Pelvic ultrasonography in normal girls and in girls with pubertal precocity

This prospective study sought to evaluate the role of pelvic ultrasonography in differentiating between various types of pubertal precocity. A control group of 117 normal girls (aged 1.1-15.6) was studied and compared with 87 girls with premature sexual maturation (aged 1.1-9.2 y). Of these patients 19 had central precocious puberty (CPP), 48 had isolated premature thelarche (IPT) and 20 had premature adrenarche (IPA). Pelvic ultrasound variables evaluated were: (i) uterus: longitudinal diameter (uterine length), cross-sectional area (CSA) and fundo-cervical ratio; and (ii) ovaries: volume and morphology. Ovarian morphology was subdivided in 6 different appearances: solid, microcystic, paucicystic, multicystic, macrocystic, and major isolated cyst. In normal control girls, uterine length and CSA increased with age, although no cut-off values could be defined between different age ranges, and they were correlated with breast stage; fundo-cervical ratio was stable through childhood and increased after age 9. Ovarian volume was significantly greater in pubertal girls with breast stage 2 than in those with only pubic and/or axillary hair. There was a clear predominance of solid ovarian appearances in the age range 2-7, with the multicystic appearance being seen only after age 7, a minority being macrocystic. After age 10 all the different patterns were observed, and after age 13 the frequency of a macrocystic pattern increased. Significantly more mature ovarian appearances were observed in subjects with breast development compared with those without, independently of the presence of pubic hair. Patients with IPT had no significant differences in pelvic ultrasound measurements when compared with age-matched controls. All the different morphological ovarian appearances were observed in IPT, in contrast to age-matched controls, where only the less mature patterns (solid, micro- and paucicystic) were seen. Patients with CPP had significantly more mature patterns of ovarian morphology compared with age-matched controls, but did not differ from pubertal pre-menarcheal controls. Those patients with IPA differed from age-matched controls only in having significantly greater uterine length and CSA. Comparison of the pelvic ultrasound parameters between patient groups (IPT, CPP, IPA) and age-matched controls revealed significantly higher values in CPP for uterine length, uterine CSA and ovarian volume. Ovarian volume was also greater in IPT than in IPA. Ovarian morphology was significantly different in patients (IPT, CPP, IPA) compared with age-matched controls, but none of the ovarian morphological appearances was exclusive to a single condition.

IN CONCLUSION

(i) pelvic ultrasound parameters increase progressively from birth to maturity, but no clear cut-off values can be established between age ranges; (ii) pelvic ultrasound variables reach adult values during puberty, with differences in the timing that may reflect geographical variations; (iii) the multicystic ovarian appearance occurs just before the onset of puberty; (iv) pelvic ultrasonography cannot always differentiate clearly between different disturbances of puberty and therefore cannot supersede other observations and investigations in the evaluation of pubertal disorders; and (v) in this study we propose a more detailed pelvic ultrasound terminology that can avoid apparent confusion in defining ovarian ultrasound appearance.

Delayed acquisition of high-avidity anti-cytomegalovirus antibody is correlated with prolonged antigenemia in solid organ transplant recipients

Previous studies have demonstrated that maturation of cytomegalovirus (CMV)-specific antibodies in solid organ transplant recipients is delayed after primary CMV infection. To investigate the clinical significance of this finding, the avidity indices of anti-CMV antibody were determined in parallel with other serologic and virologic parameters in serial serum samples from 24 solid organ transplant recipients who had primary CMV infection that began during the first 3 months after transplantation. The data obtained show that a delay in antibody maturation is significantly correlated with a long persistence of positive antigenemia.

[Platelet antiaggregants or anticoagulants in the secondary prevention after myocardial infarct]

Aspirin and oral anticoagulants are effective treatments in the secondary prevention after myocardial infarction. Aspirin at the dosage of 160-325 mg per day accomplishes a 21% reduction of the recurrences of vascular events (INR: 3-4). Oral anticoagulants are likely to be more effective; this therapy however is more demanding for the patient and the referring physician and is associated with a higher risk of hemorrhage. According to the available information from the literature, aspirin should be recommended for the majority of patients surviving after myocardial infarction. Oral anticoagulants should be reserved for post-infarction patients at high risk of thromboembolism and for those patients who present either intolerance to aspirin or recurrence of vascular events during aspirin treatment.

Molecular identification and cluster analysis of homofermentative thermophilic lactobacilli isolated from dairy products

Twenty-five strains of thermophilic lactobacilli isolated from yoghurt and from semi-hard and hard cheeses (in parallel with nine type or reference strains) were identified and grouped according to their genetic relatedness. Strains were identified by sugar fermentation patterns using the "API 50 CHL" galleries, by species-specific DNA probes in dot-blot hybridization experiments, by amplification and restriction analysis of the 16S rRNA gene (ARDRA) and by polymerase chain reaction (PCR) using species-specific oligonucleotide primers. Strains were classified as Lactobacillus delbrueckii subsp. lactis and subsp. bulgaricus, L. helveticus, and L. acidophilus. Strains which were atypical by sugar fermentation patterns were also identified. Most of the strains could not be grouped using carbohydrate fermentation profiles. PCR fingerprinting was used to identify DNA profiles for the 25 lactobacilli. Experimentally obtained PCR profiles enabled discrimination of all strains, which were grouped according to the similarities in their combined patterns. In general, the clustering of the strains corresponded well with species delineation obtained by molecular identification. The dendrogram of genetic relatedness enabled the unambiguous identification of most of the strains which were shown to be atypical by the sugar fermentation profile, except for a discrepancy in one L. delbrueckii subsp. lactis strain and one atypical Lactobacillus sp. strain.

From synthetic coiled coils to functional proteins: automated design of a receptor for the calmodulin-binding domain of calcineurin

A series of synthetic receptors capable of binding to the calmodulin-binding domain of calcineurin (CN393-414) was designed, synthesized and characterized. The design was accomplished by docking CN393-414 against a two-helix receptor, using an idealized three-stranded coiled coil as a starting geometry. The sequence of the receptor was chosen using a side-chain re-packing program, which employed a genetic algorithm to select potential binders from a total of 7.5x10(6) possible sequences. A total of 25 receptors were prepared, representing 13 sequences predicted by the algorithm as well as 12 related sequences that were not predicted. The receptors were characterized by CD spectroscopy, analytical ultracentrifugation, and binding assays. The receptors predicted by the algorithm bound CN393-414 with apparent dissociation constants ranging from 0.2 microM to >50 microM. Many of the receptors that were not predicted by the algorithm also bound to CN393-414. Methods to circumvent this problem and to improve the automated design of functional proteins are discussed.

