Cancer pain management in developing countries: a mosaic of complex issues resulting in inadequate analgesia

Cancer pain is often undertreated even in developed countries with abundant resources and easy access to oral, parenteral, and transdermal opioids. The problems in developing nations are more complex, and as a result, these medications are not available to the vast majority of patients in Latin and South America, Eastern Europe, Asia, and Africa. Some of the reasons for this are reviewed, with India cited as a case example. In spite of serious efforts by the World Health Organization and other bodies to make oral opioids available and to educate government officials and physicians, little progress has been made in relieving pain in cancer patients in the developing world. Novel approaches that address fundamental concerns regarding opioid availability in these countries are desperately needed. One such approach, which is currently under development, is presented in this manuscript. This has the potential to make opioids available to patients in rural areas, improve compliance in the poorly educated patient, reduce the number of follow-up visits necessary for medication refills, and reduce the risk that opioids will be diverted to illicit channels. The potential for relieving cancer pain and the magnitude of this problem worldwide make it imperative that innovative approaches be tailored to the complex social issues and limited resources common to developing nations.

Immunogenic epitopes of Salmonella typhi GroEL heat shock protein reactive with both monoclonal antibody and patients sera

A series of 122, 9-mer overlapping peptides based on the sequence of the Salmonella typhi GroEL gene was synthesized on the surfaces of polyethylene pins and screened with monoclonal antibody to GroEL and with human sera from patients with typhoid fever and normal healthy blood donors. Three immunogenic epitopes corresponding to peptides EGQDRGYSY, YSYNKETGE and GKGTEEKEK were identified upon screening with the human sera. In addition, screening of the peptides with a monoclonal antibody to GroEL detected binding to a third peptide, KGGKGTEEK, which contains a common overlapping sequence to peptide GKGTEEKEK. Identification and definition of these epitopes will be important in delineating the biological and immunological functions of this protein and in designing better diagnostic tests and vaccines.

Objective evaluation of the quality of voice following radiation therapy for T1 glottic cancer

BACKGROUND

Radiation therapy is commonly considered the treatment of choice for T1 glottic cancer. While it is generally believed that the quality of voice following irradiation is quite satisfactory, few studies have reported the results of objective assessment of voice after radiation therapy.

PURPOSE

To objectively evaluate the quality of voice following radiation therapy for T1 glottic cancer.

MATERIALS AND METHODS

The voices of 12 patients treated for T1 glottic cancer with radiation therapy were evaluated by acoustic analysis and speech aerodynamic studies. Eleven patients received between 6300 and 6665 cGy at a daily fraction size of 180-225 cGy. One patient received 7000 cGy at a daily fraction size of 200 cGy. Evaluation of the quality of voice was done 3 months to 7 years following completion of radiation therapy.

RESULTS

The number of patients who scored abnormal values for the measurements of fundamental frequency, jitter, shimmer and harmonic to noise ratio was 2, 10, 4 and 3, respectively. The number of patients who scored abnormal values for transglottic airflow rate, subglottal pressure and glottal resistance was 12, 8 and 9, respectively. None of the studied patients scored normal values in all given tests.

CONCLUSION

Although radiation therapy cures a high proportion of patients with T1 glottic cancer, the quality of voice does not return to normal following treatment.

Induction and characterization of heat shock proteins of Salmonella typhi and their reactivity with sera from patients with typhoid fever

The heat shock protein (HSP) response of Salmonella typhi following exposure to elevated growth temperatures was studied. Three major proteins with molecular sizes of 58, 68, and 88 kDa were abundantly expressed when S. typhi cells were shifted from 37 to 45 degrees C and to 55 degrees C. These proteins were also constitutively expressed at 37 degrees C. Western blotting and immunoprecipitation studies with anti-HSP monoclonal antibodies revealed that the 58- and 68-kDa proteins were analogous to the GroEL and DnaK proteins, respectively, of Escherichia coli. These HSPs are also abundantly present in the outer membrane fraction of disrupted cells and, to a lesser extent, in the cytosol. Immunoblotting experiments with sera from patients with a culture-positive diagnosis of typhoid fever showed the presence of antibodies to these HSPs. Nine of twelve sera reacted with the 58-, 68-, and 88-kDa proteins, while three sera reacted only with the 68- and 88-kDa proteins. All 10 sera from healthy individuals showed no binding to these HSPs. In light of the well-documented roles of HSPs in the pathogenesis of microbial infections and as immunodominant antigens, these findings may be relevant for a better understanding of disease processes and for the future development of diagnostic and preventive strategies.

