Cardiovascular response of a continuous variable rate alfentanil infusion for abdominal aortic surgery

A prospective study was undertaken to determine the cardiovascular response of a continuous alfentanil infusion during abdominal aortic surgery (AAS). Each subject (n = 20) received a beta-blocking drug preoperatively, and was premedicated with oral lorazepam. Anaesthesia was induced with alfentanil 50 micrograms.kg-1 and thiopentone 3 mg.kg-1, and was maintained with a variable rate infusion of alfentanil and 66 per cent nitrous oxide in oxygen. During the infusion, boluses of alfentanil, 7.5 micrograms.kg-1, were administered to maintain heart rate and blood pressure within 20 per cent of awake baseline values. Haemodynamic stability during surgery was achieved with infusion rates varying between 0.5 and 2.5 micrograms.kg-1, which resulted in mean alfentanil serum concentrations ranging from 186 +/- 53 to 315 +/- 98 ng.ml-1. The mean cumulative alfentanil dose was 15.4 +/- 6.2 mg.patient-1 for surgery which lasted an average of 141 +/- 41 min. Throughout surgery, no patient required inhalational anaesthetic agents or vasoactive drugs. Fifteen of the 20 patients had perioperative Holter monitoring. No myocardial ischaemia was detected during the intraoperative period. However, there was a 33 per cent incidence of myocardial ischaemia on the first postoperative day. There were no myocardial infarcts and no deaths. We conclude that in beta-blocked patients undergoing aortic reconstructive surgery, a variable rate alfentanil infusion administered with 66 per cent nitrous oxide provides anaesthesia characterized by good haemodynamic control without the need for supplemental agents or vasoactive drugs.

Alfentanil controls the haemodynamic response during rapid-sequence induction of anaesthesia

Laryngoscopy and tracheal intubation often cause hypertension and tachycardia, which may be exaggerated during rapid-sequence induction of anaesthesia. A placebo-controlled, double-blind study was conducted in 60 patients to determine dose-response and effects on myocardial performance of alfentanil when used to attenuate this cardiovascular response. Patients were divided into four groups to receive a pre-induction bolus from a coded syringe, which contained either normal saline (PLAC), alfentanil 30 micrograms.kg-1 (ALF 30), alfentanil 45 micrograms.kg-1 (ALF 45) or alfentanil 60 micrograms.kg-1 (ALF 60). Anaesthesia was induced in rapid sequence with thiopentone 4.0 mg.kg-1 and succinylcholine 1.5 mg.kg-1, and the trachea was intubated 60 sec later. Increases in heart rate (21 +/- 10 bpm), mean arterial pressure (28 +/- 13 mmHg), and systemic vascular resistance index (1420 +/- 780 dynes.sec-1.cm-5) were observed in response to intubation with PLAC but in none of the 3 ALF groups (P less than 0.05). However, heart rate and mean arterial pressure decreased significantly in both the ALF 45 and ALF 60 groups (P less than 0.05), whereas ALF 30 resulted in no change in these variables over time. Cardiac index, stroke volume index, and ejection fraction tended to decrease in all four groups, but none of these variables was different at corresponding time when comparing the ALF groups with PLAC.(ABSTRACT TRUNCATED AT 250 WORDS)

Years of potential life lost: another indicator of the impact of cutaneous malignant melanoma on society

Years of potential life lost (YPLL) is an indicator of premature mortality that complements traditional incidence and mortality rates and that facilitates comparisons among different cancers. We calculated YPLL from cutaneous melanoma and 11 other cancers routinely recorded and tracked by Surveillance, Epidemiology and End Results (SEER). YPLL from cutaneous melanoma ranked eighth for persons younger than 65 years of age and fourth for those 20 to 49 years of age. An average of 17.1 YPLL per death were due to melanoma, one of the highest rates for adult-onset cancers. The results of our study, the first to apply YPLL to cutaneous melanoma, emphasize the disproportionate impact of this cancer on young and middle-aged adults and reemphasize the importance of this cancer as a public health priority.

