In situ hybridisation for the detection of Leishmania species in paraffin wax-embedded canine tissues using a digoxigenin-labelled oligonucleotide probe

The diagnosis of canine leishmaniosis (CanL) is currently predominantly achieved by cytological or histological identification of amastigotes in biopsy samples, demonstration of specific anti-Leishmania antibodies and PCR-based approaches. All these methods have the advantage of being sensitive and more or less specific; nevertheless, most of them also have disadvantages. A chromogenic in situ hybridisation (ISH) procedure with a digoxigenin-labelled probe, targeting a fragment of the 5.8S rRNA was developed for the detection of all species of Leishmania parasites in routinely paraffin wax-embedded canine tissues. This method was validated in comparison with traditional techniques (histology, PCR), on various tissues from three dogs with histological changes consistent with a florid leishmaniosis. Amastigote forms of Leishmania gave clear signals and were easily identified using ISH. Various tissues from 10 additional dogs with clinical suspicion or/and a positive serological test but without histological presence of amastigotes did not show any ISH signals. Potential cross-reactivity of the probe was ruled out by negative outcome of the ISH against selected protozoa (including the related Trypanosoma cruzi) and fungi. Thus, ISH proved to be a powerful tool for unambiguous detection of Leishmania parasites in paraffin wax-embedded tissues.

Newer agents for blood glucose control in type 2 diabetes: systematic review and economic evaluation

BACKGROUND

In May 2008, the National Institute for Health and Clinical Excellence (NICE) issued an updated guideline [clinical guideline (CG) 66] for the management of all aspects of type 2 diabetes. This report aims to provide information on new drug developments to support a 'new drugs update' to the 2008 guideline.

OBJECTIVE

To review the newer agents available for blood glucose control in type 2 diabetes from four classes: the glucagon-like peptide-1 (GLP-1) analogue exenatide; dipeptidyl peptidase-4 (DPP-4) inhibitors sitagliptin and vildagliptin; the long-acting insulin analogues, glargine and detemir; and to review concerns about the safety of the thiazolidinediones.

DATA SOURCES

The following databases were searched: MEDLINE (1990-April 2008), EMBASE (1990-April 2008), the Cochrane Library (all sections) Issue 2, 2008, and the Science Citation Index and ISI Proceedings (2000-April 2008). The websites of the American Diabetes Association, the European Association for the Study of Diabetes, the US Food and Drug Administration, the European Medicines Evaluation Agency and the Medicines and Healthcare Products Regulatory Agency were searched, as were manufacturers' websites.

REVIEW METHODS

Data extraction was carried out by one person, and checked by a second. Studies were assessed for quality using standard methods for reviews of trials. Meta-analyses were carried out using the Cochrane Review Manager (RevMan) software. Inclusion and exclusion criteria were based on current standard clinical practice in the UK, as outlined in NICE CG 66. The outcomes for the GLP-1 analogues, DPP-4 inhibitors and the long-acting insulin analogues were: glycaemic control, reflected by glycated haemoglobin (HbA1c) level, hypoglycaemic episodes, changes in weight, adverse events, quality of life and costs. Modelling of the cost-effectiveness of the various regimes used the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model.

RESULTS

Exenatide improved glycaemic control by around 1%, and had the added benefit of weight loss. The gliptins were effective in improving glycaemic control, reducing HbA1c level by about 0.8%. Glargine and detemir were equivalent to Neutral Protamine Hagedorn (NPH) (and to each other) in terms of glycaemic control but had modest advantages in terms of hypoglycaemia, especially nocturnal. Detemir, used only once daily, appeared to cause slightly less weight gain than glargine. The glitazones appeared to have similar effectiveness in controlling hyperglycaemia. Both can cause heart failure and fractures, but rosiglitazone appears to slightly increase the risk of cardiovascular events whereas pioglitazone reduces it. Eight trials examined the benefits of adding pioglitazone to an insulin regimen; in our meta-analysis, the mean reduction in HbA1c level was 0.54% [95% confidence interval (CI) -0.70 to -0.38] and hypoglycaemia was marginally more frequent in the pioglitazone arms [relative risk (RR) 1.27, 95% CI 0.99 to 1.63]. In most studies, those on pioglitazone gained more weight than those who were not. In terms of annual drug acquisition costs among the non-insulin regimes for a representative patient with a body mass index of around 30 kg/m2, the gliptins were the cheapest of the new drugs, with costs of between 386 pounds and 460 pounds. The glitazone costs were similar, with total annual costs for pioglitazone and for rosiglitazone of around 437 pounds and 482 pounds, respectively. Exenatide was more expensive, with an annual cost of around 830 pounds. Regimens containing insulin fell between the gliptins and exenatide in terms of their direct costs, with a NPH-based regimen having an annual cost of around 468 pounds for the representative patient, whereas the glargine and detemir regimens were more expensive, at around 634 pounds and 716 pounds, respectively. Comparisons of sitagliptin and rosiglitazone, and of vidagliptin and pioglitazone slowed clinical equivalence in terms of quality-adjusted life-years (QALYs), but the gliptins were marginally less costly. Exenatide, when compared with glargine, appeared to be cost-effective. Comparing glargine with NPH showed an additional anticipated cost of around 1800 pounds. Within the comparison of detemir and NPH, the overall treatment costs for detemir were slightly higher, at between 2700 pounds and 2600 pounds.

