Novel phase I trial design to evaluate the addition of cediranib or selumetinib to preoperative chemoradiotherapy for locally advanced rectal cancer: the DREAMtherapy trial

BACKGROUND

The DREAMtherapy (Dual REctal Angiogenesis MEK inhibition radiotherapy) trial is a novel intertwined design whereby two tyrosine kinase inhibitors (cediranib and selumetinib) were independently evaluated with rectal chemoradiotherapy (CRT) in an efficient manner to limit the extended follow-up period often required for radiotherapy studies.

PATIENTS AND METHODS

Cediranib or selumetinib was commenced 10 days before and then continued with RT (45 Gy/25#/5 wks) and capecitabine (825 mg/m2 twice a day (BID)). When three patients in the cediranib 15-mg once daily (OD) cohort were in the surveillance period, recruitment to the selumetinib cohort commenced. This alternating schedule was followed throughout. Three cediranib (15, 20 and 30 mg OD) and two selumetinib cohorts (50 and 75 mg BID) were planned. Circulating and imaging biomarkers of inflammation/angiogenesis were evaluated.

RESULTS

In case of cediranib, dose-limiting diarrhoea, fatigue and skin reactions were seen in the 30-mg OD cohort, and therefore, 20 mg OD was defined as the maximum tolerated dose. Forty-one percent patients achieved a clinical or pathological complete response (7/17), and 53% (9/17) had an excellent clinical or pathological response (ECPR). Significantly lower level of pre-treatment plasma tumour necrosis factor alpha (TNFα) was found in patients who had an ECPR. In case of selumetinib, the 50-mg BID cohort was poorly tolerated (fatigue and diarrhoea); a reduced dose cohort of 75-mg OD was opened which was also poorly tolerated, and further recruitment was abandoned. Of the 12 patients treated, two attained an ECPR (17%).

CONCLUSIONS

This novel intertwined trial design is an effective way to independently investigate multiple agents with radiotherapy. The combination of cediranib with CRT was well tolerated with encouraging efficacy. TNFα emerged as a potential predictive biomarker of response and warrants further evaluation.

Abstract P1-14-06: Selective internal radiation therapy (SIRT) with Yttrium-90 resin microspheres and FOLFOX/5FU chemotherapy in pre-treated breast cancer patients with liver metastases: A retrospective analysis of response rates, times to progression and survival of patients treated in Manchester UK between 2010 and 2016

Background:

SIRT is a globally licensed technique of Radio-Embolization (RE) of hepatic tumors via intra-arterial infusion of β-particle emitting Yttrium-90 (Y-90) radio-labelled microspheres. It increases response rates and hepatic time to progression in metastatic colorectal cancer when used in combination with 5FU/Oxaliplatin (FOLFOX) chemotherapy with acceptable toxicity profile. FOLFOX gives a radio-sensitizing effect and also controls disease outside the liver. Breast cancer liver metastases (BCLM) patients often have extra-hepatic disease and respond to multiple lines of systemic therapy and SIRT is infrequently used.

Methods and patients

Between 2010 and 2016 we treated 25 BCLM patients with Y-90 SIRT.

Receptor status: 20 ER+ve/HER-2 -ve, 3 ER-ve/HER-2 +ve, 2 triple -ve.

Eleven patients had liver only disease with 14 also having known extra-hepatic disease. Average number of previous lines of therapy in metastatic setting: chemotherapy = 2.4; endocrine = 1. Sixty-four % patients had prior Capecitabine (n=16); 12% platinum (n=3, all Carboplatin). Twenty patients received chemotherapy with SIRT: 17 had modified FOLFOX6 (Oxaliplatin/bolus 5FU day1, infusional 5FU day 1-3 (46 hrs); 3 patients had Modified de Gramont style 5FU alone. Five patients had no chemotherapy.

Sir-spheres were inserted on day 2 of FOLFOX with the 5FU infusion pump continuing to day 3. Further 2-weekly FOLFOX chemo cycles were at clinician's discretion: average number delivered 3.8. Four patients had the liver treated in two halves, approximately 6 weeks apart. One patient received SIRT only to half the liver. Patients were imaged with PET-CT/CT before and 2-3 months after SIRT. Retrospective case note review was performed and data correlated to evaluate tumor response (RR); hepatic and extra hepatic progression free survival (HPFS and EHPFS) and overall survival (OS). Accurate toxicity data was not recorded.

