GLUT3 is induced during epithelial-mesenchymal transition and promotes tumor cell proliferation in non-small cell lung cancer.

BACKGROUND: Alterations in glucose metabolism and epithelial-mesenchymal transition (EMT) constitute two important characteristics of carcinoma progression toward invasive cancer. Despite an extensive characterization of each of them separately, the links between EMT and glucose metabolism of tumor cells remain elusive. Here we show that the neuronal glucose transporter GLUT3 contributes to glucose uptake and proliferation of lung tumor cells that have undergone an EMT. RESULTS: Using a panel of human non-small cell lung cancer (NSCLC) cell lines, we demonstrate that GLUT3 is strongly expressed in mesenchymal, but not epithelial cells, a finding corroborated in hepatoma cells. Furthermore, we identify that ZEB1 binds to the GLUT3 gene to activate transcription. Importantly, inhibiting GLUT3 expression reduces glucose import and the proliferation of mesenchymal lung tumor cells, whereas ectopic expression in epithelial cells sustains proliferation in low glucose. Using a large microarray data collection of human NSCLCs, we determine that GLUT3 expression correlates with EMT markers and is prognostic of poor overall survival. CONCLUSIONS: Altogether, our results reveal that GLUT3 is a transcriptional target of ZEB1 and that this glucose transporter plays an important role in lung cancer, when tumor cells loose their epithelial characteristics to become more invasive. Moreover, these findings emphasize the development of GLUT3 inhibitory drugs as a targeted therapy for the treatment of patients with poorly differentiated tumors.

Kaposi sarcoma incidence in the Swiss HIV Cohort Study before and after highly active antiretroviral therapy.

Between 1984 and 2006, 12 959 people with HIV/AIDS (PWHA) in the Swiss HIV Cohort Study contributed a total of 73 412 person-years (py) of follow-up, 35 551 of which derived from PWHA treated with highly active antiretroviral therapy (HAART). Five hundred and ninety-seven incident Kaposi sarcoma (KS) cases were identified of whom 52 were among HAART users. Cox regression was used to estimate hazard ratios (HR) and corresponding 95% confidence intervals (CI). Kaposi sarcoma incidence fell abruptly in 1996-1998 to reach a plateau at 1.4 per 1000 py afterwards. Men having sex with men and birth in Africa or the Middle East were associated with KS in both non-users and users of HAART but the risk pattern by CD4 cell count differed. Only very low CD4 cell count (<50 cells microl(-1)) at enrollment or at HAART initiation were significantly associated with KS among HAART users. The HR for KS declined steeply in the first months after HAART initiation and continued to be low 7-10 years afterwards (HR, 0.06; 95% CI, 0.02-0.17). Thirty-three out of 52 (63.5%) KS cases among HAART users arose among PWHA who had stopped treatment or used HAART for less than 6 months.

Non-pharmacological interventions for chronic pain in people with spinal cord injury.

