Studies to Assess the Utility of Serum Neurofilament Light Chain as a Biomarker in Chemotherapy-Induced Peripheral Neuropathy

Chemotherapy-induced peripheral neuropathy (CIPN) is one of the most common and disabling dose-limiting toxicities of chemotherapy. We report here the results of two separate non-interventional studies (49 patients), which evaluated blood neurofilament light chain (NfL) as a biomarker of CIPN in breast cancer patients treated with paclitaxel. All patients underwent a standard treatment protocol that was established independently of the present studies. NfL was measured in serum using an ultrasensitive single-molecule array and compared with the self-administered European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-CIPN twenty-item scale (CIPN20) and Total Neuropathy Score clinical version (TNSc), a clinician-reported measure of neuropathy progression. The TNSc increased with cumulative dose compared with baseline, and the NfL concentrations were also strongly associated with the cumulative dose of chemotherapy. The analysis showed a correlation between TNSc and NfL. Both TNSc and NfL showed weak to moderate associations with CIPN20 subscores, with a better association for the CIPN20 sensory compared with motor and autonomic subscores. Data from the two studies provide evidence that serum NfL has the potential to be used as a biomarker to monitor and mitigate CIPN. However, studies with additional patients planned in the ongoing clinical trial will determine the universal application of NfL as a biomarker in CIPN.

Using Clinical Scales and Digital Measures to Explore Falls in Patients with Lewy Body Dementia

Introduction

PRESENCE was a phase 2 clinical trial assessing the efficacy of mevidalen, a D1 receptor positive allosteric modulator, for symptomatic treatment of Lewy body dementia (LBD). Mevidalen demonstrated improvements in motor and non-motor features of LBD, global functioning, and actigraphy-measured activity and daytime sleep. Adverse events (AEs) of fall were numerically increased in mevidalen-treated participants.

Methods

A subset of PRESENCE participants wore a wrist actigraphy device for 2-week periods pre-, during, and posttreatment. Actigraphy sleep and activity measures were derived per period and analyzed to assess for their association with participants' reports of an AE of fall. Prespecified baseline and treatment-emergent clinical characteristics were also included in the retrospective analysis of falls. Independent-samples t test and χ² test were performed to compare the means and proportions between individuals with/without falls.

Results

A trend toward more falls was observed with mevidalen treatment (31/258 mevidalen-treated vs. 4/86 in placebo-treated participants: p = 0.12). Higher body mass index (BMI) (p < 0.05), more severe disease measured by baseline Movement Disorder Society-Unified Parkinson's Disease Rating Scale (MDS-UPDRS) part II (p < 0.05), and a trend toward improved Alzheimer's Disease Assessment Scale-Cognitive Subscale 13 (ADAS-Cog₁₃) (p = 0.06) were associated with individuals with falls. No statistically significant associations with falls and treatment-emergent changes were observed.

Conclusion

The association of falls with worse baseline disease severity and higher BMI and overall trend toward improvements on cognitive and motor scales suggest that falls in PRESENCE may be related to increased activity in mevidalen-treated participants at greater risk for falling. Future studies to confirm this hypothesis using fall diaries and digital assessments are necessary.

Evaluating the Use of Digital Biomarkers to Test Treatment Effects on Cognition and Movement in Patients with Lewy Body Dementia

Background:

PRESENCE was a Phase 2 trial assessing mevidalen for symptomatic treatment of Lewy body dementia (LBD). Participants received daily doses (10, 30, or 75 mg) of mevidalen (LY3154207) or placebo for 12 weeks.

Objective:

To evaluate if frequent cognitive and motor tests using an iPad app and wrist-worn actigraphy to track activity and sleep could detect mevidalen treatment effects in LBD.

Methods:

Of 340 participants enrolled in PRESENCE, 238 wore actigraphy for three 2-week periods: pre-, during, and post-intervention. A subset of participants (n = 160) enrolled in a sub-study using an iPad trial app with 3 tests: digital symbol substitution (DSST), spatial working memory (SWM), and finger-tapping. Compliance was defined as daily test completion or watch-wearing ≥23 h/day. Change from baseline to week 12 (app) or week 8 (actigraphy) was used to assess treatment effects using Mixed Model Repeated Measures analysis. Pearson correlations between sensor-derived features and clinical endpoints were assessed.

Results:

Actigraphy and trial app compliance was > 90% and > 60%, respectively. At baseline, daytime sleep positively correlated with Epworth Sleepiness Scale score (p < 0.01). Physical activity correlated with improvement on Movement Disorder Society –Unified Parkinson Disease Rating Scale (MDS-UPDRS) part II (p < 0.001). Better scores of DSST and SWM correlated with lower Alzheimer Disease Assessment Scale –Cognitive 13-Item Scale (ADAS-Cog₁₃) (p < 0.001). Mevidalen treatment (30 mg) improved SWM (p < 0.01), while dose-dependent decreases in daytime sleep (10 mg: p < 0.01, 30 mg: p < 0.05, 75 mg: p < 0.001), and an increase in walking minutes (75 mg dose: p < 0.001) were observed, returning to baseline post-intervention.

Conclusion:

Devices used in the LBD population achieved adequate compliance and digital metrics detected statistically significant treatment effects.

Species distribution and susceptibility profile to fluconazole, voriconazole and MXP-4509 of 551 clinical yeast isolates from a Romanian multi-centre study

This is the first multi-centre study regarding yeast infections in Romania. The aim was to determine the aetiological spectrum and susceptibility pattern to fluconazole, voriconazole and the novel compound MXP-4509. The 551 isolates were identified using routine laboratory methods, matrix-assisted laser desorption ionisation time-of-flight mass spectrometry (MALDI-TOF MS) and DNA sequence analysis. Susceptibility testing was performed using the European Committee for Antimicrobial Susceptibility Testing (EUCAST) method and breakpoints. The yeasts originated from superficial infections (SUP, 51.5 %), bloodstream infections (BSI, 31.6 %) and deep-seated infections (DEEP, 16.9 %), from patients of all ages. Nine genera and 30 species were identified. The 20 Candida species accounted for 94.6 % of all isolates. C. albicans was the overall leading pathogen (50.5 %). Lodderomyces elongisporus is reported for the first time as a fungaemia cause in Europe. C. glabrata and Saccharomyces cerevisiae, as well as the non-Candida spp. and non-albicans Candida spp. groups, showed decreased fluconazole susceptibility (<75 %). The overall fluconazole resistance was 10.2 %. C. krusei accounted for 27 of the 56 fluconazole-resistant isolates. The overall voriconazole resistance was 2.5 % and was due mainly to C. glabrata and C. tropicalis isolates. Fluconazole resistance rates for the three categories of infection were similar to the overall value; voriconazole resistance rates differed: 4 % for BSI, 3.2 % for DEEP and 1.4 % for SUP. The antifungal activity of MXP-4509 was superior to voriconazole against C. glabrata and many fluconazole-resistant isolates. There was a large percentage of non-albicans Candida isolates. A large part of the high fluconazole resistance was not acquired but intrinsic, resulting from the high percentage of C. krusei.

