Thalidomide and chemotherapy combination

Angiogenesis has been shown to be important in tumor growth and metastasis. Thalidomide, an oral sedative, has recently been found to inhibit angiogenesis. We therefore set out to ask whether thalidomide can be used as therapy for breast cancer. In a mouse model of breast cancer, we found that thalidomide alone did not suppress tumor growth. However, mice treated with thalidomide in combination with cytoxan and adriamycin had significantly smaller tumors than those given the two chemotherapeutic agents alone (3,432 +/- 303 mm(3) versus 4,643 +/- 203 mm(3), p = 0.0005). We proceeded to administer thalidomide together with chemotherapy to seven breast cancer patients in the context of a Phase I trial. Side effects attributed to thalidomide were minimal, and included constipation and a rash. We concluded that an approach at cancer therapeutics combining an antiangiogenic agent such as thalidomide with conventional chemotherapy may be feasible and deserves further studies.

Marizomib, a proteasome inhibitor for all seasons: preclinical profile and a framework for clinical trials

The proteasome has emerged as an important clinically relevant target for the treatment of hematologic malignancies. Since the Food and Drug Administration approved the first-in-class proteasome inhibitor bortezomib (Velcade) for the treatment of relapsed/refractory multiple myeloma (MM) and mantle cell lymphoma, it has become clear that new inhibitors are needed that have a better therapeutic ratio, can overcome inherent and acquired bortezomib resistance and exhibit broader anti-cancer activities. Marizomib (NPI-0052; salinosporamide A) is a structurally and pharmacologically unique β-lactone-γ-lactam proteasome inhibitor that may fulfill these unmet needs. The potent and sustained inhibition of all three proteolytic activities of the proteasome by marizomib has inspired extensive preclinical evaluation in a variety of hematologic and solid tumor models, where it is efficacious as a single agent and in combination with biologics, chemotherapeutics and targeted therapeutic agents. Specifically, marizomib has been evaluated in models for multiple myeloma, mantle cell lymphoma, Waldenstrom's macroglobulinemia, chronic and acute lymphocytic leukemia, as well as glioma, colorectal and pancreatic cancer models, and has exhibited synergistic activities in tumor models in combination with bortezomib, the immunomodulatory agent lenalidomide (Revlimid), and various histone deacetylase inhibitors. These and other studies provided the framework for ongoing clinical trials in patients with MM, lymphomas, leukemias and solid tumors, including those who have failed bortezomib treatment, as well as in patients with diagnoses where other proteasome inhibitors have not demonstrated significant efficacy. This review captures the remarkable translational studies and contributions from many collaborators that have advanced marizomib from seabed to bench to bedside.

Low proteasome activity as a means to track and target breast cancer stem cells in-vivo

Abstract #5055

Based on clinical observations, the existence of cancer stem cells (CSCs)/cancer initiating cells (CICs) in solid cancers has been postulated by radiation biologists and oncologists for decades. According to the stem cell hypothesis, only a small number of CSCs/CISs within a tumor have the ability to repopulate an entire tumor while their progeny does not. CSCs/CISs in solid tumors can now be identified prospectively in gliomas, head & neck cancers, pancreatic cancers, colon cancers, prostate cancers, melanomas, and in breast cancers. CSCs/CISs are thought to be mostly quiescent and relatively resistant to conventional anti-cancer therapy.
 Breast CSCs/CICs are enriched in cell populations with high CD44 and low or absent CD24 expression. Unfortunately, detection of breast CSCs/CISs, using CD44 and CD24 expression analysis, requires dissociation of the tumors and antibody staining for surface markers. We recently discovered that cancer stem cells, and specially breast CSCs/CICs, have low proteasome activity. In order to utilize this novel marker for the identification of breast CSCs/CICs, we developed retroviral vectors coding for fusion proteins between thymidine kinase (TK), the fluorescent protein ZsGreen and the c-terminal degron of murine ornithine decarboxylase (cODC). We stably transfected human breast cancer cells lines (MCF-7, MDA-MB-231, T47-D) with this reporter gene construct for 26S proteasome activity.
 Our reporter construct allowed us to track CSCs/CICs responses to radiation therapy in vivo via fluorescent imaging, but also to target them selectively using suicide gene (TK) therapy. Thus, the use of thymidine kinase in our fusion constructs allows for specific elimination of this cell population by ganciclovir preventing self-renewal in-vitro and causing T47-D and MDA-MB-231 tumor xenograft regression in vivo.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5055.

