The Role of Nonprofit and Nongovernmental Organizations and People With Viral Hepatitis on the Path Toward Hepatitis C Virus Elimination

Nonprofit and nongovernmental organizations have driven and continue to drive hepatitis C elimination by putting people with viral hepatitis and their affected communities at the center of hepatitis elimination efforts. They have been key in driving the decentralization of services and community-based delivery in the hepatitis care pathway to improve the health and well-being of the populations most affected by hepatitis C. This article explores how the formation of the World Hepatitis Alliance (WHA), an international network of community organizations in >100 countries, led to powerful advocacy from community leaders and people with hepatitis, resulting in the establishment of World Hepatitis Day. Since then, the World Health Organization (WHO) has recognized the importance of viral hepatitis by setting the 2030 global elimination targets. WHA and WHO have collaborated on 3 World Hepatitis Summits, which have built momentum across many sectors to help elevate hepatitis through the global health agenda. The article discusses their paradigm-shifting campaigns and also presents civil society organizations' hepatitis elimination efforts in Egypt, Mongolia, Bangladesh, and the United Kingdom and their significant impact through local resource mobilization and engagement of national governments.

A global investment framework for the elimination of hepatitis B

BACKGROUND & AIMS

More than 292 million people are living with hepatitis B worldwide and are at risk of death from cirrhosis and liver cancer. The World Health Organization (WHO) has set global targets for the elimination of viral hepatitis as a public health threat by 2030. However, current levels of global investment in viral hepatitis elimination programmes are insufficient to achieve these goals.

METHODS

To catalyse political commitment and to encourage domestic and international financing, we used published modelling data and key stakeholder interviews to develop an investment framework to demonstrate the return on investment for viral hepatitis elimination.

RESULTS

The framework utilises a public health approach to identify evidence-based national activities that reduce viral hepatitis-related morbidity and mortality, as well as international activities and critical enablers that allow countries to achieve maximum impact on health outcomes from their investments - in the context of the WHO's 2030 viral elimination targets.

CONCLUSION

Focusing on hepatitis B, this health policy paper employs the investment framework to estimate the substantial economic benefits of investing in the elimination of hepatitis B and demonstrates how such investments could be cost saving by 2030.

LAY SUMMARY

Hepatitis B infection is a major cause of death from liver disease and liver cancer globally. To reduce deaths from hepatitis B infection, we need more people to be tested and treated for hepatitis B. In this paper, we outline a framework of activities to reduce hepatitis B-related deaths and discuss ways in which governments could pay for them.

Global hepatitis C elimination: an investment framework

WHO has set global targets for the elimination of hepatitis B and hepatitis C as a public health threat by 2030. However, investment in elimination programmes remains low. To help drive political commitment and catalyse domestic and international financing, we have developed a global investment framework for the elimination of hepatitis B and hepatitis C. The global investment framework presented in this Health Policy paper outlines national and international activities that will enable reductions in hepatitis C incidence and mortality, and identifies potential sources of funding and tools to help countries build the economic case for investing in national elimination activities. The goal of this framework is to provide a way for countries, particularly those with minimal resources, to gain the substantial economic benefit and cost savings that come from investing in hepatitis C elimination.

Innovative strategies for the elimination of viral hepatitis at a national level: A country case series

Viral hepatitis is a leading cause of morbidity and mortality worldwide, but has long been neglected by national and international policymakers. Recent modelling studies suggest that investing in the global elimination of viral hepatitis is feasible and cost-effective. In 2016, all 194 member states of the World Health Organization endorsed the goal to eliminate viral hepatitis as a public health threat by 2030, but complex systemic and social realities hamper implementation efforts. This paper presents eight case studies from a diverse range of countries that have invested in responses to viral hepatitis and adopted innovative approaches to tackle their respective epidemics. Based on an investment framework developed to build a global investment case for the elimination of viral hepatitis by 2030, national activities and key enablers are highlighted that showcase the feasibility and impact of concerted hepatitis responses across a range of settings, with different levels of available resources and infrastructural development. These case studies demonstrate the utility of taking a multipronged, public health approach to: (a) evidence-gathering and planning; (b) implementation; and (c) integration of viral hepatitis services into the Agenda for Sustainable Development. They provide models for planning, investment and implementation strategies for other countries facing similar challenges and resource constraints.

Global progress on the elimination of viral hepatitis as a major public health threat: An analysis of WHO Member State responses 2017

In 2016, the World Health Assembly passed a resolution to eliminate viral hepatitis as a public health threat by 2030. We aimed to examine the status of the global viral hepatitis response.

Methods

In 2017, the World Health Organization (WHO) asked the Ministries of Health in all 194 Member States to complete a Country Profile on Viral Hepatitis policy uptake indicators, covering national plans/funding, engagement of civil society, testing guidance, access to treatment, and strategic information.

