The immediate effects of diacutaneous fibrolysis on pain and mobility in patients suffering from painful shoulder: a randomized placebo-controlled pilot study

OBJECTIVES

To describe the immediate effects of diacutaneous fibrolysis on pain and mobility in patients suffering from painful shoulder, and to assess the ability of the placebo technique to blind participants to group allocation.

DESIGN

A double-blind before-after randomized placebo-controlled pilot study.

SETTING

Two public centres of Primary Health Care of the Spanish National Health System.

PARTICIPANTS

Fifty patients (29 women, 21 men) with a diagnosis of painful shoulder of subacromial origin were included.

INTERVENTION

Participants were randomly allocated to one of two groups. The intervention group (N = 25) was actually treated with diacutaneous fibrolysis, while the placebo group (N = 25) was treated with placebo diacutaneous fibrolysis.

MEASUREMENTS

Active range of motion (flexion, abduction, extension, external and internal rotation) and pain intensity in the hand-behind-back position were measured. Participants were also asked about their perception in terms of comfort of the technique and results obtained.

RESULTS

Between-groups differences were significant in flexion (mean 11.4 degrees; 95% confidence interval (CI) 5.7-17.1), abduction (mean 7.2 degrees; 95% CI 2.0-12.5) and internal rotation movements (mean 3.1 cm; 95% CI 0.1-6.1). There were no significant differences between groups in pain intensity, extension or external rotation movements. The placebo technique showed its ability to blind participants to group allocation. None of the participants suffered any adverse effects from diacutaneous fibrolysis.

CONCLUSION

Diacutaneous fibrolysis may be an effective and safe therapeutic option to improve active range of motion in patients suffering from painful shoulder.

[Asthma and obesity: related inflammatory diseases]

Asthma and obesity are diseases that have increased their prevalence parallely in the last years, becoming health problems in our country. Asthma is a chronic inflammatory disease and in the last years obesity has also been catalogued as a systemic inflammatory disease considering that adipose tissue is an endocrine organ that produces cytokines that can promote severity of asthma; therefore generating interest in the investigators to perform studies that can relate both conditions.

Biological modifiers as cytoreductive therapy before stem cell transplant in previously untreated patients with multiple myeloma

BACKGROUND

High dose chemotherapy with supporting autologous stem cell transplantation is now considered the treatment of choice in patients with multiple myeloma <65 years old. The best regimen appears to be VAD (vincristine, doxorubicin and dexamethasone), but acute and late toxicity can limit the use of this combination. The use of biological modifiers has not been considered in this situation. We developed a new cytoreductive regimen, in an attempt to retain clinical efficacy but reduce toxicity.

PATIENTS AND METHODS

Thirty-six patients, previously untreated with diagnosis of multiple myeloma were enrolled to received the DAI regimen (dexamethasone 30 mg/m(2), i.v., days 1-4, all-trans-retinoic acid 45 mg/m(2), p.o., days 5-14 and interferon alpha 2a, 4.5 MU s.c., days 5-14) administered every 28 days for six cycles before high-dose chemotherapy (melphalan 200 g/m(2)) and autologous stem cell transplantation.

RESULTS

Overall response was observed in 29 cases (80%), complete response in 19 and partial response in 10 patients. Five patients were >65 years old and were treated with dexamethasone/thalidomide. Twenty-four patients underwent transplants. At a median follow-up of 31.6 months, no relapse or disease progression was observed, thus actuarial curves at 3-years showed that event-free survival was 86% and overall survival was 94%. Toxicity was mild.

CONCLUSIONS

This regimen appears to be an excellent alternative as cytoreductive treatment before high-dose chemotherapy and autologous stem cell transplantation with excellent overall response and minimal toxicity. Controlled clinical trials are warranted to define the role of this new therapeutic approach.

[Study of cancer-associated asthenia: foundation of the ASTHENOS group]

Asthenia in cancer patients is a highly controversial subject. A distinct definition of asthenia in medical literature is lacking as well as its prevalence and incidence. Also, no simple tools for its diagnosis are available. Moreover its etiopathogenesis is complex and multifactorial, thereby making therapeutic approaches difficult. Recently, a Spanish group has been set up for the study and treatment of asthenia in cancer patients. This paper reports on its establishment, objectives and first conclusions.

