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Basement membranes form a boundary between intravascular and extravascular compartments that is remodeled by matrix metalloproteinases (MMP) expressed by endothelial cells. These cells are at risk of exposure to reactive oxygen intermediates generated as a consequence of interactions with drugs, x-radiation, activated neutrophils, or cancer cells. Herein we have investigated the hypothesis that endothelial cells alter their expression of MMP after sublethel exposure to H2O2 and that this leads to degradation of adjacent basement membranes. Cultured human umbilical vein endothelial cells were treated with concentrations of H2O2 ranging from 1.5 to 32 microM or with 2 x 10(-6)M phorbol myristate acetate (PMA). After 24 hours, the cells were placed into serum-free medium for an additional 24 hours. This conditioned medium or cell lysates were studied by matrix degradation assays, gelatin zymography, immunoblots, and Northern analysis. H2O2-treated or PMA-treated cells, or their serum-free conditioned medium, caused a 2-fold increase in degradation of [3H]-proline-labeled endothelial basement membranes or purified type IV collagen compared to untreated cells. Endothelial cells constitutively expressed gelatinases at Mr 96,000 and 72,000, consistent with MMP-9 and inactive MMP-2. H2O2 exposure caused increased expression of these MMP and appearance of Mr 64,000 to 66,000 gelatinases corresponding to activated MMP-2. In cell lysates, H2O2 or PMA treatment led to increased expression of membrane-type MMP-1, an activator of latent MMP-2. The results suggest that oxidants such as H2O2 may stimulate MMP expression and influence the remodeling of vascular basement membranes by endothelial cells.

OBJECTIVE To review the diagnostic and therapeutic roles of laparoscopy in women of reproductive age with acute and chronic pelvic pain. DATA IDENTIFICATION Studies relating to the use of laparoscopy in women with acute and chronic pelvic pain were identified through the literature and MEDLINE searches. CONCLUSION(S) Laparoscopy has an important place in the management of conditions that cause acute pelvic pain in women of reproductive age, including ectopic pregnancy, pelvic inflammatory disease, tubo-ovarian abscess, and adnexal torsion. The procedure frequently facilitates the diagnosis and provides the necessary access for surgical treatment. Prompt diagnosis and effective management prevent complications and help preserve fertility. The role of laparoscopy in women with chronic pelvic pain is more controversial and limited, but abnormal laparoscopic findings are detected in approximately 60% of those who have undergone a multidisciplinary investigation and received a tentative clinical diagnosis. The access provided by laparoscopy permits the effective surgical treatment of many of the conditions encountered, including endometriosis, pelvic adhesions, ovarian lesions, and symptomatic uterine retroversion.

OBJECTIVE To avoid oocyte retrieval for IVF-ET during the weekend, the scheduled method of ovarian hyperstimulation, in which oocyte retrieval is planned in advance for Monday through Wednesday, was evaluated. DESIGN A retrospective study. SETTING The IVF-ET unit of the Department of Obstetrics and Gynecology at Tokushima University Hospital. PATIENT(S) One hundred seventy-eight cycles in patients undergoing ovarian hyperstimulation for IVF-ET were stimulated according to the scheduled method of ovarian hyperstimulation (scheduled group). One hundred seventy-one cycles in patients of similar age and with comparable causes of infertility were stimulated according to the conventional method of ovarian hyperstimulation for IVF-ET (conventional group). INTERVENTION(S) In the scheduled method, under GnRH-a, the day of oocyte retrieval was determined in advance for IVF-ET. Ovarian stimulation with FSH and hMG was started 12 days before oocyte retrieval. MAIN OUTCOME MEASURE(S) The cancellation and clinical pregnancy rates (PRs), the days of oocyte retrieval, and other clinical parameters were evaluated in the two groups. RESULT(S) The cancellation rates in the scheduled and conventional groups were 9.6% and 4.7%, respectively. In about 75% of cycles in the scheduled group, oocyte retrieval was conducted on the scheduled day. When oocyte retrieval was scheduled for Monday through Wednesday, overtime work on the weekend could be avoided in 91% of the cycles without cancellation. The clinical PR was comparable between the two groups. CONCLUSION(S) The scheduled method of ovarian hyperstimulation for IVF-ET was useful for avoiding oocyte retrieval on the weekend.

OBJECTIVE To determine whether the concentrations of proteoglycans and hyaluronan in human follicular fluid (FF) are associated with follicular volume, oocyte fertilization, and ET during IVF. DESIGN The FF from individual follicles were collected. Enzyme-linked immunosorbent assay methods for quantification of a larger chondroitin sulfate proteoglycan and a smaller composite heparan-chondroitin sulfate proteoglycan were established. Hyaluronan and E2 were measured by RIA techniques. PATIENT(S) Sixteen infertile women participating in the IVF program. MAIN OUTCOME MEASURE(S) Concentrations of the proteoglycans, follicular volume, fertilization, and ET rates. RESULT(S) The follicles contained high concentrations of proteoglycans with an average of 0.8 mg/mL of FF, and approximately 70% consisted of the larger chondroitin sulfate proteoglycan, and 30% of the heparan-chondroitin sulfate proteoglycan. A negative correlation was found between the follicular volume, the chondroitin sulfate proteoglycan (r = -0.43), and hyaluronan (r = -0.56). The percentage of embryos developed in culture was significantly higher in follicles larger than 2 mL. A significant and 35% lower concentration of the chondroitin sulfate proteoglycan was found in larger follicles from which subsequent ET was observed. THe heparan-chondroitin sulfate proteoglycan and hyaluronan were both unrelated to fertilization and ET in vitro. CONCLUSION(S) Lower concentrations of chondroitin sulfate proteoglycan were associated with higher follicular volumes and greater fertilization and ET rates. These associations could merely reflect the maturation of the follicle or a role of the chondroitin sulfate proteoglycan in the fertilization process.

OBJECTIVE To investigate whether the consequences of premature P elevation on IVF-ET outcome are modulated by the quality of the ovarian response to controlled ovarian hyperstimulation (COH). DESIGN Retrospective analysis. SETTING Assisted Reproduction Unit, Clamart, France. PATIENT(S) One thousand twelve women undergoing 1,189 IVF-ET cycles. INTERVENTION(S) Patients underwent COH with a time-released GnRH agonist and hMG. The ovarian response to COH was classified as strong (< or = 50 hMG ampules, peak E2 levels > 2,500 pg/mL, and > or = 10 mature oocytes; n = 340), weak (> 50 hMG ampules, peak E2 levels < or = 1,500 pg/mL, and < or = 5 mature oocytes; n = 285), or intermediate (remaining cases; n = 564). The IVF-ET outcome in each group was analyzed according to whether or not plasma P levels exceeded 0.9 ng/mL. MAIN OUTCOME MEASURE(S) Pregnancy rates (PRs). RESULT(S) Clinical PRs were similar irrespective of low or high P levels in the strong (30% and 34%, respectively) and intermediate (31% and 30%, respectively) groups. However, in the weak group, P levels > 0.9 ng/mL were associated with lower PRs (3.2% and 23%, respectively). CONCLUSION(S) In the presence of an adequate response to COH, P levels > 0.9 ng/mL were not associated with lower PRs, indicating that good embryo quality may compensate for the adverse endometrial effects of P. Conversely, when the response to COH was weak, premature P elevation led to drastically reduced PRs.

OBJECTIVE To examine the predictive value of midluteal serum P as a marker of a luteal phase defect (LPD) in future pregnancies of recurrent aborters. DESIGN Prospective analysis. SETTING Nagoya City University Hospital. PATIENT(S) One hundred ninety-seven women with a history of two consecutive first trimester abortions, none of whom had any other medical problems or an identifiable cause of recurrent miscarriages, such as uterine anomalies or evidence of antiphospholipid antibodies. None of the study subjects received any medication for miscarriage or infertility. MAIN OUTCOME MEASURE(S) A midluteal phase single serum P level < 10 ng/mL was used as the criterion for a potential LPD: those whose subsequent pregnancy was successful and those in which failure was the end result. RESULT(S) Of the 197 patients, 46 (23.4%) demonstrated LPD without other endocrine abnormalities and 38 (19.3%) recurrent aborters suffered another abortion, with figures for LPD-negative and LPD-positive patients of 20.5% (31/151) and 15.2% (7/46), respectively. There was no statistically significant difference between the two groups. CONCLUSION(S) Progesterone, E2, and the P/E2 ratio may not predict future pregnancy loss in recurrent aborters.

OBJECTIVE To compare the pharmacokinetics and pharmacodynamics of 100 mg/d, 200 mg/d, and 400 mg/d (200 mg two times per day) of P administered vaginally for 14 days to estrogen-primed postmenopausal women. DESIGN Randomized, open-label, three-way crossover study. SETTING Two university-based investigative sites. PATIENT(S) Twenty healthy postmenopausal women with histologically normal endometria. INTERVENTION(S) Oral 17 beta-E2 was given each day of a 28-day cycle; a P vaginal suppository was inserted daily according to the randomization schedule during days 15-28 of each cycle; blood samples were collected; an endometrial biopsy was obtained on day 25; and patients were crossed over to the next treatment cycle after a washout period of at least 30 days. MAIN OUTCOME MEASURE(S) Mean P blood levels, endometrial dating/conversion. RESULT(S) There was good vaginal absorption of P for all dosages. Endometrial conversion occurred in all 200- and 400-mg/d P-dosed cycles, whereas the 100-mg/d dosage failed to convert primed endometria consistently. There also was a significantly increased tendency for earlier bleeding and spotting with the 100-mg/d dosage. CONCLUSION(S) Both the 200- and 400-mg/d dosage regimens consistently convert an estrogen-primed endometrium, and yield appropriate endometrial dating and bleeding patterns. However, the 400-mg/d dosage attains the highest sustained blood levels and may be the best dosage regimen for further study.

OBJECTIVE To assess whether implantation in assisted reproductive technology (ART) cycles is a random event. DESIGN Retrospective analysis of results. SETTING Division for Reproductive Endocrinology and ART, Department of Obstetrics and Gynecology, Haemek Medical Center, Afula, Israel. PATIENT(S) A cohort of all cycles reaching ET from July 1, 1995, through June 30, 1996, and a cohort of all pregnancies recorded from January 1, 1995, through October 31, 1996. INTERVENTION(S) None. MAIN OUTCOME MEASURE(S) Rate of multifetal pregnancy in relation to overall pregnancy rate. The number of gestational sacs observed by sonography, out of transferred embryos in conception cycles, was defined as the individual implantation rate. RESULT(S) Of 367 ETs, 75 (20.4%) yielded pregnancies, of which 31 (41%) were multifetal. Considering the mean number of embryos transferred (3.67), if implantation would have been random, multifetal gestation rate should have been only 14.8%, significantly less than the observed rate. In 110 pregnancies recorded between January 1995 and October 1996, individual implantation rate was 49.4% +/- 27.1% in intracytoplasmic sperm injection cycles compared with 40.5% +/- 20.4% in IVF cycles. CONCLUSION(S) Embryo implantation is not a random event. The index of individual implantation rate may help shed light on mechanisms underlying implantation.

OBJECTIVE To determine the incidence of cytomegalovirus in the ejaculates of infertile men who were seropositive for IgG antibodies to cytomegalovirus. DESIGN Prospective study. PATIENT(S) We tested cytomegalovirus infection in the semen of men participating in an IVF-ET program. MAIN OUTCOME MEASURE(S) IgG and IgM antibodies to cytomegalovirus were measured in sera. We used polymerase chain reaction (PCR) and cell culture to look for both cytomegalovirus DNA and infectious virus in the semen of 70 men with cytomegalovirus-specific antibodies detected in sera. RESULT(S) Of the infertile couples, 13.5% exhibited "mismatching" serology (i.e., detection of IgG antibodies to cytomegalovirus in male serum only and not in female serum) and constituted a potential risk for cytomegalovirus transmission. Cytomegalovrius was identified in the semen of two patients who were positive for IgG antibodies to cytomegalovirus. Cytomegalovirus DNA also was detected in one positive sample after centrifugation through a three-layer Percoll gradient. CONCLUSION(S) Human cytomegalovirus was present in the semen from a population of infertile men. Rapid detection can be achieved by molecular techniques such as PCR combined with a hybridization assay. Even though cytomegalovirus was infrequently detected in semen, these data must be considered in determining the risk of transmission and developmental anomalies in infected fetuses.

OBJECTIVE To determine whether reactive oxygen species in peritoneal fluid might be a factor in infertility. DESIGN Prospective study. SETTING Andrology laboratory and gynecology clinic at a tertiary care facility. PATIENT(S) Women with endometriosis (n = 15) or idiopathic infertility (n = 11) who underwent laparoscopy for infertility. Patients undergoing tubal ligation served as controls (n = 13). INTERVENTION(S) Aspiration of peritoneal fluid. MAIN OUTCOME MEASURE(S) Reactive oxygen species levels, presence of polymorphonuclear granulocytes, and leukocyte distribution in peritoneal fluid. RESULT(S) Reactive oxygen species were present in the peritoneal fluid of patients with endometriosis, idiopathic infertility, and tubal ligation. Levels of reactive oxygen species did not show a statistically significant difference between patients with endometriosis and the control group in either unprocessed or processed (cell-free) peritoneal fluid, but did differ significantly between patients with idiopathic infertility and controls in processed peritoneal fluid. Polymorphonuclear granulocytes (> 1 x 10(6)/mL) were not present in the peritoneal fluid of any patient. Macrophage concentrations of peritoneal fluid did not differ significantly between controls and patients with endometriosis or idiopathic infertility. CONCLUSION(S) Reactive oxygen species in the peritoneal fluid may not affect fertility directly in women with endometriosis; however, they may have a role in patients with idiopathic infertility.

OBJECTIVE At present, only limited data are available on endometrial volume during the menstrual cycle. Most of these studies deal with animal models and use magnetic resonance imaging for volume measuring. The application of three-dimensional ultrasound in endometrial volume estimation is the subject of this study. SETTING Patients visiting the outpatient unit of the division of endocrinology and reproductive medicine of a university hospital. PATIENT(S) Twenty patients with a history of a normal menstrual cycle were selected. INTERVENTION(S) Ultrasound examinations were performed during a single menstrual cycle in addition to routine laboratory tests. MAIN OUTCOME MEASURE(S) Uterus-endometrial volume ratio. RESULT(S) Data from 18 patients could be evaluated. In 81 examinations the endometrium volume could be determined. Mean endometrial volume measured by three-dimensional ultrasound was 1.23 cm3. Mean uterus volume was 48.93 cm3. The change of the uterus-endometrial volume ratio showed a good correlation with the day of menstrual cycle. Quadratic regression analysis of volume and cycle length was R2 = 0.432. CONCLUSION(S) Three-dimensional ultrasound allows assessment of volume data of the female internal genitalia. In this study changes of the endometrial volume in menstrual cycles were measured. Additional studies are required to give information on the clinical impact of this new technique of endometrial volume estimation.

