Final results of a phase I study using oral temozolomide (TMZ) daily for 14 days with weekly paclitaxel in patients (pts) with advanced malignancies

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Background: TMZ is an alkylating agent with activity in a variety of neoplasms. The optimal schedule of administration for TMZ has not been established and only a few studies have studied it in combination with other agents. Repair of TMZ-induced DNA damage is associated with the activity of O-6 alkylguanine-DNA-alkyl transferase (AGT). Preclinical and clinical data indicate that prolonged exposure to TMZ results, not only in enhanced DNA alkylation, but also in depletion of AGT. This serves as the rationale to study TMZ using protracted schedules. Methods: The aim of this study was to determine the maximum tolerated dose (MTD) and dose limiting toxicity (DLT) of oral TMZ given daily for 14 days with weekly paclitaxel in pts with advanced cancers. Forty-five pts received 136 cycles of TMZ at escalating doses (50, 75, 100, 125 and 150 mg/m2/day × 14 days) plus paclitaxel at 80 mg/m2 on days 1, 8, and 15. Pts were stratified as lightly (LP) or heavily (HP) pretreated and MTD defined as the dose level (DL) at which 1/6 patients developed DLT. Results: Twenty-four LP patients were treated at 5 DLs with all but one evaluable for toxicity. Febrile neutropenia and grade 3 thrombocytopenia were the DLTs. MTD in this group was the 125 mg/m2/day level. Twenty-six HP were treated at 5 DLs and 21 were evaluable for toxicity. Febrile neutropenia and grade 3 thrombocytopenia were the DLTs. MTD for this group was also 125 mg/m2/day. Thirty-eight (84%) pts were evaluable for response after 2 cycles of therapy. Three (8%) pts had a partial response (lung, lymphoma, ependymoma), 20 (53%) remained stable and 15 (39%) developed disease progression. Six (16%) pts remained stable for 6 cycles or more (2 sarcomas, 2 lung, 1 pancreas, 1 glioblastoma). Conclusions: We concluded that combining oral TMZ at a dose of 125 mg/m2/day for 14 days with standard-dose weekly paclitaxel is safe in both HP and LP pts.

[Table: see text]

Development of an antibody-detection ELISA for Fasciola hepatica and its evaluation against a commercially available test

An ELISA was developed for the detection of Fasciola hepatica antibody in serum of cattle. The assay was applied to sera from 258 naturally infected cattle, 256 non-infected cattle and six calves experimentally infected with F. hepatica. The diagnostic sensitivity and specificity of the ELISA test was 98% (95% confidence intervals, 96-100%) and 96% (95% confidence intervals, 93-98%) respectively at a cut-off value of 15% positivity. The results using sera from the experimentally infected calves showed that antibodies were first detected 2-4 weeks after infection. The ELISA test was also compared to the commercially available Bio-X bovine F. hepatica ELISA kit. A subset of 39 positive sera and 47 negative sera were selected from the samples used to evaluate the in-house test. The results indicated that the agreement between the two tests was almost perfect (k statistic=0.82).

[Management in clinical nutrition]

