Methotrexate/fluorouracil scheduling influences normal tissue toxicity but not antitumor effects in patients with squamous cell head and neck cancer: results from a randomized trial

To test the hypothesis that sequential scheduling of methotrexate (MTX) and fluorouracil (FU) produces a synergistic antitumor effect, we randomized 113 patients with recurrent or locally advanced squamous cell carcinoma of the head and neck to receive MTX-FU either 18 hours apart or simultaneously, with leucovorin rescue. There were 100 patients with locally advanced newly presenting disease and 13 patients with recurrence. Excessive toxicity was observed in the first 11 patients who received MTX 250 mg/m2 administered intravenously (IV) and leucovorin at 36 hours, therefore all subsequent patients received MTX 200 mg/m2 administered IV and leucovorin at 24 hours. FU 600 mg/m2 IV was administered to all patients, and treatment was given on days 1 and 8 of 21-day cycles. The treatment groups were well balanced for known prognostic variables. The response rate was 47.3% (26 of 55) for simultaneous v 44.8% (26 of 58) for sequential therapy. These results exclude a 20% difference in response rate favoring sequential therapy at P = .04. There was no observed difference in survival between the two treatment arms (P = .55) with a minimum follow-up of 8 months. Toxicity was greater in patients who received sequential therapy, and the difference was confined to the gastrointestinal (GI) tract. A comparison of the distribution in maximum Eastern Cooperative Oncology Group (ECOG) toxicity scores during chemotherapy for the two treatment groups showed greater stomatitis (P = .001), diarrhea (P = .04), and overall toxicity (P = .02) for sequential treatment without an observed difference in bone marrow toxicity. The results of this trial indicate that sequential MTX-FU is not superior to simultaneous therapy for the treatment of patients with head and neck cancer. Biochemical modulation of MTX-FU by drug scheduling may occur in vivo and may be organ specific.

Dactylaria gallopava encephalitis in two grey-winged trumpeters (Psophia crepitans)

Encephalitis caused by Dactylaria gallopava is reported in two 17-to-18-day-old grey-winged trumpeters (Psophia crepitans). One of the chicks was housed in a tropical exhibit, and the other was in an adjacent room. Fir bark litter and aerosol infection were the suspected source and route of infection. The occurrence of this disease in a species other than the domestic chicken and turkey suggests the presence of a broader avian population at risk than previously indicated. Adult trumpeters and both young and old passerines housed in the same exhibit were not affected.

Magnetic resonance imaging techniques in children

A method of scanning children using magnetic resonance imaging (MRI) is described. Besides detailing ways to keep the patient comfortable and relaxed, which also allows for better resolution, the authors point out the necessity to plan objectives before beginning the MRI study.

Survival results from a phase III study of simultaneous versus 1-hour sequential methotrexate-5-fluorouracil chemotherapy in head and neck cancer

There were 79 patients with squamous cell head and neck cancer randomized to receive simultaneous or 1 hour sequential methotrexate-5 fluorouracil (MTX--5-FU) chemotherapy: 47 patients were previously untreated and 32 patients had recurrent disease. The treatment groups were comparable for important prognostic features. The median survival for the 47 newly presenting patients was 22 months and for recurrent disease patients was 14 months. No difference could be detected in the survival of patients who received simultaneous versus sequential chemotherapy. When only chemotherapy responders were compared, no difference in survival was detected for those who received sequential versus simultaneous therapy. Subsequently, 19 chemotherapy responders received radical radiation therapy, and 15 were rendered disease-free whereas only 4 of 17 chemotherapy nonresponders were rendered disease-free by subsequent radiation (P = .002). The survival of the 19 chemotherapy responders was 34 months compared with 16 months for the 17 chemotherapy nonresponders treated with radiation. We conclude that there is no therapeutic advantage for 1 hour sequential MTX-5 FU chemotherapy compared with simultaneous use of these drugs in squamous cell head and neck cancer. Chemotherapy responders are more likely to respond to radiation therapy.

Value of antigen quantitation in Haemophilus influenzae type b meningitis

We studied Haemophilus influenzae type b meningitis in 68 patients to evaluate whether quantitative determination of PRP in body fluids obtained at admission or measurement of the duration of its presence helped identify patients at risk for complications. Geometric mean admission PRP concentrations in CSF, blood, and urine increased with severity of disease, but individual values varied greatly. Measurements of the duration of antigenemia and antigenuria also varied widely and were best predicted by the admission or peak PRP concentration. The mean duration of both antigenemia and antigenuria increased with severity of disease. In contrast, the elimination half-life of PRP did not differ significantly with severity of hospital course, peak PRP concentration in blood or urine, or patient age. Clearance from CSF could not be accurately assessed, but PRP was detectable in only six of 41 patients in whom spinal fluid was obtained after the eighth day of hospitalization; all had complicated courses. Although latex particle agglutination assay is a valuable aid in rapid diagnosis of invasive Hib infections, the predictive value of antigen quantitation at admission and the determination of its duration in body fluids is limited by the wide range of observed values.

