Correlation of CT with histopathological findings in patients with gastric and gastro-oesophageal carcinomas following neoadjuvant chemotherapy

Gastric carcinoma is the fourth commonest cause of death from malignant disease in United Kingdom. In the Western hemisphere, it usually presents with advanced disease, which contributes to its very poor prognosis. Pre-operative (neoadjuvant) chemotherapy offers the possibility of down-staging such tumours and the potential to render tumours operable. Computed tomography (CT) plays a central role in the assessment of patients presenting with the disease, and in those who undergo chemotherapy, in evaluating their response.

OBJECTIVE

This study was undertaken to evaluate the role of CT in predicting loco-regional spread of tumour following neoadjuvant chemotherapy in non-metastatic gastric and gastro-oesophageal cancers.

METHODS AND MATERIALS

We correlated CT evidence of loco-regional spread with pathological findings following surgery in 21 patients who received pre-operative chemotherapy.

RESULTS

Residual masses were seen on CT in 19 patients, and 15 contained active tumour, although in four patients no viable tumour was demonstrated at histopathology. The overall accuracy of CT in assessing loco-regional disease was disappointing with sensitivities, specificities, positive and negative predictive values of 57%, 43%, 75% and 33%, respectively.

CONCLUSIONS

We conclude that CT is not accurate in identifying residual loco-regional spread and therefore should not preclude surgery in those patients who have received neoadjuvant chemotherapy.

Effects of hypoproteinemia-induced myocardial edema on left ventricular function

In previous studies, we observed left ventricular (LV) systolic and diastolic dysfunction in association with interstitial myocardial edema (IME) induced by either coronary venous hypertension (CVH) or lymphatic obstruction. In the present study, we examined the effects of myocardial edema induced by acute hypoproteinemia (HP) on LV systolic and diastolic function. We also combined the methods of HP and CVH (HP-CVH) to determine their combined effects on LV function and myocardial water content (MWC). We used a cell-saving device to lower plasma protein concentration in HP and HP-CVH groups. CVH was induced by inflating the balloon in the coronary sinus. Six control dogs were treated to sham HP. Conductance and micromanometer catheters were used to assess LV function. Contractility, as measured by preload recruitable stroke work, did not change in control or HP groups but declined significantly (14.5%) in the HP-CVH group. The time constant of isovolumic LV pressure decline (tau) increased significantly from baseline by 3 h in the HP (24.8%) and HP-CVH (27.1%) groups. The end-diastolic pressure-volume relationship (stiffness) also increased significantly from baseline by 3 h in the HP (78.6%) and HP-CVH (42.6%) groups. Total plasma protein concentration decreased from 5.2 +/- 0.2 g/dl at baseline to 2.5 +/- 0.0 g/dl by 3 h in the HP and HP-CVH groups. MWC of the HP (79.8 +/- 0.25%) and HP-CVH groups (79.8 +/- 0.2%) were significantly greater than that of the control group (77.8 +/- 0.3%) but not different from one another. In conclusion, hypoproteinemia-induced myocardial edema was associated with diastolic LV dysfunction but not systolic dysfunction. The edema caused by hypoproteinemia was more than twice that produced by our previous models, yet it was not associated with systolic dysfunction. CVH had a negative inotropic effect and no significant influence on MWC. IME may not have the inverse causal relationship with LV contractility that has been previously postulated but appears to have a direct causal association with diastolic stiffness as has been previously demonstrated.

Prevention of bone loss with alendronate in postmenopausal women under 60 years of age. Early Postmenopausal Intervention Cohort Study Group

BACKGROUND

Estrogen-replacement therapy prevents osteoporosis in postmenopausal women by inhibiting bone resorption, but the balance between its long-term risks and benefits remains unclear. Whether other antiresorptive therapies can prevent osteoporosis in these women is also not clear.

METHODS

We studied the effect of 2.5 mg or 5 mg of alendronate per day or placebo on bone mineral density in 1174 postmenopausal women under 60 years of age. An additional 435 women who were prepared to receive a combination of estrogen and progestin were randomly assigned to one of the above treatments or open-label estrogen-progestin. The main outcome measure was the change in bone mineral density of the lumbar spine, hip, distal forearm, and total body measured annually for two years by dual-energy x-ray absorptiometry.

