Guidelines for hormone replacement therapy of Asian women during the menopausal transition and thereafter

These Guidelines summarize the position of an Expert Panel on Menopause in Asian Women regarding the use of hormone replacement therapy (HRT) during the menopausal transition and thereafter. They are intended to aid gynecologists, family physicians and other health-care professionals in providing optimal care to menopausal Asian women who desire HRT.

Effect of topical atropine on astigmatism

AIM

The aim of this study was to determine if topical atropine, used to retard axial length elongation and myopia progression, had any effect on ocular astigmatism.

METHODS

Data collected from subjects enrolled in the Atropine in the Treatment of Myopia (ATOM) study were analysed. In this study, 400 myopic children (aged 6-12 years) were randomly assigned to administer atropine 1% or a placebo daily to a randomly selected eye for 2 years. Cycloplegic autorefraction and keratomy readings were measured using a Canon RK5 autorefractor. The refractive error was then split into its power vector components: J0 and J45.

RESULTS

Astigmatism increased by 0.12-0.16 D per year in both treated and placebo groups. There was no difference between groups (p = 0.182). The increase was mirrored by an increase in corneal astigmatism of 0.10-0.13 D per year, suggesting that most of the change was corneal in nature. There was an increase in J0 vector (with-the-rule astigmatism) with no change in the J45 (oblique) vector over time. The change in the J0 vector was significantly larger in the atropine-treated versus atropine-untreated eyes during the 2-year treatment period (p = 0.011), but this difference disappeared after atropine was stopped.

CONCLUSION

The use of atropine on a daily basis over 2 years did not have any clinically significant effect on astigmatism.

Effectiveness of physiotherapy for adults with cerebellar dysfunction: a systematic review

Objective: To systematically review the literature investigating the effectiveness of physiotherapy in adults with cerebellar dysfunction and to document treatment strategies currently employed in the physiotherapy management of this patient population.

Data sources: Eight electronic databases were searched to source English-language studies published up to December 2007. Secondary searching of reference lists was also undertaken.

Review methods: Studies were included if they used a quantitative research design to investigate the effect of physiotherapy on adults with diagnosed cerebellar dysfunction. Three reviewers were involved in study selection. Eligible studies were assessed for methodological quality. Data pertaining to the participants, interventions received, outcomes measured, and the effectiveness of the intervention were systematically extracted and synthesised in a narrative format.

Results: Nine studies were included in the review. The majority of the studies (n = 7) were case studies or case series. The median quality score was 8/16 (range 4—10). The studies were heterogeneous in terms of patient characteristics, interventions received and outcomes measured. All studies reported positive effects of physiotherapy over a range of outcomes measured, in particular balance, gait and function.

Conclusion: There is some evidence that supports the effectiveness of physiotherapy in adults with cerebellar dysfunction. However, these results need to be interpreted with caution due to the low volume, quality and clinical applicability of this evidence. There is a need for further high-quality research in this area.

Identification and expression of the achaete-scute complex in the silkworm, Bombyx mori

Recently, the study of achaete-scute (AS-C) homologues has contributed enormously to understanding of gene duplication and function evolution, particularly in Diptera. We identified four AS-C homologue genes in the silkworm, Bombyx mori, referred to as BmASH, BmASH2, BmASH3, and Bmase. The complex displayed tandem array structure in the genome. Analysis of spatial expression profiles showed that they all were expressed in obviously higher levels in wing disc than in other tissues, suggesting that they might play important roles in the development of the wing. Furthermore, we found that their expression profiles in the wing discs were mostly correlated with the development of the scales, especially the BmASH gene. RNA interference results further indicated that BmASH was necessary for scale formation in silkworm wing.

Carbonyl-scavenging drugs & protection against carbonyl stress-associated cell injury

This mini-review highlights the chemical and cytoprotective properties of various hydralazine analogues that block the induction of cell death by acrolein, a highly toxic contributor to "carbonyl stress" during a diverse range of human diseases. Recent work on the action of hydralazine against various carbonyl-mediated pathologies is also reviewed.

