Dabrafenib plus trametinib in unselected advanced BRAF V600-mut melanoma: a non-interventional, multicenter, prospective trial

OBJECTIVE

The efficacy of combined BRAF and MEK inhibition for BRAF V600-mutant melanoma in a broad patient population, including subgroups excluded from phase 3 trials, remains unanswered. This noninterventional study (DATUM-NIS) assessed the real-world efficacy, safety and tolerability of dabrafenib plus trametinib in Austrian patients with unresectable/metastatic melanoma.

METHODS

This multicenter, open-label, non-interventional, post-approval, observational study investigated the effectiveness of dabrafenib plus trametinib prescribed in day-to-day clinical practice to patients ( N  = 79) with BRAF V600-mutant unresectable/metastatic melanoma with M1c disease (American Joint Committee on Cancer staging manual version 7), ECOG > 1, and elevated serum lactate dehydrogenase (LDH). The primary endpoint was 6-, 12- and 18-month progression-free survival (PFS) rates. Secondary endpoints were median PFS, disease control rate and overall survival (OS).

RESULTS

The 6-, 12- and 18-month PFS rates were 76%, 30.6% and 16.2%, respectively. Subgroup analysis showed a significant PFS benefit in the absence of lung metastasis. The median PFS and OS were 9.1 (95% CI, 7.1-10.3) months and 17.9 (95% CI, 12.7-27.8) months, respectively. The 12- and 24-month OS rates were 62.7% and 26.8%, respectively. Subgroup analyses showed significant OS benefits in the absence of bone or lung metastasis and the presence of other metastases (excluding bone, lung, brain, liver and lymph nodes). Furthermore, S100 and Eastern Cooperative Oncology Group performance status (ECOG PS) showed a significant impact on survival. No new safety signals were observed.

CONCLUSION

Despite an unselected population of melanoma patients with higher M1c disease, ECOG PS > 1 and elevated LDH, this real-world study demonstrated comparable efficacy and safety with the pivotal phase 3 clinical trials for dabrafenib-trametinib.

[PIMS-a new pediatric challenge]

The boy of Egyptian origin was previously healthy. After a history of fever for 7 days, abdominal pain, vomiting and dry cough resistant to treatment with oral antibiotics, he was admitted to hospital. The clinical examination showed a slightly red throat, a tense abdomen and erythema. The blood tests revealed leukocytosis and significantly increased inflammatory parameters. The abdominal ultrasound showed thickened intestinal loops in the left lower abdomen and the echocardiography showed minimal mitral regurgitation, a narrow pericardial effusion lamella over both ventricles and normal coronary arteries. Accordingly, cardiac enzymes were elevated. The day after admission, the boy developed an increasing rash and was transferred to the PICU because of septic shock refractory to high volume resuscitation, requiring hemodynamic support with noradrenaline and noninvasive respiratory assistance. The initial testing for SARS-CoV‑2 on nasopharyngeal aspirates was negative twice; however, serum IgG antibodies were positive. Other viral and bacterial infections were excluded as the cause of the symptoms.The patient received IVIG, ASS, furosemide and methylprednisolone and the antibiotic treatment was continued. The dosage of the catecholamine could be reduced according to the patient's condition and the serially performed echocardiographic findings. The patient recovered in his general condition and was discharged from the PICU after 8 days. With the help of a detailed family history, we were able to figure out that the whole family, including the patient himself, had symptoms of a cold about 1 month earlier. Hence, SARS-CoV‑2 antibody tests carried out showed a positive result for all of them.Pediatric inflammatory multisystem syndrome (PIMS) can quickly lead to manifest shock symptoms, necessitating close monitoring. A PICU background is crucial to treat possibly occurring symptoms and complications. High-dose steroids are used therapeutically alongside supportive therapies.

Advances Using Single-Particle Trajectories to Reconstruct Chromatin Organization and Dynamics

Chromatin organization remains complex and far from understood. In this article, we review recent statistical methods of extracting biophysical parameters from in vivo single-particle trajectories of loci to reconstruct chromatin reorganization in response to cellular stress such as DNA damage. We look at methods for analyzing both single locus and multiple loci tracked simultaneously and explain how to quantify and describe chromatin motion using a combination of extractable parameters. These parameters can be converted into information about chromatin dynamics and function. Furthermore, we discuss how the timescale of recurrent encounter between loci can be extracted and interpreted. We also discuss the effect of sampling rate on the estimated parameters. Finally, we review a polymer method to reconstruct chromatin structure using crosslinkers between chromatin sites. We list and refer to some software packages that are now publicly available to simulate polymer motion. To conclude, chromatin organization and dynamics can be reconstructed from locus trajectories and predicted based on polymer models.

Towards effective phosphorus recycling from wastewater: quantity and quality

Precipitation in the Mg-Ca-NH3-PO4 system has been explored to improve understanding of likely phases recoverable from complex wastewaters. Over a range of Mg/Ca combinations (0-100%) and pH 5-11, at least seven identifiable crystalline phases could be precipitated from artificial wastewater including: struvite, hydroxylapatite, newberyite, brushite, merrilite/whitlockite, octocalcium phosphate, and monetite. This experimental study has outlined the physicochemical conditions required to produce various phosphate products from synthetic wastewater, and found that large differences exist between experimentally formed phases and thermodynamical predictions. Struvite formation is the most desirable precipitate for the recovery of phosphate based upon purity, growth characteristics, dewatering properties, phosphate removal efficiency, and its ability to simultaneously remove ammonia. This study has also demonstrated that in specific cases the preliminary precipitation of brushite is a possible means of decreasing calcium content such that subsequent struvite formation could achieve higher-purity. Utilising experimental results and information on current commodity prices, discussion on the choice of Mg and Ca sources for phosphorus recovery provides guidance on appropriate means to optimise the formation and yield of high quality cost-optimised products.

