Alterations in neutrophil (PMN) free intracellular alpha-keto acid profiles and immune functions induced by L-alanyl-L-glutamine, arginine or taurine

The objective of this study was to determine the dose as well as duration of exposure-dependent effects of L-alanyl-L-glutamine, arginine or taurine on polymorphonuclear neutrophil (PMN) free alpha-keto acid profiles and, in a parallel study, on PMN immune functions. Exogenous L-alanyl-L-glutamine significantly increased PMN alpha-ketoglutarate, pyruvate PMN superoxide anion (O2-) generation, hydrogen peroxide (H2O2) formation and released myeloperoxidase (MPO) activity. Arginine also led to significant increases in alpha-ketoglutarate, pyruvate, MPO release and H2O2 generation. Formation of O2- on the other hand was decreased by arginine. Incubation with taurine resulted in lower intracellular pyruvate and alpha-ketobutyrate levels, decreased O2- and H2O2 formation and a concomitant significantly increased MPO activity. We therefore believe that considerable changes in PMN free-alpha-keto-acid profiles, induced for example by L-alanyl-L-glutamine, arginine or taurine, may be one of the determinants in cell nutrition that considerably modulates the immunological competence of PMN.

Nuclear time-reversal violation and the Schiff moment of 225Ra

We present a comprehensive mean-field calculation of the Schiff moment of the nucleus 225Ra, the quantity that determines the static electric-dipole moment of the corresponding atom if time-reversal (T) invariance is violated in the nucleus. The calculation breaks all possible intrinsic symmetries of the nuclear mean field and includes, in particular, both exchange and direct terms from the full finite-range T-violating nucleon-nucleon interaction, and the effects of short-range correlations. The resulting Schiff moment, which depends on three unknown T-violating pion-nucleon coupling constants, is much larger than in 199Hg, the isotope with the best current experimental limit on its atomic electric-dipole moment.

Platelet monoamine oxidase B (MAO-B) activity and its relationship to DL-fenfluramine-induced prolactin response in healthy men

Several techniques are used to assess central serotonergic neurotransmission in man, e.g. challenge tests (hormonal and physiological responses to serotonin active drugs), platelet MAO-B activity as well as brain imaging techniques. Little is known about how these tests relate to each other. The aim of the present study was therefore to investigate if platelet MAO-B activity could be related to hormonal and temperature responses to the serotonin active drug DL-fenfluramine in healthy men. Twelve male subjects without any history of psychiatric disorders or drug abuse/dependencies were recruited. Prior to the challenge with 60 mg DL-fenfluramine, which was given orally, blood for determination of platelet MAO-B activity was drawn. Blood samples for determination of serum prolactin and serum cortisol were drawn at baseline and thereafter every hour for the following six hours. In addition, body temperature was measured at the same time-points. Delta-values were calculated as the difference between the baseline values and the highest (prolactin and cortisol) or lowest value (temperature) thereafter. There was a strong positive correlation (r = 0.75, p < 0.02) between platelet MAO-B activity and Delta-prolactin. No correlations were found to Delta-cortisol, Delta-temperature or any of the baseline values. The results support the notion that the peripheral marker platelet MAO-B activity is related to the function of the central serotonergic neurotransmitter system as assessed by the prolactin response to 60 mg DL-fenfluramin.

Prevalence of epilepsy its treatment gap and knowledge, attitude and practice of its population in sub-urban Senegal an ILAE/IBE/WHO study

A door-to-door survey was used to determine the prevalence of epilepsy among 4500 people within the Pikine Health District (population 480,000) Senegal. Prevalence was 14.2/1000, and 23.4% of all people with epilepsy had never received appropriate treatment. Figures for the prevalence had increased since a previous survey in 1989. In parallel a study of knowledge attitude and practice was performed in the same district. Salient findings were that: two-thirds of interviewees had at some time witnessed a seizure, 51% agreed when asked if epilepsy is caused by evil spirits, 35% said epilepsy is contagious, only about 18% said that traditional therapy is best, 60% would not mind their child to play with a child with epilepsy but only 32% would agree if their child would want to marry a person with epilepsy.

Influence of hospital volume on local recurrence and survival in a population sample of rectal cancer patients

AIMS

To investigate the role of hospital volume and individual hospitals on long term outcomes (local recurrence and survival) of rectal cancer patients.

METHODS

One thousand thirty-eight patients with rectal cancer were diagnosed between 1996 and 1998. From these, we analysed 884 patients with a resected invasive primary rectal cancer. Median follow-up was 5.7 years. The impact of hospital volume (<10, 10-30 and >30 rectal cancer patients annually) on local recurrence and survival was examined in a Cox model. Differences between the four largest clinics in the high volume group were also investigated.