Evidence for a potential tumor suppressor role for the Na,K-ATPase beta1-subunit

The Na,K-ATPase, consisting of two essential subunits (alpha, beta), plays a critical role in the regulation of ion homeostasis in mammalian cells. Recent studies indicate that reduced expression of the beta1 isoform (NaK-beta1) is commonly observed in carcinoma and is associated with events involved in cancer progression. In this study, we present evidence that repletion of NaK-beta1 in Moloney sarcoma virus-transformed Madin-Darby canine kidney cells (MSV-MDCK), a highly tumorigenic cell line, inhibits anchorage independent growth and suppresses tumor formation in immunocompromised mice. Additionally, using an in vitro cell-cell aggregation assay, we showed that cell aggregates of NaK-beta1 subunit expressing MSV-MDCK cells have reduced extracellular regulated kinase (ERK) 1/2 activity compared with parental MSV-MDCK cells. Finally, using immunohistochemistry and fully quantitative image analysis approaches, we showed that the levels of phosphorylated ERK 1/2 are inversely correlated to the NaK-beta1 levels in the tumors. These findings reveal for the first time that NaK-beta1 has a potential tumor-suppressor function in epithelial cells.

A novel bispecific antibody (bsMAb) construct for nuclear imaging of pancreatic cancer

4564

Background: The initial diagnosis of pancreatic cancer is difficult at best. We developed MAb-PAM4 reactive with a unique epitope within MUC1 that is expressed in most pancreatic cancers, but not in normal or inflammatory pancreas, nor most other normal and neoplastic tissues. Our current focus is the development of a pretargeting procedure that can greatly enhance targeting sensitivity while retaining the MAb’s high specificity. Methods: TF10 is a novel humanized recombinant bsMAb with divalent binding to PAM4-defined MUC1 and monovalent binding to histamine-succinyl-glycine (HSG). TF10 is a 157 kDa protein having >85% binding to MUC1 and >90% with HSG. Athymic nude mice bearing CaPan1, human pancreatic cancer, were injected with 125I-TF10 to assess biodistribution. Other animals were given varying doses of TF10 followed 16 h later with 111In-IMP-288, a divalent-HSG-peptide. These animals were imaged 3 h after the 111In-IMP-288-injection and then necropsied. Results: 125I-labeled TF10 cleared rapidly from the blood, with blood levels <0.25 ± 0.02 %ID/g at 16 h, and no accumulation in any normal tissues. Tumor uptake was 7.16 ± 1.10, 3.47 ± 0.66, and 1.65 ± 0.57 % ID/g at 6, 16, and 48 hrs, respectively. These data confirmed that for a pretargeted imaging study a 16-h interval is sufficient to clear the blood so that 111In-IMP-288 could be administered. At 3 h, the imaging studies showed intense uptake of radiolabeled peptide within the tumors (avg. 0.5 cm3 - 0.3 g at necropsy) with no evidence of uptake in any normal tissues, while no targeting was seen in animals given the 111In-IMP-288 alone. At necropsy, tumor uptake of the 111In-IMP-288 in the TF10 pretargeted animals was 24.3 ± 1.7 % ID/g, while for 111In-IMP-288 alone tumor uptake was only 0.012 ± 0.002 % ID/g. Tumor/blood, liver, lungs, and kidney ratios averaged 2800:1, 139:1, 184:1, and 14.2:1, respectively, in the pretargeted animals. Conclusions: These results demonstrate that this novel PAM4-based pretargeting agent targets and images xenografted human pancreatic cancer with high signal-to-background ratios. In addition to imaging, TF10 may prove useful for pretargeted therapy of pancreas cancer. (Supported in part by grant CA115755 from the NIH.)

