Adjuvant high-dose rate brachytherapy with or without external beam radiotherapy post-hysterectomy for endometrial cancer

The purpose of this study was to evaluate patient selection, local control, survival and late toxicity of posthysterectomy adjuvant radiotherapy and compare adjuvant external beam therapy and high-dose rate (HDR) brachytherapy versus HDR brachytherapy alone. A retrospective analysis was performed on a series of 225 patients with endometrial cancer treated with external beam radiotherapy and HDR brachytherapy or HDR brachytherapy alone posthysterectomy from 1985 to June 1993. Of these 225 patients, 82 received external beam radiotherapy and brachytherapy and 143 received brachytherapy alone. The HDR fraction size was 8.5 Gy prescribed to the mucosal surface; two fractions were given after external beam and four fractions if brachytherapy alone was used. The median follow-up was 6.9 years. The patients who received combined external beam and brachytherapy had higher stage and grade tumors. The survival outcome was similar for either group when matched for stage. Overall relapse-free survival at five years was 96% and 81%, respectively for brachytherapy alone and combined adjuvant therapy. Pelvic recurrence was seen in 2.7% of patients. Toxicity was more common with external beam radiotherapy and brachytherapy compared to brachytherapy alone (45.1% vs 23.1%, P = 0.003). However, moderate or severe toxicity was rare but again was more common in the combined radiotherapy group (8.5% vs 2.1%, P = 0.04). There was a non-significant trend to increased toxicity after lymphadenectomy and external beam radiotherapy compared with patients who did not have a staging lymphadenectomy prior to external beam radiotherapy (62% vs 38%, P = 0.16). Adjuvant radiotherapy can be individualized and be based upon the information provided by the pathological specimens, which excluded external beam radiotherapy if a lymphadenectomy was performed and there was no evidence of extra-uterine disease. This study found more toxicity associated with adjuvant radiotherapy compared with other studies, but this may reflect different reporting criteria. There was more toxicity related to external beam radiotherapy and brachytherapy compared to brachytherapy alone. The two HDR brachytherapy protocols used in this series appear effective and safe.

Purification of a highly modified RNA-aptamer. Effect of complete denaturation during chromatography on product recovery and specific activity

To evaluate RNA-aptamers as potential drug candidates, efficient and scaleable purification protocols are needed. Because aptamers are highly structured and rigid molecules, denaturation during the purification process is a critical aspect to obtain a pure and active product. A two-step chromatographic procedure was developed to purify a synthetic anti-VEGF aptamer at the preparative scale. A reversed-phase chromatographic step was optimized with a highly hydrophobic ion pairing reagent, followed by ion-exchange chromatography in which heat and a chaotropic salt were used. Because of the presence of 2'-modified ribose, denaturation conditions had to be optimized in both chromatographic steps to achieve a fully active molecule.

Effect of repaglinide addition to metformin monotherapy on glycemic control in patients with type 2 diabetes

OBJECTIVE

To compare the effect of repaglinide in combination with metformin with monotherapy of each drug on glycemic control in patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 83 patients with type 2 diabetes who had inadequate glycemic control (HbA1c > 7.1%) when receiving the antidiabetic agent metformin were enrolled in this multicenter, double-blind trial. Subjects were randomized to continue with their prestudy dose of metformin (n = 27), to continue with their prestudy dose of metformin with the addition of repaglinide (n = 27), or to receive repaglinide alone (n = 29). For patients receiving repaglinide, the optimal dose was determined during a 4- to 8-week titration and continued for a 3-month maintenance period.

