A phase I study of oral uracil/ftorafur (UFT) plus leucovorin and bis-acetato-ammine-dichloro-cyclohexylamine-platinum IV (JM-216) each given over 14 days every 28 days

PURPOSE

To determine the feasibility, maximal tolerated doses, and response rates for a combined regimen of the platinum and 5-fluorouracil oral analogues bis-acetato-ammine-dichloro-cyclohexyl-amine platinum(IV) (JM-216) and uracil/ftorafur (UFT) coadministered as a 14 consecutive-day every 28-day schedule.

METHODS

Of 20 patients enrolled in this investigation, 17 on the following dose escalation scheme were evaluable for toxicity and/or response: I UFT 300 mg/day, JM-216 5 mg/day (three patients), II UFT 300 mg/day, JM-216 10 mg/day (four patients), III UFT 300 mg/day, JM-216 20 mg/day (ten patients).

RESULTS

All 17 evaluable patients were evaluable for toxicity. At dose level III dose-limiting nausea and emesis were observed in one patient despite maximal antiemetic support. Importantly, neurotoxicity and nephrotoxicity were not observed at the JM-216 dose levels examined in this study. This observation is consistent with results seen with single agent JM-216.

CONCLUSION

For JM-216 and UFT administered at 20 mg/day and 300 mg/day over 14 days, nausea and emesis were observed as the principal dose-limiting toxicities. These doses are considerably below the maximally tolerated doses of single agent JM-216 and UFT. Shorter administration schedules should be explored in an attempt to increase the dose intensity and minimize the toxicity of this combination oral regimen.

Outcomes and costs of a community support worker service for the severely mentally ill

There has recently been an expansion of paraprofessional staff involved in the provision of care for the severely mentally ill. In this paper we shall evaluate the effects of a community support worker (CSW) service in South London. A sample of patients with severe mental illness receiving the service was assessed over a 6-month period in order to examine the effects of continuing use of CSWs on outcomes, service use and costs. During the study period there were improvements in outcome reflecting service satisfaction, needs, quality of life and social behaviour. Whilst provision of the CSW service did not lead to extra total service costs, service use and cost data suggest that CSWs are associated with the substitution of in-patient use by community-based services.

Combination therapy with fludarabine and cyclophosphamide as salvage treatment in lymphoproliferative disorders

Seventeen patients (aged 50-85 years) with relapsed or refractory non-Hodgkin's lymphoma (NHL, 10 patients) or chronic lymphocytic leukaemia (CLL, seven patients) were treated with a combination of fludarabine 25 mg/m2/d and cyclophosphamide 250 mg/m2/d for 3 d repeated every 4 weeks. 12 patients had previously received purine analogue therapy of which four had progressive disease during treatment. The overall response rate of patients with CLL was 71% (28% CR, 43% PR) and for NHL was 50% (0% CR, 50% PR). Toxicity consisted of nausea and vomiting which was maximal in the 3 d after therapy, infections and haematological suppression which was prolonged in some patients. This combination, which is based on a rational prediction of synergistic activity, is highly effective but associated with significant problems with tolerance.

The abundance of cell cycle regulatory protein Cdc4p is controlled by interactions between its F box and Skp1p

Posttranslational modification of a protein by ubiquitin usually results in rapid degradation of the ubiquitinated protein by the proteasome. The transfer of ubiquitin to substrate is a multistep process. Cdc4p is a component of a ubiquitin ligase that tethers the ubiquitin-conjugating enzyme Cdc34p to its substrates. Among the domains of Cdc4p that are crucial for function are the F-box, which links Cdc4p to Cdc53p through Skp1p, and the WD-40 repeats, which are required for binding the substrate for Cdc34p. In addition to Cdc4p, other F-box proteins, including Grr1p and Met30p, may similarly act together with Cdc53p and Skp1p to function as ubiquitin ligase complexes. Because the relative abundance of these complexes, known collectively as SCFs, is important for cell viability, we have sought evidence of mechanisms that modulate F-box protein regulation. Here we demonstrate that the abundance of Cdc4p is subject to control by a peptide segment that we term the R-motif (for "reduced abundance"). Furthermore, we show that binding of Skp1p to the F-box of Cdc4p inhibits R-motif-dependent degradation of Cdc4p. These results suggest a general model for control of SCF activities.

