Differential aspects in ratio measurements of [Ca(2+)](i) relaxation in cardiomyocyte contraction following various drug treatments

This study is concerned with the analysis of the time dependency of [Ca(2+)](i), monitored by indo-1-AM, via the ratiometric time response curve R(t) as measured during contractions of spontaneous or electrical stimulated cardiomyocytes (in culture). A mathematical formulation which describes the relaxation phase of R(t) was developed. By fitting formulation to the measured data of R(t), the extraction of characteristic parameters is feasible, which may reflect the factors regulating intracellular Ca concentration. The usefulness of the suggested formulation was examined by monitoring changes induced in those parameters following the exposure of the myocytes to different drugs, among which are: caffeine, ryanodine, thapsigargin db, cyclic AMP, isoprenaline, doxorubicin, and Cl-IB-MECA.

Analysis of early apoptotic events in individual cells by fluorescence intensity and polarization measurements

Apoptosis is a dynamic process of variable duration. The ability to continuously detect the death process occurring in single or subgroups of cells is therefore very important in identifying apoptotic cells within a complex population. The Individual Cell Scanner (ICS), a multiparametric, multilaser-based scanning static cytometer, was used in the present report for the continuous monitoring of the apoptosis process. Fluorescence intensity (FI), polarization (FP), kinetic measurements, and cluster analysis of subpopulations were carried out utilizing various fluorescent probes. Hydrogen peroxide-induced apoptosis was monitored online in intact live lymphocytes by continuous sequential measurements of intracellular hyperpolarization. Plasma membrane asymmetry, mitochondrial membrane potential, and lysosomal rupture were monitored in individual cells. Cytoplasmic condensations, due to cell shrinkage and early lysosomal rupture, were found to be very early events of apoptosis. The new analytical capabilities suggested here may provide simple and convenient methods for detecting apoptosis from its earlier stages.

Very late relapse of Hodgkin's disease: a report of five patients

The majority of patients with Hodgkin's disease can be cured with current treatment modalities. Relapses beyond 3 years are rare; however, the outcome for patients in late relapse with standard-dose salvage therapy is excellent. In this article, we report five patients who had such relapses and describe their outcome.

Post-infantile giant cell hepatitis associated with autoimmune hepatitis and polyarteritis nodosa

We report the case of a patient with corticosteroid-responsive giant cell hepatitis associated with typical manifestations and changes of polyarteritis nodosa from the kidney and central nervous system. Initially, the patient presented with transient right hemiparesis, followed by spontaneous remission without any abnormalities on computed tomography scan, magnetic resonance imaging and cerebrospinal fluid examination. A few months later he was admitted to our clinic because of icterus, peripheral oedema and abdominal distension. He was found to have clinical signs of active cirrhosis. Serological tests for hepatitis B, C and HIV virus were negative. Serum ceruloplasmin. a1-AT and ferritin levels were within normal limits. Antinuclear antibodies were positive (1: 160). Liver biopsy showed micronodular cirrhosis with many eosinophils in the portal tracts and giant hepatocytes with multiple nucleoli in the lobule. Fulfilling the diagnostic criteria for autoimmune hepatitis, he was started on treatment with prednisolone and azathioprine, resulting in both clinical and biochemical responses. Four years later he presented with severe pain at the right costovertebral angle. Ultrasonography revealed a haematoma at the right kidney, and selective angiography of the abdominal aorta, renal arteries and hepatic artery documented microaneurysms in both kidney and liver arteries. Because of severe haemorrhage, right nephrectomy was performed. Histology of kidney specimen showed characteristic lesions of polyarteritis nodosa. Several months later, while on treatment with prednisolone and cyclophosphamide, the patient experienced a fatal episode of brain haemorrhage. An association between autoimmune hepatitis, polyarteritis nodosa and postinfantile giant cell hepatitis has not been reported previously.

