The REWRITE Study - REal-WoRld effectIveness of TrifluridinE/tipiracil in Patients with Previously Treated Metastatic Colorectal Cancer

AIMS

In the pivotal RECOURSE trial, trifluridine/tipiracil improved survival outcomes in refractory metastatic colorectal cancer (mCRC), while demonstrating an acceptable toxicity profile. Routine clinical practice evidence is important to support the ongoing value of recently approved medicines. Our objective was to assess the utilisation patterns and real-world effectiveness of trifluridine/tipiracil in previously treated mCRC patients.

MATERIALS AND METHODS

This was a retrospective observational study including consecutive patients who started trifluridine/tipiracil between 1 April 2018 and 30 September 2019 in the medical oncology departments of three major public hospitals in Portugal. The primary outcome measure was overall survival. Associations between overall survival and patient and tumour characteristics were assessed using multivariate Cox regression analyses.

RESULTS

In total, 111 patients were included in the study, with a mean age of 64 years. From these, 45.9% received two prior lines of treatment, 47.8% had three or more previous lines of treatment and 83.6% had Eastern Cooperative Oncology Group (ECOG) performance status 0-1 at baseline. The median duration of trifluridine/tipiracil treatment was 3.7 cycles (95% confidence interval 3.4-4.1). Most patients (80.4%) remained on their planned dose throughout the trifluridine/tipiracil treatment period, fulfilling 100% relative dose intensity. The median overall survival in the total study cohort was 7.9 months (95% confidence interval 6.4-9.8) and the median progression-free survival was 3.4 months (95% confidence interval 3.2-3.9). The median overall survival was significantly higher in patients with a normal serum lactate dehydrogenase (LDH) level (median overall survival 11.2 months for [135, 205] IU/l LDH [95% confidence interval 8.2-NR] and 13.6 months for [205, 251] IU/l LDH [95% confidence interval 8.2-NR]) and in better fitted (ECOG = 0-1) patients (median overall survival 8.0 months; 95% confidence interval 6.7-10.0). The median time to worsening performance status was 6.2 months (95% confidence interval 5.0-8.0). Treatment discontinuation due to adverse events was low (3.1%).

CONCLUSION

Our study confirms the effectiveness of trifluridine/tipiracil in real-life mCRC patients. Overall survival and progression-free survival outcomes are consistent with the efficacy profile reported in the earlier randomised RECOURSE clinical trial. Like other real-world studies, we found no additional safety concerns in the use of trifluridine/tipiracil.

Alcohol, place conditioning, and male rats: A systematic review for outcome prediction

RATIONALE

Although Place Conditioning (PC) has been used to study the motivational effects of alcohol for almost 50 years, variables and situations in which alcohol induces PC in rats are still unclear, especially for short PC protocols (up to 10 conditioning trials).

OBJECTIVES

To predict primary outcomes (namely, conditioning failure, conditioned place aversion (CPA), and conditioned place preference (CPP)) of alcohol-induced PC with male outbred rats.

METHODS

Systematic review: structured search for relevant records in PUBMED and two other sources, eligible articles defined as those conforming to all inclusion criteria, selection of experiments failing all the exclusion criteria, and analysis of procedure-outcome relations according to the background of variables affecting associative learning, alcohol interventions in rats, and PC interventions themselves.

RESULTS

We selected 192 experiments (133 short protocols, 27 long protocols, and 32 protocols with alcohol pre-exposure) from 62 articles to compose the review. Rates of conditioning failure are mainly predicted by interactions of alcohol dose and the number of habituation sessions and conditioning trials. Different conditions (housing systems) and characteristics (age and weight) of animals predict different rates of CPA and CPP: higher rates of CPA are predicted by single-housed, older, and heavier animals, while higher rates of CPP are predicted by group-housed, younger, and lighter animals.

CONCLUSIONS

We recommend settings for CPP induction in short protocols, indicate the predictive analysis has broad consequences (from theoretical to translational ones) for PC in alcohol research, and specify variables needing more accurate investigation (rat sex, age, weight, strain, spatial configuration of the apparatus, and conditioning timetable). This review may improve our comprehension of results of alcohol-induced PC with rats, refining our understanding of the motivator function of alcohol and the alcohol-seeking behavior triggered by environmental contexts, and opening new research venues on their neurobiological basis.

Low-cost apparatus for cigarette smoke exposure in rats

BACKGROUND

The effects of tobacco smoke on the central nervous system are usually studied with isolated nicotine, ignoring other compounds present in cigarette smoke. The few studies that use in vivo whole-body cigarette smoke exposure are usually performed in expensive commercial apparatus.

NEW METHOD

We presented a feasible, safe, and low-cost apparatus for cigarette smoke exposure in rodents.

RESULTS

Rats exposed to cigarette smoke in this apparatus showed cotinine levels similar to human active smokers. Additional results showed that cigarette smoke exposure increased glutamate and aspartic acid levels and decreased leucine, isoleucine, ornithine, phenylalanine, and tryptophan levels in the cerebrospinal fluid of rats.

COMPARISON WITH EXISTING METHOD(S)

Our apparatus is feasible, safe, and costs 67-fold less than a commercial automatized smoking machine. Beyond the low cost, it does not require specialized knowledge for building or maintenance.

