Prophylactic surgery plus hyperthermic intraperitoneal chemotherapy (HIPEC CO2) versus standard surgery for gastric carcinoma at high risk of peritoneal carcinomatosis: short and long-term outcomes (GOETH STUDY)-a collaborative randomized controlled trial by ACOI, FONDAZIONE AIOM, SIC, SICE, and SICO

INTRODUCTION

At the time of diagnosis, 15-20% of gastric carcinomas are in stage T4 or T4b. Furthermore, 5-20% of patients undergoing potentially curative surgery suffer from synchronous or metachronous peritoneal metastases. To date, neither surgery nor systemic chemotherapy successfully controls peritoneal dissemination, offering a limited impact on survival. Peritoneal metastases are in fact responsible for death in around 60% of gastric cancer patients. Several Eastern studies in the past have focused on hyperthermic intraperitoneal chemotherapy (HIPEC) as a prophylactic measure in patients with serosal extension, nodal involvement, and positive peritoneal fluid cytology. Therefore, a new multimodal therapeutic strategy based on aggressive surgery plus new locoregional treatment may prolong survival in this particular clinical scenario.

METHODS

This study compares the efficacy of prophylactic surgery (radical gastric resection, appendectomy, resection of the round ligament of the liver, and bilateral adnexectomy) plus hybrid CO2 HIPEC system versus standard surgery in patients with T3-T4 N0-N + gastric adenocarcinoma. Patients will be randomly assigned (1:1 ratio) to the experimental arm or standard surgery. The primary endpoint is to establish the difference in disease-free survival between the groups. The secondary objective is to compare the safety and tolerability of prophylactic surgery plus HIPEC CO₂ versus standard surgery.

DISCUSSION

Considering the poor prognosis of patients with peritoneal dissemination from gastric cancer, a prophylactic strategy to prevent peritoneal metastases may be beneficial. In patients with gastric cancer at high risk of peritoneal carcinomatosis, we propose aggressive surgical treatment with radical gastrectomy, removal of organs at risk of harbouring tumour cells, and HIPEC.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03917173. Registered on 16 April 2019.

PROTOCOL VERSION

v1, March 27, 2019. Protocol number: IRFMN-GCC-7813. EudraCT number: 2019-001478-27.

Effect of Phenobarbital on Cyclophosphamide Cytotoxic Activity and Pharmacokinetics in Mice

The interaction between cyclophosphamide (CPA) and phenobarbital (PB) was investigated in B6D2F, mice, checking both the antileukemic and immunosuppressive activity together with the serum levels of CPA and its metabolites. A reduced cytotoxic activity of CPA has been observed when PB is given for 2 days before CPA and an interval of at least 6 hours elapses between the last treatment of PB and the administration of CPA. On the contrary, when PB is given simultaneously with CPA for 2 or 4 consecutive days, an increased antileukemic activity of CPA occurs. In the experimental condition where PB decreases the activity of CPA, serum levels of CPA, assayed by means of a new specific gas-chromatographic method, and of its NBP-alkylating metabolites, indicate that this effect may be explained on a pure pharmacokinetic basis. However, for the situation where an increased effect of CPA was observed under the influence of PB, pharmacokinetic data did not provide a clear explanation.

Polarographic Assay of Submicrogram Quantities of Cis-Dichlorodiamineplatinum (II) in Biological Samples

Differential pulse Polarographic assay of the antineoplastic agent cis-dichlorodiamineplatinum II and its analogues was performed after acid oxidative hydrolysis (HCIO4, HNO3, HCI) of biological samples (plasma, tissue homogenates, urine) and reaction with ethylenediamine. Platinum levels and kinetics were determined in blood and urine of patients with non-oat-cell lung carcinoma. Detection limit of the polarographic assay was 0.5 ng platinum; analytical error was ± 3%. Levels of free cis-dichlorodiamineplatinum (II) in plasma fell in samples stored at –20 °C; the half-life of free drug was 38 h.

