Dose-escalating conformal thoracic radiation therapy with induction and concurrent carboplatin/paclitaxel in unresectable stage IIIA/B nonsmall cell lung carcinoma: a modified phase I/II trial

BACKGROUND

A modified Phase I/II trial was conducted evaluating the incorporation of three-dimensional conformal radiation therapy into a strategy of sequential and concurrent carboplatin/paclitaxel in Stage III unresectable nonsmall cell lung carcinoma (NSCLC). The dose of thoracic conformal radiation therapy (TCRT) from 60 to 74 gray (Gy) was increased. Endpoints included response rate, toxicity, and survival.

METHODS

Sixty-two patients with unresectable Stage III NSCLC were included. Patients received 2 cycles of induction carboplatin (area under the concentration curve [AUC], 6) and paclitaxel (225 mg/m(2) over 3 hours) every 21 days. On Day 43, concurrent TCRT and weekly (x 6) carboplatin (AUC, 2) and paclitaxel (45 mg/m(2)/3 hours) were initiated. The TCRT dose was escalated from 60 to 74 Gy in 4 cohorts (60, 66, 70, and 74 Gy).

RESULTS

The response rate to induction carboplatin/paclitaxel was 40%. Eight patients (13%) progressed on the induction phase. No dose-limiting toxicity was observed during the escalation of the TCRT dose from 60 to 74 Gy. The major toxicity was esophagitis, however, only 8% developed Grade 3/4 esophagitis using Radiation Therapy Oncology Group criteria. The overall response rate was 52%. Survival rates at 1, 2, 3, and 4 years were 71%, 52%, 40%, and 36%, respectively, with a median survival of 26 months. The 1-, 2-, and 3-year progression free survival probabilities were 47%, 35%, and 29%, respectively.

CONCLUSIONS

Incorporation of TCRT with sequential and concurrent carboplatin/paclitaxel is feasible, and dose escalation of TCRT to 74 Gy is possible with acceptable toxicity. Overall response and survival rates are encouraging. Both locoregional and distant failure remain problematic in this population of patients.

Conversational repair in pediatric epilepsy

This study examined if children with complex partial seizures disorder (CPS) and primary generalized epilepsy with absence (PGE) were impaired in the use of self-initiated repair during a conversation compared to normal children. Transcriptions of speech samples of 92 CPS, 51 PGE, and 65 normal children, ages 5-16 years, were coded for self-initiated repair according to Evans (1985). The WISC-R, a structured psychiatric interview, and seizure-related information were obtained for each child. We found impaired use of repair in both the CPS and PGE groups compared to the normal subjects. The CPS patients, particularly those with a temporal lobe focus, overused self-initiated corrections of referents and syntax compared to the PGE and normal subjects. The CPS and PGE patients with frontal lobe involvement underused fillers compared to the normal children. These findings provide additional evidence that both CPS and PGE impact the ongoing development of children's communication skills.

Laser Glare in the Cockpit: Psychophysical Estimates versus Model Predictions of Veiling Luminance Distribution

Two methods for estimating the visual effects of light scattered from a laser glare source were compared: (1) a veiling luminance (VL) model that convolves a radiometric scan of the corneal light distribution with a point-spread function to calculate the retinal distribution and (2) psychophysically determined equivalent background luminance (EBL). For six subjects, detection thresholds for a 12-arc-min-diameter test spot were measured at 24 points in the glare field (4 quadrants x 6 eccentricities between 0.25 and 8 deg). Measured Weber fractions were used to calculate EBL's for each test point. Output of the VL model matched the EBL data well, but underestimated the EBL at the smallest (0.25-deg) eccentricity and overestimated it at eccentricities from 1 to 4 deg. This model can be a useful predictor of visual decrements in a variety of glare situations.