Results

Hepatic CT response rates: PR 56% (n=14), SD 28% (n=7) and PD 16% (n=4). Hepatic PET response rates: CR 32% (n=8), PR 40% (n=10), SD 12% (n=3), PD 16%(n=4). (Overall PET liver disease control rate = 84%).

Eight patients (32%) had extra-hepatic PD at first assessment. Of them, 4 had PR, 2 SD and 2 PD in the liver at that assessment. Two HER-2 +ve patients had brain metastases as first sign of PD within 75 days, an area not previously screened. Of 16 pre-treated with Capecitabine, liver CT response rates: 62.5% PR, 18.75% SD (n=10,3). Post SIRT/FOLFOX, average number of therapy lines: 2 for chemo and 0.75 for endocrine, with 8 patients still alive at time of censoring.

Median OS: 766 HPFS: 210 days (CI 140-286). Median EHPFS in patients with extra-hepatic disease: 152 days (CI 96-636).

Conclusions

SIRT with FOLFOX in previously treated BCLM patients produces high response rates, excellent tumor control and time to progression in the liver with good overall survival. It does not seem to decrease the ability to give further lines of chemotherapy and can be considered as an option for breast cancer patients with liver metastases.

Citation Format: Wilson G, Mullamitha S, Bentley D, Bell J, Mullan D, Carter L, Chittalia A, Howell S, Laasch H-U, Westwood T, Jeans S, Tipping J, Ryder D, Farquharson F, Arumugam P, Sheen A, Rajashanker B, Armstrong A, Misra V, Manoharan P, Lawrance J. Selective internal radiation therapy (SIRT) with Yttrium-90 resin microspheres and FOLFOX/5FU chemotherapy in pre-treated breast cancer patients with liver metastases: A retrospective analysis of response rates, times to progression and survival of patients treated in Manchester UK between 2010 and 2016 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-14-06.

Evidence of ‘sickness behaviour’ in bats with white-nose syndrome

Many animals change behaviour in response to pathogenic infections. White-nose syndrome (WNS) is a fungal skin disease causing rapid declines of North American bats. Infection with Pseudogymnoascus destructans causes hibernating bats to arouse from torpor too often, potentially causing starvation. Mechanisms underlying increased arousals are not understood but fungal invasion of the wings could trigger thirst to relieve fluid loss or grooming to relieve skin irritation. Alternatively, bats might exhibit ‘sickness behaviour’, a suite of responses to infection that save energy. We quantified behaviours of healthy and experimentally inoculated little brown bats (Myotis lucifugus) that could reflect active (i.e., drinking, grooming) or inactive (i.e., sickness behaviour) responses to infection. Infected bats groomed less and were less likely to visit their water dish compared to controls. These results are consistent with research suggesting that P. destructans causes sickness behaviour which could help bats compensate for energetic costs associated with infection.

A phase II trial of low-dose estradiol in postmenopausal women with advanced breast cancer and acquired resistance to aromatase inhibition

BACKGROUND

High-dose oestrogen (HDE) is effective but toxic in postmenopausal women with advanced breast cancer (ABC). Prolonged oestrogen deprivation sensitises BC cell lines to estrogen and we hypothesised that third-generation aromatase inhibitors (AIs) would sensitise BCs to low-dose estradiol (LDE).

METHODS

A single-arm phase II study of LDE (2 mg estradiol valerate daily) in postmenopausal women with estrogen receptor-positive (ER+) ABC. The primary end-point was clinical benefit (CB) rate. If LDE was ineffective, HDE was offered. If LDE was effective, retreatment with the pre-LDE AI was offered on progression.

RESULTS

Twenty-one patients were recruited before the trial was closed early due to slow accrual; 19 were assessable for efficacy and toxicity. CB was seen in 5 in 19 patients (26%; 95% confidence interval 9.1-51.2%), all with prolonged SD (median duration 16.8 months; range 11.0-29.6). Treatment was discontinued for toxicity in 4 in 19 patients (21%) and 8 in 11 women without hysterectomy experienced vaginal bleeding (VB). After primary LDE failure, three patients received HDE and one achieved a partial response (PR). Following CB on LDE, four patients restarted pre-LDE AI and three achieved CB including one PR. Those with CB to LDE had a significantly longer duration of first-line endocrine therapy for ABC than those without (54.9 versus 16.8 months; p < 0.01) CONCLUSION: LDE is an effective endocrine option in women with evidence of prolonged sensitivity to AI therapy. LDE is reasonably well tolerated although VB is an issue. Re-challenge with the pre-LDE AI following progression confirms re-sensitisation as a true phenomenon.

