[Tonsillar squamous cell carcinoma in the dog. A retrospective study of 33 cases]

OBJECTIVE

Retrospective evaluation of clinical findings in 33 dogs with tonsillar squamous cell carcinomas.

MATERIAL AND METHODS

At the owners' request 9 patients were euthanized after diagnosis. 24 treated patients were grouped into six categories depending on the type of therapy: 1. tonsillectomy and NSAID (Piroxicam or Metacam) (n=10); 2. tonsillectomy, NSAID, and palliative radiation (24-30Gy in 3-5 fractions) (n=4); 3. tonsillectomy, NSAID, palliative radiation, and chemotherapy (5´ Carboplatin 280-300mg/m2 BSA) (n=3); 4. NSAID, palliative radiation, and chemotherapy (n=1); 5. NSAID alone (n=5), 6. tonsillectomy alone (n=1).

RESULTS

There were no breed predispositions but medium sized (10-20kg; 43%) and large dogs (>20kg; 20%), and males (n=22; 71%) were overrepresented. The average age was 10.7years (range, 6.5-14.5years). At the first presentation, 22 of the 33 dogs (67%) had lymph node metastasis. None of the dogs had lung metastasis at the time of diagnosis, as determined by three view chest X-rays. The best survival times (ST) were achieved in groups 2 and 3 with three of seven patients living longer than 1year. Patients without lymph node metastasis had a trend for longer survival times, independent of the type of therapy. Treated patients with lymph node metastasis (n=17) had a mean and median ST of 9.5 and 4months, respectively. Only two dogs survived longer than 1year. Dogs without lymph node metastasis had a mean and median ST of 17.7 and 12 months, respectively; the ST for four of the eight dogs exceeded 1year, two survived longer than 2years.

CONCLUSION

It could be confirmed that tonsillar squamous cell carcinomas are aggressive tumours with a high rate of cervical lymph node metastasis. In most cases with metastasis the survival times were relatively short, irrespective of treatment. In early stages of the disease however, good survival times could be achieved using surgical debulking followed by multimodality treatment.

CLINICAL RELEVANCE

In squamous cell carcinoma of the tonsils thorough staging is mandatory due to the high metastatic potential of the tumour. Verification of metastasis carries a poor prognosis. Further studies are required to find the best treatment (combination) for these patients.

[Incidence of chronic kidney disease in general population, EPIRAN study]

AIMS

To assess incidence of chronic kidney disease in general population and to describe baseline characteristics of incident patients.

METHODS

Between 1st/01/04 and 30/06/06 all incident cases of chronic kidney disease in the Nancy district were prospectively identified. New cases were identified from all medical laboratories in this area and determined by a persistently increased serum creatinine level (> or = 150micromol/l, or paediatric levels) for 3 months after the 1st/01/04, and by living in Nancy area.

RESULTS

The annual incidence rate of detected chronic kidney disease was 1 per thousand inhabitants (1,3 per thousand for men and 0,7 per thousand for women). Incidents patients were old (mean age: 77 years) and with numerous comorbidities (diabetes: 34 %, cardiac failure: 23 %). More than 30% of incident patients were diagnosed at sever stage of chronic kidney disease (<30ml/min/1,73m(2)).

CONCLUSIONS

The annual incidence of diagnosed chronic kidney disease is common: 10 times more than end-stage renal disease in France. Most of these patients are diagnosed in a severe stage of chronic kidney disease whereas they could be detected earlier and benefit from adequate, appropriate and multidisciplinary take care.

[Medical care of chronic kidney disease after kidney transplantation]

Kidney transplantation is the treatment of choice to enhance survival, morbidity and quality of life perceived by the patient. Despite improvements in short-term outcomes, a gap persists comparing with health of general population. A stringent collaboration between the family physician, the community nephrologists, the transplant center and others specialists is required. Recent recommendations have been published in France.

Nectar sugar composition and concentration in relation to pollination syndromes in Bromeliaceae

A first comprehensive dataset of nectar sugar composition and concentration in Bromeliaceae is presented, covering 111 species belonging to all three subfamilies. Based on this dataset, we examined the relationship between nectar traits and pollination syndromes in the family. Sugars in samples were assayed by high pressure liquid chromatography. All sampled species were grouped into three broad categories (trochilophilous, chiropterophilous, or lepidopterophilous) according to their main pollination mode. Significant differences between the different pollination syndromes were found in nectar sugar composition as well as concentration. For a total of four genera (Guzmania, Pitcairnia, Tillandsia and Vriesea), a comparison of nectar composition showed significant differences between trochilophilous and chiropterophilous species. Data presented here indicate that the characteristics of nectar in Bromeliaceae are predominantly determined by putative adaptations of nectar sugars to preferences of the pollinators rather than by phylogenetic relations.

