Endothelial nitric oxide synthase gene polymorphisms and genetic susceptibility to prostate cancer

The endothelial cell-specific form of nitric oxide synthases (ecNOS) is localized at 7q35-q36 and is involved in vascular development and tumour growth in human prostate cancer. We have conducted a case-control study to investigate the prevalence of two polymorphisms at intron 4 (ecNOS4a/b) and exon 7 (Glu-Asp298) of ecNOS gene in 125 prostate cancer (PCa) patients and in 153 controls. We observed that the a-allele (aa or ab genotypes from ecNOS4a/b) was over-presented in the group of PCa with Gleason histological grade >or=7 (P=0.041). With regard to the Glu-Asp298 polymorphism, patients with the T-allele were younger than patients with no T-allele (P=0.037), and a statistically significant difference was noted in the Glu-Asp298 genotype distribution between cases with advanced disease and cases with localized disease (P=0.0013). When comparing cases and controls with logistic regression analysis we observed that the presence of the a-allele is associated with prostate cancer risk (odds ratio (OR) 1.83; 95% confidence interval (CI) 1.06-3.17; P=0.029), to high histological grade (Gleason >or=7) of PCa (OR 2.18; 95% CI 0.95-4.98; P=0.062) and with the risk of progression of the cancer disease (OR 2.85; 95% CI 1.19-6.82; P=0.018). Furthermore, we found that carriers with the combination of the a-allele (aa and ab ecNOS4a/b genotypes) and T-allele (GT and TT from Glu-Asp298) have a threefold increase in prostate cancer risk (OR 3.13; 95% CI 1.41-6.91, P=0.004). In summary, we have identified an NO-related genetic risk factor for prostate cancer that may help in understanding the molecular mechanism involved in the individual susceptibility to prostate cancer.

Vinorelbine and cisplatin in metastatic squamous cell carcinoma of the oesophagus: response, toxicity, quality of life and survival

BACKGROUND

Vinorelbine and cisplatin are active against squamous cell oesophageal carcinoma. The purpose of this phase II study was to evaluate the efficacy and safety of vinorelbine plus cisplatin in previously untreated patients with metastatic squamous cell oesophageal carcinoma and to estimate the progression-free survival, overall survival and quality of life (QoL) of the patient population.

PATIENTS AND METHODS

Seventy-one eligible patients were entered into a study of vinorelbine 25 mg/m2 on days 1 and 8 plus cisplatin 80 mg/m2 on day 1, every 3 weeks. Degree of dysphagia relief was monitored and QoL was measured using the EORTC QLQ-C30.

RESULTS

All eligible patients were assessed for response and 24 achieved a confirmed partial response (33.8%; 95% confidence interval 23-46); the median duration of response was 6.8 months, progression-free survival was 3.6 months and median survival of the whole group was 6.8 months. Toxicity was mainly related to neutropenia (grade 3/4 in 41% of patients). At cycle 2, 43% of the patients reported at least a moderate improvement in global health status/QoL and 25% experienced a large improvement.

CONCLUSIONS

Vinorelbine plus cisplatin represents a well-tolerated active palliative regimen for patients with advanced squamous cell carcinoma of the oesophagus. This combination may offer a better therapeutic index than cisplatin-5-fluorouracil.

Quantitation of GSTP1 methylation in non-neoplastic prostatic tissue and organ-confined prostate adenocarcinoma

BACKGROUND

Methylation of regulatory sequences near GSTP1, which encodes the pi class glutathione S-transferase, is the most common epigenetic alteration associated with prostate cancer. We determined whether the quantitation of GSTP1 methylation in histopathologically distinct prostate tissue samples could improve prostate cancer detection.

METHODS

We used a fluorogenic real-time methylation-specific polymerase chain reaction (MSP) assay to analyze cytidine methylation in the GSTP1 promoter in prostate tissue samples from 69 patients with early-stage prostatic adenocarcinoma (28 of whom also had prostatic intraepithelial neoplasia lesions) and 31 patients with benign prostatic hyperplasia. The relative level of methylated GSTP1 DNA in each sample was determined as the ratio of MSP-amplified GSTP1 to MYOD1, a reference gene. We also performed a prospective, blinded investigation to quantitate GSTP1 promoter methylation in sextant prostate biopsy specimens from 21 additional patients with elevated serum prostate-specific antigen levels, 11 of whom had histologically identified adenocarcinoma and 10 of whom had no morphologic evidence of adenocarcinoma. All data were analyzed by using nonparametric two-sided statistical tests.

RESULTS

The median ratios (and interquartile ranges) of MSP-amplified GSTP1 to MYOD1 in resected benign hyperplastic prostatic tissue, intraepithelial neoplasia, and adenocarcinoma were 0 (range, 0-0.1), 1.4 (range, 0- 45.9), and 250.8 (range, 53.5-697.5), respectively; all of these values were statistically significantly different (P< .001). The median ratios of MSP-amplified GSTP1 to MYOD1 in the prospectively collected sextant biopsy samples were 410.6 for the patients with adenocarcinoma and 0.0 for the patients with no evidence of adenocarcinoma (P< .001).

CONCLUSION

Quantitation of GSTP1 methylation accurately discriminates between normal hyperplastic tissue and prostatic carcinoma in small samples of prostate tissue and may augment the standard pathologic/histologic assessment of the prostate.