BACKGROUND: Chronic pain is frequent in persons living with spinal cord injury (SCI). Conventionally, the pain is treated pharmacologically, yet long-term pain medication is often refractory and associated with side effects. Non-pharmacological interventions are frequently advocated, although the benefit and harm profiles of these treatments are not well established, in part because of methodological weaknesses of available studies. OBJECTIVES: To critically appraise and synthesise available research evidence on the effects of non-pharmacological interventions for the treatment of chronic neuropathic and nociceptive pain in people living with SCI. SEARCH METHODS: The search was run on the 1st March 2011. We searched the Cochrane Injuries Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OvidSP), Embase (OvidSP), PsycINFO (OvidSP), four other databases and clinical trials registers. In addition, we manually searched the proceedings of three major scientific conferences on SCI. We updated this search in November 2014 but these results have not yet been incorporated. SELECTION CRITERIA: Randomised controlled trials of any intervention not involving intake of medication or other active substances to treat chronic pain in people with SCI. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed risk of bias in the included studies. The primary outcome was any measure of pain intensity or pain relief. Secondary outcomes included adverse events, anxiety, depression and quality of life. When possible, meta-analyses were performed to calculate standardised mean differences for each type of intervention. MAIN RESULTS: We identified 16 trials involving a total of 616 participants. Eight different types of interventions were studied. Eight trials investigated the effects of electrical brain stimulation (transcranial direct current stimulation (tDCS) and cranial electrotherapy stimulation (CES); five trials) or repetitive transcranial magnetic stimulation (rTMS; three trials). Interventions in the remaining studies included exercise programmes (three trials); acupuncture (two trials); self-hypnosis (one trial); transcutaneous electrical nerve stimulation (TENS) (one trial); and a cognitive behavioural programme (one trial). None of the included trials were considered to have low overall risk of bias. Twelve studies had high overall risk of bias, and in four studies risk of bias was unclear. The overall quality of the included studies was weak. Their validity was impaired by methodological weaknesses such as inappropriate choice of control groups. An additional search in November 2014 identified more recent studies that will be included in an update of this review.For tDCS the pooled mean difference between intervention and control groups in pain scores on an 11-point visual analogue scale (VAS) (0-10) was a reduction of -1.90 units (95% confidence interval (CI) -3.48 to -0.33; P value 0.02) in the short term and of -1.87 (95% CI -3.30 to -0.45; P value 0.01) in the mid term. Exercise programmes led to mean reductions in chronic shoulder pain of -1.9 score points for the Short Form (SF)-36 item for pain experience (95% CI -3.4 to -0.4; P value 0.01) and -2.8 pain VAS units (95% CI -3.77 to -1.83; P value < 0.00001); this represented the largest observed treatment effects in the included studies. Trials using rTMS, CES, acupuncture, self-hypnosis, TENS or a cognitive behavioural programme provided no evidence that these interventions reduce chronic pain. Ten trials examined study endpoints other than pain, including anxiety, depression and quality of life, but available data were too scarce for firm conclusions to be drawn. In four trials no side effects were reported with study interventions. Five trials reported transient mild side effects. Overall, a paucity of evidence was found on any serious or long-lasting side effects of the interventions. AUTHORS' CONCLUSIONS: Evidence is insufficient to suggest that non-pharmacological treatments are effective in reducing chronic pain in people living with SCI. The benefits and harms of commonly used non-pharmacological pain treatments should be investigated in randomised controlled trials with adequate sample size and study methodology.

Recent advances and hurdles in melanoma immunotherapy.

Worldwide incidence of malignant melanoma has been constantly increasing during the last years. Surgical excision is effective when primary tumours are thin. At later disease stages patients often succumb, due to failure of metastasis control. Therefore, great efforts have been made to develop improved strategies to treat metastatic melanoma patients. In the search for novel treatments during the last two decades, immunotherapy has occupied a prominent place. Numerous early phase immunotherapy clinical trials, generally involving small numbers of patients each time, have been reported: significant tumour-specific immune responses could often be measured in patients upon treatments. However, clinical responses remain at a dismal low rate. In some anecdotal cases, objective clinical benefit was more frequently observed among immune responders than immune non-responders. This clearly calls for a better understanding of protective immunity against tumours as well as the cross talk taking place between tumours and the immune system. Here we discuss advances and limitations of specific immunotherapy against human melanoma in the light of the literature from the last 5 yr.