Adequate irradiation of the internal jugular lymph node chain: technical considerations

PURPOSE

This research aimed to study the anatomic relationship between the internal jugular vein with the surrounding internal jugular lymph node chain and the underlying bony anatomical structures which are commonly used as landmarks for radiation therapy planning.

METHODS AND MATERIALS

Twelve patients with carcinoma of the head and neck region were studied prospectively. Using our three-dimensional planning system, a beam's-eye view of the internal jugular vein was projected onto a lateral and anterior simulation film. Quantitative measurements were made in every case of the anatomic relationship between the internal jugular vein and the posterior border of the cervical vertebrae and sagittal midline.

RESULTS

The distance between the posterior border of the internal jugular vein and the posterior border of the cervical vertebrae ranged between 0 and 2.5 cm. The distances between the sagittal midline and the medial border of the internal jugular veins ranged between 2 and 4 cm.

CONCLUSION

To ensure adequate irradiation of the internal jugular lymph nodes, the posterior border of the lateral radiation therapy upper-neck fields should be placed at least 1 cm posterior to the posterior aspect of the cervical vertebrae. The midline block used in the lower neck anterior field should not exceed 2 cm in width.

Clinical profile of sickle cell disease in Orissa

Children comprised 52% of patients with Sickle Cell Disease (SCD). Types of Sickle Cell Disease encountered were SS (92.7%). SB thalassaemia (6.7%) and SD disease (0.7%). The disease was widespread in almost all castes and communities in the society; largest number of patients (20%) belonging to scheduled castes and only 1.4% were from scheduled tribes. Maximum number of cases were in the age group 2-4 and 4-6 years, many of whom died around this age. Besides attacks of pain, jaundice and anemia, frequent attacks of fever with anemia or only anemia in childhood were a predominant presenting feature. Splenic sequestration was frequent (10.1%). The patients usually had a steady state hemoglobin level of 6-10 g/dl, with which they thrived well. Fetal hemoglobin was 5-30%. Blood transfusion was not a frequent requirement, but prophylactic long acting penicillin was helpful in preventing frequency of crisis.

Multifractionated high-dose-rate brachytherapy with concomitant daily teletherapy for cervical cancer

BACKGROUND

High-dose-rate (HDR) brachytherapy has been the preferred treatment for cervical cancer at Wayne State University since 1987. The outcome of the first 105 patients treated is analyzed.

PURPOSE

To determine clinical efficacy of the HDR modality.

METHODS

We reviewed 105 patients and evaluated the 88 patients treated for cervical carcinoma with HDR and external beam radiotherapy (EBRT) from August 1987 to December 1992. Patients received initial external radiation to the pelvis (total dose of 19.8 to 39.6 Gy in 11 to 22 fractions), followed by outpatient HDR brachytherapy (3 fractions/week, 386 cGy/fraction to Point A, total of 8 to 12 fractions) and concurrent daily EBRT (1.8 to 2.0 Gy) to lateral parametria. During the HDR period of treatment, step wedge transmission blocks were used to shield central pelvic tissue while treating peripheral pelvic tissues with EBRT. Patient distributions were as follows: 25, IB/IIA; 35, IIB/IIIA; and 28, IIIB/IVA. There were 56 African American and 32 Caucasian patients with mean age of 55 (range 19-89). The median follow-up was 33 months (range 20 to 76 months). Kaplan-Meier analysis was performed.

RESULTS

Three-year survival rates were 88%, IB/IIA; 69%, IIB/IIIA; 56%, IIIB/IVA; and 72% overall. Local control was achieved in 71/88 (80%) of patients. Failure site was cervix or within the pelvis in 12 patients, distant metastasis only 17 patients, and combined local and distant in 5 patients. Of the failures, 82% (28/34) died within 2 years. There were 3 grade III/complications (3.4%).

CONCLUSION

Results compare favorably with previous LDR experience.

Significance of lymphocytic sister chromatid exchange frequencies in ovarian cancer patients

Very few studies report the analysis of sister chromatid exchanges in ovarian cancer patients. We tested the null hypothesis that SCE frequency increases with the advancing stages of ovarian cancer and follows a Poisson distribution. As controls we examined age- and sex-matched healthy volunteers who had no such past history. An increased average SCE frequency was observed in ovarian cancer patients (6.34 +/- 0.09) vis-à-vis controls (4.47 +/- 0.12). Further, the data also suggested a stage-wise increase in the SCE frequency.

