Evaluation of continuous-infusion gallium nitrate and hydroxyurea in combination for the treatment of refractory non-Hodgkin's lymphoma

Based on preclinical studies demonstrating synergy between gallium and hydroxyurea, we evaluated the efficacy and toxicity of continuous intravenous gallium nitrate in combination with oral hydroxyurea in patients with refractory non-Hodgkin's lymphoma. Fourteen patients, median age 64 years (range 53-89), with stage III or IV low- or intermediate-grade lymphoma were treated with gallium nitrate and hydroxyurea in combination for 7 days at four different dose levels: (a) gallium nitrate, 200 mg/m2/day; hydroxyurea, 500 mg/day; (b) gallium nitrate, 250 mg/m2/day; hydroxyurea, 1,000 mg/day; (c) gallium nitrate, 300 mg/m2/day; hydroxyurea, 1,000 mg/day; and (d) gallium nitrate, 350 mg/m2/day, hydroxyurea, 1,000 mg/day. All patients had progressive disease and had been heavily pretreated. Six of 14 patients had objective tumor regression following treatment (one complete response, one near-complete response, and four partial responses) with a median duration of response of 7 weeks (range 3-38 weeks). An additional four patients had minor responses. Responses occurred at all dose levels and in both low- and intermediate-grade histologic subtypes. The predominant toxicities encountered were anemia and reversible nephrotoxicity. Combination gallium nitrate and hydroxyurea has significant activity in lymphoma and is well tolerated even by elderly patients. Because of the lack of cross-resistance to other drugs and the potential synergistic antineoplastic activity, gallium nitrate and hydroxyurea should be further evaluated in combination with other chemotherapeutic agents.

Characterisation of atherosclerotic plaque by spectral analysis of intravascular ultrasound: an in vitro methodology

Raw 30-MHz intravascular ultrasound data have been captured from postmortem coronary arteries (n = 4) to develop radio frequency analysis techniques for the characterisation of atherosclerotic plaque. Digitised data acquired from positions (n = 8) within diseased sections of artery were compared with the corresponding histology and radiology. Scan-converted images were used to locate regions of interest (ROI = 33) within areas of tissue composition: loose fibrotic tissue (LFT), dense fibrotic tissue (DFT) and calcium (CA). A range of parameters was extracted from the normalised power spectrum of each ROI within the bandwidth 17-42 MHz. Significant discrimination between LFT/DFT and between LFT/CA was provided by maximum power and spectral slope (dBMHz-1). However, the greatest discriminative power was given by the y-axis (0 Hz) intercept of the spectral slope: LFT/DFT (p = 0.001); LFT/CA (p = 0.0001); and DFT/CA (p = 0.089).

High-dose chemotherapy supported by peripheral blood progenitor cells in poor prognosis metastatic breast cancer--phase I/II study. Edinburgh Breast Group

Current treatments for metastatic breast cancer are not associated with significant survival benefits despite response rates of over 50%. High-dose therapy with autologous bone marrow transplantation (ABMT) has been investigated, particularly in North America, and prolonged survival in up to 25% of women has been reported, but with a significant treatment-related mortality. However, in patients with haematological malignancies undergoing autologous transplantation, haematopoietic reconstruction is significantly quicker and mortality lower than with ABMT, when peripheral blood progenitor cells (PBPCs) are used. In 32 women with metastatic breast cancer, we investigated the feasibility of PBPC mobilisation with high-dose cyclophosphamide and granulocyte colony-stimulating factor (G-CSF) after 12 weeks' infusional induction chemotherapy and the subsequent efficacy of the haematopoietic reconstitution after conditioning with melphalan and either etoposide or thiotepa. PBPC mobilisation was successful in 28/32 (88%) patients, and there was a rapid post-transplantation haematopoietic recovery: median time to neutrophils > 0.5 x 10(9) l-1 was 14 days and to platelets > 20 x 10(9) l-1 was 10 days. There was no procedure-related mortality, and the major morbidity was mucositis (WHO grade 3-4) in 18/32 patients (56%). In a patient group of which the majority had very poor prognostic features, the median survival from start of induction chemotherapy was 15 months. Thus, PBPC mobilisation and support of high-dose chemotherapy is feasible after infusional induction chemotherapy for patients with metastatic breast cancer, although the optimum drug combination has not yet been determined.

