Stress biomarkers in individuals with fibromyalgia syndrome: a systematic review with meta-analysis

ABSTRACT

Evidence suggests an involvement of hypothalamic-pituitary-adrenal (HPA) axis dysregulation in the development and maintenance of fibromyalgia syndrome (FMS). However, studies on the stress response via the HPA-axis in individuals with FMS show conflicting results. To better understand the relationship between FMS and HPA-axis dysregulation, we (1) systematically summarized the current level of evidence on HPA biomarkers in individuals with FMS compared with individuals without and (2) evaluated whether FMS is associated with a specific pattern of HPA dysregulation. The main outcome measures were cortisol, adrenocorticotropic hormone (ACTH), corticotropin-releasing hormone (CRH), epinephrine, and norepinephrine. A systematic search of MEDLINE, EMBASE, and PsychMed yielded 47 studies eligible for meta-analysis, including 1465 individuals with FMS and 1192 FMS-free controls. No main effect of FMS was found on altered levels of blood cortisol, ACTH, CRH, and epinephrine. Compared with controls, salivary and urinary cortisol levels were decreased in individuals with FMS, whereas blood levels of norepinephrine were increased. However, heterogeneity of data was high with significant evidence for publication bias. Overall, the data are compatible with association of FMS with adrenocortical hypofunction in the presence of increased sympathetic tone. However, the data are partially contradictory, so it must be assumed that the data are highly dependent on the respective study designs, patient samples, and analytical methods and do not necessarily demonstrate an abnormal HPA-axis function in FMS.

[Psychosomatics in Pain Therapy - Challenges of Chronic Pain]

Although there is growing awareness among physicians regarding chronic pain, the patient with chronic pain is often considered a complex, if not "difficult" patient in practice. Patients with chronic pain are thus at increased risk of being hastily dismissed and sent on their way. At the same time, therapeutic options are often limited and therapeutic successes not satisfying.

Incisional hernia rate after ileostomy closure in lateral pararectal stoma versus transrectal stoma placement: follow-up of the randomized PATRASTOM trial

AIM

Because damage to the rectus abdominis muscle during ileostomy placement and reversal might be a risk factor for the development of stoma-site incisional hernia (SSIH), we hypothesized that positioning of the stoma lateral to the rectus abdominis muscle might prevent SSIH.

METHOD

To investigate whether a lateral pararectal stoma position lowers the incidence of SSIH in comparison with a transrectal position, a follow-up study of the PATRASTOM trial, which had randomized stoma placement (lateral pararectal versus transrectal), was conducted. All former participants were invited simultaneously for a follow-up visit in September 2016, 2 years after database closure of the PATRASTOM trial. For patients who were not able to attend the follow-up, the electronic chart as well as MRI/CT scans were reviewed with regard to the presence of SSIH.

RESULTS

Follow-up - either clinical or radiological - was available for 47 of the 60 PATRASTOM participants. The median duration of follow-up was 3.4 years (interquartile range 3.0-4.1 years). SSIH occurred in 3 of 23 patients (13.0%) in the lateral pararectal group compared with 7 of 24 patients (29.2%) in the transrectal group (P = 0.287). Four of the 10 patients diagnosed with SSIH had already undergone or were scheduled for hernia repair. Of the patient and procedure characteristics which may have an impact on the development of incisional hernia none was a significant risk factor for SSIH.

CONCLUSION

In the present follow-up study, no difference in the incidence of SSIH was found between lateral pararectal and transrectal stoma construction in an elective setting.

The importance of placebo effects in enhancing palliative care interventions

In this narrative review, we examine evidence that may help to explain how placebo effects contribute to the effectiveness of palliative care interventions for the relief of symptoms such as pain, breathlessness and depression, and how they may underlie the impact of complementary therapies. We discuss the different ways of conceptualising placebo phenomena, including the importance of the therapeutic relationship, the context of care and the significance of meaning. There is increasing evidence from neuroscience that the term 'placebo effect' describes a number of phenomena that may explain the effectiveness of therapeutic interventions that affect the perception of symptoms. A greater appreciation of placebo effects emphasises the importance of addressing social, psychological, and spiritual factors with equal rigour. Commissioning bodies, rightly concerned about the evidence base for clinical interventions, need to recognise the multifaceted nature of symptom control measures and to realise that the focus for palliative care research needs to be on the specialty as a complex integrated intervention rather than on a series of individually evaluated measures.

[Psychosocial distress and communication about cancer in ill partners and their spouses]

INTRODUCTION

Each cancer can have a psychological impact not only on the patient himself/herself, but also on his/her spouse.

OBJECTIVE

Our study concerned 30 couples encompassing a member treated for a cancer, non related to gender. It was aimed at determining the links between the levels of psychosocial distress measured in both members of each couple, patients' sociodemographic and clinical characteristics, as well as communication skills about cancer in both members of the couples.

METHODS

Psychosocial distress and communication about cancer were measured by the general health questionnaire (GHQ-28) and the openness to discuss cancer in the nuclear family (ODCF), with an additional version adapted for the spouse on the occasion of this study.

