Use of the immunotoxin N901-blocked ricin in patients with small-cell lung cancer

In patients with small-cell lung cancer (SCLC), relapse with resistant disease often causes death. N901-blocked ricin (N901-bR), a murine monoclonal antibody (MAb)-blocked ricin immunotoxin, is a potential therapeutic for SCLC. N901-bR targets CD56, present on SCLC and cells of neuro-ectodermal origin. N901-bR kills up to 5 logs of CD56-positive cells at a concentration of 0.25 nM, while CD56-negative cells require 1000-fold more drug to achieve similar cell kill. We treated 21 patients with relapsed or refractory SCLC with a single 7-day course of N901-bR as a continuous infusion. We determined the MTD and toxicity profile, demonstrated drug binding to tumor cells in biopsies of lung, liver and bone marrow, and determined the time to development of human anti-mouse and anti-ricin antibodies. One patient had a documented PR and 6 patients demonstrated stable disease. Toxicity included transient elevation of liver enzymes, mild thrombocytopenia, hypoalbuminemia, fever, malaise, and evidence of capillary leak syndrome. Toxicities were controllable and reversible. No apparent drug-related central- or peripheral-nervous-system toxicity was noted by serial neurologic examinations, EMGs, and nerve conduction studies. Trials of N901-bR are planned in SCLC patients achieving CR and PR following chemoradiotherapy, and in relapsed/refractory patients. Anti-B4-bR will be added as an immunosuppressant in order to permit delivery of multiple courses of N901-bR. Additional trials will investigate synergy with conventional chemotherapeutics and the use of N901-bR as a sensitizing agent for chemotherapy-resistant tumors.

Long-term traumatic stress reactions in British Falklands War veterans

This brief report summarizes the first available findings on long-term traumatic stress syndromes among ex-servicemen who are veterans of the Falklands War. The results reveal a correlation between physical injury during the War and post-traumatic stress disorder, indicating the need for a long-term follow-up survey incorporating treatment evaluations and welfare rights.

Biopsy-proven isolated sarcoid meningitis. Case report

Neurosarcoidosis without systemic involvement is rare and difficult to diagnose. The case of a 27-year-old man with a 6-week history of headache, mental status changes, and polyradiculopathy attributable to hypoglycorrheic lymphocytic meningitis is presented. Extensive testing for occult systemic sarcoidosis was negative. The presence of noncaseating granulomatous inflammation was established by open brain biopsy, and the patient improved clinically with oral steroid therapy. In individuals with undiagnosed chronic meningitis, brain biopsy may be necessary to rule out isolated neurosarcoidosis.

Metabolic changes during serial squash matches in older men

We have previously reported dramatic changes in heart rate and blood biochemistry in older men during and shortly after competitive squash. In this study we sought to determine whether these changes are attenuated or exaggerated during tournament matches played in rapid succession. Ten veteran (greater than 45 yrs) players were studied during three competitive matches played over a 36-hr period. Squash was associated with significant changes in heart rate and circulating concentrations of catecholamines, lactate, free fatty acids, and potassium. These changes were of equal magnitude and in some cases tended to be exaggerated during the second and third matches. These data confirm the acute changes in cardiac function and metabolism that occur during competitive squash and suggest that these responses are not down-regulated but may in fact be accentuated during sequential tournament matches.

Transmetatarsal amputation. A literature review and case study

The effect of diabetes on the lower extremity can be devastating. Surgical intervention on the diabetic foot must be carefully planned, and long-term results must be anticipated. The authors present a case history of a patient with multiple previous amputations of the forefoot, resulting in a severe deformity and a nonfunctional foot. Transmetatarsal amputation, if performed correctly, should provide a relatively functional extremity.

The history of water fluoridation

The positive effects of fluorides on the enamel have been known for a hundred years now. The author leads his readers from research to the present use of fluoridation in dentistry.

How to become involved in EDS

This article presents ways in which dental students may become involved in EDS. It is important that EDS has the support of dental students as it is a Committee which works in their interest.

The effect of various forms of immobilization on plantar foot pressure

In this study, 16 subjects wore different types of immobilization devices while peak pressures on the plantar aspect of the foot were measured using the Electrodynogram (E.D.G.) system. Objective and subjective data were generated and analyzed. Peak pressures decreased on the plantar aspect of the foot as the form of immobilization progressed up the leg.

Audit of cranial computerised tomography in a general medical unit

Over a two year period 108 patients had cranial computerised tomographic (CCT) scans while under the care of a general medical team. Sixty eight scans showed 70 abnormalities. Completed stroke, transient ischaemic attacks (TIA), epilepsy and headache were the most common indications for CTT while infarct, atrophy, haemorrhage and tumour were the most common abnormalities. Eight tumours were identified comprising 12% of epileptics and 9% of stroke patients.

