Clinically occult avascular necrosis of the hip in systemic lupus erythematosus

OBJECTIVE

To study the natural history of clinically occult avascular necrosis (AVN) of the hip in patients with systemic lupus erythematosus (SLE).

METHODS

Sixty-six patients with SLE (without symptoms referable to the hip) receiving at least 5 mg/day prednisone for > or = 6 months were screened by magnetic resonance imaging (MRI) for AVN of the hip. A complete MRI evaluating class and percentage of femoral head involvement, AP and lateral radiographs of the hips, bone scan, and physical examination were performed for patients with positive MRI. Medical records were reviewed for serologic and clinical variables that might predict AVN. Repeat MRI were obtained at 3, 6, and 12 months to assess possible progression or resolution of the lesion. Patients with negative screening MRI underwent repeat screening after one year to assess the one year incidence rate.

RESULTS

Eleven asymptomatic hips (8%) in 8 patients (12%) had MRI documented AVN. The percentage of femoral head involvement ranged from 1 to 46%. One lesion was MRI class B, the remaining lesions were class A. The radiographic stage of 10 hips was stage 1, the MRI class B hip was stage 2. Risk factors for clinically occult AVN included Afro-American origin, Raynaud's phenomenon, migraine headaches, and a maximal corticosteroid dose of at least 30 mg/day. After 12 months, 43 of 58 patients with an initially negative MRI underwent repeat screening examinations; no new lesions were observed.

CONCLUSION

Clinically occult AVN of the hip is common in patients with SLE. The short term natural history of these lesions appears stable without spontaneous healing or clinical or radiographic progression. Risk factors for these asymptomatic lesions are similar to the risks for symptomatic AVN and surgical intervention appears not to be indicated in these patients.

99Tcm-MDP blood-pool phase in the assessment of repetitive strain injury

We reviewed three-phase bone scans of the limbs of 7 patients suffering from limb pain suggestive of occupational repetitive strain injury (RSI) and compared them with 13 patients with limb pain due to various aetiologies. Doppler ultrasound measurement of blood flow had been performed in 13 of the 20 patients. The bone scan results showed increased blood flow and pooling (second phase) in the affected limbs of patients with RSI as compared to those with algodystrophy or non-specific limb pain (sensitivity 86%, specificity 85%). Doppler ultrasound also demonstrated increased blood flow to the affected limbs (sensitivity 83%) but failed to differentiate between the different aetiologies of pain (specificity 14%). We conclude that the blood-pool phase of three-phase bone scans can play a potential role in screening RSI patients.

A prospective randomised trial of protracted venous infusion 5-fluorouracil with or without mitomycin C in advanced colorectal cancer

BACKGROUND

To compare protracted venous infusion (PVI) 5-fluorouracil (5-FU) with and without mitomycin C (MMC) in a prospectively randomised study and analyse for tumour response, survival, toxicity and quality of life (QL).

PATIENTS AND METHODS

Two hundred patients with advanced colorectal cancer received PVI 5-FU 300 mg/m2/day for a maximum of 24 weeks and were randomised to PVI 5-FU alone or PVI 5-FU + MMC 10 mg/m2 (7 mg/m2 from June 1995) 6 weekly for 4 courses.

RESULTS

Overall response was 54% (95% confidence interval [CI] 44.1%-63.9%) with PVI 5-FU + MMC compared to 38% (95% CI: 28.3%-47.7%) for PVI 5-FU alone (P = 0.024). The median failure free survival was 7.9 months in PVI 5-FU plus MMC and 5.4 months with PVI 5-FU alone (P = 0.033) and at one year 31.9% for the combination compared to 17.7% for PVI 5-FU alone. Median survival was 14 months with MMC and 15 months in 5-FU alone; one-year survival 51.7% vs. 57.2%. PVI 5-FU + MMC caused more overall haematological toxicity but CTC grades 3/4 was increased only for thrombocytopaenia. Two patients treated with a cumulative dose of MMC of 40 mg/m2 developed haemolytic uraemic syndrome warranting the reduction in cumulative MMC dose to 28 mg/m2. The global QL scores were better for PVI 5-FU + MMC arm at 24 weeks, but the remaining QL data showed no differences.

CONCLUSIONS

PVI 5-FU + MMC results in failure-free survival and response advantage, tolerable toxicity and better QL when compared to PVI 5-FU alone but no overall survival advantage. There is no irreversible toxicity with MMC at a cumulative dose of 28 mg/m2.

X-ray phototherapy for canine brain masses

Brain masses diagnosed in 47 pet dogs as tumors by CT scans, and confirmed in 12 dogs by necropsies, were injected with iodinated contrast media and treated by a modified CT scanner, the CTRx. Twenty-six dogs that received six or more weekly treatments of about 5.6 Gy per fraction, of which about 25% was contributed by radiation from the iodine, for a median total dose of 39 Gy, had a median survival of 230 days. This compares well with the 150 days reported for 25 dogs given 46-48 Gy of cobalt-60 radiation to the whole brain, and is significantly greater than the 6 to 13 days in untreated historic controls.

Evaluation of the lactulose/mannitol and 51Cr-ethylenediaminetetraacetic acid/14C-mannitol methods for intestinal permeability

BACKGROUND

We earlier compared the lactulose/mannitol and 51Cr-ethylenediaminetetraacetic acid (EDTA)/14C-mannitol methods for intestinal permeability We have now investigated an increased number of control subjects, with special regard to the influence of urinary volume, sex, age, and smoking on marker excretion, and patients with intestinal disorders, with special regard to correlations between markers.

METHODS

The 0- to 6-h urinary excretion of orally administered markers was measured in 65 control subjects and in 70 patients.

RESULTS

In the control group excretion of mannitol and 14C-mannitol (small-pore permeability markers) was strongly correlated to urinary volume, whereas such correlation was weak for lactulose and absent for 51Cr-EDTA (large-pore permeability markers). No sex difference in marker excretion was found, but correlation to urinary volume was more pronounced in males. There was a slightly decreasing excretion of markers with increasing age, reaching significance for 51Cr-EDTA and 14C-mannitol; their excretion ratio was unaffected. Smoking did not significantly affect marker excretion. In the patient group the excretion of large-pore markers tended to be higher and that of small-pore markers to be lower than in the control group; correlation between the large-pore markers, between the small-pore markers, and between the large-pore/small-pore marker ratios was higher than in the control group.

CONCLUSIONS

Correction for urinary volume substantially reduces variability in small-pore marker excretion. Excretion of both types of markers tends to decrease with age, the large-pore/small-pore marker ratio remaining unchanged. Smoking does not affect small-intestinal permeability. 14C-mannitol is preferred to chemically determined mannitol owing to lower test variability.

