Management of left ventricular assist device infection with heart transplantation

BACKGROUND

Left ventricular assist devices (LVADs) are being used as bridges to heart transplantation (HT). Infection of the LVAD in this patient population represents a serious complication, as simple LVAD removal or delaying HT may result in death. To improve outcomes in this group of patients, we performed HT in the presence of LVAD infection.

METHODS

Eighteen patients underwent LVAD implantation followed by HT. Ten underwent HT in the absence of LVAD infection (group 1); and 8, in the presence of LVAD infection (group 2). All patients were treated similarly except for modification of immunosuppression in group 2 patients.

RESULTS

Infectious and noninfectious complications were equivalent between the two groups. There was no difference between groups in regard to intraoperative deaths (one versus none), long-term survival (8/10 versus 7/8), wound complications (three versus none), and mean length of hospital stay after HT (21 versus 26 days).

CONCLUSIONS

Patients with LVAD infection are too seriously ill to allow LVAD removal or delay of HT. Transplantation in the face of infection is an effective treatment option.

Glutamine-enriched enteral diet enhances bacterial clearance in protected bacterial peritonitis, regardless of glutamine form

BACKGROUND

The effects of glutamine (Gln)-enriched enteral diets on bacterial clearance were investigated in a rat protracted peritonitis model. The effects of the Gln form, peptide-based vs free amino acid-based, were also compared.

METHODS

Twenty-three rats underwent gastrostomy. An osmotic pump was implanted in the peritoneal cavity. The rats received a continuous intragastric infusion of one of three diets: Gln-depleted (Gln 0), Gln-enriched with the Gln in free amino acid form (Gln F), or Gln-enriched with the Gln in oligopeptide form (Gln P). The three formulas were isocaloric and isonitrogenous. The pumps delivered a continuous infusion of Escherichia coli, starting at 48 hours after implantation, for 24 hours. Then, the animals were killed.

RESULTS

Bacterial numbers in peritoneal lavaged fluid (PLF) and the liver were significantly lower in the Gln P and Gln F groups than in the Gln 0 group. The bacterial number in PLF correlated with that in the liver. Neither the number nor the population of peritoneal exudative cells differed among groups. Plasma levels of proline, alanine and citrulline were significantly higher in the Gln P and Gln F groups than in the Gln 0 group. Both Gln supplemented groups showed significantly greater villous height, crypt depth, and numbers of mitoses per crypt in the small intestine than the Gln 0 group.

CONCLUSIONS

Supplemental Gln enhances peritoneal and hepatic bacterial clearance, regardless of Gln form. Gln-enriched may be more beneficial than Gln-depleted enteral diets in peritonitis.

Dictyophorines A and B, two stimulators of NGF-synthesis from the mushroom Dictyophora indusiata

Two novel eudesmane-type sesquiterpenes, dictyophorines A and B, and a known compound, teucrenone, were isolated from the mushroom Dictyophora indusiata. Dictyophorines A and B promoted nerve growth factor (NGF)-synthesis by astroglial cells.

Comparison of the long-term results of brachytherapy for T1-2N0 oral tongue cancer treated with Ir-192 and Ra-226

BACKGROUND

The authors report the compatibility of iridium-192 (Ir-192) to Radium-226 (Ra-226) based on the clinical results of three-decades.

METHODS

From 1967 through 1985, 119 patients with early oral tongue cancer (T1-2N0) were treated with conventional Ra-226 needles and 135 patients with Ir-192 hair pins.

RESULTS

Local control rates at 10 years for T1 and T2 tongue cancer were 79% and 61% for patients treated with Ra-226, 83% and 68% with Ir-192. The 10-year cause-specific survival rates for the T1 and T2 patients with Ra-226 were 76% and 63%, and those with Ir-192 were 77% and 68%, respectively.

CONCLUSIONS

Ir-192 showed good possibilities as a substitute for Ra-226 in brachytherapy for early oral tongue cancer.

