CTAD Task Force Paper: Neuropsychiatric Symptoms in AD: Clinical Trials Targeting Mild Behavioral Impairment: A Report from the International CTAD Task Force

The International CTAD Task Force (TF) addressed challenges related to designing clinical trials for agitation in dementia, presenting accomplishments from the two previous TFs on neuropsychiatric symptoms (NPS). In addition, this TF proposed a paradigm shift in NPS assessment and management, presenting Mild Behavioral Impairment (MBI) as a clinical syndrome. MBI is marked by later-life emergent and persistent NPS in dementia-free older persons (ranging from cognitively unimpaired to subjective cognitive decline to mild cognitive impairment), which facilitates earlier detection and better prognostication of Alzheimer's disease (AD). The TF has made the following recommendations for incorporation of NPS into AD preventative trials: (1) clinical trials targeting improvement in MBI symptoms should be undertaken; (2) treatment trials for MBI should be disease specific and confirm the diagnosis of participants using biomarkers; trials should include measures sensitive to cognitive changes in preclinical AD, which can serve as outcome measures, in addition to changes in biomarker levels; (3) as a first step, pharmacotherapeutic trials should address the full MBI complex as well as the specific symptoms/domains that constitute MBI; (4) clinical trials using problem-adaptation psychotherapy to target affective MBI should be considered; and (5) MBI should be considered in AD trials of disease modifying therapies. The well-validated and widely-used MBI Checklist (MBI-C) is an appropriate symptom rating scale for these studies, as it was developed specifically to identify and measure MBI in dementia-free persons. Other scales such as the Neuropsychiatric Inventory (NPI) may be used, although administration at two timepoints may be necessary to operationalize the MBI criterion of symptom persistence.

A Framework for Developing Pharmacotherapy for Agitation in Alzheimer's Disease: Recommendations of the ISCTM* Working Group

Dementia is characterized by a significant decline in one of several cognitive domains such as memory, language and executive function, affecting independence and representing a significant deterioration from a previous level of functioning (1). Alzheimer’s Disease (AD) represents the most common form of dementia and contributes up to 70% of the almost 50 million dementia cases worldwide, a number that is projected to double in 20 years (2).

Identifying Better Outcome Measures to Improve Treatment of Agitation in Dementia: A Report from the EU/US/CTAD Task Force

For the second time in the past 3 years, the EU-US CTAD Task Force addressed challenges related to designing clinical trials for agitation in dementia, which is one of the most disruptive aspects of the condition for both patients and caregivers. Six recommendations emerged from the Task Force meeting: 1 - Operationalizing agitation criteria established by the IPA; 2 - Combining clinician- and caregiver-derived outcomes as primary outcome measures; 3 - Using global ratings to define clinically meaningful effects and power studies; 4 - Improving the accuracy of caregiver reports by better training and education of caregivers; 5 - Employing emerging technologies to collect near real-time behavioral data; and 6 - Utilizing innovative trial designs and increasing the use of biomarkers to maximize the productivity of clinical trials for neuropsychiatric symptoms.

EU/US/CTAD Task Force: Lessons Learned from Recent and Current Alzheimer's Prevention Trials

At a meeting of the EU/US/Clinical Trials in Alzheimer's Disease (CTAD) Task Force in December 2016, an international group of investigators from industry, academia, and regulatory agencies reviewed lessons learned from ongoing and planned prevention trials, which will help guide future clinical trials of AD treatments, particularly in the pre-clinical space. The Task Force discussed challenges that need to be addressed across all aspects of clinical trials, calling for innovation in recruitment and retention, infrastructure development, and the selection of outcome measures. While cognitive change provides a marker of disease progression across the disease continuum, there remains a need to identify the optimal assessment tools that provide clinically meaningful endpoints. Patient- and informant-reported assessments of cognition and function may be useful but present additional challenges. Imaging and other biomarkers are also essential to maximize the efficiency of and the information learned from clinical trials.

Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States

The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.

Risk factors for lymph node metastases in women with endometrial cancer: A population-based, nation-wide register study-On behalf of the Swedish Gynecological Cancer Group

The role of lymphadenectomy in the management of early endometrial cancer remains controversial. In the recent ESMO-ESGO-ESTRO guidelines, lymphadenectomy is recommended for patients with endometrioid adenocarcinoma Grade 3 with deep myometrial invasion, but complete agreement was not achieved. In Sweden, DNA aneuploidy has been included as a high-risk factor. The aim of our study was to evaluate the impact of tumor histology, FIGO grade, DNA ploidy and myometrial invasion (MI) on occurrence of lymph node metastasis (LNM) in patients with endometrial cancer. The study design is a retrospective cohort study based on prospectively recorded register data. Endometrial cancer patients registered in the Swedish Quality Registry for Gynecologic Cancer 2010-2015 with FIGO Stages I-III and verified nodal status were included. Data on DNA ploidy, histology, FIGO grade and MI were included in multivariable log-binomial regression analyses with LNM as dependent variable. 1,165 cases fulfilled the inclusion criteria. The multivariable analyses revealed increased risk of LNM in patients with tumors with MI ≥ 50% (risk ratio [RR] = 4.1; 95% confidence interval [CI] 3.0-5.6), nonendometrioid compared to endometrioid histology (RR 1.8; CI 1.4-2.4) and FIGO Grade 3 compared to Grade 1-2 tumors (RR 1.5; CI 1.1-2.0). No statistically significant association between DNA ploidy status and LNM was detected. This population-based, nation-wide study in women with endometrial cancer confirms a strong association between MI ≥ 50%, nonendometrioid histology and FIGO Grade 3, respectively, and LNM. DNA ploidy should not be included in the preoperative decision making of removing nodes or not.