Postnatal development of the collagen matrix in rabbit tibial plateau articular cartilage

Changes in the 3-dimensional arrangement of the articular cartilage matrix during growth of the rabbit tibial plateau were studied. Knees from newborn, and 1, 2 and 6 wk-old rabbits were compared with those of adults by light and electron microscopy. The specimens were fixed, embedded en bloc in epoxy resin and sectioned vertically/coronally through the point where the articular cartilage was thickest in the adult medial tibial plateau. At birth, the proximal tibial epiphysis was cartilaginous, but nascent articular cartilage was recognisable as a densely cellular layer covering the tibial condyle. Within 30 microns of the articular surface, the chondrocytes were flattened and collagen fibres ran among these cells in a direction parallel to the surface. Deeper in the articular cartilage, rounded cells were evenly distributed within a random collagen fibril network. At the centre of the plateau, the tangential layer changed little during growth, whereas the subjacent cellular layer grew in thickness and steadily achieved a more vertical character in the organisation of its constituent collagen and cellular elements. At 1 wk, cells were separated into clusters by acellular regions filled with collagen fibrils. At 2 wk, cells within the forming radial zone were aligned in columns bracketed by vertical collagen fibres. Continuity of these vertical fibres with those in the tangential surface layer was evident at this age. The chondrocytes were surrounded by fibrous capsules typical of chondrons. By 6 wk, the bases of the radial collagen fibres in the very centre of the condyle had calcified, as had the adjacent hypertrophic hyaline cartilage. A solid subchondral plate and tidemark did not appear until skeletal maturity. From birth to age 6 wk, maximum thickness of the layer identified as primordial articular cartilage increased from 0.13 mm to 0.70 mm, and was 1.5 mm in the adult. Throughout growth, however, the thickness of the tangential layer in the centre of the plateau never exceeded 0.05 micron. In the patella, femoral head and peripheral tibial plateau, cartilage development followed the same general sequence. In contrast to the central tibial plateau, the tangential layer also grew in thickness, but at a slower rate than that of the radial zone. At all ages, the developing articular cartilage was structurally distinct from the deeper hyaline cartilage which contributed to growth of the ossification centre through enchondral ossification. The collagen matrix of articular cartilage acquires a characteristic, orderly 3-dimensional structure soon after birth. Growth in cartilage thickness occurs primarily through enlargement of the radial zone.

Effects of norepinephrine infusion and exercise on blood pressure in rats

Two experiments were conducted to test the hypotheses that norepinephrine (NE) infusion would increase blood pressure and wheel running activity level, and, secondly, that voluntary exercise would lower NE-induced increases in blood pressure. NE-bitartrate was infused into male Sprague-Dawley rats using an implanted osmotic pump (3.75 micrograms/kg/min in 0.9% saline). Control rats received the vehicle solution. Systolic blood pressure was measured by the tail-cuff method. Voluntary wheel running activity expressed as wheel revolutions per 24 hr was measured on the 5th, 9th, and 13th day. Blood pressure on the 13th day and wheel running activity on the 9th day were significantly higher in NE-infused rats. The NE content of heart tissue was not altered, but urinary excretion of NE and epinephrine was increased in the NE-infused animals. Food intake, body weight gain, and kidney weight per 100 g body wt were not changed but heart weight per 100 g body wt was increased by NE infusion. Urinary total calcium excretion was higher in the NE-infused rats. Spontaneous voluntary exercise in running wheels attenuated increases of blood pressure in NE-infused rats. The results of the present study suggest that rats receiving exogenous NE exhibit increased blood pressure and voluntary wheel running activity. Voluntary wheel running exercise also reduces blood pressure in NE-infused rats.

Management of school leavers given a diphtheria and tetanus vaccine intended for children instead of the intended low dose preparation

In November 1995, 102 school leavers in two North Staffordshire schools were given high dose diphtheria and tetanus vaccine (intended for primary immunisation of children) rather than a preparation with a low dose of diphtheria vaccine intended for adults and adolescents. We describe the management of the incident and the action taken to minimise the risk of such an error being made again. Pupils who had received the high dose vaccine and a control group were surveyed with a self-administered questionnaire. Thirteen children out of 67 given the higher dose diphtheria vaccine consulted their general practitioner and the same number had time off school, compared with none of 25 from a control school. This excess morbidity was probably attributable to the higher dose of diphtheria vaccine.

Elimination of theophylline metabolites in healthy adults

The metabolism of theophylline (TP) (540 mg per os) was determined by measuring plasma and saliva concentrations of TP and its metabolites, 0-24 h after loading, and urinary excretion 0-48 h after loading. TP and its five metabolites were separated and quantified by combining high-performance liquid chromatography and capillary electrophoresis. In addition to TP, 1,3-U, 3-X and 1-U were consistently found in plasma and saliva. The area under the plasma concentration-time curve (AUC) showed that TP accounted for 91 +/- 4% (mean +/- SD) of the total AUC in plasma with 1,3-U accounting for 3.1 +/- 1.4%, 3-X for 3.4 +/- 1.8% and 1-U for 2.5 +/- 1.5%. The urine analyses showed that unchanged TP accounted for 19 +/- 5% of total excretion, the remainder being 1, 3-dimethyluric acid (1,3-U, 41 +/- 6%), 1-methylxanthine (1-X, 2 +/- 0.8%), 1-methyluric acid (1-U, 26 +/- 6%), 3-methylxanthine (3-X, 11 +/- 3%) and 3-methyluric acid (3-U, 1 +/- 0.3%). Highest excretion rates were observed for 1,3-U (70 +/- 29 mumol/h), 1-U (40 +/- 26 mumol/h) and 3-X (20 +/- 15 mumol/h) 6-9 h after TP ingestion suggesting the high excretion of 1,3-U, 1-U and 3-X by the kidneys. The highest excretion rate of TP (50 +/- 8 mumol/h) occurring at 0-6 h after the load and rapidly declining thereafter, indicated the lower excretion of TP compared with its metabolites. N3-demethylation of TP accounted for 34 +/- 6% of the urinary metabolites, N1-demethylation of TP for 15 +/- 3% and C8-oxidation of TP for 51 +/- 9%. C8-oxidation of 1-X and 3-X was 93 +/- 4%, and 9 +/- 4%, respectively, of the excreted amount of monomethylxanthine plus formed monomethylurate. Since the extent of all metabolic reactions remained constant during the load, it is suggested that TP is metabolized by hepatic reactions that occurred simultaneously and not sequentially.

A prospective analysis of 949 long-term central venous access catheters for ambulatory chemotherapy in patients with gastrointestinal malignancy

We present a prospective analysis of the insertion complications and longevity of 949 cuffed, tunnelled central venous catheters used for ambulatory chemotherapy. Mean catheter life span was 121.8 days, 13.4% had complications at insertion, 17.7% had complications not necessitating removal and 18.6% had complications requiring removal. The more experienced operators had fewer complications inserting catheters (P < 0.0001). Late-onset shoulder pain occurred in 4.8% and was associated with an increased incidence of venous thrombosis (P < 0.0001) and infection (P = 0.06). Complications necessitating removal were not predicted by patient' age, site of insertion or malignancy, chemotherapy regimen, insertion platelet and fibrinogen counts, insertion complications, leucocyte count or cuff distance from the exist site. Catheters inserted with their tip in the superior vena cava were more at risk of removal (2.57 times) than those in the right atrium (P = 0.003).

Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer

PURPOSE

We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous infusion fluorouracil (5-FU) (ECF regimen) with the standard combination of 5-FU, doxorubicin, and methotrexate (FAMTX) in previously untreated patients with advanced esophagogastric cancer.

PATIENTS AND METHODS

Two hundred seventy-four patients with adenocarcinoma or undifferentiated carcinoma were randomized and analyzed for survival, tumor response, toxicity, and quality of life (QL).

RESULTS

The overall response rate was 45% (95% confidence interval [CI], 36% to 54%) with ECF and 21% (95% CI, 13% to 29%) with FAMTX (P = .0002). Toxicity was tolerable and there were only three toxic deaths. The FAMTX regimen caused more hematologic toxicity and serious infections, but ECF caused more emesis and alopecia. The median survival duration was 8.9 months with ECF and 5.7 months with FAMTX (P = .0009); at 1 year, 36% (95% CI, 27% to 45%) of ECF and 21% (95% CI, 14% to 29%) of FAMTX patients were alive. The median failure-free survival duration was 7.4 months with ECF and 3.4 months with FAMTX (P = .00006). The global QL scores were better for ECF at 24 weeks, but the remaining QL data showed no differences between either arm of the study. Hospital-based cost analysis on a subset of patients was similar for each arm and translated into an increment cost of $975 per life-year gained.

CONCLUSION

The ECF regimen results in a survival and response advantage, tolerable toxicity, better QL and cost-effectiveness compared with FAMTX chemotherapy. This regimen should now be considered the standard treatment for advanced esophagogastric cancer.

A phase I/II study of leucovorin, carboplatin and 5-fluorouracil (LCF) in patients with carcinoma of unknown primary site or advanced oesophagogastric/pancreatic adenocarcinomas

Carcinoma of unknown primary site (CUPS) accounts for 5-10% of all malignancies. Forty patients with metastatic CUPS or advanced oesophagogastric/pancreatic adenocarcinomas were recruited. Eligibility included ECOG performance status 0-2, minimum life expectancy of 3 months and measurable disease. The regimen consisted of bolus intravenous 5 fluorouracil (5-FU) and leucovorin (20 mg m-2) days 1-5 and carboplatin (AUC5) on day 3. The leucovorin/carboplatin/5-FU (LCF) was repeated every 4 weeks. The starting dose of 5-FU was 350 mg m-2 day-1 with escalation to 370 and then 400 mg m-2 day -1 after the toxicity at the previous level had been assessed. The maximum tolerated dose (MTD) was defined as the dosage of 5-FU that achieved 60% grade 3/4 toxicity. In addition, objective and symptomatic responses, quality of life and survival were assessed. The MTD of 5-FU in the LCF regimen was 370 mg m-2. The predominant toxicity was asymptomatic marrow toxicity. The 350 mg m-2 level was then expanded. There were two toxic deaths due to neutropenic sepsis, one at 370 mg m-2 after one course and one at 350 mg m-2 after four courses. The objective response rate was 25% with one complete response (CR) and nine partial responses (PRs). The median duration of response was 3.4 months (range 1-10). The CR and eight of the nine PRs were in CUPS patients. Twelve patients developed progressive disease on LCF. Median survival for all 40 patients was 7.8 months (10 months median survival for those treated at 350 mg m-2). The majority of patients described a symptomatic improvement with LCF chemotherapy. The recommended dose of 5-FU for future studies is 350 mg m-2 combined with leucovorin 20 mg m-2 and carboplatin (AUC5).

Fertility after chemotherapy for testicular germ cell cancers

PURPOSE

To analyze the probability of recovery of spermatogenesis after orchidectomy and cisplatin-based chemotherapy (CT) for testicular germ cell cancer.

PATIENTS AND METHODS

One hundred seventy-eight patients treated between 1979 and 1991 were selected by the requirement of sperm count both pre-CT and post-CT. Counts were classified as normospermic (NS) if more than 10 x 10(6)/mL, oligospermic (OS) if 1 to 9 x 10(6)/mL, and azoospermic (AS) if less than 1 x 10(6)/mL. The median follow-up time after CT before sperm analysis was 30 months.

RESULTS

Analysis of 170 patients whose spermatogenesis was reassessed at least 1 year after CT showed that of 89 patients whose pre-CT counts were NS, the post-CT count was NS in 64%, OS in 16%, and AS in 20%. There was clear evidence for continued recovery beyond 1 year; the probability of spermatogenesis increased to 48% by 2 years and 80% by 5 years. There was a significantly higher probability of recovery to OS and NS count levels in the 54 patients treated with carboplatin-rather than cisplatin-based therapy. There was an independent and similar effect of normal pre-CT count. There was a reduced probability to recover to OS in the 26 patients treated with more than four cycles of CT. A prognostic model identified three groups with 25%, 45%, and 82% probabilities of recovering spermatogenesis by 2 years after CT.

CONCLUSION

Analysis of pre-CT sperm count together with details of planned treatment can be used to predict recovery of spermatogenesis following germ cell CT.

Residual mass following chemotherapy of seminoma

BACKGROUND

The residual mass so frequently found after chemotherapy of advanced seminoma may consist entirely of benign tissue or may contain residual disease amenable to adjuvant therapy.

PATIENTS AND METHODS

A detailed retrospective analysis was performed on 45 patients treated with cisplatin based chemotherapy for advanced seminoma between 1978 and 1994.

RESULTS

The probability of a residual mass after chemotherapy was higher if the pre-treatment mass diameter was > 5 cm (78% versus 15%, P = 0.0009). Of 33 patients with residual masses following cisplatin chemotherapy, 4 were explored surgically showing fibrosis only, 15 were treated by adjuvant radiotherapy and 14 were managed by observation alone. Recurrence occurred in 2 of 14 patients managed by observation and in 2 of 15 managed by radiotherapy. There was no evidence that risk of recurrence was related to diameter of residual mass.

CONCLUSION

Residual masses persisted following cisplatin based combination chemotherapy for seminoma in 73% of cases. In our study, recurrence was rare and there was no evidence that this was influenced by either the size of the residual mass or the use of adjuvant therapy.

Randomized trial comparing epirubicin, cisplatin, and fluorouracil versus fluorouracil, doxorubicin, and methotrexate in advanced esophagogastric cancer

PURPOSE

We report the results of a prospectively randomized study that compared the combination of epirubicin, cisplatin, and protracted venous infusion fluorouracil (5-FU) (ECF regimen) with the standard combination of 5-FU, doxorubicin, and methotrexate (FAMTX) in previously untreated patients with advanced esophagogastric cancer.

PATIENTS AND METHODS

Two hundred seventy-four patients with adenocarcinoma or undifferentiated carcinoma were randomized and analyzed for survival, tumor response, toxicity, and quality of life (QL).

