Atherosclerosis of the lower extremity and free-tissue reconstruction for limb salvage

Atherosclerosis of the lower extremity frequently leads to limb-threatening ischemic soft-tissue wounds. Over the past 44 months, 30 selected patients with arterial disease documented by angiography were treated with combined vascular reconstruction and free-tissue transfer for limb salvage. Soft-tissue defects occurred on the plantar and dorsal surfaces of the foot and distal tibia with significant bone, tendon, or joint exposure. Thirteen patients had osteomyelitis. Eighteen patients underwent simultaneous soft-tissue and vascular reconstruction, while 12 patients underwent delayed soft-tissue reconstruction. The free-flap tissues included the rectus abdominis flap in 13, the latissimus dorsi flap in 7, the radial forearm flap in 5, the scapular flap in 3, and the omentum flap in 2. Autogenous venous bypass was performed to the popliteal segment in 6 patients and the infrapopliteal arteries in 18. Five patients had inadequate outflow for complete vascular reconstruction and were treated with proximal vein grafts directed into the free flap. Twenty-two patients (73 percent) had successful free-tissue transfer and bypass graft patency and were independent ambulators over the mean follow-up period of 22 months. Of the 8 unsuccessful reconstructions, 3 patients had early free-flap and graft failure. Five patients developed new areas of ischemic disease despite graft and flap patency. All 8 patients were treated with amputation; 7 never regained ambulation. The combined application of vascular and free-flap soft-tissue reconstruction for the threatened ischemic lower extremity has produced excellent functional results in the majority of our patients.

Impact of the preparation technique on DNA content measured by image analysis in early stage human testis cancer

Current clinical staging which includes serum tumour markers and imaging techniques fails to identify 30-40% of clinical stage I nonseminomatous germ cell testicular tumour (NSGCT) patients who have occult metastatic disease at time of orchiectomy and who will, therefore, develop clinically evident metastases, usually within two years of follow-up. Therefore, there is a real clinical need to evaluate new biological parameters of the primary tumour which might be useful as predictors for occult metastatic disease. Some investigators have described that DNA content measured by image cytometry is of prognostic value in early stage NSGCT to detect patients at risk for occult metastatic disease. However, optimal preparatory techniques are mandatory in establishing new tumour biological markers in order to obtain reliable and reproducible results. This study has analyzed the impact of the sedimentation technique in comparison to the cytocentrifugation technique on DNA measurement in early stage NSGCT obtained by image cytometry. Different tissue blocks of formalin fixed, paraffin embedded primary testicular tumours (NSGCT) of 50 clinical stage I patients, who underwent retroperitoneal lymph node dissection between 1985 and 1989, were analyzed. Thirty (60%) patients had histologically proven lymph node involvement (pathological stage B), whereas 20 (40%) patients (pathological stage A) had neither lymph node metastases nor tumour recurrence during follow-up. The samples were prepared according to a modified Hedley technique: Individual tissue digestion times were monitored closely to avoid overdigestion. The times varied from 30 to 60 min depending on the constituents of the tissue section. Prolonged digestion times did not correlate with poor quality of the preparations and brief digestion times did not always yield optimal specimens. The impact of two different techniques (cytocentrifugation and gravity sedimentation) on the Feulgen staining results were compared. Cytocentrifuged samples consistently provided larger and paler nuclei with less well defined borders compared to slides from the same cell suspension processed by the sedimentation technique. Nuclei from pathologic stage II samples were more vulnerable to cytocentrifuge alteration than those of stage I. According to the results obtained in this study, the sedimentation slide preparation technique should be preferred for DNA ICM in NSGCT, and possibly in other human malignancies as well.

