Advanced non-small cell lung cancer in the elderly: effective and well tolerated weekly gemcitabine and cisplatin regimen. A pilot study

BACKGROUND

The frequency of advanced non-small cell lung cancer (NSCLC) increases with age and more effective and less toxic chemotherapy schedules are needed in elderly patients. Cisplatin-based regimens are considered the best treatment for advanced NSCLC, although they produce only a modest advantage in overall survival with considerable toxicity.

METHODS

In the present study the activity and toxicity of a weekly gemcitabine and cisplatin schedule was evaluated in a small group of advanced NSCLC patients aged 68 years or more. Treatment consisted of gemcitabine 1000 mg/m2 i.v. and cisplatin 35 mg/m2 i.v., both given weekly on days 1, 8, 15 followed by 1 week of rest.

RESULTS

Fifteen previously untreated patients entered the study; their median age was 72 years (range 68-76). One hundred and sixteen weekly administrations were delivered. The median dose-intensity was 614.5 mg/m2 per week for gemcitabine (82%) and 21 mg/m2 per week for cisplatin (80%). All the 15 patients were evaluable for response and toxicity. The overall response rate was 40% [95% CI = 16-68%]. The main toxicity was WHO grade III-IV thrombocytopenia that was recorded in 6 patients (40%). Other major toxicities were very low and no treatment-related deaths were reported.

CONCLUSIONS

This schedule appears to be active, to have a favourable toxicity profile and can be considered in advanced NSCLC elderly patients. Of interest, the patients enrolled received high dose intensities of both drugs.

A phase I-II study of gemcitabine and docetaxel in advanced pancreatic cancer: a report from the Italian Group for the Study of Digestive Tract Cancer (GISCAD)

BACKGROUND

Gemcitabine and docetaxel have been claimed to be active single agents in advanced pancreatic cancer. We determined the maximum tolerable dose of docetaxel combined with a weekly fixed dose of gemcitabine and assessed the activity of this combination in advanced pancreatic cancer.

PATIENTS AND METHODS

Phase I. Patients were treated with gemcitabine on days 1 and 8, every three weeks, at a fixed dose of 1,000 mg/m2; docetaxel was given at escalating doses starting from 70 mg/m2 on day 8. Phase II. In accord with the optimal two-stage phase II study design, 18 patients were treated with gemcitabine (1000 mg/m2) and the maximum tolerable dose of docetaxel (70 mg/m2).

RESULTS

Phase I. Dose-limiting toxicities occurred at the second dose level of docetaxel (80 mg/m2), with all three patients developing grades 3 or 4 neutropenia. Consequently, the dose tested in the phase II study was 70 mg/m2. Phase II. In the 18 patients enrolled in the study, we registered only one partial response. The time to progression was 3 months, and the median treatment survival was 5.4 months. Grade 3-4 toxicities consisted of neutropenia (three episodes) and thrombocytopenia (two episodes). Furthermore, 10 patients complained of grade 3 fatigue.

CONCLUSIONS

The addition of docetaxel to gemcitabine does not appear to be useful in advanced pancreatic cancer, since gemcitabine alone achieves similar results.

[Chronic arthritis in a child with primary agammaglobulinemia]

OBJECTIVES: To report a case of a child with Bruton's disease and the unusual association with chronic aseptic arthritis resembling juvenile rheumatoid arthritis. METHODS: A 16 month-old boy was seen at the Pediatric Rheumatology unit of HC-UFG and Hospital da Criança (Goiânia- GO). The authors evaluated relevant clinical and laboratorial features, including follow-up and response to therapy. The data were then compared to previous reports published in the world literature based on a Medline search of the subject. RESULTS: Since the age of 6 months, the patient had recurrent episodes of infection that responded poorly to antibiotics. Forty days before admission, he had onset of arthritis in his left knee. The diagnosis of Bruton's disease was based on the seric levels of immunoglobulins and the response to intravenous gammaglobulin infusions. Besides improvement with this therapy, clinical characteristics and other indirect laboratorial tests highly suggested the diagnosis of chronic, aseptic arthritis. CONCLUSION: We present a case of a rare association between Bruton's disease and chronic, aseptic arthritis, very similar to juvenile rheumatoid arthritis. Early recognition of this rare aseptic articular involvement is important for early and efficient therapy with intravenous gammaglobulin infusions, avoiding unnecessary hospital admissions and inappropriate use of antibiotics.

A phase II study of Tomudex alternated with methotrexate, 5-fluorouracil, leucovorin in first-line chemotherapy of metastatic colorectal cancer

PURPOSE

This multicenter phase II study was designed to assess the efficacy of the alternating schedule of tomudex with methotrexate (MTX)/5-fluorouracil (5-FU)/leucovorin (LV) in first-line chemotherapy for metastatic colorectal cancer.

