A multicenter, randomized phase 2 study to establish combinations of CBP501, cisplatin and nivolumab for ≥3rd-line treatment of patients with advanced pancreatic adenocarcinoma

BACKGROUND

There is no standard of care for ≥ 3rd-line treatment of metastatic pancreatic adenocarcinoma (PDAC). CBP501 is a novel calmodulin-binding peptide that has been shown to enhance the influx of platinum agents into tumor cells and tumor immunogenicity. This study aimed to (1) confirm efficacy of CBP501/cisplatin/nivolumab for metastatic PDAC observed in a previous phase 1 study, (2) identify combinations that yield 35% 3-month progression-free survival rate (3MPFS) and (3) define the contribution of CBP501 to the effects of combination therapy.

METHODS

CBP501 16 or 25 mg/m2 (CBP(16) or CBP(25)) was combined with 60 mg/m2 cisplatin (CDDP) and 240 mg nivolumab (nivo), administered at 3-week intervals. Patients were randomized 1:1:1:1 to (1) CBP(25)/CDDP/nivo, (2) CBP(16)/CDDP/nivo, (3) CBP(25)/CDDP and (4) CDDP/nivo, with randomization stratified by ECOG PS and liver metastases. A Fleming two-stage design was used, yielding a one-sided type I error rate of 2.5% and 80% power when the true 3MPFS is 35%.

RESULTS

Among 36 patients, 3MPFS was 44.4% in arms 1 and 2, 11.1% in arm 3% and 33.3% in arm 4. Two patients achieved a partial response in arm 1 (ORR 22.2%; none in other arms). Median PFS and OS were 2.4, 2.1, 1.5 and 1.5 months and 6.3, 5.3, 3.7 and 4.9 months, respectively. Overall, all treatment combinations were well tolerated. Most treatment-related adverse events were grade 1-2.

CONCLUSIONS

The combination CBP(25)/(16)/CDDP/nivo demonstrated promising signs of efficacy and a manageable safety profile for the treatment of advanced PDAC.

CLINICAL TRIAL REGISTRATION

NCT04953962.

Prediction of 2000-m On-Water Rowing Performance with Measures Derived from Instrumented Boats

PURPOSE

Rowing instrumentation systems provide measures of stroke power, stroke rate, and boat velocity during rowing races, but how well these measures predict race performance has not been reported previously.

METHODS

Data was collected per stroke from 45 2000-m races using Peach PowerLine and OptimEye S5 GPS units. The boat classes assessed were nine male singles, eight female singles, three male pairs, and six female pairs. Random effects and residuals from general linear mixed modelling of stroke velocity adjusted for stroke power, stroke rate, and mean headwind provided measures interpreted as technical efficiency, race conditions, and stroke-velocity variability. These measures, along with mean race power, mean stroke rate, and mean headwind were then included in multiple linear regressions to predict race velocity from official race times. Effects were assessed for 2-SD changes in predictors and interpreted using interval-hypothesis tests.

RESULTS

Effects of mean race power, mean stroke rate, and mean headwind on race velocity ranged from small to extremely large and were mostly decisively substantial. Effects of technical efficiency and race conditions ranged from trivial to extremely large but were generally unclear, while stroke-velocity variability had trivial-small and mostly unclear effects. Prediction error was small to moderate and decisively substantial. Men's pairs lacked sufficient data for analysis.

CONCLUSION

On-water rowing race performance can be predicted with mean race values of power, stroke rate and headwind. Estimates from stroke data are potentially useful predictors but require impractical numbers of boats and races to reduce their uncertainty.

Concurrent Validity of Power From Three On-Water Rowing Instrumentation Systems and a Concept2 Ergometer

Purpose: Instrumentation systems are increasingly used in rowing to measure training intensity and performance but have not been validated for measures of power. In this study, the concurrent validity of Peach PowerLine (six units), Nielsen-Kellerman EmPower (five units), Weba OarPowerMeter (three units), Concept2 model D ergometer (one unit), and a custom-built reference instrumentation system (Reference System; one unit) were investigated.

