Exposure to 27 polychlorinated biphenyls in the indoor environment of a workplace: a controlled bio-monitoring study

PURPOSE

To assess the exposure to a broad-spectrum of polychlorinated biphenyl congeners (PCBs) from the indoor environment through bio-monitoring of people working in a building with PCB-containing materials and elevated PCB levels in the indoor air.

METHODS

A cross-sectional study comparing the plasma concentration of 27 PCB congeners in 15 people working in a PCB-contaminated building and 30 matched controls.

RESULTS

Median concentration of eight low-chlorinated PCB congeners was significantly higher in the exposed than in the control group. The sum of median concentrations of tri + tetra-chlorinated PCB was almost ten times higher in the exposed group than in the unexposed, and sums of dioxin-like and non-dioxin-like PCB were both relatively increased by 60 % in the exposed group.

CONCLUSIONS

The occupational indoor environment may significantly add to PCB exposure, especially to the lower-chlorinated congeners. Health effect from this little-acknowledged exposure has not yet been documented, but data supporting lack of effect are sparse and research generating information on effect of exposure to specific congeners including at levels relevant for the indoor environment should be encouraged.

Pulmonary toxicity following exposure to a tile coating product containing alkylsiloxanes. A clinical and toxicological evaluation

CONTEXT

Coating products are widely used for making surfaces water and dirt repellent. However, on several occasions the use of these products has been associated with lung toxicity.

OBJECTIVE

In the present study, we evaluated the toxic effects of an aerosolized tile-coating product.

METHODS

Thirty-nine persons, who reported respiratory and systemic symptoms following exposure to the tile-coating product, were clinically examined. The product was analysed chemically and furthermore, the exposure scenario was reconstructed using a climate chamber and the toxicological properties of the product were studied using in vivo and by in vitro surfactometry.

RESULTS

The symptoms developed within few hours and included coughing, tachypnoea, chest pain, general malaise and fever. The physical examination revealed perihilar lung infiltrates on chest radiograph and reduced blood oxygen saturation. The acute symptoms resolved gradually within 1-3 days and no delayed symptoms were observed. By means of mass spectrometry and X-ray spectroscopy, it was shown that the product contained non-fluorinated alkylsiloxanes. The exposure conditions in the supermarket were reconstructed under controlled conditions in a climate chamber and particle and gas exposure levels were monitored over time allowing estimation of human exposure levels. Mice exposed to the product developed symptoms of acute pulmonary toxicity in a concentration-and time-dependent manner. The symptoms of acute pulmonary toxicity likely resulted from inhibition of the pulmonary surfactant function as demonstrated by in vitro surfactometry. Among these patients only a partial association between the level of exposure and the degree of respiratory symptoms was observed, which could be because of a high inter-individual difference in sensitivity and time-dependent changes in the chemical composition of the aerosol.

CONCLUSION

Workers need to cautiously apply surface coating products because the contents can be highly toxic through inhalation, and the aerosols can disperse to locations remote from the worksite and affect bystanders.

Surgical/Pathologic Breast Cancer Indicators: Adherence by the Florida Initiative for Quality Cancer Care (FIQCC) Consortium

Background: The FIQCC is comprised of 11 practice sites across the state that participate in a comprehensive review of quality of care specific to cancer patients across many disease sites. Quality indicators were scripted based on the accepted QOPI, NCCN, ACOS, and site-specific PI panel consensus indicators for breast cancer patients. An evaluation was done to assess adherence to performance indicators among the sites.Methods: Comprehensive chart reviews were conducted for all patients with breast cancer first seen in 2006 by a medical oncologist at one of the 11 FIQCC sites (3 academic/8 community). Quality measures included: 1) presence and completeness of the pathology report (tumor size, grade, specimen orientation, margins inked, margin status, receptor status); 2) documentation of surgery type (breast conserving vs. mastectomy); 3) documentation of sentinel lymph node biopsy (SLNB) and if SLNB positive for metastatic disease documentation of a complete axillary node dissection; 4) mammogram usage post surgery; and 5) referral to radiation. Statistical comparisons were performed using chi-square test.Results: Charts of 622 patients (99% female) with a median age of 60 years (range 22-95) were reviewed. With respect to pathologic reporting, there was strong compliance (>90%) for documentation of a pathology report, AJCC or TMN staging, tumor size and grade, status of margins, and receptor status. However, only 370 of 537 (69%) reports documented that the specimen was oriented and 474 of 537 (88%) stated the margins were inked. Breast conserving surgery was performed in 294 of 539 patients (55%). In clinical N0 patients, SLNB was performed in 447 of 543 (82%). Of the patients with a metastatic SLNB, 123 of 156 (79%) went on to have a complete axillary node dissection. Compliance was highly variable with obtaining a mammogram within 14 months of surgery (77%; range 26-98%). However, referral to radiation within 1 year was highly consistent (97%; range 80-100%). Significant variances across practice sites were noted for the reporting of margin orientation (p<0.001), inking of the margins (p<0.001), performance of SLNB (p<0.001), and obtaining a mammogram within 14 months of surgery (p<0.001).Discussion: The FIQCC allows for identification of the need for quality improvement in multiple aspects of breast cancer care. Findings based on 2006 cases identified a need for improvements in margin orientation and inking, use of SLNB and obtaining mammograms in follow-up after breast conserving surgery. These findings are now being used at the participating sites to guide quality improvement efforts.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1079.

