Male and female WorldSID and post mortem human subject responses in full-scale vehicle tests

OBJECTIVE

This study compares the responses of male and female WorldSID dummies with post mortem human subject (PMHS) responses in full-scale vehicle tests.

METHODS

Tests were conducted according to the FMVSS-214 protocols and using the U.S. Side Impact New Car Assessment Program change in velocity to match PMHS experiments, published earlier. Moving deformable barrier (MDB) tests were conducted with the male and female surrogates in the left front and left rear seats. Pole tests were performed with the male surrogate in the left front seat. Three-point belt restraints were used. Sedan-type vehicles were used from the same manufacturer with side airbags. The PMHS head was instrumented with a pyramid-shaped nine-axis accelerometer package, with angular velocity transducers on the head. Accelerometers and angular velocity transducers were secured to T1, T6, and T12 spinous processes and sacrum. Three chest bands were secured around the upper, middle, and lower thoraces. Dummy instrumentation included five infrared telescoping rods for assessment of chest compression (IR-TRACC) and a chest band at the first abdomen rib, head angular velocity transducer, and head, T1, T4, T12, and pelvis accelerometers.

RESULTS

Morphological responses of the kinematics of the head, thoracic spine, and pelvis matched in both surrogates for each pair. The peak magnitudes of the torso accelerations were lower for the dummy than for the biological surrogate. The brain rotational injury criterion (BrIC) response was the highest in the male dummy for the MDB test and PMHS. The probability of AIS3+ injuries, based on the head injury criterion, ranged from 3% to 13% for the PMHS and from 3% to 21% for the dummy from all tests. The BrIC-based metrics ranged from 0 to 21% for the biological and 0 to 48% for the dummy surrogates. The deflection profiles from the IR-TRACC sensors were unimodal. The maximum deflections from the chest band placed on the first abdominal rib were 31.7 mm and 25.4 mm for the male and female dummies in the MDB test, and 37.4 mm for the male dummy in the pole test. The maximum deflections computed from the chest band contours at a gauge equivalent to the IR-TRACC location were 25.9 mm and 14.8 mm for the male and female dummies in the MDB test, and 37.4 mm for the male dummy in the pole test. Other data (static vehicle deformation profiles, accelerations histories of different body regions, and chest band contours for the dummy and PMHS) are given in the appendix.

CONCLUSIONS

This is the first study to compare the responses of PMHS and male and female dummies in MDB and pole tests, done using the same recent model year vehicles with side airbag and head curtain restraints. The differences between the dummy and PMHS torso accelerations suggest the need for design improvements in the WorldSID dummy. The translation-based metrics suggest low probability of head injury. As the dummy internal sensor underrecorded the peak deflection, multipoint displacement measures are therefore needed for a more accurate quantification of deflection to improve the safety assessment of occupants.

Oblique Loading in Post Mortem Human Surrogates from Vehicle Lateral Impact Tests using Chestbands

While numerous studies have been conducted to determine side impact responses of Post Mortem Human Surrogates (PMHS) using sled and other equipment, experiments using the biological surrogate in modern full-scale vehicles are not available. The present study investigated the presence of oblique loading in moving deformable barrier and pole tests. Threepoint belt restrained PMHS were positioned in the left front and left rear seats in the former and left front seat in the latter condition and tested according to consumer testing protocols. Three chestbands were used in each specimen (upper, middle and lower thorax). Accelerometers were secured to the skull, shoulder, upper, middle and lower thoracic vertebrae, sternum, and sacrum. Chestband signals were processed to determine magnitudes and angulations of peak deflections. The magnitude and timing of various signal peaks are given. Vehicle accelerations, door velocities, and seat belt loads are also given. Analysis of deformation contours, peak deflections, and angulations indicated that the left rear seated specimen were exposed to anterior oblique loading while left front specimens in both tests sustained essentially pure lateral loading to the torso. These data can be used to validate human body computational models. The occurrence of oblique loading in full-scale testing, hitherto unrecognized, may serve to stimulate the exploration of its role in injuries to the thorax and lower extremities in modern vehicles. It may be important to continue research in this area because injury metrics have a lower threshold for angled loading.