OBJECTIVE To determine the effects of hormone replacement therapy (HRT) on dehydroepiandrosterone (DHEA), DHEA sulfate (DHEAS), and cortisol (F) responses to treadmill exercise. DESIGN Controlled clinical study. SETTING Female volunteers in an academic research environment. PATIENT(S) Sixteen healthy, postmenopausal women (7 were receiving HRT, 9 were not). INTERVENTION(S) Blood samples were taken from an intravenous catheter before, during, and after 30 minutes of treadmill exercise following an overnight fast. A second session was conducted one month later for the same subjects using the same blood sampling protocol without exercise. MAIN OUTCOME MEASURE(S) Serum DHEA, DHEAS, and F concentrations. RESULT(S) The HRT and untreated DHEA area under the curve (AUC) for the exercise trials was significantly greater than that for the control trials. The untreated, but not the HRT, DHEAS AUC for the exercise trials was significantly greater than that for the control trials. The HRT and untreated F AUC for the exercise trials was significantly greater than that for the control trials. The AUC for the HRT exercise trials was significantly higher than the untreated exercise trials for DHEA and F, but not DHEAS. CONCLUSION(S) Data suggest that treadmill exercise elevates DHEA, DHEAS, and F levels in postmenopausal women and that HRT enhances the DHEA and F responses.

OBJECTIVE To test the effectiveness, safety, and reversibility of the combined administration of cyproterone acetate and T undecanoate. DESIGN Open clinical trial. SETTING Healthy volunteers in an academic research environment. PATIENT(S) Eight healthy men, aged 25-42 years were selected. INTERVENTION(S) Cyproterone acetate, 12.5 mg, and T undecanoate, 80 mg, were administered orally twice daily for 16 weeks. MAIN OUTCOME MEASURE(S) Semen analyses every 2 weeks; physical examination, chemistries, hematology, prostatic-specific antigen, gonadotropins and T levels, and a questionnaire on sexual and behavioral function every 4 weeks. RESULT(S) In all subjects a profound suppression of spermatogenesis occurred; one subject became azoospermic, five subjects had sperm counts of < or = 3 x 10(6)/mL, and in two subjects sperm counts were 4 and 6 x 10(6)/mL in week 16. Sperm counts returned to baseline in all men after hormone administration was discontinued. No changes in metabolic parameters and total prostatic-specific antigen were detected. Hemoglobin and hematocrit decreased statistically significantly at week 16 of treatment and returned to baseline by week 12 of recovery. There was no change in sexual function or behavior. CONCLUSION(S) The oral administration of T undecanoate plus cyproterone acetate induces a profound suppression of spermatogenesis with no major adverse effects. These data suggest the feasibility of oral contraception in men.

OBJECTIVE To evaluate the effectiveness of i.v. albumin in preventing severe ovarian hyperstimulation syndrome (OHSS) in patients at risk. DESIGN Retrospective review and data analysis. SETTING University-based tertiary referral center for assisted reproductive technologies (ART). PATIENT(S) Sixty women at high risk of developing severe OHSS after superovulation for ART. INTERVENTION(S) One liter of albumin (4.5%) administered i.v. during oocyte retrieval and immediately afterward. RESULT(S) Of the 60 women who had prophylactic i.v. albumin, 5 (8%) developed severe OHSS, which led to hospitalization. Eight (13%) developed moderate OHSS. Forty-seven (78%) did not develop any symptoms. Four of the 5 women who developed severe OHSS had ET and 3 of them (75%) were pregnant (1 twin and 2 singletons). CONCLUSION(S) Intravenous albumin administered at oocyte retrieval does not prevent the occurrence of severe OHSS, especially in cases associated with pregnancy. It is important that clinicians are not lured into a false sense of security by the early report, full of promise, on the use of i.v. albumin to prevent severe OHSS.

OBJECTIVE To investigate whether establishment and maintenance of chronic opioid blockade throughout the follicular phase of the menstrual cycle influences midcycle and luteal phase prolactin levels. DESIGN Randomized, double-blind, crossover study. SETTING Academic research environment. PATIENT(S) Volunteers, aged 21-35 years, with regular menstrual cycles. INTERVENTION(S) Naltrexone (50 mg) or placebo were administered on cycle days 2-14. Blood samples were obtained in the early follicular phase and in the periovulatory and midluteal phases of the menstrual cycle. MAIN OUTCOME MEASURE(S) Serum prolactin levels. RESULT(S) In the early follicular phase, serum prolactin levels were equivalent in naltrexone (12.0 +/- 2.7 microgram/L; mean +/- SE) and placebo (12.1 +/- 2.9 micrograms/L) cycles. A statistically significant increase in serum prolactin was observed on the day of the LH surge (naltrexone: 22.6 +/- 3.7 micrograms/L; placebo: 21.7 +/- 2.7 micrograms/L; P < 0.05 versus early follicular phase), but no difference between treatments was observed. However, midluteal prolactin levels were statistically significantly lower in naltrexone cycles compared with placebo cycles (12.6 +/- 3.3 versus 15.4 +/- 3.0 micrograms/L; P < 0.05). CONCLUSION(S) Chronic blockade of opioid activities during the follicular phase does not affect midcycle prolactin increments, but withdrawal of opioid blockade may enhance opioid effects on prolactin levels in the luteal phase.

OBJECTIVE To evaluate the efficacy of the GnRH agonist (GnRH-a) nafarelin compared with placebo administered for 6 months after reductive laparoscopic surgery for symptomatic endometriosis. DESIGN Randomized, prospective, placebo-controlled, multicenter clinical trial. SETTING Thirteen clinics including private practice and university centers. PATIENT(S) One hundred nine women aged 18-47 with laparoscopically proven endometriosis and pelvic pain who had undergone reductive laparoscopic surgery for endometriosis. INTERVENTION(S) Patients were randomized to receive either the GnRH-a nafarelin (200 micrograms twice daily) or placebo for 6 months. MAIN OUTCOME MEASURE(S) Time to initiation of alternative treatment (the length of time from beginning study medication to receiving alternative therapy or to deeming that the study drug was ineffective) and patient-reported and physician-assessed pelvic pain scores. RESULT(S) The median time to initiation of alternative treatment was > 24 months in the nafarelin group versus 11.7 months in the placebo group. Fifteen (31%) of 49 nafarelin-treated patients required alternative therapy, compared with 25 (57%) of 44 placebo-treated patients. The patients' pelvic pain scores dropped significantly in the nafarelin and placebo groups after 6 months of treatment. Physician summary ratings showed significant improvement in the nafarelin group and no significant changes in the placebo group after 6 months of treatment. CONCLUSION(S) Compared with placebo, nafarelin administered after reductive laparoscopic surgery for endometriosis significantly delays the return of endometriosis symptoms requiring further treatment.

OBJECTIVE To review and evaluate a series of patients who underwent microsurgical anastomosis of previously sterilized fallopian tubes. DESIGN Retrospective clinical study. SETTING Tertiary care academic center. PATIENT(S) In the 134-month span from January 1980 to February 1991, 1,118 women were evaluated for microsurgical reversal of previous tubal sterilization. MAIN OUTCOME MEASURE(S) Clinical characteristics of patients, pregnancy rates (PRs), and factors influencing the outcome. RESULT(S) Of 1,118 patients, 633 (56.6%) had been sterilized by laparoscopic cautery. Loss of children was a leading reason for requesting tubal reversal. The mean interval between tubal sterilization and reversal was 51.9 months. Nine hundred twenty-two (82.5%) patients were followed up for > 5 years. The overall PR after microsurgical tubal anastomosis was 54.8% (505 of 922) with a delivery rate of 72.5% (366 of 505), and the estimated anatomical success rate was 88.2% (814 of 922). There was no statistically significant difference in the PR or in the interval from tubal reversal to conception among the different operative procedure groups. In addition, no statistically significant difference in the PR was observed regardless of the postoperative tubal length. However, the interval from operation to pregnancy decreased significantly as the postoperative tubal length increased. The pregnant patients (n = 505) were younger and had a longer postoperative tube than the nonpregnant patients (n = 417); these differences were statistically significant. CONCLUSION(S) The pregnancy rate after microsurgical reversal of tubal sterilization was not significantly correlated with the method and duration of sterilization, the operative procedure, or the postoperative tubal length.

OBJECTIVE To examine factors determining choice of radical or conservative surgical procedure for tubal ectopic pregnancy and subsequent pregnancy rates. DESIGN A retrospective study collating information from the operative notes and previous gynecologic history associated with the choice of procedure and pregnancy rates and outcome over 3 years after a primary tubal ectopic pregnancy. PATIENT(S) Thirty-four women who had undergone conservative (tube sparing) and 56 who had undergone radical (salpingectomy) surgical treatment for tubal ectopic pregnancy at least 3 years before the study. MAIN OUTCOME MEASURE(S) The main outcome measure was the occurrence of a pregnancy (live birth, miscarriage, or ectopic pregnancy) over 3 years after the ectopic pregnancy. RESULT(S) The type of surgery performed was not affected by a previous history of infertility, known pelvic inflammatory disease, the presence of tubal adhesions, or abnormalities on the contralateral tube. Intrauterine pregnancy was not more likely after conservative treatment of ectopic pregnancy but, equally important, the risk of a further ectopic pregnancy was not increased. The single factor that was clearly associated with future fertility problems was a past history of infertility. CONCLUSION(S) Better results may be obtained by careful selection of operative procedure based on history and findings at the time of surgery.

OBJECTIVE To survey what factors influence the pregnancy outcome in an effort to improve the pregnancy rate (PR) after microsurgical reversal of tubal sterilization. DESIGN Retrospective clinical study. PATIENT(S) Three hundred eighty-seven patients who had microsurgical tubal reversal between March 1982 and January 1994. INTERVENTION(S) Postoperative pregnancy outcomes were determined by telephone, letters, and direct interviews. RESULT(S) Pregnancy outcomes were identified in 94.1% of the total patients. The overall PR was 91.6%, of which 3.9% spontaneously aborted and 1.7% were ectopic. The probability that pregnancy occurred within the first 12 months was 0.80. The median interval from the tubal reversal to pregnancy was 5.34 months. The pregnancy success rate after reversal of Falope ring sterilization was statistically significantly higher than in the other groups. Patients with reversed tubal length > or = 7 cm had a statistically significantly higher PR than those with < 7 cm. CONCLUSION(S) The overall probability of pregnancy was 0.89. The tubal length reconstructed after tubal reversal and the type of sterilization performed previously were the important factors affecting the PR.

OBJECTIVE To determine the contribution of several variables to fluid loss during transcervical resection of submucous myomas. DESIGN An observational study using multiple linear regression analyses. SETTING A university-affiliated training hospital and a university department of clinical epidemiology and biostatistics. PATIENT(S) Patients with submucous myomas. INTERVENTION(S) Transcervical resection of submucous myomas and monitoring of fluid loss. MAIN OUTCOME MEASURE(S) Patient age, uterine enlargement, treatment with GnRH analogues or 8-ornithine-vasopressin, type of anesthesia, number of myomas, intramural extension of the myoma (type of myoma), and operating time were tested as variables. RESULT(S) Only intramural extension of the myoma and operating time were obviously related to fluid loss. For the other variables, such a relation was weak at best. The relation between fluid loss and operating time was not modified by any of the other variables. CONCLUSION(S) Because fluid loss is an important limiting factor in the transcervical resection of submucous myomas, special attention should be paid to reduction of the operating time and preoperative assessment of the intramural extension of the myoma to guide appropriate patient selection.

OBJECTIVE To examine the efficacy of microsurgical tubal anastomosis among patients having failed attempts to correct cornual-isthmic tubal obstruction by hysteroscopic tubal catheterization. DESIGN An open observational trial. SETTING A tertiary referral reproductive medicine practice. PATIENT(S) Forty-three patients with laparoscopically confirmed bilateral cornual-isthmic obstruction and otherwise normal fallopian tubes. Thirty-three control patients with a history of elective sterilization presenting for tubal anastomosis. INTERVENTION(S) All patients with bilateral cornual-isthmic obstruction underwent attempted hysteroscopic tubal cannulation. Those unsuccessfully catheterized proceeded with microsurgical resection and anastomosis. Candidates for reversal of sterilization underwent microsurgical repair in standard layered technique. MAIN OUTCOME MEASURE(S) Mean time to achieve pregnancy, as well as cumulative pregnancy rates for all three groups using life-table analysis, were calculated. RESULT(S) Cumulative pregnancy rates for patients with successful tubal catheterization, for those requiring microsurgical repair, and for reversal of elective sterilization were 0.68%, 0.56%, and 0.29%, respectively, at 12 months. Mean duration to achieve pregnancy was similar for both cornual-isthmic blockage-treated groups and was shorter than that for the sterilization-reversal group. CONCLUSION(S) Patients with cornual-isthmic obstruction and otherwise normal fallopian tubes who are treated successfully by either tubal catheterization or resection and microsurgical anastomosis demonstrate high pregnancy rates, short interval to achieve pregnancy, and similar obstetric outcome. If no pregnancy is achieved within 1 year of surgery, reevaluation and consideration for possible IVF and ET is indicated.

OBJECTIVE To compare the outcome of intracytoplasmic sperm injection (ICSI) with fresh and frozen-thawed testicular spermatozoa in patients with nonobstructive azoospermia. DESIGN Retrospective analysis of consecutive ICSI cycles. SETTING In Vitro Fertilization Unit, Assaf Harofeh Medical Center. PATIENT(S) Eighteen with nonobstructive azoospermia in whom testicular sperm was found after testicular sperm extraction. INTERVENTION(S) Testicular sperm retrieval, cryopreservation, and ICSI with fresh or frozen-thawed testicular spermatozoa. MAIN OUTCOME MEASURE(S) Two-pronuclear fertilization; embryo cleavage rates, mean number of embryos transferred per cycle, and their relative quality, embryo implantation, clinical pregnancy, and ongoing pregnancy rates (PRs) per ET. RESULT(S) No statistically significant differences were noted in all parameters examined between ICSI cycles with fresh or cryopreserved testicular spermatozoa from the same nine patients and comparing all ICSI cycles performed; with fresh (25 cycles) and thawed (14 cycles) testicular spermatozoa, respectively: two-pronuclear fertilization, 47% versus 44%; embryo cleavage rates, 94% versus 89%; implantation rates, 9% versus 11%; and clinical PR, 26% versus 27%. The delivery or ongoing PR using fresh sperm was better (21% versus 9%), but the difference did not reach statistical significance. The cumulative clinical PRs and ongoing PRs per testicular sperm extraction procedure were 36% and 24%, respectively. CONCLUSION(S) Testicular sperm cryopreservation using a simple freezing protocol is promising in patients with nonobstructive azoospermia augmenting the overall success achieved after surgical sperm retrieval.

