Docetaxel (T) followed by capecitabine (X) as first-line chemotherapy in patients (pts) with metastatic breast cancer (MBC): Preliminary findings from a phase II study

10692

Background: X and T are highly active single agents in MBC. The XT combination leads to superior overall survival (OS), time to progression (TTP) and response rate (RR) vs. T alone in anthracycline-pretreated MBC [O’Shaughnessy et al. J Clin Oncol 2002]. The aim of this trial was to evaluate the efficacy and safety of sequentially administered T then X as first-line treatment in MBC. Methods: Pts ≥ 18 years with previously untreated, HER2neu-negative MBC, ECOG PS ≤ 2, were included in this prospective, multicenter, non-randomized, phase II study. Pts received 3 cycles of T (100mg/m2 d1) followed by 3 cycles of X (1250mg/m2 bid d1–14), every 3 weeks. Results: To date, 38 pts are evaluable for safety and 33 pts for efficacy. Baseline characteristics: median age 54.4 years (range 33–76); PS ≥ 1 50%; 36 (95%) pts had previous (neo)adjuvant anthracyclines, 8 (21%) concomitant with paclitaxel. The most frequent metastatic sites were: bone 47%, nodes 39% and liver 36%. 69% of pts had ≥ 2 metastatic sites. To date, 38 pts have received 3 cycles of T and 33 have also received 3 cycles of X. A total of 195 cycles have been administered: T 108 cycles (median 3, range 1–3); X 87 cycles (median 3, range 1–3). Dose reductions and interruptions for T vs. X were 32 vs. 21% and 21 vs. 21%, respectively. Median relative dose intensity: T 0.97 (range 0.62–1.00), X 0.93 (range 0.26–1.00). T grade 3/4 toxicities (37 evaluable pts): asthenia 19%, mucositis 16%, nausea 13%, febrile neutropenia 11%, rash 5%, diarrhea 5%, infection 3%. X grade 3/4 toxicities (33 evaluable pts): hand-foot syndrome 9%, diarrhea 9%, vomiting 9%, asthenia 6%, nausea 3%, anorexia 3%. In the 33 pts evaluable for efficacy, the RR was 61%, including 4 CRs and 16 PRs. At a median follow-up of 6.1 months, median TTP has not yet been reached. Conclusions: These preliminary results show that the sequential regimen of T followed by X is feasible, effective and well tolerated in first-line MBC, although giving X before T should also be investigated. Findings from a recent trial of XT vs. T followed by X [Beslija et al. ECCO 2005] suggest that XT should be standard in fit poor-prognosis pts with aggressive disease.

No significant financial relationships to disclose.

Preliminary data of a phase I-II clinical and pharmacokinetic study of plitidepsin in children with malignant tumors. On behalf of the European ITCC (Innovative Therapies for Children with Cancer) Consortium

9060

Background: Plitidepsin (Aplidin) is a cyclic depsipeptide isolated from the tunicate Aplidium albicans, nowadays manufactured by synthesis. It is a rapid and potent inductor of apoptosis. Phase I trials in adults explored 5 different schedules. Muscle and liver toxicities were dose-limiting; hematological toxicity was not observed at the recommended dose (RD). Methods: This is a multicentre, open-label, non-randomized phase I-II study with a dose finding stage in children with solid tumors, and two expanded cohorts in leukemia and solid tumors at the RD. Plitidepsin was administered as a 3 h iv infusion every 2 weeks (=1 cycle). The initial dose level was 4 mg/m2 (80% of the RD in adults), with a classical escalation to 5 and 6 mg/m2. Results: 16 patients have been entered to date with median age 7.5 years (range 2–17). 54 cycles in 15 patients were evaluable for toxicity. 8 patients were treated at 4 mg/m2, five at 5 mg/m2 and three at 6 mg/m2. One patient presented dose-limiting G2 myalgia lasting more than 2 weeks at 4mg/m2. The Maximum Tolerated Dose (MTD) has not been reached at 6 mg/m2. Non-hematological toxicities included G1-G2 muscle side effects: (myalgia, CPK elevation, muscle weakness), G1–2 fatigue, G3 vomiting. One G3 hypersensitivity reaction was observed without prophylactic treatment. Pharmacokinetic data are similar to those reported in adult (extensive tissue distribution, a long half-life); if any, clearance was slightly higher and half-life shorter. Partial response was observed in a pancreatoblastoma and disease stabilization in a progressive medulloblastoma. Conclusions: Plitidepsin was well tolerated in children, with muscular side effects being the most relevant toxicity observed. The MTD for the pediatric population has not yet been achieved at a dose 1.2 fold above the RD in adults.

[Table: see text]

Neuregulin (NRG) expression modulates clinical response to trastuzumab in patients with metastatic breast cancer (MBC)

