Development, implementation, and dissemination of operational innovations across the trial innovation network

Improving the quality and conduct of multi-center clinical trials is essential to the generation of generalizable knowledge about the safety and efficacy of healthcare treatments. Despite significant effort and expense, many clinical trials are unsuccessful. The National Center for Advancing Translational Science launched the Trial Innovation Network to address critical roadblocks in multi-center trials by leveraging existing infrastructure and developing operational innovations. We provide an overview of the roadblocks that led to opportunities for operational innovation, our work to develop, define, and map innovations across the network, and how we implemented and disseminated mature innovations.

ErbB3 upregulation by the HNSCC 3D microenvironment modulates cell survival and growth

Head and neck squamous carcinomas (HNSCC) present as dense epithelioid three-dimensional (3D) tumor nests that can mediate signals via the human epidermal growth factor receptor (ErbB) tyrosine kinase family to promote intratumoral survival and growth. We examined the role of the tumor microenvironment on ErbB receptor family expression and found that the status of intercellular organization altered the receptor profile. We showed that HNSCC cells forced into tumor island-like 3D aggregates strongly upregulated ErbB3 at the level of transcription. Not only was the elevated ErbB3 responsive to HRG-β1-induced enhanced signaling mechanism, but also analysis by siRNA-knockdown and kinase inhibitor strategies revealed that the ErbB3/AKT signaling pathway was sufficient to enhance tumor cell survival and growth potential. Elevated ErbB3 expression in the high-density 3D culture system was strongly associated with hypoxia-induced HIF-1α. Hypoxia-regulated ErbB3 expression was mediated by the HIF-1α-binding consensus sequence in the ErbB3 proximal promoter. The findings show that the local 3D tumor microenvironment can trigger reprograming and switching of ErbB family members and thereby influence ErbB3-driven tumor growth.

[Chromobacterium violaceum peritonitis: case report and literature review]

We report a case of Chromobacterium violaceum infection and we review the literature for all published cases. C. violaceum grew from a peritoneal fluid of a 47-year-old woman operated on for peritonitis following perforative gastroduodenal ulcer. She was just coming back from a 1-month-holyday in French Guyana, where she might have been in contact with this micro-organism. The patient fully recovered after surgical management associated with antibiotic therapy consisting of ofloxacin plus piperacillin-tazobactam. Among the more than a hundred of published cases of human infections with C. violaceum that we retrieved, there was not any other case of peritonitis.

Intrinsic efficacy of antipsychotics at human D2, D3, and D4 dopamine receptors: identification of the clozapine metabolite N-desmethylclozapine as a D2/D3 partial agonist

Drugs that antagonize D2-like receptors are effective antipsychotics, but the debilitating movement disorder side effects associated with these drugs cannot be dissociated from dopamine receptor blockade. The "atypical" antipsychotics have a lower propensity to cause extrapyramidal symptoms (EPS), but the molecular basis for this is not fully understood nor is the impact of inverse agonism upon their clinical properties. Using a cell-based functional assay, we demonstrate that overexpression of Galphao induces constitutive activity in the human D2-like receptors (D2, D3, and D4). A large collection of typical and atypical antipsychotics was profiled for activity at these receptors. Virtually all were D2 and D3 inverse agonists, whereas none was D4 inverse agonist, although many were potent D4 antagonists. The inverse agonist activity of haloperidol at D2 and D3 receptors could be reversed by mesoridazine demonstrating that there were significant differences in the degrees of inverse agonism among the compounds tested. Aripiprazole and the principle active metabolite of clozapine NDMC [8-chloro-11-(1-piperazinyl)-5H-dibenzo [b,e] [1,4] diazepine] were identified as partial agonists at D2 and D3 receptors, although clozapine itself was an inverse agonist at these receptors. NDMC-induced functional responses could be reversed by clozapine. It is proposed that the low incidence of EPS associated with clozapine and aripiprazole used may be due, in part, to these partial agonist properties of NDMC and aripiprazole and that bypassing clozapine blockade through direct administration of NDMC to patients may provide superior antipsychotic efficacy.

