Evaluation of the atypical cytologic smear. Validity of the 1991 Bethesda System

The 1991 Bethesda System states that atypical squamous or glandular cells of undetermined significance should be further classified as reactive or premalignant/malignant. The validity of this qualification for identification of patients with cervical intraepithelial neoplasia (CIN) was tested. One hundred twenty-four cytologic smears with squamous atypia were reviewed retrospectively by two cytopathologists blind to the colposcopy results. The smears were classified as favoring either reactive or premalignant/malignant processes. Subjective criteria used in the classification were based on the pathologists' experience. All patients underwent colposcopy and selected biopsy under the direction of a gynecologic oncologist. Of the 124 atypical smears, 69 were classified as favoring reactive processes and 55 as favoring premalignant/malignant processes by cytopathologist 1. Cytopathologist 2 classified 68 as reactive and 56 as premalignant/malignant. Colposcopy and selected biopsy revealed the following lesions: 34 cases of human papillomavirus (27.4%), 17 of CIN 1 (13.7%), 4 of CIN 2 (3.2%), 2 of CIN 3 (1.6%) and 67 without pathology (54.0%). All six patients with squamous atypia and underlying CIN 2 and 3 lesions had their cytology classified as premalignant/malignant by the cytopathologists. In these patients this qualification had high sensitivity (100%) and negative predictive value (100%). The 1991 Bethesda System classification above, when applied to patients with squamous atypia, was effective in identifying patients with serious pathologic cervical lesions. If used as a triage method, colposcopy should be reserved for atypical lesions classified as premalignant/malignant, potentially decreasing the cost of health care without decreasing the quality of that care.

Cloning and sequencing of the genes from Salmonella typhimurium encoding a new bacterial ribonucleotide reductase

A plasmid library of Salmonella typhimurium was used to complement a temperature-sensitive nrdA mutant of Escherichia coli. Complementation was obtained with two different classes of plasmids, one carrying the E. coli nrdAB-like genes and the second containing an operon encoding a new bacterial ribonucleotide reductase. Plasmids harboring these new reductase genes also enable obligately anaerobic nrdB::Mud1 E. coli mutants to grow in the presence of oxygen. This operon consists of two open reading frames, which have been designated nrdE (2,145 bp) and nrdF (969 bp). The deduced amino acid sequences of the nrdE and nrdF products include the catalytically important residues conserved in ribonucleotide reductase enzymes of class I and show 25 and 28% overall identity with the R1 and R2 protein, respectively, of the aerobic ribonucleoside diphosphate reductase of E. coli. The 3' end of the sequenced 4.9-kb fragment corresponds to the upstream region of the previously published proU operon of both S. typhimurium and E. coli, indicating that the nrdEF genes are at 57 min on the chromosomal maps of these two bacterial species. Analysis of the nrdEF and proU sequences demonstrates that transcription of the nrdEF genes is in the clockwise direction on the S. typhimurium and E. coli maps.

FDA recommendations for preclinical testing of gonadotropin releasing hormone (GnRH) analogues

Gonadotropin-releasing hormone (GnRH) agonists and antagonists are synthetic analogues synthesized by modifications of the naturally occurring hypothalamic decapeptide GnRH. These modifications significantly increase the biological potency and duration of action of GnRH agonists as well as the solubility, potency, and duration of action of GnRH antagonists while decreasing GnRH antagonists toxicity. The field of GnRH analogues has expanded significantly during the past few years in terms of the number of analogues, therapeutic indications, formulations, and mode of administration. This paper provides recommendations for nonclinical testing of GnRH analogues and reflects the type and degree of toxicity testing expected by the Division. However, these recommendations are not formal guidelines in that alternative testing methods will be considered. Furthermore, these recommendations should not be used as guidance for testing of other new drugs.

