AB1173 INCIDENT CASES OF COVID-19 AND VACCINATION ADHERENCE IN A MULTICENTRIC COHORT OF INFLAMMATORY ARTHRITIS IN BRAZIL

Background

The SARS-CoV-2 virus has caused a worldwide health crisis. Patients with inflammatory arthritis are at higher risk of hospitalization and death by COVID-19 due to comorbidities or immunosuppressive treatments. Vaccination is one the most important strategies to control the pandemic.

Objectives

To evaluate the incident cases of SARS-CoV-2 infection in a multicentric cohort of inflammatory arthritis in Brazil.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (1). The present analysis is a retrospective evaluation of adult patients with inflammatory arthritis (rheumatoid arthritis – RA, spondylarthritis -SpA and psoriatic arthritis-PsA) that were alive since the beginning of the COVID-19 pandemics in Brazil in February 2020. We evaluated the incidence and severity of COVID-19 infection and the adherence to anti- SARS-CoV-2 vaccines schedules, up to January 2022.

Results

A total of 300 patients were interviewed and 69 (23.0%) reported confirmed anti-SARS-CoV infection and 5 (1.7%) had a second infection. Among known infected patients, 18.8% need hospitalization and oxygen support, 7.2% were admitted at ICU, and 5.8% died. After COVID-19 infection, 31.8% reported worsening of disease activity but only 6.1% had modification in medication due to disease activity. Distribution of cases followed the pattern of waves observed in Brazil (Figure 1). Regarding vaccination, 285 (95%) reported to have received at least one dose of any anti-SARS-CoV-2 vaccine: 43% received the first with the adenovirus ChAdOx1 nCoV-19 (AstraZeneca) adenovirus vaccine, 32% received the Sinovac-CoronaVac inactivated vaccine, 22% received the BNT162b2 (Pfizer-BioNtech) mRNA vaccine and 3% received the BNT162b2 (Pfizer-BioNtech) adenovirus vaccine. Almost all (98.1%) of these patients had already received the second dose of vaccine and after the first and second vaccine doses, 6% and 4% of patients, respectively, reported worsening of articular disease activity, while, after the third dose, no patient reported disease activity worsening.

Figure 1.

Conclusion

During the pandemics, patients with inflammatory arthritis had a pattern of distribution of cases very similar to general population. Adherence to vaccination is high and well tolerated.

References

[1]Bredemeier et al. J Rheumatol 2021;48:1519-27

Disclosure of Interests

None declared

POS0650 THE IMPACT OF OLD AGE ON THE PERSISTENCE AND SAFETY OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

The effect of age on persistence and safety of treatment with biologic disease modifying anti-rheumatic drugs (bDMARDs) in rheumatoid arthritis has been a subject to research interest. Two recently published studies did not observe significantly different survival of treatment with bDMARDs among older age (≥ 65 years) individuals (1,2); incidence of serious adverse events was higher in these patients (2).

Objectives

to evaluate association of the age with treatment survival and overall safety among patients receiving one or multiple courses of bDMARDs or targeted synthetic (ts-) DMARDs.

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment necessarily involving a bDMARD or tsDMARD (latest date, Nov 19, 2019). Treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. Primary outcome was the incidence treatment interruption for any reason (except for pregnancy or disease remission), while interruption due to adverse events (AEs; including death) and due to inefficacy served as secondary outcomes. Incidence of serious adverse events (SAEs) also served as a secondary outcome. Extended (frailty) multivariate Cox proportional hazards models and negative binomial regression with generalized estimating equations (to calculate incidence rate ratios [IRRs]) were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6508 patient-years [PY]) were enrolled. Of these, 160 patients (643 PY; 237 treatment courses) were ≥ 65 years old, mean age at starting treatment = 71 ± 5 yrs (84% female). Old age was not significantly associated with treatment interruption for any reason, but presented higher risk of interruption due to adverse events (after multivariate adjustment) and lower risk of stopping because of inefficacy (see Table 1). Older patients presented higher incidence of SAEs than younger ones (16.0 vs 8.4/100 PY, respectively; multivariate IRR: 2.06, 95% CI: 1.51 to 2.80, P<0.001). Among old patients, tocilizumab (HR: 2.73, 95% CI: 1.13 to 6.64, P=0.026), etanercept (2.13, 1.12 to 4.07, P=0.022), and infliximab (2.39, 1.19 to 4.79, P=0.014) presented higher risk of treatment termination as compared with adalimumab. In this subgroup (age ≥65 yrs), there was no significant difference in the risk of SAEs between different bDMARDs/tsDMARDs.

Table 1.

Univariate and multivariate hazard ratios (HRs) of interruption of treatment course comparing older (≥65 years) versus younger patients (reference category). Results are HRs, 95% CIs, and P values.

Cause of interruption (n of events)Crude analysisAdjusted covariates*Interruption - any reason (1321)0.96 (0.75 to 1.23), P=0.7601.09 (0.82 to 1.43), P=0.550Interruption - adverse events (368)1.33 (0.75 to 0.89), P=0.1601.59 (1.07 to 2.35), P=0.020Interruption - inefficacy (680)0.56 (0.39 to 0.80), P=0.0020.57 (0.38 to 0.87), P=0.009

* Age, baseline DAS28, disease duration, gender, smoking, RF or anti-CCP, previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B,C, treatment sequence.

Conclusion

The overall risk of treatment interruption with biologic or targeted synthetic DMARDs is not higher in older patients. Higher risk of interruption due to AE was balanced by a lower risk of stopping treatment due to inefficacy. Older patients had a higher incidence of SAEs.

References

[1]Mathieu et al. Rheumatol Int 2021;41:879-85.

[2]Freitas et al. Drugs Aging 2020;37:899-907.

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

POS0242 THE EFFECT OF ANTIMALARIALS ON THE OVERALL SAFETY AND PERSISTENCE OF TREATMENT WITH BIOLOGIC AGENTS OR JAK INHIBITORS IN RHEUMATOID ARTHRITIS

Background

Antimalarials (AM) are frequently part of the initial scheme of conventional synthetic DMARDs in the treatment of rheumatoid arthritis (RA), and have been associated with lower incidence of diabetes and better lipid profile in these patients (1). However, the role of AM in schemes involving biologic (b-) or targeted synthetic (ts-) DMARDs has been much less extensively studied. In addition, a recent large scale study (2) and a consensus article (1) casted doubt on the long-term cardiovascular safety of AM.

Objectives

To evaluate the association of concomitant use of AM with the overall safety and survival of

treatment course among patients receiving one or multiple courses of bDMARDs or tsDMARDs

Methods

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients with rheumatic diseases starting their first bDMARD or tsDMARD (3). The present analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over one or multiple (up to six) courses of treatment (latest date, Nov 19, 2019). A treatment course is defined as a period during which the medication scheme does not change. The primary outcome was the incidence of serious adverse events (SAEs). Total and system-specific adverse events (AEs), treatment interruption for any reason, interruption due to AEs and due to inefficacy served as secondary outcomes. Negative binomial regression with generalized estimating equations (to calculate the incidence rate ratios [ÌRRs]) and extended (frailty) Cox proportional hazards models were used for statistical analyses (both types of analyses including time-varying covariates over multiple courses of treatment).