RESULTS

In the multivariate model predicting survival the following variables were significant: UICC stage, grade, age, local recurrence, and (neo-) adjuvant therapy treatment. In the multivariate model predicting local recurrence UICC stage, tumour localisation, and neoadjuvant therapy treatment were significant variables. Hospital volume was not a significant factor for survival or local recurrence. Within the high volume category one hospital showed significantly worse local recurrence rates than all other hospitals, but no survival difference could be seen between the four largest hospitals of the high volume group.

CONCLUSIONS

This analysis of a rectal cancer population found that hospital volume did not determine survival or local recurrence. Detailed clinical data with long term follow-up from cancer registries are vital to demonstrate the quality of routine care.

Statistical methods for testing plaque removal efficacy in clinical trials

OBJECTIVES

To evaluate the ability of different statistical approaches in finding a statistically significant difference in plaque removal efficiency between brushes in clinical trials.

MATERIALS AND METHODS

The approaches, which are evaluated, concern the scores after brushing only, the difference in scores before and after brushing and the relative difference scores (i.e. score before minus score after brushing divided by the score before brushing). In each case the scores before brushing may be included as a covariate. Except for the relative difference scores, the power of the test statistics of the approaches has been compared by assuming a simple statistical model. These theoretical results have been compared with the numerical results of two particular clinical trials--one with a between-subject design and one with a within-subject design.

RESULTS

The numerical results of these clinical trials show that the calculated p-values support the conclusions drawn from the statistical model, i.e. the power of the F-test is highest when evaluating the data after brushing with the data before brushing included as a covariate. Using the differences in scores before and after brushing--again with the data before brushing as a covariate--does not add additional power to the test. Omitting the data before brushing as a covariate only gives satisfactory results when the variance over the subjects or the error variance is zero, which in general is not the case.

CONCLUSIONS

This investigation reveals that in general the approach of analysing the scores after brushing with the scores before brushing as a covariate yields the highest chance of finding a statistically significant difference between two brushes.

Survival for rectal cancer patients and international comparisons

BACKGROUND

Population-based cancer registry data are important because they reflect routine care, present long-term follow-up, can show differences in treatment, outcomes and health care over time, and can be used for comparisons between regions and countries.

PATIENTS AND METHODS

Details of all cancer patients in the Munich region are recorded by the Munich Cancer Registry. Rectal cancer patients with an invasive primary tumor diagnosed between 1996 and 1998 were included in this analysis (n=936). Observed and relative survival are presented. Observed survival was also investigated with a Cox proportional hazards regression model.

RESULTS

Median follow-up time of survivors was 5.7 years. Five-year relative survival for the whole sample was 62.2%. International Union Against Cancer (UICC) stage was the most important prognostic factor in the multivariate analysis. Compared with the 1992-1999 Surveillance Epidemiology and End Results (SEER) data (62.4%), relative survival for each disease stage and the whole sample were very similar. In comparison with other European registries, Munich patients had slightly higher survival rates per stage (for example, 5-year relative survival in UICC III was 58.3% in Munich, 54.6% in South East Netherlands, 33.3% in Modena and 47.4% in Cote d'Or); however, more patients in Munich were in higher disease stages with worse prognoses, indicating poorer early detection.

CONCLUSIONS

These results indicate that treatment of rectal cancer in Munich is good, but early detection could be improved. Cancer registries should publish their population-based stage data to ensure quality of care and provide regular feedback to health-care workers and decision makers. Comparisons between countries without stage data should be conducted cautiously.

Extrapituitary effects of GnRH antagonists in assisted reproduction: a review

GnRH antagonists are used to prevent premature LH surges in assisted reproduction. The pregnancy rates obtained in several studies have been similar to those obtained in the long protocol with gonadotrophin-releasing hormone (GnRH) agonists. However, lower oestrogen serum concentrations have been observed and fewer oocytes retrieved using GnRH antagonists. Thus, potential effects at extrapituitary GnRH receptors in the ovary and the endometrium have been claimed. The article reviews the currently available data from the literature as well as current investigations with respect to effects of cetrorelix on the ovary and the endometrium. No evidence was found to support the hypothesis of extrapituitary effects of GnRH antagonists such as cetrorelix at doses used in assisted reproduction.

Benzodiazepine receptor-dependent modulation of neutrophil (PMN) free amino- and ?-keto acid profiles or immune functions

We have examined the effects of midazolam, Ro 5-4864 (agonist for "peripheral" [p] benzodiazepine receptors [BR]), PK 11195 (antagonist for pBR), flumazenil (antagonist for "central" BR), naloxone (antagonist for opiate receptors) and the combination of midazolam and Ro 5-4864, PK 11195, flumazenil or naloxone on intracellular amino- and alpha-keto acids and the immune function markers superoxide anion (O(2)(-)), hydrogen peroxide (H(2)O(2)) and released myeloperoxidase (MPO) activity in neutrophils (PMN). Only midazolam and Ro 5-4864 led to significant changes in the dynamic PMN free amino- and alpha-keto acid pools. Concerning PMN immune function markers, midazolam and Ro 5-4864 significantly decreased O(2)(-) and H(2)O(2) formation and released MPO. When midazolam and Ro 5-4864 were applied together they appeared to act additively. Pre-incubation with PK 11195 partially neutralized the midazolam effects whereas flumazenil or naloxone showed no effects. We therefore believe that pBR are involved in the signal transmission of anesthetic-induced cellular metabolic changes in PMN.