A randomized double-blind comparison of fentanyl- and sufentanil-oxygen anesthesia for abdominal aortic surgery

Twenty-four patients undergoing abdominal aortic surgery for aneurysm or occlusive vascular disease entered a randomized, double-blind protocol comparing high-dose narcotic anesthesia with fentanyl (125 micrograms/kg) or sufentanil (25 micrograms/kg). All patients received perioperative beta-adrenergic blockade therapy. Hemodynamic and electrocardiographic (leads II and V5) responses to induction, intubation, skin incision, aortic cross-clamping, and declamping were studied. Sufentanil produced a transient decrease in mean arterial pressure and a significant reduction of systemic vascular resistance during induction. However, no significant hemodynamic differences were observed between the two groups during intubation, or at any other time during surgery. To maintain mean arterial pressure within 20% of the awake control value, the fentanyl group required an average infusion of 1.0 +/- 1.1 micrograms/kg/min of nitroglycerin compared with 1.7 +/- 2.8 micrograms/kg/min for the sufentanil group. Low-dose isoflurane was required in 30% of patients in the fentanyl group, compared with 41% of the sufentanil group, for control of blood pressure. The multiple-bolus technique of narcotic administration resulted in a wide but parallel range of plasma concentrations from induction to the end of surgery with both narcotics. Mean plasma fentanyl concentrations varied between 7.2 +/- 1.4 ng/mL and 26.5 +/- 7.9 ng/mL, and mean sufentanil plasma concentrations varied between 1.0 +/- 0.1 ng/mL and 10.6 +/- 7.2 ng/mL throughout surgery. Within this range of narcotic serum levels, the authors were unable to identify a specific threshold level for either narcotic above which hemodynamic responses were consistently attenuated. A low incidence (4.5%) of intraoperative myocardial ischemia was observed.(ABSTRACT TRUNCATED AT 250 WORDS)

Diazepam use in relation to breast cancer: results from two case-control studies

The relation between diazepam use and breast cancer was explored in two case-control studies. The first (1981-1987) was a hospital-based study in the United States of 3,078 cases of breast cancer, 1,259 controls with other malignancies, and 672 controls with nonmalignant conditions. The relative risk estimates for regular diazepam use (at least 4 days per week for at least 6 months) that antedated the diagnosis of breast cancer by at least 12 months were 1.0 (95% confidence interval (CI) 0.6-1.7) using the cancer controls and 0.8 (95% CI 0.4-1.8) using the noncancer controls. Risk factors for breast cancer were taken into account in the estimates. There was no association for regular use lasting at least 5 years or for regular use that took place exclusively in the recent or more distant past. The second study (1982-1986), conducted in Toronto, Ontario, Canada, was community-based, and included 607 cases of breast cancer and 1,214 neighbor controls selected from municipal voting and census records. After control of confounding, the relative risk estimate for regular diazepam use was 0.8 (95% CI 0.5-1.3). Again, there was no association for long-term, past, or recent regular use. The results of both studies suggest that regular diazepam use does not increase the risk of breast cancer. The findings are strengthened by the similarity of the results using three different control groups--women with cancer, women with nonmalignant conditions, and neighbors.

Day 7 marrow response and outcome for children with acute lymphoblastic leukemia and unfavorable presenting features

The percent of marrow blasts on day 7 of therapy was determined for 128 children with previously untreated acute lymphoblastic leukemia and white blood count (WBC) greater than or equal to 50,000/microliters and/or lymphomatous features enrolled in the Childrens Cancer Study Group trial of the Berlin Frankfurt Munster 76/79 regimen (CCG-193P). Patients received four-drug induction therapy including vincristine, prednisone, l-asparaginase, and daunomycin. Ninety-seven patients had fewer than 25% marrow blasts on day 7. Of these, 94 survived and maintained remission through day 28 and were designated early responders. Thirty-one patients had greater than 25% marrow blasts on day 7. Of these, 28 survived and achieved remission on day 28 and were designated late responders. The outcome of patients who underwent a day 7 marrow aspiration was similar to those who did not. Early responders had a 77.4% +/- 4.5% (standard deviation) 3-year estimated disease free survival, while late responders had 47.3% +/- 9.8% (P less than 0.001). Early responders had a superior outcome both in the subset with an initial WBC less than 50,000/microliters (P = 0.025) and in the subset with a WBC greater than or equal to 50,000/microliters (P = 0.01). The day 7 marrow response had prognostic value in this population of children with unfavorable presenting features who received four-drug remission induction therapy.