Feasibility of a multdisciplinary lung cancer videoconference between a peripheral hospital and a comprehensive cancer centre

OBJECTIVE

Treatment of lung cancer patients is changing rapidly and new treatment options have emerged in recent years. In 2007, to guarantee the best treatment procedure for lung cancer patients being treated in our peripheral hospital, we decided to introduce an interdisciplinary tumour videoconference between the Haemato-Oncological Day Hospital in Merano and the Comprehensive Cancer Centre Innsbruck. This retrospective analysis aims to describe the feasibility of such a conference.

PATIENTS AND METHODS

Two hundred and three patients with lung cancer treated at the peripheral hospital of Merano between May 2003 until May 2011 were retrospectively analysed. After introduction of the tumour videoconference in 2007, 54% (n = 110) of the patients in this cohort were discussed in the conference.

RESULTS

One hundred and four videoconferences were performed. Videoconference was feasible for 110 patients. Radiotherapeutic treatments were prescribed more frequently in patients from the conference group. Overall, major and minor treatment changes were undertaken in 7% (n = 8) and 18% (n = 20), respectively.

CONCLUSION

Interdisciplinary tumour videoconference is feasible between a peripheral hospital and a comprehensive cancer centre. Radiotherapeutic treatment was prescribed more frequently, suggesting that such a conference facilitates the access to cancer-centre-specific treatment modalities. Accordingly, tumour videoconference between a peripheral hospital and a cancer centre is to be recommend.

Randomized, double-blind comparison of 1 mg/L versus 5 mg/L methoxsalen bath-PUVA therapy for chronic plaque-type psoriasis

BACKGROUND

Bath-psoralen plus ultraviolet A (PUVA) radiation therapy is increasingly replacing oral PUVA because of its superior short- and long-term safety profile. Several investigations in recent years have led to a refinement of the bath-PUVA protocol; however, the optimal therapeutic concentration of methoxsalen in the bath water has as yet not been delineated.

OBJECTIVES

The therapeutic efficacy and tolerability of bath-PUVA by using two different dilutions of methoxsalen (1 mg/L vs 5 mg/L or 0.0001% vs 0.0005%) were compared in 46 patients with chronic plaque-type psoriasis in a prospective, randomized, double-blind study.

METHODS

Scores of the Psoriasis Area and Severity Index excluding psoriasis of the head (PASI(TUL)) and the Plaque Severity Index (PSI) were assessed at baseline and at biweekly intervals thereafter until (near)complete clearance or maximal improvement. In addition, methoxsalen plasma levels were determined immediately after the psoralen bath during the first week of treatment and treatment-related side effects were recorded throughout the entire study period.

RESULTS

The median baseline PASI(TUL) score decreased from 11.7 (7.5-32.8) to 3.3 (0.6-1.2) (-72%) in the 1 mg/L methoxsalen group and from 10.8 (6.6-20.7) to 1.4 (03.2) (-87%) in the 5 mg/L methoxsalen group (P < .01). The median baseline PSI score decreased from 9 (6-12) to 3.1 (0.6-10) (-66%) in the 1 mg/L methoxsalen group and from 9.3 (7.3-12) to 1.6 (0-3.6) (-83%) in the 5 mg/L methoxsalen group (P < .01). The median cumulative UVA exposure dose was 25.4 (5.3-81.5) J/cm2 for 5 mg/L methoxsalen and 71.9 (20.7-587.3) J/cm2 for 1 mg/L methoxsalen (P = .001). The number of exposures (22 [11-29] vs 23 [11-34]) and treatment duration (43 [19-68] vs 44 [23-66] days) was comparable for both methoxsalen dilutions (P = .97). Median psoralen plasma levels were 0 (0-26) ng/mL after the 1 mg/L and 30 (0-64) ng/mL after the 5 mg/L methoxsalen immersion (P = .001). Mild to moderate adverse events were more common in the 5 mg/L methoxsalen group.

LIMITATIONS

The conclusions of this randomized controlled study are limited by the relatively small sample size.

CONCLUSIONS

Our data indicate that in bath-PUVA treatment the use of a high (5 mg/L) methoxsalen concentration is substantially more effective in clearing chronic plaque-type psoriasis than a low (1 mg/L) concentration.

Temozolomide and interferon alpha 2b in metastatic melanoma stage IV

BACKGROUND

A multicentre, centrally randomized, open-labelled study with temozolomide and interferon (IFN)-alpha 2b was carried out to study the therapeutic effect in patients with metastatic melanoma stage IV.

OBJECTIVES

The response rate, efficacy, side-effects, reasons for discontinuation of therapy and survival rate of 47 patients treated with temozolomide in combination with two different dosing regimens of IFN-alpha 2b were documented.

PATIENTS/METHODS

Twenty-nine male and 18 female patients (mean age 57.6 years, range 34-74) were centrally randomized to two different arms: 20 patients received a treatment schedule with temozolomide 150 mg m(-2) on days 1-5 orally every 28 days in combination with IFN-alpha 2b 10 MIU m(-2) every other day and 27 patients received temozolomide 150 mg m(-2) on days 1-5 every 28 days in combination with IFN-alpha 2b in a fixed dose of 10 MIU every other day.

RESULTS

We observed an overall response rate of 27.6% comprising five complete remissions (10.6%: one patient group A, four patients group B), in two of these five patients at the last follow-up in the study (4.3%, both in group B); and eight partial remissions (17%: six patients in group A, two patients in group B), in three of these eight patients at the last follow-up in the study (6.4%, two patients in group A, one patient in group B). Three patients showed stable disease (6.4%: one patient in group A, two patients in group B). Mean survival was 14.5 months [95% confidence interval (CI) 10-19] with no significant differences between treatment groups. However, there was a significant correlation with response after three cycles (log rank test, P < 0.03). Within the 32 patients who completed at least three cycles of therapy, seven patients (three in group A and four in group B) with a partial or complete response showed a significantly better mean survival of 30.6 months (95% CI 19.1-42) compared with 25 patients who did not respond (13.7 months 95% CI 9.2-18.3). In total, patients with at least one complete remission showed the longest survival (37.1 months 95% CI 26.3-47.9), followed by patients with at least one partial response (17.4 95% CI 10.9-23.9). Major side-effects of the treatment were nausea, vomiting, headache, leucopenia, thrombopenia, elevation of liver function parameters and neurological symptoms. In five patients, the side-effects led to a discontinuation of treatment: neurological symptoms (two patients), sepsis (one patient), brain haemorrhage (one patient) and exanthema (one patient). There were no treatment-related deaths.

