A technique for developing a master cast with previously made dies

This article describes a technique for preparing final working casts to be used in the laboratory phase of restorative treatment. The goal is to produce accurate working casts that have stable dies which are easily removed from the base and reliably replaced. Most casts with removable dies are made from a single master impression. However, individual dies are sometimes made previously from individual tooth (preparation) impressions. In such cases, transfer copings are required to relate the dies and produce the final working cast. Hollow plastic casting sprues are used as temporary dowels in this technique until a transfer coping pickup impression has been made. After the dies are seated and secured in the transfer coping pickup impression, the plastic casting sprues are replaced with conventional brass dowel pins. This technique ensures well-placed dowel pins that will facilitate easy and accurate withdrawal and replacement of the dies.

Treatment-related symptoms during the first year following transperineal 125I prostate implantation

PURPOSE

To summarize the urinary, rectal, and sexual symptoms occurring during the first 12 months following 125I prostatic implantation.

METHODS AND MATERIALS

Thirty-one patients with Stage T1 or T2 prostatic carcinoma were evaluated for morbidity following computed tomography-guided transperineal 125I implants from 1988 to 1991. The median total activity used was 47 mCi (range 35-73 mCi). Toxicity was evaluated using a modification of the Radiation Therapy Oncology Group grading system.

RESULTS

Nocturia was the most common treatment-related symptom, reported by 80% of patients within 2 months after implantation, and persisted at 12 months in 45% of the patients. Mild dysuria developed in 48% of patients within 2 months of implantation; two patients needed analgesics for their dysuria. Terazosin hydrochloride (2-10 mg qd) provided subjective improvement of urinary symptoms in seven of eight patients in whom it was tried. Rectal urgency, soft stools, and increased frequency of bowel movements was reported by 25% of the patients within 1-2 months after implantation. The incidence of asymptomatic rectal bleeding or ulceration occurring at any time after implantation was 47%, but resolved in all patients with expectant treatment. Self-limited ulceration of the rectal mucosal occurred in 16%, but only one patient developed a prostato-rectal fistula, managed with an ileal conduit. Five of the 18 potent patients experienced discomfort on erection or ejaculation, beginning within several weeks of their implant. The discomfort resolved within 6 months in three of the patients, but persisted for 18 and 24 months in the other two.

CONCLUSION

125I implantation, as performed in this series, is generally associated with only mild-moderate genitourinary and rectal symptoms that may persist 6 months or more after implantation. Prostatic carcinoma, Brachytherapy, Morbidity.

Cisplatin, fluorouracil, and leucovorin. Increased toxicity without improved response in squamous cell head and neck cancer

OBJECTIVE

To evaluate the activity and toxicity of the drug combination cisplatin, fluorouracil by continuous infusion, and high-dose oral leucovorin calcium (PFL) as induction chemotherapy in patients with advanced and untreated squamous cell head and neck (SCHN) cancer.

DESIGN

Nonrandomized, prospective trial.

SETTING

Referral center (comprehensive cancer center).

PATIENTS

Twenty-two patients with stage III (n = 7) and IV (n = 15) M0 SCHN cancer of the larynx (n = 13), hypopharynx (n = 7), and oropharynx (n = 2) whose standard treatment would have required total laryngectomy.

INTERVENTIONS

Three cycles of PFL were administered prior to local-regional therapy (concomitant cisplatin and radiation and/or neck dissection, with total laryngectomy reserved for nonresponse or relapse). Chemotherapy included cisplatin (100 mg/m2) on day 1 by short intravenous infusion; fluorouracil (800 mg/m2) on days 1 through 5 by continuous infusion; and leucovorin (100 mg) every 4 hours by mouth for 30 doses. The PFL combination was administered every 21 days.

MAIN OUTCOME MEASURES

Clinical response to chemotherapy and observed toxic effects during chemotherapy.

RESULTS

Five patients were inevaluable for response, with three early deaths (infection in two and sudden death in one), one cerebrovascular accident, and one patient declining further chemotherapy. Of the remaining 17 patients, 10 had a major response to chemotherapy, but in only five patients (29%) was this complete (95% confidence interval, 8% to 51%). Other significant toxic effects included grade 3 to 4 mucositis in eight patients and grade 3 to 4 neutropenia in 10.

CONCLUSIONS

While PFL is active in patients with SCHN cancer, we were unable to reproduce the high complete response rates reported by other centers. Its use can be associated with significant toxic effects. We do not recommend the use of PFL for the treatment of patients with SCHN cancer outside the context of a clinical trial until there is further critical assessment of its activity and toxicity.

