Combined therapy for rectal cancer in the elderly

14504

Background: Neoadjuvant or Adjuvant Chemoradiotherapy (CRT) plus surgery is the standard of care for treatment of Stage II/Stage III rectal cancer. Previous studies of practice patterns have evaluated SEER data using single dose chemotherapy as a surrogate for having ever been treated. No study to date has evaluated the use of CRT along with surgery to determine the ability of elderly patients with rectal cancer to complete prescribed therapy. Methods: A retrospective study of all patients treated for Stage II/III rectal cancer identified by Tumor Registrar from January 1, 1987 to June 1, 2006 at the Boston VAMC and Boston Medical Center were analyzed. Data was extracted from computerized records and paper charts. Statistical analysis was performed with SAS software. The primary endpoint was to determine if younger (<70 yr) and older (>=70yr) patients were equally likely to complete CRT and surgery without having a dose of chemotherapy or radiation reduced, held, or delayed. Secondary endpoints were to determine if older and younger age groups were equally likely to receive CRT and a multivariate analysis of factors (age, having received neoadjuvant therapy, number of comorbidities, stage of tumor) had an effect on these outcomes. Results: A total of 266 patients were identified and included in the study. The likelihood of completing CRT and surgery without a dose being held, delayed or reduced was statistically similar among patients age 70 and older (16.1%) as among younger patients (23.9%) (Chi-square 2.16 p=0.1414). However, older patients were far less likely (58.24%) than younger patients (76%) to receive CRT (Chi-square 8.79 p=0.003). A multivariate analysis of factors associated with completion of CRT without a dose being held, delayed or reduced identified only the number of comorbidities (one or more) OR=0.383 (95% CI 0.186–0.790) as statistically significant. In addition, multivariate analysis of factors associated with receiving CRT identified having received neoadjuvant therapy OR=5.397 (95% CI 2.303–12.60) and age >=70 OR=0.424 ( 95% CI 0.201–0.898) as statistically signficant. Conclusion: Elderly patients with rectal cancer are less likely to be prescribed CRT than younger patients. However, elderly patients who are prescribed to receive CRT appear to be able to tolerate the therapy as well as younger patients.

No significant financial relationships to disclose.

Brief report: improvements in the behavior of children with autism following massage therapy

Twenty children with autism, ages 3 to 6 years, were randomly assigned to massage therapy and reading attention control groups. Parents in the massage therapy group were trained by a massage therapist to massage their children for 15 minutes prior to bedtime every night for 1 month and the parents of the attention control group read Dr. Seuss stories to their children on the same time schedule. Conners Teacher and Parent scales, classroom and playground observations, and sleep diaries were used to assess the effects of therapy on various behaviors, including hyperactivity, stereotypical and off-task behavior, and sleep problems. Results suggested that the children in the massage group exhibited less stereotypic behavior and showed more on-task and social relatedness behavior during play observations at school, and they experienced fewer sleep problems at home.

Circulating neutrophil CD18 receptor expression and ischemic flap neutrophil infiltration in a guinea pig model

This article demonstrates a correlation between circulating neutrophil CD18 expression, neutrophil infiltration, and varying periods of ischemia induced in guinea pig island skin flaps. Fifty adult female Hartley guinea pigs were equally separated into a control group, a sham group, and ischemic groups of 2, 4, and 10 hours. All, except those in the control group, had single guinea pig island flank skin flaps raised. Systemic neutrophil surface receptor (CD18) expression was analyzed with monoclonal antibodies, and flap skin biopsy specimens were analyzed for neutrophil infiltration. The results show that neutrophil counts and receptor detection increase as flap ischemia increases. However, a trend toward declining receptor expression was observed in the 10-hour ischemic group. In conclusion, systemic neutrophil adhesion receptor upregulation is correlated with cutaneous flap neutrophil infiltration and ischemia-reperfusion injury in a guinea pig model. A trend toward declining receptor expression with advanced ischemia was observed.

Circulating Neutrophil CD18 Receptor Expression and Ischemic Flap Neutrophil Infiltration in a Guinea Pig Model

This article demonstrates a correlation between circulating neutrophil CD18 expression, neutrophil infiltration, and varying periods of ischemia induced in guinea pig island skin flaps. Fifty adult female Hartley guinea pigs were equally separated into a control group, a sham group, and ischemic groups of 2, 4, and 10 hours. All, except those in the control group, had single guinea pig island flank skin flaps raised. Systemic neutrophil surface receptor (CD18) expression was analyzed with monoclonal antibodies, and flap skin biopsy specimens were analyzed for neutrophil infiltration. The results show that neutrophil counts and receptor detection increase as flap ischemia increases. However, a trend toward declining receptor expression was observed in the 10-hour ischemic group. In conclusion, systemic neutrophil adhesion receptor upregulation is correlated with cutaneous flap neutrophil infiltration and ischemia-reperfusion injury in a guinea pig model. A trend toward declining receptor expression with advanced ischemia was observed.