Phase II randomized multicenter study evaluating a treatment regimen alternating docetaxel and cisplatin-vinorelbine with a cisplatin-vinorelbine control group in patients with stage IV non-small-cell lung cancer: GFPC 97.01 study

BACKGROUND

The potential absence of cross-resistance between cisplatin and docetaxel in non-small-cell lung cancer (NSCLC) suggests that alternating regimens of cisplatin-based chemotherapy and docetaxel might increase the activity of chemotherapy in stage IV NSCLC.

PATIENTS AND METHODS

Randomized, multicenter, non-comparative phase II study in patients with stage IV NSCLC (Eastern Cooperative Oncology Group performance status of 0-2). Patients randomized to alternating treatment group (A) received docetaxel 100 mg/m2 on days (D) 1 and 43 alternating with cisplatin 100 mg/m2 on D22 and vinorelbine 30 mg/m2 on D22, D29 and D36. Those randomized to the control group (B) received cisplatin 80 mg/m2 on D1, D22 and D43 and vinorelbine 30 mg/m2 once a week from D1 to D57. Treatment was continued for a further 6 weeks in the event of objective response or stabilization.

RESULTS

Seventy patients were enrolled (group A: 38, group B: 32). More premature treatment discontinuations due to toxicity were observed in group A (median number of cycles: 3) than in group B (median number of cycles: 5). The intention-to-treat objective response rate was 10.8% [95% confidence interval (CI) 0.8% to 20.8%] in group A compared with 25% (95% CI 10% to 40%) in group B, the median time to treatment failure being 10.2 weeks and 17.3 weeks, respectively. The median survival and 1-year survival were 29.1 weeks and 39% in group A compared with 41.6 weeks and 42% in group B. Febrile neutropenia occurred in 5.9 and 4.9% of the cycles in group A and group B, respectively. Non-hematological toxicity was moderate in the two groups.

CONCLUSIONS

The addition of docetaxel alternating with cisplatin-vinorelbine did not enhance the activity of this combination. The development of sequential regimens might be a more promising way of exploiting the absence of cross-resistance between these two drugs.

The making of a gradient: IcsA (VirG) polarity in Shigella flexneri

The generation and maintenance of subcellular organization in bacteria is critical for many cell processes and properties, including growth, structural integrity and, in pathogens, virulence. Here, we investigate the mechanisms by which the virulence protein IcsA (VirG) is distributed on the bacterial surface to promote efficient transmission of the bacterium Shigella flexneri from one host cell to another. The outer membrane protein IcsA recruits host factors that result in actin filament nucleation and, when concentrated at one bacterial pole, promote unidirectional actin-based motility of the pathogen. We show here that the focused polar gradient of IcsA is generated by its delivery exclusively to one pole followed by lateral diffusion through the outer membrane. The resulting gradient can be modified by altering the composition of the outer membrane either genetically or pharmacologically. The gradient can be reshaped further by the action of the protease IcsP (SopA), whose activity we show to be near uniform on the bacterial surface. Further, we report polar delivery of IcsA in Escherichia coli and Yersinia pseudotuberculosis, suggesting that the mechanism for polar delivery of some outer membrane proteins is conserved across species and that the virulence function of IcsA capitalizes on a more global mechanism for subcellular organization.

[Pseudomonas aeruginosa osteitis of the spinal process after peridural anesthesia]

BACKGROUND

Osteitis of the posterior wall of the spinal canal is an exceptional complication after peridural anesthesia. Prognosis depends on early diagnosis based on clinical signs and imaging data.

CASE REPORT

A 73-year-old man was hospitalized for lower back pain and fever of 3 weeks duration after a total hip arthroplasty performed under general anesthesia. Computed tomography and magnetic resonance imaging of the lumbar spine disclosed osteitis of the spinal processes. Local bacteriology sample evidenced Pseudomonas aeruginosa. Outcome was favorable after a 6-month treatment.

