Evolution of combined modality therapy for stage III non-small-cell lung cancer

A number of randomized clinical trials and meta-analyses now support the conclusion that combined modality regimens that include cisplatin (Platinol)-based chemotherapy improve survival in stage III non-small-cell lung cancer (NSCLC) more effectively than radiotherapy or surgery alone. Depending on the therapy, chemotherapy may play a cytoreductive role by eradicating distant micrometastases, a radiosensitizing role by improving local control, or do both. In general, sequential therapies in which platinum-based chemotherapy precedes thoracic radiation or surgery have improved outcome by affecting distant metastases. In contrast, concurrent chemoradiotherapy utilizing low-dose cisplatin improves survival by reducing local recurrence without an effect on distant failure rates. In view of these observations, chemoradiotherapy strategies that integrate both radiosensitizing agents and dose levels of chemotherapy that are effective against micrometastases may prove to be most efficacious. Since distant metastases remain the major site of failure, it is also likely that more effective chemotherapy or other systemic antitumor agents are necessary to increase the current level of response and survival. Fortunately, several new chemotherapeutic agents are highly effective against NSCLC as well as potent radiosensitizers.

Nucleus-vacuole junctions in Saccharomyces cerevisiae are formed through the direct interaction of Vac8p with Nvj1p

Vac8p is a vacuolar membrane protein that is required for efficient vacuole inheritance and fusion, cytosol-to-vacuole targeting, and sporulation. By analogy to other armadillo domain proteins, including beta-catenin and importin alpha, we hypothesize that Vac8p docks various factors at the vacuole membrane. Two-hybrid and copurfication assays demonstrated that Vac8p does form complexes with multiple binding partners, including Apg13p, Vab2p, and Nvj1p. Here we describe the surprising role of Vac8p-Nvj1p complexes in the formation of nucleus-vacuole (NV) junctions. Nvj1p is an integral membrane protein of the nuclear envelope and interacts with Vac8p in the cytosol through its C-terminal 40-60 amino acids (aa). Nvj1p green fluorescent protein (GFP) concentrated in small patches or rafts at sites of close contact between the nucleus and one or more vacuoles. Previously, we showed that Vac8p-GFP concentrated in intervacuole rafts, where is it likely to facilitate vacuole-vacuole fusion, and in "orphan" rafts at the edges of vacuole clusters. Orphan rafts of Vac8p red-sifted GFP (YFP) colocalize at sites of NV junctions with Nvj1p blue-sifted GFP (CFP). GFP-tagged nuclear pore complexes (NPCs) were excluded from NV junctions. In vac8-Delta cells, Nvj1p-GFP generally failed to concentrate into rafts and, instead, encircled the nucleus. NV junctions were absent in both nvj1-Delta and vac8-Delta cells. Overexpression of Nvj1p caused the profound proliferation of NV junctions. We conclude that Vac8p and Nvj1p are necessary components of a novel interorganelle junction apparatus.

Future directions in health for the new Government: our health and the public health

The 'no model' model awaited the invisible hand. However, 'more government' demands more hands-on direction of the health system. To whom will the government turn for advice? The health professionals were excluded from the market experiment because of the concern that they would 'capture the process'. With the change in the political will, some of the most simplistic, fallacious perceptions of New Zealand's society should have less influence on health policy. The new government has the opportunity to re-engage New Zealanders in advancing the health of the nation. Public health specialists have a wealth of information to guide decision-making which deserves wider dissemination and more executive consideration. In personal health care, health professionals have the will to continue innovation but need a system in which their values are respected. One caveat: there is a tendency, whether the approach is 'more market' or 'more government', to try to measure everything and tick every box. When dealing with complex systems which need highly skilled professionals, however, there simply needs to be a high level of trust As when getting on a plane, central planners, like the rest of us, need to understand that sometimes the pilots must 'capture the process' in order to get back on course.

