Aneurysmectomy in the octogenarian. A study of morbidity and quality of survival

The records of 52 octogenarians who underwent resection of an abdominal aortic aneurysm were reviewed. Thirty-five elective operations were performed with an operative mortality of 8.6 percent, which was twice that of the group less than 80 years of age. Seventeen emergency operations were performed for rupture with an operative mortality of 58.8 percent. Postoperative follow-up in the elective group found that by 6 months 93 percent of surviving patients had returned to their preoperative status. Survival rates by life table analysis were 67 percent at 1 year, 52 percent at 3 years, and 14 percent at 5 years. In the ruptured group, all patients at risk were alive at 1, 3, and 5 years. We advise elective resection of an abdominal aortic aneurysm in the octogenarian with good functional capacity using the same criteria that we use for younger patients. Most octogenarians can anticipate a prompt return to their usual environment and a meaningful postoperative life-style.

The photoreceptors of the West Indian manatee

Using light and electron microscopy we found that the manatee retina has both rodlike and conelike photoreceptors in accord with its diurnal behavior pattern. Outer segment disks in both cell types appear to be enclosed along most of their length within the plasma membrane. The synaptic terminals are simple, with small, superficial postsynaptic contacts. The cones have long inner segments, short, conical outer segments and terminals with numerous synaptic ribons and deeply embedded postsynaptic elements. There are two cone subclasses that may subserve color vision. Morphometry shows that there are more ganglion cells of small size ventrally, and that the thickness of the nerve fiber layer there is reduced, suggesting the presence of a specialized visual area in the retina. However, there were no pronounced differences in cone cell density in any of the regions examined.

Quality control for estrogen receptor quantification by dextran-coated charcoal assay: a single laboratory's experience

Wide fluctuations in results obtained by different laboratories for the content of estrogen receptors from a single source of tissue powder were reported by several investigators at the 1979 NCI Consensus Committee Meeting for Steroid Receptors in Breast Cancer and were further supported by data collected by our laboratory for the Eastern Cooperative Oncology Group. In a multilab study the inconsistency in the receptor content is a product of the variations associated with the assay procedures used by different laboratories and those due to unavoidable daily changes in the experimental conditions within each laboratory. In this report we present data on the variation of estrogen receptor measurements obtained by a single laboratory for any single source of tissue powder repeatedly analyzed. A retrospective analysis of the data collected on the receptor content of several different batches of calf uteri analyzed on different days (inter-assay variation) under uniform conditions revealed a coefficient of variation averaging +/- 35% (standard deviation divided by mean X 100). Experiments showed that the fluctuations in the receptor yield from aliquots of the same tissue powder are primarily an effect of the homogenization step that precedes cytosol preparation. Therefore, for establishing quality control, distribution of lyophilized cytosols should precede lyophilized powders to test the efficiency of performance of laboratories. A homogenizer designed to minimize thermal denaturation is also essential.

Immunohistochemical localization of estrogen receptors in human mammary carcinoma using antibodies to the receptor protein

An immunofluorescent method has been developed for localizing estrogen receptors (ER) in frozen sections of human breast cancer biopsies which utilizes the biochemically well-characterized antibodies to the cytoplasmic ER of human breast cancer produced in rabbits. Frozen sections of sixteen breast cancer biopsies, in which the receptor content has been quantified using dextran-coated charcoal assay (DCC technique), were used to study the localization of ER. Two aspects of ER detection, namely "estrogen-binding" and ability to react with the homologous antibodies, have been analyzed and the results compared with those of DCC technique. Fluorescent labelled estrogen method (F.E2) of Pertschuk was utilized to detect the distribution of estrogen binding proteins and the indirect immunofluorescent (IM-AR) method using anti-receptor antibodies to assess the antigenic sites of the receptor protein. In addition to the comparison of the results of three techniques, DCC, IM-AR and F.E2, for ER detection, a procedure for processing the frozen sections, which enables the study of estrogen binding characteristic as well as the antigenic reactivity of the receptor molecules, is described.

