A case report of a patient with metastatic ocular melanoma who experienced a response to treatment with the BRAF inhibitor vemurafenib.

BACKGROUND: Conjunctival malignant melanoma (CMM) is a rare malignancy and in the advanced setting there is no effective treatment. In contrast, half of cutaneous melanomas have BRAF mutations and treatment with BRAF inhibitors is established for patients with disseminated disease. The most common form of ocular melanoma, uveal melanoma, lacks these mutations, however, their presence has been reported for CMM. CASE PRESENTATION: We used the BRAF inhibitor vemurafenib to treat a 53 year-old female suffering from a BRAF(V600E) mutated metastatic CMM. The patient benefited from the treatment, a response was evident within a week and she experienced a progression free survival of four months. CONCLUSIONS: To our knowledge, this is the first described case of response to vemurafenib treatment in a patient with ocular melanoma.

LXR is a negative regulator of glucose uptake in human adipocytes.

AIMS/HYPOTHESIS: Obesity increases the risk of developing type 2 diabetes mellitus, characterised by impaired insulin-mediated glucose uptake in peripheral tissues. Liver X receptor (LXR) is a positive regulator of adipocyte glucose transport in murine models and a possible target for diabetes treatment. However, the levels of LXRα are increased in obese adipose tissue in humans. We aimed to investigate the transcriptome of LXR and the role of LXR in the regulation of glucose uptake in primary human adipocytes. METHODS: The insulin responsiveness of human adipocytes differentiated in vitro was characterised, adipocytes were treated with the LXR agonist GW3965 and global transcriptome profiling was determined by microarray, followed by quantitative RT-PCR (qRT-PCR), western blot and ELISA. Basal and insulin-stimulated glucose uptake was measured and the effect on plasma membrane translocation of glucose transporter 4 (GLUT4) was assayed. RESULTS: LXR activation resulted in transcriptional suppression of several insulin signalling genes, such as AKT2, SORBS1 and CAV1, but caused only minor changes (<15%) in microRNA expression. Activation of LXR impaired the plasma membrane translocation of GLUT4, but not the expression of its gene, SLC2A4. LXR activation also diminished insulin-stimulated glucose transport and lipogenesis in adipocytes obtained from overweight individuals. Furthermore, AKT2 expression was reduced in obese adipose tissue, and AKT2 and SORBS1 expression was inversely correlated with BMI and HOMA index. CONCLUSIONS/INTERPRETATION: In contrast to murine models, LXR downregulates insulin-stimulated glucose uptake in human adipocytes from overweight individuals. This could be due to suppression of Akt2, c-Cbl-associated protein and caveolin-1. These findings challenge the idea of LXR as a drug target in the treatment of diabetes.

When to order a biopsy to characterise a metastatic relapse in breast cancer.

Today, the diagnosis of metastatic breast cancer is usually based on radiological findings, and therapeutic decisions are made by considering the pathological characteristics and predictive markers of the primary tumour. Accumulating evidence suggests that tumour characteristics, including estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2), are unstable through tumour progression. Several retrospective studies and, recently, two prospective studies have investigated the discrepancies in receptor status between primary tumours and the corresponding metastases in a total of 1773 patients (for ER) and 2845 patients (for HER2). Changes in ER and HER2 status in these studies range from 14.5% to 40% and from 0% to 37.5%, respectively. In the two prospective studies, a different diagnosis, usually non-malignant, was obtained in 3% and 9% of the cases, and the biopsy led to a treatment modification in about one out of seven patients. Here, we review and discuss the currently available data and provide our recommendations on when a metastatic biopsy should be obtained.

Individually tailored treatment with epirubicin and paclitaxel with or without capecitabine as first-line chemotherapy in metastatic breast cancer: a randomized multicenter trial.