Prospective randomized trial of one-hour sequential versus simultaneous methotrexate plus 5-fluorouracil in advanced and recurrent squamous cell head and neck cancer

Results from experimental systems suggest that the combination of methotrexate (MTX) and 5-fluorouracil (5-FU) produces synergistic cytotoxic effects that are dependent on the sequence of drug administration. Biochemical studies have demonstrated plausible mechanisms of a synergistic effect when MTX precedes 5-FU. A variety of phase I and phase II studies have employed this sequential combination with promising but inconclusive results. In this study, 79 evaluable patients with squamous cell head and neck cancer were randomized to receive MTX (200 mg/m2 IV) and 5-FU (600 mg/m2 IV) either simultaneously or sequentially with MTX preceding 5-FU by one hour. All patients were ambulatory and patients were stratified as to whether they presented with primary disease or with recurrence after prior radiation and/or surgical therapy. The overall response rate was superior for simultaneous therapy (62%) compared with sequential therapy (38%) (p less than 0.06). Among patients with primary head and neck cancer, the stage of the disease influenced the response rate. Eight of nine stage III patients who received simultaneous therapy responded while none of the four patients who received sequential therapy responded (p less than 0.01). This study demonstrates that one-hour sequential MTX plus 5-FU is not superior to simultaneous treatment in patients with squamous cell head and neck cancer.

Diagnostic palpation of the spine: a review of procedures and assessment of their reliability

Spinal palpation as employed by practitioners of manipulative therapy is a common diagnostic tool used to identify manipulable lesions. Three methods of diagnostic palpation are static palpation, active motion palpation and passive motion palpation. As a diagnostic technique, spinal palpation suffers from a lack of research on its statistical reliability. Assessment of the clinical efficacy of manipulative therapy would be better addressed if a statistically reliable method of palpatory diagnosis were developed.

Trimethoprim and rifampin in combination for chemoprophylaxis of household contacts of patients with invasive infections due to Haemophilus influenzae type b

We compared the effectiveness of rifampin-trimethoprim in fixed combination (3.75:1) to rifampin alone in the eradication of Haemophilus influenzae type b carriage among contacts of patients with invasive infection caused by this organism. The study population was composed of 127 index patients and 620 contacts. Twenty-six percent of contacts were colonized. Rifampin-trimethoprim eradicated carriage in 77.6% of contacts (71.1% in contacts less than 5 years, 84.2% in contacts greater than or equal to 5 years) whereas rifampin eradicated carriage in 69.9% of contacts (56.4% in contacts less than 5 years, 81.8% in contacts greater than or equal to 5 years). A single isolate resistant to rifampin and rifampin-trimethoprim was encountered. The eradication rate achieved with this regimen of rifampin-trimethoprim was too low to recommend its routine use. However, a higher dose or longer course might merit clinical trial.

Antigenic relationships of murine coronaviruses

Two serological tests were used to examine the antigenic relationships between murine hepatitis viruses that cause different diseases in mice. Antisera prepared by immunization of mice with the individual viruses were tested for their ability to neutralize both the homologous immunogen and the other viruses. By a plaque reduction neutralization test, each antiserum was found to be specific for the immunizing virus; however, there was substantial cross-reactivity, indicating the viruses were closely related. By kinetic neutralization, two of the viruses tested, MHV-JHM and MHV-2, were found to be antigenically distinct. MHV-3 and MHV-A59 were found to be antigenically very similar but distinct. These data show that kinetic neutralization is a more precise method for determining the antigenic relationships between murine coronaviruses.

Oral rehydration therapy of infantile diarrhea: a controlled study of well-nourished children hospitalized in the United States and Panama

Although oral glucose-electrolyte solutions containing 90 mmol of sodium per liter have been widely used in the treatment of acute diarrhea among under-nourished children in the developing world, they have rarely been studied in well-nourished children. We therefore conducted a controlled randomized study among well-nourished children three months to two years who were hospitalized with acute diarrhea (52 in the United States, and 94 in Panama), to compare the efficacy of this solution with that of one containing 50 mmol of sodium per liter and with standard intravenous therapy. Oral rehydration with both solutions according to protocol was successful in 97 of 98 children (one required unscheduled intravenous therapy), and in 87 (89 per cent) no intravenous therapy was required. All of six children admitted with hypernatremia were successfully treated with oral therapy alone. We conclude that glucose-electrolyte oral solutions containing either 50 or 90 mmol of sodium per liter are effective and safe in the treatment of well-nourished children hospitalized with acute diarrhea, and that they may completely replace the intravenous fluids in the majority of such children.

Diet of the Yellow-bellied Glider Petaurus australis (Marsupialia: Petauridae) in north Queensland

The diet of the Yellow-bellied Glider was studied at Herberton in north Queensland by faecal analysis. The Glider was found to consume a variety of arboreal arthropods, principally tree crickets, adult and larval beetles, caterpillars and spiders. The bulk of the diet was thought to consist of exudates including eucalypt sap, eucalypt nectar and to a lesser extent insect honey dew. Some aspects of the life history of this species are consistent with a high sap, low arthropod (and hence protein) diet.

The neuroleptic malignant syndrome

The neuroleptic malignant syndrome is an uncommon, potentially fatal, adverse reaction to major tranquillisers. Prompt diagnosis, cessation of medication and supportive medical care are essential in management.