Molecular analysis of the mannitol operon of Clostridium acetobutylicum encoding a phosphotransferase system and a putative PTS-modulated regulator

Clostridium acetobutylicum DSM 792 accumulates and phosphorylates mannitol via a phosphoenolpyruvate (PEP)-dependent phosphotransferase system (PTS). PEP-dependent mannitol phosphorylation by extracts of cells grown on mannitol required both soluble and membrane fractions. Neither the soluble nor the membrane fraction could be complemented by the opposite fraction prepared from glucose-grown cells, indicating that the mannitol-specific PTS consists of both a soluble (IIA) and a membrane-bound (IICB) component. The mannitol (mtl) operon of C. acetobutylicum DSM 792 comprises four genes in the order mtlARFD. Sequence analysis of deduced protein products indicated that the mtlA and mtlF genes respectively encode the IICB and IIA components of the mannitol PTS, which is a member of the fructose-mannitol (Fru) family. The mtlD gene product is a mannitol-1-phosphate dehydrogenase, while mtlR encodes a putative transcriptional regulator. MtlR contains two PTS regulatory domains (PRDs), which have been found in a number of DNA-binding transcriptional regulators and in transcriptional antiterminators of the Escherichia coli BglG family. Also, near the C-terminus is a well-conserved signature motif characteristic of members of the IIA(Fru)/IIA(Mtl)/IIA(Ntr) PTS protein family. These regions are probably the sites of PTS-dependent phosphorylation to regulate the activity of the protein. A helix-turn-helix DNA-binding motif was not found in MtlR. Transcriptional analysis of the mtl genes by Northern blotting indicated that the genes were transcribed as a polycistronic operon, expression of which was induced by mannitol and repressed by glucose. Primer extension experiments identified a transcriptional start point 42 bp upstream of the mtlA start codon. Two catabolite-responsive elements (CREs), one of which overlapped the putative -35 region of the promoter, were located within the 100 bp upstream of the start codon. These sequences may be involved in regulation of expression of the operon.

Induction carboplatin/paclitaxel followed by concurrent carboplatin/paclitaxel and dose-escalating conformal thoracic radiation therapy in unresectable stage IIIA/B nonsmall cell lung carcinoma: a modified Phase I trial

BACKGROUND

A modified Phase I trial was conducted evaluating the incorporation of 3-dimensional conformal radiation therapy (3DCRT) into a strategy of sequential and concurrent carboplatin/paclitaxel in Stage III, unresectable nonsmall cell lung carcinoma (NSCLC). In addition, dose escalation of thoracic conformal radiation therapy (TCRT) from 60 to 74 gray (Gy) was performed. Endpoints included response rate, toxicity, and survival.

METHODS

Twenty-nine patients with unresectable Stage III NSCLC were included. Patients received 2 cycles of induction carboplatin (AUC 6) and paclitaxel (225 mg/m(2)/3 hours) every 21 days. On Day 43, concurrent TCRT and weekly (x6) carboplatin (AUC 2) and paclitaxel (45 mg/m(2)/3 hours) was initiated. The TCRT dose was escalated from 60 to 74 Gy in 4 cohorts.

RESULTS

The response rate to induction carboplatin/paclitaxel was 52%. Three patients (10%) experienced disease progression during the induction phase. No dose-limiting toxicity was seen during the escalation of the TCRT dose from 60 to 74 Gy. The major toxicity was esophagitis, with 18% of patients developing Radiation Therapy Oncology Group Grade 3 esophagitis. The overall response rate was 70% (1 complete response and 18 partial responses). Survival rates at 1 and 2 years were 69% and 45%, with a median survival of 21 months. The 1-year progression free survival probability was 41% (95% confidence interval, 23-59%).

CONCLUSIONS

Incorporation of 3DCRT with sequential and concurrent carboplatin/paclitaxel is feasible, and dose escalation of TCRT to 74 Gy is possible with acceptable toxicity. Overall response and survival rates are encouraging. Accrual is continuing in a Phase II fashion at 74 Gy with sequential and concurrent carboplatin/paclitaxel.

