Secondary vs. primary cachexia in patients with advanced cancer

9128

Background: Cachexia results in decreased survival and adherence to chemotherapy, and increased treatment toxicity. Primary Cachexia (PC) is characterized by weight loss, anorexia and fatigue and it is the result of tumor-host interactions producing neurohormonal dysfunction and an aberrant pro-inflammatory response. The clinical effects of PC may be exacerbated by complications capable of decreasing energy intake (Secondary Cachexia) such as dysgeusia, anxiety, depression, pain, early satiety, nausea and constipation. The objective of this study was to determine the causes and the frequency of secondary cachexia (SC) in a cohort of patients with PC. Methods: We reviewed the charts of 50 consecutive advanced cancer patients who underwent a structured assessment in a specialized cachexia clinic at a comprehensive cancer center. Results: All patients gathered criteria for cachexia, including a weight loss of >5% within the preceding 6 months. The most frequent causes of SC were early satiety in 40 patients(80%), constipation in 37(74%), depression or anxiety in 30(60%), uncontrolled pain in 31(62%), chronic nausea in 21(42%), dysgeusia in 14(28%),dental problems in 4(8%), dysphagia in 3(6%)chronic aspiration in 2 (4%) and oral candidiasis in 1 (2%).All 50 patients presented with at least 2 secondary causes of cachexia, and 44(88%) presented with = 3. The median number of causes of secondary cachexia was 4 (range 2–5). 211 interventions were used in these patients to treat secondary causes of cachexia. 14(28%) of the patients referred were already on a medication for appetite stimulation (megestrol acetate, dronabinol, corticosteroids). Conclusions: SC should be ruled out in all patients who have PC since the vast majority of patients referred to a cachexia clinic have 2 or more causes of SC. All cancer patients with involuntary weight loss in our series had “mixed cachexia”. Inexpensive effective treatments are available for most of the causes of SC, but they are frequently underused.

No significant financial relationships to disclose.

Vinflunine in patients with advanced unresectable hepatocellular carcinoma and liver impairment

15023

Background: In patients (pts) with advanced hepatocellular carcinoma (HCC) and liver cirrhosis, systemic chemotherapy has most commonly been associated with a very low response rate and high toxicity leading to death from liver failure. Vinflunine (VFL) is a new microtubule inhibitor of the vinca alkaloid class which has demonstrated clinical activity in several tumour types. Methods: A phase I trial was designed to determine VFL dose adjustments in cancer pts with various degrees of liver dysfunction. A high number of pts with HCC and concomitant liver cirrhosis (Child-Pugh grades A and B) were included in the study (18/30 pts). Therefore, a subgroup analysis was carried out in order to determine the safety profile of VFL in these pts (NCI-CTC version 2.0) and to estimate its anti-tumour activity (WHO criteria). Results: Eighteen pts (15 males) of median age 60.7 [26.4–75.3] years with advanced stage and unresectable HCC were treated with VFL. All these pts were outside Milan criteria and ineligible for liver transplantation. Thirteen pts had been previously treated by chemotherapy. The WHO performance status was 0: 11 pts, 1: 5 pts, 2: 2 pts. They received a median number of 4 cycles [1.0–31.0] of different doses of VFL according to the severity of the underlying liver impairment 320 mg/m2 (3 pts), or 250 mg/m2 (6 pts) or 200 mg/m2 (9 pts). One partial response (PR) was observed while 11 pts (61.1%) had stable disease (SD) yielding a disease control rate (PR + SD) of 66.7%. The median progression free survival was 3.4 months [95% confidence interval (CI): 2.6–6.0]. Haematological toxicity: grades (G) 3 anaemia = 4 pts, G3/4 neutropenia = 11 pts, G3 thrombocytopenia = 7 pts, no febrile neutropenia. Other G3 toxicities included G3 abdominal pain (2 pts), constipation (3 pts), neutropenic infection (1 pt). Six pts experienced G3 (5 pts) or 4 (1 pt) fatigue. Conclusions: Vinflunine can be given safely at 320 mg/m2 or 250 mg/m2 or 200 mg/m2 in pts with unresectable advanced HCC with different degrees of liver impairment. The disease control rate is promising (66.7%).

No significant financial relationships to disclose.

Gene expression profiling of B lymphocytes and plasma cells from Waldenström's macroglobulinemia: comparison with expression patterns of the same cell counterparts from chronic lymphocytic leukemia, multiple myeloma and normal individuals

The tumoral clone of Waldenström's macroglobulinemia (WM) shows a wide morphological heterogeneity, which ranges from B lymphocytes (BL) to plasma cells (PC). By means of genome-wide expression profiling we have been able to identify genes exclusively deregulated in BL and PC from WM, but with a similar expression pattern in their corresponding cell counterparts from chronic lymphocytic leukemia (CLL) and multiple myeloma (MM), as well as normal individuals. The differentially expressed genes have important functions in B-cell differentiation and oncogenesis. Thus, two of the genes downregulated in WM-BL were IL4R, which plays a relevant role in CLL B-cell survival, and BACH2, which participates in the development of class-switched PC. Interestingly, one of the upregulated genes in WM-BL was IL6. A set of four genes was able to discriminate clonal BL from WM and CLL: LEF1 (WNT/beta-catenin pathway), MARCKS, ATXN1 and FMOD. We also found deregulation of genes involved in plasma cell differentiation such as PAX5, which was overexpressed in WM-PC, and IRF4 and BLIMP1, which were underexpressed. In addition, three of the target genes activated by PAX5 - CD79, BLNK and SYK - were upregulated in WM-PC. In summary, these results indicate that both PC and BL from WM are genetically different from the MM and CLL cell counterpart.

[Increase in cigarette smoking and decrease in the level of physical activity among Spanish adolescentes. AVENA study]

OBJECTIVE

Cigarette smoking among adolescents as well as the level of physical activity constitutes a public health care issue. The aim is knowing the relationship between cigarette smoking and practice of physical activity.

SETTING

Schooled Spanish adolescents

SUBJECTS

2859 Spanish adolescents (1357 boys, 1502 girls; age range: 13-18.5 years).

INTERVENTIONS

A questionnaire is applied to know the level of cigarette smoking and four other questionnaires to know the level of physical activity during different periods.