National survey of physicians practice patterns: Fertility preservation and cancer patients

CRA9508

Background: Addressing the impact of cancer treatment on fertility is a high priority in providing quality cancer care to patients of childbearing age. Evidence suggests less than 50% of patients receive adequate fertility information prior to cancer treatment. This study assessed the practice patterns of physicians and identified perceptions of barriers to communication about fertility. Methods: A 37 item survey was developed by a review of the literature and previous qualitative interviews. A random sample of physicians from the American Medical Association Masterfile was stratified by board specialty related to oncology. Three waves of surveys were distributed across the United States. The domains of the survey included demographics, knowledge, attitudes and practice behaviors related to FP with patients of childbearing age. Results: Of 1,979 physicians identified, a total of 613 physicians completed the survey, yielding a 33% response rate among oncologists. Oncologists with favorable attitudes towards FP were 4.9 times more likely to discuss the impact of cancer treatment on future fertility than those who have unfavorable attitudes. GYN or Medical/Hematological oncologists were 2.1 times more likely than other specialists to report feeling comfortable discussing FP with their patients. The majority of oncologists reported discussing FP with patients and indicated the primary barrier to discussion was a patient too ill to delay treatment. However, less than 25% of oncologists report referring patients for FP and only 38% report knowledge of the ASCO guidelines suggesting oncologists should discuss FP and refer all patients of childbearing age. Less than 25% of physicians surveyed reported distributing educational materials regarding FP. Conclusions: The majority of physicians in this survey report discussing FP; however they are not consulting specialists or providing educational materials to their patients. Future research will include the development of physician and nurse training curricula and interventions to facilitate discussion of FP between physicians and cancer patients.

No significant financial relationships to disclose.

National survey of physicians practice patterns: Fertility preservation and cancer patients

CRA9508

The full, final text of this abstract will be available in Part II of the 2009 ASCO Annual Meeting Proceedings, distributed onsite at the Meeting on May 30, 2009, and as a supplement to the June 20, 2009, issue of the Journal of Clinical Oncology.

No significant financial relationships to disclose.

Adherence to National Quality Forum (NQF) colorectal cancer indicators among members of the Florida Initiative for Quality Cancer Care (FIQCC) consortium

6563

Background: FIQCC is a consortium of 10 institutions participating in a comprehensive practice-based system of quality self-assessment across a number of cancer types. The NQF has endorsed several performance measures to assess the quality of care for colorectal cancer (CRC) patients. We have sought to identify adherence to NQF CRC indicators among members of FIQCC. Methods: Comprehensive chart reviews were conducted for all patients with CRC first seen in 2006 by a medical oncologist at one of the 10 FIQCC sites (2 academic/8 community). NQF quality measures included: 1) consideration or administration of chemotherapy to patients with stage III colon cancer (CC); 2) completeness of pathology reporting for CRC; 3) >12 regional lymph nodes (LN) examined for resected CC. Statistical comparisons were performed using chi-squared analysis. Results: The population consisted of 475 patients (250 men and 225 women) with a median age of 65 years (range 27–92). Chemotherapy was considered/administered in 96.5% (136/141) of stage III CC patients. With respect to CRC pathologic reporting, there was strong compliance (>90%) for reporting the number of LN examined and involved by tumor, proximal/distal margin status, depth of invasion, and histologic grade. However, only 225 of 295 (76.2%) reports documented lymphovascular invasion status. Radial margin status was included for 45% (27/60) of surgical rectal cancer specimens. Only 73.9% (173/234) of CC cases had >12 LN examined. Of the NQF measures, significant differences across practice sites were noted for the reporting of histologic grade (p = 0.0002), proximal/distal margin status (p = 0.049), and lymphovascular invasion (p < 0.0001). Conclusions: Although there was uniformly strong adherence to the application of adjuvant therapy for stage III CC across FIQCC sites, the adequacy of lymphadenectomy and LN examination for resected CC was lower and varied considerably across sites. There remains room for improvement of pathologic CRC reporting across the whole consortium as well as at individual sites. The FIQCC initiative allows for the identification of targets for global quality improvement as well as of specific measures for individual institutions.

No significant financial relationships to disclose.

Impact of patient age on quality of care in the treatment of colorectal cancer: Results from the Florida Initiative for Quality Cancer Care (FIQCC)

6548

Background: The quality of colorectal cancer (CRC) treatment has been suggested to vary by age, with older patients receiving poorer quality care. As part of a state-wide quality improvement effort, the FIQCC developed and implemented methods to assess the quality of care of several cancers among practices across the state of Florida. The current report focuses on the variability of adherence to CRC quality indicators for treatment and surveillance by patient age. Methods: Medical chart reviews were conducted of all patients first seen by a medical oncologist for CRC in 2006 at one of the 10 FIQCC sites (2 academic/8 community). Abstractors were trained and periodically monitored. Abstraction focused on assessing adherence to quality indicators consistent with evidence-, consensus-, and regulatory-based guidelines. Variability in adherence across age quartiles was evaluated using a Fisher's exact test. Of the 475 patients whose charts were reviewed, 53% were male, 80% were diagnosed with colon cancer and the median age was 65 years (range 27 to 92 years). Results: Adherence was consistently (p values>.05) high across all age quartiles for presence of chemotherapy flow sheets (85%-93%), assessment of body-surface area (98%-100%) and performance of complete colon evaluation within 12 months of surgery (87%-89%). Moderate-to-low adherence was consistent by age for performance of CEA test before (74%-84%) or in the 6 months after (75%-82%) surgery/chemotherapy, and documentation of planned chemotherapy dose (51%-59%). Adherence decreased with increasing age for documentation of discussion/referral for chemotherapy in non-metastatic CRC cases (100%, 99%, 93%, and 89%; p = 0.001), but was consistently adhered to for all ages among metastatic cases (100%). The documentation of consent for patients treated with chemotherapy also varied by age-quartile (63%. 57%, 79%, and 73%; p = 0.02). Conclusions: Overall quality of CRC treatment was not consistent across the broad spectrum of patient age. Our data suggest age related disparity in the recommendation for adjuvant chemotherapy. Efforts should be made to understand the reasons for these differences and to improve and standardize the quality of CRC care for patients across all age groups.

No significant financial relationships to disclose.