Anthracyclines and taxanes are active cytotoxic drugs in the treatment of early metastatic breast cancer. It is yet unclear whether addition of capecitabine to the combination of these drugs improves the treatment outcome. Patients with advanced breast cancer were randomized to first-line chemotherapy with a combination of epirubicin (Farmorubicin(®)) and paclitaxel (Taxol(®)) alone (ET) or in combination with capecitabine (Xeloda(®), TEX). Starting doses for ET were epirubicin 75 mg/m(2) plus paclitaxel 175 mg/m(2), and for TEX epirubicin 75 mg/m(2), paclitaxel 155 mg/m(2), and capecitabine 825 mg/m(2) BID for 14 days. Subsequently, doses were tailored related to side effects. Primary endpoint was progression-free survival (PFS); secondary endpoints were overall survival (OS), time to treatment failure (TTF), objective response (OR), safety and quality of life (QoL). 287 patients were randomized, 143 to ET and 144 to TEX. Median PFS was 10.8 months for patients treated with ET, and 12.4 months for those treated with TEX (HR 0.84, 95% CI 0.65-1.07, P = 0.16); median OS was 26.0 months for women in the ET versus 29.7 months in the TEX arm (HR 0.84, 95% CI 0.63-1.11, P = 0.22). OR was achieved in 44.8% (ET) and 54.2% (TEX), respectively (χ(2) 3.66, P = 0.16). TTF was significantly longer for patients treated with TEX, 6.0 months, versus 5.2 months following ET (HR 0.73, 95% CI 0.58-0.93, P = 0.009). Severe hematological side effects related to epirubicin and paclitaxel were evenly distributed between the treatment arms, mucositis, diarrhea, and Hand-Foot syndrome were significantly more frequent in the TEX arm. Toxicity-adjusted treatment with ET and TEX showed similar efficacy in terms of PFS, OS, and OR. In this trial with limited power, the addition of capecitabine to epirubicin and paclitaxel as first-line treatment did not translate into clinically relevant improvement of the outcome.

Endothelin-1 stimulates human adipocyte lipolysis through the ET A receptor.

OBJECTIVE: Levels of the vascular peptide endothelin-1 (ET-1) are significantly elevated in obesity. Adipose tissue-derived ET-1 attenuates insulin-mediated antilipolysis in human visceral adipocytes through the activation of the ET receptor B (ET(B)R), thereby linking ET-1 to insulin resistance. Whether ET-1 has direct effects on lipolysis in human adipocytes is not known. RESEARCH DESIGN AND SUBJECTS: Endothelin-1 receptor (ETR) mRNA expression was determined by quantitative PCR in 130 non-obese and obese subjects. ET-1 mRNA in different adipose tissue regions was also assessed. ETR protein expression was analyzed by western blotting in 37 subjects. The effect of ET-1 on lipolysis was assessed in freshly isolated adipocytes and in vitro differentiated adipocytes from human donors. RESULTS: Freshly isolated human adipocytes incubated with different concentrations of ET-1 showed no acute effect on lipolysis. In contrast, a 24 h incubation in primary cultures of human adipocytes resulted in a significant 50% increase in lipolysis. This effect was concentration dependent and could be mimicked by an agonist of the ET(A) receptor but not with a selective ET(B)R agonist. Adipocyte differentiation was not affected by any of the agonists. In subcutaneous (s.c.) adipose tissue from 19 non-obese and 18 obese subjects, the protein expression of ET(A)R was significantly higher in obese subjects whereas there was no difference in ET(B)R expression. Interestingly, the differences in protein expression were not observed at the mRNA level as ET(A)R expression was similar between lean and obese subjects. CONCLUSION: Long-term but not acute incubation of human adipocytes with ET-1 results in a significant increase in lipolysis. This appears to be mediated through the activation of ET(A)R, demonstrating a yet another receptor-specific effect of ET-1. In addition, the protein expression of ET(A)R is increased in s.c. adipose tissue in obesity, possibly through post-transcriptional mechanisms. An increased effect of ET-1 could be a mechanism that contributes to increased basal lipolysis in human obesity.