RESULTS

40.8% of the adolescents stated not doing any physical activity at all, boys being more active than girls (p < 0.001). 29.9% of the adolescents stated usually smoking cigarettes, without differences by gender. Both active boys and girls stated smoking less (P < or = 0.01). The greater the age, the higher cigarette smoking and the lower the level of physical activity, both in boys and girls (p < 0.001).

CONCLUSIONS

The level of physical activity is low, being even lower for girls. Cigarette smoking shows a negative relationship with the level of physical activity, the individuals more physically active being those smoking the less.

Adjuvant Chemotherapy for Prevention of Recurrence of Invasive Hepatocellular Carcinoma After Orthotopic Liver Transplantation

Orthotopic liver transplantation (OLT) is the best treatment for nonresectable hepatocellular carcinoma (HCC), but tumor recurrence reduces long-term and medium-term survival. The effectiveness of adjuvant chemotherapy to prevent tumor recurrence has not been fully established.

METHODS

Three hundred eighty-seven consecutive patients, including 43 with HCC superimposed on liver cirrhosis, underwent OLT. Twelve patients with one or more prognostic criteria for HCC recurrence were entered into a prospective prophylaxis protocol with monthly cycles of cisplatin (60 mg/m(2)) and adriamycin (30 mg/m(2)), beginning the fourth week post-OLT for a maximum of seven sessions.

RESULTS

The 5-year survival of the non-HCC patients was 65.7% and that of the HCC patients was 60.46% (P = NS). Chemotherapy was reasonably well tolerated, but the 9 patients with hepatitis C- or B-associated cirrhosis showed viral and histological recurrence of the primary disease. A high proportion of patients (7 of 12) developed tumor recurrence during the first year after OLT. Six of these patients died, all but one due to HCC relapse. Five patients remain healthy and tumor free at 58 to 130 months. Post-OLT adjuvant chemotherapy does not avoid tumor recurrence and its fatal consequences but may contribute to prolonged tumor-free survival among a significant proportion of patients with high-risk HCC. However, the uncertain implications on viral recurrence and the lack of control groups do not allow post-OLT chemotherapy to be recommended outside controlled clinical trials, which are clearly warranted.

Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis

BACKGROUND AND STUDY AIMS

An ideal treatment for choledocholithiasis in the laparoscopic era has not been established. The objective of this study was to elucidate whether a treatment strategy of performing intraoperative endoscopic retrograde cholangiopancreatography (ERCP) during laparascopic cholecystectomy (when choledocholithiasis is confirmed by intraoperative cholangiography) is better for patients with suspected common bile duct stones than the current strategy (preoperative ERCP followed by laparoscopic cholecystectomy).

PATIENTS AND METHODS

This was a prospective randomized study to evaluate which of these two approaches was most benefit- and cost-effective for patients with intermediate risk of choledocholithiasis. Patients underwent either preoperative ERCP followed by a laparoscopic cholecystectomy a few weeks later (the "preoperative ERCP" group) or intraoperative ERCP (the "intraoperative ERCP" group). Intraoperative ERCP was performed using the rendezvous technique.

RESULTS

There were 64 patients in the preoperative ERCP group and 59 patients in the intraoperative ERCP group. The demographic and clinical characteristics of the two groups were similar, except that the bilirubin and gamma-glutamyl transferase (GGT) levels and the number of patients treated on an inpatient basis were higher in the preoperative ERCP group. Success rates were similar (96.6 % in the preoperative ERCP group vs. 90.2 % in the intraoperative ERCP group in the per-protocol study). Total morbidity, post-ERCP morbidity, and post-ERCP acute pancreatitis rates were higher in the preoperative ERCP group, but there were no differences between the two groups in the frequency of residual common bile duct stones, the conversion rate to open cholecystectomy, or surgical morbidity. The length of hospital stay and costs were lower in the intraoperative ERCP group despite the longer surgical times in this group. Univariate analysis did not find any relationship between morbidity and total bilirubin or GGT. Logistic regression analysis confirmed that morbidity was related only to the treatment group and the time spent in the operating room: the relative risk (RR) was 4.37 for morbidity and 1.015 for the time spent in the operating room); the RR for papillotomy was 5.49.

CONCLUSIONS

Both treatment approaches were equally effective but the intraoperative ERCP group had less morbidity, a shorter hospital stay, and reduced costs. The lower morbidity in the intraoperative ERCP group resulted from the lower rate of papillotomy and lower rates of post-ERCP pancreatitis and cholecystitis. Total morbidity was principally related to the type of treatment approach used.

Therapeutic effect of urocortin and adrenomedullin in a murine model of Crohn's disease

BACKGROUND AND AIMS

Urocortin 1 (UCN) and adrenomedullin (AM) are two recently discovered neuropeptides that, due to their distribution and binding to receptors in immune cells, have emerged as potential endogenous anti-inflammatory factors. Crohn's disease is a chronic debilitating disease characterised by a Th1 driven severe inflammation of the gastrointestinal tract. This study investigated the therapeutic effect of UCN and AM in a murine model of colitis.

METHODS AND RESULTS

Treatment with UCN or AM ameliorated significantly the clinical and histopathological severity of the inflammatory colitis, abrogating body weight loss, diarrhoea, and inflammation, and increased the survival rate of colitic mice. The therapeutic effect was associated with downregulation of both inflammatory and Th1 driven autoimmune responses, including regulation of a wide spectrum of inflammatory mediators. In addition, partial involvement of interleukin 10 secreting regulatory cells in this therapeutic effect was demonstrated. Importantly, UCN or AM treatments were therapeutically effective in established colitis and avoided recurrence of the disease.

CONCLUSIONS

This work identifies UCN and AM as two potent anti-inflammatory factors with the capacity to deactivate the intestinal inflammatory response and restore mucosal immune tolerance at multiple levels. Consequently, both peptides represent novel multistep therapeutic approaches for the treatment of Crohn's disease and other Th1 mediated inflammatory diseases.