RESULTS

A positive correlation was found between the respective scores of the two members of the couples, for the GHQ-28 (r=0.53; p=0.005) as well as for the ODCF (r=0.44; p=0.024). GHQ-28 scores were not associated with the sociodemographic characteristics of the patients, nor with the stage of cancer, the number of months elapsed since the diagnosis of cancer, or the ODCF personal or spouse's score. On the other hand, when the communication within each couple was classified into concordant (insufficient or, on the contrary, open for both members) or discordant (insufficient for one of the two members and open for the other), and after controlling for gender, higher levels of psychosocial distress were found in patients (p=0.038) as well in spouses (p=0.052) belonging to discordant compared with concordant couples.

CONCLUSION

These results suggest an effect of contamination or a mutual reinforcement of the distress of each member of such couples, as well as the presence of relatively similar styles of communication in the two partners of each couple. They also underline the possible adaptive function of a restricted style of communication about cancer, if such a restriction is shared by both the members of the couple, and incites particular attention to be paid to couples where one of the partners, but not the other, adopt an open style of communication about cancer.

Establishing content validity of the oral assessment guide in children and young people

There is a need for accurate and consistent oral assessment to measure mucosal changes and oral complications associated with cancer therapies. Mucositis is an important and common side effect of cancer therapies that merits the identification of improved health-care interventions. Developing appropriate and reliable oral assessment instruments for use with children is relevant to the evaluation of these interventions. The purpose of this study was to determine the content validity of the oral assessment guide (OAG) in children: an instrument that was designed to objectively assess the physiological changes of the oral cavity following administration of chemotherapy and radiotherapy to adults. This process is considered to be most effective when undertaken systematically. A judgement quantification process was used with health care professionals in paediatric oncology to establish content validity of items (n=9) and instrument (n=10). A revised OAG more pertinent to children and young people was produced in the light of this process.

Broadband Dielectric and Resistivity Spectroscopy of WO3·H2O in the Range of 103−1010 Hz: Particle Size Effect

The interest in studying the electrical properties of WO(3) x H(2)O powders is made absolutely necessary because their infrared modulation properties depend on their morphologies and electronic populations. Broadband dielectric and resistivity spectra of WO(3) x H(2)O powders were recorded in a frequency range of 10(3)-10(10) Hz at temperatures varying between 200 and 300 K. Complex resistivity and permittivity diagrams have permitted thermal behavior of both dc-conductivity and permittivity to be obtained. A dielectric relaxation is found, attributed to water molecules motions. The role of the powder morphology has been investigated on two types of compounds: the first one being constituted by nanometric particles and the second by micrometric particles. Strong differences are observed in the thermal behaviors of the dc-conductivities (activation energies). Particle size effect is evidenced, giving rise to stronger electron localization on the nanometric particles. The permittivity values and the dynamical behavior of the structural water are also influenced by the particle size effect. A strong interaction between moving polarons and water molecules has been determined.

Mercuric resistance genes in gram-positive oral bacteria

Mercury-resistant bacteria isolated from the oral cavities of children carried one of two types of merA gene that appear to have evolved from a common ancestor. Streptococcus oralis, Streptococcus mitis and a few other species had merA genes that were very similar to merA of Bacillus cereus strain RC607. Unlike the B. cereus RC607 merA gene, however, the streptococcal merA genes were not carried on Tn5084-like transposons. Instead, comparisons with microbial genomic sequences suggest the merA gene is located on a novel type II transposon. Coagulase-negative staphylococci and Streptococcus parasanguis had identical merA genes that represent a new merA variant.

Characterisation of viridans group streptococci with different levels of Tet(M)-mediated tetracycline resistance

Streptococcus oralis 264-3, Streptococcus mitis 254-1 and S. mitis 264-1, isolated from the oral cavities of two children were each found to carry the tet(M) gene but exhibited different degrees of reduced susceptibility to tetracycline (tetracycline MICs of 2, 8 and 64 mg/L, respectively). The aim of this study was to determine the molecular basis for the different levels of tetracycline resistance (Tc(R)) observed. Escherichia coli HB101 carrying the cloned tet(M) genes exhibited similar levels of tetracycline susceptibility to those observed in the parental streptococcal strains (MICs of 1, 16, and 64 mg/L for tet(M) genes from S. oralis 264-3, S. mitis 254-1 and S. mitis 264-1, respectively). DNA sequencing revealed that S. oralis 264-3 had a tet(M) gene highly homologous to tet(M) carried by Tn916 from Enterococcus faecalis (99.6% identity), while the intermediate- and high-level Tc(R) strains had tet(M) sequences that resembled the tet(M) gene of Tn5251 from Streptococcus pneumoniae (99.3% and 99.4% identity, respectively). No differences were observed in the upstream attenuator structure for each of the strains and differences in reduced tetracycline susceptibilities could be attributed to changes in the deduced amino acid sequences of the Tet(M) proteins.

Effect of restoration of children's teeth with mercury amalgam on the prevalence of mercury- and antibiotic-resistant oral bacteria

The purpose of this study was to determine whether placement of mercury amalgam restorations in children's teeth induces an increase in oral bacteria resistant to mercury, penicillin, ampicillin, erythromycin, or tetracycline. Dental plaque and saliva samples from 16 children without mercury amalgam restorations were screened for bacteria resistant to mercury or to one of the antibiotics prior to, and 1 month after, placement of the amalgam restoration. Following amalgam placement, there was no significant increase in the number of children harboring bacteria resistant to mercury, penicillin, ampicillin, erythromycin, or tetracycline; neither was there an increase in the proportions of such organisms. This study has shown that the presence of mercury restorations in children's teeth has little effect on the prevalence of mercury- or antibiotic-resistant oral bacteria.

