Intraperitoneal cisplatin and etoposide in the treatment of refractory/recurrent ovarian carcinoma

To determine the efficacy of a 6-month course of combination intraperitoneal (IP) chemotherapy with cisplatin and etoposide in patients with refractory or recurrent advanced ovarian carcinoma, 67 patients were entered into this prospective, nonrandomized, single-institution trial. Cisplatin at 100 mg/m2 and etoposide at 200 mg/m2 were administered IP on day 1 every month for 6 months. Exploratory laparotomy was performed before protocol entry and was planned after the completion of 6 months of IP therapy to surgically document response. All patients had received prior intravenous (IV) chemotherapy with a cisplatin-based regimen. At protocol entry, 18 (27%) patients had surgically defined residual tumor (maximal tumor diameter) greater than 2.0 cm, 17 (25%) patients greater than 0.5 cm - less than or equal to 2.0 cm, and 32 (48%) patients less than or equal to 0.5 cm. Sixteen patients (24%) who had experienced a treatment-free interval of more than 1 year prior to study entry were considered as having recurrent disease and the remaining 51 (76%) patients were considered as having refractory disease. Toxicity was tolerable: four patients (6%) had nadir fever, three (4%) had culture-documented bacterial peritonitis, five (7%) had IP catheter-related complications, and 27 (40%) had an increase in serum creatinine greater than 1.5 mg/dL. Among the 57 patients who are fully evaluable for response, the overall surgically defined response rate, complete (CR), and partial response (PR), was 40% (23/57), and the CR rate was 21% (12/57). Among the patients with recurrent disease, eight of 13 (62%) responded, with responses seen among all categories of residual disease. Among the patients with refractory disease, 15 of 44 (34%) had surgically documented responses. However, responses were more frequent in patients with residual disease less than 0.5 cm; 11 of 20 (55%) versus four of 24 (17%) with residual greater than 0.5 cm, P = .019 (chi 2, one degree of freedom, Yates correction). The duration of the CRs ranges from 4 to 18+ months. Longer follow-up is needed to determine if there is any impact on survival.

Intraperitoneal therapy in the management of ovarian carcinoma

The intraperitoneal administration of chemotherapeutic and biological agents as therapy of ovarian carcinoma is based on both theoretical considerations and experimental evaluations which suggest that tumor present in the cavity can be exposed to higher concentrations of certain antineoplastic drugs than can be accomplished if the agents are administered systemically. Recent clinical data have confirmed both the safety and pharmacokinetic advantage associated with this approach. Surgically defined responses have been observed in patients with small-volume residual refractory ovarian carcinoma treated with several single-agent and combination intraperitoneal therapeutic programs. While significant activity has been noted in this clinical setting, a clearly defined role for intraperitoneal treatment in the standard management of ovarian carcinoma remains to be determined.

The expanded role nurse. Part II. Role implementation strategies

This is the second article of a two-part series describing implementation of Expanded Role Nurse positions at University Hospital, London, Ontario. In Part II, the author discusses sources of role stress and strain and presents strategies to prevent or minimize role problems. Role stress results when the role incumbent is unable to meet the expectations of the social structure. Goal attainment is impaired and role relationships are disrupted. Strategies to prevent role problems should be identified and implemented during role development.

Expanded role nurse. Part I. Role theory concepts

This is the first article of a two-part series describing implementation of Expanded Role Nurse positions at University Hospital, London, Ontario. Part I presents a review of the literature on expanded roles for nurses and the background to implementation of the ERN role at University Hospital. Concepts or role theory are applied to role development and implementation. Expanded role nurse positions have been created at University Hospital in order to maintain high quality patient care in the face of resident cutbacks. These positions provide exciting opportunities for nurses who wish to develop clinical expertise while remaining at the bedside.

Elevated alpha-fetoprotein in pregnancy complicated by aplasia cutis after exposure to methimazole

A case of aplasia cutis after exposure to methimazole (Tapazole) in early pregnancy is described. Elevated maternal serum alpha-fetoprotein (MSAFP) and amniotic fluid alpha-fetoprotein (AFP) were found. Elevated MSAFP and amniotic fluid AFP in women exposed to methimazole may suggest this rare fetal condition.

A phase I trial of intraperitoneal recombinant gamma-interferon in advanced ovarian carcinoma

The interferons are a class of biological agents that have demonstrated antineoplastic activity in a variety of tumors both in vitro and in vivo. Previous reports have suggested that interferons can be safely administered by the intraperitoneal (IP) route with a pharmacokinetic advantage for peritoneal cavity exposure compared with the systemic circulation and with objective antitumor activity being demonstrated. On the basis of these reports and laboratory data suggesting activity for recombinant gamma-interferon (r-GIFN) against several malignant cell lines, we treated 27 refractory ovarian carcinoma patients, including six with very-small-volume residual disease, with this agent delivered by the IP route. While r-GIFN was found to be remarkably well tolerated, with a 150- to 200-fold pharmacokinetic advantage for peak levels achieved in the peritoneal cavity compared with the plasma, no objective responses were observed. Despite the lack of demonstrated activity for single-agent IP-administered r-GIFN in this clinical setting, there remains considerable interest in this agent when delivered by the IP route because of in vitro data suggesting concentration-dependent synergy between r-GIFN and other biological agents.

