Thyrotropin-secreting microadenoma and the importance of a prompt diagnosis: A case report

Background

The prevalence of thyrotropin-secreting pituitary adenomas, most being macroadenomas, is one to two cases per million inhabitants. Their differential diagnosis may be challenging, especially for microadenomas.

Case description

We present the case of a 50-year-old male with progressive neck enlargement, hot sudorific hands, anorexia, diarrhea, and weight loss over the preceding three months. Laboratory evaluation revealed high thyroid hormones, predominantly high free triiodothyronine of 7.74 pg/mL (reference range 2.3-4.2), with a non-suppressed thyroid stimulating hormone (TSH) of 1.73 µIU/mL (reference range 0.55-4.78). A high level of suspicion directed additional evaluation that revealed a high total alpha-subunit of glycoprotein hormones (αGS) and αGS/TSH ratio. Magnetic resonance imaging revealed a six mm pituitary lesion. A microthyrotropinoma was diagnosed, and long-acting octreotide was initiated before surgery for symptomatic control. Endoscopic transnasal transsphenoidal tumor resection was performed months later. The patient was in remission one year after surgery with no pituitary deficits.

Conclusions

Reaching an accurate diagnosis on time is crucial for deciding the optimal therapeutic approach and preventing and decreasing the frequency of endocrine and neurological complications. HIPPOKRATIA 2022, 26 (4):157-160.

Development of an automated sensor for in-situ continuous monitoring of streambed sediment height of a waterway

The sedimentary processes play a major role in every aquatic ecosystem, however, there are few automated options for in-situ monitoring of sediment displacement in the streambed of waterways. We present an automated optical instrument for in-situ continuous monitoring of sediment deposition and erosion of the streambed that requires no calibration. With a production cost of 32€, power consumption of 300 μA in sleep mode, and capacity to monitor the bedform of a waterway, the sensor was developed to evaluate the sediment dynamics of coastal areas with a wide spatial and temporal resolution. The novel device is intended to be buried in the sand and uses 32 infrared channels to monitor the streambed sediment height. For testing purposes, a maximum measuring length of 160 mm and 5 mm resolution was chosen, but these values are scalable. Sensors can be built with different ranges and precision according to the needs of the fieldwork. A laboratory experiment was conducted to demonstrate the working principle of the instrument and its behaviour regarding the turbidity originated by suspended sediment and the settling and deposition of the suspended particles. The device was deployed for 119 days in an estuarine area and was able to detect patterns in the sediment deposition and resuspension during the tidal cycles. Also, abnormal events occurred during the experiment as floods and algae blooms. During these events, the sensor was able to record exceptional erosion and sediment deposition rates. The reported automated instrument can be broadly used in sedimentary studies or management and planning of fluvial and maritime infrastructures to provide real-time information about the changes in the bedform of the watersheds.

Abstract P5-08-09: Characterization of the Rac/Cdc42 inhibitor MBQ-168 as an anti-cancer compound

Metastasis continues to be the primary cause of cancer-related death in women with breast cancer, needing targeted therapies to inhibit this process. Therefore, we developed inhibitors targeting the homologous Rho GTPases Rac1 and Cdc42, which direct the actin cytoskeletal changes required for cell migration/invasion; and thus, metastasis. We characterized the potent inhibitor, MBQ-167 that blocks both Rac1 and Cdc42 at IC50s 103 nM and 78 nM, respectively, in human HER2 (+) and triple-negative breast cancer (TNBC) cells. Consequently, MBQ-167 inhibits tumor growth and metastasis by ~90% in pre-clinical mouse models of breast cancer (Humphries-Bickley, et al., 2017). To improve the activity and solubility of MBQ-167, we synthesized a panel of derivatives, maintaining the 9-ethyl-3-(1H-1,2,3-triazol-1-yl)-9H-carbazole as the core for each derivative. Of the derivatives tested, MBQ-168 demonstrated improved solubility and comparable efficacy. Similar to MBQ-167, MBQ-168 induced actin cytoskeletal disintegration, cell rounding, and detachment to ultimately undergo anoikis. In 120hrs, MBQ-168 significantly inhibited the viability of MDA-MB-231 at a GI50 of 228nM and HER2+ MDA-MB-435 cells with a GI50 of 137 nM, without affecting the viability of Human Mammary Epithelial Cells (HMEC). In apoptosis assays, MBQ-168 treatment, at 500nM for 48 hrs, demonstrated a similar response to MBQ-167 by >4-fold increase in Caspase 3/7 activity in HER2 (+), and MDA-MB-231 and MDA-MB-468 TNBC cells. In wound healing assays, MBQ-168 also responded similar to MBQ-167 by a ~80% inhibition of breast cancer cell migration at 250nM and 500nM for 24hrs. Moreover, as quantified from Rac1.GTP pulldown assays, following 250nM treatment for 24hrs, MBQ-168 inhibited Rac1 activation in the attached cell population by ~70%, and in the detached cell population by ~100%, demonstrating a potent inhibition of Rac1 activation. In a preliminary study for relative efficacy in mice, MBQ-168 significantly reduced HER2+ MDA-MB-435 mammary tumor growth (~90%) at 5mg/kg BW via IP administration. In conclusion, MBQ-168 is an effective Rac inhibitor that reduces breast cancer cell viability, induces apoptosis, and inhibits breast cancer cell migration, actin cytoskeletal extensions, and Rac1 activation to result in a drastic reduction in mammary tumor growth in mice. We predict that the increased solubility of MBQ-168 will make it more bioavailable than MBQ-167. Thus, we have demonstrated that small structural modifications of MBQ-167 can affect the cytotoxic activity of carbazole derivatives with potential as anti-cancer drugs, and as tools to block Rac/Cdc42 activities in biological systems.

