Temozolomide Combined with Irradiation as Postoperative Treatment of Primary Glioblastoma Multiforme

BACKGROUND AND PURPOSE: The role of radiochemotherapy in the treatment of primary glioblastoma multiforme is still discussed controversially. To evaluate the feasibility and toxicity of irradiation and concomitant administration of 50 mg/m(2) temozolomide in patients with primary malignant glioma, this phase I/II study was conducted. PATIENTS AND METHODS: 53 Patients with histologically confirmed WHO grade IV malignant glioma were enrolled into the study. All patients were treated with radiation therapy up to a total dose of 60 Gy using conventional fractionation of 5 x 2.0 Gy/week. Temozolomide was administered orally each therapy day at a dose of 50 mg/m(2). RESULTS: Prior to radiochemotherapy, complete resection (n = 14), subtotal resection (n = 22) or a biopsy (n = 17) of the tumor was performed. The median time interval between surgery and radiochemotherapy was 21 days. Treatment-related toxicity was very mild. Acute toxicity > grade 2 was observed in one patient who developed grade 4 hemotoxicity. Minor side effects of chemotherapy included nausea and vomiting. No severe late effects were observed. Median progression-free and overall survival were 8 and 19 months, respectively. The overall survival rate was 72% at 1 and 26% at 2 years. Age and extent of surgery significantly influenced survival. CONCLUSION: The combination of temozolomide plus radiation therapy is feasible and safe in terms of toxicity. Overall survival times were relatively long compared to survival times reported for radiotherapy alone. The application of 50 mg/m(2) of temozolomide can be performed throughout the whole time course without interruption due to side effects and might largely contribute to the prolonged overall survival. Further evaluation is warranted as to which dose of temozolomide is optimal with regard to tumor response and toxicity.     

Diffuse peritoneal metastases from primary colon cancer demonstrated by Tc-99m-labeled red blood cell scintigraphy

An 80-year-old man, who underwent complex abdominal surgery for left colon cancer 2 years earlier, was hospitalized because of severe anemia and recurrent episodes of melena. Esophagogastroduodenoscopy and colonoscopy did not reveal abnormal findings. Abdominal ultrasonographic examination and computed tomographic scan failed to detect tumor recurrence or metastatic lesions but moderate ascites was found. Tumoral marker serum levels were abnormal. Tc-99m red blood cell scintigraphy was performed and disclosed a potential site of intestinal hemorrhage: both dynamic and static images showed a slight but diffuse and persistent uptake of Tc-99m erythrocytes in the entire abdomen with no clear evidence of a site of active bleeding. These findings suggested diffuse peritoneal micrometastases, which were confirmed at autopsy.     

Influence of salivary contamination on marginal microleakage of pit and fissure sealants

PURPOSE: To assess quantitatively the influence of salivary contamination in vitro on marginal microleakage of pit and fissure sealants. METHODS: Forty-eight sound human third molars were selected and assigned to three groups: 1) Fluroshield (F), 2) Single Bond + Fluroshield (SBF) and 3) Ketac-fil (KF). Each group was divided into two subgroups: control (C) and with salivary contamination (SC). The occlusal surfaces were etched with 40% polyacrylic acid for 10 seconds or 37% phosphoric acid for 30 seconds, for either glass-ionomer or resin-based sealants, respectively. Specimens were contaminated with 0.25 mL of fresh human saliva for 20 seconds and dried afterwards. The sealants were placed and samples were thermocycled, immersed in a 0.2% Rhodamine B solution for 24 hours, embedded in acrylic resin and serially sectioned. The sections were viewed under an optical microscope connected to a computer and a video camera, and the images obtained were digitized. The extent of dye penetration along buccal and lingual slopes was measured in millimeters, using specific computer software, and converted into percentage, according to the fissures extension. RESULTS: The microleakage means (%) were: F/C:0 (+/- 0); F/SC: 31.71 (+/- 31.69); SBF/C: 0 (+/- 0); SBF/SC: 0 (+/- 0); KF/C: 0.98 (+/- 2.79) and KF/SC: 11.82 (+/- 15.45). ANOVA and Tukey test showed that salivary contamination provided significant increase in microleakage. Under salivary contamination, only SBF provided complete marginal sealing. When F and KF were compared, the glass-ionomer cement yielded the best sealing.     