Effect of medium composition on the susceptibility of oral streptococci to mercuric chloride

Although there is considerable interest in identifying mercury-resistant bacteria, no standardized assay exists for this purpose. In this study, the effect of the composition of the medium on the susceptibility of oral streptococci to HgCl(2) was investigated. The minimum inhibitory concentration (MIC) of HgCl(2) for 52 streptococcal strains and the reproducibility of MIC values for Hg-sensitive and Hg-resistant strains was determined with 11 different media. Addition of blood increased the MIC values, and some media (tryptone soya agar, with or without blood) could not discriminate between Hg-sensitive and Hg-resistant strains. The proportion of streptococci that appeared to be resistant to Hg was very high (>70%) on some media (mitis-salivarius, tryptone soya, Columbia), but not on others (Mueller-Hinton, Brain Heart Infusion, Isosensitest). The MICs of the control strains varied considerably on different testing occasions for tryptone soya agar (with and without blood), Isosensitest agar, and Columbia agar (with blood). Mueller-Hinton (without blood) appeared to be the most suitable medium for isolating Hg-resistant oral streptococci.

Prevalence and antibiotic resistance profile of mercury-resistant oral bacteria from children with and without mercury amalgam fillings

Genes encoding resistance to mercury and to antibiotics are often carried on the same mobile genetic element and so it is possible that mercury-containing dental materials may select for bacteria resistant to mercury and to antibiotics. The main aim of this study was to determine whether the prevalence of Hg-resistant oral bacteria was greater in children with mercury amalgam fillings than in those without. A secondary aim was to determine whether the Hg-resistant isolates were also antibiotic resistant. Bacteria in dental plaque and saliva from 41 children with amalgam fillings and 42 children without such fillings were screened for mercury resistance by cultivation on a HgCl(2)-containing medium. Surviving organisms were identified and their susceptibility to mercury and to several antibiotics was determined. Seventy-eight per cent and 74% of children in the amalgam group and amalgam-free group, respectively, harboured Hg-resistant bacteria; this difference was not statistically significant. Nor was there any significant difference between the groups in terms of the proportions of Hg-resistant bacteria in the oral microflora of the children. Of Hg-resistant bacteria, 88% and 92% from the amalgam group and the amalgam-free group, respectively, were streptococci; 41% and 33% were resistant to at least one antibiotic, most frequently tetracycline. The results of this study show that there was no significant difference between children with amalgam fillings and those without such fillings with regard to the prevalence, or the proportion, of Hg-resistant bacteria in their oral microflora. The study also found that Hg-resistant bacteria were common in children regardless of whether or not they had amalgam fillings and that many of these organisms were also resistant to antibiotics.

A cephalometric analysis of patients with recessive dystrophic epidermolysis bullosa

Patients diagnosed with Recessive Dystrophic Epidermolysis Bullosa (RDEB) suffer from severe growth inhibition due to reduced food intake as a result of severe oropharyngeal and esophageal blistering. This investigation examined the patterns of facial growth in a group of 42 children with RDEB for whom lateral skull radiographs were available. The differences between RDEB patients and patients with normal cephalometric values were also assessed. Lateral skull radiographs were digitized and a number of orthodontic indices were compared to the published normal values. The RDEB patients examined demonstrated smaller maxillae than normal (length 41.3 +/- 2.9 mm compared to 47.4 +/- 2.5 mm) and smaller mandibles than normal (length 82.3 +/- 6.1 mm compared to 93.1 +/- 4.2 mm). This impaired growth may result from reduced food intake or severe orofacial scarring associated with RDEB. This contributes significantly to dento-alveolar disproportion and dental crowding and puts patients at increased risk of dental caries.

Multicenter phase II-III study of oxaliplatin plus cyclophosphamide vs. cisplatin plus cyclophosphamide in chemonaive advanced ovarian cancer patients

PURPOSE

A phase II-III randomised study to compare safety and efficacy of an oxaliplatin/cyclophosphamide (OXAC) combination, vs. the reference combination of cisplatin/cyclophosphamide (CPC), in untreated advanced ovarian cancer patients.

PATIENTS AND METHODS

182 patients were enrolled, of whom 177 were treated: 86 with OXAC (130 mg/m2 oxaliplatin two-hour intravenous (i.v.) infusion, 1,000 mg/m2 cyclophosphamide two-hour i.v. infusion), and 91 with CPC (100 mg/m2 cisplatin one-hour i.v. infusion. 1,000 mg/m2 cyclophosphamide two-hour i.v. infusion). Treatment cycles were repeated every three weeks (maximum of six cycles).