Influence of the interval between the administration of doxorubicin and paclitaxel on the pharmacokinetics of these drugs in patients with locally advanced breast cancer

PURPOSE

The combination of bolus doxorubicin followed by a 3-h infusion of paclitaxel has high antitumor activity in patients with metastatic breast cancer, but is limited by unexpected cardiac toxicity. In contrast, the administration of the two drugs 16 h apart has similar antitumor activity but less cardiac toxicity. The purpose of this study was to compare the pharmacokinetics of these drugs when doxorubicin administration preceded paclitaxel by 30 min or by 24 h.

PATIENTS AND METHODS

Women with locally advanced breast cancer were treated with doxorubicin (60 mg/m2 i.v. bolus) followed 24 h later by paclitaxel (200 mg/m2 i.v. over 3 h) for six cycles (four before and two after surgery). In one of the first two cycles doxorubicin preceded paclitaxel by 30 min instead of 24 h, with plasma sampling for pharmacokinetic analysis up to 48 h. Determination of drug levels in plasma was done by HPLC.

RESULTS

A total of 28 patients were included. No clinical cardiac toxicity was observed but five patients discontinued doxorubicin-paclitaxel treatment after four cycles because of a decrease in LVEF of at least 15% from baseline or to less than 50%. While paclitaxel pharmacokinetics were not changed, there was a 30% and an 80% increase in the AUC0, 24h for doxorubicin and doxorubicinol, respectively, when the drugs were administered 30 min instead of 24 h apart. Even when paclitaxel was given 24 h after doxorubicin, there was a rebound 240% increase in the plasma concentration of doxorubicinol.

CONCLUSIONS

Paclitaxel interferes with the pharmacokinetics of doxorubicin leading to higher systemic exposure to both doxorubicin and doxorubicinol, which is more evident when the plasma concentration of the anthracyclines is higher. This interference may explain the higher incidence of cardiac toxicity observed when the two drugs are administered within a short interval.

Pulmonary transvalvular and venous flows in the estimation of left ventricular diastolic pressures. A comparative Doppler-catheterization study

OBJECTIVES

To evaluate the association between patterns of pulmonary transvalvular and venous flows in patients with ischemic heart disease, assessed by Doppler echocardiography, and invasive measurements of left ventricular (LV) diastolic pressures.

POPULATION

Thirty-seven patients with clinical diagnosis or suspicion of coronary heart disease and referred for coronary angiography; all were in sinus rhythm, and had no known valvular heart or chronic pulmonary disease.

METHODS

The following were recorded during transthoracic Doppler echocardiography: acceleration time (AT) and total ejection time (ET) of right ventricular outflow; duration of the flow at atrial contraction (a duration) and duration of the "A" wave of mitral inflow (A duration). These data were correlated with the values of LV filling pressures previously obtained by cardiac catheterization.

RESULTS

We found a significant correlation of LV end-diastolic pressures with the difference a-A duration (r = 0.75; p < 0.001) and also with the ratio AT/ET (r = -0.73;.

Mitochondrial mutations in early stage prostate cancer and bodily fluids

We recently demonstrated the existence of specific patterns of somatic mitochondrial DNA (mtDNA) mutations in several cancers. Here we sought to identify the presence of mtDNA mutations in prostate cancer and their paired PIN lesions. The D-loop region, 16S rRNA, and the NADH subunits of complex I were sequenced to identify mtDNA mutations in 16 matched PIN lesions and primary prostate cancers. Twenty mtDNA mutations were detected in the tumor tissue of three patients. Identical mutations were also identified in the PIN lesion from one patient. This patient with multiple point mutations also harbored a high frequency of microsatellite instability (MSI-H) in nuclear mononucleotide repeat markers. Remarkably, identical mutations were also detected in all (3/3) matched urine and plasma samples obtained from these patients. Although mitochondrial mutations are less common in prostate adenocarcinoma, they occur early in cancer progression and they can be detected in bodily fluids of early stage disease patients. The identification of MtDNA mutations may complement other early detection approaches for prostate cancer.

The spatial arrangement of tubules in human dentin

We applied two-dimensional numerical methods to describe the spatial arrangement of tubules in human dentin. The methods considered were two-point correlation functions, entropy-like measures, and angular distributions between nearest neighbors. The correlation functions were based on Fourier transform methods. The latter two approaches were based on stochastic geometry, and involved developing the Delaunay tessellations of the tubule patterns and their dual Voronoi diagrams. We discovered that for analyzing the distribution of tubules the geometric methods of lattice tessellations were more sensitive to structural order of the tubules than were Fourier-based schemes. Analysis of the data indicated that dentinal tubules are highly ordered in normal dentin.

Serological study of the frequency of leptospiral infections among dairy cows in farms with suboptimal reproductive efficiency in Galicia, Spain

Between March 1996 and September 1997, 15 farms located in Galicia (NW Spain) and experiencing suboptimal reproductive efficiency were visited and blood samples were obtained from all the lactating cows (n=442). Additionally, 1060 samples were obtained monthly from a cohort of 219 lactating cows belonging to nine of the farms between March 1996 and April 1997. All the samples were tested by microscopic agglutination (MAT) using live antigens representing the following Leptospira interrogans serogroups: Australis, Autumnalis, Ballum, Canicola, Grippotyphosa, Icterohaemorrhagiae, Louisiana, Pomona, Sejroe, Shermani and Tarassovi. Eighty-one of the 442 cows were positive against one or more serogroups (P=18.33%). Serologically, L. bratislava and L. grippotyphosa were detected as the most prevalent serovars (P=7.92 and 7.69%, respectively) and as the serovars against which the probability of seroconversion was highest (P=0.27 and 0.25, for a 12-month period, respectively) among those studied. The proportional hazards regression method was used for evaluating the seasonal trend of seroconversions against these two serovars. The risk of seroconversion against L. grippotyphosa was significantly higher during spring. The risk of seroconversion against L. bratislava did not differ significantly among seasons. Our results suggest that infections by L. bratislava did not follow, among the study animals and during the study period, the pattern typically described for non-adapted serovars, pointing out the possibility that some strains of this serovar could behave as adapted serovars.

