Sentinel lymph node biopsy is unreliable in predicting melanoma mortality for both younger and older patients

BACKGROUND

Melanoma disease patterns vary with patient age.

AIM

To evaluate sentinel lymph node biopsy (SLNB) in managing melanoma at differing patient ages.

METHODS

Online prediction tools were applied to compare SLNB positivity (SLNB+) and survival risk at patient ages 20-80. Tübingen melanoma data were used to determine variations in the hazard ratio of SLNB+ for mortality at different patient ages.

RESULTS

Regardless of tumour thickness, predicted SLNB+ rates were markedly higher than mortality rates for 20-year-old patients. For 80-year-old patients, it is the opposite.

DISCUSSION

If 1000 20-year-olds with a 0.4 mm thickness non-ulcerated melanoma underwent SLNB, 100 would likely be positive. If all 100 were to be offered adjuvant drug therapy (ADT), fewer than three more melanoma deaths in those 1000 patients would be avoided. In total, 97 patients would have received medication they may never have needed. If 1000 80-year-olds with a 3 mm thickness non-ulcerated melanoma underwent SLNB, only 40 would likely be positive. In total, 274 patients would be predicted to die of melanoma, 245 being SLNB negative and 29 SLNB+. ADT linked to SLNB+ could deny treatment to 89% of these high-risk patients.

LIMITATIONS

The authors relied on published risk data.

CONCLUSION

SLNB has poor specificity at predicting mortality in young melanoma patients and poor sensitivity in older patients. SLNB is not indicated in managing cutaneous melanoma for patients under 40 or over 60 years of age. Many such patients could be managed with wide local excision alone in their clinician's office-based practice. For all cutaneous melanoma patients at all ages, linking ADT to BAUSSS biomarker, (an algorithm of Breslow thickness, age, ulceration, subtype, sex and Site) rather than SLNB+ is likely more appropriate. BAUSSS provides a more accurate melanoma-specific mortality risk assessment for patients without burdening them with added surgery, hospitalization, costs or morbidity risk.

Evaluation of the impact of enhanced recovery after surgery protocol implementation on maternal outcomes following elective cesarean delivery

BACKGROUND

Despite significant improvements in outcomes following non-obstetric surgery with implementation of enhanced recovery after surgery (ERAS) protocols, development of these protocols for cesarean delivery is lacking. We evaluated implementation of an ERAS protocol for patients undergoing elective cesarean delivery, specifically the effect on opioid consumption, pain scores and length of stay as well as complications and re-admissions.

METHODS

An ERAS protocol was developed and implemented for women undergoing elective cesarean delivery. The protocol construction included specific evidence-based items applicable to peripartum management and these were grouped into the three major phases of patient care: antepartum, intrapartum and postpartum. A before-and-after study design was used to compare maternal outcomes. To account for confounders between groups, a propensity matched scoring analysis was used. The primary outcome was postpartum opioid use in mg-morphine equivalents (MMEQ).

RESULTS

We included 357 (n=196 before; n=161 after) women who underwent elective cesarean delivery. A significant difference in opioid consumption (28.4 ± 24.1 vs 46.1 ± 37.0 MMEQ, P <0.001) and in per-day postoperative opioid consumption (10.9 ± 8.7 vs 15.1 ± 10.3 MMEQ, P <0.001), lower peak pain scores (7 [5-9] vs 8 [7-9], P=0.007) and a shorter hospital length of stay (2.5 ± 0.5 vs 2.9 ± 1.2 days, P <0.001) were found after the introduction of the ERAS protocol.

CONCLUSIONS

Implementation of ERAS protocols for elective cesarean delivery is associated with significant improvements in analgesic and recovery outcomes. These improvements in quality of care suggest ERAS protocols should be considered for elective cesarean delivery.

Management of invasive melanoma

BACKGROUND

Maximising survival for patients with invasive melanoma hinges on early diagnosis of primary melanoma and appropriate management. Despite well-documented guidelines, many patients with melanoma have not been managed ideally.

