Cell-Free DNA Fragmentomics for Early Detection of Malignant Transformation in NF1 Patients Harboring Plexiform Neurofibromas

PURPOSE/OBJECTIVE(S)

Malignant peripheral nerve sheath tumors (MPNST) are aggressive soft tissue sarcomas that are resistant to radiotherapy and chemotherapy, and are associated with poor survival. MPNST typically arise from benign or atypical plexiform neurofibromas (PN) in the setting of neurofibromatosis type 1 (NF1). Unfortunately, early detection by imaging and clinical examination remains very challenging. We hypothesize that cell-free DNA fragmentomic analysis can be used to precisely detect the risk for developing MPNST in NF1 patients, which could significantly improve clinical outcomes in the future through early cancer detection.

MATERIALS/METHODS

We performed low-pass whole genome sequencing of plasma cell-free DNA samples from healthy controls (n = 21), patients with PN (n = 113), AN (n = 39) and MPNST (n = 71). Cell-free DNA was analyzed at a per-fragment level by tracking 4-nucleotide end motifs, and using a bin-wise fragmentomic machine learning approach called DELFI, which integrates across ratios of short (100-150 bp) versus long (151-220 bp) fragments in 5 megabase bins across the genome. End motif frequencies were compared between MPNST and PN patients, and receiver operating characteristic (ROC) analysis was used to classify disease states using DELFI fragmentomic scores.

RESULTS

Using DELFI for genome-wide fragmentomics, followed by ROC analysis, we obtained the following accuracies: MPNST vs. AN (acc 0.62), MPNST vs. PN (acc 0.83), MPNST vs. healthy (acc 0.86), AN vs. PN (acc 0.87), AN vs. healthy (acc 0.72) and PN vs. healthy (acc 0.88). DELFI-based cell-free DNA fragmentomics was superior to the ichor CNA-based copy number alteration classifier that we published previously (Szymanski et al. PLOS Medicine, 2021) for all the aforementioned group comparisons (p < 0.001 by McNemar's test). Strikingly, the two AN cases with DELFI scores most closely resembling MPNST were separately identified by independent clinical care teams to have very high-risk features and recent history warranting short-interval follow up. Specifically, one patient had a paraspinal AN exhibiting new onset pain and rapid growth on imaging, while the other had increased FDG uptake of multiple AN lesions in a supraclavicular field treated years earlier with radiotherapy. We also measured fragment end motifs across different patient groups, and found that the CTCA end motif was more commonly present in cell-free DNA from MPNST and PN patients compared to healthy donors (Bonferroni-corrected p-value < 0.001).

CONCLUSION

This study suggests that fragmentomic analysis of cell-free DNA can accurately risk-stratify NF1 patients with plexiform neurofibromas. Cell-free DNA fragmentomics outperformed our previously published copy number alteration method for distinguishing closely related patient subgroups with different malignancy risks. Atypical neurofibroma patients with cell-free DNA fragmentomic scores suggestive of MPNST were deemed clinically very high-risk for malignant transformation.

Intrinsic tumor resistance to CAR T cells is a dynamic transcriptional state that is exploitable with low-dose radiation

Chimeric antigen receptor (CAR) T-cell therapy represents a major advancement for hematologic malignancies, with some patients achieving long-term remission. However, the majority of treated patients still die of their disease. A consistent predictor of response is tumor quantity, wherein a higher disease burden before CAR T-cell therapy portends a worse prognosis. Focal radiation to bulky sites of the disease can decrease tumor quantity before CAR T-cell therapy, but whether this strategy improves survival is unknown. We find that substantially reducing systemic tumor quantity using high-dose radiation to areas of bulky disease, which is commonly done clinically, is less impactful on overall survival in mice achieved by CAR T cells than targeting all sites of disease with low-dose total tumor irradiation (TTI) before CAR T-cell therapy. This finding highlights another predictor of response, tumor quality, the intrinsic resistance of an individual patient's tumor cells to CAR T-cell killing. Little is known about whether or how an individual tumor's intrinsic resistance may change under different circumstances. We find a transcriptional "death receptor score" that reflects a tumor's intrinsic sensitivity to CAR T cells can be temporarily increased by low-dose TTI, and the timing of this transcriptional change correlates with improved in vivo leukemia control by an otherwise limited number of CAR T cells. This suggests an actionable method for potentially improving outcomes in patients predicted to respond poorly to this promising therapy and highlights that intrinsic tumor attributes may be equally or more important predictors of CAR T-cell response as tumor burden.

Sustained alternate-day fasting potentiates doxorubicin cardiotoxicity

Fasting strategies are under active clinical investigation in patients receiving chemotherapy. Prior murine studies suggest that alternate-day fasting may attenuate doxorubicin cardiotoxicity and stimulate nuclear translocation of transcription factor EB (TFEB), a master regulator of autophagy and lysosomal biogenesis. In this study, human heart tissue from patients with doxorubicin-induced heart failure demonstrated increased nuclear TFEB protein. In mice treated with doxorubicin, alternate-day fasting or viral TFEB transduction increased mortality and impaired cardiac function. Mice randomized to alternate-day fasting plus doxorubicin exhibited increased TFEB nuclear translocation in the myocardium. When combined with doxorubicin, cardiomyocyte-specific TFEB overexpression provoked cardiac remodeling, while systemic TFEB overexpression increased growth differentiation factor 15 (GDF15) and caused heart failure and death. Cardiomyocyte TFEB knockout attenuated doxorubicin cardiotoxicity, while recombinant GDF15 was sufficient to cause cardiac atrophy. Our studies identify that both sustained alternate-day fasting and a TFEB/GDF15 pathway exacerbate doxorubicin cardiotoxicity.

