P16 ATRIAL FIBRILLATION INCIDENCE IN SARS–COV–2 INFECTED PATIENTS: PREDICTORS AND RELATIONSHIP WITH IN–HOSPITAL MORTALITY

Background

Among the different CardioVascular (CV) manifestation of the COronaVIrus–related Disease (COVID) particular attention has been paid to arrhythmia and particularly to Atrial fibrillation (AF). The aim of our study was to assess the incidence of AF episodes in patients hospitalized for COVID and to evaluate its predictors and its relationship with in–hospital all–cause mortality.

Methods

We enrolled 3435 cases of SARS–CoV2 infection admitted in four hospitals in Northern Italy. We collected data on clinical history, vital signs, Intensive Care Unit (ICU) admission, laboratory tests and pharmacological treatment. AF incident and all–cause in–hospital mortality were considered as outcomes.

Results

145 (4.2%) patients develop AF during hospitalization, with a median time of 3 days (IQR: 0, 11.5) from admission. Incident AF patients were older and had lower eGFR, lower platelet and lymphocytes count and higher C–Reactive Protein (CRP), were admitted more frequently to ICU and more frequently died compared to subjects that didn’t present AF. At the Cox regression model significant determinants of incident AF were older age (HR 1.070; 95% CI: 1.048, 1.092), history of AF (HR 2.800; 95% CI: 1.465, 5.351), ischemic heart disease (HR 0.324; 95% CI: 0.130, 0.811) and ICU admission (HR 8.030; 95% CI: 4.511, 14.292). Incident AF was a predictor of all–cause mortality (HR 1.679; 95% CI: 1.170, 2.410), together with age (HR 1.053; 95% CI: 1.042, 1.065), dementia (HR 1.553; 95% CI 1.151, 2.095), platelet count (HR 0.997; 95% CI: 0.996, 0.999) higher CRP (HR 1.004; 95% CI: 1.003, 1.005) and eGFR (HR: 0.991; 95% CI: 0.986, 0.996)

Conclusion

AF present as the main arrhythmia in COVID–19 patients and its development during the hospitalization strongly relates with in–hospital mortality.

Work and Breast Cancer: Recommendations to Address Research Needs

A review of case-control, cohort, and meta-analytic studies on breast cancer, occupation, and work-related exposures from 2002 to 2017 revealed significant methodological limitations in the current literature. As part of our review, we tabulated the demographic and life history data, breast cancer risk factors, occupational history, and exposure estimates collected and analyzed in each study. Opportunities exist for future research to explore occupation and breast cancer more rigorously and with greater nuance by gathering specific data on age at diagnosis, menopausal status, tumor characteristics, demographics, breast cancer risk factors, and occupational histories, work roles and settings, and exposures. Inclusion of workers in the planning and implementation of research on their occupational risks and exposures is one effective way to refine research questions and ensure research is relevant to workers' needs and concerns.

Work and Female Breast Cancer: The State of the Evidence, 2002-2017

The authors undertook a scoping review to assess the literature from 2002 to 2017 on the relationship between occupation and female breast cancer. Case-control, cohort, and meta-analytic studies suggest that women working as flight attendants, in medical professions, some production positions, sales and retail, and scientific technical staff are likely to have elevated risk of breast cancer. In addition, occupational exposures to night-shift work, ionizing radiation, some chemicals, job stress, and sedentary work may increase risk of breast cancer. Occupational physical activity appears to decrease risk. Workplace exposures to passive smoke and occupational exposure to nonionizing radiation do not appear to affect breast cancer risk. Some studies of occupational categories and workplace exposures indicate that risk may be modified by duration of exposure, timing of exposure, dose, hormone-receptor subtypes, and menopausal status at diagnosis. The compelling data from this review reveal a substantial need for further research on occupation and breast cancer.

State of the evidence 2017: an update on the connection between breast cancer and the environment

BACKGROUND

In this review, we examine the continually expanding and increasingly compelling data linking radiation and various chemicals in our environment to the current high incidence of breast cancer. Singly and in combination, these toxicants may have contributed significantly to the increasing rates of breast cancer observed over the past several decades. Exposures early in development from gestation through adolescence and early adulthood are particularly of concern as they re-shape the program of genetic, epigenetic and physiological processes in the developing mammary system, leading to an increased risk for developing breast cancer. In the 8 years since we last published a comprehensive review of the relevant literature, hundreds of new papers have appeared supporting this link, and in this update, the evidence on this topic is more extensive and of better quality than that previously available.

CONCLUSION

Increasing evidence from epidemiological studies, as well as a better understanding of mechanisms linking toxicants with development of breast cancer, all reinforce the conclusion that exposures to these substances - many of which are found in common, everyday products and byproducts - may lead to increased risk of developing breast cancer. Moving forward, attention to methodological limitations, especially in relevant epidemiological and animal models, will need to be addressed to allow clearer and more direct connections to be evaluated.

Hypovitaminosis D is associated with negative outcome in dogs with protein losing enteropathy: a retrospective study of 43 cases

Background

Hypovitaminosis D has previously been shown to be prevalent amongst dogs with protein losing enteropathy (PLE).

