Results of the Two-County trial of mammography screening are not compatible with contemporaneous official Swedish breast cancer statistics

BACKGROUND

National mammography screening programmes are based on the results of randomised trials, but the quality of these trials has recently been questioned. The Swedish Two-County trial reported a 31% reduction in breast cancer mortality and was instrumental for the introduction of screening in many countries. In this trial, official Swedish health registries were used to identify breast cancers and breast cancer deaths in the study population.

METHODS

We used data from the same registries to estimate the numbers of breast cancer cases and breast cancer deaths among the included women.

RESULTS

Compared to official Swedish statistics we found that 192 breast cancer cases and 43 breast cancer deaths seem to be missing in the main publication of the Two-County trial; we found similar discrepancies in two updates of the trial. These large differences can hardly be explained by random fluctuations in the cancer occurrence.

CONCLUSION

The data reported for the Two-County trial are incomplete. Other data indicate that the mortality results in a recent report were flawed.

WITHDRAWN: Results of the Two-County trial of mammography screening are not compatible with contemporaneous official Swedish breast cancer statistics

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Hydrocortisone and the mitogen-activated protein kinase inhibitor U0126 acutely suppress reactive oxygen species generation from circulating granulocytes after gunshot injuries in the pig

OBJECTIVE

Several external stimuli, including trauma, increase the endogenous production of reactive oxygen species that spontaneously attack vital biological molecules. In addition to their direct toxic effects, several secondary messenger systems are induced. To forestall a subsequent organ dysfunction, a short-term posttraumatic down-regulation of granulocyte function has been advocated. Corticosteroids are potent and universal anti-inflammatory agents, but they have well-known side effects. Modulation of the mitogen-activated protein kinase cascade is an alternative approach. The purpose of this study was to investigate how the posttraumatic production of reactive oxygen species can be modulated by hydrocortisone or the extracellular signal-regulated kinase inhibitor U0126.

DESIGN

Prospective randomized trial.

SETTING

Field hospital and research laboratory.

SUBJECTS

Seventeen male pigs.

INTERVENTIONS

In general anesthesia, the pigs were exposed to a standardized insult: one gunshot hitting the right femur from a distance of 25 m, and one pistol shot to the left upper abdomen from close range. Following immediate first aid treatment, the animals were transported to a nearby field hospital. According to randomization, the animals received either hydrocortisone 250 mg intravenously (group 1, n = 9) or a similar amount of saline (group 2, n = 8). The injections were given 5 mins after the last shot. Blood samples were drawn before shooting, immediately before hydrocortisone was given, and 60 mins after shooting. Circulating neutrophils were isolated, and the production of reactive oxygen species was measured fluorometrically. Neutrophils from nine randomly chosen animals (five from group 1 and four from group 2) were treated in vitro with the extracellular signal-regulated kinase inhibitor U0126.

MEASUREMENTS AND MAIN RESULTS

The injuries as evaluated by the abbreviated injury scale did not differ between the animals. All survived the first 60 mins. While the in vivo production of reactive oxygen species tended to increase in the controls, a significant reduction was measured in the hydrocortisone group. Subsequent treatment with U0126 further reduced the synthesis of reactive oxygen species by about two thirds in both groups, independently of time.

CONCLUSIONS

Early injection of hydrocortisone after trauma inhibits the synthesis of reactive oxygen species from circulating neutrophils. Inhibition of the extracellular signal-regulated kinase branch of the mitogen-activated protein kinase signaling cascade is an alternative approach. The powerful in vitro capacity of selective extracellular signal-regulated kinase inhibitors to reduce the posttraumatic reactive oxygen species generation deserves further investigations, and compelling evidence of their in vivo usefulness is still lacking.

Interference with visual memory in rats following infusion of the functional NMDA receptor antagonist, HA-966, into temporal regions

Results from lesion studies show that selective damage to the temporal cortex or lateral entorhinal cortex impairs visual memory, whereas damage to the hippocampal region does not affect retention of a visual discrimination task. Major input pathways of the above structures use glutamate as neurotransmitter. The glutamate NMDA receptor appears to play an important role for cognitive functions. The objective of the present study was to examine whether microinjections of the functional NMDA receptor antagonist, 3-amino-1-hydroxy-2-pyrrolidinone ((+)-HA-966), might result in effects mimicking those seen in lesion studies. The results show that infusion of HA-966 into the temporal cortex or lateral entorhinal cortex 1.5-3 h after the learning criterion had been obtained led to an impeded visual memory when tested 13 days later, whereas HA-966 infused into the hippocampal region did not affect memory. A similar retention deficit with HA-966 infusions in the temporal cortex or lateral entorhinal cortex was seen when testing took place 23 days later, whereas a markedly weaker effect was observed when the retention period was reduced to 3 days. It is suggested that the hippocampal region is a temporary storing site for nonspatial memory engrams, and later posttraining memory consolidation involves the temporal and lateral entorhinal cortices. Furthermore, the degree of the effect of HA-966 is related to the length of the retention period.

