Cardiopulmonary Toxicity from Intensity Modulated Proton Therapy for Thymic Malignancies

PURPOSE/OBJECTIVE(S)

Use of radiation therapy for thymic malignancies is limited by excess dose to organs at risk (OARs) including heart, lung, and esophagus. Intensity Modulated Proton Therapy with Pencil Beam Scanning (IMPT/PBS) allows the conformality benefits of volumetric modulated arc therapy (VMAT) combined with dosimetry benefits of protons making it an exciting tool to treat thymic tumors. Very limited clinical data are reported with the use of IMPT/PBS to treat thymic malignancies. This study evaluates the incidence of acute and delayed toxicities among patients who underwent IMPT/PBS for thymic tumors.

MATERIALS/METHODS

Our single center retrospective study identified 27 patients with diagnosis of either thymic carcinoma or thymoma who received IMPT/PBS between 2015 and 2022. Patient demographics, IMPT treatment details and clinical outcomes (toxicity, recurrence, and survival) were recorded. Frequency distributions are described for primary endpoints of acute (≤ 90 days) and late (>90 days) toxicity graded using CTCAE version 5.0. Specific toxicities assessed were dermatitis, esophagitis, pneumonitis, pulmonary fibrosis, and cardiac toxicity. Recurrence and survival data were analyzed as secondary endpoint using Kaplan-Meier method.

RESULTS

Median follow-up was 22 months. Median age of the patients was 59 years (range, 30-87), predominantly female (55%), and white (66%), and stage ¾ (72%). Histologically showed mainly thymoma (59%) and Masaoka stage ¾ (70%). Surgery prior to IMPT was performed in 19 (70%) patients; of whom 5 patients had positive margins. Chemotherapy was used in 12 (44%) patients. Median IMPT dose was 50.4 GyE. Patients were primarily planned with 2 or 3 fields (81%), coplanar distribution (74%), using SFO technique (70%). Robust planning was performed accounting for 5 mm margin and 3.5-5% range uncertainty. All patients required use of range shifter ranging from 2-5 cm. Median of Heart-mean (10.3 GyE), Heart-max (54 GyE), Lung-mean (8.1 GyE), Lung V20 Gy (16.1%), Lung-V30 Gy (11.4%), Esophagus-mean (10.3 GyE) and Cord-Max (1.4 GyE). QACT was performed in 21 (77%) patients with replan needed in 5 of them. Only 1 (3.7%) patient had a grade 3+ acute toxicity (dermatitis) and only 2 (7.4%) patients had a grade 3+ late toxicity (both pulmonary). No patients had any acute or delayed cardiac-related adverse effects following PBT treatment. One (3.7%) patient had an infield recurrence of malignancy and 6 had out-of-field metastatic failure. Local control and overall survival were 74.1% and 85.2%, respectively.

CONCLUSION

In this largest single-institution analysis of IMPT/PBS experience, we note extremely low incidence of grade 3+ acute or late toxicity with excellent local control and overall survival. No marginal failures were noted. In a patient population at high risk of cardiopulmonary radiation toxicities, IMPT/PBS should be strongly explored as a possible treatment option.

AB1318-HPR VAGUS NERVE STIMULATION IN PATIENTS WITH RHEUMATOID ARTHRITIS: 48 MONTH SAFETY AND EFFICACY

Background:

Rheumatoid arthritis (RA) is a disease with significant remaining unmet medical needs for better treatments. Vagus nerve stimulation (VNS) to activate the inflammatory reflex (cholinergic anti-inflammatory pathway) represents a novel experimental therapy for RA.1Previously, we reported that inflammatory reflex activation by VNS reduced pro-inflammatory cytokine production and improved disease activity in a 17-patient rheumatoid arthritis (RA) proof-of-concept study using a reprogrammed epilepsy stimulator2; clinical improvement was sustained for 24 months without untoward safety signals.3Here we report the 48 months results from this long-term observational study.

Objectives:

Determine the long-term safety and efficacy of VNS for the treatment of RA

Methods:

In the primary study, a VNS device was implanted into 17 RA patients, mostly with insufficient response to multiple conventional and biologic DMARDs, on stable background of methotrexate (≤25 mg weekly) therapy2. The device electrically stimulated the vagus nerve, 1-4 min/day, over a 12-week open label period. On completion, subjects were offered to enroll into a follow-up study, where the study physicians were given flexibility to alter VNS dosing parameters and/or to add a biologic disease-modifying antirheumatic drug (DMARD) to the treatment regimen to induce disease remission. Clinical disease activity measures and safety were accessed over 4 years.