PATIENTS AND METHODS

Patients with histologically proven metastatic colorectal cancer and at least one bidimensionally measurable lesion, aged 18-70, with performance status < or = 2, normal baseline biological values, and no prior chemotherapy, were selected. Treatment was tomudex 3 mg/m2 and, after two weeks, MTX, 200 mg/m2 by 30' infusion after hydration with 1500 ml saline solution, followed on day 2 by 5-FU, 600 mg/m2 and leucovorin, orally, 15 mg for six times every 6 hours, beginning 24 hours after MTX. Cycles were repeated every four weeks. Tumor response assessment was performed after three cycles.

RESULTS

Thirty-four patients were enrolled in this study, of whom twenty-four had liver metastases, nine local relapse, five lymph node involvement, four lung metastases, and three peritoneal carcinomatosis. Four patients achieved objective responses (one complete and three partial), for an overall response rate of 12% (95% CI: 0%-22%). Twelve patients had stable disease and 18 progressed on therapy. Median survival for all patients was 13 months. Two patients experienced grade 3 WHO neutropenia while hepatotoxicity was reported in 13 patients (6 grade 1, 3 grade 2, 3 grade 3, 1 grade 4), suggesting that this combination could increase hepatic toxicity in comparison to tomudex or MTX/5-FU alone.

CONCLUSIONS

Our results suggest that this regimen does not warrant further investigation in advanced colorectal cancer patients, at least not with this schedule and doses.

A combination of gemcitabine and 5-fluorouracil in advanced pancreatic cancer, a report from the Italian Group for the Study of Digestive Tract Cancer (GISCAD)

In a randomized clinical trial, gemcitabine (GEM) was more effective than 5-fluorouracil (5-FU) in advanced pancreatic cancer patients. GEM and 5-FU have different mechanisms of action and their combination, from a theoretical point of view, could result in a higher activity. To test activity and feasibility of such a combination, a multi-institutional phase II study was initiated in November 1996 by the Italian Group for the study of Digestive Tract Cancer (GISCAD). Primary objectives of this study were to determine the activity in terms of response rate and clinical benefit, while the secondary objective was toxicity. According to the optimal two-stage phase II design, 54 patients were enrolled. Schedule was: GEM 1000 mg m(-2) intravenous (i.v.), and 5-FU 600 mg m(-2) bolus i.v. weekly for 3 weeks out of every 4. All the 54 patients were symptomatic (pain, weight loss, dyspepsia). A clinical benefit was obtained in 28 patients (51%) (95% confidence interval (CI) 38-64%). Two patients achieved a partial response and 34 a stable disease. Median survival for all the patients was 7 months. Side-effects were mild: no gastrointestinal or haematological grade 3-4 toxicity (WHO) were recorded. We observed only six episodes of grade 2 (WHO) leukopenia and seven episodes of thrombocytopenia. Although the non-randomized design of this study suggests caution in the interpretation of these data, in consideration of the low incidence of toxicity and the favourable results obtained in terms of clinical benefit, it may be worthwhile to test more active schedules of 5-FU (continuous infusion) in combination with gemcitabine.

Systemic mycobacterioses in AIDS patients as determined by blood cultures on biphasic medium

Bacteremia due to mycobacteria can occur in AIDS patients in whom a rapid diagnosis is extremely important in order to plan a therapeutic conduct. Blood culture of mycobacteria using a biphasic system was set up in the Regional Laboratories of the Adolfo Lutz Institute, SP (Campinas, Ribeirão Preto, Santo André, Santos, São José do Rio Preto and Sorocaba). During a three year period (1994-97), 1521 blood samples were analyzed from 1336 AIDS patients, with CD4+ cell count < 100/ml, hematocrit < 30% and serum albumin concentration < 3.0 g/dl seen in regional outpatient clinics or as inpatients in hospitals. Of the blood samples examined, 9.9% were positive for mycobacteria. The predominant species was Mycobacterium avium complex (MAC) (53.8%) followed by Mycobacterium tuberculosis (28.0%). Mycobacterium xenopi was isolated in one case (0.8%) and in the remaining 17.4% the mycobacteria isolated were not identified. The implementation of blood culture for mycobacteria in our Institute has permitted the laboratory diagnosis of mycobacterial infections, in addition to providing data on the frequency of disseminated mycobacterial disease in AIDS patients in the region.

Neuroleptic malignant syndrome in children and adolescents

OBJECTIVE

Neuroleptic malignant syndrome (NMS) is a serious iatrogenic condition. This report reviews the world literature to characterize the syndrome and evaluate factors that promote early detection and effective intervention.

METHOD

The review identified 77 NMS cases (49 males, 27 females, 1 gender unknown); ages ranged from 0.9 to 18 years (mean 14.8 +/- 3.96). Univariate and multiple regression analyses were applied to 38 variables to identify early signs of the disorder, to identify correlates of outcome, and to evaluate treatments.

