P2Y12 Inhibitor Monotherapy versus Conventional Dual Antiplatelet Therapy in Patients with Acute Coronary Syndrome after Percutaneous Coronary Intervention: A Meta-Analysis

P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) in the modern era. Clinical trials have shown that it could lower the risk of bleeding complications without increased ischemic events as compared to standard dual antiplatelet therapy (DAPT). However, the efficacy and safety of this novel approach among patients with acute coronary syndrome (ACS) are controversial because they have a much higher risk for recurrent ischemic events. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with ACS. We conducted a meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12-month DAPT in ACS patients who underwent PCI with stent implantation. PubMed, Embase, the Cochrane library database, ClinicalTrials.gov, and other three websites were searched for data from the earliest report to July 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE), a composite of all-cause mortality, myocardial infarction, stent thrombosis, or stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE), defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. Five randomized controlled trials with a total of 21,034 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy as compared with standard DAPT(OR: 0.59, 95% CI: 0.46-0.75, p < 0.0001) without increasing the risk of MACCE (OR: 0.98, 95% CI: 0.86-1.13, p = 0.82). The NACE was favorable in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.82, 95% CI: 0.73-0.93, p = 0.002). Of note, the overall clinical benefit of P2Y12 inhibitor monotherapy was quite different between ticagrelor and clopidogrel. The incidence of NACE was significantly lower in ticagrelor monotherapy as compared with DAPT (OR: 0.79, 95% CI: 0.68-0.91), but not in clopidogrel monotherapy (OR: 1.14, 95% CI: 0.79-1.63). Both clopidogrel and ticagrelor monotherapy showed a similar reduction in bleeding complications (OR: 0.46, 95% CI: 0.22-0.94; OR: 0.60, 95% CI: 0.44-0.83, respectively). Although statistically insignificant, the incidence of MACCE was numerically higher in clopidogrel monotherapy as compared with standard DAPT (OR: 1.50, 95% CI: 0.99-2.28, p = 0.06). Based on these findings, P2Y12 inhibitor monotherapy with ticagrelor would be a better choice of medical treatment for ACS patients after PCI with stent implantation in the current era.

Comparative Efficacy and Safety of P2Y12 Inhibitor Monotherapy and Dual Antiplatelet Therapy in Patients with and without Diabetes Mellitus Undergoing Percutaneous Coronary Intervention

Increasing evidence has shown P2Y12 inhibitor monotherapy is a feasible alternative treatment for patients after percutaneous coronary intervention (PCI) with stent implantation in the modern era. However, patients with diabetes mellitus (DM) have a higher risk of ischemic events and more complex coronary artery disease. The purpose of this study is to evaluate the efficacy and safety of this novel approach among patients with DM and those without DM. We conducted a systematic review and meta-analysis of randomized controlled trials that compared P2Y12 inhibitor monotherapy with 12 months of dual antiplatelet therapy (DAPT) in patients who underwent PCI with stent implantation. PubMed, Embase, Cochrane library database, ClinicalTrials.gov, and three other websites were searched for our data from the earliest report to January 2022. The primary efficacy outcome was major adverse cardiovascular and cerebrovascular events (MACCE): a composite of all-cause mortality, myocardial infarction, stent thrombosis, and stroke. The primary safety outcome was major or minor bleeding events. The secondary endpoint was net adverse clinical events (NACE) which are defined as a composite of major bleeding and adverse cardiac and cerebrovascular events. A total of four randomized controlled trials with 29,136 patients were included in our meta-analysis. The quantitative analysis showed a significant reduction in major or minor bleeding events in patients treated with P2Y12 inhibitor monotherapy compared to standard DAPT (OR: 0.68, 95% CI: 0.46-0.99, p = 0.04) without increasing the risk of MACCE (OR: 0.96, 95% CI: 0.85-1.09, p = 0.50). The number of NACE was significantly lower in the patients treated with P2Y12 inhibitor monotherapy (OR: 0.84, 95% CI: 0.72-0.97, p = 0.019). In DM patients, P2Y12 inhibitor monotherapy was associated with a lower risk of MACCE compared to standard DAPT (OR: 0.85, 95% CI: 0.74-0.98, p = 0.02). Furthermore, P2Y12 inhibitor monotherapy was accompanied by a favorable reduction in major or minor bleeding events (OR: 0.80, 95% CI: 0.64-1.05, p = 0.107). In non-DM patients, P2Y12 inhibitor monotherapy showed a significant reduction in major or minor bleeding events (OR: 0.58, 95% CI: 0.38-0.88, p = 0.01), but without increasing the risk of MACCE (OR: 0.99, 95% CI: 0.82-1.19, p = 0.89). Based on these findings, P2Y12 inhibitor monotherapy could significantly decrease bleeding events without increasing the risk of stent thrombosis or myocardial infarction in the general population. The benefit of reducing bleeding events was much more significant in non-DM patients than in DM patients. Surprisingly, P2Y12 inhibitor monotherapy could lower the risk of MACCE in DM patients. Our study supports that P2Y12 inhibitor monotherapy is a promising alternative choice of medical treatment for patients with DM undergoing PCI with stent implantation in the modern era.

Immune Checkpoints Inhibitors and Chemotherapy as First-Line Treatment for Metastatic Urothelial Carcinoma: A Network Meta-Analysis of Randomized Phase III Clinical Trials

Simple Summary

On the basis of the efficacy and tolerable safety profiles of immune checkpoints inhibitors (ICIs) in second-line metastatic urothelial carcinoma (mUC) patients, some emerging clinical trials focus on the first-line treatment. Thus, we conducted a network meta-analysis (NMA) to assess and compare the response and toxicity of ICIs in naïve-chemotherapy mUC setting. According to our results, combination therapy (either ICIs plus chemotherapy (CTX) or ICIs plus ICIs) had a higher priority in terms of overall survival. Concerning monotherapy, ICIs are not inferior to CTX in terms of OS. In view of the adverse effect, ICIs are very tolerable, and combination therapy did not lead to a higher incidence of grade 3–5 AEs when compared with CTX.

Abstract

Immune checkpoints inhibitors (ICIs) were considered as second-line treatments in metastatic urothelial carcinoma (mUC) based on better survival benefit and safety profile than chemotherapy (CTX). We aimed to assess different ICIs regimens in the efficacy and safety for front-line treatments in mUC patients. A comprehensive literature search was performed and Phase II-III randomized controlled trials (RCTs) on ICIs for patients with mUC were included. The outcome was evaluated by overall survival (OS), progression of free survival (PFS), objective response rate (ORR), and grade 3–5 adverse events. Network meta-analysis was used to estimate the effect size. Surface under cumulative ranking curves (SUCRAs) were applied to rank the included treatments for each outcome. Results: The survival benefit of a single ICI was non-inferiority to chemotherapy (CTX). Although no superior effects were indicated, combination therapy (either ICIs plus CTX or ICIs plus ICIs) presented better OS compared with CTX alone. In terms of PFS, combination therapy produced a noticeable benefit over CTX. Regarding the SUCRA ranking, atezolizumab plus CTX was associated with the best ranking for OS and pembrolizumab plus CTX was the best in PFS. In terms of safety, a single ICI had better safety profile than CTX and combination therapy had a similar risk of grade 3–5 adverse events with CTX. Conclusions: Our NMA results revealed that combination therapy has better ranking compared with monotherapy in OS and acceptable AEs. ICIs alone present non-inferior OS but a lower incidence of AEs compared with CTX.

Clinic image surveillance reduces mortality in patients with primary hepato-gastrointestinal cancer who develop second primary lung cancer: A STROBE-compliant retrospective study

Second primary cancer is prevalent in patients with gastrointestinal (GI) cancer, for which lung cancer is the most common and associated with high lethality. Image screening for lung cancer was proved to be effective in early diagnosis and lower mortality. However, trials of screen for lung cancer generally excluded patients with a previous diagnosis of malignancy. The study aimed to investigate the outcome of second primary lung cancer and the factor that improve survival in patients with hepato-GI cancer.A total of 276 patients with secondary lung cancer were found among 3723 newly-diagnosed lung cancer patients diagnosed in Chang Gung Memorial Hospital, between 2010 and 2014. Patients' clinical characteristics, stages and survival were recorded and analyzed. The patients were separated into 2 groups: Group I was defined as lung cancer detected in original primary cancer clinic and group II patients defined as lung cancer detected in other medical places.Sixty-nine cases with primary GI-hepatic and secondary lung cancer were diagnosed (42 (60.8%) in Group I and 27 (39.1%) in Group II). Although both groups had comparable primary cancer stages and treatment, more patients in Group I than Group II were diagnosed as early stage lung cancer (stage I-II: 40.5% vs 11.1%; P = .023). Group II had larger lung tumor sizes than Group I (4.7 vs 3.5 cm; P = .025). Group I showed better 5-year overall survival than Group II (P = .014, median survival: 27 vs 10 months). Among Group II, only 37% had received image follow up in clinic compared with 67% of Group I cases (P = .025). Patients with chest image follow up in clinics also had better 5-year overall survival (P = .043).GI-hepatic cancer was the most common primary malignancy in the lung cancer cohort. Patients had better survival outcome when secondary lung cancer was diagnosed in original primary cancer clinic. Chest image screening strategy may contribute better survival in secondary lung cancer due to detection at an earlier stage.