A multinational comparison of aphasia management practices

The effect of restructuring of healthcare on the quality, quantity, and nature of aphasia management is largely unknown. The current study is the first to examine access, diagnostic, treatment, and discharge patterns of patients with aphasia in Australia, Canada, the UK, the US private sector (US-Private), and the US Veterans Health Administration in the Department of Veterans Affairs (US-VA). The authors developed a 37-item survey to be completed by clinicians working with aphasic patients. The survey focused on eight areas: access to care, evaluation procedures, group treatment, number and duration of treatment sessions, limitations of the number of sessions, termination of treatment, follow-up practices, and resumption of treatment. 394 surveys were distributed and 175 were returned completed (44% return rate). Respondents represented a range of ages, work experiences, and work settings. There was considerable consistency among respondents from our five healthcare systems. Results suggest that patients may be routinely denied treatment in direct contradiction to the research literature. Just as we carefully monitor the progress of patients receiving our treatment, we are obliged to monitor the effects of managed care on our patients, fellow clinicians, and our profession.

Can 16-18-year-old elite ballet dancers improve their hip and ankle range of motion over a 12-month period?

OBJECTIVE

To determine the effect of a 12-month intensive ballet training regimen on hip and ankle range of motion in male and female, first- and second-year professional dancers.

DESIGN

12-month longitudinal follow-up.

SETTING

National classical ballet school in Australia.

PARTICIPANTS

28 female and 20 male full-time ballet students with a mean +/- 1 SD, ages 16.8 +/- 0.8 and 17.7 +/- 1.2 years, respectively.

MAIN OUTCOME MEASURES

Degrees of range of motion of left and right sides for the following movements: standing plié in parallel-passive ankle dorsiflexion (DF); standing turnout in the balletic first position--lower leg external rotation (LLER); supine hip external rotation (ER); supine hip internal rotation (IR). An additional range of motion was calculated: external rotation below the hip joint (BHER) derived by subtracting hip ER from LLER.

MAIN RESULTS

In all subjects combined, hip and ankle ranges increased statistically on the right. However, the amount was generally minimal and most at the borderline of the amount of error associated with the measurement tool. While there was no change in LLER, there was a decrease in BHER. There were no overall gender differences, and year differences existed only for left hip ER and total hip ER with first-year dancers showing significant improvements in these ranges. For DF and sum of hip IR, first-year males and second-year females had increases in range. There was a negative relationship between baseline range and the amount of change over the 12 months.

CONCLUSIONS

Dancers ages 16-18 years who enter full-time ballet training did not augment their ankle dorsiflexion to any appreciable degree. Some, but certainly not all, increased their hip active external rotation over 12 months without increasing their total lower limb turnout. Hip ER was more likely to improve in the first-year rather than second-year student in this elite full-time training school.

Increased defibrillation threshold with right-sided active pectoral can

The aim of this study was to identify the optimal position on the chest wall to place an implant able cardioverter defibrillator in a two-electrode system, consisting of a right ventricular electrode and active can.

METHODS AND RESULTS

Defibrillation thresholds (DFT) were measured in 10 anaesthetised pigs (weight 33-45 kg). An Angeflextrade mark lead was introduced transvenously to the right ventricular apex. The test-can (43 cc) was implanted submuscularly in each of four locations: left pectoral (LP), right pectoral (RP), left lateral (LL) and apex (A). The sequence in which the four locations were tested was randomized. Ventricular fibrillation (VF) was induced using 60 Hz alternating current. Rectangular biphasic shocks were delivered 10 seconds after VF induction. The DFT was measured using a modified four-reversal binary search. The results of the four configurations were: LP, 14.6+/- 4.0 J; RP, 18.8+/- 4.2 J; LL, 14.7+/- 4.1 J; A, 14.9+/- 3.1 J. Repeated measures analysis of variance showed that the DFT of RP was significantly higher than LP, LL and A (p < 0.05).

CONCLUSIONS

Implanting an active can in the RP position increases the DFT by 29% compared to LP, LL and A sites. The can position on the left thorax does not appear to have a significant influence on DFT.

