Man flu is not a thing - Gender-specific secondary analysis of a prospective randomized-controlled trial for acute rhinosinusitis

BACKGROUND

'Man flu' is a popular term to describe hypersensitivity to acute rhinosinusitis (ARS) in men. While this pop-cultural description may influence the social perspective of ARS, so far, no prospective observational data on the gender-specific natural development of ARS is available.

METHODS

Secondary data analyses were performed from the placebo arm of a prospective, interventional phase IV clinical trial. Objective measurement of ARS symptoms were assessed with the Major Symptom Score (MSS), a clinician-rated assessment tool. The Sino-Nasal Outcome Test-22 (SNOT-22) was used for symptom self-report. Repeated measures analysis of variance (ANOVA) with gender as a group variable were used to investigate changes in MMS and SNOT-22 total score and subscales over time.

RESULTS

While MMS scores did not differ at baseline, women showed a significantly greater reduction than men with a medium effect size (p = .040) over time. In the patient-reported symptom score, women showed a significantly higher symptom load at baseline (p = .038), but also a significantly faster subjective improvement of symptoms than men during the course of time with a medium effect size (p = .020). However, when separately assessing the SNOT-22 subscales, a significant time*gender effect was only found for emotional symptoms (p = .047). No gender effect was found for neither nasal, otological, or sleep symptoms (all p > .05).

DISCUSSION

Although a certain gender difference was found both in the clinician- as well as patient-rated ARS symptoms, the hypothesis of a 'man flu' should be disregarded. Gender differences in ARS symptomatology should be carefully evaluated without stigmatizing symptom distress based on gender perceptions.

Phase 1 trial of temsirolimus in combination with irinotecan and temozolomide in children, adolescents and young adults with relapsed or refractory solid tumors: a Children's Oncology Group Study

BACKGROUND

mTOR inhibitors have activity in pediatric tumor models. A phase I trial of the mTOR inhibitor temsirolimus (TEM) with irinotecan (IRN) and temozolomide (TMZ) was conducted in children with recurrent/refractory solid tumors, including central nervous system (CNS) tumors.

METHODS

Escalating doses of intravenous (IV) TEM were administered on days 1 and 8 of 21-day cycles. IRN (50 mg/m(2)/dose escalated to a maximum of 90 mg/m(2)/dose) and TMZ (100 mg/m(2)/dose escalated to a maximum of 150 mg/m(2)/dose) were administered orally (PO) on days 1-5. When maximum tolerated doses (MTD) were identified, TEM frequency was increased to weekly.

RESULTS

Seventy-one eligible pts (median age 10.9 years, range 1.0-21.5) with neuroblastoma (16), osteosarcoma (7), Ewing sarcoma (7), rhabdomyosarcoma (4), CNS (22) or other (15) tumors were enrolled. Dose-limiting hyperlipidemia occurred in two patients receiving oral corticosteroids. The protocol was subsequently amended to preclude chronic steroid use. The MTD was identified as TEM 35 mg/m(2) IV weekly, with IRN 90 mg/m(2) and TMZ 125 mg/m(2) PO on days 1-5. At higher dose levels, elevated serum alanine aminotransferase and triglycerides, anorexia, and thrombocytopenia were dose limiting. Additional ≥ grade 3 regimen-related toxicities included leukopenia, neutropenia, lymphopenia, anemia, and nausea/vomiting. Six patients had objective responses confirmed by central review; three of these had sustained responses through ≥ 14 cycles of therapy.

CONCLUSION

The combination of TEM (35 mg/m(2)/dose IV weekly), IRN (90 mg/m(2)/dose days 1-5) and TMZ (125 mg/m(2)/dose days 1-5) administered PO every 21 days is well tolerated in children. Phase 2 trials of this combination are ongoing.

