Search for B0 decays to invisible final states and to nunugamma

We establish upper limits on branching fractions for B0 decays to final states where the decay products are purely invisible (i.e., no observable final state particles) and for B0 decays to nunugamma. Within the standard model, these decays have branching fractions that are below current experimental sensitivity, but various models of physics beyond the standard model predict significant contributions from these channels. Using 88.5 x 10(6) BB pairs collected at the Upsilon(4S) resonance by the BABAR experiment at the PEP-II e(+)e- storage ring at the Stanford Linear Accelerator Center, we establish upper limits at the 90% confidence level of 22 x 10(-5) for the branching fraction of B0-->invisible and 4.7 x 10(-5) for the branching fraction of B0-->nunugamma.

Measurement of the B-->Xsl+l- branching fraction with a sum over exclusive modes

We measure the branching fraction for the flavor-changing neutral-current process B-->X(s)l(+)l(-) with a sample of 89x10(6) Upsilon(4S)-->BBmacr; events recorded with the BABAR detector at the PEP-II e(+)e(-) storage ring. The final state is reconstructed from e(+)e(-) or micro(+)micro(-) pairs and a hadronic system X(s) consisting of one K+/- or K(0)(S) and up to two pions, with at most one pi(0). We observe a signal of 40+/-10(stat)+/-2(syst) events and extract the inclusive branching fraction B(B-->X(s)l(+)l(-))=(5.6+/-1.5(stat)+/-0.6(exp syst)+/-1.1(model syst))x10(-6) for ml(+)(l(-))>0.2 GeV/c(2).

Bound on the ratio of decay amplitudes for -B0-->J/psiK*0 and B0-->J/psiK*0

We have measured the time-dependent decay rate for the process B-->J/psiK(*0) (892) in a sample of about 88x10(6) Upsilon(4S)-->B(-)B decays collected with the BABAR detector at the PEP-II asymmetric-energy B factory at SLAC. In this sample we study flavor-tagged events in which one neutral B meson is reconstructed in the J/psiK(*0) or J/psi(-)K(*0) final state. We measure the coefficients of the cosine and sine terms in the time-dependent asymmetries for J/psiK(*0) and J/psi(-)K(*0), find them to be consistent with the standard model expectations, and set upper limits at 90% confidence level (C.L.) on the decay amplitude ratios |A((-)B(0)-->J/psiK(*0))|/|A(B0-->J/psiK(*0))|<0.26 and |A(B0-->J/psi(-)K(*0))|/|A((-)B(0)-->J/psi(-)K(*0))|<0.32. For a single ratio of wrong-flavor to favored amplitudes for B0 and (-)B(0) combined, we obtain an upper limit of 0.25 at 90% C.L.

Measurement of the direct CP asymmetry in b-->s gamma Decays

We describe a measurement of the direct CP asymmetry between inclusive b-->s gamma and b-->s gamma decays. This asymmetry is expected to be less than 0.01 in the standard model, but could be enhanced up to about 0.10 by new physics contributions. We use a sample of 89 x 10(6) BB pairs recorded with the BABAR detector at SLAC PEP-II, from which we reconstruct a set of 12 exclusive b-->s gamma final states containing one charged or neutral kaon and one to three pions. We measure an asymmetry of A(CP)(b-->s gamma)=0.025+/-0.050(stat)+/-0.015(syst), corresponding to an allowed range of -0.06<A(CP)(b-->s gamma)<+0.11 at 90% confidence level.

Dehydroepiandrosterone 7-hydroxylase CYP7B: predominant expression in primate hippocampus and reduced expression in Alzheimer's disease

Neurosteroids such as dehydroepiandrosterone (DHEA), pregnenolone and 17beta-estradiol are synthesized by cytochrome P450s from endogenous cholesterol. We previously reported a new cytochrome P450 enzyme, CYP7B, highly expressed in rat and mouse brain that metabolizes DHEA and related steroids by hydroxylation at the 7alpha position. Such 7-hydroxylation can enhance DHEA bioactivity in vivo. Here we show that the reaction is conserved across mammalian species: in addition to mouse and rat, DHEA hydroxylation activity was present in brain extracts from sheep, marmoset and human. Northern blotting using a human CYP7B complementary deoxyribonucleic acid (cDNA) probe confirmed the presence of CYP7B mRNA in marmoset and human hippocampus; CYP7B mRNA was present in marmoset cerebellum and brainstem, with lower levels in hypothalamus and cortex. In situ hybridization to human brain revealed higher levels of CYP7B mRNA in the hippocampus than in cerebellum, cortex, or other brain regions. We also measured CYP7B expression in Alzheimer's disease (AD). CYP7B mRNA was significantly decreased (approximately 50% decline; P<0.05) in dentate neurons from AD subjects compared with controls. A decline in CYP7B activity may contribute the loss of effects of DHEA with ageing and perhaps to the pathophysiology of AD.

Radiotherapy patterns of care study in lung carcinoma

PURPOSE

For the first time, a lung Patterns of Care Study was conducted to determine the national patterns of radiation (RT) practice in patients treated for nonmetastatic lung cancer in 1998 to 1999.

MATERIALS AND METHODS

A national survey of randomly selected RT institutions in the United States was conducted using two-stage cluster sampling, stratified by practice type. Patients with nonmetastatic lung cancer (Karnofsky performance score [KPS] > or = 60), who received RT as definitive or adjuvant therapy, were randomly selected. To determine national estimates, sample size was weighted by the relative number of institutions per strata and the number of patient records reviewed per the number of patients eligible. Accordingly, 42,335 patient records from 58 institutions were reviewed by trained research associates. The unweighted sample size (or number of patients) was 541.

RESULTS

The histologies were small-cell lung cancer (SCLC) in 14.5% of patients versus non-small-cell lung cancer (NSCLC) in 85.5% of patients. The median age was 67 years (range, 29 to 92 years); 61% of patients were male, and 38% were current smokers. Bone scans and brain imaging were not obtained in 34% and 52% of clinical stage (CS) III NSCLC patients, respectively. Regarding treatment strategies, for SCLC and CS III NSCLC, chemotherapy plus RT was used significantly more than RT alone (P <.05); in CS I NSCLC, RT alone was the primary treatment (P <.05). Overall, 58% of patients received systemic therapy. On multivariate analysis, factors correlating with increased use of chemotherapy included younger age, histology (SCLC > NSCLC), increasing CS, increasing KPS, and lack of comorbidities. Only 3% of all patients were treated on prospective clinical trials.

CONCLUSION

This study establishes the general patterns of care for lung carcinoma in RT facilities within the United States. As supported by clinical trials, patients with limited-stage SCLC and CS III NSCLC received chemotherapy plus RT more than they received RT alone. Further improvements in staging, smoking cessation, and increased accrual to clinical trials must be encouraged.

