Rapidly alternating radiotherapy and high dose cisplatin chemotherapy in stage IIIB non-small cell lung cancer: results of a phase I/II study

Alternating radiotherapy and chemotherapy increases tumor cure rates in some animal models with reduced normal tissue damage compared to sequential use of these modalities. To test this concept in non-small cell lung cancer, 23 patients with predominantly Stage IIIB disease were treated on a Northern California Oncology Group pilot study of alternating radiotherapy and high dose cisplatin. Radiotherapy consisted of 6000 cGy delivered in three separate 10-day courses of 200 cGy/fraction/day during weeks 1 and 2, 5 and 6, and 9 and 10. High dose cisplatin, 100 mg/m2 in 3% saline, was administered on weeks 3 and 4, 7 and 8, 11 and 12, and 15 and 16. The response rate in 22 eligible patients is 73% (16/22) with four complete responses and 12 partial responses. Feasibility of this approach is demonstrated by 20/22 patients completing radiotherapy and a median of 2.5 courses of chemotherapy administered. Median survival time is 14.2 months (range 2-40+ months). One- and 2-year survival rates are 64% (14/22) and 41% (9/22), respectively. Hematologic, renal, and radiation-related toxicities were significant but manageable. We conclude that rapid alternation of radiotherapy and a high dose intensity cisplatin regimen is feasible in Stage IIIB non-small cell lung cancer, with a high response rate and acceptable toxicity. The long-term impact on local control and survival remains unclear, although preliminary survival data are encouraging in this poor prognosis population. Further studies of this concept are warranted.

Role of diagnostic techniques in the initial evaluation of stab wounds to the anterior abdomen, back, and flank

Despite the widespread availability of firearms, stab wounds to the abdomen, back, and flank continue to account for a significant number of injuries. The proper sequencing of diagnostic modalities in this patient group is constantly undergoing change. We report our experience with these injuries and present a new algorithm for the use of currently available diagnostic procedures. In 1987, 162 patients were seen, 103 with anterior abdominal wounds and 59 with back and flank wounds. Patients with shock, peritonitis, and evisceration were resuscitated and explored. The remainder of the cohort underwent tap and lavage, and patients with a negative study were observed. Patients with back and flank wounds underwent contrast enhanced computerized tomographic enemas (CECTE). Seventeen patients underwent immediate exploration and 108 of the 162 patients were spared exploration. Fifty-four patients were explored with six negative laparotomies. Of the 126 taps and lavages, the false positive rate was zero, and only one patient had a false negative study. Of the 47 CECTE studies, only three were interpreted as an indication for angiography which proved negative, and all patients were safely observed. The overall mortality was 4.3%, including three patients without vital signs on admission and four who expired intraoperatively due to irreversible shock. We concluded that this algorithm can be safely applied to patients with these injuries with a high degree of specificity and sensitivity.

Clinical trials with etanidazole (SR-2508) by the Radiation Therapy Oncology Group (RTOG)

Following the completion of a phase I study of etanidazole (SR 2508), a new hypoxic cell sensitizer, the RTOG, began a phase II/III trial. The objectives of the study were to determine the toxicity and efficacy of SR 2508, combined with conventional radiotherapy for the management of unresectable stage III and IV head and neck squamous carcinomas. During the first step (or the Phase II portion) of the study, 33 patients received radiotherapy plus SR 2508 (RT + SR 2508). The incidence of drug toxicities was modest; including 24% grade I peripheral neuropathy (PN), 6% grade II PN, 27% grade I or II nausea and vomiting, 9% allergy and 15% reversible neutropenia. Because observed toxicities were deemed acceptable, the second step (or phase III portion) was then activated. Patients were randomized to receive either RT or RT + SR 2508. As of November 20, 1989, a total of 242 patients have been entered onto the Phase III portion of the study. One hundred twenty-two patients were randomized to the RT + SR 2508 arm and 120 patients were randomized to the RT alone arm. The analyses presented in this report are based on data available. The incidence of drug toxicities has been low, with 18% grade I or II PN, 26% nausea and vomiting (including one grade III), 14% allergy (including one grade III) and 13% reversible neutropenia.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased expression of a putative adenoma-associated antigen in pre-colonoscopic effluent of patients with colorectal cancer

A monoclonal antibody Adnab-9, was raised against antigens derived from benign polyps of the colon. Adnab-9 was tested against pre-colonoscopic effluent material obtained from groups of patients with a macroscopically normal colonscopic examination, histologically confirmed adenomatous polyps and patients with colorectal cancer (CRC). The resultant binding levels displayed little overlap between the CRC group and the normal, and the difference was statistically significant. Since this putative early neoplasia associated antigen is essentially not expressed in CRC extracts, it may originate from a region of the colon predisposed to neoplasia, increasing in expression as the tendency to malignancy progresses, useful in the diagnosis of early stage malignancy.

