Is Less Chemotherapy Detrimental in Adults with Philadelphia Chromosome (Ph)-Positive Acute Lymphoblastic Leukemia (ALL) Treated with High-Dose Imatinib? Results of the Prospective Randomized Graaph-2005 Study

Aim: To compare a less intensive regimen based on high-dose imatinib (IM) to an intensive IM/HyperCVAD regimen in adults with Ph+ ALL, in terms of early response and outcome after stem cell transplantation (SCT). Methods: Patients aged 18-60 years with previously untreated Ph+ ALL not evolving from chronic myeloid leukemia were eligible if no contra-indication to chemotherapy and SCT (ClinicalTrials.gov ID, NCT00327678). After a steroid prephase allowing Ph and/or BCR-ABL diagnosis, cycle 1 differed between randomization arms. In arm A (IM-based), IM was given at 800 mg on day 1-28, combined with vincristine (2 mg, day 1, 8, 15, 22) and dexamethasone (40 mg, day 1-2, 8-9, 15-16, and 22-23) only. In arm B (IM/HyperCVAD), IM was given at 800 mg on day 1-14, combined with adriamycin (50 mg/m2, day 4), cyclophosphamide (300 mg/m2/12h, day 1, 2, 3), vincristine (2 mg, day 4 and 11), and dexamethasone (40 mg, day 1-4 and 11-14). All patients received a cycle 2 combining high-dose methotrexate (1 g/m2, day 1) and AraC (3 g/m2/12h, day 2 and 3) with IM at 800 mg on day 1-14, whatever their response. Four intrathecal infusions were given during this induction/consolidation period. Minimal residual disease (MRD) was centrally evaluated by quantitative RQ-PCR after cycle 1 (MRD1) and cycle 2 (MRD2). Major MRD response was defined as BCR-ABL/ABL ratio <0.1%. Then, all patients were to receive allogeneic SCT using related or unrelated matched donor stem cells or autologous SCT if no donor and a major MRD2 response. IM/chemotherapy maintenance was planned after autologous SCT. In the absence of SCT, patients received alternating cycles 1 (as in arm B) and cycles 2 followed by maintenance, like in the published IM/HyperCVAD regimen. The primary objective was non-inferiority of arm A in term of major MRD2 response. Secondary objectives were CR rate, SCT rate, treatment- and transplant-related mortality, relapse-free (RFS), event-free (EFS) and overall (OS) survival. Results: Among the 270 patients randomized between May 2006 and August 2011, 265 patients were evaluable for this analysis (133 arm A, 132 arm B; median age, 47 years; median follow-up, 40 months). Main patient characteristics were well-balanced between both arms. Due to higher induction mortality in arm B (9 versus 1 deaths; P=0.01), CR rate was higher in the less intensive arm A (98% versus 89% after cycle 1 and 98% versus 91% after cycle 2; P= 0.003 and 0.006, respectively). A total of 213 and 205 patients were evaluated for bone marrow MRD1 and MRD2. The rates of patients reaching major MRD response and undetectable MRD were 45% (44% arm A, 46% arm B; P=0.79) and 10% (in both arms) at MRD1 and 66% (68% arm A, 63.5% arm B; P=0.56) and 25% (28% arm A, 22% arm B; P=0.33) at MRD2, respectively. The non-inferiority primary endpoint was thus demonstrated (P= 0.002). Overall, EFS was estimated at 42% (95% CI, 35-49) and OS at 51% (95% CI, 44-57) at 3 years, with no difference between arm A and B (46% versus 38% and 53% versus 49%; P=0.25 and 0.61, respectively). Of the 251 CR patients, 157 (80 arm A, 77 arm B) and 34 (17 in both arms) received allogeneic and autologous SCT in first CR, respectively. Allogeneic transplant-related mortality was similar in both arms (31.5% versus 22% at 3 years; P=0.51). Of the 157 allografted patients, 133 had MRD2 evaluation and 89 had MRD2 <0.1%. In these patients, MRD2 did not significantly influence post-transplant RFS and OS, either when tested with the 0.1% cutoff or as a continuous log covariate. Of the 34 autografted patients, 31 had MRD2 evaluation and, according to the protocol, 28 had MRD2 <0.1%. When restricting the comparison to patients achieving major MRD2 response and with the current follow-up, a trend for better results was observed after autologous as compared to allogeneic SCT (RFS, 63% versus 49.5% and OS, 69% versus 58% at 3 years; P=0.35 and P=0.08, respectively). Conclusions: In adults, the use of TK inhibitors (TKI) has markedly improved the results of Ph+ ALL therapy, now close to those observed in Ph-negative ALL. We demonstrated here that chemotherapy intensity may be safely reduced when associated with high-dose IM. We will further explore this TKI-based strategy using nilotinib prior to SCT in our next GRAAPH-2013 trial. The trend towards a better outcome after autologous compared to allogeneic SCT observed in MRD responders validates MRD as an important early surrogate endpoint for treatment stratification and new drug investigation in this disease.

