Effect of ABCB1 C3435T polymorphism on docetaxel pharmacokinetics according to menopausal status in breast cancer patients

Background:

It can be hypothesised that inherited polymorphisms in the drug-transporter ABCB1 gene may interfere with interindividual variations in drug response in breast cancer patients. Docetaxel is a substrate for ABCB1 whose function has been shown to be modulated by oestrogen and progesterone.

Methods:

Whether ABCB1 polymorphisms including T-129C, A61G, C1236T, G2677T/A and C3435T polymorphisms could account for variations in the disposition of docetaxel and whether menopausal status at the time of diagnosis might interact with this effect were analysed in women receiving neoadjuvant chemotherapy for breast cancer (n=86).

Results:

A highly significant association was observed, but restricted to premenopausal women (n=53), between the pharmacokinetics of docetaxel and C3435T polymorphism, as patients with CC genotype had lower mean values of the area under the plasma concentration-time curve (AUC) of docetaxel than patients with CT and TT genotypes (P<0.0001). Comparison between pre- and postmenopausal women with the same C3435T genotype yielded a significant difference in docetaxel AUC only for CC genotype (P<0.0001).

Conclusion:

These results suggest that C3435T polymorphism genotyping and menopausal status at the time of diagnosis might be useful when considering chemotherapy regimens including docetaxel in breast cancer patients.

Gemcitabine-oxaliplatin combination for ovarian cancer resistant to taxane-platinum treatment: a phase II study from the GINECO group

Advanced ovarian carcinoma in early progression (<6 months) (AOCEP) is considered resistant to most cytotoxic drugs. Gemcitabine (GE) and oxaliplatin (OXA) have shown single-agent activity in relapsed ovarian cancer. Their combination was tested in patients with AOCEP in phase II study. Fifty patients pre-treated with platinum–taxane received q3w administration of OXA (100 mg m^–2, d1) and GE (1000 mg m^–2, d1, d8, 100-min infusion). Patient characteristics were a : median age 64 years (range 46–79),and 1 (84%) or 2 (16%) earlier lines of treatment. Haematological toxicity included grade 3–4 neutropaenia (33%), anaemia (8%), and thrombocytopaenia (19%). Febrile neutropaenia occurred in 3%. Non-haematological toxicity included grade 2–3 nausea or vomiting (34%), grade 3 fatigue (25%),and grade 2 alopecia (24%). Eighteen (37%) patients experienced response. Median progression-free (PF) and overall survivals (OS) were 4.6 and 11.4 months, respectively. The OXA–GE combination has high activity and acceptable toxicity in AOCEP patients. A comparison of the doublet OXA–GE with single-agent treatment is warranted.

Modulation of placental protein expression of OLR1: implication in pregnancy-related disorders or pathologies

The lectin-like oxidized low-density lipoprotein (LDL) receptor-1 (OLR1) is a newly described receptor for oxidatively modified LDL. The human pregnancy is associated with hyperlipidemia and oxidative stress. It has been reported that modification in maternal lipid profile can induce disturbance during pregnancy. In this study, we have evaluated the expression protein level of OLR1 in human term placenta of women having plasma cholesterol level lower to 7 mM or higher to 8 mM and women of gestational diabetes mellitus (GDM) by western blot analysis. The present study demonstrates that the maternal lipid profile is associated with placental protein expression of OLR1. A significant increase in the protein expression of OLR1 was observed in placenta of women with elevated plasmatic total cholesterol level (>8 mM). In addition, the placental protein expression of OLR1 is increased in mothers having the highest pre-pregnancy body mass index (BMI) and low (<7 mM) plasmatic total cholesterol level at term. Interestingly, the placental protein expression of OLR1 is increased in the presence of GDM pregnancies compared with normal lipids level pregnancies, without the modification of mRNA expression. In conclusion, placental OLR1 protein expression is associated with maternal lipid profile, pre-pregnancy BMI, and pathology of GDM.

Hyperlipidemic profiles during remission in childhood idiopathic nephrotic syndrome

Hyperlipidemia, an important characteristic of idiopathic nephrotic syndrome in children (NS), is usually observed during the active phase of the disease and disappears with the resolution of the proteinuria. However, persisting lipid anomalies during remission have been reported in a few studies and raise the question of the later development of atherosclerosis. Plasma lipid profiles in 25 children with NS at remission, with or without active prednisone treatment, were compared with those of an age-matched population. The results indicate that plasma total and LDL-cholesterol levels were above the 95(th) percentile for age and sex in 12 of the 25 patients (48%) with 7 of them having apolipoprotein B and triglyceride concentrations above the 95(th) percentile. Moreover, frequently relapsing children were more likely to have abnormal lipid profile during the remission. We conclude that close monitoring of lipid levels during the remission of the NS especially in those with frequent relapses, is necessary to select the high-risk patients.

Manic episodes: the direct cost of a three-month period following hospitalisation

INTRODUCTION

Few data exist to estimate the burden of manic episodes on healthcare systems or the therapeutic strategies used. This study was undertaken to identify treatment strategies chosen, and to assess the "real-world" direct medical cost of treating manic episodes necessitating hospitalisation.

METHOD

Case record data were reviewed during the three months following hospitalisation for a manic episode in France. Healthcare resource utilisation was assessed, direct costs calculated, and treatment strategies analysed. A total of 137 patients files (51.8% female; mean age: 35 years) were reviewed and data on 185 hospitalisations collected.

