[129 liver surgeries--five years of experience in a surgery department]

Major hepatic resections have been associated with significant morbidity and mortality. In the past decade or so this has changed and such procedures are now done in increasing numbers. In the past 5 years we operated on 129 patients with benign or malignant hepatic lesions (75 females, 54 males; age-range 14-84). The reason for surgery was malignancy in 94 (72.9%) and benign lesions in 35 (27.1%). The most common indication for surgery was liver metastases secondary to colorectal cancer in 45% of all patients or 61.7% of those operated for malignancy. Primary liver cancer was the cause for liver resection in 13.2% of all patients or 18.1% for those with malignancy. Of the 35 patients with benign lesions the leading causes for surgery included: giant cavernous hemangioma, simple liver cysts, echinococcus cysts and focal nodular hyperplasia (11%, 22.8%, 20% and 14.3%, respectively). 76 patients underwent anatomical resection and 63 had either a nonanatomical resection or a different operation. Among the former the most common procedure was right hepatectomy (36) and among the later a nonanatomical resection equal to 1-3 Couinod segments (44). Operating time ranged from 55 min. to 8:41 hours with a mean of 3:31 +/- 1:37. Mean hospital stay was 8.7 +/- 5.8 days and 86.8% received between 0-2 units of blood. Overall mortality was 6.2% and 31.2% of the fatalities had cirrhosis. Overall mortality in noncirrhotic patients was 2.6%. The complication rate was 16.3% and only 7 patients (4.4%) were hospitalized in the intensive care unit. This indicates that major liver resections can be done safely, with morbidity and mortality similar to that of other major abdominal operations.

Susceptibility of serum lipids to copper-induced peroxidation correlates with the level of high density lipoprotein cholesterol

As a first step in evaluating the significance of our recently developed method of monitoring the kinetics of copper-induced oxidation in unfractionated serum, we recorded the kinetics of lipid oxidation in the sera of 62 hyperlipidemic patients and analyzed the correlation between oxidation and lipid composition of the sera [high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol, and triglycerides]. We used six factors to characterize the kinetics of oxidation, namely, the maximal absorbance of oxidation products (ODmax), the maximal rate of their production (Vmax), and the time at which the rate was maximal (t(max)) at two wavelengths (245 nm, where 7-ketocholesterol and conjugated dienic hydroperoxides absorb intensely, and 268 nm, where the absorbance is mostly due to dienals). The major conclusions of our analyses are that: (i) Both ODmax and Vmax correlate positively with the sum of concentrations of the major oxidizable lipids, cholesterol, and cholesteryl esters. (ii). The value of t(max), which is a measure of the lag preceding oxidation and therefore reflects the resistance of the serum lipids to copper-induced oxidation, exhibits a negative correlation with HDL cholesterol. Although this finding accords with the observation of shorter lags for HDL than for LDL, it is apparently inconsistent with the role of HDL as an antirisk factor in coronary heart diseases.

Vertical shift in cerebral autoregulation curve: a graded head-up tilt study

According to the classical theory of cerebral autoregulation, cerebral blood flow (CBF) will be maintained at a near-constant level for cerebral perfusion pressure (CPP) within the range of 60-150 mmHg. In recent years, however, studies with contradicting results have demonstrated a change in CBF when the level of CPP had not changed significantly. It is suggested that a shift in the autoregulation curve may have taken place along the horizontal axis or along the vertical axis. This paper describes previously unreported findings of a graded head-up tilt (HUT) study which was designed as a preliminary experiment to test the protocol for possible use on astronauts upon returning from space-flight. Data from this study tend to support the findings of previous studies regarding possible shifts in the cerebral autoregulation curve. Five female and four male healthy volunteers were exposed to HUT for 5 minutes at each angle of 30 degrees, 60 degrees, and 90 degrees. Throughout the test, cerebrovascular and cardiovascular responses were evaluated by use of continuous acquisition of mean flow velocity (MFV) from the right middle cerebral artery with transcranial Doppler sonograhy, mean arterial blood pressure (MABP, Finapres) and heart rate (HR, ECG). Based on the last 60 seconds of data at each tilt angle and baseline, the percentage changes in MFV from baseline were found to be similar to those in MABP at the level of the brain (MABPbrain), and both were significant (p<0.05) at the 60 degrees (-9.1 +/- 7% for MABP brain, -9.8 +/- 5% for MFV) and 90 degrees (-13 degrees +/- 8%, -12.0 +/- 6%) positions. Heart rate (HR) increased significantly (p<0.05) from the baseline at 30 degrees (6.3 +/- 5%) through 90 degrees (23.3 +/- 8%). The trend toward decreasing MFV in normal subjects, even while MABP brain remained within the normal limits of cerebral autoregulation, may suggest a downward shift of the cerebral blood flow plateau in the classic cerebral autoregulation curve.

[Intestinal transplantation--world experience and future perspective]

Intestinal transplantation, which until recently has been considered an experimental procedure, is now undergoing considerable change and becoming a standard treatment for patient with intestinal failure. The major improvement in results is due to the introduction of new immunosuppressive agents that have led to significant reduction in acute rejection. Nevertheless, reduction in severe infectious complications, which are the main cause of mortality after transplant, as well as improved techniques for early diagnosis of rejection are needed before intestinal transplantation can be widely used. We describe our experience in post-transplant follow-up of a woman, aged 32-years, who had undergone intestinal transplantation for short bowel syndrome after extensive bowel resection.

Recurrent Clostridium difficile disease: epidemiology and clinical characteristics

OBJECTIVE

To describe the epidemiology, diagnosis, risk factors, patient impact, and treatment strategies for recurrent Clostridium difficile-associated disease (CDAD).

DESIGN

Data were collected as part of a blinded, placebo-controlled clinical trial testing a new combination treatment for recurrent CDAD. Retrospective data regarding prior CDAD episodes were collected from interviews and medical-chart review. Prospective data on the current CDAD episode, risk factors, and recurrence rates were collected during a 2-month follow-up.

SETTINGS

National referral study.

PARTICIPANTS

Patients with recurrent CDAD.

INTERVENTIONS

Treatment with a 10-day course of low-dose (500 mg/d) or high-dose (2 g/d) vancomycin or metronidazole (1 g/d).

RESULTS

Recurrent CDAD was found to have a lengthy course involving multiple episodes of diarrhea, abdominal cramping, nausea, and fever. CDAD may recur over several years despite frequent treatment with antibiotics. Recurrence rates were similar regardless of the choice or dose of antibiotic. Recurrent CDAD is not a trivial disease: patients may have multiple episodes (as many as 14), may require hospitalization, and the mean lifetime cost of direct medical care was $10,970 per patient. Fortunately, the disease does not become progressively more severe as the number of episodes increase. Two risk factors predictive for recurrent CDAD were found: increasing age and a decreased quality-of-life score at enrollment.

CONCLUSIONS

Recurrent CDAD is a persistent disease that may result in prolonged hospital stays, additional medical costs, and rare serious complications.

Serum and cerebrospinal fluid pharmacokinetics of intravenous and oral lamivudine in human immunodeficiency virus-infected children

We studied the pharmacokinetics of intravenously and orally administered lamivudine at six dose levels ranging from 0.5 to 10 mg/kg of body weight in 52 children with human immunodeficiency virus infection. A two-compartment model with first-order elimination from the central compartment was simultaneously fitted to the serum drug concentration-time data obtained after intravenous and oral administration. The maximal concentration at the end of the 1-h intravenous infusion and the area under the concentration-time curve after oral and intravenous administration increased proportionally with the dose. The mean clearance of lamivudine (+/- standard deviation) in the children was 0.53 +/- 0.19 liter/kg/h (229 +/- 77 ml/min/m2 of body surface area), and the mean half-lives at the distribution and elimination phases were 0.23 +/- 0.18 and 2.2 +/- 2.1 h, respectively. Clearance was age dependent when normalized to body weight but age independent when normalized to body surface area. Lamivudine was rapidly absorbed after oral administration, and 66% +/- 25% of the oral dose was absorbed. Serum lamivudine concentrations were maintained above 1 microM for >/=8 h of 24 h on the twice daily oral dosing schedule with doses of >/=2 mg/kg. The cerebrospinal fluid drug concentration measured 2 to 4 h after the dose was 12% (range, 0 to 46%) of the simultaneously measured serum drug concentration. A limited-sampling strategy was developed to estimate the area under the concentration-time curve for concentrations in serum at 2 and 6 h.