Epithelial-mesenchymal transition (EMT) and activated extracellular signal-regulated kinase (p-Erk) in surgically resected pancreatic cancer

BACKGROUND

EMT or transformation to the mesenchymal phenotype plays an important role in tumor invasion and metastasis. In vitro data suggest that mesenchymal transformation may correlate with the activation of PI3 kinase and Ras/Erk pathways. We investigated the expression of EMT markers (low E-cadherin, high fibronectin, and vimentin) and their association with p-Erk in resected pancreatic cancer.

METHODS

Clinical data/surgical specimens from 34 consecutive pancreatic cancer patients (pts) who underwent pancreatectomy were included. Immunohistochemical staining was performed on formalin-fixed paraffin-embedded tissues using monoclonal antibodies against vimentin, fibronectin, E-cadherin, and p-Erk. The results were correlated with clinicopathological parameters and survival. Survival analysis (log-rank test, Cox proportional hazard model), categorical data analysis (Pearson's chi-square, Fisher's exact test) and Kendall's tau were performed at a significance level of 0.05.

RESULTS

The patient population was formed from 13 males and 21 females, with a median age of 66 years (range 38-84 years); American Joint Committee on Cancer (AJCC) stage 1 (n = 2), 2 (n = 27), 3 (n = 5); histological grade 1 (n = 4), 2 (n = 13), 3 (n = 16), 4 (n = 1). Median survival was 15 months (95% CI: 11-24 months). Fibronectin overexpression correlated with the presence of vimentin (p = 0.0048) and activated Erk (p = 0.0264). There was a borderline association of fibronectin with worsening grade (p = 0.06). A negative association between vimentin and E-cadherin was noted (p = 0.0024). Increased fibronectin or vimentin and decreased E-cadherin correlated with poor survival.

CONCLUSION

EMT is associated with poor survival in surgically resected pancreatic adenocarcinoma. A correlation between activated Erk and fibronectin was identified that may open avenues for targeted therapy for this subgroup.

Morphoproteomic depiction of constitutively activated mTOR and ERK pathways in adenocarcinoma of the large intestine: A pilot study

14580

Background: Preclinical studies have demonstrated a role for the mammalian target of rapamycin (mTOR) pathway in intestinal tumorigenesis. However, the mTOR and its related ERK pathway in human adenocarcinoma of the large intestine (ALI) have been little examined. Methods: To assess morphoproteomic alterations of ALI, tissue materials from three patients with ALI were analyzed in the present study. Antibody probes used included phosphorylated (p)-mTOR (Ser-2448) and one of its downstream effectors, p-p70S6K (Thr-389); bcl-2, which undergoes mTOR-dependent phosphorylative inactivation; and p-extracellular signal-regulated kinase (ERK)1/2 (Thr-202/Tyr-204), a co-activator of p-p70S6K. The intensity of the chromogenic signal and the cellular compartmentalization (plasmalemmal, cytoplasmic, and/or nuclear) were assessed and scored on a scale of 0–3+. Results: Moderate to strong (up to 2+ or 3+) expression of p-mTOR and its substrate, p-p70S6K, and p-ERK1/2 was present in all three cases. We also found plasmalemmal translocation of p-mTOR and nuclear translocation of p-p70S6K and p-ERK1/2, indicating constitutive activation of these protein analytes and their corresponding signal transduction pathways. We did not detect bcl-2 expression in any of these cases. Conclusions: Morphoproteomic analysis reveals constitutive activation of the mTOR and ERK pathways in ALI as evidenced by the collective commonalities of expression of p-mTOR, p-p70S6K, and p- ERK1/2 and the plasmalemmal translocation of p-mTOR and nuclear translocation of p-p70S6K and p-ERK1/2. The absence of bcl-2 expression in this context is noteworthy. These findings coincide with the preclinical data on the efficacy of rapamycin and a rapamycin analogue against colon cancer cell lines and xenograft models. Although preliminary, these observations of morphoproteomic alterations represent the first in primary human ALI specimens according to a review of the literature. The present pilot study offers a starting point for further studies (we are currently conducting a confirmatory study with larger series of cases) and the design of clinical trials using such small molecule inhibitors(e.g. rapamycin, RAD001) in a combinational strategy against ALI.

