Binge eating, mood, and quality of life in youth with type 2 diabetes: baseline data from the today study

OBJECTIVE

The current study examines the prevalence of binge eating and its association with adiposity and psychosocial functioning in a large, diverse sample of youth with type 2 diabetes.

RESEARCH DESIGN AND METHODS

In the TODAY study, 678 (mean age 14.0 years; 64.9% girls) of the 704 youth randomized to the study completed a self-report measure of eating disorder symptoms and were categorized as nonovereaters, overeaters, subclinical binge eaters, or clinical binge eaters.

RESULTS

Youth with clinical (6%) and subclinical (20%) levels of binge eating had significantly higher levels and rates of extreme obesity, global eating disorder and depressive symptoms, and impaired quality of life.

CONCLUSIONS

These findings highlight the importance of evaluating youth with type 2 diabetes for the presence of binge eating. Future research is needed to determine the cumulative effects of disordered eating, obesity, and psychosocial distress on adherence to lifestyle change recommendations and longitudinal response to treatment.

The epidemiology of ovarian granulosa cell tumors: a case-control study

OBJECTIVE

This study identified risk factors for ovarian granulosa cell tumors (GCT) through a case-control study comparing women with GCT to women with epithelial ovarian cancers (OC) and general population (GP) controls.

METHODS

Women with GCT and OC were identified from our hospital tumor board and the Massachusetts and New Hampshire Statewide Cancer Registries between January, 1988 and November, 2008. Age, gender and county matched GP controls were identified through town books in Massachusetts and drivers' license lists in New Hampshire. Epidemiologic factors including age, race, obesity, pregnancy history, smoking, and family history were evaluated. Odds ratio (OR) was calculated and adjusted for race and age.

RESULTS

Seventy-two women with GCT, 1578 GP controls, and 1511 OC controls were identified. Patients with GCT were significantly more likely to be non-white (OR 8.49; 4.07, 17.7), obese with a BMI >30 (OR 5.80; 3.01, 11.2), and have a family history of breast (OR 2.13; 1.19, 3.80) or ovarian cancer (OR 2.89; 1.08, 7.72) than GP controls. The risk of developing GCT was significantly decreased in women who smoked (OR 0.46; 0.27, 0.78), used oral contraceptive pills (OR 0.32; 0.17, 0.63) or were parous with 1-2 (OR 0.30; 0.16-0.56) or greater than 2 births (OR 0.50; 0.27, 0.94) when compared to GP controls.

CONCLUSION

These findings suggest an independent association between non-white race and obesity as a hyperestrogenic state in the development of GCT while parity and OCP use may be protective. An unknown familial predisposition for GCT may exist.

Longitudinal decline in autopsy-defined frontotemporal lobar degeneration

BACKGROUND

The natural history of patients with pathologically proven frontotemporal lobar degeneration (FTLD) is important from clinical and biologic perspectives, but is not well documented quantitatively.

METHODS

We examine longitudinal decline in cognitive functioning in an autopsy-proven cohort of patients with the clinical diagnosis of a FTLD spectrum disorder or FTLD pathology using a panel of neuropsychological measures. Patients are categorized according to findings at autopsy into tau-positive FTLD, tau-negative FTLD, and frontal variant-Alzheimer disease (fvAD) subgroups.

RESULTS

Patients decline significantly over time on all neuropsychological measures. Moreover, several measures differentiate between histopathologically distinct subgroups throughout the course of the disease process. This includes a significant double dissociation involving relative difficulty on a visual constructional measure in tau-positive patients compared to relatively impaired visual confrontation naming in tau-negative patients. Longitudinal measures of FAS naming fluency and animal naming fluency also distinguish tau-positive patients and tau-negative patients with FTLD from patients with fvAD. Other measures show significant decline but do not distinguish between histopathologic groups longitudinally.

CONCLUSION

Our findings suggest different longitudinal patterns of cognitive decline in pathologically defined subgroups of patients. Measures consistently distinguishing between patient subgroups can be used to bolster diagnostic accuracy throughout the course of these diseases, while measures demonstrating undifferentiated longitudinal decline may serve as useful endpoints in treatment trials.

Results of all-intraperitoneal carboplatin and paclitaxel regimen shows good tolerability and efficacy for advanced ovarian cancer

5521

Background: A phase III trial (GOG 172) demonstrated improved survival for patients (pts) with optimally-debulked ovarian cancer treated with intraperitoneal (IP) cisplatin and paclitaxel, as compared with standard IV dosing. Studies to further enhance efficacy and minimize toxicity of IP platinum/taxane regimens are needed. We present the clinical results of a novel IP regimen in follow-up to the pharmacokinetics (pk) results presented last year. Methods: Carboplatin at an AUC 6 on day 1 and paclitaxel 60 mg/m2 on days 1, 8, 15 was given, IV in cycle 1 and IP in the 5 subsequent 21-day cycles. The initial IV cycle was designed to allow for intra-patient IV vs. IP pk comparison. Pts completing 6 cycles with clinical complete response (CCR) underwent second-look operation (SLO). Results: Accrual is complete with 40 evaluable pts, 8 pts remain on trial. Pts came off study for: port-related complications (7), allergy (2), heme tox (2), vaginal leak (2), and infection (4). Toxicity was mild, with grade 3 or 4 toxicity consisting of neutropenia: 10 (25%), plts: 2 (5%), vomiting: 2 (5%), fatigue: 2 (5%) and anemia: 1 (2.5%). There was no grade 3 or 4 peripheral neuropathy or alopecia. Completion rate was good with 82% of pts completing = 4 cycles, as compared with 52% in GOG 172. All pts completing chemotherapy were judged to be in CCR; there was no progressive disease on trial. Of the pts undergoing SLO, 14 pts were negative, 4 pts were positive, for complete pathological response rate of 78%. Conclusions: Pts were able to complete more cycles of therapy on this regimen as compared with GOG 172. The incidence of gastrointestinal, metabolic, and neurotoxicity is very low. Preliminary SLO rate compares favorably to the 57% seen in GOG 172. Previously reported pk results as well as tolerability and efficacy are encouraging and suggest this regimen should be studied in a larger population. Final toxicity and response data will be available.

