Combined BRAF and HSP90 Inhibition in Patients with Unresectable BRAF V600E-Mutant Melanoma

Purpose: BRAF inhibitors are clinically active in patients with advanced BRAF^V600-mutant melanoma, although acquired resistance remains common. Preclinical studies demonstrated that resistance could be overcome using concurrent treatment with the HSP90 inhibitor XL888.Patients and Methods: Vemurafenib (960 mg p.o. b.i.d.) combined with escalating doses of XL888 (30, 45, 90, or 135 mg p.o. twice weekly) was investigated in 21 patients with advanced BRAF^V600-mutant melanoma. Primary endpoints were safety and determination of a maximum tolerated dose. Correlative proteomic studies were performed to confirm HSP inhibitor activity.Results: Objective responses were observed in 15 of 20 evaluable patients [75%; 95% confidence interval (CI), 51%-91%], with 3 complete and 12 partial responses. Median progression-free survival and overall survival were 9.2 months (95% CI, 3.8-not reached) and 34.6 months (6.2-not reached), respectively. The most common grade 3/4 toxicities were skin toxicities, such as rash (n = 4, 19%) and cutaneous squamous cell carcinomas (n = 3, 14%), along with diarrhea (n = 3, 14%). Pharmacodynamic analysis of patients' peripheral blood mononuclear cells (PBMC) showed increased day 8 HSP70 expression compared with baseline in the three cohorts with XL888 doses ≥45 mg. Diverse effects of vemurafenib-XL888 upon intratumoral HSP client protein expression were noted, with the expression of multiple proteins (including ERBB3 and BAD) modulated on therapy.Conclusions: XL888 in combination with vemurafenib has clinical activity in patients with advanced BRAF^V600-mutant melanoma, with a tolerable side-effect profile. HSP90 inhibitors warrant further evaluation in combination with current standard-of-care BRAF plus MEK inhibitors in BRAF^V600-mutant melanoma. Clin Cancer Res; 24(22); 5516-24. ©2018 AACR See related commentary by Sullivan, p. 5496.

Perineal stapled prolapse resection for full-thickness external rectal prolapse: a multicentre prospective study

AIM

Many different surgical techniques have been reported for the surgical treatment of full-thickness external rectal prolapse. Perianal stapled prolapse resection (PSP) is a relatively newly reported technique for full thickness external rectal prolapse. The aim of this prospective multicentre study was to evaluate the results of this procedure.

METHOD

Consecutive patients who underwent a PSP resection for full-thickness external rectal prolapse at five centres were recruited to the study. Median operating time, hospital stay, complications, recurrence and functional results according to the Wexner Incontinence Scale and obstructive defaecation syndrome score were recorded.

RESULTS

There were 27 patients treated by PSP. The median Wexner incontinence score improved from 10 presurgery to 5 after surgery (P < 0.001); the median obstructed defaecation syndrome score improved from 12 presurgery to 5 (range 4-10) after surgery (P < 0.001). A laparoscopically assisted procedure was performed in three patients (11.1%). The median number of cartridges used was six (range four to nine). The median operating time was 48 min. Early complications occurred in six patients (22.2%) and late complications in two (7.4%). The median length of hospital stay was 5 days. The recurrence rate at a median follow-up of 30.3 months was 14.8%.

CONCLUSION

PSP appears to be an easy, fast and safe procedure. Early functional results are good. The recurrence rate compares favourably with other perineal procedures like the Delorme or the Altemeier operations. Long-term functional results need to be investigated further.

Serum Levels of Cortisol, Immunoglobulin, and C-reactive Protein in Burn Patients

Thermal injury is known to induce alterations in the immune system, but the precise mechanisms have yet to be elucidated. It has been shown that thermal injury in more than 20% of the total body surface area (TBSA) leads to disturbances in the cortisol metabolism and the equilibrium of the hypothalamic-pituitary-adrenal axis. We investigated the temporal relationship between serum cortisol levels, C-reactive protein, and immunoglobulin levels in the post-burn period. Twenty-one adult burn patients (mean age, 52 ± 17 yrs) were included in the study (TBSA, 10-80%); nine developed sepsis and five died. The nonseptic group consisted of twelve patients. Thirty healthy blood donors served as controls. Our results suggest that increased cortisol and decreased immunoglobulin levels could be related to severe sepsis and clinical outcome.

Medical ethics, clinical research, and special aspects in nuclear medicine

Medical ethics is the science of survival. It studies the working out of judgments on right or wrong referred to the human being as a biological entity interacting with the whole ecosystem. Medical ethics in clinical research raises numerous moral and technical issues. Methodological aspects are essential for carrying out the aim of clinical research. Medical ethics documents are inspired by the Nuremberg Code and culminate in the recently updated Helsinki Declaration of 1964. In Italy 2 ministerial decrees in 1997 and 1998 laid the basis for the work of a medical ethics committee. They acknowledge the European Good Clinical Practice Guidelines and set professional needs within ethical committees. In clinical research the use of ionising radiation merits special consideration. In the recent past, serious human rights abuses in radiation experiments of the 1950s and 1960s have been found. As regards research in this field we can refer to the publication of the International Commission on Radiological Protection (ICRP) and to the report of the World Health Organisation (WHO). Legislative decree no. 187 of May 26, 2000, which transposed the 97/43/ EURATOM Directive represents the most comprehensive and recent normative reference to clinical research using ionising radiation. However, law no. 39 of March 1, 2002 is important for the partial modifications of previous decrees (art. 108 of L.D. no. 230 of March 17, 1995 and, art. 4 and attachment III of L.D. no. 187 of May 26). In this paper medical ethics, research, methodological issues and aspects of ionizing radiation are discussed.