Interference study of the chi c0(13P0) in the reaction -pp-->pi0pi0

Fermilab experiment E835 has observed (-)pp annihilation production of the charmonium state chi(c0) and its subsequent decay into pi(0)pi(0). Although the resonant amplitude is an order of magnitude smaller than that of the nonresonant continuum production of pi(0)pi(0), an enhanced interference signal is evident. A partial wave expansion is used to extract physics parameters. The amplitudes J=0 and 2, of comparable strength, dominate the expansion. Both are accessed by L=1 in the entrance (-)pp channel. The product of the input and output branching fractions is determined to be B((-)pp-->chi(c0))xB(chi(c0)-->pi(0)pi(0))=(5.09+/-0.81+/-0.25)x10(-7).

Swallowing function and weight change observed in a phase I/II study of external-beam radiation, brachytherapy and concurrent chemotherapy in localized cancer of the esophagus (RTOG 9207)

BACKGROUND

A multi-institutional, prospective study was designed to determine the feasibility and tolerance of combined-modality chemotherapy, external-beam irradiation, and esophageal brachytherapy in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus. Swallowing function and weight were assessed before and after treatment.

MATERIALS AND METHODS

Planned treatment was with 50 Gy of external-beam irradiation (25 fractions/5 weeks) followed 2 weeks later by esophageal brachytherapy (either a high dose rate of 5 Gy at weeks 8, 9, and 10 for a total of 15 Gy or a low dose rate of 20 Gy at week 8). Chemotherapy was given weeks 1, 5, 8, and 11 with cisplatinum, 75 mg/m2, and 5-fluorouracil, 1,000 mg/m2/24 hours in a 96-hour infusion. Swallowing was graded from 0 (no dysphagia) to 4 (complete obstruction for solids and liquids). Weight "loss" or weight gain was defined as a change in 3-month post- to pretherapy weight of < or = 5% or > 5%, respectively.

RESULTS

The estimated survival rate at 1 and 2 years was 49% and 31%, respectively, and the estimated median survival was 11 months. Swallowing before treatment was graded as grade 1 in 14 patients, grade 2 in 22 patients, grade 3 in nine patients, and grade 4 in four patients. Swallowing grade after treatment was reported as improved in 29 patients (59%), unchanged in 12 patients (24.5%), and worse in eight patients (16.5%). The bestimproved dysphagia score after treatment in the 29 patients reporting improvement was grade 0 in 19 patients, grade 1 in five patients, grade 2 in four patients, and grade 3 in one patient. A posttreatment weight in 42 evaluable patients was categorized as a loss in 29 patients (69%), a gain in four patients (9.5%), and stable in nine patients (21.5%). Weight loss was significantly correlated with high swallowing grade, low performance status, and absence of a feeding tube.

CONCLUSIONS

Swallowing function after brachytherapy and concurrent chemoradiation therapy is satisfactory in most surviving patients. Ninety-two percent of patients were able to swallow at least liquids at some point after therapy. Future plans are to compare this with other cooperative group studies that utilized chemoradiation or surgery, without brachytherapy.

Cysteine residues of SNAP-25 are required for SNARE disassembly and exocytosis, but not for membrane targeting

The release of neurotransmitter at a synapse occurs via the regulated fusion of synaptic vesicles with the plasma membrane. The fusion of the two lipid bilayers is mediated by a protein complex that includes the plasma membrane target soluble N-ethylmaleimide-sensitive fusion protein (NSF) attachment protein (SNAP) receptors (t-SNAREs), syntaxin 1A and synaptosome-associated protein of 25 kDa (SNAP-25), and the vesicle SNARE (v-SNARE), vesicle-associated membrane protein (VAMP). Whereas syntaxin 1A and VAMP are tethered to the membrane by a C-terminal transmembrane domain, SNAP-25 has been suggested to be anchored to the membrane via four palmitoylated cysteine residues. We demonstrate that the cysteine residues of SNAP-25 are not required for membrane localization when syntaxin 1A is present. Analysis of the 7 S and 20 S complexes formed by mutants that lack cysteine residues demonstrates that the cysteines are required for efficient SNARE complex dissociation. Furthermore, these mutants are unable to support exocytosis, as demonstrated by a PC12 cell secretion assay. We hypothesize that syntaxin 1A serves to direct newly synthesized SNAP-25 through the Golgi transport pathway to the axons and synapses, and that palmitoylation of cysteine residues is not required for targeting, but to optimize interactions required for SNARE complex dissociation.

A time-to-treatment analysis in the medicine versus angiography in thrombolytic exclusion (MATE) trial

Patients with acute coronary syndromes who are considered ineligible for thrombolytic therapy are at high risk of recurrent ischemia and death. This trial randomized 201 patients to triage angiography in the first 24 hours of hospital admission versus conventional medical care. Of the 165 patients who underwent angiography that was either protocol-driven or on the basis of physician preference, those who underwent angiography within 6 hours of symptom onset had a reduction in early and late adverse events. The rates of in-hospital recurrent ischemia were 15.4%, 15.4%, 17.5%, 32.4%, and 38.5%, respectively (P = 0.01 for trend), and rates of cumulative recurrent myocardial infarction or death were 0%, 12.8%, 10.0%, 11.8%, and 7.7%, respectively (P = 0.48 for trend) for patients who underwent angiography at 0-6, 6-12, 12-24, 24-48, and over 48 hours, respectively from symptom onset. Future trials of invasive versus conservative therapy should focus on performing angiography within 6 hours of symptom onset.

Pharmacokinetics and pharmacodynamics of an antisense phosphorothioate oligonucleotide targeting Fas mRNA in mice

ISIS 22023 is a modified phosphorothioate antisense oligonucleotide targeting murine Fas mRNA. Treatment of mice with ISIS 22023 reduced Fas expression in liver in a concentration-dependent and sequence-specific manner, which completely protected mice from fulminant death induced by agonistic Fas antibody. In this study, we characterized the relationships in mice between total dose administered, dose to the target organ, and ultimately, the intracellular concentration within target cell types to the pharmacologic activity of ISIS 22023. After subcutaneous injection, ISIS 22023 distributed to the liver rapidly and remained in the liver with the t(1/2) ranging from 11 to 19 days, depending on dose. There were apparent differences in patterns of uptake and elimination in different types of liver cells. Oligonucleotide appeared within hepatocytes rapidly, whereas the peak concentrations in Kupffer cells were delayed until 2 days after dose administration. Hepatocytes cleared oligonucleotide the most rapidly, whereas Kupffer cells appeared to retain oligonucleotide longer. The reduction of Fas mRNA levels (pharmacodynamic response) paralleled the increase of oligonucleotide concentration in mouse liver with maximum mRNA reduction of 90% at 2 days after a single 50 mg/kg subcutaneous administration. Moreover, the pharmacodynamics of ISIS 22023 correlated better with the pharmacokinetics in hepatocytes, supporting the concept that the presence of oligonucleotide in target cells results in reductions in mRNA and, ultimately, pharmacologic activity. These results provide a comprehensive understanding of the kinetics of an antisense drug at the site of action and demonstrate that the reductions in mRNA induced by this antisense oligonucleotide correlate with its concentrations in cell targets.