Conformal mixed neutron and photon irradiation in localized and locally advanced prostate cancer: preliminary estimates of the therapeutic ratio

PURPOSE

To determine the incidence of chronic toxicity and the probability of biochemical and histologic complete response among patients with nonmetastatic prostate cancer, treated with three dimensional (3D) conformal mixed neutron and photon irradiation.

METHODS AND MATERIALS

Between November 1991 and December 1994, 151 patients with prostate cancer were entered in three prospective dose-finding studies of conformal mixed neutron and photon irradiation. Patients with low stage, low to intermediate grade prostate cancer (T1-2NXM0, Gleason Score < or = 7) received 38 Photon Gy (PhGy) plus 9 (51 patients) or 10 (53 patients) Neutron Gy (NGy) to the prostate and seminal vesicles. Forty-seven patients with locally advanced prostate cancer (T3-4 N0-1 M0 and/or Gleason Score > or = 8) received 15 NGy + 18 PhGy to the prostate and seminal vesicles and 9 NGy + 18 PhGy to the pelvic lymph nodes.

RESULTS

The median follow-up was 16 months (range: 3-30 months). There was no Grade 3-5 GI or GU toxicity recorded. At 20 months, the actuarial rates of Grade 2 GI morbidity were 6 and 29% for the 9-10 and 15 NGy protocols, respectively (p = 0.07). At 20 months, the incidences of Grade 2 GU morbidity were 4 and 16%, respectively (p = 0.08). Stiffness in flexing or abducting the hips was seen in 20 and 42% of patients receiving 9-10 and 15 NGy, respectively (p = 0.01). Potency was maintained in 65% of all patients. Among patients with an initial PSA < or = 10, 100% had a 12-month PSA < 2 and 78% < 1 ng/ml. Negative postradiation biopsies were seen in 30% of patients 6 months, 79% at 12 months, and 84% of patients at 18 months.

CONCLUSION

The use of conformal mixed neutron and photon irradiation has been well tolerated with no severe bladder or rectal complications observed. However, because of the enhanced toxicity seen with 15 NGy, the current maximum dose levels of neutron irradiation have been limited to 11 NGy.

In vitro demonstration of the invasive ability of Campylobacters

By means of the gentamicin HEp-2 cell invasion assay, it was demonstrated that 82% of the Campylobacters tested were cell-invasive, including 83% of isolates from bloody diarrhoea and 80% of isolates from watery diarrhoea. The large number of invasive strains from watery diarrhoea suggests the possible role of invasiveness in the production of watery diarrhoea. Whether this stage can progress further to more severe symptoms such as bloody diarrhoea remains to be elucidated. Whether this progression to bloody diarrhoea occurs as a result of toxin production is still debatable. In Vero cells, invasion was less efficient and intracellular multiplication was not observed.

Changes in uptake of calcium caused by phytotoxicity of cadmium in Salvinia molesta

: The effect of Ca on the uptake of Cd by root and leaves of Salvinia molesta was investigated at different time intervals and under different photoperiods. For detailed study on uptake and interaction, (15)Ca and (109)Cd were used and it was found that there was a higher uptake of (45)Ca in the root and leaves at 48 h and a concurrent reduction in (109)Cd content at 48 h suggesting alterations in Ca functions due to the phytotoxicity of Cd. Ultrastructural changes due to cadmium toxicity included swirling of thylakoid membranes of the chloroplasts as well as detachment of the tips of trichomes from the leaf.

A rapid silver staining and destaining technique for the nucleolus organizer region

Silver staining of nucleolar organizing regions (NOR) is common, but a standard protocol is lacking. A modification of a rapid silver nitrate staining technique for NORs is presented here. Advantages of the modified technique include reliability, speed, cost and the fact that it can be carried out in the light.

Characterisation of Campylobacters from Malaysia

Eight-five clinical and 15 poultry isolates of Campylobacter species were characterised by biotyping, serotyping and by using a radiolabelled DNA probe. A total of 80% of the isolates from both sources were identified as C. jejuni. Also amongst the clinical strains were 5 c. jejuni subsp. doylei, 7 C. coli, 3 C. lari and 8 were untypable. The similarity in the distribution of C. jejuni in the clinical and poultry isolates adds credibility to published reports of chickens being the most common source of Campylobacter infections. Although the gold standard for identification of C. jejuni is the DNA probe, serotyping is more discriminating while biotyping is the most feasible method in most laboratories.