A phase I trial and pharmacokinetic study of IMC-A12 in pediatric patients with relapsed/refractory solid tumors: A Children's Oncology Group Phase I Consortium study

10013

Background: IMC-A12, a fully human IgG1 monoclonal antibody to the Insulin-Like Growth Factor-I Receptor (IGF-IR), is active preclinically in a variety of pediatric solid tumors. We performed a phase I trial to determine the toxicities, maximum tolerated dose (MTD), pharmacokinetics (PK), and pharmacodynamics (PD) of IMC-A12 in children with refractory solid tumors. Methods: IMC-A12 was administered as a weekly 1 hr IV infusion, without interruption. Two dose levels, 6 and 9 mg/kg, were evaluated using a standard 3+3 cohort design. After defining initial safety, patients (pts) with refractory Ewing sarcoma (ES) were treated in an expanded cohort at each dose level. Results: 24 eligible patients (11 male), median 15.3 yrs (range, 7.0 to 21.5), were enrolled. Among the 12 pts enrolled on the dose-escalation component, DLT (grade 4 thrombocytopenia) occurred in 1/6 pts at 6 mg/kg. No DLTs occurred in 6 pts at 9 mg/kg or in the ES cohort. 1/10 evaluable pts with ES at the 6 mg/kg dose had a partial response; no CRs were observed. Grade 2 or higher non-DLTs possibly attributable to IMC-A12 observed in the first course include anemia (n=4), leukopenia (n=1), lymphopenia (n=2), neutropenia (n=2), opportunistic infection (n=1), ↑liver transaminases (n=2), and hyperglycemia (n=1). No ≥ grade 3 hyperglycemia occurred. Mean (± SD) trough IMC-A12 concentrations were 59.8 ± 31.1 and 117 ± 70.8 μg/ml at the 6 and 9 mg/kg dose levels, respectively. A majority of pts at both dose levels exhibited > 50% reduction in PBMC IGF-IR protein levels. Conclusions: In order to exceed target trough concentrations associated with optimal anti-tumor activity in pre-clinical models, 9 mg/kg IV weekly is the recommended Phase II IMC-A12 dose in children. A phase II protocol for children with refractory solid tumors will be performed.

[Table: see text]

[Operative treatment of proximal humeral fractures with helix wire]

BACKGROUND

Between 1 January 2000 and 31 December 2002, a total of 50 patients with a dislocated or unstable fracture of the proximal humerus were treated surgically with a titanium helix wire introduced retrogradely into the medullary cavity.

MATERIAL AND METHODS

Fracture classification showed 8 cases of a two-fragment fracture, 32 cases of a three-fragment fracture, and 10 cases of a so-called four-fragment fracture. A retrospective radiographic and medical review of all 50 patients showed postoperative complications in 24% of the cases; in 8 cases (16%) secondary loss of retention occurred with consecutive projection of the helix wires into the subacromial joint space. There were two cases each (4%) of perforation of the helix wire into the joint space without loss of retention and fracture dehiscence because of a blocking mechanism by the helix wire in the subcapital fracture gap. The postoperative revision rate was 18% (9/50) as a result. Of 50 patients with a titanium helix wire, 38 (76%) were reviewed after an average of 23 months (12-31). Radiologically partial necrosis of the head of the humerus was seen in two patients and there was necrosis of the head of the humerus with pseudarthrosis in one patient, which had a negative effect on the Constant score.

RESULTS

Because of a change of procedure (n=5) and intercurrent deaths (n=5) only 2 of 12 patients, in whom complications had occurred postoperatively, could be followed up clinically; the results of the follow-up are sure to be distorted by this selection effect. Of 38 patients, 32 (84%) showed very good to good results functionally; the average Constant score was 74 points and the average age- and sex-specific corrected score was 92%.

DISCUSSION

Thus, the procedure does not achieve better functional results compared to other rigid and semirigid internal fixation methods while it has a high complication and revision rate compared to other rigid and semirigid internal fixation methods. Moreover, early functional treatment is not possible so that the titanium helix wire represents a retention aid rather than stable internal fixation. Overall we cannot recommend the procedure for the operative management of proximal humerus fractures further and have abandoned it ourselves.

A phase I study of 17-AAG in relapsed/refractory pediatric patients with solid tumors: A Children’s Oncology Groups study