Enhancement of drug sensitivity of human malignancies by epidermal growth factor

We have previously shown that epidermal growth factor (EGF) enhances the in vitro and in vivo sensitivity of human ovarian carcinoma 2008 cells to cisplatin. EGF was found to enhance selectively the in vivo toxicity of cisplatin to 2008 cell xenografts without altering the toxicity of cisplatin to non-malignant target tissues such as the kidney or bone marrow. We now show that recombinant human EGF (rhEGF) enhances the cisplatin sensitivity of cell lines representative of many other types of malignancies in addition to ovarian carcinoma, including cancers of the head and neck, cervix, colon, pancreas and prostate, as well as non-small-cell carcinoma of the lung. In addition, rhEGF was found to sensitise cells to other platinum-containing drugs and several other classes of chemotherapeutic agents. rhEGF sensitised 2008 cells not only to cisplatin, but also to carboplatin and tetraplatin, as well as taxol, melphalan and 5-fluorouracil. We conclude that modulation of drug sensitivity by rhEGF is observed in cell lines representative of many human malignancies and for multiple classes of chemotherapeutic agents, indicating that it alters one or more components of the cellular damage response that are both common between cell lines and classes of drugs and fundamental to survival.

Compliance with primary prevention in private practice: creating a tobacco-free environment

A sample of private orthodontic practices (n = 40) from a controlled trial for clinician-initiated tobacco-use prevention was used to test the effectiveness of preventive medicine representative (PMR) visits in creating and maintaining an anti-tobacco office environment. Clinical staff of 20 offices, randomly assigned to the experimental group, were trained by a PMR on the use of anti-tobacco materials (no-smoking signs, posters, and print materials). Twenty control-group offices did not receive any training or special treatment. Subsequently, experimental-group offices were visited by a PMR once every three months and were telephoned six weeks after each visit over a 12-month period. During visits and phone calls, PMRs prompted offices to order anti-tobacco materials. Visits served to introduce offices to new materials and to encourage their continued use. Data from direct observations and self-report measures showed significant differences between experimental and control offices for display of anti-tobacco materials at 1.5 months and 12 months (P < .001). Results suggest that PMR visits may serve as an effective method of introducing and maintaining preventive medicine procedures in clinical environments.

The protective action of chlormethiazole against ischaemia-induced neurodegeneration in gerbils when infused at doses having little sedative or anticonvulsant activity

1. The effect of chlormethiazole administration on delayed neuronal death in gerbil hippocampus following transient global ischaemia has been examined. Chlormethiazole was administered either intraperitoneally or by intravenous infusion with either the dose or the time of infusion varied. 2. Chlormethiazole (600 mumol kg-1, i.p.) given 60 min after ischaemia produced substantial (> 60%) neuroprotection when damage was assessed 5, 14 or 21 days later, indicating the drug does not merely delay cell death. 3. Infusion protocols were developed which would result in sustained and defined plasma concentrations. Chlormethiazole (930 mumol kg-1) was then infused intravenously for 30 min, 76.5 min or 110 min in ways resulting in sustained plasma concentrations of 200, 100 and 50 nmol ml-1 respectively. When treatment was initiated 30 min after the ischaemic episode all protocols provided effective neuroprotection. There was a dose-dependent decline in protection when plasma chlormethiazole concentrations of 50, 30 and 10 nmol ml-1 were sustained for 110 min with no protection observed at 10 nmol ml-1. 4. In contrast, when a plasma concentration of 10 nmol ml-1 was sustained by infusion for 24 h, almost total neuroprotection against the ischaemic damage was achieved. This plasma concentration produced no sedative or anticonvulsant activity. 5. These data suggest that neuroprotection depends on both dose and duration of chlormethiazole administration and that excellent neuroprotection is possible in the absence of the sedative and anticonvulsant effects of the drug.

