Phase 1 study of the pan-RAF inhibitor tovorafenib in patients with advanced solid tumors followed by dose expansion in patients with metastatic melanoma

PURPOSE

Genomic alterations of BRAF and NRAS are oncogenic drivers in malignant melanoma and other solid tumors. Tovorafenib is an investigational, oral, selective, CNS-penetrant, small molecule, type II pan‑RAF inhibitor. This first-in-human phase 1 study explored the safety and antitumor activity of tovorafenib.

METHODS

This two-part study in adult patients with relapsed or refractory advanced solid tumors included a dose escalation phase and a dose expansion phase including molecularly defined cohorts of patients with melanoma. Primary objectives were to evaluate the safety of tovorafenib administered once every other day (Q2D) or once weekly (QW), and to determine the maximum-tolerated and recommended phase 2 dose (RP2D) on these schedules. Secondary objectives included evaluation of antitumor activity and tovorafenib pharmacokinetics.

RESULTS

Tovorafenib was administered to 149 patients (Q2D n = 110, QW n = 39). The RP2D of tovorafenib was defined as 200 mg Q2D or 600 mg QW. In the dose expansion phase, 58 (73%) of 80 patients in Q2D cohorts and 9 (47%) of 19 in the QW cohort had grade ≥ 3 adverse events. The most common of these overall were anemia (14 patients, 14%) and maculo-papular rash (8 patients, 8%). Responses were seen in 10 (15%) of 68 evaluable patients in the Q2D expansion phase, including in 8 of 16 (50%) patients with BRAF mutation-positive melanoma naïve to RAF and MEK inhibitors. In the QW dose expansion phase, there were no responses in 17 evaluable patients with NRAS mutation-positive melanoma naïve to RAF and MEK inhibitors; 9 patients (53%) had a best response of stable disease. QW dose administration was associated with minimal accumulation of tovorafenib in systemic circulation in the dose range of 400-800 mg.

CONCLUSIONS

The safety profile of both schedules was acceptable, with QW dosing at the RP2D of 600 mg QW preferred for future clinical studies. Antitumor activity of tovorafenib in BRAF-mutated melanoma was promising and justifies continued clinical development across multiple settings.

CLINICALTRIALS

GOV IDENTIFIER

NCT01425008.

Paediatric Strategy Forum for medicinal product development in mitogen-activated protein kinase pathway inhibitors: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration

As the mitogen-activated protein kinase (MAPK) signalling pathway is activated in many paediatric cancers, it is an important therapeutic target. Currently, a range of targeted MAPK pathway inhibitors are being developed in adults. However, MAPK signals through many cascades and feedback loops and perturbing the MAPK pathway may have substantial influence on other pathways as well as normal development. In view of these issues, the ninth Paediatric Strategy Forum focused on MAPK inhibitors. Development of MAPK pathway inhibitors to date has been predominantly driven by adult indications such as malignant melanoma. However, these inhibitors may also target unmet needs in paediatric low-grade gliomas, high-grade gliomas, Langerhans cell histiocytosis, juvenile myelomonocytic leukaemia and several other paediatric conditions. Although MAPK inhibitors have demonstrated activity in paediatric cancer, the response rates and duration of responses needs improvement and better documentation. The rapid development and evaluation of combination approaches, based on a deep understanding of biology, is required to optimise responses and to avoid paradoxical tumour growth and other unintended consequences including severe toxicity. Better inhibitors with higher central nervous systempenetration for primary brain tumours and cancers with a propensity for central nervous system metastases need to be studied to determine if they are more effective than agents currently being used, and the optimum duration of therapy with MAPK inhibition needs to be determined. Systematic and coordinated clinical investigations to inform future treatment strategies with MAPK inhibitors, rather than use outside of clinical trials, are needed to fully assess the risks and benefits of these single agents and combination strategies in both front-line and in the refractory/relapse settings. Platform trials could address the investigation of multiple similar products and combinations. Accelerating the introduction of MAPK inhibitors into front-line paediatric studies is a priority, as is ensuring that these studies generate data appropriate for scientific and regulatory purposes. Early discussions with regulators are crucial, particularly if external controls are considered as randomised control trials in small patient populations can be challenging. Functional end-points specific to the populations in which they are studied, such as visual acuity, motor and neuro psychological function are important, as these outcomes are often more reflective of benefit for lower grade tumours (such as paediatric low-grade glioma and plexiform neurofibroma) and should be included in initial study designs for paediatric low-grade glioma. Early prospective discussions and agreements with regulators are necessary. Long-term follow-up of patients receiving MAPK inhibitors is crucial in view of their prolonged administration and the important involvement of this pathway in normal development. Further rational development, with a detailed understanding of biology of this class of products, is crucial to ensure they provide optimal benefit while minimising toxicity to children and adolescents with cancer.

146 GOLD STANDARD GOAL-SETTING: ARE WE HITTING THE MARK? IMPLEMENTING AN INTERDISCIPLINARY GOAL-SETTING PATHWAY IN STROKE REHABILITATION

Background

The cornerstone of rehabilitation is effective and realistic interdisciplinary goal-setting with patient and family engagement across the continuum of recovery. The Royal College of Physicians National Clinical Guidelines for Stroke (2016) highlights the importance of encouraging self-management and self-efficacy to support a more person-orientated approach. This quality improvement initiative aimed to introduce a structured interdisciplinary goal-setting pathway on a post-acute 14-bed stroke unit.

Methods

An interdisciplinary working group was established comprising of Physiotherapy, Occupational Therapy, Speech & Language Therapy, Medical Social Work and Nursing. Quality improvement methodology was used to sequentially implement change over a 6-month period. The restructure included the introduction of an initial and review goal-focused family meeting. An interdisciplinary tool was developed based on the East Kent Outcome System (EKOS). A series of workshops was delivered to support implementation.

Results

An interdisciplinary goal-setting pathway is currently being piloted for 6 months on the stroke unit. To date, 22 staff have been trained and 9 patients have progressed through the updated pathway. Analysis has provided useful clinical insights and qualitative feedback has been collated regarding the benefits of the early opportunity to meet the team, establishing patient’s personal goal priorities and clear timeframes.Furthermore, repeat trials followed by reflections have enabled the team to develop consistency and confidence in person-centred, interdisciplinary goal-setting. It is acknowledged that this initiative has been a significant change process for the team and that adjustments are being made, in line with the principles of quality improvement.

Conclusion

This person-orientated interdisciplinary process is evidence-based and in line with national standards and guidelines for stroke rehabilitation. Formal training in EKOS is planned and a clinical audit will follow the pilot phase to systematically evaluate the change in practice.

187 ‘OUR LANGUAGE’: AN INITIATIVE TO RAISE STAFF AWARENESS OF THE IMPACT OF OUR CHOICE OF WORDS ON PATIENTS

Background

In a hospital specialising in older persons’ rehabilitation, the Speech & Language Therapy team (SLT) commenced an initiative to raise awareness of the impact of all staff’s language on patients. Our language can either support or undermine patient well-being. Supportive language is easy-to-follow, everyday English and respects each person’s autonomy (‘Would you like help to eat?’). Unnecessary jargon or impersonal words can be undermining (e.g. ‘He needs supervision with feeding’). This is supported by national and international guidance tools such as the online ‘Plain Language Style Guide’ by the Health Service Executive Health Promotion Unit and National Adult Literacy Agency.

