The effects of transdermal estradiol alone or with cyclical dydrogesterone on markers of cardiovascular disease risk in postmenopausal women with type 2 diabetes: a pilot study

The objective of this open, longitudinal, controlled study was to assess the effect of transdermal estradiol alone or combined with cyclical dydrogesterone on the markers of cardiovascular disease (CVD) risk in postmenopausal women with type 2 diabetes. The control group consisted of postmenopausal diabetic women who declined menopausal hormone replacement therapy (HRT). Twenty-eight postmenopausal women (19 on HRT and 9 controls) with type 2 diabetes were followed up for 12 months. From the active treatment group 14 women with a uterus in situ had 80 microg/24 hr transdermal estradiol (Fematrix 80; Solvay Healthcare Ltd, Southampton, UK) and oral dydrogesterone 10 mg daily for the first 12 days of the calendar month, whereas 5 women with previous hysterectomy had 80 microg/24 hr transdermal estradiol (Fematrix 80) alone. CVD risk markers were measured before and at regular intervals after starting HRT. The main outcome measures were weight, systolic and diastolic blood pressure, fasting plasma glucose, glycated hemoglobin (HbA1c), glucose/insulin ratio, total cholesterol, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, triglycerides, lipoprotein (a), high-sensitivity C-reactive protein (hs-CRP), fibrinogen, and endothelin-1. Transdermal estradiol with or without dydrogesterone in women with type 2 diabetes did not adversely affect any of the measured markers of cardiovascular risk. There was a significant decrease in HbA1c, total cholesterol, and LDL cholesterol at 6 months in women receiving HRT. Some of the cardiovascular disease risk markers may improve in postmenopausal women with type 2 diabetes with transdermal estradiol. This effect may have important clinical implications and it deserves further investigation in appropriately designed trials.

Treating dyslipidaemia in non-insulin-dependent diabetes mellitus -- a special reference to statins

Patients with non-insulin-dependent diabetes (NIDDM) have an increased incidence of ischaemic heart disease (IHD) when compared with nondiabetic subjects. In addition, they have a worse prognosis after their first myocardial infarction (MI). According to the recent USA recommendations, the threshold for initiation of dietary intervention in diabetic subjects is an LDL greater than 2.6 mmol/l, with the goal to achieve levels less than 2.6 mmol/l (100 mg/dl). This is also the threshold for initiation and treatment goal for pharmacological intervention in diabetic subjects, unless they are completely free of IHD, peripheral vascular disease or cerebrovascular disease and have no other IHD risk factors. In the latter circumstances, the threshold for treatment is an LDL greater than 3.38 mmol/l (130 mg/dl), with the goal to achieve levels less than 3.38 mmol/l. The HMG-CoA reductase inhibitors (statins) can improve the lipid profile effectively and safely in NIDDM. Results from post hoc analyses of diabetic subgroups in the large intervention trials suggest that some statins significantly reduce the risk for IHD-related mortality/morbidity. However, because these results are derived from secondary prevention trials, we cannot be sure if these benefits apply to all diabetic subjects or only to those who already have IHD. Nevertheless, it seems logical to assume that this benefit also applies to NIDDM patients who do not have IHD because they share a similar vascular risk as nondiabetic subjects who have IHD. Intervention trials using statins and fibrates, alone or in combination, in NIDDM are under way. In a few years these trials will provide definitive end-point-based evidence in this high-risk group of patients.

Surviving native beta-cells determine outcome of syngeneic intraportal islet transplantation