Vasodilatory actions of the dietary peptide carnosine

The objective of this study was to test the hypothesis that the dietary dipeptide carnosine (beta-alanine-L-histidine) causes direct decreases in arterial tone. Isolated descending thoracic aortic rings from male Sprague-Dawley rats were used for all studies. Preconstriction of vessels was accomplished with phenylephrine. Carnosine (0.625-20 mM) produced dose-dependent vascular relaxation (P < 0.05) that was independent of endothelium. The constituent amino acid L-histidine did not produce any significant relaxation over the same dose range, whereas beta-alanine actually produced dose-dependent vasoconstriction (P < 0.05). The soluble guanylate cyclase inhibitor methylene blue (10(-5) M) significantly decreased the relaxation produced by carnosine (P < 0.05). Measurement of cyclic GMP in the presence and absence of methylene blue after carnosine and phenylephrine exposure was also done. Methylene blue 10(-5) M resulted in a decrease in cyclic GMP levels from 65.3 +/- 15.6 fmol/mg protein to 8.6 +/- 0.9 fmol/mg of protein (P = 0.001). We conclude that carnosine produces relaxation of isolated rat aorta independent of endothelium. The effect of carnosine is at least in part mediated via cyclic GMP production and is not reproduced by its constituent amino acids, L-histidine and beta-alanine.

Resistance of vaccinia virus to inactivation by solvent/detergent treatment of blood products

The inactivation of enveloped viruses by two different solvent/detergent combinations, i.e. tri-n-butyl phosphate (TNBP)/Triton X-100 or TNBP/Tween 80, has been investigated using a high purity factor VIII (Replenate) and factor IX (Replenine) respectively. Treatment with TNBP/Triton X-100 rapidly inactivated all the typical enveloped viruses tested, i.e. Sindbis, semliki forest virus (SFV), herpes simplex virus type-1 (HSV-1) and vesicular stomatitis virus (VSV), by 3.7-5.8 log within 15 seconds. While virus inactivation with TNBP/Tween 80 was slower, effective inactivation of Sindbis, HSV-1, VSV and human immunodeficiency virus type-1, i.e. 4.1-->6.3 log, occurred within 30 minutes. In contrast, vaccinia virus was relatively resistant to inactivation in either of these solvent/detergent combinations. Incubation times of 10 minutes for TNBP/Triton X-100 or 6-24 hours for TNBP/Tween 80, were required to reach inactivation levels of about 4 log.

Improved efficacy of anodal biphasic defibrillation shocks following a failed defibrillation attempt

Although it is generally assumed that defibrillation becomes more difficult when the duration of VF is prolonged, after a failed defibrillation attempt, there is little information on the defibrillation efficacy of multiple shocks delivered at the same energy. The purpose of this study was to systematically examine the efficacy of a second shock delivered at the same or reversed polarity after a failed first shock. Defibrillation was attempted after 10 seconds of VF in 12 pigs (30-56 kg) using biphasic waveforms and a nonthoracotomy lead system. Shock energy was held constant for the first and second shocks at 50%-90% of the DFT. The second shock was delivered 10 seconds after a failed first shock. First and second shock polarity (first phase) was randomized to (+, +), (+, -), (-, -), (-, +). The incidence of successful defibrillation (for all polarities) was 12.3% for first and 49.1% for second shocks (P < 0.0001). Anodal first shocks had a 17.2% incidence of success as opposed to a 7.4% incidence of success with cathodal first shocks (P = 0.001). Anodal second shocks had a 55.5% incidence of success compared to a 42.7% incidence of success with cathodal second shocks (P = 0.008). There was no significant benefit from polarity reversal after a failed first shock (P = 0.29). In conclusion, less energy is required for successful defibrillation by a second shock after a failed first. The optimal configuration for first and second shocks is with the RV as anode. Polarity reversal of a second shock after a failed first does not affect the probability of second shock success.

Renal medullary carcinoma: prolonged remission with chemotherapy, immunohistochemical characterisation and evidence of bcr/abl rearrangement

BACKGROUND

Renal medullary carcinoma (RMC), an extremely rare tumour of the kidney, carries a dismal prognosis, with no reports to date of significant response to chemotherapy or radiotherapy. A case of this tumour in a male child, who showed a dramatic response to chemotherapy, is described.

PROCEDURE

A detailed histological evaluation of the tumour and cytogenetic analysis using fluorescent in situ hybridisation (FISH) was carried out. The child was treated with multiagent chemotherapy, followed by abdominal radiotherapy.