RESULTS

The mean duration of hospitalisation was 47 days over the study period. The most common treatment strategy during hospitalisation was the combination of a mood stabilizer with a neuroleptic drug (64% of patients at day 30). Anticonvulsants including valproate (39%) and carbamazepine (20%) were more common than lithium (42%). Treatment received during hospitalisation was generally continued after discharge, with a trend away from neuroleptics and towards mood stabilizers. The mean direct costs incurred over the three-month study period was Euro 22297, with 98.6% of those costs due to hospitalisation.

CONCLUSION

These results confirm that the costs of treating a manic episode are high, and overwhelmingly due to the cost of hospitalisation.

Sim1 haploinsufficiency causes hyperphagia, obesity and reduction of the paraventricular nucleus of the hypothalamus

The bHLH-PAS transcription factor SIM1 is required for the development of the paraventricular nucleus (PVN) of the hypothalamus. Mice homozygous for a null allele of Sim1 (Sim1(-/-)) lack a PVN and die perinatally. In contrast, we show here that Sim1 heterozygous mice are viable but develop early-onset obesity, with increased linear growth, hyperinsulinemia and hyperleptinemia. Sim1(+/-) mice are hyperphagic but their energy expenditure is not decreased, distinguishing them from other mouse models of early-onset obesity such as deficiencies in leptin and melanocortin receptor 4. Quantitative histological comparison with normal littermates showed that the PVN of Sim1(+/-) mice contains on average 24% fewer cells without a selective loss of any identifiable major cell type. Since acquired lesions in the PVN also induce increased appetite without a decrease in energy expenditure, we propose that abnormalities of PVN development cause the obesity of Sim1(+/-) mice. Severe obesity was described recently in a patient with a balanced translocation disrupting SIM1. Pathways controlling the development of the PVN thus have the potential to cause obesity in both mice and humans.

[Bisprolol in heart failure: efficacy and costs in a French setting according to CIBIS II]

After a significant mortality benefit with bisoprolol in heart failure was demonstrated in CIBIS-II, an economic evaluation has been performed in cost-effectiveness terms. Average direct costs per patient were based on clinical data from 231 French patients, and measured in the perspective of the French National Health Insurance, effectiveness being expressed in terms of life days gained per patient. The extra cost of bisoprolol treatment and follow-up (averaging FF 1300 per 1.3 years) is outweighed by the reduction in hospitalization costs (representing a saving of FF 10,500 per patient) and other medication costs. Finally, bisoprolol therapy induces benefits in terms of both cost and survival: on average FF 9500 and 11 life days per patient. Sensitivity analyses confirm these results.

Determinants of lipid level variability in French-Canadian children with familial hypercholesterolemia

The wide variability in the biochemical expression of familial hypercholesterolemia (FH) is only partly explained by mutational heterogeneity in the low density lipoprotein receptor (LDLR) gene. In the current study, we measured this biochemical variability in a group of children heterozygous for the >15-kb LDLR gene deletion (n=67) and examined the contribution of apolipoprotein (apo) E and B allelic variations to this phenotypic variability. Variances of total cholesterol (TC), LDL-C, and apoB concentrations and of the ratio of TC to high density lipoprotein cholesterol (HDL-C) were increased in FH subjects compared with controls. However, after taking the means into account, the coefficients of variation showed that the variability of LDL-C and apoB concentrations was smaller for FH than for controls and that the variability of TC and of the ratio TC to HDL-C was similar between both groups. The epsilon2/3 genotype was associated with lower mean TC, LDL-C, and apoB concentrations in FH. The magnitude of this effect was smaller in controls than in FH. Indeed, the percentages of total variance of TC, LDL-C, and apoB attributable to the apoE locus were 19.9%, 18.1%, and 11.8%, respectively, in FH cases and 5.9%, 7.4%, and 6.0%, respectively, in controls. We did not detect any effect of the apoB insertion/deletion polymorphism on lipid traits in FH children. However, in controls, we observed a strong interaction between apoE and apoB genotypes on apoB concentrations and on TC to HDL-C ratios. Our study reemphasizes the important role of apoE in lipid metabolism and illustrates that the effects of allelic variations on lipid traits are context dependent.

The 1999 French Venous Disease Survey: epidemiology, management, and patient profiles

A recent (1999) Sofres survey of representative samples of the adult French population aged 15 and over showed that almost half this population suffered from lower limb venous complaints and that 43% of them were untreated. Of those treated, 24.2% received venotropics, including 21.5% by prescription, while 6.0% practiced self-medication. Venous disease sufferers form a relatively underprivileged sector of the population in terms not only of age, income, work and living conditions, but also of general health and medical history. Despite its clinical efficacy and potential social utility, venotropic treatment is possible only if backed by adequate state health insurance coverage supplemented by mutual and private insurance schemes. Any restriction to such coverage will only decrease access to prescription venotropics.

[Management of venous leg ulcer by French physicians, diversity and related costs: a prospective medicoeconomic observational study]

OBJECTIVES

The purpose of this study was to better ascertain how French physicians manage venous ulcers of the lower limbs. We explored the various therapeutic approaches used and their respective costs. Particular attention was focused on dressing prescriptions.