In moderately diabetic rats (plasma glucose 20-30 mmol/L), where there is some residual pancreatic islet function, normoglycemia can be restored by transplantation of pancreatic islets into the liver via the portal vein. To examine whether normoglycemia can also be achieved in more severely diabetic animals (which more closely resemble human type I diabetes), we have compared the effect of transplanting 1000 islets intraportally in Lewis rats made moderately diabetic (55 mg/kg streptozotocin injected IP while nonfasting) or severely diabetic (65 mg/kg streptozotocin injected IP while fasting). In the moderately diabetic rats in which residual pancreatic insulin was 128 +/- 40 mU insulin (2.0% of control), plasma glucose stabilized (32 +/- 2.8 mmol/L at 1 week, 34 +/- 2 mmol/L at 3 weeks) as did body weight (falling from 290 +/- 5 to 265 +/- 5 g at 1 week and 253 +/- 6 g at 3 weeks). In contrast, in severely diabetic rats in which residual pancreatic insulin was only 13.5 +/- 4.2 mU insulin (0.21% of control), there was a progressive rise in plasma glucose (30 +/- 1.3 mmol/L at 1 week, 49 +/- 4 mmol/L at 2 weeks, and 67 +/- 7 mmol/L at 3 weeks) and a progressive fall in body weight (from 304 +/- 10 to 260 +/- 5 g by week 1 and to 209 +/- 6 g by week 3). Following islet transplantation, nonfasting plasma glucose normalized in moderately diabetic rats (10.5 +/- 0.6 vs. 9.1 +/- 0.6 mmol/L in nondiabetic controls, NS) after 23 +/- 5 days. In contrast, in the severely diabetic rats plasma glucose stabilized at 32 +/- 5 mmol/L (p < 0.05 compared to moderately diabetic group) but did not normalize. This difference was not attributable to different plasma glucose levels at the time of transplantation (35.1 +/- 1.8 in moderately diabetic vs. 32.5 +/- 2.5 mmol/L in severely diabetic rats). These observations demonstrate that residual native beta-cells (equivalent to only 60-80 islets) contribute to the survival or function of intraportally transplanted islets.

Growth and survivorship of dipterocarp seedlings: differences in shade persistence create a special case of dispersal limitation

A series of growth experiments and observations on natural populations have been carried out on dipterocarp species of contrasting ecology growing in artificial gaps and the forest understorey. These studies have demonstrated that although differences exist between species in photosynthetic and growth responses to the high-light environment, competition for light in canopy gaps is highly asymmetrical and tends to reinforce any pre-existing dominance hierarchy. We propose that differences in seedling persistence in forest canopy shade are highly influenced by species-specific biotic and abiotic interactions. Our experiments suggest that as seedlings, dipterocarp species trade off traits which enhance persistence and growth in shade against those that enhance their ability to exploit gaps. Less competitive species survive for progressively longer periods of time after a gregarious fruiting event. This leads to significant shifts with time in the number of species present in the seedling bank and hence in the importance of interspecific competition in determining which species dominates regrowth in gaps. We propose that this special case of dispersal limitation is more likely to account for coexistence of dipterocarp species than differences in growth responses to gaps of different size, with stochastic and environmental variables interacting to determine species distribution and abundance.

Elevated serum creatine kinase activity in a patient with acute pancreatitis

A 62-year-old man presented with a five-day history of a 'flu-like' illness, epigastric pain and a state of increasing confusion. His serum values for amylase and glucose were grossly elevated, as was the creatine kinase (CK) activity, being 23 times above the upper limit of normal. CK-MB was less than 5% of his total CK activity. There was no past history of diabetes or recent history of intramuscular injections or injury. A diagnosis of acute pancreatitis complicated by hyperosmolar non-ketotic (HONK) diabetic pre-coma was made. The patient was treated with intravenous fluids, insulin and subcutaneous heparin. Normal values for serum amylase and CK activity were recorded with convalescence. This case indicates a possible association of a rise in total CK activity with acute pancreatitis complicated by HONK diabetic pre-coma. This observation was made in the absence of clinically evident muscle pathology.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy

PURPOSE/OBJECTIVE

1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response.

METHODS AND MATERIALS

Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression.

RESULTS

Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010).

CONCLUSION

The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

Telomerase activity in normal and neoplastic breast

Telomerase activity is detected in the majority of human tumors and provides a mechanism to escape from proliferative limitations due to telomere loss. Similar to other studies, telomerase activity was detected with a modified telomeric repeat amplification protocol in the majority (76%) of 49 human breast cancer specimens, including most (75%) ductal carcinoma in situ specimens. There were no correlations between telomerase activity and tumor stage or estrogen/progesterone receptor status. In four of seven invasive tumors, telomerase expression seemed to be heterogeneous because not all microdissected regions were telomerase positive. Low levels of telomerase activity were also detected in a minority (17%) of breast specimens from patients without evidence of cancer. These findings suggest that telomerase activation can occur early in breast cancer progression and may be periodically down-regulated during subsequent progression.

