Topical treatment of CIN 2+ by cidofovir: results of a phase II, double-blind, prospective, placebo-controlled study.

OBJECTIVE: Randomized controlled trial evaluating a topical treatment for cervical intraepithelial neoplasia 2 and 3 (CIN 2+) using cidofovir. METHODS: Fifty-three women with a biopsy-proven CIN 2+ were randomly assigned, 6 weeks before their planned conisation, either 3 applications of 3 ml 2% cidofovir in Intrasite gel in a cervical cap or a placebo (the same volume of Intrasite alone). A cervical sample for high-risk types of human papillomaviruses (HPV) (Hybrid Capture 2 or HC2) was taken before treatment and before conisation. The cone was submitted for pathological examination, and subsequently, along with the initial biopsy, to in situ hybridization (ISH) for high-risk HPV. RESULTS: Forty-eight patients were treated and followed according to the protocol, (23 cidofovir, and 25 placebo). Fourteen of the 23 cones were free of any CIN (60.8%) in the cidofovir group. Only 5 of 25 cones were free of any CIN (20%) in the placebo group (p<0.01). The difference remained significant in the ITT group (p<0.05). In the per-protocol and ITT populations, we observed more frequent viral clearance in the cidofovir group, but the difference was significant only when evaluated by ISH and not by HC2. No systemic toxicity was observed. Cervico-vaginal side effects of cidofovir were limited, and not statistically different from placebo. CONCLUSION: The medical topical treatment with cidofovir, at this point, cannot replace conisation, but it is a promising candidate for topical chemotherapy of CIN 2+ lesions; a larger prospective randomized study is needed to confirm our results.

National survey on cholecystectomy related bile duct injury--public health and financial aspects in Belgian hospitals--1997.

Public health and financial aspects of cholecystectomy related bile duct injury (BDI) are highlighted in a National Cholecystectomy Survey carried out through 'datamining' the Federal State Medical Records Summaries and Financial Summaries of all Belgian hospitals in 1997. All cancer diagnoses, children < or = 10 years, cholecystectomies performed as an abdominal co-procedure or patients having undergone other non-related surgery were excluded from the study. 10.595 laparoscopic (LC) and 1.033 open cholecystectomies (OC) as well as 137 secondary BDI treatments (LC/OC) were included in the survey (total 11.765). Both LC and OC groups turned out to be significantly different as to distribution of patient's age and APR-DRG severity classes. Composite criteria in terms of ICD-9-CM and billing codes were elaborated to classify: 1) primary, intra-operatively detected and treated BDI (N = 30), 2) primary delayed BDI treatments (N = 38), 3) secondary BDI treatments (N = 137), 4) non-BDI abdomino-surgical complications (N = 119), 4) uneventful laparoscopic (N = 7.476) and 5) uneventful open cholecystectomy (N = 681). Complication rates, community costs of LC and OC groups, incidence of preoperative ERCP and/or intra-operative cholangiography as well as interventions for complications were studied. Incidence of cholecystectomy related BDI was 0.37% in LC, 2.81% in OC and 0.58% overall. Average costs amounted to [symbol: see text] 1.721 for uneventful LC, [symbol: see text] 2.924 for uneventful OC, [symbol: see text] 7.250 for primary, intra-operatively detected and immediately treated BDI [symbol: see text] 9.258 for primary delayed BDI treatments, [symbol: see text] 6.076 for secondary BDI treatments and [symbol: see text] 10.363 for non-BDI abdomino-surgical complications. In conclusion BDI with cholecystectomy reveals to be a serious complication increasing the overall average cost factor ninefold if not detected intra-operatively, in which case the raise is only fourfold. As a consequence BDI should be avoided by all means. In this respect 4 crucial surgical guidelines are emphasised.

['Evidence-based' perioperative antibiotic prophylaxis policy in Belgian hospitals after a change in the reimbursement system]. / Perioperatief antibiotisch profylaxebeleid in de Belgische ziekenhuizen 'evidence-based' door afgestemd vergoedingensysteem.

The costs of antibiotics in Belgian hospitals are nearly fully reimbursed by the health insurance. Such a situation is not conductive to rational drug use. A new reimbursement system for perioperatively-administered antibiotics in Belgian hospitals was implemented in May 1997 by Royal Decree. A reimbursement code for antibiotic use was linked to the reimbursement of surgical interventions. This code represents a reimbursement which covers 75% of the cost of perioperative prophylaxis based on optimal indication, dose, and duration as recommended by international and Belgian consensus guidelines. The actual antibiotic prescribed during the 72-hour perioperative period (the day before, during and after surgery) is reimbursed at only 25% of its full cost. Thus, if the perioperative prophylactic antibiotic regimen complies with the evidence-based guidelines, the costs of antibiotic prescribing will be fully reimbursed by the health insurance (75% of the standard +25% of the actual costs). The new reimbursement system does not apply to antibiotics which are prescribed for treatment of intercurrent infections; these antibiotics continue to be fully reimbursed. Annual expenditures for antibiotics, for both antibiotic treatment and prophylaxis, nationwide and per hospital, have shown marked improvements in perioperative antibiotic use after the decree was implemented. Surgeons' adherence to the evidence-based standard of prophylactic antibiotic use has improved over time. In conclusion, rapid implementation of the perioperative antibiotic prophylaxis policy was achieved through changes in the reimbursement of antibiotics for surgery patients.