CONCLUSIONS

The combination of temozolomide and IFN-alpha 2b can easily be administered and shows tolerable toxicity. When an objective response occurs after three cycles, it indicates a significant survival advantage.

Longitudinal study examining the neurotoxicity of occupational exposure to aluminium-containing welding fumes

OBJECTIVES

The neurotoxicity of occupational exposure to aluminium (Al)-containing welding fumes has been discussed with controversial results. The aim of the longitudinal study was to examine a group of Al welders for significant central nervous changes in comparison with a non-exposed cohort.

METHODS

A group of 98 Al welders (mean age 37 years) in the car-body construction industry, with a median of 6 years of occupational exposure to Al welding fumes, and an education-matched, gender-matched, age-matched control group of 50 car-production workers (mean age 36 years) at the same plant, were included in this longitudinal study. Two cross-sectional studies were done in 1999 and 2001. In the second cross-sectional study 97 welders and 50 controls could be examined. The examination programme consisted, for example, of a standardised anamnesis, focussing on occupational history, education, illnesses, medication, accidents and current alcohol consumption, a physical examination that included neurological status, and the assessment of Al concentration in plasma and urine. The neurobehavioral methods included a symptom questionnaire, modified Q16, and computerised and non-computerised tests: psychomotor performance (steadiness, line tracing, aiming, tapping), verbal intelligence (WST), simple reaction time, digit span, block design (HAWIE), symbol-digit substitution, digit span, switching attention (European neurobehavioral evaluation system, EURO-NES), and standard progressive matrices. The data were analysed by multivariate analysis of covariance (MANCOVA) for repeated measurements with covariates age, education, and carbohydrate-deficient transferrin in plasma (CDT). RESULTS. The median Al urine concentration (mean preshift/postshift) was 52.4 microg/g creatinine (2001) and 57.6 microg/g creatinine (1999). Median respirable air dust was 0.67 mg/m(3) (2001) and 0.47 mg/m(3) (1999). Welders and controls did not report significantly more symptoms in the modified Q16. Furthermore, no significant differences in psychomotor performance and other neurobehavioral tasks, except for reaction time, were seen between welders and non-welders. Regression analyses reveal a significant relationship between reaction time and Al excretion in urine that was confounded by other factors.

CONCLUSIONS

At present the outcome for reaction time has to be interpreted as a single result. However, as the modified Q16 questionnaire and the rest of the psychomotor performance showed no significant changes, the next cross-sectional study, in 2003, will provide further information on which a final conclusion can be based.

Physiological and psychological approaches to chemosensory effects of solvents

Workplace related standard settings for solvents are based in a remarkable extent on information about sensory irritations. However, data from controlled human exposure studies are seldom available. Therefore, the aim of this study was to present the association of self-reported symptoms and physiological processes leading to sensory irritations. Three series of laboratory experiments each with 24 young male subjects were performed. Ethyl benzene (EB), 2-butanone (methyl ethyl ketone or MEK), isopropyl alcohol (IPA), 1-octanol (OCT), and 2-ethylhexanol (EHEX) were investigated in low and high concentrations. Ratings for sensory irritations (eyes and nose), olfactory symptoms, and annoyance were assessed repeatedly before, during and after the 4-h-exposures. The anterior active rhinomanometry (AAR) was employed measuring the nasal flow. The nasal lavage was used for the analysis of the neuropeptide substance P as indicator of nasal chemosensory irritations. Goodness-of-fit was calculated for non-linear regression analyses by fitting the sine function on the data of the ratings given during the 4-h-exposure. In general, ratings for annoyance and odor symptoms were fitted on a higher level than those for sensory irritations. However, a high fit could be shown for nasal irritations due to EHEX. In these experiments, a significant reduction of the nasal flow and a significant increase of substance P could be proved.

A comparison of psoralen plus ultraviolet A (PUVA) monotherapy, tacalcitol plus PUVA and tazarotene plus PUVA in patients with chronic plaque-type psoriasis

BACKGROUND

Numerous studies have shown that the additional administration of topical or systemic antipsoriatic agents might serve as an effective means to increase the efficacy of photochemotherapy [psoralen plus ultraviolet (UV) A (PUVA)] for psoriasis.

OBJECTIVES

To compare the therapeutic response to tacalcitol plus PUVA, tazarotene plus PUVA and PUVA monotherapy in patients with chronic plaque-type psoriasis. In addition, we also assessed the duration of remission induced by each regimen and the tolerability of the two combination treatments.

METHODS

Thirty-one patients with chronic plaque-type psoriasis were included in this observer-blinded, intrapatient comparison trial. PUVA treatment was given four times weekly. Additionally, tacalcitol ointment and 0.1% tazarotene gel were applied separately on two target areas once daily in the evening. At the onset of therapy and every 2 weeks thereafter the response to treatment was determined by the Psoriasis Severity Index score, which assesses the degree of erythema, infiltration and scaling of the psoriatic lesions. After complete or near complete clearing patients were followed-up until relapse.

RESULTS

Twenty-four patients completed the study. The treatment requirements to induce complete or near complete clearing were significantly lower for both combination treatments than for PUVA monotherapy (P < 0.01). The median cumulative UVA dose and number of exposures were 30.6 J cm-2 (95% confidence interval, CI 22.5-71.2) and 14 (95% CI 11-16) for tacalcitol plus PUVA, 32.3 J cm-2 (95% CI 22.5-73.8) and 14 (95% CI 11-19) for tazarotene plus PUVA, and 37.0 J cm-2 (95% CI 29.5-83.9) and 16 (95% CI 14-22) for PUVA monotherapy. No difference between the three regimens was observed with regard to duration of remission. Adverse reactions occurred more often with 0.1% tazarotene than with tacalcitol but were in general mild and completely reversible upon using a lower concentration of 0.05% tazarotene.