RESULTS

The duration of NMS spanned from 1 to 119 days. Nine percent of patients died and 20% resolved with serious sequelae. Patients receiving low-potency neuroleptics had a poorer outcome (p = .01). Fever was related to longer duration of illness (p = .03). Anticholinergics and bromocriptine were effective and without fatalities, but dantrolene was not useful in this sample of children and adolescents.

CONCLUSIONS

Early detection and appropriate interventions appear important in moderating the course and outcome of NMS.

Weekly gemcitabine and cisplatin in advanced non-small-cell lung cancer: a phase II study

BACKGROUND

The combination of gemcitabine and cisplatin has proven effective in the treatment of advanced non-small-cell lung cancer (NSCLC). However, the optimal schedule for administration of the two drugs has not yet been determined. In this study we evaluated the activity and toxicity of a weekly gemcitabine and cisplatin schedule.

PATIENTS AND METHODS

Thirty-six untreated patients with stage IIIB IV NSCLC entered the study. Treatment consisted of gemcitabine 1000 mg/m2 i.v. and cisplatin 35 mg/m2 i.v., both given weekly on day 1,8, and 15, followed by one week of rest.

RESULTS

Ninety-seven courses (273 weekly administrations) were delivered. The median dose-intensity was 612 mg/m2 per week for gemcitabine (82%) and 21 mg/m2 per week for cisplatin (80%). All 36 of the patients were evaluable for toxicity, and 30 for response. Partial remissions were observed in 12 patients, for an overall response rate of 40% (95% confidence interval (95% CI): 22.5%-57.5%). Most of the partial remissions were seen in IIIB patients (54% of the stage IIIB and 22% of the stage IV patients responded). According to the intent-to-treat principle, the response rate was 33.3% (12 of 36 patients). The median response duration was 9.9 months (range 4-23) and the median survival time 11.8 months (range 1-24). World Health Organization (WHO) grade 3-4 myelotoxicity was: thrombocytopenia in nine patients (25%), neutropenia in six (16.6%) and anemia in six (16.6%); there was very little additional major toxicity.

CONCLUSIONS

This regimen appears to be active and to have a favourable toxicity profile.

Aortic reconstruction with crimped bovine pericardial conduits

BACKGROUND AND AIM OF THE STUDY

A bovine pericardial conduit processed in glutaraldehyde was designed, incorporating the principle of crimping used for synthetic vascular prostheses. The crimping process did not affect the integrity of collagen fibers and tissue structure. This conduit, designed for aortic reconstruction, is available in different sizes, with or without a biological valve.

METHODS

Between October 1989 and May 1997, 40 patients with aortic dissection, aortic aneurysm, aortic coarctation or aortoiliac occlusive disease underwent aortic reconstruction using this vascular substitute. Procedures included total reconstruction of the ascending aorta and aortic valve with reimplantation of coronary arteries (nine patients), single ascending thoracic aorta (six), descending thoracic aorta (two), aortic arch (one) and thoracoabdominal aorta (one); the abdominal aorta was reconstructed in 21 cases, including those undergoing aortoiliac or aortofemoral bypass.

RESULTS

The hospital mortality rate was 20% (eight patients); causes of deaths were low cardiac output, recurrence of aortic dissection, multiple organ failure and bleeding. Mean follow up was 3.6 years; total follow up was 114 patient-years. Late conduit-related complications occurred in four patients, including a limb obstruction in one patient subjected to aortofemoral bypass and infection of three resulting in pseudoaneurysm (incidence of 3.5 +/- 1.8% per patient-year). All underwent reoperation. There were four late deaths due to sudden death, coronary artery disease, pneumonia and metabolic complications of diabetes and renal failure (incidence of 3.5 +/- 1.8% per patient year). The eight-year actuarial survival rate was 63.7 +/- 11.6%, including hospital mortality, and the eight-year actuarial freedom from conduit failure due to primary tissue structural degeneration was 100%.

CONCLUSIONS

The crimping design provides a circular tube which makes construction of the anastomosis easier, retains its shape with bending, and avoids kinking. The material is very soft, easy to handle and suture, coapts nicely to suture lines resulting in a hemostatic anastomosis. The eight-year follow up demonstrated a satisfactory performance without report of fibrosis, calcification or aneurysmal dilation.

Risperidone in children and adolescents with pervasive developmental disorder: pilot trial and follow-up

