Chemical component and in vitro protective effects of Matricaria chamomilla (L.) against lipopolysaccharide insult

ETHNOPHARMACOLOGICAL RELEVANCE

Chamomile (Matricaria chamomilla L.) is a popular herbal tea for the treatment of hepatitis and cholecystitis in traditional Uygur medicines.

AIM OF THE STUDY

To investigate the anti-inflammatory activity and chemical composition of M. chamomilla, and clarify its molecular mechanism.

MATERIALS AND METHODS

M. chamomilla was extracted with 75% ethanol and then extracted with different solvents to obtain five fractions, namely petroleum ether fraction (EOPE), dichloromethane fraction (EOD), ethyl acetate fraction (EOEA), n-butanol fraction (EOB), and water fraction (EOW). Cytotoxicity and the effect on the nitric oxide (NO) production of RAW264.7 cells induced by LPS of the five fractions were screened, and the most active one (EOD) was selected for further investigations. The components of EOD were identified by LC-MS/MS analysis in combination with comparison of retention time and UV absorption with authentic compounds by HPLC. In addition, five most abundant compounds of EOD were isolation by column chromatography and semi-preparative HPLC and their structures were further confirmed by HRMS and NMR data analysis and comparison with data in literatures. Then the underlying anti-inflammatory mechanism of EOD were predicted through Network pharmacology using the identified compounds from EOD, and further verified by Western Blot and ELISA experiments.

RESULTS

EOD showed the most significant inhibition ratio against NO in RAW264.7 cells without toxicity among the tested five fractions. Thirty-seven compounds including flavonoid-O-glycoside, flavonoid aglycone, methylated flavonoid aglycone, phenolic acid, coumarin, sesquiterpene, and triterpene were identified from EOD by LC-MS/MS and comparison with authentic compounds. The five most abundant compounds in EOD were isolated and determined to be axillarin (26), tricin (30), chrysoeriol (31), centaureidin (33) and chrysosplenetin (35). IL-6, NF-κB, ERK1 and ERK2 cascade, TNF were the most important anti-inflammatory targets of EOD predicted by Network pharmacology. Western Blot and ELISA experiments revealed that EOD significantly decreased the protein expression levels of inflammatory factors (PGE₂, MCP-1, IL-6, TNF-α), iNOS, COX-2, NF-κB (p-P65 and p-IκBα), MAPKs (p-p38, p-ERK and p-JNK), and increased the protein expression levels of Nrf2, HO-1 and CYP2E1. In addition, EOD blocked the p65 protein into the nucleus and promoted the nuclear translocation of Nrf2 in RAW264.7 cells induced by LPS.

CONCLUSION

M. chamomilla exerted anti-inflammatory effect via NF-κB, MAPK and Nrf2/HO-1 pathways. It could be further applied as a safe anti-inflammatory agent from natural source.

Health disparities in systemic lupus erythematosus-a narrative review

PURPOSE OF REVIEW

To describe root causes of health disparities by reviewing studies on incidence and outcomes of systemic lupus erythematosus (SLE) related to ethnic, race, gender, or socioeconomic differences and to propose solutions.

RECENT FINDINGS

SLE outcomes have steadily improved over the past 40 years but are not uniformly distributed across various racial and ethnic groups. Belonging to racial and ethnic minority has been cited as a risk factor for more severe disease and poor outcome in SLE. Population-based registries have demonstrated that Black patients with SLE have significantly lower life expectancy compared to White patients. Lower socioeconomic status has been shown to be one of the strongest predictors of progression to end stage renal disease in lupus nephritis. An association between patient experiences of racial discrimination, increased SLE activity, and damage has also been described. The lack of representation of marginalized communities in lupus clinical trials further perpetuates these disparities. To that end, the goal of a rheumatology workforce that resembles the patients it treats has emerged as one of many solutions to current shortfalls in care. Disparities in SLE incidence, treatment, and outcomes have now been well established. The root causes of these disparities are multifactorial including genetic, epigenetic, and socioeconomic. The underrepresentation of marginalized communities in lupus clinical trials further worsen these disparities. Efforts have been made recently to address disparities in a more comprehensive manner, but systemic causes of disparities must be acknowledged and political will is required for a sustained positive change.

