Incisional hernia following colorectal cancer surgery according to suture technique: Hughes Abdominal Repair Randomized Trial (HART)

BACKGROUND

Incisional hernias cause morbidity and may require further surgery. HART (Hughes Abdominal Repair Trial) assessed the effect of an alternative suture method on the incidence of incisional hernia following colorectal cancer surgery.

METHODS

A pragmatic multicentre single-blind RCT allocated patients undergoing midline incision for colorectal cancer to either Hughes closure (double far-near-near-far sutures of 1 nylon suture at 2-cm intervals along the fascia combined with conventional mass closure) or the surgeon's standard closure. The primary outcome was the incidence of incisional hernia at 1 year assessed by clinical examination. An intention-to-treat analysis was performed.

RESULTS

Between August 2014 and February 2018, 802 patients were randomized to either Hughes closure (401) or the standard mass closure group (401). At 1 year after surgery, 672 patients (83.7 per cent) were included in the primary outcome analysis; 50 of 339 patients (14.8 per cent) in the Hughes group and 57 of 333 (17.1 per cent) in the standard closure group had incisional hernia (OR 0.84, 95 per cent c.i. 0.55 to 1.27; P = 0.402). At 2 years, 78 patients (28.7 per cent) in the Hughes repair group and 84 (31.8 per cent) in the standard closure group had incisional hernia (OR 0.86, 0.59 to 1.25; P = 0.429). Adverse events were similar in the two groups, apart from the rate of surgical-site infection, which was higher in the Hughes group (13.2 versus 7.7 per cent; OR 1.82, 1.14 to 2.91; P = 0.011).

CONCLUSION

The incidence of incisional hernia after colorectal cancer surgery is high. There was no statistical difference in incidence between Hughes closure and mass closure at 1 or 2 years.

REGISTRATION NUMBER

ISRCTN25616490 (http://www.controlled-trials.com).

The Pregnant Trauma Patient

Trauma is the leading non-obstetric cause of maternal death. Optimal management of the pregnant trauma patient requires a multidisciplinary approach. The anaesthetist and critical care physician play a pivotal role in the entire continuum of fetomaternal care, from initial assessment, resuscitation and intraoperative management, to postoperative care that often involves critical care support and patient transfer. Primary goals are aggressive resuscitation of the mother and maintenance of uteroplacental perfusion and fetal oxygenation by the avoidance of hypoxia, hypotension, hypocapnia, acidosis and hypothermia. Recognizing and understanding the mechanisms of injury, the factors that may predict fetal outcome, and the pathophysiological changes that can result from trauma, will allow early identification and treatment of fetomaternal injury. This in turn should improve morbidity and mortality. A framework for the acute care of the pregnant trauma patient is presented.

Incidence and risk factors for alopecia in survivors of critical illness: A multi-centre observational study

PURPOSE

To investigate the incidence, nature and risk factors for patient-reported alopecia in survivors of critical illness.

MATERIALS AND METHODS

A multi-centre, mixed methods observational study in the intensive care units (ICU) of ten hospitals in Wales. All patients with an ICU stay of 5 days or more, able to give consent were included. Demographic variables and risk factors were collected. A pre-designed survey was completed at three months post-ICU discharge. Statistical analysis included numbers and percentages (categorical variables) and medians and interquartile ranges (continuous variables). Comparisons between patients with and without alopecia were made using Fisher's Exact test (categorical variables) and Mann Whitney U test (continuous variables). Multivariate logistic regression analysis was used to determine the risk factors for alopecia.

RESULTS

The survey was completed by 123 patients with alopecia reported in 44 (36%) patients. The only risk factor for alopecia on analysis was sepsis / septic shock (p < .001; OR: 5.1, 95%CI: 2.1-12.4).

CONCLUSIONS

Limited research exists examining the incidence, nature and risk factors for patient-reported alopecia in adult survivors of critical illness. The results of this study highlight the need to discuss the potential for alopecia with survivors of critical illness, who had sepsis / septic shock.

Erratum to: 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15-18 March 2016

[This corrects the article DOI: 10.1186/s13054-016-1208-6.].

Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrollment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis-none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.

