High-intensity versus moderate-intensity statin treatment for patients with ischemic stroke: Nationwide cohort study

PURPOSE

Guidelines recommend high-intensity statin treatment after ischemic stroke, but evidence is sparse on the effectiveness and safety of different statin treatment intensities. We examined effectiveness and safety outcomes among patients initiating high-intensity versus moderate-intensity statins after ischemic stroke.

METHODS

In this population-based new-user active-comparator cohort study, we used the Danish Stroke Registry, covering all Danish hospitals, to identify patients with a first-time ischemic stroke during 2012-2021. Using multiple Danish registries, patients who redeemed a statin prescription within 21 days after stroke admission were classified as high-intensity statin initiators or moderate-intensity statin initiators. Propensity score inverse probability of treatment weighting was used to balance patient characteristics. We used competing risk methods to compute 5 year risk differences (RDs) and Cox proportional hazards regression to compute 5 year hazard ratios (HRs) of stroke recurrence, myocardial infarction, heart failure, venous thromboembolism, and all-cause mortality (effectiveness outcomes) and diabetes, liver disease, and kidney disease (safety outcomes).

RESULTS

High-intensity (n = 13,032) and moderate-intensity (n = 14,355) statin initiators were identified. Risks of most examined effectiveness outcomes were comparable between statin intensities. There was no clear association between statin intensity and stroke recurrence (RD: 0.8% [95% CI: 0.1, 1.4], HR: 1.08 [95% CI: 0.96, 1.22]). All-cause mortality was slightly reduced among high-intensity statin initiators (RD: -1.1% [95% CI: -0.1, -2.1], HR: 0.93 [95% CI: 0.85, 1.01]. Risks of most safety outcomes were comparable between statin intensities, but high-intensity statin use was associated with an increased risk of diabetes (RD: 1.2% [95% CI: 0.4, 1.9], HR: 1.10 [95% CI: 1.00, 1.21]).

DISCUSSION AND CONCLUSION

Compared with initiation of moderate-intensity statins, initiation of high-intensity statins after ischemic stroke was associated with similar risks of most effectiveness and safety outcomes. However, mortality risk was reduced, and diabetes risk was increased.

Senescence in immunity against helminth parasites predicts adult mortality in a wild mammal

Our understanding of the deterioration in immune function in old age-immunosenescence-derives principally from studies of modern human populations and laboratory animals. The generality and significance of this process for systems experiencing complex, natural infections and environmental challenges are unknown. Here, we show that late-life declines in an important immune marker of resistance to helminth parasites in wild Soay sheep predict overwinter mortality. We found senescence in circulating antibody levels against a highly prevalent nematode worm, which was associated with reduced adult survival probability, independent of changes in body weight. These findings establish a role for immunosenescence in the ecology and evolution of natural populations.

Nimotuzumab and radiotherapy for treatment of newly diagnosed diffuse intrinsic pontine glioma (DIPG): a phase III clinical study

BACKGROUND

Diffuse intrinsic pontine glioma (DIPG) is a devastating cancer of childhood and adolescence.

METHODS

The study included patients between 3 and 20 years with clinically and radiologically confirmed DIPG. Primary endpoint was 6-month progression-free survival (PFS) following administration of nimotuzumab in combination with external beam radiotherapy (RT). Nimotuzumab was administered intravenously at 150 mg/m² weekly for 12 weeks. Radiotherapy at total dose of 54 Gy was delivered between week 3 and week 9. Response was evaluated based on clinical features and MRI findings according to RECIST criteria at week 12. Thereafter, patients continued to receive nimotuzumab every alternate week until disease progression/unmanageable toxicity. Adverse events (AE) were evaluated according to Common Terminology Criteria for Adverse Events (CTC-AE) Version 3.0 (CTC-AE3).

RESULTS

All 42 patients received at least one dose of nimotuzumab in outpatient settings. Two patients had partial response (4.8%), 27 had stable disease (64.3%), 10 had progressive disease (23.8%) and 3 patients (7.1%) could not be evaluated. The objective response rate (ORR) was 4.8%. Median PFS was 5.8 months and median overall survival (OS) was 9.4 months. Most common drug-related AEs were alopecia (14.3%), vomiting, headache and radiation skin injury (7.1% each). Therapy-related serious adverse events (SAEs) were intra-tumoral bleeding and acute respiratory failure, which were difficult to distinguish from effects of tumor progression.