RESULTS

The women who received placebo lost bone mineral density at all measured sites, whereas the women treated with 5 mg of alendronate daily had a mean (+/-SE) increase in bone mineral density of 3.5+/-0.2 percent at the lumbar spine, 1.9+/-0.1 percent at the hip, and 0.7+/-0.1 percent for the total body (all P<0.001). Women treated with 2.5 mg of alendronate daily had smaller increases in bone mineral density. Alendronate did not increase bone mineral density of the forearm, but it slowed the loss. The responses to estrogen-progestin were 1 to 2 percentage points greater than those to the 5-mg dose of alendronate. Alendronate was well tolerated, with a safety profile similar to that of placebo or estrogen-progestin.

CONCLUSIONS

Alendronate prevents bone loss in postmenopausal women under 60 years of age to nearly the same extent as estrogen-progestin.

Adapting operator settings in genetic algorithms

In the majority of genetic algorithm implementations, the operator settings are fixed throughout a given run. However, it has been argued that these settings should vary over the course of a genetic algorithm run--so as to account for changes in the ability of the operators to produce children of increased fitness. This paper describes an investigation into this question. The effect upon genetic algorithm performance of two adaptation methods upon both well-studied theoretical problems and a hard problem from operations research, the flowshop sequencing problem, are therefore examined. The results obtained indicate that the applicability of operator adaptation is dependent upon three basic assumptions being satisfied by the problem being tackled.

Solving a real-world problem using an evolving heuristically driven schedule builder

This work addresses the real-life scheduling problem of a Scottish company that must produce daily schedules for the catching and transportation of large numbers of live chickens. The problem is complex and highly constrained. We show that it can be successfully solved by division into two subproblems and solving each using a separate genetic algorithm (GA). We address the problem of whether this produces locally optimal solutions and how to overcome this. We extend the traditional approach of evolving a "permutation + schedule builder" by concentrating on evolving the schedule builder itself. This results in a unique schedule builder being built for each daily scheduling problem, each individually tailored to deal with the particular features of that problem. This results in a robust, fast, and flexible system that can cope with most of the circumstances imaginable at the factory. We also compare the performance of a GA approach to several other evolutionary methods and show that population-based methods are superior to both hill-climbing and simulated annealing in the quality of solutions produced. Population-based methods also have the distinct advantage of producing multiple, equally fit solutions, which is of particular importance when considering the practical aspects of the problem.

A prospective randomised trial of protracted venous infusion 5-fluorouracil with or without mitomycin C in advanced colorectal cancer

BACKGROUND

To compare protracted venous infusion (PVI) 5-fluorouracil (5-FU) with and without mitomycin C (MMC) in a prospectively randomised study and analyse for tumour response, survival, toxicity and quality of life (QL).

PATIENTS AND METHODS

Two hundred patients with advanced colorectal cancer received PVI 5-FU 300 mg/m2/day for a maximum of 24 weeks and were randomised to PVI 5-FU alone or PVI 5-FU + MMC 10 mg/m2 (7 mg/m2 from June 1995) 6 weekly for 4 courses.

RESULTS

Overall response was 54% (95% confidence interval [CI] 44.1%-63.9%) with PVI 5-FU + MMC compared to 38% (95% CI: 28.3%-47.7%) for PVI 5-FU alone (P = 0.024). The median failure free survival was 7.9 months in PVI 5-FU plus MMC and 5.4 months with PVI 5-FU alone (P = 0.033) and at one year 31.9% for the combination compared to 17.7% for PVI 5-FU alone. Median survival was 14 months with MMC and 15 months in 5-FU alone; one-year survival 51.7% vs. 57.2%. PVI 5-FU + MMC caused more overall haematological toxicity but CTC grades 3/4 was increased only for thrombocytopaenia. Two patients treated with a cumulative dose of MMC of 40 mg/m2 developed haemolytic uraemic syndrome warranting the reduction in cumulative MMC dose to 28 mg/m2. The global QL scores were better for PVI 5-FU + MMC arm at 24 weeks, but the remaining QL data showed no differences.

