Cytotoxic activity of 2',2'-difluorodeoxycytidine (gemcitabine) in poorly differentiated thyroid carcinoma cells

Poorly differentiated and anaplastic thyroid cancers are aggressive and usually fatal neoplasms, despite aggressive treatment. We performed an in vitro study to assess the activity of gemcitabine (2',2' difluorodeoxycytidine), a new fluorinated nucleoside analogue, against three poorly differentiated human thyroid carcinoma cell lines (ARO, WRO, and NPA). Each cell line was exposed to increasing concentrations of gemcitabine (0.0003 to 3000 mumol/L) for 24, 48, and 72 hours. Maximal reduction in cell viability was seen after 72 hours of gemcitabine for all three cell lines as measured by 3-(4,5-dimethyl thiazolyl-2)-2,5-diphenyl tetrazolium bromide (MTT) assay. NPA cells were more sensitive than the other two lines after 24 and 48 hours of exposure, but all cell lines were similarly sensitive at 72 hours. A cytotoxic effect was confirmed by DNA assay of adherent cells. IC50 concentrations for reduction in cell viability ranged from 0.731 and 0.986 mumol/L for each cell line after 72 hours of exposure. These concentrations are lower than serum levels in phase 1 clinical trials of gemcitabine for other malignancies. In summary, gemcitabine has activity against poorly differentiated thyroid cancer cell lines in vitro. In vivo studies using xenograft models are warranted to confirm these promising observations.

Cardiogenic shock due to cardiac free-wall rupture or tamponade after acute myocardial infarction: a report from the SHOCK Trial Registry. Should we emergently revascularize occluded coronaries for cardiogenic shock?

OBJECTIVES

We sought to compare the characteristics and outcomes of patients with acute myocardial infarction (MI) and cardiogenic shock (CS) caused by rupture of the ventricular free wall or tamponade versus shock from other causes.

BACKGROUND

Free-wall rupture is a recognized cause of mortality in patients with acute MI. Some of these patients present subacutely, which provides an opportunity for intervention. Recognition of factors that distinguish them from the overall shock cohort would be beneficial.

METHODS

The international SHOCK Trial Registry enrolled patients concurrently with the randomized SHOCK Trial. Thirty-six centers consecutively enrolled all patients with suspected CS after MI, regardless of trial eligibility.

RESULTS

Of the 1,048 patients studied, 28 (2.7%) had free-wall rupture or tamponade. These patients had less pulmonary edema, less diabetes, less prior MI, and less prior congestive heart failure (all p < 0.05). They more often had new Q waves in two or more leads (51.9% vs. 31.5%, p < 0.04), but MI location and time to shock onset after MI did not differ. Of patients with rupture or tamponade, 75% had pericardial effusions. No hemodynamic characteristics identified patients with rupture/tamponade. Most patients with rupture/tamponade had surgery and/or pericardiocentesis (27/28); their in-hospital survival rate was identical to that of the group overall (39.3%). Women and older patients with rupture/tamponade tended to survive intervention less often.

CONCLUSIONS

Free-wall rupture and tamponade may present as CS after MI, and survival after intervention is similar to that of the overall shock cohort. All patients with CS after MI should have echocardiography in order to detect subacute rupture or tamponade and initiate appropriate interventions.

Sperm and ova conservation: existing standards of practice in North America

BACKGROUND AND PROCEDURE

Rapid advances have occurred in both reproductive medicine and survival from childhood cancer. To establish the current level of best clinical practice for sperm, ovarian, and prepubertal tissue collection and storage, a cross-sectional survey of a major pediatric oncology collaborative study group (Pediatric Oncology Group, POG) was performed.

RESULTS

Of the 110 centers surveyed, 69 questionnaires (63%) were completed. No responding center had guidelines regarding which young people should be offered sperm, ovarian, or prepubertal testicular tissue conservation; 93% centers had offered sperm and 10% ova conservation; 15% had offered sperm conservation to males prior to completion of sexual development and 3% to girls prior to sexual maturation. All centers were more likely to offer sperm conservation than ova conservation for any given disease. The most common diseases for which conservation was offered were Hodgkin and non-Hodgkin lymphoma, and sarcomas. Fertility counseling was offered in a variety of settings by 71% of centers by health care professionals, including doctors, nurses, social workers, psychologists, and geneticists.

CONCLUSION

There was little agreement regarding appropriate indications for, and method of, gamete preservation in children's cancer centers. It is hard to establish best clinical practice from these data. Unresolved medical, legal, and ethical issues necessitate the development of a voluntary code of practice and guidelines in order to ensure good clinical practice.