9018

Background: A pediatric phase I study of 17-allylaminogeldanamycin (17-AAG), an Hsp90 inhibitor, was conducted to determine the dose limiting toxicities (DLTs), the recommended phase II dose, the pharmacokinetics (PK), and to evaluate a surrogate marker for Hsp90 inhibition in peripheral blood mononuclear cells (PBMCs). Methods: Cohorts of 3–6 pts were enrolled at dose levels of 150, 200, 270 and 360 mg/m2/dose, administered as a 60 min infusion, on days 1, 4, 8 and 11 of a 21-day cycle. PK and PBMC evaluations were done during the first course of therapy. Results: 17 pts (7 male), median 7 yrs of age (range 1–19), were enrolled. 5 pts who developed PD prior to completing a full cycle of therapy were not considered evaluable for toxicity. No DLTs occurred. Non-DLTs included elevated transaminases (n=6), anemia (n=3), and vomiting (n=3). Based on the adult recommended dose and challenges posed by infusing the large volumes of DMSO, dose escalation was stopped at dose level 4. No CRs or PRs were observed; 3 patients remain on therapy at 6, 7 and 9 months with SD. One patient with hepatoblastoma had a reduction in AFP and SD over 3 cycles. PK data is available from the initial 3 dose levels. Drug exposure increases in proportion to dose for both17-AAG and its metabolite 17-AG. At 270 mg/m2/dose the Cmax and AUC of 17-AAG were 5,303 ± 1,591 ng/ml and 13,150 ± 5,086 ng/ml*hr, respectively, similar to the exposure in adults. The mean terminal half-life for 17-AAG was 3.0 ± 0.5 hrs. Induction of Hsp72, a surrogate marker for inhibition of Hsp90 was detected at all dose levels. Conclusions: The recommended phase II dose of 17AAG is 360mg/m2/day. Non-DMSO formulations may allow for further dose escalation in children and should be studied.

No significant financial relationships to disclose.

Lymphedema after sentinel lymphadenectomy for breast carcinoma

BACKGROUND

Initial studies of sentinel lymphadenectomy for patients with breast carcinoma confirmed that the status of the sentinel lymph nodes was an accurate predictor of the presence of metastatic disease in the axillary lymph nodes. Sentinel lymphadenectomy, as an axillary staging procedure, has risks of morbidity that have yet to be defined.

METHODS

Patients were enrolled in a two-phase protocol that included concurrent data collection of patient characteristics and treatment variables. During the first (validation) phase, 72 patients underwent sentinel lymph node excision followed by a level I-II axillary dissection. After the technique had been established, the second phase commenced, during which only patients with positive sentinel lymph nodes underwent an axillary dissection.

RESULTS

During the second phase, lymphedema was identified in 9 of 303 patients (3.0%) who underwent sentinel lymphadenectomy alone and in 20 of 117 patients (17.1%) who underwent sentinel lymphadenectomy combined with axillary dissection (P < 0.0001). Of 303 patients who underwent sentinel lymphadenectomy alone, 8 of 155 patients (5.1%) with tumors located in the upper outer quadrant and 1 of 148 patients (0.7%) with tumors in other locations developed lymphedema (P = 0.012).

CONCLUSIONS

The risk of developing lymphedema after undergoing sentinel lymphadenectomy was measurable but significantly lower than after undergoing axillary dissection. Tumor location in the upper outer quadrant and postoperative trauma and/or infection were identifiable risk factors for lymphedema.

Surgical management of symptomatic spinal metastases. Postoperative outcome and quality of life

STUDY DESIGN

Eighty-six surgical interventions in 76 consecutive patients with symptomatic spinal metastases were reviewed retrospectively.

OBJECTIVES

To evaluate the postoperative outcome and quality of life of patients surgically treated for symptomatic spinal metastases.

SUMMARY OF BACKGROUND DATA

The standard surgical treatment for patients with symptomatic spinal metastases is anterior spinal cord decompression with stabilization. However, because therapy is only palliative, satisfactory quality of life and high patient acceptance are essential.

METHODS

The medical records of all patients were reviewed retrospectively. Furthermore, all surviving patients or the next of kin of deceased patients were interviewed by telephone, and the family doctors or the care-providing physicians of external institutions were contacted.

RESULTS

First-choice surgical treatment was anterior spinal cord decompression with stabilization. Postoperative mean survival was 13.1 months, and mean time at home after spinal surgery was 11.1 months. Neurologic improvement with regard to Frankel classification was observed in 58% of the patients, and 93% were able to walk postoperatively. Pain relief was noted in 89%. Overall, 67% of the patients achieved moderate or good general health as shown by the Karnofsky Index, and 80% were satisfied or very satisfied with the surgical intervention. Moreover, 19% of the surgical interventions were associated with complications, local tumor recurrence developed in 22% of the patients, and paraplegia ultimately developed in 18% of patients.

CONCLUSIONS

Surgical management of symptomatic spinal metastases, in particular anterior decompression, is of benefit in most metastatic lesions in terms of satisfactory postoperative outcome and quality of life. However, in patients with melanoma or lung carcinoma, the authors advocate spinal surgery only in very exceptional cases.

