Apparent subadditivity of the efficacy of initial combination treatments for type 2 diabetes is largely explained by the impact of baseline HbA1c on efficacy

AIM

To explain the subadditive efficacy typically observed with initial combination treatments for type 2 diabetes.

METHODS

Individual subject data from 1186 patients with type 2 diabetes [mean glycated haemoglobin (HbA1c) = 8.8%] treated with metformin, canagliflozin or canagliflozin + metformin were used. The baseline HbA1c versus ΔHbA1c relationships for monotherapy arms were determined using analysis of covariance and then used to predict efficacy in the combination arms by modelling how applying one treatment lowers the 'effective baseline HbA1c' for a second treatment. The model was further tested using data from several published combination studies.

RESULTS

The mean ΔHbA1c levels were -1.25, -1.33, -1.37, -1.77 and -1.81% with metformin, canagliflozin 100 mg, canagliflozin 300 mg, canagliflozin 100 mg/metformin and canagliflozin 300 mg/metformin, respectively. Using the monotherapy results, the predicted efficacy for the canagliflozin/metformin arms was within 10% of the observed values using the new model, whereas assuming simple additivity overpredicted efficacy in the combination arms by nearly 50%. For 10 other published initial combination studies, predictions from the new model [mean (standard error) predicted ΔHbA1c = 1.67% (0.14)] were much more consistent with observed values [ΔHbA1c = 1.72% (0.12)] than predictions based on assuming additivity [predicted ΔHbA1c = 2.19% (0.21)].

CONCLUSIONS

The less-than-additive efficacy commonly seen with initial combination treatments for type 2 diabetes can be largely explained by the impact of baseline HbA1c on the efficacy of individual treatments. Novel formulas have been developed for predicting the efficacy of combination treatments based on the efficacy of individual treatments and the baseline HbA1c of the target patients.

Efficacy and safety of canagliflozin when used in conjunction with incretin-mimetic therapy in patients with type 2 diabetes

AIMS

To assess the efficacy and safety of canagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, in patients with type 2 diabetes enrolled in the CANagliflozin cardioVascular Assessment Study (CANVAS) who were on an incretin mimetic [dipeptidyl peptidase-4 (DPP-4) inhibitor or glucagon-like peptide-1 (GLP-1) receptor agonist].

METHODS

CANVAS is a double-blind, placebo-controlled study that randomized participants to canagliflozin 100 or 300 mg or placebo added to routine therapy. The present post hoc analysis assessed the efficacy and safety of canagliflozin 100 and 300 mg compared with placebo in subsets of patients from CANVAS who were taking background DPP-4 inhibitors or GLP-1 receptor agonists with or without other antihyperglycaemic agents at week 18.

RESULTS

Of the 4330 patients in CANVAS, 316 were taking DPP-4 inhibitors and 95 were taking GLP-1 receptor agonists. At 18 weeks, canagliflozin 100 and 300 mg provided larger placebo-subtracted reductions in glycated haemoglobin (HbA1c) in patients taking DPP-4 inhibitors [-0.56% (95% confidence interval [CI]: -0.77, -0.35), and -0.75% (95% CI: -0.95, -0.54), respectively] and GLP-1 receptor agonists [-1.00% (95% CI: -1.35, -0.65), and -1.06% (95% CI: -1.43, -0.69), respectively]. Body weight and blood pressure (BP) reductions were seen with canagliflozin versus placebo in both subsets. Higher incidences of genital mycotic infections and osmotic diuresis-related adverse events (AEs) were seen with canagliflozin compared with placebo. The incidence of hypoglycaemia was numerically higher with canagliflozin versus placebo; nearly all events occurred in patients on background insulin or insulin secretagogues.

CONCLUSIONS

In patients on background incretin mimetics, canagliflozin improved HbA1c, body weight and BP, with an increased incidence of AEs related to SGLT2 inhibition.

A novel 8-color flow cytometry panel to study activation, maturation and senescence of CD4 and CD8 T lymphocytes in HIV-infected individuals at different stages of disease

Multicolor flow cytometry allows to study the markers differentially expressed during maturation, activation, function and senescence on immune cells. Despite the availability of reagents and technology, scarce agreement has been gained regarding phenotypic markers of HIV disease progression other than CD4 T-cell count. In this work, we present a novel high-throughput global analysis of CD4 and CD8 T-lymphocyte profiles by standardized 8-color combinations of antibodies aimed at analyzing HIV disease course progression. For this purpose, two tubes with lyophilized reagent cocktails (CD4- and CD8-specific tubes) were designed to compare the immunological characteristics of HIV-infected persons (37 "high CD4" HAART-treated and 32 "low CD4" naïve or failed-treatment patients) with healthy donors (HD). In particular, T-cell activation (CD25, CD38, CD69), differentiation (CD45RA, CCR7), apoptosis (CD95) and immune suppression profiles (CD25(high)CD127-) in HIV+ patients were compared with HD. Statistical analysis was performed by identifying the parameters associated with disease progression, namely markers that were found to be significantly different between groups with high CD4 counts (including HD) and low CD4 counts (restricted to HIV patients) but not between the HD and the "high CD4" group. This set of markers, including those identifying different maturation and senescence subtypes of CD4 and CD8 T cells, was found to be associated with therapy failure, and it is in fact evaluated in an ongoing study aimed to verify its prognostic value. This robust assay was found feasible on a semi-routine scale for HIV-infected persons, and allows for broader clinical studies aimed at defining markers associated with treatment outcome, possibly having a high impact on the clinical management of HIV disease.

