Ibero-Panamerican Federation of Periodontology Delphi study on the trends of periodontology and periodontics by the year 2030. A Latin American consensus

BACKGROUND AND OBJECTIVE

As elsewhere in the world, the prevalence of periodontitis in stages I-II is high in the Latin American population, this scenario emphasizes the need for identification of urgent needs for allocating adequate resources to provide diagnosis, prevention, and treatment of these diseases. The aim of this Delphi study was to predict the trends in periodontology/periodontics in the Latin American region by the year 2030.

METHODS

A steering committee and an advisory group of experts in periodontology/periodontics were selected from 16 countries. An open questionnaire of 60 questions was validated and used following the Delphi methodology.

RESULTS

Two hundred and twenty-five experts from Latin America answered the two rounds of the questionnaire. Moderate to strong consensus was reached on 45 questions (75%). The prediction was that the prevalence of gingivitis and periodontitis in stages I and II will be maintained, the importance of the link with systemic diseases will increase, and the impact of prevention and periodontal treatment will also increase, mainly in the private sector. There was a strong consensus that plastic and regenerative surgical procedures will increase, as well as the demand for training in the specialty of periodontology.

CONCLUSIONS

The present study has provided relevant and useful information on predictions in periodontology/periodontics in Latin America, with important level of consensus among experts. It has been predicted that periodontitis will still be a highly prevalent disease, and its links with other medical conditions should demand more attention by health authorities to develop adequate prevention and management policies and strategies.

Factors Associated with the Extent of Clinical Attachment Loss in Periodontitis: A Multicenter Cross-Sectional Study

Periodontitis has significant public health implications, affecting individuals' overall health, well-being, and quality of life. This study aimed to assess the risk factors associated with the extent of clinical attachment loss (CAL) in a population diagnosed with periodontitis. Six hundred and sixty-seven patients with different degrees of CAL (mild, n = 223; moderate, n = 256; and advanced, n = 188) were enrolled. Socio-demographics, lifestyle, microbiological profiles, specific immune response, obesity, and single-nucleotide polymorphism of the IL1 gene were determined. Unconditional logistic regression models were conducted to determine the factors associated with the extent of CAL. Aging, smoking, microbial factors, plaque index, and IgG2 antibodies against Aggregatibacter actinomycetemcomitans were associated with advanced CAL. IgG2 antibodies against A. actinomycetemcomitans (OR 1.50; CI 95% 1.23-1.81), plaque accumulation (OR 2.69; CI 95% 2.20-3.29), Porphyromonas gingivalis (OR 1.93; CI 95% 1.35-2.76), Tanerella forsythia (OR 1.88; CI 95%1.30-2.70), and current smoking (OR 1.94; CI 95% 1.31-2.87) were associated with advanced CAL. Gene IL polymorphisms, obesity, and stress were not associated with the extent of CAL. Aging, plaque accumulation, smoking, and having antibodies against A. actinomycetemcomitans were the most critical factors associated with advanced CAL. In contrast, obesity, stress, and gene polymorphisms were not associated with the extent of CAL.

Valorisation of cellulosic rejections from wastewater treatment plants through sugar production

The widespread use of wipes and other sanitary products made of nonwoven fibres has led to an enormous problem in wastewater treatment systems that has been underestimated for some time. To date, there are no practical alternatives for recycling and valorisation. In this study, cellulosic rejections recovered from a wastewater treatment plant in Barcelona (Spain) were characterised and treated using hydrothermal and enzymatic methods to obtain free sugars. Steam explosion and autoclave pre-treatments were performed at different temperatures (120, 130, or 150 °C) and residence times (10-40 min) under neutral, acidic or basic conditions. The solids obtained after the pre-treatment, as well as the untreated material, were subjected to enzymatic hydrolysis using commercial enzymes. The untreated substrate reached the highest sugar production: 29 g glucose and xylose per 100 g of the cellulosic rejections, equivalent to 86% of the sugars contained in the initial material. These sugars can subsequently be transformed into biofuels or bioproducts within a biorefinery approach.

