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Objective To evaluate co-prescribing of sedatives hypnotics and opioids.Design Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing.Setting and participants Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA.Outcome measures Coprescription of sedative-hypnotics and opioids.Results A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date.Conclusions Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.

IntroductionDiffuse Low-grade gliomas (DLGG, WHO Grade II) are a heterogenous group of tumors comprising 13–16% of glial tumors. While maximal safe resection is endorsed as the best approach to DLGG, compared to more conservative interventions like stereotactic biopsy, the added costs and risks have not been systematically evaluated. The purpose of this study was to better understand the complication rates and costs associated with each intervention.MethodsA retrospective cohort study using data from the IBM Watson Health MarketScan® Commercial Claims and Encounters database was conducted, using the International Classification of Diseases, Ninth Revision (ICD-9) codes corresponding to DLGG (2005–2014). Current Procedure Terminology, 4th Edition (CPT-4) codes were used to differentiate resection and biopsy cohorts. Inverse weighting by the propensity score was used to balance baseline potential confounders (age, sex, pre-op seizure, geographic region, year, Charleston Comorbidity Index). Complication rates, hospital mortality, readmission, and costs were compared between groups.ResultsWe identified 5,784 and 3,635 patients undergoing resection and biopsy, respectively, for initial DLGG management. Resection was associated with greater 30-day complications (29.17% vs. 26.34%; p

Abstract Opioid use among metastatic breast cancer (MBC) patients has not been well-studied. This study examined the trends and patterns of opioid use among working-age, privately insured patients diagnosed with MBC. Using MarketScan data, we identified female patients diagnosed with MBC in 2006–2015. We determined the proportion of patients who filled a prescription for an opioid and calculated days’ supply and daily morphine milligram equivalents (MMEs) from 1 year prior to diagnosis till 1 year after. We assessed the trend in opioid use over the 10-year study period and examined opioid usage patterns after the diagnosis of MBC. Among 24,752 patients included, 11,579 (46.8%) had an opioid prescription within 1 year before diagnosis of MBC, and 20,416 (81.4%) had an opioid prescription within 1 year after diagnosis. The proportion of patients with opioid prescriptions after diagnosis was relatively stable from 2006 to 2015. However, both the median daily MME and median days’ supply decreased over time with most of the decline from the subgroup of patients with prior prescription opioid use. Most patients received an opioid prescription in the first month after diagnosis (57.3%), dropping to approximately 20% from 3 to 12 months after diagnosis. Also, the median days’ supply increased substantially during the year after diagnosis for patients who received opioids (from 7 to 19). Most women with MBC require opioid analgesia within the first month after diagnosis. Judicious, long-term management of pain after diagnosis of MBC will continue to be necessary for many patients.

IntroductionThrombotic thrombocytopenic purpura (TTP) is a diagnostic and therapeutic emergency. Therapeutic plasma exchange (TPE) combined with immunosuppression has been the cornerstone of the initial management. To produce optimal benefits, emerging treatments must be used against a background of best standard of care. Clarifying current uncertainties is therefore crucial.MethodsThe objective of this study was to analyze a large high-quality database (Marketscan) of TTP patients managed between 2005 and 2014, in the pre-caplacizumab era, in order to assess the impact of time to first TPE and use of first-line rituximab on mortality, and whether mortality declines over time.ResultsAmong the 1096 included patients (median age 46 [IQR 35-55], 70% female), 28.8% received TPE before day 2 in the ICU. Hospital mortality was 7.6% (83 deaths). Mortality was independently associated with older age (hazard ratio [HR], 1.024/year; 95% confidence interval [95%CI], [1.009-1.040]), diagnosis of sepsis (HR, 2.360; 95%CI [1.552-3.588]), and the need for mechanical ventilation (HR, 4.103; 95%CI, [2.749-6.126]). Factors independently associated with lower mortality were TPE at ICU admission (HR, 0.284; 95%CI, [0.112-0.717]), TPE within one day after ICU admission (HR, 0.449; 95%CI, [0.275-0.907]), and early rituximab therapy (HR, 0.229; 95% CI, [0.111-0.471]). Delayed TPE was associated with significantly higher costs.ConclusionsImmediate TPE and early rituximab are associated with improved survival in TTP patients. Improved treatments have led to a decline in mortality over time, and alternate outcome variables such as the use of hospital resources or longer term outcomes therefore need to be considered.