Desensitization of exposed root surfaces using a semilunar coronally positioned flap

A definitive treatment is described for cervical dentinal sensitivity, featuring a semilunar coronally positioned flap to cover the denuded root surface. Many patients who complain of having sensitive teeth from exposed dentin secondary to gingival recession can be easily and conservatively treated with a semilunar flap procedure.

Safety of intrathecal sodium nitroprusside for the treatment and prevention of refractory cerebral vasospasm and ischemia in humans

BACKGROUND AND PURPOSE

The delayed type of cerebral vasoconstriction known as cerebral vasospasm (DCV) remains an important cause of permanent neurological injury and death following aneurysmal subarachnoid hemorrhage despite best current medical therapy. The mechanism of DCV remains unknown. A new treatment for refractory DCV using intrathecally delivered sodium nitroprusside and results in 21 patients is reported.

METHODS

Candidates for treatment were patients with secured cerebral aneurysms presenting with clinical or radiographic SAH of grade 3 or higher. Patients with and without established DCV were treated. In 57% (12/21 patients) the diagnosis of severe DCV refractory to conventional treatment (HHH therapy and nimodipine) was established before treatment. Ten patients received ITSNP prophylactically. All patients with established DCV were in grave neurological condition before treatment. Procedures for vasospasm reversal were performed under simultaneous angiographic control with extensive hemodynamic and neurophysiologic monitoring. ITSNP was delivered by intraventricular or subdural catheter or by direct intraoperative suffusion. End points of intervention for established DCV were (1) durable angiographic reversal of vasoconstriction, (2) failure to effect reversal within 30 minutes, and (3) adverse effect. End points for DCV prevention were (1) post-SAH day 10 without evidence of vasoconstriction and (2) adverse effect. Cerebral angioplasty was used concomitantly in 9 treatments. The total number of treatments recorded was 171.

RESULTS

The overall neurological outcome was good or excellent in 76% of patients (16/21) overall and in 88.9% of patients (16/18) having at least a 1-month follow-up. Of the 5 patients with less-than-good outcome, 4 had presented initially with severe neurological injury (clinical SAH grade 4). Angiography demonstrated reversal or amelioration of vasoconstriction in 83% (5/6 cases) of established DCV treated by ITSNP alone. Among patients treated prophylactically, none developed clinical DCV.

CONCLUSIONS

These results suggest that ITSNP is a safe and potentially effective treatment for established DCV and cerebral ischemia refractory to conventional treatment. The preliminary results of prophylactic treatment are also favorable with regard to safety.

Comparative genomes of Chlamydia pneumoniae and C. trachomatis

Chlamydia are obligate intracellular eubacteria that are phylogenetically separated from other bacterial divisions. C. trachomatis and C. pneumoniae are both pathogens of humans but differ in their tissue tropism and spectrum of diseases. C. pneumoniae is a newly recognized species of Chlamydia that is a natural pathogen of humans, and causes pneumonia and bronchitis. In the United States, approximately 10% of pneumonia cases and 5% of bronchitis cases are attributed to C. pneumoniae infection. Chronic disease may result following respiratory-acquired infection, such as reactive airway disease, adult-onset asthma and potentially lung cancer. In addition, C. pneumoniae infection has been associated with atherosclerosis. C. trachomatis infection causes trachoma, an ocular infection that leads to blindness, and sexually transmitted diseases such as pelvic inflammatory disease, chronic pelvic pain, ectopic pregnancy and epididymitis. Although relatively little is known about C. trachomatis biology, even less is known concerning C. pneumoniae. Comparison of the C. pneumoniae genome with the C. trachomatis genome will provide an understanding of the common biological processes required for infection and survival in mammalian cells. Genomic differences are implicated in the unique properties that differentiate the two species in disease spectrum. Analysis of the 1,230,230-nt C. pneumoniae genome revealed 214 protein-coding sequences not found in C. trachomatis, most without homologues to other known sequences. Prominent comparative findings include expansion of a novel family of 21 sequence-variant outer-membrane proteins, conservation of a type-III secretion virulence system, three serine/threonine protein kinases and a pair of parologous phospholipase-D-like proteins, additional purine and biotin biosynthetic capability, a homologue for aromatic amino acid (tryptophan) hydroxylase and the loss of tryptophan biosynthesis genes.

