[SIGNIFICANCE OF IgG4 IN IDIOPATHIC RETROPERITONEAL FIBROSIS]

(Objective)Retroperitoneal fibrosis is largely divided into the idiopathic and secondary types. Some idiopathic cases include IgG4-related diseases, which are often similar to malignant diseases, such as lymphoma and sarcoma. The diagnostic criteria for IgG4-related disease are used and pathologic examination is necessary for a definitive diagnosis of IgG4-related retroperitoneal fibrosis. The first choice of treatment for IgG4-related retroperitoneal fibrosis is steroid administration, but no consensus has been established regarding its dose and tapering schedule. We investigated the significance of IgG4 in diagnosis and treatment of idiopathic retroperitoneal fibrosis. (Patients and methods)We examined 14 cases diagnosed as idiopathic retroperitoneal fibrosis between April 2013 and March 2019. Serum IgG4 was measured at the time of diagnosis in 13 cases, and changes over time in serum IgG4 before and after the induction of steroid therapy were measured in 6 cases. Computed tomography-guided biopsy was performed on 4 cases. (Results)Of all cases, 1 patient was diagnosed as IgG4-related retroperitoneal fibrosis and 5 patients were classified as possible group. Ten patients were administered steroid therapy. Percutaneous nephrostomy tube was placed in 3 patients and was removed in 2 of these patients after steroid therapy. The serum high levels of IgG4 were confirmed in all 4 patients who were classified into the possible group and who were treated with steroids. (Conclusion)Although histologic examination is necessary for the diagnosis of retroperitoneal fibrosis, tissue collection by open or laparoscopic surgery is highly invasive. CT-guided biopsy may be useful in high-risk cases, such as elderly patients on anticoagulation. After excluding other diseases in high-risk cases, response to empiric steroid therapy may be diagnostic. In the possible group, changes in serum IgG4 levels may reflect the disease condition and might be useful in determining the maintenance dose of steroids.

Acid rain footprint three decades after peak deposition: Long-term recovery from pollutant sulphate in the Uhlirska catchment (Czech Republic)

The granitic Uhlirska headwater catchment with a size of 1.78km² is located in the Jizera Mountains in the northern Czech Republic and received among the highest inputs of anthropogenic acid depositions in Europe. An analysis of sulphate (SO₄^2-) distribution in deposition, soil water, stream water and groundwater compartments allowed to establish a SO₄^2- mass-balance (deposition input minus surface water export) and helped to evaluate which changes occurred since the last evaluation of the catchment in 1997. The determined SO₄^2- concentrations decreased in the following order: wetland groundwater>groundwater from 20m below ground level (bgl)>groundwater from 30m bgl>stream water>groundwater from10m bgl>hillslope soil water>wetland soil water>bulk deposition with median values of 0.24, 0.21, 0.17, 0.15, 0.11, 0.07, 0.03 and 0.01mmolL^-1, respectively. Our results show that average deposition reductions of 62% did not result in equal changes of the sulphate mass-balance, which changed by only 47%. This difference occurs because sulphate originates from internal sources such as the groundwater and soil water. The Uhlirska catchment is subject to delayed recovery from anthropogenic acid depositions and remains a net source of stored sulphur even after three decades of declining inputs. The wetland groundwater and soil water provide environmental memories of legacy pollutant sulphate. Elevated stream water sulphate concentrations after the unusually dry summer 2015 imply importance of weather and climate patterns for future recovery from acidification.

Synthesis of N-succinyl-L,L-diaminopimelic acid mimetics via selective protection

The search for potential inhibitors that target so far unexplored bacterial enzyme mono-N-succinyl-L,L-diaminopimelic acid desuccinylase (DapE) has stimulated a development of methodology for quick and efficient preparation of mono-N-acylated 2,6-diaminopimelic acid (DAP) derivatives bearing the different carboxyl groups or lipophilic moieties on their amino group.

