Pericardial metastasis in carcinoma of the uterine cervix

Cardiac metastasis from gynecological malignancies is rare. Only six cases of carcinoma of the uterine cervix have been reported where the diagnosis of malignant pericardial effusion was made antemortem. The treatment of neoplastic pericardial effusion is controversial; both surgical and nonsurgical treatments are advocated. We present a patient with pericardial effusion secondary to carcinoma of the cervix and recommend subxiphoid pericardial fenestration for reliable long-term control of malignant effusion.

Treatment results for 149 medulloblastoma patients from one institution

PURPOSE

Retrospective analysis of patients with medulloblastoma to determine the effectiveness of previous treatments for medulloblastoma and plan for future management strategies.

METHODS AND MATERIALS

During the period March 1976 to December 1991, 172 patients with cerebellar medulloblastoma were referred to King Faisal Specialist Hospital and Research Center. One hundred and forty-nine patients were treated with curative intent. There were six postoperative deaths, and 10 patients planned for radiotherapy treatment failed to complete the prescribed course. One hundred and thirty-three patients completed a course of radiotherapy after surgery. Adjuvant chemotherapy was not used routinely (six patients only). Tumors were staged retrospectively according to the Chang staging system. There were no T1 patients, 32 patients had T2 tumors, 76 had T3 tumors, and 29 had T4 tumors. The T stage could not be allocated in 12 patients. Ninety-nine patients required a shunting procedure either pre- or postoperatively. Forty-six patients had complete resection of tumor, 91 had incomplete resection, and 6 patients had biopsy only. The extent of resection could not he determined in six patients. The median radiation dose for the whole brain was 34 Gy, spine 32.5 Gy, and posterior fossa 52.8 Gy. Fraction sizes ranged from 1.7-1.8 Gy for craniospinal fields and 2 Gy for the posterior fossa boost. Seventy percent completed the prescribed course within 7 weeks.

RESULTS

Actuarial survival for the whole group of 149 patients was 53% at 5 years and 38% at 10 years. On univariate analysis, patients with T2 tumors did significantly better as compared to patients with T3 and T4 tumors. Survival of patients who had clinical and radiological complete resection of tumor at surgery was significantly better than patients with incomplete tumor removal. The presence of a ventriculoperitoneal (VP) shunt had a significant negative impact on survival. Treatment failure by site was analyzed with respect to the radiation dose. Doses greater than 50 Gy for the posterior fossa, and greater than 30 Gy for craniospinal axis, resulted in significantly better survival. On multivariate analysis, the only significant prognostic factor was the presence of a VP shunt in patients with T2 tumors.

CONCLUSION

T stage, VP shunt, radiation doses and extent of surgery were important prognostic factors. In this study, radiation doses of more than 50 Gy to the posterior fossa and 30 Gy to the craniospinal axis resulted in improved survival.

Insulin-like growth factor I is a major fibroblast mitogen produced by primary cultures of human airway epithelial cells

1. The ability of airway epithelial cells to produce insulin-like growth factor I may be important in the pathogenesis of subepithelial fibrosis observed in the airways of patients with asthma. We determined whether human airway epithelial cells are capable of producing polypeptide mediators that could induce fibroblast proliferative activity, in particular insulin-like growth factor I. 2. We examined 12 primary cultures of human airway epithelial cells grown to confluence on collagen gel-coated dishes. Using a colorimetric assay based on the uptake and subsequent release of Methylene Blue, increased proliferation of human fetal lung fibroblasts was detected in conditioned media from airway epithelial cells. The median stimulation of fibroblast proliferation was 49.9% (range 25.6-113.3%) above control values (observed at 1:2 dilution of media). 3. A neutralizing antiserum to insulin-like growth factor I partly inhibited fibroblast proliferation induced by epithelial cell conditioned media by 52.2% (49.9-109%; n = 5). 4. Radioimmunoassay for insulin-like growth factor I in conditioned media demonstrated a median concentration of 54.1 ng/ml (32.4-96.8 ng/ml). 5. Insulin-like growth factor I mRNA was detected in epithelial cell monolayers by Northern blot analysis using an insulin-like growth factor I cDNA probe. 6. The insulin-like growth factor I gene is expressed in cultured human airway epithelial cells, which also secrete insulin-like growth factor I protein. Insulin-like growth factor I also accounts for the major mitogenic activity for fibroblasts of cultured human epithelial cell conditioned media. Insulin-like growth factor I may function in a paracrine manner to modulate fibroblast behaviour and may be involved in airway processes, such as those occurring in asthma.

