Thermotolerance in the absence of induced heat shock proteins in a murine lymphoma

Three murine lymphoma cell lines, CH1, a B-cell lymphoma, and VL3 and RDM4, both T-cell lymphomas, were tested for their ability to induce heat shock protein synthesis and thermotolerance after heat shock. All three lines could develop thermotolerance, but the persistence of tolerance was less than can be measured in nonlymphoid cell lines. Analysis of protein synthesis patterns by one-dimensional gel electrophoresis suggested that only the VL3 cells were capable of the induction of heat shock proteins. After two-dimensional gel analysis, however, the induction of one heat shock protein was evident in RDM4 cells. No induced heat shock proteins could be detected in the CH1 cells. These data provide strong evidence that, while the induction of heat shock proteins may be sufficient for development of thermotolerance, they are not necessary and that another mechanism is available to cells.

Breast tumor recurrence following lumpectomy with and without breast irradiation: an overview of recent NSABP findings

The latest findings from the NSABP B-06 trial on ipsilateral breast tumor recurrence (IBTR) continue to demonstrate that through 9 years of follow-up more patients treated with radiation remained IBTR free as compared to those receiving no radiation (P less than 0.001), regardless of age, nodal status, or tumor size. There is no significant difference in distant disease-free survival (DDFS) or survival between the two lumpectomy groups despite the highly significant difference in their probability of remaining IBTR free. A recent analysis shows that when a patient is diagnosed with an IBTR, the risk of distant metastatic disease increases, indicating that an IBTR is a marker for, not a cause of, distant metastatic disease. An IBTR indicates a greater risk for distant disease when the primary tumor was removed. Mastectomy or breast irradiation following lumpectomy eliminates or reduces the opportunity for identifying a marker of risk for distant disease, thus emphasizing the importance of an IBTR beyond the need for its removal. Since an IBTR is associated with a relative risk of 3.41 for the development of distant metastatic disease, systemic therapy subsequent to an IBTR should be considered. Evidence presented from recent NSABP studies indicates the value of systemic therapy for lowering the incidence of IBTR following lumpectomy and breast irradiation.

Ipsilateral breast tumor recurrence and survival following lumpectomy and irradiation: pathological findings from NSABP protocol B-06

Ipsilateral breast tumor recurrence (IBTR) occurred in 42 of 488 (9%) pathologically evaluable patients enrolled in NSABP protocol B-06 with a mean potential follow-up of 103 months (range 68-161 months) following treatment for Stage I and II invasive breast cancer by lumpectomy and local breast irradiation (LXRT). IBTR were observed at or close to the same quadrant as the index cancers and their histologic types and nuclear grades were similar if not identical in 95 and 93%, respectively. This information confirms our earlier findings which indicated that multicentricity is of little or no clinical significance in the treatment of breast cancer by LXRT; breast cancers rarely if ever change their biologic potential once clinically detected; and lastly, most if not all IBTR represent residual cancer. Cox regression analyses revealed only a patient age less than 35 years to be significantly related to IBTR. No relationship between IBTR and so-called extensive intraductal component (EIC) or 31 other pathologic features of the index cancers was found. Overall survival was significantly related to nodal status (P = 0.01), nuclear grade (P = less than 0.001) histologic tumor type (P = 0.01) and IBTR (P = less than 0.001). This latter was considered as an indicator rather than instigator of distant disease and reduced survival since the latter is no different in patients treated by LXRT, lumpectomy alone after which IBTR is much more frequent, or mastectomy, which precludes its expression. We conclude that there are as yet no viable markers which would contraindicate treating patients with breast cancer by LXRT.

Use of brainstem auditory-evoked response testing to assess neurologic outcome following near drowning in children

OBJECTIVE

To determine a correlation between serial brainstem auditory-evoked response measurements and ultimate neurologic outcome in pediatric patients who suffered a cardiac arrest resulting from a submersion accident.

DESIGN

Inception cohort, prospective correlational study.

SETTING

A 15-bed pediatric ICU (within a 150-bed tertiary care pediatric hospital) admitting patients of all ages except nonsurgical neonates.

PATIENTS

All previously normal pediatric patients who suffered a cardiac arrest after a submersion accident. Patients evaluated: 111; patients studied: 89.

METHODS

Patients received serial brainstem auditory-evoked response testing within 6 hrs of resuscitation and then once daily for up to 10 days. Brainstem auditory-evoked response measurements included wave I-V interpeak latency, wave V amplitude, and wave I/V amplitude ratio. Upon discharge, patients were evaluated and classified into one of four neurologic outcome groups: normal, handicapped, vegetative, or dead. Patients classified into the handicapped group exhibited mild neurologic deficits after discharge. Vegetative patients were noninteractive with their environment and required full-time caretaker support. Serial brainstem auditory-evoked response measurements from the four outcome groups were compared with brainstem auditory-evoked response measurements obtained from a group of 39 healthy children of comparable age.

