The importance of cell uptake in photothermal treatments mediated by biomimetic magnetic nanoparticles

Biomimetic magnetic nanoparticles (BMNPs) mediated by MamC have proven to be photothermal agents able to allow an optimized cytotoxicity against tumoral cells when used simultaneously as drug nanotransporters and as hyperthermia agents. However, it remains unclear whether BMNPs need to be internalized by the cells and/or if there is a threshold for internal Fe concentration for the photothermal therapy to be effective. In this study, three different situations for photothermal treatments have been simulated to disentangle the effect of BMNPs cell uptake on cell viability after photothermal treatments. Human hepatoblastoma (HepG2) cell line was treated with suspensions of BMNPs, and protocols were developed to have only intracellular BMNPs, only extracellular BMNPs or both, followed by photothermal exposure of the treated cell cultures. Our data demonstrate that: (1) Although the heating efficiency of the photothermal agent is not altered by its location (intra/extracellular), the intracellular location of BMNPs is crucial to ensure the cytotoxic effect of photothermal treatments, especially at low Fe concentration. In fact, the concentration of BMNPs needed to reach the same cytotoxic effect following upon laser irradiation of 0.2 W/cm2 is three times larger if BMNPs are located extracellularly compared to that needed if BMNPs are located intracellularly; (2) For a given location of the BMNPs, cell death increases with BMNPs (or Fe) concentration. When BMNPs are located intracellularly, there is a threshold for Fe concentration (∼ 0.5 mM at laser power intensities of 0.1 W/cm2) needed to affect cell viability following upon cell exposure to photothermia. (3) Bulk temperature rise is not the only factor accounting for cell death. Actually, temperature increases inside the cells cause more damage to cell structures and trigger cell death more efficiently than an increase in the temperature outside the cell.

Understanding the key features of the spontaneous formation of bona fide prions through a novel methodology that enables their swift and consistent generation

Among transmissible spongiform encephalopathies or prion diseases affecting humans, sporadic forms such as sporadic Creutzfeldt-Jakob disease are the vast majority. Unlike genetic or acquired forms of the disease, these idiopathic forms occur seemingly due to a random event of spontaneous misfolding of the cellular PrP (PrPC) into the pathogenic isoform (PrPSc). Currently, the molecular mechanisms that trigger and drive this event, which occurs in approximately one individual per million each year, remain completely unknown. Modelling this phenomenon in experimental settings is highly challenging due to its sporadic and rare occurrence. Previous attempts to model spontaneous prion misfolding in vitro have not been fully successful, as the spontaneous formation of prions is infrequent and stochastic, hindering the systematic study of the phenomenon. In this study, we present the first method that consistently induces spontaneous misfolding of recombinant PrP into bona fide prions within hours, providing unprecedented possibilities to investigate the mechanisms underlying sporadic prionopathies. By fine-tuning the Protein Misfolding Shaking Amplification method, which was initially developed to propagate recombinant prions, we have created a methodology that consistently produces spontaneously misfolded recombinant prions in 100% of the cases. Furthermore, this method gives rise to distinct strains and reveals the critical influence of charged surfaces in this process.

Effect of ATG12-ATG5-ATG16L1 autophagy E3-like complex on the ability of LC3/GABARAP proteins to induce vesicle tethering and fusion

In macroautophagy, the autophagosome (AP) engulfs portions of cytoplasm to allow their lysosomal degradation. AP formation in humans requires the concerted action of the ATG12 and LC3/GABARAP conjugation systems. The ATG12-ATG5-ATG16L1 or E3-like complex (E3 for short) acts as a ubiquitin-like E3 enzyme, promoting LC3/GABARAP proteins anchoring to the AP membrane. Their role in the AP expansion process is still unclear, in part because there are no studies comparing six LC3/GABARAP family member roles under the same conditions, and also because the full human E3 was only recently available. In the present study, the lipidation of six members of the LC3/GABARAP family has been reconstituted in the presence and absence of E3, and the mechanisms by which E3 and LC3/GABARAP proteins participate in vesicle tethering and fusion have been investigated. In the absence of E3, GABARAP and GABARAPL1 showed the highest activities. Differences found within LC3/GABARAP proteins suggest the existence of a lipidation threshold, lower for the GABARAP subfamily, as a requisite for tethering and inter-vesicular lipid mixing. E3 increases and speeds up lipidation and LC3/GABARAP-promoted tethering. However, E3 hampers LC3/GABARAP capacity to induce inter-vesicular lipid mixing or subsequent fusion, presumably through the formation of a rigid scaffold on the vesicle surface. Our results suggest a model of AP expansion in which the growing regions would be areas where the LC3/GABARAP proteins involved should be susceptible to lipidation in the absence of E3, or else a regulatory mechanism would allow vesicle incorporation and phagophore growth when E3 is present.

