Safety and Efficacy of Stereotactic Radiosurgery with Concurrent Targeted Systemic Therapy for Brain Metastases

PURPOSE/OBJECTIVE(S)

Data describing the safety and efficacy of central nervous system (CNS)-active targeted systemic therapies in combination with stereotactic radiosurgery (SRS, 1 fraction) and/or radiotherapy (SRT, 3-5 fractions) for brain metastases are emerging but limited. We report rates of local and intracranial failure and radiation necrosis in patients receiving CNS-active targeted systemic therapy and SRS/SRT.

MATERIALS/METHODS

We retrospectively identified patients with intact brain metastases at two institutions from 2009-2022 who were treated with SRS/SRT and CNS-active targeted systemic therapy in any sequence. Patients were followed for a minimum of 3 months after SRS/SRT with brain MRI. Patients typically stopped the targeted agent 2-4 days prior to radiation and resumed 2-4 days after. Targeted therapies included inhibitors of ALK/ROS1 (Alectinib, Ceritinib, Crizotinib, Lorlatinib), EGFR (Afatinib, Erlotinib, Gefitinib, Osimertinib), BRAF (Dabrafenib, Encorafenib, Vemurafenib), MEK (Binimetinib, Trametinib), CDK 4/6 (Abemaciclib, Palbociclib, Ribociclib), HER2 (Afatinib, Lapatinib, Neratinib, Pertuzumab, Trastuzumab, T-DM1, T-DXd, Tucatinib), KRAS (Adagrasib and Sotorasib), PARP (Niraparib, Olaparib), VEGF(R) (Axitinib, Bevacizumab, Ramucirumab), and less-selective tyrosine (receptor) kinase inhibitors (Bosutinib, Brigatinib, Entrectinib, Lenvatinib, Pazopanib, Sorafenib, Sunitinib). Local failure (LF) and radiation necrosis were determined radiographically with clinical impression (grade 2 (symptomatic) or higher (G2+)) and compared between different systemic agents.

RESULTS

The study included 95 patients with 310 metastases (SRS 246, SRT 64 metastases). Most common primary histologies were non-small cell lung cancer (36% 34/95), breast cancer (28% 27/95), and melanoma (16% 15/95). Overall survival at 1 and 2 years was 80% (76/95) and 55% (52/95), respectively. Median follow-up was 16.6 (range 3-91) months. Median tumor size was 7mm (range 1-75mm). Median number of brain metastases per patient was 2.5 (range 1-12). The G2+ radiation necrosis rate was 5.8% (18/310) while the LF rate was 9.7% (30/310) per metastasis. There was no significant difference in G2+ radiation necrosis by class of targeted therapy. Sixty-two percent (59/95) of patients experienced distant intracranial failure. Median intracranial progression free survival (PFS) was 8.0 (range 0.4-61.4) months.

CONCLUSION

Although heterogeneous, patients treated with SRS/SRT and ongoing CNS-active targeted systemic therapies have on average >6 month intracranial PFS and little evidence of significant toxicity. We observed <6% G2+ radiation necrosis for this cohort, and no particular class of agent was associated with a significantly higher rate of G2+ radiation necrosis.

Circulatory efficiency in patients with severe aortic valve stenosis before and after aortic valve replacement

BACKGROUND

Circulatory efficiency reflects the ratio between total left ventricular work and the work required for maintaining cardiovascular circulation. The effect of severe aortic valve stenosis (AS) and aortic valve replacement (AVR) on left ventricular/circulatory mechanical power and efficiency is not yet fully understood. We aimed to quantify left ventricular (LV) efficiency in patients with severe AS before and after surgical AVR.

METHODS

Circulatory efficiency was computed from cardiovascular magnetic resonance (CMR) imaging derived volumetric data, echocardiographic and clinical data in patients with severe AS (n = 41) before and 4 months after AVR and in age and sex-matched healthy subjects (n = 10).

RESULTS

In patients with AS circulatory efficiency was significantly decreased compared to healthy subjects (9 ± 3% vs 12 ± 2%; p = 0.004). There were significant negative correlations between circulatory efficiency and LV myocardial mass (r = - 0.591, p < 0.001), myocardial fibrosis volume (r = - 0.427, p = 0.015), end systolic volume (r = - 0.609, p < 0.001) and NT-proBNP (r = - 0.444, p = 0.009) and significant positive correlation between circulatory efficiency and LV ejection fraction (r = 0.704, p < 0.001). After AVR, circulatory efficiency increased significantly in the total cohort (9 ± 3 vs 13 ± 5%; p < 0.001). However, in 10/41 (24%) patients, circulatory efficiency remained below 10% after AVR and, thus, did not restore to normal values. These patients also showed less reduction in myocardial fibrosis volume compared to patients with restored circulatory efficiency after AVR.

CONCLUSION

In our cohort, circulatory efficiency is reduced in patients with severe AS. In 76% of cases, AVR leads to normalization of circulatory efficiency. However, in 24% of patients, circulatory efficiency remained below normal values even after successful AVR. In these patients also less regression of myocardial fibrosis volume was seen. Trial Registration clinicaltrials.gov NCT03172338, June 1, 2017, retrospectively registered.

Phase Ib study of atezolizumab combined with cobimetinib in patients with solid tumors

BACKGROUND

Preclinical evidence suggests that MEK inhibition promotes accumulation and survival of intratumoral tumor-specific T cells and can synergize with immune checkpoint inhibition. We investigated the safety and clinical activity of combining a MEK inhibitor, cobimetinib, and a programmed cell death 1 ligand 1 (PD-L1) inhibitor, atezolizumab, in patients with solid tumors.