3,5-Diiodo-L-thyronine and 3,5,3'-triiodo-L-thyronine both improve the cold tolerance of hypothyroid rats, but possibly via different mechanisms

The effects of 3,5-diiodo-L-thyronine (3,5-T2, 2.5-10 microg/100 g BW) on cold tolerance, energy expenditure and oxidative capacity of four metabolically very active tissues (brown adipose tissue, skeletal muscle, liver and heart) were determined in hypothyroid, cold-exposed rats. Hypothyroid rats survived cold for only 3-4 days. 3,5-T2 improved survival dose dependently; with 10 microg/100 g BW the rats survived 3 weeks (limit of observation). This effect was paralleled by an increased energy expenditure of the whole animal for the entire 3 weeks. Similar effects were observed in hypothyroid rats treated with 3,3',5-triiodo-L-thyronine (T3). 3,5-T2 stimulated the specific oxidative capacity (expressed as cytochrome oxidase activity per milligram protein) of all four tissues dose dependently. When the oxidative capacity was expressed as total activity (cytochrome oxidase activity times organ weight), the percentage increases were of the same order. T3 exerted similar effects, but the changes in total activity were much greater than in specific activity, indicating an effect on the tissue trophism. The effect of 3,5-T2 on cold tolerance thus mimics the effect of T3, but via different cellular mechanisms. T3 seems to act primarily on the trophism of the tissues, while 3,5-T2 may act directly on mitochondria without an effect on tissue trophism.

Multiple binding mode of reversible synthetic thrombin inhibitors. A comparative structural analysis

The central role of the serine protease thrombin in hemostasis and thrombosis brought many scientists to develop highly potent and selective thrombin inhibitors. Thrombin-inhibitor complexes have extensively been studied in order to understand structure-function relationships, and to design new inhibitors that can be used with broader efficacy over existing antithrombotic agents. In this paper, we summarize in a comparative manner the state of the art on reversible thrombin inhibitors and we discuss some structural aspects of thrombin-inhibitor interaction, which account for the different affinity and potency of these molecules. We also report here our approach to develop a new class of synthetic, multisite-directed thrombin inhibitors, named hirunorms, designed to mimic the distinctive binding mode of hirudin. We emphasize here that, despite the high specificity of thrombin action, the interaction of inhibitors in its active site may occur with quite different mechanisms.

Neuronorm is a potent and water soluble neurokinin A receptor antagonist

We report here the synthesis and preliminary pharmacological characterization of a novel water soluble Neurokinin A receptor antagonist named Neuronorm. The synthesis was achieved in high yield by a combination of classical peptide synthesis methodologies, in both solution and solid phase. The pharmacological properties as neurokinin A receptor antagonist were assessed in in vitro experiments on rat vas deferens and guinea pig trachea, and were compared to those of MEN10627.

Effect of 3,5-diiodo-L-thyronine on thyroid stimulating hormone and growth hormone serum levels in hypothyroid rats

We have investigated the biological effects of physiological doses of 3,5-diiodo-L-thyronine (3,5-T2) and 3,3'-diiodo-L-thyronine (3,3'-T2) (at doses from 2.5 to 10 microg/100 g BW) on serum TSH and GH levels in rats made hypothyroid by propylthiouracil and iopanoic acid administration. In such animals deiodinase activities were inhibited and thyroid hormones serum levels strongly reduced. The effects of T2s were compared with those elicited by 3,5,3'-triiodo-L-thyronine (T3) (2.5 microg/100 g BW).The serum TSH level was much greater in hypothyroid rats than in euthyroid ones. T3 administration suppressed TSH by 88% compared to control (i.e, the level in hypothyroid rats); it thus reached a value not significantly different from that seen in the euthyroid rats. 3,5-T2 produced a similar effect, suppressing the TSH level by about 75% compared to control; it thus reached values not significantly different from those of the euthyroid and T3-treated rats. By contrast, 3,3'-T2 had no effect on TSH, whatever the dose. The serum GH level was much lower in hypothyroid rats than in euthyroid ones. T3 administration increased the GH level by about 5-fold, restoring it to the value seen in euthyroid rats. 3,5-T2-treated hypothyroid rats, at all the doses used (from 2.5 to 10 microg/100 g BW), showed increased serum GH levels: at a dose of 10 microg/100 g BW the level reached a value about 5-fold higher than that in hypothyroid rats. This value was not significantly different from those of euthyroid and T3-treated rats. 3,3'-T2 did not affect GH levels whatever the dose. Thus, 3,5-T2 (but not 3,3'-T2) seems to mimic the effects of T3 on serum TSH and GH levels in rats.

Modulating effect of lonidamine on response to doxorubicin in metastatic breast cancer patients: results from a multicenter prospective randomized trial

Previous results from our preclinical studies have shown that lonidamine (LND) can positively modulate the antiproliferative activity of doxorubicin (DOX) on breast cancer cell lines. To evaluate the effect of LND in a clinical setting, a multicenter randomized trial was carried out on patients with advanced breast cancer. From September 1991 to July 1993, 181 patients were enrolled in the trial and received an initial treatment of DOX at 75 mg/m2 for 3 cycles. The 137 patients who reached complete remission, partial remission, or stable disease were randomized to receive either DOX alone (75 mg/m2 day 1) (arm A) or DOX plus LND (600 mg orally/day) (arm B). The patients enrolled in the two arms were fairly homogeneous in terms of major clinical characteristics. Toxicity was similar in both arms except for myalgia: WHO grade > or=2 was observed in 57% of arm B patients. Overall response rate to DOX + LND was 50% and to DOX alone 38% in evaluable patients, and 48% vs 37% in all registered patients, as determined by an intention-to-treat analysis. The differences did not reach statistical significance. Conversely, in agreement with previous findings, we observed a significant difference in response rate in the subgroup of patients with liver metastases, regardless of the extent of hepatic involvement (DOX + LND 68% vs DOX 33%, p=0.03). This observation makes LND an important tool in association with anthracyclines in the treatment of this subgroup of patients.

Interference on Helicobacter pylori growth and adhesion by omeprazole and other drugs

Helicobacter pylori is the causative agent of gastritis and a co-agent in other gastroduodenal diseases. Gastroduodenal ulcer and MALT-lymphoma in particular, regress when patients are administered antimicrobial agents to eradicate infection. Sometimes eradication is not definitive and is difficult to check. The aim of our study was to test the antimicrobial activity of omeprazole on H. pylori in comparison with ampicillin and other anti-H2 drugs (ranitidine and famotidine), and to evaluate their interference with bacterial adhesion of H. pylori. We also compared results of the agar dilution antibacterial sensitivity test on H. pylori to those obtained using a bacteria adherence to cell monolayers model, to see if drug activity was different against adhered bacteria. We evaluated omeprazole and ampicillin MIC90s (minimum inhibitory concentrations) against 20 H. pylori isolates by traditional agar dilution method and by exposing previously adhered bacteria to an Hep-2 monolayer to different drug concentrations. The activity against bacteria adhered to cell lines was evaluated by counting viable adhered bacteria after 1, 6, 12 hours of contact with drug. Interference with adherence to Hep-2 cells was also tested. Omeprazole and ampicillin MICs were comparable to other findings (omeprazole MIC90 was 12.5 microg/ml and ampicillin MIC90 was 0.016 microg/ml), while higher concentrations were necessary (4 x MIC90) against adhered bacteria. These findings suggest that MICs evaluated with traditional assays can have different predictivity than tests on adhered H. pylori.