Terms such as management, costs, efficacy, efficiency, etc. that are so common in the discourse of managers are now beginning to appear in the vocabulary of clinicians. Management in Clinical Nutrition is an innovative aspect of interest among health-care professionals dealing with the needs of undernourished patients or those at risk of malnutrition. The basic goal of this paper is to show that the tools for clinical management of hospitals are applicable to such a multidisciplinary and complex speciality as clinical nutrition and also to propose the measures needed to improve our information systems and optimize management in this field. The very concept of hospitals has changed, as has their activity, over the years. Hospitals are nowadays no longer just a charitable institution but has become a service company, a public utility for the promotion of good health and they have to be managed in accordance with criteria of efficacy, efficiency, equity and quality. The concepts of Evidence-Based Medicine (EBM) and Cost-Effective Medicine (CEM) are of evident importance in the different ways of managing health-care services. Good clinical practice is the combination of EBM and CEM. This review defines the various cost studies of fundamental importance when taking decisions in hospital management and analyzes such clinical management tools as analytical accounting, Minimum Hospital Database Set (MHDS) and encoding systems, among others, thus facilitating an analysis of the usefulness of data in clinical nutrition management systems. Finally, after reviewing some specific examples, measures are proposed to optimize current information systems. The medical staff and those of us responsible for Nutrition Units operate in hospitals as part of a centralized service transferring information to the various departments where the patient is physically located (Surgery, Internal Medicine, Digestive, ICU, etc.). One of the priority goals in micro-management and middle management is to observe the quality improvement in the discharge reports for the patients admitted, including the nutritional diagnosis within the section for the main diagnosis, and also the administration of artificial nutrition (enteral or parenteral) in the section on procedures. With all of these measures we will improve the quality of the hospitals' information systems and contribute directly to ensuring that our activities in clinical nutrition have an impact on the overall results of the hospital when measured in terms of effectiveness, efficacy or quality.

[Catastrophic antiphospholipid syndrome in the immediate puerperium]

We describe a female previously diagnosed of primary antiphospholipid antibody syndrome who presented a preclampsia in the second pregnancy. An urgent caesaria was made because of a worsening high blood pressure and oliguria. In the immediated puerperium she showed low platelets and persistent high blood pressure. Afterwards acute renal failure and neurological signs with a severe aortic valvulopathy were diagnosed. An haemolytic anemia was also detected. Definitive diagnosis was made by kidney biopsy with the result of a thrombotic microangiopathy. Treatment with low weight heparin and aspirin and systemic corticosteroids was started in the immediate puerperium and fresh frozen plasma was then added with a good response to treatment. Actually she is still with high blood pressure, aortic valvulopathy. Renal function is normal one year later.

High incidence of severe infections in heart transplant recipients receiving tacrolimus

BACKGROUND

Tacrolimus (FK) is being increasingly used as an alternative to cyclosporine (CyA) in heart transplantation (HTx). It is believed to engender slightly more powerful protection against acute rejection. However, the increased immunosuppression could result in an excess of infectious complications.

METHODS

Our study compared the incidence of major infections (MInf), defined as life-threatening infectious episodes requiring admission and intravenous (IV) antimicrobial therapy, among a series of HTx recipients treated with either FK (n=30) or CyA (n=84).

RESULTS

A total of 21 patients received FK in an elective protocol and 9 patients initially treated with CyA were converted to FK. Tacrolimus was combined with azathioprine and prednisone in 21 cases, and with mycophenolate mofetil and steroids in 8 recipients. After a follow-up between 6 and 37 months, 11 patients (37%) in the FK group developed 13 episodes of MInf, most (85%) occurring during the first posttransplant year. Conversely, CyA patients (n=84), a group with similar characteristics and follow-up, showed a MInf incidence of 12% (P<.05). Among the FK group, the most common site of MInf was pulmonary (69%). A variety of opportunistic agents caused MInf in 54% of cases, whereas the remaining ones were attributed to nosocomial bacteria. There were three deaths (27% of all MInf), all in azathioprine-treated patients with initial FK therapy.

CONCLUSIONS

Tacrolimus therapy seems to be associated with an increased incidence of severe infections in HTx recipients. We recommend aggressive diagnostic and therapeutic approaches for patients on FK who develop signs or symptoms of infection in the first year after HTx.

Differential characteristics of heart transplantation in patients older than 60 years

BACKGROUND

The effect of advanced age on the results of heart transplantation (HTx) is still controversial. The few articles addressing this issue have not been conclusive, due to either short follow-up periods or small numbers of patients.

METHODS

We present a retrospective study of 560 HTx which were divided into group A, including patients of 60 or less years at HTx (n=465, 83%), and group B, of 95 recipients older than 60 years. A subgroup of the latter, named B1, includes 24 patients older than 65. More than 100 recipient, donor and surgical procedure variables were analyzed for their impact on actuarial survival and incidence of common causes of posttransplant morbidity and mortality during a follow-up period longer than 10 years.

