Oncology Nursing Minimum Data Set (ONMDS): can we hypothesize a set of prevalent Nursing Sensitive Outcomes (NSO) in cancer patients?

Background

The nursing minimum data set (NMDS) was created in 1977 in the United States to collect uniform standardised data that could be comparable among different nursing areas or patients. So far, in the literature, an NMDS in an oncology setting has not yet been described. Considering an oncology nursing minimum data set (ONMDS), which data could be chosen to define this tool regarding cancer patient care?

Material and methods

At the European Institute of Oncology (IEO), 20 experienced oncology nurses representing surgical, medical, and critical areas participated in a nursing record working group. All nurses followed an educational course on NMDS, and they shared clinical experiences to find which data common among different areas could be useful to care. To identify these data, nurses considered three issues: what is nursing care for nurses in the IEO? What is the nurses’ responsibility in the IEO? What is the organisational nursing model in the IEO? Nurses in the IEO are autonomous in decision making and recognised by patients and by a multi-professional team; the organisational nursing model is primary nursing with patient-centred care. Nursing data must therefore show the quality and results of this care. With this in mind, the working group decided to orient the ONMDS toward nursing-sensitive outcomes (NSOs), meeting also with psychologists, physiotherapists, and dieticians. Nurses analysed Oncology Nursing Society outcomes, and through focus groups, experiential meetings, role playing, and case studies, they integrated them with other NSOs.

Results

The ONMDS is composed of 49 NSOs recognised as the most common and frequent oncologic outcomes regardless of the treatment that the patient undergoes. These outcomes were clustered into 15 categories. The categories are: gastrointestinal outcomes, genitourinary outcomes, respiratory outcomes, skin outcomes, fluid and electrolyte balance outcomes, neurological outcomes, security, functional status, vascular access outcomes, nutritional status, pain, psychosocial discomfort, activities of daily living (ADL), instrumental activities daily living (IADL), and self-care outcomes.

Conclusions

Efforts to identify an ONMDS based on NSOs allow us to develop an tool that can standardise language, assessment, and intervention, but overall could be used to measure nursing care. To evaluate these potentialities, the ONMDS was introduced into nursing records, and it was tested with a pre–post research study.

Active immunotherapy in HER2 overexpressing breast cancer: current status and future perspectives

BACKGROUND

The use of anti-HER2 monoclonal antibodies (mAbs) has improved the clinical outcome of HER2-overexpressing breast cancers (BCs). Unfortunately, often these tumors tend to relapse and, when metastatic, the duration of clinical benefit is limited over time and almost invariably followed by tumor progression. Alternative approaches to this essentially passive immunotherapy are therefore needed in HER2-overexpressing BC patients. As HER2 is one of the most suitable targets for active immunotherapy in BC, manipulating the immune system is a highly attractive approach.

MATERIAL AND METHODS

A computer-based literature search was carried out using PubMed (keywords: breast neoplasm, HER2 vaccine, immunology); data reported at international meetings were included.

RESULTS

This review provides a focus on the following active vaccinal approaches under clinical investigation against HER2-overexpressing BC: (i) peptide and protein based; (ii) DNA based; (iii) whole tumor cell based; (iv) dendritic cell based. Moreover, the review discuss future challenges in the field, trying to define the best setting for the development of this innovative strategy, considering both immunological and clinical aspects of HER2 targeting.

CONCLUSIONS

Development of effective vaccines for BC remains a distinct challenge but is likely to become a substantial advance for patients with HER2-overexpressing BCs.

Intelligent Social Media Indexing and Sharing Using an Adaptive Indexing Search Engine

Effective sharing of diverse social media is often inhibited by limitations in their search and discovery mechanisms, which are particularly restrictive for media that do not lend themselves to automatic processing or indexing. Here, we present the structure and mechanism of an adaptive search engine which is designed to overcome such limitations. The basic framework of the adaptive search engine is to capture human judgment in the course of normal usage from user queries in order to develop semantic indexes which link search terms to media objects semantics. This approach is particularly effective for the retrieval of multimedia objects, such as images, sounds, and videos, where a direct analysis of the object features does not allow them to be linked to search terms, for example, nontextual/icon-based search, deep semantic search, or when search terms are unknown at the time the media repository is built. An adaptive search architecture is presented to enable the index to evolve with respect to user feedback, while a randomized query-processing technique guarantees avoiding local minima and allows the meaningful indexing of new media objects and new terms. The present adaptive search engine allows for the efficient community creation and updating of social media indexes, which is able to instill and propagate deep knowledge into social media concerning the advanced search and usage of media resources. Experiments with various relevance distribution settings have shown efficient convergence of such indexes, which enable intelligent search and sharing of social media resources that are otherwise hard to discover.

