Diversity and demographics of APSA members: Understanding our identity

INTRODUCTION

There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care.

METHODS

1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests.

RESULTS

Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools.

CONCLUSION

There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential.

TYPE OF STUDY

Survey; original research.

LEVEL OF EVIDENCE

Level IV.

Lurbinectedin, a selective inhibitor of oncogenic transcription, in patients with pretreated germline BRCA1/2 metastatic breast cancer: results from a phase II basket study

BACKGROUND

Lurbinectedin, a selective inhibitor of oncogenic transcription, has shown preclinical antitumor activity against homologous recombination repair-deficient models and preliminary clinical activity in BRCA1/2 breast cancer.

PATIENTS AND METHODS

This phase II basket multitumor trial (NCT02454972) evaluated lurbinectedin 3.2 mg/m² 1-h intravenous infusion every 3 weeks in a cohort of 21 patients with pretreated germline BRCA1/2 breast cancer. Patients with any hormone receptor and human epidermal growth factor receptor 2 status were enrolled. The primary efficacy endpoint was overall response rate (ORR) according to RECIST v1.1. Secondary endpoints included duration of response (DoR), progression-free survival (PFS), overall survival (OS) and safety.

RESULTS

Confirmed partial response (PR) was observed in six patients [ORR = 28.6%; 95% confidence interval (CI) 11.3% to 52.2%] who had received a median of two prior advanced chemotherapy lines. Lurbinectedin was active in both BRCA mutations: four PRs in 11 patients (36.4%) with BRCA2 and two PRs in 10 patients (20.0%) with BRCA1. Median DoR was 8.6 months, median PFS was 4.1 months and median OS was 16.1 months. Stable disease (SD) was observed in 10 patients (47.6%), including 3 with unconfirmed response in a subsequent tumor assessment [ORR unconfirmed = 42.9% (95% CI 21.8% to 66.0%)]. Clinical benefit rate (PR + SD ≥ 4 months) was 76.2% (95% CI 52.8% to 91.8%). No objective response was observed among patients who had received prior poly (ADP-ribose) polymerase inhibitors. The most common treatment-related adverse events (AEs) were nausea (61.9%), fatigue (38.1%) and vomiting (23.8%). These AEs were mostly grade 1/2. The most common grade 3/4 toxicity was neutropenia (42.9%: grade 4, 23.8%: with no febrile neutropenia).

CONCLUSIONS

This phase II study met its primary endpoint and showed activity of lurbinectedin in germline BRCA1/2 breast cancer. Lurbinectedin showed a predictable and manageable safety profile. Considering the exploratory aim of this trial as well as previous results in other phase II studies, further development of lurbinectedin in this indication is warranted.

Hemoglobin A1c Is a Predictor of New Insulin Dependence After Partial Pancreatectomy: A Multi-Institutional Analysis

BACKGROUND

Pancreatic diseases have long been associated with impaired glucose control. This study sought to identify the incidence of new insulin-dependent diabetes mellitus (IDDM) after pancreatectomy and the predictive accuracy of hemoglobin A1c (HbA1c) or blood glucose.

METHODS

Patients who underwent partial pancreatectomy and had preoperative HbA1c available at two academic institutions were assessed for new IDDM on discharge in relation to complication rates and survival.

RESULTS

Of the 267 patients analyzed, 67% had abnormal HbA1c levels prior to surgery (mean 6.8%, glucose 135 mg/dL). Two hundred eight (77.9%) were not insulin-dependent prior to surgery, and 35 (16.8%) developed new IDDM after resection. On multivariable regression, increasing HbA1c and preoperative glucose were the only significant predictors for new IDDM. Optimal predictive cutoffs (HbA1c of 6.25% and glucose of 121 mg/dL) were determined in a discovery group (n = 143) and confirmed in a validation group (n = 124) with a diagnostic sensitivity of 72.7% and specificity of 84.8%. Patients with new IDDM after resection had higher rates of severe complications (OR 3.39), increased TPN at discharge (OR 4.32), and increased rates of discharge to nursing facilities (OR 2.57) (all P < 0.05). New IDDM was also associated with a decreased cancer-specific survival.

CONCLUSION

Preoperative HbA1c ≥ 6.25% and blood glucose ≥ 121 mg/dL can accurately identify patients at increased risk of IDDM. These diagnostics may help identify patients in a preoperative setting that may benefit from interventions such as diabetes education or enhanced glucose control preoperatively.

