Treatments for Burning Mouth Syndrome: A Network Meta-analysis

The aim of this systematic review and network meta-analysis (NMA) of randomized controlled trials was to evaluate the effectiveness of treatments for pain relief of burning mouth syndrome (BMS). Five databases and gray literature were searched. Independent reviewers selected studies, extracted data, and assessed the risk of bias. The primary outcome was pain relief or burning sensation, and the secondary outcomes were side effects, quality of life, salivary flow, and TNF-α and interleukin 6 levels. Four comparable interventions were grouped into different network geometries to ensure the transitivity assumption for pain: photobiomodulation therapy, alpha-lipoic acid, phytotherapics, and anxiolytics/antidepressants. Mean difference (MD) and 95% CI were calculated for continuous outcomes. The minimal important difference to consider a therapy beneficial against placebo was an MD of at least -1 for relief of pain. To interpret the results, the GRADE approach for NMA was used with a minimally contextualized framework and the magnitude of the effect. Forty-four trials were included (24 in the NMA). The anxiolytic (clonazepam) probably reduces the pain of BMS when compared with placebo (MD, -1.88; 95% CI, -2.61 to -1.16; moderate certainty). Photobiomodulation therapy (MD, -1.90; 95% CI, -3.58 to -0.21) and pregabalin (MD, -2.40; 95% CI, -3.49 to -1.32) achieved the minimal important difference of a beneficial effect with low or very low certainty. Among all tested treatments, only clonazepam is likely to reduce the pain of BMS when compared with placebo. The majority of the other treatments had low and very low certainty, mainly due to imprecision, indirectness, and intransitivity. More randomized controlled trials comparing treatments against placebo are encouraged to confirm the evidence and test possible alternative treatments (PROSPERO CRD42021255039).

Environmental DNA metabarcoding for benthic monitoring: A review of sediment sampling and DNA extraction methods

Environmental DNA (eDNA) metabarcoding (parallel sequencing of DNA/RNA for identification of whole communities within a targeted group) is revolutionizing the field of aquatic biomonitoring. To date, most metabarcoding studies aiming to assess the ecological status of aquatic ecosystems have focused on water eDNA and macroinvertebrate bulk samples. However, the eDNA metabarcoding has also been applied to soft sediment samples, mainly for assessing microbial or meiofaunal biota. Compared to classical methodologies based on manual sorting and morphological identification of benthic taxa, eDNA metabarcoding offers potentially important advantages for assessing the environmental quality of sediments. The methods and protocols utilized for sediment eDNA metabarcoding can vary considerably among studies, and standardization efforts are needed to improve their robustness, comparability and use within regulatory frameworks. Here, we review the available information on eDNA metabarcoding applied to sediment samples, with a focus on sampling, preservation, and DNA extraction steps. We discuss challenges specific to sediment eDNA analysis, including the variety of different sources and states of eDNA and its persistence in the sediment. This paper aims to identify good-practice strategies and facilitate method harmonization for routine use of sediment eDNA in future benthic monitoring.

Desensitizing Toothpastes for Dentin Hypersensitivity: A Network Meta-analysis

The goal of this systematic review and network meta-analysis was to compare the relative effects of toothpaste formulations for dentin hypersensitivity (DH), tested in randomized controlled trials (RCTs). We searched 7 databases to February 2019. Paired reviewers independently screened studies, extracted data, and performed risk of bias assessment. The outcome of interest was painful response measured through tactile, cold, and air stimuli. We conducted a random-effects Bayesian network meta-analysis using standardized mean difference (SMD) and their credible intervals (CIs) as the measure of effect for each pain stimuli. We assessed certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. We included 125 RCTs (12,541 patients). For tactile stimulus, the following active ingredients showed large beneficial effects compared to fluoride with moderate certainty of evidence (SMD; 95% CI): potassium + stannous fluoride (SnF₂) (3.05; 1.69-4.41), calcium sodium phosphosilicate (CSP) (2.14; 0.75-3.53), SnF₂ (2.02; 1.06-2.99), potassium + hydroxyapatite (2.47; 0.3-4.64), strontium (1.43; 0.46-2.41), and potassium (1.23; 0.48-1.98). For cold stimulus, CSP showed large beneficial effects compared to fluoride (3.93; 0.34-7.53) with moderate certainty; for air stimulus, arginine (2.22; 1.45-2.99), potassium + hydroxyapatite (2.44; 0.33-4.55), potassium + SnF₂ (2.28; 0.87-3.69), CSP (1.98; 0.99-2.98), and SnF₂ (1.9; 1.03-2.77) showed large beneficial effects compared to fluoride with moderate to high certainty. Most toothpaste formulations showed evidence of superiority against placebo or fluorides (amine fluoride, sodium monofluorophosphate, or sodium fluoride). CSP was most beneficial for all 3 stimuli with high to moderate certainty. SnF₂ alone and potassium combined with SnF₂ or hydroxyapatite were beneficial for tactile and air stimulus with high to moderate certainty. Arginine was beneficial for air stimulus, and strontium and potassium were beneficial for tactile stimulus, with moderate certainty.