10069

Background: ErbB2 overexpression is the major determinant of response to trastuzumab (Herceptin, H). Recently, some authors have reported the potential role of the expression of NRG on ErbB2 activation in breast cancer cells, and its consequences in response to treatment with H. In the present study we analyze the relationship between response to H and expression of ErbB2 and NRG in patients (pt) with MBC. Methods: Data and frozen tissue samples from 30 consecutive pt with MBC and positive ErbB2 at diagnosis [Immunohistochemistry (IHC)] were collected. All pt were treated with an Herceptin-based regimen. Central Pathologic review of ErbB2 expression was performed in all samples (Herceptest and FISH). NRG expression was studied by IHC on paraffin embedded material and by Western blotting on frozen tissue using an antibody raised against the intracellular domain of NRG. NRG expression by IHC was evaluated using a semiquantitative scoring system that assesses both extension and intensity of cytoplasmic staining. Correlation between ErbB2 and NRG expression and its influence in response to H was analyzed. Characteristics of pt: Median Age: 54; Median mts sites: 2; Treatment: H alone:1 pt; H+Taxol:15 pt; H+Taxol+Carbo: 4 pt; H+Taxol+Lip.Doxorub:2 pt, H+Vinorelbine:7 pt; H+CDDP:1 pt. Results: ORR: 76% (CR:23%, PR:53%). Median TTP: 7.8 m. After central Pathologic review, a total of 20 tumors showed ErbB2 amplification by FISH and 19 of them were Herceptest 3+. A positive correlation was observed between ErbB2 amplification and NRG expression. All complete responses (n=7) were seen in pt with ErbB2 amplification. Interestingly, in the group of tumors without ErbB2 amplification (n=10), 7 had high NRG expression levels, as assessed by IHC. Six out of these 7 tumors having high levels of NRG expression, exhibited partial responses. NRG expression, in turn, did not have impact on response among ErbB2 amplified tumors. Conclusions: These preliminary results suggest that responses to H regimens in pt with MBC can be seen in pt lacking ErbB2 amplification in presence of high levels of expression of transmembrane ligand NRG. This suggests that the group of pt that may benefit from treatment with H could be broader than currently established. A confirmatory study is ongoing in a larger series.

No significant financial relationships to disclose.

Frequency of familiar cancer in a cohort of newly-diagnosed patients with colorectal cancer

13588

Background: Incidence on Hereditary Non Poliposis Colorectal Cancer (HNPCC) is 3–5% of all colorectal cancers (CRC). Primary identification of patients (p) with high risk of this hereditary syndrome is the first step before genetic testing for MSH2, MLH1 or MSH6 mutations. AIMS: To determine the frequency of family history of CRC in our population Methods: We have assessed cancer history (full family pedigree, including at least 2 generations of ascendants plus all descendants) in a cohort of 100 newly-diagnosed p with CRC cancer seen as first visit at the Division of Medical Oncology of the University Hospital of Zaragoza, Spain, from 2005. We have used the revised Bethesda Guideline for HNPCC published in JNCI (Vol 96. Feb 2004) Results: Median age was 72 (range: 26 - 85). 29 females/71 males. Considering Bethesda criteria for genetic testing, percentages of families fulfilling them were: Cancer before age 50: 7 (7%), synchronous/metachronous cancer: 1 (1%), other HNPCC associated tumors before age 50: 1 (ovarian 1%), One first-degree relative with HPNCC related tumor before age 50: 4 (4%), Two or more family members with HNPCC related cancer: 5 (5%). Overall, 14 (14%) fulfilled at least 1 of these criteria. Number of cases of tumors in the family (for a total of 909 family members) was 82, 10 cases of breast cancer, 23 of colorectal, 6 of gastric, 5 of prostate, 3 gynecologic, 11 lung, and 21 others. Conclusions: Frequency of familiar CC in unselected breast cancer patients of Zaragoza, Spain, is substantially higher than that expected. Assessment of cancer familiar history in the newly-diagnosed patients with CC cancer, helps us to identify families in which a genetic study is to be considered, and this could be useful to prevent new case of cancer.

No significant financial relationships to disclose.

Randomized open label phase II study of pegilated liposomal doxorubicine (PLD) four or six-week scheduled in metastatic breast cancer (MBC) patients (p)

10751

Background: PLD has the advantage of delivering the active anthracycline directly to the tumour site, provide comparable efficacy to conventional doxorubicin with a more favourable toxicity profile and significantly less cardiotoxicity. The most frequent dosing schedule is 50 mg/m2 every 4 weeks. Recent studies have shown that PLD 60 mg/m2 every 6 weeks is an active and well tolerated treatment, and could be more convenient for the p. The primary objective was to evaluate response rate in six- and four-week schedule (arms A and B). Secondary objective was toxicity profile. Methods: P histologically confirmed of MBC, age 18–75 years old, ECOG PS ≤ 2, at least one measurable lesion and adequate bone marrow, renal, hepatic and cardiac function, were eligible. Prior chemotherapy with anthracyclines for MBC or adjuvant anthracycline-based regimen in the previous 12 months was not allowed. P were randomly assigned to receive PLD 60 mg/m2 i.v. in 1 hour every 6 weeks (arm A) or PLD 50 mg/m2 i.v. in 1 hour every 4 weeks (arm B). Results: Ten p have been included in the interim analysis over 11 enrolled, with median age of 50 years, ECOG PS 0–1 70% and stage IV 50%. Median time from diagnosis of metastatic disease was 9.2 months. Histology: 80% of p had ductal carcinoma, 10% lobular and 10% undifferentiated. Main tumour locations were lung (60%), liver (60%) and bone (40%). Two p had positive hormonal receptor status in arm A and 4 in arm B. Previous treatment included chemotherapy (80%), hormonotherapy (80%) and radiotherapy (40%). Up to date, a total of 15/17 cycles (median 3/3, range 1–6/1–5) were administered. Absolute dose intensity was 2.2 mg/day in arm A and 3.0 mg/day in arm B. Two p were not evaluated and over 8 evaluable p for efficacy (4 A and 4 B), 2 achieved partial response in arm A and 1 in arm B. Median time to progression was 168 days in arm A and 104 in arm B. The only grade III/IV toxicity was mucositis and stomatitis in 4 p. The most common grade I/II toxicities were palmar-plantar erythrodysesthesia (5p), anorexia (4p) and alopecia (4p). Conclusions: PLD at 50 mg/m2 every 4 weeks and 60 mg/m2 every 6 weeks are effective and well tolerated regimens in MBC p. The most relevant adverse events were mucositis and palmar-plantar erythrodysesthesia.