Targeting anticancer therapy : clinical and preclinical approaches

AbstractCancer treatment has shifted from cytotoxic and nonspecific chemotherapy to chronic treatment with targeted molecular therapies. These new classes of drugs directed against cancer-specific molecules and signaling pathways, act at a particular level of the tumor cell development. However, in both types of therapeutic approaches (standard cytotoxic chemotherapy and targeted signal transduction inhibitions), toxicity and side effects can occur. The aim of this thesis was to investigate various approaches to improve the activity and tolerability of cancer treatment, in a clinical setting, a) by molecular targeting through the use of tyrosine kinase inhibitors (TKIs), whose dosage can be adapted to each patient according to plasma levels, and, b) in a preclinical model, by tissue targeting with locoregional administration of cytotoxic chemotherapy to increase drug exposure in the target tissue while reducing systemic toxicity of the treatment.A comprehensive program for the Therapeutic Drug Monitoring (TDM) of the new class of targeted anticancer drugs of TKIs in patient's blood has been therefore initiated comprising the setting up, validation and clinical application of a multiplex assay by liquid chromatography coupled to tandem mass spectrometry of TKIs in plasma from cancer patients. Information on drugs exposure may be clinically useful for an optimal follow-up of patients' anticancer treatment, especially in case of less than optimal clinical response, occurrence of adverse drug reaction effects and the numerous risks of drug-drug interactions. In this context, better knowledge of the potential drug interactions between TKIs and widely prescribed co- medications is of critical importance for clinicians, to improve their daily care of cancer patients. For one of the first TKI imatinib, TDM interpretation is nowadays based on total plasma concentrations but, only the unbound (free) form is likely to enter cell to exert its pharmacological action. Pharmacokinetic analysis of the total and free plasma level of imatinib measured simultaneously in patients have allowed to refine and validate a population pharmacokinetic model integrating factors influencing in patients the exposure of pharmacological active species. The equation developed from this model may be used for extrapolating free imatinib plasma concentration based on the total plasma levels that are currently measured in TDM from patients. Finally, the specific influence of Pglycoprotein on the intracellular disposition of TKIs has been studies in cell systems using the siRNA silencing approach.Another approach to enhance the selectivity of anticancer treatment may be achieved by the loco-regional administration of a cytostatic agent to the target organ while sparing non- affected tissues. Isolated lung perfusion (ILP) was designed for the treatment of loco-regional malignancies of the lung but clinical results have been so far disappointing. It has been shown in a preclinical model in rats that ILP with the cytotoxic agent doxorubicin alone allows a high drug uptake in lung tissue, and a low systemic toxicity, but was characterized by a high spatial tissular heterogeneity in drug exposure and doxorubicin uptake in tumor was comparatively smaller than in normal lung tissue. Photodynamic therapy (PDT) is a new approach for the treatment of superficial tumors, and implies the application of a sensitizer activated by a laser light at a specific wavelength, that disrupts endothelial barrier of tumor vessels to increase locally the distribution of cytostatics into the tumor tissue. PDT pre-treatment before intravenous administration of liposomal doxorubicin was indeed shown to selectively increase drug uptake in tumors in a rat model of sarcoma tumors to the lung.RésuméLe traitement de certains cancers s'est progressivement transformé et est passé de la chimiothérapie, cytotoxique et non spécifique, au traitement chronique des patients avec des thérapies moléculaires ciblées. Ces médicaments ont une action ciblée en interférant à un niveau spécifique du développement de la cellule tumorale. Dans les deux types d'approches thérapeutiques (chimiothérapie cytotoxique et traitements ciblés), on est confronté à la présence de toxicité et aux effets secondaires du traitement anticancéreux. Le but de cette thèse a donc été d'étudier diverses approches visant à améliorer l'efficacité et la tolérabilité du traitement anticancéreux, a) dans le cadre d'une recherche clinique, par le ciblage moléculaire grâce aux inhibiteurs de tyrosines kinases (TKIs) dont la posologie est adaptée à chaque patient, et b) dans un modèle préclinique, par le ciblage tissulaire grâce à l'administration locorégionale de chimiothérapie cytotoxique, afin d'augmenter l'exposition dans le tissu cible et de réduire la toxicité systémique du traitement.Un programme de recherche sur le suivi thérapeutique (Therapeutic Drug Monitoring, TDM) des inhibiteurs de tyrosine kinases a été ainsi mis en place et a impliqué le développement, la validation et l'application clinique d'une méthode multiplex par chromatographie liquide couplée à la spectrométrie de masse en tandem des TKIs chez les patients souffrant de cancer. L'information fournie par le TDM sur l'exposition des patients aux traitements ciblés est cliniquement utile et est susceptible d'optimiser la dose administrée, notamment dans les cas où la réponse clinique au traitement des patients est sous-optimale, en présence d'effets secondaires du traitement ciblé, ou lorsque des risques d'interactions médicamenteuses sont suspectés. Dans ce contexte, l'étude des interactions entre les TKIs et les co-médications couramment associées est utile pour les cliniciens en charge d'améliorer au jour le jour la prise en charge du traitement