Can chronic poststernotomy pain after cardiac valve replacement be reduced using thoracic epidural analgesia?

BACKGROUND

The aim of our study was to evaluate the use of thoracic epidural analgesia (TEA) in acute pain management after cardiac valve replacement and determine if the incidence of chronic pain related to the sternotomy was reduced by the use of TEA. This patient group was chosen to exclude pain related to the use of the internal mammary artery and angina pectoris.

METHODS

Patients scheduled for elective cardiac valve replacement were offered TEA. A match-control group was selected. Epidural catheter placement, complications and postoperative neurological state were noted for both groups. Eighteen months postoperatively, a questionnaire was sent out concerning pain management, wound discomfort and pain.

RESULTS

Forty-nine patients were included. The TEA group consisted of 35 patients. At 18 months' follow up, 37% from the TEA group and 21% from the control group had pain or discomfort related to the sternum (NS). Two in the TEA group had severe pain.

CONCLUSION

We found in our small material that TEA provided excellent analgesia in the peri- and postoperative period, but we did not find a protective effect of TEA on chronic poststernotomy pain, neither weak pain nor severe pain.

Interactions between plant RING-H2 and plant-specific NAC (NAM/ATAF1/2/CUC2) proteins: RING-H2 molecular specificity and cellular localization

Numerous, highly conserved RING-H2 domains are found in the model plant Arabidopsis thaliana (thale cress). To characterize potential RING-H2 protein interactions, the small RING-H2 protein RHA2a was used as bait in a yeast two-hybrid screen. RHA2a interacted with one of the plant-specific NAC [NAM ('no apical meristem'), ATAF1/2, CUC2 ('cup-shaped cotyledons 2')] transcription factors, here named ANAC (abscisic acid-responsive NAC). The core RING-H2 domain was sufficient for the interaction. The ability of 11 structurally diverse RING-H2 domains to interact with ANAC was then examined. Robust interaction was detected for three of the domains, suggesting multi-specificity for the interaction. The domains that interacted with ANAC contain a glutamic acid residue in a position corresponding to a proline in many RING-H2 domains. Conversion of this glutamic acid residue into proline in RHA2a decreased its ability to interact with ANAC, most likely by changing the interaction surface. This suggested that a short, divergent region in RING-H2 domains modulate interaction specificity. ANAC contains a degenerate bipartite nuclear localization signal (NLS), while RHG1a, also identified as an ANAC interaction partner, contains a basic NLS. Both signals localized beta-glucuronidase reporter fusions to the nucleus. N-terminally truncated RHA2a also directed nuclear localization, apparently dependent on basic amino acids in the RING-H2 domain. Nuclear co-localization of the RING-H2 proteins and ANAC may enable their interaction in vivo to regulate the activity of the ANAC transcription factor.

A Danish population-based analysis of 105 mantle cell lymphoma patients: incidences, clinical features, response, survival and prognostic factors

This study presents the first large clinical analysis of 105 unselected mantle cell lymphoma (MCL) patients diagnosed from 1992 to 2000 in a well-defined Danish population. The annual incidences were 0.7/100000 for men and 0.2/100000 for women, with no significant change during the study period. Of 97 evaluable cases, 43% achieved a complete response (CR) after initial therapy. The median disease-free (DFS) and overall survival (OS) rates were 15 and 30 months, respectively. In multivariate analysis, splenomegaly (P=0.002), anaemia (P=0.0001) and age (P=0.002), but not the international prognostic index (IPI) and the Ann Arbor staging system, had an independent impact on survival. Moreover, in a sub-analysis of 45 younger MCL patients (<65 years), a trend towards an OS plateau of 58% was observed in cases without splenomegaly and anaemia (n=29). Thus, in contrast to previously suggested prognostic factors, these variables may prove useful for clinical decisions in a significant subset of MCL patients.