PATIENTS AND METHODS

This phase I/Ib study treated PD-L1/PD-1-naive patients with solid tumors in a dose-escalation stage and then in multiple, indication-specific dose-expansion cohorts. In most patients, cobimetinib was dosed once daily orally for 21 days on, 7 days off. Atezolizumab was dosed at 800 mg intravenously every 2 weeks. The primary objectives were safety and tolerability. Secondary end points included objective response rate, progression-free survival, and overall survival.

RESULTS

Between 27 December 2013 and 9 May 2016, 152 patients were enrolled. As of 4 September 2017, 150 patients received ≥1 dose of atezolizumab, including 14 in the dose-escalation cohorts and 136 in the dose-expansion cohorts. Patients had metastatic colorectal cancer (mCRC; n = 84), melanoma (n = 22), non-small-cell lung cancer (NSCLC; n = 28), and other solid tumors (n = 16). The most common all-grade treatment-related adverse events (AEs) were diarrhea (67%), rash (48%), and fatigue (40%), similar to those with single-agent cobimetinib and atezolizumab. One (<1%) treatment-related grade 5 AE occurred (sepsis). Forty-five (30%) and 23 patients (15%) had AEs that led to discontinuation of cobimetinib and atezolizumab, respectively. Confirmed responses were observed in 7 of 84 patients (8%) with mCRC (6 responders were microsatellite low/stable, 1 was microsatellite instable), 9 of 22 patients (41%) with melanoma, and 5 of 28 patients (18%) with NSCLC. Clinical activity was independent of KRAS/BRAF status across diseases.

CONCLUSIONS

Atezolizumab plus cobimetinib had manageable safety and clinical activity irrespective of KRAS/BRAF status. Although potential synergistic activity was seen in mCRC, this was not confirmed in a subsequent phase III study.

CLINICALTRIALS.GOV IDENTIFIER

NCT01988896 (the investigators in the NCT01988896 study are listed in the supplementary Appendix, available at Annals of Oncology online).

Purification of protein complexes and characterization of protein-protein interactions

In plants and all other multicellular organisms, both the intra- and extracellular environments are filled with dynamic biomolecular interactions that control many biological processes. Most of these interactions are biochemical in nature and often exist between proteins. For instance, many protein-protein interactions assist in sustained cellular homeostasis but also allow for rapid intracellular communication in response to stimuli. Thus, the discovery and validation of protein-protein interactions, and the consequent formation of protein complexes, is an integral and essential component of plant biology research. The ability to efficiently and accurately determine existing protein networks is necessary to further our understanding of plant biology. However, discovering protein networks represents a challenge for both present and future researchers. Here we have outlined several straightforward methods aimed at first discovering protein-protein interactions and then characterizing them utilizing additional approaches. We first describe methods for rate-zonal centrifugation, in vitro binding assays, and co-immunoprecipitation experiments in the context of discovering novel protein-protein interactions. Next, we discuss methods for characterizing and validating these interactions using alternative approaches: yeast two-hybrid, in vitro pull-down assays, and bimolecular fluorescence complementation (BiFC). Obviously each of these methods need not be performed in parallel; rather our goal was to describe several approaches, some of which may be more appropriate for increasingly specialized laboratory environments.

Single-particle analysis of aerosols at Cheju Island, Korea, using low-Z electron probe X-ray microanalysis: a direct proof of nitrate formation from sea salts

A recently developed electron probe X-ray microanalysis (EPMA), called low-Z EPMA, employing an ultrathin window energy-dispersive X-ray detector, was applied to characterize aerosol particles collected at two sampling sites, namely, Kosan and 1100 Hill of Cheju Island, Korea, on a summer day in 1999. Since low-Z EPMA can provide quantitative information on the chemical composition of aerosol particles, the collected aerosol particles were classified and analyzed based on their chemical species. Many different particle types were identified, such as marine-originated, carbonaceous, soil-derived, and anthropogenic particles. Marine-originated particles, such as NaNO3- and Na2SO4-containing particles, are very frequently encountered in the two samples. In this study, it was directly proven that the observed nitrate particles were from sea salts. In addition, two types of nitrate particles from sea salts were observed, with and without Mg. The sodium nitrate particles without Mg were believed to be collected as crystalline form, either with the sodium nitrate particles being fractionally recrystallized within evaporating seawater drops or with recrystallized sodium chloride particles having reacted with gaseous nitrogen species in the air to form the crystalline sodium nitrate particles. The other seemed to be collected as seawater drops, where the atmospheric reaction had occurred in the droplets, and thus sodium as well as magnesium nitrates were observed. Carbonaceous particles are the most abundant in the samples at both sites. From this study, it was found that about three-quarters of the carbonaceous particles in the samples were biogenic, which partially explains a previously reported observation of a large concentration of organic carbon particles as compared to elemental carbon. Various soil-derived particles were also observed. In addition to aluminosilicate- and iron oxide-containing particles, which are ubiquitous components in soil-derived particles, CaCO3-, Al2O3- and Cr-containing particles were also frequently encountered.