The hypothesis of this study was that Low 25-hydroxyvitamin D (25(OH) D) serum concentrations could be a risk factor for negative outcome in dogs with PLE.

Forty-three dogs diagnosed with PLE (2005–2014) and which serum Vitamin D serum concentrations were collected and archived at −80 Degrees C were analyzed.

Post-diagnostic communication with referring veterinarians was made to determine outcome of PLE dogss: Dogs which died due to PLE within 4 months after diagnosis (negative outcome group, n = 22) and dogs alive or which died due to another disease at the end point of the study (1 year after diagnosis, good outcome group, n = 21). Serum samples taken at the time of diagnosis were analysed for ionized calcium (iCa) concentrations and serum 25(OH) D concentration.

Results

Clinical (CCECAI) scores, age at PLE diagnosis, and iCa concentrations were not significantly different between dog groups. A significantly greater (p < 0.001) number of PLE dogs treated with hydrolyzed or elimination diet alone showed good outcome as compared to the PLE negative outcome group. Median serum 25(OH) D concentration was significantly (p = 0.017) lower in dogs with negative outcome versus PLE dogs with good outcome. Using logistic regression analysis, 25(OH) D serum concentration was shown to be a statistically significant factor for outcome determination. Cox regression analysis yielded a hazard ratio of 0.974 (95% CI 0.949, 0.999) per each one nmol/l increase in serum 25(OH) D concentration.

Conclusions

Low serum 25(OH) D concentration in PLE dogs was significantly associated with poor outcome. Further studies are required to investigate the clinical efficacy of Vitamin D (cholecalciferol) as a potential therapeutic agent for dogs with PLE.

Environmental exposures, breast development and cancer risk: Through the looking glass of breast cancer prevention

This review summarizes the report entitled: Breast Cancer and the Environment: Prioritizing Prevention, highlights research gaps and the importance of focusing on early life exposures for breast development and breast cancer risk.

Ascaris lumbricoides infection in urban schoolchildren: specific IgE and IL-10 production

BACKGROUND

Helminth infections and allergies are diseases with intense Th2 lymphocytes participation and characterised by a high IgE and Interleukin-(IL) IL-4, IL-5 production and eosinophilia. However, helminths also induce IL-10 production, which may alter the outcome of allergic diseases in infected patients.

OBJECTIVE

This experimental study analyses the relationship between IL-10 production by cell culture from geohelminth infected and non-infected children and specific IgE to Ascaris lumbricoides (Asc) or Blomia tropicalis (BT).

METHODS

IL-10 content in supernatant from peripheral blood mononuclear cell culture from nine helminth infected and eleven non-infected patients was determined by ELISA after in vitro stimulation with Asc or BT extracts.

RESULTS

A positive association was observed between total IgE levels and anti-Ascaris and anti-Blomia tropicalis specific IgE, independent of infection status. For both helminth-infected and non-infected groups, there was no difference in IL-10 production in response to Asc extract, even though anti-Ascaris IgE levels were higher in the latter group. In response to BT stimulus, a lower production of IL-10 by the geohelminth-infected group was observed, but with no relationship between IL-10 production and specific IgE to BT.

CONCLUSION

The results suggest that anti-Ascaris IgE in non-infected patients may be associated to a resistance to parasites. Levels of specific IgE to parasite antigens or B. tropicalis allergen were not impaired by IL-10 production in children from an urban area in which geohelminthiasis is endemic.

Food packaging and bisphenol A and bis(2-ethyhexyl) phthalate exposure: findings from a dietary intervention

BACKGROUND

Bisphenol A (BPA) and bis(2-ethylhexyl) phthalate (DEHP) are high-production-volume chemicals used in plastics and resins for food packaging. They have been associated with endocrine disruption in animals and in some human studies. Human exposure sources have been estimated, but the relative contribution of dietary exposure to total intake has not been studied empirically.

OBJECTIVES

To evaluate the contribution of food packaging to exposure, we measured urinary BPA and phthalate metabolites before, during, and after a "fresh foods" dietary intervention.

METHODS

We selected 20 participants in five families based on self-reported use of canned and packaged foods. Participants ate their usual diet, followed by 3 days of "fresh foods" that were not canned or packaged in plastic, and then returned to their usual diet. We collected evening urine samples over 8 days in January 2010 and composited them into preintervention, during intervention, and postintervention samples. We used mixed-effects models for repeated measures and Wilcoxon signed-rank tests to assess change in urinary levels across time.

RESULTS

Urine levels of BPA and DEHP metabolites decreased significantly during the fresh foods intervention [e.g., BPA geometric mean (GM), 3.7 ng/mL preintervention vs. 1.2 ng/mL during intervention; mono-(2-ethyl-5-hydroxy hexyl) phthalate GM, 57 ng/mL vs. 25 ng/mL]. The intervention reduced GM concentrations of BPA by 66% and DEHP metabolites by 53-56%. Maxima were reduced by 76% for BPA and 93-96% for DEHP metabolites.

CONCLUSIONS

BPA and DEHP exposures were substantially reduced when participants' diets were restricted to food with limited packaging.