Systematic Review and Network Meta-Analysis of Immune Checkpoint Inhibitors in Combination with Chemotherapy as a First-Line Therapy for Extensive-Stage Small Cell Carcinoma

Patients with extensive-stage small cell lung cancer (ED-SCLC) have a very short survival time even if they receive standard cytotoxic chemotherapy with etoposide and platinum (EP). Several randomized controlled trials have shown that patients with ED-SCLC who received a combination of EP plus immune checkpoint inhibitors (ICIs) had superior survival compared with those who received EP alone. We conducted a systematic review and network meta-analysis to provide a ranking of ICIs for our primary endpoints in terms of overall survival (OS), progression free survival (PFS), and objective response rate (ORR), as well as our secondary endpoint in terms of adverse events. The fractional polynomial model was used to evaluate the adjusted hazard ratios for the survival indicators (OS and PFS). Treatment rank was estimated using the surface under the cumulative ranking curve (SUCRA), as well as the probability of being best (Prbest) reference. EP plus nivolumab, atezolizumab or durvalumab had significant benefits compared with EP alone in terms of OS (Hazard Ratio HR = 0.67, 95% Confidence Interval CI = 0.46-0.98 for nivolumab, HR = 0.70, 95% CI = 0.54-0.91 for atezolizumab, HR = 0.73, 95% CI = 0.59-0.90 for durvalumab) but no significant differences were observed for pembrolizumab or ipilimumab. The probability of nivolumab being ranked first among all treatment arms was highest (SCURA = 78.7%, Prbest = 46.7%). All EP plus ICI combinations had a longer PFS compared with EP alone (HR = 0.65, 95% CI = 0.46-0.92 for nivolumab, HR = 0.77, 95% CI = 0.61-0.96 for atezolizumab, HR = 0.78, 95% CI = 0.65-0.94 for durvalumab, HR = 0.75, 95% CI = 0.61-0.92 for pembrolizumab), and nivolumab was ranked first in terms of PFS (SCURA = 85.0%, Prbest = 66.8%). In addition, nivolumab had the highest probability of grade 3-4 adverse events (SUCRA = 84.8%) in our study. We found that nivolumab had the best PFS and OS in all combinations of ICIs and EP, but nivolumab also had the highest probability of grade 3-4 adverse events in our network meta-analysis. Further head-to head large-scale phase III randomized controlled studies are needed to verify our conclusions.

Abiraterone and enzalutamide had different adverse effects on the cardiovascular system: a systematic review with pairwise and network meta-analyses

BACKGROUND

Abiraterone and enzalutamide may increase the risk of cardiovascular events in patients with castration-resistant prostate cancer (CRPC).

METHODS

A comprehensive literature search was performed using a combination of keywords related to "abiraterone," "enzalutamide," "prostate cancer," and "adverse events." Phase II-IV randomized controlled trials (RCTs) on abiraterone or enzalutamide for patients with nonmetastatic or metastatic CRPC were included. Outcome measures included (1) any grade cardiac disorder, (2) severe grade cardiac disorder, (3) any grade hypertension, and (4) severe grade hypertension, as defined by the Common Terminology Criteria for Adverse Events. Pairwise meta-analysis and Bayesian network meta-analyses were performed to investigate the risk ratios (RRs) of abiraterone and enzalutamide. Surface under cumulative ranking curves (SUCRAs) and cumulative ranking probability plots based on the probability of developing cardiac disorders or hypertension were presented.

RESULTS

A total of 7103 patients from seven RCTs were included. Upon pairwise meta-analysis, abiraterone was associated with increased risks of any grade (RR = 1.34, 95% confidence interval (CI) = 1.05-1.73) and severe grade cardiac disorders (RR = 1.71, 95% CI = 1.16-2.53); enzalutamide was associated with increased risks of any grade (RR = 2.66, 95% CI = 1.93-3.66) and severe grade hypertension (RR = 2.79, 95% CI = 1.86-4.18). Based on the SUCRA rankings, abiraterone had a higher probability of cardiac disorders (84.84% for any grade and 85.12% for severe grade) than enzalutamide (62.83% for any grade and 50.76% for severe grade); whereas enzalutamide had a higher probability of hypertension (99.43% for any grade and 89.71% for severe grade) than abiraterone (49.08% for any grade and 49.37% for severe grade).

CONCLUSIONS

Abiraterone and enzalutamide had different adverse effects on the cardiovascular system. We should take this into consideration when we are deciding on the choice of novel hormonal agents for patients with CRPC.

Mirabegron is alternative to antimuscarinic agents for overactive bladder without higher risk in hypertension: a systematic review and meta-analysis

PURPOSE

Mirabegron, a β3-adrenoceptor agonist, was approved for overactive bladder (OAB), but worsened hypertension was a potential risk based on its mechanism of action. Besides, head to head comparisons were limited between mirabegron and antimuscarinic agents, the prior first-line pharmacotherapy of OAB. In this regard, we performed a systematic review and meta-analysis to compare their efficacy as well as safety, especially in blood pressure changes.

MATERIALS AND METHODS

Literature search was conducted in PubMed, Medline and seven randomized clinical trial (RCT) register databases of WHO, EU, USA, Taiwan, China, Japan and Cochrane. Completed RCTs for OAB with mirabegron and antimuscarinics were identified and the last comprehensive search was run in August 2017. Cochrane risk of bias tool was used to assess the potential bias, and RevMan5 software was performed for meta-analysis.

RESULTS

Seven eligible RCTs (four for mirabegron vs. tolterodine and three for mirabegron vs. solifenacin) were included and demonstrated similar efficacy in micturitions, incontinence, and nocturia between mirabegron and antimuscarinics. In hypertension issue, no statistical differences were showed in risk ratio (RR) of hypertension events, change of blood pressure from baseline and change of blood pressure from placebo for all participants. On the other hand, RR of dry mouth was significantly lower in mirabegron users.

CONCLUSIONS

Mirabegron was not inferior effective in improving OAB symptoms compared with antimuscarinic agents. In addition, mirabegron presented lower incidence of dry mouth and not higher risk for hypertension. Therefore, mirabegron has potential to be an alternative therapeutic option for OAB control.

Blunt Abdominal Trauma with Left Kidney Dropped into Lower Retroperitoneal Cavity: A Case Report and Literature Review

Blunt abdominal injury with kidney laceration is not unusually seen in high-energy traffic accident. It can present with no symptoms and yet lead to fatal complications. High-grade lacerations of kidney (American Association for the Surgery of Trauma [AAST] grade IV to V) will show up with contrast extravasation and disrupted kidney/pelvicalyceal system morphology in computed tomography (CT). However, it is rare to see kidney dislocation from retroperitoneal space because of the presence of the Gerota's fascia. We present a case of a 16-year-old boy suffering from traffic accident with blunt truncal/abdominal injury. The contrast CT of abdomen revealed that his left kidney was dislocated from the original retroperitoneal space and sagged to the lower retroperitoneal cavity. We performed emergency left nephrectomy. He recovered well and there was no complication noted after the surgical intervention. We also review the literature of kidney laceration regarding diagnosis and treatment. (Hong Kong j.emerg.med. 2016;24:176-179)

Using a Text-Mining Approach to Evaluate the Quality of Nursing Records

Nursing records in Taiwan have been computerized, but their quality has rarely been discussed. Therefore, this study employed a text-mining approach and a cross-sectional retrospective research design to evaluate the quality of electronic nursing records at a medical center in Northern Taiwan. SAS Text Miner software Version 13.2 was employed to analyze unstructured nursing event records. The results show that SAS Text Miner is suitable for developing a textmining model for validating nursing records. The sensitivity of SAS Text Miner was approximately 0.94, and the specificity and accuracy were 0.99. Thus, SAS Text Miner software is an effective tool for auditing unstructured electronic nursing records.