Genome sequence of an obligate intracellular pathogen of humans: Chlamydia trachomatis

Analysis of the 1,042,519-base pair Chlamydia trachomatis genome revealed unexpected features related to the complex biology of chlamydiae. Although chlamydiae lack many biosynthetic capabilities, they retain functions for performing key steps and interconversions of metabolites obtained from their mammalian host cells. Numerous potential virulence-associated proteins also were characterized. Several eukaryotic chromatin-associated domain proteins were identified, suggesting a eukaryotic-like mechanism for chlamydial nucleoid condensation and decondensation. The phylogenetic mosaic of chlamydial genes, including a large number of genes with phylogenetic origins from eukaryotes, implies a complex evolution for adaptation to obligate intracellular parasitism.

Resection and graft repair for localized hypertrophic neuropathy

OBJECTIVES

Formulation of surgical management recommendations for localized hypertrophic mononeuropathy has been difficult because of the infrequency of the lesion, lack of precise pathological diagnosis, and uncertainties regarding its cause. The purpose of this retrospective review of the Louisiana State University (LSU) experience with this unusual neuropathy was to evaluate the efficacy of lesion resection and interposition grafting in its management.

METHODS

The charts of 15 patients operated on at LSU during a 15-year period with a pathological diagnosis of localized hypertrophic neuropathy were reviewed.

RESULTS

Hypertrophic lesions were located on major named peripheral nerves of the extremities, distributed equally to the upper and lower extremities. Family history was negative for all patients, and entrapment or trauma, other than previous surgery, were unlikely by symptom location or history. Weakness was the most common presentation. The mean length of symptoms was 76 months. Atrophy, sensory loss, Tinel's sign, focal tenderness, and a mass were found in the majority of patients. Preoperative electrophysiological studies showed chronic denervational changes in all patients. At surgery, if no action potential or one of low amplitude was recorded across the lesion, the lesion was resected and an autologous nerve graft measuring from 3.5 to 8.5 cm in length was interposed. During follow-up periods of 1 or more years, seven of nine patients with localized hypertrophic mononeuropathy treated with graft repairs were either unchanged or improved.

CONCLUSION

Localized hypertrophic mononeuropathy is a progressive process associated with pathological nerve changes that correlate with eventual severe functional loss. If intraoperative histological examination shows onion bulb neuropathy and intraoperative nerve action potentials confirm a nonfunctioning or poorly functioning segment, lesion resection with interposition graft repair provides the possibility of some degree of recovery.

Collagen shortening. An experimental approach with heat

Decreasing joint laxity is a clinical goal of ligament reconstructions. This in vitro study examined the structural and histologic effects of heat shrinkage of human collagen. Two preliminary studies were performed to assess the effect of heat on fresh frozen human tendons obtained from a local tissue bank. As heat was applied to tissue in a saline solution, the percent shrinkage was plotted against temperature. A second study used a freebeam Nd:YAG laser to maximally shrink patellar tendons measuring percent shrinkage versus energy applied. Finally, the effects of 10% shrinkage of fresh frozen human patellar tendons were analyzed mechanically and histologically. Consistent tendon shrinkage curves were found with increasing temperatures in a saline solution. A sharp increase in shrinkage to approximately 70% of resting length was noted around 70 degrees C. Tendon shrinkage by laser induced heat was precise and dose related. Tensile testing of the tendons shortened 10% of their resting length showed a decrease in load to failure to approximately 1/3 compared with that of historical control specimens. Histologic sections showed a well demarcated site of diffuse denaturation and degeneration of collagenous elements. Normal collagen was present adjacent to these thermal changes. These experiments showed that collagen tissue can be shortened precisely by the application of heat. Future studies need to examine the in vivo biologic response of shortened collagen tissue with time, especially recollagenization, restoration of length, and the long term biomechanical effects.