CONCLUSIONS

We concluded that our low-cost apparatus is reliable and reproduces cigarette smoke use in humans.

Prevalence of maxillary sinus septa: systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to determine the prevalence and characteristics of maxillary sinus septa using cone beam computed tomography and computed tomography data. Publications were searched until October 5, 2020 in three electronic databases. Additionally, article bibliographies were searched, and authors were contacted if required. This review has been registered in PROSPERO (CRD42019124933). Two independent evaluators assessed methodological quality using the Joanna Briggs Institute levels of evidence; inter-rater reliability tests were performed (Cohen's κ). The prevalence of maxillary sinus septa was expressed as a proportion; differences according to sex were reported in terms of the odds ratio (OR) and 95% confidence interval (95% CI). Heterogeneity and sources of heterogeneity were evaluated by meta-regression. Publication bias was assessed by visual analysis of the funnel plot. Statistical significance was set at P < 0.05. The 62 studies identified and included in the review involved 13,701 patients (22,460 sinuses). The meta-analysis of 35 studies (14,664 sinuses) revealed an overall mean sinus septa prevalence per sinus of 33.2% (95% CI 27.8-38.5%; I² = 98.32%). The meta-analysis of 42 studies (9631 patients) found an overall mean sinus septa prevalence per patient of 41.0% (95% CI 36.0-46.0%, I² = 96.45%). The OR for the difference in septa prevalence between sexes was 0.785 (95% CI 0.590-1.046; P = 0.098, I² = 73.24%). Septa were most frequent in the middle area of the sinus and with a transverse orientation (86.0%). Within the limitations, the results suggest a high proportion of septa in the sinus, commonly in the middle area, which can interfere with the success of sinus floor elevation required for implant rehabilitation.

Levamisole, a cocaine cutting agent, induces acute and subchronic systemic alterations in Wistar rats

The use of the anthelmintic levamisole as a cocaine adulterant has been increasing worldwide. Complications caused by this association include systemic vasculitis, agranulocytosis, neutropenia, tissue necrosis, pulmonary hemorrhage, and renal injury. Data about toxicity of levamisole are scarce, therefore the aim of this study was to evaluate the acute and subchronic toxic effects of levamisole in rats. Male Wistar rats received saline or levamisole by intraperitoneal route at the doses of 12, 24 and 36 mg/kg in the acute toxicity test; and at 3, 6 and 12 mg/kg in the subchronic toxicity test. Toxicity was evaluated using behavioral, cognitive, renal, hematological, biochemical and histopathological parameters. Acute administration of levamisole caused behavioral and histopathological alterations. Subchronic administration caused behavioral, cognitive and hematological alterations (p < 0.0001 and p < 0.05, respectively), impairment of liver and kidney functions (p < 0.05), and changes of antioxidant defenses (p ≤ 0.0001). Both administrations produced toxic effects of clinical relevance, which make levamisole a dangerous cutting agent. Furthermore, the knowledge of these effects can contribute to the correct diagnosis and treatment of cocaine dependents with unusual systemic alterations.

Design, metallurgical features, mechanical performance and canal preparation of six reciprocating instruments

AIM

To compare six reciprocating instruments regarding their geometric design, metallurgical characteristics, mechanical behaviour and ability to prepare root canals.

METHODOLOGY

A total of 246 new 25-mm NiTi instruments (41 per group) from six reciprocating systems (Reciproc, Reciproc Blue, One Files, One Files Blue, Reverso Silver, and WaveOne Gold) were evaluated throughout a multimethod approach regarding their design using stereomicroscopy (number of blades and helix angle) and scanning electron microscopy (blades symmetry, cross section and surface finishing), nickel-titanium composition, phase transformation temperatures, mechanical performance (cyclic fatigue, torsional and bending resistance) and unprepared canal surface area on anatomically matched mandibular molars assessed by micro-CT. One-way ANOVA and post hoc Tukey's or Mood's median tests were selected depending on sample distribution with significance level set at 5%.

RESULTS

The instruments had similarities regarding their metal composition and unprepared canal area, whilst differences in phase transformation temperatures and geometric design (number of blades, surface finishing and tip geometry) were observed. Overall, no difference was observed regarding the maximum torque values (P > 0.05), whilst One Files (72 s) and One Files Blue (414 s) had the shortest and longest times to fracture, respectively (P < 0.05). Similar angles of rotation were observed in Reciproc (310°), One Files (285°) and Reverso Silver (318°) instruments (P > 0.05), which were significantly lower than Reciproc Blue (492°), One Files Blue (456°) and WaveOne Gold (492°; P < 0.05). Maximum bending load demonstrated that Reciproc Blue (201.3 gf) was significantly more flexible that the other instruments (P < 0.05).

CONCLUSION

Although there were similarities in metal composition and percentage of unprepared canal surface, the instruments had differences in the overall geometric design, phase transformation temperatures and in the four mechanical resistance parameters (time to fracture, maximum torque, angle of rotation and maximum bending load).