Citation Format: Julia Medina, Tatiana Matos, Luis Velazquez, Michael Rivera, Ailed Cruz-Collazo, Eliud Hernandez, Cornelis Vlaar, Suranganie Dharmawardhane. Characterization of the Rac/Cdc42 inhibitor MBQ-168 as an anti-cancer compound [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P5-08-09.

A New Dual-cure Universal Simplified Adhesive: 18-month Randomized Multicenter Clinical Trial

CLINICAL RELEVANCE

Non-carious cervical lesion restorations using a dual-cure universal adhesive in self-etch and etch-and-rinse mode showed satisfactory clinical performance after 18 months.

SUMMARY

Objectives: The objective of this multicenter, double-blind, split-mouth randomized clinical trial was to evaluate the clinical performance of a new dual-cure universal adhesive system (Futurabond U, Voco GmBH) when applied using different strategies over a period of 18 months.Methods and Materials: Fifty patients participated in this study. Two hundred non-carious cervical lesions were restored using the adhesive Futurabond U according to four adhesive strategies (n=50 per group): only self-etch (SEE), selective enamel etching + self-etch (SET), etch-and-rinse with dry dentin (ERDry), and etch-and-rinse with wet dentin (ERWet). After the adhesive application, cavities were restored using Admira Fusion composite resin. These restorations were evaluated according to FDI World Dental Federation criteria for the following characteristics: retention/fracture, marginal adaptation, marginal staining, postoperative sensitivity, and caries recurrence.Results: After 18 months, only four patients (12 months: one patient, n=4 restorations; and 18 months: three patients, n=12 restorations) were not evaluated. Fourteen restorations were lost after 18 months of clinical evaluation (four for SEE, three for SET, three for ERDry, and four for ERWet). The retention rates for 18 months (95% confidence interval) were 92% (81%-97%) for SEE, 94% (83%-97%) for SET, 94% (83%-97%) for ERDry, and 92% (81%-97%) for ERWet (p>0.05). Thirty-eight restorations were considered to have minor discrepancies in marginal adaptation at the 18-month recall (13 for SEE, 13 for SET, six for ERDry, and six for ERWet; p>0.05). Fourteen restorations were detected as a minor marginal discoloration at the 18-month recall (six for SEE, six for SET, one for ERDry, and one for ERWet; p>0.05). However, all were considered clinically acceptable. No restorations showed postoperative sensitivity or caries recurrence at the time.Conclusion: The clinical performance of the Futurabond U did not depend on the bonding strategy used, and it was considered reliable after 18 months of clinical evaluation, although more marginal discrepancy was observed in the self-etch group.