OBJECTIVE

The aim of this paper is to identify suboptimal aspects of melanoma management.

DISCUSSION

Delayed or erroneous diagnosis is more likely to occur when a shave or punch biopsy is used to obtain histopathology. Wherever feasible, local excision with a narrow margin is the preferred biopsy choice for a suspected melanoma. The Breslow thickness of the primary melanoma remains the greatest predictor of outcome. Ulceration is associated with a poorer prognosis. Most invasive melanomas are managed with a margin of ≥10 mm of normal tissue. Patients who have developed one primary melanoma are at high risk of a second tumour. Ongoing management includes regular lifelong skin checks. Targeted approaches to improve occupational or lifestyle exposure to ultraviolet radiation are useful. Imaging is largely used when metastases are suspected on the basis of clinical symptoms or signs.

Cutaneous melanoma: Latest developments

BACKGROUND

Several new medications have shown improved survival rates in high-risk patients with melanoma.

OBJECTIVE

The aim of this article is to discuss the new medications and outline their roles, the expected benefit from each and the risk of adverse events. We explain the place of sentinel lymph node biopsy (SLNB) and ultrasonography with fine needle aspiration (US-FNA) in assessing and treating patients with melanoma.

DISCUSSION

Ipilimumab has limited efficacy and a very concerning complication profile. More than 50% of patients taking ipilimumab have severe or life-threatening adverse events. BRAF inhibitors have greater efficacy and fewer adverse events than ipilimumab. Combining BRAF inhibitors with mitogen-activated protein kinase inhibitors enhances their effect and improves the overall adverse event profile. BRAF inhibitors are only effective when the melanoma has a BRAF gene mutation, something that occurs in only 50% of cases. Programmed cell death protein 1 medications are also more effective and have a much more acceptable adverse event profile than ipilimumab. Both SLNB and US-FNA can detect early node involvement in patients with melanoma, although US-FNA is a safer procedure.

Prolonged adverse events following photodynamic therapy: regulatory implications

OBJECTIVE

To determine whether field photodynamic therapy (PDT) of actinic keratoses (AKs) using a novel preparation of 5-aminolevulonic acid (ALA) would result in fewer subsequent invasive skin cancers developing on the face.

DESIGN

A prospective multi-center randomized controlled trial. The protocol was approved by the Bond University Human Research Ethics Committee in accord with the TGA's Clinical Trial Notification Scheme. The trial was registered (12609000025235) on the Australian New Zealand Clinical Trials Registry.

SETTING

Six centers in four states in Australia.

PROTOCOL

Two treatments of ALA PDT, 2 weeks apart for each patient. Controls were observed. Patients were followed up with biopsies of any suspicious lesions every 6 months for 2 years.

MAIN OUTCOME MEASURE(S)

Development of new skin cancers.

RESULTS

The trial was suspended after 3 months and closed after 6 months after ethics committee approval was withdrawn on the basis of a breakdown in trial governance. Over the following 2 years, some investigators noted and formally reported the continued occurrence of serious adverse events in excess of those described with other approved cutaneous PDT treatments. USA dermatologists with experience managing AKs with FDA approved ALA products subsequently confirmed prolonged and severe adverse events in 6 of the former trial intervention patients.

DISCUSSION AND CONCLUSIONS

Adverse effects experienced by patients using the investigational ALA PDT appeared more severe than those experienced when an FDA-approved ALA product is used. We believe the former should be further evaluated for safety. It is of concern that this ALA product and lamp could be promoted and used widely in Australia following these reports of significant adverse events and continued lack of TGA approval.

Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy

BACKGROUND

The aim was to identify risk factors for postoperative bleeding following skin cancer surgery.

METHODS

This was a prospective study of 5950 skin lesions excised in 2394 patients. No patient stopped taking aspirin or warfarin unless the international normalized ratio (INR) exceeded 3.0.