RESULTS

Group B showed a lower number of acute rejection episodes than group A, (1.53+/-1.87 versus 1.96+/-1.81, P<.04). Both groups showed a similar incidence of infection episodes, malignancies or graft vasculopathy, but older patients experienced fewer viral infections than younger ones (9% in group A versus 18% in group B, P<.05). Log-rank test showed a trend to shorter survival in group B (P=.08), a disadvantage that reached significance (P=.01) among patients older than 65 years.

CONCLUSIONS

Patients who were older than 60 at HTx displayed a lower incidence of acute rejection episodes and viral infections, but a trend toward shorter long-term survival. This disadvantage in prognosis was statistically significant among recipients older than 65 years.

Role of prostaglandins and nitric oxide in gastric damage induced by metamizol in rats

OBJECTIVE AND DESIGN

In addition to the depletion of prostaglandins (PGs), oxygen free radicals generation and nitrogen species haven been implicated in non-steroidal anti-inflammatory drugs (NSAIDs)-induced gastric injury. The aim of the present study was to examine changes in PGE2 generation and its relationship with proinflammatory parameters and nitric oxide (NO) production in the comparative pathogenesis of gastric injury induced by metamizol vs. diclofenac, NSAIDs that present different gastric tolerability and cyclooxygenase (COX) inhibition profiles.

MATERIAL

Studies were performed in Wistar-Han rats.

TREATMENTS

Metamizol (120, 500 and 1,000 mg/kg body weight) and diclofenac (50 mg/kg body weight) were given by oral administration.

METHODS

Determinations were made of macroscopic and histological evaluation of gastric mucosal injury, gastric prostaglandin synthesis (PGE2 levels), myeloperoxidase activity (MPO), tumor necrosis factor-alpha levels (TNF-a), cyclic guanosine monophosphate (cGMP), nitric oxide synthase activity (NOS) and NOS mRNA expression.

RESULTS

Metamizol, only at the highest doses assayed, provoked weak lesions in the gastric mucosa. To the contrary, diclofenac treatment presented the highest grade of lesion. All treatments decreased PGE2 gastric generation. Treatment of the animals with metamizol neither modified the MPO activity nor TNF-alpha levels. In contrast, statistically significant increases in both parameters were observed after diclofenac administration. cGMP levels were not influenced with diclofenac treatment, nevertheless metamizol reduced the nucleotide levels, which was accompanied by an inhibition of constitutive NOS (cNOS) activity without modifying the mRNA expression of the enzyme.

CONCLUSIONS

In addition to inhibition of PG synthesis, damage induced by metamizol was associated with an inhibition of the NO/cGMP pathway and cNOS activity. In contrast, diclofenac-induced gastric damage was associated with an increase of the inflammatory response.

Quantification of foetomaternal haemorrhage. An analysis of two cytometric techniques and a semiquantitative gel agglutination test

Traditional tests to screen for foetomaternal haemorrhage are time-consuming and difficult to perform. The Kleihauer test is widely used but difficult to standardize. We evaluated three techniques for quantifying foetomaternal haemorrhage: a semiquantitative gel agglutination test and two flow cytometric techniques. The gel agglutination test is based on the consumption of anti-D reagent by D+ cells, analysing the reaction of the supernatant against indicator cells in a Coombs-gel card. In the two colour direct immunofluorescent technique, the sample is incubated with Per-CP labelled anti CD45 antibody, fixed with glutaraldehyde and permeabilized by exposure to Triton X-100. An aliquot is stained with an antibody to foetal haemoglobin, conjugated with fluorescein isothiocyanate or phycoerythrin. The indirect immunofluorescent technique is based on the labelling of Rh (D) antigen with an anti D reagent, followed by the addition of an anti IgG antibody conjugated with phycoerythrin. Foetomaternal haemorrhage was not detected in 75 of the 85 samples analysed by the direct immunofluorescent technique. In the remaining 10 samples, the volume was very low. Thirty-five samples with Rh (D) antigen incompatibility were analysed in parallel by the indirect immunofluorescent technique and in 15 of the 35 samples, the gel agglutination technique was also carried out. The three techniques gave similar results. The gel agglutination test can be used to screen for foetomaternal haemorrhage, while greater volumes should be quantified by flow cytometric techniques.