Increased circulating platelet-leukocyte aggregates in myeloproliferative disorders is correlated to previous thrombosis, platelet activation and platelet count

Platelet-leukocyte adhesion may occur as a consequence of platelet activation and possibly plays a key role in the deposition of activated platelets and fibrin in the thrombotic plug. The aim of the present study was to assess by whole blood flow cytometry the presence of circulating platelet-leukocyte aggregates (PLA) and the platelet-leukocyte response to platelet agonist stimulation (ADP and TRAP) in 50 patients with chronic myeloproliferative disorders (MPD) and 30 controls. PLA were identified as platelet-granulocyte/monocyte aggregates (PGMA), platelet-monocyte aggregates (PMA) and defined as the percentage of leukocytes coexpressing the platelet-specific marker glycoprotein Ib. Compared to controls the mean percentage of PGMA and PMA was increased in unstimulated whole blood from patients with MPD (7.98 vs. 1.76%; p<0.001 and 12.34 vs. 3.2%; p<0.001, respectively). The percentage of PGMA was correlated to the platelet count (r=0.46; p<0.001), percentage of P-selectin (r=0.69; p<0.001) and thrombospondin (r=0.58; p<0.001) positive platelets and platelet expression of GPIV (r=0.33; p=0.02). The mean percentage of PGMA and PMA was significantly increased in ADP-stimulated whole blood of patients (57.14 vs. 47.92%; p=0.009 and 54.91 vs. 45.89%; p<0.001, respectively). Compared to patients without a history of thrombosis, patients having experienced microvascular disturbances or a thrombotic event had a higher mean percentage of PGMA and PMA in non-stimulated whole blood (10.07 vs. 6.34%; p=0.025 and 14.81 vs. 10.48%; p=0.021, respectively) and a higher percentage of PGMA in ADP stimulated whole blood (64.32 vs. 51.50%; p<0.01). These data document an increased frequency of PLA in non-stimulated whole blood in MPD associated with a previous history of thrombosis or microvascular disturbances.

[The chronic Philadelphia chromosome-negative myeloproliferative syndrome II. Clinical findings, diagnostics and treatment]

Polycythaemia vera (PV) and essential thrombocytosis (ET) are clinically characterised by non-specific neurologic symptoms, peripheral circulatory disturbances (acrocyanosis, wounds, erythromelalgia) or abdominal symptoms. The treatment of PV includes phlebotomy, antiaggregation and cytoreduction. In ET, the primary treatment is also low-dose aspirin except for patients presenting with a haemorrhagic diathesis. Hydroxyurea may be associated with an increased risk of acute leukaemia or myelodysplasia. Therefore alpha-interferon and anagrelide should be considered in younger patients. Early cytoreductive therapy is advocated in patients with idiopathic myelofibrosis (IMF) to inhibit further progression of bone marrow fibrosis and further expansion of myeloid metaplasia in the spleen and liver. Treatment with androgens (danazol) and glucocorticoids may improve severe anaemia and thrombocytopenia. In younger patients, allogeneic bone marrow transplantation should be considered.

[Acute thrombotic complication at the debute of the Philadelphia chromosome-negative myeloproliferative syndrome]

METHODS

We describe eight patients with a diagnosis of a chronic myeloproliferative disorder, characterised in most patients by severe thrombotic complications at the debut of the disease.

RESULTS

The symptoms were life-threatening in seven patients: acute upper gastrointestinal haemorrhage from oesophageal varices in four, an acute abdominal catastrophy owing to mesenteric vein thrombosis with intestinal gangrene in two, and a large cerebral infarction, which was lethal, in one. The same patient also suffered a thrombosis of the axillary and subclavian veins. Neurological symptoms, with headache, visual disturbances, dizziness, and impaired memory, were initial cardinal symptoms. In two patients, explorative laparotomy was performed with intestinal resection owing to gangrene. One patient had a toe amputation.

DISCUSSION

The above symptoms are explained by thrombosis in the microcirculation because of thrombocytosis and circulating platelet aggregates. In patients with polycythaemia vera, the elevated haematocrit contributes significantly to the impaired microcirculation. Early diagnosis and management of these disorders are of utmost importance to prevent the potentially life-threatening complications described above.