Effects of ornithine on neutrophil (PMN) free amino acid and ?-keto acid profiles and immune functions in vitro

The objective of this study was to determine the effects of ornithine on polymorphonuclear leucocyte (PMN) free amino- and alpha-keto acid profiles, superoxide anion (O2-) generation, hydrogen peroxide (H2O2) formation and released myeloperoxidase activity (MPO). Exogenous ornithine significantly increased PMN asparagine, glutamine, aspartate, glutamate, arginine, citrulline, alanine, alpha-ketoglutarate and pyruvate as intracellular ornithine increased. Concerning PMN immune function markers ornithine increased H2O2-generation and MPO activity while O2- -formation was decreased. We believe therefore that ornithine is important for affecting PMN "susceptible free amino- and alpha-keto acid pool" although the mechanisms are not yet clear. This may be one of the determinants in PMN nutrition considerably influencing and modulating PMN host defense capability.

Miltefosine for New World Cutaneous Leishmaniasis

The oral agent miltefosine has demonstrated a >95% cure rate in Indian visceral leishmaniasis. We performed a large, placebo-controlled study of miltefosine therapy (2.5 mg/kg per day orally for 28 days) against cutaneous leishmaniasis in Colombia and Guatemala. In regions in Colombia where Leishmania vianna panamensis is common, the per-protocol cure rates for miltefosine and placebo were 91% (40 of 44 patients) and 38% (9 of 24). These values are similar to historic values for the antimony standard of care and placebo. In regions in Guatemala where L. v. braziliensis and L. mexicana mexicana are common, the per-protocol cure rates were 53% (20 of 38) for miltefosine and 21% (4 of 19) for placebo. The miltefosine rate was lower than historic antimony cure rates of >90%. Miltefosine was well tolerated. Miltefosine is a useful oral agent against cutaneous leishmaniasis due to L. v. panamensis in Colombia but not against leishmaniasis due to L. v. braziliensis in Guatemala.

Total sleep deprivation increases extracellular serotonin in the rat hippocampus

Sleep deprivation exerts antidepressant effects after only one night of deprivation, demonstrating that a rapid antidepressant response is possible. In this report we tested the hypothesis that total sleep deprivation induces an increase in extracellular serotonin (5-HT) levels in the hippocampus, a structure that has been proposed repeatedly to play a role in the pathophysiology of depression. Sleep deprivation was performed using the disk-over-water method. Extracellular levels of 5-HT were determined in 3 h periods with microdialysis and measured by high performance liquid chromatography coupled with electrochemical detection. Sleep deprivation induced an increase in 5-HT levels during the sleep deprivation day. During an additional sleep recovery day, 5-HT remained elevated even though rats displayed normal amounts of sleep. Stimulus control rats, which had been allowed to sleep, did not experience a significant increased in 5-HT levels, though they were exposed to a stressful situation similar to slee-deprived rats. These results are consistent with a role of 5-HT in the antidepressant effects of sleep deprivation.

Human cytoplasmic actin proteins are encoded by a multigene family

We characterized nine human actin genes that we isolated (Engel et al., Proc. Natl. Acad. Sci. U.S.A. 78:4674-4678, 1981) from a library of cloned human DNA. Measurements of the thermal stability of hybrids formed between each cloned actin gene and alpha-, beta-, and gamma-actin mRNA demonstrated that only one of the clones is most homologous to sarcomeric actin mRNA, whereas the remaining eight clones are most homologous to cytoplasmic actin mRNA. By the following criteria we show that these nine clones represent nine different actin gene loci rather than different alleles or different parts of a single gene: (i) the restriction enzyme maps of the coding regions are dissimilar; (ii) each clone contains sufficient coding region to encode all or most of an entire actin gene; and (iii) each clone contains sequences homologous to both the 5' and 3' ends of the coding region of a cloned chicken beta-actin cDNA. We conclude, therefore, that the human cytoplasmic actin proteins are encoded by a multigene family.

Effector ExoU from the type III secretion system is an important modulator of gene expression in lung epithelial cells in response to Pseudomonas aeruginosa infection

Pseudomonas aeruginosa is an important pathogen in immunocompromised patients and secretes a diverse set of virulence factors that aid colonization and influence host cell defenses. An important early step in the establishment of infection is the production of type III-secreted effectors translocated into host cells by the bacteria. We used cDNA microarrays to compare the transcriptomic response of lung epithelial cells to P. aeruginosa mutants defective in type IV pili, the type III secretion apparatus, or in the production of specific type III-secreted effectors. Of the 18,000 cDNA clones analyzed, 55 were induced or repressed after 4 h of infection and could be classified into four different expression patterns. These include (i) host genes that are induced or repressed in a type III secretion-independent manner (32 clones), (ii) host genes induced specifically by ExoU (20 clones), and (iii) host genes induced in an ExoU-independent but type III secretion dependent manner (3 clones). In particular, ExoU was essential for the expression of immediate-early response genes, including the transcription factor c-Fos. ExoU-dependent gene expression was mediated in part by early and transient activation of the AP1 transcription factor complex. In conclusion, the present study provides a detailed insight into the response of epithelial cells to infection and indicates the significant role played by the type III virulence mechanism in the initial host response.