The balanced scorecard: an integrative approach to performance evaluation

In addition to strict financial outcomes, healthcare financial managers should assess intangible assets that affect the organization's bottom line, such as clinical processes, staff skills, and patient satisfaction and loyalty. The balanced scorecard, coupled with data-warehousing capabilities, offers a way to measure an organization's performance against its strategic objectives while focusing on building capabilities to achieve these objectives. The balanced scorecard examines performance related to finance, human resources, internal processes, and customers. Because the balanced scorecard requires substantial amounts of data, it is a necessity to establish an organizational data warehouse of clinical, operational, and financial data that can be used in decision support. Because it presents indicators that managers and staff can influence directly by their actions, the balanced-scorecard approach to performance measurement encourages behavioral changes aimed at achieving corporate strategies.

Specific heterologous F(ab')2 antibodies revert blood incoagulability resulting from envenoming by Lonomia obliqua caterpillars

Contact with Lonomia obliqua caterpillars results in a bleeding syndrome characterized by hemorrhage and blood coagulation disturbances. Conventional therapy using antifibrinolytics or cryoprecipitates has been unable to treat pathophysiologic alterations. As antivenoms are effective therapy for treatment of victims of venomous animals, a process of manufacturing a specific antilonomic serum by immunizing horses with Lonomia caterpillar bristle extracts (LBE) was developed. Lonomia caterpillar bristle extracts exhibited several protein bands on SDS-PAGE, induced blood coagulation abnormalities and lethality in mice, and stimulated specific antibody production in horses. Sera obtained from immunized horses were rich in anti-LBE specific antibodies distributed among the horse IgG isotypes. These antibodies had the ability to recognize various LBE antigens as well as to neutralize their coagulopathy-inducing activity. The antivenom manufactured by the developed process was composed of purified and sterilized F(ab')2 with ED50 = 38.61 microl, potency = 0.29 mg/ml, and 95% confidence limit of potency 0.20-1.36.

[Immunologic and epidemiologic characterization of non-responders/low-responders to hepatitis B vaccine]

An important reduction in morbidity and mortality due to hepatitis B was achieved with the discovery of an effective vaccine. However, 2 to 10% of healthy adults do not respond to vaccination with the production of protective levels of antibody anti-HBs (assumed as protective, concentrations of ab. anti-HBs > 10 UI/L). Therefore, the aim of the present work was to study epidemiological (sex, age, obesity, alcoholic and smoking habits, previous diseases) and immunological factors (white cell count, immunoglobulins and sub-classes of IgG, lymphocytic populations and sub-populations) in a group of 20 healthcare workers with a low response (anti-HBs < 50 UI/L) to a genetically-engineered vaccine (Engerix B). The results were compared to the ones found in an identical sample of responders (anti-HBs > 100 UI/L) from the same population. No statistically significant differences regarding the epidemiological data, differential white cell counts and immunoglobulin quantification (IgG, IgA, IgM, IgG1, IgG2, IgG3) were detected. The mean value of IgG4 (mean = 54.53 +/- 59.8 mg/dl) in non/hyporesponders was significantly higher (p = 0.038) when compared to the same result in responders (mean = 33.76 +/- 31.30 mg/dl). A statistically significant difference (p < 0.05) in the quantification of double negative lymphocytic T sub-populations was also found, the mean value being higher in the responders (mean = 6.5 +/- 4.1% versus 4.6 +/- 2.3%).

CONCLUSIONS

The effectiveness of recombinant hepatitis B vaccines is well known. However, a number of apparently healthy people are unable to achieve protective titres of anti-HBs after vaccination. As our study groups did not have a considerable number of cases, we can not establish definitive conclusions based on differences found in the quantification of IgG4 and double negative lymphocytic T sub-populations. It seems to us that an investment in future research into the eventual causes of nonprotective response and into new strategies of immunization of non/hyporesponders are appropriate. In the meantime, the occupational daily risk of exposure to infected body fluids makes adequate hepatitis B immunization of healthcare workers a priority.

Single-step purification of recombinant human growth hormone (hGH) directly from bacterial osmotic shock fluids, for the purpose of (125)I-hGH preparation

A good quality tracer, to be used in the radioimmunoassay of human growth hormone, was prepared by applying the chloramine-T iodination technique to the recombinant product obtained after a single-step high-performance size-exclusion chromatography purification of a bacterial osmotic shock fluid. The labeling reaction presented a yield of about 65% and the purified tracer exhibited an antibody binding of approximately 50% (NIDDK reference antiserum diluted 1:600,000). These values are very similar to those obtained by radioiodinating highly purified clinical-grade recombinant human growth hormone obtained from the same periplasmic extract after the regular six-step purification process. Both tracers provided the same accuracy, when evaluated with the use of commercial-quality control samples in a classical radioimmunoassay methodology, their stability being practically identical: about 18% decrease in antibody binding after 2 months of storage at -20 degrees C. The novel approach permits the utilization of transformed Escherichia coli strains as a source of freshly prepared, radioiodination-grade recombinant proteins, capable of providing better reproducibility and reagent continuity.