CONCLUSIONS

Tacalcitol ointment and tazarotene gel are both comparably effective in improving the therapeutic result of PUVA therapy in patients with chronic plaque-type psoriasis. Besides accelerating the treatment response, both agents, by virtue of their UVA dose-sparing effect, might also help to reduce possible long-term hazards of PUVA treatment.

Psychomotor performance and subjective symptoms at low level toluene exposure

OBJECTIVES

Possible effects of long term occupational exposure to toluene below the level of 100 ppm on psychomotor performance and subjective symptoms were investigated in a cross sectional approach.

METHODS

From German rotogravure printing plants 278 male workers, mean age 39.8 years, mean duration of employment 14.9 years, were examined. A mean lifetime weighted average exposure (LWAE) of 45.1 ppm toluene in ambient air was found for 154 exposed workers (rotogravure printing area), with a mean current exposure of 24.7 ppm. The corresponding data for a second group of 124 workers with very low exposure (endprocessing area) had LWAE of 9.3 ppm and a current exposure of 3.3 ppm toluene. Psychomotor performance (steadiness, line tracing, aiming, tapping, and peg board) and subjective symptoms were examined.

RESULTS

No significant differences between the two exposure groups were found by analysis of variance (ANOVA). By stepwise linear regression analyses there were weak associations of LWAE with one performance variable and two symptoms scales, but the results were not significant after correction for the alpha error. Psychomotor performance was mostly affected by age (maximum explained variance up to 13%), and handedness (up to 9%), whereas subjective symptoms are mostly affected by anxiety (up to 38%).

CONCLUSIONS

The weak associations between long term exposure to toluene should be used to indicate further longitudinal investigations. The results of this cross sectional study show no obvious dose response relation for psychomotor functions and subjective symptoms among workers exposed to toluene at a current exposure level of 1-88 ppm.

High-dose versus medium-dose UVA1 phototherapy for patients with severe generalized atopic dermatitis

BACKGROUND

Several studies have demonstrated the efficacy of UVA1 (340-400 nm) phototherapy for patients with severe atopic dermatitis. However, the optimum treatment dose has yet to be determined. Although in seminal investigations high UVA1 doses were used, comparable results were reported in recent studies with a medium-dose regimen.

OBJECTIVE

Our purpose was to compare the efficacy of high-dose with medium-dose UVA1 phototherapy for patients with severe generalized atopic dermatitis.

METHODS

Ten adult patients with a median baseline SCORAD score of 67 were enrolled in an investigator-blinded, bilateral comparison study. Treatment was given 5 times weekly over a period of 3 weeks on an outpatient basis. Irradiation was performed by exposing one half of the patient's body to high-dose UVA1 (< or =130 J/cm(2)), and the contralateral body side received only half that dose. The clinical response was assessed after 5, 10, and 15 treatments. After completion of the study, patients were followed up for 6 months to evaluate the duration of clinical improvement.

RESULTS

All but one patient responded favorably to treatment. High-dose UVA1 led to a decrease of the median SCORAD score by 33.4% after 1 week, 38.4% after 2 weeks, and 34.7% after 3 weeks. The respective values for the medium-dose regimen were 29.7%, 36.4%, and 28.2%. The difference in efficacy between the two dosages remained below the level of significance at all time points. Relapses occurred after a median of 4 weeks. Time of onset and severity of relapse were the same for both doses.

CONCLUSION

Our data support previous uncontrolled observations that medium-dose UVA1 is comparably as effective as high-dose treatment for patients with severe generalized atopic dermatitis. Irrespective of the dose regimen, follow-up examinations revealed early relapse in the majority of patients.

Correlation between 8-methoxypsoralen bath-water concentration and photosensitivity in bath-PUVA treatment

BACKGROUND

Bath-PUVA treatment, originally established in Scandinavia, offers several advantages over oral PUVA and has become increasingly popular in recent years. Outside Scandinavia 8-methoxypsoralen (8-MOP) is the prevailing photosensitizer for this PUVA modality and is used arbitrarily in a wide range of concentrations. Up to the present, data are lacking on the impact of 8-MOP bath-water concentration on UVA dosimetry.

OBJECTIVE

We investigated the influence of increasing 8-MOP bath-water concentrations on photosensitivity in bath-PUVA treatment.

METHODS

Fifteen healthy volunteers without abnormal photosensitivity or recent exposure to ultraviolet radiation were included in an intraindividually controlled comparison study. In all volunteers the minimal phototoxic dose (MPD) was determined on the volar side of their forearms after immersion for 20 minutes in 4 different 8-MOP bath-water concentrations (0.5, 1, 2.5, and 5 mg/L). The correlation between 8-MOP concentration and photosensitivity (defined as the reciprocal value of the MPD) was analyzed by linear regression analysis. In addition, the time course of erythema formation and the UVA dose-erythema response curve was assessed for each psoralen concentration.

RESULTS

The median MPD and the 25%-75% interquartile were 5.7 J/cm(2) (5.7-8), 4 J/cm(2) (4-5.7), 2.8 J/cm(2) (2.8-5.7), and 2 J/cm(2) (2-2.8) at an 8-MOP concentration of 0.5, 1, 2.5, and 5 mg/L, respectively. Linear regression analysis revealed a significant correlation between 8-MOP bath-water concentration and photosensitivity (r = 0.98; P =.019). Bath-PUVA-induced erythema peaked after a median time interval of 3 days, with a range of 2 to 4 days. The slope of the UVA dose-erythema response curve was similar for all psoralen concentrations.