Consumption and harm: drinking patterns of the Irish, the English and the Irish in England

There has been controversy over the relationship between alcohol consumption and related problems amongst the Irish in England. Irish migrants have high Standardised Mortality Ratios for chronic liver disease and cirrhosis and high hospital admission rates for alcohol-related diagnoses in England. Yet it has been considered that people from the Republic of Ireland, whether living in Ireland (Conniffe et al., 1990) or in England (Pearson et al., 1991), actually drink less than the English. This paper reviews the evidence. In recent years Irish per capita volume alcohol consumption has been comparable to that of the U.K., although the distribution of consumption differs. Women in Ireland are less likely to drink than women in England and Wales, while men in Ireland are more likely to drink at high-risk levels than men in England and Wales: their average weekly consumption levels are closer to those of high-consuming men in Yorkshire and Humberside, who also drink more than the U.K. national average. Men in Ireland also appear to be more likely to experience drinking problems than their counterparts in England and Wales, although this may be related to factors other than the total amount of alcohol consumed. Although a previous study of General Household Survey data indicated low-risk alcohol consumption levels for people from the Irish Republic living in Britain, a reanalysis of these data adjusting for age and gender shows drinking rates that are very high.(ABSTRACT TRUNCATED AT 250 WORDS)

Dealing with child abuse: development and evaluation of a short workshop for nurses

A 1-day workshop was evaluated in terms of its effectiveness in enhancing nurse (N = 70) understanding of child abuse. Measures of their knowledge and attitudes concerning abuse were administered before and after the workshop. The results indicated that the workshop led to a significant improvement in these two areas, in particular, a sub-sample (N = 25) who received an additional teaching aid (a programmed learning script) did better than their colleagues. Finally, a teaching evaluation form indicated a high degree of consumer satisfaction. It is concluded that the brief workshop was successful in enhancing knowledge and attitudes, and that it illustrates the kind of 'professional approach' recently advocated in the literature.

The effect of setup uncertainties on the treatment of nasopharynx cancer

PURPOSE

As radiation treatment techniques become more complicated, the need to understand the effect of uncertainties on dose distributions increases. This study investigates the effect of positional uncertainities for patients with nasopharynx carcinoma treated with a multiple field conformal boost technique. Three dimensional setup errors were measured for six patients and the effect on patient dose was evaluated using dose volume histograms.

METHODS AND MATERIALS

A method is presented for determining 3-dimensional translational and rotational setup errors by identifying anatomical landmarks on two treatment field images and their corresponding simulation images. Measurements were made on a daily basis for six patients undergoing conformal treatment.

RESULTS

The average magnitude of the translational errors was between 1.5 and 3 mm while the average distance between simulation and treatment isocenters was 5 mm. Both systematic and random setup errors were observed. Dose volume histograms incorporating these uncertainties for standard parallel opposed and conformal techniques were generated for patients experiencing random and systematic setup errors.

CONCLUSION

The data imply that positional uncertainties effect the daily dose distributions for target and critical structures differently and that the effect may be treatment technique dependent. These results demonstrate the need to measure setup uncertainties for all sites and to develop techniques for incorporating dose uncertainties in treatment plans.

Factors influencing the frequency of ventilator circuit changes

Nosocomial infections and their subsequent treatment are costly in terms of pain and suffering and the financial burden on the health service. Critically ill patients are subjected to invasive therapy and monitoring and increased handling and therefore the likelihood of contamination and cross-infection is increased. Ventilator circuitry has been implicated in the development of respiratory infections. Intensive care personnel must be vigilant with infection control procedures, most importantly hand washing and disinfection. In intensive care units the changing of ventilator circuits every 24 hours is based upon tradition rather than analysis of research and reflective practice. Research indicates that a bacterial filter has a significant influence in reducing the contamination of ventilator circuitry. Research shows that there is no significant increase in bacterial colonization of respiratory gas or tubing after 48 hours as opposed to 24 hours. It is possible to be cost-effective without sacrificing quality of care.

Evaluation of a portable prothrombin time monitor for home use by patients who require long-term oral anticoagulant therapy

BACKGROUND

The anticoagulant activity of warfarin sodium is monitored by the prothrombin time (PT). The introduction of a portable PT monitor has raised the possibility that patients could reduce the inconvenience of anticoagulant therapy by measuring their PT at home. We performed this study to determine the feasibility and accuracy of home use of the portable PT monitor.

METHODS

A prospective cohort study was performed in consecutive eligible patients who required long-term anticoagulant therapy. Patients performed multiple measurements of their PT at home by means of the portable monitor and at their usual laboratory within a 4-hour interval. The accuracy of the portable monitor was evaluated by two criteria for agreement. Standard agreement was achieved if the portable monitor and laboratory results were both either within or outside the patient's targeted therapeutic range or if the two results were within 0.4 international normalized ratio units of each other. Expanded agreement was achieved if both the portable monitor and laboratory results were within +/- 0.4 international normalized ratio units of the targeted therapeutic range.

RESULTS

Forty patients (19 men and 21 women, aged 25 to 74 years) were followed up for 6 to 24 months by means of the portable PT monitor. The mean level of agreement achieved per patient was 83% (95% confidence interval, 79% to 87%) by the standard criteria and 96% (95% confidence interval, 94% to 98%) by the expanded criteria. Twenty-seven patients (68%) and 39 patients (98%) achieved more than 80% agreement by the standard and the expanded criteria, respectively. Questionnaire results revealed that 97% of the patients preferred using the portable monitor to measure their PT.

CONCLUSIONS

Patients receiving long-term anticoagulant therapy achieved a high rate of clinically important agreement between self-measurements of the PT with the use of a portable monitor and laboratory PT results. Patients strongly preferred using the portable monitor to measure their PT levels. The use of the portable monitor as the primary method for measuring the PT can be recommended in selected patients receiving long-term anticoagulant treatment.