OBJECTIVE To evaluate serum leptin concentrations in hirsute women. DESIGN Controlled clinical study. SETTING Tertiary institutional hospital. PATIENT(S) Thirty-three hirsute women and 11 healthy female controls. INTERVENTION(S) Serum samples were obtained at baseline and on day 1 (gonadal stimulation) and day 21 (gonadal suppression) after the IM injection of a single 3.75-mg dose of triptorelin. MAIN OUTCOME MEASURE(S) Leptin, T, sex hormone-binding globulin (SHBG), insulin, and glucose levels and free androgen index. RESULT(S) Leptin levels were increased in hirsute women in comparison with control subjects at baseline and on day 1. Leptin levels increased on day 1 compared with baseline and then decreased to baseline by day 21. Leptin levels correlated with body mass index (r = 0.76), SHBG levels (r = -0.52), free androgen index (r = 0.38), insulin levels (r = 0.46), and the glucose/insulin ratio (r = -0.38). When the effect of obesity on these results was removed by analysis of covariance and partial correlation analysis, leptin levels remained elevated only on day 1 and the only correlations that remained significant were those of leptin with insulin (r = 0.24) and the glucose/insulin ratio (r = -0.24). CONCLUSION(S) The increased leptin levels found in hirsute women are related mainly to obesity and also to insulin resistance. Leptin levels increased during gonadal stimulation and returned to baseline during gonadal suppression, suggesting that leptin also is influenced by the gonadal axis.

OBJECTIVE To study the levels of glutathione S-transferase Alpha 1-1 and glutathione S-transferase Pi 1-1 in human preovulatory ovarian follicular fluid (FF) and pooled granulosa and cumulus cells. DESIGN The relation of glutathione S-transferase Alpha 1-1 and glutathione S-transferase Pi 1-1 with P and 17 beta-E2 concentrations were studied. SETTING The Department of Obstetrics and Gynecology, the Department of Gastroenterology, and the Laboratory of Endocrinology and Reproduction of the University Hospital Nijmegen in Nijmegen, the Netherlands. PATIENT(S) Infertile women participating in an IVF program. RESULT(S) Detectable amounts of glutathione S-transferase Alpha 1-1 and glutathione S-transferase Pi 1-1 were found in ovarian FF and pooled cumulus and granulosa cells. Concentrations of glutathione S-transferase Alpha 1-1 were always much higher than those of glutathione S-transferase Pi 1-1. Both ovarian FF concentrations of glutathione S-transferase Alpha 1-1 and glutathione S-transferase Pi 1-1 did not correlate with ovarian FF concentrations of 17 beta-E2 and P. CONCLUSION(S) The high FF concentrations of glutathione S-transferase Pi 1-1 and especially of glutathione S-transferase Alpha 1-1 suggest that these enzymes may play an important role in the detoxification processes in the follicles. The lack of correlation between follicular P and 17 beta-E2 and glutathione S-transferase Alpha 1-1 and glutathione S-transferase Pi 1-1 indicates that both enzymes presumably are not present as a result of the high steroid levels.

OBJECTIVE To assess the proliferative activity of eutopic and ectopic endometrium throughout the menstrual cycle and its correlation to steroid receptor content. DESIGN The immunohistochemical use of Ki 67 was applied to investigate the proliferation index. A recently advanced stereographic computer technology was used to investigate steroid receptors. SETTING University hospital department of gynecology. PATIENT(S) Biopsies of eutopic endometrium, black and red peritoneal endometriotic lesions, and ovarian endometriomas were taken from infertile patients and classified according to the phase of the cycle. RESULT(S) In normal endometrium, the glandular proliferation index was highest during the proliferative phase and was statistically significantly reduced during the secretory phase. No proliferative activity was observed in the late secretory phase. No statistically significant differences were found between ectopic endometrium and eutopic endometrium except during the late secretory phase, when proliferative activity was still present in endometriotic tissue. The stromal proliferation index was similar in red lesions, ovarian endometriomas, and eutopic endometrium during the secretory phase. In normal endometrium, the highest concentrations of estrogen receptors (ERs) and P receptors (PRs) occurred in the epithelial and stromal cells during the late proliferative phase of the menstrual cycle. Estrogen receptor and PR content declined throughout the secretory phase. In ectopic endometrium, PR persisted in the glandular epithelium during the late secretory phase. Estrogen receptors persisted in the glandular epithelium and stroma of red peritoneal lesions and ovarian endometriomas during the late secretory phase. CONCLUSION(S) The high proliferative activity and the persistence of ERs and PRs in the stroma of red lesions and ovarian endometriomas emphasize the primordial role of the stroma in the development of endometriosis and suggest different mechanisms of proliferation control from those observed in eutopic endometrium.

OBJECTIVE To investigate effects of cryoprotectant and cryopreservation on the chromosome and microtubule configuration of human immature oocytes. DESIGN Intact cumulus-enclosed immature oocytes were collected from unstimulated ovaries and divided into three groups: group 1, no treatment (control); group 2, only 1,2-propanediol treatment, and group 3, cryopreserved oocytes. Oocytes in groups 1 and 2, and oocytes that survived after cryopreservation in group 3 were cultured for 48 hours. SETTING Infertility Medical Center at the CHA General Hospital, Seoul, Korea. PATIENT(S) Oocytes were obtained from patients undergoing gynecologic surgery. MAIN OUTCOME MEASURE(S) Maturation rate and abnormality in chromosomes by fluorescence in situ hybridization and in the spindle by immunostaining for tubulin. RESULT(S) There was no effect of propanediol-only treatment on the chromosomal (41.4%) and spindle abnormalities (35.3%) in group 2 compared with control oocytes (31.8% and 22.2%, respectively), whereas a statistically significant increase in abnormalities in chromosomes (77.8%) and spindles (70%) was found in group 3. CONCLUSION(S) Human oocytes matured in vitro after cryopreservation at the germinal vesicle stage showed increased incidence of chromosomal and spindle abnormalities. These abnormalities may impair the capacity for further development of the embryos derived from frozen-thawed oocytes.

OBJECTIVE To evaluate the effect of low-dose aspirin use in oocyte donation recipients with an endometrial thickness of < 8 mm. DESIGN A prospective, randomized study. SETTING An oocyte donation program in a private infertility practice. PATIENT(S) Twenty-eight recipients undergoing oocyte donation who failed to develop an endometrial thickness of at least 8 mm in a previous evaluation cycle. INTERVENTION(S) Fifteen recipients received low-dose aspirin (81 mg/d) in addition to standard hormone replacement for an oocyte donation cycle. The remaining 13 recipients did not receive aspirin. MAIN OUTCOME MEASURE(S) Clinical pregnancy rates, delivery rates, implantation rates, and change in endometrial thickness were compared in the aspirin and nonaspirin groups. RESULT(S) There was no demonstrable increase in endometrial thickness in the aspirin-treated group. However, there was a statistically significant increase in implantation rates in the aspirin-treated group (24% versus 9%) and in implantation rates and clinical pregnancy rates in the aspirin-treated group when the final endometrial thickness was < 8 mm. CONCLUSION(S) Low-dose aspirin therapy improves implantation rates in oocyte donation recipients with a thin endometrium.

OBJECTIVE To report successful ovulation induction in a woman with premature ovarian failure (POF) resulting from a partial Xq deletion. DESIGN An uncontrolled study. SETTING University hospital. PATIENT(S) A 27-year-old woman with 46,X,del(X)(q22) who had hypergonadotropic secondary amenorrhea. INTERVENTION(S) Injections of hMG (225 IU/d) for 8 consecutive days after endogenous gonadotropin suppression with a long-acting GnRH agonist (900 micrograms/d) for 12 weeks, together with cyclic sex steroid replacement therapy. MAIN OUTCOME MEASURE(S) Serum concentrations of E2 and P as well as ultrasonography. RESULT(S) Folliculogenesis and ovulation. CONCLUSION(S) Ovulation induction is possible in patients with POF caused by X chromosome aberrations.

OBJECTIVE To assess whether uterine artery blood flow impedance, measured as the pulsatility index on the day of ET in patients undergoing IVF-ET with microinjection, can predict the likelihood of pregnancy. DESIGN Prospective clinical study. SETTING A tertiary referral center for assisted reproduction. PATIENT(S) Seventy patients undergoing intracytoplasmic sperm injection (ICSI) for andrologic indications. INTERVENTION(S) Transvaginal color Doppler examination performed on the day of ET. MAIN OUTCOME MEASURE(S) Mean (+/- SD) pulsatility index value of the left and right uterine arteries, serum E2 levels, implantation rates, and ongoing pregnancy rates (PRs). RESULT(S) The patients were divided into pregnant and nonpregnant groups and were separated according to whether the pulsatility index was low (1.00-1.99), medium (2.00-2.99), or high (> or = 3.00). The pulsatility index values did not change statistically in the pregnant and nonpregnant groups. The implantation rates were 19.5%, 15.4%, and 25% for the low-, medium-, and high-pulsatility index groups, respectively. The ongoing PRs for the same groups were 35.3%, 26.7%, and 37.5%, respectively. CONCLUSION(S) The study suggests that blood flow, measured as the pulsatility index on the day of ET, cannot predict the likelihood of pregnancy in stimulated cycles of ICSI.

OBJECTIVE To review the use of radiotherapy for relieving the symptoms of recurrent endometriosis caused by functioning ovarian remnants. DESIGN Retrospective study (case report). PATIENT(S) A woman with recurrent endometriosis of 14 years' duration. INTERVENTION(S) After hysterectomy and bilateral oophorectomy, hormonal management, and multiple explorations for recurrent endometriosis, cycling ovarian remnants were confirmed histologically. Pelvic irradiation was used to ablate this tissue. A dose of 15 Gy in 10 daily fractions was given through anterior and posterior opposed fields using 18-mV photons. RESULT(S) The patient had a prompt increase in FSH levels associated with castration levels of serum E2. A review of the literature on the use of radiotherapy in this clinical situation is presented. CONCLUSION(S) Radiotherapy should be considered in selected patients when ovarian castration is not a viable surgical option and hormonal therapies have failed.

OBJECTIVE To describe the occurrence of endometriosis in monozygotic twins. DESIGN Postal questionnaire plus confirmation of disease status. SETTING Twins were recruited via the American Endometriosis Association and the National Endometriosis Society of Great Britain and via British gynecologists. RESULT(S) Fourteen twin pairs were concordant for endometriosis, and two were discordant. Nine pairs of twins had moderate-severe endometriosis. CONCLUSION(S) These findings contribute to the growing body of literature that suggests endometriosis has a genetic basis.

We have studied prospectively, in nine children requiring sedation to facilitate mechanical ventilation, the metabolic, biochemical and haemodynamic effects of infusion of propofol. Children were given infusions of propofol 1-4mg kg-1 h-1 and fentanyl 1-5 micrograms kg-1 h-1 for 48 h. Heart rate, arterial pressure, central venous pressure, fluid balance and urine output were recorded hourly and sedation scores every 4 h. In addition to routine haemodynamic and biochemical measurements in the intensive care, 6-hourly arterial blood-gas analysis and 12-hourly measurements of serum concentrations of glucose, lactate and electrolytes, renal function, triglycerides and liver function tests were performed. Urine was analysed for ketones. There were no significant differences in haemodynamic or biochemical variables during the 48-h period. In this small sample of children, propofol combined with fentanyl provided excellent sedation with no evidence of cardiac, renal or hepatic impairment. Under these very proscriptive conditions we did not encounter lipaemia or acidosis with infusion of propofol. Thus propofol may be a safe sedative agent for use in paediatric intensive care if used appropriately. Further large scale studies are needed to determine if warnings against the use of this agent in paediatric intensive care units are justified.

In a prospective, randomized, double-blind clinical study, we have studied 100 children, aged 2-12 yr, to compare halothane and sevoflurane in outpatient dental anaesthesia. All patients were unpremedicated and received inhalation induction using nitrous oxide in oxygen supplemented with either halothane (maximum inspired concentration 5%) or sevoflurane (maximum inspired concentration 8%). Time to loss of the eyelash reflex was more rapid using sevoflurane although time to adequate anaesthesia (to allow insertion of a mouth prop) was slower in the sevoflurane group. The incidence of cardiac arrhythmia was higher during halothane (62%) than during sevoflurane anaesthesia (28%) (P < 0.005) and the arrhythmias were more often ventricular in origin. The two agents were comparable in terms of ease of use and quality of anaesthesia, and times to eye opening and satisfying discharge criteria were similar. We conclude that sevoflurane has qualities that have made halothane the most used inhalation agent for children, and that it is superior to halothane in dental outpatients where cardiac arrhythmias are a particular problem.

We have examined the differences in ventilatory characteristics between halothane and sevoflurane when used for adult vital capacity induction of anaesthesia. The study was conducted in a randomized, double-blind manner. After 13 patients had been enrolled, the study was curtailed because the blinded observer thought that there was an unacceptably high incidence of adverse events. After the randomization code was revealed, the adverse events were found to be in the halothane group. Although the sample size was small, minute volumes appeared to be maintained in the sevoflurane group. Ventilatory frequencies were similar in the two groups after insertion of the laryngeal mask airway, but tidal volumes were significantly greater in the sevoflurane group (P = 0.0013).

Low flow and closed system anaesthesia have considerable advantages in economy, limited atmospheric pollution, and maintenance of humidification and temperature. To benefit from these techniques leakage from the breathing system should be as low as possible. The sealing of the airway is crucial to ensure this. Therefore, we have investigated in 30 children, aged 2-6 yr, the effectiveness of the laryngeal mask airway (LMA) and the uncuffed tracheal tube (TT) for closed system paediatric anaesthesia, during positive pressure ventilation, in a prospective, randomized study. Ventilation was adequate in all cases with both devices. Loss of gas from the breathing system was less than 100 ml min-1 in 13 (87%) patients in the LMA and in 12 (80%) patients in the TT group, with a maximum of approximately 700 ml min-1 in the TT and approximately 350 ml min-1 in the LMA group. We conclude that the airway sealing with both devices was tight enough to perform low flow or closed system anaesthesia in paediatric patients aged 2-6 yr.