CONCLUSIONS

PVI 5-FU + MMC results in failure-free survival and response advantage, tolerable toxicity and better QL when compared to PVI 5-FU alone but no overall survival advantage. There is no irreversible toxicity with MMC at a cumulative dose of 28 mg/m2.

Performance of the new plasma-compatible Advantage blood glucose test strips

OBJECTIVE

To establish a plasma calibration curve for the Advantage Blood Glucose System that would permit direct comparison with results provided by clinical laboratories.

DESIGN AND METHODS

The initial study involved the comparison between the Advantage whole blood referenced results and the laboratory plasma results. The second study validated the plasma-compatibility of the first new lot of Advantage test strips with this new calibration curve.

RESULTS

Plasma and whole blood glucose data, obtained at Hôpital Maisonneuve-Rosemont in Montréal, demonstrated the typical differences between these two sample types. Mathematical correction of the Advantage results eliminated this difference. This new equation was then encoded into the code keys of a new lot of Advantage test strips and a second study was conducted to verify the comparability to laboratory plasma glucose.

CONCLUSION

The results for the Advantage Blood Glucose System may now be compared directly with the laboratory plasma or serum glucose results.

I. NGD 94-1: identification of a novel, high-affinity antagonist at the human dopamine D4 receptor

NGD 94-1 was evaluated for selectivity and in vitro functional activity at the recombinant human D4.2 receptor stably expressed in Chinese hamster ovary cells. NGD 94-1 showed high affinity for the cloned human D4.2 receptor (Ki = 3.6 +/- 0.6 nM) and had greater than 600-fold selectivity for the D4.2 receptor subtype compared with a wide variety of monoamine or other neurotransmitter receptor or modulatory sites except for 5-HT1A and 5-HT3 receptors, in which NGD 94-1 was approximately 50- and 200-fold selective, respectively, for the D4.2 receptor. In measures of in vitro functional activity, NGD 94-1 showed an antagonist profile at the cloned human D4.2 receptor subtype. NGD 94-1 completely reversed the decrease in forskolin-stimulated cAMP levels produced by the dopamine receptor full agonist quinpirole. Furthermore, NGD 94-1 produced a complete reversal of GTPgamma35S binding induced by quinpirole, but was unable on its own to affect GTPgamma35S binding. These data suggest that NGD 94-1 functions as an antagonist rather than a full or partial agonist at the human D4.2 receptor. In addition, NGD 94-1 binding affinity at the D4.2 receptor subtype was unaffected by G-protein activation by GTP, consistent with the binding affinity seen for other antagonists at the D4 receptor. The binding of tritiated NGD 94-1 was saturable and of high affinity at cloned human D4.2 receptors. Furthermore, the binding of [3H]NGD 94-1 to cloned human D4.2 receptors expressed in Chinese hamster ovary cells displayed a pharmacological profile similar to that observed with the nonselective dopamine receptor ligand [3H]YM 09151-2. Saturation and pharmacological analyses of [3H]NGD 94-1 binding at cloned human D4.2, D4.4 and D4.7 receptor variants showed no difference between the three variants. NGD 94-1 is a novel, high-affinity, D4 receptor-selective antagonist. The clinical use of this subtype-specific compound should permit direct evaluation of the role of D4 receptors in psychiatric disorders.

[Tricentric study of the sensitivity of Pseudomonas aeruginosa serotyping to beta-lactams and aminoglycosides]

The aim of this study was to evaluate the susceptibility of 300 Pseudomonas aeruginosa strains to 6 beta-lactams and to 2 aminoglycosides and to compare this susceptibility according to the serotype, the sample nature, the unit activity and the geographic situation of the hospital. The susceptibility level was ascertained using the disk method. Serotyping of the strains was also performed. Susceptibility level was 67% for ticarcillin, 82% for piperacillin-tazobactam combination, 85% for ceftazidim, 81% for cefepim, 74% for aztreonam, 83% for imipenem, 73% for tobramycin and 86% for amikacin. Non-serotypable strains represented 20.6%. The most common serotypes were O6 (19%) and O11 (13%). Discrepancies between cefepime and ceftazidime were found in 15 strains after MIC determination, 6 of them were O12 strains. It appears that strain susceptibility was function of the serotype distribution. Cefepime exhibited outstanding activity against P. aeruginosa, similar to ceftazidim activity.

