Direct improvement of quality of life using a tailored quality of life diagnosis and therapy pathway: randomised trial in 200 women with breast cancer.

BACKGROUND: Despite thousands of papers, the value of quality of life (QoL) in curing disease remains uncertain. Until now, we lacked tools for the diagnosis and specific treatment of diseased QoL. We approached this problem stepwise by theory building, modelling, an exploratory trial and now a definitive randomised controlled trial (RCT) in breast cancer, whose results we report here. METHODS: In all, 200 representative Bavarian primary breast cancer patients were recruited by five hospitals and treated by 146 care professionals. Patients were randomised to either (1) a novel care pathway including diagnosis of 'diseased' QoL (any QoL measure below 50 points) using a QoL profile and expert report sent to the patient's coordinating practitioner, who arranged QoL therapy consisting of up to five standardised treatments for specific QoL defects or (2) standard postoperative care adhering to the German national guideline for breast cancer. The primary end point was the proportion of patients in each group with diseased QoL 6 months after surgery. Patients were blinded to their allocated group. RESULTS: At 0 and 3 months after surgery, diseased QoL was diagnosed in 70% of patients. The QoL pathway reduced rates of diseased QoL to 56% at 6 months, especially in emotion and coping, compared with 71% in controls (P=0.048). Relative risk reduction was 21% (95% confidence interval (CI): 0-37), absolute risk reduction 15% (95% CI: 0.3-29), number needed to treat (NNT)=7 (95% CI: 3-37). When QoL therapy finished after successful treatment, diseased QoL often returned again, indicating good responsiveness of the QoL pathway. CONCLUSION: A three-component outcome system including clinician-derived objective, patient-reported subjective end points and qualitative analysis of clinical relevance was developed in the last 10 years for cancer as a complex intervention. A separate QoL pathway was implemented for the diagnosis and treatment of diseased QoL and its effectiveness tested in a community-based, pragmatic, definitive RCT. While the pathway was active, it was effective with an NNT of 7.

Chronotypic action of theophylline and of pentobarbital as circadian zeitgebers in the rat.

In the rat the deep body temperature rhythm, monitored by telemetry, can be reset in a predictable direction by a stimulant (theopylline) and by a depressant (pentobarbital). When the drugs are applied immediately before or during the early active phases of the circadian cycle, the rhythm is set back (phase delay). When applied later, past the thermal peak, theophylline, but not pentobarbital, shifts the rhythm ahead (phase advance). Theophylline and pentobarbital in addition to having a number of already established pharmacological properties are now further identified as chronobiotics: they are drugs that may be used to alter the biological time structure by rephasing a circadian rhythm.

Implementing a system of quality-of-life diagnosis and therapy for breast cancer patients: results of an exploratory trial as a prerequisite for a subsequent RCT.

A system for quality-of-life diagnosis and therapy (QoL system) was implemented for breast cancer patients. The system fulfilled the criteria for complex interventions (Medical Research Council). Following theory and modeling, this study contains the exploratory trial as a next step before the randomised clinical trial (RCT) answering three questions: (1) Are there differences between implementation sample and general population? (2) Which amount and type of disagreement exist between patient and coordinating practitioners (CPs) in assessed global QoL? (3) Are there empirical reasons for a cutoff of 50 points discriminating between healthy and diseased QoL? Implementation was successful: 74% of CPs worked along the care pathway. However, CPs showed preferences for selecting patients with lower age and UICC prognostic staging. Patients and CPs disagreed considerably in values of global QoL, despite education in QoL assessment by outreach visits, opinion leaders and CME: Zero values of QoL were only expressed by patients. Finally, the cutoff of 50 points was supported by the relationship between QoL in single items and global QoL: no patients with values above 50 dropped global QoL below 50, but values below 50 and especially at 0 points in single items, induced a dramatic fall of global QoL down to below 50. The exploratory trial was important for defining the complex intervention in the definitive RCT: control for age and prognostic stage grading, support for a QoL unit combining patient's and CP's assessment of QoL and support for the 50-point cutoff criterion between healthy and diseased QoL.

