Effect of radiotherapy after breast-conserving treatment in women with breast cancer and germline BRCA1/2 mutations

PURPOSE

Recent laboratory data suggest a role for BRCA1/2 in the cellular response to DNA damage. There is a paucity of clinical data, however, examining the effect of radiotherapy (RT), which causes double-strand breaks, on breast tissue from BRCA1/2 mutation carriers. Thus the goals of this study were to compare rates of radiation-associated complications, in-breast tumor recurrence, and distant relapse in women with BRCA1/2 mutations treated with breast-conserving therapy (BCT) using RT with rates observed in sporadic disease.

PATIENTS AND METHODS

Seventy-one women with a BRCA1/2 mutation and stage I or II breast cancer treated with BCT were matched 1:3 with 213 women with sporadic breast cancer. Conditional logistic regression models were used to compare matched cohorts for rates of complications and recurrence.

RESULTS

Tumors from women in the genetic cohort were associated with high histologic (P =.0004) and nuclear (P =.009) grade and negative estrogen (P=.0001) and progesterone (P=.002) receptors compared with tumors from the sporadic cohort. Using Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer toxicity scoring, there were no significant differences in acute or chronic morbidity in skin, subcutaneous tissue, lung, or bone. The 5-year actuarial overall survival, relapse-free survival, and rates of tumor control in the treated breast for the patients in the genetic cohort were 86%, 78%, and 98%, respectively, compared with 91%, 80%, and 96%, respectively, for the sporadic cohort (P = not significant).

CONCLUSION

There was no evidence of increased radiation sensitivity or sequelae in breast tissue heterozygous for a BRCA1/2 germline mutation compared with controls, and rates of tumor control in the breast and survival were comparable between BRCA1/2 carriers and controls at 5 years. Although additional follow-up is needed, these data may help in discussing treatment options in the management of early-stage hereditary breast cancer and should provide reassurance regarding the safety of administering RT to carriers of a germline BRCA1/2 mutation.

Interaction of the human immunodeficiency virus type 1 nucleocapsid with actin

The nucleocapsid (NC) domain of the retrovirus Gag protein plays several important roles in the viral life cycle, including virus assembly, viral genomic RNA encapsidation, primer tRNA placement, and enhancement of viral reverse transcription. In this study, deletion of NC domain of human immunodeficiency virus type 1 (HIV-1) Gag was found to drastically reduce virus particle production in CD4(+) T cells. Cellular fractionation experiments showed that although most of the uncleaved wild-type HIV-1 Gag, unmyristylated Gag, and p6(Gag) domain-truncated Gag molecules copurified with the host cell cytoskeleton, most of the mutant Gag molecules lacking both the NC and p6(Gag) domains failed to cofractionate with cytoskeleton. In wild-type virus-infected cells, in which the viral protease was active, the cleaved NCp7 copurified with the cytoskeleton, whereas most of the MAp17 and CAp24 did not. Monoclonal antibody against actin coimmunoprecipitated full-length Gag and p6(Gag) domain-truncated Gag molecules from cell lysates but failed to precipitate the truncated mutant Gag molecules lacking NC plus p6(Gag). Purified recombinant NCp7, but not CAp24, was able to bind F-actin in cosedimentation experiments. Furthermore, wild-type NCp7 and a zinc finger mutant NCp7(F16A), like a cellular actin-binding protein (the villin headpiece), bound F-actin in a dose-dependent fashion in vitro. Taken together, these results suggest that HIV-1 NCp7 can bind F-actin directly and that interaction between HIV-1 Gag and the actin cytoskeleton through the NC domain may play an important role in HIV-1 assembly and/or other steps of the viral life cycle.

Ethical review of health research: a perspective from developing country researchers

BACKGROUND

Increasing collaboration between industrialised and developing countries in human research studies has led to concerns regarding the potential exploitation of resource deprived countries. This study, commissioned by the former National Bioethics Advisory Commission of the United States, surveyed developing country researchers about their concerns and opinions regarding ethical review processes and the performance of developing country and US international review boards (IRBs).