The ecology of psychotherapy research

The ecology of psychotherapy research was examined with patient reports of demand characteristics and awareness of research instrumentation. Patients were part of the Vanderbilt II project that explored the effectiveness of manualized training. A total of 59 patients from the pretraining and posttraining phases of the project were interviewed after termination assessments were made. Patients who were highly aware of their role as a "subject" in an experiment had outcomes that were consistent with the primary hypotheses of the study, although training did not significantly improve outcomes. In the pretraining cohort, patients who were highly aware of their "subject" role had poorer outcomes and engaged less in exploratory process. In the posttraining cohort, patients who were highly aware had good outcomes and engaged in more exploratory processes. Interestingly, therapists of these patients offered a positive relationship but failed to adhere to the principles taught during training. Demands of the research, especially how the patient defines his or her role, may affect results in significant ways.

The ecology of psychotherapy research

The ecology of psychotherapy research was examined with patient reports of demand characteristics and awareness of research instrumentation. Patients were part of the Vanderbilt II project that explored the effectiveness of manualized training. A total of 59 patients from the pretraining and posttraining phases of the project were interviewed after termination assessments were made. Patients who were highly aware of their role as a "subject" in an experiment had outcomes that were consistent with the primary hypotheses of the study, although training did not significantly improve outcomes. In the pretraining cohort, patients who were highly aware of their "subject" role had poorer outcomes and engaged less in exploratory process. In the posttraining cohort, patients who were highly aware had good outcomes and engaged in more exploratory processes. Interestingly, therapists of these patients offered a positive relationship but failed to adhere to the principles taught during training. Demands of the research, especially how the patient defines his or her role, may affect results in significant ways.

Biomechanics and running economy

Running economy, which has traditionally been measured as the oxygen cost of running at a given velocity, has been accepted as the physiological criterion for 'efficient' performance and has been identified as a critical element of overall distance running performance. There is an intuitive link between running mechanics and energy cost of running, but research to date has not established a clear mechanical profile of an economic runner. It appears that through training, individuals are able to integrate and accommodate their own unique combination of dimensions and mechanical characteristics so that they arrive at a running motion which is most economical for them. Information in the literature suggests that biomechanical factors are likely to contribute to better economy in any runner. A variety of anthropometric dimensions could influence biomechanical effectiveness. These include: average or slightly smaller than average height for men and slightly greater than average height for women; high ponderal index and ectomorphic or ectomesomorphic physique; low percentage body fat; leg morphology which distributes mass closer to the hip joint; narrow pelvis and smaller than average feet. Gait patterns, kinematics and the kinetics of running may also be related to running economy. These factors include: stride length which is freely chosen over considerable running time; low vertical oscillation of body centre of mass; more acute knee angle during swing; less range of motion but greater angular velocity of plantar flexion during toe-off; arm motion of smaller amplitude; low peak ground reaction forces; faster rotation of shoulders in the transverse plane; greater angular excursion of the hips and shoulders about the polar axis in the transverse plane; and effective exploitation of stored elastic energy. Other factors which may improve running economy are: lightweight but well-cushioned shoes; more comprehensive training history; and the running surface of intermediate compliance. At the developmental level, this information might be useful in identifying athletes with favourable characteristics for economical distance running. At higher levels of competition, it is likely that 'natural selection' tends to eliminate athletes who failed to either inherit or develop characteristics which favour economy.

Congenital absence of permanent second molars

During the last eight years, Canterbury Archaeological Trust has excavated over 1,600 articulated human skeletons from sites under threat of redevelopment in Kent. The recovered material, ranging in date from prehistoric to Victorian, provides a unique corpus for the study of disease and abnormalities in earlier societies.

