Mortality in women given diethylstilbestrol during pregnancy

We used Cox regression analyses to assess mortality outcomes in a combined cohort of 7675 women who received diethylstilbestrol (DES) through clinical trial participation or prenatal care. In the combined cohort, the RR for DES in relation to all-cause mortality was 1.06 (95% CI=0.98–1.16), and 1.11 (95% CI=1.02–1.21) after adjusting for covariates and omitting breast cancer deaths. The RR was 1.07 (95% CI=0.94–1.23) for overall cancer mortality, and remained similar after adjusting for covariates and omitting breast cancer deaths. The RR was 1.27 (95% CI=0.96–1.69) for DES and breast cancer, and 1.38 (95% CI=1.03–1.85) after covariate adjustment. The RR was 1.82 in trial participants and 1.12 in the prenatal care cohort, but the DES–cohort interaction was not significant (P=0.15). Diethylstilbestrol did not increase mortality from gynaecologic cancers. In summary, diethylstilbestrol was associated with a slight but significant increase in all-cause mortality, but was not significantly associated with overall cancer or gynaecological cancer mortality. The association with breast cancer mortality was more evident in trial participants, who received high DES doses.

The role of door orientation on occupant injury in a nearside impact: a CIREN, MADYMO modeling and experimental study

OBJECTIVE

This study addressed the effects of vehicle height mismatch in side impact crashes. A light truck or SUV tends to strike the door of a passenger car higher causing the upper border to lead into the occupant space. Conversely, an impact centered lower on the door, from a passenger car, causes the lower border to lead. We proposed the hypothesis that the type of injury sustained by the occupant could be related to door orientation during its intrusion into the passenger compartment.

METHOD

Data on door orientation and nearside occupant injuries were collected from 125 side impact crashes reported in the CIREN database. Experimental testing was performed using a pendulum carrying a frame and a vehicle door, impacting against a USDOT SID. The frame allowed the door orientation to be changed. A model was developed in MADYMO (v 6.2) using the more biofidelic dummies, BIOSID, and SIDIIs as well as USDOT SID.

RESULTS

In side impact crashes with the lower border of the door leading, 81% of occupants sustained pelvic injury, 42% suffered rib fractures, and the rate of organ injury was 0.84. With the upper border leading, 46% of occupants sustained pelvic injury, 71% sustained rib fracture, and the rate of organ injuries per case increased to 1.13. The differences in the groups with respect to pelvic injury were significant at p = 0.01, rib fracture, p = 0.10, and organ injury, p = 0.001. Experimental testing showed that when the door angle changed from lower to upper border leading, peak T4 acceleration increased by 273% and pelvic acceleration decreased by 44%. The model demonstrated that when the door angle changed from lower to upper border leading, the USDOT SID showed a 29% increase in T4 acceleration and a 57% decrease in pelvic acceleration. The BIOSID dummy demonstrated a 36% increase in T1 acceleration, a 44% increase in abdominal rib 1 deflection, a 91% increase in thoracic rib 1 deflection, and a 33% decrease in pelvic acceleration.

CONCLUSIONS

These data add more insight to the problem of mismatch during side impacts, where the bumper of the striking vehicle overrides the door beam, causing the upper part of the door to lead the intrusion into the passenger compartment. Even with the same delta V and intrusion, with the upper border of the door leading, more severe chest and organ injuries resulted. This data suggests that door orientation should be considered when testing subsystems for side impact protection.

An evaluation of the association between vehicle type and the source and severity of pedestrian injuries

