The "Little Circles Test" (LCT): a dusted-off tool for assessing fine visuomotor function

BACKGROUND

The fine visuomotor function is commonly impaired in several neurological conditions. However, there is a scarcity of reliable neuropsychological tools to assess such a critical domain.

AIMS

The aim of this study is to explore the psychometric properties and provide normative data for the Visual-Motor Speed and Precision Test (VMSPT).

RESULTS

Our normative sample included 220 participants (130 females) aged 18-86 years (mean education = 15.24 years, SD = 3.98). Results showed that raw VMSPT scores were affected by higher age and lower education. No effect of sex or handedness was shown. Age- and education-based norms were provided. VMSPT exhibited weak-to-strong correlations with well-known neuropsychological tests, encompassing a wide range of cognitive domains of clinical relevance. By gradually intensifying the cognitive demands, the test becomes an indirect, performance-oriented measure of executive functioning. Finally, VMSPT seems proficient in capturing the speed-accuracy trade-off typically observed in the aging population.

CONCLUSIONS

This study proposes the initial standardization of a versatile, time-efficient, and cost-effective neuropsychological tool for assessing fine visuomotor coordination. We propose renaming the VMSPT as the more approachable "Little Circles Test" (LCT).

The Neglected Factor in the Relationship between Executive Functioning and Obesity: The Role of Motor Control

Background: The association between obesity and executive functions (EFs) is highly controversial. It has been suggested that waist circumference (WC), compared to body mass index (BMI), is a better indicator of fat mass and EFs in obesity. Moreover, according to the viewpoint that the brain’s functional architecture meets the need for interactive behavior, we hypothesize that the relationship between EFs and body weight might be mediated by the motor performance. Methods: General executive functioning (frontal assessment battery-15), additional cognitive subdomains (trail making test and digit span backward), and motor performance (finger tapping task) were assessed in a sample that included 330 volunteers (192 females, M age = 45.98 years, SD = 17.70, range = 18–86 years). Results: Hierarchical multiple regression analysis indicated that the FAB15 score and FTT negatively predicted WC but not BMI. A subsequent mediation analysis highlighted that the indirect effect of FAB15 on WC through finger tapping was statistically significant. Conclusions: Our results suggest that WC, as compared to BMI, is a more effective measure for studying the association between EFs and body weight. Still, we found that the motor domain partially mediates the dynamics of such a relationship.

Comparative safety profiles of intravitreal bevacizumab, ranibizumab and pegaptanib: the analysis of the WHO database of adverse drug reactions

PURPOSE

The purpose of this study is to conduct a comparative analysis of the suspected adverse drug reactions (ADRs) associated with intravitreal bevacizumab, ranibizumab and pegaptanib in the WHO database in order to have a real-life information on these drugs, which now is only based on data coming from clinical trials.

METHODS

ADR reports for intravitreal use of bevacizumab, ranibizumab and pegaptanib from January 2002 to December 2012 were selected from the WHO-VigiBase. Reporting odds ratio (ROR) with confidence interval of 95 % and p value was calculated. The analysis was performed for drug-reaction pairs. The Medical Dictionary for Regulatory Activities (MedDRA) terminology for ADRs was used.

RESULTS

The analysis was performed on 3180 reports corresponding to 7753 drug-reaction pairs. Significant RORs for endophthalmitis and uveitis (1.90, 95 % confidence interval (CI) 1.48-2.43, and 10.62, 6.62-17.05, respectively) were retrieved for bevacizumab, and cerebrovascular accident and myocardial infarction produced significant ROR (1.54, 1.14-2.10 and 1.73, 1.18-2.53, respectively) for ranibizumab. Pegaptanib was significantly associated with visual impairment (1.98, 1.12-3.5, p = 0.02), nausea (3.29, 1.57-6.86, p < 0.001), vomiting (2.91, 1.2-7.07, p = 0.01) and drug hypersensitivity (8.75, 3.1-24.66, p < 0.001).

CONCLUSIONS

Our data showed an elevated disproportionality for cardiovascular ADRs in patients treated with ranibizumab and for infective ocular reactions in those treated with bevacizumab. No relevant safety issues were identified for pegaptanib. These findings suggest bevacizumab as a suitable choice for AMD therapy due to its effectiveness similar to that of ranibizumab, its favourable safety profile and for its lower cost.

Sgk1 enhances RANBP1 transcript levels and decreases taxol sensitivity in RKO colon carcinoma cells

The serum- and glucocorticoid-regulated kinase (Sgk1) is essential for hormonal regulation of epithelial sodium channel-mediated sodium transport and is involved in the transduction of growth factor-dependent cell survival and proliferation signals. Growing evidence now points to Sgk1 as a key element in the development and/or progression of human cancer. To gain insight into the mechanisms through which Sgk1 regulates cell proliferation, we adopted a proteomic approach to identify up- or downregulated proteins after Sgk1-specific RNA silencing. Among several proteins, the abundance of which was found to be up- or downregulated upon Sgk1 silencing, we focused our attention of RAN-binding protein 1 (RANBP1), a major effector of the GTPase RAN. We report that Sgk1-dependent regulation of RANBP1 has functional consequences on both mitotic microtubule activity and taxol sensitivity of cancer cells.