LIMITATIONS

The UKPDS Outcomes Model does not directly address aspects of the treatments under consideration, for example the direct utility effects from weight loss or weight gain, severe hypoglycaemic events and the fear of severe hypoglycaemic events. Also, small differences in QALYs among the drugs lead to fluctuations in incremental cost-effectiveness ratios.

CONCLUSIONS

Exenatide, the gliptins and detemir were all clinically effective. The long-acting insulin analogues glargine and detemir appeared to have only slight clinical advantages over NPH, but had much higher costs and did not appear to be cost-effective as first-line insulins for type 2 diabetes. Neither did exenatide appear to be cost-effective compared with NPH but, when used as third drug after failure of dual oral combination therapy, exenatide appeared cost-effective relative to glargine in this analysis. The gliptins are similar to the glitazones in glycaemic control and costs, and appeared to have fewer long-term side effects. Therefore, it appears, as supported by recent NICE guidelines, that NPH should be the preferred first-line insulin for the treatment of type 2 diabetes. More economic analysis is required to establish when it becomes cost-effective to switch from NPH to a long-acting analogue. Also, long-term follow-up studies of exenatide and the gliptins, and data on combined insulin and exenatide treatment, would be useful.

No effect in combining chondrogenic predifferentiation and mechanical cyclic compression on osteochondral constructs stimulated in a bioreactor

Traumatic and degenerative osteochondral lesions are a common problem in orthopaedic surgery. The concept of tissue engineering represents the possibility of a promising therapeutical approach. The purpose of this study has been to improve the characteristics of osteochondral grafts consisting of a human certified collagen I-bone hybrid matrix seeded with human bone marrow stromal cells and stimulated in a custom-made biomechanoreactor. This study was undertaken as a follow-up to our prior studies. Based on our established system, we added chondrogenic growth factors (IGF-1 and TGF-beta(2)) and evaluated their effect on chondrogenic differentiation. Constructs were stimulated for 14, 21 and 28 days respectively by different protocols, including cyclic mechanical stimulation, hormonal stimulation or a combination of both. More than 70% of the cells were viable throughout the entire experimental period. Histological analysis revealed a homogeneous distribution of cells in a cartilage-like matrix organization. Immunohistological collagen II staining was positive irrespective of stimulation manner and time. Levels of DNA and glycosaminoglycans, having been normalized to DNA, did not change. Analysis of the biomechanical stiffness after 14 days showed increased stiffness in the hormonally and mechanically stimulated group compared to the static group. Stimulation time did not have a significant influence. The media supplements to foster the quality of the tissue tested here did not show any progress in our system. We conclude that cyclic compression enhances matrix stiffness, but stimulation time should be kept short and growth factors should be left out in this system with regard to clinical applicability and financial concerns.

Macrophage-modulating cytokines predict adverse outcome in heart failure

Cytokines regulating the mobilisation, recruitment and survival of mononuclear cells may play an important role in progression of heart failure. Therefore, we investigated the role of granulocyte colony stimulating factor (G-CSF), monocyte chemoattractant protein 1 (MCP-1) and macrophage colony stimulating factor (M-CSF) in patients with advanced heart failure. G-CSF, MCP-1 and M-CSF were determined in plasma of 351 patients with advanced heart failure by specific ELISAs. During a median follow up period of 16 months (95% confidence interval [CI]: 15-17 months) 175 patients (50%) experienced the composite endpoint rehospitalisation and all-cause mortality. M-CSF tertiles were associated with a gradually increasing risk with hazard ratios (HR) of 2.2 (95% CI: 1.5-3.2; for trend, p<0.001) for the composite endpoint and 2.6 (95% CI: 1.5-4.6; for trend, p=0.002) for all-cause mortality comparing third and first tertile. These associations remained significant in a multivariable Cox regression model after adjustment for BNP and other known risk factors (p=0.043 and p=0.024). High MCP-1 concentrations were associated with an increased risk of all-cause mortality with an adjusted HR of 1.9 (third vs. first tertile, 95% CI: 1.1-3.3; for trend, p=0.034). In contrast, G-CSF tertiles were not significantly associated with the composite endpoint or all-cause mortality in multivariable Cox regression. In conclusion, the independent and concentration-dependent association of macrophage-modulating cytokines and in particular of M-CSF with adverse outcome in advanced HF patients suggests that these cytokines may play an important pathophysiological role in progression of cardiomyopathy.