Persistence of phylogeographic footprints helps to understand cryptic diversity detected in two marine amphipods widespread in the Mediterranean basin

Amphipods of the genus Gammarus are a vital component of macrozoobenthic communities in European inland and coastal, marine and brackish waters of the Mediterranean and the Black Sea. Exceptional levels of cryptic diversity have been revealed for several widespread freshwater Gammarus species in Europe. No comprehensive assessment has yet been made for brackishwater counterparts, such as Gammarus aequicauda and G. insensibilis, which are among the most widely dispersed members of the so-called "G. locusta group" in the Mediterranean and in the Black Sea. Here we probe the diversity of these morphospecies examining the partitioning of mtDNA and nDNA across multiple populations along their distribution range and discuss it within the regional paleogeographic framework. We gathered molecular data from a collection of 166 individuals of G. aequicauda and G. insensibilis from 47 locations along their distribution range in the Mediterranean including the Black Sea. They were amplified for both mitochondrial COI and 16S rRNA as well as the nuclear 28S rRNA. All five MOTU delimitation methods (ABGD, BIN, bPTP, GMYC single and multiple threshold models) applied revealed deep divergence between Black Sea and Mediterranean populations in both G. aequicauda and G. insensibilis. There were eight distinct MOTUs delimited for G. aequicauda (6-18% K2P) and 4 MOTUs for G. insensibilis (4-14% K2P). No sympatric MOTUs were detected throughout their distribution range. Multimarker time-calibrated phylogeny indicated that divergence of both G. aequicauda and G. insensibilis species complexes started already in the late Oligocene/early Miocene with the split between clades inhabiting eastern and western part of the Mediterranean occurring in both species at the similar time. Our results indicate a high cryptic diversity within Mediterranean brackishwater Gammarus, similar to that observed for freshwater counterparts. Moreover, the phylogenetic history combined with the current geographic distribution indicate that the evolution of both studied Gammarus morphogroups has been strongly connected with the geological events in the Mediterranean Basin and it reflect the turbulent history of the area.

Gingival crevicular fluid levels of human beta-defensin 1 in individuals with and without chronic periodontitis

BACKGROUND AND OBJECTIVE

Human beta-defensins (hBDs) contribute to innate immunity antimicrobial activity. They are also effective in the adaptive immune response and may play a crucial role in the susceptibility to diseases of the oral cavity. This study aimed to evaluate the levels of hBD-1 in the gingival crevicular fluid of individuals with and without chronic periodontitis.

MATERIAL AND METHODS

Twenty periodontally healthy individuals (H) and 20 individuals with chronic periodontitis were recruited. Gingival crevicular fluid samples were collected from: healthy sites (Hh) from periodontally healthy individuals; and healthy sites (Ph), sites with gingivitis (Pg), and sites with periodontitis (Pp) from individuals with periodontitis. The levels of hBD-1 (pg/mL) were measured using enzyme-linked immunosorbent assay. Comparisons of hBD-1 between individuals (H and chronic periodontitis) and among sites (Hh, Ph, Pg, Pp) were performed through hierarchical linear modeling.

RESULTS

Gingival crevicular fluid levels of hBD-1 were: Hh = 229.52 ± 138.96 (median 199.26), Ph = 53.88 ± 58.17 (median 35.75), Pg = 57.11 ± 40.18 (median 39.90) and Pp = 55.31 ± 37.28 (median 54.19). No influence of site diagnosis (level 1; health/gingivitis/periodontitis) was observed; however, individual diagnosis (level 2; health/periodontitis) influenced the levels of hBD-1 (P < .001).

CONCLUSION

Periodontally healthy individuals showed higher gingival crevicular fluid levels of hBD-1 when compared to individuals with chronic periodontitis. This suggests a potential protective role of hBD-1 in the susceptibility to chronic periodontitis.