Corticopontine projections of the lateral suprasylvian cortex: de-emphasis of the central visual field

Layer V pyramidal cells of the cat lateral suprasylvian visual areas project to the pontine nuclei. Although all 6 of the suprasylvian visual areas project to the pons, the densest projections are from 3 areas: anterior medial lateral suprasylvian (AMLS), posterior medial lateral suprasylvian (PMSL) and ventral lateral suprasylvian (VLS). The organization of the corticopontine pathway from one of these areas (PMLS) suggests a disproportionate representation of the peripheral visual fields. This pattern of projection would serve to de-emphasize the central visual field.

Management of postoperative stroke after carotid endarterectomy

Major postoperative stroke after carotid endarterectomy is often due to carotid thrombosis, and prompt thrombectomy can reverse the neurologic deficit. We advise reoperation providing the stroke occurs within several hours of carotid endarterectomy, preferably when the patient is in the recovery room, and reoperation can be done immediately. We do not delay reoperation for angiography. Reoperation has not been beneficial for strokes that occur later in the patient's course or when there has been a severe preoperative neurologic deficit. Patients with a mild postoperative stroke, especially if the stroke represents worsening of a preoperative deficit, will often improve without intervention.

Estrogen receptor status and response to chemotherapy in advanced breast cancer: the Tufts-Shattuck-Pondville experience

Eighty-eight patients with advanced breast cancer were retrospectively reviewed to compare estrogen receptor (ER) data with response to cytotoxic chemotherapy. All assays were done in a single laboratory. All patients were cared for at a single institution. Thirty-four patients were treated with chemotherapy, 30 of whom were evaluable for response by criteria of the Eastern Cooperative Oncology Group (ECOG). Of 16 ER-positive patients, 12 (75%) responded; of 14 ER-negative patients, six (43%) responded (P < 0.05). The two groups did not differ significantly in chemotherapy received, menopausal status, site of predominant disease, stage at diagnosis, or disease-free interval. Response to cytotoxic chemotherapy does not appear to correlate with ER status.

Estrogen receptors in male breast cancer

Estrogen receptor assays were performed on tumor specimens from 6 male patients with documented breast cancer. Five out of six (83%) males had positive ER assays with values ranging from 23-384 femtomoles per mg cytosol protein. A review of the literature showed that 32 out of 38 patients (84%) reported were positive for estrogen receptor. Four out of five ER positive males responded to orchiectomy. Estrogen receptors are present in a high percentage of males with breast cancer and may predict response to treatment, similar to female breast cancer.

Metabolism of methotrexate in man after high and conventional doses

Methotrexate has been found to be extensively metabolized to 7-hydroxymethotrexate in patients receiving conventional doses (less than 10 mg/kg) and high doses (greater than 10 mg/kg). Twelve hours after administration, plasma levels of this metabolite in several patients treated with low doses exceeded those of methotrexate. No 7-hydroxymethotrexate was found in CSF after CNS administration of methotrexate; however, small amounts of the metabolite was found in the CSF after intravenous high dose infusion. We conclude that methotrexate is significantly metabolized in man at all doses used clinically.

Distribution of adriamycin in cancer patients: tissue uptakes, plasma concentration after IV and hepatic IA administration

Twenty patients with solid tumors received 30 mg/M2 of adriamycin. Various tissue samples were intraoperatively obtained from 18 patients, about 1.5--5 hours after an intravenous (IV) bolus dose. Normal liver showed the highest levels of adriamycin uptake (2.3--19.8 micrograms/g); lymph nodes were second; muscle and bone marrow, next; fat and skin had the lowest adriamycin uptake (0.04--0.40 microgram/g). Tumor tissue, excluding that with much necrosis and hemorrhaging, had adriamycin concentrations which approximated those of the liver (1.1--9.2 micrograms/g). Six patients, all with hepatic malignancies, had prolonged plasma concentration studies after IV administration; 5 also had adriamycin administered directly into the hepatic artery catheter. Adriamycin-plasma-time courses were similar, whether the drug was administered by bolus directly into the hepatic artery or peripheral vein. The concentration of metabolites after hepatic intraarterial administration was definitely higher than that after IV administration. Patients with hepatic dysfunction had delayed plasma clearance and secondarily elevated levels approximately 160 and 300 minutes after administration.

