Breast self-examination practices and attitudes of women with and without a history of breast cancer

Breast self-examination (BSE) practices and attitudes of three groups of women were compared using a mailed survey. Subjects were 59 women with previous breast cancer, 33 women with previously treated benign breast lump(s), and 80 general-population women with no history of breast disease. Groups were compared on frequency, proficiency, and knowledge of BSE. Determinants of practice were examined using attitudinal variables from the Health Belief Model. Results indicated that the breast cancer group had significantly higher rates of BSE frequency, proficiency, and knowledge than did the general-population group. The breast cancer group perceived cancer to be significantly less threatening than did the other two groups, although the general-population group reported significantly less susceptibility to breast cancer. Within-group analyses revealed that barriers to BSE practice accounted for the greatest amount of variance in BSE frequency in all three groups. These results are discussed.

Focal salmonella enteritidis infection of urinary tract

A case of upper urinary tract infection with Salmonella enteritidis is presented. The patient was diabetic which may have resulted in diminished immunocompetence, but no other predisposing factor was uncovered. Thorough search for an extraurinary primary source of this infection was unrevealing. The implications of this type of infection are reviewed.

Fine needle aspiration of the breast. Importance of the aspirator

All 503 fine needle aspirations (FNAs) of the breast performed over a three-year period at the Medical Center Hospital of Vermont were analyzed. There were 93 aspirates diagnosed as "positive," all of which were from patients eventually shown to have cancer. However, there were 38 patients with primary carcinoma in which the FNA was not diagnosed as positive, for a diagnostic failure rate of 31.4%. In order to determine the possible effect of technique as practiced by an experienced aspirator in diminishing such diagnostic failures, we compared 190 aspirates obtained by a single individual with 193 aspirates obtained by 15 individuals in the same community. For the single experienced aspirator, the technical failure rate was 9.8% whereas in the group with many aspirators it was 45.9%. This finding confirms that, although fine needle aspiration of the breast is considered easy to perform, skill on the part of the aspirator is important for satisfactory results.

Prevention of post-prostatectomy vesical neck contracture by prophylactic vesical neck incision

Most vesical neck contractures occur after resection of adenomas weighing less than 20 gm. This complication is believed to be secondary to excessive resection or fulguration of an undilated bladder neck. Prophylactic bladder neck incision was performed in conjunction with transurethral resection of the prostate on 114 patients with prostatic adenomas weighing less than 20 gm. Vesical neck contracture occurred in 1 patient (0.87 per cent), compared to 12 contractures in 161 patients who underwent transurethral resection of the prostate alone (7.5 per cent). Increasing bladder neck diameter by incision appears to be protective against formation of vesical neck contractures in patients with small obstructing prostatic adenomas.

Vesical endometriosis: medical or surgical treatment

A case report of endometriosis of the bladder is presented, with special reference to treatment options. Recent experience with this lesion illustrates the dilemma facing the physician who must determine a course of treatment. It seems that removal of the bladder lesion by segmental cystectomy is the preferred treatment.

Congenital posterior urethral polyps

Congenital posterior urethral polyps are benign growths that can cause a variety of symptoms in young boys. They are pathologically distinct growths usually discovered by voiding cystourethrography. We present 5 cases of congenital posterior urethral polyps, and discuss the presentation and pathophysiological status of these lesions. These lesions must be considered in the differential diagnosis of voiding dysfunction in young boys.

Inhibition of wound healing by Corynebacterium parvum

Corynebacterium parvum (C. parvum), an immunostimulant, was examined for its effects on wound healing in mice. Animals injected intraperitoneally with C. parvum, 1400 micrograms 48 hr prior to wounding had significantly decreased wound strength at 5, 7, 11, 14, and 21 days after wounding compared to saline-injected controls (P less than 0.05-P less than 0.001). Mice injected with C. parvum at 48 or 2 hr before wounding, synchronous with wounding and 2 or 48 hr after wounding had significantly decreased wound disruption strength of 11-day-old wounds (P less than 0.01-P less than 0.001). Formalin fixations of wound strips from C. parvum-treated animals were consistently weaker than similarly treated wound strips from controls (P less than 0.05-P less than 0.01). Histologic analysis of wounds from C. parvum-treated animals revealed decreased amounts of wound collagen and increased inflammatory reaction compared to saline-injected animals. While C. parvum can improve survival following injury or septic challenge, the potential for marked alterations in wound healing may limit its clinical application in surgical and trauma patients.

