Phase II trial of pegylated liposomal doxorubicin-cyclophosphamide combination as first-line chemotherapy in elderly metastatic breast cancer patients

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Background: Although the majority of metastatic breast cancer (MBC) patients (pts) responds to endocrine therapy, treatment failure is a concern, as well as front-line therapy for pts with ER/PR negative disease.The combination of anthracyclines (A) and cyclophosphamide (C) is active in younger pts, but cardiac toxicity of A in elderly MBC pts has to be considered. Pegylated liposomal doxorubicin (PLD) (Caelyx®) is active in MBC and has much less cardiotoxicity than A, and we present the preliminary data of the PLD/C in elderly MBC pts. Methods: This was a multicentric phase II trial. Inclusion criteria included: pts aged between 65 and 75, histologically proven measurable MBC, ECOG PS 0–1, LVEF = 50%, first-line chemotherapy for MBC. Prior adjuvant chemotherapy was allowed if stopped for = 6 or 12 months without and with anthracyclines, respectively. Endocrine therapy either in the adjuvant or metastatic setting had to be stopped for = 1 month. All pts gave a written informed consent. The treatment schedule was : PLD 40mg/m2 and C 500mg/m2 d1 every 4 weeks. Efficacy as well as response duration and tolerance were the primary and secondary end-points, respectively. Results: 35 patients were enrolled (Median age 71.3, range 65.6–75.9). A total of 166 cycles have been administered. The median number of cycles was 6 (range 1–9). No toxic death was reported, one patient died of diabetes mellitus decompensation. No congestive heart failure or decrease in LVEF was reported, although 1 pt experience grade 3 dyspnea and stopped treatment. Other (gr3–4) NCI-CTC toxicity included: neutropenia in 7 (gr3) and 3 (gr4) pts; gr3 mucositis (4). No febrile neutropenia was reported. Grade 3 hand-foot syndrome occurred in 1 pt, whereas treatment was stopped due to a generalized rash in 1 pt. An objective response (CR + PR) was achieved in 10 (28,6%) pts (1 CR and 8 PR), and a disease control in 24 (68.6%) with a progression free survival of 8.8 months and a median survival of 20.4 months Conclusions: The LPD-C combination is active in elderly MBC pts, with an acceptable toxicity profile.

No significant financial relationships to disclose.

Rehabilitation und Diagnosis Related Groups (REDIA-Studie): Auswirkungen der DRG-Einführung im Akutbereich auf die medizinische Rehabilitation

As experiences from other countries show, introduction and use of Diagnosis Related Groups (DRG), as of January 2004 now also mandatory in Germany, may have a significant impact on associated rehabilitation. The Institute of Hospital Management (IKM) in a multi-centre study promoted by Deutsche Rentenversicherung Bund and Deutsche Rentenversicherung Westfalen is conducting a study regarding potential diversion of healthcare expenditures from acute care towards rehabilitation as a result of DRG introduction in Germany. For documentation of potential short-term changes in patient populations and patient streams, extensive data have been collected in the first two phases in 2003/04 and 2005/06 for a total of 1342 cardiologic and orthopaedic patients. Indication-specific comparison of the two phases showed significantly shorter stays in the acute sector as well as shorter transition times between the sectors, resulting in an intake of patients into rehabilitative care at an earlier stage of their recovery process. Significant diversion of treatment efforts from the acute to the rehabilitative sector, regarding increased nursing effort and potential changes in the therapeutic and medical treatment to be provided, has not been proven as yet. The increase in wound problems expected by practitioners was confirmed in the orthopaedic area by an increasing number of wound healing disturbances and haematomas; in bypass-patients, an increasing number of pericardium and pleura bruises was found. The analyses performed on the data collected revealed no limitations in the patients' ability to participate in rehabilitative measures when the first and the second phase of the study are compared. To be able to depict the further course and interdependencies of changes, continuous systematic observation of developments would be desirable. To ascertain a lasting impact of DRG implementation at least a third study-phase will be necessary, which should be placed at the end of 2008, at the time when the DRG convergence phase will end.

[Difficulties and reproducibility of radiological measurement of the proximal tibial axis according to Lévigne]

PURPOSE OF THE STUDY

The angle between the anatomic axis of the tibia and the tangent to the superior borders of the tibial plateaus is, on average, tilted 3 degrees in the varus position. If there is no bone wear, this angle measures the constitutional epiphyseal axis of the proximal tibia. When degenerative joint disease modifies the aspect of the tibial plateaus, this angle measures the sum of the constitutional varus and the bone wear, without distinguishing between the two. It is known however that the respective contribution of these two deformations can have therapeutic implications, particularly when tibial osteotomy for valgus correction or implantation of a unicompartmental prosthesis is proposed. Lévigne proposed a radiographic measurement of the proximal tibial axis to distinguish between these two sources of tibial deformation. We studied the intra- and interobserver reproducibility of these measurements.

MATERIAL AND METHODS

Fifty volunteers free of knee disease were chosen at random among a population of patients undergoing upper limb surgery. All patients provided their informed consent for participation in the study. Full-limb radiographs of one lower limb (chosen at random) were obtained using a standardized technique. The proximal tibial axis was measured according to the Lévigne technique using a manual goniometer graduated in degrees. One operator performed two series of measures independently on the same films. Two other operators performed a series of measurements on each film. The intra- and inter-observer reproducibility was determined with the interclass coefficient of correlation (rho).

RESULTS

The proximal epiphyseal axis of the tibia could not be determined on 7 to 18 films, depending on the operator. All three operators were able to make the all measurements (four per film) for only 25 patients. The mean epiphyseal axis varied from 2.5 degrees to 4.7 degrees for the four series of measurements. Intra-observer reproducibility was considered good (rho=0.62). Inter-observer reproducibility was considered moderate (rho=0.41).