State of the evidence: the connection between breast cancer and the environment

A substantial body of scientific evidence indicates that exposures to common chemicals and radiation, alone and in combination, are contributing to the increase in breast cancer incidence observed over the past several decades. Key recurring themes in the growing scientific literature on breast cancer and environmental risk factors are: (a) the importance of understanding the effects of mixtures and interactions between various chemicals, radiation and other risk factors for the disease; and (b) the increasing evidence that timing of exposures matters, with exposures during early periods of development being particularly critical to later risk of developing breast cancer. A review of the scientific literature shows several classes of environmental factors have been implicated in an increased risk for breast cancer, including hormones and endocrine-disrupting compounds, organic chemicals and by-products of industrial and vehicular combustion, and both ionizing and non-ionizing radiation.

Policy and research recommendations emerging from the scientific evidence connecting environmental factors and breast cancer

A substantial body of evidence links environmental exposures to increases in breast cancer incidence over the past decades. State and federal legislative initiatives that could help prevent breast cancer include: federal standards to achieve consistency in radiation-emitting medical and dental equipment; improved state quality assurance standards for radiation-emitting equipment; federal and state exposure limits for electromagnetic radiation; an overhaul of the federal Toxic Substances Control Act to reduce unsafe chemical exposures; strengthened premarket health and safety testing and regulation of pesticides; a federal ban on the manufacture, distribution and sale of consumer products containing bisphenol A and phthalates; and strengthened oversight and regulation of the cosmetics industry. We recommend public and private investment in research on low dose exposures, mixtures, and the timing of chemical exposures, as well as the development of health tracking and biomonitoring programs designed to link data from pollution surveillance systems with disease registries.

Chimeric RNA-DNA molecular beacon assay for ribonuclease H activity

Current methods to detect and assay ribonuclease H (RNase H) activity are indirect and time-consuming. Here we introduce a direct and sensitive method, based on the fluorescence quenching mechanism of molecular beacons, to assay RNA cleavage in RNA:DNA hybrids. An RNA-DNA chimeric beacon assay for RNase H enzymatic activity was developed. The substrate is a single-stranded RNA-DNA chimeric oligonucleotide labeled with a 5'-fluorescein and a 3'-DABCYL. The fluorophore (fluorescein) of the probe is held in close proximity to the quencher (DABCYL) by the RNA:DNA stem-loop structure. When the RNA sequence of the RNA:DNA hybrid stem is cleaved, the fluorophore is separated from the quencher and fluorescence can be detected as a function of time. Chimeric beacons with different stem lengths and sequences have been surveyed for this assay with E. coli RNase H. We found that the beacon kinetic parameters are in qualitative agreement with previously reported values using more cumbersome assays. This method permits real-time detection of RNase H activity and a convenient approach to RNase H kinetic and mechanistic study.

A phase I study of bizelesin, a highly potent and selective DNA-interactive agent, in patients with advanced solid malignancies

BACKGROUND

The aim of this study was to assess the feasibility of administering bizelesin, a cyclopropylpyrroloindole with extraordinarily high potency as a bifunctional DNA-damaging agent and selectivity for specific AT-rich DNA sequences, as a single i.v. bolus injection every 4 weeks in patients with advanced solid malignancies. The study also sought to determine the maximum tolerated dose (MTD) of bizelesin, characterize its pharmacokinetic behavior, and seek preliminary evidence of anticancer activity.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with escalating doses of bizelesin as an i.v. bolus injection every 4 weeks. The selection of the specific starting dose, 0.1 micro g/m(2), which was equivalent to one-tenth the toxic dose low in dogs, factored in large interspecies differences in myelotoxicity as gauged using an ex vivo hematopoietic colony-forming assay. Due to concerns about the high potency of bizelesin and the large interspecies differences in toxicity, a conservative dose-escalation scheme was used for dose-level assignment to determine the MTD levels for both minimally pretreated (MP) and heavily pretreated (HP) patients. A variety of analytical assays were assessed to reliably measure bizelesin concentrations in plasma.

RESULTS

Sixty-two patients were treated with 185 courses of bizelesin at eight dose levels ranging from 0.1 to 1.5 micro g/m(2). Myelosuppression, principally neutropenia that was always brief, was the most common toxicity observed. Thrombocytopenia and anemia were uncommon and severe non-hematological effects were not observed. Severe neutropenia alone and/or associated with fever was consistently experienced by HP and MP patients at doses exceeding 0.71 and 1.26 micro g/m(2), respectively. These doses also resulted in functionally non-cumulative myelosuppression as repetitive treatment was well-tolerated. A 40% reduction in measurable disease lasting 24 months was noted in a patient with advanced ovarian carcinoma. Various analytical methods were evaluated but none demonstrated the requisite sensitivity to reliably quantify the minute plasma concentrations of bizelesin and metabolites resulting from administering microgram quantities of drug.

CONCLUSIONS

The highly potent and unique cytotoxic agent, bizelesin can be feasibly administered to patients with advanced solid malignancies. The recommended doses for phase II studies of bizelesin as a bolus i.v. injection every 4 weeks are 0.71 and 1.26 micro g/m(2) in HP and MP patients, respectively. The characteristics of the myelosuppression, the paucity of severe toxicities with repetitive treatment, the preliminary antitumor activity noted, and, above all, its unique mechanism of action as a selective DNA-damaging agent and high potency, warrant disease-directed evaluations of bizelesin in solid and hematopoietic malignancies and consideration of its use as a cytotoxic in targeted conjugated therapeutics.

