Abstract P4-17-03: Global Cancer Institute online tumor boards to improve global patterns of clinical practice for breast cancer

Background: The Global Cancer Institute (GCI) breast cancer multi-disciplinary tumor boards (MTBs) are live, online telemedicine discussions of breast cancer patient case scenarios between breast cancer specialists in low- and middle-income countries (LMICs) and expert breast cancer specialists in the United States (US). In the US MTBs are routinely held in most cancer centers and have been shown to improve patient outcomes and patient and family quality of life. GCI launched breast cancer MTBs in 2012 with the goals to improve breast cancer patient care in underserved populations globally, to establish an online platform to allow live communication and collaboration among oncologists, and to serve as an educational tool for oncologists.

Methods: During our MTBs case scenarios are presented by global oncologists for discussion and input by a panel of both community/tertiary care expert breast oncologists from our global network. During each MTB, three cancer centers present challenging breast cancer patient scenarios. Patient scenarios are presented in English, according to a standard PowerPoint template. After presentation guideline - or clinical trial-based discussions are held for each case. As the patient cases originate from oncologists in LMICs, optimal and best locally available clinical care in rural and remote settings are discussed. For educational purposes the MTBs and the associated YouTube panel discussions are archived online and can subsequently be viewed by practicing oncologists and trainees globally. Links to relevant international guidelines, published and ongoing clinical trials, and other educational resources are also provided to all MTB attendees.

Results: Since its initiation in 2012, the GCI MTBs have engaged a network of 370 oncologists in LMICs and 20 expert panelists from nine cancer centers in the United States. Together the oncologists in LMICs represent 28 tertiary cancer centers and 116 community oncologists in 19 countries across Latin America, Eastern Europe, Asia, and Africa.

Conclusions: GCI breast cancer MTBs are a powerful educational and networking tool for oncologists in LMICs to improve their patterns of clinical practice, conduct multi-disciplinary discussions and access research collaborations. GCI invites oncologists throughout Latin America, Europe, Asia, and Africa to join our tumor boards and further expansion of its MTB network. GCI currently surveys oncologists in our network before and after attendance of MTBs to measure modifications in oncologists' practice and adherence to international clinical practice guidelines.

Citation Format: St. Louis J, Bukowski A, Paulino E, Ferreyra ME, Nunes J, Mejia G, Duarte C, Ruiz R, Touya D, Polo S, Chavarri-Guerra Y, Moreno J, Georgieva N, Tsolko T, Obayedullah Baki M, Luna HC, Goss PE. Global Cancer Institute online tumor boards to improve global patterns of clinical practice for breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P4-17-03.

Lessons learned from implementing Clostridium difficile-focused antibiotic stewardship interventions

OBJECTIVE

To determine whether controlling the prescription of targeted antibiotics would translate to a measurable reduction in hospital-onset Clostridium difficile infection (CDI) rates.

DESIGN

A multicenter before-and-after intervention comparative study.

SETTING/PARTICIPANTS

Ten medical centers in the greater New York region. Intervention group comprised of 6 facilities with early antimicrobial stewardship programs (ASPs). The 4 facilities without ASPs made up the nonintervention group.

INTERVENTIONS/METHODS

Intervention facilities identified target antibiotics using case-control studies and implemented ASP-based strategies to control their use. Pre- and postintervention hospital-onset CDI rates and antibiotic consumption were compared for a 20-month period from June 2010 to January 2012. Antibiotic usage was compared using defined daily dose, days of therapy, and number of courses prescribed. Comparisons used bivariate and regression techniques.

RESULTS

Intervention facilities identified piperacillin/tazobactam, fluoroquinolones, or cefepime (odds ratio, 2.0-9.8 in CDI case patients compared with those without CDI) as intervention targets and selected several interventions (all included a component of audit and feedback). Varying degrees of success were observed in reducing antibiotic consumption over time. Total target antibiotic use significantly decreased (P < .05) when measured by days of therapy and number of courses but not by defined daily dose. Intravenous moxifloxacin and oral ciprofloxacin use showed significant reduction when measured by defined daily dose and days of therapy (P ≤ .01). Number of courses with all forms of these antibiotics was reduced (P < .005). Intervention hospitals reported fewer hospital-onset CDI cases (2.8 rate point difference) compared with nonintervention hospitals; however, we were unable to show statistically significant decreases in aggregate hospital-onset CDI either between intervention and nonintervention groups or within the intervention group over time.

