Abstract 3729: Prognostication using Hif-1 alpha may require simultaneous nicotine assessment

Background: Current cancer diagnosis and treatment increasingly incorporates biomarker expression in the prognostication and therapeutic stratification of cancer patients; however, there is no accurate assessment of exposure to environmental agents such as nicotine that may significantly impact biomarker expression patterns.

Methods: Athymic nude mice with human H460 lung cancer cell xenografts were stratified into three treatment groups (n=5 per group) beginning when tumors reached 5 mm in maximal dimension: control (CON), short term nicotine (STN, 60 ug subcutaneously every other day x 6 days), or long term nicotine (LTN, 60 ug SC every other day until tumor explant). All tumors were explanted at endpoint defined when tumors reached 15 mm in maximal dimension. Tumors were analyzed immunohistochemically for hypoxia (using CA-IX expression) and hypoxia-inducible factor 1-alpha (Hif-1) expression. This protocol was approved by the Institutional Animal Care and Use Committee at the University of Kentucky.

Results: Nicotine administration had no effect on tumor growth rate and all tumors reached endpoint within a median of 9 days following treatment initiation (range 8-11 days). Areas of hypoxia were defined using CA-IX expression. Tumor hypoxia was not significantly affected by nicotine administration. Moreover, Hif-1 expression was only minimally increased in areas of hypoxia in CON animals. In STN animals, Hif-1 expression was very similar to CON animals. In contrast, LTN animals demonstrated widespread marked increases in Hif-1 expression at the viable: necrotic tumor interface. Separately, xenografts removed at day 6 demonstrated similar widespread Hif-1 expression confirming that Hif-1 expression is significantly increased after 6 days of nicotine administration.

Conclusions: This study demonstrates that widespread Hif-1 expression may be dominated by the presence of nicotine rather than hypoxia. Furthermore, acute removal of nicotine results in the restoration of basal low-level Hif-1 expression within 3 days of nicotine removal. This data may significantly limit the prognostic utility of clinical Hif-1 expression in the absence of simultaneous nicotine assessment.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 3729.

DBA/1 mice exhibit chronic susceptibility to audiogenic seizures followed by sudden death associated with respiratory arrest

One proposed cause of sudden unexpected death in epilepsy (SUDEP) in patients is generalized convulsive seizures with respiratory malfunction. We evaluated DBA/1 mice as a chronic SUDEP model. In DBA/1 mice, audiogenic seizures induced by acoustic stimulation resulted in generalized convulsive seizures followed by respiratory arrest from postnatal day (PND) 21 to 100. The incidence of respiratory arrest susceptibility increased, reaching approximately 90-100% by three to seven daily seizures when testing began on PND 21-30. Respiratory arrest was reversible with resuscitation in approximately 98% of mice, which allows repeated seizure testing. Electrocardiographic activity in DBA/1 mice was detectable for approximately 4-6 minutes after respiratory arrest, indicating that death is likely due to respiratory cessation, as cardiac changes occur later. These findings suggest that DBA/1 mice are a useful chronic SUDEP model. These mice die suddenly from respiratory arrest after generalized convulsive seizures until reaching PND >or=100, allowing testing of chronic preventive treatments for SUDEP.

Practice patterns of radiotherapy in endometrial cancer among member groups of the gynecologic cancer intergroup

PURPOSE

To describe radiotherapeutic practice of the treatment of endometrial cancer in members of the Gynecologic Cancer Intergroup (GCIG).

METHODS

A survey was developed and distributed to the members of the GCIG. The GCIG is a global association of cooperative groups involved in the research and treatment of gynecologic neoplasms.

RESULTS

Thirty-four surveys were returned from 13 different cooperative groups. For the treatment of endometrial cancer after hysterectomy, mean (SD) pelvic dose was 47.37 (2.32) Gy. The upper border of the pelvic field was L4/5 in 14 respondents, L5/S1 in 13 respondents, and not specified in 6 surveys. When vaginal brachytherapy (VBT) was used in conjunction with external beam radiotherapy, most groups used high dose rate versus low dose rate on 24 versus 5 respondents, respectively. Twenty-eight of the 34 respondents performed computed tomographic simulation. Intensity-modulated radiotherapy was used routinely in 3 of the 34 respondents. For a para-aortic field, the upper border was, most commonly, at the T12-L1 interspace (17 of the 28 respondents), and the mean (SD) dose was 46.15 (2.18) Gy. For VBT alone after hysterectomy, 23 groups performed high-dose-rate brachytherapy (27.57 [10.13] Gy in a mean of 4.3 insertions), and 5 groups used low-dose-rate brachytherapy (41.45 [17.5] Gy). Nineteen of the 28 respondents measured the doses to the bladder and the rectum when performing VBT. For brachytherapy, there was no uniformity in the fraction of the vagina treated or the doses and schedules used.

CONCLUSIONS

Radiotherapy practices among member groups of the GCIG are similar in doses and dose per fraction with external beam. There is a moderate discrepancy in the brachytherapy practice after hysterectomy. There are no serious impediments to intergroup participation in radiation oncology practices among GCIG members with the use of external beam.