Quality-of-life (QoL) outcome of standard chemotherapy for advanced non-small cell lung cancer (NSCLC): A comparison between cisplatin- and non-cisplatin-based regimens

18067

Background: Among standard chemotherapy regimens for NSCLC, cisplatin-based regimen is known to be associated with significant nausea and vomiting. QoL during treatment with cisplatin-based chemotherapy, when compared with others is unclear. Methods: We performed a MEDLINE search for all phase III randomized controlled trials of NSCLC that reported QoL outcomes and used standard chemotherapy regimens containing cisplatin in one arm and non-cisplatin in the other. Two reviewers independently extracted data and assess quality. QoL reporting criteria were priori hypothesis stated, rationale for instrument reported, psychometric properties reported, cultural validity verified, adequacy of domains covered, instrument administration reported, baseline compliance reported, timing of assessment documented, missing data documented, clinical significance addressed, and presentation of results (Efficace et al, JCO 2003). Results: Out of 893 potential titles, 9 studies were identified. Two did not meet the minimum QoL reporting criteria and were excluded. Of the 7 included studies (N=3439), only one measured QoL as a primary endpoint; only two satisfied all 11 quality criteria for QoL reporting. Due to the heterogeneity of the reporting formats, we were unable to pool data on QoL. Two of seven studies indicated that a cisplatin-containing regimen was associated with a significantly worse QoL when compared with a non-cisplatin regimen (Table). Among these selected studies, treatment-related death was higher with cisplatin-based regimens [reported from 8 studies, N=3290, RR=0.66;95%CI (0.46–0.95), p=0.03]. Grade 3 and 4 neutropenia and neutropenic fever were also more common in the cisplatin-based arms. Conclusion: We found a suboptimal quality of QoL reporting and a lack of standardization of QoL analysis method in these trials. This limits a comparison between studies and the usefulness of QoL endpoint for clinical decision-making.

[Table: see text]

No significant financial relationships to disclose.

Fatigue is a cause of functional dependence in older cancer survivors

8538

Background: The incidence and prevalence of cancer increase with age, but the impact of cancer and its treatment on the function of older cancer survivors is unknown. The aim of the study was to establish the prevalence of fatigue in older cancer patients off chemotherapy and the correlation of fatigue with Instrumental Activities of Daily Living (IADL) and Activities of Daily Living (ADL). Methods: We reviewed the cases of 214 individuals aged 70–90 with different cancers, subsequently processed through the Senior Adult Oncology Program (SAOP) over 4 months. All patients of the SAOP are evaluated for function, depression, comorbidity and fatigue, and all of them have a complete blood count. Depression is assessed with the geriatric depression scale (GDS); comorbidity with the cumulative illness rating scale for geriatrics (CIRS-G), and fatigue with the Fatigue symptom inventory (FSI). Results: We found that 82% of the patients reported some degree of fatigue and in 74% of cases fatigue interfered with their daily activities. The average fatigue severity was 5.38 ± 2.59; the FSI interference score 19.1 ± 16.1, the average number of days fatigued in a week 4.07 ± 2.6. Fatigue severity was positively correlated with CIRS_G score (p = 0.04), creatinine clearance (p = 0.02) performance status (PS) (p < 0.0001), GDS (p = 0.04); ADL (0.02); Minimental status (MMS) (p = 0.05); fatigue interference with Cr Clp = ).005); PD (p = 0.001) ADL (p = 0.02); GDS (p = 0.01), and fatigue frequency with CIRS-G (p = 0.04); Cr CL (p = 0.01), PS (p = 0.0001), ADL (p = 0.03); IADL (p = 0.03), and GDS(0.09). ADL dependence was related to intensity (0.02), interference (0.0001) and days of fatigue; IADL dependence to interference score (p = 0.0001) and days of fatigue (p = 0.017) and GDS to intensity (p = 0.004); interference score (p = 0. 006) and frequency of fatigue. Conclusions: Fatigue is common in long term older cancer survivors, and is associated with functional dependence and depression. Control of fatigue may improve the function of older cancer survivors

No significant financial relationships to disclose.

Aldosterone synthase (CYP11B2) -344T/C polymorphism is not associated with the initiation and progression of diabetic nephropathy in Caucasian Type 1 diabetic patients

AIMS

Aldosterone is one of the main effectors of the renin-angiotensin-aldosterone system regulating blood pressure. Previous studies have shown that the aldosterone synthase promoter polymorphism -344T/C influences aldosterone levels and is associated with hypertension, a risk factor for the initiation and progression of diabetic nephropathy. Therefore, we investigated whether the -344T/C polymorphism is associated with the development and progression of diabetic nephropathy in Type 1 diabetes mellitus.

METHODS

The -344T/C polymorphism was determined using standard PCR techniques in 422 Type 1 diabetic patients with overt diabetic nephropathy [mean age 43 years (SD 11)], and in 479 patients with persistent normoalbuminuria and long-standing Type 1 diabetes [age 47 years (SD 12), duration of diabetes 27 years (SD 10)]. Furthermore, we genotyped 163 Type 1 diabetic patients with overt diabetic nephropathy treated with angiotensis-converting enzyme inhibitors (ACE-I). These patients were followed for a median of 6 years (range 3-14), with nine measurements (range 3-29) of glomerular filtration rate (GFR), and had a decline in GFR of 3.1 (-3.2; 23.7) ml/min per year.

RESULTS

There was no significant difference between cases and controls in either genotype distributions (cases TT 0.33, TC 0.48, CC 0.19; controls TT 0.32, TC 0.48, CC 0.20) or allele frequencies (cases T/C 0.57/0.43; controls T/C 0.56/0.44). Furthermore, a genotype-phenotype interaction analysis in the normoalbuminuric patients revealed no differences in sex distribution, age, duration of diabetes, blood pressure, HbA(1c,) or urinary albumin excretion rate across genotypes. In the observational follow-up study, the rate of decline in GFR did not differ between groups of patients with different -344T/C genotype (P = 0.41). However, the T-allele made a statistically significant contribution to both systolic and diastolic pressure during follow-up (P = 0.006 and 0.032, respectively).

CONCLUSIONS

The -344T/C polymorphism of the aldosterone synthase gene is not associated with initiation or progression of diabetic nephropathy in Caucasian Type 1 diabetic patients, but modulates blood pressure variation.