Methods: Eight female and seven male rowers [age, 21 ± 2.5 years; rowing experience, 7.1 ± 2.6 years, mean ± standard deviation (SD)] performed a 30-s maximal test and a 7 × 4-min incremental test once per week for 5 weeks. Power per stroke was extracted concurrently from the Reference System (via chain force and velocity), the Concept2 itself, Weba (oar shaft-based), and either Peach or EmPower (oarlock-based). Differences from the Reference System in the mean (representing potential error) and the stroke-to-stroke variability (represented by its SD) of power per stroke for each stage and device, and between-unit differences, were estimated using general linear mixed modeling and interpreted using rejection of non-substantial and substantial hypotheses.

Results: Potential error in mean power was decisively substantial for all devices (Concept2, –11 to –15%; Peach, −7.9 to −17%; EmPower, −32 to −48%; and Weba, −7.9 to −16%). Between-unit differences (as SD) in mean power lacked statistical precision but were substantial and consistent across stages (Peach, ∼5%; EmPower, ∼7%; and Weba, ∼2%). Most differences from the Reference System in stroke-to-stroke variability of power were possibly or likely trivial or small for Peach (−3.0 to −16%), and likely or decisively substantial for EmPower (9.7–57%), and mostly decisively substantial for Weba (61–139%) and the Concept2 (−28 to 177%).

Conclusion: Potential negative error in mean power was evident for all devices and units, particularly EmPower. Stroke-to-stroke variation in power showed a lack of measurement sensitivity (apparent smoothing) that was minor for Peach but larger for the Concept2, whereas EmPower and Weba added random error. Peach is therefore recommended for measurement of mean and stroke power.

Relationships between measures of boat acceleration and performance in rowing, with and without controlling for stroke rate and power output

Purpose

Boat acceleration profiles provide a valuable feedback tool by reflecting both rower technique and force application. Relationships between measures of boat acceleration and velocity to inform interpretation of boat acceleration profiles in rowing were investigated here.

Methods

Thirteen male singles, nine female singles, eight male pairs, and seven female pairs participated (national and international level, age 18–27 y). Data from each stroke for 74 2000-m races were collected using Peach PowerLine and OptimEye S5 GPS units. General linear mixed modelling established modifying effects on velocity of two within-crew SD of boat acceleration variables for each boat class, without and with adjustment for stroke rate and power, to identify potential performance-enhancement strategies for a given stroke rate and power. Measures of acceleration magnitude at six peaks or dips, and six measures of the rate of change (jerk) between these peaks and dips were analyzed. Results were interpreted using rejection of non-substantial and substantial hypotheses with a smallest substantial change in velocity of 0.3%.

Results

Several boat acceleration measures had decisively substantial effects (-2.4–2.5%) before adjustment for stroke rate and power. Most effect magnitudes reduced after adjustment for stroke rate and power, although maximum negative drive acceleration, peak drive acceleration, jerk during the mid-drive phase, and jerk in the late recovery remained decisively substantial (-1.8–1.9%) in some boat classes.

Conclusion

Greater absolute values of maximum negative drive acceleration and jerk in the late recovery are related to improved performance, likely reflecting delayed rower centre-of-mass negative acceleration in preparation for the catch. Greater absolute values of peak drive acceleration, first peak acceleration, and jerk in the early and mid-drive are also associated with improved performance, likely reflecting propulsive force during the drive. These proposed mechanisms provide potential strategies for performance enhancement additional to increases in stroke rate and power output.

Technical Determinants of On-Water Rowing Performance

Purpose: Research establishing relationships between measures of rowing technique and velocity is limited. In this study, measures of technique and their effect on rowing velocity were investigated.

Methods: Ten male singles, eight female singles, three male pairs, and six female pairs participated. Data from each stroke for forty-seven 2,000 m races were collected using Peach PowerLine and OptimEye S5 GPS units. General linear mixed modeling established modifying effects on velocity of two within-crew SD of predictor variables for each boat class, with subsequent adjustment for power, and for power and stroke rate in separate analyses. Twenty-two predictor variables were analyzed, including measures of boat velocity, gate force, and gate angle. Results were interpreted using superiority and inferiority testing with a smallest important change in velocity of 0.3%.

Results: Substantial relationships with velocity were found between most variables assessed before adjustment for power, and for power and stroke rate. Effect magnitudes were reduced for most variables after adjustment for power and further reduced after adjustment for stroke rate and power, with precision becoming inadequate in many effects. The greatest modifying effects were found for stroke rate, mean and peak force, and power output before adjustment, and for catch angle after adjustment for stroke rate and power. Substantial between-crew differences in effects were evident for most predictors in some boat classes before adjustment and in some predictors and some boat classes after adjustment for stroke rate and power.

