Utility of the of the M. D. Anderson Symptom Assessment Inventory (MDASI) for symptom evaluation during chemoradiation (CRT) in patients with gastrointestinal malignancies

6613

Background: Symptom assessment has become an important therapeutic endpoint in clinical trials. Measures that evaluate symptoms during CRT are needed for evaluation of clinical benefit in developing therapeutics and in monitoring quality improvement in clinical practice. Methods: 330 patients with gastrointestinal malignancies (Liver/Biliary:44; Colon:45; Rectal:197; Gastric:44) were evaluated during CRT with the self-reported MDASI-GI. All patients received 45–56Gy of radiation (1.8Gy/fraction); 78% received between 45–50.4Gy. In all cases fluoropyrimidine (oral or intravenous) was given concurrently during radiation. Lowess curves were used to describe the severity and pattern of each symptom evaluated. ANOVA was used to compare the mean severity of symptoms by tumor type. Follow-up evaluations were performed with a t-test using a Bonferroni corrected level of significance [p< 0.002]. Results: Relationships among symptoms were examined using 1,020 symptom measurements (Liver/Biliary:141; Colon:132; Rectal:613; Gastric:134 observations). Lowess curves showed almost parallel steep increases in pain and poor appetite between weeks 2–4 of CRT. Fatigue was most profound in Liver/Biliary and Rectal cancers. As expected, no significant differences in dyspnea were found among these cancers. CRT for Rectal cancer produced the worst symptom burden with significantly more pain, skin pain, and diarrhea. Consistent with clinical findings, poor appetite, nausea and vomiting were statistically more common during CRT for Gastric cancer. Conclusions: The MDASI is a brief and easy to use symptom measure in the clinical setting and is sensitive to treatment-related symptom changes during CRT in abdominopelvic malignancies.

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Baseline and temporal patterns of fatigue predict pathological response in patients treated with preoperative chemoradiation therapy (CRT) for rectal cancer

14522

Background: We investigated whether symptom burden before and during preoperative chemoradiation therapy (CRT) for rectal cancer predicts for pathological response, a surrogate for treatment outcome. Methods: Fifty-four patients with T3/T4/N+ rectal cancers were treated on a Phase II trial using preoperative capecitabine and concomitant boost radiotherapy. Most patients had T3 tumors (94%) and hemoglobin > 12 (85%). Symptom burden was prospectively assessed prior to (baseline) and weekly during CRT by a patient self-reported questionnaire, the MD Anderson Symptom Inventory (MDASI). Survival probabilities were estimated non-parametrically using Kaplan-Meier’s product limit method. Lowess curves were plotted for symptom burden across time. Logistic regression was used to determine whether symptom burden levels predicted for pathological response. Results: Among 51 patients evaluable for pathological response, 9 patients (18%) achieved pCR, and 26 patients (51%) had TDS. The actuarial rates of local control (LC), disease-free survival (DFS), and overall survival (OS) at 2 years were 93%, 76%, and 98%, respectively. Patients with TDS had lower levels of fatigue at baseline and at completion (week 5) of CRT compared to those without TDS (p = 0.03 for both). A similar trend was not observed for other symptom burden parameters of pain, sleep disturbance, appetite, nausea, or feeling of sadness. Evaluation of the potential effect of symptom burden on pCR, LC, DFS, or OS was not possible because of the low number of events during the 2-year median follow-up. Conclusions: Lower levels of fatigue at baseline and completion of CRT were significant predictors of pathological response, as gauged by TDS. Unlike studies that have documented improved quality of life among responders, our study demonstrates the converse, i.e. fatigue, a measure of symptom burden, independently predicted for tumor response. This provocative finding could potentially be used to stratify patients into prognostic groups, influence treatment decisions, and/or modify treatment. An evaluation of changes in cytokine profile during CRT is ongoing to determine the molecular basis of this phenomenon.

No significant financial relationships to disclose.