Impaired culprit vessel flow in acute coronary syndromes ineligible for thrombolysis

The majority of patients with acute myocardial infarction and other acute coronary syndromes (ACS) are considered ineligible for thrombolysis and do not routinely receive reperfusion therapy. We hypothesized that predictors and outcomes of angiographically impaired culprit vessel flow can be identified and compared. This trial evaluated the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n=201) with<24 hours of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy. This analysis was performed in 165 patients, from experimental and control arms, in whom angiography was performed on the index hospitalization with the outcome of interest being target vessel flow (Thrombolysis In Myocardial Infarction [TIMI] grades 0 to 2) on initial angiography. Patients with and without impaired culprit lesion flow were similar with respect to age, gender, diabetes, and prior coronary disease. A family history of premature coronary disease was more common in those with impaired flow, 50.0 versus 28.5% (p=0.02). Abnormal culprit vessel flow was found in 19.2% of patients who underwent angiography within 6 hours of symptom onset; however, after 24 hours this rate was reduced to 11.7%. Impaired culprit lesion flow can be expected in approximately 20% of patients presenting with ACS who are ineligible for reperfusion therapy by conventional guidelines and therefore represents an opportunity for early intervention within 6 hours of the onset of symptoms in these patients.

Development and geometry of isotropic and directional shrinkage-crack patterns

We have studied shrinkage-crack patterns which form when a thin layer of an alumina/water slurry dries. Both isotropic and directional drying were studied. The dynamics of the pattern formation process and the geometric properties of the isotropic crack patterns are similar to what is expected from recent models, assuming weak disorder. There is some evidence of a gradual increase in disorder as the drying layer become thinner, but no sudden transition, in contrast to what has been seen in previous experiments. The morphology of the crack patterns is influenced by drying gradients and front propagation effects, with sharp gradients having a strong orienting and ordering effect.

A phase I/II study of external beam radiation, brachytherapy, and concurrent chemotherapy for patients with localized carcinoma of the esophagus (Radiation Therapy Oncology Group Study 9207): final report

BACKGROUND

A multiinstitutional, prospective study of the Radiation Therapy Oncology Group (RTOG) was designed to determine the feasibility and toxicity of chemotherapy, external beam radiation, and esophageal brachytherapy (EB) in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus. A preliminary analysis indicated a 17% 1-year actuarial risk of treatment-related fistulas. A final analysis of this study was considered important to determine the median survival time, local control, and late toxicity associated with this treatment regimen.

METHODS

Planned treatment was 50 grays (Gy) of external beam radiation (25 fractions given over 5 weeks) followed 2 weeks later by EB (either high-dose-rate 5 Gy during Weeks 8, 9, and 10, for a total of 15 Gy, or low-dose-rate 20 Gy during Week 8). Chemotherapy was given during Weeks 1, 5, 8, and 11, with cisplatin 75 mg/m(2) and 5-fluorouracil 1000 mg/m(2)/24 hours in a 96-hour infusion.

RESULTS

Of the 49 eligible patients, 45 (92%) had squamous histology and 4 (6%) had adenocarcinoma. Forty-seven patients (96%) completed external beam radiation plus at least 2 courses of chemotherapy, whereas 34 patients (69%) were able to complete external beam radiation, EB, and at least 2 courses of chemotherapy. The estimated survival rate at 12 months was 49%, with an estimated median survival of 11 months. Life-threatening toxicity or treatment-related death occurred in 12 (24%) and 5 (10%) cases, respectively. Treatment-related esophageal fistulas occurred in 6 cases (12% overall, 14% of patients starting EB) at 0.5-6.2 months from the first day of brachytherapy, leading to death in 3 cases.

CONCLUSIONS

In this study, severe toxicity, including treatment-related fistulas, occurred within 7 months of brachytherapy. Based on the 12% incidence of fistulas, the authors continue to urge caution in employing EB, particularly when used in conjunction with chemotherapy.

Acoustically elicited behaviours in Lister hooded and Wistar rats

It has been reported previously that experimenter-presented 20-kHz tones at low intensities produce bursts of locomotor running in Lister hooded rats, but reduced locomotion (freezing) in Wistar rats. Because rats emit 20-kHz tones when stressed, it was proposed that this ultrasound-elicited running and freezing behaviour in Lister hooded and Wistar rats, respectively, represents a model for qualitative strain differences in fear behaviour. The present studies examined the acoustic specificity of acoustically elicited locomotor behaviours in Lister hooded and Wistar rats. In Experiment 1, it was found that brief exposure (i.e., 15 s) of Lister hooded rats to tones at frequencies of 7, 12, or 20 kHz and intensities of 85-95 dB SPL, elicited running behaviour characterised by brief bursts of locomotion followed by periods of quiescence. Somewhat surprisingly, the 7- and 12-kHz tones elicited running behaviour at lower intensities than did the 20-kHz tones. In Experiment 2, it was found that exposure of Lister hooded rats to the 20-kHz acoustic stimulus (91-101 dB, SPL) for a much longer duration, up to 9 min, resulted in episodic bursts of locomotion and convulsions in a significant proportion of subjects. Both the maximal velocity of locomotion and the likelihood of occurrence of convulsions was related to the intensity of the acoustic stimulus. Exposure of Lister hooded rats to white noise for up to 9 min also elicited episodic bursts of locomotion and convulsions in an intensity-dependent manner. The white noise stimulus was found to be a more effective stimulus than the 20-kHz stimulus in this regard. In Experiment 3, it was found that Lister hooded rats exhibited reduced locomotion when they were exposed to a low-intensity 20-kHz acoustic stimulus (e.g., 81 dB, SPL). In Experiment 4, it was found that Wistar rats did not exhibit locomotor bursts or convulsions when presented with 20-kHz tones using stimulus parameters equal to and even greater than those that had been shown to be effective in producing locomotor bursts in Lister hooded rats. Rather, Wistar rats exhibited only reduced locomotion. The present data indicate that (1) running behaviour in Lister hooded rats is not specific for the 20-kHz stimulus. Moreover, (2) when compared to Lister hooded rats, Wistar rats are relatively insensitive to the running and convulsions elicited by acoustic stimuli. Finally, (3) both Lister hooded and Wistar rats exhibited reduced locomotion when presented with the 20-kHz tones, although the range of stimulus intensities that produces freezing behaviour is much more limited in Lister hooded rats because of their propensity to exhibit locomotor bursting and convulsions. Thus, it appears that the difference between the two strains with respect to their unconditioned locomotor responses to novel acoustic stimuli relates to the fact that Lister hooded rats are uniquely susceptible to acoustically elicited locomotor bursts and/or convulsions.