No significant financial relationships to disclose.

Refinements in the collection of energy filtered diffraction patterns from disordered materials

In this paper a method for collecting electron diffraction patterns using a Gatan imaging filter is presented. The method enables high-quality diffraction data to be measured at scattering angles comparable to those that can be obtained using X-ray and neutron diffraction. In addition, the method offers the capability for examining small regions of sample in, for example, thin films and nano-structures. Using X-ray, neutron and electron diffraction data collected from the same sample, we demonstrate quantitative agreement between all three. We also present a novel method for obtaining the single scattering contribution to the total diffracted intensity by collecting data at various electron wavelengths. This approach allows pair distribution functions to be determined from electron diffraction in cases where there exists significant multiple scattering.

Astigmatic electron diffraction imaging: a novel mode for structure determination

In a conventional transmission electron microscope, stigmators are used to correct for the effects of axial astigmatism in the diffraction lens. It seems feasible that these same stigmators could also be used to form a series of 'astigmatic' diffraction patterns. It is shown how this series of diffraction patterns could then be used to perform exit-surface wavefunction reconstruction. This has the advantage that the diffraction patterns are not resolution limited by the objective aperture as are images when performing exit-surface wavefunction reconstruction from a focal series. A scheme for carrying out phase reconstruction from a series of astigmatic diffraction patterns in an electron microscope is presented.

Retrieval of a complex-valued object from its diffraction pattern

It is commonly understood that the retrieval of a complex-valued object from its diffraction pattern using a support constraint is a difficult problem, the more so if the support is symmetric. In this Letter we show that, for just such a symmetric support, use of an iterative algorithm in which the basic iteration is specified by a difference map converges routinely. All that is required is sufficient oversampling in the diffraction pattern coupled with judicious choices of the parameters defining the difference map.

Investigation of the effects of partial coherence on exit wave reconstruction

In a recent work we presented an iterative wave function reconstruction (IWFR) method that reconstructs a wave function from measurements of its amplitude taken as it propagates in free space (a focal series of images). Although the ideal environment for application of the IWFR method is in a coherent imaging system, it has been developed so that it can be applied in a partially coherent imaging system, in particular for a high-resolution transmission electron microscope using a field-emission gun. In this paper we investigate the effects of partial coherence on the accuracy of results obtained using the IWFR method. We then show how results obtained under such conditions can be improved by estimating and subtracting components from the amplitude measurements of the wave function that derive from incoherence in the electron beam.

Exit wave reconstruction at atomic resolution

An iterative method for exit wave function reconstruction based on wave function propagation in free space is presented. The method, which has the potential for application to many forms of microscopy, has been tailored to work with a through focal series of images measured in a high-resolution transmission electron microscope. Practical difficulties for exit wave reconstruction which are pertinent in this experimental environment are the slight incoherence of the electron beam, sample drift and its effect upon the defocus step size that can be utilised, and the number of image measurements that need to be made. To gauge the effectiveness of the method it is applied to experimental data that has been analysed previously using a maximum likelihood formalism (the MAL method).

Phase imaging with a half-plane aperture

A method that effects phase reconstruction from a single image of a phase object is presented. The method, which is founded on the iterative transform algorithm, more specifically the error reduction version of this algorithm, applies this algorithm in an unusual way, in that it attempts to solve the phase problem from the measurement of a single image of the object taken by using a half-plane aperture rather than its diffraction pattern. A description of the method, an analysis of its performance, and suggestions as to its potential application are given.

Electron diffraction from nanovolumes of amorphous material using coherent convergent illumination

Using a conventional transmission electron microscope that incorporates a field emission gun it is possible to focus an electron beam to form a small probe (<1nm full-width at half-maximum). Such a probe can then be used to perform high spatial resolution diffraction experiments. The high spatial resolution allows technologically interesting amorphous volumes, such as those found in glassy intergranular phases or in semiconductor implantations, to be investigated directly. In order to achieve the probe characteristics necessary to investigate nanovolumes of material the probe must be highly convergent which results in it being highly coherent. In this paper we examine the effect of coherent convergent illumination on electron diffraction data taken from nanovolumes of amorphous material. It is shown that, for amorphous volumes as small as 1.2nm in diameter, the additional interference effects induced in the diffraction data by the use of coherent convergent illumination are largely suppressed by the lack of order in amorphous materials. This allows the use of deconvolution techniques, developed for the correction of broadening of the diffraction pattern in the case of incoherent illumination, and the subsequent application of reduced density function (G(r)) analysis, to also be used for coherent illumination.

