Evaluation of the usefulness of open lung biopsies

The role of open lung biopsy (OLB) in the diagnosis of the etiology of lung infiltrates in children was analyzed for a 10-year period 1979-1989 in a tertiary referral center. A total of 18 children had 19 lung biopsies to ascertain the cause of lung infiltrates. Thirteen of these children (72%) were immunocompromised due to treatment of hematological/solid malignancies and bone marrow transplantation. The clinical diagnosis was bilateral lung infiltrates of unknown etiology in 17 of 18 children. Eight of these children were ventilated for respiratory failure. The biopsy was useful in achieving a histological diagnosis in 18 of 19 samples (diagnostic yield 95%) and an etiological diagnosis in 14 of 19 samples (etiological yield 74%). Therapeutic strategy was altered in 14 of 18 patients based on the biopsy results. Five of 14 patients responded favorably to a change in specific treatment. The time interval from onset of respiratory illness to biopsy was 2-60 days (mean 16 days). Despite the critical state of these children there were few complications associated with the biopsy and no mortality directly related to the procedure. We recommend that OLB be undertaken sooner rather than later in immunocompromised children with bilateral pulmonary infiltrates of unknown etiology.

p53 germline mutations in Li-Fraumeni syndrome

Germline mutations within a defined region of the p53 gene have recently been found in families with the Li-Fraumeni syndrome (LFS). In the present study this region of p53 was sequenced in affected individuals from 8 families with LFS. In only 2 of them were such mutations detected. Our findings suggest that the p53 mutation could be the primary lesion in some but not all families with LFS, and confirm that there is a "hot spot" for these mutations at the CpG dinucleotide moiety of codon 248. Assigning risks and counselling families on the basis of presence of p53 mutations should be approached with caution.

SC-46275: a potent, long-acting gastric antisecretory prostaglandin with low oral bioavailability in the dog

The synthetic prostaglandin, SC-46275, an omega chain cyclopentenyl analog of enisoprost, was studied to determine its gastric antisecretory potency and duration of action in meal-stimulated innervated (Pavlov) pouch dogs and its p.o. bioavailability in unoperated fasted dogs. SC-46275 exhibited potent antisecretory activity when administered directly into the gastric pouch, the ED50 being 0.01 micrograms/kg. It had a long duration of antisecretory action; significant (P less than or equal to .05) inhibition of total acid output was observed 16 hr after intrapouch administration of 0.03 micrograms/kg. At this dose p.o., neither SC-46275 nor its free acid metabolite was detected in plasma. These data indicate that SC-46275 has novel properties: it is a potent, long-acting gastric antisecretory agent which is not readily available systemically after p.o. administration. Thus, potential systemic side effects are expected to be absent or minimized at doses of SC-46275 which inhibit gastric acid secretion, and therefore it might be useful in peptic ulcer disease.

Omeprazole and Helicobacter pylori: temporary suppression rather than true eradication

Twenty-four Helicobacter pylori (H. pylori)-positive patients were treated for 28 days with either 20 mg omeprazole o.m. (n = 12) or 40 mg omeprazole o.m. (n = 12). Clearance (absence of H. pylori at the end of or shortly after treatment) and eradication (absence of H. pylori 1 month after cessation of treatment) were assessed using the 14C-urea breath test. Observed clearance and eradication were: 20 mg omeprazole 3/12 and 0/12; 40 mg omeprazole 6/12 and 1/12 respectively. The effect on H. pylori is probably due to the change in gastric pH from acid to neutral, however it is insufficient to recommend the inclusion of omeprazole in regimens aimed at eradicating H. pylori.

Therapeutic radiation at a young age is linked to secondary thyroid cancer. The Late Effects Study Group

We estimated the risk of thyroid cancer among 9170 patients who had survived 2 or more years after the diagnosis of a cancer in childhood. As compared with the general population, patients had a 53-fold increased risk (95% confidence interval, 34-80). Risk increased significantly with time since treatment for the initial cancer (P = 0.03). Detailed treatment data were obtained for 23 cases and 89 matched controls from the childhood cancer cohort. Sixty-eight % of the thyroid cancers arose within the field of radiation. Radiation doses to the thyroid of greater than 200 cGy were associated with a 13-fold increased risk (95% confidence interval, 1.7-104). The risk of thyroid cancer rose with increasing dose (P less than 0.001), but this was derived almost entirely from the increase from less than 200 to greater than 200 cGy. The risk of thyroid cancer did not decrease, however, at radiation doses as high as 6000 cGy.