Results

In total, 1316 patients (2335 treatment courses, 6711 patient-years [PY]) were enrolled. The overall incidence of serious adverse events was 9.2/100 PY. AM were used over 354 courses (1254.5 PY) of therapy. The IRRs for the primary and secondary outcomes are presented in Table 1. AM were also associated with better treatment course survival (Figure 1), reducing the risk of interruption due to AEs (multivariate hazard ratio: 0.56, 95% CI: 0.39 to 0.81, P=0.002) and inefficacy (0.65, 0.48 to 0.87, P=0.003).

Figure 1.Table 1.

Univariate and multivariate incidence rate ratios (IRRs) of adverse events comparing use versus non-use (reference category) of antimalarials. Results are IRRs, 95% CIs, and P values.

Type of adverse event (n of events)Crude analysisAdjusted covariates*Serious adverse events (617)0.60 (0.41 to 0.87), P=0.0070.51 (0.37 to 0.69), P<0.001Any adverse event (3494)0.65 (0.54 to 0.77), P<0.0010.68 (0.57 to 0.81), P<0.001Cardiovascular‡Serious (52)1.04 (0.49 to 2.20), P=0.9241.06 (0.45 to 2.50), P=0.891Total (163)0.90 (0.59 to 1.38), P=0.6420.93 (0.59 to 1.45), P=0.737InfectionsSerious (277)0.78 (0.44 to 1.39), P=0.4040.53 (0.34 to 0.83), P=0.006Total (1400)0.77 (0.61 to 0.98), P=0.0330.75 (0.60 to 0.94), P=0.014Hepatic‡Total (66)0.20 (0.07 to 0.64), P=0.0070.16 (0.04 to 0.57), P=0.005Glicemic control-relatedTotal (34)0.74 (0.29 to 1.92), P=0.5400.73 (0.26 to 2.00), P=0.535DyslipidemiaTotal (83)0.60 (0.31 to 1.13), P=0.1140.55 (0.28 to 1.06), P=0.074

*Age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF or anti-CCP), previous malignancy, interstitial lung disease, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, concomitant use of each cs-, b-, and tsDMARDs, corticosteroids, starting year, osteoporosis, hepatitis B and C, and treatment sequence. ‡ Excluding infections.

Conclusion

Among RA patients on treatment with bDMARDs or tsDMARDs, concomitant use of antimalarials reduced the incidence of serious and total AEs, including infections and hepatic AEs, and prolonged treatment course survival. No significant increase in the risk of cardiovascular AEs was observed.

References

[1]Desmarais et al. Arthritis Rheumatol 2021;73:2151-60.

[2]Lane et al. Lancet Rheumatol 2020;2:e698–e711

[3]Bredemeier et al. J Rheumatol 2021;48:1519-27.

Disclosure of Interests

None declared

Physiological and pharmacological impact of oxytocin on epididymal propulsion during the ejaculatory process in rodents and men

During the emission phase of ejaculation, the sperm is driven from the cauda epididymidis, where it is stored, through the vas deferens by strong contractions. These contractions are thought of as being mainly induced by the sympathetic nervous system and the neurotransmitter noradrenaline. In the present study, we investigated the effect of oxytocin (suggested to exert effects during ejaculation as well) on defined segments of the rat and human epididymis using live imaging. Our results indicate that it is the very last part of the epididymis, segment 19 (S19) in rat and likewise segment 9 in human, which responds in a uniquely strong and rapid manner to oxytocin (similar to noradrenaline). Because of the complex nature of this contractile response, we developed an imaging analysis method, which allowed us to quantify multidirectional contractions and to display them using heat maps. The reaction of S19 to oxytocin was concentration-dependent and could be inhibited by pretreatment with oxytocin antagonists (atosiban and cligosiban), but not with an arginine vasopressin 1_A antagonist (SR49059). In both rat and human tissue, pretreatment with the alpha-1 adrenoreceptor antagonist tamsulosin inhibited the response to noradrenaline, whereas the effect of oxytocin was unimpaired. Our data (from men and rodents) strongly suggest that the hormone oxytocin is involved in the ejaculatory process. Thus, oxytocin-based medications might be a promising non-adrenergic treatment option for ejaculatory disorders. Additionally, we propose that S19 could be an advantageous model (detecting very low concentrations of oxytocin) to test the bioactivity of new oxytocin agonists and oxytocin antagonists.

Contractions transport exfoliated epithelial cells through the neonatal epididymis

Contractions of the adult epididymal duct are well known in the context of sperm transport. Some reports also describe contractions of the epididymal duct during development, but data about their character, regulation and function are sparse. In the foetal human epididymis we found luminal cells and could identify them as exfoliated epithelial cells originating from the epididymis and not from testis by using antibodies against neutral endopeptidase as an epithelial epididymal duct marker. Exfoliated cells were also found in the epididymal duct after birth. Time-lapse imaging revealed directional transport of luminal cells in the neonatal rat epididymis interrupted by pendular movement. Spontaneous contractions were discovered in the neonatal epididymis and an association between these contractions and the transport of the luminal cells could be observed. Both, transport and spontaneous contractions, were affected significantly by substances known to contract (noradrenaline) or relax (the phosphodiesterase 5 inhibitor sildenafil) smooth muscle cells. Immunohistochemistry showed staining for the proliferation marker proliferating-cell-nuclear-antigen (PCNA) in cells of the ductal lumen of the neonatal rat epididymis indicating the extrusion of cells also during proliferation. Our data showed spontaneous contractions of the immature epididymal duct associated with the transport of exfoliated luminal cells before the first occurrence of sperm cells. Results suggest an important role including both (i) a mechanical place holder function of exfoliated luminal cells (ii) together with a novel idea of organized waste disposal of these cells during development.

POS0676 SURVIVAL OF THE FIRST COURSE OF BIOLOGIC OR JAK INHIBITOR IN RHEUMATOID ARTHRITIS: ASSOCIATION WITH THE CHOICE OF AGENT AND CONCOMITANT CONVENTIONAL SYNTHETIC DMARDS

Background:

After failure of conventional synthetic disease modifying anti-rheumatic drugs (csDMARDs) in the therapy of rheumatoid arthritis (RA), treatment may be escalated to biologic (bDMARDs) or JAK inhibitors (JAKi) (1). Analysis of drug survival can provide useful information on the effectiveness of these therapeutic schemes.

Objectives:

to evaluate the association of the choice of therapeutic agent with the survival of treatment course in RA patients receiving their first bDMARD or JAKi.

