Randomized clinical trial of adjuvant radiotherapy and 5-fluorouracil infusion in colorectal cancer (AXIS)

Background

Postoperative portal vein infusion (PVI) of 5-fluorouracil (5-FU) is a well tolerated and widely applicable treatment for colorectal cancer that might have an enormous public health impact, even if it produced survival benefits of just a few per cent. Very large trials are required to detect such differences, and the Adjuvant X-ray and 5-FU Infusion Study (AXIS) is the largest such trial yet reported.

Methods

Consenting patients with presumed colorectal cancer were randomized to surgery with or without 7 days of PVI (1 g 5-FU plus 5000 units heparin in 1 litre 5 per cent dextrose infused over each 24-h period). In addition, patients with rectal cancer could be randomized to radiotherapy or no radiotherapy to be given either before or after surgery.

Results

Between November 1989 and December 1997, 3583 patients were randomized with respect to PVI. The survival hazard ratios (95 per cent confidence interval (c.i.)) in all patients randomized and in the curatively resected subgroup (71·2 per cent of patients) were 1·00 (0·92 to 1·11) and 0·94 (0·83 to 1·06) respectively. Tests for heterogeneity suggested a greater treatment benefit for patients with colonic cancer than for patients with rectal cancer with respect to disease-free survival (hazard ratio 0·79 versus 1·03; P = 0·07), and there was a non-significant trend with respect to overall survival (hazard ratio 0·87 versus 1·03; P = 0·17). No survival benefit was seen in the 761 patients randomized with respect to radiotherapy; although not statistically significant, the impact on local recurrence rates was similar to that reported in the literature.

Conclusion

No overall benefit of PVI was established in AXIS when colonic and rectal cancers were considered together, but the evidence suggesting a differential treatment effect according to site of cancer in AXIS was strongly supported by a meta-analysis incorporating the previous trials. Combining the data gave hazard ratios of 0·82 and 1·00 for colonic and rectal tumours respectively (test for interaction, P = 0·024), equating to an absolute survival benefit for patients with colonic cancer of 5·8 (95 per cent c.i. 2·8 to 8·5) per cent, a level close to that seen for prolonged systemic therapy.

A placebo-controlled multi-centred evaluation of an anaesthetic gel (Oraqix) for periodontal therapy

AIMS

Six Canadian dental schools investigated the ability of a thermosetting gel containing 25 mg/g prilocaine and 25 mg/g lidocaine as active agents to produce analgesia in periodontal pockets utilizing a randomized, double-blind, placebo-controlled study.

MATERIALS AND METHODS

The study consisted of 130 patients, each of whom received the active or placebo gel in periodontal pockets in one quadrant of the mouth for 30 s prior to periodontal debridement (scaling and root planing). Pain was measured using both a 100-mm Visual Analogue Scale (VAS) and a Verbal Rating Scale (VRS).

RESULTS

The median VAS pain score for the patients treated with the anaesthetic gel was 5 mm (range 0-85 mm) as opposed to 13 mm (range 0-79 mm) in the placebo-treated patients (P=0.015). There was no significant difference in the percentage of patients reporting no or mild pain (78% and 76% for the anaesthetic gel and placebo, respectively). No significant differences were seen in patient demographics, or mandible versus maxilla.

CONCLUSIONS

The VAS pain scores showed that the anaesthetic gel 5% was statistically more effective than the placebo in reducing pain during periodontal debridement.

Chinese herbal nephropathy and urothelial malignancy

In Belgium, between 1991 and 1992, seven women under the age of 50 years were admitted to a regional renal dialysis unit with progressive renal failure. All seven had been following the same slimming regimen, prescribed by the same clinic. They had an identical pattern of interstitial fibrosis on renal biopsy. Subsequently it became evident that all were at risk of developing urothelial malignant change. Could there possibly be a link to the prescribed drugs, which included Chinese herbs?

