Efficacy of immune checkpoint inhibitors for the treatment of advanced melanoma in patients with concomitant chronic lymphocytic leukemia

BACKGROUND

Immune checkpoint inhibitors (ICIs) have revolutionized the management of advanced melanoma (AM). However, data on ICI effectiveness have largely been restricted to clinical trials, thereby excluding patients with co-existing malignancies. Chronic lymphocytic leukemia (CLL) is the most prevalent adult leukemia and is associated with increased risk of melanoma. CLL alters systemic immunity and can induce T-cell exhaustion, which may limit the efficacy of ICIs in patients with CLL. We, therefore, sought to examine the efficacy of ICI in patients with these co-occurring diagnoses.

PATIENTS AND METHODS

In this international multicenter study, a retrospective review of clinical databases identified patients with concomitant diagnoses of CLL and AM treated with ICI (US-MD Anderson Cancer Center, N = 24; US-Mayo Clinic, N = 15; AUS, N = 19). Objective response rates (ORRs), assessed by RECIST v1.1, and survival outcomes [overall survival (OS) and progression-free survival (PFS)] among patients with CLL and AM were assessed. Clinical factors associated with improved ORR and survival were explored. Additionally, ORR and survival outcomes were compared between the Australian CLL/AM cohort and a control cohort of 148 Australian patients with AM alone.

RESULTS

Between 1997 and 2020, 58 patients with concomitant CLL and AM were treated with ICI. ORRs were comparable between AUS-CLL/AM and AM control cohorts (53% versus 48%, P = 0.81). PFS and OS from ICI initiation were also comparable between cohorts. Among CLL/AM patients, a majority were untreated for their CLL (64%) at the time of ICI. Patients with prior history of chemoimmunotherapy treatment for CLL (19%) had significantly reduced ORRs, PFS, and OS.

CONCLUSIONS

Our case series of patients with concomitant CLL and melanoma demonstrate frequent, durable clinical responses to ICI. However, those with prior chemoimmunotherapy treatment for CLL had significantly worse outcomes. We found that CLL disease course is largely unchanged by treatment with ICI.

Handling prevents and reverses cognitive deficits induced by sub-chronic phencyclidine in a model for schizophrenia in rats

Treatments for schizophrenia are not effective in ameliorating cognitive deficits. Therefore, novel therapies are needed to treat cognitive impairments associated with schizophrenia (CIAS), which are modelled in rats through administration of sub-chronic phencyclidine (scPCP). We have previously shown that enrichment via voluntary exercise prevents and reverses impairments in novel object recognition (NOR) in this model. The present study aimed to investigate if handling could prevent delay-induced NOR deficits and prevent and reverse scPCP-induced NOR deficits. Two cohorts of adult female Lister Hooded rats were used. In experiment one, handling (five minutes/day, five days/week for two weeks), took place before scPCP administration (2 mg/kg, i.p. twice-daily for seven days). NOR tests were conducted at two, four, and seven weeks post-handling with a one-minute inter-trial interval (ITI) and at five weeks post-dosing with a six-hour ITI. In experiment two, rats were handled after scPCP administration and tested immediately in the one-minute ITI NOR task and again at two weeks post-handling. In both handling regimens, the scPCP control groups failed to discriminate novelty, conversely the scPCP handled groups significantly discriminated in this task. In the 6 h ITI test, vehicle control and scPCP control failed to discriminate novelty; however, the vehicle handled and scPCP handled groups did significantly discriminate. Handling rats prevented and reversed scPCP-induced deficits and prevented delay-induced NOR deficits. These findings add to evidence that environmental enrichment is a viable treatment for cognitive deficits in rodent tests and models of relevance to schizophrenia, with potential to translate into effective treatments for CIAS.

Investigation of a Prolonged and Large Outbreak of Healthcare-Associated Mucormycosis Cases in an Acute Care Hospital-Arkansas, June 2019-May 2021

Background

Outbreaks of healthcare-associated mucormycosis (HCM), a life-threatening fungal infection, have been attributed to multiple sources, including contaminated healthcare linens. In 2020, staff at Hospital A in Arkansas alerted public health officials of a potential HCM outbreak.

Methods

We collected data on patients at Hospital A who had invasive mucormycosis during January 2017-June 2021 and calculated annual incidence of HCM (defined as mucormycosis diagnosed within ≥7 days after hospital admission). We performed targeted environmental assessments, including linen sampling at the hospital, to identify potential sources of infection.