LITE SABR M1: A phase I trial of Lattice stereotactic body radiotherapy for large tumors

PURPOSE

Stereotactic body radiotherapy (SBRT) is an attractive treatment option for patients with metastatic and/or unresectable tumors, however its use is limited to smaller tumors. Lattice is a form of spatially fractionated radiotherapy that may allow safe delivery of ablative doses to bulky tumors. We previously described Lattice SBRT, which delivers 20 Gy in 5 fractions with a simultaneous integrated boost to 66.7 Gy in a defined geometric arrangement (Lattice boost). The goal of this study was to prospectively evaluate the acute toxicity and quality of life (QoL) of patients with large tumors (>5 cm) treated with Lattice SBRT.

METHODS

This was a single-arm phase I trial conducted between October 2019 and August 2020. Patients with tumors > 4.5 cm were eligible. Lattice SBRT was delivered every other day. The primary outcome was the rate of 90-day treatment-associated (probably or definitely attributable) grade 3 + acute toxicity by Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 criteria. Other outcomes included changes in patient reported toxicity and QoL inventories, GTV, and peripheral blood cytokines.

RESULTS

Twenty patients (22 tumors) were enrolled. Median GTV was 579.2 cc (range: 54.2-3713.5 cc) in volume and 11.1 cm (range: 5.6-21.4 cm) in greatest axial diameter. Fifty percent of tumors were in the thorax, 45% abdomen/pelvis, and 5% extremity. There was no likely treatment-associated grade 3 + toxicity in the 90-day period (acute and sub-acute). There was one case of grade 4 toxicity possibly associated with Lattice SBRT.

CONCLUSIONS

This phase I study met its primary endpoint of physician reported short-term safety. An ongoing phase II clinical trial of Lattice SBRT will evaluate late safety and efficacy of this novel technique.

Current applications and outcomes of venoarterial extracorporeal membrane oxygenation based on six years of experience. Risk factors for in-hospital mortality

Introduction

The data about use of venoarterial ECMO as a temporary circulatory support system in cardiogenic shock (CS) for Central Europe are scarce.

Objectives

The aim was to disclose the indications, in-hospital and long-term (1 year) mortality along with risk factors.

Patients and methods

The study is a retrospective investigation of patients who underwent VA ECMO support for the CS in the cardiac and cardiosurgical tertiary centre, from January 2013 to June 2018. We tested a broad spectrum of pre– and post-implantation factors along with their impact on mortality using univariate logistic regression analysis.

Results

198 patients met the inclusion criteria. The median duration of support was 207 (IQR 91–339) hours, with no significant disparity in the length of support among hospital survivors and nonsurvivors (p=0.09). 40,4% of all patients deceased during ECMO support, while the joined in-hospital and six-month mortality progressed to 65,2% and one-year mortality to 67,2%. 9% underwent subsequent heart transplantation. The most frequent adverse events were bleeding (76%), infection (56%), neurologic injury (15%) and limb ischemia (15%). Multi-organ failure was identified as the most decisive risk factor of in-hospital mortality (OR 4,45, p&lt;0,001). Patients with postcardiotomy cardiogenic shock had a significantly lower out-of-hospital survival rate than those with decompensated heart failure (32,3% vs 45%, log-rank p=0,037). The learning curve of our centre is noted with the lowest survival in the first two years of ECMO employment in comparison to the following 6-year period.

Conclusion

The outcomes of the study reinforce the clear survival benefit, despite frequent complications.

The protocol focusing on proper candidate selection and timing can positively impact patients survival. The additional risk reduction can be achieved with the further increase of the team experience with ECMO.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Cardiology in Warsaw, Poland - research grant. Figure 1Figure 2

Improvement of exercise tests and reduction of heart failure biomarkers in short term follow up after comprehensive rehabilitation program of patients with implanted LVAD

Background

There is increasing recognition of the importance of rehabilitating patients after LVAD implantation. The novel method of comprehensive rehabilitation starting directly after LVAD implantation was designed for our LVAD patients population.

Aim of the study

The study aimed to determine, if novel rehabilitation program improves functional and biochemical parameters in patients after recent LVAD implantation.

Study group

37 recent LVAD (22 Heart Mate III, 15 HeartWare) recipients (19–67, mean 58.7 years, 35 men) participated in specially designed rehabilitation program. The program included 4–5 weeks of sationary rehabilitation: supervised endurance training on cycloergometer (5 times per week), resistance training, general fitness exercises with elements of equivalent and coordination exercises (every day). It was followed by individual exercises performed at home. At the beginning and at the end of rehabilitation program the patients performed 6 minute walking test (6MWT), cardiopulmonary exercise test (CPET). Following prognostic biomarkers of heart failure: NT-proBNP, galectin-3 and ST2 were also measured.