Nature of child sexual abuse and psychopathology in adult survivors: results from a clinical sample in Scotland

The relationship between history of childhood sexual abuse and psychopathology in adult life is well established. However, understanding of the mechanisms by which abuse exerts its effects is limited. To our knowledge, this is the first study which investigates the relationship between a wide range of sexual abuse characteristics (i.e. age at onset, frequency of assaults, number of perpetrators and their relationship to the victim) and the severity of psychopathological disorders in a large sample of adult child sexual abuse (CSA) survivors who attended a specialist Psychotherapy Service for CSA survivors. CSA survivors in our study experienced severe sexual assault(s) in their early years and presented with severe pathology which could suggest a strong causal link. However, none of the examined trauma characteristics significantly predicted severity of psychopathology. This may suggest that for severely disordered, treatment-seeking CSA survivors post-abuse psychopathology could be caused by other factors. The study adds to the growing body of evidence suggesting that CSA effects may be dependent on factors which are not necessarily related to the nature of sexual abuse. The study findings will help improve clinicians' insight into the determinants of psychopathology.

The myth of Brucella L-forms and possible involvement of Brucella penicillin binding proteins (PBPs) in pathogenicity

Brucella spp. L-forms have been proposed to be stationary phase organisms in the evolution of new variants and enduring entities in the host in complicated cases of brucellosis and during latent brucellosis. In vitro formation of Brucella L-forms has been achieved by treating the cells with sub-lethal doses of penicillin. Interestingly, Brucella spp. have classified during the evolution into two groups, penicillin susceptible or penicillin resistant, yet both types grow on 20 microg/ml of methicillin. Strains proven susceptible to penicillin grew in the presence of methicillin as L-forms as demonstrated by light and electron microscopy. In addition, the B. melitensis vaccine strain Rev.1, a penicillin susceptible organism, responded to sheep serum by development of L-form-like structures unlike wild type, strain 16M. The two strains grew normally in sheep macrophages. We propose, for the first time, a model that associates Brucella pathogenicity with the structure and activity of two of their penicillin binding proteins (PBPs). According to the model, PBP1 has evolved as the major cell wall synthesizing enzyme of the genus, capable of responding to host serum growth factor(s) necessary for Brucella survival in the host. This property is associated with high avidity to beta-lactam antibiotics. PBP2 complements the activity of PBP1. New beta-lactam antibiotics and improved vaccines might be developed based on this property.

Estrogen receptor (ER) and progesterone receptor (PgR), by ligand-binding assay compared with ER, PgR and pS2, by immuno-histochemistry in predicting response to tamoxifen in metastatic breast cancer: a Southwest Oncology Group Study

Results of estrogen receptor (ER) and progesterone receptor (PgR) ligand-binding assays (LBAs) are strongly correlated with ER and PgR by immuno-histochemistry (IHC). To investigate whether ER and PgR by IHC are also strongly correlated with tamoxifen response, time to treatment failure (TTF) and overall survival (OS), the results of the 2 methods were directly compared in 205 patients with ER(+) metastatic breast cancer treated with daily tamoxifen (Southwest Oncology Group protocol 8228) with 9 years median follow-up. pS2, another estrogen-regulated molecule, was also analyzed. Tumors were scored for IHC from 0 to 5, according to the proportion of positively stained cells. These IHC scores for both ER and PgR were significantly associated with LBA levels (p < 0.001). There was a significant direct relationship between higher IHC ER, PgR and pS2 and increasing response to tamoxifen. TTF and OS were also significantly longer for patients with higher ER or PgR, but not pS2, IHC scores. Low, intermediate and high ER or PgR categories showed similar differences in response rates whether defined by LBA or IHC. In logistic regression models which included ER, PgR and pS2 by IHC; ER and PgR by LBA; and menopausal status, only ER (IHC) and pS2 (IHC) retained significance for predicting tamoxifen response (p = 0. 02 and p = 0.005, respectively), along with menopausal status (for PgR by IHC, p = 0.09). Increasing ER and PgR by IHC, as by LBA, are thus significantly associated with a progressively better response and longer survival in ER(+) metastatic breast cancer. pS2 is also predictive in this setting.