Autophagy protein LC3C binding to phospholipid and interaction with lipid membranes

Autophagy is a process in which parts of the eukaryotic cell are selectively degraded in the lysosome. The materials to be catabolized are first surrounded by a double-membrane structure, the autophagosome. Autophagosome generation is a complex event, in which many proteins are involved. Among the latter, yeast Atg8 or its mammalian orthologues are essential in autophagosome membrane elongation, shaping and closure. A subfamily of the human Atg8 orthologues is formed by the proteins LC3A, LC3B, and LC3C. Previous studies suggest that, at variance with the other two, LC3C does not participate in cardiolipin-mediated mitophagy. The present study was devoted to exploring the binding of LC3C to lipid vesicles, bilayers and monolayers, and the ensuing protein-dependent perturbing effects, in the absence of the mitochondrial lipid cardiolipin. All Atg8 orthologues are covalently bound to a phospholipid prior to their involvement in autophagosome elongation. In our case, a mutant in the C-terminal amino acid, LC3C G126C, together with the use of a maleimide-derivatized phosphatidyl ethanolamine, ensured LC3C lipidation, up to 100% under certain conditions. Ultracentrifugation, surface pressure measurements, spectroscopic and cryo-electron microscopic techniques revealed that lipidated LC3C induced vesicle aggregation (5-fold faster in sonicated than in large unilamellar vesicles) and inter-vesicular lipid mixing (up to 82%), including inner-monolayer lipid mixing (up to 32%), consistent with in vitro partial vesicle fusion. LC3C was also able to cause the release of 80-90% vesicular aqueous contents. The data support the idea that LC3C would be able to help in autophagosome elongation/fusion in autophagy phenomena.

SEOM-GECP-GETTHI Clinical Guidelines for the treatment of patients with thymic epithelial tumours (2021)

Thymic epithelial tumours (TET) represent a heterogeneous group of rare malignancies that include thymomas and thymic carcinoma. Treatment of TET is based on the resectability of the tumour. If this is considered achievable upfront, surgical resection is the cornerstone of treatment. Platinum-based chemotherapy is the standard regimen for advanced TET. Due to the rarity of this disease, treatment decisions should be discussed in specific multidisciplinary tumour boards, and there are few prospective clinical studies with new strategies. However, several pathways involved in TET have been explored as potential targets for new therapies in previously treated patients, such as multi-tyrosine kinase inhibitors with antiangiogenic properties and immune checkpoint inhibitors (ICI). One third of patient with thymoma present an autoimmune disorders, increasing the risk of immune-related adverse events and autoimmune flares under ICIs. In these guidelines, we summarize the current evidence for the therapeutic approach in patients with TET and define levels of evidence for these decisions.

No man is an island: spatial clustering and access to primary care as possible targets for the development of new community mental health approaches

BACKGROUND

to understand if patients seen at Centro Hospitalar Psiquiátrico de Lisboa (CHPL) live in geographical clusters or randomly throughout the city, as well as determine their access to the psychiatric hospital and primary care facilities (PCF).

METHODS

spatial autocorrelation statistics were performed (queen criterion of contiguity), regarding all patients observed at CHPL in 2017 (at the census subsection level), and considering not only their overall number but also main diagnosis, and admission to the psychiatric ward - voluntary or compulsory. Distance to the hospital and to the closest PCF was measured (for each patient and the variables cited above), and the mean values were compared. Finally, the total number of patients around each PCF was counted, considering specified radius sizes of 656 and 1000 m.

RESULTS

All 5161 patients (509 psychiatric admissions) were geolocated, and statistical significance regarding patient clustering was found for the total number (p-0.0001) and specific group of disorders, namely Schizophrenia and related disorders (p-0.007) and depressive disorders (p-0.0002). Patients who were admitted in a psychiatric ward live farther away from the hospital (p-0.002), with the compulsory admissions (versus voluntary ones) living even farther (p-0.004). Furthermore, defining a radius of 1000 m for each PCF allowed the identification of two PCF with more than 1000 patients, and two others with more than 800.

CONCLUSIONS

as patients seem to live in geographical clusters (and considering PCFs with the highest number of them), possible locations for the development of programs regarding mental health treatment and prevention can now be identified.

A new scenario in metastatic renal cell carcinoma: a SOG-GU consensus

BACKGROUND

This article describes and compares approved targeted therapies and the newer immunotherapy agents.

MATERIALS AND METHODS

This article especially performs an in-depth review of currently available data for tivozanib, explaining its mechanism of action, its safety profile and its role as an efficacy drug in the management of renal cancer.

RESULTS

Despite the fact that the treatment of advanced RCC has been dramatically modified in recent years, durable remissions are scarce and it remains a lethal disease. For first- and second-line therapy, there is now growing evidence to guide the selection of the appropriate treatment.

CONCLUSIONS

Several TKIs are standard of care at different settings. Among those approved TKIs, tivozanib has similar efficacy than others with a better safety profile. The use of prognostic factors is critical to the selection of optimal therapy.