Occupational exposure to PCDDs, PCDFs, and DL-PCBs in metallurgical plants of the Brescia (Lombardy Region, northern Italy) area

The concentration values of polychlorodibenzodioxins (PCDDs), polychlorodibenzofurans (PCDFs), and dioxin-like polychlorobiphenyls (DL-PCBs) in blood serum samples (pools) of metallurgical workers in the area of the city of Brescia (northern Italy) were statistically processed. As to workers' exposure characteristics, pools were divided into 34 professionally exposed (PE) and 11 non-professionally exposed (NPE). A further subdivision of PE pools was according to workplaces in which ferrous (N = 24) and non-ferrous (N = 10) materials were handled. To evaluate the aforesaid differences we applied the age-adjusted Generalized Linear Models. We identified significant (P ≤ 0.05) exposure models of the classification groups. The first subdivision was confirmed by the concentrations of 1,2,3,4,6,7,8-H₇CDF, DL-PCB 105, and DL-PCB 189; the second was confirmed by the concentrations of PCDF TEQ₉₇, PCDD + PCDF + DL-PCB (TEQ_TOT) TEQ₉₇, 2,3,4,7,8-P₅CDF, 1,2,3,6,7,8-H₆CDD, 1,2,3,4,6,7,8-H₇CDD, and PCB 189. Based on the literature, all mentioned congeners have been found in stack gas and fly ash samples of metallurgical plants: therefore, these indicators indicate the exposure to such work environments. Specifically, the concentrations measured in the workers' blood serum appear to depend on the type of material processed during work.

Some examples of interactions between drugs in cancer chemotherapy

Drug combinations in cancer treatment are widely utilized because they frequently result in better therapeutic activity than the single treatments. The mechanism(s) by which this can be achieved may reside in an enhanced chemotherapeutic effect or in reduced toxicity, it being difficult to dissociate the two aspects. To underline this difficulty, experimental studies will be reported. A first example illustrates the interaction between phenobarbital and cyclophosphamide. Depending on the schedule of administration, different effects can be obtained. These effects cannot always be explained by pharmacokinetic data. A second example deals with the combination of anthracycline antibiotics (daunomycin and adriamycin) with immunostimulant treatment (C. parvum). Both in vitro and in vivo adriamycin was less toxic than daunomycin for macrophages. As predicted on the basis of this finding, adriamycin resulted in a synergistic antitumoral effect when combined with macrophage activators.

Evidence of the existence of two different intraneuronal pools from which pharmacological agents can release serotonin

The effect of various drugs on the release of [(3)H]-serotonin from synaptosomes of reserpine-treated rats was compared with that obtained with synaptosomes of untreated animals. The increase in [(3)H]-serotonin release induced by d-fenfluramine was virtually abolished by reserpine; the effect of d-norfenfluramine, the main metabolite of fenfluramine, was instead enhanced in synaptosomes of reserpine treated animals. [(3)H]-serotonin release induced by l-isomers of fenfluramine or norfenfluramine was increased or not affected, respectively, after reserpine treatment. The effects of other drugs, known to activate serotonin mechanisms such as metachlorophenylpiperazine and quipazine, like d-norfenfluramine, were increased by the reserpine treatment. The present data show that [(3)H]-serotonin can be released by drugs from two pools with different sensitivity to reserpine. The reserpinized synaptosomes could provide useful information on the mechanisms of action of drugs acting on brain serotonin.

[Dust and silica exposure on metallurgical furnace maintenance using refractory materials]

In the metallurgical industries the silica risk has long been known, particularly for the refractoryes maintenance workers. The maintenance of furnaces, ladles and tundisches refractory linings, on the current organization of production, is provided by companies under contract. The information available about the characterization of risk for this group of workers are at present inadequate. The study investigates the exposure to dust, also containing free crystalline silica (SLC), through the analysis of samples of commercial products used in the reconstruction of refractory linings of furnaces, ladles and tundisches, materials from the demolition of refractory articles and dust from work areas. It also presents the results of an environmental investigation conducted during the demolition and reconstruction of the refractory in three steel mills. The Authors, by the numerous inspections and the systematic survey of working conditions, have formulated a SLC risk profile and some proposals for prevention.