The prognostic value of testicular biopsy in childhood acute lymphoblastic leukemia: a report from the Childrens Cancer Study Group

One of the objectives of Childrens Cancer Study Group (CCSG) study 141 (CCG-141) was to determine the frequency of occult testicular leukemia (TL) after 3 years of disease-free survival (DFS) and to retreat boys with occult TL to prolong their subsequent DFS. Of the 494 boys entered on study, 255 (51.6%) were in complete continuous remission (CCR) 3 years after entering remission and an additional eight were in CCR 3 years after localized extramedullary relapse and retreatment; 263 boys were eligible for testicular biopsy. Elective testicular biopsy was performed on 235 (89.4%) boys. Of the 204 (86.8%) boys with negative biopsies, 175 (85.8%) remained in CCR 10 to 12 years after diagnosis and 25 (12.3%) relapsed, 11 (44%) of whom died. Isolated overt TL occurred in four (2.0%) and all remained in CCR 22+ to 60+ months after re-treatment. Of the 26 boys with occult TL, 16 (62%) remained in CCR. Ten (38%) relapsed despite local testicular irradiation and systemic re-treatment; six of the 10 died. Of the 26 boys who did not undergo biopsy, 21 (80.8%) remained in CCR; two (7.7%) developed isolated overt TL. DFS after testicular biopsy was significantly better in boys without occult TL (P = .001). Occult TL after 3 years of CCR represents aggressive minimal-residual disease and carries a worse prognosis than absence of TL. Initial treatment should be directed at obviating occult and overt testicular relapse. Conventional therapy as used in this study was suboptimal in preventing subsequent bone marrow (BM) relapse and death. If occult TR is identified during or at the end of planned therapy, a higher salvage rate may require intensified alternate therapy. As such, testicular biopsies may be clinically useful. Further investigation is limited by the relative rarity of, and the lack of identifying features in boys with occult TL.

A case-control study of alcoholic beverage consumption and breast cancer

In many studies, moderate alcohol consumption has been associated with increases in the risk of breast cancer of about 50-100%. The authors examined recent alcoholic beverage consumption in relation to the risk of breast cancer in a case-control study of women aged less than 70 years, conducted in Toronto, Ontario, Canada, from 1982 to 1986: 607 breast cancer cases identified in a cancer hospital were compared with 1,214 controls matched to the cases on neighborhood and decade of age. The subjects were interviewed at home. Confounding factors were controlled by conditional logistic regression. The relative risk estimates for women who consumed alcohol, relative to women who drank less than one alcoholic beverage (drink) per month, were close to 1.0: for women who drank at least one alcoholic beverage per day, the multivariate estimate was 0.9 (95% confidence interval 0.6-1.2). Among subgroups of women, including those at low baseline risk, there was also no association. For a subset of cases compared with hospital controls, once again there was no association. The relative risk (RR) estimate was elevated for women who drank at least one beer daily (RR = 1.7) and reduced for women who drank at least one glass of wine daily (RR = 0.7), but neither estimate was statistically significant. The results suggest that recent alcohol consumption does not influence the risk of breast cancer. Selection bias cannot be ruled out, however. In addition, because determinants of alcohol use are not well understood, control of confounding may have been incomplete in the present study and in other observational studies of alcohol and breast cancer.

