CC-10004 but not thalidomide or lenalidomide inhibits lamina propria mononuclear cell TNF-α and MMP-3 production in patients with inflammatory bowel disease.

BACKGROUND: Thalidomide, one of whose activities is to inhibit Tumour Necrosis Factor (TNF)-α production, has been reported to be an effective treatment for refractory inflammatory bowel disease (IBD). TNF-α driven production of matrix metalloproteinase (MMP)-3 by gut lamina propria mononuclear cells (LPMCs) is a major pathway of tissue injury in IBD; however the effect of thalidomide and newer more potent immunomodulatory derivatives on this pathway has not been studied. AIM: To investigate the effect of thalidomide, CC-4047 (pomalidomide), CC-5013 (lenalidomide), and CC-10004 (apremilast) on gut LPMC TNFα and MMP-3 production in patients with IBD. METHODS: Gut LPMCs and myofibroblasts were isolated from patients with IBD, and cultured with thalidomide, CC-4047, CC-5013, and CC-10004. MMP-3 and TIMP-1 levels were determined by western blotting and real-time PCR, and TNF-α levels by ELISA. RESULTS: CC-10004 significantly reduced both TNF-α production and MMP-3 production by cultured LPMCs. Thalidomide and CC-4047 and CC-5013 had no significant effect on the production of TNF-α or MMP-3 by LPMCs. CONCLUSION: These results provides a mechanistic rationale for both the failure of lenalidomide (CC-5013) in a recent randomised controlled trial in Crohn's disease, and for the evaluation of CC-10004 as a novel oral therapy in the treatment of CD and UC.

Cancer cachexia.

Cancer cachexia is a severe debilitating disorder for which there are currently few therapeutic options. It is driven by the release of pro-inflammatory cytokines and cachectic factors by both host and tumour. Over the past few years, basic science advances have begun to reveal the breadth and complexity of the immunological mechanisms involved, and in the process have uncovered some novel potential therapeutic targets. The effectiveness of thalidomide and eicosapentaenoic acid at attenuating weight loss in clinical trials also provides a further rationale for modulating the immune response. We are now entering an exciting period in cachexia research, and it is likely that the next few years will see effective new biological therapies reach clinical practice.

Thalidomide in the treatment of cancer cachexia: a randomised placebo controlled trial.

BACKGROUND: Proinflammatory cytokines, especially tumour necrosis factor alpha (TNF-alpha), play a prominent role in the pathogenesis of cancer cachexia. Thalidomide, which is an inhibitor of TNF-alpha synthesis, may represent a novel and rational approach to the treatment of cancer cachexia. AIMS: To assess the safety and efficacy of thalidomide in attenuating weight loss in patients with cachexia secondary to advanced pancreatic cancer. METHODS: Fifty patients with advanced pancreatic cancer who had lost at least 10% of their body weight were randomised to receive thalidomide 200 mg daily or placebo for 24 weeks in a single centre, double blind, randomised controlled trial. The primary outcome was change in weight and nutritional status. RESULTS: Thirty three patients (16 control, 17 thalidomide) were evaluated at four weeks, and 20 patients (eight control, 12 thalidomide) at eight weeks. At four weeks, patients who received thalidomide had gained on average 0.37 kg in weight and 1.0 cm(3) in arm muscle mass (AMA) compared with a loss of 2.21 kg (absolute difference -2.59 kg (95% confidence interval (CI) -4.3 to -0.8); p = 0.005) and 4.46 cm(3) (absolute difference -5.6 cm(3) (95% CI -8.9 to -2.2); p = 0.002) in the placebo group. At eight weeks, patients in the thalidomide group had lost 0.06 kg in weight and 0.5 cm(3) in AMA compared with a loss of 3.62 kg (absolute difference -3.57 kg (95% CI -6.8 to -0.3); p = 0.034) and 8.4 cm(3) (absolute difference -7.9 cm(3) (95% CI -14.0 to -1.8); p = 0.014) in the placebo group. Improvement in physical functioning correlated positively with weight gain (r = 0.56, p = 0.001). CONCLUSION: Thalidomide was well tolerated and effective at attenuating loss of weight and lean body mass in patients with cachexia due to advanced pancreatic cancer.

Thalidomide and its derivatives: emerging from the wilderness.

Forty years on from its worldwide withdrawal, thalidomide is currently undergoing a remarkable renaissance as a novel and powerful immunomodulatory agent. Over the last decade it has been found to be active in a wide variety of inflammatory and malignant disorders where conventional therapies have failed. Recently, considerable progress has been made in elucidating its complex mechanisms of action, which include both anticytokine and antiangiogenic properties. However, in addition to its well known teratogenic potential, it has a significant side effect profile that leads to cessation of treatment in up to 30% of subjects. In response to this, two new classes of potentially safer and non-teratogenic derivatives have recently been developed. This review summarises the biological effects, therapeutic applications, safety profile, and future potential of thalidomide and its derivatives.

Biological therapy in Crohn's disease.

The discovery of the central role of tumour necrosis factor-alpha in Crohn's disease and the subsequent introduction of infliximab into routine clinical practice has transformed the treatment of refractory disease. Advances in understanding of the immunopathological basis of Crohn's disease are leading to the development of new biological therapies which are likely to play an increasing role in future.

Lead poisoning: case studies.