Comprehensive network analysis to identify the molecular pathogenesis of pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PAH) is a chronic progressive disease that may lead to right heart failure and eventually death. At present, great progress had been achieved in the treatment of pulmonary hypertension. However, pulmonary hypertension cannot be fundamentally cured, and its pathogenesis is still unclear.

METHODS

A multifactor-driven dysfunction module of pulmonary hypertension has been constructed in order to explore its potential pathogenesis. We performed differential expression analysis, coexpression analysis, enrichment analysis and hypergeometric test to calculate the potential regulatory effects of multiple factors on the module.

RESULTS

Four modules and corresponding hub genes were identified. In addition, we also obtained a series of ncRNA (MALAT1 and miR-17-5p) and transcription factor (HIF1A). Network analysis revealed that MALAT1, NFKB1 and RELA targeting IL1B of module 4 and IL6 of module 1 to participate in the occurrence and development of pulmonary hypertension through Toll-like receptor signaling pathway.

CONCLUSIONS

It is necessary to identify disease-related disorders by integrating multiple regulatory factors. The regulatory network may play an important role in PAH. The results not only provided new methods and ideas for follow-up research, but also helps researchers to have a deeper understanding of potential pathogenesis for PAH.

Isothermal microcalorimetry minimal inhibitory concentration testing in extensively drug resistant Gram-negative bacilli: a multicentre study

OBJECTIVES

To evaluate the performance of an isothermal microcalorimetry (IMC) method for determining the MICs among extensively drug-resistant Gram-negative bacilli.

METHODS

A collection of 320 clinical isolates (n = 80 of each) of Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa and Acinetobacter baumannii from Sweden, Spain, Italy and the Netherlands were tested. The MICs were determined using the IMC device calScreener (Symcel, Stockholm, Sweden) and ISO-broth microdilution as the reference method. Essential agreement, categorical agreement, very major errors (VME), major errors (ME) and minor (mE) errors for each antibiotic were determined.

RESULTS

Data from 316 isolates were evaluated. Four errors (two ME, one VME, one mE) among 80 K. pneumoniae, six errors (four ME, one VME, one mE) among 79 E. coli, 15 errors (seven VME, three ME, five mE) among 77 P. aeruginosa and 18 errors (12 VME, two ME, four mE) among 80 A. baumannii were observed. Average essential agreement and categorical agreement of the IMC method were 96.6% (95% confidence interval, 94.2-99) and 97.1% (95% confidence interval, 95.4-98.5) respectively when the MICs were determined at the end of 18 hours. Categorical agreement of the IMC method for prediction of MIC by the end of 8 hours for colistin, meropenem, amikacin, ciprofloxacin and piperacillin/tazobactam were 95%, 91.4%, 94%, 95.2% and 93.7% respectively.

CONCLUSIONS

The IMC method could accurately determine the MICs among extensively drug-resistant clinical isolates of E. coli, K. pneumoniae, P. aeruginosa and A. baumannii isolates.

Pattern and Correlates of Hypomagnesemia Among Subset of Diabetes Mellitus

BACKGROUND

Nowadays, there is an accumulated data about the relation between hypomagnesemia (low Serum Mg level < 0.7 mmol/l) and diabetes.

OBJECTIVE

In this study, we aimed to determine the prevalence of hypomagnesemia in a carefully diagnosed diabetes patients and to show how some factors could contribute to the prevalence of low serum Mg level among the population under study.

METHODS

In short, 62 patients of both type 1 and 2, who attended AL-Sadir medical city/ diabetes and endocrinology centre during the period of the study were included in the study. A detailed history was taken and participants were informed verbally about the procedure of this study. Serum magnesium and creatinine were measured using standardized methods.