Quantitation of oestrogen receptors: use of solid-phase antisteroid antibodies to quantify binding sites and determination of dissociation constant

The dextran-coated charcoal assay method of McGuire and DeLaGarza is a well-known method for quantitation of oestrogen receptors in breast tumour tissues. Castañeda and Liao reported that the solid-phase antisteroid antibodies are superior to dextran-coated charcoal for quantitating the receptor bound steroids. In this report we compare the results obtained using both methods to quantitate oestrogen receptors and determine the affinity for steroid binding in seven human breast tumours and the uteri of rat and calf.

Corticopontine visual projections in macaque monkeys

These experiments were designed to study the projections to the pons from visual and visual association cortex of monkeys by degeneration staining and horseradish peroxidase (HRP) methods. When lesions were made in these cortical visual areas, degenerated fibers were found in the rostral dorsolateral area of the pontine nuclei. When HRP was injected among visually responsive cells in this region of the pons, layer V cortical pyramidal cells were labeled. These labeled cells were concentrated most heavily on both banks of the superior temporal and intraparietal fissures, and on the rostral bank of the parieto-occipital fissure. The efferent targets and receptive field properties of these cortical regions are consistent with their possible role in visual guidance of movement.

The use of EMG feedback and progressive relaxation in the treatment of a woman with chronic back pain

In this systematic single-case study, a 71-year-old white female with chronic back pain and paravertebral muscle spasm was treated with 17 sessions of electromyographic (EMG) feedback, with recording site just below the right inferior scapular angle. Progressive relaxation practice was also employed. EMG level was monitored during baseline, treatment, and follow-up phases. Backaches were recorded by the subject on a daily basis. There was a marked decrease in both EMG level and frequency of backaches, as well as an increase in activities at home. Improvement was maintained 12 weeks after the last treatment session.

Carotid bruit: a follow-up report on its significance in patients undergoing an abdominal aortic operation

The records of 516 patients who underwent an elective abdominal aortic operation for aneurysmal or occlusive disease are reviewed. Four patients operated on twice are considered an individual patient for each operation. Excluding 27 patients who had a prior carotid endarterectomy, there were 84 with a carotid bruit. Thirty-six patients without a carotid bruit had experienced an episode of cerebral ischemia. Four patients had a postoperative stroke. There was no correlation between the stroke and presence of a carotid bruit or history of cerebral ischemic symptoms. We do not challenge the validity of prophylactic carotid endarterectomy but question if the need for an abdominal aortic operation should be considered indication for carotid angiography and surgery in patients with a carotid bruit.

Cellular pharmacology of 7(R)-O-methylnogarol: a new anticancer agent

The cellular accumulation and disposition of 7(R)-O-methylnogarol (7-OMEN), a derivative of the anthracycline antibiotic, nogalamycin, were compared to those of daunorubicin. Although both drugs were avidly accumulated by cells, intracellular concentrations of 7-OMEN were 5 to 10 times those of daunorubicin. Lowered temperature (0 degrees C) reduced intracellular accumulation of both drugs, but 10 mM sodium azide reduced the accumulation of 7-OMEN only. Both drugs exited from cells placed in drug-free medium, a process that was reduced at 0 degrees C. Sodium azide, 10 mM, did not alter the efflux of daunorubicin from cells but hastened the efflux of 7-OMEN. Unlike whole cells, isolated nuclei accumulated more daunorubicin than 7-OMEN. This process was not reduced at 0 degrees C. Both drugs were lost from nuclei placed in drug free buffer with only slight reduction at 0 degrees C. Unlike daunorubicin which localized in cell nuclei, 7-OMEN localized in the cytoplasm with no detectable nuclear fluorescence. Both drugs produced nearly equivalent dose-dependent inhibition of [3H]thymidine incorporation by L1210 and P388 cells. P388/ADR cells proved resistant to both anthracyclines. [3H]uridine and [3H]valine incorporations were inhibited by daunorubicin but were not altered by 7-OMEN.

