Brachytherapy for high grade prostate cancer induces distinct changes in circulating CD4 and CD8 T cells - Implications for systemic control

This exploratory study is a follow up to our previous investigation of immune response in the circulation of high-grade Gleason 9 prostate cancer patients treated with EBRT + BT compared to EBRT alone. Notably, EBRT + BT demonstrates the potential to elicit an effect on CD4/CD8 ratio which may have attributed to improved clinical response to therapy. Our findings show promise for leveraging circulating immune cells as predictive biomarkers for radiotherapy response.

Outcomes and complications following non-oncologic total femoral replacement

BACKGROUND

Non-oncologic total femoral replacement (TFR) is utilised as a limb-salvage option in the setting of massive bone loss during revision total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, complication rates, including infection and reoperation, remain a concern.

METHODS

In this study, 16 consecutive TFRs from a single institution with an average clinical follow-up of 4 years were retrospectively reviewed. Indications for TFR, previous surgeries, implants used, complications, reoperations, and ambulatory status at final follow-up were recorded.

RESULTS

The reoperation rate was 50%, and those patients averaged 2 additional surgeries after TFR. The most common reason for reoperation was infection with a 33% incidence of a new periprosthetic infection and an overall infection rate of 44% (7/16). 6/7 were managed with irrigation and debridement and implant retention. Dual-mobility and constrained acetabular liners were used consistently, and no patient experienced a subsequent dislocation. At final follow-up, 81% were ambulatory but only 2 patients (13%) could walk without an assistive device. No patient required amputation.

CONCLUSIONS

While TFR achieved limb salvage in all patients with fair clinical outcomes, patients were at high risk for new or persistent infection and reoperation. Dual-mobility and constrained acetabular liners were effective in preventing dislocation is this cohort.

Reasons for long-term tunneled dialysis catheter use and associated morbidity

OBJECTIVE

Tunneled dialysis catheters (TDCs) are generally used as a temporary means to provide hemodialysis until permanent arteriovenous (AV) access is established. However, some patients may have long-term catheter-based hemodialysis because of the lack of alternatives for other dialysis access. Our objective was to evaluate characteristics of patients with, reasons for, and mortality associated with long-term TDC use.

METHODS

A retrospective single-institution analysis was performed. Long-term TDC use was defined as >180 days without more than a 7-day temporary removal time. Reasons for long-term TDC use and complications were recorded. Summary statistics were performed. Kaplan-Meier analysis compared mortality between patients with long-term TDC use and a comparison cohort who underwent AV access creation with subsequent TDC removal.

RESULTS

We identified 50 patients with long-term TDC use from 2013 to 2018. The average age was 63 years, 44% were male, and 76% were African American. Previous TDC use was found in 42% of patients with subsequent removal after alternative access was established. Median TDC duration was 333 days (range, 185-2029 days). The primary reasons for long-term TDC use were failed (occluded) AV access (34%), nonmaturing AV (nonoccluded) access (32%), delayed AV access placement (14%), no AV access options (10%), patient refusal for AV access placement (6%), and medically high risk for AV access placement (4%). In 46% of patients, TDC complications including central venous stenosis (33.4%), TDC-related infections (29.6%), TDC displacement (27.8%), and thrombosis (7.9%) occurred. Overall, 47.6% required a catheter exchange during the prolonged TDC period. The majority (76.4%) had the catheter removed because of established alternative access during follow-up. The long-term TDC group, in relation to the comparator group (n = 201), had fewer male patients (44% vs 61.2%; P = .028) and higher proportion of congestive heart failure (66% vs 40.3%; P = .001). Kaplan-Meier analysis showed no significant difference in survival at 24 months for the long-term TDC group compared with the comparator group (93.6% vs 92.7%; P = .28).

CONCLUSIONS

Patients with long-term TDCs experienced significant TDC-related morbidity. Whereas permanent access is preferable, some patients may require long-term TDC use because of difficulty in establishing a permanent access, limited access options, and patient preference. There was no difference in survival between the groups.

Aseptic Loosening at the Tibia in Total Knee Arthroplasty: A Function of Cement Mantle Quality?

BACKGROUND

Aseptic loosening remains one of the leading causes for failure of total knee arthroplasty (TKA). We sought to identify early radiographic measures that may associate with aseptic tibial component loosening, emphasizing systematic evaluation of the cement mantle.

