EXPERIMENTAL IMMUNOLOGIC ADRENAL INJURY : A RESPONSE TO INJECTIONS OF AUTOLOGOUS AND HOMOLOGOUS ADRENAL ANTIGENS IN ADJUVANT

Twenty-three unilaterally adrenalectomized guinea pigs were injected with autologous and homologous adrenal tissue homogenates respectively, in Freund's adjuvant. Widespread adrenal lesions were found in 10 of 12 animals receiving auto-antigen and to a lesser extent in 6 of 11 animals injected with homologous pooled antigen. Widespread systemic lesions were present in both these and in control animals receiving Freund's adjuvant alone. These latter animals showed no adrenal involvement. The early changes within the adrenal consisted of perisinusoidal cellular proliferations in the deeper layers of the cortex. Focal granulomata developing at a later stage tended to become confluent and to displace cortical cells. Some loss of these cells was attributable to ischemic injury. The localization in the deep fasciculata and reticularis was thought to depend (a) on the varying antigenicity of adrenal cortical components, (b) the possible inhibitory effect of antiphlogistic adrenal cortical hormones on the development of lesions in the outer cortex, and (c) the presence of littoral cells in the deep cortex. These cells are thought to be involved in the mediation of the stimulus initiating differentiation of primitive mesenchymal cells in response to a circulating auto-antigen. The medullary lesions may be related to the presence of ectopic reticularis cells in this location. It was suggested that the cellular response in the target organ to injections of adrenal homogenates may denote a specific "organ-self" recognition mechanism involving an immune (i.e. defensive) reaction. It was postulated that this may be an accentuation of the physiological function of immunologically competent cells. Their proliferation, under normal circumstances, would prevent by means of production of "binding" globulins, the escape and dissemination of endogenous freed adrenal antigens into the circulation. Although the experimental stimulus arose from without the gland, by virtue of the presence of a circulating adjuvant-bound antigen, the adrenal reaction followed the same pattern as would obtain if the antigen was liberated within the suprarenal cortex.

AVAGAST: A randomized, double-blind, placebo-controlled, phase III study of first-line capecitabine and cisplatin plus bevacizumab or placebo in patients with advanced gastric cancer (AGC)

LBA4007

Background: The median survival for patients (pts) with AGC in most phase III studies is less than 1 year. The addition of bevacizumab (bev) to chemotherapy (chemo) is supported by a strong preclinical rationale and by phase II evaluation. AVAGAST is the first randomized study to compare the efficacy and safety of bev + chemo vs placebo + chemo.

Methods: Pts with inoperable, locally advanced or metastatic stomach/gastroesophageal junction adenocarcinoma with no prior therapy were randomized 1:1 to capecitabine (cape, or 5-FU) + cisplatin (cis) and either bev (7.5 mg/kg iv) or placebo q3w. Stratification variables: geographical region, fluoropyrimidine treatment, disease status. Cis was given for 6 cycles; bev/placebo + cape/5-FU were given until disease progression or unmanageable toxicity. Primary objective: compare overall survival (OS); secondary objectives: compare progression-free survival (PFS), overall response rate (ORR), and safety (as overseen by an independent DSMB).

Results: From Sep 2007 to Dec 2008, 774 pts were enrolled. Treatment arms were balanced. Approx 95% of pts were metastatic. Two-thirds of pts were male, 49% of pts were from Asia/Pacific, 32% from Europe and 19% from the Americas. Median OS was 10.1 months with chemo + placebo and 12.1 months with chemo + bev in the intent-to-treat population (HR 0.87; p=0.1002). Median OS according to geographical region was 6.8 vs. 11.5 months (HR 0.63) in the Americas, 8.6 vs. 11.1 months (HR 0.85) in Europe and 12.1 vs. 13.9 months in Asia-Pacific (HR 0.97). Secondary endpoints and AEs of special interest for Bev are summarized below ( Table ).

Conclusions: While the primary endpoint was not met (median OS HR 0.87; p=0.1002), there was a significant improvement in PFS and ORR and an acceptable safety profile for bev + chemo in patients with AGC.

[Table: see text]

[Table: see text]

[First trimester screening for Down syndrome: five years prospective experience]

First trimester screening for Down syndrome is yet to become the first intention strategy in France. This screening program at 11-14 weeks of gestation using maternal age, fetal nuchal translucency, maternal serum free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A has already been validated for a long time by many international studies. It seems to improve detection rate and decrease false positive rates. We report here five years prospective experience.

