Classification of human liposarcoma and lipoma using ex vivo proton NMR spectroscopy

Prognostication in patients with liposarcoma is a complex and controversial subject based on recognition of lipoblasts, adipocyte nuclear atypia, and qualitative estimations of cellularity and cell size. We show here that for 30 patients with liposarcoma and 5 patients with lipoma, spectral differences on high-resolution, magic angle spinning proton nuclear magnetic resonance (hr-MAS 1H-NMR) spectroscopy relate to known biochemical changes and correlate with adipocyte tissue differentiation, histologic cell type, and cellularity. The NMR-visible level of triglyceride is shown to correlate with liposarcoma differentiation, since the triglyceride level in well-differentiated liposarcoma is 33-fold higher on average than for myxoid/round cell liposarcoma, which in turn is 6-fold higher than the dedifferentiated and/or pleomorphic subtypes. The NMR-visible phosphatidylcholine level serves as an estimate of total tissue cell membrane phospholipid mass and was found to correlate with liposarcoma subtype. Pleomorphic liposarcoma, the most aggressive and metastatic subtype, was found to have a threefold increase in NMR-visible phosphatidylcholine level compared with dedifferentiated liposarcoma. The level of NMR-visible phosphatidylcholine was twofold greater in well-differentiated liposarcoma compared with lipoma and was threefold larger for the hypercellular myxoid/round cell subtype compared with the pure myxoid histology. Thus, NMR-derived parameters of tissue lipid may be used for objective distinction of liposarcoma histologic subtype/grade and lipoma from liposarcoma. These biochemical parameters may ultimately improve prognostication in patients with liposarcoma.

Adherence to management of high blood pressure: recommendations of the Canadian Coalition for High Blood Pressure Prevention and Control

Adherence or compliance, in the context of medical treatment, refers to how well a patient follows and sticks to the management plan developed with her/his health care provider, which may include pharmacologic agents as well as changes in lifestyle. Adherence is of great concern in asymptomatic conditions such as hypertension, where lack of control may have serious ramifications including end organ damage and premature mortality. To address this issue, the Canadian Coalition for High Blood Pressure Prevention and Control established a national Advisory Committee on Adherence to the Management of High Blood Pressure. The Advisory Committee consisted of 11 members from different disciplines of health care providers. The Committee reviewed all evidences to date and drew up four practical recommendations with respect to patient, provider and environment. Based on Canadian Task Force on Periodic Health Examination's guidelines, all four recommendations can be classified as 'level C' with a quality of evidence of II.

Adherence to pharmacologic management of hypertension

Adherence to pharmacologic therapy of hypertension is low (in the range of 50-70%) and has important implications both for blood pressure control and cardiovascular complications. Based on a review of the literature using the levels of evidence grading technique, determinants of adherence to the pharmacologic therapy of hypertension have been assessed. Additionally, interventions to improve compliance were evaluated. Patient-centred, health care provider-centred and drug-specific factors have all been shown to affect adherence rates. We conclude that the extent of adherence to pharmacologic therapy is modifiable. Measurable improvements in adherence can be obtained from simplified medication regimens and a combination of behaviour strategies, including the tailoring of pill-taking to patients' daily habits and rituals, the advocacy of self-monitoring of pills and blood pressure, and the institution of reward systems.

Aorto-atrial fistula without aneurysm formation in Behçet's disease

Cardiac disease is known to occur in patients with the multisystemic inflammatory disorder Behçet's disease. An aorto-atrial fistula secondary to Behçet's disease without a sinus of Valsalva aneurysm has not been previously reported. A 30 year old man with a four year history of symptoms and signs consistent with Behçet's disease presented with an aorto-atrial fistula and a large left to right shunt. At operation the defect was repaired with a bovine pericardial patch. There was no evidence of aneurysm formation. The patient made a good recovery and was well at one year follow up.

Fluctuations in blood lipid levels during furosemide therapy: a randomized, double-blind, placebo-controlled crossover study

BACKGROUND

Acute decreases in intravascular volume are associated with increases in lipid levels. Furosemide causes acute changes in intravascular volume during prolonged therapy but is thought to have little effect on lipid levels.