METHODS

All TKA revisions from 2007 to 2015 with the primary indication of tibial aseptic loosening were identified using in an institutional implant retrieval database. After exclusion criteria, 61 TKAs comprised the study group. A matched control group of 59 TKAs that had not failed at a minimum of 3 years was identified for comparison. Radiographic analysis on all 6-week postoperative radiographs included angulation of components, cement penetration depth, and presence of radiolucency at the implant-cement and bone-cement interfaces. Groups were compared with Student's t-test, chi-squared test, and Mann-Whitney U-test. A final multivariable logistic regression model was formed for the outcome of aseptic loosening.

RESULTS

On multivariable analysis, failure was associated with a greater number of zones with cement penetration <2 mm (5.6 vs 3.4 zones, odds ratio [OR] 1.89, P < .001), increasing percent involvement of radiolucency at the implant-cement interface (8.7% vs 3.1%, OR = 1.15, P = .001), and increased varus alignment of the tibial component (1.5° vs 0°, OR = 1.35, P = .014). A greater number of zones with a radiolucent line at the bone-cement interface did not significantly associate (1.1 vs 0.3, P = .091).

CONCLUSION

Our results suggest that radiographic indicators of poor cement mantle quality associate with later aseptic loosening. This emphasizes the need for surgeons to perform careful cement technique in order to reduce the risk of TKA failure.

LEVEL OF EVIDENCE

III (Case-control).

A Cost Analysis of Pathology Evaluation of Carotid Plaque after Endarterectomy

BACKGROUND

Overtreatment and overuse of resources are leading causes of rising health care costs. Identification and elimination process of low value services is important in reducing such costs. At many institutions it is routine to send excised plaque after carotid endarterectomy (CEA) for pathology evaluation. With more than 140,000 CEAs performed annually in the United States, this represents an opportunity for potential cost savings. We set out to examine the cost and clinical use of pathology evaluation of plaque after CEA.

METHODS

We performed a retrospective review of patients undergoing CEA at a single institution from 2016 to 2019. Patients were excluded if they had a prolonged postoperative length of stay or if they had a preoperative stroke. Demographics, perioperative outcomes, and billing costs were recorded.

RESULTS

We identified 82 total CEAs, of which 42 were excluded according to the aforementioned exclusion criteria. We reviewed 40 CEAs. Mean age of this cohort was 67.2 (±8.3) years. Most (72.5%) were asymptomatic at the time of admission, whereas 27.5% presented with a transient ischemic attack. Mean postoperative length of stay was 1.8 days. The primary insurers were 39.5% private, 39.5% Medicare, and 21.1% Medicaid. Mean total charges for the hospitalization were $83,367 (±$42,874). Of this total, professional fees were $3,512 (±$980) and facility fees were $80,395 (±$42,886). Mean pathology charges were $285 (±$88). The pathology professional fee was $61 (±$27), which represented 1.82% (±0.88) of the professional costs. Reimbursement for the facility pathology charge was $229 (±$57) and for the professional pathology charge was $25 (±$14). All plaque samples were submitted for gross examination and hematoxylin and eosin staining. The correlation rate for the clinical and pathologic diagnosis was 100%. The pathology reports simply read "atherosclerotic plaque" and "calcific plaque" in 32.5% and 45% of samples. For the remaining plaques, 12.5% and 10% of reports also noted fibrosis and degenerative changes, respectively. There were no clinical implications or decisions made based on the pathology reports. Cost of pathology evaluation was on average $285, with an average reimbursement of $235. With 140,000 CEAs done annually, this represents a potential $32.9-$39.9 million saved to the health care system.

CONCLUSIONS

Pathology evaluation of carotid plaque incurs significant costs to the health care system with no clear value for the postoperative care of the patient. Hospital policy regarding mandatory pathologic examination and surgeon preferences regarding plaque analysis should be more closely examined.

Salvage Re-irradiation With Single-modality Interstitial Brachytherapy for the Treatment of Recurrent Gynaecological Tumours in the Pelvis: A Multi-institutional Study

AIMS

Recurrent gynaecological tumours can cause significant morbidity with limited salvage options. This study investigates the strategy of salvage single-modality interstitial brachytherapy (SM-ISBT) for recurrent gynaecological pelvic cancer at two specialised ISBT centres.

MATERIALS AND METHODS

Patients who had received salvage SM-ISBT for pelvic recurrence of gynaecological cancers from September 2008 to January 2017 were included. None had distant metastasis at the time of recurrence. Local control, progression-free and overall survival and long-term toxicities were evaluated.