Involvement of protein kinase C and protein kinase A in the muscarinic receptor signalling pathways mediating phospholipase C activation, arachidonic acid release and calcium mobilisation

The involvement of protein kinase C (PKC) and protein kinase A (PKA) in cholinergic signalling in CHO cells expressing the M3 subtype of the muscarinic acetylcholine receptor was examined. Muscarinic signalling was assessed by measuring carbachol-induced activation of phospholipase C (PLC), arachidonic acid release, and calcium mobilisation. Carbachol activation of PLC was not altered by inhibition of PKC with chelerythrine chloride, bisindolylmaleimide or chronic treatment with phorbol myristate acetate (PMA). Activation of PKC by acute treatment with PMA was similarly without effect. In contrast, inhibition of PKC blocked carbachol stimulation of arachidonic acid release. Likewise, PKC inhibition resulted in a decreased ability of carbachol to mobilise calcium, whereas PKC activation potentiated calcium mobilisation. Inhibition of PKA with H89 or Rp-cAMP did not alter the ability of carbachol to activate PLC. Similarly, PKA activation with Sp-cAMP or forskolin had no effect on PLC stimulation by carbachol. Carbachol-mediated release of arachidonic acid was decreased by H89 but only slightly increased by forskolin. Forskolin also increased calcium mobilisation by carbachol. These results suggest a function for PKC and PKA in M3 stimulation of arachidonic acid release and calcium mobilisation but not in PLC activation.

Home monitoring of 17 hydroxyprogesterone levels in congenitx127drenal hyperplasia with filter paper blood samples

OBJECTIVE

The purpose of this study was to evaluate the usefulness of 17 hydroxyprogesterone (17OHP) determination in dried filter paper blood samples from patients with congenital adrenal hyperplasia caused by 21-hydroxylase deficiency. It was hypothesized that these home samples would enhance patient treatment.

STUDY DESIGN

Results of 17OHP determination in simultaneously collected venous and dried filter paper blood samples were compared to establish assay reliability. Thereafter, parents mailed dried filter paper blood samples collected before each hydrocortisone dose.

RESULTS

The 17OHP levels in wet and dried blood samples correlated well (r = 0.98). Results did not change when stored for 2 weeks under various conditions. Blood sampling at different times of the day provided insights into the patterns of 17OHP secretion and identified times of inadequate adrenal suppression. Dose adjustments were then made considering the time of day when adrenal suppression was inadequate.

CONCLUSION

Home monitoring of 17OHP is a reliable and practical approach for assessing adrenal steroid activity in patients with congenital adrenal hyperplasia. Considering the time of day of 17OHP elevations also facilitates hydrocortisone dosing adjustment.

Four new DP alleles identified in a study of 500 unrelated bone marrow donor-recipient pairs

HLA-DP genotyping of 500 donor recipient pairs in a retrospective analysis sponsored by the National Marrow Donor Program (NMDP) identified four new DP alleles, two DPB1 and two DPA1. DNA sequencing confirmed that DPB1*8001 and *8101, each found in a single individual, are novel combinations of previously described sequence motifs in the six variable regions of DPB1. DPA1*02014, found in two individuals, is identical to DPA1*02011 except for a novel silent substitution, a G to A transition at the third position of codon 14. DPA1*01032, found in one individual, is identical to DPB1*01031 except for a silent G to A transition at the third position of codon 20. The identification of these novel alleles brings the total number of reported DPB1 alleles to 85 and DPA1 alleles to 15.

Impact of environment on adolescent mental health and behavior: structural equation modeling

This study uses structural equation models to describe how objective neighborhood, perceived neighborhood, and environmental support predict mental health; 792 adolescents responded to highly structured interviews. The effect of objective environment on mental health was mediated through its influence on perceived neighborhood. Environmental support mitigated negative perceptions of environment and the effect of perceived environment on mental health, while exposure to violence augmented the negative effect of perceived environment.