METHODS

To determine if there are daily acute rises in lipid and lipoprotein levels associated with changes in intravascular volume during long-term furosemide ingestion therapy, we performed a randomized, double-blind, placebo-controlled crossover study in 10 patients.

RESULTS

In the 8 hours after furosemide ingestion there were increases in levels of plasma cholesterol (10.1%; P = .001), high-density lipoprotein cholesterol (9.0%; P = .006), and apolipoprotein B (9.8%; P = .003). The increases in levels of triglycerides (11.5%; P = .17) and apolipoprotein A-1 (13.3%; P = .051) were of similar magnitude but more variable and did not achieve statistical significance. There was no substantial change in the total cholesterol-high-density lipoprotein cholesterol ratio (0.6%; 95% CI,-0.74% to 8.6%; P =.88).

CONCLUSION

This study indicates that there are acute increases in lipid levels after furosemide ingestion during prolonged therapy, which could affect the interpretation of lipid levels and cardiovascular risk in patients.

Gradient, high-resolution, magic angle spinning 1H nuclear magnetic resonance spectroscopy of intact cells

The application of new gradient, high-resolution, magic angle spinning (MAS) 1H nuclear magnetic resonance (NMR) spectroscopy to the study of intact undifferentiated and differentiated NIH 3T3 F442A cells demonstrated improved spectral resolution and sensitivity compared with static studies. MAS of cells permits the detection and quantitation of many cellular metabolites that are not clearly resolved in nonspinning measurements and provides an improved visibility of phospholipids. Gradient, MAS enables the use of diffusion weighting for compartment assignment and the determination of mobility for many metabolites which are incompletely resolved using static techniques. The smaller, undifferentiated preadipocytes show no microscopic evidence of cell lysis after 2 h of MAS at 3.5 kHz and 82% of these cells remain viable by trypan blue exclusion. In contrast, 15-19% of the larger, lipid-laden differentiated adipocytes were found to suffer some degree of cell lysis with MAS. This new method is an attractive alternative to either nonspinning perfusion or extraction techniques for NMR studies of cells.

Factors influencing blood loss in transurethral resection of the prostate (TURP): auditing TURP

OBJECTIVES

To assess the blood loss accompanying TURP and investigate its association with the resected weight of prostatic tissue, type of anaesthesia, type of presentation, histology, different surgeons and their differing techniques, and thus to reduce the morbidity associated with blood loss and transfusion.

PATIENTS AND METHODS

All prostatectomies carried out in a district general hospital were audited prospectively, recording the pre- and post-operative haemoglobin concentration (Hb), blood transfusions and the variables listed above. The audit was repeated a year later.

RESULTS

The peri-operative blood loss, as assessed by various indicators, was equivalent to a decrease in Hb of 10-15 g/L (8-11%). The weight of the resected prostatic tissue was the most important measurable factor in determining blood loss. Regional anaesthesia was associated with less blood loss than general anaesthesia. The added use of a suprapubic catheter for irrigation appeared to have a marginal advantage in large resections. The type of presentation, elective or otherwise, and the histological nature of the prostate did not influence blood loss. Smaller transfusions were probably avoidable in patients having smaller resections and a normal pre-operative Hb. On re-auditing, the overall transfusion rate was reduced from 10.8% to 8.2% and from 4.4% to 1% in patients having resections of < 30 g.

CONCLUSION

Blood transfusion can be reduced and rationalized. Patients with a normal pre-operative Hb and undergoing resections of < 30 g do not usually require transfusion. Regional anaesthesia is associated with less blood loss but its advantage is overshadowed in practice by the weight of the resected tissue. An audit of this type is repeatable and is useful in raising awareness, objectively assessing differences and advocating and assessing any changes made.

Closed kinetic chain tarsal mechanics of subtalar joint arthroereisis

The weightbearing biomechanics of the tarsus with and without subtalar joint arthroereisis was investigated in 11 fresh frozen cadaver specimens using a three-dimensional (3-D) radiowave tracking system. Specimens, consisting of the distal half of the tibia and fibula and the intact ankle and foot, were mounted on a nonmetallic loading frame test system that allowed positioning of the foot to simulate midstance position of gait. The tibia was axially loaded to 756 N (one bodyweight) with 15% of the total load diverted through the fibula. Receiving transducers were attached to the talus, navicular, calcaneus, and cuboid bones. Tarsal movements were monitored as the specimen was loaded with and without subtalar joint arthroereisis. Three-dimensional data sets of osseous positions and orientations were collected and analyzed. Significant rotational differences were detected with and without subtalar joint arthroereisis for all four tarsal bones (p < or = 0.05). Tarsal translational position changes were small and not statistically significant.