[A sensitive two-site (sandwich) enzyme immunoassay system for measuring nerve growth factor (NGF)]

Nerve growth factor (NGF) is a prototype of neurotrophin family neurotrophic factors that have nearly 50% amino acid sequence homology with each other. NGF is known to support survival and stimulate differentiation of sympathetic and neural crest-derived some sensory neurons in the peripheral nervous system and the basal forebrain cholinergic neurons in the central nervous system. Recent investigations have expanded NGF action to much wider cell populations than previously known. Namely, NGF stimulates differentiation and/or proliferation of immune cells including lymphocytes, leucocytes and mast cells. These findings suggest important roles of NGF in the crosstalk between the nervous system and immune system. Therefore, a practical and sensitive method to quantify physiological NGF is in great demand. We developed a sensitive two-site enzyme immunoassay (EIA) system for mouse NGF, based on the sandwiching of the antigen between anti-mouse NGF antibody IgG coated to a plastic plate and biotinylated-anti-NGF antibody. Avidin-beta-D-galactosidase was then bound to biotines, and galactosidase activity was determined fluorometrically. This method is simple, rapid and sensitive. Purified NGF is detectable at a concentration as low as a few pg/ml, which is enough to detect physiological NGF in various tissues and NGF secreted from cultured non-neuronal cells such as fibroblasts, astrocytes and Schwann cells.

Administration of corticosterone alters intracellular localization of brain-derived neurotrophic factor-like immunoreactivity in the rat brain

We investigated the distribution of immunoreactivity for brain-derived neurotrophic factor (BDNF) in rat brain after peripheral administration of corticosterone or vehicle. In the immunohistochemical study, BDNF-like immunoreactivity (LI) was observed predominantly in the nucleus of the cortical and hippocampal neurons in the brain of vehicle-treated rats. In corticosterone-treated rats, BDNF-LI was markedly reduced in the nucleus and concomitantly increased in cytoplasm. Western immunoblot study also demonstrated that corticosterone significantly reduced BDNF-LI in the nuclear fraction of the cerebral cortex and hippocampus. These results indicate that corticostrone regulates the intracellular localization of BDNF and/or its derivatives in the rat brain.

[Oral single-dose and 13-week repeat-dose toxicity studies of RCC-36, the active metabolite of (+/-)-4-diethylamino-1,1-dimethylbut-2-yn-1-yl 2-cyclohexyl-2-hydroxy-2-phenylacetate monohydrochloride monohydrate(NS-21), a novel drug for urinary frequency and incontinence, in rats]

Oral single-dose and 13-week repeat-dose toxicity studies of (+/-)-4-ethylamino-1, 1-dimethylbut-2-yn-1-yl 2-cyclohexyl-2-hydroxy-2-phenylacetate monohydrochloride (RCC-36), an active metabolite of (+/-)-4-diethylamino-1,1-dimethylbut-2-yn-1-yl 2-cyclohexyl-2-hydroxy-2-phenylacetate monohydrochloride monohydrate (NS-21), a new drug for the treatment of urinary frequency and incontinence, were conducted in male and female Sprague-Dawley rats. In the single-dose toxicity study, rats were given the drug at doses of 0 (control), 400, 600, 900, 1350 and 2030 mg/kg. In the 13-week repeat-dose toxicity study, rats were given the drug for 13 weeks at doses of 0 (control), 3, 30 and 300 mg/kg. After discontinuation of the treatment, a 5-week recovery test was also conducted. In the single-dose toxicity study, death occurred in the 600 mg/kg group and over, and LD50 values were 735 mg/kg in both sexes. The major clinical signs observed following the administration of this drug were mydriasis, salivation, decreased spontaneous locomotor activity, ataxic gait, lacrimation and urorrhea in the 400 mg/kg group and over, hypopnea and soft feces in the 600 mg/kg group and over. In addition, prone or lateral position and tonic or clonic convulsion were observed in the dead animals. Rats showed a decrease in body weight or a suppression of its weight gain in the 400 mg/kg group and over. Macroscopic findings in the dead animals were congestion in lung and retention of foamy mucinous fluid in trachea. The animals alive showed no abnormalities attributable to the treatment. In the 13-week repeat-dose toxicity study, 13 cases of death occurred in the 300 mg/kg group. Main pathological findings in these cases were congestion and edema in lung. Mydriasis was seen in the 30 mg/kg group and over. Lacrimation, salivation, wheezing, emaciation [corrected] wasting and unkempt fur were seen in the 300 mg/kg. A suppression of body weight gain and a decrease in food consumption were observed in the 300 mg/kg group. An increase in water consumption was seen in the 30 and 300 mg/kg groups. Ophthalmologic examination confirmed the mydriasis in the 30 mg/kg group and over. Urinalysis showed an increase in urine volume and a decrease in Na+ excretion in the 30 and 300 mg/kg groups and decreases in K+ and Cl- excretions in the 300 mg/kg group. Hematological examination showed decreases in hemoglobin, hematocrit, MCV and MCH, and an increase in MCHC in the 300 mg/kg group. Blood chemical examination showed decreases in triglyceride and glucose, and an increase in total protein in the 300 mg/kg group. Pathological examination disclosed hepatocellular hypertrophy associated with hyperplasia of smooth-ER, a decrease in number of glycogen granules and an increase in number of lipofuscin in the 300 mg/kg group. Stimulated thyroid follicles were seen in the 300 mg/kg/group. In kidney, an increase in number of hyaline droplets in the proximal tubular epithelium, in which lysosomes and dense bodies were increased, was observed in the 300 mg/kg group. Dense bodies were increased also in the glomerular epithelium. In this dose group, adrenocortical hypertrophy was also observed. The recovery test showed that the above-mentioned changes were satisfactorily reversible or the degree and frequency of these changes were lowered. No treatment-related effects were seen in the 3 mg/kg group. These results show that the NOAEL (no observed adverse effect level) of RCC-36 is 3 mg/kg for 13-week oral toxicity in rats.