The effect of disulfiram on cyclophosphamide-mediated myeloid toxicity

We have previously shown that disulfiram (DSF) blocks the urotoxicity of cyclophosphamide (CYT) in mice and increases the oncolytic effect of CYT in the L1210 murine leukemia. However, mice treated with CYT and DSF appeared to have longer-lasting neutropenia than animals treated with CYT alone. To determine whether DSF uroprotection of CYT-treated mice was associated with increased myeloid toxicity, we examined the effects of DSF plus CYT treatment on the bone marrow granulocyte/macrophage progenitor cell (GM-CFC). Marrow cellularity and GM-CFC numbers were analyzed at 1, 2 and 3 days after injection of CYT (62.5 or 125 mg/kg) or CYT plus DSF (200 mg/kg). CYT alone caused a decrease in total marrow cellularity varying from 20% to 50% of control. Animals given CYT plus DSF had a somewhat greater decrease in total marrow cellularity than those treated with CYT alone. However, in mice treated with CYT plus DSF, the GM-CFC were relatively well preserved and the recovery of the GM-CFC was not prolonged by DSF. It appears from these studies that the acute toxic effect of CYT on the granulocyte/macrophage progenitor cells is not enhanced by DSF.

Refeeding differentially affects tumor and host cell proliferation

Tumor and host tissue DNA synthesis in C3H female mice with MA16/C tumors were examined for the effects of starvation and refeeding. Animals with subcutaneously implanted tumors were randomized to either regular diet or starvation for 48 hr followed by refeeding for 6, 12, 24, 48, or 72 hr. With starvation, both tumor and host tissues demonstrated a decrease in DNA synthetic activity. After refeeding, resumption in DNA tumor synthesis preceded that of host tissues and was greatest within the first 6-12 hr. Host tissue DNA synthetic activity resumed at different times in the various tissues examined with bone marrow being earlier than spleen or liver. The differential time course between induction of tumor and host DNA synthesis could allow a more precise modeling in studies dealing with the interaction of nutritional repletion and antitumor therapy.

Effect of burn injury on granulocyte and macrophage production

Using a model of uncomplicated burn injury in mice, we assayed the bone marrow and splenic production of granulocytes and macrophages after burn injury. The effects of burn size and burn wound excision and closure were studied. Using an in vitro quantitative clonal culture technique for granulocyte/macrophage progenitor cells (GM-CFC), myeloid precursors were directly assayed. Burns of a 10% body surface area were equal to burns of larger magnitude for effects on marrow and splenic granulocyte/macrophage production. The total peripheral blood leukocyte and lymphocyte counts were depressed at days 1 and 4 postburn but were elevated at days 8 and 12. Granulocytes, however, remained significantly increased at days 8 and 12. The bone marrow response to burning showed an initial depression in marrow cellularity on day 1 with return to normal values by days 8 and 12. The numbers of GM-CFC were significantly elevated on days 4-12 with a near threefold increase in the number of GM-CFC 12 days following burn injury. The splenic response to burn injury was characterized by a decrease in the splenic index on day 1 but then a persistent increase at days 8 and 12. Total splenic cellularity was depressed on day 1 but significantly increased at days 8 and 12. The total number of splenic GM-CFC was increased on days 4-12 with a 100-fold increase on day 8. The immediate or delayed excision of the burn wound did not alter marrow or splenic response to burning. We conclude that following a cutaneous injury there is a marked alteration in the generation of the phagocytic cells of the granulocyte and macrophage series and that this response is secondary to the wounding process.

The quantity and function of pulmonary alveolar macrophages after splenectomy and Corynebacterium parvum

We have previously shown that Corynebacterium parvum (C. parvum), a nonspecific immunomodulator, partially protects splenectomized and nonsplenectomized mice when challenged with aerosolized pneumococci. We report here the effects of both splenectomy and C. parvum on the phagocytic function of the lavageable pulmonary alveolar macrophage (PAM). Groups of young adult male Sprague Dawley rats underwent splenectomy or sham operation 3 weeks before injection of C. parvum 1.5 mg IP (or saline) per animal. One week postinjection PAM's were harvested. The in vitro phagocytic indices (PI) for PAM incubated with tritiated thymidine-labeled S. aureus or Streptococcus pneumoniae, type 14, opsonized with normal rat serum, were determined. Splenectomy had no effect on lung weights, PAM yield, or PAM phagocytic activity. C. parvum administration significantly increased spleen weight in sham-operated animals, but had no effect on lung weights, PAM yield, or phagocytic activity of either control or splenectomized animals. Splenectomy in the adult rat did not induce a phagocytic defect in the PAM and thus the lavageable PAM cannot be considered a significant site of the postsplenectomy defect. Since C. parvum protects animals from respiratory challenge with Streptococcus pneumoniae but does not alter the number or activity of lavageable alveolar macrophages, we hypothesize that C. parvum protection is more likely related to our previous finding of an increased clearance of blood-borne bacteria by the expanded and enhanced reticuloendothelial system.