Dopamine receptor antagonists, particularly haloperidol, have been the most effective medications in currently available double-blind placebo-controlled studies for treating the disruptive behaviors often associated with pervasive developmental disorder (PDD). The rationale for trying risperidone in this population includes its dopamine-blocking activity; its seemingly lower incidence of tardive dyskinesia when compared to standard neuroleptics; the possibility that risperidone may ameliorate the social withdrawal of PDD, as it does the negative symptoms in schizophrenia; and substantial effects on serotonergic neurotransmission, which has been shown to be dysregulated in some patients with PDD. This study was an open-label pilot trial of risperidone in 6 subjects (aged 7-14 years, mean = 10.7) who met DSM-III-R criteria for a PDD diagnosis. The mean optimal dose was 2.7 mg daily (range 1-6). Mean duration of risperidone administration was 5.2 months (range 1-8). Despite the small sample size, risperidone treatment appeared to be associated with significant improvements in ratings of angry affect (p = 0.04) and lability of affect (p = 0.03) and with a trend (p = 0.10) toward a reduction of mean hyperactivity scores. Clinical Global Improvement scale ratings were statistically significant (p < 0.001). Increased sociability was reported in 3 subjects by their parents and family following the study. Three patients continued on risperidone for over 2 years, and none showed any loss of its apparent therapeutic effects. Weight gain was observed in 5 of 6 patients, with a median increase of 5.4 kg (12 lbs) in 7 weeks. Other side effects included transient sedation, increased salivation, and stereotypies. One child showed a worsening of pre-existing tic and phobic symptoms after 5 months of successful monotherapy. No loss of therapeutic effect was noted in the 3 subjects who remained on risperidone for over 2 years, but 1 patient developed hepatotoxicity and another developed withdrawal dyskinesia, similar to her prior experience with haloperidol. Overall, 5 of the 6 patients derived significant clinical benefits from risperidone. Pharmacologic alternatives for treating behavioral symptoms in PDD are need, and risperidone may be a promising possibility.

Mitral valve replacement with glutaraldehyde preserved aortic allografts

OBJECTIVE

To present long-term results after mitral valve replacement with stent mounted glutaraldehyde preserved aortic allografts in patients older than 15 years. The clinical support for this study was to combine the glutaraldehyde technique of biological tissue preservation with the advantages of allografts when compared to xenografts. This was demonstrated in previous studies using other methods of tissue processing.

METHODS

Between September 1984 and November 1994, 70 patients aged 16-77 years (mean 35.4 years) underwent mitral valve replacement with this preserved and mounted allograft. Of these, 40 patients (57.2%) were aged 16-35 years and 15 (21.4%) were 20 years old or younger; 46 (65.7%) were females and 24 (34.3%) males. Single mitral valve replacement was performed in 60 patients and 10 were also subjected to other combined cardiac procedures. Human aortic valves were obtained during routine autopsy, processed in glutaraldehyde and mounted into flexible stents, using the same technique as that used for porcine bioprostheses.

RESULTS

Hospital mortality was 1.4%. Total follow-up was 543.1 patient-years, corresponding to a mean follow-up of 7.9 years per patient. Echocardiography demonstrated a hemodynamic performance similar to porcine bioprostheses. Late mortality was 0.7 +/- 0.6% per patient-year and the causes were congestive heart failure in 2, prosthetic endocarditis in 1 and acute myocardial infarction in 1. The 12-year actuarial survival was 92.4 +/- 3.2%. The incidence of late complications was 5.2 +/- 1.2% per patient-year, including congestive heart failure, prosthetic endocarditis, periprosthetic leak, thromboembolic episodes, recurrence of rheumatic disease, coronary artery disease and allograft failure. Complications related to heart disease represented 2.8 +/- 0.6% and allobioprosthesis-related 2.4 +/- 0.5% per patient-year. The 12-year actuarial freedom from primary valve failure was 81.0 +/- 15.0%. The incidence of reoperations was 1.5 +/- 0.8% per patient-year and the main indication was prosthetic endocarditis. Other causes were periprosthetic leak, aortic insufficiency in the native aortic valve and allobioprosthesis dysfunction. Functional results demonstrated a significant improvement in patients clinical condition.

CONCLUSION

This 12-year follow-up shows a very low incidence of primary allograft failure for patients older than 15 years undergoing mitral valve replacement, and much superior than our results with porcine bioprosthesis in the same age group. This supports our assumption that this investigational valve represents a new advance in cardiac valve surgery.

Intensive day program for psychiatrically disturbed truant adolescents

Results of a day treatment program tailored to psychiatrically disturbed truant adolescents were compared to those of traditional outpatient treatment for effects on truancy, psychiatric symptoms, global improvement, and global functioning. Significantly greater reductions of truancy were found in the day treatment program, along with significantly greater improvement in the other factors measured.

Intensive weekly chemotherapy for advanced gastric cancer using fluorouracil, cisplatin, epi-doxorubicin, 6S-leucovorin, glutathione, and filgrastim: a report from the Italian Group for the Study of Digestive Tract Cancer

PURPOSE

A multiinstitutional trial was performed to confirm the clinical activity, in terms of response rate and toxicity (primary objectives) and duration of responses and survival (secondary objectives), of an intensive weekly regimen in advanced gastric cancer.

PATIENTS AND METHODS

Patients with measurable unresectable and/or metastatic gastric carcinoma received 1-day per week administration of cisplatin (CDDP) 40 mg/m2, fluorouracil (5FU) 500 mg/m2, epi-doxorubicin (epi-ADR) 35 mg/m2, 6S-stereoisomer of leucovorin 250 mg/m2, and glutathione 1.5 g/m2. On the other days, filgrastim was administered by subcutaneous injection at a dose of 5 mg/kg. One cycle of therapy consisted of eight 1-week treatments. Patients who showed a response or stable disease received a further 6 weeks of therapy.