RESULTS

The main toxicities, which were significantly less severe in the OXAC arm, were myelosuppression and vomiting, including (OXAC vs CPC, % patients): grade 3-4 leukopenia (37% vs. 56%), and anaemia (7% vs. 32%), with blood transfusions in 8% vs. 21%. In the OXAC arm, 64% of surgically assessable patients and 33% of clinically assessable patients achieved an objective response. In the CPC arm, 67% patients achieved a surgical response and 42% achieved an objective clinical response. In the OXAC and CPC arms, median progression free-survival was 13.0 and 13.3 months, and overall survival was 36.0 and 25.1 months respectively, without statistically significant difference.

CONCLUSION

The activity and time-related parameters of the OXAC and CPC combinations in advanced ovarian cancer patients, are comparable. Combined with the better safety profile of the oxaliplatin-containing regimen, this confirms the interest of oxaliplatin combined with active new agents in this indication.

LL-Z1271alpha: an interleukin-1beta production inhibitor

LL-Z1271alpha, a fungal metabolite, dose-dependently inhibited interleukin-1beta (IL-1beta) production in lipopolysaccharide (LPS)-stimulated human whole blood. Oral administration of LL-Z1271alpha to LPS-challenged mice caused significant lowering in the IL-1beta levels in peritoneal cavity. Data presented suggest that LL-Z1271alpha inhibits IL-1beta production by a novel mechanism as the inhibitory activity was not due to effects on caspase-1 (IL-1beta converting enzyme), the ATP-induced release mechanism or a lysosomotrophic effect.

Multiple myeloma in elderly patients: presenting features and outcome

Few studies have been performed regarding multiple myeloma (MM) in elderly patients. We report a retrospective series of 130 unselected patients with MM aged 75 yr or more at diagnosis. Presenting features were identical to those reported in younger patients, except for a higher rate of infection. Heavy comorbidity was characteristic of unselected geriatric patients. Ninety-four patients received conventional chemotherapy. The response rate was 62%. Treatment toxicity was mild. Median survival was 22 months. Durie-Salmon (DS) clinical stages II and III MM were severe and often led to death, while significantly more patients with DS stage I MM died from unrelated causes (p<0.0001). Univariate analysis showed that age > or = 85 yr, performance status > or = 2, creatinine level > or = 120 micromol/l, beta 2 microglobulin level > 4 mg/l, C-reactive protein level > 6 mg/l, platelet count < 100 x 10(9)/l, presence of infection and lack of response to chemotherapy were adverse prognostic factors for survival. In Cox multivariate regression analysis, age > or = 85 yr (p<0.0001), performance status > or = 2 (p<0.0001) and creatinine level > or = 120 micromol/l (p<0.0001) were independent factors in predicting short survival. This study provides evidence that in patients with symptomatic MM age should not be considered as a major obstacle to active treatment. Prospective clinical trials are needed in this population of patients and should include an assessment of quality of life.

A comparison of fetal echocardiography in university and health maintenance organization settings

Fetal echocardiographic findings, and decisions to continue or to terminate affected pregnancies, may differ between university (UNIV) and health maintenance organization (HMO) settings. The aim of this study was to review the fetal echocardiographic experience at a combined university/health maintenance organization program over a 4-year period. Imaging and counseling for affected pregnancies were provided by the same, single investigator at both sites. Out of a total of 1382 studies (940 UNIV, 442 HMO), 127 abnormals were identified (94 UNIV, 33 HMO). Among the 127 pregnancies with fetal heart disease, 24 (19%) underwent elective termination, 16% at UNIV and 27% at HMO (p = 0.2). Mean gestational age at the time of diagnosis was 25.2 weeks at UNIV compared with 22.3 weeks at HMO (p = 0.002). At UNIV, only 51% of diagnoses were made before 24 weeks compared with 79% at HMO (p = 0.003). Screening fetal sonograms, performed between 18 and 20 weeks on every pregnancy at HMO but not at UNIV, enabled earlier detection of congenital heart disease (CHD) and allowed more women with severely affected pregnancies the option to terminate. In both settings, indications with the highest yields for CHD included a right-sided stomach, abnormal four-chamber view, sustained bradycardia, abnormal fetal karyotype, fetal omphalocele, and maternal indomethacin. An echogenic reflector was identified in 86 pregnancies (7%) and did not represent a risk factor for CHD. No major differences in CHD were found between UNIV and HMO. In summary, this study found a significantly earlier diagnosis of CHD at HMO than at UNIV. This discrepancy between programs may explain, at least in part, the trend toward a higher frequency of decisions to terminate affected pregnancies at HMO than at UNIV, despite similar fetal findings.

Odontogenic bacteremia following tooth cleaning procedures in children

PURPOSE

This study was designed to investigate the prevalence and intensity of odontogenic bacteremia from tooth cleaning procedures in children and adolescents.

METHODS

One hundred and fifty five children receiving dental treatment under general anesthesia at The Great Ormond Street Hospital for Children and Guy's Hospital were recruited. Each child was randomly allocated to one of three tooth cleaning groups. These were (1) toothbrushing, (2) professional cleaning with a rubber cup and (3) scaling.

RESULTS

There was no significant difference in the prevalence of positive blood cultures or intensity of bacteremia between the three groups. The bacterial species isolated were similar to those reported by other workers. These were S. mitis, S. sanguis and Coagulase--negative staphylococci, all of which are implicated in the pathogenesis of Bacterial Endocarditis.