A novel super-potent neurokinin A receptor antagonist containing dehydroalanine

We report here the synthesis and preliminary pharmacological characterization of a novel Neurokinin A receptor antagonist. This molecule contains a dehydroalanine residue. It displays a high conformational rigidity and possesses very high activity. Its pharmacological properties as a neurokinin A receptor antagonist were assessed in in vitro experiments on rat vas deferens and were compared to those of Neuronorm and MEN10627.

Analysis and design of three-stranded coiled coils and three-helix bundles

Three-stranded coiled coils and three-helix bundles are increasingly being identified in proteins. Design and engineering on the scaffolds of these motifs is a potential route towards combating associated viral infections as well as introducing novel functional sites.

[Desmoids associated with multiple familial polyposis: description of a clinical case]

The Authors report a case of great desmoid tumor of the abdominal wall with intestinal adhesions and enterocutaneous fistula, in a patient with Gardner's syndrome, who underwent total colectomy with ileorectal anastomosis. The patient was treated at first with non steroidal antiinflammatory drugs, then with local chemotherapy. The Authors performed a second surgical procedure resecting the tumor and opening a temporary ileostomy. Despite of these treatment patient showed a local recurrence. Desmoid tumor is a neoplastic benign lesion arising from aponeurotic muscle tissue. Local infiltration and post-operative recurrence are very common. Several surgical and medical treatments are proposed, but they are not totally effective. Surgical treatment might be radical, with wide resection to reduce local recurrences. Radiotherapy and chemotherapy are second choice treatments.

Effects of alendronate on gastric and duodenal mucosa

OBJECTIVES

This single-center, double-blind, randomized study assessed the effect of alendronate 5 and 10 mg on the gastroduodenal mucosa.

METHODS

Overall, 95 postmenopausal women without a recent history of major upper gastrointestinal (GI) disease and not taking gastric-irritant drugs, were screened with an upper GI endoscopy. Fourteen women (15% of the total) were found to have baseline endoscopic gastric and/or duodenal abnormalities, including mucosal hemorrhages (n = 4), erosions (n = 11), and ulcers (n = 3). Two additional women had baseline esophageal abnormalities. Thus, 79 postmenopausal women (mean age 51 yr, range 41-64 yr), free of esophageal, gastric and/or duodenal erosions or ulcer, were enrolled. Subjects received placebo, alendronate 5 mg/day or 10 mg/day, or aspirin 650 mg q.i.d. for 14 days. Endoscopy was repeated on Day 8 and on Day 15. Gastric and duodenal mucosae were graded separately using a 5-point scale for erosive mucosal injury.

RESULTS

The proportions of subjects with a gastric or duodenal erosion score > or = 2 (presence of at least one mucosal erosion) on either Day 8 or 15 were four of 22 (18.2%) in the placebo group; four of 22 (18.2%) in the alendronate 5 mg group; five of 21 (23.8%) in the alendronate 10 mg group; and 14 of 14 (100.0%) in the aspirin group. Thirty-five of 76 (46%) subjects were H. pylori-positive (Pyloritek test), and were equally distributed across treatment groups.

CONCLUSIONS

Alendronate 5 and 10 mg/day for 2 wk was associated with a lower incidence of gastric erosions than aspirin. The incidence of gastric erosions in the alendronate groups did not differ significantly from the placebo group. In this study, unlike aspirin, alendronate did not induce gastric erosions.

Growth, insulin-like growth factor I (IGF-I), and IGF-binding proteins 1 and 3 in children with severe liver disease before and after liver transplantation: a longitudinal and cross-sectional study

We aimed to study the growth and growth factors of children with liver disease before and after liver transplantation (LT). Three observation intervals: 1) before LT (preLT), 2) after LT on daily prednisone treatment (dP), and 3) on alternate day prednisone (adP). A longitudinal study (LS) involved 17 infants (9 male) aged 0.73-2.38 y at LT; mean (+/- SD) height (Ht) SD score (SDS) at LT was -2.02 (+/- 1.25). In a cross-sectional study, there were 123 children (73 male) aged 0.16-14.88 y (mean 3.72 y). IGF-I and IGF binding proteins (BP) 1 and 3 were measured at the same intervals. The results were, for LS, preLT height velocity (HV) SDS (X +/- SD -0.8+/-1.4) lower (p < 0.01) than adP-HV SDS (3.1+/-1.8) but not different from dP-HV SDS (-1.0+/-1.9). For the cross-sectional study, dP-Ht SDS (X+/-SD -1.94+/-1.31) lower (p < 0.001) than preLT-Ht SDS (-1.03+/-1.06) and adP-Ht SDS (-0.98+/-1.20). Parental target SDS was not different from adP-Ht SDS. (Similar observations were made in the LS.) The dP- sitting height (SH) and subischial leg length (SLL) SDS were significantly lower than both preLT- and adP-SH SDS and SLL SDS (p = 0.02 and 0.002, respectively). There was a significant improvement of head circumference SDS and arm circumference SDS from preLT to adP. The dP and adP IGF-I and IGF-BP3 levels were greater than preLT levels (p < 0.001); no differences were found between preLT, dP, and adP IGF-BP1 levels. We conclude that growth in children with liver disease does not improve after LT on dP, but catch-up growth is shown on adP, appearing to depend mainly on the clinical course and corticosteroid regimen. IGF-I and IGF-BP3 increment on dP (and sustained on adP) is possibly due to liver regeneration, in contrast with inhibition of body growth on dP, possibly due to central and peripheral effects of corticosteroid.

[Acute hepatic necrosis in a patient treated with cyproterone acetate]

The Authors report a case of prostatic carcinoma in a 84 year old male, treated with cyproterone acetate (CPA), complicated by a fatal fulminant hepatitis. He was admitted with a mixed jaundice followed by a derange of all liver function tests. Serological markers for hepatitis were negative. Ultrasonography and CT revealed no hepatic abnormality but gallstones and dilatation of principal bile duct with a terminal stricture. By the endoscopic retrograde cholangiography and sphincterotomy we put an external drain tube. He died 9 days after admission. Fatal hepatis due to CPA is a very rare complication but all patients on anti-androgenic drugs should have liver function closely monitored. CPA must be discontinued immediately at the first derange of liver function tests.