BCL-2 antisense therapy in patients with non-Hodgkin lymphoma

BACKGROUND

Overexpression of BCL-2 is common in non-Hodgkin lymphoma and leads to resistance to programmed cell death (apoptosis) and promotes tumorigenesis. Antisense oligonucleotides targeted at the open reading frame of the BCL-2 mRNA cause a specific down-regulation of BCL-2 expression which leads to increased apoptosis. Lymphoma grown in laboratory animals responds to BCL-2 antisense oligonucleotides with few toxic effects. We report the first study of BCL-2 antisense therapy in human beings.

METHODS

A daily subcutaneous infusion of 18-base, fully phosporothioated antisense oligonucleotide was administered for 2 weeks to nine patients who had BCL-2-positive relapsed non-Hodgkin lymphoma. Toxicity was scored by the common toxicity criteria, and tumour response was assessed by computed tomography scan. Efficacy was also assessed by quantification of BCL-2 expression; BCL-2 protein levels were measured by flow cytometry in samples from patients.

FINDINGS

During the course of the study, the daily dose of BCL-2 antisense was increased incrementally from 4.6 mg/m2 to 73.6 mg/m2. No treatment-related toxic effects occurred, apart from local inflammation at the infusion site. In two patients, computed tomography scans showed a reduction in tumour size (one minor, one complete response). In two patients, the number of circulating lymphoma cells decreased during treatment. In four patients, serum concentrations of lactate dehydrogenase fell, and in two of these patients symptoms improved. We were able to measure BCL-2 levels by flow cytometry in the samples of five patients, two of whom had reduced levels of BCL-2 protein.

INTERPRETATION

In patients with relapsing non-Hodgkin lymphoma, BCL-2 antisense therapy led to an improvement in symptoms, objective biochemical and radiological evidence of tumour response, and down-regulation of the BCL-2 protein in some patients. Our findings are encouraging and warrant further investigations of BCL-2 antisense therapy in cancer treatment.

Development and validation of a discriminative quality of life questionnaire for osteoporosis (the OPTQoL)

We report the development and validation of an osteoporosis-targeted quality of life questionnaire to measure the impact of the disease in the general population. From multiple focus groups with women with osteoporosis, healthy women at risk for osteoporosis, spouses and relatives of women with osteoporosis, and health care providers, we identified over 300 potential items related to the disease. A lengthy questionnaire incorporated these items and was administered to a second large study cohort of 222 women with clinical osteoporosis (history of fracture, significant height loss, and/or kyphosis); 101 women with known low bone mineral density levels that would categorize them as osteoporotic but who had not yet shown obvious physical manifestations of the disease; and 142 women with other conditions (such as arthritis, cancer, depression) expected to also have an impact on quality of life. Final items from among the original 300 were chosen for their demonstrated relationship with osteoporosis as measured by clinical manifestations and low bone density and with quality of life measured by a standard generic questionnaire, the SF-36. The final questionnaire contains 26 scored items in three domains-physical activity, adaptations, and fears- and six nonscored questions relating to osteoporotic changes and diagnosis. This instrument is unique among osteoporosis-targeted questionnaires in that it attempts to measure the total impact of the disease on quality of life within a population at a single point in time.