Change in mood instability (MI) with time and treatment

Introduction

The literature indicates that most patients with Major Depression mention sudden short “mood swings” (MI) when asked. MI is known to be distressing but little is known about the treatment.

Objectives

To determine whether MI changes with community treatment of depression.

Aim

To study changes in MI with 3-6 months of treatment for depression in patients with Major Depression and complaints of MI.

Methods

34 patients with Major Depression and complaints of “mood swings” were recruited from 4 psychiatric practices. They were interviewed with the MINI diagnostic interview and the Mood Disorders Questionnaire. They completed the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory Trait Form (STAI-T), and Visual Analogue Scales for Depressed Mood (VAS) and Anxious Mood twice a day for a week. The Mean Square Successive Difference Statistic (MSSD) was calculated from the VAS readings. The BDI, STAI-T, and VAS were repeated after 6 months of treatment.

Results

25/34 patients reported past hypomania. Most patients were treated with a combination of antidepressants and mood stabilizers. The BDI and STAI-T scores improved with treatment. There was no overall change in depressed and anxious MI. Change in Depressed MI and Anxiety MI correlates with change in BDI from T1 to T2

Conclusions

Anxiety and depression improved with treatment as expected. Change in MI is inconsistent. Research into medications and psychosocial treatments that improve MI is needed and this will probably improve depression treatment outcome.

[Retroperitoneal surgery in the treatment of germ-cell tumors of the testis: retroperitoneal lymph node dissection (RPLND)]

Germ-cell tumors of the testis (GCTT) are rare, but have a high social impact. In fact they represent no more than 1% of male tumors (about 700 new cases per year in Italy), but electively occur in young patients, 20 to 40 years old, during their fully mature social and working life. More than 80% of patients are cured and return to a normal social, sexual, and working life. Improvements achieved both in diagnosis, with the use of scans (CT, MRI, US and recently PET) and of serum tumor markers alpha-fetoprotein (AFP), beta-fraction of human chorionic gonadotropin (b-HCG) and lactate dehydrogenase (LDH), and mainly in treatment, through the amelioration of radiotherapy and surgical techniques and, especially, with the introduction of Cisplatin, Etoposide and Ifosfamide in chemotherapic regimens, have made germ-cell tumor a model of "curable disease". Retroperitoneal lymph node dissection (RPLND) has indications in patients with clinical stage I (CS1) as well as in advanced disease, where it is integrated in the multimodality treatment. Anatomical studies, as well as a long-term experience, have gradually but consistently modified the surgical techniques of RPLND. Currently, "nerve sparing" RPLND represents a safe management of CS1 nonseminomatous germ cell testicular tumor with minimal morbidity and excellent outcomes. Nonetheless, surveillance and adjuvant chemotherapy are as effective as RPLND, but, in our opinion, associated with some discomforts for the patients. Laparoscopic retroperitoneal lymph node dissection (Lap-RPLND) is gaining popularity as a minimally invasive staging procedure for clinical stage I nonseminomatous testicular carcinoma, but its therapeutic role is still under investigation.

Retroperitoneal Surgery in the Treatment of Germ-Cell Tumors of the Testis: Retroperitoneal Lymph Node Dissection (RPLND)

Germ-cell tumors of the testis (GCTT) are rare, but have a high social impact. In fact they represent no more than 1% of male tumors (about 700 new cases per year in Italy), but electively occur in young patients, 20 to 40 years old, during their fully mature social and working life. More than 80% of patients are cured and return to a normal social, sexual, and working life. Improvements achieved both in diagnosis, with the use of scans (CT, MRI, US and recently PET) and of serum tumor markers alpha-fetoprotein (AFP), beta-fraction of human chorionic gonadotropin (β-HCG) and lactate dehydrogenase (LDH), and mainly in treatment, through the amelioration of radiotherapy and surgical techniques and, especially, with the introduction of Cisplatin, Etoposide and Ifosfamide in Chemotherapic regimens, have made germ-cell tumor a model of “curable disease”. Retroperitoneal lymph node dissection (RPLND) has indications in patients with clinical stage I (CS1) as well as in advanced disease, where it is integrated in the multimodality treatment. Anatomical studies, as well as a long-term experience, have gradually but consistently modified the surgical techniques of RPLND. Currently, “nerve sparing” RPLND represents a safe management of CS1 nonseminomatous germ cell testicular tumor with minimal morbidity and excellent outcomes. Nonetheless, surveillance and adjuvant chemotherapy are as effective as RPLND, but, in our opinion, associated with some discomforts for the patients. Laparoscopic retroperitoneal lymph node dissection (Lap-RPLND) is gaining popularity as a minimally invasive staging procedure for clinical stage I nonseminomatous testicular carcinoma, but its therapeutic role is still under investigation.

