Nasopharyngeal carcinoma: Comparison of concomitant chemoradiotherapy with neoadjuvant chemotherapy in the caucasian population

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Background: Nowadays, concomitant chemoradiotherapy (CT-RT) is the standard treatment for nasopharyngeal carcinoma (NPC). Neoadyuvant chemotherapy (CT) has been investigated without definitive conclusions. The aim of this study is to compare results of patients(pts) treated with neoadyuvant CT with those treated with concurrent CT-RT. Methods: 38 pts with histologically proven NPC stage II-IVb (PS 0–2) were treated. 27 pts (71.1%) (Group A) (June 1994-May 2000) received Cisplatin (P) 100 mg/m2, Epirrubicin (E) 70 mg/m2, Bleomicin (B) 15 mg D1 and B 12 mg/m2 continous infusion (c.i) for 5 days every 3 week with sequential RT. The other 11 pts (28.9%) (Group B) (June 2002-August 2006) received P 100 mg/m2 D1, D22 and D43 concurrent with RT followed by adyuvant CT P 80 mg/m2 and 5-Fluorouracil 1,000mg/m2/d D1-D4 c.i every 28 day for 3 cycles. Results: 38 pts: 30 male(79%), 8 female(21%). Median age: 53(range 15–75). Stages:II:7, III:11, IVA:12, IVB:8(AJCC 2002). Histology:WHO I-II:11, WHO III:27. Overall response rate: Group A: 25/27 (92.5%), Group B: 10/11 (90.9%) p=0.65. Group A: CR: 17/27 (62.9%); PR: 8/27 (29.6%); PD: 1/27( 3.7%). Group B: CR: 8/11(72.7%); RP: 2/11 (18.1%). 1 pts of each group was not evaluated. Median overall survival (OS) was 34 months (m) in Group A and has not been reached in Group B. Estimated 3 years OS was 48% in GroupA and 80% in GroupB. Median progression free survival (PFS) was 42 m in Group A and 45 m in Group B p=0.72. Estimated 3 years PFS was 50.6% and 66.7% respectively. In the multivariate analysis concurrent CT-RT (HR=5.94 p=0.03) and stage (HR=0.17 p=0.01) were associated with OS. There was 2 toxic death in Group A. The most common toxicities was; Group A: bone marrow suppresion, nausea; Group B: mucositis. Conclusions: These data suggest that P based concomitant CT-RT improves OS and PFS compared with neoadyuvant CT (BEC) followed by RT.

No significant financial relationships to disclose.

Kyste synovial articulaire postérieur lombaire révélé par un syndrome pluriradiculaire : à propos de deux cas

INTRODUCTION

Multiradicular nerve root compression, and long lasting radicular syndrome occur very often. They happen particularly on degenerative spine. Huge synovial cyst of the zygapophyseal joints may account for it, expand in the epidural area and cause radicular syndrome.

EXEGESIS

Two cases of huge synovial cysts spreading into the spinal channel are reported here. Diagnostic and therapeutic modalities are discussed. On degenerative spine, facet joints osteoarthritis may result in synovial cysts. Physical examination findings are radicular syndrome.

CONCLUSION

Huge synovial cysts may result in multiple nerve root compression syndrome, as reported in our two cases. Typically, there's no history of preceding trauma and symptoms appear progressively. Magnetic resonance imaging of the spine shows an intra-spinal round mass with typical signal intensity and capsular formation. Treatment consists either in facet joint steroid injection performed with radiologic guidance or in surgical excision.

