Reasoned therapeutic protocol in outpatients with COVID-19

BACKGROUND

Seventy percent of patients affected by SARS-COV-2 disease are asymptomatic or with symptoms that not required Hospitalization. A prodromal period lasting about 5 days can be identified. In this phase a patient with a positive swab for viral RNA may or may not evolve towards the phase of symptomatic disease.

METHODS

In this paper we reviewed the literature related to COVID-19 therapy we propose a reasoned treatment protocols in outpatients according to the age and the comorbidity.

RESULTS

The aim of this study was to reduce the impact of the virus by reducing its ability to attack cells and the inflammatory burden and the prothrombotic effects proposing two therapeutic schemes of proven efficacy according to the age of the patients and the comorbidities.

CONCLUSIONS

We aimed to reduce worsening of clinical status and hospitalization while protecting patients at home.

Mauro Bartolo and Franco Pratesi

This paper is part of the monographic issue: ‘Did the Masters of the past know the future? History and update of Italian Phlebolymphology’  Guest editor: Alberto Macciò (Phlebology - Part I edited by G. Agus; Phlebology - Part II edited by P. Bonadeo; Lymphology edited by F. Boccardo)

Oedema in Chronic Venous Insufficiency: Physiopathology and Investigation

Aim:

To review the physiology of the venous system in the leg and the events in the microcirculation of the skin leading to development of the symptoms of chronic venous insufficiency (CVI).

Method:

A review of current literature in the field of CVI has been conducted, with particular reference to the microcirculation and the means of investigating this.

Synthesis:

Venous valvular incompetence and obstruction in the lower limb causes damage to the microcirculation of the skin. The resulting venous hypertension is resisted by the microcirculation. Cutaneous vasomotion alters, with a prevalence of closing periods of the pre-capillary sphincters, limiting capillary hypertension and resulting in capillary haemoconcentration. This phenomenon promotes drainage of fluids from the interstitial spaces and prevents hypoxic damage to the endothelium. In severe CVI this defence mechanism is overwhelmed, vasomotion declines and arteriolar vasoparalysis occurs. The capillary bed is filled and the intracapillary pressure increases. Reduced microcircula-tory perfusion flow velocity favours capillary plugging by white cells. Leucocyte activation damages the endothelium through the release of proteolytic enzymes, oxygen metabolites and lipid oxidation products. Increased permeability of the endothelium allows passage of fibrinogen and results in a perivascular fibrin cuff. Initially this protects the capillary but later blocks oxygen exchange. These events lead to capillary thrombosis with destruction of capillaries with tissue ischaemia and trophic lesions.

Conclusions:

The result of venous hypertension in the large veins of the lower limb is damage to the microcirculation of the skin. This leads to lipodermato-sclerosis and eventually ulceration in some patients.

Venous hemodynamic changes in lower limb venous disease: the UIP consensus according to scientific evidence

There are excellent guidelines for clinicians to manage venous diseases but few reviews to assess their hemodynamic background. Hemodynamic concepts that evolved in the past have largely remained unchallenged in recent decades, perhaps due to their often complicated nature and in part due to emergence of new diagnostic techniques. Duplex ultrasound scanning and other imaging techniques which evolved in the latter part of the 20th century have dominated investigation. They have greatly improved our understanding of the anatomical patterns of venous reflux and obstruction. However, they do not provide the physiological basis for understanding the hemodynamics of flow, pressure, compliance and resistance. Hemodynamic investigations appear to provide a better correlation with post-treatment clinical outcome and quality of life than ultrasound findings. There is a far better prospect for understanding the complete picture of the patient's disability and response to management by combining ultrasound with hemodynamic studies. Accordingly, at the instigation of Dr Angelo Scuderi, the Union Internationale de Phlebologie (UIP) executive board commissioned a large number of experts to assess all aspects of management for venous disease by evidence-based principles. These included experts from various member societies including the European Venous Forum (EVF), American Venous Forum (AVF), American College of Phlebology (ACP) and Cardiovascular Disease Educational and Research Trust (CDERT). Their aim was to confirm or dispel long-held hemodynamic principles and to provide a comprehensive review of venous hemodynamic concepts underlying the pathophysiology of lower limb venous disorders, their usefulness for investigating patients and the relevant hemodynamic changes associated with various forms of treatment. Chapter 1 is devoted to basic hemodynamic concepts and normal venous physiology. Chapter 2 presents the mechanism and magnitude of hemodynamic changes in acute deep vein thrombosis indicating their pathophysiological and clinical significance. Chapter 3 describes the hemodynamic changes that occur in different classes of chronic venous disease and their relation to the anatomic extent of disease in the macrocirculation and microcirculation. The next four chapters (Chapters 4-7) describe the hemodynamic changes resulting from treatmen by compression using different materials, intermittent compression devices, pharmacological agents and finally surgical or endovenous ablation. Chapter 8 discusses the unique hemodynamic features associated with alternative treatment techniques used by the CHIVA and ASVAL. Chapter 9 describes the hemodynamic effects following treatment to relieve pelvic reflux and obstruction. Finally, Chapter 10 demonstrates that contrary to general belief there is a moderate to good correlation between certain hemodynamic measurements and clinical severity of chronic venous disease. The authors believe that this document will be a timely asset to both clinicians and researchers alike. It is directed towards surgeons and physicians who are anxious to incorporate the conclusions of research into their daily practice. It is also directed to postgraduate trainees, vascular technologists and bioengineers, particularly to help them understand the hemodynamic background to pathophysiology, investigations and treatment of patients with venous disorders. Hopefully it will be a platform for those who would like to embark on new research in the field of venous disease.