[State of the art and controversies in the treatment of testis germ-cell tumors (TGT)]

Many different, intersecting strategies are available for managing germ-cell cancers,particularly in early-stage disease. Which is 'right' remains a matter of debate, and requires balancing efficacy against late effects, bearing in mind the complexity of treatment strategies and the available expertise. </font></font></i>

State of the Art and Controversies in the Treatment of Testis Germ-Cell Tumors (TGT)

Many different, intersecting strategies are available for managing germ-cell cancers, particularly in early-stage disease. Which is ‘right’ remains a matter of debate, and requires balancing efficacy against late effects, bearing in mind the complexity of treatment strategies and the available expertise.

Open versus laparoscopic retroperitoneal lymph node dissection (RPLND) in clinical stage I nonseminomatous germ-cell tumors (NSGCTs): Two contemporary series from a single institution

5084

Background: Primary RPLND is our choice for clinical stage I (CSI) NSGCTs. Open RPLND (O-RPLND) has been our standard policy since 1985, while laparoscopic RPLND (L-RPLND) has been introduced since the late-1990s. Methods: Between June 2003-March 2008, 150 consecutive CSI NSGCT patients (pts) have been submitted to O-RPLND (n = 91) or L-RPLND (n = 59). Pts with high risk disease (vascular invasion/embryonal carcinoma > 90% in the primary tumor) were more frequently offered O-RPLND, while pts with low risk disease (none of the 2 above) were usually considered for L-RPLND. We reviewed our data focusing on: complications, operating time (OT), hospital stay (HS), number of removed nodes, occurrence of nodal metastases as well as of metastasis during follow-up and global need of chemotherapy (CT). Results: O-RPLND (91). 59/91 (64.8%) were high-risk patients. Median OT was 140 min (IQR 110–150). Five (5.5%) complications occurred: 4 lymphorrea and 1 hemorrhage. Median HS was 6 days (IQR 5–7). Nodal metastases were found in 24 (26.4%) pts. Median number of removed nodes was 20 (IQR 14–25). L-RPLND (59). 54/59 (91.2%) were low-risk patients. Median OT was 210 min (IQR 180–240). Ten (16.9%) complications occurred: 5 required conversions to open procedure due to intraoperative bleeding (4) or technical impossibility to conclude the procedure (1). Median HS was 4 days (IQR 4–5). Nodal metastases were found in 5 (8.5%) pts: 2 of them received immediate adjuvant CT. Median number of removed nodes was 14 (IQR 11–20). OT and HS were significantly better in O-RPLND and L-RPLND series, respectively (p.0001 at Mann Whitney test). After a median follow-up of 15.1 months (1–52), distant metastases were observed in 10 (0.7%) pts: 7/91 (7.7%) following O-RPLND and 1/59 (1.7%) following L-RPLND. CT was administered to 7 (7.7%) pts following O-RPLND and to 3 (5.1%) pts following L-RPLND. Conclusions: In this large case-series, no excess of recurrences but a higher rate of complications were recorded in L-RPLND pts. O-RPLND had a significant better OT while HS was shorter in L-RPLND series. Both procedures are still being applied: pts are currently offered one of the 2 modalities after counseling.

No significant financial relationships to disclose.

Induction of gemcitabine (GCB)-related genes by pemetrexed (MTA): Assessment of the best time interval between MTA and GCB administration