Effect of aeration and unsaturated fatty acids on expression of the Saccharomyces cerevisiae alcohol acetyltransferase gene

The reduction of acetate ester synthesis by aeration and the addition of unsaturated fatty acids to the medium has been reported to be the result of the reduction in alcohol acetyltransferase (AATase) activity induced by inhibition of this enzyme. However, regulation of the AATase gene ATF1 has not been reported. In this study, ATF1 gene expression was studied by Northern analysis, and the results showed that the ATF1 gene was repressed both by aeration and by unsaturated fatty acids. The results also showed that the reduction of AATase activity is closely related to the degree of repression of ATF1 mRNA, which suggested that the gene repression is the primary means of reducing AATase activity in vivo. Using the Escherichia coli lacZ gene as a reporter gene, it was shown that a 150-bp fragment of the 5' flanking sequence played a major role in the repression by aeration and unsaturated fatty acid addition.

A case of early myoclonic encephalopathy with the congenital nephrotic syndrome

We describe a male infant with early myoclonic encephalopathy (EME) associated with the congenital nephrotic syndrome, microcephaly, multiple minor anomalies, and cerebellar hypoplasia. He had erratic and massive myoclonus, and partial seizures from the neonatal period. Electroencephalography showed the so-called suppression-burst pattern. He died of disseminated intravascular coagulation caused by the congenital nephrotic syndrome at the age of two months. Our patients is the first reported case with EME associated with the congenital nephrotic syndrome.

Dependence of frequency modulation detection on frequency modulation coherence across carriers: effects of modulation rate, harmonicity, and roving of the carrier frequencies

Furukawa and Moore [S. Furukawa and B. C. J. Moore, J. Acoust. Soc. Am. 100, 2299-2312 (1996)] found that the detection of frequency modulation (FM) imposed on two inharmonically related carriers was better when the FM was coherent across carriers than when it was incoherent. Here, "coherence" refers to whether the pattern of frequency change over time was identical or different across carriers. The present paper was designed to explore three possible mechanisms underlying this effect. Thresholds were measured for the detection of a single cycle of sinusoidal FM imposed on two sinusoidal carriers. The FM of each carrier was equally detectable, as determined in preliminary experiments. A continuous pink-noise background was used to mask the outputs of auditory filters tuned between the two carrier frequencies. The modulation rate was either 2.5, 5, or 10 Hz. Three combinations of carrier frequencies were used, varying in the extent to which the carriers were harmonically related (1050 and 2069 Hz; 1100 and 2000 Hz; and 1100 and 1925 Hz). The carrier frequencies were either fixed at these values, or were randomly varied (roved) from one trial to another (+/-10%) keeping the frequency ratio constant. Performance for coherent FM was generally better than for incoherent FM. The effect of FM coherence was greater at the lowest modulation rate and was slightly greater when the carrier frequencies were fixed throughout a block of trials than when they were roved. For the two lowest modulation rates, the effect of FM coherence was greater for carriers that were (nearly) harmonically related. It is proposed that sensitivity to FM coherence depends partly on comparing patterns of phase locking to the carriers; this is done most effectively at low modulation rates. However, two other factors may play a small role. These are: sensitivity to the coherence of amplitude modulation induced in the auditory system by the FM (which is somewhat disrupted by roving the carrier frequencies); and sensitivity to fluctuations in the residue pitch evoked by the two carriers (the residue pitch being less salient for inharmonically related carriers.

