Expression of mRNAs encoding uncoupling proteins in human skeletal muscle: effects of obesity and diabetes

To explore the potential role of the uncoupling protein (UCP) family in human obesity and diabetes, we have used the reverse transcription-polymerase chain reaction to quantify UCP mRNA expression in human skeletal muscle. Levels of mRNA for UCP2, and for both short (UCP3S) and long (UCP3L) forms of UCP3, were highly correlated in individuals, indicating that gene transcription of these UCPs may be coordinately regulated by common mechanisms. In normal glucose-tolerant individuals, muscle UCP2 mRNA levels were positively correlated with percentage of body fat and with BMI (r = 0.6 and P < 0.05 for both). UCP3S mRNA levels were also positively correlated with percentage of body fat (r = 0.52, P < 0.05), and UCP3L mRNA tended to increase as a function of obesity (0.05 < P < 0.1). UCP mRNA levels, however, were not correlated with resting metabolic rate. UCP3S and UCP3L mRNA levels (P < 0.05) and the UCP2 mRNA level (P = 0.09) were increased by 1.8- to 2.7-fold in type 2 diabetes, an effect that could not be explained by obesity. No significant difference was found for UCP2, UCP3S, or UCP3L mRNA levels between insulin-sensitive and insulin-resistant nondiabetic subgroups. We conclude that 1) skeletal muscle mRNA levels encoding UCP2 and UCP3 are correlated among individuals and may be coordinately regulated; 2) UCP3 expression is not regulated by differential effects on UCP3L and UCP3S forms of the mRNA; and 3) UCP mRNA expression tends to increase in muscle as a function of obesity but not of resting metabolic rate or insulin resistance, and is increased in patients with type 2 diabetes.

Paclitaxel administration to gynecologic cancer patients with major cardiac risk factors

PURPOSE

To examine the safety of administering paclitaxel to patients with preexisting significant cardiac risk factors.

PATIENTS AND METHODS

The medical records of gynecologic cancer patients with major cardiac risk factors who had been treated with paclitaxel (single-agent or combination regimen with cisplatin or carboplatin) at The Cleveland Clinic Foundation from 1993 through February 1998 were examined to determine the acute toxicity of therapy.

RESULTS

A total of 15 patients were found who met these criteria, of whom none were found to have suffered a worsening of cardiac function following treatment with paclitaxel. A single patient developed a severe paclitaxel-associated hypersensitivity reaction, but no cardiac sequela.

CONCLUSION

This series suggests that paclitaxel can be safely administered as a single agent or in a combination regimen with a platinum agent to some patients with significant cardiac risk factors, such as those associated with ischemic heart disease. However, since few patients had baseline severe conduction defects before paclitaxel treatment, the safety of this drug in this clinical setting remains to be determined.

Low-dose oral granisetron (1 mg) plus intravenous dexamethasone: efficacy in gynecologic cancer patients receiving carboplatin-based chemotherapy

OBJECTIVE

The objective of this study was to determine the efficacy of a low-dose oral granisetron plus intravenous dexamethasone prophylactic antiemetic regimen in patients receiving carboplatin-based chemotherapy.

PATIENTS AND METHODS

Patients with gynecologic malignancies being treated with either single-agent carboplatin or a carboplatin-paclitaxel regimen received a single 1-mg oral dose of granisetron 30 min prior to chemotherapy plus intravenous dexamethasone (20 mg) as prophylaxis for emesis. Patients either had not previously been treated with chemotherapy or had not received any cytotoxic drugs for >/=4 months prior to study entry. Effectiveness was evaluated based on the degree of control of nausea and vomiting during the 24 h following treatment.

RESULTS

Of the 32 patients participating in this phase 2 trial, only 2 (6%) experienced any degree of nausea or vomiting within the first 24 h of chemotherapy administration. Both of these individuals had carcinomatosis and were experiencing emesis prior to chemotherapy. One patient developed mild delayed nausea >24 h after treatment. No major or minor toxic effects of the antiemetic regimen observed.

CONCLUSION

A 1-mg dose of oral granisetron plus intravenous dexamethasone (20 mg) is a safe, effective, and relatively inexpensive prophylactic antiemetic regimen for patients receiving single-agent carboplatin or combination carboplatin-paclitaxel chemotherapy.