Comparison of design, metallurgy, mechanical performance and shaping ability of replica-like and counterfeit instruments of the ProTaper Next system

AIM

To compare the ProTaper Next (PTN) system with a replica-like and a counterfeit system regarding design, metallurgy, mechanical performance and shaping ability.

METHODOLOGY

Replica-like (X-File) and counterfeit (PTN-CF) instruments were compared to the PTN system regarding design (microscopy), phase transformation temperatures (differential scanning calorimetry), nickel-titanium ratio (energy-dispersive X-ray spectroscopy), cyclic fatigue, torsional resistance, bending strength, and untouched canal areas in extracted mandibular molars (micro-CT). anova, post hoc Tukey's and Kruskal-Wallis tests were used according to normality assessment (Shapiro-Wilk test) with the significance level set at 5%.

RESULTS

Overall similarities in design and nickel-titanium (Ni/Ti) ratio were observed amongst instruments with the X-File having a smoother surface finish. PTN and PTN-CF had mixed austenite plus R-phase (R-phase start approximately at 45 ºC and near 30 ºC, respectively), whilst X-File instruments were austenitic (R-phase started at approximately at 17 ºC) at room temperature (20 ºC). PTN-CF had the greatest inconsistency in the phase transformation temperatures. Time to fracture of PTN-CF X2 and X3 was significantly shorter than PTN and X-File instruments (P < 0.05), whilst no difference was noted in maximum torque to fracture amongst the tested systems (P > 0.05). X-Files and PTN-CF had a stress-induced phase change during bending load. Mean unprepared surface areas of root canals were 25.8% (PTN), 31.1% (X-File) and 32.5% (PTN-CF) with no significant difference amongst groups (P > 0.05).

CONCLUSION

Similarities amongst the systems were noted in the Ni/Ti ratio and maximum torque to fracture, whilst differences were observed in the design, phase transformation temperatures and mechanical behaviour. The ProTaper Next counterfeit instruments could be considered as the less secure system considering its low-cyclic fatigue resistance. Apart from these differences, the unprepared canal surface areas, obtained with the tested systems, were similar.

Street Medical Consultation: health access of the Homeless People and intersectoral articulation

Background

The Homeless People is marked by serious social vulnerability, related to the absence of human dignity. Requirements of personal and residential documents, reception and inadequate approaches are barriers to access these people. The creation of Street Medical Consultation (CnaR), based on the logic of harm reduction in association with the other services, is a strategy that seeks to expand access to the services of the Public Healthcare System (SUS) in Brazil. The research aimed to analyze the characteristics and vulnerabilities of this population, the performance of CnaR and its articulation with services from the health care and the social assistance care network.

Methods

Study of a qualitative approach using 8 semi-structured interviews and the Thematic Content Analysis method. The study scenario was the CnaR multiprofissional team in a city in the interior of São Paulo.

Results

Three categories were found: (1) Population in Street Situation - complexity of those who live on the street: prejudices, violence and barriers in society and health institutions constitute a process of invisibility. (2) CnaR's work in the perspective of harm reduction: it is organized to meet the clinical and alcohol and other drugs demands through fixed fields, mobile fields and team meeting. (3) Beyond CnaR - network relationships: bringing dynamics to relationships, being strengthened or weakened. Ignorance of the service and their performance also generates CnaR invisibility process. The strategies developed include coping, dialogue, building partnerships and the process of visibility and fighting for the rights of the Homeless Persons.

Conclusions

CnaR finds itself as an insufficient service to meet all the demands of this vulnerable population in isolation, needing the network to expand access to health and other goods. It is necessary to combat prejudice against this population among health professionals and develop more efficient intersectoral articulation.

Key messages

The Homeless People have serious vulnerability and need humanization, guaranteeing equity in assistance in all sectors of society, especially the health care and the social assistance. The Street Medical Consultation faces performance difficulties to guarantee access to the Homeless People within the intersectoral network, often being the sole responsible for this population.

Developmental Outcomes Among Young Children With Congenital Zika Syndrome in Brazil

IMPORTANCE

Although birth defects in children with congenital Zika syndrome (CZS) are expected to result in significant intellectual disabilities, the extent of delay and profiles of development have yet to be fully described.

OBJECTIVES

To describe the neurodevelopmental profiles of children with CZS and to test whether prenatal and postpartum characteristics were associated with the severity of developmental delays.

DESIGN, SETTING, AND PARTICIPANTS

This is a case series of the trajectories of developmental, behavioral, and medical needs of 121 young children with CZS who were assessed at a specialized rehabilitation center in Recife, Brazil, beginning in January 2018 as part of 5-year longitudinal study. Children were included if they had serologic confirmation of Zika virus and met clinical criteria accompanied by parental report of suspected exposure to Zika virus during pregnancy.

EXPOSURES

Prenatal Zika virus exposure.

MAIN OUTCOMES AND MEASURES

The Brazilian version of the Bayley Scales of Infant and Toddler Development, Third Edition, was administered by trained assessors as part of an initial comprehensive assessment battery. Caregiver interviews and medical record reviews were conducted to gather basic demographic information and medical comorbidities. Linear regression was used to identify potential factors for development.