Conclusion: The results presented reveal variables associated with improvements in rowing performance and can be used to guide technical analysis and feedback by practitioners. Higher stroke rates and greater catch angles should be targeted to improve rowing performance, and rower force development for the improvement of power output. Relationships between rowing technique and velocity can be crew-dependent and are best assessed on an individual basis for some variables.

Two-site jumps in dimethyl sulfone studied by one- and two-dimensional 17O NMR spectroscopy

Polycrystalline dimethyl sulfone is studied using central-transition oxygen-17 exchange NMR. The quadrupolar and chemical shift tensors are determined by combining quantum chemical calculations with line shape analyses of rigid-lattice spectra measured for stationary and rotating samples at several external magnetic fields. Quantum chemical computations predict that the largest principal axes of the chemical shift anisotropy and electrical field gradient tensors enclose an angle of about 73°. This prediction is successfully tested by comparison with absorption spectra recorded at three different external magnetic fields. The experimental one-dimensional motionally narrowed spectra and the two-dimensional exchange spectrum are compatible with model calculations involving jumps of the molecules about their two-fold symmetry axis. This motion is additionally investigated by means of two-time stimulated-echo spectroscopy which allows for a determination of motional correlation functions over a wider temperature range than previously reported using carbon and deuteron NMR. On the basis of suitable second-order quadrupolar frequency distributions, sin-sin stimulated-echo amplitudes are calculated for a two-site model in the limit of vanishing evolution time and compared with experimental findings. The present study thus establishes oxygen-17 NMR as a powerful method that will be particularly useful for the study of solids and liquids devoid of nuclei governed by first-order anisotropies.

Periodizing heat acclimation in elite Laser sailors preparing for a world championship event in hot conditions

Purpose: To examine the retention and re-acclimation responses during a periodized heat acclimation (HA) protocol in elite sailors preparing for the 2013 World Championships in Muscat, Oman (∼27–30°C, 40–60% RH). Methods: Two elite male Laser class sailors completed 5 consecutive days of HA (60 min per day in 35°C, 60% RH). Heat response tests (HRT) were performed on day 1 and 5 of HA, then 1 (decay 1, D1) and 2 (D2) weeks following HA. Participants were then re-acclimated (RA) for 2 days, within the next week, before a final HRT ∼72 h post-RA. Rectal temperature, plasma volume, heart rate, sweat rate, as well as thermal discomfort and rating of perceived exertion were measured during each HRT. Results: Rectal temperature decreased with HA (0.46 ± 0.05°C), while individual responses following D1, D2 and RA varied. Heart rate (14 ± 7 bpm), thermal discomfort (0.6 ± 0.1 AU) and rating of perceived exertion (1.8 ± 0.6 AU) decreased across HA, and adaptations were retained by D2. Plasma volume steadily increased over the decay period (D2 = 8.0 ± 1.3%) and after RA (15.5 ± 1.1%) compared with baseline. RA resulted in further thermoregulatory improvements in each Athlete, although individual adjustments varied. Conclusion: Heat strain was reduced in elite Laser sailors following HA and most thermoregulatory adaptations were retained for 2 weeks afterwards. RA may ‘top up’ adaptations after 2 weeks of HA decay.

Keeping your cool: possible mechanisms for enhanced exercise performance in the heat with internal cooling methods

Exercising in hot environments results in a rise in core body temperature; an effect associated with impaired performance over a variety of exercise modes and durations. Precooling has become a popular strategy to combat this impairment, as evidence has shown it to be an effective method for lowering pre-exercise core temperature, increasing heat storage capacity and improving exercise performance in the heat. To date, the majority of precooling manoeuvres have been achieved via external means, such as cold water immersion and the application of cooling garments. However, these methods have been criticized for their lack of practicality for use in major sporting competitions. Recent evidence has shown that internal or endogenous cooling methods, such as drinking cold fluids or ice slurries, are able to lower core temperature and enhance endurance performance in the heat. These methods may be more advantageous than current forms of precooling, as ingesting cold fluids or ice slurries can be easily implemented in the field and provide the additional benefit of hydrating athletes. While the precise mechanisms responsible for these performance enhancements are yet to be fully explained, the effect of ice ingestion on brain temperature, internal thermoreception and sensory responses may be involved. This article addresses the evidence supporting the use of endogenous cooling methods for improving endurance performance in the heat, as well as discussing the potential mechanisms behind the improvements observed and providing practical recommendations to optimize their success.

