Immune biomarker evaluation of sequential tyrosine kinase inhibitor and nivolumab monotherapies in renal cell carcinoma: the phase I TRIBE trial

Background

Predictive biomarkers for immune checkpoint blockade in the second-line treatment of metastatic renal cell carcinoma (mRCC) are lacking.

Materials and methods

Patients with histologically confirmed RCC who started nivolumab after at least 4 months of tyrosine kinase inhibitors (TKIs) were recruited for this study. Serial tissue and blood samples were collected for immune biomarker evaluation. The primary endpoint was to determine the association of specific T-cell subsets with clinical outcomes tested using Wilcoxon rank sum for clinical benefit rate (CBR) and log-rank test for progression-free survival (PFS).

Results

Twenty patients were included in this trial with a median age of 64 years and followed-up for a median of 12 months. The median PFS for patients who received TKI was 13.8 months, while for those subsequently treated with nivolumab following TKI therapy, the median PFS was 2.6 months. CBR of nivolumab was 20% with two partial responses. Functionally active programmed cell death protein 1+ CD4+ T cells were enriched in non-responders (q = 0.003) and associated with worse PFS on nivolumab (P = 0.04). Responders showed a significant reduction in the effector CD4+T-cell (TEF) fraction compared to non-responders at 3 months on nivolumab (0.40 versus 0.80, P = 0.0005). CD127+CD4+ T cells were enriched in patients who developed immune-related adverse effects (q = 0.003). Using in-house validated multiplex immunohistochemistry for six markers, we measured tumour-associated immune cell densities in tissue samples. Responders to nivolumab showed a significantly higher mean of immune cell densities in tissue samples compared to non-responders (346 versus 87 cells/mm2, P = 0.04).

Conclusions

In this small study, analysis of tissue-based and peripheral blood immune cell subsets predicted clinical outcomes of nivolumab. Further studies are warranted with larger populations to validate these observations.

"I Like and Prefer to Work Alone": Social Anxiety, Academic Self-Efficacy, and Students' Perceptions of Active Learning

Although active learning improves student outcomes in science, technology, engineering, and mathematics (STEM) programs, it may provoke anxiety in some students. We examined whether two psychological variables, social anxiety (psychological distress relating to the fear of negative evaluation by others) and academic self-efficacy (confidence in one's ability to overcome academic challenges), interact with student perceptions of evidence-based instructional practices (EBIPs) and associate with their final grades in a STEM-related course. Human anatomy and physiology students in community college courses rated various EBIPs for their perceived educational value and their capacity to elicit anxiety (N = 227). In general, practices causing students the most anxiety (e.g., cold calling) were reported by students as having the least educational value. When controlling for students' self-reported grade point averages, socially anxious students rated several EBIPs as more anxiety inducing, whereas high-efficacy students reported less anxiety surrounding other EBIPs. Furthermore, mediation analysis revealed that individual differences in academic self-efficacy at the beginning of the term explained some of the negative association between students' social anxiety levels and final grades in the course. Our results, obtained in a community college context, support a growing body of evidence that social anxiety and academic self-efficacy are linked with how students perceive and perform in an active-learning environment.

Angina, quality of life and prognosis: prospective comparison of patients undergoing invasive management

Background

Angina is associated with impaired quality of life and an adverse prognosis.

Purpose

Prospectively evaluate quality of life and clinical outcomes in patients with angina undergoing invasive coronary angiography according to endotype: symptoms and/or signs of ischaemia and no obstructive coronary artery disease (INOCA) compared to obstructive coronary artery disease subjects managed by medical therapy, revascularization with percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery, respectively.

Methods

We conducted a prospective clinical evaluation of patients with angina undergoing clinically indicated invasive management (NCT03193294). Symptom severity and quality of life were assessed at baseline and repeated after 6 months. Comparisons between treatment groups were based on analysis of covariance general linear models adjusting for baseline score, sex, and cardiovascular risk. INOCA subjects were considered as one diagnostic group and not all subjects had invasive vasoreactivity testing.

Results

391 patients (mean age 62±10 years, 52% female) were enrolled over 12 months and classified into one of four groups: INOCA (N=185; 47%), obstructive CAD treated by PCI (N=126; 32%), obstructive CAD treated by CABG (N=48; 12%) and obstructive CAD managed with medical therapy (N=32; 8%). After adjusting for between group differences and overall risk, INOCA subjects had worse angina and worse treatment response at follow up (21% and 27% reduction in angina score compared to CAD patients revascularized with PCI and CABG respectively). INOCA subjects had numerically lower treatment response than CAD patients managed with medications (6.4 units, −12%; P=0.181). Population baseline mean Seattle Angina Questionnaire (SAQ) frequency score (60±26) and SAQ summary score (52.5±19) were similar between groups. The absolute difference was 6.4 units versus medically managed CAD (95% CI: −3.0 to 15.9; P=0.181), 11.3 units versus the CAD group undergoing PCI (6.1 to 16.5; P<0.001) and 14.3 units versus CABG (6.2 to 22.3; P=0.001). INOCA subjects had overall reduced quality of life (EQ5D index) and increased psychological distress scores versus all CAD groups at 6 months. During longer-term follow-up (median 18 months), 23 (6%) MACE events occurred with no differences between the groups (Kaplan Meier log-rank P=0.890).