Ninety boys, aged 13-53 months, undergoing repair of hypospadias, were allocated randomly to receive 0.8 ml kg-1 of one of three solutions into the caudal extradural space: group B received bupivacaine 2 mg kg-1, group T received tramadol 2 mg kg-1 in 0.9% saline and group BT a mixture of both. Postoperative pain was assessed hourly for 12 h after injection using a modified TPPPS pain score and additional analgesia was administered to those children whose pain scores were > 3/10. Nine patients (30%) in group T required additional analgesia within 1 h of surgery compared with only two (6.7%) and three (10%) patients in groups B and BT, respectively (P = 0.04). Mean duration before additional analgesia was required in the remaining patients was 9.3 (SD 3.0) h in group B, 10.7 (2.2) h in group T and 10.5 (2.0) h in group BT (P > 0.20). There were no significant differences between the groups in mean ventilatory frequency, sedation scores, incidence of emesis, facial flushing or pruritus. We conclude that caudal tramadol had a slow onset of action and that the addition of tramadol to bupivacaine, when both drugs were administered caudally, did not significantly prolong the duration of action of bupivacaine.

Single, end-holed and multi-orifice extradural catheters were compared in terms of efficacy and complications when used for infusion of 0.1% bupivacaine during labour. In this study of 364 patients there was no difference in unilateral block after an initial bolus dose (18 (11.5%) for single, end-holed and 16 (10.9%) for multi-orifice catheters). Unilateral block recurred with seven (4.0%) single, end-holed and with eight (4.8%) multi-orifice catheters. Unilateral blocks, arising for the first time during infusion of local anaesthetic, occurred significantly more frequently when single, end-holed catheters were used (29 (16.4%)) compared with multi-orifice catheters (14 (8.4%)) (P < 0.05).

Several studies have reported transient neurological symptoms after spinal anaesthesia with 5% lignocaine. In order to evaluate the role of concentrated solutions of local anaesthetic in the development of transient neurological symptoms, 200 ASA I or II patients undergoing minor orthopaedic or rectal surgery under spinal anaesthesia were allocated randomly to receive 4% mepivacaine 80 mg or hyperbaric 0.5% bupivacaine 10 mg. All patients were interviewed by an anaesthetist approximately 24 h after spinal anaesthesia, and after 1 week patients were asked to return a written questionnaire. The incidence of transient neurological symptoms consisting of pain in the buttocks or pain radiating symmetrically to the lower extremities differed (P < 0.001) between patients receiving mepivacaine (30%) and those receiving bupivacaine (3%). Hyperbaric 0.5% bupivacaine can be recommended for minor operations on the lower abdomen or lower extremities.

Pressure controlled ventilation (PCV) is an alternative mode of ventilation which is used widely in severe respiratory failure. In this study, PCV was used for one-lung anaesthesia and its effects on airway pressures, arterial oxygenation and haemodynamic state were compared with volume controlled ventilation (VCV). We studied 48 patients undergoing thoracotomy. After two-lung ventilation with VCV, patients were allocated randomly to one of two groups. In the first group (n = 24), one-lung ventilation was started by VCV and the ventilation mode was then switched to PCV. Ventilation modes were performed in the opposite order in the second group (n = 24). We observed that peak airway pressure (P = 0.000001), plateau pressure (P = 0.01) and pulmonary shunt (P = 0.03) were significantly higher during VCV, whereas arterial oxygen tension (P = 0.02) was significantly higher during PCV. Peak airway pressure (Paw) decreased consistently during PCV in every patient and the percentage reduction in Paw was 4-35% (mean 16.1 (SD 8.4) %). Arterial oxygen tension increased in 31 patients using PCV and the improvement in arterial oxygenation during PCV correlated inversely with preoperative respiratory function tests. We conclude that PCV appeared to be an alternative to VCV in patients requiring one-lung anaesthesia and may be superior to VCV in patients with respiratory disease.

Despite numerous studies on extravascular lung water (EVLW) in patients undergoing coronary artery bypass surgery, few data are available on the perioperative time course of EVLW in patients undergoing mitral valve replacement for mitral valve insufficiency (MVI). We have investigated 26 patients undergoing elective mitral valve replacement in order to determine the influence of the preoperative degree of mitral valve insufficiency (degree III or IV) and the effect of different priming solutions for cardiopulmonary bypass. Crystalloid priming with Ringer's lactate was compared with human albumin priming solution. Measurement of EVLW was performed using the thermo-dye dilution technique, before and 1, 6 and 24 h after surgery. Before operation, EVLW is increased significantly in patients with MVI degree IV (MVI-degree IV) compared with patients with degree III (MVI-degree III) and patients undergoing coronary artery bypass surgery. During the postoperative time course a significant decrease in EVLW was observed in patients with MVI-degree IV whereas in patients with MVI-degree III the amount of EVLW did not change. However, compared with patients undergoing coronary artery bypass surgery, EVLW remained above normal in both groups. There was no interaction between the type of priming solution and the postoperative time course of EVLW, and no differences in respiratory variables or duration of mechanical ventilation were observed between groups.

We hypothesized that the success of postoperative blood conservation after acute normovolaemic haemodilution (NVHD) is influenced by the extent of intraoperative bleeding and surgical trauma, and the timing of autologous blood transfusion. As total knee replacement is associated with minimal intraoperative but extensive postoperative blood loss, this procedure is ideally suited to acute NVHD. Therefore, to test our hypothesis, 30 patients undergoing elective total knee replacement were enrolled in a prospective, randomized, controlled study. In groups NVHD-2 and NVHD-6, before induction of anaesthesia patients were bled to a target packed cell volume (PCV) of 28-30%, and in the post-anaesthesia care unit autologous blood was transfused over a 2-h period terminating after operation at 2 and 6 h, respectively. In the control group, NVHD was not performed. After operation, platelets, fibrinogen, prothrombin and partial thromboplastin time, and liver function, urea and electrolytes were measured and compared with preoperative baseline values. Significantly (P < 0.024) more allogeneic blood was transfused in the control group (21 u.) compared with either group NVHD-2 (7 u.) or group NVHD-6 (5 u.). In the control group, despite the allogeneic blood transfusion, postoperative PCV decreased until day 4 after operation. Coagulation profile, liver function and urea and electrolytes concentrations were unaffected by the method of treatment. We conclude that for total knee replacement, acute NVHD is an effective blood conservation strategy. However, there was no difference in allogeneic blood administration between the two NVHD groups. Coagulation and liver function, and urea and electrolyte concentrations were unaffected by treatment.

We have studied 746 males and females undergoing general anaesthesia for any type of surgical procedure in a double-blind, controlled, randomized study. After experiencing at least one nausea and/or one emetic episode in the 6 h after recovery from anaesthesia, patients received either ondansetron 4 mg i.v. or metoclopramide 10 mg i.v. Patients were observed for postoperative nausea and vomiting (PONV) for 24 h after drug administration. Complete control of PONV was achieved more frequently in the ondansetron-treated patients compared with the metoclopramide-treated patients during the 24-h period (59% vs 41% (P < 0.001) and 44% vs 34% (P = 0.006) for emetic episodes and nausea, respectively). Furthermore, ondansetron was associated with greater patient satisfaction than metoclopramide (P < 0.001) with 49% and 32% of patients, respectively, very satisfied. The overall incidence of adverse events was similar in the ondansetron (7%) and metoclopramide (8%) groups. Ondansetron was as well tolerated and more effective than metoclopramide for all assessment criteria in the treatment of established PONV.

The aim of this study was to find, using modern techniques, any histological differences in muscle biopsies between malignant hyperthermia (MH) susceptible (MHS), MH equivocal (MHE) and MH negative (MHN) patients. On the basis of the European MH contracture test carried out in 83 patients, 23 were shown to be MHS, nine MHE and 51 MHN. Four lesions were found with a significantly high frequency in MHS and MHE biopsies: muscle fibre hypertrophy and atrophy, internal nuclei and myofibrillar necrosis. These four lesions were observed together in 35% of MHS but in none of the MHE or MHN biopsies. Three of these lesions occurred together in 57% of MHS, 33% of MHE and 4% of MHN biopsies. Our results support a histological difference between MHE, MHS and MHN biopsies and attempt to contribute towards a better definition of MHE status.

Malignant hyperthermia (MH) is a potentially fatal autosomal dominant disorder of skeletal muscle and is triggered in susceptible people by all commonly used inhalation anaesthetics and depolarizing neuromuscular blocking agents. To date, eight mutations in the skeletal muscle ryanodine receptor gene (RYR1) have been identified in malignant hyperthermia susceptible (MHS) and central core disease (CCD) cases. We have screened the RYR1 gene in affected individuals for novel MHS mutations by single stranded conformational polymorphism (SSCP) analysis and have identified a G to T transition mutation which results in the replacement of a conserved arginine (Arg) at position 614 with a leucine (Leu). The Arg614Leu mutation was present in three unrelated MHS individuals of 151 investigated. The mutation was not detected in 148 normal chromosomes and segregated precisely with MHS in family members from one of the probands where DNA was available for analysis. This mutation occurs at the same position as the previously identified Arg to Cys mutation reported in all cases of porcine MH and in approximately 5% of human MH. A comparison of the phenotypes of the Arg614Leu and Arg614Cys probands is presented.

Transplantation is associated with an inflammatory rejection response. Graft reperfusion causes typical haemodynamic and biochemical responses. In this study we have investigated the relationship between these haemodynamic responses and changes in circulating inflammatory mediators after graft reperfusion in 10 consecutive patients undergoing orthotopic liver transplantation. After reperfusion, systemic vascular resistance index decreased (P = 0.011) and cardiac index increased (P = 0.038). These characteristic haemodynamic changes of the reperfusion syndrome were accompanied by global increases in cytokine concentrations. Plasma concentrations of leukotrienes decreased, while thromboxane B2 and platelet activating factor remained increased throughout. Reperfusion-mediated changes in inflammatory mediators may account for the haemodynamic disturbance.

Recent research has shown that gaseous induction in adults with sevoflurane is an acceptable technique. This study was undertaken to assess if gaseous induction using sevoflurane carried in both oxygen alone, and in nitrous oxide and oxygen combined, would provide acceptable pollution levels. As an occupational exposure standard has not been set for sevoflurane, we used the target level of 20 ppm set by the manufacturer. Environmental monitoring was carried out in the anaesthetic room during eight lists where consecutive triple vital capacity sevoflurane inductions were performed. Time-weighted averages for both gases over the duration of the lists were well below the occupational exposure standards (mean 1.1 (range 0.6-1.7) for sevoflurane and 17.3 (12-23) for nitrous oxide). There were high peak concentrations during the induction process (8.3 (4.1-17) for sevoflurane and 172.4 (65-310) for nitrous oxide) although these decreased to low concentrations between anaesthetic inductions. Personal sampling was carried out from the anaesthetist's breathing zone and concentrations were also low (1.2 (0.8-2.1) for sevoflurane and 45.9 (10.1-261.6) for nitrous oxide.

Acute perioperative anaemia may affect neurological injury from permanent focal ischaemic insults. We modelled the opposing effects of haemodilution (increasing cerebral blood flow, decreasing arterial oxygen content) on oxygen availability and uptake in the ischaemic penumbra. First, we validated a mathematical model of regional cerebral oxygen uptake by using published arterial oxygen content and cerebral blood flow values from normal rabbits with progressive anaemia. Then we applied the model to the problem of interest (i.e. the ischaemic penumbra of a focal embolic stroke). We re-analysed published experimental data giving the cerebral blood flow response to anaemia in the ischaemic penumbra. Penumbral extraction reserves were nearly exhausted at a haemoglobin concentration of approximately 10g 100ml-1. Oxygen uptake in the ischaemic penumbra decreased progressively when haemoglobin concentrations decreased to less than 10g 100ml-1. We conclude that, given the available clinical and experimental literature, and until a suitable randomized clinical study has been performed, a haemoglobin concentration of 10 g 100 ml-1 is the rational transfusion "trigger" for the acutely anaemic stroke patient.

Tramadol is an atypical centrally acting analgesic agent with relatively weak opioid receptor affinity in comparison with its antinociceptive efficacy. Evidence suggests that block of monoamine uptake may contribute to its analgesic actions. Therefore, we have examined the actions of (+/-)-tramadol, (+)-tramadol, (-)-tramadol and O-desmethyltramadol (M1 metabolite) on electrically evoked 5-HT efflux and uptake in the dorsal raphe nucleus (DRN) brain slice, measured by fast cyclic voltammetry. Racemic tramadol and its (+)-enantiomer (both 5 mumol litre-1) significantly blocked DRN 5-HT uptake (both P < 0.05) and increased stimulated 5-HT efflux (P < 0.01 (+/-)-tramadol; P < 0.05 (+)-tramadol). The (-)-enantiomer and metabolite, O-desmethyltramadol, were inactive at the concentration tested (5 mumol litre-1). For both (+/-)-tramadol and the (+)-enantiomer, the action on 5-HT efflux preceded an effect on 5-HT uptake, suggesting that uptake block was not the cause of the increased 5-HT efflux and that tramadol might therefore have a direct 5-HT releasing action. This activity, at clinically relevant concentrations, may help to explain the antinociceptive efficacy of tramadol despite weak mu opioid receptor affinity and adds to evidence that tramadol exerts actions on central monoaminergic systems that may contribute to its analgesic effect.

We have studied the effects of i.v. bolus doses of magnesium sulphate (MgSO4) 60, 90 and 120 mg kg-1 on haemodynamic state, the coronary circulation and myocardial metabolism in nine dogs anaesthetized with pentobarbitone and fentanyl. MgSO4 produced dose-dependent decreases in arterial pressure, heart rate, left ventricular dP/dtmax and left ventricular minute work index (LVMWI) and an increase in the time constant of left ventricular isovolumic relaxation. Stroke volume increased, systemic vascular resistance decreased and cardiac output did not change significantly. MgSO4 produced decreases in coronary perfusion pressure, coronary vascular resistance and myocardial oxygen consumption (MVO2). Coronary sinus blood flow, lactate extraction ratio and the ratio of LVMWI to myocardial MVO2, that is an index of cardiac efficiency, did not change significantly. This study indicated that the depressant effect of MgSO4 on cardiac function was offset by lowering of peripheral vascular resistance, so that cardiac pump function remained effective, and the almost constant coronary sinus blood flow resulted from the decrease in coronary vascular resistance even at higher doses.

We have studied the train-of-four (TOF) response mechanomyographically during onset of neuromuscular block produced by subclinical doses of suxamethonium in order to follow the augmentation of the first twitch of the TOF (T1) and TOF fade compared with control TOF responses before the drug was given. In the groups given suxamethonium 0.05, 0.1, 0.2 and 0.3 mg kg-1, the increments in T1 after administration of the drug were observed before twitch depression occurred; these were mean 22.3 (SEM 8.1)%, 19.2 (3.3)%, 10.8 (2.0)% and 4.2 (2.2)%, respectively. This effect was more marked with the lower doses (P < 0.05). The degree of TOF fade was moderate during onset of neuromuscular block and depended on the dose of drug. The results of this study suggest that low doses of suxamethonium produced transient increase in muscle tension and twitch depression with significant TOF fade. We conclude that suxamethonium was associated with presynaptic effects as a consequence of brief stimulation of acetylcholine release followed by progressive diminution at the neuromuscular junction.