S-Adenosylmethionine modulates inducible nitric oxide synthase gene expression in rat liver and isolated hepatocytes

BACKGROUND/AIMS

Hepatocellular availability of S-adenosylmethionine, the principal biological methyl donor, is compromised in situations of liver damage. S-Adenosylmethionine administration alleviates experimental liver injury and increases survival in cirrhotic patients. The mechanisms behind these beneficial effects of S-adenosylmethionine are not completely known. An inflammatory component is common to many of the pathological conditions in which S-adenosylmethionine grants protection to the liver. This notion led us to study the effect of S-adenosylmethionine administration on hepatic nitric oxide synthase-2 induction in response to bacterial lipopolysaccharide and proinflammatory cytokines.

METHODS

The effect of S-adenosylmethionine on nitric oxide synthase-2 expression was assessed in rats challenged with bacterial lipopolysaccharide and in isolated rat hepatocytes treated with proinflammatory cytokines. Interactions between S-adenosylmethionine and cytokines on nuclear factor kappa B activation and nitric oxide synthase-2 promoter transactivation were studied in isolated rat hepatocytes and HepG2 cells, respectively.

RESULTS

S-Adenosylmethionine attenuated the induction of nitric oxide synthase-2 in the liver of lipopolysaccharide-treated rats and in cytokine-treated hepatocytes. S-Adenosylmethionine accelerated the resynthesis of inhibitor kappa B alpha, blunted the activation of nuclear factor kappa B and reduced the transactivation of nitric oxide synthase-2 promoter.

CONCLUSIONS

Our findings indicate that the hepatoprotective actions of S-adenosylmethionine may be mediated in part through the modulation of nitric oxide production.

Deposition of atmospheric nitrogen compounds in humid tropical Cuba

Acid deposition, a direct effect of gaseous air pollutants, is causing widespread damage to terrestrial and aquatic ecosystems. Further, these pollutants are responsible for the corrosion of building materials and cultural objects, as well as having an impact on human health. In Cuba, main atmospheric deposition of nitrogen compounds varies from approximately 12.0 to 65.0 kg N ha(-1) year(-1) in rural areas. Ammonia and ammonium are the most important elements in Cuba's tropical conditions.

Spectroscopic study of the interactions of alkali fluorides with D-xylose

The interactions of alkali fluorides with D-xylose have been studied by X-ray diffraction (XRD), infrared spectroscopy (IR), nuclear magnetic resonance (NMR, 1H and 13C) and atomic absorption spectrophotometry. KF and CsF form complexes with D-xylose in a 1:1 molar ratio. These complexes can be obtained by solid state milling the reactants in an agate mortar or from methanolic solutions of the sugar and the salt. LiF and NaF do not form complex with D-xylose. IR and XRD prove the identical nature of the complexes obtained by milling and from solution. IR spectra indicate strong perturbation of the OH stretching vibrations with considerable shifts to lower frequencies, which must be caused by strong hydrogen bond formation to the fluorine anion. The perturbations of C-O bond are weak, indicating that cation binding to the oxygen atoms is not the main interaction responsible for the complex formation. 1H NMR spectra of the D-xylose-KF complex dissolved in deuterium oxide is equal to that of pure D-xylose, indicating the destruction of the complex in solution. The complex is stable in DMSO, and 13C spectra of the complex in DMSO-d6 and in solid state (CPMAS) spectra are in accordance with the observed interactions in the IR spectra. As far as we know, this is the first report of a sugar-halide salt complex in which the anion instead of the cation provides the binding forces.