Conclusion(s)

Patients with INOCA had more severe angina symptoms reflecting worse quality of life and treatment response at 6 months with similar MACE as CAD subjects even after adjustment for confounding factors. This study highlights the need for evidence-based antianginal therapies and disease-modifying treatments for angina patients regardless of the presence of obstructive coronary disease.

Figure 1

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): This work was funded by the British Heart Foundation (PG/17/2532884; RE/13/5/30177; RE/18/6134217)

Does Hospital-at-Home Make Economic Sense? Early Discharge Versus Standard Care for Orthopaedic Patients

Hospital-at-home has been promoted as a potentially effective means of replacing costly inpatient care with cheaper domiciliary care. We studied three hospital-at-home schemes in West London providing intensive home care for early discharge orthopaedic patients, comparing their costs with those of standard inpatient care.

Although costs per day of hospital-at-home care were lower than those of inpatient care, the schemes appeared to increase the total duration of orthopaedic episodes, so that the costs of standard care, per episode, were lower than those of hospital-at-home.

While hospital-at-home may offer considerable future potential, substitution of home care for inpatient care will not necessarily save resources.

Central noradrenergic responsiveness to a clonidine challenge in Generalized Anxiety Disorder: a Single Photon Emission Computed Tomography study

Generalized Anxiety Disorder (GAD) may involve hypo-responsiveness of noradrenaline a2 receptors. To test this hypothesis, we used (99m)Tc-hexa-methyl-propylene-amine-oxime (HMPAO) Single Photon Emission Computed Tomography to measure regional cerebral perfusion in patients with untreated GAD, venlafaxine-treated patients and healthy controls during word generation before and after clonidine. Concurrent psychological and physiological measures supported noradrenergic hypofunction in GAD in some cases. A single-day split-dose technique was used. Images were processed using SPM5 (Institute of Neurology). Factorial analysis revealed no significant results. Exploratory analyses were done. Regional perfusion during verbal fluency differed by group pre-clonidine. Compared with healthy controls, patients with untreated GAD displayed increased perfusion in the left Broca's area and left occipitotemporal region. Treated GAD patients displayed increased cerebellar perfusion bilaterally. Clonidine was associated with different changes in cerebral perfusion in each group. Increases were seen in the right supra-marginal gyrus in healthy subjects, in the left pre-central gyrus in treated GAD patients and in the right cerebellum and middle frontal gyrus in untreated GAD patients. Despite these differences, the findings were not consistent with a noradrenergic hypo-responsiveness hypothesis, as the treated group showed a different pattern of response rather than a normalization of response.

Daily morphine injection and withdrawal disrupt 24-h wheel running and PERIOD2 expression patterns in the rat limbic forebrain

Symptoms of opiate withdrawal include disturbances in circadian rhythms. We examined in male Wistar rats (n=48) the effects of a daily, mid-morning morphine injection (5-40 mg/kg, i.p.) and its withdrawal on 24-h wheel-running activity and on the expression of the clock protein, PERIOD2 (PER2), in the suprachiasmatic nucleus (SCN), oval nucleus of the bed nucleus of the stria terminalis (BNSTov), central amygdala (CEA), and dorsal striatum. Rats were killed over 2 days at 10, 22, 46, and 58 h after the last daily morphine injection at zeitgeber times (ZT) 1 or ZT13. Daily morphine injections and their withdrawal suppressed nighttime wheel running, but did not entrain any increase in activity in advance of the injection. Neither morphine injection nor its withdrawal affected PER2 expression in the SCN, whereas the normal daily peaks of PER2 in the BNSTov, CEA, and dorsal striatum were blunted both during morphine administration and its withdrawal. Treatment with a dopaminergic agonist (the D2/3 agonist, quinpirole, 1.0 mg/kg) or a noradrenergic agonist (alpha2 agonist, clonidine, 0.1 mg/kg) in morphine withdrawal did not restore normal PER2 patterns in each affected region; however, both quinpirole and clonidine themselves altered normal daily PER2 expression patterns in morphine-naive rats. These findings confirm and extend previous observations that opiates disrupt daily patterns of clock gene expression in the limbic forebrain. Furthermore, catecholaminergic drugs, which have been previously found to alleviate symptoms of opiate withdrawal, do not alleviate the effects of morphine withdrawal on PER2, but do modulate daily patterns of PER2 expression in saline controls.

