Factors influencing the functional outcome of patients with acute epidural hematomas: analysis of 200 patients undergoing surgery

OBJECTIVE

To determine the prognostic factors of the functional outcome of patients surgically treated for acute epidural hematomas.

METHODS

Two hundred patients who consecutively underwent neurosurgery for acute epidural hematomas over the past 9-year period were studied. Clinical characteristics, radiologic findings, and the time intervals with regard to treatment course were investigated to determine the interactions between all these factors and functional outcome.

RESULTS

Functional outcome showed a significant correlation with preoperative consciousness state, Glasgow Coma Scale score, pupillary sizes, and motor posturing (chi2 test, p < 0.05). Functional outcome correlated with the period of brain herniation, the length of time of the operation, as well as the period of hospitalization (chi2 test, p < 0.05), but not with the length of time of craniotomy decompression relative to the length of time from the injury until admission. The radiologic findings of the associated brain injury, the size and the density of the clot, the degree of the brain shift, and the obliteration of the basal cisterns significantly correlated with functional outcome (chi2 test, p < 0.05), whereas no significance was attributable to skull fracture. Multivariate analysis indicated that the following four factors independently correlated with functional outcome: (1) associated brain injury, (2) best motor response, (3) hematoma volume, and (4) period of hospitalization (chi2 test, p < 0.05). A combination of the four factors led to the prediction of the functional outcome with 91% accuracy (1.5 % falsely pessimistic predictions and 7.5 % falsely optimistic prediction) and 82.1% at over 90% confidence level. These four parameters correlated significantly with preoperative neurologic deterioration (chi2 test, p < 0.05).

CONCLUSION

This study identifies the risk factors involved in the functional outcome of patients who underwent surgical treatment for acute epidural hematomas. Our results indicate that associated brain injury plus best motor response are the optimal set of two prognostic indicants, with 87% correct predictions and 70.1% at over a 90% confidence level. Prevention of in-hospital neurologic deterioration would improve the patients' functional outcome with a resultant unfavorable recovery rate ranging from 11.5% to 17%.

Cerebral blood flow velocity and vasomotor reactivity before and after shunting surgery in patients with normal pressure hydrocephalus

The purpose of this study was to evaluate pre- and post-shunting haemodynamic changes and their correlation with the clinical results in normal pressure hydrocephalus (NPH). Accordingly, eleven demented patients with clinical signs suggestive of NPH received examinations of cerebral blood flow velocity (BFV) and vasomotor reactivity (VMR) by transcranial Doppler sonography with carbogen testing before and after shunt treatment. Computerized tomography (CT), clinical assessment and neuropsychological grading were performed prior to and at 3 months following surgery. A control group consisting of 10 patients was included to establish baseline data. The pre-operative CBF studies in the anterior cerebral artery (ACA) and the middle cerebral artery (MCA) revealed the NPH patients did not have significant decreases of BFVs, but had significant decreases of carbogen VMR (P < 0.05). After shunting, there were no significant changes of the BFVs as compared with the pre-shunting data. The post-shunting VMR of the ACA was significantly higher than the pre-shunting one (p < 0.05), but there was no variation in that of the MCA. Both the values of post-shunting VMR in ACA and the post-shunting increase in VMR in MCA of the 7 shunt-responsive patients who improved mentally and in other symptoms were significantly higher than those of patients without improvement (p < 0.05). In addition, the five patients with gait improvement showed significantly higher values of post-shunting VMR of ACA and the post-shunting increase of VMR for both ACA and MCA when compared with those patients without gait improvement (p < 0.05, respectively). Our study supports the view that patients with NPH had various degrees of impaired VMR in both the ACA and the MCA, but showed insignificant reduction in BFVs, indicating a compensatory mechanism of CBF over time to accommodate the subnormal state of cerebral perfusion pressure. Shunt placement would improve the VMR in responsive patients. Postoperatively, an increase of VMR tends to accompany improvement of the functional state: that in the MCA alone is associated with symptomatic improvement in mental function and that increase in VMR in both the ACA and the MCA with improvement in gait, respectively.

