A Retrospective Clinical Study on 1075 Lithium Disilicate CAD/CAM Veneers with Feather-Edge Margins Cemented on 105 Patients

PURPOSE

To evaluate the clinical performance of lithium disilicate (LiDiSi) computer-aided- design/computer-assisted-manufacturing (CAD/CAM) veneers with feather-edge margins.

METHODS

Over 4 years (2015-2019), 1075 LiDiSi veneers with feather-edge margins were fabricated with a fully digital workflow and cemented on 105 patients. The outcome variables were survival of the restorations, colour matching, quality of the ceramic surface, presence of marginal discolouration and marginal integrity. The last four variables were assessed using the modified California Dental Association (CDA) and Ryge criteria.

RESULTS

The mean observation period was 30.8 months. The cumulative survival rate was 99.83%. At the last follow-up control, the colour matching of the surviving 1074 restorations was rated Alpha (1064 veneers, 99.06%) and Bravo (10 veneers, 0.94%); the ceramic surface was rated Alpha (1070 veneers, 99.62%) and Bravo (4 veneers, 0.38%); the marginal discolouration was rated Alpha (1069 veneers, 99.53%) and Bravo (5 veneers, 0.47%); and the marginal integrity was rated Alpha (1070 veneers, 99.62%) and Bravo (4 veneers, 0.38%).

CONCLUSION

CAD/CAM LiDiSi veneers with feather-edge margins fabricated with a fully digital workflow showed good clinical performance in terms of survival, colour matching, ceramic surface, marginal discolouration and integrity. Further, prospective and long-term studies are needed to confirm these positive results.

Continuous Scan Strategy (CSS): A Novel Technique to Improve the Accuracy of Intraoral Digital Impressions

PURPOSE

To present the results obtained with the "Continuous Scan Strategy" (CSS), a direct intraoral scanning technique based on the connection of the implant scan bodies (SBs) with thermoplastic resin.

METHODS

40 patients were restored with 45 long-span monolithic implant-supported zirconia restorations (10 partial prostheses [PP] and 35 full arches [FA]) fabricated via a full-digital workflow after the capture of an intraoral impression (Trios3®) using the CSS technique. The primary outcomes were the marginal adaptation and passive fit of the superstructures, checked at T0 (intraoral try-in of polyurethane or metal replica of the final prosthesis) and T1 (delivery of the final zirconia restoration). The secondary outcomes, registered at T2 (2 years after the delivery of the final prosthesis), were implant survival, prosthetic success, and complications. A throughout statistical analysis was performed.

RESULTS

At T0, 40/45 replicas demonstrated a perfect passive fit and adaptation. At T1, one prosthesis had fractured, and at T2, an additional prosthesis had fractured and one had chipped. The implant survival rate was 100%. The prosthetic success was 93.3%.

CONCLUSIONS

CSS seems to represent a viable option for capturing accurate intraoral digital impressions for the fabrication of precise long-span implant-supported restorations.

Accuracy of 6 Desktop 3D Printers in Dentistry: A Comparative In Vitro Study

PURPOSE

To compare the accuracy of 6 desktop 3D printers in dentistry.

METHODS

A parallelepiped (PP) with known geometry and holes of different diameters was designed and printed with 6 desktop 3D printers (Sheraprint 40®; Solflex 350®; Form 2®; MoonRay D75®; Vida HD®; XFAB 2000®). For each printer, 9 PPs were printed with proprietary materials; these PPs were not cured and underwent dimensional analysis by optical microscopy and precision probing. A file representative of a dentate model (DM) was also printed with the aforementioned printers. For each printer, 3 DMs were printed with the proprietary materials. These DMs were cured and after 1 month, scanned with a desktop scanner and superimposed on the virtual reference model, to investigate trueness.

RESULTS

Dimensional analysis by optical microscopy and precision probing highlighted the reliability of the 3D printed models; errors were compatible with clinical use. However, both linear and diameter measurements revealed statistically significant differences between the machines. The trueness of the DMs 1 month after printing was low, suggesting that they underwent dimensional contraction over time, albeit with differences between the printers.

CONCLUSIONS

The 3D printed models showed acceptable accuracy, although statistically significant differences were found among them.

Human immunology studies using organ donors: Impact of clinical variations on immune parameters in tissues and circulation

Organ donors are sources of physiologically healthy organs and tissues for life-saving transplantation, and have been recently used for human immunology studies which are typically confined to the sampling of peripheral blood. Donors comprise a diverse population with different causes of death and clinical outcomes during hospitalization, and the effects of such variations on immune parameters in blood and tissues are not known. We present here a coordinate analysis of innate and adaptive immune components in blood, lymphoid (bone marrow, spleen, lymph nodes), and mucosal (lungs, intestines) sites from a population of brain-dead organ donors (2 months-93 years; n = 291) across eight clinical parameters. Overall, the blood of donors exhibited similar monocyte and lymphocyte content and low serum levels of pro-inflammatory cytokines as healthy controls; however, donor blood had increased neutrophils and serum levels of IL-8, IL-6, and MCP-1 which varied with cause of death. In tissues, the frequency and composition of monocytes, neutrophils, B lymphocytes and T cell subsets in lymphoid or mucosal sites did not vary with clinical state, and was similar in donors independent of the extent of clinical complications. Our results reveal that organ donors maintain tissue homeostasis, and are a valuable resource for fundamental studies in human immunology.