Primary differences in lipolysis between human omental and subcutaneous adipose tissue observed using in vitro differentiated adipocytes.

Catecholamine-induced lipolysis is elevated in omental as compared to subcutaneous adipocytes due to primary differences between the two cell types (i.e., they have different progenitor cells). Whether there is regional variation in atrial natriuretic peptide (ANP)-induced lipolysis is unknown. We studied whether beta-adrenoceptor signaling to lipolysis and ANP-induced lipolysis are involved in the primary differences in lipolysis. In vitro experiments on differentiated preadipocytes from human subcutaneous and omental adipose tissue were performed. The cells were kept in culture for a relative long duration, so any influence of local environment and circulation in the various adipose tissue depots could be excluded. Using beta1-, beta2-, and beta3-adenoceptor agonists, lipolysis was found to be significantly higher in omental as compared to subcutaneous differentiated preadipocytes. Forskolin and dibutyryl cAMP, which act at post-adrenoceptor levels, did not show any regional difference. There was no regional difference in ANP-induced lipolysis. Gene expression of beta1- and beta3-adrenoceptors was higher and beta2-adrenoceptor expression was lower in the omental cells. Omental fat cells have an increased beta-adrenoceptor-mediated lipolysis principally due to primary differences in the early event that couples beta-adrenoceptor subtypes to G-proteins. ANP-induced lipolysis is not subject to primary regional variation.

Diagnosis of a patient with oncogenic osteomalacia using a phosphate uptake bioassay of serum and magnetic resonance imaging.

A previously healthy man with no family history of fractures presented with muscle pain, back pain and height loss. Investigations revealed hypophosphataemia, phosphaturia, undetectable serum 1,25-dihydroxyvitamin D and severe osteomalacia on bone biopsy, suggestive of a diagnosis of oncogenic osteomalacia. Thorough physical examination did not locate a tumour. Support for the diagnosis was obtained by detection of phosphate uptake inhibitory activity in a blinded sample of the patient's serum using a renal cell bioassay. On the basis of detection of this bioactivity, a total body magnetic resonance (MR) examination was performed. A small tumour was located in the right leg. Removal of the tumour resulted in the rapid reversal of symptoms and the abnormal biochemistry typical of oncogenic osteomalacia. Inhibitory activity was also demonstrated using the bioassay in serum from two other patients with confirmed or presumptive oncogenic osteomalacia, but not in serum from two patients with hypophosphataemia of other origin. This is the first case to be reported in which the diagnosis of oncogenic osteomalacia was assisted by demonstration of inhibitory activity of the patient's serum in a renal cell phosphate bioassay that provided an impetus for total body MR imaging.

Investigation of the mechanism of perforation of an intrauterine device in pigs and dogs.

In the last few years the risk of perforations in connection with the insertion and later use of intrauterine devices (IUDs) has been the subject of much discussion in Sweden. In this experimental study, which was carried out on five pigs and nine dogs and in which four different types of IUDs were used, the following clinical situations encountered in women were simulated: IUD in correct position in the uterus, IUD in an adverse position in the uterus, and IUD more or less inserted through the uterine wall. The animals were observed for 3 to 6 months. The findings indicate that, when perforation occurs, it is most probably ascribable to the insertion procedure.

The possible risks of a copper and an inert intrauterine device situated in the abdominal cavity: an experimental study in pigs and dogs.

The possible injurious effects of abdominal intrauterine devices (IUDs), including Cu-IUDs, inert IUDs, and "closed' IUDs, were evaluated in an experimental study. Pigs and dogs were used as they have, respectively, a propensity to form adhesions and a pronounced tendency to develop serious peritonitis. The reactions expected in humans might be intermediate to those found in these two kinds of experimental animals. The results of this study indicate that an inert or copper-bearing IUD usually remains in its initial position in the abdominal cavity, encapsulated by adhesions. The risk of strangulation of the intestine by a "closed' IUD seems minimal.