Extracranial stereotactic radioablation: physical principles

Extracranial stereotactic radioablation (ESR) involves treating well-demarcated targeted tissues (e.g. tumor with minimal margin for set-up uncertainties) with very large doses of radiation in single or a few fractions with the intent of causing profound late tissue damage within the targeted volume. In such circumstances, considerable effort must be taken to reduce non-target tissue exposure to the high dose levels in order to prevent late complications to involved organs. Consequently, the following conditions for effective delivery of the ESR techniques have to be satisfied: 1) delivery of a high dose per fraction, i.e. 10-24 Gy; 2) delivery of only a few fractions per course of treatment (e.g. 1-4); 3) shaping of the prescription isodose surface conformally to the target surface; 4) delivery of a non-uniform dose distribution within the target with the highest dose in centrally located regions of hypoxia; 5) rapid fall-off of dose from the target volume to healthy tissue in all directions. In this paper it is shown that high doses per fraction in few fractions can be delivered to a variety of locations with both efficacy and acceptable toxicity (conditions 1 and 2). Conformal shaping of the high isodose surfaces is best accomplished by employing many beams (5-10) each with carefully milled apertures precisely coincident with the target projection (condition 3). Beam intensity modulation creating parabolic beam entrance fluence profiles both concentrates the highest dose in central regions of tumor hypoxia and increases fall-off gradients outside of the target (conditions 4 and 5). It is also shown that isotropic, highly non-coplanar beam arrangements avoiding oppositional fields allow more optimal fall-off gradients to normal tissue as opposed to coplanar treatments (condition 5).

Patterns of Care for Radiotherapy in Vulvar Cancer: A Gynecologic Cancer Intergroup Study

Background:

This study aimed to describe radiotherapeutic practice in the treatment of vulvar cancer in member study groups of the Gynecologic Cancer Intergroup (GCIG).

Methods:

A survey was developed and distributed to representatives of the member study groups of the GCIG, targeting the use of radiotherapy (RT) in vulvar cancer.

Results:

Thirty-two surveys were returned from 12 different cooperative groups. The most common indications for neoadjuvant RT include unresectable disease or International Federation of Gynecology and Obstetrics stage ≥III. For the neoadjuvant treatment of vulvar cancer, pelvic doses were 48.2 ± 5.0 Gy (mean ± SD). The upper border of the pelvic field was L4/5 in 4, L5/S1 in 12, and not specified in 4. Of 21 groups that perform neoadjuvant RT, 17 use concomitant chemotherapy and 4 individualize treatment. Weekly cisplatin was the most commonly used chemotherapy. For the neoadjuvant RT treatment of the inguinal region, doses were 49.9 ± 5.5 Gy (mean ± SD). Sixteen of 18 groups used computed tomographic simulation for planning. After initial surgery, the most common indications for RT included positive lymph nodes or positive margins. Chemotherapy was not routinely used after surgery.

Conclusions:

Doses of RT among GCIG members are similar; however, the indications for treatment, treatment fields, and use of chemotherapy differ somewhat between groups. This is likely due to the rarity of the disease. The lack of randomized trials may contribute to the absence of a broadly accepted standard. This underscores the importance of international cooperation as in GCIG to gather more reliable data for uncommon tumors in gynecologic oncology.

Changes in shape, ossification and quality of bones in children with spina bifida

Changes in the cross-sectional shape, size, bone mass and amount of unmineralised osteoid tissue were studied in 17 dissected tibiae from spina-bifida babies who died with paralysis and foot deformities and in 14 tibiae from non-spina bifida controls of matching age. In addition, 12 tibiae from young experimental rats with myotomy of foot dorsiflexors and foot plantiflexors were double-labelled with bone-seeking markers and studied in order to find the role of experimental muscle imbalance in the dynamic remodelling of the developing long bones. It was found that in tibiae from spina-bifida children with paralysis the total area of cortical bone, its thickness, number of Haversian systems and number of large remodelling cavities are diminished. Significant changes in the cross-sectional shape of the midshaft of the tibia were found, ranging from the triangular shape seen in normal babies and in those with spina bifida and calcaneus-type foot deformity, to the circular shape of tibiae from babies with spina-bifida paralysis and no foot deformity or with spina bifida and equinovarus-type of deformity. Results of experimental myotomy on growing rats showed the direct influence of working muscles on the remodelling process of growing tibiae. On the side of myotomy the flat cortex resumed a bulging convex shape and the centre of gravity shifted towards the myotomised side. These principles cannot on their own explain the specific changes in the shape of human tibiae found during anatomical studies. There is, however, a common denominator in these apparently contradictory findings. This is the combined action of two factors previously reported: the combination of paralysis of the growing limb and mechanical intra-uterine pressure acting on it. The findings in the present study also indicate that they played a major role in the production of deformities. The total amount of osteoid tissue in spina-bifida paralysed bone is increased. This delay of mineralisation of newly laid-down bone matrix would lead to softening of the new bone matrix and osteoid-rich subepiphyseal and metaphyseal regions. This 'paralytic rickets', together with the diminished total bone mass found, could probably be the cause of the common spina-bifida fractures in these regions.

Hypoxanthine-guanine phosphoribosyltransferase deficiency: biochemical and molecular findings in six Argentine patients

Hypoxanthine-guanine phosphoribosyltransferase (HPRT) deficiency is an inborn error of purine metabolism responsible for Lesch-Nyhan Disease (LND) and its partial phenotypes, HPRT-related hyperuricemia with neurologic dysfunction (HRND) and hyperuricemia alone. We report here the recognition of six Argentine patients, two with LND and four with HRND. All patients presented elevated excretion of uric acid, hypoxanthine, and xanthine and decreased HPRT enzyme activities <1 nmol/h/mg Hb. The molecular analysis demonstrated in the two LND patients a novel inherited transition mutation, c.203T >C (L68P), in one subject and a germline transition mutation, c.209G >A (G70E), in the other. In the HRND patients a novel transversion mutation, c.584 A >C (Y195S), was found in three related patients and an inherited transition mutation, c.143G >A (R48H), in the fourth subject.

