Measuring heroin use in methadone maintenance programmes

This study compares a number of self-reported measures of drug use with the results of urine testing in a group of patients receiving methadone maintenance treatment. One hundred and twenty-nine subjects were interviewed and 4-5 months later, a second interview was obtained from 87 of these. At each interview subjects were asked about drug use on each of the preceding 7 days and also about the number of days of drug use in the previous month. It was found that most patients were continuing to use heroin, usually fairly infrequently. Direct comparisons of urine test results and self-reported drug use indicate substantial positive correlations. However, there was a tendency for self-report to underestimate drug use in this patient sample. It appears that urine testing is the single most useful measure of drug use. This supports the notion that it is a valid tool in evaluation research. However, the combination of self-report and urine tests provides more information about drug use than any single measure.

Pain and addiction

In a society which is drug-orientated yet is committed to a 'War on Drugs', guidelines for prescribing narcotic analgesics are marked by division and inconsistency. A fear of engendering an addiction leads to anxiety in doctors about prescribing these analgesics and to the inadequate treatment of pain. The concept of 'addiction' is derived from an essentially moralistic view of drug use, and serves as a barrier to effective treatment of chronic non-malignant pain. A biopsychosocial approach to disease provides a better basis for treatment of this type of pain.

Susceptibility of ascites tumor cells to ex-vivo killing by the oncolytic virus JX-963 in epithelial ovarian cancer

e16537

Background: Epithelial ovarian cancer (EOC) has a poor prognosis, and novel therapies are urgently needed. One-third of patients with EOC will develop clinical ascites, an adverse prognostic factor. The ascitic fluid is rich in tumor cells which can be purified and used as a valuable source of patient material for in vitro analysis. In this study, we describe a method to evaluate the efficacy of ascitic tumor cell killing by the oncolytic virus, JX-963 (vaccinia strain) currently approved for use in a NCIC-CTG phase I trial. Methods: Research ethics approval and patient consent was obtained for this study. 15 samples were collected prospectively with relevant clinicopathologic information. Infection with JX-963 was performed using viral doses ranging from a multiplicity of infection (MOI) of 0.5 to 8. Following a seven-day infection period, viability was assessed using the Alamar Blue metabolic assay and tracked by virally encoded green fluorescent protein (eGFP) expression, immunohistochemistry (IHC) and flow cytometry. Results: A standardized protocol was developed for the collection and purification of EOC cells from patient ascites for subsequent infection and quantification of viral killing. Qualitative analysis using phase contrast imaging of the total cell content showed greater opaque dead cell aggregates with increasing MOI over time. Although variable between individual samples, there was a strong correlation between escalating MOI and enhanced cell death in all patient ascites samples, when quantified by Alamar Blue assay and confirmed by flow cytometry and IHC. Similar cell killing profiles by JX-963 were observed for ascites tumor cells derived from both chemotherapy-naïve patients and chemotherapy-exposed (>1 prior line of chemotherapy) patients. Conclusions: EOC cells from patient ascites show effective but differential susceptibility to viral oncolysis by the JX-963 virus that appears to be independent of prior exposure to chemotherapy. The relevance of this work is that in an individual patient, this assay will allow the testing of panels of oncolytic viruses to identify candidate viral therapeutics which may predict response to treatment.

No significant financial relationships to disclose.

Elective intra-aortic balloon counterpulsation during a high risk liver resection

SUMMARY

We present the case of a 65-year-old male with severe coronary artery disease and a single colorectal liver metastasis. An elective intra-aortic balloon pump (IABP) was inserted following induction of anaesthesia to reduce left ventricular workload during his liver resection. After an uneventful recovery he was discharged on day 5. We review the literature on the elective use of these devices in cardiac surgery in which it is becoming routine practice in high risk patients. However in non-cardiac surgery there have been only 15 published cases all in very high risk patients, with favourable outcomes. To our knowledge this is the first published case of the use of elective IABP during liver surgery.

Propranolol, post-traumatic stress disorder and narrative identity

Research funded by Canadian Institutes of Health Research, NNF 80045, States of Mind: Emerging Issues in Neuroethics. While there are those who object to the prospective use of propranolol to prevent or treat post-traumatic stress disorder (PTSD), most obstreperous among them the President's Council on Bioethics, the use of propranolol can be justified for patients with severe PTSD. Propranolol, if effective, will alter the quality of certain memories in the brain. But this is not a serious threat to the self understood in terms of narrative identity. A narrative identity framework acknowledges that memory is always being subtly altered or modified. For severe cases of PTSD propranolol may help victims who don't respond to any other therapy or therapy combination regain their authentic self-narrative and engage once more in life activities. For those whose symptoms are not so severe the potential risks and side-effects of the drug may outweigh the benefits. Patients and family members should be allowed to decide, in consultation with their physician, whether this drug is appropriate in their case.