Histopathological study of placentae in low birth weight babies in India

Background:

The antenatal health-care given to pregnant women has great influence on the rates of perinatal death and morbidity. Amongst the different causes of perinatal mortality, low birth weight (LBW) is the single most significant factor therefore placenta from all the LBW babies (LBWB) should be examined routinely to find out the likely cause.

Aims:

The aims of this study were to assess the pathological changes in the placenta in association with LBWB.

Materials and Methods:

This is a Case control study performed at Medical College Allahabad,(MLN) India. In this study, 90 placentae were included. 30 placentae from full-term vaginally delivered babies, weighing more than 2500 g were included as the control group. 60 placentae belonged to babies whose birth weight was less than 2500 g (LBW). Weight of the baby was taken within the 1^st h of birth and Apgar score was noted. Gross and microscopic examination of placentae was done. Statistical correlation of was carried out between them by using SPSS 18 version. Chi-square test with or without yate's correction was used as and when required. P < 0.05 was taken as critical level of significance.

Results:

Placenta was circum-marginal in both groups. Attachment of cord was mainly central in the control group 90% (27/30), whereas eccentric attachment was prominent in patient group 66.67% (40/60). The difference was statistically significant (P < 0.001). Calcification and sub-chorionic fibrin deposition was seen in significantly higher numbers of placentae from patients than controls (P < 0.01) infarction and meconium staining were seen in placentae from patients only. Histologically placental ischemia, infarction and calcification were seen in significantly higher number of patients (P < 0.001, P < 0.001 and < 0.01 respectively). Fibrinoid necrosis, stromal fibrosis, placental dysmaturity and obstructive vasculopathy were seen in placentae from patients only.

Conclusion:

Placental pathology among LBW infants was high in comparison to control group. The findings suggest that chronic ischemia and associated secondary changes probably lead to improper perfusion and LBWB.

Comparative study of intra-operative cytology, frozen sections, and histology of tumor and tumor-like lesions of nose and paranasal sinuses

Background:

The nasal cavity and paranasal sinuses - including the maxillary, ethmoid, sphenoid, and frontal sinuses are collectively referred to as the sinonasal tract. Fine needle aspiration (FNA) of paranasal sinus lesions for early diagnosis of neoplastic lesions is difficult due to closed architecture, and only one study has been documented in the literature.

Aims:

To find the efficacy of intra-operative cytology and frozen section for frequently encountered tumor and tumor-like lesions of the nose and paranasal sinuses.

Materials and Methods:

Thirty cases were included in this study. The material for cytologic examination and frozen sections were taken per-operatively. Cytological smears were prepared by imprint/squash methods from the representative tissue pieces and stained with Leishman-Giemsa and Papanicolaou. Frozen section and paraffin-embedded section were stained with hematoxylin and eosin stain. A rapid opinion regarding the benign or malignant nature of the lesion and the type of tumor was given.

Results:

The sensitivity, specificity, and positive predictive value of imprint cytology, squash cytology, and frozen section were 100%, 100%, and 100%; 100%, 96.15%, and 80.0%; and 100%, 96.15%, and 80.0%, respectively. Overall diagnostic accuracy of imprint smears, squash smears, and frozen section was100%, 96.7%, and 96.7%, respectively. Imprint smears had better specificity as cells morphology could be more accurately appreciated.

Conclusions:

Intra-operative cytology and frozen section examinations of lesions of nose and paranasal sinuses are useful, quick, and reliable diagnostic technique for rapid diagnosis in the operation theatre and can be used as an adjunct to histopathology for better management of patients.

The effect of Zhangfei on the unfolded protein response and growth of cells derived from canine and human osteosarcomas

The objective of this study was to determine whether the protein Zhangfei could suppress the unfolded protein response (UPR) and growth of osteosarcoma cells. Dog (D-17) and a human (Saos-2) osteosarcoma cells were infected with adenovirus vectors expressing either Zhangfei or the control protein beta- galactosidase. We monitored cell growth as well as levels of UPR gene transcripts and proteins. We found that Zhangfei suppressed the growth of both D-17 and Saos-2 cells. Zhangfei-expressing D-17 cells displayed large vacuoles containing culture medium and expressed phosphatidylserine on their external surface suggesting that Zhangfei induced macropinocytosis and apoptosis in these cells. While Zhangfei inhibited the growth of both D-17 and Saos-2 cells, it inhibited thapsigargin-induced UPR, as detected by a decrease in transcripts for UPR genes, and HERP and GRP78 proteins, only in D-17 cells, suggesting that the ability of Zhangfei to suppress the UPR and tumour cells growth may not be linked.