Methods:

BiobadaBrasil is a multicentric registry-based cohort study of Brazilian patients starting their first bDMARD/JAKi (2). This analysis includes RA patients recruited from Jan 2009 to Oct 2019, followed-up over the first course of treatment with a bDMARD/JAKi until censoring (latest date, Nov 19, 2019) or occurrence of the outcome of interest. A treatment course is defined as a period during which the medication scheme does not change, except for dose adjustments. The primary outcome was the interruption of treatment course for any reason (except for pregnancy or disease remission); interruption of treatment due to adverse events (AEs) or death and due to inefficacy served as secondary outcomes. Multivariate Cox proportional hazards models were used for analyses.

Results:

In total, 1177 patients (3800 patient-years [PY]) were enrolled. The overall incidence of treatment interruption was 17.5/100 PY. Adalimumab was the most frequently prescribed agent, followed by infliximab (n= 267). The hazards ratios (HR) of the primary and secondary outcomes are presented in Table 1. Figure 1 compares the survival of treatment curves of different bDMARDs/JAKi.

Table 1.

Hazard ratios (HR) of interruption of therapy course of each therapeutic agent (the reference category for bDMARDs/ JAKi is infliximab). Results are HR, 95% CIs, and P values*.

Agent (number of patients)Interruption for any reason (665 events)Interruption due to adverse events or death (196 events)Interruption due to inefficacy (319 events)Adalimumab (354)0.83 (0.68 to 1.01), P= 0.0620.68 (0.48 to 0.96), P=0.0291.08 (0.80 to 1.44), P=0.621Etanercept (257)0.81 (0.66 to 1.01), P=0.0630.56 (0.37 to 0.83), P=0.0040.93 (0.68 to 1.29), P=0.674Certolizumab (80)0.74 (0.47 to 1.16), P=0.1850.33 (0.13 to 0.86), P=0.0241.32 (0.74 to 2.35), P=0.350Golimumab (53)0.86 (0.53 to 1.38), P=0.5300.46 (0.18 to 1.19), P=0.1111.07 (0.53 to 2.15), P=0.849JAKi (tofacitinib) (59)0.54 (0.30 to 0.99), P=0.0470.19 (0.04 to 0.82), P=0.0260.89 (0.41 to 1.96), P=0.779Rituximab (48)0.87 (0.55 to 1.37), P=0.5400.48 (0.20 to 1.18), P=0.1090.58 (0.26 to 1.34), P=0.205Abatacept (30)0.52 (0.25 to 1.07), P=0.0770.46 (0.14 to 1.56), P=0.2150.46 (0.14 to 1.52), P=0.203Tocilizumab (29)0.29 (0.14 to 0.63), P=0.0020.40 (0.12 to 1.30), P=0.1260.28 (0.09 to 0.90), P=0.033Methotrexate (792)0.95 (0.79 to 1.14), P=0.5610.86 (0.62 to 1.19), P=0.3620.98 (0.75 to 1.28), P=0.860Leflunomide (497)1.17 (0.99 to 1.39), P=0.0611.44 (1.06 to 1.96), P=0.0201.02 (0.80 to 1.30), P=0.856Sulfasalazine (48)1.18 (0.80 to 1.75), P=0.4011.94 (1.07 to 3.54), P=0.0300.85 (0.45 to 1.59), P=0.605Antimalarials (230)0.80 (0.65 to 0.98), P=0.0270.67 (0.45 to 0.99), P=0.0430.67 (0.50 to 0.92), P=0.011

* All tests adjusted for other variables presented in the table and for age, baseline DAS28, disease duration, gender, smoking, seropositivity (RF/anti-CCP), previous malignancy, diabetes, hypertension, hypercholesterolemia, renal failure, ischemic cardiomyopathy, COPD, heart failure, use of corticosteroids, starting year, hypercholesterolemia, osteoporosis, hepatitis B and C.

Conclusion:

In our study, infliximab was related to an overall higher hazard of treatment course interruption than tolicizumab and tofacitinib, and higher hazard of interruption due to AEs than most other anti-TNF agents and tofacitinib. Maintaining antimalarials in patients receiving advanced therapies for RA may reduce interruption of treatment due to inefficacy and AEs.

Disclosure of Interests:

None declared

AB0848 PARTICIPATION OF UNDERGRADUATE MEDICAL STUDENTS AS INVESTIGATORS IN A RHEUMATOLOGIC COHORT: IMPACT ON DEPRESSION, ANXIETY & STRESS SCALE

Background:

Mental health was widely affected during the new coronavirus pandemic. In addition, some measures adopted by most countries in order to contain the virus spread, such as isolation and social distancing, leading to the interruption of routine activities, including partial or complete interruption of face-to-face classes may be associated with increased stress, depression and anxiety among undergraduate medical students (1). From March to September, 2020, the Brazilian Society of Rheumatology carried out the Mario Pinotti II Project (MPII), a prospective, multicenter, observational cohort study designed to monitor the COVID-19 in patients with rheumatic disease on hydroxychloroquine, using periodic telephone calls performed by undergraduate medical students (2).

Objectives:

To compare the mental health status of medical students who were participating from the MPII with theirs colleagues not involved in this project.

Methods:

A web-based survey via google forms platform was developed by a panel composed of undergraduate medical students, rheumatologists, medical school professors, and a psychology professor. It included details on demographic and life habits data and domains regarding depression, anxiety and stress, using the DASS-21 (Depression, Anxiety & Stress Scale), Brazilian version. Data collection occurred from July 20th to August 31st, 2020. Statistical analysis was performed using the SPSS version 20.0. Univariate and multivariate linear regression analysis were performed to verify associations with the DASS-21, defined as dependent variable. A p-value < 0.05 was deemed as significant. This study was approved by the Institutional Research Ethics Committee.

Results:

A total of 684 undergraduate medical students were included in this study, of whom 228 as MPII volunteers (VG) and 456 as control group (CG). Median age was 23 years (IQ 21-24) and the CG was older than the VG (p<0.03). Most of them were white (68.8%) and women (63%). There were no significant differences regarding comorbidities, ethnicity, smoking status, alcohol intake and physical activity. Older age, male gender, participation of MPII study, absence of a worsening in sleep pattern during the pandemic and a lower number of prior comorbidities were associated with lower DASS21 scores, suggesting a better mental health (Table 1).

Conclusion:

Several aspects may be involved with mental health, including increased emotional maturity, gender and sleep pattern. Although with marginal independent association, medical students with participation in the MPII study had better mental health than their student colleagues not engaged with this research. Our data pointed out that voluntary participation in a research project which foresees interaction by telephone contact with rheumatic patients, professors, rheumatologists, and colleagues is associated with better mental health.

References:

[1]Meo SA, Abukhalaf AA, Alomar AA, Sattar K, Klonoff DC. Covid-19 pandemic: Impact of quarantine on medical students’ mental wellbeing and learning behaviors. Pakistan J Med Sci 2020;36(COVID19-S4):S43–8.