Methods

Quality improvement methodology was adopted to facilitate an ongoing, flexible approach. SLT delivered pilot workshops on person-centred language to ward staff. Afterward, staff spent a week self-identifying examples of language that could be improved during their work day. Examples were collated and presented back to teams. Online feedback surveys were conducted. Trolley rounds were then rolled out with quiz-style exercises to raise staff awareness across the hospital. Examples of person-centred language generated by staff were shown on rolling videos in key areas across the hospital.

Results

Staff engaged actively in workshop and trolley activities generating a range of examples of more person-centred language. Surveys revealed a new awareness of the need to adapt our language. Several months later, staff continue to demonstrate increased vigilance with their choice of words and regularly consult SLT for advice on language in clinical sessions, documentation or signage. There is still room for improvement in the language used in other areas such as Care Planning Meetings and clinical documentation.

Conclusion

This initiative has started to increase staff awareness of the importance of our choice of words to patient well-being. With the support of hospital management, this initiative will be continued, reviewed and reported on a rolling basis.

The Critical Role of Academic Clinical Trials in Pediatric Cancer Drug Approvals: Design, Conduct, and Fit for Purpose Data for Positive Regulatory Decisions

PURPOSE

For decades, academic clinical trials consortia have collaborated to optimize outcomes for childhood cancers through evaluating incremental improvements in conventional mutimodality treatment regimes. There are now increasing opportunities to partner with industry to test new medicines in academic-sponsored trials, but these collaborative studies rarely contribute to marketing authorizations. We addressed why this is the case and sought solutions to enable academic-sponsored trials to directly contribute to the licensing of new medicines.

METHODS

Under the auspices of the multistakeholder platform ACCELERATE, we convened a working group of representatives from clinical academia, pharmaceutical industry, European Medicines Agency, US Food and Drug Administration, and patient advocacy to define the challenges and propose recommendations to facilitate academic-sponsored trial design and conduct to be aligned to both the needs of the pharmaceutical company who own the asset and the expectations of the regulatory (licensing) authorities.

RESULTS

We identified that although academic consortia have long-standing expertise to conduct robust clinical trials, there were critical gaps in knowledge, standard procedures, and resources that hindered the trial data directly contributing to marketing authorization applications. We propose a suite of recommendations focused on (1) essential documents, (2) essential data, (3) data management, and (4) trial resources, specifically aimed at enabling academic-industry partnerships to deliver an academic-sponsored trial that meets the requirements for a marketing authorization submission. These recommendations pivot around transparency in academic-industry partnerships and early engagement with regulators.

CONCLUSION

Academic sponsors and industry partners need to prospectively recognize when the planned collaborative trial could contribute to an application to marketing authorization and plan accordingly. Transparent collaboration and knowledge sharing between the partners opens an important pathway for accelerating new treatments into clinical practice for children with cancer.

Second Paediatric Strategy Forum for anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies: ACCELERATE in collaboration with the European Medicines Agency with the participation of the Food and Drug Administration

The first (2017) and sixth (2021) multistakeholder Paediatric Strategy Forums focused on anaplastic lymphoma kinase (ALK) inhibition in paediatric malignancies. ALK is an important oncogene and target in several paediatric tumours (anaplastic large cell lymphoma [ALCL], inflammatory myofibroblastic tumour [IMT], neuroblastoma and hemispheric gliomas in infants and young children) with unmet therapeutic needs. ALK tyrosine kinase inhibitors have been demonstrated to be active both in ALK fusion-kinase positive ALCL and IMT. ALK alterations differ, with fusions occurring in ALCL, IMT and gliomas, and activating mutations and amplification in neuroblastoma. While there are many ALK inhibitors in development, the number of children diagnosed with ALK driven malignancies is very small. The objectives of this ALK Forum were to (i) Describe current knowledge of ALK biology in childhood cancers; (ii) Provide an overview of the development of ALK inhibitors for children; (iii) Identify the unmet needs taking into account planned or current ongoing trials; (iv) Conclude how second/third-generation inhibitors could be evaluated and prioritised; (v) Identify lessons learnt from the experience with ALK inhibitors to accelerate the paediatric development of other anti-cancer targeted agents in the new regulatory environments. There has been progress over the last four years, with more trials of ALK inhibitors opened in paediatrics and more regulatory submissions. In January 2021, the US Food and Drug Administration approved crizotinib for the treatment of paediatric and young adult patients with relapsed or refractory ALCL and there are paediatric investigation plans (PIPs) for brigatinib and for crizotinib in ALCL and IMT. In ALCL, the current goal is to investigate the inclusion of ALK inhibitors in front-line therapy with the aim of decreasing toxicity with higher/similar efficacy compared to present first-line therapies. For IMT, the focus is to develop a joint prospective trial with one product in children, adolescents and adults, taking advantage of the common biology across the age spectrum. As approximately 50% of IMTs are ALK-positive, molecular analysis is required to identify patients to be treated with an ALK inhibitor. For neuroblastoma, crizotinib has not shown robust anti-tumour activity. A focused and sequential development of ALK inhibitors with very good central nervous system (CNS) penetration in CNS tumours with ALK fusions should be undertaken. The Forum reinforced the strong need for global academic collaboration, very early involvement of regulators with studies seeking possible registration and early academia-multicompany engagement. Innovations in study design and conduct and the use of 'real-world data' supporting development in these rare sub-groups of patients for whom randomised clinical trials are not feasible are important initiatives. A focused and sequenced development strategy, where one product is evaluated first with other products being assessed sequentially, is applicable for ALK inhibitors and other medicinal products in children.

Navigating the Regulatory Landscape to Develop Pediatric Oncology Drugs: Expert Opinion Recommendations

Regulatory changes have been enacted in the United States (US) and European Union (EU) to encourage the development of new treatments for pediatric cancer. Here, we review some of the factors that have hampered the development of pediatric cancer treatments and provide a comparison of the US and EU regulations implemented to address this clinical need. We then provide some recommendations for each stage of the oncology drug development pathway to help researchers maximize their chance of successful drug development while complying with regulations. A key recommendation is the engagement of key stakeholders such as regulatory authorities, pediatric oncologists, academic researchers, patient advocacy groups, and a Pediatric Expert Group early in the drug development process. During drug target selection, sponsors are encouraged to consult the Food and Drug Administration (FDA), European Medicines Agency (EMA), and the FDA target list, in addition to relevant US and European consortia that have been established to characterize and prioritize oncology drug targets. Sponsors also need to carefully consider the resourcing requirements for preclinical testing, which include ensuring appropriate access to the most relevant databases, clinical samples, and preclinical models (cell lines and animal models). During clinical development, sponsors can account for the pharmacodynamic (PD)/pharmacokinetic (PK) considerations specific to a pediatric population by developing pediatric formulations, selecting suitable PD endpoints, and employing sparse PK sampling or modeling/simulation of drug exposures where appropriate. Additional clinical considerations include the specific design of the clinical trial, the potential inclusion of children in adult trials, and the value of cooperative group trials.

