Vaccinia-based oncolytic immunotherapy Pexastimogene Devacirepvec in patients with advanced hepatocellular carcinoma after sorafenib failure: a randomized multicenter Phase IIb trial (TRAVERSE)

Pexastimogene devacirepvec (Pexa-Vec) is a vaccinia virus-based oncolytic immunotherapy designed to preferentially replicate in and destroy tumor cells while stimulating anti-tumor immunity by expressing GM-CSF. An earlier randomized Phase IIa trial in predominantly sorafenib-naïve hepatocellular carcinoma (HCC) demonstrated an overall survival (OS) benefit. This randomized, open-label Phase IIb trial investigated whether Pexa-Vec plus Best Supportive Care (BSC) improved OS over BSC alone in HCC patients who failed sorafenib therapy (TRAVERSE).

129 patients were randomly assigned 2:1 to Pexa-Vec plus BSC vs. BSC alone. Pexa-Vec was given as a single intravenous (IV) infusion followed by up to 5 IT injections. The primary endpoint was OS. Secondary endpoints included overall response rate (RR), time to progression (TTP) and safety.

A high drop-out rate in the control arm (63%) confounded assessment of response-based endpoints. Median OS (ITT) for Pexa-Vec plus BSC vs. BSC alone was 4.2 and 4.4 months, respectively (HR, 1.19, 95% CI: 0.78–1.80; p = .428). There was no difference between the two treatment arms in RR or TTP. Pexa-Vec was generally well-tolerated. The most frequent Grade 3 included pyrexia (8%) and hypotension (8%). Induction of immune responses to vaccinia antigens and HCC associated antigens were observed.

Despite a tolerable safety profile and induction of T cell responses, Pexa-Vec did not improve OS as second-line therapy after sorafenib failure. The true potential of oncolytic viruses may lie in the treatment of patients with earlier disease stages which should be addressed in future studies.

ClinicalTrials.gov: NCT01387555

Cross-cultural adaptation and preliminary validation of a zygosity determination questionnaire for twins in Sri Lanka

We report the process of adaptation into Sinhala of a questionnaire given to mothers of twins to determine zygosity. Adaptation and validation was carried out in three stages. Firstly, we used a nominal group to translate the English version and to assess the extent of agreement (consensus measurement) on the appropriateness of the translation and resolve disagreement (consensus development). Secondly we used a qualitative interview with 25 mothers of twins. The three main stems of the translated questionnaire were used as a semi-structured interview, and the responses noted verbatim. These were categorised and analysed, and the translated full questionnaire was then presented as closed questions with fixed choice responses. The categorised responses generated during the qualitative interview were compared with the responses to the fixed choices in the full questionnaire. The third stage was the appraisal of the questionnaire by 17 bilingual parents of twins. The source and translated version of the questionnaire were given to them at least 3 days apart. The responses were rated and the total scores were computed to determine the zygosity. This step was carried out to measure the validity and reliability of the Sinhala version. A perfect correlation between the original and adapted version was obtained, with a kappa of 1. The results suggest that the Sinhala version of the questionnaire is conceptually equivalent to the original questionnaire. Comparison of the zygosity determination by using this adapted questionnaire with results from analysis of genetic markers on Sri Lankan twins is needed for final validation of the translated questionnaire. Twin Research (2000) 3, 205–212.

Safety profile of morphine following surgery in neonates

OBJECTIVE

To determine the effect of morphine on duration of mechanical ventilation, apnoea and hypotension among full-term neonates who underwent thoracic or abdominal surgery in a level III neonatal intensive care unit.

METHOD

Medical records of 82 infants were reviewed retrospectively and data including patient demographics, clinical diagnosis, type of surgery, postoperative opioid administration, duration of mechanical ventilation, hypotension, apnoea and pain scores (premature infant pain profile (PIPP) score) were collected.