Toxicology of depot medroxyprogesterone acetate

Depo-Provera (depot-medroxyprogesterone acetate or DMPA), administered either subcutaneously or intramuscularly, has undergone a thorough toxicological evaluation in a number of animal species. DMPA has been tested in short- and long-term toxicity studies in rodents, rabbits, and monkeys. It has been examined for its effects on reproduction in mice, rats, and rabbits, and for carcinogenic potential in rats, mice, beagle dogs, and rhesus monkeys. Genotoxicity tests have been performed in vitro and in vivo. This paper describes the toxicology data submitted to the US FDA in support of the New Drug Application (NDA) for Depo-Provera as well as data published in the literature. When interpreted in the light of the available pharmacokinetic information, these data demonstrate that DMPA is not significantly different from other contraceptive progestogens in its toxic and tumorigenic potential.

Analysis of preoperative prognostic factors in first-time surgery for lumbar disc herniation, including Finneson's and modified Spengler's score systems

In a retrospective study, 18 preoperative demographic and physical variables were evaluated for their preoperative prognostic value in 261 patients, following first-time lumbar disc surgery. Special reference was given to the Spengler and Finneson index-scores. "Low Back Pain Rating Scale" was used as the outcome assessment instrument. Comprehensive statistical analysis was undertaken in order to separate only the contingently independent variables. Gender was a highly significant prognostic factor. Other independently statistically significant prognostic factors include dermatomal hypoalgesia, smoking, and the Finneson index score. Results of the study are discussed with reference to the available literature.

Back pain, sciatica and disability following first-time conventional haemilaminectomy for lumbar disc herniation. Use of "Low Back Pain Rating Scale" as a postal questionnaire

To determine the value of "Low Back Pain Rating Scale" as a postal questionnaire, a retrospective study was undertaken of patients who had undergone first-time lumbar disc surgery 14-72 months previously. Rate of response was 86% (261/304). From the results, it was concluded that 87% of the patients felt that a satisfactory surgical outcome was obtained; 67% had minor or major functional restrictions of their daily activities; 65% experienced significant low-back symptoms in the period prior to follow-up examination; and 57% experienced sciatica. Thirty-seven patients were receiving pensions in the postoperative period due to continued back pain. "Low Back Pain Rating Scale" used as a postal questionnaire was found to be useful in determining general overall assessment status in patients who had undergone lumbar surgery. This evaluation method could be used as a quality control in future studies regarding this patient group.

Development and testing of SAR-visualizing phantoms for quality control in RF hyperthermia

A new prototype of an elliptical standard phantom with fat-equivalent walls and a lamp matrix for SAR (specific absorption rate) visualization has been developed. This paper outlines the manufacture of solid components based upon either polyester resin or epoxy resin, as well as the adjustment of their electrical conditions (epsilon r, sigma) by admixtures of carbon and/or aluminium powder. Visualizing sensors (LED = light-emitting diodes, miniature lamps) are evaluated with respect to their transformation of electric field strength into light. Standard SAR patterns of the hyperthermia system BSD-2000 have been semiquantitatively assessed by the visualizing technique (power stepping method) and quantitatively by E field sensor scans. Extracted iso-SAR distributions are in good agreement with E field sensor scans performed with a lamp sensor coupled to a fibre or using a dipole probe with high resistive leads. The requirement for periodic quality control of SAR patterns of RF (radio frequency) hyperthermia systems is demonstrated. Comparisons between techniques are given, specifically with respect to the LED phantom of Schneider and van Dijk.

Regulatory considerations for oligonucleotide drugs: updated recommendations for pharmacology and toxicology studies

This article describes pharmacology and toxicity studies for oligonucleotide drugs that are recommended for inclusion in the initial Investigational New Drug Application (IND), a first request to use an investigational drug in clinical trials. Recent observations of non-sequence-dependent cardiovascular toxicity and deaths in monkeys following intravenous infusions of phosphorothioates have raised a potential safety concern for oligonucleotide drugs. This concern should be considered by drug sponsors in designing pre-IND nonclinical development programs and Phase I clinical protocols. Pre-IND conduct of pharmacodynamic cardiovascular screening is highly recommended for defining safe clinical dosing regimens for phosphorothioate (and, possibly, other charged-backbone) oligomers. Additionally, drug sponsors are encouraged to (1) conduct research into-the mechanisms responsible for this dose-limiting toxicity, (2) institute liberal publication policies for research conducted under industrial sponsorship, and (3) communicate with reviewing divisions at FDA for updated guidance in this field when planning pre-IND safety studies. Recommendations for nonclinical studies during development of oligonucleotides will be modified as new information regarding the biological properties of oligonucleotides becomes available.