Assembling and auditing a comprehensive DNA barcode reference library for European marine fishes

A large-scale comprehensive reference library of DNA barcodes for European marine fishes was assembled, allowing the evaluation of taxonomic uncertainties and species genetic diversity that were otherwise hidden in geographically restricted studies. A total of 4118 DNA barcodes were assigned to 358 species generating 366 Barcode Index Numbers (BIN). Initial examination revealed as much as 141 BIN discordances (more than one species in each BIN). After implementing an auditing and five-grade (A-E) annotation protocol, the number of discordant species BINs was reduced to 44 (13% grade E), while concordant species BINs amounted to 271 (78% grades A and B) and 14 other had insufficient data (grade D). Fifteen species displayed comparatively high intraspecific divergences ranging from 2·6 to 18·5% (grade C), which is biologically paramount information to be considered in fish species monitoring and stock assessment. On balance, this compilation contributed to the detection of 59 European fish species probably in need of taxonomic clarification or re-evaluation. The generalized implementation of an auditing and annotation protocol for reference libraries of DNA barcodes is recommended.

Tooth loss in individuals under periodontal maintenance therapy: 5-year prospective study

BACKGROUND AND OBJECTIVE

Tooth loss (TL), one of the most visible results of the evolution of periodontitis, causes physiological and psychological impacts on a patient's life. This prospective study aimed to evaluate the incidence, underlying reasons and influence of risk predictors for the occurrence of TL in a program of periodontal maintenance therapy (PMT) over 5 years.

METHODS

The sample comprised 212 individuals diagnosed with chronic moderate-severe periodontitis, who had finished active periodontal treatment, were incorporated in a PMT program. Individuals were divided in to two groups: 96 regular compliers (RC) and 116 irregular compliers (IC). Full-mouth periodontal examination was performed. Social, demographic, behavioral and biological variables of interest were collected at all PMT visits. The effect of risk predictors and confounders for TL, as well as the underlying reasons of TL, were assessed by univariate and multivariate analysis.

RESULTS

TL was significantly lower among RC (0.12 teeth lost/year) in comparison to IC (0.36 teeth lost/year; p < 0.01). Individuals that were > 55 years old, males and smokers lost significantly more teeth in both groups (with IC > RC). The number of teeth lost due to periodontal reasons was significantly higher than TL for other reasons in both groups (p < 0.01). The final linear and logistic model for TL included: male gender, smoking, probing depth 4-6 mm in up to 10% of sites and irregular compliance.

CONCLUSION

IC individuals undergoing PMT presented higher rates of TL when compared to RC individuals. Findings demonstrated the influence of irregular compliance and the importance of monitoring other risk predictors for TL such as smoking, male gender and severity of probing depth during PMT.

Investigating the taxonomy and systematics of marine wood borers (Bivalvia : Teredinidae) combining evidence from morphology, DNA barcodes and nuclear locus sequences

Marine wood-boring teredinids, some of the most destructive wood borers in the sea, are a particularly difficult group to identify from morphological features. While in most bivalve species shell features are used as diagnostic characters, in the teredinids shell morphology shows high intraspecific variation and thus identification is based almost entirely on the morphology of the pallets. In the present study we aimed at improving ‘taxonomic resolution’ in teredinids by combining morphological evidence with mitochondrial and nuclear DNA sequences, respectively Cytochromec oxidase subunitI and small subunit rRNA 18S gene, to generate more rigorous and accessible identifications. DNA barcodes of Atlantic and Mediterranean populations of Lyrodus pedicellatus diverged by ~20%, suggesting cryptic species in the morphospecies L. pedicellatus. The low intraspecific divergence found in barcodes of specimens of Nototeredo norvagica (0.78%) confirms that Atlantic and Mediterranean forms of N. norvagica, the latter sometimes reported as Teredo utriculus, are the same species. Teredothyra dominicensis was found for the first time in the Mediterranean. A match was obtained between our 18S sequences and sequences of T. dominicensis from Netherlands Antilles, confirming that T. dominicensis in the Mediterranean is the same species that occurs in the Caribbean. There were differences in 18S sequences between Bankia carinata from the Mediterranean and Caribbean, which may indicate cryptic species.

Prevalence of periodontopathogens in a black Brazilian secluded community matched with a black urban population

OBJECTIVE

To evaluate the prevalence of periodontopathogens according to periodontal profile in a black Brazilian secluded community matched with an urban black population.

PARTICIPANTS

A total of 84 subjects were selected, 42 (mean age 25.7 sd 18.0 years) from a secluded community called Santo Antonio do Guapore (SAG) and 42 (mean age 25.4 sd 18.1 years) from an urban area of Sao Paulo State (SPT).