RESULTS

Of 105 enrolled patients, 11 had locally advanced unresectable disease only; 33 had primary nonresected and metastatic disease; 48 had metastatic disease and primary tumor resected; 10 had locoregional recurrence and metastatic disease; and three had locoregional recurrence only. After one cycle, 18 complete responses (CRs) and 47 partial responses (PRs) were achieved, for an overall response rate of 62% (95% confidence interval [CI], 53% to 71%). Twenty patients had stable disease and 20 progressed on therapy. The median survival duration of all 105 patients was 11 months, with 1- and 2-year survival rates of 42% and 5%, respectively. World Health Organization (WHO) grade III to IV toxicity, in terms of anemia, neutropenia, thrombocytopenia, and mucositis, was experienced by 40 patients (38%). There were no treatment-related deaths.

CONCLUSION

These data support the results of the pilot study and confirmed the high activity of the regimen, with acceptable toxicity. This schedule deserves evaluation in the adjuvant setting.

Mitoxantrone, fluorouracil, and L-folinic acid in anthracycline-pretreated metastatic breast cancer patients

In this phase II trial we have evaluated the activity and toxicity of a combination regimen containing mitoxantrone, L-leucovorin, and fluorouracil in patients with advanced breast cancer pretreated with anthracyclines. Forty-six patients were included into the study; they received a total of 227 cycles of chemotherapy. Median age was 63 years (range 34-78), median performance status was 80 (range 60-100). Visceral metastases were present in 37 patients, 6 patients had bone involvement only, while 3 patients had soft tissue/lymph node disease. Median number of previous chemotherapy regimens for advanced disease was 2 (range 1-3). Ten patients had anthracycline primary resistance (progressive disease during treatment). Twenty-three patients received mitoxantrone 12 mg/sqm day 1; fluorouracil 370 mg/sqm and L-folinic acid 100 mg/sqm days 1-3 administered every three weeks. Another group of 23 patients were treated with the same regimen using a prolonged 5FU/L-FA schedule (5 days). Two complete responses and 6 partial responses were recorded with the 3-day schedule; 7 partial responses in the 5-day schedule (overall response rate 32.6%, 95% C.I. 19-46%). Two partial responses were observed in patients with anthracycline primary resistance. Median response duration was 9 months (range 3-16). Hematologic toxicity was mild: grade 3-4 leukopenia was recorded in 5 patients, grade 3-4 thrombocytopenia in 3 patients. Grade III-IV stomatitis and diarrhea was recorded in 4 and 5 patients respectively (all receiving the 5-day 5-FU/L-FA schedule). Cardiac toxicity was observed in two cases. This regimen proved active in advanced breast cancer following anthracycline-containing chemotherapy, and the 3-day schedule could be offered to such patients with acceptable toxicity.

An enzyme-linked immunosorbent assay (ELISA) that discriminates between the venoms of Brazilian Bothrops species and Crotalus durissus

Enzyme-linked immunosorbent assays (ELISAs) were developed to detect specific antigens from Bothrops sp. and Crotalus durissus snake venoms in Brazil. Cross-reactive immunoglobulins from hyperimmune horse anti-Bothrops and anti-Crotalus sera were removed by immunoaffinity chromatography. Specific IgGs for Bothrops sp. and C. durissus venom antigens were prepared and used to set up a sandwich-type ELISA. The specificity of the assay was demonstrated by its capacity to identify correctly the circulating antigens in mice experimentally inoculated with both venoms. Measurable absorbance signals were obtained with 5 ng of venom per assay. The ELISA was also used to identify circulating antigens in the sera of humans bitten by Bothrops sp. and C. durissus. These ELISAs could be valuable for clinicians and epidemiologists if they prove to have both the high sensitivity and specificity required for such tests.

Granisetron plus dexamethasone in moderately emetogenic chemotherapy: evaluation of activity during three consecutive courses of chemotherapy

In this study we evaluated the antiemetic activity of a combination of 3 mg granisetron in a short i.v. infusion followed by 12 mg dexamethasone i.v. in 64 patients with cancer receiving moderately emetogenic chemotherapy scheduled in a single day. No patient had previously undergone chemotherapy and three consecutive cycles were evaluated. Response to antiemetic treatment was graded as follows: complete response, no episodes of vomiting; major response, only one episode; minor response, two to four episodes; failure, more than four episodes. Nausea was graded as absent, mild, moderate or severe (patients bedridden). At the first cycle a complete protection from acute vomiting and nausea was achieved in 95% and 73% of patients respectively; the rate of complete response for delayed vomiting was 90%, while 45% of patients complained of delayed nausea. The antiemetic and antinausea efficacy remained substantially unchanged during the second and third cycles of chemotherapy. Constipation and headache were the most frequent adverse events. In conclusion this antiemetic regimen appears very effective in preventing nausea and vomiting in moderately emetogenic chemotherapy.

