Gefitinib (ZD1839) in Previously Treated Advanced Non-Small-Cell Lung Cancer: Experience from a Single Institution

BACKGROUND

We conducted an analysis of gefitinib in patients with advanced non-small-cell lung cancer (NSCLC) to assess the antitumor efficacy of this epidermal growth factor receptor tyrosine kinase inhibitor.

METHODS

Our single-center, prospective landmark analysis included 183 patients with advanced NSCLC who received 250 mg of gefitinib orally once daily in an expanded-use program at our institution. Thirty-three of the 183 patients were previously untreated. The patients included in this analysis had all received at least 12 weeks of gefitinib.

RESULTS

The objective tumor response rate was 3.8%, but an additional 53.5% of patients experienced clinically meaningful disease stabilization. Median progression-free survival time was 3.6 months, and median overall survival time was 8.8 months. The 1-year survival rate for the entire cohort was 35%. Predictors of longer survival included female gender, adenocarcinoma or bronchoalveolar carcinoma histology, and an Eastern Cooperative Oncology Group performance status of 0 or 1. Adverse events were generally mild (grade 1 or 2) and consisted mainly of skin reactions and diarrhea.

CONCLUSIONS

In this single-center experience, gefitinib demonstrated clinically significant antitumor activity and provided good palliation in a predominantly pretreated group of patients. Our results, which are likely to be reproducible in a community setting, demonstrated a 1-year survival rate of 35% in a cohort of patients who were able to take the drug for at least 12 weeks.

Temporal arteritis: improving patient evaluation with a new protocol

CONTEXT

The process of diagnosing temporal arteritis remains controversial. Although temporal artery biopsy has long been the standard tool of evaluation, its poor sensitivity has prompted investigation of other methods to aid in diagnosis. Improved clinical evaluation and various imaging techniques have been suggested as ways to establish the diagnosis through noninvasive means and to improve biopsy yield.

OBJECTIVE

To retrospectively report and evaluate the process and experience of the Kaiser Permanente Northwest Region in implementing a new protocol that includes an enhanced clinical evaluation as well as the incorporation of color duplex ultrasonography in addition to biopsy when appropriate for temporal arteritis evaluation.

RESULTS

A 38% reduction in the number of temporal artery biopsies performed was achieved through the new protocol, which was created by a multidisciplinary process, including stakeholders from all departments involved. The percentage of abnormal biopsy results rose from 8.5% at baseline to 24%. No cases of the disease were missed after careful evaluation of clinical and medical-legal records.

CONCLUSIONS

Adding specialist clinical evaluation and color duplex ultrasonography to the standard diagnostic workup for temporal arteritis creates a rapid, noninvasive, resource-sensible means to diagnose giant cell arteritis, to improve temporal artery biopsy yield, and to decrease the total number of biopsies done. The diagnosis can be made in some cases by clinical evaluation and color duplex ultrasonography alone, thereby saving the patient an unnecessary surgical procedure. Protocols such as this can be implemented by multidisciplinary cooperation in a patient-centered, integrated system.

Motherhood, migration and mortality in Dikgale: modelling life events among women in a rural South African community

OBJECTIVES

Although particular types of life events in populations are often studied separately, this study investigated the joint effects of three major event types in South African women's lives: motherhood, migration and mortality.

STUDY DESIGN

Data were taken from a health and demographic surveillance site (HDSS) over an 11-year period, reflecting the entire population of a defined geographic area as an open cohort, in which individuals participated in regular longitudinal surveillance for health and demographic events. This HDSS is a member of the Indepth Network.

METHODS

Multivariate Poisson regression models were built for each of the three life event types, in which individual person-time observed out of the total possible 11-year period was used as a rate multiplier. These models were used to calculate adjusted incidence rate ratios for each factor.

RESULTS

In the 21,587 person-years observed for women aged 15-49 years, from 1996 to 2006, adjusted rate ratios for mortality and migration increased substantially over time, while motherhood remained fairly constant. Women who migrated were less likely to bear children; temporary migrants were at greater risk of dying, while permanent in-migrants had higher survival rates. Women who subsequently died were much less likely to bear children or migrate.