Effect of canagliflozin, a sodium glucose co-transporter 2 (SGLT2) inhibitor, on bacteriuria and urinary tract infection in subjects with type 2 diabetes enrolled in a 12-week, phase 2 study

OBJECTIVE

To examine the effects of canagliflozin, a sodium glucose co-transporter 2 inhibitor that lowers blood glucose by increasing urinary glucose excretion (UGE), on asymptomatic bacteriuria and urinary tract infections (UTIs).

RESEARCH DESIGN AND METHODS

In a randomized, double-blind, placebo-controlled, multicenter, dose-ranging phase 2 study, subjects with type 2 diabetes with inadequate glycemic control while receiving metformin were enrolled and randomized to one of seven arms - placebo; canagliflozin doses 50 mg, 100 mg, 200 mg, 300 mg daily, or 300 mg twice daily; and sitagliptin 100 mg daily - for 12 weeks.

CLINICAL TRIAL REGISTRATION

This study is registered under Clinicaltrials.gov identification number NCT00642278.

RESULTS

Canagliflozin increased renal glucose excretion by 35.4-61.6 mg/mg creatinine in the five dose groups. In the placebo group renal glucose excretion was increased by 1.9 mg/mg creatinine, and in the sitagliptin group it decreased by 1.9 mg/mg creatinine. Asymptomatic bacteriuria (ASB) were present in 6.4% of canagliflozin and 6.5% of placebo/sitagliptin (control) subjects at randomization and, at 12 weeks, in 7.7% and 6.3% of subjects, respectively (odds ratio [OR] 1.23; 95% confidence interval [CI], 0.45-3.89). For subjects with initially negative urine cultures at baseline, 3 out of 82 (3.7%) who received controls and 10 out of 207 (4.8%) who received canagliflozin developed bacteriuria (p = 0.76) at week 12. There were 21 adverse event (AE) reports of UTI; 16 (5.0%) in canagliflozin subjects and 5 (3.8%) in control subjects (OR 1.31; 95% CI, 0.45-4.68).

CONCLUSIONS

In this trial, when compared with control subjects, canagliflozin increased UGE but was not associated with increased bacteriuria or AE reports of UTI. However, further studies enrolling larger numbers of subjects with longer term exposure to canagliflozin will be necessary to more fully understand the impact of this agent on the risk of developing UTI.

Universal features of the melt elasticity of interacting polymer nanocomposites

We study the structure and linear viscoelasticity of interacting polymer nanocomposites based on mixtures of poly(ethylene oxide) and fumed silica particles. The filler is dispersed within the polymer using two different techniques which lead to different dispersion states. The analysis of the dynamic response of our systems highlights the formation of a stress-bearing network above a critical volume fraction, Φ(c). Extending a two-phase model used to describe weakly interacting systems, we show that above Φ(c) the melt-state elasticity of the composites arises from the independent contributions of a polymer-particle network and a viscous matrix. We also find that, although Φ(c) depends on the initial state of dispersion, the network elasticity scales with volume fraction following a universal power-law, with an exponent ν ≈ 1.8. Such a scaling law has been recently predicted for the stress-bearing mechanism governed by polymer-mediated interactions.

Similarities and differences of innate immune responses elicited by smooth and rough LPS

The lipopolysaccharide is the major component of Gram-negative bacteria outer membrane. LPS comprises three covalently linked regions: the lipid A, the rough core oligosaccharide, and the O-antigenic side chain determining serotype specificity. Wild-type LPS (sLPS) contains the O-antigenic side chain and is referred to as smooth. Rough LPS (rLPS) does not contain the O-side chain. Most wt bacteria and especially wt Enterobacteriaceae express prevalently the sLPS form although some truncated rLPS molecules always reach the external membrane. The two sLPS and rLPS forms are used almost indistinctly to study the effects on innate immune cells. Nevertheless, there is evidence that their mechanism of action may be different. For instance, while sLPS requires CD14 for the initiation of both MyD88-dependent and independent signal transduction pathways at least at low doses, rLPS leads to MyD88-dependent responses in the absence of CD14 even at low doses. Here we have identified additional differences in the signaling capacity of the two LPS species in the mouse. We have found that rLPS, diversely from sLPS, is capable of activating in dendritic cells (DCs) the Ca(2+)/calcineurin and NFAT pathway in a CD14-independent manner, moreover it is also capable per se of activating the inflammasome and eliciting IL-1β secretion independent of the presence of additional stimuli required instead for sLPS. The ability of rLPS of activating the inflammasome in vitro has as a direct consequence a higher efficiency of rLPS-exposed DCs in activating natural killer (NK) cells compared to sLPS-exposed DCs. However, diversely from possible predictions, we found that the different efficiencies of the two LPS species in eliciting innate responses are almost nullified in vivo. Therefore, sLPS and rLPS induce nearly similar in vivo innate responses but with different mechanisms of signaling.