CONCLUSIONS

Although decreases in target antibiotic consumption did not translate into reductions of hospital-onset CDI in this study, many valuable lessons (including implementation strategies and antibiotic consumption measures) were learned. The findings can inform potential policy decisions regarding incorporating control of CDI and ASP as healthcare quality measures.

Prolactine borderline, a case report

Introduction

It is known that antipsychotic drugs can increase prolactinaemia, we report a case in which the use of aripiprazole after treatment with paliperidone helped regaining normality levels.

Case report

During treatment with PALiperidone12 mg/day the patient, a 27-year-old female diagnosed with borderline personality disorder, developed hyperprolactinaemia with galactorrhea and menstrual disorders. During hospitalization, aripiprazole is introduced while paliperidone is progressively decreased. Antipsychotic were prescribed because delusions of reference and auditory pseudo-hallucinations arose suddenly in a woman without history of previous psychotic breaks. Before treatment with aripiprazole, prolactinaemia was 156,96 ng/mL (pregnancy test was negative) and after stopping, paliperidone was 23,60 ng/mL.

Discussion

If hyperprolactinaemia symptoms appeared (galactorrhea…), aripiprazole is a good option if antipsychotic treatment is required. In this case, paliperidone was decreased slowly, while aripiprazole was increased, until minimum effective dose was reached.

Conclusions

Hyperprolactinaemia is a common side effect in antipsychotic treatments and if symptoms appeared aripiprazole is a good option.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Renal Autotransplantation in Lynch Syndrome: A Viable Option in a Patient With Contralateral Metachronous Ureteral Cancer

The success of human kidney allotransplantation was realized over six decades ago. First described 50 years ago, renal autotransplantation has been utilized sparingly as a salvage procedure for patients at risk of losing renal function, either from a benign or malignant condition. While classically associated with colorectal malignancies, Lynch syndrome also carries a small yet significant risk for the development of ureteral carcinoma. For these patients who develop chronic kidney disease, allotransplantation may not be an option due to the lifelong risk of several malignancies. We report the first known case of renal autotransplantation in a patient with metachronous ureteral cancer due to Lynch syndrome.

The HERC1 E3 Ubiquitin Ligase is essential for normal development and for neurotransmission at the mouse neuromuscular junction

The ubiquitin-proteasome system (UPS) plays a fundamental role in protein degradation in neurons, and there is strong evidence that it fulfills a key role in synaptic transmission. The aim of the present work was to study the implication of one component of the UPS, the HERC1 E3 Ubiquitin Ligase, in motor function and neuromuscular transmission. The tambaleante (tbl) mutant mouse carries a spontaneous mutation in HERC1 E3 Ubiquitin Ligase, provoking an ataxic phenotype that develops in the second month of life. Our results show that motor performance in mutant mice is altered at postnatal day 30, before the cerebellar neurodegeneration takes place. This defect is associated with by: (a) a reduction of the motor end-plate area, (b) less efficient neuromuscular activity in vivo, and (c) an impaired evoked neurotransmitter release. Together, these data suggest that the HERC1 E3 Ubiquitin Ligase is fundamental for normal muscle function and that it is essential for neurotransmitter release at the mouse neuromuscular junction.

Characterisation of selected active agents regarding pKa values, solubility concentrations and pH profiles by SiriusT3

The aim of this work was to determine pKa values and solubility properties of 34active agents using the SiriusT3 apparatus. The selected drug substances belong to the groups of ACE-inhibitors, β-blockers, antidiabetics and lipid lowering substances. Experimentally obtained pKa and intrinsic solubility values were compared to calculated values (program ACD/ChemSketch) and pKa values to published data as well. Solubility-pH profiles were generated to visualise the substance solubility over the gastrointestinal pH range. The relationship between the solubility characteristic of a substance, its bioavailability and categorisation according to the Biopharmaceutics Classification System (BCS) was examined as well. The results showed a good agreement between experimentally obtained, calculated and published pKa values. The measured and calculated intrinsic solubility values indicated several major deviations. All solubility-pH profiles showed the expected shape and appearance for acids, bases or zwitterionic substances. The obtained results for the pKa and solubility measurements of the examined active agents may help to predict their physicochemical behaviour in vivo, and to understand the bioavailability of the substances according to their BCS categorisation. The easy and reproducible determination of pKa and solubility values makes the SiriusT3 apparatus a useful tool in early stages of drug and formulation development.