Results

Of 194 Member States, 135 (70%) responded, accounting for 87% of the global population infected with hepatitis B virus (HBV) and/or C virus (HCV). Of those responding, 84 (62%) had developed a national plan, of which, 49 (58%) had dedicated funding, and 62 (46%) had engaged with civil society; those engaged with civil society were more likely to have a funded plan than others (52% vs. 23%, p = 0.001). Guidance on testing pregnant women (for HBV) and people who inject drugs (for HCV) was available in 70% and 46% of Member States, respectively; 59% and 38% of Member States reported universal access to optimal therapies for HBV and HCV, respectively.

Conclusions

Most people living with hepatitis B and C reside in a country with a national hepatitis strategy. Governments who engaged with civil society were more advanced in their response. Member States need to finance these national strategies and ensure that those affected have access to hepatitis services as part of efforts to achieve universal health coverage.

Lay summary

The World Health Organization's goal to eliminate viral hepatitis as a public health threat by 2030 requires global action. Our results indicate that progress is being made by countries to scale-up national planning efforts; however, our results also highlight important gaps in current policies.

Roundtable discussion: how the World Hepatitis Summit 2015 strengthened stakeholders' efforts to combat viral hepatitis

The inaugural World Hepatitis Summit was jointly convened by the World Health Organization (WHO) and the World Hepatitis Alliance and hosted by the Scottish Government and supported by Glasgow Caledonian University and Health Protection Scotland in September 2015. The three day event convened a broad range of stakeholders to meet and share ideas, experience and best practice in addressing the many facets of viral hepatitis prevention, diagnosis and treatment.

With the next World Hepatitis Summit scheduled to take place from 1 to 3 November 2017, the World Hepatitis Alliance asked Hepatology, Medicine and Policy to commission a roundtable discussion article in order to encourage reflection on how the 2015 Summit was significant for stakeholders’ efforts and why it is important to keep the momentum going ahead of the World Hepatitis Summit 2017 and in the light of the newly adopted first-ever Global Health Sector Strategy on Viral Hepatitis.

Bottom-up Meets Top-down: Complementary Physiologically Based Pharmacokinetic and Population Pharmacokinetic Modeling for Regulatory Approval of a Dosing Algorithm of Valganciclovir in Very Young Children

Population pharmacokinetic (PopPK) and physiologically based pharmacokinetic (PBPK) models are frequently used to support pediatric drug development. Both methods have strengths and limitations and we used them complementarily to support the regulatory approval of a dosing algorithm for valganciclovir (VGCV) in children <4 months old. An existing pediatric PBPK model was extended to neonates and showed that potential physiological differences compared with older children are minor. The PopPK model was used to simulate ganciclovir (GCV) exposures in children with population typical combinations of body size and renal function and to assess the effectiveness of an alternative dosing algorithm suggested by the US Food and Drug Administration. PBPK and PopPK confirmed that the proposed VGCV dosing algorithm achieves similar GCV exposures in children of all ages and that the alternative dosing algorithm leads to underexposure in a substantial fraction of patients. Our approach raised the confidence in the VGCV dosing algorithm for children <4 months old and supported the regulatory approval.

The Effect of Propranolol on Glyceryltrinitrate-Induced Headache and Arterial Response

Prophylactic drug trials in migraine are long-lasting and expensive and require long-term toxicology information. A human migraine model would therefore be helpful in testing new drugs. Immediate headache and delayed migraine after glyceryltrinitrate (GTN) has been well characterized. We have recently shown that sodium valproate has prophylactic effect in the GTN model. Here we report our experience with propranolol in this model. Nineteen subjects with migraine without aura and 16 sex- and aged-matched healthy subjects were included in a two-centre randomized double-blind cross-over study. Fourteen migraine subjects and 14 healthy subjects completed the study and results from comparison of the 28 subjects are reported. Randomly propranolol 160 mg or placebo were each given daily for 14 days to both migraine and healthy subjects. A 20-min intravenous infusion of GTN 0.25 mg/kg per min was administered on a study day at the end of both pretreatment periods. Headache was registered for 12 h after GTN infusions. Its intensity was scored on a numerical verbal rating scale from 0 to 10. Fulfilment of International Headache Society (HIS) criteria was recorded for 24 h. Radial and superficial temporal artery diameters and blood velocity of both middle cerebral arteries were measured. All migraine subjects developed headache after GTN. No reduction of overall peak headache was found after propranolol (median 5, range 0-7) compared with placebo (median 5, range 0-10) ( P = 0.441). Eight of the 14 completing migraine subject developed IHS 1.1 migraine after GTN, two subjects on both days, three subjects only after placebo, and three subjects only after propranolol. No reduction of GTN-induced migraine was found after propranolol compared with placebo (5 vs. 5, P = 1.000). All healthy subjects developed headache after GTN. No reduction of overall peak headache was found after propranolol (median 2, range 1-5) compared with placebo (median 1, range 1-7) ( P = 0.315). Two subjects fulfilled IHS criteria 1.1 for migraine without aura after propranolol but not after placebo. The fulfilment was short lasting and did not require rescue medication. Headache after GTN was more pronounced in migraine subjects than in healthy subjects both with ( P = 0.003) and without pretreatment with propranolol ( P = 0.017). We found that 2 weeks of propranolol constricted the radial artery in healthy subjects but not in migraine subjects. GTN-induced vasodilatation abolished this difference. Mean maximum blood flow velocity in the middle cerebral artery was higher in healthy subjects than in migraine patients ( P = 0.003-0.033) and unaffected by propranolol. We observed no effect of propranolol on GTN-induced headache and migraine. This could indicate that GTN induces migraine at a deeper level of the pathophysiological cascade of migraine than the prophylactic effect of propranolol. Propranolol does not constrict cerebral arteries, which therefore cannot be part of its mechanism of action in migraine.

