Open label phase II studies of modified vaccinia ankara expressing the tumor antigen 5T4 given in conjunction with IFL and FOLFOX chemotherapy regimens: Final analysis of safety and immunogenicity of MVA 5T4 given before, during and after chemotherapy

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Background: 5T4 is a tumour associated antigen that is widely expressed on the surface of most human adenocarcinomas, including colorectal, but rarely in normal cells. Modified Vaccinia Ankara (MVA) has been employed as a vaccine vector to deliver 5T4. Previously, MVA-5T4 has been evaluated in a phase I/II clinical trial in stage IV colorectal cancer patients. MVA-5T4 was shown to be safe and well tolerated and induced 5T4 specific immune responses in most patients. Furthermore, 5T4 specific antibody titres correlated with clinical benefit. Methods: Two open label phase II clinical trials were initiated in which patients with advanced colorectal cancer received MVA-5T4 in conjunction with either 5-FU/leukovorin and irinotecan (TV2-IFL; n=19 patients) or 5-FU/leukovorin and oxaliplatin (TV2-FOLFOX; n=17 patients). MVA-5T4 was administered up to 6 times, 2 prior to, 2 during and 2 post-chemotherapy. The primary objectives were to assess the safety and immunogenicity of MVA-5T4 given in combination with chemotherapy. Results: Recruitment to both trials is complete and MVA-5T4 was well tolerated in all ITT patients, with no serious adverse events being associated with MVA-5T4. 5T4-specific cellular and humoral immune responses were monitored before, during and after chemotherapy in all 23 per protocol patients (n=12 for TV2-IFL and n=11 for TV2-FOLFOX). Following vaccination, all 23 patients mounted 5T4 cellular and/or humoral responses. Immune responses were detectable during chemotherapy in the majority of patients. IFNγ ELISPOT responses to 5T4 peptides revealed precursor frequencies as high as 1 in 1000 PBMCs. Assessment of clinical responses in all PP patients demonstrated an overall response rate of 65% across both trials. Conclusions: MVA-5T4 is safe and well tolerated when administered in conjunction with IFL and FOLFOX chemotherapy regimens. Furthermore, 5T4 specific immune responses are induced in all per protocol patients and can be boosted or maintained during chemotherapy. Encouraging clinical responses have been observed and 5T4 immune responses shown to correlate with clinical benefit.

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Policies for the removal of short-term indwelling urethral catheters

BACKGROUND

Approximately 15% to 25% of all hospitalised patients have indwelling urethral catheters, mainly to assist clinicians to accurately monitor urine output during acute illness or following surgery, to treat urinary retention, and for investigative purposes.

OBJECTIVES

The objective of this review was to determine the best strategies for the removal of catheters from patients with a short-term indwelling urethral catheter.

SEARCH STRATEGY

We searched the Cochrane Incontinence Group specialised register (searched 16 December 2002), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 2, 2004), MEDLINE (January 1966 to 12 October 2004), EMBASE (January 1980 to 12 October 2004), CINAHL (January 1982 to 12 October 2004), Nursing Collection (January 1995 to January 2002) and reference lists of relevant articles and conference proceedings were searched. We also contacted manufacturers and researchers in the field. No language or other restrictions were applied.

SELECTION CRITERIA

All randomised and quasi-randomised controlled trials (RCTs) that compared the effects of alternative strategies for removal of short-term indwelling urethral catheters on patient outcomes were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eligibility of the trials for inclusion in the review, details of eligible trials and the methodological quality of the trials were assessed independently by two reviewers. Relative risks (RR) for dichotomous data and a weighted mean difference (WMD) for continuous data were calculated with 95% confidence intervals (CI). Where synthesis was inappropriate, trials were considered separately.

MAIN RESULTS

Eighteen trials involving a total of 1964 participants were included in the review. One trial included three treatment groups. In eight RCTs amongst 1020 people, removal at midnight was associated with large volumes of urine at first void, longer times to first void, and shorter lengths of hospitalisation. There was no significant difference in need for recatheterisation, although recatheterisation after removal at night was more likely to be during working hours. In eight trials amongst 822 participants early rather than delayed catheter removal was associated with shorter hospitalisation, but the estimates of other differences were all imprecise. In three trials involving 234 participants the data were too few to assess differential effects of catheter clamping compared with free drainage prior to withdrawal. No eligible trials compared flexible with fixed duration of catheterisation, or assessed prophylactic alpha sympathetic blocker drugs prior to catheter removal.