Results

During the outbreak period (June 2019-June 2021), 16 patients had HCM; clinical features were similar between HCM patients and non-HCM patients. Hospital-wide HCM incidence (per 100 000 patient-days) increased from 0 in 2018 to 3 in 2019 and 6 in 2020. For the 16 HCM patients, the most common underlying medical conditions were hematologic malignancy (56%) and recent traumatic injury (38%); 38% of HCM patients died in-hospital. Healthcare-associated mucormycosis cases were not epidemiologically linked by common procedures, products, units, or rooms. At Hospital A and its contracted offsite laundry provider, suboptimal handling of laundered linens and inadequate environmental controls to prevent mucormycete contamination were observed. We detected Rhizopus on 9 (9%) of 98 linens sampled at the hospital, including on linens that had just arrived from the laundry facility.

Conclusions

We describe the largest, single-center, HCM outbreak reported to date. Our findings underscore the importance of hospital-based monitoring for HCM and increased attention to the safe handling of laundered linens.

46. Antimicrobial Stewardship’s Selective Antibiotic Suppression Does Not Lead to Adverse Outcomes in Neutropenic Patients with Gram-Negative Bacteremia

Background

An antimicrobial stewardship program (ASP) strategy to minimize the use of overly broad antimicrobials is to suppress specific antimicrobial susceptibility results when isolates are sensitive to narrow antibiotics. There is limited data on possible adverse outcomes of this method. Patients with febrile neutropenia (FN) and gram-negative bacteremia (GNB) whose culture is sensitive to non-pseudomonal antibiotics still require broader pseudomonal coverage to treat the syndrome of FN. We evaluated if ASP suppression of anti-pseudomonal antibiotics adversely affects patients with FN and GNB.

Methods

In February 2018, our institution’s ASP began suppressing cefepime and meropenem susceptibility results from E. coli, Klebsiella spp, and Proteus spp when sensitive to cefepime (MIC ≤ 2), ceftriaxone and ceftazidime. We performed a retrospective analysis of patients with FN and GNB from 2016 – 2020 to evaluate the appropriateness of antibiotic regimens before and after the ASP intervention. Antibiotic regimens were deemed inappropriate if the patient was de-escalated to a narrow-spectrum, non-pseudomonal agent while neutropenic. Of 338 inpatient encounters identified with any bacteremia and FN, 49 were due to non-Pseudomonas, non-ESBL GNB, 20 before and 29 after the intervention. Sixteen of the 29 post-intervention patients were excluded, as their isolates did not meet suppression criteria. This resulted in a total of 13 patients in the post-intervention group.

Results

After culture susceptibility reports were released, 3 out of 20 patients in the pre-intervention group (15%) and 4 out of 13 patients in the post-intervention group (30.8%) were inappropriately tailored to narrow-spectrum antibiotics (p=0.39). There was no significant difference in 30-day mortality, 10.0% pre- and 0% post-intervention (p=0.50), or amount of meropenem prescribed, 45% pre- and 38.5% post-intervention (p=0.74).

Conclusion

These data show no significant difference in inappropriate antibiotic regimens prescribed for patients with FN and GNB after ASP antibiotic suppression was implemented. 30-day mortality was also not affected. The ASP intervention did not decrease meropenem prescriptions in this patient group, which may be appropriate. Larger studies are needed to verify these findings.

Disclosures

Ryan K. Dare, MD, MS, Accelerate Diagnostics, Inc (Research Grant or Support) Mary Burgess, MD, Pfizer Inc (Grant/Research Support)

Mucormycosis in Hematopoietic Cell Transplant Recipients and in Patients With Hematological Malignancies in the Era of New Antifungal Agents

Background

The survival benefit of combination antifungal therapy for invasive mucormycosis (IM) in patients with hematologic malignancy (HM) and hematopoietic cell transplant (HCT) is not well defined.

Methods

This multicenter, retrospective study included HM and HCT recipients with proven or probable IM between January 1, 2007 and December 31, 2017 from 10 transplant centers across North America.

Results

Sixty-four patients with proven (n = 47) or probable (n = 17) IM defined by 2008 European Organization for Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG) consensus definitions were included. Thirty-nine (61%) were HCT recipients (95% allogeneic). Sites of infection included rhino-orbital-cerebral (33), pulmonary (30%), disseminated (19%), gastrointestinal (3%), and cutaneous (3%). Surgical debridement was performed in 66%. Initial antifungal treatment consisted of the following: lipid formulation of amphotericin B (AmB) alone (44%), AmB + posaconazole (25%), AmB + echinocandin (13%), AmB + isavuconazole (8%), posaconazole alone (5%), and isavuconazole alone (3%). All-cause mortality at 30 days and 1 year were 38% and 66%, respectively. Initial treatment with AmB plus posaconazole or isavuconazole (n = 28) was associated with a trend toward lower treatment failure compared with AmB (n = 21) (42% vs 64%, P = .136).