MATERIAL AND METHODS

A prospective medicoeconomic study was conducted. Eight hundred general practitioners and specialists throughout France were included and followed two patients each, one with a "new ulcer" (less than two weeks) and another with a "longstanding ulcer" (more than six weeks). Patients were followed to healing or for up to six months. An observation chart was completed at each visit. Data collected were characteristics of the ulcer at inclusion, assessment of the clinical course, and the nature and the volume of medical care prescribed. Corresponding costs (total cost for the society) were calculated on the basis of 1996 public prices for drugs and the French national health insurance quotations for ambulatory care. For hospital care, cost was calculated from the cost of stay for homogeneous patient groups.

RESULTS

Files established for 1,098 patients by 652 physicians could be assessed. Elderly female patients predominated in this population (mean age 72 years, 74% women). The length of the ulcer at inclusion was significantly correlated with its duration: 2.82 cm for new ulcers (52.6% of the cases) versus 5.03 cm for longstanding ulcers (47.3%). The mean number of consultations for all patients was 4.8 over a 29-day period. Mean cost resulting from these consultations was 5,827 FF per patient: 48% for care, 33 for drugs, 16% for hospitalizations, and 3% for work lay-off ). Cure was achieved in 77% of the cases within a mean delay of 3 months. Older ulcer was significantly associated with longer treatment (117 days for longstanding ulcers versus 80 days for new ulcers), lower cure rate (67% versus 86%) and higher cost (7 078 FF versus 4 669 FF). Dividing care methods between those using cleaning with compression or not showed that compression was prescribed in 76% of the cases at the inclusion consultation. This predominance of compression therapy did not preclude use of a variety of other therapeutic methods depending on the clinical and demographic situation of the patient. Cost varied accordingly with a mean ranging from 3 160 FF to 6 697 FF depending on the therapeutic attitude. The study also focused on the type and amount of dressings used. Dressings were prescribed for 56 patients in this series. It can be hypothesized that these patients already had dressings. Different indicators show that the absence of prescriptions for dressings concerned less severe and less costly ulcers (4 130 FF versus 5 918 FF for those with dressing prescriptions). Among the 1 042 patients for whom dressings were prescribed, 35% were for occlusive dressings, 29% for ointment dressings and also 24% for both occlusive and ointment dressings. The type was not specified in 55% of the cases. Mean cost for these different categories ranged from 4 921 to 7 019 FF.

[Economic study of carvedilol in heart failure. A cost effectiveness study in France]

A programme of four phase III clinical trials carried out in the USA on 1094 patients showed that Carvedilol, associated with the usual bitherapy and eventually with digitalis, reduced the mortality and number of hospital admissions of patients with cardiac failure. These results, transposed to the French population, may be used to evaluate the economic advantages of Carvedilol by developing a cost-effectiveness study which consists in relating the direct expenses (drugs and hospital admissions) of each of the two strategies, with or without Carvedilol, to their respective mortalities. Hospital expenses were estimated with respect to the H.M.G. corresponding to each hospital stay at 1997-1998 values. The cost in the Carvedilol group was 2,823 FF per patient (including 1,491 FF for the drug itself) but 2,056 FF were economised in hospital expenses. With an increased cost of 767 FF but a 50% reduction in mortality corresponding to a difference in mortality of 45@1000, the cost-effectiveness of Carvedilol was 17,040 per life saved and 2,130 FF per additional year of life expectancy. A study of the sensitivity produced even more favourable results of Carvedilol. An evaluation of hospital expenses on the basis of AP-HP data indicates that the addition of Carvedilol is associated with a 4,425 FF reduction in hospital expenses, which makes it a cost saving strategy.

[Anaplastic cancers of the thyroid. Is healing possible?]

OBJECTIVE

Thyroid anaplastic carcinoma is associated with a very poor prognosis. The goal of this study was to determine whether an aggressive treatment is worthwhile.

PATIENTS AND METHODS

Of 22 thyroid anaplastic carcinomas confirmed with immunohistochemistry, 17 were judged eligible for surgery. Total thyroidectomy was planned in all patients. Frozen section of the lower lateral lymph nodes was routinely performed and in case of involvement (n = 9), a modified radical neck dissection was carried out. Fractionated radiotherapy was started within 5 weeks following surgery: 6,000 cGy was delivered on the thyroid area and all involved areas while 4,500 cGy was delivered on the lymph nodes of the neck and of the superior mediastinum when non involved.

RESULTS

The three patients without distant metastasis, with thyroid removal considered as complete, were still free of disease 10, 12 and 13 years later. One of these patients had been initially considered inoperable and was operated later when a combination of radiotherapy and chemotherapy obtained a decrease of the tumor. All other patients, 13 with incomplete removal and one with pulmonary metastasis died from their cancer; the median of the survival was 7 months.

CONCLUSION

When anaplastic carcinoma is suspected on clinical appearance, the diagnosis should be rapidly confirmed with percutaneous biopsy and immunohistochemistry. If a lymphoma is found, surgery is not indicated. Our results demonstrate that except for widely infiltrating tumors or distant metastasis, a complete removal of the tumor should be attempted as soon as possible. Surgery should be followed with hyperfractionated radiotherapy. Multimodal therapy may result in long-term survival. A patient free of disease at 5 years may be considered as definitively cured.