The implications of acute pouchitis on the long-term functional results after restorative proctocolectomy

A prospective study was conducted to determine the implications of acute pouchitis on the long-term functional results of restorative proctocolectomy with J-pouch ileoanal anastomosis (IPAA). Between July 1988 and June 1996, 137 consecutive patients underwent IPAA for treatment of ulcerative colitis. 127 patients (93%) have been available for follow-up. All patients completed diaries detailing bowel habits over a 7-day period at 3, 6, 9, 12, 18, 24 months, and yearly after reestablishment of intestinal continuity. Diaries were completed only during time periods in which patients were not suffering from acute symptomatic pouchitis. Patients with chronic pouchitis (n = 7) were excluded from this study leaving 120 patients for analysis. Fifty patients suffered at least one episode of pouchitis (Pouchitis Group). Seventy patients never had pouchitis (No Pouchitis Group). Patients with a history of pouchitis having significantly more bowel movements per day were more likely to ever have minor incontinence (75% vs. 45%, p < 0.005) or major incontinence (37% vs. 17%, p < 0.02). The stools of Pouchitis Group were less likely to be formed (24% vs. 31%, p < 0.001). Pouchitis Group patients also were more likely to wear a protective pad during the day (21% vs. 7% p < 0.04) or during the night (40% vs. 13%, p < 0.001). Even in the absence of clinically active pouchitis, patients who have suffered at least one episode of pouchitis have a poorer long-term functional result after IPAA. The results of this study suggest that ileal pouchitis may represent a chronic condition that displays episodic symptomatic exacerbations.

Ellipsometry on sputter-deposited tin oxide films: optical constants versus stoichiometry, hydrogen content, and amount of electrochemically intercalated lithium

Tin oxide thin films were deposited by reactive radio-frequency magnetron sputtering onto In(2)O(3):Sn-coated and bare glass substrates. Optical constants in the 3002500-nm wavelength range were determined by a combination of variable-angle spectroscopic ellipsometry and spectrophotometric transmittance measurements. Surface roughness was modeled from optical measurements and compared with atomic-force microscopy. The two techniques gave consistent results. The fit between experimental optical data and model results could be significantly improved when it was assumed that the refractive index of the Sn oxide varied across the film thickness. Varying the oxygen partial pressure during deposition made it possible to obtain films whose complex refractive index changed at the transition from SnO to SnO(2). An addition of hydrogen gas during sputtering led to lower optical constants in the full spectral range in connection with a blueshift of the bandgap. Electrochemical intercalation of lithium ions into the Sn oxide films raised their refractive index and enhanced their refractive-index gradient.

Optical constants of sputter-deposited ti-ce oxide and zr-ce oxide films

Films of Ti oxide, Zr oxide, Ce oxide, Ti-Ce oxide, and Zr-Ce oxide were made by means of reactive dc magnetron sputtering in a multitarget arrangement. The films were characterized by x-ray diffraction and electrochemical measurements, both techniques being firmly connected to stoichiometric information. The optical constants n and k were evalued from spectrophotometry and from variable-angle spectroscopic ellipsometry. The two analyses gave consistent results. It was found that n for the mixed-oxide films varied smoothly between the values for the pure oxides, whereas k in the band-gap range showed characteristic differences between Ti-Ce oxide and Zr-Ce oxide. It is speculated that this difference is associated with structural effects.

Thromboxane A2 in postischemic acute compartmental syndrome

OBJECTIVE

To evaluate whether thromboxane A2 participates in the ischemia-reperfusion injury associated with acute compartmental syndrome (ACS) and if by using a cyclooxygenase inhibitor this can be either reduced or abolished.

DESIGN

To assess the role of thromboxane A2 in ACS, a tourniquet was applied for 2 hours to the hind limb of 12 dogs. Group 1 (n = 6) served as controls while group 2 (n = 6) was pretreated with lysine-acetyl-salicylate (Lysoprim). Blood thromboxane B2 levels and intracompartmental pressures were assayed prior to inflation of the tourniquet and at 5 minutes, 90 minutes, and 24, 72, and 144 hours after deflation.

RESULTS

Five minutes after deflation, the compartmental pressure increased from 11.2 +/- 2.2 mm Hg to 16.1 +/- 3.3 mm Hg and 17 +/- 2.2 mm Hg (mean +/- SD) in groups 2 and 1, respectively. At 90 minutes and 24 hours, pressures were 17.1 +/- 3.3 mm Hg and 23.2 +/- 3.3 mm Hg (P<.01) and 15.3 +/- 2.6 mm Hg and 25.2 +/- 1.8 mm Hg (mean +/- SD) (P<.001), respectively, in groups 2 and 1. A similar effect, although of a lesser magnitude, was observed in the counterlateral limb. Thromboxane B2 levels increased from a mean (+/- SD) of 46 +/- 5.5 pg/0.1 mL to 132 +/- 7.5 pg/0.1 mL at 90 minutes in group 1, while remaining unchanged in group 2.

CONCLUSIONS

Thromboxane A2 plays a major role in the ischemia-reperfusion injury of acute compartmental syndrome. By using a cyclooxygenase inhibitor both the levels of thromboxane and the compartmental pressures can be reduced.

Reliability and validity of an algorithm for fuzzy tissue segmentation of MRI

PURPOSE

A new multistep, volumetric-based tissue segmentation algorithm that results in fuzzy (or probabilistic) voxel description is described. This algorithm is designed to accurately segment gray matter, white matter, and CSF and can be applied to both single channel high resolution and multispectral (multiecho) MR images.

METHOD

The reliability and validity of this method are evaluated by assessing (a) the stability of the algorithm across time, rater, and pulse sequence; (b) the accuracy of the method when applied to both real and synthetic image datasets; and (c) differences in specific tissue volumes between individuals with a specific genetic condition (fragile X syndrome) and normal control subjects.

RESULTS

The algorithm was found to have high reliability, accuracy, and validity. The finding of increased caudate gray matter volume associated with the fragile X syndrome is replicated in this sample.

CONCLUSION

Since this segmentation approach incorporates "fuzzy" or probabilistic methods, it has the potential to more accurately address partial volume effects, anatomical variation within "pure" tissue compartments, and more subtle changes in tissue volumes as a result of disease and treatment. The method is a component of software that is available in the public domain and has been implemented on an inexpensive personal computer thus offering an attractive and promising method for determining the status and progression of both normal development and pathology of the CNS.

Regulation of a common, low-affinity binding site for primary prostanoids on bovine aortic endothelial cells

Bovine aortic endothelial cells contain a prostaglandin site which binds with similar low-affinity PGE2, PGF2alpha and the thromboxane agonist U-46619. Treatment of the cells with agents that increase the level of cellular cAMP such as forskolin, a direct activator of adenylate cyclase or IBMX, a phosphodiesterase inhibitor, decreased the binding of PGE2 to the cells. Addition of dibutyryl cAMP to intact cells caused a quick reduction in PGE2 binding with a half time of less than 2 min. The reduction in PGE2 binding was completely reversible after removing the dibutyryl cAMP. The reduction in PGE2 binding after addition of dibutyryl cAMP to the intact cells was also observed after a mechanical disruption of the cells or after permeabilization with digitonin. Incubation of the cells with myristoylated PKI(14-22) amide, a specific protein kinase A inhibitor, resulted in partial suppression of the reduction of PGE2 binding by dibutyryl cAMP. Pretreatment of intact cells for 24 h with 10(-6) M PGE2 or a PKC activator did not reduce the specific binding of [3H]-PGE2. These results suggest that PKA, but not PKC, is involved in a fast reversible regulation of the common prostanoid receptor on bovine endothelial cells.

