Prior anti-CTLA-4 therapy impacts molecular characteristics associated with anti-PD-1 response in advanced melanoma

Immune checkpoint inhibitors (ICIs), including CTLA-4- and PD-1-blocking antibodies, can have profound effects on tumor immune cell infiltration that have not been consistent in biopsy series reported to date. Here, we analyze seven molecular datasets of samples from patients with advanced melanoma (N = 514) treated with ICI agents to investigate clinical, genomic, and transcriptomic features of anti-PD-1 response in cutaneous melanoma. We find that prior anti-CTLA-4 therapy is associated with differences in genomic, individual gene, and gene signatures in anti-PD-1 responders. Anti-CTLA-4-experienced melanoma tumors that respond to PD-1 blockade exhibit increased tumor mutational burden, inflammatory signatures, and altered cell cycle processes compared with anti-CTLA-4-naive tumors or anti-CTLA-4-experienced, anti-PD-1-nonresponsive melanoma tumors. We report a harmonized, aggregate resource and suggest that prior CTLA-4 blockade therapy is associated with marked differences in the tumor microenvironment that impact the predictive features of PD-1 blockade therapy response.

Sotigalimab and/or nivolumab with chemotherapy in first-line metastatic pancreatic cancer: clinical and immunologic analyses from the randomized phase 2 PRINCE trial

Chemotherapy combined with immunotherapy has improved the treatment of certain solid tumors, but effective regimens remain elusive for pancreatic ductal adenocarcinoma (PDAC). We conducted a randomized phase 2 trial evaluating the efficacy of nivolumab (nivo; anti-PD-1) and/or sotigalimab (sotiga; CD40 agonistic antibody) with gemcitabine/nab-paclitaxel (chemotherapy) in patients with first-line metastatic PDAC ( NCT03214250 ). In 105 patients analyzed for efficacy, the primary endpoint of 1-year overall survival (OS) was met for nivo/chemo (57.7%, P = 0.006 compared to historical 1-year OS of 35%, n = 34) but was not met for sotiga/chemo (48.1%, P = 0.062, n = 36) or sotiga/nivo/chemo (41.3%, P = 0.223, n = 35). Secondary endpoints were progression-free survival, objective response rate, disease control rate, duration of response and safety. Treatment-related adverse event rates were similar across arms. Multi-omic circulating and tumor biomarker analyses identified distinct immune signatures associated with survival for nivo/chemo and sotiga/chemo. Survival after nivo/chemo correlated with a less suppressive tumor microenvironment and higher numbers of activated, antigen-experienced circulating T cells at baseline. Survival after sotiga/chemo correlated with greater intratumoral CD4 T cell infiltration and circulating differentiated CD4 T cells and antigen-presenting cells. A patient subset benefitting from sotiga/nivo/chemo was not identified. Collectively, these analyses suggest potential treatment-specific correlates of efficacy and may enable biomarker-selected patient populations in subsequent PDAC chemoimmunotherapy trials.

Plasma biomarkers associated with adverse outcomes in patients with calcific aortic stenosis

AIMS

Enhanced risk stratification of patients with aortic stenosis (AS) is necessary to identify patients at high risk for adverse outcomes, and may allow for better management of patient subgroups at high risk of myocardial damage. The objective of this study was to identify plasma biomarkers and multimarker profiles associated with adverse outcomes in AS.

METHODS AND RESULTS

We studied 708 patients with calcific AS and measured 49 biomarkers using a Luminex platform. We studied the correlation between biomarkers and the risk of (i) death and (ii) death or heart failure-related hospital admission (DHFA). We also utilized machine-learning methods (a tree-based pipeline optimizer platform) to develop multimarker models associated with the risk of death and DHFA. In this cohort with a median follow-up of 2.8 years, multiple biomarkers were significantly predictive of death in analyses adjusted for clinical confounders, including tumour necrosis factor (TNF)-α [hazard ratio (HR) 1.28, P < 0.0001], TNF receptor 1 (TNFRSF1A; HR 1.38, P < 0.0001), fibroblast growth factor (FGF)-23 (HR 1.22, P < 0.0001), N-terminal pro B-type natriuretic peptide (NT-proBNP) (HR 1.58, P < 0.0001), matrix metalloproteinase-7 (HR 1.24, P = 0.0002), syndecan-1 (HR 1.27, P = 0.0002), suppression of tumorigenicity-2 (ST2) (IL1RL1; HR 1.22, P = 0.0002), interleukin (IL)-8 (CXCL8; HR 1.22, P = 0.0005), pentraxin (PTX)-3 (HR 1.17, P = 0.001), neutrophil gelatinase-associated lipocalin (LCN2; HR 1.18, P < 0.0001), osteoprotegerin (OPG) (TNFRSF11B; HR 1.26, P = 0.0002), and endostatin (COL18A1; HR 1.28, P = 0.0012). Several biomarkers were also significantly predictive of DHFA in adjusted analyses including FGF-23 (HR 1.36, P < 0.0001), TNF-α (HR 1.26, P < 0.0001), TNFR1 (HR 1.34, P < 0.0001), angiopoietin-2 (HR 1.26, P < 0.0001), syndecan-1 (HR 1.23, P = 0.0006), ST2 (HR 1.27, P < 0.0001), IL-8 (HR 1.18, P = 0.0009), PTX-3 (HR 1.18, P = 0.0002), OPG (HR 1.20, P = 0.0013), and NT-proBNP (HR 1.63, P < 0.0001). Machine-learning multimarker models were strongly associated with adverse outcomes (mean 1-year probability of death of 0%, 2%, and 60%; mean 1-year probability of DHFA of 0%, 4%, 97%; P < 0.0001). In these models, IL-6 (a biomarker of inflammation) and FGF-23 (a biomarker of calcification) emerged as the biomarkers of highest importance.

CONCLUSIONS

Plasma biomarkers are strongly associated with the risk of adverse outcomes in patients with AS. Biomarkers of inflammation and calcification were most strongly related to prognosis.

