Comparison of serum and cerebrospinal fluid levels of methotrexate in man during high-dose chemotherapy for aggressive non-Hodgkin's lymphoma

The relationship between plasma and cerebrospinal fluid levels of methotrexate was studied in five patients, four with aggressive non-Hodgkin's lymphoma and one with mixed epithelial mesothelial tumour, who were treated with high-dose methotrexate (1.5 g/m2) as part of combination chemotherapy. Cerebrospinal fluid was sampled for 24 h via a permanent indwelling lumbar catheter. No complications were observed with this technique. In two patients with central nervous system involvement adequate "cytotoxic" levels (greater than 10(-6) M) were obtained for greater than 12 h. The remaining three patients, with no direct evidence of central nervous system involvement, never attained adequate cytotoxic methotrexate levels in the cerebrospinal fluid. Serum levels were therapeutic in all patients. These results suggest that patients with central nervous system tumour involvement may receive adequate doses of methotrexate in the cerebrospinal fluid. Patients with occult central nervous system tumour involvement may not attain adequate cerebrospinal fluid levels. A 24-h serum methotrexate level of greater than 10(-5) M may indicate that patients have achieved therapeutic cerebrospinal fluid levels of methotrexate. Cranial irradiation following chemotherapy is still recommended in this tumour group until adequate cytotoxic levels of methotrexate can be obtained in all patients for prolonged periods.

High-dose cyclophosphamide and VP 16 as late dosage intensification therapy for small cell carcinoma of lung

This study investigated the use of late dose intensification therapy (LDIT) with cyclophosphamide (180 mg/kg) and VP 16 (1 g/m2) plus autologous bone marrow rescue in 22 patients with small cell lung cancer (SCLC). These patients were selected from a group of 95 patients who received three courses of a five-drug induction regimen comprising cyclophosphamide (750-1000 mg/m2), adriamycin (40 mg/m2), VP 16 (100 mg/m2) for 3 days, methotrexate (50 mg/m2) and vincristine (2 mg) (CAVMO). There were 16 patients with limited disease, 8 of whom were in complete remission (CR) and 8 in partial remission (PR) after the induction therapy. The other 6 patients had extensive disease; 3 of these achieved CR and 3 PR after induction therapy. Of the 11 patients in PR, 5 responded to LDIT; 3 had a further PR, and 2 CR. Subsequent to LDIT radiotherapy 4000 cGy was given to the primary site in 10 of the 22 patients. Since the start of the study, 19 of the 22 patients have relapsed and died (median survival 11 months), while 3 remain alive and in remission at 11, 11, and 24 months. Comparison of the survival of patients receiving LDIT with that of an equivalent group (with respect to staging and response to induction chemotherapy) of patients who received induction chemotherapy alone showed no significant difference. In this study, LDIT following conventional induction therapy in patients with chemosensitive tumours did not improve survival.

Functional and structural changes of the human proximal small intestine after cytotoxic therapy

The effects of cytotoxic therapy on the structure and function of the proximal jejunum were studied in six patients receiving intravenous cyclophosphamide (300 mg/m2), methotrexate (40 mg/m2), and 5-fluorouracil (600 mg/m2) as adjuvant therapy for breast cancer. Using a steady state, triple lumen tube perfusion system the absorption of water and electrolytes was measured before and 48 h after administration of the cytotoxic agents. Jejunal biopsies were obtained at each perfusion. Median (range) water absorption fell from 126 (40-142) to 84 (46-142) ml/h/30 cm, with parallel changes for electrolytes; none of the changes was significant. Brush border disaccharidases did not change at 48 h after chemotherapy, while mature enterocytes appeared normal by both light and electron microscopy. Crypt cells and immature enterocytes, however, showed focal vacuolation by light microscopy, corresponding to the occurrence of large residual bodies (secondary lysosomes) containing partially degraded fragments of damaged crypt cells. The confinement of ultrastructural changes to the immature cell population may explain the failure of this study to show a consistent change in the absorptive function of the jejunum 48 h after chemotherapy.