Analysis of laser scattering pattern as an early measure of apoptosis

Light scattering pattern analysis (LSPA) was applied in the current study for accurate and sensitive detection of subtle changes in cell size, which occur in mouse thymocytes undergoing apoptosis. The decrease in cell diameter as measured by LSPA was found to be an early signal of apoptosis preceding the externalization of phosphatidylserine on the outer membrane. When apoptosis was induced by dexamethasone, the change in cell size was dose and time dependent, and could be blocked by pretreatment of the thymocytes with N-acetylcysteine (NAC). This implies that the scattering pattern, when combined with fluorescent markers such as annexine-V, may be a powerful tool for early detection of apoptosis. Another advantage gained by the use of this method is the ability to repeatedly trace the same cells and to monitor the kinetics of their size changes.

Clinical intestinal transplantation: a decade of experience at a single center

OBJECTIVE

To assess the long-term efficacy of intestinal transplantation under tacrolimus-based immunosuppression and the therapeutic benefit of newly developed adjunct immunosuppressants and management strategies.

SUMMARY BACKGROUND DATA

With the advent of tacrolimus in 1990, transplantation of the intestine began to emerge as therapy for intestinal failure. However, a high risk of rejection, with the consequent need for acute and chronic high-dose immunosuppression, has inhibited its widespread application.

METHODS

During an 11-year period, divided into two segments by a 1-year moratorium in 1994, 155 patients received 165 intestinal allografts under immunosuppression based on tacrolimus and prednisone: 65 intestine alone, 75 liver and intestine, and 25 multivisceral. For the transplantations since the moratorium (n = 99), an adjunct immunosuppressant (cyclophosphamide or daclizumab) was used for 74 transplantations, adjunct donor bone marrow was given in 39, and the intestine of 11 allografts was irradiated with a single dose of 750 cGy.

RESULTS

The actuarial survival rate for the total population was 75% at 1 year, 54% at 5 years, and 42% at 10 years. Recipients of liver plus intestine had the best long-term prognosis and the lowest risk of graft loss from rejection (P =.001). Since 1994, survival rates have improved. Techniques for early detection of Epstein-Barr and cytomegaloviral infections, bone marrow augmentation, the adjunct use of the interleukin-2 antagonist daclizumab, and most recently allograft irradiation may have contributed to the better results.

CONCLUSION

The survival rates after intestinal transplantation have cumulatively improved during the past decade. With the management strategies currently under evaluation, intestinal transplant procedures have the potential to become the standard of care for patients with end-stage intestinal failure.

Surface freezing in n-alkane solutions: the relation to bulk phases

Surface freezing (SF) was investigated in tricosane-dodecane alkane solutions as a function of temperature (T) and molar concentration of tricosane (phi), using surface tension and synchrotron x-ray surface diffraction techniques. A crystalline SF monolayer, having a rotator R(II) structure, was found to exist for 35 degrees C</=T</=50 degrees C and 0.3</=phi</=1. The extended temperature range allowed to determine the linear-expansion coefficient of the SF monolayer, (dd/dT)/d=6.5 x 10(-4) degrees C-1. A simple thermodynamical model based on the theory of ideal solutions is shown to account well for the phi dependence of the SF temperature T(s)(phi). The study shows that the temperature range of existence of the surface frozen layer at each phi, the phi range over which SF is observed, and the bulk solidification behavior, are intimately related. All are determined by the rotator-liquid dissolution line T(dR)(phi).

The bridge graft: a new concept for infrapopliteal surgery

BACKGROUND

The long-term results of ePTFE grafts are particularly poor in crural reconstructions. We report on a novel surgical technique, whereby both run-off and anastomotic mismatches are concomitantly addressed.