Image Region Labelling by Humans and by an Artificial Neural Network

We reported (Troscianko et al, 1995 Perception24 Supplement, 18) that a neural network has been developed which is capable of labelling objects in natural scenes by first segmenting a scene, then obtaining a description of each segment in terms of a set of features. A neural net is then trained to label the segments on the basis of the feature set. The question we are now addressing is: how important is each of these features to overall performance, both in human and machine vision?

We carried out an experiment in which human subjects were trained in the same labelling task as the neural net. Individual segments of scenes (sometimes corresponding to a whole object, eg a car, and sometimes an incomplete region, eg part of the sky) were presented on a screen, and the subject asked to label the scene as one of eleven possible types of object (sky, vegetation, vehicle …). Feedback was given and the learning curve monitored. When the learning curve was flat, each subject's performance was investigated with both intact and degraded stimuli. The degradation consisted of partial representation of the information, such as presenting just the outer boundary, or the average colour, or the average luminance, or randomising the size, position, and texture of the segment.

The results suggest that this degradation produces significant changes in performance (F9,7=4.4, p=0.0005). A posteriori analysis indicates that certain attributes (particularly texture, boundary-only, colour-averaging) are particularly influential in mediating performance. A similar set of results was obtained by training the network on similarly degraded data. The results imply: (1) that a neural net can provide a useful model of human object labelling processes, and (2) that certain features are more important than others in mediating such performance.

A phase II study of single agent paclitaxel in patients at first relapse following initial chemotherapy for breast cancer

This study was initiated to evaluate the safety and efficacy of 3-weekly paclitaxel given at 225 mg/m2 over 3 hours without colony stimulating factor support in patients at their first relapse following adjuvant therapy for breast cancer. Thirty patients were entered into the study; all were assessable for response and toxicity. All patients had received adjuvant/neo-adjuvant chemotherapy; 22 patients had had prior hormonal therapy and 26 previous adjuvant radiotherapy. The group was characterized by a short time to first relapse (median 7.5 months (range 2-43)) and widespread disease, with 22 patients having multiple disease sites including: nodes (43%), skin and soft tissue (43%), liver (40%), lung (37%) and bone (50%). A total of 219 cycles of paclitaxel were given, with a median of eight per patient. The major non-haematological toxicities were: grade 3 alopecia (82% cycles), grade 2/3 arthralgia/myalgia (26%), grade 2/3 fatigue (16%) and grade 2/3 peripheral nervous system toxicity (12%). Haematological toxicity was mainly neutropenia of short duration, with grade 4 counts documented in 16% of cycles. Thrombocytopenia was minimal and there were no significant hypersensitivity reactions. The objective response rate was 60% (95% CI 42.5-77.5) with one complete response and 17 partial responses. The median duration of overall response was 30 weeks (range 15-75+ (95% CI 25-33)) with a median survival time for all patients of 42 weeks (range 1-124+). This study demonstrates that paclitaxel 225 mg/m2 is well tolerated as a 3-hour infusion and can be given safely in an outpatient setting without routine use of granulocyte colony stimulating factor. The response rate is encouraging and shows that this regimen is effective in this poor prognosis patient population.

