The gut microbiome: what the oncologist ought to know

The gut microbiome (GM) has been implicated in a vast number of human pathologies and has become a focus of oncology research over the past 5 years. The normal gut microbiota imparts specific function in host nutrient metabolism, xenobiotic and drug metabolism, maintenance of structural integrity of the gut mucosal barrier, immunomodulation and protection against pathogens. Strong evidence is emerging to support the effects of the GM on the development of some malignancies but also on responses to cancer therapies, most notably, immune checkpoint inhibition. Tools for manipulating the GM including dietary modification, probiotics and faecal microbiota transfer (FMT) are in development. Current understandings of the many complex interrelationships between the GM, cancer, the immune system, nutrition and medication are ultimately based on a combination of short‐term clinical trials and observational studies, paired with an ever-evolving understanding of cancer biology. The next generation of personalised cancer therapies focusses on molecular and phenotypic heterogeneity, tumour evolution and immune status; it is distinctly possible that the GM will become an increasingly central focus amongst them. The aim of this review is to provide clinicians with an overview of microbiome science and our current understanding of the role the GM plays in cancer.

An experimental therapeutics test of whether adding dissonance-induction activities improves the effectiveness of a selective obesity and eating disorder prevention program

OBJECTIVE

Compare the Healthy Weight obesity and eating disorder prevention program, which promotes participant-driven gradual lifestyle changes to bring energy intake and expenditure into balance, to a new intervention, Project Health, which adds activities to create cognitive dissonance about unhealthy eating, a sedentary lifestyle, and excess body fat, and an obesity education video-control condition.

METHOD

College students at risk for both outcomes because of weight concerns (N=364, 72% female) were randomized to condition, completing pretest, posttest, and 6, 12 and 24-month follow-up assessments.

RESULTS

Project Health participants showed significantly smaller increases in measured body mass index (BMI) through 2-year follow-up than both Healthy Weight participants and controls (both d=-0.18), and significantly lower onset of overweight/obesity over 2-year follow-up than Healthy Weight participants and controls (13 vs 21% and 22%). Healthy Weight and Project Health participants showed significantly greater eating disorder symptom reductions than controls through 2-year follow-up. Healthy Weight and Project Health participants showed marginally lower eating disorder onset over follow-up than controls (3 and 3% vs 8% respectively).

CONCLUSIONS

The reduced increases in BMI and future overweight/obesity onset for Project Health relative to both an active matched intervention and a minimal intervention control condition are noteworthy, especially given the short 6-h intervention duration. The reduction in eating disorder symptoms for Healthy Weight and Project Health relative to controls was also encouraging. Results suggest that adding dissonance-induction activities increased weight loss effects. Yet, effects for both were generally small and the eating disorder onset prevention effects were only marginal, potentially because intervention groups included both sexes, which reduced eating disorder incidence and sensitivity.

Ipilimumab and Bevacizumab in Glioblastoma

The median survival in glioblastoma is just over a year, with no standard second-line therapy. Ipilimumab is an immune checkpoint inhibitor that activates the anti-tumour immune response by cytotoxic T-lymphocyte antigen-4 blockade. There is significant evidence supporting its role in the treatment of malignant melanoma, including in patients with brain metastases. The addition of the anti-angiogenesis agent, bevacizumab, seems to offer additional benefit and limit the immune-related side-effects of ipilimumab in melanoma. To date there have been no clinical trials investigating this combination in glioblastoma. In this single practice case series, 20 patients with glioblastoma were consented for and treated with ipilimumab and bevacizumab in combination. Safety, tolerability and the response to treatment were reviewed for all patients. Three patients were treated after palliative first-line radiotherapy, one patient after first-line chemoradiation and 16 patients were treated with recurrent disease. Sixty-five per cent of patients completed four cycles of 3 weekly ipilimumab therapy, administered with 2 weekly bevacizumab. Radiographic responses for patients with recurrent disease were evaluated by Response Assessment in Neuro-oncology (RANO) criteria; 31% of patients showed a partial response, 31% had stable disease and 38% had disease progression. The treatment combination was well tolerated, with treatment terminated before completion due to adverse events in two patients. Autoimmune toxicity was manageable with systemic corticosteroid therapy. Ipilimumab and bevacizumab in combination show promising activity with a predictable and manageable toxicity profile, warranting further clinical studies.

Phase 2 pilot study of Pathfinders: a psychosocial intervention for cancer patients

PURPOSE

Pathfinders is a multi-faceted psychosocial care program for cancer patients; it was developed in community oncology and adapted to the academic oncology setting. This prospective, single-arm, phase 2 pilot study examined the acceptability and feasibility of Pathfinders for women with metastatic breast cancer.

METHODS

Over 3 months, participants completed patient-reported surveys including the Patient Care Monitor (PCM, review of systems), Functional Assessment of Chronic Illness Therapy-Breast Cancer (FACT-B), Self Efficacy, and a single-item survey asking patients whether the program was helpful to them. A technology-based data collection system was used to capture electronic patient-reported outcomes at point of care, report symptoms in real time to clinicians, and collect warehouse data to provide a detailed longitudinal picture of the patient experience when receiving Pathfinders.

RESULTS

Participants (n = 50) were: mean age 51 (SD 11); 76% white, 20% black; 74% married; 50% college degree. Forty-two (n = 42) patients completed baseline and 3-month assessments. Statistically significant improvements (all P < 0.05) occurred in PCM subscales for Distress (mean [SE] = -3.42 [1.21]), Despair (-4.53 [1.56]), and Quality of Life (2.88 [0.97]), and the FACT-B Emotional Wellbeing subscale (2.07 [0.46]). Of the 29 participants asked if Pathfinders was helpful, 27 (93%) responded positively and two did not respond. Other instruments measuring symptoms, quality of life, and self-efficacy showed improvement.