Strontium-doped hydroxyapatite polysaccharide materials effect on ectopic bone formation.

Previous studies performed using polysaccharide-based matrices supplemented with hydroxyapatite (HA) particles showed their ability to form in subcutaneous and intramuscular sites a mineralized and osteoid tissue. Our objectives are to optimize the HA content in the matrix and to test the combination of HA with strontium (Sr-HA) to increase the matrix bioactivity. First, non-doped Sr-HA powders were combined to the matrix at three different ratios and were implanted subcutaneously for 2 and 4 weeks. Interestingly, matrices showed radiolucent properties before implantation. Quantitative analysis of micro-CT data evidenced a significant increase of mineralized tissue formed ectopically with time of implantation and allowed us to select the best ratio of HA to polysaccharides of 30% (w/w). Then, two Sr-substitution of 8% and 50% were incorporated in the HA powders (8Sr-HA and 50Sr-HA). Both Sr-HA were chemically characterized and dispersed in matrices. In vitro studies performed with human mesenchymal stem cells (MSCs) demonstrated the absence of cytotoxicity of the Sr-doped matrices whatever the amount of incorporated Sr. They also supported osteoblastic differentiation and activated the expression of one late osteoblastic marker involved in the mineralization process i.e. osteopontin. In vivo, subcutaneous implantation of these Sr-doped matrices induced osteoid tissue and blood vessels formation.

Circadian manifestations of barbiturate habituation, addiction and withdrawal in the rat.

The thermal acrophase for the circadian oscillation of core temperature in Charles River male rats fed ad libitum and entrained by light (12 hr dim light and 12 hr bright light) (DL 12:12 hr) occurred near the middle of the dim phase on a control diet of 30% protein. Dietary phenobarbital (0.25%) caused an increase in amplitude of the oscillation (from 0.7 degrees to 1.2 degrees C) and a phase-angle difference (psi-advance) between the zeitgeber and the biological oscillation of about 32 degrees, equivalent to an advance in the thermal acrophase of 2.1 hr in the steady-state. Food consumption was monitored continually and was nearly the same in the two groups; however, animals on the control diet ate around the clock, albeit at a greater rate during dim light than during the bright light phase, whereas rats on phenobarbital started to eat earlier and confined their feeding almost exclusively to early dim phase. This pattern of increase in amplitude of the thermal oscillation and of feeding closely resembling programmed feeding, persisted in phenobarbital-treated animals even in the absence of a dim light-bright light (DL) zeitgeber for eight days. Similar behavior was seen in rats entrained by illumination cycles of 17 hr of dim light and 7 hr of bright light, but with this reduced phase ratio for the zeitgeber, few psi-shifts occurred, and these were smaller than those induced in the group receiving 12 hr of dim light and 12 hr of bright light. In each group, introduction of the drug into the diet and, even more noticeably, removal of the drug from the diet, induced transients of circadian dyschronism that persisted for 4-5 days.

[Arthrogryposis and maternal myasthenia gravis. Risk of recurrence]. / Arthrogrypose et myasthénie maternelle. Risque de récurrence.

A 26-year old myasthenic woman whose disease had been in remission for more than 4 years gave birth, at the end of 2 induced pregnancies, to 2 stillborn infants with arthrogryposis. The presence of inherited antibodies directed against acetylcholine receptors most probably does not explain the diffuse retractions. This case illustrates the risk of recurrent foetal arthrogryposis after a first abnormal pregnancy in women with myasthenia gravis.

[Diagnosis and clinical decision making: a conceptional framework for predictive pathology]. / Diagnose und Entscheidungsfindung: ein konzeptioneller Rahmen für prädiktive Pathologie.