DISCUSSION

Data in the French and English literature (since 1948) on bone infections following epidural anesthesia have included 5 cases of spondylodiscitis and 1 case of posterior wall osteitis. The diagnosis is suggested by the clinical presentation. Standard x-rays contribute little. Early diagnosis in the infraradiological phase can be obtained with bone scintigraphy. Computed tomography or magnetic resonance imaging are currently highly contributive to diagnosis and follow-up after treatment. Contamination may be direct or via the blood stream or result from an extension of a neighboring infectious focus. Antibiotic therapy and immobilization are indicated. Rigorous application of strict aseptic procedures during lumbar puncture and use of the epidural catheter are crucial for prevention.

Tones disappear faster in the right ear than in the left

In order to gain further information on the characteristics and physiological correlates of tone decay in humans, the tone decay test was administered to 58 normal-hearing subjects, successively in the left and right ears and in absence and presence of a contralateral noise. The results revealed that tone decay was greater in the right than in the left ear and was increased by contralateral noise. The contralateral effect of this noise on cochlear biomechanisms was then estimated by measuring contralaterally induced variations in the amplitude of click-evoked otoacoustic emissions in the same subjects. In the right ear, the increase in tone decay and the decrease in otoacoustic emission amplitude--both induced by contralateral noise--were positively correlated (r = .315, p = .016). Furthermore, the contralateral changes in otoacoustic emission amplitude were found to be on average larger in the right than in the left ear, this asymmetry being correlated with that observed for the tone decay. These findings are discussed in relation to previous results on simple and induced loudness adaptation in the vicinity of threshold, on contralateral attenuation of otoacoustic emissions and on the influence of the auditory efferents on cochlear biomechanisms.

Validation assessment of a French version of the tinnitus reaction questionnaire: a comparison between data from English and French versions

The present study compares the results obtained on original and French versions of the TRQ (Tinnitus Reaction Questionnaire) initially published by Wilson, Henry, Bowen, and Haralambous (1991) in English to evaluate the psychological distress of tinnitus sufferers. Reliability and validity of the French translation were determined using data from 173 normal hearing or hearing-impaired patients with tinnitus lasting from 1 month to 41 years. They completed the translated questionnaire and a short version of the Minnesota Multiphasic Personality Inventory. The results indicated good internal consistency (Cronbach's alpha = .94), and the reliability of the French version of the TRQ was demonstrated, except for items 5 and 20. High statistically significant correlations were found between the TRQ and Depression, Psychaesthenia, and Anxiety Mini-Mult subscales. The validation demonstrates only minor effects of language. The French version of the TRQ thus is an equally valid tool as the original English version for evaluating tinnitus distress of a patient.

Improved artificial death switches based on caspases and FADD

A number of "suicide genes" have been developed as safety switches for gene therapy vectors or as potential inducible cytotoxic agents for hyperproliferative disorders, such as cancer or restenosis. However, most of these approaches have relied on foreign proteins, such as HSV thymidine kinase, that primarily target rapidly dividing cells. In contrast, novel artificial death switches based on chemical inducers of dimerization (CIDs) and endogenous proapoptotic molecules function efficiently in both dividing and nondividing cells. In this approach, lipid-permeable, nontoxic CIDs are used to conditionally cross-link target proteins that are fused to CID-binding domains (CBDs), thus activating signaling cascades leading to apoptosis. In previous reports, CID-regulated Fas and caspases 1, 3, 8, and 9 were described. Since the maximum efficacy of these artificial death switches requires low basal and high specific activity, we have optimized these death switches for three parameters: (1) extent of oligomerization, (2) spacing between CBDs and target proteins, and (3) intracellular localization. We describe improved conditional Fas and caspase 1, 3, 8, and 9 alleles that function at subnanomolar levels of the CID AP1903 to trigger apoptosis. Further, we demonstrate for the first time that oligomerization of the death effector domain of the Fas-associated protein, FADD, is sufficient to trigger apoptosis, suggesting that the primary function of FADD, like that of Apaf-1, is oligomerization of associated caspases. Finally, we demonstrate that nuclear-targeted caspases 1, 3, and 8 can trigger apoptosis efficiently, implying that the cleavage of nuclear targets is sufficient for apoptosis.