[2]Gomides A, Ferreira G, Kakehas A, Lacerda M, Marques C, Paiva E et al. Impact of chronic use of antimalarials on SARS-COV-2 infection in patients with immune-mediated rheumatic diseases: protocol design for a multicentric observational cohort in Brazil. JMIR Research Protocols, 2020.Preprint

Table 1.

Univariate and multivariate analysis of predictors associated to the DASS-21 in undergraduate medical students during the COVID-19 pandemic

Univariate analysisMultivariate analysisVariableB95%CIp-ValueB95%CIp-ValueAge-0.32-0.61 to -0.030.03-0.47-0.81 to -0.130.008Female gender4.883.021 to 6.76<0.001---Stable love relationship-2.49-4.35 to -0.640.008-2.5-4.4 to -0.590.01Number of previous comorbidities reported4.693.71 to 5.68<0.0014.823.73 to 5.92<0.001MP-II volunteering-2.81-4.74 to -0.860.005---Worsening in sleep pattern6.414.62 to 8.20<0.0015.013.07 to 6.96<0.001

Disclosure of Interests:

None declared

Oxytocin in the Male Reproductive Tract; The Therapeutic Potential of Oxytocin-Agonists and-Antagonists

In this review, the role of oxytocin and oxytocin-like agents (acting via the oxytocin receptor and belonging to the oxytocin-family) in the male reproductive tract is considered. Previous research (dating back over 60 years) is revised and connected with recently found aspects of the role oxytocin plays in male reproductive health. The local expression of oxytocin and its receptor in the male reproductive tract of different species is summarized. Colocalization and possible crosstalk to other agents and receptors and their resulting effects are discussed. The role of the newly reported oxytocin focused signaling pathways in the male reproductive tract, other than mediating contractility, is critically examined. The structure and effect of the most promising oxytocin-agonists and -antagonists are reviewed for their potential in treating male disorders with origins in the male reproductive tract such as prostate diseases and ejaculatory disorders.

[Cystic echinococcosis and hepatocellular carcinoma--a coincidence? A case report]

INTRODUCTION

The coincidence of echinococcosis and hepatocellular carcinoma (HCC) is quite rare. We report the case of a 45-year-old man who was admitted to our hospital because of abdominal pain in the right upper quadrant and jaundice. Clinical features and diagnostics: There was no history of weight loss or fever. No abdominal mass was palpable. The laboratory reports showed increased transaminase levels. Ultrasonography revealed an inhomogenous, cystic lesion measuring 6 cm in diameter in the segments VI and VII. Serology for echinococcosis was negative, alpha-fetoprotein (AFP) was considerably increased. CT scan showed a solid mass of 3,7 cm in diameter adjacent to the cystic lesion.

THERAPY AND COURSE

Anthelminthic therapy with albendazole caused a massive increase of cholestasis parameters and treatment had to be stopped. The simultaneous occurrence of serologically negative cystic echinococcosis and HCC was suspected and partial liver resection was performed. Histological examination confirmed both diagnoses and tumor resection in healthy tissue. 5 months after resection CT scan showed multicentric HCC affecting the whole liver. Palliative therapy with sorafenib was established.

DISCUSSION

The coincidence of HCC and cystic echinococcosis in the non-cirrhotic liver of a young man is a rare event. Despite resection in healthy tissue multicentric HCC was diagnosed 5 months later. Only few cases of simultaneous occurrence of HCC and echinococcosis have been published so far. Some authors considered echinococcosis as a trigger for HCC. A causal link between both entities has not been demonstrated until now.

[Colocutaneous fistula after a PEG procedure with introducer technique and gastropexy]

INTRODUCTION

The pull-PEG (percutaneous endoscopic gastrostomy) is the most commonly used procedure for PEG placement. Alternative methods may be used in patients with an obstructed oesophagus. We here present the case of an unusual complication during PEG placement with the new introducer technique and gastropexy.

CASE REPORT

A 74-year-old men with progressive thymus cell carcinoma was referred for a PEG procedure. Since the tumour stenosis in the oesophagus was only passable with a slim-sight endoscope (5,9 mm), we decided in favour of the direct PEG method with gastropexy. The procedure was performed without any complications. 35 days later we changed the balloon catheter and were able to easily inflate the balloon. Surprisingly, the X-ray performed thereafter, revealed a misplacement of the catheter in the colon without any notable contrast medium in the stomach. Although the patient expressed no complaints, he underwent surgery on the same day proving the colocutaneous fistula. There were no signs of peritonitis. The patient's postoperative recovery was uneventful.

DISCUSSION

Pull-PEG requires an intact oesophageal passage. The spread of bacteria and tumour cells is a possible risk factor. Direct punction PEG might be better in these cases. This method is not a standard procedure, but the recent implementation of an additional gastropexy represents a significant improvement. We experienced a rare complication, which was first described in 1987. However, this case is the first documented complication in association with gastropexy. This case shows that even gastropexy does not prevent colon interposition. Therefore, an endoscopic or radiological control of the tube placement after changing seems to be necessary.

Examination, prevention and treatment of osteoporosis in patients with inflammatory bowel disease: recommendations and reality

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at increased risk of developing osteopenia and osteoporosis. Our aim was to evaluate the current practices of examination, prevention and treatment of osteoporosis in IBD patients in a routine clinical setting.

METHODS

A total of 154 consecutive patients with IBD (63 female, 91 male; 36 ulcerative colitis, 115 Crohn's disease, 3 indeterminate colitis), referred to two gastroenterological units for scheduled follow-up examinations, were included. Patient charts were evaluated regarding bone densitometry already performed and any prophylactic or therapeutic interventions in cases of low bone mineral density.

RESULTS

Bone mineral density (BMD) measurements had been performed only in 38 patients (25%). BMD was abnormally low in 27 of the examined patients (71%), 20 of whom had osteopenia and seven had osteoporosis. Among the subgroup of patients on long-term steroid therapy (77 patients), 30 had been referred to bone densitometry during the course of disease, and 21 of them were found to have low bone mineral density. Preventive measures were prescribed in 12 patients (9% of the whole study population). In the majority of the patients with low bone mineral density, calcium and vitamin D were used as treatment.

CONCLUSIONS

Despite the high prevalence of osteopenia and osteoporosis in patients with IBD, only a minority of these patients were included in a structured program in accordance with modern guidelines for diagnosing and preventing this extraintestinal complication in a routine clinical setting.

[Colonoscopy and sigmoidoscopy in patients aged eighty years or older]

BACKGROUND

The demographic development will lead to an increase in endoscopic examinations in elderly patients. Indications, feasibility and therapeutic consequences following detection of pathologic findings are important assessing the relevance of endoscopy in geriatric patients.

METHODS

We analyzed all colonoscopies and sigmoidoscopies which were performed between January 1995 and December 2000 in patients older than 80 years. The parameters indication, sedation, colonoscopy completion rate, endoscopic findings, therapeutic consequences and complications were evaluated.