Diagnosis and management of acute pancreatitis

Acute pancreatitis usually occurs as a result of alcohol abuse or bile duct obstruction. A careful review of the patient's history and appropriate laboratory studies can help the physician identify the etiology of the condition and guide management. Serum amylase and lipase levels are still used to confirm the diagnosis of acute pancreatitis. Although not routinely available, the serum trypsin level is the most accurate laboratory indicator for pancreatitis. Ultrasonography, computed tomography and endoscopic retrograde cholangiopancreatography are additional modalities that can help the family physician choose the best treatment approach. Prompt identification of patients who need intensive care referral or subspecialty consultation is crucial. The APACHE II and the multiple organ system failure scales provide prognostic information at the time of admission and may be repeated daily to monitor disease progression. Therapies such as nasogastric suctioning, anticholinergics and histamine H2-receptor blockers have not been shown to decrease symptoms or hospital stays in patients with acute pancreatitis. Systemic antibiotics have been found to improve outcome in patients with severe disease. With supportive care, most patients have a good clinical outcome.

Allantoate amidinohydrolase (Allantoicase) from Chlamydomonas reinhardtii: its purification and catalytic and molecular characterization

An allantoate-degrading enzyme has been purified to electrophoretic homogeneity for the first time from a photosynthetic organism, the unicellular green algae Chlamydomonas reinhardtii. The purification procedure included a differential protein extraction followed by conventional steps such as ammonium sulfate fractionation, gel filtration, anion exchange chromatography, and preparative electrophoresis. Under the routine assay conditions (7 mM allantoate), specific activity for the purified enzyme was 185 U/mg, which rose to 225 U/mg under kinetic considerations (saturating substrate). Therefore, a turnover number of 4.5 x 10(4) min(-1) can be deduced for the 200-kDa protein. The enzyme is a true allantoicase (EC 3.5.3.4) that catalyzes the degradation of allantoate to (-)ureidoglycolate and (+)ureidoglycolate to glyoxylate. The enzyme exhibited hyperbolic kinetic for allantoate and ureidoglycolate with K(m) values of 2 and 0.7 mM, respectively. V(max) of the reaction with allantoate as substrate was nine times higher than that with ureidoglycolate. The native enzyme has a molecular weight of 200 kDa and consists of six identical or similar-sized subunits of 34 kDa each, organized in two trimers of 100 kDa. Each subunit has five cysteine residues, four of which are involved in disulfide bonds, with a total of 12 disulfide bonds in the 200-kDa protein. Allantoate inhibits competitively the reaction with ureidoglycolate as substrate. In addition, buffers and group-specific reagents affect the activity in the same manner irrespective of the substrate used. Those results suggest that both substrates use the same active site. The effect of group-specific reagents suggest that the amino acids histidine, tyrosine, and cysteine are essentials for the allantoicase activity with both substrates.

OESCLIM: an advanced delivery system for HRT

AIMS

Transdermal estradiol offers a number of advantages over traditional oral routes of hormone replacement therapy (HRT) because it is not subject to the hepatic first-pass effect. However, transdermal systems need to balance adhesion, tolerability, and flux if they are to be effective. OESCLIM is a transdermal 17-beta estradiol HRT system designed to address the problems of conventional transdermal patches and offer optimal adhesion and tolerability in an effective HRT system. This paper reviews some of the data on OESCLIM with reference to its delivery system.

RESULTS

The innovative technology used in OESCLIM results in a smooth pharmacokinetic profile throughout the 3-4 day application period. In recent pharmacokinetic studies, OESCLIM 50 provided a more consistent release of hormone than Estraderm TTS 50 and higher mean estradiol levels than Systen and Vivelle. This smooth pharmacokinetic profile is also maintained whether OESCLIM is attached to different body sites. The local skin tolerability of OESCLIM is good. One study reported that OESCLIM 50 caused less than half the number of skin reactions as Estraderm TTS 50 (4.2% compared to 9.5%). OESCLIM has also been shown to have fewer detachments than Estraderm TTS (6% compared to 11%). Both differences were statistically significant (P < 0.001). A study has shown OESCLIM to be as effective as Estraderm TTS at reducing vasomotor symptoms even in highly symptomatic women.

CONCLUSION

OESCLIM is a very good first-line choice for estrogen replacement therapy (ERT) or HRT providing effective therapy with optimum adhesion, flux and tolerability profiles.