DISCUSSION

The Lévigne technique is to our knowledge the only method described in the literature distinguishing the relative contribution of constitutional varus and bone wear of the proximal tibia. According to the advocates of this method, the angle between the epiphyseal axis linking the center of the tibial plateaus and the center of the proximal growth cartilage scare, and the anatomic axis of the tibia is a measurement of constitutional varus. The average is 3 degrees . The angle between a line perpendicular to the epiphyseal axis and the tangent of the superior borders of the tibial plateaus measures the deformation related to bone wear. In the present work, we found that this technique enables acceptable intra-observer reproducibility but that inter-observer reproducibility is low. The differences observed are certainly related to uncertain identification of the growth cartilage scar. This illustrates the difficulty in generalizing this technique for measuring healthy knees. Such difficulties would be even greater for degenerative knees.

CONCLUSION

The Lévigne technique does not appear to be a reliable method for defining indications for different surgical procedures according to the morphology of the proximal tibia.

Surgery for non-localized bronchiectasis

Background

Resection for localized bronchiectasis is a well established therapy. However, there is little information on the role of surgery in non-localized bronchiectasis.

Methods

Between January 1992 and April 2001, 55 patients without cystic fibrosis underwent resection. Forty-eight patients (mean age 45 (range 23–74) years; 32 women) were available for long-term follow-up. Twenty-five patients underwent resection for localized disease (group 1) and 23 had bronchiectasis in at least two different lobes (group 2).

Results

Thirty-one of the 48 patients were treated by Video Assisted Thoracoscopic Surgery (VATS) resection. There was no 30-day mortality. Mean duration of hospital stay was 10·9 (range 6–31) days in group 1 and 11·1 (range 5–19) days in group 2. Three of 25 patients in group 1 required reoperation. Only minor complications occurred in group 2 (three patients). Mean follow-up for both groups was 37 (range 6–97) months. Twenty-three of 25 patients in group 1 and 16 of 23 in group 2 reported satisfaction at 6 months after the operation. Recurrent infection was noted in three patients in each group. Haemoptysis recurred in only one patient in group 2.

Conclusion

The surgical treatment of selected patients with non-localized bronchiectasis was safe and most patients were satisfied with the outcome.

Description des conditions de vie de la population âgée de 75 ans ou plus vivant à domicile en Alsace

OBJECTIVE

Our aim was to describe the living conditions of disabled elderly subjects aged 75 years and more living at home.

DESIGN

This study was conducted in 1996-97 in the Alsace region in France and included two parts. First, a sample survey was mailed to 15,600 subjects randomly selected from a pension funds list. This survey provided with a reliable representation of the study population in terms of disabilities using the Colvez classification. In the second part, the most disabled individuals were selected and, among them, 1,259 subjects were visited at home. Their disabilities and living conditions were noted using a predefined set of questions.

RESULTS

An estimated 71,000 subjects aged 75 years and more lived at home in the study region. The vast majority were free of significant disability. Help to wash and dress was needed by 6,000 until 1,500 were bedridden or confined to an armchair. Between 4,350 and 5,400 met the criteria for iso-resource grades (IRG) 1 to 3. Disability was associated with age, female gender, cognitive impairment and some social and professional characteristics. Family support was routine in almost every aspect of everyday life including personal hygiene. Professional support was mostly limited to technical interventions. Professional nursing care concerned only the most dependent persons. Nevertheless, needs for help in home and social activities remained high even in the least dependent individuals and were strongly age-dependent. Only 10% of individuals with IRG 1 to 3 complained of inadequate help. More than 80% of the elderly felt comfortable with their living conditions at home and were not thinking of moving from home to an institution for old people.

CONCLUSION

The present study confirms the important commitment of family members and their close relationships toward their elderly.

Complex Regional Pain Syndrome as a Complication of a Chemical Burn to the Foot

Complex regional pain syndrome (CRPS) is an unusual complication after burns; however, it is important to recognize so that appropriate treatment can be administered. A 60-year-old man suffered an alkali burn to the right foot. Subsequently, the patient developed CRPS with severe pain and vasomotor changes. Multimodal treatment included the early use of ropivacaine and fentanyl via epidural catheter. Oral extended-release morphine, gabapentin, and amitriptyline also were administered. Once pain was controlled, early aggressive physical therapy was instituted, and attention was turned toward wound coverage. One year after discharge, the patient was ambulating well and has returned to work. His pain was managed with a single morning dose of gabapentin and a nonsteroidal anti-inflammatory agent. Current examination of the foot revealed mild forefoot swelling without residual erythema. Ambiguities exist in the mainstay of treatment for CRPS, but this multimodal method of controlling CRPS after burn injury allowed for control of the patient's pain, early mobilization, and eventual return to work.

[Medical activity of the French internal medicine departments in 2000-2001 from the DRG system]

PURPOSE

Medical activity of the French Internal Medicine Departments has been described until now only by limited declarative surveys. The aim of this study was to describe this activity using the French DRG system.

METHODS

A postal survey was conducted using the list of the French Society of Internal Medicine. The same questionnaire was posted to 212 departments (university, public and private hospitals) to collect the 2000 or 2001 data from the DRG system.

RESULTS

192,197 reports were analysed. One hundred and eighty four groups were listed on a theoretical number of 313 medical groups. The first 10 groups concerned common general diseases (pneumonia, anaemia, heart failure, diabetes, stroke.). The main difference between university and non-university hospitals concerned the management of systemic diseases, which was more frequently quoted in university hospitals. Benign and malignant haematological diseases and oncology were frequently quoted in both types of hospitals.

CONCLUSION

This study allows for the first time in France to have an objective survey of the medical activity of Internal Medicine Departments. It confirms that these departments have a central role in the hospital management of current diseases but also of haematological diseases and cancer. University departments are more specifically implicated in the management of systemic diseases.