Results

See table 1. Increase of 6MWT distance, higher maximal workload, peak VO2 and upward shift of anaerobic threshold in CPET were observed in all patients. Significant reductions of NTproBNP, ST2 and galectin-3 levels were observed. There were no major adverse events during rehabilitation.

Conclusions

Comprehensive novel rehabilitation in LVAD recipients is safe and results in significant improvement of functional tests and biomarkers of heart failure.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development: National grant - STRATEGMED II,

The growing role of designated communicators in the monitoring of patients with left ventricular assist device in the era of the COVID pandemic

Background

Left ventricular assist devices (LVAD) are increasingly implanted in patients with end-stage heart failure. Patients require special care in terms of the safety and effectiveness of therapy, but during pandemic lockdown it is much more difficult to achieve. For many years at our institution, apart from routine personal visits, we have been using the REMEDIZER® internet communicator for remote care in LVAD group of patients.

Objective

- evaluation of the safety and effectiveness of remote monitoring in the care of patients with LVAD during the COVID pandemic

– evaluation of the safety of remote monitoring with a designated communicator instead of personal visits

Methods

During the lockdown period (01/03/2020 - 31/12/2020), 72 patients (3 female) pts mean age 54.7±12,1 years with LVAD were monitored. For epidemiological reasons, the number of personal visits has been reduced in favor of telephone consultations and an increased volume of data entered into the REMEDIZER® internet communicator. The data collected in this period were compared with the data collected on 1 March 2019 - 31 December 2019, when: 53 pts (1 female) mean age 56,2±11,78 years were routinely, personally controlled at the Center for at least every 3 months and had blood, echo and LVAD examinations. Patients entered pump parameters: flow, motor speed, power consumption, pulse and blood pressure, body weight and temperature, at least twice a day (morning and evening) INR and dose of warfarin used were also reported.

The number of complications during LVAD support was assessed: death or heart transplantation major complications: stroke, hemorrhage, pump thrombosis also other like arrhythmias requiring ICD intervention, hospitalization.

Results

Mean time of monitoring from hospital discharge after LVAD implantation to the end of observation in 2020 cohort was 651±486 days compared to 586±508, days in 2019 cohort

In 2019, personal visits were performed significantly more often, 94 v. 17 (p&lt;0.05), while remote visits (by phone or internet) were significantly more frequent in 2020 (2033 v. 1390). In 2019 patients were hospitalized significantly more often (28 vs. 10), but if we considered urgent hospitalizations, the differences were not statistically significant (9 vs. 8).

In 2020, 5 patients (6,94%) died compared with 4 (7,55%) in 2019 (NS). In 2020, 9 patients (12,5%) were transplanted v. 3 (5,66%) in 2019. We observed 22 episodes of major complications in the 2020 cohort vs 20 in 2019 (NS); 11 ICD interventions vs 13 in 2019 (NS).

Conclusions

Replacing routine personal visits with increased patient self-control and constant remote contact with the center allowed a safe organization of patient care during COVID-19 pandemic

The use of REMEDIZER® internet communicator dedicated for LVAD patients for remote care control proved to be effective and safe to control LVAD patients.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study is funded by the National Center for Research and Development, Poland

Leveraging Radiobiology for Arrhythmia Management: A New Treatment Paradigm?

Radiation therapy is a well-established approach for safely and non-invasively treating solid tumours and benign diseases with high precision and accuracy. Cardiac radiation therapy has recently emerged as a non-invasive treatment option for the management of refractory ventricular tachycardia. Here we summarise existing clinical and preclinical literature surrounding cardiac radiobiology and discuss how these studies may inform basic and translational research, as well as clinical treatment paradigms in the management of arrhythmias.

Knowledge and competency standards for specialized cognitive behavior therapy for adult obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a leading cause of disability world-wide (World Health Organization, 2008). Treatment of OCD is a specialized field whose aim is recovery from illness for as many patients as possible. The evidence-based psychotherapeutic treatment for OCD is specialized cognitive behavior therapy (CBT, NICE, 2005, Koran and Simpson, 2013). However, these treatments are not accessible to many sufferers around the world. Currently available guidelines for care are deemed to be essential but insufficient because of highly variable clinician knowledge and competencies specific to OCD. The phase two mandate of the 14 nation International OCD Accreditation Task Force (ATF) created by the Canadian Institute for Obsessive Compulsive Disorders is development of knowledge and competency standards for specialized treatments for OCD through the lifespan deemed by experts to be foundational to transformative change in this field. This paper presents knowledge and competency standards for specialized CBT for adult OCD developed to inform, advance, and offer a model for clinical practice and training for OCD. During upcoming ATF phases three and four criteria and processes for training in specialized treatments for OCD through the lifespan for certification (individuals) and accreditation (sites) will be developed based on the ATF standards.

Novel rehabilitation program after left ventricular assist device (LVAD) implantation improves functional tests and reduces levels of prognostic heart failure biomarkers

Background

Rehabilitation after LVAD implantation is increasingly used. We developed the novel method of comprehensive rehabilitation starting directly after LVAD implantation.

Study group

21 recent LVAD (15 Heart Mate III, 6 HeartWare) recipients (56.2±11.7 yrs, 100% men) were included to 5-week rehabilitation program, which included supervised endurance training on cycloergometer (5 times per week), resistance training, general fitness exercises with elements of equivalent and coordination exercises (every day). 6-minute walking test (6MWT), cardiopulmonary exercise test (CPET) and prognostic biomarkers: NT-proBNP, Galectin-3 and ST2 were investigated at the beginning and at the end of rehabilitation program.