Colchicine-induced polyploidization depends on tubulin polymerization in c-metaphase cells

The microtubule cytoskeleton plays a crucial role in the cell cycle and in mitosis. Colchicine is a microtubule-depolymerizing agent that has long been used to induce chromosome individualization in cells arrested at metaphase and also in the induction of polyploid plants. Although attempts have been made to explain the processes and mechanisms underlying polyploidy induction, the role of the cytoskeleton still remains largely unknown. Through immunodetection of alpha-tubulin, different concentrations (0.5 or 5 mM) of colchicine were found to produce opposite effects in the organization of the cytoskeleton in rye (Secale cereale L.). A low concentration (0.5 mM) induced depolymerization of the microtubular cytoskeleton in all phases of the cell cycle. In contrast, a high concentration (5 mM) was found to induce the polymerization of new tubulin-containing structures in c-metaphase cells. Furthermore, both treatments also showed contrasting effects in the induction of polyploid cells. Flow cytometric analysis and quantitative assessments of nucleolus-organizing regions revealed that only the high-concentration colchicine treatment was effective in the formation of polyploid cells. Our studies indicate that spindle disruption alone is insufficient for the induction of polyploid cells. The absence of any tubulin structures in plants treated with colchicine at the low concentration induced cell anomalies, such as the occurrence of nuclei with irregular shape and/or (additional) micronuclei, 12 h after recovery, pointing to a direct effect on cell viability. In contrast, the almost insignificant level of cell anomalies in the high-concentration treatment suggests that the presence of new tubulin-containing structures allows the reconstitution of 4C nuclei and their progression into the cell cycle.

Safety of percutaneous ethanol injection as neoadjuvant therapy for hepatocellular carcinoma in waiting list liver transplant candidates

Orthotopic liver transplantation (OLT) as therapy of hepatocellular carcinoma (HCC) improves the survival of a selected group of patients. Unfortunately, the progressive increase in waiting time for OLT may allow tumor progression. Percutaneous ethanol injection (PEI) has been proposed as neoadjuvant therapy for HCC in patients awaiting OLT, but its safety has not been defined.

PATIENTS AND METHODS

During a 60-month period, 34 patients (27 men, overall mean age of 58.5 years, range 41-67) with HCC, were listed for OLT. Ultrasonography-guided PEI was delivered into 39 nodules at 117 sessions on an inpatient basis. Written informed consent was obtained from all patients before PEI. Doppler-ultrasonography was done before PEI, immediately after, and 4 weeks later. Noninvasive monitoring of arterial pressure, cardiac rate, and temperature was performed during the procedure and during a 24-hour period after each session. Pain was considered significant if analgesia was required or discontinuation of PEI necessary. Fever was defined as a temperature > or =37.5 degrees C after PEI.

RESULTS

Minor complications included pain in 45 sessions (38.5%), fever in 17 (14.5%), arterial hypertension in 14 (12%), hypotension in 7 (7%), and vomiting in 2 (1.7%). The major complications were segmental liver infarction (n = 3), portal branch venous thrombosis (n = 2), ascites (n = 2), and one case each of subcapsular hematoma, duodenal ulcer, pneumonia, hepatic encephalopathy, and hepatic artery thrombosis. In all cases, clinical outcomes were favorable with conservative treatment. No evidence of tumor seeding in the needle track was reported and no PEI-related mortality observed.

CONCLUSIONS

PEI is a safe neoadjuvant therapy for HCC on waiting list liver transplant candidates. In our series, pain and self-limited fever were the most frequent complications. Clinically significant severe complications were uncommon, and nonconservative treatments were not required.

Potential of Agave lechuguilla biomass for Cr(III) removal from aqueous solutions: thermodynamic studies

Thermodynamic studies on the bioadsorption of Cr(III) onto Agave lechuguilla biomass were conduced. The experimental results at different temperatures were modeled using the Langmuir and Freundlich isotherms to obtain the characteristic parameters of each model. Both the Freundlich and Langmuir models were found to represent the bioadsorption process. The average adsorption capacities calculated from Freundlich (4.7 mg/g) and Langmuir (14.2 mg/g) isotherms showed A. lechuguilla to be an effective biomass in the removal of Cr(III) from an aqueous solution. Thermodynamic parameters (deltaG0, deltaH0 and deltaS0) determined in the temperature range from 10 to 40 degrees C along with the parameters of the Dubinin-Radushkevick equation support the idea that the binding of Cr(III) may be caused by interactions with functional groups such as carboxyl groups located on the outer surface of the cell tissue of the bioadsorbent.

Study on the Efficacy and Safety of Adefovir Dipivoxil Treatment in Post–Liver Transplant Patients With Hepatitis B Virus Infection and Lamivudine-Resistant Hepatitis B Virus

Hepatitis B virus (HBV) recurrence and de novo HBV infection are frequent events in liver transplantation recipients. Treatment with lamivudine is initially efficient in both infections but the incidence of lamivudine-resistant HBV emergence increases over time. Adefovir appears to be promising in post-liver transplantation patients with recurrent HBV infection and lamivudine-resistant HBV. This study analyzed adefovir treatment in 42 post-liver transplantation patients who developed recurrent HBV or de novo HBV infection with lamivudine-resistant HBV (54.8% HCV-coinfected). Patients received 10 mg of oral adefovir once daily for a mean period of time of 21.5 months (range from 12 to 31 months). In 62.9% of patients, ALT levels decreased significantly. Serum HBV-DNA was undetectable in 64% of the cases. Twenty percent of patients lost HBeAg marker and 13.3% of them developed anti-HBe. In 9.5% of recipients, HBsAg became negative. There was no significant change in serum creatinine levels. In only one patient was worsening of the renal function detected, making dose adjustment necessary. No other side effects were reported. Our results confirm the efficacy and safety of adefovir treatment in post-liver transplantation patients with lamivudine-resistant HBV, neither were adefovir-resistant mutations identified in patients after 21 months of therapy, nor were there adverse events, especially renal toxicity.

Prospective Interventional Study to Evaluate the Efficacy and Safety of Liposomal Amphotericin B as Prophylaxis of Fungal Infections in High-Risk Liver Transplant Recipients

INTRODUCTION

Invasive fungal infections are a life-threatening complication in transplant recipients. The prevalence of fungal infection after orthotopic liver transplantation (OLT) is 5% to 42%. The most common isolated pathogens are Candida and Aspergillus species. High-risk liver transplant recipients are more susceptible to the development of invasive fungal infections, with prevalence >40% and mortality rates of 78% to 100%. The strategy for fungal prophylaxis in this population has not been defined.