anticancéreux. Pour le premier TKI imatinib, l'interprétation TDM est actuellement basée sur la mesure des concentrations plasmatiques totales alors que seule la fraction libre (médicament non lié aux protéines plasmatiques circulantes) est susceptible de pénétrer dans la cellule pour exercer son action pharmacologique. L'analyse pharmacocinétique des taux plasmatiques totaux et libres d'imatinib mesurés simultanément chez les patients a permis d'affiner et de valider un modèle de pharmacocinétique de population qui intègre les facteurs influençant l'exposition à la fraction de médicament pharmacologiquement active. L'équation développée à partir de ce modèle permet d'extrapoler les concentrations libres d'imatinib à partir des concentrations plasmatiques totales qui sont actuellement mesurées lors du TDM des patients. Finalement, l'influence de la P-glycoprotéine sur la disposition cellulaire des TKIs a été étudiée dans un modèle cellulaire utilisant l'approche par la technologie du siRNA permettant de bloquer sélectivement l'expression du gène de cette protéine d'efflux des médicaments.Une autre approche pour augmenter la sélectivité du traitement anticancéreux consiste en une administration loco-régionale d'un agent cytostatique directement au sein de l'organe cible tout en préservant les tissus sains. La perfusion isolée du poumon (ILP) a été conçue pour le traitement loco-régional des cancers affectant les tissus pulmonaires mais les résultats cliniques ont été jusqu'à ce jour décevants. Dans des modèles précliniques chez le rat, il a pu être démontré que l'ILP avec la doxorubicine, un agent cytotoxique, administré seul, permet une exposition élevée au niveau du tissu pulmonaire, et une faible toxicité systémique. Toutefois, cette technique est caractérisée par une importante variabilité de la distribution dans les tissus pulmonaires et une pénétration du médicament au sein de la tumeur comparativement plus faible que dans les tissus sains.La thérapie photodynamique (PDT) est une nouvelle approche pour le traitement des tumeurs superficielles, qui consiste en l'application d'un agent sensibilisateur activé par une lumière laser de longueur d'onde spécifique, qui perturbe l'intégrité physiologique de la barrière endothéliale des vaisseaux alimentant la tumeur et permet d'augmenter localement la pénétration des agents cytostatiques.Nos études ont montré qu'un pré-traitement par PDT permet d'augmenter sélectivement l'absorption de doxorubicine dans les tumeurs lors d'administration i.v. de doxorubicine liposomale dans un modèle de sarcome de poumons de rongeurs.Résumé large publicDepuis une dizaine d'année, le traitement de certains cancers s'est progressivement transformé et les patients qui devaient jusqu'alors subir des chimiothérapies, toxiques et non spécifiques, peuvent maintenant bénéficier de traitements chroniques avec des thérapies ciblées. Avec les deux types d'approches thérapeutiques, on reste cependant confronté à la toxicité et aux effets secondaires du traitement.Le but de cette thèse a été d'étudier chez les patients et dans des modèles précliniques les diverses approches visant à améliorer l'activité et la tolérance des traitements à travers un meilleur ciblage de la thérapie anticancéreuse. Cet effort de recherche nous a conduits à nous intéresser à l'optimisation du traitement par les inhibiteurs de tyrosines kinases (TKIs), une nouvelle génération d'agents anticancéreux ciblés agissant sélectivement sur les cellules tumorales, en particulier chez les patients souffrant de leucémie myéloïde chronique et de tumeurs stromales gastro-intestinales. L'activité clinique ainsi que la toxicité de ces TKIs paraissent dépendre non pas de la dose de médicament administrée, mais de la quantité de médicaments circulant dans le sang auxquelles les tumeurs cancéreuses sont exposées et qui varient beaucoup d'un patient à l'autre. A cet effet, nous avons développé une méthode par chromatographie couplée à la spectrométrie de masse pour mesurer chez les patients les taux de médicaments de la classe des TKIs dans la perspective de piloter le traitement par une approche de suivi thérapeutique (Therapeutic Drug Monitoring, TDM). Le TDM repose sur la mesure de la quantité de médicament dans le sang d'un patient dans le but d'adapter individuellement la posologie la plus appropriée: des quantités insuffisantes de médicament dans le sang peuvent conduire à un échec thérapeutique alors qu'un taux sanguin excessif peut entraîner des manifestations toxiques.Dans une seconde partie préclinique, nous nous sommes concentrés sur l'optimisation de la chimiothérapie loco-régionale dans un modèle de sarcome du poumon chez le rat, afin d'augmenter l'exposition dans la tumeur tout en réduisant la toxicité dans les tissus non affectés.La perfusion isolée du poumon (ILP) permet d'administrer un médicament anticancéreux cytotoxique comme la doxorubicine, sélectivement au niveau le tissu pulmonaire où sont généralement localisées les métastases de sarcome. L'administration par ILP de doxorubicine, toxique pour le coeur, a permis une forte accumulation des médicaments dans le poumon, tout en épargnant le coeur. Il a été malheureusement constaté que la doxorubicine ne pénètre que faiblement dans la tumeur sarcomateuse, témoignant des réponses cliniques décevantes observées avec cette approche en clinique. Nous avons ainsi étudié l'impact sur la pénétration tumorale de l'association d'une chimiothérapie cytotoxique avec la thérapie photodynamique (PDT) qui consiste en l'irradiation spécifique du tissu-cible cancéreux, après l'administration d'un agent photosensibilisateur. Dans ce modèle animal, nous avons observé qu'un traitement par PDT permet effectivement d'augmenter de façon sélective l'accumulation de doxorubicine dans les tumeurs lors d'administration intraveineuse de médicament.