[Cumulative exposure to polychlorodibenzo-p-dioxins (PCDDS), polychlorodibenzofurans (PCDFS) and polychlorobiphenyls (PCB) in the metallurgic workers and the general population in Brescia province, northern Italy]

High temperature metallurgical processes may significantly contribute to the release of polychlorodibenzo-p-dioxins (PCDDs) and polychlorodibenzofurans (PCDFs) into the environment. Aim of this study was to evaluate the exposure to PCDDs, PCDFs, dioxin-like PCBs (DL-PCBs) and non dioxin-like PCBs (NDL-PCBs) in a sample of 300 workers of metallurgical plants operating in the Brescia area and in a control group of 113 men. Serum samples were grouped in pools of 10 and analyzed for their concentration of PCDDs and PCDFs, DL- and NDL-PCBs. Metallurgical workers show serum concentrations of NDL-PCBs similar to those observed in non-occupationally exposed living in Brescia, except in the case of some congeners, such as PCBs 28, 52, 101 which result to be significantly higher in metallurgical workers. Their concentrations range of "dioxins" was of 32.5 - 84.8 pgTEQ g(-1) lb. No significant difference was found between metallurgical workers and the control group on the whole, but the difference became significant when comparing metallurgical workers with the group of the 47 subjects living in remote non industrialised areas. In conclusion, concentrations of total PCBs observed in metallurgy workers are comparable with those observed in the control group, with the exception of a few, more volatile, congeners which resulted to be higher in metallurgy workers. Concentrations of PCDDs and PCDFs showed a range of values similar to that observed in the general population of Brescia not professionally exposed. However, concentrations of PCDDs and PCDFs observed in subjects resident in "remote" areas were significantly lower than those assessed in metallurgy workers and subjects living in the town of Brescia. On the whole, men living in the town of Brescia show levels of PCBs, PCDDs and PCDFs higher than those observed in other groups of the Italian general population, this reflecting the intense industrial activity of the town.

[Critical in demolition and removal of asbestos cement materials]

Those involved in the asbestos removal is the main category of workers currently exposed to asbestos in the province of Brescia. Although Italy, since 1991, has special rules for the protection of workers exposed to asbestos, improved further by D. Lgs. n. 81 of 2008, the working conditions found in shipyards are still far from a satisfactory degree of protection of workers. Sanitary facilities are largely lacking, management of work clothing is left to chance, use of filtering face masks is often incorrect, wetting of surfaces with encapsulant is frequently inadequate, daily cleaning of work areas and areas of construction that may have been contaminated by asbestos fibers with extractors absolute filters is shortly implemented. Little attention is also paid to the protection of workers from the premises concerned to the replacement of the cover, as well as to the dispersion in the external environment of asbestos fibers that contaminate the gutters removed and sent for disposal. Finally, it is still very high risk of falling from, documented by the tribute of serious and fatal accidents that occur in these sites. Increased surveillance of Health Prevention Services of ASL is required to achieve higher levels of prevention.

[Occupational risk and work-related diseases on steel foundries]

The iron foundries are still well represented in the area of Brescia and, despite having been involved in a major technological developments, have still risks to the health of workers. In order to verify the state of the art and effectiveness of prevention measures implemented by various companies, in recent years have carried out numerous inspections, environmental monitoring and biological. Furthermore, there were in the regional information system diseases reported and/or by the reported health. In particular it is shown that, in addition to chemical and physical risk factors, although in a much reduced compared to the 80s, are still present in our workplace pollutants (PAHs, silica, metal fumes, formaldehyde) at the base of classification of iron foundries in group 1, carcinogenic to humans, IARC, 1987 e 2012.

Stopping a trial early in oncology: for patients or for industry?

BACKGROUND

The aim of this study is to assess the use of interim analyses in randomised controlled trials (RCTs) testing new anticancer drugs, focussing on oncological clinical trials stopped early for benefit.

MATERIALS AND METHODS

All published clinical trials stopped early for benefit and published in the last 11 years, regarding anticancer drugs and containing an interim analysis, were assessed.

RESULTS

Twenty-five RCTs were analysed. The evaluation of efficacy was protocol planned through time-related primary end points, >40% of them overall survival. In 95% of studies, at the interim analysis, efficacy was evaluated using the same end point as planned for the final analysis. As a consequence of early stopping after the interim analysis, approximately 3300 patients/events across all studies were spared. More than 78% of the RCTs published in the last 3 years were used for registration purposes.

CONCLUSION

Though criticism of the poor quality of oncological trials seems out of place, unfortunately early termination raises new concerns. The relation between sparing patients and saving time and trial costs indicates that there is a market-driven intent. We believe that only untruncated trials can provide a full level of evidence which can be translated into clinical practice without further confirmative trials.