[Rickettsia infections in Portugal]

After a brief introduction about rickettsioses, we analyse Mediterranean Spotted Fever (MSF) in Portugal, and review Portuguese medical literature. We focussed on the seasonal summer pattern of the disease. MSF is very frequent in Portugal, nearly 1,000 cases are reported every year and young age groups are the most afflicted. Although usually regarded as a benign condition, MSF has emerged as a potentially lethal disease in recent years. The clinical presentation is protean, but usually suggestive enough to allow a clinical diagnosis. The complications are well documented, elderly and people with chronic debilitating diseases being the most affected. Q fever is also endemic in Portugal, although with more modest numbers (about 50 cases a year). Serological studies, however, suggest a higher incidence, probably because the disease is unfamiliar to many clinicians and, as such, it is difficult to diagnose and, consequently, then an important number of subclinical or self-limited cases. In Portugal, fever with hepatic involvement is the most common clinical presentation. Other less frequent clinical forms are atypical pneumonia and CNS involvement. Chronic Q fever is a rare condition.

Cholesterol enhances contractile responses in isolated small mesenteric arteries of normotensive and spontaneously hypertensive rats

OBJECTIVE

In order to examine possible mechanisms by which hypercholesterolemia may contribute to the development of cardiovascular disease, we investigated the effect of cholesterol enrichment on contractility in isolated small rat mesenteric arteries.

DESIGN

Contractile responses of cholesterol-enriched isolated small mesenteric arteries of normotensive Wistar-Kyoto (WKY) rats and spontaneously hypertensive rats (SHR) were compared with control groups.

METHODS

First- to second-order mesenteric arteries (327-349 microm internal lumen diameter) were dissected from the mesenteric bed of 10-20-week-old male WKY rats and SHR, and incubated in cholesterol-free and cholesterol-rich (150 microg/ml) medium. Isolated arteries were mounted on a Mulvany-Halpern myograph for measurement of isometric tension.

RESULTS

Cholesterol significantly increased active wall tension and active wall pressure in WKY rat arteries and active wall tension in SHR arteries in response to potassium chloride, norepinephrine and serotonin (P < 0.05). In addition, contractile responses to all agonists were significantly higher in cholesterol-enriched SHR arteries compared with cholesterol-enriched WKY rat vessels (P < 0.05).

CONCLUSIONS

These findings suggest that elevated cholesterol content enhances agonist-stimulated contractility in small mesenteric resistance arteries, providing a possible mechanism by which hypercholesterolemia may contribute to the development of hypertension.

Does serum ferritin correlate with coronary angiography findings?

BACKGROUND

A number of epidemiological studies have described a positive relationship between serum ferritin levels and coronary heart disease. In this prospective study, we evaluated the association between serum ferritin levels and the angiographic extent of coronary atherosclerosis.

METHOD

We studied 307 consecutive patients (60.9% male, age 60.1+/-11.0 years) referred for diagnostic coronary angiography. Risk factors for coronary artery disease, lipids and ferritin levels, as well clinical characteristics were recorded from all patients. Two experienced cardiologists blinded for clinical and laboratory data reviewed the cinefilms. Angiographic significant coronary artery disease (CAD) was defined as any more than a 50% diameter stenosis.

RESULTS

From the 307 patients, 196 (63.8%) were found to have angiographic significant CAD. The presence of significant CAD was associated with ferritin levels (P=0.015) as well as patient age (P<0.001), male sex (P<0.001), smoking (P<0.002), and cholesterol levels (P=0.028). By multivariate analysis, however, ferritin level was not an independent risk factor for CAD (P=0.27), while the association with all the other factors remained significant.

CONCLUSION

In patients referred for coronary angiography no independent relationship was found between angiographic significant coronary artery disease and serum ferritin levels.

[The determination of susceptibility to measles, rubella, mumps and chickenpox in students of health-related areas]

We present an epidemiological and serological study in 286 health care students. We found susceptibility for measles in 11.7% individuals (95% confidence interval (95% CI): 8.0-15%), for rubella: 6.7% (95% CI: 3.8-9.6%) for mumps: 12.7% (95% CI: 8.0-16.6%) and for varicella 8.5% (95% CI: 5.3-11.7%). Compared to a similar study, performed in 1992 in a population of health care workers, we found an increasing susceptibility to these diseases except for mumps, that had decreased. Among those who received one dose of measles vaccine we found 12.1% non immune. We found an high level of immunity (97.1%) for those who received rubella vaccination. We could not draw any conclusions for mumps because only seven had been vaccinated.

Lack of a relationship between serum ferritin levels and coronary atherosclerosis evaluated by coronary arteriography

Many clinical and epidemiological studies have demonstrated the relationship between serum ferritin and ischemic heart disease. In the present study we evaluated the relationship between coronary heart disease (CHD) and serum ferritin levels in patients submitted to coronary arteriography. We evaluated 307 patients (210 (68.7%) males; median age: 60 years) who were submitted to coronary angiography, measurement of serum ferritin and identification of clinical events of ischemic heart disease. Serum ferritin is reported as quartiles. Ninety-six patients (31.27%) had normal coronary angiography (group 1) and 211 (68.73%) had coronary heart disease (group 2). Of the patients with CHD, 61 (28.9%) had serum ferritin levels higher than 194 ng/ml (4th quartile), as opposed to only 14 (14.58%) of those without CHD (P = 0.0067). In the 2nd quartile, 39 patients (18.48%) had CHD, while 35 patients (36.46%) had normal coronary arteries (P = 0.00064). Multivariate analysis of the data showed that the difference between groups was not statistically significant (P = 0.33). We conclude that there is no independent relationship between coronary heart disease and increased levels of serum ferritin.