SEOM clinical guideline for treatment of kidney cancer (2019)

In this article, we review de state of the art on the management of renal cell carcinoma (RCC) and provide recommendations on diagnosis and treatment. Recent advances in molecular biology have allowed the subclassification of renal tumours into different histologic variants and may help to identify future prognostic and predictive factors. For patients with localized disease, surgery is the treatment of choice with nephron-sparing surgery recommended when feasible. No adjuvant therapy has demonstrated a clear benefit in overall survival. Considering the whole population of patients with advanced disease, the combination of axitinib with either pembrolizumab or avelumab increase response rate and progression-free survival, compared to sunitinib, but a longer overall survival has only been demonstrated so far with the pembrolizumab combo. For patients with IMDC intermediate and poor prognosis, nephrectomy should not be considered mandatory. In this subpopulation, the combination of ipilimumab and nivolumab has also demonstrated a superior response rate and overall survival vs. sunitinib. In patients progressing to one or two antiangiogenic tyrosine-kinase inhibitors, both nivolumab and cabozantinib in monotherapy have shown benefit in overall survival compared to everolimus. Although no clear sequence can be recommended, medical oncologists and patients should be aware of the recent advances and new strategies that improve survival and quality of life in patients with metastatic RCC.

Do Not be Afraid: Novel Approaches to the Treatment of Anxiety Disorders

Introduction

Anxiety disorders (AD) are associated with significant morbidity and often are chronic and resistant to the treatment. A fascinating aspect of AD is the interplay of genetic and experiential factors. It is stablished that abnormal genes predispose to pathological anxiety states; however evidence clearly indicates that traumatic life events and stress are also etiologically relevant. The behavioral theories of anxiety postulates that anxiety is a conditioned response to a specific environmental stimulus. There may be two ways to neutralize fear conditioning either by facilitating a process called extinction or by blocking a process called reconsolidation.

Objectives

Review novel approaches to the treatment of AD.

Aims

To update on treatment for AD.

Methods

A literature search was performed on PubMed database.

Results

Cognitive behavioral therapies use exposure techniques, in which the patient has to confront the fear-inducing stimuli in a safe environment in order to facilitate the fear extinction. The therapy is often context-specific, so one way of strengthen extinction learning is by boosting NMDA receptor activation, either with direct acting agonists (D-cycloserine) or with indirect glycine enhancing agents (selective glycine reuptake inhibitors). Memory reconsolidation is based on the notion that memories are dynamic rather than stable. Reactivation of a memory can return it to a labile state from which it must be reconsolidated. Blocking reconsolidation is a therapeutic opportunity of update and alter the memory, weakening traumatic memories. Beta-blockers and opioids may disrupt this process.

Conclusions

Psychotherapy and psychopharmacology may have a synergistic role in AD treatment.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Treatment of alcoholism – New targets?

Introduction

Alcohol use disorders (AUD) is a preventable cause of significant morbidity and mortality worldwide. AUD is a heterogeneous disorder stemming from a complex interaction of neurobiological, genetic, and environmental factors. To achieve treatment effectiveness this heterogenity should be considered, as well as safety.

Objectives

Review mechanisms underlying alcohol addiction in order to work out new, more effective treatment strategies.

Aim

To update on treatment for alcoholism.

Methods

A literature search was performed on PubMed database.

Results

Alcohol dependence is a chronic, relapsing condition in which there is evidence of significant change in the motivation and control systems in the brain. Increasingly drug therapy is focused not just on the treatment of the acute withdrawal syndrome, but on modifying these other dysregulated brain systems. Of the numerous neurotransmitter systems that have been identified for the development of new medicines, the most promising compounds appear to be those that modulate the function of opioids, glutamate with or without gamma-aminobutyric acid, and serotonin. Other putative therapeutic medications including direct modulators of dopamine function and enzyme inhibitors also shall be discussed. At present, only four medications are approved for the treatment of alcohol dependence in Europe, that is naltrexone, acamprosate, disulfiram and the most recent nalmefene. Among other promising strategies the following drugs are mentioned: baclofen, topiramate, ondansetron, aripiprazole, rimonabant and varenicline.

Conclusions

Pharmacological development remains a high priority in the alcoholism field. Drugs have different safety profiles that need to be balanced with the treatment objective, individual patient preferences and comorbid conditions.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Affective disorders, psychosis and lipid levels: Is there a connection? Linking psychopathology, clinical exams and neurobiology

Introduction

Published research regarding the relationship between lipid levels in affective disorders has been contradictory. Additionally, most studies correlating psychosis to lipid serum concentrations only concern schizophrenic patients.

Objective

To access the relationship between serum lipid levels with the diagnosis and pathophysiology of affective disorders.

Methods

Diagnostic data (ICD–10: F31–32), including mood and psychotic features, were prospectively collected for all patients admitted at the affective disorder ward at Centro Hospitalar Psiquiátrico de Lisboa (Portugal), during the third trimester of 2016. Serum concentrations of triglycerides and total/HDL/LDL cholesterol were evaluated using standard laboratory tests. Statistical analysis was performed for possible correlations between serum lipid levels and:

– different stages of bipolar disorder (BD);

– elevated versus depressive mood (unipolar and bipolar);

– depressive mood (BD versus non-BD);

– psychotic features.

Results

Sixty-three patients admitted were enrolled in this study: 47 presented with BD (32 manic, 10 depressives and 5 mixed episodes) and 16 presented depressive disorders. Statistical analysis (R software) revealed that depressed bipolar patients had significantly higher triglyceride (P = 0.026), total and LDL cholesterol (P = 0.525) levels than other states; mixed episodes presented higher HDL levels (P = 0.542). Although not significant, manic patients’ HDL levels were consistently elevated compared to depressive ones, whom presented with lower values overall. Finally, when adjusted for age, psychotic patients showed lower levels of total (P = 0.031) and LDL cholesterol (P = 0.052) compared to non-psychotic patients.

