Phase I Imaging and Pharmacodynamic Trial of CS-1008 in Patients With Metastatic Colorectal Cancer

PURPOSE

CS-1008 (tigatuzumab) is a humanized, monoclonal immunoglobulin G1 (IgG1) agonistic antibody to human death receptor 5. The purpose of this study was to investigate the impact of CS-1008 dose on the biodistribution, quantitative tumor uptake, and antitumor response in patients with metastatic colorectal cancer (mCRC).

PATIENTS AND METHODS

Patients with mCRC who had received at least one course of chemotherapy were assigned to one of five dosage cohorts and infused with a weekly dose of CS-1008. Day 1 and day 36 doses were trace-labeled with indium-111 ((111)In), followed by whole-body planar and regional single-photon emission computed tomography (SPECT) imaging at several time points over the course of 10 days.

RESULTS

Nineteen patients were enrolled. (111)In-CS-1008 uptake in tumor was observed in only 12 patients (63%). (111)In-CS-1008 uptake and pharmacokinetics were not affected by dose or repeated drug administration. (111)In-CS-1008 biodistribution showed gradual blood-pool clearance and no abnormal uptake in normal tissue. No anti-CS-1008 antibody development was detected. One patient achieved partial response (3.7 months duration), eight patients had stable disease, and 10 patients had progressive disease. Clinical benefit rate (stable disease + partial response) in patients with (111)In-CS-1008 uptake in tumor was 58% versus 28% in patients with no uptake. An analysis of individual lesions showed that lesions with antibody uptake were one third as likely to progress as those without antibody uptake (P = .07). Death-receptor-5 expression in archived tumor samples did not correlate with (111)In-CS-1008 uptake (P = .5) or tumor response (P = .6).

CONCLUSION

Death-receptor-5 imaging with (111)In-CS-1008 reveals interpatient and intrapatient heterogeneity of uptake in tumor, is not dose dependent, and is predictive of clinical benefit in the treatment of patients who have mCRC.

Building blocks. Roundtable discussion

Former Hospitals & Health Networks executive editor Mark Hagland and Health Facilities Management editor Kurt Luchs and associate editor Catherine Quayle recently hosted a roundtable discussion on design and construction issues in health care. They wanted to know what health care senior executives and experts in the design and construction field thought about today's most pressing issues and biggest trends. Hagland and Luchs assembled a group or experts and executives in Chicago and set the tape rolling. Here are excerpts from the discussion.

Long-term effects of exercise on psychological functioning in older men and women

The purpose of this study was to determine the psychological, behavioral, and cognitive changes associated with up to 14 months of aerobic exercise training. For the first 4 months of the study, 101 older (greater than 60 years) men and women were randomly assigned to one of three conditions: Aerobic exercise, Yoga, or a Waiting List control group. Before and following the intervention, all subjects completed a comprehensive assessment battery, including measures of mood and cognitive functioning. A semi-crossover design was employed such that, following completion of the second assessment, all subjects completed 4 months of aerobic exercise and underwent a third assessment. Subjects were given the option of participating in 6 additional months of supervised aerobic exercise (14 months total), and all subjects, regardless of their exercise status, completed a fourth assessment. Results indicated that subjects experienced a 10-15% improvement in aerobic capacity. In general, there were relatively few improvements in cognitive performance associated with aerobic exercise, although subjects who maintained their exercise participation for 14 months experienced improvements in some psychiatric symptoms. However, the healthy subjects in this study were functioning at a relatively high level to begin with, and exercise training may produce greater improvements among elderly with concomitant physical or emotional impairments.

Neuropsychological effect of lead in occupationally exposed workers: a critical review