Nitric oxide inhibition decreases neutrophil adhesion at the inflammatory site, while increasing adhesion in remote organs in peritonitis

Nitric oxide (NO) is a regulator of leukocyte adhesion in the microcirculation. This study was designed to examine the effects of a NO synthase inhibitor on neutrophil adhesion in the peritoneum, lung, liver, and kidney in a rat peritonitis model using a fluorescence microscopic method. Sprague-Dawley rats were given normal saline (control) or N omega-nitro-L-arginine methyl ester (L-NAME) at dosages of 10 mg/kg (N10) or 100 mg/kg (N100) (n = 66) intraperitoneally. One hour after pretreatment fluorescein-labeled neutrophils were infused without bacterial challenge (0 hr). Other rats received an injection of 10(7) Escherichia coli into the peritoneal cavity 1 hr after pretreatment. Labeled neutrophils were infused 1 and 5 hr after bacterial challenge. Just 2 min after neutrophil injection, blood samples were obtained and the animals were killed. Five peritoneal samples (omentum, mesentery, parietal peritoneum, colon, and ileum), both lungs, the liver, and the right kidney were harvested for counting of labeled neutrophils under epifluorescent microscopy. Combined plasma nitrite/nitrate levels were determined. In another set of rats (n = 36), an arterial catheter was inserted after L-NAME treatment and bacterial challenge. At 0, 1, 5, and 12 hr after challenge, blood pressure, heart rate, and arterial blood gas data were measured. One hour after E. coli challenge, the number of neutrophils in the peritoneum was significantly lower in both L-NAME-treated groups than in the control group. In contrast, the number of labeled neutrophils in the lungs was significantly higher in the N100 group than in the control group. Neutrophil accumulation in the lungs and peritoneum at 0 and 5 hr and in the liver and kidney at 0, 1, and 5 hr did not differ among groups, nor did combined plasma nitrite/nitrate levels. L-NAME treatment had no influence on either hemodynamic or blood gas data. In conclusion, administration of L-NAME increases neutrophil adhesion in the lung, while decreasing that in the peritoneum. NO plays an important role in neutrophil adhesion at the inflammatory site, as well as in remote organs, during peritonitis. NO inhibition may be detrimental, due to neutrophil sequestration, in this peritonitis model.

Oral administration of propentofylline, a stimulator of nerve growth factor (NGF) synthesis, recovers cholinergic neuronal dysfunction induced by the infusion of anti-NGF antibody into the rat septum

We have reported that the continuous infusion of anti-nerve growth factor (NGF) monoclonal antibody into the septum of rats produces an impairment of memory and a decrease in choline acetyltransferase (ChAT) and cholinesterase (ChE) activities in the hippocampus. Propentofylline, a xanthine derivative, has potent stimulatory effects on NGF synthesis/secretion in mouse astrocytes in vitro. To investigate the pharmacological effects of propentofylline in vivo, we induced amnesia in rats by infusing anti-NGF antibody into the septum for 16 days. One group of rats was given no further treatment, while the other group was treated with propentofylline orally once a day for 19 days, commencing 3 days before the implantation of the mini-osmotic pump, and continuing throughout the period during which the animals performed the behavioral tasks. In the treated amnesic rats, learning and memory in the 3 tasks and ChAT and ChE activity were reduced compared to values in control rats. The administration of propentofylline recovered the decreased learning capacity and the deficit in cholinergic marker enzyme activity. These results suggest that the use of NGF stimulators may provide a new approach to the treatment of dementia.