Movement of bromacil in a Hawaii soil under pineapple cultivation - a field study

Recent discovery of low concentrations of bromacil in drinking water prompted the State of Hawaii to examine the leaching behavior of bromacil in pineapple fields. This study is a follow up to earlier work on bromacil concentrations in soil profiles in a pineapple field in central Oahu, Hawaii. Soil samples were collected for bromacil analysis at different times prior to and after application from a pineapple field that was previously surveyed by other research workers. The leaching pattern of bromacil was further investigated at two different application rates (2.25 and 1.8 kg ha(-1)). The concentration of bromacil in the topsoil about 100 days after bromacil application (1.8 kg ha(-1)) was substantially higher in 2002 compared to 1999. The distribution profiles were generally consistent with the one presented in the previous study. Residual bromacil was present in the entire sampled zone (3m deep) about 18 months after the previous bromacil application. Over a period of 9 months, there was substantial dissipation of bromacil residue present in the topsoil. The residual concentration of bromacil in the area that received the reduced application rate (1.8 kg ha(-1)) were lower than those receiving the current application rate (2.25 kg ha(-1)) and the depth of penetration of the bromacil front was shallower at the reduced application rate. Because of the common practice of placing plastic mulch around the base of the pineapple plants to retain volatile nematicides, the applied bromacil was found to be concentrated in the areas between the plastic mulch, transported by runoff from the plastic. The study results encourage the use of less than the label led rate of application of bromacil for pineapple fields.

Analysis of hormonal receptor status in tissue from prostate cancer that developed 26 years after bilateral orchiectomy and following 41 years of estrogen therapy

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Background: The development of prostate cancer in the absence of normal male testosterone levels and in the presence of elevated estrogen levels is rare and poorly understood. Methods: The androgen, estrogen and progesterone receptors were evaluated in prostate cancer tissue from a 60-year-old, long-term transgender woman. Her serum hormone levels were assessed and the prostate specific antigen (PSA) level was followed during hormonal and radiation treatment. This patient began estrogen therapy at age 19 and underwent bilateral orchiectomy at age 34 during gender re-assignment surgery. Work-up for gross hematuria revealed a Gleason 8, locally advanced prostate cancer. Results: The tumor showed abundant staining for androgen receptors (AR), with a nuclear pattern consistent with hormone refractory prostate cancer. The tumor did not stain for estrogen receptors (ER) or progesterone receptors (PR). Compared to reference values for men, this transgender woman had low serum testosterone (44 ng/dl) and free testosterone (0.9 pg/mL) levels and elevated estradiol (53 pg/mL) and estrone (377 pg/mL) levels. Prior to the initiation of radiation, treatment with bicalutamide and dutasteride reduced her PSA from 240 ng/ml to 77 ng/ml at week 6 (see Table). After treatment with external beam radiation her PSA fell to 4.6 ng/mL. At week 24, her PSA was 0.8 ng/mL. Conclusions: This high-grade, locally advanced prostate cancer in a transgender woman represents the longest reported duration of a castrate state preceding the development of prostate cancer, exceeding prior reports by several decades. The AR positive and ER/PR negative status of this tumor in the setting of low testosterone and elevated estrogen levels challenge long-standing paradigms regarding the testosterone requirement for prostatic carcinogenesis. In addition, these findings raise questions about the role of estrogens in prostate cancer. [Table: see text]

[Table: see text]

Population-based pharmacokinetics of the soluble TNFr etanercept: a clinical study in 43 patients with ankylosing spondylitis compared with post hoc data from patients with rheumatoid arthritis

OBJECTIVE

The purpose of this study was to evaluate the pharmacokinetics of etanercept in patients with ankylosing spondylitis (AS) in a phase 3 study.

METHODS

Serum etanercept concentrations were analyzed from samples obtained at weeks 4 and 12 from 43 patients with AS (median age: 45 years; median body weight: 75 kg; white/non-white: 40/3; male/female: 34/9) receiving 25 mg subcutaneously twice weekly for 12 weeks. A population pharmacokinetics analysis using NONMEM was conducted to estimate individual etanercept pharmacokinetic parameters. Initially, appropriate base and covariate population pharmacokinetic models were built based on data from 10 prior clinical studies of etanercept administered subcutaneously or intravenously to healthy subjects (n = 53) and to patients with rheumatoid arthritis (RA) (n = 212). The influence of demographic characteristics on the pharmacokinetics of etanercept was thoroughly evaluated. The stability of the final model was evaluated using both internal (bootstrapping) and external (data splitting) validation approaches. Finally, the selected final population covariate model was used to estimate the Bayesian pharmacokinetic parameters for the patients with AS.

RESULTS

The data from the 10 prior clinical studies were optimally fitted to a 2-compartment linear population covariate model. Both age (< 17 years) and body weight (< 60 kg) were found to be important covariates on clearance. Both bootstrapping and data splitting validated the population model. The mean Bayesian-predicted etanercept clearance and steady-state trough concentration were 0.072 l/h and 2,004 ng/ml, respectively. The pharmacokinetic parameters of etanercept in the patients with AS were similar to those observed in the patients with RA.