CONCLUSIONS

The associations between motherhood, migration and mortality among these rural South African women were complex and dynamic. Extremely rapid increases in mortality over the period studied are presumed to reflect the effects of the human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) epidemic. Understanding these complex interactions between various life events at population level is crucial for effective public health planning and service delivery.

Effect of body mass and physical activity volume and intensity on pedometry-measured activity energy expenditure in rural black South Africans in the Limpopo Province

Objectives. We developed a novel approach to investigate patterns of pedometry-measured total weekly activity energy expenditure (EEAct) in rural black South Africans in the Limpopo Province. Design. We analysed 7-day pedometry data in 775 subjects (female: N=508; male: N=267). Variance components models for EEAct were used to estimate the variance explained by body mass (BM), total weekly steps (volume) and estimated intensity (kcal. kg-1.step-1). Univariate General Linear Models, adjusting for age, BM and physical activity (PA) volume, were used to determine if EEAct was primarily affected by volume or intensity. Results. BM (13.1%), PA intensity (24.4%) and PA volume (56.9%) explained 94.4% of the variance in EEAct. Adjusted EEAct did not differ between sexes (78 kcal.week-1, p =0.2552). There were no significant differences across activity categories (sedentary to very active) for adjusted EEAct (62 - 287 kcal.week-1, p>0.1). Adjusted EEAct for 6 - 7 days of compliance (≥10 000 steps.day-1) differed significantly from 1 - 2 days of compliance (266 - 419 kcal.week-1, p<0.04). Obese (body mass index ≥30 kg.m-2) and normal weight (body mass index 18.5 - 24.9 kg.m-2) women did not differ significantly across activity categories for EEAct (200 - 592 kcal.week-1, p>0.30). Conclusions. We have highlighted an intensity effect for days of compliance and at very active ambulatory levels (≥12 500 steps. day-1). A volume effect appeared to dominate between sexes, across activity categories and weight-by-activity categories. It is important that post hoc statistical adjustments be made for body mass and PA volume when comparing EEAct across groups.

Successful external cardioversion of atrial fibrillation in patients referred to an electrophysiologist for internal cardioversion

BACKGROUND

Internal cardioversion of atrial fibrillation with direct current energy has become an increasingly employed technique for patients who fail external cardioversion.

HYPOTHESIS

The purpose of this study was to determine whether internal cardioversion could be avoided by careful attention to cardioversion technique in a group of patients referred specifically for internal cardioversion after failed external cardioversion by community cardiologists.

METHODS

We performed external cardioversion utilizing two operators applying significant pressure to the thorax with up to 360 J prior to the planned internal cardioversion in 20 patients referred for internal cardioversion after failed attempts at external cardioversion.

RESULTS

Sixteen patients (80%) were successfully cardioverted and avoided the risk, inconvenience, and cost of internal cardioversion.

CONCLUSION

External cardioversion with significant anterior paddle pressure by two operators can decrease the need for internal cardioversion in a significant portion of patients referred to electrophysiologists for internal cardioversion and should be considered prior to an invasive procedure.

Association between insulin-like growth factor-1, insulin-like growth factor-binding protein-1 and leptin levels with nutritional status in 1–3-year-old children, residing in the central region of Limpopo Province, South Africa

The present study evaluated levels of growth factors and their associations with nutritional status with emphasis on stunting in children at 1 and 3 years of age. A follow-up study on a birth cohort (n 219) of children from villages in the central region of the Limpopo Province was undertaken. Of the original cohort, 156 and 162 could be traced and assessed at ages 1 and 3 years, respectively. Data collected included socio-demographic characteristics, anthropometric measurements, dietary intake and fasting blood (collected from 116 and 145 children at 1 and 3 years, respectively) for growth factor analysis (insulin-like growth factor (IGF)-1, IGF binding protein (BP)-1, IGFBP-3, leptin, glucose and insulin). At 1 year it was found that stunted children had lower leptin levels while their IGFBP-1 levels were higher than that in normal children. These differences were, however, not observed at 3 years. Furthermore at 1 year the biochemical parameters were more related to length measures whereas at 3 years the parameters were more associated with weight measures. The observed stunting in this group of children may be a result of chronic undernutrition resulting in long-term growth faltering which is already evident at 1 year. Thus the observed phenomenon might be an adaptive mechanism adopted by children's metabolic processes as they grow up in an environment with inadequate essential nutrients due to poor weaning practices and consumption of a diet of poor quality, resulting in them gaining more weight at the expense of linear growth.