CONCLUSION

UVA dose requirements in bath-PUVA treatment decrease linearly with increasing 8-MOP concentrations. A single MPD assessment at 72 hours after the UVA exposure is inappropriate for accurate determination of the patients' photosensitivity. The hazard of wrong UVA dosimetry is comparable at all psoralen concentrations.

Individual toluene exposure in rotary printing: increasing accuracy of estimation by linear models based on protocols of daily activity and other measures

Industrial exposure varies distinctly both between persons and for each person over time. It is often not possible to measure individual exposure repeatedly due to high costs. Therefore, a method for assessment of exposure is needed that accounts for inter- and intraindividual variability. We consider a strategy suggested by Preller et al. (1995, Scandinavian Journal of Work, Environment, and Health 21, 504-512), the idea of which is to predict exposure on several days via a linear model using additional variables as regressors. Those additional variables are easier to obtain than exposure measurements and are assumed to influence exposure. The paper gives a theoretical proof of the use of this method. An example is given using toluene exposure data from a study in a rotogravure printing plant.

Narrow-band ultraviolet B (ATL-01) phototherapy is an effective and safe treatment option for patients with severe seborrhoeic dermatitis

BACKGROUND

Seborrhoeic dermatitis is a common papulosquamous dermatosis affecting 2-10% of the adult population. Current treatment options are limited and not always satisfactory. Objectives We aimed to investigate the efficacy of narrow-band ultraviolet (UV) B (TL-01) phototherapy as an alternative treatment for seborrhoeic dermatitis.

METHODS

Eighteen patients with severe disease were enrolled in an open prospective study. Treatment was given three times weekly until complete clearing or to a maximum of 8 weeks. A clinical score assessing erythema, scaling, infiltration and pruritus was performed at baseline and every 2 weeks thereafter. Additionally, the patients were asked to rate the intensity of pruritus on a visual analogue scale. After completion of the study the patients were followed up to determine the median time interval until recurrence.

RESULTS

All patients responded favourably to treatment, with six showing complete clearance and 12 marked improvement. The median clinical score decreased from 7.5 (range 4-8) at baseline to 0.5 (range 0-3) after 8 weeks of treatment (P = 0.005). The median pruritus score decreased from 4.5 (range 0-8) at baseline to 0 (range 0-3) at week 8 (P = 0.008). Relapses occurred in all patients after a median of 21 days (range 12-40). No side-effects of treatment were observed except occasional episodes of a moderate erythemal response.

CONCLUSIONS

Narrow-band UVB phototherapy appears to be a very effective and safe treatment option for patients with severe seborrhoeic dermatitis.

Switching attention--additional aspects for the analysis

Problems related to attentional functions have often been reported within the neurotoxicology of long-term exposure to solvents, but knowledge about neuroanatomical sites involved in this degenerative process is still rare. However, some studies have emphasized the frontal cortex as a region of structural or functional changes in long-term exposed patients or accidental intoxications. Neurobehavioral tests using active switching tasks are widely used to detect frontal lobe dysfunction. Test batteries used in neurotoxicology provide such tasks but standard test interpretations often neglect these aspects. Rotogravure printing workers exclusively exposed to toluene were investigated in a longitudinal study with cross-sectional design. Data from two examination periods are presented. In the first sample 333 male workers were investigated. In the second examination period 278 workers could be retested. The workers differed with respect to level and duration of lifetime exposure to toluene. All subjects completed a neurobehavioral test battery including the task switching attention (EURONES). Different parameters were computed for consecutive trials with constant vs. shifted tasks and repetitions vs. changes of the response direction. In general the expected interaction between the two sequence factors could not be observed. In both examination periods the alternative strategy revealed no marked differences between task/response shifts. Considering the result of previous studies on task/response shifts, the results were highly unexpected. One explanation might be the strong deviations from equality for the relative frequencies of the four sequence conditions, resulting in biased expectancies. These may have superimposed on the basic effects of task shifts. However, in both examination periods weak effects of task shift could be revealed in the subgroup of the long-term exposed workers. In further studies it is necessary to balance conditions more carefully in order to exploit the sensitivity that the measurement of shift costs promises to provide. The exposure-related results of this study support this aspect.

Subjective symptoms due to solvent mixtures, dioxin, and toluene: impact of exposure versus personality factors

In this study, we analyse the impact of personality factors on the frequency of self-reported symptoms for workers under different exposure conditions. Reported symptoms may depend on the level and type of exposure, as well as on personality factors such as trait anxiety of the worker or his general sensitivity with regard to the environment. The employed data stems from three studies: The first study contains information of 60 workers who suspected to be exposed to polychlorined dibenzodioxins and dibenzofuranes (Lifetime Weighted Average Exposure, LWAE, as an index for contact with the substances). The second study concerns 40 workers who are exposed to different concentrations of solvent mixtures in paint manufacturing (LWAE of total hydrocarbons about 10 ppm). The third study includes repeated measurements of two subgroups of workers from rotogravure printing plants who are exposed to different concentrations of toluene: a "high" exposure group (n = 129, LWAE about 46 ppm, current exposure 25 ppm) and a "low" exposure group (n = 96, LWAE for toluene about 9 ppm, current exposure 3 ppm). Trait anxiety, environmental sensitivity, and self-reported symptoms are measured by validated questionnaires and age as well as verbal intelligence are controlled. To determine the effect of the individual characteristics and the different exposures on self-reported symptoms, frequency analyses and variance analyses are conducted and linear models are fitted. For all analyses, trait anxiety explains the highest share of the variance. If there is no effect of the exposure on the reported symptoms (dioxin and low-level toluene study), trait anxiety seems to have a larger explanatory power in comparison with those studies where the exposure has an effect on the reported symptoms (solvent-mixture and high-level toluene study). Neurotoxicological risk analysis has to account for the detected dependence of self-reported symptoms on personality traits: assessments for elevated symptoms should not only be linked to the intensity of exposure but also related to benchmarks derived from the normal variability of personality factors.