The role of illicit drugs in developing medication-related osteonecrosis (MRONJ): a systematic review

Medication-related osteonecrosis of the jaw (MRONJ) is a challenging condition to treat. It has primarily been associated with anti-resorptive and anti-angiogenic drugs, which are increasingly being used to prevent adverse skeletally-related complications in patients with cancer and bone pathologies. Although these medications have been proven to cause osteonecrosis of the jaws (ONJ) there are also a number of other drugs that could potentially cause this condition. The aim of this systematic review is to ascertain whether there is an associated risk of osteonecrosis of the jaw (ONJ) in recreational drug users (RDU). Three authors independently searched PubMed, MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of Controlled Trials for published reports of osteonecrosis of the jaw (ONJ) in recreational drug users (RDU) or illicit drug users (IDU) who had no history of treatment with anti-angiogenic or anti-resorptive agents. Only 30 studies were eligible for analysis, and all were independently assessed for risk of bias. There was a total of 101 patients with ONJ attributed solely to illicit drug consumption. The most common site of ONJ was the maxilla (n=54). The most common illicit drug related to ONJ was desmorphine, known as 'Krokodil', this was followed by cocaine, methamphetamine, anabolic steroids, and hydrocodone/acetaminophen. In 52 of the cases, the ONJ resolved following treatment, however, eight showed a recurrence. Although all the studies were judged to be at a high risk of bias, the limited data suggest that some patients are at risk of developing ONJ as a result of illicit drug usage. Studies of higher quality are needed to establish the relative risk of ONJ in this patient group.

Paediatric Strategy Forum for medicinal product development for acute myeloid leukaemia in children and adolescents: ACCELERATE in collaboration with the European Medicines Agency with participation of the Food and Drug Administration

Purpose:

The current standard-of-care for front-line therapy for acute myeloid leukaemia (AML) results in short-term and long-term toxicity, but still approximately 40% of children relapse. Therefore, there is a major need to accelerate the evaluation of innovative medicines, yet drug development continues to be adult-focused. Furthermore, the large number of competing agents in rare patient populations requires coordinated prioritisation, within the global regulatory framework and cooperative group initiatives.

Methods:

The fourth multi-stakeholder Paediatric Strategy Forum focused on AML in children and adolescents.

Results:

CD123 is a high priority target and the paediatric development should be accelerated as a proof-of-concept. Efforts must be coordinated, however, as there are a limited number of studies that can be delivered. Studies of FLT3 inhibitors in agreed paediatric investigation plans present challenges to be completed because they require enrolment of a larger number of patients than actually exist. A consensus was developed by industry and academia of optimised clinical trials. For AML with rare mutations that are more frequent in adolescents than in children, adult trials should enrol adolescents and when scientifically justified, efficacy data could be extrapolated. Methodologies and definitions of minimal residual disease need to be standardised internationally and validated as a new response criterion. Industry supported, academic sponsored platform trials could identify products to be further developed. The Leukaemia and Lymphoma Society PedAL/EUpAL initiative has the potential to be a major advance in the field.

Conclusion:

These initiatives continue to accelerate drug development for children with AML and ultimately improve clinical outcomes.

Population Pharmacokinetics of Gemtuzumab Ozogamicin in Pediatric Patients with Relapsed or Refractory Acute Myeloid Leukemia

BACKGROUND AND OBJECTIVE

To date, the population pharmacokinetics (popPK) of gemtuzumab ozogamicin (GO), a CD33-directed antibody-drug conjugate consisting of hP67.6 antibody linked to N-acetyl gamma calicheamicin used in the treatment of acute myeloid leukemia (AML), has not been characterized in pediatric patients. This report describes the popPK of GO following intravenous administration in 29 pediatric patients aged ≤ 17 years with relapsed or refractory AML who were enrolled in the 0903A1-102-US phase I/II study.

METHODS

The pharmacokinetics (PK) of GO, as represented by total hP67.6 antibody, were described by a two-compartment model with two clearance components: a linear clearance (CL₁) and time-dependent clearance that includes a decay coefficient. The PK of unconjugated calicheamicin (UC; payload) were described by a two-compartment model with CL₁ and an input rate of formation based on antibody rate of elimination. Allometric scaling was included in both models, with baseline body weight as a fixed effect on CL₁ and central volume.

RESULTS AND CONCLUSIONS

PK parameters for hP67.6 and UC were not significantly affected by any of the available demographic factors and safety laboratory values tested as covariates (except baseline body weight). Simulations to compare GO dosing regimens (6, 7.5, and 9 mg/m² on days 1 and 15 versus, 3 mg/m² fractionated dosing on days 1, 4, and 7) were performed, showing that total antibody and UC trough concentrations were maintained at higher concentrations during treatment following the more frequent dosing than following the original regimen.

STUDY IDENTIFIER

0903A1-102-US.

ACCELERATE and European Medicines Agency Paediatric Strategy Forum for medicinal product development of checkpoint inhibitors for use in combination therapy in paediatric patients

The third multistakeholder Paediatric Strategy Forum organised by ACCELERATE and the European Medicines Agency focused on immune checkpoint inhibitors for use in combination therapy in children and adolescents. As immune checkpoint inhibitors, both as monotherapy and in combinations have shown impressive success in some adult malignancies and early phase trials in children of single agent checkpoint inhibitors have now been completed, it seemed an appropriate time to consider opportunities for paediatric studies of checkpoint inhibitors used in combination. Among paediatric patients, early clinical studies of checkpoint inhibitors used as monotherapy have demonstrated a high rate of activity, including complete responses, in Hodgkin lymphoma and hypermutant paediatric tumours. Activity has been very limited, however, in more common malignancies of childhood and adolescence. Furthermore, apart from tumour mutational burden, no other predictive biomarker for monotherapy activity in paediatric tumours has been identified. Based on these observations, there is collective agreement that there is no scientific rationale for children to be enrolled in new monotherapy trials of additional checkpoint inhibitors with the same mechanism of action of agents already studied (e.g. anti-PD1, anti-PDL1 anti-CTLA-4) unless additional scientific knowledge supporting a different approach becomes available. This shared perspective, based on scientific evidence and supported by paediatric oncology cooperative groups, should inform companies on whether a paediatric development plan is justified. This could then be proposed to regulators through the available regulatory tools. Generally, an academic-industry consensus on the scientific merits of a proposal before submission of a paediatric investigational plan would be of great benefit to determine which studies have the highest probability of generating new insights. There is already a rationale for the evaluation of combinations of checkpoint inhibitors with other agents in paediatric Hodgkin lymphoma and hypermutated tumours in view of the activity shown as single agents. In paediatric tumours where no single agent activity has been observed in multiple clinical trials of anti-PD1, anti-PDL1 and anti-CTLA-4 agents as monotherapy, combinations of checkpoint inhibitors with other treatment modalities should be explored when a scientific rationale indicates that they could be efficacious in paediatric cancers and not because these combinations are being evaluated in adults. Immunotherapy in the form of engineered proteins (e.g. monoclonal antibodies and T cell engaging agents) and cellular products (e.g. CAR T cells) has great therapeutic potential for benefit in paediatric cancer. The major challenge for developing checkpoint inhibitors for paediatric cancers is the lack of neoantigens (based on mutations) and corresponding antigen-specific T cells. Progress critically depends on understanding the immune macroenvironment and microenvironment and the ability of the adaptive immune system to recognise paediatric cancers in the absence of high neoantigen burden. Future clinical studies of checkpoint inhibitors in children need to build upon strong biological hypotheses that take into account the distinctive immunobiology of childhood cancers in comparison to that of checkpoint inhibitor responsive adult cancers.