Long-term outcomes after resection of alcohol-related versus hepatitis-related hepatocellular carcinoma: A SEER-Medicare database analysis

BACKGROUND

The objective of this study was to define the relative impact of alcohol and/or hepatitis-related HCC etiology on the outcomes of patients who underwent resection or transplantation for HCC.

METHODS

The SEER-Medicare database was used to identify patients with HCC between 2004 and 2015. Patients with history of alcohol abuse or hepatitis were identified. Overall survival (OS) and cancer-specific survival (CSS) were calculated using the Kaplan-Meier method and multivariable Cox regression analysis.

RESULTS

Among 1140 patients, 11.9% (n = 136) of patients had alcohol-related HCC, 30.0% (n = 342) hepatitis-related HCC, and 58.1% (n = 662) had other cause-related HCC. On multivariable analysis, patients with alcohol-related HCC (HR:1.06, 95%CI:0.82-1.35) or hepatitis-related HCC (HR:1.05, 95%CI:0.88-1.26) had similar hazards of death compared with patients who had non-alcohol/non-hepatitis-related HCC. Patients who had tumor size ≤5 cm had lower hazards of death (HR:0.81, 95%CI:0.68-0.97), while individuals who underwent liver resection (vs. transplantation) had almost a two-fold higher hazards of death (HR:1.99, 95%CI:1.47-2.69).

CONCLUSION

Tumor specific factors (i.e. tumor size and stage) and operative approach (i.e. resection vs. transplantation) -rather than HCC etiology- dictated both OS and CSS.

Analysis of Authorship in Hepatopancreaticobiliary Surgery: Women Remain Underrepresented

INTRODUCTION

Given the need to increase female representation in hepatopancreatobiliary (HPB) surgery, as well as the need to increase the academic pipeline of women in this subspecialty, we sought to characterize the prevalence of female authorship in the HPB literature. In particular, the objective of the current study was to determine the proportion of women who published HPB research articles as first, second, or last author over the last decade.

METHODS

All articles pertaining to hepatopancreaticobiliary (HPB) surgery appearing in seven surgical journals (Annals of Surgery, British Journal of Surgery, JAMA Surgery, Annals of Surgical Oncology, HPB (Oxford), Surgery, and Journal of Gastrointestinal Surgery) were reviewed for the years 2008 and 2018. Information on sex of author, country of author's institution, and article type was collected and entered into a computerized database.

RESULTS

Among the 1473 index articles included in the final analytic cohort, 414 (28%) publications had a woman as the first or last author, while the vast majority (n = 1,059, 72%) had a man as the first or last author. The number of female first authors increased from 15.6% (n = 92/591) in 2008 to 25.7% (n = 227/882) in 2018 (p < 0.001). There were no differences in the proportion of second (n = 123/536, 23.0% vs n = 214/869, 24.6%, p = 0.47) or last (n = 44/564, 7.8% vs n = 88/875, 10.1%, p = 0.15) authors. Women were more likely to publish papers appearing in medium-impact journals (OR 1.40, 95% CI 1.04-1.88) and articles with a female author were more likely to be from a North American institution (referent: North America, Asia OR 0.43, 95% CI 0.31-0.59 vs Europe OR 0.67, 95% CI 0.51-0.87).

CONCLUSION

Women first/last authors in HPB research articles have increased over the past 10 years from 22 to 32%. Women as last authors remain low, however, as only 1 in 10 papers had a senior woman author. These data should prompt HPB leaders to find solutions to the gap in female authorship including mentorship of young female researchers and surgeons.

Pastoral care of cancer patients: Defining utilization of services at a comprehensive cancer center