The role of VP-16 in the treatment of small-cell lung cancer: studies of the West of Scotland Lung Cancer Group

Reviews of published studies indicate that the incorporation of VP-16 (Vepesid) into combination chemotherapy for small-cell lung cancer may improve overall response rates from 50% to between 65% and 80%. In addition, high-dose VP-16 may yield a higher response rate than that obtained with conventional doses. The West of Scotland Lung Cancer Group has therefore conducted studies to examine the effects of VP-16 both in a combination regimen as induction therapy and (together with high-dose cyclophosphamide) as late intensification therapy in high dose, aimed at preventing relapse in responding patients. Response to induction treatment improved with the addition of VP-16, compared to earlier studies carried out by the group, yielding an overall response rate of 80% for patients with limited disease and 62% for those with extensive disease. Although induction therapy comprised only three courses (lasting 9 weeks), the median response duration of 9.5 months for complete responders and the median survival of 14 months for complete responders (limited disease) were in keeping with those obtained using more prolonged induction therapy. The intensification therapy with high-dose cyclophosphamide and high-dose VP-16, however, yielded no improvement in overall survival in those responding patients who received it compared with those who did not. Radiotherapy following late-dose intensification prevented local tumor recurrence but appeared to have no effect on overall survival. Resistance to VP-16 and other drugs is a possible deterrent to successful therapy in small-cell lung cancer, and it is suggested that research focus on a possible role for calcium channel blockers in circumventing drug resistance.

Randomised trial of intravenous high dose metoclopramide and intramuscular chlorpromazine in controlling nausea and vomiting induced by cytotoxic drugs

Images

Measuring the impact of health interventions: a review of available instruments

Interest in the measurement of the impact of health services has been increasing for three main reasons. Policy makers and service providers wish to be reassured that they are: (i) benefitting the public for whom the service is provided; (ii) in times of economic recession and limited resources, achieving the 'best value for money'; and (iii) given the need to make economies in health expenditures, maintaining standards of the health care. Recent developments in information for the evaluation of health services have tended to emphasis the control and monitoring of expenditure in preference to the control and monitoring of quality. There is concern that this might lead to adverse consequences for patients and for the health service as a whole in that the quality of services provided might deteriorate. Health interventions are considered to be successful if they result in a beneficial change in the health of the population for whom they are provided. If the health of the population is not improved, or maintained, questions are raised about either the appropriateness of the intervention in relation to health policies which have been selected, or about the quality of the care which has been provided. Because of this, it is necessary to monitor both the outcome of a heath intervention in terms of the change in the level of health of the population, and also to measure the quality and the effectiveness of the care provided. Health services research has, over the years, developed a number of different types of measures which can be applied to health services and has suggested a number of applications for such measures in terms of the impact on the health of patients and the general population and the quality and effectiveness of health services. The first section of this paper reviews a selection of measures for both health and the effects of health interventions and discusses their applicability as management tools. The use to which such measures are put obviously depends upon the type of decisions which they are to inform, which in turn are dependent upon the organisational level at which the decision is to be made, and the policy objectives of the service to which they relate. The second part of the paper discusses factors which must be taken into account when choosing measures to monitor the impact of the health services. In examining the suitability of a management tool, a measure must be proven to provide information which is universally acceptable and which conforms to a number of scientific standards.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of advanced ovarian cancer with combination chemotherapy using cyclophosphamide, adriamycin and cis-platinum

Fifty-four patients with advanced ovarian cancer have been treated with combination chemotherapy using cyclophosphamide, adriamycin and cis-platinum. The toxicity of the regimen was manageable but few patients were prepared to tolerate more than 6 months of treatment. Those in complete clinical remission at that time were offered second-look laparotomy and if apparently free of disease, therapy was discontinued. Forty-seven patients could be assessed of whom 33 had had no previous therapy. Twenty-two of these were clinically free of disease after completion of chemotherapy of whom 12 had no detectable disease at second-look laparotomy. Of 14 patients who had failed previous therapy only one remains clinically free of disease. The results in the untreated patients demonstrate the primary importance of bulk reduction at initial laparotomy. The use of the regimen in patients who have failed on previous treatment or in patients with bulk disease seems to be palliative and the toxicity should be assessed in this context.