PATIENTS AND METHODS

Among 100 consecutive OLT followed for 28 months, 21 recipients (15 men, overall mean age of 48.5 years, range 23-65 years) were considered to be high risk for the development of fungal infections when they presented at least one of the following criteria: acute liver failure, assisted ventilation >7 days, retransplantation, relaparotomy, antibiotic therapy >14 days, transfusion requirements >20 red blood cells units, and/or biliary leakage. This group received intravenous liposomal amphotericin B (1 mg/kg/d for 7-10 days).

RESULTS

One-year survival in the high-risk group was 80%. Prevalence of invasive fungal infection was 9.5%. No Candida infection was observed. Two patients developed Aspergillus infection: an abdominal aspergillosis treated with percutaneous drainage and liposomal amphotericin B (5 mg/kg/d) showed a favorable clinical outcome. The other patient who developed brain aspergillosis died 25 days after OLT. Adverse events related to the drug were hypokalemia (n = 2), back pain (n = 3), and renal dysfunction (n = 2). None of these events required withdrawal of the prophylaxis regimen.

CONCLUSION

In our series, prophylaxis with liposomal amphotericin B in high-risk liver graft recipients showed a low rate of severe fungal infections. More studies are needed in order to determine the highest risk population and the best drug dosage.

Ribosomal DNA heterochromatin in plants

The aim of this review is to integrate earlier results and recent findings to present the current state-of-the-art vision concerning the dynamic behavior of the ribosomal DNA (rDNA) fraction in plants. The global organization and behavioral features of rDNA make it a most useful system to analyse the relationship between chromatin topology and gene expression patterns. Correlations between several heterochromatin fractions and rDNA arrays demonstrate the heterochromatic nature of the rDNA and reveal the importance of the genomic environment and of developmental controls in modulating its dynamics.

Aberrant expression of tetraspanin molecules in B-cell chronic lymphoproliferative disorders and its correlation with normal B-cell maturation

Tetraspanin proteins form signaling complexes between them and with other membrane proteins and modulate cell adhesion and migration properties. The surface expression of several tetraspanin antigens (CD9, CD37, CD53, CD63, and CD81), and their interacting proteins (CD19, CD21, and HLA-DR) were analyzed during normal B-cell maturation and compared to a group of 67 B-cell neoplasias. Three patterns of tetraspanin expression were identified in normal B cells. The first corresponded to bone marrow CD10(+) B-cell precursors (BCP) which showed high expression of CD81 and CD9, low reactivity for CD53 and negativity for CD37. CD10(-) B-lymphocytes showed downregulation of CD9/CD81 and upregulation of CD53/CD37. Plasma cells showed re-expressed CD9 and downregulated CD37. Hierarchical clustering analysis of flow cytometry immunophenotypic data showed a good correlation between the tumor differentiation stage and the pattern of tetraspanin expression, with all analyzed individual samples classified into three major groups, independently of their normal or neoplastic origin. Despite this, neoplastic B-cells frequently showed aberrantly high/low expression of the different markers analyzed. Interestingly, in B-cell chronic lymphocytic leukemia, abnormal expression of CD53 and CD9 were associated with different patterns of disease infiltration, which would support the role of these molecules on modulating adhesion and migration of neoplastic B cells.

Doppler ultrasonography for the assessment of tumor necrosis after percutaneous ethanol injection prior to liver transplantation as adjuvant therapy of hepatocellular carcinoma

INTRODUCTION

Percutaneous ethanol injection (PEI) is considered to be a curative treatment for hepatocellular carcinoma (HCC). The imaging technique of choice for the assessment of local response after PEI has not been well defined, but helical computerized tomography (hCT) has been recommended. The aim of this study was to assess the accuracy of Doppler ultrasonography (US) for evaluation of tumor necrosis after PEI.

PATIENTS AND METHODS

Twenty-one patients with single HCC listed for liver transplantation underwent multisession US-guided PEI. Liver Doppler US was done at the 4th week after PEI. Complete response was defined as the absence of any intratumoral Doppler signal. The liver was analyzed in transplant recipients during the follow-up. Complete pathological response was defined as necrosis > or = 90% of total tumor volume. Histological and sonographic findings were compared.

RESULTS

Twelve patients underwent transplantation (9 men, mean age 60 +/- 5.2 years). Nine of these (75%) showed a complete ultrasonographic response. In the explanted liver, complete necrosis was present in 6 nodules, and incomplete necrosis was seen in the remaining 6 cases. In comparison with histology, Doppler US showed values of sensitivity, specificity, positive predictive values, and negative predictive values of 50%, 100%, 100%, and 60%, respectively. Overall accuracy was 75%.

CONCLUSIONS

In our series, Doppler US showed low sensitivity but high specificity in the assessment of HCC necrosis after PEI. The ultrasonographic finding of complete response requires hCT for confirmation, but the presence in Doppler US of neoplastic viable tissue is enough to indicate a further cycle of PEI.

Prospective Histopathological Analysis of Hepatocellular Carcinoma Treated With Percutaneous Ethanol Injection in Patients on the Waiting List for Liver Transplantation

INTRODUCTION

Liver transplantation (LT) improves survival in selected patients suffering from hepatocellular carcinoma (HCC). Unfortunately, the long time lapse between indication and LT may cause tumor progression. Thus, percutaneous ethanol injection (PEI) has been proposed as adjuvant therapy of HCC in patients awaiting LT. The efficacy of PEI assessed using histopathological analysis of hepatectomy specimens has not been adequately evaluated.

PATIENTS AND METHODS

Twenty-nine nodules of HCC in 27 patients (21 men; mean age, 58.1 +/- 7.3 years) listed for LT were treated with PEI. Pretreatment mean serum alpha-fetoprotein (AFP) was 11 +/- 13.4 ng/mL. Mean tumor diameter was 30.8 +/- 12.9 mm. Data from the explanted livers after transplantation included percentage tumor necrosis, presence of satellite and distant nodules, vascular invasion, tumor capsule, and grade of differentiation.