Heat shock proteins hsp27 and hsp70: lack of correlation with response to tamoxifen and clinical course of disease in estrogen receptor-positive metastatic breast cancer (a Southwest Oncology Group Study)

In this study, we tested the hypothesis that heat shock proteins (hsps) 27 and 70 are associated with clinical resistance to tamoxifen. hsp27 is, like progesterone receptor, an estrogen-regulated protein. hsp70 is also of interest because of its interaction with estrogen receptors and because hsp70 is a component of the molecular chaperone machinery functioning in the assembly and trafficking of steroid receptors. In addition, hsps in general help protect cells against noxious stimuli and stress, and their expression has been linked to drug resistance. The study involved 205 tumors from estrogen receptor-positive tamoxifen-treated breast cancer patients with metastatic disease. All patients received daily tamoxifen as initial therapy for metastatic disease. The study began in 1982, and follow-up is now 9 years. hsp27 and hsp70 were detected by immunohistochemistry and scored according to the nuclear and/or cytoplasmic content. Expression of hsp27 or hsp70 was unrelated to estrogen receptor content, progesterone receptor content, menopausal status, age, and presence of visceral disease. Cytoplasmic and nuclear hsp27 positivities were weakly and inversely related to each other (P = 0.05). There was a significant association between cytoplasmic hsp27 and cytoplasmic hsp70 content (P < 0.001), as well as between nuclear hsp70 and nuclear hsp27 content (P = 0.001). Cytoplasmic and nuclear hsp70 were also associated (P = 0.02). However, increased hsp27 and hsp70 expression (nuclear or cytoplasmic) was not significantly associated with response to tamoxifen, time to treatment failure, or survival. Thus, this study clarifies the lack of clinical utility of hsp27 and hsp70 in predicting the response to tamoxifen in an estrogen receptor-positive breast cancer population.

A comparison of artificial saliva and pilocarpine in the management of xerostomia in patients with advanced cancer

This was a crossover study comparing a mucin-based artificial saliva (Saliva Orthana) and pilocarpine hydrochloride (Salagen) in the management of xerostomia in patients with advanced cancer. The pilocarpine was found to be more effective than the artificial saliva in terms of mean change in visual analogue scale scores for xerostomia (P = 0.003). Furthermore, more patients reported that it had helped their xerostomia, and more patients wanted to continue with it after the study. However, the pilocarpine was found to be associated with more side-effects than the artificial saliva (P < 0.001). These side-effects were usually reported as being mild. Of the patients who used both treatments, 50% preferred the artificial saliva, and 50% preferred the pilocarpine. The commonest reason for preferring the artificial saliva was the fact that it was a spray, rather than a tablet.

HER-2 expression and response to tamoxifen in estrogen receptor-positive breast cancer: a Southwest Oncology Group Study

HER-2/neu is a growth factor receptor, the expression of which has been associated with a more aggressive breast tumor biology and resistance to some types of chemotherapy. Preliminary laboratory and clinical data have led to claims that HER-2/neu expression is also associated with resistance to tamoxifen. Therefore, to test the hypothesis that HER-2/neu expression is associated with a poorer response to tamoxifen, a shorter time to treatment failure (TTF), and worse survival in estrogen receptor (ER)-positive metastatic breast cancer, we examined 205 paraffin-embedded blocks of tumors from patients enrolled on Southwest Oncology Group 8228 for HER-2/neu expression. Tumors were ER positive (ER level > 3 fmol/mg cytosolic protein in either primary tumors or metastases), and patients had not received any prior therapy for metastatic disease. All patients were treated with daily tamoxifen. The study began in 1982, and median follow-up of patients who are still alive is now 9 years. Membrane staining for HER-2/neu was evaluated by immunohistochemistry using antibody TAB 250 and was scored according to the proportion of cells staining positive; tumors were deemed positive if > 1% of the cells stained for HER-2/neu. HER-2/neu positivity was associated with lower ER values (P = 0.04) and low bcl-2 (P = 0.01). HER-2/neu positivity was not significantly associated with response rate (negative versus positive, 57 versus 54%; P = 0.67), TTF (median, 8 versus 6 months; P = 0.15), or survival (median, 31 versus 29 months; P = 0.36). There was also no significant evidence of a progressive relationship between an increasing proportion of cells expressing HER-2/neu and a shorter TTF or survival. HER-2/neu expression in ER-positive metastatic breast cancer is not significantly associated with a poorer response to tamoxifen or a more aggressive clinical course. Earlier suggestions to the contrary may have been due to failure to rigorously exclude ER-negative tumors, which are much less likely to respond to tamoxifen and more likely to have high HER-2/neu levels.

Scottish general practice registrars--their views on psychotherapy training

BACKGROUND

Psychological problems constitute between 10% and 30% of general practice workload. In 1993, the Royal Colleges of General Practitioners and Psychiatrists published guidelines on the psychiatric component of vocational training for general practice, recognizing the need for training in the psychological aspects of patient care and knowledge of the psychotherapies. Little is known as to how much these guidelines have been followed.