Autologous Stem Cell Transplantation Versus Standard or Dose-Dense Chemotherapy in High Risk Breast Cancer: A Systematic Review

Background/Objectives: The role of high dose chemotherapy followed by autologous stem cell transplantation (ASCT) for women with breast cancer is still a controversial issue. To-date, several randomized controlled trials (RCTs) have been completed, and for some trials follow-up data of more than 5 years are available. The aim of the current project was to review the available evidence deriving from RCTs and to determine the benefits and risks of ASCT for women with high risk breast cancer (HRBC), i.e. at least 4 involved axillary lymph nodes.Methods: We performed a systematic search in bibliographic databases (MEDLINE, EMBASE, BIOSIS Previews, The Cochrane Library) for RCTs comparing ASCT with standard (CTx) or dose dense chemotherapy (DD-CTx) as well as different ASCT strategies. In addition to clinical outcomes such as overall (OS) or disease-free survival (DFS) and toxicity, health-related quality of life (HRQL) was also analyzed. For meta-analysis, the random effects model was used. Only trials published in full text were considered for evaluation.Results: 13 trials with 5251 patients were available for analysis. 10 trials compared single ASCT with CTx, 1 ASCT with DD-CTx, and 2 tandem ASCT with CTx or DD-CTx, respectively. Single ASCT significantly prolonged DFS or a similar outcome compared to CTx. At 5 years, the meta-analysis, including 9 out of 10 trials for this comparison, revealed an absolute difference in rates of DFS of -0.05 (95% CI [-0.08; -0.01]), p=0.007, in favor of ASCT. Grade 3-5 toxicity, however, was also increased in the single ASCT groups. Tandem ASCT was superior to DD-CTx for the outcomes OS and event-free survival (EFS): 5-years OS (ASCT/DD-CTx) = 73%/59%, p= 0.02 (log rank test); 5-years EFS (ASCT/DD-CTx) = 55%/37%, p= &lt;0.001 (log rank test). Since this superiority was only observed in 1 trial (WSG AM-01), this advantage of tandem ASCT might be strongly related to the therapy protocol applied. HRQL data could be extracted from 5 trials comparing single ASCT with CTx. Scores of some HRQL indicators were significantly lower in the transplantation arm during the first months after therapy, suggesting a harm of ASCT, but results were similar at ≥1 year. Subgroup analysis indicated a benefit of ASCT for younger patients. The exact age limit – 40 or 50 years – remains to be determined. Further subgroup analyses either suffered from the lack of interaction tests or were based on the results of single trials.Summary/Conclusions: The data presented provide a comprehensive systematic review for ASCT in HRBC, including the most recent results of RCTs published to May 2009. In summary, ASCT has at most a modest benefit for women with HBRC. Current evidence does not allow a reliable appraisal of the benefit of ASCT for subgroups of HRBC patients. Benefits and risks of ASCT should be weighted in the context of contemporary therapy protocols. Since ASCT in breast cancer was introduced into health care on a vague clinical data basis, further evaluation should only be performed within the framework of clinical trials.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2096.

Surgery for recurrent ovarian cancer: role of peritoneal carcinomatosis: exploratory analysis of the DESKTOP I Trial about risk factors, surgical implications, and prognostic value of peritoneal carcinomatosis

BACKGROUND

Almost all retrospective trials pointed out that a benefit of surgery for recurrent ovarian cancer may be limited to patients in whom a macroscopic complete resection could be achieved. Peritoneal carcinomatosis has been reported to be either a negative predictor for resectability or a negative prognostic factor, or both. The role of peritoneal carcinomatosis in a multicenter trial was investigated.

METHODS

Exploratory analysis of the DESKTOP I trial (multicenter trial of patients undergoing surgery for recurrent ovarian cancer, 2000 to 2003).

RESULTS

A total of 125 patients (50%) who underwent surgery for recurrent ovarian cancer had peritoneal carcinomatosis. Univariate analyses showed worse overall survival for patients with peritoneal carcinomatosis compared with patients without carcinomatosis (P < .0001). Patients with and without peritoneal carcinomatosis had a complete resection rate of 26% and 74%, respectively (P < .0001). This corresponded with the observation that patients with complete resection had a better prognosis than those with minimal residual disease of 1 to 5 mm, which commonly reflects peritoneal carcinomatosis (P = .0002). However, patients who underwent complete resection, despite peritoneal carcinomatosis, had a 2-year survival rate of 77%, which was similar to the 2-year survival rate of patients with completely debulked disease who did not have peritoneal carcinomatosis (81%) (P = .96). Analysis of prognostic factors did not show any independent effect of peritoneal carcinomatosis on survival in patients who underwent complete resection.