Adverse relationship between blood transfusions and survival after colectomy for colon cancer

Random-donor blood transfusions are deliberately given before cadaver renal allografting to improve allograft survival. Since host modifications that improve the outcome of an allograft might be associated with a decreased ability of the host to control cancer growth, the relationship between blood transfusions and the outcome of 146 Dukes' stages A, B, and C colon cancers treated by resection during the years 1974 to 1979 was studied. It was found that 65 patients (45%) had been transfused and that at 5 years, overall survival was significantly better in the nontransfused patients compared to the transfused patients (0.68 and 0.51 5-year product limit survival fractions respectively; P = 0.03 for unadjusted log-rank comparison of entire survival curves). Relative risk of death due to cancer in transfused patients versus nontransfused patients was 2.3 (P = 0.05) when controlled for sex, age, stage, histologic differentiation, cancer location, and pre-resection hemoglobin level using Cox regression analysis. Thus, blood transfusion appears to be an additional important prognostic variable. The hypothesis suggested but not proven by these data that the outcome for some malignancies may be related to the immunomodulating effects of blood transfusions needs further study.

Adverse relationship between blood transfusions and survival after colectomy for colon cancer

Random-donor blood transfusions are deliberately given before cadaver renal allografting to improve allograft survival. Since host modifications that improve the outcome of an allograft might be associated with a decreased ability of the host to control cancer growth, the relationship between blood transfusions and the outcome of 146 Dukes' stages A, B, and C colon cancers treated by resection during the years 1974 to 1979 was studied. It was found that 65 patients (45%) had been transfused and that at 5 years, overall survival was significantly better in the nontransfused patients compared to the transfused patients (0.68 and 0.51 5-year product limit survival fractions respectively; P = 0.03 for unadjusted log-rank comparison of entire survival curves). Relative risk of death due to cancer in transfused patients versus nontransfused patients was 2.3 (P = 0.05) when controlled for sex, age, stage, histologic differentiation, cancer location, and pre-resection hemoglobin level using Cox regression analysis. Thus, blood transfusion appears to be an additional important prognostic variable. The hypothesis suggested but not proven by these data that the outcome for some malignancies may be related to the immunomodulating effects of blood transfusions needs further study.

Surgery and radiotherapy for primary breast cancer. What we have learned from the controlled clinical trials

The history of the use of surgery and radiotherapy for the management of primary breast cancer is reviewed with an emphasis on the conclusions to be reached from the controlled clinical trials. Prophylactic treatment of clinically negative regional nodes by either surgical extirpation or radiotherapy does not improve survival in comparison with a policy of observation and treatment at the time of clinical progression. Axillary node dissection is currently important for histologic staging of the axillary nodes. Early results of the controlled trials appear to support the concept that for selected patients, a regimen of complete excision of the primary tumor and breast irradiation produces results equivalent to those of total mastectomy in terms of distant recurrence and survival.

Blood transfusions and survival after surgery for breast cancer

Numerous reports have demonstrated that blood transfusions given prior to renal allografting have an immunomodulating effect that leads to increased graft survival. To determine if blood transfusions would adversely affect the outcome for patients with breast cancer, we examined 226 patients with invasive breast cancer who had a mastectomy and found 65 (29%) had received transfusions. The patients who had transfusions and those who did not were similar in age, clinical tumor-node-metastasis stage, and number of histologic nodal metastases. At a median follow-up of 52 months for surviving patients, 48 (21%) of the patients were dead. Log-rank and Cox regression analyses that compared patients who had transfusions v those who did not showed no excess of either overall deaths or deaths due to cancer in the group that received transfusions. The hypothesis that blood transfusions might have an adverse effect on survival was not supported by this study. Additional studies involving other groups of patients with malignant neoplasms and other blood donor populations are needed.

Breast self-examination practices and breast cancer survival

To determine the relation between breast self-examination and survival of breast cancer patients, the authors studied 1004 newly diagnosed invasive breast cancer patients in Vermont general hospitals from 1 July 1975 to 31 December 1982. More frequent breast self-examination was associated with a greater likelihood of the patient's detecting her own cancer, less delay from first symptom to histologic diagnosis, earlier clinical stage, smaller pathologic tumor size, and fewer axillary node metastases. At a median follow-up time of 52 months (maximum follow-up, 92 months), 14% of the breast self-examination performers had died of breast cancer versus 26% of the nonperformers (P less than 0.001 based on chi-square). The product limit survival curve for breast self-examination performers (N = 424) was significantly better (P less than 0.001 by log-rank test) than for breast self-examination nonperformers (N = 411). Survival at 5 years was 75% for breast self-examination performers versus 57% for the nonperformers. The significant survival differences persisted after adjusting for any combination of the covariates age, method of detection, family history of breast cancer, and delay in treatment (P less than 0.002). Lead-time would have to be at least 3 years to negate the apparent beneficial effects of breast self-examination on survival. The authors conclude that in this population of breast cancer patients, breast self-examination was related to earlier detection and improved survival.