Familial testicular germ cell tumors (FTGCT) - overview of a multidisciplinary etiologic study

This Review summarizes the cumulative results of the National Cancer Institute Clinical Genetics Branch Multidisciplinary Etiologic Study of Familial Testicular Germ Cell Tumors (FTGCT). Initiated 12 years ago, this protocol enrolled 724 subjects from 147 unrelated families with either ≥2 affected men (n = 90) with TGCT or a proband with bilateral TGCT and a negative family history for this cancer (n = 57). Data were collected directly from 162 subjects evaluated at the NIH Clinical Center, and 562 subjects provided information from their home communities (Field Cohort). The primary study aims included (i) ascertaining, enrolling eligible FTGCT kindred, (ii) characterizing the clinical phenotype of multiple-case families, (iii) identifying the underlying genetic mechanism for TGCT susceptibility in families, (iv) evaluating counseling, psychosocial, and behavioral issues resulting from membership in an FTGCT family, and (v) creating an annotated biospecimen repository to permit subsequent translational research studies. Noteworthy findings include (i) documenting the epidemiologic similarities between familial and sporadic TGCT, (ii) demonstrating significantly younger age-at-diagnosis for familial vs. sporadic TGCT, (iii) absence of a dysmorphic phenotype in affected family members, (iv) shifting the focus of gene discovery from a search for rare, highly penetrant susceptibility variants to the hypothesis that multiple, more common, lower penetrance genes underlie TGCT genetic risk, (v) implicating testicular microlithiasis in FTGCT risk, and (vi) observing that aberrant methylation may contribute to FTGCT risk. A clinically based, biospecimen-intensive, multidisciplinary research strategy has provided novel, valuable insights into the etiology of FTGCT, and created a research resource which will support FTGCT clinical and laboratory studies for years to come.

Serum B12 levels predict response to treatment with interferon and ribavirin in patients with chronic HCV infection

Vitamin B12 is stored in hepatocytes and inhibits hepatitis C virus (HCV) RNA translation. The implication of B12 in the setting of antiviral treatment is unknown. This study aims to retrospectively evaluate the discriminative efficacy of pretreatment B12 serum levels (s-B12) on end-of-treatment response (ETR) in patients with chronic HCV. Ninety-nine treatment naïve HCV patients, treated with interferon and ribavirin were studied. Serum B12 (s-B12) was analysed in samples collected before treatment start. Pretreatment s-B12 levels were correlated to ETR using univariate analysis. S-B12 and clinical data were evaluated in a multivariate logistic regression model. Mean pretreatment s-B12 was 331 pm in ETR and 260 pm in nonresponders (NR) (P = 0.012). In patients with s-B12 levels ≤ 360 pm, 23 (31.5%) were NR and 50 (68.5%) had ETR. In patients with s-B12 > 360 pm, one (3.8%) was NR and 25 (96.2%) had ETR (P = 0.0034). The results of the multivariate analysis were as follows: Pretreatment s-B12 > 360 vs ≤ 360 pm: OR 28.6 CI 2.31-354, P = 0.008. Fibrosis stage 3-4 vs 0-2: OR 0.29 CI 0.074-1.12, P = 0.068. Genotype 2/3 vs 1/4/5: OR 15.5 CI 2.87-83.9, P = 0.0012. Dose reduction vs no dose reduction: OR 0.21, CI 0.048-0.91 P = 0.034. Standard interferon vs pegylated-interferon: OR 0.079, CI 0.0091-0.68 P = 0.019. Age and gender were not correlated to ETR. S-B12 > 360 pm is independently correlated to ETR in HCV patients treated with interferon and ribavirin. This suggests that B12 is involved in suppression of viral replication during anti-HCV treatment.

Male Breast Cancer: A Population-Based Comparison with Female Breast Cancer

Purpose: Because of its rarity, male breast cancer is often compared to female breast cancer.Materials and Methods: To compare and contrast male and female breast cancers, we obtained case and population data from the NCI's Surveillance, Epidemiology, and End Results program for breast cancers diagnosed from 1973 through 2005. Standard descriptive epidemiology was supplemented with age-period-cohort models and breast cancer survival analyses.Results: Men with breast cancer comprised less than 1% of all breast cancers. Male compared to female breast cancers occurred later in life with higher stage, lower grade, and more estrogen receptor positive tumors. Recent breast cancer incidence and mortality rates declined over time for men and women, both overall and within each age group, but these trends were greater for women than men. Comparing cases diagnosed in 1996 through 2005 versus 1976 through 1985, and adjusting for age, stage, and grade, cause-specific hazard rates for breast cancer death declined by 28% among men (p = 0.03) and by 42% among women (p ∼ 0).Conclusion: There were three intriguing results. Age-specific incidence patterns showed that the biology of male breast cancer resembled the late-onset and hormone sensitive type of female breast cancer. Similar breast cancer incidence trends among men and women suggested that there are common breast cancer risk factors that affect both sexes, especially hormone positive breast cancer. Finally, breast cancer mortality and survival rates have improved significantly over time for male breast cancer, but progress has lagged behind for men compared to women.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 2075.