Conclusions

Long-term survival with IM among HM and HCT populations remains poor. However, initial use of AmB + azole in conjunction with surgery may result in less treatment failure. More evidence from prospective controlled studies is needed to confirm this observation.

Psychological and demographic factors associated with fatigue and social adjustment in young people with severe chronic fatigue syndrome/myalgic encephalomyelitis: a preliminary mixed-methods study

This mixed-methods study investigated factors associated with fatigue, disability and school attendance in young people with severe CFS/ME. Participants' illness experiences were also explored. Questionnaires were completed at baseline (T1) and approximately 5 months later (T2). There were 51 participants aged between 12 and 25, with a mean age of 18.8 years (SD 3.4). At T1, participants reported severe fatigue and poor social adjustment. Stronger fear avoidance beliefs at T1 were associated with higher fatigue at T2, and with worse social adjustment at T1 and T2. Female gender was associated with lower work/school attendance at T1 and T2 but not with higher fatigue or worse social adjustment. Having accessed treatment was associated with reporting lower levels of work/school attendance at T1 and T2. Multivariate analyses of key outcomes identified significant associations between stronger fear avoidance beliefs and worse social adjustment at T2, and between female gender and lower work/school attendance at T2. It was clear from the qualitative data that severe CFS/ME negatively impacted on many aspects of young people's lives. Fearful beliefs about activity could be targeted using cognitive-behavioural interventions.

Home-based family focused rehabilitation for adolescents with severe Chronic Fatigue Syndrome

AIMS:

The purpose of this article is to describe and evaluate a home based, family focused rehabilitative approach for severely affected housebound adolescents with Chronic Fatigue Syndrome (CFS). The main aims were to facilitate a return to school, improve physical functioning, reduce fatigue and assess any adverse effects of the intervention.

METHODS:

Six housebound adolescents aged 11-18, diagnosed with CFS by a paediatrician, were assessed and treated at home by an experienced cognitive behaviour therapist. Outcomes were assessed 12 months after discharge from treatment.

RESULTS:

At 12 months follow-up all patients had returned to either school or college, and physical functioning had improved in most of the patients. Fatigue had reduced in some. No adverse effects of the intervention were reported.

CONCLUSION:

Severely affected adolescents with CFS showed improved physical functioning and social adjustment after a home-based rehabilitative approach. Although several patients showed improvements in physical functioning, they did not all show substantial improvements in fatigue. At this crucial stage of development, it is important to offer young people and their parents hope by stating that improvement is possible.

The 2018 rift eruption and summit collapse of Kīlauea Volcano

In 2018, Kīlauea Volcano experienced its largest lower East Rift Zone (LERZ) eruption and caldera collapse in at least 200 years. After collapse of the Pu'u 'Ō'ō vent on 30 April, magma propagated downrift. Eruptive fissures opened in the LERZ on 3 May, eventually extending ~6.8 kilometers. A 4 May earthquake [moment magnitude (M _w) 6.9] produced ~5 meters of fault slip. Lava erupted at rates exceeding 100 cubic meters per second, eventually covering 35.5 square kilometers. The summit magma system partially drained, producing minor explosions and near-daily collapses releasing energy equivalent to M _w 4.7 to 5.4 earthquakes. Activity declined rapidly on 4 August. Summit collapse and lava flow volume estimates are roughly equivalent-about 0.8 cubic kilometers. Careful historical observation and monitoring of Kīlauea enabled successful forecasting of hazardous events.

Response to the editorial by Dr Geraghty

This article is written in response to the linked editorial by Dr Geraghty about the adaptive Pacing, graded Activity and Cognitive behaviour therapy; a randomised Evaluation (PACE) trial, which we led, implemented and published. The PACE trial compared four treatments for people diagnosed with chronic fatigue syndrome. All participants in the trial received specialist medical care. The trial found that adding cognitive behaviour therapy or graded exercise therapy to specialist medical care was as safe as, and more effective than, adding adaptive pacing therapy or specialist medical care alone. Dr Geraghty has challenged these findings. In this article, we suggest that Dr Geraghty’s views are based on misunderstandings and misrepresentations of the PACE trial; these are corrected.

Lasiodiplodia species fungal osteomyelitis in a multiple myeloma patient

Lasiodiplodia species are environmental fungi that have been reported as a cause of infection in both immunocompetent and immunocompromised patients. We present a case of fungal osteomyelitis caused by Lasiodiplodia species in a patient with multiple myeloma after autologous stem cell transplant. The patient was successfully treated with a combination of surgery and oral voriconzole. To the best of our knowledge, this is the first reported case of fungal osteomyelitis caused by Lasiodiplodia species.

