Prognostication of pancreatic adenocarcinoma by expression of thymidine phosphorylase (TP) and its correlation with survival

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Background: Preclinical studies have indicated that TP is one of the most useful markers of tumor response to capecitabine; with elevated TP expression resulting in higher intratumor levels of 5-FU. TP level in the tumor may be associated directly with survival and may be up-regulated by XRT. Methods: Twenty patients (pts) who had newly diagnosed locally advanced pancreatic cancer, age ≥ 19 years, ECOG PS 0–2, and adequate organ function received 50.4 Gy XRT with capecitabine 1,600 mg/m2 M-F x 6 wks determined from our phase I study (JCO, Dec 2005). Following capecitabine-XRT, stable and responding pts received capecitabine 2,000mg/m2 x 14 days every 3 wks till progression. Restaging was performed every 9 wks. Tumor specimens were procured with EUS-FNA prior and week 2 after starting capecitabine-XRT to evaluate TP mRNA levels by RT-PCR. Results: TP levels were elevated post-XRT when compared to pre-XRT TP (p= 0.01). Each of the 20 pts had at least one observation of TP. Mean TP level of each pt was obtained by averaging the pre-XRT and post-XRT TP levels. If one value was missing, then the other value was used for the mean TP level. Mean TP level was significantly associated with survival using the Cox proportional hazards model (p= 0.0072). Pts were separated into two groups - those with high baseline TP level and those with lower TP level with a cut off value of 213.85 using median of mean TP level. It was observed that group with higher TP levels had better survival as compared to the group with lower TP levels. However, the survival curves of these two groups crossed over after 18 months. Conclusions: Our study suggests that the higher the TP level in tumor post-XRT, the better the survival. This is most probably due to a higher accumulation of 5-FU in tumor due to up-regulation of TP. Possible explanation for the two groups crossing over after 18 months may include heterogeneity in TP due to a difference in pharmacogenomics or idiosyncratic drug toxicity profile of capecitabine. Further studies of long-term effects of treatment with a larger number of pts are needed to study exact effects of capecitabine and XRT, and to evaluate the differential role of TP with survival.

[Table: see text]

The diagnostic assessment of suspected pulmonary embolism on the acute medical take: an evidence based guide

Pulmonary Embolism is a common cardiopulmonary illness with an age and sex adjusted incidence of around 117 cases per 100 000 person years. The clinical presentation is extremely heterogeneous and non specific. Risk factors for venous thromboembolism are well established. When combined with presenting features and investigations. A multimodality algorithm has led to significant changes in the diagnostic approach of suspected PE. While the best combination of tests for any individual patient remains the subject of controversy this article aims to rationalise the acute physician's approach to diagnosis and use of available investigations.

SB-271258, A major metabolite in the dog of the thiazolidinedione, rosiglitazone, stimulates protein synthesis in re-differentiated rat cardiomyocytes in vitro

In dogs, chronic administration of thiazolidinediones causes cardiac hypertrophy in vivo at high doses. The hypertrophic action of rosiglitazone in dogs might be attributed to production of SB-271258 (a major metabolite in dogs but minor in rats and man), rather than a direct effect on myocardium. The hypothesis that SB-271258 had potential to initiate cardiomyocyte hypertrophy or to modify responses elicited by other hypertrophic stimuli was tested in an in vitro bioassay utilising adult rat ventricular cardiomyocytes. SB-271258 increased protein and incorporation of 14C-phenylalanine, a marker of protein synthesis, in rat cardiomyocytes maintained in serum-free culture (24 h), maximally at 1 microM by 15.0% and 9.1%, respectively. In the presence of serum (10% v/v), SB-271258 elicited a moderate trophic effect: cellular protein and incorporation of 14C-phenylalanine were increased, maximally at 100 nM by 31.7% and 36.3%, respectively, above basal values (18.6% and 13.3% increases above serum response). In the presence of IGF-1 (10 nM) plus SB-271258, protein synthesis was increased, maximally by 45.5% above basal value (increase of 6.9% above IGF-1 alone). In contrast, SB-271258 attenuated the increase (12.0%) in cellular protein elicited by IGF-1. In re-differentiated cardiomyocytes, a model of relevance to established hypertrophy, SB-271258 (1 nM-1 microM) elicited a marked trophic effect per se, as evidenced by the maximum increase (at 100 nM), in protein synthesis of 24.5%. In conclusion, these data imply that cardiac hypertrophy associated with chronic administration of rosiglitazone in dogs in previous in vivo studies might be partly attributable to production of the metabolite SB-271258 since this metabolite was shown to elicit trophic effects directly on rat cardiomyocytes.

The Jehovah's Witness and dementia: who or what defines 'best interests'?

An elderly woman with dementia presented for repeat surgical management of fractured neck of femur. Although no advance directive had ever been generated, the patient was declared to be a strict Jehovah's Witness by her daughter, who vetoed the transfusion of any blood products. The fracture was managed conservatively but the patient suffered repeated chest infections, from which she died 4 months after admission. This case raised several clinical, ethical and legal issues and generated a spectrum of opinion as to the appropriateness of operative intervention, transfusion and provision of intensive care. We suggest that professional guidelines and the new Mental Capacity Act 2005 do not provide explicit and comprehensive guidance for practitioners. Further deliberation is required to bring about convergence between the law, ethical principles and professional guidelines.