BackgroundThe incidence of sepsis has been rising overall but updated data in cancer patients are lacking. After a cancer diagnosis, incidence of sepsis and overall mortality peak within the first year. However, how much sepsis contributes to mortality remains unclear. We used a multistate model approach to analyze the incidence, risk factors and associated mortality of sepsis within 1 year of cancer diagnosis in middle aged adults.MethodsAnalysis of a large US health insurance claims database (Marketscan) between 2005 and 2014. Patients with a new diagnosis of cancer who received chemotherapy were included. Within a year of diagnosis, we assessed inpatient admissions for sepsis based on ICD-9 codes and survival using hospitalizations, outpatient visits and prescriptions filled. Competing risk and multistate models were used to assess the incidence of sepsis and transition probabilities between cancer, sepsis and death.Results119,379 patients (38.9% males), aged 55 (50-60) years, were included; 2,560 developed isolated sepsis, 477 severe sepsis and 1331 septic shock within 1 year, with associated hospital mortality of 14.8%, 30% and 46% respectively. The probability of sepsis increased between 2005 and 2014; at 1 year, its cumulative incidence was 3.7% with a probability of mortality after sepsis of 35.5% (95% CI 21.6%-50.9%). Age, male gender, Charlson comorbidity index, hematological malignancies and metastases at diagnosis were associated with sepsis and mortality.ConclusionsIncidence and mortality of sepsis were 3.7% and 35.5% at 1 year after cancer diagnosis and were both associated with baseline patient and cancer characteristics.

Abstract Background Hospitalized older persons with Alzheimer’s disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer’s disease and related dementias (ADRD) and improving FCG preparedness and experiences. Method We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds. Discussion Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD. Trial registration ClinicalTrials.gov, ID: NCT03046121. Registered on 8 February 2017.

Category: Ankle, Midfoot/Forefoot, Opioid Use Research Introduction/Purpose: Within the United States, opioid abuse has become a national crisis. Twenty-nine percent of patients prescribed opioids misuse them with nearly 12% developing addiction. One previous study has shown that patients undergoing foot/ankle surgery were left with extra narcotic pain medications following surgery, many of whom would have preferred to dispose of them. Our purpose was to evaluate factors in foot and ankle surgery that are associated with increased risk of prolonged post-operative opioid pain medication usage and identify the risk of various post-operative complications that may be associated with pre-operative opioid usage. We hypothesize that pre-operative opioid use will place patients at an increased risk of post-operative usage. Methods: The MarketScan commercial claims and encounters database, including approximately 39 million patients per year, was searched to identify patients who underwent foot/ankle surgery based on CPT code from 2005-2014. Preoperative comorbidities including DSM-V mental health disorders, chronic pain, chronic regional pain syndrome (CRPS), obesity, tobacco use, medications and diabetes were queried and documented. Patients who utilized opioids at least one month up to 3 months prior to surgery were identified. This timeframe was chosen to exclude patients who had been prescribed post-operative narcotic medications up to 1 months pre-operatively. We utilized odds ratios (OR), 95% Confidence Intervals (CI), and regression analysis to determine factors that are associated with prolonged post-operative opioid use at 3 time intervals. Results: 112,893 patients underwent foot/ankle surgery. 11,523 (10.2%) patients utilized opioids 1-3months pre-operatively. Of those, 5,732 (5.0%) utilized opioids post-operatively at 6 weeks, 4,364 (3.8%) at 3 months, 3,475 (3.08%) at 6 months and 2,579 (2.2%) at 1 year. Pre-operative opioid use was associated with increased post-operative use (6-12weeks: OR 7.24, 95% CI 6.92- 7.58; 3-6months: OR 11.03, 95% CI 10.45-11.63; 6-12months: OR 14.1, 95% CI 13.3-15.1; >12months: OR 14.74, 95% CI 13.68-15.88). Tobacco use, chronic pain, DSM-V diagnosis and non-opioid analgesia yielded increased risk of post-operative opioid usage. Diagnosis of CRPS, obesity or diabetes did not have an increased risk. Pre-operative opioid use was associated with an increased risk of readmission, DVT, pulmonary embolism, I&D of surgical site, myocardial infarction, UTI and post-operative bleeding (Table 1). Conclusion: Our study found a number of factors that are associated with prolonged post-operative opioid usage which included pre-operative opioid use 1-3months before surgery, tobacco use, chronic pain, DSM-V diagnoses and pre-operative use of certain non-opioid medications. We also found patients with pre-operative opioid exposure to be at an increased risk of a number of significant post-operative complications, including an increased risk of readmission at 30 and 90 days. This data provides orthopaedic surgeons a number of variables to consider when determining post-operative analgesia strategies, and provides health systems, providers and payers information on complications associated with pre-operative opioid utilization.