A phase I/II study of leucovorin, carboplatin and 5-fluorouracil (LCF) in patients with carcinoma of unknown primary site or advanced oesophagogastric/pancreatic adenocarcinomas

Carcinoma of unknown primary site (CUPS) accounts for 5-10% of all malignancies. Forty patients with metastatic CUPS or advanced oesophagogastric/pancreatic adenocarcinomas were recruited. Eligibility included ECOG performance status 0-2, minimum life expectancy of 3 months and measurable disease. The regimen consisted of bolus intravenous 5 fluorouracil (5-FU) and leucovorin (20 mg m-2) days 1-5 and carboplatin (AUC5) on day 3. The leucovorin/carboplatin/5-FU (LCF) was repeated every 4 weeks. The starting dose of 5-FU was 350 mg m-2 day-1 with escalation to 370 and then 400 mg m-2 day -1 after the toxicity at the previous level had been assessed. The maximum tolerated dose (MTD) was defined as the dosage of 5-FU that achieved 60% grade 3/4 toxicity. In addition, objective and symptomatic responses, quality of life and survival were assessed. The MTD of 5-FU in the LCF regimen was 370 mg m-2. The predominant toxicity was asymptomatic marrow toxicity. The 350 mg m-2 level was then expanded. There were two toxic deaths due to neutropenic sepsis, one at 370 mg m-2 after one course and one at 350 mg m-2 after four courses. The objective response rate was 25% with one complete response (CR) and nine partial responses (PRs). The median duration of response was 3.4 months (range 1-10). The CR and eight of the nine PRs were in CUPS patients. Twelve patients developed progressive disease on LCF. Median survival for all 40 patients was 7.8 months (10 months median survival for those treated at 350 mg m-2). The majority of patients described a symptomatic improvement with LCF chemotherapy. The recommended dose of 5-FU for future studies is 350 mg m-2 combined with leucovorin 20 mg m-2 and carboplatin (AUC5).

The need to educate primary care physicians to provide oncologic services: a changing focus

BACKGROUND

The traditional role of primary care physicians (PCPs) in cancer care has been primarily cancer detection, and their training and education were similarly oriented. Propelled by the changing health care delivery system, this role is now expanding substantially.

METHODS

A survey of 31 health maintenance organizations active in the New York market area was performed. The HMOs were grouped into three main categories according to method of payment of the physician. Patient care responsibilities vary depending on the method of payment but stay constant within the group. Of 19 HMOs that responded to the survey, 13 had shifted much of the responsibilities for diagnosis and treatment decisions to the PCP.

RESULTS

A national survey of all academic radiation oncology program directors in the United States, as well as training programs of primary care physicians, showed a unanimous lack of educational or training programs or opportunities to familiarize the PCP with radiation oncology as a therapeutic discipline and with its after-therapy requirements. This deficiency extended also to multimodality training and other aspects. The internal medicine programs surveyed scored only an average of 1.25 out of a possible 5 in education areas directly related to oncology training. These programs comprised 78% of the residents of all programs surveyed.

CONCLUSION

The information gathered from these surveys reveals a shift towards mandating the provision of oncologic services by PCPs, who have inadequate training in oncology, with no system in place to remedy the deficiencies except on-the-job training. The inevitability of the changing role of the PCP must be accompanied by either an expansion of residency programs to encompass training in important aspects of oncology care or expansion and formalization of continuing education programs to achieve the same objective.

Toxicity identification evaluation of Lake Orta (Northern Italy) sediments using the Microtox system

Pore waters extracted by centrifugation from Lake Orta (Northern Italy) sediments were studied with a modified Toxicity Identification Evaluation (TIE) procedure using the Microtox bacterial luminescence toxicity test system. The most toxic pore water samples were from stations near a rayon factory, known as a source of copper and ammonium discharges. The TIE manipulations used were filtration, EDTA chelation, and C18 solid-phase resin adsorption. The most effective treatments to remove toxicity were the EDTA and C18, indicating that both metals and nonpolar organic compounds contribute to the observed toxicity.

Contaminant-induced immunotoxicity in harbour seals: wildlife at risk?