PATIENTS AND METHODS

Short segments of vein grafts (5-15 cm in length) were used to bridge two crural artery segments. Subsequently, a femoro-distal ePTFE graft was anastomosed to the bridge graft. Venous valves were made incompetent to allow bi-directional flow. In a retrospective series of 45 patients with crural bridge grafts, 12 patients were in stage III and 33 in stage IV. In 18 patients the reconstruction was the first procedure and in the remaining 28 patients it was the first or second re-operation.

RESULTS

The primary patency rate at 1, 2, 3 and 4 years was 53, 44, 35 and 26% respectively. The secondary patency rate was 67, 53, 49 and 39% respectively. The corresponding limb salvage rate was 70, 61, 56 and 45%. In a small subgroup of patients, in which the crural bridge was the first reconstructive procedure, the primary patency was 76 at 1 year and 64 at 4 years.

CONCLUSION

convincing long-term crural bridge grafts should be considered in those patients who have more than one crural or pedal artery available for grafting and an insufficient length of saphenous vein.

Clinical autologous in vitro endothelialization of 153 infrainguinal ePTFE grafts

BACKGROUND

Over the past 17 years, our group has developed and clinically applied an in vitro endothelialization procedure whereby infrainguinal expanded polytetrafluoroethylene (ePTFE) prostheses are confluently lined with cultured autologous endothelial cells before implantation. After a successful randomized pilot study from 1989 to 1993, the procedure was adopted for routine operations.

METHODS

Since June 1993, 153 endothelialized ePTFE grafts were implanted in the infrainguinal position in 136 patients (102 above knee (AK) and 51 below knee (BK), 89 men and 47 women, mean age 64.7+/-9.4 years). Seventeen patients received an endothelialized prosthesis bilaterally. Autologous endothelial cells were harvested from 4- to 5-cm segments of a subcutaneous vein (in 86% the cephalic vein), grown to first-passage mass cultures and confluently lined onto 6- (n = 113) or 7-mm (n = 40) inner diameter (ID) ePTFE grafts, precoated with fibrin glue. The observation period for 6-mm grafts was 7 years, and for 7-mm grafts was 4 years. Patency assessment for Kaplan-Meier survivorship analyses was based on duplex sonography and angiography.

RESULTS

Kaplan-Meier survivorship function revealed a primary patency rate of 62.8% after 7 years (SE = 0.05) for all infrainguinal reconstructions (60% AK/70.8% BK). The primary patency for stage II and III patients was 64.4% after 7 years. The more recent group of 7-mm ID grafts showed a primary patency of 83.7% after 4 years.

CONCLUSIONS

Our data provide strong evidence that autologous endothelial cell lining distinctly improves the patency of small diameter vascular grafts.

Shoulder and arm problems after radiotherapy for primary breast cancer

There is little, if any, difference in disease-free or overall survival for patients with stage I and II breast cancer treated by either breast conservation therapy or mastectomy. With either treatment, there may be cosmetic and functional problems related to arm edema, limited shoulder motion, and shoulder pain. The extent to which factors such as surgery, radiotherapy, systemic therapy, and patient characteristics affect development of arm edema, limited shoulder motion, and shoulder pain is not well documented. We undertook a prospective study of arm edema, limited shoulder motion, and shoulder pain in every patient (N = 331) seen during a 6-month period for follow-up after radiotherapy postlumpectomy or mastectomy for primary breast cancer. Local treatment included lumpectomy and breast irradiation with (n = 232) or without (n = 97) axillary dissection. Ten other women underwent mastectomy and postoperative radiotherapy. Doses to each region treated were 50 Gy in 25 fractions. The operative area was treated with an additional 1,000 Gy in approximately 60% of patients. Twelve patients received axillary irradiation without axillary dissection, and 11 patients received supraclavicular irradiation. Chemotherapy with or without tamoxifen was used in 71 patients and tamoxifen alone was used in 150 patients. One hundred ten patients did not receive any adjuvant therapy. Ipsilateral arm edema occurred in 20 women (6.0%), limited ipsilateral shoulder motion in 5 (1.5%), and ipsilateral shoulder pain in 5 (1.5%). Edema was mild (1+) in 15 patients and moderate (2+) in five patients. Multivariate analysis revealed that the risk of arm edema was significantly increased in black women (p = 0.005, 4/18 versus 16/313 whites) and with mastectomy (p = 0.048, 2/10 versus 18/321 with lumpectomy). There is a low incidence of arm edema, decreased range of motion of the ipsilateral shoulder, and shoulder-arm pain in patients undergoing postlumpectomy or postmastectomy radiotherapy. The risk of arm edema is increased in black women and in patients after mastectomy as opposed to lumpectomy.