Progression of pseudovitelliform macular dystrophy

Pseudovitelliform macular dystrophy is a dominantly inherited macular disorder. It is characterized by the presence of horizontally oval yellowish deposits within the maculas that are approximately one-third disc diameter in size. As classically described, progression of the lesions over a follow-up period of as long as six years has not been described and the prognosis for retention of good visual function is excellent. We report the ophthalmoscopic appearance of six eyes of three patients from a very subtle alteration of macular pigmentation to severe disruption of macular architecture, and demonstrate in one of our patients drastic deterioration in both ophthalmoscopic appearance and visual function over a three-year period of follow-up. The prognosis for retention of good vision in this disorder must include the possibility of the eventual development of severe visual impairment.

A randomised multicentre single blind comparison of a cannabinoid anti-emetic (levonantradol) with chlorpromazine in patients receiving their first cytotoxic chemotherapy

One hundred and eight patients selected to receive combinations of highly emetic cytotoxic chemotherapy for malignant disease were included in a study of anti-emetic therapy. The patients were randomly allocated to receive levonantradol (0.5, 0.75 or 1 mg) or chlorpromazine (25 mg) prior to receiving their first course of cytotoxic therapy. The appropriate anti-emetic was administered 2 hr prior to the start of chemotherapy, 2 hr after chemotherapy and subsequently at 4-hourly intervals for a further 8 hr. The extent of anorexia, nausea and vomiting along with other side-effects were assessed at regular intervals by physicians and nursing staff during the 24 hr following chemotherapy. In addition, a self-assessment questionnaire was completed by the patients. Levonantradol (0.5 mg) was superior to chlorpromazine (25 mg) as an anti-emetic. Both were reasonably well tolerated, although at this dose of levonantradol 22% of patients experienced dysphoric reactions. At higher doses of levonantradol the proportion of patients experiencing these reactions rose to 50%, but without a concomitant increase in antiemetic activity. Neither drug achieved satisfactory control of vomiting in patients receiving combinations containing cis-platinum. We conclude that levonantradol (0.5 mg) is a more effective anti-emetic than chlorpromazine (25 mg) in patients receiving cytotoxic chemotherapy. However, its use cannot be recommended due to its high incidence of unacceptable central nervous system side-effects.

Myocardial hydroxyproline reduced by early administration of methylprednisolone or ibuprofen to rabbits with radiation-induced heart disease

The ability of methylprednisolone (MP) and ibuprofen (IB) to reduce the severity of the late state of radiation-induced heart disease was assessed in 57 New Zealand white rabbits. Before and shortly after cardiac irradiation, 15 rabbits received i.v. MP, 30 mg/kg twice daily for 3 days, and 15 others received IB, 12.5 mg/kg twice daily for 2 days. No drug was administered to 14 irradiated rabbits, and neither irradiation nor drugs were administered to 13 rabbits that served as controls, All 15 rabbits treated with MP and 13 of the 15 treated with IB lived for 100 days. Only seven of the untreated, irradiated rabbits lived that long. Longevity of each treated group of rabbits was better (p less than 0.01 and 0.05) than that of the untreated, irradiated rabbits. Surviving rabbits were killed 100 days after irradiation. Pericarditis (p less than 0.05) and pericardial effusion (p less than 0.01) were less frequent in the treated, irradiated groups than in the untreated, irradiated rabbits. At least some rabbits in each irradiated group had microscopic evidence of myocardial fibrosis. The fibrosis was quantitated by determination of myocardial hydroxyproline concentrations (MHP). MHP concentration in the untreated, irradiated rabbits was greater than in those treated with MP (p less than 0.05) or IB (p less than 0.01) and in the untreated, unirradiated rabbits (p less than 0.01). Early administration of MP or IB retarded the development of myocardial fibrosis, pericarditis and pericardial effusion, and improved survival in this experimental model of radiation-induced heart disease.

cis-Platinum(II)diamminodichloride-induced mutagenesis in E. coli K12: crowding depression of mutagenesis

Cis-Platinum(II)diamminodichloride (cis-PDD)-induced mutations to prototrophy were studied in Escherichia coli. Mutagenesis was not detected in a recA nor in a lexA mutant, but was greater in a uvrA strain than in a repair-proficient strain, at a given treatment of cis-PDD. Increasing the plating density above 10(5) cells per plate did not give an equivalent increase in revertants per plate [crowding depression of mutagenesis (Bockrath et al., 1980)]. Growth rates were similar at different plating densities and crowding depression of mutagenesis was observed in both excision-proficient and excision-deficient strains. A filtrate of a plate wash from crowded plates, of either treated or untreated cultures, further reduced the mutation frequencies over that due to crowding depression of mutagenesis.

