Long-lived radiopharmaceuticals: Dispensing from multidose vials

We report the use of broth simulation as a means of validating the practice of sub-dispensing from stock vials of long-lived sterile radiopharmaceuticals. 'Matched' vials of nutrient broth accompanied the stock vials of long-lived sterile radiopharmaceuticals during their time in use and were subject to the same handling and storage procedures. At the end of the life of each radiopharmaceutical stock vial, the matching broth residue was sent for incubation and reporting. The results to date have yielded no reports of microbial contamination in any of the simulated broths (0 in 256).

Effect of raloxifene and its interaction with human PTH on bone formation

We studied the of effects raloxifene alone or in combination with human PTH (hPTH) 1-34 in mineralizing cultures of SaOS-2 cells. Raloxifene (10(-8)-10(-6) M) increased bone nodule formation in cultures of SaOS-2 cells when added intermittently from day 8 to day 17. A single 24-h treatment with 10(-8) M hPTH (1-34) at day 8 reduced the nodule area by 75.6% at day 17, and raloxifene added concomitantly with hPTH (1-34) reduced this inhibitory effect in a dose-dependent manner. Raloxifene also reduced the hPTH (1-34)-induced inhibition of alkaline phosphatase (ALP) activity. The 10-fold stimulation of c-fos mRNA expression by hPTH (1-34) was not influenced by raloxifene co-treatment. The protein kinase A (PKA) inhibitor 6-22 amide (1.7 nM) and the protein kinase C (PKC) inhibitor-bisindolylmaleimide 1 (10 nM) did not influence the separate effects of PTH and raloxifene on mineralized bone nodule formation. This is the first report on the interaction of PTH and raloxifene in an osteoblast culture system.

Rapid access multidisciplinary lymph node diagnostic clinic: analysis of 550 patients

Lymphadenopathy is common, affecting patients of all ages. The current referral pattern for investigating patients with lymphadenopathy varies widely with no universally practised pathway. Our institution set up a lymph node diagnostic clinic (LNDC) accepting direct referrals from primary care physicians. Details of clinical presentation and investigations were recorded prospectively. Between December 1996 and July 2001, 550 patients were referred (M: 203; F:347). The median age was 40 years (range 14-90). The median time between initial referral and the first clinic visit was 6 days. Of 95 patients diagnosed to have malignant diseases, the median time from the first clinic visit to reaching malignant diagnosis was 15 days. Multivariate logistic regression analysis identified five significant predictors for malignant nodes: male gender (risk ratio (RR)=2.72; 95% confidence interval (CI): 1.63-4.56), increasing age (RR=1.05; 95% CI: 1.04-1.07), white ethnicity (RR=3.01; 95% CI: 1.19-7.6) and sites of lymph nodes: supraclavicular region (RR=3.72; 95% CI: 1.52-9.12) and > or = 2 regions of lymph nodes (RR=6.41; 95% CI: 2.82-14.58). Ultrasound and fine-needle aspiration cytology of palpable lymph nodes were performed in 154 and 289 patients, respectively. An accuracy of 97 and 84% was found, respectively. In conclusion, a multidisciplinary lymph node diagnostic clinic enables a rapid, concerted approach to a common medical problem and patients with malignant diseases were diagnosed in a timely fashion.

Management of tick bites and early Lyme disease: a survey of Connecticut physicians

Practice guidelines have been published for the treatment of Lyme disease (LD). These guidelines have been challenged as inadequate. Two common LD management problems are antibiotic prophylaxis of deer tick bites (deer ticks may carry Borrelia burgdorferi, the spirochete that causes LD) and antibiotic treatment of erythema migrans, the pathognomonic rash of LD. A 1-page questionnaire was sent to a 13% (573/4300) sample of Connecticut physicians to define how they treat deer tick bites and erythema migrans. Questionnaires were returned by 320 (56%) of 573 physicians. Questionnaires were analyzed for the 267 physicians who saw patients with LD. Seventy (26%) of the 267 surveyed physicians prescribed antibiotic prophylaxis for patients with tick bites. B burgdorferi serology was ordered by 31% of physicians for patients with tick bites. Most surveyed physicians treated erythema migrans with doxycycline or amoxicillin for a mean of 21 days. Serology was ordered by 49% of physicians for patients with erythema migrans. Most physicians did not use prophylaxis for patients with deer tick bites. In addition, most of the physicians surveyed followed established guidelines for treating patients with erythema migrans. However, many of the physicians surveyed do serologic testing for patients with tick bites and/or erythema migrans. Serologic testing for these patients is usually not necessary.