Benefit-risk paradigm for clinical trial design of obesity devices: FDA proposal

Diet and exercise, except in controlled circumstances, have not been shown to provide effective and prolonged weight loss for the majority of those who are obese. Several older drugs intended to reduce weight have been withdrawn from the market, and the new drugs show only modest weight loss. Surgical intervention, specifically procedures that alter the normal gastrointestinal anatomy, does provide prolonged periods of sustained weight loss, with rebound weight gain over time. A variety of medical devices to assist in weight reduction have been studied, but only two are legally marketed devices for obesity. The authors propose a new paradigm for devices intended to treat obesity, based on a benefit-risk determination, with the hope to provide sponsors an a priori tool for systematic assessment of the risks associated with the devices intended for treatment of obesity and to suggest appropriate levels of benefit for devices with different risk levels. The paradigm is not intended to determine the class of a device from a regulatory perspective. This approach was conceived at a Food and Drug Administration (FDA) co-sponsored workshop in October, 2011 and formally presented to an FDA advisory panel for discussion in May 2012.

Derivation of the uncontrolled donation after circulatory determination of death protocol for New York city

Evidence from Europe suggests establishing out-of-hospital, uncontrolled donation after circulatory determination of death (UDCDD) protocols has potential to substantially increase organ availability. The study objective was to derive an out-of-hospital UDCDD protocol that would be acceptable to New York City (NYC) residents. Participatory action research and the SEED-SCALE process for social change guided protocol development in NYC from July 2007 to September 2010. A coalition of government officials, subject experts and communities necessary to achieve support was formed. Authorized NY State and NYC government officials and their legal representatives collaboratively investigated how the program could be implemented under current law and regulations. Community stakeholders (secular and religious organizations) were engaged in town hall style meetings. Ethnographic data (meeting minutes, field notes, quantitative surveys) were collected and posted in a collaborative internet environment. Data were analyzed using an iterative coding scheme to discern themes, theoretical constructs and a summary narrative to guide protocol development. A clinically appropriate, ethically sound UDCDD protocol for out-of-hospital settings has been derived. This program is likely to be accepted by NYC residents since the protocol was derived through partnership with government officials, subject experts and community participants.

Phase II evaluation of treatment of complete resection of hepatic metastases from colorectal cancer and adjuvant hepatic arterial infusion of floxuridine: an Eastern Cooperative Oncology Group Study (PB083)

This study was designed to evaluate hepatic arterial infusion of floxuridine (FUDR) in patients with resected hepatic metastases from colorectal cancer. Patients who met eligibility criteria had an Infusaid pump (Infusaid Corporation, Sharon, MA, U.S.A.) implanted for intraarterial administration of chemotherapy. After complete surgical resection of hepatic metastases, FUDR (0.2 mg/kg/day) was given in 28-day cycles consisting of 14 days of treatment followed by 14 days of rest. Of 11 patients enrolled, one was ineligible, one received no treatment because of a blocked pump, and nine were treated per protocol. Of the nine treated patients, all are dead: one from hepatic toxicity, one from unrelated causes, and seven from progressive disease. Grade 3-4 toxicity included three cases of gastritis and two cases of hepatotoxicity from FUDR. Although this regimen was not successful, in part because of toxicity, the patient population studied here should be considered for future studies of adjuvant therapy.

Helping nursing students communicate with high-risk families. An educator's challenge

Lerner and Byrne advocate that students care for high-risk families during their maternity experience. Communication problems, client resistance, and newness of maternal care skills make this assignment a challenge for students and faculty as well.

Object relations in borderline adolescents

Although pathological object relations is a core aspect of borderline psychopathology, few studies have examined borderline object relations empirically, and none has focused on borderline adolescents. The present study examined four dimensions of object relations, as measured by the Thematic Apperception Test, in a sample of adolescent borderlines, psychiatric comparison subjects, and normals. These dimensions are complexity of object representations, affect-tone of relationship paradigms, capacity for emotional investment in relationships and moral standards, and understanding of social causality. Borderlines differed significantly from both comparison groups in several distinct ways, supporting some aspects of psychoanalytic theories of borderline object relations, while challenging others. Borderline adolescents have a malevolent object world, a relative incapacity to invest in others in a non-need-gratifying way, and a tendency to attribute motivation to others in simple, illogical, and idiosyncratic ways. Their object representations, however, can be quite complex, suggesting something other than a preoedipal arrest.