RESULTS

In subjects receiving combined therapy, HbA1c was reduced by 1.4 +/- 0.2%, from 8.3 to 6.9% (P = 0.0016) and fasting plasma glucose by 2.2 mmol/l (P = 0.0003). No significant changes were observed in subjects treated with either repaglinide or metformin monotherapy in HbA1c (0.4 and 0.3% decrease, respectively) or fasting plasma glucose (0.5 mmol/l increase and 0.3 mmol/l decrease respectively). Subjects receiving repaglinide either alone or in combination with metformin, had an increase in fasting levels of insulin between baseline and the end of the trial of 4.04 +/- 1.56 and 4.23 +/- 1.50 mU/l, respectively (P < 0.02). Gastrointestinal adverse events were common in the metformin group. An increase in body weight occurred in the repaglinide and combined therapy groups (2.4 +/- 0.5 and 3.0 +/- 0.5 kg, respectively; P < 0.05).

CONCLUSIONS

Combined metformin and repaglinide therapy resulted in superior glycemic control compared with repaglinide or metformin monotherapy in patients with type 2 diabetes whose glycemia had not been well controlled on metformin alone. Repaglinide monotherapy was as effective as metformin monotherapy.

The impact of an information pack on patients with stroke and their carers: a randomized controlled trial

OBJECTIVES

To assess the impact of information packs on patients with stroke and their carers, and to pilot some of the methodology for a trial of a Family Support Organiser (FSO).

SUBJECTS

Seventy-one patients admitted to Oxford hospitals with acute stroke during February-July 1995, and 49 informal carers of these patients.

DESIGN

Randomized controlled trial. Intervention group received an Information pack containing various Stroke Association publications one month after their stroke, or at discharge from hospital, whichever was sooner. Control group received nothing. Follow-up was by interview at the place of residence of the patients six months after their stroke.

MEASURES

Outcome measures assessed knowledge about stroke; satisfaction with information received; patient behaviour in terms of access to community services and benefits; and health status and quality of life.

RESULTS

Patients and carers in the intervention group tended to know more about stroke, but these differences were not significant once adjusted for age. Patients in the intervention group (but not carers) tended to be more satisfied with the information that they had received, but the differences were not significant. There were no differences with regard to any aspects of quality of life in patients in the intervention group, though carers in the intervention group were found to have significantly better mental health (p = 0.04).

CONCLUSIONS

While the study was too small to generate firm conclusions, information leaflets may lead to improved knowledge about stroke several months after they have been distributed. This finding is worth following up with larger studies. The stroke knowledge questionnaire that was piloted in this trial seems to be able to detect differences between groups.

High-dose-rate brachytherapy alone post-hysterectomy for endometrial cancer

PURPOSE

To evaluate the outcome of post-hysterectomy adjuvant vaginal high-dose-rate (HDR) brachytherapy.

METHODS AND MATERIALS

A retrospective analysis was performed on a series of 143 patients with endometrial cancer treated with HDR brachytherapy alone post-hysterectomy from 1985 to June 1993. Of these patients, 141 received 34 Gy in four fractions prescribed to the vaginal mucosa in a 2-week period. The median follow-up was 6.9 years. Patients were analyzed for treatment parameters, survival, local recurrence, distant relapse, and toxicity.

RESULTS

Five-year relapse free survival and overall survival was 100% and 88% for Stage 1A, 98% and 94% for Stage IB, 100% and 86% for Stage IC, and 92% and 92% for Stage IIA. The overall vaginal recurrence rate was 1.4%. The overall late-toxicity rate was low, and no RTOG grade 3, 4, or 5 complications were recorded.

CONCLUSION

These results are similar to reported international series that have used either low-dose-rate or HDR brachytherapy. The biological effective dose was low for both acute and late responding tissues compared with some of the HDR brachytherapy series, and supports using this lower dose and possibly decreasing late side-effects with no apparent increased risk of vaginal recurrence.

The Mayo Clinic-Canadian Cooperative trial of sulfasalazine in active multiple sclerosis

OBJECTIVE

To determine whether sulfasalazine is better than placebo in slowing disability progression in MS.

