Role of proton-coupled folate transporter in pemetrexed resistance of mesothelioma: clinical evidence and new pharmacological tools.

BACKGROUND: Thymidylate synthase (TS) has a predictive role in pemetrexed treatment of mesothelioma; however, additional chemoresistance mechanisms are poorly understood. Here, we explored the role of the reduced-folate carrier (RFC/SLC19A1) and proton-coupled folate transporter (PCFT/SLC46A1) in antifolate resistance in mesothelioma. PATIENTS AND METHODS: PCFT, RFC and TS RNA and PCFT protein levels were determined by quantitative RT-PCR of frozen tissues and immunohistochemistry of tissue-microarrays, respectively, in two cohorts of pemetrexed-treated patients. Data were analyzed by t-test, Fisher's/log-rank test and Cox proportional models. The contribution of PCFT expression and PCFT-promoter methylation to pemetrexed activity were evaluated in mesothelioma cells and spheroids, through 5-aza-2'-deoxycytidine-mediated demethylation and siRNA-knockdown. RESULTS: Pemetrexed-treated patients with low PCFT had significantly lower rates of disease control, and shorter overall survival (OS), in both the test (N = 73, 11.3 versus 20.1 months, P = 0.01) and validation (N = 51, 12.6 versus 30.3 months, P = 0.02) cohorts. Multivariate analysis confirmed PCFT-independent prognostic role. Low-PCFT protein levels were also associated with shorter OS. Patients with both low-PCFT and high-TS levels had the worst prognosis (OS, 5.5 months), whereas associations were neither found for RFC nor in pemetrexed-untreated patients. PCFT silencing reduced pemetrexed sensitivity, whereas 5-aza-2'-deoxycytidine overcame resistance. CONCLUSIONS: These findings identify for the first time PCFT as a novel mesothelioma prognostic biomarker, prompting prospective trials for its validation. Moreover, preclinical data suggest that targeting PCFT-promoter methylation might eradicate pemetrexed-resistant cells characterized by low-PCFT expression.

Effects of hospital policies and practices on initiation and duration of breastfeeding.

BACKGROUND: The aim of this study was to verify if hospital policies and practices, independently of main maternal sociodemographic determinants, influence initiation and duration of breastfeeding. METHODS: The study was carried out at the Immunization Centre of Messina where all infants born in the four maternity wards of Messina are vaccinated, using a structured questionnaire, constructed in conformity with the methodology suggested by the WHO. RESULTS: Data analysis, performed by non-parametric and multivariate analysis of variance and by Kaplan-Meier curves, showed that the highest probability rate (P < 0.001) of initiation and duration of breastfeeding, independently of maternal age, parity, education levels, smoke and work was found in infants born in a University Hospital, characterized by earlier times of first suckling, longer hospital stay and higher rate of exclusive breastfeeding at discharge. CONCLUSION: Our data emphasize the role and responsibility of hospital policies and practices in the promotion, and in the duration of breastfeeding.

Plasma leptin, insulin, and neuropeptide Y concentrations in infants.

Changes in plasma leptin, insulin, and neuropeptide Y (NPY) concentrations were determined by radioimmunological methods in healthy infants. Compared with umbilical concentrations, on the 4th day of life plasma leptin and insulin were significantly decreased, and NPY was significantly increased. No correlation was observed between leptin, insulin, and NPY.

[Comparison between pre- and postnatal echographic screening of malformative uropathies]. / Confronto tra lo screening ecografico pre- e postnatale delle uropatie malformative.

AIM: The aim of this study has been to compare the validity of postnatal echographic screening in respect of prenatal echography in early diagnosis of malformative uropathies (MU). METHODS: In 6578 infants, who have been submitted to fetal echography, and to a postnatal screening of MU in our Neonatal Service of Echography (University of Messina), we have compared the diagnostic agreement of prenatal with postnatal echography. RESULTS: Our comparison demonstrates that, in respect of postnatal screening, only 35.71% of pyelectasies and 73.17% of hydronephrosis have been diagnosed by fetal echography, and, in particular, only 18.75% of no-dilated MU. CONCLUSIONS: These data confirm that, in our country, the postnatal screening of MU has still significance and suggest that, before excluding this screening, it is necessary to verify everywhere the validity of fetal echography.

Effects of melatonin administration on cytokine production in patients with advanced solid tumors.