RESULTS

Twenty-six patients with a median follow-up of 24 months (range 2.5-106.3 months) after SM-ISBT were included. Primary cancer sites were endometrium (20), cervix (4), vulva (1) and vagina (1). All patients had prior whole-pelvic external beam irradiation and 16 had prior brachytherapy. The median disease-free survival prior to SM-ISBT was 20.3 months (interquartile range 9.9-30.5). SM-ISBT was delivered with high dose rate technique over three to six fractions. The median high-risk clinical target volume was 34.6 cm³, with a median D90 of 29.1 Gy (range 16.1-64.6). The median bladder, rectum and sigmoid D2cm³ were 15.5, 18.7 and 3.7 Gy, respectively. After SM-ISBT, complete and partial responses were achieved in 17 (64%) and 5 (19%) patients, respectively. Two (7.4%) patients had grade 3 toxicities (both vaginal stenosis), with no grade 4 complications. Eighteen patients (69%) recurred, including local, regional and metastatic in 14 (54%), 8 (30%) and 5 (19%) patients, respectively. Two-year local control, progression-free survival and overall survival were 50, 38 and 78%, respectively. In follow-up, 12 patients (46%) remained in local control.

CONCLUSIONS

Salvage SM-ISBT re-irradiation for pelvic recurrence of gynaecological malignancies was feasible and safe. With limited salvage options, the local control obtained in more than a quarter of patients seems reasonable. Further efforts are needed to establish a consensus about the optimal patient selection, dose fractionation, implant technique and combination with systemic therapies.

Quantitative spectral analysis of EEG in psychiatry revisited: drawing signs out of numbers in a clinical setting

OBJECTIVE

To evaluate the incidence, sensitivity and specificity of abnormal quantitative EEG (QEEG) measures in normal subjects and patients with mental disorders.

METHODS

Normalized QEEG measures were blindly assessed in 67 normal human beings and 340 psychiatric patients. QEEG results were correlated to subject condition or diagnosis and magnetic resonance imaging (MRI) findings.

RESULTS

QEEG was abnormal in 83% of patients, and 12% of normal subjects. The most frequent abnormality was a decrease in slow (delta and/or theta) bands, either alone, with beta increase, or with alpha decrease, followed by increase in beta band. No normal subject showed delta and/or theta decrease. Slow band decrease was more frequent in depression and mental disorders due to general medical condition, alcohol and drug dependence. However, no pattern was specific of any entity, and patients within the same diagnostic may present different patterns. Delta-theta decrease was correlated with cortical atrophy as seen in MRI. Beta increase was correlated with psychoactive medication. No association was found between any other QEEG pattern and MRI abnormalities, or medication.

CONCLUSIONS

Decrease in the delta and theta bands of the QEEG can be regarded as a specific sign of brain dysfunction, and is correlated with cortical atrophy. However, this sign, as other QEEG abnormal patterns, can be found in many different disorders and none of them can be considered as pathognomonic of any specific disorder.

SIGNIFICANCE

This work attempted to circumvent the alleged lack of Class I evidence of QEEG utility in the study of psychiatric patients by means of a prospective, blinded study, searching for specific signs of physiopathology in individual patients.

Optimization and application of SPME for the gas chromatographic determination of endosulfan and its major metabolites in the ng L(-1) range in aqueous solutions

In the present study an analytical method was optimized for the determination of alpha-endosulfan, beta-endosulfan, endosulfan sulfate, endosulfan ether and endosulfan lactone in small volumes of environmental aqueous samples using solid-phase microextraction (SPME) and gas chromatography-electron capture detection (GC-ECD). A 100 micro m polydimethylsiloxane (PDMS) phase was used for the extraction. The limit of detection (LOD) for the analytes varied between 0.01 and 0.03 micro g L(-1) with a relative standard deviation of 3 to 11%. The influence of the ionic strength on the extraction efficiency was investigated for the individual compounds. alpha-Endosulfan, beta-endosulfan, endosulfan sulfate and endosulfan ether were extracted successfully without salt addition. The extraction efficiency of endosulfan lactone was improved with 30% NaCl content. A general decrease in extraction efficiency for alpha-endosulfan, beta-endosulfan, endosulfan sulfate and endosulfan ether with high NaCl content (20-30%) in the solution was observed due to glass surface adsorption. No effect of dissolved organic material (DOM) on the extraction efficiency was observed. The extraction coefficients changed between Log K=2.17 and 3.33. A sample from the Antarctic region was analyzed using the optimized GC-ECD/SPME method. To confirm the results obtained for the real sample a GC with a mass spectrometer (MS) was used. Endosulfan sulfate, the most toxic metabolite of endosulfan, was found in the sample at a concentration of 0.3 micro g L(-1).

A high statistics measurement of the Lambda(+)(c) lifetime

A high statistics measurement of the Lambda(+)(c) lifetime from the Fermilab fixed-target FOCUS photoproduction experiment is presented. We describe the analysis technique with particular attention to the determination of the systematic uncertainty. The measured value of 204.6 +/- 3.4 (stat) +/- 2.5 (syst) fs from 8034 +/- 122 Lambda(+)(c)-->pK(-)pi(+) decays represents a significant improvement over the present world average.