Gemcitabine (Gem) and nab-paclitaxel (NP) ± nivolumab (nivo) ± CD40 agonistic monoclonal antibody APX005M (sotigalimab), in patients (Pts) with untreated metastatic pancreatic adenocarcinoma (mPDAC): Phase (Ph) 2 final results

4019

Background: Results from a ph1b trial evaluating gem/NP with CD40 agonistic monoclonal antibody APX005M ± nivo demonstrated promising clinical activity in pts with untreated mPDAC (O’Hara 2021). Herein, we report results from the follow-on, randomized (rand) ph2 trial evaluating gem/NP ± nivo ± APX005M. Methods: Pts with untreated mPDAC were rand to 1 of 3 open-label arms: gem/NP/nivo (A), gem/NP/APX005M (B), gem/NP/nivo/APX005M (C). All pts were treated with 1000 mg/m2 gem and 125 mg/m2 NP. Patients received 240 mg nivo in arms A and C and 0.3 mg/kg APX005M (RP2D) IV in arms B and C. Ph1b pts were included in ph2 analyses. 1° endpoint: 1-year OS rate of each arm, compared to a 35% historical OS rate for gem/NP (Von Hoff 2013). Key 2° endpoints: ORR, DCR, DOR, PFS and safety. Tumor and blood were collected for biomarker analysis. Planned enrollment of 35 pts/arm provided 81% power for testing the alternative of 58% OS rate vs 35%, using a 1-sided, 1-sample Z test with 5% type I error. Trial was not powered for cross-arm comparison. Results: 93 pts were rand in ph2 (N = 34, 30, 29 to A, B, C); when ph1b pts included, a total of 105 pts (34, 36, 35) were analyzed for efficacy and 108 pts (36, 37, 35) for safety. Min follow-up was 14 months (mos). Baseline characteristics were balanced across arms, inclusive of tumor burden, presence of liver metastases and stage at initial diagnosis (stage 1-3 vs 4). 1-year OS rate was 57% (1-sided p = 0.007 vs 35% historical rate, 95% lower CI bound = 41%) for A, 51% (p = 0.029, 95% bound = 36%) for B and 41% (p = 0.236, 95% bound = 27%) for C. Median OS and secondary endpoints are listed in Table. TRAE rates were similar across arms and to ph1b. 8 (7%) pts experienced an AE leading to tx discontinuation (6, 1, 1 in A, B, C), 40 (37%) pts experienced a serious TRAE (14, 15, 11 in A, B, C) and 2 pts died due to TRAEs; 1 each in B (acute hepatic failure) and C (intracranial hemorrhage). Conclusions: In this ongoing, seamless ph1b/2 trial of gem/NP ± nivo ± APX005M in pts with mPDAC, antitumor activity was observed in all arms. 1° endpoint of 1-year OS > 35% was met when combining gem/NP with either nivo or APX005M; however, not the combination. Safety was manageable; consistent with ph1b. Detailed multiomic immune and tumor biomarker analyses are underway to elucidate mechanisms of action and inform pt subsets that benefit most from these combinations. Clinical trial information: NCT03214250. [Table: see text]

Circulating and tissue matricellular RNA and protein expression in calcific aortic valve disease

Aortic valve sclerosis is a highly prevalent, poorly characterized asymptomatic manifestation of calcific aortic valve disease and may represent a therapeutic target for disease mitigation. Human aortic valve cusps and blood were obtained from 333 patients undergoing cardiac surgery (n = 236 for severe aortic stenosis, n = 35 for asymptomatic aortic valve sclerosis, n = 62 for no valvular disease), and a multiplex assay was used to evaluate protein expression across the spectrum of calcific aortic valve disease. A subset of six valvular tissue samples (n = 3 for asymptomatic aortic valve sclerosis, n = 3 for severe aortic stenosis) was used to create RNA sequencing profiles, which were subsequently organized into clinically relevant gene modules. RNA sequencing identified 182 protein-encoding, differentially expressed genes in aortic valve sclerosis vs. aortic stenosis; 85% and 89% of expressed genes overlapped in aortic stenosis and aortic valve sclerosis, respectively, which decreased to 55% and 84% when we targeted highly expressed genes. Bioinformatic analyses identified six differentially expressed genes encoding key extracellular matrix regulators: TBHS2, SPARC, COL1A2, COL1A1, SPP1, and CTGF. Differential expression of key circulating biomarkers of extracellular matrix reorganization was observed in control vs. aortic valve sclerosis (osteopontin), control vs. aortic stenosis (osteoprotegerin), and aortic valve sclerosis vs. aortic stenosis groups (MMP-2), which corresponded to valvular mRNA expression. We demonstrate distinct mRNA and protein expression underlying aortic valve sclerosis and aortic stenosis. We anticipate that extracellular matrix regulators can serve as circulating biomarkers of early calcific aortic valve disease and as novel targets for early disease mitigation, pending prospective clinical investigations.

Development of a Chemiluminescent ELISA Method for the Detection of Total Anti-Adeno Associated Virus Serotype 9 (AAV9) Antibodies

Recombinant adeno associated viruses (rAAV) have become an important tool for the delivery of gene therapeutics due to long-standing safety and success in clinical trials. Since humans often become exposed to AAVs and develop anti-AAV antibodies (Abs), a potential impediment to the success of gene therapeutics is neutralization of the viral particle before it has had a chance to bind and enter target cells to release the transgene. Identification of subjects with preexisting Abs having neutralizing potential, and exclusion of such subjects from clinical studies is expected to enhance drug efficacy. In vitro cell-based reporter assays are most often employed to determine the level of neutralizing antibodies in a given population. Such assays measure the ability of the Abs to prevent viral binding and entry into cells by engaging epitopes on the viral capsid involved in host cell receptor binding. In general, cell-based assays are low throughput and labor intensive and may suffer from high variability and low sensitivity issues. In contrast, enzyme-linked immunosorbent assays (ELISAs) are simpler, less variable, and have higher throughput. Demonstrating a correlation between neutralizing Abs assessed by a cell-based assay and total binding Abs measured in an ELISA will enable the use and substitution of the latter for screening and exclusion of subjects. In this work, we describe the development of a highly sensitive, specific, robust, and reproducible chemiluminescent ELISA method for the detection of total anti-AAV9 Abs. Using this method, we analyzed the prevalence of preexisting anti-AAV9 Abs in 100 serum samples from heart disease patients. Analysis of neutralizing Abs in the same samples using an in vitro cell-based assay showed a strong correlation between total anti-AAV9 Abs and neutralizing Abs, indicating the feasibility of using the total Ab ELISA in the future for patient screening and exclusion.

