Intermediate dose thalidomide (200 mg daily) has comparable efficacy and less toxicity than higher doses in relapsed multiple myeloma

Thalidomide at doses >200 mg has 100% grade 1-2 and 25% grade 3-4 toxicities requiring discontinuation. We report a retrospective study of relapsed myeloma patients treated with thalidomide 200 mg with no dose escalation. Thirty patients were identified; 43% of patients responded with paraprotein decline >75% -- 2 (6%), 50-75% -- 7 (23%), 25-50% -- 4 (14%) and 2 (6%) were stable. All five patients with 13q deletion responded. Only 54% reported grade 1-2 toxicities (none reporting > grade 2) with 5 (17%) discontinuing treatment due to toxicity. Thalidomide 200 mg daily with no dose escalation appears as effective and better tolerated than escalated doses for relapsed myeloma patients.     

Use of the anti-idiotype breast cancer vaccine 11D10 in conjunction with autologous stem cell transplantation in patients with metastatic breast cancer

The results of cytotoxic therapy, including dose-intensive therapy requiring autologous stem cell transplantation (ASCT), have been disappointing in patients with metastatic breast cancer, as almost all patients eventually experience disease progression. There has been a renewed interest in immunotherapeutic strategies in this disease, including evaluation of several breast cancer vaccines. In the current study, we describe the results of a program in which the anti-idiotype breast cancer vaccine 11D10 (TriAb) was administered before and after ASCT in patients with metastatic breast cancer chemosensitive to previous conventional therapy. The toxicity of this approach was acceptable, and idiotype-specific humoral and T-cell proliferative responses were observed in the majority of patients within a few weeks post-ASCT. The actuarial 3-year overall survival rate was 48% (95% CI, 32%-64%), while the progression-free survival rate was 32% (95% CI, 19%-45%). Multivariate analysis identified achievement of a strong antibody and cellular immune response to the vaccine as the only significant prognostic factors for outcome. The ability to reliably produce robust immune responses after ASCT is encouraging. Further studies are required to determine if the immune response mediates an antitumor benefit in these patients.     

Central challenges facing the national clinical research enterprise

Nancy S. Sung, PhD; William F. Crowley, Jr, MD; Myron Genel, MD; Patricia Salber, MD, MBA; Lewis Sandy, MD, MBA; Louis M. Sherwood, MD; Stephen B. Johnson, PhD; Veronica Catanese, MD; Hugh Tilson, MD, DrPH; Kenneth Getz, MBA; Elaine L. Larson, RN, PhD; David Scheinberg, MD, PhD; E. Albert Reece, MD, PhD, MBA; Harold Slavkin, DDS; Adrian Dobs, MD, MHS; Jack Grebb, MD; Rick A. Martinez, MD; Allan Korn, MD; David Rimoin, MD, PhD

JAMA. 2003;289:1278-1287.

Medical scientists and public health policy makers are increasingly concerned that the scientific discoveries of the past generation are failing to be translated efficiently into tangible human benefit. This concern has generated several initiatives, including the Clinical Research Roundtable at the Institute of Medicine, which first convened in June 2000. Representatives from a diverse group of stakeholders in the nation's clinical research enterprise have collaborated to address the issues it faces. The context of clinical research is increasingly encumbered by high costs, slow results, lack of funding, regulatory burdens, fragmented infrastructure, incompatible databases, and a shortage of qualified investigators and willing participants. These factors have contributed to 2 major obstacles, or translational blocks: impeding the translation of basic science discoveries into clinical studies and of clinical studies into medical practice and health decision making in systems of care. Considering data from across the entire health care system, it has become clear that these 2 translational blocks can be removed only by the collaborative efforts of multiple system stakeholders. The goal of this article is to articulate the 4 central challenges facing clinical research at present—public participation, information systems, workforce training, and funding; to make recommendations about how they might be addressed by particular stakeholders; and to invite a broader, participatory dialogue with a view to improving the overall performance of the US clinical research enterprise.

     

Effect of torso adipose tissue thickness on effective dose in a broad parallel photon beam

The effect of torso adipose tissue thickness on effective dose was studied for external broad parallel photon beams using the MCNP code and a mathematical anthropomorphic phantom. The variation of torso adipose tissue thickness was modeled by adding a layer of soft tissue (1-7 cm) around the torso of the phantom. This study found that effective dose varies almost linearly with the thickness of the adipose tissue layer. For most irradiation geometries (i.e., antero-posterior, postero-anterior, and lateral), effective dose decreases with the thickness of the adipose tissue layer due to the shielding effect of the layer. Effective dose decreases by 11-35% when the thickness of the adipose tissue layer increases from 0 to 7 cm considering all photon energies (0.08, 0.3, and 1.0 MeV) and irradiation geometries in this study. For overhead irradiation geometry, however, an increase of adipose tissue layer thickness results in an increase of effective dose. This is because the organs and tissues in the body are additionally exposed by the photons that are scattered from the added adipose tissue layer. For the overhead irradiation geometry, effective dose increases by 13-27% when the adipose tissue thickness increases from 0 to 7 cm.     