Alternating conformal neutron and photon irradiation for locally advanced adenocarcinoma of the prostate

The substantial local failure rate for patients with locally advanced carcinoma of the prostate (LACaP) following photon irradiation, the association of local failure with a poor prognosis, and the promising results of mixed neutron/photon (40%/60%) radiotherapy supplied the rationale for this study. The purpose of this study was to evaluate the combined advantages of mixed neutron/photon (75%/25%) irradiation, 3D treatment planning, as well as fully conformal beam shaping capabilities in reducing the morbidity associated with neutron irradiation. The first 35 patients treated with this technique are the basis for this analysis. After CT stimulation and treatment planning, the normal tissue and target structures were entered into the 3D planning system. The neutron dose was delivered in 15 fractions at 1.0 Gy/fraction (NGy) to the prostate and seminal vesicles (PSV) and 0.6 NGy/fraction to the pelvic lymph nodes (LN). The photon dose was given in 10 fractions of 1.8 Gy each to both the PSV and LN volumes. Neutron and photon dose-volume histograms (DVHs) were generated in each patient for the prostate, seminal vesicles, lymph nodes, bladder, and rectum. The adequacy of the neutron and photon components of the treatment were compared with respect to target volume and normal tissue irradiation. Based on the DVH analysis, the prostate and seminal vesicles received the prescribed dose with both neutrons (99% +/- 2%) and photons (99% +/- 2%). There was no significant difference in the dose to the bladder and rectum for both the neutrons and photons. The acute treatment related reactions have been mild, with only one grade III bladder reaction. The 3D conformal technology utilized in this study has been shown to allow for the delivery of neutron irradiation with no increase in dose to the adjacent normal tissues compared with that achieved with conformal photon treatment. Further follow-up will reveal whether the dosimetric advantage demonstrated by this technique translates into an improved therapeutic ratio.

Biologic activities of the beta-chemokine TCA3 on neutrophils and macrophages

Previous in vivo and in vitro studies demonstrated that the murine beta-chemokine TCA3 is a chemoattractant for monocytes/macrophages and neutrophils. The ability of TCA3 to activate these cell populations is now evaluated. Treatment with 10 to 20 nM rTCA3 induced a respiratory burst with the production of superoxide and hydrogen peroxide in both casein-elicited and unstimulated neutrophil and macrophage populations. In addition, TCA3 treatment induced the production of reactive nitrogen intermediates, whereas stimulation with higher concentrations (100 nM) of TCA3 induced the exocytosis of lysozyme and elastase in the presence of cytochalasin B (7 micrograms/ml). Subnanomolar concentrations (100 pM) of TCA3 also caused integrin-mediated increases of adhesiveness to fibrinogen by neutrophils and macrophages. Increased adhesiveness is the most sensitive assay for TCA3 bioactivity. TCA3 treatment appears to involve signaling through a G-protein-linked receptor as Pertussis toxin abolished the TCA3-mediated increase of adhesiveness and the production of reactive nitrogen intermediates. The dose dependence of the TCA3-mediated activities indicate a coordinated inflammatory response mediated by varying concentrations of TCA3.

Biologic activities of the beta-chemokine TCA3 on neutrophils and macrophages

Previous in vivo and in vitro studies demonstrated that the murine beta-chemokine TCA3 is a chemoattractant for monocytes/macrophages and neutrophils. The ability of TCA3 to activate these cell populations is now evaluated. Treatment with 10 to 20 nM rTCA3 induced a respiratory burst with the production of superoxide and hydrogen peroxide in both casein-elicited and unstimulated neutrophil and macrophage populations. In addition, TCA3 treatment induced the production of reactive nitrogen intermediates, whereas stimulation with higher concentrations (100 nM) of TCA3 induced the exocytosis of lysozyme and elastase in the presence of cytochalasin B (7 micrograms/ml). Subnanomolar concentrations (100 pM) of TCA3 also caused integrin-mediated increases of adhesiveness to fibrinogen by neutrophils and macrophages. Increased adhesiveness is the most sensitive assay for TCA3 bioactivity. TCA3 treatment appears to involve signaling through a G-protein-linked receptor as Pertussis toxin abolished the TCA3-mediated increase of adhesiveness and the production of reactive nitrogen intermediates. The dose dependence of the TCA3-mediated activities indicate a coordinated inflammatory response mediated by varying concentrations of TCA3.

Detection of haemolytic activity of campylobacters by agarose haemolysis and microplate assay

There are several methods for the detection of haemolytic activity in campylobacters. However, we found the haemolytic effect of campylobacters on conventional blood agar plates to be variable, inconsistent and difficult to interpret. Blood agarose plates showed campylobacter haemolytic activity more clearly. The incubation conditions (temperature and gaseous) appear to be important for the expression of this activity. Ninety four percent of the Campylobacter isolates examined were found to be haemolytic by the microplate assay with minimal haemolytic units that ranged from 1 to 64. Haemolytic activity was detected only from live bacterial cultures and not from any of the 50 bacterial culture supernates, which suggests that campylobacters may possess a cell-associated haemolysin. The identification of such haemolytic activity in a large number of campylobacters (94%) suggests its potential role as a virulence factor in campylobacter gastroenteritis.