Advanced glycation end product is implicated in amyloid‐related kidney complications

BACKGROUND

Kidney failure is a common complication in familial amyloidotic polyneuropathy (FAP). It has been suggested that advanced glycation end products (AGEs) play an important role in the development and pathogenesis of FAP.

MATERIAL AND METHODS

To evaluate the impact of AGEs on FAP patients' kidney dysfunction, we measured AGE in serum and urine of 28 FAP patients and 18 healthy controls by AGE-specific enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry utilizing antibodies to AGE and the receptor for AGE (RAGE) were used on kidney tissue from 3 FAP patients and 3 diabetic patients to disclose a correlation between amyloid deposits and AGE-RAGE.

RESULTS

The glomeruli of FAP patients were heavily deposited with amyloid and the glomerular size was enlarged. The space between Bowman's capsule and glomerulus was totally covered by the enlarged glomerulus. AGE and RAGE were deposited in glomeruli and tubuli and correlated with amyloid deposits. Decreased AGE levels in the liver-transplanted FAP patients' serum compared with that of non-transplanted patients were noted, and AGE concentration in serum tended to be higher in non-transplanted FAP patients compared with normal control subjects. There were no differences in the AGE urine levels in FAP patients compared with controls. No correlation could be found between AGE in urine and serum compared with serum albumin, serum creatinine and creatinine clearance.

CONCLUSIONS

The accumulation of AGE, RAGE and amyloid in the kidney of FAP patients suggests that these molecules play an important role in the origin and pathogenesis of renal failure in FAP patients.

Spatial variation in 2-methyl-4-chlorophenoxyacetic acid mineralization and sorption in a sandy soil at field level

The phenoxyacetic acid herbicide MCPA (2-methyl-4-chlorophenoxyacetic acid) is frequently detected in groundwater beneath Danish agricultural fields. We investigated spatial variation in microbial MCPA mineralization potential in a flat agricultural field of fine sandy soil (USDA classification: Humic Dystrudept) located on the Yoldia plains of Northern Jutland, Denmark. Samples for determination of MCPA mineralization and sorption were collected from the Ap and Bs horizons at 51 sampling sites located in a 200 x 220 m grid. Spatial variation in sorption was low in both horizons (distribution coefficient, 0.36-4.16 L kg(-1)). Sorption correlated strongly with soil organic carbon content in both horizons (CV, 93 and 83%, respectively) and negatively with soil pH. [Ring-(14)C]-MCPA mineralized readily in the Ap horizon, with 49 to 62% of the (14)C-MCPA being converted to (14)CO(2) during the 67-d incubation period. With the subsoil, mineralization of (14)C-MCPA varied considerably between samples (0.5-72.8%). At neither depth was there correlation between (14)C-MCPA mineralization and sorption, soil pH, organic carbon content, clay content, number of colony-forming units (CFU), pseudomonad CFU, or any of the four microbial activity parameters measured. The presence of microbial genes encoding for the TfdA enzyme was quantified using real-time polymerase chain reaction. No correlation was found between MCPA mineralization potential and the natural background number of tfdA genes present in the soil samples. The degradation kinetics suggests that the high (14)C-MCPA mineralization rate detected in soil samples was linked to growth of the MCPA-degrading soil microbial community.

Impact of basic soil parameters on pesticide disappearance investigated by multivariate partial least square regression and statistics

Dissipation time is a key parameter when studying and modeling the environmental fate of pesticides. This study was conducted to characterize the variability of pesticide disappearance in soil and to identify possible controlling parameters related to intrinsic soil properties and microbiology. Multivariate data analysis was used to study spatial variability in three horizons from 24 sandy soil profiles. The time for 50% disappearance (DT(50)) was characterized for two herbicides, metribuzin (MBZ) and MCPA, and methyltriazine amine (MTA; transformation product of metsulfuron-methyl, tribenuron-methyl, thifensulfuron-methyl, and chlorsulfuron). Normal and log-normal distributions were compared for DT(50) and soil properties and descriptive statistics were calculated. Conformity with log-transformed distributions was observed and assuming normality of the DT(50) data would cause 5 to 35% overestimation. Mean DT(50) were: MCPA 9.5, MBZ 168, and MTA 127. Significant effect of soil depth on DT(50) was shown for MCPA and MBZ, with low values in deeper horizons. Simple linear correlation for combinations of MCPA, MTA, pH, and total organic carbon (TOC) was observed. Using partial least squares regression (PLS) 71 to 85% of the total DT(50) variance was explained. A specific predictor variable could not be identified as the controlling components differed within horizons and compounds. For MCPA the overall important predictor variables were microbiology and TOC, whereas for MTA and MBZ it was inorganic variables (Al, Fe, cation exchange capacity, base saturation percent, and pH) and microbiology. The study indicates that PLS generated input data can improve pesticide fate modeling and reduce the uncertainty in dissipation estimation.

Usefulness of symphysis-fundal height in predicting fetal weight in healthy term pregnant women

BACKGROUND

There are some works reporting that the measurement of the symphysis-fundal height (SFH) of a full-term uterus is a simple method for estimating the fetal weight.