RESULT

Sixty-two neonates (76%) received morphine following surgery as a continuous intravenous infusion during the postoperative period. Linear regression analysis showed that morphine dosage and duration were significantly associated with the duration of mechanical ventilation. An increase in morphine infusion rate by 10 microg kg(-1) h(-1) was associated with an increase in the duration of mechanical ventilation by 24 h (P<0.0001) and an increase in morphine duration of 1 hour was associated with a longer duration of mechanical ventilation by 38 min (P<0.0001). Logistic regression analysis showed no association between morphine infusion rate or duration and hypotension. Apnoea was not associated with morphine dosage or duration of infusion in neonates receiving morphine following extubation. Score on the PIPP correlated significantly with morphine infusion rate across time (r=0.47, P<0.01).

CONCLUSION

Postoperative morphine dose and duration may prolong the duration of mechanical ventilation but there are no significant dose-dependent effects on other parameters including apnoea or hypotension following extubation in term neonates. More research is needed to determine the safety profile of morphine for management of pain in non-ventilated neonates.

[Coronary revascularization with extracorporeal circulation, aortic clamping or OPCAB: does the method's choice influence the results?]

BACKGROUND AND OBJECTIVES

Off pump CABG-OPCAB is the most recent development in coronary surgery and is aimed to avoid the complications of extracorporeal circulation and to compete with interventional cardiology. The objective of this study is to compare 3 methods for cardiac support for CABG.

METHODS

Between February 2001 and December 2002 ninety consecutive patients were operated by the same surgeon and the same team with the following techniques: extracorporeal circulation (CEC) and ischaemic arrest, CEC and beating heart, and OPCAB.

RESULTS

There were no difference in mortality and morbidity for the 3 groups of patients. The OPCAB group showed less ventilation time, less blood transfusion needs and shorter hospital stays than the other 2 groups of patients that showed no differences between each other.

CONCLUSION

OPCAB is safe and showed slight advantage over CEC supported groups but the number of grafts per patient was smaller.

Feasibility of using different approaches for recruiting younger twins to establish a population based twin register in Sri Lanka

Identifying twins for a population-based register can be achieved through birth records or community surveys. We studied the feasibility and effectiveness of different methods of identifying and recruiting twins to establish a population based register. To trace twins a population survey was carried out using an interviewer administered questionnaire. We also inspected the birth registration certificates at a divisional secretariat reported from a specified hospital between the years of 1985-1997 and compared it to the birth register of this same hospital. To recruit twins a random sample of 75 twin pairs (150 twins) identified at the Divisional Secretariat were contacted through the post and 25 twin pairs (50 twins) were personally visited. The prevalence of twins was 6.5 twins per 1000 people in the area surveyed. The twinning rate at the hospital was 18.92 twins per 1000 births. A discrepancy of 38 multiples births between the hospital labour room records and those registered at the DS was noted. The response from the postal invitation for recruitment was 59% and the response from the personal invitation was 68%. (Difference 9.4% 95% CI; 7.06-11.73). Community survey and systematic inspection of birth records either at the hospital or the birth registration office was an effective method to trace twins. Once traced, personal contact was more effective than the postal invitation for recruitment of younger twins. A cost-effective approach would be to use a postal coverage followed by personal contact for non-responders. The alternative method, community coverage, would have financial implications.

Bacterial and fungal pathogens isolated from corneal ulcerations in domesticated elephants (Elephas maximus maximus) in Sri Lanka

Infective corneal diseases are common among the domesticated elephants in Sri Lanka, causing morbidity including blindness leading to loss of revenue to their owners. From 140 elephants of different ages and both sexes, 36 animals (25.7%) had evidence of keratitis, corneal ulcers, corneal opacities, and some had foreign bodies in their eyes. Nine elephants (6.4%) had lesions in both eyes (6.41%). Cultures for both bacteria and fungi were obtained from 26 corneal ulcers, including the nine elephants with bilateral lesions. The other 10 animals could not be restrained for sample collection. Swabs from the normal corneas of an additional 20 elephants without signs of any ophthalmic diseases were also collected. Twenty-three of the 35 (65.71%) samples from affected corneas yielded bacterial pathogens, and 14 (40%) also had fungal isolates. None of them yielded a fungal isolate alone. The predominant bacteria isolated were Staphylococcus aureus, beta hemolytic streptococci and coliforms. Fusarium, Cladosporium, Curvularia and Aspergillus species were the primary fungal isolates. No bacteria or filamentous fungi were isolated from the eyes with the normal corneas. Microbial identification including fungal isolations is suggested in the management of infective corneal diseases in elephants.