To evaluate the effect of vehicle type (passenger vehicle vs. light truck vehicle) on crash trajectory and on the consequent source and severity of pedestrian injury, we analyzed data from the Pedestrian Crash Data Study (PCDS), conducted by National Highway Traffic Safety Administration (NHTSA) from 1994 to 1998. While 62% of the adults in PV (passenger vehicle)-related crashes were carried by the vehicle, such pedestrian-vehicle interaction was observed only in 28% of LTV (light truck vehicle)-adult crashes. Being thrown forward or knocked down were the most common (65%) type of pedestrian-vehicle interactions for LTV-adult crashes. For children, 93% of those struck by LTVs and 46% of those struck by PVs were thrown forward or knocked down. For adults, LTVs were more likely than PVs to cause thorax (37% vs. 20%) and abdomen injuries (33% vs. 18%). For children, LTVs were more likely than PVs to cause injuries to the upper extremity (71% vs. 56%) and abdomen (14% vs. 8%). For adults struck by PVs the most common sources of injury were windshield for head injuries (63%), hood surface for thorax (67%), abdomen (58%), spine (30%), and upper extremity (36%) injuries, and bumper for the lower extremity injuries (60%). The leading causes of injury for adult-LTV crashes were ground for head (39%) and upper extremity (37%) injuries, hood edge for thorax (48%) and abdomen (56%) injuries, hood surface for spine injuries (36%), and bumper for lower extremity injuries (45%). For child-PV crashes, ground was the most common source of face (37%) abdomen (83%), spine (43%), and upper extremity injuries (54%). For children hit by LTVs, 52% of face, 67% of abdomen, 100% of spine, and 60% of upper extremity injuries were attributed to ground contacts. Altogether, the major sources of injury were hood surface and windshield for PV-pedestrian crashes and hood surface and hood edge for LTV-pedestrian crashes. Changes in design, such as altering the geometry and stiffness of front-end structures, might be associated with considerable decrease in the frequency and severity of pedestrian injury.

Factors affecting pelvic and thoracic forces in near-side impact crashes: a study of US-NCAP, NASS, and CIREN data

The goal of this study was to identify variables related to vehicle design which are associated with pelvic and thoracic accelerations as measured by the driver's (near side) crash dummy during new car assessment program (NCAP) testing of motor vehicles. Vehicle specific parameters were analyzed using NCAP side impact test results. Data from national automotive sampling system, crashworthiness data system (NASS-CDS) and crash injury research and engineering network (CIREN) (both National Highway Traffic Safety Administration (NHTSA) injury databases) were assessed to confirm NCAP test observations. In addition, door armrest stiffness measurements were performed using a mechanical tester on a sample of 40 vehicles. NCAP data showed that of 10 variables tested using multiple linear regression, vehicle weight and door crush correlated with pelvic acceleration of the driver's crash dummy (overall, r2=0.58, p=0.002, n=165). For thoracic trauma index (TTI) vehicle weight and peak door velocity correlated, significantly (overall, r2=0.41, p=0.03, n=165). Mean TTI was 63.7 g with no side airbag (n=108) and 55.6 g with a thoracic side airbag (n=54), p=0.01. The mean vehicle weight and door crush between airbag and no airbag groups were not significantly different. NASS-CDS data demonstrated a direct relationship between increased door crush and increased abbreviated injury score (AIS). CIREN data showed that occupants who sustained pelvic injuries had a median AIS of 3 with 24.9 cm of door crush, with abdominal injuries, a median AIS of 3 and 30 cm of crush, and with thoracic injuries, a median AIS of 4 and 34 cm of door crush. In addition, the frequency of bilateral pelvic injuries was significantly higher for subjects in CIREN crashes who were in a vehicle with a center console, but only if door intrusion was greater than 15 cm. This information may be useful in design of vehicles with greater protection in side impact crashes.

Pedestrian crashes: higher injury severity and mortality rate for light truck vehicles compared with passenger vehicles

INTRODUCTION

During the last two decades changes in vehicle design and increase in the number of the light truck vehicles (LTVs) and vans have led to changes in pedestrian injury profile. Due to the dynamic nature of the pedestrian crashes biomechanical aspects of collisions can be better evaluated in field studies.

DESIGN AND SETTING

s: The Pedestrian Crash Data Study, conducted from 1994 to 1998, provided a solid database upon which details and mechanism of pedestrian crashes can be investigated.