RESULTS

The rate of postoperative bleeding was 0.7 per cent overall and 2.5 per cent in the 320 patients taking warfarin. The rate of bleeding was 1.0 per cent for skin flap repairs, 0.4 per cent for simple excision and closure, and 5.0 per cent for skin grafts. Diabetic patients and smokers were not at increased risk of bleeding. There were four independent factors for bleeding: age 67 years or older (odds ratio (OR) 4.7 (95 per cent confidence interval 1.8 to 12.2); P = 0.002), warfarin therapy (OR 2.9 (1.4 to 6.3); P = 0.006), surgery on or around the ear (OR 2.6 (1.2 to 5.7); P = 0.012) and closure with a skin flap or graft (OR 2.7 (1.4 to 5.3); P = 0.004). Aspirin therapy was not an independent risk factor for bleeding.

CONCLUSION

Most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin. There was no case for discontinuing aspirin before skin surgery, but the INR should be monitored in patients taking warfarin.

Prospective study of long-term patient perceptions of their skin cancer surgery

BACKGROUND

We identified factors that influence patient perceptions of their skin cancer surgery through a prospective study of patients referred to a single surgeon during 18 months.

METHOD

Patients having surgery resulting in a wound sutured and dressed were surveyed 6 to 9 months later. Monitoring for complaints continued for 3 years.

RESULTS

In all, 74% of patients returned the survey (576 of 778). A total of 250 (43%) rated their scar excellent, 177 (31%) very good, 72 (12.5%) good, 40 fair (6.9%), and 14 (2.4%) poor or very poor. Age, sex, diagnosis, or closure method did not result in a variation in scar perception. In all, 27.3% of scars (21/77) on the trunk were rated neutral or negative compared with 6.9% (33/476) of scars elsewhere (P < .001) and only 5% (15/305) of head and neck scars (P < .001). Complications did not change scar or overall evaluation ratings. In all, 393 patients (68%) rated the overall service excellent, 145 (25%) very good, 22 (4%) good, and 3 (0.5%) fair. No patient rated the service poor or very poor. Patients rating the service lower were most dissatisfied with scar appearance, time waiting before surgery, pain from the local anesthetic, nursing care, follow-up care, cost, and written material. In all, 99% of patients who rated their scar very good or excellent rated the overall service optimally, compared with only 85% of patients who rated their scar as good or worse.

LIMITATIONS

A single experienced surgeon in a southern Australia locale might not reflect the perceptions in other clinicians and locations.

CONCLUSION

Complications and patient complaints do not identify patient dissatisfaction from cutaneous surgery. The patients' perception of their scars markedly influences their overall service perception. Patients experienced more dissatisfaction with repairs on the trunk.

Randomized clinical trial of the effect of applying ointment to surgical wounds before occlusive dressing

BACKGROUND

A blinded randomized clinical trial was undertaken to evaluate the effect of applying ointment to a wound before occlusive dressing, in comparison with no ointment or sterile paraffin.

METHODS

Some 778 patients with 1801 surgical wounds following excision of skin lesions were enrolled in the trial. No ointment was placed on 510 sutured wounds of 247 patients, paraffin ointment was put on 729 wounds (269 patients) and mupirocin ointment on 562 wounds (262 patients). Wound infection, scar, haemorrhage, dehiscence and other complications were assessed at suture removal. At 6-9 months after surgery, patients were surveyed to assess the wounds, with a response rate of 74.0 per cent.

RESULTS

There were no significant differences in outcome for all endpoints evaluated. The infection rate was 1.4 per cent with no ointment, 1.6 per cent for paraffin and 2.3 per cent for mupirocin (P = 0.490). Total complication rates were 3.5, 4.7 and 4.8 per cent for no ointment, paraffin and mupirocin respectively (P = 0.590). Some 10.9, 10.3 and 8.2 per cent of patients respectively had a neutral or negative perception of their wounds at 6-9 months after surgery (P = 0.650). There was no difference in postoperative pain, degree of inconvenience or overall level of satisfaction with treatment.

CONCLUSION

Putting ointment on a surgical wound before occlusive dressing does not benefit the patient. In view of the risk of antibiotic resistance, mupirocin ointment is not indicated for clean surgical wounds.