Detection of parvovirus B19 in donated blood: a model system for screening by polymerase chain reaction

A highly sensitive and rapid method for routinely screening large numbers of donated blood units for parvovirus B19 by the polymerase chain reaction (PCR) was developed. Over a 3-month trial period in Edinburgh, B19 DNA was detected in 6 of 20,000 consecutive units of blood (0.03%), in concentrations ranging from 2.4 x 10(4) to 5 x 10(10) copies of viral DNA per ml. Seroconversion for B19-specific immunoglobulin M and immunoglobulin G and disappearance of circulating B19 DNA occurred in the interval between donation and recall in four of the five implicated donors who could be recalled. B19 DNA was detected in 18 of 27 separate batches of non-heat-treated factor VIII and IX concentrate manufactured from donated plasma unscreened for B19 DNA. Dry-heat treatment at 80 degrees C for 72 h reduced but did not always eliminate detectable B19 from factor VIII concentrates, consistent with recent observations that current methods for virus inactivation during blood product manufacture are insufficient to entirely eliminate B19 infectivity. The methods developed in this study for PCR screening could be applied routinely to prevent transfusion of B19 in blood and blood products and could play an important role in the prevention of iatrogenic transmission of infection. PCR screening could also be used for detection and exclusion of a range of other transmission-associated viruses for which current serological detection methods are only partially effective.

Inductive heating of ferrimagnetic particles and magnetic fluids: physical evaluation of their potential for hyperthermia

The potential of colloidal subdomain ferrite particle suspensions (SDP) ('magnetic fluids'), exposed to an alternating magnetic field, is evaluated for hyperthermia. Power absorption measurements of different magnetic fluids are presented in comparison to multidomain ferrite particles (MDP). Variations with frequency as well as magnetic field strength have been investigated. The experimental results clearly indicate a definite superiority of even non-optimized magnetic fluids over MDP ferrites regarding their specific absorption rate (SAR). Based on the work of Shliomis et al. (1990) and Hanson (1991), a solid-state physical model is applied to explain the specific properties of magnetic fluids with respect to a possible use in hyperthermia. The experimentally determined SAR data on magnetic fluids are used to estimate the heating capabilities of a magnetic induction heating technique assuming typical human dimensions and tissue parameters. It is considered that for a moderate concentration of 5 mg ferrite per gram tumour (i.e. 0.5% w/w) and clinically acceptable magnetic fields, intratumoral power absorption is comparable to RF heating with local applicators and superior to regional RF heating (by comparison with clinical SAR measurements from regional and local hyperthermia treatments). Owing to the high particle density per volume, inductive heating by magnetic fluids can improve temperature distributions in critical regions. Furthermore, localized application of magnetic fluids in a tumour might be easier and less traumatic than interstitial implantation techniques.

Regulatory considerations for evaluating the pharmacology and toxicology of antisense drugs

This article focuses on pharmacology and toxicology data that should be included in an Investigational New Drug Application (IND), a request to use an investigational drug in clinical trials. In general, pharmacology and toxicology testing programs for antisense compounds are held to the same regulatory standards applied to other new therapeutic classes. Biological properties of oligonucleotide therapeutics are mentioned where they may pertain to clinical safety issues. Nonclinical data submitted to the IND should characterize the pharmacology, disposition, and toxicology of a new drug; these data form the basis for clinical risk assessment. Concomitant evaluation of pharmacokinetics allows for better interpretation of in vivo studies and increased accuracy of dose extrapolation to humans. Recommendations for nonclinical drug development will be modified as new information regarding the biological properties of oligonucleotides becomes available.

FDA requirements for nonclinical testing of contraceptive steroids

Written guidelines for the preclinical testing of contraceptive steroids have not been revised since 1968 despite the fact that many important changes have been implemented by the FDA's Division of Metabolism and Endocrine Drug Products. This paper describes the new preclinical testing requirements and the rationale for their implementation.