Placental pathology in antiphospholipid syndrome

One of the major targets of antiphospholipid antibodies (aPL) is the placenta, the evolution of which during pregnancy has been well documented. Histopathological findings are related to gestational age, and several physiologic and pathologic alterations that occur during its development. The major findings in placentae from aPL positive patients are thrombosis, acute atherosis, a decreased number of syncytio-vascular membranes, increased number of syncytial knots and obliterative arteriopathy. These findings are not specific to the antiphospholipid syndrome (APS) and sometimes do not correlate with the fetal outcome. Histopathological study of placentae may elucidate mechanisms of action of aPL in fetal loss and other obstetric complications. In addition, it may assist in the investigation of the differential diagnosis between APS and pregnancy-induced hypertension. Immunohistochemical studies of local placental proteins contribute to this differential diagnosis.

An EORTC-ECSG phase II study of vinorelbine in patients with recurrent and/or metastatic squamous cell carcinoma of the head and neck

BACKGROUND

Vinorelbine is an active drug in the treatment of lung and breast cancers and has a favorable toxicity profile. Many clinical trials have demonstrated its antitumor activity in other tumor types including squamous cell carcinoma of the head and neck (SCCHN). We investigated the efficacy and tolerability of vinorelbine in patients with recurrent and/or metastatic SCCHN, previously untreated by chemotherapy.

PATIENTS AND METHODS

Seventy-one patients with locoregional recurrent and/or metastatic SCCHN were treated with vinorelbine at a dose of 30 mg/m2/week i.v. by short-duration infusion on an out-patient basis. Doses were adjusted according to tolerance.

RESULTS

Two complete and seven partial responses were observed among 56 evaluable patients, yielding a response rate of 16% (95% confidence interval (CI): 8%-28%). The overall response rate of all eligible patients (63) was 14%. The responses were seen in recurrent tumors, lymph nodes and in lung metastases, and their median duration was 19 weeks (12-63). The main toxicity, severe and reversible neutropenia (grade 3-4) occurred in 53% of the 69 evaluable (for toxicity) patients. Twelve patients developed severe bronchopulmonary infections, which caused two early deaths. Constipation was observed in 31 patients (45%). Other gastrointestinal toxicities, asthenia, acute pain syndrome and peripheral sensory neuropathy, were mild to moderate. The median number of treatments was seven cycles and the median relative dose intensity of vinorelbine was 85% (25.5 mg/m2/week).

CONCLUSIONS

Vinorelbine is an active drug, with acceptable toxicity, in recurrent and/or metastatic SCCHN, at the dose and schedule administered in the present study. Further evaluation in association with other agents and/or radiotherapy is warranted.

Evaluation of dose due to ingestion of natural radionuclides of the uranium series in spring waters

The concentrations of uranium isotopes and their decay products 226Ra, 222Rn, 210Pb and 210po have been analyzed in the mineral spring waters of a highly radioactive region of Brazil: Aguas da Prata. This region is located in the Poços de Caldas Plateau, one of the largest weathered alkaline intrusions in the world. Dose calculations were performed to evaluate the relative importance of these radionuclides in the exposure of the local population to radiation. Based upon concentrations measured in all the springs available, effective doses per year varying from 1.4 x 10(-4) mSv year(-1) for 238U to 5.1 x 10(-2) mSv year(-1) for 222Rn were observed. The doses from the ingestion of 222Rn, 210Po and 210Pb are of the same order of magnitude, and therefore these radionuclides are the most critical as far as the consumption of these waters is concerned.

Proteinuria is still useful for the screening and diagnosis of overt diabetic nephropathy

OBJECTIVE

To assess the performance of urinary total protein measurements in timed 24-h urine collection (24-h UP) and in a diurnal random urine specimen (RUS) for the screening and diagnosis of overt diabetic nephropathy.

RESEARCH DESIGN AND METHODS

A total of 167 diabetic patients (20 type 1 and 147 type 2 diabetic patients; 78 women and 89 men), aged 20-84 years, collected 217 timed 24-h urine specimens. Albumin was measured by immunoturbidimetry, total protein by sulfosalicylic acid technique, and creatinine by Jaffe's method. According to the timed 24-h urinary albumin excretion rate (UAER), samples were divided into three groups: normoalbuminuric (NORMO) (UAER < 20 micrograms/min; n = 84), microalbuminuric (MICRO) (UAER 20-200 micrograms/min; n = 78), and macroalbuminuric (MACRO) (UAER > or = 200 micrograms/min; n = 55). Eighty-six patients also collected 105 RUSs (NORMO, n = 47; MICRO, n = 37; MACRO, n = 21), and urinary protein concentration (UPC) and urinary protein-to-creatinine ratio (UPCR) were measured. The receiver operating characteristics (ROC) curve approach was used to analyze the performance of the diagnostic tests.

RESULTS

Spearman's coefficient of correlation of 24-h UAER versus 24-h UP was 0.95 (P < 0.001), and of 24-h UAER versus UPC and UPCR were 0.77 and 0.72, respectively (P < 0.001). The calculated areas (+/- SEM) under the ROC curve for the diagnosis of over diabetic nephropathy were 0.9987 +/- 0.001 for 24-h UP, 0.9926 +/- 0.006 for UPC, and 0.9751 +/- 0.014 for UPCR. In the ROC curves, the first points with 100% sensitivity were 541 mg (95.7% specificity) for 24-h UP, 431 mg/l (92.9% specificity) for UPC, and 0.2 (76.2% specificity) for UPCR.