Selective high ligation of the sapheno-femoral junction decreases the neovascularization and the recurrent varicose veins in the operated groin

AIM

High ligation (HL) and stripping of GSV can be distinguished in Babcock's radical ligation (RHL), and selective (SHL): the new technique consists to ligate the SFJ keeping some of the tributary veins. The study analyzes the neovascularization and recurrence incidence in the groin after the SHL.

METHODS

A retrospective study performed in a center specialized in venous surgery in Italy, it included 360 patients underwent unilateral varicose vein surgery from January 2001 to December 2008 (210 females and 150 males, mean aged 51.9 years, range 18 to 75 years, the limbs were 222 rights and 138 lefts), CEAP classification was C2,s. Operative technique was standardised to SFJ ligation with the SHL, the GSV was stripped to the level of the knee, multiple phlebectomies were performed and the ligation of the incontinent perforating veins was performed if it was necessary. All patients had a venous reflux from terminal valve of SFJ and the femoral valves were continent. All patients were submitted to clinical examination of the lower limbs and Duplex Scanning (DS) in the pre/postoperative period every year after surgery and by two independent operator in 2013. The follow-up is from 5 years for the patients operated in 2008 to 12 years for the patients operated in 2001.

RESULTS

The neovascularizations and recurrencies in the groin were founded in 7 patients, the incidence is 1.9% of the total cases. The GSV stump and the left tributaries were open to venous flow, it was no venous reflux from the groin, no venous thrombosis of the GSV stump were detected.

CONCLUSION

The SHL of the SFJ is a reliable technique, decreasing the incidence of neovascularizations and recurrent varicose veins in the operated groin.

Quality of live as measured by the CIVQ 20. Questionnaire following oral mesoglycan treatment of patients with chronic venous disease

AIM

Several studies have demonstrated the effective antithrombotic action of mesoglycan to treat chronic venous disease (CVD). The study aimed to assess clinical and quality of life (QoL) (CIVIQ 20 questionnaire) improvements in mesoglycan-treated patients with clinical, etiological, anatomical and pathophysiological (CEAP) stages 2 and 3.

METHODS

The open, multicentre, uncontrolled, observational, prospective study involved treating patients with 50 mg x 2/day mesoglycan for 2 months and measuring improvement to lower-limb edema and QoL in the Global, Physical, Pain, Psychological, and Social Dimensions of the Chronic Venous Disease Quality-of-Life Questionnaire (CIVIQ 20) at the first, baseline visit (V1), at the end of treatment (V2) and 2 (V3) and 4 months after treatment completion (V4). At the last visit (V4), patient disease status was assessed objectively (by the treating physician) and subjectively (by the patient). The study population was divided into three groups: 1) patients with only varicose veins; 2) patients with only lower-limb edema; 3) patients with varicose veins and edema (ITT population).

RESULTS

Seventy-five centers enrolled 1066 patients (ITT population); 914 patients completed the study. Mesoglycan treatment produced significant improvement of edema and lower-limb circumference at every visit, in both patients with edema alone and those with edema and varicose veins (paired sample t-test P<0.001). QoL improved significantly in all questionnaire dimensions in all three patient groups even after treatment was concluded (V2). Improvement continued up to the end of the study observation period (V4) (paired sample t-test P<0.001). Objective clinical improvement of the underlying CVD was found in 76.82% of patients with varicose veins alone, in 82.83% of patients with edema alone, and in 76.7% of patients with varicose veins and edema. Patients' own subjective assessment of improvement was 82.0%, 79.39% and 79.39% respectively for the three groups.

CONCLUSION

Results showed mesoglycan treatment to improve QoL significantly in patients with CVD as measured by a specific questionnaire like the CIVIQ 20. The extent of average edema reduction observed at the last visit (4 months after the end of drug treatment), suggests mesoglycan might have an etiological role, modifying the physiological factors underlying CVD and not just affording temporary improvement of symptoms.

Acceptance, compliance and effects of compression stockings on venous functional symptoms and quality of life of Italian pregnant women

AIM

The rates of pregnant women with functional symptoms of venous insufficiency who accepted or refused to wear therapeutic compression stockings were evaluated and compared in relation to their clinical evolution and their compliance levels.

METHODS

The observational study was conducted in pregnant women between 4 and 28 weeks of amenorrhea presenting a CEAP C0S to C3S venous disease. Therapeutic compression stockings (BSN medical, UltraSheer Maternity stockings, 15-20 mmHg) were offered to pregnant women satisfying the inclusion criteria during routine check visits, and both groups of patients (those who accepted as well as those who refused) were followed up until the end of the pregnancy. The clinical profiles of both groups and the evolution of the venous insufficiency were monitored and compared. The women were requested to indicate pain and further quality of life parameter by means of a specific questionnaire (CIVIQ).