Hyperthyroidism in men with germ cell tumors and high levels of beta-human chorionic gonadotropin

A retrospective review was done on all high volume choriocarcinomas and other germ cell tumors of men with serum beta-human chorionic gonadotropin (beta-HCG) levels greater than 50,000 mIU/ml to determine the incidence and characteristics of hyperthyroidism in this setting. Nineteen patients were identified with high beta-HCG levels, but because 2 did not have thyroid function tests performed, the cases of only 17 patients were evaluable. Of these, 14 (82%) had primary testicular carcinoma and 3 (18%) had extragonadal tumors. Beta-HCG levels on presentation ranged from 80,000 to 3,058,000 mIU/ml, with a median of 243,500 mIU/ml. Seven of the 17 evaluable cases (41%) had T4 serum levels higher than 12 micrograms/dl (normal level 4 to 12 micrograms/dl) with a median value of 15.4 micrograms/dl (range, 12.6 to 33.5 micrograms/dl); serum T4 levels correlated with beta-HCG levels (r = 0.84). All seven patients with elevated T4 levels had beta-HCG values greater than 200,000 mIU/ml, and three of these seven had clinical manifestations that could be attributed to an elevated serum T4; only one patient required specific antithyroid treatment; and after control of primary disease, all other patients had normalization of thyroid function. The most common manifestations of hyperthyroidism in our series were tachycardia, hypertension, and a systolic flow murmur; none of the patients had thyroid gland enlargement. We conclude that subclinical hyperthyroidism is a relatively common phenomenon in germ cell tumors of men with high levels of beta-HCG and that control of the primary disease results in serum T4 level normalization.

A phase I study of everolimus plus sorafenib in patients with metastatic renal cell carcinoma (mRCC)

e16056

Background: Everolimus, a mTOR inhibitor and Sorafenib, a Raf kinase inhibitor had shown their efficacy in RCC, as single agents. Combining these two active agents could have potential additive or synergistic effects. We conducted a phase I study to evaluate the maximum tolerated dose (MTD) of this combination in patients with progressive mRCC. Methods: Patients predominantly had clear cell RCC, and progressive measurable diseases on prior treatments including immunotherapy, TKI and/or Everolimus. Patients were evaluated weekly for toxicities and every 8 weeks for radiological response, including at least both PET/CT and CT scans at baseline and 1st staging. Patients received daily Everolimus and twice daily sorafenib both orally at escalating dose levels of 2.5mg/400mg (dose level 0), 5mg/400mg (+1), and 10mg/400mg (+2). Results: 18 patients with mRCC were enrolled and 15 patients were evaluable. 6 patients were treated on dose level 0, dose- limited toxicity (DLT) was found in 2/6 patients, one with thrombocytopenia/leukopenia, the other with pneumonitis; 6 patients were treated on dose level +1, DLT of pulmonary embolism was found in 1/6 patient; and 3 patients were treated on dose level +2, without DLT. The most common side effect was grade 1/2 hand-foot syndrome (4/15, 27%). The MTD was dose level +2. Overall response by RECIST was 27% (4/15 patients): pathological complete response (CR) was 6% (1/15); radiographic CR was 6% (1/5); surgical CR after resection was 6% (1/15). 47% (7/15) of the patients had stable disease. Decreased FDG uptake was found in 67% (10/15) of the patients. The median PFS was 5.53 months (range, 1.4–14.7), and OS was 7.9 months (range, 2.3–23). Conclusions: The MTD of combining daily Everolimus 10mg and twice daily sorafenib 400mg are safe and effective for progressive metastatic RCC. The phase II trial is planned to start in early 2009.

[Table: see text]

Granulocyte macrophage: Colony stimulating factor (GM-CSF), ketoconazole, and mitoxantrone as second-line therapy in patients (Pts) with progressive hormone refractory prostate cancer (HRPC)

e16033

Background: A variety of docetaxel regimens have been tested in HRPC pts, yielding response rates between 38% - 69%. Docetaxel therapy has been widely used as first line therapy. Second line therapies, which are non - taxane based with comparable activities do not exist. This trial is built on the significant body of work which has demonstrated anti-tumor activity of GM-CSF, Ketoconazole and Mitoxantrone alone and in combination in pts with HRPC. The trial is designed to assess the combination of all three agents. Methods: No more than two prior chemotherapy regimens (one which contained docetaxel), progressive disease, and adequate marrow / organ function. Treatment consisted of: Ketoconazole daily 400mg po tid, GM-CSF subcutaneous 250mcg / m2 (14 days on/ 7 days off) and Mitoxantrone 12mg / m2 every 3 weeks (maximum cumulative dose of 140mg / m2), until either the completion of Mitoxantrone or maximum anti-tumor benefit. Pts continued Ketoconazole/ GM-CSF until disease progression. PSA was evaluated every 3 weeks and radiographic studies were performed every 9 weeks. Results: 31 pts were enrolled; 4 pts with PSA only, 9 bone only, 5 soft tissue only, and 13 bone and soft tissue. 2 pts withdrew from study due to toxicity. 8 pts had a PSA response of ≥ 50%, 5 pts had a PSA response of ≥ 80%, and 7 pts had a PSA response of ≥ 90%. 9 pts progressed. The majority of pts had stabilization of their bone and soft tissue involvement and 2 pts with nodal involvement demonstrated a radiographic CR. Significant adverse events included grade III/IV neutropenia, thrombocytopenia, and nausea. Median duration of treatment was 6.22 months (range 2 months - 20.5 months). Conclusions: GM-CSF, Ketoconazole and Mitoxantrone in combination demonstrate significant anti-tumor activity and reversible toxicity in pts who have failed prior docetaxel therapy. Information regarding PSA response, radiographic outcome and adverse event data will be presented. This data warrants further investigation such as a randomized phase II study.