Phase I trial of concurrent intraperitoneal and continuous intravenous infusion of fluorouracil in patients with refractory cancer

In an effort to maximize both local-regional and systemic drug exposure to tumor in the peritoneal cavity, a phase I study was conducted that examined the simultaneous daily intraperitoneal (IP) and continuous intravenous infusion (CVI) of fluorouracil (5-FU) to 32 patients with refractory cancer. IP 5-FU administered at 1,000 mg/d with concurrent 5-FU by CVI at 1,000 mg/m2/d for four consecutive days was well tolerated. One patient with a primary gastrointestinal (GI) malignancy with minimal volume disease experienced a surgically defined complete remission. In theory, this regimen may demonstrate clinical utility as an adjuvant treatment of certain GI malignancies. Future studies are planned in this clinical setting.

Antireflux surgery in infants with bronchopulmonary dysplasia

We reviewed the medical records of nine infants with severe bronchopulmonary dysplasia and gastroesophageal reflux who underwent fundoplication-gastrostomy surgery. All the infants were born prematurely, required preoperative mechanical ventilation, and were failing to thrive. The operative procedure was well tolerated by all the infants. Seven patients were extubated by day 11, and two patients required long-term ventilation. There were two postoperative deaths, both attributed to acute respiratory deterioration followed by cardiorespiratory failure. The postsurgical respiratory response was observed to be a rapid decrease in oxygen requirements and an absence of further aspiration episodes. A mean decrease of 0.14 in fractional inspired oxygen concentration was noted by 30 days postoperatively, and by 180 days the decrease in fractional inspired oxygen concentration was 0.22. All infants were fed by gastrostomy by postoperative day 4, with no evidence of clinical reflux. The nutritional response was noted to be an increase in growth velocity with increasing age (ie, catch-up growth) and ease of feeding. At both 30 and 180 days postoperatively, the mean growth velocity was more than double the preoperative growth velocity. In addition, ease of postoperative feeding reduced the nursing care requirements and allowed earlier discharge from hospital. Fundoplication and gastrostomy is effective in facilitating growth and feeding in addition to decreasing oxygen requirements in infants with severe bronchopulmonary dysplasia and gastroesophageal reflux.

Familial polyposis coli in childhood

Familial polyposis coli has generally been considered a disorder of adulthood that is rarely identified in children. We report 3 affected kindreds in which the disorder was diagnosed in 6 of 11 potentially affected children between 8 and 16 years of age. Experience with these kindreds demonstrates that polyps frequently develop during childhood in affected individuals. Colonoscopy was found to be preferable to the air-contrast barium enema, in that it was as sensitive a technique for detection of adenomas, and in that it also permitted collection of biopsies for histologic confirmation. We recommend that colonoscopy be performed late in the first decade of life before symptoms develop. Total colectomy, rectal mucosectomy, and ileo-anal anastomosis eliminated the risk of malignancy, preserved anal sphincter function by both clinical and manometric assessment, and was readily adapted to by these children.

Pulmonary complications of total parenteral nutrition in a neonate

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Extended field irradiation in the treatment of patients with cervical carcinoma involving biopsy proven para-aortic nodes

Between November 1974 and November 1979, 15 patients with cervical carcinoma were treated with extended field irradiation for biopsy proven para-aortic lymph node (PALN) metastases. Treatment consisted of pelvic and para-aortic irradiation at a daily dose of 180 to 200 rad per day, delivering 4000 to 6000 rad to the pelvis and 4000 to 5000 rad to the para-aortic nodes. One or two intracavitary insertions each delivered an additional 2000 to 3500 rad to point A. The three year actual disease free survival for the 12 patients with Stage I and II disease was 50%. All six survivors remain alive without evidence of disease for 41 to 93 months, with a mean and median follow-up of 65 months. All patients dying of disease did so within 26 months, all but one dying within one year. All patients with Stage III and IV are dead of disease. Pelvic disease was controlled in 11 of 12 patients with Stage I or II disease, and in one of the three patients with Stage III and IV disease. There was no clinical indication of failure in the PALN in any patient. Nine patients failed with disseminated disease. Three of 15 patients (20%) suffered serious treatment-related complications. Two of these were attributed to the pelvic irradiation, with one patient requiring a colostomy. Thus, complications resulting from the extended field irradiation were seen in only one patient (6.7%). There was no treatment related mortality. Extended field irradiation can lead to a 50% survival in patients with Stage I and II cervical carcinoma and PALN metastases, a survival comparable to that reported in patients with involved pelvic nodes.