Spontaneous movements are sometimes observed of the arm into which rocuronium is administered. In order to assess a possible relationship between these movements and pain, we injected in 10 awake, ASA I patients, in a double-blind manner, both rocuronium 1 ml (10 mg) and 0.9% NaCI 1 ml (placebo), with a 30-s interval in between. None of the patients receiving placebo complained of pain, but eight of 10 patients reported a strong burning pain during injection of rocuronium with brisk flexion of the elbow and wrist, similar to those observed in patients after induction of anaesthesia. A second injection of rocuronium did not produce such pain and no movements were observed. We conclude that injection of rocuronium is associated with severe, burning pain of short duration, responsible for the spontaneous movements in the arm observed after induction of anaesthesia.

We studied 60 ASA I patients with Mallampati grade 1 airways to compare emergency intubating conditions with either alfentanil 20 micrograms kg-1, propofol 2.5 mg kg-1 and vecuronium 0.1 mg kg-1, or with thiopentone 5 mg kg-1 and suxamethonium 1 mg kg-1. Ease of laryngoscopy, vocal cord status and cough response were graded. The trachea of all patients was intubated; 83% of patients in the alfentanil-propofol-vecuronium group and 86% in the thiopentone-suxamethonium group were considered to have satisfactory intubating conditions at 60 s. We conclude that the combination of alfentanil 20 micrograms kg-1, propofol 2.5 mg kg-1 and vecuronium 0.1 mg kg-1 provided adequate conditions for rapid tracheal intubation.

We sought to determine if the solvent in the formulation of etomidate is responsible for haemolysis in patients. In a randomized, prospective, double-blind study of 49 patients undergoing otolaryngological surgery, patients received etomidate dissolved in propylene glycol or in lipid emulsion. Concentrations of free haemoglobin and haptoglobin were measured before and for up to 360 min after injection of etomidate. Free haemoglobin concentrations increased by 216.8 mg litre-1 in patients who received the propylene glycol formulation and by 11.8 mg litre-1 in the lipid emulsion group (P < or = 0.0004). Correspondingly, reductions in haptoglobin concentrations were significantly greater in the propylene glycol group (P < or = 0.002). We conclude that with respect to haemolysis, lipid emulsion is superior to propylene glycol as a solvent for etomidate.

Enhancement of choline acetyltransferase (ChAT) activity and increased intraneuronal acetylcholine (ACh) may explain the convulsant activity of some inhaled compounds. Enflurane, for example, enhances such activity. Accordingly, we measured choline acetyltransferase (ChAT) activity in rat cortical synaptosomes in the presence of two inhaled convulsants, flurothyl (CF3CH2OCH2CF3) and 1,2-dichlorohexafluorocyclobutane at partial pressures below and greatly exceeding those which produce convulsions in vivo. Neither agent changed the kinetic parameters, maximum velocity (vmax) or Michaelis constant (Km). The vmax for controls in the flurothyl series was 016 (0.06) nmol mg-1 min-1 and the Km was 0.23 (0.11) mmol litre-1. For the 1,2-dichlorohexafluorocyclobutane series of experiments the results for the controls were vmax 0.23 (0.10) nmol mg-1 min-1 and Km 0.20 (0.08) mmol litre-1. Modification of ChAT activity did not contribute to the excitatory effects of these agents.

Three patients in whom difficult tracheal intubation was expected but awake fibreoptic intubation was not feasible presented for head and neck surgery. Anaesthesia was induced rapidly and smoothly by inhalation of sevoflurane followed by fibreoptic or conventional tracheal intubation.

A typical case of transient radicular irritation after spinal anaesthesia with 2% isobaric lignocaine is described. The definition and history of this syndrome and the implications of the use of pencil point needles with lignocaine for spinal anaesthesia are discussed.

We report a case of unsuspected difficult intubation in an adult caused by laryngeal web formation in the anterior commissure of the larynx. After induction of anaesthesia, most parts of the posterior commissure of the vocal cords were seen clearly at laryngoscopy, but a 7.5-mm internal diameter (id) tracheal tube could not be advanced below the level of the vocal cords because of resistance. Intubation was re-attempted several times after oxygenation by mask with trials of smaller tubes. Finally, a 5.0-mm id cuffed tube was passed successfully through the vocal cords, and secured in place. Because of the unexpected difficulties in intubation, an otolaryngologist was consulted to examine the larynx with a microscope. A web of 0.5 cm in the anterior commissures was found which caused subglottic stenosis.

The "I-NOvent delivery system" (Ohmeda Inc., Madison, WI, USA) is a device designed to add nitric oxide to a ventilator breathing system so that the inspired nitric oxide concentration remains constant in spite of changes in minute ventilation. In a laboratory study the device maintained the inspired nitric oxide concentration delivered to a model lung in the range 10.2-10.7 parts per million (ppm) when set to deliver 10 ppm, and in the range 40.5-42 ppm when set to deliver 40 ppm, for tidal volumes of 500, 700 and 900 ml, ventilator rates of 10, 15 and 20 bpm, peak inspiratory flow rates of 30, 40 and 50 litre min-1, and square, sine and decelerating ramp flow waveforms.

From its introduction in 1847, chloroform proved to be a potent anaesthetic agent and over the next 50 yr its use became widespread. However, in 1912 the Committee on Anaesthesia of the American Medical Association stated that they were concerned with the occurrence of delayed chloroform poisoning in a number of cases. This conclusion was based on case reports and experimental animal data. However, subsequent studies and reported series of chloroform anaesthesia in humans have suggested a lower incidence of clinically significant liver injury. In this article we have investigated this discrepancy by analysing the published clinical data relating chloroform anaesthesia to liver damage.

Epidemiological evidence has suggested that the declining prevalence of duodenal ulcer disease may be attributable to rising consumption of polyunsaturated fatty acids, a hypothesis supported by in vitro evidence of toxicity of such substances to Helicobacter pylori. The objective of the present study was to establish whether this association is causal. Forty patients with proven infection with H. pylori and endoscopic evidence of past or present duodenal ulcer disease were randomized to receive either polyunsaturated fatty acids (PUFA group), in the form of capsules and margarine, or a placebo (control). Both groups received concurrent H2 antagonist therapy. Efficacy of therapy was determined endoscopically by assessment of ulcer healing while H. pylori status was determined by antral biopsy, urease (EC 3.5.1.5) culture and histological assessment of the severity of H. pylori infection. Antral levels of prostaglandin E2 (PGE2) and leukotriene B4 (LTB4) were quantified. Compliance was monitored. Before treatment, both groups were comparable for severity of H. pylori infection, smoking status and levels of LTB4 and PGE2. Despite a significant difference in consumption of linoleic acid (19.9 (SE 1.6) g for PUFA group v. 6.7 (SE 0.8) g for controls (P < 0.01) and linolenic acid (2.6 (SE 0.2) g v. 0.6 (SE 0.03) g (P < 0.01) there was no significant change in either the severity of H. pylori infection or prostaglandin levels in either group at 6 weeks. Consumption of a considerable amount of PUFA does not inhibit the colonization of the stomach by H. pylori nor does this alter the inflammatory changes characteristic of H. pylori gastritis. We conclude that the association between duodenal ulceration and a low level of dietary PUFA is likely to be spurious, probably reflecting the effect of confounding factors such as affluence, social class or smoking.

Pregnancy in insulin-dependent diabetes mellitus is associated with a greater incidence of fetal abnormality. Animal studies suggest that increased free-radical production and antioxidant depletion may contribute to this risk. The aim of the present study was, therefore, to assess nutritional antioxidant status and lipid peroxidation in diabetic mothers in comparison with a control group. A 7 d dietary history and a food-frequency questionnaire were performed and venous blood collected for biochemical analyses from thirty-eight diabetic mothers and matched control subjects before 12 weeks gestation. Protein intake was significantly greater in diabetic patients (81.4 (SE 14.8) v. 72.7 (SE 15.8) g/d, P = 0.015), while total sugar intake was less (79.5 (SE 13.2) v. 104.8 (SE 28.8) g/d, P < 0.001). There were no significant differences in the intake of the major antioxidant vitamins (retinol, vitamin C or vitamin E) or beta-carotene. However, intakes of a number of other micronutrients (including Se, Zn, Mg, Mn, riboflavin, thiamin, niacin and folate) were greater in diabetic patients. Among the nutritional chain-breaking antioxidants, serum levels of alpha-tocopherol (21.6 (SE 5.7) v. 17.3 (SE 4.7) mumol/, P = 0.0013), beta-carotene (0.27 (SE 0.18) v. 0.14 (SE 0.11) mumol/l, P = 0.003) and lycopene (0.23 (SE 0.17) v. 0.16 (SE 0.13) mumol/l, P = 0.03) were greater in diabetic patients. There was no evidence of greater lipid peroxidation in diabetic patients, and total antioxidant capacity was similar in the two groups. Overall, these results indicate that nutritional antioxidant status is better in this group of diabetic mothers than in control pregnant non-diabetic subjects attending the same maternity hospital.

We suggested that food preference depends on the interplay between flavour and post-ingestive effects, and we predicted that protein-restricted lambs would acquire preferences for foods paired with supplemental sources of N, including urea (Expts 1 and 2), casein (Expt 3), and gluten (Expt 4). In each experiment, twenty lambs, in two groups of ten, were conditioned as follows: on odd-numbered days, lambs in group 1 received wheat straw (Expts 1, 3, and 4) or ground barley (Expt 2) flavoured with a distinctive flavour, and lambs in group 2 received the same food but with a different flavour. On even-numbered days, flavours were switched and lambs received capsules containing different amounts of urea (ranging from 0.12 to 0.92 g N/d), casein (ranging from 0.23 to 0.69 g N/d), or gluten (ranging from 0.23 to 0.69 g N/d). After conditioning period of 8 d, lambs were given a two-choice test to determine preference for flavours paired with N. In Expts 1 and 2, lambs preferred the flavours conditioned with urea at lower doses (0.12 g N/d in Expt 1, 0.23 and 0.46 g N/d in Expt 2), but they avoided the flavour associated with urea at the highest dose (0.23 g N/d in Expt 1 and 0.92 g N/d in Expt 2). In Expts 3 and 4, lambs avoided the flavours associated with the lowest doses of casein or gluten (0.23 g N/d), but they preferred the flavours paired with casein or gluten at higher doses (0.46 and 0.69 g N/d). After conditioning, N administrations were suspended and lambs in Expts 3 and 4 were offered a choice of the two flavours at weekly intervals for 2 weeks (extinction); preferences persisted during extinction. Collectively, these results suggest that the post-ingestive effects of N in different forms and concentrations influenced the development of food preferences by lambs.

Mechanistic rumen models of Baldwin (1995), Danfaer (1990) and Dijkstra et al. (1992) were compared on identical inputs that were derived from trials with lactating dairy cows fed on grass herbage. Consistent differences were detected between models and between predicted and observed outputs. None of the models seemed to predict all nutrient flows best. The models particularly differed in the representation of microbial metabolism: degradation of insoluble substrate, fermentation of substrate into volatile fatty acids, and incorporation of substrate into microbial matter. Differences amongst models in the prediction of these processes compensated for each other and consequently all models predicted the duodenal flow of non-NH3 N, microbial N and organic matter reasonably well. Large differences remained in the prediction of individual nutrient flows, however, and it was stressed that in order to enhance prediction of the profile of nutrient flows, the mechanisms of microbial metabolism need to be tested on their ability to describe the intraruminal transactions. However, this requires more-detailed information on individual nutrient flows and on the microbial or non-microbial origin of duodenal contents. Parameter inputs for physical and chemical feed properties were identified that are improperly defined in extant models or susceptible to error. The description of these feed characteristics needs to be developed further and become identifiable for a wide range of dietary conditions.

Three ruminally and duodenally cannulated non-lactating Finnish Ayrshire cows were used to investigate ruminal and intestinal digestion of cell-wall carbohydrates by a combined in situ method. Five grasses cut at 10 d intervals were incubated in the rumen for 0, 6, 12, 24, 48, 72 and 96 h, and the undegraded residues were exposed to intestinal digestion. With advancing maturity of grass both the rate and extent of cell-wall digestion decreased. At early stages of growth the decreases were faster for the rate of digestion and at late stages of growth for the extent of digestion. Applying a passage rate of 0.02/h in one compartmental rumen model resulted in digestibility values markedly lower than typically observed in vivo. However, applying a rumen model incorporating a selective retention of particles and time-dependent release of particles from the non-escapable pool resulted in much higher digestibility values. Recovery of lignin after 96 h ruminal incubation with a subsequent mobile-bag incubation was very low (from 244 to 460 mg/g). Intestinal disappearance of neutral-detergent fibre (NDF) and hemicellulose decreased with advancing maturity of grass and with increasing length of preceding ruminal incubation period, i.e. with decreasing potential digestibility of the material. Disappearance of hemicellulose was much greater than that of cellulose for intact grasses but the difference diminished with increasing length of preceding rumen incubation period. On average, 195 mg/g of potentially digestible NDF disappeared from the mobile bags in the intestines. The post-ruminal digestion as a proportion of the total NDF digestibility varied between 0.034 and 0.058. Despite methodological problems both in ruminal in situ and intestinal mobile bag techniques, these methods can be used to investigate ruminal and intestinal cell-wall digestion and to partition cell-wall digestibility between ruminal and post-ruminal digestion providing that appropriate rumen models are used.

The effects of acidogenic conditions, a high S level and the addition of thiamin on the rumen microbial metabolism of thiamin were investigated in vitro in a semi-continuous fermenter (RUSITEC), using a factorial design. Acidogenic conditions were obtained by simultaneously increasing the starch: cellulose ratio and the amount of solid substrate fed, and by decreasing the buffering capacity of the liquid phase of the fermenter. S in the form of sulfate was supplied at two levels, one corresponding to a control amount of S (2 g/kg dietary DM), the second to an excess (5 g/kg DM) which is sufficient to trigger cerebrocortical necrosis (CCN) when used in vivo. Acidogenic conditions decreased the pH of the fermenters, CH4 production and cellulose digestibility, increased the short-chain fatty acid production, but had no effect on thiamin production. The high S level enhanced the production of sulfide considerably, had no effect ont he microbial metabolism of energy and N, and decreased thiamin production (326 v. 266 nmol/d). The added thiamin was rapidly converted into phosphorylated compounds which largely decreased the apparent synthesis of this vitamin by the rumen microflora. The total thiamin flow was increased by added thiamin. In no case was thiaminase activity in the fermenter liquid phase significantly modified. The high level of S induced only a limited decrease of total thiamin flow. Consequently, it is unlikely that the investigated factors could be considered to be high risk factors for the thiamin-dependent CCN.