Clinical pharmacokinetics (PK) and translational PK-pharmacodynamic (PD) modeling and simulation to predict antitumor response of various dosing schedules to guide the selection of a recommended phase II dose (RP2D) and schedule for the investigational agent MLN0128

2567

Background: MLN0128 (INK128) is an investigational oral, potent, and highly selective inhibitor of mammalian target of rapamycin complex 1 and 2 (mTORC1/2) currently in clinical investigation. In the phase1 study INK128-001, MLN0128 was administered once daily (QD), once weekly (QW), QDx3D/week, and QDx5D/week, with respective MTDs of 6, 40, 16, and 10 mg. To guide selection of dose/schedule for further investigation, PD modulation in skin (pS6, p4EBP1, pNDRG1, pPRAS40) was put into context of clinical PK in INK128-001. A preclinical translational dynamic-PK efficacy model was used to describe the relationship and determine PK drivers of efficacy in tumor xenograft models. This model was implemented using human PK parameters to predict tumor volume-time curves, which was utilized to help determine the optimal MLN0128 dose/schedule. Methods: Phoenix NLME v1.1 was used for compartmental modeling of clinical and preclinical PK data, and modeling the preclinical PK-efficacy relationship of MLN0128. PD activity in skin was measured by immunohistochemistry, reported as H scores. Tumor growth curves were simulated using NONMEM v7.2; predicted tumor growth curves were plotted in S-Plus v8.1. Results: Clinical skin PD data suggests exposure dependent inhibition of pS6, and p4EBP1. A two compartment PK model adequately described the PK characteristics of MLN0128 [mean (%CV) ka: ~5.305 h-1 (114), k12: ~0.490 h-1(85), k21: ~0.67 h-1(69), V/F: ~180 L (44), Tlag: 0.317 h (73)]. Simulation of human tumor volume-time curves suggest efficacy is dependent on schedule and that MLN0128 administered in more frequent schedules (QD, QDx5D) provides stronger antitumor effect vs less frequent schedules (QW, QDx3D). Conclusions: The results indicate that per unit MLN0128 plasma exposure, QD and QDx5D may be optimal in comparison with QDx3D and QW dosing. However, these results will also need to be put into context with the overall safety profile and respective MTDs and RP2Ds for each schedule with their resultant achievable total cycle dose by schedule. Clinical trial information: NCT01058707.

Clofarabine in pediatric acute leukemia: current findings and issues

Clofarabine is a second-generation purine nucleoside analog and has significant anti-leukemic activity as a single agent. It is approved by the United States Food and Drug Administration (FDA) for the treatment of relapsed or refractory acute lymphoblastic leukemia (ALL) in children. Combinations of clofarabine with purine nucleoside analogs or DNA-damaging agents have been investigated utilizing synergistic effects and now tested in a number of studies including a frontline study. In this article, we review the development of clofarabine, rationale and history of combination regimens, and their potential roles and toxicities in the treatment of pediatric ALL that are important to treating clinicians.

ADHD and DAT1: further evidence of paternal over-transmission of risk alleles and haplotype

We [Hawi et al. (2005); Am J Hum Genet 77:958-965] reported paternal over-transmission of risk alleles in some ADHD-associated genes. This was particularly clear in the case of the DAT1 3'-UTR VNTR. In the current investigation, we analyzed three new sample comprising of 1,248 ADHD nuclear families to examine the allelic over-transmission of DAT1 in ADHD. The IMAGE sample, the largest of the three-replication samples, provides strong support for a parent of origin effect for allele 6 and the 10 repeat allele (intron 8 and 3'-UTR VNTR, respectively) of DAT1. In addition, a similar pattern of over-transmission of paternal risk haplotypes (constructed from the above alleles) was also observed. Some support is also derived from the two smaller samples although neither is independently significant. Although the mechanism driving the paternal over-transmission of the DAT risk alleles is not known, these finding provide further support for this phenomenon.

Right-sided spatial difficulties in ADHD demonstrated in continuous movement control

Children with Attention Deficit Hyperactivity Disorder (ADHD) often show spatial attentional deficits, exhibiting a subtle rightwards bias, possibly due to dysfunction within the right hemisphere fronto-parietal network. Approximately 50% of children with ADHD also show signs of movement dysfunction. The nature of this movement dysfunction and possible interactions with spatial attention difficulties has not been clearly described. This study compared 31 children with and 31 children without ADHD on a movement kinematic task that tested hand-drawing movement precision. Participants used an electronic pen on a digitizing tablet. The pen tip position was sampled as X and Y coordinates at 200Hz. The task was to join targets of either 10 or 20mm diameter that were separated by a distance of 62.5 or 125 mm. Constant error in the X and Y planes, peak absolute velocity and acceleration, movement time, the number of pauses and pause time were analysed. Apart from a significantly increased rate of acceleration across all conditions, the children with ADHD demonstrated no temporal difficulties with the task; rather they showed subtle spatial difficulties, possibly suggestive of cerebellar involvement. The children with ADHD showed difficulties in accuracy of movement towards the right. They were less accurate in the X plane when moving towards the right-sided targets over the long distance. Greater variability in target accuracy was shown when moving towards the small target on the right side. The children with ADHD made significantly more pauses on the left target, when preparing the right movement, than the control group. These results suggest that the subtle spatial bias towards the right that has been demonstrated in ADHD in spatial attention also extends into the continuous movement domain.

Association of the steroid sulfatase (STS) gene with attention deficit hyperactivity disorder

Attention deficit hyperactivity disorder (ADHD) is the most common behavioral disorder affecting children worldwide. The male bias in the prevalence of the disorder, suggests that some susceptibility genes may lie on the X chromosome. In this study we present evidence for a role of the X-linked steroid sulfatase (STS) gene and neurosteroids in the development of ADHD. Previously it has been observed that probands with ADHD have lower serum concentrations of the neurosteroids DHEA, which is synthesized from DHEA-S by STS. In further support, boys that suffer from XLI, a skin disorder caused by the deletion of the STS gene, have higher rates of ADHD, in particular the inattentive subtype. In a moderately sized sample of ADHD families (N = 384), we genotyped seven single nucleotide polymorphisms, tagging the entire gene. TDT analysis of the data yielded two polymorphisms that were significantly associated with ADHD (rs2770112-Transmitted: 71 Not Transmitted; 48; rs12861247-Transmitted: 43 Not Transmitted: 21), located towards the 5' end of the gene (P < 0.05). We conclude that the STS gene may play a role in susceptibility for ADHD, and that the neurosteroids pathways should be investigated further to access their potential contribution in susceptibility to the disorder.

Replication of a rare protective allele in the noradrenaline transporter gene and ADHD

Replication is a key to resolving whether a reported genetic association represents a false positive finding or an actual genetic risk factor. In a previous study screening 51 candidate genes for association with ADHD in a multi-centre European sample (the IMAGE project), two single nucleotide polymorphisms (SNPs) within the norepinephrine transporter (SLC6A2) gene were found to be associated with attention deficit hyperactivity disorder (ADHD). The same SNP alleles were also reported to be associated with ADHD in a separate study from the Massachusetts General Hospital in the US. Using two independent samples of ADHD DSM-IV combined subtype trios we attempted to replicate the reported associations with SNPs rs11568324 and rs3785143 in SLC6A2. Significant association of the two markers was not observed in the two independent replication samples. However, across all four datasets the overall evidence of association with ADHD was significant (for SNP rs11568324 P = 0.0001; average odds ratio = 0.33; for SNP rs3785143 P = 0.008; average odds ratio = 1.3). The data were consistent for rs11568324, suggesting the existence of a rare allele conferring protection for ADHD within the SLC6A2 gene. Further investigations should focus on identifying the mechanisms underlying the protective effect.

