Clinical Significance of Serum p53 Antibodies in Oral Cancer

Aim and Background

The incidence and mortality due to oral cancer have increased worldwide. In India, the use of tobacco has been found to be the major etiological factor for the development of oral cancers. Various studies on serum p53 antibodies have suggested their clinical importance as prognostic markers in cancer. However, there is a dearth of data on serum p53 antibodies in oral cancer patients in India. The present study was carried to evaluate the clinical significance of serum p53 antibodies in oral cancer.

Materials and Methods

The serum p53 antibody status was analyzed by means of ELISA in 55 healthy individuals, 60 patients with oral precancerous conditions, 75 untreated oral cancer patients, and 86 follow-up blood samples of the oral cancer patients.

Results

We found serum p53 antibodies in 23% of cancer patients. The frequency of p53 antibody positivity was higher in patients with lymph node metastasis, advanced disease and well-differentiated tumors. Furthermore, p53 antibody positivity strongly correlated with poor treatment outcome in cancer patients. Kaplan-Meier survival analysis showed significantly poorer disease-free survival in patients with serum p53 antibodies.

Conclusion

The results of this study suggest the usefulness of serum p53 antibodies in the prognostication of oral cancer patients.

Prognostic Significance of DNA Aneuploidy and p21ras Oncoprotein Expression in Colorectal Cancer and Their Role in the Determination of Treatment Modalities

The purpose of the present study was to investigate the prognostic significance of DNA ploidy, S-phase fraction and p21ras oncoprotein expression in patients with colorectal cancer and to correlate these factors with the clinical behavior of the tumors and their response to therapy. Of 79 patients with colorectal cancer 57% (45/79) had early stage disease. Forty-one percent (32/79) had aneuploid tumors while 30% (24/79) of the tumors had a high (>10%) S-phase fraction. p21ras oncoprotein expression was detected in 38% (30/79) of tumors. Patients with aneuploid tumors had a worse prognosis than patients with diploid tumors (p=0.0002). Similarly, patients with high S-phase fraction tumors had a shorter survival than those with low S-phase fraction tumors (p=0.005). No such difference was found between p21ras-positive and p21ras-negative tumor subgroups. In early stage colorectal cancer, aneuploidy was closely correlated with disease outcome (p=0.029). Early stage patients with diploid tumors who received radiotherapy and chemotherapy had a better prognosis than patients with aneuploid tumors. In conclusion, DNA ploidy is a significant and independent prognostic factor in colorectal cancer. Aneuploidy and genetic alteration of the p21ras oncoprotein are important in determining the biological aggressiveness of colorectal cancer. Furthermore, DNA ploidy may identify those subgroups of patients with early stage disease who may benefit from more aggressive treatment.

Stat3 Expression in Oral Squamous Cell Carcinoma: Association with Clinicopathological Parameters and Survival

The present study sought to explore the occurrence of signal transducer and activator of transcription 3 (Stat3) in patients with oral squamous cell carcinoma (n=135) and its potential relationship with clinicopathological parameters and survival. Stat3 expression was studied by immunohistochemistry. Cytoplasmic or nuclear localization of Stat3 was observed in 62% of patients, whereas only nuclear Stat3 expression was found in 44%. Stat3 positivity in early-stage patients was 45% compared to 79% in advanced-stage patients. However, early-stage Stat3-positive patients showed a gradual increase in staining intensity, with intense staining seen in 52% of the tumors compared to 18% in Stat3-positive advanced-stage patients, where a gradual decrease in intensity expression was observed (p=0.001). Stat3 showed a significant positive correlation with disease stage (p=0.001), nodal status (p=0.033) and tumor size (p=0.001). Multivariate survival analysis using the Cox proportional hazard regression model showed that nuclear Stat3 was a significant independent prognosticator for both relapse-free survival (p=0.014) and overall survival (p=0.042) in early-stage patients. Our results indicated that Stat3 activation is an early event in oral squamous cell carcinoma and represents a potential risk factor for poor prognosis in early-stage patients.

p53 Expression in Leukoplakia and Carcinoma of the Tongue

There is growing interest in assessing multistep carcinogenesis and predicting its course using different molecular markers. TP53 is a tumor suppressor gene and appears to be one of the molecular targets of tobacco-related carcinogens in oral cancer. The present study evaluated the role of p53 expression in patients with leukoplakia and carcinoma of the tongue. p53 expression was studied by immunohistochemistry. All patients with leukoplakia of the tongue were male tobacco users. Nuclear staining of p53 was observed in 79% of those patients. Fifty percent, 25% and 4% of the patients expressed 1+, 2+ and 3+ nuclear staining, respectively. When leukoplakia patients were graded according to histopathology, 67% had hyperplasia and 33% had dysplasia. Nuclear p53 accumulation was 88% in hyperplasia and 62% in dysplasia. In patients with tongue cancer, nuclear accumulation of p53 was seen in only 19% of the tumors, with a staining intensity of 1+ in 13%, 2+ in 2% and 3+ in 4% of the tumors. The prevalence of nuclear p53 positivity (79%) was significantly higher in patients with leukoplakia than in patients with tongue cancer (19%; χ2 = 34.32, r = –0.45, df = 1, p = 0.0001; odds ratio (OR) = 16.66, 95% CI, 5.25–52.86). Therefore, leukoplakia patients who show p53 expression have a higher risk of developing tongue cancer than those who do not show p53 expression. As the percentage of positivity of nuclear p53 was very low, none of the clinicopathological parameters or disease status showed any significant association with it. The interesting finding is that none of the female cancer patients showed nuclear p53 expression. Therefore, p53 accumulation is believed to be an early event in neoplastic progression of the tongue.