Conclusions

There is a potential link between serum lipid levels and diagnosis/psychopathology of affective disorders. Further research is needed to characterize its pathophysiologic relevance.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Insomnia and aggressiveness in affective disorders: Self-assessment versus clinical examination

Introduction

Although, disturbances of sleep, as well as aggressiveness, have been described in patients with mood disorders, these patients may not be aware of them.

Objectives/aims

To access the personal perception of sleep, disturbances and aggressiveness in patients with mood disorders, admitted to an acute psychiatric ward.

Methods

Diagnostic data (ICD-10: F31–33), including mood evaluation, were prospectively collected for all patients admitted at the affective disorder ward at Centro Hospitalar Psiquiátrico de Lisboa (Portugal), during the third trimester of 2016. Then, 2 auto-questionnaires – Athens insomnia scale (AIS) and Buss and Perry aggression scale (both validated to the Portuguese population) – were applied to these patients. Statistical analysis was performed for possible correlations between patients’ mood and the questionnaires’ scores, using R software.

Results

Thirty-eight patients admitted were enrolled in this study: 28 with bipolar disorder (19 manic, 4 depressive and 5 mixed episodes), and 10 with depressive disorder. Depressed patients presented statistically higher values in the AIS (average = 20), compared to manic (14) and mixed ones (17.2) (P = 0.031). However, there were no statistical differences found between depressed patients (bipolar versus non-bipolar). Even though manic patients presented an increased average score in the Buss and Perry questionnaire (both total–65; but also sub-scores), these values were not significantly different than depressed (60) or mixed patients’ scores (57.4).

Conclusions

Even though some symptoms (like sleep or aggressiveness) seem to be relevant to the clinics, patients with affective disorders do not seem to be aware these disturbances, and therefore are not able to acknowledge their relevance.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Do not forget alcohol damage – Cognitive impairments related to alcohol

Introduction

Chronic excessive alcohol consumption may lead to structural and functional damage of the brain. Alcohol-related cognitive impairments are well-established and confirmed by neuropsychological and neuroimaging studies. However, the influence of each neuropathological mechanisms is still under discussion. This topic is increasingly becoming focus of attention in psychiatry.

Objectives

Review the neuropathology, clinical features, neuropsychology and management of alcohol-related cognitive impairments.

Aims

Evaluate clinical impact, management and prognosis of alcohol-related cognitive impairments.

Methods

A literature search was performed on PubMed and Medscape database.

Results

According to our literature research, there is a debate concerning the relative contributions of the direct toxic effect of alcohol and the impact of thiamine deficiency on the alcohol-related cognitive impairments. Research about this issue is challenging, considering the multiple patterns of alcohol abuse, the personal and lifestyle factors, and the vulnerability of specific brain regions. The cognitive decline is linked to neuroanatomical alterations and primarily affects executive functions, episodic memory, and visuospatial capacities. These deficits may range from mild to severe but usually remain undiagnosed, unless they are specifically investigated. Maintenance of lasting abstinence is associated with cognitive recovery, but some impairments may persist and interfere with the prognosis.

Conclusion

Recognizing and screening for alcohol-related cognitive impairments is crucial to offer significant benefits to patients by optimising management strategies.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

SEOM Clinical Guideline for treatment of muscle-invasive and metastatic urothelial bladder cancer (2016)

The goal of this article is to provide recommendations for the diagnosis and treatment of muscle-invasive and metastatic bladder cancer. The diagnosis of muscle-invasive bladder cancer is made by pathologic evaluation after transurethral resection. Recently, a molecular classification has been proposed. Staging of muscle-invasive bladder cancer must be done by computed tomography scans of the chest, abdomen and pelvis and classified on the basis of UICC system. Radical cystectomy and lymph node dissection are the treatment of choice. In muscle-invasive bladder cancer, neoadjuvant chemotherapy should be recommended in patients with good performance status and no renal function impairment. Although there is insufficient evidence for use of adjuvant chemotherapy, its use must be considered when neoadjuvant therapy had not been administered in high-risk patients. Multimodality bladder-preserving treatment in localized disease is an alternative in selected and compliant patients for whom cystectomy is not considered for clinical or personal reasons. In metastatic disease, the first-line treatment for patients must be based on cisplatin-containing combination. Vinflunine is the only drug approved for use in second line in Europe. Recently, immunotherapy treatment has demonstrated activity in this setting.

