Subgroup analysis in RAISE: a randomized, double-blind phase III study of irinotecan, folinic acid, and 5-fluorouracil (FOLFIRI) plus ramucirumab or placebo in patients with metastatic colorectal carcinoma progression

BACKGROUND

The RAISE phase III clinical trial demonstrated that ramucirumab + FOLFIRI improved overall survival (OS) [hazard ratio (HR) = 0.844, P = 0.0219] and progression-free survival (PFS) (HR = 0.793, P < 0.0005) compared with placebo + FOLFIRI for second-line metastatic colorectal carcinoma (mCRC) patients previously treated with first-line bevacizumab, oxaliplatin, and a fluoropyrimidine. Since some patient or disease characteristics could be associated with differential efficacy or safety, prespecified subgroup analyses were undertaken. This report focuses on three of the most relevant ones: KRAS status (wild-type versus mutant), age (<65 versus ≥65 years), and time to progression (TTP) on first-line therapy (<6 versus ≥6 months).

PATIENTS AND METHODS

OS and PFS were evaluated by the Kaplan-Meier analysis, with HR determined by the Cox proportional hazards model. Treatment-by-subgroup interaction was tested to determine whether treatment effect was consistent between subgroup pairs.

RESULTS

Patients with both wild-type and mutant KRAS benefited from ramucirumab + FOLFIRI treatment over placebo + FOLFIRI (interaction P = 0.526); although numerically, wild-type KRAS patients benefited more (wild-type KRAS: median OS = 14.4 versus 11.9 months, HR = 0.82, P = 0.049; mutant KRAS: median OS = 12.7 versus 11.3 months, HR = 0.89, P = 0.263). Patients with both longer and shorter first-line TTP benefited from ramucirumab (interaction P = 0.9434), although TTP <6 months was associated with poorer OS (TTP ≥6 months: median OS = 14.3 versus 12.5 months, HR = 0.86, P = 0.061; TTP <6 months: median OS = 10.4 versus 8.0 months, HR = 0.86, P = 0.276). The subgroups of patients ≥65 versus <65 years also derived a similar ramucirumab survival benefit (interaction P = 0.9521) (≥65 years: median OS = 13.8 versus 11.7 months, HR = 0.85, P = 0.156; <65 years: median OS = 13.1 versus 11.9 months, HR = 0.86, P = 0.098). The safety profile of ramucirumab + FOLFIRI was similar across subgroups.

CONCLUSIONS

These analyses revealed similar efficacy and safety among patient subgroups with differing KRAS mutation status, longer or shorter first-line TTP, and age. Ramucirumab is a beneficial addition to second-line FOLFIRI treatment for a wide range of patients with mCRC.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT01183780.

Complaints of foodborne illness in San Francisco, California, 1998

Foodborne diseases are an important public problem affecting millions of Americans each year and resulting in substantial morbidity and mortality. Many foodborne infections occur in outbreak settings. Outbreaks are often detected by complaints from the public to health authorities. This report reviews complaints received by the San Francisco Department of Public Health involving suspected foodborne illness in 1998. Although such foodborne complaints are commonly received by health officials, we provide the first review of population-based data describing such complaints. We use a broad definition of a foodborne disease outbreak. We judged a complaint to be a "likely foodborne disease outbreak" if it involved more than one person and more than one family; no other common meals were shared recently by ill persons; diarrhea, vomiting, or both was reported; and the incubation period was more than one hour. In 1998, 326 complaints of foodborne illness, involving a total of 599 ill people, were received by the Communicable Disease Control Unit in San Francisco. The complaints involved from 1 to 36 ill persons, with 61% involving one ill person and 25% involving two ill persons. Of the 126 reports involving illness in more than one person, 77 (61%) were judged to be likely foodborne disease outbreaks. Three of these 77 outbreaks had been investigated prior to our review. This project confirms that more foodborne disease outbreaks occur than are reported to state and national outbreak surveillance systems. Our review of the San Francisco system highlights opportunities for gleaning valuable information from the foodborne disease complaint systems in place in most jurisdictions.

Addition of dextrose 3.5% to intrathecal sufentanil for labour analgesia reduces pruritus

PURPOSE

To determine whether the addition of a low concentration (3.5%) of dextrose would minimize pruritus while maintaining the quality of analgesia.

