A Multicentric, Retrospective, Real-world Study on Immune-related Adverse Events in Patients with Advanced Non-small Cell Lung Cancers Treated with Pembrolizumab Monotherapy

AIMS

We present 7 years of clinical experience with single-agent pembrolizumab immune checkpoint inhibitor immunotherapy in non-small cell lung cancers (NSCLC) from four UK cancer centres.

MATERIALS AND METHODS

This multi-institutional retrospective cohort study included 226 metastatic NSCLC patients. Outcomes were number and severity of immune-related adverse events (irAEs), median progression-free survival (mPFS) and median overall survival (mOS).

RESULTS

Within our cohort, 119/226 (53%) patients developed irAEs. Of these, 54/119 (45%) experienced irAEs affecting two or more organ systems. The most common irAEs were diarrhoea and rash. The development of an irAE was associated with better mOS (20.7 versus 8.0 months; P < 0.001) and mPFS (12.0 versus 3.9 months; P < 0.001). The development of grade 3/4 toxicities was associated with worse outcomes compared with the development of grade 1/2 toxicities (mOS 6.1 months versus 25.2 months, P < 0.01; mPFS 5.6 months versus 19.3 months, P = 0.01, respectively). Females had a higher proportion of reported grade 3/4 toxicities (13/44 [29.5%] versus 10/74 [13.5%], P = 0.03). Using a multiple Cox regression model, the presence of irAEs was associated with a better overall survival (hazard ratio = 0.42, 95% confidence interval 0.29-0.61; P < 0.01) and better PFS (hazard ratio 0.38, 95% confidence interval 0.27-0.53; P < 0.001).

CONCLUSION

In this multicentre retrospective cohort study, the development of at least one irAE was associated with significantly longer mPFS and mOS; however, more severe grade 3 and 4 irAEs were associated with worse outcomes. Delayed-onset irAEs, after the 3-month timepoint, were associated with better clinical outcomes.

The Impact of Supervised, Individualized Exercise on Fatigue and Quality of Life during Adjuvant Radiotherapy for Breast Cancer

PURPOSE/OBJECTIVE(S)

Adjuvant radiation therapy in treatment for breast cancer has been shown to improve patient outcomes and reduce mortality rates. However, many patients experience debilitating fatigue as a result. Currently, there are limited treatment options for fatigue in cancer survivors. Options include pharmaceutical agents, psychological interventions, or nutrition strategies, all of which have limited efficacy. Exercise is recommended in survivorship care plans, but it not widely implemented beyond the use of generalized statements or resource guides given to patients. Therefore, the purpose of this study was the examine the impact of an individualized exercise program on fatigue, quality of life, and physical functioning during radiation therapy for breast cancer.

MATERIALS/METHODS

This multi-institutional prospective trial evaluated the effects of supervised, individualized exercise therapy in 422 patients undergoing adjuvant radiotherapy for breast cancer. Following a comprehensive fitness assessment and the completion of the Brief Fatigue Instrument (BFI) questionnaire, each participant participated in a 12-week individualized exercise program offered through Maple Tree Cancer Alliance. At its conclusion, the patients repeated the assessment and questionnaire.

RESULTS

Individualized exercise had a positive impact on fitness parameters and severity of fatigue. Specifically, cardiovascular endurance, muscular strength, muscular endurance, and flexibility all significantly improved following the exercise intervention (p<0.05). On average, patients fatigue levels decreased by 31.1% (P<0.01).

CONCLUSION

These results signify that fatigue levels are positively impacted by exercise among patients with breast cancer.

Pathogenesis of the inflammatory bowel disease in context of SARS-COV-2 infection

To date, the latest research results suggest that the novel severe acute respiratory syndrome-related coronavirus 2 (SARS-CoV-2) can enter host cells directly via the gastrointestinal tract by binding to the enterocyte-expressed ACE2 receptor, or indirectly as a result of infection of type II alveolar epithelial cells. At the same time, entry of SARS-CoV-2 through the gastrointestinal tract initiates the activation of innate and adaptive immune responses, the formation of an excessive inflammatory reaction and critical increase in the expression of proinflammatory cytokines, which, subsequently, can presumably increase inflammation and induce intestinal damage in patients suffering from inflammatory bowel disease (IBD). The aims of the present review were to reveal and analyze possible molecular pathways and consequences of the induction of an innate and adaptive immune response during infection with SARS-CoV-2 in patients with IBD. A thorough literature search was carried out by using the keywords: IBD, SARS-CoV-2, COVID-19. Based on the screening, a number of intracellular and extracellular pathways were considered and discussed, which can impact the immune response during SARS-CoV-2 infection in IBD patients. Additionally, the possible consequences of the infection for such patients were estimated. We further hypothesize that any virus, including the new SARS-CoV-2, infecting intestinal tissues and/or entering the host's body through receptors located on intestinal enterocytes may be a trigger for the onset of IBD in individuals with a genetic predisposition and/or the risk of developing IBD associated with other factors.