The glycan structure of albumin Redhill, a glycosylated variant of human serum albumin

Although human serum albumin is synthesized without carbohydrate, glycosylated variants of the protein can be found. We have determined the structure of the glycan bound to the double-mutant albumin Redhill (-1 Arg, 320 Ala-->Thr). The oligosaccharide was released from the protein using anhydrous hydrazine, and its structure was investigated using neuraminidase and a reagent array analysis method, which is based on the use of specific exoglycosidases. The glycan was shown to be a disialylated biantennary complex type oligosaccharide N-linked to 318 Asn. However, a minor part (11 mol%) of the glycan was without sialic acid. The structure is principally the same as that of glycans bound to two other types of glycosylated albumin variants. Glycosylation can affect, for example, the fatty acid binding properties of albumin. Taking the present information into account, it is apparent that different effects on binding are caused not by different glycan structures but by different locations of attachment, with the possible addition of local conformational changes in the protein molecule.

Self-mutilative behavior in adolescents who attempt suicide by overdose

OBJECTIVE

To examine the cognitive/affective and behavioral symptoms of adolescent suicide attempters with self-mutilative behavior (SMB).

METHOD

Adolescents evaluated after a suicide attempt that occurred between 1996 and 2000 were divided into two groups: suicide attempters with a history of SMB (n = 52) and suicide attempters without SMB (n = 43). The groups were then compared on psychiatric diagnosis, suicide intent, depression, hopelessness, loneliness, anger, reckless behavior, substance use, and family functioning.

RESULTS

Carving on the skin and picking at a wound were the most commonly reported SMBs, occurring in about one third of the sample. The SMB group was significantly more likely to be diagnosed with oppositional defiant disorder, major depression, and dysthymia and had higher scores on measures of hopelessness, loneliness, anger, risk taking, reckless behavior, and alcohol use than did the non-SMB group. Loneliness increased the odds of SMB almost 6-fold.

CONCLUSIONS

Adolescent suicide attempts with SMB are associated with greater cognitive/affective and behavioral symptoms. Adolescent suicide attempters should be routinely screened for SMB.

An overview of biochemical markers in acute coronary syndromes

The cardiac troponins (cTns), cTnT and cTnI, are currently regarded as being the most useful diagnostic and prognostic biochemical markers of myocardial damage in patients with suspected acute coronary syndromes (ACSs). In spite of the evidence-based nature of this observation, the uptake of serum cTn measurement in routine clinical practice--in both the UK and elsewhere, is patchy, indeed, there still exists wide variability in the range of testing and sampling strategies involving usage of the many existing cardiac markers. For evaluating suspected acute myocardial infarction (AMI) and other ACSs, international opinion favours either serum cTnT or cTnI (measured 12-24 h after admission to the emergency room)--together with a short-time window marker such as serum creatine kinase (CK) (measured on admission and perhaps again within the 12-24 h window). Translation of this strategy into universal clinical practice would require not only formulation of, but also strict adherence to, agreed clinical decision-making protocols which, in turn, would need to be backed by adequate funding.

The role of perfectionism and depressive cognitions in understanding the hopelessness experienced by adolescent suicide attempters

This study examined the relation of two cognitive variables, depressive cognitions and perfectionism, to the hopelessness experienced by adolescent suicide attempters. Adolescent suicide attempters (N = 68) were administered three measures assessing cognitive characteristics commonly associated with adolescent suicidal behavior: the Child and Adolescent Perfectionism Scale (CAPS), the Depressive Experiences Questionnaire for Adolescents (DEQ-A), and the Hopelessness Scale for Children (HSC). Socially prescribed perfectionism on the CAPS and self-criticism on the DEQ-A were both highly correlated with HSC. Regression analyses indicated that perfectionism was significantly related to hopelessness, but this relationship was attenuated after the effects of depressive cognitions on hopelessness were controlled. Self-criticism was the cognitive variable most strongly associated with hopelessness suggesting that it is a more important focus for cognitive interventions in adolescent suicide attempters than perfectionism.

Personality characteristics of adolescent suicide attempters

OBJECTIVE

The purpose of this study was to explore both the personality characteristics and the symptoms of personality disorder of adolescent suicide attempters, as well as the relationship between personality variables and hopelessness in this population.

METHOD

Two sample populations were used in this study. First, 102 adolescent suicide attempters between 13 and 18 years of age completed the Millon Adolescent Personality Inventory (MAPI) and the Hopelessness Scale for Children (HSC). A second group of 35 adolescent suicide attempters were administered the HSC and the revised Diagnostic Interview for Borderlines (DIB).