METHODS

Participants received clinical examinations as follows: periodontal pocket depth; clinical attachment loss; plaque and gingival indexes. After examination, the secluded population was classified as periodontal health (13), gingivitis (15) or periodontitis (14). Then, 182 urban volunteers were screened and 42 subjects were selected matched for the variables: periodontal diagnosis, age (+/- 2 years) and gender. Samples were taken for microbial analysis. Genomic DNA for Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Campylobacter rectus, Tannerella forsythia and Prevotella intermedia was provided by polymerase chain reaction.

RESULTS

Except for C. rectus, all pathogens were present in both groups with no statistically significant difference. In particular, C. rectus was more prevalent only in gingivitis subjects from the SPT group (p<0.05). A high frequency of periodontopathogens was related to the severity of periodontal disease.

CONCLUSION

In general, the prevalence of the examined periodontopathogens in this study did not differ between a secluded black Brazilian population and an urban black population.

Detection of periodontal pathogens in newborns and children with mixed dentition

We report the age-related prevalence of red complex periodontal pathogens, Porphyromonas gingivalis, Treponema denticola, and Tannerella forsythia, along with four strains of orange complex pathogens. The bacteria present in samples isolated from tongue, cheek, and subgingival sulcus in edentulous newborns and children with mixed dentition were monitored by polymerase chain reaction (PCR). P. gingivalis was not detected in any site of any subject in the two groups tested. However, T. denticola was not only found in the 6-13 years age group, but also in edentulous newborns at a relatively high prevalence, indicating non-dentition-related colonization by T. denticola. Campylobacter rectus, Prevotella intermedia, T. forsythia, Eikenella corrodens, and Parvimonas micra were found in the oral cavity of most subjects belonging to the 6-13 years age group compared to newborns. This suggested a pronounced association between these colonizing bacteria and the presence of teeth. There was also a strong relation between T. denticola and T. forsythia for their prevalence in the subgingival sulcus of the 6-13 years age group (p < 0.0001), but not in the other sites tested, suggesting that the colonization of dentition-related T. forsythia may be associated with the increased prevalence of non-dentition-related T. denticola in the subgingival sulcus. Overall, these results suggest that dentition is a key determinant of bacterial colonization, especially orange complex bacteria and the red complex bacterium T. forsythia.

Saliva as a source of HCMV DNA in allogeneic stem cell transplantation patients

OBJECTIVE

The purpose of this study was to investigate the use of saliva for the identification of human cytomegalovirus (HCMV) in allogeneic hematopoietic stem cell transplant patients by real time PCR compared with blood.

MATERIALS AND METHODS

Saliva and blood samples were sampled weekly in 30 allogeneic hematopoietic stem cell transplant patients until 100 days after transplant. Total genomic DNA, extracted from saliva and whole-blood samples, was used for HCMV real time PCR. Nonparametric tests were performed, and P value <or=0.05 was considered statistically significant.

RESULTS

Human cytomegalovirus DNA load in saliva showed a high correlation with viral DNA in the blood (R = 0.858; P < 0.0001). Blood DNA levels also correlated with HCMV antigenemia (R = 0.773; P < 0.0001). The HCMV levels in saliva (P = 0.015) and blood (P = 0.008) showed higher levels at the beginning of antiviral treatment, with clear reduction after this period. Saliva showed earlier HCMV reactivation than blood detected by real time PCR and antigenemia assay in 11 out of 22 subjects.

CONCLUSIONS

This study shows that the real time PCR test could be useful to identify HCMV DNA in saliva and to monitor patients at risk of cytomegalovirus disease after allogeneic hematopoietic stem cell transplant. However, further studies are necessary to confirm this data.

Prevalence and risk variables for peri-implant disease in Brazilian subjects

OBJECTIVES

The aim of this study was to verify the prevalence of peri-implant disease and analyse possible risk variables associated with peri-implant mucositis and peri-implantitis. The study group consisted of 212 partially edentulous subjects rehabilitated with osseointegrated implants.

MATERIAL AND METHODS

The implants placed were examined clinically and radiographically to assess the peri-implant status. The degree of association between peri-implant disease and various independent variables was investigated using a multinomial regression analysis.

RESULTS

The prevalence of peri-implant mucositis and peri-implantitis were 64.6% and 8.9%, respectively. In univariate modelling, healthy peri-implant subjects presented lower plaque scores, less periodontal bleeding on probing, and less time elapsed since placement of supra-structures. In multivariate analyses, the risk variables associated with increased odds for having peri-implant disease included: gender, plaque scores, and periodontal bleeding on probing. Presence of periodontitis and diabetes were statistically associated with increased risk of peri-implantitis. The only two factors, which did not contribute to the presence of the disease, were the time elapsed since placement of supra-structures and the frequency of visits for maintenance care.