RESULTS

A total of 951 endoscopies in patients older than 80 years (781 colonoscopies, 170 sigmoidoscopies; mean age 84.3 years) were performed. The most frequent indications were: abdominal pain (n = 144; 15 %), bleeding (n = 115; 12 %), constipation (n = 97; 10 %), anemia (n = 85; 9 %), and history of polyps (n = 78; 8 %). Sedation was used in 183 examinations (19 %), mostly with midazolam (n = 179). Colonoscopy was completed successfully to the coecum in 71 %. 214 examinations were unremarkable (23 %). Frequent pathologic findings were: diverticular disease (n = 396; 42 %), polyps (n = 256; 27 %), and colorectal carcinoma (n = 75; 8 %). Curative surgery was possible in 55 % and palliative surgery in 9 % of patients with colorectal carcinoma, respectively. A complication was observed in six patients (0.6 %), four bleedings following polypectomy, one perforation after dilatation of a stenotic tumor, and one transient neurologic deficit.

CONCLUSIONS

Endoscopy of the lower gastrointestinal tract is feasible in geriatric patients with a low rate of complications. The low number of normal findings and the frequent diagnosis of colorectal carcinoma were remarkable. In spite of old age more than half of the patients with carcinoma could be operated curatively emphasizing the importance of endoscopic investigations in this age group.

[Indications and results of endoscopic examinations in intensive care units]

The aim of the study was to analyze retrospectively all endoscopies performed on 3 intensive care units in a tertiary referral center with more than thousand beds during a period of ten years. The study evaluates all endoscopies with regard to indication and findings. In the years 1989-1998 a total of 326 endoscopic examinations was performed, most of them were done as an upper gastrointestinal endoscopy (88%). In more than 87% the indication was a suspected gastrointestinal bleeding. The most frequent findings consisted in ulcers of the stomach or duodenum and esophageal varices, then followed by Mallory-Weiss-lesions, esophagitis and erosive gastritis. The etiology of gastrointestinal bleeding was similar to that of non intensive care patients. Specific causes of bleeding such as esophagitis caused by nasogastric tubes were only found in 3% of all bleedings. The numbers of endoscopies on the 3 intensive care units were increasing during the ten year period, however the numbers of the patients treated on the intensive care units were also increasing, but the increase of endoscopies was not always parallel to the rising number of intensive care patients.

[Obstructive jaundice and acute pancreatitis due to an obstruction of the afferent loop after billroth-II-resection]

An obstruction of the afferent loop after Billroth-II-resection is an extremely rare late complication of this procedure. We report on a 76-year-old female patient with a history of Billroth-II-resection 11 years ago who was admitted due to acute pancreatitis and obstructive jaundice. Abdominal sonography lead to the suspicion of a dilated afferent loop, which could be proven by means of magnetic resonance imaging. A tumorous lesion as cause of the obstructive jaundice was not detectable. Intraoperatively a volvulus of the small intestine and strangling adhesions near the Braun's anastomosis were seen, causing the obstruction of the afferent loop. Following reposition of the small intestine and adhesiolysis the patient gained a quick relief of symptoms and the jaundice disappeared completely.

[Current concepts in therapy of reflux disease]

Proton pump inhibitors have replaced H2-blockers as first line agents for the therapy of gastroesophageal reflux disease due to their effective acid suppression and faster healing rate. The endoscopic severity of esophagitis and the clinical response are the most important determinants of dosing and duration of therapy. In patients with severe esophagitis continuous maintenance treatment with proton pump inhibitors is recommended. In recent years antireflux surgery has been established as an important alternative therapy.

Effect of additives on the flow-analysis determination of weak-acid-dissociable and total cyanide

The effect of reductants, complexants, and nitrite eliminators on the flow-analysis determination of weak-acid-dissociable and total cyanide has been studied for: 1. cyanide recovery from copper, nickel, and iron complexes; 2. cyanide generation from the reagents in the presence of common interferents; and 3. cyanide consumption by the reagents in the presence of those interferents. In the absence of additives the UV-assisted recovery of (total) cyanide from the iron complexes (using a succinate buffer) was insufficient. Arsenite and hypophosphite had no measurable effect on the recovery, ascorbic acid resulted in total recovery but under these conditions nitrite and sulfite seemed to destroy cyanide. Phenanthroline promoted the recovery of cyanide from iron complexes but led to formation of cyanide from thiocyanate. Citrate resulted in good recovery but in the presence of nitrite cyanide was formed; the recovery with EDTA was also good. It proved necessary to destroy nitrite by use of sulfamic acid. If a combination of EDTA, citrate, and sulfamic acid is used rather high concentrations of thiocyanate, nitrite, thiosulfate, and sulfite can be tolerated in the samples. It is strongly advisable to test modifications of the cyanide determination comprehensively, because some surprising results have been obtained.

Adenosine-enhanced ischemic preconditioning modulates necrosis and apoptosis: effects of stunning and ischemia-reperfusion

BACKGROUND

Adenosine-enhanced ischemic preconditioning extends the protection of ischemic preconditioning by both significantly decreasing infarct size and significantly enhancing postischemic functional recovery.

METHODS

The effects of adenosine-enhanced ischemic preconditioning on necrosis and apoptosis were investigated in the sheep heart using models of stunning (15 minutes regional ischemia, 120 minutes reperfusion) and ischemia-reperfusion (30 and 60 minutes regional ischemia, 120 minutes reperfusion). Ischemic preconditioned hearts received 5 minutes regional ischemia, 5 minutes reperfusion before ischemia. Adenosine-enhanced ischemic preconditioned hearts received a 10 mmol/L adenosine bolus (10 mL) through the left atrium coincident with ischemic preconditioning. Adenosine hearts received a 10 mmol/L bolus (10 mL) of adenosine. Regional ischemic hearts received no pretreatment.

RESULTS

Minimal apoptosis (< 45 per 3,000 myocytes) was observed in the stunning models but was significantly increased with ischemia-reperfusion in regional ischemic hearts after 30 minutes (p < 0.05 versus ischemic preconditioning, adenosine, or adenosine-enhanced ischemic preconditioning) and in adenosine and ischemic preconditioned hearts after 60 minutes ischemia (p < 0.05 versus adenosine-enhanced ischemic preconditioning). DNA laddering was apparent after 60 minutes ischemia in regional ischemia, adenosine, and ischemic preconditioning but not in adenosine-enhanced ischemic preconditioned hearts.

CONCLUSIONS

Adenosine-enhanced ischemic preconditioning significantly ameliorates necrosis and apoptosis in the regional ischemic blood-perfused heart.

Concomitant manifestation of achalasia and sphincter of Oddi dysfunction

We report the case of a 44-year-old woman who suffered from biliary-type pain after cholecystectomy, dysphagia, and weight loss. Examinations revealed sphincter of Oddi dysfunction (SOD) and achalasia. Complete relief of symptoms was achieved by endoscopic sphincterotomy and pneumatic dilation of the distal esophagus. This case report demonstrates for the first time the concomitant manifestation of two motility disorders of the upper gastrointestinal tract, i.e. achalasia and SOD. At present, any causal relationship seems speculative; however, both diseases were successfully treated using endoscopic procedures.