Surveillance bronchoscopy in lung transplant recipients

STUDY OBJECTIVES

To establish whether a consensus exists among active transplant centers regarding the use and interpretation of information obtained by surveillance bronchoscopic lung biopsy (SBLB).

DESIGN

Prospective standardized questionnaire answered via mail and telephone communications.

PARTICIPANTS

A five page, 18-question survey was sent to all lung transplant programs listed by the United Network of Organ Sharing in North America, as well as eight selected international programs. Ninety-one surveys were sent to 83 North American and eight international programs. Seventy-four programs (81%) responded. Seventeen programs (19%) were excluded secondary to inactivity. The remaining 57 programs (63%) were included in final data analysis.

INTERVENTIONS

None.

RESULTS

Sixty-eight percent (39/57) of the responding programs perform SBLBs. Ninety-two percent of the programs performing SBLBs do so within the first month, and 69% continue to do so on a regular basis. Sixty-nine percent (27/39) of programs performing SBLBs continue to do so after 1 year. Eighty-six percent (32/37) of respondents believe that SBLB impacts on patient management at least 10% of the time. Technically, 90% (35/39) take biopsy specimens from more than one lobe per SBLB session. Fifty-nine percent (23/39) took 6 to 10 biopsy specimens per session, 33% (13/39) took three to five biopsy specimens, and 7% (4/39) took > 10 biopsy specimens per session. Eighty-six percent (32/37) of the responding centers reported treating asymptomatic rejection at grade 2A, while 14% (5/37) waited until histologic grade 3A before beginning treatment. Complications from SBLB were minimal with < 5% rates of pneumothorax, requirement for chest tube placements, or significant bleeding during SBLB reported by > 95% of the programs performing SBLB.

CONCLUSIONS

Most active lung transplant centers perform SBLBs and do so on a regular basis. However, a wide range of opinion exists over the utility and technique of SBLB and the impact of its results influencing outcome in the lung transplant recipient. To answer these questions, a randomized multicentered trial or registry to determine the effect of SBLB on lung transplant recipient morbidity and mortality is required.

Alanylglutamine-enriched total parenteral nutrition improves protein metabolism more than branched chain amino acid-enriched total parenteral nutrition in protracted peritonitis

Branched chain amino acids (BCAAs) and glutamine are both recommended in catabolic states. The object of this study was to compare the efficacies of alanylglutamine (Ala-Gln)-enriched and BCAA-enriched total parenteral nutrition (TPN) on the protein kinetics in peritonitis. Rats were divided into Ala-Gln and BCAA groups after intraperitoneal implantation of an osmotic pump, delivering a continuous infusion of Escherichia coli. Glutamine composed 30.0% (w/v) of the total amino acids in the Ala-Gln group, and BCAA composed 30.5% (w/v) of the total amino acids in the BCAA group. The two solutions were isocaloric and isonitrogenous. Whole body protein turnover and organ fractional protein synthetic rates (FSR) were measured on days 3 and 5. Serum amino acid levels and mucosal morphology were determined. Ala-Gln group had higher rates of whole body protein turnover, and hepatic FSR on both days. Serum glutamine levels correlated with hepatic and muscle FSR. Ala-Gln TPN group had greater mucosal thickness, numbers of mitoses per crypt, and FSR in distal intestine. Ala-Gln-enriched TPN may be a useful nutritional treatment modality in sepsis.

Möbius-like syndrome associated with a 1;2 chromosome translocation

We report here a rare case of Möbius-like syndrome associated with a 1;2 chromosome reciprocal translocation (46,XY,t(1;2)(p22.3;q21.1). The patient had facial diplegia, ptosis, anteverted nostrils, malformed and lowset ears, and slight developmental delay. Since a microdeletion could be present at the breakpoint in a reciprocal translocation, it is possible that the gene responsible for Möbius syndrome is located in this region of chromosome 1.