The hexameric structure of the human mitochondrial replicative helicase Twinkle

The mitochondrial replicative helicase Twinkle is involved in strand separation at the replication fork of mitochondrial DNA (mtDNA). Twinkle malfunction is associated with rare diseases that include late onset mitochondrial myopathies, neuromuscular disorders and fatal infantile mtDNA depletion syndrome. We examined its 3D structure by electron microscopy (EM) and small angle X-ray scattering (SAXS) and built the corresponding atomic models, which gave insight into the first molecular architecture of a full-length SF4 helicase that includes an N-terminal zinc-binding domain (ZBD), an intermediate RNA polymerase domain (RPD) and a RecA-like hexamerization C-terminal domain (CTD). The EM model of Twinkle reveals a hexameric two-layered ring comprising the ZBDs and RPDs in one layer and the CTDs in another. In the hexamer, contacts in trans with adjacent subunits occur between ZBDs and RPDs, and between RPDs and CTDs. The ZBDs show important structural heterogeneity. In solution, the scattering data are compatible with a mixture of extended hexa- and heptameric models in variable conformations. Overall, our structural data show a complex network of dynamic interactions that reconciles with the structural flexibility required for helicase activity.

Management of angioedema without urticaria in the emergency department

Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.

Functional conformations for pyruvate carboxylase during catalysis explored by cryoelectron microscopy

The tetrameric enzyme pyruvate carboxylase (PC), a biotin-dependent carboxylase, produces oxaloacetate by two consecutive reactions that take place in distant active sites. Previous crystal structures revealed two different configurations for PC tetramers, the so-called symmetric and asymmetric, which were understood as characteristic molecular architectures for PC from different organisms. We have analyzed PC samples from Staphylococcus aureus while the enzyme generates oxaloacetate, expecting PC tetramers to display the conformational landscape relevant for its functioning. Using cryoelectron microscopy (cryo-EM) and sorting techniques, we detect previously defined symmetric and asymmetric architectures, demonstrating that PC maps both arrangements by large conformational changes. Furthermore, we observe that each configuration is coupled to one of the two consecutive enzymatic reactions. The findings describe the structural transitions relevant for the allosteric control of the multifunctional PC and demonstrate that by cryo-EM and classification, we can characterize freely working macromolecules.

Bronchopulmonary complications associated to enteral nutrition devices in patients admitted to internal medicine departments

BACKGROUND AND AIMS

Enteral nutrition using feeding devices such as nasogastric (NG) tube or percutaneous endoscopic gastrostomy (PEG) is an effective feeding method subject that may give rise to complications. We have studied the relationship between enteral nutrition feeding devices in patients admitted to the Internal Medicine Departments and the development of pulmonary complications (bronchial aspiration and aspiration pneumonia).

PATIENTS AND METHODS

All of the patients discharge between 2005 and 2009 from the Internal Medicine (IM) Departments of the public hospitals of the National Health System in Spain were analyzed. The data of patients with bronchial aspiration or aspiration pneumonia who also were carriers of NG tubes or PEG, were obtained from the Minimum Basic Data Set (MBDS).

RESULTS

From a total of 2,767,259 discharges, 26,066 (0.92%) patients with nasogastric tube (NG tube) or percutaneous gastrostomy (PEG) were identified. A total of 21.5% of patients with NG tube and 25.9% of patients with PEG had coding for a bronchopulmonary aspiration on their discharge report versus 1.2% of patients without an enteral feeding tube. In the multivariate analysis, the likelihood of suffering bronchoaspiration was 9 times greater in patients with SNG (OR: 9.1; 95% CI: 8.7-9.4) and 15 greater in subjects with PEG (OR: 15.2; 95% CI: 14.5-15.9) than in subjects without SNG or PEG. Mean stay (9.2 and 12.7 more days), diagnostic complexity and costs were much higher in patients with SNG or PEG compared to patients in hospital who did not require these devices.

CONCLUSIONS

An association was found between SNG and PEG for enteral feeding and pulmonary complications. Mean stay, diagnostic complexity and cost per admission of these patients was higher in patients who did not require enteral nutrition.

Comprehensive overview of the efficacy and safety of sorafenib in advanced or metastatic renal cell carcinoma after a first tyrosine kinase inhibitor

We performed a literature search that shed light on the signaling pathways involved in the sorafenib activity as first- or subsequent-line treatment, taking into account its toxicity profile. Sorafenib appears to have better tolerability when compared with other agents in the same indication. Cross-resistance between tyrosine kinase inhibitors (TKIs) may be limited, even after failure with a previous VEGFR inhibitor, but the optimal sequence with TKIs remains to be determined. Randomized trials of second-line treatment options have showed either modest or no differences in terms of progression-free and overall survival (OS). Direct comparison between sorafenib and axitinib demonstrated differences in terms of PFS in favor of axitinib, but not in terms of OS as second-line treatment. In contrast, a phase III study showed a benefit in OS, favoring sorafenib when compared with temsirolimus. In conclusion, after using other VEGF inhibitor such as sunitinib, sorafenib is active and safe for the treatment of patients with advanced or metastatic RCC.

The cryo-EM structure of the UPF-EJC complex shows UPF1 poised toward the RNA 3' end

Nonsense-mediated mRNA decay (NMD) is a eukaryotic surveillance pathway that degrades aberrant mRNAs containing premature termination codons (PTCs). NMD is triggered upon the assembly of the UPF surveillance complex near a PTC. In humans, UPF assembly is prompted by the exon junction complex (EJC). We investigated the molecular architecture of the human UPF complex bound to the EJC by cryo-EM and using positional restraints from additional EM, MS and biochemical interaction data. The heptameric assembly is built around UPF2, a scaffold protein with a ring structure that closes around the CH domain of UPF1, keeping the helicase region in an accessible and unwinding-competent state. UPF2 also positions UPF3 to interact with the EJC. The geometry is such that this transient complex poises UPF1 to elicit helicase activity toward the 3' end of the mRNP.