Neurobehavioral study on the interactive effects of age and solvent exposure

Initial research revealed interaction effects on health measures between exposure to neurotoxicants and age. Symptom reports of workers were conspicuously increased if high-concentration occupational exposure (e.g. to organic solvents, lead) was combined with age above 54 years. The symptom increase in elderly workers was interpreted as a possible indicator of a biological vulnerable phase or delayed response of former high exposure. A second study of the hypothesized age-exposure interaction was performed with a group of workers who had homogenous exposure to a single organic solvent using a neurobehavioral performance evaluation (the EURO-NES). Workers in the rotogravure printing industry who were exposed to toluene were examined two times with an interval of one year (n =333/278). The sample was stratified by workers with significantly different toluene exposure, printers and end-processing operators, and four age classes (< 31, 31-40, 41-50, > 50). The mean lifetime weighted average exposure (LWAE) varied depending on age classes and years of employment with exposure between 7 and 17 ppm in the operators and between 35 to 62 ppm toluene in the printers. Multivariate analyses revealed a significant performance decrease with age (simple reaction time, symbol digit, switching attention, digit span). Again an interaction between age and exposure was found depending on diverging psychometric performance trends with older age. However, contrary to the hypothesis the group with higher exposures (printers) and older age revealed better performance and less symptoms than the group with lower exposure (end-processing operators). The paradoxical results are explained by differences in the intellectual capability in the oldest strata and a possible reversibility of neurobehavioral effects of former high toluene exposure under the condition of later low exposure. There are no hints of adverse delayed effects of former toluene exposure in a possible vulnerable phase in age over 50 years. The different interaction findings of the initial and present study seem to depend mainly on exposure differences in quality and quantity.

Correlation between bathing time and photosensitivity in 8-methoxypsoralen (8-MOP) bath PUVA

Bath PUVA (psoralen plus ultraviolet A) using 8-methoxypsoralen has become increasingly popular in recent years as an effective treatment option for a continuously expanding range of skin disorders. Among the various variables of bath PUVA treatment, the impact of bathing time on photosensitivity has never been investigated in detail. We therefore determined the threshold UVA dose for erythema induction after different bathing periods. A marked influence of bathing time on photosensitivity was found. Increasing the soaking period from 5 min to 30 min resulted in a greater than 60% reduction of the minimal phototoxic and minimal perceptible phototoxic dose. Our results demonstrate that the duration of the psoralen bath is a critical parameter in bath PUVA treatment and has a major influence on UVA dose requirements.

Scleroderma-like syndrome in a child: eosinophilic fasciitis or scleredema adultorum?

A 6-year-old female patient presented with a rapidly progressive scleroderma-like syndrome involving almost the entire integument. Initially clinical patterns and histopathological data of both eosinophilic fasciitis and scleredema adultorum were present. The course of the disease remained unusual for both conditions but finally argued in favour of the diagnosis of eosinophilic fasciitis.

CONCLUSION

Eosinophilic fasciitis and scleredema adultorum might be subtypes of one disease entity.

Psychological effects upon exposure to polyhalogenated dibenzodioxins and dibenzofurans

Thirty workers who had been exposed to combustion products for several years due to testing of flame retarding qualities of building materials and 30 controls from the same facility were investigated. Concentrations found in samples taken from different places of the facility were up to 14,660 microg/kg for polybrominated dibenzofurans and up to 67.1 microg/kg for polychlorinated dibenzodioxins (PCDDs) and dibenzofurans (PCDFs). Physical examination, routine laboratory parameters, and blood fat concentrations of PCDDs and PCDFs revealed normal findings. Neurotoxic symptoms showed a weak tendency of overrepresentation among the exposed workers. The frequency of neurobehavioural symptoms increased significantly with trait anxiety independent of exposure to combustion products.

A meta-analysis for neurobehavioural results due to occupational lead exposure with blood lead concentrations <70 microg/100 ml

The size of performance effects caused by exposure to inorganic lead was determined by a meta-analytical procedure. Twenty-two studies covering exposure conditions of <70 microg/100 ml blood lead concentration were considered as to whether the methods of recording performance deficits were comparable. As a consequence of different test procedures and insufficient documented test results only 13 tests out of 12 studies could be included in the analysis. For the tests Block Design, Logical Memory and Santa Ana performance deficits were found, which may be interpreted as 'small' effects in accordance with a convention for evaluating effect sizes. For the example of Block Design it could be shown that these effects are nevertheless serious. The extent of the exposure related decrease of performance was comparable with those changes of performance which can be expected during aging of up to 20 years. Subsequently, a blood lead concentration of 70 microg/100 ml cannot be considered as a safe limit against long-term decreases of psychological performance.

High dose intravenous immunoglobulin (IVIG) in dermatomyositis: clinical responses and effect on sIL-2R levels

An open study was conducted to identify and investigate dermatomyositis patients who benefit from IVIG treatment, based on dermatological criteria, myositis-related symptoms and immune/inflammatory parameters. 19 patients (16 females and three males, ages 31-84) suffered from dermatomyositis, and 4/19 patients had paraneoplastic dermatomyositis. We monitored the disease activity by documenting the clinical symptoms, recording muscle-related parameters (electromyography, serum creatine kinase, histopathology), and by determining circulating autoantibodies and serum levels of IL-6, sIL-2R, sTNF-a-R, sICAM-1, and sCD8. 7/19 patients responded to IVIG. They had severe skin but only moderate muscle involvement, no autoantibodies, and no malignancy. IVIG-nonresponders had severe skin and muscle disease, concomitant with autoantibodies and/or malignancy. sIL-2R levels were initially elevated in all patients but reverted to normal in IVIG-responders only. Creatine kinase-levels and other parameters did not correlate with disease activity and/or treatment response. IVIG is effective in selected dermatomyositis patients. sIL-2R serum levels appear to be useful predictors of IVIG-induced treatment response and disease activity.