Phase I and pharmacologic study of OSI-774, an epidermal growth factor receptor tyrosine kinase inhibitor, in patients with advanced solid malignancies

PURPOSE

To assess the feasibility of administering OSI-774, to recommend a dose on a protracted, continuous daily schedule, to characterize its pharmacokinetic behavior, and to acquire preliminary evidence of anticancer activity.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with escalating doses of OSI-774 in three study parts (A to C) to evaluate progressively longer treatment intervals. Part A patients received OSI-774 25 to 100 mg once daily, for 3 days each week, for 3 weeks every 4 weeks. Part B patients received OSI-774 doses ranging from 50 to 200 mg given once daily for 3 weeks every 4 weeks to establish the maximum tolerated dose (MTD). In part C, patients received this MTD on a continuous, uninterrupted schedule. The pharmacokinetics of OSI-774 and its O-demethylated metabolite, OSI-420, were characterized.

RESULTS

Forty patients received a total of 123 28-day courses of OSI-774. No severe toxicities precluded dose escalation of OSI-774 from 25 to 100 mg/d in part A. In part B, the incidence of severe diarrhea and/or cutaneous toxicity was unacceptably high at OSI-774 doses exceeding 150 mg/d. Uninterrupted, daily administration of OSI-774 150 mg/d represented the MTD on a protracted daily schedule. The pharmacokinetics of OSI-774 were dose independent; repetitive daily treatment did not result in drug accumulation (at 150 mg/d [average]: minimum steady-state plasma concentration, 1.20 +/- 0.62 microg/mL; clearance rate, 6.33 +/- 6.41 L/h; elimination half-life, 24.4 +/- 14.6 hours; volume of distribution, 136. 4 +/- 93.1 L; area under the plasma concentration-time curve for OSI-420 relative to OSI-774, 0.12 +/- 0.12 microg/h/mL).

CONCLUSION

The recommended dose for disease-directed studies of OSI-774 administered orally on a daily, continuous, uninterrupted schedule is 150 mg/d. OSI-774 was well tolerated, and several patients with epidermoid malignancies demonstrated either antitumor activity or relatively long periods of stable disease. The precise contribution of OSI-774 to these effects is not known.

Phase I and pharmacokinetic study of NSC 655649, a rebeccamycin analog with topoisomerase inhibitory properties

PURPOSE

To assess the feasibility of administering NSC 655649, a water-soluble, rebeccamycin analog with topoisomerase inhibitory properties, as a brief intravenous (IV) infusion once every 3 weeks and to determine the maximum-tolerated dose (MTD) of NSC 655649, characterize its pharmacokinetic behavior, and seek preliminary evidence of antitumor activity.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with escalating doses of NSC 655649 administered over 30 to 60 minutes IV once every 3 weeks. An accelerated dose-escalation method was used to guide dose escalation. After three patients were treated at the first dose level, doses were escalated in increments that ranged up to 150% using single patient cohorts until moderate toxicity was observed, when a more conservative dose-escalation scheme was invoked. MTD was defined as the highest dose level at which the incidence of dose-limiting toxicity did not exceed 20%. MTD was determined for both minimally pretreated (MP) and heavily pretreated (HP) patients. Plasma and urine were sampled to characterize the pharmacokinetic and excretory behavior of NSC 655649.

RESULTS

Forty-five patients were treated with 130 courses of NSC 655649 at doses ranging from 20 mg/m(2) to 744 mg/m(2). Myelosuppression was the principal toxicity. Severe neutropenia, which was often associated with thrombocytopenia, was unacceptably high in HP and MP patients treated at 572 mg/m(2) and 744 mg/m(2), respectively. Nausea, vomiting, and diarrhea were common but rarely severe. The pharmacokinetics of NSC 655649 were dose dependent and fit a three-compartment model. The clearance and terminal elimination half-lives for NSC 655649 averaged 7.57 (SD = 4.2) L/h/m(2) and 48.85 (SD = 23.65) hours, respectively. Despite a heterogeneous population of MP and HP patients, the magnitude of drug exposure correlated well with the severity of myelosuppression. Antitumor activity was observed in two HP ovarian cancer patients and one patient with a soft tissue sarcoma refractory to etoposide and doxorubicin.

CONCLUSION

Recommended phase II doses are 500 mg/m(2) and 572 mg/m(2) IV once every 3 weeks for HP and MP patients, respectively. The absence of severe nonhematologic toxicities, the encouraging antitumor activity in HP patients, and the unique mechanism of antineoplastic activity of NSC 655649 warrant further clinical development.

DX-8951f, a hexacyclic camptothecin analog, on a daily-times-five schedule: a phase I and pharmacokinetic study in patients with advanced solid malignancies

PURPOSE

To assess the feasibility of administering DX-8951f (exatecan mesylate), a water-soluble, camptothecin analog, as a 30-minute intravenous infusion daily for 5 days every 3 weeks, determine the maximum-tolerated dose (MTD) and pharmacokinetic (PK) behavior of DX-8951f, and seek preliminary evidence of anticancer activity.