Natural progress of a bone scan after cementless hydroxyapatite-coated total hip arthroplasty

To establish the natural progress pattern of postoperative bone uptake, a periprosthetic quantitative technetium-99m methylene diphosphonate scintiscan was done on 80 asymptomatic hips (62 patients) with uncomplicated cementless hydroxyapatite-coated total hip arthroplasties and 20 healthy control hips (10 subjects) without previous surgery. The patients were studied in eight groups at scheduled intervals of 1 to 48 months. There were 10 hips in each group. The measurement of bone uptake in the healthy untreated control group indicated that the uptake ratio in the proximal femur was physiologically higher in the metaphyseal area than in the diaphyseal area and the uptake ratio in the acetabulum appeared to be much higher than that of the proximal femur. In the patient group, the uptake ratio around the femoral stem area and the acetabular cup area showed a statistically significant decrease between 1 and 3 months after surgery and changed little after 3 months. Comparing the result of the patient group with that of the healthy untreated control group, the uptake ratio decreased much faster in the hydroxyapatite-coated metaphyseal zone than in the noncoated diaphyseal zone of the femoral stem area. In the acetabular cup area, the uptake ratio decreased fast, as in the hydroxyapatite-coated metaphyseal zone of the femoral stem area. Based on these clinical results, a quantitative bone scan may be a helpful diagnostic procedure for evaluating postoperative progress when used in conjunction with clinical symptoms and radiologic examinations.

On the interactivity of complex synthesis and tumor pharmacology in the drug discovery process: total synthesis and comparative in vivo evaluations of the 15-aza epothilones

The total syntheses of 12,13,15-desoxy-15(S)-aza-epothilone B (aza-dEpoB; dEpoB-lactam) and 12,13,15-desoxy-15(R)-aza-epothilone B (15-epi-aza-dEpoB; 15-epi-dEpoB-lactam) have been accomplished via a highly convergent strategy. We have also successfully oxidized 12,13,15-desoxy-15(S)-aza-epothilone B to aza-epothilone B (aza-EpoB; EpoB-lactam). Aza-epothilone B has been advanced to phase I clinical trials by the Bristol-Myers Squibb group. Our synthesis is efficient and was amenable to the production of significant quantities of these lactams. Using our fully synthetically derived lactams, in vitro and in vivo studies were conducted in comparison with advanced clinical candidates, 12,13-desoxyepothilone B and 12,13-desoxyepothilone F, also derived by total synthesis.

Insights into long-range structural effects on the stereochemistry of aldol condensations: a practical total synthesis of desoxyepothilone F

A processable total synthesis of a potent antitumor agent, desoxyepothilone F (dEpoF, 21-hydroxy-12,13-desoxyepothilone B, 21-hydroxyepothilone D), has been accomplished. The route is highly convergent. The new technology has also been applied to a total synthesis of 12,13-desoxyepothilone (dEpoB). The crucial point of departure from previous syntheses of dEpoB and dEpoF involves presentation of the C1-C11 sector for Suzuki coupling with C3 in reduced form. Hitherto, the required S stereochemistry at C3 had been implemented via reduction of a keto function after Suzuki coupling. Whereas that chemistry worked quite well in a synthesis of dEpoB, it was not transferable to a high-yielding synthesis of dEpoF. The reduction of the keto group at C3 via a Noyori protocol after Suzuki coupling had proved to be very difficult. In our current approach, two consecutive aldol reactions are used to fashion the acyl sector. In the first aldol condensation, C6 becomes attached to C7. Following protection at C7, a two-carbon acetate equivalent is used to join C2 and C3 with very high asymmetric induction at C3. Only after this center has been implemented is the Suzuki reaction conducted. This major advance allowed us to synthesize dEpoF in a straightforward fashion. These findings found ready application in the total synthesis of dEpoB. Another part of the study involved analysis of the factors associated with aldol condensations joining C6 to C7. In the work described herein, the consequences of the status of C3 in promoting the C6-C7 aldol coupling are probed in detail. Dramatic stereochemical long-range effects uncovered during the study are described, and a working model to explain these effects has emerged.

Effect of thyroid hormone on the alcohol dehydrogenase activities in rat tissues

The effects of thyroid hormone on hepatic and gastric alcohol dehydrogenase (ADH) activities (nM of NADH/min/mg of cytosolic protein) have been investigated in male Sprague Dawley rats treated with thyroxine (1 mg/kg, po) for 14 days. Whereas hepatic ADH activity in thyroxine-treated rats decreased by 61.3% of control rats (26.4 vs 43.2, p<0.001), gastric ADH activity increased by 262.9% of control rats (4.9 vs 1.9, p<0.001). As for the activities of the lung and kidney, thyroxine treatment did not produce any statistically significant changes. These data suggest that thyrotoxicosis causes a decrease of hepatic alcohol metabolism, and that the increase of gastric ADH activity in thyrotoxic rats can partly restore the first-pass metabolism of ethanol.

Geminal dicarboxylates as carbonyl surrogates for asymmetric synthesis. Part II. Scope and applications

An enantioselective synthesis of allylic esters has been achieved by a novel asymmetric alkylation of allylic gem-dicarboxylates. The catalyst derived from palladium(0) and R,R-1,2-di(2'-diphenylphosphinobenzamido)cyclohexene efficiently induced the alkylation process with a variety of nucleophiles to provide allylic esters as products in good yield. High regio- and enantioselectivities were observed in the alkylation with most nucleophiles derived from malonate, whereas a modest level of ee's was obtained in the reactions with less reactive nucleophiles such as bis(phenylsulfonyl)ethane. In the latter case, a slow addition procedure proved effective, leading to significantly improved ee's. The utility of the alkylation products was demonstrated by several synthetically useful transformations including allylic isomerizations, allylic alkylations, and Claisen rearrangements. Using these reactions, the chirality of the initial allylic carbon-oxygen bond could be transferred to new carbon-oxygen, carbon-carbon, or carbon-nitrogen bonds in a predictable fashion with high stereochemical fidelity. The conversion of gem-diesters to chiral esters by the substitution reaction is the equivalent of an asymmetric carbonyl addition by stabilized nucleophiles. In conjunction with the subsequent reactions that occur with high stereospecificity, allylic gem-dicarboxylates serve as synthons for a double allylic transformation.