METHODS

Contact lists from four international organisations were used to identify and survey 670 health researchers in developing countries. A questionnaire with 169 questions explored issues of IRB review, informed consent, and recommendations.

RESULTS

The majority of the developing country researchers were middle aged males who were physicians and were employed by educational institutions, carrying out research on part time basis. Forty four percent of the respondents reported that their studies were not reviewed by a developing country IRB or Ministry of Health and one third of these studies were funded by the US. During the review process issues such as the need for local language consent forms and letters for approval, and confidentiality protection of participants were raised by US IRBs in significantly higher proportions than by host country IRBs.

CONCLUSION

This survey indicates the need for the ethical review of collaborative research in both US and host countries. It also reflects a desire for focused capacity development in supporting ethical review of research.

The role of nucleocapsid of HIV-1 in virus assembly

The role of the nucleocapsid protein of HIV-1 Gag in virus assembly was investigated using Gag truncation mutants, a nucleocapsid deletion mutant, and point mutations in the nucleocapsid region of Gag, in transfected COS cells, and in stable T-cell lines. Consistent with previous investigations, a truncation containing only the matrix and capsid regions of Gag was unable to assemble efficiently into particles; also, the pelletable material released was lighter than the density of wild-type HIV-1. A deletion mutant lacking p7 nucleocapsid but containing the C-terminal p6 protein was also inefficient in particle release and released lighter particles, while a truncation containing only the first zinc finger of p7 could assemble more efficiently into virions. These results clearly show that p7 is indispensable for virus assembly and release. Some point mutations in the N-terminal basic domain and in the basic linker region between the two zinc fingers, which had been previously shown to have reduced RNA binding in vitro [Schmalzbauer, E., Strack, B., Dannull, J., Guehmann, S., and Moelling, K. (1996). J. Virol. 70: 771-777], were shown to reduce virus assembly dramatically when expressed in full-length viral clones. A fusion protein consisting of matrix and capsid fused to a heterologous viral protein known to have nonspecific RNA binding activity [Ribas, J. C., Fujimura, T., and Wickner, R. B. (1994) J. Biol. Chem. 269: 28420-28428] released pelletable material slightly more efficiently than matrix and capsid alone, and these particles had density higher than matrix and capsid alone. These results demonstrate the essential role of HIV-1 nucleocapsid in the virus assembly process and show that the positively charged N terminus of p7 is critical for this role.

Goal-setting in rehabilitation: report of a workshop to explore professionals' perceptions of goal-setting

OBJECTIVE

To explore the views of therapists, nurses and doctors working in a variety of rehabilitation settings on the goal-setting process.

METHODS

Sixteen rehabilitation staff from three different settings attended a goal-setting workshop in which the difficulties associated with goal-setting were described with their potential solutions.

RESULTS

Five difficulties with goal-setting were identified. (1) Formal goal-setting was felt to be an activity unusual for many of the patients although intrinsic to the activity of many professional groups. (2) Goal-setting is often insensitive to people's roles in the community. (3) Goal-setting in the hospital environment does not transfer easily to the community. (4) External factors (e.g. staff turnover) over which staff felt they had little control were important in the success of a goal-setting programme. (5) Goals tend to be formulated and owned by the team, rather than the patient.

CONCLUSIONS

Goal-setting is a very satisfactory activity for the team but to be as successful for the patient their needs must be acknowledged. People with mild disability and a short inpatient stay have different needs to those with acute onset severe permanent disability and those with chronic or progressive disability admitted from the community. Comparison of both process and outcome effects of different types of goal-setting is an area for future study.

Detection of Cryptosporidium parvum oocysts in faeces: comparison of conventional coproscopical methods and the polymerase chain reaction

Conventional and coproscopical methods were compared with the polymerase chain reaction (PCR) for the detection of Cryptosporidium oocysts in bovine faeces. Oocysts were not detected in samples seeded with 10,000 oocysts following formol ether sedimentation and examination using auramine phenol (AP) or by immunofluorescent (IF) staining. When oocysts were concentrated using sucrose flotation the threshold of detection was 4000 oocysts per gram for both staining methods. Following salt flotation 4000 oocysts per gram could be reliably detected by AP staining but the detection limit was increased to 6000 oocysts per gram using IF staining. The recovery of oocysts was significantly less than expected for all techniques. A specific PCR coupled with immunomagnetic particle separation (IMS) of samples detected five oocysts per ml of diluted faeces, which corresponds to 80-90 oocysts per gram. Even allowing for the dilution of formed faecal samples, required for IMS, this represents an increase in sensitivity of several orders of magnitude over the conventional corpodiagnostic methods.