Design of a Multipoint Cost-Effective Optical Instrument for Continuous In-Situ Monitoring of Turbidity and Sediment

A cost-effective optical instrument for continuous in-situ monitoring applications is presented. With a production cost in raw materials of 38 €, a power consumption of 300 µA in sleep mode and 100 mA in active mode (5 ms reading), and a capacity to monitor turbidity and sedimentary displacement at eight different depths in the water column, the sensor was developed for sediment monitoring in coastal areas. Due to the extent and dynamics of the processes involved in these areas, observations require a wide spatial and temporal resolution. Each of the eight monitoring nodes uses one infrared backscatter channel, to estimate turbidity and sediment concentration, and one ultraviolet with one infrared transmitted light channels to distinguish organic/inorganic composition of the suspended material load. An in-lab calibration was conducted, using formazine to correlate turbidity with the electronic outputs of the instrument. An analysis of the influence of external light sources and correction techniques were performed. Moreover, an in-lab experiment was conducted to study the behaviour of the sensor-to-sediment transport, wash load and sediment accumulation. The device was deployed, with a water level sensor, in an estuarine area with high sediment dynamics. The monitoring data were analysed, showing the potential of the device to continuously monitor turbidity, sediment processes, and distinguish between organic and inorganic matter, at the different depths in the water column.

Adesivos Universais de Condicionamento Total e Restaurações Indiretas em Resina com Polimerização Dual: Propriedades Adesivas

Avaliou-se a resistência ao microcisalhamento (RUM) e a nanoinfiltração (NI) de adesivos universais aplicados como sistemas convencionais em restaurações indiretas com ou sem ativador de autopolimerização (AA) usando diferentes protocolos de polimerização. Utilizou-se dentina oclusal de 55 molares humanos. Os espécimes foram alocados aleatoriamente para: All-Bond Universal / Core Flo DC [ABU] Clearfil Universal Bond / Clearfil DC Core Plus [CFU] Prime & Bond Elect / FluoroCore 2+ [PBE] e One Coat 7 Universal / ParaCore [OCU]. O Clearfil SE Bond / Clearfil DC Core Plus [CSE] foi utilizado como controle. Para CFU, PBE e OCU, foram utilizados protocolos de fotopolimerização [FP], polimerização dual [DP] e autopolimerização [AP]. Testes ANOVA e Tukey foram utilizados (a 0,05). RUM: Modo FP - ABU resultou em RUM menor do que todos os outros adesivos FP. Modo DP - CSE mostrou resultado maior do que CBU e OCU, porém semelhante ao PBE. Modo AP - PBE resultou em RUM menores que os modos PBE / DP e FP.  Para CBU e OCU, não houve diferença nos modos FP,  DP e AP.  NI: ABU resultou em    NI menor que o modo PBE / FP, mas semelhante ao modo CBU / FP e OCU / FP. O modo CSE / DP resultou em NI maior em comparação com todos os adesivos universais DP. O modo CFU / AP resultou em NI maior que CFU / FP e modo DP. PBE / FP e DP resultaram em NI maior que o modo PBE / AP. O modo OCU / DP resultou em NI maior do que OCU / FP e modo AP. Para os adesivos universais, AA e os diferentes protocolos de polimerização influenciaram o RUM e NI todavia, esta influência foi adesivo- dependente.Palavras-chave: Microcisalhamento. Nanoinfiltração. Restaurações Indiretas.

Nucleic acid and protein extraction from electropermeabilized E. coli cells on a microfluidic chip

Due to the extensive use of nucleic acid and protein analysis of bacterial samples, there is a need for simple and rapid extraction protocols for both plasmid DNA and RNA molecules as well as reporter proteins like the green fluorescent protein (GFP). In this report, an electropermeability technique has been developed which is based on exposing E. coli cells to low voltages to allow extraction of nucleic acids and proteins. The flow-through electropermeability chip used consists of a microfluidic channel with integrated gold electrodes that promote cell envelope channel formation at low applied voltages. This will allow small biomolecules with diameters less than 30 A to rapidly diffuse from the permeabilized cells to the surrounding solution. By controlling the applied voltage, partial and transient to complete cell opening can be obtained. By using DC voltages below 0.5 V, cell lysis can be avoided and the transiently formed pores can be closed again and the cells survive. This method has been used to extract RNA and GFP molecules under conditions of electropermeability. Plasmid DNA could be recovered when the applied voltage was increased to 2 V, thus causing complete cell lysis.

PP145. Hypertensive disorders of pregnancy: A two year study (2008-2009)

INTRODUCTION

The hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. According to the group studies of NHPBEB 2000 four entities are defined: Chronic Hypertension (CH) previous to pregnancy, Gestational Hypertension (GH), Preeclampsia/Eclampsia (PE/E) and superimposed Preeclampisa/Eclampsia in Chronic Hypertension (PE/E CH). All this entities have different outcomes and require adequate follow-up and specific attitude.