Molecular cloning and analysis of the argC gene from Corynebacterium glutamicum

The argC gene encoding N-acetylglutamate 5-semialdehyde dehydrogenase has been cloned from Corynebacterium glutamicum by transforming Escherichia coli arginine auxotroph with the genomic DNA library. Based on the restriction map of the cloned DNA, we have subcloned and sequenced the minimal DNA fragment complementing the E. coli argC mutant. The coding region of the cloned gene is 1041 nucleotides long with a predicted molecular mass of about 38 kDa polypeptide. Enzyme activity and size of the expressed protein in the E. coli auxotroph carrying the recombinant argC gene revealed that the cloned gene indeed codes for N-acetylglutamate 5-semialdehyde dehydrogenase. Computer analysis of the amino acid sequences of the predicted protein revealed a strong similarity to the corresponding protein of other bacteria.

Orbital rhinocerebral mucormycosis associated with diabetic ketoacidosis: report of survival of a 10-year-old boy

Cerebral mucormycosis is a rare fungal infection that occurs mostly in association with diabetic ketoacidosis. This central nervous system infection is characterized by a rapid decline in clinical status, and has been recognized as a uniformly fatal event if aggressive therapy is not instituted. We report a diabetic child who presented with blurred vision, chemosis, and pain in the left periorbital region noted for about 1 week during an episode of ketocidosis. Neurologic examinations revealed that there was a decreased range of motion in the upward and lateral gaze, along with incomplete pupillary dilatation and papilledema of the left eye. Imaging studies demonstrated left-side orbital cellulitis, paranasal sinusitis, and a large lobulated abscess in the left frontal lobe. Two surgical procedures, including functional endoscopic sinus surgery for sinus debridement and a subsequent open craniotomy for abscess resection were performed. Pathologic specimens obtained from the abscess wall revealed necrotic inflammation and wide, nonseptate hyphae with right angle branching, which are typical characteristics of the family Mucoraceae. Postoperatively, the patient was treated with 1.5 g of amphotericin B over a 7-week period, and aggressive diabetic control for 2 months. Through the combination of medical and surgical treatment the child made an uneventful recovery.

Action of Ulmi radicis cortex extract on systemic and local anaphylaxis in rats

1. To assess the contribution of an aqueous extract of Ulmi radicis cortex (AEURC) in systemic anaphylaxis, compound 48/80 was used as a fatal anaphylaxis inducer in rats. 2. AEURC completely inhibited anaphylactic shock with a dose of 1.0 g/kg body weight (BW) 1 hr before injection of compound 48/80. 3. AEURC significantly inhibited serum histamine levels induced by compound 48/80. 4. AEURC (1.0 g/kg BW) also inhibited by 79.1% passive cutaneous anaphylaxis activated by anti-dinitrophenyl (DNP) IgE. 5. AEURC dose dependently inhibited the histamine release from the rat peritoneal mast cells (RPMCs) by compound 48/80. Moreover, AEURC had a significant inhibitory effect on anti-DNP IgE-induced histamine release and tumor necrosis factor-alpha production from RPMC. 6. The level of cAMP in RPMC, when AEURC was added, significantly increased compared with that of a normal control. 7. These results indicate that AEURC may possess strong antianaphylactic action.

A randomized controlled trial of filgrastim during remission induction and consolidation chemotherapy for adults with acute lymphoblastic leukemia: CALGB study 9111