Geminal dicarboxylates as carbonyl surrogates for asymmetric synthesis. Part I. Asymmetric addition of malonate nucleophiles

Asymmetric alkylations of allylic geminal dicarboxylates with dialkyl malonates have been investigated. The requisite allylic geminal dicarboxylates are prepared in good yields and high isomeric purities by two catalytic methods, ferric chloride-catalyzed addition of acid anhydrides to alpha,beta-unsaturated aldehydes and palladium-catalyzed isomerization and addition reactions of propargylic acetates. The complex of palladium(0) and the chiral ligand derived from the diamide of trans-1,2-diaminocyclohexane and 2-diphenylphosphinobenzoic acid most efficiently catalyzed the asymmetric process to provide allylic carboxylate esters with high ee. By systematic optimization studies, factors affecting the enantioselectivity of the reaction have been probed. In general, higher ee's have been achieved with those conditions which facilitate kinetic capture of the incipient pi-allylpalladium intermediate. These conditions also proved effective for achieving high regioselectivities. The minor regioisomeric product was formed when reactive substrates or achiral ligands were employed for the reaction, and could be minimized through the use of the chiral ligand. Under the established conditions, the alkylation of various gem-dicarboxylates afforded monoalkylated products in high yields with greater than 90% ee. The process constitutes the equivalent of an addition of a stabilized nucleophile to a carbonyl group with high asymmetric induction.

Chilling stress-induced changes of antioxidant enzymes in the leaves of cucumber: in gel enzyme activity assays

To investigate the antioxidant defense system, chilling stress-induced changes of antioxidant enzymes were examined in the leaves of cucumber (Cucumis sativus L.). Chilling stress preferentially enhanced the activities of the superoxide dismutase (SOD), ascorbate peroxidase (APX), glutathione reductase (GR) and peroxidase specific to guaiacol, whereas it induced the decrease of catalase activity. In order to analyze the changes of antioxidant enzyme isoforms against chilling stress, foliar extracts were subjected to native PAGE. Leaves of cucumber had four isoforms of Mn-SOD and two isoforms of Cu/Zn-SOD. Fe-SOD isoform was not observed in this plant. Expression of Cu/Zn-SOD and Mn-SOD was preferentially enhanced by chilling stress. Expression of Mn-SOD-2 and -4 was enhanced after 48 h of the poststress period. Five APX isoforms were presented in the leaves of cucumber. The intensities of APX-4 and -5 were enhanced by chilling stress, whereas that of APX-3 was significantly increased in the poststress periods after chilling stress. Gel stained for GR activity revealed six isoforms in the plant. Activation levels for most of GR isoforms were higher in the stressed-plants than the control and poststressed-plants, but that of GR-1 isoform was significantly higher in the poststressed-plants than chilling stressed-plants. These results collectively suggest that chilling stress activates the enzymes of an SOD/ascorbate-glutathione cycle under catalase deactivation in the leaves of cucumber, but the response timing of enzyme isoforms against various environmental stresses is not the same for all isoforms of antioxidant enzymes.

Total synthesis and antitumor activity of 12,13-desoxyepothilone F: an unexpected solvolysis problem at C15, mediated by remote substitution at C21

A new epothilone analogue, 12,13-desoxyepothilone F (dEpoF, 21-hydroxy-12,13-desoxyepothilone B, 21-hydroxyepothilone D), was synthesized and evaluated for antitumor potential. A convergent strategy employed for the semipractical synthesis of 12,13-desoxyepothilone B (dEpoB) has been utilized to yield an amount of dEpoF sufficient for relevant biological studies. The results from an in vitro assay reveal that this new analogue is highly active against various tumor cell lines with a potency comparable to that of dEpoB. In particular, the growth of resistant tumor cells is inhibited by dEpoF at concentrations where paclitaxel (Taxol) is basically ineffective. A preliminary assessment of its in vivo activity is also promising. The new analogue, containing an additional hydroxyl group at C21, exhibits advantages over other epothilones in terms of water solubility, and can serve as a readily functionalizable handle to produce other useful compounds for pertinent biological studies.

Spontaneous rupture of hydronephrotic kidney during pregnancy: value of serial sonography

Hydronephrosis during pregnancy is common but rarely results in renal rupture. We report an unusual case of spontaneous rupture of a hydronephrotic kidney during pregnancy. Although we could not predict the renal rupture on the basis of sonographic findings, serial sonography was useful in the early detection and management of the rupture.

Possible universal transitional scenario in a flat plate boundary layer: measurement and visualization

An experimental investigation was undertaken to reveal the characteristic flow structure in the regime of nonlinear boundary layer instability and onset of turbulence. A controlled Tollmien-Schlichting wave was introduced into a two-dimensional boundary layer over a flat plate to study the growth and evolution of the controlled disturbances using both hot film measurements and an improved hydrogen bubble visualization technique. The results demonstrate that the actual breakdown of the laminar boundary layer and the breakdown of the Lambda vortices do not imply the immediate onset of turbulence. Rather, the onset occurs later with the breakdown of the long streaks. Therefore, an alternative transitional scenario was developed.

En route to a plant scale synthesis of the promising antitumor agent 12,13-desoxyepothilone B

[reaction--see text] Efficient and processable syntheses of key building blocks of the antitumor agent 12,13-desoxyepothilone B (dEpoB) by catalytic asymmetric induction are herein described.