Reducing opposed multilobed flaps results in fewer complications than traditional repair techniques when closing medium-sized defects on the leg after excision of skin tumor

BACKGROUND

The reducing opposed multilobed (ROM) flap involves a series of transpositions effected cephalic and caudal to the primary defect, sequentially mobilized toward and then into the primary defect.

OBJECTIVE

To compare the ROM flap with other techniques to close defects below the knee after excision of skin tumor.

METHOD

This retrospective study compares 140 defects closed with a ROM flap with 85 defects closed with traditional techniques.

RESULTS

A total of 225 defects between 11 and 44 mm in diameter were excised over 3 years from July 1, 2002. There were 140 defects closed by ROM flap and 85 non-ROM closures including 29 "O-to-Z" flaps and 12 bilateral transposition flaps. A total of 111 squamous cell carcinomas, 64 basal cell carcinomas, and 11 melanoma were excised. ROM flap closures developed 20 complications (14.3%): 13 infections, 5 partial dehiscence, and 2 partial end flap necrosis. Non-ROM closures developed 27 complications (31.8%): 13 infections, 6 partial end flap necrosis, 4 partial dehiscence, 2 wound depression, 1 hemorrhage, and 1 persisting pain. Three ROM and 7 non-ROM cases suffered two complications. The total complication rate was significantly lower with ROM flaps (p=.003), including lower end flap necrosis incidence (p=.027).

CONCLUSION

The ROM flap results in fewer complications than traditional techniques when closing defects 11 to 45 mm in size on the leg and foot. In particular, end flap necrosis incidence is lower with ROM flap closure.

Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics

OBJECTIVE

The study aimed to identify wound sites/procedures where infection incidence was over 5%, such that these circumstances may warrant wound infection antibiotic prophylaxis.

METHOD

We undertook a 3-year prospective study of 5,091 lesions (predominantly nonmelanoma skin cancer) treated on 2,424 patients from July 2002 to June 2005. No patient was given prophylactic antibiotics, and no patient ceased warfarin or aspirin.

RESULTS

Overall infection incidence was 1.47%. Individual procedures had the following infection incidence: curettage 0.73% (3/412); skin flap repairs 2.94% (47/1601); simple excision and closure 0.54% (16/2974); skin grafts 8.70% (6/69); and wedge excision 8.57% (3/35). Analysis of regions of the body demonstrated that surgery below the knee (n = 448) had an infection incidence of 6.92% (31/448) (p < .0001). Subanalysis demonstrated that all regions below the knee were at high infection risk. Elsewhere, groin excisional surgery had an infection incidence of 10% (1/10) (p = .027). No other body site demonstrated an infection incidence beyond 5% of statistical significance. Procedures on the face demonstrated an infection incidence of 0.81% (18/2,209). Diabetic patients, those on warfarin and/or aspirin, and smokers showed no difference in infection incidence.

CONCLUSION

Based on a prediction of infection incidence over 5%, the following cutaneous oncologic procedures warrant consideration of oral antibiotic wound infection prophylaxis: all procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin. Other than under these circumstances, surgery to the nose, ear, fingers, lips, skin flap surgery, and surgery on diabetics, smokers, and those on anticoagulants have previously been considered for wound infection prophylaxis but do not warrant such intervention based on our data. The authors have indicated no significant interest with commercial supporters.

Managing skin cancer--23 golden rules

From their collective experience in Australia and the USA, dermasurgeons Anthony Dixon and Scott Hall have compiled a list of "golden rules" for general practitioners to help reduce errors and problems with skin cancer management. It is anticipated that these tips will provide a brief yet informative reference when faced with skin cancer management concerns in general practice.

Multiple superficial basal cell carcinomata--topical imiquimod versus curette and cryotherapy

BACKGROUND

Superficial basal cell carcinoma can be successfully managed by means other than surgical excision. Nonexcisional approaches include topical imiquimod, and curette and cryotherapy (C&C).