Perioperative changes in cerebral ischemic markers in the cerebrospinal fluid after preoperative nimodipine treatment

BACKGROUND

Elderly patients with previous organ damage are at risk for minor neurologic deficits after major surgery. Spinal catheter analgesia is used whenever possible in this group and enables regular cerebrospinal fluid (CSF) sampling. Nimodipine, a calcium blocker, may have neuroprotective effects. We examined whether preoperative treatment with nimodipine affects ischemic markers in the CSF during extracranial surgery.

METHODS

We performed a prospective, randomized, placebo-controlled, double-blind study in patients (ASA III or IV, 65-85 years) that underwent elective implantation surgery of the hip joint with intrathecal catheter anesthesia. Starting 15 h before surgery, patients received either 30 microg x kg(-1) h(-1) of nimodipine (n = 20) or 0.9% saline solution (placebo, n = 23) as a central venous infusion. The concentrations of neuron-specific enolase, hypoxanthine, creatine-kinase, lactate and pH in the CSF were determined before and immediately after surgery as well as 6 and 24 h after surgery.

RESULTS

Before surgery, the baseline CSF pH was normal in all patients. Immediately after surgery it fell significantly to 7.08 +/- 0.29 in the placebo group and non-significantly to 7.27 +/- 0.38 in the treatment group; all values were normalized at 6 and 24 h after surgery in both groups. In the placebo group, lactate levels rose significantly from 1.48 +/- 0.28 mmol l(-1) before surgery to 1.77 +/- 0.27 mmol l(-1) immediately after surgery, and to 2.03 +/- 0.32 mmol l(-1) 24 h after surgery. In the treatment group, lactate concentrations remained stable up to 6 h after surgery (1.55-1.62 mmol l-1), while an increase to 2.10 +/- 0.48 mmol l(-1) was observed 24 h after the operation. Neuron-specific enolase, hypo-xanthine and creatine-kinase showed no change in either group.

CONCLUSION

In conclusion, preoperative nimodipine treatment reduced intraoperative CSF acidosis and delayed surgery-related increases in lactate concentration in the CSF by several hours in elderly, comorbid patients at risk for minor postoperative neurologic deficits.

Localization of the calcium channel subunits Cav1.2 (alpha1C) and Cav2.3 (alpha1E) in the mouse organ of Corti

Voltage-activated Ca2+ channels play an important role in synaptic transmission, signal processing and development. The immunohistochemical localization of Cav1.2 (alpha1C) and Cav2.3 (alpha1E) Ca2+ channels was studied in the developing and adult mouse organ of Corti using subunit-specific antibodies and fluorescent secondary antibodies with cochlear cryosections. Cav1.2 immunoreactivity has been detected from postnatal day 14 (P14) onwards at the synapses between cholinergic medial efferents and outer hair cells as revealed by co-staining with anti-synaptophysin and anti-choline acetyltransferase. Most likely the Cav1.2 immunoreactivity was located presynaptically at the site of contact of the efferent bouton with the outer hair cell which suggests a role for class C L-type Ca2+ channels in synaptic transmission of the medial efferent system. The localization of the second Ca2+ channel tested, Cav2.3, showed a pronounced change during cochlear development. From P2 until P10, Cav2.3 immunoreactivity was found in the outer spiral bundle followed by the inner spiral bundle, efferent endings and by medial efferent fibers. Around P14, Cav2.3 immunoreactivity disappeared from these structures and from P19 onwards it was observed in the basal poles of the outer hair cell membranes.

Miltefosine (Impavido): the first oral treatment against leishmaniasis

Miltefosine is a novel antileishmanial drug that has significant selectivity in both in vitro and in vivo models. Clinical efficacy was demonstrated for the treatment of visceral leishmaniasis with the advantage of oral administration over the currently recommended antileishmanial drugs that require parenteral administration. Miltefosine produces high cure rates also in patients resistant to the standard antimonial therapy.