A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside the hospital. European Epinephrine Study Group

BACKGROUND

Clinical trials have not shown a benefit of high doses of epinephrine in the management of cardiac arrest. We conducted a prospective, multicenter, randomized study comparing repeated high doses of epinephrine with repeated standard doses in cases of out-of-hospital cardiac arrest.

METHODS

Adult patients who had cardiac arrest outside the hospital were enrolled if the cardiac rhythm continued to be ventricular fibrillation despite the administration of external electrical shocks, or if they had asystole or pulseless electrical activity at the time epinephrine was administered. We randomly assigned 3327 patients to receive up to 15 high doses (5 mg each) or standard doses (1 mg each) of epinephrine according to the current protocol for advanced cardiac life support.

RESULTS

In the high-dose group, 40.4 percent of 1677 patients had a return of spontaneous circulation, as compared with 36.4 percent of 1650 patients in the standard-dose group (P=0.02); 26.5 percent of the patients in the high-dose group and 23.6 percent of those in the standard-dose group survived to be admitted to the hospital (P=0.05); 2.3 percent of the patients in the high-dose group and 2.8 percent in the standard-dose group survived to be discharged from the hospital (P=0.34). There was no significant difference in neurologic status according to treatment among those discharged. High-dose epinephrine improved the rate of successful resuscitation in patients with asystole, but not in those with ventricular fibrillation.

CONCLUSIONS

In our study, long-term survival after cardiac arrest outside the hospital was no better with repeated high doses of epinephrine than with repeated standard doses.

[Validation of French translation of the "Tinnitus Reaction Questionnaire", Wilson et al. 1991]

The present study proposes a validation of a french translation of the TRQ initially published by Wilson et al., for evaluating the psychological distress of tinnitus sufferers. The 26 items translated into french were used on a sample of 173 tinnitus sufferers, who also filled out the Mini-Mult, a short version of the MMPI proposed by Kincannon. Internal validity was demonstrated by strong correlations (i) between each item (except items 5 and 20) and total TRQ score (0.33 < or = r < or = 0.87, p < or = 0.0001), (ii) between each internal TRQ factor (0.58 < r < 0.81, p < 0.0001) and the others. Cronbach's alpha test also showed the questionnaire to have a good internal validity (alpha = 0.94). The external factors used for testing concurrent validity were the scores on depression, psychaesthenia and anxiety Mini-Mult scales. The strong correlations (one factor ANOVA and simple linear regression tests) between scores on depression and psychaesthenia scales and (1) each TRQ item, (2) each TRQ factor, (3) total TRQ scores, confirmed concurrent validity. Scores obtained on anxiety index showed high correlations only with TRQ score, factor 3 score and some TRQ items (most of them included in factor 3). The internal and concurrent validities of the French version of the TRQ justify the use of this questionnaire, with the reserve that items 5 and 20 appeared irrelevant for the measuring of tinnitus distress in French-speaking countries. Such a questionnaire should improve our knowledge of tinnitus' life-impact and enable detection of patients whose psychological distress necessitates rapid intervention.

[Translation and validation of the questionnaire "Tinnitus Handicap Questionnaire, 1990]

OBJECTIVE

The Tinnitus Handicap Questionnaire (THQ) measures subjective tinnitus handicap in terms of emotional, social, and health impact (factor 1), hearing (factor 2), and perception of tinnitus (factor 3). A French version of the THQ was used with 178 tinnitus sufferers in ENT consultation. Internal validity was confirmed by correlations between (i) semigroups of items (Cronbach's alpha), (ii) item and total scores, and (iii) individual items, for each factor (Pearson's r), and was found to be strong (alpha = .90). All items (except 25 and 26) showed strong total-score correlations (.30 < or = r < or = .74). All factor 1 items intercorrelated strongly (.34 < or = r < or = .70). The factor 2 axis was coherent, with interitem correlations between .46 and .74, and its concurrent validation in strong factor 2 items correlations with hearing loss, if any (multiple linear regression: r = .67, p < .0001). Moreover, hearing-impaired (mean = 44.47 +/- 31.13) and normal-hearing (mean = 15.2 +/- 21.10) factor 2 scores were significantly different.