Prediction of in-hospital mortality and length of stay using an early warning scoring system: clinical audit

This aim of this study was to assess the impact of the introduction of a standardised early warning scoring system (SEWS) on physiological observations and patient outcomes in unselected acute admissions at point of entry to care. A sequential clinical audit was performed on 848 patients admitted to a combined medical and surgical assessment unit during two separate 11-day periods. Physiological parameters (respiratory rate, oxygen saturation, temperature, blood pressure, heart rate, and conscious level), in-hospital mortality, length of stay, transfer to critical care and staff satisfaction were documented. Documentation of these physiological parameters improved (P<0.001-0.005) with the exception of oxygen saturation (P=0.069). The admission early warning score correlated both with in-hospital mortality (P<0.001) and length of stay (P=0.001). Following the introduction of the scoring system, inpatient mortality decreased (P=0.046). Staff responding to a questionnaire indicated that the scoring system increased awareness of illness severity (80%) and prompted earlier interventions (60%). A standardised early warning scoring system improves documentation of physiological parameters, correlates with in-hospital mortality, and helps predict length of stay.

Safety of extended treatment with anakinra in patients with rheumatoid arthritis

OBJECTIVE

To determine the safety profile of anakinra after extended exposure in a diverse clinical trial population of patients with rheumatoid arthritis.

METHODS

A six month, randomised, double blind phase comparing anakinra (100 mg/day) with placebo was followed by open label anakinra treatment for up to three years in patients with rheumatoid arthritis. Concomitant non-steroidal anti-inflammatory drugs, corticosteroids, and other disease modifying antirheumatic drugs were permitted.

RESULTS

In all 1346 patients with rheumatoid arthritis received anakinra for up to three years. Patients had varying levels of disease severity, concomitant drug use, and comorbid conditions. Cumulative, exposure adjusted event (EAE) rates for all adverse events (AEs), serious AEs, and deaths were similar during each year of anakinra treatment; the overall rate (0 to 3 years) was similar to that observed for controls during the blinded phase. The most frequent AEs were injection site reactions (122.26 events/100 patient-years), rheumatoid arthritis progression (67.80 events/100 patient-years), and upper respiratory infections (26.09 events/100 patient-years). The EAE rate of serious infections was higher for patients treated with anakinra for 0 to 3 years (5.37 events/100 patient-years) than for controls during the blinded phase (1.65 events/100 patient-years). However, if the patient was not receiving corticosteroid treatment at baseline, the serious infection rate was substantially lower (2.87 event/100 patient-years). The overall incidence of malignancies was consistent with expected rates reported by SEER. Neutralising antibodies developed in 25 patients, but appeared to be transient in 12; neutralising antibody status did not appear related to occurrence of malignancies or serious infections. There were no clinically significant trends in laboratory data related to anakinra.

CONCLUSION

Anakinra is safe and well tolerated for up to three years of continuous use in a diverse population of patients with rheumatoid arthritis.

Polymorphisms of the DNA repair genes XPD (Lys751Gln) and XRCC1 (Arg399Gln and Arg194Trp): relationship to breast cancer risk and familial predisposition to breast cancer

Family history is a risk factor for breast cancer and could be due to shared environmental factors or polymorphisms of cancer susceptibility genes. Deficient function of DNA repair enzymes may partially explain familial risk as polymorphisms of DNA repair genes have been associated, although inconsistently, with breast cancer. This population based case-control study examined the association between polymorphisms in XPD (Lys751Gln) and XRCC1 (Arg399Gln and Arg194Trp) genes, and breast cancer. Breast cancer cases (n=321) and controls (n=321) were matched on age and menopausal status. Conditional logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). The analysis was conducted omitting observations with missing data, and by using imputation methods to handle missing data. No significant association was observed between the XPD 751Gln/Lys (OR 1.37, 95% CI 0.96-1.96) and Gln/Gln genotypes (OR 1.08, 95% CI 0.62-1.86) (referent Lys/Lys), XRCC1 399Arg/Gln (OR 1.48, 95% CI 0.92-2.38) and Gln/Gln genotypes (1.11, 95% CI 0.67-1.83) (referent Arg/Arg) or the XRCC1 Arg/Trp and Trp/Trp genotypes (OR 1.12, 95% CI 0.69-1.83) (referent Arg/Arg) and breast cancer. In multivariate analysis, the adjusted odds ratios for the XPD and XRCC1 399 polymorphisms increased and became statistically significant, however, were attenuated when imputation methods were used to handle missing data. There was no interaction with family history. These results indicate that these polymorphisms in XPD and XRCC1 genes are only weakly associated with breast cancer. Without imputation methods for handling missing data, a statistically significant association was observed between the genotypes and breast cancer, illustrating the potential for bias in studies that inadequately handle missing data.

The impact of weekends on outcome for emergency patients

Levels of staffing and access to diagnostics at weekends are recognised to be significantly lower than on weekdays. It is unclear if subsequent inpatient mortality and readmission rates for acute medical admissions are increased for weekend admissions compared to those on a weekday. A large Canadian study demonstrated increased weekend mortality but does the Edinburgh healthcare model support these findings? This study analysed all hospital admissions in 2001 to the Royal Infirmary of Edinburgh for six predetermined diagnoses (total 3,244): chronic obstructive pulmonary disease, cerebrovascular accidents, pulmonary embolism, pneumonia, collapse and upper gastrointestinal bleed. We compared hospital mortality rates, readmission rates and hospital length of stay for weekend admissions as compared to those on a weekday. Weekend admission was not associated with significantly higher in-hospital mortality, readmission rates or increased length of stay compared to the weekday equivalent for any of the six conditions. The implementation of an acute medical admissions unit in the Royal Infirmary of Edinburgh, with consistent staffing levels and 24-hour access to diagnostics for the early phase of critical illness, may have helped address the discrepancy in care suggested by previous studies.

