Feasibility study of the treatment of primary unresectable carcinoma of the pancreas with 103Pd brachytherapy

PURPOSE

The purpose of this study was to assess the feasibility of 103Pd brachytherapy in the management of primary unresectable carcinoma of the pancreas.

METHODS AND MATERIALS

Between August 1988 and January 1992, 11 patients with biopsy-proven primary unresectable adenocarcinoma of the pancreas were treated with 103Pd brachytherapy during laparotomy. The median age was 66 (range 57-70). The most common presenting symptoms were weight loss (eight patients), pain (six patients), and nausea/vomiting (four patients). Less common symptoms were jaundice (two patients), early satiety (two patients), and ascites (one patient). All patients underwent laparotomy and surgical staging. Eight patients had T3N0M0 disease, two patients had T3N1M0 disease, and one patient had T3N1M1 disease. The surgical procedure performed was biliary bypass in six patients, biopsy only in four patients, and gastric bypass in one patient. The average tumor dimension was 4.0 cm. The median activity, matched peripheral dose (MPD) and implanted volumes were 95.3 mCi, 124.4 Gy, and 33 cm3, respectively. The median initial dose rate was 0.21 Gy per hour. Five patients received postoperative external beam radiation therapy (median 45 Gy) and seven patients received chemotherapy postoperatively. The median follow-up was 7 months (range 1-19).

RESULTS

The median survival for the entire group of patients was 6.9 months. Ten of 11 patients have died, with 1 patient presently alive and receiving chemotherapy for metastatic disease to the liver, but without local progression radiographically. Five of 11 patients (45%) were locally controlled, defined as either a complete response or freedom from progression at the site of the implant as evaluated by computed tomography scan. In the other six patients, the median time to local progression was 6.9 months. Five patients developed distant metastases (four liver, one subcutaneous nodule). Two patients failed in regional sites (one omentum, one paraaortic lymph node). Four of 11 patients (36%) developed acute postoperative complications that included one gastric outlet obstruction, one duodenal perforation, and two with sepsis. One of 11 patients (9%) developed a late complication of radiation enteritis 5 months after implantation. The median survival for patients experiencing complications was 1.7 months as compared to 8.4 months for the patients who did not develop a complication (p = 0.10). Pain relief was obtained in five out of six (83%) of the patients presenting with pain for a median duration of 24 weeks. Local control did not appear to be related to the MPD, dose rate, implanted volume, treatment with external beam irradiation, or the use of chemotherapy. Patients were more likely to develop a complication if the MPD was greater than 115 Gy (four out of six patients) as compared to those whose MPD was less than 115 Gy (one out of five patients) (p = 0.12).

CONCLUSIONS

Because there was no improvement in median survival over conventional modalities, and the complication rate was high; we do not recommend 103Pd brachytherapy as a component of the treatment of unresectable adenocarcinoma of the pancreas.

Poorer prognosis in older patients with endometrial adenocarcinoma

It has been suggested that there are two types of endometrial carcinoma: the first arises in younger women who have hyperestrogenism and has a favorable prognosis and the second occurs in older women, is not associated to estrogen stimulation, and has a poorer prognosis. This study examined the hypothesis that more aggressive carcinomas are found in older patients with no evidence of estrogen stimulation. A retrospective review of all patients (N = 82) with endometrial carcinoma diagnosed and treated at our institution between 1978 and 1990 was undertaken. The following data were analyzed: age at diagnosis, stage, race, histologic type, grade, depth of myometrial invasion, absence or presence of associated hyperplasia, and survival. The mean age of the patients was 64.8 years. Sixty (73%) of the 82 patients were considered estrogen-positive either because of obesity (body mass index > or = 27.3) or the use of unopposed exogenous estrogen. There were no statistically significant differences between estrogen-positive and estrogen-negative patients. Patients > or = 65 years had a 5-year survival of 60% compared with 74% for younger patients. There was a trend toward higher histologic grade among the older patients. Otherwise no statistically significant differences were found between these two groups. Estrogen-negative women > or = 65 years had the worst prognosis with a 5-year survival of 29%. As identified by other investigators, age at diagnosis is a significant indicator of prognosis in patients with endometrial carcinoma. In this series, thin, older (> or = 65 years) women who developed endometrial carcinoma had the worst prognosis.