CONCLUSIONS

Peritoneal carcinomatosis was a negative predictor for complete resection but had no effect on prognosis if complete resection could be achieved. Improving surgical skills might be one step to increase the proportion of patients who might benefit from surgery for recurrent disease.

[Expiratory vocal cord dysfunction? Case report and review of the literature]

Wood and Milgrom defined vocal cord dysfunction (VCD) as paradoxical adduction of the vocal folds during inspiration or during inspiration and expiration. We describe the case of a patient with attacks of dyspnea with an isolated expiratory paradoxical adduction of the vocal folds. A review of the literature reveals many factors associated with VCD. Because of the similar risk factors and order of events concerning VCD, we believe that even expiratory laryngeal dysfunctions could be denoted as subtypes of VCD.

Comparison of techniques for decompressive lumbar laminectomy: the minimally invasive versus the "classic" open approach

OBJECT

Decompressive laminectomy offers an effective surgical treatment of lumbar spinal stenosis. The purpose of this study was to compare the elements of treatment commonly associated with successful outcomes in the assessment of laminectomies - operating room times, estimated blood loss, length of stay, and complications - of the minimally invasive and open approach laminectomies.

METHODS

We retrospectively reviewed the medical records and relevant imaging of 126 patients who underwent surgical decompression for lumbar stenosis. Thirty-eight patients underwent bilateral decompression via a unilateral minimally invasive technique, while 88 patients underwent bilateral decompression via a standard open technique. A chart review was performed to determine intraoperative blood loss, length of operative time, length of hospital stay, and number and nature of complications.

RESULTS

The minimally invasive lumbar laminectomy (MID) patients had shorter operating room times, less estimated blood loss, shorter length of stay, and fewer complications.

CONCLUSIONS

Bilateral decompression of lumbar spinal stenosis via a unilateral approach involves shorter operating times and less blood loss, less muscle dissection, fewer and less severe complications, and better mobility in the immediate postoperative period than open decompressive techniques. In addition, this technique is very similar to the commonly performed microendoscopic discectomy and is easily mastered over time.

Dipeptidyl peptidase-4 (DPP-4) inhibitors for type 2 diabetes mellitus

BACKGROUND

In type 2 diabetes mellitus there is a progressive loss of beta-cell function. One new approach yielding promising results is the use of the orally active dipeptidyl peptidase-4 (DPP-4) inhibitors like sitagliptin and vildagliptin.

OBJECTIVES

To assess the effects of dipeptidyl peptidase-4 (DPP-4) inhibitors for type 2 diabetes mellitus.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE and The Cochrane Library.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials in adult people with type 2 diabetes mellitus and had a trial duration of at least 12 weeks.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed risk of bias and extracted data. Pooling of studies was performed by means of fixed-effect meta-analysis.

MAIN RESULTS

Twenty-five studies of good quality were identified, 11 trials evaluated sitagliptin and 14 trials vildagliptin treatment. Altogether, 6743 patients were randomised in sitagliptin and 6121 patients in vildagliptin studies, respectively. Sitagliptin and vildagliptin studies ranged from 12 to 52 weeks duration. No data were published on mortality, diabetic complications, costs of treatment and health-related quality of life. Sitagliptin and vildagliptin therapy in comparison with placebo resulted in an HbA1c reduction of approximately 0.7% and 0.6%, respectively. Data on comparisons with active comparators were limited but indicated no improved metabolic control following DPP-4 intervention in contrast to other hypoglycaemic agents. Sitagliptin and vildagliptin therapy did not result in weight gain but weight loss was more pronounced following placebo interventions. No definite conclusions could be drawn from published data on sitagliptin and vildagliptin effects on measurements of beta-cell function. Overall, sitagliptin and vildagliptin were well tolerated, no severe hypoglycaemia was reported in patients taking sitagliptin or vildagliptin. All-cause infections increased significantly after sitagliptin treatment but did not reach statistical significance following vildagliptin therapy. All published randomised controlled trials of at least 12 weeks treatment with sitagliptin and vildagliptin only reported routine laboratory safety measurements

AUTHORS' CONCLUSIONS

DPP-4 inhibitors have some theoretical advantages over existing therapies with oral antidiabetic compounds but should currently be restricted to individual patients. Long-term data especially on cardiovascular outcomes and safety are urgently needed before widespread use of these new agents. More information on the benefit-risk ratio of DPP-4 inhibitor treatment is necessary especially analysing adverse effects on parameters of immune function. Also, long-term data are needed investigating patient-oriented parameters like health-related quality of life, diabetic complications and all-cause mortality.