Impaired cell-mediated immunity in experimental abdominal sepsis and the effect of interleukin 2

A murine model of experimental sepsis, ie, cecal ligation and puncture, was used to determine the potential effects of infection on in vitro cell-mediated immunity. Following cecal ligation and puncture, in vitro responses of mouse splenocytes to mitogens (phytohemagglutinin and concanavalin A), the effects of in vitro interleukin 2 on these responses, and the impact of in vivo interleukin 2 on survival were studied. Compared with controls (sham cecal ligation and puncture), phytohemagglutinin responses 1 day after cecal ligation and puncture were enhanced (43% +/- 17%, n = 9), phytohemagglutinin and concanavalin A responses at day 4 were suppressed (45.5% +/- 4.4% and 57.5% +/- 5.6%), and, by day 7, phytohemagglutinin and concanavalin A responses were approaching values in mice treated by sham cecal ligation and puncture. Suppressed phytohemagglutinin responses at day 4 after cecal ligation and puncture were restored to normal with in vitro interleukin 2 (61,052 +/- 3407 cpm for cecal ligation and puncture and 64,643 +/- 4727 cpm for sham cecal ligation and puncture). Mortalities following cecal ligation and puncture were identical at day 1 after cecal ligation and puncture (6/20) for both interleukin 2- and vehicle-treated groups; thereafter, interleukin 2-treated groups fared better. At day 1 after cecal ligation and puncture, the mean spleen cell phytohemagglutinin response was enhanced (43.8% +/- 17%, n = 9) compared with sham cecal ligation and puncture (= 10). By day 4, the responses to both concanavalin A and phytohemagglutinin were suppressed (45.5% +/- 4.4% and 57.5% +/- 5.6%, respectively). Responses at day 7 approached those of controls given sham cecal ligation and puncture. Sepsis causing a temporary impairment of cell-mediated immunity may be a factor in the frequent coexistence of altered cell-mediated immunity and sepsis, and interleukin 2 may have a role in limiting the adverse effects of sepsis.

Suppressor T-cell levels are unreliable indicators of the impaired immune response following thermal injury

The presence of increased levels of suppressor T cells after thermal injury and their relevance remain controversial. It is unclear whether suppressor T cells are the cause or result of sepsis complicating thermal injury. Spleen cells from a standardized murine burn model and sham burn controls were studied and the relationship between the levels of suppressor cytotoxic T cells (CD8, Lyt-2+), helper T cells (CD4, L3T4+), response to concanavalin A (ConA) and to phytohemagglutinin (PHA) and interleukin-2 (IL-2) production was examined. Mortality following infection via cecal ligation and puncture (CLP) of matched controls was also studied. At day 7 postburn, mean ConA (70 +/- 12% of control) and PHA response (58% +/- 5.2% of controls) and IL-2 production (43% +/- 5.4%) were significantly less than sham burn values (100%; p less than 0.05). However, the mean percentage of cells staining with anti-Lyt-2 and anti-L3T4 (9.1 +/- 0.59 and 13.9 +/- 0.65) was similar to the mean percentage in sham burn animals (9.4 +/- 0.65 and 16.6 +/- 1.1). Furthermore, no significant differences were observed between burned mice and controls in helper (17.3% +/- 1.8% burn vs. 21.2% +/- 1.7% sham) or suppressor cell levels (7.8% +/- 1.2% burn vs. 8.6% +/- 0.7% sham) or helper-suppressor ratios on day 10 postburn. Mortality of 20 litter-matched controls subjected to CLP on day 10 postburn was 90%, which was significantly greater than the sham burn mortality of 20%.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute hemodynamic effects of terazosin in hypertensive and normotensive patients