RESULTS

The sample included 121 young children (mean [SD] age, 31.2 [1.9] months; 61 [50.4%] girls). At age approximately 2.5 years, nearly all children in this sample demonstrated profound developmental delays across all domains of functioning, with a mean (SD) developmental age equivalent to approximately 2 to 4 months (eg, cognitive domain, 2.24 [3.09] months; fine motor subscale, 2.15 [2.93] months; expressive language subscale, 2.30 [2.52] months). A relative strength was found in receptive language, with scores on this scale significantly higher than most other domains (eg, cognition: t = 3.73; P < .001; fine motor: t = 6.99; P < .001). Head circumference at birth was the single strongest factor associated with outcomes across all developmental domains (eg, cognitive: β = 1.41; SE, 0.67; P = .04; fine motor: β = 1.36; SE, 0.49; P = .007).

CONCLUSIONS AND RELEVANCE

The findings of this study provide important information regarding the severity of disability that these children and their families will experience. The findings also establish an initial point from which to monitor developmental trajectories, medical comorbidities (eg, seizures), effectiveness of interventions, and cumulative consequences on families.

Validation of a Portuguese version of the Groningen radiotherapy-induced xerostomia questionnaire

Background

The aim of this study was to validate and determine at pretest level the reliability of the Portuguese version of the Groningen radiotherapy-induced xerostomia questionnaire.

Material and Methods

This study employed 37 head and neck cancer patients. Each patient signed an informed consent and responded to the Portuguese version of the questionnaire in the form of an interview. This was repeated again after 2 weeks. A standard single question provided a validity check. Data were analyzed using Cronbach’s α to test its reliability and total and interitem correlation, and intraclass correlation to determine its internal consistency and test-retest reliability. Construct validity supported by objective measurements as salivary secretion was also investigated. Significance was set at .05.

Results

Cronbach’s α was 0.91 and 0.89 for the first and second test administrations, respectively, which indicates that the internal consistency was excellent. The intraclass correlation coefficient value for the test-retest reliability was 0.70. The correlation between the total score of the questionnaire and standard single dry mouth question was 0.72 for the first round, indicating a good correlation.

Conclusions

Demonstrating very good psychometric properties, the Portuguese version of the Groningen radiotherapy-induced xerostomia questionnaire is a valid tool and can be considered a reliable instrument to measure xerostomia in head and neck cancer patients.

Key words:Xerostomia, quality of life, xerostomia questionnaire, transcultural validation, head and neck cancer, radiotherapy, saliva.

Mind the food: Survival, growth and fecundity of a Neotropical land planarian (Platyhelminthes, Geoplanidae) under different diets

Although most land planarians are sensitive to environmental changes, some species are well adapted to human-disturbed areas and are easily transported to new places, having the potential to threaten native ecosystems. We investigated growth and survival in a land planarian common in human-disturbed areas in southern Brazil. Specimens of Obama anthropophila were divided into three groups that received different diets: (1) only the land planarian Luteostriata abundans (N=13), (2) only the slug Deroceras leave (N=12), and (3) alternating both prey types (N=13). We monitored the weight of the specimens for a month and counted and weighed egg capsules. Planarians receiving a mixed diet tended to survive less than the groups receiving a single prey type; there were significant differences between those feeding on D. laeve and the other groups. Planarians with the mixed diet ate L. abundans more often than D. laeve, and those feeding only on L. abundans tended to eat more than the other groups. Most egg capsules were laid by specimens with a diet based on D. laeve but the mixed-diet group laid heavier capsules. Both prey species are suitable as food for O. anthropophila, although it prefers planarians when both food items are available. The constant alternation between food items seems to have adverse effects, perhaps related to physiological changes to digest different food items. The heavier egg capsules of the mixed-diet group, considering its lower survival, suggest terminal investment, i.e., an increased reproductive effort when approaching death. The ability to feed on both snails and planarians, combined with its proximity to humans, make O. anthropophila a potentially invasive species.

Neonatal maternal separation opposes the facilitatory effect of castration on the respiratory response to hypercapnia of the adult male rat: Evidence for the involvement of the medial amygdala

Respiratory manifestations of panic disorder (PD) include a greater respiratory instability and enhanced responsiveness to CO₂ compared to normal individuals. Although the prevalence of PD is approximately three times greater in women compared to men, the origins of this sexual dimorphism remain poorly understood. Similar to PD patients, adult female rats previously subjected to neonatal maternal separation (NMS) show an increase in their ventilatory response to CO₂ . Because this effect of NMS is not observed in males, we hypothesised that testosterone prevents NMS-induced hyper-responsiveness to CO₂ . Pups subjected to NMS were placed in an incubator for 3 h d^-1 from postnatal days 3-12. Control pups remained undisturbed. At adulthood (8-10 weeks of age), rats were then subjected either to sham surgery or castration. Fourteen days later, breathing was measured at rest (room air) and during acute exposure to hypercapnia (5 and 10% CO₂ for 10 minutes each) using plethysmography. To gain insight into the mechanisms involved, c-fos expression was used as an indicator of neuronal activation. Brains were collected following air or CO₂ exposure for quantification of c-fos positive cells by immunohistochemistry in selected regions, including the paraventricular nucleus of the hypothalamus, the dorsomedial hypothalamus and the amygdalar complex. Castration produced a 100% increase of hyperventilatory response to 10% CO₂ in control rats. Unexpectedly, castration had no effect on the hyperventilatory response of NMS rats. The intensity of the hypercapnic response was inversely correlated with c-fos expression in the medial amygdala. We conclude that testosterone prevents the hyper-responsiveness to CO₂ , whereas NMS attenuates sensitivity to hormone withdrawal. We propose that an inhibitory influence from the medial amygdala contributes to this effect.