[The chronic Philadelphia chromosome-negative myeloproliferative syndrome I. Pathogenesis and pathophysiology]

In polycythaemia vera (PV) the erythroid progenitors proliferate autonomously independently of the circulating erythropoietin. The progenitors are hypersensitive to various growth factors, including insulin-like growth factor 1, which inhibits apoptosis in erythroid and myeloid progenitor cells. No change has been found in the erythropoietin (EPO) receptor. Thrombopoietin (Tpo) regulates the production of haematopoietic progenitor cells, particularly of platelets. By inhibiting apoptosis, this growth factor may be responsible for the autonomous proliferation of the megakaryocyte cell lineage in PV and idiopathic myelofibrosis (IMF), which are featured by highly elevated circulating Tpo levels. Thrombopoietin may also be involved in the pathogenesis of myelofibrosis and development of extramedullary haematopoiesis. Both fibrogenesis and angiogenesis in the bone marrow, spleen, and liver develop secondary to the release of various growth-promoting factors from the megakaryocyte cell lineage. The lesion of the pluripotent stem cell in PV and IMF seems to imply several defects, including lack of or decreased expression of the Tpo receptor, alterations in the sensitivity of progenitor cells to various growth factors, and alterations in important gene systems (Bcl-2), which govern cell survival. Essential thrombocytosis seems to be a heterogeneous disease entity, as about 50% of the patients have polyclonal haematopoiesis.

High prevalence of hyperhomocysteinemia due to marginal deficiency of cobalamin or folate in chronic myeloproliferative disorders

Hyperhomocysteinemia is an established risk factor for thrombosis. In patients with myeloproliferative disorders, thrombotic events are common. Our aim was to investigate whether the increased burden of proliferating cells present in these patients implies a risk of homocysteine (HCY) accumulation secondary to depletion of folate and/or cobalamin. Fifty patients (PV, 25; ET, 10; IMF, 15) and 163 healthy volunteers (HV) participated in the study. The prevalence of hyperhomocysteinemia was 56.0% in PV, 70.0% in ET, 60.0% in IMF, and 34.9% in HV. The mean P-homocysteine (P-HCY) was 13.88 +/- 4.24 micromol/L in PV, 12.78 +/- 3.70 in ET, 11.34 +/- 4.22 in IMF, and 9. 71 +/- 2.76 in HV. In PV and ET, but not in IMF, the mean P-HCY was significantly higher than in the HV group (P < 0.001, P = 0.028, and P = 0.163, respectively). Thirty-three percent of the patients with hyperhomocysteinemia displayed metabolic changes compatible with cobalamin deficiency (P-HCY and P-methylmalonic acid both elevated), while 67% were folate deficient (P-HCY elevated, P-methylmalonic acid normal). Supplementation therapy with the relevant vitamin was implemented in 11 vitamin-deficient patients and led to normalization of metabolite levels in all cases. No correlation between hyperhomocysteinemia and thrombosis was found. Our data indicate that patients with PV, ET, and IMF frequently develop hyperhomocysteinemia due to discrete depletion of cobalamin or folate. Vitamin therapy leads to normalization of P-HCY and should be considered, even though hyperhomocysteinemia does not seem to be of crucial importance for the thrombotic tendency in the myeloproliferative disorders.

[Thoracic aortobifemoral bypass in chronic lower limb ischemia]

In cases of critical limb ischemia caused by aorto-iliac arteriosclerosis the most common operation is aortobifemoral bypass. This operation has a high patency. We describe two cases in which a thoracic aortobifemoral bypass was chosen as an alternative bypass operation because of a hostile abdomen. Both operations were performed without complications and resulted in normally perfused extremities.

Incidence, clinical features and outcome of essential thrombocythaemia in a well defined geographical area

In an attempt to characterise the clinical features, incidence and outcome of essential thrombocythaemia (ET) we report our experience in a large unselected series of patients from a well defined region. All new cases of ET in the County of Copenhagen were registered during the period 1977-98. We identified 96 cases of ET, yielding an age- and sex-adjusted annual incidence rate of 0.59/100.000 and a point-prevalence at last follow up of 11/100.000. The overall incidence rate was 0.31 and 1.00 per 100.000 population during the consecutive periods 1977-89 and 1990-98, respectively, corresponding to a 3.2-fold increase. Median age at diagnosis was 67 yr (females 68 yr, males 66 yr, range 18-87 yr), and the female to male (F/M) ratio was 2.6:1. At diagnosis, 52% of the patients displayed no ET-related symptoms and were discovered fortuitously by a routine platelet count. Forty-eight percent presented with thrombohaemorrhagic phenomena, of which microvascular disturbances of the central nervous system (CNS), extremities and skin were most frequently observed (23%). Compared to patients diagnosed after 1989, patients diagnosed before 1990 had a significantly higher mean platelet count, white blood cell (WBC) count, lactate dehydrogenase (LDH) value and alkaline phosphatase value. With a median follow up of 70 months, 5-yr survival was 76%, significantly lower than the expected survival of an age- and sex-matched control group (p = 0.0052). Thirty-seven patients experienced a total of 55 thrombohaemorrhagic events during follow-up, corresponding to an incidence of thrombosis and microvascular disturbances or haemorrhage of 8.1% per pt-yr and 2.5% per pt-yr, respectively. The number of patients experiencing thrombosis or microvascular disturbances was significantly higher among the 29 patients who never received acetylsalicylic acid (ASA) compared to the 67 patients who received ASA during follow up (45% vs. 21%; p = 0.017). This study provides population-based data suggesting the benefit of treatment with low-dose ASA in a non-selected population of patients with ET.