CONCLUSION

Our data suggest that subjects with periodontitis, diabetes, and poor oral hygiene were more prone to develop peri-implantitis.

Analysis of formulation effects in the dissolution of ibuprofen pellets

In this work the effects of citric acid and of two common fillers, lactose (soluble) and tricalcium phosphate (insoluble) are examined on the release profiles from pellets, using ibuprofen as a model drug with pH-dependent solubility. Also studied is the dependence of these profiles on the specific surface area, bulk density, apparent density, porosity and porosity parameters (pore size distribution, total pore surface area, mean pore diameter and pore shape), as determined by mercury intrusion porosimetry. Pellets with high porosity and total pore surface area but small median pore diameter (tricalcium phosphate pellets-IPM) are found to produce similar dissolution results to those of low porosity and low total pore surface area, but having a high median pore diameter (lactose pellets-ILM), irrespective of the solubility of excipients. Addition of citric acid causes a delay in the initial dissolution for both formulations. During dissolution, however, citric acid reduces the median pore diameter of lactose-based pellets. In contrast, in tricalcium phosphate/citric acid pellets (CIPM), this parameter increases considerably during dissolution, when compared to the IPM formulation. These findings may justify the contrasting dissolution behaviors of CIPM and CILM (lactose/citric acid) pellets, after their common behavior in the initial stages, and show that porosity and its related parameters, along with physical properties of excipients such as solubility, density and specific surface area, are helpful to predict pellet behavior in drug release profiles.

Comparison of dissolution profiles of Ibuprofen pellets

In this work we use both model dependent and independent techniques to assess the difference between dissolution profiles in which ibuprofen, in the form of uncoated pellets, is used as a model drug. The choice of a proper regression function, the relevance of the estimated parameters and the influence of the choice of dissolution points in the assessment of differences is discussed. The results obtained via mean dissolution times (MDT) and fit-factors (f(1) and f(2)) are also discussed and a non-quantitative method based on profiles correlation with graphical representation (concentration vs. concentration and rate vs. rate) presented. The tested methods discriminate similarly between curves, although not in all cases, but those based on modeling, MDT and fit-factors have shown to be less informative than the correlation approach.

Effects of temperature and salinity on life history of the marine amphipod Gammarus locusta. Implications for ecotoxicological testing

The life history of Gammarus locusta was analysed in the laboratory under the following temperature and salinity combinations: 20 degrees C-33/1000, 15 degrees C-20/1000 and 15 degrees C-33/1000 (reference condition). Life history analysis comprised survival, individual growth, reproductive traits and life table parameters. Compared to 15 degrees C, life history at 20 degrees C was characterised by at least a four-week reduction in the life-span, lower life expectancy, shorter generation time, faster individual growth, anticipation of age at maturity and higher population growth rate. These temperature effects constituted an acceleration and condensation of the life cycle, compared to the reference condition. Concerning salinity effects, with few exceptions, results show that overall this amphipod life history did not differ significantly between the salinity conditions tested. Regarding ecotoxicological testing implications, findings from this study indicate that the range of temperature and salinity conditions acceptable for testing was substantially expanded both for acute and chronic assays. A temperature of 20 degrees C or higher (for a salinity of 33/1000) is suggested for routine chronic sediment toxicity testing with G. locusta, in order to reduce the life cycle and consequently improve cost-effectiveness and standardisation. Results also suggest that a multiple-response approach, including survival, growth and reproduction, should be applied in chronic toxicity tests.

Acute marine sediment toxicity: a potential new test with the amphipod Gammarus locusta

Although amphipod toxicity tests have been successfully used in the United States to assess coastal sediment toxicity, few tests have been developed with European species. The authors have been working with the amphipod Gammarus locusta, a widely spread species along European coastal areas that is particularly abundant in the Portuguese Sado estuary. This amphipod fulfills the most important requirements of a test species. It can be easily reproduced in laboratory and it is tolerant to a broad range of sediment types. A series of tests demonstrated its sensitivity to copper and gamma-hexachlorocyclohexane (lindane) in the sediment (LC50 = 6.8 mg Cu/dry kg, 0.9% total volatile solids; LC50 = 60.5 micrograms HCH/dry kg, 2% total volatile solids) and to some heavily contaminated field sediments. After assessment of the species sensitivity to several noncontaminant variables, an experimental protocol was designed to conduct acute sediment toxicity tests that are briefly described. Proposed is a 10-day static toxicity test at 15 degrees C and 33-34/1000 salinity, with laboratory-produced juveniles and mortality as the endpoint. General assay performance is identical to the American Society for Testing and Materials (ASTM) standard for sediment toxicity tests with marine and estuarine amphipods. The results previously obtained revealed a strong potential for this amphipod to be used in toxicological testing. Considering the wide geographic distribution of this species and its amenability for culturing, it may be an alternative or complementary test for ecotoxicological studies in other European coastal systems where the existing tests cannot be applied or do not offer a definitive solution.