CONCLUSION

As with the original THQ, factor 3 items were not strongly intercorrelated; moreover, items 25 and 26 failed to correlate with total score, suggesting that factor 3 is to be regarded with great caution.

Mammographic pattern due to residual Lipiodol after galactography

The purpose of this pictorial essay is to describe the different mammographic aspects of residual Lipiodol ultra fluid (LUF) after galactography, and to define some specific patterns, because it may in some cases mimic microcalcifications and give diagnostic problems. The mammograms of 14 patients, aged 32-63 years, presenting LUF residues related to previous galactography, were analyzed retrospectively. In 12 cases the diagnosis was easy because the patients presented a typical pattern on mammography and came with their initial galactography. In 2 cases the diagnosis was more difficult because the patients did not remember the previous injection and the progressive resorption mimicked perfectly intraductal calcification. Benign duct ectasia with inflammatory reaction to foreign bodies were found in 3 cases in which surgery was performed. Lipiodol ultra fluid is no longer used for galactography, but it may persist in breast ducts or cysts for years and seems to still be used in some countries. There are in most cases specific signs enabling the diagnosis.

[Acute drug-induced agranulocytosis: experience of the Regional Center of Pharmacovigilance of Lyon over 7 years]

Sixty-two cases of drug-induced agranulocytosis, spontaneously reported to the regional drug monitoring centre in Lyon from 1988 to 1994, have been analysed. The mean age of patients was 58.6 years, and sex ratio was 1:1. The mean delay of onset was 46.2 days and absolute neutrophil counts (ANC) dropped below 0.1 x 10(9)/l in 73 per cent of patients. Bone marrow aspirates disclosed absence of myeloid series in 28 per cent of investigated cases. Neutrophil recovery occurred after a mean of 9.3 days, and the overall fatality rate was 6.5 per cent. Haematopoietic growth factors (HGF) were used in 11 patients with an ANC below 0.1 x 10(9)/l and/or a hypoplastic bone marrow. We have found no clear indication for a potential benefit of HGF treatment, but HGF were usually administered late during the course of neutropenia, i.e., after a mean of 6 days. The incidence rate estimated for people living in the Rhône administrative division was 3.3 per million per year, similar to that found in epidemiological studies. Drugs most frequently involved were anti-infective agents and psychotropic drugs.

Experimentally induced ulno-carpal instability. A study on 13 cadaver wrists

This experimental work studies the role of ligamentous structures in suspending the carpal bones from the radius and ulna. Thirteen human cadaver wrists underwent a distal radio-ulnar arthrodesis in a neutral position and an arthrodesis between the three bones of the first carpal row. Progressive postero-anterior forces in a palmar direction were applied to the fused carpal bones. Displacement was measured by two dial gauges before and after sequential section of the different fibrous structures. The largest absolute average displacement (both, dorso-palmar and induced rotational displacement) was observed after section of the ulnar styloid process. No significant differences were observed after section of the extensor retinaculum, extensor carpi ulnaris sheath, posterior ulno-carpal and posterior radio-carpal ligaments. This work suggests that the carpus is suspended not only from the radius, but also from the distal ulna and particularly at the ulnar styloid and the structures which insert onto it.

Multicenter randomized trial comparing cisplatin-mitomycin-vinorelbine versus cisplatin-mitomycin-vindesine in advanced non-small cell lung cancer. 'Groupe Français de Pneumo-Cancérologie'