Latex allergy: Position Paper

Correct management of latex allergy is essential to ensure adequate care of patients who are allergic to latex, which is ubiquitous in the health care setting. In this Position Paper, the Latex Committee of the Spanish Society of Allergology and Clinical Immunology provides guidelines for the management of latex allergy.

Adaptation and validation of the Spanish version of the Quality Of Life in Latex Allergy questionnaire (QOLLA)

OBJECTIVE

The aim of the present study was to translate into Spanish and transculturally adapt the Quality of Life in Latex Allergy questionnaire (QOLLA) in order to provide a validated instrument for use in research and daily practice.

METHODS

Patients diagnosed with latex allergy were invited to participate in an observational prospective multicenter study to validate the Spanish version of the QOLLA following the recommendations of the World Health Organization. The study included 3 phases--feasibility, reliability, and cross-sectional validation-and was approved by the Ethics Committee of Hospital Ramón y Cajal.

RESULTS

Mean time to complete the questionnaire was 4.7 minutes. The maximum score was 28 (mean, 7.7; median, 4).The SF-12 score ranged from 25.8 to 51.6 in the physical domain and from 20.8 to 61.5 in the mental domain. Internal consistency was excellent (Cronbach alpha, 0.9348). The kappa index fluctuated between 0.40 and 0.93. A kappa of 0.84 was obtained for the global score in 5 categories. Sixty patients were included to evaluate construct validity. Mean age was 39 years and 49 patients were women (80%). The global score ranged between 0 and 30 (mean, 11.69; median, 11). Spearman correlation coefficients between the QOLLA and a visual analog scale and the SF-12 physical, mental, and severity scales according to the researcher were--0.47, 0.37, 0.29, and 0.54, respectively.

CONCLUSION

The QOLLA is a feasible, valid, and reliable instrument for the measurement of disease-specific quality of life in adult patients diagnosed with latex allergy. It could play an important role in determining suitable treatment for latex-allergy.

Activity of a multitargeted, metronomic, and maximum-tolerated dose “chemo-switch” regimen in metastatic renal cell carcinoma (mRCC): A phase II study of sorafenib, gemcitabine (Gem), and metronomic capecitabine (Cap) in patients with advanced mRCC (SOGUG-02–06)

5040

Background: Maximal tolerated dose (MTD) chemotherapy followed by metronomic chemotherapy (low doses administered on a frequent schedule) acts on tumor vascular endothelial cells and enhances the antitumor effect of anti-angiogenic agents (Pietras et al. J Clin Oncol. 2007). This study investigated treatment of mRCC with Gem at MTD combined with metronomic Cap and the multikinase inhibitor sorafenib. Methods: Eligible patients had cytologically or histologically confirmed mRCC, Eastern Cooperative Oncology Group (ECOG) performance status ≤1 and no previous targeted therapy or chemotherapy, and were unsuitable for or intolerant to immunotherapy. Treatment consisted of six 3-week cycles of Gem 1000 mg/m2 i.v. (days 1 and 8), oral Cap 500 mg/m2 b.i.d. (days 1 to 14) and oral sorafenib 400 mg b.i.d. (every day), followed by sorafenib monotherapy (at the discretion of the investigator). Study endpoints included median progression-free survival (PFS, primary endpoint), disease control rate according to Response Evaluation Criteria in Solid Tumors, and safety. Results: Forty patients were enrolled and received at least one dose of treatment (median age 63 yrs, male n = 24, ECOG 0/1 n = 18/22, 1–2/>2 metastatic sites n = 31/9). Median duration of treatment was 6 months. Among 36 evaluable patients, 17 (47%) had a partial response and 17 (47%) achieved stable disease. Median PFS was 10.2 months (95% CI 7.6, 20.5). The most common adverse events (AEs) were fatigue/asthenia (78%) hand-foot syndrome (75%) and mucositis (69%). Most AEs were grade1/2, no grade 4 toxicities occurred. One patient had grade 5 dyspnea; 6 patients discontinued treatment for AEs. Conclusions: PFS and objective responses in this study were greater than those observed in previous studies with Gem and Cap or sorafenib monotherapy in patients with mRCC, while AEs remained moderate in the majority of patients. These findings confirm the synergistic activity of the “chemo-switch” concept seen in preclinical models. The combination of sorafenib with MTD Gem and metronomic Cap warrants further investigation in mRCC.