Randomised placebo controlled trial of nebulised corticosteroids in acute respiratory syncytial viral bronchiolitis

OBJECTIVE

To evaluate short and long term effects of giving nebulised budesonide early in respiratory syncytial viral (RSV) bronchiolitis.

DESIGN

A multicentre randomised double blind placebo controlled trial.

SUBJECTS

Infants admitted to hospital with their first episode of RSV positive bronchiolitis.

INTERVENTION

Randomisation to receive either 1 mg of nebulised budesonide (Bud) or placebo (Pla) twice daily from admission until 2 weeks after discharge. Follow up was for 12 months.

MAIN OUTCOME MEASURES

Duration of hospital admission, time taken to become symptom free, re-admission rates, general practitioner consultation rates, and use of anti-wheeze medication during follow up.

RESULTS

161 infants were studied. Both arms were similar with respect to initial clinical severity, age, sex, socioeconomic class, and tobacco exposure. Median time from first nebulisation to discharge: Bud and Pla, 2 days. Median number of days for 50% of infants to be symptom free for 48 hours: Bud, 10 days; Pla, 12 days. Respiratory re-admission rates in the 12 month follow up: Bud, 16%; Pla, 18%; median difference (95% confidence interval (CI)), -2 (-14 to 10). Median respiratory related general practitioner attendances: Bud, 4.0; Pla, 4.5; median difference (95% CI), -1 (-2 to 0). Percentage of infants receiving at least one prescription for anti-wheeze medication during follow up, corticosteroids: Bud, 50%; Pla, 60%; difference (95% CI), -10 (-26 to 6); bronchodilators: Bud, 60%; Pla, 67%; difference (95% CI), -7 (-22 to 8).

CONCLUSIONS

There are no short or long term clinical benefits from the administration of nebulised corticosteroids in the acute phase of RSV bronchiolitis.

Increased gelsolin expression and retarded collagen lattice contraction with smooth muscle cells from Crohn's diseased intestine

Intestinal smooth muscle cells (SMC) produce the fibrotic tissue, strictures, that characterize Crohn's disease. These SMC change their phenotype from a contractile muscle form to an inflammation-responsive form that migrates and synthesizes a collagen matrix. It is postulated that the inflammatory responsive SMC form associates differently with its surrounding collagen matrix compared to the normal SMC form. SMC derived from Crohn's diseased and uninvolved bowel were sustained in cell culture. Cultured SMC incorporated in collagen lattices have the capacity to reduce the size of that lattice, referred to as lattice contraction. At day 2, Crohn's SMC-populated collagen lattices were reduced to 21% of their initial area, while non-Crohn's SMC collagen lattices were reduced to 8%. Crohn's SMC demonstrate retarded lattice contraction compared to non-Crohn's SMC. When grown in monolayer culture, Crohn's-derived SMC cover 30% more area than non-Crohn's SMC. By Western blot analysis Crohn's SMC express more gelsolin, an actin-binding protein found elevated in cells exhibiting increased cell motility. Was the increased expression of gelsolin related to retarded collagen lattice contraction? Intracellular levels of gelsolin were elevated by the electroporation of plasma gelsolin protein into suspended non-Crohn's SMC. When incorporated in collagen lattices, gelsolin loaded cells showed retarded lattice contraction compared to SMC loaded with albumin. Crohn's SMC show increased expression of gelsolin, which may be associated with a diminished capacity to reorganize collagen fiber bundles. It is suggested that increased concentrations of gelsolin in Crohn's SMC is consistent with enhanced cell migration as a consequence of the inflammatory state of Crohn's diseased intestine.

Strain differences to the effects of aversive frequency ultrasound on behaviour and brain topography of c-fos expression in the rat

Previous studies have shown that ultrasound at 20 kHz produces an escape (defence) response in the hooded Lister rat. This study compares the ultrasound-induced behavioural response in the hooded Lister and albino Wistar rat. Ultrasound (continuous tone, square wave, 20 kHz) produced an initial characteristic startle response (brisk running) in the hooded Lister rat that was followed immediately after cessation of the ultrasound by a period of freezing behaviour. In contrast, Wistar rats showed no initial escape response but a prolonged period of freezing that started during the ultrasound and continued for a period after the end of the ultrasound. Immunohistochemical assessment of c-fos expression also showed a difference between the two strains with preferential expression in the dorsal region of the rostral and caudal periaqueductal grey (PAG) in the hooded Lister rat, while the expression occurred in the ventral PAG in the Wistar rats. In summary, the two strains exhibit distinct defensive behaviours and patterns of neuronal activation in response to the same aversive signal. It remains to be determined whether these differences relate to neuronal circuitry or perception of the signal, but analysis of the mechanisms involved may help our understanding of the heterogeneity of anxiety disorders.

Usefulness of intravenous enoxaparin for percutaneous coronary intervention in stable angina pectoris

This pilot study was designed to determine whether the low molecular weight heparin, enoxaparin, could be used for elective percutaneous coronary intervention (PCI) to provide antithrombotic effects without the full systemic anticoagulation that occurs with the use of unfractionated heparin. Sixty patients were randomized to receive intravenous enoxaparin (1 mg/kg bolus dose) or unfractionated heparin at the time of coronary intervention. Laboratory testing was performed at baseline, 5 minutes, and 4 hours after study drug to test if a single bolus dose of intravenous enoxaparin can consistently achieve therapeutic antithrombotic effect, thus eliminating the need for multiple doses of heparin and closely monitoring levels of anticoagulation during PCI. Thirty percent of patients who received unfractionated heparin required a second bolus of intravenous heparin to achieve the target-activated clotting time of 300 seconds before PCI. Enoxaparin showed antithrombotic properties comparable to that of unfractionated heparin as measured by anti-Xa levels, with less inhibition of thrombin (factor IIa) at the time points measured (p <0.0001). Angioplasty success rates, in-hospital ischemia, bleeding, and vascular complications were similar in both groups. Thus, intravenous enoxaparin has predictable and effective antithrombotic effects during elective PCI. Although the level of anticoagulation attained with enoxaparin is significantly lower than that after unfractionated heparin, no increase in ischemic complications were noted. The use of a single bolus of intravenous enoxaparin, without the need for measuring the activated clotting time or titrating heparin anticoagulation, has the potential for simplifying the performance and perhaps enhancing the safety of PCI.

Local intramural heparin delivery during primary angioplasty for acute myocardial infarction: results of the Local PAMI Pilot Study

The feasibility and safety of local heparin delivery during acute infarct angioplasty was evaluated in a prospective, multicenter, 120-patient series. Angioplasty was performed using standard techniques, after which heparin (4,000 U) was delivered locally; 25% of patients received stents. Procedural success was reported in 98% of patients; 6.7% of patients suffered death, reinfarction, recurrent ischemia, or stroke during the index hospitalization. The 6-month target vessel revascularization rate was 12.5%. Local heparin therapy with provisional stenting in acute myocardial infarction patients is safe, feasible, associated with a low rate of infarct artery revascularization at 6 months, and may potentially eliminate the need for systemic heparin following the procedure.