AIM

To determine Scottish general practice registrars' views on whether the above training objectives had been met.

METHOD

An anonymous self-report questionnaire was sent to all general practice registrars in west and south-east Scotland one month before the end of their trainee year with a 95% response rate. This provided basic descriptive information on the population surveyed and their attitudes to psychotherapy training.

RESULTS

Altogether, 53% had spent time in psychiatry and half of these had had access to a consultant psychotherapist, but only 9% had been involved in using a psychological approach to treatment. A total of 51% disagreed that they had had enough psychotherapy experience, and 44% did not feel confident in assessing patients for psychotherapy, 15% saying that lack of knowledge would prevent them from referring patients. Of the whole sample, 88% felt that further psychotherapy training would be helpful.

CONCLUSION

The majority of general practice registrars in Scotland did not feel that training objectives had been met regarding the attainment of skills in the psychotherapies.

Increased intensification and total dose of cyclophosphamide in a doxorubicin-cyclophosphamide regimen for the treatment of primary breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-22

PURPOSE

The National Surgical Adjuvant Breast and Bowel Project (NSABP) initiated a randomized trial (B-22) to determine if intensifying but maintaining the total dose of cyclophosphamide (Cytoxan, Bristol-Myers Squibb Oncology, Princeton, NJ) in a doxorubicin (Adriamycin, Pharmacia, Kalamazoo, MI)-cyclophosphamide combination (AC), or if intensifying and increasing the total dose of cyclophosphamide improves the outcome of women with primary breast cancer and positive axillary nodes.

PATIENTS AND METHODS

Patients (N = 2,305) were randomized to receive either four courses of standard AC therapy (group 1); intensified therapy, in which the same total dose of cyclophosphamide was administered in two courses (group 2); or intensified and increased therapy, in which the total dose of cyclophosphamide was doubled (group 3). The dose and intensity of doxorubicin were similar in all groups. Disease-free survival (DFS) and overall survival were determined using life-table estimates.

RESULTS

There was no significant difference in DFS (P = .30) or overall survival (P = .95) among the groups through 5 years. At 5 years, the DFS of women in group 1 was similar to that of women in group 2 (62% v 60%, respectively; P = .43) and to that of women in group 3 (62% v 64%, respectively; P = .59). The 5-year survival of women in group 1 was similar to that of women in group 2 (78% v 77%, respectively; P = .86) and to that of women in group 3 (78% v 77%, respectively; P = .82). Grade 4 toxicity increased in groups 2 and 3. Failure to note a difference in outcome among the groups was unrelated to either differences in amount and intensity of cyclophosphamide or to dose delays and intervals between courses of therapy.

CONCLUSION

Intensifying or intensifying and increasing the total dose of cyclophosphamide failed to significantly improve either DFS or overall survival in any group. It was concluded that, outside of a clinical trial, dose-intensification of cyclophosphamide in an AC combination represents inappropriate therapy for women with primary breast cancer.

bcl-2, p53, and response to tamoxifen in estrogen receptor-positive metastatic breast cancer: a Southwest Oncology Group study

PURPOSE

To test the hypothesis that high bcl-2 expression and accumulation of p53 protein, both of which should inhibit apoptosis, are associated with a poorer tamoxifen response and a more aggressive clinical course in estrogen receptor (ER)-positive metastatic breast cancer.

METHODS

A total of 205 paraffin-embedded tumor blocks were evaluated for nuclear p53 (a marker of p53 inactivation) and cytoplasmic bcl-2 by immunohistochemistry (IHC). All patients received tamoxifen as initial therapy for metastatic disease. The study began in 1982 and follow-up duration of the 24 patients last known alive is 8 years.

RESULTS

Response to tamoxifen and time to treatment failure (TTF) were not significantly associated with p53 status, although patients with higher p53 had a worse survival (P = .008; median, 36 v 20 months). Higher bcl-2 expression was associated with higher levels of ER (P = .02), better response to tamoxifen (62% v 49%; P = .07), longer TTF (median, 9 v 5 months; P = .002), and better survival (median, 40 months v 25 months; P = .009). In multivariate analyses, including ER, progesterone receptor (PgR), and p53, high bcl-2 remained significantly associated with a longer TTF (P = .007) and survival (P = .07). p53 status was a significant factor for shorter survival (P = .05), but not for TTF (P = .61).