Antigen-specific inhibition of CD4+ T-cell responses to beta-lactoglobulin by its single amino acid-substituted mutant form through T-cell receptor antagonism

T-cell responses can be antagonized by some single amino acid-substituted analogs of a peptide ligand for T-cell receptors (TCR), and these are called TCR antagonists. In this study, we addressed the question of whether TCR antagonism can be elicited by a whole protein antigen carrying a mutated T-cell determinant region corresponding to a TCR antagonist peptide. To clarify this, we examined the ability of a single amino acid-substituted mutant form of bovine beta-lactoglobulin (beta-Lg) to inhibit three CD4+ T-cell clones recognizing a peptide corresponding to an immunodominant determinant region 119-133 of beta-Lg (p119-133). First, we identified pD129A, an analog of p119-133 with a substitution of Ala for 129Asp, as an antagonist which can inhibit the response of two of the three T-cell clones. Then, using a yeast expression system, we prepared a mutant beta-Lg (mutD129A) with the same substitution of Ala for 129Asp as that in pD129A. This mutant protein could inhibit the proliferation of the two T-cell clones in a manner similar to the effect of pD129A. From these results we can demonstrate that TCR antagonism can be elicited by peptides naturally processed from a single-substituted mutant protein as well as by the corresponding peptides added exogenously.

Extracorporeal support of oxygenation and ventilation

The management of the patient with respiratory failure is instituted in step-wise fashion. Each successive step requires higher levels of intervention. The final level of support when all conventional means fail is the use of ECMO. The specific method of extracorporeal support may or may not be important in determining ultimate outcome. However, the means of ventilator support during extracorporeal support is controversial. No study has shown a beneficial effect of one method over another. The avoidance of further barotrauma and high oxygen concentration is the keystone to individual ventilator management. The method of introducing extracorporeal devices on to a patient's cardiovascular circuit varies. The technical aspects differ from institution to institution and may reflect surgeon preference. However, all methods are relatively quick and efficient. The amount of personnel needed to manage an extracorporeal circuit varies from institution to institution but nonetheless requires extra people and equipment. The cost of instituting this type of therapy is high. And, although the cost efficiency of ECMO has not been closely analyzed, it is hoped that the judicious use of this technology will produce a favorable result.

Preoperative total parenteral nutrition influences postoperative systemic cytokine responses after colorectal surgery

Previous human studies have investigated the influences of nutritional routes on the serum kinetics of cytokines following intravenous administration of lipopolysaccharide. However, it is unclear whether preoperative nutritional routes influence responses of systemic cytokines in patients after surgery. This study was designed to investigate whether preoperative total parental nutrition (TPN) influences systemic interleukin-6 (IL-6) and interleukin-8 (IL-8) responses in patients following surgery for colorectal cancer. Patients with colorectal cancer received TPN (TPN group, n = 6) or an oral diet (oral group n = 6) for more than 7 d before the operation. Patients in the TPN group received standard TPN. Patients in the oral group received an ordinary hospital diet. Blood samples were collected before the operation, on postoperative day 1 (POD1), POD3, and POD7. Levels of IL-6, IL-8, and C-reactive protein (CRP) in plasma were determined. The characteristics of patients in the TPN and oral groups were comparable. Mean carbohydrate intake was greater (28 versus 19 kCal/kg), and lipid intake was smaller (0 versus 7 kCal/kg) in the TPN group than in the oral group. Plasma CRP levels did not differ between the two groups. Plasma IL-6 and IL-8 levels were marginally higher before the operation and were significantly higher on POD1 in the TPN group than in the oral group. The IL-6 levels showed a positive regression relation with the amounts of blood loss only in the TPN group (P < 0.05, r = 0.881). The slope of the regression line was steeper in the TPN group than in the total enteral nutrition (TEN) group (P < 0.01). In conclusion, routes of nutritional supply have an impact on the production of systemic cytokines after insult. The postoperative systemic IL-6 and IL-8 responses in patients who received standard TPN preoperatively were greater than in patients who received an oral diet. Preoperative nutrition via the enteral route may provide better regulation of cytokine responses after surgery than parenteral nutrition.