RESULTS

The overall prevalence of the hypomagnesemia, among diabetic population involved in this study, was 29.03 % and it was nearly similar in male (29.41 %) and female (28.57 %). The means(SD) of serum Mg level were similar in type 1 and type 2 diabetic patients. Other difference in prevalence among other characteristics has been reported. Within all participants, gender (r = -0.02), fasting blood glucose (r = -0.514) and metformin use (r = -0.014) were negatively correlated with serum Mg level, in contrast to other variables, which were positively correlated. While among type 1 DM, age (r= 0.193), serum creatinine (r= 0.031) and insulin use (r= 0.217) were positively correlated with serum Mg level. In contrast, others were negatively correlated. In type 2 DM, age (r = -0.283) and fasting blood glucose (r = -0.496) were negatively correlated with serum Mg level. On the other hand, other variables were positively correlated with serum Mg level.

CONCLUSION

Hypomagnesemia prevalence was detected in nearly one-third of the diabetic population, which is quite high prevalence. Some factors have shown to play an essential role in this prevalence. A large study is warranted to address this issue.

Changes in mucin 1 expression in a rat model of allergic airway inflammation

PURPOSE

To explore the distribution and expressional changes of mucin 1 (Muc1) in airway of rats with allergic airway inflammation.

MATERIALS AND METHODS

Ovalbumin (OVA) was used to induce acute allergic inflammation in male Wistar rats. The distributions and expressions of Muc1 in lungs of normal and model rats were assessed by immunohistochemical staining and western blotting, respectively.

RESULTS

Immunohistochemical staining showed that Muc1 distributed in airway epithelial cells with ciliates, but not those nonciliated cells. Mucin 1 protein expression in the lung was increased during the development of allergic airway inflammation when compared with the normal rats.

CONCLUSION

Mucin 1 distributes in the airway epithelial cells with ciliates and the expressional increase of Muc1 in lung may imply its functions on allergic inflammatory episodes.

Anthropometric measurements in children having transfusion-dependent beta thalassemia

OBJECTIVES

The aim of this study was to determine the anthropometric measurements in transfusion-dependent β-thalassemia children in Pakistan. The secondary aim was to correlate serum ferritin with the physical growth.

METHODS

We enrolled 367 children (aged 5-17 years) with transfusion-dependent beta-thalassemia major in the study. Anthropometric measurements, serum ferritin levels, and pre-transfusion hemoglobin levels were measured. Serum ferritin was correlated with the height z-score for age.

RESULTS

Laboratory evaluation showed that patients had significantly low mean pre-transfusion hemoglobin of 7.66 ± 1.34 g/dl (range 2.5-10.5) and high median (Q3-Q1) serum ferritin of 5012 ng/ml (6829-3532). The median (Q3-Q1) height-for-age z-score of children was low at -2.69 and (-1.46 to -3.80) and 65.4% children had stunted growth (height for age z-score <-2). There was a significant negative correlation between height for age z-score and serum ferritin levels (p < 0.000). Stunting of growth began early during 5-10 years of age but increased markedly with the progress of time.

CONCLUSIONS

The study showed that children with beta thalassemia major had delayed physical growth possibly secondary to iron overload. Effective and early iron chelation is needed for preventing growth failure in transfusion-dependent beta thalassemia.

Randomized, double-blind, placebo-controlled superiority trial of the Yiqigubiao pill for the treatment of patients with chronic obstructive pulmonary disease at a stable stage

In traditional Chinese medicine (TCM), the Yiqigubiao pill is commonly used to enhance physical fitness. The current clinical trial was designed to evaluate the efficacy and safety of the Yiqigubiao pill as an adjuvant therapy for patients with stable chronic obstructive pulmonary disease (COPD). The current trial was a randomized, double-blind, placebo-controlled superiority trial. The participants were recruited from outpatients at the Traditional Chinese Medicine Hospital affiliated with Xinjiang Medical University (Ürümqi, China) between February and September 2012. All participants were patients with stable COPD that were randomized to the Yiqigubiao pill (YQGB; n=84) or placebo (Pb; n=87) groups. The occurrences of acute exacerbation (AE) of COPD during the trial were recorded. Lung function value assessments, scoring of life quality and exercise endurance, arterial blood gas analysis and serum inflammatory cytokines level determination were performed prior to and throughout the study. A total of 139 participants completed the intervention and 132 participants completed the study. The interval between the initial intervention and the first AECOPD was greater in the YQGB group compared with the Pb group (P<0.01). The incidence rate of AECOPD was lower in the YQGB group than in the Pb group (P<0.01). Subsequent to the intervention or at the end of the study, the 6-min walking distance difference was longer in the YQGB group compared with the Pb group (P<0.01). The scores reflecting life quality decline became lower in the YQGB group (P<0.01). The serum levels of proinflammatory factors were downregulated to a greater extent in the YQGB group compared with the Pb group. Thus, the Yiqigubiao pill is an efficient and safe adjuvant therapy for the treatment of stable patients with COPD.