[Hepatic angiomyolipoma--a rare liver tumor]

A 22-year-old woman was treated for a hepatic lesion with a high suspicion of a liver adenoma at another hospital. The patient presented with unspecific abdominal pain. Further physical examination was unremarkable. A biopsy of the liver lesion revealed hepatic adenoma. Because of the increasing tumour size over a one-year period the patient was referred to our department for surgical therapy. On MRI scan, the liver mass measured 10 x 9 x 9 cm in the right liver lobe with contact to the right hilum. Because of the histological signs of adenoma a right hepatic lobectomy was performed. Postoperative follow-up was uneventful. The pathological diagnosis of hepatic angiomyolipoma was obtained. Angiomyolipoma of the liver is a rare benign mesenchymal tumour often mimicking other hepatic lesions. Histological features are thick-walled blood vessels, mature fat and smooth muscle in various proportions. The biological behaviour of the tumour is benign, although distant metastases are occasionally possible. Due to the potential for malignant transformation, tumour resection should be performed.

Influence of the fluctuations of the alignment tensor on the analysis of the structure and dynamics of proteins using residual dipolar couplings

It has been suggested that the fluctuations of the alignment tensor can affect the results of procedures for characterizing the structure and the dynamics of proteins using residual dipolar couplings. We show here that the very significant fluctuations of the steric alignment tensor caused by the dynamics of proteins can be safely ignored when they do not correlate with those of the bond vectors. A detailed analysis of these correlations in the protein ubiquitin reveals that their effects are negligible for the analysis of backbone motions within secondary structure elements, but also that they may be significant in turns, loops and side chains, especially for bond vectors that have small residual dipolar couplings. Our results suggest that methods that explicitly consider the motions of the alignment tensor will be needed to study the large-scale structural fluctuations that take place on the millisecond timescale, which are often important for the biological function of proteins, from residual dipolar coupling measurements.

Rosiglitazone for type 2 diabetes mellitus

BACKGROUND

Diabetes has long been recognised as a strong, independent risk factor for cardiovascular disease, a problem which accounts for approximately 70% of all mortality in people with diabetes. Prospective studies show that compared to their non-diabetic counterparts, the relative risk of cardiovascular mortality for men with diabetes is two to three and for women with diabetes is three to four. The two biggest trials in type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP) study did not reveal a reduction of cardiovascular endpoints through improved metabolic control. Theoretical benefits of the peroxisome proliferator activated receptor gamma (PPAR-gamma) activator rosiglitazone on endothelial function and cardiovascular risk factors might result in fewer macrovascular disease events in people with type 2 diabetes mellitus.

OBJECTIVES

To assess the effects of rosiglitazone in the treatment of type 2 diabetes.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE and The Cochrane Library.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials in adult people with type 2 diabetes mellitus and had a trial duration of at least 24 weeks.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Pooling of studies by means of fixed-effects meta-analysis could be performed for adverse events only.

MAIN RESULTS

Eighteen trials which randomised 3888 people to rosiglitazone treatment were identified. Longest duration of therapy was four years with a median of 26 weeks. Published studies of at least 24 weeks rosiglitazone treatment in people with type 2 diabetes mellitus did not provide evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised (OR 2.27, 95% confidence interval (CI) 1.83 to 2.81). The single large RCT (ADOPT - A Diabetes Outcomes Progression Trial) indicated increased cardiovascular risk. New data on raised fracture rates in women reveal extensive action of rosiglitazone in various body tissues.

AUTHORS' CONCLUSIONS

New studies should focus on patient-oriented outcomes to clarify the benefit-risk ratio of rosiglitazone therapy. Safety data and adverse events of all investigations (published and unpublished) should be made available to the public.

Meta-analysis does not allow appraisal of complex interventions in diabetes and hypertension self-management: a methodological review

Common methodologies used in systematic reviews do not allow adequate appraisal of complex interventions. The aim of the present study was to describe and critically appraise current methods of systematic reviews on complex interventions, using diabetes and hypertension patient education as examples. PubMed, the Cumulative Index to Nursing and Allied Health (CINAHL), the Cochrane Library and Health Technology Assessment databases were searched. Systematic reviews focusing on diabetes or hypertension patient education were included. Authors were contacted. Two investigators independently evaluated the reviews. The available evidence of three patient education programmes of diabetes and hypertension self-management implemented in Germany was used as a reference. We included 14 reviews; 12 reviews mentioned that the included education programmes were multidimensional. Reviews on comparable topics identified different publications of the same programme. Identical programmes were classified differently within and between reviews. Education programmes were dissected to analyse effects of single components. Different components of identical programmes were used. Interdependencies between components were not explored. Six reviews performed meta-analysis across programmes with heterogeneous educational or organisational approaches. The complexity of efficacy measures was disregarded: e.g. HbA(1c) was used as an isolated outcome variable without considering treatment goals, effects on hypoglycaemia, body weight or quality of life. Our results indicate that methods of current systematic reviews are not fully equipped to appraise patient education and self-management programmes. Since these are complex and heterogeneous interventions, consideration of aggregated evidence is necessary.