RESULTS

Ninety-eight women were included in the study and followed up; 30.6% (N.=30) of the women refused to wear compression stockings (Wr), 69.4% accepted 10.6% were not compliant to a daily wear (Wanc) and 58.8% wore them every day (Wac). Leg pain was more prominent in case of the Wac group (49.5 ± 21.3) than in case of the Wanc (42.1 ± 20.4) and Wr groups (36.6 ± 18). Their global quality also decreased (48.8 ± 15.7 vs. 43.6 ± 16.1 and 36.6 ± 15.6). Regular use of compression stockings led to decrease of pain (Wac -17 ± 10.1 vs. Wanc -10.3 ± 10.5 vs. Wr -4.2 ± 9.8 [P < 0.0001]) and enhanced total quality of life (Wac 13.5 ± 9.6 vs. Wanc 10.7 ± 11.3 vs. Wr -3.3 ± 9.4 [P < 0.0001). Similar results were observed on the CIVIQ subscale (pain, psychological, social, physical impact of legs' pain on women quality of life).

CONCLUSION

In daily practice, more than two third of the pregnant women accepted to wear compression stockings. The use of compression stockings reduced the legs pain and increased the quality of life of pregnant women.

The CEAP-L classification for lymphedemas of the limbs: the Italian experience

AIM

A method to classificate lymphedema has been needed to gather all the important information on the clinical evolution of the disease using a common language and an easy clinical applicability.

METHODS

The proposal for a new classification of the limb lymphedema was inspired by the C.E.A.P. classification for chronic venous insufficiency of the lower limb. The classification adopts the acronym C.E.A.P. by adding the letter L to underline the aspect ''lymphedema'' and is based on clinical data such as extension of lymphedema, presence of lymphangitis, leg ulcers and loss of functionality of the limb and instrumental criteria that permit to confirm and precise diagnosis. The Clinical classification is based on the most objective sign in these patients, the edema which is subdivided into 5 classes depending on the clinical manifestations. The etiological aspect considers 2 types of alterations of the lymphatic system: congenital and acquired. The anatomic is aimed to locate the anatomical structures involved. Pathophysiological conditions are gathered into 5 groups: agenesia or hypoplasia, hyperplasia, reflux, overload, obstruction.

RESULTS

The classification has already been appraised after 4 years of activity at the unit of Vascular and Endovascular Surgery of Ferrara, at the S. Giovanni Battista Hospital in Rome, at the Umberto I Ancona Hospital and at the S. Giovanni-Addolorata Hospital in Rome.

CONCLUSIONS

The proposal for a new classification of lymphedema C.E.A.P. L was developed in order to categorize patients with definite and objective marks, creating clinical reports with a common vocabulary, clear to all clinicians, permitting to stage the disease, evaluate treatment and finally obtain epidemiological and statistical data.

Skin necrosis during oral anticoagulant long-term treatment: an atypical side

The effectiveness of anticoagulant therapy for venous thromboembolism, with regards to both acute phase and long term prophylaxis, in patients with recurrent deep venous thrombosis (DVT) and persistence of risk factors, has been confirmed by many studies. However, it is not free of complications such as hemorrhage or, more rarely, skin necrosis. The patient, observed by us since 1994, was treated with oral vitamin K antagonists: he was affected by post-thrombotic syndrome and deficiency of congenital procoagulant factors (factor II heterozygote and MTHFR positive heterozygote) and secondary deficiency of procoagulant factors due to the consumption of protein C, with appearance of skin necrosis that occurred after many years of oral anticoagulant treatment. The change of therapy from oral anticoagulant to low molecular weight heparin and the use of local dressing, led to the resolution of the clinical symptoms and on to healing.

Propionyl-L-carnitine in Leriche-Fontaine stage II peripheral arterial obstructive disease

Peripheral arterial obstructive disease (PAOD) of the lower limbs affects 5% of the adult population. Uncontrolled arteriopathy is established due to a microcirculatory deficit, which may be present despite a good Winsor index and which leads to exhaustion of the functional microcirculatory reserve. The target of this study was to examine possible improvements in microvascular and tissue homeostasis by the administration of propionyl-L-carnitine (PLC). A total of 26 patients were enrolled in this study, aged 65 +/- 15 years; two males were diagnosed at stage IIA and 17 males and seven females at stage IIB PAOD. The main criterion of inclusion was the worsening of walking distance during the last month. In this study the duration of therapy was 33 days. PLC was administered in three flasks, each containing 300 mg in 250 cc saline by continuous infusion. The following parameters were measured before and after treatment: pain-free and maximum walking distance (measured on a treadmill at 3.2 km/hr with a gradient of 12%), recovery time from pain after maximum walking distance, ankle-brachial index by means of the Doppler apparatus, and evaluation of the microcirculation using capillaroscopy. The results showed that therapy with PLC was effective at restoring activity of skeletal muscle in ischemic conditions. In particular, capillaroscopy showed improvement in the angioarchitecture in the microcirculation fields, expressed as increased numbers of visible capillaries and diminution in the time of loss of sodium fluorescein marker. The clinical data showed increased walking distance and diminished time to recover from pain, and the clinical improvement correlated with improved microcirculatory function. From these preliminary data has emerged an indication of therapy with PLC for chronic obstructive arteriopathy of the lower limbs at stage II. Further studies with higher numbers of patients and more controlled variables are planned.