Terazosin, a selective alpha 1-adrenergic antagonist, was administered intravenously to 10 patients undergoing cardiac catheterization to determine its short-term hemodynamic effects. Hemodynamic measurements were performed before and 30 minutes after three doses of the drug: 1, 1, and 3 mg. One milligram of terazosin reduced the blood pressure (systolic/diastolic, mean) from a mean of 152.0/86.3, 110.7 mm Hg by -24.3/-9.4, -15.3 mm Hg (p less than 0.05). In the five patients who received 5 mg of the drug, blood pressure declined in a dose-dependent manner by -21.8/-3.8, -11.6 mm Hg after 1 mg, and by -35.8/-14.8, -22.8 mm Hg (p less than 0.05) after all 5 mg of the drug. The changes in blood pressure paralleled the terazosin-induced decrease in systemic resistance. Similar changes were recorded for pulmonary artery and capillary wedge pressures and pulmonary vascular resistance. The greatest hemodynamic response was noted with the first drug dose; succeeding doses had a progressively diminished incremental effect. Cardiac output, heart rate, and maximum left ventricular dp/dt demonstrated little change, whereas left ventricular end-diastolic pressure decreased after all three doses, reaching significance after 2 mg (-3.4 +/- 0.9 mm Hg, p less than 0.05), and left ventricular ejection fraction tended to increase (+5.6% +/- 2.4%, p less than 0.05 after 1 mg) and showed a dose dependence analogous to that of systemic resistance. Although not generally reaching statistical significance, indexes of aortic stiffness and compliance displayed a favorable effect. These data are consistent with terazosin's specific alpha 1-antagonism. Left ventricular performance is improved by afterload reduction, since terazosin demonstrated no direct effect on cardiac contractility.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chemoembolization in primary hepatocellular carcinoma]

The only generally recognised form of treatment for primary liver cell carcinomas is partial liver resection; occasionally this may be curative. This form of treatment is only applicable in 5% to 30% of patients. All drug-based forms of treatment have proved of little value. The new interventional radiological method of chemo-embolisation has shown results in improving survival rates which are comparable with resection. By using a new coaxial catheter system, embolisation can be performed as a selective intrahepatic procedure; it has few side effects and the quality of life subsequently does not deteriorate.

Peribulbar anesthesia. Effect of bicarbonate on mixtures of lidocaine, bupivacaine, and hyaluronidase with or without epinephrine

The pH-adjustment of local anesthetic solutions with sodium bicarbonate may shorten onset time and improve spread of neural blockade. The authors undertook a prospective, double-masked, randomized study to see if a pH-adjusted mixture of lidocaine, bupivacaine, and hyaluronidase had faster and more complete onset of neural blockade, when used for peribulbar anesthesia. Eighty patients were randomly assigned to four groups and received a peribulbar block with one of four mixtures: group 1 (L) = 2% lidocaine, group 2 (LPH) = 2% lidocaine with 0.06 meq/ml sodium bicarbonate, group 3 (LE) = 2% lidocaine with 1:100,000 epinephrine (commercially prepared), or group 4 (LEPH) = 2% lidocaine with 1:100,000 epinephrine with 0.06 meq/ml sodium bicarbonate. To 5 ml of each of the preceding groups, 5 ml of 0.75% bupivacaine and 150 units of hyaluronidase was added. After each block, extraocular muscle movement was followed in each quadrant until akinesia developed. In the event of incomplete akinesia, blocks were supplemented at 20 minutes. The LPH group had the fastest onset to complete akinesia (7.0 +/- 2.0 minutes, mean +/- SEM) when compared with the onset time of all other groups (group 1 = 11.5 +/- 1.9 minutes, group 4 = 13.1 +/- 1.4 minutes, and group 3 = 16.0 +/- 1.8 minutes, significance greater than 95% by analysis of variance). Furthermore, when compared with group 3 by analysis of variance, group 4 had a faster onset time. The authors conclude that pH-adjustment of solutions with bicarbonate of either lidocaine/bupivacaine/hyaluronidase or commercially prepared lidocaine with epinephrine/bupivacaine/hyaluronidase decreases the onset time of peribulbar anesthesia.

Recombinant interleukin-2 (rIL-2) improves immune response and host resistance to septic challenge in thermally injured mice

Impaired immune competence leading to decreased resistance to sepsis is a major cause of death in burn patients. We have previously shown that increased mortality from a septic challenge correlated with impaired splenocyte interleukin-2 (IL-2) production and response to T cell mitogens in mice subjected to a 25% surface area scald burn. We report now that the addition of recombinant (r) IL-2 (100 U/ml) in vitro to splenocytes from burned animals restored mitogen responses to normal. Burned mice intraperitoneally received 16,000 U of rIL-2 (selected on the basis of dose-response experiments) once daily in 0.5 ml 5% dextrose (5% D) on days 1 through 6 after thermal injury and were compared with burned mice treated with only 5% D. Both groups were subjected to cecal ligation and puncture 10 days after burn; 4 days later, there were no survivors in the 5% D group, whereas 45% of the rIL-2 group remained alive (p = 0.001; Gehan statistic). We found that rIL-2 treatment at the dose selected resulted in no apparent toxicity in burned mice. Finally, splenocytes from rIL-2-treated burned mice showed improved responses to T cell mitogens in vitro compared with 5% D-treated controls. We conclude that rIL-2 therapy may have a role in the restoration of immune competence after thermal injury.