Poly(3-hydroxybutyrate-co-3-hydroxyhexanoate)-based scaffolds for tissue engineering

Development and selection of an ideal scaffold is of importance for tissue engineering. Poly(3-hydroxybutyrate-co-3-hydroxyhexanoate) (PHBHHx) is a biocompatible bioresorbable copolymer that belongs to the polyhydroxyalkanoate family. Because of its good biocompatibility, PHBHHx has been widely used as a cell scaffold for tissue engineering. This review focuses on the utilization of PHBHHx-based scaffolds in tissue engineering. Advances in the preparation, modification, and application of PHBHHx scaffolds are discussed.

Delivery of the Sox9 gene promotes chondrogenic differentiation of human umbilical cord blood-derived mesenchymal stem cells in an in vitro model

SRY-related high-mobility-group box 9 (Sox9) gene is a cartilage-specific transcription factor that plays essential roles in chondrocyte differentiation and cartilage formation. The aim of this study was to investigate the feasibility of genetic delivery of Sox9 to enhance chondrogenic differentiation of human umbilical cord blood-derived mesenchymal stem cells (hUC-MSCs). After they were isolated from human umbilical cord blood within 24 h after delivery of neonates, hUC-MSCs were untreated or transfected with a human Sox9-expressing plasmid or an empty vector. The cells were assessed for morphology and chondrogenic differentiation. The isolated cells with a fibroblast-like morphology in monolayer culture were positive for the MSC markers CD44, CD105, CD73, and CD90, but negative for the differentiation markers CD34, CD45, CD19, CD14, or major histocompatibility complex class II. Sox9 overexpression induced accumulation of sulfated proteoglycans, without altering the cellular morphology. Immunocytochemistry demonstrated that genetic delivery of Sox9 markedly enhanced the expression of aggrecan and type II collagen in hUC-MSCs compared with empty vector-transfected counterparts. Reverse transcription-polymerase chain reaction analysis further confirmed the elevation of aggrecan and type II collagen at the mRNA level in Sox9-transfected cells. Taken together, short-term Sox9 overexpression facilitates chondrogenesis of hUC-MSCs and may thus have potential implications in cartilage tissue engineering.

Gender and age differences in the impact of overweight on obesity-related quality of life among Korean adults

SUMMARY

OBJECTIVE

To investigate gender and age difference in impact of overweight on health-related quality of life (HRQOL) among Korean adults.

METHODS

Cross-sectional obesity-related quality of life (QOL) scores were measured by a Korean obesity-related QOL scale (KOQOL) from 448 Korean adults aged 20-80 years. A body mass index (BMI) was categorized with normal-weight as BMI < 23 kg/m(2), overweight as BMI ≥ 23 kg/m(2) based on the alternative cutoff points for Asians. Each gender was respectively stratified by median age, 45 years for men and 50 years for women, to examine the obesity-related QOL by age groups.

RESULTS

Women had a poorer obesity-related QOL compared to men (p < 0.001). In the younger age group, overweight women had a poorer obesity-related QOL compared with normal-weight women (p < 0.001), however normal-weight and overweight men showed no difference in obesity-related QOL. In the older age group, overweight men showed better QOL on the domains of work-related and psychosocial health than those for normal-weight men, but overweight women still suffered from work-related and routine life QOL.

CONCLUSIONS

This study showed the impact of overweight on obesity-related QOL was different for gender and age group. We should consider the results to manage weight in overweight persons.

Phase II and UGT1A1 genotype study of irinotecan dose escalation as salvage therapy for advanced gastric cancer

Background:

To assess the efficacy and safety of individualised dose optimisation of irinotecan monotherapy as salvage treatment for advanced gastric cancer (AGC).

Methods:

A total of 43 patients were enrolled. Intravenous irinotecan (350 mg m⁻²) was administered every 3 weeks. The dose was increased (425 mg m⁻² and 500 mg m⁻²) or decreased (250 mg m⁻²) depending on patient tolerance. UGT1A1 genotypes were determined by direct sequencing of genomic DNA extracted from peripheral blood.

Results:

A total of 183 cycles of irinotecan were administered, with a median of four cycles per patient. The overall response rate was 9.3%, and the disease control rate was 62.8%. Median time to disease progression was 2.8 months, and median overall survival was 8.0 months. Grade 3–4 neutropenia was the most common toxicity (53.5%), and febrile neutropenia was the least common toxicity (4.6%). Compared with defective allele groups, UGT1A1 *1/*1 was associated with a lower incidence of grade 3–4 neutropenia during the first cycle (P=0.018).

Conclusion:

Individualised irinotecan dose escalation based on patient tolerance was not associated with increased toxicity and shows modest activity as salvage chemotherapy for AGC. The role of UGT1A1 genotype in clinical toxicity requires further evaluation.

Brain attack: needing resuscitation

The brain is extremely susceptible to focal ischaemia. Following vascular occlusion, a core of severely damaged brain tissue develops, surrounded by an ischaemic penumbra. This potentially-salvageable penumbra may be estimated by advanced neuroimaging techniques, particularly by diffusion-perfusion mismatch. Clinical trials have demonstrated the efficacy of intravenous thrombolysis within three hours of onset of ischaemic stroke in reducing short-term disability. Recanalisation is enhanced by intra-arterial thrombolysis, sonothrombolysis and clot-retrieval devices. Occasionally, reperfusion injury may lead to clinical deterioration. The search continues for effective neuroprotectants. Brain perfusion needs to be maintained through blood and intracranial pressure management. Hemicraniectomy for 'malignant' cerebral oedema reduces death and disability. Elevated glucose should be controlled and hypoxia alleviated. Public education of symptoms and the need for immediate presentation to a medical facility is needed. Stroke unit care reduces death and disability with little increase in cost. Current evidence supports urgent efforts to resuscitate the brain after stroke.

A study on white organic light-emitting diodes co-doped with red fluorescent and blue phosphorescent dopants

White organic light-emitting diodes (WOLEDs) have drawn increasing attention due to their potential use in various applications such as solid-state lighting and backlight of liquid crystal displays and full-color OLEDs of red, green, and blue pixel. N,N'-dicabazolyl-3,5-benzene (mCP), the host material, was co-doped with Iridium (III) bis[(4,6-difluorophenyl)-pyridinato-N,C2']-picolinate (FIrpic), which functions not only as phosphorescent sensitizer but also blue emitter, and (2Z,2'Z)-3,3'-[4,4"-bis (dimethylamino)-1,1':4',1"-terphenyl-2',5'-diyl]bis (2-phenylacrylonitrile) (ABCV-P), which is a red fluorescent material. The fabricated device structures were as follows: (device A) Indium tin oxide (ITO)/N,N'-bis-(1-naphyl)-N,N'-diphenyl-1,1'-biphenyl-4,4'-diamine (NPB)/(mCP)/mCP:ABCV-P (1%)/4,7-diphenyl-1,10-phenanthroline (Bphen)/lithium quinolate (Liq)/aluminum (Al), (device B) ITO/NPB/mCP/mCP:FIrpic (8%)/Bphen/Liq/Al and (device C) ITO/NPB/mCP/mCP:FIrpic:ABCV-P (8%, 1%)/Bphen/Liq/Al, respectively. Phosphorescent FIrpic harvesting both singlet and triplet excitions not only emitted blue light but also transferred energy to fluorescent ABCV-P. The maximum luminance efficiency, external quantum efficiency, and luminance of white light device were measured to be 5.95 cd/A, 2.45% and 2500 cd/m2, respectively. The white device gave practically white light with the Commision Internationale de l'Eclairage (CIE(xy)) coordinate of (0.44, 0.49) which was close to warm white color (CIE(xy) = 0.45, 0.45).

A randomized controlled trial of rivastigmine in patients with cognitive impairment no dementia because of cerebrovascular disease

OBJECTIVES

The safety and efficacy of early acetylcholinesterase inhibitors therapy in patients with cognitive impairment no dementia (CIND) after a cerebrovascular accident have not been examined. In this study, we investigated the safety and efficacy of rivastigmine in cognition, particularly executive function in patients with CIND because of cerebrovascular disease.

METHODS

This study was a 24-week, double-blind, randomized, placebo-controlled trial of ischemic stroke patients seen at a tertiary hospital who had cognitive impairment no dementia because of cerebrovascular disease. The intervention was either rivastigmine or placebo up to 9 mg/day. The primary outcome of interest was mean change from baseline in the Ten-Point Clock Drawing and Color Trails 1 and 2.