Pretreatment correlation between hemoglobin, unintentional weight loss, and inflammatory status in patient with advanced non-small cell lung cancer (NSCLC)

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Background: Anemia, defined as a hemoglobin level < 12 g/dL, is frequent in cancer and affect quality of life and performance status. Of all the pretreatment possible causes of cancer-related anemia, unintentional weight loss, early indicator of malnutrition, is often underestimated or completely ignored. The aim of this study is to evaluate the possible pretreatment correlation between hemoglobin level, recent unintentional weight loss (≥ 5% in the last three months) and inflammatory status (C-reactive protein ≥ 10 mg/dL) in NSCLC. Methods: 56 consecutive outpatients with NSCLC (IIIB - IV stage), 68% males, 32% females, were enrolled. Criteria for eligibility included absence of comorbidity (diabetes, hepatic or renal failure) and not previous oncological treatment All patients were evaluated for hemoglobin level (Hb), percentage of involuntary weight loss (WL) and C- reactive protein (CRP) before chemotherapy. Results: 25% of patients had a Hb level < 12 g/dL, 38% referred a recent WL ≥ 5% and 54% had a CRP ≥ 10 mg/dL. Hb was WL-related (p = 0.001) and not CRP-related (p = 0.160), WL was CRP-related (p = 0.022). In the subgroup of patients, the differences of haemoglobin concentrations were minimal, but stastically significant only when inflammatory status was associated with WL. On Table we reported the mean concentrations of haemoglobin as measured in the subgroups of patients. Conclusions: Our data suggest that an early and intensive management of weight loss might prevent or reduce anemia in NSCLC before treatment.

[Table: see text]

No significant financial relationships to disclose.

Modulators of arginine metabolism support cancer immunosurveillance

Background

Tumor-associated accrual of myeloid derived suppressor cells (MDSC) in the blood, lymphoid organs and tumor tissues may lead to perturbation of the arginine metabolism and impairment of the endogenous antitumor immunity. The objective of this study was to evaluate whether accumulation of MDSC occurred in Th2 prone BALB/c and Th1 biased C57BL/6 mice bearing the C26GM colon carcinoma and RMA T lymphoma, respectively, and to investigate whether N(G) nitro-L-arginine methyl ester (L-NAME) and sildenafil, both modulators of the arginine metabolism, restored antitumor immunity.

Results

We report here that MDSC accumulate in the spleen and blood of mice irrespective of the mouse and tumor model used. Treatment of tumor-bearing mice with either the phosphodiesterase-5 inhibitor sildenafil or the nitric-oxide synthase (NOS) inhibitor L-NAME significantly restrained tumor growth and expanded the tumor-specific immune response.

Conclusion

Our data emphasize the role of MDSC in modulating the endogenous tumor-specific immune response and underline the anti-neoplastic therapeutic potential of arginine metabolism modulators.

Continous low dose oral chemotherapy administration in heavily pretreated breast cancer patients

10664

Background: The efficacy and the antiangiogenic effect of low dose continous (metronomic) administration of chemotherapy are well known. In thi study we tested the clinical activity of oral Ciclophosphamide (CTX) and Methotrexate (MTX) in advanced breast cancer (ABC). Methods: From november 2004 to september 2005 35 ABC patients were enrolled. Median age 59 (range 36–74), ECOG PS 0–2. All patients received at least two prior chemotherapeutic regimens (range 2–4). Metastatic sites were as follow: liver (16), lung (6), bone (9) and skin (4). patients with CNS involvement were excluded. All patients received CTX at the dose of 50 mg/die and MTX at the dose of 2.5 mg twice daily on days 3 and 4 of each week. After two months of treatment patients were re-evalated for disease response. Results: All patients were evaluable for response. After 2 months of treatment we observed 3 PR (8.5%) and 12 SD (34%), for an overall RR of 42%. 23 patients experienced PD. On the whole treatment was well tolerated, with mild toxicity; no patients discontinued treatment due to toxicity. Grade 2 or 3 neutropenia was observed in 14/35 patients and grade 2 trombocytopenia was observed in 9/35 patients. No grade 4 toxicity was observed. Conclusions: Metronomic administration of chemotherapy is well tolerated even in pretreated patients and shows moderate activity in advanced breast cancer

No significant financial relationships to disclose.