Deconvolution of electron diffraction patterns of amorphous materials formed with convergent beam

To perform reduced density function (G(r)) analysis on electron diffraction patterns of amorphous materials formed with convergent beams, the effects of convergence must be removed from the diffraction data. Assuming electrons incident upon the sample in different directions are incoherent, this can be done using deconvolution (Ultramicroscopy 76 (1999) 115). In this letter we show that the combination of an energy filtering transmission electron microscope with an image plate, increases the accuracy with which diffraction data can be measured and, subsequently, the accuracy of the deconvolution.

Enhancement of tumor radioresponse by docetaxel: Involvement of immune system

Docetaxel, a potent chemotherapeutic drug and a strong enhancer of tumor radioresponse, possesses immunomodulating properties. We previously reported that 40% of murine tumors responding to docetaxel by growth delay showed heavy infiltration with macrophages or lymphocytes. The present study explored the effect of whole body irradiation on antitumor action of docetaxel alone or docetaxel plus tumor irradiation. Mice bearing 8-mm MCa-K mammary carcinoma in the leg received 33 mg/kg docetaxel i.v., 5 to 65 Gy tumor irradiation, or both (radiation given 24 h after docetaxel). Docetaxel delayed tumor growth and enhanced the efficacy of radiation: it dramatically reduced TCD50 (radiation dose yielding 50% tumor cure) from the control value of 38.6 Gy to 11.8 Gy, for an enhancement factor of 3.27. In addition to enhancing tumor radioresponse, docetaxel decreased the lung metastatic rate in mice with local tumor control from 26% in mice receiving radiation alone to 11% in mice receiving docetaxel plus radiation. Docetaxel induced heavy infiltration of tumors with lymphocytes, determined 2-4 days after treatment: the percentage of lymphocytes increased from the control value of <2% to 27% in mice that received docetaxel 3 days earlier. This increase was due to the influx of helper/inducer T-lymphocytes and natural killer cells. Immunosuppression of tumor-bearing mice with 6 Gy whole-body irradiation prior to tumor isotransplantation reduced docetaxel-induced lymphocyte infiltration of tumors, antitumor and anti-metastatic action of docetaxel, and docetaxel-induced enhancement of tumor radioresponse. Thus, our results showed that docetaxel stimulates tumor infiltration with immune cells, which then participate in antitumor action of docetaxel alone or when combined with radiotherapy.

Characterization of Amorphous Materials by Electron Diffraction and Atomistic Modeling

The technique of energy selected electron diffraction gives information about amorphous structures which can be used to characterize amorphous materials in terms of their structure. The diffraction data can be used to refine models obtained using molecular dynamics, resulting in physically reasonable models consistent with the diffraction data.

Adapting the CAUSN accreditation process for emerging models of nursing education in Canada

This paper highlights the accreditation issues raised by new and emerging models of baccalaureate nursing education and program delivery in Canada. It suggests ways of adapting the accreditation process to address recent changes. Nursing degree programs now offered by universities include programs at several sites, collaborative programs with partner institutions at multiple sites, and programs offered primarily through distance education. The accreditation program developed by the Canadian Association of University Schools of Nursing (CAUSN) provides a mechanism for monitoring the quality of a nursing education program and promoting the growth of the school that offers the program. Since the decision to undergo accreditation signifies a major commitment on the part of a nursing program, it is essential that the accreditation process be adaptable to meet the needs of evolving nursing education and program delivery models, and that it be fair, equitable, and credible.

