimed at investigating the barriers and enablers experienced by primary care physicians (PCPs) for trial participation.

METHODS

PCPs were surveyed on 11 regional primary care medical education (CME) events using a standardised questionnaire. Regression analyses were used to identify predictors for future trial participation.

RESULTS

Of 804 invited PCPs, 408 (50.7%) participated in the survey (51 ± 9 years, female 35%). 69% of participants could imagine their participation in a clinical trial. Of 12 potential factors assessed, the final model retained the 2 predictors (OR; CI; P-value) "research questions relevant to practice" (2.25; 1.61-3.14;<0.001) and "new challenges/change from everyday life" (2.24; 1.67-2.97;<0.001). While 58% of participants were principally willing to participate in investigator training courses according to Good Clinical Practice (GCP), only 6% had participated in such training at the time of answering. Short events were preferred. Only 7% were willing to take over at least half of the costs of these courses.

CONCLUSION

To enhance German PCPs motivation to participate in clinical trials, both trials and training courses should be tailored to the needs in the primary care setting.

Self-metalation of 2H-tetraphenylporphyrin on Cu(111): an x-ray spectroscopy study

The bonding and the temperature-driven metalation of 2H-tetraphenylporphyrin (2H-TPP) on the Cu(111) surface under ultrahigh vacuum conditions were investigated by a combination of x-ray photoelectron spectroscopy (XPS) and near-edge x-ray absorption fine structure (NEXAFS) spectroscopy with density functional theory calculations. Thin films were prepared by organic molecular beam epitaxy and subsequent annealing. Our systematic study provides an understanding of the changes of the spectroscopic signature during adsorption and metalation. Specifically, we achieved a detailed peak assignment of the 2H-TPP multilayer data of the C1s and the N1s region. After annealing to 420 K both XPS and NEXAFS show the signatures of a metalloporphyrin, which indicates self-metalation at the porphyrin-substrate interface, resulting in Cu-TPP. Furthermore, for 2H-TPP monolayer samples we show how the strong influence of the copper surface is reflected in the spectroscopic signatures. Adsorption results in a strongly deformed macrocycle and a quenching of the first NEXAFS resonance in the nitrogen edge suggesting electron transfer into the LUMO. For Cu-TPP the spectroscopic data indicate a reduced interaction of first-layer molecules with the substrate as demonstrated by the relaxed macrocycle geometry.

[HeiCare®: a project aiming to improve medication communication across health care sectors]

BACKGROUND AND OBJECTIVE

Changes between health care sectors represent a critical phase in long-term pharmacotherapy. The aim of the Hei CARE(®) project was to close the communication gap at the interface between primary care physicians (PCP), hospital physicians and patients, and to improve quality and safety of pharmacotherapy.

METHODS

Physicians who enrolled patients with long-term pharmacotherapy were able to participate in the Hei CARE(®) project. After enrolment the patient's medication was entered in the internet-based medication knowledge data base AiD PRAXIS and checked for medication interactions and optimized if necessary. At hospitalisation medication was transferred electronically to the hospital (AiD KLINIK(®)) and on discharge integrated in the discharge letter and faxed to the primary care physician (PCP). The project was evaluated using quantitative and qualitative methods. Hei CARE(®) -cases, in which medication was transferred electronically as planned, were compared with the other cases. PCPs' experiences were collected in focus groups.

RESULTS

One thousand and three chronically ill patients of 56 primary care practices participated. 259 patients were hospitalized between October 2005 and March 2009 of which entrance and discharge medication were transferred both ways via the electronic prescribing platform in 67 cases. The number of changes in medication was reduced in comparison to the other cases. Participating PCPs reported positive changes through Hei CARE(®) as well as further potential for optimizing communication across health care sectors.

CONCLUSION

Use of a common internet-based medication knowledge data base (Hei CARE(®) ) in both health care sectors reduced the number of changes in pharmacotherapy. Seamless care in chronically ill patients was thereby improved. The project also demonstrated that improving communication across health care sectors is a slow process.

[Development, factor-analytical control and psychometric evaluation of a questionnaire on specialty choices among medical students]

AIM OF THE STUDY

A questionnaire was developed and validated which assesses factors influencing career choices of medical students and their perception of possibilities in general practice.