Accumulation, detoxification, and genotoxicity of heavy metals in Indian mustard (Brassica juncea L.)

Plants of Indian mustard (Brassica juncea L.) were exposed to different concentrations (15, 30, 60, 120 microM) of (Cd, Cr, Cu, Pb) for 28 and 56 d for accumulation and detoxification studies. Metal accumulation in roots and shoots were analyzed and it was observed that roots accumulated a significant amount of Cd (1980 microg g(-1) dry weight), Cr (1540 microg g(-1) dry weight), Cu (1995 microg g(-1) dry weight), and Pb (2040 microg g(-1) dry weight) after 56 d of exposure, though in shoot this was 1110, 618, 795, and 409 microg g(-1) dry weight of Cd, Cr, Cu, and Pb, respectively. In order to assess detoxification mechanisms, non-protein thiols (NP-SH), glutathione (GSH) and phytochelatins (PCs) were analyzed in plants. An increase in the quantity of NP-SH (9.55), GSH (8.30), and PCs (1.25) micromol g(-1) FW were found at 15 microM of Cd, however, a gradual decline in quantity was observed from 15 microM of Cd onwards, after 56 d of exposure. For genotoxicity in plants, cytogenetic end-points such as mitotic index (MI), micronucleus formation (MN), mitotic aberrations (MA) and chromosome aberrations (CA) were examined in root meristem cells of B. juncea. Exposure of Cd revealed a significant (P < 0.05) inhibition of MI, induction of MA, CA, and MN in the root tips for 24 h. However, cells examined at 24 h post-exposure showed concentration-wise recovery in all the endpoints. The data revealed that Indian mustard could be used as a potential accumulator of Cd, Cr, Cu, and Pb due to a good tolerance mechanisms provided by combined/concerted action of NP-SH, GSH, and PCs. Also, exposure of Cd can cause genotoxic effects in B. juncea L. through chromosomal mutations, MA, and MN formation.

Safety of high doses of urokinase and reteplase for acute ischemic stroke

BACKGROUND AND PURPOSE

ET is considered in selected patients with AIS with persistent arterial occlusion after receiving IVT. Limited data exist on the safety of IA high doses of UK and RT for ET. We investigated any correlation between IA doses of UK or RT and safety outcomes in patients who underwent ET.

MATERIALS AND METHODS

We identified all patients from our stroke registry who received UK or RT for ET from 1998 to 2008. Demographics, baseline National Institutes of Health Stroke Scale scores, recanalization rates, rates of attempted MT, mortality, SICH, and discharge modified Rankin Scale scores were collected.

RESULTS

Of 197 patients; 72 received UK and 125 received RT. More than 90% of patients in both groups had received prior IVT. The median IA dose of UK was 200,000 U (range, 25,000-1,500,000 U) and of RT was 2 mg (range, 1-8 mg). Concurrent MT was attempted in 59.7% of UK-treated patients and 72.0% of RT-treated patients, with SICH rates of 4.2% and 8.0%, respectively. Logistic regression adjusting for prior IVT and MT revealed no correlation between SICH and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .94) or RT (OR, 0.803; 95% CI, 0.48-1.33; P = .39). There was no correlation between mortality and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .51) or RT (OR, 1.048; 95% CI, 0.77-1.42; P = .75).

CONCLUSIONS

High IA doses of UK and RT may be safe when given with or without MT in patients with AIS despite receiving a full dose of intravenous recombinant tissue plasminogen activator. These results need prospective validation.

Interfacial Properties of Si-Si3N4formed by Remote Plasma Enhanced Chemical Vapor Deposition

This paper presents results on the interfacial properties of Si3N4on NMOSFETs and PMOSFETs. Silicon nitride, formed by remote plasma enhanced chemical vapor deposition, was found to display severely degraded interfacial properties, in which the PMOS interfaces were significantly more degraded than NMOS interfaces. This is believed to be indicative of a relatively high density of interface traps located below the Si mid-gap that inhibit hole channel formation. These traps are believed to originate from the intrinsic nature of Si- Si3N4interface. Bonding constraint theory was applied to conclude that the Si-Si3N4interface is over-constrained compared to the Si-SiO2interface and consequently results in a higher intrinsic defectivity. A systematic study of the oxygen and hydrogen content in the silicon nitride film and its effect on electrical properties is also presented. Based on the electrical results it is concluded that the presence of oxygen either as a) a monolayer at the interface or b) within the silicon nitride film can produce high quality interfaces suitable for aggressively scaled CMOS devices.