Hormone-activated nuclear receptors inhibit the stimulation of the JNK and ERK signalling pathways in endothelial cells

Glucocorticoid hormones, retinoids, and vitamin D3 display anti-angiogenic activity in tumor-bearing animals. However, despite their in vivo effect on the tumor vasculature little is known about their mechanism of action. Here we show that the synthetic glucocorticoid dexamethasone (Dex) and retinoic acid (RA) inhibit the activation of c-Jun N-terminal kinase (JNK) and extracellular-regulated kinase (ERK) signalling pathways by the pro-angiogenic agents tumor necrosis factor and vascular endothelial growth factor in endothelial cells. In contrast, Dex and RA failed to inhibit the activation of the p38 mitogen-activated protein kinase cascade. As a number of pro-angiogenic factors activate AP-1 transcription factor via the JNK and ERK pathways, our results suggest that the antagonism with AP-1 may underlie at least partially the anti-angiogenic effect of glucocorticoids and retinoids.

Patterns of HIV-1 evolution in individuals with differing rates of CD4 T cell decline

Evolution of HIV-1 env sequences was studied in 15 seroconverting injection drug users selected for differences in the extent of CD4 T cell decline. The rates of increase of either sequence diversity at a given visit or divergence from the first seropositive visit were both higher in progressors than in nonprogressors. Viral evolution in individuals with rapid or moderate disease progression showed selection favoring nonsynonymous mutations, while nonprogressors with low viral loads selected against the nonsynonymous mutations that might have resulted in viruses with higher levels of replication. For 10 of the 15 subjects no single variant predominated over time. Evolution away from a dominant variant was followed frequently at a later time point by return to dominance of strains closely related to that variant. The observed evolutionary pattern is consistent with either selection against only the predominant virus or independent evolution occurring in different environments within the host. Differences in the level to which CD4 T cells fall in a given time period reflect not only quantitative differences in accumulation of mutations, but differences in the types of mutations that provide the best adaptation to the host environment.

Randomised trial of effect of amiodarone on mortality in patients with left-ventricular dysfunction after recent myocardial infarction: EMIAT. European Myocardial Infarct Amiodarone Trial Investigators

BACKGROUND

Ventricular arrhythmias are a major cause of death after myocardial infarction, especially in patients with poor left-ventricular function. Previous attempts to identify and suppress arrhythmias with various antiarrhythmic drugs failed to reduce or actually increase mortality. Amiodarone is a powerful antiarrhythmic drug with several potentially beneficial actions, and has shown benefit in several small-scale studies. We postulated that this drug might reduce mortality in patients at high risk of death after myocardial infarction because of impaired ventricular function, irrespective of whether they had ventricular arrhythmias.

METHODS

The European Myocardial Infarct Amiodarone Trial (EMIAT) was a randomised double-blind placebo-controlled trial to assess whether amiodarone reduced all-cause mortality (primary endpoint) and cardiac mortality and arrhythmic death (secondary endpoints) in survivors of myocardial infarction with a left-ventricular ejection fraction (LVEF) of 40% or less. Intention-to-treat and on-treatment analyses were done.

FINDINGS

EMIAT enrolled 1486 patients (743 in the amiodarone group, 743 in the placebo group). Median follow-up was 21 months. All-cause mortality (103 deaths in the amiodarone group, 102 in the placebo group) and cardiac mortality did not differ between the two groups. However, in the amiodarone group, there was a 35% risk reduction (95% CI 0-58, p = 0.05) in arrhythmic deaths.

INTERPRETATION

Our findings do not support the systematic prophylactic use of amiodarone in all patients with depressed left-ventricular function after myocardial infarction. However, the lack of proarrhythmia and the reduction in arrhythmic death support the use of amiodarone in patients for whom antiarrhythmic therapy is indicated.

