Berzosertib Plus Topotecan vs Topotecan Alone in Patients With Relapsed Small Cell Lung Cancer: A Randomized Clinical Trial

Importance

Patients with relapsed small cell lung cancer (SCLC), a high replication stress tumor, have poor prognoses and few therapeutic options. A phase 2 study showed antitumor activity with the addition of the ataxia telangiectasia and Rad3-related kinase inhibitor berzosertib to topotecan.

Objective

To investigate whether the addition of berzosertib to topotecan improves clinical outcomes for patients with relapsed SCLC.

Design, Setting, and Participants

Between December 1, 2019, and December 31, 2022, this open-label phase 2 randomized clinical trial recruited 60 patients with SCLC and relapse after 1 or more prior therapies from 16 US cancer centers. Patients previously treated with topotecan were not eligible.

Interventions

Eligible patients were randomly assigned to receive topotecan alone (group 1), 1.25 mg/m2 intravenously on days 1 through 5, or with berzosertib (group 2), 210 mg/m2 intravenously on days 2 and 5, in 21-day cycles. Randomization was stratified by tumor sensitivity to first-line platinum-based chemotherapy.

Main Outcomes and Measures

The primary end point was progression-free survival (PFS) in the intention-to-treat population. Secondary end points included overall survival (OS) in the overall population and among patients with platinum-sensitive or platinum-resistant tumors. The PFS and OS for each treatment group were estimated using the Kaplan-Meier method. The log-rank test was used to compare PFS and OS between the 2 groups, and Cox proportional hazards models were used to estimate the treatment hazard ratios (HRs) and the corresponding 2-sided 95% CI.

Results

Of 60 patients (median [range] age, 59 [34-79] years; 33 [55%] male) included in this study, 20 were randomly assigned to receive topotecan alone and 40 to receive a combination of topotecan with berzosertib. After a median (IQR) follow-up of 21.3 (18.1-28.3) months, there was no difference in PFS between the 2 groups (median, 3.0 [95% CI, 1.2-5.1] months for group 1 vs 3.9 [95% CI, 2.8-4.6] months for group 2; HR, 0.80 [95% CI, 0.46-1.41]; P = .44). Overall survival was significantly longer with the combination therapy (5.4 [95% CI, 3.2-6.8] months vs 8.9 [95% CI, 4.8-11.4] months; HR, 0.53 [95% CI, 0.29-0.96], P = .03). Adverse event profiles were similar between the 2 groups (eg, grade 3 or 4 thrombocytopenia, 11 of 20 [55%] vs 20 of 40 [50%], and any grade nausea, 9 of 20 [45%] vs 14 of 40 [35%]).

Conclusions and Relevance

In this randomized clinical trial, treatment with berzosertib plus topotecan did not improve PFS compared with topotecan therapy alone among patients with relapsed SCLC. However, the combination treatment significantly improved OS.

Trial Registration

ClinicalTrials.gov Identifier: NCT03896503.

Targeting Replication Stress and Chemotherapy Resistance with a Combination of Sacituzumab Govitecan and Berzosertib: A Phase I Clinical Trial

PURPOSE

Despite promising preclinical studies, toxicities have precluded combinations of chemotherapy and DNA damage response (DDR) inhibitors. We hypothesized that tumor-targeted chemotherapy delivery might enable clinical translation of such combinations.

PATIENTS AND METHODS

In a phase I trial, we combined sacituzumab govitecan, antibody-drug conjugate (ADC) that delivers topoisomerase-1 inhibitor SN-38 to tumors expressing Trop-2, with ataxia telangiectasia and Rad3-related (ATR) inhibitor berzosertib. Twelve patients were enrolled across three dose levels.

RESULTS

Treatment was well tolerated, with improved safety over conventional chemotherapy-based combinations, allowing escalation to the highest dose. No dose-limiting toxicities or clinically relevant ≥grade 4 adverse events occurred. Tumor regressions were observed in 2 patients with neuroendocrine prostate cancer, and a patient with small cell lung cancer transformed from EGFR-mutant non-small cell lung cancer.

CONCLUSIONS

ADC-based delivery of cytotoxic payloads represents a new paradigm to increase efficacy of DDR inhibitors. See related commentary by Berg and Choudhury, p. 3557.

ATR inhibition augments the efficacy of lurbinectedin in small-cell lung cancer

Small-cell lung cancer (SCLC) is the most lethal type of lung cancer. Specifically, MYC-driven non-neuroendocrine SCLC is particularly resistant to standard therapies. Lurbinectedin was recently approved for the treatment of relapsed SCLC, but combinatorial approaches are needed to increase the depth and duration of responses to lurbinectedin. Using high-throughput screens, we found inhibitors of ataxia telangiectasia mutated and rad3 related (ATR) as the most effective agents for augmenting lurbinectedin efficacy. First-in-class ATR inhibitor berzosertib synergized with lurbinectedin in multiple SCLC cell lines, organoid, and in vivo models. Mechanistically, ATR inhibition abrogated S-phase arrest induced by lurbinectedin and forced cell cycle progression causing mitotic catastrophe and cell death. High CDKN1A/p21 expression was associated with decreased synergy due to G1 arrest, while increased levels of ERCC5/XPG were predictive of increased combination efficacy. Importantly, MYC-driven non-neuroendocrine tumors which are resistant to first-line therapies show reduced CDKN1A/p21 expression and increased ERCC5/XPG indicating they are primed for response to lurbinectedin-berzosertib combination. The combination is being assessed in a clinical trial NCT04802174.