In their discussion of field testing of health effects of environmental and industrial toxins, Gullion and Eckerman make the following observations which can be applied to the current literature survey: "The general inattention to methodological consistency makes it difficult to integrate the research to date into a clear picture of what is known and not known about the effects of toxic substances on human behavior. In view of the variation in methods of subject selection, measurement, and statistical analysis, the completion of a series of studies of a particular toxic substance does not assure that there has been a concurrent accumulation of reliable knowledge about the effects of that substance. Apparent replications or failures to replicate a significant relationship must be evaluated carefully, since different studies may have measured different things in different populations." Therefore, the issue of psychological and neuropsychological effects of low-level lead exposure in adults remains to be resolved in the studies reviewed. The methodologies were so varied and the cultures in which the studies were conducted so diverse that it is impossible to generalize across findings. For example, studies were conducted in the U.S., Denmark, Sweden, Finland, and Australia. Although, in some instances, equivalent versions of neuropsychological and psychological tests were used, this was generally not the case. Nevertheless, a few general statements can be made. Studies that have been carried out in recent years are beginning to pay attention to more methodology and therefore do a much better job of controlling for possible confounding variables. Also, their statistical methods are more sophisticated and reporting techniques are superior to the earlier investigations in this area. The issue of whether current blood lead levels or cumulative levels are preferable is still unresolved with regard to the relationship of neuropsychological impairment. In the area of psychosocial functioning, there appears to be at least some evidence to support the observation that increased irritability and fatigue may lead to the interpersonal problems noted in various studies. However, this observation may be related to other factors which have not been controlled for, such as the workers' attitudes toward their job, level of motivation, and overall level of mental health. With regard to neuropsychological functions, there is some suggestive preliminary evidence for subtle changes in the ability to process information quickly.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiovascular and behavioral effects of aerobic exercise training in healthy older men and women

The cardiovascular and behavioral adaptations associated with a 4-month program of aerobic exercise training were examined in 101 older men and women (mean age = 67 years). Subjects were randomly assigned to an Aerobic Exercise group, a Yoga and Flexibility control group, or a Waiting List control group. Prior to and following the 4-month program, subjects underwent comprehensive physiological and psychological evaluations. Physiological measures included measurement of blood pressure, lipids, bone density, and cardiorespiratory fitness including direct measurements of peak oxygen consumption (VO2) and anaerobic threshold. Psychological measures included measures of mood, psychiatric symptoms, and neuropsychological functioning. This study demonstrated that 4 months of aerobic exercise training produced an overall 11.6% improvement in peak VO2 and a 13% increase in anaerobic threshold. In contrast, the Yoga and Waiting List control groups experienced no change in cardiorespiratory fitness. Other favorable physiological changes observed among aerobic exercise participants included lower cholesterol levels, diastolic blood pressure levels, and for subjects at risk for bone fracture, a trend toward an increase in bone mineral content. Although few significant psychological changes could be attributed to aerobic exercise training, participants in the two active treatment groups perceived themselves as improving on a number of psychological and behavioral dimensions.

Psychosocial factors in the irritable bowel syndrome. A multivariate study of patients and nonpatients with irritable bowel syndrome

In this multivariate analysis of the irritable bowel syndrome (IBS) we describe the symptomatic and psychologic features of the condition and their possible contributions to health care seeking. We studied 72 IBS patients, 82 persons with IBS who had not sought medical treatment, and 84 normal subjects. All subjects received complete medical evaluation, diary card assessment of abdominal pain and stool habit, and standard psychologic tests of pain, personality, mood, stressful life events, illness behavior, and social support. Pain and diarrhea were the most important symptoms associated with patient status. When controlling for these symptoms we found that (a) IBS patients have a higher proportion of abnormal personality patterns, greater illness behaviors, and lower positive stressful life event scores than IBS nonpatients (p less than 0.001) and normals (p less than 0.001); (b) IBS nonpatients, although psychologically intermediate between patients and normals, are not different from normals (p less than 0.21); and (c) IBS nonpatients have higher coping capabilities, experience illness as less disruptive to life, and tend to exhibit less psychologic denial than patients. These factors may contribute to "wellness behaviors" among people with chronic bowel symptoms. We conclude that the psychologic factors previously attributed to the IBS are associated with patient status rather than to the disorder per se. These factors may interact with physiologic disturbances in the bowel to determine how the illness is experienced and acted upon.