Phase separation in rat lenses cultured in low glucose media

Experimental evidence that indicates the nuclear opacity that develops in the hypoglycemic cataract in rat lenses is the result of a phase separation of the lens cytoplasm is presented. Phase diagrams of the cytoplasm of organ-cultured lenses were constructed for a series of incubation times in normal and hypoglycemic media. In normal media, the maximum phase separation temperature, Tmax, of the lens cytoplasm decreases with time. In hypoglycemic media, Tmax increases with time and exceeds 37 C after 24 hrs. The increase in Tmax can be stopped and reversed if the lens is returned to normal media within 8 hrs; in good agreement with an earlier biochemical analysis of the kinetics of hypoglycemic cataract formation.

Serological evidence of Ureaplasma urealyticum infection in neonatal respiratory disease

Since up to 80 percent of pregnant women and 30 percent of neonates may be colonized with genital mycoplasmas, it is difficult to determine whether true infection occurs. The antibody responses to eight serotypes of U. urealyticum were assessed in mothers and infants in 21 cases of neonatal respiratory disease (RD) and 24 normal cases. Among the normal population of mothers and infants, a titer of greater than or equal to 1:32 occurred in 0.25 percent (1/394). In mother-infant paired titers, a fourfold difference occurred in 2.6 percent (5/192). Among 54 RD neonates, 55.6 percent had a titer of greater than or equal to 1:32 compared to only 4.2 percent of normal neonates (p less than .001). Fourfold elevations in antibody titers of greater than 1:32 were observed in the neonate in 52.4 percent of RD cases compared to 0 percent of 24 normal pairs (p less than .001) and in 28.6 percent of mothers of RD neonates compared to 0 percent in normal cases (p = .013). We observed that 43.3 percent of RD neonates with titers greater than or equal to 1:32 died compared to 16.6 percent of RD neonates exhibiting no elevation of antibody response over the maternal level. Among the six who died, 66.7 percent of neonates and 16.7 percent of their mothers had elevated titers, compared to 33.3 percent of 15 surviving infants and 40.0 percent of their mothers. These elevated antibody responses strongly support the concept that U. urealyticum causes infection in the perinatal period in association with neonatal respiratory disease. Since the elevation in titers was detected close to delivery in many cases, the infection may occur in utero.

Effect of aging on respiratory responses to CO2 and inspiratory resistive loads

We studied 10 elderly individuals over 60 years of age and 18 individuals less than 30 years to determine whether aging affects the response of the respiratory control system to chemical stimuli or to altered mechanical conditions. Both groups consisted of males and females who were nonsmokers. Ventilation and the isometric force developed by the inspiratory muscles (occlusion pressure) was assessed during hypercapnia while the subjects breathed under control conditions or through a load at the mouth that increased inspiratory resistance. Ventilation responses to progressively increasing CO2 were lower but not significantly so in the older group. There were significant differences in ventilatory pattern in the two groups. However, occlusion pressure responses to hypercapnia and to resistive loads were the same. The results suggest that aging has little or no adverse effect on respiratory control.

Role of vasodilators in the changing phases of acute myocardial infarction

Application of vasodilators in evolving myocardial infarction has not yet received wide acceptance. Heretofore, clinical trials of a variety of vasodilator agents have been conducted without regard to the phase of the disease with its changing pathologic features and altering cardiac function. A classification of these phases based on the underlying myocardial disease--ischemia, necrosis, compensation, and healing--may allow a more rational interpretation of the available information. At present, vasodilators are not recommended during the ischemic phase, although some evidence suggests that preload modification by use of nitroglycerin may be beneficial in certain instances. Vasodilator drugs productive of arterial impedance reduction are probably of the greatest value late in the necrotic phase and in the compensation and healing phases. It is in these circumstances that heart failure becomes clinically manifest and maximal short-term efficacy of this intervention can be achieved. Impedance reduction, using agents such as sodium nitroprusside, will cause a prompt improvement manifested by a reduction in left ventricular filling pressure and in pulmonary congesting pressure and an increase in cardiac output. A significant improvement in short-term survival, at least, should be expected by judicious use of vasodilators.

Congenital lobar emphysema: a case with bronchial atresia and abnormal bronchial cartilages

An infant with congenital left upper lobe emphysema presenting with respiratory distress and failure to thrive, which necessitated lobectomy, is described. Careful pathological examination revealed two defects in association with the emphysema: bronchial atresia and defective bronchial cartilage in the affected lobe. Whilst congenital lobar emphysema is the term usually employed to describe this clinical presentation of respiratory distress in infancy, 'panlobular emphysema of infancy' would be a more accurate description. Congenital defects in the airways may account for the development of emphysema, but there may be a more fundamental congenital tissue abnormality at alveolar level.

