Potent inhibition by ropivacaine of metastatic colon cancer SW620 cell invasion and NaV1.5 channel function.

BACKGROUND: Metastatic breast and colon cancer cells express neonatal and adult splice variants of NaV1.5 voltage-activated Na(+) channels (VASCs). Block of VASCs inhibits cell invasion. Local anaesthetics used during surgical tumour excision inhibit VASC activity on nociceptive neurones providing regional anaesthesia. Inhibition of VASCs on circulating metastatic cancer cells may also be beneficial during the perioperative period. However, ropivacaine, frequently used to provide analgesia during tumour resection, has not been tested on colon cancer cell VASC function or invasion. METHODS: We used reverse transcription-polymerase chain reaction and sequencing to identify NaV1.5 variants in the SW620 metastatic colon cancer cell line. Recombinant adult and neonatal NaV1.5 variants were expressed in human embryonic kidney cells. Voltage-clamp recordings and invasion assays were used to examine the effects of ropivacaine on recombinant NaV1.5 channels and the metastatic potential of SW620 cells, respectively. RESULTS: SW620 cells expressed adult and neonatal NaV1.5 variants, which had similar steady-state inactivation profiles, but distinctive activation curves with the neonatal variant having a V1/2 of activation 7.8 mV more depolarized than the adult variant. Ropivacaine caused a concentration-dependent block of both NaV1.5 variants, with IC50 values of 2.5 and 3.9 µM, respectively. However, the reduction in available steady-state current was selective for neonatal NaV1.5 channels. Ropivacaine inhibited SW620 invasion, with a potency similar to that of inhibition of NaV1.5 channels (3.8 µM). CONCLUSIONS: Ropivacaine is a potent inhibitor of both NaV1.5 channel activity and metastatic colon cancer cell invasion, which may be beneficial during surgical colon cancer excision.

Swallowing outcomes following surgical and non-surgical treatment for advanced laryngeal cancer.

BACKGROUND: Treatment for advanced laryngeal cancer includes surgery, and/or chemoradiotherapy or radiotherapy. Each of these treatments results in major changes to the swallowing mechanism. Dysphagia is strongly correlated with poorer quality of life. A good understanding of outcomes is needed for well-informed treatment decisions. METHOD: This study reports on patients' swallowing outcomes following surgical and non-surgical treatments based on the results of three different swallowing tests. A total of 123 data sets were collected in out-patient clinics across two hospitals in North East England. RESULTS: There were no significant differences between treatment groups for patient-reported swallowing outcomes or swallowing performance. However, patients who had undergone chemoradiotherapy or radiotherapy (with or without laryngectomy) had significantly more diet restrictions than other groups. CONCLUSION: Long-term dysphagia is a common outcome of treatment for advanced laryngeal cancer. Patients treated with chemoradiotherapy and laryngectomy reported the worst overall outcomes. More longitudinal prospective research with large treatment groups is needed to investigate swallowing outcomes following different treatment methods.

Effect of short-term exercise training on aerobic fitness in patients with abdominal aortic aneurysms: a pilot study.

BACKGROUND: Patients with abdominal aortic aneurysms (AAA) represent a high-risk surgical group. Despite medical optimization and radiological stenting interventions, mortality remains high and it is difficult to improve fitness. The aim of this pilot study was to evaluate the effect of a 6 week, supervised exercise programme (30 min continuous moderate intensity cycle ergometry, twice weekly) on anaerobic threshold (AT) in subjects with AAA. METHODS: Thirty participants with an AAA under surveillance were randomized to either the supervised exercise intervention (n=20) or a usual care control group (n=10). AT was measured using cardiopulmonary exercise testing, at baseline (AT1), week 5 (AT2), and week 7 (AT3). The change in AT (AT3-AT1) between the groups was compared using a mixed model ancova, providing the mean effect together with the standard deviation (sd) for individual patient responses to the intervention. The minimum clinically important difference (MCID) was defined as an improvement in AT of 2 ml O(2) kg(-1) min(-1). RESULTS: Of the 30 participants recruited, 17 of 20 (exercise) and eight of 10 (control) completed the study. The AT in the intervention group increased by 10% (equivalent to 1.1 ml O(2) kg(-1) min(-1)) compared with the control (90% confidence interval 4-16%; P=0.007). The sd for the individual patient responses to the intervention was 8%. The estimated number needed to treat (NNT) for benefit was 5 patients. CONCLUSIONS: The small mean benefit was lower than the MCID. However, the marked variability in the individual patient responses revealed that a proportion of patients did benefit clinically, with an estimated NNT of 5.