Increased platelet activation and abnormal membrane glycoprotein content and redistribution in myeloproliferative disorders

Chronic myeloproliferative disorders (MPDs) are characterized by a high incidence of thrombohaemorrhagic complications, possibly caused by platelet dysfunction. In an attempt to define platelet functional abnormalities, we assessed the expression of activation-dependent membrane proteins in unstimulated and agonist [ADP and thrombin receptor-activating peptide (TRAP)]-stimulated platelets using quantitative whole blood flow cytometry in samples from 50 MPD patients and 30 controls. The receptor densities of activation markers and glycoproteins (GPs) were quantified using standardized fluorescent beads. Compared with controls, the mean percentage of P-selectin-positive (15.3% vs. 7.2%; P < 0.001) and thrombospondin (TSP)-positive (6.6% vs. 3.7%; P = 0.003) platelets was increased in unstimulated platelets from patients. Patients having experienced a thrombotic event had a higher mean percentage of TSP-positive non-stimulated platelets than patients without a history of thrombosis (9.0% vs. 4.6%; P = 0.02) and a higher GPIV molecules of equivalent fluorochrome (MEF) value (33113 vs. 24471 MEF; P = 0.02). Mean MEF values of monoclonal antibodies (mAbs) against GPIb (34055 vs. 38945 MEF; P < 0.001) and GPIIb/IIIa (1416 vs. 1648 MEF; P < 0. 001) were significantly reduced among patients, whereas surface expression of GPIV was increased in patients (28273 vs. 16258 MEF; P < 0.001). In TRAP (10 micromol/l) stimulated whole blood, the MEF of P-selectin (9611 vs. 13293 MEF; P = 0.004) and CD63 (2385 vs. 5177 MEF; P < 0.001) and the ratio of PAC-1/GPIIb/IIIa MEF (0.98 vs. 2. 00; P < 0.001) was reduced in patients, indicating either a reduced granule GP content or an intrinsic cellular defect in receptor-mediated granule secretion and activation of the GPIIb/IIIa complex. Expressed as the relative change of MEF compared with unstimulated platelets, TRAP induced decrease of GPIb (7.8% vs. 45%; P < 0.001) and increase of GPIIb/IIIa (49.1% vs. 95.7%; P < 0.001) and GPIV expression (17.8% vs. 55.2%; P < 0.001) was attenuated in patients.

[Smoking cessation in patients with stable or unstable ischemic heart disease]

The purpose of this study was to investigate the relation between severity of disease and smoking cessation in patients with ischaemic heart disease (IHD). Patients admitted to hospital with IHD, who were current smokers, entered the study. Patients were grouped as either stable or unstable IHD (unstable angina or acute myocardial infarction). All patients received identical information on smoking and IHD. After three months patients were interviewed about present smoking habits. In 42 patients a carbonmonoxide-haemoglobin (CO-hgb) test was done to evaluate the reliability of the answers. One hundred and five patients entered the study; 67 patients in the unstable group and 38 in the stable group. At follow-up 39% of patients in the unstable group had stopped smoking compared to only 13% in the stable group (p < 0.05). Two patients who claimed to be ex-smokers had CO-hgb-values indicating current smoking. We conclude that smoking cessation in patients with IHD seems to be dependent on the severity of IHD.