Stochastic Multilayer Optimization for an Acrylic Acid Reactor

In this paper, a multilayer stochastic optimization approach is implemented to solve a dynamic optimization problem under uncertainties for an acrylic acid reactor. The proposed methodology handles different sources of uncertainties (internal, external, process), being a novel approach to obtain more realistic solutions in the context of process optimization. A comparison against deterministic dynamic optimization, single-layer stochastic optimization, and typical PI control loops is carried out. The results show the efficacy of the multilayer stochastic optimization approach for handling different sources of uncertainties, improving the economic profitability of the process while fulfilling the safety constraints in all of the scenarios analyzed.

Is metabolically healthy obesity indeed healthy at the microvascular level?

Background

In the current “obesity epidemic”, obese individuals without insulin resistance, lipid disorders, or hypertension, have been called “metabolically healthy” (MHO) and considered to have intermediate cardiovascular risk, between that of healthy nonobese (HNO) individuals and of metabolically unhealthy obese (MUO). Nonetheless, this is controversial, as MHO may have subclinical abnormalities, and indeed may be a transitory state in the way to the unhealthy phenotype.

Purpose

To evaluate systemic microvascular reactivity in MHO, MUO and HNO.

Methods

Ten MHO, 10 MUO and 20 HNO individuals were studied. Obesity was considered as a BMI ≥30 kg/m2. The NCEP/ATPIII criteria, excluding waist circumference, were used to define the metabolically healthy phenotype (absence of all criteria) or unhealthy phenotype (presence of any of the criteria). Laser speckle contrast imaging coupled with skin acetylcholine (Ach) iontophoresis was employed to study cutaneous microvascular reactivity (endothelial-dependent vasodilatation), as a surrogate for systemic microvascular function, and cutaneous vascular conductance [CVC in arbitrary perfusion units of microvascular flow (APU)/mean arterial pressure (mmHg)] was measured.

Results

Mean age was 34.8, 36.7 and 32.3 years (P=0.17, ANOVA) and BMI was 20.7, 32.2 and 33.3 kg/m2 (P<0.0001) for HNO, MHO and MUO, respectively. Both MHO and MUO had significantly decreased microvascular vasodilation in comparison to HNO (Figure 1). Of note, there was no significant difference between MHO and MUO regarding CVC (both similarly decreased when compared to the healthy controls).

Conclusions

This study underscores that MHO is not a “benign” condition, as it has adverse effects on microvascular function, similarly to those found in MUO. The study of cutaneous microvascular function may be useful to identify subclinical abnormalities in obese individuals who might deserve more intensive management.

Figure 1

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): FAPERJ - Fundação de Amparo à Pesquisa do Estado do Rio de Janeiro - Brazil

Exceptional preservation of mid-Cretaceous marine arthropods and the evolution of novel forms via heterochrony

Evolutionary origins of novel forms are often obscure because early and transitional fossils tend to be rare, poorly preserved, or lack proper phylogenetic contexts. We describe a new, exceptionally preserved enigmatic crab from the mid-Cretaceous of Colombia and the United States, whose completeness illuminates the early disparity of the group and the origins of novel forms. Its large and unprotected compound eyes, small fusiform body, and leg-like mouthparts suggest larval trait retention into adulthood via heterochronic development (pedomorphosis), while its large oar-like legs represent the earliest known adaptations in crabs for active swimming. Our phylogenetic analyses, including representatives of all major lineages of fossil and extant crabs, challenge conventional views of their evolution by revealing multiple convergent losses of a typical "crab-like" body plan since the Early Cretaceous. These parallel morphological transformations may be associated with repeated invasions of novel environments, including the pelagic/necto-benthic zone in this pedomorphic chimera crab.

Accuracy of cotinine serum test to detect the smoking habit and its association with periodontal disease in a multicenter study

Background

The validity of the surveys on self-reported smoking status is often questioned because smokers underestimate cigarette use and deny the habit. It has been suggested that self-report should be accompanied by cotinine test. This report evaluates the usefulness of serum cotinine test to assess the association between smoking and periodontal status in a study with a large sample population to be used in studies with other serum markers in epidemiologic and periodontal medicine researches.

Material and Methods

578 patients who were part of a multicenter study on blood biomarkers were evaluated about smoking and its relation to periodontal disease. Severity of periodontal disease was determinate using clinical attachment loss (CAL). Smoking was assessed by a questionnaire and a blood sample drawn for serum cotinine determination.