Molecular diagnosis of haemophilia A at Centro Hospitalar de Coimbra in Portugal: study of 103 families--15 new mutations

Haemophilia A (HA), the most commonly inherited bleeding disorder, has well known phenotype heterogeneity, influenced by the type of mutation, modulating factors and development of inhibitors. Nowadays, new technologies in association with bioinformatics tools allow a better genotype/phenotype correlation. With the main objective of identifying familial carrier women and to offer prenatal diagnosis, 141 HA patients belonging to 103 families, followed or referred to the Haemophilia Centre of CHC, E.P.E., were studied. Molecular diagnosis strategy was based on HA severity: IVS22 and IVS1 inversions, direct sequencing and MLPA technique. New missense and splicing mutations were further analyzed using molecular modelling. Genotype/phenotype correlation was assessed taking into account the known modulating factors. During this study, mutations were detected in 102/103 families, carrier status was determined in 83 women and 14 prenatal diagnoses were performed. In a total of 46 different mutations identified, 15 have not been reported previously by the HAMSTeRS and HGMD. Genotype/phenotype correlation revealed two cases with a clinical picture less severe than expected by the type of mutation identified. Six patients developed inhibitors: five severe (IVS22, IVS1, large deletion) and one mild (p. Gln2265Lys). The adopted strategy allowed the identification of 99% of the molecular alterations underlying the HA phenotype (98% detection rate for severe and 100% for moderate and mild). Evaluation of genotype-phenotype correlation was complemented with structural protein modelling of newly identified missense mutations, contributing to better understanding of the disease-causing mechanisms and to deepening knowledge on protein structure-function.

Detection of the steroidogenic acute regulatory protein, StAR, in human liver cells

Overexpressing StAR (a mitochondrial cholesterol transporter) increases (>5-fold) the rate of 27-hydroxylation of cholesterol and the rates of bile acid synthesis in primary rat hepatocytes; suggesting that the transport of cholesterol into mitochondria is rate-limiting for bile acid biosynthesis via the CYP27A1 initiated 'acidic' pathway. Our objective was to determine the level of StAR expression in human liver and whether changes in StAR would correlate with changes in CYP27A1 activity/bile acid synthesis rates in human liver tissues. StAR mRNA and protein were detected in primary human hepatocytes and HepG2 cells by RT-PCR/Northern analysis and by Western analysis, respectively. In immunocompetition assays, liver StAR was competed away with the addition of purified human adrenal StAR. Overexpressing CYP27A1 in both cell types led to >2-fold increases in liver StAR concentration. StAR protein levels also increased approximately 2-fold with the addition of 27-hydroxycholesterol to HepG2 cell culture medium. Overexpressing StAR increased the rates of 27-hydroxylation of cholesterol/bile acid synthesis in both cell lines and increased intracellular levels of 27-hydroxycholesterol. In conclusion, human liver cells contain regulable StAR protein whose level of expression appears capable of regulating cellular cholesterol homeostasis, representing a potential therapeutic target in the management of hyperlipidemia.

A novel crosslinking reagent and its application for the detection and isolation of heparin-binding protein(s) on the platelet surface

A new hetero-bifunctional photo crosslinking reagent, 2-(4-azidoanilyl)-4-(4-azabicyclo-[2,2, 2]hexylammonio)-6-morpholino-1,3,5-triazine chloride, was designed to detect and isolate heparin-binding protein(s) that may act as heparin-receptor(s) on the platelet surface. In a preliminary study using ethanol as a model substrate, the reagent was shown to react with the alcoholic hydroxy group under mild conditions and its crosslinking photoreactivity was high. The reagent effectively formed similar covalent bonds with heparin, while preserving its anticoagulant anti-Xa activity. [3H]Heparin labeled with this reagent crosslinked to antithrombin III very specifically but not to ovalbumin, as analyzed by the Bio-imaging Analyzer System (BAS, Fuji Photo Film, Tokyo). Affinity crosslinking of [3H]heparin was then used to detect heparin-binding proteins on the surface of intact platelets. Several discrete protein bands were detected by the BAS-imaging of SDS-PAGE.

Polypectomy and endometrial resection in postmenopausal patients

STUDY OBJECTIVE

To evaluate the therapeutic efficacy of polypectomy associated with endometrial resection for the treatment of polyps in postmenopausal women.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Private urban hospital with facilities for endoscopic surgery.

PATIENTS

Sixty-six women with endometrial polyps.

INTERVENTIONS

Sixty-four of the 66 patients underwent polypectomy followed by endometrial resection. One patient had hysterectomy because endometrial biopsy showed serous papillary carcinoma.