Persistent, lipophilic polyhalogenated aromatic hydrocarbons (PHAHs) accumulate readily in the aquatic food chain and are found in high concentrations in seals and other marine mammals. Recent mass mortalities among several marine mammal populations have been attributed to infection by morbilliviruses, but a contributing role for immunotoxic PHAHs, including the polychlorinated biphenyls (PCBs), polychlorinated dibenzo-p-dioxins (PCDDs), and polychlorinated dibenzofurans (PCDFs) was not ruled out. We addressed this issue by carrying out a semi-field study in which captive harbour seals were fed herring from either the relatively uncontaminated Atlantic Ocean or the contaminated Baltic Sea for 2 years. We present here an overview of results obtained during this study. An impairment of natural killer (NK) cell activity, in vitro T-lymphocyte function, antigen-specific in vitro lymphocyte proliferative responses, and in vivo delayed-type hypersensitivity and antibody responses to ovalbumin was observed in the seals fed the contaminated Baltic herring. Additional feeding studies in PVG rats using the same herring batches suggested that an effect at the level of the thymus may be responsible for changes in cellular immunity, that virus-specific immune responses may be impaired, and that perinatal exposure to environmental contaminants represents a greater immunotoxic threat than exposure as a juvenile or adult. Together with the pattern of TCDD toxic equivalents of different PHAHs in the herring, these data indicate that present levels of PCBs in the aquatic food chain are immunotoxic to mammals. A review of contaminant levels in free-ranging harbour seals inhabiting polluted areas of Europe and North America suggests that many populations may be at risk to immunotoxicity. This could result in diminished host resistance and an increased incidence and severity of infectious disease.

The role of helper lipids in cationic liposome-mediated gene transfer

In the procedure for cationic liposome-mediated transfection, the cationic lipid is usually mixed with a "helper lipid" to increase its transfection potency. The importance of helper lipids, including dioleoylphosphatidylcholine (DOPC) and phosphatidylethanolamine (dioleoyl PE), DO was examined. Freeze-fracture electron microscopy of DNA:cationic complexes containing the pSV-beta-GAL plasmid DNA, the cationic lipid dioleoyl trimethylammonium propane, and these helper lipids showed that the most efficient mixtures were aggregates of ensheathed DNA and fused liposomes. PE-containing complexes aggregated rapidly when added to culture media containing polyanions, whereas PC-containing complexes did not. However, more granules of PC-containing complexes were formed on cell surfaces after the complexes were added to Chinese hamster ovary (CHO) cells in transfection media. Pronase treatment inhibited transfection, whereas dilute poly-L-lysine enhanced transfection, indicating that the attachment of DNA:liposome complexes to cell surfaces was mediated by electrostatic interaction. Fluorescence spectroscopy studies confirmed that more PC-containing complexes than PE-containing complexes were associated with CHO cells, and that more PC-containing complexes were located in a low pH environment (likely to be within endosomes) with time. Cytochalasin-B had a stronger inhibitory effect on PC-containing liposome-mediated than on PE-containing liposome-mediated transfection. Confocal microscopic recording of the fluorescently label lipid and DNA uptake process indicated that many granules of DNA:cationic liposome complexes were internalized as a whole, whereas some DNA aggregates were left out on the cell surfaces after liposomes of the complexes fused with the plasma membranes. For CHO cells, endocytosis seems to be the main uptake pathway of DNA:cationic liposome complexes. More PC-containing granules than PE-containing granules were formed on cell surfaces by cytoskeleton-directed membrane motion, after their respective DNA:liposome complexes attached to cell surfaces by electrostatic means. Formation of granules on the cell surface facilitated and/or triggered endocytosis. Fusion between cationic liposomes and the cell membrane played a secondary role in determining transfection efficiency.

Laboratory-scale purification of microcystins using flash chromatography and reversed-phase high-performance liquid chromatography

Microcystins were extracted from 7 l (equivalent to 313 g dry weight) of cyanobacterial scum collected from Rutland Water in Leicestershire, UK in 1989. The resulting aqueous extract was rapidly concentrated on a C18 flash chromatography cartridge and microcystins were eluted using a step gradient. Fractions were collected manually and monitored by UV spectrophotometer and analytical HPLC. Fractions containing microcystins of similar polarity were pooled to give three fractions. Simple isocratic methods for separating each fraction were developed on an analytical column and scaled up to a 15 x 7.5 cm I.D. column. Closed-loop recycling was used to maximise yield and purity of two hydrophobic microcystins.