AUTHORS' CONCLUSIONS

There is suggestive but inconclusive evidence of a benefit from midnight removal of the indwelling urethral catheter. There are resource implications but the magnitude of these is not clear from the trials. The evidence also suggests shorter hospital stay after early rather than delayed catheter removal but the effects on other outcomes are unclear. There is little evidence on which to judge other aspects of management, such as catheter clamping.

Anaesthesia for hip fracture surgery in adults

BACKGROUND

The majority of people with hip fracture are treated surgically, requiring anaesthesia.

OBJECTIVES

To compare different types of anaesthesia for surgical repair of hip fractures (proximal femoral fractures) in adults.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (November 2003), MEDLINE (1996 to February week 2 2004), EMBASE (1988 to 2004 week 10) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials comparing different methods of anaesthesia for hip fracture surgery in adults. The primary focus of this review was the comparison of regional (spinal or epidural) anaesthesia versus general anaesthesia. The use of nerve blocks preoperatively or in conjunction with general anaesthesia is evaluated in another review. The primary outcome was mortality.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data.

MAIN RESULTS

Twenty two trials, involving 2567 predominantly female and elderly patients, comparing regional anaesthesia with general anaesthesia were included. All trials had methodological flaws and many do not reflect current anaesthetic practice. Pooled results from eight trials showed regional anaesthesia to be associated with a decreased mortality at one month (56/811 (6.9%) versus 86/857 (10.0%)); however, this was of borderline statistical significance (relative risk (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95). The results from six trials for three month mortality were not statistically significant, although the confidence interval does not exclude the possibility of a clinically relevant reduction (86/726 (11.8%) versus 98/765 (12.8%), RR 0.92, 95% CI 0.71 to 1.21). The reduced numbers of trial participants at one year, coming exclusively from two trials, preclude any useful conclusions for long-term mortality (80/354 (22.6%) versus 78/372 (21.0%), RR 1.07, 95% CI 0.82 to 1.41).Regional anaesthesia was associated with a reduced risk of deep venous thrombosis (39/129 (30%) versus 61/130 (47%); RR 0.64, 95% CI 0.48 to 0.86). However, this finding is insecure due to possible selection bias in the subgroups in whom this outcome was measured. Regional anaesthesia was also associated with a reduced risk of acute postoperative confusion (11/117 (9.4%) versus 23/120 (19.2%), RR 0.50, 95% CI 0.26 to 0.95). There was insufficient evidence to draw any conclusions from a further four included trials, involving a total of 179 participants, which compared other methods of anaesthesia (a 'light' general with spinal anaesthesia; intravenous ketamine; nerve blocks).

REVIEWERS' CONCLUSIONS

Overall, there was insufficient evidence available from trials comparing regional versus general anaesthesia to rule out clinically important differences. Regional anaesthesia may reduce acute postoperative confusion but no conclusions can be drawn for mortality or other outcomes.

Survival of Escherichia coli O157:H7, O111:H− and O26:H11 in artificially contaminated chocolate and confectionery products