OBJECTIVES

Review all cases of hypertensive disorders in a two-year period, its incidences, and related maternal and fetal complications.

METHODS

In a retrospective study, from January 2008 to December 2009, all files related with hypertensive disorders, seen in our department, were reviewed. The statistic analysis was based on Excel 2007.

RESULTS

The global incidence of hypertensive disorders was 3.8% (309 cases), with each entity with an incidence of: 40% in CH, 40% GH, 25% PE/E and 7% PE/E CH. In terms of demographic characteristics the majority of the population were caucasian (46%) and black (40%), the mean age was of 31years (minimum of 12-maximum of 47), and mainly previous Chronic Hypertension and endocrinologic disorders as co-morbidities (Diabetes Mellitus, obesity and thyroid pathology). The fetal/maternal complications were mainly preterm delivery (26.2%), with a low percentage of Abruptio Placentae (1%). Maternal complications were analysed in terms of ICU admissions of 7%, cardiovascular/renal disorders of 1% and maternal bleeding 1%. No maternal death was described. Fetal outcomes were also studied, specifically in terms of birth weight, with an average of 2794 (500-5480g), apgar index in 1st and 5th minute below seven in respectively, 14% and 3.5%.

CONCLUSION

The incidence of maternal complications in our analysis was lower than described in literature. The incidence of preterm delivery was similar to that reported in other studies, mostly due to late pre-terms (>32w).

PP100. Pre-eclampsia: Risk factors and outcomes - A two-year study

INTRODUCTION

Pre-eclampsia (PE) is a hypertensive disorder responsible for major morbidity and mortality in both mother and fetus. There are some risk factors associated with this entity, but it remains very difficult to predict.

OBJECTIVES

Study the incidence of PE and the related risk factors, as well as the maternal and fetal outcome.

METHODS

We reviewed the clinical records of pregnant women admitted to Prof. Fernando Fonseca's Hospital from January 2008 to December 2009, with the diagnosis of pre-eclampsia. The statistic analysis was based on Excel 2007.

RESULTS

There were 90 cases of PE, among the 308 hypertensive disorders reviewed, with an incidence of 1,1% in overall population of pregnant women. Risk factors with higher association were Chronic Hypertension before pregnancy (24,4%), maternal age above 35 years old (16,67%), maternal age under 20 years old (14,44%), and previous episode of pre-eclampsia (8,89%). Major maternal complications that determined Intensive Care Unit admission were recorded in 17 cases (18,89%), with 3 HELLP syndromes (Hemolysis, elevated liver enzymes, and low platelets)(3,33%). No maternal death was recorded. Preterm delivery (PTD) was seen in 61,1%, 32% before 34weeks and 6,67% before 28weeks. There were 19 cases of 1st minute Apgar Index below 7 and 5 cases of 5th minute Apgar Index below 7. There was one in utero death and two interruptions of pregnancy below 24 weeks due to serious PE. Three twin pregnancies.

CONCLUSIONS

PE is a form of hypertensive pregnancy disorder, with a risk of recurrence in subsequent pregnancies. It has a catastrophic potential, mainly associated to PTD, and also with significant morbidity to the pregnant women, reflected in the incidence of admissions to ICU, HELLP syndrome and end-organ failure. In our study we confirmed the adverse outcomes related to this entity, and the risk factors associated.

PP099. Chronic hypertension: follow-up of chronic hypertension pregnant women in 2008-2009

INTRODUCTION

Chronic Hypertension (CH) is one of the most prevalent diseases in the world. Because women are getting pregnant in late ages, the incidence of Chronic Hypertension in pregnancy is raising (2-3%). As a long term disease in its essential form, with low repercussion in target-organs at reproductive age, the medical complications related to CH are not the main concern of the pregnant women. However, it influences the pregnancy and may result in serious maternal-fetal complications, especially if a preeclampsia/eclampsia superimposes to pregnancy. The complications may be manifested as placental abruption, acute renal failure, cardiac decompensation, and cerebral accidents in the mother and of growth restriction and unexplained mid-trimester fetal death. The main goal in the follow-up of this pregnant women is to achieve controlled levels of blood pressure (Systolic - 110-140mmHg, Diastolic - 80-90mmHg) with anti-hypertensive drugs, and evaluate and early diagnose the most serious complication, preeclampsia/eclampsia(PE/E).