Chronic subcutaneous octreotide decreases gastrointestinal blood loss in blue rubber-bleb nevus syndrome

BACKGROUND

A patient affected by blue rubber-bleb nevus syndrome had chronic gastrointestinal bleeding requiring weekly blood transfusions. Despite multiple surgical and endoscopic procedures to treat the venous malformations, the patient continued to bleed primarily from lesions in the small bowel. Therefore, this patient was treated with octreotide, a somatostatin analog known to decrease splanchnic blood flow and that is used for acute and chronic gastrointestinal bleeding.

METHODS

Octreotide therapy, 5.7 microg/kg subcutaneously twice daily, was initiated, and the patient was followed up clinically. Complete blood counts, blood glucose concentration, pancreatic enzyme concentration, liver function tests, and growth hormone concentration were monitored during treatments.

RESULTS

During the 4 weeks after initiation of octreotide therapy, hemoglobin concentration was maintained without the need for transfusions. Octreotide decreased the patient's monthly need for blood transfusion from 52 +/- 7 mL. kg-1. mo-1 of packed red blood cells to 23 +/- 7 mL. kg-1. mo-1. She had no detectable side effects or growth inhibition. Other medical interventions including -epsilonaminocaproic acid, nadolol, and total parenteral nutrition with bowel rest were not as effective as octreotide alone.

CONCLUSION

Octreotide decreased the patient's need for blood transfusions. Possible mechanisms include altering blood flow to the gastrointestinal tract and direct effects on the venous malformations.

Rectal prolapse in pediatrics

Rectal prolapse in pediatrics has its highest incidence in infancy and is uncommonly seen in industrialized countries. The prolapse may involve only the mucosa (mucosal prolapse) or all layers of the rectum (complete prolapse or procidentia). It is usually detected by the child's parents and is brought urgently to medical attention; however, it is usually spontaneously reduced by the time they reach the practitioner's office. Rectal prolapse should be viewed as a symptom of an underlying condition rather than a discrete disease entity. Potential causes are increased intraabdominal pressure, diarrheal and neoplastic diseases, malnutrition, and conditions predisposing to pelvic floor weakness. Its strong association with cystic fibrosis makes the sweat test mandatory for infants and children with recurrent rectal prolapse. Of particular importance are three entities related to rectal prolapse that may easily escape diagnosis by practitioner: occult rectal prolapse, solitary ulcer of the rectum syndrome, and inflammatory cloacogenic polyps. The treatment of rectal prolapse is mainly conservative and is directed at the underlying conditions. Surgical intervention may be required for recurrent rectal prolapse refractory to conservative measures. The simplest, less invasive, yet highly effective approach, appears to be perirectal injection with a sclerosing agent. While the majority of children experience spontaneous resolution of the prolapse, the prognosis is worse when presentation occurs after the age of 4 years.

Effective prophylactic therapy for cyclic vomiting syndrome in children using amitriptyline or cyproheptadine

OBJECTIVE

To evaluate our experience using the antimigraine prophylactic drugs, amitriptyline and cyproheptadine, for the prophylactic management of cyclic vomiting syndrome (CVS) in children.

METHODS AND PATIENTS

Twenty-seven patients (16 males) ranging in age from 2 to 16 years at diagnosis, fulfilling the diagnostic criteria for CVS and treated prophylactically with either amitriptyline (22) or/and cyproheptadine (6) were identified through retrospective chart review. Individual patient data were corroborated by the attending physician and/or interviews with patients and families. Minimum follow-up time before entry into the study group was 5 months. Patients were stratified according to three treatment outcomes: 1) complete response-no attacks, 2) partial response-50% or greater reduction in frequency of attacks, and 3) no response-less than 50% decrease in frequency of attacks.