Those who can, teach, but who teaches the learners to learn?

This article was stimulated by Mike Grace's editorial Can those who do--teach? I have been an undergraduate and postgraduate teacher for over 30 years and I agreed with everything that Mike said about the difficulties of combining doing and teaching. The best doers may not make the best teachers and conversely the best teachers are not always incapable of doing, whatever some colleagues may think to the contrary!

Dual blockade of the renin-angiotensin-aldosterone system in diabetic nephropathy: the role of aldosterone

Dual blockade of the renin-angiotensin-aldosterone system (RAAS) with both ACE inhibitors and angiotensin II receptor-blockers has been shown to reduce both albuminuria and blood pressure compared to either monotherapy. The mechanisms behind these beneficial effects are not known, and we hypothesized that the effect of dual RAAS blockade may be due to a more complete suppression of circulating aldosterone. We performed a combined analysis on three randomized, double-masked, cross-over trials where 51 type 1 diabetic patients suffering from diabetic nephropathy received 8 weeks of dual RAAS blockade using an angiotensin II receptor blocker in combination with an ACE inhibitor and 8 weeks of monotherapy with the same ACE inhibitor. Albuminuria, 24 h blood pressure, GFR, and plasma aldosterone were determined at the end of each treatment period. Compared to ACE inhibition alone, dual RAAS blockade lowered blood pressure by 7/5 mm Hg from 137/76 mm Hg, decreased albuminuria by 37% from 558 mg/24 hour, and reduced plasma aldosterone by 28% from 59 pg/ml and caused a reversible decline in GFR of 4 ml/min/1.73 m2 (p < or = 0.01 for all comparisons). There was and a significant correlation between changes in 24-hour diastolic blood pressure and changes in albuminuria. Furthermore, the antialbuminuric response to dual blockade was influenced by the ACE/ID polymorphism, that is, patients carrying the D-allele had a significantly lower reduction of 31% compared to the 55% in patients with the II genotype (p = 0.021). Multiple linear regression analysis revealed that ACE/ID genotypes and reduction in plasma aldosterone, diastolic blood pressure and GFR is associated with changes in albuminuria on dual blockade treatment (R2 (adjusted) = 0.57, p < 0.001). Dual RAAS blockade is a new treatment concept that may offer additional cardiovascular and renal protection in type 1 diabetic patients with diabetic nephropathy. The beneficial response may be influenced by genetic factors and reductions in blood pressure and plasma aldosterone concentrations.

Effect of short-term hyperglycaemia on haemodynamics in type 1 diabetic patients

OBJECTIVES

Mechanisms underlying glucose-mediated development and progression of diabetic complications are incompletely understood. We tested the impact of short-term hyperglycaemia on systemic blood pressure and regulatory hormones in type 1 diabetic patients.

DESIGN AND METHODS

We included 18 patients [13 men, mean (SEM) diabetes duration 10 (1) years] without signs of autonomic neuropathy or renal complications in a randomized single-blinded cross-over trial using insulin-glucose clamp technique. Patients were clamped for 90 min to blood glucose of 5 mmol L(-1) (euglycaemia) and 15 mmol L(-1) (hyperglycaemia) in random order. Blood pressure was measured noninvasively every 5 min (Takeda TM2421 device). Regulatory hormones were determined at the end of each clamp period.

RESULTS

Systolic blood pressure increased [mean (95% CI)] 3 (1, 5) mmHg during hyperglycaemia from 123 (SEM 2) during euglycaemia, P=0.01. Diastolic blood pressure remained unchanged at 78 (2) mmHg. Hyperglycaemia reduced plasma concentrations of: renin [14 (4, 23)%, P=0.02], angiotensin II [17 (8, 25)%, P<0.01] and adrenaline [20 (10, 29)%, P<0.01]. Plasma concentration of atrial natriuretic peptide increased by 11 (6, 17) pg mL(-1) (P<0.01) from 43 (2) pg mL(-1). We calculated a median (range) increase in extracellular volume and plasma volume (PV) of 2.6 (0.7-5.3)% and 5.0 (-4.7 to 8.6)%, respectively.

CONCLUSIONS

In type 1 diabetic patients without signs of autonomic neuropathy short-term hyperglycaemia induced a modest increase in systolic blood pressure and suppression of the renin-angiotensin system, possibly caused by PV expansion because of fluid shift from intra- to extracellular compartment.

Birth weight--a risk factor for progression in diabetic nephropathy?

OBJECTIVES

Intrauterine growth retardation, as seen in individuals with low weight at birth, may give rise to a reduction in nephron number. Oligonephropathy has been linked to hypertension and renal disease in adult life. We tested the concept that low weight at birth acts as a risk factor for progression of diabetic nephropathy.

DESIGN AND SUBJECTS

We performed an observational follow-up study of 161 (97 men) type 1 diabetic patients with diabetic nephropathy [mean age (SD): 35 (11) years, mean duration of diabetes: 22 (8) years]. All patients had been followed for at least 3 years [median (range): 8 (3-20)] with at least three measurements [9 (3-31)] of glomerular filtration rate (GFR) (51Cr-EDTA). Information about birth size was obtained from midwife registrations.

SETTINGS

Steno Diabetes Center, a tertiary referral centre.

MAIN OUTCOME MEASURES

Loss of kidney function according to birth weight and weight/length ratio at birth.

RESULTS

There was no correlation in univariate analysis between birth weight or weight/length ratio and rate of decline in GFR, neither in men nor in women. Furthermore, the 27 patients with birth weights below the 20th centile had a rate of decline in GFR [median (range)] similar to the 134 patients above: 2.6 (-4.7; 9.6) vs. 3.4 (-2.3; 19.3) mL min(-1) year(-1), respectively (NS). A multiple regression analysis revealed that albuminuria, arterial blood pressure, and haemoglobin A1C during follow-up showed a significant correlation with the decline in GFR [R2 (adjusted) = 0.34], whereas birth weight and birth weight/length ratio did not.