High-resolution spectroscopic imaging of the human skin.

High-resolution water, fat and chemical shift artefact-free images of different areas of the skin were obtained on a whole-body MR unit (1.5 T) with commercial receiver surface coil with a diameter of 25 mm and high-power gradients (23 mT/m). Sufficient signal-to-noise ratio was achieved by lowering receiver bandwidth to +/-10 kHz or lower and shortening the echo time to 11 (13) ms. Spectroscopic image data sets were acquired with resolution 0.102 x 0.133 mm in plane and slice thickness 0.5 mm. The results demonstrate that it is possible to produce high-quality water and fat micro-images of the skin layers using only a few chemical shift encoding steps in a clinically reasonable time (approximately 2 minutes per slice).

Experienced nurses' narratives of their being in ethically difficult care situations. The problem to act in accordance with one's ethical reasoning and feelings.

In previous interviews, experienced nurses have reported that their decisions in ethical matters depended "on the situation at hand." We interviewed 18 good, experienced cancer nurses to determine how they handled ethical decisions. They were asked to give an account of difficult situations that required ethical decisions to be made. The 60 narrated situations were interpreted step-by-step departing from the following two questions: What do nurses experience when being in ethically difficult care situations? What does the expression "it depends on the situation at hand how I act" mean? In complex situations, the nurses reported that the ethical situations that arose were regarded either as overwhelming or at the other end of the spectrum, as possible to grasp, and they expressed either loneliness or togetherness, respectively. When reporting overwhelming situations, the nurses mostly referred to themselves by using the word "one," i.e., "one would" and used "they" when referring to their coactors. When narrating situations possible to grasp, they used the terms "I" and "we." The most important situational factor that was revealed in these narratives was whether or not the nurses had a support group in which to share their thoughts. Without the support group, they reported difficulties acting in accordance with their ethical reasoning and feelings.

Effect of oxytocin and its long-acting analog on milk let-down and intramammary pressure in healthy lactating sows.

Ten healthy lactating sows were given single IV injections of 5 to 10 IU of oxytocin and single IV or IM injections of 0.2 to 0.6 mg of deamino-1-monocarba-(2-O-methyltyrosine)-oxytocin [d(COMOT)]. Studies were done with d(COMOT) concerning the dose-response relationship, the influence of the lactation stage on the duration of the milk let-down effect, and the difference between the IV and IM injections. The mean duration of response was 14 minutes for oxytocin and 6.2 hours for d(COMOT). Intramammary pressure was also measured in 3 sows, using 10 IU of oxytocin IV or 0.6 mg of d(COMOT) IV. Oxytocin resulted in a strong initial increase of the intramammary pressure for about 7 minutes. The d(COMOT) caused the same initial response, followed by secondary oscillations lasting for at least 4 hours.

Effect of procaine benzylpenicillin alone or in combination with dihydrostreptomycin on udder pathogens in vitro and in experimentally infected bovine udders.

Minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of benzylpenicillin (PEN) and dihydrostreptomycinsulfate (DHS) were determined for freshly isolated bovine udder pathogens. Killing curves were determined to study synergism of PEN and DHS on Staphylococcus aureus and Streptococcus uberis. Healthy udder quarters of cows in their first lactation were inoculated with Str dysgalactiae or Str uberis strains. After development of acute mastitis, procaine PEN alone or combined with DHS were given IM, and the concentrations of PEN and DHS in plasma and normal and mastitic milk were determined. Twenty-four hours after 10 mg of procaine PEN/kg of body weight (IM), concentrations in mastitic milk equal to MIC or MBC were maintained only for Str dysgalactiae. Twenty-four hours after 20 mg of procaine PEN/kg (IM), MBC in mastitic milk was maintained for Str uberis and 50% of the S aureus. When concentrations equal to MIC or MBC Of PEN were combined with a sub-MIC amount of DHS, the in vitro synergistic killing of Str uberis was not observed in vivo. In agreement with in vitro killing effect at PEN concentrations equal to MBC, Str dysgalactiae was 100% eliminated in 5 cows when MBC of PEN in mastitic milk was maintained for 24 to 36 hours. On the contrary, only 2 of 6 cows inoculated with Str uberis were free of this pathogen, although MBC of PEN was maintained for 24 to 36 hours in mastitic milk.