[Table: see text]

Evaluation of clinical use of darbepoetin alfa in patients with chemotherapy-induced anemia

e20585

Background: Chemotherapy-induced anemia (CIA) is a frequent complication of patients (pts) with cancer and could be treated with erythropoiesis-stimulating agents such darbepoetin alfa (DA). The aim of this study was to investigate the patterns of use and effect of DA to treat CIA in clinical practice conditions. Methods: This was an observational, retrospective, multicenter study performed in 58 Spanish centres. Eligible pts were ≥18 yrs, diagnosed with non-myeloid malignancies and treated with chemotherapy (CT) and DA from October 2005 to October 2006. Data on demographic and clinical characteristics, CT and radiotherapy (RT), DA administration, red blood cell (RBC) transfusions, and haemoglobin (Hb) levels were collected from DA treatment initiation up to a maximum of 16 weeks or until treatment discontinuation. Results: A total of 685 pts were included in the study. Median age was 64.66 years (range 18.54–88.95), 50.7% were women, 74.11% had ECOG status 0–1 and 71.38% had stage III/IV cancer. Solid tumours represented 72.55% of the cases. The CT regimen included platinum derivates in 33.58% of the pts. At DA initiation, mean (SD) Hb was 10.00 g/dL (1.05) Administration of DA every three weeks occurred in 54.01% of the pts. Mean (SD) DA administration was 9.20 weeks (5.31). Hematopoietic response (defined as Hb ≥ 12 g/dL or Hb rise from baseline >2 g/dL in the absence of RBC transfusions during the previous 28 days) occurred in 63.24% (95% CI 59.49–66.83) of pts. A total of 88 pts (12.85%) required RBC transfusions from week 5 to end of treatment. Mean Hb (SD) at the end of treatment with DA was 11.36 g/dL (1.73). Adverse event (AE) potentially related to DA were reported in 20 pts (2.92%) and considered severe in 6 cases (0.88%). Conclusions: The findings of this study indicate that the use of DA for the treatment of CIA in real-life, daily oncology and haematology practice, is well-tolerated and effective for increasing haemoglobin to reduce the need of RBC transfusions.

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Bevacizumab (B), cisplatin, and vinorelbine in chemotherapy-naive patients (p) with nonsquamous non-small cell lung cancer (NSCLC): A Galician Lung Cancer Group phase II study

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Background: Bevacizumab, an anti-VEGF monoclonal antibody, improves response rates and prolongs survival in p with non squamous NSCLC when combined with carboplatin-paclitaxel or cisplatin-gemcitabine. This single-arm, open-labeled phase II trial aims to evaluate the efficacy and safety profile of B in combination with another widely used chemotherapy doublet for NSCLC: cisplatin and vinorelbine. Methods: Chemotherapy-naïve p diagnosed with stage IIIB or IV non squamous NSCLC received cisplatin (80 mg/m2), vinorelbine (25 mg/m2 IV days 1 and 8) and B (15 mg/kg IV) on day 1 every 3 weeks for up to 6 cycles followed by B 15 mg/kg alone every 3 weeks until disease progression. Main eligibility criteria were: PS 0–1, no brain metastases, no history of hemoptysis, stable cardiac condition and no full dose anticoagulation. Primary endpoint was progression-free survival and secondary endpoints were RR, duration of response, OS, 1-year survival and safety profile of the combination. Results: 38 p have been enrolled in the study and data of 27 p have been included in this analysis. P characteristics were: male 66.7%; median age 57 years (range 41–74); ECOG PS 0/1 (%) 33.3/66.7; adenocarcinoma/other (%) 74.1/25.9; stage IIIB/IV (%) 25.9/74.1. Median number of cycles for B/cisplatin/vinorelbine was 4.0 (range 1–6) and median number of cycles for B maintenance was 2 (range 1–4). 17 p were evaluable for response according to RECIST criteria: PR 29.4% and SD 41.2%. With a median follow-up of 3.9 months (range 0.7–11.1), median PFS was 4.6 months (95% CI: 2.6–6.6) and median OS has not been reached yet. Hematological toxicities were: 1 p gr. 3 anemia; 2 p gr. 3 and 2 p gr. 4 leucopenia; 10 p gr. 3, 1 p gr. 4 neutropenia and 3 p febrile neutropenia. Most common grade 3/4 non hematological toxicities were: vomiting (1p gr. 4), high blood pressure, asthenia and hyperglycemia. 1 p experienced gr. 4 abdominal pain, 1 p. gr. 4 constipation, 1 p. gr. 4 nausea and 1 p gr. 4 respiratory infection. No grade 3/4 hemoptysis were reported. Conclusions: This interim analysis shows that B in combination with cisplatin and vinorelbine is safe and well tolerated and has a promising activity in chemo-naïve p with non squamous NSCLC. Survival data will be updated.

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Erlotinib as maintenance therapy after concurrent chemoradiotherapy in patients (p) with stage III non-small cell lung cancer (NSCLC): A Galician Lung Cancer Group phase II study