Results

See Table 1.

At the end of rehabilitation program, significant increase in 6MWT distance, maximum workload, peak VO2 and upward shift of anaerobic threshold in CPET were observed in all patients. Significant reductions of NTproBNP, ST2 and galectin-3 levels were observed. There were no major adverse events during rehabilitaton.

Conclusions

Comprehensive novel rehabilitation in LVAD recipients is safe and results in significant improvement of 6-minutes walking test distance and cardiopulmonary exercise test results. Moreover, this novel rehabilitation program reduces levels of prognostic biomarkers of heart failure: NT-proBNP, Galectin-3 and ST2.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development - STRATEGMED II project

Regular training in a hospital in patients with left ventricle assist device (LVAD): influence on exercise capacity, muscular strength and complex coordination

 

Heart failure (HF) significantly reduces physical capacity and harms the overall functioning. In the end-stage cases of HF, the only options are surgical procedures including left ventricular assist devices (LVAD) implantation and heart transplant. Due to the insufficient number of available organs for transplantation, LVAD are used more and more frequently. Rehabilitation of patients with LVAD is a crucial element of therapy because of long-term immobilization of patients awaiting transplant or heart muscle regeneration.

Purpose

The aim of the study was to evaluate the impact of early hospital rehabilitation on exercise tolerance, muscles strength and complex coordination in LVAD patients.

Methods

The total of 20 LVAD patients were recruited to the study (all male, aged 19–66 years). All patients underwent standard cardiac rehabilitation in the postoperative and medical treatment wards. After the end of hospitalization, patients were admitted to the rehabilitation department for 4–5 weeks. During that period they performed endurance training, conditioning exercises with elements of resistance and coordination exercises. All patients were tested before and after the rehabilitation program using ergospirometry (CPX), 6-MWT, upper and lower limbs muscle strength (30 Second Chair Stand) and complex coordination (Up&Go test).

Results

A significant increase in the values of most of studied parameters was observed after exercise training in comparison to the results before rehabilitation process (VO2 peak) [ml/kg/min]: 11.1±2.2 vs. 12.5±2.7, p&lt;0.001; Watt: 42.6±12.4 vs. 54.1±13.1, p&lt;0.0001; 6- MWT [m]: 300.1±102.2 vs. 404.8±105.9, p&lt;0.0001; 30 Seconds Chair Stand [number of stands] 8.4±3.3 vs. 11.6±4.8, p&lt;0.0001; Up&Go [sec] 9.0±1.7 vs. 7.1±1.5, p&lt;0.0001; left hand grip strength [kg]: 31.5±8.4 vs. 34.8±8.1, ns; right hand grip strength [kg]: 33.6±11,2 vs. 36.0±9.0, ns. No adverse effects were observed during rehabilitation process.

Conclusions

Hospital-based rehabilitation is safe and effective in LVAD patients. Rehabilitation after LVAD implantation brings significant benefits in terms of exercise capacity and tolerance, muscle strength and complex coordination in this group of patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – EU funding. Main funding source(s): NATIONAL RESEARCH AND DEVELOPMENT CENTER

Parkes Weber syndrome associated with two somatic pathogenic variants in RASA1

Parkes Weber syndrome is associated with autosomal dominant inheritance, caused by germline heterozygous inactivating changes in the RASA1 gene, characterized by multiple micro arteriovenous fistulas and segmental overgrowth of soft tissue and skeletal components. The focal nature and variable expressivity associated with this disease has led to the hypothesis that somatic “second hit” inactivating changes in RASA1 are necessary for disease development. We report a 2-yr-old male with extensive capillary malformation and segmental overgrowth of his lower left extremity. Ultrasound showed subcutaneous phlebectasia draining the capillary malformation; magnetic resonance imaging showed overgrowth of the extremity with prominence of fatty tissues, fatty infiltration, and enlargement of all the major muscle groups. Germline RASA1 testing was normal. Later somatic testing from affected tissue showed two pathogenic variants in RASA1 consistent with the c.934_938del, p.(Glu312Argfs*14) and the c.2925del, p.(Asn976Metfs*20) with variant allele fractions of 3.6% and 4.2%, respectively. The intrafamilial variability of Parkes Weber syndrome involving segmental overgrowth of soft tissue, endothelium, and bone is strongly suggestive of a somatic second-hit model. There are at least two reports of confirmed second somatic hits in RASA1. To our knowledge, this is the first report of an individual with two somatic pathogenic variants in the RASA1 gene in DNA from a vascular lesion.

P239 Total artificial heart implantation as a bridge to candidacy - an approach to treating primary cardiac sarcoma?

Background

Primary cardiac tumors are rare entities, only 25% of them are malignant. Most common malignant neoplasms of the heart are sarcomas - aggressive tumors with a high rate of local recurrence and systemic metastases. They may lead to a rapid clinical deterioration and sudden circulatory collapse due to obstruction of the intracardiac outflow tract. Most patients affected are younger than 65 years of age. Early diagnosis of cardiac tumors is challenging, echocardiography remains a mainstay of their evaluation. The prognosis is very poor, most patients succumb to disease within months of diagnosis. Complete surgical resection and adjuvant chemotherapy offers palliation and improves survival. Total artificial heart implantation (TAH) allows through, radical resection of large tumors yielding the best possible outcome.