RESULTS

From 552 recorded cases in this database, 542 patients had complete injury related information, making a meaningful study of pedestrian crash characteristics possible. Pedestrians struck by LTVs had a higher risk (29%) of severe injuries (abbreviated injury scale >/=4) compared with passenger vehicles (18%) (p = 0.02). After adjustment for pedestrian age and impact speed, LTVs were associated with 3.0 times higher risk of severe injuries (95% confidence interval (CI) 1.26 to 7.29, p = 0.013). Mortality rate for pedestrians struck by LTVs (25%) was two times higher than that for passenger vehicles (12%) (p<0.001). Risk of death for LTV crashes after adjustment for pedestrian age and impact speed was 3.4 times higher than that for passenger vehicles (95% CI 1.45 to 7.81, p = 0.005).

CONCLUSION

Vehicle type strongly influences risk of severe injury and death to pedestrian. This may be due in part to the front end design of the vehicle. Hence vehicle front end design, especially for LTVs, should be considered in future motor vehicle safety standards.

Vehicle mismatch: injury patterns and severity

Light truck vehicles (LTV) are becoming more popular on US highways. This creates greater opportunity for collisions with passenger vehicles (PV). The mismatch in weight, stiffness, and height between LTV and PV has been surmised to result in increased fatalities among PV occupants when their vehicles collide with LTV. We reviewed cases of vehicle mismatch collisions in the Seattle Crash Injury Research and Engineering Network (CIREN) database to establish patterns and source of injury. Of the first 200 Seattle CIREN cases reviewed, 32 collisions with 41 occupant cases were found to involve LTV versus PV. The cases were reviewed by type of collision and vehicle of injured occupant: side impact of PV with LTV, front impact of PV with LTV, and front impact of LTV with PV. For each type of crash, injury patterns and mechanisms were identified. For side impact to PV, head and upper thorax injuries were frequently encountered due to LTV bumper frame contact above the PV side door reinforcement. For frontal impact to PV, severe multiple extremity fractures along with some head and chest injuries were caused by intrusion of the instrument panel and steering column due to bumper frame override of the LTV. Underriding of the PV when colliding with the LTV resulted in severe lower extremity fractures of the LTV occupant due to intrusion of the toe pan into the vehicle compartment of the LTV. The injuries and the sources identified in this case series support the need for re-designing both LTV and PV to improve vehicle compatibility. Revising Federal Motor Vehicle Safety Standard 214 to reinforce the entire door, consider adding side airbags, and re-engineering LTV bumpers and/or frame heights and PV front ends are possible ways to reduce these injuries and deaths by making the vehicles more compatible.

Correlation of head injury to vehicle contact points using crash injury research and engineering network data

Head injury is the most common cause of morbidity and mortality in motor vehicle crashes. Efforts to improve vehicle design, which minimize forces exerted to the occupant's head, may lead to a reduction in the frequency and severity of head injury. We therefore set out to identify mechanisms producing severe head injury in motor vehicle crashes (MVC) derived from the crash injury research and engineering network (CIREN) database. CIREN combines crash site analysis, vehicle damage assessment, and occupant kinematics in relation to the occupant's injuries. From the Seattle CIREN database of 101 cases, compiled from 1997 to 1998, we selected those crashes in which the occupant sustained severe head injury (abbreviated injury score, AIS>or=4) for analysis. We examined crash mechanism, energy transfer, point of head contact, vehicle intrusion and resulting injuries. There were 15 cases with severe head injury. These were primarily due to side impacts (n=10) in comparison to front impacts (n=5). The average net change in velocity (delta velocity, DV) was 15 mile/h (range 4-29 mile/h). In cases where the primary point of head contact could be elucidated the B-pillar predominated (4 cases, 33.3%) followed by the striking external object (2 cases, 16.7%), A- (1 case, 8.3%) and C- (1 case, 8.3%) pillars, roof side rail (1 case, 8.3%), windshield header (1 case, 8.3%), windowsill (1 case, 8.3%) and airbag (1 case, 8.3%). In this series the predominant mechanism of head injury was lateral impacts, especially those in which the victims' heads struck the B-pillar. The need for improved head protection from lateral impacts is indicated.