Recombinant human granulocyte colony-stimulating factor (G-CSF; filgrastim) shortens the time to neutrophil recovery after intensive chemotherapy, but its role in the treatment of adults with acute lymphoblastic leukemia (ALL) is uncertain. We randomly assigned 198 adults with untreated ALL (median age, 35 years; range, 16 to 83) to receive either placebo or G-CSF (5 microgram/kg/d) subcutaneously, beginning 4 days after starting intensive remission induction chemotherapy and continuing until the neutrophil count was >/=1, 000/microL for 2 days. The study assignment was unblinded as individual patients achieved a complete remission (CR). Patients initially assigned to G-CSF then continued to receive G-CSF through 2 monthly courses of consolidation therapy. Patients assigned to placebo received no further study drug. The median time to recover neutrophils >/=1,000/microL during the remission induction course was 16 days (interquartile range [IQR], 15 to 18 days) for the patients assigned to receive G-CSF and 22 days (IQR, 19 to 29 days) for the patients assigned to placebo (P < .001). Patients in the G-CSF group had significantly shorter durations of neutropenia (<1, 000/microL) and thrombocytopenia (<50,000/microL) and fewer days in the hospital (median, 22 days v 28 days; P = .02) compared with patients receiving placebo. The patients assigned to receive G-CSF had a higher CR rate and fewer deaths during remission induction than did those receiving placebo (P = .04 by the chi-square test for trend). During Courses IIA and IIB of consolidation treatment, patients in the G-CSF group had significantly more rapid recovery of neutrophils >/=1,000/microL than did the control group by approximately 6 to 9 days. However, the patients in the G-CSF group did not complete the planned first 3 months of chemotherapy any more rapidly than did the patients in the placebo group. Overall toxicity was not lessened by the use of G-CSF. After a median follow-up of 4. 7 years, there were no significant differences in either the disease-free survival (P = .53) or the overall survival (P = .25) for the patients assigned to G-CSF (medians, 2.3 years and 2.4 years, respectively) compared with those assigned to placebo (medians, 1.7 and 1.8 years, respectively). Adults who received intensive chemotherapy for ALL benefited from G-CSF treatment, but its use did not markedly affect the ultimate outcome.

Inhibition of nitric oxide synthesis by butanol fraction of the methanol extract of Ulmus davidiana in murine macrophages

Since there is increasing evidence that nitric oxide (NO) plays a crucial role in the pathogenesis of inflammatory diseases, this study was undertaken to address whether the methanol (MeOH) extract and its fractions of the bark of Ulmus davidiana Planch (Ulmaceae) could modulate the expression of inducible NO synthase (iNOS) in thioglycollate-elicited murine peritoneal macrophages and murine macrophage cell line, RAW264.7 cells. Stimulation of the peritoneal macrophages and RAW264.7 cells with interferon-gamma (IFN-gamma) and lipopolysaccharide (LPS) resulted in increased production of NO in the medium. However, the butanol (BuOH) fraction of the MeOH extract of U. davidiana barks showed marked inhibition of NO synthesis in a dose-dependent manner. The inhibition of NO synthesis was reflected in the decreased amount of iNOS protein, as determined by Western blotting. The BuOH fraction did not affect the viability of RAW264.7 cells, as assessed by methylthiazol-2-yl-2, 5-diphenyl tetrazolium bromide (MTT) assay; rather, it reduced endogenous NO-induced apoptotic cell death via inhibition of NO synthesis in RAW264.7 cells. On the other hand, the BuOH fraction showed no inhibitory effect on the synthesis of NO by RAW264.7 cells, when iNOS was already expressed by the stimulation with IFN-gamma and LPS. Collectively, these results demonstrate that the BuOH fraction inhibits NO synthesis by inhibition of the induction of iNOS in murine macrophages.

Detection of mutations and polymorphism of N-acetyltransferase 1 gene in Indian, Malay and Chinese populations

The xenobiotic metabolizing enzymes N-acetyltransferases (NATs) are important for the biotransformation and/or bioactivation of drugs and carcinogens. NATs are coded for in humans by two distinct genes, designated NAT1 and NAT2. NAT1, which was originally thought to be monomorphic, was recently reported to exhibit variation in human populations. Recent studies suggested that a genetic polymorphism of NAT1 may be associated with colorectal cancer risk. The distributions of NAT1 allele and genotype frequencies in unrelated individuals among Indian (n = 140), Malay (n = 122) and Chinese (n = 181) populations in Singapore were characterized by polymerase chain reaction-restriction fragment length polymorphism and allele-specific-polymerase chain reaction. The allelic frequencies of NAT1*3, NAT1*4, NAT1*10 and NAT1*11 among Indians were 0.3, 0.51, 0.17 and 0.02, respectively. The corresponding NAT1 allelic frequencies in Malays were 0.29, 0.30, 0.39 and 0.02, respectively, and were similar to those in Chinese in the region. The allelic frequencies of NAT1*3, NAT1*4, NAT1*10 and NAT1*11 among Chinese were 0.33, 0.35, 0.30 and 0.02, respectively. These findings are of importance for the determination of cancer risk in these populations. In addition, nucleotide changes at positions 350-351 (GG to CC) and 497-499 (GGG to CCC) of the NAT1 gene were not found in the alleles of the populations studied.