Results

The optimal cut-off point for serum cotinine was 10 ng/ml. Serum cotinine showed greater association with severity of CAL than self-report for mild-moderate CAL [OR 2.03 (CI95% 1.16-3.53) vs. OR 1.08 (CI95% 0.62-1.87) ] advanced periodontitis [OR 2.36 (CI95% 1.30- 4.31) vs. OR 2.06 (CI95% 0.97-4.38) ] and extension of CAL > 3 mm [ OR 1.78 (CI95% 1.16-1.71) vs. 1.37 (CI95% 0.89-2.11)]. When the two tests were evaluated together were not shown to be better than serum cotinine test.

Conclusions

Self-reported smoking and serum cotinine test ≥ 10ng/ml are accurate, complementary and more reliable methods to assess the patient’s smoking status and could be used in studies evaluating serum samples in large population and multicenter studies. Clinical Relevance: The serum cotinine level is more reliable to make associations with the patient’s periodontal status than self-report questionnaire and could be used in multicenter and periodontal medicine studies.

Key words:Biological markers, serum, cotinine, periodontitis, smoking.

Association of metabolic syndrome and chronic periodontitis in Colombians

BACKGROUND

Metabolic syndrome (MetS) is a common chronic condition that increases the cardiovascular disease risk and is also linked to periodontitis. The study aim was to determine if a relationship exists between MetS and chronic periodontitis in adult Colombians.

METHODS

Participants were 220 healthy-gingivitis subjects and 431 periodontitis patients coming from the three largest Colombian cities. Periodontal status and MetS were determined in subjects. Univariate analysis and odds ratio were calculated within the 95 % confidence intervals and chi² test compared the groups. Variables were compared among the clinical periodontal groups and MetS by Wilcoxon and multivariate analysis, and logistic regression was performed for MetS and periodontitis.

RESULTS

MetS had higher prevalence in periodontitis group (6.3 %) versus controls (3.2 %). In multivariate analysis, periodontitis was associated with MetS (adjusted OR = 2.72, 95 % CI 1.09-6.79), glucose intolerance with another component of MetS (adjusted OR = 1.78, 1.16 to 2.72), glucose resistance (adjusted OR = 11.46, 95 % CI 1.41-92.88), smoking (OR = 1.72, 95 % CI 1.09-2.71), and city of origin (2.69, 95 % CI 1.79-4.04).

CONCLUSION

The study confirmed the positive association between MetS and periodontitis, being glucose sensitivity the strongly associated component.

CLINICAL RELEVANCE

MetS must be taken into account by the dentist when evaluating risk factors for periodontitis, being useful for dentists to evaluate glycemia, lipidic profile, central obesity, and high blood pressure in patients. Interdisciplinary treatment must be recommended when a patient with MetS and periodontitis is being treated.

Sugar production from barley straw biomass pretreated by combined alkali and enzymatic extrusion

A pretreatment that combines a thermo-mechanical process (extrusion) with chemical and biological catalysts to produce fermentable sugars from barley straw (BS) biomass was investigated. BS was firstly extruded with alkali and then, the pretreated material (extrudate) was submitted to extrusion with hydrolytic enzymes (bioextrusion). The bioextrudate was found to have 35% (w/w dwb) of total solids in soluble form, partly coming from carbohydrate hydrolysis during bioextrusion. About 48% of soluble solids dry weight is comprised by sugars, mostly glucose and xylose. Further enzymatic hydrolysis of bioextrudate could be successfully carried out at high solid loading level of 30% (w/v), with sugar production yield of 32 g glucose and 18 g xylose/100g bioextrudate at 72 h incubation (equivalent to 96 and 52 g/l concentration, respectively). These results, together with the high level of integration of the process, indicate a great potential of this pretreatment technology for sugar production from lignocellulosic substrates.