Recurrent septicemia with lethal outcome during and after cyclosporine therapy in severe ulcerative colitis

High dose corticosteroids have been the mainstay in the treatment of fulminant ulcerative colitis (UC) for a long time. In the last years intravenous cyclosporine (CyA) has been reported to be rapidly effective and relatively safe in patients with severe corticosteroid-resistant UC. We report on a 64 year old patient with a severe flare-up of UC who responded well to intravenous CyA after a standard therapy with high dose corticosteroids alone had been ineffective. However, recurrent staphylococcus aureus sepsis developed during CyA therapy. Despite a long-time antibiotic therapy two further episodes of staphylococcus aureus sepsis occurred after discontinuation of CyA treatment. Being in remission with his UC the patient died 14 months later of staphylococcus aureus sepsis despite intense antibiotic treatment. Infectious complications of this therapeutic regime in severe UC are known but to our knowledge a recurrent sepsis complicating this therapy even after cessation of CyA has not been reported in the literature so far.

[Angiographic image of intestinal angiodysplasia of the duodenum in comparison with endoscopy--case report]

Angiodysplasia of the bowel wall is a malformation of intestinal giodysplasia of the bowel wall is a malformation of intestinal blood vessels. There seem to be different aetiologies of this disease entity. It is reported to be a common cause of occult intestinal bleeding in patients with negative findings on primary endoscopy of the upper and lower gastrointestinal tract. They occur most frequently in the right colon. The case reported demonstrates endoscopy and arteriography of extensive angiodysplasia in duodenum and proximal jejunum causing severe bleeding.

Hydrocortisone enhances total IgE levels--but not the synthesis of allergen-specific IgE--in a monocyte-dependent manner

Recently, hydrocortisone (HC), when combined with human IL-4, has been reported to increase IgE levels in supernatants (SN) of in vitro cultured leucocytes. In this study we investigated the influence of HC on allergen-specific IgE synthesis. Moreover, we examined the relevance of different cell types in this respect. Peripheral blood mononuclear cells (PBMC), T-cell depleted PBMC, CD14-depleted PBMC and highly purified B cells from 10 allergic (birch pollen and/or grass pollen) patients and five non-allergic individuals were investigated. The cells were incubated with HC and/or recombinant human IL-4 (rIL-4) for 8 days. A considerable increase of total IgE was observed in HC/rIL-4-stimulated cultures compared with rIL-4 alone, HC alone or non-stimulated cultures. We demonstrate that this effect depends on the presence of monocytes in in vitro cultures. These results were seen in every experiment, irrespective of healthy or atopic state of the blood donor. The increase of IgE could not be attributed to a rise of birch pollen-and/or grass pollen-specific IgE in patients allergic to these allergens, as shown by IgE-immunoblot. Radio-allergosorbent test (RAST) investigations of HC/rIL-4-stimulated cells cultures from allergic and non-allergic patients confirmed that HC/rIL-4-induced elevated IgE production was also not due to increased production of IgE, specific for important aero-allergens (pollens, house dust mite or animal dander). Therefore we conclude that newly synthesized IgE is not specific for allergens, but that sequential isotype switching in human B cells leads to increased polyclonal IgE production.

Substrate specificity of the gastrin-amidating enzyme

As is the case with many other peptide hormones of the brain and gut, gastrin requires a carboxyl-terminal amide moiety for optimal biological activity. In the structure of progastrin, the carboxyl-terminal Phe of gastrin is followed by the sequence Gly93-Arg94-Arg95, which must be processed sequentially by an endoprotease, a carboxypeptidase, and an amidating enzyme to produce amidated bioactive gastrin. To examine the molecular determinants of peptide amidation in vivo, we mutated the wild-type Gly93 residue of progastrin to Ala93 and Ser93 and expressed the three progastrin DNAs in GH3 and MTC 6-23 endocrine cell lines. Although substantial quantities of amidated gastrin were seen in cells expressing wild-type progastrin, replacement of Gly93 with Ala93 completely abolished production of amidated gastrin when the cells were incubated in standard medium containing only L-alanine. In a similar fashion, cells expressing [Ser93]progastrin also demonstrated no production of amidated gastrin. When cells expressing [Ala93]- or [Ser93]progastrin were incubated in the presence of 1 mg/ml D-alanine or D-serine, respectively, a small but consistent amount of amidated gastrin production was detected (< 1% of wild type). These data lead us to conclude that the amidating enzyme has a rigid substrate specificity for a glycine-extended precursor. Furthermore, this in vivo substrate specificity confirms the importance of the pro-S-alpha-hydrogen of the carboxyl-terminal glycine for enzyme-substrate recognition.

Lack of effect of drinking water chlorine on lipid and thyroid metabolism in healthy humans

Animal studies and a single human epidemiological study have suggested that chlorine in drinking water may raise the level of blood cholesterol. The purpose of this study was to determine whether a 4-week exposure to drinking water chlorine (1.5 L per day) at a concentration of 20 ppm (ppm = mg/L) under controlled conditions would alter circulating parameters of lipid metabolism in healthy humans. Thirty men and thirty women each completed an 8-week protocol during which diet (600 mg cholesterol per day, 40% calories as fat) and other factors known to affect lipid metabolism were controlled. For the first 4 weeks of the protocol, all subjects consumed distilled water. For the second 4 weeks, half of the subjects were assigned randomly to drink 1.5 L per day of chlorinated water (20 ppm), while the others continued drinking distilled water. Four blood samples were collected from each subject at the end of each 4-week study period. Compared to the control group, those subjects given chlorine showed no significant changes in total plasma cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, or apolipoproteins A1, A2, or B. There was a trend toward low serum thyroxine and triiodothyronine levels in men given chlorine, though thyroid-stimulating hormone levels were unchanged. This trend, if real, was not clinically significant. Thus, short-term exposure to chlorinated drinking water at 20 ppm appears to have no significant impact on parameters of lipid or thyroid metabolism in healthy humans.

Effects of drinking water monochloramine on lipid and thyroid metabolism in healthy men

The purpose of this study was to determine whether a 4-week consumption of 1.5L per day of drinking water containing monochloramine at a concentration of 2 ppm (ppm = mg/L) or 15 ppm under controlled conditions would alter parameters of lipid or thyroid metabolism in healthy men. Forty-eight men completed an 8-week protocol during which diet (600 mg cholesterol per day, 40% calories as fat) and other factors known to affect lipid metabolism were controlled. During the first 4 weeks of the protocol, all subjects consumed distilled water. During the second 4 weeks, one-third of the subjects were assigned randomly to drink 1.5 L per day of water containing 2 ppm of monochloramine, to drink 1.5 L per day of water containing 15 ppm monochloramine, or to continue drinking distilled water. Four blood samples were collected from each subject at the end of each 4-week study period. Subjects drinking monochloramine at a concentration of 2 ppm showed no significant changes in total cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, apolipoproteins A1, A2, or B when compared to the distilled water group. Parameters of thyroid function also were unchanged by exposure to monochloramine at this concentration. However, subjects drinking monochloramine at a concentration of 15 ppm experienced an increase in the level of apolipoprotein B. Other parameters of lipid and thyroid metabolism did not change. We conclude that consumption of drinking water containing 2 ppm of monochloramine does not alter parameters of lipid and thyroid metabolism in healthy men. Consumption of water containing 15 ppm monochloramine may be associated with increased levels of plasma apolipoprotein B.