Induction of the growth arrest and DNA damage-inducible gene GADD153 by cisplatin in vitro and in vivo

The inability to assess the extent of tumour damage immediately following treatment is a major clinical obstacle to improving the management of cancer patients. Normally, the effectiveness of chemotherapy or radiation therapy cannot be determined for at least several weeks after treatment. We studied the increase in mRNA of the growth arrest and DNA damage-inducible gene GADD153 in human 2008 ovarian carcinoma cells in vitro and in vivo to determine whether treatment-induced increases in the level of GADD153 mRNA could be used as a marker of the extent of tumour damage. GADD153 mRNA was increased in a transient, dose-dependent manner by cisplatin (DDP) when the tumour cells were grown both in vitro and as tumour xenografts in nude mice. The magnitude of induction of GADD153 mRNA did not vary significantly between different 2008 xenografts treated with equal doses of DDP, and GADD153 mRNA induction correlated with the degree of in vitro cytotoxicity for two different schedules of drug exposure. DDP increased GADD153 mRNA levels in melanoma and head and neck xenograft models as well. We conclude that the increase in GADD153 mRNA can be used to detect tumour injury at time points as short as 24 h after administration of DDP.

Tamoxifen delays the development of resistance to cisplatin in human melanoma and ovarian cancer cell lines

The development of resistance to cisplatin (DDP) occurs rapidly both in vitro and in vivo, and constitutes a major obstacle to effective therapy. We have previously demonstrated that there is a highly synergistic interaction between tamoxifen (TAM) and DDP against cell lines representative of three different human cancers: melanoma, ovarian carcinoma and small-cell lung cancer. The purpose of these studies was to determine if TAM interferes with the development of resistance to DDP. T-289 melanoma cells and 2008 ovarian cancer cells were cultured with increasing concentrations of DDP +/- TAM in an attempt to induce resistance to DDP. At various time points the cells were removed from culture and the degree of resistance to DDP was quantitated. Concurrent exposure to TAM and DDP decreased both the rate and the absolute magnitude of resistance to DDP in both melanoma and ovarian cancer cell lines. In the T-289 cell line the rate was decreased by a factor of 3.4 +/- 1.4 (P < 0.05), while in the 2008 cell line the rate was decreased by a factor of 2.4 (P < 0.01). TAM decreases the rate as well as the absolute magnitude of in vitro resistance to DDP in both melanoma and ovarian cancer cell lines. These data suggest that the concurrent administration of TAM and DDP may result in a delay in the development of resistance to DDP which may have important clinical implications in the design of DDP-containing regimens.

Falls among nursing home residents: an examination of incident reports before and after restraint reduction programs

OBJECTIVE

To examine changes in the rate of falling of an experimental group of restrained subjects who underwent restraint reduction, and to compare their rate of falling with a group of subjects who did not have restraint orders during the study period.

DESIGN

A quasi-experimental, multiple time-series study utilizing the principles of single-subject design. Each subject was followed for 25 weeks before and 25 weeks after initiation of the intervention.

SETTING

Seven nursing homes.

INTERVENTION

Formal programs aimed at reducing all bed and chair restraints were initiated in all sites after staff received education and training. Multidisciplinary teams implemented the restraint reduction process on a case-by-case basis, beginning with 1 unit/floor at a time in each site. Most experimental subjects reached their optimum restraint-elimination/reduced status within 2 weeks of intervention initiation. The implementation periods ranged from 4 months to more than a year.

PARTICIPANTS

Subjects with chart orders for restraints at the start of the study comprised the experimental group and participated in the restraint reduction program (184 subjects). Subjects with no orders for restraints during the study period comprised the nonequivalent control group (111 subjects) and, therefore, did not undergo the intervention.

MEASUREMENTS

Incident reports documenting all falls during the study period were examined. Falls, the dependent variable, were classified as serious or nonserious. The independent variable (intervention) was the restraint reduction program offered to experimental subjects. Based on the principles of single subject design, the impact of the intervention on falls was calculated before and after the date the restraint reduction process was initiated for an individual (experimental group) subject. For the control group, the pre- and posttest period was calculated from the start date of the restraint reduction program on the unit on which each subject resided.