The state of hepatitis B and C in the Mediterranean and Balkan countries: report from a summit conference

The burden of disease due to chronic viral hepatitis constitutes a global threat. In many Balkan and Mediterranean countries, the disease burden due to viral hepatitis remains largely unrecognized, including in high-risk groups and migrants, because of a lack of reliable epidemiological data, suggesting the need for better and targeted surveillance for public health gains. In many countries, the burden of chronic liver disease due to hepatitis B and C is increasing due to ageing of unvaccinated populations and migration, and a probable increase in drug injecting. Targeted vaccination strategies for hepatitis B virus (HBV) among risk groups and harm reduction interventions at adequate scale and coverage for injecting drug users are needed. Transmission of HBV and hepatitis C virus (HCV) in healthcare settings and a higher prevalence of HBV and HCV among recipients of blood and blood products in the Balkan and North African countries highlight the need to implement and monitor universal precautions in these settings and use voluntary, nonremunerated, repeat donors. Progress in drug discovery has improved outcomes of treatment for both HBV and HCV, although access is limited by the high costs of these drugs and resources available for health care. Egypt, with the highest burden of hepatitis C in the world, provides treatment through its National Control Strategy. Addressing the burden of viral hepatitis in the Balkan and Mediterranean regions will require national commitments in the form of strategic plans, financial and human resources, normative guidance and technical support from regional agencies and research.

Quality Adjusted Time without Symptoms or Toxicities (Q-TWiST) of Ixabepilone (Ixa) Plus Capecitabine (Cape) Versus Capecitabine for Metastatic Breast Cancer (MBC) Patients with Poor Prognostic Features (PPF)

Background: Data for this analysis is provided by pooled data from 2 randomized phase III trials (046 and 048) comparing Ixa + Cape versus cape alone in women with MBC refractory to or pretreated with anthracyclines (A) and taxanes (T). Pre-specified sub-group analyses (SGA) were undertaken in MBC patients with PPF including triple negative phenotype (TN), symptomatic KPS 70-80 (KPS), and post adjuvant rapid relapse (PARR, recurrence ≤ 12 months after adjuvant A and T). For each SGA, a clinically meaningful PFS increase was seen with Ixa + Cape (Table 1), consistent with the overall population (OP). A significant overall survival (OS) improvement was not observed in the OP. In the SGA, the OS results were as follows: TN (10.3 vs 9.0 months, p=0.1802c), PARR (15.1 vs 12.5 months, p=0.2081c) and KPS (12.3 vs 9.5 months, p=0.0015c). Across SGA, treatment related adverse events (AEs) were more common for Ixa + Cape, but similar to the OP. A Q-TWiST analysis was undertaken for each SGA to evaluate the trade off between toxicity and PFS.Methods: The area under the OS curves for each SGA was partitioned into 3 health states: 1) Toxicity (TOX) - time the subject spent prior to progression with grade 3/4 treatment toxicity, 2) TWiST - time spent without grade 3/4 AEs prior to progression, 3) Relapse (REL) - time from progression to death or end of follow-up. Utility weights (UW) between 0 and 1 were assigned to the TOX and REL health states with the base case analysis using 0.5 for TOX and REL. The TWiST UW was assumed to equal 1.0 as the most favorable health state achievable. The utility weighted sum of the mean health state durations was derived and treatment comparisons were made. Sensitivity analyses were performed varying the UW of the TOX and REL states between 0 and 1 and calculating the differences in the weighted sum for all combinations.Results: For each SGA, all UW combinations for REL and TOX were associated with greater observed quality adjusted survival (QAS) durations for Ixa + Cape compared to Cape. The base case showed improvements in mean QAS in favor of Ixa + Cape (Table 1), with differences ranging from 4.9 to 9.6 weeks and the PARR group deriving the largest benefit.Median PFS and Mean QAS in Pooled PPF MBC Sub-Groups* Median PFSa, monthsMean QASb, weeksaPatient Sub-GroupsIxa + CapeCapeHR (95% CI)P value cIxa + CapeCapeP value cTN(N = 191) 4.2(N = 208) 1.70.63 (0.52 -0.77)&lt;0.0001(N = 213) 35.3(N = 230) 30.40.0031KPS(N = 268) 4.6(N = 257) 3.10.76 (0.64 - 0.90)0.0021(N = 314) 39.8(N = 292) 33.4&lt;0.0001PARR(N = 123) 5.6(N = 111) 2.80.58 (0.45 - 0.76)&lt; 0.0001(N = 149) 45.6(N = 144) 36.00.0007*Pooled data from trials 046 and 048 a PFS computed on all randomized 046 patients and 048 patients randomized to measurable disease stratum. b QAS computed on all randomized patients from both studies c Not adjusted for multiple comparisonsConclusions: This Q-TWIST analysis supports the positive benefit:risk of Ixa + Cap in MBC patients with poor prognostic features, previously treated with an A and T.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 5051.