In-Center Nutrition Practices of Clinics within a Large Hemodialysis Provider in the United States

BACKGROUND AND OBJECTIVES

Eating during hemodialysis treatment remains a controversial topic. It is perceived that more restrictive practices in the United States contribute to poorer nutritional status and elevated mortality compared with some other parts of the world. However, in-center food practices in the United States have not been previously described.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

In 2011, we conducted a survey of clinic practices and clinician (dietitian, facility administrator, and medical director) opinions related to in-center food consumption within a large dialysis organization. After the initial survey, we provided clinicians with educational materials about eating during treatment. In 2014, we performed a follow-up survey. Differences in practices and opinions were analyzed using chi-squared tests and logistic regression.

RESULTS

In 2011, 343 of 1199 clinics (28.6%) did not allow eating during treatment, 222 clinics (18.2%) did not allow drinking during treatment, and 19 clinics (1.6%) did not allow eating at the facility before or after treatment. In 2014, the proportion of clinics that did not allow eating during treatment had declined to 22.6% (321 of 1422 clinics), a significant shift in practice (P<0.001). Among the 178 (6.8%) clinics that self-reported that eating was "more allowed" in 2014, the main reason for this shift was an increased focus on nutritional status. Among clinicians, a higher percentage encouraged eating during treatment (53.1% versus 37.4%; P<0.05), and facility administrators and medical directors were less concerned about the seven reasons commonly cited for restricting eating during treatment in 2014 compared with 2011 (P<0.05 for all).

CONCLUSIONS

We found that 28.6% and 22.6% of hemodialysis clinics within the United States restricted eating during treatment in 2011 and 2014, respectively, a rate more than double that found in an international cohort on which we previously published. However, practices and clinician opinions are shifting toward allowing patients to eat. Additional research is warranted to understand the effect that these practices have on patient outcomes and outline best practices.

Training, supervision and therapists' adherence to manual-based therapy

Objectives

To describe the development, delivery and quality control of three manual-based therapies as given in an inter-professional multi-centre randomized controlled trial of therapies for chronic fatigue syndrome (CFS).

Methods

Experienced therapy leaders were recruited. These therapy leaders then developed the treatments and therapy manuals, piloted them, and planned training and supervision. Appropriately-qualified therapists were recruited to deliver each therapy and trained in the specific therapy philosophy, model and delivery. Training and supervision was face-to-face and by telephone, and included reviewing audio recordings of therapy sessions.

Results

At the end of the trial, the therapists delivering all three trial therapies were similarly highly rated as adhering well to their manuals and scored similarly and highly on therapeutic alliance with patients and therapy differentiation.

Conclusions

High-quality delivery of therapy can be achieved if there is an experienced therapy lead, if therapy manuals have been piloted, and if therapists are well trained and supervised, including the review of recorded treatment sessions. Routine clinical practice could benefit from the implementation of these procedures.

Adolescents with severe chronic fatigue syndrome can make a full recovery

The needs of children and adolescents severely affected by chronic fatigue syndrome, myalgic encephalomyelitis (CFS/ME) are currently inadequately addressed in the UK. Sadly, there are few specialists addressing the needs of these patients who are primarily bed-bound, wheelchair users or who can only leave home on an infrequent basis. Uncertainty about what to offer as well of a lack of funding may play a part. Action for Young people with ME (AYME) suggests that at least 350 severely affected children/adolescents are receiving little or inadequate care to help them overcome this debilitating illness. This case report illustrates how recovery can occur with pragmatic rehabilitation combined with a committed compassionate family based approach.

Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial

BACKGROUND

Trial findings show cognitive behaviour therapy (CBT) and graded exercise therapy (GET) can be effective treatments for chronic fatigue syndrome, but patients' organisations have reported that these treatments can be harmful and favour pacing and specialist health care. We aimed to assess effectiveness and safety of all four treatments.

METHODS

In our parallel-group randomised trial, patients meeting Oxford criteria for chronic fatigue syndrome were recruited from six secondary-care clinics in the UK and randomly allocated by computer-generated sequence to receive specialist medical care (SMC) alone or with adaptive pacing therapy (APT), CBT, or GET. Primary outcomes were fatigue (measured by Chalder fatigue questionnaire score) and physical function (measured by short form-36 subscale score) up to 52 weeks after randomisation, and safety was assessed primarily by recording all serious adverse events, including serious adverse reactions to trial treatments. Primary outcomes were rated by participants, who were necessarily unmasked to treatment assignment; the statistician was masked to treatment assignment for the analysis of primary outcomes. We used longitudinal regression models to compare SMC alone with other treatments, APT with CBT, and APT with GET. The final analysis included all participants for whom we had data for primary outcomes. This trial is registered at http://isrctn.org, number ISRCTN54285094.