CONCLUSION

p53 status, as determined by IHC is not significantly associated with response to tamoxifen, although tumors with altered p53 protein are inherently more aggressive. Contrary to expectation, high bcl-2 identifies a relatively indolent phenotype of ER-positive metastatic breast cancer, in which patients experience a better clinical response to tamoxifen and a longer survival.

Tinnitus coping style and its relationship to tinnitus severity and emotional distress

The structure of the Tinnitus Coping Style Questionnaire (TCSQ) is examined in a sample of 108 tinnitus sufferers. Factor analysis of the TCSQ items identified two coping styles that were termed "effective coping" and "maladaptive coping". It is shown that "maladaptive coping," but not "effective coping," is related to reports of subjective tinnitus severity and emotional distress. The clinical implications of these findings are discussed.

The relationship between locus of control, tinnitus severity, and emotional distress in a group of tinnitus sufferers

One hundred and nine tinnitus sufferers attending a specialist out-patient clinic completed questionnaires assessing the following: locus of control of behaviour, anxiety (STAI), depression (BDI) and tinnitus severity. Anxiety and depression were found to be correlated with tinnitus severity, as was locus of control, with "internals" reporting their tinnitus to be less severe than "externals." Partial correlations indicated that locus of control did not directly affect tinnitus severity, but rather, this effect was mediated by the effect of locus of control on anxiety and depression.

Patients' reports of the effect of alcohol on tinnitus

One hundred chronic sufferers attending a tinnitus outpatient clinic completed self-report questionnaires assessing the quantity of alcohol they consumed weekly and its effect on tinnitus. The results showed a mixed effect of alcohol on tinnitus with 22% of the sample reporting that drinking worsened tinnitus, 62% reporting no effect of alcohol on tinnitus and 16% reporting that alcohol improved tinnitus. The reported effect of alcohol on tinnitus significantly influenced the reported change in the level of alcohol intake since tinnitus onset, with significantly more units of alcohol being consumed by those sufferers who reported that alcohol improved their tinnitus. However, for the sample as a whole, drinking behaviour was not significantly different to that of the general population.

Estimating numbers of homeless and homeless mentally ill people in north east Westminster by using capture-recapture analysis

OBJECTIVES

To use routinely collected data to provide a reliable estimate of the size and psychiatric morbidity of the homeless population of a given geographical area by using capture-recapture analysis.

DESIGN

A multiple sample, log-linear capture-recapture method was applied to a defined area of central London during 6 months. The method calculates the total homeless population from the sum of the population actually observed and an estimate of the unobserved population. Data were collected from local agencies used by homeless people.

SUBJECTS

Homeless people in north east Westminster residing in bed and breakfast accommodation and hotels or sleeping rough who had contacted statutory or voluntary agencies in the area.

RESULTS

2150 contacts by 1640 homeless people were recorded. The estimated unobserved population was 3293, giving a total homeless population for the period of around 5000 (SD 1250). Mental health problems were significantly less prominent in the unobserved compared with the observed population (23% (754) v 40% (627), P < 0.0001). For both groups the prevalence varied greatly with age and sex.

CONCLUSIONS

Capture-recapture techniques can overcome problems of ascertainment in estimating populations of homeless and homeless mentally ill people. Prevalences of mental illness derived from surveys that do not correct for ascertainment are likely to be falsely inflated while at the same time underestimating the total size of the homeless mentally ill population. Population estimates derived from capture-recapture techniques may usefully provide a good basis for including homeless populations in capitation calculations for allocating funds within health services.

Selective memory for sensory and affective information in chronic pain and depression

Mood congruity effects in induced mood states and affective disorders are well established. Recent evidence suggests that a similar process occurs in chronic pain patients, although the extent to which the memory bias is a consequence of the affective or sensory state of the subject in this group is unknown. In this study selective memory for sensory and affective pain-related information was investigated in depressed and non-depressed chronic pain patients and depressed psychiatric patients. A recall test comprising sensory, affective and neutral adjectives matched for frequency was followed by a recognition task, where the words of the recall test were randomized with an equal number of new adjectives matched for word type and frequency. Comparison of the three patient groups with normal controls revealed specific recall biases directly related to pain and depression in both chronic pain groups and the controls. Contrary to expectations, the depressed psychiatric patients failed to show a recall bias for affective adjectives: the possibility of cognitive avoidance as an explanation for this is discussed. Signal detection analysis of the recognition results suggested that selective memory in chronic pain and depression may to some extent be accounted for by differences in 'true memory', the contribution of response bias remaining less clear.