Early response to induction therapy as a predictor of disease-free survival and late recurrence of childhood acute lymphoblastic leukemia: a report from the Childrens Cancer Study Group

The Childrens Cancer Study Group (CCSG) CCG-160 protocol series was designed to evaluate prognostic factors in acute lymphoblastic leukemia (ALL). Patients were assigned to one of three prognostic groups based upon initial WBC count and age. To determine the optimal duration of therapy, CCG-160 patients completing 2 years of treatment in continuous remission were randomized ("late randomization") to discontinue therapy or receive another year of maintenance therapy. The prognostic significance of early response to induction therapy, as measured by the percentage of lymphoblasts in the day-14 bone marrow (d14 BM) aspirate, was evaluated in 2,516 children. For 1,490 patients with complete data, the status of the d 14 BM was a highly significant predictor of disease-free survival (DFS) by univariate and multivariate analysis (P less than .0001). The observed/expected (O/E) failure rate in patients with d14 M1 (less than 5% blasts), M2 (4% to 25% blasts), or M3 (greater than 25% blasts) BM rating who were subsequently M1 on day 28 or day 42, was .87, 1.59, and 2.30, respectively (P less than .0001). Patients with M2 or M3 d14 BM were more likely to have L2 ALL (modified French-American-British [FAB] morphologic classification), P less than .001. The significance of the d14 BM rating persisted after correction was made for WBC count and clinical prognostic groups using current CCSG criteria, except in infants less than 12 months of age. The d14 BM was also the most significant predictor of DFS in 975 patients after late randomization at 2 years following diagnosis. The O/E failure rate in patients with d14 M1, M2, or M3 BM was .88, 1.78, and 2.02, respectively (P = .0002, trend). Other significant predictors of late relapse were prognostic groups (P = .0003, trend) and initial WBC count (P = .004, trend). Predictive for both early and late relapse of ALL, early response should be monitored closely and alternative treatment regimens should be considered for slow responders.

Acquired immune deficiency syndrome (AIDS). Indications for abdominal surgery, pathology, and outcome

Thirty-six major abdominal operations were performed on 35 Acquired Immune Deficiency Syndrome (AIDS) patients (33 men, two women). Twenty-two elective operations were indicated for diagnosis of abdominal or retroperitoneal mass (6), incomplete bowel obstruction (5), intra-abdominal infection (4), biliary symptoms (3), thrombocytopenia (3), and toxic megacolon (1). Fourteen emergency operations were for perforated viscus or peritonitis (11), massive gastrointestinal bleeding (2), and cecal volvulus (1). In 5 of 22 (23%) elective operations AIDS was unknown to the treating physicians until diagnosed by the surgical pathology; in contrast, all 14 emergency operations were in patients who had a known diagnosis of AIDS. The operative findings were related to AIDS in 34 of 36 (94%) operations. Cytomegalovirus was the most common pathogen, isolated or identified microscopically in 11 patients (eight emergency and three elective operations). Mycobacterial infections presented as retroperitoneal adenopathy or splenic abscess in six patients. Non-Hodgkins lymphoma was the most common malignancy found, presenting as an abdominal mass (4), bowel obstruction (3), or with gastrointestinal bleeding (2). Kaposi's sarcoma was diagnosed at laparotomy in four patients. The 1-month operative mortality rate for elective operation was 9% (2 of 22) and 46% (6 of 13) in emergencies. Postoperative complications included 1 reoperation for sepsis caused by inadequately resected CMV colitis; 1 pancreatic fistula; 1 wound dehiscence, and 2 minor wound infections.

Bolus administration of esmolol for the treatment of intraoperative myocardial ischaemia

We report the successful treatment with esmolol of intraoperative myocardial ischaemia associated with concurrent hypertension and tachycardia, in a patient with risk factors for coronary artery disease undergoing peripheral vascular surgery. The pathophysiology of myocardial ischaemia, and the therapeutic role of beta blocking drugs are briefly reviewed. Esmolol, a short-acting cardioselective beta blocking drug, was administered in a bolus of 1.5 mg.kg-1, and resulted in prompt resolution of the haemodynamic abnormalities, with concomitant restitution of the ST segments to isoelectric baseline. We conclude that bolus administration of esmolol is practical and can be effective for the treatment of intraoperative myocardial ischaemia.