Search for CP violation in the decays D+--> K(S)pi+ and D+-->K(S)K+

A high-statistics sample of photoproduced charm from the FOCUS experiment has been used to search for direct CP violation in the decay rates for D+-->K(S)pi+ and D+-->K(S)K+. We have measured the following asymmetry parameters relative to D+-->K-pi+pi+: A(CP)(K(S)pi+) = (-1.6+/-1.5+/-0.9)%, A(CP)(K(S)K+) = (+6.9+/-6.0+/-1.5)%, and A(CP)(K(S)K+) = (+7.1+/-6.1+/-1.2)% relative to D+-->K(S)pi+. We have also measured the relative branching ratios and found Gamma(D+-->K(0)pi+)/Gamma(D+-->K-pi+pi+) = (30.60+/-0.46+/-0.32)%, Gamma(D+-->K(0)K+)/Gamma(D+-->K-pi+pi+) = (6.04+/-0.35+/-0.30)%, and Gamma(D+-->K(0)K+)/Gamma(D+-->K(0)pi+) = (19.96+/-1.19+/-0.96)%.

Measurement of the branching ratios of D(+) and D(+)(s) hadronic decays to four-body final states containing a K(S)

We have studied hadronic four-body decays of D(+) and D(+)(s) mesons with a K(S) in the final state using data recorded during the 1996-1997 fixed-target run of the Fermilab high energy photoproduction experiment FOCUS. We report a new branching ratio measurement of gamma(D(+)-->K(S)K-pi(+)pi(+))/gamma(D(+)-->K(S)pi(+)pi(+)pi(-)) = 0.0768+/-0.0041+/-0.0032. We make the first observation of three new decay modes with branching ratios gamma(D(+)-->K(S)K+pi(+)pi(-))/gamma(D(+)-->K(S)pi(+)pi(+)pi(-)) = 0.0562+/-0.0039+/-0.0040, gamma(D(+)-->K(S)K+K-pi(+))/gamma(D(+)-->K(S)pi(+)pi(+)pi(-)) = 0.0077+/-0.0015+/-0.0009, and gamma(D(+)(s)-->K(S)K+pi(+)pi(-))/gamma(D(+)(s)-->K(S)K-pi(+)pi(+)) = 0.586+/-0.052+/-0.043, where in each case the first error is statistical and the second error is systematic.

Study of the decay D0 --> K+pi-

Using a large sample of photoproduced charm mesons from the FOCUS experiment at Fermilab (FNAL-E831), we observe the decay D0-->K+pi- with a signal yield of 149+/-31 events compared to a similarly cut sample consisting of 36 760+/-195 D0-->K-pi+ events. We use the observed ratio of D0-->K+pi- to D0-->K-pi+ (0.404+/-0.085+/-0.025)% to obtain a relationship between the D0 mixing and doubly Cabibbo suppressed decay parameters.

Low colorectal anastomosis after radical pelvic surgery: a risk factor analysis

OBJECTIVE

This study was conducted to analyze our experience with low (8-12 cm above the anal verge) and very low (<6 cm above the anal verge) colorectal resection and primary anastomosis at the time of radical en bloc resection of pelvic malignancies.

STUDY DESIGN

A retrospective review of 77 patients undergoing supralevator pelvic exenteration with low colorectal resection and primary anastomosis in our gynecologic oncology service was carried out. Data were obtained from patient medical records and from the tumor registry. Univariate statistical analysis of the data was used.

RESULTS

The distribution of primary malignancies in this cohort was as follows: 33 (43%) recurrent or primary cervical carcinomas, 27 (35%) primary or recurrent ovarian carcinomas, 7 (9%) recurrent vaginal carcinomas, 4 (5%) endometrial carcinomas, 3 (4%) colon carcinomas, and 3 (4%) cases of stage IV endometriosis. Forty patients underwent total pelvic exenteration, and 37 patients underwent posterior exenteration. Thirty-six patients in the total pelvic exenteration group had a history of pelvic irradiation. Twelve (30%) of these patients had development of breakdown or fistulas of the anastomosis. Six of the 12 patients (50%) had undergone protective colostomy. Thirty-seven patients underwent posterior exenteration with primary anastomosis for ovarian cancer, endometrial cancer, colon cancer, or endometriosis, and only 1 of these had received pelvic irradiation. This patient did not have a protective colostomy, and a rectovaginal fistula developed. In addition, there were 3 other breakdowns in the posterior exenteration group. Finally, the presence of preoperative ascites did not appear to alter the breakdown rate of the anastomosis among the patients with ovarian cancer who underwent cytoreductive surgery.