[Table: see text]

Vaccination of renal cell cancer (RCC) patients with modified vaccinia Ankara (MVA) delivering tumor antigen 5T4 administered alone or with interleukin 2 (IL-2) or interferon-alpha (IFN)

3026

Background: The attenuated vaccinia virus (MVA) has been engineered to deliver the tumor antigen 5T4 (TroVax). More than 90% of RCCs overexpress the 5T4 antigen. A series of clinical trials were conducted to evaluate the effectiveness of MVA 5T4 as a single agent or in combination with either IL-2 or IFN. Methods: Eligibility: Pathologic diagnosis of clear cell or papillary RCC, progressive measurable metastases, any prior therapy, adequate physiological parameters, Karnofsky performance status ≥ 80%, and no active CNS involvement. A regimen of MVA 5T4 alone or in combination with IL-2 or IFN was given. Results: A total of 53 pts received MVA 5T4 alone or in combination with IL-2 or IFN. 13 pts received MVA 5T4 alone, 25 pts received low dose subcutaneous IL-2, and 15 pts received IFN. Clinical responses were assessed by measuring changes in tumor burden via computed tomography or magnetic resonance imaging scan. 5T4-specific cellular and humoral responses were monitored throughout the study. 5T4 was well tolerated with no serious adverse events attributed to vaccination. Of 48 intention-to-treat pts, 43 mounted 5T4-specific antibody responses. 2 pts showed a complete response for > 36 months and 2 other pts had a partial response for > 24 months and 12 months respectively. 20 pts demonstrated disease stabilization for ≥ 3 months. Median progression-free survival and overall survival for all pts was 3.6 months (range 0.8–29.7) and 13.2 months (range 1–38) respectively. A significant relationship was detected between the magnitude of 5T4-specific antibody response and overall survival. Conclusions: 5T4, whether administered alone or in combination, was well tolerated. High frequency of 5T4-specific immune responses and associated enhanced patient survival is encouraging and warrants further investigation.

[Table: see text]

A phase II trial of RAD001 in patients (Pts) with metastatic renal cell carcinoma (MRCC)

5107

Background: RAD001 is an oral mammalian target of Rapamycin (mTOR) inhibitor. Three mechanisms of anti-tumor activity; shuts down tumor response to nutrients and growth factors; cell cycle arrest at late G1 and anti-angiogenesis via VEGF. Molecular alterations in the mTOR modular pathway increase sensitivity in PTEN deficient tumors such as RCC. Endpoints: time-to-progression (TTP), response rate (RR), overall survival (OS), toxicity, and to assess changes in metabolic imaging utilizing CT-PET. Methods: Eligibility included; predominant clear cell, progressive measurable MRCC, adequate organ/marrow function, zubrod performance status (ZPS) = 2, no more than 1 prior therapy, and no active CNS involvement. RAD001 is given orally at a dose of 10mg daily without an interruption (28-day cycle), with dose modifications for toxicity. Re-evaluation was assessed every 2 cycles (8 weeks). RECIST criteria is utilized. TTP and OS are determined from entry into the study. Results: 41 pts have been enrolled. 37 pts are evaluable for response/toxicity. 2 pts toxicity only. 2 pts screened failures. 31 were male/8 female, median age 60 (38–80) years. 31 pts received prior therapy. 23 pts had a ZPS of 0, 13 /1 and 3/2. Sites of disease included; lung, nodal, liver, bone, adrenal, and kidney. 9 pts had 1 metastatic site, 17 pts/2 and 13 pts/3 or more. 15 pts continue to receive RAD001. 12 pts had partial responses, 19 pts were stable for 3+ months. Median duration of therapy is 8+ (range 01–20+) months. Treatment related adverse events; mucositis, skin rash, pneumonitis, hypophosphatemia, hyperglycemia, hypertriglyceridemia, hypercholesterolemia, thrombocytopenia, anemia and elevated LFTs. PET scans have demonstrated decreased metabolic activity in responding or stable pts. Median overall survival is 11.5+ months (range 01–20+). Conclusion: RAD001 has promising anti-tumor activity in pts with MRCC demonstrated by partial response rate. Anti-tumor activity is further suggested by prolonged TTP =3 months. Anti-tumor activity, toxicity and metabolic imaging correlation will be presented. An additional 40 pts who failed prior sunitinib or sorafenib therapy are being enrolled.

No significant financial relationships to disclose.