Production of interleukin-18 and interleukin-12 in patients suffering from chronic hepatitis C virus infection before antiviral therapy

Interleukin-12 and -18 (IL-12 and IL-18) are known to enhance the cytotoxic T-lymphocyte response synergistically, but their precise involvement in hepatitis C virus (HCV) infection is not well known, especially for IL-18. Enzyme-linked immunosorbent assay (ELISA) was used to study the production of these cytokines in plasma and peripheral blood mononuclear cells (PBMCs) stimulated by lipopolysaccharide (LPS) of patients infected chronically with HCV before initiation of antiviral therapy. Fifty-six patients and 40 healthy controls were evaluated. Patients infected with genotype 1 or with genotype other than genotype 1 HCV had significantly a high production of plasma IL-12 compared with controls (P < 0.05). However, patients infected with genotype 1 HCV had lower levels of PBMC IL-18 than were founded in the controls (P < 0.05); plasma IL-18 also tended to be lower in this group of patients than in the controls, although nonsignificantly. Plasma IL-18 was related to hepatic histological activity (P < 0.05). The data suggest a relationship between these two cytokines and some features of HCV infection, so that their respective production in relation to the outcome of the infection deserves further study.

[Benefits of a preventive psychiatric accompaniment in patients Hepatitis C Virus seropositive (HCV): prospective study concerning 39 patients]

Hepatitis C represents a major public health challenge due to its chronic evolution and major complications (eg liver tumor and cirrhosis). New treatment strategies (interferon pégylé +/- ribavirine) have recently improved the prognosis except in case of poor compliance. Psychiatric comorbidity, especially affective disorders, is commonly associated with hepatitis C and constitutes the main cause of poor compliance, therapeutic discontinuations and treatment contra-indication. At this moment of new therapeutic protocols and the possibility of curing HCV infections, it is of utmost importance to widen antiviral treatment in many indications, to upgrade compliance, and to limit therapeutic discontinuations. In this context, where anxious and depressive disorders are the main reasons for failure in curing, it is necessary to anticipate the appearance of these troubles within an earlier multidisciplinary taking in charge. The primary aim of our study is to emphasize the utility of a multi-disciplinary approach including psychiatric evaluation, preventive follow-up and preventive treatment. The secondary objective is to show that a previous story of depression or use of drugs should not be considered as an insuperable contra-indication provoding the implementation of a specific follow-up. Thirty nine interferon treated patients were included in a prospective study. Our data confirm the high rate (28%) of Major Depressive Disorders among the population of hepatitis C treated patients in a preventive follow-up. A previous story of alcoholism, of suicide attempt or break off treatment with Major Depressive disorders might be predictive of such a complication. According to the subjective feeling of these patients with previous break'off treatment associated, specific psychiatric follow-up may improve tolerance for the treatment.

METHODS AND OBJECTIVES

39 patients (17 men and 22 women) accepted, on (or after) the non-systematic proposal of their hepatologist, to consult the psychiatrist of the network, prior to any therapeutic decision. The first objectives of the consultations were to inform the patient (and, with his agreement, his -relatives), about the risk of depressive disorders while under treatment by interferon, as well as their potential consequences. Moreover, the psychiatrist answers their questions concerning this issue, and proposes him a long-term psychotherapeutic follow up (up to several months after the antiviral treatment end) including availability in emergency if necessary and preventive antidepressive treatment. In this framework, we assessed in a prospective way the frequency, the intensity and the time (or moments) when major depressive episode (MDE) (according to the DSM IV) appeared under interferon alpha, the predictive factors for these MDE, the interest and the quality of a preventive antidepressive treatment prescription and the psycho-social benefits of this taking in charge for the patient.

RESULTS

Among these 39 patients -regularly followed during and after the antiviral therapy, 11 (28%) had a MDE while under treatment. These MDE, except for 2 (5%) of them which led to an hospitalization, were mild to moderate. They mainly appeared within the 2 first quarters of treatment without significant difference. Patients with antecedents of suicide attempt (80%), drug addiction (50%) or alcohol addiction (50%) are more likely to have a MDE under interferon alpha than other patients, but these risk factors are not a contra-indication for treatment because 95% of the patients ended their treatment and the 2 antiviral treatment discontinuations observed were secon-dary to (or following) an acute psychotic episode (hospitalization) and a maniac episode in a schizophrenic patient (outpatient care). The existence of antecedents of antiviral treatment discontinuations due to MDE (33%) does not seem to be a risk factor anymore when preventive care is provided. It is interesting to point out the existence of a certain male fragility, men are more psychologically sensitive to interferon alpha than women. About 90% of patients chose to take an antidepressant. The latter was mainly a treatment with sertraline (45% out of cases), with citalopram (40% out of cases), and for 15% of them antidepressive treatment previously prescribed and non modified because they were well-tolerated and efficient. 86% of the first prescriptions were not changed during the follow up. 75% of patients already treated by a previous antiviral treatment with interferon alpha estimated that an earlier psychiatric accompaniment was very beneficial for them, in terms of compliance and socio-professional insertion.

CONCLUSION

A specialized psychiatric accompaniment within a coherent multidisciplinary network provides a major benefit to the patients in terms of compliance and safe care (even for population considered as having higher risks) although it is not possible to define accurately the influence of the preventive prescription of a antidepressant (which is not prejudicial anyway). a previous story of depressive disorder should not be considered as a contra-indication, but should imply a specific psychiatric follow-up especially when alcoholism, previous story of suicidal attempt and previous break'off treatment are reported.

Genetic alterations in primary osteosarcoma from 54 children and adolescents by targeted allelotyping

At present, the only recognised prognostic factor for primary osteosarcoma is the histological response to preoperative chemotherapy. Our study was designed to identify new diagnostic markers that could eventually have a prognostic value. A total of 54 patients under 20 years of age with primary osteosarcomas were studied while under treatment by the French Society of Paediatric Oncology OS 94 protocol. Paired normal and biopsy samples were collected. In addition, surgical resection specimens, following preoperative chemotherapy, were obtained in 13 cases. After genomic DNA extraction, an allelotyping analysis targeting microsatellites linked to Rb and p53 genes, and 9p21, 7q31 and 5q21 regions was performed. In all, 94% of the samples at diagnosis showed allelic imbalance and the biopsies were highly rearranged except for the microsatellite targeting 7q31. The same panel was highly informative at surgical resection. Microsatellites investigating Rb, p53 and the 9p21 region were particularly altered without a significant correlation with prognosis. On the other hand, the alteration of the 7q31 locus at diagnosis was significantly correlated with a worse prognosis and a new frequently altered locus, 5q21, was described. In conclusion, this panel allowed us to characterise paediatric osteosarcomas. Correlation of prognosis with the altered 7q31 region could be a useful tool and further studies are required to confirm the importance of 5q21.