The assessment between IL-6 and IL-8 and anthropometric status in malnourished children

PURPOSE

To evaluate the correlations between the pro-inflammatory interleukins IL-6 and IL-8 and the anthropometric measurements in malnourished vs. non-malnourished children.

PATIENTS AND METHODS

We have examined 219 children from Pediatric Clinic I, University of Medicine and Pharmacy of Tirgu Mures, Romania, during January 1, 2012-March 1, 2013 and divided according to Body Mass Index (BMI kg/m(2)) in the following two groups: 164 with normal nutritional status - control group (BMI between -2SD and +2SD), and 55 children with malnutrition (BMI <-2SD). All the children were evaluated anthropometric: BMI, weight for age (W/A), height for age (H/A), mid-upper-arm circumference (MUAC), tricipital skinfold (TSF) and paraclinical: IL-6 and IL-8 levels.

RESULTS

From 219 children, 25.1% were malnourished. The mean age was 5.16 years in malnourished. IL-6 and IL-8 mean levels were 2.54 pg/mL, respectively 6.83 pg/mL in malnourished and 6.02 pg/mL, respectively 9.06 pg/mL in non-malnourished. By statistically comparing IL-6 in malnourished group vs. control group, we observed decreased values (p<0.0001) and also significantly lower values for IL-8. We also obtained statistical differences between the two groups in BMI, W/A, MUAC and TSF. The BMI SD have an increasing trend line, from -4SD in newborn malnourished to -2SD in near 18-year-old malnourished; the trend line had only a slight ascension in non-malnourished children.

CONCLUSIONS

The interleukin levels and BMI, W/A, MUAC and TSF are significantly lower in malnourished children than in non-malnourished. This functional impairment may be involved in the malnutrition to develop a specific immune response in these children.

Critical period of weed control in aerobic rice

Critical period of weed control is the foundation of integrated weed management and, hence, can be considered the first step to design weed control strategy. To determine critical period of weed control of aerobic rice, field trials were conducted during 2010/2011 at Universiti Putra Malaysia. A quantitative series of treatments comprising two components, (a) increasing duration of weed interference and (b) increasing length of weed-free period, were imposed. Critical period was determined through Logistic and Gompertz equations. Critical period varied between seasons; in main season, it started earlier and lasted longer, as compared to off-season. The onset of the critical period was found relatively stable between seasons, while the end was more variable. Critical period was determined as 7–49 days after seeding in off-season and 7–53 days in main season to achieve 95% of weed-free yield, and 23–40 days in off-season and 21–43 days in main season to achieve 90% of weed-free yield. Since 5% yield loss level is not practical from economic view point, a 10% yield loss may be considered excellent from economic view point. Therefore, aerobic rice should be kept weed-free during 21–43 days for better yield and higher economic return.

Millimeter wave carrier generation based on a double-Brillouin-frequency spaced fiber laser

An all-optical generation of a millimeter wave carrier from a multiwavelength Brillouin-erbium fiber laser is presented. Four-channel output with spacing of about 21.5 GHz is generated from the fiber laser by controlling the gain in the cavity. A dual-wavelength signal with spacing correspondent to six orders of Brillouin frequency shift is obtained by suppressing the two channels at the middle. Heterodyning these signals at the high-speed photodetector produces a millimeter wave carrier at 64.17 GHz. Temperature dependence characteristic of Brillouin frequency shift realize the flexibility of generated millimeter wave frequency to be tuned at 6.6 MHz/ °C.

The association between the embolic load and atrial size in acute pulmonary embolism

BACKGROUND

Early identification by computed tomography pulmonary angiography (CTPA) of patients with acute pulmonary embolism (PE) who have signs associated with a high embolic burden would be highly desirable.

OBJECTIVES

To investigate whether an increased obstruction of the pulmonary vasculature is associated with reduced left atrial (LA) and increased right atrial (RA) areas.

METHODS

We retrospectively analyzed a consecutive series of CTPA studies of 137 patients with acute PE and 38 controls without PE between October 2004 and March 2006. Left and right atrial areas and longitudinal and short axis diameters were measured and correlated with the pulmonary arterial obstruction index (PAOI) divided into tertiles (obstruction of < 12.5%, 12.5%-42.5% and ≥ 42.5%).

RESULTS

There was a significant negative age- and gender-adjusted correlation between the PAOI and LA measurements, particularly the LA area (r = -0.259) and the LA short axis diameter (r = -0.331). All RA measurements had positive correlations (RA area, r = 0.279; RA short axis diameter, r = 0.313). The LA/RA area ratio correlated negatively with the PAOI (r = -0.447). All above-mentioned correlations had P < 0.002. All the LA measurements were the largest in the controls and gradually decreased with higher PAOIs. A receiver operating characteristic curve analysis demonstrated that the RV/LV diameter, LA/RA area and LA/RA short axis diameter ratios had comparable discriminative ability for higher PAOI tertiles.

CONCLUSIONS

The higher the clot load in the pulmonary arteries, the smaller the LA area and the larger the RA area. Atrial area measurements by CTPA may serve as a real-time parameter in assessing the severity of PE upon diagnosis.

[Prevalence of tuberculosis in Mureş County, Romania, 2006-2008]

The aim of this study is analysis of tuberculosis prevalence in Mures county for a period of three years (2006-2008).

MATERIAL AND METHOD

We monitored the prevalence of tuberculosis cases in the Mureş area recorded at Tg. Mureş TB Dispensary, the new cases and readmitted cases, chronic or abandonment, separately for children and adults, evolving for 2006-2008, data compared with national registration.

RESULTS

From 2006 to 2008, frequency of TB illness in our area decreased instead of the share of patients with positive results (BK+) which have increased, associated with an amplified risk. In our study the assessment during the three years showed a decrease of the total number of TB cases, instead of increased frequency of new cases of acute than those of chronic, increased cases of adults against children and cases of failed healing. Number of new cases of TB in Mureş urban areas, by years, showed the same decreasing trend for cities monitored, except Tg. Mureş where the number of new cases recorded in 2008 was higher than in 2006.

CONCLUSION

TB control programs in order to be effective, must be conducted throughout the all country, to be permanent, to the satisfaction of the population and to integrated structure of community health.

All-optical generation of a 21 GHz microwave carrier by incorporating a double-Brillouin frequency shifter

An all-optical generation of a microwave carrier at 21 GHz that incorporates a double-Brillouin frequency shifter is presented. The frequency shift of approximately 21 GHz is achieved by generating the second-order Brillouin Stokes signal from the Brillouin pump. This is accomplished through the circulation and isolation of its first-order Stokes signal in the optical fiber. The Brillouin pump signal is heterodyned with its second-order Brillouin Stokes signal at a high-speed photodetector, and the output beating frequency is equal to the offset between these two signals. The generated microwave carrier is measured at 21.3968 GHz, and the carrier phase noise as low as -58.67 dBc/Hz is achieved.

Periodontitis-specific molecular signatures in gingival crevicular fluid

BACKGROUND AND OBJECTIVE

Periodontitis is currently diagnosed almost entirely on gross clinical manifestations that have been in situ for more than 50 years without significant improvement. The general objective of this study was, therefore, to evaluate whether mid-infrared spectroscopy can be used to identify disease-specific molecular alterations to the overall biochemical profile of tissues and body fluids.