Positive control wells: a potential answer to remote-area quality assurance of malaria rapid diagnostic tests

Malaria rapid diagnostic tests (RDTs) are a potential breakthrough in the provision of accurate diagnosis in remote areas, but widescale use is hampered by uncertainty over accuracy under field conditions. Positive control wells, which contain recombinant malaria parasite antigen, are a novel method for addressing this need for quality assurance. The potential of a commercially available positive control well, reconstituted with blood, was assessed for use in routine monitoring of RDT sensitivity in a remote malaria-endemic region. When maintained at 4 degrees C, the wells produced a consistent level of parasite lactate dehydrogenase (pLDH) antigen activity, as detected by pLDH-detecting RDTs, but activity reduced after cumulative exposure to temperatures likely to be encountered over a few months in a malaria-endemic area. This limitation was successfully overcome in the field through centralized, controlled storage. Monitoring of RDT sensitivity was successfully incorporated into routine supervisory visits to remote clinics. However, improved temperature stability of the wells would enhance their potential. The threshold at which the wells' signal reduced RDT sensitivity requires further investigation. The wells show potential to overcome an important obstacle to the wide implementation of accurate parasite-based diagnosis and appropriate treatment. Further assessment of their place in malaria management is warranted.

Pilocytic astrocytoma of the adult--clinical features, radiological features and management

Pilocytic astrocytoma is a histological subtype of astrocytoma classically located in the cerebellum of children and young adults. Cases occurring over the age of 30 years are rare and have not been classified in terms of their clinical features and management. Suitable cases were identified using diagnostic coding and by reviewing a neuropathology database. Casenotes and neuroradiology were reviewed retrospectively. Ten cases were identified over a 6 year period with an incidence of 0.49 cases per million population per year. Tumours were equally distributed between the supra- and infra-tentorial spaces. The most common symptom was headache occurring in 90%. No patient suffered seizures. Total macroscopic treatment remains the treatment of choice. Pilocytic astrocytoma of the adult is a rare tumour with a favourable prognosis.

Unequal treatment access and malaria risk in a community-based intervention program in the Philippines

This study assesses the influence of several malaria risk factors and volunteer health worker (VHW) accessibility on parasite prevalence and treatment-seeking in a remote area of Mindanao, the Philippines. An anti-malaria program in the area seeks to devolve malaria diagnosis and treatment to the VHWs. Firstly, the relationship between malaria and demographic factors, bednet use, and access to treatment was investigated. Secondly, adults from villages with and without resident VHWs were questioned on historical and proposed treatment-seeking for fever and the capacity of the communities to support more health workers was assessed. Parasite prevalence was significantly higher among patients living in villages lacking a resident VHW (adjusted OR=3.88, p=0.02), where proposed delays in consulting VHWs and the official health service, and the use of alternative medicine, were also significantly higher. Kinship or social closeness to VHWs appears to play a role in accessibility. The educational and economic requirements demanded of VHWs impede potential expansion of the program to non-serviced villages. If the effectiveness and equity of community-based treatment strategies is to be increased, increased flexibility allowing use of local, less-educated, drug dispensers needs to be considered.

Asthma management in police study

Asthma is a common condition and, therefore, may be seen by the clinical forensic physician and police in widely different circumstances ranging from the autopsy room to roadside breath alcohol testing. This paper concentrates on the assessment and treatment of asthmatics detained in custody and does not refer to the Road Traffic Act provisions. A careful history and objective recording of simple severity markers and peak expiratory flow rate should identify patients who may require hospitalization or urgent treatment. Asthma mortality may be reduced by better understanding of the disease and its treatment and by greater use of prophylactic rather than reliance on relief therapy for bronchospasm.

Host-dependent Anopheles flavirostris larval distribution reinforces the risk of malaria near water

Malaria control strategies are more likely to be successful if groups at high risk can be accurately predicted. Given that mosquitoes have an obligate aquatic phase we were interested in determining how vector larval abundance relates to the spatial distribution of human malaria infection. We examined the relationship between malaria parasite prevalence and distance from vector larval habitat, and vector larval abundance and distance from human habitation, in separate studies in rural, low-endemic areas of the Philippines. Parasite prevalence among symptomatic patients was significantly higher among those living in proximity (< or = 50 m) to potential larval habitats of the major vector, Anopheles flavirostris (adjusted odds ratio [AOR] = 2.64, P = 0.02 and AOR = 3.43, P = 0.04). A larval survey of A. flavirostris revealed a higher density of early and late instars near human habitation (adjusted P < 0.05). The results suggest that larvae are associated with human habitation, thereby reinforcing malaria risk in people living close to larval habitats. This has implications for understanding the interaction between vectors, hosts, and parasites, and the potential for success of localized malaria control measures.

Novel murine model of pneumococcal pneumonia: use of temperature as a measure of disease severity to compare the efficacies of moxifloxacin and levofloxacin

Surface temperature measured by an infrared temperature-scanning thermometer was used to evaluate disease severity and predict imminent death in a murine model of pneumococcal pneumonia. We showed that a decrease in temperature was associated with increasing severity of disease and concomitant histological changes and also that a temperature of 30 degrees C or less was a predictor of death. Furthermore, viable bacterial counts in the lungs of mice euthanized at a temperature of < or = 30 degrees C were not significantly different from those seen in the lungs of mice allowed to die without intervention. These data support temperature change as a more subtle indicator of outcome than death and demonstrate that this could be used as a reliable end point for euthanasia. To test the utility of our model in a drug trial, we examined the efficacies of moxifloxacin and levofloxacin by using temperature as a measure of disease severity prior to and during treatment. Regardless of the antibiotic used, mice assessed as moderately ill (temperature > or = 32 degrees C) at the start of treatment had better clinical and bacteriological outcomes than mice assessed as severely ill (temperature < 32 degrees C). However, moxifloxacin offered better protection and greater bacterial clearance than did levofloxacin in all infected mice independent of disease severity. This model not only allows a more subtle evaluation of drug efficacy but also ensures a better degree of standardization and a more humane approach to drug efficacy studies involving animals.