From fenfluramine racemate to d-fenfluramine. Specificity and potency of the effects on the serotoninergic system and food intake

Experiments using the binding of various ligands for monoamines to rat brain membranes and synaptosomal preparations for studying monoamine uptake and release have shown that d-fenfluramine is more potent than the l isomer in inhibiting 5-HT uptake, whereas d-norfenfluramine preferentially releases 5-HT from a reserpine-insensitive compartment. Studies on brain monoamine metabolism in intact animals have shown that the d and l isomers of fenfluramine at relatively low doses have a specific action on brain 5-HT and catecholamines, respectively. Based on the different ability of metergoline and ritanserin to displace 5-HT2 binding to rat brain membranes and to antagonize d-fenfluramine's anorexia, evidence has been provided that d-fenfluramine preferentially uses 5-HT1 sites in the rat brain to cause anorexia in this animal species. Finally, characteristics, regional distribution, and pharmacological characterization of a high-affinity [3H]d-fenfluramine binding to rat brain membranes have been described. This binding appears to be different from 5-HT uptake sites ([3H]imipramine binding) and 5-HT receptors and is not regionally related to the endogenous levels of 5-HT in the rat brain. It is, however, preferentially displaced by some agents using 5-HT to cause anorexia in rats, raising the possibility that it is somewhat related to 5-HT mechanisms involved in feeding control.

Effects of new smoking regulations in Italy

BACKGROUND

From 10 January 2005 the Italian government banned smoking in all indoor public places. We conducted a population-based survey to provide information on attitudes towards smoking regulation and to disentangle the impact of the smoking ban on tobacco consumption.

PATIENTS AND METHODS

We considered data from a survey on smoking, based on 3114 subjects aged 15 or over, representative of the general adult Italian population in terms of age, sex, geographic area and socioeconomic status.

RESULTS

Once smoke-free policies were introduced, support for them in the public opinion tended to increase. In Italy, smoke-free policies accounted for around 8% decrease in cigarette consumption in the short run. Moreover, tobacco bans were almost universally accepted, and the smoke-free legislation did not seem to unfavourably affect the business of restaurants or cafes.

CONCLUSIONS

The results of our study on the first extensive smoking ban in a large country show the advantages of smoke-free legislations, which may have major public health implications.

Ten years of marketing approvals of anticancer drugs in Europe: regulatory policy and guidance documents need to find a balance between different pressures

Despite important progress in understanding the molecular factors underlying the development of cancer and the improvement in response rates with new drugs, long-term survival is still disappointing for most common solid tumours. This might be because very little of the modest gain for patients is the result of the new compounds discovered and marketed recently. An assessment of the regulatory agencies' performance may suggest improvements. The present analysis summarizes and evaluates the type of studies and end points used by the EMEA to approve new anticancer drugs, and discusses the application of current regulations. This report is based on the information available on the EMEA web site. We identified current regulatory requirements for anticancer drugs promulgated by the agency and retrieved them in the relevant directory; information about empirical evidence supporting the approval of drugs for solid cancers through the centralised procedure were retrieved from the European Public Assessment Report (EPAR). We surveyed documents for drug applications and later extensions from January 1995, when EMEA was set up, to December 2004. We identified 14 anticancer drugs for 27 different indications (14 new applications and 13 extensions). Overall, 48 clinical studies were used as the basis for approval; randomised comparative (clinical) trial (RCT) and Response Rate were the study design and end points most frequently adopted (respectively, 25 out of 48 and 30 out of 48). In 13 cases, the EPAR explicitly reported differences between arms in terms of survival: the range was 0–3.7 months, and the mean and median differences were 1.5 and 1.2 months. The majority of studies (13 out of 27, 48%) involved the evaluation of complete and/or partial tumour responses, with regard to the end points supporting the 27 indications. Despite the recommendations of the current EMEA guidance documents, new anticancer agents are still often approved on the basis of small single arm trials that do not allow any assessment of an ‘acceptable and extensively documented toxicity profile’ and of end points such as response rate, time to progression or progression-free survival which at best can be considered indicators of anticancer activity and are not ‘justified surrogate markers for clinical benefit’. Anticipating an earlier than ideal point along the drug approval path and the use of not fully validated surrogate end points in nonrandomised trials looks like a dangerous shortcut that might jeopardise consumers' health, leading to unsafe and ineffective drugs being marketed and prescribed. The present Note for Guidance for new anticancer agents needs revising. Drugs must be rapidly released for patients who need them but not be at the expense of adequate knowledge about the real benefit of the drugs.