An unusual case of ascites

A 76-year-old woman with abdominal pain and diarrhoea developed ascites that did not respond to treatment. There were no signs of liver damage. Abdominal ultrasonography with colour Doppler revealed an arterial-like flow in the enlarged splenic vein. Using selective mesenteric arteriography, we were able to diagnose a shunt between the inferior mesenteric artery and the inferior mesenteric vein. This is an unusual case of ascites due to prehepatic portal hypertension secondary to an extrahepatic arterioportal fistula.

The Regulatory Role of Dendritic Cells in the Immune Response

Dendritic cells (DCs) are key regulators of immune reactions. They control early innate responses, regulate long-lasting adaptive immunity and contribute to the maintenance of self-tolerance. DCs continuously monitor the environment through a multifaceted innate antigen receptor repertoire and, in response to perturbations, start a complex genetic reprogramming that leads to a complete activation of innate and, then, adaptive immune responses. This review discusses how DCs become efficient activators of NK and, subsequently, T cells following a microbial encounter.

Tamoxifen in the treatment of hepatocellular carcinoma: 5-year results of the CLIP-1 multicentre randomised controlled trial

BACKGROUND

In 1998, when data of a meta-analysis on tamoxifen in the treatment of hepatocellular carcinoma (HCC) had suggested a little advantage for this treatment, we published the results of a multicenter randomised controlled trial, that showed no survival benefit for tamoxifen vs. control. Here we report an updated analysis of the study results 4.5 years after the closure of enrollment.

METHODS

The study had a planned sample size of 480 patients. Patients with any stage HCC were eligible, irrespective of locoregional treatment. Tamoxifen was given orally, 40 mg/die, from randomisation until death.

RESULTS

496 patients were randomised by 30 Institutions from January 1995 to January 1997. Information was available for 477 patients. As of July 2001, 374 deaths (78%) were recorded, and median survival times were 16 and 15 months (p=0.54), in the control and tamoxifen arm. Data were further analysed separately for advanced patients and for those eligible to potentially curative locoregional treatments: relative hazard of death for patients receiving tamoxifen was equal to 0.98 (95% CI 0.76-1.25) for the former group and 1.38 (95% CI 0.95-2.01) for the latter. The prognostic score recently devised by our group (CLIP score) was, as expected, strictly correlated (p<0.0001) to the locoregional treatment received and strongly correlated with prognosis.

CONCLUSIONS

the update of the present study confirms that tamoxifen is not effective in prolonging survivals, both in advanced patients and in those potentially curable and that the CLIP score is able to predict prognosis.

[Suspected acute appendicitis. Role of enhanced helical computed tomography. Prospective study of 100 patients]

AIM OF STUDY

To assess the diagnosis accuracy of helical computed tomography (CT) in patients with suspected appendicitis.

PATIENTS AND METHODS

This prospective study included 100 consecutive patients hospitalized for suspected appendicitis. There were 57 men and 43 women with a median age of 30 years (range: 17-91). An enhanced helical CT was performed at admission, without digestive opacification. Four criteria were interpreted as positive signs for appendicitis: appendix enlarged > or = 7 mm, right lower quadrant inflammation, stercorolith, and peri-appendicular collection. The patient was managed by the surgeon without knowing the result of CT. The final diagnosis was made pathologically.

RESULTS

Eighty-one patients were operated on laparoscopically for suspected appendicitis. Intraoperative diagnosis was corrected in three cases and 78 appendectomies were performed (73 histological appendicitis, six normal appendix). Final diagnosis was a medical disease in 19 patients. The findings of 67 CT were interpreted as positive (63 true positive and four false positive) and the findings of 33 CT were interpreted as negative (24 true negative, nine false negative). Sensitivity was 87%, specificity was 86%, positive predictive value was 94%, and negative predictive value was 73%. If the nine false negative cases with minimal lesions at pathological examination were considered as true negative, the rates would be 100%, 89%, 94%, 100%, respectively.

CONCLUSION

Enhanced helical CT is a good imaging diagnostic tool for suspected appendicitis. It may reduce the number of patients admitted for observation and decrease the rate of negative appendectomy.

Combination of paclitaxel and etoposide in the treatment of advanced non-small cell lung cancer: a phase I-II study

Thirty-six patients (pts) with unpretreated advanced non-small cell lung cancer (NSCLC) stages IIIB and IV were enrolled in this two-stage phase I-II study aimed to establish the maximum tolerated dose (MTD) of paclitaxel and to evaluate the efficacy and safety of paclitaxel combined with etoposide every 3 weeks for a maximum of 6 courses, increasing the dose of paclitaxel according to a modified Fibonacci scheme. Nineteen pts were enrolled in the first stage and 17 pts in the second stage. The characteristics of the pts were as follows: median age 56 years (40-70), median Karnofsky's Performance Status 80% (70-80), 11 pts were stage IIIB and 25 pts stage IV. The doses of etoposide administered were 50 mg/m2 for 15 pts and 100 mg/m2 for 21 pts. MTD has not been reached and the study proceeded with the dose of paclitaxel 250 mg/m2. We obtained 9 (25%) partial remissions (PR) and 11 (31%) stable disease (SD) in 33 objectively evaluable pts. Median time to progression (TTP) was 4 months (0.3-21), median survival was 9.3 months (0.3-27). The main toxicity was neutropenia and neurotoxicity, while the gastrointestinal toxicity was mild. Two pts deceased after the first course. The causes of death were necrotizing enteritis in the first pt and congestive heart failure in the second pt. A total of 156 courses were administered at 7 dose levels, with a median of 4 courses per patient (1-6). The results seem to support the use of this combination in advanced non-small cell lung cancer.