Antibodies against neo-epitope of microbial and human transglutaminase complexes as biomarkers of childhood celiac disease

Tissue transglutaminase (tTG) and microbial transglutaminase (mTG) cross-link gliadins to form complexes that expose immunogenic neo-epitopes to produce tTG and mTG-neo-epitope antibodies. The aim of this study was to test the diagnostic performance of antibodies against non-complexed and complexed forms of transglutaminases, to correlate their activities to the intestinal damage and to explore age group dependency in celiac disease (CD). A total of 296 children with untreated CD and 215 non-celiac disease controls were checked by in-house enzyme-linked immunosorbent assays detecting immunoglobulin (Ig)A, IgG or combined detection of IgA and IgG (check) against tTG, AESKULISA® tTG New Generation (tTG-neo) and mTG-neo (RUO), IgA and IgG antibodies against deamidated gliadin peptide (DGP) and human IgA anti-endomysium antibodies (EMA) using AESKUSLIDES® EMA. Intestinal pathology was graded according the revised Marsh criteria, and age dependencies of the antibody activities were analysed. Using cut-offs estimated from receiver operating characteristic (ROC) curves, the highest area under curve (AUC) of the TG assays was 0·963 for tTG-neo check, followed by tTG check (0·962) when the diagnosis was based on enteric mucosal histology. tTG-neo check was the most effective to reflect the intestinal abnormalities in CD (r = 0·795, P < 0·0001). High levels of anti-mTG-neo IgG and anti-tTG-neo IgG appeared in the earlier age groups, as compared to anti-tTG IgG (P < 0·001). Considering antibody diagnostic performance based on AUC, enteric damage reflection and predictability at an early age, the anti-neo tTG check was the most effective diagnostic biomarker for pediatric CD. The mTG neo check might represent a new marker for CD screening, diagnosis and predictability.

Genome-wide methylation profiling in granulosa lutein cells of women with polycystic ovary syndrome (PCOS)

Polycystic Ovary Syndrome (PCOS) is the most common endocrine disorder amongst women of reproductive age, whose aetiology remains unclear. To improve our understanding of the molecular mechanisms underlying the disease, we conducted a genome-wide DNA methylation profiling in granulosa lutein cells collected from 16 women suffering from PCOS, in comparison to 16 healthy controls. Samples were collected by follicular aspiration during routine egg collection for IVF treatment. Study groups were matched for age and BMI, did not suffer from other disease and were not taking confounding medication. Comparing women with polycystic versus normal ovarian morphology, after correcting for multiple comparisons, we identified 106 differentially methylated CpG sites with p-values <5.8 × 10^-8 that were associated with 88 genes, several of which are known to relate either to PCOS or to ovarian function. Replication and validation of the experiment was done using pyrosequencing to analyse six of the identified differentially methylated sites. Pathway analysis indicated potential disruption in canonical pathways and gene networks that are, amongst other, associated with cancer, cardiogenesis, Hedgehog signalling and immune response. In conclusion, these novel findings indicate that women with PCOS display epigenetic changes in ovarian granulosa cells that may be associated with the heterogeneity of the disorder.

Signal Hyperintensity on Unenhanced T1-Weighted Brain and Cervical Spinal Cord MR Images after Multiple Doses of Linear Gadolinium-Based Contrast Agent

BACKGROUND AND PURPOSE

The clinical implications of gadolinium deposition in the CNS are not fully understood, and it is still not known whether gadolinium tends to be retained more in the brain compared with the spinal cord. In this study, we assessed the effects of linear gadolinium-based contrast agents on the T1 signal intensity of 3 cerebral areas (dentate nucleus, globus pallidus, and the less studied substantia nigra) and the cervical spinal cord in a population of patients with MS.

MATERIALS AND METHODS

A single-center population of 100 patients with MS was analyzed. Patients underwent 2-16 contrast-enhanced MRIs. Fifty patients received ≤5 linear gadolinium injections, and 50 patients had ≥6 injections: Fifty-two patients had both Gd-DTPA and gadobenate dimeglumine injections, and 48 patients received only gadobenate dimeglumine. A quantitative analysis of signal intensity changes was independently performed by 2 readers on the first and last MR imaging scan. The globus pallidus-to-thalamus, substantia nigra-to-midbrain, dentate nucleus-to-middle cerebellar peduncle, and the cervical spinal cord-to-pons signal intensity ratios were calculated.

RESULTS

An increase of globus pallidus-to-thalamus (mean, +0.0251 ± 0.0432; P < .001), dentate nucleus-to-middle cerebellar peduncle (mean, +0.0266 ± 0.0841; P = .002), and substantia nigra-to-midbrain (mean, +0.0262 ± 0.0673; P < .001) signal intensity ratios after multiple administrations of linear gadolinium-based contrast agents was observed. These changes were significantly higher in patients who received ≥6 injections (P < .001) and positively correlated with the number of injections and the accumulated dose of contrast. No significant changes were detected in the spinal cord (mean, +0.0008 ± 0.0089; P = .400).

CONCLUSIONS

Patients with MS receiving ≥6 linear gadolinium-based contrast agent injections showed a significant increase in the signal intensity of the globus pallidus, dentate nucleus, and substantia nigra; no detectable changes were observed in the cervical spinal cord.