RESULTS

No distinctive personality characteristics or symptoms of personality disorders were found. However, affective distress seemed to be the most prominent feature in the presentation of these adolescents. Additionally, high scores on the HSC were associated with elevated scores on the Personality Style scales of the MAPI and higher (more dysfunctional) scores on Affect Regulation on the DIB.

CONCLUSIONS

The results suggest that clinicians should focus most on the personality characteristic of sensitivity and on affect regulation when assessing adolescent suicide attempters. In addition, hopelessness is important to systematically assess because it appears to be related to a variety of dysfunctional personality characteristics that may affect follow-up outcome.

Patterns of children's coping with life stress: implications for clinicians

In a study of children's patterns of coping with daily stressors, boys and girls 9-17 years old were asked to complete a coping checklist in response to one of four types of stressors--school, parents/family, siblings, or peer/interpersonal. Patterns of coping-strategy use were found to be similar across the various stressors, with wishful thinking, problem-solving, and emotional regulation being among those most frequently used. Older adolescents, compared to younger children, tended to use a broader range of coping strategies, regardless of stressor. Implications for clinical practice are discussed.

Epitheliotropic lymphoma (mycosis fungoides) presenting as blepharoconjunctivitis in an Irish setter

An 11-year-old neutered female Irish setter was presented with a six-week history of blepharoconjunctivitis affecting the right eye. A conjunctival biopsy was taken and histopathological examination revealed a heavy cellular infiltrate involving the epithelial and subepithelial tissues. Immunohistochemical staining showed the intraepithelial cell population to uniformly have the phenotype CD3 (T-cell specific marker). A diagnosis of epitheliotropic lymphoma (mycosis fungoides) was made. The use of a synthetic retinoid and topical prednisolone in the management of the case is discussed.

Liquorice and its health implications

This article presents an overview of the health implications of liquorice. Liquorice has beneficial applications in the medicinal and the confectionery sectors; the substance, therefore, is both widely available and commercially attractive. However, the ingestion of liquorice, and/or its active metabolites, can sometimes produce an acquired form of apparent mineralocorticoid excess (AME) syndrome, expressed as sodium retention, potassium loss and suppression of the renin-angiotensin-aldosterone system, in addition to clinical consequences such as raised blood pressure and oedema. Moreover, these metabolic changes, the mechanisms underlying which are highlighted in the accompanying text, are associated with a number of additional clinical symptoms. Considering the easy availability of liquorice itself and also of other products containing its active metabolites, it is quite possible that the health burden of liquorice-induced morbidity could be substantial. Healthcare practitioners need to be fully aware of the risks in view of a large number of reports in the literature concerning its toxicity.

Metabolic changes after injection of quinolinic acid or 6-hydroxydopamine in the rat striatum: a time-course study using cytochrome oxidase and glycogene phosphorylase a histochemistry

Injection of excitotoxins, such as quinolinic acid (QA), into the striatum has been extensively used as an experimental model of Huntington's disease, while injection of 6-hydroxydopamine (6-OHDA) into the dopaminergic nigrostriatal pathway provides a well established model of Parkinson's disease. In the present study, we have examined the metabolic changes induced by an intrastriatal injection of QA or 6-OHDA using histochemical staining for the metabolic markers cytochrome oxidase (COx) and active glycogene phosphorylase (GPa). Intrastriatal injection of QA produced major changes in COx (decrease of staining) and GPa (increase of staining, except in the core of the lesion where the staining was virtually absent) histochemistry at the level of the striatum and of most of the other basal ganglia nuclei. Although attenuated over time, these changes persisted up to one year after the lesion. On the contrary, after the intrastriatal injection of 6-OHDA (which induces only a partial lesion of the nigrostriatal pathway), we did not observe any remarkable changes in COx or GPa staining. This study illustrates the discrepancies between the morphological changes and metabolic changes that are induced when using these experimental models of neurodegenerative disorders.