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Background: Addressing the religious/spiritual needs of patients is an important component of comprehensive cancer care. Patients often report that providers infrequently engage them about their needs during treatment. In addition, providers cite inadequate training as a significant barrier to providing spiritual care. While patients may benefit from the presence of a spiritual care specialist during cancer treatment, the utilization and content of these services are not well defined. We sought to characterize utilization of pastoral care (PC) services, as well as delineate differences in PC utilization among patients with cancer. Methods: Data on patients being treated for cancer at a Comprehensive Cancer Center between 2015-2018 were obtained from the electronic medical record. Overall utilization, type of PC services utilized, as well as factors associated with use of PC were assessed. Analyses included descriptive statistics and logistic regression. Results: Among 14,322 cancer patients, roughly one-third (n = 5166, 36.1%) had at least one PC encounter during their cancer treatment. Interventions most frequently provided by PC included supportive presence (93.5%) and active listening (86.6%), while the most frequently explored topics were treatment expectations (59.8%), issues with faith/beliefs (42.9%), and available coping mechanisms (35.4%). Patients diagnosed with colorectal (OR:1.42, 95%CI:1.07-1.89), liver (OR:2.41, 95%CI:1.80-3.24), or pancreatic cancer (OR:1.43, 95%CI:1.02-2.00) were more likely to utilize PC services compared with other cancers. Patients that identified as Catholic (OR:1.47, 95%CI:1.17-1.84) or Christian (OR:1.73, 95%CI:1.39-2.15) were more likely to request PC services (both p < 0.001) than individuals who had no religious preference/affiliation. Among surgical patients (n = 1,174), the majority of encounters with PC services were in the postoperative setting (n = 801, 70.6%). Patients most often reported that PC helped with verbalization of their feelings (93.6%) and helped reduce stress (76.9%). Conclusions: Over one-third of patients with cancer interacted with PC and received services that often addressed both psychosocial and spiritual concerns. Overall PC utilization and types of PC services rendered varied relative to demographic and religious factors. Providers should be aware of varying patient religious/spiritual needs so as to optimize the entire cancer care experience for patients.

Racial/ethnic disparities in hospice utilization among Medicare beneficiaries dying from pancreatic cancer

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Background: While racial/ethnic treatment disparities among patients with pancreatic cancer have been documented, variation in other aspects of care including hospice utilization have not. As such, we sought to define the incidence, as well as characterize the timing, of hospice utilization among racial/ethnic minority patients following pancreatectomy for pancreatic cancer. Methods: The Medicare Standard Analytic Files were used to identify white and racial/ethnic minorities (African Americans and Hispanics) who underwent pancreatectomy for pancreatic cancer. Trends and timing related to overall hospice utilization among racial/ethnic minority and white patients were analyzed. Results: Among the 6,530 individuals (median age: 73, IQR 69-78; 51.5% female; 6.6% % racial/ethnic minority) who underwent a pancreatectomy for pancreatic cancer, 64.6% (n = 4221) had died by the end of the follow-period. Among deceased individuals, three-fourths of patients (n = 3149, 74.6%) had used hospice leading up to the time of death. Among individuals who died, age and comorbidity burden were similar among racial/ethnic minority and white patients; racial/ethnic minority patients were less likely, however, to have used hospice services compared with white patients (racial/ethnic minorities: n = 188, 68.9%, whites: n = 2,961, 75.0%; p = 0.024). On multivariable analysis, after controlling for clinical factors, racial/ethnic minority patients remained 27% less likely than whites to initiate hospice services prior to death (OR 0.73, 95%CI 0.56-0.95, p = 0.021). Despite overall lower use of hospice, racial/ethnic minority patients had comparable odds of late hospice utilization (i.e. within 3 days of death) versus white patients (OR 0.75, 95% CI 0.49-1.14, p = 0.18). Conclusions: While most patients undergoing pancreatectomy for pancreatic cancer utilized hospice services prior to death, ethnic/racial minority were less likely to use hospice services than whites. Further research should seek to better understand possible barriers to hospice initiation among racial/ethnic minority patients with cancer.

Postoperative Pancreatic Fistula Following Pancreaticoduodenectomy-Stratification of Patient Risk

BACKGROUND

Postoperative pancreatic fistula (POPF) remains a major cause of morbidity following pancreaticoduodenectomy (PD). We sought to develop and validate a risk score system that utilized preoperative computed tomography (CT) measurements, laboratory values, and intraoperative pancreatic texture to estimate risk of developing POPF after PD.

METHODS

Patients who underwent PD between 2014 and 2017 were identified. Pre- and intraoperative risk factors associated with POPF were identified. Three separate risk models were developed and assessed using multivariable analyses and receiver operating curves.