Carpal tunnel syndrome after epiphysiolysis of the distal radius in a 5-year-old child. Case report

Carpal tunnel syndrome after fracture of the distal radius is a well known complication in adults, but in small children carpal tunnel syndrome is extremely rare. A case of carpal tunnel syndrome in a 5-year-old girl is presented. She had a distal epiphysiolysis of the radius, which was treated conservatively. Eight weeks after removal of the plaster of Paris she had clinical signs of carpal tunnel syndrome after exercise but without new injuries. Conservative treatment with a dorsal splint was effective, and all her symptoms disappeared. So conservative treatment seems worth considering before operation in similar cases.

Osmoregulation and salinity effects on the expression and activity of Na+,K(+)-ATPase in the gills of European sea bass, Dicentrarchus labrax (L.)

The European sea bass, Dicentrarchus labrax, tolerates salinities ranging from freshwater (FW) to hypersaline conditions. In two experiments, we analysed changes in plasma ions, muscle water content (MWC), gill Na+,K(+)-ATPase activity, and alpha-subunit mRNA expression during the course of acclimation from 15 ppt salt water to FW or high salinity seawater (HSSW). In Experiment 1, fish (6.2 +/- 1.1 g) were acclimated from 15 ppt to either FW, 5, 15, 25, 50, or 60 ppt SW and sampled after 10 days. Gill Na+,K(+)-ATPase activity was stimulated in FW- and in 50 and 60 ppt SW-groups relative to the 15 ppt control group. In Experiment 2, subgroups of fish (89 +/- 7 g) were transferred from 15 ppt SW to FW or 50 ppt SW, and sampled 1, 2, 4, and 10 days later. Plasma osmolality, [Na+] and [Cl-] decreased in the FW-group and increased in the HSSW-group one day after transfer and lasting until day 10. This was accompanied by a pronounced increase in MWC in the FW-group and an insignificant decrease in the HSSW-group. The plasma [Na+]:[Cl-]-ratio increased markedly in the FW-group and decreased slightly in the HSSW-group, suggesting acid-base balance disturbances after transfer. Gill Na+,K(+)-ATPase activity was unchanged in 15 ppt SW but doubled in FW- and HSSW-groups after transfer. In both groups, this was preceded by a 2- to 5-fold elevation of the gill alpha-subunit Na+,K(+)-ATPase mRNA level. Thus increased expression of alpha-subunit mRNA is part of the molecular mechanism of both FW and SW acclimation in sea bass. Gill Na+,K(+)-ATPase Na(+)-, K(+)-, and ouabain-affinity were similar in fish acclimated to FW, 15 ppt, and HSSW, suggesting that identical isoforms of the catalytic subunit of the enzyme are expressed irrespective of salinity.

Intraoperative crystallization on the intraocular lens surface

PURPOSE

To report a physician survey, laboratory studies, and clinical observations of intraoperative crystallization on the surface of the intraocular lens (IOL).

METHOD

We sent a survey to all ophthalmologists in the states of Wyoming, Idaho, Montana, Utah, and Colorado asking whether crystallization on the IOL surface had occurred in any of their patients and what viscoelastics, IOLs, and other solutions were used. All returned surveys were tabulated and analyzed by standard statistical means. A sample of crystallization from an IOL on a glass slide submitted by a physician was analyzed to ascertain the relative elemental composition. During in vitro laboratory studies, BSS Plus (Alcon Surgical, Fort Worth, Texas) and BSS (Alcon Surgical) were measured and analyzed for precipitation. Healon GV (Pharmacia/Upjohn, Kalamazoo, Michigan) and calcium chloride were combined in various solutions and examined for precipitate formation. Silicone IOLs and plate silicone were placed in different BSS and BSS Plus solutions with different viscoelastics and varying calcium concentrations. In seven patients, prominent crystallization on an IOL surface was examined, photographed, and followed for up to 3 years.

RESULTS

Two hundred six surveyed ophthalmologists returned 181 surveys (88%) and reported 29,609 cataract surgeries, with IOL implantation with 22 eyes (0.07%) (22 patients) in which intraoperative crystallization was observed on the IOL surface during 1993. The survey indicated there was a correlation with BSS Plus (chi-square = 4.9, P = .0268) and silicone IOLs (chi-square = 6.8, P = .0093). The sample showed the cation to be calcium.

CONCLUSION

Crystallization on the IOL surface during cataract surgery is a rare occurrence that may be associated with calcium as the cation related to an osmotic gradient around the IOL with increased calcium concentration. If encountered surgically, the lens should be exchanged in the operating theater after irrigating the anterior chamber with BSS and completely filling the capsular bag with a low molecular weight viscoelastic.