Preliminary results of concurrent radiotherapy and chemotherapy in advanced cervical carcinoma: a phase I-II prospective intergroup NCOG-RTOG Study

Thirty-eight patients with advanced carcinoma of the cervix were prospectively treated with a concurrent combination of radiotherapy (RT) and chemotherapy (CT) using the drugs 5-fluorouracil (5FU), mitomycin C and cis-platinum as part of a Northern California Oncology Group (NCOG) and Radiation Therapy Oncology Group (RTOG) intergroup study. RT consisted of 36.00 Gy to the pelvis in 4 weeks followed by a 9.00-Gy parametrial boost. This was followed by two intracavitary applications for a total of 4000 mg hr of radium equivalent when possible. 5FU (1000 mg/m2/24 hr for 96 hr by iv infusion) and mitomycin C (10 mg/m2/iv bolus) were given during the second week of external RT. 5FU (dose as above) and cis-platinum (75 mg/m2/iv over 6 hr) were given during the first intracavitary application. Of 36 patients evaluable for toxicity, 11% had grade 3 nonhematological toxicity and 11% had reversible grade 4 hematological toxicity. There were no toxic deaths. A complete response rate of 62.5% was obtained overall (median survival not reached). This study suggests that this particular combination of RT and CT in advanced cervical carcinoma is effective and well tolerated.

A CT-based computerized treatment planning system for I-125 stereotactic brain implants

A computer program has been developed at the University of California, San Francisco, as an aid in planning and evaluating stereotactic brain implants made with 125I seeds. The program allows images of seeds and catheters to be positioned in the target volume revealed by CT. It then generates and displays the resulting isodose distributions. Catheters may be changed interactively until an optimum implant is achieved. From the geometry of a stereotactic implant frame as measured by CT, the program calculates the approach angles of the catheters in the frame coordinate system. After the seeds are implanted, films made with a fiducial marker box can be used to generate true seed positions and hence true isodoses. This paper describes mathematically the geometrical transformations used by the program, and also outlines its many features and options. In its first 2 years of use the program has proved to be a valuable contributor to improved patient care.

Site-directed chemical modification and cross-linking of a monoclonal antibody using equilibrium transfer alkylating cross-link reagents

A new, more reactive group of protein cross-linkers in the class of equilibrium transfer alkylating cross-link (ETAC) reagents has been synthesized. These compounds include alpha,alpha-bis[(p-chlorophenyl)methyl]- and alpha,alpha-bis[(p-tolylsulfonyl)methyl]acetophenones substituted in the acetophenone ring with chloro, nitro, amino, and carboxyl groups and derivatives. Included are an 125I-labeled ETAC reagent and a 111In-labeled DTPA (diethylenetriaminepentaacetic acid) ETAC for site direction and biodistribution studies. These ETAC compounds were reacted with unreduced and partially reduced antibody under mild pH (pH 4-8) and room temperature conditions to give cross-linked structures. Examination of resultant cross-linked antibody via size-exclusion HPLC, sodium dodecyl sulfate (SDS) polyacrylamide gel electrophoresis, and an enzyme linked immunosorbent assay revealed that (1) both interantibody as well as intraantibody cross-linking had occurred; (2) the level of inter- and intraantibody cross-linking varied with the substituent on the ETAC; (3) the stability of the cross-links on the reducing SDS gels varied with substituents on the ETAC; (4) little if any immunoreactivity was lost after reaction with one of the more effective ETAC cross-linking compounds; (5) the 125I-labeled ETAC sulfhydryl cross-linking in partially reduced antibody increased with pH whereas amine cross-linking with the unreduced antibody decreased with pH; (6) the optimum pH for sulfhydryl site direction was pH 5.0; (7) the 111In DTPA ETAC labeled antibody had a biodistribution in CD1 mice similar to that of the 111In bis cyclic anhydride DTPA labeled antibody.