Mitoxantrone, folinic acid, 5-fluorouracil and prednisone as first-line chemotherapy for advanced breast carcinoma. A phase II study

The purpose of this prospective clinical trial was an attempt to find an effective and relatively non-toxic schedule for patients with metastatic breast cancer who decline to receive aggressive cytotoxic chemotherapy. A total of 36 patients with disseminated breast cancer were treated with mitoxantrone 8 mg/m2 intravenously (i.v.) day 1, folinic acid 400 mg/m2 in a 2-h i.v. infusion with 5-fluorouracil 500 mg/m2 as an i.v. bolus 1 h later, days 1 and 8 at 3-week intervals plus prednisone 20 mg/m2 orally daily with diminishing doses over several weeks. Objective regressions were observed in 24/36 (67%) patients, 9 being complete (25%). Responses were seen at all disease sites, mainly pleural/lung, bone and liver. The median duration of response was 8 months (range 4-25+) and the median survival 12 months (range 3-26+). Myelosuppression, mainly leucopenia and thrombocytopenia, was the major toxicity but without complications. Other toxicities included mild or moderate nausea and/or vomiting (50%), stomatitis (33%) and diarrhoea (11%). Alopecia was minimal. No cases of cardiotoxicity were detected. The substantial response rate obtained with this relatively well tolerated regimen against advanced breast cancer warrants its assessment in a larger number of patients.

Primary chemotherapy with mitoxantrone and prednisone in advanced breast carcinoma. A phase II study

Thirty-seven evaluable patients with progressive disseminated breast carcinoma were treated with a combination of mitoxantrone 14 mg/m2 i.v. every 3 weeks plus prednisone 20 mg/m2 p.o. daily with a reducing dose over several weeks. Thirteen of 37 patients (35%) achieved an objective response with two complete regressions. The median duration of response was 7 months and the median duration of survival 14 months. The cardiac function of all patients was monitored by serial left ventricular ejection fraction, at rest and after stress, and 3-monthly thereafter. Ten patients showed a deterioration in the ejection fraction after a minimum cumulative dose of 86 mg/m2 (six cycles), but only four developed clinical cardiac failure which was easily reversible after stopping mitoxantrone. Leucopenia was the dose-limiting toxicity. Nausea and/or vomiting were generally mild and transient. Alopecia was minimal. These results confirmed that this combination is effective and well tolerated in the treatment of disseminated breast carcinoma, and cardiotoxicity can be avoided with adequate monitoring of the left ventricular ejection fraction after six cycles of therapy (86 mg/m2).

A comparison of two doses of adriamycin in the primary chemotherapy of disseminated breast carcinoma

Forty-eight patients with advanced breast carcinoma who had not received prior chemotherapy (minimum follow up 21 months) were randomised to receive either adriamycin 70 mg m-2 i.v. 3-weekly for 8 cycles (Regimen A) or adriamycin 35 mg m-2 i.v. 3-weekly for 16 courses (Regimen B). Objective responses were seen in 14/24 (58%) patients with regimen A (4 complete) and 6/24 (25%) with regimen B (1 complete) (P less than 0.02). The median duration of response was 14 months with regimen A and 6.5 months with regimen B. The median duration of survival was 20 months and 8 months respectively (P less than 0.01). The toxicity was similar with each regimen. There was no evidence of deterioration in left ventricular ejection fraction nor congestive heart failure in any patient. It is concluded that when given at 3-weekly intervals adriamycin is a more effective treatment for advanced breast cancer at higher rather than lower dosage.

Cytotoxic chemotherapy of disseminated cutaneous malignant melanoma--a prospective and randomized clinical trial of procarbazine, vindesine and lomustine versus procarbazine, DTIC and lomustine