Molecular Alterations in Oral Carcinogenesis: Significant Risk Predictors in Malignant Transformation and Tumor Progression

In this study an attempt was made to establish the significance of a battery of molecular alterations and thereby identify risk predictors in oral carcinogenesis. For this purpose, EGFR, Stat3, H-ras, c-myc, p53, cyclin D1, p16, Rb, Ki-67 and Bcl-2 were localized immunohistochemically in normal mucosa (n=12), hyperplasia (n=35), dysplasia (n=25), early stage carcinoma (n=65) and advanced stage carcinoma (n=70). Deregulation occurred at an early stage and the number of alterations increased with disease progression. Using multivariate logistic regression analysis, the significant risk predictor for hyperplasia from normal mucosa was Ki-67 (OR=5.75, p=0.021); the significant risk predictors for dysplasia from hyperplasia were EGFR (OR=12.96, p=0.002), Stat3 (OR=17.16, p=0.0001), p16 (OR=5.50, p=0.039) and c-myc (OR=5.99, p=0.052); the significant risk predictors for early stage carcinoma from dysplasia were p53 (OR=6.63, p=0.0001) and Rb (OR=3.81, p=0.056); and the significant risk predictors for further progression were EGFR (OR=5.50, p=0.0001), Stat3 (OR=4.49, p=0.0001), H-ras (OR=4.05, p=0.001) and c-myc (OR=2.99, p=0.015). Cyclin D1 holds a key position linking upstream signaling pathways to cell cycle regulation. Gene products of the mitogenic signaling pathway play an equally significant role as cell cycle regulatory proteins in the hyperplasia-dysplasia-early-advanced-carcinoma sequence and together may provide a reference panel of markers for use in defining premalignant lesions and predicting the risk of malignant transformation and tumor progression.

Cytoplasmic Localization of BAG-1 in Leukoplakia and Carcinoma of the Tongue: Correlation with p53 and C-Erbb2 in Carcinoma

Background

The present study evaluated the clinical significance of BAG-1, an antiapoptotic protein, in leukoplakia and carcinoma of the tongue.

Methods

BAG-1 expression was evaluated by immunohistochemistry in paraffin-embedded tissues of leukoplakia (n=25) and carcinoma of the tongue (n=61).

Results

Cytoplasmic expression was predominantly seen in 80% and 70% of patients with leukoplakia and carcinoma, respectively. BAG-1 expression was found to be significantly lower in tobacco users than in non-tobacco users. BAG-1 expression in tobacco-using leukoplakia and carcinoma patients was compared by grouping the carcinoma patients according to lymph node status and disease stage. Carcinoma patients with tumor-positive lymph nodes had significantly lower BAG-1 expression than patients with negative lymph nodes and leukoplakia. Further, a trend towards an inverse correlation was observed with p53 and c-erbB2. In univariate and multivariate survival analysis, patient subgroups with 2+ or 3+ marker positivity (BAG-1 negativity, p53 and c-erbB2 positivity) had a reduced overall survival compared with patient subgroups with 1+ marker positivity or negativity.

Conclusion

BAG-1 negativity in association with p53 and c-erbB2 positivity identified a subgroup of tongue cancer patients with an aggressive phenotype. Hence, an antiapoptotic protein, BAG-1, was found to be down-regulated in chewing-tobacco-mediated tongue carcinogenesis.

Clinical Characteristics and prognostic analysis of Triple-negative Breast Cancer: Single institute experience

BACKGROUND

Triple-negative breast cancer (TNBC) is a poor prognostic subset of breast cancer that lacks the benefit of specific targeted therapy.

MATERIALS AND METHODS

A prospective study of the clinical profile of triple negative breast cancer cases at a tertiary referral centre. The duration of the study period was 26 months and the median follow up period was ten months. A total of 111 invasive breast cancer patients were evaluated from 1st August 2009 to 31st October 2011. We examined TNBC patients with respect to clinicopathological parameters, adjuvant chemotherapy regimens and relapse free survival.

RESULTS

In our study, patients were young (median age at presentation, 47yrs), premenopausal (54%), tumour size was discordant with lymph node positivity, the histology was predominantly intraductal carcinoma (90%), histological grade higher than two (90%). Relapses were early and preferential visceral (32%) and CNS metastasises (11.7%). 91% of patients were eligible for adjuvant therapy but only 80% of the patients could complete full course of adjuvant chemotherapy. Anthracycline-based regimens (43%), sequential anthracycline and taxane-based regimen (24%) and other regimes like CMF (13%) were used as adjuvant chemotherapy in eligible TNBC patients. Median relapse free survival in patients following adjuvant chemotherapy was around 10 months at last follow-up.

CONCLUSIONS

Patients with TNBC have aggressive clinicopathological characteristics with early and higher rate of disease relapse and therefore derive inadequate benefit from current adjuvant chemotherapy. So, new treatment strategies in adjuvant chemotherapy for TNBC are needed.

Identification of site-specific prognostic biomarkers in patients with oral squamous cell carcinoma

The purpose of the present study was to identify site-specific prognostic biomarkers in patients with oral squamous cell carcinoma (OSCC). For this purpose, Epidermal growth factor receptor (EGFR), Stat3, H-ras, c-myc, p53, cyclin D1, p16, Rb and Bcl-2 were localized immunohistochemically in buccal mucosa carcinoma (n=74) and tongue carcinoma (n=61) patients. Expression of markers was compared between buccal mucosa and tongue carcinoma and assessed for their prognostic value in site-specific manner. On comparison, only cyclin D1 showed significant difference in expression with higher accumulation in tongue tumors (r=+0.177, p=0.039). Moreover, univariate survival analysis showed that in buccal mucosa patients, loss of p16 and overexpression of H-ras were significant prognosticators for relapse-free survival (RFS) and overall survival (OS), respectively. However, in Cox multivariate analysis, they lost their significance after adjusting for significant clinicopathological parameters. On the other hand, in tongue cancer patients, Cox multivariate analysis showed that for RFS, Stat3 and c-myc, and for OS, Stat3, Bcl-2 and p53 were significant prognosticators after adjusting for significant confounding factors. Our findings indicated that buccal mucosa and tongue carcinoma exhibit different biological behavior which is reflected in prognosis. Therefore, this approach might be helpful to precisely identify patients for more effectively tailored treatment strategy.