SUMMARY: BACKGROUND Naltrexone is one of only two medications currently approved by the Food and Drug Administration for the treatment of alcoholism. We attempted to determine the proportion of patients with a diagnosis of alcoholism who were prescribed naltrexone in the Department of Veterans Affairs health-care system during a 6-month period and the sociodemographic and clinical characteristics that distinguished them from veterans who were not prescribed naltrexone.METHODS By using Veterans Affairs workload databases, all outpatients diagnosed with alcoholism (International Classification of Diseases, 9th revision, codes 303.xx or 305.00) during a 6-month period (October 2000 to March 2001) were selected (n = 194,001). Patients in this group who were prescribed naltrexone during this period were identified. Logistic regression was used to compare those who were prescribed naltrexone with other alcoholics.RESULTS In this sample, only 3,705 patients (1.9%) of the 194,001 veterans with an alcohol use disorder were prescribed naltrexone. Logistic regression analysis showed that naltrexone use was associated with comorbid disorders (bipolar disorder, dysthymia, major depressive disorder, posttraumatic stress disorder, and drug abuse) and recent psychiatric hospitalization. African Americans and veterans with organic brain syndromes were less likely to be prescribed naltrexone.CONCLUSIONS These results suggest that prescribers have not embraced reports of naltrexone's efficacy in alcohol dependence, perhaps due to a general disinclination to use medications rather than a specific attitude toward naltrexone, especially in uncomplicated alcoholism. [ABSTRACT FROM AUTHOR]

optimize management, monitoring, and therapy compliance in patients with hypertension (HTN). It could potentially prevent unnecessary emergency room visits and hospital admissions.Methods: We surveyed patients with HTN in cardiology and primary care clinics regarding their use of mobile technology.Results: 148 patients were included (79 female; age 16-64: 47%, >65: 53%, 70 male; 18-64:41%, >65: 59%). Associated diagnosis were coronary artery disease (21%), myocardial infarction (13%), arrhythmias (36%), heart failure (6%), or other forms of heart disease (3%). 83% own a cell phone, 29% are smartphones. 78% own a personal computer, laptop, iPod, or tablet. 35% report using APPS, of which 26% use health-related applications. 2% used APPS for blood pressure monitoring or management. 17% used APPS for diet or calorie counters, 13% for exercise, fitness or heart monitoring. 63% use APPS on a smartphone, 12% on iPod Touch, 62% on Tablet. Among all HTN patients surveyed, 64% report looking up medical information online on a computer, 53% more than once per month. When asked about willingness to pay, 44% were not willing to pay for a smartphone or tablet that would help monitor their condition. 61% were not willing to pay if an ER visit and its copayment could be prevented. 26% were not willing to use these devices if they were free or covered by insurance.Conclusions: A majority of HTN patients surveyed had access to technology with 22% using smartphones with APPS. However, there was limited use of health-specific APPS, especially those related to HTN. Limiting factors may include lack of outcomes-based research, structured programs that incorporate APPS and devices, or lack of familiarity with APPS and technological devices. A comprehensive strategy to develop, market, and demonstrate benefits of this rapidly growing technology is urgently needed. [ABSTRACT FROM AUTHOR]

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver program's impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing., (Project HOPE—The People-to-People Health Foundation, Inc.)