Effects of protein-calorie malnutrition and refeeding on fluorouracil toxicity

Mice were used to study the effects of protein-calorie malnutrition and its reversal on granulocyte-macrophage production and fluorouracil's toxic effect on bone marrow. An in vitro quantitative clonal culture technique for bone marrow granulocyte-macrophage progenitor cells (GM-CFC) was used. Animals on a protein-free but otherwise complete diet for ten days had a significant contraction in total marrow cellularity and GM-CFC numbers paralleling the animal's weight loss. The acute toxic effect of fluorouracil on bone marrow was not increased in protein-deprived animals. On refeeding, there was a biphasic response in the degree of toxic effect on marrow. Animals refed for one day had significantly increased fluorouracil-related marrow abnormalities. However, animals refed for four days, when marrows were repleted, were partially protected from the drug's cytotoxic effects. The increased sensitivity in mice refed for one day was related to more GM-CFC in active DNA synthesis.

Improved survival after pneumococcus in splenectomized and nonsplenectomized mice with Corynebacterium parvum

Splenectomy increases the susceptibility to infections with certain bacteria, particularly Streptococcus pneumoniae. Because the immunomodulator Corynebacterium parvum expands the phagocytic cell compartment and enhances reticuloendothelial function, we tested the effect of C parvum in mice challenged with aerosolized pneumococci. Mice splenectomized seven days before pneumococcal challenge and treated intraperitoneally with 700 micrograms of C parvum immediately after exposure were protected when compared with splenectomized or sham-operated saline-injected controls. Analysis of proportional hazards showed the risk of dying in order of greatest to least as follows: splenectomy/saline, sham/saline, splenectomy/C parvum and sham/C parvum. The benefits of an intact spleen and C parvum seemed to be additive in their protective effects after aerosol pneumococcal challenge. After intravenous challenge, bloodstream clearance was improved in sham-operated mice at three days after C parvum injection compared with saline-injected sham-operated controls and C parvum-injected splenectomized mice. A significant improvement in bacterial clearance did not occur until seven days after C parvum treatment in splenectomized mice. The results demonstrate the value of a nonspecific immunomodulator for enhancing the defense mechanisms of both normal and splenectomized animals.

Content and context in health education: persuading women to perform breast self-examination

Content in a breast self-examination (BSE) education program was tested according to three motivational approaches with 923 women in Vermont women's clubs. The program was a slide-tape presentation using one of the three approaches and a BSE demonstration followed by a group discussion led by a nurse. A post-test of 374 women 6 months later showed a significant increase in monthly BSE performance from 40 to 71% regardless of motivational approach and an increase in breast cancer knowledge that was somewhat varied by approach, but was significant across all three approaches. Women who did not adopt monthly BSE after the program had an increase in knowledge similar to those who had adopted it. After the program, older women had somewhat less knowledge but performed BSE as often as younger women. Women with a family history of breast cancer were somewhat less likely to perform monthly BSE than other women, and women admitting to inhibitions about BSE were significantly less likely to adopt the practice than other women, yet their monthly BSE also increased as a result of the program. The significant positive change in BSE and knowledge across all groups appeared to be more a result of the supportive women's club context than of variations in program content. Thus, to achieve desired changes in prevention-oriented health behavior, it is suggested that health educators emphasize structuring a favorable context for the presentation of recommended actions such as BSE.

Lack of protection by pneumococcal vaccine after splenectomy in mice challenged with aerosolized pneumococci

The efficacy of pneumococcal vaccine given after splenectomy lacks experimental validation. Adult CD-1 male mice that received type III pneumococcal capsular polysaccharide vaccine 1 microgram IP, 48 hours postsplenectomy and 7 days before challenge with aerosolized type III Streptococcus pneumoniae had a significantly higher mortality (96%) compared to immunized controls (64%) (p less than 0.002). The vaccine protected immunized sham-operated mice compared to unimmunized controls (p less than 0.015). Mice immunized 7 days before splenectomy were equally protected when compared to immunized sham-operated mice (p = NS). All deaths were secondary to culture-proven pneumococcal infection. These findings corroborate previous experimental and clinical studies demonstrating an impaired immunologic response and increased susceptibility to infection in asplenic individuals. Pneumococcal vaccines should be given before nonemergent splenectomy. Alternatives to splenectomy should be considered for patients with traumatized spleens where possible.