Hyperammonemic coma caused by Providencia rettgeri infection in a child with prune belly syndrome

OBJECTIVE: To report a case of hyperammonemic encephalopathy in the absence of liver disease caused by a urinary tract infection with a previously unreported organism. DESIGN: Case report. SETTING: Pediatric intensive care unit. Patient: Critically ill child who presented with hyperammonemic coma. INTERVENTION: Bladder drainage and antimicrobial therapy for the urinary tract infection. Measurements: Rapid resolution of the hyperammonemia. MAIN RESULTS: Rapid improvement in the patient's neurologic status and a return to his baseline function without neurologic deficit. CONCLUSIONS: Patients with abnormal urinary collecting systems who present with altered mental status should have a serum ammonia concentration sent as part of the initial evaluation. We have added Providencia species to the list of documented causative organisms in this rare association between urinary tract infections and hyperammonemia.

Cancer statistics, 2001

Each year the American Cancer Society compiles estimates of the number of new cancer cases and deaths expected in the US in the current year and the most recent data on cancer incidence, mortality, and survival. An estimated 1,268,000 new cases of cancer will be diagnosed in the year 2001 and an estimated 553,400 Americans will die from cancer. Overall cancer incidence and death rates have continued to decrease in men and women since the early 1990s, and the decline in overall cancer mortality has been greater in recent years. Despite reductions in age-adjusted rates of cancer death, the total number of recorded cancer deaths in the US continues to increase, due to an aging and expanding population. Large disparities in cancer incidence and mortality across racial/ethnic groups continue. Black men and women experience higher incidence of cancer and poorer survival than white men and women. The disparity in survival reflects both diagnosis of cancer at later disease stages, and poorer survival within each stage of diagnosis.

The influence of osteoporotic fractures on health-related quality of life in community-dwelling men and women across Canada

Health-related quality of life (HRQL) was examined in relation to prevalent fractures in 4816 community-dwelling Canadian men and women 50 years and older participating in the Canadian Multicentre Osteoporosis Study (CaMos). Fractures were of three categories: clinically recognized main fractures, subclinical vertebral fractures and fractures at other sites. Main fractures were divided and analyzed at the hip, spine, wrist/forearm, pelvis and rib sites. Baseline assessments of anthropometric data, medical history, therapeutic drug use, spinal radiographs and prevalent fractures were obtained from all participants. The SF-36 instrument was used as a tool to measure HRQL. A total of 652 (13.5%) main fractures were reported. Results indicated that hip, spine, wrist/forearm, pelvis and rib fractures had occurred in 78 (1.6%), 40 (0.8%), 390 (8.1%), 19 (0.4%) and 125 (2.6%) individuals, respectively (subjects may have had more than one main fracture). Subjects who had experienced a main prevalent fracture had lower HRQL scores compared with non-fractured participants. The largest differences were observed in the physical functioning (-4.0; 95% confidence intervals (CI): -6.0, -2.0) and role-physical functioning domains (-5.8; 95% CI: -9.5, -2.2). In women, the physical functioning domain was most influenced by hip (-14.9%; 95% CI: -20.9, -9.0) and pelvis (-18.1; 95% CI: -27.6, -8.6) fractures. In men, the role-physical domain was most affected by hip fractures (-35.7; 95% CI: -60.4, -11.1). Subjects who experienced subclinical vertebral fractures had lower HRQL scores than those without prevalent fractures. In conclusion, HRQL was lower in the physical functioning domain in women and the role-physical domain in men who sustained main fractures at the hip. Subclinical vertebral fractures exerted a moderate effect on HRQL.

Culturing the throat to protect the heart: Dr. Milton Markowitz and the prevention of rheumatic fever

The purpose of this article is to briefly review how the understanding of rheumatic fever has evolved over the last 50 years. Particular emphasis is given to the identification of the Group A streptococcus as the causative agent of rheumatic fever and the use of antibiotics to treat and prevent rheumatic fever. Throughout his 50-year career, Dr. Milton Markowitz, former chairman of the department of pediatrics at the University of Connecticut School of Medicine, has been involved in these advances as an international expert on rheumatic fever prevention. Using archival materials, including some of the earliest literature descriptions of rheumatic fever, as well as an extended interview with Dr. Markowitz, the authors present a unique personal perspective both on the history of rheumatic fever and the context within which the scientific advances that have led to contemporary treatment and prevention strategies have evolved.