To date, the survival of Escherichia coli O157:H7 and other verocytotoxin-producing E. coli (VTEC) in chocolate and other confectionery products has not been fully established, unlike Salmonella, which have been responsible for occasional outbreaks of infection linked to contaminated chocolate and related products, although none of these outbreaks have been related to products produced in the United Kingdom. The United Kingdom Biscuit, Cake, Chocolate and Confectionery Alliance commissioned this study to obtain information on the decline and potential survival of E. coli, particularly verocytotoxin-producing strains, in reduced aw confectionery products chocolate, biscuit cream and mallow. These products were artificially contaminated with high (4 log10 cfu/g) and low (2 log10 cfu/g) levels of E. coli O157:H7, O111:H- and O26:H11 and their survival, as affected by storage temperature (10, 22 and 38 degrees C), was monitored over 12 months. Preliminary studies to establish the best inoculation and recovery procedures indicated that differences between counts on selective and non-selective media used were not sufficiently different to influence the outcome of this study. Irrespective of sample type, rapid decline was observed in products stored at 38 degrees C and increased survival occurred in products stored at 10 degrees C. In chocolate (average aw 0.40), these bacteria were detected for up to 43 days in samples stored at 38 degrees C. At 22 degrees C they survived for up to 90 days and in product stored at 10 degrees C they could still be detected after 366 days storage. In biscuit cream (average aw 0.75) they survived for 2 days at 38 degrees C, 42 days at 22 degrees C and 58 days at 10 degrees C. Whilst mallow (aw ca. 0.73) was not stored at 38 degrees C, these bacteria could still be detected in samples stored for up to 113 and 273 days at 22 and 10 degrees C, respectively. The observed prolonged survival of these bacteria under conditions of reduced aw and lowered storage temperature in this study is supported by previous studies with Salmonella and E. coli O157:H7 in other foods. In the same way that Salmonella bacteria can survive for long periods, in excess of 12 months, in chocolate, this study provides evidence that E. coli, including pathogenic strains, can also survive for similar periods of time. Assuming the routes of transmission are similar, controls currently used by the confectionery industry to prevent contamination by Salmonella should also be effective against E. coli, including VT-producing strains, providing that all raw materials have been suitably processed, stored and handled before and during manufacture.

National symptom surveillance using calls to a telephone health advice service--United Kingdom, December 2001-February 2003

INTRODUCTION

Recent terrorist activity has highlighted the need to improve surveillance systems for the early detection of chemical or biologic attacks. A new national surveillance system in the United Kingdom (UK) examines symptoms reported to NHS Direct, a telephone health advice service.

OBJECTIVES

The aim of the surveillance system is to identify an increase in symptoms indicative of early stages of illness caused either by a deliberate release of a biologic or chemical agent or by common infections.

METHODS

Data relating to 10 key syndromes (primarily respiratory and gastrointestinal) are received electronically from 23 call centers covering England and Wales. Data are analyzed daily and statistically significant excesses, termed exceedances, in calls are automatically highlighted and assessed by a multidisciplinary team.

RESULTS

During December 2001-February 2003, a total of 1,811 exceedances occurred, of which 126 required further investigation and 16 resulted in alerts to local or national health-protection teams. Examples of these investigations are described.

CONCLUSION

Surveillance of call-center data has detected substantial levels of specific syndromes at both national and regional levels. Although no deliberate release of a biologic or chemical agent has been detected thus far by this or any other surveillance system in the UK, the NHS Direct surveillance system continues to be refined.

Preoperative saline versus gelatin for hip fracture patients; a randomized trial of 396 patients

BACKGROUND

The aim of this study was to determine if the preoperative administration of 500 ml of a gelatin colloid solution intravenously before hip fracture surgery improves outcome, compared with a conventional i.v. fluid regime with a crystalloid solution.

METHODS

Randomized, double blind, controlled trial of i.v. saline vs colloid for 396 patients having hip fracture surgery admitted to a district general hospital. Patients were followed up for 1 yr.

RESULTS

There was no statistically significant difference between groups for mortality (30-day mortality 9/198 for saline group vs 19/198 for colloid group, 95% confidence intervals 0.21-1.02), length of hospital stay (22.5 days vs 17.3 days, 95% CI -10.78 to 0.38), or occurrence of postoperative complications.

CONCLUSIONS

The inclusion of 500 ml of colloid solution to the i.v. fluid regime before hip fracture surgery does not improve outcome.

Sex-specific foraging behaviour in a monomorphic seabird

Sexual differences in the foraging behaviour of parents have been observed in a number of sexually sizedimorphic birds, particularly seabirds, and the usual inference has been that these sex-specific differences are mediated primarily by differences in body size. To test this explanation, we compared the foraging behaviour of parents in a monomorphic seabird species, the northern gannet Morus bassanus. Using specially designed instruments and radio telemetry we found that individuals of both sexes were consistent in the directions and durations of their foraging trips. However, there were significant differences in the foraging behaviour of males and females. Female gannets were not only more selective than males in the areas where they foraged, but they also made longer, deeper dives and spent more time on the sea surface than males. As the sexes are morphologically similar in this species, then these differences are unlikely to have been mediated by body size. Our work highlights the need to investigate sexual differences in the foraging behaviour of seabirds and other species more closely, in order to test alternative theories that do not rely on differences in body size.