Effects of closed head trauma and lipopolysaccharide on body temperature, brain tissue water content, and PGE2 production in rats

Closed head trauma (CHT) increases brain tissue prostaglandin E2 (PGE2) concentration, and that increase is associated with cerebral edema formation and worsening of the neurologic severity score (NSS). Injection of the bacterial endotoxin lipopolysacharride (LPS) increases cerebral and hypothalamic PGE2, and the hypothalamic increase is associated with increased body temperature. The present study determined (a) whether LPS-induced increase of PGE2 causes brain edema or worsens NSS and (b) whether CHT increases hypothalamic PGE2 and thereby increases body temperature. Halothane-anesthetized rats were divided into four groups: group 1 = surgery with no CHT and no LPS (n = 8); group 2 = surgery with LPS and no CHT (n = 8); group 3 = surgery with CHT and no LPS (n = 8); and group 4 = surgery with CHT plus LPS (n = 8). NSS was determined at 1 and 24 h after injury, and brain tissue PGE2 and edema were determined when animals were killed 24 h after injury. As compared with group 1, LPS alone, but not CHT or CHT plus LPS, increased rectal temperature. CHT and CHT plus LPS, but not LPS alone increased brain water content and worsened NSS. LPS, CHT, and CHT plus LPS all increased hypothalamic and cerebral PGE2 production. We conclude that although LPS and CHT increased PGE2 levels, LPS alone did not affect neurologic status or brain edema, CHT did not increase rectal temperature, and addition of LPS to CHT did not aggravate the sequelae of CHT.

Biologic classification as an alternative to anatomic staging for clinically localized prostate cancer: a proposal based on patients treated with external beam radiotherapy

OBJECTIVES

The prognostic significance of clinical stage in patients with prostate cancer who are treated with external beam radiotherapy is unclear. This study evaluates multiple pretreatment factors, including clinical stage, to determine which are the best prognostic factors, and develops a classification system based on these factors.

METHODS

All 249 evaluable patients with clinically localized adenocarcinoma of the prostate treated with definitive conformal external beam radiotherapy without androgen deprivation at our institution between 1989 and 1993 were analyzed. Clinical stage, serum PSA level, Gleason score, race, and history of transurethral resection of the prostate (TURP) were evaluated for their ability to predict biochemical disease-free survival (BDFS). Factors predictive of BDFS were then used to construct a classification system. The classification system was then analyzed for its ability to predict BDFS, distant metastases, local recurrence, and clinical disease free survival in univariate and multivariate analyses. Median follow-up was 27 months.

RESULTS

Gleason score and PSA predicted BDFS in multivariate analysis (both P <0.0001), whereas clinical stage, race, and history of a TURP did not. These two biologic factors were combined into a four-level classification system. This classification system was analyzed together with Gleason score and PSA and was found to be the only predictor of BDFS on multivariate analysis (P <0.0001). In addition, this classification system was the only predictor of distant metastases in multivariate analysis (P <0.0001).

CONCLUSIONS

The classification system derived herein based on the biologic factors of Gleason score and serum PSA levels is the sole predictor of distant metastases and biochemical recurrence for patients treated with definitive conformal external beam radiotherapy for clinically localized prostate cancer. This classification system may be useful when comparing competing therapies and stratifying patients in clinical trials, but requires validation from other institutions and other therapies prior to its widespread use.

Use of fine needle aspiration for solid breast lesions is accurate and cost-effective

BACKGROUND

Palpable breast tumors have traditionally been diagnosed with open biopsy or core biopsy. We propose fine needle aspiration biopsy (FNA) as a reliable, cost-saving initial procedure in these patients.

METHODS

Eighty-five palpable solid breast masses of the breast in 85 patients were classified by a combination of physical examination, mammography, and/or ultrasound as probably benign, indeterminate, or highly suspicious for cancer. All tumors had FNA biopsies. All patients had either a confirmatory open biopsy (55) or close clinical follow-up (30) with a mean follow-up of 29 months (range 6 to 36).

RESULTS

Thirty-four patients classified as clinically benign had a benign FNA biopsy. No cancers were detected in this group by either open surgical biopsy or clinical follow-up. Twenty patients were classified clinically as indeterminate. All had FNA biopsies, and 6 were either positive for cancer or suspicious for cancer. Fourteen patients had negative FNA biopsies. Five of the 6 abnormal biopsies had cancer on open biopsies. The 1 false-positive result occurred in a lactating patient. Thirty-one patients were classified clinically as highly suspicious for cancer. Twenty-three were confirmed as cancer with FNA biopsy. Eight needed open surgical biopsy to confirm cancer. All 31 patients clinically suspicious for cancer had cancer. In patients classified clinically as highly suspicious or probably benign, FNA was a reliable first diagnostic step (100% positive predictive value, 100% specificity, 87% sensitivity, and 89% negative predictive value).

CONCLUSIONS

Fine needle aspiration biopsy of solid palpable breast lesions should be the diagnostic procedure of choice for those patients classified clinically as probably benign or clinically as highly suspicious for cancer. Cost analysis revealed elimination of an open biopsy in such cases would save $1,100 per patient. For highly suspicious cases, a negative fine needle aspiration should not deter an open surgical biopsy. For patients classified as indeterminate, fine needle aspiration biopsy results are not reliable enough to determine treatment.

Cardiac ultrasonography

The use of cardiac ultrasonography in the emergency department currently has two primary indications: determining the presence of cardiac tamponade and determining cardiac activity in patients with apparent pulselessness. Physicians are able to recognize both conditions after appropriate, but not overextensive, training sessions. The evaluation of penetrating trauma, acute myocardial infarction, and severe shock of uncertain origin require a higher degree of training and experience. All of these conditions are discussed in this article.

Hemiparetic acute myopathy of intensive care progressing to triplegia

OBJECTIVE

To describe a unique case of acute asymmetrical myopathy following high-dose intravenous use of corticosteroids that initially mimicked a stroke and then evolved into a picture suggestive of myelopathy.

DESIGN

Case report.

SETTING

Tertiary hospital.

PATIENTS

A 71-year-old woman treated with high-dose steroids for an acute asthmatic exacerbation developed acute hemiparesis that progressed to triplegia without evidence of central nervous system involvement.

RESULTS

Nerve conduction studies, electromyography, and muscle biopsy revealed the typical features of necrotizing myopathy with loss of thick filaments.

CONCLUSIONS

This case demonstrates that high-dose corticosteroid therapy can induce asymmetrical myopathic weakness. Hemiplegia evolving to triplegia in a setting of corticosteroid treatment could potentially misdirect the diagnosis toward a lesion of the brain or spinal cord. When a central nervous system abnormality cannot be demonstrated a search for a peripheral abnormality, such as myopathy, is warranted.

Prospective study of the features, indications, and surgical treatment in 513 consecutive patients affected by Crohn's disease

BACKGROUND

The aim of this prospective study was to elucidate the features, indications, and surgical treatment in patients affected by complications of Crohn's disease.

METHODS

Between January 1985 and July 1996, 513 consecutive patients (248 male, 265 female; mean age, 38 years) were operated on for 542 occurrences of Crohn's disease. Data were collected prospectively.

RESULTS

Indications for abdominal surgery were often multiple but included failure of medical management (n = 220), obstruction (n = 94), intestinal fistula (n = 68), mass (n = 56), abdominal abscess (n = 33), hemorrhage (n = 7), and peritonitis (n = 9). Four hundred sixty-four abdominal procedures were performed, necessitating 425 intestinal resections and 97 stricture plasties. The use of stricture plasty was more common in the second half of the study (16.0% versus 7.3%, second half versus first half; p < 0.01). Perioperative complications occurred in 75 of the 464 abdominal operations (16%). There were no deaths. One hundred thirty patients (25%) required operation for perineal complications of Crohn's disease. The presence of Crohn's disease in the rectal mucosa was associated with a higher risk for permanent stomas in patients requiring operation for treatment of perianal Crohn's disease (67% versus 11%; p < 0.001).

CONCLUSIONS

Patterns of surgical treatment in Crohn's disease are changing, with more emphasis on nonresectional options. The presence of rectal involvement significantly increases the need for a permanent stoma in patients with perianal Crohn's disease.