CONCLUSIONS

Patients at risk are as likely to develop odontogenic bacteremia from toothbrushing at home as from professional scaling and polishing of the teeth at dental surgery.

Multicenter phase II study of bimonthly high-dose leucovorin, fluorouracil infusion, and oxaliplatin for metastatic colorectal cancer resistant to the same leucovorin and fluorouracil regimen

PURPOSE

To evaluate the objective tumor response rates and toxicities of leucovorin (LV) plus fluorouracil (5-FU) cancer regimen combined with oxaliplatin (85 mg/m(2)) every 2 weeks on metastatic colorectal cancer patients with documented proof of progression while on bimonthly LV and 5-FU alone.

PATIENTS AND METHODS

One hundred patients were enrolled onto this study and 97 received the study drugs between October 1995 and December 1996. Eighty-nine patients were eligible for per-protocol efficacy analysis with documented proof of progression on one of the following two treatments: LV 500 mg/m(2) and continuous 5-FU infusion 1.5 to 2 g/m(2)/22 hours, days 1 through 2 every 2 weeks (FOLFUHD); or LV 200 mg/m(2), bolus 5-FU 400 mg/m(2), and continuous 5-FU infusion 600 mg/m(2)/22 hours, days 1 through 2 every 2 weeks (LV5FU2). In our study, 40 patients received FOLFUHD + 85 mg/m(2) of oxaliplatin day 1 (FOLFOX3) and 57 patients received LV5FU2 + 85 mg/m(2) of oxaliplatin day 1 (FOLFOX4).

RESULTS

Of the 97 patients treated, 20 partial responses were observed (FOLFOX3/4: response rate, 20.6%; 95% confidence interval, 13% to 31.1%; FOLFOX3: response rate,18.4%; FOLFOX4: response rate, 23.5%). For patients treated with FOLFOX3/4, the median response duration for was 7.5 months, and the major toxicities were peripheral neuropathy and neutropenia. The incidence of grade 3 (National Cancer Institute common toxicity criteria) peripheral neuropathy was 20.6%; whereas the overall incidence of grade 3 to 4 neutropenia was 27.8%, 15%, and 36.9% for FOLFOX3/4, FOLFOX3, and FOLFOX4, respectively (P =.02). From the start of treatment, median progression-free survival was 4. 7, 4.6, and 5.1 months for FOLFOX3/4, FOLFOX3, FOLFOX4, respectively, and median overall survival was 10.8, 10.6, and 11.1 months, respectively.

CONCLUSION

This phase II study of oxaliplatin at 85 mg/m(2) in combination with bimonthly LV plus 5-FU in patients with colorectal cancer resistant to LV plus 5-FU alone confirms the enhanced antitumor activity of oxaliplatin in combination with 5-FU.

The pattern of change in salivary immunoglobulins and antibodies to S. mitis and S. oralis in children undergoing bone marrow transplantation: use of an indirect method of assessment

The objective of this study was to assess the pattern of change in salivary immunoglobulins and antibodies to S. mitis and S. oralis in 23 children following allogeneic bone marrow transplantation and their matched controls. To overcome the difficulty of obtaining a sufficient quantity of whole saliva from very young, sick children saliva was collected in a 5-ml oral rinse of sterile normal saline. It was not possible to measure the volume of whole saliva in each rinse and the concentration of the salivary immunoglobulins and bacterial antibodies were estimated from 1 ml of oral rinse. Despite these shortcomings a pattern of change in the mean concentrations of total salivary IgA, secretory IgA, antibodies to S. mitis and S. oralis and total IgG at specific event- related times during the transplantation period has been demonstrated. There was a significant increase in the concentration of salivary IgG 7 days post-transplantation, followed by significant decreases in total salivary IgA, secretory IgA and antibodies to S. mitis after recovery of the peripheral neutrophil count above 0.5 x 10(9). The concentrations of total IgA and antibodies to S. oralis was significantly greater in the transplant group 119 days post-transplantation.

Outpatient treatment with subcutaneous interleukin-2 and interferon alfa administration in combination with fluorouracil in patients with metastatic renal cell carcinoma: results of a sequential nonrandomized phase II study. Subcutaneous Administration Propeukin Program Cooperative Group

PURPOSE

We report the results of the Subcutaneous Administration Propeukin Program (SCAPP) II trial of an outpatient treatment in renal cell carcinoma using interleukin-2 (IL-2) and interferon alfa-2a (IFN-alpha) administered subcutaneously in combination with fluorouracil (5-FU). The objective of this multicenter trial was to confirm that the combination of IL-2, IFN-alpha, and 5-FU leads to a response rate greater than 20%.

PATIENTS AND METHODS

Patients with metastatic renal cell carcinoma were included in this study. During the induction phase of the treatment, which lasted 10 weeks, IL-2 and IFN-alpha were administered subcutaneously three times a week for 8 weeks at doses of 18 MIU and 9 MIU, respectively. During these 8 weeks, every Monday, 5-FU was administered at a dose of 750 mg by intravenous infusion over 30 minutes. After evaluation, responding patients or patients with stable disease (SD) were given maintenance treatment, until disease progression (PD) or the appearance of unacceptable toxicity. Each maintenance cycle consisted of a 2-week treatment followed by a three-week rest period. During treatment, IL-2 and IFN-alpha were administered subcutaneously three times a week at doses of 18 MIU and 9 MIU, respectively. Every Monday, 5-FU was administered at a dose of 750 mg by intravenous infusion over 30 minutes.