A comparison of two transcutaneous monitors for the measurement of arterial PO2 and PCO2 in neonates

We examined the ability of two transcutaneous devices (Fastrac, Sensormedics Corporation, Yorba Linda, California, U.S.A. and Hewlett Packard M1018A, Hewlett Packard Component Monitoring System, Hewlett Packard, North Hollywood, U.S.A.) to measure arterial PCO2 and PO2 in neonates. Thirty-seven neonates had transcutaneous oxygen measured with the Hewlett Packard (HPO2 group), 38 neonates had transcutaneous carbon dioxide measured with the Hewlett Packard (HPCO2 group) and the Fastrac was used on 27 neonates (FTCO2 group). Both devices were operated with electrode temperatures of 43.5 degrees C although an additional ten subjects were studied using the Fastrac with an electrode temperature of 43.0 degrees C. The mean differences (transcutaneous--arterial) and upper and lower limits of agreement were calculated for each group. For the HPO2 group they were 3.78 mmHg (-12.23 to 19.80 mmHg), for the HPCO2 group they were 0.40 mmHg (-4.50 to 5.30 mmHg) and for the FTCO2 they were -0.96 mmHg (-7.85 to 5.92 mmHg). For the Fastrac group at an electrode temperature of 43.0 degrees C the mean difference and limits of agreement were -1.00 mmHg and -4.58 mmHg to 2.58 mmHg. The average sensitivity and specificity for both machines for the detection of hypocarbia were 82% and 92% respectively while for hypercarbia they were 90% and 94% respectively. For hypoxaemia, the sensitivity and specificity were 40% and 94% while for hyperoxaemia the sensitivity and specificity were 83% and 97%. We conclude that both machines provide a useful supplement to arterial PCO2 measurements and the Fastrac performs better at 43.0 degrees C. The measurement of PO2 is less accurate but is still of clinical use.

Breast self-examination: knowledge and practices of Hispanic women in two southwestern metropolitan areas

The breast self-examination (BSE) practices of 1,453 Hispanic women in Phoenix, Arizona and San Diego, California were the focus of this study. Variables proposed as factors that influence the frequency and proficiency of BSE were demographic variables, particularly language and level of acculturation, having been taught BSE by a health professional, and experience with the disease. Results indicate that even though the majority of the women at both the Phoenix (78.1%) and San Diego (83.7%) sites had been taught BSE by a professional and most women in Phoenix (62.5%) and San Diego (63.4%) reported performing BSE within the past month, only 0.7% of the women at both sites were found to be proficient in the technique of BSE. Further, results indicate that language and acculturation were correlated with whether or not a woman performed BSE. These findings suggest that BSE education classes must provide information and techniques that promote proficiency in BSE, and must be designed to meet the unique needs of Hispanic women, particularly those of low acculturation levels.

Guidelines for measurement of blood pressure, follow-up, and lifestyle counselling. Canadian Coalition for High Blood Pressure Prevention and Control

As part of the Coalition's mandate to promote the prevention and control of high blood pressure in Canada, an interdisciplinary Workgroup was established to review and update the existing standards (1987) for blood pressure measurement and referral guidelines. The intent was to prepare a scientifically based document which contained practical guidelines for the measurement of blood pressure and criteria for follow-up, and one which promoted the concept of cardiovascular health in the assessment and interpretation of blood pressure readings. These guidelines were primarily developed to assist primary health care providers and/or clinicians to assess, monitor, counsel, refer, and develop treatment plans for adults-at-risk for high blood pressure or those with the confirmed diagnosis of hypertension. Readers are referred to The Canadian Hypertension Society Consensus Conference series (Canadian Medical Association Journal 1993) for specific guidelines on the evaluation, diagnosis, and treatment of hypertension. The document is divided into three sections: 1. Measurement of blood pressure 2. Criteria for follow-up 3. Guidelines for lifestyle counselling Each section cites the references used in developing the guidelines and where relevant, identifies other resources which can be used in clinical practice.

Conflict with physician pregnancy revisited

A 10-year follow-up survey found medical school physicians (N = 200) at one institution were more interested in and accepting of pregnancy among colleagues. A greater number of physicians in 1990 than in 1980 reported that pregnant colleagues maintained their work efficiency and interest in medicine. Fewer physicians in 1990 reported being inconvenienced during a colleague's pregnancy, and fewer perceived hiring women of childbearing age to be a risk to the optimal functioning of their departments.