Postoperative adjuvant chemotherapy or BCG for colon cancer: results from NSABP protocol C-01

Data are presented from 1,166 patients with Dukes B and C carcinoma of the colon who were entered into the National Surgical Adjuvant Breast and Bowel Project (NSABP) Protocol C-01 between November 1977 and February 1983. Patients were randomized to one of three therapeutic categories: 1) no further treatment following curative resection (394 patients); 2) postoperative chemotherapy consisting of 5-fluorouracil, semustine, and vincristine (379 patients); or 3) postoperative BCG (393 patients). The average time on study was 77.3 months. A comparison between patients receiving postoperative adjuvant chemotherapy and those treated with surgery alone indicated that there was an overall improvement in disease-free survival (P = .02) and survival (P = .05) in favor of the chemotherapy-treated group. At 5 years of follow-up, patients treated with surgery alone were at 1.29 times the risk of developing a treatment failure and at 1.31 times the likelihood of dying as were similar patients treated with combination adjuvant chemotherapy. Comparison of the BCG-treated group with the group treated with surgery alone indicated that there was no statistically significant difference in disease-free survival (P = .09). There was, however, a survival advantage in favor of the BCG-treated group (P = .03). At 5 years of follow-up, patients randomized to the surgery-alone arm were at 1.28 times the risk of dying as were similar patients treated with BCG. Further investigation disclosed that this survival advantage in favor of BCG was a result of a diminution in deaths that were non-cancer related. When analyses were conducted on which events not related to cancer recurrence were eliminated, the survival difference between the BCG and control groups became nonsignificant (P = .40); the cumulative odds at 5 years decreased from 1.28 to 1.10. The findings from this study are the first from a randomized prospective clinical trial to demonstrate that a significant disease-free survival and survival benefit can be achieved with postoperative adjuvant chemotherapy in patients with Dukes B and C carcinoma of the colon who have undergone curative resection.

Postoperative adjuvant chemotherapy or radiation therapy for rectal cancer: results from NSABP protocol R-01

Information is presented from 555 patients with Dukes B and C rectal cancers treated by curative resection who were entered into the National Surgical Adjuvant Breast and Bowel Project (NSABP) protocol R-01 between November 1977 and October 1986. Their average time on study was 64.1 months. The patients were randomized to receive no further treatment (184 patients), postoperative adjuvant chemotherapy with 5-fluorouracil, semustine, and vincristine (MOF) (187 patients), or postoperative radiation therapy (184 patients). The chemotherapy group, when compared with the group treated by surgery alone, demonstrated an overall improvement in disease-free survival (P = .006) and in survival (P = .05). Employing the proportional hazards model, a global test was used to determine the presence of treatment interactions. Investigation of stratification variables employed in this study indicated that sex, and to a lesser extent age and Dukes stage, made individual contributions to the disease-free survival and the survival benefit from chemotherapy. When evaluated according to sex, the benefit for chemotherapy at 5 years, both in disease-free survival (29% vs. 47%; P less than .001; relative odds, 2.00) and in survival (37% vs. 60%; P = .001; relative odds, 1.93), was restricted to males. When males were tested for age trend with the use of a logistic regression analysis, chemotherapy was found to be more advantageous in younger patients. When the group receiving post-operative radiation (4,600-4,700 rad in 26-27 fractions; 5,100-5,300 rad maximum at the perineum) was compared to the group treated only by surgery, there was an overall reduction in local-regional recurrence from 25% to 16% (P = .06). No significant benefit in overall disease-free survival (P = .4) or survival (P = .7) from the use of radiation has been demonstrated. The global test for interaction to identify heterogeneity of response to radiation within subsets of patients was not significant. In conclusion, this investigation has demonstrated a benefit from adjuvant chemotherapy (MOF) for the management of rectal cancer. The observed advantage was restricted to males. Postoperative radiation therapy reduced the incidence of local-regional recurrence, but it failed to affect overall disease-free survival and survival.

The technique of segmental mastectomy (lumpectomy) and axillary dissection: A syllabus from the National Surgical Adjuvant Breast Project workshops

Surveys conducted by the American College of Surgeons indicate an increasing trend toward the treatment of primary breast cancer by segmental mastectomy and radiotherapy. This operation has never been formally taught in training programs, and scant standard descriptive material exists. The National Surgical Adjuvant Breast Project conducted a series of workshops to develop guidelines for the performance of the operation. The essential points are (1) pathologic control of margins to ensure complete surgical excision, (2) surgical principles of complete tumor excision, (3) attention to optimum cosmetic results, and (4) axillary dissection for accurate staging and regional control of the disease. This article summarizes the recommendations made at those workshops.

The rorschach assessment of borderline defenses: a concurrent validity study

This study assesses the concurrent validity of two Rorschach defense scales designed to identify borderline defensive structure. A Rorschach scale designed by Cooper and his colleagues was systematically compared to a defense scale constructed by Lerner and Lerner. Despite considerable overlap on a conceptual and operational level, the scales are based on divergent theoretical models (developmental arrest and fixation) and Rorschach units of analysis (all responses and human responses). Our results are based on the capacity of each scale to discriminate between independently diagnosed samples (neurotic, outpatient borderline, inpatient borderline, schizophrenic) and the relative discriminatory power of particular defenses within each scale to differentiate between groups.