Biochemical, biophysical, and pharmacological characterization of bacterially expressed human agouti-related protein

The agouti-related protein gene (Agrp) is a novel gene implicated in the control of feeding behavior. The hypothalamic expression of Agrp is regulated by leptin, and overexpression of Agrp in transgenic animals results in obesity and diabetes. By analogy with the known actions of agouti, these data suggest a role for the Agrp gene product in the regulation of melanocortin receptors expressed in the central nervous system. The availability of recombinant, highly purified protein is required to fully address this potential interaction. A nearly full-length form of AGRP (MKd5-AGRP) was expressed in the cytosolic or soluble fraction of Escherichia coli and appeared as large intermolecular disulfide-bonded aggregates. Following oxidation, refolding, and purification, this protein was soluble, and eluted as a single symmetric peak on RP-HPLC. Circular dichroism studies indicated that the purified protein contains primarily random coil and beta-sheet secondary structure. Sedimentation velocity studies at neutral pH demonstrated that MKd5-AGRP is monomeric at low micromolar concentrations. Mobility shifts observed using SDS-PAGE under reducing and nonreducing conditions for bacterially expressed and mammalian expressed AGRP were identical, an indication of a similar disulfide structure. The purification to homogeneity of a second, truncated form of AGRP (Md65-AGRP) which was expressed in the insoluble or inclusion body fraction is also described. Both forms act as competitive antagonists of alpha-melanocyte stimulating hormone (alpha-MSH) at melanocortin-3 (MC-3) and melanocortin-4 receptors (MC-4). The demonstration that AGRP is an endogenous antagonist with respect to these receptors is a unique mechanism within the central nervous system, and has important implications in the control of feeding.

Protection against allograft rejection with intercellular adhesion molecule-1 antisense oligodeoxynucleotides

BACKGROUND

We designed an antisense phosphorothioate oligodeoxynucleotide (oligo) to specifically inhibit the expression of rat intercellular adhesion molecule-1 (ICAM-1) mRNA (IP-9125).

METHODS

IP-9125 oligo was delivered intravenously by osmotic pump alone or in combination with cyclosporine (CsA) to recipients in order to prevent the rejection of kidney or heart allografts. In additional experiments, kidney allografts were perfused with IP-9125 before grafting.

RESULTS

IP-9125 inhibited ICAM-1 mRNA and ICAM-1 protein expression in rat aortic endothelial cells; scrambled controls IP-12140 and IP-13944 were ineffective. Untreated ACI (RT1a) recipients rejected Lewis (RT1l) kidney allografts at a mean survival time of 8.5+/-1.1 days. A 14-day intravenous administration of 2.5 mg/kg/day IP-9125 prolonged the survival of kidney allografts to 39.2+/-16.4 days; 5.0 mg/kg/day, to 43.0+/-17.5 days; and 10.0 mg/kg/day, to 50.4+/-21.6 days. In contrast, a scrambled control IP-12140 was not effective. A combination of 10 mg/kg/day IP-9125 and 1.0 mg/kg/day CsA delivered for 14 days synergistically extended kidney allograft survival times 88.5+/-7.5 days. In contrast, the combination of 10.0 mg/kg/day control IP-12140 with CsA was ineffective (20.7+/-3.2 days) when compared with CsA alone (20.2+/-4.0 days). Similar results were obtained for heart transplants in recipients treated with IP-9125 alone or in combination with CsA. Furthermore, in situ immunostaining showed that IP-9125 significantly reduced the expression of ICAM-1 protein in kidney allografts. Finally, perfusion of kidney grafts alone with 20.0 mg per 2 ml of IP-9125 protected kidney allografts from rejection (37.5+/-7.5 days; P < 0.001), whereas perfusion with 20 mg per 2 ml of control IP-12140 was ineffective (12.6+/-5.0 days).

CONCLUSIONS

Rat ICAM-1 IP-9125 oligo inhibits ICAM-1 protein expression in vitro and in vivo as well as blocks allograft rejection when used for pretreatment of donors, graft perfusion, or postoperative treatment of recipients.

A prospective randomized trial of triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Results of the medicine versus angiography in thrombolytic exclusion (MATE) trial

OBJECTIVES

The purpose of this study was to determine if early triage angiography with revascularization, if indicated, favorably affects clinical outcomes in patients with suspected acute myocardial infarction who are ineligible for thrombolysis.

BACKGROUND

The majority of patients with acute myocardial infarction and other acute coronary syndromes are considered ineligible for thrombolysis and therefore are not afforded the opportunity for early reperfusion.

METHODS

This multicenter, prospective, randomized trial evaluated in a controlled fashion the outcomes following triage angiography in acute coronary syndromes ineligible for thrombolytic therapy. Eligible patients (n=201) with <24 h of symptoms were randomized to early triage angiography and subsequent therapies based on the angiogram versus conventional medical therapy consisting of aspirin, intravenous heparin, nitroglycerin, beta-blockers, and analgesics.

RESULTS

In the triage angiography group, 109 patients underwent early angiography and 64 (58%) received revascularization, whereas in the conservative group, 54 (60%) subsequently underwent nonprotocol angiography in response to recurrent ischemia and 33 (37%) received revascularization (p=0.004). The mean time to revascularization was 27+/-32 versus 88+/-98 h (p=0.0001) and the primary endpoint of recurrent ischemic events or death occurred in 14 (13%) versus 31 (34%) of the triage angiography and conservative groups, respectively (45% risk reduction, 95% CI 27-59%, p=0.0002). There were no differences between the groups with respect to initial hospital costs or length of stay. Long-term follow-up at a median of 21 months revealed no significant differences in the endpoints of late revascularization, recurrent myocardial infarction, or all-cause mortality.

CONCLUSIONS

Early triage angiography in patients with acute coronary syndromes who are not eligible for thrombolytics reduced the composite of recurrent ischemic events or death and shortened the time to definitive revascularization during the index hospitalization. Despite more frequent early revascularization after triage angiography, we found no long-term benefit in cardiac outcomes compared with conservative medical therapy with revascularization prompted by recurrent ischemia.

Extending the indications for breast-conserving treatment to patients with locally advanced breast cancer

PURPOSE

Breast-conserving therapy (BCS) has generally been limited to T1 and T2 lesions because it has been thought impossible to achieve good local control with satisfactory cosmesis in patients with more advanced disease. However, many patients with T3 and T4 lesions will exhibit dramatic tumor downstaging with neoadjuvant chemotherapy. It is our hypothesis that for these patients BCS can be performed with good local control and cosmesis.