OBJECTIVES

Review the cases of Chronic Hypertension followed in our institution in 2008-2009, with the analysis of population, anti-hypertensive drugs required to control HTA, fetal complications (growth restriction, preterm delivery and fetal death) and maternal/fetal complications (PE/E, Abruption placentae, Renal and Cardiac acute insufficiency, and cerebral accidents).

METHODS

In a retrospective study, from January 2008 to December 2009, were analysed all files related with Chronic Hypertension followed in the obstetric department of Prof. Fernando Fonseca's Hospital. The statistic analysis was based on Excel 2007.

RESULTS

The incidence of Chronic Hypertension was 40% of all hypertensive disorders in this period and of 1,5% in overall pregnant population. The maternal mean age of this group was 33,8 years (16;44) being the most prevalent pre-existing co-morbidities the endocrinologic disorders (obesity, Diabetes and thyroid pathology). 38% were previous medicated with anti-hypertensive drugs, the majority of them needing only one drug to control blood pressure (BP) (64%). During the pregnancy follow up, 78% were medicated with one or more anti-hypertensive drugs, requiring only one drug to control BP in the majority of cases 66%. In terms of fetal complications 3 cases of growth restriction were signed (2%), preterm delivery in 26 cases (21%) and 2 interruptions of pregnancy in the second trimester before 24 weeks because of maternal complications (2%). There was one case of Abruption Placentae (1%). In terms of maternal complications there were 5 ICU internments (4%), and one situation of acute cardiac disfunction (1%). The CH was complicated by PE/E in 22 cases (18%).

CONCLUSION

Chronic Hypertension is a prevalent disease, with an elevated incidence in pregnancy, and potential major fetal-maternal complications, obliging medical professionals to a straight and careful follow-up to control BP levels and early diagnose the adversely outcomes.

A7445G mtDNA mutation present in a Portuguese family exhibiting hereditary deafness and palmoplantar keratoderma

Mitochondrial DNA (mtDNA) A7445G point mutation has been shown to be responsible for familial nonepidermolytic palmoplantar keratoderma (NEPPK) associated with deafness without any additional features. To date, only a few cases have been described. We report a Portuguese pedigree presenting an inherited combination of NEPPK and sensorineural deafness compatible with maternal transmission. Clinical expression and age of onset of NEPPK and deafness were variable. Normal expression patterns of epidermal keratins and filaggrin, intercellular junction proteins including connexin 26, loricrin and cornified envelope proteins, were observed. Molecular analysis revealed that all the affected members, previously screened for Cx26 mutations with negative results, presented the mtDNA A7445G point mutation in the homoplasmic form. To our knowledge, this is the fifth family in whom inherited NEPPK and hearing loss are related to this mitochondrial mutation.

Intestinal prevalence of the neurotropic black yeast Exophiala (Wangiella) dermatitidis in healthy and impaired individuals

A screening of 2300 samples of faeces from humans with and without underlying disease revealed that the black yeast Exophiala dermatitidis is present at a frequency of 5.2 per thousand (n=12). Eight individuals positive for the fungus had diarrhoea at the moment of its isolation, out of 11 where relevant information was available. Judging from repeated isolation over several weeks in one patient, the organism is able to persist in the human intestinal tract.

Molecular diversity of oligotrophic and neurotropic members of the black yeast genus Exophiala, with accent on E. dermatitidis

Analysis of ITS rDNA of the black yeast Exophiala dermatitidis revealed a close phylogenetic relationship to the meristematic fungus Sarcinomyces phaeomuriformis. As most strains of S. phaeomuriformis have a yeast-like phenotype corresponding to the anamorph genus Exophiala, a new combination in Exophiala is proposed. On the basis of ITS sequence, M-13 fingerprint and SSU intron data, two main entities could be distinguished within E. dermatitidis. One of these (B) contained prevalently strains from environmental sources, while the other (A) mainly comprised strains from clinical sources. This may be due to a difference in virulence. All strains from severe brain and disseminated infections in East Asia clustered in group A. However, strains of group A caused a relatively mild fungemia in patients outside East Asia.