Practice Patterns of Radiotherapy in Cervical Cancer Among Member Groups of the Gynecologic Cancer Intergroup (GCIG)

PURPOSE

The aim of this study was to describe radiotherapeutic practice of the treatment of cervical cancer in member groups of the Gynecologic Cancer Intergroup (GCIG).

METHODS AND MATERIALS

A survey was developed and distributed to the members of the GCIG focusing on details of radiotherapy practice. Different scenarios were queried including advanced cervical cancer, postoperative patients, and para-aortic-positive lymph node cases. Items focused on indications for radiation therapy, radiation fields, dose, use of chemotherapy, brachytherapy and others. The cooperative groups from North America were compared with the other groups to evaluate potential differences in radiotherapy doses.

RESULTS

A total of 39 surveys were returned from 13 different cooperative groups. For the treatment of advanced cervical cancer, external beam pelvic doses and total doses to point A were 47 + 3.5 Gy (mean + SD) and 79.1 + 7.9 Gy, respectively. Point A doses were not different between the North American cooperative groups compared with the others (p = 0.103). All groups used concomitant chemotherapy, with 30 of 36 respondents using weekly cisplatin. Of 33 respondents, 31 intervened for a low hemoglobin level. For a para-aortic field, the upper border was most commonly (15 of 24) at the T12-L1 interspace. Maintenance chemotherapy (after radiotherapy) was not performed by 68% of respondents. For vaginal brachytherapy after hysterectomy, 23 groups performed HDR brachytherapy and four groups used LDR brachytherapy. In the use of brachytherapy, there was no uniformity in dose prescription.

CONCLUSIONS

Radiotherapy practices among member groups of the GCIG are similar in terms of both doses and use of chemotherapy.

Randomized trial results of quality of life comparing whole abdominal irradiation and combination chemotherapy in advanced endometrial carcinoma: A gynecologic oncology group study

OBJECTIVE

To prospectively compare quality of life (QOL) outcomes in patients with advanced endometrial cancer treated with whole abdominal irradiation (WAI) or doxorubicin-cisplatin (AP) chemotherapy.

METHODS

Using the Fatigue Scale (FS), Assessment of Peripheral Neuropathy (APN), Functional Alterations due to Changes in Elimination (FACE), and Functional Assessment of Cancer Therapy-General (FACT-G), QOL was measured at: pre-treatment, end of treatment (EOT), and 3 and 6 months post-treatment.

RESULTS

317 of 396 eligible patients provided a baseline QOL assessment. The AP arm produced a statistically significant survival benefit along with greater toxicities, including peripheral neuropathy persisting up to 6 months. WAI patients reported worse FS (p < 0.001) and FACE (p < 0.001) scores at EOT and poorer FACE scores 3 months post-treatment (p = 0.004) compared to AP patients. APN scores were significantly worse among AP patients at EOT, and 3 and 6 months post-treatment (p < 0.001 for all). There is no indication that FACT-G scores differed between the two arms at any assessment point.

CONCLUSIONS

The trade-off for increased survival with AP is its potential for clinically significant peripheral neuropathy. This should be discussed with patients, particularly those who work with their hands or on their feet, in weighing therapeutic choices. Further research is needed to manage side effects having an enduring impact on QOL.

Safety of Arch Aortography for Assessment of Carotid Arteries

PURPOSE

To retrospectively review the safety of arch aortography and compare complication rates with published figures for selective catheter angiography.

METHODS

The medical records of patients undergoing arch aortography over the last 3 years (n=311; 180 male, 131 female; mean+/-SD age 71.0+/-9.2 years, range 42-90 years) were retrospectively reviewed. Any peri-procedural (0-48 h) complications were recorded. A certified neurologist (MSR/GSV) classified all questionable neurological events.

RESULTS

There were no focal neurological events or deaths (n=0; 0%; CI: 0-0.96%). Non-focal neurological events included mild disorientation (n=2; 0.6%; CI: 0.176-2.31) and unequal pupils (n=1; 0.3%; CI: 0.056-1.79%). Cardiovascular events included symptomatic hypotension (n=4; 1.3%; CI: 0.50-3.25%), angina (n=1; 0.3%; CI: 0.056-1.79%) and arrhythmia (n=4; 1.3%; CI: 0.50-3.25). There were 27 minor access site complications (8.7%; CI: 6.0-12.3). None of these complications extended hospital stay. None of the arch angiograms had to be followed by selective carotid angiography.

CONCLUSION

Arch aortography appears to have a lower neurological complication rate than selective carotid angiography.

Automated selection of appropriate pheromone representations in ant colony optimization

Ant colony optimization (ACO) is a constructive metaheuristic that uses an analogue of ant trail pheromones to learn about good features of solutions. Critically, the pheromone representation for a particular problem is usually chosen intuitively rather than by following any systematic process. In some representations, distinct solutions appear multiple times, increasing the effective size of the search space and potentially misleading ants as to the true learned value of those solutions. In this article, we present a novel system for automatically generating appropriate pheromone representations, based on the characteristics of the problem model that ensures unique pheromone representation of solutions. This is the first stage in the development of a generalized ACO system that could be applied to a wide range of problems with little or no modification. However, the system we propose may be used in the development of any problem-specific ACO algorithm.