Breech presentation after 34 weeks-a meta-analysis of corrected perinatal mortality/morbidity according to the method of delivery

We conducted a meta-analysis of the mortality and morbidity of the breech presentation according to the method of delivery. Using the term 'breech', we used the Medline data base to search the English and French-language literature from 1978 to July 1995. Twenty-two studies (7239 deliveries) were found and analysed. The meta-analysis concerning perinatal mortality did not reveal a significant increased risk, when vaginal deliveries were compared with those delivered by a caesarean section (odds ratio: 1.90; confidence interval: 0.59-8.22) or when vaginal deliveries were compared with those done by planned caesarean section (odds ratio: 4.95; confidence interval: 0.44-80.06). The neonatal morbidity showed an increased risk with vaginal delivery. It is concluded that the practice of resorting to caesarean section for every breech presentation at term does not seem defensible.

Hypothyroïdie fruste et grossesse

Pregnancy has an important impact on thyroid homeostasis. The main hormonal criteria of the thyroid function are modified particularly in case of low iodine supply. Subclinical hypothyroidism is defined by a slight elevation of TSH (with a cut-off still under discussion near to 4 mU/l) although serum thyroxine and triiodothyronine levels are within the normal range. Maternal morbidity as well as prenatal morbidity and consequences on the neuropsychological development of the child are fairly well established in subclinical hypothyroidism. However, to date, there are no convincing trials assessing the efficacy levothyroxine in subclinical hypothyroidism all the more when TSH levels are between 3 and 4 mU/l. Therefore routine screening for and treatment of subclinical hypothyroidism during pregnancy are unwarranted.

Sustainable improvement in quality indicators in Ontario's surgical oncology program (SOP)

6638

Traditional approaches to quality improvement (QI) have in general utilized performance data against benchmarks, and pay for performance to drive quality. In 2002 the SOP of Ontario, Canada, population 12 million, combined such a QI strategy with philosophical, cultural change aimed on the development of a workforce capable of setting and implementing improvements through communities of practice (CoPs) and application of evidence. The objective was to facilitate implementation of a rigorously developed set of performance indicators, guidelines and standards of care. The most tangible examples of early success include the reduction in operative mortality of pancreatic cancer and the improvement in harvesting lymph nodes in colorectal cancer. A series of indicators, guidelines and standards for colorectal, prostate, thoracic, and hepatobiliary cancers, were developed in partnership with the program in evidence-based care utilizing a rigorous and transparent methodological framework. A value-based purchasing contract (volume-based funding dependent on submission of wait time data). Health service delivery research to identify gaps and evaluate success. CoPs approach to engaging surgeons in solving quality gaps, including opinion leaders, workshops, multidisciplinary teamwork and website tools. Significant improvements have been seen in colorectal and pancreatic caancer indicators. In pancreatic cancer they include a reduction in 30 day operative mortality, in Ontario from a mean of 10.2% in 1988–1996 to 4.5% in 2002–2004, a reduction in numbers of surgeons and hospitals performing pancreatic surgery, and an increase in volumes performed in high volume institutions. In colorectal cancer the compliance with the NCI guideline of 12 lymph nodes harvested increased from 27% in 1997–2000 to 69% in 2005. Oncologists have been engaged in solving system gaps through participation in guideline and standard development and implementation using the CoPs approach. Our experience supports the hypothesis that guidelines, standards and performance indicators, value- based purchasing, and CoPs social influence elements are essential components that can change practice and improve quality in a large jurisdiction cancer system.

No significant financial relationships to disclose.

Phase IV study of first-line bevacizumab plus irinotecan and infusional 5-FU/LV in patients with metastatic colorectal cancer: AVIRI