FINDINGS

We recruited 641 eligible patients, of whom 160 were assigned to the APT group, 161 to the CBT group, 160 to the GET group, and 160 to the SMC-alone group. Compared with SMC alone, mean fatigue scores at 52 weeks were 3·4 (95% CI 1·8 to 5·0) points lower for CBT (p = 0·0001) and 3·2 (1·7 to 4·8) points lower for GET (p = 0·0003), but did not differ for APT (0·7 [-0·9 to 2·3] points lower; p = 0·38). Compared with SMC alone, mean physical function scores were 7·1 (2·0 to 12·1) points higher for CBT (p = 0·0068) and 9·4 (4·4 to 14·4) points higher for GET (p = 0·0005), but did not differ for APT (3·4 [-1·6 to 8·4] points lower; p=0·18). Compared with APT, CBT and GET were associated with less fatigue (CBT p = 0·0027; GET p = 0·0059) and better physical function (CBT p=0·0002; GET p<0·0001). Subgroup analysis of 427 participants meeting international criteria for chronic fatigue syndrome and 329 participants meeting London criteria for myalgic encephalomyelitis yielded equivalent results. Serious adverse reactions were recorded in two (1%) of 159 participants in the APT group, three (2%) of 161 in the CBT group, two (1%) of 160 in the GET group, and two (1%) of 160 in the SMC-alone group.

INTERPRETATION

CBT and GET can safely be added to SMC to moderately improve outcomes for chronic fatigue syndrome, but APT is not an effective addition.

FUNDING

UK Medical Research Council, Department of Health for England, Scottish Chief Scientist Office, Department for Work and Pensions.

Fourier transform infrared spectroscopic analysis of normal and torn rotator-cuff tendons

We have used Fourier transform infrared spectroscopy (FTIR) to characterise the chemical and structural composition of the tendons of the rotator cuff and to identify structural differences among anatomically distinct tears. Such information may help to identify biomarkers of tears and to provide insight into the rates of healing of different sizes of tear. The infrared spectra of 81 partial, small, medium, large and massive tears were measured using FTIR and compared with 11 uninjured control tendons. All the spectra were classified using standard techniques of multivariate analysis.

FTIR readily differentiates between normal and torn tendons, and different sizes of tear. We identified the key discriminating molecules and spectra altered in torn tendons to be carbohydrates/phospholipids (1030 cm−1 to 1200 cm−1), collagen (1300 cm−1 to 1700 cm−1 and 3000 cm−1 to 3350 cm−1) and lipids (2800 cm−1 to 3000 cm−1).

Our study has shown that FTIR spectroscopy can identify tears of the rotator cuff of varying size based upon distinguishable chemical and structural features. The onset of a tear is mainly associated with altered structural arrangements of collagen, with changes in lipids and carbohydrates. The approach described is rapid and has the potential to be used peri-operatively to determine the quality of the tendon and the extent of the disease, thus guiding surgical repair.

Advance care planning in the skilled nursing facility: what do we need for success?

INTRODUCTION

Despite the established benefits of advance care planning (ACP) in the geriatric population, documentation of ACP counseling in the skilled nursing facility (SNF) setting remains poor. The primary aim of this study was to identify key barriers to ACP completion among SNF providers. A secondary aim was to identify ACP practice-based differences between SNF physicians and midlevel providers.

METHODS

As part of a divisional quality improvement project, 43 SNF providers from the area's 9 facilities were asked to complete an optional 14-item electronic survey. The survey was designed to explore and contrast SNF physicians' and midlevel providers' experiences with ACP counseling and documentation.

RESULTS

We obtained a 91% completion rate. Systems-based factors, such as lack of a centralized document location, inconsistent documentation habits, dispersion of responsibility, lack of time, and under-recognition of team members' efforts, were cited as key barriers to ACP documentation. Perceived patient characteristics contributing to a low completion rate included cognitive impairment and lack of family involvement. Key differences between the 2 provider groups included the location of their ACP documentation (electronic medical record vs paper chart), frequency of documentation, and recognition of who is documenting the ACP.