The influence of vinegars on exposure of dentinal tubules: a SEM evaluation

Dentin hypersensitivity is a common painful condition observed in clinics. Dietary habits have been much associated with its development and persistence during and following periodontal treatment. The aim of this in vitro study was to evaluate the influence of vinegars on the removal of smear layer and exposure of dentinal tubules. Extracted human teeth were submitted to manual scaling with Gracey curettes in order to remove the cementum as well as to form a smear layer. Dentin samples with 3 mm(2) were obtained and distributed into six experimental groups: one control and five types of vinegars (alcohol, apple, rice, white wine and balsamic). Each group included two methods of vinegar application: topical and friction. After routine preparation for SEM analysis, photomicrographs were assessed by a calibrated and blind examiner using an appropriate index system. Kruskal-Wallis test indicated a significant influence of vinegars on smear layer removal. There was a statistically significant difference between groups treated with apple, white and rice vinegars and the control group (p < 0.05). Nevertheless, Mann-Whitney test indicated that removal of smear layer did not vary with the method of application (topical versus friction) for any of the tested substances. We can conclude that the contact of vinegar may remove smear layer and expose dentinal tubules, regardless of the type of application. However, balsamic vinegar was associated with less removal of smear layer after both methods of application.     

Frequencies of inherited organic acidurias and disorders of mitochondrial fatty acid transport and oxidation in Germany

The lack of epidemiological data on the frequency and/or burden of organic acidurias (OA) and mitochondrial fatty acid transport and oxidation disorders (mtFATOD) is one reason for hesitation to expand newborn screening (NBS) by tandem mass spectrometry (MS-MS). From 1999 to 2000, the frequency of ten potentially treatable OA and mtFATOD was assessed by active nation-wide surveillance on cases presenting with clinical symptoms using the German Paediatric Surveillance Unit (ESPED) system. Case ascertainment was complemented by a second independent source: 3-monthly inquiries in the metabolic laboratories performing secondary selected screening for OA and mtFATOD. Frequency estimates for clinically symptomatic cases older than 7 days in a birth cohort of 844,575 conventionally screened children was compared to the frequency found in a cohort of 382,247 screened by MS-MS in Bavaria and Baden-Württemberg. The overall frequency of the ten conditions considered was 1:8,000 (95% CI 1:11,000–1:6,000) by MS-MS as compared to 1:23,000 (95% CI 1:36,000–1:17,000) in symptomatic cases presenting mainly with metabolic crisis. The contributions of medium-chain acyl-CoA dehydrogenase deficiency (MCADD), other mtFATOD and OA were 29, 4 and 13 among the 46 cases identified by MS-MS, and 19, 1 and 13 among the 33 clinically symptomatic cases, respectively. Acute metabolic crisis, with a lethal outcome in four patients, was reported for 22/33 clinically symptomatic cases. No clinically symptomatic cases were reported from cohorts with screened by MS-MS. Conclusion: ten potentially treatable organic acidurias and mitochondrial fatty acid transport and oxidations disorders were more common than phenylketonuria with organic acidurias accounting for 28% of the cases detected by newborn screening and 39% of the cases identified on high risk screening. These conditions were related to considerable morbidity and mortality. Considerations for their inclusion in expanded newborn screening programmes might be warranted.Abbreviations ESPED Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland (German Paediatric Surveillance Unit) - MCADD medium-chain acyl-CoA dehydrogenase deficiency - MS-MS tandem mass spectrometry - mtFATOD mitochondrial fatty acid transport and oxidation disorders - NBS newborn screening - OA organic acidurias     

Association of peroxisome proliferator-activated receptor gamma 2 Pro-12-Ala polymorphism with endometriosis

We explored the association of the PPAR-gamma2 (peroxisome proliferator-activated receptor) Pro-12-Ala polymorphism with endometriosis in a case-control study with 51 women with endometriosis stages I-IV and 55 control women without endometriosis. The 12-Pro allele of PPAR-gamma2 may have protective effects avoiding the development and progression of endometriosis.     

