Allelic deletion analysis of the FHIT gene predicts poor survival in non-small cell lung cancer

The fragile histidine triad (FHIT) gene at chromosome 3p14.2 is a candidate tumor suppressor gene linked to cancers of the lung, breast, colon, pancreas, and head and neck. Reports of frequent allelic deletion and abnormal transcripts in primary lung tumors plus recent evidence that it is targeted by tobacco smoke carcinogens suggest that it plays an important role in lung carcinogenesis. Non-small cell lung carcinoma still maintains a poor 5-year survival rate with the stage of disease at presentation as a major determinant of prognosis. We examined for allelic deletion at the FHIT locus in a series of 106 non-small cell lung carcinomas for which a full clinical, epidemiological, and 5-year survival profile was available. We found an allelic deletion frequency of 38% at one or two intragenic microsatellites. Allelic deletion of FHIT was related to tumor histology with 4 of 20 adenocarcinomas (20%) displaying loss of heterozygosity (LOH) compared with 12 of 22 (55%) nonadenocarcinomas (P = 0.03). We found that 63% of tumors with LOH of FHIT also had p53 missense mutations whereas only 26% with LOH had wild type p53 negative sequence (P = 0.02). We also found a significant trend toward poorer survival in patients with LOH of at least one locus of the FHIT gene (log rank, P = 0.01). This survival correlation is independent of tumor stage, size, histological subtype, degree of differentiation, and p53 mutation status. Our data support the hypothesis that the loss of the FHIT contributes to the molecular pathogenesis of human lung cancer and is an indicator of poor prognosis.

Predicting cognitive decline in patients with hypoxaemic COPD

The objective was to identify predictors of cognitive decline in patients with hypoxaemic COPD on continuous oxygen therapy. Eighty-four consecutive ambulatory hypoxaemic COPD patients in stable clinical conditions were prospectively studied over the course of 2 yr. Baseline multidimensional assessment included respiratory function tests, blood gas analysis, Mini Mental Status (MMS) test, Geriatric Depression Scale (GDS), Activities of Daily Living (ADLs) and Charlson's index of comorbidity. Reassessments were made 1 yr and 2 yr thereafter. Sequential changes in MMS, GDS and ADLs were assessed by Friedman's ANOVA by rank test. Forty patients completed the study (group A), while 44 died or were lost to follow-up (group B). Group B was characterized by more severe respiratory function impairment and worse performances on ADLs and GDS. In group A, MMS deteriorated from baseline to the 1 yr and 2 yr reassessments (27 +/- 2.9 vs. 25.8 +/- 4.1 and 25.4 +/- 4, P < 0.005), whereas GDS and ADLs did not change significantly; the 23 patients experiencing a decline of MMS had baseline lower percentage predicted FVC (52.3 +/- 17.1 vs. 66.9 +/- 13.4, P < 0.03) and FEV1 (27.2 +/- 8.6 vs. 44 +/- 26.8, P < 0.02) values and better affective status (GDS score: 11.9 +/- 7.7 vs. 16.5 +/- 5.6, P < 0.04). Two-year changes in MMS and in GDS scores were inversely correlated (Spearman's p = -0.32, P = 0.04). Cognitive decline is faster in the presence of severe bronchial obstruction and parallels the worsening of the affective status in COPD patients on oxygen therapy. The onset of depression rather than baseline depressive symptoms seems to be a risk factor for cognitive decline.