Pre-cooling with ice slurry ingestion leads to similar run times to exhaustion in the heat as cold water immersion

The purpose of this study was to compare the effects of pre-exercise ice slurry ingestion and cold water immersion on submaximal running time in the heat. On three separate occasions, eight males ran to exhaustion at their first ventilatory threshold in the heat (34.0 ± 0.1 ° C, 52 ± 3% relative humidity) following one of three 30 min pre-exercise manoeuvres: (1) ice slurry ingestion; (2) cold water immersion; or (3) warm fluid ingestion (control). Running time was longer following cold water immersion (56.8 ± 5.6 min; P = 0.008) and ice slurry ingestion (52.7 ± 8.4 min; P = 0.005) compared with control (46.7 ± 7.2 min), but not significantly different between cold water immersion and ice slurry ingestion (P = 0.335). During exercise, rectal temperature was lower with cold water immersion from 15 and 20 min into exercise compared with control and ice slurry ingestion, respectively, and remained lower until 40 min (P = 0.001). At exhaustion rectal temperature was significantly higher following ice slurry ingestion (39.76 ± 0.36 ° C) compared with control (39.48 ± 0.36 ° C; P = 0.042) and tended to be higher than cold water immersion (39.48 ± 0.34 ° C; P = 0.065). As run times were similar between conditions, ice slurry ingestion may be a comparable form of pre-cooling to cold water immersion.

Refractive and structural changes in infantile periocular capillary haemangioma treated with propranolol

PURPOSE

To evaluate the optical and anatomical effects of oral propranolol treatment for infantile periocular capillary haemangioma.

METHODS

All children diagnosed with infantile capillary haemangioma in 2008-2010 at a tertiary paediatric medical centre underwent comprehensive evaluation, including imaging, by a multidisciplinary team followed by oral propranolol treatment. Clinical follow-up was performed regularly until the lesions disappeared. Main outcome measures included changes in anatomical extraocular extension, refractive sphere and cylindrical power, and spherical equivalent in the involved eye before and after treatment and between the two eyes.

RESULTS

A total of 30 patients (8 male; mean age at diagnosis, 1.6±2.8 months) participated. The lesions affected the left eye in 53.3% and were located preseptally in 83.3%. Four patients (13.3%) received steroids before propranolol. A treatment dosage of 2 mg/kg per day was started at mean age 5.0±4.5 months, 3.3±4.3 months from disease onset. Side effects occurred in 11 patients and warranted a dose reduction (to 1 mg/kg per day) in 3 and treatment termination in 1. Findings were significant for mean reduction in involved extraocular area (P<0.0001), post-treatment reduction in mean cylindrical power in involved eyes (P=0.02), pre- and post-treatment differences in mean cylindrical power between involved and uninvolved eyes (P=0.02 and P=0.01, respectively), and post-treatment change in absolute values of mean spherical power between involved and uninvolved eyes (P=0.025).

CONCLUSIONS

Early diagnosis of infantile periocular capillary haemangioma and prompt treatment with propranolol lead to a significant reduction in the involved ocular area, in astigmatism, and prevent ocular/facial disfiguration/deformation, without rebound. Propranolol is recommended as the preferred treatment compared with other accepted therapies.

Ice slurry ingestion increases core temperature capacity and running time in the heat

PURPOSE

To investigate the effect of ice slurry ingestion on thermoregulatory responses and submaximal running time in the heat.

METHODS

On two separate occasions, in a counterbalanced order, 10 males ingested 7.5 g·kg(-1) of either ice slurry (-1°C) or cold water (4°C) before running to exhaustion at their first ventilatory threshold in a hot environment (34.0°C ± 0.2°C, 54.9% ± 5.9% relative humidity). Rectal and skin temperatures, HR, sweating rate, and ratings of thermal sensation and perceived exertion were measured.