No significant financial relationships to disclose.

Safety of long-term administration of capecitabine in metastatic breast cancer patients

10755

Background: To evaluate the effectiveness and tolerability of long -term treatment with capecitabine in metastatic breast cancer patients. Capecitabine (C) has been administered offering clinical benefit to women with metastatic breast cancer (MBC) (ORR: 42%). The aim of this trial was to evaluate the efficacy and tolerance of capecitbine in long-term treatment, administered as first, second and third line treatment in MBC. Methods: Patients ≥ 18 years old with MBC, ECOG performance status (PS) ≤2, HER-2 neu negative, non-chemotherapy naive were included in this prospective, multicentre, non-randomized. To date, twenty-two ambulatory patients were evaluable for toxicity and response. Median age 59.2 years (37–81). All of patients had previously received adjuvant treatment. Hormonal therapy were allowed as clinically required. They received three weekly cycles of oral capecitabine 1000–1250 mg/m2 twice daily, days 1–14, followed one week rest until progression or relapse. Results: The overall response rate (ORR) is including PR, CR, and EE 78%. The median treatment duration was 14 months, median range (3–32). Median progression-free and overall survival have not yet been reached. The most common grade ½ (NCIC CTC) treatment related adverse events were /23, hand foot syndrome 4/23, diarrea 1/23. Conclusions: These preliminary data confirm that the treatment with capecitabine (C) is an effective and well tolerated regiment in metastatic breast cancer patients.

No significant financial relationships to disclose.

Needs satisfaction for cancer patients in an ambulatory chemotherapy service (ACS). An exploratory study

18607

Background: ACS are currently the main way for the delivery of Chemotherapy to cancer patients. Aproximately half of them require intravenous chemotherapy and many need two or three separate lines of treatment during their clinical career. How these treatments are delivered will affect their health and quality of life. Appraisal of needs along chemotherapy process enable to identify problems related to health satisfaction status and quality of health care provided. Methods: We have evaluated the perceived needs of patients receiving ambulatory chemotherapy through an “ad hoc” questionnaire of 49 items exploring the following areas: treatment related symptoms, information and communication/interpersonal interaction, psychological, social and spiritual support, economical needs and management of health service. Results: 141 consecutive patients attending the ACS one year after its set up were evaluated. Demographics (age, gender and income), diagnosis and types of Chemotherapy (Adjuvant vs. Palliative) were considered for interrelationships. The most frequent tumors were breast and colorectal carcinoma. More than 50% of the patients reported having controlled symptoms (pain, nausea and vomiting, mucositis etc.). Information needs related to their illness and treatment were satisfied to more than half of the sample, but reported a need for more information about diagnostic procedures and prognosis; 48% perceived shortcomings in communication with their clinicians and 50% believed they received little advice about how cancer affects their sexual behaviour. Most patients (53%) reported not to need pshycological support neither for their family (60%) nor themselves, 83% not needing spiritual support and 50% were satisfied with the economical support they received. With respect to the facilities’ structure, 50% perceived enough intimacy in doctor’s offices and Chemotherapy Room and 64% felt comfortable in the waiting room but 72% perceived waiting too long before being attended by doctor’s and nurses. Conclusions: younger patients and breast cancer diagnosis are among the people that express more unsatisfaction related to the accomplishment of their needs (p < 0.05).

No significant financial relationships to disclose.

OryGenesDB: a database for rice reverse genetics

Insertional mutant databases containing Flanking Sequence Tags (FSTs) are becoming key resources for plant functional genomics. We have developed OryGenesDB (), a database dedicated to rice reverse genetics. Insertion mutants of rice genes are catalogued by Flanking Sequence Tag (FST) information that can be readily accessed by this database. Our database presently contains 44166 FSTs generated by most of the rice insertional mutagenesis projects. The OryGenesDB genome browser is based on the powerful Generic Genome Browser (GGB) developed in the framework of the Generic Model Organism Project (GMOD). The main interface of our web site displays search and analysis interfaces to look for insertions in any candidate gene of interest. Several starting points can be used to exhaustively retrieve the insertions positions and associated genomic information using blast, keywords or gene name search. The toolbox integrated in our database also includes an ‘anchoring’ option that allows immediate mapping and visualization of up to 50 nucleic acid sequences in the rice Genome Browser of OryGenesDB. As a first step toward plant comparative genomics, we have linked the rice and Arabidopsis whole genome using all the predicted pairs of orthologs by best BLAST mutual hit (BBMH) connectors.

Phase II randomised trial of raltitrexed-oxaliplatin vs raltitrexed-irinotecan as first-line treatment in advanced colorectal cancer