Tobacco dependence in the general population in Italy

BACKGROUND

Measures of tobacco dependence are mainly used in the clinical setting, but limited information is available on tobacco dependence on a population level.

MATERIALS AND METHODS

To obtain estimates of tobacco dependence on a population level, a six-item Fagerstrom questionnaire was used in two surveys, conducted in 2002-2003 on a sample of 6773 individuals aged 15 years or over, representative of the Italian adult population.

RESULTS

Overall, 27.1% of Italian adults described themselves as current cigarette smokers (32.2% of men, 22.4% of women). Of all smokers, 42.8% were classified as very low dependent, 28.6% as low dependent, 11.0% as intermediate, 13.8% as high and only 3.8% as very high dependent. The proportions of very low/low dependent were 67.4% in men and 76.8% in women. Those of high/very high dependent smokers were 21.4% in men and 12.5% in women, but only 2.8% at age 15-17 years and 8.4% at age 18-24 years. Only 23% of smokers, moreover, found it difficult to avoid smoking in places where smoking was forbidden.

CONCLUSIONS

The observation that over two-thirds of smokers on a population level in Italy report low or very low dependence has useful implication for intervention on stopping smoking, particularly in the young, who appear to be low dependent. However, in this age group cessation rates were comparatively low.

A mortality cohort study among workers in a graphite electrode production plant in Italy

BACKGROUND

Graphite electrode manufacturing workers are exposed to coal tar and its volatiles containing a variety of polycyclic aromatic hydrocarbons (PAH), silica and graphite dusts, and asbestos.

AIMS

To investigate mortality from cancer and other diseases among workers in a graphite electrode production plant in Italy.

METHODS

A total of 1291 males actively employed between 1 January 1950 and 31 December 1989 who had worked at the plant for at least one year were studied. The follow up extended from 1950 to 1997. Standardised mortality ratios (SMR) and their 95% confidence intervals (CI) were computed using mortality rates for the Italian and regional male population.

RESULTS

Excess mortality was observed for all causes (SMR 1.44, CI 1.32 to 1.56), all cancers (SMR 1.27, CI 1.07 to 1.50), liver cancer (SMR 4.19, CI 2.68 to 6.23), silicosis (SMR 66.39, CI 52.56 to 82.7), and cirrhosis and other chronic diseases of the liver (SMR 1.87, CI 1.31 to 2.59) in comparison with the national male population. When regional rates were used to calculate the number of expected deaths, SMRs remained higher for silicosis (SMR 57.32, 42.11 to 76.22), and liver cancer (SMR 2.57, 1.57 to 3.97). Mortality from silicosis was increased in workers hired at young ages (<25 years, SMR 81.79; 25-34 years, SMR 82.73), and in workers aged <45 at death (SMR 333.3, CI 159.8 to 613). Mortality from liver cancer increased threefold (SMR 3.11, CI 1.78 to 5.05) in workers with more than 10 years of employment at the plant during the manufacture of Karbate products.

CONCLUSIONS

Results support the association between excess mortality from silicosis and occupational exposure to siliceous sands experienced during graphite electrode manufacturing. The observed excess mortality from liver cancer is compatible, to some extent, with exposures that may have occurred during the manufacture of phenolic and furfuryl resins treated products, although a role of lifestyle factors and viral infections cannot be excluded.

[Exposure to neurotoxic metals and prevalence of parkinsonian syndrome in the area of Brescia]

The prevalence of parkinsonian syndromes was studied in the province of Brescia (Northern Italy), in order to verify its possible increase in the surroundings of ferroalloy plants located in a valley of the pre-Alps. A case-list of subjects affected by these disturbances was identified using four different sources of information: a) registers from local medical clinics; b) admission charts from local hospitals; c) consumption of levodopa; d) NHS list of exemption from prescription payment, due to the illness. Exploratory data show a frequency of parkinsonian disturbances among the residents in the surroundings of the ferroalloy plants and downwind (crude prevalence = 358/100,000 population, standardized for age and sex = 438) significantly higher (s.m.r, = 1.58; C.I. = 1.41-1.76) than the entire Province (crude prevalence 246/100,000). This preliminary result could indicate the interaction of prolonged environmental exposure to heavy metals, such as manganese, and genetic factors, potentially relevant in this mountain population.