OBJECTIVE

This article discusses the management of an insulin dependent diabetic man aged 52 years presenting with 17 torso basal cell carcinomas (BCCs); mostly superficial BCCs (SBCCs).

DISCUSSION

Half were treated with topical imiquimod. The remaining lesions were treated with curette and cryotherapy. All lesions resolved with proven histologic clearance. The patient considered C&C caused him less discomfort and disruption. He developed a late secondary infection in some sites treated with imiquimod. At 12 months there was no evidence of recurrence though new nodular BCCs and SBCCs had developed elsewhere on his upper torso. He has elected to have future SBCCs managed with C&C. While excisional surgery remains the benchmark management for nonmelanoma skin cancer, topical imiquimod and C&C are important options for treating SBCCs.

Reducing opposed multilobed flap repair, a new technique for managing medium-sized low-leg defects following skin cancer surgery

BACKGROUND

Following skin cancer excision, skin defects on the low leg between 10 and 35 mm in diameter can be problematic. Direct closure of the wound risks excessive wound tension and wound dehiscence. Skin grafts heal slowly and often remain unsightly. Traditional skin flaps have a limited role.

OBJECTIVE

The objective was to develop a random-pattern skin flap that offers significant advantages over traditional techniques including grafting.

METHODS

The reducing opposed multilobed flap involves a series of semicircular lobes extending both cephalic and caudal from the defect. The technique involves lobes most distant from the primary defect being transposed in turn closer to the defect. The technique does not result in the unnecessary excision of Burrows triangle skin.

RESULTS

The reducing opposed multilobed (ROM) flap reduces skin tension concerns, lowers the risk of flap necrosis, and allows for quicker and more aesthetic healing. After 20 cases, we have yet to experience dehiscence, infection, or delayed healing. The healing wound is resistant to contraction and invariably produces an acceptable aesthetic outcome.

CONCLUSION

The ROM flap repair allows the dermatologic surgeon an additional option when faced with a medium-sized lower leg defect following skin cancer excision.

Ultraviolet radiation from welding and possible risk of skin and ocular malignancy

Arc welding produces the full spectrum of ultraviolet radiation (UVR). It is possible that welders are at greater risk of developing skin cancer than the general population, but there is a dearth of well designed studies in this area. The only major study of the relationship between arc welding and skin cancer risk did not reveal an increased incidence of skin cancer in welders. As the welders examined were all well protected and the length-of-exposure period was limited, the findings cannot be generalised to all welders. Studies have demonstrated that welding increases the risk of ocular melanoma. Just as we urge the public to protect themselves from UVR, we need to consider similar advice for arc welders.

An effective, cosmetically acceptable, novel hydro-gel emollient for the management of dry skin conditions

BACKGROUND

A novel hydro-gel emollient (Doublebase) has been developed with improved moisturizing effects.

OBJECTIVE

To test this novel hydro-gel for its moisturizing effect, for its potential to cause skin irritancy/allergy and for its clinical effectiveness and acceptability in dry skin conditions.

METHODS/RESULTS

Skin hydration (corneometry) and trans-epidermal water loss (TEWL) studies with a single application in 18 volunteers confirmed its efficacy (p < 0.0001) and showed that it was superior to Ultrabase and Diprobase (p < 0.001). Skin hydration studies with multiple applications in 12 volunteers also showed that it was superior to Ultrabase and Diprobase (p < 0.0001). Irritation tests in 74 eczema-prone patients resulted in only one mild reaction, and allergy tests in 99 healthy volunteers elicited no positive reactions. The clinical acceptability and effectiveness of Doublebase was demonstrated in an open study of 78 patients with dry skin conditions.

CONCLUSION

Doublebase may be considered a suitable preparation that can be used effectively by most patients with dry skin conditions.

Evaluating the efficacy of vaccine storage in the general practice setting

OBJECTIVES

To describe the implementation of guidelines for vaccine storage in general practice, and their effectiveness in achieving optimum vaccine storage temperatures in fridges.

DESIGN

Repeated cross-sectional surveys over time--phase 1 1996/97, phase 2 1998/99, phase 3 1999/2000.