Phylogenetic relationships of the Orang Asli and Iban of Malaysia based on maternal markers

Malaysia remains as a crossroad of different cultures and peoples, and it has long been recognized that studying its population history can provide crucial insight into the prehistory of Southeast Asia as a whole. The earliest inhabitants were the Orang Asli in Peninsular Malaysia and the indigenous groups in Sabah and Sarawak. Although they were the earliest migrants in this region, these tribes are divided geographically by the South China Sea. We analyzed DNA sequences of 18 Orang Asli using mitochondrial DNA extracted from blood samples, each representing one sub-tribe, and from five Sarawakian Iban. Mitochondrial DNA was extracted from hair samples in order to examine relationships with the main ethnic groups in Malaysia. The D-loop region and cytochrome b genes were used as the candidate loci. Phylogenetic relationships were investigated using maximum parsimony and neighbor joining algorithms, and each tree was subjected to bootstrap analysis with 1000 replicates. Analyses of the HVS I region showed that the Iban are not a distinct group from the Orang Asli; they form a sub-clade within the Orang Asli. Based on the cytochrome b gene, the Iban clustered with the Orang Asli in the same clade. We found evidence for considerable gene flow between Orang Asli and Iban. We concluded that the Orang Asli, Iban and the main ethnic groups of Malaysia are probably derived from a common ancestor. This is in agreement with a single-route migration theory, but it does not dismiss a two-route migration theory.

The role of flumazenil in the treatment of benzodiazepine dependence: physiological and psychological profiles

Two-related studies are presented here, detailing our early experience with benzodiazepine-dependent patients treated with a four-day flumazenil infusion using a novel delivery technique. Patients with long-term benzodiazepine dependence who attended the Australian Medical Procedures Research Foundation (AMPRF, Perth, Australia) for treatment were recruited for these studies. Self-reported psychological and physical symptoms, as well as objective vital signs data were collected at intervals before, during and 2 weeks postinfusion. Study A is a case series with cardiovascular measures; study B is an open trial that tracks the psychological profiles of 13 subjects. Withdrawal symptoms were tracked, however, the nature and severity of these symptoms differed between patients. No major complications or discomfort prompting study dropout was observed. Significant benzodiazepine abstinence occurred with this flumazenil infusion method despite high levels of initial dependence, comorbid substance use and comorbid psychiatric illness. Low-dose flumazenil infusion appears to be a safe and effective treatment resulting in withdrawal symptoms of lesser severity than any other cessation method currently available. Recommendations for future research are discussed.

Clinical service organisation for heart failure

BACKGROUND

Chronic heart failure (CHF) is a serious, common condition associated with frequent hospitalisation. Several different disease management interventions (clinical service organisation interventions) for patients with CHF have been proposed.

OBJECTIVES

To assess the effectiveness of disease management interventions for patients with CHF.

SEARCH STRATEGY

We searched: Cochrane CENTRAL Register of Controlled Trials (to June 2003); MEDLINE (January 1966 to July 2003); EMBASE (January 1980 to July 2003); CINAHL (January 1982 to July 2003); AMED (January 1985 to July 2003); Science Citation Index Expanded (searched January 1981 to March 2001); SIGLE (January 1980 to July 2003); DARE (July 2003); National Research Register (July 2003); NHS Economic Evaluations Database (March 2001); reference lists of articles and asked experts in the field.

SELECTION CRITERIA

Randomised controlled trials comparing disease management interventions specifically directed at patients with CHF to usual care.

DATA COLLECTION AND ANALYSIS

At least two reviewers independently extracted data information and assessed study quality. Study authors were contacted for further information where necessary.

MAIN RESULTS

Sixteen trials involving 1,627 people were included. We classified the interventions into three models: multidisciplinary interventions (a holistic approach bridging the gap between hospital admission and discharge home delivered by a team); case management interventions (intense monitoring of patients following discharge often involving telephone follow up and home visits); and clinic interventions (follow up in a CHF clinic). There was considerable overlap within these categories, however the components, intensity and duration of the interventions varied. Case management interventions tended to be associated with reduced all cause mortality but these findings were not statistically significant (odds ratio 0.86, 95% confidence interval 0.67 to 1.10, P = 0.23), although the evidence was stronger when analysis was limited to the better quality studies (odds ratio 0.68, 95% confidence interval 0.46 to 0.98, P = 0.04). There was weak evidence that case management interventions may be associated with a reduction in admissions for heart failure. It is unclear what the effective components of the case management interventions are. The single RCT of a multidisciplinary intervention showed reduced heart-failure related re-admissions in the short term. At present there is little available evidence to support clinic based interventions.

AUTHORS' CONCLUSIONS

The data from this review are insufficient for forming recommendations. Further research should include adequately powered, multi-centre studies. Future studies should also investigate the effect of interventions on patients' and carers' quality of life, their satisfaction with the interventions and cost effectiveness.