CONCLUSIONS

In a phase 2 pilot study, Pathfinders was helpful to patients and is feasible in an academic medical center. Follow-up data collected at the 3-month assessment suggest that the program impacts various psychological outcomes, notably distress and despair.

Profile of the oral healthcare team in countries with emerging economies

Health is a critical dimension of human well-being and flourishing, and oral health is an integral component of health: one is not healthy without oral health. Significant barriers exist to ensuring the world's people receive basic healthcare, including oral healthcare. Amongst these are poverty, ignorance, inadequate financial resources and lack of adequate numbers of educated and trained (oral) healthcare workers. Emerging economies are encouraged to develop a national strategic plan for oral health. International organizations have developed goals for oral health that can be referenced and adapted by emerging economies as they seek to formulate specific objectives for their countries. Demographic data that assess the nature and extent of oral diseases in a country are essential to sound planning and the development of an oral healthcare system that is relevant, effective and economically viable. Prevention should be emphasized and priority consideration be given to oral healthcare for children. The types and numbers of members of the oral healthcare team (workforce) will vary from country to country depending on the system developed. Potential members of the workforce include: generalist dentists, specialist dentists, dental therapists, dental hygienists, denturists, expanded function dental assistants (dental nurses) and community oral health workers/aides. Competences for dentists, and other members of the team, should be developed to ensure quality care and developed economies should cooperate with emerging economies. The development, by more advanced economies, of digital, virtual curricula, which could be used by emerging economies for educating and training members of the oral healthcare team, should be an important initiative. The International Federation of Dental Educators and Associations (IFDEA) should lead in such an effort.

Phase I study of PM00104, a novel cytotoxic anti-cancer drug, administered to patients with advanced solid tumors or lymphoma

2517

Background: PM00104 (Zalypsis [Z]) is a novel synthetic alkaloid related to the marine compounds Jorumycin and the family of Renieramycins. Preliminary analyses of its mechanisms of action suggest effects on the cell cycle, DNA binding properties, as well as transcriptional inhibition. Z has shown antitumor activity in vitro (IC50 =10-8 M) and in xenografts models, and an acceptable toxicology profile. Methods: Patients (pts) with advanced cancers or lymphoma were enrolled to determine the safety, tolerability, maximum tolerated dose (MTD), recommended dose (RD), pharmacokinetics (PK) and antitumor activity of Z administered as a 1- hour IV infusion every 3 weeks. Sequential cohorts of 3–6 pts received the following doses: 0.225, 0.45, 0.9, 1.8, 3.0 and 3.6 mg/m2. Results: 27 pts were treated (19 M; median age: 58, range: 39–79; ECOG PS =2). 2 of 6 pts at 3.6 mg/m2 experienced dose-limiting toxicities (DLT), defining the MTD; 1 pt with colorectal cancer with extensive liver metastases developed grade 4 thrombocytopenia and neutropenia, grade 3 transaminase elevation, and grade 4 troponin I rise without cardiac symptoms or electrocardiogram alterations. These toxicities all resolved. Another pt with adrenal carcinoma developed grade 3 nausea, vomiting and asthenia despite anti-emetics, which resolved with dexamethasone 2 days after infusion. Other toxicities were =grade 2 and included: nausea, vomiting, transient transaminase elevation and asthenia at doses =0.225 mg/m2 and myelosuppression (neutropenia and leukopenia) at doses =3.0 mg/m2. No DLTs were seen in 6 pts at a dose of 3.0 mg/m2, establishing this dose as the RD. 3 more pts were added to complete the expanded cohort at this RD. To date, 2 pts have SD lasting >3 months. PK data indicate that drug AUC and Cmax increase proportionally across the dose range until doses =3.0 mg/m2, when a disproportionate increase in AUC and Cmax was seen. Z has a long half-life (=50 hours) and wide volume of distribution (Vss ∼500 l/m2). Conclusions: Z has a favorable safety profile. The MTD on this schedule has been established at 3.6 mg/m2. Alternative schedules are being evaluated to try and increase dose intensity.

No significant financial relationships to disclose.

Phase I dose escalation study of the anti-IGF-1R monoclonal antibody CP-751,871 in patients with refractory solid tumors

3586

Background: The insulin-like growth factor 1 receptor (IGF-IR), a tyrosine kinase, and its ligands (IGF-I & -2) are upregulated in many human tumors (e.g., breast, prostate, colon and non-small cell lung cancer) and enhance proliferative and prosurvival signaling. Inhibition of IGF-IR activation in tumor models suppresses tumor growth and increases tumor sensitivity to chemotherapy, supporting the development of agents targeting IGF-IR. CP-751,871 is a potent, highly specific, fully humanized, monoclonal antibody that inhibits IGF-IR autophosphorylation and induces receptor internalization. Methods: A Phase I dose escalation study was initiated to define the safety and tolerability, and to characterize the pharmacokinetic properties of CP-751,871 in patients with advanced solid tumors refractory to standard therapies. Results: Following informed consent and screening, a total of 24 patients with refractory solid tumors (e.g. colorectal, NSCLC, sarcoma and prostate cancer; 1–6 previous regimens) were enrolled. Patients received 3 to 20 mg/kg of CP-751,871 by IV infusion on Day 1 of 3-week cycles in four dose-escalation cohorts of 3 patients. No dose limiting toxicities were identified and the maximum feasible dose (MFD) cohort of 20 mg/kg was extended with 12 additional patients. No higher than grade 3 CTCAE v3.0 toxicities, attributed to study drug, have been so far reported. Grade 3 toxicities, all reported in patients dosed with 20 mg/kg of CP-751,871, are increased GGT (4%) and fatigue (4%). Grade 2 toxicities include: anorexia (7%), diarrhea (7%), increased GGT (4%), hyperglycemia (4%), fatigue (4%), increased urinary frequency (4%), nausea (4%), increased ALT (4%) and increased AST (4%). Pharmacokinetic analysis is currently ongoing. No objective responses were observed. At the MFD, patients received a median of 4 cycles (1–16). Three patients were stable for > 6 months and one patient, currently at cycle 16, remains on study. An additional cohort of 12 adrenocortical cancer patients is under evaluation. Conclusions: These data indicate that CP-751,871 is safe and well tolerated. Due to its good safety profile, CP-751,871 may constitute a suitable targeted agent to use in combination with approved therapies in multiple tumor types.