Prevalence of gestational diabetes mellitus and the effect of weight on measures of insulin secretion and insulin resistance in third-trimester pregnant rural women residing in the Central Region of Limpopo Province, South Africa

AIMS

To examine the prevalence of gestational diabetes in third-trimester pregnant women as well as to assess their insulin secretion and insulin resistance (IR).

METHODS

Third-trimester pregnant women (n= 262) attending antenatal care at local clinics in the central region of the Limpopo Province underwent a 2-h oral glucose tolerance test (OGTT) with blood collected at 0, 30 and 120 min. Glucose and insulin were measured.

RESULTS

The prevalence of gestational impaired glucose tolerance (GIGT) and gestational diabetes mellitus (GDM) was 8.8% (7.3% GIGT; 1.5% GDM). Women with GIGT/GDM were significantly older and had more children compared with women with a normal response to the OGTT. Homeostasis model assessment(HOMA)-IR and fasting insulin were lower in the GIGT/GDM group compared with the normal group, as were measures of insulin secretion (HOMA B-cell function and insulinogenic index). Furthermore, women with body mass index (BMI)> or =30.0 kg/m2 were significantly older and had higher parity, systolic and diastolic blood pressure measurements than those with BMI 25.0-29.9 kg/m2 and BMI < 25.0 kg/m2. However,increased BMI was not associated with an increased risk of GIGT/GDM.

CONCLUSION

The present study shows that there is a high prevalence of GIGT/GDM, with most women having IGT. The GIGT/GDM present in these women is characterized by increased insulin sensitivity accompanied by reduced pancreatic B-cell function. Additionally, heavier women appear to have increased first phase insulin secretion, suggesting the presence of insulin resistance.

Implications and Outcome of Permanent Coronary Sinus Lead Extraction and Reimplantation

OBJECTIVE

We examined the implications and outcome of coronary sinus (CS) lead removal including the feasibility of laser use within the CS.

BACKGROUND

Cardiac anatomy and lead interactions are more complex with the advent of biventricular pacemakers and atrial cardioverters requiring permanent lead/shocking coil placement in the coronary sinus and its branches.

METHODS

Fifty-five permanent cardiac leads were extracted during 2003 in 28 consecutive patients. Our study population included a 10/55 (18%) subset (all males; age 73 +/- 6 years; EF = 0.24 +/- 0.09) that underwent CS (1/10) or vein branch (9/10) lead extraction. Leads were extracted with an excimer laser sheath (n = 4) or by direct traction (n = 6). Median times between implantation and lead removal were 9.5 months (range 5-59) in the laser group and 3 months (range 3-4) in the direct traction group. Indication for extraction was infection (n = 4), dislodgement (n = 3), diaphragm stimulation (n = 2), and elevated threshold (n = 1). The CS was divided into distal, mid, and proximal segments by venogram.

RESULTS

Entry of the laser sheath into the CS was necessary in three of four laser patients. The two distal CS laser cases (left lateral CS coil and anterior-lateral left ventricular (LV) lead) required both 14- and 12-Fr sheaths, separately. The proximal CS laser case (posterior-lateral LV lead) required a 12 Fr sheath. The remaining laser patient required a 12-Fr sheath to pass to the mid SVC. There were no procedural complications as a result of CS lead extraction. Reimplantation of a CS lead was attempted in 7/10 patients at a median of 4 days (range 1-300). CS venograms were available for review in patients before initial implantation (6/10) and after extraction (7/10). The postextraction venograms demonstrated complete occlusion of the vein from which the lead was extracted, and its distal branches, which were unusable in 5/10 (50%). The vein occlusions were present in patients with indwelling leads for greater than 3 months and were independent of extraction method.

CONCLUSIONS

Laser lead extraction in the coronary sinus appears feasible in carefully selected cases with mandatory indications. However, special intraoperative monitoring and echocardiographic imaging with surgical backup ready is strongly recommended. Target vein selection may be limited for the purpose of reimplantation when leads are indwelling for greater than 3 months.