On the total synthesis and preliminary biological evaluations of 15(R) and 15(S) aza-dEpoB: a Mitsunobu inversion at C15 in pre-epothilone fragments

[reaction-see text] The syntheses of two epothilone analogues, 15(S)-aza-12,13-desoxyepothilone B and the epimeric 15(R)-aza-12,13-desoxyepothilone B, are described. A Mitsunobu inversion was utilized for elaboration of pre-epothilone fragments to the corresponding macrolactam. Tubulin binding and cytotoxicity profiles of these analogues are presented.

Expression of cyclin D1 and cyclin E in human gastric carcinoma and its clinicopathologic significance

Cyclin D1 and cyclin E are the mammalian G1 cydins that are both required and rate limiting for entry into S phase. Alterations in cell cycle regulators and subsequent deregulation of the cell cycle are frequently involved in tumorigenesis and/or tumor progression. We investigated the expression of cyclin D1 and cyclin E protein in 84 gastric carcinoma by immunohistochemical staining and also the relevance of each cyclin expression to the clinical outcomes. Overexpression of cyclin D1 and cyclin E was noted in 21 of 84 (25.0%) and 34 of 84 (40.5%) gastric cancer tissues, respectively. There was a significant correlation between overexpression of cyclin E and lymph node metastasis (p=0.003), recurrence (p=0.043), disease free survival (p=0.0378) and overall survival (p=0.0319), but no correlation was noted between overexpression of cyclin D1 and other clinicopathologic variables. These findings suggest that overexpression of cyclin E and cyclin D1 is a frequent finding in gastric cancer and immunohistochemical analysis for cell cycle regulators, especially cyclin E might be a useful prognostic indicator in gastric cancer.

Stabilization by glycinebetaine of photosynthetic oxygen evolution by thylakoid membranes from Synechococcus PCC7002

Active thylakoid membranes were prepared from Synechococcus PCC7002 in a medium that contained glycinebetaine. The oxygen-evolving activity of photosystem II of these thylakoid membranes was enhanced and stabilized by the presence of glycinebetaine. The heat stability of the oxygen-evolving activity of the thylakoid membranes was also enhanced by glycinebetaine.

Beneficial effects of pravastatin on fasting hyperinsulinemia in elderly hypertensive hypercholesterolemic subjects

We undertook this prospective double-blind, placebo-controlled study to evaluate the efficacy and safety of low-dose (15 mg) pravastatin in elderly hypercholesterolemic hypertensive subjects with concurrent antihypertensive treatment and to determine whether fasting hyperinsulinemia could also be improved. At three hypertension and lipid clinics of two medical centers, 96 elderly (49 women, 47 men) ambulatory subjects were randomized to active treatment or placebo for 12 months after a 3-month single-blind lead-in period. Hypertensive subjects with plasma total cholesterol levels of at least 6.47 mmol/L (250 mg/dL) and triglyceride levels less than 3.39 mmol/L (300 mg/dL) were treated with 15 mg pravastatin for 12 months after receiving 3 months of the American Heart Association step I diet. Lipid, glucose, and fasting insulin levels were measured; clinical laboratory tests included liver function and creatine kinase determinations. After 12 months of pravastatin therapy, plasma total cholesterol concentration decreased by 25.1% (from a mean of 7.29 to 5.47 mmol/L, P < .05), low-density lipoprotein cholesterol decreased by 30.2% (from 5.27 to 3.68 mmol/L, P < .05), and triglycerides decreased by 10.7% (from 1.68 to 1.50 mmol/L, P < .05). High-density lipoprotein cholesterol increased by 9.2% (from 1.20 to 1.31 mmol/L, P < .05). Fasting insulin levels decreased from 89.0 to 61.5 pmol/L (P < .05). All of these changes were greater (P < .05) than any tendency toward change in the placebo group. Adverse events and clinical laboratory abnormalities were generally mild and transient in both placebo and pravastatin groups. Study drugs were withdrawn from one subject in each group with asymptomatic creatine kinase elevations. We conclude that low-dose pravastatin was effective and safe in the treatment of hypercholesterolemic hypertensive subjects on concurrent antihypertensive therapy. It also improved fasting hyperinsulinemia despite the use of beta-blockers and diuretics in these hypertensive subjects.

The importance of the helix 2 region for the cis-cleaving and trans-cleaving activities of hepatitis delta virus ribozymes

The sequence, secondary structure, and size requirements of the helix 2 region (H2) of a cis-acting hepatitis delta virus ribozyme Rz 1 were examined in this study. Mutational analysis was performed, and the cleavage rate of each H2 mutant of Rz 1 was assayed. We found that H2 could be elongated to twice its original size without affecting ribozyme folding while the shortening of H2 by one base pair severely decreased autolytic activity. In addition, the maintenance of the Watson-Crick base-pairing interactions of the last base pair of H2 (A16U58) was not critical for cis-cleavage reaction. Nevertheless, mutants with an AA, an AG, an AC, or a GG pair at the bottom of H2 were less active, and the sequence of the H2/H3 interface might affect the stability of the catalytic core. The negative effects on ribozyme folding, such as the destabilization of H2, the unfavorable sequences at the last base pair of H2 as well as the disruption of the continuity of H2 and H3, could be compensated for by elongating the H2 region of the corresponding mutants. The extension of H2 may alter the conformation of ribozyme molecules; in addition, it stabilized the catalytic core and enhanced the resistance to formamide. Finally, for a trans-acting ribozyme and its substrate that require the formation of H1, H2, and H4 to reconstitute the autocatalytic domain of HDV RNA, the extension of H2 stabilized the substrate/ribozyme complex and speeded up the cleavage rate but hindered the product release process.