From cost of illness to cost-effectiveness in heart failure

Congestive heart failure is a severe condition responsible for 1%-2% of total health expenditure. In France, three-quarters of the medical cost of congestive heart failure, i.e. FF7 billion, is attributed to 150000 annual hospital admissions. But new treatments, especially ACE inhibitors and beta-blockers, have demonstrated, through large controlled trials (SAVE, AIRE, US trials on carvedilol and CIBIS I) that these drugs can reduce mortality and hospitalization. These results, translated in terms of cost per life year saved, show that they are all very cost effective and could be cost saving, under some conditions.

Toxicity of fluorouracil in patients with advanced colorectal cancer: effect of administration schedule and prognostic factors

PURPOSE

Fluorouracil (5-FU) continuous infusion is superior to 5-FU bolus in patients with advanced colorectal cancer, but the survival difference between the two treatments is small and, therefore, the difference in toxicity profile is crucial in choosing a treatment for individual patients.

MATERIALS AND METHODS

We conducted a meta-analysis of all randomized trials that compared 5-FU bolus with 5-FU CI, based on individual data from 1,219 patients, to compare the toxicity of the two schedules of 5-FU administration and to identify predictive factors for toxicity. The toxicities considered were World Health Organization (WHO) grade 3 to 4 anemia, thrombopenia, leukopenia, neutropenia, nausea/vomiting, diarrhea, mucositis, and hand-foot syndrome.

RESULTS

Hematologic toxicity, mainly neutropenia, was more frequent with 5-FU bolus than with 5-FU CI (31% and 4%, respectively; P < .0001). Hand-foot syndrome was less frequent with 5-FU bolus than with 5-FU CI (13% and 34%, respectively; P < .0001). There was no difference between the two treatment groups in terms of other nonhematologic toxicities. Independent prognostic factors were age, sex, and performance status for nonhematologic toxicities, performance status, and treatment for hematologic toxicities, and age, sex, and treatment for hand-foot syndrome.

CONCLUSION

Based on a large data set, this study confirmed and quantified the toxicity profile of the two schedules of administration of 5-FU and allowed the identification of clinical predictors of toxicity.

Apolipoproteins in human fetal colon: immunolocalization, biogenesis, and hormonal regulation

The present investigation aimed at defining the localization of apolipoproteins (apo) A-I, A-IV, B-48, and B-100 along the crypt-villus axis of the human fetal colon, their biogenesis during gestation, and their hormonal regulation. Using immunofluorescence, the distribution of apo A-I and A-IV appeared as a gradient, increasing from the developing crypt to the tip of the villus. On the other hand, apo B-100 staining was found in the crypt and the lower mid-villus region with varying intensities in the upper villus cells, while the 2D8 antibody which recognizes both apo B-100 and B-48, revealed uniform staining along the crypt-villus axis. Apolipoprotein synthesis, determined by [35S] methionine labeling, immunoprecipitation, and SDS-PAGE showed a predominance of apo A-IV (53%), followed by apo A-I (23.9%), apo B-48 (13.4%), and apo B-100 (9.7%). The synthesis of each apolipoprotein was significantly modulated by hydrocortisone, insulin and epidermal growth factor (EGF). Apart from a decrease in apo B-100 exerted by EGF and a reduction in apo A-I resulting from the addition of insulin, the other apolipoproteins were all enhanced. Our data confirm that the fetal colon has the capacity to synthesize apolipoprotein A-I, A-IV, B-48, and B-100 and establish that their synthesis are modulated by hormonal and growth factors known to be involved in the regulatory mechanism of the functional development of human jejunum.

Familial lipoprotein lipase deficiency in infancy: clinical, biochemical, and molecular study

OBJECTIVES

To describe the characteristics of lipoprotein lipase (LPL)-deficient patients seen in infancy and to evaluate the safety and efficacy of severe fat restriction.

METHODS

Children <1 year old presenting with chylomicronemia between 1972 and 1995 were identified, and their clinical courses were reviewed retrospectively.

RESULTS

LPL deficiency was demonstrated in 16 infants who presented with irritability (n = 7), lower intestinal bleeding (n = 2), pallor, anemia, or splenomegaly (n = 5), and a family history or fortuitous discovery (n = 2). All plasma samples were lactescent at presentation. Chylomicronemia responded rapidly to dietary fat restriction, and it was possible to maintain satisfactory metabolic control for a prolonged period of time. Only 1 adolescent girl had an episode of pancreatitis associated with the use of oral contraceptives. No persistent adverse effects on growth were seen. We obtained abnormal values for serum iron, alkaline phosphatase, and total calcium.

CONCLUSIONS

The presentation of LPL deficiency is heterogeneous during infancy. Close dietary monitoring is required to avoid nutritional deficiencies. Estrogen therapy should be avoided in LPL-deficient patients.