[Interstitial radiotherapy of breast cancer. Preliminary report of a prospective study of 165 cases subjected to breast-conserving treatment]

The results of a prospective study on breast conserving therapy in early stage breast cancer are presented. From January 1983 to June 1987 165 patients were treated by a standardized therapy-protocol. The criteria for entering the trial were stage T1 to T2 and N0 to N1. Surgical breast conservation was achieved by segmental resection in 148 cases and by tumorectomy in 17 cases. 160 patients underwent axillary lymph node dissection. Obligatory 45 to 50 Gy were delivered percutaneously to the operated breast and optional 50 Gy to the regional lymph nodes (axillary lymph node involvement greater than 3 nodes). In addition, the area of the primary breast lesion itself was boosted interstitially by an Iridium 192 implant (LDR-technique: 15 to 20 Gy, HDR-technique: 10 to 12 Gy).

RESULTS

Progression of disease in 10% of the patients (16/165), local recurrence rate in the operated breast: 2% (3/165), axillary recurrence: 0.5% (1/165). 5% of the patients (8/165) died from metastatic disease, two patients died free of recurrence for reasons unrelated to cancer, two other patients died on unknown reasons. Because of the low number of local recurrences and the observation period of 32 months, no statistically contribution on high risk factors for local failure could be found.

Prognostic factors for local recurrence in patients with limited surgery and irradiation of breast cancer

Between January 1975 and December 1984, 239 patients after breast conserving surgery were referred to the University Clinic for Radiotherapy and Radiobiology of Vienna. Of these patients 214 were available for analysis with regard to loco-regional control and cosmetic outcome. The breast received supervoltage irradiation from two tangential fields, in 82% with a tumor dose of 50 Gy and in 15% 50 to 60 Gy. In addition 70% of the patients received a boost dose with 7.5 to 15 MeV electrons to the tumor bed and the scar. The overall local failure rate was 10.2%. For patients with T1,2 and negative axillary nodes or less than four positive lymph nodes (N = 160) a recurrence rate of 7.1% was observed. Factors correlated to a higher local recurrence rate were in this retrospective study axillary status (greater than 3 positive lymph nodes), histopathologic grade (G III), absence of clear margin after surgery and absence of additional electron boost.

Regional chemotherapy of inoperable maxillofacial tumours combined with radiotherapy. Long-term results

At the Department of Oral Maxillo-Facial Surgery, University of Vienna, we have from January 1973 to September 1985, subjected 117 patients with inoperable malignant tumours in the maxillo-facial area to intra-arterial chemotherapy consisting of methotrexate and bleomycin. In this group 103 patients have also been given radiotherapy. In this report only 68 patients of the group of 103 patients who have undergone combined treatment have been considered eligible for evaluation on the basis of their post-therapeutic survival time, which ranged from 2 to 11 years. 10 cases with complete remission and 34 cases with partial remission were observed, indicating that 65% responded to combined treatment.

[Breast-preserving treatment of breast carcinoma]

Based on our 14-year experience with breast-preserving treatment of breast cancer, we recommend limited surgical intervention for the removal of a small mammary carcinoma under the proviso that adequate radiotherapy is available and that the patient can be thoroughly followed up. We are convinced that the good cosmetic result and especially the excellent psychological reaction are particularly important in order that women lose their fear of an ablative operation. Only then, by performing an operation which is not excessive at the earliest possible time can the prognosis of this type of carcinoma, which is increasing be improved.

Local control and outcome of patients irradiated for isolated chest wall recurrences of breast cancer

Between January 1970 and December 1978, 149 breast cancer patients with isolated chest wall recurrences developing after initial curative treatment (mastectomy with or without postoperative irradiation) were referred to the University Clinic for Radiotherapy and Radiobiology of Vienna. Following radiotherapy, survival was analysed in 134 patients with regard to the amount of disease in the chest wall at the time of treatment and local tumour control. Patients with "subclinical" disease (after excision of solitary recurrences) had a median survival time of 55 and 50 months for controlled and uncontrolled disease in the entire chest wall, respectively. The corresponding survival times for patients with "macroscopic" chest wall disease was 36 and 25 months, respectively. Local tumour control within the irradiated field was 69% for patients with subclinical disease and 49% for patients with macroscopic tumour manifestation. Freedom from tumours in the entire chest wall could be achieved in 41% of patients with subclinical and 24% of patients with macroscopic disease. The 5-year survival rate for patients with subclinical disease, with tumour control in the entire chest wall is 53%. Of all 134 patients, 22% survived 5 years from the time of local recurrence.

Human interleukin-3-like activity, basophil and eosinophil growth promoting activities and colony stimulating factor derived from several cell lines

Human IL-3-like activity, colony stimulating factor (CSF) and basophil/eosinophil growth promoting activity (Ba/Eo GPA) in serum-free conditioned media (CM) derived from various cell lines of human origin were examined. Squamous cell carcinoma (Colo-16), osteogenic sarcoma (R97KL4) and human placental (HP) cells produced 10-20% IL-3 activity present in supernatants from a mouse myelomonocytic cell line (WEHI-3BCM) when assayed using a murine IL-3 dependent cell line (32Dcl/H4). The human T-cell leukemic cell line (Mo) and several neuroblastoma cell lines did not produce IL-3-like activity, nor did purified human erythroid potentiating activity (EPA) from Mo contain IL-3. CSF and Ba/Eo GPA were detected in CMs from Mo, HP, Colo-16 but not from R97KL4. No IL-2 activity was detected in any of these CMs. These observations point to the existence of diverse sources of human IL-3-like activity and to the probable distinctiveness of human IL-3, basophil or eosinophil GPA, and EPA. Analogies drawn between human and murine hemopoietic activities need to be made with caution.

[Male breast cancer]

Between 1974 and 1982 inclusive 18 male patients were treated for breast carcinoma. 12 patients had postoperative radiotherapy whereas 4 were referred for treatment of recurrent or metastatic disease. One patient showed signs of inflammatory breast cancer and was treated with chemo-radiotherapy and one was being followed up in our department after radiotherapy for prostatic cancer in 1970. Median overall survival was 52 months and the median disease-free interval was 21 months.