The prevalence of suicidal behavior among preadolescent children who are psychiatric inpatients

The prevalence of suicidal behavior displayed by preadolescent children hospitalized on inpatient psychiatric units is estimated to range between 18% and 80% of the population. The current study provides an independent estimate of the prevalence of this problem. A semistructured interview was used to assess suicidal behavior displayed by 61 admissions to a child psychiatric inpatient unit between April 1988 and September 1989. According to the Pfeffer Spectrum of Suicidal Behavior Scale, 63% of the sample engaged in some form of suicidal behavior. Preadolescents and their parents reported similar rates of suicidal thoughts, threats and attempts. The dangerousness of recent suicidal behavior was not found to differ by age, sex, legal custody status or socioeconomic status.

Vaccination of sheep with purified cysteine proteinases of Fasciola hepatica decreases worm fecundity

There has been some evidence from several parasite systems that proteinases might have potential as protective antigens against parasitic infection. A cysteine proteinase complex identified in the regurgitant of adult F. hepatica was examined in this context. The thiol-cathepsin-related proteinases of M(r) 28,000 were purified and tested in vaccine trials of sheep infected with liver fluke. Ten animals were immunised with the purified proteinases and developed antibodies to the cysteine proteinases prior to challenge with F. hepatica metacercariae. Infection appeared to cause a boost in antibody response by Week 4 into infection, and antibody levels were generally sustained throughout infection. The cysteine proteinases are not novel antigens, since low-level antibody titres were also detected in nonimmunised controls by late infection. On completion of the trial, there was no difference in worm burden between the two groups. However, faecal egg counts and therefore worm fecundity were significantly decreased.

Oral treatment with low molecular weight heparin normalizes blood pressure in hypertensive rats

Increased calcium uptake in vascular tissue, leading to elevated cytosolic free calcium has been implicated in the pathophysiology of hypertension. This study examined the effect of oral low molecular weight heparin (Logiparin) on systolic blood pressure, platelet cytosolic free calcium and aortic calcium uptake in spontaneously hypertensive rats. Starting at age 12 weeks, spontaneously hypertensive rats were divided into three groups of six animals each. The drinking water of groups 1, 2 and 3 was replaced by 100% H2O, 0.5 mg (low dose) or 1 mg (high dose) low molecular weight heparin/ml H2O, respectively, for next 11 weeks. Six normotensive Wistar-Kyoto rats (age 12 weeks) on H2O and six on low dose heparin in H2O were used as controls. At age 23 weeks, increase in systolic blood pressure, platelet cytosolic free calcium and aortic calcium uptake in spontaneously hypertensive rats was significantly lowered by low dose LMW heparin as compared to spontaneously hypertensive rats on H2O, but was significantly higher than Wistar-Kyoto rats on H2O and LMW heparin. This dose of heparin did not have any effect on these parameters in normotensive Wistar-Kyoto rats. High dose LMW heparin normalized the elevated platelet cytosolic free calcium, aortic calcium uptake and systolic blood pressure in spontaneously hypertensive rats, but it had a limited effect on adverse renal vascular changes. Oral low molecular weight heparin did not cause any abnormal hematological, biochemical or pathological changes in rats.

Plasma intestinal alkaline phosphatase isoenzymes in neonates with bowel necrosis

AIM

To determine if the intestinal isoenzymes of alkaline phosphatase (ALP) are biochemical markers of bowel necrosis in neonates.

METHODS

Plasma ALP isoenzymes were measured in 22 babies with bowel necrosis, histologically confirmed, and in 22 matched controls. The isoenzymes were also measured in 16 infants with signs of necrotising enterocolitis, who recovered without histological confirmation of bowel necrosis. The isoenzymes were separated by polyacrylamide gel electrophoresis. Auxiliary tests for identification included neuraminidase digestion and treatment with monoclonal and polyclonal antiplacental antibodies.

RESULTS

Intestinal ALP was detected in 16 infants with bowel necrosis--13 had fetal intestinal ALP (FI-ALP) and three had adult intestinal ALP (AI-ALP). FI-ALP was detected in nine of the controls. In the babies with bowel necrosis intestinal ALP was found over all gestations, but in the controls only in those less than 34 weeks. The percentages of total ALP activity due to intestinal ALP were significantly higher in those with bowel necrosis compared with matched controls (p = 0.028). In babies of all gestations diagnostic sensitivity for the presence of intestinal ALP as a marker of bowel necrosis was 73% and diagnostic specificity 59%. In babies greater than 34 weeks' gestation, diagnostic sensitivity fell to 60% but the test became completely specific. In two babies FI-ALP increased from zero/trace to high activity coincident with the episode of bowel necrosis. In 16 babies with signs of necrotising enterocolitis but unconfirmed bowel necrosis FI-ALP was detected in four.