Endobronchial Metastases in Colorectal Adenocarcinoma

Between 1982 and 1990, 2388 brochoscopic examinations were carried out in patients with cancer in our hospital. A diagnosis of endobronchial metastasis was established in 30 patients (2.09 %), with the following primary tumors in descending order of frequency: breast, large bowel, melanoma, neuroblastoma, leiomyosarcoma and endometrial. Despite the rarity of endobronchial metastases secondary to colon adenocarcinoma, we were able to study 3 cases from our Center. In one case the diagnosis of endobronchial metastasis was simultaneous with that of the primary tumor, and in the other 2 this metastatic complication occurred 16 and 42 months, after the original diagnosis. When this complication occurred, the stage of the disease was advanced in all 3 cases: 2 were Dukes’ stage C and one stage D. Although this metastatic location usually implies a very negative prognosis as regards life expectancy, it did not seem to significantly reduce the latter in our patients.

Beneficial and Adverse Effects of an LXR Agonist on Human Lipid and Lipoprotein Metabolism and Circulating Neutrophils

The development of LXR agonists for the treatment of coronary artery disease has been challenged by undesirable properties in animal models. Here we show the effects of an LXR agonist on lipid and lipoprotein metabolism and neutrophils in human subjects. BMS-852927, a novel LXRβ-selective compound, had favorable profiles in animal models with a wide therapeutic index in cynomolgus monkeys and mice. In healthy subjects and hypercholesterolemic patients, reverse cholesterol transport pathways were induced similarly to that in animal models. However, increased plasma and hepatic TG, plasma LDL-C, apoB, apoE, and CETP and decreased circulating neutrophils were also evident. Furthermore, similar increases in LDL-C were observed in normocholesterolemic subjects and statin-treated patients. The primate model markedly underestimated human lipogenic responses and did not predict human neutrophil effects. These studies demonstrate both beneficial and adverse LXR agonist clinical responses and emphasize the importance of further translational research in this area.

Autologous pericardium annuloplasty: a "physiological" mitral valve repair

AIM

Autologous pericardium annuloplasty (APA) is an alternative to prosthetic ring implantation for mitral valve (MV) repair, avoiding the use of foreign material and preserving the mitral annulus' physiological motion. However, data on durability are questionable. Therefore, we analyzed long-term outcomes of treating degenerative mitral regurgitation (MR) with APA.

METHODS

Four hundred ninety patients (mean age, 54.3±11.3 years, [15-77 years]; N.=360 men [74.1%]) who had undergone APA and neochordae implantation between July 1988 and December 2006 were retrospectively studied.

RESULTS

MR was purely degenerative in 434 (89.3%) patients; endocarditis was present in 44 (9.1%) patients; an anterior, posterior, or bileaflet prolapse was present in 32 (6.6%), 241 (49.6%), and 213 (43.8%) patients, respectively. Clinical follow-up was 100% complete at a median of 6.5 years (5th percentile, 0.9; 95th percentile, 14.9) with an echocardiographic study in 92% of patients. In-hospital mortality was 1% (5 deaths); overall and late cardiac mortality were 7.6% and 3.9% (37 and 19 deaths), respectively. Kaplan-Meier curves for overall survival, late cardiac survival, and freedom from reoperation at 15 years (20 cases) were 86% (95%CI 80-91), 93% (95%CI 88-96), and 93% (95%CI 88-96), respectively. At 15 years, freedom from recurrent MR (28 patients) and endocarditis (6 events) were 86% (95%CI 76-91) and 97% (95%CI 92-99). Dehiscence, significant calcification of APA, and hemolysis never occurred. At reoperations, annular pericardium appeared covered by a smooth layer of tissue.

CONCLUSION

APA is feasible, safe, and cost-effective, providing long-term durability, high survival, and a low rate of valve-related complications.

The cost-effectiveness of paliperidone extended release in Spain

BACKGROUND

Paliperidone Extended Release OROS (ER) is a new atypical antipsychotic for the treatment of schizophrenia. The objective is, based on a previously published model, to analyze the clinical and economic effects of Paliperidone ER in a Spanish setting compared to olanzapine oral and aripiprazole.

METHODS

An existing discrete event simulation model was adapted to reflect the treatment of schizophrenia in Spain in terms of costs, resource use, and treatment patterns. Inputs for the model were derived from clinical trial data, literature research, database analysis and interviews with local clinical experts. The time horizon is 5 years and Spanish discount rate was applied. Outputs include direct medical costs and Quality Adjusted Life-Years (QALYs). Extensive sensitivity analyses were carried out to assess the robustness of the results, using ordinary least squares analysis and cost-effectiveness scatter plots.

RESULTS

The results show that the mean incremental QALYs (95% CI) compared to olanzpine is 0.033 [-0.143, 0.304] and compared to aripiprazole 0.029 [-0.107, 0.300]. The corresponding mean incremental costs and corresponding confidence intervals are -€1425 [-€10,247, €3084] and -€759 [-€10,479, €3404], respectively. The probability that paliperidone ER is cost-saving and health gaining compared to olanzapine and aripiprazole is 76% and 72%, respectively. Paliperidone ER was estimated to have 80% and 81% probability of being cost-effective compared to olanzapine at a willingness to pay of €20,000 and €30,000 and 73% and 74% compared to aripiprazole, respectively.

LIMITATIONS

Some of the modeled inter-relationships had to be based on expert opinion due to a lack of information. Also, foreign sources for the disutility of adverse events had been used due to a lack of Spanish data. Prolactin-related side-effects, indirect costs, and potential compliance advantages of paliperidone ER were not considered. It is unlikely that these limitations affected the conclusions.

CONCLUSION

Based on differences in drug acquisition costs, side-effects, and risk of relapse, the model predicts that, in the Spanish healthcare setting, paliperidone ER dominates oral olanzapine and aripiprazole, with a probability of 76% and 72%, respectively.