The mitogenic effects of the B beta chain of fibrinogen are mediated through cell surface calreticulin

We have previously shown that soluble partially degraded fibrin(ogen) remains in solution after fibrin clot formation and is a potent fibroblast mitogen (Gray, A.J., Bishop, J.E., Reeves J.T., Mecham, R.P., and Laurent, G.J. (1995) Am. J. Cell Mol. Biol. 12, 684-690). Mitogenic sites within the fibrin(ogen) molecule are located on the A alpha and B beta chains of the protein (Gray, A.J., Bishop, J. E., Reeves, J.T., and Laurent, G.J. (1993) J. Cell Sci. 104, 409-413). However, receptor pathways through which mitogenic effects are mediated are unknown. The present study sought to determine the nature of fibrin(ogen) receptors expressed on human fibroblasts which interact with the fibrinogen B beta chain. Receptor complexes were isolated from 125I-surface-labeled fibroblasts and purified on a fibrinogen B beta chain affinity column. Subsequent high performance liquid chromatography and SDS-polyacrylamide gel electrophoresis analysis indicated fibrinogen B beta chain bound specifically to a 60-kDa surface protein. Sequence analysis of the amino terminus of this protein indicated 100% homology to human calreticulin. Immunoprecipitation experiments employing a polyclonal anti-calreticulin antibody provided further evidence that the 60-kDa protein isolated in this study was calreticulin. Further, polyclonal antibodies to human calreticulin significantly inhibited the mitogenic activity of fibrinogen B beta chain on human fibroblasts. The present study has shown that cell surface calreticulin binds to the B beta chain of fibrinogen mediating its mitogenic activity.

Role of thrombin in pulmonary fibrosis

Pulmonary fibrosis commonly develops in systemic sclerosis. We assessed the role of thrombin in promoting fibroblast proliferation in the lungs in this disorder. Bronchoalveolar lavage fluid (BALF) thrombin concentrations were higher in ten patients with systemic sclerosis than in 12 healthy controls (14.6 vs 3.6 nmol/L, p < 0.02), but values in patients with cryptogenic fibrosing alveolitis (n = 10) or sarcoidosis (n = 10) were not increased. BALF from all patients induced fibroblast proliferation. This proliferation was attenuated by thrombin inhibitors for BALF from systemic sclerosis patients only. We suggest thrombin contributes to lung fibroblast proliferation in this disorder.

Management of retained ear-rings using an ear block

A local anaesthetic block of branches of the greater auricular and auriculotemporal nerves was used to facilitate the extraction of retained butterfly backs and ear-ring studs. A total of 28 ear blocks were performed on 26 patients. Two patients required bilateral ear blocks, and 17 earlobes were infected. Complete analgesia was obtained in 25 cases, and two patients complained of tolerable discomfort during removal of the ear-ring. Assessment of analgesia was not possible in one 5-year-old child. We recommend this quick and simple technique for removal of retained ear-rings, particularly when there is associated soft tissue infection, in which case infiltration of local anaesthetic into the earlobe is contraindicated.

Doctors' legal position in treating temporarily incompetent patients

Doctors in accident and emergency departments are sometimes presented with patients with potentially life threatening conditions who refuse to consent to treatment. The doctors then face a dilemma: to withhold necessary treatment or to act against a patient's express wishes. Two such cases are presented, and we asked a lawyer, two medical ethicists, a psychiatrist, and an accident and emergency physician to comment on the implications.