AIM

Evaluating the goodness of distance between the symphysis and uterine fundus in predicting both low-weight fetuses and high-weight fetuses, comparing it with the third quarter ultrasound estimation of fetal weight and then assessing the clinical effectivity of symphysis-fundal measurement associated with third quarter echography in predicting birth weight.

METHODS

A prospective study was carried out on 96 single physiologically full-term pregnancies. The diagnostic accuracy of the SFH, echographic fetal growth estimated between the 32nd and the 35th week (expressed in percentiles), and of both was expressed as sensitivity, specificity, predictive positive and negative value, likelihood ratios and compared.

RESULTS

There was a correlation between the SFH and fetal birth weight. A SFH below 33 cm is predictive of a fetus whose weight is less than 3,100 g whereas a SFH above 34 cm is predictive of a fetus whose weight is more than or equal to 4,000 g. The diagnostic effectiveness of the SFH was not significantly higher than the ultrasound scanning evaluation of fetal weight in the third quarter and could be slightly improved if it is taken into account along with the ultrasound scanning data.

CONCLUSIONS

The measurement of the SFH at term may be helpful in foretelling the fetal birth weight and may improve the diagnostic accuracy of the third quarter echographic estimation of birth weight.

A randomized phase-III study on adjuvant treatment with radiation (RT) ± chemotherapy (CT) in early-stage high-risk endometrial cancer (NSGO-EC-9501/EORTC 55991)

5503

Background: Adjuvant therapy for early stage high-risk endometrial cancer remains controversial. Methods: Patients with surgical stage I, II, IIIA (positive peritoneal fluid cytology only), or IIIC (positive pelvic lymph nodes only) were eligible if they, according to departmental guidelines, had a sufficiently high risk for micrometastatic disease to qualify for adjuvant therapy. Most patients had two or more of the risk factors: grade 3, deep myometrial invasion, or DNA non-diploidy, while some patients had only one of these. Patients with serous, clear cell, or anaplastic carcinomas were eligible regardless of risk factors. Patients with para-aortic metastases were not eligible. Lymph node exploration at staging surgery was optional. Pelvic RT ± vaginal brachytherapy was given to a dose =44 Gy. CT was given before or after RT. Before August 2004 CT consisted of four courses of cisplatin =50 mg/m2 + doxorubicin 50 mg/m2 or epirubicin 75 mg/m2 (AP). Thereafter several CT regimens were allowed, of which AP, paclitaxel 175 mg/m2 + epirubicin 60 mg/m2 + carboplatin AUC 5, and paclitaxel 175 mg/m2 + carboplatin AUC 5–6 were used. Progression-free survival (PFS) was the primary end-point. The study was terminated before the aimed goal of 400 patients because of slow recruitment. We decided to make an early analysis since new studies on endometrial cancer are presently discussed. Results: 372 patients were entered between May 1996 and Oct 2006. Of 367 evaluable patients 190 were randomized to RT and 177 to RT+CT. Risk factors were well balanced between the randomization arms. The median follow-up time was 3.5 years. The hazard ratio for PFS was 0.58 in favor of RT+CT (95 % confidence interval (CI) 0.34 - 0.99; p=0.046). This translates to an estimated 7 % absolute difference in 5-year PFS from 75 % (95 % CI 67 % - 82 %) to 82 % (95 % CI 73 % - 88 %). Conclusion: RT+CT was better than RT alone. Next question is if RT+CT is better than CT alone.

No significant financial relationships to disclose.

Malignant mixed müllerian tumor of the fallopian tube coincident with a primary serous carcinoma of the ovary. Case report

Malignant mixed müllerian tumors are very rare neoplasms of the fallopian tube, and treatment is not well defined. A case of malignant mixed müllerian tumor of the tube concomitant with a primary serous carcinoma of the ovary is reported. It was unclear if there were two distinct neoplasms in the same patient, or if it was a single tumor with a sarcomatous fallopian conversion of the serous component, as described for some recurrent ovarian carcinomas. Chemotherapy for ovarian carcinoma with intraperitoneal metastasis was performed, with about a three-year interval-free period of disease, as could be expected for ovarian carcinomas at the same stage. Such coexistence of these two tumors does not afford adequate staging of the malignancy. Therapy for the very rare cases similar to the one reported here needs to be improved.

Effects of cigarette smoking on serum fluoride concentrations and renal function integrity after 1 MAC-h sevoflurane anaesthesia

BACKGROUND

Tobacco smoke contains various chemicals which may affect drug metabolism. Sevoflurane is metabolized to inorganic fluoride, and elevated serum fluoride concentrations (S-F(-)) may cause deterioration of renal function. Whether smokers develop high S-F(-) and associated disturbances in renal function is not known.

METHODS

We investigated sevoflurane metabolism in 25 non-smoking and 25 smoking (> 10 cigarettes/day) generally healthy women, aged 19-68 years, undergoing gynaecological elective surgery under one minimum alveolar concentration-hour (1 MAC-h) standardized sevoflurane anaesthesia. S-F(-) was measured for 24 h. Glomerular and tubular function was assessed by measuring serum and urine tumour-associated trypsin inhibitor (TATI), beta(2)-microglobulin and serum creatinine for 48 h after sevoflurane inhalation.