Cryptic epitopes on alpha-fetoprotein induce spontaneous immune responses in hepatocellular carcinoma, liver cirrhosis, and chronic hepatitis patients

To determine alpha-fetoprotein (AFP) immunogenicity in vivo, the presence of antibodies in sera of 60 hepatocellular carcinoma, 15 liver cirrhosis, and 15 chronic hepatitis patients was evaluated by Western blotting and immunoprecipitation analyses using purified human AFP. High titers of anti-AFP immunoglobulins were detected in 14 hepatocellular carcinomas (P = 0.0006), 3 liver cirrhosis (P = 0.0173), and 1 chronic hepatitis patient, but they were not detected in 40 healthy individuals. Therefore, spontaneous immune responses to AFP are significantly associated to liver diseases (P = 0.0015). Patient immunoglobulins recognized proteic linear epitopes that were cryptic in the native protein, as demonstrated by their restricted reactivity with denatured deglycosylated AFP. Thus, in pathological liver conditions, tolerance to this self-molecule is circumvented. The identification of AFP immunogenic epitopes may contribute to defining novel immunotherapeutic strategies targeting this antigen.

[Anthropometric measurements of the male inguinal canal]

BACKGROUND

A problem in the use of a prosthesis in the treatment of inguinal hernia is the form and dimension the mesh should have. There are no precise indications in the international literature and manufactured pre-cut prostheses available are not always suitable for all patients. In this study some measurements within the male inguinal canal have been compared with the patients' physical characteristics, such as weight, height and body mass index, and with inguinal hernia too. The purpose was to look for a relation between these data, in order to establish the form and size of the ideal mesh prosthesis for every patient before operation. A "list" of different prosthesis sizes could help both the surgeon and the manufacturers.

METHODS

The study was carried out on 150 male patients who underwent surgery for inguinal hernia.

RESULTS

The analysis of the results does not demonstrate a relationship between the data examined.

CONCLUSIONS

The conclusion is drawn that there could be two solutions to the problem of mesh size: one being the expensive prepacking of meshes of various sizes, and the cheaper one being to find out a method which, not considering the internal ring variability, will not influence the production of a universal mesh.

[The dynamic self-regulating prosthesis. A new method for the treatment of hernias in the inguinal area: preliminary notes on 153 cases]

BACKGROUND

Good results have been obtained by using prosthesis in the treatment of inguinal hernia. However, there is still some uncertainty on "free tension" and "suture less" techniques, about traction, tension or torsion, wrinkle and dislocation and the consequences on the postoperative period. To resolve these problems a new procedure by using a new prosthesis, called PAD, by polypropylene (Prolene), is proposed; excellent results about recurrences, excluding every traction, torsion, wrinkle and dislocation and improved postoperative comfort, have been observed. The PAD is suitable in all inguinal hernias in males and is composed of two layers superposed and fixed to some structures of inguinal canal on one side only, opposite to the other, to allow movements of aponeurotic and muscular structures, of the inguinal region.

METHODS

The study has been carried out on 153 patients, males, non selected, having primary inguinal hernia, all subjected to PAD procedure and followed-up from 30 to 48 months.

RESULTS AND CONCLUSIONS

The results show a remarkable reduction in use of analgesics by patients in the postoperative period due to a better comfort achieved. This procedure avoids the risk of a prosthesis placed under the transversalis fascia and is easily repeatable.

[Loco-regional persistence and recurrences of operated differentiated thyroid cancers. 22 cases on 589 treated patients from 1964 to 1990, follow-up from 5 to 31 years]

AIM OF THE STUDY

Evaluation of frequency and outcome of loco-regional persistance and recurrences of differentiated thyroid carcinomas after surgery.

MATERIAL AND METHODS

from 1964 to December 1990, we operated and followed up more than 5 years (from 5 to 31 years): 589 thyroid cancers (309 papillary, 262 follicullar et 18 Hürthle cells); 145 patients were lost to follow-up (24%), 33% of them were microcarcinomas. Surgery consisted ultimately in 411 total thyroidectomies, 51 sub-total thyroidectomies, 113 lobectomies with isthmusectomies, 9 isthmusectomies or tumorectomies and 4 tracheotomies. Neck dissection was not routinely performed but rather selectively (n = 137). All Patients were put under suppressive hormone therapy. After total thyroidectomy, ablative 131 iodine was almost routinely done. All patients have been controlled by clinical examination, radio-iodine scanning and, since 1983, by sequential thyroglobulin assays. We have analysed the course of patients according to L. J. Degroot's staging (Stage I: Patient with intrathyroidal disease. Stage II: Patient with cervical node involvement. Stage III: Patient with extra-thyroidal neck invasive disease. Stage IV: Distant metastasis).