RESULTS

Running time was longer (P = 0.001) after ice slurry (50.2 ± 8.5 min) versus cold water (40.7 ± 7.2 min) ingestion. Before running, rectal temperature dropped 0.66°C ± 0.14°C after ice slurry ingestion compared with 0.25°C ± 0.09°C (P = 0.001) with cold water and remained lower for the first 30 min of exercise. At exhaustion, however, rectal temperature was higher (P = 0.001) with ice slurry (39.36°C ± 0.41°C) versus cold water ingestion (39.05°C ± 0.37°C). During exercise, mean skin temperature was similar between conditions (P = 0.992), as was HR (P = 0.122) and sweat rate (P = 0.242). After ice slurry ingestion, subjects stored more heat during exercise (100.10 ± 25.00 vs 78.93 ± 20.52 W·m(-2), P = 0.005), and mean ratings of thermal sensation (P = 0.001) and perceived exertion (P = 0.022) were lower.

CONCLUSIONS

Compared with cold water, ice slurry ingestion lowered preexercise rectal temperature, increased submaximal endurance running time in the heat (+19% ± 6%), and allowed rectal temperature to become higher at exhaustion. As such, ice slurry ingestion may be an effective and practical precooling maneuver for athletes competing in hot environments.

The influence of ice slurry ingestion on maximal voluntary contraction following exercise-induced hyperthermia

The purpose of this study was to determine whether ingestion of a small bolus of ice slurry (1.25 g kg(-1)) could attenuate the reduction in maximal voluntary isometric contraction (MVC) torque output during a 2-min sustained task following exercise-induced hyperthermia. On two separate occasions, 10 males (age: 24 ± 3 years, .VO(2peak): 49.8 ± 4.7 ml kg(-1) min(-1)) ran to exhaustion at their first ventilatory threshold in a hot environment (34.1 ± 0.1°C, 49.5 ± 3.6% RH). Prior to and after exercise, subjects performed a 2-min sustained MVC of the right elbow flexors in a thermoneutral environment (24.6 ± 0.8°C, 37.2 ± 4.5% RH). The post exercise MVC was performed immediately following the ingestion of either 1.25 g kg(-1) of ice slurry (-1°C; ICE) or warm fluid (40°C; CON), in a counterbalanced and randomised order. Run time to exhaustion (42.4 ± 9.5 vs. 41.7 ± 8.7 min; p = 0.530), and rectal (39.08 ± 0.30 vs. 39.08 ± 0.30°C; p = 0.934) and skin temperatures (35.26 ± 0.65 vs. 35.28 ± 0.67°C; p = 0.922) and heart rate (189 ± 5 vs. 189 ± 6 beats min(-1); p = 0.830) at the end of the run were similar between trials. Torque output during the post-exercise 2-min sustained MVC was significantly higher (p = 0.001) following ICE (30.75 ± 16.40 Nm) compared with CON (28.69 ± 14.88 Nm). These results suggest that ice slurry ingestion attenuated the effects of exercise-induced hyperthermia on MVC, possibly via internal thermoreceptive and/or temperature-related sensory mechanisms.

Development of a novel clinical biomarker assay to detect and quantify aggrecanase-generated aggrecan fragments in human synovial fluid, serum and urine

OBJECTIVE

Proteolytic degradation of aggrecan in articular cartilage is a hallmark feature of osteoarthritis (OA). The present study was aimed at developing a sensitive enzyme linked immunosorbent assay (ELISA) for the detection of aggrecanase-cleaved fragments of aggrecan in human serum and urine to facilitate the clinical development of aggrecanase inhibitors for OA.

METHODS

The BC3 monoclonal antibody that detects the ARGS neoepitope sequence in aggrecanase-cleaved aggrecan was engineered and optimized using complementarity determining region (CDR)-saturation mutagenesis to improve its binding affinity to the neoepitope. A sandwich ELISA (BC3-C2 ELISA) was developed using the optimized alpha-ARGS antibody (BC3-C2) as capture antibody and a commercially available antibody directed against the hyaluronic-acid binding region (HABR) of aggrecan as detection antibody. Aggrecanase-cleaved fragments of aggrecan present in in vitro digests, human cartilage explant culture supernatants and in human synovial fluid, serum and urine were detected and quantified using this ELISA.