Interim results of preoperative gemcitabine (gem) plus cisplatin followed by rapid fractionation chemoradiation for resectable pancreatic adenocarcinoma

4037

Background: Over 80% of pts who undergo potentially curative pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma develop local or distant recurrence. Chemotherapy and external-beam radiation therapy (EBRT) prior to surgery maximizes the number of pts who receive multimodality therapy and undergo a complete (R0) resection. Methods: Pts with biopsy proven, stage I/II adenocarcinoma of the pancreatic head or uncinate process received systemic therapy with 4 infusions of gem (750 mg/m2) + cisplatin (30 mg/m2) every 2 wks followed by 30 Gy of EBRT (3 Gy/Fx, M-F over 2 wks) and 4 weekly doses of gem (400 mg/m2). Pts underwent complete restaging 4–6 wks after the last dose of gem. Those without disease progression and with acceptable PS underwent surgery. Results: This study has currently enrolled 87 pts over 4 years. Median age is 65 yrs (38–80), most pts (96%) had ECOG-PS (0–1) at study entry. Median CA19–9 is 170. Six pts were excluded from analysis and 4 are currently on treatment. Of the 77 pts who finished chemoradiation, 72 completed restaging (3 await restaging, 2 drop outs). Of these 72 pts, 10 had disease progression, 1 had a decline in PS, and 61 (79 %) went to surgery. 49 of 61 pts (64 %) underwent a successful PD and metastatic or locally advanced disease was found in 12 (15 %). 44 (90 %) of 49 pts underwent R0 resection. Pathologic PR rate (>50 % tumor kill) was 61 %. The predominant toxicity prompting hospitalization during preoperative therapy was biliary stent occlusion (44 %). Gastrointestinal toxicity ≤ grade 3 was common but controllable. Grade 3 and 4 neutropenia was seen in 19 (25 %) and 3 pts (4 %) respectively. Grade 3–4 thrombocytopenia was rare. Median survival for resected pts was ∼ 21 months. Conclusions: This study, builds on our previous gem-based preop chemoradiation program ( ASCO 2002, Abs # 516) producing good local treatment effect and a high R0 resection rate. However, interim analysis suggests that the addition of systemic chemotherapy delivered prior to preoperative chemoradiation does not appear to improve survival. Optimal treatment sequencing of chemoradiation, systemic therapy and surgery needs further refinement. Supported in part by Eli Lilly and Co.

[Table: see text]

Recurrence of suicidal ideation across depressive episodes

BACKGROUND

In recent years it has become clear that depression is a recurrent disorder, with the risk of recurrence in those with two or more episodes being as high as 90%. This has prompted interest in the consistency of individual depressive symptoms across consecutive episodes, an issue that is important for symptoms such as suicidal ideation, where a past history may give important indicators of future behaviour.

METHODS

We prospectively examined 69 individuals with a history of Major Depression, over 12 months, 38 of whom experienced a recurrence of major depression during the follow-up period.

RESULTS

Spearman's rank order correlations between severity ratings of each symptom of major depression during a previous episode and severity ratings at recurrence showed significant associations for suicidality, guilt or worthlessness and thinking difficulties only. Weighted kappa coefficients indicated relatively low levels of agreement across episodes for most diagnostic symptoms, with suicidality showing the strongest relationship. Using a broad definition of suicidality-- any reporting of thoughts of death or suicide during episode-- a much higher level of agreement (kappa = .64) was found, with 83% of individuals falling into the same category (suicidal/non-suicidal) at both episodes.

LIMITATIONS

This study was based on a relatively small sample and examines re-emergence of suicidal ideation in the absence of suicidal behaviour.

CONCLUSIONS

This study provides preliminary evidence of cross-episode consistency in the recurrence of suicidal ideation, in line with the differential activation theory of suicidality in depression.

Duration of relapse prevention after cognitive therapy in residual depression: follow-up of controlled trial

BACKGROUND

Although there is good evidence that cognitive therapy (CBT) lessens relapse and recurrence in unipolar depression, the duration of this effect is not known.

METHOD

One hundred and fifty-eight subjects, from a randomized controlled trial of CBT plus medication and clinical management versus medication and clinical management alone, were followed 6 years after randomization (4 1/2 years after completion of CBT) and the longitudinal course assessed.

RESULTS

Effects in prevention of relapse and recurrence were found to persist, with weakening, and were not fully lost until 3 1/2 years after the end of CBT. Residual symptoms were also lessened.

CONCLUSIONS

The effect of CBT in reduction of relapse and recurrence persists for several years. The potential value of subsequent additional CBT some time after cessation should be explored.

Elective groin irradiation is not indicated for patients with adenocarcinoma of the rectum extending to the anal canal

PURPOSE

To evaluate the inguinal nodal failure rate in patients with locally advanced rectal cancer with anal canal involvement (ACI) treated with pelvic chemoradiation without elective inguinal irradiation.