[Antibiotics and pregnancy]. / Antibiotiques et grossesse.

Antibiotherapy during pregnancy has to be adapted according two factors: pregnancy related pharmacodynamic changes and potentially negative side effects for the developing foetus of some antibiotics. Pregnancy induce a weight gain, an increase of intravascular volume, of glomerular filtration, and of hepatic metabolism. The foetoplacental unit create a new volume in which antibiotics penetrates increasingly during gestation. As a consequence, during pregnancy, maternal plasmatic levels of antibiotics reaches values 10-50% under the ranges observed with the same dosages administered to non pregnant women. Tobramycin of which clearance diminish during pregnancy is the only exception for this rule. In term pregnancy, placental transfer of antibiotics is very high, except for macrolides. Thalidomide, a well-known responsible of phocomely, is still used in the treatment of leprae. No other antibiotic as a well demonstrated teratogenic effect in human foetuses. Nevertheless, tetracyclin use in pregnancy must be avoided according a high risk of enamel dysplasia, with brownish discoloration of deciduous teeth. No teratogenic effect has been recorded for betalactams and for erythromycin, the first choice antibiotics during pregnancy. Some antibiotherapy are specific of obstetrical conditions. Antibiotics interferes with estrogens metabolism, inducing a fall in circulating level of estriol.

Phase II double-blind, placebo-controlled study of the safety and efficacy of cidofovir topical gel for the treatment of patients with human papillomavirus infection.

Genital condylomata acuminata are nonmalignant human papillomavirus (HPV)-induced tumors in which HPV types 6 and 11 are most commonly found. Usual treatments for condylomata acuminata are nonspecific and are based on the destruction or removal of infected tissue. These procedures are often painful and are characterized by a high relapse rate. We report here what is to our knowledge the first double-blind, placebo-controlled study of the use of cidofovir, a nucleotide analogue, for the treatment of genital papillomavirus infections. Thirty patients were enrolled in the study; 19 received cidofovir, and 11 received placebo. The median number of warts and the median baseline wart area were comparable for both groups. Nine (47%) of 19 patients in the cidofovir group had a complete response (total healing), compared with 0 of the patients in the placebo group (P=.006). None of the patients in the cidofovir group experienced progression of the disease, compared with 5 (45%) of 11 patients in the placebo group. The side effects recorded for both groups were comparable.

Successful treatment of recurrent vulvar intraepithelial neoplasia resistant to interferon and isotretinoin with cidofovir.

Vulvar intraepithelial neoplasias are difficult to eradicate completely without extensive surgical intervention. Cidofovir, a deoxycytidine monophosphate analog, may have a therapeutic role in this disease. A 43-year-old woman with a 20-year history of genital warts presented with extensive vulvar intraepithelial neoplasia III, and refused surgical resection. Topical cidofovir 1% in Beeler base completely eradicated the lesion. Successive treatment applications, however, were necessary. Cidofovir is a promising topical antiviral compound for HPV induced vulvar intraepithelial neoplasia.

Cidofovir, a new approach for the treatment of cervix intraepithelial neoplasia grade III (CIN III).

Cervix intraepithelial neoplasia grade III (CIN III) is an intraepithelial proliferative process with different levels of severity depending on both the extension of the proliferation in the epithelium and the presence of cellular atypia. Human papillomavirus (HPV) has been clearly associated with such lesions. The results of a preliminary study are described on the local application of cidofovir, an acyclic nucleoside phosphonate derivative with broad-spectrum anti-DNA virus activity for the treatment of CIN III. Cidofovir 1% in gel was applied three times, every other day, on the cervix of each of 15 women with biopsy proven CIN III. Within 1 month after the start of treatment, the cervix was removed surgically. Histology and human papillomavirus polymerase chain reaction (HPV-PCR) were carried out. In 7 of the 15 patients the histology showed a complete response, whereas 5 patients had a partial response characterized by the persistence of CIN II-III lesions, 1 patient had a dysplasia of lower grade (CIN I), and 2 patients did not show differences in the histology. Complete response was confirmed by PCR in 4 of the 7 patients, with complete response histologically. Cidofovir was not toxic to the normal epithelium. Cidofovir 1% gel was able to inhibit partially or completely cervical dysplasia lesions after only three applications (every other day). This effect was specific and tissue other than the dysplastic epithelium was not affected by the treatment.