Does a drug do better when it is new?

BACKGROUND

When assessing a new, promising therapeutic approach, a clinician's perception of a drug's effectiveness may be shaped by different kinds of phenomena, and among them, a favorable attitude towards new treatments, and as a result a tendency to overestimate their efficacy (wish bias).

MATERIALS AND METHODS

A retrospective study of published randomized clinical trials of doxorubicin-based chemotherapy for advanced breast cancer was carried out. Global (complete plus partial) response rate over time with allowance for type of drug regimen (mono- or polychemotherapy) and prior adjuvant therapies was assessed in the doxorubicin-containing arm using multivariate logistic regression analysis.

RESULTS

Twenty-nine studies published from 1975 to 1999 were retrieved for a total of 2234 women with advanced breast cancer enrolled in the doxorubicin-containing arms. There was a significant decrease in response rate to doxorubicin as first-line treatment over time that resisted adjustment for important differences in therapeutic management [odds ratio for global response = 0.89, 95% confidence interval (CI) 0.81 to 0.99].

CONCLUSIONS

Although only one drug (doxorubicin) in one clinical context (advanced breast cancer) has been analyzed, our findings support the use of double blind methodology whenever possible when assessing subjective endpoints and encourage further studies aimed at defining the clinical relevance of a wish bias in medicine.

Modulating the profit motive to meet needs of the less-developed world

The success, despite the problems, of academic/industrial collaborations over the past decade owes much to the profit motive. However, market-driven research and development has little to offer patients in the less-developed world. Some flexibility has already been demonstrated on drugs for orphan (rare or under-researched) diseases. Many diseases in less-developed countries are not rare. Academic researchers should be encouraging the establishment of funding for basic and clinical research that is directed at patients' needs in the less-developed world and that is independent of a commercial ethos.

Psychotropic drug use in Italy, 1984-99: the impact of a change in reimbursement status

After years of corruption surrounding drug reimbursement, in 1994, a change in drug reimbursement status was implemented in Italy according to cost-effectiveness criteria. The aim of this study was to assess the impact of these changes on the use of psychotropic drugs. National trends in antipsychotic, antidepressant and benzodiazepine prescriptions were analysed from 1984 to 1999. During the study period, prescriptions of antipsychotic drugs were stable from 1984 to 1994 but, in the subsequent 5 years, increased by 54%. Although the use of atypical compounds in 1999 accounted for only 6% of total antipsychotics sold, the cost of these new drugs accounted for almost one-half the total antipsychotic expenditure. The use of benzodiazepines increased by 53%. In 1999, the psychotropic drugs lorazepam and alprazolam were the most sold by value. From 1984 to 1999, the total antidepressants sold increased by 55%. Although the use of selective serotonin reuptake inhibitors and newer antidepressants in 1999 accounted for less than 50% of total antidepressants sold, the cost of these drugs accounted for 65% of total antidepressant expenditure. This analysis highlights specific areas of concern which should become the object of public health programs.

Health-related quality of life (HR-QOL) and regulatory issues. An assessment of the European Agency for the Evaluation of Medicinal Products (EMEA) recommendations on the use of HR-QOL measures in drug approval