Efeito da densidade de plantas e da adubação NPK na produção inicial de palmito de pupunheira

Avaliaram-se os efeitos da densidade de plantas e doses de adubação na produção de palmito de pupunheira, em condições de campo, na Fazenda Yuricam, Rio Preto da Eva (AM). O delineamento experimental foi de blocos casualizados com três repetições, com os tratamentos em arranjo fatorial 3 x 5, sendo avaliados os fatores: densidade de plantas (10.000; 5.000 e 3.333 plantas ha-1) e doses de adubação NPK (0-0-0; 112,5-12,5-90; 337,5-38-270; 225-90-180, 225-25-180 em kg ha-1 de N, P2O5 e K2O, respectivamente). Os resultados do primeiro ano de produção de palmito, em termos de estipes colhidas, para efeito das doses de adubação NPK, foram: 225-90-180 (66 %); 225-25-180 (57 %); 337,5-38-270 (50 %); 112,5-12,5-90 (26 %); 0-0-0 (1 %) - os números entre parênteses indicam os percentuais de plantas coletadas em relação às plantadas - e para efeitos de densidade: 3.333 plantas ha-1 (58 %); 5.000 plantas ha-1 (28 %); 10.000 plantas ha-1 (40 %). O tempo médio para extração de palmito foi menor na densidade de 3.333 plantas ha-1 (18,4 meses) e na dose de adubação NPK de 225-90-180 (18,1 meses). O efeito simples da adubação NPK dentro da densidade de 10.000 plantas ha-1 com a adubação 225-90-180 e 225-25-180 apresentou maior produção de palmito, com 841 e 779 kg ha-1, e de 1.154 e 1.223 kg ha-1 de estipe tenro, respectivamente, nas duas adubações.

Quantification of brain glycogen concentration and turnover through localized 13C NMR of both the C1 and C6 resonances.

We have recently shown that at isotopic steady state (13)C NMR can provide a direct measurement of glycogen concentration changes, but that the turnover of glycogen was not accessible with this protocol. The aim of the present study was to design, implement and apply a novel dual-tracer infusion protocol to simultaneously measure glycogen concentration and turnover. After reaching isotopic steady state for glycogen C1 using [1-(13)C] glucose administration, [1,6-(13)C(2)] glucose was infused such that isotopic steady state was maintained at the C1 position, but the C6 position reflected (13)C label incorporation. To overcome the large chemical shift displacement error between the C1 and C6 resonances of glycogen, we implemented 2D gradient based localization using the Fourier series window approach, in conjunction with time-domain analysis of the resulting FIDs using jMRUI. The glycogen concentration of 5.1 +/- 1.6 mM measured from the C1 position was in excellent agreement with concomitant biochemical determinations. Glycogen turnover measured from the rate of label incorporation into the C6 position of glycogen in the alpha-chloralose anesthetized rat was 0.7 micromol/g/h.

Measures of health and disease in Africa: are current methods giving us useful information about trends in cardiovascular diseases?

An enormous burst of interest in the public health burden from chronic disease in Africa has emerged as a consequence of efforts to estimate global population health. Detailed estimates are now published for Africa as a whole and each country on the continent. These data have formed the basis for warnings about sharp increases in cardiovascular disease (CVD) in the coming decades. In this essay we briefly examine the trajectory of social development on the continent and its consequences for the epidemiology of CVD and potential control strategies. Since full vital registration has only been implemented in segments of South Africa and the island nations of Seychelles and Mauritius - formally part of WHO-AFRO - mortality data are extremely limited. Numerous sample surveys have been conducted but they often lack standardization or objective measures of health status. Trend data are even less informative. However, using the best quality data available, age-standardized trends in CVD are downward, and in the case of stroke, sharply so. While acknowledging that the extremely limited available data cannot be used as the basis for inference to the continent, we raise the concern that general estimates based on imputation to fill in the missing mortality tables may be even more misleading. No immediate remedies to this problem can be identified, however bilateral collaborative efforts to strength local educational institutions and governmental agencies rank as the highest priority for near term development.