Antecubital central venous catheter placement complicated by a persistent left superior vena cava

A 14-year-old female in whom we encountered a persistent left superior vena cava during placement of a central venous catheter is presented. The patient had a history of coarctation of the aorta, but the left superior vena cava was unknown. Since the incidence of persistent left superior vena cava in patients with congenital heart disease is ten times as great as those without, in this patient population it may be useful to obtain radiographic confirmation of catheter position before use.

Efficacy and safety of radiologically placed gastrostomy tubes in paediatric haematology/oncology patients

BACKGROUND

The treatment of malnutrition, which is of great concern in paediatric haematology/oncology patients, is fraught with problems. The goals of our study were to document the complications and assess the weight gain with gastrostomy tubes (G-tubes) in this population.

PROCEDURE

Patient data were acquired by retrospective review of all haematology, oncology, and bone marrow transplant (BMT) patients (n = 44) who received radiologically placed G-tubes at our institution over a 4-year period.

RESULTS

Forty-four G-tubes were placed (59% peri-BMT). At tube placement, 55% of patients were malnourished and 45% were nourished. Seventy-five percent of patients had the procedure without general anaesthetic. Localized G-tube-site infection was the most common complication (41%). Major complications occurred in 3 patients; 2 patients experienced localized peritonitis, and 1 patient developed a localized collection of pus in the abdominal wall. There were no G-tube-related deaths. At 1 month after the tube insertion, 39% of patients had gained, 54% maintained, and 7% lost weight. At 3 months, 69% had gained, 28% maintained, and 3% lost weight. There was a statistically significant weight gain from the time of the G-tube placement to both 1 month (P < 0.018) and 3 months (P < 0.0001) after G-tube placement. Patients in all diagnosis categories showed improvement from 1 to 3 months.

CONCLUSIONS

We conclude that retrograde tube placement is safe and can frequently be done without general anaesthetic and that G-tube feeding effectively reverses malnutrition and prevents weight loss in this patient population.

Changing physicians' attitudes toward self-help groups: an educational intervention

BACKGROUND

Members of self-help groups (SHGs) for support of cancer patients are concerned that physicians are skeptical about these groups and see them as potentially harmful. The purpose of this study was to assess family physicians' attitudes towards self-help groups and see whether these could be changed through an educational intervention.

METHODS

A questionnaire assessing attitudes toward SHGs was mailed to 1,422 eligible Ontario family physicians, to which 911 responded (64% response rate). Responders were sent an educational package consisting of an article about self-help groups, a list of local cancer self-help groups, and a follow-up questionnaire.

RESULTS

The study was completed by 584/911 family physicians (64%). After being exposed to educational material, the physicians were more positive about the helpfulness of SHGs (p = 0.021), and less concerned about SHGs' being harmful (p = 0.003). They were more positive about the potential for SHGs to provide participants with opportunities for: sharing information (p = 0.004), bonding with other patients (p < 0.001), feeling understood (p = 0.004), sharing common experiences (p = 0.004), providing hope (p < 0.001), sharing laughter (p = 0.001), becoming more assertive (p < 0.001), communicating with health professionals (p = 0.04), dealing with issues related to death and dying (p = 0.005), advocacy (p = 0.01), and overcoming isolation (p = 0.002). They were less concerned with the potential for SHGs to provide misinformation (p = 0.003), the negative effects of associating with the very ill (p = 0.002), dwelling on illness (p = 0.002), or cultivating false hope (p = 0.001).

CONCLUSION

Having family physicians complete a questionnaire, followed by educational material specific to their concerns, changed their attitudes toward self-help groups. Further study is needed to see whether behavioral changes resulted.

Developing alternate revenue sources

During the 1990s, with the proliferation of managed care and aggressive negotiating postures by insurance companies, the reimbursement paid to physicians decreased drastically. In order to compensate, physicians have had to extend their work week, reduce overhead or seek alternative revenue sources. Developing alternative sources of revenue without having to work additional hours is the most palatable option. In our practice, almost 15 percent of revenue is derived from alternate or non-physician revenues collected at 100 percent of posted charges. This article highlights some of these solutions and discusses their applicability and appropriateness within a practice.

Myth and reality. Recent NJ Supreme Court decisions and the physician-patient relationship

The NJ Supreme Court recently decided that a physician must obtain the patient's informed consent based on a discussion of all medically reasonable alternative treatments, regardless of whether the recommended course is noninvasive. The meaning of the phrase "medically reasonable," however, poses its own problems.