MATERIAL AND METHODS

A total of 190 gingival crevicular fluid samples were obtained from periodontitis (n = 64), gingivitis (n = 61) and normal sites (n = 65). Corresponding infrared absorption spectra of gingival crevicular fluid samples were acquired and processed, and the relative contributions of key functional groups in the infrared spectra were analysed. The qualitative assessment of clinical relevance of these gingival crevicular fluid spectra was interpreted with the multivariate statistical analysis-linear discriminant analysis.

RESULTS

Using infrared spectroscopy, we have been able to identify four molecular signatures (representing vibrations in amide I, amide II/tyrosine rings and symmetric and asymmetric PO2- stretching vibrations of phosphodiester groups in DNA) in the gingival crevicular fluid of subjects with periodontitis or gingivitis and healthy control subjects that clearly demarcate healthy and diseased periodontal tissues. Furthermore, the diagnostic accuracy for distinction between periodontally healthy and periodontitis sites revealed by multivariate classification of gingival crevicular fluid spectra was 98.4% for a training set of samples and 93.1% for a validation set.

CONCLUSION

We have established that mid-infrared spectroscopy can be used to identify periodontitis-specific molecular signatures in gingival crevicular fluid and to confirm clinical diagnoses. Future longitudinal studies will assess whether mid-infrared spectroscopy represents a potential prognostic tool, recognized as key to advancement of periodontics.

In vivo determination of multiple indices of periodontal inflammation by optical spectroscopy

BACKGROUND AND OBJECTIVE

Visible, near-infrared (optical) spectroscopy can be used to measure regional tissue hemodynamics and edema and therefore may represent an ideal tool with which to study periodontal inflammation in a noninvasive manner. The study objective was to evaluate the ability of optical spectroscopy to determine simultaneously multiple inflammatory indices (tissue oxygenation, total tissue hemoglobin, deoxyhemoglobin, oxygenated hemoglobin and tissue edema) in periodontal tissues in vivo.

MATERIAL AND METHODS

Spectra were obtained, processed and evaluated from healthy, gingivitis and periodontitis sites (n = 133) using a portable optical, near-infrared spectrometer. A modified Beer-Lambert unmixing model that incorporates a nonparametric scattering loss function was used to determine the relative contribution of each inflammatory component to the overall spectrum.

RESULTS

Optical spectroscopy was harnessed to generate complex inflammatory profiles of periodontal tissues. Tissue oxygenation at periodontitis sites was significantly decreased (p < 0.05) compared to sites with gingivitis and healthy controls. This was largely the result of an increase in deoxyhemoglobin in the periodontitis sites compared with healthy (p < 0.01) and gingivitis (p = 0.05) sites. Tissue water content per se showed no significant difference between the sites, but a water index associated with tissue electrolyte levels and temperature differed significantly between periodontitis sites and both healthy and gingivitis sites (p < 0.03).

CONCLUSION

This study established that optical spectroscopy can simultaneously determine multiple inflammatory indices directly in the periodontal tissues in vivo. Visible, near-infrared spectroscopy has the potential to be developed into a simple, reagent-free, user-friendly, chairside, site-specific, diagnostic and prognostic test for periodontitis.

[Cumulative antibiogram--means of following local resistance phenomena based on material gathered in the laboratory of microbiology]

The cumulative antibiogram (CA) represents a report which summarizes the susceptibility of commonly isolated microorganisms to usual antibiotics in a defined period of time. We have evaluated the local resistance data during the year 2007 by generating CA from the bacteriology laboratory's database in Mures County Emergency Clinical Hospital for 3 categories of microorganisms: Gram-positive cocci, Gram-negative enteric rods and non-fermenters. A total of 1382 individual antibiotic susceptibility reports were analysed. Gram-positive cocci were susceptible 100% to glycopeptides and oxazolidinones. Fifty percent of S. aureus isolates were methicillin-resistant. More than 90% of S. aureus and MRSA (methicillin-resistant S. aureus) isolates were susceptible to trimethoprim-sulfamethoxazole. Gram-negative enteric rods were 100% susceptible to carbapenems. The susceptibility of Escherichia coli and Klebsiella pneumoniae to broad spectrum cephalosporins was 72% and 26%, respectively. The activity of carbapenems against Acinetobacter spp. and Pseudomonas aeruginosa was 43% and 35%, respectively. Colistin was active in 100% of the isolated nonfermenters. CA is a useful tool for evaluation of local resistance data but careful interpretation of generated data is required in order to avoid under- or overestimation of resistance.

[Bacterial etiology of the conditions associated with bacteremia/septicemia during the years 2006-2007]

PURPOSE

Evaluation of the etiology of bacterial diseases associated with bacteremia/ sepsis in the Emergency County Hospital of Tg. Mureş during 2006-2007.

MATERIALS AND METHODS

Blood samples of 684 patients hospitalized in Emergency County Hospital of Tg. Mureş during January 2006 - December 2007 were analyzed. The isolated germs have been identified according to standard methods. The blood culture results were centralized and processed in electronic databases.

RESULTS

In 2006 and 2007 the frequency of identified germs from blood cultures remained unchanged: the predominant germs are coagulase-negative staphylococci, followed by enterobacteria (Klebsiella spp prevailing), S. aureus (mostly methicillin-resistant (MRSA)) and other bacteria.

CONCLUSIONS

The main bacteria isolated from blood culture are staphylococci and enterobacteria. In medical sections undertaking invasive procedures, the infections with methicillin-resistant staphylococci are common.

[Intestinal parasitic diseases in children]

PURPOSE

To compare the incidence of intestinal parasitosis between children with residence in urban and rural areas: to compare the efficacy of parasitologic diagnostic methods.

MATERIALS AND METHODS

In our study we included two lots of children. The first lot consisted in 74 children from rural areas from which we collected 44 samples of feces and 55 samples for the "Scotch tape" test. The second lot consisted in 214 children from urban areas from which we collected 44 samples of feces. We examined each sample of feces by three different methods. The study was performed between April to June 2006.

RESULTS

The incidence of intestinal parasitosis increases in children from urban areas towards rural areas, and in children between 5 and 10 years. Ascariasis is the most frequent disease in both urban and rural areas. By examination of each fecal sample by three different methods, the number of positive cases increased.

CONCLUSIONS

The residence in rural areas and age between 5 to 10 years are risk factors for intestinal parasitosis. The "Scotch tape" test was more efficient in Enterobius vermicularis infection than the methods performed from feces. We recommend using at the same time three diagnostic methods for feces examination to improve the diagnostic sensibility.

[Re-emergent etiologies: Clostridium difficile]

Clostridium difficile-associated disease (CDAD) can range from uncomplicated diarrhea to sepsis and even death. CDAD rates and severity are increasing, possibly due to a new strain. Transmission of C. difficile occurs primarily in health care facilities via the fecal-oral route following transient contamination of the hands of health care workers and patients; contamination of the patient care environment also plays an important role. Education of hospital staff appropriate diagnostic testing, early treatment, and measures for preventing spread of the pathogen could lead to decreasing the morbidity and mortality rates.