CONCLUSION

Intestinal ALP seems to be released into the circulation in some babies with bowel necrosis, but its detection does not have the diagnostic sensitivity and specificity to be a reliable biochemical marker of the condition.

Rumination: the eating disorder of infancy

Rumination is a relatively rare, potentially fatal syndrome in infants. This article reviews the historical and current treatment of rumination. Two cases are presented: a six-month-old who narrowly escaped surgery when the disorder was not recognized, and a complicated case from the neonatology intensive care unit. Environmental changes and enhanced mothering are described as being critical to correction of rumination and appropriate weight gain.

Antenatal detection of renal abnormalities

The aim of this retrospective study is to assess the value of routine ultrasonography in the detection of renal abnormalities. Twenty-nine pregnancies (one set of twins) with suspected renal abnormalities (i.e. renal cystic spaces, oligohydramnios or hyperechoic kidneys) were delivered over a two year period (1.8.1987-31-7-1989) in a unit where 90% of pregnancies (6,562) were scanned routinely at 18-20 weeks gestation or later, if booking for confinement was delayed. In pregnancies with suspected anomalies prenatal ultrasound was performed monthly until 28 weeks and fortnightly until delivery. Non survivors [5] had histological or postmortem examination. Liveborn infants [25] had renal ultrasonography in the neonatal period and paediatric follow-up if abnormal. Sixteen (53%) of the 30 cases (one set of twins) suspected of renal abnormalities by routine prenatal ultrasonography had renal anomalies confirmed postnatally. Five women were non survivors, all of which had associated anomalies. In the eleven survivors the diagnoses were pelvi-ureteric junction obstruction [6], renal dysplasia [2], vesicoureteric reflux [2] and suspected ureterocele [1]. Fourteen infants with pelvicalyceal dilatation had normal postnatal renal ultrasound. Although abnormal prenatal renal ultrasound is a useful indicator of postnatal disease and aids decisions on the management of pregnancy, further large collaborative studies with extended paediatric follow-up are required to assess the significance of pelvicalyceal dilatation.

Differences in cancer-risk-related behaviors in Latino and Anglo adults

METHODS. Latino (n = 358) and Anglo (n = 113) adults living in the San Diego area were surveyed on nutrition, smoking, and cancer screening behaviors. The Latino respondents were dichotomized into a low (L-Latino) or high (H-Latino) acculturation group according to a median split of an acculturation index. RESULTS. After controlling for age, years of education, gender, marital status, and income, significant cross-cultural differences were found in saturated fat/cholesterol avoidance, and fiber and high calorie food consumption. L-Latino respondents had the lowest degree of saturated fat/cholesterol avoidance, followed by H-Latinos and Anglos. A pattern of decreasing consumption with increasing acculturation was observed for fiber and high calorie foods. Significant differences were found among women in the prevalence of Pap smear exams, with L-Latinas having the lowest prevalence of ever and in the past year having had a Pap smear, followed by H-Latinas and Anglos. A similar significant pattern was observed among women 50 years of age or older with respect to the prevalence of ever having had a mammogram.

Increased calcium uptake in vascular tissue by plasma of patients with essential hypertension

Plasma factors have been implicated in causing increased calcium uptake and cytosolic (Ca++) in vascular tissue leading to hypertension. We compared the effect of plasma from hypertensive and normotensive subjects on rat aortic calcium uptake. Plasma from hypertensive subjects was fractionated and the fractions assessed for their activity on aortic calcium uptake. Aortic calcium uptake was significantly higher in plasma from hypertensives as compared to normotensives (p less than 0.05). There was a significant positive correlation between diastolic blood pressure and aortic calcium uptake (r = 0.645; p = 0.002). There was a significant positive correlation between percentage ideal body weight and aortic calcium uptake in normotensives and hypertensives (r = 0.522; p less than 0.05). The calcium uptake stimulatory activity in plasma of hypertensives was found in nonesterified fatty acid and cholesterol ester fractions.