Imaging supramolecular aggregates in bile models and human bile

Investigation of cholesterol crystallization is essential for the understanding of gallstone formation. Previous work has revealed a variety of aggregates of different sizes and shapes prior to the appearance of "classical" plate-like cholesterol monohydrate crystals both in native biles and model systems. In this article, we review existing data based on various microscopic techniques and present data on microstructural pathways leading to cholesterol crystal formation in two different bile models and in native bile. In continuation of our recent investigation of microstructures in nucleating human bile, we now present data suggesting that polymorphism is not limited to complex native bile, but also appears in two, simplified model systems. These studies employed cryo-transmission electron microscopy (cryo-TEM) and video-enhanced light microscopy, using Nomarski optics (VELM). Only the combined use of these two complementary, non-perturbing direct methods can cover the whole range of microstructures ranging from a few nanometers to several microns. Concentrated isotropic solutions of bile models, composed of cholesterol, lecithin and taurocholate, were diluted to induce cholesterol supersaturation and start an evolution of microstructures, leading to cholesterol crystallization. Initially, small spheroidal micelles were observed by cryo-TEM. Subsequently, uni-, oligo- and multilamellar vesicles, compatible with structures seen at the same time by VELM, appeared in coexistence with micelles. Thereafter, during a dynamic phase of cholesterol crystallization, filaments, tubular and helical microstructures, as well as classical plate-like cholesterol monohydrate crystals were noted by light microscopy. Eventually, large plate-like crystals were observed by VELM, while cryo-TEM revealed only small spheroidal micelles. The crystallization process in native human bile during ex vivo incubation was found to bear close resemblance to the findings in the model systems, further supporting the applicability of these systems to the exploration of microstructural aspects of nucleating human bile.

Apocrine adenocarcinoma presenting as a large ulcerated axillary mass

BACKGROUND

Apocrine adenocarcinomas are one of the rarest cutaneous cancers with few reported cases. Previously regarded nonspecifically as sweat gland tumors variants, they are now established as apocrine derivatives. Most occur in the axilla.

OBJECTIVE

To provide a gross and histological description of an apocrine adenocarcinoma presenting in a 49-year-old African-American man.

METHODS

The mass was removed en bloc with axillary lymph node dissection. The specimens were routinely embedded, and sectioned. Hematoxylin & eosin and periodic acid Schiff staining was done. Ploidy evaluation was performed by cytometry.

RESULTS

The mass was firm, nontender, and mobile (15 x 14 x 7 cm) with overlying areas of ulcerated skin. It was closely associated with the axillary vessels, and latissimus dorsi and pectoralis major muscles, but was well circumscribed with extensive dystrophic calcification. Histological examination revealed an adenocarcinoma with predominant apocrine features. The tumor was arranged in solid sheets and large glands in the reticular dermis and had a loose trabecular pattern extending to the ulcerated skin surface. Two of seven local lymph nodes were positive for tumor; level two and three nodes were negative for tumor. DNA ploidy study determined the tumor to be an aneuploid cell line with an 18% S-phase fraction.

CONCLUSIONS

Tumor growth in this patient was rapid, histology unfavorable, and local nodes positive. However, aggressive surgical intervention resulted in 12 months follow-up without evidence of recurrence.

Detection of circulating prostate carcinoma cells via an enhanced reverse transcriptase-polymerase chain reaction assay in patients with early stage prostate carcinoma. Independence from other pretreatment characteristics

BACKGROUND

Circulating prostate cells can be detected in the venous blood of patients with clinically localized prostate carcinoma by applying reverse transcriptase-polymerase chain reaction (RT-PCR) techniques using primers specific for the prostate specific antigen (PSA) gene. This study evaluates whether the detection of circulating cells correlates with established prognostic factors, treatment, and pathologic stage.

METHODS

Two hundred and twenty-seven patients with clinically localized adenocarcinoma of the prostate had an RT-PCR assay performed as part of their staging evaluation. No treatment decisions were made on the basis of the RT-PCR results. Of these, 156 patients were treated with radical prostatectomy (RP) and 71 with radical external beam radiotherapy (EBRT). Forty-eight patients were treated with hormonal therapy prior to RP (n = 39) or EBRT (n = 9). The prognostic factors analyzed for their relationship to RT-PCR were clinical stage, pretreatment serum PSA levels, Gleason score of the biopsy specimen, and Gleason score of the surgical specimen. An analysis of the relationship between treatment and RT-PCR results was also performed. Multivariate logistic regression analysis of predictors of RT-PCR positivity was performed as well. In addition, univariate and multivariate analyses of predictors of pathologic stage, including RT-PCR, were performed.

RESULTS

Sixty-one patients (26.9%) had a positive RT-PCR assay. There was no relationship between clinical stage, pretreatment PSA, biopsy Gleason score, or surgical Gleason score and RT-PCR positivity. In univariate analysis, patients treated with RP had a higher rate of RT-PCR positivity than patients treated with EBRT (P = 0.054). However, in multivariate logistic regression analysis no factor, including treatment with RP, was a significant predictor of RT-PCR positivity. RT-PCR and pretreatment PSA predicted pathologic stage in univariate and multivariate analyses (P < 0.0001 and P = 0.002, respectively).

CONCLUSIONS

The detection of circulating prostate cells using RT-PCR occurs in approximately 25% of early stage prostate carcinoma patients and is independent of other established prognostic factors. In addition, a positive RT-PCR assay is a strong predictor of pathologic upstaging in patients with clinically organ-confined disease.

Abnormal prostate development in C3(1)-bcl-2 transgenic mice

BACKGROUND

Recent hypotheses to explain the etiology of abnormal growth associated with prostate disease have invoked perturbations in the rate of apoptosis as an important contributor to the onset and progression of these diseases. For this reason, the apoptosis suppressing oncoprotein bcl-2 has come under scrutiny with regards to its role in prostate diseases. In order to evaluate the role of bcl-2 in human prostate disease and to develop an animal model to test anti-bcl-2 therapies, we generated transgenic mice in which bcl-2 expression is targeted to the mouse prostate gland.

METHODS

Mouse embryos were microinjected with recombinant DNA constructed by fusing a modified rat C3(1) promotor element to cDNA encoding human bcl-2. Presence of the C3(1)-bcl-2 transgene in progeny was identified by Southern blot and polymerase chain reaction (PCR) analysis. RNase protection assays were used to analyze RNA from 15 organs of these mice. Western blot assays and immunohistochemical staining were used to confirm the tissue-specific protein expression of human bcl-2 and its cellular localization.

RESULTS

Three lines of C3(1)-bcl-2 transgenic mice were established. Founder mice carried 2-20 copies of the transgene. Expression of human bcl-2 from the transgene was limited to the prostate gland and testis of males as well as the uterus of females. In the prostate gland, human bcl-2 protein was found only in prostatic epithelial cells. Microscopic analysis of prostate glands from individual males (three lines) showed that these glands were often abnormal, with increased accumulation of cells in the prostatic stroma as well as the epithelium.

CONCLUSIONS

These transgenic mice appear to provide a novel animal model for studying neoplastic development of the prostate, with particular emphasis on the bcl-2 protein and the role of apoptosis regulation in such development.

Detection of circulating prostate carcinoma cells via an enhanced reverse transcriptase-polymerase chain reaction assay in patients with early stage prostate carcinoma. Independence from other pretreatment characteristics

BACKGROUND

Circulating prostate cells can be detected in the venous blood of patients with clinically localized prostate carcinoma by applying reverse transcriptase-polymerase chain reaction (RT-PCR) techniques using primers specific for the prostate specific antigen (PSA) gene. This study evaluates whether the detection of circulating cells correlates with established prognostic factors, treatment, and pathologic stage.