Value of whole brain re-irradiation for brain metastases--single centre experience

AIMS

There is controversy in published studies regarding the role of repeat whole brain radiation (WBRT) for previously irradiated brain metastases. The aim of our retrospective study was to document the practice at Princess Margaret Hospital with respect to the re-irradiation of patients with progressive or recurrent brain metastatic disease after initial WBRT.

MATERIALS AND METHODS

A comprehensive computerised database was used to identify patients treated for brain metastases with more than one course of WBRT between 1997 and 2003. Seventy-two patients were treated with WBRT for brain metastases and retreated with WBRT at a later date. The records of these patients were reviewed.

RESULTS

The median age was 56.5 years. The most common primary sites were lung (51 patients) and breast (17 patients). The most frequent dose used for the initial radiotherapy was 20 Gy/5 fractions (62 patients). The most common doses of re-irradiation were 25 Gy/10 fractions (22 patients), 20 Gy/10 fractions (12 patients), 15 Gy/5 fractions (11 patients) and 20 Gy/8 fractions (10 patients). Thirty-one per cent of patients experienced a partial clinical response after re-irradiation, as judged by follow-up clinical notes; 27% remained stable; 32% deteriorated after re-irradiation. Patients who had Eastern Cooperative Oncology Group performance status 0-1 at the time of retreatment lived longer. In responders, the mean duration of response was 5.1 months. The median survival after re-irradiation was 4.1 months. One patient was reported as having memory impairment and pituitary insufficiency after 5 months of progression-free survival.

CONCLUSION

Repeat radiotherapy may be a useful treatment in carefully selected patients. With increased survival and better systemic options for patients with metastatic disease, more patients may be candidates for consideration of repeat WBRT for recurrent brain metastases, but prospective studies are needed to more clearly document their outcomes.

Use of empiric antimicrobial therapy in neutropenic fever. Australian Consensus Guidelines 2011 Steering Committee

Administration of empiric antimicrobial therapy is standard practice in the management of neutropenic fever, but there remains considerable debate about the selection of an optimal regimen. In view of emerging evidence regarding efficacy and toxicity differences between empiric treatment regimens, and strong evidence of heterogeneity in clinical practice, the current guidelines were developed to provide Australian clinicians with comprehensive guidance for selecting an appropriate empiric strategy in the setting of neutropenic fever. Beta-lactam monotherapy is presented as the treatment of choice for all clinically stable patients while early treatment with combination antibiotic therapy is considered for patients at higher risk. Due consideration is given to the appropriate use of glycopeptides in this setting. Several clinical caveats, accounting for institution- and patient-specific risk factors, are provided to help guide the judicious use of the agents described. Detailed recommendations are also provided regarding time to first dose, timing of blood cultures, selection of a first-line antibiotic regimen, subsequent modification of antibiotic choice and cessation of therapy.

Mutations of the human immunodeficiency virus type 1 p6Gag domain result in reduced retention of Pol proteins during virus assembly