RESULTS

Fifty patients were randomized into rivastigmine (n = 25) and placebo (n = 25) arms. Patients in the rivastigmine group showed statistically significant improvement (1.70 vs 0.13, P = 0.02) on the animal subtask of the verbal fluency measure compared with placebo. There was also a trend (non-significant) towards improvement in Color Trails II.

CONCLUSIONS

In this pilot study, we demonstrated that rivastigmine was well tolerated in patients with CIND because of cerebrovascular disease and may potentially improve executive functioning.

Middle cerebral artery occlusive disease: the New England Medical Center Stroke Registry

To analyze the clinical features, vascular lesions, and infarct distribution in Asian and white patients with middle cerebral artery (MCA) territory ischemia, we studied age, sex, race, risk factors, angiographic, and neuroimaging findings among patients in the New England Medical Center Stroke Registry. We included patients with well-defined intrinsic occlusive lesions of the MCAs and patients with embolic MCA territory infarcts. Among 695 patients in the stroke registry, 89 (12.8%) qualified. They had 28 MCA intrinsic stenoses, 17 MCA embolic occlusions (cardiogenic or unknown origin), and 44 carotid artery (CA) stenoses or occlusions. MCA intrinsic disease patients were more often Asians and women, and more often had hypertension. Asians were older than whites. Coronary artery disease (27%), peripheral vascular disease (20.5%), and smoking (39%) were more common in CA disease patients. The most common site of MCA intrinsic stenosis (78%) and embolic occlusion (59%) was the mainstem MCA. Infarcts in patients with MCA intrinsic disease mostly involved the striatocapsular area (61%). Infarcts in patients with MCA embolic occlusion (75%) and CA disease (43%) most often involved the parietal lobe. In our hospital, most patients with MCA intrinsic disease are Asians and women and have hypertension and striatocapsular infarctions. Asian patients are usually older than white patients. The most common site of vascular lesions is the mainstem MCA.

Investigation of papulopustular eruptions caused by cetuximab treatment shows altered differentiation markers and increases in inflammatory cytokines

BACKGROUND

Epidermal growth factor receptor (EGFR) critically regulates tumour cell division, survival and metastasis. Agents that inhibit EGFR have been used in the treatment of advanced-stage malignancies, but cause variable cutaneous side-effects, most often papulopustular eruptions and xerosis.

OBJECTIVES

We assayed expression of inflammatory cytokines [interleukin (IL)-1alpha, tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, human leucocyte antigen (HLA)-DR and intercellular adhesion molecule (ICAM)-1], differentiation markers (filaggrin, involucrin and loricrin) and phosphorylated EGFRs (pEGFRs) in papulopustular eruptions to determine the association between these markers and the eruptions caused by cetuximab.

PATIENTS/METHODS

Twelve papulopustular lesion biopsies were selected from patients with colon cancer who had received cetuximab treatment. Immunohistochemistry and immunofluorescence with a confocal laser scanning microscopy were performed.

RESULTS

Filaggrin expression decreased and expression of involucrin, various inflammatory markers (IL-1alpha, TNF-alpha, ICAM-1 and HLA-DR) increased and the expression of pEGFR was markedly downregulated in papulopustular eruptions. In perilesions, decreased pEGFR expression was noted in hair follicles compared with interfollicular epidermis. The increase of IL-1alpha and TNF-alpha was observed in perilesions as in the lesions.

CONCLUSIONS

The early inflammatory events (IL-1alpha and TNF-alpha expression) seen, and the lack of pEGFR in perilesional follicles, indicate that inflammatory events induced by EGFR inhibition may initiate papulopustular eruptions along with the altered differentiations. The decrease of filaggrin may contribute to the pathogenesis of the xerosis caused by cetuximab.

Metabolic syndrome and quality of life (QOL) using generalised and obesity-specific QOL scales

OBJECTIVES

We investigated the association between metabolic syndrome (MS) and health-related quality of life (HRQOL) assessed using generalised and obesity-specific QOL instruments.

METHODS

We recruited 456 outpatients [age: 19-81 years, body mass index (BMI): 16.3-36.7 kg/m2] in the primary care division from 12 general hospitals in Korea. HRQOL was measured using EuroQol comprising the health states descriptive system (EQ-5D) and visual analogue scale (EQ-VAS) as a general instrument. The Korean Obesity-related QOL scale (KOQOL) composed of six domains was used as a disease-specific QOL instrument. MS was defined on the basis of International Diabetes Federation (IDF) criteria with Korean-specific waist circumference cutoffs (men: 90 cm, women: 85 cm).

RESULTS

Subjects with MS displayed significantly higher impairment of EQ-5D and KOQOL. Binary logistic regression analysis of MS patients with controls for age, gender, smoking, alcohol, exercise, education, income, marital status and medication history disclosed odds ratio (OR) values of 2.13 (1.33-3.41) for impaired total KOQOL, 2.07 (1.31-3.27) for impaired physical health, 1.63 (1.03-2.60) for impaired work-related health, 2.42 (1.45-4.04) for impaired routine life, 2.08 (1.27-3.40) for impaired sexual life and 2.56 (1.59-4.11) for diet distress. Among the EQ-5D dimensions, only pain/discomfort displayed a significantly increased OR of 1.60 (1.01-2.56) in MS group.

CONCLUSIONS

Subjects with MS displayed a significantly impaired HRQOL compared with those without MS. MS and HRQOL were more strongly associated in obesity-specific QOL than in generalised QOL.

A double-blind, placebo-controlled, randomized, multicenter study to investigate CHInese Medicine Neuroaid Efficacy on Stroke recovery (CHIMES Study)

Rationale Traditional Chinese Medications(TCM) have been reported to have beneficial effects in stroke patients, but were not rigorously evaluated by GCP standards. Aim This study tests the hypothesis that Neuroaid, a TCM widely used in China post-stroke, is superior to placebo in reducing neurological deficit and improving functional outcome in patients with acute cerebral infarction of an intermediate severity. Design This is a multicenter, randomised, double-blind, placebo-controlled study of Neuroaid in ischemic stroke patients with National Institute of Health Stroke Scale(NIHSS) 6-14 treated within 48 h of stroke onset. Neuroaid or placebo is taken (4 capsules) 3 times daily for 3 months. Treatments are assigned using block randomization, stratified for centers, via a central web-randomization system. With a power of 90% and two-sided test of 5% type I error, a sample size is 874. Allowing for a drop-out rate of up to 20%, 1100 individuals should be enrolled in this study. Study Outcomes The primary efficacy endpoint is the modified Rankin Scale(mRS) grades at 3 months. Secondary efficacy endpoints are the NIHSS score at 3 months; difference of NIHSS scores between baseline and 10 days, and between baseline and 3 months; difference of NIHSS sub-scores between baseline and 10 days, and between baseline and 3 months; mRS at 10 days, 1 month, and 3 months; Barthel index at 3 months; Mini Mental State Examination at 10 days and 3 months. Safety outcomes include complete blood count, renal and liver panels, and electrocardiogram.

STUDY REGISTRATION

ClinicalTrials.gov identifier: NCT00554723.

Growth inhibition and induction of apoptosis in U937 cells by Coptis chinensis extract

Dried Coptidis Rizoma was extracted with boiling water. Conditioned medium was prepared by stimulating human peripheral blood mononuclear cells with Coptidis Rizoma extract (CR). The conditioned medium was then added to human leukemic U937 cells suspension for investigating the antiproliferation effect and the induction of apoptosis. Apparent DNA fragmentation and morphological changes occurred in U937 cells after incubating for 48 h to 72 h with the conditioned medium that had been prepared with 400 microg CR solids/mL. Flow cytometric analysis revealed that the percentage of apoptotic U937 cells increased in a time- and concentration-dependent manner. The upregulation of Bax expression, the downregulation of Bcl-2 and procaspase-3 expression, and the release of cytochrome c from the mitochondria in U937 cells were all observed. Reverse transcription-polymerase chain reaction detected cytokine-related mRNA expressions in human mononuclear cells incubated with CR. An increase in the concentration of CR in culturing medium downregulated granulocyte macrophage colony-stimulatory factor mRNA expression while upregulated interleuken-2 mRNA expression. All the above-mentioned evidences suggest that CR induces the apoptosis of human leukemic U937 cells via the changes in cytokine profile and protein expressions in mitochondria pathway and that CR has the potential to be used in the therapy of leukemia due to its strong apoptosis-promoting effect.