RESULTS

Among the 150 patients who underwent a PD, mean age was 64 years and the majority of the patients were male (59.3%, n = 89). Overall, the incidence of BL/POPF following PD was 22%. On multivariable analysis, factors associated with POPF included preoperative total serum protein < 6 g/dL (OR 3.35, 95% CI 1.04-10.34, p = 0.04), radiologic pancreatic duct diameter (OR 0.72, 95% CI 0.53-0.97, p = 0.03), intraoperative pancreatic gland texture estimated by surgeon (OR 0.17, 95% CI 0.05-0.62, p = 0.006), as well as intraoperative pancreatic duct diameter measured by surgeon (OR 0.77, 95% CI 0.61-0.98, p = 0.030). Each risk factor was assigned a weighted score (CT pancreatic duct diameter < 5 mm: 8 points; soft pancreatic gland texture: 5 points; total serum protein < 6 g/dL: 3 points; CT visceral abdominal fat ≥ 230 cm²: 2 points). Patients scoring 4-5 were at low risk of POPF, while patients with a score of 6-18 had a high risk for POPF. The Harrell's c-index for the scoring system was 0.71 (standard error [SD] 0.094) for the training set and 0.67 (SD 0.034) for the test set (with n = 1000 bootstrapping resamples).

CONCLUSION

A simple risk score for POPF that utilized preoperative radiologic and clinical variables combined with specific intra-operative factors was able to stratify patients relative to POPF risk with good discriminatory ability.

Index versus Non-index Readmission After Hepato-Pancreato-Biliary Surgery: Where Do Patients Go to Be Readmitted?

INTRODUCTION

The Center for Medicare and Medicaid Services (CMS) has identified readmission as an important quality metric. With an increased emphasis on regionalization of complex hepato-pancreato-biliary (HPB) surgery to high-volume centers, care of readmitted HPB patients may be fragmented if readmission occurs at a non-index hospital. We sought to define the proportion of HPB readmissions, as well as evaluate outcomes, that occur at an index versus non-index hospitals and to identify factors associated with non-index hospital readmission.

METHODS

The National Readmissions Database (NRD) was used to identify patients who underwent major HPB surgery between 2010 and 2015. Factors associated with readmission at 30 and 90 days at index versus non-index hospitals were analyzed. Differences in mortality and complications were analyzed among patients readmitted to index versus non-index hospitals.

RESULTS

A total of 49,080 patients underwent HPB surgery (liver n = 27,081, 55%; pancreas n = 14,787, 30%; biliary n = 7212, 15%). Overall, 6643 (14%) and 11,709 (24%) patients were readmitted within 30 and 90 days, respectively. Among all first readmissions, 18 and 21% were to a non-index hospital within the first 30 and 90 days, respectively. On multivariable analysis, factors associated with readmission to a non-index hospital included age (OR 1.19, 95% CI 1.05, 1.34), pancreatic cancer (OR 1.40, 95% CI 1.14, 1.34) and ≥ 3 comorbidities (OR 1.34, 95% CI 1.10, 1.63), while procedures on the pancreas (OR 0.69, 95% CI 0.61, 0.80), private insurance (OR 0.77, 95% CI 0.68, 0.87), initial admission at a large hospital (OR 0.77, 95% CI 0.65, 0.91), and initial admission length of stay > 7 days (OR 0.77, 95% CI 0.69, 0.86) were associated with decreased odds of a non-index hospital readmission (all p < 0.05). Patients readmitted to a non-index hospital had higher inpatient mortality (3.7 vs. 2.7%, p = 0.010).

CONCLUSIONS

Roughly 1 in 5 patients were readmitted to a non-index hospital where the initial HPB operation had not taken place. Readmission to a non-index hospital was associated with higher overall in-hospital mortality. The impact of regionalization of HPB care relative to site of subsequent readmission may have important implications for patients.

Perioperative use of blood products is associated with risk of morbidity and mortality after surgery

BACKGROUND

Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients.

METHODS

Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions.

RESULTS

Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10).

CONCLUSIONS

The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.

The Association Between Patient Satisfaction and Patient-Reported Health Outcomes

Objective:

Although patient satisfaction is increasingly used to rate hospitals, it is unclear how patient satisfaction is associated with health outcomes. We sought to define the relationship of self-reported patient satisfaction and health outcomes.

Design:

Retrospective cross-sectional analysis using regression analyses and generalized linear modeling.

Setting:

Utilizing the Medical Expenditure Panel Survey Database (2010-2014), patients who had responses to survey questions related to satisfaction were identified.

Participants:

Among the 9166 patients, representing 106 million patients, satisfaction was rated as optimal (28.2%), average (61.1%), and poor (10.7%). Main Outcome Measures: We sought to define the relationship of self-reported patient satisfaction and health outcomes.