RESULT

Serious falls did not increase, but nonserious falls increased significantly after restraints were removed or reduced in experimental subjects. The total mean weekly fall rate for this group increased from 1.87% of residents falling per week during preintervention to 3.01% during postintervention. The mean weekly fall rate of the control group was 3.18% at pretest and did not change statistically over time.

CONCLUSIONS

The increase in nonserious falls among the experimental group may be attributed to restraint reduction. The mean weekly fall rate in the experimental group postintervention (25 weeks) became comparable to the mean weekly fall rate for the control group during the entire study period (50 weeks). In light of such findings, policy makers have to confront the ethical choice between tying some frail, elderly subjects to beds and chairs versus exposing them to the risks of freedom in their old age.

Taurolidine peritoneal lavage as prophylaxis against infection after elective colorectal surgery

A total of 300 patients undergoing elective colorectal surgery over a 3-year period were randomly assigned to receive intraoperative peritoneal lavage with either taurolidine or saline. Culture swabs were taken from the region of surgery before and after lavage and the development of postoperative infection monitored. Of the positive culture swabs before lavage, a significantly higher proportion were negative after lavage with taurolidine than after that with saline. However, there was no difference in the incidence of postoperative infection between groups, suggesting that taurolidine intraoperative peritoneal lavage confers no clinical benefit over that with saline.

Quantitative DNA measurement by flow cytometry and image analysis of human nonseminomatous germ cell testicular tumors

Current clinical staging, which includes the use of serum tumor markers and imaging techniques, fails to identify the 30-40% of clinical stage I (CS I) nonseminomatous germ cell testicular tumor (NSGCT) patients who have occult metastatic disease. Therefore, there is a real clinical need to evaluate new biological parameters of the primary tumor that might be useful as predictors of occult metastatic disease. This study was undertaken to compare quantitative DNA measurements by flow cytometry and image analysis in CS I NSGCT, and to analyze the relevance of these parameters for predicting occult lymph node involvement. Different blocks of formalin-fixed, paraffin-embedded NSGCTs of 62 CS I patients who underwent retroperitoneal lymph node dissection between 1985 and 1989 were prepared according to the Hedley technique, and analyzed by quantitative cytometry. Thirty-six (58.1%) patients had histologically proven lymph node involvement (pathological stage II), whereas 26 (41.9%) patients (pathological stage I) had neither lymph node metastases according to retroperitoneal lymph node dissection (RPLND) specimens nor tumor recurrence during follow-up. Concordant results were found in 76.5% of the samples by both cytometric techniques. For flow cytometry, the percentages of aneuploid cells in the S- and the G2M + S-phase were the most robust predictive parameters for lymph node involvement, whereas for image analysis the 5c exceeding rate (5cER) had the most predictive significance. Based on the experience obtained in this study, both cytometric techniques provide additional information on tumor aggressiveness that might be useful in therapeutic selection of early stage NSGCT patients for either RPLND or surveillance only.

Temporomandibular ganglion or synovial cyst? A case report and literature review

A ganglion of the temporomandibular joint is a rare finding but it is important in the differential diagnosis of a preauricular swelling. This case report illustrates the usefulness of ultrasound in attempting to establish a preoperative diagnosis of a preauricular swelling. This article also illustrates the histologic techniques that may be used to distinguish a true ganglion from a synovial cyst or bursa.

