Radiosensitization by BRAF inhibitor therapy-mechanism and frequency of toxicity in melanoma patients.

BACKGROUND: Recent evidence suggests that ionizing radiation may be associated with unexpected side-effects in melanoma patients treated with concomitant BRAF inhibitors. A large multicenter analysis was carried out to generate reliable safety data and elucidate the mechanism. METHODS: A total of 161 melanoma patients from 11 European skin cancer centers were evaluated for acute and late toxicity, of whom 70 consecutive patients received 86 series of radiotherapy with concomitant BRAF inhibitor therapy. To further characterize and quantify a possible radiosensitization by BRAF inhibitors, blood samples of 35 melanoma patients were used for individual radiosensitivity testing by fluorescence in situ hybridization of chromosomal breaks after ex vivo irradiation. RESULTS: With radiotherapy and concomitant BRAF inhibitor therapy the rate of acute radiodermatitis ≥2° was 36% and follicular cystic proliferation was seen in 13% of all radiotherapies. Non-skin toxicities included hearing disorders (4%) and dysphagia (2%). Following whole-brain radiotherapy, rates of radiodermatitis ≥2° were 44% and 8% (P < 0.001) for patients with and without BRAF inhibitor therapy, respectively. Concomitant treatment with vemurafenib induced acute radiodermatitis ≥2° more frequently than treatment with dabrafenib (40% versus 26%, P = 0.07). In line with these findings, analysis of chromosomal breaks ex vivo indicated significantly increased radiosensitivity for patients under vemurafenib (P = 0.004) and for patients switched from vemurafenib to dabrafenib (P = 0.002), but not for patients on dabrafenib only. No toxicities were reported after stereotactic treatment. CONCLUSION: Radiotherapy with concomitant BRAF inhibitor therapy is feasible with an acceptable increase in toxicity. Vemurafenib is a more potent radiosensitizer than dabrafenib.

Management of complex anorectal fistulas with seton drainage plus partial fistulotomy and subsequent ligation of intersphincteric fistula tract (LIFT).

BACKGROUND: Ligation of intersphincteric fistula tract (LIFT) is a relatively new technique in the treatment of complex anorectal fistulas. As it spares the anal sphincter, rates of post-operative incontinence may be lower when compared to conventional treatment. To date, there have not been enough reports of long-term fistula recurrence rates. We performed a long-term follow-up study of 75 patients who underwent LIFT following seton drainage and partial fistulotomy. METHODS: Only patients with complex cryptogenic anorectal fistulas were included. After seton insertion and partial fistulotomy, the tract was reviewed at 4 months for the absence of anorectal sepsis. Patients then underwent LIFT in a day surgery setting. Operative time, complications, recurrences and incontinence were evaluated. RESULTS: Between May 2008 and June 2013, 75 patients [51 men, mean age 49.5 years, standard error of the mean (SEM) 1.4 years] were treated with a LIFT protocol. The mean operating time for LIFT was 13.2 min (SEM 1.5 min). Complications included minor bleeding, superficial wound dehiscence and perianal pain. At a mean follow-up of 14.6 months (SEM 1.7 months), there were nine (12 %) recurrences, diagnosed at a mean 9.2 months (SEM 2.7 months). They were treated with seton insertion followed by LIFT with biomesh or anorectal advancement flap, and there were no subsequent recurrences. Review of preoperative and post-operative continence scores revealed only one (1.3 %) patient with minor incontinence following LIFT. Recurrences were significantly related to fistulas with multiple tracts (p < 0.001). CONCLUSIONS: Our results suggest that the protocol of seton insertion and partial fistulotomy followed by LIFT is associated with a low recurrence rate comparing well with published results from studies involving other techniques and protocols for treating anal fistula.

Unusual acute and delayed skin reactions during and after whole-brain radiotherapy in combination with the BRAF inhibitor vemurafenib. Two case reports.