Chronic toxicity of cadmium in Pteris vittata, a roadside fern

: The effect of Cd at concentrations of 0.1, 1.0, 2.5, 5.0 and 10.0 ppm on Pteris vittata, a commonly occurring roadside fern was studied during the entire life cycle from spore germination to spore production. Light, fluorescence, scanning and transmission electron microscopy were used to study the structural changes due to Cd. With increasing Cd concentrations the following changes were observed: inhibition of first and second generation spores, abnormal development of protonema, disintegration of thylakoid organization, delayed formation of reproductive elements and abnormal sporangia. As the Cd content of the plants increased with increasing concentration in the medium, biomass-specific concentrations of chlorophyll and carotenoids decreased. The gametophytic phase was more sensitive than the sporophytic stage to Cd. The differences noticed during the three stages of development could be useful as markers for Cd contamination in the environment.

Biologic activities of the murine beta-chemokine TCA3

The murine beta-chemokine TCA3 was purified to homogeneity. The biologic activities of the purified glycoprotein were evaluated in vivo and in vitro. Mice injected i.p. with 1- to 100-ng purified rTCA3 exhibited a rapid influx of neutrophils and macrophages. Increased numbers of neutrophils and monocytes were observed in peripheral blood within 15 min and peak at 45 min. After 45 min neutrophil and macrophage levels were increased in the peritoneal exudate with peak levels occurring at 2 h, followed by a subsequent decline by 24 h. Inflammatory responses were induced in a dose-dependent fashion. The in vivo inflammatory responses were mirrored by the pattern of TCA3-induced chemotaxis in vitro. Neutrophils and macrophages responded to similar concentrations of TCA3 (3 x 10(-9) to 10(-8) M). Lymph node cells responded to other chemokines but did not migrate to TCA3. We also demonstrated that rTCA3 stimulates a transient increase in cytoplasmic free calcium in monocytic cells through a PTX-sensitive pathway. Cross-desensitization studies indicate that TCA3 acts independently of other beta-chemokines (MIP-1 alpha and RANTES) and the alpha-chemokine IL-8. Furthermore, TCA3 does not induce a Ca2 lux in cells transfected with cDNA for the C-C CKR-1 chemokine receptor, supporting the conclusion that there are distinct receptors for TCA3.

Biologic activities of the murine beta-chemokine TCA3

The murine beta-chemokine TCA3 was purified to homogeneity. The biologic activities of the purified glycoprotein were evaluated in vivo and in vitro. Mice injected i.p. with 1- to 100-ng purified rTCA3 exhibited a rapid influx of neutrophils and macrophages. Increased numbers of neutrophils and monocytes were observed in peripheral blood within 15 min and peak at 45 min. After 45 min neutrophil and macrophage levels were increased in the peritoneal exudate with peak levels occurring at 2 h, followed by a subsequent decline by 24 h. Inflammatory responses were induced in a dose-dependent fashion. The in vivo inflammatory responses were mirrored by the pattern of TCA3-induced chemotaxis in vitro. Neutrophils and macrophages responded to similar concentrations of TCA3 (3 x 10(-9) to 10(-8) M). Lymph node cells responded to other chemokines but did not migrate to TCA3. We also demonstrated that rTCA3 stimulates a transient increase in cytoplasmic free calcium in monocytic cells through a PTX-sensitive pathway. Cross-desensitization studies indicate that TCA3 acts independently of other beta-chemokines (MIP-1 alpha and RANTES) and the alpha-chemokine IL-8. Furthermore, TCA3 does not induce a Ca2 lux in cells transfected with cDNA for the C-C CKR-1 chemokine receptor, supporting the conclusion that there are distinct receptors for TCA3.

Exotoxin profiles of Campylobacters isolated in Malaysia

Approximately 57% of clinical and 33% of poultry isolates examined produced a cytotoxin. Cytotoxic activity was detected in 25 (50%) isolates of Campylobacter of which 12 were isolated from bloody diarrhea and 9 from watery stools. The cytotoxin titers were low, ranging from 2 to 16. The crude filtrates from 50 Campylobacter isolates showed no cytotoxic effect in Vero cells, no fluid accumulation in suckling mice and no hemolytic activity.