Phase III trial of ixabepilone plus capecitabine compared to capecitabine alone in patients with metastatic breast cancer (MBC) previously treated or resistant to an anthracycline and resistant to taxanes

1006

Background: Patients with MBC who have progressed after anthracyclines and taxanes have limited treatment options. Ixabepilone, a novel epothilone B analog, is active in resistant breast cancer. Methods: In this large multinational phase III trial, patients with MBC who were anthracycline pretreated and met predefined resistance criteria to taxanes were randomized to ixabepilone (40mg/m2 IV over 3h Q3w) + capecitabine (1,000mg/m2 PO BID Q14d) or capecitabine (1,250mg/m2 PO BID Q14d). The primary endpoint was progression-free survival (PFS); secondary endpoints included objective response rate (ORR), safety, and overall survival (available after 2007). Response and progression were assessed by an independent review committee (IRC) and the investigators (INV). Results: 752 patients were randomized. Median age was 53; 84% had visceral disease, 48% and 43% had 1 and =2 prior metastatic regimens. Median of 5 and 4 cycles of ixabepilone + capecitabine and capecitabine were administered. Ixabepilone + capecitabine was superior to capecitabine. Significant benefit was consistently maintained across predefined subgroups, including HER2-/ER- /PR- and HER2+. *Primary analysis of PFS; hazard ratio= 0.75. Grade (G) 3/4 adverse events included neuropathy (ixabepilone + capecitabine 23% vs capecitabine 0%), hand-foot syndrome (18% vs 17%), and fatigue (9% vs 3%). Neuropathy was cumulative and reversible (median time to resolution of G3/4 to baseline/G1 was 6 weeks). G3 and 4 neutropenia were reported in 32% and 36% vs 9% and 2%, respectively; febrile neutropenia was 5% with ixabepilone + capecitabine. Toxic death rate was 3% vs 1%. Patients with liver dysfunction were at greater risk. Conclusions: Ixabepilone + capecitabine has superior efficacy to capecitabine across endpoints and has a manageable safety profile in this heavily pretreated population. It offers a new potential option for patients with MBC.

[Table: see text]

No significant financial relationships to disclose.

Ixabepilone given weekly in patients with advanced malignancies: Final efficacy and safety results of a phase I trial

2040

Background: Ixabepilone is a potent tubulin-targeting agent. The first epothilone analog, ixabepilone, has been developed to optimize the characteristics of the naturally occurring epothilone B. Methods: This open-label, single-arm Phase I dose escalation study was designed to establish the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), safety and a recommended dose of ixabepilone when administered as a weekly infusion to patients (pts) with solid tumors who had failed standard therapy. Eligible pts were aged ≥18 years and had histologically/cytologically confirmed solid tumor disease and an ECOG status of 0–2. Ixabepilone was administered weekly as a 30-minute infusion on a 21-day schedule. Due to neurotoxicity, infusion time was increased to 1 hour with a 1-week break allowed. Dosing ranged from 1–30 mg/m2. Tumor evaluations were performed every 6 or 8 weeks (21-day or 28-day schedule, respectively). Toxicity was evaluated continuously. Results: 34 pts were treated on the 21-day schedule (median age 55, range 30–73) and 52 on the 28-day schedule (median age 55, range 33–79). 88% of pts had received prior chemotherapy. Grade 3 fatigue was the DLT in 2 of the 4 pts treated with 30 mg/m2 ixabepilone. No DLTs were seen at doses ≤25 mg/m2 on the 21-day schedule, or at doses of 15, 20 or 25 mg/m2 on the 28-day schedule. The MTD was 25 mg/m2 for the 21-day schedule. Of 12 pts who received this dose and schedule, 7 (58%) experienced Grade 1/2 neuropathy, 1 (8%) developed Grade 3 sensory neuropathy and 3 (25%) experienced Grade 3 fatigue. Of 52 pts who received 20 mg/m2 on the 28-day schedule, 2 (13%) had Grade 3 neutropenia, 1 (7%) had Grade 3/4 sensory neuropathy and 4 (27%) had Grade 3 fatigue. Five pts (two pts [21-day schedule], three pts [28-day schedule]) with breast, colon, ovary, head and neck tumors achieved objective partial responses. Conclusions: The recommended doses of ixabepilone from this study are 25 mg/m2 (30-minute weekly infusion, 21-day schedule) and 20 mg/m2 (1-hour weekly infusion, 28-day schedule). Ixabepilone demonstrated efficacy and an acceptable safety profile in pts with a broad range of tumor types, several of whom had failed a taxane.