SETTING

Central Coast, New South Wales.

PARTICIPANTS

Phase 1--all general practices on the Central Coast. Phases 2 and 3--samples of practices.

INTERVENTIONS

Each practice was surveyed about how they stored vaccines. A datalogger recorded fridge temperatures over six days. Individual feedback and advice were given.

MAIN OUTCOME MEASURES

Proportion of: 1. fridges maintaining a temperature in the 2-8 degrees C range; 2. fridges freezing; 3. practices with one person responsible for vaccine storage; 4. bridge temperature checked daily; 5. fridges storing no items other than vaccines; 6. bridges with thermometers; and 7. associations between storage practices and fridge temperatures.

RESULTS

In phase 1, 102 fridges, and in phase 3, a random sample of 36 practices was surveyed. The findings for phase 1 and phase 3 respectively were: 31% and 50% of fridges were in the 2-8 degrees C range; 36% and 25% were <0 degrees C; one person was responsible in 52% and 53% of cases; 20% and 38% reported daily checks; 74% and 94% of fridges had no extraneous items and 53% and 86% of fridges had thermometers. No statistically significant associations were found between vaccine storage practices and bridge temperatures.

CONCLUSIONS

Despite improvements in vaccine storage practices, a quarter of fridges were freezing, thereby compromising the potency of many of the immunisation schedule vaccines.

Probable colchicine-induced neutropenia not related to intentional overdose

OBJECTIVE

To report a case of neutropenia caused by colchicine not associated with intentional overdose or with preceding severe gastrointestinal symptoms.

CASE SUMMARY

A 68-year-old white man was admitted to the hospital with intractable pain from an acute attack of gout. The patient was treated with standard doses of oral colchicine for several days. He experienced mild loose stools, but no severe diarrhea or nausea during treatment. The patient then developed severe neutropenia, with an absolute neutrophil count of 240 cells/mm3. His white blood cell count returned to normal after discontinuing colchicine and administering filgrastim.

DISCUSSION

Although colchicine is commonly associated with neutropenia in cases of intentional or accidental overdose, the patient developed this adverse effect after being treated with doses commonly used for the acute treatment of gout. In addition, this patient had taken low-dose colchicine for many years without experiencing hematologic adverse effects.

CONCLUSIONS

Colchicine is often an attractive alternative to nonsteroidal antiinflammatory agents for the treatment of gout, especially in patients at risk for renal impairment or gastropathy. Our case illustrates that colchicine treatment can cause hematologic adverse effects; the clinician should monitor cell counts in patients receiving this agent, especially at the higher doses used for acute treatment of gout.

Novel kainic acid analogues. Effects on cyclic GMP content of adult rat cerebellar slices

On the basis of previous electrophysiological studies, it has been proposed that there are three main classes of excitatory amino acid receptor in the mammalian central nervous system, which are activated preferentially by kainic acid, quisqualic acid and N-methyl-D-aspartate respectively. Although the pharmacology of the N-methyl-D-aspartate receptor has been investigated extensively, potent and selective ligands which act at the kainate or quisqualate sites are lacking. In this study, we report that a number of novel kainate analogues possess either agonist or antagonist activity in a system which permits investigation of receptor-mediated coupled responses, viz. the ability of excitatory amino acids to elevate cyclic GMP concentrations in incubated cerebellar slices prepared from the adult rat. The data reported here provide some clues as to the likely structural requirements for developing effective kainate antagonists.

Kainic acid derivatives with anticonvulsant activity

beta-Kainic acid, and the glycine and amino-methylphosphonate derivatives of alpha- and beta-kainic acid, have been injected intracerebroventricularly in DBA/2 mice, that show sound-induced seizure responses. An anticonvulsant effect is observed with marked protection against the tonic and clonic phases of the seizure response. ED50 values against clonus are (in mumol): beta-kainic acid, 0.09; beta-kainylglycine, 0.11; alpha-kainylglycine, 0.28; alpha-kainylaminomethylphosphonate, 0.31; beta-kainylaminomethylphosphonate, greater than 1.5. In addition a direct convulsant effect occurs after the alpha-kainyl derivatives.