Ocean sequestration of carbon dioxide: modeling the deep ocean release of a dense emulsion of liquid Co2-in-water stabilized by pulverized limestone particles

The release into the deep ocean of an emulsion of liquid carbon dioxide-in-seawater stabilized by fine particles of pulverized limestone (CaCO3) is modeled. The emulsion is denser than seawater, hence, it will sink deeper from the injection point, increasing the sequestration period. Also, the presence of CaCO3 will partially buffer the carbonic acid that results when the emulsion eventually disintegrates. The distance that the plume sinks depends on the density stratification of the ocean, the amount of the released emulsion, and the entrainment factor. When released into the open ocean, a plume containing the CO2 output of a 1000 MW(el) coal-fired power plant will typically sink hundreds of meters below the injection point. When released from a pipe into a valley on the continental shelf, the plume will sink about twice as far because of the limited entrainment of ambient seawater when the plume flows along the valley. A practical system is described involving a static mixer for the in situ creation of the CO2/seawater/pulverized limestone emulsion. The creation of the emulsion requires significant amounts of pulverized limestone, on the order of 0.5 tons per ton of liquid CO2. That increases the cost of ocean sequestration by about $13/ ton of CO2 sequestered. However, the additional cost may be compensated by the savings in transportation costs to greater depth, and because the release of an emulsion will not acidify the seawater around the release point.

Anthracycline-induced cardiotoxicity: course, pathophysiology, prevention and management

Although effective anti-neoplastic agents, anthracyclines are limited by their well recognized and pervasive cardiotoxic effects. The incidence of late progressive cardiovascular disease in long-term survivors of cancer is established and may contribute to heart failure and death. To maximize the benefits of these drugs, a high-risk population has been identified and new strategies have been investigated to minimize toxic effects, including limiting the cumulative dose, controlling the rate of administration and using liposomal preparations and novel anthracycline analogues. Dexrazoxane also shows promise as a cardioprotectant during treatment. This paper reviews these strategies, as well as medications used to manage anthracycline-induced cardiotoxicity, and functional and biochemical means of monitoring cardiotoxicity, including echocardiography, radionuclide scans and biomarker analysis. The treatment of adult cancer survivors who have had anthracycline-related cardiotoxicity has not been systematically studied. Empirically, anthracycline-associated cardiac dysfunction is treated very similarly to other forms of heart failure. These treatments include avoiding additional cardiotoxic regimens, controlling hypertension, lifestyle changes, medications and heart transplantation.

A phase I study of clofarabine in combination with cyclophosphamide and etoposide: A new regimen in pediatric patients with refractory or relapsed acute leukemia

9529

Background: Clofarabine is a promising new agent in the treatment of childhood leukemia as evidenced by single agent activity in previous phase I and II studies. We conducted a pilot phase I study of clofarabine used in combination with cyclophosphamide and etoposide to determine the maximum tolerated dose (MTD) and dose limiting toxicities (DLT). Methods: Patients between 1 and 21 years old with relapsed or refractory acute lymphoblastic leukemia (ALL) and acute myelogenous leukemia (AML) were enrolled. A standard 3+3 design was followed to determine the safe dose when used in combination. All drugs were administered by IV infusion daily for 5 consecutive days in induction and 4 days in consolidation. Patients received up to 2 induction cycles depending on the response, followed by consolidation cycles (maximum of 8 total cycles). The initial doses (cohort 1) were as follows: clofarabine: 20 mg/m2/day, etoposide 75 mg/m2/day and cyclophosphamide 340 mg/m2/day. Once etoposide and cyclophosphamide were escalated to their target dose (100 mg/m2/day and 440 mg/m2/day respectively in cohort 3), clofarabine was then increased to 30 mg/m2/day in cohorts 4 and would be increased to 40 mg/m2/day in cohort 5. Results: Thirteen patients (10 ALL; 3 AML) were enrolled in the first 4 dose cohorts to this date. The median number of prior regimens was 2. Response data (based on investigator assessment) are available for the first 8 patients: 6 patients (including 1 patient with AML) achieved either complete remission (CR) or complete remission without platelet recovery (CRp), for an overall response rate of 75%. Four patients proceeded to HSCT. One patient in cohort 4 experienced a DLT which resolved (grade 3 elevation of lipase) and possible veno-occlusive disease leading to cohort expansion. Common toxicities noted include febrile neutropenia and fever. Conclusions: The phase I study is ongoing until determination of MTD for this combination but these early results indicate that this combination shows significant activity in children with refractory or relapsed acute leukemias and is well-tolerated.

No significant financial relationships to disclose.

Favorable Outcome for Adolescents With Acute Lymphoblastic Leukemia Treated on Dana-Farber Cancer Institute Acute Lymphoblastic Leukemia Consortium Protocols

Purpose

Historically, adolescents with acute lymphoblastic leukemia (ALL) have had inferior outcomes when compared with younger children. We report the outcome of adolescents treated on Dana-Farber Cancer Institute (DFCI; Boston, MA) ALL Consortium Protocols conducted between 1991 and 2000.

Patients and Methods

A total of 844 patients aged 1 to 18 years, with newly diagnosed ALL were enrolled onto two consecutive DFCI-ALL Consortium Protocols. We compared outcomes in three age groups: children aged 1 to 10 years (n = 685), young adolescents aged 10 to 15 years (n = 108), and older adolescents aged 15 to 18 years (n = 51).

Results

With a median follow-up of 6.5 years, the 5-year event-free survival (EFS) for those aged 1 to 10 years was 85% (SE, 1%), compared with 77% (SE, 4%) for those aged 10 to 15 years, and 78% (SE, 6%) for those aged 15 to 18 years (P = .09). Adolescents were more likely to present with T-cell phenotype (P < .001) and less likely to have the TEL-AML1 fusion (P = .05). The incidence of pancreatitis and thromboembolic complications, but not asparaginase allergy, was higher in patients ≥ 10 years of age compared with those younger than 10 years. However, there was no difference in the rate of treatment-related complications between the 10- to 15-year and 15- to 18-year age groups.

Conclusion

Adolescents were more likely to present at diagnosis with biologically higher risk disease (T-cell phenotype and absence of the TEL-AML1 fusion) and more likely to experience treatment-related complications than younger children. However, the 5-year EFS for older adolescents was 78% ± 6%, which is superior to published outcomes for similarly aged patients treated with other pediatric and adult ALL regimens. Based on this experience, we currently are piloting our regimen in patients aged 18 to 50 years.