Expression of genes controlling steroid metabolism and action in granulosa-lutein cells of women with polycystic ovaries

INTRODUCTION

Aberrant function of granulosa cells has been implicated in the pathophysiology of PCOS.

MATERIALS & METHODS

Granulosa lutein (GL) cells were collected during oocyte retrieval for IVF/ICSI. RT-qPCR was used to compare gene expression between 12 control women, 12 with ovulatory PCO and 12 with anovulatory PCOS. To examine which genes are directly regulated by androgens, GL cells from an additional 12 control women were treated in-vitro with 10 nM dihydrotestosterone (DHT).

RESULTS

GL cells from women with PCOS showed reduced expression of CYP11A1 3-fold (p = 0.005), HSD17B1 1.8-fold (p = 0.02) and increased expression of SULT1E1 7-fold (p = 0.0003). Similar results were seen in ovulatory women with PCO. GL cells treated with 10 nM DHT showed a 4-fold (p = 0.03) increase in expression of SULT1E1 and a 5-fold reduction in SRD5A1 (p = 0.03).

CONCLUSIONS

These findings support the notion that aberrant regulation of steroid metabolism or action play a part in ovarian dysfunction in PCOS.

The direct and indirect effects of kisspeptin-54 on granulosa lutein cell function

STUDY QUESTION

What are the in vivo and in vitro actions of kisspeptin-54 on the expression of genes involved in ovarian reproductive function, steroidogenesis and ovarian hyperstimulation syndrome (OHSS) in granulosa lutein (GL) cells when compared with traditional triggers of oocyte maturation?

SUMMARY ANSWER

The use of kisspeptin-54 as an oocyte maturation trigger augmented expression of genes involved in ovarian steroidogenesis in human GL cells including, FSH receptor (FSHR), LH/hCG receptor (LHCGR), steroid acute regulatory protein (STAR), aromatase, estrogen receptors alpha and beta (ESR1, ESR2), 3-beta-hydroxysteroid dehydrogenase type 2 (3BHSD2) and inhibin A (INHBA), when compared to traditional maturation triggers, but did not alter markers of OHSS.

WHAT IS KNOWN ALREADY

hCG is the most widely used trigger of oocyte maturation, but is associated with an increased risk of OHSS. The use of GnRH agonists to trigger oocyte maturation is a safer alternative to hCG. More recently, kisspeptin-54 has emerged as a novel therapeutic option that safely triggers oocyte maturation even in women at high risk of OHSS. Kisspeptin indirectly stimulates gonadotropin secretion by acting on hypothalamic GnRH neurons. Kisspeptin and its receptor are also expressed in the human ovary, but there is limited data on the direct action of kisspeptin on the ovary.

STUDY DESIGN SIZE, DURATION

Forty-eight women undergoing IVF treatment for infertility consented to kisspeptin-54 triggering and/or granulosa cell collection and were included in the study. Twelve women received hCG, 12 received GnRH agonist and 24 received kisspeptin-54 to trigger oocyte maturation. In the kisspeptin-54 group, 12 received one injection of kisseptin-54 (9.6 nmol/kg) and 12 received two injections of kisspeptin-54 at a 10 h interval (9.6 nmol/kg × 2).

PARTICIPANTS/MATERIALS, SETTING, METHODS

Follicular fluid was aspirated and pooled from follicles during the retrieval of oocytes for IVF/ICSI. GL cells were isolated and either RNA extracted immediately or cultured in vitro ± kisspeptin or hCG.

MAIN RESULTS AND THE ROLE OF CHANCE

GL cells from women who had received kisspeptin-54 had a 14-fold and 8-fold higher gene expression of FSHR and a 2-fold (ns) and 2.5-fold (P < 0.05) higher expression of LHCGR than GL cells from women who had received hCG or GnRH agonist, respectively. CYP19A1 expression was 3.6-fold (P < 0.05) and 4.5-fold (P < 0.05) higher, STAR expression was 3.4-fold (P < 0.01) and 1.8-fold (P < 0.05) higher, HSD3B2 expression was 7.5- (P < 0.01) and 2.5-fold higher (P < 0.05), INHBA was 2.5-fold (P < 0.01) and 2.5-fold (P < 0.01) higher in GL cells from women who had received kisspeptin-54 than hCG or GnRHa, respectively. ESR1 (P < 0.05) and ESR2 (P < 0.05) both showed 3-fold higher expression in cells from kisspeptin treated than GnRHa treated women. Markers of vascular permeability and oocyte growth factors were unchanged (VEGFA, SERPINF1, CDH5, amphiregulin, epiregulin). Gene expression of kisspeptin receptor was unchanged. Whereas treating GL cells in vitro with hCG induced steroidogenic gene expression, kisspeptin-54 had no significant direct effects on either OHSS genes or steroidogenic genes.

LIMITATIONS REASONS FOR CAUTION

Most women in the study had PCOS, which may limit applicability to other patient groups. For the analysis of the in vitro effects of kisspeptin-54, it is important to note that GL cells had already been exposed in vivo to an alternate maturation trigger.