14145

Background: Both MTA and GCB are active drugs in non-small cell lung cancer (NSCLC). Many molecular events induced by MTA support the synergic interaction between the two drugs and explain why the sequence MTA ? GCB is more active than GCB ? MTA. Of major interest, MTA induces the expression of deoxycytidine kinase (dCK), the rate-limiting enzyme of GCB activation, and of the human equilibrative nucleoside transporter-1 (hENT1), the key transporter for the intracellular penetration of GCB. Even if the optimal sequence is well established, no information on the best administration time between the two drugs is available. Methods: To evaluate if there is a reproducible timing of maximum dCK and hENT1 expression by MTA, we measured these targets in patients with advanced NSCLC after administration of MTA 500 mg/m2 q2wks. All patients were not pre-treated with MTA or GCB. Gene-expression was measured in normal lymphocytes by quantitative real-time PCR (qRT-PCR), at various interval (up to 48 hrs) at each of the first 3 chemotherapy cycles. Results: Between September and December 2006, 8 out of the 19 planned patients were enrolled in the present study. At the time of this analysis, dosages from 63 samples / 9 cycles of chemotherapy are available. In all treatment cycles, qRT-PCR analysis revealed an increase of hENT1 and/or dCK genes at least in one time-point. With respect to gene expression levels at basal time, dCK increased both early (+1h: 3 out of 9 valuable cycles; + 4–6 hrs: 4 out of 9 cycles) and late (+ 24–48 hrs: 5 out of 9 cycles); hENT1 increased poorly at +1h (1 out of 6 valuable cycles) but consistently at + 4–6 hrs (5 out of 6 cycles) and late (+24–48 hrs: 6 out of 6 cycles). The increase of dCK and hENT1 gene expression was from + 15% to 285% and from 21% to + 380%, respectively. Conclusions: MTA induces GCB- related genes both at early and late time points with an inter-patients variability. The most rationale time interval between the two drugs administration will be valuated at the completion of the study.

No significant financial relationships to disclose.

A dose finding pharmacokinetic study of the tumor-targeting human L19-IL2 monoclonal antibody-cytokine fusion protein in patients with advanced solid tumors

3057

Background: L19-IL2 is a tumor targeting immunocytokine constituted by a single chain Fragment variable format directed against ED-B domain of fibronectin and the human cytokine interleukin-2 (IL-2). It has striking anticancer activity in preclinical models. We evaluated safety, pharmacokinetic profile (PK) and activity of L19-IL2 in advanced cancer patients. Patients and Methods: Five cohorts of patients with recurrent/refractory solid tumors received a dose escalation intravenous infusion of L19-IL2 (5, 10, 15, 22.5 e 30 Mio IU IL2 equivalent dose) on days 1, 3 and 5 every 21 days. Serum samples for PK assessment, immunophenotyping and assays for detection of human antifusion protein antibodies to L19 (HAFA) were collected at screening and on day 1, 3, 5 and 10 of each cycle. Results: Eighteen solid cancer patients were enrolled from 11/05 to 9/06 (6 colorectal and 3 renal cell cancer (RCC) patients, 3 with melanoma, and 1 neuroendocrine tumor, thymic carcinoma, biliary tract carcinoma, breast cancer, peritoneal mesothelioma and parotid gland carcinoma). Median age was 49 years (range 35–69), 14 patients were male and 4 female. All patients were evaluable for safety and activity. The maximum tolerated dose was determined to be 22.5 Mio IU IL-2 equivalent. Drug-related dose-limiting toxicities at 30 Mio IU L19-IL2 were hypotension requiring vaso-pressor support and acute renal failure. Treatment-related deaths did not occur, and all toxicities were reversible. Five patients achieved stable disease (RCC, n=3; biliary tract carcinoma, n=1; peritoneal mesothelioma, n=1). All other patients progressed. Immunophenotyping disclosed IL2-typical transient activation of T-cell subsets. Very preliminary data showed a weak induction of HAFA at day 10 in 5 patients. These data could not be confirmed by competition ELISA experiments. Conclusions: Up to 22.5 Mio IU IL2 equivalent of L19-IL2 can be safely administered to advanced solid cancer patients in an outpatient setting. Some evidence of clinical activity in patients susceptible to immunomodulatory therapy (RCC) was found. All observed toxicity was mild and reversible. An expanded study at recommended dose in RCC patients is currently ongoing.

[Table: see text]

Cirrhotic cardiomyopathy

Decompensated liver cirrhosis is characterized by a peripheral vasodilation with a low-resistance hyperdynamic circulation. The sustained increase of cardiac work load associated with such a condition may result in an inconstant and often subclinical series of heart abnormalities, constituting a new clinical entity known as "cirrhotic cardiomyopathy". Cirrhotic cardiomyopathy is variably associated with baseline increase in cardiac output, defective myocardial contractility and lowered systo-diastolic response to inotropic and chronotropic stimuli, down-regulated beta-adrenergic function, slight histo-morphological changes, and impaired electric "recovery" ability of ventricular myocardium. Cirrhotic cardiomyopathy is usually clinically latent or mild, likely because the peripheral vasodilation significantly reduces the left ventricle after-load, thus actually "auto-treating" the patient and masking any severe manifestation of heart failure. In cirrhotic patients, the presence of cirrhotic cardiomyopathy may become unmasked and clinically evident by certain treatment interventions that increase the effective blood volume and cardiac pre-load, including surgical or transjugular intrahepatic porto-systemic shunts, peritoneo-venous shunts (LeVeen) and orthotopic liver transplantation. Under these circumstances, an often transient overt congestive heart failure may develop, with increased cardiac output as well as right atrial, pulmonary artery and capillary wedge pressures.