No significant financial relationships to disclose.

Chemotherapy and radiation therapy in UPSC

5535

Purpose: To analyze the impact of chemotherapy (Ch) and radiation therapy (RT) on relapse rates in patients with uterine papillary serous carcinoma (UPSC). Materials and Methods: The outcomes of 160 women with UPSC seen between 1980–2005 at the BW/DFCC were analyzed. Exclusion criteria included stage IVB disease, no hysterectomy, unknown stage, or unknown type of RT. Results: The median age was 67 years (range 31–90). FIGO Stage was IA (21), IB (28), IC (13), IIA (7), IIB (10), IIIA (42), IIIB (2), IIIC (21), and IVA (16). Treatment included none (40), Ch alone (20), Ch and whole abdominal radiation (WA) (11), Ch and pelvic radiation (P) (30), Ch and vaginal brachytherapy (VB) (2), WA alone (24), P alone (19), and VB alone (14). The median dose of RT was WA 30 Gy and P 45 Gy. Ch was given to 63 patients; the median number of cycles of Carboplatin, Adriamycin and Paclitaxel was 3. Overall survival (OS) and disease-free survival (DFS) for the entire group were 67% and 57% at 2 years, 62% and 51% at 3 years and 51% and 38% at 5 years. A total of 58 patients relapsed. Among those who received no RT or Ch, 48% (19/40) relapsed; among those treated with Ch only, 50% (10/20) relapsed; in the group treated with RT only, 26% (15/57) relapsed; and, in those treated with Ch and RT, 33% (14/43) relapsed. A significant difference in recurrence rate was seen in patients treated with RT compared to those who received no treatment (OR 0.40, p=0.03). This difference persisted after controlling for Stage, which did significantly affect the relationship between RT treatment and recurrence. Local recurrence (in an RT field) was a component of failure for 14% (14/100) treated with RT, versus 42% (25/59) that received no RT (OR 0.22, p=0.0001). Distant metastases were a component of first failure in 15% (9/61) that received Ch versus 11% (11/97) that did not; there was no significant difference in distant recurrence rate for patients treated with Ch (OR 1.35, p=0.53). Conclusion: This single-institution study represents the largest series of UPSC to date. The use of RT significantly decreases the overall recurrence rate of UPSC in this series and should be considered in patients with stages I-IVA UPSC. Future studies looking at the optimal type, dose and duration of chemotherapy, as well as the use of novel agents, are needed to improve outcomes in this population.

No significant financial relationships to disclose.

An evaluation of the vitamin D3 content in fish: Is the vitamin D content adequate to satisfy the dietary requirement for vitamin D?

It has been suggested that the major source of vitamin D should come from dietary sources and not sun exposure. However, the major fortified dietary source of vitamin D is milk which often does not contain at least 80% of what is stated on the label. Fish has been touted as an excellent source of vitamin D especially oily fish including salmon and mackerel. Little is known about the effect of various cooking conditions on the vitamin D content in fish. We initiated a study and evaluated the vitamin D content in several species of fish and also evaluated the effect of baking and frying on the vitamin D content. Surprisingly, farmed salmon had approximately 25% of the vitamin D content as wild salmon had. The vitamin D content in fish varied widely even within species. These data suggest that the tables that list the vitamin D content are out-of-date and need to be re-evaluated.

A phase II trial of three sequential doublets for the treatment of advanced müllerian malignancies☆☆Funding provided by Eli Lilly Pharmaceutical Company and Amgen

OBJECTIVES

In an effort to improve the results of primary chemotherapy for müllerian malignancies a novel chemotherapy program was piloted that delivered three sequential chemotherapy doublets. The primary endpoints were surgically defined response rates and evaluation of toxicity.

METHODS

After primary cytoreductive surgery patients were treated with three sequential doublets including three initial cycles of carboplatin and paclitaxel (doublet 1) and then two cycles of cisplatin (day 1) and gemcitabine (days 1 and 8; doublet 2), and finally two cycles of doxorubicin (day 1) and topotecan (days 3,4, and 5; doublet 3). Cycles 4 through 7 were given with G-CSF (Neupogen) support at a dose of 5 mcg/kg/day. After therapy, all women were clinically staged and evaluated by second-look laparoscopy/laparotomy (SLO) if clinical staging was negative for residual disease.

RESULTS

A total of 49 eligible patients were enrolled with a median age of 52 (SD 9). Forty-four women had either ovarian cancer or primary peritoneal carcinoma with 3 women diagnosed with fallopian tube carcinoma and 2 with papillary serous carcinoma of the uterus. Eighty-four percent of patients had stage IIIc/IV tumors, with 29% having >1 cm residual disease after primary cytoreductive surgery. Thirty-nine of 49 (80%) patients completed therapy. A total of 283 cycles of chemotherapy were delivered with acceptable toxicities. There were no toxic deaths. Five women were withdrawn from trial (3 for Taxol hypersensitivity, 1 for gemcitabine pulmonary hypersensitivity, and 1 for serious line infection). Neutropenia, typically without fever, was relatively frequent in the first doublet. Nausea and thrombocytopenia were the predominant toxicities in doublet 2. Thirty-nine women completed all cycles of treatment. Thirty-six women had restaging results consistent with a clinical complete response (CR) and underwent SLO. The pathologic CR rate of the patients undergoing SLO was 38%.