Surgical prophylaxis in Belgian hospitals: estimate of costs and potential savings.

Between 1991 and 1995 the Belgian National Program for Surveillance of Hospital Infections (NSIH) collected data on perioperative antibiotic prophylaxis in 72 acute care hospitals. From the costs of prophylactic antibiotics for six categories of surgical procedure and from discharge summaries for hospitalization episodes nationwide, annual drug costs were estimated for 73% of Belgian surgical activity. Costs of antibiotics used in these surgical activities were estimated at 386-410 million Belgian francs (Bf) per year (US$12.1-12.9 million). After agreeing recommendations for best practice, the hypothetical costs of 'optimal' antimicrobial prophylaxis were calculated for the same selection of surgical procedures. It was calculated that savings of at least 194 million Bf (US$6.1 million) could be made if recommendations were followed closely. Only the costs borne by the National Health Insurance Institute for reimbursement of the dispensed drugs were considered in this study. Other direct costs, such as those related to drug storage, dispensing and administration, were not included.

Therapy of bacterial vaginosis using exogenously-applied Lactobacilli acidophili and a low dose of estriol: a placebo-controlled multicentric clinical trial.

The efficacy of vaginal tablets (Gynoflor) containing 50 mg of a lyophilisate of viable, H2O2-producing Lactobacillus acidophilus (at least 10(7) colony forming units/tablet) and 0.03 mg estriol (CAS 50-27-1) for the treatment of bacterial vaginosis (BV) was tested in a multicentric, randomised, placebo-controlled clinical trial with parallel-group design. 32 non-menopausal women with positive diagnoses for BV, including intermediate cases, participated in the trial. Patients were diagnosed using the classical clinical parameters of BV according to Amsel and using microscopic analysis of the Gram-stained vaginal smear. A positive clinical diagnosis of BV required at least 2 of the following 4 clinical criteria to be positive; greyish-white, homogeneous leukorrhea; vaginal pH > 4.5; KOH test for volatile amines; presence of clue cells. Microscopic diagnosis of BV, on the other hand, was obtained if examination of the Gram-stained vaginal smear showed less than 6 lactobacilli per field of view (1000 x magnification). This corresponds to another definition of BV as "lactobacilli deficiency syndrome". The efficacy of the 6-day therapy with 1-2 vaginal tablets daily was evaluated using both clinical and microscopic analysis. Using Amsel's classical clinical parameters of BV, the cure rate (defined as < or = 1 of the 4 clinical criteria positive) two weeks after the start of therapy was 77% in the verum group and 25% in the placebo group. Four weeks after the start of therapy, the cure rate was 88% in the verum group and 22% in the placebo group. At both control examinations, the cure rate for the test group was significantly higher than that for the placebo group (p < 0.05, Fisher's exact test, 2-sided, significance level 0.05). In addition, the trial showed that after 6 days of treatment with the test preparation, the lactobacilli were capable of recolonising the vagina. A significant increase in the number of lactobacilli was observed in the Gram-stained vaginal smear for the patient group treated with the test preparation compared to the placebo patient group (p < 0.05, Fisher's exact test, 2-sided, significance level 0.05), two and four weeks after the start of the 6-day treatment.

Kinetics of prostate-specific antigen after manipulation of the prostate.

Kinetics of prostate-specific antigen (PSA) were investigated after manipulation of the prostate in two groups of patients: those treated with digital rectal examination (DRE), and those with needle biopsy. 8 patients had serial PSA measurements to study the effect of DRE (group 1). 7 of 8 patients had PSA baseline values < 10 ng/ml. Blood samples were taken at 1 min, 30 min, 1, 3, 6, 12 and 24 h after DRE. Some patients were further monitored for 5 days with one blood sample taken at the same time each day. Statistically significant increased PSA levels were found after DRE (P < 0.001). Maximal increase was 70%. In most patients, peak levels were found between 30 and 60 min after DRE. Based on the results, it is concluded that after DRE it is prudent to wait 3 days before PSA is determined. 7 patients had serial PSA measurements after transrectal prostate needle biopsy (group 2). PSA sampling was similar as in the previous group. All patients had increased PSA levels after biopsy (range 1.3-9.5-fold). After 5 days, only 2 of 7 patients had returned to baseline levels. We conclude that biopsies of the prostate induce an important and long-lasting PSA elevation.

Biological half-life of prostate-specific antigen after radical prostatectomy.