Invertebrate responses to the management of genetically modified herbicide-tolerant and conventional spring crops. I. Soil-surface-active invertebrates

The effects of herbicide management of genetically modified herbicide-tolerant (GMHT) beet, maize and spring oilseed rape on the abundance and diversity of soil-surface-active invertebrates were assessed. Most effects did not differ between years, environmental zones or initial seedbanks or between sugar and fodder beet. This suggests that the results may be treated as generally applicable to agricultural situations throughout the UK for these crops. The direction of the effects was evenly balanced between increases and decreases in counts in the GMHT compared with the conventional treatment. Most effects involving a greater capture in the GMHT treatments occurred in maize, whereas most effects involving a smaller capture were in beet and spring oilseed rape. Differences between GMHT and conventional crop herbicide management had a significant effect on the capture of most surface-active invertebrate species and higher taxa tested in at least one crop, and these differences reflected the phenology and ecology of the invertebrates. Counts of carabids that feed on weed seeds were smaller in GMHT beet and spring oilseed rape but larger in GMHT maize. In contrast, collembolan detritivore counts were significantly larger under GMHT crop management.

Effects of natural products on soil organisms and plant health enhancement

TerraPy, Magic Wet and Chitosan are soil and plant revitalizers based on natural renewable raw materials. These products stimulate microbial activity in the soil and promote plant growth. Their importance to practical agriculture can be seen in their ability to improve soil health, especially where intensive cultivation has shifted the biological balance in the soil ecosystem to high numbers of plant pathogens. The objective of this study was to investigate the plant beneficial capacities of TerraPy, Magic Wet and Chitosan and to evaluate their effect on bacterial and nematode communities in soils. Tomato seedlings (Lycopersicum esculentum cv. Hellfrucht Frühstamm) were planted into pots containing a sand/soil mixture (1:1, v/v) and were treated with TerraPy, Magic Wet and Chitosan at 200 kg/ha. At 0, 1, 3, 7 and 14 days after inoculation the following soil parameters were evaluated: soil pH, bacterial and fungal population density (cfu/g soil), total number of saprophytic and plant-parasitic nematodes. At the final sampling date tomato shoot and root fresh weight as well as Meloidogyne infestation was recorded. Plant growth was lowest and nematode infestation was highest in the control. Soil bacterial population densities increased within 24 hours after treatment between 4-fold (Magic Wet) and 19-fold (Chitosan). Bacterial richness and diversity were not significantly altered. Dominant bacterial genera were Acinetobacter (41%) and Pseudomonas (22%) for TerraPy, Pseudomonas (30%) and Acinetobacter (13%) for Magic Wet, Acinetobacter (8.9%) and Pseuodomonas (81%) for Chitosan and Bacillus (42%) and Pseudomonas (32%) for the control. Increased microbial activity also was associated with higher numbers of saprophytic nematodes. The results demonstrated the positive effects of natural products in stimulating soil microbial activity and thereby the antagonistic potential in soils leading to a reduction in nematode infestation and improved plant growth.

Repetition of an unusual stress fracture in an anorexic man: a case report

Stress fractures of the fibula commonly occur distally in runners, whereas stress fractures of the proximal fibula are uncommon and typically occur in jumpers. Furthermore, it is rare for a stress fracture to be repeated in the same bone. We report a case of a repeated stress fracture of the proximal fibula in a male runner with abnormal gait that primarily involved excessive pronation. Unusual risk factors in this case were anorexia nervosa and use of an inhaled corticosteroid. The patient was treated conservatively, and healing of the fracture was completed at 12 weeks.

How well do radiologists diagnose intracerebral tumour histology on CT? Findings from a prospective multicentre study

The management of patients with intracranial tumours relies on accurate diagnosis of tumour type. To assess the accuracy with which tumour histology could be diagnosed from brain CT we reviewed data from a prospective, population-based study from three Scottish neuroscience centres. Between October 1997 and April 1999 all patients from the Edinburgh, Aberdeen and Dundee Neuroscience Centres with a CT-diagnosis of a solitary, supratentorial intra-cerebral tumour were recruited. General and neuroradiologists were asked to give their best guess tumour diagnosis. Biopsy confirmed neuropathological tumour type was available for comparison with best guess CT-diagnosis in 221 of 324 patients. Histological diagnosis was either malignant glioma, low grade glioma or metastasis in 199 cases. The accuracy of CT lesional diagnosis for these three categories was 60% (95% confidence interval 54-67%), 85% (80-89%) and 82% (77-88%), respectively. The diagnostic accuracy of an intra-cerebral tumour was 0.81 with a positive predictive value of 0.93. There was no significant difference between histological diagnostic accuracy of neuroradiologists and general radiologists. In 10% of patients the initial CT scan was reported as negative for intracranial tumour, with 62% of these scans having been carried out without contrast. Based on CT alone radiologists are good at identifying an intra-cerebral tumour, but not so good at distinguishing between different tumour types. The implications of the findings for patient management are discussed.

Platelet lipid(s) bound to albumin increases endothelial electrical resistance: mimicked by LPA

The objectives were to determine whether the permeability-decreasing activity of platelet-conditioned medium (PCM) is associated with a lipid bound to albumin and whether lysophosphatidic acid (LPA) is present in the PCM. A decrease in permeability was assessed by an increase in electrical resistance across endothelial cell monolayers derived from bovine pulmonary arteries and microvessels. The Sephacryl S-200 fraction of PCM that contained albumin, the albumin immunoprecipitate from the PCM, and the methanol extract from the albumin immunoprecipitate all increased endothelial electrical resistance. Increased electrical resistance induced by PCM was not abolished by boiling and was mimicked by 1-oleoyl-LPA and 1-palmitoyl-LPA. Analysis of a methanol-chloroform extract of one sample of PCM by electrospray mass spectrometry revealed many fatty acids, ceramide, diacylglycerol, phosphatidic acid, and palmitoyl-LPA, but analysis of a second sample of PCM and the methanol extract of its albumin immunoprecipitate revealed no LPA, only lipids. These findings indicate that a bioactive lipid(s), possibly LPA, released from platelets and subsequently bound to albumin forms an active complex that decreases endothelial permeability.