Rotational Moulding of PVC Plastisol

The viscosity during the earlier stages of the gelation process of plastisols formulated with 15 different commercial plasticizers has been obtained. Plastisols prepared were rotomoulded and mouldings obtained were characterized according to their wall thickness distribution. This parameter strongly depends on the minimum viscosity and on the rate of viscosity change during gelation (slope of the curves during the viscosity increase), and also on the temperature where no more flow of the plastisol is observed (gelation temperature). These variables are conditioned by the characteristics of the plasticizer and PVC employed, among other variables.

The effect of plate and arm velocity and rotation rate on the wall thickness distribution was also studied.

A simple model has been proposed to correlate the initial stage of the gelation of PVC plastisols formulated with the phthalate plasticizers. The suggested model assumes that the plastisol is a suspension constituted by a continuous phase (initially pure plasticizer) and a discontinuous phase constituted by PVC particles. It has been considered that the viscosity of the plastisol is influenced by the average mass molecular weight of the continuous phase and the temperature. The quantity of PVC dissolved in the continuous phase has been calculated by using a generic n-order kinetic equation for PVC dissolution rate. Additionally, a swelling process of the PVC particle by the plasticizer has also been considered and its effect on the viscosity of the suspension has also been accounted for. The model proposed provides a very good fitting of the sharp viscosity increase observed and is useful to predict the evolution of the viscosity of the parts in a rotomoulding process.

Class II alloantibody and mortality in simultaneous liver-kidney transplantation

Hyperacute kidney rejection is unusual in crossmatch positive recipients of simultaneous liver-kidney transplants (SLKT). However, recent data suggest that these patients remain at risk for antibody-mediated kidney rejection. To further investigate the risk associated with donor-specific alloantibodies (DSA) in SLKT, we studied 86 consecutive SLKT patients with an available pre-SLKT serum sample. Serum samples were analyzed in a blinded fashion for HLA DSA using single antigen beads (median florescence intensity≥2,000=positive). Post-SLKT samples were analyzed when available (76%). Thirty patients had preformed DSA, and nine developed de novo DSA. Preformed class I DSA did not change the risk of rejection, patient or allograft survival. In contrast, preformed class II DSA was associated with a markedly increased risk of renal antibody mediated rejection (AMR) (p=0.006), liver allograft rejection (p=0.002), patient death (p=0.02), liver allograft loss (p=0.02) and renal allograft loss (p=0.045). Multivariable modeling showed class II DSA (preformed or de novo) to be an independent predictor of patient death (HR=2.2; p=0.043) and liver allograft loss (HR=2.2; p=0.044). These data warrant reconsideration of the approach to DSA in SLKT.

[Descriptive study of transexuality in Navarre]

BACKGROUND

Transexuality has been recognized in Navarre as a clinical entity that must be attended to in a multidisciplinary form in the Navarre Health Service.

METHODS

An analysis was made of the epidemiological data of 35 subjects who have attended the Navarre Transexual and Intersex Unit (UNATI - Unidad Navarra de Transexuales e Intersexos) since April 2011. The variables related to socio-demographic parameters, transexuality and treatment were collected.

RESULTS

The average age was 37.3 years. Sixty-five point seven percent of the subjects were born in Spain. Seventy-one point four percent of the users are feminine transsexuals. At present 62.9% of the subjects are receiving hormonal treatment. Amongst the feminine transexuals 20% have had a mamoplasty, 4% have had a vaginoplasty and 20% have had both operations. Ten percent of the masculine transsexuals have had a mastectomy, 10% have had a hysterectomy with double anexectomy and 10% have had both operations.

CONCLUSIONS

The majority of the transsexuals in Navarre are being evaluated in the UNATI. More feminine transsexuals have attended than masculine ones. The feminine transsexuals more frequently have reassignation surgery, while the masculine ones have extirpative surgery.

Garlic derivative propyl propane thiosulfonate is effective against broiler enteropathogens in vivo