METHODS AND MATERIALS

Between February 1991 and November 1995, 34 patients with T3/T4, N0-N2, M0 breast cancer completed treatment consisting of 90 mg/m2 of doxorubicin every 21 weeks x 4, surgery (a local excision if sufficiently downstaged, or mastectomy if not), high dose cyclophosphamide (CMF) every 2 weeks x 4, and radiation therapy. Radionuclide ventriculograms were performed on all patients pre- and postdoxorubicin, and at 6-12 months post radiation therapy. Patients were evaluated for toxicity, local control, cosmesis, disease-free and overall survival.

RESULTS

Median follow-up is 30 months. 15/34 (44%) patients underwent BCS with only one local-regional failure and actuarial 3-year disease-free and overall survival of 77% and 88%. Cosmetic results were good to excellent in 80% of the patients. Left ventricular ejection fraction, which predictably declined following doxorubicin, did not further decline after radiation therapy.

CONCLUSIONS

These results suggest that with this regimen a subset of patients with locally advanced breast cancer can preserve their breast with acceptable cosmesis without compromising local control or survival.

Continuous infusion of epidural morphine in frostbite

After frostbite injury, the phases of rewarming and progressive injury may cause intense pain for the patient. Although parenteral narcotic agents are the usual method of pain relief, they have well-described adverse effects such as heavy sedation, respiratory depression, and nausea and vomiting. In frostbite injury of the lower extremities, epidural blockade has the potential to provide good pain relief with fewer of those complications. However, the associated sympathetic blockade is believed by many clinicians to be of no benefit and by some to be potentially harmful. Epidural narcotics have the selective advantage of providing analgesia without sympathetic blockade. In this case report, the use of continuous epidural morphine during the first 24 hours after severe bilateral frostbite injury to the feet is described. The technique provided effective pain control, and no complications occurred. To our knowledge, use of continuous epidural morphine after frostbite injury has not been reported previously. Further use of this technique will be required to clarify its efficacy.

The Epilepsy Outcome Scale: the development of a measure for use with carers of people with epilepsy plus intellectual disability

This paper describes the development of a new scale for the assessment of epilepsy in people with learning disabilities. The scale was developed and validated in consultation with principal carers, and reflects their concerns about seizures, their impact and their treatment. Further testing of the scale revealed high internal consistency, testretest reliability and a robust factor structure. The scale can be completed in 5-10 min and may be useful as an outcome measure both in clinical practice and in research trials.

Identity, place, and erotic community within gay leather culture in Stockholm

There has been much recent attention to the relationship between the construction of place, identity, and the body. This paper examines some of these themes in a presentation of the gay leather scene in Stockholm, Sweden. Based on ethnography of Stockholm's only true leather club, it shows how identity and spatial location are implicated in one another. It also looks at social and cultural processes of containment and dispersion within leather culture, the creation of erotic bodies, and forms of erotic interaction. These processes are seen as reflecting features of the wider Swedish gay scene and society in general, which is sometimes less tolerant than it is imagined to be. Aspects of current and possible future transformations of leather culture and style are also briefly considered.

Randomized placebo-controlled study of recombinant human interleukin-11 to prevent chemotherapy-induced thrombocytopenia in patients with breast cancer receiving dose-intensive cyclophosphamide and doxorubicin

PURPOSE

Thrombocytopenia may compromise cancer treatment, causing chemotherapy dose reductions, schedule alterations, or the need for platelet transfusions. We evaluated the efficacy and safety of recombinant human interleukin-11 (rhIL-11; Neumega, Genetics Institute, Inc, Cambridge, MA), a novel thrombopoietic growth factor, in reducing the need for platelet transfusions in patients who undergo dose-intensive chemotherapy.

PATIENTS AND METHODS

Women with advanced breast cancer received cyclophosphamide (3,200 mg/m2) and doxorubicin (75 mg/m2) plus granulocyte colony-stimulating factor (G-CSF; 5 microg/kg/d). Patients were randomized to blinded treatment with placebo or 50 microg/kg/d rhIL-11 subcutaneously for 10 or 17 days after the first two chemotherapy cycles.

RESULTS

Seventy-seven patients were randomized and constitute the intent-to-treat (ITT) population. Sixty-seven patients (the assessable subgroup) either completed both cycles without a major protocol violation (n = 62) or received a platelet transfusion before treatment was discontinued after the first cycle. In the ITT population, rhIL-11 significantly decreased the requirement for platelet transfusions; 27 of 40 (68%) patients who received rhIL-11 did not require transfusions, compared with 15 of 37 (41%) in the placebo group (P = .04). Treatment with rhIL-11 significantly reduced the total number of platelet transfusions required in the assessable subgroup (P = .03) and the time to platelet recovery to more than 50,000/microL in the second cycle (P = .01). Most adverse events associated with rhIL-11 were reversible, mild to moderate in severity, and likely related to fluid retention.

CONCLUSION

rhIL-11 is safe and effective in reducing treatment-associated thrombocytopenia and the need for platelet transfusions in patients who undergo dose-intensive chemotherapy, and thus may permit chemotherapy to be administered as planned at intended doses and thereby maximize the potential for a successful outcome.

Liver lesion detection, characterization, and effect on patient management: comparison of single-phase spiral CT and current MR techniques

This study compares liver lesion detection, characterization, and effect on patient management between single-phase spiral CT and MRI using spoiled gradient echo (SGE), T2-weighted fat-suppressed spin echo, and serial post gadolinium SGE. All patients with suspected liver lesions who underwent spiral CT and MRI within a 1-month period between January 1993 and September 1996 were included in the study. Spiral CT and MRI were interpreted prospectively in a blinded fashion by separate individual experienced investigators, and lesion detection and characterization were determined. Confirmation was obtained by surgery (6 patients), biopsy (18 patients), imaging follow-up (36 patients), or combined reading of all imaging studies and clinical follow-up (29 patients). Effect on patient management was determined by combined chart review and interview of the patients' physicians and by retrospective clinical assessment performed by a surgical oncologist and medical oncologist separately. Eighty-nine patients were included in the study. Regarding true positive lesion detection, 295 and 519 lesions were detected on spiral CT and MR images, respectively, which was significantly different on a patient-by-patient basis (P < .001). More lesions were detected on MR than on spiral CT in 44 of 89 patients (49.4%), and 11 of these 44 patients had lesions shown on MRI in whom no lesions were apparent on CT images. No patients had true positive lesions shown on spiral CT that were not shown on MRI. Regarding lesion characterization, 129 and 466 lesions were characterized on spiral CT and MRI images, respectively, which was significantly different on a patient-by-patient basis (P < .001). More lesions were characterized on MR than CT images in 67 patients (75.3%). Regarding effect on patient management, chart review with physician interview demonstrated that findings on MRI provided information that altered patient management as compared with findings on spiral CT in 57 patients. Retrospective clinical evaluation by the surgical and medical oncologist showed that MRI was considered to have a greater effect on patient management than spiral CT in 58 and 55 patients, respectively. Comparing current MRI technique to single-phase spiral CT, MRI detected more lesions in 49.4% and characterized more lesions in 75.3% of patients investigated for focal liver disease. MRI had a greater effect on patient management in each of the three methods than single-phase spiral CT in more than 61% of patients.