There is growing evidence that the pineal gland has antineoplastic properties, which include the action of melatonin (MLT) on the immune system through the release of cytokines by activated T-cells and monocytes. Despite these intriguing preliminary findings, only few studies have been undertaken to date on MLT's action in cancer patients. The present study was carried out on 23 patients (15 males and 8 females, range 48-71 years), with advanced solid tumors, who received MLT (10 mg/day orally for a month) after conventional therapy. Blood was assayed for tumor necrosis factor alpha (TNF-alpha), Interleukin-2 (IL-2) and human interferon gamma (IFN-gamma). Blood samples were taken immediately before the start of MLT administration and 30 days after therapy. Plasma was collected in EDTA tubes on ice, centrifuged immediately at 4-degrees-C and stored frozen at -80-degrees-C until assayed. Cytokines were quantified by immunoradiometric assays. Circulating levels of TNF-alpha, IL-2 and IFN-gamma increased by 28%, 51% and 41% respectively after MLT administration. These increments were statistically significant (paired Student's t-test, p<0.01). These findings are consistent with the hypothesis that MLT modulates immune functions in cancer patients by activating the cytokine system.

Cyclophosphamide, epidoxorubicin and Carboplatin as treatment for advanced-carcinoma of the bladder - a phase-ii study.

In advanced carcinoma of the bladder, the M-VAC chemotherapy schedule can yield positive results, but at the cost of very high toxicity. Recent studies have shown epidoxorubicin and to a lesser degree, carboplatin to be active against urothelial tumors, with cardiac, haematological and renal toxicity lower than that observed with CISCA or M-VAC chemotherapy regimens. In this study, we determined the toxicity and efficacy of cyclophosphamide 400 mg/m(2), epidoxorubicin 75 mg/m(2) and carboplatin 300 mg/m(2) in a 28-day course. From February 1990 to December 1991, we enrolled 33 advanced bladder cancer patients (25 males, 8 females), mean age 63 years. 31 patients were evaluable for toxicity and response. The major disease localizations were: locoregional 15 (48%), lymph nodes 6 (20%), liver 5 (16%), lung 3 (10%) and bone 2 (6%). A total of 186 cycles of therapy were administered, with a mean of 5.4 per patient. Six patients (19%) had a complete response (CR): 2 locoregional, 3 lymph node and 1 lung. Eleven patients (36%) had a partial response (PR), for an overall response rate of 55%. The median duration of response was 53 weeks and median survival for the entire group of patients was 40 weeks. No delays or interruptions due to sepsis occurred during therapy; haematological, cardiac and renal toxicity were below WHO grade 3. The efficacy of this chemotherapy regimen proved to be comparable to that of more aggressive schedules, while its toxicity was markedly lower.

Complete androgen blockade as treatment for advanced prostate cancer: clinical response and side-effects.

Treatment of advanced prostatic cancer is currently based on hormonal manipulation. In 1982 Labrié supported a new concept of hormonal treatment based on complete androgen blockade. The objective of this study was to evaluate the effects of total androgen suppression, achieved by the combination of a LHRH agonist (buserelin) plus a pure anti-androgen (flutamide) in the long-term treatment of advanced prostate cancer. Forty-seven untreated consenting patients with advanced prostatic cancer entered in the study, and 41 of these proved evaluable for response and toxicity. Buserelin and Flutamide were administered three times daily, intranasally and orally respectively, at a dose of 1.2 mg and 750 mg for twelve months. Circulating testosterone levels, regularly measured during the study, were reduced by the treatment to castrated levels. Clinical results are encouraging for the high rate of objective and clinical responses PR + SD = 37 (90%), for its duration (12 months), for the significant improvement of urological symptoms and for the decrease of cancer-related pain, even in cases with detectable bone metastases. Compliance was excellent in all the subjects and no patient was forced to interrupt treatment because of cardiovascular toxicity or severe side-effects, which were limited to occasional loss of libido and potency, hot-flashes, mild diarrhea and nausea.

Gemcitabine plus Epi-doxorubicin as first-line chemotherapy for bladder cancer in advanced or metastatic stage: a phase II.