The effect of transcatheter injections on cell viability and cytokine release of mononuclear cells

BACKGROUND AND PURPOSE

Several studies suggest that various types of cellular therapies enhance recovery after stroke in animal models. IA-based delivery of cells to the brain is under investigation for stroke, but it is unknown whether cells are injured as a result of being injected through a catheter or exposed to iodinated contrast medium or solutions containing heparin.

MATERIALS AND METHODS

We assessed the effect of catheterization with the Excelsior SL-10 catheter or exposure to heparin or iodine contrast on human bone marrow MNCs. Viability and cell injury were assessed by trypan blue exclusion, caspase-3 activity, and lipid peroxidation. Cellular function of MNCs was assessed by their production and release of VEGF, IL-10, and IGF-1.

RESULTS

Flow rates of 10 million cells from 0.5 to 2 mL/min did not alter MNC viability; however, 5 mL/min of MNCs did reduce viability by 19%. Iodine and low-dose heparin exposure did not affect cell viability; however, high-dose heparin was cytotoxic. Catheter delivery at 2 mL/min did not affect levels of VEGF, IL-10, or IGF-1.

CONCLUSIONS

MNCs do not appear to be damaged by heparin, iodine contrast, and the Excelsior SL-10 catheter at flow rates up to 2 mL/min. However, higher flow rates did reduce viability, and high-dose heparin did cause cell death.

Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia

BACKGROUND

Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). We determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI.

METHODS

Patients treated with IV tissue plasminogen activator (tPA) within 3 hours of symptom onset were identified from our stroke registry from June 2004 to October 2008. We collected admission NIH Stroke Scale (NIHSS) score, modified Rankin score (mRS), length of stay (LOS), symptomatic intracerebral hemorrhage (sICH), and discharge diagnosis.

RESULTS

Among 512 treated patients, 21% were found not to have an infarct on follow-up imaging. In the SM group (14%), average age was 55 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. The most common etiologies were seizure, complicated migraine, and conversion disorder. In the NNCI group (7%), average age was 61 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. Nearly all SM (87%) and NNCI (91%) patients were functionally independent on discharge (mRS 0-1).

CONCLUSIONS

Our data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct.

A micropower electrocardiogram amplifier

We introduce an electrocardiogram (EKG) preamplifier with a power consumption of 2.8 muW, 8.1 muVrms input-referred noise, and a common-mode rejection ratio of 90 dB. Compared to previously reported work, this amplifier represents a significant reduction in power with little compromise in signal quality. The improvement in performance may be attributed to many optimizations throughout the design including the use of subthreshold transistor operation to improve noise efficiency, gain-setting capacitors versus resistors, half-rail operation wherever possible, optimal power allocations among amplifier blocks, and the sizing of devices to improve matching and reduce noise. We envision that the micropower amplifier can be used as part of a wireless EKG monitoring system powered by rectified radio-frequency energy or other forms of energy harvesting like body vibration and body heat.

Live Three-Dimensional Transthoracic Echocardiographic Assessment of Transcatheter Closure of Atrial Septal Defect and Patent Foramen Ovale

We report the usefulness of live three-dimensional transthoracic echocardiography in the accurate assessment of the morphology and efficacy of Amplatzer transcatheter devices used for closure of atrial septal defect and patent foramen ovale.

What is the evidence for rechallenging with anthracyclines or taxanes in metastatic breast cancer? A review of the data

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Background: Anthracyclines and taxanes are widely used in the adjuvant setting for high risk, early stage breast cancer. This raises the issue of what is the optimal therapy for those patients who relapse, and what the potential role, if any, there is for rechallenge with these agents. The current evidence base for rechallenging with anthracyclines/anthracediones and taxanes in metastatic breast cancer (MBC) is examined in this study. Methods: Medline/Pubmed database searches were performed upto October 2008 to identify studies in which patients (pts) were rechallenged with anthracyclines/anthracediones or taxanes in MBC. Results: The efficacy data, as well as the safety data relating to neurotoxicity and cardiotoxicity from these studies, are summarized in the Table. Twenty-seven studies were identified (20=anthracycline/anthracedione, 7= taxane) of which only two were prospective studies. Both were small (n= 74 & 51) and related to anthracycline rechallenging. Conclusions: Evidence exists to support rechallenging with anthracyclines and taxanes. However, there are few prospective data on reexposure to taxanes and no data comparing anthracyclines versus taxanes following adjuvant exposure to both agents, supporting the need for clinical trials in this area. Such trials should ideally incorporate a cross-over design at treatment failure, which would shed light on the optimal sequence in which these agents should be administered.