Once-daily pravastatin in patients with primary hypercholesterolemia: a dose-response study

This multicenter, double-blind, placebo-controlled study was conducted to evaluate dose-response effects and safety of once-daily administration of pravastatin, a new inhibitor of 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase. Pravastatin 5, 10, 20, 40 mg or placebo was administered at bedtime to 150 patients with primary hypercholesterolemia inadequately controlled on a low-fat, low-cholesterol (AHA Phase I) diet. After 8 weeks of treatment, pravastatin produced dose-dependent reductions in low-density lipoprotein (LDL) cholesterol of 19.2 to 34.1% (p less than or equal to .001 vs. baseline and placebo) and reductions in total cholesterol of 14.3 to 25.1% (p less than or equal to .01 to p less than or equal to .001 vs. placebo and p less than or equal to .001 vs. baseline). The relationship between the loge dose of pravastatin and decrease in LDL cholesterol was linear (p less than 0.002). High-density-lipoprotein cholesterol increased up to 11.7% and triglycerides decreased by as much as 23.9%. Pravastatin was well tolerated; no patient withdrew from the study as a consequence of treatment-related adverse events. Despite its relatively short serum half-life of approximately 2 h, once-daily administration of pravastatin provides a safe and effective means of reducing elevated LDL and total cholesterol.

Helicobacter pylori infection treated with a tripotassium dicitrato bismuthate and metronidazole combination

Seventy-two patients with H. pylori infection in their antral mucosa took part in the study. Forty-three received metronidazole 400 mg t.d.s. for two weeks, plus De-Nol tabs 2 b.d. for four weeks, and the remaining 29 patients received metronidazole 400 mg t.d.s. for two weeks plus De-Nol liquid 5 ml q.d.s. for four weeks. Seven of 57 H. pylori isolates were found to have pre-treatment metronidazole resistance. Success, in terms of eradication of H. pylori, was assessed using a one-month post-treatment 14C urea breath test. Successful eradication of H. pylori was achieved in 72% and 79%, respectively, of the metronidazole/De-Nol tablet and metronidazole/De-Nol liquid groups. These figures increased to 87% and 84%, respectively, if the patients whose organisms were known to be metronidazole-sensitive were considered in isolation. H. pylori was successfully eradicated in only one of seven patients with a metronidazole-resistant organism.

Cancer in the families of children with soft tissue sarcoma

The cancer experience among 754 first-degree relatives (mothers, fathers, and siblings) of a population-based series of 177 children with soft tissue sarcoma is reported. The current study represents an extension of our earlier work in which the authors found an excess of breast cancer in the mothers of 143 of these children. There were 40 cancers among all first-degree relatives, compared with 24.82 expected (relative risk [RR] 1.61, P = 0.006). There was no excess in fathers, but an excess of borderline significance was seen in mothers (RR 1.67, P = 0.0545), and a significant excess in siblings (RR 4.55, P = 0.0002), mainly due to carcinoma of the breast and pediatric tumors. Results of a step forward Cox multivariate analysis identified three variables in the index child which were independently associated with high cancer risk in relatives, as follows: age younger than 24 months at diagnosis; histologic type, embryonal rhabdomyosarcoma or other and unspecified soft tissue sarcoma; and male sex. It was possible, therefore, to identify a subgroup of children whose relatives are at high risk of early onset cancer (RR in this group 10.14). The pattern of cancers is consistent with the Li-Fraumeni syndrome. The authors conclude that a marked proportion of childhood soft tissue sarcoma has a genetic basis.

Chemistry and structure-activity relationships of C-17 unsaturated 18-cycloalkyl and cycloalkenyl analogues of enisoprost. Identification of a promising new antiulcer prostaglandin

A series of delta 17 unsaturated cycloalkyl and cycloalkenyl analogues of enisoprost was synthesized to investigate the effects of omega chain unsaturation on gastric antisecretory activity and diarrheogenic side effects. Of these, the 17E, 18-cyclopentenyl analogue 5d displayed potent gastric antisecretory activity in dogs but very weak diarrheogenic properties in rats and is the most selective prostaglandin compound discovered in these laboratories. Structurally, 5d contains both a conjugated diene and tertiary allylic alcohol in the omega chain, and these chemical features impart some interesting oxidative and acid-catalyzed epimerization and allylic rearrangement reactivities, respectively.