Positional order and thermal expansion of surface crystalline N-alkane monolayers

We report a high-resolution synchrotron grazing incidence x-ray diffraction measurement of a surface crystalline monolayer at the liquid-vapor interface of the n-alkane eicosane (C20H42) just above its melting temperature. The peak width of the surface monolayer rotator phase is shown to be resolution limited and implies positional correlations of at least approximately 1 microm. The high resolution allowed determination of the temperature dependence of the peak position over the narrow (3 degrees C) temperature range of the surface crystal phase. The two-dimensional thermal expansion was determined to be (dA/dT)/A=1.8(+/-0.1)x10(-3) degrees C-1, which is comparable to the expansion in similar chain length bulk n-alkane rotator phases. Our data are consistent with the power-law shaped scattering tails expected from quasi-long-range order in two dimensions.

Pairing interactions and Gibbs adsorption at the liquid bi-in surface: a resonant X-ray reflectivity study

Resonant x-ray reflectivity measurements from the surface of liquid Bi(22)In(78) find only a modest surface Bi enhancement, with 35 at. % Bi in the first atomic layer. This is in contrast to the Gibbs adsorption in all liquid alloys studied to date, which show surface segregation of a complete monolayer of the low surface tension component. This suggests that surface adsorption in Bi-In is dominated by attractive interactions that increase the number of Bi-In neighbors at the surface. These are the first measurements in which resonant x-ray scattering has been used to quantify compositional changes induced at a liquid alloy surface.

Lumpectomy and breast irradiation for breast cancer arising after previous radiotherapy for Hodgkin's disease or lymphoma

Twelve women treated with radiotherapy with or without chemotherapy for Hodgkin's disease (11 patients) and non-Hodgkin's lymphoma (1 patient) and in whom breast cancer subsequently developed 10 to 29 years later were treated with lumpectomy and breast irradiation. 5,000 cGy/25-30 fractions to the whole breast and 900 cGy to 1.000 cGy/5 boost to the operative area. Six also received adjuvant chemotherapy for breast cancer. Breast irradiation was well tolerated without any unusual acute or chronic sequelae. All women had a good to excellent cosmetic result. Ten women are alive and well 1 to 174 months (median: 46) from completion of breast irradiation. Two women died with distant metastasis but without local recurrence. Breast conservation therapy with radiotherapy is not contraindicated in the woman who has previously been treated with radiotherapy for Hodgkin's disease or lymphoma.

Radiotherapy for postmastectomy local-regional recurrent breast cancer

From 1980 to 1989, 70 women with postmastectomy local-regional recurrent breast cancer and no clinical or radiographic evidence of distant metastasis were treated with radiotherapy with or without systemic therapy. The interval from mastectomy to local-regional recurrence ranged from 5 to 240 months (median, 34 months). The chest wall alone was involved in 37 patients, the supraclavicular area in 12 patients, the internal mammary node area in 3 patients, the infraclavicular area in 2, and the axilla in 1. Fifteen patients had multiple areas of involvement. The complete response rate was 87%. Further local-regional recurrence developed in at least 21 patients, and distant metastasis developed in at least 41 patients. Twenty-five patients (36%) survived at least 5 years and 15 patients (21%) survived at least 10 years. An initial negative node status and long disease-free interval from mastectomy to recurrence were associated with an improved postrecurrence survival. Patients with local-regional recurrence postmastectomy who do not have clinical or radiographic evidence of distant metastasis should be treated aggressively with radiotherapy with or without systemic therapy. Distant metastasis will develop in most such patients, but the majority will remain free of further local-regional recurrence.