4068

Background: Bevacizumab (BEV) is a monoclonal antibody that inhibits tumour angiogenesis by targeting VEGF. In a phase III trial (AVF2107g), BEV significantly improved overall (OS) and progression-free survival (PFS) when combined with first-line irinotecan plus bolus 5-fluorouracil (5-FU)/leucovorin (LV) (IFL) in patients with metastatic colorectal cancer (mCRC). A multicentre, open-label trial is being conducted to evaluate the efficacy and safety of first-line BEV in combination with irinotecan and infusional 5-FU (FOLFIRI), a widely used first-line chemotherapy (CT) regimen. Methods: Patients had to have: mCRC; no surgery within 28 days; no prior CT for metastatic disease; ECOG PS 0/1, adequate organ function; no CNS metastases. CT consisted of a minimum of six cycles of irinotecan plus infusional 5-FU/LV according to the classical FOLFIRI regimen; variations like the simplified FOLFIRI and the weekly regimen were also allowed. BEV 5mg/kg was given on day 1 with CT and then every 2 weeks until disease progression. Tumour assessments were performed every 3 months during the first 12 months and every 4 months thereafter. Safety was assessed at the time of CT administration and every 4 weeks thereafter. The primary objective was PFS; secondary objectives included safety, overall response rate, time to response, duration of response and OS. Results: A total of 209 patients were enrolled at 31 centres worldwide, between April and November 2005. An interim analysis showed that the safety profile of BEV plus FOLFIRI appeared to be similar to that reported for Avastin plus IFL. The 44% overall response rate and 90% disease control rate are at least equivalent to that reported in comparable trials. Additionally, the 6 months PFS estimate of 82% was superior to that reported in AVF2107. Mature PFS data will be presented. Conclusions: AVIRI is the largest clinical trial, to date, to report data for BEV in combination with FOLFIRI in first-line patients with mCRC. The safety profile appears consistent with that observed in other BEV trials in mCRC, while the preliminary efficacy data suggest that this regimen is as active as the bolus regimen.

No significant financial relationships to disclose.

Fetal electrocardiogram ST-segment analysis and prediction of neonatal acidosis

OBJECTIVE

To determine the diagnostic value of fetal ST-segment analysis (STAN) in predicting neonatal acidosis.

METHODS

The STAN S21 was used to monitor singleton fetuses in labor with abnormal FHR. Physicians later reviewed tracings to identify any ST events dictating intervention. Outcome measures were umbilical artery pH< or =7.15 and pH< or =7.05 at birth. The sensitivity, specificity, PPV, and NPV of a significant ST event to predict both outcomes were calculated.

RESULTS

Analysis included 411 women. Sensitivity of a significant ST event for screening pH< or =7.15 (21.9%) was 38% (41/108), specificity 83% (252/303), PPV 45% (41/92) and NPV 79% (252/319), and for pH< or =7.05, it was (3.4%), 62.5% (10/16), 79% (313/395), 11% (10/92), and 98% (313/319), respectively.

CONCLUSION

In a population with abnormal FHR in labor, STAN sensitivity is moderate (almost 40%) for predicting pH< or =7.15 and better (almost 60%) for more severe acidosis (pH< or =7.05).

Multidisciplinary cancer conferences: a systematic review and development of practice standards

BACKGROUND

Multidisciplinary cancer conferences (MCCs) are a forum for health care providers to discuss diagnostic and treatment aspects of a cancer patient's care. In Ontario, we have found that very few hospitals have developed cancer conferences or forums for the prospective discussion of patient cancer care. In this paper, we describe the process of creating a province-wide standards document for MCCs.

METHODS

A systematic review and environmental scan were conducted to evaluate the literature regarding the impact of MCCs on physician practice patterns and patient outcomes, using the methodology of the Practice Guidelines Development Cycle. An Expert Panel was created to develop draft MCC standards. Ontario administrators and practitioners were surveyed to elicit feedback regarding the standards document. The findings were collated, and practice standards were developed.

RESULTS

Multidisciplinary care, predominantly in the form of multidisciplinary clinics, has been shown to improve patient outcomes. While only limited evidence suggested a benefit for MCCs, they have been documented as influential in changing patient management plans. MCCs were also found to be part of standard cancer care on an international level. Ontario practitioners surveyed generally supported MCC implementation.

DISCUSSION

We have described the process of creating an Ontario MCC standards document, including a literature review and an examination of the attitudes of Ontario practitioners and hospital administrators regarding the development and implementation of a MCC Standards document.

Shared decision making for in-patients with schizophrenia

OBJECTIVE

Patients' participation in treatment planning is being increasingly advocated in mental health. The model of "Shared Decision Making" (SDM) is proposed as a promising method of engaging patients in medical decisions and improving health-related outcomes. In the present study, the feasibility and effects of SDM for in-patients with schizophrenia should be evaluated.

METHOD

Randomized controlled trial comparing a SDM program with routine care (n = 107).

RESULTS

The intervention studied was feasible for most of the patients and did not take up more of the doctors' time. Patients in the intervention group had a better knowledge about their disease (P = 0.01) and a higher perceived involvement in medical decisions (P = 0.03). The intervention increased the uptake of psychoeducation (P = 0.003).

CONCLUSION

Sharing medical decisions with acutely ill in-patients with schizophrenia is in many cases possible and improves important treatment patterns. This might help in destigmatizing this group of patients and improving schizophrenia-related health outcomes.