CONCLUSIONS

The pharmacokinetics of etanercept in patients with AS were similar to those in patients with RA. The AS disease state does not appear to alter the disposition of etanercept.

WHO Collaborating Centre consensus meeting on anti-cytokine therapy in rheumatoid arthritis

Severe adult rheumatoid arthritis is a cause of progressive disability and increased mortality across Europe. A cure for the disease remains elusive, but control of symptoms and maintenance of individual independence is possible. Anti-cytokine therapies offer a new approach to disease management. They are effective after the failure of full doses of methotrexate, and are at least as effective as methotrexate in retarding the progression of radiological changes. Until more is known about the long-term safety and efficacy of these drugs they should be reserved for patients with severe disease who are progressing despite adequate doses of methotrexate or other disease-modifying anti-rheumatic drugs. They should be continued until therapeutic failure or intolerance. A comprehensive health economic evaluation is needed to optimally direct the use of these drugs. This should be undertaken when long-term safety and efficacy studies are completed.

Predictors of Gleason pattern 4/5 prostate cancer on prostatectomy specimens: can high grade tumor be predicted preoperatively?

PURPOSE

Radical prostatectomy provides excellent cancer control in men with clinically localized prostate carcinoma. However, to our knowledge preoperative parameters for distinguishing indolent from clinically significant cancer are not well characterized. In fact, recent evidence suggests that the percent of Gleason pattern 4/5 carcinoma in the complete radical prostatectomy specimen is one of the strongest predictors of prostate cancer progression and a valid measure of cancer severity. However, it is unclear whether preoperative parameters, including biopsy Gleason pattern 4/5 carcinoma, may predict radical prostatectomy Gleason pattern 4/5 disease and, thereby, distinguish indolent from clinically significant cancer.

MATERIALS AND METHODS

We prospectively obtained 101 consecutive radical prostatectomy specimens and processed them in whole mount fashion. In addition to total tumor volume, we determined tumor volume for each Gleason pattern. Biopsy tumor area was measured in a similar fashion. Univariate and multivariate analyses were performed to identify preoperative clinical and pathology parameters for predicting Gleason pattern 4/5 carcinoma on prostatectomy specimens.

RESULTS

Biopsy Gleason score 7 or greater, Gleason pattern 4/5 carcinoma, perineural invasion and biopsy tumor area had statistically significant associations for identifying Gleason pattern 4/5 carcinoma on prostatectomy specimens. Logistic regression models for predicting any or greater than 10% Gleason pattern 4/5 carcinoma on prostatectomy specimens revealed that an area of pattern 4/5 disease of greater than 0.01 cm.2 on biopsy was the best single predictor with odds ratios of 15.0 (95% confidence interval 3.3 to 69.0, p = 0.0005) and 3.9 (95% confidence interval 1. 4 to 10.9, p = 0.009), respectively. For predicting any pattern 4/5 carcinoma on prostatectomy specimens a biopsy area of pattern 4/5 disease of greater than 0.01 cm.2 had only 38% sensitivity but 96% specificity. Similarly for predicting significant pattern 4/5 disease on prostatectomy specimens, defined as 10% or greater pattern 4/5, sensitivity and specificity for a biopsy area of greater than 0.01 cm.2 were 34% and 88%, respectively. Therefore, due to high false-negative rates these models had limited predictive value on an individual basis.

CONCLUSIONS

Biopsy parameters such as Gleason pattern 4/5 carcinoma may provide adequate specificity for predicting clinically significant cancer, as defined by high grade Gleason patterns in the corresponding radical prostatectomy specimen. However, the accuracy of these parameters for predicting indolent cancer is limited by a prohibitive rate of false-negative findings.

A comparison of ventilatory prostate movement in four treatment positions

PURPOSE

To ensure target coverage during radiotherapy, all sources of geometric uncertainty in target position must be considered. Movement of the prostate due to breathing has not traditionally been considered in prostate radiotherapy. The purpose of this study is to report the influence of patient orientation and immobilization on prostate movement due to breathing.

METHODS AND MATERIALS

Four patients had radiopaque markers implanted in the prostate. Fluoroscopy was performed in four different positions: prone in alpha cradle, prone with an aquaplast mold, supine on a flat table, and supine with a false table under the buttocks. Fluoroscopic movies were videotaped and digitized. Frames were analyzed using 2D-alignment software to determine the extent of movement of the prostate markers and the skeleton for each position during normal and deep breathing.