New progesterone esters as 5alpha-reductase inhibitors

The pharmacological activity of four new progesterone derivatives: 4-bromo-17alpha-(p-fluorobenzoyloxy)-4-pregnene-3,20-dione (7), 4-bromo-17alpha-(p-bromobenzoyloxy)-4-pregnene-3,20-dione (8), 4-bromo-17alpha-(p-chlorobenzoyloxy)-pregnene-3,20-dione (9) and 4-bromo-17alpha-(p-toluoyloxy)-4-pregnene-3,20-dione (10) was determined. These compounds were evaluated as 5alpha-reductase inhibitors on gonadectomized hamster seminal vesicles and flank organs. The pharmacological data of this study indicate that compounds 7 and 9 having at C-17 p-fluorobenzoyloxy and p-chlorobenzoyloxy ester functions respectively showed the highest antiandrogenic effect as measured by the reduction of the weight of the seminal vesicles. In the flank organ model, the same compounds 7 and 9 exhibited a smaller diameter, 1.8 and 1.0 mm, respectively, than the commercially available finasteride 3 (2.3 mm), thus indicating a higher inhibitory effect on 5alpha-reductase enzyme. Steroid 7 showed a higher inhibitory activity on the conversion of T to DHT (Fig. 3) than the presently used finasteride, thus indicating a higher antiandrogenic effect. The nonsubstituted benzoyloxy ester (compound 15) showed a lower antiandrogenic activity as measured in the seminal vesicles model than the p-substituted benzoyloxy compounds.

Fungi test for evaluation of new antiandrogenic molecule

Antiandrogens have high impact in medicine as they are compounds capable of decreasing the effect of benign prostatic hyperplasia, cancer, and other androgen-dependent diseases that affect a large percentage of the male population in the world. [figure: see text] Dihydrotestosterone, a 5 alpha-reductase metabolite of testosterone, has been implicated as the responsible factor of these androgen abnormalities. This fact indicates that the logical step in the treatment of these diseases is the inhibition of this enzyme activity using molecules that compete selectively with its natural substrates. The study of the pharmacological effect of antiandrogens requires specific animal models using a large number of laboratory animals. On basis of this concept, presently there is a tendency to eliminate studies with animals. In this paper we report a new method for antiandrogenic evaluation using microbial transformations.

Antiandrogenic effect of new synthetic steroids

These results indicate that castration decreased the flank organ diameter and the weight of the seminal vesicles, whereas daily injection of testosterone restores them. However injections of finasteride together with testosterone inhibited the diameter of the flank organs, the weight of the seminal vesicles, and the conversion of testosterone to dihydrotestosterone. The four compounds tested inhibited flank organ diameter size and the weight of the seminal vesicles as compared to the testosterone-treated animals. On the other hand, none of these compounds suppressed the conversion of testosterone to dihydrotestosterone. These results suggest that the synthesized steroids compete with androgen receptors.

Antiandrogenic effect of 16-substituted, non-substituted and D-homopregnane derivatives

The pharmacological activities of 12 pregnane derivatives (4-15) were determined on gonadectomized male hamster flank organs and seminal vesicles as antiandrogens and as 5alpha-reductase inhibitors. The results from this study indicate that subcutaneous injection of testosterone for 3 d increased the diameter of the pigmented spot in the flank organs, whereas finasteride when injected with testosterone decreased the size of the spot significantly when steroids 4-15 were injected together with testosterone, the diameter of the flank organs of gonadectomized male hamsters, decreased significantly (p<0.005) compared to testosterone. Compound 11 was the most active steroid and reduced the diameter of the pigmented spot more than the other synthesized steroids or finasteride. Subcutaneous injections of testosterone to gonadectomized animals restore the seminal vesicle size lost upon castration. Injection of testosterone plus finasteride decreased significantly the weight of these glands (p<0.005). Steroids 5-15 when injected with testosterone decreased the weight of the seminal vesicles compared to testosterone. Finasteride is a good inhibitor of the conversion of testosterone to dihydrotestosterone (DHT) (low formation of DHT) measured as pmole of DHT/g of protein/h. Steroids 6-15 inhibited the conversion of testosterone to DHT as compared to testosterone however finasteride and 10 appeared to be the most effective compounds. Castration increases the protein content of the seminal vesicles (control) expressed as microg/mg of tissues. Testosterone tends to decrease it significantly, as did compounds 4, 5, 7, 9, and 15. We demonstrated that DHT as well as cyproterone acetate and steroids 5, 6, 8, 9, 11, and 14 at increasing non radioactive steroid concentration, inhibited the binding of [3H]DHT to cytosolic androgen receptor (AR), as indicated by its Ki values. However, 4, 7, 10, 12, and 13 did not have any inhibitory effect.