Influence of the medium composition and plasmid combination on the growth of recombinant Escherichia coli JM109 and on the production of the fusion protein EcoRI::SPA

Plasmid-free and plasmid-harbouring E. coli JM109 strains were investigated in shaken flasks, stirred tanks in batch and continuous operation. The shaken flask cultivations were performed in M9 minimal medium and in media with various protein supplements. The host hardly grows on M9 minimal medium as opposed to the plasmid-harbouring cells, which grow well on this medium. All of the investigated cells propagate well on protein-containing media. The influence of the combinations of repressor plasmid pRK248cI, the protection plasmid EcoR4 and the production plasmid pMTC48 were determined on the initial specific growth rate of the E. coli JM109 without gene expression, on the yield coefficient of cell growth, acetate concentration and acetate yield coefficient in the yeast extract-containing (HM) medium. The influence of various media on the induction of the gene expression were evaluated. In cultivation media with protein supplement, the growth rate and yield coefficient increased. The variation of the volumetric and specific beta-lactamase activities with the cultivation time were determined in a stirred tank reactor in HM medium. With increasing dilution rate the process performance decreased. Simple relationships exist between the substrate uptake rate and the specific growth rate of the continuous cultivated cells in M9 and HM media. The influence of the dilution rate on the cell mass concentration, colony forming units, acetate formation, yield coefficients of growth and acetate formation, substrate uptake rate, CO2 production rate, ammonium formation rate and beta-lactamase activity in M9 and HM media were determined as well. Carbon balances of the batch and continuous cultivations indicated high carbon recoveries. On account of the higher growth rate of plasmid-harbouring cells than than of the plasmid-free cells, the behaviour of the investigated plasmid-free and plasmid-harbouring E. coli JM109 cells deviates from the published properties of other plasmid-free and plasmid-harbouring E. coli cells.

[Significant injury of the neck including the cervical spine and soft tissue in suicidal strangulation]

A 46-year-old man committed suicide by jumping from a height of app. 4.5 m with a running noose round his neck. The neck was nearly cut through by the tightened ligature, so that there was only a small "bridge" of soft tissue between head and trunk.

Characterization of a modified human tissue plasminogen activator comprising a kringle-2 and a protease domain

To study structure/function relationships of tissue plasminogen activator (t-PA) activity, one of the simplest modified t-PA structures to activate plasminogen in a fibrin-dependent manner was obtained by constructing an expression vector that deleted amino acid residues 4-175 from the full-length sequence of t-PA. The expression plasmid was introduced into a Syrian hamster cell line, and stable recombinant transformants, producing high levels of the modified plasminogen activator, were isolated. The resulting molecule, mt-PA-6, comprising the second kringle and serine protease domains of t-PA, produced a doublet of plasminogen activator activity having molecular masses of 40 and 42 kDa. The one-chain mt-PA-6 produced by cultured Syrian hamster cells was purified in high yield by affinity and size exclusion chromatography. The purified mt-PA-6 displayed the same two types of microheterogeneity observed for t-PA. NH2-terminal amino acid sequencing demonstrated that one-chain mt-PA-6 existed in both a GAR and a des-GAR form. Purified mt-PA-6 also existed in two glycosylation forms that accounted for the 40- and 42-kDa doublet of activity produced by the cultured Syrian hamster cells. Separation of these two forms by hydrophobic interaction chromatography and subsequent tryptic peptide mapping demonstrated that both forms contained N-linked glycosylation at Asn448; in addition, some mt-PA-6 molecules were also glycosylated at Asn184. Plasmin treatment of one-chain mt-PA-6 converted it to a two-chain molecule by cleavage of the Arg275-Ile276 bond. This two-chain mt-PA-6, like t-PA, had increased amidolytic activity. The fibrinolytic specific activities of the one- and two-chain forms of mt-PA-6 were similar and twice that of t-PA. The plasminogen activator activity of one-chain mt-PA-6 was enhanced greater than 80-fold by CNBr fragments of fibrinogen, and the one-chain enzyme lysed human clots in vitro in a dose-dependent manner. The ability to produce and purify a structurally simple plasminogen activator with desirable fibrinolytic properties may aid in the development of a superior thrombolytic agent for the treatment of acute myocardial infarction.