CONCLUSIONS

Treatment with this sequential doublet regimen is feasible with a 38% pathologic CR rate.

Comparison of once-daily mometasone furoate versus once-daily budesonide in patients with moderate persistent asthma

We conducted this study to compare the efficacy and safety of once-daily mometasone furoate (MF) administered by dry powder inhaler (DPI) with once-daily budesonide (BUD)-DPI and placebo in patients with moderate persistent asthma previously using twice-daily inhaled corticosteroids. A total of 262 patients (> or = 12 years of age) with moderate persistent asthma were randomised to once-daily morning treatment with MF-DPI 440 microg (metered dose), BUD-DPI 400 microg (metered dose), or placebo in an eight-week, multicentre, placebo-controlled, double-blind, double-dummy study. The primary efficacy variable was percent change in FEV1 from baseline to endpoint (last evaluable visit). At endpoint, the percent change in FEV1 was significantly greater (p < 0.01) following treatment with MF-DPI 440 microg (8.9%) than with both BUD-DPI 400 microg (2.1%) and placebo (-3.9%). Secondary efficacy variables, including morning and evening peak expiratory flow rates, albuterol use, percentage of asthma symptom-free days, and physician-evaluated response to therapy were also significantly improved at endpoint in the MF-DPI group compared with both the placebo and BUD-DPI groups (p < 0.05). Both active treatments were well tolerated. In conclusion, once-daily treatment in the morning with MF-DPI 440 microg significantly improved pulmonary function and asthma control compared with morning administration of BUD-DPI 400 microg and placebo.

Plasma naltrexone during opioid detoxification

Orogastric naltrexone is used for opioid detoxification, but it is not known how gastric absorption affects plasma concentrations of the drug. We measured plasma naltrexone during orogastric naltrexone, given in repeated doses of 12.5 mg, 25 mg, 50 mg and 50 mg. Plasma naltrexone was measured after each naltrexone dose. The increase in plasma naltrexone was highly variable between patients during orogastric administration. Adequate detoxification was questioned in 4 of 10 patients because plasma naltrexone did not increase above 5 ng/ml. There was a negative correlation between plasma naltrexone and the presence of withdrawal symptoms on the day after the procedure (r = -0.78, P < 0.05). These results show that the increase in plasma naltrexone is variable during orogastric administration and this may impair successful detoxification.

Aspergillus laryngotracheobronchial infection in a 6-year-old girl following bone marrow transplantation

Localised fungal infection of the larynx and tracheobronchial tree is extremely uncommon. We report the case of a 6-year-old girl with acute lymphocytic leukaemia, who developed symptoms of upper airways obstruction 6 months after a cord blood transplant. Bronchoscopy showed a pale plaque lesion in the larynx and tracheobronchial tree. Aspergillus fumigatus was cultured from a biopsy of the lesion. The patient was treated successfully with a prolonged course of amphotericin B and assessed with multiple surveillance bronchoscopies.

Construction and molecular analysis of gene transfer systems derived from bovine immunodeficiency virus

Because lentiviruses are able to infect nondividing cells, these viruses might be utilized in gene therapy applications where the target cell does not divide. However, it has been suggested that the introduction of primate lentivirus sequences, particularly those of human immunodeficiency virus, into human cells may pose a health risk for the patient. To avoid this concern, we have constructed gene transfer systems based on a nonprimate lentivirus, bovine immunodeficiency virus. A panel of vectors and packaging constructs was generated and analyzed in a transient expression system for virion production and maturation, vector expression and encapsidation, and envelope protein pseudotyping. Virion preparations were also analyzed for transduction efficiency in a panel of human and nonhuman primary cells and immortalized cell lines. The virion preparations transduced most of the target cell types, with efficiencies up to 90% and with titers of unconcentrated virus up to 5 x 10(5) infectious doses/ml. In addition, infection of nondividing human cells, including unstimulated hematopoietic stem cells and irradiated endothelial cells, was observed.

Combining median electroencephalography frequency and sympathetic activity in an index to evaluate opioid detoxification in patients

During rapid opioid detoxification, increased sympathetic activity and a greater median frequency (MF) of activity on electroencephalography (EEG) have been reported. The purpose of this study was to evaluate a new index for detoxification that combines sympathetic activity and MF data. After informed consent was obtained, eight patients were sedated with propofol. The MF of EEG activity derived from frontal electrodes was determined. Heart rate variability was evaluated in 256-second segments by power spectral analysis, and sympathetic activity was determined by the low frequency component. The Hoffman Index for narcotic detoxification was weighted 70% to sympathetic activity and 30% to MF to normalize the difference in scales and to provide adequate weight to the sympathetic component. Opioid detoxification was produced by infusion of 25 mg naloxone for 30 minutes, followed by a 24-hour infusion of 1 mg per hour. The MF showed a rapid increase during high-dose infusion of naloxone, but the peak response occurred 1 to 2 hours later. Sympathetic activation and the Hoffman Index increased more slowly after the start of naloxone infusion, but peak increases in all components occurred at approximately the same time. The peak increases in Hoffman Index (110% of baseline), MF (260%), and sympathetic activity (304%) during administration of naloxone were significant and correlated with respect to time (r = 0.89-0.94). The Hoffman Index showed an early increase related to MF and a well-defined peak response indicative of sympathetic and MF activity. The behavior of the Hoffman Index in relation to the MF and sympathetic activity more clearly indicated the onset of opioid detoxification and the maximum response to opioid reversal than did MF or sympathetic activity alone.