Erectile dysfunction: a significant health need in patients with coronary heart disease

BACKGROUND AND AIMS

Erectile dysfunction (ED) is a common condition, which negatively affects quality of life, and shares similar risk factors with Coronary Heart Disease (CHD). Studies from the pre - sildenafil era confirm a higher risk of ED in patients with cardiovascular disease. The high profile and success of sildenafil therapy has made it easier for some men to discuss erectile difficulties with healthcare professionals. Our aim therefore was to estimate the prevalence of ED in our cardiac rehabilitation patients .

METHODS AND RESULTS

We surveyed 150 random male cardiac rehabilitation patients using the International Index of Erectile Function (IIEF) questionnaire. 61% of all respondents had erectile difficulties, rising to 75% in the over 55 age group. 48% of respondents indicated their wish to discuss erectile problems with the healthcare team.

CONCLUSION

ED and CHD commonly co-exist. A large proportion of our respondents wished further discussion of erectile insufficiency. We recommend that cardiac rehabilitation programmes should adopt a proactive approach to detection and treatment of ED.

Relative receptor expression is a determinant in xenobiotic-mediated CYP3A induction in rat and human cells

1. Species differences in xenobiotic-mediated transcriptional activation of CYP3A genes are known to exist. These differences are proposed to be due, in part, to host cell differences. 2. Host cell effects were investigated by trans-species transient transfection of reporter genes containing either the rat CYP3A23 or human CYP3A4 proximal promoters into human HepG2 and rat FaO and H4IIEC3 hepatoma cells. HepG2 and FaO cells supported activation of both CYP3A constructs by xenobiotics in a species-specific manner, whereas H4IIEC3 cells were non-permissive. 3. The mRNA complement of the cell lines was then quantified by semiquantitative RT-PCR for adult CYP3As (CYP3A23, CYP3A4/5), steroid hormone receptors (constitutive androstane receptor, glucocorticoid receptor-alpha, pregnane X receptor) and transcription factors (Hepatic nuclear factor 4alpha, retinoid X receptor). 4. Principal component analysis of absolute receptor levels demonstrated a wide scattering, with no coherent pattern. In contrast, PCA of relative receptor ratios segregated H4IIEC3 cells from all other samples. 5. The observation is confirmed that species differences in response to xenobiotics are a result of host cell environment. In addition, new evidence is provided to support the hypothesis that in addition to individual receptor activation profiles, the relative abundance of steroid hormone receptors that control CYP3A gene expression play an important role in this observed species difference.

The influence of sex and age on response to head-up tilt-table testing in patients with recurrent syncope

BACKGROUND

Syncope is a common problem, accounting for 6% of hospital admissions. Often a diagnosis is not established. Head-up tilt testing is a diagnostic test for neuro-cardiogenic syncope, a condition which is often thought to affect younger women and be relatively rare in older people. We examined the effect of sex and age on response to head-up tilt testing in patients with unexplained syncope.

METHODS

We performed a retrospective analysis on consecutive tilt tests performed using the Westminster drug-free protocol from January 1992 to June 1998. Patients were divided into four groups on the basis of sex and age (< or = or > 65 years). Responses were classified according to the Vasovagal International Study Investigators' criteria.

RESULTS

We performed 665 tests in 590 patients. Mean age was 50 years +/-17.6 (range 12-83). One hundred and fifty-three patients (23%) were > 65 years. There was an almost equal sex distribution. Two hundred and eight tests (31%) were positive, with 113 (54%) showing a mixed response (type 1), 65 (32%) a cardio-inhibitory response (type 2) and 30 (14%) a vasodepressor response (type 3). Age and sex had no effect on rates of positive tests or time to positive result. There was no gender influence with respect to response type. However, subjects aged > 65 years had a higher incidence of vasodepressor response (type 3)-29% versus 9% (P < 0.001).

CONCLUSIONS

Head-up tilt testing is a useful tool in the investigation of all patients with suspected neuro-cardiogenic syncope. Age and sex do not influence the likelihood of a positive response, but older patients have an increased frequency of pure vasodepressor responses. This may have implications with respect to treatment strategies.

An inner city GP unit versus conventional care for elderly patients: prospective comparison of health functioning, use of services and patient satisfaction

BACKGROUND

GP units are generally nurse-led wards, where GPs have direct admitting rights and retain clinical responsibility for their patients. While GP-led wards are not new, they are relatively uncommon in urban areas. In addition, there has been little comparative evaluation of this type of service.

OBJECTIVES

The aim of the present study was to compare patients admitted to an inner city GP unit with comparable patients in conventional care (e.g. district nursing, nursing/residential homes, acute care of the elderly wards) in terms of mental and physical functioning, use of health and social services and patient satisfaction.