Partially degraded fibrin(ogen) stimulates fibroblast proliferation in vitro

The conversion by thrombin of soluble plasma fibrinogen to an insoluble fibrin matrix is central to hemostasis and subsequent wound healing. Fibroblasts adhere to and rapidly grow into fibrin clots, resulting in collagen deposition and, ultimately, scar formation. Although a number of soluble mediators have been implicated in this process, a role for fibrin(ogen) itself has not been described. The present study further investigated the nature of mitogenic activity remaining in solution after in vitro fibrin clot formation. Liquid expressed from a fibrin clot (clot supernatant) elicited a mitogenic response of up to 83 +/- 4.7% above media control. Upon addition of a polyclonal fibrinogen antibody, this activity was reduced by 50%. The remaining activity was attributed to the presence of thrombin and was neutralized by the addition of a specific thrombin inhibitor. Fibrinogen cleavage products were separated by molecular sieve chromatography and the mitogenic potential of each fraction assessed. A peak of activity was observed in fractions containing proteins with apparent molecular weights of 200 to 300 kD. Enhanced chemiluminescence Western blotting of these fractions established the presence of several fibrin(ogen)-derived protein bands. It is therefore proposed that thrombin cleavage of fibrinogen, in addition to producing fibrin, generates high-molecular-weight soluble cleavage products that may play an important role during normal wound healing and in the pathogenesis of disease states associated with vascular leakage and fibrosis.

Intracapsular fractures of the femoral neck in young patients

The details of the aetiology, treatment and outcome of acute intracapsular fractures for 58 fractures in 57 patients aged less than 60 years, were prospectively studied. The majority of the injuries were sustained by low energy trauma. Eighty-four per cent united uneventfully. There was a non-union rate of 7 per cent, and avascular necrosis rate of 10 per cent. Better results were obtained from closed than open reduction. The results do not support the commonly held view that this injury carries a poor prognosis in young patients.

A 5-10 year follow-up of the Sheehan total knee endoprosthesis in Tayside

The Sheehan total knee endoprosthesis has been widely used since 1971. It takes the form of a semi-constrained hinge with intramedullary stems cemented into the femur and tibia for fixation. In Tayside the prosthesis has been in use since 1980. The clinical impression was that the prosthesis was not performing well and formal assessment of surviving prostheses was therefore carried out using the Hospital for Special Surgery (HSS) scoring system. Thirty-seven patients were available for follow-up, 15.6% of whom had good results while 40% had poor results according to this assessment. At review, 31% of patients had undergone revision surgery or were awaiting such surgery. This compares poorly with reported results of surface joint replacements. In the light of these results the authors feel that the Sheehan knee replacement is now obsolete.

Characterization of fibroblast mitogens and chemoattractants produced by endothelial cells exposed to hypoxia

During pulmonary hypertension there is remodeling of the pulmonary vasculature, with enhanced fibroblast proliferation and connective tissue production. The stimulus for this process is not understood, but one explanation is that endothelial cells secrete moieties that expand local cell populations by acting as chemoattractants and mitogens. Here, we investigated the effect of hypoxia (35 mm Hg) on the production of chemoattractants and mitogens by human umbilical vein endothelial cells. Endothelial cells were subjected to hypoxia for up to 24 h and the resultant conditioned media tested for chemotactic and mitogenic activity. Chemotaxis of pulmonary artery fibroblasts were measured using a 48-well Boyden chamber and replication assessed by a spectrophotometric method, based upon the uptake and subsequent elution of methylene blue by fibroblasts. Within 6 h of culture, media derived from both hypoxic and normoxic endothelial cells stimulated fibroblast chemotaxis and replication. This activity increased with time, and by 24 h there was a significantly greater response toward media obtained from cells exposed to hypoxia compared with normoxic controls (P < 0.01). The addition of antibodies to endothelin-1 (Et-1) or platelet-derived growth factor (PDGF) reduced the chemotactic activity in hypoxic conditioned media by almost 50% (45 +/- 6 to 24 +/- 5 cells/h.p.f. and 45 +/- 6 to 26 +/- 4.5 cells/h.p.f. for anti-Et-1 and anti-PDGF, respectively; P < 0.001). Fibroblast proliferation in response to hypoxic conditioned media was also reduced in the presence of antibodies to PDGF (55 +/- 11% to 14 +/- 12% above media control; P < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Anterior cruciate ligament reconstruction with the Leeds-Keio prosthesis plus extra-articular tenodesis. Results after six years