RESULTS

The overall response rate was 45% (95% confidence interval [CI], 36% to 54%) with ECF and 21% (95% CI, 13% to 29%) with FAMTX (P = .0002). Toxicity was tolerable and there were only three toxic deaths. The FAMTX regimen caused more hematologic toxicity and serious infections, but ECF caused more emesis and alopecia. The median survival duration was 8.9 months with ECF and 5.7 months with FAMTX (P = .0009); at 1 year, 36% (95% CI, 27% to 45%) of ECF and 21% (95% CI, 14% to 29%) of FAMTX patients were alive. The median failure-free survival duration was 7.4 months with ECF and 3.4 months with FAMTX (P = .00006). The global QL scores were better for ECF at 24 weeks, but the remaining QL data showed no differences between either arm of the study. Hospital-based cost analysis on a subset of patients was similar for each arm and translated into an increment cost of $975 per life-year gained.

CONCLUSION

The ECF regimen results in a survival and response advantage, tolerable toxicity, better QL and cost-effectiveness compared with FAMTX chemotherapy. This regimen should now be considered the standard treatment for advanced esophagogastric cancer.

Faecal bile acid excretion during detoxification in patients with alcohol abuse

BACKGROUND

We wanted to ascertain whether alcohol abuse is associated with a changed faecal bile acid excretion.

METHODS

Faecal bile acid excretion was studied in seven chronic alcoholic subjects when admitted to hospital for detoxification. Bile acids in faeces and serum were quantified by gas-liquid chromatography and identified by mass spectrometry.

RESULTS

Daily faecal bile acid excretion was on average 948 mumol in the patients at admission, compared with 400 mumol in eight healthy controls (P < 0.01). The daily faecal bile acid excretion decreased slowly during the detoxification period but was still higher in the patients than in controls after 9 days of detoxification (P < 0.05). Faecal bile acid excretion varied greatly between the different patients, with poor correlation to diarrhoea. In one patient the faecal bile acid excretion was remarkably high, amounting to an average of 6800 mumol day-1 during the first 3 days. The percentage metabolites of total faecal bile acids in the patients did not differ significantly from that of controls. The faecal wet weight was higher in the patients than in the controls, although significantly so only after the first 3 days of detoxification.

CONCLUSIONS

Faecal bile acid excretion is increased after alcohol abuse. A gradual decrease in faecal bile acid excretion was observed during the 9-day observation period when the subjects abstained from alcohol.

An analysis of surveillance for stage I combined teratoma--seminoma of the testis

We analysed 973 patients with stage I testicular tumours presenting between 1983 and 1994. The median ages at presentation for non-seminomatous germ cell tumour (teratoma) were 27 years, seminoma 36 years and combined tumour 33 years. These differences were statistically significant (Mann-Whitney P < 0.05), suggesting that combined tumours may have a separate natural history. We, therefore, analysed all stage I patients managed with surveillance (530 in total) post orchidectomy. The actuarial 5 year relapse-free survival and anatomical patterns of relapse were identical for non-seminomatous germ cell tumour (NSGCT) and combined tumour and both were statistically distinct from seminoma (P = 0.01, log-rank test, chi-square test P = 0.001). The association of seminoma within a histologically confirmed NSGCT has no influence on the clinical outcome.

Elimination of theobromine metabolites in healthy adults

The metabolism of theobromine (TB) (500 mg per os) was determined by measuring plasma and saliva concentrations of TB and its metabolites 0-24 h after the load, and urinary excretion 0-48 h after the load. TB and its six metabolites were separated and quantified by combining high performance liquid chromatography and capillary electrophoresis. The urine analyses showed that unchanged TB accounted for 21 +/- 4% (mean +/- SD) of total excretion, the remainder being 7-methylxanthine (7-X, 36 +/- 5%), 3-methylxanthine (3-X, 21 +/- 4%), 6-amino-5[N-methylformylamino]-1-methyluracil (6-AMMU, 11 +/- 4%), 7-methyluric acid (7-U, 10 +/- 2%), 3,7-dimethyluric acid (3,7-U, 1.3 +/- 0.6%) and 3-methyluric acid (3-U, 0.5 +/- 0.4%). In addition to TB, 7-X and 3-X were consistently found in plasma and saliva; 6-AMMU and 7-U were found in plasma and saliva at concentrations < or = 2 mumol l-1 and 0.2 mumol l-1, respectively. TB concentrations in plasma and saliva were similar, whereas the saliva concentrations for 7-X and 3-X were found to be 63 +/- 17% of the plasma concentrations for 7-X and 74 +/- 13% for 3-X, respectively. The high urinary-to-plasma concentration ratio of 7-U (200-300) suggests high excretion of 7-U by the kidneys. Excretion of 7-X, 3-X and 6-AMMU was also high (urinary-to-plasma concentration ratio 45-150), whereas the excretion of TB was significantly lower than its metabolites (urinary-to-plasma concentration ratio 4-6). N3-demethylation of TB accounted for 58 +/- 7% of the urinary metabolites, N7-demethylation for 27 +/- 6%, C8-oxidation of 7-X for 22 +/- 4%, C8-oxidation of 3-X for 2 +/- 2% and formation of 6-AMMU for 13 +/- 4%. The ratio of N3- to N7-demethylation of TB remained constant during the load, but the large interindividual variation observed in ratio makes it unsuitable as a function test for evaluation of liver disease.

Assessment of dimethylxanthine formation from caffeine in healthy adults: comparison between plasma and saliva concentrations and urinary excretion of metabolites

Caffeine (CA), paraxanthine (PX), theobromine (TB) and theophylline (TP) were determined in plasma (i.e. total concentrations), ultrafiltrate of plasma (free concentrations) and saliva, by isocratic high performance liquid chromatography (HPLC), 0-24 h after a 200 mg oral load of CA in 10 healthy adults. Total metabolism of CA was established by determination of urinary metabolites, 24 h after CA ingestion, by gradient HPLC and capillary electrophoresis. Saliva concentrations of CA, PX, and TP were lower than plasma concentrations (p < 0.001), whereas TB concentrations in plasma and saliva were similar. Saliva concentrations of CA, PX, TB and TP were higher than the free plasma concentrations (p < 0.001). The area under the plasma concentration-time curve (AUC) showed that PX accounted for 63 +/- 13% of the dimethylxanthines in plasma, while TB accounted for 27 +/- 15% and TP for 10 +/- 2.6%. In contrast, the urine analyses showed that 78 +/- 11% of the excreted metabolites were metabolized through the PX pathway, 14 +/- 8% through the TB pathway and 9 +/- 4% through the TP pathway. The percentage of the AUC for PX, TB and TP in plasma was similar to the percentage of each dimethylxanthine excreted unmetabolized in urine. The percentages of the AUC for PX and TB were correlated to the percentages of PX (r = 0.78, p < 0.001) and TB (r = 0.88, p < 0.001) in urine. The AUC for PX in plasma was lower than (p < 0.001) and correlated to the total PX pathway value (r = 0.95, p < 0.001) and the value for PX plus its specific metabolites in urine. The AUC for TB in plasma was higher than (p < 0.001) and correlated to the total TB pathway value (r = 0.93, p < 0.001) and the value for TB plus its specific metabolites in urine. The AUC for TP in plasma was similar to both the TP pathway value and the value for TP plus its specific metabolites in urine. It is concluded that the AUC for dimethylxanthines in plasma underestimates the formation of PX, overestimates the formation of TB and gives a similar formation of TP from CA, as judged from the urinary metabolites formed through the PX, TB, and TP pathways.