Clinical significance of matrix metalloproteinase 2 and 9 in breast cancer

BACKGROUND

Invasion and metastasis are the most strenuous problems in the management of breast cancer. These events require diverse proteolytic enzymes, among which MMP-2 and MMP-9 play a significant role in degradation of type IV collagen, the major component of the basement membrane. Therefore, the major objective of the study is to evaluate the clinical usefulness of MMP-2 and MMP-9 with respect to malignant tumor growth, invasion, and metastasis in breast cancer.

MATERIALS AND METHODS

Gelatin zymography was performed on 157 tissue extracts of malignant and adjacent normal breast tissues as well as negative and positive lymph nodes from 49 breast cancer patients. Statistical analysis was carried out using SPSS statistical software (version 10).

RESULTS

ProMMP-2 levels were significantly higher in adjacent normal tissues. Active MMP-2 and MMP-9 levels were higher in malignant breast tissues. Activation ratios of MMP-2 and MMP-9 were significantly higher in malignant breast tissues and in patients with lymph node metastasis. ProMMP-2, active MMP-2, and active MMP-9 could significantly discriminate between malignant and adjacent normal breast tissues. The MMP-2 activation ratio showed significant discriminatory efficacy between patients with and without lymph node metastasis and significant association with increased risk of lymph node metastasis in node-negative patients.

CONCLUSION

The results indicate significant clinical utility of these proteolytic enzymes in malignant tumor growth, invasion, and metastasis in breast cancer.

A new recurring chromosome 13 abnormality in two older patients with de novo acute myeloid leukemia: An Indian experience

We report here two cases of trisomy 13 in acute myeloid leukemia M1 subtype. short-term unstimulated bone marrow and peripheral blood lymphocyte culture showed 47, XY, +13 in all metaphase plates and trisomy 13 was confirmed with whole chromosome paint probes. Trisomy 13 in AML-M1 is a rare numerical abnormality. This is the first Indian report of sole trisomy 13 in AML-M1. Here, we present two cases of elder male patients, which may constitute a distinct subtype.

A case of acute myeloid leukemia-M2 with trisomy 4 in addition to t(8;21)

t(8;21)(q22;q22) is the most frequently observed karyotypic abnormality associated with acute myeloid leukemia (AML), specifically in FAB-M2. Short-term unstimulated bone marrow (BM) and peripheral blood lymphocyte culture showed 47,XX, +4,t(8;21) in all metaphase plates; and interphase and metaphase results of AML-ETO fusion was positive and trisomy of 4 was confirmed with WCP probes. Trisomy 4 in AML with t(8;21) is a rare numerical abnormality. Here we present such case of patient which may constitute a distinctive subtype.

Determination of 243Am by pulse shape discrimination liquid scintillation spectrometry

Alpha specific activity of 243Am was determined using pulse shape discrimination in liquid scintillation spectrometry. 238Pu, 36Cl and 239Np (purified from 243Am) were used for obtaining the spillover of alpha/beta particles into the beta/alpha channels, respectively. Synthetic mixtures of 241Am/243Am were prepared. Using the alpha-specific activity, weights of the stock solutions used and the half-life of 241Am and 243Am isotopes, the expected 241Am/243Am atom ratios in the mixtures were determined and compared with those obtained by thermal ionization mass spectrometry (TIMS). An agreement of about 1% was obtained between the 241Am/243Am atom ratios determined by the two methods. This shows that liquid scintillation counting with pulse shape discrimination can be used for 243Am determination with an accuracy better than 1%.

Robotic mitral valve surgery: a United States multicenter trial

OBJECTIVE

In a prospective phase II Food and Drug Administration trial, robotic mitral valve repairs were performed in 112 patients at 10 centers by using the da Vinci surgical system. The safety of performing valve repairs with computerized telemanipulation was studied.

METHODS

After institutional review board approval, informed consent was obtained. Patients had moderate to severe mitral regurgitation. Operative technique included peripheral cardiopulmonary bypass, a 4- to 5-cm right minithoracotomy, a transthoracic aortic crossclamp, and antegrade cardioplegia. The successful study end point was grade 0 or 1 mitral regurgitation by transthoracic echocardiography at 1 month after surgery.

RESULTS

Valve repairs included quadrangular resections, sliding plasties, edge-to-edge approximations, and both chordal transfers and replacements. The average age was 56.4 +/- 0.09 years (mean +/- SEM). There were 77 (68.8%) men and 35 (31.2%) women. Valve pathology was myxomatous degeneration in 105 (91.1%), and 103 (92.0%) had type II leaflet prolapse. Leaflet repair times averaged 36.7 +/- 0.2 minutes, with annuloplasty times of 39.6 +/- 0.1 minutes. Total robot, aortic crossclamp, and cardiopulmonary bypass times were 77.9 +/- 0.3 minutes, 2.1 +/- 0.1 hours, and 2.8 +/- 0.1 hours, respectively. On 1-month transthoracic echocardiography, 9 (8.0%) had grade 2 mitral regurgitation, and 6 (5.4%) of these had reoperations (5 replacements and 1 repair). There were no deaths, strokes, or device-related complications.

CONCLUSIONS

Multiple surgical teams performed robotic mitral valve repairs safely early in development of this procedure, with a reoperation rate of 5.4%. Advancements in robotic design and adjunctive technologies may help in the evolution of this minimally invasive technique by decreasing operative times.