Are drivers more likely to injure their right or left foot in a frontal car crash: a crash and biomechanical investigation

In this study we hypothesized that for frontal crashes, the driver was more likely to sustain foot injury than the front seated passenger and the right foot was more likely to be injured than the left because the driver's right foot was positioned in dorsiflexion and eversion during the crash and less able to tolerate crash forces. Seventeen CIREN frontal crashes were studied to document the circumstances and resulting foot injuries. NASS data was sampled to determine frequencies of injury to foot side and occupant position. Biomechanically, matched pairs of cadaveric feet were tested in compression with one in dorsiflexion, and the other, dorsiflexion, and eversion. Results showed that drivers were more likely than passengers to sustain a foot or ankle injury and this was almost exclusively due to a higher frequency of right foot injuries in drivers. Braking, with significant toepan intrusion, was associated with an increase in both right and left foot injuries in drivers. Biomechanically, 9 of 15 pairs tested provided useable data. There was a significant decrease in load to failure between specimens forced into dorsiflexion and eversion (mean, 4107 N, sd = 1630 N) compared with dorsiflexion alone (mean, 6468 N, sd = 2435 N, p = 0.001). The majority (16 of 17) of foot injuries in the CIREN cases were to drivers of which 13 injured their right foot and ankle. An implication of this work is that if thresholds based on data from dorsiflexion and compression loading are used to predict foot and ankle injury in frontal crashes they may not represent that population of drivers who are braking at the time of the crash and could suffer injuries at forces lower than current threshold values.

Role of antibiotic prophylaxis for wound infection in percutaneous endoscopic gastrostomy (PEG): result of a prospective double-blind randomized trial

A randomized, double-blind, controlled trial was carried out to determine the value of antibiotic prophylaxis in the prevention of wound infection in percutaneous endoscopic gastrostomy (PEG) procedures. The wound was evaluated using ASEPSIS method and categorized as disturbance of healing, minor or major wound infection on the 7th day and the 28th day. The rate of infection including major wound infection was lower in the prophylaxis group of patients at both seven and 28 days.

Femur fractures in relatively low speed frontal crashes: the possible role of muscle forces

In a sample of relatively low speed frontal collisions (mean collision speed change of 40.7 kph) the only major injury suffered by the partly or fully restrained occupant was a femur fracture. However, femur load measurements from standardized barrier crash tests for similar vehicles at a greater speed change (mean of 56.3 kph) showed that in almost all the cases, the occupant's femur would not have fractured because the loads were below fracture threshold. In order to address this discrepancy, the load in the femurs of the occupants in the crash sample were estimated and compared with the femur fracture threshold. Femur load was estimated by inspecting the scene and measuring deformations in each vehicle, defining occupant points of contact and interior surface intrusion, and calculating crash change in velocity and deceleration. From this data, the measured femoral loads from standardized crash test data in a comparable vehicle were scaled to the actual crash by considering crash deceleration, occupant weight, and restraint use. All the occupants (7 males, average age 26.7 years, 13 females, average age 36 years) sustained at least a transverse midshaft fracture of the femur with comminution, which is characteristic of axial compressive impact, causing bending and impaction of the femur. However, the estimated average maximum axial load was 8187 N (S.D. = 4343N), and the average probability for fracture was only 19% (based on the femur fracture risk criteria). In 13 crashes the fracture probability was less than 10%. Two factors were considered to explain the discrepancy. The occupant's femur was out of position (typically the driver's right front leg on the brake) and did not impact the knee bolster, instead hitting stiffer regions of the dashboard. Also, since most victims were drivers with their foot on the brake to avoid the collision, additional compressive force on the femur probably resulted from muscle contraction due to bracing for impact. Adding the estimated muscle load on the femur to the estimated external load increased the femur loads beyond threshold, explaining the fracture in all but one case. Since crash tests using dummies cannot simulate out of position occupants or muscle contraction loading, they may underestimate the total load acting on the femur during actual impacts where the driver is bracing for the crash. These results may have implications for altering knee bolster design to accommodate out of position occupants and the additional load caused by muscle forces during bracing.