[Evalutation of health monitoring in Bavaria by computer-assisted telephone interviews (CATI) in comparison to the German National Health Examination Survey conducted in 1998 by the Robert Koch Institute]

Between June 1999 and May 2000, 2051 residents of Bavaria were interviewed on health and health-related behaviour. The objective of the study was to assess the representativeness and validity of data acquired by computer-assisted telephone interviewing (CATI) as compared to results of the German National Health Examination Survey 1998. The following variables showed excellent agreement: subjective health status, lifetime disease prevalences, such as myocardial infarction, stroke, cancer, asthma, diabetes, hypertension, hypercholesterolaemia, utilisation of medical services, and smoking habits (prevalence of present and former smoking, average cigarette consumption per day). Minor differences were found with respect to the frequency of consulting naturopathic doctors. Self-reported anthropometric data from the present study differed considerably from the results of the objective measurements during the German Health Survey. We conclude that, in terms of data quality, CATI compares well with traditional methods such as face-to-face interviewing or mailed questionnaires. In view of several practical advantages of the method, we recommend CATI as a future basic methodology of a German health surveillance system consisting of different coordinated health data collections.

[Regional and sex-specific differences in fulfillment of patient rights: results of a representative population survey in Munich, Dresden, Vienna and Bern]

OBJECTIVES

The European Office of the World Health Organization formulated the Amsterdam Declaration in 1994, demanding thereby the realisation of the principles of a humane health care. These principles relate to the protection of dignity of personhood, to self-determination, the right of information, and the right of quality, continuity and equality in health care. The present study aims at a gender-specific analysis of the fulfillment of these rights.

METHODS

Computer-assisted telephone interviews were conducted during the months February and March 2000 in four German speaking European cities (Munich, Dresden, Vienna and Berne). A paragraph of the Declaration on the Promotion of Patients' Rights was regarded as fulfilled if there was at least 80% agreement.

RESULTS

Deficiencies were most pronounced for the provision of community and domiciliary services after hospital treatment and for the right concerning humane terminal care and death in dignity. Moreover, regional differences were found between Munich, Dresden and Vienna on one side and Berne on the other side, with degrees of fulfillment being higher in Berne.

CONCLUSIONS

In summary, these regional differences are more pronounced than single gender-specific differences, which may be due to chance. Areas with potential for improvement could be identified and can be actively restructured, e.g., in the context of the setting of health targets. An evaluation of the influence of the managed care system which has been established only sporadically in Berne requires more data.

Influence of pre-, intra- and post-operative parameters of donor liver on the outcome of isolated human hepatocytes

The aim of the present study was to analyse, retrospectively on a large panel of patients (149), the influence of the donor liver characteristics on the outcome of human hepatocyte isolation obtained from resected liver biopsies from surgical waste after hepatectomy. Among the pre-operative parameters, the type of disease, age and sex of the patient, previous chemotherapy, alcohol or tobacco consumption did not affect the yield, viability, attachment rate and function of the isolated human hepatocytes. Pre-operative biological and anatomopathological data indicated that, while mild steatosis (</=10% steatotic hepatocytes) did also not affect the outcome of hepatocyte isolation, stronger steatosis (>10% steatotic hepatocytes) tended to decrease hepatocyte yield. Cholestasis, as assessed by gamma-glutamyl transferase serum values, significantly negatively correlated with the percentage of digested liver and the yield of viable cells. Intra-operative clamping time, that is, warm ischaemia, longer than 30 min was found to decrease both the percentage of digested liver and cell yield. Among the post-operative parameters, the percentage of digested liver decreased when biopsy weights were higher than 100 g, the use of glue tended to increase both the percentage of digested tissue and the yield of viable cells.In conclusion, human diseased livers appear to be a valuable source of isolated functional human hepatocytes. We recommend, for an optimal isolation, to use liver biopsies weighing less than 100 g, to glue the section surfaces of the biopsies and to avoid the use of moderate steatotic livers (>10% steatotic hepatocytes) and cholestatic livers, as well as livers undergoing warm ischaemia or clamping during resection due to the decrease in cell yield.

Genes other than TLR4 are involved in the response to inhaled LPS

For several decades, the mouse strains C3H/HeJ and C57BL/10ScNCr have been known to be hyporesponsive to endotoxin or lipopolysaccharide (LPS). Recently, mutations in Toll-like receptor (TLR) 4 have been shown to underlie this aberrant response to LPS. To further determine the relationship between TLR4 and responsiveness to LPS, we genotyped 18 strains of mice for TLR4 and evaluated the physiological and biological responses of these strains to inhaled LPS. Of the 18 strains tested, 6 were wild type for TLR4 and 12 had mutations in TLR4. Of those strains with TLR4 mutations, nine had mutations in highly conserved residues. Among the strains wild type for TLR4, the inflammatory response in the airway induced by inhalation of LPS showed a phenotype ranging from very sensitive (DBA/2) to hyporesponsive (C57BL/6). A broad spectrum of airway hyperreactivity after inhalation of LPS was also observed among strains wild type for TLR4. Although the TLR4 mutant strains C3H/HeJ and C57BL/10ScNCr were phenotypically distinct from the other strains with mutations in the TLR4 gene, the other strains with mutations for TLR4 demonstrated a broad distribution in their physiological and biological responses to inhaled LPS. The results of our study indicate that although certain TLR4 mutations can be linked to a change in the LPS response phenotype, additional genes are clearly involved in determining the physiological and biological responses to inhaled LPS in mammals.