Faculty ownership of medical facilities: inappropriate conflict or an opportunity that benefits physicians and patients?

As a result of a confluence of issues, including faculty compensation in an academic health center (AHC), increasing awareness of conflict-of-interest issues, growing interest by faculty in entrepreneurial activities, and the creation of numerous new facilities and buildings associated with the AHC, the Indiana University School of Medicine (IUSM) in Indianapolis addressed the question of whether its faculty or even faculty groups could invest in any of these new entities, either as individuals or as groups. The dean of IUSM appointed a subcommittee of the school's standing Conflict of Interest Committee that included distinct groups of stakeholders and those without any fiduciary interests. As a result of meetings of this subcommittee, a new policy was set forth in a Points to Consider document to meet the emerging needs of the school to deal with such issues. The authors present the policy and the deliberations leading up to it as an example of how to address the issue of faculty ownership of medical facilities.

Monte Carlo simulation of the Leksell Gamma Knife®: II. Effects of heterogeneous versus homogeneous media for stereotactic radiosurgery

The absence of electronic equilibrium in the vicinity of bone-tissue or air-tissue heterogeneity in the head can misrepresent deposited dose with treatment planning algorithms that assume all treatment volume as homogeneous media. In this paper, Monte Carlo simulation (PENELOPE) and measurements with a specially designed heterogeneous phantom were applied to investigate the effect of air-tissue and bone-tissue heterogeneity on dose perturbation with the Leksell Gamma Knife. The dose fall-off near the air-tissue interface caused by secondary electron disequilibrium leads to overestimation of dose by the vendor supplied treatment planning software (GammaPlan) at up to 4 mm from an interface. The dose delivered to the target area away from an air-tissue interface may be underestimated by up to 7% by GammaPlan due to overestimation of attenuation of photon beams passing through air cavities. While the underdosing near the air-tissue interface cannot be eliminated with any plug pattern, the overdosage due to under-attenuation of the photon beams in air cavities can be eliminated by plugging the sources whose beams intersect the air cavity. Little perturbation was observed next to bone-tissue interfaces. Monte Carlo results were confirmed by measurements. This study shows that the employed Monte Carlo treatment planning is more accurate for precise dosimetry of stereotactic radiosurgery with the Leksell Gamma Knife for targets in the vicinity of air-filled cavities.

Contamination dose from photoneutron processes in bodily tissues during therapeutic radiation delivery

Dose to the total body from induced radiation resulting from primary exposure to radiotherapeutic beams is not detailed in routine treatment planning though this information is potentially important for better estimates of health risks including secondary cancers. This information can also allow better management of patient treatment logistics, suggesting better timing, sequencing, and conduct of treatment. Monte Carlo simulations capable of taking into account all interactions contributing to the dose to the total body, including neutron scattering and induced radioactivity, provide the most versatile and accurate tool for investigating these effects. MCNPX code version 2.2.6 with full IAEA library of photoneutron cross sections is particularly suited to trace not only photoneutrons but also protons and heavy ion particles that result from photoneutron interactions. Specifically, the MCNPX code is applied here to the problem of dose calculations in traditional (non-IMRT) photon beam therapy. Points of calculation are located in the head, where the primary irradiation has been directed, but also in the superior portion of the torso of the ORNL Mathematical Human Phantom. We calculated dose contributions from neutrons, protons, deutrons, tritons and He-3 that are produced at the time of photoneutron interactions in the body and that would not have been accounted for by conventional radiation oncology dosimetry.

Monte Carlo simulation of the Leksell Gamma Knife: I. Source modelling and calculations in homogeneous media

The Monte Carlo code PENELOPE has been used to simulate photon flux from the Leksell Gamma Knife, a precision method for treating intracranial lesions. Radiation from a single 6OCo assembly traversing the collimator system was simulated, and phase space distributions at the output surface of the helmet for photons and electrons were calculated. The characteristics describing the emitted final beam were used to build a two-stage Monte Carlo simulation of irradiation of a target. A dose field inside a standard spherical polystyrene phantom, usually used for Gamma Knife dosimetry, has been computed and compared with experimental results, with calculations performed by other authors with the use of the EGS4 Monte Carlo code, and data provided by the treatment planning system Gamma Plan. Good agreement was found between these data and results of simulations in homogeneous media. Owing to this established accuracy, PENELOPE is suitable for simulating problems relevant to stereotactic radiosurgery.

High-dose-rate brachytherapy for vaginal cancer: Learning from treatment complications

Abstract.

Tyree WC, Cardenes H, Randall M, Papiez L. High-dose-rate brachytherapy for vaginal cancer: learning from treatment complications.

Historically, early stage vaginal cancer has been treated with low-dose-rate (LDR) brachytherapy with or without external beam radiation therapy (EBRT). Complication rates have been low and treatment efficacious. Although high-dose-rate (HDR) brachytherapy has been used for cervical cancer in many countries for over a decade, only more recently has it been integrated into treatment plans for vaginal cancer. This paper describes three patients treated with HDR brachytherapy who experienced significant late effects. Given the very limited amount of literature regarding the use of HDR brachytherapy in vaginal cancer, this analysis potentially contributes to an understanding of treatment-related risk factors for complications among patients treated with this modality.