CONCLUSION

The survey demonstrated that systems-based barriers contribute to poor ACP documentation in the SNF setting. Key differences in attitudes about the impact of ACP on loved ones were identified between provider groups. Strategies aimed at mitigating practice-level barriers, such as standardizing a location for ACP documentation and formalizing workflow, are needed for increased ACP completion rates in SNFs.

Right ventricular function in children with severe respiratory syncytial virus (RSV) bronchiolitis

BACKGROUND

Previous studies have demonstrated the development of myocardial damage and hepatitis in children with severe respiratory syncytial virus (RSV) infection. The aim of this study was to assess right ventricular function in children with severe RSV disease and to investigate an association with disease severity, myocardial damage, and hepatitis.

METHODS

This was a prospective observational study performed at a 20-bed regional multidisciplinary tertiary pediatric intensive care unit (PICU) in a university-affiliated children's hospital. Pulse wave Doppler echocardiographic assessments with a calculation of the right ventricular function (Tei index), left ventricular ejection fraction and diameters, cardiac troponin T levels, transaminase and C-reactive protein levels were performed at admission on consecutive children who were ventilated and diagnosed with a severe RSV infection and without congenital heart disease.

RESULTS

Thirty-four ventilated children with confirmed RSV bronchiolitis were enrolled. The median age was 1.4 months (range 0.4-11.7), and the median length of ventilation was 5 days (range 2-10). Seven (20%) infants had an elevated right ventricular Tei index indicating reduced right ventricular function. Left ventricular function as well as C-reactive protein and transaminase levels were not different between patients with and without an elevated right ventricular Tei index. Cardiac troponin T was elevated in 14 patients (41%): 3/7 with an elevated and 11/27 with a normal Tei index (P=1). Ventilation and oxygenation indices and the duration of mechanical ventilation were not different between the two groups.

CONCLUSION

A raised right ventricular Tei index, consistent with reduced right ventricular function, was observed in severe RSV disease, but the degree of dysfunction was not related to the level of biochemical myocardial or hepatic damage or level of respiratory support.

Inhibition of cervical cancer cell growth in vitro and in vivo with dual shRNAs

RNA interference (RNAi)-based gene silencing is widely used in laboratories for gene function studies and also holds a great promise for developing treatments for diseases. However, in vivo delivery of RNAi therapy remains a key issue. Lentiviral vectors have been employed for stable gene transfer and gene therapy and therefore are expected to deliver a stable and durable RNAi therapy. But this does not seem to be true in some disease models. Here, we showed that lentivirus delivered short-hairpin RNA (shRNA) against human papillomavirus (HPV) E6/E7 oncogenes were effective for only 2 weeks in a cervical cancer model. However, using this vector to carry two copies of the same shRNA or two shRNAs targeting at two different but closely related genes (HPV E6 and vascular endothelial growth factor) was more effective at silencing the gene targets and inhibiting cell or even tumor growth than their single shRNA counterparts. The cancer cells treated with dual shRNA were also more sensitive to chemotherapeutic drugs than single shRNA-treated cells. These results suggest that a multi-shRNA strategy may be a more attractive approach for developing an RNAi therapy for this cancer.

A randomized, prospective study of total hip wound closure with resorbable subcuticular staples

Resorbable subcuticular staples are a new way to close surgical wounds and have not been reported in the orthopedic literature. This randomized, controlled study compared a resorbable subcuticular staple system with stainless steel wound stapling in patients undergoing unilateral primary total hip arthroplasty (THA). Institutional Review Board approval and patient consent was obtained for all patients. Sixty patients (30 each group) were randomized to receive either resorbable subcuticular staples or stainless steel staples after primary THA. Incision length, number of staples used, and any staple insertion problems were recorded. Subjective reports of pain levels or incision complaints were solicited, and wound photographs were obtained on days 1 and 14 and 6 weeks postoperatively. The presence of wound drainage, erythema, wound separation, or echymosis was recorded at each visit, as well as all postoperative complications. The average incision length in the resorbable group was 13.2 cm and required 16 staples for closure, compared to 15 cm and 20 staples for the metal staple group. No infections occurred in either group, although the incidence of erythema and wound drainage at 2 weeks was higher for patients in the stainless steel group. One patient with metal staples had a postoperative hematoma requiring secondary irrigation and debridement. Patient satisfaction was higher with the resorbable staples. A resorbable subcuticular staple system can provide comparable wound closure to stainless steel staples following THA and may do so with less local discomfort, wound drainage, or erythematous reaction.