Polymorphisms in glutathione S-transferases are associated with altered risk of nonmelanoma skin cancer in renal transplant recipients: a preliminary analysis

Non-melanoma skin cancer (NMSC) represents a significant cause of morbidity and mortality among renal transplant recipients, with tumors behaving more aggressively than those in nontransplant patients. Not all immunosuppressed patients develop NMSC, however, and in those that do, the rate of accrual and numbers of lesions vary considerably. Though ultraviolet light is critical, it is unlikely that this alone explains the observed phenotypic diversity, suggesting the possible involvement of genetic factors. Furthermore, although twin studies in nontransplant patients with NMSC suggest a low genetic component, several genes associated with susceptibility and outcome in these patients have been identified. Thus, having previously shown that polymorphism in members of the glutathione S-transferase (GST) supergene family is associated with altered NMSC risk in nontransplant patients, we examined allelism in GSTM1, GSTP1, GSTM3, and GSTT1 in 183 renal transplant recipients. GSTM1 null was associated with increased squamous cell carcinoma (SCC) risk (p = 0.042, OR = 3.1). This remained significant after correction for age, gender, and ultraviolet light exposure (p = 0.012, OR = 8.4) and was particularly strong in patients with higher ultraviolet light exposure (e.g., sunbathing score > 3, p = 0.003, OR = 11.5) and in smokers (p = 0.021, OR = 4.8). Analysis of the interaction between GSTM1 null and sunbathing score showed that the two factors were synergistic and individuals with both risk parameters demonstrated a shorter time from transplantation to development of the first SCC (p = 0.012, hazard ratio = 7.1). GSTP1*Ile homozygotes developed larger numbers of SCC (p = 0.002, rate ratio = 7.6), particularly those with lower ultraviolet light exposure and cigarette consumption. GSTM3 and GSTT1 also demonstrated significant associations, though some genotype frequencies were low. These preliminary data suggest that genetic factors mediating protection against oxidative stress are important in NMSC development in immunosuppressed patients and may be useful in identifying high-risk individuals.     

Diabetic embryopathy: pathogenesis, prenatal diagnosis and prevention

In spite of the overall improvement in the management of diabetic pregnancies, congenital anomalies among infants of diabetic mothers still remain two to three times higher than in the nondiabetic population. Approximately 40 per cent of all perinatal deaths among diabetic offspring are due to congenital malformations. This article reviews the subject and discusses current views on pathogenesis, based on human and experimental work, describes methods available for prenatal diagnosis, and suggests an approach to the possible prevention of these malformations.     

Estimated fetal weight in the evaluation of growth in twin gestations: a prospective longitudinal study

A prospective longitudinal study was conducted in order to determine by sonographically estimated fetal weight the patterns of fetal growth in twins. Thirty-five healthy women with normal twin pregnancies were examined every three weeks from the 15th week of gestation to delivery. Among the measurements obtained were the biparietal diameter (BPD), the abdominal circumference, and the calculated fetal weight. From 15-28 weeks, the growth velocity of the BPD and abdominal circumference remained fairly constant, with a steady increase in incremental growth. Beyond this age, we observed a slowing in growth of the BPD, while the abdominal circumference continued at a constant rate. The growth velocity of the weight steadily increased throughout pregnancy. Although greater biologic variability in weight between twin A and B was observed as gestational age progressed, the overall mean weights of twin A and B were not statistically different. We have generated a nomogram of fetal weight gain throughout pregnancy.     

Comparative treatment and mortality correlates and adverse event profile of implant naltrexone and sublingual buprenorphine

There is increasing interest in the use of implantable naltrexone as a new treatment for opiate dependence. This center has been one of the leaders in this form of treatment in Australia and has recently completed a registry-controlled review of our mortality data. As part of the study of the safety profile of this therapy, we were interested to review both the treatment correlates of previously presented mortality data and of adverse events. A total of 255 naltrexone implant therapy (NIT) and 2,518 buprenorphine (BUP) patients were followed for 1,322.22 and 8,030.02 patient-years, respectively. NIT patients had significantly longer days in treatment per episode (mean ± standard deviation, 238.32 ± 110.11 vs. 46.96 ± 109.79), total treatment duration (371.21 ± 284.64 vs. 162.50 ± 245.76), and mean treatment times but fewer treatment episodes than BUP (all p < .0001). Serious local tissue reaction or infection each occurred in 1% of 200 NIT episodes. These data show that NIT economizes treatment resources without compromising safety concerns.