Why high levels of net migration present problems for unemployment and external debt stabilisation

"Unemployment [in Australia] is affected by two factors: increases in the productivity of labour and increases in its supply. Both of these factors could, in principle, be offset by strong economic growth. But, if the economy grows fast enough to accommodate both productivity gains and the addition of migrants to the labour force, it will draw in more imports and the balance of trade will deteriorate. Economic growth of around two per cent per annum may be all that we can sustain without increasing our foreign debt. This level of economic growth is not enough to reduce unemployment in the face of any net immigration (or any growth in labour productivity)."

The effects of deinstitutionalization on adults with learning disabilities

We compared a group of people with learning disabilities who have been deinstitutionalized with a control group remaining in an institution on measures of adaptive and maladaptive behaviour, community living skills, social skills, and quality of life. In general, there was no change over 30 months for the control group. Changes for the experimental group were either not seen or were generally modest in scale, and tended to occur within 6 months of moving, the measures staying relatively stable thereafter. Implications for detailed examination of the effects of deinstitutionalization were discussed.

Analysis of the bone surface area in resected tibia. Implications in tibial component subsidence and fixation

Anterior subsidence of the tibial component is still a clinical complication requiring revision in total knee replacement. Using the scanning electron microscope, a quantitative 3-dimensional stereoscopic and digitizing study was conducted on the cortical and cancellous bone surface area from 10 resected human cadaveric tibia. The data demonstrated that the cortical bone surface area covered an average of 6% of the total tibial surface area, cancellous bone 18%, and bone marrow space 76%. By conducting anatomic regional analysis, the data showed significantly higher (p < or = 0.05) bone quantities in the posteromedial and medial regions as compared with the anterior and anterolateral regions. These data help to explain why tibial component subsidence occurs anteriorly in total knee replacement. The data also suggest that if long-term component subsidence and loosening is to be limited, either biologic cement or bone cement would be required to increase the surface attachment between the tibial component and resected cancellous bone.

Pharmaceutical prices, quantities and innovation. Comparing Japan with the US

Per capita expenditure on pharmaceuticals is higher in Japan than in the US, despite a series of drug price reductions instigated by the Japanese Ministry of Health and Welfare that began in 1981. For some individual products, these price reductions cumulatively totalled more than 50%. This article argues that although the price of individual drugs is lower in Japan than in the US, aggregate expenditure is higher because of the greater use of newly-introduced original drugs and lower use of generics. Providers and consumers also tend to use drugs in larger quantities in Japan, because of polypharmacy and greater use of vitamins and nutrients, antihypertensives, cerebral metabolic activators (e.g. idebenone) and milder-acting drugs (i.e. drugs with low toxicity but unproven clinical efficacy). The level of expenditure is unlikely to decline, despite changes to pricing policy and ongoing efforts to improve the pharmaceutical distribution system and to discourage physician dispensing activities.

Differentiating between marketing-driven and technology-driven vendors of medical information systems

Buyers of medical information systems such as laboratory information systems need to recognize that the vendors of such systems may pursue corporate strategies emphasizing expenditures on marketing and client services, expenditures on technology and research and development (R&D), or a more balanced approach. The strategic goals and objectives of a vendor of an information system should align closely with those of a potential hospital client. A restless hospital client seeking cutting-edge technology will probably be dissatisfied with a system vendor who emphasizes slow ongoing incremental system development. Objective criteria for distinguishing between a marketing-driven vendor and a technology-driven vendor of medical information systems, and their variants, are presented based on the ratio of marketing expenditures to sales revenue compared with the ratio of research and development expenditures to sales revenue of the company. More subjective narrative criteria are also offered for making such distinctions.