CONCLUSION

Radical resection of pelvic tissue remains a crucial part of the armamentarium of the gynecologic oncologist. Previous pelvic irradiation appears to be a major risk factor (35% vs 7.5%) for anastomotic breakdown and fistulas, independent of the presence of a protective colostomy. The overall results appear to be better for patients undergoing this procedure as part of a posterior exenteration.

Hyperfractionated radiotherapy concomitant with cisplatin and granulocyte colony-stimulating factor (filgrastim) for laryngeal carcinoma

An open-label, non-randomized study evaluated the feasibility and efficacy of filgrastim (recombinant methionyl human granulocyte colony-stimulating factor, r-metHuG-CSF) to prevent mucositis induced by accelerated hyperfractionated radiotherapy (1.6 Gy b.i.d., total dose 67.2 Gy in six weeks with a two-week split) and concomitant chemotherapy (cisplatin, 20 mg/m2/day, days 1-5 by continuous intravenous infusion) in patients with laryngeal carcinoma. Filgrastim 300 microg/day was administered on days 1, 3, and 5 in weeks 2-6 of radiotherapy, after the second fraction. Twenty patients (three stage II, six stage III, and eleven stage IV, according to AJCC) were enrolled in the trial. Oral mucosal toxicity was grade 2 in nine patients (45%), grade 3 in eight (40%), and grade 4 in three (15%). Severe hematological toxicity (WHO criteria) was uncommon. Nineteen patients (95%) completed the treatment in the planned time. Overall survival was 55% at three years. The administration of filgrastim with this regimen was feasible, and it appeared to reduce the severity and duration of mucositis induced by the combined treatment.

Antitumor activity of a novel glyco-nitric oxide conjugate in ovarian carcinoma

BACKGROUND

Several studies have shown that nitric oxide (NO)-releasing agents can kill tumor cells. Unfortunately, currently available NO delivery molecules do not target tumor cells preferentially. To exploit the overexpression of glucose transport proteins and the high level of glucose transport characteristics of tumor cells, glucose was conjugated to S-nitroso-N-acetyl-penicillamine (2-gluSNAP) and evaluated for cytotoxicity in human ovarian carcinoma cells.

METHODS

The cytotoxicity of 2-gluSNAP and SNAP was assessed by clonogenic cell survival assays performed in A2780S (cisplatin sensitive) and A2780cP (cisplatin-resistant) ovarian carcinoma cells in vitro. Immunoblotting and immunohistochemistry were used to assess the expression of Glut-1 hexose transport protein in the cell lines as well as in paraffin blocks from 28 surgical specimens of epithelial ovarian carcinoma. Apoptosis was assessed by an end-labeling assay.

RESULTS

The ovarian carcinoma cell lines consistently were more sensitive to 2-gluSNAP than SNAP alone. The median effective doses (MEDs) for 2-gluSNAP and SNAP in the A2780s cell line were 0.0042 microM and 20.4 microM, respectively. Therefore, 2-GluSNAP was nearly 5000-fold more potent than the NO-donating moiety (SNAP) alone. In the A2780cP cells, the MED for 2-gluSNAP (0.38 microM) was 250-fold lower than that for SNAP alone (100 microM). Immunoblotting and immunohistochemistry studies showed overexpression of Glut-1 in the cell lines and in 23 of 28 epithelial ovarian carcinoma specimens.

CONCLUSIONS

The novel glyco-NO conjugate 2-gluSNAP exhibits a much greater cytotoxicity than the parent NO donor without the hexose moiety. These agents have the potential to target tumor cells preferentially, that overexpress Glut-1. This transporter is expressed highly in epithelial ovarian carcinoma.

Age-related loss of proliferative activity of human vascular smooth muscle cells in culture

This work studied the proliferation activity in cultures of vascular smooth muscle cells (SMC) from individuals of different ages. The cells derived from arteries of 12 donors of both sexes from 45 to 91 years of age. The main parameter considered was the 'proliferation rate' (cells grown per day in the different culture passages) taking into account the age of the donor. No significant relationship between age of the donor and the cell life in proliferation was found. On the contrary, the mean time of passage duration for reaching the maximum of proliferation as well as its 'efficiency' (maximum of proliferation rate registered/mean time of passage duration) show a statistically significant dependence on the age of the donor. Furthermore, the proliferation rate measured in each passage is statistically significant related to donor age. The regressions obtained show a similar negative slope (VC 4%). Considering the first five culture passages, the regression crosses the x-axis at the age of 105.6+/-11.7 years. This age in which no proliferative activity of human SMC would be expected lies near the limit of maximum life potential for human beings. Our results suggest that with advancing donor age there is an increasing number of senescent SMC either primarily transferred or appeared in the culture. Vascular SMC of individuals whose life is near the end would almost be all senescent and therefore show extremely low proliferation rates in the culture. If the proliferative activity of arterial SMC is a condition for atherogenesis, the proportion of senescent cells would be inversely related to the propensity of developing the atheroma because of the inability of these cells to divide.