RESULTS

There were no differences between the two study groups with regard to S-F(-). It increased significantly in both groups: in non-smokers, from a baseline between 1.0 and 11 micromol/l (median, 1.6 micromol/l) to a maximum between 8.2 and 40 micromol/l (26 micromol/l) (P < 0.001) and, in smokers, from a baseline between 0.5 and 5.2 micromol/l (1.7 micromol/l) to a maximum between 19 and 71 micromol/l (25 micromol/l) (P < 0.001). In both groups, S-F(-) remained elevated for the entire sampling period (P < 0.001). In all five women (one non-smoker and four smokers) with a maximum S-F(-) of 40 micromol/l or higher and an area under the serum fluoride concentration-time curve (AUC(F0-24)) of 500 micromol/h/l or higher, serum TATI increased above the pathological concentration of 3.0 nmol/l, whereas only six of the 45 patients with S-F(-) below 40 micromol/l had serum TATI above 3.0 nmol/l (P < 0.001). Beta(2)-Microglobulin increased significantly (> 1 mg/l) in two patients with high S-F(-) relative to two of the 45 patients with S-F(-) below 40 micromol/l (P= 0.005). None of the patients developed clinically detectable renal dysfunction.

CONCLUSION

Smoking did not affect S-F(-) after sevoflurane anaesthesia. Glomerular dysfunction, seen as increased serum TATI, was noted in five women with S-F(-) above 40 micromol/l. Our results suggest that the renal toxic threshold of S-F(-) seems to be lower than the earlier reported value of 50 micromol/l.

Comparison of 30 and the 100% inspired oxygen concentrations during early post-resuscitation period: a randomised controlled pilot study

OBJECTIVES

High oxygen concentration in blood may be harmful in the reperfusion phase after cardiopulmonary resuscitation. We compared the effect of 30 and 100% inspired oxygen concentrations on blood oxygenation and the level of serum markers (NSE, S-100) of neuronal injury during the early post-resuscitation period in humans.

METHODS

Patients resuscitated from witnessed out-of-hospital ventricular fibrillation were randomised after the return of spontaneous circulation (ROSC) to be ventilated either with 30% (group A) or 100% (group B) oxygen for 60 min. Main outcome measures were NSE and S-100 levels at 24 and 48 h after ROSC, the adequacy of oxygenation at 10 and 60 min after ROSC and, in group A, the need to raise FiO(2) to avoid hypoxaemia. Blood oxygen saturation <95% was the threshold for this intervention.

RESULTS

Thirty-two patients were randomised and 28 (14 in group A and 14 in group B) remained eligible for the final analysis. The mean PaO(2) at 10 min was 21.1 kPa in group A and 49.7 kPa in group B. The corresponding values at 60 min were 14.6 and 46.5 kPa. PaO(2) values did not fall to the hypoxaemic level in group A. In another group FiO(2) had to be raised in five cases (36%) but in two cases it was returned to 0.30 rapidly. The mean NSE at 24 and 48 h was 10.9 and 14.2 microg/l in group A and 13.0 and 18.6 microg/l in group B (ns). S-100 at corresponding time points was 0.21 and 0.23 microg/l in group A and 0.73 and 0.49 microg/l in group B (ns). In the subgroup not treated with therapeutic hypothermia in hospital NSE at 24h was higher in group B (mean 7.6 versus 13.5 microg/l, p=0.0487).

CONCLUSIONS

Most patients had acceptable arterial oxygenation when ventilated with 30% oxygen during the immediate post-resuscitation period. There was no indication that 30% oxygen with SpO(2) monitoring and oxygen backup to avoid SpO(2)<95% did worse that the group receiving 100% oxygen. The use of 100% oxygen was associated with increased level of NSE at 24h in patients not treated with therapeutic hypothermia. The clinical significance of this finding is unknown and an outcome-powered study is feasible.

Fluoride metabolism in smokers and non-smokers following enflurane anaesthesia

BACKGROUND

Inorganic fluoride is released by the metabolism of enflurane and the increased serum fluoride concentrations may impair renal function. Tobacco smoke consists of numerous reactive compounds that can either induce or inhibit drug metabolism. Studies on the interaction of smoking with anaesthetic drug metabolism and possible toxicity are warranted.

METHODS

Sixteen non-smoking and 17 smoking (>10 cigarettes day(-1)) generally healthy women undergoing elective gynaecological surgery were given 1 MAC (minimum alveolar concentration)-hour standardized anaesthesia with enflurane in oxygen-air mixture. The serum inorganic fluoride and renal function markers beta(2)-microglobulin, tumour-associated trypsin inhibitor (TATI) and serum creatinine were measured for 48 h.

RESULTS

The greatest inorganic fluoride concentration was between 8.4 and 21.0 (mean 13.8 (SD 3.4)) micromol litre(-1) in the non-smokers and between 8.6 and 38.0 (18.7 (7.0)) micromol litre(-1) in the smokers; the mean difference was 4.9 micromol litre(-1) (95% confidence interval (CI) 1.0-8.8, P<0.05). Serum beta(2)-microglobulin, TATI and creatinine were not increased. Serum inorganic fluoride concentrations were significantly greater in the smokers compared with the non- smokers 1, 2, 3 and 6 h after 1 MAC-hour inhalation with enflurane (P<0.05). Inorganic fluoride concentrations were still increased 24 h after anaesthesia in both groups. Urine beta(2)-microglobulin and TATI creatinine ratio remained at low values during the whole 48-h period in both groups.