[Population-based health monitoring via computer-assisted telephone interviews in Bavaria]

From June 1999 until May 2000, 2051 computer-assisted telephone interviews concerning health and health related behaviours were assessed in Bavarian households. The aim of the study was the evaluation of the validity and representativity of this data by a comparison of selected variables from the Bavarian Mikrozensus-survey 1999. The distribution patterns of the marital status, the size of the households, the gainful employment, the household-netto-income, the school qualification and of the smoking status correspond well with those of the Mikrozensus 1999. As often found in questionnaire based surveys, a disproportionately high rate of participation of highly educated persons was observed. This led to an effect only in terms of a too small rate of persons with a low household-netto-income. Within the study, two different designs were compared. The commitment of the telephone numbers to a gender for an equal quotation of men and women led to an under-representation of single-households and therefore also of unmarried persons, but it had no effect on the other characteristics. The results of this study show, that the method of computer assisted-telephone interviews is a valid and cheap basis for the establishment of an exhaustive health surveillance system in Germany.

Raman spectroscopic surface characterization of cellulose derivatives

First results of experiments on the surface characterization of cellulose derivatives are presented. Different water contents of the surface of microcrystalline cellulose have been investigated by means of Raman spectroscopy, SERS, and environmental scanning electron microscopy (ESEM).

Standardization of non-aggregated data: theory and practice

Direct standardization of rates is a classical method in epidemiology by which the relationship between confounders and variables of analysis is balanced between the samples or populations to be compared. While the method is appropriate if single variables of aggregated data sets are to be compared, it is limited with respect to handling many variables of different measurement scale, especially in primary data situations. Therefore the method of direct standardization is adapted to the analysis of non-aggregated data. Computation of not only rates but other statistics of central tendency and dispersion as well as confidence intervals hence becomes feasible. In addition it is possible to re-adjust the primary data weights in order to perform stratified analyses. A procedure to do so, based solely on the available original weights without the need for analyzing the standard population is proposed along with an extensive SAS macro. The utility allows for the rapid and standardized analysis and tabulation of large multi-variable data sets. Both the statistical and technical properties of the macro are discussed and its usage is explained as well as exemplified.

A fluorescent reporter gene as a marker for ventricular specification in ES-derived cardiac cells

We have established a CGR8 embryonic stem (ES) cell clone (MLC2ECFP) which expresses the enhanced cyan variant of Aequorea victoria green fluorescent protein (ECFP) under the transcriptional control of the ventricular myosin light chain 2 (MLC2v) promoter. Using epifluorescence imaging of vital embryoid bodies (EB) and reverse transcription-polymerase chain reaction (RT-PCR), we found that the MLC2v promoter is switched on as early as day 7 and is accompanied by formation of cell clusters featuring a bright ECFP blue fluorescence. The fluorescent areas within the EBs were all beating on day 8. MLC2ECFP ES cells showed the same time course of cardiac differentiation as mock ES cells as assessed by RT-PCR of genes encoding cardiac-specific transcription factors and contractile proteins. The MLC2v promoter conferred ventricular specificity to ECFP expression within the EB as revealed by MLC2v co-staining of ECFP fluorescent cells. MLC2ECFP-derived cardiac cells still undergo cell division on day 12 after isolation from EBs but withdraw from the cell cycle on day 16. This ES cell clone provides a powerful cell model to study the signalling roads of factors regulating cardiac cell proliferation and terminal differentiation with a view to using them for experimental cell therapy.

Chromatographic comparison of the UVA sensitizers present in brunescent cataracts and in calf lens proteins ascorbylated in vitro

The water-insoluble (WI) fraction from aged human lenses contains yellow chromophoric sensitizers, which generate reactive oxygen species (ROS) when irradiated with UVA light. The WI proteins from type I to V brunescent cataract lenses were assayed for UVA-dependent superoxide anion synthesis. Rates varied from 8.4-15 nMol h(-1)mg protein(-1), but there was no significant difference in specific activity between cataract types. When calf lens soluble proteins were incubated with ascorbic acid for 4 weeks and dialyzed, they were capable of generating 30-40 nMol h(-1)mg protein(-1)superoxide anion when irradiated with UVA light. Two preparations each of brunescent cataract WI proteins and bovine lens proteins ascorbylated in vitro were extensively digested with proteolytic enzymes and the released amino acids separated by normal phase HPLC. The elution profiles of the digests were very similar based upon the absorbance at 330 nm and fluorescence at 350 nm excitation/450 nm emission. Each peak was pooled and analyzed for the UVA-dependent generation of both superoxide anion and singlet oxygen. Every peak exhibited sensitizer activity, and the UVA-dependent ROS generation was roughly proportional to the absorbance at 330 nm. In addition, the ratio of superoxide anion to singlet oxygen generated was similar with both preparations. These data argue that it is the brown, fluorescent compounds which accumulate during aging and cataract formation that are responsible for the UVA-dependent ROS formation, and that these browning products may be similar to the advanced glycation endproducts produced by ascorbylation of lens proteins under oxidative conditions. This work also presents an initial report of a chromatographic method to separate the UVA-sensitizers present in each of these protein preparations without the use of acid or base hydrolysis.

[Evaluation of biological impregnation of a population exposed to high concentration of arsenic in water supply, Ferrette, 1997]

BACKGROUND

The population of Ferrette has been exposed to well-water with arsenic (As) levels higher than legal threshold. The aim of this study was to assess the relationships between daily tap-water consumption, As quantities thus ingested and biological arsenical impregnation.

METHODS

The study was carried out on a sample of 100 people in the town of Ferrette and 100 people in the town of Seppois-le-Bas where the water quality is satisfactory. Ingested water and As were assessed by the mean of a food questionnaire. The quantity of ingested As was related to the body weight and compared to the tolerable daily intake (TDI) of 2 micrograms/kg/d. Biological impregnation was assessed by measuring out As in hair sample.