In the clinical pathway of diagnosis and therapy of diseases two decisions are distinguished: diagnostic and therapeutic decision. The former is analysed by decision tables, the latter by decision trees. In both decisions pathology plays a dominant role, especially as a gold standard that is a test to which most people have developed trust. This definition is remarkably soft. An efficient diagnostic prediction depends on a high prevalence of the disease. This is frequently forgotten when tests have a high sensitivity and specificity. The mathematical concept behind this observation is the Bayesian theorem. This is highly important for predictive pathology because it allows to combine attributes with high likelihood ratio simply by multiplication and has been shown to be remarkably stable, e. g. in the differential diagnosis of acute abdominal pain. Pathology should take the leadership in prediction since it has a considerable power as the gold standard of many tests. However, a network is advisable with other basic disciplines.

Alpha-methyl-p-tyrosine shifts circadian temperature rhythms.

alpha-Methyl-p-tyrosine shifts the acrophase (time of highest temperature) of the circadian temperature rhythm of the rat to earlier or later times of day depending on the phase of the circadian cycle at which the drug is administered. When alpha-methyl-p-tyrosine methyl ester HCl is injected intraperitoneally at a dose of 100 mg/kg late in the projected 8-h light phase, the acrophase of the intraperitoneal temperature rhythm is delayed by up to 3 h. However, when the same dose of drug is given 9-10 h into the projected 16-h dark phase of the daily cycle, the acrophase of the temperature rhythm occurs about 2 h earlier than expected. The times of alpha-methyl-p-tyrosine administration leading to maximal phase delays or advances are correlated with the times of minimal and maximal turnover of norepinephrine in the hypothalamus. These results suggest that changing rates of norepinephrine turnover in the hypothalamus may regulate the circadian temperature rhythm in rats. The results also emphasize the fact that the effects of drugs may vary as a function of the time of administration. This fact must be taken into account in pharmacologic testing.

Glucocorticosteroid injection is a circadian zeitgeber in the laboratory rat.

Intraperitoneal temperatures were monitored by radiotelemetry to observe the thermoregulatory rhythm of male laboratory rats (Rattus norvegicus albinus) Rats received single injections of dexamethasone (as dexamethasone sodium phosphate) during constant darkness (0.1 lx) with food freely available or no food available. No phase shifts occurred following saline injection or dexamethasone at 1 mg/kg body wt. Depending on the phase of injection relative to the circadian cycle, dexamethasone at 10 mg/kg caused thermoregulatory peaks to be either delayed or advanced on the 4th and 5th day after injection. There was an insensitive interval which corresponded to subjective day. Phase shifts induced by dexamethasone during ad libitum feeding were of less magnitude than those induced during starvation. The determination of phase-shifting parameters (i.e., a phase-response curve) for hormonal substances represents a rigorous and broadly applicable technique for determining endogenous mechanisms for circadian phase control and entrainment.

Circadian variations in the activity of tyrosine hydroxylase, tyrosine aminotransferase, and tryptophan hydroxylase: relationship to catecholamine metabolism.

Circadian variations in the activity of tyrosine hydroxylase, tyrosine aminotransferase, and tryptophan hydroxylase were observed in the rat brain stem. Tyrosine hydroxylase exhibited a bimodal pattern with peaks occurring during both the light and dark phases of the circadian cycle. Tyrosine aminotransferase had one daily peak of activity occurring late in the light phase, whereas tryptophan hydroxylase activity was maximal late in the dark phase. Circadian fluctuations in tyrosine hydroxylase activity did not correlate well with circadian variations in the turnover rates of norepinephrine or dopamine nor with levels of these catecholamines. This supports the idea that although tyrosine hydroxylase is the rate-limiting enzyme in the synthesis of catecholamines, other factors must also be involved in the in vivo regulation of this process. Administration of alpha-methyl-p-tyrosine (AMT) methyl ester HCl (100 mg/kg) had no effect on the activity of tryptophan hydroxylase, but effectively eliminated the peak of tyrosine hydroxylase activity that occurred during the light phase. AMT also lowered levels of tyrosine aminotransferase, but only at times near the daily light to dark transition. These chronotypic effects of AMT emphasize the importance of "time of day" as a factor that must be taken into account in evaluating the biochemical as well as the pharmacological and toxicological effects of drugs.

Tissue distribution of cadmium and metallothionein as a function of time of day and dosage.