A randomised multicentre phase II trial of capecitabine vs S-1 as first-line treatment in elderly patients with metastatic or recurrent unresectable gastric cancer

This randomised multicentre phase II study was conducted to investigate the activity and safety of two oral fluoropyrimidines, capecitabine or S-1, in elderly patients with advanced gastric cancer (AGC). Elderly (⩾65 years) chemo-naive patients with AGC were randomly assigned to receive capecitabine 1250 mg m⁻² two times daily on days 1–14 every 3 weeks or S-1 40–60 mg two times daily according to body surface area on days 1–28 every 6 weeks. Ninety-six patients were enrolled and 91 patients were randomised to capecitabine (N=46) or S-1 (N=45). Overall response rate, the primary end point, was 27.2% (95% CI, 14.1–40.4, 12 of 44 assessable patients) with capecitabine and 28.9% (95% CI, 15.6–42.1, 13 of 45) with S-1. Median times to progression and overall survival in the capecitabine arm (4.7 and 9.5 months, respectively) were similar to those in the S-1 arm (4.2 and 8.2 months, respectively). The incidence of grade 3–4 granulocytopenia was 6.8% with capecitabine and 4.8% with S-1. Grade 3–4 nonhaematologic toxicities were: asthenia (9.1% with capecitabine vs 7.1% with S-1), anorexia (6.8 vs 9.5%), diarrhoea (2.3 vs 0%), and hand–foot syndrome (6.8 vs 0%). Both capecitabine and S-1 monotherapies were active and tolerable as first-line treatment for elderly patients with AGC.

Polymorphisms in VEGF and IL-8 predict tumor recurrence in stage III colon cancer

BACKGROUND

Identifying molecular markers for tumor recurrence is critical in successfully selecting patients with stage III colon cancer who are more likely to benefit from adjuvant chemotherapy. The present study analyzed a subset of 10 polymorphisms within eight genes involved in the tumor angiogenesis pathway and their impact on prognosis in stage III colon cancer patients treated with adjuvant chemotherapy.

PATIENTS AND METHODS

Blood samples were obtained from 125 patients with locally advanced colon cancer at University of Southern California medical facilities. DNA was extracted from peripheral blood and the genotypes were analyzed using PCR-restriction fragment length polymorphism and 5'-end [gamma-(33)P] ATP-labeled PCR protocols.

RESULTS

Polymorphisms in vascular endothelial growth factor (VEGF) (C+936T; P = 0.003, log-rank test) and interleukin-8 (IL-8) (T-251A; P = 0.04, log-rank test) were independently associated with risk of recurrence in stage III colon cancer patients. In combined analysis, grouping alleles into favorable versus nonfavorable alleles, high expression variants of VEGF C+936T and IL-8 T-251A were associated with a higher likelihood of developing tumor recurrence (P < 0.001).

CONCLUSION

High expression variants of VEGF C+936T and IL-8 T-251A were associated with shorter time to tumor recurrence, indicating that the analysis of angiogenesis-related gene polymorphisms may help to identify patient subgroups at high risk for tumor recurrence.

Electrical transport studies of individual IrO(2) nanorods and their nanorod contacts

We have studied the electrical transport properties of individual single-crystalline IrO(2) nanorods prepared by the metal-organic chemical vapour deposition method. With the help of the standard electron-beam lithographic technique, individual nanorods are contacted by Cr/Au submicron electrodes from above. Utilizing two-probe, three-probe and four-probe measurement configurations, not only the intrinsic electrical transport properties of the individual nanorods but also the electronic contact resistances, R(c)(T), have been determined from 300 K down to liquid-helium temperatures. Our measured resistivity behaviour of the nanorods is in close agreement with the current theoretical understanding of this rutile material. On the other hand, we found that the temperature behaviour of the electronic contact resistance obeys the law [Formula: see text] over an extremely wide temperature range, from approximately 100 K down to liquid-helium temperatures. This latter conduction process is ascribed to the hopping of electrons through nanoscale Cr granules and/or an amorphous coating incidentally formed at the interface between the submicron Cr/Au electrode and the nanorod.

Prognostic significance of p53 gene mutations and protein overexpression in localized gastrointestinal stromal tumours

AIMS

Mutation of c-kit is a relatively early event in the tumorigenesis of gastrointestinal stromal tumours (GISTs). The aim was to determine the prognostic significance of p53 alterations as an additional genetic change in GISTs.

METHODS AND RESULTS

We reviewed 125 patients with localized GISTs subjected to complete resection between 1990 and 2002. Mutational analyses of c-kit exons 9, 11, 13 and 17, p53 exons 4-8 and immunohistochemistry for p53 protein were conducted using paraffin-embedded tissues. Alterations of p53 were observed in 50 patients (40.0%). Based on the National Institutes of Health's risk category, p53 alterations were noted more frequently in the higher risk categories (P = 0.041). With a median follow-up of 56.5 months (range: 2.3-126.8), 5-year relapse-free survival (RFS) rates were 61.7% without p53 alterations, compared with only 40.2% with p53 alterations (P = 0.009). Multivariate analysis indicated that p53 alterations comprised an independent, poor prognostic factor for RFS, in addition to c-kit mutations, large size, a high mitotic count and non-gastric primary sites.

CONCLUSIONS

Alterations in p53 were more commonly observed in localized GISTs at higher risk of relapse. This suggests that they are significant as an independent, poor prognostic factor.

Cutaneous metastasis resembling acute dermatitis in patient with advanced gastric cancer

The most common metastatic sites from gastric cancer are the liver, intra-abdominal lymph nodes, ovary and peritoneal cavity. Cutaneous metastasis of gastric cancer is rare, and most cutaneous metastases are typically solitary, nodular, have a firm consistency, and are red or hyperpigmented. Thus, cutaneous metastasis is easily distinguished from other skin disease. We report a case of a 60-year-old woman with cutaneous metastasis of gastric cancer, whose facial skin showed painless pruritic eczema, resembling acute dermatitis. She had earlier undergone a total gastrectomy for advanced gastric cancer in our hospital. After 14 months, she developed eczematous facial lesions; the presumptive diagnosis was acute dermatitis. However, skin biopsy unexpectedly revealed cutaneous metastasis of gastric cancer. After 6 months of systemic chemotherapy with capecitabine and cisplatin, the cutaneous metastasis was markedly improved and a clinically complete remission was accomplished.

Adjuvant chemotherapy with 5-fluorouracil, doxorubicin and mitomycin-C (FAM) for 6 months after curative resection of gastric carcinoma

AIM

This study aimed to evaluate the efficacy and safety of 5-fluorouracil (5-FU), doxorubicin and mitomycin-C (FAM) adjuvant chemotherapy in patients who had undergone curative resection of gastric carcinoma.

METHODS

From Nov 1999 to Jan 2002, 291 consecutive patients with stage IB-IIIB gastric adenocarcinoma were given FAM adjuvant chemotherapy. Chemotherapy comprised intravenous 5-FU 600 mg/m(2) (days 1, 8, 29 and 36), doxorubicin 30 mg/m(2) (days 1 and 29) and mitomycin-C 10 mg/m(2) (day 1), every 8 weeks for 6 months.

RESULTS

The median follow-up time was 60.6 months, 92 patients died, and 93 patients had recurrent disease. The 5-year overall survival (OS) rates were 85.9% for stage IB, 72.1% for stage II, 58.0% for stage IIIA, and 48.2% for stage IIIB (p=0.002). The 5-year relapse-free survival (RFS) rates were 85.2% for stage IB, 71.2% for stage II, 53.3% for stage IIIA, and 39.2% for stage IIIB (p<0.001). A total of 769 cycles of chemotherapy were delivered, and 15 patients experienced grade 3 or higher leukopenia. The most common grade 3 or higher non-hematologic toxicity was nausea/vomiting (11 patients), followed by stomatitis (3 patients).

CONCLUSIONS

Adjuvant chemotherapy with FAM for 6 months for gastric carcinoma indicated comparable RFS and OS with an acceptable toxicity profile.

Guidewire assisted cephalic vein cutdown for insertion of totally implantable access ports

BACKGROUND

Totally implantable access ports (TIAP) placed by the cephalic vein cutdown technique have high failure rates.

METHODS

We describe a guidewire assisted technique of the cephalic vein cutdown for TIAP placement that can be easily introduced catheter when difficulties in insertion of the catheter. The key point of the presented technique is the use of J guidewire to go beyond the stenosis and advancement of catheter through the guidewire into the superior vena cava.

RESULTS

We used this technique for introducing the catheter in six patients without failure or complication.