Comparison of breast and rectal cancer patients' quality of life: results of a four year prospective field study

This paper compares quality of life in breast and rectal cancer patients. The Munich Cancer Registry records clinical details of all cancer patients in the region. Over a 2-year period, cooperating clinicians recruited patients who were sent quality of life questionnaires, including the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire - C30 over 4 years. Breast cancer patients were compared to both male and female rectal cancer patients. A total of 1315 patients returned questionnaires (988 breast cancer, 327 rectal cancer). More breast cancer patients were under 70 years old, received adjuvant therapy, had a good prognosis, took medication and rated psychological support as important. Breast cancer patients reported poorer quality of life than rectal cancer patients in more than half the variables. In particular, they suffered significantly worse emotional functioning, fatigue, pain and sleeplessness. Female rectal cancer patients did not suffer the same problems. Both age groups and those with or without adjuvant therapy indicated the same trend, with breast cancer patients reporting lower scores. Breast cancer patients, despite better prognoses, appear to suffer more psychological problems than rectal cancer patients. Gender, age and therapy did not seem to explain these differences. The negative public perception of breast cancer may play a role.

The process of metastasisation for breast cancer

To investigate the process of metastasis, primary clinical data and disease events such as metastases, local recurrence and survival (median follow-up 9.4 years) from the Munich Cancer Registry from 1978 to 1996 were analysed. Since metastases, even from small tumours, may be initiated before the diagnosis of the primary tumour, the growth of the primary tumour and metastasisation may be two autonomous processes. In our data, survival following metastases was almost unrelated to primary tumour size. However, the number of M1 cases and the time to metastasisation depended on the tumour diameter at diagnosis. The time from initiation of metastases to its diagnosis was estimated as 5.8 years. The growth of metastases was almost homogeneous. However, the growth time following metastasisation-depending on the metastases-free time, receptor status and histological grade-only varied by approximately a factor of 2. Local recurrence, above all, was an indicator of metastases. Furthermore, local recurrence may also have the potential to metastasise. Excess mortality due to local recurrence was estimated up to 9.3 years after diagnosis. Our hypothesised metastases model illustrates the importance of early detection, the concept of breast-conserving therapy and additional metastases from local recurrence. It highlights the benefits of optimal local therapy of the primary tumour and the limitations of systemic therapy. It also questions the use of axilla dissection and lymph node irradiation. Its generalisation to solid tumours may help to clarify many of the current controversial debates.

[Small pox--infection, therapy and anaesthesiological management (part 1)]

Smallpox is an acute contagious and sometimes fatal infectious disease. It is caused by the variola-virus. Smallpox is characterized by a typical disease form with a progressive distinctive skin rash, especially at face, arms and legs. Smallpox has a fatality rate of about 30 % and the therapy of infected patients is only symptomatically. As prevention the WHO initiated worldwide vaccination programs in the year 1967. The last naturally occurring case of smallpox in the world was in Somalia in 1977. Since then the only known cases of smallpox happened from an outbreak in Birmingham, England caused by a laboratory accident in the year of 1979. On May the 8 th 1980 the disease was declared as eliminated from the world by the WHO (WHO-Resolution 33.33). A natural occurrence of the variola-virus seems to be not given. Nevertheless the virus exists for research in two laboratories, the American Centers of Disease Control and Prevention in Atlanta, Georgia and in the Russian Research Center for Virology and Biotechnics in Kolzowo, Sibiria. Threatening infections with smallpox or other microorganisms, used as bioweapons, get a new dimension through global terrorism. The variola-virus represents an optimal candidate for bioweapons. It is easy to replicate, it is highly contagious and the transmission over aerosol or direct contact from man to man is easy to handle. After the disease was eliminated from the world, routine vaccination among general public was stopped. Therefore younger people don't possess any vaccination protection. Older formerly vaccinated people probably have only a non-sufficient protection. Because of the smallpox elimination a lot of physicians have no experience with this disease. An outbreak of this smallpox isn't only controlled by new vaccination. In our times we need adapted prevention-standards, pox-alarm plans and quarantine standards.

No influence of body weight on pregnancy rate in patients treated with cetrorelix according to the single- and multiple-dose protocols

The question of whether adjustment to body weight is necessary in in-vitro fertilization (IVF) cycles using GnRH antagonists is currently under discussion. Therefore, a data analysis of five prospective studies using either the single- or the multiple-dose antagonist protocol with cetrorelix (Cetrotide) was performed. The influence of stimulation procedure, gonadotrophins and body weight on pregnancy rate was evaluated in a linear logit model. The effect of the stimulation procedure and body weight on the cumulus-oocyte complex (COC) and follicle number was explored in an ANOVA model. Cetrorelix plasma concentrations were tested for any correlation with body weight. Baseline and outcome parameters in different body weight groups (<50 kg, 50-59 kg, 60-69 kg, 70-79 kg, > or =80 kg) were assessed for human menopausal gonadotrophin and recombinant human FSH stimulation separately. Cetrorelix plasma concentrations were correlated with body weight, but no influence of the type of stimulation or body weight on pregnancy rate was found. Body weight did not influence cetrorelix plasma concentrations. In contrast, body weight significantly influenced the number of retrieved COC as well as the number of follicles on the day of human chorionic gonadotrophin administration. Body weight does not influence the outcome of treatment in cetrorelix cycles.