[Surgery for phimosis with Plastibell. A follow-up study]

Fifty-three boys were interviewed 11 years (9-14 years) after an operation for phimosis using the Plastibell technique. The interview concentrated on the cosmetic result, sexual function and late complications. Seventeen patients (31%) experienced cosmetic complications, and 11 patients (21%) claimed to have experienced psycho-social problems due to the appearance of the penis after the operation. Nonetheless an overall of 44 patients (83%) were fully satisfied/satisfied with the cosmetic result. Four patients (8%) claimed to have pain or discomfort on erection or intercourse. One patient (2%) was re-operated three years after the primary operation because of a recurrence of the symptoms. Overall 48 patients (91%) were fully satisfied or satisfied with the result after the operation. In conclusion we find the Plastibell procedure to be a safe and reliable method in treating phimosis. There are some minor technical pitfalls that have to be addressed in learning the technique, but performed in trained hands, the technique offers a very high satisfaction rate at long term follow-up.

EBV-positive primary central nervous system lymphomas in monozygote twins with common variable immunodeficiency and suspected multiple sclerosis

Common variable immunodeficiency represents the most frequently occurring primary immunodeficiency disorder and is usually detected sporadically in patients with no family history of immunodeficiency. We present the case stories of two monozygote twins, who following a period of decreasing serum immunoglobulins developed primary central nervous system lymphomas. One twin had clinical and paraclinical features mimicking multiple sclerosis. Immunohistochemical investigations on biopsy tissue showed expression of the bcl-2 and p53 gene products, and Epstein-Barr virus (EBV) encoded small RNA's (EBER) indicating latent infection were detected in lymphoma cells using in situ hybridisation techniques. The pathogenetic role of EBV in oncogenesis is discussed.

Metabolic cobalamin deficiency in patients with low to low-normal plasma cobalamins

Over a 2-year period, we examined 48 patients with P-cobalamin levels in the difficult "grey zone" at the lower reference limit detected by a competitive protein binding assay using intrinsic factor as binder. In 21 of 30 patients (70%) with low P-cobalamins we could not establish the diagnosis of metabolic cobalamin deficiency, but 1 of 18 patients (6%) with low-normal P-cobalamin values was confirmed metabolically cobalamin-deficient. Half of these 30 patients with low P-cobalamins had neuropsychiatric disorders, but only one-third of the latter patients had metabolic cobalamin deficiency. Ten of the remaining 15 patients (67%) were characterized as non-deficient. In patients with low-normal P-cobalamin level, we found neuropsychiatric disorders in 5 of the 18 (28%), but none of these had metabolic cobalamin deficiency. We conclude that P-cobalamins below the reference interval combined with typical neuropsychiatric symptoms or findings are not diagnostic of cobalamin deficiency and that further analyses are necessary.

Long-term survival and development of secondary malignancies in patients with acute myeloid leukemia treated with aclarubicin or daunorubicin plus cytosine arabinoside followed by intensive consolidation chemotherapy in a Danish national phase III trial. Danish Society of Haematology Study Group on AML

In 1991 we reported the results from a prospective randomised phase 3 trial comparing 7 days continuous infusion of cytosine arabinoside (ara-C) combined with either daunorubicin (DNR) or aclarubicin (ACR) as direct i.v. injection for 3 days as induction chemotherapy (CT) for patients with de novo acute myeloid leukemia (AML) followed by early intensive consolidation CT with two alternating cycles of high-dose ara-C and two cycles of amsacrine plus etoposide, and finally 3 days of daunomycin plus 7 days of ara-C as administered for induction of remission. A total of 174 patients with de novo AML in the age group 17-65 years were included. The patients have now been followed till death or for at least 7 years, and an evaluation of the long-term survival and the risk of developing secondary neoplasms has been made. The overall survival rate 5-years after diagnosis was 23%, and after 10 years 19%. No difference was found between the two treatment regimens in overall survival or disease-free survival (DFS). For the subgroup of 99 patients who achieved complete remission after one or two induction courses, 5- and 10-year survival rates were 35% and 31% respectively, with the highest survival rates in the age group 17-39 years (57% at 5 years) as compared with 27% in patients aged 40-60 years (P= 0.007). Seven secondary neoplasms were diagnosed simultaneously with or after the diagnosis of AML indicating a standardized incidence ratio (SIR) of 3.41, (95% CI: 1.60-7.26). In three cases the secondary neoplasms were diagnosed simultaneously with the AML diagnosis and were for that reason completely unrelated to the chemotherapy administered for AML, as the psammomatous meningeoma diagnosed after only 8 months. The remaining three neoplasms which developed subsequently did not significantly exceed the expected number, with a SIR = 1.46 (0.47-4.57). Thus, no increased risk of solid tumors causally related to the intensive chemotherapy for de novo AML was observed. However, a generally increased risk of solid tumors in patients diagnosed simultaneously with the AML diagnosis seems likely. Over 20% of the patients were alive and in complete remission 5 years after the AML diagnosis, and they have a high probability of surviving the next 5-year period.