RESULTS

The daily ingested As intake of Ferrette population ranged from 0 to 32 micrograms/kg/d. One half of the population ingested more than 2 micrograms/kg/d. A quarter of the population ingested more than 4.3 micrograms/kg/d. 15% of Ferrette inhabitants yielded an As hair level higher than 0.1 ng/mg [IC95%: 8.7%-23.5%], versus 7% [IC95%: 2.9-13.9%] for the inhabitants of Seppois-le-Bas (p = 0.07). Among those who ingested an amount of As higher than the TDI, 19% were found to have detectable As hair levels, versus 9% for those who ingested less than the daily acceptable amount (p = 0.18).

CONCLUSION

One half of the population of Ferrette absorbed an As amount double to the TDI, evidencing the reality of the exposure. We did not find any statistically significant relation between the ingested As amount and biological As impregnation nor between exposure to water containing excessive As level and As biological impregnation.

Lipoprotein lipase compensates for the defective function of apo E variants in vitro by interacting with proteoglycans and lipoprotein receptors

Lipoprotein lipase (LPL) and apolipoprotein E (apo E) independently enhance binding and uptake of lipoproteins to cells. A coordinate effect of LPL and apo E has been previously described in human hepatozytes where simultaneous addition of both proteins resulted in an additive increase of chylomicron binding and uptake. The role of lipoprotein receptors and proteoglycans in this coordinate effect was now analysed using various cell types and heparinase treatment. To investigate a pathophysiological relevance, the effect of LPL and normal apo E-3 was compared to LPL and four apo E variants, associated with type III hyperlipoproteinemia (HLP). Apo E-3 and LPL increased the binding and uptake of chylomicrons and beta-very low density lipoproteins (VLDL) in an additive way in all cell types analysed, except proteoglycan deficient Chinese hamster ovary (CHO)-cells. Heparinase treatment almost completely abolished the effect of apo E and LPL. Addition of LPL to the apo E variants resulted in significant compensation of their defective function in mediating beta-VLDL binding to low density lipoprotein (LDL)-receptor defective fibroblasts. These findings indicate that the coordinate effect of apo E and LPL is mediated by proteoglycans and lipoprotein receptors, independent of the LDL receptor. LPL may compensate for the defective function of apo E variants by enhancing lipoprotein binding to these receptors. Defects in this mechanism may explain how mutations in the LPL molecule contribute to the manifestation of type III HLP in addition to the presence of a defective apo E.

Using physiologic and pharmacologic stress testing in the evaluation of coronary artery disease

Evaluating and treating coronary artery disease (CAD), the leading cause of death in the United States, are priorities for primary care practitioners. Stress testing is a noninvasive, cost-effective technique to help diagnose CAD and evaluate its extent. The test can also be used to clarify the etiology of chest pain, evaluate a medical regimen, identify arrhythmias, risk-stratify patients preoperatively, and determine exercise tolerance. Myocardial perfusion imaging and echocardiography can increase the test's sensitivity and specificity. Pharmacologic testing is available to evaluate patients who are unable to exercise adequately. Test selection is based on the patient's ability to exercise, concurrent illnesses (for example, reactive airway disease), and desired findings. The evaluation of results should be based on history and the pretest probability of cardiovascular disease. A cardiologist should evaluate any results that fall to correlate with the patient's presentation or pretest likelihood of disease for possible coronary angiography.

Identification of megalin/gp330 as a receptor for lipoprotein(a) in vitro

Lipoprotein(a) [Lp(a)] is an atherogenic lipoprotein of unknown physiological function. The mechanism of Lp(a) atherogenicity as well as its catabolic pathways are only incompletely understood at present. In this report, we show that the low density lipoprotein receptor (LDLR) gene family member megalin/glycoprotein (gp) 330 is capable of binding and mediating the cellular uptake and degradation of Lp(a) in vitro. A mouse embryonic yolk sac cell line with native expression of megalin/gp330 but genetically deficient in LDLR-related protein (LRP) and a control cell line carrying a double knockout for both LRP and megalin/gp330 were compared with regard to their ability to bind, internalize, and degrade dioctadecyltetramethylindocarbocyanine perchlorate (DiI)-fluorescence-labeled Lp(a) as well as equimolar amounts of 125I-labeled Lp(a) and LDL. Uptake and degradation of radiolabeled Lp(a) by the megalin/gp330-expressing cells were, on average, 2-fold higher than that of control cells. This difference could be completely abolished by addition of the receptor-associated protein, an inhibitor of ligand binding to megalin/gp330. Mutual suppression of the uptake of 125I-Lp(a) and of 125I-LDL by both unlabeled Lp(a) and LDL suggested that Lp(a) uptake is mediated at least partially by apolipoprotein B100. Binding and uptake of DiI-Lp(a) resulted in strong signals on megalin/gp330-expressing cells versus background only on control cells. In addition, we show that purified megalin/gp330, immobilized on a sensor chip, directly binds Lp(a) in a Ca2+-dependent manner with an affinity similar to that for LDL. We conclude that megalin/gp330 binds Lp(a) in vitro and is capable of mediating its cellular uptake and degradation.

Altered expression of beta 1 integrins in renal carcinoma cell lines exposed to vinblastine

BACKGROUND

Cellular expression of P-glycoprotein (P-gp) which mediates a well characterized mechanism of multidrug resistance (MDR) has been reported previously to be associated with an enhanced tumor dissemination. Since adhesion receptors of the beta 1 integrin family play a substantial role in tumor spread, we studied expression of VLA-1 to -6 in a total of four renal carcinoma cell (RCC) lines prior to and after induction of MDR via exposure to vinblastine.

MATERIAL AND METHODS

Surface expression of P-gp and VLA-1 to -6 was determined immunocytochemically in untreated pre-established renal carcinoma cell lines (Caki-1, Caki-2, A498) and a cell line derived from a RCC patient who had received a vinblastine-containing therapy regimen prior to the resection of a local relapse of the tumor (EH). Resistant sublines were cultivated in the presence of 1 ng/ml and 10 ng/ml of vinblastine sulfate, respectively.

