Participation in a workplace web-based health risk assessment program.

BACKGROUND: Web-based health risk assessment (HRA) programs can be effective in primary prevention of cardiovascular diseases (CVD). Insight into determinants of participation could improve implementation in the workplace. AIMS: To evaluate determinants of participation and reasons for non-participation in a web-based HRA offered to 5125 employees at four Dutch financial and information technology services companies. METHODS: The study consisted of a questionnaire to compare sex, age, self-rated health, smoking, current work ability and sick leave between participants and non-participants in the HRA program, as well as reasons for non-participation. RESULTS: HRA participation rate was 37% (1907/5125) and 14% of the non-participants (423/3102) completed the non-participant questionnaire. There were no differences between participants and non-participants in sex, education level, smoking, and current work ability. Compared with non-participants, participants were older (44 versus 41 years, P < 0.001). Among participants, 85% rated their health as 'good' or 'very good', compared with 78% among non-participants (P < 0.001); 88% of the participants reported fewer than 10 days sickness absence in the previous year, compared with 86% of the non-participants (P < 0.05). Reported reasons for non-participation included lack of time (39%) and not being aware of the opportunity to participate (11%). CONCLUSIONS: Evaluation of demographic, health-related, and work-related determinants of participation in a web-based HRA showed differences between participants and non-participants in self-rated health and absenteeism. Implementing a less time-consuming HRA process and providing adequate information to employees prior to inviting them may be necessary to reach larger proportions of employees, including those with less favourable health and work characteristics.

Prognostic relevance of P-glycoprotein expression in breast cancer.

BACKGROUND: P-glycoprotein (Pgp) expression has been reported to be associated with a poor prognosis in some malignancies such as neuroblastoma, soft tissue sarcoma and acute myeloid leukemia. The prognostic role of Pgp expression in breast cancer is still unclear. We investigated the expression of Pgp in primary and metastatic breast cancer tissues in relation to patient characteristics and treatment outcome. PATIENTS AND METHODS: Pgp expression was evaluated in 92 primary and 12 metastatic breast cancers by the use of immunohisto/cytochemistry with three monoclonal antibodies (MAbs) (JSB-1, C219, MRK16), and an RNAse protection assay. Follow-up information was available for 77 primary breast cancer patients (median follow-up 42 months; range 2-63 months). RESULTS: Concordance among the anti-Pgp MAbs varied, the highest being between JSB-1 and MRK16 (71%; p=0.002). Pgp expression was more frequent in metastatic disease (58%) than in primary breast cancer (29%) (JSB-1; p=0.055). Pgp expression as assessed with JSB-1 (univariate analysis; p<0.05) was associated with shorter overall survival (OS). Nineteen (21%) primary breast cancers had Pgp expression in fibroblasts in desmoplastic stroma and this did not correlate with Pgp expression in the tumor. The combination of Pgp-positive tumor cells and Pgp-expressing fibroblasts was the strongest prognostic factor for OS by multivariate analysis. Subgroup analysis suggested that Pgp expression was associated with a shorter OS in tamoxifen-treated patients, but not in those who received chemotherapy (most often CMF). CONCLUSIONS: Pgp expression in tumor cells, and especially when accompanied by Pgp expression in fibroblasts in desmoplastic stroma, has prognostic value in primary breast cancer patients and is likely to be a marker of a more malignant phenotype. Pgp expression of tumor cells might play a role in tamoxifen resistance. These findings may have important implications for teh treatment of breast cancer patients, and warrant further prospective investigation in a larger patient population.

Clinical and pharmacologic study of multidrug resistance reversal with vinblastine and bepridil.