Effects of autoclaving on compressive strength of bovine bones and their use as chewing agents for dogs

This study aimed to evaluate the effect of autoclave processing on compressive stress of spongy and cortical bones, and the effect of autoclaved bones as chewing agents to reduce dental calculus in adult dogs. Spongy and cortical bones were autoclaved (1 ATM, 30 min, and 120°C) and compressive strength was evaluated in autoclaved and raw bone specimens. Autoclaved bones were offered to ten Beagle dogs divided into two groups of 5 dogs each: Group 1 – received a portion of the autoclaved bovine cortical bone (ACB) and Group 2 – received a portion of the autoclaved bovine spongy bone (ASB). Prior to the experimental period (1-d) and every two days thereafter, oral photographs were taken on both sides of the dental arch to evaluate dental calculus reduction over time. The vestibular surface of the canines, premolars, and molars teeth was evaluated using integration software to measure the proportion between the area covered by calculus and the total teeth area. The effect of bone type, treatment (raw vs. autoclaved), and their interaction were evaluated using the PROC GLIMMIX procedure of SAS (version 9.4). Linear equations were generated to estimate calculus reduction over time for ACB and ASB. Compressive strength was higher (P < 0.05) in cortical bones compared to spongy bones. However, the autoclaving procedure did not affect (P > 0.05) compressive strength, regardless of the bone type. The teeth area covered by calculus of dogs that were offered ACB reduced from 41% to 32% in 5 days, and at the end of 15 days a reduction of 62.2% was observed, resulting in a remaining of 15.5% of teeth area covered by calculus. In this group, the dental calculus area reduced by 57.7% after 5 days, and at the end of the trial, only 5.4% of teeth were still covered by calculus, which represents a reduction of 81%. The linear regression analysis revealed no significant difference between the slopes for the ACB and ASB equations (P > 0.05). No health complications such as tooth fracture, intestinal obstructions, and oral lesions were observed throughout the study. Our results demonstrated that the autoclave processing did not impair compressive strength of spongy and cortical bones. This corroborates with the results observed in vivo, which suggests that autoclaved bones are chewing agents for adult dogs with additional benefits of lower risk of bacterial contamination.

NCOG-75. ESTIMATED PHYSICIAN COST OF A NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM (MDT) TUMOR BOARD MEETING AT A SINGLE ACADEMIC CENTER

BACKGROUND

Multidisciplinary teams (MDTs) to improve coordination across disciplines have become commonplace in oncology. Quantifying the impact of MDTs is challenging, and they carry significant costs. Weekly neuro-oncology tumor boards are attended by neuro-oncologists, neurosurgeons, radiation-oncologists, neuro-radiologists, neuro-pathologists, and support staff including mid-level practitioners, research coordinators, social workers, nurses and trainees. Our aim was to estimate costs associated with neuro-oncology MDTs.

METHODS

The estimated physician cost of MDT meetings were calculated from reported salaries of each physician specialty. Annual salaries from the Doximity 2019 Physician Compensation Report (PCR) included data for 4 neurosurgeons, 4 radiation-oncologists, 2 radiologists, 2 oncologists, and 2 neurologists. Medscape 2019 PCR data was compiled for 4 general surgeons, 2 radiologists, 2 oncologists, 2 pathologists, and 2 neurologists. The Physician Wages Across Specialties by Leigh in 2011 (JAMA) was utilized for 4 neurosurgeons, 4 radiation oncologists, 2 oncologists, and 2 neurologists. Annual salary data was divided by annual hours per specialty as reported by the Annual Work Hours Across Specialties, 2011. These values were then applied to an MDT for one patient, one hour, weekly, and annually.

RESULTS

The Doximity 2019 PCR yielded a per meeting cost of $2,520.84, and an annual cost of $131,083.68. The Medscape 2019 PCR produced a cost of $1,570.60 weekly, and $81,671.20 annually. JAMA data estimated a per meeting cost of $1,448.06, and $75.299.12. The mean per meeting and annual costs were $1846.50, and $96,018.00, respectively. With 6-10 cases per MDT, the mean costs per patient were $184.65 to $307.75.

CONCLUSIONS

Costs of MDT are not negligible. The impact of MDTs on patient outcomes are harder to quantify, but evidence exists that organized MDTs improve patient prognosis, and unorganized MDTs may negatively affect prognosis. Processes to streamline MDTs could help answer outcomes research questions, improve efficiency, and generate clinically relevant performance metrics.