Long-term outpatient vasodilator therapy of congestive heart failure. Consideration of agents at rest and during exercise

Increased left ventricular filling pressure and reduced cardiac output are two major hemodynamic deficits in pump failure. In patients with chronic heart failure, consequences of these hemodynamic deficits and diminished cardiac reserve are manifested initially during stress and eventually at rest. The purpose of therapeutic interventions include reduction of ventricular filling pressure increase in cardiac output and improvement in cardiac reserve. To achieve these goals, the hemodynamic effects of predominantly venodilators (nitrates), predominantly arteriolar dilators (hydralazine) and the combination of nitrates and hydralazine were evaluated in patients with chronic heart failure at rest: left ventricular filling pressure (mm Hg) control 28, nitrates 17, hydralazine 25, nitrates plus hydralazine 18; cardiac output (liters/min/m2) control 2.1, nitrates 2.1, hydralazine 3.2, nitrates plus hydralazine 3.3; mean blood pressure (mm Hg) control 87, nitrates 85, hydralazine 83, nitrates plus hydralazine 85. These data suggest improved left ventricular performance with a combination of nitrates and hydralazine. Exercise hemodynamics improved in some patients, suggesting that such vasodilator therapy may be beneficial in chronic heart failure.

Tumor invasion of the upper inferior vena cava: the use of profound hypothermia and circulation arrest as a surgical adjunct

Two children presented with abdominal tumors invading the upper inferior vena cava. To facilitate removal of the tumors, cardiopulmonary bypass with profound hypothermia and circulation arrest were utilized. This technique simplifies tumor excision and is worthwhile even in children with advanced malignant disease.

Serum fucose as a monitor for recurrent malignancy

Serum fucose determinations were performed on 19 patients with "stable" or "inactive" malignancies, 33 patients with "active" malignancies, and 14 "normals." A significant difference in the values between "normal" and "stable" patients and those with "active" cancer is shown. A role for this relatively simple serological test for diagnosing and following metastatic cancer is suggested.

Evaluation of cardiac size in chronic bronchitis and pulmonary emphysema

The accuracy of interobserver variability of roentgenographic analysis for cardiac size in patients dying with chronic bronchitis and pulmonary emphysema were correlated with pathologic data derived from special studies. Three trained observers were able to accurately and consistently diagnose chronic bronchitis and pulmonary emphysema and to detect cardiomegaly on the chest x-ray film. The best criteria for chronic bronchitis and pulmonary emphysema were those of overinflation; however, none of the roentgenographic criteria usually suggested for the specific diagnosis of right ventricular or left ventricular hypertrophy were found to be reliable. The inaccuracy and interobserver variability in the detection of enlargement of specific chambers make it evident that the usual criteria are not valid and that roentgenographic appraisal of cardiac size in these patients in limited to findings of normalcy or cardiomegaly.

A comparison of granulopoiesis in culture from blood and marrow cells of nonleukemic individuals and patients with acute leukemia

The objective of this study was to compare the concentration of committed granulopoietic progenitor cells (CFU-C) in marrow and blood. For individuals without leukemia, a highly significant correlation was observed between the concentration of CFU-C obtained from the two sites. However, CFU-C in blood had a slower sedimentation velocity than that reported for marrow and were found not to be in the DNA synthetic phase of the cycle using the tritiated thymidine suicide tehcnique. In patients with acute leukemia, no correlation was observed between concentrations of CFU-C in marrow and peripheral blood, regardless of whether the patients were newly diagnosed, in remission, or in relapse. We concluded that studies of the peripheral blood do not yield the same information in respect to granulopoietic progenitor cells as do studies of the marrow.

Creatine phosphokinase in prostatic tissue

A histochemical study of creatine phosphokinase (CPK) in the rat ventral prostate revealed that the epithelial cells had a high cytoplasmic activity which was retained or even increased when the cells were atrophic as a consequence of castration. Both the fibromuscular stroma, which is prominent in the ventral prostate of castrated rats, and the secretion had a high level of activity. In human benign prostatic tissue where CPK was present in the epithelium, secretion and stroma, pronounced differences in activity could sometimes be observed between the epithelium of adjacent acini and also between cells in the same acinus. There was no obvious correlation between CPK activity and degree of epithelial hyperplasia. The activity in carcinomatous prostatic epithelial cells varied considerably between specimen from different patients but was uniform within a given specimen in contrast to the variation of epithelial CPK activity within non-carcinomatous tissue. Thus, a difference in the pattern of CPK activity was observed between malignant and non-malignant epithelial cells.