Ventilatory response to an inhaled constant CO2 load and added dead space in healthy men, awake and asleep

Experiments were conducted in ten adult men to determine if rapid-eye-movement sleep (REMS) reduced the ventilatory response to two 'steady-state' respiratory loads compared to slow wave sleep (SWS). A constant addition of 150 (or 200) ml/min pure CO2 to the inspirate (7 subjects) and 230 ml of added dead space (5 subjects) were the two respiratory loads. Inspiratory ventilation was measured by pneumotachygraph for at least five continuous minutes in wakefulness, SWS and REMS. The increase in ventilation to both stimuli was equal in SWS and REMS with no suggestion of an impaired response during the latter: increases in ventilation during CO2 loading being 49 and 51%, SWS and REMS, respectively, and during additional dead space they were 53 and 59%, SWS and REMS, respectively. Following the addition of extra dead space, end tidal PCO2 levels did not rise significantly more during REMS compared to SWS (P greater than 0.5). These findings show that when ventilatory responses to CO2 are considered across the whole of REMS (including periods with and without actual eye-movements) then they do not appear to be blunted compared to SWS.

Intra-epidermal neutrophilic IgA dermatosis with colitis

We report the association of an intra-epidermal blistering disease of the skin with colitis. Both the skin and large bowel epithelium were infiltrated by neutrophils and eosinophils, and showed intra-epithelial deposition of IgA in an intercellular pattern. The colitis and the blisters responded well to treatment with dapsone.

Exposure of the internal carotid artery near the skull base: the posterolateral anatomic approach

Internal carotid injuries in zone III near the base of the skull are technically the most challenging of the carotid injuries. Diagnostic angiography is important to evaluate the exact site and extent of injury and the presence or absence of prograde flow in the injured segment. Vascular repair in this area is highly dependent on the adequacy of surgical exposure. Previous approaches have emphasized displacement of the mandible either by subluxation or mandibulotomy. Problems related to mandibulotomy, such as intraoral contamination, infection, and nonunion, are potential complications of this approach to the high carotid artery. In addition, it does not give adequate exposure of the internal carotid artery at the critical area, near the base of the skull. Experience gained from the extended radical neck dissection exposing the internal carotid artery up to the skull base has demonstrated that a posterolateral anatomic approach can provide superior exposure of the high carotid artery with lower morbidity and shortened operative time. This surgical approach involves cutting the sternomastoid muscle close to the mastoid and dissecting all the tissues away from the surface of the mastoid. Dividing the posterior belly of the digastric and styloid group of muscles assists in exposure of the internal carotid artery. Rarely, dissection of the facial nerve and removal of the tail of parotid add additional access to this area. This article describes the stepwise anatomic approach to the internal carotid artery near the base of the skull.

Improved dose distribution with customized I-125 source loading in temporary interstitial implants

I-125 sources are being used in temporary interstitial implants of various sites. Radiation safety considerations favor its use over other available radioisotopes. Cost containment is achieved by using the same sources for a number of patients. Loading I-125 seeds into implant catheters at our institutions permit customized source arrangement to optimize the implant dose patterns. Clinical examples are given for which the dose distributions achieved with customized source loading are superior to those achievable with standard Ir-192 ribbons.

Postmortem stability of somatostatin in brain tissue

The stability of somatostatin (SS) in brain tissue was studied in human material obtained post-mortem and in the rat. In both human and rat brain, loss of SS was found to occur in tissue frozen to -70 degrees C. In the rat, this loss varied from 26 to 70 percent depending on the type of tissue processing used. These data suggest that, for the study of SS in post-mortem brain, use of frozen material should be avoided.

Primary intraocular lymphoma (ocular reticulum cell sarcoma) diagnosis and management

The authors retrospectively reviewed the diagnosis and management of 20 intraocular lymphoma patients who initially presented with either ocular or central nervous system (CNS) disease. As the ophthalmic community has become more aware of this entity, the interval between symptoms and diagnosis has significantly shortened. Diagnosis can usually be made on cytopathologic examination of vitreous cells. However, in three cases more than one vitreous biopsy was necessary. Results of cytologic examination appeared to be more accurate than those of conventional lymphocyte surface marker studies in the diagnosis of an intraocular lymphoma. Long-term survival occurred in some patients treated with a combination of intrathecal chemotherapy and ocular/CNS irradiation.