Near-maximal fractional oxygen extraction by active skeletal muscle in patients with chronic heart failure

Systemic oxygen uptake and deep femoral vein oxygen content were determined at peak exercise in 53 patients with chronic heart failure with impaired systolic function (mean left ventricular ejection fraction 0.18; n = 41) or preserved systolic function (mean left ventricular ejection fraction 0.70; n = 12) and in 6 age-matched sedentary normal subjects. At peak exercise, deep femoral vein oxygen content in heart failure patients with impaired systolic function and preserved systolic function were similar, both significantly lower than that of normal subjects (2.5 +/- 0.1, 2.9 +/- 0.2, and 5.0 +/- 0.1 ml/100 ml, respectively; P < 0.05). Deep femoral venous oxygen content was lower in patients with the greater impairment of aerobic capacity, regardless of the underlying systolic function (r = 0.72, P < 0.01). Fractional oxygen extraction in the skeletal muscle at peak exercise is enhanced in patients with chronic heart failure when compared with normal subjects, in proportion to the degree of aerobic impairment.

Phase I trial of carboplatin, paclitaxel, etoposide, and cyclophosphamide with granulocyte colony stimulating factor as first-line therapy for patients with advanced epithelial ovarian cancer

OBJECTIVES

The goal of this study was to determine the maximally tolerated doses (MTDs) of carboplatin, paclitaxel (Taxol), etoposide, and cyclophosphamide (CTEC) with granulocyte-colony stimulating factor (G-CSF, Filgrastim) support as first-line chemotherapy in women with advanced epithelial ovarian cancer (EOC).

METHODS

Newly diagnosed patients with either stage IV EOC, or stage III EOC and any amount of gross residual tumor after surgical debulking were eligible to receive six cycles of CTEC over five different dose levels in this phase I trial (planned 21-day cycle length). Paclitaxel, carboplatin, and cyclophosphamide were administered intravenously on Day 1, and oral etoposide was administered on Days 1, 2, and 3. G-CSF was administered beginning Day 4.

RESULTS

Twenty patients received a total of 98 cycles of CTEC over the five dose levels evaluated. Bone marrow suppression was the major toxic effect, with grade 4 neutropenia and thrombocytopenia being observed in 25 and 23% of cycles, respectively. The overall incidence of febrile neutropenia was 10%, and no toxic deaths occurred. No grade IV thrombocytopenia or febrile neutropenia was observed once the carboplatin dose was reduced from AUC of 7 to 5. Nonhematologic toxicity was generally mild (grade 2 or less). Dose-limiting toxicity was not observed at the highest dose level evaluated in this study, preventing assignment of the MTD. The clinical complete response rate was 92%, although 15 of 16 evaluable patients have progressed with a median progression-free interval of 4 months (range, 2-11 months). One patient remains disease-free 9 months from the completion of CTEC.

CONCLUSIONS

The CTEC regimen is well tolerated and highly active. Although the MTD was not reached in this study, the short median progression-free interval suggests that this regimen is unlikely to be superior to standard treatment with paclitaxel and carboplatin. Strategies to optimize the development of future combination chemotherapy regimens in the treatment of newly diagnosed ovarian cancer are discussed.

Onset-of-action for antihistamine and decongestant combinations during an outdoor challenge

BACKGROUND

Medications containing a combination antihistamine-decongestant are commonly used for allergic rhinitis yet onset-of-action comparisons for symptom relief after a single dose have not been performed.

OBJECTIVE

To determine the onset of symptom relief and efficacy of antihistamine-decongestant medications (acrivastine-pseudoephedrine and loratadine-pseudoephedrine) compared with placebo in an outdoor park.

METHODS

This study was conducted during the spring of 1997 using a double-blind, placebo-controlled design. Patients completed baseline rhinitis symptom diaries from 7:30 to 9:30 AM. Subjects with qualifying symptom scores received one dose of either acrivastine-pseudoephedrine, loratadine-pseudoephedrine, or placebo at 10:00 AM. Symptom diaries were recorded for the next 4 hours.

RESULTS

Of 593 patients randomized to treatment, 592 were included in efficacy analysis. Acrivastine-pseudoephedrine and loratadine-pseudoephedrine demonstrated a mean onset-of-action by 45 and 30 minutes respectively for total symptom and rhinitis symptom scores for the five sites. Onset-of-action for nasal congestion scores was 45 minutes for both medications. Sites having higher pollen exposure (>100 pollen grains over 6 hours) demonstrated a difference between the antihistamine combinations: acrivastine-pseudoephedrine had an onset of action at 45 minutes for total symptom and rhinitis symptom scores, and 15 minutes for nasal congestion scores whereas loratadine-pseudoephedrine had onset-of-action for nasal congestion score of 105 minutes but failed to reach significance at any timepoint for total symptom and rhinitis symptom scores.

CONCLUSIONS

Both antihistamine-decongestant combinations demonstrate an onset-of-action within 60 minutes of administration but under conditions of higher pollen exposure, the acrivastine combination was more effective for total symptoms, rhinitis symptoms, and nasal congestion with an onset-of-action within 45 minutes for rhinitis symptoms and 15 minutes for congestion.

CSF/serum beta-hCG ratio in patients with brain metastases of gestational trophoblastic tumor

OBJECTIVE

To assess the accuracy of cerebrospinal fluid (CSF)/serum ratio of beta-subunit of human chorionic gonadotropin (beta-hCG) in detecting brain metastasis of gestational trophoblastic tumor (GTT).

STUDY DESIGN

The subjects were ten patients with GTT and brain metastases. Spinal puncture and veni-puncture were performed for measurement of beta-hCG titer in CSF and serum to determine the CSF/serum ratio before starting multiagent chemotherapy and/or brain irradiation.

RESULTS

Five patients manifested a CSF/serum beta-hCG ratio > 1/60, and five manifested a ratio < 1/60.