Influence of vitamin D3 metabolites on the production of interleukins 1,2 and 3

We investigated the effect of vitamin D3 metabolites on the release of the three interleukins (IL) IL 1, IL 2 and IL 3 by mononuclear cells. Models for the production of these mediators were the release of IL 1 by the murine macrophage cell line P388D1, of IL2 by rat spleen cells, and of IL 3 by the murine WEHI-3 cell line. IL 1 production was significantly increased with 1 alpha,25-dihydroxyvitamin D3 (1,25(OH)2D3) at 10(-10)M and above. 1,25(OH)2D3 did not stimulate cell proliferation as assessed with [methyl-3H]thymidine (3H-TdR) incorporation. 24,25-dihydroxyvitamin D3 (24,25(OH)2D3) and 25-hydroxyvitamin D3 (25(OH)D3) were about 1000 times less effective than 1,25(OH)2D3. IL 2 production, by cultured rat spleen cells stimulated with Concanavalin A, was decreased by increasing concentrations of 1,25(OH)2D3. The minimal effective dose varied between experiments and ranged from 10(-11) to 10(-8) M. Moreover, proliferation (3H-TdR incorporation) of mouse thymocytes treated with phytohemagglutinin and IL 1 was decreased in a dose-dependent fashion by 1,25(OH)2D3 starting at 10-11) M. This effect might be secondary to a decrease of endogenous IL 2 production. IL 3 release by WEHI-3 cells was significantly increased with 10(-11)-10(-9) M 1,25(OH)2D3, whereas higher concentrations were less effective or decreased IL 3 production. These results show that 1,25(OH)2D3 and, to a lesser extent, 24,25(OH)2D3 and 25(OH)D3 have selective effects on lymphokine production. It is tempting to speculate that the actions of 1,25(OH)2D3 on bone might in part be mediated by lymphokines. Moreover, we suggest that 1,25(OH)2D3 might not be an immunoregulator per se, but makes use of the immune system to exert its influence on one of its classical targets, namely the bone, and possibly on other connective tissues.

[10 years' experience with the concept of breast-saving therapy in the treatment of breast cancer]

A therapeutic concept dependent on staging of breast carcinoma is presented. In 1974 we started at the 2. Surgical University Clinic Vienna to use the non ablative treatment in patients with breast cancer smaller than 2 cm. Up to 1984 102 patients underwent quadrantectomy axillary dissection, and radiotherapy. With equal therapeutic results the smaller and cosmetically preferable surgical intervention is recommended.

[Prognostic factors in the treatment of inoperable orofacial tumors with simultaneous radiotherapy and intra-arterial chemotherapy]

Between January 1973 and April 1982 66 evaluable patients with advanced inoperable orofacial tumours underwent intraarterial Bleomycin and Methotrexate with simultaneous radiotherapy in a prospective study. 32 patients had no previous treatment, 34 patients had initial surgery, radiotherapy and/or chemotherapy. 15 mg Bleomycin were administered through a catheter into the arteria externa carotis daily in the morning. 25 mg Methotrexate were given in the same way at night followed by 3 mg Calcium-Leucovorin i.m. every 8 hours. The cumulative dose was 300 mg Bleomycin and 500 mg Methotrexate. Four hours after the administration of Bleomycin the target volume was irradiated (single fraction 2 Gy, total dose 60 to 65 Gy). The overall response rate was 65% containing 17% complete and 48% partial remission. Destruction of the bone appeared to be the most important index at the start of the therapy. Further prognostic determinants as previous treatment, localisation of the primary tumours (maxilla and mandibula respectively oral cavity and oropharynx) and local regional lymphnode stage missed statistically significance in the survival time, may be due to a possible radiosensitizing effect of the simultaneous chemotherapy. Complete remission turned out to be the most important prognostic factor after the end of treatment. Patients responding with complete remission show a median disease free survival of 56+ months and a median survival time of 82 months. Acute reactions were reversible. Only in 14% of the patients the treatment could not be finished. Better results could be obtained by electron-affinic radiosensitizers and high LET radiation.

Misonidazole and irradiation in the treatment of high-grade astrocytomas: further report of the Vienna Study Group

A randomized study investigating the value of misonidazole in patients irradiated for grade III and IV supratentorial astrocytomas was started in June 1977. With a minimum follow-up time of 6 months, 45 patients who completed therapy are available for analysis. All patients received the same radiation treatment (66.5 Gy in 31 fractions over 7.5 weeks, field size reduction after 45 Gy). In the first, second and eighth week, a 4 Gy tumor dose was given on Monday and Thursday. Misonidazole was given 4 hours before irradiation to 18 randomized patients on those 6 treatment days (2.1-2.7 g/m2 per treatment day). Daily tumor doses of 1.7 Gy were administered Monday through Friday from the third until the seventh week. Median survival for patients treated with misonidazole is 13.8 months; for those treated by irradiation alone it was 9.8 months. The corresponding 1 year survival rates are 64 and 25%, respectively. Survival plots indicate some advantage for the patients treated with misonidazole, however statistically there is no significant difference observed (p greater than 0.08). There are no significant differences in Karnofsky performance status, sex and in histological grade or in age distribution between the groups. However, the type of surgery (complete or subtotal) influenced survival markedly: patients with complete surgery lived significantly longer (p less than 0.0009). Neurotoxic side effects of misonidazole were minimal.

[Role of radiotherapy in inflammatory local recurrence of breast cancer : first experiences with combined radio-chemotherapy]

Between June 1976 and October 1981 ten patients with extended inflammatory recurrent mammary carcinoma of the chest wall and distant metastases underwent sequential chemo- and radiotherapy at the University Clinic for Radiotherapy and Radiobiology in Vienna. Five of these patients had received local treatment of recurrent mammary carcinoma of the chest wall before. Eight of ten patients responded to therapy, 5 showed complete remission. The mean remission period of 8.8 months for the chest wall area is significantly longer than that of distant metastases with 6.1 months (p less than 0.05). Local megavolt therapy has no influence on the mean survival time, but improves the quality of life considerably. All patients under treatment achieved at least 80% on the Karnofsky score. After a comprehensive study of recent international literature the authors have come to the conclusion that local and regional recurrence after initial treatment obviously prove an advanced stage. For this very reason the prevention of local regional recurrence by means of postoperative megavolt therapy is of great significance.

[Clinical course of patients with isolated chest wall recurrences of breast cancer]

A retrospective study was done of 149 patients with isolated chestwall recurrences of breast cancer. All patients received chestwall irradiation for the recurrence. The absolute survival for the patients at five years from the onset of chestwall recurrence was 28,4%. The amount of chestwall disease at the time of irradiation for the recurrence (subclinical versus macroscopic) as well as the time interval between mastectomy and recurrence were found to be prognostically significant factors. For patients with subclinical chestwall disease and a time interval to recurrence of at least two years the survival rate at five years was 53,8%. As about 80% of all patients with chestwall recurrences ultimately developed distant metastases, the importance of elective postoperative irradiation as part of the initial curative management of breast cancer is stressed.