Plasma homocysteine and inflammation in elderly patients with cardiovascular disease and dementia

Increased levels of plasma total homocysteine (tHcy) may play a role in both cardiovascular diseases (CVD) and old-age dementias via enhancement of vascular inflammation. However, the association between plasma tHcy and serum C-reactive protein (sCRP), taken as a marker of low-grade inflammation, is still uncertain. We investigated this association in normal aging, CVD, and dementia, and examined whether it was modified by the presence of two major comorbid diseases of older age: chronic obstructive pulmonary disease (CPOD) and peptic ulcer (PU). Six hundred-twenty-seven individuals aged > or = 65 yr (74+/-7 yr) were selected for this study: 373 healthy controls; 160 patients with CVD but no evidence of comorbid diseases (CVD+/comorbidity-); 46 patients with CVD and concurrent CPOD and/or PU (CVD+/comorbidity+); and 48 patients with dementia. A positive association between plasma tHcy and serum CRP, independent of several confounders (socio-demographic status, known tHcy and sCRP determinants, inflammation markers, traditional vascular risk factors), was found for CVD+/comorbidity+ (p=0.001; not affected by dementia type) and dementia (p=0.001; not affected by dementia type), but not for CVD+/comorbidity- and controls. The results suggest that the association between plasma tHcy and sCRP is more an aspecific reflection of poor health than a specific correlate of vascular inflammation.

COMMON POLYMORPHISMS IN METHYLENETETRAHYDROFOLATE REDUCTASE (MTHFR): RELATIONSHIPS WITH PLASMA HOMOCYSTEINE CONCENTRATIONS AND COGNITIVE STATUS IN ELDERLY NORTHERN ITALIAN SUBJECTS

Hyperhomocysteinemia may be a risk factor for cognitive impairment. Methylenetetrahydrofolate reductase (MTHFR) is a key enzyme in homocysteine (Hcy) metabolism. Both the MTHFR 677C-->T and the 1298A-->C polymorphisms are associated with mild hyperhomocysteinemia, particularly in conditions of low folate status. The prevalence of these MTHFR polymorphisms and their relationships with plasma total Hcy (tHcy), serum folate and cognitive function was evaluated in 194 elderly Italian individuals: 122 healthy controls (73.8 +/- 7.1 years of age), 24 cognitively- impaired- not-demented individuals (78.6 +/- 9.3 years), and 48 subjects with Alzheimer dementia (AD = 26), vascular dementia (VD =22; 85.5 +/- 7.0 years). Twenty-one percent of all subjects were homozygous for 677C-->T and 7 % for 1298A-->C polymorphism. No significant relationship was found betweenMTHFR polymorphisms and age, cognitive status and type of dementia. Plasma tHcy did not differ significantly by MTHFR genotypes, but, subjects of all genotypes with low serum folate (<12 nmole/l) had higher plasma tHcy (p < 0.001), than subjects with high serum folate (>= 12 nmole/l). The study suggests that 677C-->T and 1298A-->C polymorphisms are common in the Northern Italian population, but do not significantly affect plasma tHcy levels of elderly individuals, even under conditions of low folate status. The lack of association of age and cognitive function with MTHFR genotypes argues against a negative selection for these polymorphisms.

The clock-drawing test in elderly Italian community dwellers: associations with sociodemographic status and risk factors for vascular cognitive impairment

To evaluate whether performance in the clock-drawing test (CDT) is associated with sociodemographic status and risk factors for cognitive impairment, we examined 744 Italian community dwellers aged > or =65 (73 +/- 6) years scoring > or =24 on the MMSE. CDT was scored by two different methods, the Sunderland and the Wolf-Klein methods. Sociodemographic, lifestyle, clinical and biochemical variables were also recorded. For both scoring methods, lower CDT scores were associated with age, poor education, increased serum C-reactive protein and history of cancer. Associations of lower CDT scores with increased serum glucose and history of cerebrovascular disease were also found for the method with the highest sensitivity to cognitive impairment. This study shows that in elderly community dwellers, CDT may be not totally free from sociodemographic biases, and that it is associated with risk factors for cognitive impairment and frailty.

Easy Medic: an Internet application for the general practitioner

A research project has been carried out to develop a client server application which supplies the general practitioner (GP) with a 'personal digital assistant' (hand-held mobile computer) to connect to Web servers at a hospital site through the Internet. This allows the doctor to book medical examinations, hospital admissions and manage patient data. The application used advanced object-oriented techniques, on both the client and the server side. The connection to a Web server was achieved through GSM wireless cellular telephones using standard Internet protocols (HTTP, TCP/IP and CGI). Conventional telephone lines can be used as well. Other application modules on the client side provided patients medical record supervision, GP schedule management, general information about hospitals and clinics, and pharmacy consultation. These services should help GPs in their daily work. Moreover, the quality of health-care resource management and cost supervision should improve, since each GP 'transaction' is automatically entered in realtime into a database at the server. The services are under test in the health-care system of an urban area in southern Italy.