Effectiveness and safety of low-dose pravastatin and squalene, alone and in combination, in elderly patients with hypercholesterolemia

A double-blind, placebo-controlled study was conducted to compare the efficacy and safety of low-dose (10 mg) prevastatin and squalene (860 mg), either alone or in combination therapy, with placebo in the treatment of elderly patients with hypercholesterolemia. Ambulatory elderly patients (N = 102) were assigned in randomized fashion to receive active treatment or placebo for 20 weeks after a single-blind placebo lead-in period of 8 weeks. Total cholesterol and triglyceride levels in plasma were at least 250 mg/dL and less than 300 mg/dL, respectively. Concentrations of lipids and lipoproteins were measured, and clinical laboratory tests included liver function and creatine kinase determinations. Pravastatin 10 mg daily was more effective than squalene in reducing total cholesterol, low-density lipoprotein (LDL) cholesterol, and triglycerides and in increasing levels of high-density lipoprotein (HDL) cholesterol. Combination therapy significantly reduced total cholesterol and LDL cholesterol and increased HDL cholesterol to a greater extent than either drug alone. Adverse events and clinical laboratory abnormalities were generally mild and transient in all groups, and all but two patients finished the study. The incidence of side effects was low; myopathy did not occur. Coadministration of pravastatin and squalene combined the specific effects of the two drugs on lipoprotein concentrations. This combination may be useful and more cost-effective in elderly patients with hypercholesterolemia, who might have a higher incidence of side effects when using larger doses of pravastatin alone.

Ginsenoside Rh4, a genuine dammarane glycoside from Korean red ginseng

A genuine glycoside, named ginsenoside Rh4, was isolated from Korean red ginseng (Panax ginseng C. A. Meyer) through repeated column chromatography, and its chemical structure was established to be 6-O-beta-D-glucopyranosyldammar-20(22),24-diene-3 beta,6 alpha,12 beta-triol by spectral and chemical methods. The stereochemistry of a double bond at C-20(22) of ginsenoside Rh4 was characterized as (E) from a NOESY experiment in the 1H-NMR of the aglycone. Cytotoxic activities of ginsenoside Rh4 and its aglycone against cancer cell lines were evaluated by use of the SRB method.

The effectiveness and safety of low dose pravastatin in elderly hypertensive hypercholesterolemic subjects on antihypertensive therapy

To evaluate the efficacy and safety of low dose (10 mg) pravastatin in hypercholesterolemic, hypertensive elderly subjects undergoing antihypertensive treatment, a randomized, double-blind, placebo-controlled 6-month trial was conducted. The subjects had a total plasma cholesterol of at least 250 mg/dL and had been, for at least 3 months, consuming a standard lipid-lowering diet (American Heart Association Step 1 Diet). Sixty elderly hypertensive patients randomly received placebo (n = 30) or pravastatin (n = 30) treatment. The dosage consisted of 10 mg of pravastatin daily during the 6-month trial. Over that period, in the pravastatin group, plasma levels of total cholesterol and LDL-cholesterol significantly (P < .01) dropped (-20% and -25%, respectively) compared to the placebo group. The plasma level of HDL-cholesterol increased (+5%) while triglycerides slightly decreased (-8%) (P < .05). No serious side effects occurred, and pravastatin was generally tolerated. Fasting hyperinsulinemia (11.0 +/- 0.8 v 9.3 +/- 0.7 microU/mL; P = .06) also improved, although not significantly, after 6 months of pravastatin therapy. Results from this study confirmed that a low dose (10 mg) of pravastatin daily is a safe and effective method of reducing plasma total and LDL-cholesterol in hypercholesterolemic, hypertensive elderly patients who are on concurrent antihypertensive drug therapy.

Phenotypic correction of hypercholesterolemia in apoE-deficient mice by adenovirus-mediated in vivo gene transfer

To investigate the potential use of apoE in gene therapy of hyperlipidemias, an adenoviral vector was constructed that contained the human apoE3 cDNA under the control of the RSV promoter (Av1RE). Transduction of HepG2 cells resulted in the overexpression of human apoE secreted into the culture medium. Intravenous injection of 5 x 10(11) Av1RE vector particles into apoE-deficient mice resulted in expression of human apoE3 in mouse plasma at levels of 1.2 +/- 0.4 micrograms/L (mean +/- SEM, n = 5) 7 days after injection. Mice injected with the control vector Av1Lacz4 did not express detectable levels of human apoE. Average plasma cholesterol concentrations were reduced approximately eightfold from 737.5 +/- 118 mg/dL (mean +/- SEM, n = 6) to 98.2 +/- 4.4 mg/dL (mean +/- SEM, n = 5) and were unaffected in the control vector group. Expression of human apoE resulted in a shift in the plasma lipoprotein distribution from primarily VLDL and LDL in the control mice to predominantly HDL in the Av1RE-treated group. Western blot analysis of fast protein liquid chromatography-fractionated mouse plasma showed that the human apoE protein was associated with VLDL, LDL, and HDL. Correction of the hyperlipidemic condition found in the apoE-knockout mouse strain by direct in vivo gene transfer establishes the potential of this approach for treatment of hyperlipidemia caused by apoE deficiency or malfunction in human disease.

Comparisons between female and male patients with mitral stenosis

OBJECTIVE

To compare Doppler, echocardiographic, and clinical variables in female and male patients with mitral stenosis.