METHODS

In a double blind study 48 parturients in early labour were randomized to one of two study groups: dextrose (Dex, n = 24; 10 microg sufentanil in dextrose 3.5%), or normal saline (NS, n = 24; 10 microg sufentanil in normal saline). Parturients received the study drug as the intrathecal injection of the combined spinal-epidural (CSE) technique for labour analgesia. Duration and degree of analgesia were measured until epidural analgesia was initiated or delivery of the baby. The intensity and distribution (above T6, T6-L1, and below L1) of pruritus were measured at five minute intervals during first 25 min after injection.

RESULTS

Quality and duration of analgesia did not differ between groups, but the overall incidence of pruritus was less in the Dex group (88% vs 42%, P = 0.001). Within each region, the incidence of pruritus was less in the Dex group. In patients who had pruritus, for the Dex group, the incidence of pruritus in the upper region (>T6) was lower than the NS group. There was no difference in the lower regions.

CONCLUSION

The addition of dextrose 3.5% to intrathecal sufentanil reduced the incidence of pruritus without affecting the duration or quality of analgesia in parturients in early labour. The distribution of pruritus in the Dex group was limited to below T6 suggesting that pruritus to intrathecal sufentanil is mediated at the spinal level.

A longitudinal study of ventricular volume in early relapsing-remitting multiple sclerosis

The specific aim of this study was to determine whether progressive brain atrophy could be detected within 18 months of establishing a diagnosis of relapsing-remitting multiple sclerosis (RRMS). Fifteen patients with clinically definite RRMS (mean disease duration from first symptom=6 months, mean EDSS=1.2) completed 6 - 14 monthly quantitative MRI sessions. The volume of the lateral ventricles was determined each month using a semi-automated thresholding technique from T1-weighted axial images. The number of new monthly gadolinium-enhancing (Gd+) lesions and EDSS scores were also recorded. Lateral ventricular volumes increased significantly during this study. When individual data were examined, statistically significant changes were observed in six of 15 patients. Monthly change in ventricular volume was related to baseline EDSS and total number of new Gd(+) lesions. These observations indicate brain atrophy, a putative imaging marker of diffuse demyelination and axonal loss, can occur as early as 18 months after first symptoms of RRMS, and is related to the baseline level of disability and to the number of new Gd+ lesions. Multiple Sclerosis (2000) 6 332 - 337

Are you caring or caretaking?

People in helping roles often confuse caretaking with being a caring professional. This confusion leads to burnout, self-neglect, and perpetuates destructive relating habits. This article describes the signs of caretaking, exposes some of the common family roles/dynamics that encourage caretaking, and points out ways to change.

Increased number of Leu-2-bearing non-T cells with natural killer activity in chimpanzees

Peripheral blood lymphocytes from adult and adolescent chimpanzees, as well as adult humans, were studied for phenotypic surface markers by flow cytometry. Lymphocytes from chimpanzees were found to have increased numbers of Leu-1-, Leu-2+ cells as compared to humans. These cells, following preparative electronic cell sorting, were shown to possess natural killer function. Further analysis of this subpopulation indicated that they lacked responsiveness to a number of T-cell mitogens. The differences in lymphocyte subpopulations between chimpanzees and humans can almost be totally accounted for by the Leu-1-, Leu-2+ cells. Phylogenetic disparity between these two species may also be found within this population.

Reuse of permanent cardiac pacemakers

Cardiac pacemakers are part of a growing group of expensive implantable electronic devices; hospitals in which 100 pacemakers are implanted per year must budget over $300 000 for these devices. This cost represents a considerable burden to health care resources. Since the "life-span" of modern pacemakers often exceeds that of the patients who receive them, the recovery and reuse of these devices seems logical. Pacemakers can be resterilized and tested with current hospital procedures. Reuse should be acceptable under Canadian law, but the manner in which the pacemakers are recovered and the patients selected should follow careful guidelines. Every patient should provide written informed consent before receiving a recovered pacemaker. Properly executed, reuse of pacemakers should provide a high level of health care while maintaining or reducing the cost of these devices.

Treatment of intestinal cryptosporidiosis with spiramycin

Nine male patients with the acquired immunodeficiency syndrome and one female patient who had an allogeneic bone marrow transplant for acute myeloblastic leukemia in relapse developed severe debilitating diarrhea. Cryptosporidium species were found in the stools of all patients. After receiving treatment with spiramycin for 1 week, five patients had complete resolution of the diarrhea and four patients had symptomatic improvement. One patient responded gradually and the diarrhea resolved after 30 days of treatment with spiramycin.