Biological profile of L-745,870, a selective antagonist with high affinity for the dopamine D4 receptor

L-745,870,(3-([4-(4-chlorophenyl)piperazin-1-yl]methyl)-1H- pyrollo[2,3-b] pyridine, was identified as a selective dopamine D4 receptor antagonist with excellent oral bioavailability and brain penetration. L-745,870 displaced specific binding of 0.2 nM [3H] spiperone to cloned human dopamine D4 receptors with a binding affinity (Ki) of 0. 43 nM which was 5- and 20-fold higher than that of the standard antipsychotics haloperidol and clozapine, respectively. L-745,870 exhibited high selectivity for the dopamine D4 receptor (>2000 fold) compared to other dopamine receptor subtypes and had moderate affinity for 5HT2, sigma and alpha adrenergic receptors(IC50 < 300 nM). In vitro, L-745,870 (0.1-1 microM) exhibited D4 receptor antagonist activity, reversing dopamine (1 microM) mediated 1) inhibition of adenylate cyclase in hD4HEK and hD4CHO cells; 2) stimulation of [35S] GTPgammaS binding and 3) stimulation of extracellular acidification rate, but did not exhibit any significant intrinsic activity in these assays. Although standard antipsychotics increase dopamine metabolism or plasma prolactin levels in rodents, L-745,870 (</=30 mg/kg p.o.) had no effect in these assays. The lack of a suitable in vivo assay for D4 receptor activation prompted the use of in vivo surrogate marker assays which confirmed that doses of 5-60 microg/kg L-745,870 would be sufficient to occupy 50% D4 receptors in the brain. These results show that dopamine D4 receptor antagonism in the brain does not result in the same neurochemical consequences (increased dopamine metabolism or hyperprolactinemia) observed with typical neuroleptics.

Cloning and characterization of a microsomal aminopeptidase from the intestine of the nematode Haemonchus contortus

In order to characterise the integral membrane glycoprotein H11 from the intestinal microvilli of the nematode Haemonchus contortus, cDNA libraries prepared using mRNA from adult worms from the UK and Australia were immunoscreened with anti-H11 sera. Antibodies affinity purified on the protein expressed by insert DNA (295 bp) of a positive clone from a UK library bound specifically to H11. A longer clone (948 bp) was obtained from the Australian library by hybridisation. Using a primer based on sequence common to these, a polymerase chain reaction product of 3.3 kb was generated from cDNA from UK H. contortus. The sequences from the UK and Australian nematodes were essentially identical over the 929 bp region in which both were represented. All three cloned DNAs hybridised to mRNA of about 3.5 kb. Analysis of the deduced amino acid sequence, which showed 32% identity with those of mammalian microsomal aminopeptidases, indicated that H11 has a short N-terminal cytoplasmic tail, a single transmembrane region and a long extracellular region with putative N-linked glycosylation sites and the HEXXHXW motif characteristic of microsomal aminopeptidases. Microsomal aminopeptidase activity co-purifies with H11. It is inhibited by bestatin, phenanthroline and amastatin. The recombinant protein has been expressed in active form in insect cells.

Anemia and perinatal death result from loss of the murine ecotropic retrovirus receptor mCAT-1

The mCAT-1 gene encodes a basic amino acid transporter that also acts as the receptor for murine ecotropic leukemia viruses. Targeted mutagenesis in embryonic stem cells has been used to introduce a germ-line null mutation into this gene. This mutation removes a domain critical for virus binding and inactivates amino acid transport activity. Homozygous mutant pups generated from these cells were approximately 25% smaller than normal littermates, very anemic, and died on the day of birth. Peripheral blood from homozygotes contained 50% fewer red blood cells, reduced hemoglobin levels, and showed a pronounced normoblastosis. Histological analyses of bone marrow, spleen, and liver showed a decrease in both erythroid progenitors and mature red blood cells. Mutant fetal liver cells behaved normally in in vitro hematopoietic colony-forming assays but generated an anemia when transplanted into irradiated C.B.-17 SCID mice. Furthermore, reconstitution of the white cell compartment of SCID mice by mutant fetal liver cells was less complete than that observed with a mixed population of wild-type and heterozygous fetal liver cells. Primary embryo fibroblasts from mutant mice were completely resistant to ecotropic retrovirus infection. Thus, mCAT-1 not only appears to be the sole receptor for a group of murine ecotropic retroviruses associated with hematological disease but also plays a critical role in both hematopoiesis and growth control during mouse development.

Management of chronic pain with epidural steroids

Perioperative nurses need to be aware of the multiple treatment modalities associated with chronic back problems. Patients who undergo back surgeries often have been and may continue to be pain therapy patients. In addition, many conditions other than back problems are treated in pain clinics. Perioperative nurses may be in a position to refer patients for pain therapy and are encouraged to do so. Patients may look to nurses for guidance when making decisions about using pain therapy clinics. Pain management programs vary from small single-discipline or modality clinics to large multidisciplinary centers. Regardless of the type of clinic, team members should place a strong emphasis on assessing patients' physical, mental, and psychosocial statuses so that coherent treatment plans can be developed. Patients should be encouraged to participate in all decision making because they have much of the responsibility for their treatment. Patients also should be cautioned not to expect miracles but to look for significant improvement and the opportunity to lead more effective and satisfying lives with minimal pain.

Hypothalamic expression of ART, a novel gene related to agouti, is up-regulated in obese and diabetic mutant mice

We have isolated cDNA clones that encode a novel human gene related to agouti. Sequence analysis of this gene, named ART, for agouti-related transcript, predicts a 132-amino-acid protein that is 25% identical to human agouti. The highest degree of identity is within the carboxyl terminus of both proteins. Like agouti, ART contains a putative signal sequence and a cysteine rich carboxyl terminus, but lacks the region of basic residues and polyproline residues found in the middle of the agouti protein. Both agouti and ART contain 11 cysteines, and 9 of these are conserved spatially. ART is expressed primarily in the adrenal gland, subthalamic nucleus, and hypothalamus, with a lower level of expression occurring in testis, lung, and kidney. The murine homolog of ART was also isolated and is predicted to encode a 131-amino-acid protein that shares 81% amino acid identity to humans. The mouse was found to have the same expression pattern as human when assessed by RT-PCR. Examination by in situ hybridization using mouse tissues showed localized expression in the arcuate nucleus of the hypothalamus, the median eminence, and the adrenal medulla. In addition, the hypothalamic expression of ART was elevated approximately 10-fold in ob/ob and db/db mice. ART was mapped to human chromosome 16q22 and to mouse chromosome 8D1-D2. The expression pattern and transcriptional regulation of ART, coupled with the known actions of agouti, suggests a role for ART in the regulation of melanocortin receptors within the hypothalamus and adrenal gland, and implicates this novel gene in the central control of feeding.