Outcome of adolescents with acute lymphoblastic leukemia (ALL) treated on Dana-Farber Cancer Institute (DFCI) ALL Consortium Protocols, 1991–2000

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Background: Historically, adolescents with ALL have had inferior outcomes compared with younger pediatric patients (pts). Recent studies suggest that older adolescents treated on pediatric protocols have better outcomes than similarly aged pts treated on adult protocols. We report the outcome of adolescents enrolled on two consecutive DFCI ALL Consortium protocols conducted between 1991–2000. Methods: Pts aged 1–18 years (yrs) with newly diagnosed ALL were enrolled on two consecutive protocols, 91–01 (1991–1995) and 95–01(1995–2000). All adolescent pts received 20–30 weeks asparaginase (post-remission consolidation), 18 Gy cranial radiation and doxorubicin (cumulative dose 300 mg/m2). Results: 847 pts were enrolled. Median follow-up was 6.5 yrs. Presenting characteristics and outcome of pts according to age are displayed in the table below. Older pts (age ≥ 10 yrs) were more likely to experience pancreatitis (p=0.007) and thromboembolic complications (p<0.001) from asparaginase, but had similar rates of asparaginase-related allergic events (p=0.21) compared to younger pts. Conclusions: Older adolescents (aged 15–18 yrs) with ALL are more likely to present with T-cell phenotype and TEL/AML1-negative disease than younger children. Despite these biologic differences, older adolescents (aged 15–18 yrs) fared relatively well on DFCI ALL Consortium protocols, with a 5-year EFS of 75 ± 6%. This EFS rate compares favorably to published outcomes for older adolescents treated on other childhood ALL protocols. Although adolescents had an increased risk of asparaginase-related toxicity, this therapy was well-tolerated overall. Based on this experience, we are currently piloting our treatment regimen in adults aged 18–50 yrs.

[Table: see text]

No significant financial relationships to disclose.

Local and regional air pollution in Ireland during an intensive aerosol measurement campaign

An intensive two month measurement campaign has been performed during a two year study of major component composition of urban PM10 and PM2.5 in Ireland (J. Yin, A. G. Allen, R. M. Harrison, S. G. Jennings, E. Wright, M. Fitzpatrick, T. Healy, E. Barry, D. Ceburnis and D. McCusker, Atmos. Res., 2005, 78(3-4), 149-165). Measurements included size-segregated mass, soluble ions, elemental carbon (EC) distributions, fine and coarse fraction organic carbon (OC) and major gases along with standard meteorological measurements. The study revealed that urban emissions in Ireland had mainly a local character and therefore were confined within a limited area of 20-30 km radius, without significantly affecting regional air quality. Gaseous measurements have shown that urban emissions in Ireland had clear, but fairly limited influence on the regional air quality due to favorable mixing conditions at higher wind speeds, in particular from the western sector. Size-segregated mass and chemical measurements revealed a clear demarcation size between accumulation and coarse modes at about 0.8 microm which was constant at all sites. Carbonaceous compounds at the urban site accounted for up to 90% of the particle mass in a size range of 0.066-0.61 microm. Nss SO4(2-) concentrations in PM2.5 were only slightly higher at the urban site compared to the rural or coastal sites, while NO3- and NH4+ concentrations were similar at the urban and coastal sites, but were a factor of 2 to 3 higher than at the rural site. OC was highly variable between the sites and revealed clear seasonal differences. Natural or biogenic OC component accounted for <10% in winter and up to 30% in summer of the PM2.5 OC at urban sites. A contribution of biogenic OC component to PM2.5 OC mass at rural site was dominant.

Limestone-particle-stabilized macroemulsion of liquid and supercritical carbon dioxide in water for ocean sequestration

When liquid or supercritical CO2 is mixed with an aqueous slurry of finely pulverized (1-20 microm) limestone (CaCO3) in a high-pressure reactor, a macroemulsion is formed consisting of droplets of CO2 coated with a sheath of CaCO3 particles dispersed in water. The coated droplets are called globules. Depending on the globule diameter and the CaCO3 sheath thickness, the globules sink to the bottom of the water column, are neutrally buoyant, or float on top of the water. The CaCO3 particles are lodged at the CO2/ H2O interface, preventing the coalescence of the CO2 droplets, and thus stabilizing the CO2-in-water emulsion. We describe the expected behavior of a CO2/H2O/CaCO3 emulsion plume released in the deep ocean for sequestration of CO2 in the ocean to ameliorate global warming. Depending on the amount of CO2 injected, the dense plume will descend a few hundred meters while entraining ambient seawater until it acquires neutral buoyancy in the stratified ocean. After equilibration, the globules will rain out from the plume toward the ocean bottom. This mode of CO2 release will prevent acidification of the seawater around the release point, which is a major environmental drawback of ocean sequestration of liquid, unemulsified CO2.

Preventing accidental falls among older people in long stay units

A fall prevention programme for older long-stay patients in a 95 bedded District Hospital was undertaken. Data on falls and resulting injuries for the year prior to the intervention were compared with equivalent data after one year (Year 1) and after two years (Year 2) of the intervention. In the pre-intervention year 25% of patients had at least one fall compared with 20.9% and 17.4% in Year 1 and Year 2 respectively. This difference was not statistically significant. However, there were 21% fewer falls in Year 1 and 49.3% fewer in Year 2 than in the pre-intervention year. This difference was significant in Year 2. In both intervention years there was a significant reduction in the incidence of fracture from 20.5% of falls (pre-intervention) to 2.8% in Year 1 and no fractures occurred in Year 2. Significant reductions in soft tissue injuries occurred in Year 2 but not in Year 1, dropping from 38.5% (pre-intervention) to 36.1% and 15.4% respectively. The percentage of patients uninjured after a fall increased from 41% to 61.1% to 84.6%. This intervention reduced falls and their adverse consequences for older people living in the long stay unit. The effect of the intervention escalated in Year 2. The intervention cost IR4,800 pounds. Fall prevention should be part of the routine care of older people in all types of long stay care.

Cloning and expression profiling of Hpa2, a novel mammalian heparanase family member

Heparan sulfate proteoglycans are important constituents of the extracellular matrix and basement membrane. Cleavage of heparan sulfate by heparanase, an endoglycosidase, is implicated in the extravasation of leukocytes and metastatic tumour cells, identifying this enzyme(s) as a target for anti-inflammatory and anti-metastatic therapies. The cloning of a cDNA encoding human heparanase (Hpa1) was reported recently, together with evidence indicating that the hpa1 gene is unique and unlikely to belong to a family of related genes. Here we report the cloning of a cDNA encoding a novel human protein, HPA2, with significant homology to Hpa1. Alternative splicing of the hpa2 transcript yields three different mRNAs, encoding putative proteins of 480, 534, and 592 amino acids. Sequence analyses predict that all three Hpa2 proteins are intracellular, membrane-bound enzymes. Hpa2 also shows a markedly different mRNA distribution to Hpa1 in both normal and cancer tissues. The difference in expression profiles and predicted cellular locations suggests that Hpa2 and Hpa1 proteins have distinct biological functions.