METHODS AND MATERIALS

From 1990 and 1998, 536 patients received preoperative or postoperative chemoradiation for rectal cancer with curative intent; 186 patients had ACI (<4 cm from the anal verge on rigid proctoscopy). Two patients had positive inguinal nodes at presentation. Chemoradiation was delivered preoperatively (45 Gy in 25 fraction) or postoperatively (53 Gy in 29 fractions) with concurrent continuous infusion of 5-fluorouracil (300 mg/m2/d). The inguinal region was specifically irradiated in only 2 patients who had documented inguinal nodal disease.

RESULTS

The median follow-up was 50 months. Only 6 of 184 ACI patients who had clinically negative inguinal nodes at presentation developed inguinal nodal recurrence (5-year actuarial rate 4%); 4 of the 6 cases were isolated. Two patients underwent successful salvage. Only 1 died of uncontrolled groin disease. Local control was achieved in both patients with inguinal nodal disease at presentation, but both died of metastatic disease. Only 3 patients with tumors >4 cm from the verge developed inguinal recurrence (5-year actuarial rate <1%).

CONCLUSIONS

Inguinal nodal failure in rectal cancer patients with ACI treated with neoadjuvant or adjuvant chemoradiation is not high enough to justify routine elective groin irradiation.

Elective groin irradiation is not indicated for patients with adenocarcinoma of the rectum extending to the anal canal

PURPOSE

To evaluate the inguinal nodal failure rate in patients with locally advanced rectal cancer with anal canal involvement (ACI) treated with pelvic chemoradiation without elective inguinal irradiation.

METHODS AND MATERIALS

From 1990 and 1998, 536 patients received preoperative or postoperative chemoradiation for rectal cancer with curative intent; 186 patients had ACI (<4 cm from the anal verge on rigid proctoscopy). Two patients had positive inguinal nodes at presentation. Chemoradiation was delivered preoperatively (45 Gy in 25 fraction) or postoperatively (53 Gy in 29 fractions) with concurrent continuous infusion of 5-fluorouracil (300 mg/m2/d). The inguinal region was specifically irradiated in only 2 patients who had documented inguinal nodal disease.

RESULTS

The median follow-up was 50 months. Only 6 of 184 ACI patients who had clinically negative inguinal nodes at presentation developed inguinal nodal recurrence (5-year actuarial rate 4%); 4 of the 6 cases were isolated. Two patients underwent successful salvage. Only 1 died of uncontrolled groin disease. Local control was achieved in both patients with inguinal nodal disease at presentation, but both died of metastatic disease. Only 3 patients with tumors >4 cm from the verge developed inguinal recurrence (5-year actuarial rate <1%).

CONCLUSIONS

Inguinal nodal failure in rectal cancer patients with ACI treated with neoadjuvant or adjuvant chemoradiation is not high enough to justify routine elective groin irradiation.

1st annual oncology update: advances and controversies. Steamboat Springs, Colorado, USA, 13-17 February 2001

In addition to the scientific component to the meeting, the conference was successful in many social aspects. The setting permitted the conference to be informal, with casual dress and lively audience participation involvement. In general, the conference was able to provide an excellent multidisciplinary overview of a wide-variety of oncology topics.

Improved overall survival among responders to preoperative chemoradiation for locally advanced rectal cancer