CONCLUSION

The presented technique is easy and simple. It can be used where there are difficulties in insertion of the catheter by cephalic vein cutdown method.

Identification and characterization of novel low-density lipoprotein receptor mutations of familial hypercholesterolaemia patients in Taiwan

BACKGROUND

Familial hypercholesterolaemia (FH) is an autosomal dominant disease associated with a very high risk of coronary vascular disease. The study objective was to identify patients with FH in Taiwan and characterize novel mutations.

MATERIALS AND METHODS

Fifty-one patients with suspected FH living in Taiwan were screened for mutations in both the low-density lipoprotein (LDL) receptor and the apolipoprotein (apoB) genes using the multiplex polymerase chain reaction and exon-by-exon DNA sequencing technique. Functional consequences on LDL receptor activity were characterized in vitro for novel mutations and family pedigree was also analyzed.

RESULTS

Thirteen different functional mutations in the LDL receptor gene and one mutation in the apoB gene were found in 21 patients. Among the 13 mutations in the LDL receptor gene, 10 were single-point missense mutations, one was a two-point mutation in the same allele, one was a non-sense mutation and one was a frame-shift mutation. There were three novel mutations, including two missense mutations (M510K and W512R) and one frame-shift mutation (1953 delTA mutation). The characterization of missense M510K retained 36.2% of the activity of the normal receptor. Conversely, frame-shift 1953 delTA and missense W512R led to defective proteins, with only 0-6% of normal receptor activity.

CONCLUSIONS

The study identified 13 LDL receptor gene mutations and characterized three novel mutations causing FH in Taiwan. This facilitated a better understanding of FH among the Chinese population and may enable diagnosis of FH at the molecular level at a presymptomatic, early age.

Efficacy of PET/CT in the accurate evaluation of primary colorectal carcinoma

AIM

This study was performed to assess in the accurate evaluation of primary colorectal carcinoma using PET/CT.

METHODS

One hundred patients with primary colorectal carcinoma were evaluated during 2004. All patients underwent PET/CT when their preoperative serum carcinoembryonic antigen was >or=10 ng/mL or when CT showed equivocal findings. The appropriateness of PET/CT-induced changes was noted by subsequent operative findings and follow-up.

RESULTS

PET/CT more detected 15 intra-abdominal metastatic lesions than abdomino-pelvic CT scan. PET/CT showed true negative findings in 13 patients and false positive or negative findings in 10. Due to PET/CT results, management plans were altered in 27 patients; 9 had inter-modality changes, 10 received more extensive surgery, and 8 avoided unnecessary procedures.

CONCLUSIONS

PET/CT altered management plan in 24% of patients with primary colorectal carcinoma in correct direction. These findings suggest that PET/CT should be considered a part of standard work up for preoperative evaluation in a subset of patients with colorectal carcinoma.

An alternative technique for totally implantable central venous access devices. A retrospective study of 1311 cases

AIM

The aim of the present study was to report our experience of totally implantable central venous access devices (TICVAD) implantation using two techniques and attempt to define the better technique.

MATERIALS AND METHODS

From January 1998 to September 2003, 1131 patients were reviewed and divided into two groups with implantation by cephalic vein cut-down (group A) done by general surgeons and subclavian vein puncture with the Seldinger technique (group B) done by vascular surgeons. The operative time, early and late complications of these two groups were compared. Data were analysed by Student's t-test.

RESULTS

The average of operative time was 43 min in group A (35-70 min) and 40 min in group B (35-60 min) (P>0.05). No post-operative pneumothorax, hemothorax and fragmentation occurred in group A; the incidence of peri-operative complication was higher in group B. The overall and early complications of group A were significantly lower than that of group B (P<0.0001).

CONCLUSION

This retrospective study showed that the cephalic vein cut-down approach for TICVAD placement avoided the risks of pneumothorax, hemothorax and catheter fragmentation.

Phase II study of capecitabine and cisplatin as first-line combination therapy in patients with gastric cancer recurrent after fluoropyrimidine-based adjuvant chemotherapy

To evaluate the efficacy and safety of capecitabine and cisplatin in patients with recurrent gastric cancer after fluoropyrimidine-based adjuvant therapy. Patients with histologically confirmed and measurable advanced gastric cancer that had relapsed after fluoropyrimidine-based adjuvant chemotherapy received oral capecitabine (1250 mg m⁻² twice daily, days 1–14) and intravenous cisplatin (60 mg m⁻² over 1 h, day 1) every 3 weeks. In total, 32 patients were enrolled, of whom 30 were evaluable for efficacy and 32 for safety. A median of 5 cycles (range 1–10) was administered. One patient achieved a complete response and eight had partial responses, giving an overall response rate of 28% (95% CI, 13–44%). The median time to progression and median overall survival were 5.8 months (95% CI, 4.1–7.5 months) and 11.2 months (95% CI, 5.5–16.9 months), respectively. Grade 3 neutropenia and thrombocytopenia were observed in 38 and 6% of patients, respectively. Grade 2/3 nonhaematological toxicities included diarrhoea (19%), stomatitis (19%) and hand-foot syndrome (31%). No grade 4 toxicity, neutropenic fever or treatment-related deaths occurred. Capecitabine in combination with cisplatin was effective and well tolerated as first-line treatment in patients with recurrent gastric cancer after fluoropyrimidine-based adjuvant chemotherapy.

Imaging cells and tissues with refractive index radiology

Can individual cells, including live cells, be imaged using hard x rays? Common wisdom until now required sophisticated staining techniques for this task. We show instead that individual cells and cell details can be detected in culture solution and tissues with no staining and no other contrast-enhancing preparation. The sample examined can be much thicker than for many other microscopy techniques without sacrificing the capability to resolve cells. The key factor in our approach is the use of a coherent synchrotron source and of contrast mechanisms based on the refractive index. The first successful tests were conducted on a variety of cell systems including skin and internal leaf cells, mouse neurons, rabbit fibroblast cells, and human tumor cells.

The clinicopathological significance of inferior mesenteric lymph node metastasis in colorectal cancer

AIMS

There are few studies reporting survival or recurrence patterns in colorectal cancer patients with inferior mesenteric lymph node metastasis (IMLN+). The present study evaluated the prognostic significance of patients being IMLN+ or IMLN- in colorectal cancer.

METHODS

Survival, recurrence pattern and treatment protocols were compared between 63 IMLN+ patients and 108 IMLN- patients with stage III and IV rectal and sigmoid cancer undergoing curative surgery. Lymph node sampling was routinely performed prior to inferior mesenteric artery ligation and excision flush with aorta. Limited principal node dissection including IMLN was performed in cases of identified node metastasis.

RESULTS

The 5-year disease-free survival rates were 50% in IMLN- and 31% in IMLN+ patients (P=0.004). The 5-year disease-free survival rate was greater in the N1 group than the N2 group (P=0.038). Cox regression analysis showed IMLN+, lymphovascular tumour invasion, T4, M1, and pre-operative serum CEA level over 6 ng/ml were independently associated with unfavorable disease-free survival. The prognostic significance of M category was greater when the IMLN+ was included in the M1 as opposed to the N category. In patients undergoing absolute curative surgery, post-operative recurrence rates were 34% for IMLN- and 57% for IMLN+ patients (P=0.009; OR, 2.611; 95% CI, 1.313-5.194). For IMLN+ patients, post-operative adjuvant treatment independently correlated with disease-free survival (P=0.029).

CONCLUSIONS

IMLN+ is an independent survival factor enhancing the prognostic significance of the M category in the AJCC staging. Curative radical surgery and post-operative chemoradiotherapy appears to be warranted for IMLN+ colorectal cancer patients as it resulted in 5-year disease-free survival rates of up to 31% compared to 50% in IMLN- patients.

Phase II study of capecitabine plus cisplatin as first-line chemotherapy in advanced biliary cancer

BACKGROUND

A phase II study was conducted to assess the efficacy and tolerability of substituting capecitabine for 5-fluorouracil in combination with cisplatin in patients with advanced biliary cancer.

PATIENTS AND METHODS

Patients with previously untreated metastatic or unresectable measurable biliary adenocarcinoma received oral capecitabine 1250 mg/m(2) twice daily on days 1-14, and intravenous cisplatin 60 mg/m(2) on day 1. This cycle was repeated every 21 days.