hSmad5 gene, a human hSmad family member: its full length cDNA, genomic structure, promoter region and mutation analysis in human tumors

hSmad (mothers against decapentaplegic)-related proteins are important messengers within the Transforming Growth Factor-beta1 (TGF-beta1) superfamily signal transduction pathways. To further characterize a member of this family, we obtained a full length cDNA of the human hSmad5 (hSmad5) gene by rapid amplification of cDNA ends (RACE) and then determined the genomic structure of the gene. There are eight exons and two alternative transcripts; the shorter transcript lacks exon 2. We identified the hSmad5 promoter region from a human genomic YAC clone by obtaining the nucleotide sequence extending 1235 base pairs upstream of the 5' end of the cDNA. We found a CpG island consistent with a promoter region, and we demonstrated promoter activity in a 1232 bp fragment located upstream of the transcription initiation site. To investigate the frequency of somatic hSmad5 mutations in human cancers, we designed intron-based primers to examine coding regions by polymerase chain reaction-single strand conformation polymorphism (PCR-SSCP) analysis. Neither homozygous deletions or point mutations were found in 40 primary gastric tumors and 51 cell lines derived from diverse types of human cancer including 20 cell lines resistant to the growth inhibitory effects of TGF-beta1. These results suggest that the hSmad5 gene is not commonly mutated and that other genetic alterations mediate the loss of TGF-beta1 responsiveness in human cancers.

Verbal memory impairment in COPD: its mechanisms and clinical relevance

STUDY OBJECTIVES

Identification of mechanisms accounting for verbal memory impairment in patients with severe COPD; assessing the relationship between verbal memory and the overall cognitive performance; verifying if verbal memory impairment affects medication adherence.

DESIGN

Case-comparison study.

SETTING

Outpatient Departments of Pneumology and Neurology, Day Hospital of General Surgery.

PATIENTS

Forty-two COPD ambulatory patients, age 70+/-9.7 years, with hypoxemia and hypercarbia (group A); 27 normal subjects of comparable age and educational level (group B); 31 patients with Alzheimer's disease (group C); and 26 older normal subjects (group D).

MEASUREMENTS AND RESULTS

The overall cognitive function and verbal memory were evaluated by the Mental Deterioration Battery and 14 indexes of verbal memory. Defective retrieval and recognition mechanisms distinguished group A from group B. According to discriminant analysis, verbal memory profile of COPD patients was group specific in 38.1% of cases and conformed to that of group B, C, and D in 19%, 16.7%, and 26.2% of cases, respectively. In COPD patients, both immediate and delayed recall, the strongest determinants of the discriminant function, were significantly correlated with the overall cognitive performance (rho=0.64, p=0.001; rho=0.61, p=0.001, respectively). Poor adherence to medication regimen was significantly associated with abnormal delayed recall score (82.3% vs 36% in subjects with normal delayed recall, p<0.008).

CONCLUSIONS

Decline of verbal memory parallels that of the overall cognitive function in COPD patients and is due to the impairment of both active recall and passive recognition of learned material. It could be an important determinant of the level of medication adherence.

Neuropsychologic effects of carotid endarterectomy

This study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.

The interaction between age and comorbidity contributes to predicting the mortality of geriatric patients in the acute-care hospital

OBJECTIVE

To test the predictive power of comorbidity and of the interaction between age and comorbidity in geriatric patients with acute medical illness.

DESIGN

Prospective observational study.

SETTING

Medical and geriatric wards of an acute-care hospital.

SUBJECTS

Three hundred and seventy patients over 70 years of age consecutively admitted in an 18-month period.

MAIN OUTCOME MEASURE

In-hospital mortality.

METHOD

On admission a multidimensional assessment was performed, and a comorbidity index and an age-comorbidity index developed on a comparable training population were calculated. The comorbidity index is based upon a scoring system that quantifies the prognostic weight of individual diseases, while the age-comorbidity index corrects the former for the age-related increase of the risk of death. The predictive power of variables univariately correlated with the outcome was tested by logistic regression.

RESULTS

Death was independently predicted by clinical diagnosis of malnutrition (odds ratio = 1.87, confidence limits CL = 1.20-2.86), age-comorbidity index > 7 (odds ratio = 1.77, CL = 1.15-2.72), preadmission impairment in activities of daily living (odds ratio = 1.74, CL = 1.13-2.69), lymphocytopenia (odds ratio = 1.74, CL = 1.15-2.61). A weaker predictive model was obtained by substituting the comorbidity index for the index of age-comorbidity. Excluding comorbidity from the logistic regression greatly weakened the predictive model.