RESULTS

In all cell lines examined, an increased number of P-gp expressing cells was observed upon exposure to vinblastine. Significant changes of beta 1 integrin expression were observed in three of four RCC cell lines. A de novo expression of VLA-1, VLA-2, and VLA-4 as detected by immunocytochemistry occurred in resistant Caki-1 cells. A498 cells showed an increasing number of VLA-2 positive cells in drug resistant sublines. In contrast, a decrease of VLA-2 and VLA-5 expression was found in EH cells, the only cell line exhibiting P-gp expression prior to vinblastine exposure. Caki-2 cells showed no significant changes of surface integrin expression upon treatment with vinblastine.

CONCLUSIONS

Our results demonstrate that induction of drug resistance can be associated with substantial changes of the integrin phenotype in renal carcinoma cell lines. In our experiments, among all VLAs studied, VLA-2 was most frequently altered in expression by RCC cell lines. The significance of these observations for aberrant metastatic properties of multidrug resistant tumor cells will be the subject of further studies.

Hepatic lipase mediates an increase in selective uptake of high-density lipoprotein-associated cholesteryl esters by human Hep 3B hepatoma cells in culture

Selective uptake of high-density lipoprotein- (HDL-) associated cholesteryl esters (CE), i.e. lipid uptake independent from particle uptake, delivers CE to the liver and steroidogenic tissues in vivo. In vitro, besides hepatocytes and steroidogenic cells many other cell types selectively take up HDL CE. Hepatic lipase (HL) stimulates the internalisation of apoprotein (apo) B-containing lipoproteins by hepatocytes independent from lipolysis. In this study the role of HL in the hepatic metabolism of apo A-I-containing lipoproteins, i.e. HDL, was investigated. HDL3 (d = 1.125-1.21 g/ml) was radiolabeled in its protein (125I) and in its CE moiety ([3H]cholesteryl oleyl ether, ([3H]CEt)). HL originated from tissue culture media of hepatoma cells and from post-heparin plasma. Human Hep 3B hepatoma cells incubated in medium containing radiolabeled HDL3. In the absence of HL, the rate of apparent HDL3 particle uptake according to the lipid tracer ([3H]CEt) was in most cases in approximately 10-fold excess on that due to the protein label (125I), indicating selective CE uptake from HDL3. Addition of HL to these incubations increased the cellular uptake of [3H]CEt and of 125I from HDL3 and quantitatively the most prominent effect was an up to approximately 2.5-fold stimulation of apparent selective CE uptake ([3H]CEt-125I). This increase in selective CE uptake was observed in the presence of tetrahydrolipstatin, an inhibitor of the catalytically active site of HL, suggesting that this HL effect is independent from lipolysis. HL binds to cell surface heparan sulfate proteoglycans. To explore the role of these molecules for the HL effect on selective CE uptake, hepatoma cells were depleted of proteoglycans or Chinese hamster ovary (CHO) cells deficient in proteoglycan synthesis were used. Proteoglycan-deficiency reduced the HL-mediated increase in selective uptake by more than 80%. To investigate if low-density lipoprotein (LDL) receptors or the LDL receptor-related protein (LRP) are involved in the HL effect on selective CE uptake, murine embryonic fibroblasts (MEF) were used which are deficient in these receptors; alternatively, monensin, an inhibitor of endocytosis was present in the medium of Hep 3B cells during the uptake assay for labeled HDL3. These experiments yielded no evidence for a role of LDL receptors or LRP in the HL-mediated increase in selective CE uptake. In summary, HL mediates an increase in HDL3 selective CE uptake by human Hep 3B hepatoma cells. This HL effect is independent from lipolysis and independent from LRP and LDL receptors. However this HL effect is susceptible to cell surface proteoglycan deficiency. The potential physiologic implication is that HL modifies HDL selective CE uptake by the liver in vivo and such an effect could play a role in reverse cholesterol transport.

Lipoprotein lipase mediates an increase in the selective uptake of high density lipoprotein-associated cholesteryl esters by hepatic cells in culture

In this study the effect of lipoprotein lipase (LPL) on the selective uptake of high density lipoprotein (HDL) cholesteryl esters (CE) by hepatic cells was investigated. Human HDL3 (d 1.125-1.21 g/ml) was radiolabeled with 125I in the protein moiety and with 3H in the CE moiety. LPL was prepared from bovine milk. Human hepatocytes in primary culture and human Hep3B hepatoma cells were incubated in medium containing doubly radiolabeled HDL3 with or without LPL. Without LPL, apparent HDL3 particle uptake according to the lipid tracer (3H) was in excess of that due to the protein label (125I) indicating selective CE uptake from HDL3. Addition of LPL increased selective CE uptake up to 7-fold. This stimulation of HDL3 selective CE uptake was independent of the lipolytic activity of LPL as suggested by several experimental approaches. Cell surface heparan sulfate proteoglycan deficiency decreased the LPL-mediated increase in selective CE uptake suggesting an important role for these molecules. In low density lipoprotein (LDL) receptor- or LDL receptor-related protein-(LRP)-deficient cells, LPL increased selective CE uptake as it did in normal cells yielding no evidence that these receptors play a role in the LPL effect on selective CE uptake. In summary, lipoprotein lipase increases the selective uptake of high density lipoprotein-associated cholesteryl ester by hepatic cells in culture. This effect is dependent on cell surface heparan sulfate proteoglycans but independent of lipolysis and of endocytosis mediated by low density lipoprotein receptor-related or low density lipoprotein receptors.