CONCLUSION

The CSF/serum beta-hCG ratio is not accurate enough to be routinely considered in the workup, management, and/or surveillance of GTT with brain metastases. Hence, it is perhaps not necessary to perform spinal puncture if the only purpose is to determine the CSF/serum ratio.

Median EEG frequency is more sensitive to increases in sympathetic activity than bispectral index

Sympathetic heart rate variability is correlated with the increase in plasma catecholamines during rapid opioid detoxification. We evaluated whether the bispectral index, median frequency, or 95% spectral edge of the electroencephalogram are sensitive to the sympathetic response seen during reversal of opioid dependence. Eight patients undergoing rapid opioid detoxification gave informed consent. Two-channel frontal electroencephalogram was measured. Sympathetic heart rate variability was measured in 256 second segments by Fourier transform of continuous heart rate and the low frequency segment (0.02-0.13 Hz) analyzed for sympathetic function. Patients were anesthetized with propofol infusion. After a 30-60 min steady state, naloxone was infused intravenously at a rate of 25 mg/30 min, followed by an infusion of 1 mg/hr. During induction of anesthesia, sympathetic heart rate variability decreased from 1.80 to 0.3, bispectral index from 86 to 47, median frequency from 10.2 to 3.4, spectral edge from 23.5 to 16.7 (all P<.05). During naloxone infusion, the median percent increase in sympathetic heart rate variability was 487% (P<.05), median frequency increased 163% (P<.05), bispectral index (10%), and spectral edge (7%) did not significantly change. The increase in median frequency was delayed compared to sympathetic heart rate variability and median frequency remained elevated after sympathetic heart rate variability returned to anesthetized baseline in 5 of 8 cases. Our results show that median frequency and sympathetic heart rate variability increase during opioid detoxification, but the time course of each response is different. Median frequency is a more sensitive electroencephalogram indicator of opioid reversal than bispectral index or spectral edge.

Heart rate variability and plasma catecholamines in patients during opioid detoxification

It has been shown that rapid opioid detoxification is associated with increased sympathetic activity (SYMP) and plasma catecholamines. Heart rate (HR) variability may provide a noninvasive method of evaluating withdrawal and sympathetic activation caused by the reversal of opioid binding in patients who are opioid dependent. The purpose of this study was to evaluate the relationship between HR variability and plasma catecholamines during opioid detoxification. Patients were anesthetized with propofol, intubated, paralyzed with rocuronium infusion, and ventilated. The bispectral index (BIS) of the electroencephalogram was recorded with the patient awake as well as during propofol anesthesia. SYMP was determined by power spectral analysis of HR variability. Plasma epinephrine and norepinephrine were measured at baseline propofol anesthesia and during naltrexone treatment in eight opioid-dependent patients. Nonopioid-dependent controls (n = 7) were monitored during surgery without naltrexone treatment or measurement of plasma catecholamines. Compared with an awake status, propofol anesthesia significantly decreased the BIS and SYMP in both groups of patients. Controls showed no change from baseline anesthetized levels during surgery. Plasma norepinephrine and epinephrine as well as SYMP increased 300 to 400% (P < .05) during naltrexone treatment in opioid-dependent patients, and the time to peak increase in plasma norepinephrine correlated with the increase in SYMP (r = 0.89, P < .01). These results confirm that opioid detoxification increases plasma catecholamines and SYMP in a similar manner. HR rate variability may provide a low-cost real-time noninvasive method of evaluating the reversal of opioid binding in opioid-dependent patients.

Bulky, barrel-shaped cervical carcinoma (stages IB, IIA, IIB): the prognostic factors for pelvic control and treatment outcome

The purpose of this study was to assess the prognostic factors for pelvic control and the treatment outcome in bulky, barrel-shaped cervical carcinomas. Between September 1980 and December 1992, 65 patients with stage IB or stage IIA-B carcinoma of the uterine cervix classified as barrel-shaped or concentrically expanded (i.e., at least 5 cm in greatest diameter) were treated with curative intent. Forty patients had stage IB or stage IIA carcinoma (according to the classification of the International Federation of Gynecology and Obstetrics [FIGO]), and 25 patients had FIGO stage IIB carcinoma. Seventy-two percent of the patients were treated with radiotherapy (RT) alone and 28% with radiotherapy followed by extrafascial hysterectomy (RT + S). The median follow-up time of surviving patients was 68 months (range 33-172). Survival and control rates were calculated by the Kaplan-Meier method. The 10-year actuarial pelvic control rate was 75% for all patients. The likelihood of pelvic control was not affected by FIGO stage, tumor size, patient's age, histologic features, or treatment modality (RT vs. RT + S). The extent of tumor regression following external beam radiotherapy correlated with the likelihood of local control (p = 0.02). For patients treated with RT alone, increased brachytherapy dose was associated with an increased likelihood of local control. The 10-year actuarial overall and cause-specific survival rates were 53% and 68%, respectively, and did not differ significantly between treatment groups. It is concluded that for most patients with bulky cervical carcinoma, RT alone provides good local control and survival. However, for patients with tumors that respond poorly to external beam radiotherapy, local control and survival are poor. More aggressive treatment protocols should be considered for these patients. The routine use of adjuvant hysterectomy is not recommended.

Topical antimicrobial therapy in the prevention of early childhood caries

PURPOSE

Early childhood caries (ECC) is microbiologically characterized by heavy infection of mutans streptococci (ms) on dental surfaces. Accordingly, it is reasonable to speculate that suppression of dental ms levels would decrease risk for ECC. On this basis, randomized double blind, placebo controlled pilot study was performed to test this concept.