A focused review of hospital and departmental treatment records was done on three patients treated with HDR brachytherapy. Abstracted information included clinical data, treatment parameters (technique, doses, volume, combinations with other treatments) and outcomes (local control, survival, early and late effects). A review of the available literature was also undertaken.

All patients had significant complications. Although statistical correlations between treatment parameters and complications are impossible given the limited number of patients, this descriptive analysis suggests that vaginal length treated with HDR brachytherapy is a risk factor for early and late effects, that the distal vagina has a lower radiation tolerance than the upper vagina with HDR as in LDR, and that combining HDR with LDR as done in our experience carries a high risk of late toxicity.

Integration of HDR brachytherapy techniques into treatment plans for early stage vaginal cancers must be done cautiously. The etiology of the significant side effects seen here is likely to be multifactorial. For users of HDR brachytherapy in vaginal cancer, there is a need to further refine and standardize treatment concepts and treatment delivery. Ideally this will be based on continued careful observation and reporting of both favorable and unfavorable outcomes and experiences.

High-dose-rate brachytherapy for vaginal cancer: learning from treatment complications

Historically, early stage vaginal cancer has been treated with low-dose-rate (LDR) brachytherapy with or without external beam radiation therapy (EBRT). Complication rates have been low and treatment efficacious. Although high-dose-rate (HDR) brachytherapy has been used for cervical cancer in many countries for over a decade, only more recently has it been integrated into treatment plans for vaginal cancer. This paper describes three patients treated with HDR brachytherapy who experienced significant late effects. Given the very limited amount of literature regarding the use of HDR brachytherapy in vaginal cancer, this analysis potentially contributes to an understanding of treatment-related risk factors for complications among patients treated with this modality.A focused review of hospital and departmental treatment records was done on three patients treated with HDR brachytherapy. Abstracted information included clinical data, treatment parameters (technique, doses, volume, combinations with other treatments) and outcomes (local control, survival, early and late effects). A review of the available literature was also undertaken. All patients had significant complications. Although statistical correlations between treatment parameters and complications are impossible given the limited number of patients, this descriptive analysis suggests that vaginal length treated with HDR brachytherapy is a risk factor for early and late effects, that the distal vagina has a lower radiation tolerance than the upper vagina with HDR as in LDR, and that combining HDR with LDR as done in our experience carries a high risk of late toxicity. Integration of HDR brachytherapy techniques into treatment plans for early stage vaginal cancers must be done cautiously. The etiology of the significant side effects seen here is likely to be multifactorial. For users of HDR brachytherapy in vaginal cancer, there is a need to further refine and standardize treatment concepts and treatment delivery. Ideally this will be based on continued careful observation and reporting of both favorable and unfavorable outcomes and experiences.

Reliability of the Melbourne assessment of unilateral upper limb function

This study examines the reliability of the Melbourne Assessment of Unilateral Upper Limb Function: a quantitative test of quality of movement in children with neurological impairment. The assessment was administered to 20 children aged from 5 to 16 years (mean age 9 years 10 months, SD 2 years 10 months) who had various types and degrees of cerebral palsy (CP). The performances of the 20 children during assessment were videotaped for subsequent scoring by 15 occupational therapists. Scores were analyzed for internal consistency of test items, inter- and intrarater reliability of scorings of the same videotapes, and test-retest reliability using repeat videotaping. Results revealed very high internal consistency of test items (alpha=0.96), moderate to high agreement both within and between raters for all test items (intraclass correlations of at least 0.7) apart from item 16 (hand to mouth and down), and high interrater reliability (0.95) and intrarater reliability (0.97) for total test scores. Test-retest results revealed moderate to high intrarater reliability for item totals (mean of 0.83 and 0.79) for each rater and high reliability for test totals (0.98 and 0.97). These findings indicate that the Melbourne Assessment of Unilateral Upper Limb Function is a reliable tool for measuring the quality of unilateral upper-limb movement in children with CP.

2-microm Doppler lidar transmitter with high frequency stability and low chirp

A coherent Doppler lidar system was frequency stabilized in a master-slave configuration by a phase-modulation technique. The short-term frequency stability, ~0.2 MHz rms, was maintained in a vibrational environment on a ship during a field campaign in the tropical Pacific Ocean. The long-term frequency stability was <2.6 kHz/h. Thus, in many applications, shot-to-shot frequency correction can be disregarded, which will result in increased speed and simplicity of the data-acquisition system. A frequency chirp could not be detected. These properties permit Doppler wind measurements with high efficiency and duty cycles to be made, even on airborne and spaceborne platforms.

Comparison of outcomes by gender and for fee-for-service versus managed care: a study of nine community programs

During-treatment services and 7-month posttreatment entry outcome of cocaine- or alcohol-dependent men (n = 145) and women (n = 149) Target City patients receiving either standard fee-for-services (n = 183) or managed care treatment funding (n = 111) in nine community outpatient programs were compared. No differences were found in treatment services received by the various subgroups. Regression analyses compared the four described subgroups (Gender x Type of Funding) on their seven Addiction Severity Index composite scores at 7 months postadmission controlling for the respective baseline composite score and several background variables on which the groups differed. Surprisingly few outcome differences were revealed between men and women patients and patients receiving the two forms of treatment funding. The only difference noted was that patients treated via managed care showed more improvement in the drug area. The need for further evaluation of the effects of managed care is emphasized.