The purpose of this phase II randomised trial was to determine which of two schemes, raltitrexed-irinotecan or raltitrexed-oxaliplatin, offered better activity and less toxicity in patients with advanced colorectal cancer (CRC). A total of 94 patients with previously untreated metastatic CRC were included and randomised to receive raltitrexed 3 mg m⁻² followed by oxaliplatin 130 mg m⁻² on day 1 (arm A), or CPT-11 350 mg m⁻² followed by raltitrexed 3 mg m⁻² (arm B). In both arms treatment was repeated every 3 weeks. Intent-to-treat (ITT) analysis showed an overall response rate of 46% (95% CI, 29.5–57.7%) for arm A, and 34% (95% CI, 19.8–48.4%) for arm B. Median time to progression was 8.2 months for arm A and 8.8 months for arm B. After a median follow-up of 14 months, 69% of patients included in arm A were still alive, compared to 59% of those included in arm B. Overall, 31 patients (65%) experienced some episode of toxicity in arm A and 32 patients (70%) in arm B, usually grade 1–2. The most common toxicity was hepatic, with 29 patients (60%) in arm A and 24 patients (62%) in arm B, and was grade 3–4 in four (8%) and four (9%) patients, respectively. In all, 14 patients (29%) from arm A and 24 patients (52%) from arm B had some grade of diarrhoea (P<0.03). Neurologic toxicity was observed in 31 patients (64%) in arm A, and was grade 3–4 in five patients (10%), while a cholinergic syndrome was detected in nine patients (19%) in arm B. There were no differences in haematologic toxicity. One toxic death (2%) occurred in arm A and three (6.5%) in arm B. In conclusion, both schemes have high efficacy as first-line treatment in metastatic CRC and their total toxicity levels are similar. Regimens with raltitrexed seem a reasonable alternative to fluoropyrimidines.

Scientific management of Mediterranean coastal zone: a hybrid ocean forecasting system for oil spill and search and rescue operations

The oil spill from Prestige tanker showed the importance of scientifically based protocols to minimize the impacts on the environment. In this work, we describe a new forecasting system to predict oil spill trajectories and their potential impacts on the coastal zone. The system is formed of three main interconnected modules that address different capabilities: (1) an operational circulation sub-system that includes nested models at different scales, data collection with near-real time assimilation, new tools for initialization or assimilation based on genetic algorithms and feature-oriented strategic sampling; (2) an oil spill coastal sub-system that allows simulation of the trajectories and fate of spilled oil together with evaluation of coastal zone vulnerability using environmental sensitivity indexes; (3) a risk management sub-system for decision support based on GIS technology. The system is applied to the Mediterranean Sea where surface currents are highly variable in space and time, and interactions between local, sub-basin and basin scale increase the non-linear interactions effects which need to be adequately resolved at each one of the intervening scales. Besides the Mediterranean Sea is a complex reduced scale ocean representing a real scientific and technological challenge for operational oceanography and particularly for oil spill response and search and rescue operations.

Reliability of the E-test method for detection of colistin resistance in clinical isolates of Acinetobacter baumannii

We compared the E-test to the broth microdilution method for testing the susceptibility of 115 clinical isolates of Acinetobacter baumannii to colistin. Twenty-two (19.1%) strains were resistant to colistin and 93 (80.8%) strains were susceptible according to the reference broth microdilution method. A categorical agreement of 98.2% was found, with only two (1.7%) very major errors. Agreement within 1 twofold dilution between the E-test and the broth microdilution was 16.5%. Complete agreement was found for the strains for which MICs fell within the range of 0.25 to 1 microg of colistin/ml. However, there was poor concordance, particularly in extreme dilutions with higher MICs by the E-test method.

Mutant Prevention Concentration of Isoniazid, Rifampicin and Rifabutin against Mycobacterium tuberculosis

BACKGROUND

Mutant prevention concentration (MPC) is a new parameter that may be of aid in determining the risk of resistant mutants being selected.

METHODS

The MPCs of 224 Mycobacterium tuberculosis clinical isolates were estimated by plating more than 10(10) cells on drug-containing agar and determining the concentration that allowed no colony growth. Antibiotics used were isoniazid, rifampicin and rifabutin.

RESULTS

The MPC90 of clinical isolates in our setting is 2.4, 2.2 and 0.4 mg/l for isoniazid, rifampicin and rifabutin, respectively.

CONCLUSIONS

Isoniazid and rifampicin are two drugs that present a low risk of selection of resistant mutants when used in monotherapy. However, determination of the MPC of each strain can provide data to minimize this risk and thus enable treatment to be optimized.

Great vessels transposition and aortic arch exclusion

AIM

We describe our experience in endovascular repair of Thoracic Aortic Aneurysms and Dissections (TAAD) involving the aortic arch in high risk patients (HRP).

METHODS

Twenty-nine patients presented with TAAD involving the aortic arch and were treated by endovascular exclusion. Pathologies were as follows: atherosclerotic aneurysms of the descending thoracic aorta in 15 cases, acute Stanford type A dissections in 6 cases, Stanford type B dissections in 7 cases (1 acute), and 1 false aneurysm of the ascending aorta. Total-arch transpositions of all supra-aortic vessels (aortic debranching) to the ascending aorta were done in 11 cases throught median sternotomy. We performed carotido-carotid bypass (hemi-arch transposition) in 16 patients by cervicotomy. Secondary to surgical transpositions, we placed endovascular stentgrafts in all but 2 patients for final exclusion, the 2 remaining being planned for later exclusion. The Talent, Excluder, TAG and Zenith endografts were used in 12, 3, 1 and 4 cases respectively. Banding technique was associated in some cases.

RESULTS

All surgical transpositions were successful although 1 led to a minor stroke (1/29=3.5%), which worsened to major stroke after endovascular exclusion. Endovascular procedures were performed in all but one case (26/27=96.3%). Two patients (2/26=7.7%) died from catheterization related complications after endovascular exclusion (iliac rupture and left ventricle perforation). One patient had a delayed minor stroke (1/26=3.8%). Recirculation was found in 13.3% (2/15) of aneurysms and 27.3% of thoracic false channels. During a mean follow-up of 15.7 months (13 days to 45.5 months), 1 patient (1/26=3.8%) who had preoperative chronic pulmonary failure died at 6 months from respiratory worsening. We observed one case (3.8%) of unilateral limb palsy unrelated to cerebral ischemia, which we successfully treated by cerebrospinal fluid (CSF) drainage. No stent-related complication was seen. One new type 1 endoleak appeared at 12 months on an aneurysm, which resolved after stentgraft extension. Three thoracic dissection false channels remained patent during follow-up, of which one was retrograde originating distally in the descending aorta.