Activin A as a marker of intrauterine infection in women with preterm prelabour rupture of membranes

OBJECTIVE

To assess maternal serum activin A, an early phase response protein in systemic infection, as an early marker of intrauterine infection in women with preterm prelabour rupture of membranes (PPROM).

STUDY DESIGN

A prospective cohort study of women with singleton pregnancies complicated by PPROM at 24 to 34 weeks' gestation. Serum was collected for activin A and cytokine measurements. Activin A was measured using commercial enzyme-linked immunosorbent assay. Cytokines were measured using commercial multiplex assay. Pregnancy outcomes including infection were determined by case-record review.

RESULT

Eighteen women with PPROM were studied, with seven developing intrauterine infection. Serum activin A in women with and without infection did not differ. Peripheral white cell count, interleukin (IL)-6 and IL-10 were higher (P=0.03, 0.05 and 0.009, respectively) and IL-7 lower (P=0.04) 72 h before delivery in women with infection.

CONCLUSION

Activin A is not a clinically useful marker of intrauterine infection in women with PPROM.

[Anesthesia considerations for deep-brain stimulation in a patient with type-2 pantothenate kinase deficiency (Hallervorden-Spatz disease)]

Neurodegeneration associated with pantothenate kinase deficiency is an autosomal recessive condition caused by mutations in the pantothenate kinase 2 gene (PANK2). Clinical characteristics include progressive motor impairment and dementia. Medical treatment is limited and the dystonia tends to be refractory, making stereotactic surgery with placement of deep-brain electrodes an option that is being adopted with greater frequency in these patients. We report the case of a 32-year-old woman with severe dystonia associated with PANK2 protein deficiency. The patient was scheduled for stereotactic bilateral placement of electrodes in the medial globus pallidus, guided by computed tomography and under general anesthesia, to treat the debilitating dystonia and generalized stiffness associated with her condition. Anesthesia was maintained with propofol, rocuronium and remifentanil in perfusion during the intervention, which was uneventful. After the procedure, the patient was transferred to the intensive care unit and sedation was provided with remifentanil to allow slow, gradual emergence from anesthesia. The patient was discharged from hospital after placement of the implanted pulse generator, and subsequent follow-up showed improvement of the dystonia.

[Importance of monitoring neuroendoscopic intracranial pressure during anesthesia for neuroendoscopic surgery: review of 101 cases]

OBJECTIVE

The aim of this study was to describe monitoring, anesthetic management, and risk factors for complications in neuroendoscopic surgery.

PATIENTS AND METHODS

Patients who underwent neuroendoscopy between 1994 and 2003 under general anesthesia, with monitoring of intracranial pressure from inside the neuroendoscope, were studied retrospectively. In some patients, the blood flow rate in the middle cerebral artery was monitored using transcranial Doppler ultrasound. Information was collected related to surgical procedure and the development of complications.

RESULTS

Of 101 patients included in the study, transcranial Doppler ultrasound images were available for 20. In 75 patients neuroendoscopic intracranial pressure exceeded 20 mm Hg. Forty-five percent of the patients with available transcranial Doppler ultrasound images showed episodes of reduced diastolic flow rate in the middle cerebral artery during ventricular irrigation. Hemodynamic instability was associated with higher neuroendoscopic intracranial pressures (P < .05). An increase of more than 30 mm Hg in neuroendoscopic intracranial pressure was associated with more postoperative complications, the most common of which was delayed awakening. Procedures that were more complicated than a simple ventriculostomy were performed in 58% of the cases. Mean (SD) neuroendoscopic intracranial pressures in such cases were higher (50.5 [30.9] mm Hg vs 31.8 [25.1 mm Hg] in the simpler procedures) and the postoperative complication rate was higher (P = .003).

CONCLUSIONS

Neuroendoscopic surgery can causes increases in neuroendoscopic intracranial pressure that are associated with disturbances in cerebral blood flow and complications. This situation demonstrates the importance of monitoring intracranial pressure and cerebral blood flow.

Expression profile of male germ cell-associated genes in mouse embryonic stem cell cultures treated with all-trans retinoic acid and testosterone

Cells that morphologically and functionally resemble male germ cells can be spontaneously derived from ES cells. However, this process is inefficient and unpredictable suggesting that the expression pattern of male germ cell associated genes during spontaneous ES cell differentiation does not mimic the in vivo profiles of the genes. Thus, in the present study, the temporal profile of genes expressed at different stages of male germ cell development was examined in differentiating ES cells. The effect of all-trans retinoic acid (RA) which is a known inducer of primordial germ cell (PGC) proliferation/survival in vitro and testosterone which is required for spermatogenesis in vivo on the expression of these genes was also determined. Each of the 12 genes analyzed exhibited one of four temporal expression patterns in untreated differentiating ES cells: progressively decreased (Dppa3, Sycp3, Msy2), initially low and then increased (Stra8, Sycp1, Dazl, Act, Prm1), initially decreased and then increased (Piwil2, Tex14), or relatively unchanged (Akap3, Odf2). RA-treated cells exhibited increased expression of Stra8, Dazl, Act, and Prm1 and suppressed expression of Dppa3 compared to untreated controls. Furthermore, testosterone increased expression of Stra8 while the combination of RA and testosterone synergistically increased expression of Act. Our findings establish a comprehensive profile of male germ cell gene expression during spontaneous differentiation of murine ES cells and describe the capacity of RA and testosterone to modulate the expression of these genes. Furthermore, these data represent an important first step in designing a plausible directed differentiation protocol for male germ cells.

[Discrepancy between clinical and radiologic manifestations of an epidural hematoma after catheterization]

Neuraxial techniques are considered safe if certain guidelines are followed, but they are not risk free. We report the case of an 81-year-old woman with an invasive bladder tumor who underwent radical cystectomy with a Bricker-type procedure. General anesthesia was used and epidural analgesia was also provided for surgical and postoperative pain management. Late in the postoperative recovery period a large epidural hematoma was diagnosed based on radiologic signs of spinal cord compression, in the absence of symptoms other than mild and progressive back pain that developed after extubation. The surgeon decided against emergency surgery to reduce compression. Symptoms resolved gradually, and a magnetic resonance image 45 days after discharge confirmed that the hematoma was smaller. In addition to the usual safety recommendations for epidural anesthesia with regard to drugs that alter hemostasis, it is important to bear in mind circumstances that have pharmacokinetic repercussions and that increase risk. Lower back pain can be a warning sign. Some cases may resolve spontaneously.