Results:

Patients who were younger, male, black/African American, with Medicaid insurance, as well as patients with lower socioeconomic status were more likely to report poor satisfaction (all P < .001). In the adjusted model, physical health score was not associated with an increased odds of poor satisfaction (1.42 95% confidence interval [CI]: 0.88-2.28); however, patients with a poor mental health score or ≥2 emergency department visits were more likely to report poor overall satisfaction (3.91, 95% CI: 2.34-6.5; 2.24, 95% CI: 1.48-3.38, respectively).

Conclusion:

Poor satisfaction was associated with certain unmodifiable patient-level characteristics, as well as mental health scores. These data suggest that patient satisfaction is a complex metric that can be affected by more than provider performance.

The impact of a malignant diagnosis on the pattern and outcome of readmission after liver and pancreatic surgery: An analysis of the nationwide readmissions database

BACKGROUND AND OBJECTIVES

Reducing readmissions is an important quality improvement metric. We sought to investigate patterns of 90-day readmission after hepato-pancreatic (HP) procedures.

METHODS

The Nationwide Readmissions Database (NRD) was used to identify patients undergoing HP procedures between 2010 and 2014. Patients were stratified according to benign versus malignant HP diagnoses and as index (same hospital as operation) versus non-index (different hospital) readmissions.

RESULTS

Among the 41 059 patients who underwent HP procedures, 26 563 (65%) underwent a liver resection while 14 496 (35%) pancreatic resection. Among all patients, 11 902 (29%) had a benign diagnosis versus 29 157 (71%) who had a cancer diagnosis. Overall 90-day readmission was 22% (n = 8 998) with a slight increase in readmissions among patients with a malignant (n = 6 655;23%) versus benign (n = 2 343;20%) diagnosis (P < 0.001). Readmission to an index hospital was more common (n = 7 316 81%) versus a non-index hospital (n = 1 682 19%). Non-index hospital readmissions were more frequent among patients with malignant HP diagnoses (OR, 1.41;P  = 0.001).

CONCLUSIONS

Up to one in four patients were readmitted after HP surgery. Late readmission was more common among patients with a cancer-diagnosis. While most readmissions occurred at the index hospital, 19% of all readmissions occurred at a non-index hospital and were more frequent among patients with malignant diagnoses.

Epidermoid cyst within an intrapancreatic accessory spleen

This is a case of an epidermoid cyst in an intrapancreatic accessory spleen at the tail of the pancreas. Concurrent epidermoid cyst within the accessory spleen is an exceedingly rare entity. The patient initially presented with abdominal pain, nausea and vomiting. Imaging studies revealed a 3.6 cm cystic mass in the tail of the pancreas that was concerning for a mucinous cystic neoplasm (MCN). The patient underwent a robotic distal pancreatectomy for a suspected diagnosis of MCN, which following histologically examination was found to be an epidermoid cyst of an intrapancreatic accessory spleen. Further imaging characteristics are needed to characterise and differentiate these lesions from those of malignant potential. Robotic distal pancreatectomy is a safe alternative with many benefits including decreased length of stay and decreased blood loss.

Factors associated with poor outcomes in patients with lupus nephritis

The objective of this study was to identify the factors associated with important clinical outcomes in a case-control study of 213 patients with lupus nephritis. Included were 47% Hispanics, 44% African Americans and 9% Caucasians with a mean age of 28 years. Fifty-four (25%) patients reached the primary composite outcome of doubling serum creatinine, end-stage renal disease or death during a mean follow-up of 37 months. Thirty-four percent African Americans, 20% Hispanics and 10% Caucasians reached the primary composite outcome ( P < 0.05). Patients reaching the composite outcome had predominantly proliferative lupus nephritis (WHO classes: 30% III, 32% IV, 18% V and 5% II, P < 0.025) with higher activity index score (7 ± 6 versus 5 ± 5, P<0.05), chronicity index (CI) score (4 ± 3 versus 2 ± 2 unit, P<0.025), higher baseline mean arterial pressure (MAP) (111 ± 21 versus 102 ± 14 mmHg, P<0.025) and serum creatinine (1.9 ± 1.3 versus 1.3 ± 1.0 mg/dL, P<0.025), but lower baseline hematocrit (29 ± 6 versus 31 + 5%, P<0.025) and complement C3 (54 ± 26 versus 65 + 33 mg/dL, P<0.025) compared to controls. More patients reaching the composite outcome had nephrotic range proteinuria compared to controls (74% versus 56%, P<0.025). By multivariate analysis, CI (hazard ratio [95% CI] 1.18 [1.07-1.30] per point), MAP (HR 1.02 [1.00-1.03] per mmHg), and baseline serum creatinine (HR 1.26 [1.04-1.54] per mg/dL) were independently associated with the composite outcome. We concluded that hypertension and elevated serum creatinine at the time of the kidney biopsy as well as a high CI are associated with an increased the risk for chronic renal failure or death in patients with lupus nephritis.