Use of aquaporins 1 and 5 levels as a diagnostic marker in mild-to-moderate adult-onset asthma

Characteristic features of asthma include airway inflammation and hyperactivity, mucus hypersecretion, mucosal edema, and airway remodeling. These features could be due to pathological water transport across pulmonary epithelia and aquaporins (AQPs) have recently been isolated as key proteins in fluid transportation in the human respiratory tract. We aimed to evaluate the role of aquaporins in the pathogenesis of asthma and their possible use a diagnostic marker of the disease. A total of 110 hospitalized and outpatients with mild to moderate adult-onset asthma were invited to participate in this study and 34 submitted an induced sputum sample adequate for analysis. The amount of AQP1, AQP5 and MUC5AC were measured with ELISA assay. The amount of IL-2, IL-4, IL-6, IL-10, TNF-α, IFN-γ and IL-17 in both serum and sputum were measured with Cytometry Bead Array (CBA kit). Our results suggest that sputum AQP5, AQP1 and MUC5AC are all in a good correlation (r=0.498 between AQP5 and AQP1, r=0.529 and r=0.661 between MUC5AC and AQP5 or AQP1, respectively, all P<0.05). The AUC value for AQP1 and AQP5 to diagnose asthma were 0.729 and 0.745, respectively. In conclusion, water homeostasis plays an important role in maintaining adequate fluid transportation within the lung and is involved in the pathogenesis of asthma. Our results suggest that AQP may influence pulmonary physiology that their dysfunction can contribute to pulmonary pathogenesis, such as asthma. Moreover, their quantification could serve as biomarkers for the diagnosis of asthma.

Dissemination of the multidrug-resistant extended-spectrum β-lactamase-producing Escherichia coli O25b-ST131 clone and the role of house crow (Corvus splendens) foraging on hospital waste in Bangladesh

Two hundred and thirty-eight faecal samples from crows foraging on hospital wastes were analysed for extended-spectrum β-lactamase (ESBL)-producing Enterobacteriaceae. ESBL-producing crow isolates were characterized and compared with 31 patient isolates. Among the crows, 59% carried ESBL producers. These included Escherichia coli, Klebsiella pneumoniae, Raoultella terrigena and Enterobacter cloacae harbouring the genes for CTX-M-1, CTX-M-15, CTX-M-55, CTX-M-79, and CTX-M-14. Human isolates carried only the CTX-M-15 gene. Two-thirds of crow E. coli isolates and all human E. coli isolates were multidrug resistant. Crows and patients shared E. coli sequence types, including the epidemic E. coli O25b-ST131 clone. The scavenging behaviour of crows at poorly managed hospital waste dumps made them potential reservoirs of antibiotic resistance, including ESBLs.

Echinococcus granulosus infection reduces airway inflammation of mice likely through enhancing IL-10 and down-regulation of IL-5 and IL-17A

BACKGROUND

Cystic echinococcosis (CE) is a near cosmopolitan zoonosis caused by the larval stage of the dog tapeworm Echinococcus granulosus. E. granulosus infection induces a polarized T-helper type 2 (Th2) systematic immune response in its intermediate hosts. However, it is not known whether the infection modulates lung inflammation by regulating local immune response. In this study, we examined the effects of E. granulosus infection on mouse ovalbumin (OVA)-induced asthma model.