Effect of 3,5-di-iodo-L-thyronine on the mitochondrial energy-transduction apparatus

We examined the effect of a single injection of 3,5-di-iodo-L-thyronine (3,5-T2) (150 microg/100 g body weight) on the rat liver mitochondrial energy-transduction apparatus. We applied 'top-down' elasticity analysis, which allows identification of the site of action of an effector within a metabolic pathway. This kinetic approach considers oxidative phosphorylation as two blocks of reactions: those generating the mitochondrial inner-membrane potential (DeltaPsi; 'substrate oxidation') and those 'consuming' it ('proton leak' and 'phosphorylating system'). The results show that 1 h after the injection of 3,5-T2, state 4 (respiratory state in which there is no ATP synthesis and the exogenous ADP added has been exhausted) and state 3 (respiratory state in which ATP synthesis is at maximal rate) of mitochondrial respiration were significantly increased (by approx. 30%). 'Top-down' elasticity analysis revealed that these increases were due to the stimulation of reactions involved in substrate oxidation; neither 'proton leak' nor the 'phosphorylating system' was influenced by 3,5-T2. Using the same approach we divided the respiratory chain into two blocks of reactions: cytochrome c reducers and cytochrome c oxidizers. We found that both cytochrome c reducers and cytochrome c oxidizers are targets for 3,5-T2. The rapidity with which 3,5-T2 acts in stimulating the mitochondrial respiration rate suggests to us that di-iodo-L-thyronine may play an important role in the physiological conditions in which rapid energy utilization is required, such as cold exposure or overfeeding.

Conformational behaviour of C(alpha,alpha)-diphenylglycine: folded vs. extended structures in DphiG-containing tripeptides

The crystal structures of three fully protected tripeptides containing the Dphi g residue (C[alpha,alpha]-diphenylglycine) in the central position are reported, namely Z-Gly-Dphi g-Gly-OMe (a), Z-Gly-Dphi g-Aib-OMe (b) and Z-Aib-Dphi g-Aib-OMe (c). The molecular conformations are quite unusual because the Dphi g residue adopts a folded conformation in the 3(10)-helical region when the following residue adopts a folded conformation of opposite handedness (peptides b and c). In contrast, the Dphi g residue adopts the more frequently observed fully extended conformation when the following residue adopts a semi-extended conformation (peptide a). These findings are in agreement with the theoretical calculations on Ac-Dphi g-Aib-NHCH3 and Ac-Aib-Dphi g-NHCH3 also reported in this work.

Hirunorms are true hirudin mimetics. The crystal structure of human alpha-thrombin-hirunorm V complex

A novel class of synthetic, multisite-directed thrombin inhibitors, known as hirunorms, has been described recently. These compounds were designed to mimic the binding mode of hirudin, and they have been proven to be very strong and selective thrombin inhibitors. Here we report the crystal structure of the complex formed by human alpha-thrombin and hirunorm V, a 26-residue polypeptide containing non-natural amino acids, determined at 2.1 A resolution and refined to an R-factor of 0.176. The structure reveals that the inhibitor binding mode is distinctive of a true hirudin mimetic, and it highlights the molecular basis of the high inhibitory potency (Ki is in the picomolar range) and the strong selectivity of hirunorm V. Hirunorm V interacts through the N-terminal tetrapeptide with the thrombin active site in a nonsubstrate mode; at the same time, this inhibitor specifically binds through the C-terminal segment to the fibrinogen recognition exosite. The backbone of the N-terminal tetrapeptide Chg1"-Val2"-2-Nal3"-Thr4" (Chg, cyclohexyl-glycine; 2-Nal, beta-(2-naphthyl)-alanine) forms a short beta-strand parallel to thrombin main-chain residues Ser214-Gly219. The Chg1" side chain fills the S2 subsite, Val2" is located at the entrance of S1, whereas 2-Nal3" side chain occupies the aryl-binding site. Such backbone orientation is very close to that observed for the N-terminal residues of hirudin, and it is similar to that of the synthetic retro-binding peptide BMS-183507, but it is opposite to the proposed binding mode of fibrinogen and of small synthetic substrates. Hirunorm V C-terminal segment binds to the fibrinogen recognition exosite, similarly to what observed for hirudin C-termninal tail and related compounds. The linker polypeptide segment connecting hirunorm V N-and C-terminal regions is not observable in the electron density maps. The crystallographic analysis proves the correctness of the design and it provides a compelling proof on the interaction mechanism for this novel class of high potency multisite-directed synthetic thrombin inhibitors.

How the thyroid controls metabolism in the rat: different roles for triiodothyronine and diiodothyronines

1. Although the first evidence of a relationship between the thyroid and metabolism was reported in 1895, the mechanism by which thyroid hormones influence resting metabolic rate in whole animals is still poorly understood. This paper reports an attempt to test whether diiodothyronines (T2s) and triiodothyronine (T3) have different roles in the control of resting metabolism (RM). 2. Changes in resting metabolic rate were measured in hypothyroid rats treated acutely (25 micrograms (100 g body weight)-1) either with one of the T2s or with T3. Injection of T3 induced an increase of about 35% in RM that started 25-30 h after the injection and lasted until 5-6 days after the injection, the maximal value being observed at 50-75 h. The injection of T2s evoked a temporally different pattern of response. The increases in RM started 6-12 h after the injection, had almost disappeared after 48 h, and the maximal stimulation was observed at 28-30 h. 3. When actinomycin D (an inhibitor of protein synthesis) and T3 were given together, the stimulation of RM was almost completely abolished. The simultaneous injection of actinomycin D and either of the T2s, on the other hand, did not cause any attenuation of the stimulation seen with the T2s alone. 4. Following chronic treatment (3 weeks) with either T3 or T2s there was a stimulation of organ growth only after the administration of T3. 5. Chronic administration of either T2s or T3 to hypothyroid rats significantly enhanced the oxidative capacity of each of the tissues considered. In the case of T2s the stimulation was almost the same whether it was expressed as an increase in specific activity or total tissue activity. In the case of T3 the increases were, in the main, secondary to the hypertrophic or hyperplastic effect. 6. These results indicate that T2s and T3 exert different effects on RM. The effects of T2s are rapid and possibly mediated by their direct interaction with mitochondria. Those of T3 are slower and more prolonged, and at least partly attributable to a modulation of the cellularity of tissues that are metabolically very active.