BACKGROUND: Besides radiotherapy (RT) and surgery, the introduction of BRAF inhibitors like vemurafenib has provided new opportunities for treatment of patients with metastasized malignant melanomas. RT and vemurafenib are being increasingly used concurrently, although little is known about the potential side effects of this combination. Vemurafenib is known to cause severe cutaneous skin reactions such as phototoxicity and evidence is accumulating that RT may further enhance these side effects. PATIENTS AND METHODS: We report two cases of unusual skin reactions occurring during and after treatment with a combination of vemurafenib and whole-brain irradiation in patients with cerebral metastases arising from malignant melanomas. RESULTS: One case report describes excessive acute radiodermatitis which arose during whole-brain irradiation in combination with vemurafenib. The second describes a late skin reaction occurring approximately 30 days after completion of RT. CONCLUSION: These two case reports show that combination of both treatment modalities is possible, but requires close monitoring of patients and good interdisciplinary collaboration.

Characterization of Aerosol Hygroscopicity Over the Northeast Pacific Ocean: Impacts on Prediction of CCN and Stratocumulus Cloud Droplet Number Concentrations.

During the Marine Aerosol Cloud and Wildfire Study (MACAWS) in June and July of 2018, aerosol composition and cloud condensation nuclei (CCN) properties were measured over the N.E. Pacific to characterize the influence of aerosol hygroscopicity on predictions of ambient CCN and stratocumulus cloud droplet number concentrations (CDNC). Three vertical regions were characterized, corresponding to the marine boundary layer (MBL), an above-cloud organic aerosol layer (AC-OAL), and the free troposphere (FT) above the AC-OAL. The aerosol hygroscopicity parameter (κ) was calculated from CCN measurements (κ CCN) and bulk aerosol mass spectrometer (AMS) measurements (κ AMS). Within the MBL, measured hygroscopicities varied between values typical of both continental environments (~0.2) and remote marine locations (~0.7). For most flights, CCN closure was achieved within 20% in the MBL. For five of the seven flights, assuming a constant aerosol size distribution produced similar or better CCN closure than assuming a constant "marine" hygroscopicity (κ = 0.72). An aerosol-cloud parcel model was used to characterize the sensitivity of predicted stratocumulus CDNC to aerosol hygroscopicity, size distribution properties, and updraft velocity. Average CDNC sensitivity to accumulation mode aerosol hygroscopicity is 39% as large as the sensitivity to the geometric median diameter in this environment. Simulations suggest CDNC sensitivity to hygroscopicity is largest in marine stratocumulus with low updraft velocities (<0.2 m s-1), where accumulation mode particles are most relevant to CDNC, and in marine stratocumulus or cumulus with large updraft velocities (>0.6 m s-1), where hygroscopic properties of the Aitken mode dominate hygroscopicity sensitivity.

Piperacillin/tazobactam vs ceftazidime in the treatment of neutropenic fever in patients with acute leukemia or following autologous peripheral blood stem cell transplantation: a prospective randomized trial.

Piperacillin/tazobactam was compared with ceftazidime for the empirical treatment of febrile neutropenia in patients with acute leukemia or following autologous peripheral blood stem cell transplantation. Owing to inclusion criteria, it was possible for the same patient to be randomized several times. A total of 219 individual patients were admitted to a prospective randomized clinical study: 24 patients were included twice. Patients (23.5%) remained afebrile. Patients who developed febrile neutropenia were randomized to receive intravenous ceftazidime (n = 74 patients, group I) or piperacillin/tazobactam (n = 87 patients, group II). Response to first-line antibiotic treatment was seen in 55% (group I) and 53% (group II). After the addition of vancomycin, a further 19% (group I) and 24% (group II) of the patients became afebrile. Causes of fever were: microbiologically documented infection in 36 and 34 patients of group I and II; Clostridium difficile in eight and 12 patients of group I and II, and fever of unknown origin in 30 and 41 patients of group I and II. One patient died in each group. Single-agent therapy with piperacillin/tazobactam is as effective as ceftazidime in the treatment of neutropenic fever and is well tolerated. Direct and indirect costs of both treatment regimes are equivalent.

Floral colours in a world without birds and bees: the plants of Macquarie Island.