Constitutive expression of the Vi polysaccharide capsular antigen in attenuated Salmonella enterica serovar typhi oral vaccine strain CVD 909

Live oral Ty21a and parenteral Vi polysaccharide vaccines provide significant protection against typhoid fever, albeit by distinct immune mechanisms. Vi stimulates serum immunoglobulin G Vi antibodies, whereas Ty21a, which does not express Vi, elicits humoral and cell-mediated immune responses other than Vi antibodies. Protection may be enhanced if serum Vi antibody as well as cell-mediated and humoral responses can be stimulated. Disappointingly, several new attenuated Salmonella enterica serovar Typhi oral vaccines (e.g., CVD 908-htrA and Ty800) that elicit serum O and H antibody and cell-mediated responses following a single dose do not stimulate serum Vi antibody. Vi expression is regulated in response to environmental signals such as osmolarity by controlling the transcription of tviA in the viaB locus. To investigate if Vi antibodies can be stimulated if Vi expression is rendered constitutive, we replaced P(tviA) in serovar Typhi vaccine CVD 908-htrA with the constitutive promoter P(tac), resulting in CVD 909. CVD 909 expresses Vi even under high-osmolarity conditions and is less invasive for Henle 407 cells. In mice immunized with a single intranasal dose, CVD 909 was more immunogenic than CVD 908-htrA in eliciting serum Vi antibodies (geometric mean titer of 160 versus 49, P = 0.0007), whereas O antibody responses were virtually identical (geometric mean titer of 87 versus 80). In mice challenged intraperitoneally with wild-type serovar Typhi 4 weeks after a single intranasal immunization, the mortality of those immunized with CVD 909 (3 of 8) was significantly lower than that of control mice (10 of 10, P = 0.043) or mice given CVD 908-htrA (9 of 10, P = 0.0065).

Regulatory science: a special update from the United States Food and Drug Administration: Preclinical issues and status of investigation of botanical drug products in the United States

A recent survey was conducted across the therapeutic divisions within the CDER, U.S. FDA regarding the number of submissions related to botanical drug products over the past ten years. The overall number of botanical submissions as expressed in the parenthesis are as follows: 1990 (1), 1991 (4), 1992 (4), 1993 (5), 1994 (6), 1995 (5), 1996 (13), 1997 (16), 1998 (10). In the total of 64 counted, 50 of them are submitted in original IND and the rest (14) in pre-IND format. The therapeutic categories are focused on dermatological and topical (19), anti AIDS/antiviral (12), oncologic (13), neuropharmacologic (8), endocrine and metabolic (3), urologic (2), tobacco (2), and cardio-renal products (1). The regulatory actions taken on these submissions showed that 68% of them are evaluated as safe to proceed for the human trials, while the rest (32%) of submissions required agency's regulatory guidance. Among the submissions that required further guidance, 81% were deficient in preclinical pharmacology/toxicology information and the rest (19%) lacks information in other areas (chemistry, clinical protocols). Following agency's guidance, 93% of the submissions that were put on hold were allowed to proceed. In summary, a total of 94% of all the botanical INDs submitted to the agency were allowed to proceed without additional animal toxicity studies conducted. In conclusion, this survey indicates that the growing public interest in botanical supplements has prompted more formal evaluation of the efficacy/safety claims of these products.

Nonepileptic posttraumatic seizures

PURPOSE

Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI.

METHODS

We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989-1995) and selected patients with seizures attributed to a head injury occurring < or =3 years before the onset of their seizures.

RESULTS

Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15-56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs.

CONCLUSIONS

Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIs, particularly mild HIs, should be carefully evaluated for NESs.

Analysis of clinical and environment Yersinia isolates in the Republic of Georgia

The Center for Infectious Diseases Control, Georgian Ministry of Health, isolated 2,493 Yersinia enterocolitica and Y. enterocolitica-like strains, 22 Y. pestis strains, and 21 Y. pseudotuberculosis strains from 130,574 clinical and environmental samples. Analysis of 100 Y. enterocolitica and Y. enterocolitica-like strains showed none to be within traditional pathogenic biogroups or serogroups, and none carried genetic markers for virulence. However, some strains were enterotoxigenic in infant mice, while others were associated with prolonged carriage in adult mice.

Attenuated Salmonella as live oral vaccines against typhoid fever and as live vectors

Attenuated Salmonella typhi vaccine strain CVD 908, which harbors deletion mutations in aroC and aroD, has been shown to be well-tolerated and highly immunogenic, eliciting impressive serum antibody, mucosal IgA and cell-mediated immune responses. A further derivative prepared by introducing a deletion in htrA (which encodes a heat-shock protein that also has activity as a serine protease in CVD 908 (Chatfield et al., unpublished data) resulted in CVD 908-htrA. In phase 1 clinical trials, CVD 908-htrA appears very attractive as a live oral vaccine candidate. Both CVD 908 and CVD 908-htrA are useful as live vector vaccines to deliver foreign antigens to the immune system. Conditions that enhance the expression and immunogenicity of foreign antigens carried by CVD 908 and CVD 908-htrA are being investigated.

Radiologic appearance of the dysembryoplastic neuroepithelial tumor

PURPOSE

To evaluate the computed tomographic (CT) and magnetic resonance (MR) imaging features of dysembryoplastic neuroepithelial tumor (DNT).

MATERIALS AND METHODS

Six CT studies (four with contrast material enhancement) and 10 MR imaging studies (seven with gadolinium enhancement) obtained in 10 patients with a history of seizures and pathologically proved DNT were retrospectively reviewed.

RESULTS

All tumors were intracortical or subcortical. CT showed a low-attenuation mass in all cases except one of mixed isoattenuation and low attenuation. The DNT had decreased signal intensity on T1-weighted MR images and well-demarcated increased signal intensity on T2-weighted images without peritumoral edema. Prominent MR imaging features were a gyriform configuration on T1- or T2-weighted images in 10 patients (100%), well-demarcated lobular tumor margins on T2-weighted images in eight (80%), and a high rate of bone remodeling of the adjacent calvaria on MR (60% [n = 6]) and CT (67% [n = 4]) images.

CONCLUSION

Diagnosis of DNT with imaging modalities alone may be difficult, but these radiologic features may aid in differentiating DNT from other gliomas.

Panic attacks as ictal manifestations of parietal lobe seizures

Although most panic attacks appear to be primary psychiatric disturbances, some evidence suggests a biologic basis for panic disorder, possibly associated with temporal lobe dysfunction. Fear is a common affective change associated with some complex partial seizures (CPS) originating from the right temporal lobe. We describe a previously unreported association between panic attacks and seizures originating from the parietal lobe in 2 patients with right parietal lobe tumors. Intracranial monitoring documented correlations between the symptoms of fear and restricted regional parietal cortical discharges. Surgical resections of the lesions (one total, one subtotal) resulted in complete recovery or improvement.

Complex partial status epilepticus accompanied by serious morbidity and mortality

Nonconvulsive status epilepticus (NCSE) accounts for approximately 20% of all status epilepticus (SE). Although convulsive SE is recognized as a medical emergency, prompt diagnosis and treatment of patients with NCSE is often not emphasized because its consequences are thought to be benign. We report 10 patients with persistent neurologic deficits or death after well-documented NCSE in the form of complex partial status epilepticus (CPSE). All patients had prolonged CPSE lasting 36 hours or longer, as documented by clinical and EEG findings. Causes for CPSE were preexisting epilepsy with partial and secondarily generalized seizures (3 patients), vascular disease (2 patients), encephalitis (2 patients), and metabolic disease (1 patient); causes were unknown for two patients. Poor outcomes identified included persistent (lasting at least 3 months) or permanent cognitive or memory loss (5 patients), cognitive or memory loss plus motor and sensory dysfunction (3 patients), and death (3 patients). NCSE in the form of CPSE is not a benign entity. Serious morbidity and mortality may occur due to the adverse effects of prolonged seizures and as a result of acute brain disorders that precipitate the seizures.

Pleocytosis after status epilepticus

OBJECTIVE

To determine the incidence of pleocytosis in patients experiencing status epilepticus (SE), regardless of seizure type or cause.