Results:

All patients electively continued VNS treatment in the long-term follow-up study, 4 subjects withdrew prior to month 48. Reasons for discontinuation were withdrawal of consent (N=3) and adverse event due to device discomfort (N=1). At the start of the follow-up study, the mean DAS28-CRP, CDAI and HAQ-DI were significantly reduced compared to the pre-implant baseline (mean difference± SD: DAS28-CRP=-1.60± 1.13, p<0.001; CDAI=-21.19± 13.5, p<0.001; HAQ-DI=-0.44± 0.49, p<0.01), and this effect was retained through 48 months. Patients using VNS monotherapy and those using a combination of VNS with biologic DMARDs exhibited stable improvements in DAS28-CRP, CDAI and HAQ-DI at month 48 (Table 1). Improvements were observed for patients who both previously had an insufficient response to targeted biological therapies as well those who had an insufficient response to standard DMARDs. No association was seen between DAS28-CRP and stimulation frequency (Range= 1X-8X/day). There was no difference in the adverse events profile between the two groups.

Table 1.

Efficacy of VNS treatment.

Treatment ReinitiatedN=9VNS MonotherapyN=8TotalN=17Mo. 24Mo. 36Mo.48Mo. 24Mo. 36Mo. 48Mo. 24Mo. 36Mo. 48Mean change from baseline (SD)DAS28-CRP-2.58 (1.0)***-2.40 (1.0)**-2.28 (1.3)**-2.61 (1.3)*-1.77 (1.8)-2.0(1.7)-2.59 (1.1)***-2.19(1.2)**-2.17(1.4)**CDAI-24.06 (8.3)***-18.02 (13.3) *-16.2 (19.6)-33.5 (11.1)***-27.8 (16.0)*-27.9 (12.7)*-28.20 (10.5)***-21.93 (14.5)*-20.83(17.5)*HAQ-DI-.60 (0.64)*-.63(0.45)*-.31(0.60)-.89 (0.69)*-.88 (0.92)-.88(0.61)-0.73(0.66)***-0.73(0.64)**-0.54(0.64)*

*P<0.05, **P<0.01, ***P<0.001 versus primary study baseline (month -3.5)

Conclusion:

VNS was safe, well-tolerated, and resulted in significant and clinically important improvements in disease activity measures that were maintained over 48 months. These results support development of VNS devices as a new therapeutic option for RA treatment.

References:

[1]van Maanen MA, et al.Nat Rev Rheum2009

[2]Koopman FA, et al.PNAS2016

[3]Koopman FA, et al.Arthritis Rheum2018

Disclosure of Interests:

Frieda Koopman: None declared, Anne Musters: None declared, Marieke Backer: None declared, Danielle Gerlag Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline, Sanda Miljko: None declared, Simeon Grazio Speakers bureau: Abbvie., Roche, MSD, Eli Lilly, Pfizer, Mylan, Amgen, Fresenius Kabi, Stada, Berlin-Chemie, Sekib Sokolovic: None declared, Yaakov Levine Shareholder of: SetPoint Medical, Employee of: SetPoint Medical, Emmett Glass Employee of: SetPoint Medical, David Chernoff Shareholder of: SetPoint Medical, Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Consultant of: Adamas Pharmaceuticals, Olly Nutrition, NAIA Pharma, Aquinox Pharma, Crescendo Bioscience, Employee of: SetPoint Medical, Niek de Vries Grant/research support from: AbbVie, Janssen, Ergomed Clinical Research, GlaxoSmithKline, Pfizer, Boehringer Ingelheim, Roche, Consultant of: MSD, Pfizer, Paul P. Tak Shareholder of: GlaxoSmithKline, Employee of: GlaxoSmithKline

Awareness and implementation of the regional animal welfare strategy for the Americas: a questionnaire