Contemporary perioperative care strategies.

BACKGROUND: Historically, the preoperative and postoperative care of patients with gastrointestinal cancer was provided by surgeons. Contemporary perioperative care is a truly multidisciplinary endeavour with implications for cancer-specific outcomes. METHODS: A literature review was performed querying PubMed and the Cochrane Library for articles published between 1966 to 2012 on specific perioperative interventions with the potential to improve the outcomes of surgical oncology patients. Keywords used were: fast-track, enhanced recovery, accelerated rehabilitation, multimodal and perioperative care. Specific interventions included normothermia, hyperoxygenation, surgical-site infection, skin preparation, transfusion, non-steroidal anti-inflammatory drugs, thromboembolism and antibiotic prophylaxis, laparoscopy, radiotherapy, perioperative steroids and monoclonal antibodies. Included articles had to be randomized controlled trials, prospective or nationwide series, or systematic reviews/meta-analyses, published in English, French or German. RESULTS: Important elements of modern perioperative care that improve recovery of patients and outcomes in surgical oncology include accelerated recovery pathways, thromboembolism and antibiotic prophylaxis, hyperoxygenation, maintenance of normothermia, avoidance of blood transfusion and cautious use of non-steroidal anti-inflammatory drugs, promotion of laparoscopic surgery, chlorhexidine-alcohol skin preparation and multidisciplinary meetings to determine multimodal therapy. CONCLUSION: Multidisciplinary management of perioperative patient care has improved outcomes. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Fatal and nonfatal AIDS and non-AIDS events in HIV-1-positive individuals with high CD4 cell counts according to viral load strata.

BACKGROUND: This study compared the incidence of fatal and nonfatal AIDS and non-AIDS events in HIV-positive individuals with a CD4 cell count more than 350  cells/μl among viral load strata: low (<500  copies/ml), intermediate (500-9999.9  copies/ml) and high (≥ 10000  copies/ml). METHODS: Individuals contributed person-years at risk if their most recent CD4 cell count was more than 350  cells/μl. Follow-up was censored if their CD4 cell count dropped below 350  cells/μl. Poisson regression analysis investigated the relationship between viraemia and the incidence of AIDS and non-AIDS events. RESULTS: Three hundred and fifty-four AIDS events occurred during 51 732  person-years of follow-up (PYFU), crude incidence rate of AIDS across the three strata was 0.53, 0.90 and 2.12 per 100 PYFU, respectively. After adjustment, a higher rate of AIDS was observed in individuals with moderate [incidence rate ratio (IRR) 1.44, 1.02-2.05, P = 0.03] and high viraemia had a higher rate (IRR 3.91, 2.89-5.89, P < 0.0001) compared with low viraemia. Five hundred and seventy-two non-AIDS events occurred during 43 784 PYFU, the crude incidence rates were 1.28, 1.52, and 1.38 per 100 PYFU, respectively. After adjustment, particularly for age, region of Europe and starting combination antiretroviral therapy, there was a 61% (IRR 1.61, 1.21-2.14, P = 0.001) and 66% (IRR 1.66, 1.17-2.32, P = 0.004) higher rate of non-AIDS in individuals with intermediate and high viraemia compared with low viraemia. CONCLUSION: In individuals with a CD4 cell count more than 350  cells/μl, an increased incidence of AIDS and a slightly increased incidence of non-AIDS was found in those with uncontrolled viral replication. The association with AIDS was clear and consistent. However, the association with non-AIDS was only apparent after adjustment and no differences were observed between intermediate and high viraemia.

Self-reported alcohol consumption and its association with adherence and outcome of antiretroviral therapy in the Swiss HIV Cohort Study.