Radical hysterectomy for cervical cancer: hysterectomy before pelvic lymphadenectomy or vice versa?

The technique for radical abdominal hysterectomy (RAH) and lymphadenectomy (LND) for patients with cervical cancer has been well described. Whether RAH should be performed before or after pelvic lymph node dissection (PLND) is a controversial issue. This study compared the two procedures performed at the same institution. Patients treated with type III RAH for cervical cancer stage IB-IIA at our institution between 1987 and 1995 were included in this study. Only patients who underwent para-aortic lymph node dissection (PALND) first, followed by PLND and then RAH (Group A) or RAH and then PLND (Group B) were included. Clinical and surgical information including intraoperative and postoperative complications was collected. Operative reports were used to identify the patients who had RAH performed before PLND or vice versa. Data analysis was obtained using unpaired t-test with significance set at P < 0.05. Complete information was obtained for 314 patients. The results of Group A (157 patients) and Group B (157 patients) were as follows: mean age = 45.3 and 44.8 (P = 0.73); mean weight = 149 and 149 lb.; mean length of stay = 10 and 8 days (P < 0.0001); mean operative time = 230 and 172 mins (P = 0.004); mean estimated blood loss (EBL) = 1,238 and 1098 cc (P = 0.21); mean number of PALN removed = 7 and 6 (P = 0.06); mean number of PLN removed = 28 and 26 (P = 0.24). No statistical difference in major intraoperative and postoperative complications was observed. The most common complication was postoperative fever (53/157 in Group A and 49/157 in Group B). Radical hysterectomy can be safely performed either before or after PLND. The number of pelvic lymph nodes removed, as well as the EBL and the intraoperative complications are similar and are not affected by the operative time. The surgeon should decide the sequence of the procedures accordingly to his/her personal preference.

Thalidomide-resistant HIV-associated aphthae successfully treated with granulocyte colony-stimulating factor

Thalidomide has been advocated as the treatment of choice for recalcitrant aphthae. We describe the case of patient with HIV infection and extensive aphthae whose condition failed to respond to corticosteroids, cyclosporine, and thalidomide. The patient's course was complicated by colonic aphthae. Rapid and sustained resolution was achieved through treatment with granulocyte colony-stimulating factor, a previously unreported therapeutic option.

Recall of informed consent after endoscopic procedures

PURPOSE

The aim of this study was to determine if recall of informed consent is affected by the timing of obtaining informed consent before endoscopic procedures.

METHODS

Sixty patients scheduled for colonoscopy or esophagogastroduodenoscopy were enrolled in this prospective, randomized study. Each patient received informed consent 24 to 72 hours or immediately before the procedure, and follow-up occurred one to three days postprocedure.

RESULTS

There was no statistically significant difference in recall of informed consent or the individual elements of informed consent (indication, risks, benefits, alternatives) between the two groups.

CONCLUSION

Recall of informed consent is similar whether consent is obtained immediately or several days before endoscopic procedures.

Laser lithotripsy of difficult bile duct stones by means of a rhodamine-6G laser and an integrated automatic stone-tissue detection system

This report describes the initial clinical implementation of a new laser lithotripter system capable of effective fragmentation of common bile duct stones with a high degree of safety provided by an integrated stone-tissue detection system. This system automatically terminates laser pulse transmission if tissue contact is sensed. Eighteen patients with giant or impacted common bile duct stones refractory to standard treatment techniques were treated via the endoscopic retrograde route using a rhodamine-6G dye laser with an integrated stone-tissue detection system. In the event of tissue contact, the stone-tissue detection system cuts off the laser pulse after 190 ns (after transmission of 5% to 8% of the total pulse energy). Nine patients were treated under cholangioscopic control, and nine patients were treated blindly under fluoroscopic control using only standard duodenoscopes with either a 6F standard endoscopic retrograde cholangiopancreatography catheter (4 patients), a 6.8F balloon catheter (3 patients), or a laser lithotriptor basket (2 patients). Laser-induced fragmentation was achieved in all 18 patients (100%). Sixteen of 18 patients (89%) became completely stone-free after completion of the treatment, including additional intracorporeal shock wave lithotripsy in five patients. The only major complications occurred in one fully anticoagulated patient with a prosthetic heart valve who developed significant hemobilia and transient cholangitis but recovered after conservative treatment. Laser lithotripsy using the rhodamine-6G dye laser plus stone-tissue detection system appears safe and effective and allows "blind" fragmentation of difficult common bile duct stones to be performed under radiologic control.