A comparison of stapled and handsewn anastomoses in patients undergoing resection for Dukes' B and C colorectal cancer. An analysis of disease-free survival and survival from the NSABP prospective clinical trials

This study was to assess the effect of stapled colorectal anastomoses on local recurrence, disease-free survival, and survival following curative resection for Dukes' B and C adenocarcinoma. Data were derived from two randomized prospective trials of the National Surgical Adjuvant Breast and Bowel Project designed to evaluate the efficacy of adjuvant therapy in colorectal cancer. Of 1111 patients with colonic anastomoses, 255 were stapled mechanically. There were no significant differences in disease-free survival, survival, or local tumor recurrence among patients subjected to stapled or handsewn anastomoses. Of the 181 patients undergoing anterior resection for rectal cancer, 82 anastomoses were fashioned with staples. No significant disadvantage in disease-free survival, survival, or local recurrence could be attributed to use of the mechanical stapling devices. Twelve percent of patients undergoing stapled rectal anastomoses developed a local recurrence as a first sign of treatment failure compared with 19 percent for the handsewn group. No significant differences in the length of distal margins were detectable. The average time on study was 41 months. The use of stapled anastomoses for carcinoma of the colon or rectum is not associated with an adverse effect on long-term outcome.

Sequential methotrexate and 5-fluorouracil with bleomycin and cisplatin in the chemotherapy of advanced squamous cancer of the head and neck

A bolus intravenous dose of 5-fluorouracil of 600 mg/M2 was added exactly 1 hour after methotrexate administration in an established combination program including bleomycin and cisplatin for advanced squamous cell cancer of the head and neck. Results were no better than those observed previously with the three drugs, and hematologic and mucosal toxicities were slightly worse. The overall response rate was 41% in 34 patients with recurrent or metastatic disease, with only 6% complete remissions. Median time to disease progression for responding patients was 14 weeks, compared with 10 weeks for nonresponders. Partial response had little impact on survival. Among 12 patients with far-advanced disease confined above the clavicles without prior radiotherapy, 9 (75%) achieved partial remission, but the median survival, even with later surgery or irradiation, was only 34 weeks.

The influence of the surgical scrub on hand bacterial flora

The skin bacterial flora of subjects who scrub their hands routinely was compared to subjects who usually do not scrub their hands, to determine the influence of the surgical scrub on the skin bacterial population. Aerobic, anaerobic and yeast cultures of 15 surgical residents and 15 internal medicine residents were obtained. The skin bacterial population of 15 medical students rotating through surgery was also determined to assess the influence of hand contact with infected wounds on the bacterial flora. The medical students had been in contact with infected wounds as had the surgical residents, but they had not been scrubbing their hands. The internal medicine residents had not been in contact with infected wounds or scrubbing their hands. The number of bacteria cultured from the medical students was superior to the bacterial count obtained from internal medicine residents, but inferior to the number of microorganisms isolated from surgical residents (p less than 0.01). Pathogenic bacteria were isolated from cultures of eight surgical residents, five medical students and one internal medicine resident. Yeast was cultured from one surgical resident's hand. This study indicates that both the frequent contact with infected wounds and the routine use of the ten minute surgical scrub may modify the bacterial flora of the hand. The alterations observed in the two situations were an increased number of both pathogenic and nonpathogenic bacteria.

Doxorubicin and cisplatin for recurrent or metastatic squamous cell carcinoma of the head and neck

Thirty-six patients with recurrent or metastatic squamous cell carcinoma of the head and neck were treated with doxorubicin and cisplatin. The overall response rate (complete + partial) was 30%, with a median duration of response of 4 months. Median survival durations for responders and nonresponders were 15 and 4 months, respectively. Nausea, vomiting, and alopecia were common. Neither grade 4 myelosuppression nor irreversible renal failure was observed.

The Rorschach H response and object relations

Developmental theory, cognitive psychology, and object relations theory now offer a general conceptual framework for integrating diverse research findings on the Rorschach human response and for highlighting the developmental significance of interpersonal relationships and their formative contribution to building psychological structure. A comprehensive study of the human response on the Rorschach utilizing three dimensions of Blatt's Concept of the Object Scale (accuracy, differentiation, content) demonstrates that a systematic assessment of object relations--of concepts of self and others--is an important core issue in personality development and useful in making distinctions among diagnostic groups (neurotics, outpatient borderlines, inpatient borderlines, schizophrenics). The results illustrate that particular developmental and cognitive properties of human responses produced on the Rorschach show distinct patterns of differential impairment related to type and severity of psychopathology.

The prognostic significance of preoperative carcinoembryonic antigen levels in colorectal cancer. Results from NSABP (National Surgical Adjuvant Breast and Bowel Project) clinical trials

This analysis explores the prognostic significance of preoperative carcinoembryonic antigen (CEA) levels in patients with colorectal cancer. The data were derived from 945 patients entered into two randomized prospective clinical trials of the National Surgical Adjuvant Breast and Bowel Project. A strong correlation was evident between preoperative CEA level and Dukes class. The mean CEA progressively increased with each Dukes category and the mean value for each of the four classes was significantly different. This relationship was prevalent whether the data were analyzed for all colorectal lesions regardless of location or specifically for right-sided colon tumors. The prognostic function of preoperative CEA level was independent of the number of positive histologic nodes. Preoperative CEA level correlated with the degree of lumen encirclement by tumor. Tumors that did not encircle more than one half the lumen were associated with significantly lower preoperative CEA levels than those that did. The presence or absence of lumen obstruction was unrelated to the preoperative CEA level. The relative risk of developing a treatment failure was associated with preoperative CEA, in both Dukes B and C patients, demonstrating that the prognostic significance of preoperative CEA was independent of Dukes class.

