Cefepime versus imipenem-cilastatin as empirical monotherapy in 400 febrile patients with short duration neutropenia. CEMIC (Study Group of Infectious Diseases in Cancer)

This open, comparative, randomized, multicentre equivalence study compared cefepime 2 g bd and imipenem-cilastatin 1 g tds (50 mg/kg/day) as empirical monotherapy for febrile episodes in a homogeneous cohort of cancer patients with short duration neutropenia following chemotherapy for solid tumour, lymphoma or myeloma. The study was conducted in 17 French anti-cancer centres in 1995 and 1996. Response to monotherapy was assessed 7 days after treatment and was based on resolution of fever and signs and symptoms, eradication of pathogens, absence of new infection, relapse, and death of infectious origin, without addition of other antibiotics. Patients were treated for a minimum of 4 days. Of the 400 episodes randomized, 344 (86%) were evaluable for efficacy. Patient characteristics were comparable between treatment groups. Success of monotherapy was observed in 79% of episodes with cefepime and 72% with imipenem-cilastatin (equivalence, P <0.0001). The response rate for microbiologically documented infections was 66% with cefepime and 61% with imipenem-cilastatin (bacteraemic episodes: 63% for cefepime; 44% for imipenem-cilastatin). A second antibiotic (usually a glycopeptide) was added in 20% and 21% of the cases, respectively. Overall, the response to therapy, with or without an additional antibiotic, was 95% (cefepime) and 90% (imipenem-cilastatin). Survival was similar in both groups (95% and 98%, respectively). Cefepime treatment was better tolerated, with 9% of the patients experiencing related intercurrent events compared with 19% in the imipenem-cilastatin group (P = 0.003). Nausea/vomiting was significantly more frequent in the imipenem-cilastatin group (15%) than in the cefepime group (5%; P = 0.001). Cefepime monotherapy was as effective as, and better tolerated than, imipenem-cilastatin in the empirical treatment of fever during short duration neutropenia.

Introduction of a normal retinoblastoma (Rb) gene into Rb-deficient lymphoblastoid cells delays tumorigenicity in immunodefective mice

Inactivation of the Rb susceptibility gene occurs in various human cancers and has been associated with tumorigenicity. Rb gene is inactivated in 30% of acute leukaemias. The effect of Rb protein expression was assessed in the lymphoblastoid cell line IM-9 defective for Rb protein, after stable transfection with a wild-type Rb gene. The Rb transgene was under the control of the MoMuLv-LTR. Protein expression by the transduced cells was confirmed by Western blot and flow cytometry analyses. Compared to the parental cell line, growth rate remained unchanged in the Rb transfected clones. In SCID mice however, tumor formation originating from these clones was delayed. The current data suggest therefore that, in this Rb-defective haematopoietic cell line, Rb expression correlates with reduced tumorigenicity but not with reduced growth rate.

Zinc regulation of insulin-like growth factor-I (IGF-I), growth hormone receptor (GHR) and binding protein (GHBP) gene expression in rat cultured hepatocytes

Dietary zinc depletion in vivo attenuates growth, decreases circulating insulin-like growth factor-I (IGF-I) and liver growth hormone (GH) receptors (GHR). In order to investigate a direct role of zinc in the regulation of IGF-I, GHR and GH binding protein (GHBP) gene expression, we evaluated the response of their mRNAs to changes in zinc availability in primary culture of rat hepatocytes. Exposition of cells to the zinc chelator DTPA (diethylenetriaminepenta-acetic acid) did not decrease IGF-I and GHBP mRNAs while it strongly inhibited metallothionein (MT) gene expression. On the other hand, zinc excess (50 vs. 1.5 microM) decreased IGF-I, GHR and GHBP mRNAs while it stimulated MT mRNA. However, the response of IGF-I to GH was not affected by the exposure to DTPA nor zinc excess. Furthermore, zinc repletion of primary cultured hepatocytes isolated from zinc-deprived rats did not increase IGF-I nor GHR/GHBP mRNAs. Therefore, our results suggest that the IGF-I decline induced in vivo by zinc deficiency is not caused by reduced extracellular zinc availability at the hepatocyte level. Although IGF-I and MT gene expression is down-regulated by dietary zinc depletion, underlying mechanisms of regulation are different for both genes.