The World Organisation for Animal Health (OIE) is the global standard-setting organisation for animal health and these standards are references for the World Trade Organization legal framework. In 2002, noting the relationship between animal health and welfare, the OIE accepted the mandate to develop animal welfare standards. These standards were subsequently adopted by Member Countries and have been included in the TerrestrialAnimal Health Code and the Aquatic Animal Health Code. The implementation of the OIE standards by Member Countries is continually promoted. National OIE Delegates are encouraged to nominate National Focal Points for key topics, including animal welfare. In 2012, the OIE Regional Commission of the Americas adopted a Regional Animal Welfare Strategy (Regional Strategy) to promote a coordinated approach to the implementation of the OIE animal welfare standards by the 29 Member Countries in the region. In February 2015, the OIE Regional Representation for the Americas distributed a questionnaire to determine the level of awareness and implementation of the Regional Strategy. This paper presents the results of the questionnaire. With a few exceptions, veterinary officials and stakeholders are only just becoming aware of the strategy and implementation is at an early stage. To promote the implementation of the Regional Strategy, it will be.necessary to continue building the capacity of the national Veterinary Services, strengthening public-private partnerships, modernising legislation and promoting veterinary involvement in animal welfare. Through the implementation of the Regional Strategy, the OIE will provide support to countries in establishing animal welfare standards, in line with government priorities and consumer concerns.

Corticotropin-releasing hormone skin signaling is receptor-mediated and is predominant in the sebaceous glands

There is increasing evidence that the sebaceous gland expresses receptors for several neuropeptides and is involved in responses to stress. Among them, corticotropin-releasing hormone (CRH) was currently found to be produced also in the skin. In this study, the distribution of CRH, CRH receptors 1 and 2 (CRH-R1 and CRH-R2), and CRH binding protein (CRH-BP) in cultured human (SZ95) sebocytes was further characterized. Moreover, the effects of CRH and CRH-like peptides on proliferation and inflammatory signaling of CRH receptor-expressing SZ95 sebocytes IN VITRO were investigated. Urocortin (Uct), urotensin and sauvagine are recently described members of the family of structurally related CRH-like peptides, whereas Uct shares a 45% homology with CRH. CRH and Uct inhibited SZ95 sebocyte proliferation with CRH also stimulating interleukin-6 (IL-6) and interleukin-8 (IL-8) release from SZ95 sebocytes. However, CRH had no effect on interleukin-1alpha and interleukin-1beta production in these cells. alpha-Helical-CRF, a CRH antagonistic peptide, annulled the CRH effect on SZ95 sebocyte proliferation and interleukin secretion, while the non-peptidic CRH-R1 selective antagonist antalarmin inhibited the increased production of neutral lipids caused by CRH. In conclusion, CRH, and to a lesser extent Uct, may be involved in signaling of stress pathophysiology in the skin. However, further investigations into the downstream effects of CRH and Uct are required to elucidate the mechanism by which these neuropeptides could establish a stress-related pathophysiological condition in the skin.

Auditory Language Comprehension in Children with Developmental Dyslexia: Evidence from Event-related Brain Potentials

In the present study, event-related brain potentials (ERPs) were used to compare auditory sentence comprehension in 16 children with developmental dyslexia (age 9–12 years) and unimpaired controls matched on age, sex, and nonverbal intelligence. Passive sentences were presented, which were either correct or contained a syntactic violation (phrase structure) or a semantic violation (selectional restriction). In an overall sentence correctness judgment task, both control and dyslexic children performed well. In the ERPs, control children and dyslexic children demonstrated a similar N400 component for the semantic violation. For the syntactic violation, control children demonstrated a combined pattern, consisting of an early starting bilaterally distributed anterior negativity and a late centro-parietal positivity (P600). Dyslexic children showed a different pattern that is characterized by a delayed left lateralized anterior negativity, followed by a P600. These data indicate that dyslexic children do not differ from unimpaired controls with respect to semantic integration processes (N400) or controlled processes of syntactic reanalyses (P600) during auditory sentence comprehension. However, early and presumably highly automatic processes of phrase structure building reflected in the anterior negativity are delayed in dyslexic children. Moreover, the differences in hemispheric distribution of the syntactic negativity indicate different underlying processes in dyslexic children and controls. The bilateral distribution in controls suggests an involvement of right hemispherically established prosodic processes in addition to the left hemispherically localized syntactic processes, supporting the view that prosodic information may be used to facilitate syntactic processing during normal comprehension. The left hemispheric distribution observed for dyslexic children, in contrast, suggests that these children do not rely on information about the prosodic contour during auditory sentence comprehension as much as controls do. This finding points toward a phonological impairment in dyslexic children that might hamper the development of syntactic processes.