Combination chemotherapy with newer, more active drugs in patients with advanced and/or metastatic bladder cancer might show improved response rate and survival. Gemcitabine (GEM) and Epidoxorubicin (EPI) have demonstrated activity in this disease. In addition, experimental studies in vitro have shown that the two agents have additive-synergistic effects when used in combination. Our prior phase I dose-finding study in previously untreated patients with advanced or metastatic bladder cancer defined recommended doses for further trials of GEM 1000 mg/m2 and EPI 25 mg/m2 on days 1, 8 and 15 every 28 days. A phase II trial at this dose level was initiated in previously untreated patients to assess efficacy and toxicity. Eligible patients had measurable disease; Karnofsky performance status (PS) of > 40; no prior chemotherapy; and adequate bone marrow reserve, cardiac, hepatic and renal function. Thirty- one patients (22 males, 9 females) with median age of 64 (range 44-75) and median PS of 80 were accrued, and all were eligible. Twelve patients had T4N1-2 M0, 8 had lymph node only metastases, while 11 had visceral metastases (liver, bone, lung). A total of 181 cycles was administered (range 3-7 per patient). Major toxicities (WHO grade > or = 3) were: neutropenia in 5 patients, thrombocytopenia in 2 patients, and anemia in 2 patients. Three patients had febrile neutropenic episodes and only 3 patients required dose reduction. Grade 1-2 non-hematological toxicities included nausea/vomiting, stomatitis and alopecia. No cardiac toxicity was observed. Of the 30 response evaluable patients, 17 (57%) demonstrated a major response (3 complete and 14 partial) (95% CI: 39%-75%), 7 had stable disease (23%) and 6 progressed (20%). These preliminary results confirm the phase I observation that the combination of GEM--EPI is highly active in the treatment of advanced and metastatic bladder cancer with a favourable toxicity profile.

Melatonin as biological response modifier in cancer patients.

The neuroendocrine system modulates the immune response through neuropeptides and neurohormones, findings which point to the existence of a neuro-endocrine-immune system regulatory axis. At the same time, there is growing evidence that the pineal gland has anti-neoplastic properties, which include the action of its principal hormone, melatonin (MLT), on the immune system through the release of cytokines by activated T-cells and monocytes. The present study was carried out on 31 patients (19 males and 12 females, age range 46-73 years) with advanced solid tumors (7 gastric, 9 enteric, 8 renal, 5 bladder, 2 prostate) who either failed to respond to chemotherapy and radiotherapy or showed insignificant responses and were therefore shifted to MLT therapy (10 mg/die orally for 3 months). We obtained blood samples just before the start of MLT administration and after 30 days of therapy. Plasma was collected in EDTA tubes on ice, immediately centrifuged at 4 degrees C and stored frozen at -80 degrees C; samples were measured by immunoradiometric assays (Medgenix-Fleurus, Belgium) for tumor necrosis factor alpha (TNF), interleukin-1, 2 and 6 (IL-1, IL-2, IL-6) and interferon gamma (IFN). We used Student's paired t-test to compare each patient's cytokine circulating levels before and after MLT administration and found a significant differences (p < 0.05). After 3 months of therapy, none of our patients displayed adverse reactions to MLT or had to discontinue treatment. Nineteen patients (61%) showed disease progression. The other 12 (39%), however, achieved disease stabilization with no further growth of either the primary tumor or of secondaries; moreover, they experienced an improvement in their general well-being, in terms of Tchekmedyian's criteria, associated with a significative decrease of IL-6 circulating levels. These findings are consistent with the hypothesis that MLT modulates immune function in cancer patients by activating the cytokine system which exerts growth-inhibitory properties over a wide range of tumor cell types. Furthermore, by stimulating the cytotoxic activity of macrophages and monocytes, MLT plays a critical role in host defence against the progression of neoplasia.

Creatine kinase isoenzyme BB: a lung cancer associated marker.

We investigated the diagnostic role of creatine kinase isoenzyme BB (CK-BB) in lung cancer. CK-BB was assayed using a radioimmunological system by saturation with Mallinchrodt double antibody 125I labelled (RIA Quant-CPK-BB). Sensitivity was 97% and specificity 90% in 44 cancers (T2-T3), in 36 non-cancers (chronic bronchitis) and in 48 healthy controls. Mean serum CK-BB values for patients with chronic bronchitis (2.64 +/- 1.1 ng/ml) were virtually the same as in normal subjects. Patients with lung cancer had markedly higher serum CK-BB values (9.17 +/- 2.6 ng/ml) than either the control group (healthy subjects) or the chronic bronchitis patients (p less than 0.01). These results lead us to suggest that CK-BB serum determination might prove useful in screening pulmonary disorders. However, further studies are essential to establish: 1) the relationship between serum levels of the isoenzyme and the histology and stage of the neoplastic disease; 2) the relation between CK-BB and the aggressive potential of the neoplastic clone.

Balloon dilatation of a porcine bioprosthetic valve in aortic position.

We describe a case of percutaneous balloon valvoplasty of a stenotic Hancock bioprosthesis in aortic position. The procedure reduced the peak systolic gradient from 110 to 25 mm Hg. The calculated area of the orifice increased from 0.59 to 1.07 cm2. A cineaortogram performed after the procedure showed trivial aortic regurgitation and the subsequent immediate course was uneventful. The mechanism of dilatation and the risks of the procedure are discussed.