Systemic delivery of E6/7 siRNA using novel lipidic particles and its application with cisplatin in cervical cancer mouse models

Small interfering RNA (siRNA) shows great promise in cancer therapy, but its effectiveness in vivo still remains a crucial issue for its transition into the clinics. Although the successful use of polyethylene glycol (PEG)ylated lipidic delivery systems have already been reported, most of the formulation procedures used are labour intensive and also result in unstable end products. We have previously developed a simple yet efficient hydration-of-freeze-dried-matrix (HFDM) method to entrap siRNA within lipid particles, in which the products exhibited superior stability. Here, we show that these HFDM-formulated particles are stable in the presence of serum and can deliver siRNA efficiently to tumours after intravenous administration. Using these particles, around 50% knockdown of the target gene expression was observed in tumours. With the use of siRNA targeting the E6/7 oncogenes expressed in cervical cancer, we showed a 50% reduction in tumour size. This level of tumour growth suppression was comparable to that achieved from cisplatin at the clinically used dose. Overall, our results demonstrate the feasibility of using HFDM-formulated particles to systematically administer E6/7-targeted siRNA for cervical cancer treatment. The simplicity of preparation procedure along with superior product stability obtained from our method offers an innovative approach for the in vivo delivery of siRNA.

Heart failure among younger rheumatoid arthritis and Crohn's patients exposed to TNF-alpha antagonists

OBJECTIVES

New onset heart failure (HF) has been associated with the use of TNF-alpha antagonists etanercept and infliximab based upon spontaneous adverse event reports. HF clinical trials of these agents were stopped early due to futility or worsening of existing HF. A potential association between etanercept and infliximab and new onset HF has been studied minimally at a population level.

METHODS

Using administrative claims from a large U.S. health care organization, we identified rheumatoid arthritis (RA) and Crohn's disease (CD) patients receiving infliximab or etanercept (exposed), and comparator cohorts of RA and CD patients receiving non-biologic immunosuppressives (unexposed). We studied adults < 50 years to reduce potential confounding related to common age-related comorbidities. Based on abstracted medical records of suspected HF cases, a physician panel adjudicated cases as definite, possible or no HF.

RESULTS

Among 4018 RA and CD patients with mean duration follow-up of 18 months, 9 of 33 suspected HF cases (identified using claims data) were adjudicated as definite (n = 5) or possible (n = 4) HF. The relative risk of HF among TNF-alpha antagonist-treated RA and CD patients was 4.3 and 1.2, respectively (P = NS for both). The absolute difference in cumulative incidence of HF among infliximab or etanercept-exposed compared to unexposed patients was 3.4 and 0.3 cases per 1000 persons for RA and CD (P = NS), respectively, yielding a number needed to harm of 294 for RA and 3333 for CD.

CONCLUSION

We found only a small number of presumed HF cases (n = 9, or 0.2%) in a large population of relatively young RA and CD patients. Although there was an increased relative risk of incident, HF that was not statistically significant among those exposed to TNF-alpha antagonists compared to those unexposed, larger cohorts are needed to provide more precise risk estimates and permit adjustment for potential confounding.

Relationship between myocardial perfusion and dysfunction in diabetic cardiomyopathy: a study of quantitative contrast echocardiography and strain rate imaging

OBJECTIVE

To use quantitative myocardial contrast echocardiography (MCE) and strain rate imaging (SRI) to assess the role of microvascular disease in subclinical diabetic cardiomyopathy.

METHODS

Stress MCE and SRI were performed in 48 patients (22 with type II diabetes mellitus (DM) and 26 controls), all with normal left ventricular systolic function and no obstructive coronary disease by quantitative coronary angiography. Real-time MCE was acquired in three apical views at rest and after combined dipyridamole-exercise stress. Myocardial blood flow (MBF) was quantified in the 10 mid- and apical cardiac segments at rest and after stress. Resting peak systolic strain rate (SR) and peak systolic strain (epsilon) were calculated in the same 10 myocardial segments.

RESULTS

The DM and control groups were matched for age, sex and other risk factors, including hypertension. The DM group had higher body mass index and left ventricular mass index. Quantitative SRI analysis was possible in all patients and quantitative MCE in 46 (96%). The mean epsilon, SR and MBF reserve were all significantly lower in the DM group than in controls, with diabetes the only independent predictor of each parameter. No correlation was seen between MBF and SR (r = -0.01, p = 0.54) or between MBF and epsilon (r = -0.20, p = 0.20).

CONCLUSIONS

Quantitative MCE shows that patients with diabetes but no evidence of obstructive coronary artery disease have impaired MBF reserve, but abnormal transmural flow and subclinical longitudinal myocardial dysfunction are not related.