Calciphylaxis of the penis: a unique cause of Fournier's gangrene

Calciphylaxis is a rare disease that is caused by calcium deposition in medium and small sized vessels of the skin causing ischemic necrosis. These lesions often become infected and cause septicemia. We report a unique case of penile and scrotal calciphylaxis that rapidly progressed to Fournier's gangrene. We review the etiology of calciphylaxis and also its management.

The outcome of ambulatory DVT management using a multidisciplinary approach

Low molecular weight heparins (LMWHs) have been demonstrated to be at least as safe and effective as unfractionated heparin (UFH) in the initial management of deep vein thrombosis (DVT). However, the effectiveness of using LMWH in the ambulatory management of DVT in a 'real-life' setting has yet to be evaluated. This multicentre retrospective study involving 697 patients considers the outcome data of patients under- going ambulatory DVT treatment with tinzaparin (Innohep(R), Leo Pharmaceuticals, Risborough, Buckinghamshire, UK). During the 6 months following presentation, 17 (2.5%) patients had confirmed thromboembolic complications, of which 14 occurred subsequent to the initial LMWH treatment phase ('late'). There were no deaths in this group. Bleeding complications were reported in 23 (3.4%) patients, with 13 of these being classified as 'late'. Of these, two events were considered major resulting in hospitalization and death. Hospitalization for all causes was 6.8% (45 patients) with 32 patients being admitted for thromboembolic or bleeding complications. Overall mortality was 6.7%. These results compare favourably with published clinical trial data. This study demonstrates that ambulatory treatment of proven DVT with LMWH is both safe and effective.

Randomized, open-label, phase II trial of oral capecitabine (Xeloda) vs. a reference arm of intravenous CMF (cyclophosphamide, methotrexate and 5-fluorouracil) as first-line therapy for advanced/metastatic breast cancer

BACKGROUND

Oral capecitabine was evaluated in terms of overall response rate, safety, and tolerability as first-line therapy in women aged > or = 55 years with advanced/metastatic breast cancer.

PATIENTS AND METHODS

Ninety-five patients were randomized (2:1) to either intermittent oral capecitabine 1,255 mg/m2 twice daily (two weeks' treatment followed by a one-week rest period) or intravenous CMF (cyclophosphamide. methotrexate, 5-fluorouracil [5-FU]) administered every three weeks.

RESULTS

The overall response rate in the capecitabine group was 30% (95% confidence interval (95% CI): 19%-43%), including three complete responses (5%). The response rate observed in the CMF group was 16% (95% CI: 5%-33%), with no complete responses. Median time to disease progression was 4.1 months with capecitabine and 3.0 months with CME. Survival was similar in the two treatment groups (median 19.6 months with capecitabine. 17.2 months with CMF). The safety profiles were different for capecitabine and CMF. However, both regimens were generally well tolerated and treatment interruption and/or dose modification was effective in managing toxicities associated with capecitabine. Alopecia and myelosuppression were rare in patients receiving capecitabine while diarrhea and hand-foot syndrome were more common. Treatment interruption and/or individual dose adjustment of capecitabine was required in 34% of patients and was generally effective in managing adverse events. Treatment was stopped owing to toxicity in 16% of patients in the capecitabine arm. The incidence of deaths during or within 28 days of stopping study treatment was 8% and 6% in the capecitabine and CMF arms, respectively.

CONCLUSIONS

An oral, twice-daily regimen of capecitabine is effective and well tolerated when used as first-line chemotherapy in older patients (> or = 55 years) with advanced/metastatic breast cancer, and is suitable for outpatient therapy.

Quality of life post radical prostatectomy: a male perspective

The purpose of this qualitative study was to explore the meaning and effect of urinary incontinence and impotence on the quality of life for men with prostate cancer. The Cancer Recovery Model guided the study. This model is based on the assumption that the chronicity of cancer is a function of recovery as well as illness and focuses on the strength of an individual to regain his powers of survival until death. The study identified indicators for quality of life for men who have had a radical prostatectomy for cancer that should be included in developing discharge teaching plans and reinforced in community followup.

A unitary patient record improves admission documentation in a medical assessment unit in a major teaching hospital

OBJECTIVE

To ascertain the impact of the introduction of a unitary patient record (UPR) on clerking documentation of emergency medical admissions.

DESIGN

Retrospective casenote audit.

SUBJECTS AND SETTING

Random sample of 100 unselected admissions to the medical assessment unit of a major teaching hospital, comprising two groups pre- and post-introduction of the UPR.

RESULTS

Statistically significant improvements in the documentation of several items were achieved; function before episode, ethnic origin, chest pain, breathlessness, ankle oedema, cough, bowel habit and locomotor symptoms and recording of blood pressure and peripheral pulses. There were trends towards improvement in other areas and there were no areas in which the UPR performed less well than standard documentation.

CONCLUSIONS

Introduction of the UPR represents the successful application of multidisciplinary principles to over 10,000 acute general medical admissions. It has improved some, but not all, aspects of documentation. Revision of the design of the UPR should lead to further progress, as part of an ongoing process of development and re-audit.