Steroidal antiandrogens and 5alpha-reductase inhibitors

The purpose of this work is to synthesize a pregnane derivative with a high antiandrogenic effect or a high inhibitory activity for the enzyme 5 alpha-reductase type 2. Benign prostatic hyperplasia and prostate cancer are androgen dependent diseases which afflict a large percentage of the male population. Dihydrotestosterone 3, a 5 alpha-reductase metabolite of testosterone 2 has been implicated as a causative factor in the progression of these diseases, largely through the clinical evaluation of males who are genetically deficient of steroid 5 alpha-reductase enzyme. As a result of this study, the inhibition of this enzyme has become a pharmacological strategy for the design and synthesis of new drugs. The advent of finasteride 22 "figure 5" a 5 alpha-reductase inhibitor, has greatly alleviated the symptoms associated with benign prostatic hyperplasia. On the other hand, the discovery of cyproterone acetate 4 "figure 2" alone or in combination with the antiandrogens flutamide 14 "figure 3" or bicalutamide 21 has greatly reduced the misery of prostate cancer. Prostate cancer kills about 40,000 men in the USA and approximately 400,000 prostatectomies are performed each year. In our laboratory we have recently synthesized ten new progesterone derivatives 17 alpha-acyloyloxy-6-halo (chloro, bromo) 16 beta-methyl-4, 6-pregnadiene-3, 20-diones (54a-54e and 55a-55e), "figure 10". These steroids were evaluated as antiandrogens and exhibited a much higher activity than the commercially available cyproterone acetate 4. The same compounds were also evaluated as 5 alpha-reductase inhibitors and showed a slightly higher inhibitory activity than that of finasteride 22, the drug of choice today for the treatment of benign prostatic hyperplasia In another study we synthesized several new 4-halo (bromo and chloro) 17 alpha-benzoyloxy and also 4-halo-17 alpha-acetoxy progesterone derivatives (58-63) "figure 13". These compounds were prepared from the commercially available 17 alpha-acetoxy progesterone 56. The pharmacological evaluation of these steroids "figure 14" indicated that the 17 alpha-benzoyloxy derivatives (4-chloro and bromo) 62 and 63 were very potent antiandrogens. On the other hand, the 4-halo (bromo and chloro) 17 alpha-acetoxy (58, 59) and the 17 alpha-benzoyloxy-4-chloro analog 63 showed a very high inhibitory activity for the enzyme 5 alpha-reductase type 2 "figure 15".

Comparative study of the clinical efficacy of two different coumarin dosages in the management of arm lymphedema after treatment for breast cancer

In a randomized, double-blind, parallel group study, we compared the clinical efficacy of coumarin 90 mg/day (Group A) with 135 mg/day (Group B) in 77 women (age 35-65 years) with lymphedema of the upper limb secondary to surgery and irradiation for treatment of breast cancer. During 12 months of coumarin therapy, the arm volume of lymphedema and a clinical score (degree of arm edema, heaviness, hardness, and neuralgia/dysesthesia) were determined. In both groups, the volume of arm lymphedema decreased (14.9% in Group A and 13.2% in Group B) (N.S.), the overall clinical score improved (12.9 +/- 4.3 to 5.7 +/- 3.5 in Group A and from 11.7 +/- 3.7 to 4.7 +/- 3.9 in Group B) (N.S.), and the overall efficacy of coumarin was similarly good or excellent (71.9% in Group A and 68.6% in Group B) (N.S.). Only mild to moderate side effects of drug therapy were recorded. Coumarin prevents a spontaneous trend toward an increase in arm lymphedema after treatment of breast cancer, decreases the severity of local symptoms, and overall improves the quality of life. No difference was found between the apparent benefits of coumarin at 90 mg/day compared with 135 mg/day.

UFT in combination as adjuvant therapy for breast cancer. Grupo Oncologico de Sevilla Seville, Spain

Between 1989 and 1993, 409 evaluable patients with breast cancer have been treated with tegafur and uracil (UFT) in an adjuvant setting in two different trials. Data from both trials were reviewed in December 1995 after a mean follow-up of 5.09 +/- 1.1 years (range, 2.9 to 7.1 years). The aim of the first trial was to demonstrate the activity of UFT 400 mg/day for 6 months plus prednimustine 60 mg/m2 for 7 consecutive days, every 28 days in 6 cycles given orally (arm B). This scheme was compared with 6 cycles of cyclophosphamide 600 mg/m2, plus methotrexate 40 mg/m2, plus fluorouracil 600 mg/m2, every 4 weeks (arm A). In this study, 187 premenopausal women were evaluable, 96 in arm A and 91 in arm B, all of whom had positive axillary nodes. Although there were more younger patients in arm A than in arm B, prognostic factors were similar in both groups. Disease-free survival and overall survival were similar in both arms. However, some concern is raised by the low disease-free survival rate. The toxicity was mild (mainly nausea and vomiting and alopecia) and slightly worse in arm A. We believe that oral administration could be a useful alternative to the parenteral route. In the second trial, 222 evaluable patients received 20 mg/day of tamoxifen (Nolvadex) for 1 year (arm A), or the same dose of tamoxifen plus UFT 400 mg/day for 6 months. All patients were postmenopausal, and the characteristics of the tumors were the same as those in patients in the first trial. In arm A there were 109 patients and in arm B, 113. The groups were well balanced. The overall survival and the disease-free survival rates were equal in both arms, but were longer in arm B in the subset of patients with five or more axillary-involved nodes. The toxicity was negligible in both arms. We conclude that UFT/tamoxifen might be useful in postmenopausal patients with five or more involved nodes who are unable to follow a more aggressive schedule because of their age or low performance status.