Increased splanchnic arterial vascular resistance in oldest old patients

OBJECTIVES

The aim of this study was to evaluate possible age-related changes in mesenteric artery and portal venous blood flow dynamics in relation to systemic haemodynamics in order to delineate putative haemodynamic changes relevant for postprandial hypotension in the elderly. Studies were performed over a wide age-range and for the first time in over 85-year-old patients.

DESIGN

Superior mesenteric artery (SMA) parameters (diameter, peak systolic velocity, end diastolic velocity, pulsatility index, volume flow) and portal vein (PV) parameters (diameter, portal vein velocity, volume flow) were measured by duplex ultrasound (General Electrics, Vivid 3) in 98 fasting subjects aged from 21 to 96 years. Systemic vascular parameters such as blood pressure, heart rate and cardiac output (echocardiography) were also determined. Excluded were patients with severe heart failure, liver cirrhosis, sepsis and those with mesenteric artery stenosis.

RESULTS

Pulsatility index (PI) was positively correlated with age (r=0.33, p=0.015). In patients over 85 years, PI was significantly increased (p=0.002) as compared to younger controls. Cardiac output was negatively correlated with age (r=-0.247, p=0.005). The other haemodynamic parameters did not show age-dependent alterations.

CONCLUSION

The increase of PI in the SMA in patients over 85 years represents an increase of vascular resistance in the splanchnic area, because PI is sensitive to resistance changes of small arterial vessels. The pulsatility index in the splanchnic area seems to rise steeply in oldest old patients, probably as an attempt to compensate diminutions in cardiac output seen in this age group. These findings indicate that the splanchnic vascular bed is already used in the fasting state to guarantee systemic haemodynamics. Vasodilatation of this vascular bed as physiologically seen postprandially may therefore easily induce postprandial hypotension in the oldest old.

Intragastric balloon for obesity

BACKGROUND

Obesity is one of the major public health problems of modern society. Intragastric balloon (IGB) treatment for obesity has been developed as a temporary aid. Its primary objective is the treatment of obese people, who have had unsatisfactory results in their clinical treatment for obesity, despite of being cared for by a multidisciplinary team, and super obese patients with a higher surgical risk. However, the effects of different IGB procedures compared with conventional treatments and with each other are uncertain.

OBJECTIVES

To assess the effects of intragastric balloon in people with obesity.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE, LILACS, The Cochrane Library and other electronic databases. Furthermore, reference lists of relevant articles and hand searches of selected journals were performed. Experts in the field were contacted.

SELECTION CRITERIA

Randomised and quasi-randomised controlled trials fulfilling the inclusion criteria were used. Short term weight loss is common, so studies were included if they reported measurements after a minimum of four weeks follow-up.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed the quality of trials.

MAIN RESULTS

Nine randomised controlled trials involving 395 patients were included. Six out of nine studies had a follow-up of less than one year, the longest study duration was 24 months. Only a third of the analysed studies revealed a low risk of bias. No information was available on quality of life, all-cause mortality and morbidity. Compared with conventional management, IGB did not show convincing evidence of a greater weight loss. On the other hand, complications of intragastric balloon placement occurred, however few of a serious nature. The relative risks for minor complications like gastric ulcers and erosions were significantly raised.

AUTHORS' CONCLUSIONS

Evidence from this review is limited for decision making, since there was large heterogeneity in IGB trials, regarding both methodological and clinical aspects. However, a co-adjuvant factor described by some authors in the loss and maintenance of weight has been the motivation and the encouragement to changing eating habits following a well-organized diet and a program of behavioural modification. The IGB alone and the technique of positioning appear to be safe. Despite the evidence for little additional benefit of the intragastric balloon in the loss of weight, its cost should be considered against a program of eating and behavioural modification.