Dornase alfa: a new option in the management of cystic fibrosis

Recombinant human DNase I, or dornase alfa, is the first new therapy developed specifically for cystic fibrosis in almost 30 years. It selectively digests extracellular DNA and reduces the viscosity of purulent sputum. In clinical trials dornase alfa modestly improved pulmonary function, slightly decreasing the number of respiratory exacerbations requiring parenteral antibiotics compared with placebo. Phase III studies suggest that patients receiving dornase alfa also spend slightly fewer days in the hospital than those treated with placebo. The aerosolized preparation is safe and generally well tolerated. Voice alteration and sore throat are the most commonly reported adverse effects. Further research is necessary to determine the optimum time to initiate therapy and to evaluate the agent's pharmacoeconomic impact on the treatment of cystic fibrosis. Aerosolized dornase alfa should always be given in conjunction with standard cystic fibrosis therapies including antibiotics, chest physiotherapy, and pancreatic enzyme supplementation.

Purification of DNA fragments from lyophilized agarose gels

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Characterization of novel phorbol ester- and serum-responsive sequences of the rat ornithine decarboxylase gene promoter

Ornithine decarboxylase (ODC), the key regulatory enzyme in mammalian polyamine biosynthesis, is rapidly induced by mitogens and tumor promoters. We used transient expression assays and DNA-protein binding studies to examine the regulation of ODC promoter activity by phorbol esters and serum growth factors. A fragment of the ODC 5' flanking region (nt-1156 to +13) was sufficient to confer 12-O-tetradecanoylphorbol-13-acetate (TPA)-responsive expression to a luciferase reporter gene when transfected into H35 cells. However, induction by TPA was not observed in Rat2 fibroblasts, although refeeding of serum-starved Rat2 cells with fresh serum-containing medium rapidly induced a fivefold to sixfold increase in ODC promoter activity, maximal about 8 h after refeeding. Deletion analysis demonstrated that several sequences contributed to basal ODC promoter activity but that nt -92 to +13 was sufficient for induction by TPA or by serum. This sequence lacked canonical TPA-responsive elements, and an activator protein-1 (AP-1) consensus oligonucleotide failed to compete effectively for proteins binding to this region. Two of four protein complexes observed by gel-shift analysis of nt -92 to +13 were competitively inhibited by wild-type but not mutant oligonucleotides encompassing a variant cyclic AMP-response element (CRE) (ODC nt -50 to -42); however, a consensus CRE did not compete. Mutagenesis of this site demonstrated that it contributes to basal expression of the ODC promoter but not to TPA or serum responsiveness. Thus, we conclude that the proximal ODC promoter (nt -92 to +13) responds to TPA and serum stimulation in a cell-type-specific manner that is not mediated by canonical AP-1 elements.

The effectiveness of the Masterson curette in sampling the endometrial cavity

The Masterson curette was used to sample the endometrial cavity of 25 women prior to scheduled hysterectomy for benign or malignant pathology. Adequate amount of tissue was obtained in 20 (87%) of 23 patients who did not have endometrial atrophy. The Masterson curettage detected all seven cases of endometrial hyperplasia or adenocarcinoma for a sensitivity of 100%. However, the Masterson curette does not sample the entire endometrial cavity. If abnormal uterine bleeding persists despite normal histology on curettings obtained with the Masterson or other endometrial sampling device, hysteroscopy is recommended.

HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California

Few data are available on human immunodeficiency virus (HIV) infection and risk behaviors among lesbians and bisexual women. A total of 498 lesbians and bisexual women was sampled from public venues in San Francisco and Berkeley, Calif, during 1993. The overall HIV seroprevalence was 1.2%. Ten percent of participants reported injecting drugs since 1978. Forty percent of the participants reported unprotected vaginal or anal sex with men during the past 3 years, including unprotected sex with gay and bisexual men and male injection drug users. The high rates of injection drug use and unsafe sexual behaviors suggest that lesbians and bisexual women frequenting public venues in San Francisco and Berkeley are at risk for HIV infection.