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) preferentially induces apoptosis in malignant cells by binding to the death receptors TRAIL-R1 (DR4) and TRAIL-R2 (DR5). Several agents that therapeutically exploit this phenomenon are being developed. We investigated the anticancer activity of two novel, highly specific agonistic monoclonal antibodies to TRAIL-R1 (mapatumumab, HGS-ETR1) and TRAIL-R2 (lexatumumab, HGS-ETR2) in colon cancer cell lines. Our analyses revealed that colon cancer cells display significantly higher surface expressions of TRAIL-R2 than TRAIL-R1, and are more sensitive to lexatumumab-induced apoptosis. The proapoptotic effects of lexatumumab in TRAIL-resistant HCT8 and HT29 cells were dramatically augmented by the histone deacetylase inhibitors trichostatin A or suberoylanilide hydroxamic acid. The presence of p21, but not p53, was critical for the synergy between lexatumumab and histone deacetylase inhibitors. The absence of p21 did not interfere with the formation of the death-inducing signaling complex by lexatumumab, suggesting the involvement of other apoptotic and/or cell cycle regulators. Indeed, treatment with suberoylanilide hydroxamic acid greatly reduced the expression of the inhibitor of apoptosis protein survivin and cdc2 activity in HCT116 p21(+/+) cells but not in the HCT116 p21(-/-) cells. Inhibition of cdc2 activity with flavopiridol decreased survivin expression and sensitized the p21-deficient cells to lexatumumab-induced apoptosis. Similarly, small interfering RNA-mediated knockdown of survivin also enhanced lexatumumab-mediated cell death. Therefore, survivin expression plays a key role in lexatumumab resistance, and reducing survivin expression by inhibiting cdc2 activity is a promising strategy to enhance the anticancer activity of lexatumumab.