Flow-cytometric and quantitative histologic parameters as prognostic indicators for occult retroperitoneal disease in clinical-stage-I non-seminomatous testicular germ-cell tumors

Our study was performed to clarify whether the combination of DNA flow-cytometric and quantitative histopathological parameters improves the prediction of occult metastatic disease in clinical stage-I non-seminomatous testicular germ-cell tumors (NSGCT). We used archival paraffin primary-tumor tissue of 67 clinical stage-I NSGCT patients who had undergone retroperitoneal lymph-node dissection (RPLND). According to the RPLND specimens, 24 patients were at pathological stage I and 43 at pathological stage II. Archival blocks were redissected for histological re-evaluation. In addition, 50 microns sections were prepared according to the Hedley technique in order to obtain nuclear suspensions which were processed for flow cytometry (FC). In univariate analysis, the percentage of embryonal carcinoma, the percentage of immature teratoma and vascular invasion were the most accurate predictive histopathological parameters. The percentage of aneuploid cells in S-phase was the best predictive FC parameter. In multivariate analysis, the percentage of embryonal carcinoma and the S-phase fraction of aneuploid cells were the only independent markers for occult metastatic disease. According to this statistical approach, 91.0% of pathological stage-I and stage-II cases were correctly classified. Sensitivity was 95.3% and specificity was 83.3%. Using histopathological criteria alone, only 56.7% NSGCT patients were correctly classified.

Signaling and drug sensitivity

Even though alterations in receptor and nonreceptor kinases are involved in the development of human cancer, many cancer cell lines still retain their responsiveness to growth factors. We have investigated the hypothesis that cellular signaling events regulate the sensitivity of cancer cells to chemotherapeutic agents. In 2008 human ovarian carcinoma cells, activation of a number of different transduction pathways resulted in a 2 to 4-fold increase in the sensitivity to cisplatin. These signaling events include pathways activated by the epidermal growth factor (EGF) receptor, tumor necrosis factor alpha (TNF alpha) receptor, bombesin receptor, protein kinase A (PKA), and protein kinase C (PKC). Enhanced sensitivity to chemotherapeutic agents is presumed to be mediated by phosphorylation of critical target protein(s). beta-tubulin has been identified as one such target for the protein kinase signaling cascade. For other signal transduction pathways the key substrates that regulate drug sensitivity have not yet been identified. Recent work has shown that DNA damaging agents activate signaling cascades one of which involves the Src, Ras, and Raf proteins as intermediates and results in induction of a number of genes, including c-fos, c-jun, and the growth arrest and DNA damage-inducible (gadd) genes. This signaling cascade has been shown to involve activation of protein kinase C and to have a protective function. With the growing understanding of how signaling events relate to damage response and drug sensitivity, new and potentially useful strategies for modulating drug sensitivity are evolving.

Treatment of traumatic radioulnar synostosis by excision and postoperative low-dose irradiation

Post-traumatic radioulnar synostosis can have a profound effect on upper extremity function. Prior reports of excision, with and without interposition material, have demonstrated frequent recurrence and disappointing results. Based on a favorable experience with radiation prophylaxis of heterotopic ossification following total hip arthroplasty, this modality has been used in the management of post-traumatic forearm synostosis. Four cases using excision of bony synostosis followed by single-fraction, low-dose (800 cGy), limited-field irradiation are presented. With a follow-up period of 1-4 years after excision and irradiation, all four patients had total arcs of forearm rotation between 115 degrees and 120 degrees. Each patient noted sustained functional improvement, and there was no x-ray film evidence of recurrent synostosis formation. Single fraction irradiation did not require ongoing patient compliance nor did it complicate rehabilitative efforts. Furthermore, soft tissue and bony healing were not impaired.

Gains in dental care use not shared by minority elders

Americans have steadily increased their reported use of dental services over the past 30 years. Persons aged 65 years and older have made the greatest gains, from 16 percent in 1957-58 to 43 percent in 1989. This article reviews national data on reported use of dental care over the past three decades, focusing on differences in rates of utilization on the basis of age, race, and national origin. In addition, differences in sample selection, definitions of race and national origin, and data collection methodology were reviewed to identify systematic sources of bias in comparing the data. Findings indicate that reported dental care use among minority elders has not increased parallel with elders of all races and national origins. In 1957-59, 17 percent of white elders versus 9 percent of nonwhite elders had seen a dentist within the past year. By 1989 percentages had improved to 45 percent of whites, but only 22 percent of blacks and 40 percent of Hispanics. In addition, reporting and recording race and national origin varied considerably during the three decades, hampering comparisons over time. Finally, published national data on usual correlates of dental care use (dentition status, insurance, age, income, and education) are inadequate to explain the causes of these discrepancies. More research is needed to identify barriers to use of dental care by all Americans, particularly those of African and Hispanic descent.(ABSTRACT TRUNCATED AT 250 WORDS)