No significant financial relationships to disclose.

A phase I dose escalation study of BIBW 2992, an irreversible dual EGFR/HER2 receptor tyrosine kinase inhibitor, in patients with advanced solid tumours

3027

Background: BIBW 2992 is a novel, potent, orally bioavailable irreversible inhibitor of EGFR and HER2 receptor tyrosine kinases with IC50 values of 0.5 and 14 nM, respectively. Methods: Patients (pts) with advanced solid malignancies were enrolled. BIBW 2992 was given orally as a continuous once daily dose from 10 mg, doubled in successive cohorts until drug-related toxicity > grade 2, when escalation of no more than 50% was allowed. All pts had pharmacokinetic sampling and pre- and post-treatment skin biopsies. DNA sequencing of tumour cell EGFR and HER2 was performed on pts achieving objective response. Results: Twenty-six pts were treated (14 M/11 F). Median age: 53 (range: 30–68). ECOG PS 0/1: 7/19. 19 pts completing ≥ 28 days were evaluable for adverse events (AEs). Three dose-limiting toxicities (DLT) were seen. One pt with HER2+ breast cancer who had previously received trastuzumab and lapatinib treated at 30 mg of BIBW 2992 developed dyspnoea with radiological interstitial changes, which fully recovered on drug discontinuation. The 2 other DLTs were grade 3 acneiform skin rash, at doses of 40 mg and 50 mg daily. AEs resolved on drug discontinuation and the pts were dose reduced to 30 mg and 40 mg, respectively. The 50 mg dose level is being expanded. One pt treated at 50mg developed grade 3 diarrhoea in cycle 2 and was dose reduced to 40mg with resolution of the AE. Other AEs were mild (CTCAE v3 grade 1 or 2); nausea, diarrhoea, mucositis and fatigue. Two female pts with lung adenocarcinoma treated with 10 mg and 40 mg daily had confirmed partial responses (PR) and remain on study after 14 and 5 months, respectively. The pt with PR at 10mg has a complex heterozygous EGFR mutation in tumour cells, including a deletion and missense mutations of 4-amino acids (WT: KELREATSPKANKEILD; Patient: KEP—-SPRANKEILD) in the kinase domain, but a wildtype HER2 domain. One pt with cervical and one pt with colorectal cancer had stabilization of disease and tumour markers for 6 and 4 months, respectively. Conclusions: BIBW 2992 shows promising activity with skin rash as the main AE. Maintained PR seen in lung adenocarcinoma indicates effective mutated EGFR kinase modulation at the lowest evaluated dose level. Exploration of BIBW 2992 in Phase II is warranted.

[Table: see text]

Phase I dose-escalation study of ZK 304709, an oral multi-target tumor growth inhibitor (MTGI), administered for 14 days of a 28-day cycle

2076

Background: ZK 304709 is a novel oral MTGI that induces cell cycle arrest and inhibits tumour angiogenesis by selectively inhibiting Cyclin Dependent Kinases (CDKs) 1, 2, 4, 7 and 9,VEGF-R 1, 2 and 3, and PDGF-Rβ tyrosine kinases. Methods: Adult patients (pts) (WHO PS ≤2) with a histologically or cytologically confirmed solid tumor, resistant or refractory to conventional therapy, were eligible. ZK304709 was administered orally, once daily, at a 15 mg starting dose, on days 1–14 of a 28-day cycle, then escalated by 33–100% depending on incidence of drug-related toxicity ≥ grade (gr) 2 (CTC v2.0). At least 3 pts were treated at each dose level. The primary objective was to identify the maximum tolerated dose (MTD) and dose-limiting toxicities (DLT). Secondary objectives were to determine the tolerability, pharmacokinetic (PK) profile, and preliminary efficacy. Results: Interim results were available for 24 pts (19 M/5 F; median age 56.5) at 5 dose levels (15–120 mg qd). Pts received a median of 2 cycles (range 0–10). Common drug related toxicities were nausea, vomiting, and fatigue. Two DLT were observed: dizziness and hypertension. However, the MTD has yet to be established. The PK profile for dose levels up to 90 mg demonstrated rapid absorption and a dose-dependent increase of exposure and Cmax. Disease stabilization for ≥4 cycles has been observed. Conclusions: ZK 304709 was rapidly absorbed and has been tolerated on this schedule at up to 120 mg qd. The MTD has not been reached and enrolment is ongoing. These preliminary data demonstrate that oral delivery on this schedule of an agent that inhibits both cell cycle and angiogenesis is feasible.