Case presentation

A 58-year-old male patient with a history of hypertension was admitted to our hospital with a chief complaint of worsening dyspnea and fatigue for last several weeks. Echocardiogram demonstrated a large cardiac mass with abundant vascular supply that incorporated the whole right ventricle and intraventricular septum, extended to the tricuspid valve, infiltrated the left ventricle apex and the base of posterior tricuspid leaflet. The right ventricle cavity was slit-like with small gradient in the outflow track. Cardiac magnetic resonance suggested angiosarcoma or lymphoma. PET-CT did not reveal any extracardiac metastases at that time. The case was discussed at our multidisciplinary cardio-oncology conference. The radical resection of the mass with subsequent TAH implantation was decided upon in high-risk setting, with feasible long-term survival, including eventual consideration for cardiac transplantation (HTX). Native ventricles were excised at the atrioventricular level down to the annulus of the mitral and tricuspid valves. The artificial ventricles were connected to the atrial remnants. The ascending aorta and the main pulmonary artery were dissected close to the valves and connected to outflow grafts. Histopathologic examination of the mass demonstrated angiosarcoma. The patient was started on paklitaksel. After completion of his chemotherapy regimen his eligibility for HTX will be reevaluated.

Conclusion

Diagnosis and therapy of sarcomas are challenging. Their rarity makes it difficult to standardize therapy. There is few evidence available in literature to guide the treatment of such patients. Case-specific, heart-team-based strategy must be adopted to aid decision making in this rare cases. Sarcomas are lethal, develop rapidly and affect fairly young patients. Prompt surgical resection with subsequent TAH implantation and adjuvant chemotherapy seems ideal in this situation as it offers a possible cure. It gives a slim chance of long-term survival after consecutive HTX for chemotherapy responders.

Abstract P239 Figure. Angiosarcoma in TTE, MRI and TEE.

Disruption of histamine/H3 receptor signal reduces collagen deposition in cultures scar myofibroblasts

A suitable inflammatory signal influences extracellular matrix accumulation and determines the quality of the myocardial infarction scar. The aim of the present study was to determine the influence of mast cell sonicates or histamine on collagen accumulation in heart myofibroblast culture and on the deposition of collagen in the myocardial infarction scar. The histamine receptor involved in the process was investigated. Myocardial infarction was induced by ligation of the left coronary artery. Myofibroblasts were isolated from the scar of myocardial infarction. The effects of mast cell sonicates, histamine and its receptor antagonists, i.e. ketotifen (H₁-receptor inhibitor), ranitidine (H₂-receptor inhibitor), ciproxifan (H₃-receptor inhibitor), JNJ7777120 (H₄-receptor inhibitor), imetit (H₃ receptor agonist), were investigated. The mast cell sonicates or histamine (10^-10 - 10^-5M) augmented collagen content in myofibroblast cultures; however, histamine-induced elevation was reduced by ciproxifan (10^-5M, 10^-6M). Imetit (10^-9 - 10^-5M) elevated collagen content in the culture. H₃ receptor expression on myofibroblasts was confirmed. Our findings indicate that histamine increases the deposition of collagen in cultures of myofibroblasts isolated from the myocardial infarction scar. This effect is dependent on H₃ receptor activation.

Preventable ADRs leading to hospitalization - results of a long-term prospective safety study with 6,427 ADR cases focusing on elderly patients

BACKGROUND

Studies evaluating the impact of age and potentially inappropriate medication (PIM) on avoidable adverse drug reactions (ADRs) are scarce.

METHODS

In this prospective, multi-center, long-term (8.5 years) observational study, we analysed ADRs leading to hospitalization in departments of internal medicine. ADRs causality and preventability were assessed using standardised algorithms. PIM was defined based on the PRISCUS-list. Multivariate analyses and estimation of ADR incidence rates were conducted.

RESULTS

Of all 6,427 ADR patients, a preventable ADR was present in 1,253 (19.5%) patients (elderly patients ≥70 years: 828). Risk factors for preventable ADRs in elderly patients were multimorbidity, two to four ADR-causative drugs, and intake of particular compounds (e.g. spironolactone) but not sex, PIM usage, or the total number of drugs. Regarding particular compounds associated with preventable ADRs, highest incidence rates for preventable ADRs were found for patients aged ≥70 years for spironolactone (3.3 per 1,000 exposed persons (95% CI: 1.4-6.6)) and intermediate-acting insulin (3.3 per 1,000 exposed persons (95% CI: 1.6-6.1)).

CONCLUSION

Avoiding PIM usage seems to be of limited value in increasing safety in elderly patients whereas our results underline the importance of an individualized medication review of the most commonly implicated drugs in preventable ADRs (supported by BfArM FoNr: V-11337/68605/2008-2010).