Fiber intake of normal weight, moderately obese and severely obese subjects

The lack of dietary fiber may be a contributing factor in obesity. This study examined the fiber intake of three weight groups: normal (20.0 < or = BMI < or = 27.0), moderately obese (27.1 < or = BMI < or = 39.9) and severely obese (BMI > or = 40.0). Each group contained 50 subjects. Detailed 3-day food records were used to gather the nutritional data. Fiber intake in the normal weight group was 18.8 +/- 9.3 grams, the moderately obese consumed 13.3 +/- 5.8 grams of fiber and the severely obese 13.7 +/- 5.7 grams. Total fiber intake in grams was found to be significantly higher in the lean group (p < 0.05) and was positively associated with sex and education level with men and more highly educated individuals consuming more fiber. Using regression analysis total fiber in grams and fiber in g/1000 kcalories was inversely associated with BMI after adjusting for sex, age, education level and income (p < 0.01). A high fiber diet may help to promote a negative energy balance by causing early satiety secondary to gastric distention. Dietitians and physicians need to emphasize the importance of a high fiber diet to their obese patients.

Rapid desensitization of GnRH-stimulated intracellular signalling events in alpha T3-1 and HEK-293 cells expressing the GnRH receptor

The gonadotropin-releasing hormone receptor (GnRH-R) desensitizes following chronic exposure to GnRH or its agonists. However, it is not certain whether the GnRH-R undergoes rapid homologous desensitization analogous to other members of the G-protein coupled receptor (GPCR) superfamily. This study investigated rapid desensitization events in two cell lines expressing the GnRH-R; (the pituitary gonadotrope alpha T3-1 cell line and the stably transfected human embryonal kidney cells, HEK-293). In both cell types, total inositol phosphate (IP) production did not desensitize, increasing linearly over 10 min. Short-term GnRH pretreatment also did not desensitize the rapid phase ( < or = sec) of the early Ins1,4,5P3 response despite a partial desensitization of the plateau phase ( > 1 min). It is likely that Ins1,4,5P3 metabolism rather than desensitization is responsible for this partial effect. In contrast, GnRH-stimulated calcium responses did desensitize in a dose-dependent fashion in both alpha T3-1 and HEK 293 cells expressing the GnRH-R. These results suggest that rapid GnRH-R desensitization occurs at a level beyond both the receptor and phospholipase C (PLC) activation. These events were receptor specific and not related to cell type, since similar rapid desensitization profiles were observed in both GnRH-R expressing pituitary and nonpituitary cell types. In contrast, profiles of GnRH-stimulated calcium responses were cell type specific.

Rapid desensitization of the thyrotropin-releasing hormone receptor expressed in single human embryonal kidney 293 cells

This study uses fluorescence microscopy combined with dynamic video imaging to examine the events associated with the rapid desensitization of the thyrotropin-releasing hormone receptor (TRH-R). In single non-pituitary human embryonic kidney 293 (HEK-293) cells, expressing either the rat or human TRH-Rs, TRH produced a rapid dose-dependent monophasic rise in [Ca2+]i. This Ca2+ transient was completely abolished by pretreatment of cells with the intracellular Ca2+ antagonists thapsigargin or cyclopiazonic acid, but not EGTA, the voltage-operated Ca2+ channel (VOCC) antagonist nifedipine or the second-messenger-operated Ca2+ channel antagonist SK&F 96365. These results suggest that TRH causes the mobilization of Ca2+ from thapsigargin/cyclopiazonic acid-sensitive intracellular Ca2+ stores but not the influx of extracellular Ca2+. HEK-293 cells also failed to respond to KCl or the slow Ca(2+)-channel activator BAY K 8644, suggesting that they lack L-type VOCCs. Rat and human TRH-Rs are highly conserved except at the C-terminus where the sequence differs. The C-terminus is believed to be important in receptor desensitization. Despite differences in this region, rat and human TRH-Rs expressed in HEK-293 cells underwent rapid (within 1 min) desensitization. This desensitization was dose-dependent and did not involve receptor loss. Similarly the bradykinin receptor endogenous to HEK-293 cells also displays a rapid desensitization. We conclude that in TRH-R-expressing non-pituitary HEK-293 cells, TRH mobilizes intracellular Ca2+ resulting in a monophasic Ca2+ transient. The rat and human TRH-Rs as well as the endogenous bradykinin receptor also displayed rapid receptor desensitization.