The effects of L-carnitine supplementation (50-500 mg/kg diet) of a practical layer diet, based on maize, soyabean and wheat, on the performance of laying hens and some indices of egg quality were studied for 8 weeks, using 65-week-old hens kept in cages. Albumen quality (albumen height and Haugh (1937) unit score) was improved, while yolk index and yolk colour score were not affected by dietary L-carnitine. The percentage of egg-white increased and that of egg yolk decreased in response to dietary supplementation of L-carnitine. Dietary L-carnitine did not influence laying performance (egg production rate, mean egg weight, daily feed intake, daily egg mas and feed conversion) or external egg quality measured by egg weight, egg-shape index or by eggshell quality, either measured directly as shell breaking strength or indirectly as shell weight, shell thickness or shell weight per unit surface area. Based on the results of the present study, L-carnitine had a beneficial effect on albumen quality and could modify the components of the edible part of the egg, during the late laying period.

The effects of a soluble NSP (fibre) concentrate (SFC) on plasma fibrinogen and plasminogen activator inhibitor-1 (PAI-1), serum and liver lipids and lipoproteins and glucose tolerance were compared with those of bezafibrate (BF), a lipid-lowering drug, in obese baboons (Papio ursinus). The basal diet was a high-fat (37% of total energy), low-NSP (12.4 g/d) Westernized diet, supplemented for 8 weeks with either 20 SFCg/baboon per d or 6.7 mg BF/kg body weight per baboon per d. SFC supplementation significantly lowered PAI-1, total serum cholesterol, HDL-cholesterol and circulating free fatty acid levels. BF significantly lowered total serum cholesterol, but unexpectedly raised serum triacylglycerol levels. Although not statistically significant, the mean liver triacylglycerol concentration of baboons fed on BP was lower than that of baboons fed on SFC supplements. These results suggest that: (1) the mechanism of action of the two cholesterol-lowering treatments differ, with BF having a liver triacylglycerol-lowering effect and (2) the SFC ahd additional beneficial effect on fibrinolysis by lowering PAI-1 levels.

Non-physiological amounts of oral polyamines have been reported to induce precocious gut maturation in rat pups. The aim of the present study was to investigate organ distribution and metabolic fate of orally administered stable-isotopically labelled polyamines in rat pups. Pups received tetradeuterium-labelled putrescine (Pu-d4; 3 mumol), spermidine (Sd-d4; 5 mumol), spermine (Sp-d4; 3 mumol), or physiological saline twice daily on postnatal days 7-10 or 12-15. They were killed on days 10 and 15. We determined activities of ileal lactase (EC 3.2.1.23), maltase (EC 3.2.1.20), sucrase (EC 3.2.1.48) and diamine oxidase (EC 1.4.3.6) and established villus and crypt lengths. Polyamines and their labelling percentages in organs were determined by GC and mass fragmentography. Treatments did not affect growth rate, but caused lower weights of liver, kidneys and heart. Maltase activity increased, lactase decreased, whereas sucrase and diamine oxidase did not change. Villus and crypt lengths increased. Organ polyamine pools were labelled to different extents. Irrespective of the orally administered polyamine, all organs contained Pu-d4, SD-d4 and Sp-d4. Administered Pu-d4 and Sd-d4 were recovered mainly as Sd-d4, whereas Sp-d4 was recovered as Sp-d4 and Sd-d4. Total polyamines in a caecum, colon and erythrocytes increased, but increases were only to a minor extent with regard to labelled polyamines. Our data confirm precocious gut maturation by exogenous polyamines. Putrescine appears to be limiting factor. The exogenous polyamines were distributed among all investigated organs. They are not only used for the synthesis of higher polyamines, but also retroconverted to their precursors. Changes in erythrocyte polyamine contents suggest precocious stimulation of erythropoiesis.

Weanling Wistar rats were fed on diets prepared from grain from areas deficient in I and Se where Keshan disease in endemic. Rats were divided into four groups, each of twelve rats, and received a diet supplemented with: I, Se, I + Se or nothing. At 8 weeks after weaning, myocardial alpha-glycerophosphate dehydrogenase (EC 1.1.1.8; alpha-GPD) activity and indices of Se and thyroid hormone status were determined. The group supplemented with iodine had increased plasma thyroxine levels. There was no difference in plasma triiodothyronine concentration between the groups but triiodothyronine levels in heart were reduced in the Se-supplemented group. Se supplementation increased myocardial glutathione peroxidase activity (EC 1.11.1.9) and the type I 5'-deiodinase (EC 3.8.1.4) activity in rat liver, but no type I 5'-deiodinase activity was detected in heart. alpha-GDP activity in heart was increased in group supplemented with Se, I or both. There was a significant relationship (P < 0.05) between myocardial alpha-GDP activity and plasma thyroxine levels but not between alpha-GDP and myocardial glutathione peroxidase activity. The results indicate that iodine may be more important than Se in energy metabolism in the myocardium, which may give a new insight for the study of the aetiology of Keshan disease in areas where foodstuffs are deficient in both Se and I.

A thyroid-hormonal evaluation of thirty-five women consuming commercially packed milk containing thiocyanate was carried out. The mean serum thiocyanate concentration, which was measured by the FeCl3 colour test, was significantly higher (P < 0.01) than that of control subjects. Serum thyroxine (T4), triiodothyronine (T3) and thyroid-stimulating hormone (TSH) concentrations of exposed women were compared with those of thirty-five control subjects. Thiocyanate ingestion was associated with lower levels of T4 (P < 0.01) and higher levels of TSH (P < 0.01) compared with the control subjects. T3 was found to be higher in the women consuming thiocyanate-containing milk but the difference was not significant. The serum T4 level was found to be negatively correlated (r -0.359, P < 0.05) while the TSH level was positively correlated (r 0.354, P < 0.05) with thiocyanate concentration in the exposed group. From this study, it appears that ingestion of milk with added thiocyanate impairs thyroid function.

Free-living energy expenditure was estimated by doubly-labelled water (DLW) and continuous heart-rate (HR) monitoring over nine consecutive days in nine healthy men with sedentary occupations but different levels of leisure-time physical activity. Individual calibrations of the HR-energy expenditure (EE) relationship were obtained for each subject using 30 min average values of HR and EE obtained during 24 h whole-body calorimetry with a defined exercise protocol, and additional data points for individual leisure activities measured with an Oxylog portable O2 consumption meter. The HR data were processed to remove spurious values and insert missing data before the calculation of EE from second-order polynomial equations relating EE to HR. After data processing, the HR-derived EE for this group of subjects was on average 0.8 (SEM 0.6) MJ/d, or 6.0 (SEM 4.2) % higher than that estimated by DLW. The diary-respirometer method, used over the same 9 d, gave values which were 1.9 (SEM 0.7) MJ/d, or -12.1 (SEM 4.0) % lower than the DLW method. The results suggest that HR monitoring can provide a better estimate of 24 h EE of groups than the diary-respirometer method, but show that both methods can introduce errors of 20% or more in individuals.

In a double-blind, placebo-controlled study, thirty-three subjects were allocated to undergo either a 4-week treatment with oral Mg supplementation (Mg(OH)2; 411-548 mg Mg/d) or a placebo. The urinary excretion of Mg increased significantly in both the first 2 weeks and the following 2 weeks of Mg supplementation, while the urinary Na excretion also increased significantly over the experimental period. The systolic and diastolic blood pressure values decreased significantly in the Mg group, but not in the placebo group. The urinary aldosterone excretion and packed cell volume increased significantly during the last 2 weeks of the experimental period compared with the run-in period and first 2 weeks of supplementation. There was a statistically significant positive correlation between the values for urinary noradrenaline excretion and diastolic blood pressure at the end of the supplementation period (both expressed as a percentage of the run-in value). Statistically significant increases in lecithin-cholesterol acyltransferase (EC 2.3.1.43; LCAT), HDL-cholesterol and apolipoprotein AI were also observed after Mg supplementation. A significant positive correlation was observed between the levels of LCAT and urinary Mg excretion for the experimental period (expressed as a percentage of the run-in value). The total cholesterol:HDL-cholesterol ratio decreased significantly during the last 2 weeks of Mg supplementation compared with the first 2 weeks and the run-in periods, but this did not occur in the placebo group. These results suggest that Mg supplementation may lower blood pressure through the suppression of the adrenergic activity and possible natriuresis, while also improving the serum lipids through the activation of LCAT in human subjects.

It has been suggested that decreased immune responsiveness in the elderly may be counteracted by the antioxidant vitamin E. In a 3-month double-blind placebo-controlled intervention trial among elderly subjects aged 65 years and over we studied the effects of a daily dose of 100 mg dl-alpha-tocopheryl acetate on the cellular immune responsiveness (n 52) measured by the in vitro response of peripheral blood mononuclear cells (PBMC) to the mitogens concanavalin A (ConA) and phytohaemagglutinin (PHA). Also effects on the humoral immune responsiveness (n 74) were investigated by measuring immunoglobulin (Ig)G, IgG4 and IgA antibody concentrations against various common antigens. In the vitamin E group plasma alpha-tocopherol increased by 51% (P = 0.0001) during intervention whereas no significant changes were observed in the control group. Initial proliferative PBMC responses differed between the vitamin E group and the control group whereas all other baseline characteristics were comparable. No significant changes were observed in cellular immune responsiveness when adjusted for initial values in either the control group or the vitamin E group and, after the trial period, responses in the two groups were not significantly different. Similarly, in the vitamin E group no significant changes were found in levels of IgG and IgA raised against Penicillium or IgG4 raised against egg, milk, or wheat proteins. In the control group small but significant increases in IgG anti-Penicillium (P < 0.05) and decreases in IgG4 against milk proteins (P < 0.05) were observed. Thus, the results of this study performed with the relatively low dose of 100 mg dl-alpha-tocopheryl acetate do not support the claims of a beneficial effect of vitamin E intake on the overall immune responsiveness of elderly subjects.

Granulated polyamide (PA) was tested for use as an external marker to estimate faecal DM (FDM) excretion of Zebu cattle (Bos indicus). The study was conducted in Mali, using seven and eighteen animals respectively in four field trials and six indoor experiments. Cattle ate fresh or dry pasture vegetation and half the animals were additionally supplemented with crop byproducts. Gelatine capsules containing 35, 40 or 45 g PA were administered orally at 12 h intervals. Estimates of FDM were based on the average marker concentration in faeces and were correlated with the actual excretion measured by total faecal collection. The pre-measurement period required to establish equilibrium for regular marker dosing was determined at 4 d. Except for diets with a N content of less than 9.26 g/kg organic matter, marker recovery averaged 98.1 (SE 0.93)% (n 62), and was not influenced by diet composition and the quantity of feed ingested (P > 0.05). Estimates of FDM based on average PA concentrations in faecal samples were correlated to the actual excretion with r 0.98 (n 62; P < or = 0.001). Since the PA concentration in individual faecal grab-samples is not correlated with either sample mass or sampling time, accurate estimates of FDM require a grab-sampling schedule that covers the 24 h day. However, estimates of FDM were found to be acceptable if calculations are based on the average PA concentration in the sub-total of samples collected during the day or during night respectively (r 0.95, n 29; P < or = 0.001 in both cases). It is concluded that the use of PA marker is a simple and inexpensive method resulting in reliable estimates of FDM. Since sophisticated analytical procedures are not required to recover PA in faecal samples, the marker is particularly suitable for application in extensive grazing systems and in studies conducted in less-developed countries.

The metabolic effects of a phlorizin-induced drainage of glucose were studied in six lactating ewes with or without peroral alanine drenches in a study of crossover design. Phlorizin gave rise to a small, but significant, elevation of plasma beta-hydroxybutyrate. The plasma level of alanine decreased by about 30% due to the phlorizin injections and alanine was negatively correlated to beta-hydroxybutyrate. The plasma level of free fatty acids increased due to phlorizin. Plasma insulin and glucose concentrations were not significantly affected by phlorizin while glucagon level showed a small but significant increase. Peroral alanine drenches to phlorizin-treated ewes gave rise to a transitory elevation of alanine in plasma. The plasma level of free fatty acids was about 40% lower in phlorizin-treated ewes receiving alanine and beta-hydroxybutyrate tended to be lower (P < 0.08). We suggest that beta-hydroxybutyrate, apart from its function as an oxidative fuel, might play an important role by limiting glucose oxidation and protein degradation in skeletal muscles during periods of negative energy balance in ruminants. Furthermore, it is suggested that alanine supplementation decreases lipolysis and ketogenesis in lactating ewes.

The present experiments were conducted to investigate influences of dietary methionine and cysteine on metabolic responses to immunological stress induced by Escherichia coli lipopolysaccharide (LPS) injection, and concanavalin A (Con A)-induced mononuclear cell (MNC) proliferation in male broiler chickens. In Expt 1, chicks (12 d of age) were fed on a S amino acid (SAA)-deficient diet (5.6 g SAA/kg diet) or on three kinds of SAA-sufficient diet (9.3 g SAA/kg diet; low-, medium- and high-cysteine diets) which contained 2.8, 4.65 and 6.5 g cysteine/kg diet, respectively. Plasma alpha-1 acid glycoprotein (AGP) concentration and interleukin (IL)-1-like activity in chicks fed on the SAA-deficient diet were lower following a single injection of LPS than those in chicks fed on the SAA-sufficient diets. At 16 h after LPS injection, plasma Fe and Zn concentrations and body weight were reduced, but AGP concentration and IL-1-like activity in plasma were significantly increased. These changes in body weight, plasma Zn and Fe concentrations following injection of LPS were not affected by dietary methionine: cysteine ratios. Plasma AGP concentration and IL-1-like activity in chicks fed on the high-cysteine diet were, however, greater than those in chicks fed on the other diets following a single injection of LPS. In Expt 2, chicks (7 d of age) were fed on the SAA-sufficient diets as in Expt 1 for 10 d. MNC proliferation in spleen induced by Con A in chicks fed on the high-cysteine diet was greater than that in chicks fed on the low- or medium-cysteine diet. The results suggest that dietary cysteine has an impact on the immune and inflammatory responses.