Analysis of electrocardiograms for subcutaneous monitors

We are developing a subcutaneous cardiac arrest monitor and alarm with electrodes that have spacing of a few centimeters. We hypothesize that closely spaced bipolar electrodes that provide QRS amplitudes of a millivolt or more in sinus rhythm (SR) will not provide similar amplitudes during ventricular tachyarrhythmia (VT/VF), and that an orthogonal set of electrode pairs in diagonal is necessary to produce signals of sufficient amplitude in order to distinguish these rhythms.

METHODS

Forty patients were studied during ICD implantation in the clinical electrophysiology laboratory. A square array of 9 electrodes with 4- to 10-cm spacing between adjacent electrodes was placed on the patient's anterior chest over the left heart. The center electrode in the left most column is located in the 5th intercostal space at the left sternal border. Eight-channel recordings were made in SR and during induced VT/VF from the 8 peripheral electrodes referenced to the central member of the array. From these recordings all 20 bipolar ECGs of adjacent (including diagonally adjacent) electrodes were constructed algebraically. QRS peak-peak amplitudes in SR and VT/VF were measured in each bipolar lead and in the spatial vector formed by summing the squares of each adjacent and orthogonal pair of these leads.

RESULTS

Electrode pairs that yielded optimal ECG amplitudes in SR were not always the pairs that yielded optimal amplitudes in VT/VF. But in every patient two orthogonal pairs could be found whose QRS vector amplitude is sufficient in both SR and VT/VF to separate the rhythms.

CONCLUSIONS

A patient-defined set of bipolar electrode pairs is suitable for automatic separation of SR and VT/VF by rate in subcutaneous ambulatory monitoring.

Illness cognitions, doctor-patient communication and prescription adherence among first diagnosed hypertensive patients from a rural teaching hospital in South Africa

This study examines the relationship between illness cognitions, doctor-patient communication and the use of prescribed medication among patients first diagnosed with hypertension in the outpatient department of a rural South African teaching hospital. Opsomming Hierdie studie ondersoek die verwantskap tussen siekte-kognisies, dokter-pasiënt kommunikasie en die gebruik van voorskrifmedisyne onder pasiënte wat die eerste keer met hipertensie gediagnoseer is, in die buitepasiëntafdeling van ‘n landelike Suid-Afrikaanse opleidingshospitaal. *Please note: This is a reduced version of the abstract. Please refer to PDF for full text.

Establishment of primary stroke centers: a survey of physician attitudes and hospital resources

OBJECTIVES

To survey US physicians involved in acute stroke care to determine the proportion of hospitals that currently meet the recommended Brain Attack Coalition (BAC) criteria for Primary Stroke Centers (PSC) and obtain opinions regarding the value of stroke centers.

METHODS

A survey regarding the BAC guidelines for the establishment of stroke centers was mailed to 3,245 US neurologists, neurosurgeons, and emergency physicians.

RESULTS

A total of 1,032 responses were received. Seventy-nine percent (range by specialty 58 to 98%) of respondents believed there was a need for stroke centers. If formal stroke center designation were established, 81% (range 72 to 90%) would like their hospital to become a PSC. Although 77% of respondents believed that their hospital currently met recommended criteria for a PSC, only 7% actually meet all recommended elements. However, 44% of hospitals already provide most acute stroke services. The BAC criteria most frequently lacking were continuing medical education for professional stroke center staff, stroke training for emergency department staff, formal establishment of a stroke unit, and designation of a stroke center director.

CONCLUSIONS

The majority of emergency medicine and neuroscience physician respondents involved in acute stroke care support the designation of primary stroke centers. Although respondents globally overestimated the extent to which their facilities currently meet BAC recommended criteria for PSC, detailed responses suggested that over 40% of hospitals possess substantial existing acute stroke care resources and are poised to function as PSC with modest additional administrative and financial commitment.

The effect of different apo(a) isoforms on plasminogen activation in black South African subjects

OBJECTIVE

The present study evaluates the effect of different apolipoprotein(a) [apo(a)] isofroms on plasminogen activation.