METHODS

The study population consisted of 31 subjects (age: 12 to 19 mos; sex: 18F/13M) who were clients of a Women, Infants, and Children (WIC) clinic in Puerto Rico. Inclusion criteria included: (1) unremarkable medical history; (2) presence of 4 maxillary primary incisors (PMI) with no visible defects; (3) clinically caries free; (4) use of a nursing bottle at naptime and/or bedtime which contained a cariogenic substrate; (5) two consecutive ms positive cultures (utilizing Mitis-Salivarius-Bacitracin (MSB) agar) from pooled PMI plaque. The subjects were randomized into 2 groups. The 15 subjects in the experimental group and the 16 subjects in the control group were evaluated every 2 months during the study period. At each evaluation, the subjects had 10% povidone iodine (experimental group) or placebo (control group) applied to their dentition. The placebo was commercial instant tea (without lemon or sweetener) and deionized water. Treatment failure was defined as the appearance of a white spot lesion(s) on any of the PMI during the study period.

RESULTS

The mean duration of observation to treatment failure was 155 days; the mean duration of observation for treatment success was 217 days. Five of the 16 control subjects and 0 of the 15 experimental subjects experienced treatment failure (Fisher's exact test: P = 0.04). The Kaplan-Meier estimate for incidence of treatment failure in the placebo group was 48% over 357 days (P = 0.02).

CONCLUSION

These observations suggest that topical antimicrobial therapy reduces risk for the development of ECC in high-risk children.

Simultaneous increases in respiration and sympathetic function during opiate detoxification

This study evaluated the relationship between the sympathetic withdrawal response and increases in spontaneous ventilation during naltrexone treatment in opioid-dependent patients. Naltrexone was given in repeated increasing doses by orogastric tube to 16 opioid-dependent patients during propofol anesthesia. Sympathetic activity was evaluated in 64-second segments by low frequency heart rate variability (0.02-0.10 Hz) and minute ventilation was measured every 15 minutes. During naltrexone treatment, heart rate and blood pressure increased with no change in the electroencephalogram as measured by the bispectral index. Sympathetic activity increased five-fold and minute ventilation increased by 50% during naltrexone administration. There was a significant correlation between the time of the peak sympathetic response and peak ventilation (r = 0.83, p < 0.001). In three control patients, who received anesthesia for surgery without naltrexone treatment, no increases in sympathetic or respiratory parameters were seen. These results indicate that peak sympathetic and respiratory stimulation occur together during opiate receptor antagonism in opioid addicts.

A comparison of triamcinolone acetonide MDI with a built-in tube extender and beclomethasone dipropionate MDI in adult asthmatics

STUDY OBJECTIVE

In this study, the efficacy and safety of triamcinolone acetonide (TA) metered-dose inhaler with a built-in tube extender and beclomethasone dipropionate (BDP) metered-dose inhaler without a spacer device were compared. Both treatments were dosed at their most commonly used daily doses (within labeling).

DESIGN

A 56-day, randomized, double-blind, double-dummy, placebo-controlled trial.

SETTING

Seventeen asthma/allergy centers.

PATIENTS

We enrolled 339 patients 18 to 65 years of age, with a documented history of bronchial asthma (FEV1, 50 to 90% of predicted value) for > or = 2 years who required inhaled corticosteroid therapy.

INTERVENTIONS

Patients were randomized to receive BDP 336 microg/d (4 puffs bid) plus TA placebo (4 puffs bid), TA 800 microg/d (4 puffs bid) plus BDP placebo (4 puffs bid), or TA and BDP placebos (4 puffs of each bid). The only other asthma medication permitted was inhaled albuterol that was used as a rescue medication. All medications were administered via the closed-mouth inhalation technique.

MEASUREMENTS AND RESULTS

At 8 weeks and at study end point, both active treatment groups had statistically significant and comparable improvements in FEV1 relative to baseline, and statistically significant increases relative to placebo. At study end point, improvements in forced expiratory flow (FEF25.75%), clinic peak expiratory flow (PEFR), and FVC were statistically significant for the active treatment groups compared with placebo. At end point, the mean difference between BDP and TA for mean change in FEV1 from baseline in the efficacy population was 0.02 and the 95% confidence interval was -0.11, 0.15. Asthma symptoms recorded at clinic visits showed statistically significant improvements for the BDP and TA groups compared with the placebo group. Treatment-related adverse events occurred with similar frequency in all patient groups-25.5% of placebo-treated patients, 22.3% of BDP patients, and 20.4% of TA patients. The incidence of oropharyngeal adverse events, including cough, thrush, and dysphonia, was not statistically different between the two active treatment groups.

CONCLUSION

In this randomized, double-blind, placebo-controlled study of adult asthmatics treated with either BDP without a spacer or TA with its built-in tube extender, BDP and TA were comparable in efficacy as measured by FEV1 and other pulmonary function tests, and by improvement in asthma symptoms. Both active treatments were significantly more effective than placebo. All treatment groups were comparable in safety as measured by the incidence of adverse events.

Predicting risk of complications with gynecologic laparoscopic surgery

OBJECTIVE

To determine the incidence and predictors of risk for operative complications, conversions to laparotomy, and postoperative admissions after laparoscopic procedures.

METHODS

We obtained demographic information on and medical histories of a consecutive series of 843 women who underwent laparoscopic surgery for all procedures other than tubal ligation at Brigham and Women's Hospital during 1994. All major complications after surgery were recorded. Major operative complications were defined as bowel, bladder, ureter, or vascular injuries or significant abdominal wall or other internal bleeding. Categorical analysis was used to compare differences in the rates of operative complications, conversions to laparotomy, and postoperative admissions after laparoscopy. We also estimated the influence of medical history and specific laparoscopic procedures on the risk of adverse complications after surgery.