Response to xenograft technology: a new frontier in medicine. Xenograft technology: proceed with caution

Many Americans do not deal well with aging or preparing for death as a natural part of life. One indication of this is that only about 15% of the population have completed advance directives. Growing old gracefully and dying with dignity are not foremost considerations in our culture. We ask our government and private industry to spend billions of health care dollars to prolong our lives at all costs. Organ xenotransplantation has the potential of being a very complex, high tech, and expensive way of saving lives from the jaws of death--for a few more months or years. Derenge and Bartucci (1999) pointedly ask, "...should we instead be providing support and comfort to those who are dying and not intervene?" (p. 432). Finally, Dr. Margaret Somerville from the McGill Centre of Medicine, Ethics, and Law reminds us of the importance of addressing ethical issues early during the research process. Somerville (1998) states, "It is not enough to do ethics as an add-on at the end of having done your science." Science, medicine, and ethics, in the case of xenotransplantation, must progress together. Leaders in social policy should address the issues presented here before xenotransplantation is undertaken in the United States.

Cerebellar cortical abiotrophy in a beagle

A beagle puppy was presented with clinical signs indicative of a cerebellar disease. Histopathological evaluation of the cerebellum revealed a diffuse degenerative cortical lesion. The clinical history and the histopathological findings are consistent with a neonatal cerebellar abiotrophy. Furthermore, the breeding history supports the hypothesis of an inherited genetic disorder that is, most likely, an autosomal recessive trait.

Subacute necrotising encephalopathy in an Alaskan husky

A 29-month-old female Alaskan husky was presented recumbent, tetraparetic and in a state of dementia, with blindness and cranial nerve deficits. The dog's progress was followed for over two months, as the signs resolved to an non-progressive mild hypermetria with slight proprioceptive ataxia, a diminished menace response and inability to prehend food. Magnetic resonance imaging (MRI) revealed bilateral cavitation extending from the thalamus to the medulla, with less pronounced degenerative lesions in the caudate nucleus, putamen and claustrum. Cerebrospinal fluid lactate and pyruvate concentrations were in their normal ranges. Necropsy and histological examination confirmed the MRI findings as well as neuronal degeneration of the cerebellar cortex in the vermis and degenerative changes in the neocortex at the depths of the cerebral sulci. In view of the similarity of lesions to subacute necrotising encephalomyelopathy, known as Leigh's disease in humans, a tentative diagnosis of a mitochondrial encephalopathy was made.

Motor neuron abiotrophy in a saluki

A nine-week-old saluki puppy was presented to Tufts University School of Veterinary Medicine for progressive, generalized weakness and bilateral forelimb deformities. Examination suggested a diffuse neuromuscular lesion. Cerebrospinal fluid (CSF) analysis showed normal nucleated cell count and protein level; however, many macrophages had vacuolated cytoplasm. Electromyography (EMG) recordings suggested denervation in paraspinal and appendicular muscles. Tibial motor nerve conduction velocity was normal, but direct evoked muscle potential had reduced amplitude. Histopathology revealed diffuse, symmetrical, degenerative motor neuronopathy of the ventral horn of the spinal cord with associated lesions in nerves and muscles. Histopathology was consistent with an abiotrophy that was likely inherited.

Evaluation of recombinant sporozoite antigen SPAG-1 as a vaccine candidate against Theileria annulata by the use of different delivery systems

The major sporozoite surface antigen of Theileria annulata (SPAG-1) is a candidate for inclusion in a subunit vaccine. In this paper we summarize the results of 4 vaccination experiments using recombinant SPAG-1 expressed in different systems and presented in different adjuvants. The antigen has been presented as either a C terminal 108 amino acid peptide (called SR1) expressed as both beta-galactosidase and hepatitis B core antigen fusions or as a full-length form expressed as a GST fusion with an N terminal His6 tag. We used different adjuvants, namely Freund's, saponin, ISCOMs and a proprietary adjuvant supplied by SmithKline Beecham, which we call SKBA. The data point to the conclusion that SPAG-1 can elicit partial protection and is therefore suitable for inclusion in an eventual multicomponent subunit vaccine.