Two experiments were carried out to study the effects of dietary supplementation with the garlic (Allium sativum)-derived product propyl propane thiosulfonate (PTS-O) on the intestinal log(10) number of copies of enteropathogens in broiler chickens, together with their intestinal morphology and growth performance. The additive had no significant effect on feed intake at any dose assayed. In experiment 1 (1 to 21 d of age), the BW of chickens fed on 45 mg of PTS-O/kg of diet was higher (P < 0.01) than that of controls. Birds fed on diets containing 45 and 90 mg of PTS-O/kg of diet had improved (P < 0.01) feed:gain ratios compared with the controls at 21 d of age. Ileal villus height, width and surface area, mucosal thickness, and muscular layer thickness were considerably greater (P < 0.01) than control values in chickens fed 90 mg of PTS-O/kg of diet. The Clostridium perfringens log(10) number of counts was not significantly affected at any dose assayed. The inclusion of PTS-O at both concentrations (45 and 90 mg/kg of diet) resulted in lower (P < 0.01) log(10) number of copies of ileal Salmonella spp. and crop enterobacteria and Escherichia coli. The inclusion of 90 mg of PTS-O/kg of diet also resulted in lower (P < 0.01) enterobacteria and E. coli log(10) numbers of copies in the ileal and cecal contents, respectively. The number of copies of Campylobacter jejuni was not significantly affected. In experiment 2 (15 to 28 d of age), lower (P < 0.01) log(10) number of copies of Salmonella spp. and C. jejuni were determined in the ileal contents of chickens fed on diets containing 135 mg of PTS-O/kg of diet. The addition of 90 mg of PTS-O/kg of diet lowered (P < 0.01) only the number of copies of ileal Salmonella spp. This investigation confirmed previous in vitro data and showed that PTS-O lowered the intestinal numbers of enteropathogens and improved the ileal histological structure and productive parameters of broilers.

Determination of conjugation rates on solid surfaces

A cytometric method for the estimation of end-point conjugation rates is developed and adapted to surface conjugation. This method improves the through-put of conjugation assays based on replica-plating and results in less noisy experimental data. Although conjugation on solid surfaces deviates from ideal conditions in which cells are continuously mixed, results show that, within the limits of high initial population densities and short mating times, end-point estimates of the conjugation rates are robust measurements. They are independent of the donor/recipient ratios and, to some extent, of the sampling time. Remixing the mating population in the course of a conjugation experiment results in a boost in the frequency of transconjugants.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Constitutive expression of short hairpin RNA in vivo triggers buildup of mature hairpin molecules

RNA interference (RNAi) has become the cornerstone technology for studying gene function in mammalian cells. In addition, it is a promising therapeutic treatment for multiple human diseases. Virus-mediated constitutive expression of short hairpin RNA (shRNA) has the potential to provide a permanent source of silencing molecules to tissues, and it is being devised as a strategy for the treatment of liver conditions such as hepatitis B and hepatitis C virus infection. Unintended interaction between silencing molecules and cellular components, leading to toxic effects, has been described in vitro. Despite the enormous interest in using the RNAi technology for in vivo applications, little is known about the safety of constitutively expressing shRNA for multiple weeks. Here we report the effects of in vivo shRNA expression, using helper-dependent adenoviral vectors. We show that gene-specific knockdown is maintained for at least 6 weeks after injection of 1 × 10(11) viral particles. Nonetheless, accumulation of mature shRNA molecules was observed up to weeks 3 and 4, and then declined gradually, suggesting the buildup of mature shRNA molecules induced cell death with concomitant loss of viral DNA and shRNA expression. No evidence of well-characterized innate immunity activation (such as interferon production) or saturation of the exportin-5 pathway was observed. Overall, our data suggest constitutive expression of shRNA results in accumulation of mature shRNA molecules, inducing cellular toxicity at late time points, despite the presence of gene silencing.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Limiting hepatitis C virus progression in liver transplant recipients using sirolimus-based immunosuppression

Hepatitis C virus (HCV) causes progressive liver fibrosis in liver transplant recipients and is the principal cause of long-term allograft failure. The antifibrotic effects of sirolimus are seen in animal models but have not been described in liver transplant recipients. We reviewed 1274 liver recipients from 2002 to 2010 and identified a cohort of HCV recipients exposed to sirolimus as primary immunosuppression (SRL Cohort) and an HCV Control Group of recipients who had never received sirolimus. Yearly protocol biopsies were done recording fibrosis stage (METAVIR score) with biopsy compliance of >80% at both year one and two. In an intent-to-treat analysis, the SRL Cohort had significantly less advanced fibrosis (stage ≥2) compared to the HCV Control Group at year one (15.3% vs. 36.2%, p < 0.0001) and year two (30.1% vs. 50.5%, p = 0.001). Because sirolimus is sometimes discontinued for side effects, the SRL Cohort was subgroup stratified for sirolimus duration, showing progressively less fibrosis with longer sirolimus duration. Multivariate analysis demonstrated sirolimus as an independent predictor of minimal fibrosis at year one, and year two. This is the first study among liver transplant recipients with recurrent HCV to describe the positive impact of sirolimus in respect of reduced fibrosis extent and rate of progression.