DESIGN

A retrospective medical chart review.

SETTING

Columbia-Presbyterian Medical Center, New York, NY.

PATIENTS

Of 217 patients seen by the Neurology Service for SE during a 3-year period, 138 had a cerebrospinal fluid (CSF) analysis performed and were included in the study. All seizure types and etiologies were included.

MAIN OUTCOME MEASURES

Status epilepticus was defined as a seizure or a series of continuing seizures lasting longer than 30 minutes. An abnormal CSF specimen was defined as a white blood cell (WBC) count of 6 x 10(6)/L or greater or one or more polymorphonuclear leukocytes present.

RESULTS

Overall, 22.5% of patients demonstrated abnormal WBC count or morphology. There were 21 patients (15%) with a WBC count of 6 x 10(6)/L or greater, and another 10 patients with a normal WBC count, who had polymorphonuclear leukocytes present. Among patients with illnesses usually associated with pleocytosis (such as meningitis or acute head trauma), a large proportion had abnormal CSF WBC counts. Among patients with conditions usually associated with normal CSF (including idiopathic epilepsy), a small proportion had abnormal CSF WBC counts, and the abnormalities were less severe. The highest CSF WBC count in patients with no acute insult was 28 x 10(6)/L.

CONCLUSIONS

The most important influence on the CSF WBC count is the underlying cause of the SE. Although minor elevations in WBC count can occur after SE of any type, pleocytosis should not be attributed to SE alone unless all other causes have been eliminated.

Status epilepticus and antiepileptic medication levels

To investigate the association between withdrawal from antiepileptic drugs (AEDs) and status epilepticus (SE), we evaluated AED levels at the time of, and prior to, an episode of SE in 65 patients with epilepsy. At least one AED was therapeutic in 65% of patients at the time of SE, and all prescribed AEDs were therapeutic in 48%. Ten patients had subtherapeutic AED levels before, and at the time of, SE. Sixteen patients with previously therapeutic levels (25%) had one or more subtherapeutic AED level at the time of SE. Many of the patients had other acute or remote factors that could be associated with SE, and 46 had had previous episodes of SE. Low AED levels or withdrawal can explain only some cases of SE. Citing AED irregularity as the major cause of SE in patients with epilepsy oversimplifies a complex, poorly understood situation.

Cytokine-gene expression in measles-infected adult human glial cells

The expression of interleukin (IL)-1 beta, IL-6 and tumor necrosis factor (TNF) alpha transcripts in cultured human glial cells was examined using reverse transcription followed by polymerase chain reaction (PCR) amplification and Southern blot quantitation. Microglial cultures derived from brain biopsy specimens from three different individuals expressed transcripts for the three cytokines under basal culture conditions. This expression was enhanced in response to measles virus (MV) infection (IL-1 beta, 2.2-8.8-fold; IL-6, 2.5-8.4-fold; TNF alpha, 2.2-3.2-fold). Neither IL-1 beta nor TNF alpha transcripts were detectable in undissociated brain tissue from two individuals, suggesting that the basal expression of these cytokines in culture may have been induced by tissue dissociation or by the culture conditions. Oligodendrocytes did not express cytokine transcripts under basal culture conditions, and IL-1 beta and IL-6 but not TNF alpha transcripts could be induced by MV. Similarly, meningeal fibroblasts expressed IL-1 beta and IL-6 but not TNF alpha in response to MV-infection, suggesting that the production of TNF alpha is more cell type-restricted than either IL-1 beta or IL-6. The results indicate that adult human microglia can participate in the inflammatory response to MV infection in the CNS by producing cytokines that contribute to inflammation and demyelination. In addition, besides their role in myelination, oligodendrocytes can potentially influence immunoreactivity in the CNS by producing IL-1 beta and IL-6.

Status epilepticus: the interaction of epilepsy and acute brain disease

We identified 217 patients with status epilepticus (SE), including all seizure types from all etiologies, over a 3-year period. There was a significant interaction between organic brain disease and a history of epilepsy in the development of SE. The majority of patients (59%) had no history of epilepsy. These patients were more likely to have acute precipitants associated with SE and less likely to have had prior brain disease. They were older, were more likely to have generalized convulsive seizures, and had a high proportionate mortality. Among the 88 patients with a history of epilepsy, a higher proportion had prior brain insults, but fewer had acute precipitants. These patients were younger and their mortality was low, but they often had recurrent SE before and after the identified episode. Significant acute or prior brain disease is an important factor in the development of SE, even in patients with a history of epilepsy.

Enzymatic activity of adenylate cyclase toxin from Bordetella pertussis is not required for hemolysis

Adenylate cyclase (AC) toxin from Bordetella pertussis enters cells to cause supraphysiologic increases in cAMP. AC toxin is also hemolytic. Substitution of Lys-58 with a methionine residue by site-directed mutagenesis of the structural gene for AC toxin, cyaA, and introduction of this mutation onto the B. pertussis chromosome results in an organism that synthesizes an enzyme-deficient AC toxin molecule. This mutant toxin molecule exhibits 1000-fold reduction in enzymatic activity relative to wild-type and has no toxin activity in J774 cells. The enzyme-deficient toxin molecule is not, however, impaired in its ability to lyse sheep red blood cells. In order to ascertain the importance of these two separate activities of AC toxin in vivo the enzyme-deficient organisms were used to infect infant mice. The hemolytic, enzyme-deficient mutant organisms are reduced in virulence relative to wild-type organisms after intranasal challenge indicating that, although the enzymatic activity of AC toxin does not contribute to hemolysis, it is this property of the toxin which is important for virulence of B. pertussis.

Presurgical electroencephalographic patterns and outcome from anterior temporal lobectomy

We reviewed data from 48 patients after anterior temporal lobe resection for medically intractable epilepsy. All had ictal electro-encephalographic (EEG) evidence of unilateral temporal lobe onset. Depth electrodes were used in 19 patients. Successful surgical outcome correlated significantly with factors that suggested a temporal lobe focus, particularly in the interictal scalp EEG. The most successful outcome occurred in patients with well-localized unilateral interictal temporal spikes (100% improved). The group with well-localized bilateral temporal spikes also did well (76% improved). Patients with extratemporal spread of the interictal spike on scalp EEG, either unilaterally or bilaterally, did less well. Only one third improved, despite extensive extracranial and intracranial monitoring, when indicated. The interictal scalp EEG may be the only EEG necessary for the presurgical evaluation of selected patients with intractable temporal lobe epilepsy.

Posttraumatic narcolepsy: the complete syndrome with tissue typing. Case report

Although sleep disturbances following head injury are common, well-documented posttraumatic narcolepsy has rarely been reported. A patient with all four major features of narcolepsy following significant head injury is presented. Tissue typing revealed the presence of the human lymphocyte antigen DR2, which is strongly associated with idiopathic narcolepsy. Interaction between the brain injury and a genetic predisposition appears to be involved in the development of posttraumatic narcolepsy.

Corpus callosotomy for refractory seizures in a patient with cortical heterotopia: case report

Heterotopia of the cerebral cortex, a disorder of neuronal migration, may be associated with medically intractable seizures. We report on a patient with bihemispheric cortical heterotopia who had medically intractable atonic seizures that were successfully treated by corpus callosotomy. The clinical and radiographic aspects of cortical heterotopia and the surgical management of seizures associated with heterotopia are discussed.