No significant financial relationships to disclose.

Low-dose dexamethasone and thalidomide with higher frequency zoledronic acid (dtZ) for newly diagnosed multiple myeloma

18506

Background: Although dexamethasone (Dex), thalidomide (Thal) and zoledronic acid (Zol) have frequently been combined for the treatment of multiple myeloma (MM), the ideal dosing schedule is unknown. We previously reported that lower doses of Dex and Thal can be effectively combined with high-frequency dosing of Zol (Haematologica 2005). Methods: This “dtZ” regimen - which comprises weekly Dex 20 mg OM for 4 days, Thal 50 mg ON, and 3-weekly Zol 4 mg - resulted in an impressive response rate (RR) of 61.6% and near complete remission (nCR)/complete remission (CR) rate of 7.7% in 26 patients with relapsed/refractory MM. Results: In this present study, we treated 22 newly diagnosed MM patients with “dtZ” and report an even more impressive RR of 100.0% and nCR/CR rate of 20–35%. The median time to response was 1.8 months and median time to maximum response was 2.2 months. The median time to progression (TTP) has not been achieved yet. As expected, low-dose Dex/Thal resulted in lower (18.1%) grade 3 or 4 toxicities. These were all infections; which lead to further dose-reduction of Dex. There were no thromboembolic events, despite the fact that aspirin was not routinely given. Of particular interest, 3- weekly Zol was not associated with any significant decrease in renal function, and none of our patients developed osteonecrosis of the jaw (ONJ). In fact, at the time of writing of this abstract, more than 1,000 doses of Zol had been administered in a 3-weekly fashion to these as well as other patients, and only 1 patient developed ONJ. This patient who had already received greater than 20 doses of Zol healed uneventfully after receiving appropriate outpatient dental treatment, and subsequently received another 8 doses of Zol with no recurrence of ONJ. Conclusion: In conclusion, the Zol-based “dtZ” regimen is potentially a highly-effective and safe frontline regimen for MM. Using Zol every 3 weeks with lower doses of Dex and Thal does not appear to increase the rate or severity of nephrotoxicity or ONJ. Although we do not know exactly why every patient responded to “dtZ”, we speculate that this could be due to a critical balance that has been achieved between the anti-MM, anti-osteoclastic and immunostimulatory effects of the individual drugs of the combination.

No significant financial relationships to disclose.

NT-pro-BNP measured at discharge predicts outcome in multimorbid diabetic inpatients with a broad spectrum of cardiovascular disease

The prognostic value of NT-pro-BNP has not been thoroughly evaluated in diabetic inpatients with manifest cardiovascular disease. NT-pro-BNP was measured in 156 patients with type 2 diabetes mellitus hospitalised due to cardiovascular disease. The association of NT-pro-BNP with mortality and the combined endpoint (CE) of death, heart failure decompensation, stroke and myocardial infarction was analysed during a median follow-up time of 1183 days. Patients who died (1669 IQR 788-5640 vs. 398, IQR 158-990 pg/ml) and patients with CE (1353, IQR 730-4289 vs. 304, IQR 128-784 pg/ml, both p=0.0001) had significantly elevated NT-pro-BNP compared to patients without the corresponding endpoint. Patients with supramedian NT-pro-BNP (>518 pg/ml) had significantly worse outcome regarding mortality (HR 5.5, 95%CI 2.0-14.8) and CE (HR 5.0, 95%CI 2.2-11.2) than patients with inframedian values even after adjustment for age, NYHA class and renal function. At a cut-off of 422 pg/ml, NT-pro-BNP showed a sensitivity of 89.6% and a negative predictive value of 92.8% for detection of patients with future CE. In this sample of diabetic patients with a broad spectrum of cardiovascular disease, NT-pro-BNP was a strong predictor of long-term outcome. NT-pro-BNP measured at discharge identifies high-risk patients independently of the underlying heart disease.