Activity of MVA 5T4 alone or in combination with either interleukin-2 (IL-2) or interferon-α (IFN) in patients (Pts) with metastatic renal cell cancer (MRCC)

3069

Background: MVA 5T4 consists of the highly attenuated modified Vaccinia Ankara virus containing the gene encoding the human TAA 5T4. Ninety percent or more of RCCs overexpress the 5T4 antigen. A series of clinical trials were conducted to evaluate the effectiveness of MVA 5T4 as a single agent or in combination with Interleukin-2 or Interferon Alpha 2B. Methods: Eligibility: pathologic diagnosis of clear cell or papillary RCC, progressive measurable metastases, any prior therapy, adequate physiologic parameters, Karnofsky performance status (KPS) = 80%, and no active CNS involvement. A regimen of MVA 5T4 alone or in combination with IFN or IL-2 was given. Results: A total of 41 patients received MVA 5T4 alone or in combination. 33 patients received MVA 5T4 with low dose IL-2 or IFN. 23 pts had clear cell; 12 papillary; 5 mixed clear cell; and 1 mixed papillary. 19 pts continue to receive therapy. 2 pts (both clear cell RCC) developed complete responses, 3 pts/partial responses (2 clear cell, 1 papillary) 8 pts/stable for 3+months and 6 pts are too early to be staged at this time. Median duration of therapy is 3.0+ (1+-13+) months. Conclusion: Although comparable antibody response were observed in papillary and clear cell histotypes, clear cell patients appeared to be more likely to respond in terms of clinical benefit parameters, to be presented. Of note is that preliminary analysis of clear cell patients suggests a relationship between the anti-5T4 immune response and tumor response. With the immunological potency and encouraging clinical activity, the future research will focus on the phase 3 randomized, double-blind, placebo controlled parallel group study to investigate whether MVA 5T4, added to first line standard of care therapy, prolongs the survival of patients with locally advanced or metastatic clear cell as well as studies to further optimize MVA 5T4 potency.

[Table: see text]

A phase II study of FolateImmune (EC90 with GP1–0100 adjuvant followed by EC17) with low dose cytokines interleukin-2 (IL-2) and interferon-α (IFN-α) in patients with refractory or metastatic cancer

13516

Background: FolateImmune is a folate-receptor (FR)-targeted immunotherapy that induces an immune response against tumor cells by marking them with a folate-hapten conjugate. The conjugate is specifically designed to target FR, which is over-expressed in a variety of cancers. FolateImmune therapy is comprised of a vaccine fluorescein conjugate (EC90), an adjuvant (GP-0100), and a folate-hapten conjugate (EC17). Patients (pts) receive a series of subcutaneous (SQ) injections of EC90 vaccine to stimulate the production of antibodies to the fluorescein-hapten, followed by SQ injections of EC17, which forms a molecular bridge between the tumor cell and the endogenous circulating anti-fluorescein IgG antibody. This is thought to initiate an Fc-mediated immune response leading to antibody-dependent cellular cytotoxicity and/or phagocytosis. IL-2 and IFN are utilized at low doses (7 MIU and 3 MIU, respectively) to further promote an immune response. The Phase Ib objective is to determine the safety of EC90 vaccine/EC17 folate-targeted therapy in combination with IL-2 and IFN. The previous phase I trial explored the safety of FolateImmune without cytokines. Methods: This phase 1b safety study treated eligible patients with FolateImmune therapy at dose levels of 1.2 mg EC90 and EC17 of 0.3 mg/kg. Results: As of Jan 2, 2007, all patients have tolerated therapy without significant toxicity. Grade 1–2 toxicity included: chills, fever, and nausea. One patient has had a minor response and continues on study. Laboratory studies revealed decline in circulating FR+ cells. Of 6 pts enrolled, 5 had a pathologic classification of renal cell cancer (RCC). Conclusion: Preliminary data suggest that FolateImmune therapy, with the addition of low dose cytokines, may be administered in a safe and well-tolerated manner. Phase II trials are planned for RCC.

No significant financial relationships to disclose.

Phase II study of lenalidomide in patients (pts) with metastatic renal cell cancer (MRCC)

4533

Background: Immunomodulatory drugs are compounds that originated via the deliberate structural modification of thalidomide. Lenalidomide (Revlimid) is a derivative with enhanced immunological and anti-angiogenic properties lacking toxicities associated with thalidomide. Objectives were to determine response rate, time to progression (TTP), one-year survival, and toxicity in patients with progressive MRCC. Methods: Eligibility included: progressive measurable MRCC, adequate organ/marrow function, zubrod performance status (ZPS) ≤ 2, ≤ 1 prior therapy, and no active CNS involvement. Lenalidomide is administered orally at a dose of 25mg daily for 21 days with 7 days rest (28-day cycle), with dose modifications for toxicity. Re-evaluation is done every 3 cycles (12 weeks). RECIST criteria is utilized to determine response rate. TTP is determined from entry into study. Results: 40 pts enrolled. 30 male/10 female, range 38–73 (median 63) years. 38 pts had clear cell carcinoma; 2 pts with papillary. 24 pts received prior immunotherapy and/or chemotherapy. 3 pts met criteria for good prognosis, 33 intermediate and 4 poor. Sites of disease included: lung, nodal, bone, adrenal, kidney, and liver. 17 pts had 1 metastatic site, 13 pts 2 metastatic sites, and 10 pts 3 or more metastatic sites. 36 pts completed at least 12 weeks of therapy. 4 pts had early progressive disease. 1 pt had a CR, 2 pts achieved a PR. 52% of pts had a prolonged TTP ≥ 6 months and 25% ≥ 12 months. Median overall survival of 14.8 months (4.1− 22.2+). Treatment related adverse events included: reversible grade 1/2 non-hematologic toxicity consisting of: nausea, diarrhea, constipation, myalgia and fatigue. 19 pts with grade 3/4 neutropenia and 9 pts with grade 3/4 thrombocytopenia. Median duration of therapy is 6 months (2 - 22). Conclusion: Lenalidomide was well tolerated. Anti-tumor activity has been demonstrated by the following: tumor regression and delayed TTP. The tumor effect was also demonstrated as a second line therapy following cytokine failure.