Phase I and pharmacological studies of the cryptophycin analogue LY355703 administered on a single intermittent or weekly schedule

LY355703 is a synthetic derivative of the marine cryptophycins, cytotoxic agents which induce mitotic arrest by binding at the microtubule vinca binding domain. Promising preclinical features of LY355703 were the 40-400 greater potency than paclitaxel or vinca alkaloids, the broad spectrum of antitumor activity in xenografts and the antitumour activity in multidrug resistant (MDR)-expressing murine tumours. Aims of this study were to define the maximum tolerated dose (MTD) and the dose recommended for Phase II, the pattern of toxicity, the pharmacokinetic profile and to document hints of antitumour activity of LY355703 given as 2-h infusion on day 1 every 3 weeks (Study 1) or, later on, on days 1, 8 and 15 every 4 weeks (Study 2). The latter weekly regimen was selected because of the acute dose-related toxicity reported in Study 1. The dose was escalated using a modified Continual Reassessment Method. Pharmacokinetic studies were performed on day 1 of cycle 1 in both studies; LY355703 plasma concentrations were assessed by liquid chromatography with tandem mass spectrometry. A total of 35 adult patients with solid tumours entered Study 1; the dose was escalated from 0.1 to 1.92 mg/m(2); at this dose 2 of 5 patients presented grade 3 neuropathy and myalgias; 1.48 mg/m(2) was then recommended for Phase II study. A total of 8 patients were treated in Study 2 at 1 mg/m(2); cumulative long-lasting neuroconstipation and neurosensory toxicity precluded the completion of the cycle in 9 out of 15 cycles; the clinical development of the weekly regimen was then discontinued. Other toxicities included cardiac dysrhythmia and mild alopecia. Pharmacokinetics of LY355703 appeared to be linear over the dose range studied. The administration of LY355703 on a 3-week schedule is associated with an acute dose-dependent peripheral neuropathy and myalgia of high interpatient variability for which possible risk factors and pharmacokinetic correlates could not be identified.

Acute thrombosis in an aortic prosthesis: all mechanical valves are not the same

A 65-year-old man presented with symptomatic aortic valve disease and underwent aortic valve replacement with a 21 mm Hall—Kaster valve. Warfarin was commenced, and an international normalized ratio (INR) of 2.5—4.0 was recommended. Twelve years later, the patient developed a large (10 cm) ascending aortic aneurysm not involving the descending aorta. Graft replacement of the ascending aorta was performed. Inspection of the prosthesis at that time revealed it to be clean and competent, although the aortic root was heavily calcified. Eight months later, the patient was re-admitted in extremis with acute dyspnoea. For the preceding 48 hours, the intermittent absence of valve clicks had been reported by the patient's daughter. The INR on admission was 2.5 and had ranged between 2.0 and 3.6 for the 3 months before presentation. It had not been below 2.0 for at least 4 years, but on six out of the last 20 visits to the anticoagulant clinic it had been between 2.0 and 2.5. Examination revealed cardiogenic shock with a to-and-fro murmur audible at the left sternal edge. Transoesophageal echocardiography revealed free aortic regurgitation and showed thrombosis of the valve elements. Emergency surgery was considered but deemed inappropriate since the patient was moribund. Thrombolysis was attempted but the patient deteriorated relentlessly. Post-mortem confirmed the clinical impression of prosthetic valve thrombosis with no evidence of primary mechanical failure, pannus overgrowth or endocarditis (Figure 1).

Cerebral embolisation during modern cardiopulmonary bypass

OBJECTIVES

Cerebral microembolisation still occurs during cardiopulmonary bypass and may cause both stroke and postoperative cognitive impairment. We investigated the frequency of cerebral embolisation during coronary artery bypass surgery with modern cardiopulmonary bypass and related these to ascending aortic atherosclerosis.

METHODS

Transcranial Doppler monitoring for cerebral embolisation to both middle cerebral arteries was performed in 65 patients undergoing coronary artery surgery with non-pulsatile alpha-stat hypothermic bypass. Epicardial ultrasound imaging of ascending aortic atherosclerosis was performed in 14 patients.

RESULTS

Thirty patients (56.9%) had more than 200 emboli entering the middle cerebral artery territories during surgery; most at the start of bypass and during defibrillation. Readjustment of aortic clamps and aortic cannulation also caused a large number of emboli which were probably particulate. Aortic disease was mild (mean plaque thickness 1 mm, interquartile range 0.9-1.2 mm) and did not relate to the number of cerebral emboli produced by aortic manipulation.

CONCLUSIONS

Cerebral embolisation remains common during coronary surgery despite advances in filter and bypass pump technology. Aortic manipulation and clamping was associated with emboli but epicardial ultrasound imaging was of little help in its prediction.