Role of disrupted in schizophrenia 1 (DISC1) in stress-induced prefrontal cognitive dysfunction

Recent genetic studies have linked mental illness to alterations in disrupted in schizophrenia 1 (DISC1), a multifunctional scaffolding protein that regulates cyclic adenosine monophosphate (cAMP) signaling via interactions with phosphodiesterase 4 (PDE4). High levels of cAMP during stress exposure impair function of the prefrontal cortex (PFC), a region gravely afflicted in mental illness. As stress can aggravate mental illness, genetic insults to DISC1 may worsen symptoms by increasing cAMP levels. The current study examined whether viral knockdown (KD) of the Disc1 gene in rat PFC increases susceptibility to stress-induced PFC dysfunction. Rats were trained in a spatial working memory task before receiving infusions of (a) an active viral construct that knocked down Disc1 in PFC (DISC1 KD group), (b) a 'scrambled' construct that had no effect on Disc1 (Scrambled group), or (c) an active construct that reduced DISC1 expression dorsal to PFC (Anatomical Control group). Data were compared with an unoperated Control group. Cognitive performance was assessed following mild restraint stress that had no effect on normal animals. DISC1 KD rats were impaired by 1  h restraint stress, whereas Scrambled, Control, and Anatomical Control groups were unaffected. Thus, knocking down Disc1 in PFC reduced the threshold for stress-induced cognitive dysfunction, possibly through disinhibited cAMP signaling at neuronal network synapses. These findings may explain why patients with DISC1 mutations may be especially vulnerable to the effects of stress.

Association between periodontal disease and plasma levels of cholesterol and triglycerides

Objective: Untreated periodontal disease seems to cause low grade systemic inflammation and blood lipid alteration leading to increased cardiovascular disease risk. To start testing this hypothesis in Colombian patients, a multicentre study was conducted including the three main state capitals: Bogotá, Medellín and Cali. Methods: In this study 192 (28.4%) advanced and 256 (37.8%) moderate periodontitis patients were investigated for socio-demographic variables, city of precedence, periodontal parameters, smoking, red complex periodontopathic bacteria, serum antibodies against Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans and blood lipids including total cholesterol, HDL, LDL and triglycerides (TG). Those parameters were compared to 229 (33.8%) controls having periodontal health or gingivitis. Results: Advanced periodontitis had worst periodontal indexes, than moderate periodontitis and controls. Interestingly, higher HDL and TG levels were present in periodontitis. BMI <30 and smoking were associated with increased HDL, HDL-35, LDL and TG, while glycemia >100 mg/dL associated with HDL, HDL-35 and TG. Tannerella forsythia showed a significant association with HDL-35 in bivariate analysis and serum IgG1 against P. gingivalis associated with HDL-35 and serum IgG1 against T. forsythia associated with TG and serum IgG2 against A. actinomycetemcomitans correlated with levels of HDL y HDL-35. In logistic regression the periodontitis patients from Cali presented reduced HDL levels as compared to Bogotá and Medellín patients. Presence of IgG1 antibodies against P. gingivalis and A. actinomycetemcomitans correlated with reduced HDL levels. Conclusion: This study confirmed that untreated periodontitis generates alteration in serum lipid levels and systemic bacterial exposure against important periodontopathic bacteria seems to be the biological link.

Fibromyalgia and psychopathology

Introduction

Fibromyalgia seems to be associated with various forms of psychopathology, particularly major affective disorders.

Objective

To evaluate associated psychopathology in a series of women with diagnosis of fibromyalgia.

Methods

Patient inclusion from 1st March to 30th June 2010. Symptom Checklist (SCL-90-R) was used for evaluation. SPSS was used for statistical analysis of data and results.

Results

A total of 34 women voluntarily joined our study. Mean age was 52.2 years (standard deviation (SD) 7.17). 11.4% were singled, 74.3% married or unmarried couples, 8.6% were divorced, and 5.7% were widowers. 74.3% of women lived with their couple and/or children whereas 8.6% lived by their own, and 8.6% with their parents. Results obtained with SCL-90-R showed:

Global Severity Index (GSI) 1.86 (Standard Deviation (SD) 0.54); Positive Symptom Distress Index (PSDI) 2.58 (SD 0.36); Positive Symptom Total (PST) 167.85 (SD 49.30); Somatization (SOM) 2.62 (SD 0.53); Obsessive-Compulsive (O-C) 2.59 (SD 0.78); Interpersonal Sensitivity (I-S) 1.50 (SD 0.86); Depression (DEP) 2.5 (SD 0.75); Anxiety (ANX) 1.75 (SD 0.74); Hostility (HOS) 1.11 (SD 0.82); Phobic Anxiety (PHOB) 1.09 (SD 0.84); Paranoid Ideation (PAR) 1.11 (SD 0.85); Psychoticism (PSY) 1.05 (SD 0.62), and other vague symptoms 2.15 (SD 0.70).