Predictors of relatives' attendance at a state hospital workshop on schizophrenia

A prospective research design was used to identify patient and family variables that would predict relatives' attendance at an educational workshop on schizophrenia at a state psychiatric hospital. Data were collected from patient charts and telephone interviews with relatives. Thirty-two percent of the 84 invited relatives attended the workshop. Significant predictors of attendance included relatives' proximity to the hospital, previous number of visits with the patient, knowledge about schizophrenia, and familiarity with the National Alliance for the Mentally Ill. The findings suggest that a substantial proportion of relatives of the seriously mentally ill desire information and help in coping with their ill family member. Relatives' participation might be further increased by conducting workshops at more convenient sites and encouraging attendance by those less knowledgeable about schizophrenia.

Structural and immunochemical aspects of Brucella abortus endotoxins

Smooth lipopolysaccharide (sLPS) of Brucella abortus, which is the most immunodominant component among the antigens of B. abortus isolated, has been used for diagnosis for decades. High yields of sLPS can be prepared by a modification of the procedures of Moreno et al. (J. Bacteriol. 138:361-369, 1979). Washed B. abortus cells can be disrupted by 21 freeze-quick thaw cycles and ultrasonication to separate non-membrane-bound material; then phenol extraction is performed 3 times and the phenol fraction is washed with H2O intensively. The membrane-bound sLPS can be fractionated into 3 to 5 groups according to the extent of dialysis and centrifugation. These membrane bound sLPS fractions show marked individual differences in their precipitin profile and chemical composition. Their protein content varies from 16% to 42% as determined by dye binding test and 17 to 60% by Lowry phenol method using bovine serum albumin as the standard, which indicates that these proteins associated with LPS may play important roles in the immunochemical interactions, solubility, and the heterogeneity of B. abortus lipopolysaccharides. Compared to previously published methods, a higher yield of sLPS, ranging from 3.6% to 7.7% of dried bacteria, is obtained. Group f5A, which has a standard bell shaped curve in the precipitin assay, is one of the major fractions in all three strains (1119.3, 19, 2308). The protein free sLPS (less than 1% of Lowry reactive component) can be prepared by pronase digestion. The immunochemical reactivity remains about the same before and after this treatment. The O-chains of the major fraction (f5A) of B. abortus (Strains 2308 and 19) membrane bound smooth lipopolysaccharide (sLPS) are obtained by hydrolysis of f5A native sLPS in 1% acetic acid at 100 degrees C for 2 hours. After hydrolysis, the O-chains are separated from the lipid A protein complex by centrifugation, and from small fragments by ultrafiltration of a molecular weight cut-off (MWCO) of 1.0 x 10(3). These carbohydrate haptens can be identified by precipitin-inhibition assay and further fractionated by both membrane filtration and dialysis. The size distributions of carbohydrate haptens of the endotoxins (f5A) ranged from several oligosaccharides up to 1.0 x 10(4) MWCO. Three major fractions of MWCO 8.0-10.0 x 10(3), 3.5-5.0 x 10(3), and less than 1.0 x 10(3) for both strains 2308 and 19 contain more than 85% of the total immunreactive materials.(ABSTRACT TRUNCATED AT 400 WORDS)

Immunochemical and partial chemical characterization of fractions of membrane-bound smooth lipopolysaccharide-protein complex from Brucella abortus