Probabilistic model-based methodology for the conformational study of cyclic systems: application to copper complexes double-bridged by phosphate and related ligands

A methodology for the conformational study of cyclic systems through the statistical analysis of torsion angles is presented. It relies on a combination of different methods based on a probabilistic model which takes into account the topological symmetry of the structures. This methodology is applied to copper complexes double-bridged by phosphate and related ligands. Structures from the Cambridge Structural Database (CSD) are analyzed and the chair, boat-chair and boat conformations are identified as the most frequent conformations. The output of the methodology also provides information about distortions from the ideal conformations, the most frequent being: chair ↔ twist-chair, chair ↔ twist-boat-chair and boat ↔ twist-boat. Molecular mechanics calculations identify these distortions as energetically accessible pathways.

Pharmacology of ampakine modulators: from AMPA receptors to synapses and behavior

Ampakines are drugs structurally derived from aniracetam that potentiate currents mediated by AMPA type glutamate receptors. These drugs slow deactivation and attenuate desensitization of AMPA receptor currents, increase synaptic responses and enhance long-term potentiation. This review focuses mainly on recent physiological studies and on evidence for two distinct subfamilies. Type I compounds like CX546 are very effective in prolonging synaptic responses while type II compounds like CX516 mainly increase response amplitude. Type I and II drugs do not compete in binding assays and thus presumably act through separate sites. Their differences are likely to have consequences also for synaptic plasticity and behavior. Thus, while all ampakines facilitated long-term potentiation, only CX546 enhanced long-term depression. Further discussed are studies showing that ampakine effects vary substantially between neurons, with increases in EPSCs being larger in CA1 pyramidal cells than in thalamus and in hippocampal interneurons. In behavioral tests, ampakines facilitate learning in many paradigms including odor discrimination, spatial mazes, and conditioning, and they improved short-term memory in a non-matching-to-sample task. Positive results were also obtained in various psychological tests with human subjects. The drugs were effective in correcting behaviors in various animal models of schizophrenia and depression. Lastly, evidence is discussed that ampakines have few adverse effects at therapeutically relevant concentrations and that they protect neurons against neurotoxic insults, in part by mobilizing growth factors like BDNF. Type II drugs like CX516 in particular appear to be inherently safe since their ability to prolong responses is kinetically limited.

Darbepoetin alfa once every 2 weeks for treatment of anemia in dialysis patients: a combined analysis of eight multicenter trials

AIM

Darbepoetin alfa has a longer half-life than epoetin-(EPO) alfa or beta, allowing administration at less frequent intervals for the treatment of renal anemia. The aim of the present analysis was to evaluate the efficacy and tolerability of an every-2-week (Q2W) schedule of darbepoetin alfa in a large cohort of dialysis patients.

METHODS

Data were combined from eight similarly designed 24-week phase 3b European studies, in which patients receiving EPO alfa or beta once-weekly were converted to Q2W darbepoetin alfa. Darbepoetin alfa dosage was titrated to maintain hemoglobin (Hb) between 10 and 13 g/dl and efficacy was evaluated during a 4-week evaluation period.

RESULTS

In the 1,101 patients assigned to Q2W darbepoetin alfa (i.v., n = 196, s.c., n = 905), mean (SD) Hb levels were 11.53 (0.77) g/dl at baseline and 11.35 (1.04) g/dl at evaluation (mean change in Hb -0.27 g/dl, 95% confidence interval 0.34, -0.20). Hb levels were maintained between 10 and 13 g/dl during evaluation in 85% of patients. Darbepoetin alfa doses were similar at baseline and evaluation, and the i.v. and s.c. routes were associated with similar efficacy and dose requirements. Darbepoetin alfa was well-tolerated.

CONCLUSIONS

Q2W darbepoetin alfa is effective in maintaining Hb levels in dialysis patients switched from weekly rHuEPO, regardless of the route of administration and with no notable increase in the weekly equivalent dose.