RESULTS

Operative complications and conversion to laparotomy occurred in 1.9% and 4.7% of laparoscopic procedures, respectively. Complications included four bowel, two bladder, one ureteral, two vascular, and five abdominal wall injuries. There were 165 patients (19.6%) admitted postoperatively. Aside from the type of operative procedure, increasing age was the most important predictor of complications. Relative to all other operative procedures, women treated for endometriosis or ovarian cystectomy had generally low rates of operative complications, conversions to laparotomy, and postoperative admissions. In contrast, 12.5% of women undergoing laparoscopically assisted vaginal hysterectomy experienced operative injuries or abdominal bleeding and 90% were hospitalized postoperatively.

CONCLUSION

Serious operative complications after gynecologic laparoscopy were rare in this patient population. The more complex laparoscopic procedures resulted in proportionately greater rates of operative complications, conversions to laparotomy, and postoperative admissions to the hospital.

Ultra-rapid opioid detoxification increases spontaneous ventilation

STUDY OBJECTIVE

To evaluate the effect of ultra-rapid opioid detoxification on spontaneous respiration.

DESIGN

Prospective study.

SETTING

University of Illinois, Chicago, Hospital.

PATIENTS

20 ASA physical status I and II patients undergoing ultra-rapid opioid detoxification, and 5 ASA physical status I and II control patients undergoing surgical procedures.

INTERVENTIONS

Ultra-rapid opioid detoxification patients were anesthetized with propofol, intubated, and spontaneously ventilating. Opioid detoxification was achieved by giving repeated increasing intragastric doses of naltrexone. Control patients were anesthetized with propofol and 70% nitrous oxide and were time-based controls for opioid detoxification.

MEASUREMENTS AND MAIN RESULTS

Respiratory rate and minute ventilation were measured and increased 80% to 100% during opioid detoxification (p < 0.05). Respiratory rate and minute ventilation did not change in controls. Oxygen consumption and carbon dioxide (CO2) production were measured in separate studies and increased during ultra-rapid opioid detoxification with increases in spontaneous ventilation, but not when the patients were paralyzed.

CONCLUSIONS

Spontaneous ventilation increases during opioid detoxification without a change in end-tidal CO2. An increase in metabolism is produced in opioid withdrawal that is mediated by elevated muscle activity.

Prenatal diagnosis of Glanzmann thrombasthenia using the polymorphic markers BRCA1 and THRA1 on chromosome 17

Glanzmann thrombasthenia is an autosomal recessive bleeding disorder caused by mutations in the genes encoding platelet GPIIb or GPIIIa. Both genes map to chromosome 17q21 and polymorphisms within this chromosomal region have been identified. In the current study, prenatal diagnosis was performed for a family that already had one affected child, patient 1, who had a compound heterozygous mutation in GPIIb. At the time of prenatal diagnosis, the maternal GPIIb mutation had been identified but the paternal GPIIb mutation was unknown. By sequence analysis, the fetus was identified as a carrier of the mother's mutation. To determine the probability of the fetus inheriting the father's mutation, haplotype analysis of DNA samples from the fetus, mother, father and affected child were performed using polymorphic markers on chromosome 17q12-q21. These markers included polymorphisms within the thyroid hormone receptor alpha1 gene (THRA1), the breast cancer gene (BRCA1), GPIIb, GPIIIa, and an anonymous marker D17S579. Heterozygosity within the THRA1, BRCA1 and GPIIIa polymorphic markers predicted that the fetus carried the father's normal allele. Based on genetic linkage studies, no recombination was identified with any of the informative markers, and from the map distance between GPIIb and BRCA1 the accuracy of diagnosis was predicted to be >98%. The father's mutation was subsequently identified and direct sequence analysis of fetal DNA confirmed that the fetus did not inherit the fathers' mutant allele.

A Phase I trial of ifosfamide and paclitaxel with granulocyte-colony stimulating factor in the treatment of patients with refractory solid tumors

BACKGROUND

Ifosfamide and paclitaxel are antineoplastic agents with broad activity and with different mechanisms of action. A Phase I trial was conducted to determine the maximum tolerated dose and associated toxicities of these agents when used in combination.

METHODS

Patients with refractory, incurable solid tumors were entered on a 5-step Phase I trial of ifosfamide, given in doses of 2-3 g/m2 intravenous (i.v.) bolus for 3 days with mesna support, and paclitaxel, given in doses of 135-190 g/m2 i.v. by continuous infusion over 24 hours. Paclitaxel was given after the first dose of ifosfamide on Day 1.

RESULTS

Twenty-three patients were treated, and the maximum tolerated dose was the highest planned dose level of the trial: ifosfamide, 3 g/m2/day i.v. for 3 days, and paclitaxel, 190 mg/m2 i.v. over 24 hours. Hematologic toxicity was not dose-limiting, and although neutropenia occurred, it was brief (median, 2-4 days) and resulted in hospitalization for neutropenia and fever in only 7 of 111 courses of therapy. For patients treated at the highest dose level, only 1 of 50 courses of therapy resulted in hospitalization for neutropenia and fever. Nonhematologic toxicity also was not severe and no significant neuropathy occurred. Although patients entered into the study were heavily pretreated, responses were observed, particularly in patients with breast or ovarian carcinoma.

CONCLUSIONS

Ifosfamide and paclitaxel can be administered safely in the doses used in this study and there are indications of significant antitumor effect. Further studies are necessary to explore the antineoplastic activity of this regimen, particularly for patients with breast and ovarian carcinoma.

Complete hydatidiform mole. Comparison of clinicopathologic features, current and past

OBJECTIVE

To investigate whether changes have occurred in the pathologic and clinical features of complete molar gestation in recent years.