RESULTS

A detailed histopathological and immunohistochemical portrait of this tumour is described, and FISH studies confirmed the presence of a bcr/abl rearrangement. The child obtained complete radiological remission following chemotherapy, although he later relapsed and died of progressive disease despite further attempts at treatment with chemotherapy.

CONCLUSIONS

Although there are no previous reports of response of this tumour to chemotherapy, this case illustrates that treatment of this disease is justified. The responses of other cases to similar drug regimens would be of interest to confirm whether the encouraging response described for this case could be reproduced. Cytogenetic analysis of other cases of RMC may clarify whether the abnormalities seen in this case are typical.

Redox cycles in trimethylamine dehydrogenase and mechanism of substrate inhibition

The steady-state reaction of trimethylamine dehydrogenase (TMADH) with the artificial electron acceptor ferricenium hexafluorophosphate (Fc(+)) has been studied by stopped-flow spectroscopy, with particular reference to the mechanism of inhibition by trimethylamine (TMA). Previous studies have suggested that the presence of alternate redox cycles is responsible for the inhibition of activity seen in the high-substrate regime. Here, we demonstrate that partitioning between these redox cycles (termed the 0/2 and 1/3 cycles on the basis of the number of reducing equivalents present in the oxidized/reduced enzyme encountered in each cycle) is dependent on both TMA and electron acceptor concentration. The use of Fc(+) as electron acceptor has enabled a study of the major redox forms of TMADH present during steady-state turnover at different concentrations of substrate. Reduction of Fc(+) is found to occur via the 4Fe-4S center of TMADH and not the 6-S-cysteinyl flavin mononucleotide: the direction of electron flow is thus analogous to the route of electron transfer to the physiological electron acceptor, an electron-transferring flavoprotein (ETF). In steady-state reactions with Fc(+) as electron acceptor, partitioning between the 0/2 and 1/3 redox cycles is dependent on the concentration of the electron acceptor. In the high-concentration regime, inhibition is less pronounced, consistent with the predicted effects on the proposed branching kinetic scheme. Photodiode array analysis of the absorption spectrum of TMADH during steady-state turnover at high TMA concentrations reveals that one-electron reduced TMADH-possessing the anionic flavin semiquinone-is the predominant species. Conversely, at low concentrations of TMA, the enzyme is predominantly in the oxidized form during steady-state turnover. The data, together with evidence derived from enzyme-monitored turnover experiments performed at different concentrations of TMA, establish the operation of the branched kinetic scheme in steady-state reactions. With dimethylbutylamine (DMButA) as substrate, the partitioning between the 0/2 and 1/3 redox cycles is poised more toward the 0/2 cycle at all DMButA concentrations studied-an observation that is consistent with the inability of DMButA to act as an effective inhibitor of TMADH.

A systematic evaluation of conventional and novel transvenous pathways for defibrillation

INTRODUCTION

Conventional implantable cardioverter defibrillators employ endocardial (shock) electrodes with a lead located in the right ventricular apex (RV) and a "hot-can" electrode located subcutaneously in the left pectoral region. In the event of a high defibrillation threshold (DFT) a third electrode is frequently employed in the superior vena cava (SVC). We report the comparison of conventional and novel locations of additional electrodes with the RV/Can configuration, in a porcine model.

METHOD

In 12 anesthetized pigs (30-45 kg), endocardial defibrillation electrodes were randomized to the following locations: RV/Can, RV/Can + SVC, RV/Can + main pulmonary artery (MPA) and RV/Can + left pulmonary artery wedge position (PAW), RV/Can + high inferior vena cava (HIVC), RV/Can + Low inferior vena cava (LIVC). Ventricular fibrillation (VF) was induced using 60 Hz alternating current. After 10 seconds VF a rectangular biphasic shock was delivered by the ARD9000 (Angeion Corp). The DFT was determined for each configuration using a modified four-reversal binary search. All configurations were compared using a repeated measures analysis of variance (ANOVA) statistical test and the five 3-electrode configurations were compared to the RV/Can position using a Dunnett test.