MEASUREMENTS AND MAIN RESULTS

No major complications were associated with the procedure. Histopathology showed hyperplasia in most polyps. One patient had a papillary uterine carcinoma in the polyp that was not detected by preoperative endometrial biopsy. The women were followed with transvaginal sonography for 1 year after surgery.

CONCLUSION

Polypectomy followed by endometrial resection is a very low-risk procedure for postmenopausal patients. There was no recurrence after the first year in women who completed follow-up.

Prevention of arterial thrombosis using a novel heparin with enhanced antiplatelet activity and reduced anticoagulant activity

PURPOSE

Thrombosis after arterial injury is often initiated by von Willebrand factor (vWF)-dependent platelet accumulation. A promising antithrombotic strategy is the interruption of platelet/vWF interactions. Previously, we demonstrated how chemical and affinity modification can enhance heparin's anti-vWF activity while reducing conventional anticoagulation. Here, we investigated whether a modified heparin can block platelet-dominated arterial thrombosis.

METHODS

Standard heparin was oxidized with periodate, refined to have high vWF affinity and inhibitory potency, and tested in a guinea pig model of platelet-dependent arterial thrombosis. In this model, a controlled mechanical arterial injury yields cyclic flow variations (CFVs) caused by recurrent accumulation of platelet thrombi.

RESULTS

All six control animals developed CFVs (mean, 10.4 +/- 2.6 CFVs), and six of seven animals treated with standard heparin also developed CFVs (mean, 7.6 +/- 4.6). Only one of six animals treated with the anti-vWF heparin and one of six treated with AJvW-2 (an anti-vWF antibody) developed CFVs (mean, 2.0 +/- 4.9 and 0.5 +/- 1.2, respectively). Thus both the modified heparin and AJvW-2 were more effective than standard heparin (p < 0.03). Bleeding times and platelet counts were unaffected. A modified activated partial thromboplastin time was less prolonged by the modified high-affinity heparin (91 +/- 17) seconds) than by standard heparin (144 +/- 30 seconds; p < 0.01).

CONCLUSIONS

The modified heparin with high vWF affinity was a more effective arterial antithrombotic agent, with fewer conventional anticoagulant effects than standard heparin. Interruption of the vWF/platelet interaction is a promising antithrombotic strategy that may be met by novel heparin-based antithrombotic drugs.

Structural aspects of heparin responsible for interactions with von Willebrand factor

Unfractionated heparin (UFH) binds von Willebrand factor (vWF) and inhibits the vWF-platelet GP Ib interaction. For vWF, a heparin-binding domain has been identified, but for heparin, the structures that confer such activity are unknown. To investigate this, UFH was depolymerized by methods that yield structurally distinct fragments. The glycosaminoglycans (GAGs) produced were separated into five groups of homogeneous molecular weight (MW). Anti-Xa activity, vWF binding affinity, and vWF-dependent platelet agglutination were measured. Periodate oxidation but not heparinase digestion destroyed anti-Xa activity. At all MWs, periodate conferred greater vWF binding affinity and greater ability to inhibit platelet agglutination than heparinase. As an example, at MW 6100, the binding IC50 was 100+/-19 micromol/L for a periodate-derived GAG and 527+/-70 micromol/L for a heparinase-derived GAG. At the same MW, the agglutination IC50 was 17+/-5 micromol/L for periodate and 135+/-18 micromol/L for heparinase. This suggests that the disaccharide GlcNS[6S]-IdoA2S, destroyed by heparinase but not periodate, is crucial to heparin-vWF interactions. An MW dependency was also noted, with a minimum dodecasaccharide required for activity inhibition. To further investigate the heparin/vWF interaction, affinity fractionation of heparins was performed with an immobilized peptide derived from a heparin-binding domain of vWF. Disaccharide analysis of high-affinity heparins revealed an increased ratio of IdoA2S-GlcN[S/Ac]6S to IdoA2S-GlcN[S/Ac]. Affinity fractionation of oligosaccharides (MW 3500) diminished the relative content of all disaccharides except IdoA2S-GlcNS6S, which was increased. These data suggest that the disaccharide structures IdoA2S-GlcNS6S and GlcNS6S-IdoA2S are crucial to heparin/vWF interactions. Understanding the structural aspects that confer such activity may be useful in designing heparin-based antithrombotic drugs.

Administration of medroxyprogesterone acetate after endomyometrial resection

STUDY OBJECTIVE

To assess the efficacy of endometrial resection for treatment of menorrhagia in women to whom no preoperative agent was given to prepare the endometrium.

DESIGN

Retrospective analysis of patients' records for all endometrial resections in which medroxyprogesterone acetate was used postoperatively.

SETTING

Hospital day surgery unit.

PATIENTS

Seventy patients with menorrhagia.

INTERVENTIONS

The women underwent transvaginal sonography, followed by hysteroscopy and endometrial biopsy. The endometrium was removed using the 27F resectoscope followed by coagulation with the rollerball. Medroxy-progesterone acetate was prescribed for 2 months after surgery.