[Table: see text]

No significant financial relationships to disclose.

Genotoxicity of cadmium on root meristem cells of Allium cepa: cytogenetic and Comet assay approach

Cytogenetic and DNA damaging effects of cadmium (Cd) were examined through chromosome aberrations (CA) and Comet assay on the root meristem cells of Allium cepa. Root meristem cells were exposed to Cd (10, 20, and 40 μM) for 24h and also left in water for 24h recovery. Exposure of Cd revealed significant (P<0.001) inhibition of mitotic index (MI), induction of CA, mitotic aberrations (MA), and micronucleus (MN) formation. Similarly, at 40 μM significant increase in the tail length (85.70 ± 9.40 μm) and tail moment (58.75 ± 5.30 μm) was observed as compared to control 4.50 ± 0.76 and 0.86 ± 0.03 μm, respectively. However, cells examined at 24h post-exposure showed concentration-dependent decline in all the endpoints. Findings of this study confirms the root meristem cells of A. cepa are suitable model for detecting both the environmentally induced CA as well as DNA damage analyzed by Comet assay.

Vascular changes and black hole phenomenon after coronary brachytherapy: a pathologically distinct entity

Restenosis remains an important issue even after coronary brachytherapy despite its efficacy in the treatment for in-stent restenosis. The acute and chronic changes in vascular wall are unique following brachytherapy. The restenotic tissue post coronary brachytherapy is relatively acellular and appears echolucent in intravascular ultrasound examination. This is dubbed the "black hole" phenomenon. Despite the similarity in the mode of action of brachytherapy and drug eluting stent implantation, the black hole phenomenon seems to be uncommon after drug-eluting stent implantation except in those patients who have had prior brachytherapy, bare-metal placement and after treatment of saphenous venous graft stenosis. It is possible that not all neointima in stents are created equal. We should propose that neointima be considered primary neointima if it forms after bare metal stenting, secondary neointima if it forms after CBT or DES, and perhaps tertiary if after combined CBT and DES. This type of classification may prove useful for research or clinical purposes. Almost certainly black hole phenomenon results from a modified neointima. However, we do not know whether this is the same restenotic tissue that was present before CBT but just depleted of its cellular element secondary to autolysis or a newly formed tertiary neointima? It is also not clear whether the changes in vascular wall and restenosis are similar after CBT or drug-eluting stent placement. However, there are some unique vascular changes that seem to be common after both of these procedures.

Role of diffusion in excitation energy transfer and migration

Effect of diffusion on excitation energy transfer and migration in a dye pair sodium fluorescein (donor) and Rhodamine-6G (acceptor) has been studied for different viscosities by both steady state and time domain fluorescence spectroscopic measurements. The donor-donor interaction appears to be weaker as compared to donor-acceptor interaction and thus favors direct Forster-type energy transfer. Interestingly, at low viscosity (water in this case) transfer appears to be controlled by material diffusion/energy migration. Further, acceptor dynamics reveals the fact that direct Forster transfer dominates in viscous media.

Use of Tandem Heart as a temporary hemodynamic support option for severe pulmonary artery hypertension complicated by cardiogenic shock

The TandemHeart is a recently-introduced percutaneous ventricular assist device that may be used for short-term hemodynamic support. Its utility has been shown for assisting the left ventricle in a variety of high-risk percutaneous interventions, in helping the left ventricle recover from myocarditis, in cardiomyopathies and in cardiogenic shock following acute coronary syndromes. Limited data exist on its applications in patients with right ventricular failure. We report our experience, possibly the first human case description, of a patient in cardiogenic shock secondary to severe pulmonary artery hypertension where the TandemHeart was used as a short-term hemodynamic support tool.