Water for wound cleansing

BACKGROUND

Various solutions have been recommended for cleansing wounds, however normal saline is favoured as it is an isotonic solution and does not interfere with the normal healing process. Tap water is commonly used in the community for cleansing wounds because it is easily accessible, efficient and cost effective, however, there is an unresolved debate about its use.

OBJECTIVES

The objective of this review was to assess the effects of water compared to other solutions for wound cleansing.

SEARCH STRATEGY

Randomised and quasi-randomised controlled trials were identified by electronic searches of Cochrane Wounds Group Specialised Trials Register, MEDLINE, EMBASE, CINAHL, and the Cochrane Controlled Trials Register. Primary authors, company representatives and content experts were contacted to identify eligible studies. Reference lists from included trials were also searched.

SELECTION CRITERIA

Randomised and quasi randomised controlled trials that compared the use of water with other solutions for wound cleansing were eligible for inclusion. Additional criteria were outcomes that included objective or subjective measures of wound infection or healing.

DATA COLLECTION AND ANALYSIS

Trial selection, data extraction and quality assessment were carried out independently by two reviewers and checked by a third reviewer. Differences in opinion were settled by discussion. Some data were pooled using a random effects model.

MAIN RESULTS

Three trials were identified that compared rates of infection and healing in wounds cleansed with water and normal saline, two compared cleansing with no cleansing and one compared procaine spirit with water. There were no standard criteria for the assessment of wound infection across the trials which limited the ability to pool the data. The major comparisons were water vs normal saline, and tap water vs no cleansing. For chronic wounds, the odds of developing an infection when cleansed with tap water compared with normal saline was 0.16, 95 % Confidence Interval (CI) 0.01, 2.96. Use of tap water to cleanse acute wounds was associated with a lower rate of infection than saline (OR 0.52, 95 % CI 0.28, 0.96). No statistically significant differences in infection rates were seen when wounds were cleansed with tap water or not cleansed at all (OR 1.06, 95 % CI 0.06, 17.47). Similarly there was no difference in the infection rate in wounds cleansed with water or procaine spirit and those cleansed with isotonic saline, distilled water and boiled water (OR 0.55, 95 % CI 0.18,1.62).

REVIEWER'S CONCLUSIONS

Although the evidence is limited one trial has suggested that the use of tap water to cleanse acute wounds reduces the infection rate and other trials conclude that there is no difference in the infection and healing rates between wounds that were not cleansed and those cleansed with tap water and other solutions. However the quality of the tap water should be considered prior to its use and in the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents.

Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures

BACKGROUND

Various nerve blocks using local anaesthetic agents have been used in order to reduce pain after hip fracture.

OBJECTIVES

To determine the effects of nerve blocks (inserted either pre-operatively, operatively or post-operatively) as part of the treatment for a hip fracture.

SEARCH STRATEGY

We searched the Cochrane Musculoskeletal Injuries Group specialised register (October 2001), MEDLINE -OVID WEB (1996 to October 2001) and reference lists of relevant articles.

SELECTION CRITERIA

Randomised and quasi-randomised trials involving the use of nerve blocks as part of the care of a hip fracture patient.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality, by use of a nine item scale, and extracted data. Wherever appropriate, results of outcome measures were pooled.

MAIN RESULTS

Eight randomised or quasi-randomised trials involving 328 patients were included. Three trials related to insertion of a nerve block pre-operatively and the remaining five to peri-operative insertion. Nerve blocks resulted in a reduction of the quantity of parenteral or oral analgesia administered to control pain from the fracture/operation or during surgery and/or a reduction in reported pain levels. It was not possible to demonstrate if this reduction in analgesia use was associated with any other clinical benefit.

REVIEWER'S CONCLUSIONS

Because of the small number of patients included in this review and the differing type of nerve blocks and timing of insertion, it is not possible to determine if nerve blocks confer any significant benefit when compared with other analgesic methods as part of the treatment of a hip fracture. Further trials with larger numbers of patients and full reporting of clinical outcomes would be justified.

Characterization of the 1H-cyclopentapyrimidine-2,4(1H,3H)-dione derivative (S)-CPW399 as a novel, potent, and subtype-selective AMPA receptor full agonist with partial desensitization properties

(S)-CPW399 (2b) is a novel, potent, and subtype-selective AMPA receptor full agonist that, unlike (S)-willardiine and related compounds, in mouse cerebellar granule cells, stimulated an increase in [Ca(2+)](i), and induced neuronal cell death in a time- and concentration-dependent manner. Compound 2b appears to be a weakly desensitizing, full agonist at AMPA receptors and therefore represents a new pharmacological tool to investigate the role of AMPA receptors in excitotoxicity and their molecular mechanisms of desensitization.