Subcutaneous versus intravenous low-dose IL-2 therapy after autologous transplantation: results of a prospective, non-randomized study

Use of IL-2 therapy after autologous transplantation is currently being explored to reduce relapse rate. Low doses of the cytokine induce significant immunomodulation avoiding the severe side-effects associated with high-dose IL-2 therapy. However, low-dose IL-2 is usually given by continuous infusion through central venous lines with the consequent risks of thrombosis and infections. Twenty-six consecutive patients who received autologous transplants received low-dose IL-2 after stable engraftment had been achieved. The first 13 patients (group A) were scheduled to receive 400,000/IU/m2/day for 3 months by continuous intravenous infusion. Ten of these patients suffered infectious episodes, mainly bacteriemias that often necessitated delaying IL-2 therapy (median delivered dose: 32% of planned). The next 13 patients were then assigned to receive IL-2 (800,000-1,000,000 IU/m2/day for 3 months) subcutaneously (group B). For group B patients, median dose intensity was 84% (P = 0.01 when compared with group A patients). Only one severe infectious episode was observed in these patients. Clinical toxicity in group B patients consisted mainly of s.c. nodules. Immunomodulation, measured as an increase in the absolute number of CD56+ cells and CD56+(bright) cells, was higher in patients who received the cytokine by the subcutaneous route (median peak increase of CD56+ cells: 160 and 220% for group A and B patients respectively; median peak increase of CD56+(bright) cells: 210% and 310% for group A and B respectively, P < 0.05 between groups A and B). No statistically significant increment of T lymphocytes was observed in any group. No hematologic toxicity was observed apart from eosinophilia, which was very marked in group B (P < 0.01). Our results show that low-dose s.c. IL-2 therapy is associated with low clinical and hematologic toxicity after autologous transplantation. The immunomodulation achieved is no less than that achieved with the i.v. approach.

Stoichiometry and cluster specificity of copper binding to metallothionein: homogeneous metal clusters

Experiments were done to define the stoichiometry of binding of Cu(I) to metallothionein (MT) and to determine its sites of binding in mixed-metal species. Spectrophotometric titrations of rabbit liver Cd7-MT 2, apoMT, and Cd4-alpha-domain with Cu(I) revealed endpoints of 3-4, 4 and 8, and 4 and 6-7 added Cu(I)/mol of MT for the three species respectively. Observed endpoints depended on conditions of the titration and the wavelength chosen for absorbance measurement. Nevertheless, from metal and sulphydryl analyses of titrated proteins that were pretreated with Chelex-100 to remove metal ions from solution, almost all of the cadmium was displaced from Cd7-MT by the addition of 7 Cu(I)/mol of MT. Similarly, 4 Cu(I)/mol of Cd4-alpha-domain completely displaced bound cadmium. The Cu4-alpha-domain was converted into a Cu6-alpha species upon addition of two equivalents of Cu(I)/mol of alpha-domain. Reaction of Cd7-MT with 7, 12 and 20 Cu/mol of MT, followed by reaction with Chelex resin, generated protein samples in each case with about 7 Cu/mol of MT. 111Cd-NMR analysis of the reaction of 111Cd7-MT with Cu(I) showed that nearly co-operative one-for-one replacement of 111Cd occurred and that the beta-domain cluster reacted before the alpha-domain cluster. Two mixed-metal MTs with Cu to Zn ratios approximating 3 to 4 and 6 to 4 were isolated from calf liver. After substitution of Zn with 111Cd, NMR spectra of each protein showed that 111Cd was confined almost completely to the alpha-domain. By inference, about 3 or 6 Cu were bound in the beta-domain of these proteins. Supporting this segregation of metal ions into domains, reaction of Cu6, Zn4-MT with nitrilotriacetate removed zinc exclusively, whereas reaction of Cu6,Cd4-MT with 4,7-phenylsulphonyl-2,9-dimethyl-1,10-phenanthroline extracted only Cu(I). Proteolytic digestion of both products followed by gel filtration demonstrated that Cu(I) and Cd were bound to fragments of the intact protein. Finally, reaction of rabbit liver 111Cd7-MT 2 with Cu10-MT 2 resulted in interprotein metal exchange in which 111Cd-moved from the beta- to the alpha-domain according to NMR analysis. In contrast with the prevalent view that six Cu(I) bind to each domain of MT, the present results show that Cu(I) binds to MT with a minimum stoichiometry of about 7 Cu(I)/mol of MT and can bind to the alpha-domain with stoichiometries of 4 or 6 Cu(I)/mol of MT. Although MTs interacting with 12 or 20 Cu(I)/mol of MT are less stable than that binding about 7 Cu(I)/mol, it appears that MT can bind Cu(I) in multiple stoichiometries.