The disappearance pattern of prostate-specific antigen from serum after a standard radical prostatectomy was studied in eight patients with cancer confined to the prostate. The results were used to plot an elimination curve and calculate the best fit. A biphasic pattern was found with an average biological half-life of 1.63 hours in the alpha-phase, and 4.63 days in the beta-phase. Based on these results it is concluded that determination of prostate-specific antigen concentrations less than one month after a standard radical prostato-vesiculectomy has no value for the detection or exclusion of residual malignant processes.

In vitro infection of normal human keratinocytes by human papillomavirus type 1 followed by amplification of the viral genome in reconstructed epidermis.

Primary cultures of normal human keratinocytes were inoculated in vitro with human papillomavirus type 1 (HPV-1), the agent responsible for deep plantar warts. Upon transfer to dead de-epidermized dermis and growth at the air-liquid interface, keratinocytes reconstituted a pseudoepidermis. Under these highly differentiating conditions, HPV-1 DNA amplification was found to take place in the reconstructed epidermis, being detectable from 7 days after the transfer and persisting for at least 10 days thereafter. The extent of keratinocyte differentiation may be insufficient to allow a complete HPV infectious cycle.

Type III congenital cystic adenomatoid malformation of the lung: another cause of elevated alpha fetoprotein?

In this report we document the first observation of highly elevated alpha fetoprotein (AFP) levels in the amniotic fluid of a 23-week gestation male fetus with cystic adenomatoid lung malformation (CCAML) Type III and caudal regression. The increase of AFP levels may be related to the presence of tumor-like lung masses of embryonic origin.

Expression of retrovirus-related antigen in pregnancy. I. Antigens cross-reacting with simian retroviruses in human foetal tissues and cord blood lymphocytes.

Antisera to Mason-Pfizer or Baboon Endogenous Virus possessed complement-dependent cytotoxicity for cell lines chronically infected with these viruses, with some degree of cross-reaction. When appropriately absorbed with virus-free cells, the antisera were not cytotoxic for lymphocytes of adult males but lysed lymphocytes of neonates in about half of the 30 cord blood samples tested and were also cytotoxic for one third of 26 trophoblast suspensions prepared from healthy placentae. Detection of retrovirus-related antigens was no more frequent in trophoblast from 9 pre-eclamptic placentae. These viral antigens were also demonstrated in cultures of foetal tissues, but only after a period of culture and only when the cells were treated with 5-iododeoxyuridine. The results demonstrate that retroviruses are not only expressed in vivo in the placenta but can also be induced in cultures of foetal cells. Retrovirus-related antigens also seem to be present on foetal lymphocytes.

Expression of retrovirus-related antigen in pregnancy. II. Cytotoxic and blocking specificities of immunoglobulins eluted from the placenta.

Immunoglobulins, mostly of the IgG class, were detected in eluates of the placenta of 75% of 50 healthy women in their first or second pregnancy, 92% of 30 women with more than two pregnancies, and 87% of 23 pre-eclamptic patients. The immunoglobulins were assayed for complement-dependent cytotoxicity on human and monkey cell-lines, as well as on the same cells chronically infected with either Mason-Pfizer Virus (M-P V) or Baboon Endogenous Virus (BeV). The frequency of cytotoxic reactions was very low, except with immunoglobulins from the pre-eclamptic placentae, where one third of the samples lysed virus-infected cells with occasional killing of virus-free cells. All placental immunoglobulins which were not cytotoxic were then assayed for blocking activity by testing whether they could compete with the action of anticellular sera of virus-free cells, or with the toxic effect of antiviral sera on virus producing cells. 64% of the immunoglobulins from normal placentae competed with antiviral antibodies while only 17% blocked the action of anticellular sera. The frequency of blocking immunoglobulins was no greater in eluates from pre-eclamptic placentae. The data indicate that the placenta possesses retrovirus antigen sites which bind blocking antibodies in normal pregnancy and complement-dependent cytotoxic antibodies in pre-eclampsia.

Mason-Pfizer like virus in kidney grafted patients.

Lymphocytes from a kidney grafted patient were specifically stimulated to incorporated thymidine in vitro by mitomycin C treated Hela cells infected with a Mason-Pfizer like virus (MPV). The thermolabile mutant of vesicular stomatitis virus (VSV tl) grown in leukocytes of this patient produced pseudotypes which were neutralized by the patient's sera and boy rabbit anti-MPV sera. Coculture of the patients leukocytes with SIRC cells yielded virus populations with dual properties; those of MPV plus those of another virus which was not typed serologically but possessed the biological properties of typical C particles. The patient also had neutralizing antibodies to MPV, which were detected by inhibition of syncytium formation on KC cells and by neutralization of VSV tl (MPV) pseudotypes. Preliminary results on the frequency of similar findings in other kidney grafted patients are presented.