WIDER IMPLICATIONS OF THE FINDINGS

The profile of serum gonadotropins seen with kisspeptin administration compared to other triggers more closely resemble that of the natural cycle as compared with hCG. Thus, kisspeptin could potentially permit an ovarian environment augmented for steroidogenesis, in particular progesterone synthesis, which is required for embryo implantation.

STUDY FUNDING/COMPETING INTEREST(S)

Dr Owens is supported by an Imperial College London PhD Scholarship. Dr Abbara is supported by an National Institute of Health Research Academic Clinical Lectureship. The authors do not have any conflict of interest to declare.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT01667406.

A qualitative investigation of childbearing and seasonal hunger in peri-urban Ouagadougou, Burkina Faso

Poor women who live in peri-urban communities are often faced with food insecurity due to seasonal variations in food availability and accessibility. Additionally, in these communities, fertility levels are often elevated despite geographic proximity to urban areas with low cost contraception. We conducted five focus group interviews to investigate the lived experiences of childbearing in peri-urban Ouagadougou, Burkina Faso to understand the behavioral and biological determinants of fertility outcomes. In the analysis of the interviews we pay particular attention to seasonal food insecurity experiences and the biological and behavioral determinants of childbearing. Our results suggest that there are less optimal times of year for childbearing and that poor, peri-urban women adjust their behavior accordingly. The results also suggest that there remain important barriers to contraceptive use even in cases where individuals associate pregnancy and childbearing with physical and psychological risk. This paper provides greater depth in understanding the determinants of fertility in resource-poor, peri-urban communities and points to some barriers for lowering fertility in similar areas.

The industrial food additive, microbial transglutaminase, mimics tissue transglutaminase and is immunogenic in celiac disease patients

Microbial transglutaminase (mTg) is capable of cross-linking numerous molecules. It is a family member of human tissue transglutaminase (tTg), and is involved in CD. Despite declarations of the safety of mTg for industrial use, direct evidence for immunogenicity of the enzyme is lacking. The serological activity of mTg, tTg, gliadin complexed mTg (mTg neo-epitope) and gliadin complexed tTg (tTg neo-epitope) were studied in 95 pediatric celiac patients (CD), 99 normal children (NC), 79 normal adults (NA) and 45 children with nonspecific abdominal pain (AP). Sera were tested by ELISAs, detecting IgA, IgG or both IgA and IgG (check): AESKULISA® tTg (tTg), AESKULISA® tTg New Generation (tTg neo-epitope (tTg-neo)), microbial transglutaminase (mTg) and mTg neo-epitope (mTg-neo). Marsh criteria were used for the degree of intestinal injury. Parallel, mTg and tTg neo-epitopes were purified by asymmetric field flow fractionation, confirmed by multi-light-scattering and SDS-PAGE, and analyzed in adult CD and control groups by competition ELISAs. No sequence homology but active site similarity were detected on alignment of the 2 Tgs. Comparing pediatric CD patients with the 2 normal groups: mTg-neo IgA, IgG and IgA+IgG antibody activities exceed the comparable mTg ones (p<0.0001). All mTg-neo and tTg-neo levels were higher (p<0.001). tTg IgA and IgG+IgA were higher than mTg IgA and IgA+IgG (p<0.0001). The levels of tTg-neo IgA/IgG were higher than tTg IgA/IgG (p<0.0001). The sequential antibody activities best reflecting the increased intestinal damage were tTg-neo check>tTg-neo IgA≥mTg-neo IgG>tTg-neo IgG>mTg-neo check>mTg-neo IgA. Taken together, tTg-neo check, tTg-neo IgA and mTg-neo IgG correlated best with intestinal pathology (r²=0.6454, r²=0.6165, r²=0.5633; p<0.0001, p<0.0001, p<0.0001, respectively). Purified mTg-neo IgG and IgA showed an increased immunoreactivity compared to single mTg and gliadin (p<0.001) but similar immunoreactivity to the tTg-neo IgG and IgA ELISA. Using competition ELISA, the mTg neo-epitopes and tTg neo-epitopes have identical outcomes in CD sera both showing a decrease in optical density of 55±6% (p<0.0002). mTg is immunogenic in children with CD and, by complexing to gliadin, its immunogenicity is enhanced. Anti-mTg-neo-epitope IgG antibodies correlate with intestinal damage to a comparable degree as anti-tTg-neo IgA. mTg and tTg display a comparable immunopotent epitope. mTg-neo IgG is a new marker for CD. Further studies are needed to explore the pathogenic potential of anti-mTg antibodies in CD.

Can a simple test of functional capacity add to the clinical assessment of diabetes?

AIM

To identify impairment in functional capacity associated with complicated and non-complicated diabetes using the 6-min walk distance test.

METHODS

We enrolled 111 adults, aged ≥40 years, with Type 2 diabetes from a hospital facility and 150 healthy control subjects of similar age and sex from a community site in Lima, Peru. All participants completed a 6-min walk test.