Induction of UCP2 mRNA by thyroid hormones in rat heart

The possible regulation of the expression of uncoupling protein-2 (UCP2) mRNA by thyroid hormones in different tissues was examined in rats. Triiodothyronine (T3) was found to produce an organ-specific enhancement of UCP2 expression in rat tissues. The effect of T3 was markedly observed in heart, whereas a moderate effect was seen in skeletal muscle and no effect in kidney or liver. These results suggest that UCP2 is a protein that may be involved in the nuclear-mediated effect of T3 on resting metabolic rate in the rat.

Loperamide test: a simple and highly specific screening test for hypercortisolism in children and adolescents

The overnight dexamethasone (DXM) test can give false-positive results in a few conditions (e.g. stress, strenuous exercise, depression, anorexia, anxiety, anticonvulsive therapy) in diagnosing simple obesity and hypercortisolism (HC). The loperamide (LP; a peripheral opioid agonist) test has proven useful in such conditions in adults. Thirty-one obese subjects (age 10.0-19.7 y) were studied by both overnight DXM test and LP test (8 mg orally, samples for cortisol at 0, 90, 150, 180 and 210 min) on 2 separate days. LP suppressed cortisol (< or = 138 nmol l-1) at a dose of 0.1 mg kg-1 bw (half the minimum recommended dose for the drug's antidiarrhoea effect) in 14 subjects who had normal urinary (< 4970 nmol l-1) and serum (< 552 nmol l-1) cortisol, in the absence of signs and symptoms of HC (group A). The DXM test failed to suppress cortisol in three subjects in group A, two of whom were on anticonvulsive treatment. The LP test suppressed cortisol in all of 13 subjects with elevated urinary and/or serum cortisol and/or with signs or symptoms of HC (but in whom HC was subsequently excluded on clinical grounds) (group B), while the DXM test failed to suppress cortisol in three subjects of this group. One of these was under anticonvulsive treatment and one suffered from anxiety and depression. In four patients with Cushing's syndrome (group C) neither DXM nor LP could suppress cortisol levels. Therefore, the sensitivity was 100% for both DXM and LP, while the specificity was 84% for DXM and 100% for LP. No side-effects were observed with either drug. In conclusion, LP is a useful alternative to DXM in those particular conditions that can affect its specificity in children.

Inhibition of in vitro growth of enteropathogens by new Lactobacillus isolates of human intestinal origin

Three human Lactobacillus strains, coded B21060, B21070 and B21190, have recently been isolated. The strains show a series of features (acid and bile resistance, adhesion to various types of mucosal cell) which make them particularly promising for the preparation of probiotic products. In the present study, the ability of the strains to inhibit the growth of pathogens in coculture was investigated. Lactobacilli were incubated simultaneously or after one overnight growth with enterotoxigenic Escherichia coli, Salmonella enteritidis or Vibrio cholerae. After 24 and 48 h, bacterial counts of the pathogens and of the lactobacilli were performed. The results showed that these Lactobacillus strains inhibited the in vitro growth of E. coli and S. enteritidis under both conditions. Moreover, a cumulative effect was observed for mixtures of lactobacilli. In contrast, no significant inhibition of Vibrio cholerae growth was observed, provided that the pH of the medium was kept constant. The presence of the pathogens did not affect the growth of the Lactobacillus strains. Moreover, each of the Lactobacillus strains showed coaggregation ability with two pathogenic E. coli strains, namely ATCC 25922 and ATCC 35401.

[Recurrent leiomyoma of the rectum treated by endoscopic transanal microsurgery]

The Authors report a case of recurrent leiomyoma of the rectum treated by Transanal Endoscopic Microsurgery (T.E.M.). Leiomyoma of the rectum is a rare entity (0.1-0.3%) (the incidence of smooth muscle tumours being 7% in the digestive tract). Benign leiomyomas are usually asymptomatic; discomfort or pain, related or not to defecation, sensation of foreign body, change in bowel habits, rectal bleeding are rarely reported. The distinction between a benign leiomyoma and a leiomyosarcoma is often difficult and requires an accurate microscopic study. In most cases rectal leiomyoma is detected incidentally in the course of a rectal examination. Endoscopic examination of the rectum with biopsies and endorectal ultrasonography are useful for the diagnosis, while rarely a plain radiologic examination is sufficient. Leiomyoma of the rectum also presents a high tendency to local recurrence (31%). Therefore the choice of an adequate treatment is often difficult. The Authors believe that the treatment of rectal leiomyoma by T.E.M. may substitute conventional methodics (transanal excision, proctectomy with or without amputation of the sphincter and coloanal anastomosis, endoscopic electroexcision of the neoplasm). T.E.M. allows short-term hospitalization and implies minimal surgical trauma.

Characterization of the binding of 3,3'-di-iodo-L-thyronine to rat liver mitochondria

The binding of labelled 3,3'-di-iodo-L-thyronine (3,3'-T2) to isolated rat liver mitochondria has been characterized. Specific binding could be detected only in the inner mitochondrial membrane, not in other mitochondrial subfractions. The composition of the incubation medium influenced the binding capacity, the best combination of high specific binding and low non-specific binding being observed in phosphate buffer, pH 6.4. The specific binding of 3,3'-T2 to mitochondria requires low ionic strength: concentrations of K+ and Na+ higher than 10 mmol/l and 0.1 mmol/l respectively resulted in a decreased binding capacity. The optimal calcium ion concentration was in the range 0.01-1.0 mmol/l. Varying magnesium ion, over the range of concentrations used (0.1-100 mmol/l), had no effect. Both ADP and ATP, at over 1 mmol/l, resulted in an inhibition of the specific binding. Incubation with protease resulted in a decrease in specific binding and an increase in non-specific binding, thus indicating the proteic nature of the binding sites. In addition to the above factors in the local environment the thyroid state of the animal might influence the 3,3'-T2-binding capacity. In fact, the thyroid state of the animal seemed not to have an influence on the affinity constant, but it did affect binding capacity.

[Esophago-jejuno-gastroplasty in the treatment of peptic stenosis of the esophagus]

From 1973 to 1994, 21 patients with esophageal peptic stenosis were submitted to esophago-jejuno-gastroplasty with Merendino's technique. In 14 cases peptic stenosis developed after Heller's myotomy for achalasia, associated in 3 cases with fundoplication. In 3 patients the stenosis was secondary to fundoplication. Other 3 subjects presented a primary stenosis. One patient showed Barrett's esophagus with in situ carcinoma. Endoscopic esophageal dilatation was attempted in every patient with no satisfactory results. One patient died for a postoperative cardiopulmonary failure (4.7%). One patient developed a fistula of the esophago-jejunal anastomosis treated with enteral nutrition successfully (4.7%). In another subject splenectomy was performed following a iatrogenic injury (4.7%). Minor complications developed in 5 patients (23.7%). After one year from operation in 1 patient a severe stricture of esophago-jejunal anastomosis appeared; it was treated with anastomotic resection and reconstruction. After 8 years one patient was submitted to a partial resection of interposed jejunal loop, that was redundant. In 18 patients long term follow-up showed good results in 14 patients (78%), discrete in 2 (11%), unsatisfactory in 2 (11%). Our results show that Merendino's esophago-jejunal gastroplasty allows to achieve good results with acceptable rate of mortality and morbidity.