Transduction of murine and human tumors using recombinant adenovirus vectors

BACKGROUND

Most cytokine-based cancer gene therapy clinical trials have used labor-intensive, retrovirus-mediated strategies resulting in unpredictable gene expression. Recombinant AdV vectors were evaluated for easier, more reproducible gene transfer into 12 human melanoma, 2 murine fibrosarcomas, and 8 other tumor cell lines.

METHODS

AdV vectors contained a reporter (Escherichia coli beta-galactosidase or firefly luciferase) or cytokine gene (human interleukin-2 [IL-2] or IL-7). Transduction efficiencies and expression levels were assessed by histochemical staining, flow cytometry, polymerase chain reaction, fluorometry, and enzyme-linked immunosorbent assay. Tumorigenicity was determined by subcutaneous injection of cells into syngeneic mice.

RESULTS

All cell lines studied were transduced with AdV. Most cell lines exhibited 100% transduction efficiencies (by flow cytometry) at multiplicities of infection (MOI) epsilon 10. Gene expression correlated linearly with MOI, but a cytopathic effect was observed at MOI > 100 with all vectors. Nanogram gene expression levels were routinely achieved. Irradiation (30 Gy) minimally affected expression levels. Tumorigenicity of AdV-IL-2-transduced fibrosarcoma cells in mice was inversely related to IL-2 production. A majority of mice that rejected their tumor challenge were immune to tumor rechallenge.

CONCLUSIONS

E1-deleted AdV vectors may prove useful in generating tumor vaccines ex vivo with high, transient cytokine expression levels.

In vivo trafficking of adoptively transferred interleukin-2 expanded tumor-infiltrating lymphocytes and peripheral blood lymphocytes. Results of a double gene marking trial

Adoptive immunotherapy with tumor-infiltrating lymphocytes (TIL) and IL-2 appears to produce dramatic regressions in patients with metastatic melanoma and renal cancer. However, the in vivo mechanism of TIL function is not known. We conducted an UCLA Human Subject Protection Committee, Recombinant DNA Advisory Committee, and FDA-approved clinical trial using genetically-marked TIL to test the hypothesis that these cells have unique, tumor-specific in vivo trafficking patterns. TIL and PBL (as a control effector cell population) were isolated and expanded in parallel in vitro in IL-2-containing medium for 4-6 wk. During the expansion, TIL and PBL were separately transduced with the amphotropic retroviral vectors LNL6 and G1Na. Transduced TIL and PBL were coinfused into patients and their respective numbers measured in tumor, peripheral blood, and normal tissues; integrated provirus could be quantitated and distinguished by DNA PCR. Nine patients were treated (six melanoma, three renal) and received between 4.5 x 10(8) and 1.24 x 10(10) total cells. Both "marked" TIL and PBL could be detected circulating in the peripheral blood, in some patients for up to 99 d after infusion. Marked TIL and/or PBL could be detected in tumor biopsies in six of nine patients as early as day 6 and as late as day 99 after infusion. No convincing pattern of preferential trafficking of TIL vs. PBL to tumor was noted. Moreover, concurrent biopsies of muscle, fat, and skin demonstrated the presence of TIL/PBL in comparable or greater numbers than in tumor in five patients. The results of this double gene marking trial provide interesting insights into the life span and trafficking of adoptively transferred lymphocytes, but do not support the hypothesis that TIL specifically traffic to tumor deposits.

In vivo cancer gene therapy with a recombinant interleukin-2 adenovirus vector

Recombinant adenovirus (AdV) vectors are highly efficient at in vitro and in vivo gene delivery. In vivo therapy of established murine fibrosarcoma and mammary carcinomas was attempted with intratumoral injections of a recombinant AdV vector in which the human interleukin-2 (IL-2) gene was driven by the cytomegalovirus enhancer/promoter. Delayed growth and rejection of some tumors could be achieved with a cumulative virus dose of 2 to 6 x 10(9) plaque-forming units in two or three divided doses. Lower viral doses were ineffective, and higher doses resulted in animal death due to IL-2 toxicity. Using AdV vectors with the marker genes beta-galactosidase and luciferase, it is clear that even small volume (10 to 20 microL) intratumoral injections result in substantial systemic delivery of a portion of the virus dose. These findings define the potential and limitations of in vivo AdV-based cancer gene therapy and provide support for strategies to develop tumor-specific vectors.