[Table: see text]

Final results from a phase I trial of ixabepilone in patients with advanced malignancies and lymphoma

2039

Background: Ixabepilone is the first analog in a new class of antineoplastic agents, the epothilones, which stabilizes microtubules and induces apoptosis. Ixabepilone has shown clinical activity in a broad range of tumors. Methods: This Phase I trial was designed to establish the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), efficacy, safety, pharmacokinetics and pharmacodynamics of ixabepilone when administered as a 1-hour infusion every 3 weeks to patients with advanced solid tumors or lymphoma. Eligible patients were aged ≥18 years with histologically/cytologically confirmed non-hematologic cancer, or a pathologic diagnosis of relapsed/primary refractory non-Hodgkin’s lymphoma (NHL) or relapsed/primary refractory mantle cell lymphoma, with ≤CTC Grade 1 neuropathy. Ixabepilone doses ranged from 7.5–65 mg/m2. Response was assessed every 6 weeks using RECIST. DLT was defined as Grade 4 neutropenia and/or febrile neutropenia, thrombocytopenia, ≥Grade 3 nausea/vomiting and non-hematologic toxicity, or treatment delay of >2 weeks due to delayed recovery. Results: Of 61 patients (median age 58, range 18–81), 75% had solid tumors; 25% had lymphoma. 98% and 67% of patients had received one or ≥ two prior chemotherapy regimens, respectively. The MTD of ixabepilone as a 1-hour infusion every 3 weeks was established as 50 mg/m2. The most common DLTs were neutropenia, myalgia, arthralgia and stomatitis/pharyngitis. A total of eight patients (13%) achieved a durable objective response. Complete responses were achieved in two patients with primary peritoneal cancer and NHL. A partial response was seen in six patients. The most common Grade 3/4 treatment-related adverse events (only observed at doses ≥40 mg/m2) were sensory neuropathy (13%), fatigue (13%), myalgia (10%), arthralgia (7%), nausea (5%), febrile neutropenia (5%) and neutropenia (5%). Recovery to baseline or ≤Grade 1 neuropathy occurred in some patients. Conclusions: The recommended dose of ixabepilone for the initiation of Phase II studies based on this study is 50 mg/m2 over 1 hour every 3 weeks. Ixabepilone demonstrates promising safety in patients with solid tumors or lymphoma who have failed standard therapy. Encouraging activity was reported in several tumor types.

[Table: see text]

Motifs that mediate dendritic targeting in hippocampal neurons: a comparison with basolateral targeting signals

One model for dendritic protein sorting in neurons is based on parallels with basolateral targeting in Madin-Darby Canine Kidney (MDCK) epithelial cells. The goal of this study was to further evaluate this model by analyzing the neuronal targeting of several proteins that contain well-defined basolateral sorting motifs. When we expressed FcRgammaII-B2 and CD44, two basolateral markers whose sorting depends on dihydrophobic motifs, they were unpolarized in hippocampal neurons. We also assessed the localization of the Epidermal Growth Factor Receptor (EGFR), a basolateral protein whose sorting signal contains a proline-rich motif and two dihydrophobic motifs. EGFR was restricted to the dendrites in neurons and relied on the same sorting signal for proper targeting. These results show that the dendritic sorting machinery in neurons does not recognize dihydrophobic-based basolateral sorting signals. In contrast, the sorting signal present in EGFR directs both basolateral and dendritic targeting and defines a novel dendritic targeting motif.

Environmental Effects and Economics of Mechanized Logging for Fuel Reduction in Northeastern Oregon Mixed-Conifer Stands

Fuel reduction by mechanical thinning and removal was studied in mixed-conifer stands in northeastern Oregon between 1995 and 1997. A single-grip harvester was coupled with either a forwarder or a skyline yarding system, and operational economics, fuel reduction, stand damage, soil disturbance, effects on soil biota and down-woody material were measured in three replicates of paired stands. After logging with the harvester, the two log-extraction systems achieved nearly equivalent fuel reduction with 45.7 and 46.8% mass reduction by the forwarder and skyline system, respectively. Fine-woody fuel increased slightly in all units, but mass of heavy fuels decreased. Most mass reduction in the forest floor occurred in the duff layer with 56 and 49% reduction in forwarder and skyline units, respectively. Reduction in stem density and basal area were similar for the two extraction systems; in forwarder units stem density was reduced by 61.6% and basal area by 55.4%, while in skyline units stem density was reduced by 66.5% and basal area by 51.1%. Of seedlings and trees examined, 32% had noticeable damage after harvest. Damage included bole wounding (38.9% of damaged stems), bark scraping (35.0%), wrenched stems (28.9%), broken branches (26.5%), broken terminal leaders (15.4%), and crushed foliage (4.1%). More damage occurred to residual large trees than to seedlings. Both log-extraction systems met the silvicultural prescription of reducing fuel and protecting residual large-diameter western larch, Engelmann spruce, Douglas-fir, and lodgepole pine. While fuel, stem, and basal area reduction lowered fire risk from a model 10 to a model 8 in all stands, large-woody material for wildlife also changed. Mean log length was lower in harvested units relative to unharvested controls, but this did not decrease occupation of logs by ants or the activities of woodpeckers feeding on them. Of 37 logged hectares, 1.4% (0.5 ha) of the soil area was compacted, mostly in forwarder units, within landings, and within trails close to landings. The percent area with displaced soil varied from 5 to 43% among units and was located within trails or in intertrail areas between the trails. Light displacement of soil resulted in a short-term increase in the abundance of soil microarthropods. The effects of compaction on litter microarthropods was more persistent, with lower numbers in compacted litter a year after harvest. While revenue was similar for forwarder and skyline units ($68 vs. $70/metric ton, respectively), total operational costs were $81/metric ton in the skyline units, compared to $46/metric ton in the forwarder units. These results are discussed in the context of options available to managers for balancing fuel reduction needs with both environmental and economic constraints. West. J. Appl. For. 18(4):238–249.