CONCLUSIONS

Secondary endovascular exclusion of thoracic aortic diseases involving the arch in HRP is made feasible thanks to the preliminary aortic debranching. Total-arch transposition may be of greater interest in case of proximal neck length uncertainty and potential embolization from the aortic arch. Mid-term results are good although patients must be followed carefully to detect aortic recirculation and enlargement.

Increasing the intracellular availability of all-trans retinoic acid in neuroblastoma cells

Recent data indicate that isomerisation to all-trans retinoic acid (ATRA) is the key mechanism underlying the favourable clinical properties of 13-cis retinoic acid (13cisRA) in the treatment of neuroblastoma. Retinoic acid (RA) metabolism is thought to contribute to resistance, and strategies to modulate this may increase the clinical efficacy of 13cisRA. The aim of this study was to test the hypothesis that retinoids, such as acitretin, which bind preferentially to cellular retinoic acid binding proteins (CRABPs), or specific inhibitors of the RA hydroxylase CYP26, such as R116010, can increase the intracellular availability of ATRA. Incubation of SH-SY5Y cells with acitretin (50 μM) or R116010 (1 or 10 μM) in combination with either 10 μM ATRA or 13cisRA induced a selective increase in intracellular levels of ATRA, while 13cisRA levels were unaffected. CRABP was induced in SH-SY5Y cells in response to RA. In contrast, acitretin had no significant effect on intracellular retinoid concentrations in those neuroblastoma cell lines that showed little or no induction of CRABP after RA treatment. Both ATRA and 13cisRA dramatically induced the expression of CYP26A1 in SH-SY5Y cells, and treatment with R116010, but not acitretin, potentiated the RA-induced expression of a reporter gene and CYP26A1. The response of neuroblastoma cells to R116010 was consistent with inhibition of CYP26, indicating that inhibition of RA metabolism may further optimise retinoid treatment in neuroblastoma.

[Melanocytoma of the ciliary body]

CLINICAL CASE

We report the case of a 25 year old woman who attended our Hospital with a pigmented lesion in anterior chamber angle of her right eye. She complained of reduced visual acuity on the same eye. On examination, and once complementary tests were performed, a pigmented lesion located on the iris root and ciliary body of her right eye was confirmed. A decision to perform a local resection was made and there were no surgical complication. Histology results confirmed the diagnosis of ciliary body melanocytoma.

DISCUSSION

Ciliary body melanocytoma is a benign rare lesion with only 40 cases described in the literature. A local resection of this benign lesion should be considered as alternative to enucleation, even though differential diagnosis with malignant melanoma must also be considered.

X-linked adrenoleukodystrophy in Spain. Identification of 26 novel mutations in the ABCD1 gene in 80 patients. Improvement of genetic counseling in 162 relative females

In this study, we analyzed the ABCD1 gene in 80 X-linked adrenoleukodystrophy (X-ALD) patients from 62 unrelated families. We identified 53 different mutations, of which 26 are novel and two are non-pathogenic sequence variants (L516L and 3'UTR, 2246C/G) that have been previously described. The Spanish population had significant allelic heterogeneity, in which most of the mutations were exclusive to a single family 47/53 (88.7%). Only six mutations (Y174S, G277R, FsE471, R518Q, P543L, and R554H) were found in more than one family. Mutations G277R, P543L, and R554H were the most frequent, each of them being found in three patients (5%). Intra-familiar phenotype variability was observed in most of the families, but in one, with the novel mutation R120P, only the adult mild phenotype was present (five hemizygous family members). We detected 80 heterozygous women by mutation analysis, but only 78 of them showed increased very-long-chain fatty acid levels. In conclusion, this study extends the spectrum of mutations in X-ALD and facilitates the identification of heterozygous females. Our results are also consistent with previous studies reporting the difficulty of predicting genotype-phenotype correlation.

Usefulness of various antibiotics against Mycobacterium avium-intracellulare, measured by their mutant prevention concentration

This study looked the selection of resistant mutants in Mycobacterium avium-intracellulare during antibiotic treatment. The mutant prevention concentration (MPC) of 20 Mycobacterium avium and 12 Mycobacterium intracellulare isolates was determined. Fifty percent of Mycobacterium avium strains had MPC (MPC50) values lower than 16, 64, 40, 55 and 60 mg/L for rifabutin, rifampicin, ciprofloxacin, levofloxacin and moxifloxacin, respectively. In the case of Mycobacterium intracellulare, 50% had MPC (MPC50) values below 60, 30, 35, 16, 2.5 and 14 mg/L for linezolid, rifabutin, levofloxacin, gatifloxacin, moxifloxacin and clarithromycin, respectively. The high capacity for selecting resistant mutants of all the antibiotics studied emphasises the need to restore the immune system if necessary and to administer combined treatments in order to cure patients.

Action of fluoroquinolones and Linezolid on logarithmic- and stationary-phase culture of Mycobacterium tuberculosis

BACKGROUND

The new challenges involved in the chemotherapy of tuberculosis make it necessary to find novel drugs, especially ones that are useful in the latent phase of the disease.

METHODS

We evaluated the activity of linezolid and fluoroquinolones against logarithmic- and stationary-phase Mycobacterium tuberculosis.