Factors associated with anemia among incident pre-dialysis patients managed within a French care network

BACKGROUND AND AIMS

Despite guidelines concerning the management of renal anemia, the international literature reports that a large proportion of pre-dialysis patients have hemoglobin values lower than the recommended level. The present study analyzed the evolution of pre-dialysis Hb levels and erythropoietin use over a 4-year period and investigated factors associated with anemia.

METHODS

A total of 1315 patients initiating dialysis in Lorraine, France, were enrolled since 2001-2004. For each year, anemia, defined by Hb <11 g/dl, and erythropoietin use were investigated in three groups: all patients, patients whose dialysis was planned and patients whose dialysis was unplanned.

RESULTS

At initiation of dialysis, all groups showed increases over time in mean hemoglobin levels, proportion of patients without anemia and with erythropoietin therapy. Among patients whose first dialysis was planned in 2004, 43.8% had anemia and 67.9% had received erythropoietin, compared with 75.4% and 29.4%, respectively, when dialysis was unplanned. Patients receiving unplanned dialysis were more likely to have anemia (odds ratio (OR) = 2.6), as were those with a serum albumin level < 3.5 g/dl (OR = 2.1), body mass index < 30 kg/m2 (OR = 1.9) (all p < 0.001) or glomerular filtration rate < 10 ml/min/1.73 m2 (OR = 1.4, p = 0.04). The year of dialysis initiation was also associated with anemia (p = 0.024).

CONCLUSION

The proportion ofpatients starting dialysis with anemia might be reduced by earlier nephrology referral leading to erythropoietin administration, planned first dialysis while residual renal function remains, and greater attention to nutritional status.

Tolerability of enteric-coated mycophenolate sodium to 1 year in combination with cyclosporine and corticosteroids in renal transplant recipients

Enteric-coated mycophenolate sodium (EC-MPS) is therapeutically equivalent to mycophenolate mofetil, but delays release of mycophenolic acid until it reaches the small intestine. De novo renal transplant patients taking part in a 12-month, multicenter, randomized study received cyclosporine microemulsion (CsA-ME, early or delayed to day 6), EC-MPS, steroids, and interleukin-2 antagonist induction. Tolerability data relating to EC-MPS are reported. Ninety-seven patients were randomized to early CsA-ME and 100 patients to delayed CsA-ME. Median daily dose of EC-MPS was 1440 mg at all time points throughout the 12-month period. The most frequently reported adverse events were constipation, anemia, urinary tract infection, abdominal pain, leukopenia, and cytomegalovirus infection; there were four malignancies. Fifty patients (24.6%) discontinued EC-MPS prematurely by 12 months, including 42 patients (84%) who discontinued owing to adverse events. No patient discontinued treatment because of gastrointestinal adverse events. Two-thirds of patients (137 [67.5%]) maintained full EC-MPS dose throughout the 12-month study and did not require any dose reduction or dose interruption. EC-MPS is well tolerated in de novo renal transplant recipients when administered in combination with CsA-ME and steroids, with low rates of dose reductions or interruptions. Gastrointestinal adverse events were responsible for dose reduction or interruption in only 5% of patients.

Impact of cyclosporine reduction with MMF: a randomized trial in chronic allograft dysfunction. The 'reference' study

Long-term use of calcineurine inhibitors (CNIs) may contribute to the development of chronic allograft dysfunction (CAD). We investigate the impact of the introduction of MMF combined with cyclosporine (CsA) 50% dose reduction. An open, randomized, controlled, multicenter, prospective study was conducted in 103 patients, receiving a CsA-based therapy with a serum creatinine between 1.7-3.4 mg/dL, more than 1 year after transplantation. They were randomized to receive MMF with half dose of CsA (MMF group) or to continue their maintenance CsA dose (control group). A total of 96 weeks after randomization, the evolution of renal function assessed by regression line analysis of 1/SeCr improved in the MMF group (positive slope) vs. the control group (negative slope), 4.2 x 10(-4) vs. -3.0 x 10(-4), respectively (p < 0.001). Concurrently, the absolute renal function improved significantly in the MMF group. No episode of biopsy-proven acute rejection occurred. One patient in each group lost his graft because of biopsy-proven chronic allograft nephropathy. There was a significant decrease of triglycerides level in the MMF group. Anemia and diarrhea were statistically more frequent in the MMF group. In CAD, the reduction of CsA in the presence of MMF results in significant improvement in renal function during a 2-year follow-up.