METHODS

Two hundred and twenty-seven patients with clinically localized adenocarcinoma of the prostate had an RT-PCR assay performed as part of their staging evaluation. No treatment decisions were made on the basis of the RT-PCR results. Of these, 156 patients were treated with radical prostatectomy (RP) and 71 with radical external beam radiotherapy (EBRT). Forty-eight patients were treated with hormonal therapy prior to RP (n = 39) or EBRT (n = 9). The prognostic factors analyzed for their relationship to RT-PCR were clinical stage, pretreatment serum PSA levels, Gleason score of the biopsy specimen, and Gleason score of the surgical specimen. An analysis of the relationship between treatment and RT-PCR results was also performed. Multivariate logistic regression analysis of predictors of RT-PCR positivity was performed as well. In addition, univariate and multivariate analyses of predictors of pathologic stage, including RT-PCR, were performed.

RESULTS

Sixty-one patients (26.9%) had a positive RT-PCR assay. There was no relationship between clinical stage, pretreatment PSA, biopsy Gleason score, or surgical Gleason score and RT-PCR positivity. In univariate analysis, patients treated with RP had a higher rate of RT-PCR positivity than patients treated with EBRT (P = 0.054). However, in multivariate logistic regression analysis no factor, including treatment with RP, was a significant predictor of RT-PCR positivity. RT-PCR and pretreatment PSA predicted pathologic stage in univariate and multivariate analyses (P < 0.0001 and P = 0.002, respectively).

CONCLUSIONS

The detection of circulating prostate cells using RT-PCR occurs in approximately 25% of early stage prostate carcinoma patients and is independent of other established prognostic factors. In addition, a positive RT-PCR assay is a strong predictor of pathologic upstaging in patients with clinically organ-confined disease.

Basic fibroblast growth factor causes growth arrest in MCF-7 human breast cancer cells while inducing both mitogenic and inhibitory G1 events

Basic fibroblast growth factor (bFGF), a classical mitogen in fibroblasts and endothelial cells, inhibits the proliferation of MCF-7 and other human breast cancer cell lines. To explain this paradoxic effect, we investigated the effects of bFGF on cyclins and protein members of cyclin complexes that exert positive and negative control on the progression of cells through the G1 phase of the cell cycle. bFGF induced an increase in cyclin D1, cyclin E, and cyclin-dependent kinase 4 (cdk4) protein levels in a bFGF dose-dependent manner. However, bFGF also induced a heat-stable, transferable cytoplasmic factor in MCF-7 cells that inhibited the histone H1 kinase activity of reconstituted cyclin E-cdk2 and cyclin A-cdk2 complexes from Mv1Lu mink lung epithelial cells. The appearance of this inhibitor correlated with a bFGF dose- and time-dependent increase in the levels of cdk inhibitor p21(WAF1/CIP1) mRNA and protein. The increase in the level of p21(WAF1/CIP1) was associated with the disappearance of the rapidly migrating, activated form of cdk2 from cell lysates, dephosphorylation of the retinoblastoma protein (Rb), and a decrease in cyclin A levels. These changes were represented in the cyclin D1 and E complexes by an increased association with p21(WAF1/CIP1), proliferating cell nuclear antigen (PCNA), and the inactive form of cdk2, without an absolute change in cellular PCNA levels and by a switch in the association of cyclin D1 complexes with the hyperphosphorylated form to the dephosphorylated form of Rb. These experiments demonstrate that stimulation of MCF-7 cells with bFGF, although resulting in up-regulation of G1 proteins responsible for mitogenic events, also induces a concomitant decrease in cyclin A levels and an increase in p21(WAF1/CIP1) mRNA and protein and results in inactivation of cdk2, dephosphorylation of Rb, and a segregation of PCNA to the G1 cyclin complexes. The dual, conflicting signaling by bFGF results in a net inhibitory phenotype in these cells. These experiments suggest a pleiotropic role for bFGF in breast cancer.

Biosynthesis of medium-chain triacylglycerols and phospholipids by HepG-2 cells

In an attempt to understand the metabolism by the liver of fatty acids (FA) of different chain length, we have studied the incorporation of [1(-14)C]-labeled C2, C8, C10, C12, and C16 into cellular lipids by HepG-2 cells. Over 90% of the radiolabeled FA were detected in phospholipids (PL) and triacylglycerols (TAG). The incorporation of C12 and C16 was three to four times higher than that of C8 and C10 (and reached 35 nmoles per mg protein after 1.5 h). The radioactivity of C2, C8, and C10 was recovered mainly in PL. C12 and C16 were incorporated at approximately equal amounts into PL and TAG. The radioactivity of both C2 and C8 was recovered exclusively in long-chain FA, suggesting oxidation of C8 into C2 units prior to FA synthesis. C10 likewise yielded mainly long-chain FA. However 10% of unchanged C10 was found in PL and up to 30% in TAG. 14C-C12 was largely incorporated unchanged. Under these conditions, the presence of C10 and C12 in PL and TAG was shown also by gas-liquid chromatography. In the presence of either C2, C8, or C10, up to 30% of 14C-monounsaturated FA were detected in PL and TAG. With C12 and C16, the fraction of 14C-monounsaturated FA was much smaller suggesting that extensive desaturation occurred during de novo synthesis.

The use of commercially available lipid emulsions for the preparation of amphotericin B-lipid admixtures

The use of Intralipid as a dilution medium for Fungizone, previously proposed by several groups to reduce the toxicity of amphotericin B, is limited by the instability of amphotericin B-lipid admixtures. We have shown that Fungizone-lipid admixtures with three different lipid emulsions can be stabilized by vigorous agitation. Unlike in preparations made by gentle shaking, in stable emulsions made by agitation for 18 h, most of the amphotericin B remains associated with the lipid phase for at least 1 month at 4 degrees C. The MICs of all the admixtures against various Candida spp. were similar to that of Fungizone and did not change following storage for at least 2 weeks at 4 degrees C. Furthermore, the toxicity of the admixtures, as evaluated by their haemolytic activity and amphotericin B-induced K+-leakage from human red blood cells, was much lower than that of Fungizone. Hence, amphotericin B-containing lipid emulsions made by extended agitation may be advantageous in clinical practice as they are efficient, stable, non-toxic and can be easily produced at low cost from commercially available ingredients approved for clinical use.

Proximal neuropathy in Colles' fracture

BACKGROUND

Peripheral nerve injury at the wrist following Colles' fracture is rare and usually located in the region of the fracture. Mononeuropathies in the proximal forearm have not been reported.

METHOD

We present two patients with Colles' fracture with proximal forearm neuropathies.

RESULTS

Both cases were associated with mononeuropathies in the forearm as proximal as the elbow, involving the median, ulnar and radial nerves in one, and the median and ulnar nerves in the other.

CONCLUSION

Following Colles' fracture proximal nerve involvement may occur and, with increased awareness, this lesion may be identified more frequently.

Does lipid infusion affect bile composition in humans?

A prospective study was performed to investigate the effect of short-term lipid infusion on bile composition and its lithogenicity in humans. The study group comprised 44 patients scheduled for laparotomy. The patients were hospitalized 48 h prior to elective surgery and randomized to be infused with a lipid emulsion of either long chain triglycerides (LCT) or a mixture of medium and long chain triglycerides (MCT/LCT) for 6 h of each 24 h, or with glucose-saline. Bile samples were obtained by puncture of the gallbladder during operation. In non-gallstone patients, both lipids caused an elevation of biliary cholesterol and phospholipids, but this effect was more pronounced and significant (P <0.001) only with the mixture of MCT/LCT emulsion. The fatty acid composition of biliary phospholipids was not affected by either lipid infusion. The Cholesterol Saturation Index increased significantly (P <0.005) with the MCT/LCT emulsion and there was insignificant shortening in the nucleation time. In contrast to patients with cholelithiasis, no effects could be demonstrated on gallbladder bile composition, cholesterol saturation index, nucleation time, or fatty acid composition of phospholipids. The effects of both lipid emulsions on plasma lipids and lipoproteins were similar in all groups. Our results indicate that lipid emulsions containing MCT/LCT induce lithogenic changes in the composition of human bile. We propose that the lack of effect of lipid infusion on bile composition in patients with cholelithiasis may be due to precipitation of excess cholesterol in the gallbladder of cholesterol gallstone patients whose bile is already saturated. These findings imply that patients with cholesterol gallstones cannot be grouped with non-gallstone patients in studies of alterations of bile composition.