CONCLUSIONS

Concomitant treatment with RT and nimotuzumab was feasible in an outpatient setting. The PFS and OS were comparable to results achieved with RT and intensive chemotherapy in hospitalized setting.

International registry on the use of the CytoSorb® adsorber in ICU patients : Study protocol and preliminary results

INTRODUCTION

The aim of this clinical registry is to record the use of CytoSorb® adsorber device in critically ill patients under real-life conditions.

METHODS

The registry records all relevant information in the course of product use, e. g., diagnosis, comorbidities, course of the condition, treatment, concomitant medication, clinical laboratory parameters, and outcome (ClinicalTrials.gov Identifier: NCT02312024). Primary endpoint is in-hospital mortality as compared to the mortality predicted by the APACHE II and SAPS II score, respectively.

RESULTS

As of January 30, 2017, 130 centers from 22 countries were participating. Data available from the start of the registry on May 18, 2015 to November 24, 2016 (122 centers; 22 countries) were analyzed, of whom 20 centers from four countries provided data for a total of 198 patients (mean age 60.3 ± 15.1 years, 135 men [68.2%]). In all, 192 (97.0%) had 1 to 5 Cytosorb® adsorber applications. Sepsis was the most common indication for CytoSorb® treatment (135 patients). Mean APACHE II score in this group was 33.1 ± 8.4 [range 15-52] with a predicted risk of death of 78%, whereas the observed mortality was 65%. There were no significant decreases in the SOFA scores after treatment (17.2 ± 4.8 [3-24]). However interleukin-6 levels were markedly reduced after treatment (median 5000 pg/ml before and 289 pg/ml after treatment, respectively).

CONCLUSIONS

This third interim report demonstrates the feasibility of the registry with excellent data quality and completeness from 20 study centers. The results must be interpreted with caution, since the numbers are still small; however the disease severity is remarkably high and suggests that adsorber treatment might be used as an ultimate treatment in life-threatening situations. There were no device-associated side effects.

[Pneumothorax during right-sided nephrectomy in a heifer]

A 250-kg heifer had signs of colic attributable to urolithiasis of the right kidney. Medical treatment did not result in resolution of clinical signs, and nephrectomy was carried out. The surgery was started with the heifer standing, and the 13th rib was resected. However, during blunt dissection of the kidney, air suddenly entered the pleural space and the heifer had acute severe dyspnoea. The hole in the pleural cavity was sutured and a chest drain was placed. Inhalation anaesthesia was then induced and nephrectomy could be completed without further complications. The heifer was discharged 11 days postoperatively, and was healthy and had been integrated into the herd 12 months after surgery. Pneumothorax must be considered a possible complication of rib resection in right-sided nephrectomy in cattle.

[Reversible cerebral vasoconstriction syndrome. Challenge for diagnostics and intensive care therapy]

Reversible cerebral vasoconstriction syndrome (RCVS) is a disease of unclear incidence frequently affecting middle aged women and is usually associated with use of adrenergic or serotoninergic substances. The exclusion of relevant differential diagnoses, such as aneurysmal subarachnoid hemorrhage, primary cerebral angiitis, posterior reversible encephalopathy syndrome and carotid artery dissection is critical in terms of time and significance. Thunderclap headache as well as multiple and multilocular vasospasms with direct or indirect angiography without substantial findings in cerebrospinal fluid diagnostics are typical symptoms. The necessity for intensive care treatment is often justified by initial acute impairment of vital functions and possible development of cerebral or extracerebral complications. Because the exact pathophysiology remains unknown, a specific therapy does not exist. This poses significant challenges in intensive care medicine, which are illustrated on the basis of the case study presented.

[Traumatic dissection of the carotid artery: challenges for diagnostics and therapy illustrated by a case example]

Traumatic dissection of the carotid artery is an easily overlooked consequence of trauma with notable morbidity and mortality which can be observed in up to 4% of cases involving multiple trauma. Certain mechanisms and patterns of injury as well as specific symptoms should serve as indicators of a dissection and should therefore result in further diagnostic measures. An early diagnosis is of major relevance. This report describes the case of a 45-year-old victim of a traffic accident who showed symptoms of a dissection which had initially not been diagnosed.