Comparison between a commercial blend of functional oils and monensin on the performance and microbiota of coccidiosis-challenged broilers

The aim of the study was to evaluate the effects of a cashew nut shell oil and commercial castor oil blend (CNSL-Castor oil) on the performance and microbiota of broiler chickens with and without coccidiosis challenge. A total of 864 one-day-old male chicks (Cobb) were randomly distributed to receive 6 treatments (8 pens/treatment; 18 chicks/pen) in a 3 × 2 factorial, with 3 additives (control [non-additives], 100 ppm sodium monensin, or 0.15% CNSL-Castor oil blend), and 2 levels of coccidiosis challenge at 14 D of age (unchallenged or inoculated by gavage with 1 mL of solution containing oocysts sporulated with Eimeria tenella, Eimeria acervulina, and Eimeria maxima). No differences in productive performance were observed among treatments in the pre-challenge period and in unchallenged birds (P > 0.05). Seven-days post-challenge, birds receiving monensin performed better than birds in the positive control group (non-additive and challenge) or in the CNSL-Castor oil group (P > 0.05). However, 14 D post-challenge, birds supplemented with CNSL-Castor oil presented higher weight gain and better feed conversion (P > 0.05), without any change in feed intake (P > 0.05). During the accumulated period (1 to 42 D of age), the live weight, weight gain, and feed intake did not differ between the CNSL-Castor oil and monensin groups, both of which presented higher values than the positive control. Lactobacillus spp. and Clostridium perfringens numbers were increased in the challenged birds (P < 0.05). CNSL-Castor oil supplementation reduced Clostridium cluster XIV, C. perfringens, and S. aureus, compared with the monensin and control groups (P > 0.05). In addition, the CNSL-Castor oil group presented the highest number of Lactobacillus spp. copies, followed by the monensin and positive control groups (P > 0.05). Thus, monensin and CNSL-Castor oil effectively minimized the impact of coccidiosis at different times. While monensin acts as an antimicrobial, CNSL-Castor oil modulates the intestinal microbiota with antimicrobial action against gram-positive bacteria, mainly C. perfringens and S. aureus.

Abstract P2-09-15: A multi-institutional, prospective study of incorporating the genomic platform breast cancer index as a tool for decision-making regarding extension of adjuvant endocrine therapy

Background: Extending adjuvant endocrine therapy (AET) for hormone responsive breast cancer (HRBC) from 5 to 10 years is beneficial for many in preventing late relapse. Current decision-making regarding extension relies on a decision-making process that weighs non-personalized recurrence risks against risks and benefits of extended AET. The Breast Cancer Index (BCI, BioTheranostics Inc) has been validated to quantify the risk of late recurrence and to predict likelihood of benefit from AET extension based on an individual's tumor genomic profile. The purpose of this study was to conduct a multi-institutional study to prospectively assess the impact of BCI i) on provider's recommendation using the BCI results; 2) the confidence with decision-making; and 3) patient's satisfaction regarding extension of AET.

Methods: Patients with stage I-III HRBC treated at Yale Cancer Center and University of Pittsburgh Medical Center (UPMC), who had completed at least 3.5 years of AET were eligible. BCI was performed on FFPE samples from the original tumor sample (bioTheranostics Inc.). Patients and physicians completed pre- and post-test questionnaires examining preferences for extending AET, patients also completed anxiety and decision-conflict surveys.

Results: 140 patients [mean age 61, 80% postmenopausal, 73% stage I] were included. No extended AET was recommended for 35.3% patients' pre-testing. Reasons physicians did not recommend extended AET were perceived low risk of recurrence (87%), risk of osteoporosis (25%) and side effects (13%). Extended therapy was recommended for 65.7% patients pre-testing. Integration of BCI resulted in a change in physician treatment recommendation in 29% of patients. The recommendation for no extended AET rose to 48% and recommendation for extended AET dropped to 52% (OR=1.76 95% CI 1.08-2.85; p=.003). Of the recommendations that changed (N=41), the majority (73%) was for not extending endocrine therapy. However, 27% of recommendations were to extend endocrine therapy because of high risk or high likelihood of benefit results. More physicians felt strongly confident in their recommendation after the test result (26.4%) than before (9.3%) (OR= 3.5 95% CI 1.77-6.95; p&lt;.0001). Satisfaction of decision increased in 23% of patients (OR=2.72 95% CI 1.66-4.46; p&lt;.0001). Patient reported concerns including the cost, safety and benefit of extended AET decreased from pre- to post-testing (p=.025; p&lt;.0001; p=.0012 respectively)

Conclusions: Overall, incorporation of BCI into clinical practice resulted in significant changes in physician recommendations regarding AET duration, with the majority of recommendations for no extended AET. Physicians reported increased confidence for their recommendation when incorporating the test result. There was also a significant increase in patient satisfaction and decrease in patient reported concerns regarding cost, safety and benefit of extended AET. The BCI is a tool that could be incorporated into decision-making algorithms to enhance physician confidence and patient satisfaction with recommendations for extending AET.

Citation Format: Sanft T, Berkowitz A, Schroeder B, Hatzis C, Schnabel C, Aktas B, Brufsky A, Pusztai L, vanLonden GJ. A multi-institutional, prospective study of incorporating the genomic platform breast cancer index as a tool for decision-making regarding extension of adjuvant endocrine therapy [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-09-15.