Phase II study of bevacizumab in combination with cisplatin and docetaxel as first-line treatment of patients (p) with metastatic non-squamous non-small cell lung cancer (NSCLC)

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Background: Bevacizumab (B), in addition to platinum-based chemotherapy, is indicated for 1st-line treatment of p with advanced NSCLC other than predominantly squamous cell histology. B has been shown to improve progression free survival (PFS) and overall survival (OS) when combined with cisplatin/gemcitabine and carboplatin/paclitaxel, respectively. However, there are limited data on the safety and efficacy of B in combination with other widely used chemotherapy doublets for NSCLC. This is a single-arm, open- labeled, single-stage phase II trial of cisplatin (C), docetaxel (D) and B for NSCLC. Methods: Eligibility criteria: chemo- naïve, stage IIIB wet or IV, non-squamous NSCLC, PS 0–1, no brain metastases and no history of gross hemoptysis. P received D (75 mg/m2), C (75 mg/m2), 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 or toxicity. Primary endpoint: PFS. Results: 50 p were enrolled (enrollment completed): 24% female, median age 60 (36–74), PS 1: 64%, adenocarcinoma: 72%; stage IV: 92%. Two p did not start treatment. Median follow-up is 5.3 months (range 0–13.6). Median number of cycles of B was 7 (range 0–18). 56% completed 6 cycles of treatment; 24% received ≥ 12 cycles of B. Most frequent grade ≥ 3 toxicities: diarrhea (14.6%), fatigue (14.6%), dyspnea (9.8%), anorexia (4.9%), alopecia (4.9%), esophagitis (4.9%), constipation (4.9%), mucositis (12.2%), proteinuria (4.9%); hematological toxicities: neutropenia (22%), febrile neutropenia (9.8%), leucopenia (14.6%), lymphopenia (4.9%). Of interest, 41.5% developed grade <3 epistaxis and 17% hypertension (1 p grade 3). One p died due to hemoptysis. 46 p were evaluable for response: 29 PRs (ORR: 63%). 18 of 48 p have experienced progression or death with a median SLP of 7.8 months (95% CI: 6.6-NR). Median OS is 13.5 months (95% CI: 12.7–13.6; 81.2% p censored); 1-year survival is 83.9% (95% CI: 67.4%-92.5%). Conclusions: Treatment with C, D and B, followed by maintenance B in 1st line of advanced non-squamous NSCLC shows an acceptable toxicity profile and promising efficacy. Final results will be presented.

[Table: see text]

[Gender-related differences in functional assessment of serotonergic system in healthy young subjects]

INTRODUCTION

Prolactin stimulation test with serotonergic stimulants has been widely used in the study of diverse psychiatric disorders. However, the characterization of this response in normal subjects is still incomplete.

OBJECTIVE

To compare the response to serotonin stimulation using dexfenfluramine, a specific serotonergic agent, in young healthy men and women, controlling the menstrual cycle.

METHODS

A total of 10 women and 9 men, who were given 30 mg of dexfenfluramine orally, were studied and their levels of prolactin were measured on an hourly basis for a five-hour period. Baseline, maximum and delta values of prolactin were compared for both groups.

RESULTS

According to the age groups studied (mean age for men: 19.9 +/- 2.5 years old; mean age for women: 20 +/- 1.5 years old), the prolactin maximum level and the response to prolactin (DPRL) were significantly higher in women (p-values: 0.02 and 0.04, respectively).

CONCLUSIONS

Young healthy women show a greater response to stimulation with dexfenfluramine than young healthy men. Clinical and biological implications of this observation are discussed in the context of the currently available research papers.