Eye muscle surgery

In the past year experimental studies have analyzed the ease with which specific sutures can be adjusted, have investigated ways to prevent adhesions in animal models, and have studied variations of the inferior oblique at the surgical capture site. Our knowledge of rectus extraocular muscle pulleys continues to improve, and the value of botulinum toxin type A in the treatment of several conditions has been further documented. New surgical techniques include slanted recessions of the lateral rectus muscles, combined monocular resection and bilateral anterior transposition of the inferior oblique, and intraoperative use of acetylcholine during inferior oblique myectomy. Favorable results have been reported after clinically important modifications to the superior oblique muscle silicone expander and anterior transposition of the inferior oblique procedures, as well as after bilateral inferior rectus muscle recession in dysthyroid ophthalmopathy. Conjunctival inclusion cysts, anterior segment ischemia despite microvascular dissection, and corneal topographic changes are reported as complications occurring after strabismus surgery. Recent publications discussing these issues are reviewed here.

Technetium-99m-tetrofosmin: retention of nitrogen atmosphere in kit vial as a cause of poor quality material

Technetium-99m (99Tc(m))-tetrofosmin was prepared using four different reconstitution methods. The radiochemical purity (RCP) of these products was assessed 8 h later using thin layer chromatography (TLC). Material produced using the original method supplied by the manufacturer and using an newer method, which involves the use of a vent needle and the addition of air, had acceptable RCP (mean +/- SD 94.2 +/- 1.1% and 94.7 +/- 1.7%, respectively) and similar chromatograms. In addition, both products showed good clinical efficacy and exhibited normal biodistribution behaviour. Preparing 99Tc(m)-tetrofosmin using the two other methods, one using a high radioactive concentration and the other maintaining the nitrogen content of the kit vial, gave rise to chromatograms with reduced RCP (63.5 +/- 10.9% and 61.9 +/- 7.6%, respectively) and greater levels of impurities. Although neither of these last two preparations was used clinically, we suggest that reports of poor quality images may be the result of administration of materials similar to these. Results for the high radioactive concentration method were as expected and are consistent with the restrictions imposed by the manufacturer. However, results using the last method are surprising and would suggest that the production of good quality 99Tc(m)-tetrofosmin is dependent on the quantity of nitrogen in the kit vial. We believe that the amount of nitrogen removed from the kit vial during the process of reconstitution is critical. If too much nitrogen is present this will result in poor quality material. In practice it is conceivable that there could be occasions when insufficient nitrogen is removed when following the manufacturer's original guidance, thereby leading to low RCP material. To ensure adequate nitrogen is removed during reconstitution, adoption of the manufacturer's revised method, involving the deliberate introduction of air, is therefore appropriate.

Characterization of ywhE, which encodes a putative high-molecular-weight class A penicillin-binding protein in Bacillus subtilis

The Bacillus subtilis genome sequencing project [Kunst et al., Nature 390 (1997) 249-256] identified ywhE as a gene that potentially encodes a high-molecular-weight class A penicillin-binding protein. Analysis of the expression of a translational ywhE-lacZ fusion showed that ywhE expression is sporulation-specific, and is controlled predominantly by the forespore-specific sigma factor sigma(F), and to a lesser extent by sigma(G). Primer extension analysis identified two transcription start sites located 26 and 27 nucleotides upstream of the ywhE translational initiation codon. Sequences located in the -10 and -35 regions relative to the transcription start sites showed good homology to the consensus sequences for promoter elements of sigma(F)-dependent genes. An insertional mutation in ywhE had no significant effect on growth, morphology, and sporulation, and ywhE spores had normal heat-resistance, cortex structure, and germination and outgrowth properties. However, overexpression of ywhE in Escherichia coli resulted in cell lysis.