Carbamazepine use in children and adolescents with features of attention-deficit hyperactivity disorder: a meta-analysis

OBJECTIVE

In the United States approximately 750,000 children receive psychostimulants to treat attention-deficit hyperactivity disorder (ADHD); up to 25% may not respond. The purpose of this study was to evaluate the reports in the international literature concerning the efficacy of carbamazepine (CBZ) in children with ADHD features by means of meta-analysis.

METHOD

A review of the world literature located 29 reports that dealt with behavior problems, activity levels, and CBZ in children. Of these, only 10 reports provided sufficient or pertinent information for the meta-analysis.

RESULTS

In all seven open studies, therapeutic responses were significant (ranging from p = .05 to .0001, two-tailed t test). Meta-analysis using weighted variables revealed a significant positive correlation (r = .88; p < .02) between duration of treatment and positive outcome. In three double-blind placebo-controlled studies, treatment effects for CBZ's superiority over placebo ranged from p = .07 to .0001. A meta-analysis of these three studies revealed that CBZ was significantly (p = .018) more effective than placebo at controlling target symptoms.

CONCLUSIONS

Despite the general lack of attention that CBZ has received for treating ADHD, there is preliminary evidence that CBZ may be an effective alternate treatment in children with features of ADHD.

Causes of haloperidol discontinuation in patients with Tourette's disorder: management and alternatives

BACKGROUND

Neuroleptics are considered the mainstay of treatment in Tourette's disorder, and haloperidol is deemed the treatment of choice by many. Factors such as treatment efficacy and the side effects that appear in response to neuroleptic administration have been implicated in affecting medication compliance. However, a detailed evaluation of these factors has yet to be undertaken in Tourette's disorder.

METHOD

Of 51 consecutive referrals to a Tourette's disorder clinic, 48 met DSM-III-R criteria for Tourette's disorder. Of these 48, 28 had previously received neuroleptics. In this set of 28 patients, 24 (16 male, 8 female) had initially received treatment with haloperidol, and they made up the present sample; their ages ranged from 10.4 to 47.9 years (mean = 27.1), and age at onset ranged from 2 to 16 years. Each patient completed an evaluation consisting of a Tourette Syndrome Questionnaire and a clinical interview with the patient and involoved family members. Charts were also reviewed to gather information concerning side effects and other factors that led to haloperidol discontinuation and/or noncompliance.

RESULTS

Duration of treatment ranged from 3 days to 14 years (mean = 3.6 years). In this sample, 12.5% (3/24) of the subjects continued medication without interruption (mean +/- SD = 8.4 +/- 5.1 years of medication). Of the 21 patients who discontinued haloperidol, 66.7% (14/21) did so because they experienced intolerable side effects, 9.5% (2/21) because of the fear of experiencing certain side effects, and 14.3% (3/21) because of a combination of these factors. The principal side effects that led to discontinuation included dysphoric reactions, akathisia, nervousness, sedation, dystonic reactions, and cognitive dulling/feeling drugged.

CONCLUSION

Careful monitoring of side effects and efficacy is essential to continued compliance with haloperidol. In addition, psychoeducation about potential consequences of medication administration may help promote compliance in those patients who develop fears of possible adverse reactions.

Renal effect of gentamicin in diabetic rats

To evaluate the protective effect of diabetes mellitus (DM) on renal function of rats treated with gentamicin (GM), male Wistar-EPM rats (250-350 g) were treated with streptozotocin (SZ; 45 mg/kg) and starting 10 days after induction of diabetes, GM was given for ten consecutive days at a daily dose of 40 mg/kg. In the GM-treated group (G), a significant fall in inulin and sodium-p-amino-hippurate clearance was obtained (3.57 +/- 0.16 and 12.59 +/- 0.61 ml min-1 kg-1 vs 6.43 +/- 0.21 and 17.98 +/- 0.47 ml min-1 kg-1 in control rats (C), respectively) while in the animals previously injected with SZ (diabetic+gentamicin, DG group) these changes were not observed. The diabetic (D), G and DG groups showed a significant rise in urinary flow compared to C (0.165 +/- 0.009, 0.145 +/- 0.007 and 0.173 +/- 0.009 ml min-1 kg-1 vs 0.109 +/- 0.003 ml min-1 kg-1, respectively); however, only in G was the U/P inulin ratio significantly decreased when compared to C. The fractional excretion (FE) of sodium and potassium was significantly augmented in G when compared to C, D and DG. Thus, diabetes protected against gentamicin nephrotoxicity at both the glomerular and tubular level, although it did not promote a reduction in urinary flow.

Lithium in hospitalized aggressive children with conduct disorder: a double-blind and placebo-controlled study

OBJECTIVE

To assess critically the efficacy and safety of lithium and replicate earlier findings in a larger sample of aggressive children with conduct disorder and to assess the utility of the Profile of Mood States (POMS) in this population.