Smooth lipopolysaccharide (sLPS) of Brucella abortus was prepared and fractionated by a modification of the procedures of Moreno et al. (J. Bac. 138:361-369, 1979). Washed B. abortus cells were disrupted by 21 freeze-quick thaw cycles with ultrasonication to separate the non-membrane-bound material. Ultrasonicated bacteria were used for preparation of membrane-bound sLPS (approximately f5, the main crude sLPS fraction described by Moreno et al.). Phenol extraction was repeated 3 times and then washed with H2O 10 times to remove most of the chromogen, polysaccharides and nucleic acids, eliminating the need for enzyme treatment as described previously. The membrane-bound sLPS was fractionated into 3 to 5 groups according to the extent of dialysis and centrifugation, these fractions required only 80 ng for positive ELISA, about 0.2 ng for positive Limulus lysate tests, and reacted well with precipitating antibodies in the serum from a strain 2308 infected cow. They had marked differences in precipitin curves and chemical composition. The protein content varied from 16% to 42% as determined by dye binding test and 17 to 60% by Lowry phenol method using bovine serum albumin as the standard, which implies that the proteins associated with LPS may also play important roles in the complex for the immunochemical interactions and the heterogeneity of B. abortus lipopolysaccharide protein complex. As compared with previous reports, a higher yield of sLPS, ranging from 3.6% to 7.7% of dried bacteria, was obtained. Group f5A, which had a standard bell shaped curve in the precipitin assay, is one of the major fractions in all three strains (1119.3, 19 and 2308). The amount of other subfractions obtained varied with batches or strains of B. abortus. These results provide a new profile of the immunochemical reactivities and the heterogeneity on B. abortus smooth membrane-bound endotoxins.

Short-term chemotherapy of poor-prognosis metastatic breast cancer with three non-cross resistant chemotherapy regimens. A Southwest Oncology Group Study

A Southwest Oncology Group pilot study was designed to evaluate a brief, 4.5-month induction course of chemotherapy with three presumably non-cross resistant regimens in poor-prognosis metastatic breast cancer. Sixty-three patients were treated with doxorubicin, cyclophosphamide, plus vincristine on day 1, methotrexate followed 30 minutes later by 5-fluorouracil (5-FU) on day 22, and mitomycin C plus 3 days of vinblastine on day 43. All three sequential regimens were repeated once and therapy was then discontinued in responding patients. The same chemotherapy was reinstituted at the time of relapse. The overall response rate to the induction chemotherapy was 35% and included only one complete response (2%). Median response duration was 9 months. Respondents were off all therapy for a median of 5 months (range, 1-12+ months) and were followed without evidence of progressive disease. Response to retreatment was 30% with no complete responses seen. Overall median survival from the data of diagnosis of metastatic disease was 24 months, with a median survival of 14 months from the date of initiation of therapy. Toxicity for this induction regimen was moderate with two treatment-related deaths secondary to myelosuppression. While the results of this pilot study fail to support the use of non-cross resistant regimens in breast cancer, short-term therapy appears to have no adverse effect on survival and resulted in significant periods during which no therapy was given, resulting in a reduction in overall toxicity.

Doxorubicin and methotrexate on a weekly schedule in patients with sarcomas

Fifty-five sarcoma patients with advanced measurable disease were treated with a doxorubicin and methotrexate combination in which both drugs were given on a weekly schedule. Patients received doxorubicin and methotrexate at three prospectively evaluated treatment levels with doxorubicin dosage ranging from 0.5 to 0.725 mg/kg/week and methotrexate dosage ranging from 0.25 to 0.375 mg/kg/week. Objective responses were seen in 11 of 39 (28%) patients receiving the two higher doxorubicin-methotrexate treatment levels where doxorubicin dose was greater than 0.5 mg/kg/week compared to only 2 of 16 (12%) patients receiving lower doxorubicin levels (p less than 0.05), suggestive of a dose-response relationship. Toxicity of this regimen was manageable but stomatitis was appreciable, seen in 30% of patients. These results support the activity of weekly doxorubicin in sarcoma therapy. However, no apparent improvement was associated with addition of conventional dose methotrexate to weekly doxorubicin treatment.

Thresholds of the dog for detection of inhaled eugenol and benzaldehyde determined by electroencephalographic and behavioral olfactometry

Electroencephalographic olfactometry and behavioral olfactometry were developed to evaluate objectively the olfactory function of 12 dogs. These techniques were used to determined normative thresholds for benzaldehyde, a mixed olfactory and trigeminal stimulant, and eugenol, a suspected pure olfactory stimulant, in 12 dogs. Both techniques were effective in obtaining a mean threshold for clinically normal dogs. Electroencephalographic olfactometry was demonstrated to be more sensitive than was behavioral olfactometry. The techniques measured olfactory function by failure to evoke responses in dogs after ablation of olfactory mucosa. The contribution of trigeminal stimulation to the thresholds was not determined.