Phase III study of bolus versus infusion fluorouracil with or without cisplatin in advanced colorectal cancer

BACKGROUND

Phase II studies of fluorouracil (5-FU) administered by protracted intravenous infusion have suggested an improved response rate and decreased toxicity profile when compared with 5-FU given by bolus injection in patients with metastatic colorectal cancer. Additional studies have suggested further enhancement of infusion 5-FU activity when it is combined with low-dose weekly cisplatin administration.

PURPOSE

This phase III study in adults with metastatic colorectal cancer was planned as a comparison of objective response rates, toxicity, and survival in patients receiving bolus versus protracted-infusion 5-FU with or without cisplatin.

METHODS

Four hundred ninety-seven previously untreated patients with advanced, measurable metastatic colorectal cancer were randomly assigned to receive treatment A (bolus 5-FU at 500 mg/m2 for 5 days followed in 2 weeks by weekly bolus 5-FU at 600 mg/m2), treatment B (bolus 5-FU at 500 mg/m2 for 5 days followed in 2 weeks by weekly bolus 5-FU at 600 mg/m2, plus weekly cisplatin at 20 mg/m2), treatment C (5-FU at 300 mg/m2 per day by continuous infusion), or treatment D (5-FU at 300 mg/m2 per day by continuous infusion plus weekly cisplatin at 20 mg/m2). All drugs were administered intravenously. Enrollment in the trial occurred from August 1987 through December 1990, and follow-up was through September 1995. The Kaplan-Meier method was used to estimate overall and disease-free survival, and Cox regression models were used to assess the effects of patient characteristics on survival. All P values resulted from two-sided tests.

RESULTS

Objective tumor response was observed in 28 (18%) of 153 patients receiving treatment A, in 45 (28%) of 159 patients receiving treatment C (C versus A; P = .045), and in 47 (31%) of 153 patients receiving treatment D (D versus A; P = .016). Because of excessive toxicity, treatment B was discontinued after only 12 patients had begun treatment. Median time to disease progression was 5.1 months for patients in arm A compared with 6.2 and 6.5 months for patients in arms C and D, respectively (C versus A, P = .007; D versus A, P = .017). Patterns of toxic effects differed substantially among the treatment arms. Forty-five percent of the patients receiving bolus 5-FU alone (A) experienced grade 3-4 leukopenia, with two sepsis-related deaths. Hand-foot syndrome and mucositis were the major treatment-limiting toxic effects for patients in the two treatment arms involving infusion. Despite the improvement in response rates and time to disease progression with infusion 5-FU with or without cisplatin (C and D, respectively) (P = .003), the overall survival for the three groups (A, C, and D) was similar (P = .307). This may have been due in part to a longer median survival time of 10.4 months for patients in arm A, compared with an anticipated survival of 7 months.

CONCLUSION

5-FU given as a continuous infusion produced a higher objective response rate, a modest prolongation in time to disease progression, and less life-threatening myelosuppression in patients than bolus 5-FU. Concomitant treatment with low-dose cisplatin caused added toxicity and complexity of treatment and did not provide a major clinical benefit. No statistically significant survival differences were observed among the three treatment groups.

Extensive handling of rats leads to mild urinary bladder hyperplasia

The urinary and urothelial effects of the frequent handling necessary for obtaining fresh-voided urine specimens were evaluated in 5-wk-old male F-344 rats fed control diet or diet containing 7.5% sodium saccharin. Frequent handling consisted of holding rats by the back of the neck in a position to obtain fresh-voided urine directly into centrifuge tubes 3 times per week for 10 weeks, whereas seldomly handled control rats received this treatment only twice during the entire 10 weeks. The urothelium of frequently handled rats fed control diet showed superficial necrosis and regenerative hyperplasia as observed by light and scanning electron microscopy. These changes were not observed in rats fed control diet that were seldomly handled. The necrosis and hyperplasia were not as pronounced in frequently handled rats fed control diet as in seldomly handled, sodium-saccharin-treated rats, but handling also potentiated the severity of the changes produced by sodium saccharin feeding. The urothelial exfoliation and consequent regenerative hyperplasia are likely secondary effects of stress.