DESIGN

A cross-sectional study.

SETTING

A rural village (Dikgale district) in the Northen Province of South Africa.

SUBJECT

A total of 90 apparently healthy subjects (64 females and 36 males) aged 43 to 67 years participated in the study.

RESULTS

The mean lipoprotein(a) [ Lp(a)] level in the subjects was 38.14 +/- 22.34 mg/dl. No association was found between Lp(a) isoforms. When the ratio of Lp(a):plasminogen was less then 1.3, a competitive inhibition was observed, but when the ratio exceeded 1.3, an uncompetitive inhibition was observed with all isoforms.

CONCLUSION

The results of the present study suggest that the inhibition of plasminogen activation by Lp(a) is not dependent of apo(a) size.

Effect of radiofrequency current on previously implanted pacemaker and defibrillator ventricular lead systems

We compared the response of endocardial lead systems to radiofrequency (RF) current delivered during atrio-ventricular junction ablation (AVJA) for atrial fibrillation with uncontrolled ventricular rate in 107 patients. The mean age was 67 +/- 11 years and the mean ejection fraction 42 +/- 15%. Patients were divided into 3 groups based on the type of ventricular lead present at the time of ablation: a previously implanted defibrillator lead (group 3, n = 13), a previously implanted pacemaker lead (group 2, n = 46) or a temporary lead (group 1, n = 48), which was subsequently followed by a permanent lead implantation. During AVJA, a median of 5 RF applications (44 +/- 8 W) were given via 4-5-mm electrodes. All but 1 patient had right-sided lesions, while 6 patients also had left sided lesions. Ventricular pacing thresholds were evaluated immediately pre- and post-ablation at 24 hours and at 1 to 3 months. Increases in ventricular pacing voltage thresholds were noted in all 3 groups over time, with the greatest mean increase in group 3 patients: [table: see text]. A greater than 2-fold increase in pacing thresholds was observed only with previously implanted leads, usually within the first 48 hours. It occurred significantly more often in patients with group 3 (6/13 [46%]) compared to group 2 (6/46 [13%], odds ratio 7.6, P = 0.006). A progressive rise in pacing threshold required lead revision in 2/13 group 3 patients (15%) and 2/46 group 2 patients (4%). While RF current has only minor effects on pacing threshold in most patients with previously implanted ventricular lead systems, clinically important alterations requiring device reprogramming or lead revision may occur. Group 3 are significantly more vulnerable to RF current, though the mechanisms are unclear. Group 1 during AVJA, followed by permanent lead implantation appears advisable. Pts with a previously implanted group 3 who require AVJA should be monitored closely.

The ratio of serum transferrin receptor and serum ferritin in the diagnosis of iron status

Laboratory tests used in the diagnosis of iron status lack specificity in defining iron deficiency anaemia (IDA) and anaemia of inflammation (AI). The serum transferrin receptor (sTfR) may provide more information in this regard. The iron status of 561 pre-school children was determined and classified using the conventional measurements. The value of the concentration of sTfR, the ratio of sTfR (microg/ml) to LogSF (microg/l) (TfR-Index), and the Log of the ratio of sTfR (microg/l) to SF (microg/l)--(LogTfR:Fer ratio), in the classification of the iron status were determined by comparing their distributions across the classification of iron status. Although there were significant differences in sTfR and TfR-Index across the categories of iron status, there was considerable overlap. All subjects with iron deficiency had LogTfR:Fer ratio > 2.55, whereas in all subjects classified as AI it was < 2.55, thus clearly separating the two. The LogTfR:Fer ratio was not able to exclude IDA in the presence of inflammation. However, in cases of combined IDA and AI the LogTfR:Fer ratio was < 2.55 but increased to > 2.55 after resolution of the inflammation. This novel method of calculating the LogTfR:Fer ratio may provide a more precise classification of the iron status of children.

Weight and health status of black female students

OBJECTIVE

To examine black female students for the occurrence of risk factors associated with chronic diseases of lifestyle, namely obesity, hypertension, nicotine usage, dyslipidaemia and compromised mental health (depression).