Development of new antiatherosclerotic and antithrombotic drugs utilizing F11 receptor (F11R/JAM-A) peptides

Peptides with enhanced resistance to proteolysis, based on the amino acid sequence of the F11 receptor molecule (F11R, aka JAM-A/Junctional adhesion molecule-A), were designed, prepared, and examined as potential candidates for the development of anti-atherosclerotic and anti-thrombotic therapeutic drugs. A sequence at the N-terminal of F11R together with another sequence located in the first Ig-loop of this protein, were identified to form a steric active-site operating in the F11R-dependent adhesion between cells that express F11R molecules on their external surface. In silico modeling of the complex between two polypeptide chains with the sequences positioned in the active-site was used to generate peptide-candidates designed to inhibit homophilic interactions between surface-located F11R molecules. The two lead F11R peptides were modified with D-Arg and D-Lys at selective sites, for attaining higher stability to proteolysis in vivo. Using molecular docking experiments we tested different conformational states and the putative binding affinity between two selected D-Arg and D-Lys-modified F11R peptides and the proposed binding pocket. The inhibitory effects of the F11R peptide 2HN-(dK)-SVT-(dR)-EDTGTYTC-CONH2 on antibody-induced platelet aggregation and on the adhesion of platelets to cytokine-inflammed endothelial cells are reported in detail, and the results point out the significant potential utilization of F11R peptides for the prevention and treatment of atherosclerotic plaques and associated thrombotic events.

Using direct-to-consumer marketing strategies with obsessive-compulsive disorder in the nonprofit sector

Three to four million individuals struggle with obsessive-compulsive disorder (OCD) in the United States at any given time. OCD can be a debilitating disorder associated with significant quality-of-life and occupational impairment. First-line treatments for OCD (selective serotonin reuptake inhibitors and exposure and response prevention therapy) have been shown to be effective; yet, many individuals suffering from OCD experience multiple barriers to accessing these treatments. In fact, it can take as many as 17 years from onset of symptoms to effective treatment. Given the need to increase access to and utilization of effective treatments, direct-to-consumer marketing in the context of OCD appears crucial. The International OCD Foundation (formerly the Obsessive Compulsive Foundation) was established as a nonprofit organization with a mission to educate the public and mental health professionals about appropriate practice guidelines, raise awareness of the disorder, and ensure that individuals looking for treatment find the necessary resources. This paper reviews the obstacles those struggling with OCD face in their attempts to alleviate suffering, as well as the direct-to-consumer strategies and tactics used by the International OCD Foundation to improve access to empirically supported, effective treatment.

BK virus associated renal cell carcinoma: case presentation with optimized PCR and other diagnostic tests

Polyomaviruses, including BK and JC viruses, have been associated with graft failure, but have not commonly been associated with malignancy. We present a case of renal cell carcinoma arising in an allograft kidney, in which the tumor and metastasis contain viral DNA. Tumor and biopsy specimens from this patient were examined with hematoxylin & eosin, immunohistochemistry (IHC) and in situ hybridization (ISH). The results were confirmed by real-time polymerase chain reaction (PCR) analysis with BKV primers. Other viruses including herpes simplex 1-2, cytomegalovirus (CMV), Epstein-Barr virus (EBV), and varicella zoster were not detected. The presence of BKV DNA in a renal cell carcinoma, including a metastatic focus, adds to the evidence that this virus may play a role in cancers of the kidney and urinary tract.

Pharmacokinetics of ibuprofen sodium dihydrate and gastrointestinal tolerability of short-term treatment with a novel, rapidly absorbed formulation

OBJECTIVE

This paper describes four studies investigating the dissolution, plasma pharmacokinetics and safety of a novel, fast-acting ibuprofen formulation, ibuprofen sodium dihydrate.

MATERIAL AND METHOD

Four separate studies investigated: the in vitro dissolution rates of ibuprofen sodium dihydrate (at pH 1.2, 3.5 and 7.2); the bioavailability of ibuprofen sodium dihydrate (in two pharmacokinetic studies; combined n = 38) compared with conventional ibuprofen, ibuprofen lysinate, ibuprofen arginate and ibuprofen liquagels (all 2 x 200 mg ibuprofen); and the gastroduodenal tolerance of ibuprofen sodium dihydrate and ibuprofen arginate (both 2 x 200 mg ibuprofen t.i.d.) in an endoscopy safety study, where endoscopy was performed at baseline and at the end of each treatment period using a five-point scale to assess the integrity of the gastric and duodenal mucosa.

RESULTS

Ibuprofen sodium dihydrate dissolved significantly more rapidly at pH 1.2, 3.5 and 7.2 than conventional ibuprofen, ibuprofen lysinate and ibuprofen liquagels. Ibuprofen sodium dihydrate had similar C(max) to ibuprofen lysinate and ibuprofen liquagels and significantly higher Cmax than conventional ibuprofen (p = 0.002). The mean plasma concentration for ibuprofen sodium dihydrate was significantly higher than for conventional ibuprofen (p = 0.028) 10 minutes post-dose and the t(max) for ibuprofen sodium dihydrate was reached significantly earlier than for conventional ibuprofen (p = 0.018). All three formulations were bioequivalent according to the acceptable boundaries (90% confidence intervals). No statistically significant difference was observed between the ibuprofen formulations in terms of adverse events and specifically with respect to hemorrhagic scores; 41 (46.0%) adverse events (AEs) occurred after administration of ibuprofen sodium dihydrate, and 46 (52.9%) after ibuprofen arginate. One occurrence of an invasive ulcer was observed after administration of ibuprofen arginate.