Vertebral artery injury--diagnosis and management

The literature on vascular trauma contains little information on the management of vertebral artery injuries. We have reviewed our experience consisting of 23 patients with vertebral artery injuries caused by 19 gunshot wounds, two stab wounds, one shotgun wound, and one blunt injury. Twelve patients sustained unilateral vertebral artery thrombosis, seven patients had vertebral AV fistulae (three jugular vein, four vertebral vein) and four patients sustained mural injury without thrombosis. Six patients (26.1%) developed major neurologic deficits of which five could be directly attributed to CNS missile injury. One patient had transient vertebrobasilar ischemia on the basis of a vertebral AV fistula. Four of the seven vertebral AV fistulae were managed solely by therapeutic embolization and two patients early in the series underwent surgical management alone. One patient had therapeutic embolization of the proximal vertebral artery and operative distal vertebral artery ligation for an AV fistula. The four patients who died (17.4%) did so as a direct result of their CNS missile injury. We conclude that: 1) unilateral vertebral artery occlusion seldom results in a neurologic deficit if there is a normal contralateral vertebral artery and PICA (posterior inferior cerebellar artery) blood supply is preserved; 2) accurate assessment of a vertebral artery injury requires contralateral vertebral arteriogram; 3) management of vertebral artery injury is simplified by proximal, and if possible distal, therapeutic embolization; 4) an anterior approach to the C1-2 vertebral artery is a satisfactory method of obtaining distal surgical control, obviating the need to unroof the bony canal of the vertebral artery; 5) angiography is necessary in penetrating neck trauma to identify occult vascular injuries.

Effects of intraventricular methotrexate on cerebrospinal fluid monoamine metabolites in rhesus monkeys

Previous work suggested that methotrexate (MTX) may cause encephalopathy by inhibiting biosynthetic pathways for dopamine and serotonin in the brain. We examined this issue by measuring the neurotransmitter metabolites homovanillic acid and 5-hydroxyindoleacetic acid in the lumbar CSF of rhesus monkeys receiving continuous intracerebroventricular infusions of MTX or dichloromethotrexate. Infusion of the lowest dose (0.05 mg/day) produced a large (300%) rise in homovanillic acid levels and a modest elevation in 5-hydroxy-indoleacetic acid. During higher dose infusion, which was associated with clinical encephalopathy, the biogenic amine metabolites fell from their previous elevated levels. In one encephalopathic monkey, an injection of 1 mg of leucovorin produced a marked elevation in CSF monoamine metabolites within 1 hour and rapid clinical recovery. In contrast, leucovorin produced no change in monoamine metabolites in control animals. The data suggest that MTX may block egress of monoamine metabolites from CSF at the lower doses and suppress neurotransmitter turnover at toxic doses which cause encephalopathy. Serial measurements of CSF monoamine metabolites deserve further investigation as biochemical markers for toxic effects of MTX on neuronal metabolism in the CNS.

Acute spinal cord ischemia: prevention of paraplegia with verapamil

Although irreversible damage to the central nervous system has been considered inevitable after 6 min of circulatory deprivation, there has been evidence for almost 20 years that this may be the consequence of postischemic events. Recent investigations have implicated calcium-mediated phenomena as responsible for damage to neuronal cells in the reperfusion period. We studied the effect of verapamil on the neurologic sequelae of spinal cord ischemia using somatosensory evoked potential monitoring in a canine preparation of spinal cord ischemia. Ten mongrel dogs weighing between 20 and 30 kg each were divided into two groups. The experimental group was pretreated with 0.4 mg/kg verapamil and the control group received no treatment. The thoracic aorta was then occluded. Flow was restored 17 min after there was complete loss of somatosensory evoked potentials. Experimental dogs received additional doses of verapamil upon reperfusion and at 1, 2, 3, 4, 5, 6, and 10 hr after reperfusion. Four of five verapamil-treated dogs were able to walk postoperatively, whereas all of the control dogs suffered dense paraplegias (p = .02). We conclude that verapamil can ameliorate the sequelae of spinal cord ischemia and that this preparation is suitable for the study of the mechanisms of ischemic neuronal damage in an area outside the brain.