Effectiveness of a self-adhesive resin luting system on fracture resistance of teeth restored with dentin-bonded crowns

Laboratory studies have demonstrated satisfactory fracture resistance of all-ceramic crowns placed using a conventional resin-composite luting material and a dentine bonding system. This study investigated the fracture resistance of teeth restored with dentine-bonded ceramic crowns luted with a self-etching luting material. Standardized preparations were carried out on two groups of ten sound, unrestored, maxillary premolar teeth. Ceramic crowns were constructed, their internal surfaces etched and placed using two luting system combinations. Compressive fracture resistance was determined for each group using a Universal Testing Machine. Mean compressive fracture resistance of 890 (222) N and 760 (271) N were recorded for the RelyX Unicem Aplicap and Mirage groups, respectively. There was no significant difference in the mean compressive fracture resistance of the restored teeth in both groups (P<0.05). The failure modes were different for each cements with more severe (Mode V)failures associated with the Mirage group compared with the consistent Mode II failures associated with RelyX Unicem Aplicap. We conclude that the fracture resistance of dentine-bonded crowns luted with a self-adhesive resin-based luting material was no different from that of a conventional resin-based luting system. The fracture resistance of dentine-bonded ceramic crowns may be clinically satisfactory when a self-adhesive resin-based luting material is utilised.

Pioglitazone for type 2 diabetes mellitus

BACKGROUND

Diabetes has long been recognised as a strong, independent risk factor for cardiovascular disease, a problem which accounts for approximately 70% of all mortality in people with diabetes. Prospective studies show that compared to their non-diabetic counterparts, the relative risk of cardiovascular mortality for men with diabetes is two to three and for women with diabetes is three to four. The two biggest trials in type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS) and the University Group Diabetes Program (UGDP) study did not reveal a reduction of cardiovascular endpoints through improved metabolic control. Theoretical benefits of the newer peroxisome proliferator activated receptor gamma (PPAR-gamma) activators like pioglitazone on endothelial function and cardiovascular risk factors might result in fewer macrovascular disease events in people with type 2 diabetes mellitus.

OBJECTIVES

To assess the effects of pioglitazone in the treatment of type 2 diabetes.

SEARCH STRATEGY

Studies were obtained from computerised searches of MEDLINE, EMBASE and The Cochrane Library. The last search was conducted in August 2006.

SELECTION CRITERIA

Studies were included if they were randomised controlled trials in adult people with type 2 diabetes mellitus and had a trial duration of at least 24 weeks.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. Pooling of studies by means of random-effects meta-analysis could be performed for adverse events only.

MAIN RESULTS

Twenty-two trials which randomised approximately 6200 people to pioglitazone treatment were identified. Longest duration of therapy was 34.5 months. Published studies of at least 24 weeks pioglitazone treatment in people with type 2 diabetes mellitus did not provide convincing evidence that patient-oriented outcomes like mortality, morbidity, adverse effects, costs and health-related quality of life are positively influenced by this compound. Metabolic control measured by glycosylated haemoglobin A1c (HbA1c) as a surrogate endpoint did not demonstrate clinically relevant differences to other oral antidiabetic drugs. Occurrence of oedema was significantly raised. The results of the single trial with relevant clinical endpoints (Prospective Pioglitazone Clinical Trial In Macrovascular Events--PROactive study) have to be regarded as hypothesis-generating and need confirmation.

AUTHORS' CONCLUSIONS

Until new evidence becomes available, the benefit-risk ratio of pioglitazone remains unclear. Different therapeutic indications for pioglitazone of the two big U.S. and European drug agencies should be clarified to reduce uncertainties amongst patients and physicians.

Epirubicin/paclitaxel (EP) vs. capecitabine/paclitaxel (XP) in first-line metastatic breast cancer (MBC): A prospective, randomized multicentre phase III study of the AGO breast cancer study group

517

Background: Anthracyline-taxane combinations have the highest response rates in high risk MBC. Recently, anthracyclines and taxanes have become standards for adjuvant breast cancer chemotherapy. The addition of capecitabine to docetaxel improved overall survival in MBC. This regime was associated with a high rate of side effects (actually FN was not different from Taxotere mono - it was more the addition of cape AEs to Taxotere AEs). Earlier phase II studies with XP are able to show efficacy with better tolerability including less febrile neutropenia. Methods: Our aim was to show non-inferiority of XP to EP. The primary endpoint was progression-free survival (PFS). Secondary endpoints were toxicity and overall survival (OS).Patients (pts) were treated with 6x E 60 mg/m2 and P 175 mg/m2 d1 q21d, or with 6× X 2×1000 mg/m2 d1–14 q 21d and P 175 mg/m2 d1 q21d. Results: During a period of 2.5 y the planned 340 pts (170 in each arm) in 63 centres were recruited. The median number of cycles was 6 in both arms. The median PFS for EP was 11.8 months, and 12.3 for XP (p=ns). OS also was not different between the arms. The response rate (RECIST) was 41.0% (CR 6.6%, PR 34.4%) for EP and 41.5% (CR 8.5%, PR 33.1%) for XP. The main toxicity was myelosuppression (10% of cycles grade 3/4). Febrile neutropenia was seen in 5 cases in EP and in 1 case in XP. Skin toxicity grade 3 was observed in 5 of XP pts. Two patients stopped treatment for cardiological reasons in EP, and 4 patients for GI reasons in XP. Conclusions: This first analysis shows a comparable efficacy of the non-anthracycline regimen XP to the EP combination in first-line MBC. The toxicity is relatively low compared to other non-anthracycline containing combination therapies. XP is therefore an appropriate option for pts with anthracycline pretreated first line MBC.