[Table: see text]

Gene expression profiling identifies two distinct papillary renal cell carcinoma (RCC) subgroups of contrasting prognosis

4503

Background: Despite the moderate incidence of papillary renal cell carcinoma (PRCC), there is a disproportionately limited understanding of its underlying genetic programs. There is no effective therapy for metastatic PRCC, and patients are often excluded from kidney cancer trials. A morphological classification of PRCC into Type 1 and Type 2 tumors has been recently proposed, but its biological relevance remains uncertain. Methods: We studied the gene expression profiles of 34 cases of PRCC using Affymetrix HGU133 Plus 2.0 arrays (54,675 probe sets) using both unsupervised and supervised analysis. Comparative genomic microarray analysis (CGMA) was used to infer cytogenetic aberrations, and pathways were ranked with a curated database. Expression of selected genes was validated by immunohistochemistry in 34 samples, with 15 independent tumors. Results: We identified two highly distinct molecular PRCC subclasses with morphologic correlation. The first class, with excellent survival, corresponded to three histological subtypes: Type 1, low-grade Type 2 and mixed Type 1/low-grade Type 2 tumors. The second class, with poor survival, corresponded to high-grade Type 2 tumors (n = 11). Dysregulation of G1/S and G2/M checkpoint genes were found in Class 1 and Class 2 tumors respectively, alongside characteristic chromosomal aberrations. We identified a 7-transcript predictor that classified samples on cross-validation with 97% accuracy. Immunohistochemistry confirmed high expression of cytokeratin 7 in Class 1 tumors, and of topoisomerase IIα in Class 2 tumors. Conclusions: We report two molecular subclasses of PRCC, which are biologically and clinically distinct, which may be readily distinguished in a clinical setting. This may also have therapeutic implications.

No significant financial relationships to disclose.

A multi-step approach to time series analysis and gene expression clustering

MOTIVATION

The huge growth in gene expression data calls for the implementation of automatic tools for data processing and interpretation.

RESULTS

We present a new and comprehensive machine learning data mining framework consisting in a non-linear PCA neural network for feature extraction, and probabilistic principal surfaces combined with an agglomerative approach based on Negentropy aimed at clustering gene microarray data. The method, which provides a user-friendly visualization interface, can work on noisy data with missing points and represents an automatic procedure to get, with no a priori assumptions, the number of clusters present in the data. Cell-cycle dataset and a detailed analysis confirm the biological nature of the most significant clusters.

AVAILABILITY

The software described here is a subpackage part of the ASTRONEURAL package and is available upon request from the corresponding author.

SUPPLEMENTARY INFORMATION

Supplementary data are available at Bioinformatics online.

[Epidemiology of salmonellosis in Caltagirone area (Sicily)]

The authors report the results of an epidemiological-clinical study concerning episodes of salmonellosis observed in Caltagirone (CT) from 1999 to 2002 and reported to the National Centre for Control of pathogen enterobacteria (enter-net Italy). Overall, two hundred and forty strains of salmonella were isolated, typed and in vitro tested for susceptibility to eleven different antibiotics. Cases were evaluated according to patients' age, risk factors and clinical findings. Salmonella enteritidis (39%) was the most prevalent serovar followed by S. typhimurium (16%), S. newport (6%), S. salamae (5%) and others. The highest rate of antibiotic resistance was observed in S. typhimurium.

[Sepsis: our series]

Sepsis understood as persistent bacteremia with considerable clinical symptomatology that can develop into septic shock, retains its clinical, diagnostic and therapcutic meaning. Its most recent definition as a systemic inflammatory secondary reaction to a verified infection may help us to understand the reactive events of the host against infections and prevent septic shock. We report clinical cases of sepsis with positive haemoculture observed in the Caltagirone (CT) Hospital in the last 15 years: 186 patients (117 males and 69 females), with particular focus on those over 61 years old and on patients admitted to the ICU. The clinical isolates and groups of the inpatients are listed. In particular, two cases of toxic shock syndrome and six cases of bacterial endocarditis are described. Mortality was about 30% for septic shock despite rational antibiotic therapy, support therapy and hospital admission to the intensive care unit

[Antibiotic resistance monitoring of nosocomial clinical isolates]

The authors evaluate the epidemiological trend of in vitro resistance of 2,196 clinical isolates, chiefly Gram-negative, in Caltagirone hospital in 1998/99 to piperacillin-tazobactam, piperacillin, cefotaxime, ceftazidime, ceftriaxone, imipenem, ciprofloxacin and tobramicin. The resistance percentage is reported for each year in order to study the phenomenon in time. The following results were obtained: resistance frequently increases or rarely stays constant in time for all antibiotics used; the resistance percentage is very high for some strains of bacteria; monitoring of resistance in a hospital can help in choosing the empirical therapy. Piperacillin-tazobactam, imipenem and ciprofloxacin were the most active drugs against clinical isolates.