Recurrent abdominal pain in a woman with a wandering spleen

A 28-year-old Malay woman presented with recurrent abdominal pain for five years. She had delivered her child seven months earlier. She was found to have bicytopenia, with a haemoglobin level of 7.9 g/dL and a platelet count of 85 x 10(9)/L. Computed tomography revealed a wandering spleen. Complications of a wandering spleen, for which splenectomy is advocated, include functional asplenia (due to torsion of the splenic pedicle), splenic infarction or splenic vessel thrombosis. A splenectomy was performed and at operation, splenomegaly with a long mesentery was found. Splenic histology was negative for malignancy. The bicytopenia resolved postoperatively, and she remains well.

Is downregulation of MHC class I antigen expression in human non-small cell lung cancer associated with prolonged survival?

PURPOSE

To characterize HLA class I antigen expression in non-small cell lung cancer (NSCLC) lesions, and to assess the clinical significance of these molecules' downregulation.

METHODS

One hundred and ninety primary formalin fixed, paraffin embedded NSCLC lesions were stained with HLA class I heavy chain-specific mAb HC-10. Results were scored as percentage of stained tumor cells and categorized into three groups: 0-24% (negative), 25-75% (heterogeneous) and >75% (positive). HLA class I antigen expression was correlated with clinical and pathologic predictors of time to progression and survival and analyzed using the chi-square test. Association between HLA class I antigen expression and survival was assessed using Cox regression models, while controlling for confounders.

RESULTS

HLA class I antigen expression was negative, heterogeneous and positive in 153, 25 and 12 primary NSCLC lesions, respectively. Independent variables significantly associated with survival included tumor stage, PS and weight loss. The median survival times were 40.6, 44.0 and 17.9 months for patients with a HLA class I antigen expression scored as negative, heterogeneous and positive, respectively.

CONCLUSION

HLA class I antigen defects were found with high frequency (93.6%) in NSCLC lesions. HLA class I antigen downregulation was associated with improved survival, although this association was not statistically significant. These results, which parallel similar findings in uveal melanoma and in breast carcinoma, raise the possibility that NK cells may play a role in the control of NSCLC tumors.

Addition of bortezomib to thalidomide, dexamethasone and zoledronic acid (VTD-Z regimen) significantly improves complete remission rates in patients with relapsed/refractory multiple myeloma

17537

Background: We previously treated 26 patients with relapsed/refractory multiple myeloma (MM) with thalidomide (Thal), dexamethasone (Dex) and zoledronic acid (Zol); dtZ regimen; and demonstrated an overall response rate of 75.0%. However, the rate immunofixation (IF)-negative complete remissions (CR) was only 7.7%. Recently, the bortezomib (Velcade) has been shown to be effective against MM. In this study, we added bortezomib (Vel) to dtZ (VTD-Z regimen) in a subgroup of patients to determine whether the CR rate can be improved. Methods: A non-randomized, single-arm study was conducted. Consecutive patients (n = 14) who either failed to achieve a partial response (PR) after 3 cycles; or CR after 9 cycles of dtZ were treated with 2 to 11 three-weekly cycles of VTD-Z; comprising: Vel 1.3 mg/m2 on days 1, 4, 8 and 11; Thal 50 mg ON; Dex 20 mg OM on days 1 to 4, 8 to 11, 15 to 18; and Zol 4 mg on day 1. The primary study objective was to determine the maximal response rates (RR). The end-point of the study was maximum response, graded by Bladè’s criteria. Results: Fourteen patients (3 males, 11 females; median age 63.3 years) were studied. Complex karyotypes, including 5 patients with deletion of chromosome 13 (del(13)), were present in 11 patients at diagnosis. The overall RR was 92.9% (13 out of 14), of which 42.9% (6) achieved CR (p < 0.001, chi-squared test). In addition, 21.4% (3) achieved near-CR (nCR), and 28.6% (4) achieved PR. There were no minimal responders (MR) and 1 (7.1%) non-responder (NR). Two patients who achieved CR had del(13). Painful grade 3 peripheral neuropathy was observed in 2 (14.3%) patients. Grade 1 and 2 peripheral neuropathy was observed in another 4 (25.0%) of patients; transient grade 3 thrombocytopenia was observed in 5 (35.7%) patients; and papular rashes were observed in 3 (21.4%) patients. The single NR was the only death that occurred during the period of study. Conclusions: Our study demonstrates that the VTD-Z regimen is exceptionally effective and safe in patients with relapsed/refractory MM. Addition of Vel to dtZ significantly increases the CR rate from 7.7% to 42.9%. These data suggest that combination of these 4 drugs may be at least additive, if not, even synergistic.