CONCLUSIONS

The new formulation of ibuprofen sodium dihydrate dissolves quickly in vitro, has the same extent of absorption as other fast-acting ibuprofen formulations, and is absorbed into plasma more rapidly than conventional ibuprofen. In addition, the present studies suggest that the tolerability and safety profile of ibuprofen sodium dihydrate is comparable to existing ibuprofen formulations.

Laparoscopic repair of inguinal hernias with higher risk for recurrence: independent assessment of results from 121 repairs

This study attempts to determine by independent review the results of laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair for hernias with increased risk for recurrence. Indicators used for increased recurrence risk were recurrent hernias or simultaneously repaired bilateral inguinal hernias. Office and hospital records of all such patients who had undergone TAPP repair were reviewed from one surgeon's 242-patient laparoscopic inguinal hernia database from 1992 to 1998. All were called for assessment by an independent surgeon at least 4 months postoperatively (median 34 months). Those unable to come in person were interviewed by telephone. There were 121 hernias: 34 recurrent and 100 bilateral (13 overlap). Recurrence rate was 3 per cent, which was similar for repair of bilateral and recurrent hernias. All recurrences occurred within 3 months of surgery. No unknown recurrence was detected by the independent observer. Laparoscopic TAPP inguinal hernia repair, often claimed as the method of choice for bilateral and recurrent hernia repair, is indeed a safe and effective procedure with a low early recurrent rate in these higher-risk situations.

Technique and early results of outpatient laparoscopic mesh onlay repair of ventral hernias

BACKGROUND

This report describes the technique and early results of a simple outpatient laparoscopic ventral hernia repair.

METHODS

Data were gathered prospectively for all laparoscopic ventral hernia repairs from January 1996 to December 1997 at a 228-bed hospital. Prolene mesh was stapled to the peritoneal surface of the abdominal wall, leaving sac in situ and mesh uncovered. Patients were seen by the operating surgeon within 2 months, and by an impartial surgeon (J.S.) after 3 to 14 months (average, 7 months; median, 6 months).

RESULTS

Repairs involved 44 hernias with orifice sizes 2 to 20 cm in diameter, and an average area of 20 cm(2). Of these 44 hernias, 36 were postoperative and 8 primary. Furthermore, 20% were recurrent hernias. There were four conversions. The outpatient rate was 98%, with one readmission for ileus. The early recurrence rate was 5%.

CONCLUSIONS

Laparoscopic mesh onlay repair is a safe, easy, and effective procedure with minimal discomfort and a low early recurrence rate that can be performed safely on an outpatient basis.

Variation of CYP1A2-dependent caffeine metabolism during menstrual cycle in healthy women

BACKGROUND AND OBJECTIVES

The activity of the human cytochrome P450 CYP1A2 is decreased by female sex hormones during pregnancy or treatment with oral contraceptives. However, the influence of menstrual cycle on CYP 1A2 activity is not clear.

METHODS

CYP1A2 activity was monitored in 15 women (13 with confirmed ovulatory cycles, 2 smokers, age (mean +/- SD) 27.8 +/- 3.8 years, body mass index 23.8 +/- 3.8 kg x m-2) using the specific substrate caffeine (mean doses 149 mg). After a run-in period started one week prior to expected onset of menses, daily saliva samples were taken 7.3 +/- 0.7 hours after caffeine intake throughout the cycle, and caffeine clearance was estimated from the paraxanthine to caffeine ratio therein. Ovulation was confirmed by progesterone serum concentration above 3 ng/ml in the second half of the cycle.

RESULTS

Initial (day 2) caffeine clearance (n = 15, geometric mean) was 1.37 ml/min/kg body weight (coefficient of variation (CV) 48%). The ratio of caffeine clearance for the luteal (day -9 to -4 prior to onset of the next menses) to the follicular phase (days 5-10) was (n = 13, point estimate) 1.03 (90% CI 0.95-1.12), indicating that there was no difference in CYP1A2 activity between these cycle phases. The median intraindividual CV in ovulatory cycles (n = 13) was 23% (range 11% to 39%). As an additional finding, there was evidence for long-term fluctuations of CYP1A2 activity in most individuals.

CONCLUSIONS

A dose adaptation according to the phase of menstrual cycle based on pharmacokinetics is not required for CYP1A2 substrates.

Prompt Optical Observations of Gamma-Ray Bursts

The Robotic Optical Transient Search Experiment (ROTSE) seeks to measure simultaneous and early afterglow optical emission from gamma-ray bursts (GRBs). A search for optical counterparts to six GRBs with localization errors of 1 deg2 or better produced no detections. The earliest limiting sensitivity is mROTSE>13.1 at 10.85 s (5 s exposure) after the gamma-ray rise, and the best limit is mROTSE>16.0 at 62 minutes (897 s exposure). These are the most stringent limits obtained for the GRB optical counterpart brightness in the first hour after the burst. Consideration of the gamma-ray fluence and peak flux for these bursts and for GRB 990123 indicates that there is not a strong positive correlation between optical flux and gamma-ray emission.