Half-side comparison study on the efficacy of 8-methoxypsoralen bath-PUVA versus narrow-band ultraviolet B phototherapy in patients with severe chronic atopic dermatitis

In patients with severe chronic atopic dermatitis (AD), both photochemotherapy [psoralen ultraviolet A (PUVA)] and narrow-band (TL-01) UV B phototherapy have been reported to be very effective. As no data exist on the relative therapeutic efficacy of these two regimens, we performed a randomized investigator-blinded half-side comparison study on 12 patients with severe chronic AD. Half-side irradiation with threshold erythemogenic doses of 8-methoxypsoralen bath-PUVA and narrow-band UVB was performed three times weekly over a period of 6 weeks. The severity of the disease was assessed separately for the paired halves of the patients' bodies by a modified SCORAD score at baseline and after 2, 4 and 6 weeks of treatment. Ten of the 12 patients completed the trial. All but one showed marked improvement or complete remission with both treatments. The mean baseline SCORAD score decreased by 65.7% by the bath-PUVA treatment and by 64.1% by the narrow-band UVB treatment (P = 0.48). No serious adverse reactions to either of the two regimens were observed. Our data confirm the high efficacy of bath-PUVA and narrow-band UVB phototherapy in the treatment of patients with chronic severe AD. Both regimens appear to be equally effective when administered in equi-erythemogenic doses.

Benefit of 6 months long-term physical training in polymyositis/dermatomyositis patients

OBJECTIVE

The benefit of long-term physical training in patients with chronic polymyositis or dermatomyositis (PM/DM) was studied prospectively.

METHODS

Eight patients with chronic PM/DM participated in a training programme for 6 months. A group of five PM/DM patients without any physical training was observed for control purposes.

RESULTS

While there was no significant change in serum creatine phosphokinase (CPK) levels, the 'activities of daily living (ADL)' score improved significantly (P < 0.03), peak isometric torque (PIT) generated by muscle groups in the lower extremities rose significantly (P < 0.03) and there was a statistically highly significant increase in peak oxygen uptake (VO2max) relative to body weight (P < 0.02) due to the long-term training. The patients improved their aerobic capacity by 28%, which is clinically significant. In the untrained patients, no improvement in these target parameters was observed.

CONCLUSION

In clinically stable DM/PM patients, long-term physical training can safely be performed and is recommended as part of a comprehensive rehabilitation management, particularly in view of the cardiopulmonary risk in these patients.

Treatment of metastatic malignant melanoma with dacarbazine plus fotemustine

Despite the poor prognosis of metastatic malignant melanoma, polychemotherapy with dacarbazine and fotemustine has shown promising results in several studies. We report on the clinical efficacy of a new sequential administration regimen with dacarbazine at a dose of 200 mg/m2 followed 24 h later by fotemustine 100 mg/m2 every 4 weeks in 63 patients with metastatic melanoma. A complete response was noted in 3 patients (5%), a partial response in 4 patients (6%), stable disease in 33 patients (5%) and progressive disease in 23 patients (37%). The duration of the 3 complete responses was 5, 14+ and 60+ months, for the 4 partial responses, 3, 4, 6 and 13 months. The median duration for stable disease was 4 months. The best response rates were obtained for lung and lymph node metastases. Toxicity was mild and mainly limited to haematological without pulmonary side-effects. Although there was a relatively low objective response rate, this chemotherapy regimen as a palliative treatment, is potentially valuable for patients with progressive stage IV melanoma.

Association of biochemical and subjective indicators of drinking habits with performance on different neurobehavioral tasks

The present paper outlines the association of biochemical and subjective indicators of alcohol consumption. Due to its relevance as a potential confounding variable in occupational neurotoxicology, both sources of information about drinking habits were related to neurobehavioral test performance. A sample of 308 rotogravure printers and control subjects from a cross-sectional longitudinal study in various German printing plants was studied. Duration of employment was 4 months to 44 years (mean = 14.9, sd = 9.67). Mean age was 38.4 years (range 21 - 60). From venous blood samples three parameters considered to be sensitive for increased consumption of alcohol were used. They were carbohydrate-deficient transferrin (CDT), gamma glutamyl transferase (GGT), and mean cell volume (MCV). During the medical interview subjects with any chronic liver disease were identified and excluded from data analysis. Additionally, information about weekly consumption of alcohol was assessed and transformed to grams per day (g/d) values. Neurobehavioral testing included simple reaction time (SPES version), switching attention, symbol digit substitution, and digit span (EURONEST version). Additionally, a questionnaire of neurotoxic complaints was administrated. Other covariates, i.e. verbal ability, history of solvent exposure, and age were controlled. GGT and CDT were elevated in 10.5% and 6.6% of the population. 3.5% of the subjects reported daily consumption higher than 60 gram. There were positive correlations of CDT and GGT with the subjective indicator of drinking habits. The magnitude of these relationships were low, but the associations were significant. MCV was not correlated with subjective reports of drinking habits, but it showed convergent correlations with CDT and GGT. Comparison of these two parameters with performance on neurobehavioral tasks yielded only one negative association, i.e. between the memory-loaded tasks factor and GGT. CDT and subjective estimation of alcohol consumption were not related to any cognitive function tested in this study. Especially, the digits-backward task was negatively correlated with increased GGT.

Epiluminescence microscopy-based classification of pigmented skin lesions using computerized image analysis and an artificial neural network

Epiluminescence microscopy (ELM) is a non-invasive technique for in vivo examination which can provide additional criteria for the clinical diagnosis of pigmented skin lesions (PSLs). In the present study we attempt to determine whether PSLs can be automatically diagnosed by an integrated computerized system. This system should recognize the PSL, automatically extract features and use these features in training an artificial neural network, which should--if sufficiently trained--be capable of recognizing and classifying a new PSL without human aid. One hundred and twenty images of randomly selected histologically proven PSLs (33 common naevi, 48 dysplastic naevi and 39 malignant melanomas) were used in this study. The images were digitally obtained and the morphological features of the PSLs were extracted electronically without human assistance. The numerical data were then divided into learning and testing cases and linked to an artificial neural network for training and for further classification of lesions that the system had not been trained on. Our results show that the computerized system was able to automatically identify 95% of the PSLs presented. The sensitivity and specificity of the computerized system were 90% and 74% respectively. In contrast, when differentiating between individual types of lesions, the system performed at true positive rates of only 38% for malignant melanoma, 62% for dysplastic naevi and 33% for common naevi. Our data indicate that (1) ELM images of PSLs provide an excellent source for digital image analysis; (2) the vast majority of PSLs can be correctly identified by a relatively simple (and thus not "intelligent") application of digital image analysis; (3) automatic feature extraction based mainly on ABCD rules provides reliable data on the distinction between benign and malignant PSLs; and (4) there is evidence that artificial neural networks can be trained to adequately discriminate between benign and malignant PSLs.