METHODS

In this randomized, double-blind, placebo-controlled phase III trial, 199 patients with active relapsing-remitting (n = 151) or progressive (n = 48) MS were evaluated at 3-month intervals for a minimum of 3 years (94% completed 3 years of follow-up; mean follow-up, 3.7 years). MRI studies were performed at 6-month intervals on a subset of 89 patients.

RESULTS

Sulfasalazine failed to slow or prevent disability progression as measured by the primary outcome (confirmed worsening of the Expanded Disability Status Scale [EDSS] score by at least 1.0 point on two consecutive 3-month visits). Sulfasalazine influenced favorably a number of secondary outcomes during the first 18 months of the trial (e.g., annualized relapse rate, proportion of relapse-free patients; progressive subgroup only: rate of EDSS progression at 1 and 2 years, median time to EDSS progression) but these positive findings were not sustained into the second half of the trial.

CONCLUSIONS

Sulfasalazine does not prevent EDSS score progression in the subset of MS patients studied by this protocol. Treatments may improve relapse-related outcomes in MS, at least temporarily, without providing sustained slowing of EDSS progression. Phase III MS trials should be of sufficient length to determine a meaningful impact on disease course.

Culturally sensitive validation of screening questionnaires for depression in older African-Caribbean people living in south London

BACKGROUND

We tested the validity of two screens for depression in older African-Caribbean adults, the 15-item Geriatric Depression Scale (GDS) and a new Caribbean Culture-Specific Screen for emotional distress (CCSS). Two independent criteria were used for validity: (a) a psychiatric diagnosis derived from GMS-AGECAT, and (b) a culturally sensitive assessment of mental disorder, derived from a tool developed with local African-Caribbean religious healers.

METHOD

One hundred and sixty-four consecutive African-Caribbean primary care users, aged 60 years or older, were screened with the GDS and the CCSS. Diagnostic interviews were carried out on 80% of high scorers and 20% of low scorers.

RESULTS

The number of cases detected by the two separate diagnostic approaches was similar. However, the agreement between who was and who was not a case was only modest. At a cut-off of > or = 5, the GDS was an adequate case detector for psychiatric depression, and, at a cut-off of > or = 4, for 'depressed/lost spirit', as defined by culture-specific criteria. It performed as well as the new CCSS.

CONCLUSIONS

At a cut-off of > or = 4 the 15-item GDS can be recommended as a case detector for significant forms of depression in older African-Caribbean people living in south London.

Object oriented students? (poster)

In this poster, we describe our initial experiences when teaching an Object Oriented programming language to first year undergraduate students.

Copper-dependent inflammation and nuclear factor-kappaB activation by particulate air pollution

Particulate air pollution causes increased cardiopulmonary morbidity and mortality, but the chemical determinants responsible for its biologic effects are not understood. We studied the effect of total suspended particulates collected in Provo, Utah, an area where an increase in respiratory symptoms in relation to levels of particulate pollution has been well documented. Provo particulates caused cytokine-induced neutrophil chemoattractant-dependent inflammation of rat lungs. Provo particulates stimulated interleukin-6 (IL-6) and IL-8 production, increased IL-8 messenger RNA (mRNA) and enhanced expression of intercellular adhesion molecule-1 (ICAM-1) in cultured BEAS-2B cells, and stimulated IL-8 secretion in primary cultures of human bronchial epithelium. Cytokine secretion was preceded by activation of the transcription factor nuclear factor-kappaB (NF-kappaB) and was reduced by treatment of cultures with superoxide dismutase, deferoxamine, or N-acetylcysteine. These biologic effects were replicated by culturing BEAS cells with quantities of Cu2+ found in Provo extract. IL-8 secretion by BEAS cells could be modified by addition of normal constituents of airway lining fluid to the culture medium. Mucin significantly reduced IL-8 secretion, and ceruloplasmin significantly increased IL-8 secretion and activation of NF-kappaB. These findings suggest that copper ions may cause some of the biologic effects of inhaled particulate air pollution in the Provo region of the United States, and may provide an explanation for the sensitivity of asthmatic individuals to Provo particulates that has been observed in epidemiologic studies.