The role of dietary choline in the beneficial effects of lecithin on the secretion of biliary lipids in rats

Earlier studies showed that dietary soybean lecithin increases biliary lipid secretion, which mainly comes from the contribution of high density lipoprotein (HDL) and hepatic microsomal pools of phosphatidylcholine and cholesterol. In addition, a lecithin diet enhances bile secretion and prevents bile acid-induced cholestasis. This study evaluated the contribution of choline, a component of lecithin, to the observed effect of lecithin on biliary secretory function. Rats were fed either a control diet (CD), a choline diet (ChD) or a lecithin-enriched diet (LD) for 2 weeks. Results showed that like LD, ChD induced an increase in bile flow and bile acid secretion rate when compared with the control diet. However, unlike LD, ChD did not significantly increase biliary phospholipids and cholesterol output. An increase of hydrophilic bile acids (i.e. ursodeoxycholic and muricholic acids) in bile of rats fed choline could explain why the biliary phospholipid and cholesterol secretion was not increased. During taurocholic acid infusion, both experimental diets increased bile flow and the bile acid secretion rate maximum (BASRm). The cholestasis usually observed after the BASRm is reached was inhibited by ChD and LD. Both diets induced a decrease in plasma cholesterol (total and HDL), however, only LD induced statistically significant changes. Analysis of total cholesterol and phospholipid content of microsomes and canalicular membranes indicated no statistically significant difference between control and experimental groups either under basal conditions or after bile acid infusion. Similarly, the phospholipid classes and fatty acid composition of biliary phosphatidylcholine were not altered by feeding ChD and LD. We conclude that choline contributes to the beneficial effect of a lecithin diet on bile secretion. It is postulated that this effect may be attributed to modulation of HDL and an enhancement of the cholesterol and phospholipid pools destined for biliary secretion.

"Specific" scale compared with "generic" scale: a double measurement of the quality of life in a French community sample of obese subjects

STUDY OBJECTIVE

To determine the aspects of quality of life that are affected by weight in the general population, to develop a specific questionnaire (OSQOL) that can measure with reliability and validity the impact of overweight and obesity on well being, and to compare the results with those obtained using a well known generic tool (the "SF 36" scale).

DESIGN

Cross sectional survey with matched control group.

SETTING

Community.

PATIENTS

A permanent survey base of approximately 10,000 representative ordinary households were screened for weight and height. Five hundred subjects were randomly drawn from the sub-sample of adult people with a body mass index equal or greater than 27. A control sample of 500 subjects matched for sex, age, and employment status was drawn from the non-obese population.

MAIN RESULTS

A short specific Quality Of Life scale, the OSQOL, was produced that comprises 11 items belonging to four independent dimensions. Using this scale and the SF36, it was found that: (1) moderately obese subjects (27 < or = BMI < 30) did not significantly differ from the control group except for physical capacity; (2) in the group of obese subjects with a BMI > 30, quality of life seemed to be impaired for five of nine dimensions of the SF36 compared with the control population, all related to physical consequences of obesity. This population essentially perceived itself in terms of poor general health. (3) No significant difference was observed between the samples for the psychological and social dimensions of the SF36.

CONCLUSION

The quality of life of patients with severe obesity is impaired, but it mainly affects the physical consequences of the disease. The psychological and social repercussions that could have been expected to affect this population were not demonstrated. The hypothesis of a process of adaptation of the person and their social environment cannot therefore be excluded. Methodologically, comparison of the specific OSQOL with the generic SF3 shows clearly that the two kinds of scales correspond to different objectives and should be considered as complementary.

[Adjuvant chemotherapy of soft tissue sarcoma]

The rôle of chemotherapy in the treatment of operable soft tissue sarcomas is still debatable. In high-grade tumors, randomized trials using adjuvant chemotherapy have resulted in controversial results. A recent meta-analysis showed a higher median disease-free survival in groups with chemotherapy compared to controls. Doxorubicin, ifosfamide and dacarbazine are the majors drugs. Their combination in adjuvant treatment is currently being investigated. Neoadjuvant chemotherapy has allowed conservative surgery in initially unoperable tumors, but its role in primarily operable tumors remains to be defined.

[Non-surgical treatment of cancers of the stomach]

In western countries, most gastric cancers are diagnosed at locally advanced stages. Surgery is the only curative treatment, but the risk of locoregional relapses and of distant metastases is very high. This is the rationale for adjuvant treatments. However, currently available data do not allow a definitive conclusion as to whether chemotherapy or radiation therapy are of value as adjuvant treatments for poor-prognosis gastric cancers. Further randomized clinical trials are still needed. By contrast, it is admitted that these treatments have a palliative role in the management of patients with metastases.

Calcitriol differentially modulates mRNA encoding calcitriol receptors and calcium-binding protein 9 kDa in human fetal jejunum

Human intestinal mucosa consists of highly active epithelial cells in continual renewal and differentiation processes anatomically located at different portions of the villi. Besides its well recognized role in bone cell homeostasis, calcitriol has been attributed a role in cellular differentiation and proliferation in normal and cancerous cells. In this report, we show that in human fetal jejunum, depending upon the stage of gestation, calcitriol either enhances or decreases the levels of mRNA coding for its receptor. However, it up-regulates at all times those coding for the Vitamin D-dependent Calcium Binding Protein 9kDa. The present observations open interesting possibilities as to the role of calcitriol in the in utero human gut development and the control of colorectal cancers.

Treatment of familial hypercholesterolemia in children and adolescents: effect of lovastatin. Canadian Lovastatin in Children Study Group

OBJECTIVE

Familial hypercholesterolemia (FH), an inherited autosomal dominant disorder of lipoprotein metabolism, is associated with premature atherosclerosis. The recommended pediatric therapy consists of dietary intervention and, when necessary, treatment with bile acid-binding resins. However, compliance has been poor in many children. Therefore, our objectives were to determine the efficacy, safety, and tolerance of the short-term use of lovastatin, a 3-hydroxy 3-methylglutaryl coenzyme A reductase inhibitor, in the control of severe FH in a male pediatric population and to evaluate the dose-response relationship.