Relevance of human papillomavirus screening in management of cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the utility of human papillomavirus detection in identifying women with abnormal Papanicolaou smears who can be safely followed up with cytologic study only, we conducted a study to determine the sensitivity, specificity, and negative and positive predictive values of a Food and Drug Administration-approved human papillomavirus test kit for detection of cervical intraepithelial neoplasia in colposcopically directed biopsy specimens.

STUDY DESIGN

We enrolled women with abnormal Papanicolaou smears referred to a colposcopy clinic serving indigent patients. All 1128 women had a referral Papanicolaou smear, a clinic Papanicolaou smear, and a sample for human papillomavirus deoxyribonucleic acid test; 1075 underwent colposcopically directed biopsies and endocervical curettage. We used the HPV Profile kit for human papillomavirus testing.

RESULTS

Of 486 women with low-grade squamous intraepithelial lesions on Papanicolaou smear, 35.4% had high-risk human papillomavirus deoxyribonucleic acid detected, and of 592 with high-grade lesions, 44.4% had high-risk human papillomavirus detected. Among 527 women with biopsy specimens showing cervical intraepithelial neoplasia and in 267 with cervical intraepithelial neoplasia grades 2 or 3, 38.7% and 56.2% had high-risk human papillomavirus deoxyribonucleic acid detected. However, the sensitivity of human papillomavirus deoxyribonucleic acid detection to identify biopsy-confirmed cervical intraepithelial neoplasia grades 2 or 3 was 55.7%, and the positive predictive value of the test was only 34.9%.

CONCLUSION

Human papillomavirus appears to be causally associated with cervical cancer but human papillomavirus screening does not appear to be of value to identify women with abnormal Papanicolaou smears who can be safely followed up with cytologic study alone.

Testosterone deficiency myopathy

Testosterone is recognized to have a positive effect on nitrogen balance and muscle development in hypogonadal men, but significantly myopathy secondary to testosterone deficiency has been reported only rarely. We describe a patient who presented with a myopathy associated with testosterone deficiency, and who demonstrated a significant functional and myometric response to treatment.

Myopathy in acquired partial lipodystrophy

We describe two women with acquired partial lipodystrophy, one with significant myopathic symptoms and signs. Muscle biopsy of deltoid and quadriceps was performed in each case. The light microscopy findings were of type 1 and type 2 fibre hypertrophy, with an increase in intracytoplasmic fat in both cases. Electron microscopy showed normal fibres, with accumulations of electron-lucent fat droplets between the myofibrils. The cause of the lipodystrophies is uncertain, but myopathy may be a feature, and muscle biopsy studies may help in further defining the syndrome.

Search for optimal parent for recombinant vaccinia virus vaccines. Study of three vaccinia virus vaccinal strains and several virus lines derived from them

Three vaccinia virus strains (Praha, DD--a DRYVAX Wyeth vaccine-derived virus-and LIVP) were examined for growth in various cell cultures and for virulence and immunogenicity in mice. The viruses did not differ by their growth rates in monkey kidney cells (CV-1), human diploid cells (LEP), rat TK cells (RAT 2) or primary dog kidney cells. The immunogenicity of Praha and DD viruses was similar, the virus LIVP was somewhat more immunogenic. In terms of virulence in 3-day-old mice, the DD virus was the most attenuated. Single-plaque progenies were derived from the original smallpox vaccines VARIE Sevac (strain Praha) and DRYVAX Wyeth and tested for the above markers and DNA restriction patterns. The results obtained demonstrated biological and molecular heterogeneity of the original virus populations. Close linkage was observed between immunogenic activity and virulence in 3-day but not in 3-week mice. The results indicate that smallpox vaccine preparations may serve as an abundant source of virus mutants.