Male chest enhancement: pectoral implants

The authors present their experience with the pectoral muscle implant for male chest enhancement in 21 patients. The markings and technique are thoroughly described. The implants used were manufactured and custom made. The candidates for implants comprised three groups: group 1 (18 patients seeking chest enhancement), group 2 (1 patient with muscular atrophy), and group 3 (2 patients with muscular injuries). Because of the satisfying results obtained, including significant enhancement of the chest contour and no major complications, this technique is used for an increasing number of male cosmetic surgeries.

Validation in Spanish population of the family objective and subjective burden interview (ECFOS-II) for relatives of patients with schizophrenia

INTRODUCTION

The family burden experienced by caregivers of people with schizophrenia is one of the most relevant consequences of this disorder. This paper aims to show the validity and reliability of the Spanish version of the Family Burden Interview Schedule (FBIS) designed to assess objective and subjective family burden for people with schizophrenia.

METHOD

DESIGN

cross sectional study.

PARTICIPANTS

356 patients fulfilling DSM-IV criteria for schizophrenia from four Spanish geographic areas (Barcelona, Madrid, Pamplona and Granada) and 205 main caregivers of these patients were assessed.

MATERIAL

caregivers were assessed with the Family Burden Interview Schedule (FBIS) Spanish version (ECFOS-II), which assesses family burden in eight different modules: activities of daily living, disrupted behaviors restraint, expenses, caregiver's routine, concern, help, repercussions on health, and assessment of general burden. Patients were also assessed with PANSS, DAS-sv and GAF.

STATISTICAL ANALYSIS

in order to assess internal consistency, parametrical tests of Cronbach's alpha were undertaken. To compute test-retest reliability Cohen's kappa and Weighted kappa were used. A principal component analysis was undertaken for assessing construct validity. Convergent validity was assessed with Spearman and Pearson correlation coefficients respectively, relating the instrument with the psychopathological (PANSS) and disability scale (DAS-sv) and general functioning (GAF). Moreover, a description of the viability of the ECFOS-II was described by a questionnaire especially designed for this purpose.

RESULTS

Cronbach's alpha coefficient was 0.85 for the global assessment. Test-retest coefficients were very high, both for Cohen's kappa and for Weighted kappa, most values being between 0.61 and 1. Principal component analysis detected four factors that coincide with the modules of the original schedule. In the convergent validity we found that these factors are related with the symptom, disability and global functioning characteristics of the patients.

CONCLUSIONS

ECFOS-II results in a valid and reliable instrument for assessing family burden experienced by caregivers of people with schizophrenia.

[Clinical comparison of the reusable LMA Classic laryngeal mask and the disposable Soft Seal mask in adult patients]

OBJECTIVES

To compare the clinical behavior of the disposable Soft Seal laryngeal mask to the behavior of the reusable LMA Classic mask.

METHODS

Patients were randomly assigned to 2 groups in which either the LMA Classic or the Soft Seal mask would be used. We assessed time required for positioning and number of attempts, seal pressure, fiberoptic bronchoscopic image, and complications. The masks were inserted by 2 anesthesiologists who were inexperienced in the use of laryngeal masks. We also compared compliance of the cuff in the laboratory.

RESULTS

Sixty patients were enrolled. There were no differences in time required for insertion or number of attempts (first-try success, 83%). The mean (SD) seal pressure was greater in the Soft Seal group at 23 (4) cm H2O than in the LMA Classic group at 20 (4) cm H2O. There were no significant differences in the fiberoptic bronchoscopic images, ventilation, incidence of intraoperative complications, presence of blood on the cuff (LMA Classic, 6 out of 30 vs Soft Seal, 11 out of 29), or postoperative sore throat. In 3 patients in the Soft Seal group the laryngeal mask had to be replaced by an orotracheal tube. Cuff compliance in the laboratory was lower for the LMA Classic than for the disposable mask for all sizes assessed.

CONCLUSIONS

Although the results suggest that the clinical behavior of the 2 masks is similar, the LMA Classic allowed for effective airway management in all of the cases assigned to it, whereas management was effective in 90% of the cases in which the Soft Seal mask was used. The inflatable cuff of the Soft Seal is more compliant in vitro and it provides a higher airway seal pressure than does the LMA Classic.

Cerebrospinal Fluid Composition Modifications after Neuroendoscopic Procedures

Normal saline solution is currently used as the ventricular irrigation fluid during neuroendoscopic procedures. The aim of this study is to determine the alterations in the cerebrospinal fluid (CSF) composition after neuroendoscopic interventions. Twenty nine patients who underwent a neuroendoscopic procedure under general anaesthesia were studied. Temperature inside the cerebral ventricle was measured and samples of CSF were taken to determinate oxygen and carbon dioxide partial pressures, pH, base excess, ionised calcium, standard bicarbonate, glucose, sodium, potassium, magnesium, total calcium, proteins, chlorine and osmolality before initiating the irrigation and after the neuronavigation. Patient demographics, neuronavigation time, total fluid volume used and temperature of the irrigation solution and complications that appeared in the first 24 hours were collected. Mean age of the patients was 42+/-18 years. The mean neuronavigation time was 21.5+/-15.4 minutes. The mean amount of saline solution used for irrigation was 919.6+/-994.7 mL. All the values studied in the CSF, except osmolality, showed significant variations. There was a significant correlation between the CSF variation of pH, oxygen and carbon dioxide partial pressures, base excess, standard bicarbonate, glucose and total calcium with respect to the total volume of irrigation solution, but not with respect to the neuronavigation time. A cut-off point of 500 mL of irrigation solution (sensitivity 0.7; specificity 0.87) was related with a CSF pH decrease greater than 0.2. The use of saline as irrigation solution during neuroendoscopic procedures produces important changes in CSF.