RESULTS

We observed that linezolid exhibits antibacterial action, although slowly, in both situations. Quinolones with an 8-methoxy group exhibit greater activity than levofloxacin in logarithmic growth phases, whereas levofloxacin exhibits greater activity in stationary-phase growth.

CONCLUSION

The study of the activity of drugs against the M. tuberculosis microorganism in the latent phase is one of the most important tools available in the fight against the tuberculosis epidemic, and both linezolid and the new fluoroquinolones appear to be promising drugs.

Dual blockade of EGFR and ERK1/2 phosphorylation potentiates growth inhibition of breast cancer cells

One of the major targets for breast cancer therapy is the epidermal growth factor receptor (EGFR) and related receptors, which signal via different signal transduction pathways including the mitogen-activated protein kinase (MAPK) pathway. This study determined whether there is a correlation between EGFR/HER2 status and MAPK (ERK1/2) phosphorylation in breast cancer cells, and how this affects the response to an inhibitor of the receptors. Expression of EGFR, HER2 and phosphorylated ERK1/2 were measured by immunoblotting in a panel of breast cancer cell lines. Several lines expressed high levels of pERK1/2, with no obvious correlation with the level of EGFR/HER2. The EGFR tyrosine kinase inhibitor PKI166 inhibited growth and induced apoptosis in some cells with high levels of growth factor receptors (MDA-MB-468, SUM149, SKBR3), but was less effective in cells that also had high basal ERK1/2 activity (MDA-MB-231). The combination of an inhibitor of MAPK signalling (U0126) and PKI166 produced significantly more inhibition and apoptosis than either agent alone. This suggests that constitutive activation of the MAPK pathway may bypass inhibition of EGFR/HER2 tyrosine kinases, and lead to insensitivity to agents targeting the receptors. However, inhibiting both EGFR/HER2 and MAPK signalling can result in significant growth inhibition and apoptosis of EGFR-expressing breast cancer cells.

[Development of a questionnaire for the assessment and quantification of overweight and obesity related lifestyles]

INTRODUCTION

Lifestyle intervention is mandatory for obesity treatment. The aim of this study is to design a questionnaire to describe and quantify those behaviours more closely related to obesity in the Spanish obese population.

METHODS AND PROCEDURES

An expert panel designed a preliminary 57 Liker-type item questionnaire, which was self-administered to 335 overweight patients (110 male, 225 female; age, 42 +/- 14 years; BMI, 32.6 +/- 3.7 kg/m2). After a subjacent dimensionality searching and item reducing first phase, a shrunk questionnaire of 24 items was then self-administered to 156 overweight patients (52 male, 104 female; age 42 +/- 12 years; BMI, 33.1 +/- 3.5 kg/m2); 56 of those patients were re-administered the questionnaire in order to provide test-retest information.

RESULTS

Final questionnaire includes 22 items clustered in five dimensions: diet caloric intake, searching for psychological well-being eating, physical activity, healthy eating and alcohol intake. Proposed factorial structure is mostly reproduced in different samples and using different extraction methods: all dimensions but alcohol intake score alpha values > 0.75 for liability; test-retest stability is greater than 0.90 in all dimensions but alcohol intake; results for all validity tests performed (of construct, of content and discriminative) are highly satisfactory.

CONCLUSION

Metrics study results (liability and validity) demonstrate that the proposed questionnaire provides an excellent tool to assess those lifestyles related to obesity control.

Effect of clinical and socio-economic factors on the rate of clustering of Mycobacterium tuberculosis clinical isolates in Elche (Spain)

We studied the association that exists between the epidemiological type clustering of isolates of Mycobacterium tuberculosis and certain clinical, epidemiological and socio-economic characteristics of tuberculosis patients in the Elche health district of Spain. A total of 144 patients diagnosed between 1993 and 1999 and whose isolates had been genotyped by IS6110-RFLP in an earlier study were included. Multivariate analysis showed that the independent variables associated with clustering of strain types were: age (1-25 years, OR 2.92, 95% CI 0.83 10.3), a high percentage of infection in the first circle of contacts (OR 2.89, 95% CI 0.96-8.68), urban dwelling (OR 2.12. 95% CI 0.73-6.2), use of bronchoscopy to obtain samples (OR 16.3, 95% CI 2.3-11.5) and working contact with many people (OR 2.81, 95% CI 0.94-8.3). These data contribute to a better understanding of the epidemiology of tuberculosis and improved systems of control.

Mutant prevention concentration: comparison of fluoroquinolones and linezolid with Mycobacterium tuberculosis

OBJECTIVES

The mutant prevention concentration (MPC) has recently been defined to characterize the capacity for severely restricting the selection of resistant mutants during antibiotic treatment. We determined this parameter for ciprofloxacin, levofloxacin, gatifloxacin, moxifloxacin and linezolid in Mycobacterium tuberculosis clinical isolates in our setting.

METHODS

We determined the antibiotic concentration that prevents the selection of resistant mutants following inoculation with a high mycobacteria inoculum on Middlebrook 7H11 plates with serial dilutions of the antibiotics in 224 M. tuberculosis isolates.

RESULTS

Fifty percent of the strains exhibited values of MPC (MPC(50)) lower than 0.8, 0.6, 0.4, 0.4 and 0.6 mg/L for ciprofloxacin, levofloxacin, gatifloxacin, moxifloxacin and linezolid, respectively. If 90% of the strains are considered (MPC(90)), the values are seen to rise to 2, 1.8, 1, 1.2 and 1.2 mg/L, respectively.