CONCLUSIONS

Regular smoking is associated with an increase in serum inorganic fluoride concentration after anaesthesia with enflurane, but there are no signs of renal damage.

Axonal damage to the left musculocutaneous nerve of the left biceps muscle during laparoscopic surgery

The probable etiology of axonal damage to the left musculocutaneous nerve (motor branch) of the left biceps branchii during a laparoscopic procedure was the position in which the patient was maintained. As a result of unintentional change in the angle of the arm from 90 to approximately 120 degrees while in steep Trendelenburg position, the arm might have suffered hyperextension, resulting in pressure on and stretching of the brachial plexus nerve. This in turn might be the cause of neurologic damage. We recommend taking steps to prevent such occurrences, such as tying the patient's arms parallel to the body.

Thrombolytic treatment of acute myocardial infarction after out-of-hospital cardiac arrest

OBJECTIVE

To investigate the safety and efficacy of thrombolytic treatment for an acute myocardial infarction (AMI) immediately after resuscitation in the out-of-hospital setting.

DESIGN

Retrospective.

SETTING

A middle-sized urban city (population 540000) served by a single emergency medical system using a tiered response with physicians in field.

PATIENTS AND METHODS

Sixty-eight patients with an initial diagnosis of AMI who received thrombolytic treatment in an out-of-hospital setting after cardiac arrest and cardiopulmonary resuscitation (CPR) between January 1st 1994 and December 31st 1998. An ECG and the myocardial enzymes (CK, CK-MB, Troponin-T) were used to diagnose AMI. Myocardial reperfusion was assessed by resolution of the ST-segment elevation. Side effects and complications were studied. The quality of secondary survival was evaluated. The Utstein style was used for a uniform style of reporting the cardiac arrest data.

RESULTS

The accuracy of prehospital diagnosis was found to be excellent. Retrospective analysis revealed that thrombolytic therapy had been appropriately administered in 64 (94%) of the 68 patients actually treated. Reperfusion was achieved in 71% of the patients. Haemorrhagic complications were few, and included intracranial haemorrhage (one patient), gastrointestinal bleeding (two patients), bleeding from the puncture site (one patient) and epistaxis (one patient). The incidence of hypotension during streptokinase infusion was 22%. Sixty-three (93%) of the patients were admitted alive to the hospital, with 36 subsequently surviving to discharge.

CONCLUSIONS

Thrombolytic treatment is a safe and effective treatment in AMI even after out-of-hospital cardiopulmonary resuscitation.

Ketorolac is not nephrotoxic in connection with sevoflurane anesthesia in patients undergoing breast surgery

Ketorolac, which may cause renal vasoconstriction by cyclooxygenase inhibition, is often administered to patients anesthetized with sevoflurane that is metabolized to inorganic fluoride (F(-)), another potential nephrotoxin. We assessed this possible interaction using urine N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine (U-NAG/crea) as a marker of proximal tubular, beta2-microglobulin as a tubular, urine oxygen tension (P(u)O(2)) as a medullary, and erythropoietin as a marker of tubulointerstitial damage. Thirty women (ASA physical status I-II) undergoing breast surgery were included in our double-blinded study. They were allocated into two groups receiving either ketorolac 30 mg IM (Group K) or saline (Group C) at the time of premedication, at the end of, and 6 h after anesthesia maintained with sevoflurane. Urine output, U-NAG/crea, P(u)O(2,) serum creatinine, urea, and F(-) were assessed. Blood loss was larger in Group K (465 +/- 286 mL vs 240 +/- 149 mL, mean +/- SD, P < 0.05). The MAC-doses of sevoflurane were similar. U-NAG/crea increased during the first 2 h of anesthesia and serum F(-) peaked 2 h after the anesthesia without differences between the groups. There were no statistically significant changes in P(u)O(2), erythropoietin, beta2-microglobulin, serum creatinine, urea, or urine output during anesthesia or the recovery period in either group. Our results indicate that the kidneys are not affected by ketorolac administered in connection with sevoflurane anesthesia.

IMPLICATIONS

The different kinetics of N-acetyl-beta-D-glucosaminidase indexed to urinary creatinine and serum inorganic fluoride during and after sevoflurane anesthesia suggest that the observed mild renal tubular function deterioration is not caused by inorganic fluoride. Administration of ketorolac IM is therefore considered safe in adequately hydrated healthy adult patients given sevoflurane anesthesia.

Quantitation of catecholamines in inflamed human dental pulp by high-performance liquid chromatography

Catecholamines may play an important role in the control of intrapulpal pressure as mediators of vasoconstriction. A baseline level of catecholamines (dopamine, epinephrine, and norepinephrine) in the uninflamed human dental pulp was previously reported using high-performance liquid chromatography. The purpose of this study was to compare the level of catecholamines present in the inflamed human dental pulp with the baseline level established in virgin teeth. Twelve uninflamed pulps were analyzed as a control and to validate previous findings. Pulp tissue was obtained from 10 vital and inflamed teeth requiring endodontic treatment. Selective criteria for each patient included: absence of systemic disease, medications, and allergies; a vital response to ice, heat, and electric pulp tests; and periodontal probing < or = 3 mm. A prior history of pain associated with the tooth was an additional criterion for inflamed pulps. To avoid the presence of an exogenous catecholamine, local anesthesia without epinephrine was administered. Dopamine, epinephrine, and norepinephrine were chemically extracted and analyzed by high-performance liquid chromatography with ultraviolet detection. Catecholamine levels found to be present in the pulp during inflammation were greater than the baseline level established in uninflamed pulp tissue.