Short-term behavioral effects of beta-adrenergic medications in men with mild hypertension

beta-Adrenergic-inhibiting drugs are widely prescribed for the treatment of hypertension. These drugs have previously been found to influence a variety of psychologic and behavioral functions and have, in some cases, been associated with serious psychiatric side effects. The present study examined psychologic changes associated with beta-blockade therapy. Twenty-six men with mild hypertension (diastolic blood pressure 90 to 110 mm Hg) were randomly assigned to receive either a selective beta 1-antagonist (atenolol), a nonselective beta 1- and beta 2-antagonist (propranolol), or a placebo. Both before and after a 2-week period of drug administration, subjects completed a comprehensive assessment of quality of life including measures of mood, memory performance, and side effects. In general, beta-blocker therapy was associated with relatively few adverse symptoms, particularly when compared with control subjects taking placebo. Reductions in negative emotional states (tension and anger) were observed for subjects receiving atenolol, and the largest improvements in memory performance were observed for subjects receiving propranolol. These results suggest that beta-blocker therapy is not invariably associated with negative side effects and that some behavioral functions may actually be improved.

Recollection of childhood events in adults with irritable bowel syndrome

We examined retrospectively premorbid factors that might relate to the development of irritable bowel syndrome (IBS). We administered a semistructural interview to adult IBS patients, adults with symptoms of IBS who had not visited a doctor (nonpatients), and asymptomatic normals. Patients with IBS differed from nonpatients by reporting more severe bowel problems, more frequent doctor visits in childhood, and more pain associated with current bowel symptoms. These factors may contribute to the tendency of people with bowel symptoms to seek medical care. More patients, and in most cases nonpatients with IBS, reported poorer general health and headaches, stomachaches, and bowel complaints during childhood. They also showed evidence for greater parental attention to illness with more frequent school absences and doctor visits than normal subjects. Loss and separation during childhood, and in the current family, and conflicted or dependent maternal relationships were also more frequently reported among patients and nonpatients. These factors may contribute to the development of IBS.

Urgency and fecal soiling in people with bowel dysfunction

The frequency of urgency and fecal soiling in the population and among people with irritable bowel syndrome (IBS), and the association of these symptoms with health care seeking is unknown. Among 1128 students and hospital employees that we surveyed, urgency was reported in 14.4%, fecal soiling in 5.3%, and diarrhea in 9.0%. Most persons with fecal soiling did not report urgency or diarrhea. Although bowel dysfunction compatible with IBS was present in 20% (227), only 29% of this group (65) had seen a physician for bowel complaints. People with bowel dysfunction were more likely to be women, to take laxatives, and to have rectal urgency. Fecal soiling was more likely among those with bowel dysfunction who had been to the doctor, and included almost half of the men in this group. There was no difference in the frequency of diarrhea reported among those with bowel dysfunction regardless of whether they had been to the doctor. These data suggest fecal soiling may influence people with bowel dysfunction to go to the doctor. Physiological studies are needed to determine if anal sphincter dysfunction is a component of IBS.

Memory performance by mild hypertensives following beta-adrenergic blockade

Previous experiments have reported deficits in cognitive performance following the administration of beta-adrenoceptor antagonists. These deficits have not appeared consistently, however, and it is not clear from previous studies whether changes in the central nervous system, rather than end-organ functioning, are responsible. The present experiment investigated the effects of beta blockade in a memory-search paradigm that distinguished the relatively central process of memory comparison from the more peripheral processes of stimulus encoding and response selection. Twenty-six adult men with mild essential hypertension received either a placebo or a beta blocker (atenolol or propranolol) for 2 weeks. Although beta blockade did occur in the active drug groups, there were no significant effects of the drugs on memory-search performance.

Life adaptation after percutaneous transluminal coronary angioplasty and coronary artery bypass grafting

Life adaptation of 32 patients who had undergone percutaneous transluminal coronary angioplasty (PTCA) for coronary stenosis was compared with that of 15 patients who had coronary artery bypass grafting (CABG). Patients were matched for psychosocial, anatomic and cardiac functions. Life adaptation was measured at 6 and 15 months after PTCA or CABG by the Psychosocial Adjustment to Illness Scale (PAIS), a multidimensional instrument that evaluates change in 7 primary life domains. The overall PAIS scores for patients who had undergone PTCA were significantly better (p less than 0.04) than the scores for those who had undergone CABG after 6 months, and this superior functioning continued after 15 months (p less than 0.05). After 6 months patients who had undergone PTCA functioned better at work (p less than 0.005), in sexual performance (p less than 0.0001) and with their families (p less than 0.002). The improvement in work functioning continued at 15 months (p less than 0.04), but the differences in sexual and family domains became nonsignificant.