Risk perception in context: the Savannah River Site Stakeholder Study

Environmental managers are increasingly charged with involving the public in the development and modification of policies regarding risks to human health and the environment. Involving the public in environmental decision making first requires a broad understanding of how and why the public perceives various risks. The Savannah River Stakeholder Study was conducted with the purpose of investigating individual, economic, and social characteristics of risk perceptions among those living near the Savannah River Nuclear Weapons Site. A number of factors were found to impact risk perceptions among those living near the site. One's estimated proximity to the site and relative river location surfaced as strong determinants of risk perceptions among SRS residents. Additionally, living in a quality neighborhood and demonstrating a willingness to accept health risks for economic gain strongly abated heightened risk perceptions.

A study of lung cancer mortality in asbestos workers: Doll, 1955

Between 1935 and 1953, a series of publications appeared in England, Germany and America reporting cases of lung cancer amongst asbestos workers. As early as 1943, the German scientific consensus was that the evidence was strong enough to deem the association to be causal. On reviewing a more extensive bibliography, this view was shared by an American cancer expert. The results of industry sponsored experiments, in which lung tumors had been induced in mice by asbestos, were circulated in confidence to its scientists, but being unpublished were unknown to the general scientific community. There were also cancer mortality data recorded for populations of exposed asbestos workers, but these were confidential and remained to be analyzed. To deal with the persistent allegations of a lung cancer hazard, in 1953 Dr. Richard Doll was asked by Turner Brothers Asbestos ("the Company"), whose in-house analyses had been reassuring, to study the mortality data of a group of its workers. Despite the limitations of the data, Doll convincingly demonstrated so substantial an excess of lung-cancer in heavily exposed long-term asbestos workers as to overcome honest doubt. Despite determined attempts made to dissuade them, Doll and the editor of the journal to which he submitted his paper, courageously went ahead and published the paper. Industry overestimated the harm that publication of the paper would do to their immediate interests. It produced so profound a lack of sense of urgency, that legislation addressed to the control of lung cancer specifically had to wait 20 years, and asbestos workers contracting it were to wait 25 years, before they might be considered for compensation, and even then, only under extremely limiting conditions.

Application of comparative genomic hybridization, spectral karyotyping, and microarray analysis in the identification of subtype-specific patterns of genomic changes in rhabdomyosarcoma

Rhabdomyosarcoma (RMS) in children occurs predominantly as two major histologically defined subtypes called embryonal RMS (RMS-E) and the prognostically less favorable alveolar RMS (RMS-A). Comparative genomic hybridization (CGH) was performed on 21 RMS and identified consistent gains affecting chromosomes 2 (8/10), 5 (5/10), 6 (3/10), 7 (7/10), 8 (9/10), 11 (6/ 10), and 12 (5/10) in RMS-E. Losses/deletions involved chromosomes 19 (2/10) and chromosomes 4, 9, 10, 17, 21 (1/10 each). High copy number amplification, involving the 2p24 region (5/11) and less frequently, the 12q13-21 (2/11), 9p22 (1/11), and 17q22-25 (1/11) regions, was detected in RMS-A. Gene amplification at band 2p24 was present in 6/12 alveolar tumors, and in each case, MYCN was amplified, together with the distally placed DDX1 gene. For these patients there was a shorter disease free interval and a higher mortality than patients with tumors without amplification. Detailed spectral karyotype analysis (SKY) was performed on two RMS cell lines (one of each subtype) and identified a surprisingly high level of structural change. Gene expression studies with the Atlas Human Cancer Array (588 genes) showed that 153 genes generated a signal of similar intensity in both cell lines, and 45 genes appeared to have subtype-specific expression. The chromosomal location of differentially expressed genes was compared to the pattern of genomic alteration in RMS as determined by CGH in this study and the literature.

Economic impact of accelerated cleanup on regions surrounding the U.S. DOE's major nuclear weapons sites

The regional economic impacts of the U.S. Department of Energy's accelerated environmental cleanup plan are estimated for the major nuclear weapons sites in Colorado, Idaho, New Mexico, South Carolina, Tennessee, and Washington. The analysis shows that the impact falls heavily on the three relatively rural regions around the Savannah River (SC), Hanford (WA), and Idaho National Engineering and Environmental Laboratory (ID) sites. A less aggressive phase-down of environmental management funds and separate funds to invest in education and infrastructure in the regions helps buffer the impacts on jobs, personal income, and gross regional product. Policy options open to the federal and state and local governments are discussed.

Collection devices for human papillomavirus

BACKGROUND

Human papillomavirus (HPV) testing has relied to date on samples collected by experienced health professionals. Self-administered testing devices could allow HPV testing to occur in large-scale epidemiologic studies of primary care screening populations. The purpose of this study is to determine whether a self-collection device for cervicovaginal HPV infection could be developed.