No significant financial relationships to disclose.

Successful treatment of primary granulocytic sarcoma by non-myeloablative stem cell transplant

Pre-leukemic granulocytic sarcoma (GS) may pose an initial diagnostic problem and its therapeutic approach has never been formally established. To our knowledge, non-myeloablative stem cell transplantation has been reported in cases of leukemic GS, but not in primary GS. We report a case of primary GS with extensive and aggressive presenting features and successfully treated with intensive chemotherapy followed by non-myeloablative allogeneic stem cell transplant. This resulted in complete remission with minimal complications. Our case demonstrates the potential of graft-vs.-tumour effect in the treatment of GS and suggests that non-myeloablative allogeneic stem cell transplant may be a feasible therapeutic approach for primary GS.

Geographic distribution, virologic and clinical characteristics of hepatitis B virus genotypes in China

The significance of hepatitis B virus (HBV) genotypes for the heterogeneity of chronic HBV infection and severity of liver disease is not well understood. The aim of this study was to determine the distribution and virologic characteristics of HBV genotypes in China and possible association with the diversity of liver disease. The study includes 1096 chronic HBV carriers from nine provinces in China. We collected clinical and laboratory data and analysed the HBV strains in sera by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and nucleotide sequencing techniques. The most common HBV genotypes were B (41%) and C (53%), while genotypes A and D were also found. A North-South divide was identified in genotype B and C distribution - genotype C was predominant in northern China, while genotype B was more prevalent in southern provinces. Patients with genotype B were younger than those with genotype C, and had a lower prevalence of HBeAg - 65%vs 72%, respectively (P = 0.03). However, the severity of liver disease did not differ significantly between patients infected with genotype B or C - neither when comparing liver function tests (1024 patients), nor hepatic inflammation and fibrosis (264 patients). Amongst 47 patients with genotype D (by PCR-RFLP), 37 (79%) were infected with a new subtype (designated Dc), having a recombination fragment from genotype C precore/core region. This is the first large-scale HBV genotype study from China and convincing documentation of the North-to-South gradient of genotypes C vs B in this country. HBV DNA recombination over the surface and precore/core genes increases the diversity of HBV strains and may have diagnostic and clinical implications.

Primary adenocarcinoma of cervical esophagus

Most upper esophageal malignancies are squamous cell carcinomas, rarely adenocarcinomas arising from Barrett's esophagus and very rarely adenocarcinomas from heterotopic gastric mucosa without evidence of Barrett's especially in the cervical part of the esophagus. We report a case of adenocarcinoma of the polypoid type in the upper esophagus (cervical esophagus) arising from ectopic gastric mucosa, in a 60 year-old man who presented with progressive dysphagia. Accurate diagnosis by esophagogram revealed a large mass in the cervical esophagus; CAT scan showed intraluminal mass at the level of thoracic inlet, esophagogastroscopy showed a fleshy polyp (3.2cm x 3.0cm) at 20 cm from the incisors with a biopsy confirming moderately differentiated adenocarcinoma with no evidence of Barrett's esophagus. Through a left cervical approach and resection of medial third of clavicle, the tumor was removed by partial esophagectomy followed by lymph node dissection, and proved to be T1NOMO, stage I (AJCC staging 6th ed.). Post operatively, the patient received chemoradiation with no evidence of recurrence or metastasis in six years of follow up. It seems this tumor has a much better prognosis than adenocarcinomas arising from Barrett's. To our knowledge only 19 cases have been reported in literature so far.