DESIGN

A cross-sectional analytical study design was used. All participants were examined within a period of 3 months during 1994. Weight, height, and hip and waist measurements were taken. Body mass index (BMI), waist-hip ratio (WHR) and waist circumference (WC) were calculated for each subject. Two systolic and diastolic blood pressure readings were taken for each participant. Questionnaires were used to determine specific risk factors related to lifestyle. The Beck Depression Inventory (BDI) was used to measure psychological well-being. Fasting blood samples were collected and analysed for serum lipids and iron status.

SETTING

The University of the North in the Northern Province of South Africa.

SUBJECTS

A complete data set of sociodemographic information, anthropometric measurements and blood pressure readings, as well as a psychological health test and a medical questionnaire, were obtained from 231 of the 431 first-year female students who attended the university orientation programme. Only students with a complete data set were included in the sample.

RESULTS

Eighteen per cent of students were overweight (BMI 25-29.9), 6.5% were obese (BMI > or = 30), and 26.8% were underweight. Mean blood pressure, BMI, WHR and WC increased significantly with age and were highest among the > or = 24-year-olds. Only 1.6% of students had elevated blood pressure, 1.0% smoked and 4.4% took snuff. BMI, WC and WHR were positively correlated with blood pressure and age. Few students had dyslipidaemia (3.8% cholesterol > 5.2 mmol/l). However 14.5% were anaemic (Hb < 11.5 g/dl) and 24.6% had microcytosis (< 80 fl). Nearly one-fifth of students (17.7%) were classified as being moderately to severely depressed.

CONCLUSIONS

Black female students younger than 24 years exhibited few risk factors associated with chronic diseases of lifestyle. However in older women (> or = 24 years) there were significant increases in BMI, WHR, WC and blood pressure. A large number of students of all ages exhibited moderate to severe depression and anaemia was prevalent.

Prevention of a first stroke: a review of guidelines and a multidisciplinary consensus statement from the National Stroke Association

OBJECTIVE

To establish, in a single resource, up-to-date recommendations for primary care physicians regarding prevention strategies for a first stroke.

PARTICIPANTS

Members of the National Stroke Association's (NSA's) Stroke Prevention Advisory Board and Cedars-Sinai Health System Department of Health Services Research convened on April 9, 1998, in an open meeting. The conference attendees, selected to participate by the NSA, were recognized experts in neurology (9), cardiology (2), family practice (1), nursing (1), physician assistant practices (1), and health services research (2).

EVIDENCE

A literature review was carried out by the Department of Health Services Research, Cedars-Sinai Health System, Los Angeles, Calif, using the MEDLINE database search for 1990 through April 1998 and updated in November 1998. English-language guidelines, statements, meta-analyses, and overviews on prevention of a first stroke were reviewed.

CONSENSUS PROCESS

At the meeting, members of the advisory board identified 6 important stroke risk factors (hypertension, myocardial infarction [MI], atrial fibrillation, diabetes mellitus, blood lipids, asymptomatic carotid artery stenosis), and 4 lifestyle factors (cigarette smoking, alcohol use, physical activity, diet).

CONCLUSIONS

Several interventions that modify well-documented and treatable cardiovascular and cerebrovascular risk factors can reduce the risk of a first stroke. Good evidence for direct stroke reduction exists for hypertension treatment; using warfarin for patients after MI who have atrial fibrillation, decreased left ventricular ejection fraction, or left ventricular thrombus; using 3-hydroxy-3 methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors for patients after MI; using warfarin for patients with atrial fibrillation and specific risk factors; and performing carotid endarterectomy for patients with stenosis of at least 60%. Observational studies support the role of modifying lifestyle-related risk factors (eg, smoking, alcohol use, physical activity, diet) in stroke prevention. Measures to help patients improve adherence are an important component of a stroke prevention plan.

['Abbreviated fatigue questionnaire': a practical tool in the classification of fatigue]

The 'Shortened fatigue questionnaire' (SFQ) is a short, reliable and easily used instrument to determine the intensity of the patient's bodily fatigue. It consists of four questions which the patient answers by checking an item at a 7-point scale ('I feel tired', 'I tire easily', 'I feel fit' and 'I feel physically exhausted'). The physician can then calculate a total score and compare it with the score in standard groups (standardized by load-bearing). The questionnaire can be completed simply and quickly. It constitutes a valuable addition in daily medical practice and in clinical scientific studies for the assessment of fatigue complaints.