First human case description of TandemHeart-assisted high-risk percutaneous balloon aortic valvuloplasty using bivalirudin anticoagulation

TandemHeart is a recently-introduced percutaneous left ventricular assist device that can be used for hemodynamic support during high-risk interventional procedures in severely compromised patients. Angioplasty and stent placement in patients with coronary artery disease and high-risk coronary anatomy including the left main coronary artery have been described using this device. We report the first human case description of a high-risk percutaneous balloon aortic valvuloplasty for critical bicuspid aortic stenosis using the TandemHeart for periprocedural hemodynamic support. Also not previously reported is the use of bivaluridin as the periprocedural antithrombin agent during and after high-risk aortic valvuloplasty.

Survival After Disseminated Invasive Aspergillosis in a Multivisceral Transplant Recipient

Disseminated invasive aspergillosis is a serious and potentially lethal infectious complication of immunosuppressed individuals, including transplant recipients. We report here a successfully treated case of disseminated Aspergillus fumigatus infection involving the lungs, brain, and endocardium in a multivisceral transplant recipient. In addition to supportive measures, the patient was aggressively treated with a combination of three antifungal agents, and all immunosuppression was significantly lowered with close observation for rejection. After 3 months of therapy, the patient cleared the fungal infection, made a full recovery of his cerebral function, and was discharged to a rehabilitation facility.

Ileoscopy in 39 hematochezia patients with normal colonoscopy

AIM: To assess the role of retrograde terminal ileoscopy in hematochezia patients with normal colonoscopy.

METHODS: Between January 1997 and March 2005, 39 hematochezia patients (males 36, females 3, mean age 44.7 years) with a reported normal colonoscopy underwent a repeat colonoscopy. After reaching the cecum, attempt was made to localize the ileocecal valve and intubate the terminal ileum. Any abnormality in the mucosa of the terminal ileum was carefully recorded and biopsies were obtained from suspicious-looking lesions.

RESULTS: During the study period there were 39 patients admitted for hematochezia in whom colonoscopy till cecum did not reveal any abnormality. Full-length colonoscopy till the cecum could be performed in all the patients. The terminal ileum could be intubated in 36 patients. No abnormality was noted in 31 patients. Ileal ulcers were noted in two patients. Nodularity along with ulceration of the ileal mucosa, a Dieulafoy’s lesion, and an angiomatous malformation were noted in one patient each. Histological examination of the biopsies obtained from the ulcers revealed typical tuberculous lesion in the patient with nodularity and ulceration. One of the patients had typhoid ulcers and another had non-specific ulcers.

CONCLUSION: Retrograde terminal ileoscopy gives limited but valuable information, in patients with hematochezia and should be attempted in all such patients.

Endoscopic band ligation as salvage therapy in patients with bleeding peptic ulcers not responding to injection therapy

BACKGROUND AND STUDY AIM

Endoscopic band ligation has recently been used to control bleeding from a variety of nonvariceal upper gastrointestinal sources. However, it has not been used as salvage therapy in patients with peptic ulcer in whom injection therapy has failed to control bleeding. The objective was to study the role of band ligation in patients with bleeding peptic ulcer where injection therapy had failed.

PATIENTS AND METHODS

Endoscopic band ligation was attempted in patients with upper gastrointestinal bleeding from peptic ulcers in whom at least two attempts to control bleeding by injection therapy failed. Anti- Helicobacter pylori therapy was given to patients who were infected with the bacteria.

RESULTS

Endoscopic band ligation could be performed in all the 11 patients in whom it was attempted. It was successful in controlling the bleeding in all patients. Over a mean (SD) follow-up of 23.1 (14.8) months none of the patients had recurrence of ulcer or bleeding.

CONCLUSIONS

Endoscopic band ligation is an effective means of controlling bleeding in patients with bleeding peptic ulcer in whom injection therapy is not successful. Band ligation followed by anti- H. pylori therapy is useful in preventing recurrence of ulcer and bleeding in such patients.

Colonic changes in patients with cirrhosis and in patients with extrahepatic portal vein obstruction

BACKGROUND AND STUDY AIMS

Figures for the prevalence of anorectal varices and portal hypertensive colopathy have varied considerably in the available studies of patients with cirrhosis, and few studies have observed these changes in patients with extrahepatic portal vein obstruction (EHPVO). Our aim was to investigate the colonic changes, if any, in patients with EHPVO and to compare them with those seen in patients with cirrhosis of the liver.

PATIENTS AND METHODS

A total of 50 patients with cirrhosis and 35 patients with EHPVO, all of whom had a history of at least one episode of bleeding from esophageal varices, underwent both upper gastrointestinal endoscopy and colonoscopy.