RESULTS

Nineteen patients with 20 treated lesions underwent transplantation. The median interval PEI-LT was 3 months. Complete necrosis was observed in 13 nodules (65%). Satellite nodules were present in 10% of lesions. Previously unrecognized distant lesions were seen in 15.8% of patients. Only 1 nodule presented microscopic vascular invasion. Most HCC were well differentiated (90%), and completely encapsulated (80%). No tumor-related deaths occurred. Seventeen patients are alive and recurrence-free after a median follow-up of 15 months.

CONCLUSIONS

PEI may achieve significant necrosis in cases of HCC awaiting LT. Nevertheless, previously unrecognized satellite and distant lesions may be observed. Further studies are needed to evaluate the influence of tumor necrosis on overall survival of these patients.

Gene expression profile reveals deregulation of genes with relevant functions in the different subclasses of acute myeloid leukemia

Bone marrow samples from 43 adult patients with de novo diagnosed acute myeloid leukemia (AML)--10 acute promyelocytic leukemias (APL) with t(15;17), four AML with inv(16), seven monocytic leukemias and 22 nonmonocytic leukemias--were analyzed using high-density oligonucleotide microarrays. Hierarchical clustering analysis segregated APL, AML with inv(16), monocytic leukemias and the remaining AML into separate groups. A set of only 21 genes was able to assign AML to one of these three classes: APL, inv(16) and other AML subtype without a specific translocation. Quantitative RT-PCR performed for 18 out of these predictor genes confirmed microarray results. APL expressed high levels of FGF13 and FGFR1 as well as two potent angiogenic factors, HGF and VEGF. AML with inv(16) showed an upregulation of MYH11 and a downregulation of a gene encoding a core-binding factor protein, RUNX3. Genes involved in cell adhesion represented the most altered functional category in monocytic leukemias. Two major groups emerged from the remaining 22 AML: cluster A with 10 samples and cluster B with 12. All the eight leukemias that were either refractory to treatment or that relapsed afterwards were assigned to cluster B. In the latter cluster, CD34 upregulation and serine proteases downregulation is consistent with a maturation arrest and lack of granulocytic differentiation.

Different numbers of rye B chromosomes induce identical compaction changes in distinct A chromosome domains

In rye each B chromosome (B) represents 5.5% of the diploid A genome. Rye Bs have several nuclear to whole plant effects although they seem to bear no genes except for the ones that lead to their maintenance within a population. In this context, and considering that rye Bs are enriched in repetitive non-coding regions that build up heterochromatin (het), we investigated the influence of Bs on the organization of two chromatin fractions, namely the ribosomal DNA (facultative het) and satellite (non-het) domain of rye chromosome 1 by silver staining on root tip metaphase cells. The results show that rye Bs cause condensation both in the NOR and in the chromosome 1 satellite domain. Since the silver staining technique used is indicative of the transcriptional activity of the NORs, the condensation observed at those loci demonstrates that the rRNA gene arrays are down-regulated in the presence of Bs, regardless of their number per individual. Furthermore, the organizational changes of metaphase NORs find parallel with the interphase organization of ribosomal chromatin, since the frequency of cells with intranucleolar condensed rDNA regions increases drastically and nuclear matrix attachment pattern is altered in the presence of the Bs. Our results show an identical effect of the Bs on the organization of two distinct chromosome domains displaying a presence/absence dichotomy.

Preparation of single cell detritus from Laminaria saccharina as a hatchery diet for bivalve mollusks

A high-yield technique is described for the elaboration of single cell detritus (SCD) from Laminaria saccharina, based on the sequential action of C1H, enzymes (endoglucanases and cellulases) and 2 bacteria showing a high degree of cellobiotic, proteolytic, and alginolytic activity (CECT 5255 and CECT 5256). Over 85% of dried particles of L. saccharina were transformed into a suspension of free cell and bacterial and detrital particles after 24 hours of bacterial activity with this technique. These particles were less than 20 mum in diameter, constituting a suitable diet for bivalve mollusks. After 72 hours 99% of the total particulate volume consisted of particles less than 20 mum in diameter. Tests of hatchery diets for the seed of clam Ruditapes decussatus revealed increases of 54% and 68% for live weight and length, respectively, when SCD from L. saccharina was used as the sole dietary component compared with a live phytoplankton diet. However, SCD from L. saccharina is not a suitable food for the larvae of R. decussatus.

Localized Fibrous Tumors of the Pleura: Experience With 7 Recent Cases

OBJECTIVE

Localized fibrous tumors of the pleura are rare. We report 7 cases and review the literature in order to define the range of clinical characteristics of these tumors, treatment options, and prognosis.

METHODS

A retrospective review of 7 cases treated between 1997 and 2003, focusing on clinical presentation, diagnostic tests, and treatment. The tumor was removed surgically in all cases, by thoracotomy in 6 cases and by video-assisted thoracoscopic surgery in 1 patient.

RESULTS

All patients recovered fully after surgery, with no postoperative complications. One patient experienced recurrence twice, 33 and 67 months after the initial resection. All are alive at the time of writing, after a mean follow up period of 19 months (range 1 month to 5 years and 10 months).

CONCLUSIONS

The treatment of choice for a fibrous tumor of the pleura is full resection and follow-up to detect possible late recurrence.

Polymorphisms within the promoter and the intron 2 of the serotonin transporter gene in a population of bulimic patients

The serotonin transporter (5-HTT) gene is a firm candidate to explain eating disorders. In this association study, two different polymorphisms were analysed: a variable number of tandem repeat (VNTR) polymorphism in intron 2 and a deletion/insertion polymorphism (5-HTTLPR) in the promoter region. The hypothesis that these gene polymorphisms may be a susceptibility factor in bulimia nervosa (BN) was explored in a female population of 102 purgative bulimics. BN patients who have suffered preceding anorexia nervosa (AN) episodes formed the so-called previous AN bulimic patient group. In our sample of normal-eater controls and purging type bulimics, regardless of whether or not the BN patients had suffered prior AN episodes, no differences were found considering the frequencies of genotypes, alleles or haplotypes of both polymorphic regions of the 5-HTT gene.