METHODS

Sixty-nine male patients with FH 12.9 +/- 2.4 years of age (mean +/- SD) participated in this multicenter, randomized, double-blind trial. After a 4-week placebo period, the patients were allocated to four treatment groups (lovastatin 10, 20, 30, 40 mg/d) for 8 weeks. Plasma lipid and apolipoprotein (Apo) concentrations were measured every 2 weeks. Clinical and laboratory evidence of adverse events was monitored periodically throughout the study.

RESULTS

All lovastatin doses reduced total cholesterol (-17% to -29%), low density lipoprotein cholesterol (-21% to -36%), and ApoB (-19% to -28%) concentrations. A dose-response relationship was seen, and between-group comparisons showed that results were significantly improved up to a dose of 30 mg/d. We observed a 7% increase in high-density lipoprotein cholesterol and a 4% increase in ApoA1 concentrations. The medication was well tolerated by all patients. No serious clinical adverse experience was reported. Lovastatin increased aspartate aminotransferase concentrations, but there was no evidence of a dose-response relationship, and no value exceeded two times the upper limit of normal. No significant change in alanine aminotransferase was observed. Three patients had marked (more than three times the upper limit of normal) asymptomatic elevations in their creatine kinase values, which returned spontaneously to normal, and no action was required regarding the drug.

The economic cost of obesity: the French situation

OBJECTIVE

To estimate the economic burden of obesity in France.

DESIGN

A prevalence-based approach identifying the costs incurred during a given year (1992) by obese subjects.

MEASUREMENTS

Direct costs (personal health care, hospital care, physician services, drugs) and indirect costs (lost output as a result of cessation or reduction of productivity caused by morbidity and mortality); economic benefits due to the reduced incidence of hip fractures.

RESULTS

The direct costs of obesity (BMI > or = 27) were 11.89 billion French Francs (FF), which corresponded to about 2% of the expenses of the French care system. Hypertension represented 33% of the total amount and cancer 2.5% of the direct cost of obesity. Indirect costs represented FF 0.6 billion. These are conservative estimates as far as all obesity-related diseases and all health care and indirect costs were not included due to missing information.

CONCLUSION

These results were remarkably similar to previous reports on the economic costs of obesity in other western countries (USA, Sweden, Netherlands, Australia) which concluded that the cost of obesity amounted to around 2% to 5% of the total cost of health care in industrialized societies.

[Treatment of metastases of colorectal cancers]

Important advances have been made in the management of advanced colorectal cancers during the past decade, even though prognosis remains poor. Quality of life, and sometimes overall survival have been increased. Surgery is the only potentially curative treatment of liver metastases from colorectal cancer. Radiation therapy is useful as a palliative local treatment for painful bone metastases or compressive nodes. Chemotherapy, still palliative, has been shown to improve the quality of life. Although 5-fluorouracil remains the drug of reference, various routes and schedules of administration (continuous infusion, hepatic artery infusion, chronotherapy) and biomodulation, mainly by folinic acid and methotrexate have led to a significant improvement in response rates.

A conformational model for the human liver microsomal glucose-6-phosphatase system: evidence from rapid kinetics and defects in glycogen storage disease type 1

Rapid kinetics of glucose-6-phosphate (G6P) uptake and hydrolysis as well as of orthophosphate uptake were investigated in microsomes prepared from normal and glycogen storage disease type 1a (GSD 1a) human livers using a fast sampling, rapid filtration apparatus and were compared to those of rat liver microsomes. As shown before with rat microsomes, the production of [U-14C]glucose from 0.2 mmol/L [U-14C]G6P by untreated normal human microsomes was characterized by a burst in activity during the first seconds of incubation, followed by a slower linear rate. The initial velocity of the burst was equal to the rate of glucose production in detergent-treated microsomes. In untreated and detergent-treated GSD 1a microsomes, no glucose-6-phosphatase activity was observed. When untreated normal human or rat microsomes were incubated in the presence of 0.2 mmol/L [U-14C]G6P, an accumulation of [U-14C]glucose was observed, whereas no radioactive compound (G6P and/or glucose) was taken up by GSD 1a microsomes. Orthophosphate uptake was, however, detectable in both GSD 1a and normal untreated vesicles. These results do not support a rate-limiting transport of G6P in untreated normal human microsomes and further show that in this case of GSD 1a, no distinct G6P transport activity is present.