RESULTS

Stage I, n = 383, Stage II, n = 96. Total = 479. Local recurrences in the bed of total thyroidectomy were exceptional: n = 2/323 (0.6%). Recurrences in the thyroid remnant after non total thyroidectomy were rare: n = 3/156 (2%). Cervical nodal recurrences were also rare: n = 7/479 (1.5%). Stage III (n = 73): 34/306 papillary, 9/78, well differentiated follicular, 25/175 poorly differentiated follicular. 2/9 follicular of other type and 3/18 hurtle cell. In 67 patients, the loco-regional sterilization was achieved, 5 of which were reoperated for nodal cervical metastasis. 6 patients died from continuing loco-regional disease and 10 presented distant metastases. 4 of which died from. Among opered patients are still alive (52/73 = 71,2%) no loco-regional recurrence persisted.

CONCLUSION

The true problem is not recurrence but the persistance after surgery in stage III patients, despite the application of 1131. The determining factor of the persistance and recurrence is the initial stage of the carninomatous disease at the time of treatment.

Prognostic value of the galactose test in predicting survival of patients with cirrhosis evaluated for liver transplantation. A prospective multicenter Italian study. AISF Group for the Study of Liver Transplantation. Associazione Italiana per lo Studio del Fegato

AIMS/METHODS

The present study aimed to examine whether the galactose elimination capacity can be used to predict the survival of patients with advanced liver disease. We studied 194 patients with cirrhosis, belonging to Child class B and C, for 2 years each.

RESULTS

The overall probability of survival was 79% at 6 months, 72% at 1 year and 62% at 2 years. Variables significantly associated with the duration of survival, as assessed by univariate analysis, were the Child-Pugh score, presence of ascites, size of esophageal varices, prothrombin time, albumin, bilirubin, urea, creatinine, glucose and galactose elimination capacity. By a multivariable analysis, only Pugh score (p = 0.005), creatinine (p < 0.001), varices (p = 0.001) and galactose elimination capacity (p < 0.001) were independent predictors of mortality. The galactose elimination capacity was even more sensitive when the end-point was limited to deaths due to liver failure and hepatorenal syndrome. A new score obtained by summing the Pugh score with a score derived from galactose elimination capacity was quite simple and accurate for predicting survival.

CONCLUSIONS

The quantitative measurement of liver function as the galactose elimination capacity could be of use to identify patients with cirrhosis and probable short survival who might benefit most from urgent transplantation.

Nicotinamide methylation and hepatic energy reserve: a study by liver perfusion in vitro

BACKGROUND/AIMS

The synthesis of pyridine nucleotides from nicotinamide requires adenosine triphosphate. In man when exogenous nicotinamide is poorly utilized in this synthesis, the excess follows a dissipative metabolic pathway and is excreted in urine as N-methylnicotinamide. In human cirrhosis N-methylnicotinamide serum levels are higher than normal, in basal condition and after nicotinamide oral load. The aim of this study was to verify N-methylnicotinamide production in relation to hepatic content of adenosine triphosphate during in vitro perfusion of rat liver, in normal conditions and after adenosine triphosphate depletion by metabolic stress.

METHODS

"Stress" was obtained by pre-washing with saline for 15 min before the perfusion with nutritive medium.

RESULTS

The adenosine triphosphate decrease in the stressed liver was 38% after pre-washing with saline and 80% at the end of nutritive perfusion. In control liver the corresponding decreases were 1% after pre-washing with nutritive medium and 65% at the end of perfusion with the same medium. The total nicotinamide adenine dinucleotide decreases were 44% and 56% in the stressed liver, and 19% and 52% in the control liver. The output levels of N-methylnicotinamide at 90 min of rat liver nutritive perfusion were 31.50 +/- 4.72 nmol/g for normal liver and 66.40 +/- 13.17 for stressed liver (p<0.001). Liver adenosine triphosphate was inversely related to N-methylnicotinamide production (r=0.93; p<0.001).

CONCLUSIONS

These data suggest that nicotinamide methylation may be enhanced when there is hepatic adenosine triphosphate decrease and energy failure induced by hypoxia or metabolic stress, similar to that obtained in vitro by saline washing before perfusion with nutritive medium. This study shows that the evaluation of N-methylnicotinamide production in man (before and after nicotinamide load) might be useful to explore the energy state of diseased liver.