Efficacy of lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection as a therapeutic procedure for early-stage melanoma

BACKGROUND

Lymphatic mapping, sentinel lymphadenectomy, and selective complete lymph node dissection (LM/SL/SCLND) is an increasingly popular alternative to elective lymphadenectomy (ELND) for patients with early-stage melanoma. Although several reports have demonstrated the accuracy of the LM/SL technique, there are no data on its therapeutic value.

METHODS

We performed a matched-pair statistical analysis of 534 patients with clinical stage I melanoma; one half of the patients were treated with LM/SL and the other half were treated with ELND. Patients in the two treatment groups were matched for age (54% were < or =50 years of age), gender (63% were male patients), site of the primary melanoma (49% were on the extremities, 36% on the trunk, and 15% on the head and neck), and thickness of the primary melanoma (7% were < 0.75 mm, 42% between 0.75 and 1.5 mm, 43% between 1.51 and 4.0 mm, and 8% > 4 mm). Patients in the LM/SL group underwent complete regional lymphadenectomy (SCLND) only if the LM/SL specimen contained metastatic melanoma.

RESULTS

The overall incidences of nodal metastases were no different (P = .18) between LM/SL (15.7%) and ELND (12%) groups, but the incidence of occult nodal disease was significantly (P = .025) higher among patients with intermediate-thickness (1.51-4.0-mm) primary tumors who underwent LM/SL (23.7%) instead of ELND (12.2%). Survival data were compared by the log-rank score test. LM/SL/SCLND and ELND resulted in equivalent 5-year rates of disease-free survival (79 +/- 3.3% and 84 +/- 2.2%, respectively; P = .25) and overall survival (88 +/- 3.0% and 86 +/- 2.1%, respectively; P = .98). The LM/SL and ELND groups also exhibited similar incidences of same-basin recurrences (4.8% vs. 2.1%, P = .10, respectively) and in-transit metastases (2.6% vs. 3.8%, P = .48) after tumor-negative dissections. Patients who underwent ELND showed a higher incidence of distant recurrences (8.9% vs. 4.0%, P = .03), but this may be related to the longer follow-up period for these patients (median, 169 months), compared with the LM/SL-treated patients (45 months). Among patients with tumor-positive nodal dissections, the 5-year overall survival rates were higher, and approached significance (P = .077) for patients treated by LM/SL/SCLND (64 +/- 12%) compared with ELND (45 +/- 10%).

CONCLUSIONS

These findings suggest that LM/SL/SCLND is therapeutically equivalent to ELND but may be more effective for identifying nodal metastases in patients with intermediate-thickness primary tumors.

Comparison of blue dye and probe-assisted intraoperative lymphatic mapping in melanoma to identify sentinel nodes in 100 lymphatic basins

OBJECTIVE

To determine whether combining isosulfan blue dye with a radiopharmaceutical agent will increase intraoperative detection of sentinel nodes (SNs) in patients with early-stage melanoma.

PATIENTS AND DESIGN

Clinical trial with a consecutive sample. Eighty-seven patients with clinical stage I melanoma underwent preoperative lymphoscintigraphy with 1 of 3 radiopharmaceutical agents to identify the lymphatic basin and the site of the SN. All patients subsequently underwent intraoperative lymphatic mapping and selective lymph node dissection (SLND) with isosulfan blue dye and a radiopharmaceutical agent. A handheld gamma probe determined the radioactive counts over the draining lymph node basins and individual blue-stained lymph nodes before (in vivo) and after (ex vivo) their removal. An irrelevant body site was used as the denominator of a count ratio by which absolute counts were standardized for comparison. Completion lymphadenectomy was undertaken in patients whose SLND specimen had histopathologic evidence of tumor cells.

SETTING

Tertiary care cancer center.

INTERVENTION

Lymph node sampling.

MAIN OUTCOME MEASURE

Accuracy of SN detection by blue dye and radiopharmaceutical techniques.

RESULTS

Preoperative lymphoscintigraphic images identified 100 lymph node basins and 135 lymph nodes in 87 patients. All 3 radiopharmaceutical agents were equally effective in imaging the SN before surgery. During SLND, we identified and removed 136 blue-stained and radioactive (hot) SNs and 8 additional non-blue-stained hot nodes from 98 basins (98.0%). Of the 144 excised lymph nodes, 132 nodes (91.7%) from 83 basins had either an in vivo- or an ex vivo-background count ratio of 2:1 or more and 125 nodes (86.8%) from 77 basins had a count ratio of 3:1 or more. Twelve blue-stained SNs had count ratios of less than 2:1. Seventeen SNs (11.8%) from 15 basins contained metastases: 16 were identified with blue dye and probe and 1 was identified with blue dye alone. Four (1.1%) of 377 non-SNs excised during completion lymphadenectomy contained metastases. There have been no lymph node recurrences during mean follow-up of 16.3 months (range, 7-42 months).