Efeito da Gliricidia sepium sobre nutrientes do solo, microclima e produtividade do milho em sistema agroflorestal no Agreste Paraibano

Gliricidia sepium é uma leguminosa arbórea que tem sido utilizada em sistemas em aléias no semi-árido nordestino por apresentar bom desenvolvimento em condições de estresse hídrico. Entretanto, há pouca informação disponível sobre o efeito da introdução dessa espécie nos agroecossistemas da região. No presente estudo, objetivou-se avaliar a influência da distância de plantas de Gliricidia sepium sobre características da cultura do milho e do solo e microclima no Agreste Paraibano. O estudo foi realizado no município de Esperança (PB), em área de 0,5 ha, onde, em 1996, foram plantadas fileiras de G. sepium espaçadas 6 m entre si e com 1 m entre as árvores. Nesta área, em 2002, foram delimitadas quatro parcelas de 6 x 8 m e, em cada parcela, foi estabelecido um transeto perpendicular às fileiras de árvores com três posições de amostragem: (1) nas fileiras de árvores (0 m); (2) a 1 m das fileiras de árvores, e (3) a 3 m de distância das fileiras de árvores. O delineamento experimental utilizado foi em blocos casualizados com quatro repetições. A massa seca de folhedo caído embaixo da fileira de árvores foi de 1.390 kg ha-1 e diminuiu, gradativamente, para 270 kg ha-1 a 3 m de distância das árvores. As concentrações de P, K e matéria orgânica leve (MOL) embaixo das árvores foram maiores do que a 1 e 3 m de distância das fileiras. As médias mensais das temperaturas mínimas do ar e do solo embaixo e a 3 m das árvores foram similares. Entretanto, as médias mensais das temperaturas máximas do solo e do ar foram de 6 e 2 °C mais altas a 3 m das árvores, respectivamente, ao longo do período de estudo. A umidade do solo foi significativamente menor embaixo das árvores do que a 1 e 3 m de distância. O milho produziu mais grãos e palha e acumulou mais nutrientes nas posições mais próximas das fileiras de G. sepium.

Efeito de aplicações de lodos de esgoto sobre os teores de metais pesados em folhas e grãos de milho

O lodo de esgoto é uma fonte importante de nutrientes para as culturas; contudo, os teores de metais pesados em sua constituição podem limitar seu uso em solos agrícolas. O objetivo deste estudo foi avaliar o efeito de doses de lodos de esgoto oriundos das Estações de Tratamento de Esgoto de Barueri (LB) e de Franca (LF), SP, sobre os teores de metais pesados em folhas e grãos de milho. O experimento foi realizado no Campo Experimental da Embrapa Meio Ambiente, em Jaguariúna (SP), no período de 1999 a 2001. Foram realizados três cultivos sucessivos de milho, com os seguintes tratamentos: testemunha absoluta; adubação mineral (NPK) recomendada para a cultura do milho, lodo de esgoto com base no teor de N para fornecer uma, duas, quatro e oito vezes a dose de N da adubação mineral. Avaliaram-se os teores totais (digestão nítrico-perclórica) de Cu, Mn, Ni, Pb e Zn em folhas e grãos de milho. A aplicação sucessiva dos lodos de esgoto acarretou aumento nos teores de Mn e Zn em folhas e grãos de milho. Em relação ao tratamento testemunha, a aplicação da dose mais elevada do LB (8LB) promoveu um incremento de até 270 e 625 % e de 35 e 115 % nos teores de Mn e Zn, respectivamente, nas folhas e grãos de milho. As folhas apresentaram maiores teores de metais pesados do que os grãos, o que envolve maior possibilidade de transferência de metais para a cadeia alimentar, caso essa parte da planta seja consumida. Essa elevação nos teores de metais pesados em folhas e grãos de milho, até à terceira aplicação dos lodos, não foi suficiente para atingir os níveis considerados fitotóxicos para o milho, tampouco para inviabilizar o uso dos grãos para o consumo humano.

Depleção de formas de potássio do solo afetada por cultivos sucessivos

A absorção de K pelas plantas, em geral, é maior que a quantidade inicial de K trocável, indicando que formas não-trocáveis contribuem no suprimento deste nutriente às plantas. O trabalho objetivou avaliar a depleção de formas de K por cultivos sucessivos em um solo com textura superficial arenosa, com ou sem histórico de adubação potássica. O experimento foi realizado na casa de vegetação do Departamento de Solos da Universidade Federal de Santa Maria, Santa Maria, RS. Amostras superficiais (0-0,10 m) de um Argissolo Vermelho distrófico arênico, sem ou com histórico de adubação potássica, foram submetidas à aplicação total de 0, 90 e 270 mg kg-1 de K e a cinco cultivos sucessivos com plantas em vasos. Na colheita, a parte aérea das plantas foi cortada rente à superfície do solo e seca em estufa, sendo determinados a matéria seca e o K. Uma amostra de solo na camada de 0-10 cm foi coletada, seca, moída e passada em peneira de malha de 2 mm; a extração do K trocável foi feita pelo extrator Mehlich-1; do K não-trocável, pelo tetrafenil de sódio (Na-TFBo) e HNO3 1 mol L-1 fervente; e do K total, pelo HF. A capacidade de suprimento de K do solo às plantas depende mais de suas características próprias que do seu histórico de adubação potássica. A absorção de K pelas plantas desencadeia um processo contínuo de depleção de diferentes formas de K, a qual é mais acentuada quando os teores de K disponíveis são mais baixos.

Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients.

INTRODUCTION: Oxidative stress is involved in the development of secondary tissue damage and organ failure. Micronutrients contributing to the antioxidant (AOX) defense exhibit low plasma levels during critical illness. The aim of this study was to investigate the impact of early AOX micronutrients on clinical outcome in intensive care unit (ICU) patients with conditions characterized by oxidative stress. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled, single-center trial in patients admitted to a university hospital ICU with organ failure after complicated cardiac surgery, major trauma, or subarachnoid hemorrhage. Stratification by diagnosis was performed before randomization. The intervention was intravenous supplements for 5 days (selenium 270 microg, zinc 30 mg, vitamin C 1.1 g, and vitamin B1 100 mg) with a double-loading dose on days 1 and 2 or placebo. RESULTS: Two hundred patients were included (102 AOX and 98 placebo). While age and gender did not differ, brain injury was more severe in the AOX trauma group (P = 0.019). Organ function endpoints did not differ: incidence of acute kidney failure and sequential organ failure assessment score decrease were similar (-3.2 +/- 3.2 versus -4.2 +/- 2.3 over the course of 5 days). Plasma concentrations of selenium, zinc, and glutathione peroxidase, low on admission, increased significantly to within normal values in the AOX group. C-reactive protein decreased faster in the AOX group (P = 0.039). Infectious complications did not differ. Length of hospital stay did not differ (16.5 versus 20 days), being shorter only in surviving AOX trauma patients (-10 days; P = 0.045). CONCLUSION: The AOX intervention did not reduce early organ dysfunction but significantly reduced the inflammatory response in cardiac surgery and trauma patients, which may prove beneficial in conditions with an intense inflammation. TRIALS REGISTRATION: Clinical Trials.gov RCT Register: NCT00515736.

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Combined efficacy of acamprosate and disulfiram in the treatment of alcoholism: a controlled study.

This study presents the results of a multicenter investigation of the efficacy of acamprosate in the treatment of patients with chronic or episodic alcohol dependence. One hundred eighteen patients were randomly assigned to either placebo or acamprosate, and both groups were stratified for concomitant voluntary use of disulfiram. Treatment lasted for 360 days, with an additional 360-day follow-up period. The primary efficacy parameters evaluated were: relapse rate and cumulative abstinence duration (CAD). Results were analyzed according to Intention-To-Treat principles using chi2, t, and multiple regression analyses where appropriate. After 30 days on study medication, 40 of 55 (73%) acamprosate-treated patients were abstinent, compared with 26 of 55 (43%) placebo-treated patients (p = 0.019). The treatment advantage remained throughout the study medication period and was statistically significant until day 270 (p = 0.028). Twenty-seven percent of patients on acamprosate and 53% of patients on placebo had a first drink within the first 30 days of the study. The mean CAD was 137 days (40% abstinent days) for the patients treated with acamprosate and 75 days (21% abstinent days) for the placebo group (p = 0.013). No adverse interaction between acamprosate and disulfiram occurred, and the subgroup who received both medications had a better outcome on CAD than the those on only one or no medication. Acamprosate was well tolerated. Diarrhea was the only significant treatment-induced effect. It was concluded that acamprosate was a useful and safe pharmacotherapy in the long-term treatment of alcoholism. Concomitant administration of disulfiram improved the effectiveness of acamprosate.

Soil phosphorus dynamics and availability and irrigated coffee yield

Research data have demonstrated that the P demand of coffee (Coffea arabica L.) is similar to that of short-cycle crops. In this context, the objective of this study was to evaluate the influence of annual P fertilization on the soil P status by the quantification of labile, moderately labile, low-labile, and total P fractions, associating them to coffee yield. The experiment was installed in a typical dystrophic Red Latosol (Oxisol) cultivated with irrigated coffee annually fertilized with triple superphosphate at rates of 0, 50, 100, 200, and 400 kg ha-1 P2O5. Phosphorus fractions were determined in two soil layers: 0-10 and 10-20 cm. The P leaf contents and coffee yield in 2008 were also evaluated. The irrigated coffee responded to phosphate fertilization in the production phase with gains of up to 138 % in coffee yield by the application of 400 kg ha-1 P2O5. Coffee leaf P contents increased with P applications and stabilized around 1.98 g kg-1, at rates of 270 kg ha-1 P2O5 and higher. Soil P application caused, in general, an increase in bioavailable P fractions, which constitute the main soil P reservoir.