PATIENTS AND METHODS

Patients with advanced solid malignancies were treated with escalating doses of DX-8951f. After three patients were treated at the first dose level, doses were to be escalated in increments of 100%, using a single patient at each dose level unless moderate toxicity was observed. The MTD, defined as the highest dose level at which the incidence of dose-limiting toxicity did not exceed 20%, was calculated separately for minimally pretreated (MP) and heavily pretreated (HP) patients. The PK and excretory profiles of DX-8951, the anhydrous form of DX-8951f, were also characterized.

RESULTS

Thirty-six patients were treated with 130 courses of DX-8951f at six dose levels ranging from 0.1 to 0.6 mg/m(2)/d. Brief, noncumulative neutropenia was the most common toxicity observed. Severe myelosuppression (neutropenia that was protracted and/or associated with fever and/or severe thrombocytopenia) was consistently experienced by HP and MP patients at doses exceeding 0.3 and 0.5 mg/m(2)/d, respectively. Nonhematologic toxicities (nausea, vomiting, and diarrhea) were also observed, but these effects were rarely severe. Objective antitumor activity included partial responses in one patient each with platinum-resistant extrapulmonary small-cell and fluoropyrimidine- and irinotecan-resistant colorectal carcinoma, and minor responses in patients with prostate, hepatocellular, thymic, primary peritoneal, and irinotecan-resistant colorectal carcinomas. The PKs of total DX-8951 were linear and well fit by a three-compartment model.

CONCLUSION

The recommended doses for phase II studies of DX-8951f as a 30-minute infusion daily for 5 days every 3 weeks are 0.5 and 0.3 mg/m(2)/d for MP and HP patients, respectively. The characteristics of the myelosuppressive effects of DX-8951f, paucity of severe nonhematologic toxicities, and antitumor activity against a wide range of malignancies warrant broad disease-directed evaluations of DX-8951f on this schedule.

A phase I study of rhizoxin (NSC 332598) by 72-hour continuous intravenous infusion in patients with advanced solid tumors

BACKGROUND

Rhizoxin (NSC 332598) is a novel macrolide antitumor antibiotic that inhibits microtubule assembly and also depolymerizes preformed microtubules. In preclinical evaluations, rhizoxin demonstrated broad antitumor activity in vitro and in vivo including both vincristine- and vindesine-resistant human lung cancers. Prolonged exposure schedules in xenograft models demonstrated optimal efficacy indicating schedule-dependent antitumor activity. The early phase I and II evaluations a five-minute bolus infusion schedule was studied, however, only modest anti-tumor activity was noted, possibly due to rapid systemic clearance. To overcome these limitations and to exploit the potential for schedule-dependent behavior of rhizoxin, the feasibility of administering rhizoxin as a 72-hour continuous intravenous (i.v.) infusion was evaluated.

PATIENTS AND METHODS

Patients with advanced solid malignancies were entered into this phase I study, in which both the infusion duration and dose of rhizoxin were increased. The starting dose was 0.2 mg/m2 over 12 hours administered every 3 weeks. In each successive dose level, the dose and infusion duration were incrementally increased in a stepwise fashion. Once a 72-hour i.v. infusion duration was reached, rhizoxin dose-escalations alone continued until a maximum tolerated dose (MTD) was determined.

RESULTS

Nineteen patients were entered into the study. Rhizoxin was administered at doses ranging from 0.2 mg/m2 i.v. over 12 hours to 2.4 mg/m2 i.v. over 72 hours every 3 weeks. The principal dose-limiting toxicities (DLT) were severe neutropenia and mucositis, and the incidence of DLT was unacceptably high at rhizoxin doses above 1.2 mg/m2, which was determined to be the MTD and dose recommended for phase II studies. At these dose levels, rhizoxin could not be detected in the plasma by a previously validated and sensitive high-performance liquid chromatography assay with a lower limit of detection of 1 ng/ml. No antitumor responses were observed.

CONCLUSIONS

Rhizoxin can be safely administered using a 72-hour i.v. infusion schedule. The toxicity profile is similar to that observed previously using brief infusion schedules. Using this protracted i.v. infusion schedule the maximum tolerated dose is 1.2 mg/m2/72 hours.

A performance, safety and cost comparison of reusable and disposable endoscopic biopsy forceps: a prospective, randomized trial

BACKGROUND

Many gastroenterologists believe that disposable forceps are more expensive than reusable forceps. It has been shown, however, that cross contamination and spread of infection are possible with reusable forceps. We conducted a prospective, randomized study to evaluate the performance, safety and cost of reusable versus disposable biopsy forceps.

METHODS

Endoscopists were randomly assigned reusable or disposable biopsy forceps during upper and lower endoscopy. Forceps were evaluated for ease of passage through the endoscope, ease of opening and closing, adequacy of sample, and overall evaluation following the endoscopy using an ordinal scale. The cost per biopsy session was calculated using the following formula: (Acquisition cost + Reprocessing costs)/Number of biopsy sessions.