Cadmium-109 chloride (1 mg or 48 ng Cd2+/kg body wt) was administered intraperitoneally to rats at one of eight selected times of day. Exactly 48 hr later each animal was sacrificed, and the cadmium content of the blood, brain, heart, kidney, liver, and testes was determined. Metallothionein levels in the liver and kidney were also measured. Distribution and retention of cadmium was very different at the different dose levels. Approximately 60% of the higher dose of cadmium was retained in the six tissues examined, while only 11.5% of the lower dose could be accounted for in these six tissues. The liver retained the largest percentage of the administered cadmium at both dose levels, but the magnitude of the retention differed by a factor of 6 (57.3% of the higher dose and 9.6% of the lower dose). The pattern of cadmium distribution among the other tissues was also different. At the 1-mg Cd2+/kg body wt level, the kidneys accumulated the second largest fraction of cadmium, followed by the blood, heart, testes, and brain. In the 48-ng Cd2+/kg body wt groups the order was kidney, testes, blood, heart, and brain. Only in the testes of animals receiving the low dose of cadmium was there an effect of time of day, and here the effect was marked. When cadmium was administered during the dark phase of the daily cycle, the testes contained an average of six times more cadmium than when cadmium was given during the light phase. Similarly, levels of metallothionein in the kidney were significantly higher when cadmium was administered during the dark phase. A trend toward higher metallothionein levels in the liver during the dark phase was also observed, but this trend was not statistically significant.

Preparation of an oakmoss absolute with reduced allergenic potential.

Synopsis Oakmoss absolute, an extract of the lichen Evernia prunastri, is known to cause allergenic skin reactions due to the presence of certain aromatic aldehydes such as atranorin, chloratranorin, ethyl hematommate and ethyl chlorohematommate. In this paper it is shown that treatment of Oakmoss absolute with amino acids such as lysine and/or leucine, lowers considerably the content of these allergenic constituents including atranol and chloratranol. The resulting Oakmoss absolute, which exhibits an excellent olfactive quality, was tested extensively in comparative studies on guinea pigs and on man. The results of the Guinea Pig Maximization Test (GPMT) and Human Repeated Insult Patch Test (HRIPT) indicate that, in comparison with the commercial test sample, the allergenicity of this new quality of Oakmoss absolute was considerably reduced, and consequently better skin tolerance of this fragrance for man was achieved.

Circadian chronotypic death in heat-synchronized infradian mode cultures ofTetrahymena pyriformis W.

Continuous cultures ofTetrahymena pyriformis in the infradian ("slow-exponential") growth mode can be entrained to give circadian rhythms of cell division by the application of thermal cycles with periods of 24 hr. The degree of synchronization (phasing index) is dependent on the cycling of other environmental agents, particularly food in the form of the defined medium used. The phase angles of these multiple zeitgebers to one another and to the circadian cell cycle markedly influence the quality of synchronization achieved. In wellsynchronized oxygen-limited cultures, a circadian cytotoxia (circadian chronotypic death) is observed when the culture's oxygen requirements periodically exceed the oxygen support limit of the environment.

Plant regeneration of Iris pallida Lam. and Iris germanica L. via somatic embryogenesis from leaves, apices and young flowers.

Irones are violet-scented ketonic compounds contained in the rhizome of certain species of iris. As cultivation of the iris tends to decrease, a selection program has been initiated to find the best performing clones in terms of growth and yield. Parallel to this selection, in vitro regeneration studies have been carried out in order to multiply interesting clones. A method of rapid multiplication by somatic embryogenesis associated with multibudding was developed. Callus was obtained from leaf bases, flower pieces or rhizome apices; the best explants were flower pieces. The induction media used to obtain embryogenic callus were Murashige & Skoog (1962) media. Assays with adding of proline in these media have showed that it could double the yield of embryogenic callus. The embryogenic expression medium was the Knudson's orchid agar (Knudson 1946) medium. Conformity of the plants obtained was checked by comparing their chemotypes with those of the mother plants.