The study was designed to evaluate the value of vinorelbine in a cisplatin-mitomycin-vinca alkaloid regimen for treatment of locally advanced or metastatic non-small cell lung cancer (NSCLC). A group of 227 patients with inoperable NSCLC in stage III (58%) or stage IV (42%) were included in this randomized multicenter trial comparing a reference regimen (VDS group, n = 113) cisplatin (120 mg/m2 on day 1, day 29 and day 71), mitomycin (8 mg/m2 on day 1, day 29 and day 71) and vindesine (3 mg/m2/week for 5 weeks and then every 2 weeks up to the 15th week) to a cisplatin-mitomycin-vinorelbine combination (VNB group, n = 114), with cisplatin and mitomycin at the same doses, and vinorelbine 25 mg/m2/week for 16 weeks. The objective response rate (evaluated at 17th week) was 17% in the VDS group and 25% in the VNB group (P = 0.15). Median survival was 33.4 weeks and 34.5 weeks in the VDS and VNB arms, respectively. Overall survival duration was not significantly different between the two arms (logrank test, P = 0.20) despite a trend to an increased survival in the VNB group. This essentially benefited the patients with stage III disease with a clear-cut lengthening of median (45.9 vs. 33.4 weeks) and 1 year survival (44.6% vs. 26.2%, P < 0.05) in favor of the VNB group. Nevertheless, there was no significant difference in overall survival (logrank, P = 0.13). Survival duration of the patients with stage IV disease was comparable in the two arms (logrank test, P = 0.90). Grade 3 or 4 neutropenia was found in 61% and 87% of the VDS and VNB groups, respectively (P < 0.01). Grade 2-4 peripheral neuropathy was observed in 23% of the patients in the VDS group and in 6% of the patients in the VNB group (P < 0.01). Replacement of vindesine by vinorelbine in a cisplatin-mitomycin-vinca alkaloid chemotherapeutic regimen did not lead to a significant improvement in objective response rate or in duration of survival. There was a reduction in neurotoxicity at the expense of an increased hematologic toxicity. However, for patients with stage III disease there was an increase in 1 year survival with the vinorelbine combination.

Cost analysis of hospital treatment--two chemotherapic regimens for non-surgical non-small cell lung cancer. GFPC (Groupe Français Pneumo Cancérologie)

STUDY OBJECTIVES

compare the costs of two regimens of chemotherapy. Apply weighted costs to an economic model in a hospital perspective.

DESIGN

prospective randomized study of two groups of patients receiving: branch B, mitomycin-navelbine-cisplatin (MNP); branch A, mitomycin-vindesine-cisplatin (MVP).

SETTING

pneumologic units of University and non-University hospitals.

METHODS

clinical evaluation during chemotherapy incorporated events enabling construction of an event tree. Direct hospital costs included those of: cytostatic agents, materials used and nursing time; costs of side-effects (medical and paramedical time, diagnostic and therapeutic examinations). Effectiveness was measured in terms of response rates.

PATIENTS

209 patients were included, 100 in arm B, 109 in arm A.

RESULTS

the response rates were 25% in branch B, 17% in branch A. In the hypothesis of equivalence of the two strategies, we compared only overall mean cost per patient. Despite the fact arm B needed more hospital injections, the difference was low (+4.6%). For a difference in effectiveness, the opposite was observed for the average cost-effectiveness ratio: arm B was less costly (-12 339.40 FF for a responder).

CONCLUSION

incorporation of economic parameters was found to have a bearing on the choice of chemotherapeutic regimen for the treatment of non-small cell lung cancer. Economic analyses of this kind can provide useful extra information for rational therapeutic decisions.

[Severe burnt patients: hemodynamic state, oxygen transport and consumption, plasma cytokines]

OBJECTIVE

To assess the haemodynamic and oxymetric variations measured by a pulmonary artery catheter and to correlate them with the variations of the circulating cytokines during the initial intensive care phase of severely burned patients.

STUDY DESIGN

Prospective study covering an 18-month period.

PATIENTS

Thirteen successive patients, aged over 12 years, without significant medical history, with a thermal burn affecting more than 50 percent of their total body surface area and admitted to our centre during the first six postburn hours.

METHODS

The haemodynamic and oxymetric profile was investigated by inserting a blood flow-directed balloon-tipped pulmonary artery fiberoptical catheter. All patients were treated according to the protocol previously used in our centre. Blood samples were drawn on admission, every 12 hours post-injury until the 2nd day, then on the 3rd and 5th days. Cytokines were analyzed by Elisa method. Haemodynamic and oxymetric measurements were achieved simultaneously with the biological samples during the first 5 postburn days. The analysis of variance (ANOVA) with the Duncan test was utilized for multiple comparisons between continuous variables.