RESULTS

The mean age of the 261 participants was 58.3 years, and 43.3% were male. Among those with diabetes, 67 (60%) had non-complicated diabetes and 44 (40%) had complications such as peripheral neuropathy, retinopathy or nephropathy. The mean unadjusted 6-min walk distances were 376 m and 394 m in adults with and without diabetes complications, respectively, vs 469 m in control subjects (P<0.001). In multivariable regression, the subjects with diabetes complications walked 84 m less far (95% CI -104 to -63 m) and those without complications walked 60 m less far (-77 to -42 m) than did control subjects. When using HbA1c level as a covariate in multivariable regression, participants walked 13 m less far (-16.9 to -9.9 m) for each % increase in HbA1c .

CONCLUSIONS

The subjects with diabetes had lower functional capacity compared with healthy control subjects with similar characteristics. Differences in 6-min walk distance were even apparent in the subjects without diabetes complications. Potential mechanisms that could explain this finding are early cardiovascular disease or deconditioning.

[Limb salvage and amputation after trauma : Decision criteria and management algorithm]

The clinical decision-making process for patients with severe trauma of the extremities for primary amputation or to initiate extensive reconstructive measures for limb salvage in the best interests of the patient can be complex and difficult. The many factors influencing the decision-making process, such as local anatomical, pathomechanical, physiological, psychosocial and general factors are demonstrated and discussed. In the past, the role of scores supporting the decision-making process for amputation or limb salvage has been overestimated. In the LEAP study it could clearly be demonstrated that none of the sometimes highly complex scores could fulfill the expectations to predict successful limb salvage or the need for amputation. In this article it is shown that initiators and authors of scores achieved much higher sensitivity and specificity in the inaugural studies compared to the standardized and controlled conditions used in the LEAP study. For a long time, a lack of feeling in the feet was considered a safe and reliable criterion for amputation but the LEAP study has made a substantial contribution to demythologizing this as a lead symptom. Patients with severe trauma of the ankle or foot requiring a free flap or ankle arthrodesis have a significantly worse outcome compared to patients with a below knee amputation. Taking all these influencing factors into consideration, a comprehensive algorithm is presented that facilitates, strengthens and standardizes decision-making for amputation or limb salvage. This algorithm consists of four modules: 1) decision-making, 2) emergency treatment, 3) definitive treatment and 4) fine tuning. In the decision-making module not only local and general injury severity are addressed but the expected result, the general condition, comorbidities, compliance and the will of the patient are also included.

Detection and characterization of carbapenemase-producing Enterobacteriaceae in wounded Syrian patients admitted to hospitals in northern Israel

Since 2013, four hospitals in northern Israel have been providing care for Syrian nationals, primarily those wounded in the ongoing civil war. We analyzed carbapenemase-producing Enterobacteriaceae (CPE) isolates obtained from these patients. Isolate identification was performed using the VITEK 2 system. Polymerase chain reaction (PCR) was performed for the presence of bla KPC, bla NDM, and bla OXA-48. Susceptibility testing and genotyping were performed on selected isolates. During the study period, 595 Syrian patients were hospitalized, most of them young men. Thirty-two confirmed CPE isolates were grown from cultures taken from 30 patients. All but five isolates were identified as Klebsiella pneumoniae and Escherichia coli. Nineteen isolates produced NDM and 13 produced OXA-48. Among a further 29 isolates tested, multilocus sequence typing (MLST) showed that ST278 and ST38 were the major sequence types among the NDM-producing K. pneumoniae and OXA-48-producing E. coli isolates, respectively. Most were resistant to all three carbapenems in use in Israel and to gentamicin, but susceptible to colistin and fosfomycin. The source for bacterial acquisition could not be determined; however, some patients admitted to different medical centers were found to carry the same sequence type. CPE containing bla NDM and bla OXA-48 were prevalent among Syrian wounded hospitalized patients in northern Israel. The finding of the same sequence type among patients at different medical centers implies a common, prehospital source for these patients. These findings have implications for public health throughout the region.

Manipulating duckweed through genome duplication

Significant inter- and intraspecific genetic variation exists in duckweed, thus the potential for genome plasticity and manipulation is high. Polyploidy is recognised as a major mechanism of adaptation and speciation in plants. We produced several genome-duplicated lines of Landoltia punctata (Spirodela oligorrhiza) from both whole plants and regenerating explants using a colchicine-based cocktail. These lines stably maintained an enlarged frond and root morphology. DNA ploidy levels determined by florescence-activated cell sorting indicated genome duplication. Line A4 was analysed after 75 biomass doublings. Frond area, fresh and dry weights, rhizoid number and length were significantly increased versus wild type, while the growth rate was unchanged. This resulted in accumulation of biomass 17-20% faster in the A4 plants. We sought to determine if specific differences in gene products are found in the genome duplicated lines. Non-targeted ultra performance LC-quadrupole time of flight mass spectrometry was employed to compare some of the lines and the wild type to seek identification of up-regulated metabolites. We putatively identified differential metabolites in Line A65 as caffeoyl hexoses. The combination of directed genome duplication and metabolic profiling might offer a path for producing stable gene expression, leading to altered production of secondary metabolites.