The effects of reactive oxygen species (ROS) on tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced apoptosis in solid cancers have yet to be clearly defined. In this study, we found that the classic uncoupler of oxidative phosphorylation, carbonyl cyanide m-chlorophenylhydrazone (CCCP), induced a reduction in DeltaPsim and generation of ROS. This uncoupling effect enhanced TRAIL-induced apoptosis in TRAIL-resistant human colon carcinoma cell lines (RKO, HT29, and HCT8). Sensitization was inhibited by benzyloxycarbonyl-valine-alanine-aspartate fluoromethylketone, indicating the requirement for caspase activation. CCCP per se did not induce apoptosis or release of proapoptotic factors from mitochondria. Generation of ROS by CCCP was responsible for TRAIL-induced Bax and caspase activation because scavenging ROS completely abrogated apical caspase-8 activation and further downstream events leading to cell death. Overexpression of Bcl-2 did not prevent the initial loss of DeltaPsim and ROS generation following CCCP treatment, but did prevent cell death following TRAIL and CCCP exposure. Uncoupling of mitochondria also facilitated TRAIL-induced release of proapoptotic factors. X-linked inhibitor of apoptosis overexpression abrogated TRAIL-induced apoptosis in the presence of CCCP and decreased initiator procaspase-8 processing, indicating that additional processing of caspase-8 required initiation of a mitochondrial amplification loop via effector caspases. Of interest, depletion of caspase-9 in RKO cells did not protect cells from TRAIL/CCCP-induced apoptosis, indicating that apoptosis occurred via a caspase-9-independent pathway. Data suggest that in the presence of mitochondrial-derived ROS, TRAIL induced mitochondrial release of Smac/DIABLO and inactivation of X-linked inhibitor of apoptosis through caspase-9-independent activation of caspase 3.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces apoptosis in a wide variety of malignant cell lines, in contrast to normal cells, but with considerable heterogeneity in response. Death receptor-mediated apoptosis may be attenuated by a variety of different mechanisms, including phosphorylation-based signaling pathways. We have demonstrated that casein kinase I can attenuate TRAIL-induced apoptosis in human cell lines derived from colon adenocarcinoma (HT29 and HCT8) and pediatric rhabdomyosarcoma (JR1). Inhibition of casein kinase I (CKI) phosphorylation events in HT29, HCT8, and JR1 cells by CKI-7 dramatically increased apoptosis after exposure to TRAIL, in the absence of apoptosis induced by TRAIL treatment alone. CKI inhibition enhanced the recruitment of Fas-associated death domain and procaspase-8 to the death-inducing signaling complex after TRAIL treatment and enhanced cleavage of procaspase-8 at the death-inducing signaling complex. In HT29 cells studied further, rapid cleavage of caspase-8, caspase-3, Bid, and the caspase substrate poly(ADP-ribose) polymerase occurred when CKI-7 and TRAIL were combined. Overexpression of Bcl-2, Bcl-xL, or mutant DN-Fas-associated death domain protected HT29 cells from TRAIL-induced apoptosis in the presence of the CKI inhibitor. In addition, TRAIL combined with CKI-7 promoted the release of cytochrome c, Smac/DIABLO, HtrA2/Omi, and AIF from the mitochondria and down-regulated the expression of XIAP and c-IAP1. Small hairpin RNAs directed against CKI revealed that the CKIalpha isoform contributed significantly to the inhibition of TRAIL-induced apoptosis. These findings suggest that CKIalpha plays an antiapoptotic role through the generation of phosphorylated sites at the level of the death-inducing signaling complex, thereby conferring resistance to caspase cleavage mediated by TRAIL.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces apoptosis via the death receptors DR4 and DR5 in transformed cells in vitro and exhibits potent antitumor activity in vivo with minor side effects. Protein kinase casein kinase II (CK2) is increased in response to diverse growth stimuli and is aberrantly elevated in a variety of human cancers. Rhabdomyosarcoma tumors are the most common soft-tissue sarcoma in childhood. In this investigation, we demonstrate that CK2 is a key survival factor that protects tumor cells from TRAIL-induced apoptosis. We have demonstrated that inhibition of CK2 phosphorylation events by 5,6-dichlorobenzimidazole (DRB) resulted in dramatic sensitization of tumor cells to TRAIL-induced apoptosis. CK2 inhibition also induced rapid cleavage of caspase-8, -9, and -3, as well as the caspase substrate poly(ADP-ribose) polymerase after TRAIL treatment. Overexpression of Bcl-2 protected cells from TRAIL-induced apoptosis in the presence of the CK2 inhibitor. Death signaling by TRAIL in these cells was Fas-associated death domain and caspase dependent because dominant negative Fas-associated death domain or the cowpox interleukin 1beta-converting enzyme inhibitor protein cytokine response modifier A prevented apoptosis in the presence of DRB. Analysis of death-inducing signaling complex (DISC) formation demonstrated that inhibition of CK2 by DRB increased the level of recruitment of procaspase-8 to the DISC and enhanced caspase-8-mediated cleavage of Bid, thereby increasing the release of the proapoptotic factors cytochrome c, HtrA2/Omi, Smac/DIABLO, and apoptosis inducing factor (AIF) from the mitochondria, with subsequent degradation of X-linked inhibitor of apoptosis protein (XIAP). To further interfere with CK2 function, JR1 and Rh30 cells were transfected with either short hairpin RNA targeted to CK2alpha or kinase-inactive CK2alpha (K68M) or CK2alpha' (K69M). Data show that the CK2 kinase activity was abrogated and that TRAIL sensitivity in both cell lines was increased. Silencing of CK2alpha expression with short hairpin RNA was also associated with degradation of XIAP. These findings suggest that CK2 regulates TRAIL signaling in rhabdomyosarcoma by modulating TRAIL-induced DISC formation and XIAP expression.