99Tcm-MAG3: problems with radiochemical purity testing

The radiochemical purity (RCP) of 99Tcm-MAG3 was determined using solid-phase extraction (SPE), high-performance liquid chromatography (HPLC) and thin-layer chromatography (TLC). The difference between the HPLC and SPE methods was highly significant (P < 0.001), yielding values for RCP of 94.4 +/- 1.4% and 86.0 +/- 5.1% [corrected] respectively (mean +/- s). Further qualitative analysis of the SPE fractions obtained, was carried out using HPLC and TLC. The unexpected presence of 99Tcm-MAG3 in one of the fractions was observed together with the appearance of hydrophilic impurities in the hydrophobic extract. This lack of specificity may be the reason for the discrepancy between the SPE and HPLC methods. Use of the SPE method leads to an underestimation of the RCP of 99Tcm-MAG3 and, indeed, had we been relied solely on this method of analysis, we would have had to reject most kits we prepared. In a separate study, we compared a TLC method with HPLC. Differences were found to be highly significant (P < 0.001), yielding values of 98.3 +/- 0.6% and 95.8 +/- 0.9% respectively. Comparison of the data points showed that TLC gave consistently higher RCP yield than HPLC. This elevated value was found to be due to the inability of the TLC method to separate 99Tcm-lipophilic impurity, seen on HPLC, from the 99Tcm-MAG3. Therefore, use of this TLC method leads to an overestimation of the RCP of 99Tcm-MAG3.

Cancer statistics, 2000

The Surveillance Research Program of the American Cancer Society's Department of Epidemiology and Surveillance Research reports its annual compilation of estimated cancer incidence, mortality, and survival data for the United States in the year 2000. After 70 years of increases, the recorded number of total cancer deaths among men in the US declined for the first time from 1996 to 1997. This decrease in overall male mortality is the result of recent down-turns in lung and bronchus cancer deaths, prostate cancer deaths, and colon and rectum cancer deaths. Despite decreasing numbers of deaths from female breast cancer and colon and rectum cancer, mortality associated with lung and bronchus cancer among women continues to increase. Lung cancer is expected to account for 25% of all female cancer deaths in 2000. This report also includes a summary of global cancer mortality rates using data from the World Health Organization.

Eye muscles surgery

In the past year, experimental studies have analyzed instrument-induced measurement errors during strabismus surgery, investigated intraoperative variables pertinent to adjustable sutures, and investigated ways to prevent and create adhesions in animal models. Newer surgical techniques include coincident resection and recession of a rectus muscle, recession and resection without placement of scleral sutures, and modification of graded anterior transposition of the inferior obliques. Ocular motility problems related to thyroid ophthalmopathy, or lost muscles, as well as those occurring after surgery for retinal detachment remain a challenge. Patients may avoid the risks associated with the use of topical corticosteroids after strabismus surgery by using nonsteroidal anti-inflammatory drugs in their place. Recent contributions to the literature on these issues are reviewed here.

Administering a healthy dose of security

The article describes how a hospital located in a poor, crime-ridden section of a large city has made the most of in-house resources and public-private liaisons to improve security at its 113-acre campus. Details on the facility's double-pronged approach--tight internal security and strong external liaisons with businesses, law enforcement, and community groups--are provided.

Phase I clinical and pharmacokinetic study of PK1 [N-(2-hydroxypropyl)methacrylamide copolymer doxorubicin]: first member of a new class of chemotherapeutic agents-drug-polymer conjugates. Cancer Research Campaign Phase I/II Committee

PK1 comprises doxorubicin covalently bound to N-(2-hydroxypropyl)methacrylamide copolymer by a peptidyl linker. Following cellular uptake via pinocytosis, the linker is cleaved by lysosomal enzymes, allowing intratumoral drug release. Radically altered plasma and tumor pharmacokinetics, compared to free doxorubicin, and significant activity in animal tumors have been demonstrated preclinically. We aimed to determine the maximum tolerated dose, toxicity profile, and pharmacokinetics of PK1 as an i.v. infusion every 3 weeks to patients with refractory or resistant cancers. Altogether, 100 cycles were administered (range, 20-320 mg/m2 doxorubicin-equivalent) to 36 patients (20 males and 16 females) with a mean age of 58.3 years (age range, 34-72 years). The maximum tolerated dose was 320 mg/m2, and the dose-limiting toxicities were febrile neutropenia and mucositis. No congestive cardiac failure was seen despite individual cumulative doses up to 1680 mg/m2. Other anthracycline-like toxicities were attenuated. Pharmacokinetically, PK1 has a distribution t(1/2) of 1.8 h and an elimination t(1/2) averaging 93 h. 131I-labeled PK1 imaging suggests PK1 is taken up by some tumors. Responses (two partial and two minor responses) were seen in four patients with NSCLC, colorectal cancer, and anthracycline-resistant breast cancer. PK1 demonstrated antitumor activity in refractory cancers, no polymer-related toxicity, and proof of principle that polymer-drug conjugation decreases doxorubicin dose-limiting toxicities. The recommended Phase II dose is 280 mg/m2 every 3 weeks. Studies are planned in colorectal, NSCLC, and breast cancer patients.