RESULTS

Disposable forceps received a predominantly excellent rating versus a predominantly good rating for reusable forceps. Disposable forceps were also found to be more cost-effective than reusable forceps with an average savings of $5. 94 per biopsy session. Examination of reusable forceps revealed residual patient debris despite "adequate" cleansing.

CONCLUSIONS

Disposable forceps outperformed reusable forceps and were found to be more cost-effective. Residual patient debris on reusable forceps may pose a risk of cross contamination and the spread of infection.

A randomized double-blind placebo-controlled trial evaluating the cost-effectiveness of droperidol as a sedative premedication for EUS

BACKGROUND

Droperidol is a neuroleptic agent with anti-emetic properties that produces mild sedation, reduced anxiety, and a state of mental detachment and indifference to one's surroundings. Routine premedication with droperidol has been shown to improve sedation during esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography. The purpose of this randomized double-blind placebo-controlled study was to determine whether premedication with droperidol improves sedation during routine upper endoscopic ultrasound (EUS) in a cost-effective manner.

METHODS

One hundred consecutive patients referred for EUS were randomly assigned to receive either 2.5 mg or 5 mg of droperidol or placebo before the procedure. After EUS, the physician, nurse, and recovered patient scored various parameters of procedural sedation.

RESULTS

In the group receiving 5 mg of droperidol there was significantly less gagging at intubation, less retching during the procedure, better patient cooperation, less need for physical restraint, and improved nurses' and physician's impression of sedation. Significantly less meperidine and less midazolam were required for sedation, making medication costs significantly lower in the group receiving 5 mg droperidol.

CONCLUSIONS

A 5 mg dose of droperidol given as premedication for routine upper EUS improves sedation during the procedure while significantly decreasing the overall cost of sedation.

Phase I and pharmacologic study of the tyrosine kinase inhibitor SU101 in patients with advanced solid tumors

PURPOSE

To evaluate the clinical feasibility and pharmacologic behavior of the platelet-derived growth factor (PDGF) tyrosine kinase inhibitor SU101, administered on a prolonged, intermittent dosing schedule to patients with advanced solid malignancies.

PATIENTS AND METHODS

Twenty-six patients were treated with SU101 doses ranging from 15 to 443 mg/m(2) as a 24-hour continuous intravenous (IV) infusion weekly for 4 weeks, repeated every 6 weeks. Pharmacokinetic studies were performed to characterize the disposition of SU101 and its major active metabolite, SU0020. Immunohistochemical staining of PDGF-alpha and -beta receptors was performed on malignant tumor specimens obtained at diagnosis.

RESULTS

Twenty-six patients were treated with 52 courses (187 infusions) of SU101. The most common toxicities were mild to moderate nausea, vomiting, and fever. Two patients experienced one episode each of grade 3 neutropenia at the 333 and 443 mg/m(2) dose levels. Dose escalation of SU101 above 443 mg/m(2)/wk was precluded by the total volume of infusate required, 2.5 to 3.0 L. Individual plasma SU101 and SU0020 concentrations were described by a one-compartment model that incorporates both first-order formation and elimination of SU0020. SU101 was rapidly converted to SU0020, which exhibited a long elimination half-life averaging 19 +/- 12 days. At the 443 mg/m(2)/wk dose level, trough plasma SU0020 concentrations during weeks 2 and 4 ranged from 54 to 522 micromol/L. Immunohistochemical studies revealed PDGF-alpha and -beta receptor staining in the majority (15 of 19) of malignant neoplasms.

CONCLUSION

SU101 was well tolerated as a 24-hour continuous IV infusion at doses of up to 443 mg/m(2)/wk for 4 consecutive weeks every 6 weeks. Although further dose escalation was precluded by infusate volume constraints, this SU101 dose schedule resulted in the achievement and maintenance of substantial plasma concentrations of the major metabolite, SU0020, for the entire treatment period.

Phase I study of paclitaxel in patients with recurrent malignant glioma: a North American Brain Tumor Consortium report

PURPOSE

To determine the maximum-tolerated dose (MTD) of paclitaxel administered as a 3-hour infusion in patients with recurrent malignant glioma.

PATIENTS AND METHODS

Patients were stratified by starting dose of paclitaxel and concurrent anticonvulsant (AC) use and were treated in cohorts of three patients. The starting dose was 240 mg/m2 administered intravenously with escalations of 30 mg/m2 until the MTD was established. Pharmacokinetic data were obtained for each patient for the first infusion. Tumor response was assessed at 6-week intervals and treatment was continued until documented tumor progression, unacceptable toxicity, or a total of 12 paclitaxel infusions.

RESULTS

From April 1995 to December 1996, 34 patients were treated; 27 patients in the AC group and seven patients in the non-AC group. The MTD for patients who received ACs was established at 360 mg/m2 and the dose-limiting toxicity (DLT) was central neurotoxicity, characterized as transient encephalopathy and seizures. In contrast, the MTD for patients who did not receive ACs was 240 mg/m2, and myelosuppression, gastrointestinal toxicity, and fatigue were the DLTs. Pharmacokinetic data confirmed that the plasma drug levels and clearance rates were similar for patients in both groups at the respective dose levels that produced DLTs.