BACKGROUND: Alcohol consumption leading to morbidity and mortality affects HIV-infected individuals. Here, we aimed to study self-reported alcohol consumption and to determine its association with adherence to antiretroviral therapy (ART) and HIV surrogate markers. METHODS: Cross-sectional data on daily alcohol consumption from August 2005 to August 2007 were analysed and categorized according to the World Health Organization definition (light, moderate or severe health risk). Multivariate logistic regression models and Pearson's chi(2) statistics were used to test the influence of alcohol use on endpoints. RESULTS: Of 6,323 individuals, 52.3% consumed alcohol less than once a week in the past 6 months. Alcohol intake was deemed light in 39.9%, moderate in 5.0% and severe in 2.8%. Higher alcohol consumption was significantly associated with older age, less education, injection drug use, being in a drug maintenance programme, psychiatric treatment, hepatitis C virus coinfection and with a longer time since diagnosis of HIV. Lower alcohol consumption was found in males, non-Caucasians, individuals currently on ART and those with more ART experience. In patients on ART (n=4,519), missed doses and alcohol consumption were positively correlated (P<0.001). Severe alcohol consumers, who were pretreated with ART, were more often off treatment despite having CD4+ T-cell count <200 cells/microl; however, severe alcohol consumption per se did not delay starting ART. In treated individuals, alcohol consumption was not associated with worse HIV surrogate markers. CONCLUSIONS: Higher alcohol consumption in HIV-infected individuals was associated with several psychosocial and demographic factors, non-adherence to ART and, in pretreated individuals, being off treatment despite low CD4+ T-cell counts.

Hexyl-aminolevulinate mediated photodynamic therapy: how to spare normal urothelium. An in vitro approach

Résumé Objectifs : La thérapie photodynamique a pour but la destruction sélective du tissu néoplasique par interaction de lumière, d'oxygène et d'une substance photosensibilisatrice (la Protoporphyrine IX dans notre étude). Malgré une accumulation sélective du photosensibilisateur dans le tissu tumoral, la thérapie photodynamique du carcinome urothélial de la vessie peut endommager les cellules normales de l'épithélium urinaire. La prévention de ces lésions est importante pour la régénération de la muqueuse. Notre étude sur un modèle in vitro d'urothélium porcin étudie l'influence de la concentration du photosensibilisateur, des paramètres d'irradiation et de la production d'intermédiaires réactifs de l'oxygène (ROS) sur les effets photodynamique. Le but était de déterminer les conditions seuil pour épargner l'urothélium sain. Méthode: Dans une chambre de culture transparente à deux compartiments, des muqueuses vésicales de porc maintenues en vie ont été incubées avec une solution d'hexyl-aminolévulinate (HAL), le précurseur de la Protoporphyrine IX. Ces muqueuses ont ensuite été irradiées avec des doses lumineuses croissantes en lumière bleue et en lumière blanche, et les altérations cellulaires ont été évaluées par microscopie électronique à balayage et par un colorant fluorescent, le Sytox green. Nous avons également évalué la production d'intermédiaires réactifs de l'oxygène parla mesure de la fluorescence intracellulaire de Rhodamine 123 (R123), produit de l'oxydation de la Dihydrorhodamine 123 (DHR123) non fluorescente. Ces valeurs ont été corrélées avec celles du photo blanchiment de la PAIX. Résultats : Le taux de mortalité cellulaire était dépendant de la concentration de PAIX. Après 3 heures d'incubation, la valeur seuil de dose lumineuse pour la lumière bleu était de 0.15 et 0.75 J/cm2 (irradiance 30 et 75 mW/cm2, respectivement) et pour la lumière blanche de 0.55 J/cm2 (irradiante 30 mW/cm2). Le taux de photo blanchiment était inversement proportionnel à l'irradiante. Le système de détection des intermédiaires réactifs de l'oxygène DHR123/R123 a démontré une bonne corrélation avec les valeurs seuil pour toutes les conditions d'irradiation utilisées. Conclusions : Nous avons déterminé les doses lumineuses permettant d'épargner 50% des cellules urothéliales saines. L'utilisation d'une faible irradiante associée à des systèmes permettant de mesurer la production d'intermédiaires réactifs de l'oxygène dans les tissus irradiés pourrait améliorer la dosimétrie in vivo et l'efficacité de la thérapie photodynamique. Abstract Background and Objectives: Photodynamic therapy of superficial bladder cancer may cause damages to the normal surrounding bladder wall. Prevention of these is important for bladder healing. We studied the influence of photosensitizes concentration, irradiation parameters and production of reactive oxygen species (ROS) on the photodynamically induced damage in the porcine urothelium in vitro. The aim was to determine the threshold conditions for the cell survival. Methods: Living porcine bladder mucosae were incubated with solution of hexylester of 5-aminolevulinic acid (HAL). The mucosae were irradiated with increasing doses and cell alterations were evaluated by scanning electron microscopy and by Sytox green fluorescence. The urothelial survival score was correlated with Protoporphyrin IX (PpIX) photobleaching and intracellular fluorescence of Rhodamine 123 reflecting the ROS production. Results: The mortality ratio was dependent on PpIX concentration. After 3 hours of incubation, the threshold radiant exposures for blue light were 0.15 and 0.75 J/cm2 (irradiance 30 and 75 mW/cm2, respectively) and for white light 0.55 J/cm2 (irradiance 30 mW/cm2). Photobleaching rate increased with decreasing irradiance. Interestingly, the DHR123/R123 reporter system correlated well with the threshold exposures under all conditions used. Conclusions: we have determined radiant exposures sparing half of normal urothelial cells. We propose that the use of low irradiance combined with systems reporting the ROS production in the irradiated tissue could improve the in vivo dosimetry and optimize the PDT.