Density and genetic relatedness increase dispersal distance in a subsocial organism

Although dispersal distance plays a major role in determining whether organisms will reach new habitats, empirical data on the environmental factors that affect dispersal distance are lacking. Population density and kin competition are two factors theorised to increase dispersal distance. Using the two-spotted spider mite as a model species, we altered these two environmental conditions and measured the mean dispersal distance of individuals, as well as other attributes of the dispersal kernel. We find that both density and relatedness in the release patch increase dispersal distance. Relatedness, but not density, changes the shape of the dispersal kernel towards a more skewed and leptokurtic shape including a longer 'fat-tail'. This is the first experimental demonstration that kin competition can shape the whole distribution of dispersal distances in a population, and thus affect the geographical spread of dispersal phenotypes.

[Acquired von Willebrand's disease type 2A following arteriovenous fistula for haemodialysis?]

Acquired von Willebrand's disease (aVWD) is considered to be an underestimated cause of unexplained bleeding. Adsorption of von Willebrand factor (VWF) to tumour cells or hydroxyethyl starch and elimination of VWF by autoantibodies as well as shear stress-induced mechanical alteration of VWF with concomitant cleavage by enzymes may lead to an acquired deficiency of VWF and a bleeding disorder. We report a 39-year-old woman who developed spontaneous bleeding five years after surgical creation of an arteriovenous fistula (AVF) for haemodialysis treatment. AVWD type 2A was diagnosed after successful renal transplantation. One year after surgical closure of the AVF, the aVWD could not be verified again. Thus, the aVWD may have developed because of altered blood flow and shear stress inside the arteriovenous fistula.

Texture classification by statistical learning from morphological image processing: application to metallic surfaces

A classification method based on textural information for metallic surfaces displaying complex random patterns is proposed. Because these kinds of textures show fluctuations at a small scale and some uniformity at a larger scale, a probabilistic approach is followed, considering textural variations as realizations of random functions. Taking into account information of pixel neighbourhoods, the texture for each pixel is described at different scales. By means of statistical learning, the most relevant textural descriptors are selected for each application. The performance of this approach is established on a real data set of steel surfaces.

Klinische Möglichkeiten zur Steuerung der Körpertemperatur

The constancy of body temperature (CBT) is a cornerstone of homeostatic, homothermic organisms and is essential for a regulated course of biochemical and biophysical reactions. Severe deviations from normothermia (36.8+/-0.4 degrees C) are life threatening and even a moderate perioperative reduction of the CBT is coupled with an increased morbidity and mortality especially in high-risk patients. The relevant factors are coagulation disturbances, increased infection rate and increased cardiac risk. Normothermia should be achieved by the consistent use of warmth-conserving measures. On the other hand, a deliberate reduction in temperature or induced hypothermia is a neuroprotective procedure, which offers a therapeutic option to minimize neuronal secondary damage after primary hypoxic-ischemic events as well as extending the neuronal tolerance to ischemia. Management includes the practice of cooling down to a defined temperature, rewarming as well as a differentiated control of various parameters. Furthermore, side-effects which increase in severity with decreasing temperature must be taken into consideration.

Final report of a phase II trial of nimotuzumab in the treatment of refractory and relapsed high-grade gliomas in children and adolescents

2006

Background: Despite multimodal therapy most children with high grade gliomas (HGG), including glioblastoma multiforme (GM), anaplastic astrocytoma (AA) and intrinsic pontine glioma (PG) have an infaust prognosis if they relapse or are refractory to the primary treatment. Recently novel therapeutic approaches are investigated in order to improve the survival of these patients while preserving a good quality of life. This multicentre phase II trial was designed to explore the feasibility and efficacy of the h-R3 monoclonal anti-EGFR antibody (nimotuzumab) in the treatment of these patients. Patients and Methods: Pediatric patients with GM, AA or PG with radiologically proven progressive disease following primary or relapse treatment and a life expectancy of less than 4 weeks were eligible to the study. The treatment consisted of an induction therapy including a weekly short infusion of 150 mg/m2 nimotuzumab for six weeks, and in case of non-PD a consolidation therapy of 4 infusions in a 3 week interval. The response was documented by MRI in week 8 and 21 and only clinically in rapidly progresssive disease. Results: Between June 2004 and April 2006 47 patients aged 4 to 17 years (median 11 years) were enrolled in this study. 46 patients were evaluable for response. According to RECIST 14 out of 46 patients showed objective responses (PR n=4, SD n=10) in the MRI as the best response with a median change in the largest diameter of the index lesion of -11% (-50% to +16%). The PR/SD were seen in 2/13 patients with GM, 2/11 with AA and 10/22 with PG. Thirteen patients continued with the consolidation therapy and showed 4 PR, 3 SD and 6 PD in week 21. The median overall survival was 4.4 months (0.3–25.4 months) and was significantly better for repsonders (median 10 months) than for nonresponders (median 4.0 months). No severe side effects related to the study medication were observed. Conclusions: These data suggest that the repeated application of nimotuzumab is well tolerated and safe. Nimotuzumab has cytotoxic efficacy in heavily pre- treated relapsed HGG. Based on this data a phase III trial with nimotuzumab in newly diagnosed diffuse intrinsic pontine gliomas concomittent with radiotherapy was introduced in first quarter 2006.