Efficacy and safety of bevacizumab in combination with irinotecan and infusional 5-FU as first-line treatment for patients with metastatic colorectal cancer

3544

Background: Bevacizumab is a monoclonal antibody that, by inhibiting VEGF, inhibits tumour angiogenesis. It has been proven to improve overall (OS) and progression-free survival (PFS) when administered first-line in combination with the bolus 5-FU-based IFL regimen to patients with metastatic colorectal cancer [Hurwitz et al. NEJM 2004;350:2335–42]. We have conducted a multicentre, open-label trial to further evaluate the efficacy and safety of first-line bevacizumab in combination with regimens combining irinotecan with infusional 5-FU (FOLFIRI). Methods: Eligible patients had: metastatic colorectal cancer; no surgery within 28 days; no prior chemotherapy for metastatic disease; ECOG PS 0/1; adequate organ function; no CNS metastases. Chemotherapy consisted of 6 cycles of irinotecan plus infusional 5-FU and leucovorin, according to the classical FOLFIRI regimen; however, such variations as the simplified FOLFIRI or the weekly regimen were allowed. Bevacizumab 5mg/kg was given on day 1 of chemotherapy, every 2 weeks until disease progression. Safety assessments were made at the time of chemotherapy administration during the first 12 weeks and every 4 weeks thereafter. Tumour assessments were performed every 3 months for the first year and 4-monthly thereafter. The primary objective was PFS; secondary objectives were to evaluate the safety profile of this combination as well as to determine the overall response rate, time to response, duration of response and OS. Results: A total of 209 patients were enrolled at 31 centres in Australia, Canada, Italy, Spain and China between April 2005 and November 2005. 60% of patients were male and median age was 61.9 (range 31–82) years. All patients will be eligible for interim analysis, that will be performed after the last patient enrolled has been followed for a minimum of 12 weeks (6 cycles of chemotherapy), in February 2006. Data on safety and efficacy from this analysis will be presented. Conclusions: This is the largest clinical trial that will report efficacy and safety data for bevacizumab in combination with an irinotecan and infusional 5-FU regimen.

[Table: see text]

Charging mechanisms of trapped element-selectively excited nanoparticles exposed to soft x rays

Charging mechanisms of trapped, element-selectively excited free SiO2 nanoparticles by soft x rays are reported. The absolute charge state of the particles is measured and the electron emission probability is derived. Changes in electron emission processes as a function of photon energy and particle charge are obtained from the charging current. This allows us to distinguish contributions from primary photoelectrons, Auger electrons, and secondary electrons. Processes leading to no change in charge state after absorption of x-ray photons are identified. O 1s-excited SiO2 particles of low charge state indicate that the charging current follows the inner-shell absorption. In contrast, highly charged SiO2 nanoparticles are efficiently charged by resonant Auger processes, whereas direct photoemission and normal Auger processes do not contribute to changes in particle charge. These results are discussed in terms of an electrostatic model.

[Amniotic fluid embolism: two case reports]

We report two cases of amniotic fluid embolism, confirmed by histological examination. Both patients had an immediate post-partum haemorrhage that required an haemostatic hysterectomy. A typical symptomatology of amniotic fluid embolism revelated the first case. The patient survived without any sequelae. In the second case, amniotic fluid embolism occurred immediately after the delivery. The patient developed an acute respiratory distress with a shock syndrome. Despite haemostatic hysterectomy and resuscitative efforts, she died 6 days later.

[Immediate and long term complications of episiotomy]

OBJECTIVE

The objective of this review was to describe the complications of episiotomy.

MATERIAL AND METHODS

A systematic review on Medline Database set was performed with the key words: episiotomy, dyspareunia, fecal incontinence, urinary incontinence, maternal morbidity, pelvic floor defects and sexual function. Four hundred seventy two articles were selected.

RESULTS

When performed liberally, episiotomy appears to increase the risk of post partum bleeding. More restrictive use does not appear to increase the risk of serious perineal injury. In the event of instrumental extraction, use of episiotomy appears to be associated with more severe damage. Medial episiotomy does not appear to be associated with third or fourth degree tears. Following delivery, patients who had an episiotomy complain of perineal pain more than those with an intact perineum or first or second degree tears. Three months after delivery, there is no difference. While episiotomy appears to be a source of dyspareunia during the first weeks after delivery in comparison with spontaneous tears, this does not appear to be true later after delivery.

CONCLUSION

Episiotomy appears to be the cause of more perineal pain and dyspareunia during the early post partum weeks.