CONCLUSION

The pharmacokinetics of paclitaxel are altered by ACs, and significantly larger doses of the drug can be administered to patients with brain tumors on AC therapy. The toxicity profile is different for patients on AC therapy treated at these higher doses. A phase II study has been initiated that uses a dose of 330 mg/m2 for patients on AC therapy and 210 mg/m2 for patients not on AC therapy.

Discrepancy between in vitro and in vivo antifungal activity of albendazole

Albendazole has in vitro activity against Cryptococcus neoformans and reduced in vitro activity for albendazole when compared with Candida albicans. The major metabolite of albendazole, albendazole sulphoxide showed no in vitro activity against isolates of either fungus. Immunocompetent mice infected intravenously (i.v.) with C. albicans were treated with albendazole doses of 20-600 mg kg-1 per day in noble agar or sesame oil for per oral (PO) administration, or 80 mg kg-1 per day in DMSO for intraperitoneal (i.p.) and i.v. administration for 10 days, and were observed for survival. Mice infected with C. neoformans intracranially received albendazole in daily doses of 600 mg kg-1 prepared in DMSO (i.p.) or peanut butter/rat chow (PO) for 10 days and were observed for survival. Mortality was not different between the treated and control animals in any study. Plasma samples from uninfected mice dosed with similar formulations and doses of albendazole were analysed by HPLC for albendazole and albendazole sulphoxide. No albendazole could be detected in any sample, while concentrations of albendazole sulphoxide (286-8697 ng ml-1) were observed in all samples. These data suggest that the absence of in vivo activity for albendazole is due to rapid conversion to the inactive albendazole sulphoxide metabolite.

Effect of improved disease management strategies on hospital length of stay in the treatment of congestive heart failure

Congestive heart failure (CHF) afflicts more than 4.6 million people in the United States and increases at a rate of 400,000 newly diagnosed patients per year. With more than 1.5 million hospital admissions per year attributed to CHF, it is the number one cause of hospitalization. Hospital length of stay (LOS) is one key determinant of greater hospital costs and has been the focus in some economic studies of CHF patients. In the present study, the potential economic benefits for hospitals from the implementation of improved disease-specific management programs in the treatment of CHF have been quantified in terms of LOS. We estimated the potential effects of disease management on LOS as a residual variation across hospitals, controlling for the effects of patient-specific characteristics, including severity of disease, health status, insurance status, and comorbidities. The study entry criteria and random sample selection yielded 5242 records for analysis. The average LOS was 7.1 days. The fixed effects or disease management practices across hospitals contribute to the explanatory power of the model by 4%. The 104 hospital-specific fixed effects measuring the potential impact of the differences in disease management relative to the reference hospital had values ranging from-3.41 to 4.33 days, for a total spread of 7.74 days, even after controlling for all other factors. The analysis suggests that the potential gain in profits for hospitals reimbursed on a per-case basis may be substantial, if disease management strategies practiced by those hospitals that lie to the left of the mean LOS were used by those that lie to the right of the mean LOS.

Pharmacokinetic profile of Mitoguazone (MGBG) in patients with AIDS related non-Hodgkin's lymphoma

Mitoguazone is a unique chemotherapeutic agent whose activity is believed to result primarily from the competitive inhibition of S-adenosyl-methionine decarboxylase leading to a disruption in polyamine biosynthesis. Initial clinical trials demonstrated that the dose-limiting toxicities (mucositis and myelosuppression) of Mitoguazone were both dose and schedule dependent. Early pharmacokinetic studies of Mitoguazone in man revealed a prolonged half-life. Concurrent with a recent Phase II trial of Mitoguazone in patients with AIDS related non-Hodgkin's lymphoma, the single dose pharmacokinetics of Mitoguazone were characterized. Twelve patients received 600 mg/m2 of intravenous Mitoguazone over 30 minutes on an intermittent every 2 week schedule. Blood, urine, cerebrospinal fluid (CSF), pleural fluid and tissue samples were collected and analyzed by HPLC. Mitoguazone was cleared from the plasma triexponentially with a harmonic mean terminal half-life of 175 hours and a mean residence time of 192 hours. Peak plasma levels occurred immediately post-infusion, ranged from 6.47 to 42.8 micrograms/ml, and remained (for an extended period) well above the reported concentration for inhibition of polyamine biosynthesis. Plasma clearance averaged 4.73 l/hr/m2 with a relatively large apparent volume of distribution at steady-state of 1012 l/m2 indicating tissue sequestration. Renal excretion of unchanged Mitoguazone accounted for an average of 15.8% of the dose within 48 to 72 hours post-administration. Detectable levels of drug were present in random voided samples eight days post-dose. Mitoguazone levels in CSF ranged from 22 to 186 ng/ml post-dose with CSF/plasma ratios ranging from 0.6% to 7%. The pleural fluid/plasma ratio was approximately 1. Tissue levels of Mitoguazone were highest in the liver followed by lymph node, spleen and the brain.