Comparison of analytical methods in the determination of two venlafaxine fatalities

Two venlafaxine (Effexor)-related deaths are reported with comparison of results from the analysis of specimens using capillary gas chromatography with a nitrogen-phosphorous detector (GC-NPD) and high-performance liquid chromatography (HPLC) using a UV-vis detector. Blood concentrations in Case 1 were 7.27 micrograms/mL venlafaxine and 5.03 micrograms/mL O-desmethylvenlafaxine, and Case 2 had 89.67 micrograms/mL venlafaxine with 3.44 micrograms/mL of the desmethyl metabolite. A comparison of analytical methods and specimen concentration is presented.

Preliminary study of the effect of iron dextran on a non-regenerative anaemia of housed lambs

A study of the effects of iron dextran supplementation on anaemia in indoor lambs was carried out on one commercial flock of 525 lambs from January to June 1993. The lambs were randomly allocated into two groups, one of which was given a parenteral injection of 300 mg iron dextran and the other was left untreated. Blood was collected from 22 12-day-old lambs and 106 24-day-old lambs, in each case half treated and half untreated. The supplemented lambs had significantly improved haematological values than the unsupplemented lambs. There were also significant differences in the total serum iron concentration, the unsaturated iron binding capacity and the percentage serum saturation with iron between the treated and untreated lambs. At 12 days, the untreated lambs had a total serum iron below the accepted normal range for sheep whereas the treated lambs had values within the normal range. At weaning, lambs injected with iron dextran were significantly heavier (1.0 kg) than those not injected. The daily liveweight gain to slaughter was greater and the proportion of deaths was lower in the treated lambs but these differences were not statistically significant.

A phase I/II study of external beam radiation, brachytherapy and concurrent chemotherapy in localized cancer of the esophagus (RTOG 92-07): preliminary toxicity report

PURPOSE

A multi-institutional, prospective study was designed to determine the feasibility and tolerance of external beam irradiation plus concurrent chemotherapy and esophageal brachytherapy (EB) in a potentially curable group of patients with adenocarcinoma or squamous cell carcinoma of the esophagus.

METHODS AND MATERIALS

Planned treatment was 50 Gy external beam radiation (25 fractions/5 weeks) followed 2 weeks later by EB [either high dose rate (HDR) 5 Gy, weeks 8, 9, and 10, for a total of 15 Gy, or low dose rate (LDR) 20 Gy, week 8]. The protocol was later revised to delete the LDR alternative, owing to poor accrual, and to decrease the HDR dose to 10 Gy (i.e. 5 Gy, weeks 8 and 9). Chemotherapy was given weeks 1, 5, 8, and 11 with cisplatin 75 mg/m2 and 5-fluorouracil 1000 mg2/m per 24 h, 96-h infusion. The study closed in January 1995 after 56 patients had been entered on the HDR arm. Six patients were declared ineligible owing to tumor extension to the gastroesophageal junction (three patients) or involved celiac lymph nodes (three patients). Of the 50 eligible patients, the planned EB dose was 15 and 10 Gy in 40 and 10 patients, respectively. Forty-six (92%) of the eligible patients had squamous histology, and three (6%) adenocarcinoma.

RESULTS

Life-threatening toxicity or treatment-related death occurred in 13 (26%) and 4 (8%) of the 50 eligible patients, respectively. Treatment-related esophageal fistulas occurred in three patients (12% overall, 14% of patients starting EB) at 0.5-6.2 months from the first day of brachytherapy, leading to death in three. The fourth death was secondary to renal toxicity and infection attributed to chemotherapy. No correlation was found between the development of fistula and location of primary tumor, brachytherapy active length or applicator diameter. So far, 5 of the 6 treatment-related fistulas have occurred following 15 Gy EB. The other fistula occurred after only 5 Gy of a planned 15 Gy was delivered.

CONCLUSION

Thirty-five patients (70%) were able to complete external beam, EB, and at least two courses of chemotherapy. Estimated survival rate at 12 months is 48%, with an estimated 11-month median survival rate. Survival following external beam radiation plus concurrent chemotherapy and EB does not appear to be significantly different from survival seen following external beam radiation and chemotherapy only. The development of six fistulas in the 35 patients completing EB is of concern. Based on the high incidence of fistulas, we urge extreme caution in employing EB as a boost following concurrent external beam radiation and chemotherapy.

Pharmacological manipulation of ultrasound induced defence behaviour in the rat

Rats exposed to aversive stimuli display species specific defence behaviour as part of their natural survival strategy. one component of this behaviour is the production of ultrasonic calls in the 20 to 27-kHz range, which are thought to serve a communicative role. The present study has examined the behavioural effects of exposing rats to artificially generated ultrasound and the ability of three distinct pharmacological agents to modify this response. Single tone 20 kHz ultrasound exposure for 1 min produced intensity-related locomotor behaviour, characteristic of defence behaviour, which could be measured using a computer tracking system. This was significantly reduced by peripheral pretreatment with the benzodiazepine, diazepam (0.3 and 3.0 mg/kg IP). Pretreatment with the 5-HT agonist 1-(3-chlorophenyl) piperazine (mCPP) (0.5-2.0 mg/kg IP) produced a dose-related reduction in the ultrasound-induced response. The alpha 2 adrenoceptor antagonist, yohimbine (0.5-5.0 mg/kg IP), caused an increase in the response at the lower dose (0.5 mg/kg) and a decrease at the two higher doses (2.0 and 5.0 mg/kg). The present findings suggest that defence behaviour in the rat can be artificially produced by 20 kHz ultrasound; this is sensitive to pharmacological manipulation and may offer a novel animal model of aversive behaviours that are associated with human panic.

Self-inflicted injuries. Challenging knowledge, skill, and compassion

PROBLEM BEING ADDRESSED

Self-inflicted injuries and other serious self-destructive behaviours are common and difficult to recognize, prevent, and manage. Although they have previously been understood as repeated, failed attempts at suicide, they are better understood as maladaptive coping strategies.

OBJECTIVE OF PROGRAM

Women who present repeatedly with self-inflicted injuries need help to control this self-destructive behaviour and substitute more positive coping strategies. Physicians also need help in working with patients who respond to problems in this way.

MAIN COMPONENTS OF PROGRAM

The program is made up of two broad sections. The first section involves understanding the problem and its origins in post-traumatic stress disorders. The second section offers a practical approach to helping patients presenting with injuries inflict upon themselves.

CONCLUSIONS

A deeper understanding of the etiology and management of repeated self-inflicted injuries will enable physicians to help patients with this difficult problem while minimizing their own anxiety and frustration.