Cross-cultural adaptation and preliminary validation of a zygosity determination questionnaire for twins in Sri Lanka

We report the process of adaptation into Sinhala of a questionnaire given to mothers of twins to determine zygosity. Adaptation and validation was carried out in three stages. Firstly, we used a nominal group to translate the English version and to assess the extent of agreement (consensus measurement) on the appropriateness of the translation and resolve disagreement (consensus development). Secondly we used a qualitative interview with 25 mothers of twins. The three main stems of the translated questionnaire were used as a semi-structured interview, and the responses noted verbatim. These were categorised and analysed, and the translated full questionnaire was then presented as closed questions with fixed choice responses. The categorised responses generated during the qualitative interview were compared with the responses to the fixed choices in the full questionnaire. The third stage was the appraisal of the questionnaire by 17 bilingual parents of twins. The source and translated version of the questionnaire were given to them at least 3 days apart. The responses were rated and the total scores were computed to determine the zygosity. This step was carried out to measure the validity and reliability of the Sinhala version. A perfect correlation between the original and adapted version was obtained, with a kappa of 1. The results suggest that the Sinhala version of the questionnaire is conceptually equivalent to the original questionnaire. Comparison of the zygosity determination by using this adapted questionnaire with results from analysis of genetic markers on Sri Lankan twins is needed for final validation of the translated questionnaire.

Establishing a twin register in Sri Lanka

Nearly all twin registers are based in developed countries and there is no twin register in the developing world. Our objectives were to initiate the process of establishing a nationwide twin register in Sri Lanka by starting a volunteer register first and working towards a population-based register. Regular newspaper advertisements, feature articles, radio talks, and television programmes were used to publicise a competition for twins, their parents/relatives and friends requesting them to participate by sending in details of twins. The competition ran from 28 March 1997 for a period of 3 months. It offered prizes for three winners selected by drawing lots. Advertisements highlighted the objective of the competition as establishing a twin register for future research and emphasised that informed consent would be obtained for individual research projects. Those who registered comprise 4602 twin pairs (same sex: male--1564, female--1885; different sex--1153), 80 sets of triplets (same sex: male--17, female--31; different sex--42) and two sets of quadruplets (different sex). The oldest twins, triplets, quadruplets are 85, 46, and 5 years old, respectively; 88.0% of twins are less than 30 years old. Although others have previously used media publicity to enrol twins in twin registers, we believe this to be the first time that twins have been enrolled through competition. We have more young twins, and our gender and zygosity proportions after applying Weinburg's rule do not match the proportions expected from a volunteer twin sample. Establishing a twin register for research purposes has proved possible in a developing country.

A fluorescence energy transfer method for analyzing protein oligomeric structure: application to phospholamban

We have developed a method using fluorescence energy transfer (FET) to analyze protein oligomeric structure. Two populations of a protein are labeled with fluorescent donor and acceptor, respectively, then mixed at a defined donor/acceptor ratio. A theoretical simulation, assuming random mixing and association among protein subunits in a ring-shaped homo-oligomer, was used to determine the dependence of FET on the number of subunits, the distance between labeled sites on different subunits, and the fraction of subunits remaining monomeric. By measuring FET as a function of the donor/acceptor ratio, the above parameters of the oligomeric structure can be resolved over a substantial range of their values. We used this approach to investigate the oligomeric structure of phospholamban (PLB), a 52-amino acid protein in cardiac sarcoplasmic reticulum (SR). Phosphorylation of PLB regulates the SR Ca-ATPase. Because PLB exists primarily as a homopentamer on sodium dodecyl sulfate polyacrylamide gel electrophoresis, it has been proposed that the pentameric structure of PLB is important for its regulatory function. However, this hypothesis must be tested by determining directly the oligomeric structure of PLB in the lipid membrane. To accomplish this goal, PLB was labeled at Lys-3 in the cytoplasmic domain, with two different amine-reactive donor/acceptor pairs, which gave very similar FET results. In detergent solutions, FET was not observed unless the sample was first boiled to facilitate subunit mixing. In lipid bilayers, FET was observed at 25 degrees C without boiling, indicating a dynamic equilibrium among PLB subunits in the membrane. Analysis of the FET data indicated that the dye-labeled PLB is predominantly in oligomers having at least 8 subunits, that 7-23% of the PLB subunits are monomeric, and that the distance between dyes on adjacent PLB subunits is about 10 A. A point mutation of PLB (L37A) that runs as monomer on SDS-PAGE showed no energy transfer, confirming its monomeric state in the membrane. We conclude that FET is a powerful approach for analyzing the oligomeric structure of PLB, and this method is applicable to other oligomeric proteins.