Effects of metformin and rosiglitazone, alone and in combination, in nonobese women with polycystic ovary syndrome and normal indices of insulin sensitivity

OBJECTIVE: To determine whether insulin-sensitizing drugs would improve ovulation and T levels in women with polycystic ovary syndrome (PCOS), without clinical or biochemical criteria indicating insulin resistance and whether the combination of two distinct insulin-sensitizing drugs would be of any benefit over either drug alone. DESIGN: Randomized controlled double-blind trial. SETTING: A referral center in Caracas, Venezuela. PATIENT(S): One hundred twenty-eight nonobese PCOS women with normal indices of insulin sensitivity-that is, normal glucose tolerance, fasting insulin, peak insulin during an oral glucose tolerance test (OGTT), and fasting glucose-to-insulin ratio. Twenty-eight women were lost to follow-up initially and did not receive any intervention. INTERVENTION(S): One hundred women received twice daily one of the following for 6 months: metformin (850 mg), rosiglitazone (4 mg), combination of both drugs, or at least one placebo. MAIN OUTCOME MEASURE(S): Frequencies of ovulation and serum free T after 6 months. RESULT(S): Frequencies of ovulation were higher after treatment with an insulin-sensitizing drug (ovulations per subject in 6 months: metformin, 3.3; rosiglitazone, 2.4; and combination, 3.4) than with placebo (0.4). Ovulatory frequencies increased significantly more with metformin than rosiglitazone, and the combination was not more potent. After treatment, serum free-T levels were comparable among all active treatment groups (metformin: 2.34 pg/mL, rosiglitazone: 3.06 pg/mL, and combination: 2.39 pg/mL) and were significantly lower than in the placebo group (7.26 pg/mL). Compared with placebo, fasting insulin levels, area under the insulin curve during OGTT, the homeostatic model assessment of insulin sensitivity, and OGTT-derived insulin sensitivity index improved significantly after metformin or combination therapies but not after rosiglitazone. CONCLUSION(S): These findings suggest that insulin-sensitizing drugs increase ovulatory frequency and ameliorate hyperandrogenemia, even in nonobese women with PCOS who appear to have normal insulin sensitivity.     

Leflunomide-associated pancytopenia with or without methotrexate

OBJECTIVE: To report 18 cases of pancytopenia associated with leflunomide use in Australia, 5 of which were treated at Princess Alexandra Hospital, Brisbane. case summaries: Leflunomide was used in the treatment of rheumatoid arthritis in 17 of 18 patients; the other patient was diagnosed with systemic lupus erythematosus. Median age was 65.5 years (range 18-79), and 15 of the patients were female. Fourteen patients were on combined treatment with methotrexate. Pancytopenia was typically severe, requiring hospital admission, withdrawal of the immunosuppressant(s), intensive supportive therapy, and treatment of neutropenic sepsis. Five patients died, 4 of whom were receiving concomitant methotrexate. Time to onset of pancytopenia ranged from 11 days to 4 years (median 4 mo). In one case in which the patient had been stable while receiving leflunomide, methotrexate, and hydroxychloroquine for 4 years, fatal pancytopenia was triggered by acute renal failure secondary to dehydration and use of nonsteroidal antiinflammatory drugs. The Naranjo probability scale suggested a probable causal association in 5 cases and possible association in the remainder. DISCUSSION: Leflunomide, indicated for treatment of active rheumatoid arthritis, inhibits pyrimidine synthesis in lymphocytes and other rapidly dividing cells and may rarely be associated with life-threatening pancytopenia. Combination therapy with methotrexate may increase the risk. Time to onset is variable, and clinicians should remain vigilant, particularly when there is a change in the patient's baseline health status. CONCLUSIONS: The risk of pancytopenia during leflunomide therapy appears to be increased when the drug is combined with methotrexate and in older patients. Onset may be delayed, and ongoing monitoring of blood counts is essential.     