Targeting gastrointestinal stromal tumors: the role of regorafenib

Gastrointestinal stromal tumor (GIST) is a devastating disease in the metastatic setting, but its natural history has been dramatically altered by the development of small molecule tyrosine kinase inhibitors, most notably imatinib. Although patients with advanced GIST live much longer today than they did in the past, imatinib-refractory disease remains a tremendous problem. For disease that is refractory to imatinib and sunitinib, regorafenib is an excellent option. In this review, we discuss the biology and clinical work establishing regorafenib as the standard of care for advanced GIST refractory to both imatinib and sunitinib.

Tamoxifen improves cytopathic effect of oncolytic adenovirus in primary glioblastoma cells mediated through autophagy

Oncolytic gene therapy using viral vectors may provide an attractive therapeutic option for malignant gliomas. These viral vectors are designed in a way to selectively target tumor cells and spare healthy cells. To determine the translational impact, it is imperative to assess the factors that interfere with the anti-glioma effects of the oncolytic adenoviral vectors. In the current study, we evaluated the efficacy of survivin-driven oncolytic adenoviruses pseudotyping with adenoviral fiber knob belonging to the adenoviral serotype 3, 11 and 35 in their ability to kill glioblastoma (GBM) cells selectively without affecting normal cells. Our results indicate that all recombinant vectors used in the study can effectively target GBM in vitro with high specificity, especially the 3 knob-modified vector. Using intracranial U87 and U251 GBM xenograft models we have also demonstrated that treatment with Conditionally Replicative Adenovirus (CRAd-S-5/3) vectors can effectively regress tumor. However, in several patient-derived GBM cell lines, cells exhibited resistance to the CRAd infection as evident from the diminishing effects of autophagy. To improve therapeutic response, tumor cells were pretreated with tamoxifen. Our preliminary data suggest that tamoxifen sensitizes glioblastoma cells towards oncolytic treatment with CRAd-S-5/3, which may prove useful for GBM in future experimental therapy.

Global analysis of H3K4me3 and H3K27me3 profiles in glioblastoma stem cells and identification of SLC17A7 as a bivalent tumor suppressor gene

Epigenetic changes, including H3K4me3 and H3K27me3 histone modification, play an important role in carcinogenesis. However, no genome-wide histone modification map has been generated for gliomas. Here, we report a genome-wide map of H3K4me3 and H3K27me3 histone modifications for 8 glioma stem cell (GSC) lines, together with the associated gene activation or repression patterns. In addition, we compared the genome-wide histone modification maps of GSC lines to those of astrocytes to identify unique gene activation or repression profiles in GSCs and astrocytes. We also identified a set of bivalent genes, which are genes that are associated with both H3K4me3 and H3K27me3 marks and are poised for action in embryonic stem cells. These bivalent genes are potential targets for inducing differentiation in glioblastoma (GBM) as a therapeutic approach. Finally, we identified SLC17A7 as a bivalent tumor suppressor gene in GBM, as it is down-regulated at both the protein and RNA levels in GBM tissues compared with normal brain tissues, and it inhibits GBM cell proliferation, migration and invasion.

Genetic investigation of multicentric glioblastoma multiforme: case report

The authors report a case of multicentric glioblastoma multiforme (GBM) in which all 4 tumor foci were resected and evaluated using both comparative genomic hybridization array and RNA sequencing. Genetic analysis showed that the tumors shared a common origin, although each had its own unique set of genetic aberrations. The authors note that the genetic heterogeneity of multicentric GBM likely contributes to the failures of current treatments. The case underscores the necessity of increased genetic investigation.

MT1-MMP silencing by an shRNA-armed glioma-targeted conditionally replicative adenovirus (CRAd) improves its anti-glioma efficacy in vitro and in vivo

MMP14 (MT1-MMP) is a cell membrane-associated proteinase of the extracellular matrix, whose biological roles vary from angiogenesis to cell proliferation and survival. We recently found a direct correlation between MMP14 expression levels in brain tumors of glioma patients and the disease progression. By using gene silencing as an experimental approach we found that MMP14 knockdown decreases production of pro-angiogenic factors such as VEGF and IL8 and thereby suppresses angiogenesis in glioma tumors. Although the clinical relevance of MMP14 down-regulation and its possible implications for glioma therapy in humans remain unclear, we observed a significant improvement in animal survival upon down-regulation of MMP14 in murine intracranial glioma xenografts infected with MMP14 shRNA-expressing CRAd. We further found that down-regulation of MMP14 in gliomas by combinational treatment with CRAd-S-5/3 and Marimastat, a chemical inhibitor of metalloproteinases, augments suppression of pro-angiogenic factors, caused by the replication-competent adenovirus. We also demonstrated that delivery of MMP14-targeting shRNA by a fiber-modified adenoviral vector to the glioma cells effectively suppresses their proliferation in vitro and in vivo. Thus our data indicate that inhibition of MMP14 expression in tumors in combination with glioma virotherapy could be effectively utilized to suppress angiogenesis and neovascularization of glioma tumors by decreasing production of pro-angiogenic factors.