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A practice-based evaluation of the handling of a new self-adhesive universal resin luting material

OBJECTIVE

Ease of handling of materials may be considered helpful to achieving good results. The handling properties of a new self-adhesive universal resin luting material were tested in clinical use.

METHOD AND MATERIAL

Thirteen practitioners were selected at random from the Product Research and Evaluation by Practitioners (PREP) Panel, a United Kingdom-based group of dental practitioners prepared to complete evaluations of new materials and techniques in the practice environment. Explanatory letters, questionnaires and packs of the luting material were sent to the evaluators. The practitioners were asked to use the material and return the questionnaire.

RESULTS

144 restorations were placed using the new self-adhesive resin luting material, which was rated higher by the evaluators for ease of use (4.7 on a visual analogue scale where 5 represented easy to use and 1 represented difficult to use) than both the pre-trial resin-based and 'conventional' luting materials (rated 3.7 and 4.4 respectively on the same scale). The presentation, instructions, convenience of dispensing and handling and viscosity also received high ratings.

CONCLUSION

The new material achieved ratings for ease of use superior to the pre-study resin-based and conventional luting materials in the dental practices of 13 UK dental practitioners.

Diagnostik und Therapie maligner Ovarialtumoren 2005: Die Empfehlungen der Kommission Ovar der AGO

Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

Nutritional support after open liver resection: a systematic review

BACKGROUND

Perioperative nutrition in patients with limited liver function after partial hepatic resection is still controversial. In particular, the significance of perioperative total enteral nutrition remains unresolved. The aim of this review is to investigate the impact of early postoperative total enteral nutrition on convalescence after partial liver resection.

MATERIALS AND METHODS

In an internet-based Medline-Search (time course: 1960-08/2005) a total of five prospective, randomized controlled trials were found comparing the impact of enteral and parenteral nutrition after liver resection. After study validity had been established, a systematic review was undertaken (odds ratio, 95% confidence interval, p < 0.05 level of significance; Review Manager 4.2, The Cochrane Collaboration). Primary endpoints were complication rate (infection, organ malfunction) and mortality. Standardized immune parameters were also surveyed.

RESULTS

Statistical analysis showed that enteral nutrition resulted in a significantly lower rate (p = 0.04) of wound infection and catheter-related complications than parenteral nutrition did. No statistically significant differences in mortality due to enteral or parenteral nutrition could be found. Patients receiving enteral nutrition showed better postoperative immune competence.

CONCLUSION

Early enteral nutrition after liver resection is a safe procedure. Compared to parenteral nutrition it is associated with a decreased incidence of postoperative complications. Facing the inhomogeneity of these trials, especially in nutrition protocols and end points, this first systematic review stresses the need for an update of the importance of early enteral nutrition after liver resection within randomized controlled multicenter trials.

Pegylated liposomal doxorubicin and carboplatin in advanced gynecologic tumors: a prospective phase I/II study of the Arbeitsgemeinschaft Gynaekologische Onkologie Studiengruppe Ovarialkarzinom (AGO-OVAR)

BACKGROUND

Single-agent platinum and single-agent pegylated liposomal doxorubicin (PLD) are both effective in the treatment of gynecologic malignancies. Based on evidence that combination platinum-containing regimens offer superior efficacy versus single-agent regimens, we conducted this study to determine the maximum tolerated dose (MTD) of PLD in combination with carboplatin.

PATIENTS AND METHODS

In this phase I/II dose-finding study, six courses of PLD (20, 30, 40 or 50 mg/m2) and carboplatin (AUC 6) were administered every 28 days to women with advanced gynecologic malignancies. Three to six patients were treated at each dose level; an additional 12 patients were treated at the MTD.

RESULTS

PLD 40 mg/m2 was identified as the MTD when administered with carboplatin. Five of 18 patients experienced a dose-limiting toxicity at the MTD; two patients had grade 3/4 neutropenia, and one each had grade 3 emesis and grade 3 thrombocytopenia and thrombosis. No patient developed cardiotoxicity. In 11 patients evaluable for response, there were two complete responses, two partial responses and four patients with stable disease.

CONCLUSIONS

The MTD for PLD when administered in combination with carboplatin is 40 mg/m2. This regimen is well tolerated and offers promising activity in women with advanced gynecologic malignancies.