Expression of viral arthritis-tenosynovitis infection in immunosuppressed chickens

Previously untreated chicks and those treated neonatally with either cyclophosphamide (CY) or infectious bursal disease virus (IBDV) were subcutaneously inoculated with viral arthritis virus ( VAV ) to determine whether suppression of humoral immunity would affect VAV pathogenicity. No difference was apparent in the disease process that occurred in the immunosuppressed versus the nonimmunosuppressed chickens. However, in the immunosuppressed birds, VAV was recovered from the heart and tendon tissues earlier in the postinoculation (PI) period. Also, VAV inoculated immunosuppressed birds carried higher levels of serum gamma globulins at certain PI intervals than the VAV inoculated positive controls or the untreated negative control chickens. It is suggested that the suppression of the bursa of Fabricius (BF) by CY or IBDV did not interfere in the antibody production to VAV , but the antibody produced was qualitatively defective.

Doxorubicin and CCNU with or without vincristine in patients with advanced refractory breast cancer. A randomized trial

Thirty-five patients with advanced breast cancer refractory to initial chemotherapy were randomized to receive two-drug doxorubicin-CCNU or three-drug doxorubicin-CCNU-vincristine (VCR) treatment. Doxorubicin (25-40 mg/m2) and VCR (1.4 mg/m2) were given intravenously every 21 days; CCNU (65-90 mg/m2) was given orally every 42 days. Patients with liver or bone marrow metastases initially received the lower range doses. All patients failed prior chemotherapy with cyclophosphamide and 5-FU with or without methotrexate and prednisone; 67% received prior hormonal therapy. Pretreatment patient characteristics were comparable in both groups. Objective responses (greater than 50% reduction in tumor size) were seen in 7 of 18 patients (39%) on the VCR containing arm and in 8 of 17 patients (46%) on the doxorubicin-CCNU arm. Survival was not improved by VCR addition with overall survival on the doxorubicin-CCNU arm, approximately 10% greater at all intervals (median 9.1 versus 7.0 months; not statistically significant). However, neurotoxicity was significantly greater in the VCR arm (36% versus 0%; P less than 0.05). In advanced breast cancer, no benefit to VCR addition was seen in prior randomized studies of first-line combinations where VCR was the treatment variable. Such results, combined with our experience with VCR in a salvage regimen, question the value of VCR addition to combination regimens in advanced breast cancer.

An association between hostility and poor adherence to treatment in patients suffering from depression

Direction of hostility, as measured by the Hostility and Direction of Hostility Questionnaire, was found to be associated with poor compliance during a treatment trial of a new tricyclic antidepressant. An association with other factors such as the type and severity of depression was not found. There are other studies in the literature which support these observations although some controversy surrounds the role played by personality variables in adherence to treatment. Hostility has been shown to be a possible factor in the aetiology of depression, an important factor in the classification of depression, and a symptom of depression which improves with treatment. Hostility may have a particularly large importance in compliance with treatment for depression or may have been overlooked in studies in compliance with treatment for non-psychiatric disorders.

Does lofepramine have fewer side effects than amitriptyline? Results of a comparative trial

A double blind trial was carried out comparing the tricyclic antidepressant lofepramine with amitriptyline in the treatment of patients suffering from moderate to markedly severe depression. No difference was demonstrated between the two drugs in terms of their antidepressant effect, but patients treated with lofepramine suffered from significantly less side effects than patients treated with amitriptyline. Both groups of patients had a high drop out rate but this was less marked in the groups of patients treated with lofepramine.

Cisplatin hydration with and without mannitol diuresis in refractory disseminated malignant melanoma: a southwest oncology group study

In a prospective phase II randomized trial, a dose of 100 mg/m2 iv cisplatin every 3 weeks plus forced hydration with or without mannitol diuresis was tested in patients with previously treated advanced malignant melanoma. A total of 67 patients were evaluated: 33 not given mannitol and 34 in the mannitol arm. Two partial remissions (of 2+ and 6.5 months) were achieved in the no-mannitol arm and one complete response and four partial responses (of 1, 2, 2.5, 5.5, and 8 months) were seen in the mannitol arm. Moderate, severe, and life-threatening renal toxicity was less in the mannitol arm, and patients tolerated more doses of cisplatin. The renal toxicity occurred mostly after the first dose of chemotherapy and did not seem to be cumulative. Other side effects were comparable in both arms. We concluded that renal toxicity is less severe in patients treated with cisplatin, hydration, and mannitol and that the use of cisplatin alone or in combination with other active agent(s) should be considered for further evaluation in previously untreated patients with malignant melanoma.