RESULTS

Of the 22 patients treated with amitriptyline, 16 (73%) had a complete response while 4 (18%) had a partial response. Of the 6 patients treated with cyproheptadine, 4 (66%) had a complete response and 1 (17%) had a partial response. Thus, 91% of the amitriptyline group and 83% of the cyproheptadine group had at least a partial response to therapy. No patients experienced significant side effects to either medication.

CONCLUSION

The antimigraine prophylactic drugs, amitriptyline and cyproheptadine, represent effective prophylactic agents for the management of CVS in the vast majority of patients fulfilling the diagnostic criteria for this syndrome.

Serum sickness associated with 6-mercaptopurine in a patient with Crohn's disease

A 43-year-old man with a 19-year history of Crohn's disease experienced serum sickness with acute lobular panniculitis and vasculitis within 2 weeks of initiating 6-mercaptopurine therapy. He had no history of extraintestinal manifestations of Crohn's disease or drug allergy. Symptoms included disabling joint pain, proteinuria, fever, rash, and malaise. To our knowledge, this adverse drug reaction has not been described in association with 6-mercaptopurine.

Recognition and treatment of venous malformations of the rectum

Venous malformations of the rectum are uncommon lesions that present complex management problems (1-6). The vast majority of these lesions present with rectal bleeding in infancy or childhood. Many cases have been treated as colitis for years before the correct diagnosis was made. The correct diagnosis has generally been based on gross appearance, confirmed subsequently by plain radiographs and angiography. Heroic surgical intervention has been the only repeatedly reported "cure" in the literature. One patient has been reported who did well for 20 years with sclerosis of the hemorrhoidal vein at surgery followed by intermittent transrectal sclerotherapy (7,8). Another patient would appear to have had longterm success with radiation therapy (9-11). We report four new cases of venous malformations of the rectum and results to date of a new therapeutic option with transcutaneous ethanol sclerotherapy in two of these patients. A discussion of alternate methods of treatment is included.

Platelet alpha-2 adrenoreceptor activity pre-treatment and post-treatment in major depressive disorder with melancholia

Changes in alpha-2 adrenoreceptor density and affinity during antidepressant treatment were studied using 3H-yohimbine binding to human platelet membranes. Baseline measurements were conducted in 21 patients diagnosed as having major depressive disorder with melancholia, and an equal number of age and sex matched normal controls. No differences were observed in receptor density or binding between pre-treatment subject groups and normal matched controls. Subjects participated for 6 weeks in a trial of placebo, adinazolam, or amitriptyline. Alpha-2 adrenoreceptor binding was not significantly changed from baseline following antidepressant treatment.

Psychotropic medication and nonfatal cafe coronary

Obstructive asphyxia, also known as cafe coronary, has been linked to both medicated and nonmedicated psychiatric patients. An 18-month prospective audit of choking patients was conducted in a psychiatric hospital. Based upon all medications received in the 5 days preceding the event, mean daily chlorpromazine and atropine equivalent dosages were also calculated for age, sex, and diagnosis matched controls based upon all medications received during their entire hospital stay. Paired t-tests showed no significant differences between choking patients and their matched controls except that greater mean daily chlorpromazine equivalents were present in the severe choking subgroup. Computation of log odds of choking risk increases with interaction of increased mean doses of each drug type and age, and also with interaction of increased chlorpromazine equivalents and increased atropine equivalents. Patients receiving high dosages of drug(s) with antidopaminergic or anticholinergic activity are at greater risk of choking and should be monitored closely.

Regulation of gallbladder cholesterol concentration in the hamster. Role of hepatic cholesterol level

The goal of this investigation was to determine how alterations in hepatic cholesterol metabolism influence the cholesterol content of gallbladder bile in hamsters. Although the rate of hepatic cholesterol synthesis was varied over 600-fold, there was no direct relationship between the rate of cholesterol synthesis and the cholesterol content of gallbladder bile. However, expansion of the hepatic cholesterol pool by 42-fold resulted in an 11-fold increase in gallbladder bile cholesterol. Examination of four subfractions of the hepatic cholesterol pool revealed that the cholesterol content of gallbladder bile was most consistently correlated with the free cholesterol level in both hepatic tissue and hepatic microsomes from all experimental groups. In most groups of animals in which gallbladder bile cholesterol was increased, plasma lipoprotein cholesterol levels were also increased. It was concluded that in hamsters, under these experimental conditions, changes in the cholesterol content of gallbladder bile were directly related to alterations in cholesterol content of the liver and most closely related to alterations in the free cholesterol content of that tissue.