Risk of transmission of tuberculosis among inmates of an Australian prison

In a prison in Victoria, Australia, our objectives were contact tracing of inmates and staff at risk of exposure to an identified index case; and to determine risk factors for prevalent and incident infection. Inmates and staff who were potentially exposed to the index case were screened with a Mantoux skin test and a questionnaire. Inmate movements within the prison were compared to movements of the index case. Logistic regression was used to determine risk factors for infection. The index case had smear positive, cavitating pulmonary tuberculosis (TB), which was undiagnosed for 3 months. This was the period of potential exposure. The prevalence of positive skin test reactions in 190 inmates and staff at the prison was 10%. Significant predictors of a positive skin test were being an inmate (odds ratio (OR) 15.5), older age (OR 8.3) and being born overseas (OR 10.7). Bacille Calmette Guerin (BCG) vaccination, proximity to the index case in various prison sites, duration of incarceration, number of incarcerations and number of inmates per cell were not significant. There were three recent skin test conversions from negative to positive, representing a conversion rate of 3.5%. We did not find evidence of significant transmission of TB from a single index case. The prevalence of infection in this Australian prison was lower than published rates in other countries. Better prison conditions and different demographics of prison inmates in Australia may explain these differences.

FIGO stage IIIC endometrial carcinoma with metastases confined to pelvic lymph nodes: analysis of treatment outcomes, prognostic variables, and failure patterns following adjuvant radiation therapy

OBJECTIVES

This study was undertaken to evaluate the prognostic significance of isolated positive pelvic lymph nodes on survival and to analyze other prognostic variables, overall survival, and failure patterns in surgically staged endometrial carcinoma patients with positive pelvic lymph nodes and negative para-aortic lymph nodes following radiation therapy (RT).

METHODS

Between January 1, 1987, and December 31, 1997, 782 women underwent primary treatment for uterine cancer at Indiana University Medical Center. Through a review of the medical records, we identified 58 patients with pathologic stage IIIA, 27 patients with pathologic stage IIIB, and 77 patients with pathologic stage IIIC endometrial carcinoma. Patients with pathologically positive or unsampled para-aortic lymph nodes and patients who received preoperative radiation therapy were excluded, leaving a study group of 17 patients with nodal metastases confined to pelvic lymph nodes. Thirteen patients received adjuvant pelvic RT using AP-PA or four-field technique. A median dose of 5040 cGy was delivered. Four patients received whole abdominal irradiation (WAI) delivering a median dose of 3000 cGy. Two patients received vaginal cuff boosts of 1000 and 3560 cGy to 0.5 cm from the vaginal surface mucosa via Cs-137 brachytherapy. Two patients also received adjuvant chemotherapy (cis-platinum and doxorubicin) and/or hormonal therapy (megestrol acetate). Disease-free and overall survivals were estimated using the Kaplan-Meier method of statistical analysis and prognostic variables were analyzed using the log-rank test.

RESULTS

With a median follow-up of 51 months the actuarial 5-year disease-free survival was 81% and the actuarial 2-year and 5-year overall survival rates were 81 and 72%, respectively. Univariate analysis revealed that positive peritoneal cytology in conjunction with positive pelvic lymph nodes imparts a greater risk of recurrence and decreased overall survival. There were no pelvic and/or upper abdominal failures, but there were recurrences in the para-aortic lymph nodes (two patients) and distantly (two patients).

CONCLUSION

Surgery followed by postoperative pelvic RT is a viable treatment option for pathologically staged stage IIIC endometrial carcinoma with disease confined to the pelvic lymph nodes. Failures in the para-aortic region suggest a possible role for extended-field RT. Patients with positive peritoneal cytology in conjunction with nodal metastasis fared poorly with pelvic RT. Studies evaluating the efficacy of WAI are ongoing. Finally, substages within FIGO stage IIIC are recommended in an effort to better understand and define treatment strategies which might be appropriate for these patients.

CO(2) microdialysis in retrotrapezoid nucleus of the rat increases breathing in wakefulness but not in sleep

Central chemoreceptors are widespread within the brain stem. We suggest that their function at some sites may vary with the state of arousal. In this study, we tested the hypothesis that the function of chemoreceptors in the retrotrapezoid nucleus (RTN) varies with sleep and wakefulness. In unanesthetized rats, we produced focal acidification of the RTN by means of a microdialysis probe (tip containing the semipermeable membrane = 1-mm length, 240-microm diameter, and 45-nl volume). With the use of a dialysate equilibrated with 25% CO(2), the tissue pH change (measured in anesthetized animals) was 1) limited to within 550 microm of the probe and, 2) at the probe tip, was equivalent to that observed with end-tidal PCO(2) of 63 Torr. This focal acidification of the RTN increased ventilation significantly by 24% above baseline, on average, in 13 trials in seven rats only during wakefulness. The effect was entirely due to an increase in tidal volume. During sleep defined by behavioral criteria, ventilation was unaffected, on average, in 10 trials in seven rats. During sleep, the chemoreceptors in the RTN appear to be inactive, or, if active, the respiratory control system either is not responding or is responding with very low gain. Because ventilation is increased during sleep with all central chemoreceptor sites stimulated via systemic CO(2) application, other central chemoreceptor locations must have enhanced effectiveness.