Collectins and pulmonary innate immunity

The surfactant-associated proteins SP-A and SP-D are members of a family of host defense lectins, designated collectins. There is increasing evidence that these pulmonary, epithelial-derived proteins are important components of the innate immune response to microbial challenge and participate in other aspects of immune and inflammatory regulation within the lung. Both proteins bind to glycoconjugates and/or lipid moieties expressed by a wide variety of microorganisms, and to certain organic particles, such as pollens. SP-A and SP-D have the capacity to modulate leukocyte function and, in some circumstances; to opsonize and enhance the killing of microorganisms. The biologic activity of cell wall components, such as Gram-negative bacterial polysaccharides, or viral glycoproteins, such as the hemagglutinin of influenza viruses, may be altered by interactions with collectins. In addition, complementary or cooperative interactions between SP-A, SP-D and other host defense lectins could contribute to the efficiency of this defense system. Collectins could play particularly important roles in settings of inadequate or impaired specific immunity, and acquired alterations in the levels of active collectins within the airspaces and distal airways may increase susceptibility to infection.

Long-term maintenance of infant memory

The present experiments with human infants asked whether periodic nonverbal reminders could maintain a memory established at 2 months of age over a substantial period of development. In Experiment 1, a reactivation reminder recovered infants' forgotten memory after 3 weeks, but a reinstatement reminder did not. In Experiment 2, 2-month-olds received a reminder every 3 weeks through 6(1/2) months of age and a final test at 7(1/4) months of age. A preliminary retention test preceded each reminder; which type of reminder (reinstatement or reactivation) infants received depended on performance during this test. Infants exhibited significant retention 4(1/2) months later, and most remembered 5(1/4) months later, when infants outgrew the task. Untrained controls exhibited no retention after any delay. These data confirm that periodic reminders can maintain early memories over significant periods of development and challenge popular claims that preverbal human infants cannot maintain memories over the long term because of neural immaturity or an inability to rehearse experiences by talking about them.

In vivo correlation of neutrophil receptor expression, ischemia-reperfusion injury, and selective 5-lipoxygenase inhibition in guinea pigs

OBJECTIVE

To determine whether selective 5-lipoxygenase (5-LO) inhibition decreases expression of adhesion molecules (beta2 integrins) on systemic neutrophils, decreases neutrophil infiltration in ischemic flap tissue, and improves flap survival.

DESIGN

A randomized, controlled study of 91 adult female Hartley guinea pigs divided into 3 survival groups, 4 neutrophil assay groups, 1 sham group, and 1 control group. Ischemia of varying duration and reperfusion was induced in island flank skin flaps. The treated groups received zileuton, a 5-LO inhibitor, orally during flap ischemia. After reperfusion, systemic neutrophil receptor expression, neutrophil infiltration, and flap survival were measured. Surface receptor molecules on neutrophils from whole blood samples obtained via transcardiac puncture were analyzed using monoclonal antibodies and cell-associated fluorescence. Neutrophil infiltration into a distal 1 cm2 of flap tissue was assessed using myeloperoxidase antibodies. Flap survival was determined within 7 days of surgery.

RESULTS

Untreated flaps with 10 hours of ischemia underwent total necrosis. Treated 2- and 10-hour ischemic flaps survived intact. A significant main effect of the drug treatment was detected using analysis of variance (P<.001). Neutrophil receptor detection in the untreated groups undergoing 2 and 10 hours of ischemia was significantly increased compared with that in the treated groups with the same ischemia times. Skin neutrophil infiltration was significantly decreased in the treated groups.

CONCLUSIONS

Systemic administration of a 5-LO inhibitor is effective in reducing ischemia-reperfusion injury in flap tissue. Our data indicate that there is a significant reduction in neutrophil receptor expression with administration of 5-LO, reducing the priming of systemic neutrophils from circulating cytokines.

An expanding training series protracts retention for 3-month-old infants

This research examined whether an expanding training series protracts retention for infants as it does for children and adults. In three sessions spanning an 8-day period, 3-month-olds learned to move a crib mobile by kicking. Intersession intervals were either constant (1 or 4 days) or progressively expanding (average ISI = 4 days). The expanding-series group exhibited significant retention on a delayed recognition test 3 weeks after training was over, but the two constant-series groups exhibited none. Although the 1-day constant-series group remembered after 1 week, the 4-day constant-series group did not. Surprisingly, a reactivation treatment administered 4 weeks after training was over was ineffective whether infants were trained, reminded, and tested in a distinctive context or not. These results demonstrate that the retention advantage afforded by programming training sessions in an expanding series extends to infants and suggest that the upper limit on reactivation is timed from initial encoding and not from the point of forgetting.