Food and Drug Administration guidelines for reproductive toxicity testing

The Food and Drug Administration generally requires reproductive toxicity testing of all new drugs to be used by pregnant women or women or men of reproductive potential. These requirements may vary among the centers within the FDA. Reproductive and developmental toxicity is usually tested in one or two animal species and is divided into three segments to represent treatment throughout the reproductive process. The FDA monitors adverse drug effects on human reproduction through postmarketing surveillance.

Suppression of interleukin 2 production in an animal model of thermal injury is related to prostaglandin synthesis

We performed studies using an animal model of thermal injury to confirm the observed decrease in interleukin 2 (IL-2) production in burned patients and to explore the underlying mechanisms. Ten mice subjected to a 25% scald were compared with ten anesthetized littermates (controls) and six untreated mice (normal mice) 1, 3, 5, 7, 10, 14, and 21 days after burn. Production of IL-2 by splenocytes was stimulated by concanavalin A alone, or in the presence of the cyclooxygenase inhibitor indomethacin or flurbiprofen. The IL-2 content of the resulting supernatant was determined by the response of the IL-2-dependent cell line CTLL-2. The IL-2 production was significantly suppressed in the burned mice at three days (mean +/- SEM, 30.9% +/- 5.2%), five days (19% +/- 5.5%), seven days (41.6% +/- 6.4%), and 21 days (20% +/- 4.5%). Significant enhancement of IL-2 production by indomethacin was seen in the burned group (mean, 95%), but not in controls (mean, 23.8%) or normal mice (mean, 17.2%), and similar effects were seen with flurbiprofen. In separate experiments the effects of exogenous prostaglandin E2 on lymphocyte blastogenesis and IL-2 production were studied, and an increased susceptibility to the inhibitory effects of prostaglandin E2 was observed following thermal injury.

Mechanisms of immunosuppression associated with severe nonthermal traumatic injuries in man: production of interleukin 1 and 2

Depression of cell-mediated immunity in patients following severe traumatic injury has been well documented in vitro and in vivo. However, the exact mechanism of this defect is still controversial. In this study, we have investigated the ability of injured patients' peripheral blood mononuclear cells (PBMC) to produce two important immunoregulatory molecules, interleukin 1 (IL 1) and interleukin 2 (IL 2). Eighteen traumatic injury patients were studied during the course of their hospital stay and their results compared with a group of 18 normal age- and sex-matched controls. The results showed the following. (1) Production of IL 2 by normal PBMC in response to optimal doses of mitogen may vary with sex as well as age. (2) Adherent mononuclear cells from trauma patients produced at least as much IL 1 as normals. (3) IL 2 production, however, was markedly suppressed (normals, 1.6 +/- 0.2 U; traumatic injury, 0.6 +/- 0.1 U; P = 0.001) and persisted for as long as 50 days postinjury. OKT4+ cells were not significantly decreased at any time, nor were OKT8+ suppressor/cytotoxic cells increased at any time. Decreased IL 2 production in patients treated with steroids or those who were septic was not different from that in those patients who were not treated with steroids or were not septic. These results suggest that the cause of the defect in IL 2 production in traumatic injury patients is not related to a lack of the IL 1 signal, producer T cells, or Ia+ monocytes or to increased suppressor T cells.(ABSTRACT TRUNCATED AT 250 WORDS)

[Frequency of a positive result in the chlorpropamide-alcohol flush test in type I and type II diabetes]

146 newly manifested diabetics (91 type I, 55 type II) and 20 non-diabetics were examined with the help of the chlorpropamide alcohol flush test. Also under different criteria of valuation of the increase of skin temperature (1.5 and 1.8 degrees C, respectively) no significant differences between the positive findings of the test in type I and type II diabetics were the result. Decisive for a positive result is according to our investigations the pre-existing initial temperature of the skin area, the room temperature and the air humidity. In such a case the initial temperature of the skin area depends on the moment of the last food intake.