Short-term feeding of a diet enriched in phospholipids increases bile formation and the bile acid transport maximum in rats

Earlier studies suggested that the secretory rate maximum (SRm) of bile acid and the cholestasis which occurs after the SRm is reached may be determined by the hepatic or extrahepatic biliary phospholipid pool. We therefore investigated whether bile formation and the bile acid SRm could be influenced by feeding a diet enriched in phospholipids. Male rats were fed phospholipid (PLD) or triacylglycerol (TgD)-enriched diet for 3 days, and bile formation as well as biliary lipid output were measured on the 4th day. In other similarly fed groups, cholic acid was infused in stepwise increasing doses to determine the effect of PLD on the SRm of cholic acid. The plasma lipid levels were significantly lower in PLD and TgD diets compared to basal diet. But, while the levels of total cholesterol (CH), HDL-CH, and phospholipid (PH) were not significantly altered by PLD compared to TgD, the triacylglycerol levels were markedly increased by PLD. In the liver of PLD fed rats, triacylglycerol and CH ester contents decreased by 39 and 62%, respectively, while free CH and PH contents were not significantly changed. The PLD significantly augmented spontaneous bile flow, bile acid, PH and CH secretion rates compared to TgD diet (65, 124, 164 and 654%, respectively). The enhanced biliary secretory function was associated with an increase in pericanalicular vacuoles and diverticuli in centrilobular hepatocytes. Compared to TgD fed rats, PLD rats showed a 2-fold decrease in the ratio of cholic acid/chenodeoxycholic acid in bile and a significant decrease in the % contribution of taurine conjugated BA. The PH fatty acids in bile were similar in both groups except that in PLD group the % contribution of C18:2 was higher than in TgD group. No differences were found in plasma membrane CH/PH content or total fatty acid composition. During bile acid infusion, the SRm and the total cholic acid secreted were significantly higher in the PLD than in the TgD rats. Moreover, the cholestatic response observed after high bile acid dose was markedly reduced by PLD. The results show that short-term feeding of PLD induces changes in CH and bile acid metabolism which result in enhanced biliary output of CH and PH. The enhanced pool of biliary lipid may protect plasma membranes from the deleterious effects of high bile acid concentrations.

[Cost-effectiveness analysis of captopril treatment after myocardial infarction]

The recently published "Survival and Ventricular Enlargement" (SAVE), prospective controlled trial over 4 years including over 2,000 patients, has shown that long-term treatment with captopril reduced cardiovascular mortality (- 19%) and morbidity in patients with post-infarction left ventricular dysfunction without signs of cardiac failure. Based on the trial data, the extra cost of treating the patients with captopril compared with the placebo branch is estimated at 9.3 million french francs. This expense is compensated by a reduction in the cost of hospitalisation for cardiac failure of 1.6 million francs and a reduction in the cost of further coronary events of 3.4 million francs. Above all, the extra cost is compensated by a gain of 47 deaths avoided, corresponding to about 493.5 years of life saved. The cost-effectiveness of captopril administration is therefore about 8.750 francs per year per life saved. The ratio is significantly less than that of other primary or secondary prevention therapeutic strategies. On this basis, we conclude that captopril therapy of high risk post-infarction patients is a solution that is not only medically effective but also economically sound.

Lipoprotein abnormalities associated with cholesteryl ester transfer activity in cystic fibrosis patients: the role of essential fatty acid deficiency

The purpose of this study was to elucidate the roles of lecithin:cholesterol acyltransferase (LCAT) and cholesteryl ester transfer protein (CETP) in the lipoprotein derangement of cystic fibrosis (CF) patients with respect to their essential fatty acid (EFA) status. Triglyceride enrichment and cholesteryl ester (CE) depletion were observed in the lipoproteins of 22 CF patients. The abnormal chemical composition was more severe in 12 EFA-deficient (EFAD) than in 10 EFA-sufficient (EFAS) patients. Expressed in nmol.L-1.h-1, LCAT activity was higher (P < 0.05) in both EFAS (mean +/- SE, 92.7 +/- 1.9) and EFAD (108.8 +/- 3.0) patients than in control subjects (65.2 +/- 0.9). An equal CE transfer was recorded in the lipoprotein-deficient serum, as a source of CETP activity, in all groups studied by using normal exogenous low-density lipoprotein (LDL) and high-density lipoprotein (HDL). However, in contrast to the maximal amount of CE transferred from endogenous HDL to endogenous apolipoprotein B (apo B) in control subjects, a reduction in CETP activity was seen in CF patients and more pronounced in the EFAD group. These findings indicate that impaired lipoprotein composition may have marked effects on the transfer of CE between HDL and apo B in EFAD CF patients.

Relationship of decreased hepatic lipase activity and lipoprotein abnormalities to essential fatty acid deficiency in cystic fibrosis patients

Polyunsaturated fatty acids are known to affect plasma lipids and lipoproteins but there is no information on the effect of essential fatty acid (EFA) deficiency on lipoprotein composition. The purpose of this study was to characterize lipoproteins from 17 cystic fibrosis (CF) patients in relationship to their EFA status (eicosatrienoic/arachidonic acid ratio) and compare them with those of 10 healthy siblings (SIB) and of 10 unrelated controls. In 7 EFA-deficient (EFAD) and 10 EFA-sufficient (EFAS) patients, hypocholesterolemia was associated with a decrease of HDL-cholesterol and of LDL-cholesterol which was more marked in the EFAD group. Similarly, although triglyceride enrichment of VLDL, LDL, HDL2, and HDL3 with a concomitant reduction of cholesteryl esters from all particles except HDL2 was observed in both CF groups, it was more sizable in the EFAD patients. These changes led to an increase in the particle size of VLDL, LDL, and HDL2 whereas the distribution of HDL3 was skewed to smaller particles. Alterations in the apoprotein composition of particles were greater in EFAD than in EFAS. A decrease of total postheparin lipolytic activity was observed in the two groups of CF patients as well as in siblings. It was entirely accounted for by hepatic lipase (mumol FFA/ml per h) which was more severely diminished in EFAD (2.8 +/- 0.6) than in EFAS (4.4 +/- 0.7) and SIB (5.1 +/- 0.5). Although the two groups of CF children differed in terms of growth, severity of malabsorption, and vitamin E status, these data suggest that disturbance of lipoprotein concentration, composition, size, and metabolism (hepatic lipase) may be in part related to EFA deficiency. Further studies are necessary to explore the effect of EFA deficiency on hepatic lipase activity.