Expression of the c-kit proto-oncogene and its ligand stem cell factor (SCF) in normal and malignant human testicular tissue

Recent findings suggest an important role of the proto-oncogene c-kit, a surface membrane receptor of the tyrosine kinase family, and its ligand stem cell factor (SCF) in normal spermatogenesis and possibly in the pathogenesis of certain testicular germ cell tumors. To further investigate this potential role, the expression of c-kit and SCF was studied in normal and malignant human testicular tissue specimens at the mRNA and protein level by Northern blot analysis and immunohistochemistry, respectively. The detection of the c-kit receptor in normal human germ cells and its natural ligand SCF in Sertoli cells suggests the presence of a local trophic regulatory system that may be active in human spermatogenesis. Additionally, c-kit expression was detected in the seminoma but not in the nonseminoma subtype of human testicular germ cell tumors (GCT). Stem cell factor was not expressed at the mRNA level in tissue from either subtype of GCT as determined by Northern blot analysis; however, the protein was detected immunohistochemically in the cytoplasm of rare tumor cells.

A carboxy-terminal portion of the preS1 domain of hepatitis B virus (HBV) occasioned retention in endoplasmic reticulum of HBV envelope proteins expressed by recombinant vaccinia viruses

The large envelope glycoprotein (L protein) of Hepatitis B virus (HBV) contains the preS1 domain, which is responsible for retention of the protein in the endoplasmic reticulum. To identify sequences of the preS1 domain involved in this phenomenon we constructed vaccinia virus-HBV recombinants containing the gene for L protein in which the preS1 coding sequence had been partially deleted. The retention of L protein in the endoplasmic reticulum was found to be mediated by a sequence contained within a region of 35 amino acids of the preS1 C-terminus, and not exclusively by amino acid sequences of the N-terminus of the preS1 domain as proposed by Kuroki et al. (Mol. Cell. Biol. 9, 4459-4466, 1989). Our finding could be explained by a specifically VV promoter sequence leading to exclusive synthesis of L or deleted (delta)L proteins, respectively. The ability of the coexpressed HBV S protein to facilitate export of the delta L proteins was demonstrated by coinfection experiments.

Male:female sex ratio in births resulting from IVF according to swim-up versus Percoll preparation of inseminated sperm

Two centers have independently reported a higher rate of male to female births following insemination of sperm prepared by a modified swim-up technique. The principle of the modified swim-up is that a small percentage of the x-bearing sperm are the fastest and travel to the top of the supernatant, followed by the y-bearing sperm; the bulk of the x-bearing sperm remain in the pellet. In this technique, the very top layer is discarded and the resulting supernatant is collected, leaving only the pellet. In contrast, with the conventional swim-up technique, the entire supernatant is collected. The study presented herein retrospectively evaluated the male to female sex ratio of births from in vitro fertilization using standard swim-up technique and compared these results to the ratio obtained from separating with Percoll. There were 53% male births with swim-up vs. 54% with Percoll in singleton pregnancies and 51% males with swim-up vs. 40% with Percoll with multiple births. Thus, conventional swim-up alone does not increase percentage of male births.

Effect of shortened exposure time to the critical period for ice crystal formation on subsequent post-thaw semen parameters from cryopreserved sperm

Cryopreservation of human sperm using present methods leads to a reduced fertility potential of the specimen. In many instances this prevents the successful fertilization of the female partner from the frozen-thawed specimens of males whose semen has been cryopreserved prior to surgery, chemo-therapy, or even vasectomy. Furthermore, even though some donor specimens can be successfully used for achieving pregnancies, one needs to place the sperm intrauterine to approach the same pregnancy rates as those of fresh intracervical insemination. The main mechanism considered for sperm damage by cryopreservation is ice crystal formation. The most critical time for forming ice crystals is from 0 to -10 degrees C. In the present study the effect of a modified rapid cryopreservation technique with reduction of exposure time to the 0 to -10 degrees C temperature range was compared to standard freezing procedures on subsequent semen parameters. Though no significant differences were found on post-thaw motile densities or hypoosmotic swelling test scores, a new, equally effective, but more rapid technique for cryopreservation is reported.