Expression of Gst-Mu Transferase in Breast Cancer Patients and Healthy Controls

The expression of glutathione S-transferase mu was measured by a qualitative immunoenzymatic assay in the blood samples of 108 women (63 breast cancer patients and 45 healthy controls) in order to analyze the relationships of GST-mu phenotype and smoking habits with tumor characteristics of breast cancer patients, such as tumor extension, nodal status, hormone receptor status and DNA content by flow cytometry. GST-mu was expressed in 53/108 (49%) of cases without any significant difference between healthy or neoplastic subjects, smokers or non-smokers, pre or post-menopausal, younger or older subjects. Moreover, the percentages of the GST-mu phenotype did not differ significantly in patients with different ER and PgR tumor status, tumor extension or nodal status. By contrast, aneuploid DNA tumor content was shown to be significantly associated with GST-mu expression (24% and 76% GST-mu positive, respectively, in diploid and aneuploid cases; p < 0.003). The biological meaning of this association remains to be interpreted.

Nicotinamide methylation in patients with cirrhosis

Methylation reactions play an important role in the transformation of endogenous and exogenous substances. Up to 85% of all transmethylation reactions occur in the liver. Several studies have shown that these metabolic processes are greatly influenced by the presence of hepatic diseases. We investigated the methylation of nicotinamide in 16 control subjects and in 29 patients with cirrhosis (19 Child A, 10 Child B). The basal serum value of N-methyl-nicotinamide was measured in all subjects. In seven controls and in nine patients with cirrhosis (5 Child A and 4 Child B), the serum levels and urinary excretion (5 and 24 h) of N-methyl-nicotinamide were also evaluated after oral administration of nicotinamide (1.5 mg/kg body weight). The basal serum levels of N-methyl-nicotinamide were significantly (p < 0.05) higher in patients with cirrhosis (Child A: median 34 ng/ml, 16th percentile 24, 84th percentile 61; Child B median 45, 16th percentile 34, 84th percentile 81) than in controls (median 22, 16th percentile 13, 85th percentile 28). After the nicotinamide load the urinary excretion and the time course of serum N-methyl-nicotinamide in cirrhosis were also higher (p < 0.05) than in controls (24 h urinary excretion = 66.2 mg +/- 5 S.D. in cirrhosis; 47.2 +/- 10.3 in controls) (area under the serum concentration versus time curve = 68 micrograms.ml-1.min-1 +/- 22 S.D. in cirrhosis; 32 +/- 15 in controls). In conclusion, our results show that cirrhosis does not impair the efficiency of nicotinamide methylation.

Treatment of chronic hepatitis C with recombinant interferon alfa

We studied the clinical course and the effect of alfa interferon treatment in sixty-six patients of Southern Italy suffering from chronic hepatitis C virus. The patients were randomly assigned to the control group (33 patients without treatment) or to the group treated with 3MU of interferon three times a week for six months. Alanine transaminase (ALT) levels normalized in 17 of the 33 treated subjects (52%) within two months of treatment. Seven of these "responders" relapsed at the end of the six-month treatment period, but ALT normalized in these patients after resumption of interferon at the same dosage. None of the non responders on 3MU for four months showed improvement even when the dose was increased to 6MU. Our results coincide with other reports on interferon treatment in hepatitis C virus. Further studies are required to clarify whether or not higher doses at the onset of treatment increase the number of responders and decrease the frequency of relapses.

Metabolic fate of plasma diamine oxidase: evidence of isolated and perfused rat liver uptake

After injection of an intravenous bolus of heparin (15,000 IU) in two groups of subjects, 10 normal volunteers and 6 subjects with external biliary drainage, blood and urine samples were collected; in the latter group bile samples were collected also. All samples were assayed for diamine oxidase (DAO). Persistently high values of this enzyme were found in plasma of both populations after heparin stimulation, while no increase in enzymatic activity was detected in bile and urine. In order to confirm and support the hepatic clearance of DAO, liver uptake of the enzyme derived from porcine kidney, human plasma and human placenta was studied by perfusion of isolated rat liver. Disappearance curves of the enzyme derived from three different sources showed a prompt liver uptake: activity decreased by about 50% in 10 min (endocytic uptake) and a slower but constant reduction during the remaining 110 min of perfusion was observed. These data suggest the hypothesis of liver metabolism of plasma DAO.

Evaluation of heparin toxicity in the isolated and perfused rat liver

A plasma increase of liver enzymes has been recently reported in patients receiving heparin therapy. In this study we have evaluated the toxic effect of heparin infusion in the whole rat and in the isolated and perfused rat liver. No variation of plasma enzymes was observed in heparin-treated rats (10 IU per gram body weight, daily for 12 days). The heparin addition in the perfusion medium (5,000 IU in all) has shown no difference in the kinetics of hepatic enzymes release and in the other parameters of liver function. These data do not confirm a liver-toxic effect of heparin in the rat.