Early and late determinants of survival after surgery of left ventricular aneurysm.

The fate of 103 patients consecutively operated upon for chronic left ventricular aneurysm between 1978 and 1986 was examined with a multivariate statistical approach to verify the operative indications and results. In the early risk phase, up to 39 days after operation, 15 patients (15%) died. Mortality was mostly due to a low output syndrome and was significantly related to older age and to functional (NYHA) and anginal (CCS) class. In the late risk phase, starting 1.9 years after surgery, 9 patients died (10%) and the significant risk factors were anterior aneurysm and older age at operation. Actuarial survival curves showed 82% survival at 5 years and 61% at 9.5 years. In 25 patients older than 50 years and with an anterior aneurysm, these rates were 51% and 34%, respectively. Improved functional class was observed in 87% of the patients interviewed, but 30% complained of angina or new infarctions. Survival free of ischemia was 64% at 5 years and 13% at 9.5 years. This development of ischemic recurrences was significantly related to older age and to incomplete revascularization despite multiple grafts. These results suggest modification of the grafting policy and of the techniques of repair in identified high-risk subsets.

The validity of the Apgar scores in the assessment of asphyxia at birth.

A prospective study was performed in 613 consecutively live born infants to investigate the validity of 1- and 5-min Apgar scores as an index for asphyxial assessment at birth. The independent and combined relationship between Apgar scores, metabolic acidemia, pulse oximeter (SaPO2) measurements and neonatal outcome were determined. In the term infants 1-min Apgar score was more influenced by the mode of delivery and by gestational age than by asphyxia. Instead, 5-min Apgar score had a high concordance with metabolic acidemia. Infants with low Apgar scores, metabolic acidemia and arterial desaturation have the highest incidence of neonatal intensive care unit admission and poor neonatal outcome. The study suggests that the 5-min Apgar score is useful for immediate clinical assessment and care of the neonate.

Changes in thyroid status in newborn infants utero-exposed to ritodrine.

A clinical study to assess whether utero exposure to ritodrine influences thyroid status was performed in 21 healthy term newborn infants, 10 exposed in utero to ritodrine (treated group) and 11 non-exposed in utero to drugs (control group). The treated group had a T3/T4 ratio significantly higher than the control group (mean +/- SD: 124.10 +/- 23.70 vs. 96.09 +/- 18.11, p less than 0.005) and T3 slightly increased (mean +/- SD nmol/l 2.48 +/- 0.69 vs. 1.95 +/- 0.56). The mean serum values of the other parameters studied, TSH, T4, fT4, fT3, were not significantly different in either groups. Since beta-mimetics induces deiodinating activity of the liver and propranolol reduces extrathyroidal conversion of T4 to T3, it was suggested that ritodrine enhances deiondinating activity of fetal and neonatal liver.

Effects of the mode of delivery on ANP and renin-aldosterone system in the fetus and the neonate.

Plasma ANP and aldosterone levels, plasma renin activity (PRA), haematocrit, systolic and diastolic blood pressure (BP), were evaluated in 15 full-term infants delivered by elective Caesarean section (CS group) and in 15 full-term infants delivered vaginally (vaginal group). The mode of delivery did not influence the cord blood levels of ANP and their increase at the 24th hour of life. Instead, PRA was lower and plasma aldosterone levels were higher in the CS group than in the vaginal group. Also haematocrit and BP were influenced by mode of delivery. The haematocrit values were lower in the CS group than in the vaginal group at birth as well at the 24th hour of life. The values of systolic and diastolic BP were the same in both groups, at birth, but at the 24th hour of life increases were observed only in the vaginal group. On the fourth day of life weight loss was the same in both groups. Our findings suggest that the mode of delivery has more influence on neonatal BP adaptation than on neonatal volume homeostasis.

Preliminary study on behaviour of atrial natriuretic factor in anthracycline-related cardiac toxicity.