CONCLUSIONS

Measurements of proteinuria presented almost perfect accuracy for the screening and diagnosis of overt diabetic nephropathy. Protein measurement in spot urine is a reliable and simple method for the screening and diagnosis of overt diabetic nephropathy.

[Coronary angioplasty in the acute phase of myocardial infarct]

Primary coronary angioplasty is a reperfusion method increasingly used for the treatment of acute myocardial infarction. Several studies are reviewed, demonstrating a reduction in mortality and morbidity, namely due to recurrent ischaemia and haemorrhagic stroke, in comparison to thrombolysis. This benefit seems larger in high risk patients, such as those with cardiogenic shock, anterior wall infarction, elderly patients and those with contraindications thrombolysis or with a non diagnostic electrocardiogram.

Phase III trial of modulation of cisplatin/fluorouracil chemotherapy by interferon alfa-2b in patients with recurrent or metastatic head and neck cancer. Head and Neck Interferon Cooperative Study Group

PURPOSE

In preclinical experiments, interferon alfa modulates the anticancer activity of fluorouracil (5-FU) and cisplatin (CDDP). To test this effect clinically in patients with recurrent or metastatic head and neck cancer (RMHNC), a multicenter randomized controlled trial with CDDP and 5-FU with or without interferon alfa-2b (IFNalpha) was performed.

PATIENTS AND METHODS

Eligible patients had histologically confirmed RMHNC; a good performance status; measurable disease; adequate bone marrow, hepatic, and renal function; no prior chemotherapy for recurrent or metastatic disease; only one chemotherapy regimen administered with previous local therapy; and a treatment-free interval of at least 3 months following previous local therapy. Patients were randomized and stratified according to treatment center, and prior radiotherapy and chemotherapy. The treatment regimen consisted of CDDP 100 mg/m2 on day 1 and 5-FU 1,000 mg/m2/d by continuous infusion for 96 hours (days 1 to 4), without (arm A) or with (arm B) IFNg alpha 3 x 10(6) U/d subcutaneously on days 1 to 5. Cycles were repeated every 21 days.

RESULTS

One hundred twenty-two patients were entered on each arm. The response rate (RR) was similar in both arms (arm A: complete response [CR] 10.7%, partial response [PR] 36.4%; arm B: CR 6.8%, PR 31.6%) (.70 < P < .50). There was no difference in median survival between the two arms (arm A 6.3 months v arm B 6.0 months; P = .49). Anorexia, fever, leukopenia, and thrombocytopenia grade III to IV were significantly more frequent in the IFNalpha arm.

CONCLUSION

Modulation of CDDP and 5-FU with IFNalpha as used in this study does not improve the RR or the median survival in patients with RMHNC. Patients on both study arms had a poor prognosis, which indicates the need for novel therapies.

Evolving costs of long-term left ventricular assist device implantation

BACKGROUND

To examine the long-term costs of implanting a left ventricular assist device, we reviewed the initial hospitalization and outpatient costs for 12 patients who received a vented electric left ventricular assist device, and projected the first-year costs.

METHODS

We used the ratio-of-cost-to-charges method to measure hospital costs and payments for physician time. We examined time trends in the resource use of 50 pneumatic left ventricular assist device recipients, using actuarial techniques and regression modeling.

RESULTS

The average actual cost of left ventricular assist device support is $221,313 over an average of 9.5 months. If there had been no Food and Drug Administration regulatory policy precluding hospital discharge before 30 days, this value would have been $201,148. Based on this latter figure, the average predicted first-year cost is $219,139. The length of the intensive care unit stay, one of the most costly components of care, decreased significantly over time.

CONCLUSIONS

The high costs of left ventricular assist device implantation are similar to those reported for cardiac transplantation. Given their success in supporting survival, we anticipate that these devices will be similarly cost-effective. However, further research is imperative to determine the cost-effectiveness of these devices beyond the introductory phase, when costs, benefits, and Food and Drug Administration requirements have stabilized.

Kikuchi's disease: a case report with emphasis on flow cytometric studies

We describe a case of 27 year-old female presenting with Kikuchi-Fujimoto's disease whose diagnosis was based on histopathologic and immunophenotypic studies. The illness was characterized by fever, urinary tract infections, skin rash, polyarthritis, generalized lymphadenopathy, pancytopenia, hepatic cytolysis and cholestasis, abnormal coagulation tests and elevated serum lactate dehydrogenase. The lymph node biopsy was consistent with the diagnosis of a histiocytic necrotizing lymphadenitis. Flow cyto-metric studies performed on the affected lymph node, bone marrow aspirate and peripheral blood, revealed a relative expansion of mature activated T lymphocytes, predominantly expressing a CD8 (+) phenotype.

The prevalence of diabetes in Rio de Janeiro, Brazil. The Cooperative Group for the Study of Diabetes Prevalence in Rio De Janeiro

OBJECTIVE

To assess the prevalence of diabetes and impaired glucose tolerance (IGT) in the adult population of Rio de Janeiro, a two-stage cross-sectional survey was carried out in a random sample of 2,051 individuals aged 30-69 years from Rio de Janeiro city in Brazil.

RESEARCH DESIGN AND METHODS

Subjects were first screened by fasting capillary glycemia (FCG). All individuals who screened positive (FCG > 5.6 mmol/l) and every sixth consecutive person who screened negative (FCG < 5.6 mmol/l) were subjected to a 75-g glucose load. Diagnoses of diabetes and IGT were based on World Health Organization criteria.