Rosoxacin in the therapy of uncomplicated gonorrhea

In this randomized, multicentered study, 157 males and 130 females with laboratory-confirmed, uncomplicated anogenital Neisseria gonorrhoeae infections were evaluated to determine the efficacy and safety of a single 300-mg oral dose of rosoxacin versus 3.5 g of ampicillin plus 1 g of probenecid. A total of 130 males and 101 females were evaluated. Rosoxacin cured 90.3% (P = 0.053) and 94.1% (P = 0.62), respectively, whereas ampicillin was effective in 98.5 and 98% of males and females, respectively. All 39 patients with anorectal infections were cured. One penicillinase-producing N. gonorrhoeae strain was isolated and was eradicated with rosoxacin. Of 212 pretreatment isolates tested, 201 were inhibited by 0.06 micrograms or less of rosoxacin per ml. The MICs of rosoxacin for the remaining 11 isolates ranged up to 0.5 micrograms/ml. The incidence of adverse effects was relatively high (29% for the rosoxacin group versus 18% for the ampicillin group), but none of the reactions required medical intervention nor did they result in serious sequelae.

Sensorineural deafness in early acquired syphilis

A 36 year old male developed bilateral sensorineural deafness as the chief manifestation of secondary syphilis. Cerebrospinal fluid showed pleocytosis. Treatment with penicillin and prednisone resulted in good recovery of hearing. Initial recovery seemed dependent on corticosteroids. Deafness can complicate acquired syphilis in both early and late stages of the disease and may be its sole manifestation. Early acquired syphilitic deafness is usually the result of a meningitis affecting the eighth nerve and responds well to treatment. These features are contrasted with those of late acquired syphilitic deafness.

Metronidazole: an alternate therapy for antibiotic-associated colitis

The results of treatment of 13 consecutive cases of antibiotic-associated pseudomembranous colitis with oral metronidazole are described. The diagnosis was made by typical sigmoidoscopic appearance with a confirming characteristic colonic biopsy specimen and/or stools positive for Clostridium difficile cytotoxin. All patients responded with the disappearance of diarrhea between 1 and 5 days. Two patients experienced relapse when the therapy was discontinued. Our experience with metronidazole shows that it is an effective treatment for antibiotic-associated pseudomembranous colitis. The response to metronidazole treatment compares favorably with that usually obtained with vancomycin.

Postoperative toxic shock syndrome in a man

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Penicillin tolerance of human isolates of group C streptococci

Seventeen clinical isolates of group C streptococci were tested for penicillin tolerance. Sixteen of the strains showed penicillin tolerance with a 32-fold or greater difference between the minimal inhibitory concentration and the minimal bactericidal concentration. Synergism was demonstrated with a combination of penicillin and gentamicin for all 17 strains tested. The rate of antibiotic killing was measured for five of the streptococcal strains by using the combination of penicillin and gentamicin. All isolates were killed within 5 h with the combination, but viable organisms were recovered after 48 h when either drug was used alone. Our study suggests that penicillin tolerance with group C streptococci may occur frequently and may account for the poor outcome of serious group C streptococcal infections tested with penicillin alone.

Pseudomembranous colitis: multiple relapses after treatment with metronidazole

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R-factor cointegrate formation in Salmonella typhimurium bacteriophage type 201 strains

The genetic and molecular properties of the plasmids in Salmonella typhimurium phase type 201 isolated are described. Such strains are resistant to streptomycin, tetracycline, chloramphenicol, ampicillin, kanamycin, and several other antimicrobial drugs, and are highly pathogenic for calves. These strains have been encountered with increasing frequency since 1972 in West Germany and The Netherlands. We show that isolates of this phage type constitute a very homogeneous group with regard to their extrachromosomal elements. These bacteria carry three small plasmids: pRQ3, a 4.2-megadalton (Md) colicinogenic plasmid; pRQ4, 3.4-Md plasmid that interferes with the propagation of phages; and pRQ5, a 3.2-Md cryptic plasmid. Tetracycline resistance resides on a conjugative 120-MD plasmid pRQ1, belonging to the incompatibility class H2. Other antibiotic resistance determinants are encoded by a nonconjugative 108-Md plasmid pRQ2. Transfer of multiple-antibiotic resistance to appropriate recipient strains was associated with the appearance of a 230-Md plasmid, pRQ6. It appears that pRQ6 is a stable cointegrate of pRQ1 and pRQ2. This cointegrate plasmid was transferable with the same efficiency as pRQ1. Other conjugative plasmids could mobilize pRQ2, but stable cointegrates were not detected in the transconjugants. Phase type 201 strains carry a prophage, and we show that phage pattern 201 reflects the interference with propagation of typing phages effected by this prophage and plasmid pRQ4 in strains of phage type 201.

Cryptococcal meningitis: misdiagnosis with india ink

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