Neonatal arterial switch operation: coronary artery patterns and coronary events

OBJECTIVE

To determine the incidence of coronary events following neonatal arterial switch and to identify potential risk factors for death and coronary events.

METHODS

The total experience (236 consecutive arterial switch operations) of one surgeon was studied. Associated procedures included ventricular septal defect closure in 37 patients (16%) and aortic arch repair in 14 patients (6%)). The influence of various patient, procedural, support technique and experience variables was analyzed.

RESULTS

There were 19 deaths (8-70% confidence limits = 6-10%). Survival at 1 month, 1 year and 5 years was 93, 92 and 92%, respectively. Risk factors for death included small birth weight (P = 0.0015), hypoplasia of right ventricle (P < 0.0001), aortic arch obstruction (P < 0.0001) and coronary patterns with coronary arteries coursing between the great arteries (P = 0.0066). Coronary events occurred in 26 patients (11-70% confidence limits = 9-13%) and involved coronary deaths (11 patients), non fatal myocardial infarctions (8 patients) and coronary stenoses or occlusions (7 patients). Freedom from coronary events at 1 month, 1 year and 5 years was 94, 91 and 88%, respectively. Risk factors for coronary events included coronary patterns with retropulmonary course of the left main or left circumflex coronary artery (P = 0.0122), coronary patterns with coronary arteries coursing between the great arteries (P < 0.0001), all variations of intramural coronary arteries (P = 0.0010) and commissural origin of coronary ostia (P = 0.0171).

CONCLUSIONS

(1) In most neonates, arterial switch operation carries a low operative risk and provides excellent mid-term results; (2) The operative risk remains increased in some subsets; and (3) Some coronary patterns increase the risk of coronary events. Further surgical experience may improve the results.

[Dialectic behavioral psychotherapy for patients with borderline personality disorder]

Any therapist working with borderline patients knows that this is a crisis prone population that can be as burdening for the professional clinician as for the individual who experiences these intense relational episodes. Within this context, it is quite surprising that leaders of the behavioral approach waited until the beginning of the nineties before applying their technology to the treatment of patients diagnosed with borderline personality disorder. Linehan put numerous efforts to empirically demonstrate the efficiency of her newly developed dialectical behavior therapy, which makes it a noteworthy model. This article presents some historical and philosophical underpinnings of her approach, followed by the diagnostic criteria, the main clinical tools she advocates, the various dialectal dilemma, the treatment modes as well as an overview of the basic therapeutic strategies used in this approach.

[Axillary lymphadenectomy prepared by fat aspiration versus functional axillary lymphadenectomy: preliminary results of a randomized prospective study]

The objective of this study is to compare morbidity between 2 surgical procedures of axillary clearance: functional lymphadenectomy by classical dissection versus axillary dissection prepared by liposuction (Suzanne's procedure). Two hundred consecutive patients treated for breast cancer were included in a prospective randomized trial between 1st January, 1995 and 31st January, 1996 (Huriet's law). The assessment (number of nodes, postoperative stay, drainage duration, rate of seromas, number of complications, evaluation of mobility and sensitive disorders) was done on the first, fifth, tenth and thirty postoperative days. There is no significant difference between the 2 groups. The rate of seromas decreased significantly only for fat patients (8/25 versus 21/34, p < 0.05) and for the patients treated with radical mastectomy (17/37 versus 28/39, p < 0.05). In this preliminary study, liposuction does not change postoperative effects of axillary clearance, except for fat patients or after total mastectomy. The liposuction seems to facilitate a better anatomical dissection and a better preservation of the nervous and vascular elements.