What is the role of QTc prolongation assessment in new drugs development phase I oncology trials?

2006

Background: QT interval prolongation associated with “torsades de pointes” (TdP) has been a common cause of withdrawal from the market for several promising drugs. We determined the degree of QT prolongation in patients treated within a phase I study with a thioxanthone derivative known to have arrhythmogenic potential. Methods: Clinical data and serial ECGs from 31 patients with advanced tumors who received 86 courses of investigational drug were prospectively reviewed. The drug has been administered intravenously over 24 hours every 3 weeks. Patients have been on a 24 hour Holter monitor until 24 hours after infusion was complete. Three baseline ECGs were done and compared to those every 6 hours during therapy and once 6 hours after the infusion was complete. ECGs were read at a central lab according to a standard protocol. All QT measurements were then corrected for heart rate (QTc) using Bazett’s formula (QTc = QT interval divided by the square root of the R-R interval). Results: Overall,843 ECG tracings were obtained, all evaluable for analysis. No basal ECG showed significant abnormalities. Prolonged QT intervals developed in 2 patients without clinical symptoms (1 patient had intervals 500 milliseconds).In both cases it was associated with the maximum concentration of the drug. Compared with baseline, the QTc interval was prolonged by 30 to 60 milliseconds in 20% of total tracings, and by more than 60 milliseconds in 2% of ECGs. In patients receiving multiple courses, QTc intervals returned to pretreatment levels before the second course. Conclusions: The assessment of QTc prolongation was a major effort in this study but produced an accurate information about such event. In phase I study such an effort is justified when arrhythmogenicity is suspected. The timing of collection of ECGs should be guided by the available preclinical information about the pharmacokinetic profile of the drug. Nevertheless uncertainty remains regarding the specific relationship between the degree of QT prolongation and the risk of life-threatening arrhythmias. The decision to use the drug ultimately has to be based on an estimation of the perceived risk relative to expected benefits for patients.

No significant financial relationships to disclose.

Erythrocytes dynamic viscoelasticity in beta-thalassaemia minor

Beta-thalassaemia is a hereditary hemolytic disease, in which each clinic phenotype encompasses a heterogenic group of genetic alterations resulting in beta-globin chain synthesis decrease or absence in red blood cells. Studies on beta-thalassaemia carriers suggest the existence of decreased red cell deformability. The erythrocyte deformability in the blood stream is a well-known fact regarding blood circulation efficiency. Red blood cells may be considered to be viscoelastic and their behavior may be described according to complex viscoelastic parameters when they undergo oscillatory stresses. This dynamic behavior is physiologically important due to the in vivo pulsatile blood flow. The aim of the present work was to evaluate complex erythrocyte viscoelastic parameters in patients suffering from heterozygous beta-thalassaemia in comparison with healthy individuals. Our results reveal that even though thalassaemia erythrocytes show a decreased deformability in the stationary state, in a dynamic state, hemorheological alterations are only evident at low oscillatory frequencies, i.e., at lower frequencies in contrast with the normal heart rate (60 cycles/min = 1 Hz), producing no significant alterations at increased heart rate.

Absorption of sugars and amino acids by the epidermis of Aphidius ervi larvae

Aphidius ervi Haliday (Hymenoptera, Braconidae) is an endophagous parasitoid of several aphid species of economic importance, widely used in biological control. The definition of a suitable artificial diet for in vitro mass production of this parasitoid is still an unresolved issue that, to be properly addressed, requires a deeper understanding both of its nutritional needs and of the functional properties of the larval epithelia involved in nutrient absorption. The experimental evidence presented in this paper unequivocally demonstrates that the uptake of sugars and amino acids takes place through the body surface of the larval stages of A. ervi. These nutrients are efficiently absorbed by the larval epidermis, but the transport rate progressively declines over time. The epidermis exhibits a cross-reactivity to antibodies raised against the mammalian facilitative glucose transporter GLUT2 and the sodium cotransporter SGLT1. The analysis of sugar transport sensitivity to specific inhibitors indicates the involvement of GLUT2-like transporters, while a role for SGLT1-like transporters is not supported. The peculiar pathways of nutrient absorption in A. ervi larvae further corroborate the general idea that the pre-imaginal stages of endophagous koinobiont Hymenoptera, like Metazoan parasites, show a high degree of physiological integration with their hosts.