Soluble transforming growth factor-alpha is present in the pulmonary edema fluid of patients with acute lung injury

Recent in vivo and in vitro experimental evidence indicates that transforming growth factor-alpha (TGF-alpha) is an important growth factor in the process of recovery and remodeling that occurs after acute lung injury. However, there are very little clinical data on TGF-alpha in patients with acute lung injury. Therefore, the purpose of this study was to determine if TGF-alpha is present in biologically significant concentrations in the pulmonary edema fluid from patients with acute lung injury, and to determine if the presence of TGF-alpha is specific for acute lung injury by including control patients with hydrostatic edema. Using an enzyme-linked immunosorbent assay, plasma and pulmonary edema fluid TGF-alpha levels were measured in 43 patients (34 with increased permeability edema, nine with hydrostatic edema). TGF-alpha was detected in 24 of 34 patients (71%) with increased permeability pulmonary edema (range, 0.035 to 2.57 ng/mL) compared with only two of nine patients with hydrostatic edema (p < 0.05). TGF-alpha was not detected in any plasma samples. These concentrations of TGF-alpha in pulmonary edema fluid have potent in vivo and in vitro effects on alveolar epithelial sodium transport and alveolar epithelial cell motility. In conclusion, biologically relevant concentrations of soluble TGF-alpha are present in the pulmonary edema fluid on day 1 of patients with acute lung injury, a remarkable finding with important implications for the repair and resolution of acute lung injury, particularly since TGF-alpha was detected so early in the course of acute lung injury.

Reliability and validity of the maximal anaerobic running test

Physically active men (n = 13) twice performed the Maximal Anaerobic Running Test (MART) on a treadmill and once the Wingate Anaerobic Test (WAnT) on a cycle ergometer. The MART consisted of n 20-s runs with 100-s recovery between the runs. The speed of the first run was 14.6 km.h-1 and the inclination 4 degrees. Thereafter, the speed was increased by 1.37 km.h-1 every run until exhaustion. During all tests oxygen uptake was measured breath-by-breath and blood samples were taken from the fingertip 40s after each run to determine the lactate concentration (BLa). Power at submaximal BLa levels and maximal power (P5mM, P10mM and Pmax, respectively) were calculated and P was expressed as the oxygen demand of running according to the American College of Sports Medicine equation. In the MART the Pmax was 108 ml.kg-1.min-1 and peak BLa was 15.6 mM. The reliability for the power indices in the MART were as follows: r = 0.92 (p < 0.001) for Pmax r = 0.80 (p < 0.001) for P10mM and r = 0.67 (p = 0.01) for P5mM. The average contribution of anaerobic energy expenditure was calculated to be 68% but it ranged from 64% to 72% during the MART. Although four out of seven of the correlations between the corresponding variables of the MART and WAnT were significant (0.52 < r < 0.59) they were not high. It is concluded that the anaerobic energy production is high in the MART, the test is reliable, and that the treadmill and cycle ergometer test measure slightly different qualities.

Concurrent paclitaxel/cisplatin with thoracic radiation in patients with stage IIIA/B non-small cell carcinoma of the lung

Nine patients with stage IIIB non-small cell lung cancer were entered into a phase II trial designed to determine the feasibility of giving a combination of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) plus cisplatin concurrent with thoracic radiation. Paclitaxel was given as a 24-hour infusion (135 mg/m2) followed by cisplatin (75 mg/m2) every 4 weeks, for a total of four cycles. Thoracic radiation was given concurrently with the first two cycles of chemotherapy, for a total dose of 64.8 Gy over 6 weeks. Neutropenia and esophagitis were the most common toxicities, with 66% of patients experiencing grade 3 or 4 neutropenia and 55% experiencing grade 3 or 4 esophagitis. Grade 3 pulmonary toxicity developed in 33% of patients. All patients were able to receive the full dose of radiation, although half of the patients required some modification of the chemotherapy regimen. There was one complete response and four partial responses, yielding a 56% overall response rate. This study demonstrates that it is feasible to treat patients with stage IIIB non-small cell lung cancer with paclitaxel/cisplatin plus concurrent thoracic radiation, with a degree of toxicity comparable with that associated with a degree of toxicity comparable with that associated with other concurrent combined-modality regimens for this disease.