Forty-three patients with measurable disseminated cutaneous malignant melanoma, stages III-IV, and without previous cytotoxic chemotherapy or immunotherapy, were randomly allocated from 30 June 1980 to 30 November 1984, to receive either a schedule of procarbazine (100 mg/m2 p.o., max 150 mg) days 1-10, vindesine (3 mg/m2 i.v., max 5 mg) days 1 and 8, and CCNU (150 mg/m2 p.o., max 200 mg) day 1, (regimen A), with 4-6 weeks interval between the courses, or a combination of procarbazine (100 mg/m2 p.o., max 150 mg) days 1-10, DTIC (250 mg/m2 i.v. max 400 mg) days 1-5, and CCNU (150 mg/m2 p.o. max 200 mg) day 1 (regimen B), also repeated every 4-6 weeks. Twenty-one patients were treated according to regimen A and 22, by regimen B. Objective responses (three PR, two CR) were seen in 5 out of 21 patients (23.8%) in group A and 8 out of 22 (four PR, four CR), (36%) in the group B, this difference not being statistically significant. The median duration of response was 8 and 10 months, respectively, and the estimated median survival 10 months for regimen A and 14 months for regimen B. Regimens A and B must be regarded as of no value in view of poor response rate and the unacceptable toxicity, respectively. Therefore, we are now conducting a further phase II study, to determine, prospectively, whether the previously noted high response rate obtained with our previous POC protocol can be reaffirmed.

A randomized trial of two regimens of cyclophosphamide, methotrexate, 5-fluorouracil, and prednisone in advanced breast cancer

One-hundred evaluable patients with progressive advanced breast carcinoma untreated by cytotoxic chemotherapy but resistant to hormone therapy and irradiation were randomly allocated to receive either a combination of cyclophosphamide (600 mg/m2), methotrexate (40 mg/m2), 5-fluorouracil (600 mg/m2) IV every 3 weeks and prednisone 20 mg/m2 PO daily, with diminishing doses (intermittent group), or a combination of cyclophosphamide (100 mg/m2 PO on days 1-15, alternating with a 15-day rest period), methotrexate 20 mg/m2 IV, 5-fluorouracil 500 mg/m2 IV weekly for 20 weeks and prednisone 20 mg/m2 PO daily, with diminishing doses in the remission induction period, followed by a maintenance regimen of cyclophosphamide 100 mg/m2 PO on days 1-15, methotrexate 20 mg/m2 IV on days 1, 8 and 15, 5-fluorouracil 500 mg/m2 IV on days 1, 8, and 15, and prednisone 20 mg/m2 PO on days 1-15, with a 3-week rest period between the courses (intensive group). Entry was from 1 December 1982 to 30 November 1983. Objective responses were seen in 20/49 (41%) patients in the intermittent group and 34/51 (67%) in the intensive group (chi 2 = 6.72; P less than 0.01). The estimated median duration of response was 11 months in the intermittent group and 14 months in the intensive group. The estimated median survival was greater in the intensive group, but the difference was not statistically significant, although this parameter can be influenced with alternative additional chemotherapy. Toxicity was similar in both groups. These data suggest there are no therapeutic and survival advantages to the 3-weekly IV protocol compared with our previous regimen CMFP.

Combination cytotoxic chemotherapy with procarbazine, vincristine, and lomustine (POC) in disseminated malignant melanoma: 8 years' follow-up

Forty-four consecutive ambulatory patients (24 male, 20 female; median age, 56 years [range, 21-76]) with evaluable disseminated malignant melanoma (stages III/IV) were entered in this study from October 1, 1975, to July 21, 1980 (last follow-up, October 31, 1983); they were treated with procarbazine (100 mg/,m2 orally; maximum dose, 150 mg) on Days 1-10, vincristine (1.4 mg/m2 iv; maximum dose, 2 mg) on Days 1 and 8, and lomustine (150 mg/m2 orally; maximum dose, 200 mg) on Day 1, repeated every 4-6 weeks. Twenty-one patients (48%) showed objective responses; 11 of these (25%) were complete responses. Nine patients had received previous chemotherapy, but none were treated with the drugs used in this protocol. Responses were seen mainly in cutaneous and/or nodal sites and pulmonary metastases. The median duration of remission was 10 months and the median survival of responders was 21 months compared to 5 months for nonresponders. Four responding patients are still alive and in complete response for 70+, 83+, 94+, and 95+ months, while one is alive, but in progression (83+ months). The toxicity of this regimen was clinically tolerable and hospitalization was not required. In our initial study the response rate was 60% (18 responses among 30 patients) and this regimen continues to have significant antitumor activity against disseminated malignant melanoma.