Alteration of cell membrane by stress waves in vitro

Experiments on the biological effects of laser-induced stress waves indicate that there is a transient increase in the permeability of the cell membrane. A cell viability assay (propidium iodide exclusion) shows that mouse breast sarcoma cells are viable after a stress wave. The kinetics of this transient membrane permeability are measured using time-resolved fluorescence imaging. The efflux of a membrane-impermeable fluorescent probe (calcein) following the application of a 300-bar stress wave implies that there is an increase in the membrane permeability. This efflux ceases within 80 s after a stress wave, suggesting that the membrane is no longer permeable to the fluorescent probe. Fitting the observed kinetics to a simple diffusion model yields an average initial diffusion constant of 2.2 +/- 1.3 x 10(-7) cm2/s for mouse breast sarcoma cells following the application of a laser-induced stress wave.

Double-blind study of the activity and tolerability of cabergoline versus placebo in parkinsonians with motor fluctuations

The use of a dopamine agonist with a long duration of action has theoretical advantages in attempting to reduce the motor fluctuations in Parkinson's disease. We report the results of a double-blind controlled study of adding cabergoline, an ergot derivative with potent long-lasting high affinity for the D2 receptor, to levodopa therapy in 37 patients with severe fluctuations in response to treatment. Increasing dosages of cabergoline (19 patients) or placebo (18 patients) were added to each patient's stable levodopa regime. The two patient groups were similar at baseline in terms of age, disease duration, duration of levodopa treatment, and average hours "off" per day. Following incremental dose titration, patients in the cabergoline group had a significant reduction in hours "off" per day from 5.0 (SD 2.1) to 3.0 (SD 2.5), but there was no change in this measure in the placebo group [4.0 (2.2) and 3.3 (2.3) respectively]. This was not at the expense of a significant increase in dyskinesia. However, there was no difference between the groups when comparing their average Hoehn and Yahr stage of disease, and Schwab and England activities of daily living index.

Medication use and the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis

BACKGROUND

Toxic epidermal necrolysis and Stevens-Johnson syndrome are rare, life-threatening, drug-induced cutaneous reactions. We conducted a case-control study to quantify the risks associated with the use of specific drugs.

METHODS

Data were obtained through surveillance networks in France, Germany, Italy, and Portugal. Drug use before the onset of disease was compared in 245 people who were hospitalized because of toxic epidermal necrolysis or Stevens-Johnson syndrome and 1147 patients hospitalized for other reasons (controls). Crude relative risks were calculated and adjusted for confounding by multivariate methods when numbers were large enough.

RESULTS

Among drugs usually used for short periods, the risks were increased for trimethoprim-sulfamethoxazole and other sulfonamide antibiotics (crude relative risk, 172; 95 percent confidence interval, 75 to 396), chlormezanone (crude relative risk, 62; 21 to 188), aminopenicillins (multivariate relative risk, 6.7; 2.5 to 18), quinolones (multivariate relative risk, 10; 2.6 to 38), and cephalosporins (multivariate relative risk, 14; 3.2 to 59). For acetaminophen, the multivariate relative risk was 0.6 (95 percent confidence interval, 0.2 to 1.3) in France but 9.3 (3.9 to 22) in the other countries. Among drugs usually used for months or years, the increased risk was confined largely to the first two months of treatment, when crude relative risks were as follows: carbamazepine, 90 (95 percent confidence interval, 19 to infinity); phenobarbital, 45 (19 to 108); phenytoin, 53 (11 to infinity); valproic acid, 25 (4.3 to infinity); oxicam nonsteroidal antiinflammatory drugs (NSAIDs), 72 (25 to 209); allopurinol, 52 (16 to 167); and corticosteroids, 54 (23 to 124). For many drugs, including thiazide diuretics and oral hypoglycemic agents, there was no significant increase in risk.