DESIGN

Observational study in consecutive patients with mitral stenosis of cross sectional and Doppler echocardiographic and clinical variables and a retrospective search for a history of systemic embolism.

SETTING

A medical centre with 3000 beds, serving both urban and rural populations.

PATIENTS

500 consecutive patients with an echocardiographic mitral valve area of 2 cm2 or less. 331 (66.2%) were female and 169 (33.8%) male (mean (SD) ages of 49 (13) and 48 (14) respectively).

MAIN OUTCOME MEASURES

Mitral valve areas by echocardiographic planimetry and Doppler pressure half-time method, peak early diastolic mitral velocity and pressure gradient, echocardiographic score of mitral valve, left atrial end systolic diameter, frequency of left atrial thrombus and smoky echoes as well as various valve lesions detected with Doppler and echocardiography, cardiac rhythm, symptomatic functional class of heart failure, and history of systemic embolism.

RESULTS

The prevalence of significant tricuspid (22% v 9%, P < 0.001) and pulmonary regurgitation (5% v 1%, P = 0.018) was higher in the female patients than in the male patients. Female patients also had a higher peak regurgitant velocity (3.2 (0.7) v 2.9 (0.7) m/s, P = 0.007) and pressure gradient (41 (21) v 36 (19) mm Hg, P = 0.010) across the tricuspid valve. However, the male patients had a higher echocardiographic score (9.7 (2.4) v 7.0 (2.3), P < 0.001) and a smaller Doppler-derived mitral valve area (0.9 (0.4) v 1.0 (0.4) cm2, P = 0.027). There were no differences between the female and the male patients in mitral valve area measured by planimetry, peak early diastolic mitral velocity and pressure gradient, and left atrial end systolic diameter or in the prevalence of atrial fibrillation, left atrial thrombus, left atrial smoky echoes, significant aortic stenosis, aortic regurgitation, or heart failure of New York Heart Association class III or IV.

CONCLUSIONS

Female patients not only had a higher prevalence of mitral stenosis but also had a higher prevalence of associated tricuspid and pulmonary regurgitation along with a higher velocity and gradient of tricuspid regurgitation. The echocardiographic score was higher in male patients, however. These findings suggest that the pathophysiology of mitral stenosis is different in the two sexes and that gender should be taken into account when therapeutic strategies are formulated.

Interactions of astringent substances

Two-component mixtures of astringent materials were rated for perceived intensity of astringent and taste attributes over time. Components included alum (a complex salt), gallic acid (the monomeric component of hydrolyzable tannins), catechin (the monomeric component of condensed tannins) and citric acid. Mixtures of alum and gallic acid showed mixture suppression, in that the 50/50 mixture was less intense than either component in astringency, drying, roughing and puckery/drawing sensations. Suppression was seen at concentration levels producing moderate to strong astringency but was absent or less pronounced at lower concentration levels. A similar pattern held for citric acid, although the suppressive effects were less pronounced. Catechin and gallic acid mixtures were additive. Sensory interactions between astringent materials appears to depend on the substances involved and their concentrations (or intensity levels).

Effect of mitral regurgitation and aortic regurgitation on Doppler-derived mitral orifice area in patients with mitral stenosis

Traditional Doppler pressure half-time (T1/2) method (mitral valve area = 220/T1/2) is widely used for evaluating the mitral orifice area in patients with mitral stenosis (MS). However, the effect of mitral regurgitation (MR) and aortic regurgitation (AR) on the calculation of the mitral valve area by this method is still controversial. Therefore, we examined 493 consecutive patients with MS to evaluate the effect of MR and AR on Doppler-derived mitral orifice area. The mitral orifice area planimetered from two-dimensional echocardiogram was used as the standard reference. Excluding 16 patients with either unsatisfactory Doppler or echocardiographic tracings, 477 patients were enrolled in the study. There were 162 males and 315 females with a mean age of 49 years. They were divided into 4 groups: group A, 327 patients with MS but no MR and AR; group B, 68 patients with MS + MR but no AR; group C, 64 patients with MS + AR but no MR; group D, 18 patients with MS + MR + AR. The differences between echo and Doppler area were 0.02 +/- 0.02 cm2 (mean +/- SE), p = 0.220, in group A; 0.13 +/- 0.04 cm2, p = 0.004, in group B; 0.11 +/- 0.05 cm2, p = 0.026 in group C; and 0.31 +/- 0.08 cm2, p = 0.001, in group D. Thus, in patients with MS, the associated MR or AR may invalidate the pressure half-time method for the derivation of mitral valve area.

Mechanisms for controlling balance between light input and utilisation in the salt tolerant alga Dunaliella C9AA

The yield of photosynthetic O2 evolution was measured in cultures of Dunaliella C9AA over a range of light intensities, and a range of low temperatures at constant light intensity. Changes in the rate of charge separation at Photosystem I (PS I) and Photosystem II (PS II) were estimated by the parameters ΦPS I and ΦPS II . ΦPS I is calculated on the basis of the proportion of centres in the correct redox state for charge separation to occur, as measured spectrophotometrically. ΦPS II is calculated using chlorophyll fluorescence to estimate the proportion of centres in the correct redox state, and also to estimate limitations in excitation delivery to reaction centres. With both increasing light intensity and decreasing temperature it was found that O2 evolution decreased more than predicted by either ΦPS I or ΦPS II. The results are interpreted as evidence of non-assimilatory electron flow; either linear whole chain, or cyclic around each photosystem.