Clarifying the discussion on brain death

Definitions of death are based on subjective standards, priorities, and social conventions rather than on objective facts about the state of human physiology. It is the meaning assigned to the facts that determines when someone may be deemed to have died, not the facts themselves. Even though subjective standards for the diagnosis of death show remarkable consistency across communities, they are extrinsic. They are driven, implicitly or explicitly, by ideas about what benefits the community rather than what benefits the individual. The differences that do exist across communities generally reduce to questions about legitimacy and not fact. The questions at the core of the debate about brain death are better framed by asking: "Whom ought we deem to be dead?" rather than: "Who is dead." The rationale for equating brain death with death, therefore, extends well beyond somatic and biological concepts of death.

Prediction of aspiration in patients with newly diagnosed untreated advanced head and neck cancer

OBJECTIVES

To determine the prevalence of aspiration in patients with newly diagnosed nontreated advanced head and neck cancer and to determine the ability of the clinical examination to predict aspiration in this patient population.

DESIGN

A descriptive prevalence study of the presence of aspiration in patients with advanced (stages III and IV) head and neck cancer and a prospective correlation study between variables of the clinical evaluation with the criterion standard videofluoroscopy.

SETTING

Regional veterans affairs medical center.

PATIENTS

A consecutive sample of 27 patients without previous treatment or tracheostomy.

INTERVENTIONS

All patients underwent evaluation by an otolaryngologist and speech pathologist prior to videofluoroscopy.

MAIN OUTCOME MEASURES

Variables in the dysphagia evaluation (consisting of a directed medical history, physical examination, and food challenge), the self-rated 45-item questionnaire, and the clinicians "educated prediction" of aspiration were analyzed with reference to aspiration on videofluoroscopy using univariant analysis.

RESULTS

The prevalence of aspiration determined by videofluoroscopy was 41% (11 of 27 patients). Two (6%) of 32 items in the medical history, 1 (4%) of 25 items in the physical examination, and 8 (50%) of 16 items in the food challenge were found to be statistically significantly correlated (P<.05) with aspiration on videofluoroscopy by univariate analysis. Nine (25%) of 45 items in the self-rated questionnaire were correlated with aspiration on videofluoroscopy. The clinicians' educated prediction of aspiration was not correlated with aspiration determined by videofluoroscopy.

CONCLUSIONS

Clinical evaluation alone is inadequate in predicting patients who aspirated, determined objectively by videofluoroscopic swallowing study. Further study is needed to develop an efficient dysphagia evaluation to identify patients at risk for aspiration.

Long-term cancer risk in women given diethylstilbestrol (DES) during pregnancy

From 1940 through the 1960s, diethylstilbestrol (DES), a synthetic oestrogen, was given to pregnant women to prevent pregnancy complications and losses. Subsequent studies showed increased risks of reproductive tract abnormalities, particularly vaginal adenocarcinoma, in exposed daughters. An increased risk of breast cancer in the DES-exposed mothers was also found in some studies. In this report, we present further follow-up and a combined analysis of two cohorts of women who were exposed to DES during pregnancy. The purpose of our study was to evaluate maternal DES exposure in relation to risk of cancer, particularly tumours with a hormonal aetiology. DES exposure status was determined by a review of medical records of the Mothers Study cohort or clinical trial records of the Dieckmann Study. Poisson regression analyses were used to estimate relative risks (RR) and 95% confidence intervals (CI) for the relationship between DES and cancer occurrence. The study results demonstrated a modest association between DES exposure and breast cancer risk, RR = 1.27 (95% CI = 1.07-1.52). The increased risk was not exacerbated by a family history of breast cancer, or by use of oral contraceptives or hormone replacement therapy. We found no evidence that DES was associated with risk of ovarian, endometrial or other cancer.

ATP-stimulated smooth muscle cell proliferation requires independent ERK and PI3K signaling pathways

Vascular smooth muscle cells respond to the purinergic agonist ATP by increasing intracellular calcium concentration and increasing the rate of cell proliferation. In many cells the extracellular signal-regulated kinase (ERK) cascade plays an important role in cellular proliferation. We have studied the effect of extracellular ATP on ERK activation and cell proliferation. ATP binding to a UTP-sensitive P2Y nucleotide receptor activates ERK1/ERK2 in a time- and dose-dependent manner in coronary artery smooth muscle cells (CASMC). ATP-induced activation of ERK1/ERK2 is dependent on the dual-specificity kinase mitogen-activated protein kinase/ERK kinase (i.e., MEK) but independent of phosphatidylinositol 3-kinase (PI3K) activity. We provide evidence that both ERK1/ERK2 and PI3K activities are required for CASMC proliferation. Thus ATP-stimulation of CASMC proliferation requires independent activation of both the ERK and PI3K signaling pathways.