MAIN RESULTS

Patients who recovered neurologically intact manifested brainstem auditory-evoked response measurements that were similar to controls. Brainstem auditory-evoked response measurements in the handicapped outcome group were also normal after resuscitation but showed significant reduction in wave V amplitudes over the ensuing days. When compared with controls, patients with a vegetative outcome manifested abnormally prolonged wave I-V interpeak latencies, diminished wave V amplitudes, and large-wave I/V amplitude ratios following resuscitation. However, I-V interpeak latencies normalized within 24 hrs after resuscitation. I-V interpeak latencies were no different than controls until hospital day 3, at which time they became significantly prolonged. Patients who were declared brain dead or died from cardiovascular collapse exhibited very abnormal brainstem auditory-evoked response measurements on admission and until death. Wave V could not be detected on admission in 19/31 patients within this group.

CONCLUSIONS

Brainstem auditory-evoked response testing is useful as an aid in the assessment of neurologic outcome following submersion-induced cardiac arrest. However, standardization of brainstem auditory-evoked response testing and production of normative data are required before this modality can be more widely studied and applied.

Prognostic factors in NSABP studies of women with node-negative breast cancer. National Surgical Adjuvant Breast and Bowel Project

Twenty-two pathologic (including estrogen and progesterone receptor status) and four clinical features of 950 node-negative stage I invasive breast cancers from 950 women enrolled in the National Surgical Adjuvant Breast and Bowel Project protocol B-06 were analyzed for their possible prognostic significance. Univariate analyses revealed 10 characteristics that were significant at the 1% level. Only three of these--notably nuclear grade, histologic tumor type, and race--were found to be significant when entered into a Cox regression model. Patients whose tumors exhibited a good nuclear grade fared significantly better than those whose tumors were scored as poor. Similarly, a significantly better prognosis was noted when the histologic type of cancer was found to be "favorable" (mucinous, tubular, or papillary) than when it was "intermediate" (NOS, "Not Otherwise Specified," combination; typical medullary; and lobular invasive) or "unfavorable" (NOS pure and atypical medullary). Blacks exhibited a worse prognosis than whites. Survival was 94% at 8 years when the nuclear grade was good and the tumor type favorable, but only 54% when the nuclear grade was poor and tumor type unfavorable. Patients with one favorable and one unfavorable feature exhibited an intermediate survival. A brief overview as well as our own preliminary experience indicates that the combined use of these two prognostic pathologic parameters may be as good as and in some instances a better predictor of survival in node-negative patients than information derived from more "objective" methodologies such as flow cytometry, receptor analyses and tumor labeling indices or the demonstration of oncogene overexpression. Assessment of the pathologic parameters is simple, universally available, and quick and requires only modest training to be reproducible.

Hypertonic Saline Lowers Raised Intracranial Pressure in Children After Head Trauma

Eighteen pediatric patients who sustained traumatic brain injury were enrolled in a double-blind, crossover study comparing the effects of 3% saline and 0.9% saline infusions on raised intracranial pressure (ICP). After resuscitation, each patient received a bolus of each saline concentration, and ICP was monitored for 2 h. Initial mean ICP before 0.9% saline infusions equaled 19.3 mm Hg and averaged 20.0 mm Hg during the subsequent 2-h trials (p = 0.32). Baseline mean ICP before 3% saline administration equaled 19.9 mm Hg and averaged 15.8 mm Hg for 2 h postinfusion (p = 0.003). Central venous pressure did not change significantly in either group, nor did measurements of renal function. Serum sodium concentrations increased in all 18 trials of 3% saline. Maximal concentrations of serum sodium occurred 30 min after bolus administration of 3% saline. Three percent saline significantly reduces raised ICP after traumatic brain injury when compared with normal saline. Intravascular dehydration, as measured by central venous pressure, did not occur during the study period.