One of the crucial steps in the assembly of the human immunodeficiency virus type 1 (HIV-1) and other retroviruses is the incorporation and retention of all the key viral enzymes in released virions. The viral enzymes protease, reverse transcriptase, and integrase of HIV-1 are initially synthesized as Gag-Pol fusion polyproteins. It has been shown that the incorporation of Gag-Pol polyproteins during virus assembly requires the Gag domains that are shared by the Gag and Gag-Pol precursors. We now report that truncation of the C-terminal p6 domain of HIV-1 Gag, which is present in the Gag precursor but not in the Gag-Pol precursor, drastically reduced the amount of Pol proteins in the mutant virions. Mutations in the lentivirus conserved motif P(T/S)APP in p6 also drastically reduced the amount of Pol proteins in mutant virions. The steady-state levels of Gag-Pol precursors and cleaved Pol proteins in the transfected cells were not affected by mutations in p6. The incorporation of unprocessed Gag-Pol precursors into p6 mutant virions was detected when the viral protease was mutated, suggesting that the interactions among mutant Gag molecules and Gag-Pol precursors were not significantly affected. These results suggest that the p6 domain of HIV-1 Gag may play an important role in recruiting or retaining cleaved Pol proteins during virus assembly.

Human lymphokine-activated killer cells are cytotoxic against cells infected with Toxoplasma gondii

Experiments were conducted to determine whether human lymphokine-activated killer (LAK) cells are cytotoxic against cells infected with Toxoplasma gondii. Nylon wool nonadherent (NWNA) peripheral blood lymphocytes, as well as purified natural killer cell (NK) (CD3- CD16+ CD56+) and T (CD3+ CD16- CD56-) cells obtained from five healthy T. gondii seronegative volunteers exhibited minimal cytotoxic activity against T. gondii-infected cells. When standard LAK (S-LAK) cell preparations were induced by incubation of NWNA cells with recombinant interleukin 2, induction of remarkable cytotoxic activity against T. gondii-infected cells. When standard in LAK cell preparations from each of the volunteers. The phenotype of the LAK precursor and effector cells varied depending on the target cell used. Whereas the precursor and the effector cells of most of the LAK activity against K562 and Daudi cells were cells with NK phenotype, when T. gondii-infected cells were used as targets, both cells with NK and T cell phenotypes were precursors and effectors of the lysis. When cytotoxic activity of S-LAK cells was compared with the activity of adherent LAK (A-LAK) cells, A-LAK cells displayed higher cytotoxic activity against T. gondii-infected cells, as well as against K562 and Daudi cells. Cold target inhibition experiments suggested that there is a subset of LAK effector cells capable of lysing both T. gondii-infected cells and Daudi cells, whereas other subsets preferentially or exclusively lyse one of these target cells.

A national survey of UK final year students' opinion of undergraduate oral surgery teaching

BACKGROUND

A national survey was undertaken to establish a baseline of our final year students' perception of how their undergraduate oral surgery education has equipped them for key areas of general dental practice.

MATERIALS AND METHODS

Questionnaires were distributed to the 13 UK schools with final year students, towards the end of the academic year in 2009. The questionnaires were completed anonymously and were optically scanned.

RESULTS

In total, 632 questionnaires were returned, which represents 66% of the students of the graduating year. The majority (83%) of the respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practise. Most respondents (99%) felt confident to perform forceps exodontia, but confidence in the various aspects of surgical exodontia was lower. A majority (83%) had experience of an outreach scheme performing forceps exodontia (75%) and surgical exodontia (16%) in this environment. Twenty per cent indicated a desire to undertake a career in oral surgery, 6% in oral and maxillofacial surgery and 35% in another speciality.

CONCLUSION

This survey suggests that the majority of the students perceive that the oral surgery education has prepared them well for key areas of general practice. It also suggests that there is, however, a need to provide further improvement in the delivery of surgical skills and knowledge.

Influence of prepartum protein and energy concentrations for dairy goats during pregnancy and early lactation