METHODS

Children hospitalized for treatment-refractory severe aggressiveness and explosiveness and with diagnosed conduct disorder were subjects in this double-blind, placebo-controlled clinical trial. After a 2-week placebo baseline period, children were randomly assigned to lithium or placebo treatment for 6 weeks of placebo. The main outcome measures were the Global Clinical Judgments (Consensus) Scale, Children's Psychiatric Rating Scale, Conners Teacher Questionnaire, Parent-Teacher Questionnaire, and the POMS.

RESULTS

Fifty children (mean age 9.4 years) completed this study. The mean optimal daily dose of lithium was 1,248 mg and the mean serum level was 1.12 mEq/L. Lithium was superior to placebo, although the effects on some measures were more modest than in a previous study.

CONCLUSIONS

Lithium appears to be an effective treatment for some severely aggressive children with conduct disorder. Although the POMS appeared to be reliable, it did not detect any response to lithium.

Environmental factors and related fluctuation of symptoms in children and adolescents with Tourette's disorder

The purpose of this paper is to assess how 29 different environmental factors affected Tourette symptomatology in 14 children and adolescents (6.6-14.5 years; mean 10.3) who had never received any medication for their disorder. Assessment was based on patients' responses to the Tourette Syndrome (TS) Questionnaire. Eleven different factors were associated with a decrease in symptoms and included doctor visits, talking to friends, and reading for pleasure. The 10 factors reported to have no impact on Tourette symptomatology included various foods, weather, and living away from home. Seventeen factors associated with an increase in Tourette symptoms included events causing anxiety, emotional trauma, and social gatherings.

[The coconut babaçu (Orbignya phalerata martins) as a probable risk of human infection by the agent of chromoblastomycosis in the State of Maranhão, Brazil]

During a survey of 30 patients with chromoblastomycosis followed at the Hospital dos Servidores do Estado do Maranhão, the authors observed in 2 (6.6%) patients with lesions on the buttock. This is an uncommon site for the initial lesions of chromoblastomycosis. There is often a history of microtraumatism during the farming job hence the more frequent development of lesions in the lower limbs. Both patients had 10 years disease, with the presence of nodules and vegetant warty lesions in coalescent plaques on the right buttock. Etiologic diagnosis made through histopatologic and culture exams, with Fonsecaea pedrosoi isolated. The epidemiological exposure of the patients, was suggested by the fact that both worked as babaçu coconut cutters a common activity in Maranhão State. The relation between this kind of professional activity and the development of infection merits for the investigation.

[Chromoblastomycosis associated with leprosy: report of 2 cases]

Thirty cases of chromoblastomycosis were diagnosed at Hospital dos Servidores do Estado do Maranhão, from November, 1988 to March, 1993. The authors report 2 (6.6%) cases, that presented an association with leprosy. The first patient developed both diseases together, showing palpable bilateral cubital nerves, perforanting ulcer of the right foot, infiltration and lesions in verrucoid plaques in left leg, with positive biopsy for dimorphic leprosy. The second case, a patient with history of lepromatous leprosy for 30 years without treatment, with vegetant lesions with a warty aspect in right elbow for 12 months, histopathologic and positive culture for chromoblastomycosis. The possible factors for development of this disease in these patients are discussed.

A new pictorial instrument for child and adolescent psychiatry: a pilot study

A pictorial instrument was developed to assess psychopathology in children aged 6 to 16 years. Symptom pictures (n = 137) representing DSM-III-R criteria were organized into seven diagnostic subscales. Clarity of the pictures was assessed in 31 normal children. Fifty-one psychiatric inpatient children completed the instrument using a 6-point visual analogue scale. Sensitivity to change was assessed in 15 children. The subscales' internal consistencies (Cronbach's alpha) ranged from 0.54 to 0.86. A canonical discriminant analysis among four diagnostic groups achieved a Wilks' lambda of 0.67 (p = 0.02). This instrument may be a valuable adjunct to psychiatric interviews in children.

Mitomycin C, 5Fluorouracil and Folinic Acid in Combination with Alpha 2b Interferon for Advanced Colorectal Cancer

Aims and Background

This study was conducted to investigate the activity and toxicity of 5fluorouracll + folinic acid + mitomycin C combined with alpha 2b Interferon in advanced colorectal cancer based upon recent studies suggesting a possible biochemical modulation of 5 fluorouracil by interferon.

Patients and methods

Between June 1990 and April 1991 25 previously untreated patients with advanced colorectal carcinoma were treated with mitomycin C 10 mg/m2 iv bolus on day 1, 5fluorouracil 375 mg/m2 on days 1 to 4 and folinic acid 200 mg/m2 on days 1 to 4 every 4 weeks, combined with alpha 2b interferon 3 million U day continuously.