Oral desensitisation in cow milk allergy: immunological findings

In the literature there are several reports dealing with the possibility of a desensitising treatment in food allergy, but there are very few studies about the immunological mechanisms of oral desensitisation. We studied the immunological modifications in four children who underwent oral desensitisation with cow milk. Four children with cow milk allergy underwent oral desensitisation according to a standardized protocol. Total IgE, eosinophilic cationic protein in serum, and specific IgE and IgG4 to &#x03B1;-lactalbumin, to &#x03B2;-lactoglobulin and to casein were determined at the beginning of the treatment and after 6, 12 and 18 months in the 4 children treated. All the 4 treated patients successfully completed the treatment. Specific IgE to casein showed a significant reduction (p&#x003C;0.01), while specific IgG4 to &#x03B1;-lactalbumin (p&#x003C;0.02), to &#x03B2;-lactoglobulin (p&#x003C;0.01) and to casein (p&#x003C;0.01) showed a significant increase. Total IgE, eosinophilic cationic protein, and specific IgE to &#x03B1;-lactalbumin and to &#x03B2;-lactoglobulin did not show any significant modification. Control patients did not show any immunological modification and still had a positive double-blind, placebo-controlled food challenge. These results make us think that oral desensitisation in food allergy happens with the same mechanisms of traditional desensitising treatments for respiratory and insect sting allergies.

Detection of a new Mycobacterium species in wild striped bass in the Chesapeake Bay

Investigation into recent declines in striped bass health in the Chesapeake Bay in Maryland resulted in the isolation of a putative new species of Mycobacterium. This isolate was obtained from fish showing skin ulcers and internal granulomas in various organs. The isolate was slow growing at 28 degrees C; was nonchromogenic; showed no activities of nitrate reduction, catalase activity, Tween 80 hydrolysis, tellurite reduction, or arylsulfatase reduction; grew best at low salt concentrations; and was urease and pyrazinamidase positive. By PCR a unique insertional sequence was identified which matched nothing in any database. Analysis of the nearly complete 16S rRNA gene sequence also indicated a unique sequence which had 87.7% sequence homology to Mycobacterium ulcerans, 87.6% homology to Mycobacterium tuberculosis, and 85.9% homology to Mycobacterium marinum. Phylogenetic analysis placed the organism close to the tuberculosis complex. These data support the conclusion that the isolate probably represents a new mycobacterial species.

[Hepato-pulmonary syndrome and porto-pulmonary hypertension. Nosologic features and etiopathogenic considerations]

The liver controls pulmonary vascular tone by releasing vasoactive substances. In severe liver failure, the imbalance between vasodilator and vasoconstrictive mediators may lead to alteration of the respiratory function, called as hepatopulmonary syndrome (HPS, when a significant decrease of the vascular pulmonary resistance occurs, with development of intrapulmonary vascular dilatations) and portopulmonarv hypertension (PPH, when the vasoconstrictive prevalence, with an increase of the pulmonary vascular resistances). The clinical symptoms consist of various degree of dyspnea and hypoxemia. An overt "cor pulmonale" syndrome with right-side heart failure may be present in the most severe forms of PPH. The alteration of pulmonary vascularization may be diagnosed by means of pulmonary angiography, contrast-enhanced echocardiography and perfusion lung nuclear scanning of the lungs. Both clinical syndromes respond poorly to medical treatment, the unique therapeutical possibilities being represented by orthotopic liver transplantation (or combined heart-lung-liver or lung-liver transplantation in patients with severe PPH).

Phase I and pharmacologic study of weekly gemcitabine and paclitaxel in chemo-naïve patients with advanced non-small-cell lung cancer

BACKGROUND

Gemcitabine (GEM) and paclitaxel (TAX) are active, non-cross-resistant drugs in non-small-cell lung cancer (NSCLC). We performed a phase I study to determine the maximum-tolerated dose (MTD), antitumor activity and pharmacokinetics of GEM and TAX given weekly in chemo-naïve patients with advanced NSCLC.

PATIENTS AND METHODS

Escalating doses of GEM (800-2000 mg/m2) and TAX (60-100 mg/m2) were administered on days 1, 8, 15 every 4 weeks to 35 patients with advanced NSCLC. Plasma pharmacokinetics of TAX and GEM was assessed at the three higher dose-levels.