Concentrations of penicillin, streptomycin, and spiramycin in bovine udder tissue liquids.

Concentrations of benzylpenicillin and spiramycin adipate were determined in bovine plasma and milk and in lymph draining the udder tissue after IM or IV administration. Combined benzylpenicillin and dihydrostreptomycin sulfate concentrations were also determined in the same fluids after intramammary injection. A superficial parenchymal lymph vessel, afferent to the supramammary lymph gland of the left quarters, was cannulated with a polythene catheter from which the lymph was allowed to drain freely. After injections of 9.5 mg of benzylpenicillin/kg of body weight IM, a mean peak concentration (PC) in lymph (3.7 micrograms/ml), constituting 77% of the PC in plasma (4.8 micrograms/ml), was obtained 0.5 to 1 hour after PC in the plasma. The benzylpenicillin lymph concentration was close to that in plasma for about 7 hours after injection. Thereafter, the benzylpenicillin lymph concentration continued to exceed that in plasma, but not that in milk. After IV administration of spiramycin adipate, the lymph concentration was almost identical to that in plasma. After intramammary injection of procaine benzylpenicillin (400 mg), in combination with the same amount of dihydrostreptomycin sulfate, into 2 udder quarters each, mean PC in the lymph of 3.5 micrograms/ml and 8.4 micrograms/ml, respectively, were obtained 6 hours after injection. In plasma, the mean PC of benzylpenicillin (0.07 micrograms/ml) and of dihydrostreptomycin sulfate (0.85 micrograms/ml) were obtained after 4 and 6 hours, respectively. In milk from the nontreated quarters, a mean concentration of 5 ng of benzylpenicillin/ml was obtained, whereas dihydrostreptomycin sulfate (greater than or equal to 0.3 microgram/ml) was not detected.(ABSTRACT TRUNCATED AT 250 WORDS)

When the severely ill elderly patient refuses food. Ethical reasoning among nurses.

Forty registered nurses (RNs) regarded as "good and experienced" in either cancer or dementia care, were asked about their decision to feed or not feed a severely ill elderly woman (a hypothetical case). In order to compare ethical reasoning in the two groups of nurses and to illuminate what it means to RNs to face a situation where the patients can/cannot decide for themselves, a phenomenological hermeneutic approach was used for the analysis. Both groups saw themselves as the advocate for their patients but in different ways. The RNs who talked about a mentally alert patient emphasized that they encouraged their patient to speak up for herself, while the RNs who talked about a severely demented patient emphasized that they tried very hard to interpret their patient's vague and unclear communicative cues and to act as her advocate, especially in relation to physicians. Transcending experiences of dying relatives and patients as well as role models helped them to achieve their ambition of putting themselves in the patient's shoes in order to respect and understand her or his wish and/or what was best for them. The majority of RNs strongly rejected active euthanasia.

Measures taken by veterinarians in Sweden in cases of bovine mastitis.