Reliability of the anaerobic threshold in cardiopulmonary exercise testing of patients with abdominal aortic aneurysms.

Anaerobic threshold (AT), determined by cardiopulmonary exercise testing (CPET), is a well-documented measure of pre-operative fitness, although its reliability in patient populations is uncertain. Our aim was to assess the reliability of AT measurement in patients with abdominal aortic aneurysms. Eighteen patients were recruited. CPET was performed four times over a 6-week period. We examined shifts in the mean AT to evaluate systematic bias with random measurement error assessed using typical within-patient error and intraclass correlation coefficient (ICC, 3,1) statistics. There was no significant or clinically substantial change in mean AT across the tests (p = 0.68). The typical within-patient error expressed as a percentage coefficient of variation was 10% (95% CI, 8-13%), with an ICC of 0.74 (95% CI, 0.55-0.89). We consider the reliability of the AT to be acceptable, supporting its clinical validity and utility as an objective marker of pre-operative fitness in this population.

Quality control of equipment in home mechanical ventilation: a European survey.

Quality control of the equipment used in home mechanical ventilation is necessary in order to ensure that patients safely and accurately receive the prescribed ventilatory support. The aim of this study was to carry out a survey on the quality-control procedures in different centres and countries. The survey was carried out in the context of a European Commission Concerted Action covering 16 European countries. The study was extensive and detailed, involving 326 centres, which provided home ventilation to >20,000 patients. The survey showed that: 1) ventilator servicing was mainly carried out by external companies (62% of centres), with a servicing frequency ranging 3-12 months; 2) interaction between servicing companies and prescribers was limited (only 61% of centres were always informed of major incidents); 3) participation of centres in equipment quality control was poor (only 56% of centres assessed that patients/caregivers correctly cleaned/maintained the ventilator); and 4) centres were insufficiently aware of vigilance systems (only 23% of centres). Moreover, the data showed considerable inter- and intra-country differences. The size of the centre was an important determinant of many of these quality-control aspects. This survey provides information that will enable the European Commission Concerted Action to formulate recommendations on procedures for home-ventilator quality control.

Patterns of home mechanical ventilation use in Europe: results from the Eurovent survey.

The study was designed to assess the patterns of use of home mechanical ventilation (HMV) for patients with chronic respiratory failure across Europe. A detailed questionnaire of centre details, HMV user characteristics and equipment choices was sent to carefully identified HMV centres in 16 European countries. A total of 483 centres treating 27,118 HMV users were identified. Of these, 329 centres completed surveys between July 2001 and June 2002, representing up to 21,526 HMV users and a response rate of between 62% and 79%. The estimated prevalence of HMV in Europe was 6.6 per 100,000 people. The variation in prevalence between countries was only partially related to the median year of starting HMV services. In addition, there were marked differences between countries in the relative proportions of lung and neuromuscular patients using HMV, and the use of tracheostomies in lung and neuromuscular HMV users. Lung users were linked to a HMV duration of <1 yr, thoracic cage users with 6-10 yrs of ventilation and neuromuscular users with a duration of > or =6 yrs. In conclusion, wide variations exist in the patterns of home mechanical ventilation provision throughout Europe. Further work is needed to monitor its use and ensure equality of provision and access.

Longitudinal changes in the nature, severity and frequency of COPD exacerbations.

Exacerbations are an important feature and outcome measure in chronic obstructive pulmonary disease (COPD), but little is known about changes in their severity, recovery, symptom composition or frequency over time. In this study 132 patients (91 male; median age 68.4 yrs and median forced expiratory volume in one second (FEV1) 38.4% predicted) recorded daily symptoms and morning peak expiratory flow. Patients were monitored for a median of 918 days and 1,111 exacerbations were identified. Patients with severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) category III, n=38) had an annual exacerbation frequency of 3.43 x yr(-1), 0.75 x yr(-1) higher than those with moderate COPD (GOLD II, n=94). Exacerbation frequency did not change significantly during the study. At exacerbation onset, symptom count increased to 2.23, relative to a baseline of 0.36 set 8-14 days previously, and this increase rose by 0.05 x yr(-1). Recovery to baseline levels in symptoms and FEV1 took longer (0.32 and 0.55 days x yr(-1)). Sputum purulence at exacerbation became more prevalent over time by 4.1% x yr(-1) from an initial value of 17%. The results of this study suggest that over time, individual patients have more symptoms during exacerbations, with an increased chance of sputum purulence and longer recovery times.