Familial IgA nephropathy associated with bilateral sensorineural deafness

Alport's syndrome is the most frequent disorder with familial nephritis and deafness, but other types of nephropathy have been occasionally associated with hereditary hearing loss. The familial occurrence of IgA nephropathy has been well documented. We report a family with hereditary, bilateral, sensorineural deafness spanning four generations. Three of five members with deafness had microscopic hematuria. Renal histology of the two deaf members undergoing biopsy showed mesangial glomerulonephritis with mesangial IgA deposits, without ultrastructural abnormalities of the glomerular basement membranes. Familial nephritis with deafness should not be equated with the diagnosis of Alport's syndrome.

Prevalence of antibodies to hepatitis C virus among patients with cryptogenic chronic hepatitis and cirrhosis

Many cases of chronic hepatitis and cirrhosis cannot be attributed to a known cause and are collectively referred to as cryptogenic chronic liver disease. We have evaluated the role of the hepatitis C virus in the pathogenesis of this condition in a retrospective serum analysis for antibody to hepatitis C virus in 129 patients with cryptogenic liver disease. Other causes of chronic hepatitis and cirrhosis were ruled out by clinical, serum biochemical and serological techniques. All 129 patients were HBcAg negative, but 28 (22%) had antibody to HBcAg. Sera were tested by radioimmunoassays using recombinant peptides for antibodies to nonstructural (C100-3 and C33c) and structural regions (C22) of HCV. Among the 129 patients, 61 (47%) had antibody to C100-3, 76 (59%) had antibody to C33c and 74 (57%) had antibody to C22. Seventy-nine (61%) were reactive with at least one and 76 (59%) were reactive with at least two HCV peptides (this is the criterion used for hepatitis C virus antibody reactivity). A proportion of patients with chronic hepatitis and cirrhosis (55 of 91; 60%) similar to that of patients without cirrhosis (21 of 38; 55%) had hepatitis C virus antibody. No significant clinical, serum biochemical or histological differences were noted between the group of patients with hepatitis C virus antibody and those without this antibody reactivity. Thus more than half the patients with cryptogenic chronic liver disease had hepatitis C virus antibody, suggesting that chronic HCV infection plays a major role in the origin of cryptogenic chronic hepatitis and cirrhosis.

Fulminant hepatic failure due to acute hepatitis B and delta co-infection: probable bloodborne transmission associated with a spring-loaded fingerstick device

Fulminant hepatic failure (FHF) due to acute hepatitis B and delta co-infection occurred in a 74-yr-old female, who eventually died. There was no clear-cut epidemiology other than probable bloodborne transmission from a contaminated spring-loaded fingerstick device used for glucose determination, in an outpatient facility. This unusual mode of transmission reiterates the importance of using sterile cleansing and disposal procedures anytime there is a possibility of contamination with blood.

Swallowing disorders in the elderly

The classic symptoms of dysphagia, heartburn, and chest pain are the presenting manifestation of oropharyngeal and esophageal disorders in the elderly as well as the young. Several unique conditions, including Zenker's diverticulum and vascular compression of the esophagus, may occur in the elderly. Certain disorders, such as oropharyngeal dysphagia due to neurologic disorder, increase in frequency with age. Treatment approaches are similar in elderly and younger patients, but the potential for adverse drug effects and interaction is greater in the elderly than in the young.

Seronegative rheumatoid arthritis, rheumatoid factor cross reactive idiotype expression, and hidden rheumatoid factors