High-output external fistulae of the small bowel: management with continuous enteral nutrition

Three hundred and thirty-five patients with high-output enterocutaneous fistulae arising from the small intestine are reported. Median fistula output was 1350 ml/24 h. Eighty-two per cent of patients were referred from other institutions. The fistula opening was associated with evisceration in 165 cases (49 per cent). One or more severity factors were present in 75.5 per cent of the patients. Patients were divided into three groups according to their initial therapy: 21 patients (6 per cent) referred in a moribund state were not operated on (non-intervention); 80 patients (24 per cent) were operated on as an emergency, and the fistula was either exteriorized or defunctioned; 234 patients (70 per cent) were initially managed conservatively. Appropriate local care and nutrition were provided in all cases. Enteral nutrition was the exclusive nutritional support in 285 patients (85 per cent). In 92 cases with proximal fistulae, methods limiting the fistula output or allowing reinfusion of chyme were required. The overall mortality rate was 34 per cent: 100 per cent in the non-intervention group, 55 per cent after emergency surgery, and 19 per cent after conservative treatment. In the latter group, spontaneous closure was obtained in 88 patients (38 per cent). Overall mortality rate was reduced to 19 per cent in patients treated since 1980. Enteral nutrition with appropriate local care may be used in the majority of high-output enterocutaneous fistulae, with an acceptable rate of spontaneous closure. Conservative management is the treatment of choice in the initial period. Emergency surgery should be restricted to the treatment of haemorrhage or intra-abdominal abscesses associated with uncontrolled systemic sepsis.

Septic necrosis of the midline wound in postoperative peritonitis. Successful management by debridement, myocutaneous advancement, and primary skin closure

Wound management following laparotomy for postoperative peritonitis and varying degrees of parietal necrosis remains a challenging and controversial problem. Because maintained peritoneal integrity and primary wound closure offer the best opportunity for survival, an original technique involving bilateral incisions to relax skin and rectus fascia is proposed. This technique permits medial myocutaneous advancement and primary tension-free skin closure of midline laparotomy incisions. Sixty-nine patients with severe postoperative peritonitis were treated according from 1980 through 1985. Nine of these patients died of advanced multiple organ failure soon after referral, and eight more died after prolonged treatment. Fourteen patients had one or more reoperations for complications. Only nine wound failures resulted, including five eviscerations and four wound infections followed by progressive dehiscence. The bilateral relaxing incisions healed secondarily without complication. Survivors developed midline wound hernia; ten of the 52 surviving patients have had these repaired. This method of primary closure is safe when performed in conjunction with rigorous surgical care of intraperitoneal infection and may enhance survival. We recommend the technique to surgeons who treat severe postoperative peritonitis and septic necrosis of midline laparotomy wounds.

Inhibition of upper gastrointestinal secretions by reinfusion of succus entericus into the distal small bowel. A clinical study of 30 patients with peritonitis and temporary enterostomy

We prospectively studied peritonitis secondary to small bowel leakage in 30 critically ill patients, each of whom had complete diversion of intestinal continuity by stoma, fistula, or both. All patients received total parenteral nutrition during implementation of the protocol. The proximal intestinal effluent was collected and recycled into the distal small bowel. During reinfusion of succus entericus, a significant reduction in the output of the proximal stoma was observed (mean 30.2%, p less than 0.001). The reinfusion also significantly reduced the volume from isolated small bowel loops in six patients (32.6%, p less than 0.001). When isotonic dialysate solution was infused into the distal intestine, a lesser though significant reduction in stoma output occurred (mean 20.3%, p less than 0.001). These findings demonstrate a consistent inhibitory effect upon upper gastrointestinal secretions by reinfusion of succus entericus. Clinical benefits of this technique include simplified control of fluid and electrolyte balance in patients with high output stomas and optimal utilization of remaining absorptive capacity for enteral nutrition.

[Automaton resuscitation (author's transl)]

The aim of the Automaton Resuscitation is execution, watching and maintenance of a programme of intricate resuscitation tying for the first time the therapeutic to extemporaneous outflow of biological spoliation. This apparatus executes permanently and automatically the taking of biological fluid, estimates its outflow, amounts its total and realizes or the reinstillation of the fluid in the digestive tract or the order of intravenous perfusion tied to fluid spoliation according to an adjustable connection. A first self acting regulator for the juice intestinal reinstillation has been made in 1974. The second one with 4 units of continuous aspiration, data integration, reinstillation and perfusion tied with security had waked for 6 months. Moreover it allows with fiability the reinstillation of the gastric, duodenal, bilious, pancreatic or intestinal juice, on the other hand an intravenous perfusion tied to spontaneous spoliation (digestive) or instigated spoliation (provocated diuresis) and in a fundamental way simplifies the work of the physicians and the nurses.