Hepatitis B vaccination in a school age population: a feasibility study

There remains no consensus on whether to adopt a universal hepatitis B vaccination strategy in the United Kingdom, where the endemicity of hepatitis B virus (HBV) is considered to be very low in the general population. To assess the feasibility and acceptance of a school-based adolescent vaccination approach, 11-13 years old pupils in local secondary schools in the London Borough of Camden and Islington were contacted and offered a three-dose hepatitis B vaccination course using a 0, 1, and 12 months schedule. The adult dose of hepatitis B vaccine (Engerix B GlaxoSmithKline) containing 20 mug recombinant hepatitis B surface antigen (HBsAg) in 1 ml suspension was administered. This dosage is normally intended for adults and children older than 15 years of age, but can be administered in 10-15 years old children when compliance may be low, since a higher proportion of those vaccinated develop protective antibody levels following administration of only two doses of vaccine. Overall, a total of 528 pupils were contacted, with 122 (23%) consenting to be vaccinated. Of these, 117 (96%) received the complete three-dose regimen according to the schedule (four did not receive vaccine: three were non-attendees and one was previously vaccinated; one withdrew following a flu-like adverse event). The results of this study show that it is feasible and practical to administer hepatitis B vaccination to adolescents in a school setting, and that it is possible to achieve high rates of uptake for the complete three-dose course among adolescents. However, in order to attain and sustain high coverage rates among pupils, this would require additional general health promotion, including health education and provision of information, targeting of teachers, pupils, and parents in order to increase participation in a school-based hepatitis B vaccination programme. A further requirement includes the availability of good local health support within schools so as to allow for an efficient vaccine delivery system to maximize vaccination in this setting.

Evaluierung von Arbeitsprojekten bei Drogenabhängigen im Rahmen einer Kosten-Nutzen-Analyse

The purpose of this study is to make a cost-benefit-analysis for integration projects helping drug addicts and substitutes to reintegrate into society. The study is intended to contribute to a better allocation of resources under the trade-off-situation that only a limited number of integration projects can be realized due to budget limitations. This pilot study represents an economic evaluation of health activities on integration based on the example of study projects offered by Mudra e. V. As a result the study showed that the evaluated projects are economically advantageous during the investigated research period. Furthermore, the study contains a non-monetary analysis of intangible effects which shows significant improvements in quality of life. Although the results are substantial, further research is mandatory focussing on the economic benefits of integration projects.

[Obstetrical management in the event of persistent or worsening postpartum hemorrhage despite initial measures]

Sulprostone infusion must be started without further delay if the first treatment (oxytocin, manual removal of the placenta, uterine revision, vaginal and cervical examinations) has been unsuccessful in the first 30 minutes after delivery. In France, the use of this treatment has been officially authorized in this indication (marketing approval, AMM). Intramuscular and intramyometrial injections being contraindicated, sulprostone is administered through continuous intravenous infusion. Dosage is 500 microg (one vial) per hour. Starting dose is 1.7 microg/min (10 ml/h), and can be increased if necessary in steps of 1.7 microg/min (but not exceeding 8.3 microg./min). The success rate of this treatment is linked to the rapidity of its commencement (within 30 min of the diagnosis of postpartum hemorrhage). In case of contraindications, since postpartum hemorrhage is life-threatening, the benefit-risk ratio needs to be estimated. A strict monitoring of cardiovascular parameters is compulsory before and after its administration. There is no time limit after which this treatment can be considered as ineffective: it depends on the amount of blood lost, the patient's clinical state, and on means that have already been used to stop the bleeding. However, if after 30 min of sulprostone infusion, there is no improvement or if the situation is worse, other therapeutic strategies must be considered (e.g., embolization, surgery). The use of intra-rectal misoprostol is still under assessment. To date, we have been unable to find studies that justify this treatment. Intra-uterine balloon, tube, or mesh packing has been studied in a few small series, where it was successful. Use of these strategies must not delay the treatment by sulprostone.