METHODS

Study group patients were those admitted to the GP unit; comparison group patients were identified by GP practices or conventional services who had agreed to participate in the study. Suitable patients were aged 65 years or over and fitted the eligibility criteria for the GP unit. Patients were interviewed at three time points: admission to either the GP unit or conventional care, and at 1 and 3 months after admission. Baseline comparability was assessed by demographic and medical data, cognitive function, mental state, social support, use of health and social services, and mental and physical functioning (SF-12). Mental and physical functioning and use of health and social services were compared between the groups over time. Patient satisfaction with their care was also compared between groups.

RESULTS

Change in the mental and physical functioning between patients on the GP unit (n = 67) and those in conventional care (n = 60) did not differ when the groups were compared at any of the three time points. However, the mental function of patients in the GP unit significantly improved between admission and 1 month after admission (P: < 0.05). This effect was not sustained at 3 months after admission. GP unit patients were consistently more positive about the care they received than patients receiving conventional care; this included communication and information, staff, care and the facilities. Both groups of patients were high users of health and social services, with similar patterns of use in both groups, which did not alter over time.

CONCLUSIONS

Patients who received care on the GP unit experienced a similar physical outcome to patients in conventional settings; however, they appeared to enjoy a short-term improvement in mental functioning and were consistently more positive about the quality of their care. This study has important policy implications with regard to planning future intermediate care services and will be of particular interest to health service planners and those responsible for clinical governance.

Intrinsic and extrinsic risk factors for anterior cruciate ligament injury in Australian footballers

The aim of this study was to examine the interaction between intrinsic (player-related) and extrinsic (environment-related) variables as risk factors for anterior cruciate ligament injury in Australian football. Between 1992 and 1999, 100,820 player-match exposures were analyzed for risk of anterior cruciate ligament injury using logistic regression analysis. There were 63 surgically proven noncontact anterior cruciate ligament injuries. The strongest risk factors were a player history of anterior cruciate ligament reconstruction either in the previous 12 months (relative risk [RR], 11.33; 95% confidence interval [CI], 4.02 to 31.91) or before the previous 12 months (RR, 4.44; 95% CI, 2.46 to 8.01). Weather conditions that were associated with dry field conditions--high water evaporation in the month before the match (RR, 2.55; 95% CI, 1.44 to 4.52) and low rainfall in the year before the match (RR, 2.87; 95% CI, 1.30 to 6.32)--were also significantly associated with these injuries. The increased risk of injury in the first 12 months after reconstruction was associated with the reconstructed knee, whereas after 12 months there was an even distribution of new injuries to the reconstructed knee and contralateral knee. A history of anterior cruciate ligament reconstruction is a risk factor for further injury. Weather conditions of high evaporation and low rainfall before matches are associated with noncontact anterior cruciate ligament injury.

Improving detection of alcohol misuse in patients presenting to an accident and emergency department

OBJECTIVES

To assess and improve deployment of a brief test for alcohol misuse: the Paddington Alcohol Test (PAT). Design-Prospective study of the effects of audit feedback.

SETTING

An urban accident and emergency department.

SUBJECTS

Senior house officers (SHO) (n = 13).

OUTCOME MEASUREMENTS

PAT use and categorisation of patients for each SHO; observational analysis of presenting complaints according to PAT.

RESULTS

1062 of 1737 patients (61.1%) were defined as PAT possible-that is, presented with > or = one complaint listed on the PAT test proforma. In month 1, PAT uptake was poor. PAT use improved significantly when feedback was instituted (p<0.0001). The response to audit and feedback showed marked inter-SHO variation. When feedback was withdrawn (month 4), there was a significant reduction in PAT use (p=0.003). Three other indices of detection followed this trend: (a) number of PAT positive patients identified, (b) proportion of PAT possible patients identified as PAT positive, and (c) number of PAT positive patients referred to the alcoholic health worker. The 10 most common PAT positive categories, accounting for 77% of all PAT positive complaints were: fall > collapse (including "fit", "blackout") > head injury (including "facial injury") > assault (including "domestic violence" and 'other') > nonspecific gastrointestinal problem > "unwell" > psychiatric (including "depression", "overdose", "confusion") > cardiac (including "chest pain" and "palpitations") > self neglect > repeat attendance.

CONCLUSIONS

Ongoing audit with feedback improves both PAT use and detection of alcohol misuse. The PAT is now simpler including only 10 conditions, which should further aid its use.

Are there age and sex differences in the investigation and treatment of heart failure? A population-based study

BACKGROUND

Heart failure is a serious, common, and growing problem. Hospital admissions, which account for the bulk of health service costs associated with heart failure, are becoming more frequent.

AIM

To determine whether management of heart failure differs by age and sex.

METHOD

A retrospective case note review of prevalent cases in 16 general practices in West London. Five hundred and eighty-three patients (57% women) with a diagnosis of heart failure were reviewed.