Lovastatin and simvastatin prevention studies

There is substantial evidence that drug treatment of hypercholesterolemia in patients without known coronary artery disease (CAD) can reduce fatal and nonfatal CAD events. Two trials, the Lipid Research Clinics Coronary Primary Prevention Trial and the Helsinki Heart Study used cholestyramine and gemfibrozil, respectively, to alter lipoprotein levels; their demonstrated efficacy and safety have led to their widespread use in hyperlipidemic patients. Recently, a new class of hypolipidemic agents has been shown to be extremely effective in lowering total and low-density lipoprotein cholesterol levels. These drugs, including lovastatin and simvastatin, competitively inhibit 3-hydroxy-3-methylglutaryl coenzyme A reductase, the rate-limiting enzyme of intracellular cholesterol synthesis. Results of safety and efficacy studies suggest that they may be valuable first-line treatment options for high-risk hypercholesterolemic patients. Two long-term clinical trials are planned with lovastatin and simvastatin. In the United States, lovastatin will be used in a double-blind, placebo-controlled, primary prevention trial involving 8,000 patients without clinical evidence of CAD, slight to moderate elevations of total cholesterol, and low- and high-density lipoprotein cholesterol to establish whether 5 years of treatment will decrease the rate of fatal CAD or nonfatal myocardial infarction. A Scandinavian study of 4,000 patients with ischemic heart disease and hypercholesterolemia will determine if simvastatin will improve total survival and reduce fatal or nonfatal myocardial infarction and sudden death for at least 3 years. These study designs will be discussed and compared with other studies, and the expected impact on CAD event rates presented.

Surgery in allergic nasal and paranasal disease

This paper summarizes an ENT surgeon's view of allergic rhinitis and deals with the presenting complaints and symptoms of allergic and non-allergic rhinitis, suggests the important features of the history and examination and indicates the more important special investigations; the medical and surgical treatments available to deal with the symptoms of rhinitis are discussed.

Identification of factors associated with high breast cancer risk in the mothers of children with soft tissue sarcoma

Information on the past medical history of the mothers of a population-based series of 177 children with soft tissue sarcoma was obtained by interview and from medical records. Eight mothers developed breast cancer, six premenopausally, compared with 3.26 expected (P = .04), but no excess of other types of cancers was detected. High breast cancer risk was associated with the following factors in the index child: age at diagnosis less than 24 months (relative risk [RR], 7.84), embryonal rhabdomyosarcoma (RR, 3.74), and male sex (RR, 3.02). Characteristics in the mother associated with high breast cancer risk were the following: late age at first birth (RR, 5.13), late age at birth of index child (RR, 5.69), and high birth-rank order of index child (RR, 4.08). The results suggest there may be a subset of childhood soft tissue sarcoma with a predominantly genetic etiology. The association between premenopausal breast cancer in the mother, late age at birth of index child, and early onset of soft tissue sarcoma in the index child suggests that these three events are not independent and that interactions between genetic and other factors may be important. The identification of a group of women at high risk for breast cancer affords an opportunity for screening and early detection. The study of cancer family syndromes may provide insights into underlying mechanisms in cancer genetics.

Sarcomas in three generations of a family with neurofibromatosis

The development of sarcomas in three generations of a family with neurofibromatosis (NF) is described. A 7-month-old boy developed a prostatic rhabdomyosarcoma. Family history revealed that his maternal grandmother had died of a malignant peripheral nerve sheath tumor at age 37 years and had been affected with neurofibromatosis. His mother (aged 36 years) has also developed a malignant peripheral nerve sheath tumor and NF has been confirmed in both mother and son. This family illustrates a cluster of sarcomas associated with NF and shows the importance of thorough investigation of reported family illnesses.