Issues related to the protection of human research participants

Making ethical decisions related to the protection of human research participants is often complex and fraught with uncertainty and conflict. Awareness of the basic principles outlined in the Belmont Report as well as in federal regulations and guidelines can provide a useful framework for such decisions, although the ultimate responsibility for ensuring ethical research practices rests with the individual investigator. Ongoing dialogue and discussion about these ethical issues will provide a basis for strengthening nursing research and practice while ensuring the maximum protection for research participants who make possible the advancement of nursing science.

A phase II trial of deoxyspergualin in recurrent squamous cell head and neck cancer

Fifteen patients with recurrent squamous cell head and neck cancer were treated with deoxyspergualin. There were no objective responses in 14 evaluable patients. The most common toxicity was reversible hypotension, which prompted dose reduction in nine patients. Deoxyspergualin is not recommended for the treatment of squamous cell head and neck cancer.

Investigation of the changes in neuronal distribution and phosphorylation state of MAP1X during development

Neurite outgrowth is dependent on the presence in neurites of assembled microtubules which consist of polymerized tubulin to which microtubule-associated proteins (MAPs) are bound. This study adds to previous evidence of the similarity between the high molecular weight MAPs, MAP1X, MAP1B and MAP5, and explains the different staining patterns observed by different laboratories on frozen sections, using monoclonal antibodies against each MAP. Previous studies have shown that monoclonal antibody (mAb) G10 binds to MAP1X and labels growing but not mature axons in the rat nervous system and, therefore, expression of this MAP or molecular changes in it may be important for axon growth. It has been shown that a phosphorylated form of MAP5 can be detected by SDS-PAGE in brain areas with growing axons. This study shows that there is phosphate dependency of mAbG10 binding to MAP1X which is, however, lost during brain homogenization.

Demand for hospital services following admission with suspected myocardial infarction in 1983 and 1989

Formulation of business plans by National Health hospitals requires information on likely demands for the services they provide. Two cohorts of patients admitted to the Nottingham hospitals in 1983 and 1989 with suspected myocardial infarction were sampled to determine the workload implications due to initial in-hospital tests, subsequent readmission and outpatient investigations. The results show that attendance in the first year after discharge related principally to cardiac problems, while in subsequent years non-cardiac problems predominated. An estimation of the total workload, based upon 1,000 patients admitted in 1989, suggests that demands for hospital services in the following year include over 4,000 electrocardiographs, 1,400 chest X-rays and 18,000 laboratory tests, and only 118 exercise tests and 37 cardiac catheterisations. Admission with suspected myocardial infarction makes great demand on hospital services in the year after discharge. Any change in practice, which increases the potential demand for cardiac investigations, could have important financial implications for Nottingham hospitals.

Human apurinic endonuclease gene (APE): structure and genomic mapping (chromosome 14q11.2-12)

Abasic (AP) sites in DNA are produced spontaneously and by many genotoxic agents. The repair of such damages is initiated by AP endonucleases, which are evidently ubiquitous. We employed the recently cloned cDNA, APE, that encodes the major human AP endonuclease, to isolate large genomic fragments that contain the intact APE gene. The sequence of 3 kb encompassing APE was determined (GenBank Accession No. M99703). The APE gene contains four small introns (ranging 130 to 566 bp) and five exons, the first of which is untranslated. The 0.5 kb of DNA sequence upstream of APE did revealed only a possible CCAAT box, but no other regulatory sites or a TATA box, consistent with the constitutive expression of AP endonuclease activity observed in other studies. The location of APE in the human genome was mapped to chromosome 14, bands q11.2-12, by fluorescence in situ hybridization of metaphase cells with DNA from the genomic clones and subclones. Although this locus has not been associated causally with genetic diseases of DNA repair, some translocations that affect 14q11.2-12 could compromise APE and lead to genetic instability.

Transfection of the Escherichia coli nth gene into radiosensitive Chinese hamster cells: effects on sensitivity to radiation, hydrogen peroxide, and bleomycin sulfate