[Primary cerebral non-Hodgkin's lymphomas and primary malignant brain tumors in a well-defined geographical area. Population-based data from the registry of non-Hodgkin's lymphoma in western Denmark, LYFO and the cancer registry, Kraeftens Bekaempelse]

In a Danish population-based non-Hodgkin's lymphoma (NHL) registry (LYFO) representing a population of 2.7 million all new cases of NHL were registered from 1st January 1983 to 31st May 1994. Incidence data of primary malignant tumours of the brain and central nervous system in western Denmark for the period 1971-1990 have been obtained from the Danish Cancer Registry. During the approximate 11-year period 3124 new cases of NHL were registered. Of these, 1152 (37%) were extranodal and 48 were non-AIDS related primary central nervous system lymphomas (PCNSL) accounting for 4.2% of extranodal NHL and 1.5% of all NHL, respectively. The average annual incidence rate of non-AIDS related PCNSL during the period was 1.56 cases per million population (age range: 15-85 yrs, median: 62 yrs, M/F ratio: 1). In a 23-year period there was no trend towards an increasing incidence of non-AIDS related PCNSL in a well-defined population. PCNSL accounted for 1.7% of all primary malignant brain tumours. Incidence of primary malignant brain tumours was stable, except for age ranges over 70 years. Histologically, 85% were high grade, centroblastic diffuse (60%) and immunoblastic lymphoma (13%) (Kiel classification). No T-cell lymphomas were detected. Treatment included surgical resection, whole brain irradiation (WBRT) and chemotherapy. Median survival for those receiving either WBRT or WBRT and chemotherapy was eight months and 20 months, respectively (p = 0.78). Overall survival was 53%, 38% and 26% at one, two and five years. Cox-regression analysis identified only one factor having independent impact on survival in performance score > or = 2 (PCNSL p < 0.001, RR = 5.8).

[Primary cerebral non-Hodgkin's lymphoma. Intensive chemotherapy supported by crania radiotherapy]

Four cases of primary central nervous system lymphomas treated with high dose cytosine arabinoside and high dose methotrexate prior to cranial irradiation are described. All patients achieved a complete clinical and radiological remission following treatment with chemotherapy alone. Three patients are alive with a follow-up period of 60, 45 og 24 months, respectively. One patient died 12 months after diagnosis at another hospital. Autopsy was not performed.

Justifying and implementing an ophthalmic pharmacy practice

The justification for and implementation of an ophthalmic care satellite pharmacy at the eye center of a university hospital are described. A pharmacy dedicated to ophthalmic care was developed in conjunction with a new eye care center. The eye center pharmacy staff, in consultation with other members of the pharmacy department, determined the services to be provided: preparing pharmaceuticals for operating room and clinic use, performing medication evaluations for all patients undergoing surgery, taking and documenting medication histories, providing distributive services, counseling surgical patients about their prescriptions and the care of their eyes after surgery, and checking on patients after discharge. Services were implemented after feedback was received from ophthalmology department physicians and from eye care pharmacies at other institutions. Before working in the eye center pharmacy, pharmacists received inservice instruction. To assist in its medication evaluation and counseling efforts, the pharmacy introduced a medical information form, which is used for both surgical and clinic patients. An adverse drug reaction-reporting program was also introduced. Establishment of a satellite pharmacy specializing in ophthalmic care resulted in improved outpatient and surgical pharmacy services and better provision of information on ophthalmic pharmaceuticals.