Tamoxifen modulation of cisplatin cytotoxicity in human malignancies

Recent clinical trials have indicated that addition of tamoxifen (TAM) to a combination of cisplatin (DDP), carmustine and dacarbazine markedly increases the overall objective response rate of patients with metastatic malignant melanoma. Previous studies have determined that there is remarkable synergy between TAM and DDP in a human melanoma cell line T-289. Using the technique of median effect analysis, in clonogenic assay, we observed a highly synergistic interaction between TAM and DDP. To determine whether or not this synergistic interaction was unique to human melanomas, or is generally observed in other types of malignancy, we examined the nature of this interaction using a human ovarian carcinoma and small cell lung cancer cell line. Synergy was observed in both cell lines. In the case of all 3 types of malignancy, synergy was observed at concentrations of both TAM and DDP that can be achieved in patients. Our results demonstrate that cytotoxic synergy between the DDP and TAM is observed in cell lines established from multiple types of human malignancies. It is important to note that the synergy between TAM and DDP is not dependent on the presence of estrogen or progesterone receptors. Since TAM is well tolerated by patients, it is particularly attractive as a potential agent with which to sensitize human tumors to DDP.

Extension of limb salvage by combined vascular reconstruction and adjunctive free-tissue transfer

PURPOSE

Vascular reconstruction alone can be insufficient for extremity salvage in some patients with severe soft-tissue wounds. We present our experience in 20 patients with vascular reconstruction for ischemic disease and free-tissue transfer for limb-threatening soft-tissue wounds.

METHODS

Nineteen patients underwent autogenous venous bypasses and one patient underwent an aortobifemoral bypass. Ten soft-tissue reconstruction were performed at the time of the vascular reconstruction and 10 were delayed. Free-tissue transferred included muscle, fasciocutaneous flaps, and omentum. Inflow to the flap was from the bypass graft (n = 12) or the distal tibial artery.

RESULTS

One free flap and graft failed immediately in the same patient. One successful flap and graft required a below-knee amputation for ongoing infection in the surrounding soft tissues. Eighteen of 20 patients have had free-flap and graft patency during the mean follow-up period of 17 months (range 6 to 33 months). These 18 patients ambulate independently.

CONCLUSIONS

In patients with arterial insufficiency and severe soft-tissue wounds, combined vascular reconstruction and free-tissue transfer permits extended limb salvage with excellent functional results.

Caries incidence in patients with dementia

One in ten persons over the age of 65 and as many as half the population aged 85 and over have Alzheimer's disease. Review of the literature reveals substantial decrements in oral health in persons with dementia as measured by denture hygiene, coronal decayed, missing and filled teeth, filled teeth (cervical), percentage of the population with caries, Oral Hygiene Index-simplified, and of sites with plaque, gingival bleeding and calculus. A study of caries incidence is described in 23 male veterans with moderate and advanced dementia of the Alzheimer's type, using a comparison group of male veterans from the Department of Veterans Affairs Dental Longitudinal Study, matching 2:1 for age, number of teeth and education. Baseline findings indicate significant differences in the numbers of coronal surfaces with decay, root decayed and/or filled teeth and root decayed and/or filled surfaces. Mean annual increments of coronal caries in the dementia group were 2.29 +/- 4.29 per 100 surfaces at risk, over twice that in the comparison group (0.88 +/- 1.14). For root caries, mean annual increments in the dementia group were 2.38 +/- 5.57 per 100 available surfaces, versus 0.31 +/- 0.69 in the comparison group. Despite these large mean differences, the marked variability in these small samples statistical significance in caries increments between the two groups. The article concludes by suggesting some potential modifications to clinical trials of caries preventive agents and some overall research issues in populations with dementia.