The Escherichia coli nth gene encodes endonuclease III, which catalyses the glycolytic removal of various oxidized thymine residues from DNA. A truncated version of nth, with the prokaryotic regulatory sequences removed, was ligated into the retrovirus-based vector pZipneoSV(X)1 and transfected into the radiosensitive Chinese hamster ovary cell line, xrs7. Following selection with G418, two clones (x7nth1 and x7nth6) were shown by Southern analysis to contain the nth gene. No substantial difference in gamma-ray sensitivity was detected between xrs7, clones x7nth1 and x7nth6, and the parent vector transfected clone (x7neo1). However, clones containing the nth gene were more resistant to hydrogen peroxide cytotoxicity [D0's for x7nth1 and x7nth6 were 0.072 microgram/ml (4 microM) and 0.046 microgram/ml, respectively, compared with D0's of 0.034 and 0.027 microgram/ml for xrs7 and x7neo1, respectively] but markedly more sensitive to bleomycin sulfate cytotoxicity than xrs7 and x7neo1 (e.g., 1D0's for x7nth6 and xrs7 were 0.05 and 0.12 microgram/ml, while 2D0's for x7nth1 and xrs7 were 0.35 and 0.48 microgram/ml, respectively). Alterations in sensitivity to hydrogen peroxide and bleomycin sulfate could not be explained by differences in the distribution of the cell-cycle phases and growth rate of nth-containing clones and control cell lines. These results are consistent with the hypothesis that modified thymine lesions are potentially cytotoxic. Hence, when cells incur a high level of endonuclease III-repairable damage relative to strand breakage, such as after treatment with hydrogen peroxide, increased repair capacity increases survival. Gamma radiation produces a lower level of endonuclease III-repairable damage relative to all the other types of lesions produced; hence increased repair capacity has no measurable effect on cell survival. The increased sensitivity of x7nth1 and x7nth6 to bleomycin sulfate toxicity may indicate that, when thymine damage and single-strand breaks are in close proximity on opposite strands of the DNA, endonuclease III, which incises DNA at the site of damaged residues, can increase the number of double-strand breaks and hence decrease the level of cell survival.

All-porcelain labial margin for ceramometal crowns

The elimination of the labiogingival metal collar of a porcelain-fused-to-metal (PFM) restoration is an attempt to achieve an improved esthetic result. In their expectation of a more cosmetic tooth restoration, patients may influence dentists to use the all-porcelain labial margin to avoid metal showing in the final restoration. Success of this type of restoration depends upon proper tooth preparation. The all-porcelain margin requires a 1.2-mm wide labiogingival shoulder of approximately 70 or 90 degrees wrapping into the interproximal area. Much of the effectiveness of the restoration depends upon the design of the metal substructure. The following change is made in the design of this substructure for this modified PFM crown: the labiogingival portion of the metal is finished back to the gingival-pulpal line angle with the metal against the axial wall being from 0.3 mm to 0.5 mm thick. This allows for 0.2 to 0.3 mm of opaque and 0.7 to 1.0 mm of shoulder porcelain. The direct lift-off technique is a useful method of achieving clinically acceptable all-porcelain margins. Such restorations may give excellent results.

Herpes simplex virus type 2 infection, syphilis, and hepatitis B virus infection in Haitian women with human immunodeficiency virus type 1 and human T lymphotropic virus type I infections. The Johns Hopkins University (JHU)/Centre pour le Developpement et la Santé (CDS) HIV Study Group

Antibodies to herpes simplex virus type 2 (HSV-2), antibodies to hepatitis B virus (HBV) core antigen (anti-HBc), and VDRL antibodies (serologic evidence of syphilis) were evaluated in women known to be infected with human immunodeficiency virus type 1 (HIV-1) (n = 95) or human T lymphotropic virus type I (HTLV-I) (n = 45) and controls (n = 89). HIV-1-seropositive women were more likely than controls to have antibodies to HSV-2 (88% vs. 54%; P less than .001), anti-HBc (67% vs. 43%; P = .008), and VDRL antibodies (21% vs. 8%; P = .02). Similarly, HTLV-I-seropositive women were more likely than controls to have antibodies to HSV-2 (82% vs. 54%; P = .003) and anti-HBc (67% vs. 43%; P = .008). There was no evidence that HIV-1 or HTLV-I predisposed to chronic hepatitis B virus infection. The stronger associations between HIV-1 and HTLV-I with HSV-2 than the associations with syphilis or HBV are consistent with the hypothesis that recurrent disruptions of mucous membranes caused by HSV-2 infections predispose to sexual transmission of HIV-1 and HTLV-I.

Extrahepatic portal vein aneurysm: report of a case treated by thrombectomy and aneurysmorrhaphy

Extrahepatic portal vein aneurysm is a rare condition with only 15 cases before ours being reported in the English literature. The etiology is thought to be congenital, secondary to portal hypertension or associated with abnormal weakness of the vein wall. It often presents in conjunction with major gastrointestinal bleeding, but may occur with minimal or no symptoms. Diagnosis is made with color duplex ultrasound, computed tomographic scan, venous phase mesenteric angiography, magnetic resonance imaging, or splenoportography. Thrombosis, rupture, and pressure effects are the major complications of portal vein aneurysm. Shunting procedures are recommended in cases with portal hypertension secondary to liver disease. We report the first case treated by thrombectomy and aneurysmorrhaphy with a successful 10 year follow-up. This procedure should be considered to preserve portal vein flow when portal hypertension is absent or is secondary to the aneurysm itself.

Uroporphyrinogen decarboxylase in Saccharomyces cerevisiae. HEM12 gene sequence and evidence for two conserved glycines essential for enzymatic activity

The HEM12 gene from Saccharomyces cerevisiae encodes uroporphyrinogen decarboxylase which catalyzes the sequential decarboxylation of the four acetyl side chains of uroporphyrinogen to yield coproporphyrinogen, an intermediate in protoheme biosynthesis. The gene was isolated by functional complementation of a hem12 mutant. Sequencing revealed that the HEM12 gene encodes a protein of 362 amino acids with a calculated molecular mass of 41,348 Da. The amino acid sequence shares 50% identity with human and rat uroporphyrinogen decarboxylase and shows 40% identity with the N-terminus of an open reading frame described in Synechococcus sp. We determined the sequence of two hem12 mutations which lead to a totally inactive enzyme. They correspond to the amino acid changes Gly33----Asp and Gly300----Asp, located in two evolutionarily conserved regions. Each of these substitutions impairs binding of substrates without affecting the overall conformation of the protein. These results argue that a single active center exists in uroporphyrinogen decarboxylase.