[Blood amino acids in chronic HBsAg positive liver disease]

Typical changes in blood aminoacid concentrations have been described in patients with severe liver disease. In this study we measured the serum amino acid levels, by Beckman Aminoacid Analyzer, in 11 healthy subjects and 24 HBsAg-positive patients with biopsy-proven liver disease (4 CPH, 10 CAH, 10 cirrhosis). A significant decrease in total aminoacids was observed in CAH and cirrhosis groups (-24% and -22% respectively). The three branched chain aminoacids (BCAA = val + leu + isoleu) were reduced by 24% (P less than 0.002) and 37% (P less than 0.001) in the CAH and cirrhosis groups respectively. Tyrosine was the only of the aromatic aminoacids (AAA) to increase in cirrhotics (+ 34%, P less than 0.02). The molar ratio BCAA/AAA was 3.6 in controls, 3.8 in CPH, 3.1 in CAH (P less than 0.025) and 1.9 in cirrhosis (P less than 0.001). A linear correlation was found between molar ratio BCAA/AAA and serum albumin in all patients (P less than 0.001). These results document the presence of specific quantitative changes in serum aminoacids of HBsAg positive patients, which appear related to severity of liver disease and comparable to the alterations described in non viral chronic liver disease.

[Assessment of platelet survival before and after latero-lateral portacaval shunt]

On the basis of a group of 175 patients affected by liver cirrhosis and submitted to side-to-side porto-caval shunt, we have examined the presence of hypersplenism in 49.7% and its changes after splenectomy. In order to find out a suitable method to value the changes of the platelets, we observed platelet survival in seven patients either before or after porto-caval shunt. The results obtained encourage in affirming that: 1) Hypersplenism improves after a simple shunt. 2) Hypersplenism is not severe even if it persists with an open shunt. 3) The possible onset of shunt thrombosis worsens hypersplenism. 4) Platelet survival is surely effective in the study of hypersplenism.

Changes in intestinal permeability to lactulose induced by cytotoxic chemotherapy

Intestinal function during cytotoxic therapy was studied in nine patients with nonintestinal lymphoma. An early, marked, and rapidly reversible increase in passive permeability, as disclosed by the lactulose test, was observed without concomitant changes in active absorption or in intestinal histology. The possibility of a toxic effect by cytotoxic drugs on intestinal intracellular junctions is discussed.

The cholecystokinin effect on human intestinal permeability: influence of chenodeoxycholic and ursodeoxycholic acid administration

The influence of CDCA and UDCA administration on human intestinal permeability to lactulose, as disclosed by intravenous CCK, has been investigated. For this purpose the fraction of lactulose excreted in the urine during 5 h after an oral load of the disaccharide in hypertonic solution was measured in 12 healthy subjects, with and without intravenous CCK. The lactulose test was performed in each subject before and after a 7-day course of oral CDCA or UDCA (750 mg/day). Under basal conditions CCK induced a 100% increase in lactulose excretion. CDCA treatment further augmented the response to CCK by 33% (p less than 0.001) but UDCA produced no significant change. Finally, the effect of CDCA or UDCA added directly to the lactulose test solution was investigated in 4 subjects following oral and duodenal administration. CDCA only produced an increase in lactulose excretion (more than 100%) when given in hypertonic solution. The possible reasons for these findings are discussed.

[Return to the home environment and to work of the patient treated with portacaval anastomsosis]

Social and occupational reinsertion is examined with reference to a series of 137 patients subjected to side-to-side porto-cava anastomosis for portal hypertension due to cirrhosis of the liver. Postoperative occupational reinstatement was possible in a group of patients (39.42%) who had been compelled to work less on account of haemorrhages. Considering the seriousness of the operation and the long convalescence required, there was a good overall recommencement of occupational activity (73.72%). The view is expressed that continuous contact with the hospital is essential, since this will more readily ensure that the basic hygienic and dietetic rules applicable to the patient are respected. In addition, it is felt that the patient should be required to lead as normal a life as possible, in spite of his underlying liver alteration.

Cholecystokinin and human intestinal permeability

The effect of intravenous cholecystokinin (CCK) on intestinal permeability in normal subjects and patients after cholecystectomy has been studied by measuring the fraction of orally administered lactulose excreted in the urine. CCK induced a marked increase in lactulose excretion in normal subjects when given in a hyperosmolar solution (49.4 mg lactulose during 5 h rising to 114.3 mg with CCK, p less than 0.001). CCK failed to affect lactulose excretion when given to normal subjects in an isosmolar solution, and also when given to post-cholecystectomy patients in either hyper- or isosmolar solutions. The 'CCK effect' is therefore related to gallbladder emptying. It is suggested that conjugated bile acids released following gallbladder contraction can affect intestinal permeability by enhancing the action of hypertonic solutions on the small intestinal mucosa.

[Anatomical study of the arch of the internal saphenous vein (saphena magna) in man]

The Authors present 40 dissections of the saphena magna with different branches. The variability of number is shown and they call attention to 5 cases of double vein. Two classifications are described. (MINNE, 1958; MORIN, 1970). It is very difficult to put all cases in these classifications. Later, the authors plan to show topographic marks for the saphena magna.