METHODS

BALB/c mice were intraperitoneally transplanted with 50 small E. granulosus cysts cultured in vitro. At 3 months post-inoculation, the mice were sensitized and challenged with ovalbumin (OVA). For histopathological studies, hematoxylin eosin and periodic acid schiff staining was used to examine the inflammatory cells infiltration and goblet cells hyperplasia, respectively. Cytokine levels were measured by mouse cytometric bead array (CBA) Kit and quantitative RT-PCR and other molecular biological approaches. Airway hyperresponsiveness was assessed in response to increasing doses of methacholine. Serum immunoglobulins were determined by ELISA.

RESULTS

E. granulosus infection significantly increased Th2 and Treg cytokine levels in serum and lung tissues, but down-regulated the expression of IL-5 in the lungs and IL-17A in serum and lung tissues of asthmatic mice sensitized and challenged with OVA. Histological staining of lung tissues showed that E. granulosus infection significantly reduced the severity of OVA-induced airway inflammation including reduction of eosinophil cell infiltration and mucus production. The E. granulosus infection also reduced eosinophil accumulation induced by OVA in bronchoalveolar lavage fluid (BALF) and also ameliorated airway hyperresponsiveness, a hallmark symptom of asthma.

CONCLUSIONS

E. granulosus infection remarkably reduces the severity of OVA-induced airway inflammation likely through enhancing IL-10 and down-regulation of IL-5 and IL-17A.

New clinical research strategies in thoracic oncology: clinical trial design, adaptive, basket and umbrella trials, new end-points and new evaluations of response

In the genomics era, our main goal should be to identify large and meaningful differences in small, molecularly selected groups of patients. Classical phase I, II and III models for drug development require large resources, limiting the number of experimental agents that can be tested and making the evaluation of targeted agents inefficient.

There is an urgent need to streamline the development of new compounds, with the aim of identifying “trials designed to learn”, which could lead to subsequent “trials designed to conclude”.

Basket trials are often viewed as parallel phase II trials within the same entity, designed on the basis of a common denominator, which can be a molecular alteration(s). Most basket trials are histology-independent and aberration-specific clinical trials. Umbrella trials are built on a centrally performed molecular portrait and molecularly selected cohorts with matched drugs, and can include patients’ randomisation and strategy validation. Beyond new designs, new end-points and new evaluation techniques are also warranted to finally achieve methodology and clinical improvements, in particular within immunotherapy trials.

Expression of aquaporins in the lungs of mice with acute injury caused by LPS treatment

The aim of the present study was to investigate the expression of aquaporin 1 (AQP1) and AQP5 in the lungs of mice with acute injury induced by LPS treatment. In the study, the concentrations of cytokines were all significantly increased in the BALF of mice received LPS at 12h and 24h (P<0.001). The lung wet/dry weight ratios (W/D) and total protein content in BALF were also increased in the mice treated with LPS (P<0.001). Interestingly the expression of AQP1 and AQP5 was significantly decreased (P<0.05) compared with these in the control mice, while TUNEL positive cells were increased. However, the AQP5 expression was significantly higher at 24h that it at 12h in the control mice. Our results showed that decreased AQP expression was associated with the increased inflammatory factors, as well as apoptotic cells. The increased expression of AQP5 at 24h in control mice might be due to its regulation in transcellular water reabsorption.

Changes in water channel aquaporin 1 and aquaporin 5 in the small airways and the alveoli in a rat asthma model

OBJECTIVES

To examine changes in aquaporin 1 (AQP1) and aquaporin 5 (AQP5) in the small airways and alveoli in a rat asthma model.

METHOD

Forty Wistar rats were randomly divided into a control group and an ovalbumin (OVA) sensitization asthma model group. The distribution and expression of AQP1 and AQP5 in lung tissues were analyzed using immunohistochemistry (IHC), quantified the staining intensity by assessing integrated optical densities (IOD), and Western blotting (WB).