[Indications for splenectomy in Gaucher's disease. Case report]

Gaucher's disease is a rare metabolic disorder characterized by the lack of beta-glucocerebrosidase enzyme. In this case report a 26-year-old male patient was, first diagnosed as having splenomegaly and a huge haemangioma, therefore managed by total splenectomy. Histologic examination and specific colouring techniques using PAS and Black Sudan dyes allowed the diagnosis of Gaucher's disease. Preoperative diagnosis is hence fundamental to establish the correct management procedure, which currently may be surgical or medical and/or combined. In fact, following the diagnosis the second step includes the decision-making about splenectomy. Other therapeutic approaches are enzyme replacement therapy and genic therapy. The first may be combined to partial splenectomy, while the latter still needs further evaluations.

Jejunal interposition for peptic stenosis of the esophagus following esophagomyotomy for achalasia

Retrospective analysis of the results of esophagojejunogastrostomy in 21 patients with peptic stenosis after esophagomyotomy for achalasia is reported. All patients complained of severe dysphagia. The esophagogram showed the presence of a 2 to 3 cm long stenosis in the lower esophagus with a diameter < 10 mm. Endoscopic dilatation was possible in 18 cases and it was pursued until the passage of the endoscope was possible. Manometry confirmed the presence of an aperistaltic esophagus with incompetent LES in all cases examined. GERD was detected by 24 hour pH-metry in 15/21 patients (71.4%). One patient died because of postoperative cardiopulmonary failure. Other minor complications occurred in 6 patients. During an 11 year mean follow-up good results were achieved in 17 patients (85%), fair in 2 (10%) and poor in 1 (5%), in whom redundant jejunal loop was resected after 8 years. Resective surgery in peptic strictures after esophagomyotomy is the treatment that guarantees the best long-term results. Esophagojejunogastroplasty represents a valid technique. Careful selection of patients and an accurate surgical technique are fundamental to reduce mortality and morbidity.

[The use of laser through thoracoscopy in the treatment of spontaneous pneumothorax. Presentation of a clinical case]

The authors present the case of a patient with right plurirecidive pneumothorax. During the 12 months before the operation the patient suffered from 3 episodes of pneumothorax, treated with the insertion of an intrapleural drainage. Preoperative exams showed the presence of multiple emphysematous blebs with diameter ranging from 0.5 cm to 3 cm. The patient was treated with Nd:YAG laser photocoagulation of the blebs and mechanical abrasion of the parietal pleura through thoracoscopy. The laser photocoagulation of the blebs was performed using the contact technique and a 25 Watt power. After operation a TX of the thorax, using the high resolution technique, showed the presence of residual blebs involving the apex and the mediastinal surface of the inferior lobe of the right lung. After a 12 month follow-up no recidive pneumothorax occurred and the general conditions of the patient were good. The authors state that the laser treatment of spontaneous pneumothorax secondary to bullous emphysema is effective and safe and it is also successful in patients with multiple blebs. As it is often difficult to find and treat all the blebs, it may be useful to perform thoracography during thoracoscopy.

[Repetitive movements of the upper limbs: results of exposure evaluation and clinical investigation in refinishing ceramic ornaments]

An evaluation was made of the degree of exposure to risk and the frequency of disorders attributable to biomechanical overload of the upper limb in workers performing finishing operation on ceramic vases and cups in a ceramics factory. The risks were first evaluated against a checklist, then subsequently an assessment was made of the tasks found to feature the highest risks, using an ergonomic analysis method, which identified activities associated with a large number of actions per minute (> 50). The 22 female workers performing the tasks in question underwent a risk-targeted physical examination which included an electroneurographic test using surface electrodes. The clinical test detected an extremely high frequency of carpal tunnel syndrome cases, in addition to other upper limb disorders. In particular, nine female workers (41%) were found to be suffering from carpal tunnel syndrome, and five (22%) from other pathologies of the upper limbs (4 scapulo-humeral periarthritis, 1 epicondylitis). As a result of the findings arising out of this study, immediate preventive measures were adopted; moreover, it has become evident that further epidemiological studies on larger sample populations are needed.

[Complications of surgery of Dupuytren disease. Comparison of total and partial aponeurectomy]

Total and partial aponeurectomy are the most usual operations performed for the treatment of Dupuytren's disease. Eighteen patients, for a sum of 23 treated hands, were submitted to total aponeurectomy in 20 cases and to partial aponeurectomy in 3 cases. Recurrence was present in 4 cases. Postoperative morbidity was 50% (10/20 cases) following total aponeurectomy and 0% (0/3 cases) following partial aponeurectomy. In patient with recurrence disease postoperative complications were present in 3/4 cases (75%) while in patients, operated for the first time, morbidity rate was 36.8% (7/19 cases). Postoperative complications following total aponeurectomy are extremely frequent, especially if recurrence is present. Partial aponeurectomy allows to achieve functional result as good as total aponeurectomy with significative reduction of postoperative morbidity.

Peripheral nervous system involvement in systemic sclerosis: the median nerve as target structure

OBJECTIVES

To investigate the frequency and the main electrophysiological characteristics of the canalicolar passage nerve involvement in patients with systemic sclerosis (SSc).

METHODS

Thirty-two SSc patients were enrolled in the study, classified according to the type (diffuse or limited) and the duration (> / < 5 years) of the disease. Sensory-motor nerve conduction studies (NCS) of the upper and lower limbs, in particular at the critical canalicolar points, were conducted by recording the Compound Muscular Action Potential (CMAP) and the Sensory Action Potential (sNAP). The following parameters were evaluated: Motor Nerve Conduction Velocity (MNCV) and Sensory Nerve Conduction Velocity; distal and proximal latency of the CMAP and the onset and peak latency of the sNAP; peak-peak amplitude and negative-peak area of the CMAP and sNAP; and the Terminal Latency Index (TLI) (Terminal Distance/MCNV x Distal latency).

RESULTS

Four (12.5%) patients had a distal neuropathy of the upper limbs (one with monolateral and two with bilateral involvement of the median nerve and one bilateral involvement of the ulnar nerve). Fourteen (43.7%) patients showed a decrement of the median nerve TLI and seven (21.8%) of either the median or the ulnar nerve (Table I). Motor and sensitive conduction velocity and latency studies did not show a statistical difference between SSc patients and controls. The amplitude and area of the CMAP (distal and proximal), sNAP and of the median nerve TLI were significantly decreased in patients with respect to controls.