[Table: see text]

Phase I trial involving the pharmacodynamic (PD) study of circulating tumour cells, of CP-751,871 (C), a monoclonal antibody against the insulin-like growth factor 1 receptor (IGF-1R), with docetaxel (D) in patients (p) with advanced cancer

3023

Background: C is the first specific, fully human, monoclonal antibody to target IGF-1R in clinical trials. It potently inhibits IGF-1R signaling, enhancing D antitumour activity. This trial investigated the safety, feasibility, dose limiting toxicity (DLT), PK and antitumor activity of D administered with C every 3 weeks. PD studies evaluated circulating tumor cell (CTC) IGF-1R expression and CTC counts pre- and post-treatment. Methods: The C doses tested were 0.1, 0.4, 0.8, 1.5, 3.0, 6.0 and 10 mg/kg in sequential cohorts of 3–6 p. D was fixed at 75mg/m2. P achieving disease control continued on C alone if experiencing D toxicity. Results: 21 p (20 male) have received 100 courses of C with D. 7 p received 8 or more courses of the combination. A further 21 courses of C alone have been administered. No toxicity has been attributed to C to date with the observed toxicities being attributable to D. Grade 3/4 toxicities were neutropenia (16/21 p) and neutropenic fever in 2/21 p. Grade 3 diarrhea was reported in 3 p, but this was easily controlled with antidiarrheals. Transient grade 1 hyperglycaemia was noted largely on day 1, following steroid premedication (14 p), but no significant C related hyperglycemia has been observed. An MTD has not been reached. Serial echocardiograms demonstrated no cardiac toxicity. Of 18 castration resistant prostate cancer (CRPC) p treated, 4 have had a confirmed PR, with 2 unconfirmed PR and 2 having disease stabilization for > 6 months (median number of courses: 10; range: 3–12). 5 p have maintained SD with C alone for 2–7 courses. CTC were detected in 16 of 18 p (CTC numbers ranged from 1 to 202 in 7.5ml of blood). IGF-1R expression was detected in 12 p. CTC IGF-1R was undetectable following treatment with C at doses above 3 mg/kg. Conclusions: This combination is safe and feasible with no toxicity attributed to C and encouraging antitumor activity in CRPC.

[Table: see text]

The use of parotid gland activity analysis in patients with gastro-esophageal reflux disease (GERD) and bulimia nervosa

PURPOSE

In patients with vomiting or reflux episodes, specific pathognomic signs may occur in the oral cavity. The significance of salivary gland activity in this type of disorder is a matter of dispute. The purpose of this study was to evaluate the parotid gland activity of patients with bulimic type eating disorder (group B) compared with patients affected by gastro-esophageal reflux (GERD) (group A) and healthy control subjects (group C).

MATERIAL AND METHODS

Parotid saliva was collected during the clinical examination by means of a modified Lashley cap under unstimulated and stimulated conditions and the flow rate was determined. The concentrations of Na+, K+, Ca+ (mmol/l) were determined by a colorimetric photometry method (Effox 5053, Eppendorf, Germany). Buffering capacity as a concentration of bicarbonates (mmol/l) and the pH, were measured by an automatic ion-selective electrode (ABL TM 520, Radiometer, Denmark). For the statistical analyses Kruskal Wallis one way ANOVA on Ranks with Dunn's method all pairwise multiple comparisons procedures were used with significance set at p < or = 0.05.

RESULTS

The results showed that the flow rates in the subjects in group A and B were significantly lower than in the controls. There were also significant differences in the concentration of sodium, with the lowest level in group B, and calcium where the highest level occurred in group A.

CONCLUSIONS

Since patients may deny frequent vomiting (bulimia) or are unaware of the reflux (GERD) the changes in electrolyte levels revealed by this study appear to be of use in the diagnosis of these conditions.

Dietetic guidelines: diet in secondary prevention of cardiovascular disease (first update, June 2003)

AIM

To update dietetic guidelines summarizing the systematic review evidence on dietary advice to prevent further events in people with existing cardiovascular disease (CVD) (secondary prevention).

METHODS

The Cochrane Library, MEDLINE and EMBASE were comprehensively searched to November 2002 for systematic reviews on aspects of diet and heart health. Reviews were included if they searched systematically for randomised controlled trials relating to diet and secondary prevention of CVD. Two members of the UK Heart Health and Thoracic Dietitians Group critically appraised each review. The quality and results of each review were discussed and summarized in a meeting of the whole group.

RESULTS

Providing evidence-based dietary information (including increasing omega-3 fat intake) to all people who have had a myocardial infarction will save more lives than concentrating dietary advice on just those in need of weight loss or lipid lowering. The practice of prioritizing dietetic time in secondary prevention to those with raised lipids is out of date since the advent of statin therapy. However, effective dietary advice for those with angina, stroke, peripheral vascular disease or heart failure is less clear.

CONCLUSION

There is good systematic review evidence that dietary advice to those with coronary heart disease can reduce mortality and morbidity as well as modify some risk factors. Dietary advice that does this most effectively should be prioritized.

Long-term donepezil treatment in 565 patients with Alzheimer's disease (AD2000): randomised double-blind trial

BACKGROUND

Cholinesterase inhibitors produce small improvements in cognitive and global assessments in Alzheimer's disease. We aimed to determine whether donepezil produces worthwhile improvements in disability, dependency, behavioural and psychological symptoms, carers' psychological wellbeing, or delay in institutionalisation. If so, which patients benefit, from what dose, and for how long?

METHODS

565 community-resident patients with mild to moderate Alzheimer's disease entered a 12-week run-in period in which they were randomly allocated donepezil (5 mg/day) or placebo. 486 who completed this period were rerandomised to either donepezil (5 or 10 mg/day) or placebo, with double-blind treatment continuing as long as judged appropriate. Primary endpoints were entry to institutional care and progression of disability, defined by loss of either two of four basic, or six of 11 instrumental, activities on the Bristol activities of daily living scale (BADLS). Outcome assessments were sought for all patients and analysed by logrank and multilevel models.