Trans-scleral local resection of toxic choroidal melanoma after proton beam radiotherapy.

AIM: To report on trans-scleral local resection of choroidal melanoma for exudative retinal detachment and neovascular glaucoma (toxic tumour syndrome) after proton beam radiotherapy (PBR). METHODS: A non-randomised, prospective study of secondary trans-scleral local resection of choroidal melanoma for exudative retinal detachment with or without neovascular glaucoma after PBR. The patients were treated at the Liverpool Ocular Oncology Centre between February 2000 and April 2008. The trans-scleral local resection was performed with a lamellar-scleral flap, using systemic hypotension to reduce haemorrhage. RESULTS: 12 patients (six women, six men) with a mean age of 51 years (range 20-75) were included in this study. The tumour margins extended anterior to ora serrata in six patients. On ultrasonography, the largest basal tumour dimension averaged 12.4 mm (range 6.8-18.1) and the tumour height averaged 7.1 mm (range 4.2-10.7). The retinal detachment was total in seven patients. Neovascular glaucoma was present in four patients. The time between PBR and local resection had a mean of 17.4 months (range 1-84). The ophthalmic follow-up time after the local resection had a mean of 46.2 months (range 14-99). At the latest known status, the eye was conserved in 10 patients, with a flat retina in all these patients and visual acuity equal or better than 6/30 in four patients. The reasons for enucleation were: patient request for enucleation when rhegmatogenous retinal detachment complicated the resection (one patient) and phthisis (one patient). CONCLUSIONS: Exudative retinal detachment, rubeosis and neovascular glaucoma after PBR of a choroidal melanoma can resolve after trans-scleral local resection of the tumour. Our findings suggest that these complications are caused by the persistence of the irradiated tumour within the eye ('toxic tumour syndrome').

Bone tissue engineering using foetal cell therapy.

Different cell sources for bone tissue engineering are reviewed. In particular, adult cell source strategies have been based on the implantation of unfractionated fresh bone marrow; purified, culture expanded mesenchymal stem cells, differentiated osteoblasts, or cells that have been modified genetically to express rhBMP. Several limiting factors are mentioned for these strategies such as low number of available cells or possible immunological reaction of the host. Foetal bone cells are presented as an alternative solution and review of actual treatments using these cells is presented. Finally, foetal cells used specifically for bone tissue engineering are characterised and potentially interesting therapeutic options are proposed.

Referrals of cancer versus non-cancer patients to a palliative care consult team: do they differ?