Mood response to levodopa infusion in early Parkinson's disease

Mood response to levodopa infusion was studied in 18 Parkinson's disease (PD) patients during the first year of levodopa therapy before and after 2-hour (1.0 mg/kg/h) levodopa infusions at baseline and 6- and 12-month follow-up. Mood elevation was greatest after a 2-day levodopa holiday at the 6- and 12-month assessments. Age, sex, duration and severity of PD, and ongoing oral levodopa dose did not correlate with mood response. Mood response in these patients differs from that seen in advanced patients, possibly because of sensitization to levodopa's mood effects.

Tuberculosis of the mandible in a child

The incidence of notification of tuberculosis is increasing in the developed world. The disease has a variable mode of presentation and therefore diagnosis is not easy. We present an unusual case of tuberculosis involving the ramus of the mandible in a six-year-old boy and outline its management.

Trypanosoma cruzi infection of free-ranging lion-tailed macaques (Macaca silenus) and ring-tailed lemurs (Lemur catta) on St. Catherine's Island, Georgia, USA

Free-ranging Old World primates released on St. Catherine's Island, Georgia (USA), were tested for infection with Trypanosoma cruzi as part of a study of the epizootiology of sylvatic T. cruzi in the southeastern USA. The parasite was observed in liver infusion tryptose medium cultures of blood from seven of 11 lion-tailed macaques (Macaca silenus) and one of 19 ring-tailed lemurs (Lemur catta). Cultures of blood from 10 black and white ruffed lemurs (Varecia variegata) were all negative. Analysis of small subunit ribosomal RNA gene polymorphisms detected using polymerase chain reaction techniques indicates that the parasites isolated from both the lion-tailed macaques and the ring-tailed lemur are probably the same as T. cruzi parasites isolated from raccoons (Procyon lotor) trapped on St. Catherine's Island and other locations in the southeastern USA. Foraging lion-tailed macaques were observed to handle and partially consume specimens of Triatoma sanguisuga, the triatomine bug thought to be a vector of T. cruzi in the southeastern USA. Oral transmission of the parasite may have occurred as a result of this behavior.

Neurofilament (NF) assembly; divergent characteristics of human and rodent NF-L subunits

Previous studies have shown that rodent neurofilaments (NF) are obligate heteropolymers requiring NF-L plus either NF-M or NF-H for filament formation. We have assessed the competence of human NF-L and NF-M to assemble and find that unlike rat NF-L, human NF-L is capable of self-assembly. However, human NF-M cannot form homopolymers and requires the presence of NF-L for incorporation into filaments. To investigate the stage at which filament formation is blocked, the rod domains or the full-length subunits of human NF-L, human NF-M, and rodent NF-L were analyzed in the yeast "interaction trap" system. These studies demonstrated that the fundamental block to filament formation in those neurofilaments that do not form homopolymers is at the level of dimer formation. Based on theoretical biophysical considerations of the requirements for the formation of coiled-coil structures, we predicted which amino acid differences were likely to be responsible for the differing dimerization potentials of the rat and human NF-L rod domains. We tested these predictions using site-specific mutagenesis. Interestingly, single amino acid changes in the rod domains designed to restore or eliminate the coiled-coil propensity were found respectively to convert rat NF-L into a subunit capable of homopolymerization and human NF-L into a protein that is no longer able to self-assemble. Our results additionally suggest that the functional properties of the L12 linker region of human NF-L, generally thought to assume an extended beta-sheet conformation, are consonant with an alpha-helix that positions the heptad repeats before and after it in an orientation that allows coiled-coil dimerization. These studies reveal an important difference between the assembly properties of the human and rodent NF-L subunits possibly suggesting that the initiating events in neurofilament assembly may differ in the two species.