PURPOSE: To achieve an adequate plasma concentration of bepridil, a calcium channel blocker, which reverts multidrug resistance (MDR) in vitro, when administered in combination with vinblastine in patients with advanced colorectal cancer, a tumor characterized by high MDR1 gene expression. To study the pharmacokinetics of both drugs, tolerability and antitumor activity in relation to the MDR1 expression in tumor tissue. PATIENTS AND METHODS: Sixteen colorectal cancer patients entered the study. Bepridil was administered by central venous catheter as 5-mg/kg bolus over 30 minutes, followed by 12 mg/kg for 12 hours and 5 mg/kg for 24 hours. Vinblastine 5 mg/m2 was administered as an intravenous (i.v.) bolus 24.5 hours after the start of bepridil. MDR1/P-glycoprotein (Pgp) expression was assessed in 14 tumor samples by immunohistochemistry and RNase protection assay. RESULTS: The bepridil plasma level was greater than 2 mumol/L at the time of vinblastine administration in all patients investigated. At the dose used in the study, bepridil produced a QTc-prolongation more than 50 ms, which prevented further dose escalation. However, cardiac toxicity was asymptomatic in all treated patients, and other side effects were mild. MDR1/Pgp expression was positive in nine of 14 cases. Of fifteen patients assessable for response, one complete remission of 8 months' duration and 14 progressions were observed. The responding patient attained complete remission again when re-treated on progression with vinblastine alone. CONCLUSION: Bepridil plasma concentrations needed in vitro to modulate MDR could be achieved in this study with tolerable toxicity; however, despite most tumors being MDR1/Pgp-positive, no response was obtained that could be attributed to the drug combination. Mechanisms of drug resistance other than MDR are probably implicated in drug resistance of colorectal cancer.

Overexpression of a M(r) 110,000 vesicular protein in non-P-glycoprotein-mediated multidrug resistance.

A M(r) 110,000 protein (p110) is overexpressed in P-glycoprotein-negative multidrug-resistant tumor cell lines of different histogenetic origins. These cell lines show an ATP-dependent drug accumulation defect, suggesting the presence of drug transporter molecules different from P-glycoprotein. Immunohistochemical staining with a p110-specific monoclonal antibody (LRP-56) showed that, like P-glycoprotein, the molecule has a high expression in normal epithelial cells and tissues chronically exposed to xenobiotics and potentially toxic agents, such as bronchial cells, cells lining the intestines, and kidney tubules. Staining of LRP-56 is primarily cytoplasmic, in a coarsely granular fashion, indicating that it reacts with a molecule closely associated with vesicular/lysosomal structures. Involvement of p110 in the energy-dependent drug transport process present in the cell lines is unknown.

Cortisol is transported by the multidrug resistance gene product P-glycoprotein.

The physiology of the multidrug transporter P-glycoprotein (Pgp) is still poorly understood. We now show evidence that cell lines with a high expression of Pgp display a reduced accumulation of cortisol and an ATP-dependent outward transport of the hormone. Cortisol efflux from Pgp negative cells does not have such an active component. Further we show that the steroid hormones cortisol, testosterone, and progesterone cause an immediate, dose-dependent increase of daunorubicin accumulation in Pgp overexpressing cells. These effects are particularly apparent for the more lipophilic steroids. These results demonstrate that Pgp may function as a transporter for cortisol and suggest a physiological role of the protein in steroid handling by organs such as the adrenal.

Multidrug resistance gene (P-glycoprotein) expression in the human fetus.

P-glycoprotein, a transmembrane protein associated with multidrug resistance in cancer cells, is also expressed in normal tissues. To get more insight into the physiologic role of mdr1/P-glycoprotein, we investigated its expression in human fetal tissues after 7 to 38 weeks of gestation by an immunohistochemical technique, using three different monoclonal antibodies, and by a sensitive RNAse protection assay. Expression of mdr1-mRNA could already be demonstrated in the embryonal phase of human development, after 7 weeks of gestation. Comparing the adult with the fetal tissue distribution, differences were found in specific organs, such as adrenal, intestine, respiratory epithelium, and brain capillaries. In the fetal zone cells of the fetal adrenal cortex no staining was observed by immunohistochemistry, whereas the definitive zone showed increasing expression throughout gestation. Prenatal intestine did not show staining of the epithelium, although definite mdr1-mRNA expression was observed in late specimens. Interestingly, respiratory epithelium of main bronchi and pharynx, not expressing P-gp in adults, did stain positive. Expression of P-gp in brain capillaries was not observed before the third trimester of pregnancy, whereas in kidney and liver, mdr1-mRNA expression and staining for P-glycoprotein were detected in early fetal life (11 to 14 weeks). These findings suggest a pivotal role of P-glycoprotein in physiology of various organs already in early phases of human development and may help to identify its physiologic substrates.