The relationship between the systemic inflammatory response, tumour proliferative activity, T-lymphocytic and macrophage infiltration, microvessel density and survival in patients with primary operable breast cancer

The significance of the inter-relationship between tumour and host local/systemic inflammatory responses in primary operable invasive breast cancer is limited. The inter-relationship between the systemic inflammatory response (pre-operative white cell count, C-reactive protein and albumin concentrations), standard clinicopathological factors, tumour T-lymphocytic (CD4+ and CD8+) and macrophage (CD68+) infiltration, proliferative (Ki-67) index and microvessel density (CD34+) was examined using immunohistochemistry and slide-counting techniques, and their prognostic values were examined in 168 patients with potentially curative resection of early-stage invasive breast cancer. Increased tumour grade and proliferative activity were associated with greater tumour T-lymphocyte (P<0.05) and macrophage (P<0.05) infiltration and microvessel density (P<0.01). The median follow-up of survivors was 72 months. During this period, 31 patients died; 18 died of their cancer. On univariate analysis, increased lymph-node involvement (P<0.01), negative hormonal receptor (P<0.10), lower albumin concentrations (P<0.01), increased tumour proliferation (P<0.05), increased tumour microvessel density (P<0.05), the extent of locoregional control (P<0.0001) and limited systemic treatment (P⩽0.01) were associated with cancer-specific survival. On multivariate analysis of these significant covariates, albumin (HR 4.77, 95% CI 1.35–16.85, P=0.015), locoregional treatment (HR 3.64, 95% CI 1.04–12.72, P=0.043) and systemic treatment (HR 2.29, 95% CI 1.23–4.27, P=0.009) were significant independent predictors of cancer-specific survival. Among tumour-based inflammatory factors, only tumour microvessel density (P<0.05) was independently associated with poorer cancer-specific survival. The host inflammatory responses are closely associated with poor tumour differentiation, proliferation and malignant disease progression in breast cancer.

Clinical role of flow cytometry in redefining bone marrow involvement in diffuse large B-cell lymphoma (DLBCL) - a new perspective

AIMS

The clinical role of flow cytometry in staging bone marrow in diffuse large B-cell lymphoma (DLBCL), especially its impact on outcome, remains uncertain. The aim was to determine the contribution of flow cytometry to conventional staging, and to study the impact of this revised staging on survival.

METHODS AND RESULTS

One hundred and thirteen cases of DLBCL diagnosed at The Canberra Hospital from 1996 to 2005 were identified. Blinded analysis of bone marrow (BM) morphology and flow cytometric data showed involvement on morphology (M) in 25 (22.1%) cases, on flow cytometry (F) in 21 (18.6%) cases and overall (M + F) in 32 cases (28.3%); discordance was noted in 16 cases (16.1%). Cases with and without marrow involvement on conventional staging alone (M) had no significant difference in survival (P = NS). However, when BM involvement was defined as positivity on morphology and/or flow cytometry (M + F), the median survival of patients with involvement was significantly worse than patients without involvement (P = 0.026).

CONCLUSIONS

Flow cytometry-positive cases should be included with those positive on morphology in a summative model to define BM involvement in DLBCL, as it may have a potential impact on predicting outcome.

Pneumococcal septic arthritis as the initial presentation of multiple myeloma

Septic arthritis induced by Streptococcus pneumoniae is an uncommon manifestation of pneumococcal infection. Pneumococcus has been identified as the inciting pathogen in only 6% of cases of septic arthritis in recent retrospective studies (Ross et al., 2003). Approximately 50% of patients with pneumococcal septic arthritis have a preceding or concurrent extra-articular focus of infection. The septic joint evolves from hematogenous seeding of the highly vascular synovial membrane by bacteria. Polyarticular disease occurs in only approximately 36% of patients. Most pneumococcal septic arthritis occurs with coexistant joint disease, prosthesis, alcoholism, HIV infection, or rheumatoid arthritis (Baraboutis & Skoutelis, 2004; Raad & Peacock, 2004). We report a case of polyarticular septic arthritis as the first manifestation of an underlying disease. Our literature review discloses that this is the first reported case of multiple myeloma initially presenting as pneumococcal septic arthritis in the USA and the third internationally (Cuesta et al., 1992; Renou et al., 2007).