Pancreatic cancer in a young adult after treatment for Hodgkin's disease

The authors present a case of adenocarcinoma of the head of the pancreas, which arose 14 years after extended field irradiation for Stage IIA Hodgkin's disease. The patient was aged 37 years at the time of the pancreatic cancer, which was situated within the previously irradiated volume.

Redo surgery for carotid artery stenosis: when and how?

PURPOSE

We analyzed operations performed at our institution retrospectively for recurrent carotid artery stenosis to assess the indication for surgery. We also assessed the techniques used for these operations.

PATIENTS AND METHODS

From January 1992 to December 1998 1210 carotid endarterectomies were performed. Forty two (3.4%) of these were for recurrent stenosis. A new vein patch was implanted in 27 cases, PTFE patches were used in nine cases. In six cases an interposition with the great saphenous vein was performed.

RESULTS

The mean interval between primary and secondary procedure was 60. 2months (3months to 23yr). Twenty five of our 41 patients had had ipsilateral neurologic symptoms before redo surgery, the remainder were free of symptoms. The grade of stenosis was over 90% in 22 cases, between 75 and 90% in 11 cases and below 75% in nine cases, two cases had aneurysmatic lesions. None of the patients died in the 30day observation period. One patient had a stroke with a permanent neurological deficit. In two cases postoperative bleeding occurred requiring reexploration. Two patients developed hypoglossal neurapraxia and in four patients the recurrent laryngeal nerve was injured. One patient had an apneic episode in the recovery room.

CONCLUSION

The reported incidence of recurrent carotid artery stenosis surgery ranges from 3 to 36% and our incidence is at the lower end of this range. The surgical results of reoperating are acceptable with a low incidence of complications.

Low-stage medulloblastoma: final analysis of trial comparing standard-dose with reduced-dose neuraxis irradiation

PURPOSE

To evaluate prospectively the effects on survival, relapse-free survival, and patterns of relapse of reduced-dose (23.4 Gy in 13 fractions) compared with standard-dose (36 Gy in 20 fractions) neuraxis irradiation in patients 3 to 21 years of age with low-stage medulloblastoma, minimal postoperative residual disease, and no evidence of neuraxis disease.

PATIENTS AND METHODS

The Pediatric Oncology Group and Children's Cancer Group randomized 126 patients to the study. All patients received posterior fossa irradiation to a total dose of 54 Gy in addition to the neuraxis treatment. Patients were staged postoperatively with contrast-enhanced cranial computed tomography, myelography, and CSF cytology. Of the registered patients, 38 were ineligible.

RESULTS

The planned interim analysis that resulted in closure of the protocol showed that patients randomized to the reduced neuraxis treatment had increased frequency of relapse. In the final analysis, eligible patients receiving standard-dose neuraxis irradiation had 67% event-free survival (EFS) at 5 years (SE = 7.4%), whereas eligible patients receiving reduced-dose neuraxis irradiation had 52% event-free survival at 5 years (SE = 7.7%) (P =.080). At 8 years, the respective EFS proportions were also 67% (SE = 8.8%) and 52% (SE = 11%) (P =.141). These data confirm the original one-sided conclusions but suggest that differences are less marked with time.

CONCLUSION

Reduced-dose neuraxis irradiation (23.4 Gy) is associated with increased risk of early relapse, early isolated neuraxis relapse, and lower 5-year EFS and overall survival than standard irradiation (36 Gy). The 5-year EFS for patients receiving standard-dose irradiation is suboptimal, and improved techniques and/or therapies are needed to improve ultimate outcome. Chemotherapy may contribute to this improvement.