Use of A-192621 to provide evidence for involvement of endothelin ET(B)-receptors in endothelin-1-mediated cardiomyocyte hypertrophy

Increased plasma levels of endothelin-1 correlate with the severity of left ventricular hypertrophy in vivo. The aim of the study was to determine the relative contribution of stimulation of endothelin ET(A) and endothelin ET(B) receptors, and the associated activation of protein kinase C, to the hypertrophic response initiated by endothelin-1 in adult rat ventricular cardiomyocytes maintained in culture (24 h). Endothelin-1 (10(-7) M) increased the total mass of protein and the incorporation of [14C] phenylalanine into protein to 26% and 25% greater (P<0.05) than respective basal values. The total content of RNA and the incorporation of 2-[14C] uridine into RNA were increased by 23% and 21%, respectively, by endothelin-1 (10(-8) M). Actinomycin D (5x10(-6) M), an inhibitor of transcription, abolished the incorporation of [14C] phenylalanine and the increased protein mass elicited by endothelin-1 (10(-8) M). The selective agonists at the endothelin ET(B) receptor, sarafotoxin 6c (10(-7) M) and endothelin-3 (10(-7) M), increased the incorporation of [14C] phenylalanine to 13% and 13% greater than respective basal values. The incorporation of [14C]phenylalanine in response to endothelin-1 (10(-7) M) was reduced by 50% (P<0.05) by the selective antagonist at endothelin ET(A) receptors, ABT-627 (10(-9) M), while the response to sarafotoxin 6c was not attenuated. The selective antagonist at endothelin ET(B) receptors, A192621 (10(-10) M), abolished the response to sarafotoxin 6c (10(-7) M) and attenuated the response to endothelin-1 (10(-7) M) by 43% (P<0.05). The selective inhibitor of protein kinase C, bisindolylmaleimide (5x10(-6) M) attenuated the response to sarafotoxin 6c (10(-7) M) by 78% and that to endothelin-1 (10(-7) M), elicited in the presence of A192621 (10(-10) M), by 52%. In conclusion, these data implicate endothelin ET(B) receptors, in addition to endothelin ET(A) receptors, in endothelin-1-mediated cardiomyocyte hypertrophy and provide evidence for the involvement of protein kinase C, at least in part, in the hypertrophic signalling pathways associated with activation of each receptor subpopulation.

Positive and negative contractile effects of somatostatin-14 on rat ventricular cardiomyocytes

Somatostatin-14 elicits negative inotropic and chronotropic actions in atrial myocardium. Less is known about the effects of somatostatin-14 in ventricular myocardium. The direct contractile effects of somatostatin-14 were assessed using ventricular cardiomyocytes isolated from the hearts of adult rats. Cells were stimulated at 0.5 Hz with CaCl2 (2 mM) under basal conditions and in the presence of the beta-adrenoceptor agonist, isoprenaline (1 nM), or the selective inhibitor of the transient outward current (Ito), 4-aminopyridine (500 microM). Somatostatin-14 did not alter basal contractile response but it did inhibit (IC50 = 13 nM) the response to isoprenaline (1 nM). In the presence of 4-aminopyridine (500 microM), somatostatin-14 stimulated a positive contractile response (EC50 = 118 fM) that was attenuated markedly by diltiazem (100 nM). These data indicate that somatostatin-14 exerts dual effects directly in rat ventricular cardiomyocytes: (1) a negative contractile effect, observed in the presence of isoprenaline (1 nM), coupled to activation of Ito; and (2) a previously unreported and very potent positive contractile effect, unmasked by 4-aminopyridine (500 microM), coupled to the influx of calcium ions via L-type calcium channels. The greater potency of somatostatin-14 for producing the positive contractile effect indicates that the peptide may exert a predominantly stimulatory influence on the resting contractility of ventricular myocardium in vivo, whereas the negative contractile effect, observed at much higher concentrations, could indicate that localized elevations in the concentration of the peptide may serve as a negative regulatory influence to limit the detrimental effects of excessive stimulation of cardiomyocyte contractility.

Abnormal G-actin content in single prostate cells as a biomarker of prostate cancer

The distribution of altered G-actin was investigated in prostatic cells obtained by fine needle aspiration (FNA) from 27 excised prostate glands obtained during radical prostatectomy. FNA, which was used to obtain single cells for image analysis, sampled in the region of any nodules and in grossly normal areas of the contralateral lobes. Quantitative fluorescence-image analysis was used to assay the amount of G-actin in individual cells. Abnormal G-actin, a precursor cytoskeletal protein representing cytoskeletal rearrangements accompanying cellular transformation, was associated with the presence of adenocarcinoma in 22 of 27 specimens from the dominant nodule, but only 3 of 20 in the grossly normal specimens (P<.0001). The mean G-actin content of all samples from the dominant nodule was 113.2+/-6.87 and 69.57+/-4.47 from the grossly normal area, the difference being significant at P<.0001. Altered G-actin was not associated with Gleason score (P = .95), grade (P = .26), stage (P = .058), or tumor volume (P = .32), thereby indicating it is a general marker for prostate adenocarcinoma.

Diagnosis of malaria in a remote area of the Philippines: comparison of techniques and their acceptance by health workers and the community

OBJECTIVE

To compare the efficacies of remote symptom-based diagnosis of malaria, rapid diagnostic tests and microscopy in an area of low endemicity in the Philippines.

METHODS

In Trial I, 350 symptomatic patients were tested within their villages using malaria Plasmodium falciparum (Pf)/Plasmodium vivax (Pv) immunochromatographic tests (ICT tests) and blood films stored and read under local conditions. The slides were later restained and read. In Trial II, unsupervised volunteer barangay health workers prepared ICT tests and slides after brief training. These slides were read at rural health units. Twenty-seven barangay health workers and 72 community members were later questioned about the three diagnostic strategies.

FINDINGS

A history of fever alone was sensitive (95.4%) but poorly specific (16.5%) for predicting parasitaemia. The inclusion of other symptoms reduced the sensitivity to below 85%, while specificity remained low. The axillary temperature was poorly predictive. ICT tests achieved high sensitivity (97.9%) but many cases indicated as positive by ICT tests were negative by microscopy. Further analysis of these cases in Trial I indicated that ICT tests were detecting low-level parasitaemias missed by microscopy, and that local microscopy had poor accuracy. ICT tests were well accepted and accurately performed by barangay health workers.