African swine fever. I. Morphological changes and virus replication in blood platelets of pigs infected with virulent haemadsorbing and non-haemadsorbing isolates

Replicating and mature viral particles were detected with the transmission electron microscope in blood platelets of pigs infected with virulent haemadsorbing and non-haemadsorbing African swine fever virus isolates. Although platelet numbers decreased terminally in infected pigs, the most noticeable morphological damage to these cells apparent in the last 2 days of the disease included cytoplasmic swelling, vacuolation, fragmentation and loss of dense granules.

An analysis of 161 falls from a height: the 'jumper syndrome'

Vertical deceleration injuries represent a distinct form of urban blunt trauma. We reviewed 161 adult patients, admitted over 36 months, who jumped or fell from a height of one to seven stories and survived emergency department resuscitation. Charts and radiographs were analyzed to identify common injuries, complications, and causes of death. Those who fell five or more stories had a mean ISS of 41, for a predicted survival of 50% but actual survival of 83%. Virtually all these patients had multiple fractures. Sixty per cent of them presented in shock, yet more than two thirds had angiographically demonstrated retroperitoneal hemorrhage as their major source of bleeding. Thirteen patients had significant intra-abdominal injuries, with only one associated with major hemorrhage. Utilizing early diagnostic peritoneal lavage, ten of 13 patients explored had a therapeutic laparotomy. Hollow viscus perforations accounted for about one half of the abdominal injuries, including three duodenal injuries. Conclusions. 1) Patients who present in shock after falls from height are much more likely to be bleeding from retroperitoneal than intraperitoneal sources. 2) Early tap and lavage followed by emergency angiography and transcatheter embolization is the treatment of choice in this group of patients. 3) Although these patients often have multiple complex injuries, the prognosis for long-term survival is good. Therefore, we advocate early aggressive operation stabilization of fractures to permit patient mobilization, facilitate pulmonary toilet and nursing care, and to decrease long-term disability.

Use of the contrast-enhanced CT enema in the management of penetrating trauma to the flank and back

There have been few innovations in the management of penetrating trauma of the flank and back since that reported by Peck and Berne in 1981. During 1984-1985 our Trauma Service treated 119 patients with injuries in these areas. In 56 patients management was based on the results of the contrast-enhanced CT enema (CECTE), a computerized tomographic technique designed to delineate all of the retroperitoneal viscera by simultaneously opacifying the small bowel, duodenum, colon, GU tract, and major vessels. Specific radiographic findings were present on 44 scans. Twelve scans were negative. Six scans were considered indications for angiography because of the proximity of the identified missile wounds or their hematomas to major vascular structures. One of these arteriograms revealed a renal artery pseudoaneurysm which would otherwise have remained undiagnosed. In 30 cases the penetrating wounds were well delineated by CECTE, and their nature and location were considered appropriate for nonoperative management. None required subsequent exploration. In eight cases CECTE demonstrated that the wounds were located so as to place specific viscera at risk for significant injury, but no definite injury was identified. Five of these patients were successfully managed by further evaluation and close observation, two were explored, and one signed out of the hospital. No scan demonstrated extravasation from a hollow viscus. Overall, 52 of our 56 patients (92%) were successfully managed nonoperatively on the basis of the interpretation of their CECTE findings. CECTE can be useful in the management of stable patients with penetrating trauma to the back and flank by identifying the nature and location of the resulting retroperitoneal injuries.(ABSTRACT TRUNCATED AT 250 WORDS)

In vivo modulation of glutathione by buthionine sulfoximine: effect on marrow response to melphalan

The effect of giving buthionine sulfoximine (BSO), 0.0265 g/mouse (6 mM), at 12 and 6 hr before treatment with melphalan--0.0 mg, 3 mg, 6 mg, and 9 mg/kg, was studied in C3H mice, and was compared with control groups that received normal saline 12 and 6 hr before identical melphalan treatment. BSO treatment resulted in depletion of GSH levels in bone marrow, liver, and muscle to 65, 13, and 41% of control levels, respectively. Hematological toxicity was assessed by measurement of CFU-S survival and peripheral white cell counts. CFU-S survival decreased with increasing doses of melphalan, but no difference was observed with BSO pre-treatment. Likewise, WBC counts following melphalan 9 mg/kg, were similar irrespective of BSO pre-treatment. These data suggest that the marrow toxicity seen with melphalan is not worsened by pre-treatment with BSO and that if tumors can be pre-sensitized with BSO, there may be a clinical role for melphalan/BSO drug combination.