Legume and opportunity cropping systems in central Queensland. 2. Effect of legumes on following crops

Poor yields and low grain protein in cereal crops resulting from declining soil fertility, especially nitrogen (N), are major threats to the grains industry in central Queensland. The effect of 4 different pasture-ley legumes [siratro (Macroptilium atropurpureum cv. Siratro), lucerne (Medicago sativa cv. Trifecta), lablab (Lablab purpureus cv. Highworth), and desmanthus (Desmanthus virgatus cv. Marc)] on grain yield and quality of sorghum crops was compared with that of a pulse (mungbean; Vigna radiata cv. Satin) or continuous cropping with grain sorghum (Sorghum bicolor). Legume leys consistently resulted in large increases in grain yield (188–272%), N uptake by sorghum (145–345%), and grain protein (0.21–7.0% increase in grain protein) in sorghum test-crops compared with continuous sorghum crops to which no fertiliser N had been added. The positive effect of legumes persisted up to 3 sorghum test-crops after only 1 year of legumes, although by the third year the effect was comparatively small. Mungbean and lablab generally produced the largest benefit in sorghum test-crops in the first year after legumes, whereas desmanthus and lucerne produced the least benefit. Adding fertiliser N (up to 75 kg N/ha) significantly improved grain yields and N uptake of sorghum test-crops in 3 of 4 years. However, responses to fertilisers were less than those resulting from legumes, which was ascribed to increased availability of legume N to sorghum. Legumes progressively increased soil nitrate in all subsequent sorghum test-crops (compared with continuous sorghum crops), rising from 6.8–18.9 kg NO3-N/ha after 1 year of legumes to 24.2–59.6 kg NO3-N/ha after 3 years of legumes. There was little difference between the legumes in their ability to increase soil nitrate, with the exception of desmanthus, which consistently resulted in the lowest amount of soil nitrate for subsequent test-crops and lowest uptake of N by these crops. Plant-available water content (PAWC) at planting of the sorghum test-crop was only significantly (P<0.05) affected by previous species in 1997, when it was lowest in plots previously sown to siratro and lucerne and highest in sorghum and mungbean plots. In both 1996 and 1997, plots sown to sorghum had significantly higher PAWC at anthesis and grain maturity when previous plots were sorghum rather than legumes.

Evidence that C1q binds specifically to CH2-like immunoglobulin gamma motifs present in the autoantigen calreticulin and interferes with complement activation

Calreticulin (CRT) is located predominantly in the endoplasmic reticulum (ER) of cells, where it functions as a quality control controller of protein folding. However, CRT is also a prevalent autoantigen in patients with systemic lupus erythematosus (SLE), where its release from the cell may arise as a results of dysfunctional apoptosis and inefficient removal of ER vesicles, which are an abundant source of CRT and other autoantigens. Indicative of this is the presence of autoantibodies against CRT in the sera of 40-60% of all SLE patients. Once released into the circulation, CRT might bind directly to C1q and we have suggested that this association may result in a defect in C1q-mediated clearance of antigen-antibody complexes. It has been previously shown that CRT under physiological salt conditions binds to the globular head of C1q. It is known that the globular head region of C1q binds to the CH2 domain in the Fc portion of immunoglobulin gamma (IgG). The N-terminal half of CRT contains a number of short regions of 7-10 amino acids that show sequence similarity to the putative C1q binding region in the CH2 domain of IgG. By use of a series of 92 overlapping CRT synthetic peptides, a number of C1q binding sites on the CRT molecule have been identified, including several containing a CH2-like motif similar to the ExKxKx C1q binding motif found in the CH2 domain of IgG. A number of these peptides were shown to inhibit binding of C1q to IgG and reduce binding of native CRT to C1q. Moreover, several of the peptides were capable of inhibiting the classical pathway of complement activation. These studies have identified specific binding sites on the CRT molecule for C1q and lend support to the hypothesis that interaction of CRT with C1q may interfere with the ability of C1q to associate with immune complexes in autoimmune-related disorders.

Acquisition of Clostridium difficile and Clostridium difficile-associated diarrhea in hospitalized patients receiving tube feeding

BACKGROUND

Clostridium difficile is the most common infectious cause of nosocomial diarrhea, but its role in diarrhea associated with tube feeding has not been rigorously investigated.

OBJECTIVE

To determine the incidence of C. difficile acquisition and C. difficile-associated diarrhea in tube-fed and non-tube-fed patients.

DESIGN

Prospective cohort study.

SETTING

A university-affiliated Veterans Affairs Medical Center.

PATIENTS

76 consecutive hospitalized, tube-fed patients and 76 hospitalized, non-tube-fed patients. The two cohorts were matched for age, unit location, duration of hospitalization before surveillance, and severity of illness.

MEASUREMENTS

Incidence of C. difficile acquisition, incidence of C. difficile-associated diarrhea, and C. difficile restriction endonuclease analysis typing results.