FINDINGS

Cognition averaged 0.8 MMSE (mini-mental state examination) points better (95% CI 0.5-1.2; p<0.0001) and functionality 1.0 BADLS points better (0.5-1.6; p<0.0001) with donepezil over the first 2 years. No significant benefits were seen with donepezil compared with placebo in institutionalisation (42% vs 44% at 3 years; p=0.4) or progression of disability (58% vs 59% at 3 years; p=0.4). The relative risk of entering institutional care in the donepezil group compared with placebo was 0.97 (95% CI 0.72-1.30; p=0.8); the relative risk of progression of disability or entering institutional care was 0.96 (95% CI 0.74-1.24; p=0.7). Similarly, no significant differences were seen between donepezil and placebo in behavioural and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events or deaths, or between 5 mg and 10 mg donepezil.

INTERPRETATION

Donepezil is not cost effective, with benefits below minimally relevant thresholds. More effective treatments than cholinesterase inhibitors are needed for Alzheimer's disease.

Development of a database of functional assessment measures related to work disability

The development of the Functional Assessment Measures Database is described. The database provides a method to organize and search for measures that are used to assess the functional abilities of people with medical impairments to determine work disability. The project identified 4,200 different measures that are used in the functional assessment of persons with disability across the life span, 812 of which are used to evaluate adults in terms of work disability. The database has 3,033 scales that are found in 633 measures. In the database, each measure is described and is linked to at least one functional assessment construct. The use of the database in the Social Security Administration Redesign Project is described. Other possible uses for the database are presented.

Involvement of 2p23 in pulmonary inflammatory pseudotumors

Pulmonary inflammatory pseudotumors (IP) are rare mesenchymal proliferations that have a polymorphic histology and an unpredictable biologic behavior. The histologic spectrum of IP has led to uncertainty as to whether this tumor has a reactive or neoplastic pathogenesis. Reports of extrapulmonary IP have identified clonal chromosomal aberrations involving 2p23 in the region of the ALK gene. Using fluorescence in situ hybridization with a probe flanking the ALK gene at 2p23 and immunostaining for the ALK gene product, we studied formalin-fixed, paraffin-embedded tissues of pulmonary IP and found a subset (33%) with 2p23 aberrations. We suggest that chromosomal rearrangements and ALK immunostaining may be helpful in the diagnosis of a group of pulmonary IP and should be investigated as a potential tool for predicting their future biologic behavior. An association with anaplastic large-cell lymphoma was also observed. HUM PATHOL 32:428-433.

Reexamining the prevalence of Chlamydia trachomatis infection among gay men with urethritis: implications for STD policy and HIV prevention activities

BACKGROUND

Evidence of an STD-HIV interaction and the availability of noninvasive urine-based screening tests have resulted in an increased focus on chlamydial infections in men.

GOAL

To evaluate the prevalence of chlamydial infections among men with urethritis at the San Francisco City Clinic (SFCC).

STUDY DESIGN

In 1997, male SFCC patients diagnosed with urethritis were tested for chlamydia using urine-based ligase chain reaction and for gonorrhea using urethral culture.

RESULTS

Gonorrhea was identified in 45% of men who have sex with men (MSM) versus 26% of men who have sex with women (MSW). Among men with gonorrhea, chlamydia coinfection was found among 15.2% of MSM and 8.4% of MSW. Among men with nongonococcal urethritis, 18% and 20% of MSM and MSW had chlamydial infection, respectively. Young age was associated with chlamydial infection in MSM.

CONCLUSION

After a period of low chlamydial infection rates in MSM during the pre-AIDS era, infection rates are increasing among this population. SFCC's revised clinical practice guidelines include chlamydia testing of MSM with urethritis.

Malignant meningioma with extension into the neck

One per cent of all brain tumours and twenty per cent of meningiomas eventually develop an extracranial extension. The least common site is the neck. We report a case of malignant meningioma with extension into the neck of a 39-year-old male.

Pig and goat blood as substitutes for sheep blood in blood-supplemented agar media

In many developing countries sheep and horse blood, the recommended blood supplements in bacteriological media, are not readily available, whereas pig and goat blood are. Therefore, this study examined the use of pig and goat blood as potential substitutes for sheep blood in blood-supplemented bacteriologic media commonly used in clinical microbiology laboratories. In general, the growth characteristics and colony morphologies of a wide range of aerobic and anaerobic bacteria and Candida albicans were similar on media containing pig, goat, and sheep blood, although differences were found. Enterococcus sp. uniformly produced alpha-hemolysis when incubated in CO(2), but in anaerobic conditions the hemolysis varied. In contrast, beta-hemolytic streptococci produced identical hemolytic reactions on all three media. Synergistic hemolysis was not observed on pig blood agar in the CAMP test nor on goat blood agar in the reverse CAMP test. The preparation of chocolate agar (heated) with pig blood required heating to a higher temperature than with sheep or goat blood to yield suitable growth of Haemophilus species. In general, we conclude that pig and goat blood are suitable alternatives to sheep blood for use in bacteriological media in settings where sheep and horse blood are not readily available.

Factors contributing to dehydration in nursing homes: inadequate staffing and lack of professional supervision

OBJECTIVE

To investigate the factors that influenced fluid intake among nursing home residents who were not eating well.

DESIGN

A prospective, descriptive, anthropological study.

SETTING

Two proprietary nursing homes with 105 and 138 beds, respectively.

PARTICIPANTS

Forty nursing home residents.