RESULTS

Results from every sixth individual who screened negative were extrapolated to all individuals who screened negative after adjustment for some potential bias in the subsample. Age-adjusted prevalence rates for diabetes and IGT were 7.1 and 9.0%, respectively. The rates were higher (P < 0.01) among women than among men (8.7 vs. 5.2% for diabetes and 11.7 vs. 5.8% for IGT), among obese individuals than among nonobese individuals (7.9 vs. 6.2% for diabetes and 11.4 vs. 7.3% for IGT), and among those with family history of diabetes than among those without family history of diabetes (12.4 vs. 4.8% for diabetes and 13.8 vs. 6.7% for IGT). The rates for diabetes and IGT increased with age, being 1.7 and 4.5%, respectively, for the age-group of 30-39 years, 3.9 and 8.5% for the age-group of 40-49 years, 13.6 and 13% for the age-group of 50-59 years, and 17.3 and 15.3% for the age-group of 60-69 years (P < 0.01). The prevalence of diabetes was higher among individuals with low educational levels than among those with high educational levels (7.3 vs 4.2%). For IGT, the rates increased from the group with intermediate level of education (8.3%) to the low- (11.3%) and high-education group (12.6%). Differences in the rates for whites and non-whites (6.9 vs. 7.1% for diabetes and 8.8 vs. 9.6% for IGT) were not statistically significant. Among those with confirmed diabetes in the survey, 27.6% did not know of their diabetic condition. Among previously diagnosed diabetes (self-reported diabetes), 19.5% were not being treated, 31.8% were on diet only, 40.7% were on oral hypoglycemic drugs, and 8.0% were on insulin. Self-reported prevalence of diabetes was 0.1% for the population < 30 years of age, 4.3% for the 30-69 year old age-group, and 16.6% for those > 70 years of age.

CONCLUSIONS

The numbers found for Rio de Janeiro are similar to those for more developed countries and lead us to conclude that the impact of diabetes on public health is the same as in those countries where this disease is considered an important health problem.

[Acute effects of isosorbide mononitrate on blood circulation and myocardial ischemia in patients with coronary atherosclerosis]

PURPOSE

To evaluate the acute effects of isosorbide mononitrate on circulation, cardiac function and left ventricular segmental motility in patients with isquemic heart disease due to coronary artery disease.

METHODS

Twenty-four patients with ischemic heart disease, 10 women, with mean age of 58 years, were studied during cardiac catheterization, at baseline condition and 5min after intravenous infusion of 0.3mg/kg of isosorbide mononitrate.

RESULTS

After infusion of isosorbide mononitrate there were significant reduction in mean right atrial pressure no mean pulmonary artery pressure (< 0.0001), left ventricular and diastolic pressure (p < 0.004), left ventricular systolic pressure (p < 0.002), maximum (p < 0.002) and mean (p < 0.008) aortic pressure, and left ventricular systolic volume (p < 0.004), as well as significant increase in the left ventricular ejection fraction (p < 0.001) and mean velocity of circunferential fibers shortening (p < 0.001). There was no significant modification of minimum aortic pressure, heart rate, cardiac output nor of left ventricular and diastolic volume. With respect of segmental motility of the left ventricle after medication, 38 kypokinetic segments normalized their motility, 4 akinetic segments remained intact, and of the 21 dyskinetic segments, 6 normalized, 8 became hypokinetic and 7 remained dyskinetic.

CONCLUSION

Isosorbide mononitrate, when used as intravenous infusion, have a rapid and direct effect on systemic and pulmonary circulation, and improving segmental motility and left ventricular performance in patients with impaired left ventricular motility caused by ischemic heart disease.

[The prevalence of measles, rubella, mumps and chickenpox antibodies in a population of health care workers]

We present an epidemiological and serological study in 409 health care workers randomly selected from the 4,103 workers of the University Hospital of Coimbra. A low level of susceptibility for measles (1.2%; 95% confidence interval (95% CI): 0.15-2.23%), rubella (2.4%; 95% CI: 0.9-3.9) and varicella (3.2%; 95% CI: 1.5-4.7%) and a very high one for mumps (17.3%; 95% CI: 13.7-21.1%), were found. Ineffectiveness of historical information in predicting immune status to all of these diseases was found. An economic analysis of preventive measures was done. A mumps vaccination policy for health care workers is recommended and the opportunity of measles and rubella vaccination is discussed, facing the results of this study. Continuous monitoring of these diseases is needed anticipating the changes in epidemiology that are expected to occur with childhood vaccination.

Neoadjuvant chemotherapy in locally advanced gastric carcinoma--a phase II trial with combined continuous intravenous 5-fluorouracil and bolus cisplatinum