No significant financial relationships to disclose.

Therapeutische Hypothermie und Säure-Basen-Management

Moderate hypothermia is being increasingly advocated for acute neurological clinical situations. In case of proved clinical success, however, it is relatively time consuming and requires personal and structural resources. In addition, profound knowledge and a sound understanding of the physiology of hypothermia are necessary prerequisites. In particular, the variety of untoward effects, which increase with decreasing temperature, underline the need for specific diagnostic and therapeutic skills. A further challenge is associated with the adaptation of the parameters of homoeostasis to a basically altered temperature. Among these, management of acid-base balance is a managerial cornerstone. In principle, two different regimens may be used, i.e. the pH-stat and the alpha-stat regimes. Applying pH-stat during hypothermia means keeping the pH constant, whereas the H(+)/OH(-) quotient is held constant when relying on the alpha-stat regime. Because of the lack of prospective clinical data any comparative evaluation of the two alternatives actually remains a matter of speculation. However, experimental data as well as physiological considerations may support an illness-oriented differentiated approach (e.g. increased cerebral pressure vs. cardiac arrest vs. stroke). Prospective studies are required to allow an evidence-based and substantiated clinical decision regarding the management of pCO(2) and pH during therapeutic hypothermia.

Angiopoietins in malignancy

BACKGROUND

Tumour growth is dependant upon the development of an adequate blood supply. This, in turn, is thought to depend upon a switch by the tumour, from a dormant to angiogenic state. Recent data suggest that this switch may occur when the balance of pro- and anti-angiogenic agents alters to promote angiogenesis. Angiopoietins may be involved in this balance.

METHODS

An electronic literature search was performed with respect to angiopoietins from 1996 to the present. Published data from in-vitro and in-vivo studies were critically analysed. A specific focus was made of studies relating to tumour growth and vasculature.

RESULTS

Since angiopoietin-1 was first described in 1996, three more angiopoietins have been described. All family members bind to the Tie-2 receptor. There is now a considerable accumulation of data that suggests they play a pivotal role in the development and stabilisation of tumour vasculature. angiopoietin-2 appears to be pro-angiogenic whilst angiopoietin-1 appears to be a stabilising factor.

CONCLUSIONS

Recent trials of anti-angiogenic agents show promise in the treatment of solid human cancers. The angiopoietins are a new family of proteins that appear to be influential in the development of the tumour vasculature. Manipulation of the angiopoietin balance may provide a potential therapeutic target in human cancer.

Syndromes canalaires du sportif

Peripheral nerve entrapment syndromes involve the compression of a short segment of a nerve at a specific site, as a result of the vulnerability of that nerve as it passes through a fibroosseous tunnel or an opening in fibrous or muscular tissue. Injury of the nerve may occur as a result of compression by the overlying structures. Another mechanism of injury is traction of the nerve, with or without friction of the nerve, as it travels and sharply changes direction around critical points. Imaging can be particularly helpful for the diagnosis of these uncommon injuries. Percutaneous decompression of a ganglion cyst or perineural injection for therapeutic purposes with the aid of fluoroscopy, CT, or ultrasound guidance can be performed in specific areas.