An observational study on the epidemiology of respiratory tract bacterial pathogens and their susceptibility to four injectable beta-lactam antibiotics: piperacillin, piperacillin/tazobactam, ceftazidime and ceftriaxone

Bacterial infections of the respiratory tract account for a large proportion of total medical consultations in general practice. In recent years, antibiotic resistance has increased alarmingly in a number of bacterial species that are common causes of these infections. The aim of this observational study was to determine the antibiotic resistance of microbial agents isolated from patients with acute or acutely exacerbated respiratory infections. Subjects recruited as potential sources of bacteria were either outpatients seen in a number of specialized clinics and hospital practices, or hospitalized patients. Overall, 648 consecutive patients (67% male, mean age 48.1+/-27.0 years) with infection of the upper or lower respiratory tract were observed during a 13-month period. A total of 551 pathogenic microbial strains were isolated and tested for their in vitro susceptibility to piperacillin, piperacillin/tazobactam, ceftazidime, and ceftriaxone. Among all isolates, the four most frequent pathogens were Pseudomonas aeruginosa (132 isolates, 24%), Streptococcus pyogenes (99 isolates, 18%), Staphylococcus aureus (93 isolates, 17%), and Klebsiella pneumoniae (46 isolates, 8%). The susceptibility of gram-positive isolates ranged from 97.5% to 95.1%, and no remarkable difference was found in the antibacterial activity of tested b-lactam antibiotics. The susceptibility of gram-negative isolates to piperacillin and piperacillin/tazobactam was also similar: 96.5% and 97.1%, respectively. In contrast, differences were found between piperacillin (or piperacillin/tazobactam) and either ceftazidime (p=0.003) or ceftriaxone (p<0.0003) in gram-negative isolates. We conclude that, despite the extensive use of beta-lactam antibiotics (piperacillin, ceftazidime, and ceftriaxone) in medical practice during the past three decades, the susceptibility of the most common pathogens involved in the etiology of upper and lower respiratory tract infections to these antibiotics is still high. In particular, bacterial resistance developed by gram-positive organisms against piperacillin is negligible and not alarming.

Response of biochemical markers of bone turnover to estrogen treatment in post-menopausal women: evidence against an early anabolic effect on bone formation

Bone loss following menopause can be prevented or reduced by estrogen replacement therapy (ERT). The primary action of estrogen on bone is generally considered to be antiresorptive, but some evidence would also suggest a stimulatory effect on bone formation. The aim of this study was to assess the effect of ERT on biochemical markers of bone resorption (urinary pyridinoline and deoxypyridinoline), and of bone formation (bone-specific alkaline phosphatase--B-ALP, and the C-terminal propeptide of type I collagen--CICP) in a group of 25 postmenopausal women with no evidence of osteoporosis. Since the suggested anabolic effect of estrogen seems to take place in the early period of ERT, we measured the response of markers immediately before and after the start of treatment (30, 60, 120 and 180 days). The markers of bone resorption started to decrease at 30 days and remained low thereafter. We also observed a similar decrease in serum levels of B-ALP and CICP, reflecting a reduction of bone formation rate. Our data would indicate that ERT at the given dose does not have early anabolic effects on bone, in addition to its recognized suppressive effect on bone resorption.

Serum lactate dehydrogenase isoenzyme 1 and prediction of death in patients with metastatic testicular germ cell tumors

The International Germ Cell Cancer Collaborative Group study of patients with metastatic testicular germ cell tumors showed that catalytic concentration of serum lactate dehydrogenase (S-LD), serum alpha-fetoprotein concentration (S-AFP), and serum human chorionic gonadotropin concentration (S-hCG) predicted death from tumor. The recent international TNM classification (T primary tumor, N lymph node metastasis, M distant metastasis) is based on these results. The aim of our study was to evaluate whether catalytic concentration of S-LD isoenzyme 1 (S-LD-1) was a better predictor than the criteria used for the international classification. In an evaluation series of 44 patients from Odense University Hospital, Denmark, a raised S-LD-1 (>1.0 x upper limit of reference values) had a predictive value for death from tumor in 5-years observation of 46%. The predictive value was 46% for S-LD, 25% for S-AFP, and 40% for S-hCG. A normal SLD-1 had a predictive value for survival over 5-years observation of 100%. It was 81% for S-LD, 75% for SAFP, and 77% for S-hCG. The fraction of the patients who died of tumor and had a raised tumor marker value was 100% for S-LD-1, 46% for S-LD, 9% for S-AFP, and 18% for S-hCG. The fraction of patients with a normal serum tumor marker value among those who survived was 61% for S-LD-1, 81% for S-LD, 94% for SAFP, and 94% for S-hCG. A validation series of 37 patients treated at the University of Texas MD Anderson Cancer Center showed similar findings. Combining the patients in the two series, a raised value of SLD-1 classified more patients into a subgroup with an impaired survival (53%) than S-LD (35%), S-AFP (6%), or S-hCG (11%), and the high risk subgroups based on the international classification (40%). The findings have implications for the staging and treatment of patients with metastatic testicular germ cell tumors.