Survival after percutaneous endoscopic gastrostomy: the role of dementia

BACKGROUND

Percutaneous Endoscopic Gastrostomy (PEG) is a widely used technique for enteral feeding in nursing home patients. Several factors including malnutrition, hypoalbuminemia, older age, number of co-morbidities and cognitive impairment adversely affect survival.

OBJECTIVE

This study evaluated the relative impact of age, serum albumin, number of co-morbid illnesses and dementia on survival in male nursing home patients who had undergone percutaneous endoscopic gastrostomy (PEG).

DESIGN

In a retrospective study the hospital records of all North Chicago Veterans Affair (VA) male nursing home residents (n=88) who had PEG placed between 1990 through 2000 were reviewed. Of the 88 charts reviewed, 17 were eliminated from analysis due to incomplete data. Following data was examined: Age, serum albumin, number of co-morbid illnesses, presence of dementia, survival in years following PEG placement.

RESULTS

Advancing age was associated with increasing probability of dementia and increased number of co-morbidities. Post PEG survival decreased with increasing age, with lower serum albumin, and increased number of co-morbidities. Age and serum albumin were strong predictors of survival in PEG recipients without the diagnosis of dementia. However, in PEG recipients with a diagnosis of dementia, age and serum albumin no longer predicted survival. Dementia appears to attenuate the effects of age and serum albumin on survival following PEG placement.

CONCLUSION

In the presence of dementia, none of the usual predictors of survival in PEG recipients remain significant.

The need for new therapeutic agents: what is in the pipeline?

There is a clinical need for new treatment options for serious Gram-positive infections. Recently introduced agents such as the newer fluoroquinolones and the ketolide telithromycin have limited use as they do not cover methicillin-resistant Staphylococcus aureus (MRSA) or glycopeptide-resistant enterococci (GRE). The clinical use of the streptogramin combination quinupristin/dalfopristin, which has activity against MRSA and vancomycin-resistant Enterococcus faecium, is limited because administration is via a slow infusion of a large volume. The oxazolidinone linezolid is active against MRSA and GRE but resistant organisms and treatment failures have been reported. A number of compounds currently in development show promise, the new glycopeptides oritavancin, dalbavancin and the glycolipodepsipeptide ramoplanin, as well as the new tetracyclines tigecycline and BAY73-7388. However, in some cases, there is concern that resistance may develop quickly to new compounds that are based on existing antimicrobial agents. Therefore daptomycin, a novel lipopeptide with a unique mode of action, is of particular interest. Daptomycin is active against MRSA (including vancomycin-resistant strains) and GRE. Daptomycin displays rapid concentration-dependent killing and is bactericidal even in the stationary phase of growth. Daptomycin-resistant strains are very difficult to generate in vitro. A dosage of 4 mg/kg intravenous once a day has been shown to be efficacious in two evaluator-blinded trials of complicated skin and soft tissue infections with clinical success rates similar for daptomycin and comparators (vancomycin or penicillinase-resistant penicillins). With its activity against key Gram-positive pathogens, including resistant strains, daptomycin has potential as a valuable addition to the available treatment options for serious Gram-positive infections.

Surveillance of linezolid resistance in Germany, 2001–2002

A surveillance study was performed throughout Germany from November 2001 to June 2002 to assess the prevalence of linezolid-resistant isolates among Gram-positive bacteria from routine susceptibility data and to compare the in-vitro activity of linezolid to that of other antibacterial agents. Each of 86 laboratories provided routine susceptibility data for 100 consecutive isolates. Most laboratories (c. 60%) used the disk diffusion test. Laboratories were also requested to send a representative sample of their isolates, as well as all isolates reported as intermediate or resistant to linezolid, to a reference laboratory for MIC determination. Susceptibility data for 8594 isolates were evaluated. Sites of infection were skin and soft tissue (29.9%), upper and lower respiratory tract (19.1%), foreign body or catheter (10.5%), or urinary tract (9.8%). Routine linezolid susceptibility data were reported for 6433 isolates. The prevalence of linezolid resistance, as reported to the clinician, was 0.4% in Staphylococcus aureus, 0.3% in Staphylococcus epidermidis, 2.9% in Enterococcus faecalis, 2.3% in Enterococcus faecium, 1.4% in Streptococcus pyogenes and 2.9% in Streptococcus agalactiae. Linezolid resistance was not detected in Streptococcus pneumoniae or in viridans group streptococci. Sixty-nine of 115 isolates reported as intermediate or resistant to linezolid were retested, but none was resistant to linezolid. Linezolid exhibited excellent in-vitro activity against representative isolates of the six most frequently encountered species (MIC90, 1-2 mg/L). The prevalence of resistance to linezolid was very low in Germany. Organisms reported as linezolid-resistant should be retested, either in the same laboratory with an alternative method or in a reference laboratory.

[S2 guideline for infectious endocarditis]

Microbe-induced (infectious) endocarditis is an endovascular infection, caused mainly by bacteria, of cardiovascular structures. The major predilection site are the native heart valves, but involvement of implanted intracardiac foreign material is increasingly being seen. The mortality rate of infectious endocarditis depends on clinical factors and the causal agent, but also on the time of the establishment of the diagnosis and the initiation of appropriate treatment. In Germany, the current mortality rate ranges up to 18%. Between January 2003 and July 2004, with the aim of improving patient care and thus the outcome of this condition, a guideline commission worked out recommendations for the diagnosis, treatment and management of the disease for the use of general practitioners and hospital physicians, in particular microbiologists, infectiologists, cardiologists and cardiac surgeons. The basis for this guideline was the systematic search through the literature of the European guideline. On the 16th and 28th of June 2004, the entire guideline was formerly approved in a nominal group process.