Results of a phase II trial of h-R3 monoclonal antibody (nimotuzumab) in the treatment of resistant or relapsed high-grade gliomas in children and adolescents

1522

Background: Children and adolescents suffering from high grade gliomas (HGG) have a poor prognosis when they relapse during or after primary treatment. Thus novel therapeutic approaches as the inhibition of growth-signalling pathways are needed. This multicentre phase II trial was designed to explore the feasibility and efficacy of the h-R3 monoclonal anti-EGFR antibody (Nimotuzumab) in the treatment of these patients. Methods: Pediatric patients with glioblastoma multiforme, anaplastic astrocytoma or intrinsic pontine glioma (PG) with radiologically proven progressive disease following primary or relapse treatment were eligible to the study. The treatment consisted of an induction therapy including a weekly short infusion of 150 mg/m2 Nimotuzumab for six weeks, and in case of non-PD a subsequent consolidation therapy of four infusions in a three week interval. The response was documented by MRI in week 8 and 21. Results: Between June 2004 and August 2005 34 patients aged 5.0 to 17.4 years (median 10.9 years) were enrolled in this study. According to RECIST 12 out of 34 patients showed response (PR n=1, SD n=11) in the MRI of week 8 after the induction therapy with a median change in the largest diameter of the index lesion of −5% (−39 to +16%) accompanied by clinical deterioration in four and markedly clinical improvement in two patients. Surprisingly, 9 PR/SD were seen in the 14 patients with PG. Eight patients continued with the consolidation therapy. So far 5 out of 8 Patients are evaluable for response after consolidation therapy and showed three PR, one SD and one PD in week 21. Eight patients with consolidation therapy are free of progression for a median of 7.5 months (1.2–13.2 months). No severe side effects related to the study medication were observed. Conclusions: These data suggest that the repeated application of Nimotuzumab is well tolerated and safe. It has cytotoxic efficacy in heavily pre-treated relapsed HGG, especially in intrinsic pontine glioma. A phase III study for patients with newly diagnosed PG is warranted.

[Table: see text]

Safety, efficacy and pharmacokinetics of nimotuzumab, a humanized monoclonal anti-epidermal growth factor receptor (EGFR) antibody, as monotherapy in patients with locally advanced or metastatic pancreatic cancer (PC)

12504

Background: Nimotuzumab (OSAG101, Theraloc) is a humanized monoclonal antibody (mAb) that binds to the EGFR. In preclinical studies the antibody has shown potent antitumor activity. Based on phase I data, the recommended dose has been established at 200 mg weekly. A previous phase II study in children with high grade brain tumors showed activity of nimotuzumab as a monotherapeutic agent, even in prognostically very unfavorable pontine glioma. No drug related side effects were reported. The present ongoing phase II study was aimed at evaluating the safety and efficacy of nimotuzumab monotherapy in patients (pts) with locally advanced or metastatic PC. Methods: Pts who failed standard chemotherapy with gemcitabine or another first line regimen for advanced disease and had at least one measurable lesion were eligible for the study. Nimotuzumab was given iv as induction therapy at 200 mg once weekly for 6 weeks. Follow up by CT was performed after 8 weeks. Pts continued receiving treatment 3-weekly until disease progression or unacceptable toxicity occurred. Endpoints included tumor response (RECIST), time to disease progression, and safety. Blood samples were collected prior to first dose, at end of infusion, and 3h, 6h, 48h, as well as every time before subsequent nimotuzumab doses were administered. Nimotuzumab concentrations in serum were measured by cellular ELISA. Results: Enrollment is complete, with treatment ongoing. In total, 55 pts were treated (28 women/ 27 men; ECOG status of 1 [n= 41] or 0 [n=14], median age 63.6 yrs [range 46–83 yrs]). Pts evaluable for response: n= 36; CR:0; PR:0; SD:6 pts (median TTP 19.2 weeks; 14.1–26.1). The only reported treatment-related adverse event was rash grade 1 in 1 pt. After 200 mg single dose, the mean value of Cmax was calculated to 141 ± 33 μg/ml. The t1/2 was calculated to 45 h, volume of distribution to 1.46 ± 0.3 l, respectively. The total clearance was determined to 23 ± 6 ml/h. The trough values after 168 h were 6.2 ± 6.3 μg/ml. Conclusions: These data confirm that nimotuzumab is safe and well tolerated. To improve efficacy, a combination trial with gemcitabine is planned.

[Table: see text]