Development and transferability of near-infrared methods for determination of moisture in a freeze-dried injection product

Near-infrared reflectance (NIR) methods for non-invasive and non-destructive measurement of moisture in a lyophilized product were developed independently at two sites. NIR spectra were collected with the same model instrument at each site. The spectra were scanned through the bases of unopened glass vials using a horizontal instrument accessory. The primary reference data for moisture content were generated using Karl-Fischer titration on the same individual vials. The NIR calibration equations were developed with second derivative spectral data using regression programs within the NIR software. These calibration equations were validated using independent test data from additional vials of product from the original site, and cross tested against similar data from the other site to check their robustness. This cross comparison demonstrated that a calibration equation from one site could satisfactorily be used for predicting moisture contents in product manufactured at the other site. Expected variations arising from differences in vial material, manufacturing process, analysts and instruments appeared to be satisfactorily accommodated. Finally, two test data sets were obtained by scanning a set of samples on two spectrometers at one site. The results from these data sets were comparable using the calibration equation developed solely on one of the two instruments. The results from all calibration and test sets are presented and discussed, and an assessment of the method transferability between instruments and sites is given.

Near-infrared methods for the identification of tablets in clinical trial supplies

Near-infrared reflectance analysis (NIR) methods have been developed for the confirmation of the identity of blister-packed tablets for clinical trial supplies. Three approaches are described: (1) presentation of single exposed tablets from blisters directly to the optical window; (2) presentation of unopened opaque blister-packed tablets directly to the optical window of the NIR instrument; and (3) use of a fibre-optic accessory to examine tablets through unopened opaque blister packs. For clinical purposes, all tablets in this trial were manufactured to match the appearance of one another. Tablets containing four strengths of an experimental drug (2, 5, 10 and 20% w/w of the active), a marketed product as a clinical comparator (80% w/w of the active), and a placebo were investigated. The NIR methods were developed by chemometrically building a library with second derivative spectra for each tablet type. Library validation and test data are presented along with a comparison of the three sample presentation techniques. The scope and limitation of each sample presentation technique are discussed.

Tamoxifen modulation of cisplatin resistance in patients with metastatic melanoma. A biologically important observation

BACKGROUND

Treatment with the four-drug combination of dacarbazine (DTIC), carmustine (BCNU), cisplatin (DDP), and tamoxifen (TAM) has resulted in an overall response rate of more than 50% in patients with metastatic melanoma. Deletion of TAM from the regimen resulted in a decrease in the response rate to 10%, suggesting an important role for TAM. The authors have subsequently demonstrated that TAM is highly synergistic with DDP in a human melanoma cell line, T-289, which supports the clinical observation that TAM is important in this regimen. The authors conducted a clinical trial to determine whether the addition of TAM can overcome established DDP resistance in patients with malignant melanoma.

METHODS

Patients with metastatic melanoma were initially treated with DDP 100 mg/m2 alone until they demonstrated DDP resistance. On the next cycle of treatment, patients received TAM 40 mg by mouth four times a day on the day before DDP treatment followed by 20 mg by mouth daily for the rest of the 3-week cycle plus the same dose of DDP.

RESULTS

Among 24 patients treated with DDP alone there were one complete and two partial responses. Twenty patients, in whom single-agent DDP failed, were treated with the combination of TAM and DDP. Of these 20 patients, 19 were evaluable for response. Among these 19 patients, there were three partial responses (16%) and three mixed responses (16%), for an overall response rate of 32% (0% was expected) (P < 0.001). If the three mixed responses are eliminated, the statistical significance is of borderline significance (P = 0.058).