RESULTS

This trial was closed when the sixth sequential analysis showed the lack of benefit from this combination. At the end of the induction period, of 62 patients, 12 (19%; 95% confidence interval [CI], 10% to 31%) reached an objective response, including one complete response (CR), 16 presented with SD, and 27 showed PD. Twenty-seven patients (43%) developed severe toxicity that required reduction of the planned doses (13 patients), delayed treatment (eight patients), or treatment termination (six patients). Seventeen patients were given maintenance treatment. One- and 2-year survival rates were estimated at 55% and 33%, respectively. The 2-year survival rate was 15% in 11 patients who presented with three poor-prognosis factors and 41% in 51 patients who initially presented with no, one, or two poor-prognosis factors (P = .04).

CONCLUSION

As in other recently published studies that used 5-FU, IL-2, and IFN-alpha, the multicenter SCAPP II trial in patients with metastatic renal cell carcinoma generated severe toxicity. This sequential trial failed to confirm the favorable results previously obtained by Atzpodien and Sella with this combination of three drugs. Its efficacy, assessed on the response and survival rates, is near to the results observed in programs that used IL-2 alone given subcutaneously.

Intrapericardial teratoma in a twin fetus: diagnosis and management

BACKGROUND

A rare cause of hydrops fetalis, intrapericardial teratoma is invariably associated with a pericardial effusion. In fetal life, the effusion or mass effect may cause cardiac tamponade, hydrops, and death. After delivery, ventilation and cardiac output may be compromised.

CASE

One fetus of twins was diagnosed at 20 weeks' gestation with an intrapericardial teratoma. The affected twin underwent two intrauterine pericardiocentesis and had the tumor resected after delivery at 35 weeks' gestation. One year later, both twins are alive and well and have no evidence of tumor recurrence.

CONCLUSION

Pericardiocentesis for tamponade secondary to a fetal intrapericardial teratoma, even when complicating a twin pregnancy, may prevent fetal death and allow delay of delivery until adequate fetal lung maturity has been achieved.

[Subcutaneous administration of interleukin-2 in ambulatory treatment of patients with metastatic renal cancer. Three-year results of the SCAPP I program]

We report a french experience of subcutaneous administration of interleukin-2 in treatment of patients with metastatic renal cell carcinoma. Thirty-nine patients with metastatic renal cell carcinoma were included in the study. During the 10-week induction period, interleukin-2 was administrated subcutaneously 5 days a week for 8 weeks. The weekly dosage were 90 MIU during weeks 1 and 6; 63 MIU during weeks 2 to 4 and 7 to 9. After evaluation, responders and patients with stable disease received maintenance treatment which was discontinued upon the appearance of disease progression or unacceptable toxicity. During the maintenance period, interleukin-2 was administered 5 days a week for 4 weeks followed by a 2-week rest period. The weekly dosages were 90 MIU in week 1 and 63 MIU in weeks 2 to 4. After completion of induction treatment, 7 of 39 evaluable patients (18%) had objective responses with 1 complete response. A diminution of dose or interruption of treatment occurred with 7 patients because severe toxicity. Other systemic side effects in the remaining patients were acceptable. Seventeen patients received maintenance treatment. The median follow-up of all the patients included was 21 months. The 1, 2 and 3 years survivals were 64%, 33% and 22% respectively. This multicentric trial confirms the efficacity of subcutaneously-administered interleukin-2 in patients with metastatic renal cell carcinoma in terms of both response rate and survival. Unfortunately, increasing total doses of administrated interleukin-2 does not seem to increase efficacity according to response rate, but is more toxic.

Glutathione-dependent activities of Trypanosoma cruzi p52 makes it a new member of the thiol:disulphide oxidoreductase family

Trypanothione: glutathione disulphide thioltransferase of Try-panosoma cruzi (p52) is a key enzyme in the regulation of the intracellular thiol-disulphide redox balance by reducing glutathione disulphide. Here we show that p52, like other disulphide oxidoreductases possessing the CXXC active site motif, catalyses the reduction of low-molecular-mass disulphides (hydroxyethyl-disulphide) as well as protein disulphides (insulin). However, p52 seems to be a poor oxidase under physiological conditions as evidenced by its very low rate for oxidative renaturation of reduced ribonuclease A Like thioltransferase and protein disulphide isomerase, p52 was found to possess a glutathione-dependent dehydroascorbate reductase activity. The kinetic parameters were in the same range as those determined for mammalian dehydroascorbate reductases. A catalytic mechanism taking into account both trypanothione- and glutathione-dependent reduction reactions was proposed. This newly characterized enzyme is specific for the parasite and provides a new target for specific chemotherapy.

Subcutaneous recombinant interleukin-2 (rIL-2) in out-patients with metastatic renal cell carcinoma. Results of a multicenter SCAPP1 trial

BACKGROUND

This multicenter phase II trial was conducted in order to evaluate the efficacy and toxicity of the subcutaneous route of administration of rIL-2 in the treatment of patients with metastatic renal cell carcinoma and to check whether an increased cumulative dose of rIL-2 increases efficacy.