Systemic neutrophil intrinsic 5-lipoxygenase activity and CD18 receptor expression linked to reperfusion injury

OBJECTIVE

To determine if systemic neutrophil intrinsic 5-lipoxygenase (5-LO) inhibition correlates with decreased expression of surface adhesion molecules and attenuation of ischemia-reperfusion (i/r) injury in guinea pig island skin flaps.

METHODS

Eighty-one adult female Hartley guinea pigs were divided into one control group, three 2-hour ischemia groups, and four 10-hour ischemia groups. Island dorsal skin flaps were developed (except in the control group), and 2 hours before reperfusion, zileutin (a 5-LO inhibitor) or vehicle was administered orally. Postreperfusion systemic neutrophil receptor expression, neutrophil flap infiltration, and flap survival were measured. Neutrophils from whole blood were analyzed for CD18 containing surface receptor expression using monoclonal antibodies and cell associated fluorescence. Neutrophil infiltration into a distal centimeter squared of flap tissue was assessed using myeloperoxidase antibodies, and flap survival was determined within 7 days postoperatively.

RESULTS

Flaps in the treated 2- and 10-hour ischemic groups survived totally intact, while the untreated 10-hour ischemic flaps underwent total necrosis. A significant main effect of the drug was detected using analysis of variance (ANOVA) (P =.0001). Surface receptor detection and neutrophil infiltration were significantly increased in the untreated animals.

CONCLUSIONS

Zileuton, a 5-LO inhibitor, reduces adhesion receptor expression on systemic neutrophils and attenuates i/r injury. Systemic neutrophil intrinsic 5-LO activity and CD18 receptor expression are linked to reperfusion injury and may be fundamental events in its pathogenesis.

Developmental changes in the specificity of memory over the first year of life

In two experiments with 260 infants between 2 and 12 months of age, we examined how differences between the conditions of encoding and retrieval affect retention. Initially, 9- and 12-month-olds were tested with a different cue (Experiment 1) or in a different context (Experiment 2) after delays spanning their respective forgetting functions. These data were then combined with corresponding data previously collected from 2-to 6-month-olds trained and tested in an equivalent task. The resulting analyses revealed that the specificity constraints on memory retrieval become progressively looser at the extremes of the forgetting function with age. With increasing age, retention was less affected by cue changes after shorter absolute delays and, except at 6 months, by context changes after longer absolute delays. This pattern dovetails with evidence of decreasing specificity in the retrieval cues required for deferred imitation during infants' 2nd year and reveals that the memory abilities of older children evolve gradually from early in infancy.

The ontogeny of long-term memory over the first year-and-a-half of life

This research documents the development of long-term memory in human infants from 2 months through the end of the first year-and-a-half of life. In the initial study phase, we trained 6- to 18-month-old human infants in an operant task and tested them after increasing delays until they exhibited no retention for 2 successive weeks. In the second phase, their data were combined with data previously obtained from 2- to 6-month-olds in an equivalent task. The resulting function revealed that the duration of retention increases monotonically between 2 and 18 months of age. This increase was not due to age differences in original learning. This is the first systematic analysis of the course of long-term memory across an extended period of infant development that is based on standardized parameters of training and testing. It provides a reference function against which measures of retention from infants of different ages that are obtained in different memory tasks with different parameters can be meaningfully compared.

Infant learning and long-term memory at 6 months: a confirming analysis

In three experiments, we tested the generality and validity of prior evidence of delayed recognition, memory reactivation, and retrieval specificity at 6 months of age using a new operant task. In Experiment 1, the forgetting function was found to be 2 weeks but not 3, the same as previously obtained using the mobile conjugate reinforcement task. In Experiment 2, a reactivation treatment with the original cue (train set) in the original context (room in the home) recovered the memory but was ineffective when either was changed. These results also confirmed prior findings but expanded the manipulation of context to include the place where training occurred. Following a reactivation treatment, infants in Experiment 3a failed to recognize the original cue in a different context, as before, but generalized to a different cue in the original context. Because the latter test condition was novel, a comparison group was trained in the mobile task and tested with a different mobile in the original context 1 day after a reactivation treatment (Experiment 3b); this group failed to recognize the mobile. The disparity in these outcomes was attributed to the salience of features common to the two train sets. Taken together, these findings demonstrate that, for the same parameters of training and testing, memory performance at 6 months is task-independent.