The aim of this study was to determine if the response to preoperative radiation and chemotherapy with continuous infusion 5-fluorouracil (5-FU) was predictive for survival among patients with locally advanced rectal cancer. Preoperative chemoradiation (CTX/XRT) that delivered 45 Gy in 25 fractions over 5 weeks with continuous infusion 5-FU (300 mg/m2/day) was given to 117 patients. The pretreatment stage distribution, as determined by endorectal ultrasound (u), included uT2N0 in 2%, uT3N0 in 47%, uT3N1 in 49%, and uT4N0 in 2% of cases; endorectal ultrasound was not performed in 13% of cases (15 patients). Approximately 6 weeks after completion of CTX/XRT, surgery was performed. Adjuvant chemotherapy, consisting of 400 to 425 mg/m2 of 5-FU plus 20 mg/m2 leucovorin for 5 days, was administered every 28 days for 4 to 6 cycles after surgical resection. Among the 74 patients treated with adjuvant chemotherapy, the preoperative stage of disease was 31 with T3N0 and 43 T3N1. Median follow-up was 46 months (range 2 to 89 months). The pathologic tumor stages were Tis-2N0 in 26%, T2N1 in 5%, T3N0 in 21%, T3N1 in 15%, T4N0 in 5%, and T4N1 in 1%; a complete response (CR) to preoperative CTX/XRT was pathologically confirmed in 32 (27%) of patients. Tumor down-staging occurred in 72 (62%) cases. A sphincter-saving procedure (SP) was possible in 59% of patients. The median DFS and overall survival rates for responders were 46 months and 47 months, respectively; for non-responders these outcome measures were 38 months and 41 months, respectively. Log-rank analysis showed that the distant metastatic-free survival rates improved with any response to CTX/XRT (p < 0.00001), CR to CTX/XRT (p < 0.009) and SP (p < 0.012). Likewise, these parameters also significantly influenced DFS rates (CTX/XRT p < 0.00001; CR p < 0.006; and SP p < 0.008). Control of pelvic disease was influenced by clinical size (p < 0.002) and SP (p < 0.016) on univariate analysis. On multivariate analysis only clinical size (p < 0.002) continued to be a significant factor for local control. Factors on multivariate analysis that resulted in significant improvements in cancer-specific survival included any response to preoperative CTX/XRT (p < 0.017) and administration of adjuvant chemotherapy (p < 0.034). Any response to preoperative CTX/XRT improved distant metastatic-free and disease-free survival rates. Multivariate analysis confirmed that a response to preoperative CTX/XRT predicted for improvements in overall survival among patients with locally advanced rectal cancer. Patients who fail to respond to preoperative 5-FU based chemotherapy given concomitantly with radiation have higher rates of distant metastases with adjuvant 5-FU therapy.

Phase I study of preoperative oral uracil and tegafur plus leucovorin and radiation therapy in rectal cancer

PURPOSE

Preoperative combined-modality therapy for rectal cancer may allow for sphincter preservation, while decreasing recurrence rates and improving the overall prognosis. Oral chemotherapy with uracil and tegafur (UFT) plus leucovorin (LV) may reduce costs and complications associated with protracted infusions of fluorouracil. Our goal was to evaluate the safety of UFT plus LV combined with preoperative radiation and determine the maximum-tolerated dose (MTD) and dose-limiting toxicity (DLT) of UFT plus LV in this setting.

PATIENTS AND METHODS

Patients with tumor-node-metastasis stage II or III rectal cancer received escalating doses of UFT (starting at 250mg/m(2)/d, with 50-mg/m(2)/d increments between consecutive cohorts) and fixed doses of LV (90 mg/d). The UFT and LV combination was given 5 days per week concurrently with a 5-week course of preoperative radiation totaling 45 Gy (1.8 Gy/fraction). Surgery was performed 4 to 6 weeks after radiation and was followed by four 35-day cycles of fixed doses of UFT and LV (28 days of therapy each cycle).

RESULTS

Fifteen patients were treated, and 13 received the full preoperative chemotherapy. All planned radiation was delivered successfully. The MTD of UFT with radiation was 350 mg/m(2)/d with 90 mg/d of LV. Diarrhea was the DLT. Sphincter-preserving surgery was performed in 12 of 14 patients. One patient had progressive disease before surgery. Pathologic evaluation of 14 resected specimens showed a complete response in three cases.

CONCLUSION

Preoperative chemoradiation with oral UFT plus LV is feasible and well tolerated and should be further investigated.

Preoperative UFT and calcium folinate and radiotherapy in rectal cancer

Protracted infusions of 5-fluorouracil (5-FU) combined with pelvic radiotherapy have been associated with improved survival and decreased local and distant metastases in the adjuvant therapy of rectal cancer. However, this method of 5-FU infusion requires the inconvenience and expense of central venous line placement and care, infusion pumps, and treatment of catheter-related complications. We previously demonstrated that a completely oral therapy with UFT (uracil plus tegafur in a 4:1 molar ratio) plus oral calcium folinate (Orzel) can achieve pharmacokinetic parameters similar to those associated with protracted 5-FU infusions. This trial examines the feasibility of using UFT plus oral calcium folinate both during preoperative pelvic radiation and postoperatively, and shows that patients can be treated safely and effectively with a completely oral chemotherapy program combining UFT plus oral calcium folinate with pelvic radiation therapy.