Training environment for inferior vena caval filter placement

This paper describes a Virtual Environment system designed to aid in training interventional radiologists in inferior vena cava filter placement. It is being developed as part of a VE simulator for a number of surgical and interventional radiology procedures at the Laboratory for Advanced Computer Applications in Medicine at the George Washington University. In this procedure a filter is placed in the inferior vena cava to prevent blood clots from the lower portion of the body from reaching the lungs and causing a pulmonary embolus. The simulation is designed to provide both tutorial and testing modes for the filter placement procedure.

HER-2/neu gene amplification status in prostate cancer by fluorescence in situ hybridization

HER-2/neu expression has been established as a prognostic factor in breast and other cancers. In prostate cancer (PC), a similar predictive role has been hindered by variable immunohistochemical (IHC) results. The authors studied DNA amplification of the HER-2/neu gene on 4-microm sections obtained from 62 formalin-fixed, paraffin-embedded PCs by fluorescence in situ hybridization (FISH). The results were compared with HER-2/neu protein expression as determined by IHC and correlated by logistic regression analysis with Gleason tumor grade, DNA ploidy, serum prostate specific antigen (PSA), and pathological stage. The HER-2/neu gene was localized using the Oncor (Gaithersburg, MD) digoxigenin-labeled unique sequence probe. Amplified PCs had at least 20 malignant cells, with 5 or more copies of the sequence. Amplification of HER-2/neu correlated with Gleason score (P = .0001). The mean Gleason score of unamplified tumors was 5.7 and that of amplified tumors was 7.5. Nondiploid tumors had a significantly greater rate of HER-2/neu amplification compared with diploid tumors (P = .0003). Of the 62 cases evaluated by IHC and FISH, 18 cases (29%) were overexpressed by IHC, and 27 cases (44%) were amplified by FISH. A trend for similar HER-2/neu status in each PC by the two methods did not reach statistical significance (P = .23). HER-2/neu amplification by FISH was associated with advanced pathological stage; however, this relationship reached only near-statistical significance (P = .06). There was no correlation of HER-2/neu amplification by FISH with patient age or preoperative serum PSA levels. The authors conclude that HER-2/neu gene amplification status can be determined by FISH on archival prostate cancer specimens, significantly correlates with high tumor grade and nondiploid DNA content, and is more frequently encountered in tumors with advanced pathological stage. Also, FISH is more sensitive than IHC for detection of abnormalities in the HER-2/neu gene, and further studies should be undertaken to determine whether a FISH-based HER-2/neu detection method may prove of importance in the prediction of prognosis and planning of therapy in prostate cancer patients.

The efficacy and safety of Skinner herpes simplex vaccine towards modulation of herpes genitalis; report of a prospective double-blind placebo-controlled trial

A randomised, placebo-controlled, multi-centre trial of intracellular subunit herpes simplex virus (HSV) type 1 vaccine NFU.Ac.HSV-1(S-)MRC (Skinner vaccine) was conducted at three medical centres in the United States. Subjects with documented herpes genitalis of at least 1-year duration and a history of six or more genital HSV recurrences in the 12 months prior to study entry were randomised to receive vaccine or placebo at 0, 1 and 2 months. Vaccination induced significant neutralising, enzyme-linked immunosorbent assay and lymphocyte transformation response to HSV-1 antigen. The frequency of recurrences was reduced in the vaccinated female patients at both 3 and 6 months following vaccination with an overall reduction in patients of both sexes which did not reach statistical significance. Recurrence severity was reduced as measured by decreased number of lesions and associated symptoms per recurrence (P = 0.04). The data suggest that clinical manifestations of latent HSV genital infection may be modified by therapeutic immunisation.