Mutation analysis of the transforming growth factor-beta type II receptor in human cell lines resistant to growth inhibition by transforming growth factor-beta

The transforming growth factor-beta (TGF-beta) binds the type II TGF-beta growth factor receptor (RII) to inhibit the growth of most epithelial tissues. Most human colon and gastric cancers with microsatellite instability (MI) have frameshift mutations in polynucleotide repeats within the RII coding region; these mutations truncate the receptor protein and disable the serine/threonine kinase to produce TGF-beta resistance. To further investigate the type, frequency and tissue distribution of RII mutations, we selected 24 human cancer cell lines from various tissues which were previously reported to be resistant to the inhibitory effects of TGF-beta. We developed protocols for non-isotopic SSCP analysis of PCR products from genomic DNA samples, and we tested them for microsatellite instability. PCR-SSCP analysis followed by DNA sequencing identified deletion mutations in the exon 3 poly-adenine tract in three colon tumor cell lines: LS174T and SW48 had a single base deletion and LS411 had a two base deletion. Among the 24 previously unreported cell lines, only these three demonstrated microsatellite instability. These and other recent data indicate that RII mutations are essentially confined to colon and gastric cancers with microsatellite instability. The narrow spectrum of tissues containing RII mutations illustrates the complexity of genetic checkpoints in human carcinogenesis.

Absence of mutations in the transforming growth factor-beta type II receptor in sporadic lung cancers with microsatellite instability and rare H-ras1 alleles

The transforming growth factor-beta type II receptor (RII) is commonly mutated in colon and gastric cancers with microsatellite instability (MI). We utilized our series of lung cancers with MI and rare alleles of the H-ras1 gene to determine the association between MI and RII mutations and searched the entire RII coding region in 33 lung cancers with MI by polymerase chain reaction-single-strand conformation polymorphism analysis. We found no mutations, and these data support other recent evidence that RII mutations rarely occur except in colon and gastric tumors with MI.

FHIT mutations in human primary gastric cancer

Allelic deletion of multiple regions on the short arm of chromosome 3 (3p) implies the presence of multiple important tumor suppressor genes in human carcinogenesis. The FHIT gene, identified recently in chromosome 3p14.2, shows frequent allelic deletion and aberrant transcripts in gastrointestinal tumors. After determining the intron sequences flanking each of the coding exons of the FHIT gene and designing intron primers to facilitate mutation analysis of genomic DNA samples, we analyzed the complete coding sequences in matched cancer and normal tissues from 40 cases with primary gastric cancer using intron primers, PCR-single-strand conformation polymorphism analysis, and direct sequencing. A somatic missense mutation in exon 6, codon 61, ACG (threonine) --> ATG (methionine) was found in a signet ring cell adenocarcinoma. We also evaluated allelic deletion in these tumors by PCR-based microsatellite analysis; allelic deletion occurred in 42.1% (16 of 38) of evaluable cases. This is the first report of a somatic missense mutation of the FHIT gene in a primary tumor. Presence of a point mutation and frequent allelic deletions are consistent with the hypothesis that FHIT gene alterations are involved in the development of primary gastric cancers.