MEASUREMENTS AND MAIN RESULTS

All women achieved a reduction in menstrual flow and 50% reported amenorrhea after endometrial resection. In only two was hysterectomy necessary due to recurrence of menorrhagia.

CONCLUSION

Preoperative endometrial preparation was unnecessary when endometrial resection was carried out for treatment of menorrhagia. However, the patients received medroxyprogesterone acetate postoperatively.

Hysteroscopy and transvaginal sonography in menopausal women receiving hormone replacement therapy

STUDY OBJECTIVE

To evaluate the endometrial cavity of menopausal women with irregular bleeding while receiving hormone replacement therapy.

DESIGN

Comparative evaluation of hysteroscopic and biopsy findings.

SETTING

A center for reproductive studies.

PATIENTS

Forty-one patients receiving different regimens of hormone replacement therapy.

INTERVENTIONS

Hysteroscopy, endometrial biopsy, and transvaginal sonography were performed in all 41 women. In 10 patients, endometrial polyps were removed with the resectoscope.

MEASUREMENTS AND MAIN RESULTS

Irregular bleeding during hormone replacement therapy was associated with atrophic endometrium whenever transvaginal sonography showed endometrial thickness to be less than 4 mm. In patients who developed increased endometrial thickness after hormone replacement therapy, hysteroscopy revealed the presence of endometrial polyps in the uterine cavity. Histopathologic examination of excised polyps revealed cystic or adenomatous hyperplasia confined to these lesions.

CONCLUSIONS

Endometrial polyps can appear in menopausal women receiving hormone replacement therapy despite the presence of progestins to oppose the action of estrogens.

Heparins designed to specifically inhibit platelet interactions with von Willebrand factor

BACKGROUND

Platelet interactions with the injured vessel wall may contribute significantly to the early and late failures of many cardiovascular interventions; the adhesive protein von Willebrand factor (vWF) is thought to play an important role. Previously, we demonstrated that heparin interfered with platelet/vWF hemostatic mechanisms by binding to vWF within the proteins's domain responsible for binding the platelet vWF receptor, glycoprotein Ib. The purpose of the present study was to develop and refine heparins with greater potency to inhibit platelet/vWF interactions.

METHODS AND RESULTS

Immobilized synthetic peptides based on a known heparin-binding domain of vWF were used to yield novel fractions of standard heparin that demonstrated a sevenfold increase in their ability to inhibit vWF-dependent platelet agglutination and vWF/platelet binding. The high vWF affinity heparin showed enhanced anti-factor Xa activity but comparable activated partial thromboplastin time activity. Chemical modification of a standard heparin by periodate oxidation and borohydride reduction enhanced its ability to inhibit platelet/vWF interactions by threefold, while eliminating more than 90% of its activated partial thromboplastin time and anti-factor Xa activity. Affinity chromatography of the chemically modified heparin yielded a heparin with an eightfold higher inhibitory potency than the original heparin.

CONCLUSIONS

Subspecies of heparin can be developed with significantly enhanced potency to inhibit vWF/platelet interactions. The vWF-inhibiting property of heparin can be dissociated from its antithrombin-binding activity. Based on a growing understanding of heparin/vWF interactions, combinations of affinity separations and chemical modifications could be designed to yield heparins uniquely suitable for prevention of arterial thrombosis.

Heparin binding domain peptides of antithrombin III: analysis by isothermal titration calorimetry and circular dichroism spectroscopy

The serine proteinase inhibitor antithrombin III (ATIII) is a key regulatory protein of intrinsic blood coagulation. ATIII attains its full biological activity only upon binding polysulfated oligosaccharides, such as heparin. A series of synthetic peptides have been prepared based on the proposed heparin binding regions of ATIII and their ability to bind heparin has been assessed by CD spectrometry, by isothermal titration calorimetry, and by the ability of the peptides to compete with ATIII for binding heparin in a factor Xa procoagulant enzyme assay. Peptide F123-G148, which encompasses both the purported high-affinity pentasaccharide binding region and an adjacent, C-terminally directed segment of ATIII, was found to bind heparin with good affinity, but amino-terminal truncations of this sequence, including L130-G148 and K136-G148 displayed attenuated heparin binding activities. In fact, K136-G148 appears to encompass only a low-affinity heparin binding site. In contrast, peptides based solely on the high-affinity binding site (K121-A134) displayed much higher affinities for heparin. By CD spectrometry, these high-affinity peptides are chiefly random coil in nature, but low microM concentrations of heparin induce significant alpha-helix conformation. K121-A134 also effectively competes with ATIII for binding heparin. Thus, through the use of synthetic peptides that encompass part, if not all, of the heparin binding site(s) within ATIII, we have further elucidated the structure-function relations of heparin-ATIII interactions.

A comparative study of heparin responses in arterial and venous thromboembolism using molecular markers for thrombosis

BACKGROUND

Compared with the therapy of venous thromboembolism, there is little consensus regarding guidelines for heparin anticoagulation of patients with arterial thrombosis. This study aimed to identify the quantitative differences in the activation of the coagulation cascade and platelets in these two syndromes and to characterize their specific biological responses to heparin therapy.