Efficient activation of nucleoside phosphoramidites with 4,5-dicyanoimidazole during oligonucleotide synthesis

A new activator for the coupling of phosphoramidites to the 5'-hydroxyl group during oligonucleotide synthesis is introduced. The observed time to complete coupling is twice as fast with 4, 5-dicyanoimidazole (DCI) as the activator, compared with 1 H -tetrazole. The effectiveness of DCI is thought to be based on its nucleophilicity. DCI is soluble in acetonitrile up to 1.1 M at room temperature and can be used as the sole coupling activator during routine automated solid phase synthesis of oligonucleotides. The addition of 0.1 M N -methylimidazole to 0.45 M 1 H -tetrazole also results in higher product yields during oligonucleotide synthesis than observed with 1 H -tetrazole alone.

Culture of the causative organism of donovanosis (Calymmatobacterium granulomatis) in HEp-2 cells

We report successful culture of Calymmatobacterium granulomatis by standard cell culture methods. Swabs were obtained from lesions in three patients with a clinical diagnosis of donovanosis. For two patients, there was histological confirmation of the disease (i.e., the presence of Donovan bodies in Giemsa-stained smears). Specimens were inoculated onto cycloheximide-treated HEp-2 cell monolayers in RPMI 1640 medium (supplemented with fetal calf serum, NaHCO3, vancomycin hydrochloride, and benzylpenicillin). At 48 h, organisms resembling Donovan bodies were identified in monolayer cultures from all three specimens. The organisms appeared as pleomorphic bacilli with characteristic bipolar staining and "safety pin" appearance. Using a PCR designed to differentiate C. granulomatis from the Klebsiella species (which have a high degree of molecular homology), we were able to demonstrate that the cultured organisms produced a PCR product identical to that obtained from the original swab specimens. It is now possible to test in vitro susceptibility of C. granulomatis to antibiotics and to provide a ready source of DNA and antigenic material to enable the development of serological tests and, possibly in the future, a vaccine.

Coexistence of granular cell tumor and ipsilateral infiltrating ductal carcinoma of the breast

Granular cell tumor is a benign neoplasm that is rarely seen in the breast and can mimic carcinoma, both clinically and by gross pathologic examination. The coexistence of a granular cell tumor with a primary mammary carcinoma can potentially pose diagnostic and therapeutic problems. In this report, we document a granular cell tumor of the breast coexisting with an ipsilateral infiltrating ductal carcinoma in a 74-year-old woman and discuss its clinical significance.

Job satisfaction of HIMs working in Victorian hospitals

The growing demand for Health Information Managers (HIMs) in Victorian hospitals has increased the importance of job satisfaction in maximising performance and ensuring high retention levels both within the profession and the state. This report outlines the results of a job satisfaction questionnaire completed by a sample of HIMs working in Victorian hospitals. The questionnaire focuses on task design, autonomy, performance feedback and professional development opportunities. While the study demonstrates a scope for improvement, it also highlights the general satisfaction of the Victorian HIM population.

Recognition of superpotent sweetener ligands by a library of monoclonal antibodies

Monoclonal antibodies (mAb) made to the superpotent guanidino sweet tasting ligand, N-(p-cyanophenyl)-N'-(diphenylmethyl)-guanidineacetic acid were examined for their molecular recognition specificities using 14 different sweetener analogues in a competitive radioimmunoassay. The effects of variations in pH on ligand binding was also examined by radioimmunoassay. Photoaffinity labelling of the binding site was accomplished using a radiolabelled azido-derivative of the parent ligand, and L-chain or H-chain labelling was easily identified in several different mAb. For two of the mAb examined in this study (NC6.8 and NC10.14), the analogue binding studies are in agreement with the known Fab-ligand crystal structures. Monoclonal antibodies to this family of sweet tasting compounds may be useful probes for the study of sweet taste chemistry and identification of novel sweet taste ligands from combinatorial chemical libraries.