Improvement of physical fitness and muscle strength in polymyositis/dermatomyositis patients by a training programme

In the present investigation, the benefit of physical training in patients with inflammatory myopathy was studied. In this prospective, randomized, controlled study, 14 patients with polymyositis (PM) or dermatomyositis (DM) were investigated. The training, consisting of bicycle exercise and step aerobics, took place over a 6 week period. Baseline and endpoint measurements included an 'activities of daily living' (ADL) score, peak isometric torque (PIT) generated by muscle groups in the lower extremities, peak oxygen consumption (VO2max), and creatine phosphokinase (CPK) levels. There was no significant rise in disease activity in the training group in comparison to the controls. The ADL score for the treatment group, in comparison to the control group, improved (P < 0.02), PIT rose (P < 0.05) and there was a statistically significant increase in oxygen uptake relative to body weight (P < 0.05). No rise in inflammatory activity, but significant improvement in muscle strength, oxygen uptake and well-being, were found in patients with inflammatory myopathy as a result of physical training. Besides medication, a physical training programme consisting mainly of concentric muscle contractions should therefore be an integral part of therapy, particularly in view of the cardiopulmonary risk of these patients.

Solvent exposure and ratings of well-being: dose-effect relationships and consistency of data

Ratings on analog scales for dimensions of well-being provide information about the acute state of well-being during solvent exposure. In a study of volunteers and workers exposed to solvents, tension, tiredness, complaints, and annoyance were rated on seven-point scales. Dose-effect relationships were analyzed for several scenarios; data were collected in diaries during work hours. In two studies, 40 volunteers in an exposure laboratory were exposed to ethanol by inhalation at levels between 80 and 1900 parts per million (ppm). In two other studies, 32 volunteers were exposed to acetone and ethyl acetate in single exposures (1000 and 500 ppm, respectively) and combined exposures (500 ppm acetone + 200 ppm ethyl acetate). A field study of 8 exposed workers and 8 nonexposed controls involved exposures of up to 2100 ppm acetone. Dose-effect relationships were shown for ratings of annoyance by correlations of 0.36 (ethanol) and 0.58 (acetone). Similar coefficients were found for ratings of complaints. The dimensions tension and tiredness showed no stable relationship with exposure. The consistency of ratings was assessed by means of correlations between the ratings given during periods of nearly equal exposures. Ratings of annoyance for the different studies between the periods of nearly equal exposure showed average correlations from 0.68 to 0.84. For the ratings of complaints, the coefficients were 0.53 to 0.81. The coefficients for tension had similar stabilities; those for tiredness were lower.

Standardization of a questionnaire for neurotoxic symptoms

A new version of the "Psychological-Neurological Questionnaire," designed for screening purposes, was investigated concerning its sensitivity to detect early signs of occupational exposure to potential neurotoxicants. A study population of 361 subjects was stratified into four age groups (<34, 35-44, 45-54, and >54 years) and three exposure groups (no, low, and high). According to dose and exposure history, workers exposed to dioxins and furans in combustion products, to volatile organic compounds, and to chromates were classified as low exposure. Workers exposed to alkyl lead, single solvents, and solvent mixtures were classified as high exposure. Only the group with the oldest age and highest exposure could be separated clearly from other groups, indicating an interaction effect between exposure and age. The low-exposure group could not be separated from the nonexposed controls. The most effective discriminators were neurologic symptoms. Psycho- and neurovegetative lability and irritative disturbances contributed less to the differentiation. Gastrointestinal and sleep disorders, as well as alcohol intolerance, showed no differentiation quality. The observed type of interaction effect fits models of delayed neurotoxicity.

[Established and new therapeutic approaches in dermatomyositis, polymyositis and overlapping syndromes]

An overview is presented on current antiinflammatory, cytostatic/cytotoxic and immunomodulatory treatments for immunologically mediated inflammatory myopathies with skin involvement. High-dose intravenous immunoglobulin (IVIG) therapy is discussed in the context of recent findings regarding pathogenic mechanisms of autoimmune diseases.

In search of dose-response relationships of solvent mixtures to neurobehavioural effects in paint manufacturing and painters

Four exposure indices for the evaluation of mixtures of solvents are outlined. The hygienic effect is a relative measure depending on the limit values of the single compounds of the mixture. The cumulative lifetime exposure (CE) and the lifetime-weighted average exposure (LWAE) are approaches based on measurements of total hydrocarbons at workplaces in different time periods. Estimations of litres of solvents used per day years (l/d years) are necessary if air monitoring is not available. Five studies on neurobehavioural effects due to solvent mixtures in paint manufacturing are compared as example for dose-response relations. The best prediction of neurobehavioural dose-response relations seems to be possible using CE and LWAE for total hydrocarbon as the exposure index. Moreover, four studies on neurobehavioural effects due to solvent mixtures in paints and glues are compared. These studies indicate that the index l/d years is helpful in predicting neurobehavioural deficits. Of numerous neurobehavioural tests, the test symbol digit substitution shows the most significant dose-response relations in the studies. For symptom questionnaires these relations appear only occasionally. In principle, associations between doses of solvent mixtures in paints and neurobehavioural effects are reproducible to a limited extent.