METHODS AND RESULTS

Eighteen patients receiving intravenous heparin to treat venous (n = 9) or arterial (n = 9) thromboembolism were prospectively studied for an average of 4 days each. Clinical responses to treatment, activated partial thromboplastin time (aPTT), and molecular markers for thrombosis were measured regularly. Although both groups received equivalent doses of heparin (approximately 1100 units/h), the resulting aPTTs and plasma heparin activity were significantly lower in the arterial patients (P < .05 and P < .01, respectively). The plasma levels of beta-thromboglobulin (a marker for platelet activation and granule release) were significantly higher in the arterial patients (109 +/- 9.5 versus 79 +/- 7.1 ng/mL, mean +/- SEM, P < .05). In vivo fibrin formation, as evidenced by plasma levels of fibrinopeptide A, was less effectively suppressed in the patients with arterial versus venous thrombosis (18.5 +/- 3.2 versus 10.4 +/- 2 ng/mL, P < .05). Prothrombin fragments 1 + 2, a marker for prothrombinase complex activity, was nearly normal in both heparinized groups.

CONCLUSIONS

The anticoagulant response to heparin is blunted in patients with arterial thrombosis, at least in part by the antagonistic actions of increased platelet activation. Comparing arterial with venous thrombosis, higher doses of heparin on the average may be required to achieve comparable aPTTs, plasma heparin activity, and comparable suppression of fibrin formation.

Heparin-von Willebrand factor binding as assessed by isothermal titration calorimetry and by affinity fractionation of heparins using synthetic peptides

The ability of proteins to bind heparin, a heterogeneous sulfated glycosaminoglycan, likely depends on the conformational uniqueness of specific binding domains. Based on the motif of a consensus heparin-binding synthetic peptide, a 23-residue sequence (Y565-A587) of human von Willebrand factor (vWF) was previously identified which binds heparin with affinity comparable to that of the native protein (Sobel, M., Soler, D. F., Kermode, J. C., and Harris, R. B. 1992 J. Biol. Chem. 267, 8857-8862). This peptide undergoes a conformational change upon binding heparin. Isothermal titration calorimetry has now been used to further quantify this binding reaction. In experiments done at 25 degrees C, Y565-A587 bound heparin with about the same affinity (Kd = 9.0 x 10(-7) M) as a "core" sequence peptide encompassing residues K569-I580. Binding between these peptides and heparin is overwhelmingly enthalpically favored and is dependent on the formation of productive electrostatic bonds; hydrophobic interactions do not play a significant role in mediating binding. Furthermore, when immobilized on Sepharose in a manner which does not compromise essential cationic residues, the vWF domain peptides are effective affinity ligands. They bind a species of heparin which possesses significantly enhanced affinity for native vWF. The Kd for binding between the high-affinity heparin and Y565-A587 is about threefold lower than that determined with crude, unfractionated heparin. Thus, the vWF peptides are a useful model for studying the physiological role of heparin binding to the native protein.

Mandibulofacial dysostosis: report on two Brazilian families suggesting autosomal recessive inheritance

We report on mandibulofacial dysostosis in 2 brothers born to normal nonconsanguineous parents, and a girl (F = 1/16) born to normal consanguineous parents. Normal clinical, skeletal, audiologic, and cephalometric studies in the parents, as well as the absence of limb anomalies in these children, exclude the autosomal recessive (Nager and Genée-Widemann) mandibulofacial dysostoses. The data of the present patients associated with the few additional reports on mandibulofacial dysostosis recurring in sibs, suggest the possibility of an autosomal recessive Treacher Collins-like mandibulofacial dysostosis.

Structural characterization of heparin's binding domain for human platelets

The structural features of heparin that are involved in binding to human platelets were investigated by a competitive binding approach. A range of heparin-derived glycosaminoglycans (GAGs) with relatively defined structure were prepared by different methods of depolymerization of pharmaceutical heparin, followed by fractionation according to molecular weight and net charge. Competitive binding to platelets was dependent on molecular weight but not on the net charge of the GAGs. The method for depolymerization significantly affected the binding activity of the resulting GAG. Heparinase I and nitrous acid depolymerization produced GAGs with lower binding affinity for platelets than those GAGs derived from the treatment with periodate followed by alkali. The IC20 (concentration producing 20% inhibition of binding) was 0.05 microM for unfractionated heparin, 0.11 microM for a periodate treated GAG, and 2 microM for comparably sized GAGs (M(r) approximately 6,000-8,000) derived by heparinase I or nitrous acid treatment. Thus, the disaccharide units GlcNSO3-6S--IdoA-2S or GlcNSO3--IdoA-2S [(2-deoxy-2-sulfoamido-6-O-sulfo-alpha-D-glycopyranosyl)-(1- 4)-O-(2-O-sulfo-alpha-L-idopyranosyluronic acid) or (2-deoxy-2-sulfoamido-alpha-D-glycopyranosyl)-(1-4)-O-(2-O-s ulfo-alpha-L-idopyranosyluronic acid)] may be crucial elements for binding to the platelet, because these are known to be preserved during periodate/alkali treatment, but readily decomposed by heparinase I and nitrous acid. Understanding this structural specificity for platelet binding may be useful for the development of heparins with high or low platelet reactivity.