Stenosing tenosynovitis of the flexor hallucis longus at the ankle joint

The discussion of stenosing tenosynovitis of the flexor hallucis longus at the level of the ankle joint is not found in the literature with frequency. A thorough understanding of the involved anatomy is necessary when considering this condition. A strong clinical suspicion, coupled with appropriate diagnostic tests, is necessary to arrive at a proper diagnosis. Various treatment options may be considered. However, surgical decompression of the stenosed sheath ultimately is recommended by the authors.

Heart rate and metabolic response to competitive squash in veteran players: identification of risk factors for sudden cardiac death

We studied 10 older males during a competitive game and the early post-exercise period to define the metabolic response to squash in veteran players. For comparison, all subjects were also studied during exhaustive treadmill exercise. Squash caused a dramatic increase in heart rate (150%), and circulating levels of noradrenaline (164%), adrenaline (93%), lactate (202%) and free fatty acids (67%). These effects were independent of haemoconcentration. The early post-exercise period (5 min) was characterized by persistent elevation of plasma catecholamines, lactate, and free fatty acids, hypokalaemia and ventricular arrhythmias. The heart rate and metabolic responses to squash were similar in pattern and magnitude to those observed during treadmill exercise, highlighting the strenuous nature of squash as a recreation sport. While these changes may represent appropriate physiological adaptation to exercise in health, each has been implicated in the pathogenesis of fatal ventricular arrhythmias in subjects with ischaemic heart disease. These data support the contention that squash may be an inappropriate form of exercise for older men with coronary artery disease.

A practical approach enabling staff pharmacists to prospectively review and dose aminoglycoside therapy

A simple and effective approach for staff pharmacists to prospectively review and dose aminoglycoside therapy is presented. A departmental policy was established requiring pharmacists to review each adult aminoglycoside order for appropriateness by means of a written audit form. Specific patient data and the aminoglycoside dose is obtained from an antibiotic order form and the patient's creatinine clearance is estimated using a modified Cockcoft and Gault equation. Proper initial dosage regimens are assessed by use of a modified Sarubbi and Hull nomogram or an in-house developed pharmacokinetic software program. The results demonstrate pharmacists were required to intervene in 26.8% of adult aminoglycoside orders. To determine if the percentage of pharmacist intervention changed over time, the results were compared to a sample period selected almost two years later. The percentage of pharmacists intervention was almost identical (25.3%). In both groups, over 90% of the pharmacists's dosing recommendations were accepted by the physician. The outcome of pharmacist's reviews were analyzed during the first study period. In courses of therapy with dosages recommended by pharmacists, therapeutic, non-toxic concentrations of gentamicin and tobramycin (peak 5-10 micrograms/ml, trough less than 2 micrograms/ml) comprised 47/54 (87%) of the interpretable levels. Patients judged by the pharmacist to have an appropriate dose during the initial review had 85/119 (71.4%) of interpretable serum levels in the therapeutic, non-toxic range. Without benefit of a formalized pharmacokinetic service, this program enables all staff pharmacists to perform a review of aminoglycoside therapy which ensures an appropriate initial dosage regimen. The completed aminoglycoside initial audit form serves as a communication tool as well as documentation for the department's quality assurance program.

Usefulness of abnormalities of repolarization in the electrocardiographic diagnosis of healed myocardial infarction

The authors evaluated the ability of criteria involving abnormalities of repolarization to diagnose healed myocardial infarction (MI). They studied the Q, R, S, and T waves and the ST-segments of the electrocardiograms (ECGs) of 60 angiographic-normal patients, 63 patients with angiographic evidence of healed inferior MI, and 33 patients with angiographic evidence of anterior MI. The best individual criteria involving repolarization were T wave amplitude less than or equal to 0.4 mm in lead II for inferior MI (specificity, 93%: sensitivity, 67%) and T wave amplitude greater than 2.4 mm for anterior MI (specificity, 100%: sensitivity, 27%). These T wave criteria enhanced the diagnostic performances of otherwise marginal QRS criteria for both inferior and anterior MI. The authors conclude that ECG criteria that involve abnormalities of the T waves are useful for diagnosing healed MI.

Electroconvulsive therapy and cognitive improvement in a very elderly depressed patient

A computer search of the literature revealed that the oldest documented patient to receive electro convulsive therapy (ECT) was a 94-year-old woman (Bernstein, 1972) who was diagnosed as having ‘anorexniearvosa’, but the history was suggestive of paranoid schizophrenia. She received a course of five ECTs and became much less paranoid, ate well, and put on weight. Her daughter lamented the fact that ECT had been deemed to be contra indicated 15years earlier on the grounds of advanced age.

Design and selected application of an electronic touch-sensitive switch for motor-impaired patients. Suggestion from the field

This relatively inexpensive device has been helpful not only for wheelchair-bound patients, such as individuals with spinal cord injuries, but also for other persons with minimal motor strength and control. In this case study, a patient with no control over conventional light fixtures could use the touch-sensitive relay and control all light fixtures.