PATIENTS AND METHODS

Thirty-nine patients with metastatic renal cell carcinoma were included in this study. During the induction period, rIL-2 was administered subcutaneously 5 days a week for 8 weeks. The weekly dosages were 90 MIU during weeks 1 and 6;63 MIU during weeks 2 to 4 and 7 to 9. After evaluation, responders and patients with stable disease received maintenance treatment which was discontinued upon the appearance of disease progression or unacceptable toxicity. During the maintenance period, rIL-2 was administered 5 days a week for 4 weeks followed by a 2-week rest period. The weekly dosages were 90 MIU in week 1 and 63 MIU in weeks 2 to 4.

RESULTS

After completion of induction treatment, 7 of 39 evaluable patients (18%) had objective responses (95% CI: 9% to 37%) with one complete response. Treatment was interrupted or reduced due to toxicity for seven patients: Neuropsychiatric symptoms (3 patients), joint pain (1 patient), major asthenia and anorexia (1 patient), stroke (1 patient), and septicemia (1 patient). Other systemic side effects in the remaining patients were acceptable. Seventeen patients received maintenance treatment. In none of the patients did the response status improve during this maintenance period. The median follow-up of all of the patients included was 19 months. The one- and two-year survivals were 65% and 33%, respectively, ad the median duration of response was 11 months (5 to 16+).

CONCLUSIONS

This multicentric study confirms the efficacy of subcutaneously-administered rIL-2 in patients with metastatic renal cell carcinoma in terms of both response rate and survival. The role of a maintenance therapy needs further evaluation.

Hep G2 cells: a model for studies on regulation of human cholesterol 7alpha-hydroxylase at the molecular level

The present study examines the feedback control governing human cholesterol 7alpha-hydroxylase mRNA expression in the human hepatoblastoma cell line, Hep G2. Glycochenodeoxycholate (GCDC) and glycodeoxycholate, hydrophobic bile salts, decreased cholesterol 7alpha-hydroxylase mRNA levels and bile acid synthesis in a concentration-dependent (76 +/- 8%, P<0.001, and 48 +/- 3%, P<0.01, respectively) and time-dependent manner. Cholesterol 7alpha-hydroxylase mRNA levels were repressed with a half-maximal inhibitory concentration of <12.5 microM by GCDC and a half-life of 30 min by 100 microM of the bile acid. The addition of actinomycin D (10 microgram/ml) alone or in combination with GCDC (100 microM) led to similar concentration-and time-dependent suppression of cholesterol 7alpha-hydroxylase mRNA. Glycocholate (100 microM), not internalized based on lack of uptake of a fluorescent cholate analogue, had no effect on cholesterol 7alpha-hydroxylase mRNA or total bile acid synthesis. In cultures transfected with a rat cholesterol 7alpha-hydroxylase promoter construct, reporter gene activity was decreased (31%, P<0.01) by GCDC (100 microM). Hep G2 cells maintain the intracellular machinery to express and rapidly regulate human cholesterol 7alpha-hydroxylase by hydrophobic bile acids. These data suggest that Hep G2 cells will support functional studies of the human cholesterol 7alpha-hydroxylase gene.

Purification and characterization of a trypanothione-glutathione thioltransferase from Trypanosoma cruzi

Although trypanothione [T(S)2] is the major thiol component in trypanosomatidae, significant amounts of glutathione are present in Trypanosoma cruzi. This could be explained by the existence of enzymes using glutathione or both glutathione and T(S)2 as cofactors. To assess these hypotheses, a cytosolic fraction of T. cruzi epimastigotes was subjected to affinity chromatography columns using as ligands either S-hexylglutathione or a non-reducible analogue of trypanothione disulphide. A similar protein of 52 kDa was eluted in both cases. Its partial amino acid sequence indicated that it was identical with the protein encoded by the TcAc2 cDNA previously described [Schoneck, Plumas-Marty, Taibi et al. (1994) Biol. Cell 80, 1-10]. This protein showed no significant glutathione transferase activity but surprisingly catalysed the thiol-disulphide exchange between dihydrotrypanothione and glutathione disulphide. The kinetic parameters were in the same range as those determined for trypanothione reductase toward its natural substrate. This trypanothione-glutathione thioltransferase provides a new target for a specific chemotherapy against Chagas' disease and may constitute a link between the glutathione-based metabolism of the host and the trypanothione-based metabolism of the parasite.

[Periodontal treatment needs in a Spanish school population. 2. Intraoral distribution of different signs]

The aim of this study was to assess the prevalence of the different periodontal disease indicators used in the C.P.I.T.N. per sextant in the Spaniard population under 20 years of age. We have examined a randomly chosen sample of 1450 school-aged individuals, 7, 12 and 15 to 19 years old. We have observed a healthy periodontium more frequently in the upper anterior region, calculus predominates in the lower incisors close followed by molars, and periodontal pockets of 4 mm or deeper were commonly found in the molar regions. We could'nt detect important deviations from this distribution pattern in the different age groups or between males and females.