A genetic register for von Hippel-Lindau disease

A genetic register for von Hippel-Lindau disease was set up in the north west of England in 1990. Population statistics, clinical features, age at onset, and survival of 83 people affected with von Hippel-Lindau (VHL) disease were studied. In addition, the effectiveness of the screening programme used and the occurrence of central nervous system haemangioblastomas in the general population were examined. The diagnostic point prevalence of heterozygotes in the North Western Region was 1 center dot 18/100 000 (1/85 000) people, with an estimated birth incidence of 2 center dot 20/100 000 (1/45 500) live births. The mutation rate was estimated directly to be 1 center dot 4 x 10(-6)/gene/generation (1/714 200). The mean age at onset of first symptoms was 26 center dot 25 years, with cerebellar haemangioblastoma being the most common presenting manifestation (34 center dot 9% of cases). The mean age at diagnosis of VHL disease was 30 center dot 87 years. Overall, 50 patients (60 center dot 2%) developed a cerebellar haemangioblastoma, 34 (41 center dot 0%) a retinal angioma, 21 (25 center dot 3%) a renal cell carcinoma, 12 (14 center dot 5%) a spinal haemangioblastoma, and 12 (14 center dot 5%) a phaeochromocytoma. Mean age at diagnosis of renal cell carcinoma (38 center dot 9 years) was significantly higher than that for cerebellar haemangioblastoma (30 center dot 0 years) and retinal angioma (21.1 years). Mean age at death was 40 center dot 9 years with cerebellar haemangioblastoma being the most common cause (47 center dot 7% of deaths). A total of 65 VHL manifestations were diagnosed asymptomatically following appropriate clinical and radiological screening tests, and failure to detect manifestations of VHL disease in spite of appropriate screening occurred on only two occasions. The use of DNA linkage analysis and direct mutation testing reduced the personal risk of carrying the VHL gene to below 1% in 14 people. In addition to the 83 clinically affected subjects, three obligate carriers who were considered to be lesion free in spite of extensive screening tests were identified. Fourteen percent of all CNS haemangioblastomas on the regionally based Cancer Registry were found to occur as part of VHL disease, but investigations for VHL in apparently sporadic disease appeared to be limited.

The prognostic value of serum and immunohistochemical tumour markers in advanced gastric cancer

Using a prospectively acquired database of 290 patients with advanced gastric adenocarcinoma, the prognostic significance of serum levels of carcinoembryonic antigen (CEA) (237 patients), alphafeto protein (AFP) (164 patients), beta-human chorionic gonadotrophin (beta HCG) (165 patients), CA19-9 (64 patients) and CA125 (104 patients) and tissue staining for C-erb B-2 (160 patients) and beta HCG (160 patients) was investigated. Serum was taken prior to 5-fluorouracil (5FU)-based chemotherapy and immunohistochemistry was performed on diagnostic specimens. In the univariate analysis, tumour markers of poor prognosis were CEA > or = 5 micrograms/l (P = 0.01; median survival (MS) 42 versus 35 weeks), serum beta HCG > or = 4 U/l (P = 0.02; MS 42 versus 25 weeks), CA125 > or = 35 U/ml (P = 0.03; MS 43 versus 31 weeks) and CA125 > or = 350 U/ml (P = 0.001; MS 42 versus 17 weeks). Other significant factors were poor performance status, the presence of metastases and poorly differentiated tumour histology. Tumours markers of poor prognosis in the multivariate analysis were serum beta HCG > or = 4 IU/l [hazard ratio (HR) 1.7; 95% confidence interval (CI) 2.8-1.1] and CA125 > or = 350 U/ml (HR 2.2; CI 4.2-1.2). There was a degree of subgroup variability in this model but, in general, other factors correlating with a poor survival were poor performance status, metastases and poorly differentiated tumour histology. This is the largest prognostic study of each tumour marker in advanced disease and demonstrates that serum beta HCG and CA125 in gastric cancer prior to chemotherapy do convey an independent poor prognosis which may reflect not just tumour burden but aggressive biology.

The mutational spectrum in Waardenburg syndrome

One hundred and thirty-four families or individuals with auditory-pigmentary syndromes such as Waardenburg syndrome (WS) or probable neurocristopathies were screened for mutations in the PAX3 and MITF genes. PAX3 mutations were found in 20/25 families with definite Type 1 WS and 1/2 with Type 3 WS, but in none of 23 with definite Type 2 WS or 36 with other neurocristopathies. The PAX3 mutations included substitutions of conserved amino acids in the paired domain or the homeodomain, splice-site mutations, nonsense mutations and frame-shifting insertions or deletions. No phenotype-genotype correlations were noted within WS1 families. With MITF, mutations likely to affect protein function were found in seven families, five of which had definite Type 2 WS. We conclude that Type 1 and Type 3 WS are allelic and are normally caused by loss of function mutations in PAX3; that Type 2 WS is heterogeneous, with about 20% of cases caused by mutations in MITF, and that individuals with auditory, pigmentary or neural crest syndromes which do not fit stringent definitions of Waardenburg syndrome are unlikely to have mutations in either the PAX3 or MITF genes. The molecular pathology of MITF/microphthalmia mutations appears to be different in humans and mice, with gene dosage having more significant effects in humans than in the mouse.

Cisplatin and protracted venous infusion 5-fluorouracil (CF)--good symptom relief with low toxicity in advanced pancreatic carcinoma

PURPOSE

The combination of protracted venous infusion (PVI) 5-FU with moderate dose cisplatin was evaluated in patients with advanced pancreatic cancer.

PATIENTS AND METHODS

Sixty-three patients with locally advanced or metastatic disease were treated with cisplatin (60 mg/m2 every 21 days) and PVI 5-FU (300 mg/m2/day) for a maximum of 24 weeks. All patients had histologically/cytologically confirmed tumour. Radiological response was assessed by CT scanning and toxicity, performance status and symptomatic response were assessed 3 weekly.

RESULTS

The objective response rate was 16% with two radiological complete responses. The median survival was 7.6 months with a 1-year survival of 33% and a median progression-free survival of 6.6 months. Patients who had local disease only had a median survival of 14.8 months with a 1-year survival of 52%. Thirty-four percent of patients had an improvement in performance status on treatment and specific symptom response rates were weight loss 71%, dysphagia 100%, nausea and vomiting 70%, pain 60%, anorexia 50%, and reflux 81%. Chemotherapy was well tolerated with grade 3 or 4 toxicity being nausea/vomiting 5%, diarrhoea 7%, infection 4%, stomatitis 2%, plantar palmar syndrome 2%, anaemia 14%, leucopenia 5, neutropenia 10% and thrombocytopenia 8%.