Early multidrug resistance, defined by changes in intracellular doxorubicin distribution, independent of P-glycoprotein.

Resistance to multiple antitumour drugs, mostly antibiotics or alkaloids, has been associated with a cellular plasma membrane P-glycoprotein (Pgp), causing energy-dependent transport of drugs out of cells. However, in many common chemotherapy resistant human cancers there is no overexpression of Pgp, which could explain drug resistance. In order to characterise early steps in multidrug resistance we have derived a series of P-glycoprotein-positive (Pgp/+) and P-glycoprotein-negative (Pgp/-) multidrug resistant cell lines, from a human non-small cell lung cancer cell line, SW-1573, by stepwise selection with increasing concentrations of doxorubicin. These cells were exposed to doxorubicin and its fluorescence in nucleus (N) and cytoplasm (C) was quantified with laserscan microscopy and image analysis. The fluorescence N/C ratio in parent cells was 3.8 and decreased both in Pgp/+ and Pgp/- cells with increasing selection pressure to 1.2-2.6 for cells with a resistance factor of 7-17. N/C ratios could be restored partly with verapamil only in Pgp/+ cells. N/C ratio measurements may define a general Pgp-independent type of defense of mammalian cells against certain anticancer agents which may precede Pgp expression in early doxorubicin resistance.

Bepridil in combination with anthracyclines to reverse anthracycline resistance in cancer patients.

The use of calcium antagonists as multidrug resistance reversing agents is limited by acute cardiac toxicity which, for verapamil, becomes prohibitive when concentrations in plasma approach those required in vitro for its action. A new calcium antagonist, bepridil, is as active as verapamil in reversing drug resistance in vitro. In addition, bepridil has some more favourable pharmacological properties compared with verapamil and other calcium antagonists. 14 patients with progressive advanced cancer, resistant to doxorubicin or epirubicin, were treated with the same anthracycline in combination with bepridil. Bepridil was administered in a continuous 36 h infusion at 22 mg/kg/36 h, with a dose scheme which should result in a steady state plasma concentration of approximately 5 mumol/l, able to reverse anthracycline resistance in vitro. Pharmacokinetic studies demonstrated a median bepridil plasma concentration of 5.3 mumol/l (range 2.6-19.3 mumol/l), at the time of administration of the anthracycline. No acute cardiac toxicity was observed and apparently bepiridil did not induce an increase or change in anthracycline toxicity. However, 2 patients developed overt chronic heart failure after treatment discontinuation, which caused 1 patient's death, and a significant reduction in left ventricular ejection fraction was seen in 4 patients. This chronic cardiac toxicity could be related to the total anthracycline dose received. 5 patients attained short lasting minor responses, 3 had stable disease and 6 progressed. Immunohistochemical studies in 7 tumours failed to reveal P-glycoprotein expression. Further trials with escalating doses of bepridil in combination with multiple drug resistance related anticancer agents are warranted.

Differentiation dependent expression of P-glycoprotein in the normal and neoplastic human kidney.

Adult renal cell carcinoma (RCC) is clinically resistant to chemotherapy. However, in nephroblastoma (NBL) chemotherapy has increased survival dramatically. We studied the P-glycoprotein (P-gp) expression of 18 RCC and 9 NBL as well as 1 benign renal adenoma and fetal renal tissue using three different monoclonal antibodies (MRK-16, C-219, JSB-1). P-gp was found positive with all three antibodies in 12/18 RCC, while only 2 tumors were completely negative. Staining varied with respect to intensity and number of positive cells [5%-90%]. Intense staining was seen at the apical side of malignant tubules in well differentiated parts of RCC and in tubular structures of the benign renal adenoma. Poorly differentiated parts of the tumors showed less staining. In NBL blastemal parts were negative. In 4/8 specimens showing focal epithelial differentiation, however, the luminal side of more differentiated tubular structures did stain, strongly resembling P-gp staining in the developing fetal human kidney. These results indicate that P-gp expression in normal (fetal) human kidney as well as in benign and malignant tumors derived from this organ depends on the degree of differentiation of tubules, which may have implications for chemotherapy sensitivity in both malignant tumors.