[Current census rates in inpatients hospitalized in the Hospital de Poniente in Almería [Spain]]

OBJECTIVE

To study the current census rate of patients admitted to an internal medicine service.

METHOD

We studied all patients admitted to the internal medicine service from January 1 to August 31, 2000 whose addresses were registered in four local authorities of our hospital district. We made exhaustive searches to ascertain whether these patients were included in the register in September 2000.

RESULTS

We analyzed 1,095 admissions from a total of 1,759 up to August 31, 2000. Twenty-four percent corresponded to patients who were not registered. Fifty-eight percent of those not registered were aged more than 70 years. Twenty-seven percent of patients aged less than 40 years, most of whom were immigrants, were also unregistered.

CONCLUSIONS

Twenty-four percent of the admissions to the internal medicine service that were studied corresponded to patients who were not registered with their respective local authorities. A possible explanation is the large immigrant population and the lack of registration among the elderly.

Vasoactive intestinal peptide and pituitary adenylate cyclase-activating polypeptide: players in innate and adaptive immunity

Recent reports identified and described neural pathways, both hard-wiring and soluble mediators, that control and adjust the peripheral immune response. Immune organs are innervated by fibers rich in neurotransmitters and neuropeptides released in inflammatory conditions. Here we focus on the immunomodulatory role of two peptides, the vasoactive intestinal peptide (VIP) and the pituitary adenylate cyclase-activating polypeptide (PACAP). VIP/PACAP are present and released from both innervation and immune cells, particularly Th2 cells, and immune cells express receptors for VIP/PACAP. VIP/PACAP have a general anti-inflammatory effect, both in innate and adaptive immunity. In innate immunity, VIP/PACAP inhibit the production of pro-inflammatory cytokines and chemokines from macrophages, microglia and dendritic cells. In addition, VIP/PACAP reduce the expression of costimulatory molecules (particularly CD80 and CD86) on the antigen-presenting cells, and therefore reduce stimulation of antigen-specific CD4+ T cells. In terms of adaptive immunity, VIP/PACAP promote Th2-type responses, and reduce the pro-inflammatory Th1-type responses. Several of the molecular mechanisms involved in the inhibition of cytokine and chemokine expression, and in the preferential development and/or survival of Th2 effects, are discussed.

MRI shows abnormal white matter maturation in classical holoprosencephaly

In an attempt to assess white matter maturation in holoprosencephaly (HPE), MRI scans of 47 patients with HPE were retrospectively reviewed. White matter maturation was delayed in 25/47 patients, including 24/29 patients with classic HPE who were </=12 months old at the time of imaging. Of interest, all six patients with the middle interhemispheric (MIH) variant of HPE had normal myelination, regardless of age. This study provides further evidence that the classic and MIH variants of HPE have different underlying causes.

Identification of selective inhibitors of acetylcholinesterase from a combinatorial library of 2,5-piperazinediones

The potentiation of central cholinergic activity has been proposed as a therapeutic approach for improving cognitive function in patients with Alzheimer's disease. Increasing the acetylcholine concentration in brain by modulating acetylcholinesterase (AChE) activity is among the most promising strategies. We have used a combinatorial approach to identify different 2,5-piperazinediones (DKP) with AChE inhibitory activity. Our goal was to find inhibitors exhibiting high AChE/BuChE (butyrylcholinesterase) selectivity, in order to reduce the undesirable side effects elicited by most of the inhibitors that have been developed to date. Screening of a DKP library constructed on solid-phase using the multiple parallel synthesis format, resulted in the identification of several compounds with moderate efficacy on AChE. In particular, DKP-80 had an IC50 = 2.2 microM with no significant inhibitory activity on BuChE. Moreover, estimated values of Clog P and log BB for the most active compounds fulfilled the bioavailability requirements for enzyme inhibitors acting on the central nervous system. In order to understand the inhibitory properties of the ligand at the molecular level, molecular dynamics simulations were computed on DKP-80 complexed to AChE, and the most relevant binding interactions of this inhibitor to the active center of the enzyme were characterized. Overall the present results indicate that the DKP-based compounds identified are novel AChE inhibitors which may be considered likely lead compounds for further development of drug candidates against Alzheimer's disease.

Smoking as a risk factor for preinvasive and invasive cervical lesions in female sex workers in Venezuela

OBJECTIVES

To determine whether the number of cigarettes smoked per day and years of smoking were risk factors for preinvasive and invasive cervical lesions in Venezuelan female sex workers.

METHODS

The clinical history of 438 female sex workers (FSWs) was taken and each received a gynecological examination, a Pap smear, and a colposcopic examination. A colposcopically-guided cervical biopsy was taken when the epithelium appeared abnormal.

RESULTS

The FSWs' mean age was 32.16+/-8 years. Age at first sexual intercourse was 15.9+/-2 years, parity was 4.1+/-2.3, live births were 3+/-3, and age at first delivery was 16.6+/-4.7 years. Cervical biopsies were performed in 84 FSWs. Sixty-four of them (76.2%) had preinvasive or invasive lesions and 47 (73.4%) were current smokers (Relative Risk) (RR), 1.26; 95% confidence interval (CI), 1.02-1.55; P<0.03]. FSWs who smoked more than 20 cigarettes per day had an increased RR to get a premalignant or malignant cervical lesion (RR, 1.27; 95% CI, 1.02-1.52; P<0.03). There was no statistically significant difference between FSWs who smoked 20 cigarettes or more per day and FSWs who smoked less than 20 cigarettes per day (RR, 1.36; 95% CI, 0.81-2.29; P<0.25). FSWs who had been smoking for 5 years or more were at risk to develop preinvasive or invasive cervical lesions (RR, 1.37; 95% CI, 1.01-1.86; P<0.04).

CONCLUSIONS

The risk for FSWs to develop preinvasive or invasive cervical lesions increased with the number of cigarettes they smoked per day and their years of smoking.