We describe 129 patients with disabling instability of the knee due to deficiency of the anterior cruciate ligament. They were treated by replacement of the ligament with a Leeds-Keio prosthesis supplemented by an extra-articular MacIntosh lateral substitution reconstruction. After an average period of 71 months a satisfactory outcome was found in only 60% of knees. Nine had required revision because of recurrent instability and the pivot-shift sign had become positive in 40% of patients. In our opinion the long-term results are unsatisfactory when compared with those obtained using a graft from the medial third of the patellar tendon supplemented with a MacIntosh extra-articular tenodesis.

Anterior cruciate ligament reconstruction with the Leeds-Keio prosthesis plus extra-articular tenodesis. Results after six years

We describe 129 patients with disabling instability of the knee due to deficiency of the anterior cruciate ligament. They were treated by replacement of the ligament with a Leeds-Keio prosthesis supplemented by an extra-articular MacIntosh lateral substitution reconstruction. After an average period of 71 months a satisfactory outcome was found in only 60% of knees. Nine had required revision because of recurrent instability and the pivot-shift sign had become positive in 40% of patients. In our opinion the long-term results are unsatisfactory when compared with those obtained using a graft from the medial third of the patellar tendon supplemented with a MacIntosh extra-articular tenodesis.

Audit of thrombolysis initiated in an accident and emergency department

Early thrombolytic therapy after acute myocardial infarction is important in reducing mortality. To evaluate a system for reducing in-hospital delays to thrombolysis pain to needle and door to needle times to thrombolysis were audited in a major accident and emergency (A and E) department of a district general hospital and its coronary care unit (CCU), situated about 5 km away. Baseline performance over six months was assessed retrospectively from notes of 43 consecutive patients (group 1) transferred to the CCU before receiving thrombolysis. Subsequently, selected patients (23) were allowed to receive thrombolysis in the A and E department before transfer to the CCU. The agent was administered by medical staff in the department after receiving oral confirmation of myocardial infarction from the admitting medical officer in the CCU on receipt of fax transmission of the electrocardiogram. A second prospective audit during six months from the start of the new procedure established time intervals in 23 patients eligible to receive thrombolysis in the A and E department (group 2b) and 30 ineligible patients who received thrombolysis in the CCU (group 2a). The groups did not differ significantly in case mix, pre-hospital delay, or transfer time to the CCU. In group 2b door to needle time and pain to needle time were reduced significantly (geometric mean 38 min v 121 min (group 2a) and 128 min (group 1); 141 min v 237 min (group 2a) and 242 min (group 1) respectively, both p < 0.0001). The incidence of adverse effects was not significantly different. Nine deaths occurred (six in group 1, three in group 2b), an in-hospital mortality of 9.9%. Thrombolysis can be safely instituted in the A and E department in selected patients, significantly reducing delay to treatment.

Thrombin stimulates fibroblast chemotaxis and replication

The serine protease alpha-thrombin, a product of the circulating zymogen prothrombin, plays multiple roles in homeostasis and coagulation. During blood clotting, it is present within fibrin matrices and is likely to be presented to local cell populations. It is known to be a fibroblast mitogen, but its effects on fibroblast recruitment have not been assessed. Here we compared the effect of human alpha-thrombin on chemotaxis and proliferation of human and rat skin fibroblasts and assessed the mechanism of these actions. Fibroblast chemotaxis was assayed using a 48-well Boyden chamber and replication assessed by a spectrophotometric method, based upon the uptake and subsequent elution of methylene blue by fibroblasts. Two fibroblast cell lines were used; fetal rat skin (FR) and newborn human foreskin (HS68). Human alpha-thrombin stimulated FR fibroblast chemotaxis over a wide range of doses (10(-12) M to 10(-7) M). Maximal migration was seen at 10(-10) M; 39 +/- 2.5 cells/high power field (h.p.f.) compared with 19 +/- 3 cells/h.p.f. for media control. In the same assay platelet-derived growth factor, a well characterized fibroblast chemoattractant, caused a maximal stimulation of 44 +/- 5 cells/h.p.f. at a concentration of 3 x 10(-9) M. A similar stimulation was observed with HS68 fibroblasts, although for this cell line maximal chemotaxis (190 +/- 12.5% of control) was seen at 10(-8) M thrombin. Fibroblast replication was optimal at 1.25 x 10(-9) M thrombin (134 +/- 4 and 127 +/- 5% of control for FR and HS68, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