RESULTS

IHC showed AQP1 was mainly distributed in sub-epithelial microvascular endothelial cells (MECs) and red blood cells. IOD values showed, in the asthma model group, the expression of AQP1 in alveolar MECs was lower than that in the control group (P<0.05); However, AQP1 expression in small airways sub-epithelial was higher than in the control group (P<0.05). The WB indicated that AQP1 expression in the asthma model group was 57% lower than in the control group (P<0.05). AQP5 was mainly distributed in the non-ciliated epithelial cells of the small airways and the apical membranes of type I and type II epithelial cells. IOD values showed, in asthma model group, the expression of AQP5 increased in small airways epithelium (P<0.05), and decreased in alveolar epithelium (P<0.05). The WB showed a 36% reduction in AQP5 expression compared with the control group (P<0.05).

CONCLUSION

AQP1 and AQP5 increased in small airways in rats with experimentally induced asthma, indicating that they may be involved in the formation of submucosal edema and mucus hypersecretion. Decreased AQP1 and AQP5 in pulmonary alveoli may be related to increased alveolar liquid viscosity and the formation of mucus plugs.

Trimodality therapy for malignant pleural mesothelioma: results from an EORTC phase II multicentre trial

The European Organisation for Research and Treatment of Cancer (EORTC; protocol 08031) phase II trial investigated the feasibility of trimodality therapy consisting of induction chemotherapy followed by extrapleural pneumonectomy and post-operative radiotherapy in patients with malignant pleural mesothelioma (with a severity of cT3N1M0 or less). Induction chemotherapy consisted of three courses of cisplatin 75 mg·m⁻² and pemetrexed 500 mg·m⁻². Nonprogressing patients underwent extrapleural pneumonectomy followed by post-operative radiotherapy (54 Gy, 30 fractions). Our primary end-point was "success of treatment" and our secondary end-points were toxicity, and overall and progression-free survival. 59 patients were registered, one of whom was ineligible. Subjects' median age was 57 yrs. The subjects' TNM scores were as follows: cT1, T2 and T3, 36, 16 and six patients, respectively; cN0 and N1, 57 and one patient, respectively. 55 (93%) patients received three cycles of chemotherapy with only mild toxicity. 46 (79%) patients received surgery and 42 (74%) had extrapleural pneumonectomy with a 90-day mortality of 6.5%. Post-operative radiotherapy was completed in 37 (65%) patients. Grade 3-4 toxicity persisted after 90 days in three (5.3%) patients. Median overall survival time was 18.4 months (95% CI 15.6-32.9) and median progression-free survival was 13.9 months (95% CI 10.9-17.2). Only 24 (42%) patients met the definition of success (one-sided 90% CI 0.36-1.00). Although feasible, trimodality therapy in patients with mesothelioma was not completed within the strictly defined timelines of this protocol and adjustments are necessary.

Phase II feasibility trial of induction chemotherapy (ICT) followed by extrapleural pneumonectomy (EPP) and postoperative radiotherapy (PORT) for cT3N1M0 or less malignant pleural mesothelioma (MPM) (EORTC 08031)

7509

Background: MPM is a highly lethal disease and the role of EPP in the treatment of early stage, potentially resectable MPM remains controversial. EORTC 08031 phase II trial investigated the feasibility of trimodality therapy (TMT) consisting of ICT followed by EPP and PORT. Methods: Eligibility criteria were cT3N1M0 or less, proven MPM, < 70 years, PS 0–1, fit for TMT. ICT consisted of 3 courses of cisplatin 75mg/m2 and pemetrexed 500mg/m2 q3weeks. Non-progressing patients (pts) underwent EPP followed by PORT (54Gy, 30 fractions). Primary endpoint was “success of treatment” defined as a patient receiving the full protocol treatment, still alive 90 days after end of treatment without progression and without grade (G) 3–4 toxicity. Using a one step Fleming design 52 patients and 26 successes were required. Secondary endpoints were toxicity of TMT, overall and progression-free survival. Results: 59 pts were registered between 07/26/05 and 08/24/07, 1 was ineligible. Median age was 57 years (range 26–67), M/F 46/12, all proven MPM (31 epithelial, 18 mixed, 9 other). All pts underwent mediastinoscopy, cT1/T2/T3: 36/16/6, cN0/N1: 57/1. 55 pts received 3 cycles of ICT. G3–4 toxicity related to ICT was rare. 46 pts (79%) were operated, 42 (74%) had EPP. R0/1/2: 30/10/3, 6 were re-operated, pT0/1/2/3/4: 2/5/19/15/4, pN0/1/2/3: 34/2/6/2, 90-day mortality: 3 pts (6.5%); in 38 pts (83%) postoperative complications occurred. PORT was initiated in 38 pts and completed in 37 (65%). After PORT 2 pts (3.5%) died due to infection. Persisting G3/4 toxicity after 90 days: 3 pts (5.3%) due to radiation pneumonitis and bronchopleural fistula. After median follow- up of 19.3 months (mos) median overall survival time was 18.4 mos (95% CI 14.8-NR) and median progression-free survival was 13.9 mos (95% CI 10.9–17.1). Only 24 pts (42%) met the definition of success (one-sided 90% CI 0.36–1.00). Conclusions: EORTC 08031 investigated the feasibility of TMT in pts with proven MPM. Due to the low proportion of “successes” this TMT is not considered to be feasible. Although overall results were similar to other series, adjustments to this TMT are necessary.