Three-dimensional mesoporous structures fabricated by independent stacking of self-assembled films on suspended membranes

We report an original iterative method for fabricating three-dimensional mesoporous structures by independently stacking multiple self-assembled block copolymer films supported by Si membranes. A first layer is formed on the substrate by a self-assembled PS-b-PMMA (polystyrene-block-poly(methyl methacrylate)) film. A porous, permeable Si membrane deposited on top of the first block copolymer film provides mechanical support, preventing pattern collapse during the wet developing used to selectively remove the PMMA component of the PS-b-PMMA film. A second, dense Si membrane is deposited to seal the porous membrane, resulting in an impermeable coating suspended atop the self-assembled mesoporous polystyrene structures. The process can then be iterated using the sealed membrane as the new substrate to support a subsequent self-assembled block copolymer film. This multilayer approach provides a flexible three-dimensional fabrication technique where, in each layer, pattern morphology, domain orientation and degree of ordering can be designed independently. Furthermore, the process is compatible with electron-beam directed assembly, used to achieve regular patterns with feature density multiplication at any level in the stack.

Numbers on the edges: a simplified and scalable method for quantifying the gene regulation function

The gene regulation function (GRF) provides an operational description of a promoter behavior as a function of the concentration of one of its transcriptional regulators. Behind this apparently trivial definition lies a central concept in biological control: the GRF provides the input/output relationship of each edge in a transcriptional network, independently from the molecular interactions involved. Here we discuss how existing methods allow direct measurement of the GRF, and how several trade-offs between scalability and accuracy have hindered its application to relatively large networks. We discuss the theoretical and technical requirements for obtaining the GRF. Based on these requirements, we introduce a simplified and easily scalable method that is able to capture the significant parameters of the GRF. The GRF is able to predict the behavior of a simple genetic circuit, illustrating how addressing the quantitative nature of gene regulation substantially increases our comprehension on the mechanisms of gene control.

CCSD(T) study of the far-infrared spectrum of ethyl methyl ether

Band positions and intensities for the far-infrared bands of ethyl methyl ether are variationally determined from a three-dimensional (3D) potential energy surface calculated with CCSD(T)/cc-pVTZ theory. For this purpose, the energies of 181 selected geometries computed optimizing 3n-9 parameters are fitted to a 3D Fourier series depending on three torsional coordinates. The zero point vibrational energy correction and the search of a correct definition of the methyl torsional coordinate are taken into consideration for obtaining very accurate frequencies. In addition, second order perturbation theory is applied on the two molecular conformers, trans and cis-gauche, in order to test the validity of the 3D model. Consequently, a new assignment of previous experimental bands, congruent with the new ab initio results, is proposed. For the most stable trans-conformer, the nu(30), nu(29), and nu(28) fundamental transitions, computed at 115.3, 206.5, and 255.2 cm(-1), are correlated with the observed bands at 115.4, 202, and 248 cm(-1). For the cis-gauche the three band positions are computed at 91.0, 192.5, and 243.8 cm(-1). Calculations on the -d(3) isotopomer confirm our assignment. Intensities are determined at room temperature and at 10 K. Structural parameters, potential energy barriers, anharmonic frequencies for the 3n-9 neglected modes, and rotational parameters (rotational and centrifugal distortion constants), are also provided.

Relationships between heart rate variability, functional capacity, and left ventricular function following myocardial infarction: an evaluation after one week and six months

BACKGROUND

Relationships between heart rate (HR) variability and different prognostic markers such as ejection fraction, functional capacity, and patency of the infarct-related artery, as well as the comparison of their time courses are not fully elucidated.

HYPOTHESIS

The aim of study was to assess prospectively the early postinfarction changes in HR variability and its evolution over a period of 6 months: the relationships between HR variability and functional capacity in exercise testing; left ventricular function in cardiac catheterization: status of the infarct-related artery; and the comparison of their time courses.

METHODS

In 42 patients with anterior myocardial infarction, a study was made of the early changes in HR variability analyzed by the complex demodulation method, its evolution over a period of 6 months. and the relationships between HR variability and (1) functional capacity in exercise testing, (2) left ventricular function in cardiac catheterization, and (3) status of the infarct-related artery.