CONCLUSIONS

The blue dye technique remains the criterion standard for SLND in melanoma. The addition of a radiopharmaceutical tracer serves as a useful adjunct to the visualization of blue-stained SNs.

Different vaccine strategies used to protect against Theileria annulata

SPAG-1, a sporozoite surface antigen of T. annulata, has previously been shown to elicit partial protection when used, as an hepatitis B core antigen fusion, to immunize cattle. The objective of this study was to try and improve the protective capacity of this antigen by enlisting different vaccine strategies. Cattle were immunized with SPAG-1, as a fusion protein with a His6 tag, either incorporated into ISCOMs, with or without the merozoite antigens TAMS 1-1 and 1-2, or with RWL as adjuvant three times at monthly intervals. Another group of cattle were immunized with p67, the T. parva sporozoite antigen, in RWL to assess whether any cross-protection could be induced. The animals were then challenged with an estimated LD50 of T. annulata sporozoites, and their ability to resist the infection was investigated. Serum responses and T-cell proliferative responses were analyzed throughout the trial. Post-challenge analyses included lymph node biopsies and blood smears to check for the presence of parasites, routine hematological parameters, and observation for clinical manifestations of the disease. The results of this trial will be discussed.

Intraoperative lymphatic mapping for early-stage melanoma of the head and neck

BACKGROUND

We previously reported dye-directed intraoperative lymphatic mapping and selective sentinel lymphadenectomy for primary cutaneous melanomas draining to the neck lymph nodes. In this study we determined whether combining the dye with a radiopharmaceutical agent would enhance our rate of sentinel node detection.

METHODS

One hundred seventeen patients with primary cutaneous melanomas of the upper chest and head and neck underwent preoperative cutaneous lymphoscintigraphy to confirm lymphatic drainage to neck nodes, followed by intraoperative lymphatic mapping and sentinel lymphadenectomy. In 94 cases, isosulfan blue dye was injected at the primary site; in the remaining 23 cases, a 1:3 mixture of radiopharmaceutical and dye was injected, and a hand-held probe was used to determine the radioactive counts.

RESULTS

Preoperative cutaneous lymphoscintigraphy identified 129 drainage basins; 12 patients (10%) had dual-basin drainage. During intraoperative lymphatic mapping and sentinel lymphadenectomy, 183 sentinel nodes were identified and excised from 120 basins (1.5 nodes/basin). The blue dye alone identified sentinel nodes in 93 of 101 basins (92%). The probe identified sentinel nodes in 28 of 28 basins, only one of which failed to reveal blue-staining sentinel nodes; thus, the probe plus dye identified sentinel nodes in 27 of 28 basins (96%). Histopathologic analysis revealed metastasis in sentinel nodes from 11 patients (12%) who underwent sentinel lymphadenectomy with blue dye alone and in 3 patients (13%) who underwent sentinel lymphadenectomy with dye plus probe. There were no same-basin recurrences over a mean follow-up of 46 months (range 1 to 125).

CONCLUSIONS

Selective sentinel lymphadenectomy is a highly accurate method of staging the regional nodes in patients with primary tumors of the head and neck. Although we initially demonstrated the utility of this technique with blue dye alone, our results now suggest that the combination of dye and radiopharmaceutical may be a more sensitive method to detect sentinel nodes.

Long-term low-dose cyclosporine therapy for severe psoriasis: effects on renal function and structure

BACKGROUND

The effectiveness of cyclosporine in the treatment of severe psoriasis is well known.

OBJECTIVE

We evaluated the efficacy and toxicity of systemic cyclosporine in patients with severe psoriasis, observing short-term (12 weeks) and long-term (3 to 5 years) effects.

METHODS

To further elucidate efficacy and safety, 42 patients with severe psoriasis were treated initially with cyclosporine 5 to 6 mg/kg per day for 12 weeks. A subset of 14 patients continued maintenance treatment for 3.5 years to study the long-term effects of cyclosporine on renal function and structure. Renal biopsies were performed after 2.5 years and 3.5 years of treatment. Renal histologic findings were correlated with renal function.