CONCLUSIONS

When we compare this parameter with the drug levels in serum and tissue, it can be seen that ciprofloxacin is the least useful of the fluoroquinolones studied, whereas moxifloxacin appears to be the most active. Linezolid exhibits excellent activity against this microorganism (MPC(90) 1.2 mg/L and AUC 140.3 mg.h/L) and this makes us consider that its usefulness in the treatment of this pathology should be thoroughly evaluated.

Sedación en la endoscopia digestiva. Resultados de una encuesta hospitalaria en Cataluña

INTRODUCTION

The need for sedation is increasing in digestive endoscopy units (DEU). There are no data on the use of sedation in DEU in Catalonia (Spain).

OBJECTIVE

To evaluate the use of sedation in DEU in Catalonia.

MATERIAL AND METHOD

A questionnaire on the practice of sedation was designed and sent to the heads of medical and nursing staff of the DEU of 63 public and private hospitals in Catalonia. Two mailings were sent with an interval of three months between each. The questionnaire included 62 items on the characteristics of the hospital and the DEU, number of explorations, frequency of sedation use, drugs employed, participation of an anesthesiologist, use of monitoring, and complications.

RESULTS

Forty-four DEU (70%) corresponding to 31 public hospitals and 13 private hospitals completed the questionnaire. Evaluation of sedation patterns was based on 105,904 explorations performed in the various DEU (56,453 gastroscopies, 47,278 colonoscopies and 2,173 endoscopic retrograde cholangiopancreatographies (ERCP) in 2001. Sedation, sedation-analgesia or anesthesia was used in 17% of gastroscopies, 61% of colonoscopies and 100% of ERCP. Sedation was administered by an anesthesiologist in 7% of gastroscopies, 25% of colonoscopies and 38% of ERCP. Anesthesiologist administration was more frequent in private than in public centers (gastroscopies: 25% vs. 2%; colonoscopies: 57% vs. 9%, p < 0.001). No deaths associated with the use of sedation were reported. Eighty-nine percent of the DEU complied with standard recommendations for the practice of sedation.

CONCLUSIONS

In Catalonia, the use of sedation is highly variable, depending on the endoscopic procedure and the DEU. Use of sedation in infrequent in gastroscopy, fairly widespread in colonoscopy and routine in ERCP. Anesthesiologist administration is significantly more frequent in private hospitals. Most DEU follow standard sedation practices.

Usefulness of different techniques in the study of the epidemiology of salmonellosis

Our objective was to evaluate the usefulness of serotyping, phagotyping, antibiotyping and RAPD (random amplified polymorphic DNA) in the study of the epidemiology of salmonellosis in Elche (Spain). We examined 1232 clinical isolates of non-typhoid Salmonella serotypes. Serotyping adequately differentiates 12.3% of the isolates and phagotyping raises this percentage to 37%. Antibiotyping is a suitable complement in certain circumstances, such as in the case of specific outbreaks. RAPD is a fast and simple technique which is within the reach of most laboratories, complementing the results obtained by antibiotyping and serotyping, in order to be able to control outbreaks of salmonellosis in everyday practice.

Characterisation of Salmonella spp. mutants produced by exposure to various fluoroquinolones

We repeatedly exposed six Salmonella spp. strains of different serotypes (three susceptible to nalidixic acid and three resistant) to constant low concentrations of various fluoroquinolones with the aim of characterising the mutations that produce the first decrease in susceptibility to these agents. The fluoroquinolone-susceptibility of all the strains was reduced after repeated exposure to these agents. However, gyrA mutants were not always produced. Furthermore, the type of mutation produced and the time taken for it to appear varied depending on the initial resistance to nalidixic acid, the antibiotic used and the serotype involved. Therefore, we believe that the initial decrease in quinolone-susceptibility is due to various mechanisms and, in many cases, is not caused by mutations in the gyrA gene

Prevalence of antibodies to Borrelia burgdorferi sensu lato in southern chamois (Rupicapra pyrenaica) in Spain

Ungulates are involved in the epidemiology of Borreliosis as maintenance hosts for vector tick species. We evaluated the prevalence of antibodies to Borrelia burgdorferi sensu lato in two different populations of southern chamois in Spain. Forty-six sera (40.4%) were positive at titres >/=1 : 64 using an indirect immunofluorescence assay (IFAT).

In vitro activity of new fluoroquinolones and linezolid against non-tuberculous mycobacteria

The objective of the study was to determine the activity of new fluoroquinolones and linezolid against 108 clinical isolates of different species of non-tuberculous mycobacteria isolated in Spain. Gatifloxacin and moxifloxacin were found to be more effective than levofloxacin. Mycobacterium kansasii was more susceptible to the fluoroquinolones tested than M. avium complex and M. fortuitum was more susceptible than M. chelonae. Linezolid was more active against M. kansasii than against M. avium complex. A better understanding of the relationship between the in vitro activity of these compounds and their usefulness in the treatment of these infections is needed. The new fluoroquinolones exhibit good activity against M. kansasii and M. fortuitum and linezolid is active against M. kansasii.

Synergic activity of fluoroquinolones and linezolid against Mycobacterium tuberculosis

We evaluated the in vitro activity against Mycobacterium tuberculosis of the combination of fluoroquinolones and linezolid with classical drugs. The combination of isoniazid with fluoroquinolones had synergic activity in nine of the ten isoniazid-susceptible strains. We also found synergism between rifampicin and linezolid in five of the 15 strains susceptible to rifampicin. The clinical significance of these findings should be evaluated.