RESULTS

(mean +/- SEM): The patients were 32 +/- 3 years-old and had a burn surface of 72 +/- 4%. After a short hypovolemic shock period lasting a 12 hours, a hyperdynamic shock occured which increased until the 5th day, with an increased cardiac index (6.9 +/- 0.4 at h120 vs 2.9 +/- 0.3 L.min-1.m-2 at h6, P < 0.05), increased oxygen transport and consumption (respectively 880 +/- 77 at h72 vs 543 +/- 58 mL.min-1 at h12, P < 0.05 and, 203 +/- 15 at h72 vs 129 +/- 25 mL.min-1 at h6, P < 0.05) and markedly decreased systemic vascular resistances (1,002 +/- 118 at h36 vs 2,330 +/- 328 dyn.s.cm-5.m2 at h6, P < 0.05). Circulating cytokines were not clearly modified except for interleukine-6 which reached early striking peaks (16,858 +/- 10,330 at h24 and 15,406 +/- 6,509 pg.mL-1 at h36) simultaneously with the decrease in systemic vascular resistances.

CONCLUSIONS

During the first post-injury week, critically burned patients develop a specific hyperdynamic circulatory status during which interleukine-6 could be a mainfactor decreasing systemic arterial resistances.

Alterations of the p16 (MTS1) gene in testicular, ovarian, and endometrial malignancies

PURPOSE

The p16 (MTS1) gene codes for a cyclin-dependent kinase inhibitor and may be a new tumor suppressor gene. It is frequently mutated in a variety of cell lines established from tumors. This is the first report of screening for alteration of the p16 gene in testicular, ovarian and endometrial malignancies.

MATERIALS AND METHODS

We examined alterations of p16 in 78 primary genital tumors (42 testicular, 21 ovarian and 15 endometrial cancers) and mononuclear cells from 2 patients with Lynch syndrome II as well as 5 testicular tumor cell lines by single-strand conformation polymorphism (SSCP) and Southern blot hybridization.

RESULTS

The DNA from the p16 gene of 2 testicular tumors (5%), an ovarian cancer (4%) and a testicular tumor cell line (20%) had altered migration in gel electrophoresis as shown by SSCP. Analysis of DNA sequence of these samples revealed a polymorphism at codon 140. Southern blot hybridization detected neither deletions nor rearrangements of the p16 gene in any of the samples.

CONCLUSIONS

Taken together, these results suggest that p16 alterations probably are not important for tumorigenesis of testicular, ovarian and endometrial tumors.

Standard doses versus repeated high doses of epinephrine in cardiac arrest outside the hospital

Among all of the cathecolamines used for cardiac arrest treatment, epinephrine injection during cardio-pulmonary resuscitation is currently the most powerful means of enhancing effectiveness; however, deliberations about the optimal dosage have recently become intense. In the SAMU of Lyon (F), we conducted a double blind prospective randomized study over an 18-month period, comparing repeated standard-dose epinephrine (1 mg) and repeated high-dose epinephrine (5 mg) in the management of cardiac arrest outside the hospital. Five-hundred thirty-six patients were enrolled with 265 in the standard-dose group and 271 in the high-dose group; both groups are globally similar. One-hundred eighty-one (33.8%) patients returned to spontaneous circulation (R.O.S.C.); 85 in the standard-dose group (32%) and 96 in the high-dose group (35.5%). One-hundred nineteen patients (22.2%) were admitted; 54 in the standard-dose group (20.4%) and 65 in the high-dose group (24%). At 6 months nine patients (7.6%) were alive; three patients from the standard-dose group (5.5%) and six from the high-dose group (9.2%). We never noticed cardiac or neurologic adverse effects with the high doses. The results of this study are not statistically significant, but we observed a marginal trend towards repeated 5 mg epinephrine doses. A large French multicentre study is now necessary.