Tinea capitis in south-east London--a new pattern of infection with public health implications

Recent observations on tinea capitis cases in London suggest that there has been a change in the pattern of infection with a recent and significant rise in the incidence of infections due to anthropophilic fungi. The purpose of this study was to investigate the prevalence and identity of tinea capitis in schools in south-east London and factors which might affect the spread of infection. This was achieved by carrying out a survey of all children, with parental consent for scalp examination, in 14 nursery, infant or junior schools in Lambeth. In addition, the accuracy of clinical diagnosis was compared with mycological findings. There were 1057 children from 4 to 14 years of age in the study. The infection rate in different schools ranged from 0 to 12% with a mean of 2.5%. A further 4.9% of children were scalp carriers of dermatophytes (range in classes 0-47%). A striking feature was that all infections were caused by anthropophilic fungi, mainly Trichophyton tonsurans or Microsporum rivalieri, and there was a correlation between the presence of two or more carriers within a class and the infection in the other children. There was a poor correlation between ability of trained observers to predict infection on clinical grounds and mycological results. This investigation shows variable but significant levels of scalp ringworm in schools and that the dominant organisms are anthropophilic. It provides support for the observation that there has been a shift in the pattern of tinea capitis in London and, possibly, other U.K. centres, with a trend towards more infections transmissible among children, with T, tonsurans being the commonest organism. The implications for control, which involve screening in schools, where appropriate, and guidance to general practitioners on treatment, are discussed.

Tryptophan dynamics of the FK506 binding protein: time-resolved fluorescence and simulations

The FK506-binding protein (FKBP12) is important in the immunosuppressant action of FK506 and rapamycin. We have investigated Trp side chain dynamics in FKBP12, with and without a bound immunosuppressant, by measuring the Trp time-resolved fluorescence anisotropy decay r(t). The r(t) for W59 in aqueous uncomplexed FKBP12 at 20 degrees C is well described by a single exponential with a recovered initial anisotropy, r(eff)o, of 0.192 and an overall rotational correlation time for the protein, phi p, of 4.7 ns; r(eff)o = 0.214 and phi p = 4.2 ns for the FKBP12/FK506 complex. Using an expression for the order parameter squared, namely S2 = r(eff)o/rTo, where rTo is the vitrified steady-state excitation anisotropy, we recovered an S2 of 0.75 for W59 fluorescence in uncomplexed FKBP12 and S2 approximately equal to 1 in the FKBP12/FK506 complex. Results obtained for the FKBP12/rapamycin complex are similar to those found for the FKBP12/FK506 complex. Minimum perturbation mapping simulations were performed on the free and complexed forms of FKBP12 and the results were generally in agreement with the experimental data.