Evidence that a "treatment-free interval of less than 6 months" does not equate with clinically defined platinum resistance in ovarian cancer or primary peritoneal carcinoma

The standard definition of platinum-resistant ovarian cancer or primary peritoneal carcinoma commonly includes patients whose disease initially responded to a platinum-based combination regimen, but recurred less than 6 months after the completion of primary therapy. Recent experience with several patients with these malignancies treated in the Gynecologic Cancer Program of the Cleveland Clinic Foundation, whose disease recurred within this period but who subsequently responded to platinum therapy, calls into question the validity and clinical relevance of this commonly employed definition, both for the conduct of phase 2 trials of new agents in ovarian cancer and primary peritoneal carcinoma, and for the standard management of women in this clinical setting.

Phase 2 trial of single agent ifosfamide/mesna in patients with platinum/paclitaxel refractory ovarian cancer who have not previously been treated with an alkylating agent

Ifosfamide has been shown to possess modest activity in patients with platinum/cyclophosphamide refractory ovarian cancer. Current standard initial chemotherapy for ovarian cancer does not include an alkylating agent (paclitaxel substituting for cyclophosphamide). To evaluate the activity of ifosfamide in patients with refractory ovarian cancer who had not previously received an alkylating agent, 21 patients with platinum/paclitaxel refractory disease were treated with the drug as a single agent (1.8 g/m2/day x 3 days, with treatment repeated every 28 days). Treatment was reasonably well tolerated in most patients, although 1 individual was removed from study secondary to neurotoxicity. One patient exhibited an objective response of measurable disease, while a second individual had a major decrease in CA-125 levels (no measurable disease present) following therapy. An additional patient experienced disappearance of severe pelvic pain following treatment but failed to meet the criteria for a partial response. We conclude that ifosfamide has modest activity in platinum/paclitaxel refractory ovarian cancer. However, the level of effectiveness does not appear to be increased in individuals who are alkylating-agent naive, compared to previously reported experience in patients with prior exposure to this class of cytotoxic drugs (10-15% response rate).

Phase 2 trial of moderately high dose single agent mitoxantrone in platinum and paclitaxel-refractory ovarian cancer

In the human clonogenic assay, mitoxantrone possesses among the steepest dose-response curves of any cytotoxic agent against ovarian cancer. To test the potential clinical relevance of this observation, we conducted a phase 2 trial of moderately high dose single agent mitoxantrone (28 mg/m2 delivered every 3-4 weeks) along with granulocyte-macrophage colony stimulating factor (250 micrograms/m2/day beginning 24 h after mitoxantrone and continuing until neutrophil recovery) in 34 patients with clinically defined platinum and paclitaxel-refractory ovarian cancer. The major toxicity of treatment was severe neutropenia which was almost universal. However, there were no treatment-related infectious deaths. Significant cardiac toxicity was not observed. Five of 33 evaluable patients demonstrated objective evidence of a response to treatment (1 patient achieving a partial response of measurable tumor masses, 4 patients achieving a > or = 50% reduction in CA-125 antigen level), with a median duration of response of 3 months (range 2-5 months). We conclude that moderately high dose mitoxantrone has definite, although very limited, single agent activity in platinum and paclitaxel-refractory ovarian cancer. Unfortunately, as this regimen produces severe hematologic toxicity and response durations are short, it cannot be recommended for routine clinical use. The role of an even higher dose mitoxantrone schedule employed as a component of a high dose chemotherapy program with bone marrow or peripheral progenitor cell protection in the treatment of ovarian cancer remains to be defined.

Revision of the 1990 working formulation for cardiac allograft rejection: the Sheffield experience

OBJECTIVE

To audit the 1990 International Society for Heart and Lung Transplantation cardiac rejection criteria and to evaluate the impact on classification and clinical outcomes of a modification in which grade 2 is abolished and grades 1A and 1B are amalgamated into a single "grade 1."