Drug resistance and virologic response in NUCA 3001, a randomized trial of lamivudine (3TC) versus zidovudine (ZDV) versus ZDV plus 3TC in previously untreated patients

OBJECTIVE

To study the effect of HIV-1 resistance to lamivudine (3TC) and zidovudine (ZDV), and syncytium-inducing (SI) phenotype on virologic response to treatment with ZDV, 3TC, or ZDV plus 3TC in previously untreated individuals with HIV-1 infection.

DESIGN

A prospective virologic substudy of GlaxoWellcome protocol NUCA 3001.

METHODS

HIV-1 isolates obtained at study entry and at week 12 were expanded in peripheral blood mononuclear cell (PBMC) culture, titered, and assayed for phenotypic and genotypic evidence of resistance to ZDV and 3TC, and for syncytium formation on MT-2 cells.

RESULTS

Phenotypic and genotypic resistance to 3TC was detected in the majority of HIV-1 isolates from patients who received 3TC alone or in combination with ZDV. Despite showing 3TC resistance, subjects who received 3TC in combination with ZDV had significantly greater decreases in plasma HIV-1 RNA levels compared with those who received ZDV alone. Occurrence of the K7OR ZDV resistance mutation was significantly reduced in patients who received the 3TC/ZDV combination as compared with patients on ZDV monotherapy. Plasma HIV-1 RNA returned to near-baseline levels more quickly in patients with SI isolates at study entry.

CONCLUSIONS

Despite the rapid emergence of 3TC resistance, combination therapy with 3TC plus ZDV resulted in greater reduction in plasma HIV-1 RNA levels over 24 weeks as compared to ZDV monotherapy. Prevention of ZDV resistance may contribute to the sustained activity of the combination therapy.

Lamivudine plus zidovudine compared with zalcitabine plus zidovudine in patients with HIV infection. A randomized, double-blind, placebo-controlled trial. North American HIV Working Party

OBJECTIVE

To compare the safety and activity of lamivudine plus zidovudine with the safety and activity of zalcitabine plus zidovudine in patients with moderately advanced human immunodeficiency virus (HIV) infection who had received zidovudine.

DESIGN

A multicenter, randomized, double-blind, three-arm, 24-week study with a blinded extension through at least 52 weeks.

SETTING

21 sites in the United States, Canada, and Puerto Rico.

PATIENTS

254 patients who had received zidovudine (median duration of previous therapy, 20 months) and had absolute CD4+ cell counts of 100 to 300 cells/mm3.

INTERVENTIONS

Patients were randomly assigned to receive one of three regimens: 150 mg of lamivudine twice daily plus 200 mg of zidovudine three times daily (low-dose lamivudine group); 300 mg of lamivudine twice daily plus 200 mg of zidovudine three times daily (high-dose lamivudine group); or 0.75 mg of zalcitabine plus 200 mg of zidovudine three times daily (zalcitabine group).

MEASUREMENTS

Immunologic activity was assessed primarily by changes in absolute CD4+ cell counts; virologic activity was assessed by changes in plasma HIV RNA levels as measured by reverse transcriptase polymerase chain reaction. Safety of the treatment regimens was assessed through the reporting of adverse events.

RESULTS

78% of patients completed 24 weeks of study treatment, and 63% of patients completed 52 weeks of study treatment. Changes in absolute CD4+ cell counts were significantly better for the low-dose and the high-dose lamivudine groups than for the zalcitabine group (median changes at 52 weeks were +42.5 cells/mm3 in the low-dose lamivudine group, +23.33 cells/mm3 in the high-dose lamivudine group, and -29.58 cells/mm3 in the zalcitabine group). Suppression of plasma HIV RNA levels was similar for all groups (median changes at 52 weeks were -0.48 log10 copies/mL in the low-dose lamivudine group, -0.51 log10 copies/mL in the high-dose lamivudine group, and -0.39 log10 copies/mL in the zalcitabine group). No significant differences in safety were seen among the three regimens, although the low-dose lamivudine regimen appeared to be better tolerated than the others.

CONCLUSIONS

In patients with HIV infection who had previously received zidovudine, 150 mg of lamivudine plus zidovudine resulted in greater immunologic evidence of benefit than did 0.75 mg of zalcitabine plus zidovudine and was better tolerated than 300 mg of lamivudine plus zidovudine.

Motor neuropathy due to docetaxel and paclitaxel

Paclitaxel and docetaxel are novel chemotherapeutic agents that promote the polymerization and inhibit the depolymerization of microtubules. Sensory neuropathy is common with these agents, particularly paclitaxel. We evaluated 64 patients treated with these drugs; 54 were followed prospectively. Eleven (17%, including six of the 54 prospectively followed patients) developed muscle weakness that was predominantly proximal. The weakness was idiosyncratic, occurring at any stage of treatment, had a variable course, and was reversible upon cessation of drug. All patients developed symptoms or signs of taxane-induced sensory neuropathy. Weakness was likely neuropathic in origin; electrodiagnostic studies suggested a distal axonopathy in some patients and proximal denervation (anterior horn cell or nerve root) in other.

Lamivudine in children with human immunodeficiency virus infection: a phase I/II study. The National Cancer Institute Pediatric Branch-Human Immunodeficiency Virus Working Group

The safety, tolerability, pharmacokinetic profile, and preliminary activity of lamivudine (2'-deoxy-3'-thiacytidine), a novel cytidine nucleoside analogue with antiretroviral activity, in human immunodeficiency virus (HIV)-infected children beyond the neonatal period were studied. Ninety children received dosages of 1-20 mg/kg/day. Pharmacokinetic evaluation demonstrated serum and cerebrospinal fluid concentrations that increased proportionally to dose. As of January 1994, 11 children had been withdrawn from study for disease progression and 10 because of possible lamivudine-related toxicity, and 6 had died. CD4 and CD8 cell counts remained stable over 24 weeks in therapy-naive children and decrease slightly in previously treated children. Quantitative immune complex-dissociated p24 antigen and HIV RNA were decreased significantly at 12 and 24 weeks. In vitro resistance to lamivudine was documented in sequential virus isolates from some patients by 12 weeks. Lamivudine was well-tolerated and exhibited virologic activity in children, although future use in children is likely to be in combination antiretroviral regimens.

HIV-1 RNA levels and the development of clinical disease. North American Lamivudine HIV Working Group

OBJECTIVE

To assess the prognostic value of HIV RNA levels for predicting clinical disease independently of the CD4 lymphocyte count in patients on antiretroviral therapy.

DESIGN

Cohort of HIV-infected patients from two trials of lamivudine therapy.

PATIENTS

For 620 patients randomized in the North American NUCA3001 and NUCA3002 trials of lamivudine, HIV RNA levels were measured (median, seven measures per patient) and CD4 counts were assessed at a central laboratory (median, 13 counts per patient). Patients were in the 1993 Centers for Disease Control and Prevention (CDC) stages A (n = 439), B (n = 135) or C (n = 46) at baseline.

OUTCOME MEASURES

For patients who were in CDC stage A at baseline we considered the ability of HIV RNA levels and CD4 counts to predict the development of CDC stage B or C disease. A Cox proportional hazards model was used. In a second analysis, patients who were AIDS-free at baseline were considered, and the endpoint was AIDS (CDC stage C).

RESULTS

Patients' initial CD4 counts ranged (5-95% centiles) from 104 to 529 x 10(6)/l (median, 274 x 10(6)/l) and HIV RNA levels from 1900 to 339680 copies/ml (median, 44240 copies/ml). For the first analysis, with CDC stage B or C disease as endpoint, both the most recent HIV RNA level and CD4 count predicted the development of clinical disease [relative hazard (RH) for HIV RNA, 1.96 per 10-fold difference in HIV RNA; 95% confidence interval (CI), 1.41-2.73; P = 0.0001; and RH for CD4 count, 1.82 per twofold difference in CD4 count; 95% CI, 1.27-2.56; P = 0.0009]. When both HIV RNA and CD4 count were included in a multiple regression model, both markers provided information additional to that given by the other (RH for HIV RNA, 1.75; 95% CI, 1.23-2.50; P = 0.002; and RH for CD4 count, 1.40; 95% CI, 0.95-2.07; P = 0.09). In the second analysis, with AIDS as endpoint, both HIV RNA level (P = 0.02) and CD4 count (P = 0.004) were independently associated with clinical progression. These results were essentially unchanged after adjustment for treatment arm (zidovudine/lamivudine versus control arms).