Evaluation of the OSIRIS video reader as an automated measurement system for the agar disk diffusion technique

Measurement of inhibition zones by the automated OSIRIS system was compared with manual measurement. In total, 14 176 measurements were made with 352 staphylococcal and 80 Enterobacteriaceae isolates, involving four panels of antibiotics on round and square Mueller-Hinton agar plates, according to the German DIN 58940 recommendations. Variations of +/- 3 mm in zone size measurements were defined as tolerable. Very major errors (i.e., classification of a resistant isolate as susceptible by the OSIRIS system) occurred in < 1% of tests. With staphylococci, the best concordance was recorded for rifampicin (91.3%), moxifloxacin (88.1%), and gentamicin (86.3%), while the concordance on square plates for vancomycin, pristinamycin and kanamycin was 97.2%, 96.1% and 96.0%, respectively. The poorest concordance was for cefuroxime (43.7%) and novobiocin (47.0%) on round plates, and fosfomycin (36.5%) and chloramphenicol (84.0%) on square plates. With Enterobacteriaceae, 100% concordance was recorded for ampicillin, gentamicin and ciprofloxacin on round agar plates, and for gentamicin, cefoxitin and nalidixic acid on square plates. The poorest results were recorded for nalidixic acid (32.5%) and piperacillin (82.5%) on round plates, and for nitrofurantoin (72.5%) and amoxycillin (82.5%) on square plates. It was concluded that the OSIRIS system was a rapid and reliable system for measuring disk susceptibility test results on round and square agar plates.

Serum bactericidal activity of gemifloxacin versus clarithromycin against Streptococcus pneumoniae with different susceptibility to quinolones

The objective of this study was to determine serum bactericidal titers (SBT, the highest dilution of serum showing no growth) and the serum bactericidal activity (SBA, i.e. duration of SBT greater than 1:2) as well as the serum bactericidal rate of gemifloxacin and clarithromycin after single doses in healthy male volunteers against Streptococcus pneumoniae. Strains tested had various degrees of susceptibility to penicillin as well as different susceptibility to quinolones due to a different QRDR mutation pattern (parC, gyrA). Serum samples from volunteers (n = 12) who had received a single oral dose of either 320 mg gemifloxacin or 500 mg clarithromycin in an open-label crossover study were obtained over a 24-hour period. SBA was determined, using the microdilution method. SBA of wildtype strains for gemifloxacin ranged from 8.9 to 15.4 h (mean 12.6 h). For gemifloxacin, 2 strains with solitary gyrA mutation had an SBA from 4.5 to 4.7 h (median 4.5 h). One of the 2 strains with a single QRDR mutation in parC displayed an SBA of 4.5 h, comparable to the gyrA mutation strains, whereas the second strain had a nearly twice as long SBA of 8.9 h. Two strains with two mutations (parC and gyrA) did not display any SBA. For clarithromycin, the duration of SBA ranged from 11.3 to 15.5 h (mean 13.6 h) for 6 of the 12 strains with an MIC < or = 0.06 mg/L (no SBA was found for the remaining strains, with an MIC of 0.25 mg/L or higher). In conclusion, a correlation between individual serum concentrations and SBA was found for both antibiotics.

Oral exfoliative cytology of smokers at discrete clinical stages using AgNOR staining

OBJECTIVE

This study was designed to evaluate oral exfoliative cytology of smokers without any clinically evident lesion and smokers with leukoplakia or oral cancer using AgNOR staining.

STUDY DESIGN

Cytological smears of 30 smokers without lesion, 30 smokers with leukoplakia, 30 smokers with oral cancer and 30 non-smokers (control group) were studied using one step silver staining method. The AgNOR count was established on 100 cells. Mean AgNOR count and mean % of cells with 5 or more AgNORs was evaluated. The count values of groups were compared and analysed using Student's unpaired t-test.

RESULTS

The mean AgNOR count for control group was 2.94 +/- 0.325, smokers without lesion 3.79 +/- 0.480 smokers with leukoplakia 3.89 +/- 0.433 and oral cancer 4.96 +/- 0.467. Mean % of cells with 5 or more AgNORs was 11.7, 26.5, 30.2 and 55.8 for control group, smokers without lesion, smokers with leukoplakia and oral cancer respectively.

CONCLUSION

Analysis of AgNORs suggest that smoking influences proliferative activity in cells of smokers without any clinical lesion and that oral cancer shows highest proliferative activity.

Nosocomial infections in internal medicine, University of Frankfurt, Germany--a prospective surveillance study

Nosocomial infections (NI) are serious complications associated with high morbidity and mortality. In the present study, NI were analyzed prospectively at the Center of Internal Medicine (CIM) (300 beds) of the J. W. Goethe-University -a 1380-bed major tertiary care teaching hospital- during a study period of six month. During the study period a single physician evaluated all patients with signs and symptoms of an infection during his daily rounds. NI was defined as body temperature >38 degrees C and evidence of an infection not before the third day of admission to the hospital. NI was diagnosed in 127 patients (3.5%) of the 3605 patients studied. The data of 126 patients with NI could be collected and analyzed completely. Of the 126 patients 34 patients died. The mean length of hospitalization before the diagnosis of NI was 12.0 days (standard-deviation: +/-13.1 days; median: 7 days). Compared to all patients with NI significantly more patients of the Internal Intensive care unit (11.3%), of the HIV-ward (10.3%), and of the hematology / oncology ward (5.8%) acquired a NI (p<0.05). With respect to other groups of patients the frequency of NI ranged from 0.5 to 4.6 per 100 admitted inpatients. The lower rate was in patients admitted for invasive diagnostic procedures who were hospitalized only for 3 days or less.