CONCLUSION

Distal mononeuropathy of the median nerve was the most frequent result in our patients. The involvement of the peripheral nervous system seems to be strictly topographical, following the modifications of the tissues and vascular tone (Raynaud's phenomenon) at the upper acral level. The neurophysiological alterations detected in our study at the wrist level may not be linked merely to a compressive event but also to microvascular involvement. Nerve involvement closely connected with the pathogenesis and distribution of SSc should be considered when peripheral nervous system involvement is the initial symptom of the disease.

Nerve growth factor circulating levels are increased in Kawasaki disease: correlation with disease activity and reduced angiotensin converting enzyme levels

OBJECTIVE

To investigate the serum levels of nerve growth factor (NGF) and their possible relationship with disease activity in Kawasaki disease.

METHODS

Twelve children with Kawasaki disease, 12 healthy children (afebrile controls), and 12 children with high fever related to upper respiratory tract viral infections (URTVI) were enrolled in the study. Serum NGF levels were measured by an ELISA method before and after therapy. In addition, angiotensin converting enzyme (ACE), and erythrocyte sedimentation rate (ESR), complete hemochrome, and C-reactive protein were tested as indicators of endothelial injury and disease activity, respectively.

RESULTS

NGF levels were strikingly increased in the acute phase of Kawasaki disease (1219.54 +/- 1660.29 pg/ml) and decreased in the inactive phase of the disease (277.08 +/- 245.64 pg/ml), while remaining significantly higher than controls (6.5 +/- 2.03 pg/ml). In febrile patients with URTVI, NGF levels (30.18 +/- 44.70 pg/ml) were moderately but significantly increased compared to afebrile controls, but remarkably lower in respect to active and inactive Kawasaki disease. In active Kawasaki disease, ACE values were significantly lower than in healthy children (2.8 +/- 1.7 vs 10.1 +/- 4.2 pmol/ml/min; p < 0.001) and increased during the inactive phase, but remaining lower than in controls (4.8 +/- 2.7 pmol/ml/min); ESR, hemoglobin level, and platelet count showed significant correlation with NGF, while ACE levels showed a significant inverse correlation with ESR and NGF.

CONCLUSION

In Kawasaki disease, NGF increased together with decreased ACE may be linked to a diffuse vascular inflammatory process. NGF and ACE levels remained abnormal even when there was no clinical sign of disease activity. This may indicate that the disease process is not in complete remission and suggests careful and prolonged cardiac followup until their normalization.

Increased circulating nerve growth factor is directly correlated with disease activity in juvenile chronic arthritis

OBJECTIVE

To determine the circulating serum concentrations of nerve growth factor (NGF) and compare them with indices of disease activity in juvenile chronic arthritis.

METHODS

NGF concentrations were evaluated with a two site immunoenzymatic assay (ELISA), in 17 children with systemic, 39 with polyarticular, and 24 with pauciarticular onset juvenile chronic arthritis. Each subset was divided according to different variables, appropriate to each subset, reflecting active and inactive disease.

RESULTS

NGF concentrations were significantly higher in children with systemic [254 (SD 256.1) pg ml-1; P < 0.001], polyarticular [165.2 (300.8) pg ml-1; P < 0.05], and pauciarticular [106.8 (111.8) pg ml-1; P < 0.005] onset juvenile chronic arthritis than in controls. In all subsets, NGF concentrations were higher in the active than in the inactive phase of the disease. A significant direct correlation between NGF concentrations and erythrocyte sedimentation rate was found both in the systemic and in the polyarticular onset juvenile chronic arthritis.

CONCLUSIONS

The increase in NGF concentrations in all juvenile chronic arthritis subsets and the correlation with disease activity suggest that NGF may take an active part in joint inflammation.

Biochemical and radiologic improvement in Paget's disease of bone treated with alendronate: a randomized, placebo-controlled trial

PURPOSE

The potent bisphosphonates offer great promise in the management of Paget's disease of bone, but are currently available only as parenteral preparations in most countries. There is a need for a well-tolerated, oral therapy. Furthermore, none of the currently available therapies have been rigorously demonstrated to heal the lytic bone lesions characteristic of this condition. Alendronate is a potent new oral aminobisphosphonate that has shown promising effects on Paget's disease in preliminary studies.

METHODS

We report a double-blind, randomized comparison of oral alendronate 40 mg/day and placebo over 6 months in 55 patients with Paget's disease. Efficacy was determined from measurements of biochemical indices of bone turnover (serum alkaline phosphatase and urine N-telopeptide) and blinded radiologic assessment of lytic bone lesions.

RESULTS

N-telopeptide excretion declined by 86% and serum alkaline phosphatase by 73% in patients receiving alendronate, but remained stable in patients receiving placebo (P < 0.001 between groups for both indices). Responses were similar whether or not patients had previously received bisphosphonate treatment. Alendronate treatment normalized alkaline phosphatase in 48% of patients. Forty-eight percent of alendronate-treated patients showed radiologic improvement in osteolysis whereas in the placebo group only 4% improved (P = 0.02 for between-groups comparison). No patient in either group showed worsening of osteolysis. Bone histomorphometry indicated that alendronate tended to normalize turnover indices. There was no evidence of abnormal mineralization in bone biopsies taken from 12 alendronate-treated subjects. The treatment was well tolerated.

CONCLUSION

Oral alendronate appears to be a safe and effective therapy for Paget's disease and results in healing of lytic bone lesions.

Effect of melatonin on normal and sclerodermic skin fibroblast proliferation

OBJECTIVE

We studied the effect of melatonin (MLT) (N-acetyl 5-methoxytryptamine) on the growth rate of normal skin fibroblasts and of fibroblasts from involved and apparently uninvolved skin of patients affected by systemic sclerosis (SSc).

METHODS

The growth rate was evaluated on the basis of growth curves and a 3H-thymidine incorporation assay.

RESULTS

Our results demonstrate that a dose of 200 micrograms/ml of MLT inhibits (> 80%) both control and SSc fibroblasts. Inhibition was dose-dependent and was greater than 70% for MLT concentrations of 100 micrograms/ml, 200 micrograms/ml and 400 micrograms/ml. 3H-thymidine incorporation was correlated with the effect on the growth curves (81% at 200 micrograms/ml of MLT). In contrast, at a low dosage of 6 micrograms/ml, MLT exerted a stimulatory effect on cell proliferation in all the cell lines analyzed. Cell viability was not affected by MLT at any of the concentrations tested. A recovery study indicated that replacement of MLT-containing medium with MLT-free medium resulted in a re-establishment of cell growth.