Cowden's disease: a further indication for prophylactic mastectomy

Cowden's disease (multiple hamartoma syndrome) is a syndrome involving abnormalities of multiple organ systems. Transmitted in an autosomal dominant pattern, it carries a high frequency of mammary carcinoma in early middle age in affected women. The hyperkeratotic cutaneous and gingival markers of the disease are its principal overt manifestations. Prophylactic bilateral total mastectomy with optional immediate reconstruction is recommended for women Cowden's disease. An illustrative family with the disease is presented in which one affected young woman was found to have invasive mammary carcinoma with regional metastasis at the time of prophylactic mastectomy.

Histocompatibility antigen frequencies in patients with chronic lymphocytic leukaemia: possible identification of a subgroup with relatively benign disease

A series of 57 patients with chronic lymphocytic leukaemia was typed for HLA-A, B and DR antigens and compared with a control population of equal size. There was an increased frequency of HLA-A1 and B8 in the patient group, although it was not statistically significant after allowance for the number of specificities tested. A subgroup of patients lacking both A1 and B8 differed from the others in sex ratio, degree of lymphocytosis and incidence of hypogammaglobulinaemia at presentation. This subgroup also had less need for treatment within 6 months of presentation. While these findings must be considered preliminary, it is possible that tissue typing may help to identify patients with a relatively benign form of the disease.

Care of mildly ill children enrolled in day-care centers: management by parents and by trained home workers

Because child day-care regulations exclude ill children, parents are frequently faced with problems in finding an alternative care arrangement. This pilot study compares home care of mildly ill children by parents (46 preschool children) with care by trained home workers (23 preschool children) during 20 weeks in 1977. Episodes of illness in children cared for by trained home workers showed a slightly shorter duration (median 3.0 days, range 2 to 11 days versus median 5.2 days, range 2 to 14 days) and a less severe course (fewer and milder signs of illness) when compared with episodes of illness in children cared for by parents. Other selected activities involved in the management of the mildly ill children were comparable. Although larger studies are needed, it appears that if parents desire an alternative care arrangement for their children during mild illness, care by a trained home worker may be convenient and safe.

A survey of Moraxella corneal ulcers in a derelict population

Infection with diplobacilli of the Moraxella group was the most common cause of bacterial corneal ulcer in a population of derelict alcoholics living in the Bowery district in New York City from 1965 through 1968. No distinction could be made between Moraxella subspecies on the basis of severity of ulcer or antibiotic sensitivities. Of 100 Bowery inhabitants examined, 35 harbored Moraxella in their noses. After 1968 and coinciding with an improvement in nutrition and sanitation, but with no apparent change in the incidence of alcoholism in this population, we noted a marked decline in the incidence of corneal ulcers caused by Moraxella species.

Basic tear flow. Does it exist?

Tear flow and volume were measured in 15 normal volunteers, divided into young and old age groups, using subjective fluorophotometric analysis and Schirmer testing with and without topical anesthesia. Proparacaine 0.5% was found to anesthetize cornea and conjunctiva better than cocaine 4% and produced fewer complications. Older subjects responded to stimulation with less reflex tearing than younger subjects, but had an identical rate of physiologic tear flow, and equivalent corneal and conjunctival sensitivity. Tear flow and volume decreased significantly below physiologic values in both age groups following topical anesthetic instillation. Lid margin and cilia stimulation increased the tear turnover rate more than 300% despite adequate topical anesthesia. Flow rates determined by Schirmer testing with topical anesthesia were higher than both physiologic tear flow and tear flow following topical anesthesia when these values were determined by fluorophotometry. As sensory input was decreased, tear secretion fell correspondingly, implying that all significant tear flow results frp, reflex secretion.