RESULTS

Forty-two patients were enrolled in this study. Of these, 38 were assessable for efficacy and 41 were assessable for safety. A median of three cycles of treatment (range one to eight) were administered. One patient achieved a complete response, and eight had partial responses, giving an overall response rate of 21.4% in the intention-to-treat population (95% confidence interval 9.1% to 33.9%). The median response duration was 5.1 months. The median time to progression and median overall survival were 3.7 and 9.1 months, respectively. The most common grade 3/4 adverse events were neutropenia (20% of patients), vomiting (12%), diarrhea (7%) and stomatitis (5%). There were no treatment-related deaths.

CONCLUSIONS

The combination of capecitabine and cisplatin has promising antitumor activity and is well tolerated in patients with advanced biliary cancer.

Phase II study of capecitabine plus cisplatin as first-line chemotherapy in advanced gastric cancer

BACKGROUND

A phase II study was conducted to assess the efficacy and tolerability of combination therapy with capecitabine and cisplatin in patients with advanced gastric cancer.

PATIENTS AND METHODS

Patients with previously untreated metastatic or unresectable measurable gastric adenocarcinoma received oral capecitabine 1250 mg/m(2) twice daily, days 1-14, and i.v. cisplatin 60 mg/m(2) on day 1. This cycle was repeated every 3 weeks.

RESULTS

Forty-two patients were enrolled in this study. Of these, 38 patients were assessable for efficacy and 40 were assessable for toxicity. One patient achieved a complete response and 22 patients had partial responses, giving an overall response rate of 54.8% in the intention-to-treat population (95% confidence interval 39.8% to 69.8%). The median time to progression was 6.3 months and the median overall survival was 10.1 months. The principal adverse events were neutropenia and hand-foot syndrome. Grade 3/4 adverse events were neutropenia (32.5% of patients), thrombocytopenia (10%), stomatitis (2.5%) and diarrhea (5%). Grade 2 and 3 hand-foot syndrome occurred in 20% and 7.5% of patients, respectively. There were no treatment-related deaths.

CONCLUSIONS

The combination of capecitabine and cisplatin is active and well tolerated in patients with advanced gastric cancer.

Update in the management of stroke

Recent advances have improved the outlook for patients with stroke, Singapore's fourth leading cause of death. Stroke unit care reduces death, dependency and institutionalisation, independent of age, gender and stroke severity. Neuroimaging is essential prior to initiation of specific therapies. While computed tomography (CT) Head remains the most widely used modality, magnetic resonance imaging (MRI), particularly diffusion weighted imaging (DWI) has enhanced the positive diagnosis of ischaemic stroke. General medical measures include close monitoring, adequate oxygenation, avoidance of excessive blood pressure lowering, reduction of hyperthermia, control of hyperglycaemia, adequate nutrition, prevention of complications and early rehabilitation. Despite the risk of fatal intracranial haemorrhage, thrombolysis may improve outcomes in appropriately selected patients with ischaemic stroke. No safe and effective neuroprotectant has been found. While suboccipital craniectomy is established for large cerebellar infarcts and haemorrhage, surgical evacuation of supratentorial haemorrhage has not been shown to be beneficial. Hemicraniectomy reduces mortality after massive hemispheric ischemic stroke. Early and sustained antiplatelet use after atherothrombotic stroke reduces stroke recurrence. Stroke recurrence is also reduced by sustained warfarin use for cardioembolic stroke, carotid endarterectomy for severe symptomatic internal carotid artery stenosis, blood pressure lowering starting after the acute phase of stroke and lipid lowering. On-going clinical trails are likely to provide better treatments in the near future.

A phase III randomized trial of 5-fluorouracil, doxorubicin, and mitomycin C versus 5-fluorouracil and mitomycin C versus 5-fluorouracil alone in curatively resected gastric cancer

BACKGROUND

A phase III single-center randomized trial was performed in order to determine whether the addition of mitomycin C (MMC) and/or doxorubicin to 5-fluorouracil (5-FU) as adjuvant chemotherapy could influence survival in patients with curatively resected gastric cancer.

PATIENTS AND METHODS

A total of 416 patients who had undergone curative resection for stage IB-IIIB gastric adenocarcinoma were stratified according to the stage and type of surgery, and then randomized to receive one of the three chemotherapy regimens, 5-FU alone (F) or 5-FU and MMC (FM) or 5-FU, doxorubicin and MMC (FAM) within 5 weeks after surgery.

RESULTS

Of 416 patients registered, 395 (133 in F, 131 in FM and 131 in FAM) were assessable. Median follow-up duration was 91 months. Five-year overall survival rates were 67.2% for F, 67.0% for FM and 66.7% for FAM (P = 0.97). Five-year disease-free survival rates were 62.1% for F, 63.3% for FM and 62.5% for FAM (P = 0.83). Hematological toxicities were more frequent in the FM and FAM groups, whereas stomatitis was more common in the F group.

CONCLUSIONS

Compared with adjuvant 5-FU alone, the addition of MMC and/or doxorubicin to 5-FU did not influence survival in patients with resected gastric cancer.

Diffusion weighted MR imaging in acute stroke: the SGH experience

Cerebrovascular accident (CVA) is a leading cause of death and disability in many countries. Diffusion-weighted (DW) magnetic resonance (MR) imaging has been reported to be useful in the detection of acute strokes and as an investigative tool evaluating the therapeutic effects of neuroprotective and thrombolytic agents. The objectives of this study are to share our experience using the commercially available isotropic DW scan in imaging of acute stroke, assess its usefulness over conventional T2-weighted (T2W) scans in a busy clinical radiology unit and highlight it pitfalls. We found the rapid sub-minute DW technique well suited for ill and restless stroke patients and superior to T2W scans in many ways. It was highly sensitive to acute ischaemic lesions, made lesions easily identifiable and readily differentiated the acute lesion from a background of multiple chronic infarcts. However, there are potential pitfalls in the evaluation of small hyperacute posterior fossa strokes and venous infarcts. The major strength of this MR technique lies in its ability to diagnose hyperacute strokes and thence the potential for therapeutic thrombolysis, but unfortunately patients qualifying for the "therapeutic window" were a minority. More efforts need to be focused on public education in order for this powerful imaging modality to find its true value and contribute to viability of an effective thrombolytic programme.

Salvinorin C, a new neoclerodane diterpene from a bioactive fraction of the hallucinogenic Mexican mint Salvia divinorum

Salvinorin C (1), a minor component from a biologically active TLC fraction, was isolated from the leaves of the Mexican mint Salvia divinorum. Its structure was elucidated on the basis of extensive proton and C-13 NMR experiments, as well as by comparison of the NMR data with those of the mono- and diacetate derivatives 5-7 of the major NaBH(4)-reduction product of salvinorin A (2). [structure: see text]

Determination of random- and blockwise-type de-esterified pectins by capillary zone electrophoresis

Capillary zone electrophoresis (CZE) was employed to determine the correlations between migration time and degree of esterification (DE) of pectinesterase-de-esterified pectins (PDPs) and alkaline-de-esterified pectins (ADPs) using 50 mM phosphate buffer (pH 6.5) as carrier electrolyte solution and 15 KV as applied voltage. Results showed that pectins with higher DEs exhibited shorter migration times. Linear correlation (r = 0.995) between migration time and DE of ADPs was observed, whereas down-curve correlation in PDPs was observed, regardless of the capillary length used (effective length, 30 and 60 cm). In addition, PDP appeared to migrate faster than ADP with the same DE under the same experimental conditions.

Combination Chemotherapy of Oxaliplatin, 5-Fluorouracil, and Leucovorin in 5-Fluorouracil-Pretreated Patients with Metastatic Colorectal Cancer

PURPOSE

To evaluate the efficacy and toxicity of oxaliplatin in combination with 5-fluorouracil (5-FU) and leucovorin (LV) in patients with metastatic colorectal cancer who previously treated with 5-FU-based chemotherapy.

MATERIALS AND METHODS

Between April 1999 and January 2001, thirty-two patients were enrolled in this study. Oxaliplatin 130 mg/m2 was given intravenously (IV) on day 1 as was 5-FU 500 mg/m2 IV followed by continuous infusion of 5-FU 3,000 mg/m2 and LV 100 mg/m2 for 48 hours administered every 3 weeks. Six patients had received 5-FU as an adjuvant setting and 26 patients as a palliative regimen.