[Behaviour of near-infrared cerebral oximetry readings during percutaneous carotid angioplasty]

BACKGROUND

Transluminal percutaneous carotid angioplasty and stenting (CAS) carries a risk of cerebral ischemia, hemorrhage, or edema due to relative hyperemia and hemodynamic instability during and after the procedure. Noninvasive monitoring of near-infrared regional cerebral oxygen saturation (SrO2) offers an indirect way to estimate cerebral blood flow.

OBJECTIVE

To evaluate the behaviour of SrO2 during CAS and the usefulness of this variable for continuous monitoring of cerebral blood flow variation and neurological status.

MATERIAL AND METHODS

Prospective study of 25 patients scheduled for unilateral CAS under monitored anesthesia care. SrO, and other hemodynamic and clinical data were recorded. A change in SrO2 (deltaSrO2) of 15% or more in comparison with the baseline value and lasting more than 30 seconds was considered clinically significant. Neurological complications in the first 24 hours were also registered.

RESULTS

Baseline SrO, ranged from 51% to 75%. With administration of papaverine SrO2 values increased by a mean (SD) of 5.6% (6%) (P<.05 vs baseline). They decreased during angioplasty, -2.5% (5.7%) (P<.05 vs baseline), increased after 5 minutes, and fell again at 30 minutes to a level 3% (6.54%) above baseline. Two patients showed signs of elevated intracranial pressure after the procedures and also had ASrO2 readings exceeding 15%; measures to lower arterial hypertension reduced SrO2 in these patients.

CONCLUSION

High interindividual variability of absolute SrO2 values has been confirmed. SrO, fluctuates with maneuvers that change cerebral blood flow in the same way. Changes can precede the onset of other clinical signs.

[Preoperative adverse events during stereotactic microelectrode-guided deep brain surgery in Parkinson's disease]

OBJECTIVES

To evaluate the prevalence of adverse events and complications during surgery using deep brain electrodes, mainly in the treatment of Parkinsonism. To describe the adjustment of propofol to meet the needs of neurophysiological monitoring.

PATIENTS AND METHODS

A prospective study of patients undergoing stereotactic microelectrode-guided deep brain surgery (stereotactic pallidotomy, implantation of electrodes in the thalamic or subthalamic neurons of the globus pallidus). After placement of a stereotactic frame and completion of a computed tomography scan of the head, the patients were transferred to the operating room. Monitoring included electrocardiography, pulse oximetry, arterial pressure (invasive), endtidal carbon dioxide pressure, and diuresis. Anesthesia was maintained by intermittent infusion of propofol. Variables recorded were age, sex, disease and time elapsed since diagnosis, surgical complications and their treatment, total dose of propofol, duration of surgery, and place of transfer for recovery.

RESULTS

One hundred twenty-eight patients (50 women, 78 men) with a mean (+/- SD) age of 59.6 +/- 10.2 years underwent the procedure from 1996 through 2003. The mean time elapsed since diagnosis of the disease was 14 +/- 6.2 years. The propofol dose was 890.6 +/- 571.4 mg and duration of surgery was 8.3 +/- 2.4 hours. Adverse events were observed for 101 patients (78.9%). The most common complications involved hemodynamics: arterial hypertension (59.4%), bradycardia (18.0%), arterial hypotension (7.9%), and tachycardia (6.2%). Other more serious complications were pneumocephalus with clinical repercussions (3 cases), globus pallidus hematoma (2), air embolism (2), epileptic seizure (3), anisocoria (1), and dyspnea and/or airway obstruction (7).

CONCLUSIONS

Deep brain stimulation requires surgery of long duration. Because of frequent episodes of arterial hypertension, which increases the risk of brain hemorrhage, and other less common but potentially dangerous complications, careful clinical monitoring is necessary during the procedure. The intermittent use of propofol does not interfere with neurophysiological monitoring.

Laparoscopic-assisted approach in rectal cancer patients: lessons learned from >200 patients

BACKGROUND

The applicability of laparoscopic surgery in the treatment of colorectal diseases is still controversial. Early reports on laparoscopic-assisted colectomy in patients with colon cancer suggested that it minimizes surgical trauma, decreases perioperative complications, and leads to a more rapid recovery. To our knowledge, no previous studies have compared the laparoscopic vs the open approach in rectal cancer. The aim of this paper was to assess the results of laparoscopic techniques in patients with rectal cancer.

METHODS

From March 1998 to February 2003, all patients admitted to our unit with adenocarcinoma of the rectum were evaluated for surgery by the laparoscopic approach.

RESULTS

A total of 220 patients with a mean age of 67.3 years were included in the study. One hundred thirty patients (59%) were treated with neoadjuvant chemoradiotherapy. In >75% of the patients, a surgical procedure with sphincter preservation was performed. The rate of conversion to the open approach was 20%. Ten patients had intraoperative complications. Fifty-eight patients (26.3%) developed postoperative complications. The length of hospital stay was 6.8 days. The distribution of tumor stages was as follows: stage I, 16.81%; stage II, 33.6%; stage III, 26.36%; stage IV, 19.09%. The mean number of lymph nodes was 13.8. The incidence of local relapse was 5.3%, with a follow-up of 18 months.

CONCLUSION

Laparoscopic surgery can be safely performed in patients with adenocarcinoma of the rectum with good short-term results. Randomized controlled trials are needed to confirm these results.

[Complications during epilepsy surgery. Experience after 102 interventions between 1997 and 2001]

OBJECTIVES

To describe perioperative complications in different approaches to surgery for epilepsy.

PATIENTS AND METHODS

All patients undergoing surgery related to epilepsy between January 1997 and December 2001 were studied. We gathered information on patient characteristics, diagnosis, anticonvulsant treatment, surgical procedure, type of anesthesia and perioperative complications.