RESULTS

Anorectal varices were seen more commonly in patients with EHPVO than in patients with cirrhosis (63 % vs. 38 %, P < 0.03). Of the patients with anorectal varices, large anorectal varices were also more common in patients with EHPVO than in patients with cirrhosis (73 % vs. 32 %, P < 0.01). Colopathy was noted in 40 % of patients with EHPVO and in 62 % of patients with cirrhosis (P < 0.05). Of the patients with EHPVO, colopathy was noted in 27 % of patients who also had anorectal varices and in 61.5 % of patients without anorectal varices (P < 0.05). Similarly, patients with both cirrhosis and anorectal varices were found to have a lower prevalence of colopathy than cirrhotic patients without anorectal varices (42 % vs. 74 %, P < 0.03).

CONCLUSIONS

Anorectal varices are more common in patients with EHPVO, while portal hypertensive colopathy is more common in patients with cirrhosis. Large anorectal varices are also more common in patients with EHPVO than in patients with cirrhosis and there is an inverse relationship between anorectal varices and colopathy in both cirrhotic patients and patients with EHPVO.

Low grade B cell gastric mucosa associated lymphoma presenting as upper gastrointestinal bleeding from non-healing stomal ulcers

Primary gastric lymphoma is a rare tumour. It is thought that low grade gastric mucosa associated lymphoid tissue lymphoma has not been previously reported to occur in a patient with gastrojejunostomy. This report describes such a case. The patient presented with bleeding from non-healing stomal ulcers. The ulcers healed and there was regression of the tumour after eradication of Helicobacter pylori.

Tuberculous colonic strictures: impact of dilation on diagnosis

BACKGROUND AND STUDY AIM

Colonic strictures are commonly encountered in patients with colonic tuberculosis. If the colonoscope cannot be negotiated past the stricture the procedure is abandoned, the colonic mucosa proximal to the stricture cannot be inspected, and therefore lesions in these locations may be missed.

PATIENTS AND METHODS

130 patients with colonic tuberculosis were studied. Of these 22 (17 %) had impassable colonic strictures. These strictures were dilated, the colonic mucosa proximal to the strictures was then inspected, and biopsies were obtained from lesions of suspicious appearance.

RESULTS

All strictures could be dilated. No abnormality was found in 11 patients. In the other 11 patients one or more additional findings were noted on colonoscopy after dilation. A second stricture was found in three patients. Nodularity and/or ulceration was observed in the colon proximal to the site of the primary stricture in ten patients. Dilation of the strictures and histological examination of the biopsy from target lesions of the proximal colon contributed to making the definitive diagnosis in five patients. The diagnosis was not altered in the remaining six patients.

CONCLUSION

Dilation of colonic strictures facilitates inspection of the colonic mucosa proximal to the strictures, enabling biopsy of target lesions. This approach offers important diagnostic clues and confirmation of the diagnosis in several patients in whom lesions might be missed if strictures are not dilated.

Endoscopic biopsies from normal-appearing terminal ileum and cecum in patients with suspected colonic tuberculosis

BACKGROUND AND STUDY AIMS

Colonic tuberculosis is generally diagnosed by colonoscopy and targeted biopsy of lesions. However, the diagnostic yield of colonic biopsies is not very good. So far as we are aware, there have been no studies investigating the role of biopsies from endoscopically normal-appearing cecum and terminal ileum in diagnosing colonic or ileal tuberculosis, or both.

PATIENTS AND METHODS

Patients with a clinical suspicion of colonic tuberculosis, in whom no endoscopic abnormalities were found on colonoscopy or ileoscopy, were included in the study. Multiple biopsies were obtained from the cecum and ileum.

RESULTS

Fifty patients were studied. Intubation of the terminal ileum was possible in 43 patients (86 %). Histological examination of biopsies obtained from the cecum and terminal ileum showed noncaseating granuloma in two patients. Both of these biopsies were from the terminal ileum. In two other patients, collections of loosely arranged epithelioid cells were observed. This established the diagnosis in these four patients (8 %). In the remaining 46 patients, histology showed nonspecific inflammation in 18 patients (in the cecum in 15 and in the terminal ileum in seven). The other biopsies did not show any abnormalities (33 from the cecum, 34 from the terminal ileum).

CONCLUSIONS

Histological examination of biopsies from the normal-appearing cecum and terminal ileum is useful in a small but significant number of patients with colonic tuberculosis.