CONCLUSION

The HIV RNA level shows ability to predict the development of clinical disease and may thus be of importance in addition to the CD4 count in patient monitoring.

Prospective study of the incidence, timing and treatment of pouchitis in 104 consecutive patients after restorative proctocolectomy

OBJECTIVE

To determine the incidence timing and effectiveness of treatment of symptomatic pouchitis following restorative proctocolectomy with ileal J-pouch anal anastomosis.

DESIGN

A cohort analytical study.

SETTING

University hospitals, a tertiary referral center; all subjects entered into the study followed up for a minimum of 12 months (mean follow-up, 40 months).

PATIENTS

One hundred four consecutive patients undergoing restorative proctocolectomy with ileal J-pouch anal anastomosis for either ulcerative colitis (n = 97) or familial adenomatous polyposis (n = 7) between June 1986 and December 1994.

INTERVENTIONS

Patients with symptomatic pouchitis were treated with either oral metronidazole or ciprofloxacin.

OUTCOMES

Diagnosis of pouchitis was determined by clinical symptoms and confirmed with endoscopy. Response to oral antibodies was determined by resolution of symptoms.

RESULTS

Fifty-two patients (50%) experience at lest 1 episode of pouchitis. The first episode of pouchitis occurred within the first 12 months after restoration of intestinal continuity in 56% of the cases. In 2 patients it occurred after 30 months. Response to antibiotic treatment was 96%. Two thirds of patients had multiple episodes. Chronic pouchitis occurred in 6 patients, necessitating pouch removal in 2.

CONCLUSIONS

The incidence of pouchitis after ileal J-pouch anal anastomosis is approximately 50% with two thirds of these patients having multiple episodes. Chronic pouchitis occurs in a minority of patients. In chronic pouchitis, the risk of pouch loss is substantial.

[Anterior resection for rectal carcinoma in an anemic Jehovah's Witness]

Anterior resection is accepted treatment for tumors of the middle rectum, with mortality less than 5%. Since such surgery involves blood loss, blood transfusion is regarded as essential. We report a 69-year old anemic Jehovah's Witness who had a bleeding rectal tumor but who refused blood transfusion, despite a hemoglobin level of 4.8 g/dl. Anterior resection of the tumor was successfully performed without substantial blood loss. Her hemoglobin level was 5.8 g/dl on discharge. Jehovah's Witnesses do not oppose medical treatment nor do they practice faith healing. Instead, they seek good medical care but accept only proven medical alternatives to blood transfusions. Physicians, world-wide, are now successfully performing major surgery of all types on both adult and minor Witnesses. Due to their success in the use of alternatives, over 50 hospitals in North America, Europe and Australia have established "bloodless-surgery" centers to serve not only Jehovah's Witnesses but also a growing number of other patients who wish to avoid risks associated with blood transfusion.

Involvement of p27KIP1 in G1 arrest mediated by an anti-epidermal growth factor receptor monoclonal antibody

Activation of the cyclin dependent kinases (CDK4/CDK6 and CDK2) is required for G1 phase progression and entry into S-phase. The activation of these kinases is regulated by checkpoints that monitor environmental and intracellular conditions. Progression into S-phase is controlled, in part, by the availability of growth factors, and we have investigated the relationship between growth factor availability and the activation of the CDK kinases. Blocking activation of epidermal growth factor (EGF) receptor tyrosine kinase with anti-EGF receptor monoclonal antibody (mAb) 225 induces G1 phase cell cycle arrest in DiFi human colon adenocarcinoma cells. When DiFi cells are treated with mAb 225 for 24 h, we observe marked decreases in the activities of CDK2 kinase and cyclin E-associated CDK kinase which are not accompanied by reduced levels of cyclin E and CDK2 proteins. However, the amount of cyclin/CDK kinase inhibitor p27KIP1 increases in the mAb-treated cells and p27KIP1 is bound to CDK2 in increasing amounts. Immunodepletion of p27KIP1 removes an inhibitory activity from lysates of mAb-treated cells: the immunodepleted and heated lysates lose the capacity to inhibit cyclin E/CDK2 activity in an in vitro assay. The results suggest that G1 arrest in the cell cycle induced by EGF receptor blockade involves p27KIP1.

Clinically and electrodiagnostically pure sensory demyelinating polyneuropathy

A 35-year-old woman presented with a 4 year history of stepwise sensory loss which progressed in an asymmetrical fashion (mononeuropathy multiplex) and developed into a relatively symmetric polyneuropathy which was purely sensory by clinical and electrodiagnostic criteria. Sural nerve biopsy revealed demyelination with axonal sparing. Extensive laboratory evaluation failed to reveal a definite cause. This case is unique among well-documented cases of chronic inflammatory demyelinating polyneuropathy (CIDP) in that it is purely sensory by both clinical and electrodiagnostic criteria, and may represent a distinct entity rather than an extension of the spectrum of CIDP.

The effects of dietary phospholipids enriched with phosphatidylethanolamine on bile and red cell membrane lipids in humans

The role of phospholipids in biliary cholesterol solubilization and crystallization has only recently begun to be appreciated. Phospholipid vesicles are believed to be the metastable carrier from which cholesterol nucleates. Cholesterol crystallization is influenced by the phospholipid species in bile. Feeding rats and hamsters with diets enriched in phospholipids or their precursors, especially ethanolamine, resulted in reduced cholesterol saturation of bile. Although whole phospholipids are normal dietary constituents, the effects and safety of phospholipid components have not been tested in humans. In the present study, we have evaluated the effects of a dietary phospholipid mixture, enriched with phosphatidylethanolamine, on human bile and red blood cell membrane lipid composition. Five ambulatory volunteers having a chronic indwelling T-tube, with an intact enterohepatic circulation, were investigated. Thirty-six grams of phospholipids (54% phosphatidylethanolamine, 54% linoleyl acyl chains) were added to their daily diet for fourteen days. Biliary nucleation time, cholesterol carriers, as well as plasma, red blood cell membrane, and bile lipid compositions, were monitored. Following phospholipid supplementation, the proportion of linoleyl chains (18:2) in biliary phospholipids increased significantly from 31.1 +/- 1.2 to 37.7 +/- 5.3%, while that of oleyl chains (18:1) decreased from 11.4 +/- 1.6 to 9.6 +/- 1.1%. These changes were accompanied by an increase of linoleate and its metabolite, arachidonate, in red cell membranes. Phospholipid feeding did not cause any side effects, and no significant changes in biliary nucleation time, cholesterol, phospholipid, or bile salt concentrations, or in the distribution of cholesterol within micelles or vesicles. We conclude that phospholipid feeding is safe, and can be effective as a vehicle for lecithin fatty acyl chain modulation of bile and lipid membranes. These findings may provide a basis for a controlled modulation of biliary phospholipids to increase cholesterol solubility in bile.

Changes in plasma HIV-1 RNA and CD4+ lymphocyte counts and the risk of progression to AIDS. Veterans Affairs Cooperative Study Group on AIDS

BACKGROUND

Clinical trials of antiretroviral drugs can take years to complete because the outcomes measured are progression to the acquired immunodeficiency syndrome (AIDS) or death. Trials could be accelerated by the use of end points such as changes in CD4+ lymphocyte counts and plasma levels of human immunodeficiency virus type 1 (HIV-1) RNA and beta 2-microglobulin, but there is uncertainty about whether these surrogate measures are valid predictors of disease progression.

METHODS

We analyzed data from the Veterans Affairs Cooperative Study on AIDS, which compared immediate with deferred zidovudine therapy. Patients' plasma levels of HIV-1 RNA and beta 2-microglobulin were measured in stored plasma.