RESULTS

During normal breathing, maximal movement of the prostate markers was seen in the prone position (cranial-caudal [CC] range: 0.9-5.1 mm; anterior-posterior [AP] range: up to 3.5 mm). In the supine position, prostate movement during normal breathing was less than 1 mm in all directions. Deep breathing resulted in CC movements of 3.8-10.5 mm in the prone position (with and without an aquaplast mold). This range was reduced to 2.0-7.3 mm in the supine position and 0.5-2.1 mm with the use of the false table top. Deep breathing resulted in AP skeletal movements of 2.7-13.1 mm in the prone position, whereas AP skeletal movements in the supine position were negligible.

CONCLUSION

Ventilatory movement of the prostate is substantial in the prone position and is reduced in the supine position. The potential for breathing to influence prostate movement, and thus the dose delivered to the prostate and normal tissues, should be considered when positioning and planning patients for conformal irradiation.

Progression of radiographic joint erosion during low dose corticosteroid treatment of rheumatoid arthritis

OBJECTIVE

The reported prevention of joint damage during treatment with prednisolone 7.5 mg daily in patients with early rheumatoid arthritis (RA)3 may have important implications for management of RA. We evaluated this observation in another patient population.

METHODS

Radiographic progression rates in paired hand radiographs were analyzed in 824 patients with RA who participated in a 3 year prospective, randomized clinical trial comparing the nonsteroidal antiinflammatory drugs (NSAID) etodolac (150 or 500 mg bid) and ibuprofen (600 mg qid). Disease modifying antirheumatic drugs (DMARD) were not permitted. Prednisone < or=5 mg daily was continued by 197 patients (mean dose 4.37 mg daily) who had started prednisone therapy at least 6 mo before study entry, but new prednisone starts were not allowed. Standardized hand/wrist radiographs were done yearly and at dropout; joint erosion and narrowing scores of 3 readers were averaged and progression rates were compared.

RESULTS

Mean duration of RA was 3.6 years (range 1-7); patients' ages were 21-78 years; 71% were women. Among the 824 patients, those taking prednisone were more likely to have had previous DMARD, and at study entry had higher radiographic scores for joint erosion and joint space narrowing and slightly higher swollen joint counts, C-reactive protein values, and rheumatoid factor titers than those not taking prednisone. However, for the subgroup of 252 patients with RA duration of 12-24 months, prestudy radiographic scores were not different in those taking or not taking prednisone. The mean (+/-SD) monthly rate of increase in erosion scores was 0.228 +/-0.37 for the prednisone patients and 0.206+/-0.35 for patients not taking prednisone (p = 0.994 by ANCOVA). The subgroup with 12 to 24 months' disease duration at entry also showed no significant effect of prednisone treatment on erosion progression.

CONCLUSION

Clinically indicated low dose prednisone did not prevent progressive radiographic damage in 197 NSAID treated patients whose physicians had initiated < or =5 mg daily before study entry. The risk/benefit ratio of chronic low dose prednisone in early RA remains uncertain.

Relationship and significance of greatest percentage of tumor and perineural invasion on needle biopsy in prostatic adenocarcinoma

Serum prostate-specific antigen (PSA) levels and the biopsy Gleason sum are used along with clinical staging to predict prostatectomy pathology results for men with localized prostate cancer. The additional predictive value of perineural invasion (PNI) in pretreatment prostate needle biopsies for evaluating tumor stage in this setting is controversial. The current study evaluates the independent predictive value of PNI for tumor staging in a cohort of 632 men who underwent radical retropubic prostatectomies for clinically localized adenocarcinoma of the prostate between the years 1994 and 1998. None of these men received hormonal or radiation therapy before surgery. In addition to the Gleason sum, biopsy results contained detailed information regarding tumor burden: 1) total number of biopsy cores involved by adenocarcinoma, 2) greatest percentage of any single biopsy involved by prostate carcinoma (GPC), and 3) total percentage of cancer added over all cores (TPC). The presence or absence of any PNI was recorded. Pretreatment factors were analyzed in a univariate and multivariate fashion to determine their predictive value using the TNM tumor stage (pT2 vs pT3) and the modified tumor staging system, which includes surgical margin status (pT2 vs pT3 or positive surgical margin) as end points. Univariate analysis revealed a significant association between pT3 disease and several preoperative factors including age, Gleason sum, serum PSA, digital rectal examination, PNI, GPC, TPC, and the total number of positive cores (p <0.01). Multivariate analysis indicated that serum PSA, Gleason sum, age, and GPC contributed significantly to predicting pT3 disease with odds ratios of 2.7 (95% CI, 1.7-4.3), 2.3 (95% CI, 1.7-3.1), 1.7 (95% CI, 1.1-2.7), and 1.7 (95% CI, 1.4-2.1) respectively. PNI was significant in multivariate analysis only when GPC and TPC were not considered, due to a significant interaction between GPC and PNI (p <0.0001, Wilcoxon's rank sum test). These predictive factors showed a similar relationship to adverse pathology when an alternative definition of adverse pathology was used that included positive surgical margins (pT3 or any positive margin). In the interaction between GPC and PNI, GPC was more significant than PNI in predicting pT3 disease. However, PNI added additional information when adverse pathology was defined more broadly as pT3 or any positive margin.