RESULTS

At 1 week HR variability parameters correlated directly with functional capacity indicators such as METS, percent change in HR from rest to peak exercise (%deltaHR), difference between initial and peak HR (HR range), percent peak theoretical HR (% peak HR), left ventricular ejection fraction (EF), and, inversely, with end-systolic volume (ESV). Stepwise multiple regression analysis to establish HR variability parameters (recorded at 1 week) as related to functional capacity and left ventricular function at 1 week and 6 months postinfarction established the following variables: (1) At 1 week: standard deviation (SD) of the RR cycles in relation to %deltaHR (r = 0.60, p <0.0001), HR range (r = 0.43, p < 0.01), and EF (r = 0.79, p < 0.0001). (2) At 6 months, the sole accepted HR variability parameter was the SD in relation to %deltaHR (r = 0.38, p < 0.05) and HR range (r = 0.45, p < 0.01). No variability parameter was accepted in relation to METS, % peak HR, or ESV. Relationship between EF or ESV and HR variability parameters was not significant when both were evaluated at 6 months. At that time, there was a significant increase in all HR variability parameters among all surviving patients (n = 39), with the exception of the LF/HF ratio and mean RR cycle. The percent increase in HR variability between the first week and 6 months was greater among those patients with the lowest basal EF. No relation was established between HR variability and patency of the infarct-related artery.

CONCLUSION

The decrease in HR variability observed following myocardial infarction is associated with a diminished functional capacity and an increased alteration of the EF. This does not affect the recovery of HR variability, which was observed in all surviving patients.

[Overcorrection after surgery for unilateral superior oblique palsy]

PURPOSE

To study causes of overcorrection after surgery for unilateral oblique superior palsy and treatment options.

METHODS

Nine cases with overcorrection following surgery for unilateral oblique superior palsy between 2004 and 2006 were identified. Their causes were divided into three types: excessive surgery, bilateral masked palsy and antielevation or adherence syndrome. Treatment was required when there was diplopia in primary and reading positions. A good result was achieved if vertical deviation was inferior to 5 prismatic diopters (PD) in primary position (PP) and 10 PD in oblique diagnostic positions.

RESULTS

Overcorrection was present in 27.27% of cases. Mean hyperdeviation was 17 PD in PP, 18.4 in oblique positions and 25.22 for the Bielschowsky test. Seven patients underwent two-muscle surgery, and topical anaesthesia was used in eight patients. Overcorrection was diagnosed between 15 days and 6 months following surgery. The etiology was distinct, with 2 patients with bilateral masked palsy, 2 with antielevation or adherence syndrome, and 5 with excessive surgery. Surgical intervention was performed in 6 cases and botulinum toxin used alone or associated with surgery in 4 cases. A good result was obtained in 8 patients.

CONCLUSION

The incidence of overcorrection was high, with most of these requiring surgical intervention for which good results were obtained.

Cysteine string protein-alpha is essential for the high calcium sensitivity of exocytosis in a vertebrate synapse

Cysteine string protein (CSPalpha) is a synaptic vesicle protein present in most central and peripheral nervous system synapses. Previous studies demonstrated that the deletion of CSPalpha results in postnatal sensorial and motor impairment and premature lethality. To understand the participation of CSPalpha in neural function in vertebrates, we have studied the properties of synaptic transmission of motor terminals in wild-type and CSPalpha knockout mice. Our results demonstrate that, in the absence of CSPalpha, fast Ca2+-triggered release was not affected at postnatal day (P)14 but was dramatically reduced at P18 and P30 without a change in release kinetics. Although mutant terminals also exhibited a reduction in functional vesicle pool size by P30, further analysis showed that neurotransmission could be 'rescued' by high extracellular [Ca2+] or by the presence of a phorbol ester, suggesting that an impairment in the fusion machinery, or in vesicle recycling, was not the primary cause of the dysfunction of this synapse. The specific shift to the right of the Ca2+ dependence of synchronous release, and the lineal dependence of secretion on extracellular [Ca2+] in mutant terminals after P18, suggests that CSPalpha is indispensable for a normal Ca2+ sensitivity of exocytosis in vertebrate mature synapses.

Cholecystokinin receptor positivity in children with chronic acalculous gallbladder dysfunction: a pilot study to investigate the etiology of chronic acalculous gallbladder dysfunction

BACKGROUND

The etiology of chronic acalculous gallbladder dysfunction (CAGD) is unknown. However, cholecystectomy is being performed as treatment, based on gallbladder (GB) ejection fraction studies. The aim of this study was to examine the pathology and immunohistology of GBs from children with CAGD.

METHODS

Children with a diagnosis of CAGD were identified. Control patients had their GB removed for nonbiliary indications. Immunoperoxidase staining was performed using rabbit antihuman cholecystokinin receptor (CCK-R) antibody. The pathologist was blinded to the study and controls.