RESULTS

Among the 129 patients in the immediate-treatment group, 34 had disease that progressed to AIDS, as compared with 57 of the 141 patients in the deferred-treatment group (P = 0.03). Progression to AIDS correlated strongly with base-line CD4+ lymphocyte counts (P = 0.001) and plasma levels of HIV-1 RNA (P < 0.001), but not with base-line levels of beta 2-microglobulin (P = 0.14). A decrease of at least 75 percent in the plasma level of HIV-1 RNA over the first six months of zidovudine therapy accounted for 59 percent of the benefit of treatment, defined as the absence of progression to AIDS (95 percent confidence interval, 13 to 112 percent). Plasma beta 2-microglobulin levels and CD4+ lymphocyte counts explained less of the effect of treatment. A 75 percent decrease in the plasma HIV-1 RNA level plus a 10 percent increase in the CD4+ lymphocyte count could explain 79 percent of the treatment effect (95 percent confidence interval, 27 to 145 percent).

CONCLUSIONS

Treatment-induced changes in the plasma HIV-1 RNA level and the CD4+ lymphocyte count, taken together, are valid predictors of the clinical progression of HIV-related disease and can be used to assess the efficacy of zidovudine and possibly other antiretroviral drugs as well.

Response of small cell carcinoma of pancreas to a small cell lung cancer regimen: a case report

Small cell carcinoma of the pancreas is a very rare malignancy with 18 cases reported in the literature, of which only 3 were treated with chemotherapy. A 52-year-old man was diagnosed with small cell carcinoma originating in the head of the pancreas and invading the duodenum. He was treated with a similar approach as for localized small cell lung cancer, with six cycles of combination chemotherapy and local radiotherapy, and went into complete remission. After 3 months, he developed liver metastases along with an enlarged left supraclavicular lymph node. He was treated with two cycles of CVA, but developed lung metastases and was treated with ifosfamide/mesna. However, his overall condition deteriorated and hospice care was instituted until the patient's demise. The patient survived 14 months following diagnosis, significantly longer than the 15 reported patients with small cell pancreatic carcinomas not treated with chemotherapy. Combination chemotherapy and radiation therapy as it is utilized for small cell lung cancer appear to be beneficial for small cell carcinoma of the pancreas.

A preliminary trial of lamivudine for chronic hepatitis B infection

BACKGROUND

Better treatments for chronic hepatitis B are needed. Lamivudine, the (-)enantiomer of 3'-thiacytidine, is a potent inhibitor of hepatitis B virus (HBV).

METHODS

In a double-blind trial, we randomly assigned 32 patients with chronic hepatitis B (including 17 who had no response to earlier treatment with interferon) to receive 25, 100, or 300 mg of oral lamivudine daily for 12 weeks. The patients were then followed for 24 additional weeks. All the patients had hepatitis B antigen in serum.

RESULTS

Levels of HBV DNA became undetectable (< or = 1.5 pg per milliliter) in 70 percent of the patients who received the 25-mg dose of lamivudine and 100 percent of those treated with the 100-mg or 300-mg dose. In most patients, HBV DNA reappeared after therapy was completed; however, six patients (19 percent), including five who had not responded to interferon, had sustained suppression of HBV DNA accompanied by normalization of alanine aminotransferase levels. Hepatitis B e antigen disappeared in four of these six patients (12 percent), three of whom had had no response to interferon. Levels of HBV DNA fell in all patients, including those who had had high levels at base line or normal alanine aminotransferase levels at base line, but sustained responses were more likely in patients with initially low HBV DNA levels and high alanine aminotransferase levels. During and after therapy, alanine aminotransferase levels at least doubled in five patients (50 percent) given the 25-mg dose and eight patients (36 percent) given the 100-mg or 300-mg dose. Minor adverse events occurred that were not related to the dose, as did transient, asymptomatic elevations of amylase, lipase, and creatine kinase levels.

CONCLUSIONS

In a preliminary trial, 12 weeks of lamivudine therapy was well tolerated, and daily doses of 100 mg and 300 mg reduced HBV DNA to undetectable levels.

Treatment with lamivudine, zidovudine, or both in HIV-positive patients with 200 to 500 CD4+ cells per cubic millimeter. North American HIV Working Party

BACKGROUND

The reverse-transcriptase inhibitor lamivudine has in vitro synergy with zidovudine against the human immunodeficiency virus (HIV). We studied the activity and safety of lamivudine plus zidovudine as compared with either drug alone as treatment for patients with HIV infection, most of whom had not previously received zidovudine.

METHODS

Three hundred sixty-six patients with 200 to 500 CD4+ cells per cubic millimeter who had received zidovudine for four weeks or less were randomly assigned to treatment with one of four regimens: 300 mg of lamivudine every 12 hours; 200 mg of zidovudine every 8 hours; 150 mg of lamivudine every 12 hours plus zidovudine; or 300 mg of lamivudine every 12 hours plus zidovudine. The study was double-blind and lasted 24 weeks, with an extension phase for another 28 weeks.

RESULTS

Over the 24-week period, the low-dose and high-dose regimens combining lamivudine and zidovudine were associated with greater increases in the CD4+ cell count (P = 0.002 and P = 0.015, respectively) and the percentage of CD4+ cells (P < 0.001 for both) and with greater decreases in plasma levels of HIV-1 RNA (P < 0.001 for both) than was treatment with zidovudine alone. Combination therapy was also more effective than lamivudine alone in lowering plasma HIV-1 RNA levels and increasing the percentage of CD4+ cells (P < 0.001 for all comparisons), and these advantages persisted through 52 weeks. Adverse events were no more frequent with combination therapy than with zidovudine alone.

CONCLUSIONS

In HIV-infected patients with little or no prior antiretroviral therapy, treatment with a combination of lamivudine and zidovudine is well tolerated over a one-year period and produces more improvement in immunologic and virologic measures than does treatment with either agent alone.

Morbidity of subtotal colectomy in patients with severe ulcerative colitis unresponsive to cyclosporin

PURPOSE

The aim of this study was to document the morbidity of urgent subtotal colectomy and ileostomy in patients with severe ulcerative colitis who failed cyclosporin treatment.

METHODS

We reviewed the charts of patients with severe ulcerative colitis who did not respond to cyclosporin treatment and underwent urgent subtotal colectomy and Brooke ileostomy at two inflammatory bowel disease centers over the 12-month period ending April 1994.

RESULTS

Fourteen patients (6 males; mean age, 34 years) required an urgent subtotal colectomy and Brooke ileostomy after failing treatment with cyclosporin. There were no deaths. Eight patients (57 percent) developed post-operative complications, which included ileus (3), deep vein thrombosis (2), wound infection (2), and partial dehiscence of rectal stump (1). Mean length of postoperative hospital stay was 8.8 days.

CONCLUSIONS

These initial data suggest that cyclosporin treatment may not influence the safety of urgent surgical treatment in severe ulcerative colitis.

Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis

BACKGROUND

This study was undertaken to evaluate prospectively the indications for surgical treatment and perioperative morbidity for patients with idiopathic ulcerative colitis (UC).

METHODS

Between January 1985 and August 1994, 145 patients were referred to the senior author (F.M.) for treatment of UC. Data were prospectively collected. One hundred patients have completed all stages of their surgical treatment and have been followed up for at least 1 year. These 100 patients form the basis of this study.

RESULTS

Thirty patients underwent a proctocolectomy with end-ileostomy in one (25) or two (5) stages. Seventy patients underwent a restorative proctocolectomy with ileal J-pouch anal anastomosis in either one (2), two (37), or three stages (31). In total 100 patients underwent 204 procedures. Failure of medical treatment was by far the most common indication. The initial colectomy was performed electively in 61 patients and urgently in the remaining 39. The rate of perioperative complications for elective and urgent colectomy was 26% and 44%, respectively (p < 0.05).

CONCLUSIONS

The overall perioperative morbidity rate remains high and almost doubles for urgent cases. Reducing the need for urgent procedures by earlier elective colectomy may allow for a reduction in perioperative morbidity.