We studied biotically pollinated angiosperms on Macquarie Island, a remote site in the Southern Ocean with a predominately or exclusively dipteran pollinator fauna, in an effort to understand how flower colour affects community assembly. We compared a distinctive group of cream-green Macquarie Island flowers to the flora of likely source pools of immigrants and to a continental flora from a high latitude in the northern hemisphere. We used both dipteran and hymenopteran colour models and phylogenetically informed analyses to explore the chromatic component of community assembly. The species with cream-green flowers are very restricted in colour space models of both fly vision and bee vision and represent a distinct group that plays a very minor role in other communities. It is unlikely that such a community could form through random immigration from continental source pools. Our findings suggest that fly pollination has imposed a strong ecological filter on Macquarie Island, favouring floral colours that are rare in continental floras. This is one of the strongest demonstrations that plant-pollinator interactions play an important role in plant community assembly. Future work exploring colour choices by dipteran flower visitors would be valuable.

The IL-33 receptor (ST2) regulates early IL-13 production in fungus-induced allergic airway inflammation.

Allergic airway inflammation (AAI) in response to environmental antigens is an increasing medical problem, especially in the Western world. Type 2 interleukins (IL) are central in the pathological response but their importance and cellular source(s) often rely on the particular allergen. Here, we highlight the cellular sources and regulation of the prototypic type 2 cytokine, IL-13, during the establishment of AAI in a fungal infection model using Cryptococcus neoformans. IL-13 reporter mice revealed a rapid onset of IL-13 competence within innate lymphoid cells type 2 (ILC2) and IL-33R(+) T helper (Th) cells. ILC2 showed IL-33-dependent proliferation upon infection and significant IL-13 production. Th cells essentially required IL-33 to become either GATA3(+) or GATA3(+)/Foxp3(+) hybrids. GATA3(+) Th cells almost exclusively contributed to IL-13 production but hybrid GATA3(+)/Foxp3(+) Th cells did not. In addition, alveolar macrophages upregulated the IL-33R and subsequently acquired a phenotype of alternative activation (Ym1(+), FIZZ1(+), and arginase-1(+)) linked to type 2 immunity. Absence of adaptive immunity in rag2(-/-) mice resulted in attenuated AAI, revealing the need for Th2 cells for full AAI development. Taken together, in pulmonary cryptococcosis ILC2 and GATA3(+) Th2 cells produce early IL-13 largely IL-33R-dependent, thereby promoting goblet cell metaplasia, pulmonary eosinophilia, and alternative activation of alveolar macrophages.

Altered mRNA expression of glycosyltransferases in human gastric carcinomas.

Biosynthesis of carbohydrate structures is tissue-specific and developmentally regulated by glycosyltransferases like fucosyl-, sialyl- and N-acetylglucosaminyltransferases. During carcinogenesis, aberrant glycosylation leads to the development of tumor subpopulations with different adhesion properties. The aim of this contribution was to directly compare mRNA expression of several glycosyltransferases in surgical specimens of gastric carcinomas. Carcinoma specimens were classified and characterized according to the WHO/UICC system. In each case, the expression of 12 glycosyltransferase enzymes was studied simultaneously by RT-PCR. For semi-quantitative analysis, amplification of the sample sequence was compared with that of beta-actin, co-amplified within the same tube. Expression of N-acetylglucosaminyltransferase V in gastric carcinomas was significantly enhanced compared to normal tissue. Also, expression of sialyltransferase ST3Gal-IV and fucosyltransferase FT-IV was significantly enhanced in carcinoma tissue. No significant differences in glycosyltransferase expression were found in samples positive for Helicobacter pylori or between the different gastric regions. Thus, carcinogenesis is characterized by specific alterations in mRNA expression of several glycosyltransferases. Future studies will show whether RT-PCR detection of the expression of these enzymes could be helpful for prognostic purposes.

Biocatalysis for industrial production of fine chemicals.

Chiral intermediates constitute a significant part of the fine chemicals market, which is strongly influenced by trends in the pharmaceutical industries, where approximately 70% of pharmaceuticals are expected to be enantiomerically pure in the next century as compared to 25% today. The main technologies by which enantiomerically pure ingredients are obtained today are (dynamic) resolutions of racemic mixtures. Asymmetric syntheses are being developed, but their applications in industry are still under represented. Biotechnological methods, resolutions as well as asymmetric syntheses, are becoming increasingly important in the industrial production of fine chemicals.