Thalidomide for recurrent renal-cell cancer in a 40-year-old man

A pilot study was performed at The University of Texas M. D. Anderson Cancer Center to determine the feasibility of using thalidomide in a population of renal-cell carcinoma patients who had progressive disease despite chemotherapy and immunotherapy. Metastatic renal-cell carcinoma patients with adequate oral function were entered onto a study after signing an internal review board-approved informed consent. There were no exclusion criteria for prior therapy. Nineteen previously treated patients and one untreated patient with progressive renal-cell carcinoma received oral thalidomide as a single agent. The starting dose was 200 mg and the dose was increased by 100 to 200 mg every week until it reached 1,200 mg/d. Response was assessed on the basis of a radiographic reduction of the metastatic sites involved. A case report describing one of the patients involved in the pilot trial is included.

A Phase II trial of bryostatin-1 for patients with metastatic renal cell carcinoma

BACKGROUND

Patients with metastatic renal cell carcinoma have a poor prognosis and no standard therapy is available. The authors performed a Phase II trial of the novel agent bryostatin-1 in this patient population.

METHODS

In all, 30 patients with measurable, previously untreated metastatic renal cell carcinoma were studied. Patients had excellent physiologic reserve and preserved performance status. Bryostatin-1 (25 microg/m(2)) was given in the PET (polyethyleneglycol, ethanol, and Tween 80) formulation as a 30-minute intravenous infusion on Days 1, 8, and 15 of each 28-day cycle. In general, treatment was continued until disease progression.

RESULTS

Two patients had significant objective responses, although methodologic problems made interpretation difficult. The median time to progression for all patients was 2.1 months; the median overall survival was 13.1 months. The treatment was generally well tolerated. Myalgia was the most common adverse event. One patient died while on study. This was a sudden death for a patient receiving a 15th cycle of therapy. Aside from this patient (for whom the correlation of study drug to death was not clear), no Grade 4 nonhematologic toxicity was encountered in more than 150 treatment courses delivered.

CONCLUSIONS

There is minimal, if any, clinically relevant single-agent activity of bryostatin-1 at this dose and schedule for patients with metastatic renal cell carcinoma.

Use of Dacron as an alternative carrier for evaluating oxidizing sterilants in the AOAC sporicidal test

The AOAC sporicidal method (966.04) recommends the use of porcelain penicylinders and black waxed silk sutures as carriers for demonstrating the sporicidal activity of sterilants. However, the silk carriers are not suitable for evaluating the sporicidal efficacy of oxidizing agents, and an inert polyester material (Dacron) is recommended as an alternative. Dacron provides an equivalent microbial and physical challenge to silk. Microbiologically, both materials demonstrated similar HCI resistance, which is required by the AOAC test, as well as equivalent spore loading and spore wash-off. Electron microscopy showed that both materials present the same braided microstructure, providing an equivalent physical challenge to the test sterilant. Dacron was more consistent than silk, and did not require extraction prior to spore loading. The extraction method for black waxed silk was variable and incomplete, which may compromise the activity of oxidizing sterilants and add to method variability. Silk was also structurally altered in the presence of oxidizing sterilants and increased sterilant degradation. Dacron did not affect the sterilant and was inert in the presence of oxidizing agents. Dacron sutures are proposed as inert alternatives to silk for evaluating the sporicidal efficacy of oxidizing agents.

Radioimmunodetection of residual, recurrent or metastatic germ cell tumors using technetium-99 anti-(alpha-fetoprotein) Fab' fragment

PURPOSE

The majority of patients with germ cell tumors are cured by multimodality therapy that consists of cisplatin-based chemotherapy and/or surgical resection. Serum tumor markers and conventional radiographs are utilized to stratify patients into treatment categories. Efforts to individualize chemotherapy or minimize surgical interventions without compromising outcome are important. Immunomedics (Morris Plains, New Jersey) developed an anti-(alpha-fetoprotein) (anti-AFP) monoclonal antibody IMMU-30 labeled with 15-20 mCi technetium-99, and the purpose of this study is to determine the sensitivity and specificity of radioimmunoscintigraphy using 99mTc anti-AFP antibody for the diagnosis of active germ cell tumors.

METHODS

A group of patients with germ cell tumors were enrolled in a non-prospective fashion and 48 AFP scans using 99Tc anti-AFP Fab' fragment were obtained. At the time of the AFP scan, serum AFP was elevated in 40 measurements with a median level of 21 ng/ml (1.6-66, 210.0 ng/ml). AFP scans were obtained at the initial staging, during treatment, at relapse or at long-term follow-up and compared with conventional radiographs done within 4 weeks of the AFP scans.

RESULTS

An overall diagnostic sensitivity of 89% and specificity of 58% were obtained.

CONCLUSIONS

AFP scanning appears useful and to be sufficiently sensitive to justify prospective studies comparing the procedure with conventional imaging.