RESULTS

Mean DFTs: RV = 21.5 +/- 4.8 J, SVC = 16.8 +/- 4.7 J (p < 0.05 vs. RV), HIVC = 21.1 +/- 4.7 J (p <. 0.05), LIVC = 19.1 +/- 5.7 J (p <. 0.05 vs. RV), MPA = 16.0 +/- 5.8 J (p < 0.01), PAW = 17.5 +/- 4.6 J (p < 0.05 vs. RV).

CONCLUSIONS

Relative to the RV/can configuration the addition of a third electrode in the PA, PAW or SVC significantly reduces the DFT in the pig. The addition of an electrode to the IVC did not significantly reduce the DFT in our model.

Total teamwork--the Mayo Clinic

Typical of the Mayo Clinic is its century-old team approach to treating patients. Physicians work in teams, with each team driven by the medical problems involved in a case and by the patient's preferences. Occasionally, a team will be expanded or even taken apart and reassembled. At Mayo, diagnosing a complex problem, proposing treatment and slotting the patient for surgery can happen within 24 hours of the diagnosis. The overall effect at Mayo is one of orderliness, function and, above all, vigor. Even as other medical institutions are cutting staff and reducing services, Mayo is a robust, thriving organization with revenues of $2.9 billion and a staff of roughly 30,500. Each year, more than 400,000 patients visit its seven facilities. Mayo's administrators continue to invent (and reinvent) the business side of medicine. Having developed one of the world's first systems of centralized patient records, Mayo is able to keep costs low enough to admit patients from all income levels. "The best interest of the patient is the only interest to be considered" is a motto that has become a Mayo standard on how best to practice medicine. Fearful of becoming complacent and watchful of the risks posed by its deliberative style, the clinic constantly looks for new and fresh ideas.

The development of NEdSERV: quantitative instrumentation to measure service quality in nurse education

The political climate of health care provision and education for health care in the latter years of the 20th century is evolving from the uncertainty of newly created markets to a more clearly focused culture of collaboration, dissemination of good practice, with an increased emphasis on quality provision and its measurement. The need for provider units to prove and improve efficiency and effectiveness through evidence-based quality strategies in order to stay firmly in the market place has never been more necessary. The measurement of customer expectations and perceptions of delivered service quality is widely utilized as a basis for customer retention and business growth in both commercial and non-profit organizations. This paper describes the methodological development of NEdSERV--quantitative instrumentation designed to measure and respond to ongoing stakeholder expectations and perceptions of delivered service quality within nurse education.

Effect of chain length on absorption of biologically active peptides from the gastrointestinal tract

OBJECTIVES

Protein digestion generates many peptides in the gut lumen. Some of these peptides possess biological effects when tested using in vitro systems. It is clear that dipeptides and tripeptides can be absorbed intact from the gastrointestinal tract. However, the fate of larger peptides and small proteins remains unclear. Equally unclear are the biologic potencies of absorbed peptides and the quantity of peptide that must be administered into the gut to produce a biologic effect. Thus, the purpose of this study was to determine the effect of amino acid chain length on the ability of enterally administered peptides to produce biologic effects.

METHODS

Small bowel feeding tubes, jugular catheters, and arterial lines were placed into adult male Sprague-Dawley rats. Rats were administered intravenous (50 microg) and enteral (125 and 500 microg) thyrotropin-releasing hormone (TRH, a tripeptide), intravenous (100 microg) and enteral (100 and 500 microg) luteinizing hormone-releasing hormone (LHRH, a decapeptide), and intravenous (0.5 mg) and enteral (0.5 and 25 mg) insulin (a 51-amino acid polypeptide). The quantity of peptide administered represented less than 0.5% of a rat's normal daily protein intake. The biologic effect of TRH, LHRH, and insulin were assessed using thyroid-stimulating hormone (TSH) response, follicle-stimulating hormone (FSH) response, and glucose. We also measured serum levels of insulin in the rats following enteral insulin administration.

RESULTS

The results indicate that enteral TRH (125 and 500 microg) produced the same TSH response as intravenous TRH. The response to 500 microg enteral LHRH was 50% of the response to intravenous LHRH and the response to 25 mg enteral insulin was 30% of the response to 0.5 mg intravenous insulin. Serum insulin levels increased significantly following both 0.5 and 25 mg enteral insulin.