Traumatic neuromas of the head and neck

An interesting case of a traumatic neuroma of the greater auricular nerve provides the impetus for a discussion of head and neck neuromas. Traumatic neuromas of the head and neck are relatively rare. Division of the greater auricular nerve during parotidectomy occasionally results in a traumatic neuroma. We report a case of a 73-year-old woman who presented with a traumatic neuroma nine years after undergoing superficial parotidectomy with dissection of the facial nerve for a mixed tumor. The patient had a 1.5 cm x 1.0 cm mass located below the old surgical site over the anteromedial border of the sternocleidomastoid muscle. The patient's past history was significant for Frey's syndrome, which is the result of abnormal neurologic growth. On first impression, the tumor was thought to be a recurrence of neoplastic disease; however, because of the evaluation, traumatic neuroma was suspected. An attempt at fine-needle aspiration of the mass was too painful to be carried out. At surgery, a whitish tumor was excised which, on final pathologic examination, revealed traumatic neuroma. The surgical literature is reviewed and the subject of head and neck neuromas, including their evaluation and management, is thoroughly discussed. Knowledge of this possible diagnosis may spare the patient and the surgeon needless worry, as well as unnecessary procedures, once tumor recurrence has been ruled out.

Cell death and cytoskeletal alterations in cultured hepatic fat-storing cells induced by 6-hydroxydopamine

We studied the effects of the neurotoxin, 6-hydroxydopamine (6-OHDA), on cultured fat-storing cells (FSCs) and hepatocytes. If either FSCs or hepatocytes were exposed to 6-OHDA for 4 hr, the neurotoxicant induced cell death in FSCs but not in hepatocytes. We decided to investigate why hepatocytes were refractile to injury from 6-OHDA while FSCs were labile. The activity of antioxidant enzymes within FSCs grown in vitro is remarkably lower than the activity in hepatocytes. Indeed, some specific antioxidant enzymes in FSCs were undetectable by our assays, but were easily detected in hepatocytes. Furthermore, the profile of antioxidant activity in FSCs was found to be almost identical to the profiles seen in cultured fibroblasts or myocytes. However, indirect immunolocalization of tyrosine hydroxylase in FSCs using anti-tyrosine hydroxylase antibodies was negative. Mazindol, a dopaminergic receptor antagonist, did not alleviate the toxicity of 6-OHDA suggesting that FSCs do not appear to possess a dopaminergic receptor. When the cell morphology of FSCs was examined by an indirect immunofluorescence technique, treatment of FSCs with 6-OHDA at a concentration of 200 microM for 2 hr modified the organization of alpha-smooth muscle actin into an irregular punctate pattern. Indeed, we found that the effects of 6-OHDA on cytoskeletal alterations and on the cell viability of FSCs were irreversible. These data suggest that : (1) 6-OHDA can cause irreparable injury to FSCs, but not hepatocytes; (2) hepatocytes are specially adapted to withstand an oxidative attack in contrast to FSCs. fibroblast and myocytes; (3) FSCs resemble other somatic cells in their low levels of antioxidant enzymes; and (4) this low profile of antioxidant activity may be responsible for the cell death and cytoskeletal alterations observed in FSCs in response to 6-OHDA.

Effects of steroid hormones and cyclosporine A on taurine-transporter activity in the RAW264.7 cell line

The activity of the taurine transporter is affected by various extracellular stimuli, such as ions, hormones and stress. To assess the effects of steroid hormones and cyclosporine A (CsA) on taurine-transporter activity, the murine monocytic cell line, RAW264.7, was stimulated with dexamethasone (DM), triamcinolone (TA), cortisone (CS), hydrocortisone (HCS), prednisone (PSN), prednisolone (PSL) and methylprednisolone (MPSL) in the presence of 12-O-tetradecanoylphorbol 13-acetate (TPA). Treatment of the cell with TPA led to a significant reduction in taurine-transporter activity. However, in the case of the stimulation of the cells with steroid hormones in the presence of TPA, all of the hormones reversed the TPA-induced reduction in the taurine-transporter activity. Treatment of the cells with CsA led to a significant reduction in taurine-transporter activity, but ionomycin (IM) alone did not affect taurine-transporter activity. However, IM reversed the TPA- and CsA-induced reduction in taurine-transporter activity. These results showed that both IM and the glucocorticoid hormones reversed TPA-induced reductions in taurine-transporter activity but only IM reversed the CsA-induced reduction of transporter activity in the RAW264.7 cell line.