Efficacy and safety of metamizol vs. acetylsalicylic acid in patients with moderate episodic tension-type headache: a randomized, double-blind, placebo- and active-controlled, multicentre study

We assessed the efficacy and safety of oral single doses of 0.5 and 1 g metamizol vs. 1 g acetylsalicylic acid (ASA) in 417 patients with moderate episodic tension-type headache included in a randomized, double-blind, placebo- and active-controlled, parallel, multicentre trial. Eligibility criteria included 18-65 years of age, history of at least two episodes of tension-type headache per month in the 3 months prior to enrollment, and successful previous pain relief with a non-opioid analgesic. Treatment arms were metamizol 0.5 g (n = 102), metamizol 1 g (n = 108), ASA 1 g (n = 102) and placebo (n = 105). The analgesic efficacy of 0.5 and 1 g metamizol vs. placebo was highly statistically significant (alpha: 0.025; one-sided) for sum of pain intensity differences, maximum pain intensity difference, number of patients with at least 50% pain reduction, time to 50% pain reduction, maximum pain relief and total pain relief. A trend towards an earlier onset of a more profound pain relief of 0.5 and 1 g metamizol over 1 g ASA was noticed. All medications including placebo were almost equally safe and well tolerated.

Efficacy and safety of dipyrone versus tramadol in the management of pain after hysterectomy: a randomized, double-blind, multicenter study

BACKGROUND AND OBJECTIVES

We assessed the efficacy and safety of dipyrone in comparison with tramadol in the relief of early postoperative pain following abdominal hysterectomy.

METHODS

A total of 151 women between 18 and 60 years of age undergoing abdominal hysterectomy during general anesthesia participated in a randomized, double-blind, controlled, multicenter study. Seventy-three patients received dipyrone and 78 received tramadol. Patients received an intravenous loading dose of the study drug immediately after operation followed by intravenous (IV) maintenance infusion and IV on-demand boluses up to a maximum number of predetermined doses/day of 8 g dipyrone and 500 mg tramadol. The duration of the study was 24 hours.

RESULTS

The mean (SD) number of boluses in the dipyrone group was 3.8 (2.4) and 3.5 (2.5) in the tramadol group (95% confidence interval, -0.455 to 1.175), and the percentage of patients requiring rescue IV morphine (dipyrone 26.9%, tramadol 26.8%) was not statistically significant. Other analgesic efficacy parameters, such as pain intensity differences, sum of pain intensity differences, pain relief assessed by the patient, or patients who required the maximum number of demand doses, were not different between treatment groups. A significantly higher percentage of adverse gastrointestinal effects was found in patients given tramadol (42.1%) than in patients given dipyrone (20.2%) (P <.05). Also, a significantly higher number of tramadol-treated patients required ondansetron to control nausea and vomiting at 1 hour (19% v 7%), 2 hours (26% v 11%), and 24 hours (46% v 29%) (P <.05) after surgery. Patients and the investigators reported similar tolerability for both study arms.

CONCLUSIONS

Dipyrone and tramadol showed similar efficacy for early pain relief after abdominal hysterectomy. Nausea and vomiting, possibly caused by the tramadol, occurred more frequently in those patients. In this group, the need of the antiemetic drug ondansetron was also higher.

Effect of different doses of S-adenosyl-L-methionine on paracetamol hepatotoxicity in a mouse model