CONCLUSIONS

The CF regimen provides good symptomatic palliation with low toxicity in patients with advanced pancreatic cancer.

Epirubicin, cisplatin and infusional 5-fluorouracil (5-FU) (ECF) in hepatobiliary tumours

Hepatobiliary tumours are rare, often present late and have a poor prognosis, with no current effective systemic therapy available. This study aimed to evaluate the activity and toxicity of epirubicin, cisplatin and continuous infusional 5-fluorouracil (5-FU) (ECF) in patients with these tumours. From March 1991 to November 1993, 25 patients with advanced biliary tumours and 7 with hepatoma were treated with epirubicin 50 mg/m2 and cisplatin 60 mg/m2 intravenously (i.v.) day 1, each given every 21 days and 5-FU 200 mg/m2/day given as a continuous 24 h i.v. infusion throughout the treatment course. 8 of the 20 (40%) evaluable patients with biliary tumours responded. Median duration of response was 10 months. 2 of the 7 (29%) patients with hepatoma responded. The regimen was well tolerated with minimal haematological and non-haematological toxicity. This novel regimen is active in advanced hepatobiliary tumours.

Impact of protracted venous infusion fluorouracil with or without interferon alfa-2b on tumor response, survival, and quality of life in advanced colorectal cancer

PURPOSE

The aim of this study was to investigate the effects of adding interferon alfa-2b (IFN) to protracted venous infusion fluorouracil (PVI 5-FU) from the start of treatment in patients with advanced colorectal cancer.

PATIENTS AND METHODS

Patients who attended our unit with histologically confirmed advanced colorectal cancer were randomized to receive either PVI 5-FU 300 mg/m2/d via Hickman line, and IFN 5 MU subcutaneously three times weekly, or PVI 5-FU alone. Treatment was given for a maximum of two 10-week blocks, with a 2-week gap for reassessment of all parameters. Quality of life (QL) was measured by the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) pretreatment and every 6 weeks thereafter.

RESULTS

A total of 160 patients were randomized, with 155 eligible for assessment. Radiologic response was observed in 43 patients (28%): 17 of 77 (22%) in the 5-FU-plus-IFN arm (all partial responses [PRs]) and 26 of 78 (33%) in the 5-FU-alone group (complete responses [CRs] and 22 PRs) (difference not significant). Symptomatic improvement occurred in the majority of patients, and equally in both arms: 61% to 80% depending on the symptom. There was no significant difference between the two groups in failure-free survival (median, 161 v 193 days) or overall survival (median, 328 v 357 days). However, patients who received IFN did experience significantly more toxicity in the form of leukopenia (P = .001), neutropenia (P = .04), mucositis (P = .008), and alopecia (P = .0002). There were no toxic deaths and few notable differences in QL between the two arms.

CONCLUSION

This study confirms that PVI 5-FU is effective in treating the symptoms associated with metastatic colorectal carcinoma, with only mild to moderate toxicity and maintenance of QL. IFN 5 MU three times weekly does not enhance these palliative benefits.

The prognostic value of CEA, beta HCG, AFP, CA125, CA19-9 and C-erb B-2, beta HCG immunohistochemistry in advanced colorectal cancer

BACKGROUND

Evaluation of the prognostic significance of a group of tumour markers and their ability to predict response to chemotherapy may allow better targeting of palliative treatment in advanced colorectal cancer.

PATIENTS AND METHODS

Using a prospectively acquired database of 377 patients (pts) with advanced colorectal adenocarcinoma, the prognostic significance of serum CEA (342 pts), beta HCG (203 pts), AFP (208 pts), CA125 (150 pts), CA-19-9 (76 pts) as well as C-erb B-2 (197 pts). Serum markers were taken prior to 5-FU based chemotherapy and immunohistochemistry was performed on diagnostic samples

RESULTS

Tumour markers of poor prognostic significance in the univariate analysis were CEA > or = 5 micrograms/l (p = 0.006; median survival (MS 59 weeks vs 38 weeks) and CA125 > or = 35 U/ml (p = 0.01 MS 51 weeks vs. 30 weeks). Tumour markers elevated at greater than 10 times the normal value which correlated with a poor prognosis were CEA (p = 0.001; MS 47 weeks vs. 35 weeks), Serum beta HCG (p < 0.0001; MS 44 weeks vs. 7 weeks) and CA125 (p < 0.0001; MS 38 weeks vs. 15 weeks). Poor performance status ( > 2) and poorly differentiated tumour histology were also correlated to poor survival. In the multivariate analysis, tumour markers of independent poor prognosis were CEA > or = 5 micrograms/l (Hazard Ratio (HR) 1.8; 95% Confidence Internal (CI) 2.8-1.2), CEA > or = 50 micrograms/l (HR 1.6; CI 2.1-1.2), CA125 > or = 35 U/ml (HR 1.5; CI 2.3-1.0), CA 125 > or = 350 U/ml (HR 5.0; CI 9.6-2.6) and serum BHCG > or = 0 IU/l (HR 11.7; CI 30-4.5). Poor performance status (HR 6.7-5.0) and poorly differentiated histology (HR 2.8-1.0) were the other important factors in the model. No pretreatment tumour marker correlated with response to chemotherapy.

CONCLUSIONS

This is the largest prognostic study of each tumour marker in advanced disease and it clarifies previous conflicting reports. Serum AFP, CA19-9 and immunohistochemical stains beta HCG and C-erb B-2 have no prognostic significance. Serum CEA, beta HCG, CA125 in advanced colorectal cancer prior to chemotherapy do convey an independent poor prognosis which may reflect not just tumour burden but aggressive biology.

Diagnostic procedures for Paget's disease. Radiologic, pathologic, and laboratory testing

Paget's disease is a relatively common skeletal disorder that affects older individuals. Although its causes are unknown, it is characterized by abnormal remodeling and a high rate of bone turnover that determines its pathologic, radiologic, and biochemical findings. The findings in the three phases of Paget's disease are described.