Longitudinal changes in the nature, severity and frequency of COPD exacerbations

Exacerbations are an important feature and outcome measure in chronic obstructive pulmonary disease (COPD), but little is known about changes in their severity, recovery, symptom composition or frequency over time. In this study 132 patients (91 male; median age 68.4 yrs and median forced expiratory volume in one second (FEV1) 38.4% predicted) recorded daily symptoms and morning peak expiratory flow. Patients were monitored for a median of 918 days and 1,111 exacerbations were identified. Patients with severe COPD (Global Initiative for Chronic Obstructive Lung Disease (GOLD) category III, n=38) had an annual exacerbation frequency of 3.43·yr–1, 0.75·yr–1 higher than those with moderate COPD (GOLD II, n=94). Exacerbation frequency did not change significantly during the study. At exacerbation onset, symptom count increased to 2.23, relative to a baseline of 0.36 set 8–14 days previously, and this increase rose by 0.05·yr–1. Recovery to baseline levels in symptoms and FEV1 took longer (0.32 and 0.55 days·yr–1). Sputum purulence at exacerbation became more prevalent over time by 4.1%·yr–1 from an initial value of 17%. The results of this study suggest that over time, individual patients have more symptoms during exacerbations, with an increased chance of sputum purulence and longer recovery times.

Airway epithelial inflammatory responses and clinical parameters in COPD.

This study examined inflammatory responses from primary cultured human bronchial epithelial cells in chronic obstructive pulmonary disease (COPD) and the clinical factors modulating them. Epithelial cells from bronchoscopic biopsies from 14 patients with COPD ((mean +/- SD) age 74.6 +/- 5.7 yrs, forced expiratory volume in one second (FEV1) 1.21 +/- 0.36 L, FEV1 %, predicted 51.1 +/- 15.8%, 51.5 +/- 24.0 pack-yrs of smoking, inhaled steroid dosage 1237.5 +/- 671.0 microg x day(-1), Medical Research Council (MRC) dyspnoea score 3.18 +/- 1.33) and eight current/exsmokers with normal pulmonary function (age 60.4 +/- 13.5 yrs, FEV1 2.66 +/- 1.27 L, FEV1 % pred 89.6 +/- 17.7%, 49 +/- 44 pack-yrs of smoking, MRC dyspnoea score 1 +/- 0) were grown in primary culture and exposed to 50 ng x mL(-1) tumour necrosis factor-alpha. Stimulated COPD cells produced significantly more interleukin (IL)-6 at 24 and 48 h, and IL-8 at 6 and 24 h than unstimulated COPD cells. This response was not seen in cells from current/exsmokers. IL-6 and IL-8 production was lower in COPD patients taking inhaled steroids. Following an inflammatory stimulus, bronchial epithelial cells in chronic obstructive pulmonary disease show a significant cytokine response not seen in smokers with normal pulmonary function and this may be modified by inhaled steroid therapy.

Relationship between bacterial colonisation and the frequency, character, and severity of COPD exacerbations.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are prone to frequent exacerbations which are a significant cause of morbidity and mortality. Stable COPD patients often have lower airway bacterial colonisation which may be an important stimulus to airway inflammation and thereby modulate exacerbation frequency. METHODS: Twenty nine patients with COPD (21 men, 16 current smokers) of mean (SD) age 65.9 (7.84) years, forced expiratory volume in 1 second (FEV(1)) 1.06 (0.41) l, FEV(1) % predicted 38.7 (15.2)%, FEV(1)/FVC 43.7 (14.1)%, inhaled steroid dosage 1.20 (0.66) mg/day completed daily diary cards for symptoms and peak flow over 18 months. Exacerbation frequency rates were determined from diary card data. Induced sputum was obtained from patients in the stable state, quantitative bacterial culture was performed, and cytokine levels were measured. RESULTS: Fifteen of the 29 patients (51.7%) were colonised by a possible pathogen: Haemophilus influenzae (53.3%), Streptococcus pneumoniae (33.3%), Haemophilus parainfluenzae (20%), Branhamella catarrhalis (20%), Pseudomonas aeruginosa (20%). The presence of lower airway bacterial colonisation in the stable state was related to exacerbation frequency (p=0.023). Patients colonised by H influenzae in the stable state reported more symptoms and increased sputum purulence at exacerbation than those not colonised. The median (IQR) symptom count at exacerbation in those colonised by H influenzae was 2.00 (2.00-2.65) compared with 2.00 (1.00-2.00) in those not colonised (p=0.03). The occurrence of increased sputum purulence at exacerbation per patient was 0.92 (0.56-1.00) in those colonised with H influenzae and 0.33 (0.00-0.60) in those not colonised (p=0.02). Sputum interleukin (IL)-8 levels correlated with the total bacterial count (rho=0.459, p=0.02). CONCLUSION: Lower airway bacterial colonisation in the stable state modulates the character and frequency of COPD exacerbations.