Structural and cell-adhesive properties of three recombinant fragments derived from perlecan domain III.

Domain III of the basement membrane proteoglycan perlecan was produced as three overlapping fragments in stably transfected mammalian cell clones. These recombinant fragments (43-48 kDa) were obtained in purified form and showed complete immunological cross-reactivity with perlecan, indicating their native structure. Rotary shadowing electron microscopy of each fragment demonstrated a small globular structure connected to a short rod. These data were interpreted to indicate that domain III has an elongated shape of 30 nm in length and consists of alternating globular domains (L4 modules) and short connecting segments attributed to tandem arrays of LE (laminin-type of EGF-like) modules which form rod-like segments in laminins. Sequence analyses of pepsin fragments were consistent with the disulfide-bonding patterns known for these modules from studies with laminin fragments, but two additional disulfide loops were also identified. Several cell lines which attached to mouse perlecan and/or human fibronectin failed to adhere to the domain III fragments, despite the fact that one of them contained an RGD (Arg-Gly-Asp) site in the L4 module. Furthermore, no significant binding was observed in solid phase binding assays with alpha 5 beta 1 and alpha v beta 3 integrins underscoring the low activity or accessibility of the RGD site.

The effect of the peroxisome proliferator ciprofibrate on the gastric mucosa and particularly the gastrin cell.

The peroxisome proliferator ciprofibrate induces hypergastrinemia without inhibiting acid secretion. The present study was carried out to assess the effect of ciprofibrate on serum gastrin and gastrin (G) cells in different strains of rats and to compare the effect of ciprofibrate with other lipid-reducing agents (lovastatin and simvastatin) which have a different mechanism of action. Serum gastrin was determined by a radioimmunoassay method, G cell density by histomorphometry after immunostaining for G cells, and gastrin, somatostatin and histidine decarboxylase (HDC) mRNA abundance by Northern blot analysis. Ciprofibrate (100 mg/kg/day for three weeks) induced a marked hypergastrinemia (P < 0.01) in male and female Fischer rats as well as in female Wistar rats. Simvastatin and lovastatin did not affect serum gastrin. Antral G cell density increased significantly in female Wistar rats (P < 0.05) and non-significantly in the other rats after ciprofibrate. Both gastrin and somatostatin mRNA abundance in antral mucosa increased markedly and significantly (P < 0.01) after ciprofibrate treatment. The present study shows that the peroxisome proliferator ciprofibrate induces hypergastrinemia secondary to an increased storage and synthesis of antral gastrin. Since somatostatin mRNA abundance also increased, the present study suggests that ciprofibrate and possibly other peroxisome proliferators in sufficient concentrations have a stimulatory effect on endocrine cells.

Changed composition of high-density lipoprotein subclasses HDL2 and HDL3 after renal transplantation.

The concentrations of cholesterol in the high density lipoprotein (HDL) fraction and the HDL2 and HDL3 subclasses were compared in 333 male renal transplant recipients, 36 male patients on maintenance hemodialysis, and 43 healthy men. The subclasses were separated by a precipitation method using polyethylene glycol 6000 and dextran sulphate. In hemodialyzed patients, total HDL cholesterol and both subclasses were reduced. In renal transplant recipients, both total HDL cholesterol and HDL2 were normal, whereas HDL3 remained reduced, analogous to hemodialyzed patients. It can be concluded that a successful renal transplantation has a beneficial effect on HDL metabolism and thus on the development of atherosclerosis.

Treatment of severe infections with temocillin. Clinical and bacteriological evaluation.

Included in a study of the clinical efficacy of temocillin were 20 hospitalised female patients suffering from infections of the respiratory or urinary tract, septicaemia or an abscess. Clinical evaluation revealed fully effective treatment in all patients, and all pathogens identified were eliminated during therapy with no adverse reactions being observed.

Misclassification risk of patients with bilateral cleft lip and palate and manifestations of median facial dysplasia: A new variant of del(22q11.2) syndrome?