CONCLUSIONS

These results support the concept that small (di- and tripeptides) and large (10-51 amino acids) peptides generated in the diet can be absorbed intact through the intestines and produce biologic effects at the tissue level. The potency of the enterally administered peptides decreases as the chain length increases. We postulate that absorbed dietary peptides play a role in the modulation of organ function and disease progression.

A multi-laboratory evaluation of cryopreserved monkey hepatocyte functions for use in pharmaco-toxicology

Ethical, economic and technical reasons hinder regular supply of freshly isolated hepatocytes from higher mammals such as monkey for preclinical evaluation of drugs. Hence, we aimed at developing optimal and reproducible protocols to cryopreserve and thaw parenchymal liver cells from this major toxicological species. Before the routine use of these protocols, we validated them through a multi-laboratory study. Dissociation of the whole animal liver resulted in obtaining 1-5 billion parenchymal cells with a viability of about 86%. An appropriate fraction (around 20%) of the freshly isolated cells was immediately set in primary culture and various hepato-specific tests were performed to examine their metabolic, biochemical and toxicological functions as well as their ultrastructural characteristics. The major part of the hepatocytes was frozen and their functionality checked using the same parameters after thawing. The characterization of fresh and thawed monkey hepatocytes demonstrated the maintenance of various hepato-specific functions. Indeed, cryopreserved hepatocytes were able to survive and to function in culture as well as their fresh counterparts. The ability for synthesis (proteins, ATP, GSH) and conjugation and secretion of biliary acids was preserved after deep freeze storage. A better stability of drug metabolizing activities than in rodent hepatocytes was observed in monkey. After thawing, Phase I and Phase II activities (cytochrome P450, ethoxycoumarin-O-deethylase, aldrin epoxidase, epoxide hydrolase, glutathione transferase, glutathione reductase and glutathione peroxidase) were well preserved. The metabolic patterns of several drugs were qualitatively and quantitatively similar before and after cryopreservation. Lastly, cytotoxicity tests suggested that the freezing/thawing steps did not change cell sensitivity to toxic compounds.

Maintenance of steroid metabolism and hormone responsiveness in cryopreserved dog, monkey and human hepatocytes

The efficient and effective use of hepatocytes from larger species and rare human material requires a reliable storage method for cells not needed on the day of preparation. Cryopreservation would seem to be the only viable alternative. In this study the suitability of a published cryopreservation technique on dog, monkey and human hepatocytes has been examined and the cells were tested for functionality directly after thawing and subsequent to culture using steroid metabolism and hormone responsiveness of glycogen phosphorylase a. Monkey and human hepatocytes appear to survive the freezing and thawing process better than dog cells-the latter losing the ability to respond to adrenergic stimuli and their ability to maintain steroid metabolism in culture. Although monkey and human cells do preserve their steroid metabolising capacity after freeze/thawing, there is not the significant increase in enzyme activity seen during culturing freshly isolated cells. It would appear, therefore, that some damage has occurred to the cells during the freeze/thaw process. As previously noted, Williams' medium E is superior to Ham's F-10 in maintaining enzyme activities in culture. It is suggested that cryopreservation is the way forward for the development of stockpiles of viable hepatocytes for biomedical and toxicological research and development but that further modifications to the process are still necessary to optimise the maintenance of liver-specific functions in the thawed cells.

Low voltage direct current delivered through unipolar transvenous leads: an alternate method for the induction of ventricular fibrillation