RESULTS

The optimized antibody had a 4-log improvement in affinity for the ARGS containing peptide compared to the parental BC3 antibody, while maintaining the ability to not cross-react with a spanning peptide. The BC3-C2 ELISA demonstrated the ability to detect aggrecanase-cleaved aggrecan fragments in the native state, without the need for deglycosylation. This ELISA was able to measure aggrecanase-generated ARGS containing aggrecan fragments in human articular cartilage (HAC) explant cultures in the basal state (without cytokine stimulation). Treatment with an aggrecanase inhibitor resulted in a dose-dependent inhibition of ARGS neoepitope released into the culture supernatant. The ELISA assay also enabled the detection of ARGS containing fragments in human synovial fluid, serum and urine, suggesting its potential utility as a biomarker of aggrecanase activity.

CONCLUSIONS

We have developed a novel ELISA using an optimized ARGS antibody and have demonstrated for the first time, an ELISA-based measurement of aggrecan degradation products in human serum and urine. This assay has the potential to serve as a mechanistic drug activity biomarker in the clinic and is expected to significantly impact/accelerate the clinical development of aggrecanase inhibitors and other disease modifying drugs for OA.

Tracking clinical trial accrual strategies and barriers via a Web-based screening tool

6586

Background: The National Cancer Institute Community Cancer Centers Program (NCCCP) has developed a web based tracking tool to monitor screening of patients for clinical trial participation. The system is designed to collect data from multiple research sites throughout the geographically diverse group. The log blindly collects patient demographics, successful trial entry, and reasons for trial enrollment failure. Methods: Seven NCCCP sites utilized the log during the 60 day open accrual period for the Wake Forrest WFU 07–02–03 cancer control trial (chronic lymphocytic leukemia COLD- fX) in Novermber 2008 and December 2008. Results: 327 chronic lymphocytic leukemia patients were screened mostly by chart review. 162 (50%) were eligible for study entry. 45 (14%) entered the trial. 103 (31%) eligible patients declined entry. Of the 103, 72 (70%) did not wish to participate in research, 15 (15%) had travel constraints, 5 (5%) perceived excess toxicity, 9 (9%) gave no reason. 14 (3%) eligible had their physician decline entry. Overall, 28% of eligible patients entered the trial. 165 (50%) were trial ineligible. 82 (50%) for prior therapy, 30 (18%) for co morbid conditions, 10 (6%) missed an entry time requirement, 39 (24%) have incomplete data. Conclusions: The NCCCP trial screening log successfully captures real time clinical trial participation data from a diverse network of clinical trial sites. This data base will allow future analysis of individual clinical trial and site accrual barriers and empower strategies to increase trial participation.

No significant financial relationships to disclose.

Tricuspid valve group B streptococcal endocarditis after an elective termination of pregnancy

A patient developed fever, chills, and shortness of breath after an elective first trimester dilation and curettage. Blood cultures grew Group B streptococcus, and a transesophageal echocardiogram revealed a 2 x 2 cm vegetation on the tricuspid valve and global left ventricular hypokinesis. A 6-week course of parenteral antibiotics and vasodilator therapy resulted in resolution of the valvular vegetation as well as of the left ventricular dysfunction.

Hepatic arterial Fotemustine chemotherapy in patients with liver metastases from cutaneous melanoma is as effective as in ocular melanoma

AIM

Hepatic metastases from melanoma are associated with poor prognosis. Systemic chemotherapy and biological treatments remain unsatisfactory. This study investigated the impact of hepatic arterial chemotherapy in patients with ocular and cutaneous melanoma.

METHODS

In a retrospectively analysed observational study, 36 consecutive patients with hepatic metastases from ocular or cutaneous melanoma were assigned for surgical hepatic port-catheter implantation. Fotemustine was delivered weekly for a 4-week period, followed by a 5-week rest and a maintenance period every 3 weeks until progression. Overall survival, response and toxicity were analysed and compared.

RESULTS

After port-catheter implantation 30/36 patients were finally treated (18 with ocular and 12 with cutaneous melanoma). A median of 8 infusions per patient were delivered (range 3-24). 30% thrombocytopenia grade >or=3, 7% neutropenia grade >or=3 but no nausea or vomiting grade >or=3 were encountered. Nine out of 30 patients achieved partial remission, 10/30 stable disease; 11/30 patients were progressive. Median survival for all treated patients was 14 months. Partial remission and stable disease were associated with a survival advantage compared to progressive disease (19 vs. 5 months). No significant difference in survival was observed for ocular versus cutaneous melanoma. Serum LDH was a significant predictor of both response and survival.