Molecular analysis of the cyclin-dependent kinase inhibitor genes p15INK4b/MTS2, p16INK4/MTS1, p18 and p19 in human cancer cell lines

Cyclin-dependent kinase-4 inhibitor genes (INK4) regulate the cell cycle and are candidate tumor-suppressor genes. To determine if alterations in the coding regions of the p18 and p19 genes, which are novel members of the INK4 family and if they correlate with the development of human cancer, 100 human cancer cell lines were analyzed. Two other INK4 gene family members, p15INK4b/MTS2 and p16INK4/MTS1 genes were also analyzed. Homozygous deletions of the p15INK4b/MTS2 gene were detected in 29 cancer cell lines. Thirty-five homozygous deletions and 7 intragenic mutations of the pl6INK4/MTS1 gene were also detected in these cell lines. Neither homozygous deletions nor intragenic mutations of the p18 and p19 genes were found except in an ovarian cancer cell line, SKOV3, harboring a single base pair deletion in exon 1 of p19. In p16INK4/MTS1 expression analysis, 5 cell lines with both authentic and alternative spliced p16INK4/MTS1 mRNA had no detectable p16INK4/MTS1 protein. These results suggest the hypotheses that either post-translational modification or enhanced degradation may be responsible for the lack of detection of the p16INK4/MTS1 protein. Using Western blot analysis, subsets of 26 human cancer cell lines were examined for p18 expression and 39 cell lines for p19 expression. All of these cell lines expressed the p18 or p19 protein, with the exception of SKOV3, which did not express p19. Therefore, the INK4 gene family may be divided into 2 groups. One group includes p15INK4b/MTS2 and p16INK4/MTS1, in which genetic and epigenetic alterations might contribute to the development of human cancers. The other group includes p18 and p19, in which somatic mutations are uncommon in many types of human cancer, and their role in human carcinogenesis and cancer progression is uncertain.

[Phase I study on DMDC]

Phase I study on antimetabolic carcinostatic DMDC was conducted at 16 medical institutions nationwide for patients with various types of malignant tumors. DMDC was administered by intravenous infusion as per the following three schedules: single administration, single repeated administration, and 5-consecutive-day administration. The safety of the compound was examined single administration in 16 patients, by the single repeated administration in 5 patients, and by the 5 consecutive-day administration in 7 patients, for a total of 28 patients. In the single administration trial, 200 mg/m2 (1 n) was given as an initial dose, then increased stepwise to 450 mg/m2 (2.25 n). The single repeated administration trial was conducted at a single dose of 300 mg/m2. One treatment course lasts until recovery from side effects and abnormalities in laboratory test values. As a general rule, the administration was repeated for 2 treatment courses or more. In the 5-consecutive-day administration trial, an initial dose was 30 mg/m2/day (1 n), and increased to 40 mg/m2/day (1.3 n). The dose-limiting factors for both the single and 5-consecutive-day administration trials were decreases in the numbers of leukocytes and neutrophils. The maximum tolerated dose for single administration trial was over 400 mg/m2 (2 n), and for the 5-consecutive-day administration trial 40 mg/m2 (1.3 n). The decrease in the number of leukocytes and neutrophils for both the single administration and 5-consecutive-day administration trial reached its nadir one to two weeks after administration, and recovered in about one week. In the single repeated administration trial, the administration interval for patients who had completed 2 courses was 2 approximately 3 weeks. The plasma half-life of DMDC in the final phase of elimination in the single administration trial was 5.2 approximately 6.3 hours, and no differences were seen among dose levels. The urinary excretion rate was between 32.0 approximately 61.5% until 48 hours after administration. No accumulation was seen in the 5-consecutive-day administration trial. There were no findings to suggest an antitumor effect in the present study. Given the recovery pattern for suppression of marrow, the above mentioned results led us to decide that an recommended method of administration and dosage in an early phase II trial would be 300 mg/m2 per administration by an intravenous infusion every 2 approximately 3 weeks.

The genomic structure of the gene encoding the human transforming growth factor beta type II receptor (TGF-beta RII)

The genomic structure of the human transforming growth factor-beta type II receptor gene (TGF-beta RII) was determined by two PCR-based methods, the "long distance sequencer" method and the "promoter finder" method. Genomic fragments containing exons and adjacent introns were amplified by PCR, and the nucleotide sequences were determined by direct sequencing and subcloning sequencing. The TGF-beta RII protein is encoded by 567 codons in 7 exons. This is the first report about the genomic structure of a gene that belongs to the serine/threonine kinase type II receptor subfamily. Knowledge of the genomic structure of the TGF-beta RII gene will facilitate investigation of the TGF-beta signaling pathway in normal human cells and of the aberrations occurring during carcinogenesis.