MEASUREMENTS

Participant observation, event analysis, bedside dysphagia screening, mental and functional status evaluation, assessment of level of family/advocate involvement, and chart review were used to collect data. Data were gathered on the amount of liquid served and consumed over a 3- day period. Daily fluid intake was compared with three established standards: Standard 1 (30 mL/kg body weight), Standard 2 (1 mL/kcal/energy consumed), and Standard 3 (100 mL/kg for the first 10 kg, 50 mL/kg for the next 10 kg, 15 mL/kg for the remaining kg).

RESULTS

The residents' mean fluid intake was inadequate; 39 of the 40 residents consumed less than 1500 mL/day. Using three established standards, we found that the fluid intake was inadequate for nearly all of the residents. The amount of fluid consumed with and between meals was low. Some residents took no fluids for extended periods of time, which resulted in their fluid intake being erratic and inadequate even when it was resumed. Clinical (undiagnosed dysphagia, cognitive and functional impairment, lack of pain management), sociocultural (lack of social support, inability to speak English, and lack of attention to individual beverage preferences), and institutional factors (an inadequate number of knowledgeable staff and lack of supervision of certified nursing assistants by professional staff) contributed to low fluid intake. During the data collection, 25 of the 40 residents had illnesses/conditions that may have been related to dehydration.

CONCLUSIONS

When staffing is inadequate and supervision is poor, residents with moderate to severe dysphagia, severe cognitive and functional impairment, aphasia or inability to speak English, and a lack of family or friends to assist them at mealtime are at great risk for dehydration. Adequate fluid intake can be achieved by simple interventions such as offering residents preferred liquids systematically and by having an adequate number of supervised staff help them to drink while properly positioned.

Duration of intravenous therapy and hospital stay according to choice of empirical antimicrobial treatment for community-acquired respiratory infection

A review of patients admitted to medical wards with respiratory infection was undertaken to look for differences in duration of intravenous (IV) therapy and length of patient stay based on the class of IV antimicrobial used in treatment. Data was analysed from 231 patients with community-acquired respiratory infection who were treated empirically for at least 24 h with either an IV cephalosporin (146 patients) or an IV penicillin or macrolide (85 patients). The severity of illness and indication for IV treatment was similar in each group. Those treated with a cephalosporin received IV therapy for a significantly longer period (mean = 4.44 days, SD = 2.6) than those given a penicillin or macrolide (mean = 3.3 days, SD = 1.8): P < 0.001. Patient stay was significantly longer in the cephalosporin group (mean = 11.6 days, SD = 10.4) than the penicillin/macrolide group (mean = 9.4 days, SD = 6.3): P = 0.04. These differences are most readily accounted for by the absence from the hospital formulary of a third generation oral cephalosporin, a drug that might be regarded as an obvious form of follow-on therapy in patients treated empirically with an injectable cephalosporin.

Commissioning health services research: an iterative method

The standard linear method of commissioning research involves many stages, some lengthy. While assessment criteria are usually explicit, their weighting and interaction are not. Output is assessed on completion. This method is suitable where the research question is clear-cut. However, it has drawbacks when the research question and the form and scope of the research are not clear at the outset, as is often the case with research on the delivery and organisation of services. Also, it does not encourage potential users of the research to develop a sense of ownership. An alternative method is proposed by which the scope, form and content of research are not specified in advance but are developed iteratively. A programme director, advised by a group of potential users and research commissioners, has devolved authority to commit funding for the stages of the work as it unfolds, predicated on evolving need. There are foreseeable but avoidable risks of the group over-identifying with the researchers, of research management becoming cumbersome, and of unproductive friction between research groups when they are required to work together. The iterative method, being new and untried, is itself an organisational change requiring evaluation. However, from our local experience, it provides for productive dialogue between research commissioners, researchers and potential users.

The effect of intravenous-to-oral switch guidelines on the use of parenteral antimicrobials in medical wards

The effect of an intravenous (i.v.)-to-oral switch policy on antibiotic prescribing in general medical wards was examined. Three audits, each of 2 months' duration, were carried out to examine the duration of i.v. therapy and length of patient stay. The first audit (S1) was performed before the introduction of switch guidelines, the second (S2) after guidelines had been placed in patient case-notes and the third (S3) after the guidelines had been introduced into the drug charts. The duration of i.v. therapy was significantly shorter in the S3 group (mean = 3.7 days) than in the S2 or S1 groups (mean 4.4 and 4.35 days, respectively) (P < 0.05). There was no significant difference in the length of patient stay between the three audit periods but the stay was significantly shorter in 81 switched patients (mean duration = 8.9 days) than in matched controls (mean duration = 12.6 days) (P = 0.01). Fewer patients with respiratory infection were treated for > 24 h with i.v. antimicrobials in the S3 audit period (75/549) than in the S2 (85/372) and S1 audits (83/326) (P < 0.01). The introduction of switch guidelines to drug charts reduces the length of i.v. therapy. Switched patients spend less time in hospital than their matched controls.

Mutation of the PTEN tumor suppressor gene is not a feature of ovarian cancers

OBJECTIVE

The PTEN tumor suppressor gene on chromosome 10q23 undergoes inactivating mutations in several types of malignancies including glioblastomas and prostate and endometrial carcinomas. The aim of this study was to determine if mutation of the PTEN tumor suppressor gene is a feature of sporadic or BRCA1-associated ovarian carcinomas.

METHODS

Genomic deoxyribonucleic acid was extracted from 11 ovarian cancer cell lines and 50 frozen ovarian cancers, including 4 cases that developed in women with germline mutations in the BRCA1 breast/ovarian cancer susceptibility gene. The polymerase chain reaction was used to amplify each of the nine exons and intronic splice sites of the PTEN gene. These products were then screened for mutations using single strand conformation polymorphism analysis. Variant bands were further evaluated using automated DNA sequencing.