Demographic differences in African-American patients with neoplastic lesions detected by flexible sigmoidoscopy

There is a higher incidence of colorectal cancer in young African-American patients compared with white Americans. This study examines the incidence, demographic pattern, and distribution of neoplastic lesions identified by flexible sigmoidoscopy in an African-American population. A sample of charts was reviewed from an urban gastroenterology practice that serves predominantly African Americans. A total of 455 patients were found who underwent flexible sigmoidoscopy. The sample included 391 symptomatic patients and 64 asymptomatic patients. Two hundred fifty-five patients were < 50 years old and 200 patients were > or = 50 years. More neoplastic lesions were found among older patients (21 patients: 14 with polyps and 7 cancers) than among younger patients (7 patients: 3 with polyps and 4 cancers); the difference of all positive findings between the two groups was significant. However, the cancerous rate for younger patients was not statistically different from that for older patients. These findings suggest that young African-American patients with colorectal symptoms should undergo aggressive approaches to detect cancer early.

Resistance to common viruses during intralymphatic injections of tumor cell vaccines. Correlation with circulating cytokines

Patients with advanced malignancies who received intralymphatic injections of irradiated tumor cell suspensions ("vaccines") were unexpectedly found to be resistant to common viral diseases; 17 patients with a documented past history of viral infections who have been observed for 48 to 148 months (median 108 months), were analyzed. The resistance to viruses was found to correlate closely with the presence, in the serum, of certain cytokines. Specifically, the interleukins, -2, -6, -8 and interferon-gamma, at low but sustained levels appeared to be possibly responsible for the nonspecific protection against viral infections obtained by intralymphatic injections of cellular material. These findings suggest that viral infections in normal or immunosuppressed individuals at particular risk might be prevented by treatments aimed at attaining very modest levels of certain cytokines.

Production of tumor necrosis factor alpha and interferon gamma in interleukin-2-treated melanoma patients: correlation with clinical toxicity

Interleukin-2 (IL-2)-based immunotherapy regimens are accompanied by dose-limiting toxicity consisting of fever, tachycardia, chills and capillary leak syndrome. We hypothesized that the toxicity was caused by the induction and release of endogenous cytokines such as tumor necrosis factor alpha (TNF alpha) and interferon gamma (IFN gamma). We measured the serum levels of TNF alpha and IFN gamma in IL-2-treated melanoma patients and attempted a correlation with clinical toxicity. A total of 23 patients received either 6 x 10(6) IU or 12 x 10(6) IU Cetus IL-2/m2 by i.v. bolus daily for 5 consecutive days on weeks 1, 3 and 5. Serum TNF alpha and IFN gamma levels were measured by enzyme-linked immunosorbent assay. Clinical toxicity was scored each day by objective measurements of hypotension, tachycardia, fever and chills/rigors. Clinical toxicity and IFN gamma levels correlated nicely, peaking on the 5th day of each treatment cycle. The kinetics and magnitude of TNF alpha production, however, were not predictable and did not correlate with either IFN gamma or toxicity. Some patients had modest increases in TNF alpha production while others had markedly increased levels during the second and third treatment weeks. Remarkably, these high levels persisted during nontreatment weeks and after completion of therapy. This clinical study demonstrates novel kinetics for immunoreactive TNF alpha in IL-2 cancer patients, which do not correlate well with toxicity.