METHODS

1652 heart biopsies were reviewed over a four year period. The initial 1348 biopsies (group 1), using the original 1990 criteria, were analysed in terms of diagnostic grade and compared with the 304 biopsies analysed with the modified scheme (group 2). Differences in grading with the 1990 scheme were compared between two groups (1.1 and 1.2) reflecting early and late experience with grading. Subsequently all the grade 2 and grade 1B biopsies were rescored in terms of the modified scheme. Clinical results in terms of actuarial patient survival at one year and freedom from 3A rejection were similarly audited.

RESULTS

The relative ratios of potentially significant rejection (grade 3A, 3B, 4) remained constant over the entire study in groups 1.1, 1.2, and 2. A 50% reduction in grade 2 biopsy reporting was noted comparing early and late parts of group 1. At subsequent review of the group 1 grade 2 biopsies, 97% could be reassigned to grades 0 or 1 in the modified scheme, with the majority of these diagnoses reflecting Quility effect/biopsy site reactions. Two cases (3%) of the 77 grade 2 biopsies were regraded as grade 3A rejection, with both occurring within three months of transplantation. None of the grade 1B biopsies had high grade cardiac rejection on review, most of these biopsies similarly showing pronounced Quility effect and biopsy site reactions. Actuarial survival at one year rose from 86% to 90% during the study, with freedom from 3A rejection remaining unchanged at 80%.

CONCLUSIONS

The original working formulation produces consistent grading except at grade 2, which is judged to be a misnomer resulting from Quility effect and other non-rejection phenomena. While acceptable standardisation can be achieved with the 1990 scheme, the modified scheme has advantages in that it appears to encourage clear discrimination between significant and non-significant cardiac rejection. Overall, elimination of grade 2 did not produce an increase in higher grades of cardiac rejection, and thus the value of this diagnostic grade is questioned.

Ninety-six-hour infusional paclitaxel as salvage therapy of ovarian cancer patients previously failing treatment with 3-hour or 24-hour paclitaxel infusion regimens

PURPOSE

To test the hypothesis that prolonged infusion of paclitaxel (96 hours) might overcome resistance to shorter infusion schedules (3 or 24 hours) in ovarian cancer.

PATIENTS AND METHODS

A total of 30 patients with advanced ovarian cancer (24 patients), primary carcinoma of the peritoneum (four patients), or fallopian tube cancer (two patients) who previously had received paclitaxel administered on either a 3-hour or 24-hour schedule were treated with the agent delivered as a 96-hour infusion (30 to 35 mg/m2/d x 4 days) on an every 3-week program.

RESULTS

Although the regimen generally was well tolerated, no objective responses were observed.

CONCLUSION

In patients with ovarian cancer who have shown resistance to shorter paclitaxel infusion schedules, ninety-six hour infusional paclitaxel is an inactive treatment strategy. This makes it less likely that protracted infusion of paclitaxel will improve outcome when used as part of primary therapy of ovarian cancer. An ongoing randomized study will answer that question.

Reduced quality of clot formation with gelatin-based plasma substitutes

We have studied, over a wide range of dilutions using techniques of clot weight, thrombelastography and scanning electron microscopy, the physical properties of a blood clot formed in vitro when fresh blood was diluted with gelatin-based colloid solutions compared with crystalloid controls. The colloid solutions tested (3.5% polygeline (Haemaccel) and 4% succinylated gelatin (Gelofusine)) produced clots that had reduced median weight (P < 0.001 and P = 0.018, respectively) and reduced mean shear modulus (P < 0.001) compared with crystalloid controls. Scanning electron microscopy showed that the fibrin formed a less extensive mesh in the presence of the gelatin-based colloids compared with crystalloid. Reduction in clot quality with gelatin-based colloids has not been noted previously and further work is needed to ascertain if this occurs in vivo as these solutions are used frequently in patients who require full haemostatic competence.