To study the fate of L-cysteine and amino acid homeostasis in liver after the inhibition of the trans-sulfuration pathway, rats were treated with propargylglycine (PPG). At 4 h after the administration of PPG, liver cystathionase (EC 4.4.1.1) activity was undetectable, L-cystathionine levels were significantly higher, L-cysteine was unchanged and GSH concentration was significantly lower than values found in livers from control rats injected intraperitoneally with 0.15 M-NaCl. The hepatic levels of amino acids that are intermediates of the urea cycle, L-ornithine, L-citrulline and L-arginine and blood urea were significantly greater. Ura excretion was also higher in PPG-treated rats when compared with control rats. These data suggest a stimulation of ureagenesis in PPG-treated rats. The inhibition of gamma-cystathionase was reflected in the blood levels of amino acids, because the L-methionine: L-cyst(e)ine ratio was significantly higher in PPG-treated rats than in control rats; blood concentration of cystathionine was also greater. Histological examination of liver and kidney showed no changes in PPG-treated rats when compared with controls. The administration of N-acetylcysteine (NAC) to PPG-treated rats reversed the changes in blood urea and in liver GSH. These data suggest that when liver L-cysteine production was impaired by the blockage of the trans-sulfuration pathway, the concentration of this amino acid was maintained mainly by an increase in protein degradation and by a depletion in GSH concentration that may spare L-cysteine.

Wistar rats fed on either a high-protein or a protein-free diet were examined to determine their pancreatic hydrolase mRNA stabilities in comparison with those of control animals receiving a standard diet. Actinomycin D was used to inhibit transcription and, after isolating the pancreatic RNA, the specific messengers were quantified by performing dot-blot hybridization with cDNA probes. In the rats fed on a high-protein diet, only the half-lives of anionic trypsinogen I and elastase I (EC 3.4.21.36) were affected. Interestingly, when rats were fed on the protein-free diet, most of the hydrolase mRNA half-lives showed changes, except that corresponding to lipase. In these rats, the half-life values of the mRNA coding for anionic trypsinogen I, chymotrypsinogen and procarboxypeptidase B increased, in sharp contrast with those of the amylase and elastase I mRNA, which decreased. These results strongly suggest that the mechanism whereby the biosynthesis of pancreatic hydrolases is regulated, depending on the presence or absence of proteins in the diet, is not unique and provide evidence that the stability of mRNA encoding most, if not all, the hydrolases in pancreatic cells is modulated by the dietary protein content.

Rodents fed on a Mg-deficient (Mg-D) diet develop cardiomyopathic lesions, as well as other types of cardiovascular dysfunction. In the rat, inflammatory cell infiltration of the myocardium begins to occur by week 1, and the lesions develop extensively in the third and fourth weeks on the Mg-D diet. Although the aetiologic mechanisms of Mg-D cardiomyopathy are unknown, we have previously reported that once plasma Mg is markedly reduced, one of the earliest molecular markers of the pathophysiological process is elevation of plasma substance P, calcitonin gene-related peptide and prostaglandin E2, followed by histamine and the inflammatory cytokines (interleukin-1, interleukin-6, and tumor necrosis factor-alpha). In order to evaluate the potential role of specific circulating inflammatory cell subpopulations in the mechanisms underlying pathophysiological changes observed in Mg-deficiency-induced cardiomyopathy, we analysed these cells by flow cytochemistry. Leucocyte subpopulation pools increased progressively in the Mg-D rats. Elevated circulating levels of neutrophils and lymphocytes appeared to contribute to both the acute (week 1-2) and chronic phases (week 3-4) of the inflammatory responses; monocytes, eosinophils, basophils and large unstained cells which are lymphoid in stained smears, on the other hand, increased significantly in the third and fourth weeks and thus contributed to the chronic inflammatory phase. Changes in the circulating leucocyte subpopulations paralleled the chronological progression of the cardiomyopathic lesions, particularly in weeks 3 and 4. Since a pronounced neutrophilia preceded leucocyte infiltration and deposition within the myocardial tissue, modifications of the microvascular barrier may be a prerequisite for cardiomyopathy in this model of neurogenic inflammation.

Conflicting results have been reported on the association between breast cancer risk and symptoms of luteal insufficiency, such as irregular or prolonged menstrual cycles and difficulty in becoming pregnant. Studies on the association between breast cancer risk and hormonal markers of impaired ovulation have also yielded conflicting results. Inadequate allowance for body mass and fat distribution may lead to inconsistent results when assessing the association between luteal insufficiency in premenopausal women and breast cancer risk. Ovulatory function is impaired by obesity, especially if it is predominantly abdominal in distribution. The Western diet and lifestyle favour early manifestation of hyperinsulinaemic insulin resistance in genetically-predisposed women. It is commonly associated with obesity which is predominantly abdominal in distribution. In a subset of premenopausal women, the concomitants of hyperinsulinaemia may impair maturation of ovarian follicles by a direct effect of insulin or insulin-like growth factors on ovarian tissue. Even when women are ovulating regularly, obesity may be associated with luteal insufficiency as shown by decreased levels of progestins or other changes in the sex steroid profile. Insulin resistance is likely to be involved and might explain the weak reduction in breast cancer risk associated with overweight in premenopausal Western women, in contrast with the increased risk widely reported in obese post menopausal women.

The Gastrointestinal Tract Cancer Liaison Office (GITCLO) was developed in an attempt to organise the increasing body of clinical research in gastrointestinal tumours in Europe. This paper represents an analysis, by tumour localisation, of the trials collected for the second edition of the GITCLO booklet. The list of cooperative groups, chairmen and study coordinators is given with their respective telephone and telefax numbers. A total of 84 trials were collected, conducted by 46 co-operative groups in 14 countries. For each organ and stage of disease, a summary of concepts investigated is given with the references of the study co-ordinator. Obviously, too many questions are raised at the same time. In colorectal cancer, for example, a total of 41 trials exploring 22 concepts are currently open for patients' registration. We hope that the present attempt to clarify the situation of clinical research in the field of gastrointestinal cancers in Europe will speed up therapeutic progress in the best interest of the patients.

The addition of hyperthermia (HT) to regional isolated perfusion (RIP) with Melphalan theoretically has two advantages. Firstly, heat can selectively kill cells in poorly vascularised areas that are usually not reached by the drug. Secondly, in vitro data have revealed that the effect of Melphalan is enhanced at temperatures 39-45 degrees C. However, for the simultaneous application of Melphalan and HT, as it is given in most institutes, both normal and tumour tissues within the volume are treated with both modalities. It is unclear whether--for the same heat dose--the cytotoxicity of Melphalan is enhanced more in tumour tissue than in normal tissues. As the applied dose of Melphalan in RIP is selected on maximum acceptable toxicity, any enhancement of toxicity is undesired. Indeed, Melphalan application at temperatures > 41 degrees C has resulted in unacceptable toxicity. In most institutes, the hyperthermia dose is reduced in comparison to application as a single-modality treatment, to allow simultaneous combination without unacceptable toxicity. In this review, the rationale for two different approaches is summarised which may make it possible to improve the benefit from the theoretical advantage of the use of HT in RIP. It is meant to stimulate discussion as a possible first step in the design of new treatment protocols.

The purpose of this study was to evaluate tumour response and toxicity to ifosfamide and continuous infusion etoposide in metastatic or locally advanced soft tissue sarcoma, with dose escalations under G-CSF (granulocyte colony-stimulating factor) support. Of 92 eligible patients (median age 51 years), 85% had tumours of high-grade malignancy and 82% had metastatic disease. Chemotherapy, the baseline dose, consisted of etoposide 600 mg/m2 as a 72 h infusion and ifosfamide 1500 mg/ m2/day for 3 days, followed by G-CSF support (VIG regimen). Stepwise 10% dose escalations were performed depending on haematological toxicity. For patients considered operable after induction chemotherapy, surgical resection of all identifiable residual tumour was attempted. Complete and partial response rates were 11% and 31%, for an overall response rate of 42% (95% CI 31-52%). Forty-eight per cent of courses were dose escalated by a median of 20%. Complete responders had significantly higher, and patients with progressive disease had significantly lower, dose levels than other patients. None of 20 patients with liver metastases responded despite high dose levels. Compared to a preceding pilot study, the addition of G-CSF led to significantly higher dose levels, improved schedule adherence and less haematological toxicity, but no apparent increase in response rate. In view of the modest dose of ifosfamide applied in this study, it is possible that the prolonged infusion of etoposide made a significant contribution to the regimen's antitumour activity, although this can only be determined definitively in a randomised study.

The optimal treatment of ductal carcinoma in situ (DCIS) of the breast has not yet been established. The effectiveness of adjuvant postoperative radiotherapy after conservative surgery is debated. Few data are available in Italy on the combined treatment. A collaborative multi-institutional study on this issue in 10 radiation oncology departments of the north-east of Italy was conducted. One hundred and thirty nine women with DCIS of the breast were treated between 1980 and 1990. Age ranged between 28 and 88 years (median 50 years). Surgical procedures were: quadrantectomy in 108, lumpectomy in 22 and wide excision in 9 cases. The axilla was surgically staged in 97 cases: all the patients were node-negative. Radiation therapy was delivered with 60Co units (78%) or 6 MV linear accelerators (22%) for a median total dose to the entire breast of 50 Gy (mean 49.48 Gy; range 45-60 Gy). The tumour bed was boosted in 109 cases (78%) at a dose of 4-30 Gy (median 10 Gy) for a minimum tumour dose of 58 Gy. Median follow-up was 81 months. Thirteen local recurrences were recorded, 7 intraductal and 6 invasive. All recurrent patients had a salvage mastectomy and are alive and free of disease. Actuarial overall, cause-specific and recurrence-free survival at 10 years are of 93%, 100% and 86%, respectively. The results of this retrospective multicentric study substantiate the favourable data reported in the literature and confirm the efficacy of the breast-conserving treatment of DCIS employing conservative surgery and adjuvant radiation therapy.

The aim of this study was to examine the prevalence and clinicopathological significance of K-RAS oncogene activation in endometrial carcinoma and atypical hyperplasia. We analysed K-RAS point mutation and gene amplification in 55 endometrial carcinomas using polymerase chain reaction associated with restriction fragment length polymorphism and genomic differential polymerase chain reaction. Point mutations at codon 12 of K-RAS oncogene were identified in 8 of 55 (14.5%) tumour specimens. In addition, we were unable to detect any K-RAS gene amplification in any of the endometrial carcinomas studied. No correlation was found between K-RAS gene mutation and age at onset, histological subtype, grade of differentiation, clinical stage or current patient status. We conclude that K-RAS mutation is a relatively common event in endometrial carcinomas, but with no clear prognostic value.

One hundred and fourteen patients with painful bone metastases participated in this randomised, dose-controlled study of the efficacy and safety of 153Sm-ethylenediaminetetramethylenephosphonate (EDTMP), a systemically administered radiopharmaceutical. Fifty-five patients received single doses of 0.5 mCi/kg and 59 patients received single doses of 1.0 mCi/kg. Treatment with 153-Sm-EDTMP produced improvement from baseline in all patient-rated efficacy assessments, including degree of pain, level of daytime discomfort, quality of sleep and pain relief. During the first 4 weeks after dose administration, when the patients evaluated efficacy daily, there were statistically significant changes from baseline with the 1.0 mCi/kg dose but not with the 0.5 mCi/kg dose. The difference between doses in visual analogue pain scores was statistically significant at week 4 (P = 0.0476). Among subsets of patients examined, female patients with breast cancer receiving 1.0 mCi/kg had the most noticeable improvement. The physicians judged that approximately half of the patients in each dose group were experiencing some degree of pain relief by week 2. This value increased to 55% for the 0.5 mCi/kg group and 70% for the 1.0 mCi/kg group at week 4. More patients in the higher dose group (54%) than in the lower dose group (44%) completed the 16-week study. A predictable level of dose-related marrow suppression was the only toxicity associated with 153Sm-EDTMP treatment. Values for platelets and WBCs reached nadirs at 3 or 4 weeks with both doses and recovered by 8 weeks. Even at their lowest point, the values were generally higher than those associated with infectious or haemorrhagic complications. Myelotoxicity was no greater in female patients than in male patients. Long-term follow-up revealed longer survival among breast cancer patients who had received the higher dose than among those who had received the lower dose. The results suggest that the 1.0 mCi/kg dose of 153Sm-EDTMP is safe and effective for the treatment of painful bone metastases.

A prospective study of a series of 77 patients on adjuvant radiochemotherapy following surgery for high-grade gliomas was conducted to evaluate the risk of deep vein thrombosis and identify risk factors. We found a 20.8% risk of deep vein thrombosis at 12 months (standard error = 4.8%) and a 31.7% risk (standard error = 7.4%) at 24 months (Kaplan-Meier method). Twenty patients (26%) developed deep vein thrombosis with a maximum incidence within the first 7 months after surgery when chemotherapy was still being administered, often with corticosteroids. The risk factors identified were histology (glioblastoma versus anaplastic astrocytoma, P = 0.032, log rank test; 0.0485 L-ratio) and the presence of paresis (P = 0.010, log rank test; 0.0161 L-ratio). A borderline tendency was found for an association between the deep vein thrombosis site and the side of paresis (P = 0.103, Fisher's exact test). Four patients (5%) had massive pulmonary embolism, which was fatal in 3 (4%).

The aim of this study was to investigate the prevalence of anxiety and depression in cancer patients seen at the Norwegian Radium Hospital, using the Hospital Anxiety and Depression Scale (HADS), the EORTC QLQ-C33 and an ad hoc designed questionnaire. In addition, information about the patients' malignant disease and treatment was obtained. The prevalence of anxiety and depression among 716 evaluable patients was 13% and 9% respectively, as assessed with HADS. In hospitalised patients, the risk of psychiatric distress was approximately twice that of patients in the outpatient clinic. Female patients reported significantly more anxiety than men. Patients < 30 or > 70 years old expressed less anxiety than all other patients. Age or gender had no influence on the occurrence of depression. Impaired ability to continue professional work and/or daily life activities, impaired social life and previous psychiatric problems were significantly correlated with anxiety and depression as were impaired physical function, fatigue and pain. The prevalence of depression, but not anxiety, increased in the presence of distant metastases, with less than a month since diagnosis, and with relapse or progression. In the logistic regression analysis, a history of previous psychiatric problems and impaired social life were correlated with both anxiety and depression. Female gender, impaired physical activity and impaired social role function were additional predictive parameters for anxiety, whereas fatigue predicted depression. Careful attention should be paid to cancer patients displaying these problems in order to diagnose and treat depression and anxiety disorders.