Sequence and molecular characterization of human monocyte/neutrophil elastase inhibitor

cDNA encoding human monocyte/neutrophil elastase inhibitor (EI), a M(r) approximately 42,000 protein with serpin-like functional properties, has been sequenced. The 1316-base-pair sequence was obtained from overlapping clones and amplified DNA from libraries of monocyte-like and neutrophil-like cells. Hybridization with EI cDNA identified three EI mRNA species of 1.5, 1.9, and 2.6 kilobases in U937 monocyte-like cells and no hybridizing mRNA in lymphoblastoid cells lacking detectable EI. The cDNA open reading frame encodes a 379-amino acid protein, of which 167 residues were confirmed by tryptic peptides. Although EI may function extracellularly as well as intracellularly, its deduced sequence lacks a typical cleavable N-terminal signal sequence. Sequence analysis established that EI is a member of the serpin superfamily. EI has greatest homology (50.1% identity of amino acids) with plasminogen activator inhibitor 2, also a monocyte protein, and ovalbumin and gene Y, which were previously grouped as an ancient branch of the serpin superfamily. The extent of EI identity with the functionally related serpin alpha 1 antitrypsin is only 30.1%. Sequence alignment indicates that the reactive center P1 residue is Cys-344, consistent with abrogation of elastase inhibitory activity by iodoacetamide and making EI a naturally occurring Cys-serpin. The cleavable bond, Cys-Met, suggests an oxidation-sensitive molecule capable of inhibiting more than one serine protease. Oxidation sensitivity would limit the place of action of EI to the immediate vicinity of carrier cells. The molecular structure will help clarify the likely role of EI in regulating protease action and preventing tissue damage by phagocytic cells.

Large-dose infusions of heparinoid ORG 10172 in ischemic stroke

We evaluated the safety and possible efficacy of large doses of the heparinoid ORG 10172 in 57 patients with acute or progressing ischemic stroke. Patients received a loading bolus of the drug followed by a maintenance intravenous infusion for 7 days. The plasma level of ORG 10172 was monitored by the degree of inhibition of coagulation factor Xa. In general, the drug was well tolerated and few hemorrhagic complications occurred. Two patients with large cardioembolic hemispheric strokes had intracranial hemorrhagic complications. Most patients improved during treatment. By 3 months after the stroke, 37 patients (65%) had a favorable outcome (minimal or no residual disability). This study suggests that high-dose intravenous infusions of ORG 10172 can be safely given to patients with acute ischemic stroke.

A dose escalation study of ORG 10172 (low molecular weight heparinoid) in stroke

An intravenous infusion of a low molecular weight heparinoid, with a reduced risk of hemorrhage, may be an alternative to heparin in the management of acute ischemic stroke. To evaluate this hypothesis, we studied the safety of the heparinoid, ORG 10172, in a dose-escalation study in 26 patients. The drug was administered as a loading bolus followed by a 7-day infusion in five rates with target anti-factor Xa levels from 0.2 to 1.0 U/ml. The drug was well tolerated; no major bleeding complications or thrombocytopenia occurred. There were no deaths or hemorrhagic transformation of cerebral infarctions. The results indicate that ORG 10172 at doses to achieve a level of 1.0 U/ml or less may be used safely in management of acute cerebral infarction.

Effects of gluconeogenic hormones on insulin binding in intact human red blood cells

The effects of gluconeogenic hormones, adrenaline and cortisol, on insulin binding were studied in intact human red blood cells. Insulin binding was significantly decreased when red blood cells were preincubated with 1.0 microgram . ml-1 adrenaline or cortisol respectively. The Scatchard plot suggested that this was due to a decrease in surface receptor concentration. Furthermore, it showed that adrenaline also increased insulin receptor affinity. The negative co-operativity affinity profile demonstrated that adrenaline caused a rise in only the upper limit average affinity, Ki, of the insulin receptor.