[Initial management of primary postpartum hemorrhage]

Accurate management of primary postpartum hemorrhage requires perfect knowledge of a recent protocol accessible at all times. Staff members and equipment need to be adjusted to the emergency situation. The first step is to establish a rapid diagnosis. This could be done with collecting bags, placed immediately after the birth. Once the diagnosis has been established, it has to be communicated to the whole team including obstetricians, midwives and anesthetists. A search for the cause of the hemorrhage is premordial. Abdominal uterine palpation confirms the diagnosis of uterine atony, the most frequent cause of postpartum hemorrhage. Two management schemes are possible depending on whether or not there is retention of the placenta. When the placenta is retained, manual removal has to be performed to empty the uterine cavity and to rule out uterine rupture. After placental delivery, manual control of the uterine cavity is always required. Uterine massage has to be performed after the intrauterine manoeuvres and must not be stopped too quickly. Rapidly other origins can be excluded: episiotomy or low genital tract lacerations requiring rapid repair, coagulation disorders requiring specialised care, or hematomas. During the same time, uterotonic drugs have to be used. Oxytocin (intravenous injection of 5 to 10 IU) is generally employed. Prostaglandins cannot be proposed as publications reporting their efficiency are not validated. Meanwhile, the anesthetists will have begun the first measures of resuscitation.

Anthracycline and trastuzumab in breast cancer treatment

This study was designed to evaluate the cardiac safety of the combined treatment of HER2-positive metastatic breast cancer patients with trastuzumab (Herceptin) plus epirubicin and cyclophosphamide (EC) in comparison with EC alone in HER2-negative metastatic breast cancer patients. Patients included those with metastatic breast cancer without any prior anti-HER2 treatment, anthracycline therapy, or any other chemotherapy for metastatic disease. This was a nonrandomized, prospective, dose-escalating, multicenter, open-label, phase I study in Germany. A control group of 23 patients received EC 90/600 mg/m2 3-weekly for six cycles (EC90 alone). A total of 26 HER2-positive patients were treated with trastuzumab, or H (2 mg/kg weekly after an initial loading dose of 4 mg/kg), and EC 60/600 mg/m2 3-weekly for six cycles (EC60+H); another 25 HER2-positive patients received H and EC 90/600 mg/m2 3-weekly for six cycles. Asymptomatic reductions in left ventricular ejection fraction (LVEF) of more than 10% points were detected in 12 patients (48%) treated with EC60+H and in 14 patients (56%) treated with EC90+H vs 6 patients (26%) in the EC90 alone cohort. LVEF decreases to <50% occurred in one patient in the EC60+H cohort and in two patients in the EC90+H cohort during the H monotherapy. No cardiac event occurred in the cohort with EC90 alone. The overall response rates for EC60+H and EC90+H were >60%, vs 26% for EC90 alone. The interim results of this study approve the cardiac safety of the combination of H with EC, with low risk of cardiac toxicity. The combination regimen revealed promising efficacy.

Cardiac safety of trastuzumab in combination with epirubicin and cyclophosphamide in women with metastatic breast cancer

This prospective, parallel-group, dose-escalation study evaluated the cardiac safety of trastuzumab (Herceptin) plus epirubicin/cyclophosphamide (EC) in women with human epidermal growth factor receptor-2 (HER2)-positive metastatic breast cancer (MBC) and determined an epirubicin dose for further evaluation. HER2-positive patients received standard-dose trastuzumab plus epirubicin (60 or 90 mg/m(2))/cyclophosphamide (600 mg/m(2)) 3-weekly (EC60+H, n=26; EC90+H, n=25), for four to six cycles; 23 HER2-negative patients received EC alone (90/600 mg/m(2)) 3-weekly for six cycles (EC90). All patients underwent thorough cardiac evaluation. Two EC90+H-treated patients experienced symptomatic congestive heart failure 4.5 and 6 months after the end of chemotherapy. One EC60+H-treated patient experienced an asymptomatic decrease in left ventricular ejection fraction (LVEF) to <50% 6 months after the end of chemotherapy. No such events occurred in control patients. Asymptomatic LVEF decreases of >10% points were detected in 12 (48%), 14 (56%) and 5 (24%) patients treated with EC60+H, EC90+H, and EC90. Objective response rates with EC60+H and EC90+H were >60%, and 26% for EC90 alone. These results indicate that trastuzumab may be combined with EC with manageable cardiotoxicity and promising efficacy.

Probing the molecular environment using spin-resolved photoelectron spectroscopy

Angle- and spin-resolved photoelectron spectroscopy with linearly and circularly polarized synchrotron radiation were used to study the electronic structure of model triatomic molecules, hydrogen sulfide, and carbonyl sulfide. The spin-polarization measurements of the molecular field split components of the S 2p photolines revealed a strong effect of the different molecular environments. The validity of simple atomic models to explain the results is discussed.