Recurrent Anemia in Kidney Transplant Recipients With Parvovirus B19 Infection

Parvovirus B19 (PV B19) infection is known to cause acute anemia in solid organ transplant recipients. Intravenous immunoglobulin combined with reduction of immunosuppression may be of benefit to clear the infection. However, PV B19-associated anemia can be recurrent. We describe three renal transplant recipients with a PV B19 infection. These patients showed recurrent anemia with episodes separated by as much as several months.

Prevention of cardiovascular events in end-stage renal disease: results of a randomized trial of fosinopril and implications for future studies

Cardiovascular events (CVEs) are the leading cause of death in chronic hemodialysis patients. Results of trials in non-end-stage renal disease (ESRD) patients cannot be extrapolated to patients with ESRD. It is critical to test cardiovascular therapies in these high-risk patients who are usually excluded from major cardiovascular trials. The study objective was to evaluate the effect of fosinopril on CVEs in patients with ESRD. Eligible patients were randomized to fosinopril 5 mg titrated to 20 mg daily (n=196) or placebo (n=201) plus conventional therapy for 24 months. The primary end point was combined fatal and nonfatal first major CVEs (cardiovascular death, resuscitated death, nonfatal stroke, heart failure, myocardial infarction, or revascularization). No significant benefit for fosinopril was observed in the intent to treat analysis (n=397) after adjusting for independent predictors of CVEs (RR=0.93, 95% confidence interval (CI) 0.68-1.26, P=0.35). The per protocol secondary supportive analysis (n=380) found a trend towards benefit for fosinopril (adjusted RR=0.79 (95% CI 0.59-1.1, P=0.099)). In the patients who were hypertensive at baseline, systolic and diastolic blood pressures were significantly decreased in the fosinopril as compared to the placebo group. After adjustment for risk factors, trends were observed suggesting fosinopril may be associated with a lower risk of CVEs. These trends may have become statistically significant had the sample size been larger, and these findings warrant further study.

Tacrolimus combined with two different dosages of sirolimus in kidney transplantation: results of a multicenter study

Tacrolimus combined with mycophenolate mofetil (MMF) is an effective regimen in kidney transplantation. This study compared the efficacy of combining tacrolimus and two different dosages of sirolimus with an established tacrolimus-MMF regimen. Each day in addition to tacrolimus, 325 patients received 2 mg sirolimus (TAC-SRL2 mg), 325 patients received 0.5 mg sirolimus (TAC-SRL0.5 mg) and 327 patients 1 g MMF (TAC-MMF). The initial tacrolimus dose was 0.2 mg/kg/day. Sirolimus patients received loading doses of 6 or 1.5 mg, and daily doses of 2 or 0.5 mg thereafter. Steroid administration was identical for all groups. The incidence of biopsy-proven acute rejection was lower in the TAC-SRL2 mg group (15.7%) compared with the TAC-SRL0.5 mg (25.2%, p = 0.003) and the TAC-MMF groups (22.3%, p = 0.036). Six-month graft survival was 91.0% (TAC-SRL2 mg), 92.6% (TAC-SRL0.5 mg) and 92.4% (TAC-MMF); the respective values for patient survival were 98.1%, 97.8% and 97.9%. Thirty-four patients (10.5%), 19 patients (5.8%) and 16 patients (4.9%) in the TAC-SRL2 mg, TAC-SRL0.5 mg and TAC-MMF groups, respectively, discontinued the study because of adverse events. Hyperlipemia was reported more often in the TAC-SRL2 mg group (24.0%) compared with 19.4% (TAC-SRL0.5 mg) and 11.0% (TAC-MMF; p < 0.05). Combining 2 mg sirolimus/day with tacrolimus results in lower rates of acute rejection, but a higher incidence of adverse events.

On the difficulty of neurosurgical end of life decisions

OBJECTIVE

To analyse the process of end of life decisions in a neurosurgical environment.

METHODS

All 113 neurosurgical patients, who were subject to so called end of life decisions within a one year period were prospectively enrolled in a computerised data bank. Decision pathways according to patient and physician related parameters were assessed.

RESULTS

Leading primary diagnoses of the patients were traumatic brain injury and intracranial haemorrhage. Forty-five patients had undergone an emergency neurosurgical operation prior to end of life decision, N = 69 were conservatively treated, which included intracranial pressure recording, or they were not offered neurosurgical care because of futile prognosis. N = 111 died after a median of two (zero to nine) days. Two, in whom the end of life decisions were revised, survived. Clear decisions to terminate further treatment were made by a senior staff member on call being informed by the senior resident on call (27.4%), difficult decisions on the basis of extensive round discussions (71.7%), and very difficult decision by an interdisciplinary ethical consult (0.9%). Decisions were further substantiated by electrophysiological examinations in N = 59.