The use of sliding time windows for the exploratory analysis of temporal effects of smoking histories on lung cancer risk

To examine the time-dependent effects of exposure histories on disease we use sliding time windows as an exploratory alternative to the analysis of variables like time since last exposure and duration of exposure. The method fits a series of risk models which contain total cumulative exposure and an additional covariate for exposures received during fixed time intervals. Characteristics of the fitted models provide insight into the influence of exposure increments at different times on disease risk. A simulation study is performed to check the validity of the approach. We apply the method to data from a recent German case-control study on smoking and lung cancer risk with about 4300 lung cancer cases and a similiar number of controls. The sliding time window approach indicates that the amount of cigarettes smoked from two to 11 years before disease incidence is most predicitive of lung cancer incidence. Among different smoking profiles that result in the same lifelong cumulative number of cigarettes smoked, those with a concentration of smoked cigarettes within 20 years before interview bear substantially larger risk than others.

Morphine clearance and effects in newborn infants in relation to gestational age

OBJECTIVE

We sought to provide a rational basis for morphine administration in preterm infants in the immediate postnatal period by determining the clearance and evaluating the efficacy and adverse effects of a continuous infusion.

STUDY DESIGN

Morphine was infused for 2 to 4 days (140 microg/kg over 1 hour followed by 20 microg/kg/h) to 31 ventilator-treated newborn infants (gestational age, 24 to 41 weeks; birth weight, 765 to 4,015 g). Morphine, morphine-3-glucuronide, and morphine-6-glucuronide concentrations in serum were determined from arterial blood obtained at 2, 12, 24, 48, and 60 hours after the start of morphine infusion at a median postnatal age of 10 hours.

RESULTS

The mean +/- SD steady-state morphine concentration, 167 +/- 77 ng/mL, was achieved between 24 and 48 hours of infusion, and morphine-6-glucuronide and morphine-3-glucuronide concentrations did not reach steady state within 60 hours. Morphine clearance (range, 0.8 to 6.5 mL/min/kg) correlated significantly with gestational age (r = 0.60; P < .01) and birth weight (r = 0.55; P < .01). Pain relief did not correlate with the steady-state morphine concentration. However, significantly higher morphine concentrations were found in infants with decreased gastrointestinal motility (187 +/- 82 ng/mL) compared with those without (128 +/- 51 ng/mL; P < .05).

CONCLUSIONS

Morphine should be used with caution in prematurely born infants because of its low clearance, which correlates with gestational age.

Noninvasive assessment of hemodynamics: an emphasis on bioimpedance cardiography

Evaluation of the hemodynamic response in heart failure is a useful adjunct in clinical management. Invasive monitoring has been the accepted gold standard of hemodynamic assessment but carries with it significant associated risks. Noninvasive hemodynamic assessment in heart failure previously has been either unreliable or difficult to obtain. Bioimpedance relies on the proportional change in the conduction of alternating current applied across the thorax as a function of blood volume in the heart and great vessels. Stroke volume, cardiac output, thoracic fluid content, and measures of diastolic function can be determined with bioimpedance. Impedance cardiography is becoming an accepted method for safe, reliable, and reproducible assessment of hemodynamics in heart failure.

Controlled release injectable liposomal gel of ibuprofen for epidural analgesia

The epidural administration is used commonly in the treatment of pain. Nonsteroidal anti-inflammatory drugs, especially ibuprofen, would have potential in epidural use. Like many epidurally useful drugs it, however, has a short duration of action, which is a limiting factor. To improve epidural pain treatment, a long-acting, single-dose gel injection is being developed. In the present study, the possibility of using liposomal systems to control the release and dural permeation of ibuprofen was investigated in vitro. Liposomal solutions of ibuprofen.Na (20 mg/ml) were prepared by high-pressure homogenization from egg phosphatidylcholine. The liposomal gel consisted of poloxamer 407 and the liposomal solution. No signs in the 1H-NMR spectroscopy of line broadenings or chemical shifts were observed. The liposomal formulations were reproducible and stable. Ibuprofen release in phosphate buffer, pH 7.4, at 37 degrees C from the liposomal solution and the liposomal gel were prolonged significantly compared with their respective solution and gel controls. The liposomal gel controlled ibuprofen release and dural permeation in vitro and showed a permeation pattern favourable for maintaining constant drug levels. The liposomal poloxamer gel represents a new formulation approach to increase the local epidural availability of ibuprofen. It appeared to be a promising injectable controlled-release drug delivery system.