Factors affecting caries experience in French adolescents

Three hundred French 14-15-yr-old adolescents were randomly selected. They were examined clinically and caries experience was determined by using the DMFS index. The aim of this investigation was to evaluate children's habits using a self-administered questionnaire, to clarify the actual influence of well-known factors such as fluoride exposure, diet, oral hygiene and socioeconomic factors on caries experience and to stress those factors of primary importance. A multiple regression analysis revealed the variables which significantly contributed to explain DMFS scores in a final model: Age, sex, frequency of sweet consumption, use of standard or high fluoride toothpastes, bleeding during toothbrushing, living in St Yorre (F- = 0.45 mg/l). At a time when caries experience is decreasing, it seems that fluoride supply, snacking and oral hygiene are still independent and significant determinants of caries experience in French adolescents.

Two-point discrimination tests versus functional sensory recovery in both median and ulnar nerve complete transections

Transection of both median and ulnar nerves provides an objective model to compare sensory and functional recovery. 22 patients were evaluated after nerve repair. The mean age was 30 years and the mean time since surgery 80 months. Primary direct suture was performed in 15 patients and six grafts were necessary. Median nerve suture and ulnar nerve graft were combined in one case. Both sensory and functional evaluation were completed. Statistical evaluation analyzed the relationship between age, injury location, mechanism, type of rehabilitation and the result, and the relationship between two-point discrimination distance (2-PD) and the functional score. According to the S0 to S4 grading, only 26.5% (ulnar) and 31% (median) of direct suture cases achieved S3+ or more. All nerve grafts in adults were poor. A strong relationship was found between two-point discrimination distance (moving and static) and the functional result, even after multivariate analysis. A modification of the Medical Research Council's classification is suggested.

Cefaclor-associated serum sickness-like disease: eight cases and review of the literature

OBJECTIVE

To describe the clinical features of serum sickness-like diseases (SSLD) in cefaclor-treated patients.

DESIGN

Analysis of a case series spontaneously reported to Lyons Pharmacovigilance Center.

SETTING

General and hospital practitioners and the French Network of Regional Pharmacovigilance Centers (FNRPC).

PATIENTS

All reported cases with a possible causative relationship between cefaclor treatment and SSLD.

MAIN RESULTS

Eight cases of SSLD following cefaclor treatment are described. The clinical features included cutaneous reactions, arthralgias, and moderate hyperthermia. In 50 percent of the patients, hospitalization was required because of incapacitating symptoms. The outcome was benign in all cases following discontinuation of the offending drug. All eight cases were reported in children under five years of age. Among 137 cefaclor-associated drug reactions collected by FNRPC, 27 cases of SSLD have been reported; 23 of these patients were younger than five years of age. A literature survey confirmed the higher reporting of SSLD in children with cefaclor compared with other antibiotics and suggested an incidence of 0.024-0.2 percent of SSLD per drug course of cefaclor.

CONCLUSIONS

The case reports and epidemiologic studies confirmed the presumed role of age (patients under five years of age) in cefaclor-induced SSLD and the benign outcome despite severe clinical presentations in some reports.

Acute poisonings with ethyle loflazepate, flunitrazepam, prazepam and triazolam in children

Even though acute poisonings with benzodiazepines are extremely common, less is known of the clinical toxicity of recent derivatives, particularly in children. 1,989 cases involving ethyle loflazepate, flunitrazepam, prazepam or triazolam recorded at the Lyons Poison Center and due to 1 compound and associated with clinical symptoms were selected for study. Children less than 16-y of age accounted for 482 cases. Sleepiness, agitation and ataxia were significantly more frequent in the children. Hypotonia was seldom observed but was indicative of severe poisoning. The dangerous toxic dose of these compounds in children is suggested to be 0.78-0.90 mg ethyle loflazepate/kg, 0.26-0.29 mg flunitrazepam/kg, 7.80-9.00 mg prazepam/kg and 0.06-0.07 mg triazolam/kg. These results are in keeping with the relatively low acute toxicity of the older benzodiazepines.

[The monitoring of teratogens. The methodology of a follow-up study]

The assessment of risks following drug exposure during pregnancy is of major concern to Drug-Information Centers. A computer-based management is helpful. The authors describe a computerized system to follow pregnancy outcomes and discuss their first results, stressing the merits of automatized recalls.