CONCLUSION

End of life decisions are to be considered standard situations for neurosurgeons. These decisions may reach a high rate of "positive" prediction, if substantiated by electrophysiological examinations as well as on the grounds of clinical experience and respect for the assumed will of the patient. The fact that patients may survive following revision of an end of life decision underlines the necessity for repeated reassessment of these decisions. Ethical training for neurosurgeons is to be encouraged.

Bayesian methods for the conformational classification of eight-membered rings

Two methods for the classification of eight-membered rings based on a Bayesian analysis are presented. The two methods share the same probabilistic model for the measurement of torsion angles, but while the first method uses the canonical forms of cyclooctane and, given an empirical sequence of eight torsion angles, yields the probability that the associated structure corresponds to each of the ten canonical conformations, the second method does not assume previous knowledge of existing conformations and yields a clustering classification of a data set, allowing new conformations to be detected. Both methods have been tested using the conformational classification of Csp3 eight-membered rings described in the literature. The methods have also been employed to classify the solid-state conformation in Csp3 eight-membered rings using data retrieved from an updated version of the Cambridge Structural Database (CSD).

Factors influencing the onset of diabetes mellitus after kidney transplantation: a single French center experience

Posttransplantation diabetes mellitus (PTDM) is a complication arising mostly during the first 6 months after kidney transplantation. Considering the serious outcomes of chronic hyperglycemia in kidney transplant patients, the recognition of factors that contribute to the onset of PTDM is of particular relevance. A retrospective analysis was performed to document the incidence of and the risk factors for diabetes mellitus occurring in the first year after kidney transplantation among 177 adult patients, without previously known diabetes transplanted between January 1998 and December 2000. PTDM, defined as fasting plasma glucose > or = 126 mg/dL confirmed by repeat testing on a different day, occurred in 48 (27.12%) patients of whom 36 showed transient changes during the first year after transplantation. Univariate analysis identified variables to be associated with the onset of PTDM: older recipient age (P = .05), male gender (P = .03), family history of diabetes (P = .04), advanced donor age (P = .008), absence of induction immunosuppression (P = .04), use of tacrolimus (vs cyclosporine; P = .01), one or more than one (steroid-treated) acute rejection episode(s) (P = .000001), cytomegalovirus infection (P = .02), and use of beta-blockers or diuretics (P = .05). By multivariate analysis, five factors were independently associated with the onset of PTDM: two episodes of rejection (odds ratio = 42.69, P = .000025), one episode of rejection (5.01, P = .007), older recipient age (1.06, P = .017), family history of diabetes (7.24, P = .011), and weight at transplantation (1.03, P = .048). Tacrolimus treatment remained of borderline significance (2.77, P = .05). In addition to traditional risk factors predisposing to the development of type 2 diabetes in the general population, episodes of acute rejection significantly influence the incidence of PTDM.

[Sonographically guided, minimally invasive biopsy of uncertain mammary lesions. Clinical experience with a new biopsy system]

METHODS

We performed Vacora biopsy on 53 patients for minimally invasive breast diagnostics. Each histologically malignant lesion underwent surgery. The histopathology of the Vacora biopsy was then compared to the surgical report. When there was a discrepancy between Vacora histopathology and the report, the patient underwent open biopsy. In all patients with benign histopathology results, sonography was performed 5-7 days after biopsy and after 3 months.

RESULTS

We performed biopsies on two lesions in eight patients, and on three lesions in one patient. Mean age of the patients was 52.1+/-12.8 years. A total of 62 lesions were examined. Mean size of the lesions was 13.3+/-9.6 mm. Fourteen (26.4%) were malignant (n=2 DCIS, n=12 invasive carcinoma). Histological grading was identical for Vacora biopsy and the surgical specimens. One case showed ADH by Vacora biopsy, which was confirmed by open biopsy. Vacora biopsy generated one false negative. There were a total of 36 benign lesions.

CONCLUSION

Vacora biopsy under sonographic guidance is a method which is easy to handle, diagnostically accurate and without severe complications. Due to higher costs in comparison to high speed core biopsy, Vacora biopsy should be performed only in cases in which high speed core biopsy is not expected to result in a valid result.