RESULTS

Mean age of patients with heart failure was 78 years (SD = 9.5)--74 years at diagnosis (SD = 10)--and was higher for women than men (76 years versus 71 years, P < 0.001). In 32% of patients there was no record of a chest X-ray, electrocardiogram, or echocardiogram to support diagnosis. Echocardiography, performed in 34% of patients, was less likely in older patients in both sexes (test for trend P = 0.04 in women and 0.02 in men) and, overall, in women (29% compared with 40% of men, P = 0.006). Angiotensin-converting enzyme (ACE) inhibitor treatment, recorded in 54% of patients, decreased with age in both sexes (P < 0.001) and, on unadjusted data, was more likely in men than in women (61% compared with 49%, P = 0.005). On adjustment for age, sex differences in the use of echocardiography and ACE inhibitors were reduced and no longer significant.

CONCLUSIONS

With increasing age, men and women with heart failure were less likely to have undergone echocardiography or to have received an ACE inhibitor. When account was taken of age, there were no statistically significant sex differences in management; however, because of the demographic distribution of heart failure, women are disproportionately affected by age differences in management. Clinical trials, physician practice, and service developments in heart failure have neglected older people. This balance should be redressed.

Pharmacological management of intermittent claudication: a meta-analysis of randomised trials

Intermittent claudication, a symptom of atherosclerosis in the large vessels of the lower limbs, greatly affects patient mobility and quality of life. Medical therapy for a moderate form of this condition includes vasodilators, antiplatelet agents and alternative treatments such as ginkgo biloba.A meta-analysis of results from 52 trials (including 5088 patients) was conducted for all current medical therapies for intermittent claudication. After 24 weeks, some of the medical therapies were found to be more effective than placebo for the primary end-points of either pain-free walking distance or maximum walking distance. Vasodilators presented the best results in walking distance. Pentoxifylline offered better results than naftidrofuryl, although the treatment benefit, measured in additional metres walked with treatment than without, was modest. Antiplatelets, ginkgo biloba and levocarnitine were slightly more effective than placebo, although the treatment benefit was of limited clinical importance. On average, patients walked 60m further with therapy than without, and only about half of that added distance was pain-free. Very little consistent information was available for other clinical end-points, such as overall mortality and adverse effects. These data suggest that some of the medical therapy, pentoxifylline in particular, can only modestly increase functional status in patients with moderate intermittent claudication. There is a need for uniformity in research design and reporting of trials. A future trial comparing medical therapy with physical therapy is indicated.

Changes in systolic time intervals-a non-invasive marker for the haemodynamic effects of sumatriptan

AIMS

This study assessed the use of systolic time intervals (STI) as a potential non-invasive marker of the haemodynamic effects of sumatriptan, a 5HT1 receptor agonist.

METHODS

Twenty-six patients undergoing diagnostic cardiac catheterization participated. STIs were derived from haemodynamic pressure tracings at baseline, following placebo injection and following either subcutaneous (n=18) or intravenous injection (n=8) of sumatriptan.

RESULTS

Sumatriptan (i.v. or s.c.) was associated with significant increases in mean arterial pressure (95% C.I. 9,14mmHg, P=0.0001), total electromechanical systole (95% C.I.8,36ms, P<0.0001), pre-ejection period (95%C.I. 8,21ms, P=0.0001) and left ventricular ejection time (95% C.I. 2,12ms, P=0.004). Conclusion STI responses were consistent with sumatriptan-induced changes in afterload. In summary, the measurement of STIs is a potential non-invasive method of investigating the influence of serotonergic compounds on the cardiovascular system.

Cardiac assessment of veteran endurance athletes: a 12 year follow up study

OBJECTIVES

Sustained aerobic dynamic exercise is beneficial in preventing cardiovascular disease. The effect of lifelong endurance exercise on cardiac structure and function is less well documented, however. A 12 year follow up of 20 veteran athletes was performed, as longitudinal studies in such cohorts are rare.

METHODS

Routine echocardiography was repeated as was resting, exercise, and 24 hour electrocardiography.

RESULTS

Nineteen returned for screening. Mean (SD) age was 67 (6.2) years (range 56-83). Two individuals had had permanent pacemakers implanted (one for symptomatic atrial fibrillation with complete heart block, the other for asystole lasting up to 15 seconds). Only two athletes had asystolic pauses in excess of two seconds compared with seven athletes in 1985. Of these seven, five had no asystole on follow up. Two of these five had reduced their average running distance by about 15-20 miles a week. One athlete sustained an acute myocardial infarction during a competitive race in 1988. Three athletes had undergone coronary arteriography during the 12 years of follow up but none had obstructive coronary artery disease. Ten of 19 (53%) had echo evidence of left ventricular hypertrophy in 1997 but only two (11%) had left ventricular dilatation. Ten athletes had ventricular couplets on follow up compared with only two in 1985.

CONCLUSIONS

Although the benefits of moderate regular exercise are undisputed, high intensity lifelong endurance exercise may be associated with altered cardiac structure and function. These adaptations to more extreme forms of exercise merit caution in the interpretation of standard cardiac investigations in the older athletic population. On rare occasions, these changes may be deleterious.