[Effect of anesthesia on blood coagulation factor XIII]

57 patients who had undergone surgical operations because of varicosis were examined for the influence of the mode of anaesthesia on the plasma levels of factor XIII. Within a randomized study the patients were given by alternate order halothane (NA) (n = 19), neurolept-analgesia (NLA) (n = 19) or peridural anesthesia (PA) (n = 19). Pre- and postoperatively as well as at the 1st, 3rd, 5th, and 7th p.o. day the plasma levels of factor XIII, fibrinogen (factor I) and fibrinogen-degradation-products (FDP) were measured. FDP were not found. The levels of factor XIII remained within the normal range. Fibrinogen showed an identical course: the postoperative findings were lower than the initial ones. 24 h later the levels were higher. At the 7th p.o. day the most important readings were found. In comparing the three methods of anaesthesia the most obvious differences in the data on factor XIII were in the peridural anesthesia-group, especially on the 3rd p.o. day with significant lower results than in the other groups. The modes of anaesthesia used had no visible influence on the range of factor XIII.

The prognostic significance of tumor location and bowel obstruction in Dukes B and C colorectal cancer. Findings from the NSABP clinical trials

The present study examines the prognostic significance of tumor location and bowel obstruction in Dukes B and C colorectal cancer. Data were obtained from 1021 patients entered into two randomized prospective clinical trials of the NSABP. Tumor location proved to be a strong prognostic discriminant. Lesions located in the left colon demonstrated the most favorable prognosis. Tumors of the rectosigmoid and rectum had the worst prognosis with the relative risk of treatment failure for the latter being over three fold that of the left colon. When the relative risks associated with tumor location were adjusted for nodal imbalances, the left colon continued to demonstrate the most favorable prognosis. The presence of bowel obstruction also strongly influenced the prognostic outcome. Examination of the data without considering tumor location disclosed that patients with bowel obstruction were at greater risk for treatment failure than those without obstruction. The effect of bowel obstruction was influenced by the location of the tumor. The occurrence of bowel obstruction in the right colon was associated with a significantly diminished disease-free survival, whereas obstruction in the left colon demonstrated no such effect. This phenomenon was independent of nodal status and tumor encirclement, the latter two factors proving to be of prognostic significance independent of tumor obstruction. A multivariate analysis in which the covariate effects of sex, age, nodal status, tumor obstruction, encirclement, and tumor location were adjusted underscored the role of tumor location and obstruction as prognostic discriminants. The results indicate that the definition of prognostic factors can identify patient subsets with unique characteristics.

Hydroxyurea fails to improve the results of MBD chemotherapy in cancer of the head and neck, but reduces toxicity

Thirty-six patients with advanced squamous cancer of the head and neck received chemotherapy with hydroxyurea, 2 g/m2 orally two of three weeks, plus methotrexate, bleomycin, and cisplatin (MBD) on a previously established schedule. Nineteen patients had objective responses, including six complete remissions. Eight of 13 patients with regional disease without prior radiation responded, as did 1 of 3 with distant metastases without prior radiation, and 10 of 20 with recurrent disease after radiotherapy. The median duration of response in those with recurrent or metastatic tumor was 6 months, and median survival was 6.5 months. These results are no better than those previously achieved without the addition of hydroxyurea. Toxicity, however, was milder than had previously been observed with MBD, suggesting that higher doses or more intensive schedules of hydroxyurea could be safely administered together with the other three drugs.

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update

The current findings completely affirm the validity of our original observations indicating the appropriateness of grouping primary breast cancer patients into those with negative, 1 to 3, or greater than or equal to 4 positive nodes. Results, however, reveal that there is a risk in combining all patients with greater than or equal to 4 positive nodes into a single group. Since there was a 25% greater disease-free survival and an 18% greater survival in those with 4 to 6 than in those with greater than or equal to 13 positive axillary nodes, such a unification may provide misleading information regarding patient prognosis, as well as the worth of a therapeutic regimen when compared with another from a putatively similar patient population. Of particular interest were findings relating the conditional probability, i.e., the hazard rate, of a treatment failure or death each year during the 5-year period following operation to nodal involvement with tumor. Whereas the hazard rate for those with negative, or 1 to 3 positive nodes, was relatively low and constant, in those with greater than or equal to 4 positive nodes the risk in the early years was much greater, but by the fifth year it was similar to that occurring when 1-3 nodes were involved, and not much different from negative node patients. The same pattern existed whether 4 to 6 or greater than or equal to 13 nodes were positive. When the current findings are considered relative to other factors with predictive import, it is concluded that nodal status still remains the primary prognostic discriminant.

Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update

The current findings completely affirm the validity of our original observations indicating the appropriateness of grouping primary breast cancer patients into those with negative, 1 to 3, or greater than or equal to 4 positive nodes. Results, however, reveal that there is a risk in combining all patients with greater than or equal to 4 positive nodes into a single group. Since there was a 25% greater disease-free survival and an 18% greater survival in those with 4 to 6 than in those with greater than or equal to 13 positive axillary nodes, such a unification may provide misleading information regarding patient prognosis, as well as the worth of a therapeutic regimen when compared with another from a putatively similar patient population. Of particular interest were findings relating the conditional probability, i.e., the hazard rate, of a treatment failure or death each year during the 5-year period following operation to nodal involvement with tumor. Whereas the hazard rate for those with negative, or 1 to 3 positive nodes, was relatively low and constant, in those with greater than or equal to 4 positive nodes the risk in the early years was much greater, but by the fifth year it was similar to that occurring when 1-3 nodes were involved, and not much different from negative node patients. The same pattern existed whether 4 to 6 or greater than or equal to 13 nodes were positive. When the current findings are considered relative to other factors with predictive import, it is concluded that nodal status still remains the primary prognostic discriminant.

Second malignancies diagnosed in patients receiving chemotherapy at the Pennsylvania Hospital

During the past 15 years, the records of 2,020 patients who received chemotherapy on the surgical oncology, chemotherapy service at the Pennsylvania Hospital were reviewed. Thirty-five patients had pathologically confirmed second independent malignant tumors (not recurrences). The second cancers that developed were varied. The patients who developed these second malignancies ranged in age from 35 to 77 years (24 females, 11 males). The time interval involved was two to 102 months. Nine patients in this group of second malignancies received prior radiation therapy. The following is a list of the second cancers. There were 8 colons, 5 ovaries, 5 lungs, 6 acute myelogenous leukemias, 1 esophagus, 2 bladders, 2 epidermoid carcinomas of the skin, 2 melanomas, 1 chronic lymphatic leukemia, 1 breast cancer, 1 non-Hodgkin's malignant lymphoma, and 1 stomach cancer. The majority of second malignant tumors were amenable to some form of therapy, ie, surgery, radiation or chemotherapy. However, all of the acute myelogenous leukemias were totally refractory to any therapeutic modalities and rapidly expired. The majority of second cancers developed in patients receiving adjuvant chemotherapy. This is a patient population with a much longer expected survival time, particularly when compared to patients receiving chemotherapy for advanced disease. Twenty-five of the 34 second cancers developed in patients who received adjuvant chemotherapy for breast (14) or colorectal (11) cancers. The etiology of the second malignancies is very difficult to determine. However, alkylating agents appeared to be the possible etiologic agent involved in the development of acute myelogenous leukemia.

Gastric cancer-survival at the Pennsylvania Hospital with and without adjuvant chemotherapy

From 1964 to 1974, 122 patients were treated for gastric cancer; none of these patients received chemotherapy; 13 of this group were lost to follow-up. In 34 patients, the disease was too far advanced for surgical resection. Their survival ranged from 0.1 month to 7.5 months with a median survival of 1.1 months. Seventy-four patients were resected for cure; 60 patients underwent a subtotal gastrectomy. Survival ranged from 0 to 72 months with a median of eight months. Fourteen patients had total gastrectomies; survival ranged from 0.1 to 72 months with a median of 5.5 months. Only six of the resected patients had negative lymph nodes; their survival ranged from four to 36 months. In this series there were 11 operative deaths and only seven patients survived five years. Thirty-one patients who had resections were treated with adjuvant chemotherapy consisting of 0.5 g 5-fluorouracil (5-FU) IV on days 1, 8, 15, etc, and hydroxyurea (HU), 80 mg/kg per os (p.o.), on days 4, 11, 18, etc. This group has a range of survival from three to 164 months and a median survival of 25 months. Fifteen consecutive patients with nonresectable gastric cancer were treated with HU-FU with a survival of one to 30 months and a median survival of eight months. In patients with measurable disease, objective regression was clearly demonstrated.

An object representation approach to psychostructural change: a clinical illustration

This paper presents a systematic test-retest analysis of a disturbed, hospitalized adolescent in an attempt to demonstrate recent innovation in Rorschach theory and technique based upon important conceptual and empirical advances in object relations theory. These new perspectives supplement basic ego psychological concepts of test interpretation advanced by Rapaport and test-retest analysis developed by Schafer. The new concepts presented in this paper offer the promise of providing a methodological framework and theoretical foundation for further innovative use of the Rorschach and other projective procedures.

The psychological assessment of object representation

In 1976, Blatt, Brenneis, Schimek, and Glick developed a comprehensive scale for assessing the organization and content of the "concept of the object" in Rorschach responses. Utilizing developmental theory, they developed procedures for assessing the representation of human figures on the Rorschach in terms of the degree of differentiation, articulation, and integration. This analysis of Rorschach responses has proven to be of considerable value in clinical research and has provided empirical data for the study of severe psychopathology. The present paper considers the clinical utility of this conceptual scheme. Five prototypic patients, each representing a particular diagnostic category, were selected for study on the basis of clinical case records. The object representations of the five cases are presented and analyzed in detail, and conclusions are drawn about possible configurations of object representations in different forms of psychopathology. The value of a systematic assessment of object representations for differential diagnosis as well as for the study of change in the psychotherapeutic process is considered. This approach to Rorschach interpretation represents an integration of object relations theory into Rorschach methodology. These new concepts of test assessment and interpretation offer the promise of providing a methodological framework and theoretical foundation for further innovative use of the Rorschach and other projective procedures.