Primidone-induced catatonic schizophrenia

The authors report the case of a severely retarded, 19-year-old female (treated with primidone 250 mg tid since age 12) who was admitted with visual and auditory hallucinations. After four days of continuing hallucinations, she went into classic catatonic schizophrenia. Upon examination, her primidone serum level was found to be well above the normal therapeutic range. The primidone dosage was decreased, and symptoms subsided as serum levels returned to normal.

Evaluation of a limited drug formulary in an adult internal medicine clinic

The utility of a 30-drug, limited formulary in an adult internal medicine, ambulatory-care clinic was investigated. The formulary was developed using a mail survey of a random sample of members of the ASHP Ambulatory Care Pharmacy Practice Special Interest Group. The consensus formulary comprised the 30 most frequently recommended drugs; the utility of the formulary was then tested by chart review in a primary-care internal medicine clinic. Over a two-month period, the charts of alternating patients were reviewed daily; patient data collected included demographic information and prescribed drug therapy. A panel of two physicians and one pharmacist reviewed each patient's data and determined the appropriateness of drug treatment. If an agent was prescribed that was not on the consensus formulary, the panel determined whether an appropriate formulary agent could have been prescribed. Of the prescribed drug orders, 57.8% were for agents in the consensus formulary; by including patients who could have received formulary drugs appropriately, 73.7% of all prescription orders were or could have been for formulary drugs. Age, race, and sex of patients had no significant effect on utility of formulary agents. Had the 30 drugs most commonly prescribed in this clinic been in the formulary, 82.6% of all prescription orders would have been covered. This approach to establishing a new formulary and selecting drugs for inclusion is potentially useful.

Relative rates of sterol synthesis in the liver and various extrahepatic tissues of normal and cholesterol-fed rabbits. Relationship to plasma lipoprotein and tissue cholesterol levels

The relative rates of sterol synthesis in the liver and ten extrahepatic tissues of normal and cholesterol-fed rabbits were determined by measuring the rates of incorporation of [1-14C]octanoate into digitonin-precipitable sterols by tissue slices. In normal rabbits the rate of sterol synthesis in the liver was very low compared to that in several extrahepatic tissues, particularly the small intestine. The rate of synthesis in the small intestine showed marked regional variation, with the highest rate occurring in the section proximal to the entry of the common bile duct and the lowest rate in the mid-sections of the intestine. The regional differences in intestinal sterol synthesis correlated inversely with the cholesteryl ester content of the tissue. Rabbits fed the cholesterol diet developed marked hypercholesterolemia, with much of the additional cholesterol appearing in the VLDL and LDL fractions. The cholesteryl ester content of the liver, small intestine and various other extrahepatic tissues increased significantly. Coincident with these changes was a marked suppression of sterol synthesis, not only in the liver, but also in the small intestine, adrenal gland, kidney, lung, spleen and ovary. Thus, the rabbit, like the guinea pig, normally exhibits a very low rate of hepatic sterol synthesis compared to that found in other species such as the rat, squirrel monkey and baboon and, furthermore, manifests feedback inhibition of both hepatic and extrahepatic sterol synthesis when dietary cholesterol intake is increased. This general suppression of synthesis correlates with an accumulation of cholesteryl ester in the tissues which, in turn, presumably is related to the uptake of lipoprotein cholesterol from the hypercholesterolemic plasma that develops under such dietary conditions.

Sites of tissue binding and uptake in vivo of bacterial lipopolysaccharide-high density lipoprotein complexes: studies in the rat and squirrel monkey

When gram-negative bacterial lipopolysaccharides (LPS) are injected intravenously into the rabbit or rat, they bind to plasma lipoproteins, particularly high density lipoproteins (HDL). The present studies were performed to examine the mechanisms by which LPS-HDL complexes are removed from the circulation and taken up by various tissues. Our approach was to compare the sites of specific tissue binding and uptake of HDL and of LPS-HDL complexes in the rat and squirrel monkey. In the rat, binding of homologous 125I-HDL was demonstrated principally in the adrenal gland, ovary, liver, and spleen. [3H]LPS-HDL complexes (produced in vitro by incubating Salmonella typhimurium [3H]LPS with rat HDL and lipoprotein-free plasma) bound to the same tissues, but with apparently lower affinities. The specificity of binding of both 125I-HDL and [3H]LPS-HDL to these organs was demonstrated in two ways. First, tissue binding of both radiolabeled preparations was swamped out by raising the circulating levels of HDL-cholesterol from 32 to 140 mg/dl. Second, treatment of the animals with dexamethasone abolished specific binding of both HDL preparations to the adrenal gland while administration of adrenocorticotropin increased the specific adrenal binding of the two preparations. The steady-state plasma clearance rate for 125I-HDL equaled 774 +/- 29 microliters/h and was significantly lower (557 +/- 39 microliters/h) for the LPS-HDL complex, a finding that presumably reflected the lesser ability of the various tissues to bind the LPS-HDL complex. Binding studies were also done in the squirrel monkey, an animal that has the same level of circulating HDL cholesterol as the rat, but nearly three times more cholesterol in low density lipoproteins. Specific binding of homologous 125I-HDL and [3H]LPS-HDL was again found principally in the adrenal gland and liver. The results indicate that the sites of tissue uptake of bacterial LPS are strongly influenced by binding of LPS to HDL. In particular, LPS-HDL binding may be an important determinant of the extent to which LPS are taken up by the adrenal gland during bacterial sepsis.