Adaptive changes in locust kicking and jumping behaviour during development

The hind, or metathoracic, leg of a locust is specialised, enabling it to store energy that is used to extend the tibia rapidly during kicking and jumping; behaviours which share a common motor pattern. This study describes developmental changes in kicking and jumping behaviour and relates these changes to the development of the exoskeleton and jumping performance. In mature adults and intermoult larvae, the exoskeleton is strong and kicks can readily be elicited. Before and after the adult moult, when the exoskeleton is weak, kicks can be elicited less frequently, thus avoiding skeletal damage. At these times, animals do not generate the adult motor pattern for kicking, so that extension of the tibia is powered by direct muscle contraction, rather than through the release of stored energy. The muscles of all newly moulted animals are capable of generating sufficient force to damage the leg, but 14 days later the muscles can rarely generate sufficient force to damage the leg. To mimic the forces generated during the preparation for a kick, when the flexor and extensor tibiae muscles co-contract, the extensor muscle was stimulated electrically at a range of frequencies and the nature and occurrence of the resulting mechanical damage to components of the skeleton were assessed over a 14 day period following the adult moult. In newly moulted animals, the proximal femur partially collapses and thus protects the leg from damage before the muscles generate sufficient force to damage chronically other components of the leg. This partial collapse of the femur is reversible when the extensor muscle is activated at low frequency, but high frequencies cause permanent damage. The muscles of all animals 1 day after the moult are also capable of generating sufficient force to damage the leg, but the proximal tibia breaks most commonly in the region where the extensor muscle apodeme attaches. 5 days after the moult, the muscles in only 50 % of animals can damage the leg and most commonly the extensor muscle apodeme breaks. In mature animals, the only structure that fails is the extensor muscle apodeme, which fractures close to its point of attachment to the tibia. Damaging a metathoracic leg can significantly decrease the ability of a locust to jump and to compete for mates. Changes in the likelihood of damage to a metathoracic leg occur at predictable stages of development. Locust behaviour is modified during development, avoiding such damage.

Royal Marsden phase III trial of fluorouracil with or without interferon alfa-2b in advanced colorectal cancer

PURPOSE

Phase II studies have shown that the combination of interferon alfa-2b (IFN) and fluorouracil (5-FU) is active in patients with metastatic colon cancer. This study was designed to investigate whether treatment with the combination of IFN and 5-FU could improve the response rate, duration of response, or survival compared with treatment with 5-FU alone.

PATIENTS AND METHODS

Patients with histologically confirmed advanced colorectal cancer were randomized to receive 5-FU 750 mg/m2/d by continuous infusion for 5 consecutive days followed by weekly bolus 5-FU 750 mg/m2 either with or without IFN 10 MU subcutaneously three times weekly. Treatment was continued until disease progression or unacceptable toxicity for up to 12 months.

RESULTS

Radiologic response was observed in 26 of 106 assessable patients (25%): 10 of 52 (19%) in the group that received 5-FU plus IFN (all partial responses [PRs]) and 16 of 54 (30%) in the 5-FU-alone group (three complete responses [CRs] and 13 PRs) (P = .21). There was similarly no significant difference between the two groups in progression-free survival (median, 3 months), 1-year survival, or overall survival (median, 8 months). However, patients who received IFN did experience significantly more toxicity in the form of leukopenia (P = .013), lymphopenia (P = .01), depression (P = .014), and alopecia (P = .002), and were significantly more likely to be withdrawn due to adverse events (P = .003). There were four toxic deaths, all of which occurred in patients who had received IFN.

CONCLUSION

At the doses and schedules used in this study, IFN affords no benefit to 5-FU in terms of response and survival and significantly increases toxicity for patients with advanced colorectal cancer.

Intestinal microbial bile acid transformation in healthy infants

Following the establishment of functionally active intestinal flora in three healthy Swedish children from birth up to 24 months of age, we investigated the development of different 24-carbon bile acids. The fecal bile acids were group-separated into unconjugated, glycine-conjugated, taurine-conjugated, and sulfated, so that we could follow the changes between the different fractions of conjugates. In meconium, most (55-63%) of the bile acids were conjugated with taurine; only 11-32% were conjugated with glycine. Deconjugation was the first sign of intestinal microbial activity on the bile acids. Already at 1 month of age, most of the bile acids were deconjugated; among the conjugated bile acids, the glycine-conjugated dominated over the taurine-conjugated. An unidentified conjugate of cholic and chenodeoxycholic acids (C, CDC) that separated with the sulfated bile acids was found. The unconjugated bile acids and those that arose from hydrolysis of existing conjugates were separated and identified by gas-liquid chromatography coupled to mass spectrometry (GC-MS). Twenty-nine different bile acids were identified. In meconium, 16 different bile acids were identified. C and CDC were identified in all samples. The bile acid pattern changed during the course of the study. Many of the identified bile acids were only found in one or a few of the analyzed samples, and sometimes only in samples from one child. 6 alpha-hydroxylated bile acids, probably not microbially synthesized, were present at high percentages in the children.(ABSTRACT TRUNCATED AT 250 WORDS)

Caffeine metabolism in patients with chronic liver disease

An oral load of 200 mg (1030 mumol) caffeine (CA) was given to 13 patients with chronic liver diseases and to 11 healthy controls. The metabolism of CA was determined by following plasma concentrations and urinary excretion of CA and its metabolites. In addition, [2-14C]-caffeine was given orally to six patients to confirm the excretion through the different pathways. CA and its 14 main metabolites were separated and quantified by high performance liquid chromatography and capillary electrophoresis. Median (interquartile range) half-lives of CA were 19 (6.3-32) h in the patients and 3.8 (3.4-4.7) h in the controls. The wide range in the patients indicated varying degrees of liver dysfunction. Only 3 (2-4)% of administered CA was excreted unmetabolized in urine in the controls and the main degradation was through the paraxanthine (PX) pathway 82 (75-83)%. The combined theobromine (TB) and theophylline (TP) pathways (TB + TP) accounted for 15 (13-21)% of CA metabolism. Although the excretion of unmetabolized CA in the patients 6 (3-8)%, was similar to that in the controls, the metabolism through the PX pathway, 62 (44-65)%, decreased (p < 0.01 vs. controls), whereas the metabolism through the TB + TP pathways increased to 33 (30-47)%, p < 0.01. In controls, N3-, N7- and N1-demethylations were observed in 86 (83-89)%, 66 (62-70)% and 13 (9-18)%, respectively, of excreted metabolites. In patients the N3-demethylations, 71 (66-77)%, and N7-demethylations, 54 (48-59)%, decreased (p < 0.01 vs. controls), whereas N1-demethylation increased 30 (21-46)%, p < 0.01. The major C8-oxidation reaction, the oxidation of 1-methylxanthine, increased in patients (p < 0.01). We conclude that the slowed metabolism of CA in chronic liver disease is due to reduced N3- and N7-demethylations affecting biotransformation through the PX pathway.

Partial trisomy 22 (q11.2-q13.1) as a result of duplication and pericentric inversion

A case of a 27 year old male with a duplication of part of the long arm of chromosome 22 (22q11.2-q13.1) together with a pericentric inversion of the same chromosome is reported. Particular phenotypic features of note include absence of speech, persistent self-injury, lack of daily living skills, colobomata, and very poor vision. Similarities between this case and other case reports of duplications of the long arm of chromosome 22 are discussed.