Stability of p53 tumor suppressor gene mutations during the process of metastasis and during chemotherapy

We analyzed 29 pairs of primary and metastatic lung carcinomas obtained at autopsy for mutations in the p53 gene, using the polymerase chain reaction-single strand conformation polymorphism method (PCR-SSCP). We examined the relationship between p53 gene mutations and the development of metastasis, and the stability of p53 gene mutations during chemotherapy. The tumors consisted of six small cell carcinomas, 13 adenocarcinomas, eight squamous cell carcinomas, one large cell carcinoma, and one adeno-squamous cell carcinoma. PCR-SSCP analysis showed that three small cell carcinomas (50%), three adenocarcinomas (23%), two squamous cell carcinomas (25%), and one large cell carcinoma (100%) had p53 gene mutations. All these abnormalities were found between exon five and exon eight. The mutations in the primary tumors and the metastatic tumors were identical. These results suggest that p53 gene mutations occur before distant metastases develop, and that they may be stable during the process of metastasis. There were nine metastatic tumor samples that existed before the patients received chemotherapy. These samples showed identical p53 mutations as the corresponding primary tumor. This suggests that anticancer drugs rarely induce p53 gene mutations.

Energy intake and in-hospital starvation. A clinically relevant relationship

BACKGROUND

Malnutrition is a common finding in the acute-care hospital.

OBJECTIVES

To assess the adequacy of nutritional intake to individual needs and the effects of the hospitalization on nutritional status and to identify the reasons for inadequate energy intake.

METHODS

A total of 286 patients with a mean ( +/- SD) age of 79 +/- 6 years (range, 70 to 99 years), consecutively admitted to the geriatrics and internal medicine wards of an acute-care university hospital, underwent multidisciplinary assessment on admission and at discharge and daily dietary data collection. The needed, prescribed, and actual daily energy intake for each individual was measured. Nutritional depletion was diagnosed if midarm circumference decreased by 3.6% or more from admission to discharge.

RESULTS

Nutritional depletion occurred in 27% of the patients and correlated with anorexia (86.4% vs 65.5% and 40% in patients whose midarm circumference was unchanged and increased, respectively; P < .001), Mini-Mental State Examination score (21.6 +/- 8.3 vs 23 +/- 6.9 and 26.5 +/- 3.6; P < .05), simplified premorbid Activities of Daily Living score (4.4 +/- 2.2 vs 5.1 +/- 1.8 and 5.0 +/- 1.8; P < .03), lymphocyte count (1.32 +/- 0.63 x 10(9)/L vs 1.62 +/- 0.88 x 10(9)/L and 1.47 +/- 0.50 x 10(9)/L; P < .03), serum albumin level (38 +/- 5g/L vs 40 +/- 4 g/L and 39 +/- 8 g/L; P < .002), ratio of actual to needed energy intake (56.9% +/- 22.1% vs 69.3% +/- 30.4% and 60.0% +/- 14.1%; P < .01), ratio of actual to prescribed energy intake (50.5% +/- 16.9% vs 60.5% +/- 20.%% and 65.5% +/- 15.7%; P < .001). Patients who consumed less than 40% of the prescribed food complained of anorexia and masticatory inefficiency and were unsatisfied with quality and timing of meals compared with other patients.

CONCLUSIONS

In-hospital starvation affects mainly patients with baseline nutritional, functional, and cognitive deficits and is strongly related to the inadequate energy intake.

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting

OBJECTIVE

To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status.

DESIGN

Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment.

SETTING

General Medicine and Geriatrics wards in an acute-care university hospital.