Symptom complaints and health care seeking behavior in subjects with bowel dysfunction

A significant proportion of the population (14%-22%) appears to have symptoms compatible with the irritable bowel syndrome, yet only a small number seek medical aid. To explore why some people with bowel dysfunction go to the doctor and others do not, we surveyed 566 healthy subjects. Eighty-six (15%) had bowel dysfunction compatible with irritable bowel syndrome, but the majority of those affected (53 subjects or 62%) had never been to a doctor for these complaints. Although those who consulted physicians for bowel symptoms were more likely to report abdominal pain than those who did not, pain was not sufficient to explain doctor visits. Subjects with bowel dysfunction also reported more nongastrointestinal symptoms, and those with bowel dysfunction who visited physicians were more likely to see physicians for their nongastrointestinal symptoms. The reported higher prevalence of psychopathology among the patient population with irritable bowel syndrome may be due to behavioral influences that lead to health care seeking.

Bowel patterns among subjects not seeking health care. Use of a questionnaire to identify a population with bowel dysfunction

To understand the disorders of bowel motility, it is important to know the range of bowel patterns in the general population. We have devised a brief self-administered questionnaire which, when used among a group of 789 students and hospital employees, disclosed that 94.2% had stool frequencies between three per day and three per week, and that 17.1% had bowel dysfunction. When compared with the remaining sample, the bowel dysfunction group was predominantly female. This group also reported more often that stress influenced their bowel function, and more often used laxatives and visited physicians for bowel complaints. Further medical evaluation to characterize this subgroup is needed. We believe that selection, for psychologic and physiologic study, of subjects with bowel dysfunction not seeking health care will provide a needed comparison group in our understanding of patients with irritable bowel syndrome.

The MMPI as a measure of the emotional correlates of chronic hemodialysis: a review

The MMPI has been the most frequently used objective personality measure in studies of the emotional correlates of chronic hemodialysis for end-stage renal failure. This paper reviews MMPI findings of these studies and examines the utility of this instrument with chronic dialysis patients. Overviews of the basic research strategies employed and of the methodological shortcomings of the published studies are presented. Research findings are reviewed, and pros and cons of using the MMPI with this population are briefly discussed. The most consistent finding to date has been elevation in the "neurotic triad" (scales 1, 2, and 3), but the meaning of this configuration for dialysis patients is ambiguous.

Intellectual functioning in renal failure and chronic dialysis

The research literature on intellectual functioning in uremia and maintenance hemodialysis for renal failure is critically reviewed. The most frequently assessed neuropsychological functions have been general intelligence, memory, and attentional processes. Studies have consistently found lowered performance IQ scores compared to verbal IQ scores in renal failure patients prior to dialysis onset, suggesting the presence of intellectual deficit due to cortical dysfunction. The role of intelligence in adjustment to dialysis has not been clearly explicated, due in part to methodological variations among studies. Several studies point to significant improvement in short-term memory both after onset of maintenance dialysis and from one day before to one day after an individual dialysis treatment session. Attentional functions appear to improve after onset of dialysis treatment as well, but small sample sizes limit the conclusiveness of the data on these cortical processes. Future research efforts should be aimed at correlating physiologic with neuropsychological data and at longitudinal study of intellectual functioning in dialysis patients.

Longitudinal study of neuropsychological functioning in patients on chronic hemodialysis: a preliminary report

This study is part of a five-year project to investigate the long term effect of chronic hemodialysis on patients with end-stage renal failure. Previous research has associated hemodialysis with progressive dialysis encephalopathy (PDE), which is characterized by speech disturbances, cognitive impairment, myoclonus and behavioral changes. Little is known about the cause or the course of this syndrome except that it begins 14-36 months after treatment onset and usually culminates in death. The purpose of this study was to investigate neuropsychological (cognitive and behavioral) functioning in dialysis patients over a period of years. To date, 34 patients have been studied for 22 months utilizing a cross-sectional method comparing patients at different stages of treatment combined with a longitudinal method of repeated evaluations over time. Current findings show improved cognitive functioning during at least the first year of treatment and no evidence of cognitive deterioration in patients on dialysis for more than one year (M = 4.3). These findings offer strong evidence that PDE is not necessarily a general phenomenon among patients on chronic hemodialysis.