Three versus five years of maintenance therapy are equivalent in childhood acute lymphoblastic leukemia: a report from the Childrens Cancer Study Group

Childrens Cancer Study Group protocol 141 (CCG-141), a randomized trial, was designed in part to compare 3 v 5 years of maintenance therapy, to evaluate the role of late reinduction, and to identify factors that predict relapse after 3 years of continuous complete remission (CCR) in acute lymphoblastic leukemia (ALL). Of 880 patients entered on study, 827 (94%) achieved complete remission and 499 (56.7%) were in CCR after 3 years of maintenance therapy. Boys were required to have negative testicular biopsies before randomization. A total of 481 patients were eligible for the duration of therapy phase of the study. Of the 310 (64.4%) randomly assigned patients, 101 were entered on regimen A: discontinue therapy; 105 on regimen B: reinduction for 4 weeks, then discontinue therapy; and 104 on regimen C: continue maintenance therapy for 2 more years, then discontinue. After a median follow-up of over 72 months, no significant differences in disease-free survival (DFS) or survival were noted in the three regimens. At 6 years from randomization, 93.0%, 89.1%, and 89.1% of patients on regimens A, B, and C, respectively, remained in CCR. Isolated CNS or overt testicular relapses were not significantly different in any of the study regimens. Isolated testicular relapse after a negative biopsy occurred in only two of 137 randomized males (1.5%). DFS (P = .10) and survival (P = .83) were not significantly different for all boys and girls randomized to regimens A, B, or C. The relapse rate was higher in boys than in girls randomized to discontinue therapy (11% v 4%), but the difference was not statistically significant (P = .14). Except for the presence of occult testicular leukemia (TL) in males, no other factors were identified that predicted for adverse events after 3 years of CCR. We conclude that prolongation of maintenance therapy beyond 3 years does not improve survival or decrease the risk of relapse.

Breast cancer before age 45 and oral contraceptive use: new findings

The relation between the risk of breast cancer before 45 years of age and oral contraceptive use was examined in a case-control study conducted in New York, Philadelphia, Baltimore, and Boston from 1983 to 1986 of 407 patients with breast cancer and 424 controls. With allowance for confounding, for ever use, the multivariate relative risk estimate was 2.0 (95% confidence interval (CI), 1.4-2.9). For less than 10 years of use, the estimate approximated 2.0 in all categories of duration, including less than three months; for 10 or more years of use it was 4.1 (95% CI, 1.8-9.3). The association was apparent in virtually all subgroups examined, including younger and older women, and women at low and high underlying risk of breast cancer. Contrary to some previous reports, the association was not stronger for use before a first term pregnancy or at an early age. The results suggest that oral contraceptive users, particularly those with very long durations of use, may be at increased risk of breast cancer. However, information bias, particularly for short-term use, could not be ruled out. There may also have been selection bias if oral contraceptive users were under more intensive medical surveillance. It has not been possible to reconcile the findings of the various studies to date, including the authors' earlier results showing no association. The latter results were derived from data collected using methods almost identical to those used in the present study.

Reversal of neutropenia with methotrexate treatment in patients with Felty's syndrome. Correlation of response with neutrophil-reactive IgG

We evaluated the clinical and hematologic response to methotrexate (MTX) in 4 women with Felty's syndrome (FS) who had had neutropenia for 1-3 years. Since immune complexes or antineutrophil antibodies are implicated in the pathogenesis of the neutropenia of FS, we also measured both direct and indirect levels of neutrophil-reactive IgG. All 4 patients showed a prompt and dramatic increase in neutrophil counts within 1-2 months of starting MTX therapy. In 3 patients, the symptoms of arthritis also improved; in the fourth patient, arthritis worsened. Recurring infections ceased in 3 patients. Neutrophil-reactive IgG levels, which were elevated in all patients prior to treatment, decreased toward normal while the patients were receiving MTX therapy. We conclude that MTX is effective in treating the neutropenia of FS, in part by lowering neutrophil-reactive IgG.