Stability of leukemia-associated aberrant immunophenotypes in patients with acute myeloid leukemia between diagnosis and relapse: comparison with cytomorphologic, cytogenetic, and molecular genetic findings

BACKGROUND: Multiparameter flow cytometry is increasingly used to monitor minimal residual disease in patients with acute myeloid leukemia to identify leukemic cells by leukemia-associated aberrant immunophenotypes (LAIPs). Changes in LAIPs during the course of the disease may be a limitation for this approach. METHODS: We analyzed 49 patients at diagnosis and relapse by flow cytometry, cytomorphology, cytogenetics, and molecular genetics. RESULTS: In 37 patients (76%), at least one LAIP detectable at diagnosis was present at relapse; in 12 patients (24%), none of the original LAIPs were present in at least 1% of bone marrow cells. Three groups were identified: no change in LAIPs, partial changes in LAIPs, and complete change in LAIPs. There were significant differences across these groups with regard to changes in cytomorphology (11%, 40%, and 58% of all cases, respectively; P = 0.007), cytogenetics (15%, 20%, and 25%; not significant), and molecular genetics (18%, 0, and 86%; P = 0.002). CONCLUSIONS: These data indicate that, in a subset of patients with acute myeloid leukemia, the disease is biologically different at relapse; therefore, monitoring of minimal residual disease is difficult to accomplish. In most patients with acute myeloid leukemia, multiparameter flow cytometry may be used to monitor minimal residual disease.     

Temperature-independent Inhibition of L-type calcium currents by halothane and sevoflurane in human atrial cardiomyocytes

BACKGROUND: Cardiac L-type calcium currents (ICa,L) are affected by volatile anesthetics, possibly contributing to their side effects. Actions of anesthetics on ion channels are usually studied in vitro at room temperature. However, the solubility of anesthetic gases as well as ICa,L are markedly sensitive to the study temperature. Therefore, temperature-dependent effects of halothane and sevoflurane on cardiac ICa,L were analyzed. METHODS: ICa,L were studied at 21 degrees C and 36 degrees C with the patch clamp technique in isolated human atrial cardiomyocytes. Concentrations of anesthetics brought into solution by gassing at both temperatures were determined with gas chromatography. RESULTS: The aqueous concentrations of halothane and sevoflurane were linearly related to their concentration in the gas phase (1 to 3 minimum alveolar concentration [MAC]). At 21 degrees C, the slope of this relation was 0.52 and 0.12 mm/vol % for halothane and sevoflurane, respectively, and decreased at 36 degrees C to 0.29 and 0.09 mm/vol %, respectively. ICa,L displayed significantly higher current amplitudes at 36 degrees C than at 21 degrees C and significantly accelerated time-dependent inactivation. Halothane (1-2 MAC) and sevoflurane (1-3 MAC) evoked stronger inhibitions of ICa,L at 21 degrees C than at 36 degrees C. In spite of different temperature-dependent current amplitudes, the fractional (percent) inhibition of ICa,L showed the same linear relationship to the concentrations of halothane and sevoflurane in the bath medium at both temperatures, as revealed from present and previous experiments. CONCLUSIONS: Inhibition of ICa,L by halothane and sevoflurane is determined by the aqueous concentration of the anesthetics, independently of the temperature. Increased solubility may explain the stronger effects of the anesthetics at lower temperatures.