CONCLUSIONS

These results suggest that MLT, at higher dosages, is a potent inhibitor of the proliferation of fibroblasts derived from the skin of healthy and SSc patients.

A review of the design, synthesis and biological activity of the bicyclic hexapeptide tachykinin NK2 antagonist MEN 10627

We review the reported data on the design, the conformational features and the pharmacological properties of the bicyclic peptide tachykinin NK2 receptor antagonist MEN 10,627 or cyclo(Met-Asp-Trp-Phe-Dap-Leu)cyclo(2 beta-5 beta). MEN 10,627 possesses a highly constrained structure characterized by two consecutive beta-turns, as confirmed by the almost coincident results of NMR and X-ray analyses. The compound has been efficiently synthesized by solid-phase methodology using either Boc or Fmoc strategies. It is quite stable to metabolic degradation and is endowed with high affinity and selectivity for NK2 receptor expressed in various species. At the hamster NK2 receptor MEN 10,627 is about 30-fold more potent than the nonpeptide NK2 receptor antagonist, SR 48,968, while the converse is true for the rabbit NK2 receptor. MEN 10,627 and SR 48,968 show comparable affinities for the human NK2 receptor. MEN 10,627 produces a long lasting inhibition of the response to the selective NK2 receptor agonist [beta Ala8]NKA(4-10) in the rat urinary bladder in vivo after intravenous, intranasal and intraduodenal administration. Therefore different administration routes are possible for this compound that overcomes the usual drawbacks for the application of peptides as drugs.

Calorigenic effect of diiodothyronines in the rat

1. In hypothyroid rats, we determined the effects of administration of different doses of 3,3',5-triiodo-L-thyronine (T3), 3,3'-diiodo-L-thyronine (3,3'-T2) and 3,5-diiodo-L-thyronine (3,5-T2) ("T2 isomers' refers specifically to these latter two isomers throughout this paper) on resting metabolism (RM) and on the oxidative capacity (measured as cytochrome oxidase activity) of tissues that are metabolically very active. 2. The T2 isomers induced a dose-dependent calorigenic effect when injected I.P. into hypothyroid rats. The increase in RM was already evident at a dose of 2.5 micrograms (100 g body wt)(-1), and the greatest effect was observed at the highest dose, 10 micrograms (100 g body wt)(-1), when RM reached a value not significantly different from that of the euthyroid controls (1.92 +/- 0.08 and 1.93 +/- 0.13 (1 O2) kg(-1) h(-1) for 3,5'-T2, respectively, vs. 2.1 +/- 0.12 (1 O2) kg(-1) h(-1) for euthyroid controls). T3 administration restored RM to normal euthyroid values, even at a dose of 2.5 micrograms (100 g body wt)(-1). 3. The effect of T2 isomers on RM was paralleled by an increase in the oxidative capacity of tissues that are metabolically very active (liver, skeletal muscle, brown adipose tissue (BAT) and heart). The increases were between 33% (liver + 3,3'-T2) and 63% (muscle + 3,3'-T2). By contrast, T3 induced its greatest effect on the liver, with a smaller effect on skeletal muscle, but no significant stimulation in heart and BAT, whatever the dose. 4. These results suggest that T8 isomers might be mediators of the direct thyroid hormone regulation of energy metabolism.

[Distal popliteal bypass in the diabetic patient. Clinical case]

Foot revascularization by popliteal-to-distal bypass is a well documented procedure for limb salvage in diabetic patients. The authors report their experience with a diabetic patient admitted with an ischemic left foot [transcutaneous oxygen (PtcO2): 3 mmHg] due to extensive tibial artery occlusive disease beginning at the popliteal artery trifurcation. Limb salvage was achieved by anatomical popliteal-anterior tibial bypass with inverted saphenous vein. Nine months later the patient was readmitted with an ischemic right foot (PtcO2: 16 mmHg) and a similar pattern of peripheral arterial occlusive disease. Limb salvage was achieved by extranatomical popliteal-dorsalis pedis bypass with a reversed saphenous vein. At six months from the latest surgery both feet are healed, PtcO2 is 60 mmHg and 37 mmHg for the left and right foot respectively and the patient has resumed a normal walking distance. This experience, and a review of the literature, confirm the validity of the popliteal-to-distal bypass and the need for more aggressive vascular surgical attitude to treat the ischemic diabetic foot.

Cisplatin, epirubicin, and vindesine with or without lonidamine in the treatment of inoperable nonsmall cell lung carcinoma: a multicenter randomized clinical trial

BACKGROUND

Lonidamine (LND) is an indazol-carboxylic acid derivative that selectively inhibits the energy metabolism of neoplastic cells, and increases the permeability of cell membranes. In vitro studies have demonstrated that LND can potentiate the oncolytic activity of cytotoxic drugs and is able to reverse the acquired multidrug resistance of neoplastic cells. Some clinical trials have suggested a synergism of LND with alkylating agents, cisplatin, and anthracyclines in various solid tumors.

METHODS

From June 1990 to June 1993, 158 previously untreated patients with Stage IIIB and IV nonsmall cell lung cancer (NSCLC) were enrolled into a multicentric randomized trial to evaluate the addition of LND to a cisplatin-epirubicin-vindesine regimen. Eighty patients in the control arm (A) received cisplatin, 60 mg/m2 intravenously (i.v.); epirubicin, 60 mg/m2 i.v.; and vindesine, 3 mg/m2 i.v. (PEV), on Day 1 every 4 weeks, whereas 78 patients in the experimental arm (B) received the same regimen with the addition of LND from 75 mg orally three times on Day 1 to 150 mg orally three times on Day 7+ until tumor progression occurred.

RESULTS

The experimental treatment achieved a significantly higher proportion of major responses in comparison with the control regimen (43% vs. 24%; P=0.02). The addition of LND apparently potentiated the activity of this cytotoxic treatment, particularly in patients with metastatic disease (overall response rate, 39% vs. 17%). The median time to progression (5 vs. 8 months; P=0.0007) and the median survival time (7.6 vs. 11 months; P=0.0013) were also statistically improved in Arm B. The acute toxicity of the 2 treatments was low: only 6% of patients in Arm A and 4% of patients in Arm B had to withdraw from treatment due to Grade 4 World Health Organization toxicity. The main additional side effects related to the administration of LND were epigastralgia, myalgia, asthenia, and orchialgia. However, these symptoms were mild and controlled by the concomitant administration of low doses of steroids.

CONCLUSIONS

The mild acute toxicity of the PEV regimen and the acceptable and nonoverlapping additional side effects of LND render our experimental therapy worthy of consideration for the management of NSCLC patients with poor performance status or low tolerance to more aggressive therapeutic approaches.