Hematopoietic toxicity by cimetidine. Reexamination using the antimetabolite azathioprine

By using an in vitro quantitative clonal culture technique for bone marrow granulocyte/macrophage progenitor cells (GM-CFC), we studied the effects of cimetidine alone and cimetidine plus azathioprine on bone marrow toxicity in C57BL/6 mice. Femoral bone marrow showed no effect of cimetidine in doses from 31.25 to 500 mg/kg on either marrow cellularity or the number of GM-CFC. Cimetidine pretreatment with single doses of 62.5 mg/kg or 250 mg/kg had no effect on the bone marrow suppression of azathioprine at 100 mg/kg. Chronic cimetidine pretreatment at 62.5 mg/kg daily for 7 days also had no effects on the single-dose azathioprine toxicity. Cimetidine given either before or after azathioprine had no effect on the rate or final level of recovery of GM-CFC in the marrow after depletion by azathioprine. Cimetidine in vitro at doses of 3.1 to 200 micrograms/ml caused no alteration in the proliferative response of the GM-CFC. Analysis of the serum colony-stimulating activity 1 to 24 hr following doses of cimetidine of either 12.5 mg/kg or 31 mg/kg caused no change in the serum colony-stimulating activity. We could find no evidence that at clinically relevant doses, cimetidine increased the hematopoietic toxicity of the azathioprine or altered the rate of bone marrow recovery after azathioprine depletion.

Systemic amyloidosis involving two renal transplants

Two patients with primary amyloidosis, each of whom had received a renal transplant for chronic renal failure, developed amyloid in their allografts. In one patient amyloid was present primarily in glomeruli and to a lesser extent in the interstitial tissue. This patient developed renal failure necessitating retransplantation. In the second patient amyloid was seen in the interstitium and interlobular blood vessels. Minimal amyloid was present in the glomeruli. This patient died of cardiac amyloidosis with good graft function at the time of death. Of the several patients recorded in the literature with amyloid in renal allografts, our first patient is the only one to exhibit glomerular amyloid and failure of the graft. Amyloid in areas other than the glomerulus does not appear to be incompatible with satisfactory graft function.

Staging of breast cancer: a new rationale for internal mammary node biopsy

Metastases to the axillary nodes, the internal mammary nodes, or both, define a group of patients at very high risk of having systemic micrometastases leading to recurrent disease and death if surgical therapy alone is used. In our review of 7,070 patients with breast cancer in whom both axillary nodes and internal mammary nodes were examined histologically, 5% to 10% had internal mammary node metastases in the absence of axillary node metastases. With the availability of effective systemic therapy that can improve the survival of patients with operable breast cancer who have lymph node metastases, information obtained from internal mammary node biopsies assumes practical significance. Our current policy is to perform internal mammary node biopsies on patients with operable breast cancer who have medial and central primary tumors of any size and lateral primary tumors 2 cm or greater in diameter if a frozen section of the most suspicious node in the axillary dissection shows no histologic evidence of metastasis.

Legionnaires' disease in renal transplant patients

Legionnaires disease, which is commonly manifested as pneumonia, was only recently recognized to be a bacterial infection. Diagnosis can be difficult because Gram's stain does not readily stain the bacterium in pulmonary secretions, the organism is not readily cultured, and legionellae is not affected by many commonly used antibiotics. In a retrospective review of all of our transplant patients, we identified 14 cases of Legionnaires' disease after 101 renal transplants. The patients characteristically had high fever, polymorphonuclear leukocytosis, dyspnea and an unproductive cough accompanied by radiographic changes of consolidating pneumonia. Legionnaires' disease can be diagnosed by direct immunofluorescent antibody staining, culture on special media or increases in serum titers of legionella antibodies in surviving patients. Since the recognition of Legionnaires' disease in 1977, we have successfully treated seven renal transplant patients using erythromycin with or without rifampin.

Anterior urethral polyps

The second reported case of an anterior urethral polyp is presented. The etiology, pathology and treatment of urethral polyps are discussed.

Effect of ureteral ligation and nephrectomy on granulocyte-macrophage progenitor cells and azathioprine toxicity