[A case of report of traumatic aortic regurgitation accompanying cerebral embolism]

Aortic regurgitation due to nonpenetrating trauma of the chest is an extremely rare disease and only 12 cases have been reported in this country. We report a case we treated and present additional of retrospective discussions. The patient was a 59-year-old man who lost consciousness due to a heavy blow to the chest during work. He was diagnosed as having acute aortic regurgitation. A close examination on the 3rd day after the injury revealed cerebral embolism and heart failure could not be controlled by physical treatment. Surgery was performed on the 5th day after the injury. The aorta was incised under cardiopulmonary bypass to examine aortic valves. Commissures between the RCC and the NCC and between the NCC and the LCC had been torn from the aortic wall and injured and thrombus adhesion was observed in a part of the NCC. After repairing the aortic wall, the valve was replaced by SJM valve. Postoperative course is satisfactory.

Phase III trial of high and low dose rate interstitial radiotherapy for early oral tongue cancer

PURPOSE

Oral tongue carcinomas are highly curable with radiotherapy. In the past, patients with tongue carcinoma have usually been treated with low dose rate (LDR) interstitial radiation. This Phase III study was designed to compare the treatment results obtained with LDR with those obtained with high dose rate (HDR) interstitial radiotherapy for tongue carcinoma.

METHODS AND MATERIALS

The criteria for patient selection for the Phase III study were: (a) presence of a T1T2N0 tumor that could be treated with single-plane implantation, (b) localization of tumor at the lateral tongue border, (c) tumor thickness of 10 mm or less, (d) performance status between O and 3, and (e) absence of any severe concurrent disease. From April 1992 through December 1993, 15 patients in the LDR group (70 Gy/4 to 9 days) and 14 patients in the HDR group (60 Gy/10 fractions/6 days) were accrued. The time interval between two fractions of the HDR brachytherapy was more than 6 h.

RESULTS

Local recurrence occurred in two patients treated with LDR brachytherapy but in none of the patients treated with HDR. One- and 2-year local control rates for patients in the LDR group were both 86%, compared with 100% in the HDR group (p = 0.157). There were four patients with nodal metastasis in the LDR group and three in the HDR group. Local recurrence occurred in two of the four patients with nodal metastases in the LDR group. One- and 2-year nodal control rates for patients in the LDR group are were 85%, compared with 79% in the HDR group.

CONCLUSION

HDR fractionated interstitial brachytherapy can be an alternative to traditional LDR brachytherapy for early tongue cancer and eliminate the radiation exposure for medical staffs.

Standard criteria for an acceptable donor heart are restricting heart transplantation

BACKGROUND

The lack of satisfactory donor organs limits heart transplantation. The purpose of this study was to determine whether the criteria for suitability of donors may be safely expanded.

METHODS

One hundred ninety-six heart transplantations were performed on 192 patients at our institution from January 1992 to 1995 and were divided into two groups. Group A donors (n = 113) conformed to the standard criteria. Group B donors (n = 83) deviated by at least one factor and consisted of the following: 16 hearts from donors greater than 50 years of age, 33 with myocardial dysfunction (echocardiographic ejection fraction = 0.35 +/- 0.10, dopamine level exceeding 20 micrograms.kg-1.min-1, and resuscitation with triiodothyronine), 33 undersized donors with donor to recipient weight ratios of 0.45 +/- 0.04, 48 with extended ischemic times of 297.4 +/- 53.6 minutes, 25 with positive blood cultures, 16 with positive hepatitis C antibody titers, and 7 with conduction abnormalities (Wolff-Parkinson-White syndrome, prolonged QT interval, bifascicular block).

RESULTS

Thirty-day mortality was 6.2% (7/113) in group A and 6.0% (5/83) in group B. Mortality in group A was attributed to 3 patients with myocardial dysfunction, 2 with infection, 1 with acute rejection, and 1 with pancreatitis; group B had 2 with myocardial dysfunction, 1 with infection, 1 with aspiration, and 1 with bowel infarction. At 12 months, survival and hemodynamic indices were similar between the groups. Of the 16 recipients with hepatitis C-positive hearts, 5 have become hepatitis C positive with mild hepatitis (follow up, 6 to 30 months).

CONCLUSIONS

Expanding the criteria for suitability of donor hearts dramatically increases the number of transplantations without compromising recipient outcome.