Odontogenic keratocyst of the maxilla presenting as periodontal abscess

This is a case report of an odontogenic keratocyst of the maxilla initially diagnosed and treated as a periodontal abscess. The occurrence of odontogenic keratocyst in the maxilla with involvement of the antrum is relatively rare. The radiological appearance of this lesion on both conventional and panoramic radiography can be misinterpreted and emphasizes the usefulness of the computed tomography in this region.

Fracture of Memotherm metallic stents in the biliary tract

In a series of 66 patients who had palliation of malignant obstructive jaundice by percutaneous placement of Memotherm expanding metal stents, we report four cases of stent fracture. This has not been reported previously.

Patterns of genital injury in female sexual assault victims

OBJECTIVE

New colposcopic protocols allow examiners to better document genital trauma in rape victims. We report our findings on the locations and types of genital injury seen in female assault victims versus women engaging in consensual sex.

STUDY DESIGN

Physical examinations were performed on 311 rape victims seen by San Luis Obispo County's Suspected Abuse Response Team between 1985 and 1993 and contemporaneously on 75 women after consensual sexual intercourse.

RESULTS

Among 213 (68%) victims with genital trauma, 162 (76%) had 3.1 mean sites of injury. Comparatively, 8 (11%) consenting women had just single-site trauma. Two hundred (94%) victims had trauma at one or more of four locations, as follows: posterior fourchette, labia minora, hymen, fossa navicularis. Trauma types varied by site; tears appeared most often on the posterior fourchette and fossa, abrasions appeared on the labia, and ecchymosis was seen on the hymen.

CONCLUSION

A localized pattern of genital trauma can frequently be seen in women reporting nonconsensual sexual intercourse; such findings are useful for the clinical forensic examiner.

The role of the radiologist in surgical management: an audit of clinico-radiological conferences

A prospective analysis of the radiological findings and final diagnoses of 342 patients discussed at joint surgical/radiological conferences over a seven-month period was undertaken in an attempt to define the role of the radiologist in the clinical management of surgical patients. Although the diagnosis had already been correctly made on clinical or radiological grounds in 38% (130/342) of patients presented at the X-ray conferences, careful review of the films resulted in an immediate firm diagnosis in a further 9% (31/342), or promoted further radiological investigations which were responsible for an eventual definitive diagnosis in 20% of the remainder (32/169). The input of the radiologist in selecting the most appropriate additional investigation was particularly valuable in the management of more complex clinical problems.

Lack of interaction between valaciclovir, the L-valyl ester of acyclovir, and Maalox antacid

Valaciclovir is rapidly and extensively converted to acyclovir. In this study we investigated the potential interaction between oral valaciclovir and Maalox. On each of three occasions 18 healthy volunteers received a single oral dose of 1000 mg valaciclovir, or 30 mL Maalox 65 min after valaciclovir administration, or 30 mL Maalox 30 min before valaciclovir. Acyclovir plasma concentrations and pharmacokinetic parameters were not significantly affected by administration of Maalox before or after valaciclovir. Therefore, there is no need for restriction of valaciclovir dosing in patients receiving antacid medication.

Inhibition of dihydropyrimidine dehydrogenase by 5-propynyluracil, a metabolite of the anti-varicella zoster virus agent netivudine

OBJECTIVE

To study the effects of the anti-herpetic drug netivudine on dihydropyrimidine dehydrogenase activity in elderly volunteers and to relate them to concentrations of netivudine and its metabolite 5-propynyluracil.

METHODS

Three groups of eight elderly volunteers received 400 or 800 mg netivudine or placebo once daily for 8 days. Plasma netivudine, 5-propynyluracil, and uracil, an indirect measure of dihydropyrimidine dehydrogenase activity, were assayed before the first dose and on days 2, 3, 5, 7 and 8. Full plasma profiles of netivudine and 5-propynyluracil were determined after the last dose.