Increased reproductive effort results in male-biased offspring sex ratio: an experimental study in a species with reversed sexual size dimorphism

Adaptive sex-ratio theory predicts that parents should overproduce the more beneficial offspring sex. Based on a recent experimental study of lesser black-backed gulls, we tested this hypothesis with the great skua, Catharacta skua, a bird species closely related to gulls but where females are the larger sex. When in poor body condition, the gulls overproduced daughters, the smaller and more viable sex under those circumstances. To discriminate between a mandatory physiological overproduction of female (i.e. non-male) eggs versus the overproduction of the smaller and presumably more viable sex, we conducted an egg-removal experiment with the great skua. Since the males are smaller, larger size and being male are separated. Through egg removal we induced females to increase egg production effort. Eggs were sexed using a DNA-based technique. Manipulated pairs produced a significant male bias at the end of the extended laying sequence, while the sex ratio in the control group did not differ from unity. Our results present an example of facultative sex-ratio manipulation and support the hypothesis that in sexually dimorphic birds parents overproduce the smaller sex under adverse conditions.

Identification and characterization of a novel class of interleukin-1 post-translational processing inhibitors

Lipopolysaccharide (LPS)-activated monocytes and macrophages produce large quantities of pro-interleukin (IL)-1beta but externalize little mature cytokine. Efficient post-translational processing of the procytokine occurs in vitro when these cells encounter a secretion stimulus such as ATP, cytolytic T cells, or hypotonic stress. Each of these stimuli promotes rapid conversion of 31-kDa pro-IL-1beta to its mature 17-kDa species and release of the 17-kDa cytokine. In this study, two novel pharmacological agents, CP-424,174 and CP-412,245, are identified as potent inhibitors of stimulus-coupled IL-1beta post-translational processing. These agents, both diarylsulfonylureas, block formation of mature IL-1beta without increasing the amount of procytokine that is released extracellularly, and they inhibit independently of the secretion stimulus used. Conditioned medium derived from LPS-activated/ATP-treated human monocytes maintained in the absence and presence of CP-424,174 contained comparable quantities of IL-6, tumor necrosis factor-alpha (TNFalpha), and IL-1RA, but 30-fold less IL-1beta was generated in the test agent's presence. As a result of this decrease, monocyte conditioned medium prepared in the presence of CP-424,174 demonstrated a greatly diminished capacity to promote an IL-1-dependent response (induction of serum amyloid A synthesis by Hep3B cells). Oral administration of CP-424,174 to mice resulted in inhibition of IL-1 in the absence of an effect on IL-6 and TNFalpha. These novel agents, therefore, act as selective cytokine release inhibitors and define a new therapeutic approach for controlling IL-1 production in inflammatory diseases.

The effect of treatment with Campath-1H in patients with autoimmune cytopenias

We describe 21 patients with severe and life-threatening autoimmune cytopenias resistant to standard immunosuppression who were treated with the monoclonal antibody Campath-1H. Four patients had autoimmune neutropenia, four had autoimmune haemolytic anaemia, four had pure red cell aplasia, one had immune thrombocytopenia purpura (ITP), three had autoimmune haemolytic anaemia and ITP (Evan's syndrome), three had autoimmune pancytopenia (ITP, autoimmune neutropenia and autoimmune haemolytic anaemia), one had ITP (associated with acquired Glanzmann's disease) and autoimmune neutropenia, and one had ITP and red cell aplasia. Campath-1H was administered at a dose of 10 mg/d as an intravenous infusion for 10 d. Responses were seen in 15 patients, which were sustained in six. Relapse occurred in eight patients after Campath-1H treatment. Patients entering the study later, received cyclosporine after Campath-1H in an attempt to reduce the incidence of relapse. Three patients received a second course of Campath-1H; all responded but later relapsed. Fourteen patients are alive at a median of 12 months (range 4-61) after Campath-1H. Campath-1H represents an alternative therapeutic option for severe, refractory autoimmune cytopenias.