Tuberculosis. The old and the new

BACKGROUND

The overall incidence of tuberculosis (TB) in the general Australian population is low and has been stable over the past 10 years. The incidence is, however, much higher in certain subgroups of the population and these include overseas-born people (especially from countries in Asia) and Aboriginal and Torres Strait Islander populations. Other groups regarded as at increased risk of TB are nursing home residents, the homeless, prison populations and immunosuppressed patients, especially those who are HIV positive.

OBJECTIVE

Patients regarded as high risk should be investigated promptly if they present with signs or symptoms suggestive of TB.

DISCUSSION

The best method of preventing the transmission of TB and preventing the emergence of drug resistant strains of the organism are by ensuring that sputum smear positive patients are isolated till non-infectious; that any patient with TB receives prompt and adequate treatment; that all patients with TB comply with a full course of treatment till cured: and that contact tracing is undertaken to detect newly infected patients so as to offer chemoprophylaxis and to detect previously unrecognised cases.

Assessment of psychosocial stressors and maladjustment among foreign students of the University of the Ryukyus

An extensive survey of problems encountered by foreign students of the University of the Ryukyus and the resulting levels of stress was carried out in order to determine the main stressors hindering academic progress and personal adjustment. Subjectively perceived stress levels after arrival in Japan were obtained from 134 subjects through a comprehensive questionnaire for reporting specific stressors. The 30-item General Health Questionnaire (GHQ) was included to assess mental health state. Differences in scores by area of origin were also determined for the total GHQ scores and its sub-scales. The GHQ results showed that regardless of length of time in Japan, more than 60% of the subjects scored within a range usually indicative of a mental health risk. Mean scores by area of origin showed a 50% reduction over time for non-Chinese Asians and North American/Europeans, but only a reduction of 1.1% or less for Chinese, Latin American, Middle/Near Eastern and African subjects. Limitations in achievement of academic goals were reported by the greatest number of students as causing moderate to excessive stress (57.5%); most frequently reported causes were language inadequacy (55.2%), reference materials unavailable (34.3%), unfamiliarity with Japanese study methods (32.1%), and inadequate guidance from teachers/advisors (26.9%). Various social, personal and daily life problems in the non-academic setting were also reported as causing high stress levels. Most of the stressors identified are not considered inevitable and point toward directions to pursue in preventive strategies in mitigating psychological distress and maladjustment of students.

Problem-service 'matching' in addiction treatment. A prospective study in 4 programs

BACKGROUND

Our initial attempts to "match" substance-abuse patients from an employee assistance program to an optimal setting or program failed. Scientifically, we found no differential predictors of better outcomes by setting or program. From a practical perspective, it was impossible to place patients in the intended programs. This led to a second study, designed to identify specific patient problems and match professional services to those problems within each of the 4 programs.

METHODS

Ninety-four new patients admitted to 4 substance-abuse treatment programs were randomly assigned to standard treatment and treated in the usual manner or were assigned to "matched" services, in which patients received at least 3 professional sessions directed at their important employment, family, or psychiatric problems.

RESULTS

Matched patients stayed in treatment longer, were more likely to complete treatment, and had better posttreatment outcomes than did the standard patients treated in the same programs.

CONCLUSIONS

For logistical, financial, and clinical reasons, it is improbable that patients will be matched to specific types of programs. However, within any program, it is possible and practical to match appropriate services to patients' specific treatment problems. This strategy was clinically and administratively practical, attractive to patients, and responsible for a 20% to 30% increase in the effectiveness of this substance-abuse treatment system.

"Intensive" outpatient substance abuse treatment: comparisons with "traditional" outpatient treatment

Do "intensive," freestanding outpatient substance abuse treatment programs actually provide more intensive services than "traditional" outpatient programs? Three hundred and thirty-eight patients in 6 "intensive" outpatient (IO) programs (three or more times weekly) were compared with 580 patients from 10 "traditional" outpatient (TO) programs (one or two times weekly) on severity of admission problems, treatment services received and six month outcomes.

RESULTS

1. IO subjects generally had the most severe medical, employment, legal and psychiatric problems at admission. 2. IO patients received more alcohol and drug focused services; but fewer medical and employment focused services than the TO patients. Both groups received very few psychosocial services. 3. There were not significant differences between the IO and TO program samples at follow-up. However, both groups showed significant reductions in substance use, improvements in personal health and social function.

Attitudes of medical students towards persons with mental disorders: a comparative study between Japan and Thailand

This study was conducted at three universities, two in Japan and one in Thailand, in order to elucidate the effects of medical education, especially with regard to contact experience on medical students' attitudes toward persons with mental disorders. Questionnaires, which included the Attitudes Towards Disabled Persons Scale (ATDP) and the Contact with Disabled Persons Scale (CDP), were distributed to 1st year students prior to the commencement of their medicine/psychiatry studies and distributed to 6th (or 5th) year students who had completed their psychiatric curriculum. The ATDP scores were lower for 6th year students at all universities, suggesting that post-education students had a more unfavorable attitude than pre-education students. Thai students indicated more unfavorable attitudes than did the Japanese students. Three factors were extracted from the ATDP scale and termed: negation of character, negation of ability and affirmation of normality. Four factors from the CDP scale were extracted and labeled intimate contact experience, ordinary contact experience, unpleasant contact experience and pleasant contact experience. Greater negative attitudes of post-education students than pre-education students were thought to attribute mainly to an increase in factor score of negation of ability and this result was correlated with an increase in factor score of ordinary contact experience in post-education students. Of the three ATDP factor scores, the higher score of Thai students for negation of character contributed to their overall unfavorable attitude scores. The cross-national similarities and differences of students' attitudes towards and contact experience with mentally disordered persons were discussed from the viewpoint of medical education.