Differential sensitivity of multi-drug-resistant and -sensitive cells to resistance-modifying agents and the relation with reversal of anthracycline resistance.

Calcium channel blockers, calmodulin inhibitors, and some other classes of non-related compounds reverse multi-drug resistance. In the present study, we found that several resistance modifiers are more toxic for MDR cells than for the corresponding sensitive parent cells, whereas others show the opposite effect. Several calcium channel blockers including bepridil, diltiazem, nifedipine and verapamil, as well as the calmodulin inhibitor trifluoperazine, were more toxic for several MDR cell lines than for the parent cell lines. In contrast, cross-resistance for cyclosporin A and the verapamil analogue Ro II-2933/001 was observed in the MDR/sensitive cell couple CHRC5/AUXB1, probably due to a concentration-dependent stimulation of cell growth in the range of 0-4 microM cyclosporin A and of 1-4 microM Ro II-2933/001. In partially revertant CHRC5 cells, growth inhibition by Ro II-2933/001 at concentrations below I microM, as seen in CHRC5 cells, changed into growth stimulation, and the collateral sensitivity to verapamil and bepridil disappeared almost completely. In the MDR cells CHRC5, 2780AD and DC3F/DMXX, cross-resistance to another calcium channel blocking agent, Ro II-1781/001 (tiapamil), was observed as well. This compound showed exceptional behavior: it induced marked potentiation of Dx cytotoxicity as well as stimulation of Dx accumulation in AUXB1 cells, even at low tiapamil concentrations, but not in the CHRC5 cells, even at high concentrations. It is concluded that resistance modifiers can selectively influence growth of MDR cells via more than one process, and resulting in either strong growth inhibition in MDR cells relative to the effect on sensitive cells or in growth stimulation.

Distribution of multi-drug resistance-associated P-glycoprotein in normal and neoplastic human tissues. Analysis with 3 monoclonal antibodies recognizing different epitopes of the P-glycoprotein molecule.

P-glycoprotein is a molecule strongly associated with multi-drug resistance to certain cytostatic drugs, including adriamycin, vincristine, and daunorubicin. Using 3 monoclonal antibodies directed at different epitopes of this molecule (JSB-1, MRK16, C219) we investigated the tissue distribution of P-glycoprotein in normal and malignant human tissues, employing a routine immunoperoxidase technique. P-glycoprotein was found in the gastrointestinal epithelium, epithelia of the bronchi, mammary gland, pancreatic ducts, renal tubules, prostate gland, salivary gland, sweat glands of the skin, as well as in bile canaliculi and ductules, the adrenal and in endothelium of capillaries in various organs, most notably the brain. Mostly the pattern of reactivity of the 3 antibodies was similar, but some distinctly different staining reactions were seen. Reactivity was found in a variety of human tumors, arising from tissues normally expressing P-glycoprotein. Knowledge of the distribution and function of this molecule in both normal and malignant tissues may predict resistance and thus may influence choice of therapy. The role of P-glycoprotein in normal tissues and its implications for chemotherapy is discussed.

Pharmacokinetics of trimazosin and its effects on blood pressure, renal function and proteinuria during short-term therapy of patients with impaired renal function and hypertension.

The kinetics and short-term (10 weeks) effects of trimazosin, an alpha 1-adrenoreceptor antagonist, on renal function and blood pressure in patients with moderate chronic renal insufficiency and hypertension, have been studied for the first time. Eight patients in whom the blood pressure was not normalized with a diuretic alone underwent pharmacokinetic studies and assessment of the renal function during a 10-week period of trimazosin therapy. Trimazosin significantly lowered blood pressure (recumbent and upright) without significantly altering renal function. Renal vascular resistance was decreased by 14%. Fractional sodium excretion, proteinuria and laboratory serum tests remained unchanged. Neither body weight nor pulse rate were affected. Moderate renal insufficiency did not modify the pharmacokinetics of the drug. Thus, trimazosin, as second-step antihypertensive agent, appeared to be safe and effective in patients with moderate renal insufficiency and hypertension, without exerting favourable or adverse renal effects during short-term therapy.