STUDY DESIGN

Twenty-three contemporary complete hydatidiform moles (1994-1997) and 20 historical complete moles (1969-1975) were compared regarding clinical features (gestational age at evacuation, maternal age, preevacuation diagnosis and persistence) and pathologic findings (volume of tissue, presence of gross cisterns, maximal villous size, percent of cavitated villi, percent of villi exhibiting circumferential trophoblast hyperplasia, and presence of necrosis and primitive stromal features).

RESULTS

Contemporary complete moles were evacuated at an earlier mean gestational age (8.5 vs. 17.0 weeks, P = .00008). Histologically, contemporary complete moles had less circumferential trophoblastic hyperplasia (39% vs. 75% of villi, P = .03), a smaller mean maximal villous diameter (5.7 vs. 8.2 mm, P = .001), more primitive villous stroma (70% vs. 10% of cases, P = .0003) and less global necrosis (22% vs. 54% of cases, P = .02).

CONCLUSION

These striking morphologic differences indicate that pathologic findings in complete molar gestations have changed significantly over the past several decades due to the current practice of very early uterine evacuation. Contemporary complete moles are often characterized by subtle morphologic alterations that may result in their misclassification as partial moles or nonmolar spontaneous abortions. It is important for pathologists to recognize the distinctive histopathologic features of early complete hydatidiform mole.

Efficacy and safety of loratadine plus pseudoephedrine in patients with seasonal allergic rhinitis and mild asthma

BACKGROUND

Antihistamines have been shown to have a variety of therapeutic effects in asthma. Although nasal obstruction may play an important role in modulating lower airway function, no prior trial has used a decongestant in combination with an antihistamine in patients with allergic rhinitis and concomitant asthma.

OBJECTIVE

We sought to determine the efficacy and safety of loratadine (5 mg) plus pseudoephedrine (120 mg) (L/P) twice daily in patients with seasonal allergic rhinitis and mild asthma.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial of L/P in 193 subjects during the fall allergy season. Nasal and chest symptoms, albuterol use, and peak expiratory flow rates were recorded daily for 6 weeks. Spirometry was measured at baseline and after 1, 2, 4, and 6 weeks of therapy, and health-related quality of life was rated at the beginning and end of the study.

RESULTS

Total rhinitis and asthma symptom severity scores were significantly reduced in patients receiving active therapy compared with those receiving placebo throughout the 6-week study. Peak expiratory flow rates improved significantly in patients treated with L/P during weeks 2 through 6 (peak effect [mean +/- SEM]: L/P, 26.23 +/- 4.64 L/min vs placebo, 8.52 +/- 3.53 L/min, p = 0.002) as did FEV1 (peak effect [mean +/- SEM]: L/P, 170 +/- 53 ml vs placebo, 20 +/- 40 ml, p = 0.01) at all clinic visits. In addition, select measures of asthma-specific quality of life improved significantly relative to placebo.

CONCLUSIONS

L/P significantly improved nasal and asthma symptoms, pulmonary function, and quality of life in patients with seasonal allergic rhinitis and concomitant mild asthma.

Heavy metal: beware

A 19-year-old Crouzon's syndrome patient with a history of multiple craniofacial procedures presented with severe bilateral temporal and frontal depressions and metal implants protruding through the scalp in multiple locations. Preoperative analysis revealed an extensive cranial defect that had been reconstructed with multiple large metallic mesh implants. The mesh required complete removal with an autograft cranial reconstruction. We present this case to urge that caution and forethought be exercised when contemplating the use of metallic alloplasts for major craniofacial reconstructions.

d-fenfluramine treatment of binge eating disorder

OBJECTIVE

The purpose of this study was to assess the efficacy of the appetite suppressant d-fenfluramine in the treatment of binge eating disorder.

METHOD

The authors conducted an 8-week double-blind, placebo-controlled clinical trial of the drug with 28 severely obese female patients meeting full criteria for binge eating disorder. The primary outcome measure was number of binges per week, as recorded in binge diaries and reviewed weekly with the principal investigators.

RESULTS

Random effects linear regression analysis showed that the rate of binge eating in the d-fenfluramine group fell three times more rapidly than that in the placebo group, a result that was both clinically and statistically significant. At 4-month follow-up the binge frequency of the d-fenfluramine group had increased to pretreatment levels and no longer differed from that of the placebo group.

CONCLUSIONS

d-Fenfluramine reduced the frequency of binge eating by obese women with binge eating disorder.

Frequency of the BRCA1 185delAG mutation among Jewish women with ovarian cancer and matched population controls

Among women of Ashkenazi Jewish origin, a frameshift mutation of the BRCA1 gene, designated 185delAG, occurs with a carrier frequency of approximately 1% and is estimated to account for about 39% of ovarian cancer cases occurring prior to age 50 years. To determine the actual frequency of this mutation among Jewish women with ovarian cancer, we tested DNA collected as part of an ongoing population-based case-control study of genetic and environmental factors for epithelial ovarian cancer in eastern Massachusetts. Using single-stranded conformational polymorphism analysis followed by direct sequencing, we found that 6 (19.4%) of 31 Jewish patients were carriers for a 185delAG mutation compared to 0 of 23 Jewish controls (P=0.03) Using empiric logic [correction of logits], the estimated relative risk for ovarian cancer associated with a 185delAG mutation is 12.0. The average age of the 6 patients with mutations was 48.3 years, significantly younger than the average of 57.4 years observed for the 25 patients without the mutation (P-0.05). For ovarian cancer diagnosed prior to age 50 years, three (37.5%) of eight patients carried the mutation. None of the six patients with the mutation had a history consistent with hereditary breast ovarian cancer syndrome, although two had a personal history of prior cancer. Our results provide empiric conformation of the estimated prevalence of 185delAG mutations among Jewish women with ovarian cancer.