A simple technique to estimate best- and worst-case survival in patients with metastatic colorectal cancer treated with chemotherapy

BACKGROUND

Patients with incurable cancer usually want specific information about prognosis, and clinicians' estimates are often inaccurate. Studies in breast and lung cancer have suggested that simple multiples of the median overall survival (OS) can accurately estimate the time at which 90%, 75%, 25% and 10% of patients are alive.

PATIENTS AND METHODS

We identified 46 phase III randomised clinical trials of chemotherapy in metastatic colorectal cancer, representing data from 29 011 patients. We extracted data on demographics, treatment and survival from 96 patient cohorts and assessed agreement with the estimated survival time points, calculated as 0.25, 0.5, 2 and 3 times the median OS.

RESULTS

Median OS was 16.8 months in the trials. There were 342 assessable time points. For 301 of these, the estimated survival time was within 0.75-1.33 of the actual survival time (88% agreement). The worst agreement (76%) was at the earliest (90%) level of survival.

CONCLUSIONS

Simple multiples of the median OS give reasonable estimates of the times at which different survival levels are reached in patients with metastatic colorectal cancer. Taken with previous studies, these findings are likely to be valid across a large range of patients. We would encourage clinicians to think of prognosis as a trajectory, and to consider quoting survival ranges instead of point estimates, in discussions with patients.

Early detection of acute radiation-induced lung injury with multi-section CT perfusion imaging: An initial experience

AIM

To explore the value of 64-section computed tomography (CT) perfusion imaging (CTPI) in the early diagnosis of acute radiation-induced lung injury (ARILI).

MATERIALS AND METHODS

Fifty-one patients with oesophageal cancers or malignant thymomas received postoperative radiation therapy with a 60-62 Gy dose and underwent CTPI at pre- and post-radiation therapy time points (week 0, week 4, week 8, and week 12 respectively). The CTPI values were prospectively compared and analysed in order to evaluate the diagnostic utility of CTPI in the early diagnosis of ARILI.

RESULTS

Eighteen cases (18/51) of ARILI were diagnosed. The mean values of relative regional blood flow (rrBF), relative regional volume (rrBV), and relative regional permeability surface (rrPS) in the ARILI group were correspondingly higher than those of the non-ARILI group. At week 4, rrBF, rrBV, and rrPS in the ARILI group were significantly higher than those at pre-radiation (each p < 0.05). In the non-ARILI group, rrBF and rrBV were higher than those at pre-radiation (each p < 0.05); however, rrPS was not statistically different from that of pre-irradiation. Applying the diagnostic threshold value of rrPS = 1.22, the sensitivity, specificity, and positive and negative predictive values of CTPI for early diagnosis of ARILI were better than those of CT.

CONCLUSION

CTPI metrics may reflect haemodynamic changes in the post-irradiation lung and can detect cases of early ARILI that appear normal at CT. CTPI is a promising technique for early diagnosis of ARILI.

Spinal cord lesions and disability in Hispanics with multiple sclerosis

Longitudinally extensive spinal cord lesions (LESCLs) are believed to occur predominantly with opticospinal multiple sclerosis (OSMS) and are associated with disability. The purpose of this study is to describe the prevalence and patterns of spinal cord lesions in Hispanics with multiple sclerosis (MS) and OSMS and their association with disability. A cross-sectional study of 164 patients with complete MRIs was used. In each case the spinal cord was classified: LESCLs, scattered spinal cord lesions (sSCLs) or no spinal cord lesions (noSCLs). Clinical course was defined as classical MS or OSMS. Risk of disability (Expanded Disability Status Scale ≥4.0) was adjusted for age, disease duration and sex using logistic regression. A total of 125/164 (73 %) MS patients had spinal cord lesions (sSCLs, 57 %; LESCLs, 19 %), but only 11 (7 %) had OSMS. LESCLs were associated with disability (p < 0.0001), longer disease duration (p < 0.0001) and MS (n = 21 vs. n = 10 OSMS; p < 0.0001). LESCLs were also associated with the greatest risk to disability (OR 7.3, 95 % CIs 1.9-26.5; p = 0.003; sSCLs OR 2.5, 95 % CIs 0.9-7.1; p = 0.09) compared with noSCLs. LESCLs are more common than OSMS and are associated with worse disability even in patients with MS. These results suggest that LESCLs are a more important marker of disability in MS than OSMS and may be an early indicator of more aggressive disease in this population.