Using an in vitro quantitative clonal culture technique of bone marrow granulocyte-macrophage progenitor cells (colony-forming units culture (CFU-c)), we studied the hematopoietic toxicity of azathioprine after unilateral and bilateral ureteral ligation, unilateral and bilateral nephrectomy, and splenectomy in C57BL/6 mice. Analysis of femoral bone marrow 18 hr after i.p. injection of azathioprine (300 mg/m2) revealed increased CFU-c toxicity in comparison to controls as follows: (1) bilateral ureteral ligation, P less than 0.01; (2) bilateral nephrectomy, P less than 0.01; (3) unilateral ureteral ligation, P greater than 0.05 less than 0.1; (4) unilateral nephrectomy, P, not significant; and (5) splenectomy, P, not significant. Extrapolation from a dose-response curve for the toxicity of azathioprine on the bone marrow CFU-c indicated that bilateral ureteral ligation and bilateral nephrectomy had the effect of a 25 to 50% increase in the azathioprine dose. After bilateral ureteral ligation, serum granulocyte-macrophage colony-stimulating factor levels were increased and in vitro tritiated thymidine suicide studies showed an increased proliferative rate of the CFU-c. Since azathioprine is a predominantly cell cycle-specific agent, we suggest that increased sensitivity to azathioprine is related to the increased proliferative rate of the CFU-c. The findings provide a rationale for a clinical policy of azathioprine reduction when there is depressed renal function.

Legionnaires' disease in patients with associated serious disease

Of nine patients with Legionnaires' disease, seven were receiving corticosteroids, and all nine had serious underlying diseases. Direct immunofluorescent examination of respiratory secretions, including sputum and transtracheal aspirates, showed the Legionnaires' disease (LD) bacterium in five of seven patients who seroconverted and in a sixth patient with a single elevated titer to the LD bacterium. All nine patients received erythromycin therapy, and five survived. Two patients showed persistence of their infection after receiving 2 weeks of erythromycin therapy, and two patients developed pulmonary abscesses. These cases of Legionnaires' disease show the occurrence of pulmonary abscesses, the possibility of relapse after giving only 2 weeks of erythromycin therapy, and the utility of direct immunofluorescence for early diagnosis.

Effect of Corynebacterium parvum on the proliferative rate of granulocyte-macrophage progenitor cells and the toxicity of chemotherapy

We have studied the interaction of Corynebacterium parvum and a variety of cell cycle-specific and cell cycle-nonspecific chemotherapeutic agents on granulocyte-macrophage progenitor cells [colony-forming units culture (CFU-c)] in C57BL/6 mice. In vitro tritiated thymidine suicide studies showed an increased rate of proliferation of bone marrow CFU-c 24 hr after C. parvum injection. In vivo toxicity of cell cycle-specific agents but not of cell cycle-nonspecific agents for bone marrow CFU-c was increased 24 hr after C. parvum injections. The increased numbers of CFU-c in the spleen, induced by C. parvum, were also sensitive to a cell cycle-specific agent for up to 7 days after C. parvum injection. The findings suggest differences in the kinetics of proliferation of splenic compared to bone marrow CFU-c. The relative time of administration of chemotherapy and immunostimulants such as C. parvum will have to be carefully considered in the design of clinical trials.

Breast self-examination practices and breast-cancer stage

To determine the relation between breast self-examination performance and the clinical and pathological stage of breast cancer at first diagnosis, we studied 335 patients with breast cancer. Approximately one fourth of the patients reported that they had been practicing monthly breast self-examination, and half that they had never practiced breast self-examination. More frequent performance of breast self-examination was associated with more favorable clinical stage and fewer axillary-lymph-node metastases on histologic examination. On pathological examination, the age-adjusted maximum tumor diameter of patients practicing monthly breast self-examination was 1.97 +/- 0.22 cm (mean +/- S.E.M.) as compared to 2.47 +/- 0.20 for those performing self-examination less often than monthly and 3.59 +/- 0.15 for patients never performing breast self-examination. These data associating more favorable clinical and pathological stages of breast cancer with more frequent breast self-examination need to be extended by determination of the survival rates of the various self-examination groups.

Breast biopsy. A comparison of outpatient and inpatient experience

Nine hundred ninety-seven breast biopsies that were performed at one hospital over the five-year period from 1971 through 1975 were reviewed because of a changing pattern in the use of breast biopsies on outpatients who were under local anesthesia. In 1971, 17% of all breast biopsies were performed as outpatient procedures; by 1975, the figure was 60%. In 1971, 5% of all malignant neoplasms were diagnosed by the use of biopsies as outpatient procedures and 30% in 1975. Hospital charges for biopsy on an inpatient basis of benign breast disease were 7.2 times higher than for biopsy on an outpatient basis. Interviews of 102 patients clearly suggested that most patients were satisfied with the outpatient breast biopsy experience. Outpatient breast biopsy under local anesthesia is a safe procedure that is more economical in terms of medical cost, surgeons' time, and patients' time away from home and/or job. Preliminary biopsy of malignant lesions using local anesthesia permits more efficient use of diagnostic procedures to stage the extent of disease prior to treatment. Patient acceptance of breast biopsy as an outpatient procedure under local anesthesia was similar to their acceptance of biopsy on an inpatient basis under general anesthesia.