An evaluation of the antioxidant and antiviral action of extracts of rosemary and Provençal herbs

Extracts of herbs and spices are increasingly of interest in the food industry because they retard oxidative degradation of lipids. There is also increasing interest in the antiviral activity of plant products. A liquid, deodorized rosemary extract and an oily extract of a mixture of Provençal herbs were tested for antioxidant and antiviral action in vitro. The rosemary extract (Herbor 025) and the extract of Provençal herbs (Spice Cocktail) inhibited peroxidation of phospholipid liposomes with 50% inhibition concentration values of 0.0009% (v/v) and 0.0035% (v/v), respectively. Herbor 025 and the spice cocktail (at 0.2%, v/v) reacted with trichloromethylperoxyl radical with calculated rates of 2.7 x 10(4) s-1 and 1.5 x 10(3) s-1, respectively. The main active components in the herbal preparations, carnosol and carnosic acid, at 0.05% (v/v) react with rate constants of (1-3) x 10(6) M-1 sec-1 and 2.7 x 10(7) M-1 sec-1, respectively. Both extracts show good antioxidant activity in the Rancimat test, especially in lard. Herbor 025 and the spice cocktail inhibited human immunodeficiency virus (HIV) infection at very low concentrations which were also cytotoxic. However, purified carnosol exhibited definite anti-HIV activity at a concentration (8 microM) which was not cytotoxic. Both preparations promoted some DNA damage in the copper-phenanthroline and the bleomycin-iron systems. The two herbal preparations possess antioxidant properties that may make them useful in the food matrix.

Antibody response of low birth weight infants to Haemophilus influenzae type b polyribosylribitol phosphate-outer membrane protein conjugate vaccine

OBJECTIVE

To evaluate the effectiveness in low birth weight (LBW) infants of the currently recommended immunization schedule for conjugated Haemophilus influenzae type b (HIB) vaccine.

METHODS

We quantified antibody responses in 36 preterm infants with a mean birth weight of 1060 g and a mean gestational age of 28 weeks. Infants were immunized with 0.5 mL of HIB vaccine at 2 and 4 months' postnatal age. Specific HIB antibodies were quantified on cord blood, immediately before each immunization and 2 months after the last immunization.

RESULTS

Even though the geometric mean titers increased significantly during the study period, they were still markedly lower than values reported in term infants. After the second immunization, only 24 infants (67%) attained antibody concentrations of more than 0.25 micrograms/mL, defined as seropositivity. Also, only 53% of infants achieved antibody concentrations of more than 1.0 micrograms/mL compared with 92% as reported in term infants. Stepwise logistic regression identified gestational age of 27 weeks or less and the amount of intravenous immunoglobulin received as the significant variables influencing the antibody response after the first immunization. The incidence of side effects was negligible.

CONCLUSIONS

We conclude that LBW infants, and especially those born at 27 or less weeks' gestation, do not respond as effectively to the HIB vaccine. We speculate that reevaluation of the current immunization schedule may be required for very LBW infants.

Prolonged stabilization of progressive endometrial stromal sarcoma with prolonged oral etoposide therapy

We report the case of a patient who has a 23-year history of endometrial stromal sarcoma (ESS). She initially underwent tumor-reductive surgery followed by adjuvant radiotherapy. The pelvic tumor recurred nearly 8 years later, obstructing the ureter and directly invading the bladder. It propagated into the vena cava as a thrombus and finally spread into the right heart chambers, leading to cardiac failure 13 years after the recurrence. The patient was treated with hormonal therapy, multiple resections of the pelvic tumor, chemoembolization, and systemic chemotherapy with doxorubicin and cyclophosphamide. She developed recurrent intractable symptoms and was started on prolonged oral etoposide therapy, which stabilized the size of the pelvic tumor and relieved her symptoms for 3 years. Her quality of life has markedly improved without significant morbidity. We review the options for treating recurrent ESS and suggest that use of prolonged oral etoposide therapy warrants further study in this setting.