Induction chemotherapy with paclitaxel plus carboplatin followed by paclitaxel with concurrent radiotherapy in stage IIIB non-small-cell lung cancer (NSCLC) patients: A phase II trial

PURPOSE

We conducted a prospective phase II trial to evaluate the efficacy and toxicity of induction chemotherapy with paclitaxel plus carboplatin followed by concurrent radiotherapy with weekly paclitaxel in stage IIIB non-small-cell lung cancer (NSCLC) patients.

PATIENTS AND METHODS

Patients with stage IIIB NSCLC received two 3-week cycles of paclitaxel 200mg/m(2) combined with carboplatin (target area under the plasma concentration curve (AUC) of 6 mg/ml) followed by weekly paclitaxel 50mg/m(2) concurrently with radiotherapy consisted of 2 Gy daily, 5 days per week (60 Gy total dose in 6 weeks). The median follow-up period was 5 years.

RESULTS

Between March 1999 and January 2002, 21 patients were enrolled and analyzed. Ninety percent of patients completed the planned treatment schedule. The overall response rate was 76% (24% complete response and 52% partial response). The median overall survival time was 15 months and the 1-year, 2-year and 5-year overall survival rates were 57, 33 and 24%, respectively. The disease progression rate at 1 year was 43% and the median progression-free survival was 8 months. During the chemoradiation period, grade 3-4 oesophagitis and pneumonitis were observed in 24 and 14% of patients, respectively.

CONCLUSIONS

Induction chemotherapy with carboplatin and paclitaxel followed by weekly paclitaxel with concurrent radiotherapy was found to be active and tolerable in selected stage IIIB NSCLC patients. Further studies are needed to improve the safety profile and outcome in this setting.

Single nucleotide polymorphisms and outcome in docetaxel-cisplatin-treated advanced non-small-cell lung cancer

BACKGROUND

Platinum-based doublets are the standard chemotherapy for advanced non-small-cell lung cancer (NSCLC). Excision-repair cross-complementing 1 (ERCC1), xeroderma pigmentosum group D (XPD) and ribonucleotide reductase subunit M1 (RRM1) are essential to the repair of cisplatin DNA adducts. Multidrug resistance 1 (MDR1) has been related to antimicrotubule resistance. We assessed whether single nucleotide polymorphisms (SNPs) in ERCC1, XPD, RRM1 and MDR1, and ERCC1 mRNA expression, predicted survival in docetaxel-cisplatin-treated stage IV NSCLC patients.

PATIENTS AND METHODS

Using the TaqMan 5' nuclease assay, we examined ERCC1 118, XPD 751 and 312, RRM1 -37C/A, and MDR1 C3435T SNPs in peripheral blood lymphocytes (PBLs) obtained from 62 docetaxel-cisplatin-treated advanced NSCLC patients. ERCC1 expression was measured in RNA isolated from PBLs using real-time reverse transcriptase PCR.

RESULTS

Overall median survival was 10.26 months. Median survival was 9.67 months for 34 patients with ERCC1 118 C/T, 9.74 months for 17 patients with T/T, and not reached for 11 patients with C/C (P=0.04). Similar significant differences in time to progression were observed according to ERCC1 118 genotype (P=0.03). No other significant differences were observed.

CONCLUSIONS

Patients homozygous for the ERCC1 118 C allele demonstrated a significantly better survival. ERCC1 SNP assessment could be an important component of tailored chemotherapy trials.

Biological activity of Guatteria cardoniana fractions

Methanolic extract of leaves and twigs of Guatteria cardoniana R.E. Fries (Annonaceae), a plant from the Venezuelan rain forest, was separated in alkaloid rich fractions and their biological effect on baby hamster kidney (BHK) cell line was studied. The initial plant extract (FA) induced cell proliferation, cytotoxicity as well as antiviral activity, depending on the concentration used. Further separation of this methanolic extract allowed us to separate these biological activities. The fraction with the highest antiviral activity (F7) was chromatographed and three of the nine alkaloid-rich fractions obtained, retained this activity. One of them (F(7)11) exhibited the highest inhibitory effect against a neurotropic Sindbis virus (NSV).

Venezuelan equine encephalomyelitis virus structure and its divergence from old world alphaviruses

Although alphaviruses have been extensively studied as model systems for the structural organization of enveloped viruses, no structures exist for the phylogenetically distinct eastern equine encephalomyelitis (EEE)-Venezuelan equine encephalomyelitis (VEE) lineage of New World alphaviruses. Here we report the 25-A structure of VEE virus, obtained from electron cryomicroscopy and image reconstruction. The envelope spike glycoproteins of VEE virus have a T=4 icosahedral arrangement, similar to that observed in Old World Sindbis, Semliki Forest, and Ross River alphaviruses. However, VEE virus has pronounced differences in its nucleocapsid structure relative to nucleocapsid structures repeatedly observed in Old World alphaviruses.