A phase I and pharmacokinetics study of 2-chlorodeoxyadenosine in patients with solid tumors

Preclinical studies of 2-chlorodeoxyadenosine (2-CdA) against solid tumors in the human tumor cloning assay and evidence that 2-CdA is active against slow-growing or resting tumor cells have stimulated interest in the clinical activity of this agent against solid tumors. This study sought to estimate the maximum tolerated dose, dose-limiting toxicity, and plasma and urine pharmacokinetics accompanying the intravenous administration of 2-CdA by 120-h continuous infusion in patients with solid tumors. Treated patients were also assessed for other toxicities of therapy and for antitumor response. A total of 23 patients received 35 courses of treatment given at doses of 3.5, 5.3, 6.5 and 8.1 mg/m2 per day by continuous intravenous infusion for 5 days and repeated every 28 days. Blood and urine specimens were collected before, during, and after drug infusion. The dose-limiting toxicity at 8.1 mg/m2 per day manifested as granulocytopenia in 2 of 5 patients (3 of 7 courses of treatment) and as thrombocytopenia in 3 of 5 patients (3 of 7 courses of treatment). At the dose levels of 6.5 and 8.1 mg/m2 per day, recovery from thrombocytopenia was often delayed. Severe lymphocytopenia (< 1,000/microliters) was observed at all dose levels of 2-CdA. Dose-related anemia and leukopenia were observed and were infrequently severe. Non-hematological toxicities were confined to mild-to-moderate nausea, vomiting, fatigue, and anorexia. Fever of 37 degrees-40 degrees C was induced during drug infusion in 19 patients. No antitumor response was observed. Average plasma concentrations at steady-state (Cpss) ranged from 3 ng/ml at the initial dose level to 13 ng/ml at the dose level of 8.1 mg/m2 per day. Both the Cpss and the area under the plasma concentration-time curve (AUC) were proportional to the dose. A relationship was observed between the percentage of change in absolute neutrophil count and the AUC. Renal excretion accounted for only 18% of the elimination of 2-CdA over the 5-day infusion period. The maximum tolerated dose for 2-CdA given by 5-day continuous infusion was 8.1 mg/m2 per day in this study. The recommended dose on this schedule for phase II studies is 6.5 mg/m2 per day. Granulocytopenia and thrombocytopenia were dose-limiting. No antitumor activity was observed during this study. On the basis of the plasma concentrations of 2-CdA observed, it is unlikely that this schedule of drug administration will permit achievement of the concentrations consistent with antitumor activity observed in preclinical studies.

Female pelvis: impact of MR imaging on treatment decisions and net cost analysis

PURPOSE

To determine the impact of gynecologic magnetic resonance (MR) imaging on treatment decisions and net cost.

MATERIALS AND METHODS

Sixty-nine consecutive women were referred for 70 pelvic MR imaging examinations. Diagnosis and treatment plans were obtained from referring physicians before and immediately after they were given verbal reports of MR imaging results. Outcome regarding treatment and symptoms was obtained at a mean follow-up of 10.9 months.

RESULTS

Of 49 (71%) patients originally recommended for surgery, 36 (73%) either did not undergo surgery or less invasive surgery was performed. In 58 (84%) patients, the treatment performed was that recommended after performance of MR imaging. Symptoms resolved in 57 (83%) patients. Use of MR imaging resulted in an overall savings of $63 per patient ($1,736 per patient originally recommended for surgery).

CONCLUSION

Use of pelvic MR imaging in diagnosis of some gynecologic diseases may alter treatment, decrease the number of invasive surgical procedures performed, and reduce total health care expenditures.

Omeprazole versus H2-receptor antagonists in treating patients with peptic stricture and esophagitis

BACKGROUND/AIMS

Although dysphagia in patients with peptic stricture is attributed to a decreased luminal diameter, coexistent esophagitis may be an equally important cause. The goals of this study were to determine whether medical healing of esophagitis in patients with stricture improves dysphagia and decreases dilatation need and to compare the efficacy and cost-effectiveness of omeprazole versus H2-receptor antagonists (H2RA).

METHODS

Thirty-four dysphagic patients with peptic stricture and erosive esophagitis were dilated and randomized to omeprazole 20 mg every day versus H2RA (ranitidine 150 mg twice daily or famotidine 20 mg twice daily). Patients received further dilatations only if dysphagia frequency was greater than or equal to once per week. At 3 and 6 months, patients were assessed for esophagitis healing, dysphagia relief, and bougienage requirements. Cost-effectiveness of omeprazole and H2RA was determined.

RESULTS

Patients with healed esophagitis at 3 and 6 months were more likely to dysphagia-free and to require fewer dilatations than patients with persistent esophagitis. At 6 months, omeprazole produced a significantly (P < 0.01) higher rate of esophagitis healing, dysphagia relief, and fewer dilatations compared with H2RA. Omeprazole was also 40%-50% more cost-effective.

CONCLUSIONS

Esophagitis healing improves dysphagia and decreases dilatation need in patients with peptic stricture. Omeprazole heals esophagitis and relieves dysphagia more efficaciously than H2RA while decreasing costs to patients.

Quality indicators: control maintains--propriety improves

Continuous improvement of care depends upon the efforts of all nursing personnel. Supervisors facilitate quality program operations in their specific areas; head nurses document outcomes; and staff nurses identify problems and contribute to planning. All join in evaluating appropriateness of patient care and in modifying approaches for greater effectiveness.