Utilisation en routine de l’analyse du segment ST de l’électrocardiogramme fœtal pour la surveillance du travail. Une année d’expérience (résultats préliminaires)

OBJECTIVES

Two randomized trials found that monitoring labor by analyzing the fetal electrocardiogram (STAN) appears to offer better sensitivity and specificity in screening for metabolic acidosis than cardiotocography (CTG) does. We report here the results of a descriptive study of 173 cases between 1 June 2001 and 31 May 2002, the objectives of which were twofold: to determine the number of possible false negatives (defined by neonatal metabolic acidosis with a pH less than 7.05 and base deficit (BD) greater than 12 mmol/l, in the absence of a STAN decisions event more than 30 min before birth), and to assess whether STAN indicated the need for operative intervention too late in cases of fetal distress.

PATIENTS AND METHODS

Our study was conducted on an at-risk population with CTG changes. STAN was used with a scalp electrode to monitor labor according to a protocol based upon the FIGO CTG classification and the clinical instructions used in the Swedish trial. Accordingly, we compared two groups: in group 1, a STAN decision event required a rapid conclusion to labor, while in group 2, the absence of any STAN decision event meant that labor continued, despite the changes in the tracing.

RESULTS

We found seven cases with a neonatal pH less than 7.05, but only one may involve a false negative by this method. The mean arterial pH and the number of fetuses born with an arterial pH less than 7.10 did not differ significantly between the two groups, nor were there any significant differences in the mean BD at birth, or the number of children with a BD greater than 12 mmol/l.

CONCLUSION

The results appear to indicate that use of STAN with the usual CTG enables an appropriate response to cases of fetal distress, but it remains difficult to determine the real benefits that can be expected from this method in France. Longer assessment in our population is required before we can assess its actual advantages.

[Pyelectasy]

Ultrasonography is undoubtedly an effective tool for identifying fetal urinary tract anomalies. Fetal pyelic dilatations are common and of controversial pathological significance. A 5 mm threshold for a pelvic anteroposterior diameter can be used to detect dilatation during the second trimester of pregnancy, if, and only if, all suspected dilatations are verified during the third trimester. Only the dilatations larger than 10 mm after 28 weeks merit further postnatal exploration. Urological postnatal exploration should be done if the abnormalities persist at the postnatal sonographic control. This control, if normal, should be repeated at least once at the age of one month. Further investigations are necessary to evaluate the incidence and significance of VUR, since it has been reported associated in certain cases with isolated pyelic dilatation. However, there are no grounds at present for justifying routine retrograde cystography in case of an isolated fetal pyelic dilatation. A karyotype study is not indicated in the presence of an isolated pyelic dilatation.

Changes in hypervariable region 1 of the envelope 2 glycoprotein of hepatitis C virus in children and adults with humoral immune defects

The N-terminal end of the hepatitis C virus (HCV) envelope glycoprotein E2 contains a stretch of 27 amino acids that exhibit increased variability. This hypervariable region 1 (HVR-1), as it is normally referred to, is thought to contain epitopes that come under humoral immune attack. In the present study, 10 patients (5 children and 5 adults) with humoral immune defects and chronic HCV infection were investigated, to see how HVR-1 sequences behave over time in these patients who are unable to produce antibodies. Amplicons of this region showed little or no variation at all over time, indicating that quasispecies variation in this region is driven by the host's humoral immune response.

Characterization of the active site of histidine ammonia-lyase from Pseudomonas putida

Elucidation of the 3D structure of histidine ammonia-lyase (HAL, EC 4.3.1.3) from Pseudomonas putida by X-ray crystallography revealed that the electrophilic prosthetic group at the active site is 3,5-dihydro-5-methylidene-4H-imidazol-4-one (MIO) [Schwede, T.F., Rétey, J., Schulz, G.E. (1999) Biochemistry, 38, 5355-5361]. To evaluate the importance of several amino-acid residues at the active site for substrate binding and catalysis, we mutated the following amino-acid codons in the HAL gene: R283, Y53, Y280, E414, Q277, F329, N195 and H83. Kinetic measurements with the overexpressed mutants showed that all mutations resulted in a decrease of catalytic activity. The mutants R283I, R283K and N195A were approximately 1640, 20 and 1000 times less active, respectively, compared to the single mutant C273A, into which all mutations were introduced. Mutants Y280F, F329A and Q277A exhibited approximately 55, 100 and 125 times lower activity, respectively. The greatest loss of activity shown was in the HAL mutants Y53F, E414Q, H83L and E414A, the last being more than 20 900-fold less active than the single mutant C273A, while H83L was 18 000-fold less active than mutant C273A. We propose that the carboxylate group of E414 plays an important role as a base in catalysis. To investigate a possible participation of active site amino acids in the formation of MIO, we used the chromophore formation upon treatment of HAL with l-cysteine and dioxygen at pH 10.5 as an indicator. All mutants, except F329A showed the formation of a 338-nm chromophore arising from a modified MIO group. The UV difference spectra of HAL mutant F329A with the MIO-free mutant S143A provide evidence for the presence of a MIO group in HAL mutant F329A also. For modelling of the substrate arrangement within the active site and protonation state of MIO, theoretical calculations were performed.