RESULTS

Ninety-eighty patients underwent 90 procedures under general anesthesia and 12 procedures with local anesthesia and sedation. Surgery was for anteromedial temporal resection in 74 patients, electrode implantation through the foramen ovale in 10 patients, extratemporal excisions in 7 patients, callosotomy in 3 patients, functional hemispherectomy in 3 patients, implantation of electrode grids in 2 patients, and craniotomy with an awake patient in 3 cases. Complications related to the surgical procedure were intraoperative bradycardia (5 cases), dural tension at the start of surgery (3), bleeding (2) and seizure (1). Complications related to anesthesia were bronchospasm (2 cases), histamine-releasing reaction upon administration of the muscle relaxant (1), and difficult intubation (1). During recovery we saw 1 case of postoperative aphasia, 1 of polyuria, 1 of pulmonary condensation, and 1 of factor VII deficit requiring plasma transfusion.

CONCLUSIONS

The rate of perioperative complications in surgery for drug-resistant epilepsy is low, the most common complication being self-limiting bradycardia related to surgical maneuvers.

Modified button-Bentall operation for aortic root replacement: the miniskirt technique

BACKGROUND

The aim of this study was to evaluate the midterm results of a modified button-Bentall operation (modified-bB) specifically designed to incorporate any type of prosthetic valve in composite conduit aortic root replacement.

METHODS

Between 1991 and 2000, a total of 135 patients underwent modified-bB for annuloaortic ectasia (74 patients), type A dissection (31), or aortic aneurysm without dissection (30). Of these, 34 were emergencies (25.2%). A total of 50 bioprostheses (study group 1) and 85 bileaflet mechanical prostheses (study group 2) were implanted. Group 1 mean age was 66.9 +/- 7.4 years versus 51.5 +/- 12.1 years in group 2 (p < 0.001). Composite-conduit creation occurred during proximal suture line construction as a single-step maneuver. Interrupted extracardiac polyester mattress sutures sequentially entered the aortic annulus, the prosthetic valve ring, and the vascular graft 7 mm from its free edge (miniskirt). Running monofilament suture line secured proximal hemostasis, buttressing aortic remnants and graft edge. Coronary reimplantation was accomplished in all cases by the button technique. Concomitant procedures were performed in 51 patients (37.8%).

RESULTS

The 30-day mortality was 5.18% (7/135 patients). Eight patients (5.9%) required revision for proximal (1 patient), coronary button (3), or distal (4) anastomosis leakage. Three patients (2.2%) perioperatively developed nonfatal inferior myocardial infarction. Kaplan-Meier 9-year survival is 91.8% +/- 0.026 SE with 88.1% (95% confidence limits 71.7% to 95.5%) reoperation freedom. According to the Cox proportional hazard method, stratification of the risk for death according to prosthesis type indicates previous operation (p = 0.001) and emergency (p = 0.0465) as independent predictors of hospital mortality. Associated procedures to modified-bB increased risk of reoperation (p = 0.031).

CONCLUSIONS

Modified-bB was associated with low mortality, excellent midterm survival, and freedom from reoperation. Absence of valve-to-graft tapering, reduced coronary button anastomosis tension, and prosthesis selection according to patient profile, are apparent advantages of modified-bB.

Mechanism of the antigen formation of carvone and related alpha, beta-unsaturated ketones

In the present study, the mechanism for the antigen formation of alpha, beta-unsaturated ketones was investigated. A series of analogues of carvone ((5R)-5-isopropenyl-2-methyl-2-cyclohexenone) with altered chemical reactivity and with retained overall structure or with retained reactivity and altered three-dimensional structure were synthesized. These analogues were tested for cross-reactivity in carvone-sensitized animals. Cross-reactivity was observed for analogue 3 ((5R)-5-isopropyl-2-methyl-2-cyclohexen-1-one). No cross-reactions were observed for analogues 1 ((2R,5R)-5-isopropenyl-2-methyl cyclohexanone) and 4 ((5R)-2,3-dimethyl-5-isopropenyl-2-cyclohexene-1-one). Both those compounds also failed to induce sensitization. These findings demonstrate that alpha, beta-unsaturated ketones form antigens after a nucleophilic attack at the beta-carbon with soft nucleophiles such as thiol in cysteine and not with the formation of a Schiff's base after a nucleophilic attack at the carbonyl carbon with nitrogen nucleophiles. Furthermore, no cross-reactivity was observed between R- and S-carvone indicating the importance of the 3-dimensional structure of haptens (and antigens) in T-cell recognition. The analogues were also tested for cross-reactivity on patients allergic to carvone. The results from the animal study were confirmed.

BIOMED-MEROPE project: service provision for adults with intellectual disability: a European comparison

The aim of the present paper is to describe and compare services for adults with intellectual disability (ID) and mental health needs in five European countries: Austria, England, Greece, Ireland and Spain. A framework and structure for collecting information about service provision was designed. This information was collected through a mixture of interviews with service providers, questionnaires and a review of the research literature within each country. Information was collected on historical context, policy, legislation, assessment, treatment and the structure of services for people with ID and mental health problems. Overall, the needs of those with additional mental health needs have not been specifically addressed at a national level with perhaps the exception of England and Ireland, although there are still gaps in services in these nations. Normalization has been adopted in each of the five countries, and there are moves toward deinstitutionalization, integration and inclusion. Families and self-advocacy groups have grown. The pace of this change varies between and even within countries. The main findings of the study include: unclear policy, trends for legislative changes, increased prevalence of mental health problems, inadequate generic service provision, a need for specialist mental health services, a need for improved interconnections of services, and a need for training developments. Policy and legislation in the five European countries under consideration tend to separate the disability aspects of people with ID from their mental health needs. Consequently, the service needs of this group remain largely invisible. This might be a direct reflection of policy clarity and legislation, or could be the result of a failure to implement existing guidelines. This has a detrimental effect on the lives of people with ID, and their families and carers.

Thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas

BACKGROUND

Intractable pain is the most distressing symptom in patients suffering from unresectable pancreatic carcinoma. Palliative interventions are justified to relieve the clinical symptoms with as little interference as possible in the quality of life. The purpose of this study was to examine the efficacy and safety of thoracoscopic splanchnicectomy for pain control in patients with unresectable carcinoma of the pancreas.

METHODS

Between May 1995 and April 1998, 24 patients (14 men and 10 women) with a mean age of 65 years (range, 30-85) suffering from intractable pain due to unresectable carcinoma of the pancreas underwent 35 thoracoscopic splanchnicectomies. All patients were opiate-dependent and unable to perform normal daily activities. Subjective evaluation of pain was measured before and after the procedure by a visual analogue score. The following parameters were also evaluated: procedure-related morbidity and mortality, operative time, and length of hospital stay.