The atrial natriuretic factor (ANF) plays an important role in the pathogenesis of congestive heart failure (CHF), by influencing electrolyte and water balance and by modifying peripheral vascular resistance, thus affecting left ventricular performance. Anthracycline derivatives are glycoside antibiotics, active against a wide spectrum of tumours. It is well known that acute and severe dose-related delayed cardiotoxicity constitutes the major limitation to their optimal use. A total of 26 female patients (mean age 53 years) undergoing monochemotherapy for advanced breast cancer, were studied. 4'-Epidoxorubicin (Epidx) 120 mg/m2 intravenously was administered every three weeks for a total of a mean of 6.6 therapeutic cycles (3 to 10). Left ventricular ejection fraction (LVEF) determined by radionuclide ventriculography and circulating ANF were measured periodically in all patients. Epidx administration was limited at a cumulative dose ranging between 840 and 1200 mg/m2 because of a 25% decrease in LVEF and due to a progressive rising in ANF plasma levels. Furthermore, two patients who presented clinical symptoms of CHF had also significantly increased ANF levels (56 and 49% respectively). The current evidence suggests an important pathophysiological role of ANF in anthracyclinic related CHF. Hopefully measurement of plasma ANF will provide a simple non-invasive method of assessing ventricular dysfunction related to anthracycline cardiac toxicity and might represent an additional objective indicator of the severity of haemodynamic compromise in patients with impaired cardiac function.

[Outcome of aortocoronary bypass in old age]. / Risultati del bypass aortocoronarico in età geriatrica.

43 patients over 60 years of age underwent an aortocoronary bypass operation between 1974 and 1977. The observation period after surgery ranged from 4 to 7 years. Clinical results of this group were compared with the results of a group who presented with the same presurgical and surgical characteristics, randomly chosen between 212 patients under 60 years of age operated on in the same period. Surgical mortality was 16.2%, higher than that of the control group (5.5%); similar and very low is the late mortality in both groups (average follow-up on 5.3 years): 2.9% vs 5.5%. The effects on angina are favourable: 79.4% of elderly patients are free from angina and improvement in symptoms is present in all; left ventricular failure is rarely present (7.6%); congestive heart failure is absent. Moreover we pointed out the efficacy of the aortocoronary bypass on return to work. These results lead to a more favourable attitude towards operation in subset of patients showing serious symptoms of coronary heart disease in old age.

[Significance and problems of psychological consultation for infertility. Personal experience]. / Significato e problemi della consulenza psicologica per infecondità. Una esperienza.

A sample group of 200 couples attending the Centre for the Diagnosis and Treatment of Sterility in the Couple were studied. All patients had one or more conversations with a psychologist in order to analyze the real desire for pregnancy and to encourage a better relationship between the medical team and the patients. The study throws light on many conflictual situations relating to both the individual's and the couple's desire to achieve pregnancy with the help of science. Nevertheless, it was not possible to utilise all the information gathered by the psychologist from the conversations to improve the relationship between the medical team and the patients.

[Immunoprophylaxis in the prevention of perinatal transmission of hepatitis virus B. Analysis of limiting factors]. / L'immunoprofilassi nella prevenzione della trasmissione perinatale del virus dell'epatite B. Analisi dei fattori limitanti.

The significance of obstetric anamnesis in neonatal risk identification and efficiency of a vaccinal schedule were investigated in order to verify the condition which limited the efficiency of immunoprophylaxis in the prevention of perinatal hepatitis B virus transmission. The data suggested that the lack of obstetric screening is the highest limitative factors in the realization of hepatitis B neonatal prevention. The immunoprophylaxis is surely a substantial method in the prevention of hepatitis B virus perinatal transmission, but the vaccinal schedule and follow-up should be improved.

[Diabetes and pregnancy. Maternal risk factors and neonatal morbidity]. / Diabete e gravidanza. Fattori di rischio materni e morbilità neonatale.

BACKGROUND: To verify in our population the incidence of infants of mother with insulin dependent diabetes mellitus (IDDM) or gestational diabetes (GD) and to evaluate the maternal characteristics influencing neonatal outcome. METHODS: The study was retrospectively performed on 6179 infants born between 1995 and 1998 at the Obstetric Clinic of the University of Messina and referred the Division of Neonatology. The following groups have been selected: group A (offsprings of IDDM mothers), group B (offsprings of DG mothers), group C and group D, controls, (2 infants of the same sex and gestational age born before and after the infants of group A and group B, respectively). The parameters analyzed were: diabetic familiarity, age, weight and body mass index (BMI) of the mothers, delivery, gestational age, weight at birth, neonatal outcome. RESULTS: The infants of IDDM mothers were 3% and the infants of GD mothers were 0.8%. Group A and group B present a significantly higher incidence of: diabetic familiarity, cesarean section, macrosomia, hypoglycemia, hypocalcemia, hyperbilirubinemia. The GD mothers had weight and BMI higher than IDDM mothers. The infant weight did not correlate with maternal weight and BMI. CONCLUSIONS: These data suggest that in our population GD is underestimated, metabolic control in pregnancy is insufficient, obstetric practices are too invasive, neonatal outcome is verosimely correlated only to metabolic control.