RESULTS

Plasma uracil was unquantifiable in all subjects before the first dose and at all time points in the placebo group. In recipients of netivudine it reached a plateau between days 3 and 5, with mean values of 23.2 and 23.5 mumol/L on day 8 in the subjects who received 400 and 800 mg. Plasma netivudine concentrations were approximately dose proportional, but 5-propynyluracil concentrations were similar in both groups. The half-maximal rise in plasma uracil occurred after a cumulative 5-propynyluracil exposure of 120 mumol/L.hr; such exposures will be achieved even after doses as low as 50 to 100 mg daily.

CONCLUSIONS

Netivudine dosing produces complete inhibition of plasma dihydropyrimidine dehydrogenase. Coadministration with the antimetabolite 5-fluorouracil will require a substantial reduction in 5-fluorouracil dose to avoid toxicity but may also improve the therapeutic index of 5-fluorouracil.

Alcoholism and drug abuse in patients with PTSD

The combination of PTSD and substance abuse is both common and problematic. In this chapter we review the following questions: 1) What is the relationship between PTSD, Alcoholism, and Drug Abuse? 2) Can the general "dual diagnosis" literature be of help? 3) Is the phenomenology of PTSD combined with alcoholism and/or drug abuse either unique or specific? 4) Does current pathophysiologic data allow conceptualization of a neurobiological model of PTSD, alcoholism, and drug abuse? 5) Drawing on these ideas, on the limited treatment literature, and the "dual diagnosis" literature, can we develop rational assessment and treatment approaches? Available literature suggests that diagnoses can be validly applied to these patients; that the illnesses must be treated simultaneously as co-primary illnesses; that extreme psychological symptoms reduce the efficacy of alcoholism or drug abuse treatment; and that effective control of these symptoms improves treatment outcome.

[Injuries from mines]

In autumn 1991, 157 patients injured by mine explosions were taken care of by a Norwegian military medical unit attached to the United Nations mission in the demilitarized zone between Iraq and Kuwait. 146 of the patients were seen during a three week period of Iraqi mine harvesting in the desert. The detachment worked according to the principles of a second echelon surgical installation. The patients were operated upon if necessary, stabilized and evacuated to Iraqi hospitals. 20 patients in all (13%) died primarily. Four of 109 patients evacuated to the field hospital died (4%). 68 patients had major amputations, in seven of them two extremities were blown off. One patient had an open chest wound, two had tracheal puncture wounds, and one had penetrating head injury. 27 patients had eye injuries, 13 of which were penetrating. 64 major surgical procedures were performed. When evacuation times are long after mine injuries, approximately six hours, almost only patients with injuries to the extremities can be expected to reach hospital for treatment. The pattern of injury was regular, with crushed extremities, amputations and damaged eyes.

Dextromethorphan. An overview of safety issues

Dextromethorphan is a highly effective and widely used nonopioid antitussive drug. As it has been in use for more than 30 years, a large body of clinical experience has been used to formulate a safety profile. An anthology of adverse drug events has been analysed, drawn both from published case records and a data base recording dextromethorphan-related adverse events spontaneously reported by physicians or pharmacists. The resulting safety profile indicates that adverse drug reactions are infrequent and usually not severe. The predominant symptoms are usually dose related and include neurological, cardiovascular and gastrointestinal disturbances. Particular safety concerns arise when monoamine oxidase inhibiting (MAOI) drugs and dextromethorphan are coadministered. In addition to adverse drug reactions, the safety profile of dextromethorphan is affected by episodic and sporadic abuse. In fact, abuse appeared to be the most significant hazard identified by analysis of spontaneous adverse event reporting. No evidence could be found that the well documented pharmacokinetic polymorphism observed with dextromethorphan is correlated with any clinically significant safety risk if it is used for short term treatment. In summary, the safety profile of dextromethorphan is reassuring, particularly relating to overdose in adults and children.

Inhibition of proliferation by retinoids, cytokines and their combination in four human transformed epithelial cell lines

Various combinations of retinoids and cytokines were examined for their synergistic effect on inhibition in proliferation of four human transformed epithelial cell lines, MCF7 (mammary carcinoma), SCC4, SCC15 and A431 (squamous cell carcinomas). Synergism depended on the cell line tested, to some degree on the specific retinoid but particularly on the type of cytokine used. IFN alpha had the widest spectrum of activity. IFN gamma, TNF-alpha, IL-1, EGF and TGF-beta also exerted a synergistic effect on proliferation inhibition in certain cell lines, whereas G-CSF was inactive. Association of retinoids and cytokines represents a new approach to antitumor chemotherapy.