CONCLUSIONS

Our study does not suggest that weight at birth is associated with progression of established diabetic nephropathy in type 1 diabetic patients, whilst several other potential modifiable risk factors were identified.

Analysis of scenarios for sewerage, wastewater treatment and prioritised load on environment from the Greater City of Copenhagen

The sewer system for the Greater Copenhagen area covers an area of 4460 ha contributing to the runoff. The total area serves in total 8 municipalities, however it is dominated by the areas in the City of Copenhagen proper. The catchments merge into interceptors, which feed two large treatment plants. The effluent from the two treatment plants discharges during dry weather to Oresund, the sound between Denmark and Sweden. This large system has been analysed for selected scenarios with respect to handling runoff in an optimal way in order to minimise the loads on the most sensitive receiving waters and optimising treatment plant performance.

Pregnancy and progression of diabetic nephropathy

AIMS/HYPOTHESIS

Pregnancy could damage kidney function in diabetic nephropathy. We investigated the long-term impact of pregnancy on the progression of diabetic nephropathy.

METHODS

Our observational follow-up study included all women patients with Type I (insulin-dependent) diabetes mellitus who developed diabetic nephropathy between 1970 and 1989 at Steno Diabetes Center (n = 93). Follow-up lasted 16 years (range 3-28) from the onset of diabetic nephropathy until death or the year 2000. A total of 26 women became pregnant after the onset of diabetic nephropathy (group A). The remaining 67 served as control subjects (group B). All patients received aggressive antihypertensive treatment (blood pressure goal < 140/90 mmHg).

RESULTS

The two groups were comparable at onset of diabetic nephropathy regarding blood pressure, albuminuria, s-cholesterol, smoking, retinopathy and s-creatinine (mean 79(SD 23) micromol/l). The slopes of 1/s-creatinine (1000.l.micromol(-1).year(-1)) during the whole observation period were -0.39(0.40) compared with -0.41(0.70) (group A vs B-NS). The slopes of 1/s-creatinine before and after pregnancy were similar. Decline in creatinine clearance (ml/min/yr) was 3.2 (3.4) compared with 3.2 (5.1) (group A vs B -NS). At the end of follow-up, 35 % (95 %-CI:17-53) of the pregnant women had died and 19 % (7-39) had reached end stage renal disease compared to 34 % (23-45) and 24 %(14-34) of the control subjects, respectively(NS). Group A and B had similar blood pressure levels during the whole observation period: 136(13)/83(7) vs 139 (14)/85(7) mmHg (NS).

CONCLUSION/INTERPRETATION

Pregnancy has no adverse long-term impact on kidney function and survival in Type I diabetic patients with well-preserved kidney function (normal serum creatinine) suffering from diabetic nephropathy.

Risk assessment by physicians and by the poison center: are nondrug exposures handled too actively?

BACKGROUND

The study was intended to evaluate the possible impact of poison center advice on physicians' treatment and referral of nondrug exposures.

METHODS

Doctors seeking advice on nondrug poisoning were asked for their management plan before any recommendations were given. The proportions of cases in different treatment and referral categories were compared to the poison center recommendations. Rate ratios were used as effect measure.

RESULTS

A total of 175 cases were included in the study. For 90% of these, the exposure was estimated by the poison center to be of no or minor risk. The inquiring physicians had intended to treat 43 more cases than the poison center recommended, rate ratios: 1.6 (95% CI: 1.3-2.0). The most marked difference wasfor treatment by gastrointestinal decontamination, rate ratios: 5.0 (95% CI: 2.5-9.8). For referral, 42 more cases would have been observed in a stationary hospital unit, rate ratios: 2.3 (95% CI: 1.6-3.3) and 28 excess cases would have been observed in an outpatientfacility, rate ratios: 2.0 (95% CI: 1.3-1.6). A more active attitudefor treatment and referral by the inquirers was independently associated with patients < or =14 years of age, lack of symptoms at presentation, and insignificant exposures.

CONCLUSIONS

Doctors seeking advice on the management of nondrug poisoning intended to treat and refer to health care facilities more actively than recommended by the poison center. The tendency was most pronouncedfor children exposed to substances of minor toxicological significance and treatment with gastrointestinal decontamination.

A key role for Pax7 transcripts in determination of muscle and nerve cells

Embryonic teratocarcinoma mouse cells (P19) and embryonic NIH3T3 fibroblasts were induced chemically to differentiate along neurogenic or myogenic lineages. The expression profiles of Pax7 alternate transcripts were then assessed by RNA isolation and RT-PCR. Only two transcripts, Pax7b and Pax7d, were expressed in the neurogenic lineage. By contrast, in adult skeletal muscle, four transcripts, Pax7a-d, were expressed in the myogenic lineage. Moreover, P19 cells were shown to undergo neural cell differentiation when stably transfected with a single Pax7 transcript, PAX7b, generated from human skeletal muscle. Our results suggest a key role for Pax7 transcripts in lineage determination.

A new psychosocial screening instrument for use with cancer patients

The authors performed a principal components factor analysis on the 18-item Brief Symptom Inventory (BSI-18), a new brief screening inventory. The factor analysis, in which four factors were specified, is consistent with findings in a previous community sample. The study sample consisted of 1,543 cancer patients who completed the full BSI as part of their entry into care at a regional cancer center. The reliability of the BSI-18 was determined based on the calculation of the internal consistency, mean item scores, and correlations with the total score of the BSI. In addition, sensitivity and specificity was calculated to determine the ability of the BSI-18 to discriminate positive and negative cases. The BSI-18 is a shortened version of the BSI that can serve as a brief psychological screening instrument. The BSI-18 can be incorporated into outpatient clinics to prospectively and rapidly identify cancer patients with elevated levels of distress who are in need of clinical interventions. Early identification of distress with appropriate interventions can reduce distress, enhance quality of life, and decrease health care costs.