Early open reduction and internal fixation of the disrupted pelvic ring

Early open reduction and internal fixation (ORIF) of extremity fractures in patients with multiple injuries has been demonstrated to be safe, improve survival, and decrease the incidence of respiratory failure. Complications leading to abandonment of planned operative fixation and death in several patients with pelvic fractures led us to initiate a policy of early ORIF of the disrupted pelvic ring. Early ORIF of the pelvis was performed in 15 multiply injured patients between May 1984 and August 1985. Patients ranged in age from 13 to 79 years, their Hospital Trauma Index-ISS scores ranged from 14 to 68, and number of preoperative transfusions ranged from 0 to 42. Types of fractures were A-P compression, two, lateral compression, one, vertical shear, seven, complex, two, and acetabulum with ring disruption, three. All patients were resuscitated, transported in pneumatic antishock garments, and evaluated by abdominal and pelvic CT scan (in two patients following celiotomy). Preoperative angiograms to assess retroperitoneal hemorrhage in eight patients resulted in identification and control of significant bleeding in five. The mean time from injury to pelvic stabilization was 38 hours. Seven patients underwent ORIF within the first 24 hours. In most cases simultaneous anterior and posterior internal fixation was performed with the patient in the lateral decubitus position. Excluding associated procedures, operative time averaged 5.1 hours. Intra-operative transfusions averaged 4 units (range, 0-11). Rigid fixation was achieved in all patients. Most patients were out of bed by the third postoperative day. No patient developed respiratory failure. Two patients developed wound infections. Modification of our technique has avoided this complication in the latter part of this series.(ABSTRACT TRUNCATED AT 250 WORDS)

The diagnostic superiority of computerized tomography

One hundred three patients with blunt abdominal trauma were studied using computerized tomography (CT). By protocol CT was performed in hemodynamically stable adults either: before tap and lavage (T&L)--32 patients; after 'negative' (less than 20,000 RBC/mm3) or 'borderline' (20,000-50,000 RBC/mm3) lavage--28 patients; or to evaluate hematuria--43 patients. CT was performed after administration of oral and intravenous contrast. A comparison of T&L and CT was made in 60 patients. 16 of 42 patients with negative lavage had 22 injuries identified by CT. One of these patients with bilateral renal artery transection, mesenteric and pararenal hematomas died of a closed head injury. Six of 14 patients with borderline lavage results had nine injuries found on CT, including two with actively bleeding spleens confirmed at operation or angiography. One patient with a large retroperitoneal hematoma underwent successful control of hemorrhage by embolization. Only one injury, a paranephric hematoma found at operation was not identified preoperatively by CT. Seventeen of 85 patients with hematuria had GU abnormalities identified by CT. Findings included seven intrarenal hematomas or contusions, three fractures, three major renovascular injuries, four para- and six perinephric hematomas, and three collection system injuries with extravasation. The majority of these injuries were found in patients with more than 50 RBC/HPF; however, six of 47 patients with less than 20 RBC/HPF had abnormalities including a retroperitoneal bladder perforation and a renal mass (hypernephroma). Two bladder perforations and one urethral injury were identified by CT cystogram. Abdominal CT is more sensitive and specific than T&L or IVP.(ABSTRACT TRUNCATED AT 250 WORDS)

Hemipelvectomy, a lifesaving operation in severe open pelvic injury in childhood

Near-complete traumatic hemipelvectomy probably carries an extremely high mortality rate. The usual techniques which have been used to control major hemorrhage associated with pelvic fractures such as transperitoneal vascular ligation, intra-arterial embolization, and packing are not applicable (14). Successful management requires prompt recognition of the nature of this injury so that surgical efforts may be directed at resuscitation and expeditious operative completion of the traumatic amputation. When this decision is made appropriately, the dual goals of control of hemorrhage and prevention of sepsis can be achieved. We report the management of a 7-year-old boy who sustained this injury after being struck by a tractor-trailer. In spite of massive resuscitation, hemorrhage could not be controlled and the child remained in shock. When it was recognized that he had sustained an incomplete traumatic left hemipelvectomy, it was surgically completed, permitting prompt control of the hemorrhage and restoration of hemodynamic stability. Intestinal and urinary diversion allowed an uneventful postoperative recovery without significant infection. Although hemipelvectomy appears to be a radical procedure in children with major pelvic injuries, it may be lifesaving and should therefore be considered in those with severe unilateral pelvic injury and uncontrollable hemorrhage. The potential for physical rehabilitation in the group of young, mostly male patients who have survived this injury appears to be unexpectedly good.