The effects of intermittent illumination on a visual inspection task

Two experiments are described in which eye movements were monitored as subjects performed a simple target-spotting task under conditions of intermittent illumination produced by varying the display-screen frame rate on a computer VDU. In Experiment 1, subjects executed a saccade from a fixation point to a target which appeared randomly at a fixed eccentricity of 14 character positions to the left or right. Saccade latency did not differ reliably as a function of screen refresh rate, but average saccade extent at 70 Hz and 110 Hz was reliably shorter than at 90 Hz and 100 Hz. Experiment 2 examined the same task using a range of target eccentricities (7, 14, and 28 character positions to the left and right) and across a wider range of screen refresh rates. The results confirmed the curvilinear relationship obtained in Experiment 1, with average saccade extent reliably shorter at refresh rates of 50 Hz and 125 Hz than at 75 Hz and 100 Hz. While the effect was greater for remote targets, analyses of the proportional target error failed to show a reliable interaction between target eccentricity and display refresh rate. In contrast to Experiment 1, there was a pronounced effect of refresh rate on saccade latency (corrected for time to write the screen frame), with shorter latencies at higher refresh rates. It may be concluded that pulsation at frequencies above fusion disrupts saccade control. However, the curvilinear functional relationship between screen refresh rate and saccade extent obtained in these studies differs from previously reported effects of intermittent illumination on the average size of "entry saccades" (the first saccade to enter a given word) in a task involving word identification (Kennedy & Murray, 1993a, 1996). This conflict of data may arise in part because within-word adjustments in viewing position, which are typical of normal reading, influence measures of average saccade extent.

Exercise and heart disease: cardiac findings in fatal cycle accidents

BACKGROUND

Regular cyclists have been found to have a lower incidence of coronary events (CHD) than the general public. Non-invasive studies have found that competitive cyclists develop a cardiac hypertrophy that is physiological and reversible.

METHODS

To obtain pathological support for these observations, the postmortem findings of 32 cyclists killed in accidents have been compared with those in a control group of 32 other road traffic accidents, which were matched with the cyclists by sex, age, and year of death.

FINDINGS

Large myocardial scars and complete blockage of a coronary artery were only found in the controls; serious stenoses of coronary arteries (> 50%) were found in eight controls but in only one of the cyclists. Of the cyclists, 25 had normal coronary arteries as compared with 14 of the controls. The mean age of the cyclists with evidence of CHD was greater than that of similarly affected controls. The heart weights of the two groups were almost the same but heart weight varied with the degree of CHD. The heart weight of the healthy cyclists (389 g) was greater than that of the healthy controls (371 g) but this was not statistically significant.

INTERPRETATION

The results are in keeping with the concept that regular exercise provides some protection from the development of CHD and that cycling may be a valuable form of exercise in this respect. This may be of importance as the number of physically active occupations declines.

Split tibialis posterior tendon transfer in the treatment of spastic equinovarus foot

Sixteen patients with cerebral palsy causing equinovarus deformity were treated surgically. All of these patients underwent preoperative gait analysis by using a CODA-3 motion analyzer. The equinus deformity was assessed by using sagittal kinematics, and in particular, the range of movement of the ankle during stance phase and the maximal dorsiflexion during swing. The varus deformity was assessed by the degree of varus of the foot at prepositioning. The degree of varus was obtained by measuring the angle generated between the plane of progression and a line joining a marker on the heel to a marker on the fifth metatarsal in the transverse plane. All patients underwent split tibialis posterior tendon transfer and, in 13, this was combined with tendo calcaneus lengthening. Clinical assessment and gait analysis repeated 1 year postoperatively confirmed good outcome after split tibialis posterior tendon transfer in combination with gastrocnemius lengthening. This was confirmed by using sagittal kinematic analysis and quantitative assessment of the degree of varus of the foot at the time of prepositioning.

Carboplatin plus paclitaxel in the treatment of gynecologic malignancies: the Cleveland Clinic experience