Diagnosis of intrathoracic lesions: are sequential fine-needle aspiration (FNA) and core needle biopsy (CNB) combined better than either investigation alone?

AIM

To assess the diagnostic accuracy of sequential computed tomography (CT)-guided percutaneous fine-needle aspiration (FNA) and core-needle biopsy (CNB) in comparison with FNA and CNB performed separately for diagnosing intrathoracic lesions.

SUBJECTS AND METHODS

Five hundred and eighty-two consecutive patients with thoracic lesions who underwent same-session sequential CT-guided FNA and CNB procedures were studied. The final diagnosis, which was achieved by either agreement of percutaneous procedures with clinical follow-up, bronchoscopy or thoracotomy was available for all cases. The diagnostic yield of the combined FNA+CNB procedures was compared with that of each alone.

RESULTS

Adequate samples were obtained in 541 (93%) of FNAs and 513 (88%) of CNBs. Of 582 lesions, 419 (72%) were malignant and 163 (28%) were benign. For malignant lesions, the sensitivity, specificity and accuracy of the procedures were: 376/419 (89.7%), 136/163 (83.4%), and 88% for FNA; 317/419 (75.6%), 138/163 (84.7%), and 78% for CNB; 400/419 (95.5%), 154/163 (94.5%), and 95% for FNA+CNB. The sequential procedures showed significantly better sensitivity, specificity and accuracy compared with either FNA or CNB separately (p<0.003). For the 163 benign lesions, 76 (47%) had a specific benign pathological diagnosis. The diagnosis was obtained in 16/76 (21%) by FNA, in 54/76 (71%) by CNB, and in 60/76 (79%) by FNA+CNB. There was no significant difference between the results of the sequential procedures and CNB alone (p>0.05).

CONCLUSIONS

Sequential FNA and CNB improve the diagnostic accuracy of percutaneous CT-guided procedures in malignant lesions. There was only mild improvement, which was not statistically significant, for the diagnosis of benign specific lesions by the sequential procedures compared with the yield of CNB alone.

Integration of microfluidics with biomedical infrared spectroscopy for analytical and diagnostic metabolic profiling

We describe how infrared spectroscopy of dry films (IRDF) can provide diagnostic information, and how we expect integration with laminar fluid diffusion interface (LFDI) sample pre-processing to generate new analytical and diagnostic tests. LFDI pre-processing provides sample clean-up and analyte separation. The sensitivity of IRDF to certain analytes is enhanced through the depletion of sample constituents that otherwise obscure relevant spectral features, permitting the deposition of films with larger sample volumes and, hence, of greater effective optical pathlength for the targeted analytes. An integrated LFDI-IRDF technology holds promise both as a method for rapid point-of-care quantitative analysis of biological fluids and as the engine of discovery for a wide range of novel diagnostic methods based upon metabolic profiling. In particular, successful integration will provide a versatile and cost effective technology platform that will allow for the accurate quantification of low-concentration analytes that are otherwise inaccessible and will provide the basis for diagnostic and prognostic methods that would otherwise be impossible. The specific question addressed by the proof-of-concept study summarised here is whether the spectra of LFDI processed samples can provide analytical methods that are more accurate than otherwise possible without LFDI pre-processing. The enrichment of serum creatinine is accomplished, with subsequent enhancement of its spectral contribution permitting quantification of this clinically important analyte beyond that achievable with no pre-processing. Finally, to illustrate the potential in diagnostic applications, two recently initiated studies are outlined, one involving chronic kidney disease and the other for chronic and acute coronary artery disease.

Increased local matrix metalloproteinase-8 expression in the periodontal connective tissues of smokers with periodontal disease

Matrix metalloproteinase (MMP)-8 has been associated with the progression of periodontitis, a common inflammatory disease of the supporting structures of the teeth, and with other degradative diseases. Tobacco smokers are at high risk of developing periodontitis that may progress more rapidly and respond poorly to treatment. Therefore, MMP-8 expression was determined by immunofluorescence staining in 60 random, computer-selected fields in the excised periodontal tissues of smokers and non-smokers, balanced for age, gender, and periodontal status. Immunofluorescence intensity, representing MMP-8 expression, in the periodontal tissues of smokers (30 fields from 6 subjects, mean 1154+/-124 units) was significantly higher than that in the periodontal tissues of non-smokers (30 fields from 6 subjects, mean 817+/-60 units; p < 0.05). Serum MMP-8 concentrations were measured by ELISA and compared in a larger group of smokers (n = 20) and age- and gender-balanced non-smokers (n = 20). Systemic MMP-8 concentrations in smokers and non-smokers were not significantly different (p > 0.05). A local tobacco-related increase in MMP-8 burden may contribute to periodontal disease progression in tobacco smokers. This finding may also have relevance to other tobacco-induced inflammatory diseases, such as vascular and pulmonary diseases.

CACNA1C polymorphisms are associated with the efficacy of calcium channel blockers in the treatment of hypertension

Retrospective pharmacogenetic analysis was performed on 120 Caucasian subjects. Subjects were obtained in collaboration with the Estonian Genome Project and Egeen Inc. (CA, USA), who provided blinded medical record and genetic data to the researchers, respectively. Subjects selected from the Estonian Genome Project had a diagnosis of hypertension confirmed by at least two blood pressure measurements and multiple follow-up measurements for assessing calcium channel blocker antihypertensive treatment outcome. Treatment outcome was scored positive if at least three follow-up blood pressure measurements were nonhypertensive and no more than one follow-up measurement was hypertensive (>140/90). The genotypes of 62 single nucleotide polymorphisms (SNPs) in the calcium channel, voltage-dependent, L type, α 1C subunit (CACNA1C) gene were obtained for each subject from a blood sample. Univariate analyses with multiple test correction were conducted using family-wise error rate and false discovery rate methods. Three SNPs in CANCA1C had significant associations with antihypertensive outcome, combining to yield a positive treatment outcome of less than 15 to 80%.

Tobacco-induced alterations to the Fourier-transform infrared spectrum of serum

Infrared (IR) spectroscopy can distinguish differences in the characteristics of diverse molecules by using infrared radiation to probe chemical bonds. Consequently, alterations to the molecular characteristics of tissues and body fluids that help define specific pathological processes and conditions can be identified by IR spectroscopy. This study analyzed the molecular spectrum of cotinine by IR spectroscopy and determined tobacco-induced alterations to the IR profile of serum to establish whether these alterations can differentiate smokers and nonsmokers. The IR spectra of serum samples obtained from 20 smokers and 25 nonsmokers were captured using a FTS-40 IR spectrometer. Linear discriminant analysis method was used to partition the samples into smoker and nonsmoker groups according to the discriminatory patterns in the data and into a validation set to test the accuracy of the trained algorithm in distinguishing smokers and nonsmokers. Cotinine molecules were shown to exhibit a characteristic IR absorption spectrum. Several differences in the sera spectra of the two groups were observed, including an overall shift in the secondary structure of serum proteins favoring increased beta-sheet content in smokers. The overall accuracy of the training and validation sets was 96.7%, and 82.8%, respectively. The identification of specific absorption peaks for tobacco-induced alterations to the IR molecular profile of serum permits the development of an IR spectroscopy technique that can be used to differentiate smokers from nonsmokers. This further extends the utility of IR spectroscopy as a rapidly emerging tool in the field of molecular biodiagnostics.