Syntheses of two enantiomeric pairs of myo-inositol(1,2,4,5,6) and -(1,2,3,4,5) pentakisphosphate

Two enantiomeric pairs of myo-inositol(1,2,4,5,6)P5 and -(1,2,3,4,5)P5 have efficiently been synthesized by means of the lipase catalyzed acetylation of 1,2:5,6-di-O-isopropylidene-myo-inositol and the benzoyl migration procedure.

Primary CD56-positive NK/T-cell lymphoma of median nerve: a case report

Primary extranodal lymphomas of the central nervous system constitute 2% of all malignant lymphomas. The involvement of the peripheral nervous system is very rare. A solitary primary CD56-positive NK/T-cell lymphoma of the median nerve is described in a 70-year-old woman. On physical examination, a rubbery hard mass measuring 2.0 cm in diameter was palpated on the volar aspect of second to third finger of left hand. Excisional biopsy was performed. Under the fascia, a large fusiform tumor of the median nerve encapsulated with the epineurium was noted. Microscopically, the enlarged nerve showed extensive infiltration of atypical lymphoid cells. The lymphoid elements had abundant pale cytoplasm and large vesicular nuclei with peripheral prominent nuclei. The cells strongly expressed T-cell marker (UCHL-1) and natural killer cell marker (CD56). Gene rearrangement study showed rearrangement of T cell receptor (TCR-gamma).

Acute lymphoblastic leukemia with maturation--a new entity with clinical significance

The diagnosis of 'ALL with maturation' (ALLm) is proposed. One hundred and one patients with untreated ALL were entered into this study. The diagnosis of ALLm was made when more than 20% of all nucleated elements in the bone marrow showed maturation beyond prolymphocytes by light microscopic examination. The mature-appearing leukemic cells showed the same immunophenotype to remaining lymphoblasts. The number of ALLm cases was 19 (18.8%). The mean age at presentation of ALLm was 29 +/- 18, older than that of 18 +/- 16 of the remaining typical ALL (ALLt) (P = 0.015). Remission was induced with daunorubicin, vincristine, prednisone and L-asparaginase. Only two of 19 ALLm patients achieved CR after 4 weeks induction chemotherapy. In contrast, 57 of 82 (69.5%) ALLt patients achieved CR after the same induction chemotherapy. There was no significant difference in immunophenotype of ALLm compared with ALLt. Labeling index of DNA topoisomerase IIalpha (TopoLI) was studied by immunohistochemistry. Initial TopoLI of ALLm (221 +/- 147) was much lower than that of ALLt (609 +/- 262, P = 0.005). Furthermore, the remaining leukemic cells after chemotherapy were not labeled with anti-DNA topoisomerase IIalpha. The P53 protein was expressed in nine of 18 ALLm cases (50.0%) and P-glycoprotein was not expressed in ALLm cases. Twelve of 19 ALLm cases were studied for carrying bcr/abl fusion by karyotyping and/or fluorescent in situ hybridization. Only two cases revealed bcr/abl fusion. In conclusion, ALLm is a separate entity of ALL which has a very poor clinical course and is independent of other prognostic factors. The morphologically mature leukemic cells are in resting GO phase.

Solid phase synthesis of benzamidine and butylamine-derived hydantoin libraries

We have constructed a number of benzamidine- and butylamine-based hydantoin compounds by means of an efficient route using solid phase synthesis in which neat diisopropylamine was employed for a novel cyclization/traceless cleavage step. All library compounds were obtained in excellent yield and high purity.

Solid phase synthesis of benzamidine-derived sulfonamide libraries

Using solid phase synthesis, a library has been constructed of benzamidine-derived sulfonamides which have strong inhibitory activity against blood coagulant thrombin. The library compounds were obtained in good yield and high purity.

Solid phase synthesis of benzylamine-derived sulfonamide library

Using solid phase synthesis, a library has been constructed of benzylamine-derived sulfonamides which have strong inhibitory activity against the blood coagulant thrombin. The library compounds were obtained in good yield and high purity; four of these thrombin inhibitors showed nanomolar potency (Ki 600-10 nM).