Natural Events

This paper develops an inductive theory of predictive common sense reasoning. The theory provides the basis for an integrated solution to the three traditional problems of reasoning about change; the frame, qualification, and ramification problems. The theory is also capable of representing non-deterministic events, and it provides a means for stating defeasible preferences over the outcomes of conflicting simultaneous events.

Prenatal diagnosis: current status and future trends

Many of the major single-gene disorders in man can now be detected in utero using restriction fragment length polymorphisms (RFLPs). This approach is based on the knowledge of established linkage between RFLPs and mutations in an adjacent gene. The development of the polymerase chain reaction has altered the available approaches to this problem. This technique permits very rapid detection of the specific mutation from small amounts of starting material and may enable us to detect the genotype from fetal cells in maternal blood or from single cells in embryos before implantation. This may lead to the selection of embryos that lack a defect before they are implanted, avoiding the need for termination of pregnancy. Perhaps the greatest ethical challenge related to the application of these techniques will come with the understanding of the genetic basis for common polygenic disorders. The clarification of the multiple genetic factors responsible for a large part of susceptibility to diseases such as diabetes mellitus, rheumatoid arthritis or ischaemic heart disease will be greatly facilitated by a one-centimorgan genetic map. The strategy involved in establishing such a map, using the polymerase chain reaction, and then the identification of genetic loci responsible for susceptibility to a typical polygenic disease (insulin-dependent diabetes mellitus), is discussed. The ability to identify individuals at high risk of developing such diseases may present opportunities for early intervention.

Lemierre's syndrome complicating pregnancy

Lemierre's syndrome is an anaerobic suppurative thrombophlebitis involving the internal jugular vein secondary to oropharyngeal infection. There is only one previous case report in pregnancy which was complicated by premature delivery of an infant that suffered significant neurological damage. We present an atypical case diagnosed in the second trimester with a live birth at term. By reporting this case, we hope to increase the awareness of obstetricians to the possibility of Lemierre's syndrome when patients present with signs of unabating oropharyngeal infection and pulmonary symptoms.

Virtual vs. optical colonoscopy in symptomatic gastroenterology out-patients: the case for virtual imaging followed by targeted diagnostic or therapeutic colonoscopy

AIM

To compare virtual colonoscopy with optical colonoscopy findings in symptomatic patients.

BACKGROUND

Computer tomographic colonography is an alternative to optical colonoscopy. Studies have shown that two-dimensional computer tomographic colonography does not have sufficient sensitivity. Three-dimensional computerized tomographic virtual colonoscopy compares well with optical colonoscopy for colorectal neoplasia screening in asymptomatic individuals.

METHODS

One hundred patients aged 50 and older underwent same day virtual colonoscopy and optical colonoscopy. The endoscopists were unaware of the radiologist's report until the withdrawal phase of the endoscopy when segmental unblinding occurred. The virtual colonoscopy and optical colonoscopy findings were compared by using the unblinded optical colonoscopy as the reference standard.

RESULTS

Pancolonic endoluminal virtual colonoscopy was achieved in 99 patients. Optical colonoscopy caecal intubation occurred in 91 patients. Direct comparison was possible in 90 patients. Both techniques revealed the three cancers detected. Virtual colonoscopy revealed 11 polyps > or = 6 mm diameter in nine patients. Optical colonoscopy revealed 10 polyps > or = 6 mm diameter in nine patients with a further 15-mm polyp discovered after segmental unblinding.

CONCLUSION

In symptomatic patients, three-dimensional virtual colonoscopy is equivalent to optical colonoscopy for diagnosing colon cancer and clinically significant polyps. A case can be made for three-dimensional virtual colonoscopy as a primary modality followed if necessary by same day-targeted optical colonoscopy.

Acute ventricular and aortic thrombosis post chemotherapy

We present a rare case of spontaneous arterial thrombosis in a 42-year-old male with an acute history of bilateral lower limb pain and weakness. The previous day he had received the first cycle of cisplatin-based chemotherapy for oesophageal adenocarcinoma (T2/3N0/M0). Computed tomography (CT) and angiography showed extensive abdominal aortic thrombus in a native non-aneurysmal or grossly atheromatous aorta with separate thrombus in the left ventricle. We suggest that poor left ventricular function, a hypercoaguable state secondary to malignancy and cisplatin based chemotherapy may have induced severe arterial and intra-cardiac thrombosis.