Functional role of serotonergic neuromodulation in Aplysia

The serotonergic metacerebral cell (MCC) of the mollusk Aplysia produces slow synaptic potentials in motor neurons of the buccal muscle, and increases the rate of ongoing rhythmic burst output of the buccal ganglion. In addition, the MCC acts peripherally to enhance the strength of buccal muscle contractions that are produced by firing of motor neurons. The potentiation of contraction is not associated with any detectable changes of resting membrane potential of muscle cells. Although MCC activity produces a small enhancement of excitatory junctional potentials, several experiments clearly indicate that the MCC has a direct potentiating effect on excitation-contraction coupling. The data suggest that potentiation of contraction might be mediated by cAMP. For example, activity of the MCC enchances the rate of accumulation of cAMP in buccal muscle, application of phosphodiesterase resistant analogs of cAMP potentiates muscle contraction, and a phosphodiesterase inhibitor enhances the effect of MCC stimulation. Recordings from free-moving animals indicate that the MCC becomes activated by exposure of the animal to food stimuli, and that the activation parallels the presence of a food-arousal state. Food-arousal is characterized by enhanced strength and increased frequency of biting responses. Both these effects can result from activity of the MCC. Thus, in this system, modulatory synaptic actions function to provide the substrate for a type behavioral modulation.

GLC determination of caffeine in plasma using alkali flame detection

A rapid, specific, and sensitive GLC assay for caffeine in plasma was developed utilizing alkali flame-ionization detection. The procedure involves the addition of mepivacaine as an internal standard, alkalinization of the sample, and extraction with chloroform. Peak height ratio measurements produced linear standard curves in the 0.25-10.0-microgram/ml range. Absolute sensitivity from a 1.0-ml plasma sample was 0.1 microgram/ml. The relative standard deviation of a 2.0-microgram/ml pooled plasma standard run repeatedly over several months was 5.2%. The method is applicable to time-concentration studies in human and animal plasma following typical oral doses of caffeine.

Prediction of adriamycin disposition in cancer patients using a physiologic, pharmacokinetic model

A ten-compartment flow-limited pharmacokinetic model scaled from rabbit tissue distribution data was used to predict plasma adriamycin concentrations in 23 patients and adriamycin tissue uptake in nine surgery patients following iv bolus doses of 10--60 mg/m2. The predicted concentrations were compared to experimentally determined adriamycin using a specific thin-layer chromatographic fluorescence scanning procedure. The predicted plasma time course for 11 of 16 patients with relatively normal liver and kidney function agreed closely with the observed plasma time course. Deviations in the other five patients were ascribed to possible changes in the profile of metabolite formation and/or fluctuations in biliary clearance. All four patients with elevated serum bilirubin demonstrated significantly higher and more prolonged plasma levels than predicted. The results of two patients with impaired kidney function and one patient with both hepatic and renal involvement were inconclusive. The comparison between predicted and observed tissue concentrations in biopsy samples was varied; however, all were within an order of magnitude. It is concluded that the model depicts adriamycin uptake and distribution reasonably well; however, more needs to be known concerning individual variation in metabolic and biliary excretion rates for this to become more patient-specific. Also, a tumor compartment appears to be an important addition in modifying the model to allow for clinical utility.