Recovery of induced mutations for X chromosome-linked muscular dystrophy in mice

We have used elevated levels of plasma creatine phosphokinase activity to identify muscular dystrophy phenotypes in mice and to screen the progeny of chemical mutagen-treated male mice for X chromosome-linked muscular dystrophy mutations. We were not successful in identifying heterozygous carriers of these induced muscular dystrophy mutations in greater than 8000 progeny. However, we were highly successful in identifying three additional alleles of the characterized mdx locus. These alleles of mdx were recovered from various mutagen-treated males and they occur on an X chromosome that carries flanking markers that allow us to follow the mutations in genetic crosses and in the development of corresponding mutant stocks. These alleles have been designated as mdx2Cv, mdx3Cv, and mdx4Cv. Preliminary data show that mice with mdx2Cv and mdx3Cv mutations have muscular dystrophic phenotypes that do not grossly differ from the characterized mdx mutation. These additional mdx mutations expand the value of mouse models of X chromosome-linked muscular dystrophy and potentially define additional sites of mutation that impair dystrophin expression.

Induction of terminal differentiation-resistant epidermal cells in mouse skin and in papillomas by different initiators during two-stage carcinogenesis

Carcinogen treatment of normal mouse epidermal cells causes some cells, if cultured under the appropriate conditions, to continue to proliferate instead of terminally differentiate, forming foci at 37 degrees C in medium with a calcium level above 0.1 mM. We have examined these Calcium (Ca)-resistant cells formed in the skin of SENCAR mice after treatment with the carcinogen initiator 7,12-dimethylbenz[a]anthracene (DMBA) followed by tumor promotion with 12-O-tetradecanoylphorbol-13-acetate (TPA). Although in our previous studies TPA promotion initially increased the size but reduced the number of foci caused by the carcinogen initiator N-methyl-N'-nitro-N-nitrosoguanidine (MNNG), TPA promotion of DMBA-treated mice increased the size but had no effect on the number of foci. Papillomas resulting from DMBA plus TPA treatment contained many rapidly growing Ca-resistant cells, corroborating our earlier results with MNNG. Permanent cell lines prepared from papilloma-derived foci formed squamous cell carcinomas in nude mice after relatively short periods in culture. These data provide further evidence that Ca-resistant cells may be papilloma (and perhaps carcinoma) precursors in vivo. In addition, since TPA tends to reduce the number of early Ca-resistant cells caused by MNNG but not by DMBA, this may at least partially explain why treatment with DMBA plus TPA is much more effective in producing papillomas in SENCAR mice than is treatment with MNNG plus TPA.

Intermediate-term survival results in clinically understaged prostate cancer patients following radical prostatectomy

To determine the natural history of clinically understaged prostatic cancer patients who were followed without adjuvant therapy for at least 6 years after radical prostatectomy we reviewed the clinical courses of 21 patients (1 with clinical stage A and 20 with clinical stage B disease). All patients underwent radical retropubic prostatectomy and 9 had pathological stage C disease (6 with capsular penetration only and 3 with seminal vesicle invasion). A total of 12 patients had pathological stage D1 disease by virtue of positive nodes on permanent sections after frozen sections were read as negative. Among the patients with pathological stage C disease 67 per cent were free of recurrence 6 years after radical prostatectomy. Of the patients with seminal vesicle invasion 33 per cent had recurrence compared to 17 per cent of those with capsular penetration only. Among the 12 stage D1 cancer patients 75 per cent were free of recurrence at 6 years. In both groups patients who were followed beyond 7 years had a diminished survival free of tumor owing to late tumor recurrences. The results indicate that the intermediate survival rates free of tumor in patients with clinically understaged A or B prostatic cancer are remarkably good without adjuvant therapy. However, survival without recurrence appears to decrease after 7 years. All patients who failed treatment did so distantly; no patient failed with local recurrence alone. These results may be important in the evaluation of adjuvant therapy protocols currently under investigation for patients with clinically understaged prostate cancer.