DNA flow cytometric analysis of primary operable breast cancer. Relation of ploidy and S-phase fraction to outcome of patients in NSABP B-04

Between 1971 and 1974, 1665 women with primary operable breast cancer were randomized into a National Surgical Adjuvant Breast and Bowel Project (NSABP) trial (B-04) conducted to evaluate the effectiveness of several different regimens of surgical and radiation therapy. No systemic therapy was given. Cells from archival paraffin-embedded tumor tissue taken from 398 patients were analyzed for ploidy and S-phase fraction (SPF) using flow cytometry. Characteristics and outcome of patients with satisfactory DNA histograms were comparable to those from whom no satisfactory cytometric studies were available. In patients with diploid tumors (43%), the mean SPF was 3.4% +/- 2.3%; in the aneuploid population (57%), the SPF was 7.9% +/- 6.3%. Only 29.9% +/- 17.3% of cells in aneuploid tumors were aneuploid. Diploid tumors were more likely than aneuploid tumors to be of good nuclear grade (P less than 0.001) and smaller size (P equals 0.03). More tumors with high SPF were of poor nuclear grade than were tumors with low SPF (P equals 0.002). No significant difference in 10-year disease-free survival (P equals 0.3) or survival (P equals 0.1) was found between women with diploid or aneuploid tumors. Patients with low SPF tumors had a 13% better disease-free survival (P equals 0.0006) than those with a high SPF and a 14% better survival (P equals 0.007) at 10 years than patients with high SPF tumors. After adjustment for clinical tumor size, the difference in both disease-free survival and survival between patients with high and low SPF tumors was only 10% (P equals 0.04 and 0.08, respectively). Although SPF was found to be of independent prognostic significance for disease-free survival and marginal significance for survival, it did not detect patients with such a good prognosis as to preclude their receiving chemotherapy. The overall survival of patients with low SPF was only 53% at 10 years. These findings and those of others indicate that additional studies are necessary before tumor ploidy and SPF can be used to select patients who should or should not receive systemic therapy.

A quantitative approach to radiography of the lower limb. Principles and applications

A method is described which provides standardised reproducible radiographic images of the lower limb. Anteroposterior and lateral radiographs are digitised and processed by computer to provide graphic/numeric displays of angles and linear measurements, relating the centre points of the hip, knee, and ankle. Two cases illustrate how surgical planning is facilitated when standardised data are available. These data confirm the close relationship between postoperative limb alignment and positioning of prosthetic elements.

Significance of ipsilateral breast tumour recurrence after lumpectomy

Breast cancer treatment trials from the US National Surgical Adjuvant Breast and Bowel Project have established breast-conserving operations as a replacement for radical mastectomy (NSABP B-04), and have shown that in terms of survival free from distant disease there was no significant difference between lumpectomy, lumpectomy plus breast irradiation, and total mastectomy (NSABP B-06). 9-year follow-up data from B-06 are used here to address the issue of ipsilateral breast tumour recurrence (IBTR) and the development of distant disease, a question with important clinical and biological implications. A Cox regression model on fixed co-variates (ie, features such as tumour type or size present at surgery and not subsequently alterable) and on IBTR, which is time dependent and not fixed, revealed that the risk of distant disease was 3.41 times greater after adjustment for co-variates in patients in whom an IBTR developed. IBTR proved to be a powerful independent predictor of distant disease. However, it is a marker of risk for, not a cause of, distant metastasis. While mastectomy or breast irradiation following lumpectomy prevent expression of the marker they do not lower the risk of distant disease. These findings further justify the use of lumpectomy.

Conservative management of intraductal carcinoma (DCIS) of the breast. Collaborating NSABP investigators

Seventy-six patients with intraductal carcinoma (DCIS) of the breast have been observed for 83 months (range 50-141) following treatment by lumpectomy (L) only (21), L and breast irradiation (XRT) (27), or mastectomy (28). All represented examples of DCIS retrieved after pathologic examination of a much larger cohort of patients with stage I and II invasive breast cancer enrolled in NSABP protocol 6. Local breast recurrences were similar for women with DCIS and those from this cohort at a similar period of follow-up with invasive cancer treated by L only (43% vs. 39%) and L + XRT (7% vs. 10%). The presence of moderate/marked comedonecrosis was suggestively related to local breast recurrence (P = .07). This latter was significantly reduced for patients receiving post L XRT (P = .01). All local breast recurrences in this study and 29 of 31 recorded by others occurred at or close to the site of extirpation of the index cancer minimizing multicentricity as a contraindication for the conservative surgical treatment of DCIS. Survival rates which were similar for patients with DCIS regardless of form of local treatment were better than that observed for negative node patients with invasive cancer enrolled in protocol 6. Thus, DCIS is a less, not more, ominous disease than invasive cancer. This and other features of its natural history indicate that it would be a contradiction to treat invasive cancer but not DCIS conservatively.

Panel sees high demand for diverse CFO skills

A more sophisticated healthcare industry, challenged by competition and payer demands, also looks for sophistication when filling its senior financial positions. Individuals with experience in managed care contract negotiations, knowledge of hospital-physician ventures, and superior planning and treasury management skills are increasingly sought by hospitals. Some organizations also may single out chief financial officers able to assume broader administrative duties, including chief executive officer positions. These are among the observations of a panel convened by HFMA to discuss recent trends in healthcare executive recruiting. Highlights of the session, moderated by HFMA President Richard L. Clarke, FHFMA, follow.