Transgenic expression of human thymidylate synthase accelerates the development of hyperplasia and tumors in the endocrine pancreas

Thymidylate synthase (TS) is an essential enzyme for DNA synthesis and repair and elevated levels of TS have been identified as an important prognostic biomarker for colorectal cancer and several other common human malignancies. In addition, TS gene expression has been linked with cell-cycle regulation and cell proliferation through the ability of retinoblastoma protein to repress the transcriptional activation of E2F target genes such as TS. Therefore, overproduction of TS could participate in the progression to a neoplastic phenotype. Consistent with this model, a recent study has suggested that ectopic TS expression can induce a transformed phenotype in mammalian cells. To investigate the role of deregulated TS activity in tumor development, we generated transgenic mice that express high levels of catalytically active human TS (hTS) exclusively in the pancreas and low levels of hTS in multiple other tissues. Analyses of pancreatic tissue in TS transgenic mice revealed abnormalities within the endocrine pancreas, ranging from pancreatic islet hyperplasia to the detection of islet cell tumors. Overexpression of hTS in murine islets provides a new model to study genetic alterations associated with the progression from normal cells to hyperplasia to islet cell tumors, and suggests that this mouse model may be useful for regulating TS activity in vivo for development of cancer prevention and new therapies.

Recurrent varicose veins following surgical treatment: our experience with five years follow-up

OBJECTIVE

To report the 5 year outcome of varicose veins surgery and to establish the factors determining recurrence.

STUDY DESIGN

Prospective observational study.

MATERIALS AND METHODS

This study reports the outcome in 1326 patients treated in a day surgery centre of an institutional referral centre. Patients were investigated clinically and by colour flow duplex scanning before operation. Treatments used included flush ligation of the sapheno-femoral junction (SFJ) and the sapheno-popliteal junction (SPJ). Incompetence of the great saphenous vein (GSV) and small saphenous vein (SSV) were managed by stripping of these veins. Perforating vein ligation and hook phlebectomy were also used. Patients were evaluated 3 weeks and 5 years following treatment by clinical examination and duplex ultrasonography.

RESULTS

412 patients were excluded from the study because they failed to attend for follow-up or did not wear elastic stockings post-operatively. No residual saphenous truncal reflux was found at the initial assessment 3 weeks following surgery. After 5 years, recurrence of varicose veins occurred in 332 patients out of 1326 (25 %). Recurrences arose at the sapheno-femoral junction in 109 out of 862 patients (13%), at the sapheno-popliteal junction in 39 out of 132 patients (30%), in both saphenous regions 38 out of 107 patients (36%) and in 146 out of 225 subjects (65 %) with secondary varicose veins.

CONCLUSION

Varicose veins recurred despite technically correct surgery confirmed on post-operative duplex ultrasonography. The likelihood of recurrence increased in the presence of SSV reflux, perforating vein incompetence and post-thrombotic deep vein incompetence.

Valves in small veins and venules

It is commonly believed that valves are absent in veins smaller than two millimetres in diameter. Consequently, current investigations on the pathophysiology of chronic venous disease (CVD) consider and evaluate only the valvular competence of large veins. The authors review literature from their own collections as well as from medical database searches to assess the functional relevance of these valves. Microscopic venous valves (MVVs) were first described in 1934 in the human digits and have subsequently been demonstrated in other parts of the human body as well as in many tissues and organs of animals. Their location and arrangement suggests that MVVs prevent blood reflux in small sized veins and restrict flow from postcapillary venules back into the capillary bed. This haemodynamic role of MVVs is strongly supported by the clinical finding that grafting skin rich in MVVs results in long-lasting healing leg ulcers attributable to CVD. The huge body of knowledge available concerning MVVs urges us to correct textbooks of anatomy. Studies on the pathophysiology of CVI should acknowledge that the valvular "chain" is not limited to large veins, but extends down to the venular level where MVVs play an important role in venous haemodynamics.

Veno-active drugs in the management of chronic venous disease. An international consensus statement: current medical position, prospective views and final resolution

BACKGROUND

Veno-active drugs (VAD) have effects on edema and symptoms related to chronic venous disease (CVD), especially so-called venous pain. VAD's effectiveness, although well established, is regularly debated.

OBJECTIVE

Our purpose was to select all randomized controlled trials (RCTs) and meta-analyses devoted to VAD and symptoms in CVD, to submit them to a group of international experts in CVD and to vote with secrete ballot to determine the level of efficacy of each drug, according to EBM (Evidence-Based Medicine) rules and critical analysis.

METHODS

Publications in any language devoted to VAD and venous symptoms were searched for in different databanks and submitted to the experts prior to the meeting.

RESULTS

83 papers were analyzed, including 72 RCTs or meta-analyses. Experts determined the level of EBM of each drug, according to the literature and personal experience, using 3 levels of recommendation, A, B and C (from large RCTs to non-randomized trials).

CONCLUSIONS

VAD are effective and may be applied in CVD when symptomatic, from C0s to C6s. However, etiological treatment of venous reflux and venous hypertension has always priority. In some cases VAD may replace compression and/or complement its effects. If respecting these prerequisites, VAD are safe and effective.

Results of a questionnaire regarding improvement of 'C' in the CEAP classification

BACKGROUND

One of the shortcomings of the CEAP classification is that some of the clinical conditions in the original version were not defined and, therefore, were used in different ways by those who work with CEAP.