CONCLUSIONS

The use of antibacterial sulfonamides, anticonvulsant agents, oxicam NSAIDs, allopurinol, chlormezanone, and corticosteroids is associated with large increases in the risk of Stevens-Johnson syndrome or toxic epidermal necrolysis. But for none of the drugs does the excess risk exceed five cases per million users per week.

Exercise echocardiography is an accurate and cost-efficient technique for detection of coronary artery disease in women

OBJECTIVES

This study compared the accuracy and cost implications of using exercise echocardiography and exercise electrocardiography for detection of coronary artery disease in women.

BACKGROUND

The specificity of exercise electrocardiography in women is lower than in men. Exercise echocardiography accurately identifies coronary artery disease in women, but its utility in place of exercise electrocardiography is unclear.

METHODS

One hundred sixty-one women without a previous Q wave infarction underwent exercise echocardiography and coronary angiography. Positive findings were a new or worsening wall motion abnormality on the exercise echocardiogram and ST segment depression > 0.1 mV at 0.08 s after the J point on the exercise electrocardiogram (ECG).

RESULTS

Coronary artery stenosis > 50% diameter narrowing was present in 59 patients; the sensitivity (mean +/- SD) of exercise echocardiography was 80 +/- 3%. In 48 patients with an interpretable ECG, the sensitivity of exercise echocardiography was 81 +/- 4%, and that of the exercise ECG was 77 +/- 3% (p = 0.50). In 102 patients without coronary artery disease, the overall specificity of exercise echocardiography was 81 +/- 4%. In 70 patients with an interpretable ECG, the specificity of exercise echocardiography (80 +/- 3%) exceeded that of the exercise ECG (56 +/- 4%, p < 0.0004). The accuracy of exercise echocardiography was also greater than exercise electrocardiography (81 +/- 5% vs. 64 +/- 6%, p < 0.005). Exercise echocardiography stratified significantly more patients of intermediate (20% to 80%) pretest disease probability into the high (> 80%) or low (< 20%) posttest probability group. In women without a previous exercise ECG, the specificity of exercise echocardiography continued to exceed that of exercise electrocardiography (80 +/- 3% vs. 64 +/- 3%, p = 0.05). Exercise echocardiography had the best balance between accuracy and cost for the diagnosis of coronary artery disease in women.

CONCLUSIONS

Exercise echocardiography is more specific than exercise electrocardiography for diagnosis of coronary artery disease in women and is a cost-effective approach to the diagnosis of coronary artery disease because of the avoidance of inappropriate angiography.

The effects of hyperoxia, mechanical ventilation, and dexamethasone on pulmonary antioxidant enzyme activity in the newborn piglet

It has been previously shown that prophylactic, intravenous dexamethasone (DEX) and intratracheal recombinant human Cu/Zn superoxide dismutase (SOD) ameliorate lung injury in newborn piglets treated with 48 hr of hyperoxia and mechanical ventilation. DEX has many pharmacologic effects, including the possible induction of antioxidant enzyme systems. To investigate whether the effects of DEX are mediated by an increase in endogenous antioxidant enzyme activity, 5 groups of term newborn piglets were studied: Group 1 piglets were ventilated with room air for 48 hr; Group 2 animals were ventilated with 100% O2 for 48 hr; Group 3 animals were ventilated with room air for 48 hr and received DEX (0.7 mg/kg) every 12 h; Group 4 were ventilated with 100% O2 for 48 hr and also received DEX; Group 5 animals were no ventilated and were sacrificed at time 0. At the conclusion of the studies, bronchoalveolar lavage (BAL) was performed and the lungs were removed and homogenized. Lung tissue and BAL were analyzed for SOD, catalase, GPX activities, and total protein concentration. No significant differences in any of these assays were seen in either lung tissue or BAL in the 5 groups. These observations indicate that 48 hr of hyperoxia, mechanical ventilation, or dexamethasone treatment does not induce activity of SOD, catalase, or glutathione peroxidase (GPX) in the lungs of newborn piglets. Thus postnatal DEX appears to minimize neonatal lung injury by mechanisms that are independent of these enzymes.