CONCLUSIONS

Hepatic arterial Fotemustine chemotherapy was well tolerated. Meaningful response and survival rates were achieved in ocular as well as cutaneous melanoma. Careful patient selection in consideration of extra-hepatic involvement is crucial for the effectiveness of this treatment. Independent from the primary melanoma site, it is debatable if patients with highly elevated serum-LDH may benefit from this approach.

Surgical strategies for gastric cancer with synchronous peritoneal carcinomatosis

BACKGROUND

Gastric cancer frequently spreads to the peritoneal cavity. Whether laparoscopy is useful in planning therapy remains controversial. The aim of this study was to investigate the value of laparoscopy and to develop a therapeutic algorithm.

METHODS

Six hundred and sixty consecutive patients with gastric cancer were included in this prospective observational study. The sensitivity of abdominal ultrasonography, computed tomography (CT) and laparoscopy for detecting peritoneal carcinomatosis was compared. The lesions were biopsied and classified as P1, P2 or P3 according to the recommendations of the Japanese Research Society for Gastric Cancer. Prognosis was determined according to the stage of peritoneal carcinomatosis and therapeutic procedure adopted.

RESULTS

One hundred and ten (16.7 per cent) of 660 patients presented with synchronous peritoneal carcinomatosis. The sensitivity for detecting peritoneal carcinomatosis was 85 per cent for laparoscopy compared with 19 per cent for ultrasonography and 28 per cent for CT. Patients with P3 disease did not benefit from additional surgery compared with chemotherapy alone. Those with P1 carcinomatosis had improved survival rates after complete resection followed by chemotherapy.

CONCLUSION

Laparoscopy improves the detection and classification of peritoneal carcinomatosis, and offers patients with gastric cancer a more individualized and effective therapy.

Sildenafil citrate use and the incidence of nonarteritic anterior ischemic optic neuropathy

Nonarteritic anterior ischemic optic neuropathy (NAION) has been reported rarely in men after taking sildenafil or other phosphodiesterase 5 inhibitors for erectile dysfunction (ED). The incidence of NAION in men receiving sildenafil treatment for ED was estimated using pooled safety data from global clinical trials and European observational studies. Based on clinical trial data in more than 13,000 men and on more than 35,000 patient-years of observation in epidemiologic studies, we estimated an incidence of 2.8 cases of NAION per 100,000 patient-years of sildenafil exposure. This is similar to estimates reported in general US population samples (2.52 and 11.8 cases per 100,000 men aged >or=50 years). The data cited herein do not suggest an increased incidence of NAION in men who took sildenafil for ED.

[The question of surgical therapy for necrolytic migratory erythema, a cutaneous disease]

Necrolytic migratory erythema (NME) is a rare paraneoplastic dermatologic condition. Its underlying cause is usually a pancreatic islet cell tumour with marked glucagon secretion. The glucagonoma syndrome is characterised by pancreatic neuroendocrine neoplasm, NME, and diabetes mellitus. We present a case of glucagonoma syndrome in a 58-year-old woman with a history of recurrent cutaneous manifestations who was referred for surgical resection of a pancreatic neoplasm after the NME was finally diagnosed. We discuss diagnostic methods, differential diagnosis, and therapeutic management of this disease.

Amantadine in treatment of chronic hepatitis C virus infection?

SUMMARY

Treatment of chronic hepatitis C (CHC) continues to be an important and growing challenge. As the response rate to FDA-approved treatment improved over the past decade, we are facing increasing number of difficult-to-treat patients such as those who have failed prior anti-viral therapy. The role of amantadine in the treatment of CHC remains unclear. Studies thus far have produced conflicting results, and type II error could not be excluded. This review summarized results published in the literature from 1997 to 2003, and reviewed the existing questions and controversies regarding the use of amantadine. Current literature suggests that amantadine is ineffective as monotherapy. Amantadine increased the sustained virologic response of certain treatment naïve patients when used in combination with interferon, and may be effective as an adjunct to interferon-based combination therapy in some patients who have failed or relapsed on prior therapy. Factors such as small sample size, patient characteristics, and differences in treatment protocols including amantadine preparation and duration of therapy might explain the conflicting observations of various studies. Further investigations are needed to define optimal dosing and formulation of amantadine, and its appropriate role in management of CHC infection.