Failure of effective initial chemotherapy to modify the course of stage IV (MO) squamous cancer of the head and neck

Twenty-four patients with advanced squamous cancer of the head and neck without distant metastases were given combination chemotherapy including methotrexate, bleomycin and diamminedichloroplatinum before planned local treatment with irradiation or surgery. Of 22 evaluable patients, 17 had objective partial or complete remission to initial chemotherapy. However, only ten patients ever had complete clearing at any time of all tumor on clinical evaluation. Median survival was ten months, and only two patients remained alive 14 and 29 months, respectively, from entry. Toxicity was minimal with the three-drug treatment, but the addition of mitomycin-C at the start of chemotherapy substantially increased toxicity without improving efficacy. Subsequent surgery and radiotherapy were accomplished without unusual difficulty.

Phase II evaluation of dibromodulcitol, ICRF-159, and maytansine for sarcomas

Patients with objectively measurable soft tissue sarcomas, osteosarcomas, chondrosarcomas, and mesotheliomas were treated with dibromodulcitol (DBD) (180 mg/m2 p.o. days 1-10 q4 wks.). ICRF-159 (300 mg/m2 p.o. tid days 1-3 q4 wks), or maytansine (MAYT) (1.5 mg/m2 I.V. q3 wks.). Forty-five evaluable patients received DBD, 47 MAYT, and 37 ICRF-159. Only patients who had had their histopathologic diagnoses confirmed by a pathology reference panel were included in the final analysis. Two patients had objective partial responses: a patient with osteosarcoma who responded to DBD and a patient with fibrosarcoma who had a partial response of brief duration to ICRF-159. Approximately 70% of the patients treated with each drug were of ECOG performance status 0 or 1, and over half had moderate or worse toxicity. It seems unlikely that these drugs have significant therapeutic activity for common mesenchymal malignancies.

Mitomycin-C, methotrexate, bleomycin and cis-diamminedichloroplatinum II in the chemotherapy of advanced squamous cancer of the head and neck

Thirty-four patients with advanced squamous cancer of the head and neck were treated with an outpatient regimen combining mitomycin-C, cis-diamminedichloroplatinum (II), methotrexate and bleomycin. Five had complete remissions and 15 partial remissions, for an overall response rate of 59%. Responses were noted on 11 of 13 patients (85%) with disease above the clavicles without prior irradiation. Median duration of partial remission was four months. Response rate was independent of age, performance status, presence of distant metastases and primary site. Hematologic toxicity was substantially more severe with this program than had been observed in a prior study using the same regimen without mitomycin-C. Since neither complete nor partial response rates, nor response durations improved with the addition of mitomycin, we conclude that it adds little to the efficacy of the other three agents.

Measurement of glucose concentration in the presence of coreactants with a platinum electrode

An implantable glucose sensor is being developed that is based on the use of a high-area platinum electrode. The sensor is operated in a controlled potential mode, in which the potential of the platinum working electrode versus an unpolarized reference electrode is periodically varied according to a preselected voltage-time regimen. The change in potential is accompanied by a flow of current between the platinum working electrode and a counter-electrode. This current serves to periodically rejuvenate the electrode surface and to provide a signal that is proportional to the glucose concentration. A method for analyzing this signal has been developed, the compensated net charge (CNC) method, that involves integration of the current over one complete potential cycle. This method significantly improves both the sensitivity and selectivity for determining glucose in the presence of the normal physiologic coreactants. For a solution containing glucose, amino acids, and urea, a change in glucose concentration from 50 to 150 mg/dl gives about a 50% change in the net charge. A change in the urea concentration from 20 to 40 mg/dl has no effect on the net charge. A change in the amino acids concentration from 35 to 65 mg/dl has little effect on the net charge above a glucose concentration of about 100 mg/dl. Negligible effects on the net charge have also been found for creatinine (0-1.5 mg/dl) and uric acid (0-4 mg/dl).

Chemotherapy for inoperable, non-small cell bronchogenic carcinoma: EST 2575, generation II

Between 1976 and 1978 the Eastern Cooperative Oncology Group tested ten regimens in 415 patients with histologically documented, inoperable non-small cell bronchogenic carcinoma. Most patients were ambulatory (69%) and had extensive disease (69%). Patients were stratified by cell type: squamous cell carcinoma (SQ), large cell anaplastic carcinoma (LC), or adenocarcinoma (AD). Ineffective single agents (including cell types tested and percent complete and partial responses) were dactinomycin (SQ, 6%), dianhydrogalactitol (SQ, 0), ftorafur (AD and LC, 3%), and piperazinedione (AD and LC, 7%), Ineffective combination regimens included the contemporary standard regimen cyclophosphamide (CYT) plus CCNU (SQ, AD, and LC, 9%), methotrexate plus doxorubicin (ADR) plus CYT plus CCNU (MAC) (SQ and AD, 12%), and mitolactol plus ADR (AD and LC, 8%). When compared to CYT plus CCNU the following regimens demonstrated significant activity: CYT plus bleomycin plus cisplatin (SQ, 23%; P = 0.02) and ADR plus 5-FU plus cisplatin (AD and LC, 24%; P = 0.006). Mitomycin demonstrated marginal activity in squamous cell cancer (19%, P = 0.06). Neither "active" regimen improved survival although responders to any regimen had a significant prolongation of median survival (31.6 vs 15.7 weeks, P = 0.002). The MACC regimen, piperazinedione, and mitomycin were substantially more toxic than the two effective regimens, which were adequately tolerated. Ambulatory performance status, limited disease, and prior surgery were significant positive prognostic variables whereas prior radiation and pretreatment weight loss adversely affected response or survival.