In vitro inhibition of marginal caries-like lesions with fluoride-containing amalgam

Carious lesions surrounding restorations represent one of the main causes of restoration failure. The addition of fluoride compounds to dental restorative materials prevents or reduces recurrent caries. The purpose of this study was to compare the capacity of three restorative materials to inhibit the development of recurrent caries in vitro. Thirty unrestored, noncarious premolars that were being extracted for orthodontic reasons were sectioned in half buccolingually and divided into three groups. One of the groups was restored with conventional amalgam. The second group was restored with a fluoride-containing amalgam, and the third group was restored with a glass-ionomer cement. All the samples were submitted to a medium containing Streptococcus mutans (Ingbritt strain) for 8 weeks. At the end of the 8-week incubation period, the samples were cut into 100 microns sections, soaked in Quinoline (IR = 1.62), and observed with light transmission and polarized light microscopy. The development of artificial caries in the cavity walls was measured in microns. The results show that conventional amalgam had an average caries penetration of 160 microns, fluoride-containing amalgam 46 microns, and glass-ionomer cement 11 microns. Glass-ionomer cement gave the best protection against recurrent caries.

Zygosity and umbilical cord length

Differences in cord length between weight-concordant pairs were studied in 43 monochorionic, 59 same-sex dichorionic and 42 different-sex dichorionic sets of twins and comparisons were made between groups. Of obvious and curious note was the narrow range of cord length differences between twins in monochorionic pairs (range, 0-5 cm; mean, 2.1 +/- 1.6 cm). Same-sex and different-sex dichorionic groups had significantly wider ranges of cord length differences than the monochorionic group (range, 0-34 cm; means, 7.7 +/- 6.4 and 11.0 +/- 6.1 cm, respectively). In the same-sex dichorionic group no pair whose cord lengths differ by > 5 cm has yet been found to be identical. Discordant monochorionic twins had greater differences in cord length. All other factors being equal, the remarkably similar cord lengths of concordant identical twins strongly supports the hypothesis that a genetic component influences cord length.

[Breast cancer in the pregnancy-puerperal cycle]

From 1978 to 1988, 611 cases of breast cancer were seen by the Mastology Department of the Beneficência Portuguesa Hospital in São Paulo, Brazil. Thirteen (2.12%) cases were associated to pregnancy, and nine (2.4%) became pregnant after treatment. The patients were submitted to surgery and the authors waited till the end of pregnancy to perform the Rt and/or Qt. Two cases could not be submitted to any kind of treatment. Whenever tests indicated fetal maturity, the option was to perform a caesarean section, and oophorectomy was performed in the most advanced cases. Among patients who became pregnant after treatment, initial cases were predominant and their pregnancies went to term with no problem. The authors compare their results to data found in literature and draw attention to anticonception in mastectomized patients.

[Microbiological study of salt (sodium chloride) of marine origin]

Foram analisadas 19 amostras de SAL (NaCl), tipo grosso, oriundas de diferentes salinas, para verificação da flora microbiana e presença de bactérias nocivas em Microbiologia Alimentar. O material apresentou grande contaminação por microrganismos saprófitas, bactérias aeróbias e anaeróbias, Gram positivas e negativas, proteolíticas, pigmentadas, esporuladas, leveduras e fungos. A alta incidência das bactérias halofílicas "vermelhas", responsáveis pela deterioração de carnes, pescados e outros produtos salgados foi estudada. A freqüência, em 15 amostras de SAL, de bactérias esporuladas termorresistentes foi calculada em 33%, possuindo um SAL germe termofílico. Para anaeróbios a positividade foi de 80%, havendo esporulação em 40% das culturas isoladas. Os índices para leveduras e fungos foram de 73% e 93%, respectivamente.

Patterns of change in the soluble nitrogen pool in seeds of Acer ginnala during stratification

Respiration and water uptake were previously shown to follow a three-phase pattern during the stratification period of Acer ginnala. The present study indicates that metabolism of several nitrogenous components also follows a multiphasic pattern during this period. However, total soluble nitrogen showed a rapid decline from day 9 to day 18 when respiration and water uptake were in what was essentially a plateau phase. This trend suggests that synthetic activities may be competing for substrates common to the respiratory pathway.The neutral fraction accounted for the major portion of the amino nitrogen pool and generally followed the pattern of total soluble nitrogen. The changes in the acidic and basic fractions were also phasic, but the patterns differed somewhat from that of the much larger neutral component. These results indicate that stratification is a highly active process composed of several well-defined phases.