RESULTS

Fifteen children were evaluated: 6 children with CAGD and 9 controls. All children with CAGD had abnormal cholecystokinin-stimulated nuclear imaging. Ejection fractions ranged from 8% to 30%. All patients reported resolution of symptoms on follow-up at 6 months. Histopathology of the GB was normal for both the controls and children with CAGD. Both control and CAGD GBs demonstrated positive staining for CCK-R in the vascular endothelium and smooth muscle. Mucosal epithelial staining was only observed in 5 of 6 of GBs of children with CAGD. In the sixth GB, the epithelium was too necrotic to assess.

CONCLUSIONS

In this pilot study, expression of CCK-Rs in the epithelial cells is noted in children with CAGD compared with controls. The significance of this finding requires further investigation.

Assessment of cervical involvement in endometrial carcinoma by hysteroscopy and directed biopsy

The objective of this study was to assess the diagnostic validity of hysteroscopy and directed biopsy for assessing cervical involvement in endometrial carcinoma. We conducted a study of 240 hysteroscopies and 44 cervical biopsies performed on 240 patients with endometrial carcinoma between 2000 and 2005. Hysteroscopy results suggested cervical involvement in 55 cases, of which only 31 were confirmed (a subtotal hysterectomy was performed in two cases, and the resection margins were examined for tumor invasion). In the 31 patients with confirmed cervical involvement, 19 of the hysteroscopy-directed biopsies were positive, 3 were negative, and 3 provided insufficient material. Six patients did not undergo biopsy. In the 24 patients with hysteroscopy false positive, 10 directed biopsies were positive and 9 were negative. Five patients did not undergo biopsy. Hysteroscopy suggested an absence of cervical involvement in 185 patients. Diagnosis was confirmed in 177 cases, and there were eight false negatives. In our case, office hysteroscopy proved to be a valid means of ruling out cervical involvement in endometrial carcinoma. However, it was not a valid means of detecting tumor involvement, even when combined with directed biopsy.

Intercalation of ethidium into triple-strand poly(rA).2poly(rU): a thermodynamic and kinetic study

The kinetics and equilibria of the interaction of ethidium bromide (EB) with the triple-stranded RNA, poly(rA).2poly(rU), have been investigated by stopped-flow, absorption, fluorescence, and circular dichroism methods; to properly assess the effect of the third strand on the polymer molar properties, molar volumes, adiabatic compressibilities, and heats of melting have also been measured for both poly(rA).2poly(rU) and poly(rA).poly(rU). The melting experiments reveal that ethidium tends to destabilize the triplex, whereas it stabilizes the duplex; however, the triplex/ethidium system in 0.1 M NaCl is stable below 37 degrees C. The static titrations reveal that one ethidium ion binds every three base triplets of the polymer; on the basis of the excluded-site model, this feature suggests intercalation, as in the duplex, but the binding affinity for the triplex is weaker compared to that for the duplex. The kinetic experiments displayed a two-phase behavior, which was rationalized assuming the sequence D + S right arrow over left arrow DS(I), DS(I) + S right arrow over left arrow DS(II) + S (D = drug, S = site), the second step involving direct transfer of the drug between strands. Comparison with the duplex/EB system reveals that the additional strand of poly(U), present in the triplex, hinders the formation of the intermediate complex DS(I), while stabilizing the structure of the final DS(II) complex by hampering the partial slipping out of the dye from the triplex cavity.

Detection of schistosomiasis cases in low-transmission areas based on coprologic and serologic criteria The Venezuelan experience

Low and very-low intensities of infection hinder the diagnosis of schistosomiasis. Therefore, new parameters should be established in order to more accurately identify active cases and true infection prevalence, for the adequate implementation of a control program. After the survey and analysis of the epidemiological characteristics of five Venezuelan communities, we propose three criteria for the definition of a "schistosomiasis case", based on different diagnostic methods: stool examination, ELISA-soluble egg antigen with sodium metaperiodate (SMP-ELISA), alkaline phosphatase immunoassay (APIA) and the circumoval precipitin test (COPT). Briefly, criterion I: persons with Schistosoma mansoni eggs in stools; criterion II: persons without eggs in stools, with positive COPT, without previous antischistosome chemotherapy in the last year; and criterion III: persons without eggs in stools, with negative COPT, with two positive immunoenzymatic tests (SMP-ELISA and APIA), and with no previous chemotherapy. The incorporation of serological tests to epidemiologic surveillance in areas of low-transmission tries to compensate the underestimation of prevalence based only on parasitological diagnosis.