RESULTS

Dose-escalation was discontinued in absence of MTD because of increased cumulative toxicity leading to dose modification or treatment delay at levels 6 and 7 (TAX 100 mg/m2 plus GEM 1750 and, respectively, 2000 mg/m2). Hematological toxicity included grade 4 neutropenia in 3% of cycles, grade 3 thrombocytopenia in one cycle and febrile neutropenia in three cycles. Maximal non-hematological toxicity was grade 3 elevation in serum transaminases and grade 2 neuro-sensory toxicity in 8% and 5% of cycles, respectively. At the two higher dose-levels a non-linear pharmacokinetics of GEM was observed with a remarkable variability of Cmax and AUC. No pharmacokinetic interactions were reported. Objectives responses were seen at all dose levels, with an overall response rate of 43% (95% confidence interval (95% CI): 25.5%-62.6%) in 30 evaluable patients.

CONCLUSIONS

The weekly administration of GEM and TAX is very well tolerated, and has shown promising antitumor activity in NSCLC. In view of the cumulative toxicity and of the pharmacokinetic profile of GEM, doses of 1500 mg/m2 of GEM and 100 mg/m2 of TAX are recommended for phase II studies.

[Huber needle in situ inpatients under continuous infusion chemotherapy: results of a study, Phase II]

PURPOSE

Chemotherapy administered as a continuous infusion is a widely used treatment in oncology. Huber needle deserves close attention during chemotherapy, but no data are reported on how long it can be left in situ without change. We therefore evaluated the feasibility of leaving in situ the needle for a prolonged time.

METHODS

Patients candidated to continuous infusion chemotherapy were considered eligible for the study. The needle was changed at the end of the 21-day period when the patient started a new cycle of chemotherapy. On that occasion the site of injection was evaluated while replacing the needle.

RESULTS

On 129 evaluable patients submitted to continuous infusion chemotherapy, 124 patients did not demonstrate any adverse cutaneous reaction. Five patients (3.8%) presented sores but we were able to continue the treatment leaving in situ the needle.

CONCLUSION

Our results demonstrated that the needle can be left in situ for the entire time the patient is at home between cycles of chemotherapy. This procedure avoids patient stress and anxiety due to unjustified substitutions of the needle.

Clinical usefulness of patch and challenge tests in the diagnosis of cell-mediated allergy to betalactams

BACKGROUND

Literature reports dealing with cell-mediated allergy to betalactams have appeared with increasing frequency in the last years.

OBJECTIVE

To evaluate patients with such reactions and to identify cross-reactivities among betalactams in order to provide safe guidelines for their further clinical management.

METHODS

Thirty consecutive subjects with cell-mediated allergy to betalactams (history of adverse reactions to these antibiotics; serum total IgE within the normal range; absence of serum specific IgE antibodies to penicillin G and V, amoxicillin, and ampicillin; negative skin tests with a wide pattern of betalactam preparations; and positive patch-test to at least one betalactam antigenic determinant) were investigated. The subjects admitted to the study were patch tested with a wide variety of betalactam preparations in order to identify alternative molecules tolerated by the patient. To better evaluate the cross-reactivity pattern, tolerance challenges with patch-negative betalactams were also performed in each subject.

RESULTS

Both specific IgE and skin tests were negative in all patients. The skin biopsies performed on the positive patch-tested area in four patients showed a clear T-lymphocyte, CD4+-type infiltrate, thus definitely proving the occurrence of a cell-mediated response. A total of 44 adverse reactions (mean: 1.47 episodes for each patient) were reported in history, with a mean interval of 15 hours after betalactam administration. The reported symptoms were mainly cutaneous (maculo-papular rash and urticaria) and the responsible drugs were chiefly aminopenicillins (86.4% of cases) and penicillin G (9.1%). We were able to identify three separate groups of patients on the basis of clinical history, patch-test, and tolerance challenge pattern: allergy to the side chain of aminopenicillins in 16 patients (53.3%); allergy to the thiazolidine ring in 3 patients (10.0%); undetermined specificity in the remainder 11 patients (36.7%). Cross-reactivity among different betalactam molecules (revealed by positive tolerance tests performed with patch-negative betalactams) was found in 4.8% of cases only (23.3% of all investigated patients). This fact demonstrates a very high (95.2%) predictive value of a negative patch-test in excluding the occurrence of a cross-reactivity. The mis-match between patch and tolerance tests was observed in 3 out of 178 cases only (1.7% of cases, 10.5% of patients) in groups A and B, and in as much as 12.2% of cases (45.5% of subjects) in group C (P < .05).