The relationship between the duration of platelet storage and the development of transfusion reactions

BACKGROUND

The incidence of platelet transfusion reactions may depend partly on the length of storage. The influence of reactions on the effectiveness of platelet transfusions is not known.

STUDY DESIGN AND METHODS

Platelet transfusion reactions, identified by prospective monitoring, were analyzed for the effects of component type, recipient lymphocytotoxic antibodies, bacterial contamination, and duration of storage. Posttransfusion corrected count increments (CCIs) were used to evaluate the effectiveness of transfusions associated with reactions by comparing them to those of randomly selected transfusions without reactions.

RESULTS

Reactions accompanied 4 percent of the 4926 transfusions given and included 119 febrile nonhemolytic transfusion reactions, 62 allergic reactions, and 13 reactions with features of both. Platelet concentrates contained a mean of 0.5 x 10(8) white cells per unit. Lymphocytotoxic antibodies were detectable in 20 of 84 recipients tested proximate to a reaction. Bacterial cultures from 4 of 81 units were positive; 1 unit was associated with fatal Enterobacter sp. sepsis. The incidence of febrile nonhemolytic transfusion reactions but not allergic reactions was related to platelet storage duration. The CCI was not significantly different for transfusions associated with reactions (10.97 [median, range 0-72.5; n = 165]) or not so associated (13.1 [median, range 0-39.5; n = 174]) (p = 0.08).

CONCLUSION

The incidence of febrile nonhemolytic transfusion reactions but not allergic reactions appears to be related to the duration of platelet storage. Transfusion reactions may not have an adverse impact on the effectiveness of platelet transfusions.

Solanum lyratum inhibits anaphylactic reaction and suppresses the expression of L-histidine decarboxylase mRNA

We investigated the effect of aqueous extract of Soloanum lyratum THUNB. (Solanaceae) (SLAE) on anaphylactic reaction. The mast cell is widely thought to contribute to the acute changes associated with anaphylaxis. SLAE inhibited skin mast cells-mediated anaphylactic reaction activated by anti-dinitrophenyl (DNP) IgE. SLAE dose-dependently inhibited histamine release in mouse peritoneal mast cells activated by anti-DNP IgE or substance P. Substance P increased steady state levels of L-histidine decarboxylase (HDC) mRNA in mouse mastocytoma P-815 cells. Northern-blot analysis demonstrated that significantly reduced level of the mRNA of HDC was expressed in mast cells treated with SLAE, compared to that without SLAE. We conclude that SLAE directly affect IgE-mediated anaphylactic reaction and substance P-induced HDC mRNA over-expression.

Diagnosis of ovarian torsion with color Doppler sonography: depiction of twisted vascular pedicle

The purpose of this study was to assess the diagnostic value of ultrasonography for the detection of twisted vascular pedicle in ovarian torsion and to verify whether the blood flow alterations in the twisted vascular pedicle on color Doppler sonography can predict the viability of adnexal structures. In 28 of 32 patients with surgically proved torsion, the twisted vascular pedicle was detected preoperatively by ultrasonography, which shows a diagnostic accuracy of 87%. Arterial and venous flows were present in the twisted vessels on color Doppler sonography in 16 of 28 patients with a visible twisted vascular pedicle. In 11 patients who underwent adnexectomy, the pathologic findings revealed nonnecrotic ovaries in 10 patients. Untwisting of the twisted vascular pedicle was performed in five patients, and follow-up ultrasonography showed normal follicular development and ovulation. All 12 patients who showed no blood flow within the twisted vascular pedicle had necrotic ovaries. In conclusion, identification of the twisted vascular pedicle through ultrasonography is suggestive of ovarian torsion, and color Doppler sonography could be helpful in predicting the viability of adnexal structures by depicting blood flow within the twisted vascular pedicle.

Conservative therapy of adnexal torsion employing color Doppler sonography

STUDY OBJECTIVE

To ascertain if color Doppler sonography (CDS) can detect viability of adnexa in torsion.

DESIGN

Concurrent, nonrandomized study (Canadian Task Force classification II-2).

SETTING

Tertiary medical care center in a university hospital.

PATIENTS

Twenty-seven women suspected of having torsion of the ovary in which a benign tumor was present.