No significant financial relationships to disclose.

Adjuvant chemotherapy in elderly patients: An analysis of National Cancer Institute of Canada Clinical Trials Group and Intergroup BR.10

7009

Background: Recent trials have shown significant survival benefit from adjuvant chemotherapy after resection of NSCLC. Whether elderly patients tolerate platinum-based adjuvant chemotherapy and derive the same survival advantage is unknown. This retrospective study evaluated the influence of age on survival, chemotherapy delivery and toxicity in NCIC CTG BR.10. Methods: Pretreatment characteristics and survival benefit from treatment were compared for patients ≤65 & >65. Chemotherapy delivery and toxicity were compared for 213 treated patients. Results: There were 327 young and 155 elderly patients. Baseline prognostic factors by age were similar with the exception of histology (adeno 58% young, 43% elderly; squamous 32% young, 49% elderly; p=0.001) and PS (PS 0 53% young, 41% elderly; p=0.01). Overall survival by age showed a trend favoring the young in univariate (HR 0.77, CI 0.58–1.04, p=0.084) and multivariate analyses (HR 0.75, CI 0.56–1.01, p=0.059). Patients >75 years had significantly shorter survival than those aged 66–74 (HR 1.95, CI 1.11–3.41, p=0.02). Overall survival for patients >65 was significantly better with chemotherapy v observation (HR 0.61, CI 0.38–0.98, p=0.04). Chemotherapy administration and toxicity were evaluated in 63 elderly and 150 young patients. Mean dose intensities of vinorelbine (V) and cisplatin (C) were 13.2 and 18.0 in the young and 9.9 and 14.1 in the elderly (V p=0.0004; C p=0.001). The elderly received significantly fewer doses of V (p=0.014) and C (p=0.006). Fewer elderly patients completed treatment and more refused treatment compared to the young (p=0.03). There were no significant differences in toxicities, G-CSF use or hospitalization by age group, except for myalgias and mood alteration (more frequent among the young). Six of 126 deaths (4.8%) in the young were from non-malignant causes v 12 of 71 (16.9%) in the elderly (p=0.008). Conclusions: In spite of receiving less chemotherapy than young patients, adjuvant chemotherapy improves overall survival in patients aged >65 with acceptable toxicity. Adjuvant chemotherapy should not be withheld from elderly patients, although patients >75 years of age require further study.

No significant financial relationships to disclose.

Identifying patients with non-small cell lung cancer (NSCLC) unlikely to benefit from erlotinib: An exploratory analysis of National Cancer of Institute of Canada Clinical Trials Group BR.21