AIM

To clarify the definitions of the seven clinical classes in the CEAP classification and to improve universal understanding of these in phlebology.

METHODS

The authors prepared a short questionnaire regarding the 'C' part of CEAP with five main questions, dealing with definitions of clinical items: telangiectases, corona phlebectatica, reticular veins, varicose veins and the use of CEAP. The questionnaire was translated into 11 different languages and sent around the world by means of International Venous Digest by fax. Two hundred and six answers were received from 67 countries out of 3681 faxes sent (5.6%).

RESULTS

There were a wide variety of opinions returned thus demonstrating that the same term is used with various meanings by different physicians. All physicians classify telangiectases of thigh and foot as class C1, but discrepant answers were obtained concerning the differences between reticular veins and reticular varicose veins as well as the diameter of small and large varicose veins. Sixty per cent of physicians answering this survey use the CEAP classification.

CONCLUSION

Further clarification and refinement of the CEAP classification are necessary. The authors hope that this will result in broader acceptance of CEAP.

A randomised controlled study of four-layer compression versus Unna's Boot for venous ulcers

OBJECTIVE

This study set out to compare healing rates, handling properties and patient comfort of a four-layer bandage system (Profore) and Unna's Boot in the treatment of venous leg ulcers.

METHOD

This was a prospective randomised parallel-group trial. Patients with venous leg ulcers from four centres in Italy were randomised to receive treatment with either Unna's Boot or Profore. Time to healing was recorded for a maximum of 24 weeks. Pain was assessed using a visual analogue scale. Staff assessed ease of application, while patients rated comfort.

RESULTS

Data were available for 68 patients with 68 wounds. At 24 weeks complete healing was seen in 74% of the Profore group compared with 66% of the Unna's Boot group. The median time spent in the study was 50 days (range: 7-175 days), corresponding to 51 days (range: 7-175 days) for Profore patients and 49 days (range: 7-168 days) for Unna's Boot patients. There was no difference (p = 0.13) between the groups in time to closure. Overall, more Profore than Unna's Boot applications were rated as excellent. There was a significant difference, in favour of Profore, in ease of application at the final application (p = 0.013). At the initial application, there was a significant difference in bandage appearance (p = 0.04), again favouring Profore, but this was not sustained at the final application (p = 0.18).

CONCLUSION

Profore is as effective as Unna's Boot in the treatment of venous leg ulcers.

Chronic venous insufficiency: the effects of health-care reforms on the cost of treatment and hospitalisation--an Italian perspective

OBJECTIVES

This study evaluated the evolution of chronic venous insufficiency (CVI)-related costs in Italy over 8 years by focusing on the impact of the Italian health-care reforms (drug de-reimbursement) of 1993-94.

RESEARCH AND DESIGN METHODS

The global cost of CVI to the Italian health system (Sistema Sanitario Nazionale, SSN) was divided into three sub-costs: hospitalisation, GP consultation and prescription costs. Indirect costs, such as loss of working days, were not included. CVI-related hospitalisation costs included inpatient treatment for varicose veins, venous leg ulcers and other venous disorders. They were calculated using the US-derived system, Diagnosis Related Group (DRG), used in Italian hospitals. Calculations for the whole country were based on figures determined for the Lombardy region and extrapolated. It was considered reasonable to assume that this region was representative of the whole of Italy. CVI-related GP consultation and prescription costs were derived from Intercontinental Medical Statistics (IMS) data. These costs, pre- and post-reforms, were determined and compared to evaluate the impact of the reforms on CVI-related expenditure.

RESULTS

Pre-reforms CVI-related costs analysis (1991): hospitalisations, 210 million Euro; GP consultations, 35.4 million Euro; prescriptions,115 million Euro . The total CVI-related direct costs (i.e. CVI diagnosis and management) were 360.4 million Euro. Post-reforms CVI-related costs analysis (1999): hospitalisations, 288 million Euro; GP consultations, 13 million Euro; prescriptions, 83 million Euro . The total CVI-related direct costs were 384 million Euro. Hospitalisation costs increased predominantly due to an increase in hospitalised patients. GP consultation and prescription costs decreased predominantly due to drug de-listing. The 23.6 million Euro increase in CVI management expense, post-reforms, was due to cost-redistribution from prescriptions and GP consultations to hospitalisations.

CONCLUSION

Short-term goals were achieved by the reforms, but long-term expectations were not. Drug de-reimbursement reduced both drug costs for the SSN and the number of GP consultations. Fewer patients were treated overall (mostly with advanced disease), with consequent disease worsening and increase in complications. An increase in CVI-related hospitalisation resulted. In contrast, preventative measures, including patient education and prophylactic treatment, exhibit both clinical and cost effectiveness. Larger studies are required to confirm these preliminary results.

Morphologic and functional changes of the microlymphatic network in patients with advancing stages of primary lymphedema

Using fluorescent microlymphography, we examined the morphology andfunctional characteristics of the microlymph-vascular network in 36 subjects including 9 patients with "compressible" lymphedema (Group I), 14 with minimally compressible lymphedema (Group II), 9 with noncompressible lymphedema (Group III), and 4 healthy individuals. As lymphedema progressedfrom early to advanced stages (Group I-III), an increasingly greater lymphatic capillary density and diameter were depicted and eventually fibrosis/sclerosis with lymphangiectasia, fragmentation and a gradual decrease in the number of microlymphatics. Concomitantly, there was a prolongation in transport and disappearance of fluorescent dye and a progressive increase in endolymphatic and interstitial hydrostatic pressures.