CONCLUSION

These tests meet a strong desire in the community for blood-based diagnosis and may increase the compliance and treatment-seeking behaviour of patients.

Two double-blinded, randomized, comparative trials of 4 human immunodeficiency virus type 1 (HIV-1) envelope vaccines in HIV-1-infected individuals across a spectrum of disease severity: AIDS Clinical Trials Groups 209 and 214

The potential role of human immunodeficiency virus type 1 (HIV-1)-specific immune responses in controlling viral replication in vivo has stimulated interest in enhancing virus-specific immunity by vaccinating infected individuals with HIV-1 or its components. These studies were undertaken to define patient populations most likely to respond to vaccination, with the induction of novel HIV-1-specific cellular immune responses, and to compare the safety and immunogenicity of several candidate recombinant HIV-1 envelope vaccines and adjuvants. New lymphoproliferative responses (LPRs) developed in <30% of vaccine recipients. LPRs were elicited primarily in study participants with a CD4 cell count >350 cells/mm(3) and were usually strain restricted. Responders tended to be more likely than nonresponders to have an undetectable level of HIV-1 RNA at baseline (P=.067). Induction of new cellular immune responses by HIV-1 envelope vaccines is a function of the immunologic stage of disease and baseline plasma HIV-1 RNA level and exhibits considerable vaccine strain specificity.

Phrenic nerve injury following blunt trauma

Phrenic nerve trauma in the absence of direct injury is unusual and may present diagnostic difficulty. Diaphragmatic paralysis resulting from phrenic nerve injury may closely mimic diaphragmatic rupture. This case highlights the value of magnetic resonance imaging in establishing diaphragmatic integrity and of ultrasonographic assessment during respiratory excursion in confirming diaphragmatic paralysis. In cases of non-contact injury involving torsional injury to the neck, an index of clinical awareness may help to establish the diagnosis of phrenic nerve trauma.

Prostate screening health beliefs and practices of African American men

The purpose of this study was to investigate the health beliefs and practices of African American men regarding prostate cancer screening. A descriptive non-experimental design was used with a self-administered questionnaire to identify participants' knowledge level, health beliefs and practices related to the screening and early detection of prostate cancer in African American men. Results indicate that most participants had a high level of prostate cancer knowledge, early detection and had prostate screening done on a regular basis. They believed prostate cancer was not preventable but if contracted treatment would be painful and impair sexual function. Other significant beliefs included: good health habits were important, most rated their health as good or excellent, and they rely on their faith to stay healthy. Findings of this study provide culturally appropriate information which may contribute to developing prostate cancer prevention programs in African American communities.

Genetic susceptibility to breast cancer: HLA DQB*03032 and HLA DRB1*11 may represent protective alleles

Tumors are believed to emerge only when immune surveillance fails. We wished to ascertain whether the failure to inherit putative protective alleles of HLA class II genes is linked to the development of breast cancer. We molecularly typed HLA DPB1, DQB1, DRB1, and DRB3 alleles in 176 Caucasian women diagnosed with early-onset breast cancer and in 215 ethnically matched controls. HLA DQB*03032 was identified in 7% of controls but in no patients with early-onset breast cancer (P = 0.0001). HLA DRB1*11 alleles were also significantly overrepresented (P < 0.0001) in controls (16. 3%) as compared with patients with early-onset breast cancer (3.5%). HLA DQB*03032 and HLA DRB1*11 alleles may have a protective role in human breast cancer.

Dendritic cells capture killed tumor cells and present their antigens to elicit tumor-specific immune responses

Due to their capacity to induce primary immune responses, dendritic cells (DC) are attractive vectors for immunotherapy of cancer. Yet the targeting of tumor Ags to DC remains a challenge. Here we show that immature human monocyte-derived DC capture various killed tumor cells, including Jurkat T cell lymphoma, malignant melanoma, and prostate carcinoma. DC loaded with killed tumor cells induce MHC class I- and class II-restricted proliferation of autologous CD8+ and CD4+ T cells, demonstrating cross-presentation of tumor cell-derived Ags. Furthermore, tumor-loaded DC elicit expansion of CTL with cytotoxic activity against the tumor cells used for immunization. CTL elicited by DC loaded with the PC3 prostate carcinoma cell bodies kill another prostate carcinoma cell line, DU145, suggesting recognition of shared Ags. Finally, CTL elicited by DC loaded with killed LNCap prostate carcinoma cells, which express prostate specific Ag (PSA), are able to kill PSA peptide-pulsed T2 cells. This demonstrates that induced CTL activity is not only due to alloantigens, and that alloantigens do not prevent the activation of T cells specific for tumor-associated Ags. This approach opens the possibility of using allogeneic tumor cells as a source of tumor Ag for antitumor therapies.

Behind the scenes: partners' perceptions of quality of life post radical prostatectomy

The purpose of this study was to determine the effects of the experience of a radical prostatectomy on the partners of men with prostate cancer. The women described the effects of the experience on their lives and on their partner's life. Descriptions included how they were informed of their partner's diagnosis, emotions at the time of the initial diagnosis, and the sources of information and the decision process that they and their partners used that lead to surgery. The effect of the experience on their quality of life including interpersonal and sexual relationships with their partner and the information that was needed to facilitate self-care after surgery were described. The women provided clear directions for improving the health care system in managing the cancer experience using a family-centered approach.