Substance misuse and social work qualifying training in the British Isles: a survey of CQSW courses

In 1989, all Certificate of Qualification in Social Work (CQSW) courses in the British Isles were included in a survey of the training offered social work students on responding to psychoactive substance misuse. There was a 74% response rate. Eleven per cent of the courses that responded provided no formal substance misuse training. Those that offered training provided a median of 8 hours, with over 70% of students receiving less than 11 hours, indicating that many students were being given the briefest of overviews. Outside of four or five 'centres of excellence', social workers and probation officers training in 1988-89 received less than adequate preparation to work with people with alcohol- and drug-related problems, despite evidence that they account for a large and growing proportion of their caseloads.

A reappraisal of the role of prophylactic cranial irradiation in limited small cell lung cancer

The use of prophylactic cranial irradiation in limited stage small cell lung cancer remains controversial. Prospective trials have demonstrated that PCI can reduce central nervous system relapse rates, but the impact on survival remains questionable except for the possible evidence of a beneficial effect for long term survivors. With higher rates of thoracic control now obtainable with hyperfractionated radiation and concomitant chemotherapy, it becomes important to analyze the benefit of PCI in that setting. Before 1982, we included PCI in the management of all patients with limited stage small cell lung cancer; thereafter, we discontinued its use. This report compares the outcome of the two treatment approaches and addresses the role of PCI among patients who achieve durable local control. There were 36 limited stage small cell lung cancer patients treated with PCI from 1979-1982 and 26 patients treated without PCI from 1985-1989. Induction chemotherapy was followed in both groups by thoracic irradiation (45 Gy). The PCI patients received 30 Gy to the whole brain in 10 fractions. Both groups received maintenance chemotherapy. Of complete responders, brain failure was the first failure in 18% (4/22) of PCI (+) versus 45% (10/22) of PCI (-) (p = .04). Survival at 2 years was 42% for PCI (+) versus 13% for PCI (-) (p less than .05). When the analysis was limited to those patients permanently controlled in the thorax; there were 25% (4/16) brain failures PCI (+) versus 70% (7/10) PCI (-) (p = .03). For this same subset the 2-year survival was 56% PCI (+) versus 14% PCI (-) (p less than .05). There were no 5 year survivors without PCI compared to 38% (6/16) with PCI. These data suggest that PCI appears to be effective in enhancing survival of patients who achieve durable thoracic control. Prospective trials are necessary to evaluate the use of PCI combined with therapeutic regimens with a documented ability to achieve high rates of sustained control of thoracic disease.

Pseudomycins, a family of novel peptides from Pseudomonas syringae possessing broad-spectrum antifungal activity

A family of peptide antimycotics, termed pseudomycins, has been isolated from liquid cultures of Pseudomonas syringae, a plant-associated bacterium. These compounds were purified using Amberlite XAD-2 and reverse-phase liquid chromatography. Pseudomycin A, the predominant peptide in a family of four, showed selective phytotoxicity, and had impressive activity against the human pathogen Candida albicans. Amino acid, mass spectroscopic, and comparative electrophoretic and chromatographic analyses revealed that the pseudomycins are different from previously described antimycotics from P. syringae, including syringomycin, syringotoxin and syringostatins. Pseudomycins A-C contain hydroxyaspartic acid, aspartic acid, serine, arginine, lysine and diaminobutyric acid. The molecular masses of pseudomycins A-C, as determined by plasma desorption mass spectrometry, are 1224, 1208 and 1252 Da, respectively. Pseudomycin D, on the other hand, has a molecular mass of 2401 Da and is more complex than pseudomycins A-C.

Intraoperative brachytherapy alone for incomplete resected recurrent rectal cancer

In order to determine the impact of intraoperative brachytherapy alone in patients with recurrent rectal cancer who, due to prior pelvic radiation therapy, were ineligible to receive further external beam pelvic radiation, we retrospectively reviewed the records of 36 patients with recurrent rectal cancer who had gross residual disease remaining in the pelvis following biopsy alone or subtotal resection. The median follow-up was 24 months (6-81 months). The median survival was 27 months and the 4 year actuarial survival was 25%. There was a suggestion of lower survival in patients who underwent biopsy alone compared with those who underwent a subtotal resection (21% vs. 34%). The local failure (LF) rate was 22% as the only site of failure and 44% as a component of failure. There was a lower but non-significant LF rate in patients who underwent subtotal resection vs. biopsy alone (33% vs. 66%) and those with an 125I implant volume of less than 40 cm3 vs. greater than or equal to 40 cm3 (39% vs. 100%). Four patients (11%) developed treatment-related severe complications (without evidence of LF). Our data suggest that, although it is not clear that intraoperative brachytherapy impacts on the ultimate survival rate in this group of patients, it does offer reasonable local control with acceptable morbidity. Since local control, in and of itself is an important endpoint in the treatment of rectal cancer, we continue to recommend brachytherapy as part of an overall aggressive approach in patients who are unable to receive pelvic radiation therapy.