Lipopolysaccharides of a Campylobacter coli isolate from a patient with Guillain-Barré syndrome display ganglioside mimicry

Campylobacter coli was isolated from a patient with severe, axonal type Guillain-Barré syndrome (GBS). The patient's serum was tested by ELISA for glycolipid antibodies and showed a high titer of IgG antibodies to asialo-GM1 (GA1) and GD3. Campylobacter coli lipopolysaccharide (LPS) was extracted and analyzed by ELISA, immunoblot binding and blocking studies, and found to avidly bind cholera toxin and peanut agglutinin. The LPS from the patient's isolate also induced anti-GA1 antibodies in a rat model. These findings suggest that the LPS from this bacterial isolate contains a ganglioside-like epitope, which most likely resembles GA1. Thus, it appears that ganglioside cross-reactivity is not unique to Campylobacter jejuni and seems to occur in all bacterial isolates from GBS cases so far analyzed.

Randomized study on adjuvant chemotherapy in stage I high-risk ovarian cancer with evaluation of DNA-ploidy as prognostic instrument

PURPOSE

Adjuvant chemotherapy versus observation and chemotherapy at progression was evaluated in 162 patients in a prospective randomized multicenter study. We also evaluated DNA-measurements as an additional prognostic factor.

PATIENTS AND METHODS

Patients received adjuvant carboplatin AUC 7 every 28 days for six courses (n = 81) or no adjuvant treatment (n = 81). Eligibility included surgically staged and treated patients with FIGO stage I disease, grade 1 aneuploid or grade 2 or 3 non-clear cell carcinomas or clear cell carcinomas. Disease-free (DFS) and disease-specific (DSS) survival were end-points.

RESULTS

Median follow-up time was 46 months and progression was observed in 20 patients in the treatment group and 19 in the control group. Estimated five-year DFS and DSS were 70% and 86% in the treatment group and 71% and 85% in the control group. The hazard ratio was 0.98 (95% confidence interval (95% CI): 0.52-1.83) regarding DFS and 0.94 (95% CI: 0.37-2.36) regarding DSS. No significant differences in DFS or DSS could be seen when the log-rank test was stratified for prognostic variables. Therefore, data from both groups were pooled for the analysis of prognostic factors. DNA-ploidy (P = 0.003), extracapsular growth (P = 0.005), tumor rupture (P = 0.04), and WHO histologic grade (P = 0.04) were significant independent prognostic factors for DFS with P < 0.0001 for the model in the multivariate Cox analysis. FIGO substage (P = 0.01), DNA ploidy (P < 0.05), and histologic grade (P = 0.05) were prognostic for DSS with a P-value for the model < 0.0001.

CONCLUSIONS

Due to the small number of patients the study was inconclusive as regards the question of adjuvant chemotherapy. The survival curves were superimposable, but with wide confidence intervals. DNA-ploidy adds objective independent prognostic information regarding both DFS and DSS in early ovarian cancer.

Potency of propofol, thiopentone and ketamine at various endpoints in New Zealand White rabbits

Effective plasma concentrations of propofol, thiopentone and ketamine were determined at different endpoints in a study with randomized, crossover design in nine New Zealand White rabbits. A continuous infusion was used (30 ml/h) with concentrations of 10 mg/ml for propofol, 25 mg/ml for thiopentone and 20 mg/ml for ketamine. The endpoints were loss of the righting reflex, loss of purposeful reactions to tail clamping (as an example of a peripheral pain stimulus) or to intranostril insufflation of ammonia vapour (as an example of a central reflex stimulus), and the recovery of these reflexes and reactions. According to the ED50 values the potency ratios of propofol, thiopentone and ketamine were at the loss of righting reflex 1:1.8:1.2, at the loss of reaction to ammonia vapour 1:1.5:1.6, and at the loss of reaction to tail clamping 1:1.5:3.9, respectively. Recovery was significantly faster after propofol than after thiopentone and ketamine. Measuring the effective plasma concentrations of intravenous anaesthetics provides a method of relating dose to effect, but there still remains a variable gap between plasma concentration and effect.

Effects of nonsteroidal anti-inflammatory drugs on hemostasis in patients with aneurysmal subarachnoid hemorrhage

Platelet function is impaired by nonsteroidal anti-inflammatory drugs (NSAIDs) with prominent anti-inflammatory properties. Their safety in patients undergoing intracranial surgery is under debate. Patients with aneurysmal subarachnoid hemorrhage (SAH) were randomized to receive either ketoprofen, 100 mg, three times a day (ketoprofen group, n = 9) or a weak NSAID, acetaminophen, 1 g, three times a day (acetaminophen group, n = 9) starting immediately after the diagnosis of aneurysmal SAH. Treatment was continued for 3 days postoperatively. Test blood samples were taken before treatment and surgery as well as on the first, third, and fifth postoperative mornings. Maximal platelet aggregation induced by 6 microM of adenosine diphosphate decreased after administration of ketoprofen. Aggregation was lower (P < .05) in the ketoprofen group than in the acetaminophen group just before surgery and on the third postoperative day. In contrast, maximal platelet aggregation increased in the acetaminophen group on the third postoperative day as compared with the pretreatment platelet aggregation results (P < .05). One patient in the ketoprofen group developed a postoperative intracranial hematoma. Coagulation (prothrombin time [PT], activated partial thromboplastin time [APPT], fibrinogen concentration, and antithrombin III [AT III]) was comparable between the two groups. Ketoprofen but not acetaminophen impaired platelet function in patients with SAH. If ketoprofen is used before surgery on cerebral artery aneurysms, it may pose an additional risk factor for hemorrhage.