The changing demographics of new HIV diagnoses at a London centre from 1994 to 2000.

OBJECTIVE: To document the demographic changes in new HIV diagnoses at the Royal Free Hospital, London, UK, between 1994 and 2000. DESIGN: Retrospective case note review. METHODS: Data were extracted from the Royal Free HIV database identifying new diagnoses for 1994, 1997 and 2000. All case notes were reviewed and patients were included if they had their first positive HIV test at the Royal Free Hospital, or if they first tested positive elsewhere and attended the Royal Free HIV unit for their initial HIV care. Data extracted included sex, ethnicity, age, risk factor(s) for HIV, reason for test, clinical stage of disease, CD4 count and HIV RNA viral load at diagnosis. RESULTS: One hundred and forty-four patients were identified for 1994, 136 for 1997 and 110 for 2000. Over this time period the proportion of white patients dropped from 72% (n = 104) to 48% (n = 53), P = 0.0001, whilst the proportion of black Africans rose from 24% (n = 34) to 45% (n = 49), P = 0.0004. The median CD4 count at diagnosis of the white cohort was 475 cells/microL in 1994 and 286/microL in 2000, P = 0.005, whilst in the black African patients it was 240/microL and 230/microL for the same years. CONCLUSIONS: There has been a reduction in new HIV diagnoses among the white population and a rise in the black Africans at this centre between 1994 and 2000. The clinical and immunological parameters of HIV disease have worsened over this time period for the white group, but have remained stable in the black Africans.

Phase I and pharmacological study of the oral matrix metalloproteinase inhibitor, MMI270 (CGS27023A), in patients with advanced solid cancer.

This Phase I study of MMI270, an p.o. administered matrix metalloproteinase inhibitor, assessed toxicity, pharmacokinetics, and tumor response data and investigated markers of biological activity to recommend a dose for Phase II studies. MMI270 was administered continuously at seven dose levels (50 mg once daily to 600 mg three times/day). Patients were evaluated for toxicity and tumor response, and blood and urine samples were taken for pharmacokinetics, bone resorption markers, direct targets of the inhibitor [matrix metalloproteinase-2 (MMP-2), MMP-8, and MMP-9], indirect targets [tissue inhibitor of metalloproteinase-1 (TIMP-1), TIMP-2, basic fibroblast growth factor, vascular endothelial growth factor, vascular cell adhesion molecule-1, soluble urokinase plasminogen activator receptor, and cathepsins B and H] and for a tumor necrosis factor-alpha cytokine release assay. Ninety-two patients were entered. There was no myelotoxicity. Eighteen patients developed a widespread maculopapular rash, which increased in frequency and severity at doses > or = 300 mg bid. Thirty nine patients developed musculoskeletal side effects, which were related to duration of treatment, not to dose level. Pharmacokinetics were linear, and MMI270 was rapidly absorbed and eliminated with minimal accumulation on chronic dosing. Sustained plasma concentrations in excess of 4 x mean IC(50) for the target enzymes were observed at dose levels > or = 150 mg bid. There were no tumor regressions; however, 19 patients had stable disease for > or = 90 days. There was a dose-response increase of MMP-2 and TIMP-1 with MMI270. Transient effects on the bone resorption markers were detected. MMI270 was generally well tolerated, with adequate plasma levels for target enzyme inhibition. The two main toxicities were rash, resulting in a maximum tolerated dose of 300 mg bid and musculoskeletal side effects. Biological marker data indicate drug effects. The rise in TIMP-1 suggests that a reflex rise in inhibitors could modify the effects of MMI270. The recommended Phase II dose is 300 mg bid.

MR-compatible ventilator for small animals: computer-controlled ventilation for proton and noble gas imaging.