Conclusion

Our patients with fibromyalgia scored higher in somatization, obsession-compulsion, depression, and anxiety. In view of the results, there is an important association between fibromyalgia and various forms of psychopathology.

Preliminary results of docetaxel (T) and trastuzumab (H) combination administered every 21 days in metastatic breast cancer (MBC) and HER-2 over-expression patients (P)

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Background: T combined with weekly H confers greater tumor response and survival compared to T monotherapy in P with Her-2 positive MBC. A recent report has demonstrated that H can be administered q3wks. The primary endpoint is to evaluate time to progression (TTP). Sencondary objectives are response rate, overall survival and safety profile. Methods: P cytologically or histologically confirmed of metastatic breast cancer, HER-2 positive (+++ by Herceptest, or FISH positive), age > 18, ECOG PS ≤ 2, and adequate organ function, were included. Prior chemotherapy for MBC or adjuvant anthracycline-based regimen in the previous 6 months was not allowed. Treatment: T 100 mg/m2 iv D1 q3wks for 6 cycles, H 8 mg/kg (cycle 1) and 6 mg/kg (consecutive cycles) iv D1, q3wks. P may receive H monotherapy until PD at the investigator criteria. Results: Over 41 analyzed P, median age was 57 years (29–75); ECOG PS 0–1 95% and ductal carcinoma 88%. Twenty five P received prior chemotherapy. Treatment: 217 cycles of TH (median 6) were administered. After that, 23 P received 189 cycles of H monotherapy (median 5, 1–32). During TH treatment median RDI was 97% for T and 96% for H, and it was 99% during H treatment. Over 33 P for efficacy analysis (2 consent withdrawal, 1 allergic reaction, 1 ongoing and 4 response not confirmed by RECIST criteria), 6 achieved CR and 12 PR, for an ORR of 54.6% (95% CI: 37.6–71.6). Median follow-up time was 11.8 m and median TTP was 8.8 m (95% CI, 1.9–15.6). All P were evaluable for safety. During TH treatment, grade III/IV neutropenia occurred in 16 cycles (7.4 %), 14 of them were febrile neutropenia episodes (6.5%). Other grade III/IV toxicities per cycle were: leucopenia (5.5%), hyperglycemia (2.3%), anorexia (2.3%) and skin (2.3%). During H monotherapy treatment, the only grade III-IV toxicities observed were, skin (1.6%), oedema (1.1%), nail disorders (0.5%) and malaise (4.3%). Six P (14.6%) dropped out due to cardiac toxicity: 5 had LVEF under 50% and one atrial fibrillation. Conclusions: Preliminary results suggest that TH q3wks followed by H as single agent, is an effective regimen for the treatment of P with Her2 positive MBC.

No significant financial relationships to disclose.

Local synaptic connections of basal forebrain neurons

Single, biocytin filled neurons in combination with immunocytochemistry and retrograde tracing as well as material with traditional double-immunolabeling were used at the light and electron microscopic levels to study the neural circuitry within the basal forebrain. Cholinergic neurons projecting to the frontal cortex exhibited extensive local collaterals terminating on non-cholinergic, (possible GABAergic) neurons within the basal forebrain. Elaborate axon arbors confined to the basal forebrain region also originated from NPY, somatostatin and other non-cholinergic interneurons. It is proposed that putative interneurons together with local collaterals from projection neurons contribute to regional integrative processing in the basal forebrain that may participate in more selective functions, such as attention and cortical plasticity.

EEG correlation of the discharge properties of identified neurons in the basal forebrain

The basal forebrain (BF) is a heterogeneous structure located in the ventral aspect of the cerebral hemispheres. It contains cholinergic as well as different types of noncholinergic corticopetal neurons and interneurons, including GABAergic and peptidergic cells. The BF constitutes an extrathalamic route to the cortex, and its activity is associated with an increase in cortical release of the neurotransmitter acetylcholine, concomitant with electroencephalographic (EEG) low-voltage fast activity (LVFA). However, the specific role of the different BF cell types has largely remained unknown due to the lack of chemical identification of the recorded neurons. Here we show that the firing rate of immunocytochemically identified cholinergic and parvalbumin-containing neurons increase during cortical LVFA. In contrast, increased neuropeptide Y neuron firing is accompanied by cortical slow waves. Our results, furthermore, indicate that BF neurons posses a distinct temporal relationship to different EEG patterns and suggest a more dynamic interplay within BF as well as between BF and cortical circuitries than previously proposed.