Single dose application of cetrorelix in combination with clomiphene for friendly IVF: results of a feasibility study

A prospective randomized feasibility study was carried out on 10 patients undergoing IVF treatment using a single-dose LHRH antagonist protocol (cetrorelix, Cetrotide) with clomiphene citrate in combination with either human menopausal gonadotrophin (HMG) (n = 5) or recombinant human FSH (rFSH) (n = 5). Both treatment-groups, HMG and rFSH, were comparable with regard to age (33.2 +/- 2.6 versus 34.4 +/- 4.0 years) BMI (23.2 +/- 2.6 versus 22.7 +/- 1.6) and cause of infertility. They yielded comparable results concerning gonadotrophin dose (19.8 +/- 8.7 versus 17.0 +/- 8.9), stimulation days (6.5 +/- 2.0 versus 5.8 +/- 1.9) and live births (one versus two). No premature LH surge (LH >10 IU/ml and progesterone >1 ng/ml) occurred. The overall baby take-home rate was 30%. In a small number of patients, cetrorelix could be shown to effectively prevent premature LH surges in stimulation protocols combining clomiphene with gonadotrophins with an excellent baby take-home rate per started cycle of 30%.

Communication, quality of life and age: results of a 5-year prospective study in breast cancer patients

BACKGROUND

Previous studies have employed short follow-up periods or examined only certain aspects of quality of life (QoL). This study aimed to examine the effect of communication on breast cancer patients' QoL and to investigate the role of age in this relationship.

PATIENTS AND METHODS

In a prospective, observational study breast cancer patients were sent questionnaires, including the European Organisation for Research and Treatment of Cancer QLQ-C30, over 5 years.

RESULTS

Forty-five per cent of the sample reported that some aspect of the communication they received was unclear and 59% wanted to speak with medical staff more. Patients under 50 years rated social and psychological help as more important, they were more aware of such services, had greater contact with support groups but were less satisfied with the information they received. Seventeen of the 27 QoL variables were significantly worse (P <0.01), up to 4 years after diagnosis, for those patients reporting unclear information. For patients over 50 years, QoL was significantly (P <0.001) worse when communication was unsatisfactory. Operation method or arm problems did not mitigate the association between communication and QoL.

CONCLUSIONS

Communication is clearly a vital clinical skill that may play a role in patient QoL.

Practice parameter: temporal lobe and localized neocortical resections for epilepsy: report of the Quality Standards Subcommittee of the American Academy of Neurology, in association with the American Epilepsy Society and the American Association of Neurological Surgeons

OBJECTIVES/METHODS

To examine evidence for effectiveness of anteromesial temporal lobe and localized neocortical resections for disabling complex partial seizures by systematic review and analysis of the literature since 1990.

RESULTS

One intention-to-treat Class I randomized, controlled trial of surgery for mesial temporal lobe epilepsy found that 58% of patients randomized to be evaluated for surgical therapy (64% of those who received surgery) were free of disabling seizures and 10 to 15% were unimproved at the end of 1 year, compared with 8% free of disabling seizures in the group randomized to continued medical therapy. There was a significant improvement in quantitative quality-of-life scores and a trend toward better social function at the end of 1 year for patients in the surgical group, no surgical mortality, and infrequent morbidity. Twenty-four Class IV series of temporal lobe resections yielded essentially identical results. There are similar Class IV results for localized neocortical resections; no Class I or II studies are available.

CONCLUSIONS

A single Class I study and 24 Class IV studies indicate that the benefits of anteromesial temporal lobe resection for disabling complex partial seizures is greater than continued treatment with antiepileptic drugs, and the risks are at least comparable. For patients who are compromised by such seizures, referral to an epilepsy surgery center should be strongly considered. Further studies are needed to determine if neocortical seizures benefit from surgery, and whether early surgical intervention should be the treatment of choice for certain surgically remediable epileptic syndromes.

Moderate progress for ovarian cancer in the last 20 years: prolongation of survival, but no improvement in the cure rate

Although ovarian cancer treatment has advanced in the last 20 years, long-term survival remains stable. The purpose of this study was to determine whether survival has improved in line with treatment advances in a population-based prospective cohort of ovarian cancer patients (1978-1997, with a follow-up through to 2000). The 10-year overall survival rate for cancer patients was similar before and after 1988: 32.2% (n=1661) and 34.4% (n=2089). For patients after 1988, a 12-month prolongation of median survival was observed. In terms of stage according to the International Federation of Gynecology and Obstetrics (FIGO), only FIGO I and FIGO II patients showed, in addition to a prolongation in survival, an absolute improvement of 12.9 and 12.6% after 5 years and of 13.2 and 8.6% after 10 years. This hardly affected the survival of the total sample. For the most frequent stage FIGO III patients and for FIGO IV patients, a prolongation in survival time, but no improvement in survival rate, was seen after five or 10 years. The progress in FIGO I and II patients may be due to more accurate staging. More effective chemotherapy may also explain some of the improvement. The prolongation in FIGO-stages III-IV may be due to more radical surgery. Patient selection criteria, not only the treatment modalities, may be responsible for the superior results reported in clinical trials. Cancer registries are important for evaluating the quality of healthcare delivery.