Morbidity and mortality after thyroidectomy

To assess the morbidity and mortality of thyroid operations, Professional Activity Study records of the Commission on Professional and Hospital Activities, representing an estimated one-third of all thyroidectomies performed in the United States in 1970, were reviewed. The mortality after a thyroid operation for nontoxic goiter was 0.02 per cent for patients less than the age of 50 years but increased with age to 0.66 per cent for those 70 years and older. No in-hospital deaths followed thyroidectomy for malignant goiter in 766 patients less than 40 years of age. Thyroidectomy for diffuse toxic goiter had a mortality fivefold greater than did operations for a benign nontoxic goiter. Total thyroidectomy was used for the treatment of nontoxic, nonmalignant goiter for one in 12 patients and resulted in greater morbidity than did partial or subtotal thyroidectomy. Rational choice of operation for the treatment of goiter for individual patients should be based upon knowledge of the specific risks of surgical treatment, which vary greatly depending upon the age of the patient, whether or not the goiter is toxic or nontoxic and whether or not subtotal or total thyroidectomy is performed.

Altered toxicity of 5-fluorouracil following treatment with Corynebacterium parvum

Recent studies have demonstrated that systemic Corynebacterium parvum increases serum granulocyte-macrophage colony-stimulating factor and stimulates the proliferation of granulocyte-macrophage progenitor cells. It was hypothesized that more rapid cycling of granulocyte-macrophage progenitor cells would render the cells more sensitive to a cell cycle-specific chemotherapeutic agent. The colony-forming ability of bone marrow granulocyte-macrophage progenitor cells was assayed in vitro with soft agar cultures. C. parvum given before 5-fluorouracil in C57BL/6 mice increased the granulocyte-macrophage progenitor cell toxicity, the lymphopenic effect, and the lethality of 5-fluorouracil. When C. parvum was given after 5-fluorouracil, there was more rapid rebound of granulocyte counts to normal or supranormal levels.

Effect of surgery on granulocyte/macrophage colony-stimulating factor

Eighteen surgical patients were studied to determine the effect of anesthesia (general or spinal) and surgery on serum and urinary colony-stimulating factor(s) (CSF). CSF is a leukopoietin that stimulates proliferation of macrophages and granulocytes from bone marrow precursor cells. CSF was assayed by adding aliquots of serum or urine to semisolid agar cultures of bone marrow cells and scoring the number of colonies developing after 7 days of incubation. In all but 1 case, a 3- to 30-fold increase in the 24 hour excretion of urinary CSF was seen on the day of surgery and the first postoperative day. CSF urinary excretion began declining toward normal by the second postoperative day. A parallel increase in granulocyte count, a delayed rise in monocytes, and a decline in absolute lymphocyte counts were also observed. The data suggest that immediately postoperatively there may be a strong stimulus to granulocyte/macrophage proliferation. More rapidly proliferating cells would be anticipated to have increased vulnerability to toxicity from cell cycle-active chemotherapeutic agents.

Renal ischemia and contrast urography

Exposure to urographic contrast material, meglumine diatrizoate, in a previously ischemic kidney was investigated for its effect on renal function. Eleven mongrel dogs, 19.8-32.7 kg in weight, having the left kidney ischemic for 90 minutes were given either 4 cc/kg meglumine diatrizoate or control, Ringer's lactate solution. The effect on creatinine clearance of the left kidney was determined acutely and at 72 hours. Statistical analysis of the data reveals no deleterious effect from exposure to meglumine diatrizoate over and above the effect of the ischemic episode. There was no statistically significant effect on recovery of renal function in this animal model.

Chicken embryo as an animal model for gonorrhea

Parameters of infection of the chicken embryo with Neisseria gonorrhoeae were defined in order to standardize infectious and lethal doses. Virulent (T1) and avirulent (T3) gonococci from two strains were used to infect 7- to 12-day-old White Leghorn chicken embryos via the yolk sac (YS) or chorioallantoic membrane (CAM) route. Infection of embryos was established following YS inoculation of 1 to 10 viable gonococci. Although 8- to 10-day-old embryos were the most susceptible, an inoculum of less than 100 gonococci was sufficient to kill any age embryo via this route. Embryos were less susceptible to infection via the CAM, where an inoculum of from 10(5) to 10(6) colony-forming units was lethal by 42 h. Strain and morphological type had a variable influence on the ability of the gonococcus to infect and kill the chicken embryo by either route; however, agar-grown and broth-grown organisms produced consistently similar mean lethal dose (LD(50)) and mean infective dose (ID(50)) values. LD(50) and ID(50) differences between T1 and T3 gonococci from strain 72H641 were not apparent after either YS or CAM inoculation of 8- or 10-day chicken embryos, respectively. YS and CAM LD(50) values for strain 72H641 T1 and T3 and CDC 9 T3 were also similar; however, these values were slightly lower for CDC 9 T1. In terms of infectivity or colonization, CDC 9 T1 and T3 had higher ID(50) values via the YS and lower ID(50) values via the CAM than 72H641. CDC 9 T1 was slightly more infective via the YS and less infective via the CAM than its T3 counterpart. Although the gonococcal strain used will influence interpretation of results, infection of both YS and CAM was highly reproducible in terms of gross pathology and of LD(50) and ID(50) data for a particular strain and colony type.