Doubled haploids of wheat from wheat x maize crosses:genotypic influence, fertility and inheritance of the 1BL-1RS chromosome

The wheat x maize cross as a technique for haploid induction in wheat was evaluated in a replicated block design comprising 18 wheat F1 hybrids and five Zea mays L. parents. Haploid plants were regenerated at an average of 9.1 (4.4-14.7) plants per 100 florets processed. Genotypic differences for haploid production efficiency were recorded for both wheat and Zea mays L. Interaction between parents was significant for number of plants/100 florets. All 610 of the 1,703 regenerated plantlets that were analyzed by flow cytometry were haploid. At maturity, 70% (60-81 %) of the colchicinetreated haploid plants were fertile, but the frequency of fertile and sterile plants was not consistent over the wheat hybrids from which they were derived. Flow cytometry performed using the first tiller which arose following colchicine treatment enabled prediction of fertility. The 1BL-1RS chromosome was found at the expected ratios in the F2 and in the haploid progenies produced through the wheat x maize cross but deviated from the 1∶1 ratio in the haploid progenies produced by anther culture.

Predicting daily maintenance dose of fluindione, an oral anticoagulant drug

Due to large inter-individual variations, the dose of vitamin K antagonist required to target the desired hypocoagulability is hardly predictible for a given patient, and the time needed to reach therapeutic equilibrium may be excessively long. This work reports on a simple method for predicting the daily maintenance dose of fluindione after the third intake. In a first step, 37 patients were delivered 20 mg of fluindione once a day, at 6 p.m. for 3 consecutive days. On the morning of the 4th day an INR was performed. During the following days the dose was adjusted to target an INR between 2 and 3. There was a good correlation (r = 0.83, p < 0.001) between the INR performed on the morning of day 4 and the daily maintenance dose determined later by successive approximations. This allowed us to write a decisional algorithm to predict the effective maintenance dose of fluindione from the INR performed on day 4. The usefulness and the safety of this approach was tested in a second prospective study on 46 patients receiving fluindione according to the same initial scheme. The predicted dose was compared to the effective dose soon after having reached the equilibrium, then 30 and 90 days after. To within 5 mg (one quarter of a tablet), the predicted dose was the effective dose in 98%, 86% and 81% of the patients at the 3 times respectively. The mean time needed to reach the therapeutic equilibrium was reduced from 13 days in the first study to 6 days in the second study. No hemorrhagic complication occurred. Thus the strategy formerly developed to predict the daily maintenance dose of warfarin from the prothrombin time ratio or the thrombotest performed 3 days after starting the treatment may also be applied to fluindione and the INR measurement.

Reconstitution of ionic channels from inner and outer membranes of mammalian cardiac nuclei

Recent reports suggest that the nuclear envelope possesses specific ion transport mechanisms that regulate the electrolyte concentrations within the nucleoplasm and perinuclear space. In this work, intact nuclei were isolated from sheep cardiac cells. After chromatin digestion, the nuclear envelopes were sonicated and four nuclear vesicle populations were separated by sucrose step gradients (SF1-SF4). These fractions were compared by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and their protein content was analyzed by Western blot, using lamin and SEC 61 antibodies. The lamins, which are associated with the inner nuclear membrane, were present in three fractions, SF2, SF3, and SF4, with a lower amount in SF2. The SEC 61 protein, a marker of the rough endoplasmic reticulum, was detected in small amounts in SF1 and SF2. Upon fusion of vesicles into bilayers, the activities of nuclear ionic channels were recorded in 50 mM trans/250 mM cis KCl or CsCl, pH 7.2. Two types of Cl- selective channels were recorded: a large conducting 150-180-pS channel displaying substates, and a low conducting channel of 30 pS. They were both spontaneously active into bilayers, and their open probability was poorly voltage dependent at negative voltages. Retinoic acid (10(-8) M) increases the po of the large Cl- conducting channel, whereas ATP modifies the kinetics of the low conductance anion selective channel. Our data also suggest that this anionic channel is mainly present in the SF3 and SF4 population. The presence of a 181 +/- 10 pS cation-selective channel was consistently observed in the SF2 population. The behavior of this channel was voltage dependent in the voltage range -80 to +60 mV. Furthermore, we report for the first time the activity of a channel exclusively present in the SF3 and SF4 fractions, shown to contain mainly inner membrane vesicles. This cation selective channel displays a 75-pS conductance in 50 mM trans/250 mM cis K-gluconate. It is concluded that the bilayer reconstitution technique is an attractive approach to studying the electrophysiological properties of the inner and outer membranes of the nuclear envelope.