To examine the toxicity profile and antineoplastic activity of carboplatin (area under the concentration-time curve of 4 to 7.5) plus 3-hour infusional paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) (135 or 175 mg/m2) in women with advanced gynecologic malignancies, we retrospectively reviewed the experience of the Gynecologic Cancer Program at The Cleveland Clinic with this combination chemotherapy regimen. To date, 92 patients (median age, 67 years) have received a total of 460 courses (median number per patient, six) of this two-drug combination. The initial paclitaxel dose was 175 mg/m2 and the carboplatin area under the concentration-time curve was > or = 5 in 72% and 73% of patients, respectively. The major toxicity was neutropenia (grade 4 in 9% of patients), resulting in two febrile episodes and a single septic death. Grade 4 thrombocytopenia and grade 3 peripheral neuropathy were noted in one and two patients, respectively. Twelve patients (13%) experienced at least one episode of paclitaxel-associated hypersensitivity, but all were able to continue with the treatment program. Of the 62 patients with ovarian cancer or primary peritoneal carcinoma with carbohydrate antigen-125 levels > or = 60 U/mL before the initiation of chemotherapy, 74% exhibited a > or = 90% decline in the tumor marker following treatment. We conclude that the combination of carboplatin and 3-hour infusional paclitaxel can be administered in the outpatient setting with a highly acceptable toxicity profile and with major activity in patients with ovarian cancer and primary carcinoma of the peritoneum.

Cerebral glucose metabolism in corticobasal degeneration: comparison with progressive supranuclear palsy and normal controls

The regional metabolic rate of glucose was estimated using 18F-labeled 2-deoxyglucose and positron-emission tomography (PET) in eight patients with corticobasal degeneration (CBD). Measures of cerebral glucose metabolism in these patients were compared with those for nine age-matched normal controls and eight patients with progressive supranuclear palsy (PSP). Compared with that in the normal controls, the CBD patients showed significantly reduced cerebral glucose metabolism in the contralateral hemisphere to the clinically most affected side in the dorsolateral frontal, medial frontal, inferior parietal, sensorimotor, and lateral temporal cortex, as well as in the corpus striatum and the thalamus. In comparison with that in PSP, in CBD the glucose metabolism in the contralateral hemisphere was significantly decreased in the inferior parietal, sensorimotor, lateral temporal cortex, and the corpus striatum. These results confirm the marked asymmetric cerebral involvement in CBD and suggest that there are significant differences between CBD and PSP in the cerebral metabolism in some cerebral regions such as the inferior parietal cortex and sensorimotor cortex, which might reflect the differences in their clinical characteristics.

An aldose reductase inhibitor and aminoguanidine prevent vascular endothelial growth factor expression in rats with long-term galactosemia

OBJECTIVE

To study the effects of an aldose reductase inhibitor (ARI-509, Wyeth-Ayerst, Princeton, NJ) and aminoguanidine (AMG), agents that have been reported to prevent or delay diabetic retinopathy, on retinal vascular abnormalities and the immunocytochemical expression in the retina of vascular endothelial growth factor (VEGF) in rats maintained for up to 2 years on a 50% galactose diet.

METHODS

Albino rats were placed on a control diet, a diet containing 50% galactose, or the 50% galactose diet containing either ARI-509 or AMG. Treatment with ARI-509 or AMG was initiated at the beginning of the experiment or after 12 months of galactose feeding. After 22 to 24 months, the rats were killed and the retinal vasculature from half of one eye was isolated by trypsin-elastase digestion for semiquantitative evaluation of retinal vascular lesions. The other half of the retina was prepared for immunocytochemistry and stained for the presence of VEGF, factor VIII, vimentin, and glial fibrillary acidic protein. Red blood cells, sciatic nerves, and a portion of the retina from the second eye were assayed for glucose, galactose, fructose, sorbitol, galactitol, and myo-inositol. Red blood cells were also assayed for galactosylated hemoglobin.

RESULTS

Galactose-fed animals developed a vascular retinopathy characterized by severe cellular loss in the retinal capillaries and intensification of periodic acid-Schiff staining of the vascular basement membranes. Some animals also displayed dilation and hypercellularity of vessels in the posterior retina. These changes were substantially reduced in animals receiving ARI-509 from the beginning of the galactose diet, but were unaffected in all of the other treatment groups. None of the rats receiving ARI-509 or AMG treatment, whether initiated from the onset or after 12 months of galactosemia, demonstrated VEGF immunoreactivity. With the exception of the animals receiving ARI-509 from the beginning of the experiment, all of the galactose-fed animals developed dense cataracts within 6 weeks of the beginning of the galactose diet. Galactitol levels in animals receiving ARI-509 were 86% to 93% lower in red blood cells, retina, and sciatic nerve than those in the other galactose-fed groups.