A comparison of lenient and strict operant conditioning programmes in refeeding patients with anorexia nervosa

The present paper compares a lenient and a strict operant conditioning programme in refeeding patients with anorexia nervosa. Sixty-five consecutive in-patients participated in the study. We found no significant difference in the rate of weight-gain between the two treatments. There were, however, a number of practical advantages in using the more lenient programme: it was more economical of nursing time, and patients were more accessible to psychotherapy. The programme was also more acceptable to the patients.

Traumatic hemipelvectomy: report of two survivors and review

Two surviving patients with traumatic hemipelvectomy are presented. Rapid transport, aggressive initial resuscitation, and attention to detail in the rehabilitation phase are necessary for the successful management of these patients. The viability of the psoas muscle should be assessed, because of the high possibility of avulsion. Associated nerve injury and complicating meningitis can be serious problems in the management of such patients. There is need to include this entity in the existing classifications of pelvic fractures. Hemipelvectomy is proposed as an alternative in the management of the severe unilateral open pelvic fracture with uncontrollable bleeding.

Plasma vasopressin and blood pressure. Studies in normal subjects and in benign essential hypertension at rest and after postural challenge

Plasma vasopressin levels were compared in three groups comprising normotensive, mildly hypertensive, and more severely hypertensive patients, both under basal conditions and following an 85 degrees head-up tilt, a stimulus known to provoke vasopressin release in man. Vasopressin levels increased two- to fivefold in all subjects after tilt; however, neither the basal levels nor the maximal levels attained at 45 to 60 minutes after tilt differed in the three groups. These data do not support the postulated role for vasopressin in the causation or perpetuation of non-accelerated essential hypertension in man.

The influence of glucose on serum galactose levels in man

To investigate the effect of simultaneous glucose and galactose administration on serum galactose levels in man, volunteers were given a standard galactose meal of 0.5 g galactose/kg BW alone and with various body weight related glucose loads and with fructose; lactose was also given to a group of volunteers. Two groups of subjects received the standard galactose meal alone and with a simultaneous intravenous infusion of glucose or insulin. There was a marked individual variation in the serum galactose response to the standard galactose meal, the maximum galactosemia ranged from 0.23 to 4.56 mmole/L. Peroral glucose suppressed the serum galactose response to galactose producing significant reductions in the mean area under the serum galactose response curves. At a glucose intake of 0.15 g/kg by-32 +/- 14.3%, 0.50 g/kg BW -69 +/- 5.93% and at 0.75 g/kg BW -75 +/- 4.93%. Ingestion of glucose with galactose did not increase galactose loss in the urine. Lactose produced similar serum galactose, glucose and insulin responses to those seen after administration of equal quantities of galactose and glucose as monosaccharides. Fructose did not affect serum galactose levels when given with the standard galactose meal. Intravenous glucose produced a significant reduction of 56 +/- 14.1% in the mean area under the galactose response curve [p less than 0.01], whereas intravenous insulin did not affect the serum galactose response to peroral galactose.

Antimelanoma hybridoma antibodies against partially purified melanoma antigen

We have immunised BALB/c mice with a melanoma antigen obtained after papain solubilisation of the membranes of a metastatic melanoma tumour and fused the immune spleen cells to the mouse myeloma line P3-NS1/1-Ag4.1. The produced hybridoma antibodies (Mel-PV antibodies) recognised the initial melanoma antigen in haemagglutination, but did not react with any of the HLA phenotypes tested by cytotoxicity on a panel of B lymphocytes with known HLA-A and B phenotypes. We rosetted red blood cells coated with protein A with dispersed cells from fresh melanoma tumours, and a high degree of specificity for human malignant melanocytes was observed. Purified Mel-PV antibodies were also tested by indirect immunofluorescence and found to be oriented towards cytoplasmic components of malignant melanoma cells. These results indicate that the use of melanoma antigens for preparing monoclonal antibodies maintained a satisfactory degree of specificity and may be an adequate starting point for defining common and specific antigenic determinants on human melanoma.