Pectoralis major myocutaneous flap reconstruction in head and neck surgery--experience with 60 cases

The aim of this paper is to evaluate the results of the use of the pectoralis major myocutaneous flap for reconstruction in 60 otolaryngology--head and neck patients over a five year period. There were 52 patients with Stage III (30%) and Stage IV (70%) untreated squamous cell carcinomas. Of the eight recurrent tumours, three patients had nasopharyngeal carcinoma with extensive post-radiation neck failures requiring extended neck dissections and flap reconstruction. The oral cavity and oropharynx were the predominant sites for reconstruction accounting for 70% of the operations performed. Twenty-eight patients had composite resections, ten with pectoralis osteo-myocutaneous flap incorporating a vascularised split sternum bone graft and titanium plate fixation for immediate mandibular reconstruction. All 52 patients underwent post-operative radiation. Major necrosis did not occur but minor tip necrosis of the skin island occurred in two cases (3%). The mean hospitalisation was 19 days for all patients and 21 days for patients with composite resections. The pectoralis major myocutaneous flap in our experience is not only a versatile flap but also a very reliable and robust flap for single stage immediate head and neck reconstruction.

Antiproliferative activity of retinoids, interferon alpha and their combination in five human transformed cell lines

Tretinoin, isotretinoin and acitretin were examined for their capacity to modulate the proliferation of the cell lines: HL-60 (acute promyelocytic leukemia), MCF7 (mammary carcinoma), SCC4, SCC15 and A431 (squamous cell carcinomas). Retinoids inhibited proliferation to a varying extent in all 5 cell lines. The cytokine IFN alpha had a significant antiproliferative effect only on HL-60, SCC4 and SCC15. The combination of retinoids with IFN alpha led in all 5 cell lines to a more profound reduction in proliferation than either retinoids or IFN alpha alone.

The principal tumor necrosis factor receptor in monocyte cytotoxicity is on the effector cell, not on the target cell

Several tumor target cell lines, prototypically K562 cells, are resistant to lysis by recombinant tumor necrosis factor (TNF alpha) but are killed by monocytes expressing membrane-associated TNF, suggesting that membrane TNF could account for monocyte-mediated cytotoxicity. Formaldehyde-fixed monocytes or extracted monocyte membrane fragments are cytotoxic to K562 target cells. Treatment of monocytes with interferon-gamma (IFN-gamma) increases cytotoxicity by live and fixed cells or by extracted monocyte membranes. Both TNF and TNF receptors are detectable on monocyte membranes by FACS analysis, and the levels of each are modulated by treatment with IFN-gamma. Cytotoxicity can be inhibited by either anti-TNF or anti-TNF receptor antibodies. Incubation of effector cells with exogenous soluble TNF prior to fixation or membrane preparation increases their cytotoxicity. In contrast, incubation of the target cells with exogenous TNF neither increases nor decreases killing by effector cell membrane fragments or intact effector cells. The data suggest that the TNF receptors on the effector cell, but not on the target cell, play a crucial role in TNF-mediated cytotoxicity.

Potentiation of retinoid-induced differentiation of HL-60 and U937 cell lines by cytokines

Retinoids varied in their capacity to induce differentiation in HL-60 cells in this order: Ro 13-6307, tretinoin, isotretinoin, acitretin and Ro 13-7410 (high to low). In contrast, retinoids lacking a polar carboxylic acid, such as temarotene and Ro 14-6113, were inactive. Various cytokines had no differentiation-inducing effect by themselves. However, the addition of cytokines to retinoids increased differentiation. Combined with tretinoin, cytokines increased differentiation in this order: interferon (IFN) gamma, granulocyte colony-stimulating factor, interleukin-1 alpha (IL-1 alpha), IL-4, tumour necrosis factor alpha and IFN-alpha. Combination of cytokines with isotretinoin, acitretin, Ro 13-7410, and Ro 13-6307 showed a similar pattern of potentiation to that of tretinoin. Temarotene or Ro 14-6113 did not induce differentiation, alone or with cytokines. Combinations of cytokines were not synergistic in the presence of retinoids; antagonism was even observed. In U937 cells, lower levels of differentiation-induction were observed. Potentiation of the differentiation-inducing effect of retinoids by cytokines might indicate a clinical differentiation therapy of tumours.

Modulation of human immune functions in vitro by temarotene and its metabolite

The arotinoid temarotene (Ro 15-0778) and its metabolite Ro 14-6113 were examined in a variety of in vitro assays quantitating parameters of human immune functions. Both immunosuppressive and immunostimulatory activities of these compounds were identified. These activities were compared with those of the known immunomodulatory compound ciclosporin A (CsA) at concentrations corresponding to clinically effective plasma concentrations. Like CsA, Ro 14-6113 inhibited the mitogen- or alloantigen-induced proliferation of T cells as well as their capacity to secrete interleukin-2 (IL-2), interferon-gamma and tumor necrosis factor alpha. Ro 15-0778 showed no activity in inhibiting cytokine secretion and was considerably less effective than Ro 14-6113 in inhibiting T cell proliferation. Ro 14-6113 was more effective than CsA in inhibiting IL-2 receptor expression. Ro 14-6113 modulated both positively or negatively the proliferation of B cells, depending on the concentration. Ro 14-6113 inhibited the secretion of IgM, IgG, and IgA, while stimulating IgE secretion. A different profile of activity for Ro 14-6113 and CsA was observed, suggesting differing effectiveness in immunologically mediated diseases.