7161

Background: Despite a 9% response rate, BR.21 demonstrated significant survival benefit for patients receiving erlotinib as 2nd/3rd line therapy for NSCLC. We undertook to characterize, by exploratory subset analysis, patients less likely to benefit from erlotinib. To identify factors for consideration, we first identified baseline characteristics associated with early progression by eight wks and early death by 3 mos. Methods: Using stratification factors and potential prognostic factors from BR.21, the Cox regression model with stepwise selection was used to establish a prognostic model to separate erlotinib patients into 4 risk categories based on the 10th, 50th & 90th percentiles of prognostic index scores. 7 variables (smoking history, PS, weight loss, anemia, high LDH, response to prior chemo and time from diagnosis to randomization) were used in the final model. The hypothesis was that the characteristics of the treated patients in the highest risk group would also be predictive of lack of benefit from erlotinib when erlotinib and placebo patients with the same characteristics were compared. Results: Factors associated with PD by 8 wks were: PS2–3 (p = 0.009), weight loss (p = 0.0004), anemia (p = 0.008), PD to prior chemo (p = 0.006), non-Asian (p = 0.047), EGFR IHC-negative (p = 0.005), Factors associated with survival < 3 mos were: PS2–3 (p < 0.0001), weight loss (p < 0.0001), anemia (p < 0.0001), PD to prior chemo (p < 0.0001), non-Asian (p = 0.008), high LDH (p < 0.0001), time to randomization <12 mos (p = 0.0003). Comparison of overall survival for the 4 risk groups derived from prognostic index score as follows: high benefit (HR = 0.41, p = 0.007), 2 intermediate benefit (HR 0.79, p = 0.09; HR 0.80; p = 0.09); no benefit (HR 1.23; p = 0.42). Median survivals for erlotinib (placebo) patients in each group were 17.3 (8.3), 9.7 (7.5), 4.1 (3.7), 1.9 (2.7) mos. Conclusions: By establishing a prognostic model, we identified a small group of patients who are unlikely to benefit from 2nd/3rd line erlotinib therapy. This model requires prospective validation to confirm that it is both prognostic and predictive of outcome from treatment.

[Table: see text]

Febrile seizures: factors affecting risk of recurrence in Pakistani children presenting at the Aga Khan University Hospital

OBJECTIVES

To (a) describe the effect of temperature rise on seizure recurrence in the ER (b) investigate the effect of age, gender, family and developmental history, type, duration and multiple seizures, past history and number of seizures and treatment given (either late or early) on seizure recurrence in the ER and (c) explore prognostic indicators for seizure recurrence.

METHODS

Data from 352 children [ages 3-84 months; 220 males (62.5%) 132 females (37.5%)] was taken using chart reviews for the years January 1998-August 2000 inclusive, from the Pediatric department of the Aga Khan University Hospital. Descriptive statistics, Chi-square, and Discriminant Analysis were used.

RESULTS

Of the 52 (16%) cases that had seizure recurrence in the ER, majority (36.5%) occurred in > 38.5 degrees < or = 39.5 degrees C temperature range. The percentage declined to 15% at higher temperatures. Bivariate tests showed that age, family and developmental history, type of seizure and treatment given did not affect seizure recurrence in the ER. Past history number of seizures (p = .006), duration of seizure (p < 0.001), past history of seizures (p = 0.004) and multiple seizure (p = 0.024) were factors significantly associated with seizure recurrence in the ER at the bivariate level of analysis. Duration of seizure was the most important prognostic indicator for FS recurrence in the ER at the multivariate level with beta = .79.

CONCLUSION

Duration of seizure (> 5 minutes) was the most important prognostic factor for FS recurrence. Early treatment did not affect recurrence,suggesting timely anti-pyretic vs. anti-leptic medication use.

Rupture of the uterus in labor: a review of 150 cases

We analyzed 150 cases of uterine rupture in late pregnancy that occurred over an 8-year period at the State Maternity Hospital in Ankara, Turkey. The incidence of uterine rupture was 1 in 966 deliveries, and 114 uterine ruptures occurred in previously scarred uteri. Rupture of the unscarred uterus is a more catastrophic event. There is a marked difference in fetal and maternal outcome between the group with a previously scarred uterus and the group without a previous scar. Common etiological factors for uterine rupture were grandmultiparity, cephalopelvic disproportion, fetal malpresentation, and oxytocin stimulation of labor. The fetal wastage was high, a perinatal mortality of 32.2% being recorded, but 98% of mothers were saved. Hysterectomy was commonly performed in this group. Repair of the uterus should only be performed when the rupture is simple, is in the lower segment and has no sign of infection.