METHODS

The first questionnaire version, which was developed based on a systematic literature review, was checked for comprehensibility and redundancy using concurrent think aloud. The revised version was filled out by a pilot sample of medical students and the factor structure was assessed using principal component analysis (PCA). The final version was filled out in an online survey by medical students of all 5 Medical Faculties in the federal state of Baden-Wuerttemberg. The factor structure was validated with a confirmatory factor analysis (CFA). Reliability was assessed as internal consistency using Cronbach's α.

RESULTS

The questionnaire comprises 2 parts: ratings of (A) the individual importance and of (B) the possibilities in general practice on 5-point scales. The first version comprising 118 items was shortened to 63 items after conducting interviews using concurrent think aloud. A further 3 items giving no information were removed after piloting the questionnaire on 179 students. The 27 items of part A were structured in 7 factors (PCA): image, personal ambition, patient orientation, work-life balance, future perspectives, job-related ambition, and variety in job. This structure had a critical fit in the CFA applied to the final version filled out by 1 299 students. Internal consistency of the factors was satisfactory to very good (Cronbach's α=0.55-0.81).

CONCLUSION

The questionnaire showed good psychometric properties. Further, not assessed factors influence career choice resulting in unexplained variance in our dataset and the critical fit of the model.

[Aspirations of medical students: "planning for a secure career" - results of an online-survey among students at five medical schools in Germany]

BACKGROUND

In times of shortage of doctors, expectations and interests of the future generation of doctors towards their career aspiration is of major importance. The aim of this study was to analyze expectations of medical students at the five medical schools in the State of Baden-Wuerttemberg (Germany) concerning their career choice and factors influencing it.

METHODS

Between January and February 2010, 1299 medical students (out of 12 062 medical students at the five medical schools) participated in an online-survey. In addition to sociodemographic items, career choice and aspects of planning reliability were raised.

RESULTS

Three quarters of the students assign a medical profession for their future occupation. There is a dominance of internal medicine (n = 152), gynaecology (n = 127), paediatrics (n = 125), surgery (n = 115), anaesthesiology (n = 101), and family medicine (n = 88). The time point of decision varies between the different undergraduate years of medical school and specialty. Students at the beginning of their studies seem to be interested mostly in surgery. During medical school the interests towards internal medicine grows. Regarding planning dependability important aspects for medical students were to work in a job that has a future (61.2 % fully agree), to have a safe job (57.7 %), and to have a safe income (57.1 %). Less important seems to be to have good opportunity to earn money (29.6 %).

CONCLUSIONS

Interest in a certain specialty changes markedly at during medical school. Factors such as economical guarantee, good future prospects and also the studies itself have an essential impact for students on choosing a specific career. Strategies to face physicians' shortage in different specialties need to be close to the needs and expectations of future physicians. This is not only valid for the undergraduate time period but also for the work circumstances of their future.

Antifungal therapy with itraconazole impairs the anti-lymphoma effects of rituximab by inhibiting recruitment of CD20 to cell surface lipid rafts

Immunotherapy with rituximab alone or in conjunction with chemotherapy has significantly improved the treatment outcome of B-cell lymphoma patients. Nevertheless, a subpopulation of patients does not respond to rituximab. The reason for treatment failure as well as the exact mechanism of action is still uncertain. The function of rituximab has long been associated with the partitioning of CD20 molecules to membrane microdomains. Here, we show that concomitant antifungal treatment with itraconazole impairs the rituximab anti-lymphoma effect both in vitro and in vivo. At the molecular level, recruitment of CD20 to lipid rafts is inhibited in the presence of itraconazole. Furthermore, calcium influx, which is crucial for rituximab-mediated cell death, was nearly completely abolished by itraconazole treatment. In contrast, the antifungal drug caspofungin did not inhibit CD20 recruitment to lipid rafts, nor did it affect calcium influx or the cytotoxic effect of rituximab. The finding that itraconazole also abolished the cytotoxic effects of other therapeutic antibodies directed against lipid raft-associated molecules (i.e., CD20 and CD52) but not those against the non-raft-associated molecule CD33 further supported our proposed mechanism of action. Our results argue that concomitant medications must be adjusted carefully to achieve optimal antitumor effects with monoclonal antibodies.

[Information on medications - How do chronically ill patients assess counselling on drugs in general practice?]

BACKGROUND AND OBJECTIVE

Patients with chronic disease have to rely on safe and efficacious drug treatment. They therefore need individual information on their medicaton, in which counselling within the setting of general practice plays a pivotal role. However, information that seems to be relevant from the doctor's point of view is not necessarily consistent with the information patients consider to be necessary. The question was addressed in this study on to what extent patients are satisfied with the information they have received on their medication in general practice?