PATIENTS

A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years.

MAIN OUTCOME MEASURES

Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC).

RESULTS

Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30).

CONCLUSIONS

Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.

Pilot trial of a combination comprising of consecutive oral administration of UFT, and two-divided administration of CDDP in non-small cell lung cancer

A pilot study of a combination therapy comprising of consecutive oral administration of UFT, and two-part divided administration of CDDP was undertaken in patients with inoperative non-small cell lung cancer, based on the synergistic effects of CDDP and 5FU. UFT was administered orally at a dosage of 400 mg/m2 for two consecutive weeks (Day 1-Day 14) and CDDP was administered twice by intravenous infusion, once on Day 4 and again on Day 8. The unit dose of CDDP was increased sequentially, from 40 mg/m2 in step 1, to 50 mg/m2 in step 2, and then to 60 mg/m2 in step 3, with safety being confirmed during the process. The numbers of patients registered for each dose level were 3, 3, and 20, respectively. Evaluation of toxicities could be conducted for all the patients except one. No toxicities of grade 3 or higher were observed in step 1 or 2. There was no problem with continuous administration of UFT. The following toxicities of grade 3 or higher were observed in step 3: leukocytopenia in 2 patients; reduction of the hemoglobin count in 1; decrease in creatinine clearance in 2; anorexia in 3; and nausea and vomiting in 3. Bone marrow suppression was mild and transient. Renal failure and digestive symptoms, which were proved to be transient and treatable by symptomatic treatment, were also observed. The step 3 administration was effective in 8 (47.1%) of the 17 patients with measurable lesions (95% CI: 23-71%). In conclusion, since it was determined that the dose employed in step 3 should be recommended and that it could be expected to exhibit antitumour effects with mild bone-marrow suppression, a large scale phase II study should be conducted in no prior treatment non-small cell lung cancer.

Effects of aging and of Alzheimer's disease on verbal memory

This study aimed to define the verbal memory profiles of very old normal subjects and subjects with Alzheimer's Disease, and to identify verbal memory indices having the highest discriminant power. Forty-three old normal subjects (mean age = 71 years, SD = 3, range = 65-75), 39 very old normal subjects (mean age = 81 years, SD = 4, range = 76-87), and 45 Alzheimer's patients (mean age = 70 years, SD = 5, range = 59-78) received the Rey test of verbal memory and the WAIS-R Digit Span forward and backward. All but one of the indices could distinguish very old from Alzheimer's subjects. A discriminant analysis disclosed a verbal memory profile of Alzheimer type in 15.4% of the very old group and of very old type in 16.2% of the Alzheimer's patients. Rate of forgetting, immediate and delayed Rey indices, and the true positive responses were, in decreasing order, the main determinants of the discriminant function. Thus, all of the components of verbal memory are differently affected by aging and Alzheimer's disease and contribute to define individual verbal memory profiles.

Bronchoscopic findings of extramural lung cancer invading the subepithelium or submucosa

Bronchoscopic findings from the main to segmental bronchi were compared with the histopathological findings in 185 resected cases of lung cancer, in order to determine which bronchoscopic features are associated with lung cancer invading the subepithelium or submucosa from beyond the bronchial wall. Carcinoma invaded the subepithelium or submucosa from beyond the bronchial wall in 43 cases (22.9%) out of the total of 185 cases. Bronchoscopic findings were evaluated in these 43 cases, and were summarized as follows: (1) The bronchoscopic findings in cases of subepithelial invasion consisted of vascular engorgement, bleeding, subepithelial tumor, and emphasized longitudinal relief; (2) irregularity of the mucosa was observed in cases of epithelial or muscular invasion; (3) indistinct bronchial cartilage was observed in cases of invasion proximal to the extramuscular layer; (4) accentuated irregular folds were observed in cases of invasion of the extramuscular or cartilage layers; and (5) edema and redness were not specific for malignancy. In addition, the occurrence of mediastinal lymph node metastasis was higher in cases of invasion to main or lobar bronchi. This result indicates that recognition of invasion of the subepithelium or submucosa of the central bronchus may be helpful in indicating the probability of mediastinal lymph node metastasis. Accordingly, there may be specific bronchoscopic findings which correlate with invasion of the bronchial subepithelium or submucosa. Accurate recognition of these findings may be useful in determining appropriate biopsy sites and may provide more information concerning selection of therapeutic strategy.