High prevalence of the neurotrope Exophiala dermatitidis and related oligotrophic black yeasts in sauna facilities

The black yeast Exophiala dermatitidis, an agent of fatal brain infections in East Asia, is common in European steam baths. The related fungi Sarcinomyces phaeomuriformis and Exophiala mesophila were isolated from locations in these complexes with lower ambient temperature and/or moisture. The latter two species had dry, rather than slimy, colonies and lower maximum growth temperatures (38 degrees C, 32 degrees C) than E. dermatitidis (42 degrees C). Exophiala dermatitidis produces abundant extracellular polysaccharide (EPS). The only E. dermatitidis strains lacking EPS were found outside the steam baths. Therefore it is likely that the extracellular polysaccharides commonly produced by E. dermatitidis are significant to survival under hot and moist conditions. Substrates sampled as controls, such as fruit surfaces and human faeces, yielded Exophiala dermatitidis at very low frequency.

Thyroglobulin increases cell proliferation and suppresses Pax-8 in mesangial cells

Thyroglobulin (Tg), has recently been identified as a transcriptional regulator of thyroid-restricted genes. The extrathyroidal expression of several of these genes (including the transcription factor Pax-8) together with the occurrence of specific Tg binding sites suggests a secondary role for Tg as a circulating hormone. In this study, we demonstrate using Northern analysis that Pax-8 is expressed in the mouse mesangial cell, and that its transcript levels are suppressed by Tg. These cells also express an asialoglycoprotein receptor, a receptor involved in Tg endocytosis in the thyroid, and a Tg transcript smaller than the 8.3-kb thyroidal form. Reverse transcriptase PCR showed that suppression of Pax-8 by Tg is correlated with reduced expression of bcl-2 apoptosis suppressor. Tg, but not triiodothyronine (T(3)) significantly increased MC proliferation above control as determined by DNA content of MC cultures. The effect of Tg on proliferation was not duplicated by either bovine serum albumin, gamma-globulins, lactoferrin, or the ASGPR-specific ligand,orosomucoid. These results suggest a possible endocrine role for Tg in regulating both Pax-8 related gene transcription and cell division in the mesangial cell.

Black fungi: clinical and pathogenic approaches

Data are presented on the clinically relevant black yeasts and their relatives, i.e., members of the Ascomycete order Chaetothyriales. In order to understand the pathology of these fungi it is essential to know their natural ecological niche. From a relatively low degree of molecular variability of the black yeast Exophiala dermatitidis, potential agent of brain infections in patients from East Asia, it is concluded that this species is an emerging pathogen, currently going through a process of active speciation. It is found to be an oligotrophic fungus in hot, moist environments, such as steambaths. Cladophialophora-, Fonsecaea- and Ramichloridium-like strains, known in humans as agents of chromoblastomycosis, are frequently found on rotten plant material, but the fungal molecular diversity in the environment is much higher than that on the human patient, so that it is difficult to trace the etiological agents of the disease with precision. This approach has been successful with Cladophialophora carrionii, of which cells resembling muriform cells, the tissue form of chromoblastomycosis, were found to occur in drying spines of cacti. Phagocytosis assays provide a method to distinguish between pathogens and non-pathogens, as the killing rates of strict saprobes proved to be consistently higher than of those species frequently known as agents of disease. The therapeutic possibilities for patients with chromoblastomycosis are reviewed.

Prognostic factors in invasive bladder carcinoma treated by combined modality protocol (organ-sparing approach)

PURPOSE

The results of bladder sparing approach for the treatment of muscle-invasive bladder cancer, using a combination of transurethral resection (TUR), chemotherapy, and radiotherapy, are encouraging. The survival of patients treated by this method is similar to the survival of patients treated by radical cystectomy. The aim of our study was to find out which pretreatment characteristics influence the survival of patients treated by organ sparing approach that would enable us to identify the patients most suitable for this type of treatment.

METHODS AND MATERIALS

The prognostic value of different factors, such as age, gender, performance status, hemoglobin level, clinical stage, histologic grade, presence of obstructive uropathy, and completeness of TUR, has been studied in 105 patients with invasive bladder cancer, who received a bladder sparing treatment in the period from 1988 to 1995. They were treated with a combination of TUR, followed by 2-4 cycles of methotrexate, cisplatinum, and vinblastine polychemotherapy. In complete responders the treatment was completed by radiotherapy (50 Gy to the bladder and 40 Gy to the regional lymph nodes), whereas nonresponders underwent cystectomy whenever feasible.