Effects of 25-hydroxyvitamin D3 on localisation and extent of gastrointestinal calcium absorption in dairy cattle

The combination of 25-hydroxyvitamin D3 (25-OHD3) and a diet negative in dietary cation anion difference (DCAD) has recently been shown to have beneficial effects on peripartal calcium (Ca) homeostasis in dairy cows. To further elucidate the underlying mechanisms, it was the aim of the experiments to investigate the effects of 25-OHD3 in combination with DCAD values about –70 meq/kg DM on pre-duodenal and overall gastrointestinal Ca absorption. A group of six ruminally fistulated lactating cows equipped with a cannula in the proximal duodenum were assigned to three dietary treatments (Control diet, anionic salts, anionic salts +25-OHD3) of 5 weeks each. Urine and faeces were collected quantitatively and flow of duodenal contents was calculated by applying chromium oxide. Blood samples were taken at regular intervals. Treatment with anionic salts and 25-OHD3 resulted in an increased Ca net absorption from the total gastrointestinal tract, which was mainly due to respective increases in intestinal Ca absorption. Furthermore, anionic salts and 25-OHD3-treated animals had significantly higher plasma phosphate concentrations and lower plasma levels of CrossLaps and the overall net absorption of phosphorus was significantly higher in these animals. From these data, it can be concluded that anionic salts in combination with 25-OHD3 positively influence the overall net Ca and phosphorus absorption, which is obviously associated with a reduced mobilisation of bone minerals as indicated by decreases in plasma CrossLaps concentrations.

Exploration of the gene fusion landscape of glioblastoma using transcriptome sequencing and copy number data

BACKGROUND

RNA-seq has spurred important gene fusion discoveries in a number of different cancers, including lung, prostate, breast, brain, thyroid and bladder carcinomas. Gene fusion discovery can potentially lead to the development of novel treatments that target the underlying genetic abnormalities.

RESULTS

In this study, we provide comprehensive view of gene fusion landscape in 185 glioblastoma multiforme patients from two independent cohorts. Fusions occur in approximately 30-50% of GBM patient samples. In the Ivy Center cohort of 24 patients, 33% of samples harbored fusions that were validated by qPCR and Sanger sequencing. We were able to identify high-confidence gene fusions from RNA-seq data in 53% of the samples in a TCGA cohort of 161 patients. We identified 13 cases (8%) with fusions retaining a tyrosine kinase domain in the TCGA cohort and one case in the Ivy Center cohort. Ours is the first study to describe recurrent fusions involving non-coding genes. Genomic locations 7p11 and 12q14-15 harbor majority of the fusions. Fusions on 7p11 are formed in focally amplified EGFR locus whereas 12q14-15 fusions are formed by complex genomic rearrangements. All the fusions detected in this study can be further visualized and analyzed using our website: http://ivygap.swedish.org/fusions.

CONCLUSIONS

Our study highlights the prevalence of gene fusions as one of the major genomic abnormalities in GBM. The majority of the fusions are private fusions, and a minority of these recur with low frequency. A small subset of patients with fusions of receptor tyrosine kinases can benefit from existing FDA approved drugs and drugs available in various clinical trials. Due to the low frequency and rarity of clinically relevant fusions, RNA-seq of GBM patient samples will be a vital tool for the identification of patient-specific fusions that can drive personalized therapy.

Spectral domain optical coherence tomography and adaptive optics: imaging photoreceptor layer morphology to interpret preclinical phenotypes

Recent years have seen the emergence of advances in imaging technology that enable in vivo evaluation of the living retina. Two of the more promising techniques, spectral domain optical coherence tomography (SD-OCT) and adaptive optics (AO) fundus imaging provide complementary views of the retinal tissue. SD-OCT devices have high axial resolution, allowing assessment of retinal lamination, while the high lateral resolution of AO allows visualization of individual cells. The potential exists to use one modality to interpret results from the other. As a proof of concept, we examined the retina of a 32 year-old male, previously diagnosed with a red-green color vision defect. Previous AO imaging revealed numerous gaps throughout his cone mosaic, indicating that the structure of a subset of cones had been compromised. Whether the affected cells had completely degenerated or were simply morphologically deviant was not clear. Here an AO fundus camera was used to re-examine the retina (~6 years after initial exam) and SD-OCT to examine retinal lamination. The static nature of the cone mosaic disruption combined with the normal lamination on SD-OCT suggests that the affected cones are likely still present.

Variable optical activation of human cone photoreceptors visualized using a short coherence light source

It has been shown that after a visible stimulus, optical oscillations of nearly all cone photoreceptors can be observed using long coherence length light and in a few cones using short coherence length light. Here, we show that after exposure to a visible stimulus, a short coherence length imaging source reveals light-evoked oscillation signals in a large number of cones. More than 80% of cones in a given retinal area are activated (modulation in the reflectance signal) after stimulation, and the pattern of their activation can be subjectively classified into one of four categories. The application of light-evoked signal detection techniques for in vivo retinal imaging may prove useful for assessing the functional status of cones in normal and diseased retinae.