Interactions of recombinant human pulmonary surfactant protein D and SP-D multimers with influenza A

To further study the structure and function of surfactant protein D (SP-D), recombinant human SP-D (rhSP-D) was isolated from the culture medium of Chinese hamster ovary (CHO)-K1 cells stably transfected with a full-length hSP-D cDNA. Although a significant fraction of the secreted rhSP-D was recovered as dodecamers similar to recombinant rat SP-D (rrSP-D), a major fraction accumulated as multimers of dodecamers indistinguishable from human proteinosis SP-D. As previously shown for the rat protein, rhSP-D agglutinated specific strains of influenza A virus (IAV), inhibited viral hemagglutinin activity, and protected neutrophils (PMN) from deactivation by IAV. However, the potency of rhSP-D multimers was severalfold greater than for purified dodecamers, comparable to natural, proteinosis hSP-D. Although rhSP-D multimers were also more potent than the serum collectins in mediating viral aggregation and protection of PMN, they were less potent than conglutinin in inhibiting infectivity in vitro. These studies establish that the propensity of hSP-D to form multimers of dodecamers is determined by its primary structure and demonstrate carbohydrate recognition domain valency-dependent interactions of SP-D with IAV.

Site-directed mutagenesis of Cys-15 and Cys-20 of pulmonary surfactant protein D. Expression of a trimeric protein with altered anti-viral properties

Surfactant protein D (SP-D) molecules are preferentially assembled as dodecamers consisting of trimeric subunits associated at their amino termini. The NH2-terminal sequence of each monomer contains two conserved cysteine residues, which participate in interchain disulfide bonds. In order to study the roles of these residues in SP-D assembly and function, we employed site-directed mutagenesis to substitute serine for cysteine 15 and 20 in recombinant rat SP-D (RrSP-D), and have expressed the mutant (RrSP-Dser15/20) in Chinese hamster ovary (CHO-K1) cells. The mutant, which was efficiently secreted, bound to maltosyl-agarose, but unlike RrSP-D, was assembled exclusively as trimers. The constituent monomers showed a decreased mobility on SDS-polyacrylamide gel electrophoresis resulting from an increase in the size and sialylation of the N-linked oligosaccharide at Asn-70. Although RrSP-Dser15/20 contained a pepsin-resistant triple helical domain, it showed a decreased Tm, and acquired susceptibility to proteolytic degradation. Like RrSP-D, RrSP-Dser15/20 bound to the hemagglutinin of influenza A. However, it showed no viral aggregation and did not enhance the binding of influenza A to neutrophils (PMN), augment PMN respiratory burst, or protect PMNs from deactivation. These studies indicate that amino-terminal disulfides are required to stabilize dodecamers, and support our hypothesis that the oligomerization of trimeric subunits contributes to the anti-microbial properties of SP-D.

Partial purification and identification of an immunosuppressive factor in AIDS sera

The cause of the profound immunodeficiency state induced by the human immunodeficiency virus (HIV) is not yet fully understood. Although direct cytopathic effects of the virus leading to the loss of CD4+ lymphocytes are believed to play a major role, soluble factors that cause lymphocyte dysfunction have also been identified. Here, we demonstrate that sera of AIDS patients contain a viral component capable of profoundly inhibiting normal T lymphocyte and natural killer cell functions. This factor (M(r) 30,000-50,000) is relatively resistant to proteolytic degradation, heat denaturation, extreme pH, and chemical modifications. It has been determined by Western blotting to share epitopes with the gp41 viral transmembrane component of HIV-1. This immunosuppressive factor has the characteristic property of inhibiting lymphocyte activation in the early stage (within 3 hr) of mitogenic stimulation. Concomitant with the inhibition of lymphocyte activation and interleukin 2 (IL-2) production, transcription of the IL-2 message is also reduced in a time-dependent manner. The unique time dependency of this immunosuppressive factor in lymphocyte activation could serve as a valuable tool to study the early steps of signal transduction in lymphocyte activation beyond membrane interaction.

A reapplication of the process scoring system for dreams

The first application of the new Process Scoring System for dreams was made in an intensive longitudinal case study of 1 S over a 5 1/2 year period. In this second application, the dreams of a sample of 5 experienced Feeling Therapy patients were compared to those of 5 control Ss. As in the first study, considerable support was found for both the transformation hypothesis, which holds that it is possible to shift from a symbolic mode of dream behavior to a directly expressive one, and the parallelism hypothesis, which holds that the expression of affect in dreams parallels the expression of affect in waking and vice versa.