Procalcitonin, C-reactive protein and APACHE II score for risk evaluation in patients with severe pneumonia

OBJECTIVE

Procalcitonin (PCT) is a peptide that is found elevated in patients with sepsis and severe infections. In healthy persons PCT serum levels are below 0.1 ng/mL. The aim of this study was to investigate the value of serum PCT determination for risk evaluation in patients with pneumonia.

METHODS

We focused on the correlation of PCT with the clinical status of the patient and prognosis of the disease. In a prospective study, in a nonsurgical intensive care unit the following parameters were assessed regularly in 93 patients with documented pneumonia: C-reactive protein (CRP), white blood cell count (WBC), body temperature, PCT and Acute Physiology and Chronic Health Evaluation (APACHE) II score.

RESULTS

At the onset of infection 50% of the patients had elevated PCT levels above 2 ng/mL. The model of multivariate analysis of all tested parameters on days 0-5 stratified for clinical outcome (change in clinical classification or death) showed local significance for APACHE II score only. None of the other parameters in this model serves as an isolated indicator for change of clinical status or death. An intra-individual change of body temperature or CRP was never significantly associated with a change in the clinical status of the patient.

CONCLUSION

Change in PCT on admission and at the end of the observation period significantly indicated a clinical change.

Defining opportunistic invasive fungal infections in immunocompromised patients with cancer and hematopoietic stem cell transplants: an international consensus

During the past several decades, there has been a steady increase in the frequency of opportunistic invasive fungal infections (IFIs) in immunocompromised patients. However, there is substantial controversy concerning optimal diagnostic criteria for these IFIs. Therefore, members of the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group formed a consensus committee to develop standard definitions for IFIs for clinical research. On the basis of a review of literature and an international consensus, a set of research-oriented definitions for the IFIs most often seen and studied in immunocompromised patients with cancer is proposed. Three levels of probability are proposed: "proven," "probable," and "possible." The definitions are intended for use in the context of clinical and/or epidemiological research, not for clinical decision making.

Hemodynamic effects of chest closure in adult patients undergoing cardiac surgery

OBJECTIVE

To evaluate hemodynamic effects of sternal retractor removal and sternal closure after cardiopulmonary bypass and to correlate these changes with preoperative and intraoperative variables.

DESIGN

Prospective.

SETTING

University hospital.

PARTICIPANTS

Fifty adults undergoing cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Arterial, pulmonary artery, and transesophageal echocardiography measurements were obtained immediately before and 1 minute after removal of the sternal retractor and immediately before and 1 minute after sternal closure. Retractor removal caused a significant decrease in cardiac index by 5.6% (p < 0.01), stroke volume index by 4.0% (p < 0.05), and mean pulmonary artery pressure by 4.8% (p < 0.001). Sternal closure caused a significant decrease in cardiac index by 7.7%, stroke volume index by 10.2%, and left ventricular end-diastolic area by 9.2% (p < 0.001) There were significant increases in pulmonary capillary wedge pressure and systemic vascular resistance by 9.1% and 10.8% (p < 0.01). There was no significant change in the ejection fraction area. The magnitude of decrease in stroke volume index with sternal closure correlated positively with end-diastolic area immediately before the closure.

CONCLUSION

Chest closure is associated with significant hemodynamic changes and a change in the ventricular transmural pressure-volume relationship. Patients with lower preload immediately before closure are more vulnerable to a decrease in cardiac index. Based on the results of this study, volume appears to be the appropriate preventive and treatment option to limit the impact of chest closure.

Staphylococcus aureus in lower respiratory infections: clinical relevance of antimicrobial resistance

Staphylococcus aureus is the most common cause of nosocomial infections and is responsible for many community-acquired infections. Of concern is the increase in resistance to oxacillin (methicillin), with rates as high as 60% in some countries and in some intensive care units. Most of these strains are resistant to other antibacterials. Lately, strains with reduced susceptibility to glycopeptides have been reported.

Echocardiographic correlates of left ventricular outflow obstruction and systolic anterior motion following mitral valve repair

BACKGROUND AND AIM OF THE STUDY

Systolic anterior motion (SAM) of the mitral valve resulting in left ventricular outflow obstruction is a well-recognized complication of repair of the degenerative myxomatous mitral valve. A precise mechanism is unknown. A current approach consists of sliding annuloplasty of the posterior leaflet. It was postulated that excess tissue of the anterior mitral leaflet (AML) was as equally (or more) important as the excess posterior mitral leaflet (PML) tissue in the development of SAM subsequent to valve repair.

METHODS

Thirty-two patients without post-repair SAM (No-SAM group) were compared with eight patients with SAM (SAM group). The AML and PML heights and the mitral annulus diameter were measured by TEE using mid-esophageal four-chamber and long-axis planes.

RESULTS

Pre-repair TEE showed the AML height to be greater in the SAM group (p = 0.04), and that of the posterior leaflet tended to be greater (p = 0.08), whilst the annular dimensions were similar in both groups. In the post-repair status, the AML height was markedly greater (p = 0.005) and the annulus markedly smaller (p = 0.001) in the SAM group. Post-repair assessment showed the relative difference between AML height and annular dimension (AML - Ann) as well as the difference between combined leaflet heights and annular dimension (AML + PML - Ann) to be strikingly greater in the SAM group as compared with the No-SAM group (p = 0.001).

CONCLUSION

A disparity between dimension of the annulus following mitral valve repair and combined heights of the two leaflets explains post-repair SAM. The AML height is a more important factor in the development of SAM. Thus, surgical techniques to reduce AML heights should be considered in patients with disproportionately large anterior leaflets in order to prevent SAM. Selection of size of the annuloplasty ring should take into consideration the height of the AML.