CONCLUSIONS

The addition of TAM to DDP can overcome established DDP resistance in a subset of patients with metastatic melanoma.

Effects of medication on parotid salivary flow rates in an individual with dementia of the Alzheimer type

Data available on the relationship between salivary function and specific drug therapy are sparse. We measured unstimulated and stimulated parotid salivary flow rates associated with the drug therapies. Our ancillary study design is an N = 1 double-blind randomized controlled trial in which the patient undergoes a series of treatment blocks of either placebo or active treatment. The purpose of the parent N of 1 study was to find the "best single drug" treatment for a resistive patient diagnosed with dementia of the Alzheimer type. This study demonstrates that thiothixene was associated with inconsistent effects on parotid flow. Oxazepam had no effect on his parotid function, and diphenhydramine hydrochloride had inconsistent but generally negative effects. The data also show that this individual with dementia of the Alzheimer type had lower baseline unstimulated and stimulated parotid salivary flow rates when compared with mean "normal" values; however, flow rates were above the lowest 10th percentile of "normal" volunteers.

Platelet-derived growth factor induces proliferation of hyperplastic human prostatic stromal cells

Prostatic hyperplasia (BPH) is a very common disease in elderly men and is characterized by abnormal proliferation of the stromal and epithelial cells of the prostate. The observation that BPH often occurs in association with chronic inflammation has led to the examination of the possibility that platelet-derived growth factor (PDGF), which is released in response to inflammation, may be an etiological factor in the genesis of the disease. It has been shown that cultured cells derived from human prostatic tissue express high affinity PDGF-beta receptors based on receptor binding and cross-linking studies with [125I]-PDGF-BB. The experiments presented below demonstrate that PDGF receptors are activated in response to the growth factor and that mitogenesis is induced. PDGF-BB treatment of cultured human prostate cells derived from patients with BPH activates the signal transduction pathway of the PDGF receptor as shown by the presence of several phosphoproteins in antiphosphotyrosine immunoprecipitates, including autophosphorylation of the PDGF receptor. Phosphatidylinositol (PI) 3-kinase activity is also increased in cells stimulated with PDGF. The addition of PDGF-BB to the medium causes of variable but dose-dependent increase in [3H]-thymidine incorporation. This paper describes the first demonstration that PDGF is a potent mitogen for human cells derived from patients exhibiting prostatic hyperplasia, and also demonstrates that the cellular response to PDGF-BB is heterogenous in a manner that is consistent with the varying degree of hyperplasia and inflammation clinically and histologically in the tissue specimens.

Oral health status of a long-term-care, veteran population

The Department of Veterans Affairs (VA) operates the largest, integrated health care system in the United States of America. The projected need for long-term-care in the VA health care system parallels an expected increase in need for care in the United States, but precedes the need for care in the general population by 25-30 yr. The VA's Office of Dentistry, in an effort to estimate the resource requirements of this swelling group of veterans, initiated in 1986-7 an oral health survey of long-term care patients. The overall goals were to describe the oral health status of VA nursing home care units (NHCU) residents and to develop a methodology for estimating future dental health services utilization. This study describes the oral health status of the study population. Demographic and oral health data were collected for 650 long-term care residents of six VA NHCUs between October 1986 and July 1987. Data were collected on sociodemographic status, medical history, dental caries, periodontal diseases, oral soft tissue pathology, and the presence of dental prostheses. Caries and periodontal disease were evaluated using the United States National Institute of Dental Research Survey of Employed Adults and Seniors protocols. The oral health status of the population is described using DMF and ESI indices, the prevalence of oral lesions, levels of tooth loss, oral hygiene scores, and the status of existing dentures. Findings show moderate levels of untreated dental caries and periodontal disease and significant tooth loss which increased with age. A need for preventive therapy, restorative dentistry, conservative periodontal therapy, and prosthodontic care was evident.(ABSTRACT TRUNCATED AT 250 WORDS)