Efficacy of multimodality spinal cord monitoring during surgery for neuromuscular scoliosis

STUDY DESIGN

This study determined the relative efficacy of somatosensory-evoked potentials and motor-evoked potentials in monitoring spinal cord function during surgery for patients with idiopathic versus neuromuscular scoliosis.

OBJECTIVES

To determine whether patients with idiopathic versus neuromuscular scoliosis demonstrate significantly different somatosensory-evoked potentials and motor-evoked potentials recorded during surgery.

SUMMARY OF BACKGROUND DATA

Ashkenaze et al (1993) and others have reported that cortical somatosensory-evoked potentials are unreliable when used to monitor spinal cord function in patients with neuromuscular scoliosis. It was recommended that other neurophysiologic tests be used.

METHODS

Somatosensory-evoked potentials and motor-evoked potentials were recorded from two groups of patients: those with idiopathic scoliosis and those with neuromuscular scoliosis. Somatosensory-evoked potentials were obtained before and during surgery. Motor-evoked potentials were obtained during surgery. Normal variability, as indicated from idiopathic scoliotic results, was compared with data obtained from patients with neuromuscular scoliosis. Motor-evoked potentials and somatosensory-evoked potentials were obtained sequentially during the duration of surgery.

RESULTS

Single-channel cortical somatosensory-evoked potentials demonstrated a 27% positive rate, which was consistent with results (28%) from Ashkenaze et al. The use of multiple recording sites for the somatosensory-evoked potentials and the addition of motor-evoked potential procedures indicated that a reliable response could be obtained in more than 96% of the patients. It also was found that cortical somatosensory-evoked potentials were more affected by anesthetic agents when recorded from patients with neuromuscular scoliosis compared with patients with idiopathic scoliosis.

CONCLUSIONS

Single-channel cortical somatosensory-evoked potentials demonstrated a high level of unreliability, which reduced their clinical effectiveness. However, by using multiple recording sites with the somatosensory-evoked potentials and by administering motor-evoked potential procedures, it was possible to monitor spinal cord function in neuromuscular patients and avoid postoperative neurologic deficits.

Fear of Spiders Questionnaire

The Fear of Spiders Questionnaire (FSQ), an 18-item self-report questionnaire assessing spider phobia, was developed in an attempt to complement the information provided by the Spider Phobia Questionnaire (SPQ). Data obtained from 338 undergraduates revealed that the FSQ was able to discriminate phobics from nonphobics, and indicated decrements in phobic responding from pretest to posttest following cognitive therapy. Test-retest data, obtained from non-treatment control groups, indicated that scores on the FSQ are stable over a one month period. The FSQ also demonstrated adequate convergent validity due to its significant correlations with the SPQ and a behavioral avoidance test. Finally, a factor analysis revealed two factors accounting for 55% of the variance. It is argued that, compared to the SPQ, items on the FSQ are more explicit regarding the time period to be assessed, and may be more sensitive to differences between phobics and nonphobics and decrements in phobic responding following treatment.

The use of mechanically elicited electromyograms to protect nerve roots during surgery for spinal degeneration

STUDY DESIGN

This study investigated the use of mechanically elicited electromyograms during the placement of pedicle screws in 89 patients undergoing surgery for spinal stenosis.

SUMMARY OF BACKGROUND DATA

Several methods for monitoring nerve roots are available. However, mechanically elicited electromyograms may be more sensitive to mechanical irritation of nerve roots by pedicle screws than by other methods.

METHODS

Mechanically elicited electromyograms were recorded in muscle groups innervated by cervical or lumbar nerve roots. Confirmation of surgical activity with the level of the electromyogram was correlated.

RESULTS

Results indicated that mechanically elicited electromyograms are extremely sensitive to nerve root irritation. Compared to other methods, electromyograms are a viable alternative.

CONCLUSIONS

Results from this study indicated that mechanically elicited electromyograms are sensitive and specific to nerve root firings and should be considered for use during the dynamic phases of surgery.

[Endotoxinemia in rats in the course of ethanol-induced liver damage]

Endotoxin concentrations were measured in the portal, hepatic venous blood and abdominal aorta of six groups of rats in experimental alcoholic liver injury. Groups of animal consisted of 16 rats: I.: control group; II.: rats received one dose of E. coli 0127: B8-3 mg/kg intraperitoneally (i.p.), III.: rats received three doses of E. coli; IV.: rats intoxicated with 20% ethanol ad libitum (60 days); V.: rats intoxicated with one dose of endotoxin after 20% ethanol ingestion; VI.: animal intoxicated with 20% ethanol and three doses of E. coli 0127: B8. The highest levels of endotoxin (determined by Limulus Lysate test) were in portal venous blood--3.1 pg/ml in control group to 113.4 pg/ml in VI. group. The level of endotoxin in plasma hepatic venous blood was elevated from 0.0 pg/ml (I., II. groups) to 15.8 pg/ml (III.), 34.3 pg/ml (IV.), 49.7 pg/ml (V.) up to 75.1 pg/ml (VI.). Plasma endotoxin concentration in abdominal aorta was highest in group VI.--32.2 pg/ml. The percentage of excretion rate of endotoxin by liver function was measured on the basis of difference between plasma endotoxin levels in the prehepatic blood (portal vein) and posthepatic blood (hepatic vein). The highest activity of biochemical parameters indicating liver injury was observed in animals intoxicated with ethanol and endotoxin.