High-presssure liquid chromatographic determination of methotrexate and its major metabolite, 7-hydroxymethotrexate, in human plasma

A rapid high-pressure liquid chromatographic assay is described for the analysis of methotrexate (MTX) and its major metabolite, 7-hydroxymethotrexate (7-OH-MTX), in plasma samples from patients following high-dose therapy. The method involves an ion-pair extraction of MTX from plasma with chromatography on a microparticulate anion-exchange column using ultraviolet detection at either 254 or 315 nm. Maximum sensitivity achieved was 1 X 10(-7) M. In addition to being specific for parent MTX, this procedure was used to detect and quantitate significant concentrations of 7-OH-MTX in several patients. Comparison to a protein-binding method indicated a greater degree of specificity for the chromatographic procedure. The procedure can be used to allow therapeutic monitoring of plasma MTX and metabolite for patients receiving high-dose MTX therapy as well as to determine the purity of formulations of MTX used clinically. In addition, the procedure is applicable to the support of pharmacokinetic studies of MTX in animals and man.

Immunological characteristics of a peroxidase protein in human neonatal cord serum

Adult serum haptoglobin-hemoglobin complexes exhibit acid-stable peroxidase activity. The haptoglobin level in human neonatal cord sera, however, is reported to be very low. We have isolated a protein from the cord sera of neonates, which has acid-stable peroxidase activity analagous to adult serum haptoglobins-haemoglobin complexes, but does not show any immunological identity to adult serum haptoglobins. It differs from the latter in its molecular size and electrophoretic mobility in agarose and polyacrylamide gels. It is unique to cord sera and it bears immunological identity to human IgG.

Ipsilateral blindness: a complication of carotid endarterectomy

We report on three patients in whom ipsilateral blindness developed following carotid endarterectomy. Fundoscopic examination of the retina documented ischemia and the visual field defects were permanent. In one patient, the internal carotid artery was patent and thought to be the conduit for embolization to the eye. Two patients had chronic occlusion of the internal carotid artery, and blindness resulted from atheromatous emboli to the eye through the external carotid artery in one and from postoperative thrombosis of the external cartoid artery in the other. Our experience calls attention to this infrequently reported complication of carotid endarterectomy and emphasizes the importance of the external carotid artery, especially when the internal carotid artery is occluded.

Pharmacokinetics in drug therapy II: Applications of clinical pharmacokinetics in the assessment of theophylline therapy

A patient case is presented to illustrate a systematic approach to the assessment and modification of theophylline therapy by the pharmacist using serum level analysis. The pharmacist is a pulmonary disease service is responsible for: (1) determining relevant aspects of the patient's clinical condition; (2) defining an initial theophylline administration regimen, including route, dose and schedule; (3) estimating expected theophylline levels based upon the regimen and known or assumed parameters of theophylline in the patient; (4) defining and recommending number and timing of serum samples to be drawn for analysis; (5) obtaining laboratory results and comparing with preliminary estimations; (6) assessing clinical response or toxicity, or both; and (7) recommending appropriate modifications in the theophylline regimen.

Determination of plasma and erythrocyte lithium concentrations by atomic absorption spectrophotometry

We describe a method for determining plasma and erythrocyte lithium concentrations by atomic absorption spectrophotometry. Plasma and hemolyzed whole-blood are diluted and analyzed, with use of a lithium hollow-cathode lamp, at 670.8 nm. Erythrocyte lithium concentrations are calculated indirectly from the hematocrit. The standard deviation for a 0.43 mmol/liter pool of whole blood, run daily over 11 months, was +/-20 mumol/liter (CV=5.1). The lithium concentration of a lyophilized pool assayed periodically over the same period (n=127) was 1.84+/-0.05 mmol/liter (CV=2.7%). The relatively low erythrocyte/plasma lithium ratio and the microhematocrit centrifugation force (9600 to 13 600 X g) make corrections for trapped plasma insignificant. Problems with matrix matching and viscosity are overcome by using a plasma pool standard for calculations. Values for erythrocyte lithium concentrations were unchanged in samples stored at room temperature up to 24 h. Hemolysis appears to be of possible clinical significance. This method is useful as a routine clinical laboratory procedure for monitoring patients with affective disorders, who are undergoing therapy with lithium.

Moral dilemmas in clinical cancer experimentation

An examination of certain moral tensions that have developed in clinical cancer experimentation is offered. It is argued that the individual partner must be addressed in his singular unique position, rather than as a potential for the future good.