Flavopiridol, a novel cyclin-dependent kinase inhibitor, in metastatic renal cancer: a University of Chicago Phase II Consortium study

PURPOSE

Flavopiridol is the first cyclin-dependent kinase (cdk) inhibitor to enter clinical trials. Serum levels of flavopiridol obtained during phase I studies were sufficient to inhibit in vitro cancer cell growth. Because responses were observed in kidney cancer patients in the phase I trials, we performed a phase II trial of flavopiridol in this patient population.

PATIENTS AND METHODS

Thirty-five minimally pretreated patients were accrued using a standard two-step mechanism. Flavopiridol (50 mg/m(2)/d) was administered by continuous infusion for 72 hours every 2 weeks, and response was evaluated every 8 weeks. Peripheral blood mononuclear cells (PBMCs) were collected at baseline, at completion of drug infusion, and on day 7 of the first therapy cycle, and cell cycle parameters after phytohemagglutinin and interleukin-2 stimulation were assessed.

RESULTS

There were two objective responses (response rate = 6%, 95% confidence interval, 1% to 20%). The most common toxicities were asthenia, occurring in 83% of patients (grade 3 or 4 in 9%), and diarrhea, occurring in 77% of patients (grade 3 or 4 in 20%). Also, nine patients (26%) experienced grade 3 or 4 vascular thrombotic events, including one myocardial infarction, two transient neurologic ischemic attacks, four deep venous thrombosis, and two pulmonary emboli. Cell cycle studies did not reveal any effect of flavopiridol on stimulated PBMCs.

CONCLUSION

Flavopiridol, at the dose and schedule administered in this trial, is ineffective in metastatic renal cancer. In addition to the diarrhea observed in phase I studies, we also observed a higher incidence of asthenia and serious vascular thrombotic events than expected.

Migraine with and without aura in the same patient: expression of a single clinical entity?

Migraine with aura and migraine without aura may be different clinical expressions of one disease. This theory is debated, however. In order to further address the issue, we administered a standardized questionnaire to 45 migraineurs. The results indicate a significant overlap between migraine with and without aura, most importantly with respect to response to therapy; 70% of patients had similar responses.

Optimal delivery of perioperative chemotherapy: preliminary results of a randomized, prospective, comparative trial of preoperative and postoperative chemotherapy for invasive bladder carcinoma

PURPOSE

We performed a planned interim analysis of a randomized trial comparing initial to postoperative chemotherapy for bladder cancer. The purpose of our analysis was to detect early evidence of survival differences, tolerance to therapy influenced by the sequence of treatment, predictive value of clinical state and influence of methotrexate, vinblastine, doxorubucin and cisplatin (M-VAC) on bladder resectability.

MATERIALS AND METHODS

A total of 100 consecutive patients were randomized to receive 2 M-VAC courses before and 3 courses after surgery (group 1) or 5 adjuvant M-VAC courses following cystectomy (group 2). Survival, clinical response, clinical and pathological stage, and toxicity were evaluated in this second timed interim analysis.

RESULTS

Of all patients 70% received at least 4 M-VAC courses. Overall survival at 31.7 months (range 1.8 to 87.7) was similar in groups 1 (60%) and 2 (63%), and independent of clinical stage. Preoperative clinical staging accurately identified patients at high risk for recurrence, while 37 of the 48 group 2 patients (77%) were considered at high risk by pathological staging (P3b, P4a, node-positive and unresectable disease). Comparison of pathological stage revealed that 14 of the 51 group 1 patients (28%) achieved stage P0 while only 1 of the 48 group 2 patients (2%) had P0 disease at surgery (p= 0.00043). Disease was unresectable in 3 group 1 (6%) and 8 group 2 patients (17%, p= 0.09). Tolerance to treatment was not significantly different in the 2 study arms.

CONCLUSIONS

No survival advantage was noted between neoadjuvant and adjuvant M-VAC in our interim analysis. However, results suggest that M-VAC chemotherapy may be effective in increasing the resectability of localized bladder cancer and may contribute to organ preservation. Clinical stage was a reliable predictor of pathological findings at surgery. Future studies can use clinical staging to determine therapy before surgery for the select stages that we treated. Identification of the subset likely to achieve complete pathological remission will permit the selection of patients for organ preservation strategies.

Paclitaxel, cisplatin and methotrexate combination chemotherapy is active in the treatment of refractory urothelial malignancies

PURPOSE

We investigated the activity of combination chemotherapy consisting of paclitaxel, cisplatin and methotrexate in patients with advanced urothelial cancers.

MATERIALS AND METHODS

A total of 25 consecutive patients with metastatic refractory urothelial malignancies was treated with a combination of 200 mg./m.2 paclitaxel, 30 mg./m.2 methotrexate and 70 mg./m.2 cisplatin in a pilot study.

RESULTS

There were no complete responses. Of 25 patients 10 (40%), including 3 of 7 with liver metastases, had a partial response. Hematological and nonhematological toxicity was tolerable.

CONCLUSIONS

The combination chemotherapeutic regimen of paclitaxel, cisplatin and methotrexate is active in patients with advanced urothelial cancer and warrants further study.