[The nutritional evaluation of cooking fats and oils]

Fatty acids content of locally obtained margarines, shortenings and cooking oils from businesses in Panama were determined by gas chromatographic method. The results found show that all of these oils have a high nutritional value, because of their high unsaturated fatty acid content. The soya oil group is characterized by its high content of linolenic acid (w3), for this reason they are preferably recommended as edible oils. Margarines were classified as "saturated" (high in palmitic acid) and "unsaturated" (high in linoleic acid). Saturated margarines are not very recommendable as edible fats since the high palmitic acid content is a hypercholesterolemic agent. The majority of the shortenings are also rich in palmitic acid.

[Hypercholesterolemic effect of canthaxanthin and astaxanthin in rats]

Three groups of male Wistar rats (130-140 g) were fed 30 days with a synthetic diets containing 0.1% of beta-carotene, canthaxanthin and astaxanthin respectively. Another group was fed with a synthetic diet without carotenoids. The results shows that the beta-carotene does not induce change in plasma cholesterol (49, 7 +/- 3.6 mg/dl), but canthaxanthin and astaxanthin induce a significant increase in cholesterol concentration (92.1 +/- 3.6 and 66.5 +/- 5.1 mg/dl). This increase is noted mainly in the HDL fraction of the lipoproteins. Canthaxanthin has more affinity than astaxanthin for the liver, principal site of lipoproteins catabolism. The hypercholesterolemic effect of these xanthophylls is not related to reported mechanisms of carotenoids in mammalian, because beta-carotene does not induce changes in plasma cholesterol.

[Treatment of acute lymphoblastic leukemia in low risk adults]

Forty five adult patients with low risk acute lymphoblastic leukemia were treated with prednisone, vincristine and adriamycin. 91 per cent (41 patients) obtained complete remission with a mean survival was of 39 months. The side effects of treatment were minimal and less patient had to delay his chemotherapy. This regimen of treatment is a good option for adults patients with low risk acute lymphoblastic leukemia, in consequence of: a) high value of complete remission and its duration. b) the mean survival obtained and the probability of cure. c) the absence of severe side effects and without necessity of support therapy or hospitalization.

Epirubicin in rectal cancer

Taking into account previous results with epirubicin in colorectal cancer, in January, 1985, an oriented Phase II trial was started in patients with measurable rectal cancer, previously untreated with chemotherapy. Ten patients were treated with 80 mg/m2 every 3 weeks, and another 10 patients with 100 mg/m2 every 3 weeks. One patient from the 80 mg/m2 group and 3 from the 100 mg/m2 group reached partial remission for 4, 9+, 15 and 72+ weeks. Median survival for all patients was 16 months. Hematological toxicity was not a limiting factor. Anemia was significantly more frequent in the higher dose group; clinical cardiotoxicity was not observed. The incidences of nausea/vomiting and mucositis were low. Considering the low toxicity and the responses observed, additional studies seem to be indicated with an increase in the epirubicin dose.

Glutamate synthase in greening callus of Bouvardia ternifolia Schlecht

The distribution of the two glutamate-synthase (GOGAT) activities known to exist in higher plants (NADH dependent, EC 2.6.1.53; and ferredoxin dependent, EC 1.4.7.1) was studied in non-chlorophyllous and chlorophyllous cultured tissue as well as in young leaves of Bouvardia ternifolia. The NADH-GOGAT was present in all three tissues. Using a sucrose gradient we found it in both the soluble and the plastid fraction of non-chlorophyllous and chlorophyllous tissue, but exclusively in the chloroplast fraction of the leaves. Ferredoxin-GOGAT was found only in green tissues and was confined to the chloroplasts. Ferredoxin-GOGAT activity increased in parallel with the chlorophyll content of the callus during the greening process in Murashige-Skoog medium (nitrate and ammonium as the nitrogen sources), while NADH-GOGAT was not affected by the greening process in this medium. Furthermore, both activities were differentially affected by either nitrate or ammonium as the sole nitrogen source in the medium during this process. It is suggested that each GOGAT activity is a different entity or is differently regulated.