RESULTS

Our study has confirmed an independent prognostic value of performance status, histologic grade, and obstructive uropathy, for the disease-specific survival (DSS) of bladder cancer patients treated by a conservative approach. We believe that performance status best reflects the extent of disease and exerts significant influence on the extent and course of treatment, while obstructive uropathy is a good indicator of local spread of the disease, better than clinical T-stage. Our finding that histologic grade is one of the strongest prognostic factors shows that tumor biology also is a very important prognostic factor in patients treated by conservative approach.

CONCLUSION

Patients with muscle-invasive bladder cancer who are most likely to benefit from conservative treatment approach include those with good performance status, absence of hydronephrosis, and histologic low grade transitional cell carcinoma.

Invasive bladder cancer: our experience with bladder sparing approach

PURPOSE

Muscle-invasive bladder cancer (MIBC) is a disease associated with several unresolved therapeutic questions. Radical cystectomy still represents the most frequent treatment approach. The aim of our study was to evaluate the effect and feasibility of bladder-sparing treatment by transurethral resection (TUR) and sequential chemoradiotherapy in patients with biopsy-proven invasive bladder cancer.

METHODS AND MATERIALS

After maximal TUR, 105 patients were treated with two to four cycles of methotrexate, cisplatinum, and vinblastine polychemotherapy. In complete responders, the treatment was continued by radiotherapy (50 Gy to the bladder and 40 Gy to the regional lymph nodes), whereas in nonresponders, cystectomy was performed when feasible.

RESULTS

Complete response after TUR and chemotherapy was achieved in 52% of patients. After a median follow-up of 42 months, 52 of 75 patients (69%) selected for bladder preservation were without evidence of disease in the bladder. Freedom from local failure in complete responders to chemotherapy was 80% [95% confidence interval (CI), 69-91%) at 4 years. The actuarial survival of the entire group was 58% (95% CI, 47-69%), whereas the survival rate with the bladder intact was 45% (95% CI, 34-56%) at 4 years. Survival was significantly better in patients who responded to chemotherapy (79%) than in nonresponders (35%, p < 0.0001). There was no significant difference in survival between nonresponders who underwent cystectomy and nonresponders who completed treatment with radiotherapy (approximately 30% at 3 years).

CONCLUSION

The present study confirms that MIBC is a heterogeneous disease, and that in more than half of patients who are affected, a bladder-sparing approach is safe. Our study has also demonstrated that in nonresponders, radical cystectomy as the treatment of choice is questionable.

Effects of a HIV risk reduction education program among injection drug users in Puerto Rico

This report examines the extent to which an educational component enhanced the efficacy of a community outreach program in reducing HIV transmission behaviors among injecting drug users (IDUs). The experimental enhancement comprised three group educational sessions where detailed information on HIV risk and protective behaviors was conveyed, protective behaviors were shown and practiced, and a problem solving perspective guided discussion of serostatus results. Substantial risk reduction in behaviors were prospectively measured. However, IDUs assigned on a random basis to the enhanced intervention showed no significant differences in levels of risk reduction when compared to those assigned to the standard-only intervention. The chronic and intensive use of injected drugs among the IDUs studied and their high level of HIV infection suggest the need of interventions geared to maximize the utilization of health care services and enhance the supportive functions of familial and social networks of IDUs.

Changes in HIV risk behaviors among intravenous drug users in San Juan, Puerto Rico

Strategies for reaching intravenous drug users (IVDUs) not in treatment and reducing risk behaviors are urgently needed to reduce the human immunodeficiency virus (HIV) epidemic. Of special concern is the need to detect which types of risk behaviors are more likely to change and which are resistant to change. The present paper analyzes changes occurring in HIV transmission risk behaviors among 778 IVDUs not in treatment, in the city of San Juan, Puerto Rico. Results show discontinuation rates of risk behaviors to be substantial. Discontinuation rates of injection equipment sharing practices varied from 33% in shared use of cookers to 74.2% in sharing needles with strangers. Drug injection and use of shooting galleries were also reduced, although to a lesser extent (8.5% and 19.3% respectively). Among protective behaviors, use of new needles was found to increase nearly twice as much as the use of bleach (20.6% vs. 11.3% respectively). The results suggest the need to understand the factors facilitating/inhibiting change in specific behaviors and the need to study the stability of these changes over longer periods of time.