The major rheumatoid factor cross reactive idiotype (RCRI), defined by prototypic monoclonal rheumatoid factors (RFs), is expressed as a dominant idiotype by pokeweed mitogen induced plasma cells obtained from seropositive (RF+) patients with rheumatoid arthritis (RA). Some patients who meet clinical diagnostic criteria for RA set by the American Rheumatism Association fail to express RFs at any time during their clinical course. To determine if seronegative (RF-) patients with RA, so designated by the latex fixation, Rose-Waaler classic binding assays, or a RF enzyme linked immunosorbent assay (ELISA), express the RCRI in the absence of detectable RFs we examined pokeweed mitogen plasma cells from these patients by indirect immunofluorescence. In addition, we used an inhibition ELISA to detect RCRI bearing molecules in the sera of RF- patients with RA. Five of 10 RF- patients with RA had a high prevalence of RCRI+ plasma cells (16-49% of total pokeweed mitogen plasma cells in culture). Six of 20 RF- patients with RA had high serum concentrations of molecules marked by the RCRI, equivalent to 21-110 micrograms/ml of RCRI+ reference monoclonal IgM RF. Four of five patients who expressed the RCRI in high prevalence in pokeweed mitogen plasma cells, also demonstrated high concentrations of RCRI in their sera detected by inhibition ELISA. There was significant concordance of RCRI expression determined by the two different assays. Four RF- patients with RA who expressed RCRI in their whole sera had hidden RFs detected in their 19S and, in one case, 7S serum fraction. Detection of RF related molecules in whole sera by the expression of RCRI in RF- patients with RA identifies a subgroup of RF- patients with RA who possess hidden RFs. Some RF- patients with RA can express the major RCRI in pokeweed mitogen plasma cells and in their sera and therefore are related to patients with prototypic Waldenstrom's macroglobulinaemia, who produce RCRI+ 19S IgM monoclonal RFs.

Monomeric (7S) IgM found in the serum of rheumatoid arthritis patients share idiotypes with pentameric (19S) monoclonal rheumatoid factors

Serum from some seropositive (RF+) rheumatoid arthritis (RA) patients contains relatively high concentrations of monomeric (7S) IgM molecules. Seven S IgM molecules fail to bind the Fc portion of IgG, unlike 19S IgM RFs that bind aggregated IgG in classical RF assays. Some pentameric IgM RFs are marked by crossreactive idiotypes (RCRI) defined by prototypic monoclonal RFs. In previous studies, we observed that a proportion of pokeweed mitogen (PWM) induced plasma cells from RA patients' blood lymphocytes express the major RCRI as assayed by indirect immunofluorescence with polyclonal anti-RCRI antibodies. In this study, 7S IgM obtained from three different RF+ RA patients inhibits specific anti-RCRI intracytoplasmic staining of PWM induced RF+ RA-derived plasma cells. These 7S molecules also block polyclonal anti-RCRI antibodies from reacting with red blood cells bearing 7S IgM molecules from RF+ patients with RA or Waldenstrom's macroglobulinemia. We conclude that some 7S IgM molecules in the serum of RF+ RA patients are marked by the major RCRI idiotype and are related to 19S monoclonal and polyclonal RFs.

Morphologic features of hepatic injury in cardiac disease and shock

One-hundred-forty postmortem liver specimens from patients with cardiac disease or pre-terminal hypotensive shock were examined in order to characterize the histopathologic features of ischemic and congestive hepatic disease. The study group included patients with arteriosclerotic, valvular or hypertensive heart disease, primary pulmonary disease with cor pulmonale, myocarditis, cardiomyopathy, and shock. The hepatic lesions included centrilobular congestion alone (10%), congestion with necrosis (77%), centrilobular necrosis with inflammatory reaction (neutrophil or mononuclear cell) (27%), cardiac sclerosis (48%) and regenerative hyperplasia (23%). Cardiac sclerosis, the most common form of hepatic fibrosis seen, consisted of eccentric thickening or occlusion of the walls of central veins and perivenular scars extending into the lobular parenchyma. Regeneration of liver cells was manifested by either liver-cell plate thickening within a retained cord-like framework or by nodular masses of hepatocytes (nodular regenerative hyperplasia). Only one case of developing cirrhosis was identified in this series. The morphologic features outlined in this study should provide a useful basis for the classification of liver injury in cardiac disease and shock.

Site specific cleavage of phi X-174 replicative form DNA after modification by N-acetoxy-N-2-acetylaminofluorene

Three kinds of structural disturbances were found in an 88 base pair (bp) fragment of phi X-174 DNA after exposure to N-acetoxy-N-2-acetylaminofluorene (N-Aco-AAF). (i) Frequent strand scissions at two specific guanine sites on the 5' 32P-end-labeled fragment were identified by base sequence analysis. Scissions at these two sites were induced at neutral pH and they were not increased by treatment with apurinic endonuclease. They are an immediate consequence of N-Aco-AAF action and are not primarily apurinic sites. (ii) Alkali treatment with 1 M piperidine at 90 degrees C induced strand scissions at every guanine, demonstrating adduct slices, depurination and strand scissions. (iii) Adducted DNA was sensitive to single-strand specific nuclease digestion, suggesting unwound DNA. These studies indicate the prediliction of N-Aco-AAF for certain DNA sites and they suggest three kinds of DNA modifications which can be expected after adduction by this carcinogen. Some of the sites may be premutational carcinogen-induced DNA structural modifications.