Wrist arthrodesis: modified Gill's technique

Twenty-five wrist arthrodesis procedures were performed on 24 patients, applying a modification of Gill's technique, which used a corticocancellous strut graft from the distal radius. Patients were followed up until solid bony fusion was established. Union was achieved in 21 of 25 wrists and was subsequently achieved with a further procedure in the remaining four wrists. We have found that the modified Gill's technique is a reliable, simple procedure with a low complication rate which does not require the harvest of a distant bone graft.

Ictal magnetic source imaging as a localizing tool in partial epilepsy

OBJECTIVE

To determine the feasibility and usefulness of ictal magnetoencephalography (MEG) recordings in the presurgical evaluation of patients with epilepsy.

METHODS

Twenty patients with frequent or predictable seizures were studied with the intent to capture seizures using a large array single-probe 37-channel or dual-probe 74-channel biomagnetometer.

RESULTS

Successful ictal MEG recordings were made in 6 of 20 patients with neocortical epilepsy. In one other patient, a seizure was captured but movement artifact made MEG recordings impossible. As determined by invasive EEG recording and postsurgical outcome, ictal MEG provided localizing information that was superior to interictal MEG in three of the six patients. Localization of ictal onset by MEG was at least equivalent to invasive EEG in five of the six patients, and was superior in two patients as determined by postsurgical outcome.

CONCLUSION

Larger studies are necessary to confirm that ictal MEG recordings in patients with frequent or easily provoked neocortical seizures can contribute localizing information equivalent or superior to invasive EEG recording.

Effects of arginine, L-alanyl-L-glutamine or taurine on neutrophil (PMN) free amino acid profiles and immune functions in vitro

The objective of this study was to determine the effects of arginine, L-alanyl-L-glutamine (Ala-Gln) or taurine on polymorphonuclear leucocyte (PMN) free amino acid profiles, superoxide anion (O2-) generation, hydrogen peroxide (H2O2) formation and released myeloperoxidase activity (MPO). Arginine led to significant increases in PMN arginine, ornithine, citrulline, aspartate, glutamate and alanine concentrations as well as increased H2O2-generation and MPO activity while O(2-)-formation was decreased. Ala-Gln caused significant increases in PMN free glutamine, alanine, asparagine, aspartate, glutamate, ornithine, arginine, serine and glycine concentrations and increased PMN immune functions. Taurine significantly increased PMN free taurine profiles, reduced PMN neutral amino acid content and decreased H2O2- and O(2-)-formation while MPO was increased. Altogether, the pharmacological regimens which enhance the supply of arginine, Ala-Gln or taurine in whole blood significantly affect PMN "susceptible free amino acid pool". This may be one of the determinants in PMN nutrition considerably influencing PMN immune functions. Introduction Polymorphonuclear leucocytes (PMN) ensure an important part of non-specific cell-mediated immunity and play a crucial role in the host defense

Ultradian sleep-cycle variation of serotonin in the human lateral ventricle

Serotonin is thought to be intimately involved in the regulation of sleep and waking in humans, though the evidence for such is indirect. Using in vivo microdialysis, the authors show that serotonin in human ventricular CSF covaries with the state of consciousness. They hypothesize that CSF serotonin may be acting in an endocrine-like manner through activation of known leptomeningeal serotonin receptors and possibly participating in modulation of choroidal production of CSF.

[Risk predictors, scoring systems and prognostic models in anesthesia and intensive care. Part II. Intensive Care]

The aim of the second part of this review article was to describe common scoring systems in intensive care, and to point out their possible benefits and limitations. Intensive care medicine multipurpose scoring-systems are currently used to estimate severity of illness, mortality and the amount of treatment required. Costs (only commercial available scores e.g. Acute Physiology and Chronic Health Evaluation [APACHE] III) and time needed for calculation have to be taken into consideration. Prognostic models of the third generation (APACHE III, Simplified Acute Physiology Score [SAPS] II, Mortality Prediction Model [MPM] II) should be preferred having better prognostic performance compared to scoring systems of prior generations. Although no prospective study exists comparing these three common scoring systems, it appears that all three systems are able to provide useful information to the clinician and researcher. These scoring systems were designed to classify severity of illness or the course of diagnostic and therapeutic interventions and to perform a risk stratification for scientific studies in a standardized way. In quality management and cost control, scoring systems and predictors are used for risk adjustment and evaluation of care performance.