Sixty-three multiparous Alpine does were blocked by pregnancy type (single vs. multiple) on d 90 of pregnancy and assigned to one of nine diets to evaluate the interaction of prepartum protein and energy intake on BW change, kidding, and subsequent production and composition of milk. Treatments were factorial with three percentages of CP (8.5, 11.5, and 14.5% of DM) and three concentrations of metabolizable energy (1.80, 2.16, and 2.53 Mcal/kg of DM). Does were fed for ad libitum intake during pregnancy and switched to a lactation diet (16% CP and 2.35 Mcal of metabolizable energy/kg of DM) after parturition. Milk production and composition were recorded for the first 15 wk of lactation. Prepartum BW gain increased quadratically as protein amount increased but was unaffected by energy. Kidding rate, litter weight, and gestation length were unaffected by protein or energy amounts. Milk production in the subsequent lactation increased quadratically in response to prepartum CP (2.59, 3.26, and 3.07 kg/d for 8.5, 11.5, and 14.5% CP, respectively). Milk production increased linearly in response to prepartum metabolizable energy concentration (2.63, 3.05, and 3.26 kg/d for 1.80, 2.16, and 2.53 Mcal/kg of DM, respectively). Milk fat percentage increased linearly in response to increased prepartum energy. Production of milk fat, protein, SNF, FCM, and SCM were affected quadratically by increased prepartum CP and linearly by prepartum energy, following the pattern for milk production. The present recommendations for prepartum CP and energy appear to be adequate for gestation and subsequent lactation performance of dairy goats.

Impact of gynecological screening in Lynch syndrome carriers with an MSH2 mutation

Lifetime risk of developing endometrial cancer in Lynch syndrome carriers is very high and females are also at an increased risk of developing ovarian cancer. The aim of the study was to determine the impact of gynecological screening in MSH2 mutation carriers. Gynecological cancer incidence and overall survival was compared in female mutation carriers who received gynecological screening (cases) and in matched controls. Controls were randomly selected from non-screened mutation carriers who were alive and disease-free at the age the case entered the screening program. Median age to diagnosis of gynecological cancer was 54 years in the screened group compared to 56 years in controls (p = 0.50). Stage I or II cancer was diagnosed in 92% of screened patients compared to 71% in the control group (p = 0.17). Two of three deaths in the screened group were the result of ovarian cancer. Mean survival in the screened group was 79 years compared to 69 years in the control group (p = 0.11), likely associated with concomitant colonoscopy screening. Gynecological screening did not result in earlier gynecologic cancer detection and despite screening two young women died from ovarian cancer suggesting that prophylactic hysterectomy with bilateral salpingo-oophorectomy be considered in female mutation carriers who have completed childbearing.

International validation of the European Organisation for Research and Treatment of Cancer QLQ-BRECON23 quality-of-life questionnaire for women undergoing breast reconstruction

Background

The aim was to carry out phase 4 international field-testing of the European Organisation for Research and Treatment of Cancer (EORTC) breast reconstruction (BRECON) module. The primary objective was finalization of its scale structure. Secondary objectives were evaluation of its reliability, validity, responsiveness, acceptability and interpretability in patients with breast cancer undergoing mastectomy and reconstruction.

Methods

The EORTC module development guidelines were followed. Patients were recruited from 28 centres in seven countries. A prospective cohort completed the QLQ-BRECON15 before mastectomy and the QLQ-BRECON24 at 4–8 months after reconstruction. The cross-sectional cohort completed the QLQ-BRECON24 at 1–5 years after reconstruction, and repeated this 2–8 weeks later (test–retest reliability). All participants completed debriefing questionnaires.

Results

A total of 438 patients were recruited, 234 in the prospective cohort and 204 in the cross-sectional cohort. A total of 414 reconstructions were immediate, with a comparable number of implants (176) and donor-site flaps (166). Control groups comprised patients who underwent two-stage implant procedures (72, 75 per cent) or delayed reconstruction (24, 25 per cent). Psychometric scale validity was supported by moderate to high item-own scale and item-total correlations (over 0·5). Questionnaire validity was confirmed by good scale-to-sample targeting, and computable scale scores exceeding 50 per cent, except nipple cosmesis (over 40 per cent). In known-group comparisons, QLQ-BRECON24 scales and items differentiated between patient groups defined by clinical criteria, such as type and timing of reconstruction, postmastectomy radiotherapy and surgical complications, with moderate effect sizes. Prospectively, sexuality and surgical side-effects scales showed significant responsiveness over time (P < 0·001). Scale reliability was supported by high Cronbach's α coefficients (over 0·7) and test–retest (intraclass correlation more than 0·8). One item (finding a well fitting bra) was excluded based on high floor/ceiling effects, poor test–retest and weak correlations in factor analysis (below 0·3), thus generating the QLQ-BRECON23 questionnaire.