We describe an MR-compatible ventilator that is computer controlled to generate a variety of breathing patterns, to minimize image degrading effects of breathing motion, and to support delivery of gas anesthesia and experimental inhalational gases. A key feature of this ventilator is the breathing valve that attaches directly to the endotracheal tube to reduce dead volume and allows independent control of inspiratory and expiratory phases of ventilation. This ventilator has been used in a wide variety of MR and x-ray microscopy studies of small animals, especially for MR imaging the lungs with hyperpolarized gases ((3)He & (129)Xe).

Clinical value and cost of a respiratory sleep-related breathing disorders screening service for snorers referred to a District General Hospital ENT department.

Sleep-related breathing disorders and snoring often co-exist in the community. We hypothesized that a significant proportion of patients referred from primary care to ENT surgeons for management of snoring might have significant sleep-related breathing disorders requiring medical management. The Respiratory Medicine Department at Whipps Cross Hospital, London, U.K. screened all such referrals using sleep questionnaires, overnight oximetry and diagnostic sleep studies where necessary as recommended by the Royal College of Physicians of London. Over 38 months, 115 patients were screened, of whom 43 (38%) had clinically significant sleep-disordered breathing. One-third were established on nasal continuous positive airway pressure ventilation and the remainder were mainly offered conservative treatment. The cost of the screening service is estimated at 14,000 Pounds for the initial year. The savings to the ENT service and the possible long-term benefits to the patients identified as having sleep-disordered breathing balance this. We conclude that screening all referred snorers for sleep-disordered breathing using a simple protocol identifies a significant number requiring medical management at a relatively low cost to the service provider.

Delays by patients in seeking treatment for acute chest pain: implications for achieving earlier thrombolysis.

A study was set up to identify why patients delay seeking medical assistance after myocardial infarction. The study was performed in 100 consecutive patients with suspected acute myocardial infarction admitted to either the University Hospital of Wales, Cardiff, UK, or the Royal Jubilee Hospital, Victoria, British Columbia, Canada (50 patients from each centre). The main outcome measure was the delay from the onset of symptoms to admission to hospital. The mean total delay before admission was 385 minutes (SEM 45). The mean delay incurred by the patient in seeking assistance was 172 minutes (SEM 27), representing 45% of the total. Delay was longer in patients with crescendo angina and shorter in those later confirmed to have myocardial infarction. Patients with prior ischaemic heart disease (74% of patients) presented later than those with no such history. No other demographic or clinical factors predicted early or late presentation. Delays in seeking medical assistance after the onset of severe chest pain contribute significantly to total delays in patients' hospital admission and thrombolysis. The unexpected observation that patients with known ischaemic heart disease delay longer before seeking help in spite of their frequent contact with doctors, suggests that opportunities for educating patients are being wasted. Major efforts are needed to understand and modify behaviour of patients with chest pain to further reduce delays in treatment.

Degradation of human myelin in vitro by leucocytes from patients with multiple sclerosis.

In order to study the possible autoimmune basis of multiple sclerosis (MS) a quantitative method has been used to investigate breakdown of human myelin in vitro. We found that serum from MS patients and controls was generally devoid of any myelin degradative activity. However, isolated peripheral blood mononuclear cells from 43% of MS patients showed significant myelin degradative activity as did those from 61.5% of patients with rheumatoid arthritis (RA). Myelin degradation by cells was found in only 13% of patients with other neurological diseases and in no healthy controls. It is proposed that this non-specific peripheral cellular immune degradative activity originates from cells activated within the central nervous system of MS patients or the joints of individuals with RA. As a result, activity in the blood only indirectly reflects the ongoing inflammatory response at the primary site, accounting for the lack of correlation between changes in the blood and the clinical status of the MS patient. We further propose that the lack of in vitro myelin degradative activity in cells recovered from the cerebrospinal fluid is due to autoaggressive cells being sequestered to the brain.

Nervous and immune system disorders in multiple sclerosis.

Multiple sclerosis is probably an acquired infectious disease with an autoimmune response relating to damage to the white matter of the central nervous system. There is evidence of continued intrathecal synthesis of oligoclonal antibody and there are perivascular inflammatory cell infiltrates close to areas of demyelination in the central nervous system. Following adoptive transfer, cells sensitized to the myelin basic protein can cause demyelinating disease in rodent recipients. Unlike the peripherally-mediated immune changes in the experimental model it is argued that autoaggressive cells are generated within the CNS in multiple sclerosis. The possible mechanism of cellular demyelination is discussed and the implication for therapy is reviewed.