Aluminum as an adjuvant in Crohn's disease induction

Alum (AlK(SO(4))(2)) is an adjuvant commonly utilized in vaccines, and is a ubiquitous element used extensively in contemporary life. Food, air, water, waste, the earth's surface, and pharmaceuticals all represent pathways of aluminum (Al) exposure. Crohn's disease (CD) is a chronic relapsing intestinal inflammation in genetically susceptible individuals and is caused by yet unidentified environmental factors. Al is a potential factor for the induction of inflammation in CD, and its immune activities share many characteristics with the immune pathology of CD: many luminal bacterial or dietary compounds can be adsorbed to the metal surface and induce Th1 profile cytokines, shared cytokines/chemokines, co-stimulatory molecules, and intracellular pathways and stress-related molecular expression enhancement, affecting intestinal macrobiota, trans-mural granuloma formation, and colitis induction in an animal CD model. The inflammasome plays a central role in Al mode of action and in CD pathophysiology. It is suggested that Al adjuvant activity can fit between the aberrations of innate and adaptive immune responses occurring in CD. The CD mucosa is confronted with numerous inappropriate bacterial components adsorbed on the Al compound surface, constituting a pro-inflammatory supra-adjuvant. Al fits the diagnostic criteria of the newly described autoimmune/inflammatory syndrome induced by adjuvants. If a cause and effect relationship can be established, the consequences will greatly impact public health and CD prevention and management.

Perfusion and permeability MR imaging of gliomas

Conventional contrast-enhanced MR imaging is the current standard technique for the diagnosis and treatment evaluation of gliomas and other brain neoplasms. However, this method is quite limited in its ability to characterize the complex biology of gliomas and so there is a need to develop more quantitative imaging methods. Perfusion and permeability MR imaging are two such techniques that have shown promise in this regard. This review will highlight the underlying principles, applications, and pitfalls of these evolving advanced MRI methods.

High-dose melphalan and autologous stem cell transplantation for AL amyloidosis: recent trends in treatment-related mortality and 1-year survival at a single institution

Treatment with high-dose melphalan chemotherapy supported by hematopoietic rescue with autologous stem cells produces high rates of hematologic responses and improvement in survival and organ function for patients with AL amyloidosis. Ongoing clinical trials explore pre-transplant induction regimens, post-transplant consolidation or maintenance approaches, and compare transplant to non-transplant regimens. To put these studies into context, we reviewed our recent experience with transplant for AL amyloidosis in the Amyloid Treatment and Research Program at Boston Medical Center and Boston University School of Medicine. Over the past 10 years, there was a steady reduction in rates of treatment-related mortality and improvement in 1-year survival, now approximately 5% and 90%, respectively, based upon an intention-to-treat analysis. Median overall survival of patients treated with this approach at our center exceeds 7.5 years.

Evidence-based recommendations for bowel cleansing before colonoscopy in children: a report from a national working group

BACKGROUND

There are no current recommendations for bowel cleansing before colonoscopy in children. The Israeli Society of Pediatric Gastroenterology and Nutrition (ISPGAN) established an iterative working group to formulate evidence-based guidelines for bowel cleansing in children prior to colonoscopy.

METHOD

Data were collected by systematic review of the literature and via a national-based survey of all endoscopy units in Israel. Based on the strength of evidence, the Committee reached consensus on six recommended protocols in children. Guidelines were finalized after an open audit of ISPGAN members.

RESULTS

Data on 900 colonoscopies per year were accrued, which represents all annual pediatric colonoscopies performed in Israel. Based on the literature review, the national survey, and the open audit, several age-stratified pediatric cleansing protocols were proposed: two PEG-ELS protocols (polyethylene-glycol with electrolyte solution); Picolax-based protocol (sodium picosulphate with magnesium citrate); sodium phosphate protocol (only in children over the age of 12 years who are at low risk for renal damage); stimulant laxative-based protocol (e. g. bisacodyl); and a PEG 3350-based protocol. A population-based analysis estimated that the acute toxicity rate of oral sodium phosphate is at most 3/7320 colonoscopies (0.041 %). Recommendations on diet and enema use are provided in relation to each proposed protocol.

CONCLUSION

There is no ideal bowel cleansing regimen and, thus, various protocols are in use. We propose several evidence-based protocols to optimize bowel cleansing in children prior to colonoscopy and minimize adverse events.

A simple technique for the placement of Schanz screws into bone using minimal radiologic control

The insertion of Schanz screws into the bone during external-fixation procedures in trauma and elective orthopaedic surgery is usually done under röentgenologic control. In order to minimize irradiation exposure for the patients, as well as surgeons, we describe a simple method of Schanz screw placement. The röentgenologic control of the position of the half-pins is only necessary at the beginning and the end of the procedure. This technique is simple, shortens the operating time and reduces the amount of radiation exposure to both the patient and surgeon. It is a valuable technique in many resource-poor environments who do not have the facilities for an image intensifier fluoroscopy or C-arm as well as in austere situations such as during military operations.