Signaling pathways involved in survival responses may attenuate the apoptotic response to the cytotoxic tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) in human colon carcinomas. In six lines examined, three were sensitive (GC(3)/c1, VRC(5)/c1, HCT116), HT29 demonstrated intermediate sensitivity, and RKO and HCT8 were resistant to TRAIL-induced apoptosis. Calphostin c [an inhibitor of classic and novel isoforms of protein kinase C (PKC)] sensitized five of six cell lines to TRAIL, whereas Go6976, (inhibitor of classic PKC isoforms), did not influence TRAIL sensitivity. Rottlerin, an inhibitor of novel isoforms of PKC, specifically PKC delta, sensitized five of six cell lines to TRAIL-induced apoptosis, suggesting that PKC delta may be involved in the mechanism of TRAIL resistance. Transfection of HCT116 with a proapoptotic cleaved fragment of PKC delta or an antiapoptotic full-length PKC delta did not influence the sensitivity of HCT116 to TRAIL. Furthermore, the incubation of HCT116 or RKO with phorbol myristate acetate for 16 h, which down-regulated the expression of novel PKC isoforms, also did not influence sensitivity to TRAIL either in the absence or presence of rottlerin. However, after 15-min incubation with rottlerin, mitochondrial membrane potential (Delta psi m) was dramatically reduced in RKO cells, and, in cells subsequently treated with TRAIL, rapid apoptosis was evident within 8 h. Calphostin c, but not Go6976, also caused a decrease in Delta psi m. In RKO, rottlerin induced the release of cytochrome c, HtrA2/Omi, Smac/DIABLO, and AIF from the mitochondria, potentiated in combination with TRAIL, with concomitant caspase activation and down-regulation of XIAP. In HT29, the release of proapoptotic factors was demonstrated only when rottlerin and TRAIL were combined, and Bcl-2 overexpression inhibited this release and the induction of apoptosis. TRAIL-induced apoptosis was not influenced by rottlerin or Bcl-2 overexpression in type I (GC(3)/c1) cells. Data suggest that rottlerin affects mitochondrial function independent of PKC delta, thereby sensitizing cells to TRAIL, and that mitochondria constitute an important target in overcoming inherent resistance to TRAIL in colon carcinomas.

Potentiation of 5-fluorouracil/leucovorin (FUra/LV) cytotoxicity by IFN-gamma in colon carcinoma cells is dependent on FUra-induced DNA damage, the Fas death receptor, and independent of p53 and RNA-mediated FUra toxicity, which occurs in normal gastrointestinal tissues. This provides a rationale for enhancing the selective action of FUra/LV by IFN-gamma in the treatment of colorectal carcinoma. Based on results from our preclinical studies we designed a Phase I trial combining FUra (370 mg/m2) and LV (200 mg/m2), i.v. bolus daily x 5 days, with escalating doses of IFN-gamma (10-100 micro g/m2) s.c. on days 1, 3, and 5, every 28 days. Twenty-five patients with carcinomas were enrolled; 6 patients received IFN-gamma on days 1 and 3 only. The dose-limiting toxicity, stomatitis, occurred most frequently at 100 micro g/m2 IFN-gamma. Minor response or SD was observed in 2 of 9 patients and in 4 of 12 patients at dose levels of < or =50 micro g/m2 and > or =75 micro g/m2 IFN-gamma, respectively. Three evaluable chemonaive patients demonstrated partial response (2) or complete response (1). Serial plasma samples revealed peak FUra concentrations of >100 micro M; at 100 micro g/m2 IFN-gamma plasma concentrations >5 units/ml persisted for 6.5 h and >1 unit/ml for 28.5 h. The pharmacokinetic parameters of IFN-gamma correlated with a 2-3-fold up-regulation of Fas expression at 24 h in CD15+ cells in peripheral blood samples. Furthermore, clinically relevant IFN-gamma concentrations up-regulated Fas expression and sensitized HT29 colon carcinoma cells in vitro to FUra/LV cytotoxicity. On the basis of the modulation of Fas signaling, FUra/LV combined with IFN-gamma has shown activity in a Phase I trial in colorectal carcinoma and warrants additional evaluation in Phase II.