The 'Pomeroy procedure': a new method to correct post-mitral valve repair systolic anterior motion

Systolic anterior motion (SAM), a recognized complication of mitral valve repair, is often associated with left ventricular outflow gradient and mitral regurgitation. Current surgery to prevent these conditions is to perform sliding annuloplasty to reduce the posterior mitral leaflet (PML) height and to oversize the annuloplasty ring. However, these techniques do not consistently eliminate post-repair SAM, and removal of excess tissue and reduction of anterior mitral leaflet (AML) height may be more effective; this is the 'Pomeroy procedure'. Here, we report a patient in whom all standard procedures to prevent SAM were performed, but the condition still developed. This was corrected on a second pump run, using the Pomeroy procedure.

A study of chromosome aneuploidy in hereditary breast cancer patients and their healthy blood relatives

Chromosomal abnormalities that may predispose a group of individuals to develop certain neoplasms have been reported in lymphocytes. We evaluated cytogenetic abnormalities in 21 histopathologically confirmed primary breast cancer patients (BCPs), 52 healthy blood relatives (HBRs), belonging to 19 hereditary breast cancer families (HBFs) and 25 females as control. Phytohemagglutinin stimulated peripheral blood lymphocyte (PBL) cultures were used to study the chromosomal abnormalities in BCPs and their HBRs. Short term culture of the tumor tissue was also carried out in defined growth medium. Suitable metaphases (11 to 55) from tumors and a minimum of 100 metaphases from PBL were karyotyped for the cytogenetic analysis. Heterogeneous population of cells with random and nonrandom chromosomal abnormalities was noticed in tumors. In control groups 2-5% of metaphases showed numerical abnormalities, whereas this phenomenon was observed in 3-18% of metaphases in HBRs and 3-23% of metaphases in BCPs. In tumor tissue, 47.05% of BCPs showed numerical abnormalities in more than 16 metaphases. In lymphocytes, this event was observed in 33.33% of BCPs and 13.14% of HBRs. In controls 1.28%, in BCPs 52.04% (tumor) and 13.42% (lymphocytes), and in HBRs 9.03% of metaphases were found aneuploid. Statistically it was highly significant (Fisher's exact test, P<0.00001). In lymphocytes of BCPs, chromosomes 1, 6, 8, 9, 15, 17, 18, 20, and X and in HBRs, chromosomes 8, 15, 17, 18, and X were frequently involved. It can be inferred from the findings that the above mentioned chromosomes may have an important role in early stage of breast carcinogenesis in BCFs. Moreover, presence of similar abnormalities in HBR indicates inherited pattern of this genetic error among them.

The use of levofloxacin in the treatment of respiratory tract infection

Increasing resistance among the common respiratory pathogens has encouraged assessment of alternative agents, for example, levofloxacin. Unlike earlier quinolones, levofloxacin has excellent activity against Streptococcus pneumoniae, including strains resistant to penicillin. Clinical trials show levofloxacin to be as effective as cephalosporins in acute exacerbation of chronic bronchitis and as effective as co-amoxiclav, cephalosporins or amoxycillin in community-acquired pneumonia. Levofloxacin is rarely associated with serious adverse events. Nausea, diarrhea, headache and rash are the most common adverse events but are observed less frequently than with some other new quinolones.

In vitro activity of LY333328, a new glycopeptide, against extracellular and intracellular vancomycin-resistant enterococci

The objectives of the study were to observe the activity of LY333328, a new semisynthetic glycopeptide, compared to that of vancomycin against six strains of Enterococcus faecium and Enterococcus faecalis, including four vancomycin-resistant strains. Bacteria ingested by polymorphonuclear leukocytes (PMN) as well as extracellular bacteria were studied using a colony count method. The activity against intracellular bacteria was tested with the drugs present in the extracellular medium, as well as after preincubating the PMN and removal of the drugs. LY333328 is active against the tested enterococci, regardless of their susceptibility to vancomycin, with MICs of 1-2 mg/l. It is bacteriostatic against extracellular enterococci at concentrations of 2 microg/ml and above regardless of their resistance to vancomycin. After 4 h incubation at 10 MIC, vancomycin-resistant strains of E. faecium and E. faecalis located intracellularly were reduced by 55% and 90%, respectively. Even after preincubation and removal of the drug, LY333328 had an effect at 10 MIC with a 20-30% reduction in the inoculum. The results suggest that in contrast to vancomycin, LY333328 is active against intracellular vancomycin-resistant enterococci, particularly E. faecalis, even after removal of the extracellular drug.

Bleomycin-induced chromosome damage in lymphocytes indicates inefficient DNA repair capacity in breast cancer families

In vitro mutagen susceptibility has been observed as a predictor of cancer risk. To evaluate susceptibility to mutagen, we have studied the response to in vitro bleomycin (BLM) treatment in cultured peripheral blood lymphocytes (PBL) of 9 breast cancer families (BCFs). Eleven breast cancer patients (BCPs) and 36 healthy blood relatives (HBRs) from BCFs were included in the study. Data were compared with 22 healthy control women. The frequencies of chromosomal aberrations were evaluated after exposure to BLM in the last five hours. Mean frequency of BLM-induced chromosomal aberrations per cell (CA) observed among BCPs was significantly higher as compared to their HBRs as well as control subjects. Moreover, mean BLM-induced CA/cell value observed for HBRs was also significantly higher than that of control subjects. In comparison to controls, it was observed that there was four times more cancer risk in BCPs (OR=4.148, 95% CI=5.83-687.46) and 2.5 times more cancer risk in HBRs (OR=2.67, 95% CI=5.31-39.25). Lymphocytes from 90% of BCPs and 69% of HBRs were found to be sensitive to BLM (using a cutoff value = controls group mean + 1 SD). Thus, lymphocytes of BCPs and their HBRs were more sensitive to BLM exposure as compared to controls. Our finding indicated inefficient DNA repair capacity in BCFs. The HBRs in BCFs, having increased BLM-sensitivity, may be at higher risk to develop a similar cancer.