METHODS

A standardized questionnaire consisting of the SIMS-D (German version of the Satisfaction with Information about Medicines Scale) and MARS-D (German version of the Medication Adherence Report Scale) was sent to 834 chronically ill patients between March 2007 and April 2008.

RESULTS

Patients felt quite satisfied with the information they received on "action and usage" of medication (mean 6.95; range 0 - 9). They were not quite so satisfied with the information they received on "potential problems of medication". Self-reported adherence showed a high mean of 23.6 (range 5 - 25). Less than half of the doctors (43.6 %) inquired "always" or "often" whether patients were taking any other drugs than those prescribed.

CONCLUSION

Patients wish to have more information on potential drug-related problems. More attention needs to be given to a structured review of drugs prescribed in general practice.

Mechanisms regulating cytochrome c release in pancreatic mitochondria

BACKGROUND

Mechanisms of acinar cell death in pancreatitis are poorly understood. Cytochrome c release is a central event in apoptosis in pancreatitis. Here, we assessed the regulation of pancreatic cytochrome c release by Ca(2+), mitochondrial membrane potential (Delta Psi m), and reactive oxygen species (ROS), the signals involved in acute pancreatitis. We used both isolated rat pancreatic mitochondria and intact acinar cells hyperstimulated with cholecystokinin-8 (CCK-8; in vitro model of acute pancreatitis).

RESULTS

Micromolar amounts of Ca(2+) depolarised isolated pancreatic mitochondria through a mechanism different from the "classical" (ie, liver) mitochondrial permeability transition pore (mPTP). In contrast with liver, Ca(2+)-induced mPTP opening caused a dramatic decrease in ROS and was not associated with pancreatic mitochondria swelling. Importantly, we found that Ca(2+)-induced depolarisation inhibited cytochrome c release from pancreatic mitochondria, due to blockade of ROS production. As a result, Ca(2+) exerted two opposite effects on cytochrome c release: Ca(2+) per se stimulated the release, whereas Ca(2+)-induced depolarisation inhibited it. This dual effect caused a non-monotonous dose-dependence of cytochrome c release on Ca(2+). In intact acinar cells, cytochrome c release, caspase activation and apoptosis were all stimulated by ROS and Ca(2+), and inhibited by depolarisation, corroborating the findings on isolated pancreatic mitochondria.

CONCLUSIONS

These data implicate ROS as a key mediator of CCK-induced apoptotic responses. The results indicate a major role for mitochondria in the effects of Ca(2+ )and ROS on acinar cell death. They suggest that the extent of apoptosis in pancreatitis is regulated by the interplay between ROS, Delta Psi m and Ca(2+). Stabilising mitochondria against loss of Delta Psi m may represent a strategy to mitigate the severity of pancreatitis.

Differential expression of genes encoding tight junction proteins in colorectal cancer: frequent dysregulation of claudin-1, -8 and -12

BACKGROUND AND AIMS

As integral membrane proteins, claudins form tight junctions together with occludin. Several claudins were shown to be up-regulated in various cancer types. We performed an expression analysis of genes encoding tight junction proteins to display differential gene expression on RNA and protein level and to identify and validate potential targets for colorectal cancer (CRC) therapy.

PATIENTS AND METHODS

Amplified and biotinylated cRNA from 30 microdissected CRC specimen and corresponding normal tissues was hybridized to Affymetrix U133set GeneChips. Quantification of differential protein expression of claudin-1, -8 and -12 between normal and corresponding tumour tissues was performed by Western blot analyses. Paraffin-embedded CRC tissue samples, colon cancer cell lines and normal tissue microarray were analysed for protein expression of claudin-1 by immunohistochemistry (IHC).

RESULTS

Claudin-1 (CLDN1) and -12 (CLDN12) are frequently overexpressed in CRC, whereas claudin-8 (CLDN8) shows down-regulation in tumour tissue on RNA level. Quantification of proteins confirmed the overexpression of claudin-1 in tumour tissues, whereas changes of claudin-8 and -12 were not significantly detectable on protein level. IHC confirmed the markedly elevated expression level of claudin-1 in the majority of CRC, showing membranous and intracellular vesicular staining.

CONCLUSIONS

Differential expression of genes encoding claudins in CRC suggests that these tight junction proteins may be associated to and involved in tumorigenesis. CLDN1 is frequently up-regulated in large proportion of CRC and may represent potential target molecule for blocking studies in CRC.