[Gastrointestinal decontamination. Use in non-drug poisoning]

AIM

To assess whether Danish doctors use gastrointestinal decontamination (GID) in non-drug poisoning in accordance with recommendations for restricted application.

METHOD

Doctors telephoning the Danish Poisons Information Centre about non-drug exposures were surveyed prospectively. The doctor's intention to treat, the age and sex of the patient, and information about poison, amount and time since exposure, were assessed.

RESULTS

Of the 138 telephone calls, 64% concerned children below 5 years of age and 24% patients above 15 years of age. The risk was estimated as insignificant in 63%, minor in 30%, significant in 6% and severe in only 1%. The insignificant risk was found mainly in children and the severe risk solely in those above 15 years of age. GID was proposed in 33% with the highest frequency in children with minor or insignificant risks, and the time since exposure did not influence the frequency of GID. Charcoal was not proposed.

CONCLUSION

It is clear from this small sample that Danish doctors tend to use GID more often than is recommended. Activated charcoal was apparently not used. GID was in most cases used in children with insignificant and minor risks, where it is likely to do more harm than good.

Synthesis and estrogen receptor binding affinities of novel pyrrolo[2,1,5-cd]indolizine derivatives

A series of pyrrolo[2,1,5-cd]indolizine derivatives has been synthesized and evaluated as ligands for the estrogen receptor. Properly substituted mono- and di-hydroxy derivatives showed binding in the low nanomolar range in accordance with their structural resemblance to estrogen.

Plasma concentrations of VCAM-1 and ICAM-1 are elevated in patients with Type 1 diabetes mellitus with microalbuminuria and overt nephropathy

AIMS

Elevated urinary albumin excretion is associated with macrovascular atherosclerotic complications in Type 1 diabetes mellitus. Adhesion molecules mediate leucocyte adhesion to the endothelium early in the atherosclerotic process. The present study tests the hypothesis that microalbuminuria and diabetic nephropathy are associated with elevated plasma concentrations of soluble vascular adhesion molecule (sVCAM)-1, soluble intercellular adhesion molecule (sICAM)-1, and soluble E-selectin (sE-selectin) aiming to illustrate factors of potential pathogenetic relevance for the excess cardiovascular disease in diabetic patients with renal complications.

METHODS

Soluble adhesion molecule concentrations were measured by enzyme-linked immunosorbent assays (ELISA) in healthy controls (n = 16) and in 59 Type 1 diabetic patients: group 1-patients with normoalbuminuria (n = 16); group 2-patients with microalbuminuria (n = 15); group 3-patients with macroalbuminuria and normal serum creatinine (n = 15), group 4-patients with macroalbuminuria and moderately elevated serum creatinine (n = 13).

RESULTS

Plasma concentrations of sVCAM-1 and sICAM-1 were similar in healthy controls and normoalbuminuric Type 1 diabetic patients, but the concentrations were increased by the presence of microalbuminuria and overt nephropathy (P < 0.001 and P < 0.0001, ANOVA). Concentrations of sE-selectin did not differ between diabetic patients and controls.

CONCLUSIONS

Plasma concentration of sICAM-1 is elevated in Type 1 diabetic patients with microalbuminuria and the concentrations of sICAM-1 as well as sVCAM-1 are elevated in patients with macroalbuminuria and normal s-creatinine. The elevated plasma concentrations of these soluble adhesion molecule concentrations in patients with renal complication can be of pathogenetic importance for the development of atherosclerosis and plasma soluble adhesion molecule concentrations may provide additional information on cardiovascular risk.

Synthesis and pharmacology of a novel pyrrolo[2,1,5-cd] indolizine (NNC 45-0095), a high affinity non-steroidal agonist for the estrogen receptor

1-Ethyl-2-(4-hydroxyphenyl)pyrrolo[2,1,5-cd]indolizine (NNC 45-0095) is a novel compound which represents the parent pharmacophore structure of a series of pyrrolo[2,1,5-cd]indolizine derivatives with mixed estrogen agonist/antagonist properties. NNC 45-0095 binds with high affinity to the estrogen receptor (IC50=9.5 nM) and exhibits full protection of bone loss in the ovariectomized mouse model for post-menopausal osteoporosis.

Progression of diabetic nephropathy in normotensive type 1 diabetic patients

BACKGROUND

The first aim of our long-term study was to describe the natural history of diabetic nephropathy in 59 normotensive type 1 diabetic patients. Secondly, we evaluated genetic and nongenetic progression promoters.

METHODS

The following progression promoters were determined: the insertion/deletion polymorphism in the angiotensin converting enzyme (ACE) gene, blood pressure, albuminuria, hemoglobin A1c, cholesterol, smoking, height, and gender. We studied the natural history by measuring 51Cr-EDTA plasma clearance at yearly intervals at least three times during [median (range)] 5.5 (2.2 to 18.3) years.

RESULTS

At baseline the three groups (II, N = 11; ID, N = 25, and DD, N = 23) had comparable GFR (103 +/- 16; 99 +/- 19; 113 +/- 22 ml/min/1.73 m2, respectively; mean +/- SD), arterial blood pressure, albuminuria, and hemoglobin A1c. During the follow-up there was a median rate of decline in GFR in all 59 patients of 1.2 (range 12.9 to -4.4) ml/min/year. During the study period no significant differences were observed in: the rate of decline in glomerular filtration rate [median (range) 0.9 (10.6 to -1.9); 2.5 (12.9 to -4.4); 1.4 (10.8 to -1.9 ml/min/year)], arterial blood pressure, albuminuria, hemoglobin A1c or cholesterol between the three groups (II, ID and DD), respectively. At baseline, multiple linear regression analysis including the above-mentioned putative risk factors revealed that albuminuria, short stature, and male gender independently predict an enhanced decline in GFR [R2 (adjusted) = 0.33; P < 0.002]. During the follow-up period, only albuminuria acted as an independent progression promoter [R2 (adjusted) = 0.37; P < 0.0001].