Response

Of the 25 patients entered into the study, 20 were evaluable for response as 5 patients withdrew due to toxicity (grade 3-4 thrombocytopenia in 4 cases and fatigue in 1). No complete response was recorded, 6 patients had partial remission (30 %; 95 % confidence interval, 10 % to 50 %), 4 experienced no change and 10 showed progressive disease. The toxicity of this regimen was significant, particularly myelosuppression.

Conclusions

This combination showed a significant toxicity and low response rate compared with other 5 fluorouracil based regimens in advanced colorectal cancer.

Lithium and conduct disorder

Lithium administration has been effective in treating severe aggression in children and adolescents with Conduct Disorder. An overview of the pertinent literature is presented. Side effects associated with lithium administration are discussed. Guidelines for lithium administration are given, including dosage regulation, monitoring of serum lithium, as well as of side effects and laboratory measures. When prescribed judiciously, under careful monitoring, lithium can be an important part of the comprehensive treatment program.

Persistent Tardive Dyskinesia and Other Neuroleptic-Related Dyskinesias in Tourette's Disorder

ABSTRACT Two new cases are reported of persistent tardive dyskinesia associated with neuroleptic treatment of patients with Tourette's disorder. Previously, 44 cases were described in 8 published reports, including 36 children and adolescents, but diagnostic criteria were infrequently specified. In our review of these cases, using the criteria of Schooler and Kane but modified by Gualtieri's more conservative duration criteria of 16 weeks, only 2 of these cases were consistent with a diagnosis of persistent tardive dyskinesia. The 2 new cases are reported here. A 12-year-old, who was treated with haloperidol 4 mg daily since the age of 8, developed fine vermicular movements of the tongue of moderate severity. Despite discontinuation of the neuroleptic, symptoms of tardive dyskinesia still persisted at age 15 and were associated with difficulty in speech production. A 42-year-old, who was treated with haloperidol 1 mg three times daily for 7 years, developed jaw movements and lip smacking that persisted for more than 2 years. Abnormal involuntary movement scale (AIMS) ratings supported a diagnosis of tardive dyskinesia in both patients with Tourette's disorder. The identification of tardive dyskinesia in the setting of a preexisting movement disorder is discussed. Features that helped distinguish the movements of tardive dyskinesia and Tourette's disorder in these patients included the premonitory urges of Tourette's symptoms and a differential response of the symptoms to distracting voluntary motor tasks. Clinicians should be attentive and thorough in searching for symptoms of tardive dyskinesia following treatment with relatively low doses of haloperidol in patients with Tourette's disorder.

Plasma beta-endorphin levels, naltrexone, and haloperidol in autistic children

Plasma beta-endorphin levels were measured in 13 autistic children, aged 3.67 to 11.67 years at the end of treatment (naltrexone, haloperidol, pimozide, or placebo) and in 5 of the 13 children also at baseline. Baseline plasma beta-endorphin levels were lower than those reported in the literature. There was a strong correlation between plasma beta-endorphin levels and severity of sterotypies in all children. Naltrexone did not seem to have a specific effect on plasma beta-endorphin levels; short-term haloperidol treatment was associated with an increase, whereas long-term haloperidol treatment seemed to have a depressive effect on plasma beta-endorphin levels, which rose after withdrawal of haloperidol.

The pharmacologic treatment of conduct disorders and rage outbursts

Although this article focuses on psychopharmacology, pharmacotherapy is only part of a comprehensive treatment program. Treatment should be individualized to the patient's condition and level of intellectual functioning (e.g., conduct disorder, mental retardation). Clinicians should be acquainted with the Food and Drug Administration's regulations and the Physician's Desk Reference's guidelines. Psychoactive agents should be prescribed judiciously under careful clinical and laboratory monitoring, especially when given on a long-term basis. Knowledge of potential short- and long-term side effects is imperative to minimize impairment (cognitive, sedation) and to maximize achievement of adaptive behaviors. Aggressiveness is a low-frequency behavior and therefore difficult to assess. Aggressiveness with an explosive affective component and rage seems to be more responsive to pharmacotherapy than aggressiveness alone. Children who present with covert conduct disorder symptoms, such as stealing and lying, might not be as responsive to psychoactive agents as the conduct disorder with explosive characteristics. The neuroleptics are considered the standard drugs for the treatment of aggression but sedation and concern over tardive dyskinesia have led investigators to explore and study other classes of drugs. Lithium carbonate has been studied in short-term clinical trials and has been shown to be an effective alternative to the neuroleptics. Carbamazepine and propranolol seem to be promising agents but require further critical assessment in children and adolescents. Stimulants should be considered the first choice of treatment in coexisting conduct disorder and ADHD or in milder forms of aggression. In conclusion, there is a need for systematic investigation of the effectiveness and safety of psychoactive agents in children and adolescents with aggressiveness, explosiveness, and rage outbursts. There is some supportive evidence that some patients with these target symptoms are good responders to certain drugs. Future research should compare pharmacotherapy to psychosocial treatment and the combination of both.