Early clinical features of lead toxicity are non-specific and an occupational history is particularly valuable. Lead in the body comprises 2% in the blood (t1/2 35 days) and 95% in bone and dentine (t1/2 20-30 years). Blood lead may remain elevated for years after cessation from long exposure, due to redistribution from bone. Blood lead concentration is the most widely used marker for inorganic lead exposure. Zinc protoporphyrin (ZPP) concentration in blood usefully reflects lead exposure over the prior 3 months. Symptomatic patients with blood lead concentration >2.4 micromol l-1 (50 microg dl-1) or in any event >3.8 micromol l-1 (80 microg dl-1) should receive sodium calciumedetate i.v., followed by succimer by mouth for 19 days. Asymptomatic patients with blood lead concentration >2.4 micromol l-1 (50 microg dl-1) may be treated with succimer alone. Sodium calciumedetate should be given with dimercaprol to treat lead encephalopathy.

Utility of a software assistant in critical care case review.

A computer program (the Audit Assistant) was developed to help physicians review the care of critically ill emergency department (ED) patients. The program is an example of a new class of decision aids that serves to remind physicians to consider possibilities, not an artificial intelligence program that actually attempts to simulate clinical reasoning. The goal of such programs is to enable physicians to reduce errors--in this case to enable reviewers to notice more of the errors in care in the cases they are reviewing. The objective of this study was to demonstrate on a small set of complex cases that the tested computer program enables the physician to perform a better quality review. The issue of what constitutes improved case review is addressed. In the first part of the study, reviewers reviewed two mock charts without using the Audit Assistant and then immediately reviewed the charts again with the assistance of the program. The reviews were compared. In the second part of the study, a second reviewer also compared the utility of the review of the first reviewer alone and the Audit Assistant output as an aid to review, using an additional mock chart. Six emergency physicians participated; each was a quality assurance director for the ED of one Cleveland area hospital. For the physicians reviewing without the Audit Assistant, 41% of critical actions were listed by three or four reviewers. For those using the Audit Assistant, 83% of critical actions were listed by three or four reviewers. All reviewers preferred the Audit Assistant-suggested list to the critical action list generated by a previous reviewer not using the Audit Assistant (P < .02). Use of the Audit Assistant improved the completeness and the consistency of physician review of mock charts of critically ill ED patients in a small series of cases. The critical actions added for review were important, as demonstrated by the preferential addition of critical actions chosen by other reviewers who were not using the computer program.

Altered extracellular matrices influence cellular processes and nuclear matrix organizations of overlying human bladder urothelial cells.

A central issue in tumor biology is the understanding of the interactions between tumor cells and their environment. Using normal and ras oncogene transfected rat fibroblast cells, we now demonstrate that the transfected cells make altered extracellular matrices (ECM) and that their resulting ECM influence the proliferation and genetic regulation of human bladder cancer EJ cells. Using Western blot analyses, we observed that the ras transfected fibroblast cells lacked the ability to produce extracellular matrix component laminin whereas the normal parental fibroblast cells were able to produce intact laminin. Both transfected and nontransfected fibroblast cells were able to synthesize other extracellular matrix molecules such as type IV collagen and fibronectin. Human bladder tumor EJ cells were grown on ECM derived from normal and transfected rat fibroblast cells, and the proliferation rate and type IV collagen mRNA expression of EJ cells were determined. We observed that EJ cells, when grown on ECM derived from the ras transfected fibroblast cells, had a higher growth rate than when grown on ECM derived from the normal fibroblast cells (P < 0.037). Furthermore, EJ cells grown on ECM derived from transfected fibroblast cells showed up-regulation of type IV collagen mRNA expression when compared with EJ cells grown on ECM derived from nontransfected fibroblast cells. Finally EJ cells grown on purified laminin but not on collagen IV coated flasks showed the same level of type IV collagen mRNA expression as when grown on ECM derived from nontransfected parental fibroblast cells. Haptotactic/motility assays with EJ cells and ECM derived from ras transfected and nontransfected fibroblast cells demonstrated that ECM of ras transfected fibroblast cells, but not the parental fibroblast cells, provided a permissive or fertile soil for EJ tumor cell invasion. Finally, two-dimensional gel electrophoresis of 35S-labeled nuclear matrix proteins of EJ cells cultured on ECM derived from ras transfected fibroblast cells revealed expression of proteins in the molecular weight range of M(r) 35,000-45,000 and isoelectric focusing pH range of 5.5 to 6.0. These proteins were not present in EJ cells cultured on ECM derived from parental nontransfected fibroblast cells. We conclude that extracellular matrices derived from transformed stroma producing cells may influence the proliferation, genetic regulation, and maintenance of the overlying urothelial tumor cells. The mechanism by which the ECM may influence cellular behavior and phenotype may be in their ability to modulate the nuclear matrix proteins of the overlying cell.

A spermatic cord hematoma secondary to varicocele rupture from blunt abdominal trauma: a case report and review.

Varicocele is a relatively common entity that is mostly studied because of the effects on the testes and a presumed role in infertility. Hemorrhage secondary to a varicocele, however, is a known but rare morbidity. A case is presented of a ruptured varicocele due to blunt abdominal trauma with a sudden increase in intra-abdominal pressure with transmission to the varicocele. Such a mechanism may also provide an explanation for the occurrence of a more commonly recognized phenomenon of idiopathic spermatic cord hematoma.

Biology of metastasis: clinical implications.

Bladder tumor has a spectrum of neoplastic activity. Some behave in a benign fashion, and others are highly aggressive and lead rapidly to metastatic disease and death. The processes of metastasis can be described as a sequence of interrelated steps. The processes involve 1) tumor cell adhesion to basement membranes, 2) the degradation of basement membranes, and 3) the migration of tumor cells through the destroyed stroma into blood and lymphatic vessels. Each of these processes involves the expression of molecular factors unique to tumor cells. With better understanding of the molecular basis of these factors, novel prognostic and potential therapeutic agents can be generated and applied to the clinical arena.