Infection with Ureaplasma urealyticum and Mycoplasma hominis and the development of chronic lung disease in preterm infants

In a prospective cohort study in a tertiary referral neonatal intensive care unit, the endotracheal secretions of 40 consecutively intubated newborn infants, less than 31 weeks' gestation, were examined weekly for the genital mycoplasmas and all other common bacterial pathogens. Fifteen (37%) infants were positive for Ureaplasma urealyticum and/or Mycoplasma hominis. There were no differences in gestation, birthweight, use of surfactant, or time on ventilator between the culture-positive and negative babies. Thirteen (87%) of the culture-positive group developed chronic lung disease (CLD) compared with 11 (41%) of the negative group (p = 0.0196). Of those culture-positive, 37% were not identified on the first specimen taken at the time of admission. These data suggest a significant association between infection with the urogenital mycoplasma and CLD and also stress the need for repeated cultures to identify these organisms.

Respiratory health in a total very low birthweight cohort and their classroom controls

AIMS

To compare the respiratory health and function at 8 to 9 years of age of a total population based cohort of 300 very low birthweight (VLBW) children with that of two classroom controls (n = 590) matched for age and sex.

STUDY DESIGN

Cohort study with controls.

SETTING

Schools throughout Scotland.

RESULTS

The VLBW children were more likely than their peers to use an inhaler, to be absent from school, and to be admitted to hospital because of respiratory illness. They were significantly shorter than their classroom controls, but even after adjusting for differences in height, the VLBW children had reduced forced vital capacity (FVC); this was associated with a history of prolonged ventilation (> 28 days) and pneumothorax in the neonatal period. There were no significant differences between the groups in forced expiratory volume in one second (FEV1)/FVC but twice as many (7.9% v 3.7%) of the VLBW children had ratios < 70%, denoting obstructive airways disease. Poor expiratory function was associated with neonatal respiratory distress syndrome, prolonged ventilation, and the need for > 40% oxygen. Exercise induced airway narrowing was increased in VLBW children (odds ratio = 2.0; 95% confidence interval 1.2 to 3.4) and was very little changed by adjustment for inhaler use and exposure to cigarette smoke.

CONCLUSIONS

As in other low birthweight cohorts, respiratory morbidity was increased. Unlike previous studies, FVC was more affected than expiratory function in this VLBW population. Our findings support the hypothesis that poorer lung function is associated with very low birth weight, but not with intrauterine growth retardation.

Cost of treating advanced colorectal cancer: a retrospective comparison of treatment regimens

Introduction of new agents on to hospital drug formularies requires the demonstration of efficacy, safety and cost advantages. An audit of the total monthly costs of 'Tomudex' (raltitrexed; administered every 3 weeks), a drug recently introduced for the treatment of advanced colorectal cancer, and three 5-fluorouracil-based regimens [5-day daily bolus (Mayo); continuous ambulatory pump; 48-h continuous infusion (De Gramont)] was undertaken. Patient-specific costs associated with fluids, concomitant medication and consumables were largely negligible, but chemotherapy was the main cost driver in the raltitrexed and De Gramont groups. Fixed inpatient costs were highest for the patients receiving the De Gramont regimen which required more impatient stays each month. Total costs (patient-specific plus fixed costs) were lowest in patients on the Mayo regimen (mean 954.03 Pounds; median 659.68 Pounds), followed by patients in the ambulatory pump (mean 1207.61 Pounds; median 749.19 Pounds), raltitrexed [mean 1256.93 Pounds; median 1087.14 Pounds (mean 1117.85 Pounds; median 959.34 Pounds when costs of protocol-driven visits were excluded)], and De Gramont groups (mean 2028.52 Pounds; median 1775.66 Pounds). The pattern of costs varied considerably between regimens, such that high drug costs, for example those associated with raltitrexed therapy, were partially offset by reductions in hospital visits and stays.