Bone marrow colony-forming cells in mice with virus-induced lymphoid leukemia: relation to serum colony-stimulating activity and blood granulocytes

Mice with advanced lymphoid leukemia have elevated peripheral blood granulocytes and elevated serum colony-stimulating activity, which promotes the in vitro growth of granulocyte and/or macrophage colonies. The number of bone marrow precursor cells of the in vitro granulocyte and/or macrophage colonies varied from normal to 10% of normal. The elevation of colony-stimulating activity correlated best with a combination of increased blood granulocytes and a deficiency of bone marrow precursor cells, which suggested that colony-stimulating activity is a leukopoietin that increases the efficiency and rate of production of granulocytes.

Effect of Corynebacterium parvum on colony-stimulating factor and granulocyte-macrophage colony formation

Because Corynebacterium parvum has tumor-inhibitory properties and stimulates granulocyte-macrophage production, it may have clinical value in combination with chemotherapy. The leukopoietic effect of killed suspensions of C. parvum was studied in mice using the technique of in vitro clonal culture of hematopoietic cells. After C. parvum injection, there was a prompt, sustained elevation of serum colony-stimulating factor followed by an increase in granulocyte-macrophage precursor cells in the spleen and increases in blood mononuclear and granulocyte cells. Colony-stimulating factor production is suggested as a major mechanism of stimulation of granulocyte-macrophage proliferation by C. parvum. Since rapidly proliferating hematopoietic cells may have increased sensititity to cytotoxic agents, the details of hematopoietic stimulation by C. parvum may be critical in the sequential timing of combined C. parvum and chemotherapy treatment to obtain maximal tumor inhibition and minimal hematopoietic toxicity.

Decreased liver and lung drug-metabolizing activity in mice treated with Corynebacterium parvum

Injections of killed suspensions of Corynebacterium parvum (i.p.) in young male mice were followed by time- and dose-dependent decreases in the drug-metabolizing activity of liver microsomes and lung homogenates. In vitro assays with model substrates [aminopyrine, aniline, p-nitroanisole, and benzo(a)pyrene] were used to quantitate drug-metabolizing activity. It is likely that such decreases in mixed function oxidases activity will act to significantly alter the pharmacokinetics of concurrently or subsequently administered drugs. The results provide a possible mechanism to explain several previously reported immunochemotherapeutic interactions.

Mangement of infantile esotropia

We evaluated the management of infantile esotropia-constant, alternating esotropia before 6 months of age-in 34 children. Planned one-state surgery for satisfactory mechanical alignment was highly predicatable (79 to 84%), and was obtained at any age. Stable bifoveal motor fusion was also obtained but was more frequent with alignment before 2 years of age. The use of postsurgical spectacle orthoptics (minus lenses or prisms, or both) increased the incidence of bifoveal fusion. Surgery alone resulted in bifoveal fusion in 6% of the cases, whereas an overall incidence of 33% bifoveal fusion resulted after the use of postsurgical spectacle orthoptics by some patients. Of those receiving postsurgical spectacle orthoptics, 53% obtained bifoveal fusion. This study demonstrated a correlation between the incidence of secondary A patterns (after surgery for V esotropia) and the amount of horizontal muscle surgery done in combination with bilateral inferior oblique muscle myectomies.

Electrophoretic comparison of endonuclease-digested plasmids from Neisseria gonorrhoeae

In order to associate virulence in Neisseria gonorrhoeae with an alteration of the nucleotide sequence of its small covalently closed plasmid, plasmid deoxyribonucleic acid was isolated from both virulent (T1) and avirulent (T3) morphological types for two strains. Electrophoretic and contour length measurements of intact plasmids indicated a homogeneous population with a molecular weight of approximately 2.6 x 10(6). Digestion with two restriction endonucleases. Hinf I and Hpa II, generated distinct fragment patterns which in each case were identical for T1 and T3 plasmid molecules from the same strain. The analysis suggests no sequence differences between the plasmids from virulent and avirulent types. For both strains, however, a deletion or addition of about 1.5% of the total deoxyribonucleic acid appeared in the Hpa II C digestion fragment when patterns for gonococci serially passaged 300 times were compared to those for bacteria freshly established from frozen stocks. The significance of the plasmid instability remains undetermined.