Larynx preservation with combined chemotherapy and radiation therapy in advanced but resectable head and neck cancer

Forty patients with advanced, resectable squamous cell carcinoma of the larynx, oropharynx, or hypopharynx whose surgery would have required total laryngectomy (TL), were treated with one to three cycles of cisplatin-based chemotherapy before local therapy with the goal of larynx preservation. Clinical complete responses (CRs) or partial responses (PRs) to chemotherapy were seen in 26 of 40 patients (65%). Three patients with primary-site disease unresponsive to chemotherapy underwent resection of the primary lesion and neck dissection followed by radiation therapy (RT). Thirty-seven patients were referred after chemotherapy for RT +/- neck dissection. Thirty-one of 40 patient (78%) were rendered disease-free (no evidence of disease [NED]). With a median follow-up of 49 months (range, 31 to 76), the overall actuarial survival rate for the group was 58% at 2 years and 33% at 5 years. The failure-free survival rate was 42% and 33% at 2 and 5 years, respectively. Seven patients refused recommended TL throughout their course. This may have adversely affected survival results. A greater proportion of patients who achieved a CR or PR to chemotherapy remained disease-free compared with those who achieved less than a PR (P less than .001). Sixteen patients relapsed, 10 with locoregional disease. Six patients underwent TL, either for initial induction failure or at relapse, for an actual larynx-preservation rate of 34 of 40 patients (85%). If the seven patients who refused TL are included, the anticipated preservation rate is 27 of 40 patients (68%). Larynx preservation with combined chemotherapy and radiation is feasible and effective in patients with advanced, resectable squamous cell carcinoma of the head and neck (SCHN). This treatment approach requires a motivated patient, careful patient monitoring, and close interdisciplinary cooperation among oncologists.

Addison's disease

Addison's disease is an uncommon endocrine condition manifested by a variety of nonspecific symptoms, such as malaise, anorexia and nausea. Symptoms usually do not occur until most of the adrenal gland has been destroyed. Autoimmune disease has surpassed tuberculosis as the primary cause of Addison's disease. Nevertheless, tuberculosis still accounts for a significant proportion of cases. The rapid adrenocorticotropic hormone (ACTH) stimulation test is useful for identifying adrenal insufficiency. Maintenance therapy consists of hydrocortisone and fludrocortisone.

An interactive computer graphics system for the design of molded and orthopedic shoe lasts

The Department of Computer Science at North Carolina State University, with support from the Department of Veterans Affairs and National Aeronautics and Space Administration (NASA) Langley Research Center, has developed an interactive graphics program for the development of shoe lasts from digitized images of feet or digitized images of commercial shoe lasts. The program runs on a Sun 3/260 computer with a TAAC-1 graphics accelerator. The program contains operations for region addition and deletion, techniques for narrowing the ankle area, methods for toe extension, operations to allow for shoe inserts, etc. Once the operations by the user are complete, the program will resample the resulting last in a 512 x 512 array. The user is then allowed to select an error tolerance which will guide a data reduction program to represent the last as Coons patches. These patches are then transmitted to a milling machine which will cut the last.

Anti-sperm antibodies in homosexual men: prevalence and correlation with sexual behaviour

The sera of 60 homosexual males were examined for the presence of antibodies to sperm using an indirect immunobead test (IBT). Six of 60 (10%) had antibodies of IgG isotype; in addition two of the six had antibodies of IgA isotype. The presence of antibodies was associated with the practice of unprotected receptive anal intercourse in the previous six months. Antibodies were not found in homosexual men who were celibate, or who practised only oral intercourse during the same period. There was no correlation between the presence of anti-sperm antibodies and antibodies to human immunodeficiency virus (HIV), or numbers of T lymphocytes. These preliminary results lend support to the hypothesis that antigen presentation in the lower gut may be a source of sensitisation against sperm. The possibility that anti-sperm antibodies may be a marker of receptive anal intercourse merits further investigation.

Norfloxacin versus trimethoprim-sulfamethoxazole in the treatment of urinary tract infections

In a controlled, randomized trial of 133 patients with proven urinary tract infections (UTIs), significantly more pathogens were found to be susceptible to norfloxacin than to trimethoprim-sulfamethoxazole (TMP-SMZ) (p less than 0.01). Among patients with pathogens susceptible to both drugs, more of those treated with norfloxacin were cured or improved (p = 0.06). When at least one patient variable, i.e., prior history of therapy, was corrected for, this difference became significant (p = 0.03). Norfloxacin eradicated 11 of 13 infections due to Pseudomonas aeruginosa and 6 of 7 due to enterococci. Five patients treated with norfloxacin and two treated with TMP-SMZ had relapses within 6 weeks. Significantly fewer adverse experiences occurred in patients receiving norfloxacin (p less than 0.01).