Locally advanced gastric adenocarcinomas (LAGC) have a poor prognosis, particularly when tumours are bulky, located in the cardia or in the event of locoregional lymph node involvement. Patients bearing these tumours were entered in a phase II trial of neoadjuvant chemotherapy, combining continuous intravenous 5-fluorouracil (5FU) (1000 mg/m2 for 5 days) and cisplatinum (CDDP) (100 mg/m2 on day 2) repeated every 4 weeks, for one to six cycles according to response and tolerance. 30 patients have been entered, 26 after clinical evaluation (CAT scan and upper gastrointestinal endoscopy) and 4 with unresectable tumours at prior laparotomy. Median age was 60 years, 15/30 patients had a tumour of the cardia, 15/30 had enlarged lymph nodes and 7/30 had linitis plastica (diffuse type). A mean number of three cycles was administered (range 1-6). 27 of the 30 patients were evaluable for response. One patient achieved a complete response (CR) and 14 a partial response (56%; 95% confidence interval 38-74%). No patient had tumour progression, and only 1/6 with linitis plastica responded. 28 patients underwent surgery, and 23 had a macroscopically complete resection (77% of the 30 entered patients); RO resections were performed in 60% of the cases, mainly after an objective response (13/15 versus 4/12 in nonresponders). No pathological CR were seen. Grade 4 neutropenia was observed in eight cycles (5 patients), with five septic complications and one death due to toxicity. Four postoperative complications were observed: 2 cases of severe pneumonia and 2 subphrenic abscesses. One postoperative death, due to intravascular disseminated coagulation, was observed at day 30. Median survival was 16 months and the 1-, 2- and 3-year survival was 67, 42 and 38%, respectively. Patients with linitis plastica had a significantly shorter survival (P < 0.002). We conclude that neodjuvant chemotherapy is feasible in LAGC, although randomised trials are warranted to demonstrate its efficacy on survival and resection rates.

Efficacy of combined 5-fluorouracil and cisplatinum in advanced gastric carcinomas. A phase II trial with prognostic factor analysis

Combined chemotherapy has demonstrated a degree of efficacy in gastric carcinoma. As 5-fluorouracil (5FU) and cisplatinum are two of the most active drugs, we have tested the efficacy of combined 5FU and cisplatinum in a prospective phase II trial. Cycles were administered every 4 weeks and consisted of 5FU 1000 mg/m2/day 5 days continuous intravenous (i.v.) infusion and cisplatinum 100 mg/m2 on day 2. Cycles were repeated according to tolerance and efficacy. 87 patients entered the study, 57 with metastatic or recurrent tumour (M) and 30 with locally advanced gastric cancer (LAGC). The response rate for the 83 evaluable patients was 43% [95% confidence interval (CI) 30-56%]. There were four complete responses (5%), 32 partial responses (39%), 34 cases of stable disease and 13 cases of progressive disease. Responses were more frequent in patients with a good performance status (P = 0.02), with their primary located in the cardia (P = 0.003), with a non-linitis plastica tumour form (P = 0.003) or a tumour containing less than 50% of independent cells (P = 0.016). Median survival was 9 months for the total population. It was better in patients with a good performance status (P = 0.01), and those who did not have linitis plastica (P = 0.005). Toxicity was acceptable, although grade 3-4 neutropenia was reported in 22% of the cycles, mucositis in 14% and 3 patients died of septic complications. The combination of 5FU and cisplatinum is effective in terms of tumour response in advanced gastric cancer and warrants testing with the other active regimens.

Renal toxicity mediated by continuous infusion of recombinant interleukin-2

Interleukin-2 (IL-2), a potent lymphokine with antitumoral activity, was used in continuous intravenous infusion for 5 days (18,000,000 IU/m2/day) in 9 treatment cycles in 5 patients with metastatic colorectal carcinoma. During the infusion, patients received aggressive fluid replacement titrated by invasive hemodynamic monitoring, aiming at a stable central volemia. Body weight went up an average of 4.5 kg in 5 days, mean arterial blood pressure dropped slightly from day 1 to day 5 (105.4 +/- 11.6 to 86.1 +/- 12.5 mm Hg, p < 0.05), systemic vascular resistance decreased from 1304.7 +/- 242.1 to 871.7 +/- 237.2 dyn/s/cm-5 (p < 0.05), with stable pulmonary capillary wedge pressure, cardiac output and central venous pressure. The urinary output significantly dropped from 1.9 +/- 1.2 to 0.2 +/- 0.1 ml/min (p < 0.05) with very significant rises in serum creatinine from 76.0 +/- 28.3 to 242.2 +/- 144.9 mumol/l (0.86 +/- 0.32 to 2.47 +/- 1.64 mg/dl) and N-acetyl-beta-D-glucosaminidase urinary activity from 4.97 +/- 5.0 to 23.0 +/- 12.1 U/l, and significant decrement of creatinine clearance (1.86 +/- 0.65 to 0.29 +/- 0.27 ml/s or 111.5 +/- 38.9 to 17.1 +/- 16.6 ml/min) and urinary sodium (113.8 +/- 78.3 to 9.0 +/- 6.7 mmol/l). Urine sediment evolved from normal at day 1 to 9.0 +/- 3.7 epithelial cells/mm3 and 6.9 +/- 3.6 brown casts/mm3 (p = 0.001). We concluded that cancer treatment with IL-2 in continuous infusion, even with stable hemodynamics, induces an acute renal failure in most patients treated.

[Spinal brucellosis. 4 years of experience]

The Authors retrospectively studied 17 patients who have been admitted to the Infectious Diseases Clinic of Coimbra University Hospital during a four year period and whose final diagnosis was brucellar spondylitis. Clinical, epidemiological, laboratory and imaging features are analyzed, as well as those related to the therapeutic schedules and outcome. Females were more often affected (70.58%) and the mean age was 53.35 +/- 13.82 years. Lumbar spine was most frequently involved and an unusual elevated incidence of paravertebral soft tissue swelling was noticed (23.52%). Two patients were also suffering from neurobrucellosis (11.76%). The preferred therapeutic schedule was rifampin and doxycycline and surgery was performed in one patient. Finally, several comments are made regarding basically the incidence, laboratory and imaging diagnosis, therapeutic aspects and evolution of the disease. The imaging similarities and differences between tuberculous, pyogenic and brucellar spondylitis are briefly approached.