[Measurement of viscoelastic corneal parameters (corneal hysteresis) in patients with primary open angle glaucoma]

BACKGROUND

The ocular response analyzer (ORA) uses an air-pressure-triggered, dynamic, bi-directional corneal applanation method to measure biomechanical parameters of the cornea. Corneal hysteresis (CH) is defined as the difference in intraocular pressure recorded during inward and outward applanation. CH is therefore an indicator for the viscoelastic properties of the cornea.

PATIENTS AND METHODS

CH was recorded in non-glaucoma patients (80 eyes) as well as in patients with primary open angle glaucoma (POAG, 82 eyes). The correlation between CH and central corneal thickness (CCT) was analyzed.

RESULTS

Mean CH was 10.6+/-2.2 mmHg in the non-glaucoma group and 9.3+/-2.2 mmHg in patients with POAG (p<0.01). CH and CCT showed a positive correlation in non-POAG patients, however no such correlation was found in the POAG group.

CONCLUSION

Patients with POAG show an alteration of biomechanical corneal parameters with a significant decrease in corneal hysteresis. A positive correlation between CH and CCT, which was seen in the non-glaucoma group could not be detected in the POAG group.

[Is bimedial muscle belting an alternative procedure to retro-equatorial myopexy in convergence excess esotropia?]

OBJECTIVE

Retro-equatorial myopexy is a standard procedure to reduce convergence excess esotropia and esotropia with variable deviations. However, the surgical effect of the faden operation can be accompanied by restricted eye motility in side-gaze. Revision of the operated muscle is often difficult due to scarring of the muscle and adhesions with the sclera. Bimedial muscle belting is an alternative procedure that tries to reduce these side effects.

METHODS

The surgical technique, which consists of bridging the medial rectus with a silicon band sutured to the sclera, has been demonstrated previously. Results after bimedial muscle belting were analyzed in 33 patients retrospectively after 6 weeks and 37 months, and compared with the results after the faden operation.

RESULTS

Angles at distance were reduced 6 weeks postoperatively by a median value of 6.0 degrees and for near by a median of 10.5 degrees , which is very similar to the effect seen after the faden operation. After 37 months, results remained stable with a reduction of a median of 6.0 degrees at distance and 10.0 degrees for near. Significant incomitance in side-gaze was only rarely noted after muscle belting (maximum 5 degrees ), whereas it was seen frequently after the faden operation, 4.0 degrees -6.6 degrees (maximum 9 degrees ).

CONCLUSIONS

Bimedial rectus belting is an alternative procedure to the faden operation, yielding similar results. Surgically, the procedure is more demanding, as the fixating sutures have to be passed through the sclera twice on either side. However, the integrity of the muscle is maintained and major adhesions with the sclera do not develop. Thus, the muscle can be subjected to recess or resect surgery without touching the anchoring of the belt in the sclera. In addition, revision surgery can be carried out easily with the belt left in place.

Der Einfluss von kornealer Hysterese und kornealem Resistenzfaktor auf die Messung des intraokularen Drucks

BACKGROUND

The influence of central corneal thickness (CCT) on the measurement of intraocular pressure (IOP) has been discussed extensively in recent years. The problem, however, has not been solved so far. In addition to CCT there are probably further biomechanical properties that play a role in IOP measurement. We wanted to find out whether these properties are related to Goldmann applanation tonometry (GAT), noncontact tonometry (NCT), or CCT.

MATERIAL AND METHODS

Biomechanical properties of the cornea such as corneal hysteresis (CH) and corneal resistance factor (CRF) can be measured with the Ocular Response Analyzer (ORA, Reichert Ophthalmic Instruments, Depew, NY, USA). Furthermore, a corneal compensated IOP (IOPcc) is given. We examined 156 normal eyes of 80 patients who did not show corneal pathology nor glaucoma. In each eye GAT, NCT, and ORA data as well as CCT were measured. Data were statistically analyzed with respect to agreement and the influence of CH and CRF on IOP measurement.

RESULTS

In our patients the following average values were calculated: GAT 14.8+/-3.0 mmHg, NCT 16.4+/-3.9 mmHg, IOPcc 16.2+/-4.1 mmHg, CH 10.6+/-2.3 mmHg, CRF 10.9+/-2.4 mmHg, and CCT 557+/-36 microm. IOPcc was not related to CCT in normal eyes and the only IOP value related to CH (p<0.01). CRF, however, was related to GAT and NCT values (p<0.01).

DISCUSSION

In our group of normal eyes IOPcc, i.e., the value that is adjusted by measurement of viscoelastic properties of the cornea, in contrast to GAT and NCT does not depend on central corneal thickness. Corneal hysteresis and corneal resistance factor provide further information about biomechanical properties of the cornea beyond central corneal thickness.