Norfloxacin use in urinary tract infection by urologists and infectious disease specialists

One hundred thirty-one patients of urologists and infectious disease specialists were entered into an open trial of norfloxacin in the therapy of urinary tract infections (UTIs). All patients were evaluable for tolerability and 98 were evaluable for efficacy. The patient population in this study was older (mean age 53 years) and had more underlying urogenital disorders (30%) or recent invasive urologic procedures (20%) than the typical patient population with UTIs. Over 50% of the patients had infections due to organisms other than Escherichia coli, including Pseudomonas aeruginosa (14), Klebsiella pneumoniae (5), Enterobacter spp (3) and Group D streptococcus (6). Clinical and bacteriologic cure rates were 90 and 91%, respectively. Side effects occurred in 5 patients and were generally mild.

Treatment of primary unresectable carcinoma of the pancreas with I-125 implantation

Between January 1 1974 and October 31 1987, 98 patients with biopsy proven unresectable adenocarcinoma of the pancreas were treated with I-125 implants during laparotomy. Presenting symptoms were pain (57 patients), jaundice (45 patients), and weight loss (34 patients). All patients underwent laparotomy and surgical staging. Thirty patients had T1NoMo disease, 47 patients had T2-3NoMo disease, and 21 patients had significant regional lymph node involvement (T1-3N1Mo). The surgical procedure performed was biopsy only (16 patients), gastric bypass (36 patients), biliary bypass (49 patients), and partial or total pancreatectomy with incomplete resection (5 patients). The total activity and the number of seeds used were determined from the Memorial Sloan Kettering Cancer Center (MSKCC) nomogram. Stereoshift localization X ray films were taken 3-6 days after operation. The mean activity, minimal peripheral dose (MPD), and volume of the implants were 35 mCi, 13,660 cGy, and 53 cm3, respectively. In addition, 27 patients received postoperative external irradiation and 27 patients received chemotherapy. Postoperative complications were observed in 19 patients. These included post-operative death (1 patient), biliary fistula (4), intraabdominal abscess (4), GI bleeding (3), gastric or small bowel obstruction (6), sepsis (5), and deep vein thrombophlebitis (4). Pain relief was obtained in 37/57 patients (65%) presenting with pain. A multivariate analysis showed that four factors significantly affected survival: T stage, N stage, administration of chemotherapy, and more than 30% reduction in the size of the implant on follow-up films. The median survival for the entire group was 7 months. A subgroup of patients with T1No stage disease who received chemotherapy survived 18.5 months. The indications for I-125 seed implantation in unresectable carcinoma of the pancreas are discussed.

Remote afterloading intraluminal brachytherapy in the treatment of rectal, rectosigmoid, and anal cancer: a feasibility study

From 1981 to 1986, 28 patients (27 evaluable) were treated with intraluminal brachytherapy (ILBT) using a remote afterloading technique for persistent or recurrent anal, rectal and rectosigmoid cancers. Eighty-nine percent underwent previous surgery for colorectal cancer. Seventy-seven percent of the patients received external beam irradiation (ERT) as a part of the present treatment. Intraluminal brachytherapy was given with a 2 cm diameter cylinder and the dose per fraction ranged from 440 cGy to 840 cGy at 0.5 cm from the surface of the cylinder. Follow-up ranged from 1 to 74 months with a median of 12 months. Patients were divided into two groups. Group I consisted of 15 patients receiving elective ILBT; Group II: 13 patients with recurrent disease. Seventy-one percent of the patients in Group I and 39% of the patients in Group II achieved local control. The majority of patients tolerated treatment well with only transient reactions. However, three patients (11%) developed grade 3 (G3) complications requiring surgical intervention. Eight patients developed moderate complications--grade 2 (G2)--requiring only conservative treatment. This study has identified several factors which appear to influence the risk of developing complications with this combined treatment, using remote afterloading apparatus, among which are technique of previous external beam irradiation, treatment length, anatomical location, intraluminal brachytherapy fractionation, and total cumulative dose (ERT + ILBT). This experience suggests that intraluminal brachytherapy appears to be an acceptable form of treatment, as a boost to external beam radiation therapy, in the management of rectal and colorectal cancers.

New intraoperative brachytherapy techniques for positive or close surgical margins

Tumors attached or adjacent to critical structures can often not be completely resected or resected with adequate surgical margins. Sites involving major blood vessels, the paravertebral spaces, or critical abdominal structures often present technical difficulties for standard brachytherapy procedures using I-125 or Ir-192 implants. These techniques allow for a high-dose delivery to the tumor bed with minimal normal tissue toxicity. A relatively simple and accurate method is described using I-125 seeds in Vicryl suture threaded through Gelfoam. These permanent implant procedures with radioactive I-125 seeds effectively treat small residual tumors or suspicious margins where standard brachytherapy techniques may be unsatisfactory and technically difficult to perform.