RESULTS

All procedures were completed thoracoscopically, and no intraoperative complications occurred. The mean operative time was 58+/-22 min for unilateral left splanchnicectomy and 93.5+/-15.6 min for bilateral splanchnicectomies. The median value of preoperative pain intensity reported by patients on a visual analogue score was 8.5 (range, 8-10). Postoperatively, pain was totally relieved in all patients, as measured by reduced analgesic use. However, four patients experienced intercostal pain after bilateral procedures, even though their abdominal pain had disappeared. Complete pain relief until death was achieved in 20 patients (84%). Morbidity consisted of persistent pleural effusion in one patient and residual pneumothorax in another. The mean hospital stay was 3 days (range, 2-5).

CONCLUSIONS

We found thoracoscopic splanchnicectomy to be a safe and effective procedure of treating malignant intractable pancreatic pain. It eliminates the need for progressive doses of analgesics, with their side effects, and allows recovery of daily activity. The efficacy of this procedure is of major importance since life expectancy in these patients is very short.

Audiometric and epidemiological analysis of elderly in the Veneto region

BACKGROUND

Presbyacusis, or age-related hearing loss, has become a problem of increasing social interest due to the rise in the mean age of the population. Investigations performed to date have generally been carried out with the aid of self-reporting questionnaires, without the support of objective findings.

OBJECTIVE

The purpose of this study was to analyze an extensive series of elderly people from different areas of the Veneto region to obtain an epidemiological descriptive analysis, as detailed as possible, of their presbyacusis, considering their hearing thresholds at various frequencies, distinguishing findings according to sex and age in classes and the geographical area where the survey was performed.

METHODS

The survey was carried out collecting information from the audiometric reports on 13,710 subjects of both sexes aged 60 years and over, with a proportion of males (M/F x 100) of 92.02%, referred spontaneously for hearing examination to the ENT departments of eight hospitals between 1986 and 1994. The catchment area includes three provincial capitals and five mainly rural municipalities.

RESULTS

The results show that the hearing threshold rises progressively with age in both sexes. The hearing loss is milder in women than in men, especially at the higher frequencies. No important differences emerged among findings recorded in their 80s and in their 90s or among findings in the different geographical areas considered.

CONCLUSIONS

Statistical descriptive analysis confirms the typical trend of the audiometric curve in presbyacusis, tracing the typical audiometric curve of old age described in the literature. The mean values of the audiometric curve reveal no significant differences between people residing in the country and people living in the cities.

[Outcome after spontaneous subarachnoid hemorrhage. Relationship between admission glycemia and clinical status on admission and on hospital discharge]

BACKGROUND

To determine the relationship between the glycemia on hospital admission after subarachnoid haemorrhage (SAH) and neurological score.

PATIENTS AND METHODS

On 44 patients we recorded the glycemia value on admission, coma Glasgow scale (CGS) and Hunt and Hess scale grade (HH), on admission, on discharge and six months later.

RESULTS

The patients with HH IV-V and GCS between 3 and 8 had glycemia values higher than patients with HH I-III and GCS between 9 and 15. The patients with HH IV-V on discharge had glycemia values higher than patients with HH I-III.

CONCLUSIONS

Glycemia value on admission is related with the acute injury severity and represents a prognosis factor in spontaneous subarachnoid haemorrhage outcome.

[Study of presurgical anxiety in urologic, gynecologic, and ophthalmologic surgery as a function of the administration or non-administration of anxiolytic premedication]

OBJECTIVE

Anxiety commonly appears before surgery, triggering a set of events that can be described as a general stress response. We measured changes in preoperative stress in relation to premedication or not with diazepam in patients undergoing urologic, gynecologic and ophthalmologic surgery.

PATIENTS AND METHOD

We enrolled 87 patients undergoing elective surgery in urology (n = 30), gynecology (n = 30) and ophthalmology (n = 27). Randomly, the patients were premedicated with diazepam, placebo or nothing. During the preoperative visit the patient was administered a test to determine the level of anxiety and blood pressure, heart rate and potassium plasma concentration (K+) the night before surgery and moments before entering the operating theater.

RESULTS

No significant differences in anxiety between patients undergoing different types of surgery were detected in the operating theater; however, at that time, anxiety was found to be significantly less among patients premedicated with diazepam than among those given placebo. Preoperative anxiety was significantly less in ophthalmology patients and in those premedicated with diazepam. Both systolic and diastolic blood pressure increased significantly among urologic and ophthalmologic surgery patients and in those who were not premedicated with diazepam regardless of type of surgery. Heart rate did not change significantly. Potassemia decreased significantly in all patients.

CONCLUSION

The discrepancy between the psychological and somatic response to the stress conditions studied may be the result of the calming effect of the preoperative visit by the anesthesiologist and to premedication with a tranquilizer. However, neither the preoperative visit nor premedication seem to completely block the stress response.

Could age be an indication for laparoscopic colectomy in colorectal cancer?

BACKGROUND

The incidence of colorectal carcinoma increases in the elderly. Regardless of age as an isolated factor, postoperative complications represent the main factor in increasing hospital mortality.

METHODS

The aim of this study was to compare the short-term results (first 30 postoperative days) after laparoscopically assisted colectomy (LAC) and open segmental colectomy (OC) in colorectal carcinoma between two groups of patients, older than 70 and younger than 70 years of age. In the study from November 1993 to June 1998, 255 patients were evaluated to participate.

RESULTS

Peristalsis, oral intake, and discharge from the hospital occurred earlier in LAC than in OC treated patients, in the two age groups. The mean operative time was significantly longer in the LAC than in the OC patients in the two age groups. No differences were observed in morbidity between LAC and OC in the group younger than 70 years of age. However, the overall morbidity was significantly lower in the LAC group in patients older than 70 years. One patient in the LAC group older than 70 years died.

CONCLUSION

These results suggest that laparoscopically assisted colectomy may be particularly indicated in elderly patients.