Assessment of conceptual tempo in the type A (coronary prone) behavior pattern

Previous research has documented an association between a particular behavioral complex termed Type A, and increased incidence of coronary heart disease. In an effort to define further some of the behavioral characteristics that distinguish Type A subjects from their noncoronary-prone (Type B) counterparts, subjects were administered a test of conceptual impulsivity-reflection. While there were clear sex differences in performance, the results of the present study offered only qualified support for the notion that Type A individuals are more impulsive than Type B individuals. One component of Type A, Speed and Impatience, was shown to be related to increased impulsivity in women, but not in men. The findings suggest the importance of considering the interaction of gender with behavioral subcomponents of the Type A behavior pattern.

Research issues in psychological studies of chronic dialysis

Research examining the psychological and psychosocial effects of chronic dialysis has produced numerous controversial issues, such as the role of denial in emotional adjustment and the relationship of intelligence of vocational rehabilitation in dialysis patients. Inconsistent findings leading to these controversies are attributable in part to variance in research design and to shortcomings in methodology and reporting of data. The present article briefly reviews methodological factors not previously addressed in critiques of dialysis research, focusing on subject selection, subject description, illness measures, assessment procedures, conditions of testing, comparison groups, and data analysis. It is concluded that consideration of these factors in the design and conduct of studies will enhance the quality of research in this area.

Using discriminant function analysis with clinical, demographic and historical variables to diagnose schizophrenia

An effort was made to formalize the critical clinical, demographic and historical features of schizophrenia through the development of a reliable assessment questionnaire. The criterion diagnosis was established via traditional hospital procedures and was substantiated by psychometric measures. Raters with comparable diagnostic experience were familiarized with each of the clinical, demographic and historical features before evaluating the presence or absence in a sample of both psychiatric in-patients and out-patients. A structured, standardized interview was used to reduce inconsistency and oversight due to variability in interviewing techniques and coverage of psychopathology. Using the coefficients of the discriminative functions of five major symptoms (loose associations, autism, loss of ego boundaries, emotional blunting, delusions) and two demographic and historical features (family history of mental illness, poor social relations) correctly classified 98 per cent of the total sample of 253 patients. A subsequent investigation demonstrated the utility and generalizability of the proposed system. The assets and liabilities of using such an approach are discussed.

Selecting retrieval cues for early-childhood amnesia: implications for the study of shrinking retrograde amnesia

A method for selecting semantic cues for early childhood memories is presented. The written records of episodes submitted by the subjects in the study of Crovitz and Harvey (1979) were coded into three-word strings of words in accordance with the gist of the memories. Nouns which described many retrievals (Set A) and nouns which had described few retrievals (Set B) were presented to an independent group of young adults as prompts for early childhood episodes. Prompting with semantic cues gave a fast rate of retrieval, with nouns in Set A cuing early childhood memories more successfully than nouns in Set B. The difference between words in Set A and Set B was found not to be a function of the frequency of usage of these words in the language. Implications for selecting cues to prompt retrieval of memories during the period of shrinking retrograde amnesia are discussed.

The value of prophylactic antibiotics in aorat-coronary bypass operations: a double-blind randomized trial

Prospective and retrospective studies were performed to determine the efficacy of prophylactic antibiotics in preventing infections in patients undergoing arota-coronary bypass. One-hundred five patients were randomized in a double-blind fashion to receive either methicillin or saline-placebo for 3 days. The over-all infection rate was 26.7% with 48.9% in the control group and 8.6% in the methicillin group (p less than 0.001). Significant sternal wound infection developed in 21.3% of the control group and 0% of the methicillin group (p less than 0.01). Staphylococcus aureus was the predominant organism causing significant sternal infection (methicillin group versus control group, 5.2% and 21.3%; p less than 0.05). The length of postoperative stay in hospital and the number of days with fever was significantly greater in the control group than in the methicillin group (p less than 0.001). During the same period of time, 160 patients were studied retrospectively. Of these, 150 patients received cephalothin prophylaxis and 10 received methicillin. Comparison of the rates of infection in the cephalothin group to the total methicillin group (prospective and retrospective) showed no significant difference. The study clearly demonstrated that a short course of prophylactic antistaphlococcal penicillin or cephalosporin is justified in aorta-coronary bypass.