Differential effects of a misattribution manipulation on sexually functional and dysfunctional men

Ten sexually functional and 10 dysfunctional men viewed sexually explicit films following ingestion of each of three placebo pills described as an erection enhancement pill, an erection detraction pill, and a placebo pill. Functionals evidenced a reverse placebo effect with significantly higher erectile response under the detraction relative to the enhancement and placebo conditions. Dysfunctionals evidenced a direct placebo effect with significantly lower erectile response under the detraction relative to the enhancement and placebo conditions. Fifteen Ss (75%) responded according to group patterns. Results suggest yet another arena in which functional and dysfunctional men respond in a fundamentally different manner. This pattern of differential responding may be due to relative differences in level of interoceptive awareness and/or interoceptive avoidance between functional and dysfunctional Ss and reflect on the nature of anxiety.

Teaching tomorrow's health care leaders

Business school curricula have traditionally emphasized functional skills for people who will work in functional departments and general management skills for people who will organize interdepartmental work. Recently, some business schools have begun to develop programs that teach cross-functional work and team skills to functional specialists. Students educated in such programs will be well prepared to meet the new challenges that health care organizations will face.

Differential effects of a misattribution manipulation on sexually functional and dysfunctional men

Ten sexually functional and 10 dysfunctional men viewed sexually explicit films following ingestion of each of three placebo pills described as an erection enhancement pill, an erection detraction pill, and a placebo pill. Functionals evidenced a reverse placebo effect with significantly higher erectile response under the detraction relative to the enhancement and placebo conditions. Dysfunctionals evidenced a direct placebo effect with significantly lower erectile response under the detraction relative to the enhancement and placebo conditions. Fifteen Ss (75%) responded according to group patterns. Results suggest yet another arena in which functional and dysfunctional men respond in a fundamentally different manner. This pattern of differential responding may be due to relative differences in level of interoceptive awareness and/or interoceptive avoidance between functional and dysfunctional Ss and reflect on the nature of anxiety.

Integrating information from decentralized laboratory testing sites. The creation of a value-added network

The decentralization of laboratory testing provides distinct advantages for clinicians and patients, such as the reduction of test turnaround time, but also promotes the development of scattered caches of results. This problem could be ameliorated by the creation of an integrated laboratory data base. Such an approach would provide clinicians with a patient view of laboratory information in addition to the functional view of it that is offered currently. Impressive technologic advances are being made in the development of a distributed computer architecture in which processing tasks and information are shared across multiple hardware platforms attached to a network. Such architecture could be used to create a regional value-added laboratory network to integrate test information generated in decentralized testing sites. Independent reference laboratories and tertiary-care referral hospitals are the most likely candidates to create distributed value-added networks. Pathologists should view themselves as health-care professionals responsible for the processing, storage, and transmission of information, as well as for its generation. In time, the partition of information along hospital geopolitical boundaries will appear archaic and will be replaced by an emphasis on local and regional integration of medical information similar to that advocated here.

Pseudoexstrophy

Pseudoexstrophy is a rare, mild exstrophy variant which involves the major musculoskeletal defects of the exstrophy complex without any associated defect in the urinary system. A case is reported presenting at birth as an umbilical positional anomaly. Differential diagnosis and management are reviewed.

Health care costs of veterans with multiple sclerosis: implications for the rehabilitation of MS. VA Multiple Sclerosis Rehabilitation Study Group

We retrospectively determined health care costs among veterans with multiple sclerosis (MS) and correlated the costs with neurologic dysfunction. Total health care costs for the 165 patients averaged $35,000/year. VA benefits and homecare together accounted for 85% of the total costs. Total health care costs correlated with two measures of neurologic dysfunction, the Expanded Disability Status Scale (EDSS) (r = 0.61, p < 0.001) and the Incapacity Status Scale (ISS) (r = 0.64, p < 0.001). The costs of VA benefits, homecare, and hospitalizations also correlated with the EDSS, ISS, and other measures of neurologic dysfunction whereas the cost of outpatient clinic visits did not. In a period of three years, there were 40 hospitalizations, at a total cost of $412,800, that were potentially preventable with appropriate outpatient management. Improving selfcare and avoiding preventable hospitalizations might lower the considerable health care costs of MS.