METHODS

A prospective randomized trial of a consecutive sampling of 93 women, 18 years or older, receiving routine cervical cancer screening and colposcopy in the urban gynecologic clinics in Philadelphia, Pennsylvania, were randomized into 2 arms. Women in arm 1 used a self-administered tampon before the physician-directed swabs of the cervix; in arm 2, women underwent the physician-directed swab testing before using the self-administered tampon. The concordance of HPV DNA positivity between sampling methods detected by a Hybrid Capture HPV tube test for both low- and high-risk types of HPV was the main outcome measure.

RESULTS

The concordance rate (ie, women whose cultures were classified as negative on both tests or positive on both tests) for arms 1 and 2 were similar: 78.3% and 80.9%, respectively.

CONCLUSIONS

The tampon was equivalent to the physician-directed swab in HPV detection and suggests its feasibility in long-term primary care studies of screening populations.

Nurses' perspectives on unconventional therapies

Unconventional therapies have become increasingly popular with health care consumers in recent years. As patients seek information and attempt to make decisions about unconventional therapies, they often turn to nurses, asking the nurse's opinion about certain therapies. The nurse's attitudes and beliefs about unconventional therapies quite likely will influence the response to the patient's inquiries. This article represents the findings of interviews with 20 nurses regarding their perspectives on unconventional therapies. Without exception, all nurses who were interviewed emphasized that information regarding unconventional therapies needs to be available readily for both patients and health care professionals. Other themes identified in the interviews included the following: Various people use unconventional therapies; people seek unconventional therapies for a variety of reasons; communication about unconventional therapies needs to be open, and a place should be found for unconventional therapies. The interviewees saw a clearly defined role for nurses regarding unconventional therapies.

Applications for guided bone regeneration in endodontic surgery

Regeneration of apical bony defects remains a significant problem in endodontic surgery. When a resorbable membrane is placed over a defect, it acts as a barrier between the defect and the overlying gingival tissue. This barrier membrane provides sufficient time for bone to regenerate while preventing the faster growing connective tissue from invaginating into the area. When new tissue replicates the structure and function of the lost tissue, then apical regeneration has occurred.

Apexification & apexogenesis

When there is pulpal involvement of permanent teeth with incompletely formed roots, techniques for the induction of apical closure should be completed before endodontic therapy is begun. Apexification is a method of inducing a calcified barrier at the apex of a nonvital tooth with incomplete root formation. Apexogenesis refers to a vital pulp therapy procedure performed to encourage physiological development and formation of the root end.

Lymphoproliferative disorders after organ transplantation in children

BACKGROUND

After organ transplant, patients are at risk of posttransplant lymphoproliferative disorders (PTLD). The purpose of this study was to analyze 26 pediatric cases of PTLD observed at our institution between 1988 and 1996, and to evaluate the validity of the Society for Hematopathology Workshop (SHPW) 1997 classification in our patient population.

METHODS

Charts were reviewed for analysis of incidence, clinical course, and outcome. Tissue samples were classified by a pathologist according to SHPW recommendations.

RESULTS

By morphology, 20 were monomorphic, 5 polymorphic, and 1 hyperplastic. Assessment of lineage by morphology, molecular studies, and immunophenotyping did not correlate in six cases. By immunophenotyping, 12 were B cell, 4 T cell, 8 mixed B/T cells, and 2 undetermined. The 20 patients evaluable for treatment efficacy were treated with various therapeutic combinations, including immunosuppressive drug reduction, acyclovir/ganciclovir, interferon-alpha, immunoglobulins, surgery, and local irradiation. No patient received systemic chemotherapy. Thirteen patients achieved complete remission and 3, partial; 1 died 5 days after starting therapy, and 3 of progressive disease. Adverse prognostic factors included low platelet or neutrophil counts; stage III-IV and SHPW morphology were marginally significant.

CONCLUSIONS

The majority of patients eligible for treatment can be cured with immunosuppressive drug reduction and antiviral drugs, along with surgery and irradiation when indicated. Systemic chemotherapy or innovative approaches may have a role in unresponsive cases. Morphologic SHPW grouping is feasible and seems to have clinical relevance. However, correlation with clonality and immunophenotyping is not always possible, necessitating modifications including segregation of descriptive morphology from clonality and cell origin.