RESULTS

By weeks 8 and 12, 64% (n = 27) and 86% (n = 36) of patients, respectively, were rated clear or almost clear of the psoriasis. However, a subpopulation of 15 patients did not respond to 5 mg/kg daily but improved when the dose was increased to 6 mg/kg daily. Clearance or near clearance was achieved in 67% of this subpopulation after 4 weeks. For the 29 patients whose glomerular filtration rate (GFR) was measured, mean GFR fell by 7% from baseline to week 4 (p < 0.05). This change was reversible when dosage was reduced by 1 mg/kg per day in each of these patients. Patients older than 45 years of age experienced significant elevation of mean diastolic blood pressure and had reduced GFR and increased serum creatinine. After 2.5 years, of the 14 patients who continued maintenance treatment, two had biopsy specimens that showed moderate interstitial fibrosis and tubular atrophy. The remainder showed only minimal to mild structural damage. After 3.5 years of cyclosporine treatment, repeat renal biopsy specimens revealed slight increases in structural changes in nine subjects. These changes correlated with increasing age and drug-induced hypertension.

CONCLUSION

We conclude that 5 mg/kg of cyclosporine daily is usually an effective initial dose for psoriasis. Patients who do not respond will often benefit from elevation of the dose to 6 mg/kg daily. Older patients experience cyclosporine-induced hypertension and changes in renal function and structure more frequently than do younger patients.

Simulations for FASTPAC and the standard 4-2 dB full-threshold strategy of the Humphrey Field Analyzer

PURPOSE

This study evaluates the accuracy, reproducibility, and efficiency of FASTPAC, a new fast strategy for automated perimetry using 3-dB steps with single threshold crossing, compared to the standard 4-2 dB full threshold strategy by means of computer simulations.

METHOD

An "artificial patient" module was developed to create responses to stimuli by a Monte-Carlo technique from a given probability distribution. The authors performed 10,200 simulations with threshold values ranging from 0 to 50 dB.

RESULTS

Results demonstrate an 18% decrease in the number of presentations per threshold determination, which is equal to a similar reduction in testing time. For both strategies, there is a considerable influence of the starting deviation (difference between starting value and actual threshold) on threshold error (difference between estimated threshold and actual threshold): negative starting deviations lead to negative threshold errors and vice versa. This relationship is more pronounced for FASTPAC (slope 0.18 dB/dB, P < 0.0001) than for the full-threshold strategy (slope 0.13 dB/dB, P < 0.0001). In addition, fluctuations of the determined thresholds, described as the distance between the 16th and 84th percentiles of the threshold errors, increase with increasing absolute starting deviations. This is particularly true of FASTPAC:

CONCLUSIONS

The influence of the starting value on the threshold determination may lead to a considerable underestimation of visual field defects, accompanied by a higher fluctuation. This is an intrinsic property of both staircase procedures. FASTPAC, however, is more affected than the standard 4-2 dB full-threshold strategy. FASTPAC, therefore, provides time reduction at the expense of accuracy and reliability.

Priority ethical issues in oncology nursing: current approaches and future directions

PURPOSE/OBJECTIVES

To describe ethical issues determined to be highly important to oncology nurses and to discuss strategies by which the Oncology Nursing Society (ONS) can address these priority concerns.

DATA SOURCES

Survey on oncology nurses regarding ethical issues; nursing literature.

DATA SYNTHESIS

Nine priority ethical issues of oncology nurses are identified. Past, current, and future ONS activities that address these priority issues are discussed.

IMPLICATIONS FOR NURSING PRACTICE

ONS must support activities to increase the knowledge, confidence, and involvement of oncology nurses in discussions and decision making related to the ethical issues.

CONCLUSIONS

The top three priority ethical issues for oncology nurses are assisted suicide, end-of-life decisions, and pain management. Efforts should be made to increase ethics expertise among the ONS membership.