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Background: Combination of platinum-based chemotherapy and radiotherapy is the standard treatment for p with unresectable stage III NSCLC, but considering the high rates of recurrence, it is necessary to improve these results. Erlotinib is an EGFR TKI that prolongs survival in p with recurrent and metastatic NSCLC. In this study, we aim to evaluate the role of erlotinib as maintenance therapy after a standard concurrent chemo-radiotherapy regimen in p with stage III NSCLC. Methods: P with unresectable stage IIIA/IIIB—without malignant effusions—NSCLC who had received a standard concurrent chemo-radiotherapy regimen and had no evidence of tumor progression were enrolled in this single arm, open-label phase II study and received erlotinib 150 mg/day po for 6 months. Main eligibility criteria were: PS 0–2, adequate bone marrow, hepatic and renal function and measurable disease by RECIST criteria. Primary endpoint was the percentage of p without evidence of disease progression after 6 months of erlotinib therapy and secondary endpoints were: PFS, OS, ORR and safety profile. Results: 49 p have been included in the study and data from 37 p are presented in this analysis. Baseline characteristics: median age 62 years (range 41–76); male 94.6%; caucasian 100%; smokers/never smokers (%) 97.3/2.7; ECOG PS 0/1/2 (%) 18.9/75.7/2.7; adenocarcinoma/squamous cell carcinoma/large cell carcinoma (%) 16.2/75.7/5.4; stage IIIA/IIIB (%) 16.2/83.8. Most common previous chemo-radiotherapy regimen is cisplatin/docetaxel/RT (83.8%). 27 p were evaluable for tumor response: CR 22.2%; PR 12.8%; SD 55.6%; PD 7.4%. Median TTP was 7.3 months (95% CI 5.8–16.9) and median OS was 18.7 months (95% CI 11.8-NA). Most common adverse events related to erlotinib were rash 30.6% (3 p gr. 3) and diarrhea 16.7%. Conclusions: Erlotinib as maintenance therapy is an active and well tolerated treatment after concurrent chemo- radiotherapy in p with stage III NSCLC. In spite of the majority of patients are caucasian, males, smokers with squamous cell carcinoma, maintenance with single agent erlotinib reached a promising median OS of 18.7 months. Updated data will be presented.

No significant financial relationships to disclose.

A phase II randomized trial of gemcitabine-docetaxel versus gemcitabine-cisplatin in patients with advanced non-small cell lung carcinoma

PURPOSE

To test efficacy and tolerability of non-platinum regimens for advanced non-small-cell lung cancer (NSCLC).

METHODS

Chemonaive patients with measurable stage IIIB/IV NSCLC treated with gemcitabine and cisplatin (GC), or gemcitabine and docetaxel (GD), maximumsix cycles in a phase IIB trial.

RESULTS

A total of 108 patients were randomized. Response rates (GC vs. GD, respectively): complete 3.6/2.0%, Partial 30.9/38.0%. Median Overall Survival (OS): 8.9 months in both groups (P = 0.53); and median time to progression (TTP): 6.2/5.5 months respectively (P = 0.61). Toxicities included (GC vs. GD, respectively): grade 3-4 neutropenia 49.1/41.2%; grade 3 thrombocytopenia 30.9/3.9%; grade 3 anemia 14.5/3.9%. Non-haematological toxicity was similar, except for nausea and vomiting, (16.3/2%); renal toxicity (3.7/0%) and hepatic toxicity (5.6/12.7%).

CONCLUSIONS

With a higher overall response rate and lower toxicity, GD is a good first treatment option for advanced NSCLC.

Biweekly paclitaxel as second-line treatment in advanced non-small cell lung-cancer (NSCLC). A phase II study of the Lung Cancer Galician Group

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Background: Paclitaxel is an active drug for NSCLC. Our purpose was to evaluate the efficacy and toxicity of biweekly administration of this drug in previously treated patients with advanced NSCLC. Methods: Patients with stage IIIB and IV NSCLC, which progressed after or during first-line chemotherapy, measurable disease, ECOG PS=0–1 and adequate organ function were included. Paclitaxel was administered at 150 mg/m2 iv, days 1 and 14, every 28 days, for a maximum of six cycles. Both, toxicity and efficacy analyses, were performed on the intent-to-treat (ITT) population. Results: Between September 2004 and November 2006, 42 patients (M/F, 39/3) were included, with median age 64 years (39–79). Tumor histology mainly included epidermoid (40.5%) and adenocarcinoma (35.7%). Tumor stage was IIIB (23.8%) and IV (76.2%). Median number of metastatic lesions was 1 (55%), located mainly in lymph nodes (30%), lung (25%), adrenal glands (16%) and bone (11%). Previous chemotherapy included platinum (76.1%), docetaxel (66.6%) and gemcitabine (52.4%). A total of 167 cycles (median 4, range 1–6) were administered. Median relative dose intensity was 94%. Toxicity: Grade III/IV hematologic toxicities per patient were neutropenia (2.5%) and anemia (2.5%). Grade III/IV non-hematologic toxicities were asthenia (2.5%), arthralgias/myalgias (2.5%) and peripheral neuropathy (2.5%). Efficacy: Of 39 ITT patients (3 patients have just begun chemotherapy), 7 achieved PR, 11 SD and 16 progressed, resulting in an ORR of 17.95% (95% CI: 5.9–30%). Five patients could not be evaluated for response due to early withdrawal (4 tumor-related exitus and 1 PS deterioration). Median TTP and OS were 174 days (95% CI: 115.52–232.48) and 332 days (95% CI: 261.18–402.82), respectively. Conclusions: Biweekly paclitaxel is an active and very well tolerated regimen in previously treated patients with advanced NSCLC.

No significant financial relationships to disclose.