Conclusion

The QLQ-BRECON23 is an internationally validated tool to be used alongside the EORTC QLQ-C30 (cancer) and QLQ-BR23 (breast cancer) questionnaires for evaluating quality of life and satisfaction after breast reconstruction.

The role of reduced ear size in the prenatal detection of chromosomal abnormalities

A prospective ultrasound study was performed between 18 and 38 weeks' gestation on 29 fetuses in a high-risk population, defined by the presence of structural anomalies, in order to investigate the usefulness of fetal ear measurements in the prenatal prediction of chromosomal abnormality. The prevalence of abnormal chromosomes was 34 per cent. The sensitivity (SE), specificity (SC), positive predictive values (PPV), and negative predictive values (NPV) of ear length for the detection of chromosomal abnormality were 80, 84.2, 72.7 and 88.9 per cent. The SE, SC, PPV, and NPV of ear width were 40, 94.7, 80 and 75 per cent. Fetal ear measurements may be a useful adjunct to the various ultrasound parameters in the prenatal detection of chromosome abnormality in a high-risk population of fetuses with structural anomaly(ies).

Bovine viral diarrhea virus abortion in goats housed with persistently infected cattle

Twenty-four border disease virus-seronegative, pregnant, mixed breed goats were experimentally comingled with 3 heifers persistently infected with bovine viral diarrhea virus type 2a (BVDV-2a). Twelve of the 24 exposed does aborted. Twenty-nine fetuses and 16 placentas from affected does were submitted to the Oklahoma Animal Disease Diagnostic Laboratory for a necropsy examination. Infection with BVDV was confirmed with a combination of immunohistochemistry, BVDV-2 polymerase chain reaction, and virus isolation in 19 of the 29 fetuses. On gross examination of the 19 fetuses and placentas in which BVDV-2a infection was confirmed, a mild placentitis (3/19), fetal mummification (1/19), and facial deformities (4/19) were noted. Histologically, placentitis (2/19), myocarditis (4/19), thymic depletion (5/19), choroid plexitis (3/19), encephalitis (2/19), and cerebral gliosis (1/19) were noted. Other causes of abortion in goats, including common bacterial and viral infections, were ruled out with histology, virus isolation, polymerase chain reaction, and aerobic bacteriologic cultures. As supported by the findings in this case, BVDV-2a should be included as a differential for abortion in goats. This is the first report of abortion in goats after exposure to persistently infected cattle.

Improving patients' postoperative sleep: a randomized control study comparing subcutaneous with intravenous patient-controlled analgesia

One hundred female patients undergoing major reconstructive plastic or gynaecological surgery were randomized to either receive subcutaneous patient-controlled analgesia (PCA) (bolus dose 2.5 mg diamorphine in 1 ml with a 20-minute lockout) or intravenous PCA (bolus dose 0.5 mg diamorphine in 1 ml with a 5-minute lockout). Data were collected by questionnaire and interview to evaluate the intervention on pain scores, quality of sleep on the first postoperative night, postoperative nausea and vomiting (PONV) and overall patient acceptability. The subcutaneous PCA group experienced less 'worse pain' (P < 0.01) and less sleep disturbance due to pain (P < 0.001). Subcutaneous PCA would appear to offer patients a safe and effective means of analgesia and may offer significant advantages over the intravenous route of administration.

Taxonomic and Phylogenetic Status of Living and Fossil Kangaroos and Wallabies of the Genus Macropus Shaw (Macropodidae: Marsupialia), with a New Subgeneric Name for the Larger Wallabies