Alpha-interferon does not increase the efficacy of 5-fluorouracil in advanced colorectal cancer

Two meta-analyses were conducted to quantify the benefit of combining alpha-IFN to 5FU in advanced colorectal cancer in terms of tumour response and survival. Analyses were based on a total of 3254 individual patient data provided by principal investigators of each trial. The meta-analysis of 5FU +/- LV vs. 5FU +/- LV + alpha-IFN combined 12 trials and 1766 patients. The meta-analysis failed to show any statistically significant difference between the two treatment groups in terms of tumour response or survival. Overall tumour response rates were 25% for patients receiving no alpha-IFN vs. 24% for patients receiving alpha-IFN (relative risk, RR = 1.02), and median survivals were 11.4 months for patients receiving no alpha-IFN vs. 11.5 months for patients receiving alpha-IFN (hazard ratio, HR = 0.95). The meta-analysis of 5FU + LV vs. 5FU + alpha-IFN combined 7 trials, and 1488 patients. This meta-analysis showed an advantage for 5FU + LV over 5FU + alpha-IFN which was statistically significant in terms of tumour response (23% vs. 18%; RR = 1.26;P = 0.042), and of a borderline significance for overall survival (HR = 1.11;P = 0.066). Metastases confined to the liver and primary rectal tumours were independent favourable prognostic factors for tumour response, whereas good performance status, metastases confined to the liver or confined to the lung, and primary tumour in the rectum were independent favourable prognostic factors for survival. We conclude that alpha-IFN does not increase the efficacy of 5FU or of 5FU + LV, and that 5FU + alpha-IFN is significantly inferior to 5FU + LV, for patients with advanced colorectal cancer.

Phase I and pharmacokinetic study of PKC412, an inhibitor of protein kinase C

PURPOSE

N-Benzoyl staurosporine (PKC412) is a protein kinase C inhibitor with antitumor activity in laboratory models. We determined the toxicity of oral PKC412 administered daily for repeat cycles of 28 days.

PATIENTS AND METHODS

Thirty-two patients with advanced solid cancers were treated at seven dose levels (12.5 to 300 mg daily) for a total of 68 cycles.

RESULTS

The most frequent treatment-related toxicities were nausea, vomiting, fatigue, and diarrhea. At the two top dose levels (225 and 300 mg/d), 15 of 16 patients experienced nausea/vomiting (common toxicity criteria [CTC], version 1), grade 2 in nine of 16 and grade 3 in three of 16 patients; and six of 16 patients developed CTC grade 2 diarrhea. After 1 month of treatment, there were significant reductions in circulating lymphocyte (P <.02) and monocyte (P <.01) counts in patients receiving doses > or = 100 mg/d. Nevertheless, only two patients developed myelosuppression (both grade 2). Of two patients with progressive cholangiocarcinoma, one attained stable disease lasting 4.5 months and one a partial response lasting 4 months. There was a linear relationship between PKC412 dose and area under the curve (0-24 hours) and maximum plasma concentration with marked interpatient variability. The estimated median elimination half-life was 1.6 days (range, 0.9 to 4.0 days), and a metabolite with a median half-life of 36 days was detected. Steady-state PKC412 plasma levels at the top three dose cohorts (150 to 300 mg) were five to 10 times the cellular 50% inhibitory concentration for PKC412 of 0.2 to 0.7 micromol/L.

CONCLUSION

PKC412 can be safely administered by chronic oral therapy, and 150 mg/d is suitable for phase II studies. The pharmacokinetics and lack of conventional toxicity indicate that pharmacodynamic measures may be additionally needed to optimize the drug dose and schedule.

Eosinophil influx into the airways in patients with exercise-induced asthma

Exercise-induced asthma is a common phenomenon, the mechanism of which is undetermined. Eosinophils have been suggested as playing a role in its occurrence. We studied the effect of exercise-induced asthma on the cellular and mediator composition of spontaneously obtained sputum. Twenty-five patients with bronchial asthma were investigated by studying sputum spontaneously obtained before and following challenge. One group with (n=9) and one without (n=9) exercise-induced asthma performed exercise challenge. A third group (n=7) performed methacholine challenge. The sputum was analysed using Giemsa staining for differential cell count, measuring eosinophil cationic proteins and mixtures of leukotrienes (D4, E4 and C4) in the liquid phase using ELISA. The group with exercise-induced asthma had a mean drop of 23.7+/-7.4% in FEV1, significantly (P=0.001) higher than the group without it. Following challenges, there were significant increases in sputum eosinophils only in the group with exercise-induced asthma (from 8.1+/-13.9% to 18.3+/-20.2%, P=0.0017) and not in control groups (from 0.9+/-0.9% to 1.5+/-15%) or in those who had methacholine challenge (from 23.6+/-27.2% to 22.3+/-23.8%). Eosinophil cationic proteins did not change significantly in any group. In the liquid phase of the sputum, the amount of leukotrienes increased following exercise in six of the seven patients with exercise-induced asthma in whom it was measured. The influx of eosinophils to the airway in patients who develop exercise-induced asthma can be partially explained by the leukotrienes in the airways of those patients.

PKC412--a protein kinase inhibitor with a broad therapeutic potential

The staurosporine derivative PKC412 was originally identified as an inhibitor of protein kinase C (PKC) and subsequently shown to inhibit other kinases including the kinase insert domain receptor (KDR) (vascular endothelial growth factor receptor, VEGF-R2), the receptor of platelet-derived growth factor, and the receptor for the stem cell factor, c-kit. PKC412 showed a broad antiproliferative activity against various tumor and normal cell lines in vitro, and was able to reverse the Pgp-mediated multidrug resistance of tumor cells in vitro. Exposure of cells to PKC412 resulted in a dose-dependent increase in the G2/M phase of the cell cycle concomitant with increased polyploidy, apoptosis and enhanced sensitivity to ionizing radiation. PKC412 displayed a potent antitumor activity as single agent and was able to potentiate the antitumor activity of some of the clinically used cytotoxins (Taxol and doxorubicin) in vivo. The combined treatment of PKC412 with loco-regional ionizing irradiation showed significant antitumor activity against tumors which are resistant to both ionizing radiation and chemotherapeutic agents (dysfunctional p53). The finding that PKC412 is an inhibitor of the VEGF-mediated cellular signaling via inhibition of KDR and PKC in vitro is consistent with the in vivo inhibition of VEGF-dependent angiogenesis in a growth factor implant model. Orally administered PKC412 also strongly inhibited retinal neovascularization as well as laser-induced choroidal neovascularization in murine models. In summary, PKC412 may suppress tumor growth by inhibiting tumor angiogenesis in addition to directly-inhibiting tumor cell proliferation via its effects on PKC and/or other protein kinases. PKC412 is currently in Phase I clinical trials for treatment of advanced cancer as well as for the treatment of ischemic retinopathy.