The induction of VF during testing of an ICD may not always be possible using either burst pacing or high energy T wave shocks. The purpose of this study was to evaluate the effectiveness of low energy DC stimulation for inducing VF in a porcine model. The VFT was measured using constant voltage stimuli and a step-up method in ten anesthetized pigs (25-30 kg). Stimuli of different durations (0.5, 1.0, 2.0 s) were delivered (unsynchronized) between a right ventricular apical coil and a subcutaneous test can. Current was measured from the voltage drop across a series resistor (10 omega). With anodal stimulation, VF required 6.4 +/- 0.2 V compared to 13.8 +/- 0.6 V with cathodal stimulation (P < 0.001). The current required to induce VF (measured 10 ms after the stimulus onset) was 58.3 +/- 2.2 mA with anodal stimulation and 119.3 +/- 4.7 mA with cathodal stimulation (P < 0.001). Stimulus duration did not significantly influence the voltage or current required for VF induction. In 6 of the 10 pigs, synchronizing a 0.5-second stimulus to the R wave did not significantly alter the VFT compared to same stimulus synchronized to mid-upslope of the T wave. The results indicate that VF can be consistently induced through transvenous electrodes by passing unsynchronized DC for 0.5-2 seconds. The induction of VF required about 50% less current and voltage with anodal stimulation. It should be possible to induce VF with the DC voltage available from the internal battery source of an ICD.

Identification of the t(15;17) in AML FAB types other than M3: evaluation of the role of molecular screening for the PML/RARalpha rearrangement in newly diagnosed AML. The Medical Research Council (MRC) Adult Leukaemia Working Party

Acute promyelocytic leukaemia (APL) is characterized by the t(15;17) leading to the formation of PML-RARalpha and RARalpha-PML fusion genes; this rearrangement has been considered both diagnostic for, and restricted to, this subtype of acute myeloid leukaemia (AML FAB M3). We describe two cases of AML with the t(15;17) associated with a PML/RARalpha rearrangement which lacked typical APL morphology, classified as FAB M1 and M2 respectively. In both cases morphological review revealed small populations of cells which exhibited some features associated with APL. In the case classified as M1, PML immunofluorescence studies revealed the classic microparticulate nuclear staining pattern as observed in typical cases of APL with the t(15;17). Similarly, blasts from this case were found to be sensitive to ATRA in vitro as determined by NBT reduction test and by normalization of the PML nuclear body staining pattern. To determine the frequency of PML/RARalpha rearrangements in FAB subtypes other than M3, 530 patients from the MRC AML trials were screened using nested RT-PCR. Only one individual, initially classified as M5 with a normal karyotype, was found to have a PML/RARalpha rearrangement. The diagnosis was revised to M3 variant on subsequent morphological review. In conclusion, this study demonstrates that, in rare cases, the t(15;17) is not restricted to patients with M3 morphology as defined by current FAB criteria. Therefore, although we consider cytogenetic analysis of newly diagnosed cases of AML to be mandatory, our data suggests that routine molecular screening for PML/RARalpha rearrangements is not justified and should be reserved for those cases displaying features which may be suspicious of APL even if such cells comprise only a minority of the total population.

Catheter mounted coaxially moveable ablation electrode for the creation of linear transmural endocardial lesions

INTRODUCTION

Use of a novel ablation catheter for the creation of linear transmural endocardial lesions, which uses a coaxially moving ablation electrode mounted on the terminal portion of a catheter shaft and able to move axially for a distance of up to 4 cm, is reported.

METHODS AND RESULTS

The coaxially moving ablation electrode is moved by a sliding mechanism in the catheter handle. The distal portion of the catheter shaft is steerable. Bipolar or unipolar electrograms can be recorded from electrodes on the catheter tip and the coaxially moving ablation. Radiofrequency (RF) current is delivered to the coaxially moving ablation electrode with thermocouple temperature control. This ablation catheter was evaluated in five (30 to 65 kg) anesthetized pigs and introduced via the venous/arterial systems into the right and left atrium (1 lesion) (using the retrograde aortic approach). The catheter was maneuvered to bring the slide range into apposition with atrial endocardium. The coaxially moving ablation electrode was deployed to the terminal portion of the catheter's slide range and then withdrawn in 2-mm steps. RF current was delivered to the coaxially moving ablation electrode at each point (maximum temperature 70 degrees C). Postmortem examination of eight endocardial linear lesions (2.2 to 4.1 cm length) was made 1 to 3 hours after creation. Histopathologic examination confirmed transmural myocyte necrosis along the length of the lesion, that included the trabeculated right atrium.

CONCLUSION

We conclude that a catheter using a moveable electrode creates continuous linear transmural lesions and could find clinical application in the therapy of a variety of reentry tachycardia mechanisms.