CONCLUSIONS

Delayed allergy to betalactams (mainly to aminopenicillins) may be exerted by a cell-mediated response. Patch tests and tolerance challenges are extremely useful and safe for diagnosis and further clinical treatment of these patients, helping to identify safe alternative betalactam molecules that could be successfully tolerated by the allergic subjects.

[Dynamics of ascitic fluid in decompensated cirrhosis]

The ascitic fluid in decompensated liver cirrhosis constitutes a continuously circulating pool which carries on sustained water exchanges with plasma and extracellular fluids through the whole peritoneal membrane. The actual ascites volume results therefore from the steady-state between the formation and reabsorption transperitoneal water flows. The ascitic reabsorption concerns both the "iso-osmotic" (i.e. the portion bound to the ascitic proteins and solutes) and the "free-water" (i.e. the amount exceeding the osmotic bounding ability of the peritoneal solutes) fractions of total ascitic water. By means of a simple dilution test, it is possible an in vivo estimation of both the ascites volume and the rate of transperitoneal free-water reabsorption, which is the actual free-water peritoneal clearance (CPAL) and an evaluation of the total intra-abdominal pressure (PIA). PIA results from the sum of the ascitic hydrostatic pressure, and the tension of the abdominal wall. Diuretic administration is able to significantly reduce CPAL, inducing a negative sodium balance and thus leading to a readjustment of ascites steady-state. This fact may cause reductions of ascites volume and PIA only after several days of diuretic treatment. An acute diuretic treatment by itself, even if intensive and resulting in a rapid diuresis and a significant modification of CPAL, does not appear able to determine rapid and detectable modifications of PIA. CPAL has an intrinsic prognostic value in patients with decompensated cirrhosis, since the cumulative mortality was reported to be significantly higher in the patients with lower CPAL levels. The peritoneal clearance ability may be regarded as a compensatory mechanisms of portal hypertension, and its estimate may be a reliable index of patient's aptitude to a lower hydro-retentive trend, which is in turn correlated to a greater cirrhosis severity and a worse prognosis.

Ascites free-water dynamics in decompensated cirrhosis: effects of an acute Hemaccel infusion

BACKGROUND

Plasma-expanders (PE) are commonly employed to reduce the hemodynamic effects of large-volume paracentesis in patients with decompensated cirrhosis. The aim of this paper is to investigate the effects of PE acute administration on ascites dynamics in cirrhotic patients.

METHODS

Wash-out intraabdominal pressure (IAP), ascites volume and free-water peritoneal clearance (FWPC) were evaluated in six decompensated cirrhosis by means of a methylene-blue (MB) dilution method. The method is based on the compartmental analysis of MB peritoneal clearance and has been validated by previous deuterium oxide studies. Immediately after the MB dilution test, a rapid Hemaccel i.v. infusion (500 ml 3.5% in 15 min) was perform-ed in all subjects, thereafter carrying out a second MB test. The obtained results were analyzed by two-way variance analysis.

RESULTS

IAP and ascites volume values were not appreciably modified by the PE treatment. Following the Hemaccel infusion, only a fair reduction of FWPC values (from 88.33+/-7.78 to 76.98+/-8.09 ml/min) was observed.

CONCLUSIONS

The results obtained indicate that, at least at the employed doses, Hemaccel acute administration has a low impact on the ascites dynamics in decompensated cirrhotics. These data cannot therefore support the hypothesis of a therapeutic use of PE in ascitic patients, but to avoid excessive plasma volume reductions in association with a large volume paracentesis.

Effect of pre-treatment with inhaled furosemide on allergen nasal challenge

The inhalation of furosemide has been reported to inhibit the bronchospasm induced by several agents. In the present study, we evaluated the effect of inhaled furosemide on the specific nasal challenge test in patients with allergic rhinitis. A total of 21 consecutive patients with allergic rhinitis (positive skin test and RAST) and a positive basal nasal provocation test (NPT) with the specific allergen were investigated. In each patient, we compared the changes in nasal air-flow (anterior rhinomanometry) during NPT after inhalation of placebo and 20 mg furosemide. The previously positive NPT response to the inhalation of the specific allergen became negative after the furosemide pretreatment in 16 patients (76.2%, p < 0.001, chi-square test). The nasal air flows during NPT were significantly increased after furosemide treatment with respect to placebo inhalation (F = 17.2, d.f. = 1 and 3; p < 0.03; covariance analysis). Our results suggest that the pretreatment with inhaled furosemide in atopic subjects is able to exert a protective effect on the nasal mucosa reactivity to the specific allergen. Therefore, the anti-reactive effect of the drug on the airways is not confined to the bronchial asthmatic response.