Right atrial myxoma: unusual clinical presentation and atypical glandular histology

A 57-year-old black female presented with a 1-month of right-sided congestive heart failure and clinical evidence of pulmonic and tricuspid valvular stenosis and insufficiency. The echocardiographic examination and ventriculography demonstrated a large right atrial tumor interfering with the function of both right-sided valves. The patient underwent successful surgical resection of the tumor. Histologically, the tumor had cellular areas typical of myxoma, as well as glandular areas, a feature which has been described very rarely in this lesion. Electron microscopy of the glandular zones, which has never been reported previously, shown cells having essential homology with the usual myxoma elements. The atypical histopathology of this lesion supports the theory that atrial myxomas are true neoplasms, and are not derived from unusually organized mural thrombi.

Metabolic effects of human growth hormone and of estrogens in boys with Duchenne muscular dystrophy

Metabolic balance studies were conducted in seven boys with Duchenne-type muscular dystrophy, and in six normal boys of similar age, during a 12 day control period and during a 12 day period of treatment with human growth hormone (HGH) at the following doses: 0.0168, 0.0532, and 0.168 U/kg body weight (BW)((3/4)) per day (doses A, B, and C, respectively). In five of the six normals, dose C caused positive balances in N, P, Na, and K; doses B and A had anabolic effects in two and one normal subjects, respectively. In six of the seven Duchenne cases, dose C caused negative balances of N and K, and sometimes of P. Negative balances were produced in three of the Duchenne subjects by dose B, and in one by dose A. None of the dystrophy cases exhibited an anabolic response to any dosage of HGH tested. The release of endogenous HGH in response to insulin, after 2 days' pretreatment with diethylstilbestrol, was similar in both groups of subjects. In the course of these tests, a marked anabolic effect of diethylstilbestrol in the Duchenne patients was apparent. Therefore metabolic balance studies were repeated, in both Duchenne and normal cases, during a 12 day control period and during 12 days of treatment with diethylstilbestrol (0.106 mg/kg BW((3/4)) per day). In three of the normal children, diethylstilbestrol had no effect on the elemental balances; in two cases, a retention of Na was observed. In all seven Duchenne cases, diethylstilbestrol caused positive balances in N, P, Na, and K. Ethinyl estradiol (0.0106 mg/kg BW((3/4)) per day) produced positive N, P, Na, and K balances in all three Duchenne cases tested with this agent. The data show that exogenous HGH causes a catabolic effect in boys with Duchenne dystrophy. These patients are hyperresponsive to the anabolic effect of diethylstilbestrol. The latter phenomenon may reflect the inhibitory effect of estrogen upon the peripheral actions of these boys' endogenous HGH.

Observations on the responsiveness of human subjects to human growth hormone. Effects of endogenous growth hormone deficiency and myotinic dystrophy

The effect of human growth hormone (HGH) on the N, P, Na, and K balance, and on the body weight (BW) of three groups of subjects was measured. In group I were nine cases (age 6-69) with HGH deficiency; in group II, eight cases (age 9-79) with normal endogenous HGH; in group III, four cases with myotonic dystrophy (age 45-51). After a 7 day control period, the hormone was administered for 7 days. Each subject was tested with three doses of HGH: dose A, 0.0168 U/kg BW(3/4) per day; dose B, 0.0532 U/kg BW(3/4) per day; dose C, 0.168 U/kg BW(3/4) per day. In group I, the responsiveness to HGH declined with age. Two subjects aged 6 yr responded to all three doses of HGH with positive balances in N, P, Na, and K and increases in BW. At ages 15-17, responses were obtained only to doses B and C in three cases, and only to dose C in two cases. Two subjects, aged 42 and 69, responded only to dose C. Not only did the threshold dose increase with age in group I, but the magnitude of the responses declined with age as well.Patients of group II were less responsive to all doses of HGH than were patients of group I at comparable age. None responded to dose A or dose B. All responded to dose C, but the increments in balances and in BW stimulated by this dose were only one-third to one-half as great as in HGH-deficient subjects of similar age. Three patients of group III responded to all three doses of HGH, and one responded to doses B and C. The responses were similar in magnitude to those in the 6-yr old HGH-deficient children, and greater than those in all other subjects studied. These data show that responsiveness to exogenous HGH rises with deficiency of endogenous HGH, and that individuals with myotonic dystrophy are hyperresponsive to exogenous HGH.