Cellular uptake of lipoprotein[a] by mouse embryonic fibroblasts via the LDL receptor and the LDL receptor-related protein

The sites and precise mechanisms of the catabolism of the atherogenic lipoprotein[a] (Lp[a]) are unknown. It has been proposed that the low density lipoprotein receptor (LDL-R) and the low density lipoprotein receptor-related protein (LRP) are involved in the catabolism of Lp[a]. To address the question whether and to what extent the LDL-R and/or LRP are involved in the catabolism of Lp[a], we studied the cellular uptake of Lp[a] via those two receptors using mouse embryonic fibroblast (MEF) cell lines lacking either the LDL-R, the LRP, or both receptors due to disruption of the respective mouse genes. 125I-labeled LDL and 125I-labeled Lp[a] uptake by wild-type fibroblasts (MEF1) was compared with that by fibroblasts homozygous for the disrupted LRP allele (MEF2), fibroblasts with two defective alleles for the LDL-R (MEF3), and fibroblasts homozygous for defects both in the LDL-R and LRP gene (MEF4). Compared with MEF1, 125I-labeled LDL uptake by MEF2 was 77%, by MEF3 30%, and by MEF4 24% of that by MEF1. However, no significant differences in the specific 125I-labeled Lp[a] uptake by the four mouse embryonic cell lines was observed. In comparison with MEF1, the 125I-labeled Lp[a] uptake by MEF2 was 98%, by MEF3 111%, and 73% by MEF4. Approximately 50% of the total cellular uptake of 125I-labeled Lp[a] was nonspecific. In conclusion, our results suggest that Lp[a] is a poor ligand for the LDL receptor and the LRP. The data of the displacement studies, however, indicated that the nonspecific uptake of Lp[a] constitutes a major route for the cellular Lp[a] catabolism in this study.

[Small intestine atresia and abnormal insertion of the umbilicus in a child with fetal alcohol syndrome]

BACKGROUND

Fetal alcohol syndrome is quite common in our region (incidence: 1/700 live births). It usually associates facial dysmorphism, intra-uterine growth retardation and mental delay.

CASE REPORT

Jonathan, born to an alcoholic mother, presented a typical dysmorphy of fetal alcohol syndrome and a low inserted umbilicus. A small bowel atresia was discovered at the third day of life and operated on.

CONCLUSION

Although never been previously described, this association suggests a common embryological origin between fetal alcohol syndrome, small bowel atresia, and umbilical abnormality.

Epidemiology of invasive mycosis in ICU patients: a prospective multicenter study in 435 non-neutropenic patients. Paul-Ehrlich Society for Chemotherapy, Divisions of Mycology and Pneumonia Research

OBJECTIVE

To determine the epidemiological and clinical significance of invasive fungal infections in non-neutropenic patients in intensive care who stay longer than 10 days on the intensive care unit (ICU).

DESIGN

Prospective epidemiological multicenter study over a period of 11 months, based on strict clinical, bacteriological, serological and histological criteria.

SETTING

Six surgical and two medical ICUs units in five university and two municipal hospitals.

PATIENTS

435 non-neutropenic patients from medical and surgical ICUs with an ICU stay of more than 10 days.

MEASUREMENTS AND MAIN RESULTS

A new occurrence of invasive mycosis (3 sepsis/4 peritonitis/1 disseminated candidiasis), corresponding to the protocol conditions with onset after day 10 in the ICU, was detectable in 2.0% (95% confidence interval 0.85 to 3.8%) of the 409 patients who could be assessed. Candida species were identified as an infection-relevant pathogen in all cases. The most important risk factor for the development of an invasive mycosis was the onset of peritonitis by the day 11 in the ICU (odds ratio 11.3; p = 0.003). A fungal colonization was detected in 64% of patients (Candida species 56%, Aspergillus 4%, and other fungi). Six of 8 patients with an invasive mycosis died on the ICU; ICU mortality in patients with fungal colonization was 31% and in noncolonized patients 26%. Serological tests were not helpful clinically. The sensitivity was 88% for the Candida HAT (haemagglutination test) (threshold titer > 1:160), 100% for the Candida IFT (immunofluorescence test) (threshold titer > 1:80), and 50% for the Candida Antigen Test (Candtec Ramco, threshold titer > or = 1:8), and the specificity was 26, 6, and 73%, respectively. The specificity for the Aspergillus HAT (threshold titer > 1:10) was 29%.

CONCLUSIONS

Invasive mycoses are rare in non-neutropenic ICU patients, even after a longer stay in the intensive care unit; fungal colonization, on the other hand, is frequently detectable. The mortality of invasive mycosis--even with systemic antimycotic therapy--was high; the mortality in patients with fungal colonization was not significantly increased compared to that in noncolonized patients. The serological test procedures, Candida HAT, Candida IFT, and the Candida Ramco Antigen Test, had a low specificity and were not helpful in diagnosing relevant invasive mycosis.

VLDL receptor mediates the uptake of human chylomicron remnants in vitro

The VLDL receptor has been described as a new member of the LDL receptor supergene family that specifically binds VLDL in vitro via apolipoprotein E and lipoprotein lipase. Both apolipoprotein E and lipoprotein lipase are constituents of chylomicron remnants, another triglyceride-rich lipoprotein which has been proposed as a physiological ligand for the VLDL receptor. We used human chylomicron remnants to study their uptake into LDL, receptor-deficient Chinese hamster ovary cells overexpressing the human VLDL receptor. The uptake into these cells was compared to that into cells transfected with an empty transfection vector. Human chylomicron remnants were produced in vitro by hydrolysis with lipoprotein lipase, and were labeled with 125I. The uptake of these remnants into the cells overexpressing the VLDL receptor was found to be about 3-fold higher than the uptake into the control cells. The addition of a surplus of either apolipoprotein E or inactivated lipoprotein lipase to the remnants led to an increase in particle uptake. The chylomicron remnant uptake was inhibited by addition of the 39 kDa receptor associated protein These in vitro experiments strongly support the idea that the VLDL receptor is a physiological receptor for chylomicron remnants. The increase of receptor-mediated uptake induced by the addition of apoE or lipoprotein lipase underlines the role of these two proteins in this process.