The generic term median facial dysplasia (MFD) describes a subgroup of patients with cleft lip and palate exhibiting characteristic craniofacial defects: (1) short prolabium, (2) absence of frenulum labii, (3) hypoplasia of premaxilla, (4) absent upper central and lateral incisors of the cleft side, and (5) deficient septal cartilage and nasal spine. Gross brain malformations are usually absent in MFD. The same craniofacial malformations are also described in patients with holoprosencephaly sequence (HPE-S). We report on two male patients with bilateral cleft lip and palate showing the facial findings of MFD or HPE-S. Additional congenital malformations were anal atresia in one patient and severe cardiac defect in the other. In both, HPE was excluded by brain imaging, although uncommon brain anomalies were detected consisting of multiple white-matter lesions in the one patient and unusual enlargement and tortuosity of intracerebral blood vessels in both patients. In addition to facial anomalies, the patients also had psychiatric problems typically seen in velo-cardio-facial syndrome (VCFS). Fluorescence in situ hybridization (FISH) analysis confirmed a 22q11.2 microdeletion in both.

Rare dental abnormalities seen in oculo-facio-cardio-dental (OFCD) syndrome: three new cases and review of nine patients.

Oculo-facio-cardio-dental syndrome is a very rare condition. So far, only nine cases have been documented. We report on three additional female patients representing the same entity. The clinical findings were: congenital cataract, microphthalmia/microcornea, secondary glaucoma, vision impairment, ptosis, long narrow face, high nasal bridge, broad nasal tip with separated cartilages, long philtrum, cleft palate, atrial septal defect, ventricular septal defect, and skeletal anomalies. The following dental abnormalities were found: radiculomegaly, delayed dentition, oligodontia, root dilacerations (extension), and malocclusion. For the first time, fusion of teeth and hyperdontia of permanent upper teeth were seen. In addition, structural and morphological dental changes were noted. These findings expand the clinical spectrum of the syndrome.

Serine proteases as mediators of radiographic contrast media toxicity.

Iodipamide, iodoxamine, iothalamate, diatrizoate, and ioxitalamate exhibit a dose-dependent prolongation of coagulation time of global and monospecific functional coagulation tests. This is due to an inhibition of fibrin polymerization induced by these contrast media. Furthermore, a dose-dependent generation of fibrinolytic split products by RCM was found. At low doses, biliary RCM cause hypercoagulation by binding to spontaneously existing fibrinolytic products. Biliary RCM cause a dose-dependent decrease of hemolytic complement activity and decrease of complement factors of C3, B, and, to a lesser extent, C4. Nephrotopic RCM do not show these effects. By crossed immunoelectrophoresis B and C3 split products were not detected after in vitro incubation of iodipamide in serum or EDTA-blood. In contrast, zymosan, inulin, and dextran sulfate incubation of sera readily resulted in Bb and C3b generation. The failure to demonstrate complement split products was not due to artifacts. As a working hypothesis unspecific binding of RCM to blood proteins followed by interference with antithrombin and antiplasmin inhibitor functions is proposed. Possibly other antiproteases might be involved too. This results in a lowering of the clinical manifestation threshold of coagulation and fibrinolysis. The mechanism of complement activation remains unclear, since it is not influenced by EDTA, aprotinin, steroids, or by specific sera depleted of prekallikrein, Hageman factor, C2, and gamma-globulins.

Outcome of heart transplantation in patients previously infected with hepatitis C virus.

The lack of knowledge about the course of hepatitis C virus infection (HCV) before heart transplantation (HTx) prompted us to describe our experience with 4 such patients who presented with positive HCV serology before surgery. Two experienced non-liver related deaths at 3.5 and 5 years after HTx, and none of the patients developed signs of hepatic insufficiency during the follow-up (mean 3.8 years). Tests for HCV antibodies were frequently negative, whereas viral RNA was detected in 81% of the measurements, showing that virus detection techniques seem to be more sensitive than serology techniques in detecting HCV infection in this group of patients. Although immunosuppression promotes active HCV replication, it does not seem to change the chronic features of HCV infection during the first years in patients with good liver function.