Reaction of 111Cd7-metallothionein with EDTA. A reappraisal

The ligand substitution reaction of EDTA with Cd7-metallothionein (Cd7-MT) has been reinvestigated. NMR titration of the 111Cd-protein with EDTA showed that the ligand interacts preferentially and cooperatively with Cd2+ ions in the beta-domain cluster. NMR and ultrafiltration kinetic analysis of this reaction using 5.6 mM Cd2+ as 111Cd7-MT and 56 mM EDTA indicated that cadmium-EDTA formed less rapidly than 111Cd peak intensity declined. Spectrophotometric and gel filtration studies of the reaction with 20 microM Cd2+ as Cd7-MT with various concentrations of EDTA revealed biphasic kinetics with much larger rate constants than observed in the NMR experiments. The fraction of total ligand substitution occurring in each kinetic step varied with EDTA concentration. The EDTA concentration dependence of both kinetic steps was consistent with the initial formation of protein.EDTA adducts, followed by their breakdown into products. Kinetic measurements were also made for the reactions of the isolated Cd4-alpha- and Cd3-beta-domains with EDTA. The Cd4 domain reacted with EDTA with biphasic kinetics, in which one Cd2+ was removed rapidly with first-order kinetics, which were zero-order in EDTA. The other three reacted with kinetics like those for the slower step of the holoprotein. Cd3-beta reacted with EDTA like the faster rate process associated with the Cd7-protein. The observed rate constants for the reaction of Cd7-metallothionein with EDTA and the fraction of reaction in the faster rate process were sensitive to protein concentration. These results are consistent with the hypothesis that the monomer-dimer equilibrium of the protein controls its kinetic reactivity with EDTA.

Micronised fenofibrate

Rationale and development of a new fenofibrate formulation is described. A lower dispersion of particles size and thereby a better absorption rate leads to a decrease of the daily dose and provides a better control of the amount absorbed. Improved reproducibility of the pharmacological and therapeutic effect is expected.

The European Myocardial Infarct Amiodarone Trial (EMIAT). EMIAT Investigators

The objective of the European Myocardial Infarct Amiodarone Trial (EMIAT) is to assess the efficacy of amiodarone on mortality of patients with depressed left ventricular (LV) function following myocardial infarction (MI). The rationale for the trial is as follows: patients with poor LV function after acute MI have a high sudden cardiac death (SCD) mortality; amiodarone is a successful prophylactic therapy against SCD in patients with ventricular arrhythmias; a number of small studies (Canadian Amiodarone Myocardial Infarction Arrhythmia Trial [CAMIAT] pilot study, Basel Antiarrhythmic Study & Infarct Survival [BASIS], and the Polish Amiodarone Trial [PAT]) of prophylactic amiodarone post AMI have shown a beneficial response attributable to amiodarone. Patients are enrolled between 5 and 21 days after acute MI if LV ejection fraction (assessed by multiple-gated image acquisition nuclear angiography) is < or = 40%. The study group is stratified according to ejection fraction (stratum 1, 31-40%; stratum 2, < 31%). Amiodarone or placebo treatment (blind, randomized) is initiated prior to the discharge of the patient from the hospital and each patient is followed up for the duration of the study, at least 1 year. Recruitment began on November 30, 1990, and will continue for 4 years; > 700 patients are enrolled from > 60 centers (13 countries). The total study mortality (10% at 500 days) and the differential mortality of both strata are as anticipated. Side effects have been infrequent and very few patients have been withdrawn from the study. Trial conclusion is forecast for October 1995.