Lessons to be learned: a case study approach: ascites and elevated serum CA 125 due to a pancreatic carcinoma. A diagnostic dilemma

A 72 year-old lady with unrecognised cancer of the body of the pancreas presented with a 4-month history of progressive loss of weight and ascites. The results of laboratory investigations were either negative or within normal limits--apart from a raised serum CA 125 level; no tumour mass was detected on diagnostic imaging. She underwent exploratory laparotomy for a suspected ovarian tumour, but this proved not to be the correct diagnosis. A serum CA 19-9 level was subsequently requested and found to be significantly raised; a second contrast CT scan then showed the presence of ill-defined peri-aortic tissue. A further exploratory laparotomy was carried out in order to establish the true nature of the problem; a large pancreatic carcinoma was revealed.

Stat6 regulation of in vivo IL-4 responses

Although in vitro development of a Th2 response from naive CD4+ T cells is Stat6 dependent, mice immunized with a goat Ab to mouse IgD have been reported to produce a normal primary IL-4 response in Stat6-deficient mice. Experiments have now been performed with mice immunized with more conventional Ags or inoculated with nematode parasites to account for this apparent discrepancy. The ability of an immunogen to induce a primary in vivo IL-4 response in Stat6-deficient mice was found to vary directly with its ability to induce a strong type 2 cytokine-biased response in normal mice. Even immunogens, however, that induce strong primary IL-4 responses in Stat6-deficient mice induce poor memory IL-4 responses in these mice. Consistent with this, Stat6-deficient CD4+ T cells make relatively normal IL-4 responses when stimulated in vitro for 3 days with anti-CD3 and anti-CD28, but poor IL-4 responses if they are later restimulated with anti-CD3. Thus, Stat6 signaling enhances primary IL-4 responses that are made as part of a type 0 cytokine response (mixed type 1 and type 2) and is required for normal development or survival of Th2 memory cells.

Stat6 signaling promotes protective immunity against Trichinella spiralis through a mast cell- and T cell-dependent mechanism

Studies in mice infected with the gastrointestinal nematode parasite Nippostrongylus brasiliensis demonstrated that IL-4/IL-13 activation of Stat6 suppresses development of intestinal mastocytosis and does not contribute to IL-4/IL-13 production, but is still essential for parasite expulsion. Because expulsion of another gastrointestinal nematode, Trichinella spiralis, unlike N. brasiliensis expulsion, is mast cell dependent, these observations suggested that T. spiralis expulsion would be Stat6 independent. Instead, we find that Stat6 activation by IL-4/IL-13 is required in T. spiralis-infected mice for the mast cell responses that induce worm expulsion and for the cytokine responses that induce intestinal mastocytosis. Furthermore, although IL-4 induces N. brasiliensis expulsion in the absence of B cells, T cells, and mast cells, mast cells and T cells are required for IL-4 induction of T. spiralis expulsion. Thus, Stat6 signaling is required for host protection against N. brasiliensis and T. spiralis but contributes to expulsion of these two worms by different mechanisms. The induction of multiple effector mechanisms by Stat6 signaling provides a way for a cytokine response induced by most gastrointestinal nematode parasites to protect against most of these parasites, even though different effector mechanisms are required for protection against different nematodes.

Is continued weight gain inevitable in type 2 diabetes mellitus?

Prevention and treatment of obesity are major clinical problems encountered in the management of Type 2 diabetes mellitus (DM); indeed, up to 90% of such patients are regarded as being overweight. Except for a brief period following diagnosis, when presumably enthusiasm to adopt lifestyle change is at its greatest, weight gain is generally progressive unless severe hyperglycaemia or complications intervene. Even a relatively modest weight loss of 10% can have major benefits in terms not only of reducing the risk of developing DM in the first place, but also in improving metabolic control after the disorder has become established. Behavioural therapy (BT) in combination with hypocaloric diet achieves weight loss in the short-term, but is poorly sustained in the long-term. Exercise has metabolic benefits beyond its rather minimal effects on short-term weight loss in that it may also aid long-term weight control. The difficulties encountered in maintaining lifestyle change do, however, suggest the need for ongoing intervention--perhaps including a regular period on a stricter dietary regimen (800-1000 kcalday-1), possibly a very low calorie diet (VLCD)(< 800 kcalday-1) or even the use of orlistat, a pancreatic lipase inhibitor which reduces the absorption of dietary fat. Realistically, the aim should be for long-term weight stability.