Chronic implantation of nonocclusive catheters and flow probes in the splanchnic and hindlimb vasculature of the rabbit

Flow probes and nonocclusive catheters were simultaneously implanted in the splanchnic and hindlimb vasculature to measure regional blood flows and arteriovenous differences of individual organs in the conscious rabbit. Pulsed Doppler flow probes were constructed by modifying the technique of Haywood et al., and nonocclusive catheters were designed and constructed from Silastic tubing (0.6- or 0.9-mm OD) and surgical velour. Laparotomy was performed on rabbits under anesthesia, and the renal, mesenteric, iliac, or hepatic artery and portal vein were isolated and instrumented with a flow probe. A nonocclusive catheter was then inserted into the respective vein. Instrumentation of the hepatic system required probes on the hepatic artery and portal vein, and nonocclusive catheters were placed into hepatic and portal veins. One week later, rabbits were reanesthetized and nonocclusive catheters were inserted into the cranial vena cava via the jugular vein and abdominal aorta to the level of the celiac axis. Probes and catheters were evaluated daily up to 30 days. Implants remained functional for an average of 3 weeks, permitting chronic measurement of velocity and blood variables in individual tissue beds of the conscious rabbit.

Ethical issues in oncology nursing practice: an overview of topics and strategies

An understanding of common principles of biomedical ethics provide healthcare professions with a common language. Developing a standard approach to complex ethical cases in clinical situations allows professionals to involve significant individuals and to ensure that appropriate factors are considered. This article presents a case in oncology nursing practice, using a sample model for decision making. The case is developed to demonstrate a number of issues that arise with regard to symptom management, the nurse-patient relationship, informed consent, end-of-life decisions, and truth-telling. Ethical dilemmas arising from conflicts within principles and between individuals holding differing ethical perspectives are described. Because a true ethical dilemma goes beyond a simple "right" or "wrong" answer, arguments based on differing moral grounds are presented. Nursing responsibilities are delineated and directions are provided for furthering one's understanding of ethics.

Delirium in terminally ill cancer patients

Nineteen patients believed to be in the terminal stages of cancer were evaluated for signs of delirium. Six patients improved; 13 who died during hospitalization were studied until their death. Patients were interviewed three times a week using a delirium scale; medical records also were used to gather data. Eleven (85%) of the 13 patients developed delirium. In most patients, delirium was caused by multiple factors. The authors outline strategies for management of terminal cancer patients with delirium.

Development of a transplantable model of pancreatic duct adenocarcinoma

We report here the first development of a continuous cell line in tissue culture of an animal pancreatic duct adenocarcinoma that is histologically similar to human pancreatic duct adenocarcinoma. A primary pancreatic duct adenocarcinoma, induced in a male Syrian golden hamster after 23 weeks of weekly subcutaneous injection of N-nitrobis (2-hydroxypropyl)amine, was minced and injected subcutaneously into three hamsters. After 8 weeks, a single tumor was apparent. Subsequent passages of fragments into the cheek pouches were performed at 3- to 4-week intervals. After five passages, minced fragments of a tumor were placed in tissue culture. Colonies appeared by 7 days; an epitheloid cell line, without fibroblasts, was established by 60 days. Single-cell suspensions, injected into hamster cheek pouches or subcutaneously, produced tumors in a dose-dependent fashion. Spent culture medium of tissue culture cells and saline extracts of freshly excised tumors contained pancreatic oncofetal antigen-like activity.

Phagocyte recognition by lectin receptors

A "lectin-like" receptor for bacterial cell wall sugars, originally described in the membrane of mouse peritoneal macrophages, which facilitates binding of various bacteria to the macrophage surface, has now been shown to be present on most phagocytes from a variety of species. The role of such a receptor in the inflammatory response has been investigated by examining changes in its expression in response to chemoattractants. The chemoattractants, whilst enhancing or not altering expression of C3 and Fc receptors, respectively, appeared to decrease lectin receptor expression. The possibility of a relationship between I-region gene products of the major histocompatibility complex (MHC) and the bacterial binding lectin receptor was investigated. It was found that various conventional and monoclonal antibodies directed against I-region determinants inhibited binding of bacteria to mouse peritoneal macrophages. These findings suggest the need to examine the possibility that, in addition to phagocytosis and elimination of bacteria, the lectin receptor may also be involved in antigen presentation and macrophage-T-lymphocyte cooperative events leading to an immune response.

Presence of bacterial binding 'lectin-like' receptors on phagocytes

Lectin-like receptors capable of binding the bacterium Staphylococcus albus have been demonstrated in the membranes of phagocytes including macrophages, neutrophils and eosinophils from various sources and species. Such receptors are likely to contribute to bacterial adherence and phagocytosis in the non-immune animal.