A alpha and B beta chains of fibrinogen stimulate proliferation of human fibroblasts

During blood coagulation and wound healing, fibrinogen polymerises to form a fibrin matrix, providing a substratum over which connective tissue cells migrate and proliferate. Although a number of growth factors have been implicated in this process, a possible role for the fibrin(ogen) molecules themselves has not been considered. In this study we have investigated the ability of the constituent chains of fibrin(ogen) to induce fibroblast replication. Fibrinogen chains (A alpha 1, A alpha 2, B beta and gamma) were separated by cation exchange chromatography and their mitogenic activity was assessed before and after treatment with thrombin. The A alpha 1, A alpha 2 and B beta chains where all found to stimulate fibroblast replication (23 +/- 2.9%, 29.2 +/- 5.3% and 31.4 +/- 5% stimulation above control, respectively) and on the addition of thrombin this activity was enhanced. No activity was observed in the gamma chain before or after treatment with thrombin. These results indicate that growth promoting activity is inherent in fibrin(ogen) structure, suggesting a novel mechanism for fibroblast proliferation during wound healing.

Can ambulance personnel intubate?

To assess the performance of intubation skills by advanced trained ambulance personnel, a prospective study was carried out of the intubation of cardiac arrest victims by ambulance personnel in the field. Twenty-eight ambulance personnel attempted the intubation of 87 patients over 2 years. Eighty-five patients were initially successfully intubated, one endotracheal tube became displaced and cuff leakage occurred on three occasions. This was treated appropriately in each instance. Ambulance personnel can perform the skills of intubation successfully in out-of-hospital cardiac arrest victims.

Endothelin-1 and endothelin-3 induce chemotaxis and replication of pulmonary artery fibroblasts

The remodeling of pulmonary vessels that occurs in association with pulmonary hypertension involves, in part, thickening of the adventitia. The stimulus for this process is not understood. One explanation is that endothelial cells secrete a growth factor that expands the local population of fibroblasts by acting as a chemoattractant and mitogen. Endothelins are a family of potent newly discovered vasoactive peptides. One of these compounds, endothelin-1 (ET-1), is secreted by endothelial cells and is known to constrict pulmonary vessels. Another, endothelin-3 (ET-3), is not secreted by endothelial cells and is less potent as a pulmonary vasoconstrictor. We hypothesized that the endothelins may have the capacity both to constrict these vessels and to initiate fibroblast chemotaxis and replication. Here we investigated the effects of both ET-1 and ET-3 on the chemotaxis and replication of fibroblasts derived from pulmonary vessels. Cells were isolated from rat pulmonary arteries, cultured in medium and 10% newborn calf serum, and used between passages 2 and 5. Chemotaxis was assessed using a modified Boyden chamber with a polycarbonate filter (pore size, 8 microns) separating cells in the upper chambers from endothelin in the lower chambers. Replication was assessed both by direct cell counts and by a colorimetric assay based on uptake and subsequent release of methylene blue. Both ET-1 and ET-3 induced chemotaxis of pulmonary artery fibroblasts and did so in a dose-dependent fashion. The maxima for both peptides occurred at a concentration of about 10(-7) M, when chemotaxis was greatest for ET-1 (22 +/- 1.4 versus 14 +/- 1.8 cells/grid [mean +/- SEM], (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Waiting times and patient satisfaction in the accident and emergency department

A survey of the waiting times and patients' opinions of these times was undertaken in a busy district general hospital A&E department. The various components of the overall waiting time are analysed and specific points of the patients' attendance, where waiting times were prolonged, are identified. Standards are derived which is hoped may result in 75% of patients being satisfied with the duration of their wait. The current levels of achievement are compared with these standards. Suggested and actual improvements to the department to improve our performance are described.