Tumor marker expression is predictive of survival in patients with esophageal cancer

BACKGROUND

This study was designed to determine the prognostic value of immunohistochemical tumor marker expression in a population of patients with node-negative esophageal cancer treated with complete resection alone.

METHODS

Resection specimens were collected from 61 patients with node-negative T1 (n = 31), T2 (n = 14), and T3 (n = 16) esophageal cancer. A panel of 10 tumor markers was chosen for immunohistochemical analysis, based on associations with differing oncologic mechanisms: apoptosis (p53), growth regulation (transforming growth factor-alpha, epidermal growth factor receptor, and Her2-neu), angiogenesis (factor VIII), metastatic potential (CD44), platinum resistance (p-glycoprotein and metallothionein), 5-fluorouracil resistance (thymidylate synthetase), and carcinogenic detoxification (glutathione S-transferase-pi).

RESULTS

Complete resection was performed in all patients (44 adenocarcinoma, 17 squamous cell carcinoma), with no operative deaths. Multivariable analysis demonstrated a significant relationship between cancer-specific death and the following variables: low-level P-gp expression (p = 0.004), high-level expression of p53 (p = 0.04), and low-level expression of transforming growth factor-alpha (p = 0.03). In addition, the number of involved tumor markers present was strongly predictive of negative outcome (p = 0.0001).

CONCLUSIONS

This study supports the prognostic value of immunohistochemical tumor markers, specifically the expression pattern of P-gp, p53, and transforming growth factor-alpha, in patients with esophageal carcinoma treated with complete resection alone.

Therapeutic effects of Vascupump treatment patients with Fontaine Stage II B arteriopathy

Intermittent claudication is the primary symptom of chronic obstructive arteriopathies of the lower extremities. Increased walking distance is the aim of all physical or pharmacological treatment of such patients. The study reported aims to assess the increase in distal arterial blood flow in arteriopathic patients achieved by physical treatment using a cuff, generally positioned on the upper third of the thigh to produce pulsed compressions. By tightening for a few milliseconds slightly behind the natural cardiac systole, the cuff reinforces the systolic thrust to increase distal perfusion without making any additional demand, on the cardiac pump. The cuff used is produced by Vascupump Copyright vp-El. The trial was conducted on 36 patients with intermittent claudication divided into 3 groups. Group A included 12 patients given Vascupump Copyright treatment only (20 yen 45 minute sessions); Group B included 12 patients given combined treatment with the Vascupump Copyright and endovenous Pentoxillin (3 fl/per diem for 20 days); Group C included 12 patients given Pentoxyfillin alone (3 n per diem for 20 days). Each patient was examined at the start (D0) and end (D20) of treatment as follows: Treadmill tests at 0 and 12% gradients at a speed of 3 km/h. Doppler arterial tensiometry with calculation of the Winsor Index; photoplethysmography. Group A revealed an increase in relative and absolute walking distance of 230% and 224% respectively on the flat and 357% and 343% respectively uphill. Doppler tensiometry revealed a 40.7% improvement in Group A compared to 29% in Group B and 13.6% in Group C. By contrast the improvement in the plethysmographic reading was higher in Group B (+ 119%) than in Group A (+67.3%). These results suggest that the Vascupump Copyright gives better than expected results on Fontaine Stage B arteriopathies.

The prognostic value of molecular marker analysis in patients treated with trimodality therapy for esophageal cancer

The purpose of this study was to define the prognostic value of a group of molecular tumor markers in a well-staged population of patients treated with trimodality therapy for esophageal cancer. The original pretreatment paraffin-embedded endoscopic esophageal tumor biopsy material was obtained from 118 patients treated with concurrent cisplatin + 5-fluorouracil (5-FU) + 45 Gy radiation followed by resection from 1986 until 1997 at the Duke University Comprehensive Cancer Center. Three markers of possible platinum chemotherapy association [metallothionein (MT), glutathione S-transferase-pi (GST-pi), P-glycoprotein (P-gp or multidrug resistance)] and one marker of possible 5-FU association [thymidylate synthase (TS)] were measured using immunohistochemistry. The median cancer-free survival was 25.0 months, with a significantly improved survival for the 38 patients who had a complete response (P < 0.001). High-level expression of GST-pi, P-gp, and TS were associated with a decreased survival. MT was not significant in this population. Multivariate analysis identified high-level expression in two of the platinum markers (GST-pi and P-gp) and the 5-FU marker TS as independent predictors of early recurrence and death. In conclusion, this investigation measured three possible markers associated with platinum and one possible marker associated with 5-FU in a cohort of esophageal cancer patients. Independent prognostic significance was observed, which suggests that it may be possible to predict which patients may benefit most from trimodality therapy. These data need to be reproduced in a prospective investigation.