Treatment of primary breast cancer with chemotherapy and tamoxifen

We studied the possibility that the addition of tamoxifen to L-phenylalanine mustard combined with 5-fluorouracil enhances the benefit from the latter two drugs that has been observed in women with primary breast cancer and positive axillary nodes. Recurrence of disease was reduced at two years in patients given the three-drug regimen whose tumor estrogen-receptor levels were greater than or equal to 10 fmol. Among patients greater than or equal to 50 years old treatment failure was significantly reduced (P less than 0.001): by 51 per cent in those with one to three positive nodes and by 64 per cent in those with four or more. Higher receptor levels were associated with a greater probability of disease-free survival. Patients less than or equal to 49 years old were less responsive: those with one to three positive nodes received no benefit from tamoxifen at any receptor level, whereas those with four or more appeared to have reduced treatment failure associated with higher receptor levels. This adjuvant chemotherapy is not indicated in patients less than or equal to 49 years old whose tumor receptor levels are below 10 fmol; there is a suggestion of benefit in patients greater than or equal to 50 years old whose levels are low.

Acute toxicity during adjuvant chemotherapy for breast cancer: the National Surgical Adjuvant Breast and Bowel Project (NSABP) experience from 1717 patients receiving single and multiple agents

Since 1972, the National Surgical Adjuvant Breast and Bowel Project (NSABP) has carried out a series of clinical trials evaluating the worth of adjuvant chemotherapy in the management of patients with primary breast cancer. This report provides information concerning (a) protocol compliance relative to drug administration and (b) acute toxicity encountered by patients in three separate trials who were given one-, two- or three-drug chemotherapy within 1 month of operation. The findings are derived from 1548 women who received 20,765 courses of chemotherapy, the most extensively documented experience yet reported. They indicate that despite the large number of physicians and the heterogeneity of the institutions participating, large cooperative efforts can be accomplished with credibility. Only 13 (0.8%) of the women failed to complete all courses of therapy for reasons directly related to nonprotocol compliance by physicians. Only 4.3% failed to complete therapy for miscellaneous reasons other than toxicity, treatment failure, occurrence of a second primary, or death unrelated to tumor. While almost all patients experienced toxic reactions during the therapy, only 3%--4% of recipients of melphalan (L-PAM; P) and 4%--5% of recipients of L-PAM + 5-FU(F)(PF) failed to complete 2 years of therapy because of toxicity. Of those patients receiving PF + methotrexate (MTX; M) (PMF), 15% did not finish their treatment for that reason. While there was little difference in hematologic and nonhematologic toxicity between those patients receiving P or PF, and such toxicity was generally acceptable to both patients and physicians, the addition of MTX (PMF) resulted in greater toxicity (vomiting, stomatitis, and alopecia) which was less readily accepted. Tolerance of any of these regimens was unrelated to patient age, despite the belief that older women are less tolerant of chemotherapy. The earlier toxicity occurred, the greater was the number of subsequent courses associated with toxicity, and the lower was the total amount of drug received. The extent of the toxicity produced by the NSABP regimens and the end results obtained with them, must be compared with the end results and toxicity obtained by other regimens before making a choice of the adjuvant therapy to be used.

The adjustable Harada-Ito procedure

In four patients with superior oblique palsy, symptomatic excyclotorsion was present without a substantial vertical deviation. Surgery of anteriorizing and lateralizing the anterior fibers of the superior oblique tendon on an adjustable suture was performed (adjustable Harada-Ito procedure). the morning after surgery, adjustment of the suture was made to eliminate the torsional deviation. The suture was loosened when an overcorrection was present and was tightened when an undercorrection was present. Follow-up varied from two to 20 months. All patients remained free of torsional symptoms and no vertical deviation was induced. In addition, the eyes operated on had no limitation of elevation in adduction. The technique allows the surgeon to more exactly adjust the advanced fibers of the superior oblique tendon so as to minimize or eliminate the excyclotorsion and eliminate symptomatic complaints.

Hydroxyurea in stage D carcinoma of the prostate: a pilot study

There was 13 patinets with histologically metastatic prostatic adenocarcinoma treated with a single oral dose of 80 mg. per kg. hydroxyurea every third day (based on ideal or actual weight, whichever is less) and 12.5 mg. chlorotrianisene per day. Toxicity was mild. The most common manifestations were nausea, occasional vomiting leukopenia. A definite attempt was made to depress the white blood count to approximately 2,000 cells per cu. mm. Hydroxyurea was not discontinued unless the white blood count decreased to less that 2,000 cells per cu. mm., after which a single dose was usually omitted. Omission of a single dose would allow the white blood count to return promptly to more than 2,000 cells per cu. mm. Objective tumor regression was demonstrated in 6 of the 13 patients and all patients had a definite improvement in the quality of life.