Evolution of interspersed repetitive elements inGossypium (Malvaceae)

Very little is known regarding how repetitive elements evolve inpolyploid organisms. Here we address this subject by fluorescent insitu hybridization (FISH) of 20 interspersed repetitive elements tometaphase chromosomes of the cotton AD-genome tetraploid Gossypiumhirsutum and its putative A- and D-genome diploid ancestors. Theseelements collectively represent an estimated 18% of the G.hirsutum genome, and constitute the majority of high-copyinterspersed repetitive elements in G. hirsutum. Seventeen ofthe elements yielded FISH signals on chromosomes of both G.hirsutum subgenomes, while three were A-subgenome specific. Hybridization of eight selected elements, two of which were A-subgenomespecific, to the A(2) genome of G. arboreum yielded asignal distribution that was similar to that of the G. hirsutumA-subgenome. However, when hybridized to the D(5) genome ofG. raimondii, the putative diploid ancestor of the G.hirsutum D-subgenome, none of the probes, including elements thatstrongly hybridized to both G. hirsutum subgenomes, yieldeddetectable signal. The results suggest that the majority, although notall, G. hirsutum interspersed repetitive elements haveundergone intergenomic concerted evolution following polyploidizationand that this has involved colonization of the D-subgenome byA-subgenome elements and/or replacement of D-subgenome elements byelements of the A-subgenometype.

Comparative circulatory effects of isoproterenol and dopamine in lambs with experimental cyanotic heart disease

To determine whether the hemodynamic responses to adrenergic agonists are altered during chronic hypoxemia secondary to an intracardiac right to left shunt, we studied seven lambs with surgically created pulmonic stenosis and atrial septal defect and nine controls during infusions of isoproterenol at 0.1 and 0.5 micrograms/kg/min and dopamine at 5 and 20 micrograms/kg/min. Isoproterenol increased heart rate by 89 +/- 17% in control but only 46 +/- 6% in experimental lambs (p less than 0.05). However, because resting heart rate was higher in experimental lambs (213 +/- 7 versus 177 +/- 12 beats/min, p less than 0.05), maximal heart rates were similar (310 +/- 7 versus 326 +/- 6 beats/min; NS). Cardiac output increased during isoproterenol from 219 +/- 20 to 425 +/- 54 mL/min/kg in experimental lambs (p less than 0.05) and, similarly, from 180 +/- 20 to 425 +/- 71 in controls (p less than 0.05) (experimental versus control; NS). Dopamine also increased cardiac output similarly in both groups, at both doses, but without changing heart rate. Isoproterenol did not alter aortic oxygen saturation and increased systemic oxygen transport more than oxygen consumption. In contrast, dopamine at both doses decreased aortic oxygen saturation in experimental lambs (rest, 71 +/- 2% versus dopamine, 59 +/- 2%; p less than 0.05). With dopamine, the increase in systemic oxygen transport was equalled by an increase in oxygen consumption. Thus, circulatory responses to isoproterenol are similar in lambs with experimental cyanotic heart disease and controls, although higher resting heart rate in the experimental lambs reduces chronotropic reserve.(ABSTRACT TRUNCATED AT 250 WORDS)

Differential regulation of right and left ventricular beta-adrenergic receptors in newborn lambs with experimental cyanotic heart disease

To determine whether chronic hypoxemia secondary to an intracardiac right-to-left shunt alters regulation of the myocardial beta-adrenergic receptor/adenylate cyclase system, we produced chronic hypoxemia in nine newborn lambs by creating right ventricular outflow obstruction and an atrial septal defect. Oxygen saturation was reduced to 65-74% for 2 wk. Eight lambs served as normoxemic controls. beta-receptor density (Bmax) and ligand affinity (KD) were determined with the radio-ligand [125I]iodocyanopindolol and adenylate cyclase activity determined during stimulation with isoproterenol, sodium fluoride (NaF), and forskolin. During chronic hypoxemia, Bmax decreased 45% (hypoxemic, 180.6 +/- 31.5 vs. control, 330.5 +/- 60.1 fmol/mg) in the left ventricle (exposed to hypoxemia alone) but was unchanged in the right ventricle (exposed to hypoxemia and pressure overload). KD was not different from control in either ventricle. Left ventricular isoproterenol-stimulated adenylate cyclase activity was decreased by 39% (30.0 +/- 4.3% increase vs. 44.1 +/- 9.5% increase) whereas right ventricular adenylate cyclase activity was unchanged. Stimulation of adenylate cyclase with NaF or forskolin was not different from control in either ventricle. Circulating epinephrine was increased fourfold whereas circulating and myocardial norepinephrine were unchanged. These data demonstrate a down-regulation of the left ventricular beta-adrenergic receptor/adenylate cyclase system during chronic hypoxemia secondary to an intracardiac right-to-left shunt.