The cannabinoid agonists WIN 55,212-2 and CP 55,940 attenuate rotational behavior induced by a dopamine D1 but not a D2 agonist in rats with unilateral lesions of the nigrostriatal pathway

The effect of cannabinoid receptor stimulation on rotational behavior induced by a dopamine D1 and a D2 agonist was studied in rats with unilateral 6-hydroxydopamine-induced lesions of the dopaminergic nigrostriatal pathway. The cannabinoid agonists WIN 55,212-2 (2.5 mg/kg) and CP 55,940 (0.1 mg/kg) both markedly attenuated contralateral rotation induced by the D1 agonist SKF 38393 (1.5 mg/kg). In contrast, WIN 55,212-2 and CP 55,940 did not alter rotation elicited by the D2 agonist quinpirole (0.1 mg/kg). Doses of WIN 55,212-2 and CP 55,940 that attenuated D1-mediated rotation did not produce catalepsy in intact rats or in rats with 6-hydroxydopamine-induced lesions, indicating that the reduction in rotation produced by the cannabinoids was not due to a generalized motor impairment. In addition, the effective dose of WIN 55,212-2, but not CP 55,940, produced only a slight increase in ipsilateral rotation when administered alone, making it improbable that this ipsilateral tendency accounts for the reduction in D1-mediated contralateral rotation. These results suggest a preferential interaction between cannabinoid receptor stimulation and dopamine D1 receptor-mediated behavior.

Diabetes control programs: new directions

The diabetes control programs (DCPs), which involve state and territorial health agencies working cooperatively with the Centers for Disease Control and Prevention, offer new opportunities for diabetes educators to expand their scope of practice into public health. The intervention activities of the 40 core-capacity DCPs that are proposed for the next fiscal year are summarized in this paper to provide insight into the new directions of the DCPs. These activities span a range of health-system and community-based approaches and are described by their potential impact on the audience. The interventions are aimed at a variety of intended audiences and partners, including minorities, individuals with diabetes, healthcare providers, and policymakers. As diabetes educators continue to expand their scope of practice, the DCPs offer opportunities to go beyond individual practice behaviors by participating in community development activities, disseminating practice guidelines, changing organizational practices, and advocating for health-related public policy and legislation.

A familial Alzheimer's disease locus on chromosome 1

The Volga German kindreds are a group of seven related families with autosomal dominant early-onset Alzheimer's disease (AD). Linkage to known AD-related loci on chromosomes 21 and 14 has been excluded. Significant evidence for linkage to AD in these families was obtained with D1S479 and there was also positive evidence for linkage with other markers in the region. A 112-base pair allele of D1S479 co-segregated with the disease in five of seven families, which is consistent with a common genetic founder. This study demonstrates the presence of an AD locus on chromosome 1q31-42.

Comparison of the signalling properties of the long and short isoforms of the rat thyrotropin-releasing-hormone receptor following expression in rat 1 fibroblasts

cDNA species encoding either the long or the short isoforms of the rat thyrotropin-releasing-hormone (TRH) receptor were expressed stably in Rat 1 fibroblasts, and clones expressing specific binding of [3H]TRH were detected and expanded. Clones expressing each of these receptors at levels up to 1 pmol/mg of membrane protein were selected for analysis. Reverse-transcriptase PCR on RNA isolated from these clones confirmed that each clone expressed only mRNA corresponding to the expected splice variant. Both receptor splice variants bound [3H]TRH with a Kd of some 80 nM when binding assays were performed in the presence of guanosine 5'-[beta gamma-imido]-triphosphate. In the presence of TRH, both receptor subtypes were able to cause stimulation of inositol phosphate generation in a pertussis-toxin-insensitive manner with similar EC50 values and to stimulate the mobilization of intracellular Ca2+, but, despite reports that TRH receptors can also interact with the G-proteins Gs and Gi2, neither receptor splice variant was able to modulate adenylate cyclase activity in either a positive or a negative manner. These data indicate that the long and short isoforms of the rat TRH receptor have similar affinities for TRH and display similar abilities to interact with the Gq-like G-proteins, but show no ability to regulate adenylate cyclase, at least when expressed in this genetic background.