Oncology nurses' perspectives on unconventional therapies

Unconventional therapies have become increasingly popular with health care consumers in recent years. As patients seek information and attempt to make decisions about unconventional therapies, they often turn to nurses, asking their opinion about certain therapies. The nurse's attitudes and beliefs about unconventional therapies very likely will influence the response to the patient's inquiries. This work represents the findings of interviews with 48 nurses regarding their perspectives on unconventional therapies. Without exception, all nurses interviewed emphasized the need for information regarding unconventional therapies to be readily available for patients and health care professionals. The other themes identified in the interviews included the following: various people use unconventional therapies; people seek unconventional therapies for a variety of reasons; communication about unconventional therapies needs to be open; and conventional and unconventional practitioners ought to work collaboratively. The participants interviewed saw a clearly defined role for nurses regarding unconventional therapies.

Expression of WT1 in pediatric small cell tumors: report of two cases with a possible mesothelial origin

The WT1 gene is normally expressed in fetal kidney and mesothelium, and its expression has been suggested as a marker for Wilms tumor and mesothelioma. We examined WT1 expression levels by reverse-transcriptase polymerase chain reaction (RT-PCR) in 38 childhood small-cell tumors including Wilms tumor, embryonal and alveolar rhabdomyosarcoma, Ewing sarcoma, lymphoma, desmoplastic small round-cell tumor (DSRCT), synovial sarcoma, extrarenal rhabdoid tumor, and two tumors that were atypical for this group of tumors. WT1 expression was only detected in Wilms tumor, rhabdoid tumor, and in these two cases of uncertain histogenesis. Both arose in the peritoneal cavity and by immunohistochemistry were diffusely positive for vimentin, keratin, and desmin. Tonofilaments were identified by electron microscopy in one of the cases. RT-PCR failed to detect the t(11;22) translocation associated with DSRCT in either case. Our results suggest that WT1 expression is an unusual feature of childhood non-Wilms tumors and, in the right setting, it may indicate a mesothelial origin. The expression of WT1 may play a role in mesodermal cells acquiring epithelial characteristics, a concept supported by the mixed epithelial and mesenchymal phenotype of these two cases.

Cancer self-help groups and family physicians

PURPOSE

Despite the phenomenal growth during the past decade of cancer self-help groups for adult patients with cancer, little research has been conducted to document the interface between these groups and healthcare professionals, especially physicians. This study was initiated to provide information about family physician practices, awareness, and attitudes about self-help groups.

DESCRIPTION

A survey questionnaire was mailed to a random sample of Ontario family physicians drawn from the College of Family Physicians of Canada's membership database.

RESULTS

A total of 911 completed questionnaires were returned, for a response rate of 64%. A majority (56.8%) of respondents were aware of at least one cancer self-help group in their region; 26.8% of these spoke frequently with their cancer patients about such groups. Most family physicians indicated that they were positively inclined toward cancer self-help groups, giving especially high ratings of helpfulness to sharing common experiences, overcoming isolation, feeling understood, and sharing information. Ratings of potential harm were low, with the most concern expressed about the possible provision of misinformation and the promotion of unconventional therapies. Responses to an open-ended question showed that many family physicians qualify their support for cancer self-help groups, depending on patient need, group composition, and leadership.

CLINICAL IMPLICATIONS

Family physicians and other members of the cancer care team should give increased attention to informing cancer patients about the potential benefits of self-help groups. Efforts need to be made to assist cancer self-help groups in developing informational brochures and to ensure that groups are listed in cancer resource directories. Educational initiatives about self-help groups would be useful for family physicians and other health professionals engaged in the care of cancer patients.

Achieving success with the silicone expander for overacting superior obliques

PURPOSE

To report the results of and complications with silicone expander surgery for the overacting superior oblique.

METHODS

A total of 26 patients with bilateral overaction of the superior oblique and A-pattern strabismus and 5 patients with unilateral overacting superior oblique secondary to inferior oblique palsy were treated with a 7 mm silicone expander. Care was taken not to enter the sub-Tenon's space.

RESULTS

The group that underwent bilateral superior oblique surgery had an average preoperative pattern of 37.42 diopters (D) and an average correction of 35.37 D. Three patients had a severe unilateral postoperative inflammatory incident that was successfully treated with oral and topical corticosteroids. One of these patient developed Brown's syndrome. Another patient, who had no postoperative inflammatory incident, also developed Brown's syndrome. In these 4 patients, the sub-Tenon's space was inadvertently entered during surgery.

CONCLUSION

The silicone expander surgery has a very high success rate in treating the A-pattern associated with the bilateral overacting superior oblique. This procedure also works well for the unilateral superior oblique that overacts owing to an inferior oblique palsy. No cyclotorsion symptoms occurred after this surgery. However, 4 patients had complications because the sub-Tenon's space was exposed during surgery. With this procedure, there is a learning curve to obtain the skill not to enter the sub-Tenon's space.