Listeria endocarditis causing aortic root abscess and a fistula to the left atrium

We report the case of a 74-year-old man who presented with endocarditis on a porcine aortic valve replacement. Five of six blood cultures grew listeria monocytogenes. Transoesophageal echocardiography demonstrated the presence of a cavity posterior to the aortic annulus, apparently communicating with the left atrium. The patient underwent successful aortic valve re-replacement. Listeria endocarditis is rare with only 58 reported cases in the literature and is associated with high mortality.

Effects of subcutaneous naratriptan on systemic and pulmonary haemodynamics and coronary artery diameter in humans

Naratriptan, an effective antimigraine agent, is a selective 5-hydroxytryptamine (5-HT1 )-receptor agonist with a pharmacologic profile similar to that of sumatriptan. The object of this study was to assess the haemodynamic effects of naratriptan in a clinical model previously applied to sumatriptan. Cardiac haemodynamics and coronary artery diameter were measured at baseline and after subcutaneous injections of placebo and naratriptan (1.5 mg, s.c.) in 10 patients undergoing diagnostic cardiac catheterisation. No statistically significant change in mean coronary artery diameter was observed after naratriptan [95% confidence interval (CI), -0.27-0.11 mm: p = 0.37]. Naratriptan injection was associated with statistically significant increases in systolic arterial pressure (95% CI, 7.6-22.0 mm Hg; p = 0.0015), total systemic vascular resistance (95% CI, 74-253 dyn/s/cc; p = 0.003), pulmonary artery systolic pressure (95% CI, 2.0-6.9 mm Hg; p = 0.003), pulmonary vascular resistance (95% CI, 3-34 dyn/s/cc; p = 0.025), and pulmonary artery wedge pressure (95% CI, 1.9-2.4 mm Hg; p = 0.009). Naratriptan, a selective 5-HT1-receptor agonist, caused a vasopressor response in the systemic and pulmonary arterial circulations but was not associated with coronary artery vasoconstriction.

Rainfall, evaporation and the risk of non-contact anterior cruciate ligament injury in the Australian Football League

OBJECTIVE

To determine if weather conditions affect the risk of anterior cruciate ligament (ACL) tear in Australian Football.

DESIGN

Prospective observational analytic study of football matches.

SETTING

The Australian Football League (AFL), a professional competition.

PARTICIPANTS

All players in 2280 matches from 1992-1998.

MAIN OUTCOME MEASURES

Surgically-proven ACL injury, not involving a direct contact mechanism, during a match; rainfall; water evaporation.

RESULTS

59 ACL injuries not involving direct contact occurred during the study period, more commonly in cities north of Melbourne (chi 2 = 17.0; df = 1; P < 0.001). Senior grade matches (relative risk [RR], 3.03; 95% confidence interval [CI], 1.52-6.03), high water evaporation in the month before the match (RR, 2.80; 95% CI, 1.53-5.10) and low rainfall in the year before the match (RR, 1.93; 95% CI, 1.12-3.34) were significantly associated with these injuries.

CONCLUSION

Low water evaporation and high rainfall significantly lower the risk of ACL injuries in AFL footballers. The likely mechanism is a softening of the ground, which lowers shoe-surface traction. Consistent extra watering and covering of grounds during periods of high water evaporation may lower the rate of ACL injuries.

Shifting care: GP opinions of hospital at home

Hospital at home (HaH) has become an increasingly popular model of care over the past few years. However, there is little evidence to suggest that this is a superior form of care when compared with standard inpatient care in terms of cost, satisfaction, or clinical outcomes. Despite concerns that these schemes increase general practitioner (GP) workload, there is also no published evidence on the effect of HaH on GPs. As part of a broader study, a survey was undertaken of all GPs in an inner London health authority for their views of HaH. Overall, GPs felt that such schemes increased their workload, but GPs who had used HaH were more strongly in favour of these schemes for a range of conditions.

The haemodynamic effect of the 5HT1 agonist BMS-180048: a class effect of triptans?

AIMS

To investigate the effects of an intravenous infusion of BMS-180048, a novel 5HT1-like agonist, on the systemic, pulmonary and coronary circulations in patients undergoing diagnostic cardiac catheterisation.

METHODS

Ten patients (mean age 55 years (range 41-65)) were studied during diagnostic cardiac catheterisation. The haemodynamic response to an intravenous (i.v.) infusion for 30 min of BMS-180048 (0.56 mg kg(-1) h(-1) for 10 min and 0.39 mg kg(-1) h(-1) for 20 min) was assessed via a 7F Swan Ganz catheter and thermodilution cardiac output system. Quantitative coronary angiography was performed at 10 min intervals.