Induced sputum compared to bronchoalveolar lavage for evaluating patients with sarcoidosis and non-granulomatous interstitial lung disease

Bronchoalveolar lavage (BAL), an important tool for evaluating interstitial lung diseases (ILDs), has limited utility due to its invasiveness and the difficulty of performing it in clinically contraindicated patients. We compared BAL with the induced sputum (IS) technique to analyse cells and T lymphocytes in patients with sarcoidosis (SA) and non-granulomatous ILD (NG-ILD). Pulmonary function tests and BAL were performed by conventional methods. IS induction was done 20 sec after inhalation of 3.5% saline with an ultrasonic nebulizer. Giemsa-stained cytopreps were differentially counted. T lymphocyte subsets were analysed by flow activated cell sorter (FACS). Patients with NG-ILD had impaired total lung capacity (TLC). Transbronchial biopsy demonstrated lung fibrosis in NG-ILD and non-caseating granuloma in SA. The differential cell count in both groups demonstrated a significantly lower percentage of neutrophils and a significantly higher percentage of macrophages in BAL than in IS. The IS samples of patients with SA were significantly richer in metachromatic cells and eosinophils, but had a lower percentage of lymphocytes, compared to the BAL samples. The profiles of T cell subsets showed the same pattern, in both samples, in both groups. A CD4/CD8 ratio of 2.5 or greater had a sensitivity of 100% and a specificity of 81.2%, with a positive predictive value of 81.2% to distinguish SA from NG-ILD. IS is an effective non-invasive technique to identify CD4+ inflammation which distinguishes sarcoidosis from other NG-ILDs.

The protein kinase C inhibitor CGP41251 suppresses cytokine release and extracellular signal-regulated kinase 2 expression in cancer patients

Components of cell signaling pathways provide important targets for anticancer drugs. Protein kinase C (PKC) is a serine/threonine-specific kinase that regulates cell growth and differentiation. It is also implicated in tumor promotion. The staurosporine analogue CGP41251 is a PKC inhibitor, and it is currently in a Phase I clinical trial for treatment of advanced cancer. However, it is difficult to define its biological activity. We have used two approaches to measure the in vivo biological response to CGP41251: (a) sequential whole blood samples were taken from 27 patients before and during treatment and incubated with mitogen (PHA), and cytokine [tumor necrosis factor (TNF)-alpha and interleukin (IL)-6] release was measured ex vivo; and (b) peripheral blood lymphocytes were isolated from seven of these patients, and the levels of extracellular signal-regulated kinase 2 were measured by Western blotting. Response to PHA was significantly lowered during treatment (P < 0.001 for TNF-alpha production; P < 0.03 for IL-6). This was most evident at 7 and 28 days after the start of treatment in patients receiving higher doses (150-300 mg/day; P = 0.002 and P = 0.02, respectively, for TNF-alpha and P = 0.001 and P = 0.003, respectively, for IL-6 release). Whole blood cytokine production returned to pretreatment levels after drug administration ceased. The levels of extracellular signal-regulated kinase 2 were reduced by 50-97% during treatment in all seven patients tested. These results show for the first time that a PKC inhibitor can block in vivo signaling pathways in cancer patients. The assays we describe complement toxicity studies in selecting relevant doses for Phase II trial of novel agents, particularly when biological activity occurs at doses below those that cause obvious side effects.

Assessment of hazardous dust exposure by BAL and induced sputum

OBJECTIVES

BAL, an important tool in assessing occupational lung diseases, is unsuitable for screening programs, exposure evaluation, or monitoring hazardous dust because it is an invasive technique. The results of induced sputum (IS) analysis were compared with BAL and evaluated as a possible alternative.

METHODS

We compared BAL with IS analysis of 5 workers exposed to asbestos and 14 exposed to silica and hard metals. Pulmonary function tests and BAL were performed by conventional methods. IS induction was performed after a 20-min inhalation of 3.5% saline solution with an ultrasonic nebulizer. Giemsa-stained cytopreparations were differentially counted. T-lymphocyte subsets were analyzed by flow-activated cell sorter, and messenger RNA (mRNA) was transcribed by reverse transcriptase-polymerase chain reaction. Mineralogic particles were analyzed by scanning electron microscopy and polarizing light microscopy and quantified by an analyzer.

RESULTS

The percentage of neutrophils was significantly lower in BAL fluid than in IS specimens, whereas no differences were found in the percentage of lymphocytes and subsets profile. Asbestos fibers were found in BAL but not in IS samples from workers exposed to asbestos. Polarizing particles were found in both samples. Similar mineral elements were found in qualitative analysis by scanning electron microscopy. Quantitative studies showed similar size distribution with a small shift toward larger particles in sputum; mRNA showed the same cytokine profile.

CONCLUSIONS

A comparison of BAL and IS specimens in the evaluation of the study population yielded similar quantitative and qualitative results. Further research is needed to evaluate the hypothesis that IS, being a noninvasive technique, may be useful in monitoring exposed workers.

Accelerated silicosis with mixed-dust pneumoconiosis in a hard-metal grinder

We describe a fatal case of accelerated silicosis with a component of mixed-dust pneumoconiosis in a young hard-metal grinder that we believe is the first case of its kind in Israel and one of the rare cases reported worldwide. The patient's diagnosis was based on typical features: restrictive lung function, abnormal chest roentgenogram suggesting lung fibrosis, a history of exposure to silica and hard metals, bronchoalveolar lavage (BAL) fluid findings, and mineralogical studies. BAL cells showed an abundance of giant multinucleated macrophages. The CD4/CD8 ratio of T lymphocytes was 1.1, with a high percentage of CD8 and CD8/38 positive cells (37% suppressor/cytotoxic and 12% cytotoxic T lymphocytes, respectively). mRNA transcripts isolated from BAL cells were positive for interleukin-1 (IL-1) and transforming growth factor (TGF) Il-5, IL-2, and IL-10 but not for IL-6, IL-4, and interferon. Polarizing light microscopic studies of BAL and induced sputum cells showed polarizing particles, which are typical for silica. Mineralogical studies of electron microscopy performed on BAL fluid and on dust collected at the patient's workstation revealed silica particles as well as aluminum-titanium and other particles. The latter might have contributed to the patient's lung disease.

Percutaneous core cutting needle biopsy compared with fine-needle aspiration in the diagnosis of peripheral lung malignant lesions: results in 156 patients

BACKGROUND

The authors attempted to determine the utility of percutaneous core needle biopsy (PCNB) compared with fine-needle aspiration (FNA) in the diagnosis of peripheral lung carcinoma.

METHODS

A retrospective review was undertaken of 156 computed tomography (CT)-guided PCNBs and FNAs of malignant lung lesions between 1988-1996. Both CT-guided FNA and PCNB biopsies were performed sequentially at the same visit for each subject.