[Relationship of dental treatment and oral hygiene to caries prevalence and need for periodontal treatment]

The aim of this study was to examine the relationship between differences in dental attendance and oral hygiene patterns and dental caries and periodontal treatment needs. 1469 young people, aged 7, 12 and 15-19 years, and representing the urban (60%) and rural (40%) population from Spain were evaluated. Dental caries and periodontal treatment needs were registered according to the index D.M.F.T. and C.P.I.T.N., following the criteria of W.H.O. Regular dental attendance was observed in 16.6% of subjects examined, and only 9.4 saw a dentist regularly for dental prophylaxis. Statistical analyses showed that while the more frequent the dental visits, the lower the rate of caries, and periodontal treatment needs, the higher, however, the average number of fillings and the D.M.F.T. scores. These individuals had the higher number of functioning teeth, restored or sound, but they also had the disadvantage of having higher levels of disease experience. By the other way the individuals who saw the dentist regularly for dental prophylaxis presented the lower caries rate and periodontal treatment needs, the fewer tooth loss, and also an important reduction in the D.M.F.T. scores. Similar observations had been made in the individuals who brush their teeth frequently or with a correct technique. The results suggested that while frequent dental visits do not apparently help to prevent the onset of further dental disease, we can achieve this goal with regular preventive oriented dental therapy.

[Periodontal treatment needs in a Spanish school population]

The aim of this study was to assess the periodontal treatment needs of the population under 20 years of age in Spain. 1469 young people, aged 7, 12 and 15-19 years, and representing the urban (60%) and rural (40%) population from Spain were evaluated using the Community Periodontal Index of Treatment Needs (C.P.I.T.N.). In the first age group (7 years), 12% presented calculus or overhanging restorations, and 45% had bleeding upon probing only. In the age group of 12 years the proportion of individuals with calculus, overthanging restorations or moderate pocket depths was 39%, while 38% had gingivitis as their highest treatment need. In the oldest group (15-19 years) the number of subjects with bleeding upon probing decreased to 17%, while the percentage of individuals having moderate pockets, calculus or overhanging restorations increased to 67%. 1% of this youngsters had pockets of 6 mm. or over. At age 7, only 30% had "acceptable gingival health", and no more than 15% of the 18 year-olds reached this condition.

[Prevalence of caries in Spanish school children and youth of 7, 12 and 15 to 19 years of age]

The aim of this study was to assess the dental caries prevalence and severity of the population under 20 years of age in Spain. 1469 young people, aged 7, 12 and 15-19 years, and representing the urban (60%) and rural (40%) population from Spain were evaluated, registering the decayed, extracted or filled teeth for primary and permanent dentition. Average D.M.F.T. for 7, 12 and 15-19-years-old were 1.5, 3.5 and 6.6 respectively. A comparison of the results with those of previous studies showed that the average D.M.F.T. scores have decreased since 1984. We have also observed an increment in the number of caries-free children reaching the 57.9% in the age group of 7 years. But this excitement over the increase in the number of caries-free children must be tempered by the recognition that 35% of these individuals had 70% of the caries. We still need educational, preventive and restorative programs, and focus our efforts in detecting and treating the highly susceptible children.

[Caries prevalence and periodontal treatment needs in the same individuals]

The aim of this study was to determine whether dental caries and periodontal disease occur frequently in the same subjects 1469 young people, aged 7, 12 and 15-19 years, and representing the urban (60%) and rural (40%) population from Spain were evaluated. Dental caries and periodontal treatment needs were registered according to the index D.M.F.T. and C.P.I.T.N., following the criteria of WHO. We have found a highly significant relation between both variables, average D.M.F.T. scores increased as periodontal treatment needs were more advanced. Those subjects with lower codes of C.P.I.T.N. presented also lower D.M.F.T. scores, while these individuals with higher D.M.F.T. scores, based on a great number of open carious lesions, were more affected for periodontal disease. It does not support either a directly synergistic or antagonistic correlation in the prevalence of these two diseases in the same subjects. Dental health status is at a certain time an end result of years of varying dental health behaviour. In industrialized countries a variety of factors seems to determine the prevalence of dental caries and/or periodontal disease: dietary habits, access to fluorides, efficacy of oral hygiene measures, utilization of dental health care services. These data and ideas supported the strategy of preventing the dental caries and periodontal disease simultaneously.

[Validity of partial systems of periodontal examination in epidemiological studies]

The purpose of the present study was to determine the representativeness of partial examination in the assessment of the average severity and the prevalence of periodontal disease. 343 subjects aged 7, 12 and 15-19 years were examined for the presence or absence of gingival bleeding after gentle probing, supra or subgingival calculus and pocket depths of 4-5 mm., or 6 mm. and over, of each tooth. Three sets of average severity and prevalence scores were prepared: based on the full mouth examination, on observations made from the index teeth of the P.D.I., and on the six teeth utilized for the C.P.I.T.N. in this age group. Partial indices tended to underestimate the real prevalence of the different signs, and slightly overestimate severity, being these observations statistically significant. Average severity scores were obtained more accurately with the six Ramfjord teeth, while real prevalence rates were better determined with the C.P.I.T.N. teeth. From an epidemiological point of view, the real significance of the differences observed should be further determined.