RESULTS

BMS-180048 caused a significant increase in systemic arterial systolic blood pressure (rise of 32.5 mmHg, 95% CI 24,44.5) P=0.009), pulmonary artery systolic (12.2 mmHg, 95% CI 6.8,18.5; P=0.009) and diastolic pressures (8.5 mmHg, 95% CI 5.0,13.8; P=0.009), right atrial pressure (4 mmHg, 95% CI 1.5,5.2; P=0.013) and pulmonary capillary wedge pressure (9.5 mmHg 95% CI 5.2,14.0; P=0.09). There was no significant change in cardiac output (0.1 l min(-1), 95% CI -0.17,0.57, P>0.05). Mean coronary artery diameter in the proximal coronary segments decreased by 0.73 mm (95% CI -1.22,-0.15; P=0.03) at 35 min. The corresponding reduction in middle segments was 0.26 mm (95% CI -0.395,-0.08; P=0.02). There was a non-significant trend to constriction in the most distal segments of 0.28 mm (95% CI -0.68,0.015); P=0.06). One patient experienced chest pain with ECG changes suggestive of ischaemia.

CONCLUSIONS

BMS-180048 displayed a cardiovascular profile similar to that previously reported for sumatriptan. These changes appear to reflect a class effect of these agents.

Effect of ketanserin on central haemodynamics and coronary circulation

Ketanserin is a selective 5-hydroxytryptamine (5-HT2) antagonist with vasodilator properties in the systemic and pulmonary circulation. Ketanserin also can inhibit serotonin-induced coronary artery vasoconstriction during percutaneous transluminal coronary angioplasty (PTCA). The in vivo effect of ketanserin on the coronary arteries of patients with stable angina has not previously been reported. The effects of intravenous ketanserin on cardiac haemodynamics and coronary artery diameter were measured in 10 patients with stable angina undergoing diagnostic cardiac catheterisation. Ketanserin (10 mg, i.v.) was associated with significant reductions in systemic and pulmonary arterial pressure (p < 0.05) and total systemic (SVR) and pulmonary (PVR) vascular resistance (p < 0.05). No significant change in mean coronary artery diameter or coronary artery stenotic index was evident after ketanserin. Vasodepressor responses in the systemic and pulmonary arterial circulation were observed after ketanserin injection. We assume these responses to be a direct effect of ketanserin, although non-drug-induced changes over time cannot be excluded. No significant effect on coronary artery diameter was observed, presumably because circulating serotonin levels are low in patients with stable anginal symptoms.

The treatment of oropharyngeal candidiasis in HIV-infected patients with oral amphotericin B suspension

Oropharyngeal candidiasis (OPC) is the most frequent opportunistic infection associated with HIV infection. Therapies such as topical clotrimazole and nystatin, as well as oral azoles, which had previously been effective prior to the advent of HIV, are increasingly only partially effective in OPC in HIV infection. The effectiveness of oral amphotericin B suspension for OPC is described in 17 HIV-infected patients whose response to other therapies had been unsatisfactory. Three patients yielded isolates of Candida albicans with a minimum inhibitory concentration (MIC) to fluconazole of >/=16 microg/mL. Eleven patients received amphotericin B suspension monotherapy. Of the 17 patients, the symptoms of six resolved entirely, seven patients partially responded, and four failed therapy. These data suggest that amphotericin B suspension may be a useful additional therapy for OPC in HIV-infected patients.

Outcomes of transposition of the great arteries in the ear of atrial inflow correction

OBJECTIVE

To examine long term morbidity and mortality following atrial inflow corrective procedures for transposition of the great arteries (TGA) and to investigate factors that influence morbidity and mortality.

DESIGN

Retrospective cohort study from a single centre.

SETTING

Cardiology and cardiothoracic surgical unit in a large tertiary referral centre.

PATIENTS

All 130 patients who had TGA diagnosed between August 1972 and May 1988 and were considered suitable for atrial inflow correction; 109 of these underwent surgery (operative cohort: 84 Mustard operations and 25 Senning operations); 95 survived to hospital discharge (hospital surviving cohort).

MAIN OUTCOME MEASURES

Death and cardiac events.

RESULTS

There were relatively good long term results from atrial inflow correction for TGA with 5, 10, and 15 year survivals of 77.3%, 75.9%, and 71.3%. However, there was an appreciable incidence of late cardiac death and events, with 5, 10, and 15 year cardiac event-free survivals of 74.5%, 67.1%, and 39.6%. Supraventricular tachycardia was the only significant risk factor for late cardiac death (relative risk 8.72, 95% confidence interval, 2.86 to 26.64). Senning patients had better event-free survival (p = 0.04).

CONCLUSIONS

Atrial inflow correction for TGA has a reasonably good 15 year survival (71.3%), but there is an appreciable incidence of late cardiac deaths and events (15 year event-free survival 39.6%). The Senning procedure is preferable to the Mustard procedure for cases unsuitable for arterial switching.