Adaptation of chicken vestibular nucleus neurons to unilateral vestibular ganglionectomy

Vestibular compensation refers to the behavioral recovery after a unilateral peripheral vestibular lesion. In chickens, posture and balance deficits are present immediately following unilateral vestibular ganglionectomy (UVG). After three days, most operated chickens begin to recover, but severe deficits persist in others. The tangential nucleus is a major avian vestibular nucleus whose principal cells are vestibular reflex projection neurons. From patch-clamp recordings on brain slices, the percentage of spontaneous spike firing principal cells, spike discharge rate, ionic conductances, and spontaneous excitatory postsynaptic currents (sEPSCs) were investigated one and three days after UVG. Already by one day after UVG, sEPSC frequency increased significantly on the lesion side, although no differences were detected in the percentage of spontaneous spike firing cells or discharge rate. In compensated chickens three days after UVG, the percentage of spontaneous spike firing cells increased on the lesion side and the discharge rate increased bilaterally. In uncompensated chickens three days after UVG, principal cells on the lesion side showed increased discharge rate and increased sEPSC frequency, whereas principal cells on the intact side were silent. Typically, silent principal cells exhibited smaller persistent sodium conductances and higher activation thresholds for the fast sodium channel than spiking cells. In addition, silent principal cells on the intact side of uncompensated chickens had larger dendrotoxin-sensitive potassium conductance, with a higher ratio of Kv1.1 surface/cytoplasmic expression. Increased sEPSC frequency in principal cells on the lesion side of uncompensated chickens was accompanied by decreased Kv1.2 immunolabeling of presynaptic terminals on principal cell bodies. Thus, both intrinsic ionic conductances and excitatory synaptic inputs play crucial roles at early stages after lesions. Unlike the principal cells in compensated chickens which showed similar percentages of spontaneous spike firing cells, discharge rates, and sEPSC frequencies bilaterally, principal cells in uncompensated chickens displayed gross asymmetry in these properties bilaterally.

Tibiofemoral cartilage thickness distribution and its correlation with anthropometric variables

The objective of this study was to determine tibiofemoral cartilage thickness distribution, and to investigate the relationship between cartilage geometry and anthropometric variables. In this study, 20 magnetic resonance examinations of the knee from normal individuals were reconstructed to provide three-dimensional models of the knee joint, including bony and cartilage surfaces. Three regions were defined on the articular surface, and the cartilage thickness distribution along each of these was determined. Statistically significant differences between femoral and tibial regions were examined using the paired Student t test in Microsoft Excel. Correlations were investigated using the correlation tool in Microsoft Excel. The average tibial cartilage thickness was found to be 2.76 mm and the average femoral cartilage thickness was 2.75 mm. Significant correlations exist between the tibia cartilage thickness and body height (R = 0.60; P < 0.05) and weight (R = 0.64; P < 0.05). Significant correlations exist between the femoral cartilage volume and the body height (R = 0.736; P < 0.01) and weight (R = 0.855; P < 0.01). It is suggested that the distribution and correlations of cartilage distribution indicate adaptation in response to mechanical loading. Information regarding cartilage thickness and volume distribution as found in this study may be useful in diagnosing and monitoring cartilage loss in patients with degenerative joint disease.

Neuroimaging of neuronal circuits involved in tic generation in patients with Tourette syndrome

OBJECTIVE

To identify brain regions generating tics in patients with Tourette syndrome using sleep as a baseline.

METHODS

We used [15O]H2O PET to study nine patients with Tourette syndrome and nine matched control subjects. For patients, conditions included tic release states and sleep stage 2; and for control subjects, rest states and sleep stage 2.

RESULTS

Our study showed robust activation of cerebellum, insula, thalamus, and putamen during tic release.

CONCLUSION

The network of structures involved in tics includes the activated regions and motor cortex. The prominent involvement of cerebellum and insula suggest their involvement in tic initiation and execution.

Sonographic detection of fetal cerebellar cavernous hemangioma with in-utero hemorrhage leading to cerebellar hemihypoplasia

We report the prenatal diagnosis of cerebellar cavernous angioma. Ultrasound examination at 21 weeks' gestation showed a hyperechogenic lesion measuring 12 mm in diameter, occupying most of the right cerebellar hemisphere. At 24 weeks' gestation, significant hypoplasia of the right hemisphere was diagnosed, and the pregnancy was terminated. Pathological evaluation of the lesion revealed extensive hemorrhaging and a rich network of dilated vessels and small capillaries. The right cerebellar lobe was hypoplastic and covered with blood clots. Cerebral cavernous malformation should be considered in the differential diagnosis of hyperechogenic lesions in the fetal cerebellum.

Associations between earliness, Ascochyta response, and grain yield in chickpea

Evidence from an array of dryland systems suggests that chickpea (Cicer arietinum L.) grain yield could be improved through better phenological adaptation. However, information on the relationship between phenology and Ascochyta response genes, and their possible interaction with biomass and grain yield, is missing. Accordingly, the aim of the present study was to determine the associations between the above factors and biomass and grain yield in chickpea. To that end, standard Israeli cultivars and advanced generation bulked progeny from the cv. Hadas × ICC5810 cross were used. Hadas is a late-flowering, high-yielding Israeli kabuli (0.45 g/seed) cultivar with moderate field resistance to Ascochyta blight, whereas ICC5810 is a day-neutral desi (0.15 g/seed) genotype with a strong temperature response, from India. Higher yields were observed among the late-flowering bulks of the Hadas × ICC5810 progeny. No relationship between the Ascochyta response and biomass and grain yield was observed. No interaction between the phenology and Ascochyta response grouping on biomass and grain yield was observed. The results demonstrate the feasibility of combining Ascochyta resistance with earlier flowering and its potential to improve chickpea adaptation to dryland systems.