Prevention and treatment of serous otitis media with an oral antihistamine. A double-blind study in pediatric practice

Serous otitis media (SOM) is a common and troublesome disease in childhood. Although antihistamines are commonly prescribed to prevent or treat SOM, there have been no controlled clinical trials to determine the efficacy of such interventions. This study was designed to determine if antihistamines are of value in the prevention or treatment of SOM. Using a randomized double-blind method, 206 children with acute otitis media were treated with antibiotics and either brompheniramine maleate or placebo. The children were evaluated two weeks later by tympanometry and, independently, by combined pneumatoscopy and otoscopy. There were no significant differences overall between the treatment and control groups in terms of preventing SOM: 44% of those on antihistamine and 41% of those on placebo had SOM after two weeks of therapy. However, children with a history of serous otitis media did significantly better on placebo than did those on antihistamine, and children without a history of serous otitis media did significantly better on antihistamine than did those on placebo. One hundred children continued to use antihistamine or placebo for four more weeks. There were no significant differences between the treatment and control groups in terms of resolution of SOM (64% versus 68%).

Effects of physical training on cardiovascular function following myocardial infarction

Three to twelve (7.1 +/- 3.2) months after myocardial infarction, subjects under 54 (45.0 +/- 4.7) yr were assigned randomly to high-intensity (HIE, n = 37) or low-intensity (LIE, n = 42) exercise programs. Cardiac outputs (Q) during graded bicycle ergometer exercise were measured by a CO2-rebreathing method on entry and after 6 and 12 mo of training. The initial exercise Q was low in relation to work load, due to a low stroke volume (SV). Over the year of training, the predicted maximal O2 intake of the HIE group increased significantly (from 26.0 to 30.3 ml.kg-1.min-1), while that of the LIE group showed no significant alteration. During the first 6 mo, the heart rate of the HIE group was significantly reduced at each work level. There was an associated widening of arteriovenous oxygen difference, but SV was unchanged. These findings were attributed to extracardiac factors, including a redistribution of blood flow, biochemical changes in the trained muscle, and a secondary reduction of sympathetic drive. Over the second 6 mo, the SV of the HIE group increased 10%; this may reflect an increase of intrinsic myocardial contractility that develops if high-intensity training is sustained. The LIE group showed no major changes of cardiovascular function over the year of observation.

Physiological responses of bacteria to cytochalasin A: effects on growth, transport, and enzyme induction

Cytochalasin A at 5 to 25 microgram/ml (1.0 x 10(-5) to 5.2 x 10(-5) M) inhibited the growth of three gram-positive bacteria, Arthrobacter sialophilus, Staphyloccus aureus, and Bacillus amyloliquifaciens, but had little or no effect on the growth of three gram-negative bacteria, Excherichia coli, Pseudomonas maltophilia, and Aeromonas proteolytica. A. sialophilus and S. aureus recovered spontaneously from cytochalasin A-mediated growth inhibition after a considerable lag period, which was dependent on the drug dose. It was demonstrated that this long-term recovery did not involve selection of resistant variants. Cytochalasin A had no detrimental effect on cell viability in A. sialophilus or S. aureus, but caused lysis of B. amyloliquifaciens. The drug prevented enzyme inductions and inhibited transport of valine, uridine, and glucose in the gram-positive organisms. It had little or no effect on these processes in the gram-negative organisms. In studies with A. sialophilus, the drug inhbitied respiration of exogenous substrates, but did not depress endogenous respiration. These results constitute the first unequivocal evidence for the bacteriostatic properties of this class of compounds and indicate that cytochalasin A halts various physiological processes in gram-positive bacteria primarily by inhibiting solute transport.