Natural history of the leg amputee

For 173 patients undergoing major leg amputations, the operative mortality was 13 per cent. The ratio of below-knee (BK) to above-knee (AK) amputations was approximately unity. Of the 150 patients who survived amputation, 93 were given prostheses. Amoung the latter group, 76 per cent of the unilateral AK amputees and 90 per cent of the unilateral BK amputees had a successful rehabilitation. For those patients who had to be converted from BK to AK unilateral amputations, 40 per cent experienced successful rehabilitation, and for those who had either bilateral BK or bilateral mixed amputations, 45 per cent were successful. The most common contraindications to granting prostheses were debility and dementia. The mean time interval from first amputation to latest observation was 3.5 years (range, 5 weeks to 13.5 years). At three years 49 per cent of the patients survived and at five years 31 per cent survived. Despite major impediments, satisfactory rehabilitation is accomplished frequently enough to justify optimism for a considerable number of geriatric amputees.

Femorofemoral bypass graft in intra-aortic balloon counterpulsation

Femorofemoral arterial crossover grafts were used in three patients to avoid or correct limb ischemia during intra-aortic balloon counterpulsation. In retrospec, these grafts should have been used in two earlier patients in whom the balloon was removed prematurely. They are applied to the femoral artery just distal to the site of insertion of the balloon or the the balloon access graft. Removal of the graft at the time of the balloon removal is optional.

The predictive accuracy of renal vein renin activity in the surgery of renovascular hypertension

In a consecutive group of 38 patients undergoing operations for renovascular hypertension, there were 24 arterial reconstructions and 16 nephrectomies. Thirty-two patients were available for late observation, and 25 (78 percent) had a successful result. The renal vein renin ratio (RVRR) correctly predicted successful results in 76 percent of the patients with a RVRR of 1.5 or more but was correct in predicting an unsuccessful result in only one of the six patients with an RVRR less than 1.5. This high incidence of "false-negative" results has appeared in several other reports but has received insufficient emphasis. The presumed causes include inadequate sodium depletion prior to the renal blood vein samplings or, less likely, the effects of renin-suppressing drugs such as alpha methyldopa, propranolol, or reserpine. Because five of the six patients with RVRR less than 1.5 enjoyed a successful result from operation, it is apparent the clinical factors and the aortogram should be determinant when the RVRR, performed under the conditions described, is not diagnostic of renovascular hypertension. Nonetheless, when all diagnostic factors, i.e., the aortogram, the rapid-sequence intravenous pyelogram, and the RVRR, support such a diagnosis, a successful surgical result is nearly certain.

Mortality and morbidity rates after inferior vena caval clipping

In 112 patients receiving inferior vena caval, serrated, Teflon clips over a 7 year period beginning Jan. 1, 1966, the operative mortality rate was 6 percent (seven patients) and the 1 to 12 month mortality rate was 9 percent (10 patients). Patients with severe heart disease accounted for eight of these 17 deaths. The mortaligy rate was zero in patients who were free of heart disease, malignancy, sepsis, or massive pulmonary embolism. Recurrent pulmonary embolism was suspected, but not lethal, in four patients and was proved in two. Patients who had leg swelling preoperatively were more likely to have swelling postoperatively than those who were initially free of swelling. Postoperative anticoagulation was ineffective in preventing edema and carried the risk of wound hemorrhage. Twelve months after operation, 12 of the 83 patients available for follow-up had severe lower extremity symptoms and 23 had milder, easily controlled edema. Late stasis changes, therefore, appeared at an acceptably low frequency and could reasonably be expected for patients with lower extremity phlebothrombosis. There was no instance of fatal pulmonary embolism in the follow-up period extending from 1 to 6 years.

Intercostal nerve conduction and posterior rhizotomy in the diagnosis and treatment of thoracic radiculopathy

Intercostal nerve conduction study has proved to be an accurate technique in diagnosis of thoracic radiculopathy in 161 patients, 80 of whom had subsequent posterior rhizotomy with relief of pain in 81% of those undergoing surgery. The only significant complication of intercostal nerve conduction study is an 8·8% incidence of pneumothorax.