CONCLUSIONS

Our study revealed a rather slow progression of kidney disease in normotensive type 1 diabetic patients with diabetic nephropathy. Albuminuria, short stature, and male gender act as progression promoters in such patients.

Increased sympathetic activity during sleep and nocturnal hypertension in Type 2 diabetic patients with diabetic nephropathy

AIMS

To elucidate the putative factors involved in the blunted nocturnal blood pressure reduction in hypertensive Type 2 diabetic patients with diabetic nephropathy.

METHODS

Extracellular fluid volume and fluid shift from interstitial to plasma volume (haematocrit), sympathetic nervous activity (plasma noradrenaline and adrenaline) and the internal 'body clock' (serum melatonin) were investigated in 31 hypertensive Type 2 diabetes mellitus (DM) patients with diabetic nephropathy (24 males, age 60 (45-73) years). All variables, except extracellular volume, were measured repeatedly with the patients lying awake in bed from 21:30 to 23:00 h (baseline) and during sleep from 23:00 to 07:00 h. Using the median nocturnal blood pressure reduction (8.4%) as a guide, the patients were divided into groups; group 1 with the highest and group 2 with the lowest nocturnal blood pressure reduction.

RESULTS

Haematocrit decreased from baseline to the sleep period in group 1 by a mean (95% confidence interval (CI)) of 1.7 (0.3-3.1)%, but it increased by 0.5 (-1.0-1.9)% in group 2, mean difference (95% CI), -2.1 (-4.0 to -0.2)% (P = 0.029). Noradrenaline decreased from baseline to the sleep period, mean (95% CI), by 13.3 (0.0-25.0)% in group 1 but rose by 7.7 (-9.7-28.4)% in group 2, mean difference (95% CI), -19.6 (-35-0.0)% (P = 0.049). The nocturnal blood pressure change correlated to the nocturnal change in both noradrenaline (r = 0.51, P = 0.004) and haematocrit (r = 0.42, P = 0.018). Adrenaline remained constant in both groups. Extracellular fluid volume and plasma melatonin levels were comparable in the two groups.

CONCLUSION

Sustained adrenergic activity during sleep is associated with blunted nocturnal blood pressure reduction in hypertensive Type 2DM patients with diabetic nephropathy, probably mediated through a lack of peripheral vasodilatation whereas changes in extracellular fluid volume distribution and melatonin secretion have no impact.

[Lung damage after use of conditioner sprays for leather and textiles]

A series of poisoning cases have been caused by private spraying of leather and textiles with a conditioner. Symptoms and signs from the airways as well as general symptoms have not been explained by any of the ingredients. Spray impregnation should be carried out where efficient ventilation is available.

Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D)

The Center for Epidemiological Studies Depression Scale (CES-D) is commonly used to measure depressive symptomatology in cancer patients, yet there is little known about the psychometric properties of the measure when applied to a cancer population. The aim of this study was to examine the psychometric properties of the CES-D with cancer patients. For purposes of comparison, the psychometric properties of the CES-D were assessed both in women undergoing treatment for breast cancer and women with no history of cancer. The CES-D and other study measures were administered to women undergoing treatment for breast cancer on two occasions: prior to treatment and midway through treatment. The measures were also administered to a group of women similar in age to the cancer patients who had no history of any type of cancer. These healthy comparison subjects were also assessed on two separate occasions. The CES-D was found to have good internal consistency, with alpha coefficients > 0.85 for both groups, as well as adequate test-retest reliability in both groups. Construct validity was demonstrated in two ways, via comparisons between the groups and by comparing the CES-D with measures of fatigue, anxiety, and global mental health functioning. The CES-D was established as a valid and reliable measure of depressive symptomatology in this sample of breast cancer patients. This measure may be appropriate for use in clinical psychosocial research with cancer patients, yet further research is needed to evaluate its usefulness in other cancer populations. The importance of measuring psychological symptoms with standard measures that have been validated with cancer patients is highlighted.

Breakthrough pain: characteristics and impact in patients with cancer pain

Few surveys have been performed to define the characteristics and impact of breakthrough pain in the cancer population. In this cross-sectional survey of inpatients with cancer, patients responded to a structured interview (the Breakthrough Pain Questionnaire) designed to characterize breakthrough pain, and also completed measures of pain and mood (Memorial Pain Assessment Card (MPAC)), pain-related interference in function (Brief Pain Inventory (BPI)), depressed mood (Beck Depression Inventory (BDI)), and anxiety (Beck Anxiety Inventory (BAI)). Of 178 eligible patients, 164 (92.2%) met the criteria for controlled background pain. The median age was 50.6 years (range 26 to 77 years), 52% were men, and 80.6% were Caucasian. Tumor diagnoses were mixed, 75% had metastatic disease, 65% had pain caused directly by the neoplasm, and a majority had mixed nociceptive-neuropathic pain. The median Karnofsky Performance Status score was 60 (range 40 to 90). Eighty-four (51.2%) patients had experienced breakthrough pain during the previous day. The median number of episodes was six (range 1 to 60) and the median interval from onset to peak was 3 min (range 1 s to 30 min). Although almost two-thirds (61.7%) could identify precipitants (movement 20.4%; end-of-dose failure 13.2%), pain was unpredictable in a large majority (78.2%). Patients with breakthrough pain had more intense (P < 0.001) and more frequent (P < 0.01) background pain than patients without breakthrough pain. Breakthrough pain was also associated with greater pain-related functional impairment (difference in mean BPI. P < 0.001), worse mood (mood VAS, P < 0.05; BDI, P < 0.001), and more anxiety (BAI, P < 0.001). Multivariate analysis confirmed that breakthrough pain independently contributed to impaired functioning and psychological distress. These data confirm that cancer-related breakthrough pain is a prevalent and heterogeneous phenomenon. The presence of breakthrough pain is a marker of a generally more severe pain syndrome, and is associated with both pain-related functional impairment and psychological distress. The findings suggest the need for further studies of breakthrough pain and more effective therapeutic strategies.