Continued lamivudine versus delavirdine in combination with indinavir and zidovudine or stavudine in lamivudine-experienced patients: results of Adult AIDS Clinical Trials Group protocol 370

OBJECTIVE

To compare the virologic activity of continued lamivudine (3TC) versus a switch to delavirdine (DLV) when initiating protease inhibitor therapy in nucleoside-experienced patients.

DESIGN

Randomized, open-label, multi-center study.

SETTING

Adult AIDS clinical trials units.

PATIENTS

Protease and non-nucleoside reverse transcriptase inhibitor-naive patients who had received 3TC plus zidovudine (ZDV), stavudine (d4T), or didanosine (ddl) for at least 24 weeks.

INTERVENTIONS

Patients with plasma HIV-1 RNA levels > 500 copies/ml who previously received d4T + 3TC or ddI + 3TC were randomized to ZDV + 3TC + indinavir (IDV) or ZDV + DLV + IDV.

MAIN OUTCOME MEASURES

Primary endpoints were the proportion of patients with plasma HIV-1 RNA levels < or = 200 copies/ml at 24 weeks, and occurrence of serious adverse events. The proportion of patients with plasma HIV-1 RNA levels < or = 200 copies/ml at week 48 was a secondary endpoint.

RESULTS

At week 24, 58% of subjects in the ZDV + 3TC + IDV arm and 73% in the ZDV + DLV + IDV arm had plasma HIV-1 RNA levels < or = 200 copies/ml (P = 0.29). At week 48, plasma HIV-1 RNA levels were < or = 200 copies/ml in 48% and 83%, respectively (P = 0.007). Rash and hyperbilirubinemia occurred more frequently in the DLV arm than in the 3TC arm. Steady-state plasma IDV levels were higher among patients in the DLV arm as compared with the 3TC arm.

CONCLUSIONS

Substituting DLV for 3TC when adding IDV improved virologic outcome in nucleoside-experienced patients. This result might be explained, in part, by the positive effect of DLV on IDV pharmacokinetics.

Borderline tumors of the ovary: correlation of frozen and permanent histopathologic diagnosis

OBJECTIVE

To evaluate the correlation between the diagnosis of borderline tumor of the ovary by frozen and permanent pathology.

METHODS

All pathology reports with diagnoses of borderline tumor of the ovary between 1980 and 1998 at Massachusetts General Hospital were reviewed. Univariate and multivariable logistic regression models were constructed for patient age, tumor size, histology, presence of bilateral or extraovarian disease, and concurrent diagnosis of endometriosis or endosalpingiosis.

RESULTS

We reviewed 140 cases. The average age of patients was 52.3 years. Eighty tumors were serous, 47 mucinous, 11 mixed, and two endometrioid. The mean diameter overall was 13.7 cm (range 1-70 cm), 10.2 cm for serous, and 20.1 cm for mucinous. Diagnoses of borderline tumors by frozen and permanent pathology were consistent in 60% of cases. Frozen section interpreted a benign lesion as malignant (overdiagnosed) in 10.7% of cases, and interpreted a malignant lesion as benign (underdiagnosed) in 29.3%. No variable was a significant predicator of overdiagnosis. In univariate analysis, underdiagnosis was more likely for other types of tumors than serous (P <.001), tumors larger than 20 cm (P =.039), and tumors confined to the ovaries (P =. 009). When all variables were included in a multiple regression model, only histology was a significant predictor of underdiagnosis (P =.039).

CONCLUSION

Frozen or permanent pathology reports of diagnoses of borderline tumor were consistent 60% of the time, whereas the positive predictive value of borderline by frozen section was 89.3%. Tumors other than serous are more likely to be misinterpreted.

Glutathione S-transferases M1, T1, and P1 and breast cancer

We examined associations for glutathione S-transferases M1 (GSTM1), T1 (GSTT1), and P1 (GSTP1) genotypes and breast cancer in the Carolina Breast Cancer Study, a population-based, case-control study in North Carolina. Odds ratios were close to the null value for each GST locus among African-American women (278 cases and 271 controls) and white women (410 cases and 392 controls), as well as pre- and postmenopausal women. For women with a history of breast cancer in one or more first-degree relatives, odds ratios were 2.1 (95% confidence interval, 1.0-4.2) for GSTM1 null and 1.9 (0.8-4.6) for GSTT1 null genotypes. Among women with a family history, age at diagnosis was significantly earlier for those with the GSTM1 null genotype. We did not observe strong evidence for modification of odds ratios for smoking according to GST genotypes. There was no evidence for combined effects of GSTM1, GSTT1, and GSTP1 genotypes, and there were no combined effects for GST genotypes and the catechol O-methyltransferase genotype. We conclude that GSTM1, GSTT1, and GSTP1 genotypes do not play a strong role in susceptibility to breast cancer. However, the role of GST genotypes in age at onset and risk of breast cancer among women with a family history merits further investigation.

Preferential proliferation and differentiation of double-positive thymocytes into CD8(+) single-positive thymocytes in a novel cell culture medium

The identification of factors that regulate the proliferation and differentiation of double-positive (DP) into CD4(+) and CD8(+) single-positive (SP) thymocytes has proven difficult due to the inability of DP thymocytes to proliferate, expand, and differentiate into SP thymocytes in available cell culture media. Here we report on the ability of DP thymocytes to differentiate in a novel conditioned medium, termed XLCM, derived from the supernatant of mitogen activated human cord blood mononuclear cells. During a 5-day culture in XLCM in the absence of thymic stromal cells, DP thymocytes from normal mice and MHC double knockout mice (lack SP thymocytes) proliferate, expand, and differentiate into several (alphabetaTCR(+), NK1.1(+)alphabetaTCR(+), and gammadeltaTCR(+)) subsets of CD4(+) and predominantly CD8(+) SP thymocytes. These studies suggest that the use of XLCM may aid in the characterization of factors that regulate the differentiation of DP thymocytes into CD8(+) SP thymocytes.