RESULTS

More tube-fed patients than non-tube-fed patients acquired C. difficile (15 of 76 patients [20%] compared with 6 of 76 patients [8%]; P=0.03) and developed C. difficile-associated diarrhea (7 of 76 patients [9%] compared with 1 of 76 patients [1%]; P=0.03). The mean proportion (+/-SD) of surveillance days with diarrhea was greater for tube-fed patients after the development of C. difficile-associated diarrhea than for tube-fed patients without this diarrhea (0.68+/-0.4 compared with 0.22+/-0.2 [95% CI for the mean difference, 0.08 to 0.84]). Postpyloric tube feeding (odds ratio, 3.14 [CI, 1.008 to 9.77]) and duration of surveillance (odds ratio, 1.08 [CI, 1.0009 to 1.16]) were risk factors for the acquisition of C. difficile. Nineteen restriction endonuclease analysis types of C. difficile were identified from 20 patients.

CONCLUSIONS

Hospitalized, tube-fed patients, especially those receiving postpyloric tube feeding, are at greater risk for the acquisition of C. difficile and the development of C. difficile-associated diarrhea than are hospitalized, non-tube-fed patients. Clinicians should test for C. difficile in tube-fed patients with diarrhea.

Symptom relief and side effects of postmenopausal hormones: results from the Postmenopausal Estrogen/Progestin Interventions Trial

OBJECTIVE

To assess pair-wise differences between placebo, estrogen, and each of three estrogen-progestin regimens on selected symptoms.

METHODS

This was a 3-year, multicenter, double-blind, placebo-controlled trial in 875 postmenopausal women aged 45-64 years at baseline. Participants were assigned randomly to one of five groups: 1) placebo, 2) daily conjugated equine estrogens, 3) conjugated equine estrogens plus cyclical medroxyprogesterone acetate, 4) conjugated equine estrogens plus daily medroxyprogesterone acetate, and 5) conjugated equine estrogens plus cyclical micronized progesterone. Symptoms were self-reported using a checklist at 1 and 3 years. Factor analysis reduced 52 symptoms to a set of six symptom groups.

RESULTS

In intention-to-treat analyses at 1 year, each active treatment demonstrated a marked, statistically significant, protective effect against vasomotor symptoms compared with placebo (odds ratios [ORs] 0.17-0.28); there was no additional benefit of estrogen-progestin over estrogen alone. Only progestin-containing regimens were significantly associated with higher levels of breast discomfort (OR 1.92-2.27). Compared with placebo, women randomized to conjugated equine estrogens reported no increase in perceived weight. Those randomized to medroxyprogesterone acetate reported less perceived weight gain (OR 0.61-0.69) than placebo. Anxiety, cognitive, and affective symptoms did not differ by treatment assignment. Analyses restricted to adherent women were not materially different than those using intention-to-treat, except that women adherent to medroxyprogesterone acetate and micronized progesterone regimens reported fewer musculoskeletal symptoms (OR 0.62-0.68).

CONCLUSION

These results confirm the usefulness of post-menopausal hormone therapy for hot flashes, show convincingly that estrogen plus progestin causes breast discomfort, and demonstrate little influence of postmenopausal hormones on anxiety, cognition, or affect.

The in vivo effects of bisGMA on murine uterine weight, nucleic acids and collagen

The aim of this investigation was to evaluate the ability of commercial bisGMA to stimulate growth in an estrogen-sensitive target tissue. Adult, female, Swiss-Webster mice were ovariectomized and received either oil, estradiol (100 microg/kg), or one of two bisGMA doses (25 microg/kg or 100 microg/kg). Starting on the day of surgery, the hormone, drug or oil was injected subcutaneously 3 times a week. After 3 wk of treatment, the animals were sacrificed, the uteri removed, weighed and stored at -80 degrees C for biochemical analysis. The uteri from ovariectomized mice receiving high dose (100 microg/kg) bisGMA or estradiol showed a significant increase in normalized wet weight that was 29% and 786%, respectively, greater than the ovariectomized control uterine normalized weights. In the low bisGMA dose (25 microg/kg) group, normalized uterine wet weights were not statistically significant from ovariectomized controls. Biochemical analyses of uterine tissues revealed that estradiol resulted in maintaining DNA content, RNA content, RNA/DNA ratios and collagen content significantly above the ovariectomized control. Neither the low nor high doses of bisGMA stimulated RNA content, DNA content or RNA/DNA ratios above ovariectomized controls. However, the high dose (100 microg/kg) of bisGMA caused a significant increase above ovariectomized controls in uterine collagen content.