Determination of plasma and erythrocyte lithium concentrations by atomic absorption spectrophotometry

We describe a method for determining plasma and erythrocyte lithium concentrations by atomic absorption spectrophotometry. Plasma and hemolyzed whole-blood are diluted and analyzed, with use of a lithium hollow-cathode lamp, at 670.8 nm. Erythrocyte lithium concentrations are calculated indirectly from the hematocrit. The standard deviation for a 0.43 mmol/liter pool of whole blood, run daily over 11 months, was +/-20 mumol/liter (CV=5.1). The lithium concentration of a lyophilized pool assayed periodically over the same period (n=127) was 1.84+/-0.05 mmol/liter (CV=2.7%). The relatively low erythrocyte/plasma lithium ratio and the microhematocrit centrifugation force (9600 to 13 600 X g) make corrections for trapped plasma insignificant. Problems with matrix matching and viscosity are overcome by using a plasma pool standard for calculations. Values for erythrocyte lithium concentrations were unchanged in samples stored at room temperature up to 24 h. Hemolysis appears to be of possible clinical significance. This method is useful as a routine clinical laboratory procedure for monitoring patients with affective disorders, who are undergoing therapy with lithium.

Plasma and erythrocyte kinetic considerations in lithium therapy

Developments in the analysis and pharmacokinetics of lithium, and the role of the pharmacist in the management of lithium therapy in affective disorders, are described. Research showing that lithium levels in the brain may be better predicted from erythrocyte lithium levels than plasma levels is reviewed. Also reviewed is lithium kinetics in affective disorders. The pharmacist (1) determines relevant aspects of the patient's condition, (2) develops an appropriate blood sampling schedule, (3) initiates and maintains a serial lithium erythrocyte and plasma patient profile, (4) evaluates erythrocyte and serum levels in relation to established criteria to provide a basis for differential diagnosis of the patient, and (5) individualizes lithium dosage and schedules. Four cases are used to illustrate this approach. It is suggested that outpatient mental health clinics would be likely settings for the further development of this clinical role.

Delayed vein repositioning. A procedure for improving inadequate radial-cephalic arteriovenous fistulas

Patients undergoing hemodialysis, whose radial-cephalic arteriovenous fistulas (RCAVFs) were unsatisfactory because of poor accessibility, were treated by surgical repositioning of the full length of arterialized cephalic vein in the forearm. Marked improvement in accessibility for more than one year was achieved in 15 of 18 delayed venous repositioning operations. This procedure is recommended for improving certain types of inadequate RCAVF.

Rapid GLC determination of fusaric acid in biological fluids

A simple, sensitive GLC assay was developed for fusaric acid, the active metabolite of bupicomide, to follow the disposition of this investigational antihypertensive agent in patients undergoing therapy. Fusaric acid is efficiently extracted from biological samples, derivatized by on-column methylation, and chromatographed using flame-ionization detection. An internal standard is utilized to quantitate results. The procedure is rapid and specific for fusaric acid, and has a lower limit of sensitivity of 0.1 mug/ml. The method is suitable for supporting pharmacokinetic studies of bupicomide following therapeutic doses in animals and humans.

Plasma concentration of lidocaine after endotracheal spray

The rate of absorption and plasma concentrations of lidocaine were determined in 15 supine patients under general anesthesia following either endotracheal spray of 200 mg. (average 3.3 mg./kg.) of 4 percent lidocaine hydrochloride solution with a special cannula (LTA Kit, Abbott) (N = 6) or 1 mg./kg. of 2 percent lidocaine solution as an intravenous bolus injection (N = 9). In the 6 patients after endotracheal spray, peak plasma lidocaine levels were reached at 15 to 20 minutes (mean 3.54 plus or minus 0.76 S.E. mug./ml. at 20 minutes). In the 9 patients given 1 mg./kg. intravenously, dose peak concentrations were reached within 2 minutes (mean 5.63 plus or minus 0.18 S.E. mug./ml. at 2 minutes). Plasma concentrations of lidocaine in both groups were within nontoxic ranges.