The effect of lonidamine (LND) on radiation and thermal responses of human and rodent cell lines

Rodent and human cells were tested for response to Lonidamine (LND) (1-(2,4 dichlorobenzyl) 1-indazol-3-carboxylic acid) combined with radiation or hyperthermia. Lonidamine exposure before, during, and after irradiation caused varying degrees of inhibition of potentially lethal damage (PLD) repair which was cell line dependent. In human glioma, melanoma, squamous cell carcinoma, and fibroblasts, LND exposure did not inhibit or only partially inhibited repair of potentially lethal damage. LND up to 100 micrograms/ml produced only a low level of toxicity in these cells and only slightly inhibited glucose consumption at the maximum concentration. In human glioma cells, LND treatment alone did not inhibit PLD repair, but when combined with hyperthermia treatment at moderate levels easily achievable in the clinic, there was complete inhibition of potentially lethal damage repair. These data suggest that LND effectiveness is cell type dependent. Combinations of LND, hyperthermia, and radiation may be effective in cancer therapy especially in tumors such as glioma in which repair of potentially lethal damage may be extensive.

Antinociceptive properties of intrathecal dexmedetomidine in rats

Dexmedetomidine is a highly selective alpha 2-adrenoceptor agonist. In this study, the intrathecal administration of dexmedetomidine into the rat lumbar subarachnoid space produced dose-dependent, prolonged antinociception as measured by hot plate and tail flick testing. Intrathecal administration of 3 or 10 micrograms of dexmedetomidine increased hot plate and tail flick latencies to cutoff values within 15 min of injection. Animals receiving 1 microgram of intrathecal dexmedetomidine did not show any significant antinociception when compared to saline controls. The intrathecal administration of the alpha 2-adrenoceptor antagonist, idazoxan, ablated all measurable antinociception produced by the prior injection of 10 micrograms of dexmedetomidine.

A standardized technique for lower limb radiography. Practice, applications, and error analysis

The normal standing radiograph, which provides a view of the knee only, is prone to errors of parallax and poor control of patient positioning. A standardized radiographic procedure was developed to control these sources of error. Anteroposterior and lateral views of the lower limb (hip and knee) are obtained without moving the patient from a standardized position; this includes control of ankle position and limb rotation. To correct for parallax error, radiopaque markers are positioned between the patient and the x-ray source. The locations of bone landmarks and reference markers on the radiographs are digitized, and a software package provides a display of key parameters. Error analysis of the method confirmed that most angles were sensitive to contrived positional variations, especially limb rotation and knee flexion. Load distribution between limbs was not critical. The greatest error was random. Most angles were reproducible within +/- 1.3 degrees or less at 95% confidence.

Effect of tamoxifen on serum insulinlike growth factor I levels in stage I breast cancer patients

Insulinlike growth factor I (IGF-I) has been shown to be a potent mitogen for breast cancer cells in vitro, and IGF-I receptors have been demonstrated on human primary breast neoplasms. In a randomized, placebo-controlled study, we document that administration of the antiestrogen tamoxifen to patients with breast cancer was associated with a statistically significant (P = .002) reduction in the serum level of IGF-I. The mean IGF-I level was 1.4 U/mL in the placebo-treated group and 0.9 U/mL in the tamoxifen-treated group. Because serum IGF-I level is growth hormone (GH) dependent and because data suggest that the pubertal surge in GH and IGF-I levels is sex steroid dependent, we speculate that the mechanism underlying our observation may involve blockade by tamoxifen of estrogen action in the hypothalamic-pituitary axis. We conclude that tamoxifen treatment reduces IGF-I levels and that this reduction may contribute to the therapeutic effect of the drug.

The inwardly pointing knee. An unrecognized problem of external rotational malalignment

Twelve patients with inwardly pointing knees had chronic knee pain and disability suggestive of patellofemoral subluxation. None had responded well to conservative measures or surgical correction at the level of the soft tissues. Their pattern of limb alignment was studied roentgenographically and was found to differ significantly from the control group of 49 healthy young adults. The deformities primarily related to the tibia were external tibial torsion, excess varus angulation of the tibial plateau, and varus knees. Angulation of the femoral condyles was normal and femoral anteversion did not appear to contribute significantly to the deformity. Surgery in seven cases (nine knees) was by derotation valgus Maquet osteotomy of the tibia and lateral release realignment of the patellae. Outcome assessments after a three-year follow-up period (five knees) were excellent. Early results on the remaining cases were satisfactory.