Adrenalectomy regulates apoptotic-associated genes in rat hippocampus

Morphological studies of granular neurons of the hippocampus have shown that adrenalectomy (ADX) induces the cell death of granular neurons, an effect prevented by corticosterone replacement. We addressed the hypothesis that corticosterone regulates the expression of the apoptotic bcl-2 gene family. Five days after adrenalectomy, we observed morphological changes related to hippocampal granule cell apoptosis that was accompanied by terminal dUTP nick and labeling (TUNEL) labeling in nuclei located in the hilus region. Corticosterone replacement prevented the cell death induced by ADX. Using RT-PCR we found a reduction in mRNA levels of the antiapoptotic gene bcl-2 in whole hippocampus, an effect which was prevented by corticosterone administration to ADX rats. However, Bcl-2 protein levels were not altered by this treatment. We did not observe modifications in the level of bcl-X(L) mRNA however, we did find a 40% reduction in Bcl-X(L) protein levels, an effect not reversed by corticosterone. In contrast, we found a reduction in the mRNA of the antiapoptotic gene bax and Bax levels after ADX; both effects were prevented by corticosterone. The reduction in proapoptotic bax and in antiapoptotic bcl-2 mRNA levels in the whole hippocampus, suggests that local variations in these molecules could account for both neuronal viability of the CA1-CA3 and granular cell death detected by morphological means and observed after ADX.

A conditional tetracycline-regulated increase in Gamma amino butyric acid production near luteinizing hormone-releasing hormone nerve terminals disrupts estrous cyclicity in the rat

Gamma amino butyric acid (GABA) is the main inhibitory neurotransmitter controlling LH-releasing hormone (LHRH) secretion in the mammalian hypothalamus. Whether alterations in GABA homeostasis within discrete regions of the neuroendocrine brain known to be targets of GABA action, such as the median eminence, can disrupt the ability of the LHRH releasing system to maintain reproductive cyclicity is not known but amenable to experimental scrutiny. The present experiments were undertaken to examine this issue. Immortalized BAS-8.1 astroglial cells were genetically modified by infection with a regulatable retroviral vector to express the gene encoding the GABA synthesizing enzyme glutamic acid decarboxylase-67 (GAD-67) under the control of a tetracycline (tet) controlled gene expression system. In this system, expression of the gene of interest is repressed by tet and activated in the absence of the antibiotic. BAS-8.1 cells carrying this regulatory cassette, and cultured in the absence of tet ("GAD on"), expressed abundant levels of GAD-67 messenger RNA and GAD enzymatic activity, and released GABA when challenged with glutamate. All of these responses were inhibited within 24 h of exposure to tet ("GAD off"). Grafting "GAD on" cells into the median eminence of late juvenile female rats, near LHRH nerve terminals, did not affect the age at vaginal opening, but greatly disrupted subsequent estrous cyclicity. These animals exhibiting long periods of persistent estrus, interrupted by occasional days in proestrus and diestrus, suggesting the occurrence of irregular ovulatory episodes. Administration of the tetracycline analog doxycycline (DOXY) in the drinking water inhibited GAD-67synthesis and restored estrous cyclicity to a pattern indistinguishable from that of control rats grafted with native BAS-8.1 cells. Animals carrying "GAD on" cells showed a small increase in serum LH and estradiol levels, and a marked elevation in serum androstenedione, all of which were obliterated by turning GAD-67 synthesis off in the grafted cells. Morphometric analysis of the ovaries revealed that both groups grafted with GABA-producing cells had an increased incidence of large antral follicles (>500 micrometer) compared with animals grafted with native BAS-8.1 cells, but that within this category the incidence of steroidogenically more active follicles (i.e. larger than 600 micrometer) was greater in "GAD on" than in "GAD off" rats. These results indicate that a regionally discrete, temporally controlled increase in GABA availability to LHRH nerve terminals in the median eminence of the hypothalamus suffices to disrupt estrous cyclicity in the rat, and raise the possibility that similar local alterations in GABA homeostasis may contribute to the pathology of hypothalamic amenorrhea/oligomenorrhea in humans.