Kinetic parameters of the lipoprotein transport systems in the adrenal gland of the rat determined in vivo. Comparison of low and high density lipoproteins of human and rat origin

These studies were done to characterize the rate of uptake of high (HDL) and low (LDL) density lipoprotein cholesterol by the adrenal gland of the rat under in vivo conditions. Animals were pretreated for 4 days with 4-aminopyrazolo[3,4-d]pyrimidine to essentially eliminate endogenous plasma lipoproteins and with aminoglutethimide for 1 h to block conversion of cholesterol to adrenal hormones. Such animals were then infused with varying amounts of HDL and LDL from both human and rat plasma, and this led to rapid accumulation of cholesterol, both free and esterified, in the adrenal glands over the subsequent 4-h period of observation. This uptake process was linear with respect to time and manifested saturation kinetics with respect to the steady state level of plasma lipoprotein cholesterol. When human lipoproteins were infused, the maximal rate of cholesterol uptake was approximately 0.45 mg/pair of adrenal glands/h for both HDL and LDL; however, the half-maximal rate of uptake (Km) was achieved at a plasma HDL cholesterol concentration of only 12 mg/dl while a concentration of 61 mg/dl was required to achieve the same velocity with LDL. When similar experiments were carried out with rat HDL, the Km equaled 7.2 mg/dl and a maximal rate of uptake of 0.32 mg/pair of adrenal glands/h was achieved. It was not possible to obtain complete kinetic curves using rat LDL, but at physiological plasma concentrations, there was no difference in the rate of cholesterol uptake from LDL of rat or human origin. When large amounts of both HDL (5.8 times Km) and LDL (3.1 times Km) were infused into the same animals, the rate of cholesterol uptake essentially equaled the sum of the maximal transport rates for the two lipoproteins. These data provide additional support for the concept that the adrenal gland (and ovary) of the rat can take up HDL and LDL cholesterol by separate mechanisms. However, from the quantitative data on the kinetics of these uptake processes, it is apparent that in this species HDL cholesterol must be the major substrate for the synthesis of adrenal hormones.

Hypertension associated with protamine sulfate administration

A case of protamine-associated hypertension in a 76-year-old Caucasian woman with chronic renal failure (CRF) undergoing hemodialysis is reported. Four dialysis runs during March 1977 are described in this report; all involved the i.v. administration of heparin sodium (2500-5000 units) during the five-hour procedures. Protamine sulfate (25-50 mg) was given i.v. at the end of each procedure to neutralize excess heparin. In three of the four dialyses, the patient became short of breath, hypertensive, and tachycardic, usually for less than 10 minutes. In the last of these runs, the patient first became hypotensive and then hypertensive, and was incontinent of urine and feces. Treatment in each case consisted of elevation of the head of the bed and oxygen administration. During the forth dialysis, no adverse reaction occurred. Possible explanations of this phenomenon are discussed, including hypersensitivity to protamine sulfate products and the action of protamine on platelets resulting in serotonin or histamine release. In dialyses where the patient became hypertensive, more protamine on platelets resulting in serotonin or histamine release. In dialyses where the patient became hypertensive, more protamine sulfate was given than was needed to neutralize the heparin. In the run where symptoms were most severe, the patient received only 2500 units of heparin but was given 50 mg protamine sulfate. It is concluded that this reaction occurred as a result of administering excess protamine sulfate, which then acted on platelets. The platelets released either histamine or serotonin, which mediated rapid changes in blood pressure, heart rate, and breathing pattern.