Adjuvant chemotherapy for oesophagogastric cancer with epirubicin, cisplatin and infusional 5-fluorouracil (ECF): a Royal Marsden pilot study

Previous trials of adjuvant chemotherapy for oesophagogastric cancer have shown only modest or no improvement in survival. However, the regimens used in these studies produce low response rates in patients with advanced disease. ECF is a new regimen which results in higher response rates and may therefore be more effective in the adjuvant setting. Twenty-nine patients who had undergone a potentially curative resection for oesphagogastric carcinoma were treated with ECF [epirubicin 50 mg m-2 and cisplatin 60 mg m-2 for 18 weeks]. The median age was 52.5 years. Three patients had oesophageal tumours, 14 had tumours of the oesophagogastric junction (OGJ) and 12 had gastric tumours. All were adenocarcinomas apart from one undifferentiated carcinoma. One patient had stage I disease, nine stage II, 17 stage II and two stage IV. The mean number of chemotherapy cycles per patient was 5.2 (range 2-8). The median follow-up was 8.4 months (1.5-36.3 months). Eleven patients relapsed during follow-up (38%). One patient had an anastomotic recurrence and ten patients distant metastases. Overall 3 year survival was 61.5% (95% confidence interval 42-79); 3 year survival in stage II was 50% (21.2-86.3) and in stage III 65.6% (40-86). Chemotherapy was well tolerated, with grade 3/4 toxicity as follows: leucopenia 13.5%, nausea and vomiting 10%, diarrhoea 3.5%, infection 3.5% and thrombocytopenia 3.5%. There were no treatment-related deaths. We conclude that ECF can be administered safely as adjuvant treatment to patients with surgically resected gastro-oesophageal carcinoma. The results, especially in patients with stage III disease, are encouraging and support the investigation of this regimen within a prospective randomised trial.

Adaptive speckle reduction for improving the differential diagnosis of breast lesions

Adaptive speckle reduction could mask diagnostic features and adversely affect diagnosis of focal breast lesions. Four radiologists assessed focal breast lesions (29 malignant and 31 benign) by blind review of representative static B-mode scans before and after adaptive speckle reduction processing, scoring 14 diagnostic features for breast cancer and recording their opinions on the diagnosis and on how adaptive speckle reduction affected interpretation of each feature. No adverse affect on diagnosis of malignant (P = 0.756) or benign (P = 1.000) breast lesions was found, despite some differences in scoring of the diagnostic features after adaptive speckle reduction. Observer recognition of most diagnostic features was easier after adaptive speckle reduction (e.g., edge definition [50% of cases], edge regularity [40%], lesion texture [44%], and lesion echogenicity [35%]).

Professional leadership in community nursing services

To community nurses experiencing the chaos of repeated organisational change, the NHS can seem an environment hostile to clinical excellence. But, writes Alison Norman, the changing nature of health service management offers new opportunities for health visitors and school nurses to take the lead in pushing forward the boundaries of clinical practice. Here she examines the concept of leadership, and challenges practitioners to take up the gauntlet.

A phase II study in advanced gastro-esophageal cancer using epirubicin and cisplatin in combination with continuous infusion 5-fluorouracil (ECF)

PURPOSE

A phase II study was performed in patients with unresectable or metastatic gastric cancer evaluating the efficacy of a new chemotherapy schedule combining epirubicin and cisplatin with a continuous ambulatory infusion of 5-fluorouracil (ECF).

PATIENTS AND METHODS

One hundred thirty-nine consecutive, previously untreated patients were given ECF. Of these, 128 had measurable disease. Epirubicin (50 mg/m2 i.v.) and cisplatin (60 mg/m2 i.v.) were administered every three weeks for 8 cycles during a 21 week continuous i.v. infusion of 5-fluorouracil (200 mg/m2/day). In total 773 cycles of chemotherapy were given.

RESULTS

Objective tumour responses was seen in 91 (71%) of the 128 patients with measurable disease, of which 15 (12%) had a complete response. Twenty patients with locally advanced disease responding to ECF had attempted resection of the primary--11 (55%) were completely removed, 4 of these had no residual tumour in the resected specimen. The overall median survival was 8.2 months with 1 and 2 year survivals of 30% and 10% respectively. Grade 3 or 4 emesis occurred in 13%, stomatitis in 7%, diarrhoea in 4%, infection in 6%, leucopenia in 21% and thrombocytopenia in 8% of patients. Myelosuppression delayed treatment in 39 (5%) of the 773 cycles. Six of the 139 patients (4.3%) had treatment related deaths. There was no measurable reduction in quality of life during chemotherapy, while 67% of the 66 patients with dysphagia had complete resolution of this symptom.

CONCLUSIONS

The ECF regimen displays high anti-tumour activity with moderate toxicity in patients with gastric cancer and in some cases enabled resection of previously inoperable tumours.

Determination of caffeine and its metabolites in urine by high-performance liquid chromatography and capillary electrophoresis

Caffeine (CA) and its 14 main metabolites were determined in urine by reversed-phase high-performance liquid chromatography (RP-HPLC) and capillary electrophoresis (CE). After addition of 1,3,9-trimethylxanthine, uracil and beta-hydroxyethyltheophylline as internal standards, samples were separated by RP-HPLC into three fractions; A, B and C. The fractions were concentrated by lyophilization and analysed quantitatively by CE. Fraction A contained 5-acetylamino-6-amino-3-methyluracil, 3-methyluric acid, 7-methyluric acid and 1-methyluric acid. Fraction B contained 7-methylxanthine, 3-methylxanthine, 3,7-dimethyluric acid, 1-methylxanthine, 1,3-dimethyluric acid and 3,7-dimethylxanthine, while fraction C contained 1,7-dimethyluric acid, 1,7-dimethylxanthine, 1,3-dimethylxanthine, 1,3,7-trimethyluric acid and caffeine itself. The detection limit for the various metabolites ranged from 2-5 mumol l-1. The within-run precision for the metabolites ranged between 3.6% and 15.2%. The combination of HPLC and CE techniques was found to be a practical and specific method for determination of CA and its metabolites in urine.

Intracapsular and paraarticular chondromas

Intracapsular and paraarticular chondromas are rare benign tumors. The authors report four such lesions, three of which occurred about the knee and one at the hip. Radiographs showed calcified soft-tissue masses in the infrapatellar region of the knee in three patients. In the hip, the lesion was not visible on conventional radiographs. Three lesions originated from the joint capsule and one was extracapsular. These lesions should be differentiated from synovial chondromatosis and other calcified lesions occurring about the joints. After local excision, the tumors usually do not recur.

Cystic angiomatosis of bone with sclerotic changes mimicking osteoblastic metastases

Five unusual cases of cystic angiomatosis of bone which presented with the radiologic appearance of osteoblastic lesions are reported. Three patients were female (ages 37, 41, and 65 years) and two were male (ages 24 and 66 years). Although cystic angiomatosis of bone usually produces widespread osteolytic lesions with a honeycombed appearance in the skeletal system, multiple osteoblastic lesions mimicking metastatic osteoblastic carcinoma are sometimes seen. This radiological presentation has not been well emphasized in previous reports. Histologically, in addition to the angiomatous lesions, both mature thickened lamellar bone trabeculae and immature trabeculae of woven bone were found. In one of our patients, increasing density of the osteoblastic lesions was noted over time. One previous study has suggested that the age of the lesions of cystic angiomatosis is related to radiographic density. It is important to recognize this uncommon variant of cystic angiomatosis and to include this entity among the radiologic differential diagnoses when multiple osteoblastic lesions are encountered.