Potential antisecretory antidiarrheals. 2. Alpha 2-adrenergic 2-[(aryloxy)alkyl]imidazolines

Lofexidine, an alpha 2-agonist, has central hypotensive activity and peripheral intestinal antisecretory activity. Analogues were synthesized with increased polarity in an attempt to prevent penetration of the blood-brain barrier. The compounds were evaluated in the cholera toxin treated ligated jejunum of the rat and in the Ussing chamber with a rabbit ileum preparation. Active compounds were determined to be alpha 2-adrenergic agonists by yohimbine reversals of their Ussing chamber activities. The 2,6-dimethyl derivative of lofexidine, 4a, was as active as lofexidine in vivo, but derivatives with 2,6-substituents larger than ethyl were inactive. (Aryloxy)alkyl derivatives which have an imidazoline and a methyl or larger group as part of the alkyl exhibited the best antisecretory activity. Compounds with substituents in the para position of the phenyl ring were generally inactive. 3-Amino-2,6-dimethyl derivative 21 was twice as active as 4a. A 2-methyl substituent is required in the 3-amino series to retain good activity. 2-Methyl derivative 12a had activity comparable to that of 4a, while 6-methyl derivative 12f was inactive. Substituents on the 3-amino group did not affect the activity, but substituting a hydroxyl for the amino group produced an inactive compound. Replacing the phenyl moiety with a 4-indole resulted in retention of activity, but other heterocycles were inactive. Compound 12a was resolved and d isomer 32 was five times more potent than l isomer 33. The more active compounds in the rat cholera toxin assay (RCTA), when evaluated in the dog, exhibited antisecretory activity but also exhibited central nervous system (CNS) effects, sedation and ataxia, at 10 mg/kg, and in spontaneously hypertensive rats at 50 mg/kg. A measure of polarity, log P, was calculated for the (aryloxy)alkyl groups. Regression analysis showed no correlation of antisecretory ED50 to the calculated log P. The active compounds did not show a separation of the central CNS effects from the peripheral antisecretory activity by increasing the polarity.

Epidemiological and familial aspects of hepatoblastoma

Data on the 20 cases of hepatoblastoma registered with the Manchester Children's Tumour Registry between 1954 and 1988 are presented. The cases represent about 0.6% of childhood malignancies and show a male:female ratio of 2.3:1. Age at presentation was almost always under 2 1/2 years. Cancer rates in close relatives were not significantly different from those expected. One family was confirmed as having Gardner syndrome, but the presence of other syndromes e.g., Beckwith-Wiedemann, could not be reliably detected in this retrospective series. The need to take an extensive pedigree and for clinical examination of other family members at the time of the child's diagnosis is emphasized.

18-cycloalkyl analogues of enisoprost

By use of standard cuprate methodology, a series of 18-cycloalkyl analogues of enisoprost was prepared in an effort to impede omega chain metabolism and prolong duration of gastric antisecretory activity. An initial product of omega chain oxidation, the C-20 hydroxy analogue, was also synthesized for pharmacological comparison. The cyclopropyl, cyclobutyl, and cyclopentyl analogues were approximately one-fourth as potent as enisoprost in inhibiting gastric acid secretion, while the cyclohexyl and cycloheptyl analogues showed very weak activity, and the 20-hydroxy compound was inactive at a dose 100 times the ED50 of enisoprost. The cyclobutyl compound had a longer duration of antisecretory action than enisoprost and the other cycloalkyl analogues. The cycloalkyl analogues unexpectedly possessed low diarrheogenic activity in rats.

Ovarian function following chemotherapy for childhood brain tumours

Pubertal development, basal gonadotrophin, and oestradiol levels were assessed in 21 girls who had received neuroaxis irradiation for a brain tumour followed by adjuvant chemotherapy with carmustine (BCNU) or lomustine (CCNU) and procarbazine. Thirteen received chemotherapy before the age of 11 years. Ten remained prepubertal at their last assessment, nine of whom showed biochemical evidence of primary ovarian failure. The remaining three were pubertal or adult, and although basal follicle-stimulating hormone (FSH) and luteinising hormone (LH) levels were normal, all had shown abnormalities of gonadotrophin secretion previously. Eight girls received chemotherapy after 11 years of age. Only three girls exhibited an elevated basal FSH level or exaggerated FSH response to GnRH. Elevated basal FSH values had been noted previously in two of the other five girls. All girls entered or progressed through puberty spontaneously. Seven experienced menarche at an appropriate age. However in four, gonadotrophin levels, which had been elevated, were now within the normal range. In two, menses had continued throughout with normal midfollicular oestradiol levels, whilst the other two developed secondary amenorrhoea associated with radiation-induced gonadotrophin deficiency. The majority of girls showed evidence of primary ovarian dysfunction. This did not prejudice pubertal development or the timing of menarche. Ovarian function may return to normal in the years after treatment, indicating a potential for fertility.