RESULTS

A previously unreported silent polymorphism at codon 240 (TAT to TAC) in exon 7 was noted in one of the primary ovarian carcinomas. Mutations in the PTEN gene were not found in any of the 50 primary ovarian cancers or 11 immortalized ovarian cancer cell lines.

CONCLUSION

Alteration of the PTEN tumor suppressor gene does not appear to be a feature of sporadic or BRCA1-associated ovarian cancers.

Mutation of the PTEN tumor suppressor gene in endometrial hyperplasias

Mutation and deletion of the PTEN tumor suppressor gene occurs in about 40% of endometrial carcinomas. The purpose of this study was to determine whether PTEN mutations also are present in endometrial hyperplasias, which are premalignant precursors of invasive endometrial adenocarcinomas. Genomic DNA from 51 endometrial hyperplasias was extracted from paraffin blocks, and PCR was used to amplify the nine exons of the PTEN gene. These products were screened using single-strand conformation analysis, and variant bands were sequenced. Somatic mutations in the PTEN gene were seen in 10 of 51 cases (20%), and two mutations were found in one case. An identical 4-bp deletion in exon 8 was seen in three cases, and 8 of 11 PTEN mutations predicted truncated protein products. There was no higher frequency of PTEN mutations in endometrial hyperplasias with atypia (6 of 32; 19%) relative to those without atypia (4 of 19; 21%). These data suggest that inactivation of the PTEN tumor suppressor gene is an early event in the development of some endometrial cancers.

Comparison of virus culture and the polymerase chain reaction for diagnosis of mucocutaneous herpes simplex virus infection

BACKGROUND AND OBJECTIVES

The diagnosis of mucocutaneous herpes simplex virus (HSV) is hampered by suboptimal sensitivity of virus culture and atypical clinical morphology.

GOALS

To compare the diagnostic usefulness of the polymerase chain reaction (PCR) and virus culture.

STUDY DESIGN

Consecutive samples from 246 patients at an urban sexually transmitted diseases clinic were tested for HSV by both PCR and virus culture.

RESULTS

Only 59% of HSV-positive samples were correctly diagnosed by the clinician; 11% had an atypical appearance. HSV-positive lesions were more often vesiculoulcerative or crusted than HSV-negative lesions, and of shorter median duration. Thirty-one samples were PCR positive and virus culture negative; these were often from crusted or older lesions. However, PCR was negative in 27 instances in which HSV was diagnosed clinically, of which 2 were vesicular and 15 ulcerative.

CONCLUSIONS

HSV PCR is more rapid and sensitive than virus culture for diagnosis of mucocutaneous lesions. The data suggesting that PCR may be suboptimally sensitive need to be further investigated.

Thyroid papillary carcinoma arising in a branchial cleft cyst

We describe the clinico-pathological features and discuss the possible pathogenetic mechanism of thyroid papillary carcinoma arising in a branchial cleft cyst. This has been described only once previously in the literature.

Is urine leukocyte esterase test a useful screening method to predict Chlamydia trachomatis infection in women?

We evaluated the use of the leukocyte esterase test (LET) on first-catch urine specimens from women as a screening test to predict infection with Chlamydia trachomatis. For diagnosis, we used Abbott's ligase chain reaction (LCR) on urine specimens and isolation by tissue culture (TC) on cervical brushes. Of 4,053 women attending sexually transmitted disease and family planning clinics, 4.3% (n = 174) were positive by TC and 5.9% (n = 239) were positive by LCR. When LET was compared to TC, the sensitivity, specificity, positive predictive value, and negative predictive value were 54.0, 67.0, 6.8, and 97.0%, respectively. The corresponding performance of LET versus LCR was 53.1, 67.3, 10.1, and 95.8%. Almost half of the laboratory-confirmed chlamydial infections were negative by LET. The low specificity probably reflects multiple causes of pyuria in women and results in a low positive predictive value. LET is neither sensitive nor specific as a predictor of chlamydial infection and cannot be recommended for use as a screening test for C. trachomatis with first-catch urine samples from females from low- or moderate-prevalence populations.

Noninvasive tests for diagnosis of Chlamydia trachomatis infection: application of ligase chain reaction to first-catch urine specimens of women

Ligase chain reaction (LCR) to diagnose Chlamydia trachomatis infection was evaluated using first-catch urine (FCU) specimens from 4053 women. Results were compared with those of cell culture (TC) isolation from cervix (all) and urethra (2812 women). The reference standard was TC positivity or positive LCR for chlamydial plasmid DNA confirmed by direct fluorescent antibody test or LCR for another chlamydial gene. Compared with cervical culture, LCR was 88.2% sensitive and 100% specific. Adding urethral culture increased TC sensitivity from 67.1% to 74% and reduced LCR sensitivity to 85.9%. The prevalence of chlamydial infection was 5% (142/2812) by the dual culture system and 5.9% (165/2812) by LCR on FCU specimens. LCR on FCU specimens is highly sensitive and specific for diagnosing chlamydial infection. It is more sensitive than TC and may well present public health authorities with a useful noninvasive screening test for chlamydial infection in asymptomatic women.

Sex differences in the psychiatric manifestations of Alzheimer's disease

OBJECTIVE

To test the null hypothesis, ie, that there are no gender differences in psychiatric problems manifest in patients with Alzheimer's disease.

DESIGN

Survey.

SETTING

Patients living in the community and evaluated at Alzheimer's disease and geriatric outpatient programs.

PATIENTS

Three hundred twenty-eight women and 186 men clinically diagnosed with Alzheimer's disease using NINCDS/ADRDA or DSM-III-R criteria.

MEASUREMENTS

Psychiatric signs and symptoms recorded following a psychiatric interview, including the Hamilton Depression Rating Scale.