The bile acid-activated phosphatidylinositol 3-kinase pathway inhibits Fas apoptosis upstream of bid in rodent hepatocytes

BACKGROUND & AIMS

Bile acids differentially modulate hepatocyte injury in cholestasis. Although glycochenodeoxycholate (GCDC) induces Fas-mediated hepatocyte apoptosis, taurochenodeoxycholate (TCDC) simultaneously activates a phosphatidylinositol 3-kinase (PI 3-K)-mediated survival pathway blocking Fas apoptosis. In this study, the mechanisms by which the TCDC/PI 3-K survival signal disrupts Fas signaling were examined.

METHODS

Studies were performed in primary cultures of mouse hepatocytes and the bile-salt-transporting McNtcp.24 rat hepatoma cell line.

RESULTS

GCDC, but not TCDC, resulted in cytochrome c release demonstrating that TCDC blocked apoptosis upstream of mitochondria. In contrast, both GCDC and TCDC treatment resulted in Fas aggregation and recruitment of a dominant-negative FADD green fluorescent protein (GFP) and C360S procaspase 8-GFP to the plasma membrane. Despite recruitment of procaspase 8 to the plasma membrane by both bile acids, only GCDC resulted in increases of caspase 8 activity and Bid-GFP mitochondrial translocation. However, when PI-3K was inhibited with wortmannin or dominant-negative PI 3-K, TCDC-induced Bid-GFP mitochondrial translocation and cytochrome c release.

CONCLUSIONS

The TCDC/PI 3-K survival signal blocks Fas-mediated apoptosis by preventing caspase 8 activation and Bid mitochondrial translocation. Potentiation of this survival pathway in cholestasis has the potential to attenuate liver injury.

How short can courses be in lower respiratory tract infections?

Prospective clinical studies conducted over the last 10 years provide data on which to base decisions regarding the treatment of community-acquired pneumonia (CAP), including the need for hospitalization, optimal timing of the switch from intravenous to oral antibiotic therapy and the discharge of patients. Validated treatment algorithms, such as the classification of community-acquired pneumonia, now enable decisions to be made on which patients with CAP require hospitalization, as well as identifying those who will benefit from early switch therapy. Generally, unstable CAP patients are suitable candidates for early switch therapy, which consists of rapid initiation of 1 - 2 days' intravenous therapy followed by 5 days' oral therapy, with early discharge from hospital after the receipt of one or two doses of oral antibiotic. Studies with intravenous cefuroxime and followed by oral cefuroxime axetil suggest this regimen is both effective and well tolerated as rapid switch therapy, and has the potential to reduce overall healthcare costs and improve patient satisfaction.

Behçet's syndrome with left ventricular aneurysm and ruptured renal artery pseudoaneurysm

A 21-year-old man with Behçet's syndrome presented with both a left ventricular aneurysm and a left renal artery pseudoaneurysm. After successful embolization of the ruptured pseudoaneurysm, the patient underwent successful repair of the left ventricular aneurysm. Although multiple aneurysms have been reported previously, we believe this to be the first reported case of both a ventricular aneurysm and a renal artery pseudoaneurysm afflicting a patient with Behçet's syndrome.

Mature T lymphocyte apoptosis--immune regulation in a dynamic and unpredictable antigenic environment

Apoptosis of mature T lymphocytes preserves peripheral homeostasis and tolerance by countering the profound changes in the number and types of T cells stimulated by diverse antigens. T cell apoptosis occurs in at least two major forms: antigen-driven and lymphokine withdrawal. These forms of death are controlled in response to local levels of IL-2 and antigen in a feedback mechanism termed propriocidal regulation. Active antigen-driven death is mediated by the expression of death cytokines such as FasL and TNF. These death cytokines engage specific receptors that assemble caspase-activating protein complexes. These signaling complexes tightly regulate cell death but are vulnerable to inherited defects. Passive lymphokine withdrawal death may result from the cytoplasmic activation of caspases that is regulated by mitochondria and the Bcl-2 protein. The human disease, Autoimmune Lymphoproliferative Syndrome (ALPS) is due to dominant-interfering mutations in the Fas/APO-1/CD95 receptor and other components of the death pathway. The study of ALPS patients reveals the necessity of apoptosis for preventing autoimmunity and allows the genetic investigation of apoptosis in humans. Immunological, cellular, and molecular evidence indicates that throughout the life of a T cell, apoptosis may be evoked in excessive, harmful, or useless clonotypes to preserve a healthy and balanced immune system.