Moderate-dose cyclophosphamide for disseminated ovarian carcinoma: a phase II study

Fifty-six evaluable patients with advanced ovarian carcinoma (FIGO III or IV), without prior cytotoxic chemotherapy, were studied to assess the activity of single-agent moderate-dose cyclophosphamide, 40 mg/kg to a maximum dose of 3000 mg, given intravenously as a bolus injection every 3 weeks. All patients were treated as outpatients. Moderate-dose cyclophosphamide resulted in 36 (64%) objective responses (19 CR, 17 PR). Nausea and severe vomiting occurred in all patients, but no patient needed hospitalization for this complication. Other side-effects observed were alopecia (100%), leukocytes less than or equal to 2500/microliters (18%), chemical cystitis (11%) and sepsis (4%). The median duration of response was 11 months, and the estimated median survival by the life-table method for responders was 16 months and for non-responders 4 months (P less than 0.001). Clinical trials previously performed by our group comparing cyclophosphamide alone, either vs cis-platinum, adriamycin and hexamethylmelamine or vs Hexa-CAF, showed a better remission rate with the use of moderate-dose cyclophosphamide alone. Therefore we suggest further investigation of this agent in a moderate dose in disseminated ovarian carcinoma.

cis-Platinum, adriamycin, and hexamethylmelamine versus cyclophosphamide in advanced ovarian carcinoma

Fifty-three evaluable patients with disseminated ovarian carcinoma (FIGO III or IV) not treated with prior chemotherapy were randomized to receive either combination chemotherapy consisting of cis-platinum 40 mg/m2 IV on day 1, adriamycin 40 mg/m2 IV on day 1, and hexamethylmelamine 150 mg/m2 PO on days 2-10 up to a maximum of 200 mg on a 4-weekly cycle, or moderate-dose cyclophosphamide alone 40 mg/kg given IV intermittently every 3 weeks. Entry was from 1. 11. 1978 until 30. 4. 1981 (last follow-up 31. 10. 1981). Pretreatment characteristics in both groups of patients, regarding median age at diagnosis, median time from diagnosis to chemotherapy, FIGO stage, histology, differentiation grade, type of surgery, residual disease, previous radiotherapy, and median performance status, were comparable. Objective responses were seen in 18 of 27 (66%) of patients receiving cyclophosphamide alone (range 5--32+ months) and in 10 of 26 (38%) of patients treated with the combination (range 3--30+ months), this difference being statistically significant (chi 2 = 4.228; P less than 0.05). The median duration of objective response (11 vs 10 months) and the median survival (12 vs 11 months) were greater in the cyclophosphamide group, but these differences were not statistically significant. The toxicity of the combination was more severe. It is concluded that there is no therapeutic advantage for this combination schedule over the alkylating agent used alone.

Advanced ovarian carcinoma: a prospective and randomized clinical trial of cyclophosphamide versus combination cytotoxic chemotherapy (Hexa-CAF)

Fifty-seven evaluable patients with advanced ovarian carcinoma were randomized to receive either a combination of hexamethylmelamine, cyclophosphamide, methotrexate and 5-fluorouracil (Hexa-CAF) or high-dose cyclophosphamide alone given intravenously intermittently. Objective responses were seen in 62% of patients receiving cyclophosphamide alone, and 36% of patients in the Hexa-CAF regimen, this difference being statistically significant (P less than 0.05). The median duration of objective response (10 months vs. 9 months) and the median survival (11 months vs. 10 months) were greater in the cyclophosphamide group, but these differences were not statistically significant. It is concluded that there is no therapeutic advantage for the Hexa-CAF protocol over the alkylating agent used alone.

Chemotherapy of advanced breast cancer: a randomized trial of vincristine, Adriamycin, and cyclophosphamide (VAC) versus cyclophosphamide, methotrexate, 5-fluorouracil, and prednisone (CMFP)

Fifty-one patients with metastatic breast cancer were randomly allocated to receive either a four drug combination consisting of cyclophosphamide, methotrexate, 5-fluorouracil, and prednisone (CMFP), or a combination of vincristine, Adriamycin, and cyclophosphamide (VAC) with cross-over on relapse. Objective responses were seen in 17 of 26 patients (65%) in the CMFP group and in 14 of 25 patients (56%) in the VAC group, but this difference was not statistically significant. The median duration of response for each group was one year. The estimated median survival was greater for the CMFP group, but this was not significant. Toxicity was more severe with the VAC regimen. It is concluded that there is no therapeutic advantage of the VAC over the CMFP regimen.

Combination cytotoxic chemotherapy with CCNU, procarbazine, and vincristine in disseminated cutaneous malignant melanoma: 3 years, followup

Thirty patients with disseminated cutaneous malignant melanoma were treated with a three-drug cytotoxic chemotherapy program consisting of CCNU, procarbazine, and vincristine. Eighteen of 30 patients (60%) showed objective regressions, including ten complete responses (33%). Responders had cutaneous, nodal, and/or pulmonary involvement, but objective regressions were not achieved in patients with hepatic or brain metastases. The median response duration was 8 months and the median survival of the responders was 20 months compared to 5 months for nonresponders. These promising preliminary results require confirmation.