INTERVENTIONS

Color Doppler sonography of the ovarian pedicle suggested torsion. Laparoscopy or laparotomy was performed in 19 patients and confirmed the diagnosis.

MEASUREMENTS AND MAIN RESULTS

We identified a twisted vascular pedicle of the ovarian tumor by CDS in 24 (88%) of 27 women. Pedicle arterial and venous blood flow was observed in 10 women; pathology specimens revealed normal tissue, edema with congestion, or early hemorrhage. In all nine in whom only arterial blood flow or no blood flow was observed, pathology revealed hemorrhagic necrosis. In five women with arterial and venous blood flow the tumor was managed conservatively, either by detorsion or cystectomy, after which no embolism or tumor recurrence was seen at follow-up ultrasonography. Normal follicular development and ovulation occurred in these patients.

CONCLUSION

For women of childbearing age in whom torsion of benign adnexal tumors is suspected, CDS should be performed to confirm the diagnosis and ascertain whether or not pedicle arterial and venous blood flow is present. If such blood flow is detected, the adnexa is considered to be viable and detorsion or cystectomy may be performed, thus preserving the ovary. It is recommended that further studies with a larger group be undertaken to provide a basis for statistical analysis.

An evaluation of combinations of diaziquone, etoposide and mitoxantrone in the treatment of adults with relapsed or refractory acute myeloid leukemia: results of 8722, a randomized phase II study conducted by Cancer and Leukemia Group B

A phase II trial was conducted to determine which of the three possible two-drug combinations of diaziquone, etoposide and mitoxantrone was associated with the highest response rate in patients with relapsed or refractory acute myeloid leukemia (AML). Of the 167 patients (median age 55) with AML who entered the trial, 123 were in first relapse, 22 were in second relapse and 22 had failed to achieve complete remission (CR). CR rates were 30% for diaziquone and mitoxantrone, and 23% for the other two combinations (mitoxantrone/etoposide and diaziquone/etoposide), NS. Patients in first relapse had higher CR rates (40%) than other patients. Of the 166 patients who actually received treatment, 43 died before having either a CR or persistent leukemia. Non-hematologic toxicity was primarily mucosal with 24% of patients experiencing grade 3 or greater stomatitis on the two diaziquone arms, and 43% on the mitoxantrone/etoposide arm. The combination of diaziquone and mitoxantrone was selected for further testing in patients with AML.

Tumor cell contact mediated transcriptional activation of the fibroblast matrix metalloproteinase-9 gene: involvement of multiple transcription factors including Ets and an alternating purine-pyrimidine repeat

The 92-kDa type IV collagenase (MMP-9) is a metalloproteinase frequently localized in both tumor stroma and in tumor cells, particularly at the tumor invasion front. To explore the factors regulating transcriptional activation of MMP-9 in stromal cells, we used a model system in which fibroblast MMP-9 expression can be upregulated by cell-cell contact with metastatic transformed rat embryo cells. Using transient transfection of reporter gene constructs containing 5'-deleted or mutated MMP-9 promoter fragments, as well as electrophoretic mobility shift assays, the upstream NFkappaB, SP-1, and Ets sites and the downstream AP-1 site and retinoblastoma binding element were shown to be necessary for basal transcriptional activity of fibroblast MMP-9. In contrast only Ets or SP-1 appeared to be involved in contact-mediated induction of MMP-9. Mutation of the upstream AP-1 site increased both basal and contact-stimulated promoter activation. Deletion of the alternating purine-pyrimidine repeat in the downstream promoter decreased transcriptional activity. Together these findings suggest that Ets and SP-1 are the central transcriptional activators of MMP-9 gene expression in fibroblasts specifically responding to tumor cell contact, and that promoter conformation may regulate MMP-9 expression.

Subepithelial hematoma of the renal pelvis simulating neoplasm (Antopol-Goldman lesion)

Subepithelial hematoma of the renal pelvis (Antopol-Goldman lesion) is an extremely rare lesion. We report on a 55-year-old woman who presented with gross hematuria. It was incorrectly diagnosed as renal pelvic cancer and left radical nephroureterectomy with bladder cuff resection was performed. With awareness and high suspicion of Antopol-Goldman lesion in the radiographic differential diagnosis of a renal pelvic mass, this lesion can be treated conservatively or with partial nephrectomy.