Vasoactive intestinal peptide in the immune system: potential therapeutic role in inflammatory and autoimmune diseases

Vasoactive intestinal peptide (VIP), a neuropeptide that is produced by lymphoid as well as neural cells, exerts a wide spectrum of immunological functions, controlling the homeostasis of the immune system through different receptors expressed in various immunocompetent cells. In the last decade, VIP has been clearly identified as a potent anti-inflammatory factor, which acts by regulating the production of both anti- and pro-inflammatory mediators. In this sense, VIP has been described to prevent death by septic shock, an acute inflammatory disease with a high mortality. In addition, VIP regulates the expression of co-stimulatory molecules, this being an action that may be related to modulating the shift toward Th1 and Th2 differentiation. We have recently reported that VIP prevents the deleterious effects of an experimental model of rheumatoid arthritis, by downregulating both inflammatory and autoimmune components of the disease. Therefore, VIP has been proposed as a promising candidate alternative treatment for acute and chronic inflammatory and autoimmune diseases such as septic shock, arthritis, multiple sclerosis, Crohn disease, or autoimmune diabetes.

Three days fast in sportsmen decreases physical work capacity but not strength or perception-reaction time

This study investigates, in young nonobese healthy athletes, the consequences of a 3-day fast coupled, or not, to enhanced physical activity. Eight male subjects, aged 21+/-2 years, fasted for 3 days on two separate occasions, 4 weeks apart. On the first occasion, subjects continued their daily training activities. On the second occasion, a daily physical exercise program was added to these activities. Subjects were evaluated before and after 24 hours and 72 hours of fasting. Evaluation consisted of body composition, basal respiratory exchange ratio, plasma metabolic parameters, perception-reaction time (both simple and discriminant), hand grip strength, and physical work capacity at 170 beats per minute (PWC170). Fasting determined significant reductions in body weight, body fat, and muscle mass. These reductions were not affected by enhanced physical activity. Basal respiratory exchange ratio decreased with fasting but was not influenced by increased training activities. Fasting determined a significant decrease in blood glucose levels, while plasma proteins, urea, uric acid, and free fatty acids increased. Perception-reaction time and hand grip strength were unmodified during fasting. By contrast, PWC170 was significantly and progressively reduced during fasting, and this decrease was not reversed by an increase in training activities.

Safety and preliminary immunogenicity of the recombinant outer membrane protein P64k of Neisseria meningitidis in human volunteers

P64k is a meningococcal protein from Neisseria meningitidis that has been obtained by recombinant DNA technology. Recombinant P64k has been extensively characterized by physicochemical and immunological methods. Lately this protein has been found to act as a versatile immunological carrier for weak antigens in mice. In the present work, a Phase I clinical trial was carried out in healthy volunteers who received three inoculations of either placebo or recombinant P64k (20 or 50 microg). No severe adverse events occurred during the trial. Only mild adverse events in ten volunteers were observed. At 1 month after the third dose, 15 out of 18 volunteers (83.3%) who received the recombinant antigen had a P64k-specific antibody titre > or =1:100, as detected by ELISA. A fourth dose, given 9 months after the third one, elicited a potent booster immune response in P64k vaccinees. Accordingly, these P64k formulations were considered safe and immunogenic in healthy human volunteers.

Immunisation with phage-displayed variable region 2 from meningococcal PorA outer membrane protein induces bactericidal antibodies against Neisseria meningitidis

The immunogenicity and functional activity of antibodies raised in mice against the cyclic disulphide peptide corresponding to the variable region 2 of PorA outer membrane protein from Neisseria meningitidis strain B385 (serosubtype P1.15), displayed on filamentous phage, were evaluated. The epitope, flanked either by cysteine or cysteine and three glycine residues, was expressed as a fusion to PVIII protein from M13. Immunisation of Balb/C mice with either phage generated antibody specific responses. Sera raised against the phage exposing the cyclic peptide through the three-glycine linker recognised the native protein better than those raised against the peptide with no linker. Only the phage displaying the cyclic peptide with linker was capable of inducing antibodies with bactericidal activity. These results indicate the possibility of using phage display for conformational peptide expression for immunisation to elicit functional antibody responses.

TH2 lymphocytes secrete functional VIP upon antigen stimulation

In addition to the peptidergic innervation, immune cells may also represent a source for VIP in the lymphoid organs. Previous studies reported increased VIP mRNA and protein expression in mitogen-stimulated B and T lymphocytes. To determine whether specific T cell subsets are responsible for VIP production, we derived TH1 and TH2 effector cell lines from T-cell receptor transgenic mice. TH1 and TH2 cells were stimulated with the specific (pigeon cytochrome C peptide) or nonspecific (ovalbumin) antigen presented by MHC class II compatible antigen-presenting cells. Upon stimulation with the specific antigen, TH2, but not TH1 cells express VIP mRNA and intracelllular VIP protein, as determined by Northern blots and FACS analysis. Supernatants harvested from antigen-stimulated TH2 cells contain secreted VIP, as determined by Elisa, and induce cAMP in HEK293 cells transfected with the specific VIP/PACAP receptor VPAC1. These results confirm that TH2, but not TH1 cells, express and secrete functional VIP following specific antigen stimulation. The release of VIP within the lymphoid microenvironment following antigenic stimulation provides a physiological basis for the immunoregulatory effects of VIP on neighboring immune cells, such as downregulation of macrophage activation, effects on lymphocyte migration, on antigen-induced T cell apoptosis, and on T cell differentiation.

Cyto-colpo-histological Study in Sexual Workers

OBJECTIVE

To determine the false-negative, false-positive, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) rates of Pap smears and colposcopy in sexual workers.

MATERIALS AND METHODS

Four hundred thirty-eight prostitutes were given a gynecological examination, Pap smear, and colposcopic examination of the cervix. A cervical biopsy was taken under colposcopic guidance when there was abnormal epithelium.

RESULTS

There were 81 premalignant and malignant lesions. Twenty-two Pap smear reports were abnormal: 17 CIN1, four CIN2, and one CIN3. Pap smears had a 14.4% false-negative rate, 0.9% false-positive rate, sensitivity 22.2%, specificity 98.8%, NPV 84.4%, and PPV 81.8%. Eighty-four biopsies were taken from abnormal colposcopic findings, and 96.4% were reported as premalignant and malignant lesions. Colposcopy had a 0.8% false-positive rate, sensitivity 100%, specificity 99.2%, NPV 100%, and PPV 96.4%.