Serum neuron specific enolase level as a prognostic factor in non-small cell lung cancer

In 93 patients with inoperable non-small cell lung carcinoma who underwent chemotherapy including cisplatin, the prognostic value of 9 factors were determined using Cox's proportional hazard model. Univariate analysis revealed that patients with a performance status of grade 2 (p < 0.01) or 3 (p < 0.05), those with stage IV disease (p < 0.05), those with a serum neuron specific enolase (NSE) level > 7.0 ng/ml (p < 0.001), and those with a low serum albumin level (p < 0.05) had a significantly worse prognosis. Multivariate analysis showed that a performance status of 2 or 3 and a high NSE serum level were associated with a significantly worse prognosis. More attention should be paid to the serum NSE level in patients with non-small cell lung carcinoma, because it not only reflects the tumor volume, but is also a prognostic factor which is dependent on individual tumor characteristics.

Predicting in-hospital mortality after hip fracture in elderly patients

Ninety-seven patients aged 88 +/- 4 years (range, 80-97 years) (study group), and 74 aged 75 +/- 3 years (range, 70-79 years) (control group), were prospectively studied to investigate whether basic medical variables can predict in-hospital mortality in very old patients undergoing hip surgery because of femoral fracture. Mortality was 16.5% and 6.7% in the study and control groups, respectively (p = 0.054). In the study group, mortality was significantly correlated with age (p < 0.01), venous disorders (p < 0.05), malnutrition (p < 0.0001), duration of surgery (p < 0.006), and postoperative noninfectious complications (p < 0.005). In the control group, age was the only significant correlate of mortality (p < 0.005). After exclusion of surgery-related variables, the logistic regression analysis confirmed the predictive role of venous disorders (odds ratio = 2.04, confidence limits = 1.09-3.79) and malnutrition (odds ratio = 6.01, confidence limits = 1.85-19.47) but not of age in the study group. However, the goodness-of-fit test showed that the statistical model did not fit the data adequately. We conclude that in-hospital mortality after hip surgery in the very old cannot be predicted on the basis of underlying medical conditions alone.

Post-operative electrolyte imbalance: its incidence and prognostic implications for elderly orthopaedic patients

In order to assess incidence and prognostic implications of post-operative electrolyte disorders for elderly patients, 180 patients aged 79.5 +/- 6.8 years, range 70-96 years, admitted to a geriatric-orthopaedic liaison service were prospectively followed from admission to discharge or death. The association of age, basic medical conditions, type of anaesthesia and perioperative complications with post-operative sodium/potassium imbalance and fatality was assessed by logistic regression analysis. The incidence of post-operative electrolyte imbalance and fatality was 15% and 8.8%, respectively. Electrolyte imbalance was independently predicted by spinal anaesthesia [odds ratio (OR) = 2, confidence limits (CL) = 1.24-3.19], multiple pathology (OR = 2, CL = 1.1-3.58), use of cathartics (OR = 1.76, CL = 1.05-2.91) and intra-operative complications (OR = 1.7, CL = 1.03-2.88). Death was predicted by electrolyte imbalance (OR = 2.32, CL = 1.21-4.43), post-operative noninfective complications (OR = 2.3, CL = 1.09-4.84) and age greater than 79 years (OR = 1.17, CL = 1.06-1.3). Post-operative electrolyte imbalance is a marker of very frail medical status and a risk factor for death among elderly orthopaedic patients.