The efficacies of granisetron plus dexamethasone and granisetron alone in controlling nausea and vomiting during two consecutive cycles of moderately emetogenic chemotherapy given for up to 5 days were compared in a two-centre, randomised, double-blind, placebo-controlled crossover study. In all, 110 evaluable patients received either dexamethasone, 20 mg i.v., or matching placebo, plus open-label granisetron, 3 mg i.v., given on each chemotherapy day. At cycle 2, patients crossed over to the alternative treatment; 72 patients completed the crossover. In these 72 patients, the complete response rates over 24 h for granisetron plus dexamethasone and granisetron plus placebo in cycle 1 were 87% and 70% (ns), respectively. In cycle 2 the complete response rates over 24 h were 73% and 62% (ns). Combining the two cycles, the complete response rates over 24 h were 80.6% (granisetron plus dexamethasone) and 65.3% (granisetron plus placebo; P = 0.015). Granisetron plus dexamethasone was significantly more effective in terms of times to less than complete response (P = 0.041), to first episode of moderate/severe nausea (P = 0.04), to first episode of vomiting (0.03) and to use of rescue medication (P = 0.02). Adverse events tended to be minor, with asthenia and insomnia the most common. Of those patients who expressed a preference, 67% preferred granisetron plus dexamethasone (P < 0.05). A single dose of dexamethasone added to granisetron thus enhances the efficacy of granisetron alone in preventing nausea and vomiting after moderately emetogenic chemotherapy.

The aim of this study was to evaluate the feasibility, toxicity and efficacy of escalating doses of subcutaneous recombinant interleukin-6 (IL-6) in children with solid tumours in relapse. Recombinant IL-6 was administered subcutaneously once daily for 14 consecutive days, with a 14 day follow-up period. The starting dose for IL-6 was 1 microgram/kg/day and was escalated in subsequent patients groups until 10 micrograms/kg. Doses were escalated every 3 patients, provided that grade III or IV organ toxicity did not occur at the preceding dose level. Twelve patients were treated, three at each dose level. No grade 3-4 major organ toxicity was observed. Flu-like symptoms and fatigue were the most common side effects. All these symptoms resolved after the end of IL-6 administration. Significant increases in acute-phase proteins (CRP [C reactive protein], fibrinogen) and ESR (Erthrocyte sedimentation rate) were observed in all patients. Stimulatory effects on thrombocytopoiesis were observed at every dose level, and were maximal at 5 micrograms/kg and 10 microgram/kg. There was no tumour response observed during IL-6 administration. Pharmacokinetic profiles performed in 3 patients are consistent with previous reports in adults. IL-6 is a promising new cytokine for paediatric oncology, in particular to increase thrombocyte counts. We recommend that further studies in children proceed at a dose of 5-10 micrograms/kg/day in a once or, better, twice daily administration.

Gain of chromosome arm 17q has recently been reported in neuroblastoma tumours. We analysed 17q status in relation to other known prognostic features and clinical outcome in a series of 45 tumours. Chromosome 17 status was detected by cytogenetic analysis, fluorescence in situ hybridisation (FISH) anc comparative genomic hybridisation (CGH) and correlated with other clinical and genetic factors. Survival analysis was calculated by the Kaplan-Meier estimation. Twenty-eight out of 45 tumours showed 17q gain, and this was associated with established indicators of poor prognosis; stage 4 disease (P < 0.001), age above 1 year at diagnosis (P < 0.001), 1p deletion (P < 0.01), MYCN amplification (P = 0.03) and diploidy/tetraploidy (P = 0.04). 17q gain was associated with poor outcome: 3-year survival was 13.5% compared with 100% for tumours without 17q gain (P = 0.0001); and progression-free survival (PFS) was 8.1% after 3 years compared with 83% for 17q normal tumours (P = 0.0001). PFS in 28 MYCN non-amplified patients indicated that 17q status has discriminatory power within this group: PFS 0% for 17q gain (n = 14) versus 100% for normal 17q (n = 14) (P = 0.0001). This study indicates that 17q changes have prognostic significance in neuroblastoma and should be a target for molecular cytogenetic detection at diagnosis.

To investigate the role of selected medical conditions on the risk of ovarian cancer, we analysed data from a case-control study. Cases were 971 women below the age of 75 years with histologically confirmed epithelial ovarian cancer, admitted to a network of hospitals including the major teaching and general hospitals in the greater Milan area. Controls were 2758 women admitted to the same network of hospitals for acute, non-gynaecological, non-hormone related, non-neoplastic conditions. Obesity/severe overweight were inversely associated with the risk of ovarian cancer (multivariate relative risk, RR, 0.66, 95% confidence interval, CI, 0.52-0.85). Hyperlipidaemia was also inversely related to ovarian cancer risk, (RR 0.64, 95% CI 0.45-0.89). No relationship emerged between ovarian cancer risk and diabetes (RR 0.80, 95% CI 0.54-1.19), hypertension (RR 0.85, 95% CI 0.68-1.06), thyroid diseases (RR 0.89, 95% CI 0.63-1.13) and cholelithiasis (RR 0.86, 95% CI 0.66-1.12). A decreased frequency of ovarian cancer was seen in women with a history of uterine leiomyomas (RR 0.66, 95% CI 0.47-0.92) and benign ovarian cysts (RR 0.69, 95% CI 0.41-1.13).

Between 1973 and 1993, 529 patients aged 15 years and over with Hodgkin's disease (HD) were entered into a lymphoma registry. Twenty-eight cases (1 only diagnosed at autopsy) of histologically proven HD in patients aged 70 years or older were identified. The distribution of sex, 'B' symptoms, histology and stage was not significantly different from that of younger patients, except for the fact that there were no patients aged 70 years or older with lymphocyte predominant HD. Nineteen patients were treated radically, 5 patients palliatively and 4 patients received no radiotherapy or chemotherapy. Three of the 14 patients treated with chemotherapy achieved the planned dose intensity. The cause-specific 5-year survival was 75% for patients aged 15-69 years and 28% for patients aged 70 years and over (logrank chi(2) = 43.7, P < 0.00001). The younger and older groups treated with radical intent had complete response rates of 97% and 74%, respectively (logrank chi(2) = 17.91, P < 0.00001) and relapse rates at 5 years of 27% and 56%, respectively (logrank chi(2) = 4.86, P = 0.0275). The main reason for the poorer prognosis of patients aged 70 years and over was the increasing difficulty of chemotherapy delivery associated with advancing age.

Shifts in histological tumour type distribution, chiefly an increase in adenocarcinoma, have been reported to accompany changes in lung cancer incidence in the last two decades in the United States and several other developed countries. To elucidate this phenomenon further, we analysed population-based lung cancer incidence rates in the period 1976-1992 from the Varese province, an area with 788,000 inhabitants in Northern Italy. Rates were age-standardised on the world standard population. Overall, lung cancer had stopped increasing in males since the late 1980s, and had started declining in middle-aged men. Conversely, upward trends persisted in females up to 1991-1992. Although it decreased from 13 to 9, the male-to-female incidence ratio was, in 1991-1992 still substantially higher than in the U.S. and North Europe. Specific trends emerged according to histological type(s), with declines (males) or stabilisation (females) for squamous-cell carcinoma and gradual increases for small-cell carcinoma in males. Adenocarcinoma was the only lung cancer type whose incidence rates increased similarly (2.5-fold) in males and females thus approaching, in 1991-1992, in the two sexes combined, the rate for squamous-cell carcinoma. Although advances in diagnostic techniques may have played a role, the absolute and relative increases in the adenocarcinoma rate reflect changes in cigarette manufacture (i.e. spread of filter tips and low-nicotine low-tar cigarettes) and the decrease in smokers.

We have previously demonstrated lysis of non-established cultures of human mammary carcinoma cells by parvovirus H-1, which has little effect on the proliferation of corresponding normal cultures. In the present study, we examined this effect in a number of breast-tumour specimens and found them to differ as to the amplitude of their response to parvoviral attack. We first investigated whether the differences in cell sensitivity to parvovirus infection reflected the differentiation level of the initial tumour. Among the biochemical and anatomopathological indicators of original tumour differentiation, the presence of oestrogenic receptors (ER) was found to have a predictive value as to the sensitivity of derived cultures to the cytopathic effect of H-1 virus. The ER+ tumour-derived cultures showed an increased sensitivity to the lytic effect of H-1 virus compared with the ER-tumour-derived cultures, in spite of similar average proliferation rates for the two types of cultures. The proliferation rate was more heterogeneous among ER+ tumour-derived cultures and, in this group, the faster growing cultures were also the most sensitive. This observation was corroborated by the study of established cell lines retaining ER expression under in vitro culture conditions. Oestradiol was found to increase the sensitivity of these cells to the parvovirus in parallel with induction of proliferation. This effect appeared to be mediated by ER activation, since it was not observed in the ER-negative cell line MDA-MB-231. These data point to the importance of hormonal influences and cellular parameters, notably differentiation and proliferation, in determining the extent to which human cancer cells can be targets for the cytopathic effect of parvoviruses.

Osteonectin is a secreted glycoprotein which is detected in a number of normal and neoplastic human tissues in vivo. It is an extracellular matrix (ECM)-associated protein which is postulated to regulate cell migration, adhesion, proliferation and matrix mineralisation and previous reports suggest that it may be modulated by steroid hormones in target tissues. The aim of this study was to measure osteonectin mRNA and protein expression in breast tumour biopsies and compare these with oestrogen (ER) and progesterone receptor (PR) levels in the same tumours. An inverse correlation was seen between osteonectin mRNA expression and ER level. Samples with low ER protein expression had a mean osteonectin mRNA level which was almost 4-fold greater than the mean level of expression observed in tumours containing high concentrations of ER protein. This inverse correlation was statistically significant. Despite the strong inverse relationship between osteonectin mRNA levels and tumour ER content, no correlation was seen when osteonectin protein concentration was measured in tumour cytosols on immunoblots and compared to ER and PR levels in the same tumours. However, since it is a secreted protein, osteonectin protein expression may not reflect cellular osteonectin levels in breast tumours. In summary, these data suggest that ER-mediated suppression of osteonectin gene expression may contribute to the less aggressive characteristics associated with receptor-positive tumours and that loss of ER expression may lead to over-expression of osteonectin and contribute to a poorer differentiated, more invasive phenotype.

Following our previous results which showed that TGF-beta 1 suppressed the secretion of certain cytokines, we investigated the effects of different endogenous and exogenous factors on cytokine secretion in whole blood cell culture by using an enzyme-linked immunosorbent assay (ELISA) for measurement of cytokine concentrations. Several molecules including dexamethasone, noradrenaline (NA) and ethanol differentially inhibited mitogen-induced cytokine secretion. Dexamethasone and noradrenaline suppressed secretion of IL-2, IFN alpha, IFN gamma, TNF alpha, IL-1 alpha and IL-1 beta. beta-Endorphin and Leu-Enkephalin had no significant influence on cytokine secretion. Suppression of cytokine secretion by TGF-beta 1 was further intensified significantly and dose dependently by addition of noradrenaline. GM-CSF stimulated the secretion of IL-1 alpha, IL-1 beta and TNF gamma, but had no influence on the secretion of IL-2, IFN alpha and IFN gamma. G-CSF, IL-3 and SCF did not significantly influence secretion of all cytokines tested. Thus, endogenous and exogenous factors differentially influence cytokine secretion by immunocompetent cells.

The acridine derivative m-AMCA (methyl-N-[4-(9-acridinylamino)-2-methoxyphenyl]carbamate hydrochloride), a carbamate analogue of the topoisomerase II poison amsacrine, is distinguished by its high cytotoxicity against non-cycling tumour cells. We compared the response of cultured Lewis lung carcinoma cells to m-AMCA, amsacrine and the topoisomerase I poison camptothecin. The DNA polymerase inhibitor aphidicolin reversed the cytotoxicity of camptothecin fully, that of amsacrine partially, and that of m-AMCA minimally. The ability of m-AMCA to induce the enzyme poly(ADP-ribose)polymerase (PARP) was markedly lower than that of camptothecin or amsacrine. Cell cycle responses to m-AMCA and amsacrine were similar, with slowing of progress through S-phase and arrest in G2-phase. These cell cycle changes were also observed when plateau phase cultures were exposed to drug for 1 h, washed free of drug and cultured in fresh medium, with m-AMCA having a more pronounced effect than amsacrine and camptothecin having no effect. We also examined the role of p53 protein in the response using cultured human H460 cells. Both m-AMCA and amsacrine induced p53 protein expression in proliferating but not in non-proliferating H460 cells, and induced p21WAF1 regardless of proliferation status. Both induced G1-phase cell cycle arrest. It is suggested that two cytotoxicity mechanisms can be distinguished using these drugs. The first is specific for S-phase cells, is reversed by aphidicolin and induces PARP activity. The second is cell cycle non-specific, does not induce PARP and is unaffected by aphidicolin. Camptothecin activates only the first, m-AMCA primarily the second and amsacrine activates both.

The tumour which develops most frequently in mice carrying a p53 Val135 transgene is adenocarcinoma of the lung. We established 10 cell lines from these tumours and investigated their karyotypes by detailed cytogenetic analysis using a complete set of mouse chromosome-specific paints. Consistent loss of chromosome 4 material was noted in 9 out of 10 cell lines; this loss was detected in tetraploid but not diploid cells of the same cell line, suggesting that mouse chromosome 4 plays a critical role in the progression of lung adenocarcinomas. Other frequently observed chromosome aberrations involved chromosomes 7, 5 and 8. Atypical bronchial epithelium was observed together with lung tumours and in tumour-free, apparently normal lungs indicating that mouse lung tumours induced due to the presence of a mutant p53 transgene may develop via pre-invasive lesions and thus may be effective models for the study of lung tumour progression.

This is a phase I study to determine the maximum tolerated dose (MTD) and toxicity of a combination of paclitaxel and 5-Fluorouracil (5-FU) in advanced gastric cancer patients. The patients, refractory to the PELF regimen (5-FU, leucovorin, cisplatin, epidoxorubicin), received weekly 5-FU at the fixed dose of 500 mg/m2, and escalating doses of paclitaxel every 3 weeks with a starting dose of 150 mg/m2 given as in 3-h infusion. The dose was escalated by 25 mg/m2 every 3 patients. Fifteen patients entered the study. The upper paclitaxel dose (225 mg/m2) was given to 6 patients. Up to this dose, no severe toxicity (grade 3-4) was recorded. Apart from alopecia, grade 1-2 leukopenia occurred in 5 patients and grade 1-2 neurotoxicity in 2 patients. All patients were evaluable for response (at least 2 cycles): 2 patients achieved an objective response (200 and 225 mg/m2). In 6 patients, treatment resulted in notable relief from symptoms. Out-patient paclitaxel given over 3 h and 5-FU may be combined safely for the treatment of patients with advanced gastric cancer. The recommended doses for phase II study are paclitaxel 225 mg/m2 and 5-FU 500 mg/m2.