Identification of two regulatory elements within the promoter region of the mouse connexin 43 gene

To define the minimal sequences required for expression of the connexin 43 gene (cx43) in myometrial cells, we generated 5' deletion constructs of a fragment extending 1686 base pairs upstream and 162 base pairs downstream of the transcription start site and determined their ability to drive expression of the chloramphenicol acetyltransferase reporter gene in transfected myometrial cell lines. Our investigation revealed two cis-acting regulatory elements within this fragment. Deletion of a region extending from -102 to -92 led to an increase of the promoter activity by greater than 10-fold, indicating a presence of a repressor element. Deletion of a region extending from -72 to -62 caused a decrease of the promoter activity of a similar extent, implying the existence of a positive element. Electrophoretic mobility shift assays demonstrated that synthetic oligonucleotides derived from these two small regions can each bind with a nuclear protein(s) prepared from myometrial cells, and an introduction of three and two base substitutions into each of these oligomers was sufficient to abolish their protein binding capability. These same mutations, when incorporated in the chloramphenicol acetyltransferase constructs, diminished regulatory functions of the negative and positive elements, and the protein(s) that bind to these functional elements was found in several tissues known to express cx43 gene.

Pediatric cardiac transplantation for congenital heart defects: surgical considerations and results

Among 54 children who underwent 55 heart transplantations, 24 (44%) (mean age, 4.9 +/- 4.8 years; range, 9 days to 18 years) had congenital defects with the following diagnoses: single-ventricle variants (6), hypoplastic left heart syndrome variants (5), transposition complex (6), and miscellaneous defects (7). Twenty patients (83%) had undergone 43 prior operations. Additional surgical procedures included repositioning of transposed great arteries (11), reconstruction of the aortic pathway (4), reconstruction of the pulmonary pathway (8), correction of situs inversus (1), and correction of anomalous pulmonary (1) or systemic (1) venous drainage. Reconstructive procedures were performed using donor or recipient tissue or both. There were six early deaths (hyperacute rejection, 1 patient; pulmonary hypertension, 1; graft failure, 2 patients; infection, 2) and six late deaths (sudden death, 2; chronic rejection, 2; nonspecific graft dysfunction, 1; lymphoproliferative disease, 1). The survival rate was 43% +/- 12% at 3 years. No deaths were related to surgical technique. Survival was not significantly different in pediatric recipients with cardiomyopathy (67% +/- 9%; p = 0.22). Accelerated coronary artery disease was noted in 4 operative survivors (22%; 70% confidence limits, 12% to 36%). All late survivors were free from cardiac symptoms after a mean follow-up of 34 +/- 24 months (range, 6 to 71 months). Based on this study, we reached three conclusions. (1) Careful planning of both harvesting and transplantation procedures allows heart transplantation in recipients with congenital heart diseases. (2) The surgical technique may be demanding, but the early risk is not increased.(ABSTRACT TRUNCATED AT 250 WORDS)

A tridimensional study using cuts at a low temperature of the infratemporal region

Although the infratemporal region is well defined anatomically, its complex topography has been the subject of numerous, and sometimes, opposite works. That is the reason why it appeared necessary for the authors to re-evaluate this topic using the original method of Combelles and Boyer, allowing to define three referential planes, and thereby, a tridimensional shape and the volume of this region. This study allows to conclude that the infratemporal region is a triangular prism with an horizontal main axis 47 mm long. Its anterior base has a mean area of 733 mm2. The posterior top consists of the Juvara slot and has a mean area of 490 mm2. This infratemporal prism contains another one, the pterygomandibular space, prismatic too. It widens out from coronoïd plane (93 mm2) to mandibular foramen plane (169 mm2) before ending as a narrow groove between the neck of the mandibular condyle and the interpterygoïd fascia. The volume of the pterygomandibular space is quite superior to the value usually reported in the dental literature. It is of 4.8 ml to 5.8 ml according to denture. These results point out the opportunity to accomodate more important volumes of anesthesic solutions, than the 1.8 ml usually performed, without any leak out of the infratemporal region.