Flow cytometric measurement of proliferation-associated nuclear antigen P105 and DNA content in immuno-proliferative small intestinal disease (IPSID)

Immunoproliferative small intestinal disease (IPSID), most common in Mediterranean countries, is characterized by lymphomatous infiltration of the small intestine and is usually associated with the synthesis of anomalous immunoglobulin alpha heavy chains. Flow cytometric analysis of DNA content, S phase fraction, and quantitative analysis of the proliferation-associated nuclear antigen, P105, were performed in 23 patients with IPSID to determine if they could be used as prognostic indicators in this disease. Eighteen patients had low-grade, two had intermediate-grade, and three had high-grade lymphoma. Eight patients had clinical stage IE disease, 12 had stage IIE, and three had stage IIIE disease. Eleven patients survived > 5 yr (good prognosis), four survived between 2-5 yr (intermediate prognosis), and eight survived 2 yr or less (poor prognosis). The S phase fraction of patients with poor prognosis was significantly higher than those with intermediate or good prognosis (P < 0.004). Flow cytometric evaluation of S phase fraction may offer important prognostic information in patients with IPSID and could be useful in the clinical management of patients with this highly variable clinical syndrome. Further studies evaluating the value of DNA flow cytometry in larger groups of patients with IPSID are warranted.

Evidence of birth deformities in 16th century Kent

Images

Medieval example of cleft lip and palate from St. Gregory's Priory, Canterbury

An archaeologically retrieved skeleton from medieval Canterbury possibly of the late eleventh or twelfth century, displays clear evidence of cleft lip and palate. A case of cleft palate dating from the seventh century, is known from an Anglo-Saxon cemetery at Burwell. This is the first evidence for both cleft lip and palate in British archaeological material. The individual had survived into adulthood. Apart from an odontome, there was no osseous evidence of any other abnormalities. Artistic evidence of cleft lip dates to the fourth century B.C. and surgical intervention (A.D. 390) is known from China.

Artistic and documentary evidence for tetradysmelia from sixteenth century England

A series of illustrative ballads provide evidence of tetradysmelia, including acheiropodia, from sixteenth century England. It is probable that the presented malformations represent the non-genetic Hanhart complex. Such a condition has not been reported in archaeologically retrieved skeletal material.

A comparison of methods used to calculate ultrasonic myocardial backscatter in the time domain

The cyclic variation of ultrasonic integrated backscatter from the left ventricular posterior wall and interventricular septum of the heart is now well documented in the literature, with minimal values occurring at end-systole and maximal at end-diastole. However, little work has been performed to date to determine whether cyclic cardiac variation of other, more easily derived, backscatter parameters exists. In this study, 20 baseline, epicardial, long-axis cardiac-cycle sequences were obtained from eight open-chest pigs, yielding a total of 285 ultrasonic frames of RF data, which were analysed off-line on a Sun workstation. In addition, the video data from these studies was digitised and collected from each scan. Five backscatter parameters, calculated in the time-domain, including (1) the average integrated backscatter; (2) the average of the backscatter power from the log-compressed data; (3) the square of the average of the uncompressed radio frequency (RF) amplitude; (4) the square of the average of the RF amplitude from the log-compressed data; and (5) the square of the average grey-scale video data, were analysed and their variation throughout the cardiac cycle correlated against that obtained from integrated backscatter measurements. The backscatter values obtained were referenced to a gel calibration phantom widely used for 2-D calibration studies. Significant (p < 0.001), good correlation existed between the four backscatter parameters derived from the RF data. Reduced correlation was obtained between the video backscatter parameter and those derived from the RF data. Maximum cyclic variation between systole and diastole was measured from the integrated backscatter parameter and minimum from the three log-compressed data sets.