Historical concepts of the generic status of the macropodines commonly known as kangaroos and wallabies are reviewed in this paper. A new diagnosis is provided for the genus Macropus, encompassing both living and fossil forms, and using cladistic principles to assess the phylogenetic value of diagnostic characters where possible. Cytological, biochemical and anatomical characters are used. Fourteen living and 11 extinct species of Macropus are recognized. Of these, 20 species have been classified into three subgenera, M.(Macropus), M.(Osphranter) and a new subgenus, M.(Notamacropus), as follows: M.(M.) giganteus, M.(M.) fuliginosus, M.(M.) mundjabus, M.(M.) pan, M.(M.) pearsoni and M.(M.) ferragus; M.(O.) antilopinus, M.(O.) bernardus, M.(O.) robustus, M.(O.) rufus and M.(O.) pavana; ,M.(N.) rufogriseus, M.(N.) eugenii, M.(N.) parryi, M.(N.) dorsalis, M.(N.) irma, M.(N.) agilis, M.(N.) greyi, M.(N.) parma, M.(N.) wombeyensis and M.(N) thor. Four poorly known extinct species, M. dryas, M. rama, M. woodsi and M. narada, have not yet been allocated to a subgenus. Prionotemnus palankarinnicus Stirton, 1957 is shown to belong outside Macropus. Because it is the type-species of Prionotemnus, that name is not available for a subgenus of Macropus. A current synonymy is presented for fossil species and the known stratigraphic range is given for each species. A phylogeny is presented expressing our view that M. (,Votamacropus) is the most plesiomorphic subgenus and M. (Macropus) is the most derived.

Re-irradiation of head and neck tumors. Benefits and toxicities

Most patients with head and neck cancer that recurs after irradiation should be treated with curative surgery. In patients whose tumors are nonresectable, or if surgery would cause unacceptable morbidity, a trial of curative re-irradiation may be considered. Taking into account the overall poor prognosis of these patients and the high rate of late tissue toxicity, especially soft tissue necrosis, fistula formation, and potential nerve damage, patients should be carefully selected. Several sites, notably the larynx and nasopharynx, can be re-irradiated with a relatively high rate of locoregional tumor control. In other sites, several criteria may be used to select patients for curative re-irradiation: limited tumor size, a relatively long period since previous irradiation (a suitable, though arbitrary, minimal time period may be 1 year), good performance status, and lack of evidence of skin or soft tissue damage (skin fibrosis, atrophy or telangiectasis) by the previous irradiation course. Even when these selection criteria are used, the prognosis is poor, and long-term survival rates are low even if locoregional tumor control is achieved. Innovative strategies and techniques, including aggressive combined chemoradiation, hyperfractionation, and limiting the extent of irradiated tissues by using conformal irradiation, may improve locoregional control rates. It should be emphasized, however, that the only chance for achieving locoregional control and cure is through the delivery of a full dose of radiation, similar to the dose required for primary tumors. The delivery of a low radiation dose, commonly practiced to avoid complications, is expected to achieve palliation only.

Midwifery, 1977

On January 1, 1974, an autonomous midwifery service was formed at Roosevelt Hospital in New York City to provide an obstetric service to "private" patients. While the autonomy was complete, physician consultation and participation provided by the "full-time or senior resident" staff were always available. We are now aware that this plan as opposed to any other, provided the ingredient of consumer-desired empathy of the midwife coupled with instant obstetric expertise that assured every patient the availability of modern obstetric practice. Four hundred and fifty-four patients cared for by midwives were compared to a random sample of 500 patients cared for by attending obstetricians. A striking similarity in the two groups was evident. Certain items, such as operative deliveries, were higher in the private patient group. The midwifery group had a low incidence of complications, but the incidence of acute complications made it apparent that an operating room suite must be immediately available. It is eminently clear that a low-risk group can be identified but there is no possible way to identify a "no risk" population.

Secondary T-acute lymphoblastic leukaemia mimicking blast crisis in chronic myeloid leukaemia

A 34-year-old man with chronic myeloid leukaemia (CML) firstly developed a lymphoid blast crisis of B-cell type. After a second chronic phase which lasted for > 4 years with maintenance chemotherapy of hydroxyurea, 6-mercaptopurine and methotrexate, he developed a T-cell acute lymphoblastic leukaemia of TcR-gammadelta+ type. Cytogenetic analysis revealed disappearance of the t(9;22) translocation and appearance of new abnormalities consistent with the diagnosis secondary acute leukaemia. To our knowledge, secondary leukaemia in CML has not previously been reported.