The frequency of cricopharyngeal dysfunction on videofluoroscopic swallowing studies in patients with dysphagia

PURPOSE

Dysphagia associated with cricopharyngeal dysfunction (CPD) is of particular interest to the otolaryngologist because it may respond to cricopharyngeal myotomy. There is a wide variation in the reported incidence of cricopharyngeal dysfunction in patients with dysphagia. This can be attributed to the different populations being studied, the lack of uniform criteria for diagnosis, and to different techniques used to evaluate patients. We have reviewed videofluoroscopic swallowing studies (VSS) conducted on 443 consecutive patients with complaints of dysphagia to identify the incidence of cricopharyngeal dysfunction.

PATIENTS AND METHODS

The patient population consists of 443 veterans with complaints of dysphagia who were evaluated by videofluoroscopic swallowing studies at the Department of Veterans Affairs Medical Center, East Orange, NJ, between November 1988 and March 1993.

RESULTS

Cricopharyngeal dysfunction was diagnosed radiologically as the appearance of a shelf in the posterior column of barium at the level of the cricoid cartilage. It was identified in 10 of 177 (5.7%) patients with neurological disorders, in 7 of 142 (4.9%) patients with head and neck or esophageal tumors, and in 11 of 124 (8.9%) patients with other medical problems.

CONCLUSION

These results do not support the notion that cricopharyngeal dysfunction is an important factor in a significant proportion of patients with dysphagia. It is recognized that videofluoroscopy may not always detect cricopharyngeal dysfunction and that better criteria for identifying this entity are needed.

Decreased levels of CD44 protein and mRNA in prostate carcinoma. Correlation with tumor grade and ploidy

BACKGROUND

CD44, a transmembrane protein, is associated with cell-cell and cell-matrix interaction and with tumor growth and metastasis. Expression of both standard form and variant isoforms of CD44 protein has been associated with aggressive behavior and metastasis in various tumors, but has not been characterized in prostate adenocarcinoma (PAC).

METHODS

The expression of CD44 standard (CD44s) and splice variant v3, v4/5, v6, v7/8, and v10 proteins were studied in 109 PACs and correlated with tumor grade, DNA ploidy, and mRNA levels. Monoclonal antibodies against the various CD44 proteins were applied to microwave irradiated, formalin fixed, paraffin embedded sections. The DNA content of the tumors was evaluated by the Feulgen method with the CAS200 Image Analyzer. Total RNA exhibiting 18s and 28s bands was derived from two benign prostatic tissues and 5 PACs exhibiting decreased levels of CD44 protein by immunohistochemistry. The RNA was analyzed with reverse transcriptase polymerase chain reaction using CD44 specific primers.

RESULTS

The basal cells of the benign prostatic acini revealed uniform membranous staining for CD44s, v3, and v6 in 95-97% of cases. Similar staining was observed for v4/5, v7/8, and v10 in 40%, 30%, and 2% of cases, respectively. Secretory epithelial cells of the benign prostatic acini showed predominant expression of CD44s (97% of cases). Staining for CD44 variant proteins (v3, v4/5, v6, v7/8, and v10) in this location ranged from 9-22% of cases. Approximately 70% of the PACs showed significant loss of CD44s expression, which correlated with high tumor grade (Gleason > or = 7) (P = 0.01) and aneuploid status (P = 0.002). In 93-98% of the PACS, there was a complete lack of membranous expression for all CD44 variant isoforms. The metastatic PACS did not show preferential expression of either the standard form or any variant isoform. The cDNA from the normal prostates yielded a prominent CD44 standard form polymerase chain reaction product at 482 base pair (bp) and variant isoforms at approximately 650 and 850 bp. No CD44 products could be amplified from the subset of five PAC cDNAs, even when present at four-fold excess.

CONCLUSIONS

PACS exhibit down-regulation of CD44 protein expression, which correlates with high tumor grade and aneuploidy. v6 and v3 isoforms were preferentially expressed in the basal cells of benign prostatic acini. Based on a subset of cases, loss of CD44 protein expression is associated with decreased abundance of CD44 mRNA.