Preventive effects of the probiotic Escherichia coli strain Nissle 1917 on acute secretory diarrhea in a pig model of intestinal infection

Pretreatment with the probiotic Escherichia colistrain Nissle 1917 (EcN) was assessed in a pig model of intestinal infection to prevent acute secretory diarrhea. In the model 10(10) colony forming units of the porcine enterotoxigenic Escherichia coli Abbotstown (EcA) was given via orogastric tube to weaned piglets at day 21 postpartum (-EcN/+EcA group, n = 7). Forty-eight hours after challenge electrophysiological parameters of isolated intact jejunal epithelia were characterized in Ussing chambers. In agreement with clinical signs of diarrhea, tissues of challenged animals showed an overshoot of secretory response after stimulation of the cAMP-mediated second messenger pathway by forskolin, indicating higher excitability of chloride secretory systems under infected conditions. The data were compared with respective measurements from animals that got a daily dose of 10(10) cfu of the probiotic EcN over 10 days before EcA challenge (+EcN/+EcA group; n = 4), from a group that received only EcN (+EcN/-EcA; n = 4), or from a group that remained totally untreated (-EcN/-EcA; n = 6). EcN pretreatment completely abolished clinical signs of secretory diarrhea in +EcN/+EcA animals. Furthermore, jejunum epithelia of these animals did not exhibit an overshoot of secretory response upon stimulation with forskolin. Our studies demonstrate for the first time the efficacy of prophylactic EcN in pig small intestine for preventing an effect of toxigenic EcA. This infection model with freshly weaned piglets may be predestinated to further characterize EcN effects on the cellular level, i.e., involved second messenger pathways, or it may also be useful to examine the efficacy of other substrates or microbe strains against secretory stimuli.

Influence of living and autoclaved yeasts of Saccharomyces boulardii on in vitro ruminal microbial metabolism

Experimental data on the effects of Saccharomyces boulardii on rumen microbial metabolism are scarce. The aim of this study was to examine whether S. boulardii had an effect on parameters of rumen microbial metabolism at different dosages and whether the yeast would be suitable as a probiotic agent for ruminants. To test whether the potential positive effects of S. boulardii could be attributed to the yeast's viability or to its content of nutrients, living and autoclaved yeasts were tested simultaneously. For this purpose, incubation trials were carried out using the long-term rumen simulation technique. Living and autoclaved yeasts were added to fermentation vessels at a concentration of 0.5 or 1.5 g/d. The addition of living and autoclaved yeasts stimulated microbial metabolism, with no major differences between the treatments. It was concluded that ruminal microbes digested the supplied yeast of S. boulardii as an additional substrate and that S. boulardii, at least in ruminants, is utilized as a prebiotic rather than as a probiotic agent.

Grundlagen der Applanationstonometrie

For more than 50 years Goldmann applanation tonometry has been the internationally accepted method for measuring intraocular pressure. In Goldmann applanation tonometry, however, some basic physical properties are oversimplified and the method has some flaws and restrictions. This paper is intended to promote the understanding of the methodological basis of Goldmann applanation tonometry and describes the most important factors influencing the measurement of intraocular pressure (e. g., corneal thickness, corneal radius, axial length and corneal morphology). Furthermore, the basic principles of other commonly used tonometer devices will be discussed. New developments are anticipated that will measure the true intraocular pressure more accurately than Goldmann applanation tonometry.

Studies on the time course of the effects of the probiotic yeast Saccharomyces boulardii on electrolyte transport in pig jejunum

Orally administered Saccharomyces boulardii (synonym Saccharomyces cerevisiae Hansen CBS 5926) has already been shown to affect relevant functions of the mucosa in pig jejunum such as lowering the secretory response to theophylline or stimulating sodium/glucose cotransport, but knowledge of time-dependent relationship is minimal. In this study we examined the effects of S. boulardii on sodium (Na+) and chloride (Cl-) transport in pig jejunum under nonstimulated (basal) and stimulated (secretory) conditions. For this purpose the conventional Ussing chamber method was used for measuring electrical parameters (short circuit currents, Isc; tissue conductances, G(T)) and electrolyte transport of isolated intact jejunal epithelia in the absence and presence of the secretagogue theophylline (10 mM, serosal side). Time profiles of the mucosa response were assessed by treating animals perorally with S. boulardii for 0 (control), 3, 8, and 16 days. Intestinal tissues were obtained from growing pigs in the weight range between 25 and 40 kg. All animals were fed twice daily and received 1.0-1.6 kg/day of a standard diet avoiding probiotics as food additives. After a 9- to 10-day adaptation period the diets for treated animals were supplemented with approximately 1.8 x 10(7) colony forming units (CFU)/g feed of the probiotic. Whereas basal tissue conductances were not affected by treatment duration, basal Isc values decreased significantly during 8 days of treatment, by 26%, indicating a lower electrogenic net ion transport, which, however, was reconstituted after 16 days. This effect could be explained by almost the same reduction of basal Jms of Na+ during 8 days of treatment, whereas respective flux rates in the opposite direction remained stable. Under basal conditions unidirectional and net flux rates of Cl- were not affected by S. boulardii. Induction of secretory conditions by theophylline revealed pronounced increases in net Cl- secretion but this effect was more than 60% lower after 8-day S. boulardii application, and this was reflected by a respectively lower Isc stimulation. Interestingly, this inhibitory effect on the secretory response could no longer be observed in the 16-day group. And this was reflected by a respectively lower Isc stimulation. A similar effect could be observed regarding net Na+ flux rates. Residual fluxes were affected neither by S. boulardii nor by theophylline, therefore, Isc values can be explained completely by respective Na+ and Cl- fluxes. In conclusion, S. boulardii has specific duration-dependent effects on the secretory response of the pig jejunal mucosa which developed during 8-day treatment but disappeared during further application. Thus, this study supports the concept that probiotics may exert beneficial effects in the gastrointestinal tract.