CONCLUSIONS

Although ARI-509 and AMG have different abilities to delay or prevent the diabetic-like retinopathy in galactosemic rats, even when substantial retinal microvascular acellularity occurs, both drugs prevent the immunocytochemical expression of VEGF. These results suggest that factors other than hypoxia may be responsible for VEGF expression in the retina, and that aldose reductase inhibitors and AMG have potential roles in preventing such expression and, thus, perhaps preventing retinal neovascularization.

Diagnostic value of inhibin immunoreactivity in ovarian gonadal stromal tumours and their histological mimics

AIMS

Inhibin is a heterodimeric protein hormone which appears to be a sensitive serological and immunohistochemical marker of ovarian granulosa cell tumours. The purposes of this study were to examine inhibin immunoreactivity in a wide range of gonadal stromal neoplasms and to assess its value in the differential diagnosis of problematic ovarian tumours.

METHODS AND RESULTS

Inhibin immunostaining was identified in eight cases of stromal hyperthecosis, 24 adult-type granulosa cell tumours, two juvenile granulosa cell tumours, nine Sertoli cell or Sertoli-Leydig cell tumours, one gynandroblastoma, three gonadoblastomas, two cases of sex cord tumour with annular tubules, two steroid cell tumours and two sclerosing stromal tumours. Inhibin was also present in 4/6 fibrothecomas and 2/3 unclassified gonadal stromal tumours. There was no staining of neoplastic cells in any of the problematic ovarian tumours, in many of which a diagnosis of gonadal stromal tumour had been initially considered. However, inhibin was detected in reactive stromal cells in many cases.

CONCLUSIONS

Inhibin is a sensitive immunohistochemical marker of a wide range of gonadal stromal tumours and is of value in the differential diagnosis of ovarian neoplasia.

Continued chemosensitivity to cisplatin/carboplatin in ovarian carcinoma despite treatment with multiple prior platinum-based regimens

While it is well recognized that individuals with ovarian cancer who have previously responded to platinum-based therapy can achieve a second response to cisplatin or carboplatin at the time of relapse, limited data exist in the oncologic literature regarding the number of times this process can be repeated. We briefly report here three patients with ovarian cancer currently being cared for in the Gynecologic Oncology program of the Cleveland Clinic Foundation who have achieved four (1 patient) or five (2 patients) separate clinical responses to cisplatin or carboplatin-based chemotherapy and have survived >4 years since the date of first relapse. This experience emphasizes the point that platinum resistance cannot be defined based on total treatment courses or the number of prior platinum-based regimens delivered, but only by objective evidence of failure of the drugs in an individual patient.

A comparison of the cytology of endomyocardial biopsy washings from heart transplants with biopsy histologic study and peripheral blood lymphocyte counts

Cytospin preparations of endomyocardial biopsy washings were examined on 117 occasions from 13 heart transplant recipients and categorized according to the pattern of cell types observed. Twenty-nine percent of samples were acellular, a further 10% too bloodstained for analysis, and 61% were cellular. Eight lymphocytic samples were found and in all cases there was at least grade 1B rejection (four grade 1B, three grade 2, and one grade 3A) on histologic study. However, histologic study showed at least 1B rejection in 48% of cases when cytospins showed mixed inflammatory cells, 33% of cases when cytospins were histiocytic and in 35% when cytospins were bloodstained or acellular. Furthermore 16 of these rejection episodes with nonlymphocytic cytospins were grade 2. Although the recovery of a lymphocytic cytospin was specific for rejection, the sensitivity of the test was poor. Even when the sample is adequate, this method of biopsy washings will predict only one third of cases of significant acute rejection (grade 2 or worse). The large proportion of unsuitable samples also severely limits the utility of endomyocardial biopsy washings for the diagnosis of rejection. Histiocytic cytospins were seen in 63% of samples when previous biopsy sites were reported on histologic study and also in all three samples when histologic study showed ischemic injury. A mixed inflammatory cell pattern was seen to a lesser extent (31% of samples) in relation to previous biopsy sites. High peripheral blood lymphocyte counts were found when endomyocardial biopsy washings were lymphocytic or mixed inflammatory and also when histologic study showed endocardial lymphocytic infiltration (Quilty effect).