This study investigated the hepatoprotective effects of N-acetylcysteine and different doses of S-adenosyl-L-methionine after a single intraperitoneal overdose of paracetamol in mice. Plasma concentrations of paracetamol metabolites were also determined. Female mice (Souris OFl strain) 16 weeks old and weighing 30 g were fasted for 18 h prior to intraperitoneal (i.p.) administration of 375 mg/kg (2.5 mmol/kg) of paracetamol. Experimental subgroups included mice administered paracetamol only (control group), those given of N-acetylcysteine 1 g/kg (6.13 mmol/kg) i.p. immediately after paracetamol overdose (T0) and 6 h after dosing (T6) and those administered S-adenosyl-L-methionine at doses of 20 mg/kg (0.05 mmol/kg) and 1 g/kg (2.5 mmol/kg) i.p. at T0 and T6. Twenty-four hours after paracetamol overdose, mortality and liver necrosis were significantly lower (p < 0.01) in mice treated with 2.5 mmol/kg of S-adenosyl-L-methionine and N-acetylcysteine at T0 as compared with the remaining subgroups. Plasma ALT concentrations were significantly lower (p < 0.01) in mice treated with 2.5 mmol/kg of S-adenosyl-L-methionine than in those given N-acetylcysteine. Plasma concentrations of paracetamol metabolites showed an increase in the glucuronide conjugate and a decrease in the mercapturic acid conjugate in N-acetylcysteine-treated mice and an overall decrease in the conjugation pathway without changes in the oxidative pathway in S-adenosyl-L-methionine-treated animals. We conclude that S-adenosyl-L-methionine at doses of 1 g/kg (2.5 mmol/kg) i.p. was equally effective as 1 g/kg (6.13 mmol/kg) N-acetylcysteine for preventing hepatotoxicity after paracetamol overdose in mice. S-adenosyl-L-methionine may be a therapeutic alternative to N-acetylcysteine as an antidote for poisoning with paracetamol.

Effect of S-adenosyl-L-methionine on rat brain oxidative stress damage in a combined model of permanent focal ischemia and global ischemia-reperfusion

We analyzed the effects of S-adenosyl-L-methionine (SAM) on tissue oxidative status in a combined model of permanent focal ischemia and global reperfusion in the rat brain. The production of thiobarbituric acid reactive substances (TBARS) was measured under basal conditions and after induction with ferrous salt as an indicator of brain lipid peroxidation. Total, oxidized and reduced glutathione were measured as indicators of the antioxidant defense capacity of brain tissue. Mitochondrial reduction of tetraphenyl tetrazolium (TPT) was quantified morphometrically. Results obtained in vitro showed that incubation with SAM reduced lipid peroxidation, with a maximum inhibition of 65.12+/-5.99% after incubation with 1 mmol/l; glutathione production was not significantly modified. In the brain ischemia-reperfusion model, TBARS production increased and glutathione content decreased, and mitochondrial reduction of TPT decreased significantly after ischemia-reperfusion in areas dependent on carotid circulation. The administration of 50 mg/kg SAM per day for 3 days led to the inhibition of brain lipid peroxidation and increased total glutathione production. These changes were accompanied by an increase in mitochondrial capacity to reduce TPT. We conclude that SAM reduces oxidative damage in the rat brain in an experimental model of ischemia-reperfusion.

[Transient global amnesia and vascular risk factors]

INTRODUCTION

Transient global amnesia (TGA) is a clinical syndrome determined by an episode of less than 24 hours consisting of temporo-spatial disorientation with retrograde and anterograde amnesia followed by complete recovery.

OBJECTIVES

To determine whether the presence or absence of vascular risk factors (VRF) in patients with TGA is associated with different clinical data and/or examination findings.

PATIENTS AND METHODS

A retrospective study was made of two groups of 13 and 12 patients with TGA, who presented with and without VRF, respectively. The following variables were determined: VRF, age, a previous history of migraine, triggering factors, duration and repetition of the episodes, associated neurological symptoms and findings obtained by neuroimaging, eco-Doppler of the supra-aortic trunks and transcranial Doppler. The data were subjected to statistical analysis by univariate analysis with Fischer's exact probability test.

RESULTS

The statistical studies showed no significant differences between the variables obtained in the two groups of patients.

CONCLUSIONS

Transient global amnesia has been particularly related to migraine, epilepsy and cerebral vascular pathology, although its aetiology has not been fully determined. In this study we compare clinical data between the two groups of patients with and without VRF who have had TGA. The lack of significant differences between them tends to rule out a vascular aetiology as the sole cause of this syndrome. Recently Leao's propagated depression has been suggested as the physiopathological mechanism involved. According to this theory, the vascular pathology might act as the trigger but probably not as the aetiological factor. The findings of our study may support this thesis.