A questionnaire concerning the diagnosis and treatment of bovine mastitis was sent to all 350 Swedish food animal practitioners. 287 (82%) of the questionnaires were returned. One of the main aims was to establish if Swedish food animal practitioners used a common therapeutic regime that could be used as a control treatment in future clinical trials. It was found that many factors of importance for the clinical diagnosis of mastitis such as body temperature, duration of the symptoms etc. often were not considered. On the other hand 60-70% of the practitioners regularly took milk samples to obtain a bacteriological diagnosis. Approximately 40% of the veterinarians cultured the milk samples in their home laboratory. Basic measures like frequent emptying of the udder were recommended by only 40-50% of the veterinarians. All responding field veterinarians used the systemic route for administering antibiotics when treating cases of acute, clinical bovine mastitis. The drug of choice, initially, in these cases was benzylpenicillinprocain, which was used by 65-75% of the veterinarians. Twenty-five percent used a broad-spectrum antibiotic, most commonly a combination of penicillin and streptomycin. A minority (5%) directed their initial therapy towards gram-negative bacteria. About 30-40% supported the systemic therapy with intra-mammaries. Other drugs such as NSAID, corticosteroids and oxytocin was used, on a regular basis, by only about 10% of the practitioners.

Skilled nurses' experiences of caring.

The content and the meaning of nurses' caring in practice remain poorly illuminated. To contribute to a better understanding, the meaning of caring, abilities needed for caring, experiences that make caring worthwhile, and the source of the strength needed to continue caring were focused on in interviews with experienced nurses in surgical (n = 15), medical (n = 15), and long-term (n = 15) care. The analysis showed both similarities and differences between the three groups of nurses. One similarity lay in the ability of the nurses within their caring role to understand the situation, to establish contact with the patient, and to act in the patient's best interest especially regarding the relief of pain and anxiety. On the other hand, one of the differences was that the nurses engaged in long-term care emphasized support of the patients' psychosocial needs more than nurses engaged in surgical and medical care, who emphasized support of the patients' weakened vital functions. The analysis also disclosed that almost all of the nurses had been troubled by problems of patient care when they were new to their jobs, but experience and maturity had given them strength. Care in itself gave the nurses satisfaction and pleasure and made it worthwhile. Positive cooperation with coworkers and patients' families were the main sources of their strength to continue caring.

Relations between udder infection and somatic cells in camel (camelus dromedarius) milk.

Quarter milk samples (n = 391) from 101 camels were examined to study the occurrence and causes of mastitis in traditionally managed camels in eastern Sudan and to evaluate the value of the California Mastitis Test (CMT), somatic cell count (SCC) and adenosine triphosphate (ATP) in the detection of subclinical mastitis in the camel. One hundred and seventy (43.5%) of the quarter milk samples yielded pathogenic bacteria. Streptococcus agalactiae, other Streptococcus spp., Staphylococcus aureus, coagulase-negative staphylococci, and Escherichia coli were isolated from milk. Thirty-two (8.2%) quarter milk samples yielded mixed cultures, and 189 (48.3%) yielded no growth. Mean values for CMT, SCC and ATP were higher for quarters infected with major pathogens. However, a significant number of quarter milk samples had elevated values in these tests but were from quarters from which no bacteria were isolated. The ability of the tests to predict a positive bacteriology increased slightly when 2 or 3 tests were combined.

A caprine experimental model for studies on inflammation.

A new experimental model for in vivo studies on local inflammation in the goat is presented. The teat and udder cisterns were separated by a surgical procedure, resulting in the teat cistern being an isolated pouch which is easily accessible through the teat canal and suitable for experimental studies. The surgery was consistently successful in closing the passage and no post-surgical complications were observed. The model was applied to a study of the inflammatory response induced by infusion of Salmonella endotoxin. A marked response was observed as measured by the accumulation of leukocytes, serum albumin and N-acetyl-beta-D-glucosaminidase (NAGase) in the test cistern. An initial increase in serum albumin, indicating an increase in the epithelial permeability, was observed from 1.5 h after endotoxin infusion. Approximately 0.5 h later, the cell count started to increase, reaching its peak level 3 h after infusion. The NAGase concentration was closely correlated with the cell count. The model provides new possibilities for in vivo studies on local inflammation and fulfils many of the requirements of an inflammatory model; for example, it allows non-traumatic repeated samplings from the same animal. The goat is a suitable experimental animal for many studies and, as each goat has two teats, intra-goat comparisons can be performed.