CONCLUSIONS

Pap smear had a low-sensitivity and colposcopy had a high sensitivity and specificity.

VIP and PACAP enhance the in vivo generation of memory TH2 cells by inhibiting peripheral deletion of antigen-specific effectors

In an immune response, antigen-specific CD4 T cells proliferate and differentiate into effector cells capable to produce large amounts of cytokines upon restimulation. Most effector T cells are later eliminated through antigen-induced cell death (AICD), mediated through FasL/Fas interactions. A low percentage of effector T cells survive and differentiate into long-lived memory cells. Mechanisms must operate not only to destroy no longer needed and even potentially damaging T cells, but also to allow the survival of a small number of activated T cells. Little is known about the factors and mechanisms that regulate the shift from an apoptosis-sensitive to an apoptosis-resistant phenotype. VIP and the structurally related peptide, PACAP, synthesized and/or released in the immune organs act on both innate and adaptive immunity. Recently, VIP and PACAP were shown to inhibit AICD in peripheral CD4 T cells by down-regulating FasL expression. In view of these findings, VIP and PACAP are reasonable candidates for the generation of memory T cells. To test this hypothesis, we analyzed the effects of VIP and PACAP in various models for effector and memory T cells. Our data demonstrate that both neuropeptides promote the in vivo effector function and memory phenotype of Th2, but not Th1 cells, by preferentially inhibiting the clonal deletion of Th2 cells. To our knowledge, this is the first report describing the role of a neuropeptide present in the lymphoid microenvironment on the generation and maintenance of long-lived memory T cells.

Inhibition of endotoxin-induced macrophage chemokine production by VIP and PACAP in vitro and in vivo

Inflammatory chemokines recruit immune cells which initiate and maintain the inflammatory response. Although such a response is necessary for the elimination of the antigen, the inflammation has to be eventually resolved. Peptides such as vasoactive intestinal peptide (VIP) and pituitary adenylate cyclase-activating polypeptide (PACAP), released following antigenic stimulation, contribute to the termination of an inflammatory response primarily by inhibiting the production of proinflammatory cytokines. Here we investigated the effects of VIP and PACAP on chemokine production. We report that VIP and PACAP inhibit the expression of the macrophage-derived CXC chemokines MIP-2 and KC (IL-8), and of the CC chemokines MIP-1a, MIP-1b, MCP-1 and RANTES in vivo and in vitro. The decrease of chemokine gene expression correlates with an inhibitory effect of VIP/PACAP on NFkB binding. In an in vivo model of acute peritonitis, the inhibition of chemokine production by VIP/PACAP leads to a significant reduction in the recruitment of PMNs, macrophages and lymphocytes into the peritoneal cavity. These findings support the proposed role of VIP and PACAP as key endogenous anti-inflammatory agents, and describe a novel mechanism, i.e., the inhibition of the production of macrophage-derived chemokines.

Pituitary adenylate cyclase-activating polypeptide inhibits collagen-induced arthritis: an experimental immunomodulatory therapy

Rheumatoid arthritis is a chronic, systemic, autoimmune, and inflammatory disorder that affects the synovial lining of the joints. We describe the beneficial effects of the pituitary adenylate cyclase-activating polypeptide (PACAP) in the collagen-induced arthritis experimental murine model being proposed as a novel therapeutic approach in the treatment of rheumatoid arthritis. PACAP greatly decreases arthritis frequency and severity in the studied mice by improving clinical symptoms, ameliorating joint damage, and blocking both the inflammatory and autoimmune mediators which are the main keys of the pathogenesis of this disease. With this study, PACAP emerges as a promising candidate for the treatment of a pathology with a high world incidence but currently no effective treatment.

Sedation for gastrointestinal endoscopy. Analysis of tolerance and complications

OBJECTIVE

To analyse tolerance and complications in patients undergoing a gastrointestinal endoscopy.

PATIENTS AND METHODS

One hundred forty three patients were prospectively studied: 44.8% underwent a diagnostic upper endoscopy; 13.3%, a therapeutic upper endoscopy; 37%, a diagnostic colonoscopy and 4.9%, a therapeutic colonoscopy. Midazolam or midazolam combined with meperidine were used. Tolerance, level of sedation and complications were studied. Chis quare and ratio comparison tests were used for the statistical analysis. P-values less than 0.05 were considered as statistically significant.

RESULTS

In the diagnostic upper endoscopy group, tolerance was better with midazolam plus meperidine vs midazolam only (83.8% and 59.3% respectively); p < 0.05. In the therapeutic upper endoscopy group, tolerance was also better when both drugs were combined; p < 0.05. In the diagnostic and therapeutic colonoscopy groups, tolerance was good in 63.5% and 85.7% of patients, respectively. Men had better tolerance for upper endoscopy; p < 0.05. Tolerance was worse in patients under 40 years of age for upper endoscopy; p < 0.05. Mild desaturation occur in 27.3% of patients, being more severe in therapeutic procedures; p < 0.05.

CONCLUSIONS

Tolerance was good in a high percentage of patients, and better in men and in patients older than 40 years of age. The main problem is desaturation, that increases in therapeutic procedures.

The dorsal cyst in holoprosencephaly and the role of the thalamus in its formation

The dorsal cyst is poorly understood, although it is commonly encountered in holoprosencephaly. We endeavor to establish the role of diencephalic malformations in the formation of the dorsal cyst and speculate on the developmental factors responsible. We reviewed the imaging of 70 patients with holoprosencephaly (MRI of 50 and high-quality CT of 20). The presence or absence of a dorsal cyst, thalamic noncleavage and abnormal thalamic orientation were assessed for statistical association, using Fisher's Exact Test and logistical regression. The presence of a dorsal cyst correlated strongly with the presence of noncleavage of the thalamus (P = 0.0007) and with its degree (P < 0.00005). There was a trend toward an association between abnormalities in the orientation of the thalamus and the dorsal cyst, but this was not statistically significant (P = 0.07). We speculate that the unseparated thalamus physically blocks egress of cerebrospinal fluid from the third ventricle, resulting in expansion of the posterodorsal portion of the ventricle to form the cyst.