Sexual violence in women's lives. Findings from the Women's Safety Project, a community-based survey

This article is a summary of the methods and quantitative prevalence findings from a community-based study of sexual violence in women's lives. The research was based on in-depth face-to-face interviews with 420 women who comprised a random sample of women living in the city of Toronto, Canada's largest urban center. The study generated findings on the prevalence and effects of various forms of sexual abuse and violence in women's lives, including an exploration of the links between these forms of violence over the course of women's lifetimes. Sexual abuse in childhood (including incest), sexual assault, sexual harassment, and physical assault in intimate relationships were documented, as was revictimization and the increased vulnerability for sexual assault and violence experienced by many women sexually abused in childhood. Among the findings were that 1 in 4 women in the sample was physically assaulted by a male intimate, 1 in 2 women reported being raped or experiencing an attempted rape, and nearly half of the respondents reported experiencing some kind of sexual abuse before reaching 16 years of age.

Reliability and validity of the Addiction Severity Index with a homeless sample

The Addiction Severity Index (ASI) is an instrument widely used to assess the treatment problems of substance users. Its psychometric properties have been tested and found satisfactory for many types of substance abusers entering treatment. However, there are many other subgroups of substance users not in formal treatment, such as homeless substance users. While the ASI has been used with this subgroup, its psychometric properties remain questionable. This study examined the reliability and validity of the ASI in a sample of 98 homeless substance users awaiting temporary housing placement. Test-retest reliability found the ASI to have moderate to high reliability coefficients in each of the seven domains assessed. Both composite score and severity rating measures were found to be quite independent with low intercorrelations. Three of the seven ASI composite scores were tested for and found to have moderate concurrent validity: alcohol (r = .31 to .36), drug (r = .46), and psychiatric (r = .53 to .66). Composite score interitem correlations were .70 or greater in each of the domains except for employment (.50) and family (.52). These data suggest that, although there are some limitations in using the ASI with homeless substance users, it demonstrated acceptable reliability and validity.

Infection in immunocompromised patients with malignant blood disorders in a district general hospital

The pattern and management of infection in immunocompromised patients over a period of 3 years in a district general hospital has been studied. A total of 222 positive cultures was obtained in 607 episodes of suspected infection all involving patients with malignant blood disorders. Febrile episodes requiring intravenous antibiotics occurred in 248 instances involving 107 patients. The pattern of organisms cultured and the responses to various antibiotic regimes are reported. The costs of antibiotic therapy are considered in the light of the overall response. Of the patients studied, 54 died, infection having a likely causative or contributory part in 21 of them (less than 10% of infective episodes). We conclude that the infective complications of these disorders, particularly in older patients, can be efficiently managed in a district general hospital when full supportive facilities are available.

Comparative voice results after laser resection or irradiation of T1 vocal cord carcinoma

OBJECTIVE

To compare voice results following laser resection or radiation therapy for T1a glottic carcinomas.

DESIGN

Objective recordings of acoustical data that were analyzed and calculated by an acoustic analyzer and subjective scores by patients, speech therapists, surgeons, and radiation therapists are compared.

SETTING

Academic medical center speech laboratory at an institution where patients had been treated. Archival files were searched and patients were solicited by letter to participate in this analysis.

PATIENTS

Men treated at least 6 months previously and who were without active laryngeal disease. Criteria were unilateral vocal cord carcinomatous involvement with no subglottic, anterior commissure, or arytenoid extension and tumor invasion clinically judged to be less than half of the cordal depth.

INTERVENTIONS

Thirteen patients had received approximately 63 Gy in 28 fractions, five fractions a week, with laterally opposed fields using a linear accelerator. Eleven patients had had resection of less than half of the cordal depth by using a carbon dioxide laser with a 300-microns spot size working at a 400-mm distance; 13- to 15-W power intensity with a one tenth of a second burn in a noncontinuous mode.

RESULTS

No statistically significant differences between the two study groups were found. Patients and physicians subjectively rated (1 indicates normal; 5, aphonic) the quality of voices of patients in the irradiation group (1.5 and 2.0) as slightly better than the quality of voices of patients in the laser group (2.0 and 2.4). Speech pathologists rated the voices of patients in the laser and irradiation group as indistinguishable and mildly abnormal (2.75 and 2.73).

CONCLUSION

Voice quality in highly selected patients with vocal cord carcinoma treated by laser resection can be as good as that in patients whose cancer was similarly staged after radiation therapy.

Can you trust patient self-reports of drug use during treatment?

This study compared two frequently used measures of drug use, urine testing and self-report in a sample of subjects currently enrolled in methadone treatment for a minimum of six months. A comparison between the percentage of positive opiate urine screens and subjects' self-reported opiate use indicated that more patients self-reported opiate use (80%) than had been detected by urinalysis (57%). Similar results were found for cocaine use. We present arguments that a more inclusive method of measuring drug use during treatment should include the combination of both urinalysis and self-reports.