Simultaneous extensive resection of the liver and the pancreas in dogs

Mortality, morbidity, liver function and regeneration were evaluated in dogs that had undergone simultaneous major resection of the liver and the pancreas. The 10-week survival rate was only 25% in the dogs that underwent 70% hepatectomy with more than 92% pancreatectomy, and many of them died of liver failure. Long-term survival was observed in more than 60% of the dogs after 70% hepatectomy with less than 92% pancreatectomy or after 40% hepatectomy with more than 92% pancreatectomy. The liver regeneration rate was reduced with the extent of the pancreatectomy, and the reduction was remarkable especially when more than 92% of the pancreas was resected. The frequency of diabetes was reduced when the pancreatectomy was combined with hepatectomy. Hyperlipemia and fatty liver were noted in all the dogs of the group that underwent more than 92% pancreatectomy alone. They were observed also in the postoperative diabetic groups but not in non-diabetic groups. The postoperative recovery of hepatic function and liver regeneration were delayed after simultaneous hepatectomy-pancreatectomy. Also, postoperative carbohydrate and lipid metabolism was better maintained in the hepatectomy-pancreatectomy groups than in the pancreatectomy-alone groups.

[Studies on glucose metabolism and pancreatic endocrine function after simultaneous major resection of the liver and pancreas]

Simultaneous major resection of the liver and pancreas has been recently advocated for advanced biliary carcinomas, but the subsequent changes in glucose metabolism and pancreatic endocrine function have not been investigated. In this study, changes in glucose metabolism following simultaneous major hepatic and pancreatic resection were evaluated in dogs, especially changes in pancreatic endocrine function and islet morphology. While adequate IRI levels were maintained in the peripheral blood, the incidence of diabetes was lower in dogs given simultaneous major hepatic and pancreatic resection than in those given pancreatectomy alone. Portal vein IRI levels during arginine loading were significantly higher in the former group. Early after surgery, the volume density of pancreatic islets was increased in both groups, but significantly higher in dogs that did not develop diabetes after simultaneous resection than in dogs given pancreatectomy alone, and the frequency of large pancreatic islets in the former animals was higher than the latter. The incidence of diabetes was lower in dogs after simultaneous resection than after pancreatectomy alone. This seemed to be due to promotion of pancreatic islet regeneration caused by combined hepatic resection, which was demonstrated by a sustained level of IRI secreted by islets and marked islet hypertrophy.

An endoscopic comparison of the effects of etodolac, indomethacin, ibuprofen, naproxen, and placebo on the gastrointestinal mucosa

To assess the effects of various nonsteroidal antiinflammatory drugs on gastroduodenal mucosa, 72 normal men were administered either etodolac, indomethacin, ibuprofen, naproxen, or placebo for 7 days. Gastric and duodenal mucosa were scored before and after treatment by direct endoscopy and evaluation of photographs taken during endoscopy. Subjects treated with indomethacin, ibuprofen, and naproxen had significantly worse direct gastric scores, and those treated with indomethacin and naproxen also had significantly worse direct duodenal scores, when compared with pre-treatment and placebo scores. Subjects given either of 2 doses of etodolac had gastric and duodenal scores comparable to pretreatment and placebo scores. The direct gastric scores of the etodolac groups were significantly better than the scores of subjects receiving indomethacin, ibuprofen and naproxen. Similar results were obtained when endoscopy photographs were scored.