Entrainment onset in atrioventricular reciprocating tachycardia: value in bypass tract localization and relationship to the preexcitation index

The timing of entrainment onset has been shown to correlate with the conduction time to critical elements of a tachycardia circuit in a pacemaker model of reentrant ventricular tachycardia (VT). The utility of this method in evaluating clinical reentrant tachycardias was therefore evaluated in 24 patients with symptomatic Wolff-Parkinson-White syndrome and single bypass tracts (left free wall in 17, posteroseptal in 5, anteroseptal in 1, and right free wall in 1). Right ventricular apex (RVA) pacing during orthodromic atrioventricular reentrant tachycardia (oAVRT) at 10-70 msec less than tachycardia cycle length demonstrated concealed entrainment of the tachycardia in all patients studied. An entrainment index (EI), defined as the minimal prematurity of the ventricular stimulus that first resulted in atrial reset, was calculated from multiple entrainments in each patient. The EI was 121 +/- 25, 83 +/- 19, and 55 msec for left free wall, septal, and right free-wall bypass tracts, respectively (P = 0.004 for difference between left free wall and septal). A corrected EI, derived by subtracting the amount of atrial reset from the EI, gave values of 108 +/- 22 and 71 +/- 17 msec for left free wall and septal bypass tracts (P = 0.001). These values were compared to the preexcitation index (PI) by linear regression analysis in these patients. The PI correlated closely with both the EI and the corrected EI (r = 0.90 and 0.93, respectively), but the PI could only be derived in 12/17 (71%) left free-wall tachycardias versus the EI in 17/17 (100%) (P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and clinical characteristics of a high cardiac output state in patients with multiple myeloma

PURPOSE

This study was undertaken to define the prevalence and clinical characteristics of patients with a high cardiac output state associated with multiple myeloma.

PATIENTS AND METHODS

Specifically, we evaluated clinical, laboratory, and two-dimensional and Doppler echocardiographic data in 36 patients with multiple myeloma. Cardiac output was determined noninvasively by a pulsed Doppler technique.

RESULTS

A high cardiac output state, defined as a cardiac index greater than or equal to 4.0 L/minute/m2, was present in eight of 34 (23.5%) subjects in whom cardiac output was measurable. None of the known causes of high output states could be identified in these patients. Four patients developed high output congestive heart failure, two of whom died. Age, sex, degree of anemia, serum calcium level, immunoglobulin type, or disease stage did not differ significantly between subjects with or without high output states. However, severe bone involvement was significantly more frequent in those patients with high cardiac output states, occurring in all eight patients with high cardiac indexes compared with nine of 26 patients with low or normal cardiac indexes (p = 0.001).

CONCLUSION

These data demonstrate that high cardiac output states are relatively common in patients with multiple myeloma and are associated with the presence of extensive bone disease.

Potentiation of cocaine-induced coronary vasoconstriction by beta-adrenergic blockade

STUDY OBJECTIVE

To determine whether beta-adrenergic blockade augments cocaine-induced coronary artery vasoconstriction.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

A cardiac catheterization laboratory in an urban teaching hospital.

PATIENTS

Thirty clinically stable patient volunteers referred for catheterization for evaluation of chest pain.

INTERVENTIONS

Heart rate, arterial pressure, coronary sinus blood flow (by thermodilution), and epicardial left coronary arterial dimensions were measured before and 15 minutes after intranasal saline or cocaine administration (2 mg/kg body weight) and again after intracoronary propranolol administration (2 mg in 5 minutes).

MEASUREMENTS AND MAIN RESULTS

No variables changed after saline administration. After cocaine administration, arterial pressure and rate-pressure product increased; coronary sinus blood flow fell (139 +/- 28 [mean +/- SE] to 120 +/- 20 mL/min); coronary vascular resistance (mean arterial pressure divided by coronary sinus blood flow) rose (0.87 +/- 0.10 to 1.05 +/- 0.10 mm Hg/mL.min); and coronary arterial diameters decreased by between 6% and 9% (P less than 0.05 for all variables). Subsequently, intracoronary propranolol administration caused no change in arterial pressure or rate-pressure product but further decreased coronary sinus blood flow (to 100 +/- 14 mL/min) and increased coronary vascular resistance (to 1.20 +/- 0.12 mm Hg/mL.min) (P less than 0.05 for both).

CONCLUSIONS

Cocaine-induced coronary vasoconstriction is potentiated by beta-adrenergic blockade. Beta-adrenergic blocking agents probably should be avoided in patients with cocaine-associated myocardial ischemia or infarction.