[Risk predictors, scoring systems and prognostic models in anesthesia and intensive care. Part I: anesthesia]

Risk predictors and scoring systems are commonly used in medicine to provide a reliable and objective estimation of disease prognoses, probability of adverse events and outcome. Furthermore, they were designed to classify severity of illness or the course of diagnostic and therapeutic interventions and to perform a risk stratification for scientific studies in a standardized way. In quality management and cost control, scoring systems and predictors are used for risk adjustment and evaluation of care performance. The aim of this review article was to describe common risk indices and scoring systems in anesthesia (part I) and intensive care (part II), and to point out their possible benefits and limitations. Different scoring systems and classifications are available to stratify perioperative risk and adverse events in anesthesia. Especially in cardiac surgery, an increasing interest in risk-adjusted outcome studies led to the modeling and validation of different prognostic systems for postoperative morbidity, mortality and length of stay. Furthermore, there are scoring-systems for special events, such as difficult laryngoscopy or postoperative nausea and vomiting (PONV). Risk check lists and risk indices are superior to the ASA classification of physical status in providing more exact results and the possibility of statistic risk calculation. Nevertheless, they are not frequently used in clinical routine. Because of its simplicity and easy handling the ASA classification has worldwide popularity and recent studies demonstrated at least equal prognostic performance.

Use of cetrorelix in combination with clomiphene citrate and gonadotrophins: a suitable approach to 'friendly IVF'?

BACKGROUND

With the recently introduced GnRH antagonists, soft stimulation protocols on the basis of clomiphene pretreatment should be possible as the pituitary remains fully sensitive at the beginning of the cycle.

METHODS

A prospective trial was carried out on 107 patients undergoing IVF treatment using the multiple dose GnRH antagonist protocol (cetrorelix), clomiphene citrate, and either HMG (n = 54) or recombinant FSH (rFSH) (n = 53). Different stimulation protocols were used to find the most appropriate one for clinical application.

RESULTS

Both treatment groups, HMG and rFSH, yielded comparable results concerning gonadotrophin dose, stimulation days and pregnancy rate. A mean number of 6.34 +/- 4.4 metaphase II oocytes was retrieved and a mean number of 2.45 +/- 0.65 embryos was transferred. However, the overall rate of premature LH surges was 21.5% (defined as measurement of LH >10 IU/l and progesterone >1 ng/ml) which is unacceptable for clinical practice.

CONCLUSIONS

Increasing the daily cetrorelix dose from 0.25 to 0.5 mg might decrease the number of premature LH surges. Soft stimulation protocols with clomiphene should be used cautiously.

Primary breast cancer therapy in six regions of Germany

Studies from six regions of Germany (Aachen (W1), Dresden (E1), Jena (E2), Marburg (W2), Munich (W3), and Stuttgart (C1)) have been compared to verify and assess the quality of healthcare using breast cancer as an example. All of the data collection was carried out in comprehensive cancer centres and is population-based, with the exception of C1. Classic prognostic factors and the initial treatment of 8661 women with breast cancer, diagnosed between 1996 and 1998, were examined. Primary therapy, breast conserving therapy (BCT), and the use of subsequent local radiation and/or systemic therapy (chemotherapy or hormonal therapy) were analysed. BCT was performed on 39.3-57.7% of patients. By pT-category, the proportion of BCT in the six regions were as follows: for pTis between 37.8 and 64.3%, for pT1 between 51.7 and 71.5%, for pT2 between 25.9 and 51.1%, for pT3 between 0 and 13.1% and for pT4 between 0 and 15.2%. Multivariate analyses, adjusted for age and biological factors, showed a significant influence of the treating hospital on the mastectomy rate. The use of radiotherapy after BCT (80%) was quite homogeneous in the six regions. The application of radiotherapy after mastectomy, however, varied between 10.4 and 32.2%. In all regions, for premenopausal patients, the use of adjuvant systemic therapy almost reflected the St. Gallen-Consensus recommendations. In contrast, post-menopausal women with positive lymph nodes were not always treated according to these standards. In all regions, age had an influence on the administration of treatment: elderly breast cancer patients received less BCT, less radiotherapy and less adjuvant therapy than recommended in the St. Gallen-Consensus. Feedback of the results was made available to each hospital, providing a comparative summary of patient care that could be used by the participating hospitals for self-assessment and quality-control.

Development status of miltefosine as first oral drug in visceral and cutaneous leishmaniasis

An oral treatment for visceral and cutaneous leishmaniasis has been searched for over the last decades. An oral drug would facilitate treatment and lower costs. Oral miltefosine (Zentaris/ASTA Medica AG, Germany), an alkylphosphocholine, is under clinical development for treatment of leishmaniasis. Phase I, II and III clinical trials have been performed in visceral leishmaniasis in India; the overall response rate with 100 mg/day over 4 weeks is 96%. A first clinical trial in New World cutaneous leishmaniasis has shown a final cure rate of 94% at a dose of 150 mg/day over 3 or 4 weeks. Side effects are mainly gastrointestinal (vomiting, diarrhoea). Furthermore, transient elevation of transaminases or urea/creatinine has been observed. The clinical results suggest that miltefosine is the first oral therapy that is effective and safe in visceral and cutaneous leishmaniasis.