Gastrointestinal blood loss in arthritic patients receiving chronic dosing with etodolac and piroxicam

Etodolac, a new anti-inflammatory analgesic drug found to be effective in treating arthritis in a dose range of 100 to 300 mg bid, has been shown to induce significantly less gastrointestinal microbleeding in normal men than several other NSAIDs. In this study, the effect on gastrointestinal blood loss of high-dose etodolac, 300 and 500 mg bid, versus piroxicam at its normal therapeutic dose of 20 mg qd, was investigated by the 51Cr method in 23 men with osteo- or rheumatoid arthritis. Placebo periods preceded and followed 28 days of active drug treatment. Blood and stool analyses were performed by an analyst not aware of drug assignment or study design. Patients receiving piroxicam, but not those receiving either dose of etodolac, had a significantly higher mean level of fecal blood loss in the active treatment phase compared with the pretreatment placebo level (p less than 0.01). Further, microbleeding was significantly greater for the piroxicam group during treatment than for either of the etodolac groups (p less than 0.01). There were no significant differences in fecal blood loss between the two groups receiving etodolac compared with pretreatment. Even at doses two to three times those found effective in the treatment of arthritis, etodolac produces no increase in fecal blood loss, in contrast to blood loss seen with the recommended dose of piroxicam. Fecal blood loss in osteoarthritic patients, not receiving an NSAID, was similar to normal subjects in previous studies.

Etodolac kinetics in the elderly

The effects of age and chronic dosing on the pharmacokinetics of the anti-inflammatory drug etodolac were evaluated in healthy young subjects, healthy elderly subjects, and elderly patients with osteoarthritis. After either single or chronic (7 days) dosing, both the healthy elderly subjects and the elderly patients with osteoarthritis had values for etodolac peak concentration, time to reach peak concentration, the AUC from 0 to 24 hours, elimination t1/2, and free fraction that did not differ significantly from those in the young (control) subjects. Despite the expected increases in the peak concentration and AUC from 0 to 24 hours for all groups after chronic dosing, there were no changes in etodolac free fraction, time to peak concentration, or t1/2. Because significant accumulation of etodolac was not observed in our elderly participants, adjustment of dosage when elderly subjects receive etodolac therapy is not indicated.

The effect of etodolac administration on renal function in patients with arthritis

The effect of etodolac 50-600 mg/d on renal function was assessed in four- to 52-week trials in 1,382 patients with arthritides. No patient was withdrawn from treatment due to an abnormal renal function test related to etodolac administration. There were no significant differences in the incidence of definite renal function abnormalities between patients receiving etodolac and those receiving placebo. Both etodolac and placebo groups had a significantly lower incidence of deviant BUN results than either aspirin- or sulindac-treated patients. Fewer than 2% of patients receiving etodolac showed either a persistent or variably persistent pattern of deviant renal function tests. The results in these studies indicate that chronic etodolac therapy did not adversely affect renal function in patients with arthritis.

Minimum effective dose of etodolac for the treatment of rheumatoid arthritis

Etodolac was compared with aspirin and placebo for efficacy and safety, and a minimum effective dose was established in 264 patients with adult-onset, active rheumatoid arthritis. In this six-week, 14-center, double-blind, parallel-group investigation, preceded by a washout period of up to two weeks, patients received daily doses of etodolac at 50, 100, or 200 mg/d; aspirin at 3,900 mg/d; or placebo. Both etodolac at the highest dose and aspirin produced statistically significant improvement from baseline in all disease activity assessments measured at four- and six-week end points and were superior to placebo in the majority of assessments. A greater number of patient complaints occurred with aspirin, especially in regard to gastrointestinal-related and otologic side effects. A significant therapeutic dose response was evident among the etodolac groups without an increase in side effects. Although the 100-mg/d dose was effective in many of the efficacy parameters measured, the 200-mg/d dose, which is comparably efficacious to aspirin 3.9 g/d, was suggested as the minimum effective dose for the relief of the signs and symptoms of active rheumatoid arthritis.

Early carcinoma of the gallbladder, noninvasive carcinoma originating in the Rokitansky-Aschoff sinus: a case report

A patient was reported who underwent cholecystectomy under the diagnosis of chronic cholecystitis with calculi and adenomyomatosis, but it proved to be an early carcinoma of the gallbladder originating in and limited to the Rokitansky-Aschoff sinus (cyst-like structure). Early carcinoma of the gallbladder in this category is rare and this case report may be the first one in the literature.