Interest in measuring qualitative aspects of life that are most closely related to health and healthcare has increased in recent years. Methods of describing patients' subjective health status now incorporate standardised measures, and several psychometric measures are available. Despite the thousands of empirical and conceptual papers in the medical and pharmacological literature on health-related quality of life (HR-QOL), the value of such measures in the regulatory process is still being debated. We conducted an assessment to understand and document the position of the European Agency for the Evaluation of Medicinal Products (EMEA) on the use of HR-QOL measures in studies conducted for regulatory purposes. Official documents produced and circulated by the EMEA containing recommendations on trial design, conduct and analysis for sponsors and scientific experts were independently reviewed by authors to document the position of the Agency on the specific topic of HR-QOL. All documents found in the Agency website on 30 September 1999 were identified and then assessed to: (i) identify diseases or drugs for which formal HR-QOL assessment is recommended; (ii) identify measures and methods recommended; and (iii) evaluate the reliability of recommendations across documents. Of the 189 documents retrieved, none focused directly on health-related quality of life. A few explicit recommendations were identified for 13 specific drugs or conditions. These recommendations were mostly general and vague, and used nonstandard terminology. In addition, terminology and recommendations were not consistent across documents and, in at least one case, were in contrast with the US Food and Drug Administration (FDA) guidelines. EMEA guidelines incorporating quality-of-life outcomes are welcomed but it is obvious that more detailed guidance is required. Closer collaboration between the EMEA and the FDA is also recommended. Experts from different disciplines should be involved in the preparation of such documents to assure the necessary technical expertise and the representativeness of the various counterparts.

Inflammatory cytokines and related genes are induced in the rat hippocampus by limbic status epilepticus

Limbic status epilepticus was induced in rats by unilateral 60-min electrical stimulation of the CA3 region of the ventral hippocampus. As assessed by RT-PCR followed by Southern blot analysis, transcripts of interleukin-1beta, interleukin-6, interleukin-1 receptor antagonist and inducible nitric oxide synthase were significantly increased 2 h after status epilepticus in the stimulated hippocampus. Induction was maximal at 6 h for interleukin-1beta (445%), interleukin-6 (405%) and tumour necrosis factor-alpha (264%) and at 24 h for interleukin-1 receptor antagonist (494%) and inducible nitric oxide synthase (432%). In rats with spontaneous seizures (60 days after status epilepticus), interleukin-1beta mRNA was still higher than controls (241%). Immunocytochemical staining of interleukin-1beta, interleukin-6 and tumour necrosis factor-alpha was enhanced in glia with a time-course similar to that of the respective transcripts. Sixty days after status epilepticus, interleukin-1beta immunoreactivity was increased exclusively in neurons in one third of the animals. Multiple intracerebroventricular injections of interleukin-1 receptor antagonist (0.5 microg/3 microL) significantly decreased the severity of behavioural convulsions during electrical stimulation and selectively reduced tumour necrosis factor-alpha content in the hippocampus measured 18 h after status epilepticus. Thus, the induction of spontaneously recurring seizures in rats involves the activation of inflammatory cytokines and related pro- and anti-inflammatory genes in the hippocampus. These changes may play an active role in hyperexcitability of the epileptic tissue.

Does placebo help establish equivalence in trials of new antidepressants?

Clinical trials of new antidepressants usually compare a new drug to a reference antidepressant and to a placebo. The placebo is intended to validate the trial in the case of a no-difference outcome, i.e., it helps in assessing equivalence. The aim of the present paper is to test whether placebo has indeed helped establish equivalence of effect in comparative trials of new antidepressants. We carried out an example of sample size determination first in a trial to show a difference between the new and control drug, and second in a trial to assess equivalence between two competing drugs. Finally, we retrospectively calculated the maximum difference accepted as equivalence of effect in published trials of new antidepressants. Assuming a response rate to antidepressants of 70%, 294 subjects for each treatment group are needed to show a 10% difference between two antidepressant drugs and more than 1,300 to assess equivalence at a 5% level of delta, the maximum difference acceptable as equivalence of effect. The level of delta in published trials of new antidepressants ranges between 12 and 43%, suggesting they cannot claim to demonstrate equivalence of effect. Therefore, the presence of a placebo arm for comparison didn't help establish whether both drugs really worked the same way. Comparative trials of new antidepressants should adopt a two-arm design, a suitable number of patients and a high standard in the experimental design in order to minimise possible control-event rate variation.

Glutamic acid, twenty years later

This review examines progress in understanding the physiologic functions of glutamic acid in the body since the first symposium on glutamic acid physiology and biochemistry was held at the Mario Negri Institute in Milan in 1978. The topics reviewed, although not exhaustive, include the metabolism of glutamic acid, umami taste, the role of glutamic acid as a neurotransmitter, glutamate safety and the development of new drugs resulting from the knowledge of the neurodegeneration induced by high doses of glutamic acid.