Imaging and phase I study of 111In- and 90Y-labeled anti-LewisY monoclonal antibody B3

B3 is a murine monoclonal antibody (mAb) that recognizes a LewisY carbohydrate antigen present on the surface of many carcinomas. An imaging and Phase I trial was performed to study the ability of 111In-mAb B3 to image known metastasis and determine the maximum tolerated dose (MTD), dose-limiting toxicity (DLT), kinetics, and biodistribution of 90Y-mAb B3. Patients (n = 26) with advanced epithelial tumors that express the LewisY antigen were entered. All patients received 5 mCi of 111In-mAb B3 for imaging. 90Y-mAb B3 doses were escalated from 5 to 25 mCi in 5-mCi increments. 111In-mAb B3 and 90Y-mAb B3 were coadministered over a 1-h infusion. Definite tumor imaging was observed in 20 of 26 patients. Sites imaged included lung, liver, bone, and soft tissues. The MTD of 90Y-mAb B3 was determined to be 20 mCi. The DLTs were neutropenia and thrombocytopenia. Tumor doses ranged from 7.7 to 65.1 rad/mCi. 111In- and 90Y-mAb B3 serum pharmacokinetics (n = 23) were found to be similar. The amount of B3 administered (5, 10, and 50 mg) did not alter the pharmacokinetics. Bone marrow biopsies (n = 23) showed 0.0038+/-0.0016% of injected dose/gram for 111In-mAb B3 compared to 0.0046+/-0.0017% of injected dose/gram for 90Y-mAb B3 (P = 0.009). When given to patients with carcinomas that express the LewisY antigen, 111In-mAb B3 demonstrated good tumor localization. The MTD of 90Y-mAb B3 is 20 mCi, with myelosuppression as the DLT. Higher doses of radioactivity need to be delivered to achieve an antitumor effect. Humanized mAb B3 is being developed for evaluation in radioimmunotherapy. A clinical trial to explore the use of higher doses of 90Y-mAb B3 with autologous stem cell support is planned.

The emergency department as a potential site for smoking cessation intervention: a randomized, controlled trial

OBJECTIVE

To assess the effect of physician counseling and referral on smoking cessation rates and attendance at a smoking cessation program.

METHODS

This was a prospective, randomized clinical trial set in a suburban, community teaching hospital emergency department (ED). During study hours, dedicated research associates enrolled consecutive, stable, oriented patients who were smokers. Eligible, consenting patients were randomized to one of two intervention groups. The control group received a two-page "Stop Smoking" pamphlet from the American Heart Association (AHA). Patients in the intervention group were given the AHA pamphlet along with pharmacologic information and standardized counseling by the attending emergency physician, including written and oral referral to a smoking cessation program. The primary outcome measures were telephone contact/attendance at the smoking cessation program by the intervention group and the rate of smoking cessation in both study groups at three months post-ED visit. Categorical data were analyzed by chi-square and Fisher's exact tests. Rank data were analyzed by Mann-Whitney tests and continuous data by t-tests. All tests were two-tailed with alpha set at 0.05.

RESULTS

One hundred fifty-two patients were enrolled; 78 were randomized to the intervention group. Nearly 70% of patients (103) were available for telephone follow-up. The study groups were statistically similar with regard to baseline demographic characteristics and the prevalence of moderate or severe nicotine addiction. None of the patients (0%) in the intervention group contacted or attended the smoking cessation program during the study period (95% CI = 0-4%). The percentages of patients who stopped smoking after three months were similar in the two groups [10.4% (5/48) control vs 10.9% (6/55) intervention; p = 1].

CONCLUSION

The authors found no difference in the smoking cessation rates between ED patients who received written material and those who were counseled by emergency physicians. Referral of patients who smoked to a cessation program was unsuccessful.

Endostatin inhibits microvessel formation in the ex vivo rat aortic ring angiogenesis assay

Endostatin has demonstrated potent antiangiogenic and antitumor activity in mouse models. We have investigated the ex vivo rat aortic ring assay and a human vein model to assess the biological activity of murine and human endostatin. Rat aortic rings were exposed to recombinant murine endostatin (Spodoptera frugipera; Calbiochem, San Diego, CA) or recombinant human endostatin (Pichia pastoris; EntreMed, Rockville, MD). After 5 days, murine endostatin (500 microgram/ml) demonstrated inhibition of microvessel outgrowth with dose-dependent effects (down to 16 microgram/ml). No significant inhibition was observed with human endostatin in the rat assay. Human endostatin at 250 and 500 microgram/ml inhibited outgrowths from human saphenous vein rings after a 14-day incubation. Electron microscopy assessed the formation of basal lamina, confirming that the microvessels were progenitors of patent vessels. Immunostaining for Factor VIII or CD34 demonstrated that the microvessel cells were endothelial. BrdU incorporation assays supported the presence of proliferating endothelial cells, correlating with neovascularization from the aortic wall. We conclude that the rat aortic ring assay confirms the antiangiogenic activity of murine but not human endostatin, suggesting that the model may have species specificity. However, the human form shows biological activity against human vascular tissue.