RESULTS

The authors reviewed 156 malignant lesions whose specific diagnosis was obtained by FNA in 133 cases (85.3%) and by PCNB in 121 cases (77.6%) (P < 0.05). PCNB confirmed the FNA diagnosis in 90 patients (57.7%), provided additional information in 17 patients (10.9%), and was less informative than FNA in 35 patients (22.4%), mostly those with nonsmall cell carcinoma. The PCNB was marginally superior to FNA only in cases of metastatic carcinoma. The only significant complication encountered was a 24% rate of pneumothorax, which is comparable to the reported rate for FNA alone-induced complications.

CONCLUSIONS

PCNB offers no substantial advantage over FNA in the evaluation of peripheral malignant lung lesions. Therefore, the authors recommend the use of FNA biopsy as the initial diagnostic procedure in all cases of suspected malignancy. The use of the PCNB technique is recommended when the diagnosis of malignancy by FNA is uncertain, or when a more detailed characterization of the lesion is required.

Additional information from percutaneous cutting needle biopsy following fine-needle aspiration in the diagnosis of chest lesions

OBJECTIVE

To determine the contribution of percutaneous cutting needle biopsy (PNB) subsequent to fine-needle aspiration (FNA) in the diagnosis of chest lesions.

DESIGN

A retrospective review of 220 patients who underwent CT-guided FNA followed immediately by PNB performed at our center between 1988 and 1995 was undertaken. Thirty-eight patients were excluded because FNA and/or PNB specimens were nondiagnostic, yielding a study group of 182 patients.

RESULTS

A diagnosis of malignancy was made in 141 (77.5%) and nonmalignancy in 41 (22.5%) cases. The yield of histospecific diagnosis due to FNA was marginally higher than PNB in malignant lesions (86.5% vs 78%, respectively). In contrast, PNB was superior to FNA for the histospecific diagnosis of benign lesions (87.8% for PNB vs 31.7% for FNA, p<0.00001) and lymphomas (88% for PNB vs 56% for FNA, p<0.05). In 58.8% of the patients with benign lesions and in 37.5% of the patients with lymphoma, PNB performances altered clinical management, either by avoiding further surgery or allowing specific medical treatment. Pneumothorax occurred in 24.7% of the cases but only five patients (2.7%) required hospitalization.

CONCLUSION

PNB is extremely effective for making a specific diagnosis in benign lesions compared with FNA. PNB does not increase the yield of histospecific diagnosis for malignant lesions except for the subset of lymphoma, where it seems to provide important additional information in many instances. We recommend that FNA be performed as the initial procedure, followed by PNB in cases of equivocal diagnosis of carcinoma, for lymphoma and for suspected benign lesions.

Pleural effusion as a presenting symptom of ovarian hyperstimulation syndrome

Pharmacological ovarian stimulation is an accepted technique for amplifying the normal process of follicular development and maturation. It has been in use for the past decade, especially in cases of infertility. Pleural effusion associated with ovarian hyperstimulation syndrome (OHSS), a complication of this therapy, may be more prevalent than is commonly accepted. Four young women presented to our department with dyspnoea caused by pleural effusion as a result of ovarian hyperstimulation syndrome (OHSS). The diagnosis of OHSS was based on a history of pharmacological ovarian stimulation, clinical and laboratory evidence of ovarian enlargement and exclusion of other potential causes of pleural effusion in young women, such as infections, malignancy, pulmonary embolism and collagen vascular diseases. The fluid characteristics in all cases were exudative, with low to normal LDH. All of these patients required fluid evacuation for symptomatic relief. Resolution was achieved with supportive measures and rest. Ovarian hyperstimulation syndrome may be common enough to warrant routine consideration in the differential diagnosis of pleural effusion in young women.

Role of double-stranded RNA-activated protein kinase in human hematological malignancies

The double-stranded RNA (dsRNA)-activated protein kinase (PKR) is one of many genes induced by IFN. The PKR sequentially undergoes autophosphorylation and activation on binding to dsRNA. Previous studies have shown that PKR may be an important factor in the regulation of viral and cellular protein synthesis. Recent studies suggest that PKR may function as a tumor suppressor gene. The role of PKR in various human leukemic cells was therefore investigated. PKR mRNA levels by reverse transcription-PCR, protein expression by Western blot and FACScan analysis, and activity by phosphorylation status were studied. The expression of a known inhibitor of PKR, p58, was also investigated at mRNA and protein levels. A total of 24 samples from normal mononuclear cells (MNCs), 26 samples of acute lymphoblastic leukemia, 26 samples of acute myelogenous leukemia, 32 samples of chronic lymphocytic leukemia, and 5 samples of hairy cell leukemia was investigated. Mean mRNA levels were increased in acute lymphoblastic leukemia and acute myelogenous leukemia and decreased in chronic lymphocytic leukemia compared to normal MNCs. The mRNA levels in hairy cell leukemia were similar to those of normal MNCs. PKR protein was detectable in normal MNCs and leukemic cell extracts, and on FACScan analysis, more than 70% of cells stained positive for PKR. PKR activity was detectable in all samples investigated and was enhanced 4-23-fold in the presence of the synthetic dsRNA, poly(I) x poly(C). Protein expression of a known PKR inhibitor, p58, was barely detectable in normal MNCs and leukemic cells, with high expression in the HeLa cell line. These findings provide no evidence to support the hypothesis that PKR acts as a tumor suppressor in human leukemic cells.

The effect of incentive spirometry and inspiratory muscle training on pulmonary function after lung resection

BACKGROUND

A predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 800 ml or 40% of predicted is a common criterion for exclusion of patients from lung resection for cancer. Usually, the predicted postoperative lung function is calculated according to a formula based on the number of lung segments that will be resected. Incentive spirometry and specific inspiratory muscle training are two maneuvers that have been used to enhance lung expansion and inspiratory muscle strength in patients with chronic obstructive pulmonary disease and after lung operation.

METHODS

Thirty-two patients with chronic obstructive pulmonary disease who were candidates for lung resection were randomized into two groups: 17 patients received specific inspiratory muscle training and incentive spirometry, 1 hour per day, six times a week, for 2 weeks before and 3 months after lung resection (group A) and 15 patients were assigned to the control group and received no training (group B).

RESULTS

Inspiratory muscle strength increased significantly in the training group, both before and 3 months after the operation. In group B, the predicted postoperative FEV1 value consistently underestimated the actual postoperative FEV1 by approximately 70 ml in the lobectomy subgroup and by 110 ml in the pneumonectomy subgroup. In group A, the actual postoperative FEV1 was higher than the predicted postoperative FEV1 by 570 ml in the lobectomy subgroup and by 680 ml in the pneumonectomy subgroup of patients.

CONCLUSIONS

In patients undergoing lung resection the simple calculation of predicted postoperative FEV1 underestimates the actual postoperative FEV1 by a small fraction. Lung functions can be increased significantly when incentive spirometry and specific inspiratory muscle training are used before and after operation.

Phase III randomized study to compare interferon alfa-2a in combination with fluorouracil versus fluorouracil alone in patients with advanced colorectal cancer

PURPOSE

To compare the efficacy and toxicity profiles of a combination of fluorouracil (5-FU) and recombinant human interferon alfa-2a ([IFN alpha 2a] Roferon-A; Hoffmann-LaRoche, Basel, Switzerland) versus 5-FU alone in the treatment of advanced colorectal cancer (ACC).