Early diagnosis, presenting complaints, and management of hyperandrogenism in adolescents

Hyperandrogenism in the adolescent is a common problem that may manifest in several ways, and may be the result of numerous underlying problems. This article reviews hirsutism, acne, adrenal hyperplasia, and polycystic ovarian syndrome. Presenting signs and symptoms, as well as underlying pathophysiology and treatment options, are discussed.

Short- and long-term effectiveness of an empirically supported treatment for agoraphobia

This study examined the effectiveness of individual high-density exposure (2-3 weeks, all day) for panic disorder with agoraphobia (PDAG). Participants were 416 unselected patients with a primary diagnosis of PDAG who were treated by 52 therapists in 3 outpatient clinics of the Christoph-Dornier Foundation of Clinical Psychology in Germany. Results 6 weeks after the end of therapy and at the 1-year follow-up showed highly significant reductions in anxiety symptoms, anxious cognition, agoraphobic avoidance, general symptomatology, and depressive symptoms. Results did not differ significantly between the 3 outpatient clinics and are comparable with the average effect sizes reported by meta-analytic studies of controlled efficacy research, using selected patients and specifically trained therapists. Effectiveness was not dependent on duration of disorder, number of treatment sessions, and therapist experience. The study suggests that high-density exposure can be transported from research settings to the mental health field.

Quantitative effect of intravitreally injected tissue plasminogen activator and gas on subretinal hemorrhage

PURPOSE

To quantify the effect of intravitreally injected tissue plasminogen activator (TPA) and an expanding gas on freshly formed subretinal hemorrhage (SRH).

PATIENTS AND METHODS

Thirteen patients with acute (1 week or less) SRH due to age-related macular degeneration (ARMD) were treated with an intravitreal injection of 50 microg TPA, and 24 hours later, with an expanding gas. Fundus photographs taken before and 24 hours after each injection were digitized and calibrated. Area, geometric center, and shift of the SRH were measured at each time point using NIH image analysis software. Elevation of the SRH was assessed by echography.

RESULTS

Compared to the preoperative size, SRH enlarged significantly 24 hours after TPA injection (P < 0.001). A significant shift of the geometric center toward the inferior retinal periphery out of the macula was found after gas injection (P < 0.001). Significant horizontal displacement of the SRH was not noted after TPA or gas injection. More elevated subretinal blood clots showed a larger increase in size after TPA injection than flat clots (P < 0.05).

CONCLUSION

Enlargement of SRH in a gravity-dependent manner indicates subretinal liquefaction of the clot after TPA treatment. An intravitreal injection of gas 24 hours later can significantly displace the SRH inferiorly.

Is there a seasonal variation in gonorrhea and chlamydia in adolescents?

STUDY OBJECTIVE

To determine if a seasonal variation exists in gonorrhea and chlamydia in female adolescents. DESIGN, SETTING, PARTICIPASNTS: We conducted a retrospective chart review of 604 sexually active adolescent females 21 years of age and younger in a teen pregnancy prevention clinic in a small Midwestern city. Positive gonorrhea and chlamydia tests were evaluated for seasonal variation. Chi-square, odds ratios, and 95% confidence intervals were calculated.

RESULTS

A greater percentage of tests were positive in the fall than in other seasons (P = 0.028), and there was a trend towards more cases in the summer than winter and spring.

CONCLUSIONS

Increased emphasis should be placed on prevention and screening during summer and fall.

Supporting decision making and action selection under time pressure and uncertainty: the case of in-flight icing

Operators in high-risk domains such as aviation often need to make decisions under time pressure and uncertainty. One way to support them in this task is through the introduction of decision support systems (DSSs). The present study examined the effectiveness of two different DSS implementations: status and command displays. Twenty-seven pilots (9 pilots each in a baseline, status, and command group) flew 20 simulated approaches involving icing encounters. Accuracy of the decision aid (a smart icing system), familiarity with the icing condition, timing of icing onset, and autopilot usage were varied within subjects. Accurate information from either decision aid led to improved handling of the icing encounter. However, when inaccurate information was presented, performance dropped below that of the baseline condition. The cost of inaccurate information was particularly high for command displays and in the case of unfamiliar icing conditions. Our findings suggest that unless perfect reliability of a decision aid can be assumed, status displays may be preferable to command displays in high-risk domains (e.g., space flight, medicine, and process control), as the former yield more robust performance benefits and appear less vulnerable to automation biases.