Treatment and planning decisions in non-small cell carcinoma of the lung: an Australasian patterns of practice study

Fourteen practising radiation oncologists were surveyed to assess their treatment and planning habits utilizing six sample cases of non-small cell carcinoma of the lung. Respondents were first given a general questionnaire, designed to evaluate their theoretical treatment and planning recommendations based on various tumour and patient related variables. Respondents then undertook a practical planning exercise utilizing planning CT and simulator radiographs for each of the six sample cases. Each case was accompanied by a brief history and report outlining specific tumour stage and non-stage related variables. The practical planning exercise was repeated on the second day of the survey utilizing different non-stage related variables but identical radiology and stage-related information. This design enabled firstly, a comparison of clinicians' intended policy and planning methods with actual policy and planning decisions, and secondly, an assessment of intra-clinician variability in decision making and planning practice. Good agreement was evident among clinicians with respect to general, non-case specific treatment policies; however, very significant variation occurred at an inter- and intra-clinician level and involved the entire treatment and planning process for individual cases. Despite identical treatment intent across identical radiological case pairings, clinicians chose widely differing margins and target volumes in their planning exercise. Treatment intent appeared to be influenced more by non-stage related variables rather than stage related information and radiological appearances per se. We have shown that experienced radiation oncologists do not adhere to stated case selection criteria and show inconsistencies in their treatment planning for non-small cell carcinoma of the lung.

Eosinophils adhere to and stimulate replication of lung fibroblasts 'in vitro'

Eosinophils have been implicated in several disorders associated with the development of fibrosis. This led us to investigate the interactions between eosinophils and fibroblasts in vitro. Adhesion between purified guinea pig peritoneal eosinophils and monolayers of human fetal lung fibroblasts was assessed using the rose bengal dye staining assay. Fibroblast replication was assessed using a colorimetric assay based upon the uptake and subsequent release of methylene blue. Addition of phorbol myristate acetate induced a rapid, time-dependent increase in eosinophil adhesion (127% and 328% over basal adhesion after 10 and 30 min, respectively). Phorbol myristate acetate-induced adhesion was inhibited by the peptides RGDS and GRGDS (48% and 42%, respectively using 1 mM peptide) and by nordihydroguaiaretic acid, an inhibitor of the lipoxygenase pathway of arachidonic acid metabolism (46% inhibition at 15 microM). In addition, 24 h culture of fibroblast monolayers with interleukin 1 alpha (IL-1 alpha) or tumour necrosis factor alpha (TNF alpha) resulted in enhanced adhesion (10 U/ml IL-1 alpha stimulated adhesion by 55% of control, 500 U/ml TNF alpha by 75% of control). Conditioned media from cultured eosinophils stimulated fibroblast replication in a time-dependent fashion with maximal stimulation at 3 h. In contrast, media from guinea pig peritoneal macrophages in culture did not show such an effect. This study indicates that eosinophils are capable of both adhering to and releasing mitogens for fibroblasts in vitro. These observations suggest that eosinophils have the capacity to play a role in the development of fibrosis in disorders where they have been shown to be present.

"Generic" packaging--a possible solution to the marketing of tobacco to young people

Creating a brand image is a key part of marketing tobacco products. It makes subtle promotion of a product possible in spite of national and State barriers (such as advertising bans) through print advertising and televised coverage of international sponsored sporting events. This article argues for the introduction of mandatory generic packaging of all tobacco products as an essential component of a complete ban on tobacco advertising and promotion. The rationale for such a move is that tobacco should be treated as the toxic, addictive and ultimately lethal substance that it is, and responsible governments should not allow cleverly designed and enticing packaging to promote a product if they have decided to end promotion of that product.