PATIENTS AND METHODS

A total of 245 previously untreated ACC patients were randomized to receive either IFN alpha 2a (9 million IU) subcutaneously (SC) three times weekly with 5-FU (750 mg/m2/d) by continuous intravenous (CIV) infusion on days 1 to 5 and then, after a 1-week hiatus, as a weekly IV bolus at the same dose (IFN/ 5-FU), or 5-FU alone at the same dose schedule (5-FU).

RESULTS

There were no significant differences between IFN/5-FU and 5-FU alone in the overall response rate (24% v 17%, P = .2), duration of response (median, 6.4 v 8.1 months), time to response (plateau at 3 months), time to progressive disease ([PD] median, 4.8 v 4.9 months), or survival duration (median, 13.9 v 13.2 months). Toxicity profiles were not statistically different except for constitutional symptoms, which were more frequent and more severe with IFN/5-FU. More patients interrupted treatment for adverse events (AEs) with IFN/ 5-FU (34%) than with 5-FU alone (21%) (P = .03). The number of deaths (mostly unrelated to drug treatment) during the study (8%) was similar with both regimens.

CONCLUSION

The combination IFN/5-FU produced a response rate, response duration, and survival duration similar to that of 5-FU alone. The addition of IFN to 5-FU in the doses and schedules used in this study did not provide any further benefit over 5-FU alone and cannot be recommended for patients with metastatic ACC. This study confirms the value of large prospective randomized clinical trials to determine the clinical value of regimens that emerge from smaller single-center phase II studies.

[Carinal, adenoid, cystic carcinoma mimicking bronchial asthma]

Bronchotracheal, adenoid, cystic carcinoma is a very rare tumor. Most of its symptoms relate to airway obstruction. We report a 45-year-old woman with a carinal, adenoid, cystic carcinoma who presented with symptoms suggestive of bronchial asthma 2 years prior to diagnosis. No inspiratory flow-volume curve was performed at that time and the patient was treated with inhalation of beta-2 agonists. Early diagnosis of adenoid, cystic carcinoma is important because appropriate surgical treatment results in an excellent prognosis.

N-methyl-D-aspartate (NMDA) receptors, mu and kappa opioid tolerance, and perspectives on new analgesic drug development

This laboratory perspective reviews the pharmagologic approaches that have been used in preclinical animal models to demonstrate the ability of competitive (LY274614) and noncompetitive (MK801 and dextromethorphan) N-methyl-D-aspartate (NMDA) receptor antagonists to attenuate or reverse the development of morphine tolerance. We provide additional data to support previous observations that these NMDA antagonists modulate morphine (mu) opioid tolerance but do not affect U50488H (kappa 1) opioid tolerance. A strategy, which utilizes efficacy as an NMDA receptor antagonist and clinical safety, provides the basis for a discussion of the clinical potential of dextromethorphan, ketamine, and felbamate as modulators of opioid tolerance in pain patients or opioid addicts. The potential use of NMDA receptor antagonists and nitric oxide synthase (NOS) inhibitors in neuropathic pain is also discussed.

The effect of caffeine on exercise-induced bronchoconstriction

The effect of caffeine on exercise-induced bronchoconstriction was examined in ten patients with bronchial asthma. Placebo and caffeine 3.5 mg/kg and 7 mg/kg were given two hours before exercise. Spirometry was taken at one and two hours following caffeine and at 5, 15, and 30 minutes following exercise. Caffeine significantly improved baseline FEV1 and prevented exercise-induced bronchoconstriction only at a dose of 7 mg/kg. Caffeine was well tolerated by the patients. These data suggest that only high doses of caffeine significantly prevent a postexercise drop in FEV1.

Use of luteinising hormone-releasing hormone agonist (leuprorelin) in advanced post-menopausal breast cancer: clinical and endocrine effects

Fifteen post-menopausal patients with advanced breast cancer were treated with the LH-RH agonist leuprorelin (D-leu6-des-gly10-Gn-RH-ethylamide) given in a dosage of 7.5 mg as a monthly subcutaneous depot injection, to assess the clinical activity and endocrine response to treatment. None of the 15 patients showed an objective response to treatment, although four patients had stable disease for at least 6 months. No toxicity was demonstrated. Endocrine effects after 4 weeks' treatment were as follows: mean levels of serum gonadotrophins fell to 10% of their pretreatment values; there were no significant changes in the levels of prolactin on treatment; there was a significant decrease in the levels of serum testosterone in 12 out of 14 patients; there were no significant changes in the levels of oestradiol, androstenedione and oestrone. The lowering of serum testosterone suggests that androgens in post-menopausal women may be partly produced by the ovaries, stimulated by LH and FSH. This fall in testosterone may explain why some post-menopausal breast cancer patients in other studies have been reported to respond to treatment with LH-RH agonists, as it would decrease the substrate for the peripheral synthesis of oestrogens.

Cytosine arabinoside in the management of recurrent leukaemia

A Phase II study of high dose cytosine arabinoside (ara-C) with different schedules in patients with recurrent acute myelogenous leukaemia (AML) and myeloid blast crisis of chronic myeloid leukaemia has been conducted at St. Bartholomew's Hospital. Ara-C was infused continuously for seven days at a dose of 100-200 mgs/m2 daily from day 1 with 1-2 g/m2 (3 h infusions) twice daily from day 2 for six days. Nineteen patients with acute myelogenous leukaemia and four patients with myeloid blast crisis of chronic myeloid leukaemia (CML) were treated. Complete remission was achieved in 4/19 patients with AML and in a further four patients an antileukaemic effect was observed. There were eight early deaths and three patients failed to show any response to therapy. All four patients with myeloid blast crisis of CML failed to respond to the treatment. Toxicity was considerable with gastro-intestinal and hepatotoxicity being the most serious problems. Pharmacokinetic studies revealed that mean basal levels achieved with continuous infusion prior to high-dose ara-C were 10(2) ng/ml and peak levels were of the order of 10(4) ng/ml. The considerable toxicity of the regimen, without clinical advantage over less intensive programmes, resulted in its termination.

The first clinical use of depot buserelin for advanced prostatic carcinoma

The agonist analogues of the gonadotrophin-releasing hormone now provide an alternate medical treatment of prostatic cancer. For effect repeated administration is required, either by five or six times daily intranasal or once daily subcutaneous treatment. There is an obvious disadvantage to such regimens in elderly patients who may have difficulty complying with therapy. In order to circumvent these difficulties, sustained release formulations of the agonist analogues have been synthesized. We report the first clinical use of a long-acting formulation of D-Ser (TBU)6-LHRH Ethylamide (buserelin) using a novel polymer material. Twelve symptomatic patients with previously untreated carcinoma of the prostate were treated with depot buserelin, administered once monthly. In all patients, depot buserelin suppressed serum testosterone into the range seen in castrate men at a rate equivalent to that provided by five times daily intranasal therapy. No significant increase in serum testosterone, luteinizing hormone or follicle-stimulating hormone concentrations occurred during the period of follow-up. Long-acting formulations of buserelin offer an advance in the management of prostatic cancer with agonist analogues of the gonadotrophin-releasing hormone.