Effect of indapamide SR on microalbuminuria--the NESTOR study (Natrilix SR versus Enalapril Study in Type 2 diabetic hypertensives with micrOalbuminuRia)--rationale and protocol for the main trial

In type 2 diabetic hypertensive patients, microalbuminuria can be due to hypertension and/or diabetic nephropathy. Angiotensin-converting enzyme (ACE) inhibitors act preferentially on microalbuminuria due to diabetic nephropathy. The objective is to demonstrate the efficacy of a thiazide-like diuretic, indapamide sustained release (SR), at reducing microalbuminuria in hypertensive type 2 diabetic patients in comparison with an ACE inhibitor, enalapril. The study is an international multicentre, 12-month, randomized, double-blind, controlled, two parallel group study of type 2 diabetic patients with hypertension (140 mmHg < or = systolic blood pressure <180 mmHg and diastolic blood pressure <110 mmHg) and microalbuminuria. Intervention is after a 4-week placebo period, patients with microalbuminuria > or = 20 and < or = 200 microg/min are randomized to indapamide SR 1.5 mg or to enalapril 10 mg once a day for a one-year treatment period. An additional label treatment by amlodipine 5-10 mg (1st step) and atenolol 50-100 mg (2nd step) a day is permitted after 6 weeks of treatment based upon blood pressure response. The main outcome measures are microalbuminuria expressed as urinary albumin to creatinine ratio, albumin fractional clearance, and albumin excretion rate evaluated on overnight urine collections. Secondary criteria are supine and standing systolic, diastolic and mean blood pressure; and biological and clinical safety. This study will complete the knowledge of the efficacy of indapamide SR in hypertension and target organ damage and will provide valuable information on the management of type 2 diabetic hypertensives with microalbuminuria.

In vitro activity of moxifloxacin, levofloxacin, gatifloxacin and linezolid against Mycobacterium tuberculosis

The in vitro activity of moxifloxacin, gatifloxacin, levofloxacin and linezolid was evaluated against 234 strains of Mycobacterium tuberculosis isolated in the Southeast of Spain. All drugs tested showed good activity, with an MIC(90) of less than 1 mg/l, and were active against isociacide and rifampicin resistant strains. Three strains were resistant to isoniazid and to the fluoroquinolones, which suggested the existence of mechanisms of resistance not yet described. These new compounds may prove to be therapeutic alternatives for treatment of multi-resistant tuberculosis and further studies should be done to demonstrate their true usefulness.

[Comparability between the ninth and tenth revisions of the International Classification of Diseases applied to coding causes of death in Spain]

OBJECTIVE

To analyze comparability between the ninth and tenth revisions of the International Classification of Diseases (ICD) applied to coding causes of death in Spain.

METHODS

According to the ninth and tenth revisions of the ICD, 80,084 statistical bulletins of mortality registered in 1999 were assigned the Basic Cause of Death. The statistical bulletins corresponded to the Autonomous Communities of Andalusia, Cantabria, Murcia, Navarre and the Basque Country, and the city of Barcelona. The underlying causes of death were classified into 17 groups. Simple correspondence, the Kappa index and the comparability ratio for major causes were calculated.

RESULTS

A total of 3.6% of deaths changed group due to an increase (36.4%) in infectious and parasitic diseases, mainly because of the inclusion of AIDS, and a corresponding decrease due to the exclusion of endocrine, nutritional and metabolic disorders. Furthermore, myelodysplastic syndrome was moved to the category of neoplasm. The group including nervous system diseases, eye and related diseases, and ear and mastoid apophysis diseases increased (14.7%) at the expense of mental and behavior disorders, due to the inclusion of senile and presenile organic psychosis. Poorly-defined entities increased (14.1%) due to the inclusion of cardiac arrest and its synonyms, together with heart failure, to the detriment of diseases of the vascular system. Diseases of the respiratory system increased (4.8%) due to the inclusion of respiratory failure, previously considered as a poorly defined cause. The correspondence for all causes was 96.4% and kappa's index was 94.9%

CONCLUSIONS

The introduction of ICD-10 affects the comparability of statistical series of mortality according to cause. The results of this study allow us to identify the main modifications and to quantify the changes in the major causes of mortality in Spain.

Implications on human fertility of the 677C-->T and 1298A-->C polymorphisms of the MTHFR gene: consequences of a possible genetic selection

Mutant alleles with the 677C-->T and 1298A-->C polymorphisms of the MTHFR gene, and consequent lower methylentetrahydrofolate reductase enzyme activity, have been related to higher plasma homocysteine levels, which are associated with cardiovascular diseases. We assessed the genotype frequencies, degrees of fertility and homocysteine levels, and discuss a possible genetic selection for the gene polymorphisms studied. A total of 1777 subjects (897 women and 880 men), divided into four age groups, were genotyped by PCR and restriction fragment length polymorphism. The total homocysteine concentration in plasma was determined by fluorescence polarization immunoassay. Based on random pairs and linkage disequilibrium of the two polymorphisms, we estimated the rate of fetal non-viability according to the combinations of these two polymorphisms to be 4.63% for the group >24 years old and 6.31% for the group <24 years old. We detected an increased frequency of mutant alleles in the youngest age group, coincident with a generally increased folate intake by pregnant women in Spain. The genetic selection detected leads to an increase in mutated individuals, the number of whom could increase four-fold over the next 75 years. Although generally reduced in the younger age groups, the homocysteine plasma levels were shown to increase in individuals according to the number of mutations, especially those of the 677T allele.

Mesenteric tuberculosis with jejunal infiltration

A 69-year-old female was admitted to our hospital because of asthenia, anorexia and 20 kg weight loss. An ultrasound study and computerized tomography (CT) imaging revealed a mesenteric mass and laparotomy was performed. The diagnosis was mesenteric tuberculosis with jejunal involvement. This represents an atypical onset of tuberculosis in a non-immunosuppressed patient.