In vivo characterization of two cell types in the rat globus pallidus which have opposite responses to dopamine receptor stimulation: comparison of electrophysiological properties and responses to apomorphine, dizocilpine, and ketamine anesthesia

Extracellular single-unit recording techniques were used to examine the rat globus pallidus (GP). In both locally anesthetized, paralyzed rats and ketamine-anesthetized rats, we observed two distinct biphasic extracellular waveforms, which we have labeled Type I (negative/positive waveform) and Type II (positive/negative waveform). No significant differences were observed in the firing pattern or number of cells per track between these cell types, although the Type II neurons had a faster mean firing rate in the locally anesthetized animals. A portion of both cell types could be antidromically activated from the subthalamic nucleus, although Type II neurons had significantly slower conduction velocities. The most striking pharmacological difference between the two cell types was that Type I GP neurons were inhibited by systemic administration of the dopamine agonist apomorphine; previous studies have repeatedly shown that Type II GP cells are excited by this treatment. Pretreatment with a subthreshold dose of apomorphine reduced the responsiveness of Type I cells to a subsequent high dose of apomorphine, as has been shown for Type II cells. However, pretreatment with the NMDA antagonist dizocilpine (MK801) produced a significant change in the pattern of response to apomorphine for Type II GP neurons only. Relative to observations in locally anesthetized, paralyzed rats, ketamine anesthesia reduced the firing rate of both cell types, but did not significantly alter their direction of response to apomorphine. Thus, this study has confirmed the existence of two GP cell types with distinct extracellular waveforms and different responses to dopamine receptor stimulation. These data may necessitate a reevaluation of general theoretical models of basal ganglia function in order to account for these opposite effects of dopamine receptor stimulation on pallidal output.

Reading-induced absence seizures

Reading epilepsy usually presents with jaw myoclonus and generalized tonic-clonic seizures. We report a 12-year-old girl with absence seizures induced by reading, which were diagnosed by video EEG. An absence seizure with generalized 3-Hz spike-and-wave discharge occurred within 30 seconds of each reading session. Treatment with valproate caused complete seizure control, with therapy successfully discontinued after 2 years.

The relationship between the technical accuracy of stereotactic interstitial implantation for high grade gliomas and the pattern of tumor recurrence

PURPOSE

To correlate the pattern of failure and subsequent survival with the technical accuracy of stereotactic brain tumor implantation.

METHODS AND MATERIALS

The patterns of failure of 47 consecutive patients with primary or recurrent gliomas after stereotactic implantation delivering 60 Gy via removable high activity 125I sources were reviewed. When the tumor was covered at all levels by the chosen isodose distribution, the implant was considered to be "ideal." If the coverage was not complete, a numerical description of the volume of tumor outside the isodose was assigned. Criteria for "adequate" and "inadequate" implants were defined. Standard radiographic criteria, with pathologic confirmation in 26 cases, were used to categorize the patterns of failure into the following components: central, peripheral, distant (within the brain parenchyma), leptomeningeal, and spinal. A peripheral failure was scored as being in the "direction of error" when the prescribed isodose did not cover the tumor volume and the subsequent tumor progression was in this region. Survival was calculated from the date of implantation.

RESULTS

Of 47 cases examined, 72% had an element of central and/or peripheral failure and 23% had a component of distant or meningeal failure. Among the patients with "adequate" or "inadequate" ("nonideal") implants who had a component of peripheral failure, only 19% were in the "direction of error." All patients with technically "inadequate" implants progressed in both the central and peripheral region. Among the groups who had "ideal," "adequate," and "inadequate" implants; 37%, 70%, and 75%, respectively, underwent reoperation [p = not significant (NS)]. Patients who underwent reoperation had a longer median survival than those who did not; 521 days vs. 298 days, respectively (p = 0.035). For patients with "nonideal" implants, a median survival of 470 days was found for patients undergoing reoperation vs. 184 days for those who did not (p = 0.016).