RESULTS

Approximately two-thirds of both men and women had psychiatric problems, but women had significantly more multiple symptoms. When pairs of symptoms were analyzed for independence, agitation was only significantly associated with paranoia in men, whereas in women agitation was significantly associated with most other psychiatric problems.

CONCLUSION

The higher prevalence of multiple psychiatric problems in women may be due to many factors, including sociodemographic influences, physician bias, and/or other differences between men and women. The finding of a different pattern of association of symptoms with agitation in men and women deserves replication.

Erythropoietin-specific cell cycle progression in erythroid subclones of the interleukin-3-dependent cell line 32D

Recently, a variety of growth factor-dependent subclones of the murine interleukin-3 (IL-3)-dependent cell line 32D have been isolated. These subclones include those dependent for growth on erythropoietin (Epo) (32D Epo), granulocyte-macrophage colony-stimulating factor (GM-CSF) (32D GM), or granulocyte colony-stimulating factor (G-CSF) (32D G). 32D Epo1.1 is a revertant of 32D Epo and is capable of growing in IL-3. These cell lines express the differentiation program appropriate to the specific growth factor and depend on the growth factors not only for proliferation but also for survival. To determine how the signal for proliferation is triggered by various growth factors, we examined the DNA histograms and the expression of cell cycle-specific genes in the different cell lines. The cell cycle-specific genes analyzed were myc (early G1), myb (late G1), and the structural genes for the calcium-binding protein 2A9 (middle G1) and histone H3 (G1-S boundary). The DNA histogram analysis of cells in the logarithmic phase of growth showed that approximately 40% of 32D, 32D GM, 32D G, and 32D Epo1.1 (growing in IL-3) were cells with a 2N DNA content (and therefore in G0/G1), and another 40% have a DNA content intermediate between 2N and 4N (in S phase). In contrast, 32D Epo and 32D Epo1.1 (growing in Epo) had fewer cells in the G0/G1 phase of the cell cycle compared with the number of cells that were in the S phase (19% to 31% v 69% to 78%, respectively). Because all the cell lines have comparable doubling times (15 to 18 hours), the cell distribution among the phases of the cell cycle is proportional to the length of the phase. Therefore, cells growing in IL-3 (32D and 32D Epo1.1), GM-CSF (32D GM), or G-CSF (32D G) progress along the cycle in a manner typical of previously reported nontransformed cell lines. In contrast, cells growing in Epo (32D Epo or 32D Epo1.1) spend relatively less time in G0/G1 and correspondingly more time in S. These data were confirmed by the analysis of the tritiated thymidine (3H-TdR) suicide rate and of the expression of cell cycle-specific genes. The 32D and 32D Epo1.1 cells growing in IL-3 had a suicide rate of congruent to 50%, whereas the suicide rate of 32D Epo and 32D Epo1.1 growing in Epo was higher than 75%.(ABSTRACT TRUNCATED AT 400 WORDS)

Variability in growth of Neisseria polysaccharea on colistin-containing selective media for Neisseria spp

In a prospective survey of 773 healthy schoolchildren in southern Alberta, Canada, Neisseria polysaccharea was isolated from the pharynxes of only 4 (0.5%) subjects, whereas Neisseria lactamica and Neisseria meningitidis were isolated from 110 (14%) and 15 (2%) children, respectively. These strains of N. polysaccharea, together with three other sporadic isolates from Alberta, Canada, were compared with the type strain from France and strains from Spain and Germany. All strains were phenotypically identical, except that the Canadian and German strains, for which the colistin MICs were 1 mg/liter, failed to grow on Thayer-Martin medium (TMM), whereas the type strain and the Spanish strains, for which the colistin MICs were greater than 7.5 mg/liter, were not inhibited. Multilocus enzyme electrophoresis indicated that six distinct electrophoretic types were present among the seven Canadian strains. Our results show that growth on gonococcal selective media which contain colistin is a variable feature of this taxon.

Serologic confirmation of Neisseria gonorrhoeae by monoclonal antibody-based coagglutination procedures

Two commercially available monoclonal antibody coagglutination tests, Phadebact Monoclonal GC OMNI Test (PMGOT; Pharmacia Diagnostics AB, Uppsala, Sweden) and GonoGen (GG; New Horizons Diagnostics, Columbia, Md.), for the confirmation of Neisseria gonorrhoeae were evaluated. The sensitivities of PMGOT and GG were 99.2 and 98.7% and the specificities were 91.5 and 100.0%, respectively. False-positive reactions were observed with Neisseria lactamica and Neisseria meningitidis in PMGOT. A modification of the procedure recommended by the manufacturer for PMGOT was done by substituting Todd-Hewitt broth for 0.9% saline to prepare the suspension of the test organism. This eliminated technical difficulties with the test and resulted in a sensitivity and a specificity of 99.3 and 100.0%, respectively. Advantages offered by the modified PMGOT over GG were the better predictive value of the negative test, the lower cost, the ease of reading of the test, and the lack of noninterpretable results.

DNA ploidy in thin melanoma

DNA ploidy in benign nevi (BN), thin non-metastasizing melanomas (TNM) and thin metastasizing melanomas (TMM) was investigated using an image analyser to determine whether characteristics such as nuclear area (NA) and nuclear integrated optical density (IOD) could be used to distinguish between these lesions. NA measurements showed significant differences between samples of nevus cells and melanoma cells and nuclear IOD differences were significant between TNM and TMM samples. Differences in NA and nuclear IOD were detected across the three groups (BN, TNM and TMM) but the large variability within samples and within groups indicate further studies would be necessary to determine the usefulness of these results in terms of the rate of correct group classification of a single sample for diagnostic purposes.