Spontaneous chromosomal instability in breast cancer families

Spontaneous chromosomal instability has been correlated with cancer predisposition. In the present study, the phenomenon has been evaluated using two cytogenetic markers, namely, frequency of spontaneous sister chromatid exchanges (SCE) and spontaneous chromosomal aberrations (CA) in peripheral blood lymphocytes of hereditary breast cancer (HBC) patients (n = 11) and healthy blood relatives (HBR, n = 36). A statistically significant difference was observed for both the endpoints between HBC patients and controls (P < 0.001), HBC patients and HBR (P < 0.001), as well as HBR and controls (P < 0.001). Thus, 63.64% of the HBC patients and 25% of HBR showed a mean CA/cell value higher than the highest mean CA/cell value of the controls (0.11 CA/cell). Similarly, 81.81% of the HBC patients and 61.11% of HBR showed a mean SCE/cell value higher than the highest mean SCE/cell value of the controls (9.60 SCE/cell). Chromosomal aberrations were more frequently observed in the B and E group of chromosomes in HBC patients and HBR. These findings primarily indicate the high level of chromosomal instability in breast cancer families, and might be one of the predisposing factors for high risk of cancer in HBR.

Chromosomal aberrations in young cancer patients

Spontaneous level of chromosomal aberrations (CA) is considered to be indicative of inherent cancer predisposition, which plays a major role in total cancer incidence. We have studied spontaneous CA levels in in vitro cultured peripheral blood lymphocytes of pediatric cancer patients (n = 77). Results were compared with those of control subjects (n = 72), including: age-matched controls; elder controls (minimum age 60 years); and healthy first-degree relatives (FDR) of pediatric cancer patients. Pediatric cancer patients showed the highest mean CA/cell value, which was statistically significant as compared to their age-matched counterparts, elder controls, and the FDRs. As compared to 7% of all the three control groups collectively, 32.4% of pediatric cancer patients showed > 0.1 mean CA/cell value. One of the FDRs with a very high frequency of CA developed cancer within three years. The results suggest that spontaneous levels of chromosomal aberrations may be used as one of the biomarkers for cancer predisposition study.

Multiplane transesophageal echocardiography: a roadmap for mitral valve repair

Multiplane transesophageal echocardiography (TEE) is useful in providing a detailed anatomic map for successful mitral valve repair. This report describes an approach, developed over the past two to three years, which helps to delineate valve anatomy in specific detail. Mid-esophageal views are selected to view different segments of the valve leaflets. When correlated with surgical anatomy, this approach is found to be both practical and useful.

The role of glycopeptide antibiotics in the treatment of infective endocarditis

There are several sets of guidelines for the treatment of infective endocarditis, reflecting the need for differing treatment in various countries and times. This review considers the need for differing treatment modalities and in particular the utility of the glycopeptide antibiotics vancomycin and teicoplanin. Specific recommendations are offered as to when to consider the use of glycopeptides, appropriate dosage, length of treatment course and whether to use monotherapy or combined therapy. Used judiciously, the glycopeptides give results as good as can be achieved with other antimicrobial agents without exceptional toxicity. The potential of teicoplanin for use in the outpatient treatment of infective endocarditis is considered.

Serum bactericidal activity of levofloxacin against Streptococcus pneumoniae

The objective of this study was to determine the serum bactericidal activity (SBA) of levofloxacin against Streptococcus pneumoniae strains with various degrees of susceptibility to penicillin and cefotaxime. Serum samples of volunteers (n = 12) who had received levofloxacin 500 mg as a single po dose were provided in blinded fashion. SBA was determined, using the microdilution method, in Todd-Hewitt broth supplemented with lysed horse blood inoculated with an overnight culture diluted to yield a final concentration of approximately 10(5) cfu/mL. The serum bactericidal titre was defined as the highest dilution of serum showing no growth (> 99.9% reduction of inoculum). The duration of SBA ranged from 0.75 to 6.3 h (mean 3.85 h), and was independent of the susceptibility of the strains to penicillin and cefotaxime. In conclusion, a single po dose of 500 mg levofloxacin achieved serum concentrations which were bactericidal against penicillin-resistant S. pneumoniae for a mean period of 3.85 h.

Bactericidal activity of levofloxacin against Streptococcus pneumoniae in an in-vitro model simulating serum pharmacokinetic parameters

The objective of the current study was to evaluate the bactericidal activity of levofloxacin against Streptococcus pneumoniae at concentrations equivalent to those present in serum after a po dosage of 500 mg. Nine S. pneumoniae strains (one penicillin G-resistant, one penicillin G-intermediate resistant, and two penicillin G- and cefotaxime-resistant) were exposed to a levofloxacin concentration of 6 mg/L diluted at a terminal half-life (t1/2) of 8 h. Surviving S. pneumoniae (cfu/mL) were quantified up to 24 h by the membrane filtration method. Levofloxacin was rapidly bactericidal and reduced the quantity of inoculum to below the detection level of 10 cfu/mL within 2.5-5.15 h, irrespective of susceptibility to penicillin G or cefotaxime. No viable S. pneumoniae could be detected at the end of the observation period (24 h). All strains except one (strain 17134) had an MIC < 1.0 mg/L, and the minimum bactericidal concentrations (MBCs) were, at the most, one dilution higher than the respective MICs. The inoculum was high, ranging from 2.9 x 10(5) to 7.5 x 10(6) cfu/mL. The time required to achieve 99% death ranged from 0.9 to 3.1 h, and was longest for strain 17134 which had an MIC of 1.0 mg/L and an MBC of 2.0 mg/L. A 99.9% reduction in inoculum was achieved within 1.5-4.15 h. At a serum concentration achievable after a single po dosage of 500 mg, levofloxacin showed rapid and complete bactericidal activity against the S. pneumoniae strains tested.