Negligible adjuvant effect for antibody responses and frequent adverse events associated with IL-12 treatment in humans vaccinated with pneumococcal polysaccharide

To assess whether co-administration of recombinant human IL-12 (rhIL-12) and 23-valent pneumococcal polysaccharide vaccine (PPV) enhances the antibody response to this T cell-independent antigen, healthy immunocompetent volunteers (n=34, 55-65 years old) were vaccinated intramusculary with PPV and concurrently-treated subcutaneously with either rhIL-12 (1 or 4 microg) or placebo. The increases of total anti-pneumococcal IgG antibodies were numerically higher among the rhIL-12 recipients compared with placebo recipients, but the difference was not significant. The rhIL-12 recipients had a high incidence of local and systemic side effects. Given the lack of convincing evidence that rhIL-12 enhances the antibody response to PPV, the frequency and severity of the side effects was unacceptable.

The hippurate ratio as an indicator of functional hepatic reserve for resection of hepatocellular carcinoma in cirrhotic patients

Predicting the ability of the cirrhotic liver to withstand resection remains a challenge for the surgeon. This study evaluates the use of the hippurate ratio, a novel assessment of glycine conjugation of para-aminobenzoic acid by the liver, as a preoperative indicator of functional hepatic reserve. Between 1998 and 2000, sixty-one cirrhotic patients were prospectively assessed for hepatic resection using the hippurate ratio, indocyanine green retention at 15 minutes (ICG R-15), and other standard measures of liver function. Twenty-six patients were excluded as candidates for resection on the basis of inadequate functional hepatic reserve. Patients excluded from resection had significantly higher ICG R-15 values (29% +/- 9% vs. 16% +/- 12%, P = 0.001), higher Child-Pugh scores (5.9 +/- 0.9 vs. 5.3 +/- 0.4, P = 0.01), and lower hippurate ratios (30% +/- 14% vs. 45% +/- 15%, P = 0.005). There was a significant correlation between the hippurate ratio and ICG R-15. Other indicators of liver function such as factor V, factor VII, albumin, bilirubin, prothrombin time, and transaminases were no different between patients who did and those who did not undergo resection. Of the 35 patients resected, there were seven (20%) who developed varying degrees of liver failure with three perioperative deaths (8.5%). Patients who had some degree of liver failure had significantly lower hippurate ratios than patients who had no liver failure (29% +/- 10% vs. 48% +/- 14%, P = 0.002). There was no difference in ICG R-15 values between patients who had liver failure and those who did not. The hippurate ratio offers information on hepatocellular reserve that is not provided by other measures of liver function and may allow better selection of cirrhotic patients for liver resection.

[Multiple gastrointestinal tract duplication : a neonatal case report]

We report the case of newborn with multiple GI tract duplication cysts. Prenatal diagnosis was that of duodenal stenosis. A complete screening for polymalformative syndrome is required in the neonatal period and the authors insist on the importance of US and color Doppler US imaging.

Inverse detection and heteronuclear editing in 1H-15N correlation and 1H-1H double-quantum NMR spectroscopy in the solid state under fast MAS

Signal enhancement in heteronuclear correlation spectra as well as signal selection in 1H experiments can be achieved through inverse, i.e., 1H, detection in the solid state under fast MAS conditions. Using recoupled polarization transfer (REPT), a heteronuclear 1H-15N single-quantum correlation (HSQC) experiment is presented whose symmetrical design allows the frequency dimensions to be easily interchanged. By observing the 15N dimension indirectly and detecting on 1H, the sensitivity is experimentally found to be increased by factors between 5 and 10 relative to conventional 15N detection. In addition, the inverse 1H-15N REPT-HSQC scheme can be readily used as a filter for the 1H signal. As an example, we present the combination of such a heteronuclear filter with a subsequent 1H-1H DQ experiment, yielding two-dimensional 15N-edited 1H-1H DQ MAS spectra. In this way, specific selection or suppression of 1H resonances is possible in solid-state MAS experiments, by use of which the resolution can be improved and information can be unravelled in 1H spectra.