[The fermentation diagnosis and histologic studies in blood and the liver of surviving rats after 1 and 2 administrations of a median toxic dose of parathion methyl. 2. Tyrosine aminotransferase and pathologico-morphological findings in the liver]

Tyrosine-amino transferase, an enzyme induced to the liver via glucocorticoids, caused clearly measurable activity rises in either sex, 24 hours after 1 and 2 applications. Increased levels continued to recordable from males on the 3rd day from application, whereas enzyme activities in females had already returned to normal by that time. Histological examination of liver sections, following 1 and 2 applications of parathion methyl (PM), revealed the tissue pattern of clearly manifest toxic hepatosis with detectable mesenchymal reactions. Histologically detectable damage reached its maximum on the 2nd and 3rd days from application. Sex-related differences were not recordable. Damage in response to the 2nd application was characterised by faster mesenchymal activation and higher frequency of cell necroses. The morphological picture of the liver was rated as having returned to normal, 14 days after 1 and 2 applications of PM. These results should not be interpreted as evidence to the involvement of specific, non-cholinergic mechanisms in the processes of damage observed. The alterations might rather be attributed to unspecific disorders in the energy balance or to the effect of "stress" during intoxication.

[Pathological myophosphorylase reaction in malignant hyperthermia]

In malignant hyperthermia, myophosphorylase reaction shows characteristic changes that take place within minutes: (1) a generally strongly weakened reaction; (2) numerous negatively reacting fibres; (3) frequently, fibre sections that show spotty and/or striatal weak or negative reactions and fibre sections with strong striatal reactions with relatively narrow sarcomere spacings (a "sign of hypercontraction"). Obviously, the morphological findings that show characteristic "striated fibres" are typical of the malignant hyperthermia syndrome! It is important to note that the muscular fibres showing such changes are, as a rule, inconspicuous when using other stains and reactions. These pathological myophosphorylase reactions were observed in five deceased patients (one independently of anaesthesia after an extended walk) and in 19 pigs (18 times after halothane testing and once in an experimental animal with clinical evidence of the presence of malignant hyperthermia). These reactions were not noted in pigs with negative halothane reactivity or prior to halothane testing. They were also not seen in a large number of very different healthy and diseased control and reference cases from our biopsy and autopsy material. Myophosphorylase reaction enables convincing demonstration of malignant hyperthermia, past or present. Hence, it is possible to elucidate puzzling deaths or verify apparently clear death occurring during or subsequent to anaesthesia or simply following stress ("human stress syndrome"). Many of these deaths doubtlessly escape the attention of clinicians using the usual morphological examination methods. However, the reaction cannot be used to identify potential victims.

[Contribution to the formal origin of multiple branched ossifications in the lung]

The observation of multiple ossifications in the lungs as secondary findings of the post-mortem examination of a 62-year-old male with chronic cardiac stasis and emphysema of the lung is reported. Apart from bone nodules larger branched mature bone clasps with marrow caves as well as a in most cases fibromatosis with a small focus which represents the matrix of ossification is represented. Apart from this histologically a hyperaemia with an oedema rich in protein, focal precipitation of protein with formation of a granulation tissue and later fibrosation are to be proved as presteps of nodular fibromatosis which according to the kind of the desmal ossification changes into bones. The chronic haemostasis in the pulmonary circulation is thus apparently of importance in our observation. The case is compared with literature. Up to now about 65 of such observations are reported which nearly exclusively concern old men. The etiology remains unclear.

[Lethal varicella in infants]

Varicella are regarded as relatively harmless disease. Since the application of antibiotics as complication appear rare mortal courses of generalised varicella above all as a sequel of haemorrhagic-gangrenous forms of course (especially under therapy of corticosteroids), of varicella pneumonia and of encephalitides, while the bacterial superinfection is in second place concerning exitus letalis. Two own observations of varicella infections having a fatal outcome in a 1 1/2-year-old child and a 2-year-old child are reported. In the two cases the efflorescences of the skin were already healing. While one child suddenly died at home (concerning the cells a typical perivenous encephalitis as well as a varicella hepatitis without nuclear inclusion bodies was proved), the older child was admitted to hospital after sudden deterioration and abscess-formation of a chickenpox pustule. Clinically a meningo-encephalitis was established, which after dramatic course led to death still at the day of admission. As to the cells only slight perivenous round cell infiltrates could be proved in severe cerebral oedema, cytolyses and sporadic perivascular haemorrhages and emedullations.