Improved visual function in IDDM patients with unchanged cumulative incidence of sight-threatening diabetic retinopathy

OBJECTIVE

To evaluate trends in visual acuity and the cumulative incidence of diabetic retinopathy in a clinic-based observational follow-up study.

RESEARCH DESIGN AND METHODS

All patients visiting Hvidore Hospital in 1984 whose diagnosis of IDDM had been made before 41 years of age and between 1965 and 1979 (n = 356) were followed until 1994 or until their deaths. All patients were Caucasians and resided in Copenhagen. Patients were divided into three prevalence cohorts based on time of diabetes onset: group A, 1965-1969 (n = 113); group B, 1970-1974 (n = 130); and group C, 1975-1979 (n = 113).

RESULTS

Fifteen years after diabetes onset, the visual acuity was significantly improved in patients with increasing calendar year of the disease onset. The median (interquartile range) visual acuity was 1.0 (0.8-1.0), 1.0(0.9-1.0), and 1.0 (1.0-1.0) in groups A, B, and C, respectively (P < 0.01 overall; P = 0.28 for group A vs. group B; and P < 0.01 for group A vs. group C) with 60, 66, and 93 having a visual acuity of 1.0 in groups A, B, and C, respectively. The cumulative incidence (+/-SEM), expressed as a percentage and calculated according to the life-table method, of proliferative retinopathy, maculopathy, and laser-treated retinopathy 15 years after onset of diabetes were, respectively, 13+/-3, 11+/-3, and 12+/-3 in group A; 16+/-3, 12+/-3, and 21+/-4 in group B; 11+/-3, 5+/-2, and 12+/-3 in group C, respectively (NS). The development of proliferative retinopathy was associated with the degree of retinopathy and albuminuria at baseline and the mean HbA1c during follow-up.

CONCLUSIONS

The study revealed an improvement in visual acuity with increasing calendar year of diabetes onset but an unchanged cumulative incidence of diabetic retinopathy.

Progress toward guidelines for the management of fatigue

Fatigue is a subjective state of overwhelming, sustained exhaustion and decreased capacity for physical and mental work that is not relieved by rest. Cancer-related fatigue has many causes. Included in the causes are the illness itself, the side effects of virtually every treatment, depression, and other biopsychosocial factors. As a result, fatigue is the most common symptom reported by cancer patients in most descriptive studies. In addition to arising from multiple etiologies, fatigue is also multidimensional in its manifestation and impact. Its effect on the quality of life of the patient is comparable to that of pain. Experienced by most patients as an extremely frustrating state of chronic energy depletion, it leads to loss of productivity which can reduce self-esteem. As a subtle and chronic symptom, it also places people at risk for being questioned about the veracity of their complaints, particularly during the post-treatment, disease-free survival period. Patients themselves are reluctant to complain of fatigue, perhaps because they believe little can be done about it, or they wish to avoid drawing attention away from treating their cancer.

ZK200775: a phosphonate quinoxalinedione AMPA antagonist for neuroprotection in stroke and trauma

Stroke and head trauma are worldwide public health problems and leading causes of death and disability in humans, yet, no adequate neuroprotective treatment is available for therapy. Glutamate antagonists are considered major drug candidates for neuroprotection in stroke and trauma. However, N-methyl-D-aspartate antagonists failed clinical trials because of unacceptable side effects and short therapeutic time window. alpha-Amino-3-hydroxy-5-methyl-4-isoxazolepropionate (AMPA) antagonists derived from the quinoxalinedione scaffold cannot be used in humans because of their insolubility and resulting renal toxicity. Therefore, achieving water solubility of quinoxalinediones without loss of selectivity and potency profiles becomes a major challenge for medicinal chemistry. One of the major tenets in the chemistry of glutamate antagonists is that the incorporation of phosphonate into the glutamate framework results in preferential N-methyl-D-aspartate antagonism. Therefore, synthesis of phosphonate derivatives of quinoxalinediones was not pursued because of a predicted loss of their selectivity toward AMPA. Here, we report that introduction of a methylphosphonate group into the quinoxalinedione skeleton leaves potency as AMPA antagonists and selectivity for the AMPA receptor unchanged and dramatically improves solubility. One such novel phosphonate quinoxalinedione derivative and competitive AMPA antagonist ZK200775 exhibited a surprisingly long therapeutic time window of >4 h after permanent occlusion of the middle cerebral artery in rats and was devoid of renal toxicity. Furthermore, delayed treatment with ZK200775 commencing 2 h after onset of reperfusion in transient middle cerebral artery occlusion resulted in a dramatic reduction of the infarct size. ZK200775 alleviated also both cortical and hippocampal damage induced by head trauma in the rat. These observations suggest that phosphonate quinoxalinedione-based AMPA antagonists may offer new prospects for treatment of stroke and trauma in humans.

[The significance of deletion polymorphism in the ACE gene for progression of diabetic nephropathies treated with ACE inhibitors]

The aim of the study was to evaluate the effect of an insertion/deletion polymorphism of the angiotensin converting enzyme (ACE) gene on progression of diabetic nephropathy. We performed an observational follow-up study of 35 patients with insulin-dependent diabetes and diabetic nephropathy. Patients were investigated during captopril treatment for a median of seven (range three to nine) years. Eleven patients were homozygous for the deletion allele (DD) and 24 were hetero- or homozygous for the insertion allele (ID + II). The two groups had comparable glomerular filtration rate, albuminuria and blood pressure at baseline and captopril induced nearly the same mean reduction in blood pressure--to 103 (SD 5) mm Hg in the DD-group and 102 (8) mm Hg in the ID + II-group. The rate of decline in glomerular filtration rate was significantly steeper in the DD group than in the other group (mean 5.7 (SD 3.7) versus 2.6 (2.8) ml/min/year, p = 0.01). In conclusion, the deletion polymorphism in the ACE gene reduces the long term beneficial effect of ACE inhibition on the progression of diabetic nephropathy in patients with insulin dependent diabetes.