User perspective on needs and satisfaction with mental health services. PRiSM Psychosis Study. 8

BACKGROUND

Measurement of the impact of different types of service provision on the views of service users is important in planning mental health services.

METHOD

Needs (met and unmet) and satisfaction with services, were assessed. People with psychosis (n = 131) were interviewed before (Time 1) and after (Time 2) the introduction of two community mental health services in south London. One was intensive, with two specialist teams, the other standard. Outcomes were compared at Time 2, controlling for the Time 1 values.

RESULTS

Overall, 70% of needs were met and mean satisfaction was between 'mixed' and 'mainly satisfied'. There was evidence for higher met needs in the intensive sector, but no evidence for lower unmet needs in the intensive sector or for differences in satisfaction. The additional needs met by the intensive service were associated with aspects of basic living situation. Satisfaction was negatively correlated with both unmet and met needs.

CONCLUSIONS

Both services were reasonably successful, with little difference from the user perspective. The intensive service provided benefits in terms of met needs, but this has to be balanced against a possible increase in unmet needs.

Frequency and predictors of adverse events. PRiSM Psychosis Study. 3

BACKGROUND

Community care has been criticised as a hazardous policy associated with high rates of adverse events. There is little research evidence as to the truth of this claim.

METHOD

Best available evidence from public records, interviews, case notes, key workers and general practitioners was assembled to establish: (a) which of the 514 subjects initially identified as having psychotic illnesses had died during an average follow-up of 4.9 years; (b) care currently received by all 286 subjects originally selected for interview; and (c) rates of major adverse events and of admission for these 286 individuals.

RESULTS

Twenty-eight natural and II unnatural deaths had occurred. Among subjects still living at the end of the follow-up, 84% were in contact with specialist mental health services and 11% only with primary care services. Rates of serious violence, imprisonment and homelessness were relatively low. Forty-one per cent had been admitted at least once during a mean follow-up of 3.2 years and 20% at least once under the Mental Health Act. After adjustment, there were no significant differences between standard and intensive care sectors.

CONCLUSIONS

Rates of adverse events and 'slipping through the net' are relatively low among individuals receiving community-based services, whether intensive or standard care.

From efficacy to effectiveness in community mental health services. PRiSM Psychosis Study. 10

BACKGROUND

The PRiSM Psychosis Study investigated the outcomes of community mental health services for epidemiologically representative cases of psychosis in London.

METHOD

The results presented in the preceding nine papers are interpreted.

RESULTS

(a) The health and social gains reported in experimental studies of community health services are replicable in ordinary clinical settings, and are more effective than hospital-oriented services which they replace. (b) Dilution does occur--these gains are less pronounced than in experimental (efficacy) studies. (c) Both models of community services produced a range of improved outcomes. (d) Some limited extra advantages (in terms of met needs, improved quality of life, and social networks) were found in the intensive sector. (e) There is no consistent evidence that community-oriented services (which include in-patient beds) fail service users, their families or the wider public. On balance the results weigh slightly in favour of the two-team model (for acute and continuing care) in terms of clinical effectiveness, but the general model is almost as effective and is less expensive.

CONCLUSIONS

The evidence supports a community-oriented rather than a hospital-oriented approach and there is little difference between the community mental health team models.

Resistance mutations in protease and reverse transcriptase genes of human immunodeficiency virus type 1 isolates from patients with combination antiretroviral therapy failure

High-density oligonucleotide arrays were used to determine the sequence of the protease (PR) and reverse transcriptase (RT) genes of human immunodeficiency virus type 1 isolates from 35 patients in whom combination therapy that included a protease inhibitor had failed. Isolates had a median of three PR mutations (range, none to six). Three isolates had no known resistance mutations in PR. Twelve isolates (34%) had two or fewer resistance mutations in PR. The most commonly observed PR mutations were L10I, V82A/T/F, and L90M. No mutations were observed at codons 30 or 48. Mutations at RT codons 215 and 184 were observed in the majority of isolates. These data suggest that therapy can fail in some patients with relatively few PR resistance mutations. Clinical failure in the absence of resistance mutations implies inadequate drug exposure due to pharmacologic factors or suboptimal patient adherence to drug therapy.