Predictive value of skin toxicity severity for response to panitumumab in patients with metastatic colorectal cancer (mCRC): A pooled analysis of five clinical trials

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Background: Panitumumab, a fully human monoclonal antibody against the epidermal growth factor receptor (EGFr), is approved for EGFr-expressing mCRC patients (pts) with disease progression (PD) on or following fluoropyrimidine (5FU)-, oxaliplatin (Ox)-, and irinotecan (Ir)-containing chemotherapy. Skin toxicities are common with panitumumab; we examined the association between severity of skin toxicity and panitumumab efficacy. Methods: Data from 5 clinical trials were pooled (4 phase II studies and 1 phase III study). Pts with mCRC had documented PD on or after 5FU, Ox, and/or Ir. Pts received panitumumab 6 mg/kg every two weeks (Q2W) or 2.5 mg/kg weekly (QW) until PD or intolerability. Tumors were assessed using modified WHO or RECIST criteria (blinded central review in 4/5 studies). Endpoints included objective response rate (ORR), progression-free survival (PFS), and overall survival (OS). PFS and OS were measured from enrollment. Only pts with =2 infusions (exposure over 2 wks for QW dosing or over 4 weeks for Q2W dosing) were analyzed to help correct for lead-time bias. Results: 612 of 640 pts were included in the analysis set (62% were male, 92% were white, and median age [range] was 61 [21, 88] years). The median (95% CI) duration of PFS was 8.4 weeks (8.0 to 11.3), the median (95% CI) survival was 6.9 months (6.2 to 7.9), and the ORR (95% CI) was 9.0% (6.8 to 11.5). The most common skin toxicities (any grade, grade 3/4) were erythema (54%, 4%) pruritus (53%, 2%), dermatitis acneiform (52%, 5%), and rash (39%, 2%). ORR, PFS, and OS appeared to favor pts with grade 2–4 skin toxicity vs pts with grade 0- 1 skin toxicity ( table ). Conclusion: In this large combined analysis, severity of skin rash was correlated with increased efficacy of panitumumab in terms of ORR, PFS, and OS.

[Table: see text]

No significant financial relationships to disclose.

Safety of panitumumab, a fully human monoclonal antibody against the epidermal growth factor receptor (EGFr), in patients (pts) with metastatic colorectal cancer (mCRC) across clinical trials

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Background: Panitumumab is indicated in pts with EGFr-expressing mCRC refractory to chemotherapy. We present a summary of safety with panitumumab monotherapy in mCRC pts across 10 clinical trials. Methods: Data were pooled from pts enrolled in 10 clinical trials (including 2 extension studies). Pts received at least 1 dose of panitumumab at 2.5 mg/kg QW, 6 mg/kg Q2W, or 9 mg/kg Q3W. Adverse events were graded using NCI-CTC or CTCAE criteria. Results: A total of 920 mCRC pts were included in this analysis: 60% were male; 88% were white; median age (range) was 61 (20, 88) years. All pts had prior therapy; 77% had failed prior fluoropyrimidine, irinotecan, and/or oxaliplatin. Most (80%) pts received panitumumab 6 mg/kg Q2W; 17% and 3% of pts received panitumumab 2.5 mg/kg QW and 9 mg/kg Q3W, respectively. Median (range) follow-up time was 21 (1–124) weeks. A total of 7264 panitumumab infusions were administered with a median (range) of 5 (1–94) infusions/pt. Treatment-related adverse events (AE) were experienced by 94% (grade = 3, 20%) of pts. All pts had = 1 AE. The most common AEs were skin-related and GI toxicities ( table ). Skin-related AEs resulted in discontinuation in 2% of pts. Overall, 12% of pts discontinued panitumumab due to toxicity. Four (0.4%) pts had grade = 3 infusion reactions. In pts with postdose samples (n = 613), increased and persistent postdose levels of anti-panitumumab antibodies were detected in 0.5% of pts by ELISA and in 4.6% of pts by Biacore assay. Conclusions: Skin toxicity was common, but rarely treatment-limiting. Most AEs were mild to moderate and infrequently resulted in discontinuation. Infusion reactions and formation of anti-panitumumab antibodies were rare. The safety profile of 9 mg/kg Q3W panitumumab appeared consistent with other dosages; however, because of the small pt size further evaluation is needed. Panitumumab at 2.5 mg/kg QW and 6 mg/kg Q2W was well tolerated across 10 clinical studies.

[Table: see text]

No significant financial relationships to disclose.