Prevention and therapy of serous otitis media by oral decongestant: a double-blind study in pediatric practice

We studied the efficacy of (1) preventing the development of serous otitis media (SOM) by using an oral decongestant in children with acute otitis media and (2) treating SOM with an oral decongestant. In a randomized double-blind study, 190 children were treated for acute otitis media with antibiotics and either pseudoephedrine hydrochloride (Sudafed) or placebo. They were evaluated two weeks later by tympanometry and (independently) by clinical evaluation and pneumotoscopy. There were no significant differences between the two groups, except that males developed SOM significantly more often than did females. Use of decongestant and placebo was continued in 78 patients with SOM for up to four more weeks. Again, there were no siginificant differences between the treatment groups except that patients with an allergic history did significantly worse using a decongestant. Overall there was no benefit from pseudoephedrine in either the prevention or treatment of SOM.

Long-term follow-up study of survival and recurrence rates following myocardial infarction in exercising and control subjects

Male subjects (N = 68), under age 51 years, with previous myocardial infarction, who participated in a program of graduated exercises over a 7-year period (1964-71), have been compared with a control group (N = 131) for incidence of nonfatal recurrence and cardiac death. The controls fulfilled the criteria to enter the exercise program, but did not. Of the 68 exercising subjects, 66 were traced in January 1971. Two (3.0%) had had a nonfatal recurrence. Of the 131 control subjects, only 117 gave valid information concerning possible recurrence. Thirteen (11.1%) had suffered a nonfatal recurrence ( P < 0.10). The incidence of cardiac death (7.6%) was significantly lower ( P < 0.05) in the exercising subjects than in the 127 control subjects (four of the 131 could not be traced).

In 1969 a separate comparison of recurrence and survival over a 5-year period was made between 77 exercising subjects who had remained in the program for a minimum of 3 months and 127 control subjects in Toronto. One (1.3%) of the exercising subjects had had a nonfatal recurrence, and 31 (27.9%) of 111 Toronto control subjects (16 others were alive but information on recurrence was lacking) gave a history of nonfatal recurrence ( P < 0.001). There were three (3.9%) deaths in the exercise group and 15 (11.8%) deaths in the Toronto control group ( P < 0.10).

Variables affecting prognosis, but not included in the study, were blood pressure, prior angina, and current angina. Although results of this investigation suggest that an exercise program in a selected group may favorably affect prognosis following recovery from myocardial infarction, they should be interpreted cautiously. One or more variables not related to the exercise program per se may have been operative in producing the apparent benefit.

A comparison of the conversion in vitro of pregnenolone sulphate and pregnenolone to steroid hormones by tissue from a clear cell adenoma of the adrenal gland

Tissue from a clear cell adenoma of the adrenal gland was incubated simultaneously with [7α-3H]pregnenolone sulphate and [4-14C]pregnenolone in Krebs—Ringer bicarbonate-glucose solution. Evidence was obtained for the conversion of pregnenolone sulphate to cortisol and corticosterone. The differences in the ability of the tissue to convert the sulphate and the free steroid to corticosteroids and androgens are discussed in relation to theories on the functional zonation of the human adrenal cortex.

Insulin biosynthesis: evidence for a precursor

Human islet cell tumor tissue and isolated islets of Langerhans from rats incorporated radioactive amino acids in vitro into insulin and a larger acid-alcohol soluble protein which could be separated from insulin by gel filtration. The amino acids were incorporated into the larger protein earlier than into insulin; only after incubation of islets for approximately 30 minutes did radioactivity begin to appear in insulin. The transfer of about 70 percent of the radioactivity of the larger protein to insulin was demonstrated in the absence of new peptide bond synthesis (cycloheximide), or during incubation with unlabeled amino acid (chase). The results indicate that the larger protein is a precursor in the biosynthesis of insulin. The name "proinsulin" is suggested for this protein.

Steroid biosynthesis in vitro by tissue from a granulosa cell multilocular cystadenoma

A granulosa cell multilocular cystadenoma was removed from a 7-yr.-old girl who showed breast growth and had a history of almost continuous vaginal bleeding for 9 days. Tissue, which microscopically was shown to consist almost exclusively of granulosa cells, was incubated with [4-14C]-DHA and [7-3H]pregnenolone in Krebs-Ringer bicarbonate solution. The ability of this tissue to synthesize oestrogens from these precursors was investigated. These results and those of pre- and post-operative urinary steroid estimations are discussed in relation to current theories of steroid biosynthesis.