Short- and long-term results of catheter balloon percutaneous transvenous mitral commissurotomy

Percutaneous transvenous mitral commissurotomy (PTMC) was performed in 219 patients with symptomatic, severe rheumatic mitral stenosis. There were 59 men and 160 women, aged 19 to 76 years (mean 43). Pliable, noncalcified valves were present in 139 (group 1), and calcified valves or severe mitral subvalvular lesions, or both, in 80 patients (group 2). Atrial fibrillation was present in 133 patients (61%) and 1+ or 2+ mitral regurgitation in 59 (27%). Technical failure occurred with 3 patients in our early experience. There was no cardiac tamponade or emergency surgery. The only in-hospital death occurred 3 days after the procedure in a group 2 premoribund patient in whom last-resort PTMC created 3+ mitral regurgitation. Mitral regurgitation appeared or increased in 72 patients (33%); 3+ mitral regurgitation resulted in 12 patients (6%). There were 3 systemic embolisms. Atrial left-to-right shunts measured by oximetry developed in 33 patients (15%). Immediately after PTMC, there were significantly reduced (p = 0.0001) left atrial pressure (24.2 +/- 5.6 to 15.1 +/- 5.1 mm Hg), mean pulmonary artery pressure (39.7 +/- 13.0 to 30.6 +/- 10.9 mm Hg) and mitral valve gradient (13.0 +/- 5.1 to 5.7 +/- 2.6 mm Hg). Mitral valve area increased from 1.0 +/- 0.3 to 2.0 +/- 0.7 cm2 (p = 0.0001) and cardiac output from 4.4 +/- 1.4 to 4.7 +/- 1.2 liters/min (p less than 0.01). The results mirrored clinical improvements in 209 patients (97%). Multivariate analysis showed an echo score greater than 8, and valvular calcification and severe subvalvular lesions as independent predictors for suboptimal hemodynamic results.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-photochemical quenching of chlorophyll fluorescence in the green alga Dunaliella

The relaxation of the non-photochemical quenching of chlorophyll fluorescence has been investigated in cells of the green alga Dunaliella following illumination. The relaxation after the addition of DCMU or darkening was strongly biphasic. The uncoupler NH4Cl induced rapid relaxation of both phases, which were therefore both energy-dependent quenching, qE. The proportion of the slow phase of qE increased at increasing light intensity. In the presence of the inhibitors rotenone and antimycin the slow phase of qE was stabilised for in excess of 15 min. NaN3 inhibited the relaxation of almost all the qE. The implications of these results are discussed in terms of the interpretation of the non-photochemical quenching of chlorophyll fluorescence in vivo and the mechanism of qE.

Epidemiology of an outbreak of infectious syphilis in Manitoba

An outbreak of 82 cases of infectious syphilis (primary, secondary, and early latent) which occurred in 1984 in the province of Manitoba was analyzed by age, sex, geographic distribution, and stage of disease. In the preceding four years, from 1980-1983, there were 19, 24, 13, and 32 cases, respectively, of infectious syphilis, of which 89% involved males. Compared with 1983, the overall crude incidence rate in 1984 increased by 259%, from 2.9 to 7.5/100,000 population, with a peak incidence in the 25- to 29-year age group of 25.8/100,000 population. This increase was predominantly due to a striking increase in incidence in females which rose 6.3-fold, from 0.4 to 2.5/100,000 females, compared with a 2.3-fold increase in males. This increase was accompanied by a decline in the male-to-female ratio, from 15.0 to 4.9. Of the 68 males, 45 named women as their sexual contacts. Females were 2.4 times more likely to present with early latent disease, whereas males were 7.0 times more likely to present with primary disease (p less than 0.01). There was clustering in suburban locations with regard to clinical presentation (60% primary disease) and overall incidence (46% of all cases). These data suggest the occurrence of a major change in the epidemiology of syphilis in the province of Manitoba, with a shift from homosexual to heterosexual transmission.

Rhegmatogenous retinal detachment in infancy

A 5-week-old male infant had small stature, microphthalmia, bilateral rhegmatogenous retinal detachments, ventricular septal defect, and fundus lesions suggestive of previous chorioretinitis. Diagnostic workup failed to disclose a cause of the intraocular disorder. Bilateral retinal detachment surgery, performed when the boy was 2 and 3 months of age, has appeared successful 12 months postoperatively. This may be a description of the youngest patient with rhegmatogenous retinal detachments that were subsequently repaired.

Cryotherapy of proliferative sickle retinopathy. Part I. Single freeze-thaw cycle

Transconjunctival cryocoagulation was used to treat proliferative sickle retinopathy in 6 patients. Ten eyes were treated with a single freeze-thaw cycle and were observed for 3 to 18 months. Nine of 13 (70%) neovascular lesions were completely closed without occluding major vascular trunks, while the remaining 4 (30%) showed marked attenuation.

Spontaneous remodeling of the peripheral retinal vasculature in sickling disorders

Periodic photographic and angiographic surveys of patients with the earliest stages of sickle retinopathy showed a number of fundus findings. In seven cases (sickle cell anemia, four; sickle cell hemoglobin C, three), these findings included: (1) a variety of vascular abnormalities in the equatorial and post-equatorial retina such as segmented dilations of the vessel walls, hairpin-shaped vascular loops, hypertrophic, tortuous A-V anastomoses, intraluminal plugs, closure and loss of capillary bed, and terminal budding of capillaries; and (2) a continuous, spontaneous remodeling of the peripheral retinal vasculature due to successive closures and reopenings of equatorial retinal vessels. A centripetal recession of the peripheral retinal vasculature usually resulted. No correlation between the ophthalmoscopic and the systemic condition of the patients could be made.