Carcinoma of major salivary glands. Recent trends

We have reviewed a 44-year experience with previously untreated carcinomas arising in major salivary glands to compare 319 patients treated before 1966 with 155 who received therapy between 1966 and 1982. Actuarial analysis indicates that five- and ten-year survival of our more recently treated patients was 80% and 65%, compared with 60% and 50% in patients treated before 1966. Explanation for this includes the higher proportion of patients with less aggressive histologic subtypes seen in recent years, as well as the fact that many of our patients treated before 1966 had surgical procedures considered inadequate by current standards. We also believe that adjunctive radiation oncology enhanced survival, but it could not be proved in this retrospective study. Multivariate analysis confirms that the clinical stage was the most important prognostic variable.

A study of repeatability of dietary data over a seven-year period

A repeatability study of dietary intake has been carried out using 94 control subjects from a previously reported case-control study of diet and colorectal cancer. Dietary histories readministered on average seven years after an initial interview were used to estimate intake of various macro- and microdietary components. Comparisons of current intake with intake of seven years previously yielded good reliability for macrocomponents among subjects reporting no dietary change during the time period. Reliability was poorer for microcomponents and for subjects reporting a dietary change. Comparisons were also made between diet measured seven years previously with subjects' recall of that diet. It is concluded that current diet is at least as reliable a measure of past diet as that assessed by a questionnaire addressed to the past period.

New catheter technique for recording left free-wall accessory atrioventricular pathway activation. Identification of pathway fiber orientation

The ability to record accessory atrioventricular (AV) pathway activation consistently may be uniquely beneficial in improving pathway localization, identifying anatomic relations, and providing insight into unusual conduction properties. For the purpose of recording left AV accessory pathway activation, an electrode catheter was specially designed for use in the coronary sinus. The orthogonal catheter has three sets of four electrodes spaced evenly around the circumference. Electrograms were recorded at low gain (less than 1 cm/mV) between adjacent electrodes on the same set (interelectrode distance, 1.5 mm, center to center). This provides a recording dipole perpendicular to the atrioventricular groove to enhance recording of accessory pathway activation while minimizing overlapping atrial or ventricular potentials. The orthogonal electrode catheter was used in the electrophysiological study of 48 consecutive patients with 59 left AV accessory pathways. The catheter could be advanced along the coronary sinus beyond the site of earliest retrograde atrial activation in 49 of the 59 accessory pathways. Activation potentials were recorded from 45 of the 49 (92%) accessory pathways accessible to the catheter (5 of 5 anterior, 8 of 8 anterolateral, 15 of 16 lateral, 5 of 5 posterolateral, 5 of 5 posterior, and 7 of 10 posteroseptal). Accessory pathway potentials were validated by dissociating them from both atrial and ventricular activation by programmed-stimulation techniques. During surgery, accessory pathway potentials were identified from orthogonal catheter electrodes in the coronary sinus in 14 of 16 accessory pathways (12 patients). Epicardial mapping confirmed the location of the accessory pathway, and direct pressure over the orthogonal catheter electrode that recorded the accessory pathway potential resulted in transient conduction block in nine of the 14 accessory pathways. Orthogonal electrode maps of the coronary sinus identified an oblique course in 39 of 45 recorded accessory pathways. Thirty-two of 38 left free-wall accessory pathways were oriented with atrial insertion 4-30 mm (median, 14 mm) proximal (posterior) to the ventricular insertion. In the remaining six free-wall accessory pathways, the lateral excursion could not be determined because either only the atrial end of the accessory pathway was recorded or activation of multiple pathway fibers prevented tracking of individual strands. The seven recorded posteroseptal pathways exhibited accessory pathway potentials throughout an 8-18-mm (median, 10 mm) length of the proximal coronary sinus, but fiber orientation was difficult to determine.(ABSTRACT TRUNCATED AT 400 WORDS)

Pseudothrombosis in pregnancy

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Very-high-dose cisplatin with bleomycin infusion as initial treatment of advanced head and neck cancer

Fifty-one patients with locally advanced squamous cancer of the head and neck (SCHN) were treated with up to three cycles of very-high-dose cisplatin, 187.5 mg/m2 (administered over five days) in hypertonic saline, and bleomycin infusion, 60 U/m2 (administered over five days), prior to definitive local therapy, in an attempt to improve complete remission (CR) and overall response rates. After chemotherapy, patients underwent surgery if the tumor was resectable for cure, (unless the operation involved total laryngectomy), and/or locoregional radiation therapy. Twelve patients (24%) achieved CR and 23 (45%) partial remission (PR) for an overall response rate of 69%. Thirty-nine of the 51 patients are evaluable following chemotherapy and locoregional treatment, and 28 (72%) have achieved disease-free status. Seven of these 28 (25%) have subsequently relapsed. Eleven of the 51 patients (22%) have died at median follow-up of 10+ months (3+ to 24+). Nausea and vomiting (94%) was the most severe acute toxicity. Myelosuppression was mild and nephrotoxicity was effectively prevented by the 3% saline diuresis. Bleomycin was withheld in 12 of 49 (24%) because of deterioration in pulmonary function tests. Ototoxicity in 12 of 49 (25%) and neurotoxicity in 19 of 49 (39%) were the most significant long-term toxicities. Very-high-dose cisplatin and bleomycin in this study was an effective chemotherapy regimen, but not more so than more conventional doses of cisplatin. Toxicity from both drugs was significant.