This retrospective study compared 100 consecutive non-cancer (NC) patients referred to a palliative care consult team (PCT) in a Swiss university hospital to 506 cancer (C) patients referred during the same period. The frequencies of reported symptoms were similar in both groups. The main reasons for referral in the NC group were symptom control, global evaluation, and assistance with discharge. Requests for symptom control predominated in the C group. Prior to the first visit, 50% of NC patients were on opioids, compared to 58% of C patients. After the first visit, the proportion of NC patients on opioids increased to 64% and the proportion of C patients to 73%. The median daily oral morphine equivalent dose for NC patients taking opioids prior to the first PCT visit was higher than that for C patients (60 mg versus 45 mg). At the time of death or discharge, the percentage of NC patients on opioids was 64%, while that of C patients was 76%. Moreover, NC patients were on significantly lower median doses of opioids than C patients (31 mg versus 60 mg). Over half the NC patients died during hospitalization, as compared to 33% of C patients. Only 6% of NC patients were discharged to palliative care units, as compared to 22% of C patients.

Video-assisted thoracoscopic surgery lobectomy or open lobectomy for non-small-cell lung cancer? Minimizing selection bias in observational studies.

PURPOSE OF REVIEW: Adherence to preventive measures and prescribed medications is the cornerstone of the successful management of hypertension. The role of adherence is particularly important when treatments are not providing the expected clinical results, for example, in patients with resistant hypertension. The goal of this article is to review the recent observations regarding drug adherence in resistant hypertension. RECENT FINDINGS: Today, the role of drug adherence as a potential cause of resistant hypertension is largely underestimated. Most studies suggest that a low adherence to the prescribed medications can affect up to 50% of patients with resistant hypertension.A good adherence to therapy is generally associated with an improved prognosis. Nonetheless, adherence should probably not be a target for treatment per se because data on adherence should always be interpreted in the view of clinical results. In our opinion, the availability of reliable data on drug adherence would be a major help for physicians to manage patients apparently resistant to therapy. SUMMARY: The actual development of new drugs for hypertension is slow. Thus, focusing on drug adherence to the drugs available is an important way to improve blood pressure control in the population. More emphasis should be put on measuring drug adherence in patients with resistant hypertension to avoid costly investigations and treatments.

AIDS defining opportunistic infections in patients with high CD4 counts in the combination antiretroviral therapy (cART) era: things ain't what they used to be.

INTRODUCTION: According to reports from observational databases, classic AIDS-defining opportunistic infections (ADOIs) occur in patients with CD4 counts above 500/µL on and off cART. Adjudication of these events is usually not performed. However, ADOIs are often used as endpoints, for example, in analyses on when to start cART. MATERIALS AND METHODS: In the database, Swiss HIV Cohort Study (SHCS) database, we identified 91 cases of ADOIs that occurred from 1996 onwards in patients with the nearest CD4 count >500/µL. Cases of tuberculosis and recurrent bacterial pneumonia were excluded as they also occur in non-immunocompromised patients. Chart review was performed in 82 cases, and in 50 cases we identified CD4 counts within six months before until one month after ADOI and had chart review material to allow an in-depth review. In these 50 cases, we assessed whether (1) the ADOI fulfilled the SHCS diagnostic criteria (www.shcs.ch), and (2) HIV infection with CD4 >500/µL was the main immune-compromising condition to cause the ADOI. Adjudication of cases was done by two experienced clinicians who had to agree on the interpretation. RESULTS: More than 13,000 participants were followed in SHCS in the period of interest. Twenty-four (48%) of the chart-reviewed 50 patients with ADOI and CD4 >500/µL had an HIV RNA <400 copies/mL at the time of ADOI. In the 50 cases, candida oesophagitis was the most frequent ADOI in 30 patients (60%) followed by pneumocystis pneumonia and chronic ulcerative HSV disease (Table 1). Overall chronic HIV infection with a CD4 count >500/µL was the likely explanation for the ADOI in only seven cases (14%). Other reasons (Table 1) were ADOIs occurring during primary HIV infection in 5 (10%) cases, unmasking IRIS in 1 (2%) case, chronic HIV infection with CD4 counts <500/µL near the ADOI in 13 (26%) cases, diagnosis not according to SHCS diagnostic criteria in 7 (14%) cases and most importantly other additional immune-compromising conditions such as immunosuppressive drugs in 14 (34%). CONCLUSIONS: In patients with CD4 counts >500/ µL, chronic HIV infection is the cause of ADOIs in only a minority of cases. Other immuno-compromising conditions are more likely explanations in one-third of the patients, especially in cases of candida oesophagitis. ADOIs in HIV patients with high CD4 counts should be used as endpoints only with much caution in studies based on observational databases.