Ultrastructural localisation of fibronectin in mouse kidney

The ultrastructural localisation of fibronectin in mouse kidney was investigated by indirect immunoperoxidase cytochemistry. In glomeruli, fibronectin was found predominantly in matrix between endothelial and mesangial cells. Smaller quantities were demonstrable in peripheral capillary walls both subendothelially and around visceral epithelial cell foot processes. It was present between parietal epithelial cells and Bowman's capsule and at the base of tubular epithelial cells outlining the inner aspect of tubular basement membranes.

Interstitial nephritis

The clinical and pathological findings are reviewed in ten cases where renal biopsy showed abnormalities predominantly within the interstitium. In six the nephritis was considered to be drug-induced; in two the aetiology was slightly obscure but the most likely diagnosis was considered to be sarcoidosis. Of the remaining two cases one was chronic pyelonephritis and the other polyarteritis nodosa. The diagnosis and pathogenesis of the renal lesions are discussed and attention is drawn to the importance of distinguishing primary interstitial changes from those found in association with glomerular disease.

Distribution of fibronectin in normal and diseased human kidneys

The distribution of fibronectin in 42 renal biopsies was investigated using an indirect immunoperoxidase technique on paraffin sections of formalin-fixed material. Biopsies were obtained from normal human kidneys and from patients with a variety of glomerular disorders. In normal glomeruli, fibronectin was present in Bowman's capsule, in the mesangium, and outlining peripheral capillary loops. A significant increase in fibronectin was observed in most types of glomerulopathy with a distribution closely related to the histopathological diagnosis. Fibronectin was diminished or absent in segmental scars, old diabetic nodules, and hyalinised glomeruli.

Immunoperoxidase localisation of fibronectin in glomeruli of formalin fixed paraffin processed renal tissue

An indirect immunoperoxidase technique was used to demonstrate fibronectin in sections of routine formalin fixed paraffin embedded renal tissue. Previous exposure of the sections to a solution of pepsin (4 mg/ml) in 0.01 N HCl for 2 h at 37 degrees C was essential in order to demonstrate antigenicity of fibronectin previously masked by fixation and embedding procedures.

Indoprofen and naproxen in the treatment of rheumatoid arthritis: a clinical trial

Thirty-six patients suffering from rheumatoid arthritis took part in a double-blind crossover trial, in which they received either indoprofen 800 mg/day, naproxen 500 mg/day, or a matching placebo. Indoprofen was shown to be significantly superior as an analgesic and in improving grip strength and the patients preferred it. Adverse effects were comparable, although indigestion was seen slightly more often during indoprofen treatment. Indoprofen is therefore at least as effective as existing anti-inflammatory drugs in rheumatoid arthritis and seems to be better tolerated.

The great toe as a clinical problem in rheumatoid arthritis

Two hundred consecutive in-patients with rheumatoid arthritis were examined for pain or deformity of the feet, and of the great toe in particular. Some abnormality occured in 196 feet and the deformities observed are presented. The symptoms that arise from these deformities are mainly derived from ill-fitting shoes, and the need for suitable foot-wear is emphasized. Two hitherto un-named entities are described namely Hallux tortus and chisel toe, since they give rise to their own shoe-fitting problems.

Synthetic D(-)penicillamine in rheumatoid arthritis. Double-blind controlled study of a high and low dosage regimen

Doses of 600 mg and 1200 mg of D(-)penicillamine daily were superior to a standard regimen of therapy in rheumatoid arthritis. The higher dose did not produce significantly greater therapeutic benefit in the group of patients so treated, although individual patients sometimes improved more. The frequency of rashes, blood dyscrasias, and withdrawals from the trial increased withe dosage. It is concluded that D(-)penicillamine is a useful treatment that the daily dose should be as low as possible, and that it should be increased at infrequent intervals only, with due regard to the likelihood of further improvement in relation to an increased risk of adverse reactions.