Snakebites and ethnobotany in the northwest region of Colombia: Part I: traditional use of plants

In Antioquia and Chocó, traditional healers attend 60% of snakebites. With the aim to produce an inventory of the plants used by the healers to treat snakebites and to document the methods of preparation, administration, the dosage, number of patients treated throughout their years of practice with treatment results, 20 healers with experience in Bothrops, Porthidium and Bothriechis envenomations were interviewed between August, 1996 and November, 1998. They belong to nine black and three indigenous rural communities located near the towns of Bojayá, Vigía del Fuerte, Unguía (Atrato river valley), Nuquí and Bahía Solano (Pacific coast). Based on field interviews, 101 species of plants were identified as used to treat snakebites. The part used of each plant varies according to the species. Sixty plants are used in the form of drinks prepared by infusion, decoction or maceration; 78 as external baths on the affected extremity; 11 for steam application and 39 for poultices; the latter is used mainly when the bite is complicated by local necrosis. In mild and moderate envenomations, they generally use a mixture of three plants, while in severe cases they mix from five to 12, a handful of each one. Treatment is generally performed for 1-3 days, when the patient reacts positively. They reported to have treated 454 patients during their years of experience, 20 of them (4.4%) died. With the guidance of the healers, 77 species of plants were collected and photographed. These plants belong to 41 families, of which Piperaceae (13 species), Araceae (six species), Asteraceae (five species) and Gesneriaceae (three species) have the highest number of species.

A cohort study on the risk of acute liver injury among users of ketoconazole and other antifungal drugs

AIMS

The aim of this cohort study was to estimate the risk of clinical acute liver injury among users of oral antifungals identified in the general population of the General Practice Research Database in UK.

METHODS

The cohort included 69 830 patients, 20-79 years old, free of liver and systemic disease, who had received at least one prescription for either oral fluconazole, griseofulvin, itraconazole, ketoconazole, or terbinafine between 1991 and 1996.

RESULTS

Sixteen cases of acute liver injury were identified and validated. Ten cases occurred during nonuse of oral antifungals with a background rate of 0.6 per 100,000 person-months (95% confidence interval 0.3,1.1). Five cases occurred during current use of oral antifungals. Two were using ketoconazole, another two itraconazole, and one terbinafine. Incidence rates of acute liver injury were 134.1 per 100 000 person-months (36.8,488.0) for ketoconazole, 10.4 (2.9-38.1) for itraconazole, and 2.5 (0.4,13. 9) for terbinafine. The remaining case was associated with past use of fluconazole. Ketoconazole was the antifungal associated with the highest relative risk, 228.0 (95% confidence interval 33.9,933.0), when compared with the risk among nonusers, followed by itraconazole and terbinafine with relative risks of 17.7 (2.6,72.6) and 4.2 (0.2, 24.9), respectively.

CONCLUSIONS

Ketoconazole and itraconazole were the two oral antifungal associated with a marked increase of clinical acute liver injury. The risk associated with ketoconazole should be taken into account when prescribing it as initial treatment for uncomplicated fungal infections.

Comparison of the anti-inflammatory effect and gastrointestinal tolerability of aceclofenac and diclofenac

Aceclofenac (CAS 89796-99-6) and diclofenac (CAS 15307-79-6) are orally effective non-steroidal anti-inflammatory drugs. Their anti-inflammatory and potential gastrointestinal damaging effects were compared following single and repeated administration (5 days). Both drugs exerted an anti-inflammatory activity and showed a similar gastrointestinal tolerability in the rat.

Evaluation of the methodological quality of clinical trial protocols. A preliminary experience in Spain

The methodological quality of 50 clinical trial protocols submitted to our hospital has been assessed by means of a check-list. The most frequent methodological deficiencies found were related to statistical analysis, selection criteria, sample size, incorrect use of placebo, homogeneity of the groups, concomitant medication, randomisation plan, monitoring of adverse events and study design. Lack of insurance for the patients and inadequacies in the investigators' brochure and case report forms were observed in a significant number of cases. The results suggest the importance of a multidisciplinary team in the elaboration of clinical trial protocols to prevent methodological errors.

Epirubicin in rectal cancer

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