Phase I trial of Staphylococcus aureus Cowan I immunoperfusion

Staphylococcus aureus Cowan I has shown antitumor activity in in vitro and in animal tumor models. It is hypothesized that this antineoplastic effect results from the interaction of protein A on the cell surface of Cowan I strain S. aureus and immunosuppressive circulating immune complexes. Therefore, we treated five patients with ex vivo plasma immuno-perfusion over killed and fixed S. aureus Cowan I. Toxic effects were marked in all patients and appeared to be related to the plasma volume infused and rate of infusion. Toxic reactions occurred in the cardiovascular, respiratory, and hematopoietic systems. No responses even minimal or transient, were observed in this phase I trial. This toxicity may be reduced if the rate of plasma infusion decreases.

Preliminary results of RTOG phase I/II study of misonidazole and radiation for bladder cancer

Eleven patients were entered in a phase I/II study to evaluate the toxicity and effectiveness of the use of misonidazole with radiation in cancer of the bladder. The radiation fractionization used is shown in Figure 1. Misonidazole was administered in a dose of 1.5 g/m2, 4-6 hours before the radiation dose. The large radiation dose (400 rad) used with misonidazole was designed to obtain maximum enhancement of radiation sensitizer effect. Only minor misonidazole toxicity was observed. Tumor regression was dramatic, with 7/9 patients achieving complete regression of disease. Three patients however, developed severe small bowel complications, probably from the unconventional radiation fractionation used. In view of this high complication rate, this study was terminated.

Alterations in heart rate and rhythm at urography with sodium diatrizoate

One hundred and thirty-five consecutive patients referred for urography were monitored electrocardiographically before, during and after injection of 60 ml Hypaque 45% (sodium diatrizoate 45% w/v) over 60 seconds. The injection produced a significant increase in heart rate, while venepuncture alone had no such effect. Twenty-nine (21%) patients developed minor arrhythmias and 6 (4.4%) major arrhythmias following the injection. Major arrhythmias occurred in the older age groups and were more frequent in males. An abnormal baseline rhythm strip had significant predictive value in determining the development of further arrhythmias.

Effect of brain growth stages on T-maze acquisition in mice

Recently, it has been shown that brain growth is characterized by periods of especially large increases in growth, with "plateaus" in growth between these "spurt" periods. In humans, these spurts in brain growth are correlated with spurts in mind growth, collectively termed phrenoblysis. Brain growth spurts in rodents occur at 0-6, 8-12, and 17-23 days of age with plateaus in-between. We examined two questions. First, are there differences in learning ability associated with spurts and plateaus in brain growth? Second, can learning during these stages be altered through genetic and environmental manipulations? We employed the high and low lines of the Fuller brain weight selection mice, which are known to have different developmental patterns, and early handling procedures, known to alter growth rates. The results showed that animals tested during a proposed brain growth spurt were superior to animals tested during a brain growth plateau in learning a shock-escape T-maze.

Combined modality therapy of hepatic metastasis. Northern California Oncology Group Pilot Study

Twenty-two patients with adenocarcinoma metastatic to the liver were treated with rapid fractionation whole-liver irradiation (1350-2100 rads in 300-rad fractions) with simultaneous intrahepatic 5-fluorouracil (10-15 mg/kg/day) and intrahepatic Adriamycin 2.5-10 mg/m2/day) as part of a Phase I-II study. Of the 21 patients who completed therapy, 19 had colorectal carcinoma and 2 had metastatic adenocarcinoma of unknown origin. Objective response was judged by measurement of liver size, evaluation of liver function tests, and by liver scan or CAT scan of the liver. Ten of the 21 evaluable patients responded, yielding an overall response rate of 47.6%. The response rate in patients with colorectal carcinoma was 55% (10/19). At this time, median duration of response is 14+ weeks and median survival from onset of therapy is 15+ weeks. Hematologic and gastrointestinal toxicity were tolerable. No hepatic toxicity was documented. This combined modality therapy was found to be a safe effective method for the palliation of liver metastasis.