RESULTS

The median age of the patients was 50 years (range; 19-69) and the dominant sites of metastasis were the liver, lung or both in 9, 5 and 2 patients respectively. In 30 evaluable patients, the overall response rate was 27% including 1 complete response and 7 partial responses. The median response duration was 28 weeks (95% confidence interval; 22~34 weeks) and the median progression free survival of all patients was 24 weeks (95% confidence interval; 15~33 weeks). A median 5 cycles (range; 2~9) and total 155 cycles were performed in 32 patients. 150 cycles were evaluable for toxicity. The most common hematologic toxicity was grade 1~2 anemia in 78 cycles (52%). Leukopenia (39%) and thrombocytopenia (23%) were fully reversible. The most common non-hematologic toxicity was nausea/vomiting (43/30%) followed by diarrhea (23%), hepatotoxicity (21%) and neurotoxicity (21%). One patient ceased therapy due to grade 4 diarrhea. No other severe toxicity interrupted this treatment.

CONCLUSION

Oxaliplatin, 5-FU and LV in combination showed significant activity in previously treated metastatic colorectal cancer with favorable toxicity.

Change in particle size of pectin reacted with pectinesterase isozymes from pea (Pisum sativum L.) sprout

Four pectinesterase (PE) isozymes were isolated by CM-Sepharose CL-6B chromatography from etiolated pea (Pisum sativum L.) sprouts and then reacted with citrus pectin (degree of esterification = 68%, 30-100 kDa) to observe the change in pectin particle size using a laser particle size analyzer. After incubation of a pectin-PE mixture (pH 6.5) at 30 degrees C for 4 h, PE 1 was observed to catalyze the transacylation reaction most remarkably, increasing the particle size from approximately 50-70 to approximately 250-350 nm, followed by PE 3, PE 2, and PE 4.

Axotomy along with hypoxia enhances the neuronal NADPH-d/NOS expression in lower brain stem motor neurons of adult rats

This study was aimed to determine whether axotomy coupled with hypoxia would exert a more profound effect on injury-induced neuronal nitric oxide synthase (NOS) expression. In this connection, the vagus and the hypoglossal nerves of adult rats were transected unilaterally in the same animal, and half of the operated animals were subjected to hypoxia treatment. Both the neuronal NOS immunohistochemistry and the nicotinamide adenine dinucleotide phosphate-diaphorase (NADPH-d) histochemistry were used to assess the neuronal NOS expression. The present results have shown that the number of NADPH-d/NOS-positive [NADPH-d/NOS(1)] neurons in the hypoglossal nucleus (HN) peaked at 14 days after axotomy, while that in dorsal motor nucleus of vagus (DMN) and nucleus ambiguus (NA) was progressively increased up to 60 days. The up-regulation of NADPH-d/NOS in HN and DMN was more pronounced in hypoxic than in normoxic animals, a feature that was not evident in the NA. Quantitative analysis showed that the number of surviving motoneurons in normoxic animals was significantly higher than those subjected to hypoxia at 14 days postaxotomy in HN and at all postaxotomy time points in DMN. The difference may be attributed to their different functional components. Since O2 deprivation leads to poor cellular function, the stronger expression of NADPH-d/NOS and the more drastic neuronal loss following nerve transection in the hypoxic animals compared with the controls suggest that hypoxia plays an important role in peripheral neuropathies in which NO is implicated.

Molecular scanning of the human sorbin and SH3-domain-containing-1 (SORBS1) gene: positive association of the T228A polymorphism with obesity and type 2 diabetes

In the mouse, the SH3P12 or the c-Cbl-associated protein (CAP) has been shown as an important signaling molecule in insulin-stimulated glucose uptake. The human homolog for the sorbin and SH3-domain-containing-1 gene, termed SORBS1, might play a role in human disorders with insulin resistance. To explore the genetic role of SORBS1 in human obesity and type 2 diabetes, we investigated the nucleotide polymorphisms in the SORBS1 gene with molecular scanning. After scanning for a total of 13,136 bp in each of 40 chromosomes, we have identified 14 single nucleotide polymorphisms (SNPs) in the human SORBS1 gene. Among them, two SNPs affected amino acid coding (R74W and T228A), four occurred within exons but did not affect amino acid coding, and the remaining eight occurred within introns, which were located outside of the consensus region of the splicing mechanism. Further studies in 202 non-obese, 113 obese and 455 subjects with type 2 diabetes revealed that the A-allele of the T228A polymorphism in exon 7 exerted a protective role for both obesity [relative risk 0.466; 95% confidence interval (95% CI) 0.265-0.821] and diabetes (relative risk 0.668; 95% CI 0.472-0.945). Neither allele of the R74W polymorphism was associated with either obesity or diabetes. In conclusion, our results suggest that the A228 allele of the T228A polymorphism of the SORBS1 gene is a protective factor for both obesity and diabetes, and also imply that the SORBS1 gene plays an important role in the pathogenesis of human disorders with insulin resistance.

Allogeneic bone marrow transplantation for chronic myeloid leukemia: a retrospective study of busulfan-cytoxan versus total body irradiation-cytoxan as preparative regimen in Koreans

From January 1990 to December 1997, 53 Korean patients with chronic myeloid leukemia (CML) receiving bone marrow transplantation (BMT) from human leucocyte antigen (HLA)-identical sibling donors conditioned with either busulfan and cyclophosphamide (BU/CY regimen) or total body irradiation and cyclophosphamide (TBI/CY regimen) were compared retrospectively. Transplantation-related mortality was 19% in BU/CY and 12% in TBI/CY, and early death (<100 d) occurred in 3 patients conditioned with BU/CY. Grade II-IV acute graft-versus-host disease (GVHD) was 9% of BU/CY and 52% of TBI/CY patients. Overall incidence of chronic GVHD was 50% of BU/CY and 52% of TBI/CY patients. In patients with chronic phase, 5-yr overall survival was 73% in the BU/CY group compared with 87% in the TBI/CY group (p=NS), and overall disease-free survival was 75% in the BU/CY group and 59% in the TBI/CY group (p=NS). So far, with a median follow-up of 45 months, 11 patients have relapsed; three relapses occurred after BU/CY and 8 after TBI/CY. The actuarial 5-yr relapse rate was 15% after BU/CY, 34% after TBI/CY (p=0.46). For patients transplanted in chronic phase within 1 yr after diagnosis, there was a clear trend for a lower relapse rate in the BU/CY group (5-yr relapse rate 0%) compared with the TBI/CY group (5-yr relapse rate 30%). The BU/CY group had similar BMT-related toxicity and similar overall survival and showed a clear trend of low relapse compared with the TBI/CY group. Therefore, BU/CY is an acceptable alternative for patients with CML during HLA-identical sibling allogeneic BMT.

Cloning, Mapping, and Characterization of the Human Sorbin and SH3 Domain Containing 1 (SORBS1) Gene: A Protein Associated with c-Abl during Insulin Signaling in the Hepatoma Cell Line Hep3B

SH3P12/CAP/ponsin, a gene product with a sorbin homology domain and three consecutive SH3 domains in the carboxy-terminus, has been isolated from murine adipocytes and identified as an important adaptor during insulin signaling. Here we describe the cloning, mapping, and expression of the human homologue, termed SORBS1 (sorbin and SH3 domain containing 1). Multiple transcripts of this gene with different mRNA isoforms were observed among different tissues. Here we report 13 alternatively spliced exons, which were ascertained from the full-length cDNA cloned in adipose, liver, and skeletal muscle tissues. Among the major isoforms, the shortest, 2223-bp, open reading frame (ORF) encodes a protein with a predicted molecular weight of 81.5 kDa, while the longest, 3879-bp, ORF encodes a protein of about 142.2 kDa. This gene was mapped to human chromosome 10q23.3-q24.1, which is a candidate region for insulin resistance found in Pima Indians. In human hepatoma Hep3B cells, SORBS1 was partly dissociated from the insulin receptor complex and bound to c-Abl protein upon insulin stimulation. This interaction with c-Abl was through the third SH3 domain and a possible conformational change of SORBS1 induced by insulin. Our data suggest that c-Abl oncoprotein via SORBS1 might play a role in the insulin signaling pathway.

Quantification of L-ascorbic acid and total ascorbic acid in fruits and spinach by capillary zone electrophoresis

A standard curve for the quantification of L-ascorbic acid (L-AA) by capillary zone electrophoresis (CZE) was established, and the quantification of ascorbic acid and total ascorbic acid in fruits (lemon, Sunkist, and pineapple) and spinach were performed using D-isoascorbic acid (D-IAA) as an internal standard. The minimum detection limits (MDLs) for L-AA and D-IAA were determined to be 1 and 2 microg/mL, respectively, at 265 nm. Dehydroascorbic acid (DHAA) in fruits and spinach was quantified in the presence of DL-homocysteine. The recoveries for L-AA in these juices were between 95 and 105%.