[The "rete venosum plantare" (the plantar venous network or Lejars' venous sole of the foot)]

Looking at the bibliography of the venous sole of the foot (Lejars), the authors point out the opposite convictions concerning this structure. For some ones, it doesn't exist, but fort the others, it is a very important network of tiny veins, such as it was described by Lejars himself. However, all this studies, are made upon cadavers, injected or not, and must be compared with results from living people by the mean of angiography, non invasive Vascular Assessment, or RMN, which take in account vasomotricity.

[Inter-related arterial and venous pathologies]

The authors concomitant arterial and venous disorders. On the same patient. They point out the obvious preeminence of arterial disease on venous ones, and discuss about the panel of therapy association usable. They underline the necessity of saving the venous capital.

[Structural and functional anatomical bases of deep venous insufficiency of the lower limbs]

The authors consider the Extent of the several anatomical structures which constitute the deep venous network, and the part they can take in the case of deep venous insufficiency. Congenital Vascular diseases are called back in mind when considering Embryology, and point out the extent of the deep venous state; such veins can gather in periarterial plexus, at the muscular Level, and in going past all along main arterial axes. Among all the critical points of these axes, we must keep the popliteal veins, the femoral crossing, and the iliocaval one and elsewhere, the important question of venous valves and communicating and perforating veins. The part of the lymphatic network must be pointed out, because of its extent in the stasis phenomenons.

[Pelvic circulation in the pregnant woman]

The authors point out the fact that there are few publications on this subject. Besides variations related to functional and hormonal associated with pregnancy, temporary variations occur in the venous system and which take the form of the development of extra-intra pelvic anastomoses at several sites.

[The anatomic basis of vascular malformations]

Basing themselves on anatomical and embryological considerations, the authors suggest a distinction between angiodysplasias and abnormalities. They define the characteristics proper to these varieties and establish the bases of therapeutic inferences. They briefly recall the lymphatic malformations. Practical and therapeutic inferences.

The organogenesis and anatomy of vascular malformation

According to an embryological basis, the Authors analyze the development of the vascular system and try to establish a differentiation between angiodysplasias and abnormalities. They define the characteristics of each group and make an attempt at classification. The major characteristics of differentiation are the evolutional aspects and the presence of arteriovenous fistulas.

[Phlebology and gynecology]

The authors give the pattern of several situations where are added phlebological and gynecological diseases. They summarize the several treatments and the practical uses for this. Medicolegal viewpoints are also taken in account.

[Intra- and extra-pelvic venous connections. Anatomical study]

Regarding to clinical diseases, the authors emphasize the important part of pelvic veins as collateral flows when iliac channels are occluded. They point out the three mains streams of this collateral network: the obturator veins, the gluteal veins, and the pudendal veins. Longitudinal anastomoses are connected each other by transversal veins such as Santorini plexus, and sacral veins; they allow venous supply from one side to the other when two levels or more are involved.

Human IL-3 and GM-CSF act synergistically in stimulating hematopoiesis in primates

Interleukin-3 (IL-3) is a member of a family of growth factors, each of which supports the proliferation and development of hematopoietic precursors in culture. Although the biologic effects of the different hematopoietic growth factors have been well documented in different culture systems, it has only recently become possible to study the activities of these molecules in vivo. In comparison with the later acting hematopoietic growth factors granulocyte-macrophage colony-stimulating factor (GM-CSF) and granulocyte colony-stimulating factor, IL-3 elicited a delayed and relatively modest leukocytosis when continuously infused intravenously in primates. The IL-3 infusion, however, greatly potentiated the responsiveness of the animal to subsequent administration of a low dose of GM-CSF. These results suggest that IL-3 expands an early cell population in vivo that subsequently requires the action of a later acting factor such as GM-CSF to complete its development. Optimal stimulation of hematopoiesis may be achieved with combinations of hematopoietic growth factors.