CONCLUSIONS

(a) Patients with "inadequate" implants failed in both the central and peripheral region in all cases. This pattern, while less common in those with "ideal" or "adequate" implants, occurred in the majority of cases. (b) The technical excellence of the implant had no impact on survival. (c) Patients with "nonideal" implants were more likely to have reoperation than those with "ideal" implants, and this intervention was associated with a significant survival advantage.

Subspecies discrimination of staphylococci from revision arthroplasties by ribotyping

Sixty-six cultures of Staphylococcus spp. were obtained from bone and tissue samples collected from 37 patients during revision arthroplasties and were speciated and ribotyped to assess strain diversity in each species. There were 10 ribotypes among 51 isolates of S. epidermidis, three among three isolates of S. capitis, two among four isolates of S. aureus and two among two isolates of S. simulans. One ribotype was found among each of: two isolates of S. warneri; two isolates of S. haemolyticus and single isolates of S. cohnii and S. saprophyticus. Low molecular weight bands of ribotype patterns characterized one or two related species whereas high molecular weight bands were useful for distinguishing types within species. Specimens from 17 patients yielded more than one isolate of Staphylococcus spp. In 13 of these patients the isolates were representatives of a single species but in only eight did ribotyping show the isolates to be identical. The findings of multiple species and ribotypes from samples taken from the same patient may have implications for understanding the nature of infection in revision arthroplasty and for antibiotic therapy.

Recruiting from the community: lessons learned from the diabetes care for older adults project

Recruitment methods for enrolling community-based older adults into a study of intensive diabetes management are presented. Analysis of a three-step enrollment procedure revealed that persons who declined at the first step were slightly older and lived farther away from the study site than persons who continued in the enrollment process. Persons who declined cited distance from clinic, some aspect of the study protocol, or health/personal problems as major barriers to involvement. Recruitment strategies were compared, revealing that press releases and newspaper advertisements were the most effective strategies for recruiting eligible participants. Methods such as those described here should help to facilitate future recruitment efforts with community-based older adults.

Tensile fatigue of 4-META cement bonding three base metal alloys to enamel and comparison to other resin cements

The tensile median fatigue limits and fracture mode of 4-META cement were evaluated after bonding Ni-Cr, Ni-Cr-Be, and Co-Cr alloys to enamel. Alloy surfaces, 6 mm in diameter, were grit blasted with 50 microns Al2O3 and cemented to etched bovine enamel under a 2 kg load. Samples were cycled in tension to failure or 10(6) cycles at 5 Hz in Ringer's solution at 37 degrees C. Two-point strategy was used to determine median fatigue limits (S50). Fracture modes were evaluated by SEM on samples failing before 10(6) cycles. Results indicated differences between all sample groups where S50 (Ni-Cr-Be) > S50 (Co-Cr) > S50 (Ni-Cr). Failure analysis revealed mixed cohesive fractures near both interfaces with small areas of delamination within the cement. Comparison to reported median fatigue limits of two commercially available cements were discussed.

Behavioral and developmental changes associated with prenatal opiate receptor blockade

Pregnant Long-Evans hooded rats were dosed with 1, 5, or 10 mg/kg per day naloxone from gestational day 7 (GD7) through GD20. The control groups included both uninjected animals and injected animals pairfed to the 10-mg dose animals. At birth, all litters were culled to four males and four females, and fostered to undosed surrogate dams. Prenatal naloxone exposure produced changes in body weight development, pain sensitivity, and motor behavior in the offspring. Five and 10 mg/kg naloxone increased adult body weights in females only, as did the pairfeeding condition. The 10 mg/kg naloxone altered pain sensitivity (in males only) as measured by the tail flick test. Animals in the 1 mg/kg dose condition habituated more rapidly than uninjected (UN) subjects in the open field, and showed less activity than UNs as they matured. Bar pressing rates were reduced in the 10 mg/kg dose males in a visual discrimination task, while 10 mg/kg males and females showed reduced bar pressing rates on differential reinforcement of low rates of responding (DRL). These findings confirm that prenatal exposure to naloxone alters some aspects of neurobehavioral development in the rat, and are consistent with the hypothesis that 1 mg/kg prenatally may increase opiate function in offspring, while 10 mg/kg prenatally may decrease opiate functioning in the offspring.