Induction of Myc-intron-binding polypeptides MIBP1 and RFX1 during retinoic acid-mediated differentiation of haemopoietic cells

Retinoic acid-mediated differentiation of HL60 cells is associated with an alteration of chromatin structure that maps to protein-binding sequences within intron I of the c-myc gene and with down-regulation of c-myc expression. By using HeLa cell extracts, we previously identified two polypeptides, designated MIBP1 (for Myc-intron-binding peptide) and RFX1, that interact in vivo and bind to the intron I element; we showed that tandem repeats of an MIBP1/RFX1-binding site can exhibit silencer activity on a heterologous promoter. Here we demonstrate that p160 MIBP1 and p130 RFX1 are absent from undifferentiated HL60 cells. In addition, we show that treatment with retinoic acid induces both MIBP1 and RFX1 protein, as well as their DNA-binding activity, upon granulocytic differentiation of HL60 cells, with a gel mobility pattern identical to that of HeLa cells. In the absence of p160 MIBP1 and p130 RFX1, we observed that the altered gel mobility-shift pattern detected in undifferentiated HL60 cells reflects the binding of two novel polypeptides, p30 and p97, that can be cross-linked to the same recognition intron sequence. We also show that the time course of MIBP1 and RFX1 induction is inversely correlated with the down-regulation of c-myc levels during the treatment of HL60 cells with retinoic acid.

A pilot study of interferon alpha-2a, fluorouracil, and leucovorin given with granulocyte-macrophage colony stimulating factor in advanced gastrointestinal adenocarcinoma

We reported previously that the addition of recombinant Escherichia coli human granulocyte-macrophage colony stimulating factor (GM-CSF) to a 5-fluorouracil (5-FU) and leucovorin (LV) regimen seemed to ameliorate diarrhea and permit increased 5-FU dose intensity (J. L. Grem et al., J. Clin. Oncol., 12: 560-568, 1994). We then tested the effect of GM-CSF given with a more toxic regimen of 5-FU/LV/IFN-alpha (IFN alpha-2a). Thirty-one patients with a good performance status and no prior chemotherapy for systemic disease received IFN alpha(-2a (5 MU/m2 s.c., days 1-7), 5-FU (370 mg/m2 i.v., days 2-6), LV (500 mg/m2 i.v., days 2-6), and GM-CSF (Saccharomyces cerevisiae 250 microg/m2 s.c., days 7-18) every 3 weeks. Toxicities and 5-FU dose intensity were compared with that observed in our prior Phase II trial with 5-FU/LV/IFN alpha-2a (J. L. Grem et al., J. Clin. Oncol., 11: 1737-1745, 1993). In comparison with the prior Phase II study, the WBC and granulocyte nadirs in the present trial were significantly higher. When trends in toxicity grades for all cycles were compared, stratifying for 5-FU dose, the incidence and severity of mucositis, skin rash, WBC toxicity, and granulocyte toxicity were significantly lower in the present trial, whereas nausea/vomiting and fatigue were significantly worse. The delivered 5-FU dose intensity for all cycles of therapy appeared to be significantly higher in the present trial. Six of 28 evaluable patients had a partial response (21.4%), and 13 (46%) had stable disease for > or =12 weeks. Despite treatment-related toxicity, patient quality of life did not worsen during the study. No correlation was observed between thymidylate synthase content in primary tumor specimens and response, time to treatment failure, or survival. The addition of GM-CSF appeared to decrease the severity of leukopenia, granulocytopenia, mucositis, and skin rash when compared with our prior experience with this regimen of 5-FU/LV/IFN alpha-2a, at the cost of greater nausea/vomiting and fatigue. The potential impact of increased 5-FU dose intensity on clinical response, however, remains to be determined.

Adjuvant 5-fluorouracil and leucovorin with or without interferon alfa-2a in colon carcinoma: National Surgical Adjuvant Breast and Bowel Project protocol C-05

BACKGROUND

National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol C-03 showed a benefit from leucovorin (LV)-modulated 5-fluorouracil (5-FU) adjuvant therapy (5-FU + LV) in patients with Dukes' stage B or C carcinoma of the colon. Preclinical and clinical phase I/II data suggested that interferon alfa-2a (IFN) enhanced the efficacy of 5-FU therapy. Accordingly, in NSABP protocol C-05, the addition of recombinant IFN to 5-FU + LV adjuvant therapy was evaluated.

METHODS

Data are presented for 2176 patients with Dukes' stage B or C cancer entered onto protocol C-05 during the period from October 1991 through February 1994. Individuals with an Eastern Cooperative Oncology Group performance status of 0-2 (ranges from fully active to ambulatory and capable of self-care but unable to work), a life expectancy of at least 10 years, and curative resection were stratified by sex, disease stage, and number of involved lymph nodes and were randomly assigned to receive either 5-FU + LV or 5-FU + LV + IFN; the mean time on the study as of June 30, 1997, was 54 months. All statistical tests were two-sided.

RESULTS

There was no statistically significant difference in either disease-free survival (5-FU + LV, 69%; 5-FU + LV + IFN, 70%) or overall survival (5-FU + LV, 80%; 5-FU + LV + IFN, 81%) at 4 years of follow-up. Toxic effects of grade 3 or higher were observed in 61.8% of subjects in the group treated with 5-FU + LV and in 72.1% of subjects in the group treated with 5-FU + LV + IFN; fewer patients in the latter group completed protocol-mandated 5-FU + LV therapy than in the former group (77.1% versus 88.5%).

CONCLUSION

The addition of IFN to 5-FU + LV adjuvant therapy confers no statistically significant benefit, but it does increase toxicity.