Injuries in Full-Scale Vehicle Side Impact Moving Deformable Barrier and Pole Tests Using Postmortem Human Subjects

OBJECTIVE

To conduct near-side moving deformable barrier (MDB) and pole tests with postmortem human subjects (PMHS) in full-scale modern vehicles, document and score injuries, and examine the potential for angled chest loading in these tests to serve as a data set for dummy biofidelity evaluations and computational modeling.

METHODS

Two PMHS (outboard left front and rear seat occupants) for MDB and one PMHS (outboard left front seat occupant) for pole tests were used. Both tests used sedan-type vehicles from same manufacturer with side airbags. Pretest x-ray and computed tomography (CT) images were obtained. Three-point belt-restrained surrogates were positioned in respective outboard seats. Accelerometers were secured to T1, T6, and T12 spines; sternum and pelvis; seat tracks; floor; center of gravity; and MDB. Load cells were used on the pole. Biomechanical data were gathered at 20 kHz. Outboard and inboard high-speed cameras were used for kinematics. X-rays and CT images were taken and autopsy was done following the test. The Abbreviated Injury Scale (AIS) 2005 scoring scheme was used to score injuries.

RESULTS

MDB test: male (front seat) and female (rear seat) PMHS occupant demographics: 52 and 57 years, 177 and 166 cm stature, 78 and 65 kg total body mass. Demographics of the PMHS occupant in the pole test: male, 26 years, 179 cm stature, and 84 kg total body mass. Front seat PMHS in MDB test: 6 near-side rib fractures (AIS = 3): 160-265 mm vertically from suprasternal notch and 40-80 mm circumferentially from center of sternum. Left rear seat PMHS responded with multiple bilateral rib fractures: 9 on the near side and 5 on the contralateral side (AIS = 3). One rib fractured twice. On the near and contralateral sides, fractures were 30-210 and 20-105 mm vertically from the suprasternal notch and 90-200 and 55-135 mm circumferentially from the center of sternum. A fracture of the left intertrochanteric crest occurred (AIS = 3). Pole test PMHS had one near-side third rib fracture. Thoracic accelerations of the 2 occupants were different in the MDB test. Though both occupants sustained positive and negative x-accelerations to the sternum, peak magnitudes and relative changes were greater for the rear than the front seat occupant. Magnitudes of the thoracic and sternum accelerations were lower in the pole test.

CONCLUSIONS

This is the first study to use PMHS occupants in MDB and pole tests in the same recent model year vehicles with side airbag and head curtain restraints. Injuries to the unilateral thorax for the front seat PMHS in contrast to the bilateral thorax and hip for the rear seat occupant in the MDB test indicate the effects of impact on the seating location and restraint system. Posterolateral locations of fractures to the front seat PMHS are attributed to constrained kinematics of occupant interaction with torso side airbag restraint system. Angled loading to the rear seat occupant from coupled sagittal and coronal accelerations of the sternum representing anterior thorax loading contributed to bilateral fractures. Inward bending initiated by the distal femur complex resulting in adduction of ipsilateral lower extremity resulted in intertrochanteric fracture to the rear seat occupant. These results serve as a data set for evaluating the biofidelity of the WorldSID and federalized side impact dummies and assist in validating human body computational models, which are increasingly used in crashworthiness studies.

The influence of sex and histology on outcomes in non-small-cell lung cancer: a pooled analysis of five randomized trials

BACKGROUND

Some non-small-cell lung cancer (NSCLC) surgical series have indicated that the positive prognostic effect of female sex is limited to patients with adenocarcinoma. We carried out a retrospective analysis to investigate the role of sex and histology on efficacy, toxicity, and dose delivery after chemotherapy.

PATIENT AND METHODS

Individual patient data were pooled from five randomized, phase III, advanced NSCLC chemotherapy trials. Primary outcomes were response rate, overall survival (OS), toxicity, and dose delivery. A secondary analysis examined survival by sex in histological subgroups.

RESULTS

Of 2349 patients, 34% were women. Women had a higher response rate to chemotherapy (42% versus 40%, P = 0.01) and longer survival than men (median OS 9.6 versus 8.6 months, P = 0.002). The difference in OS remained after adjusting for age, stage, performance status, and histology (hazard ratio 0.83, 95% confidence interval 0.74-0.92, P = 0.0005). Upon further examination, longer survival in women was only seen in patients with adenocarcinoma (test for interaction P = 0.006). There were no differences in hematological toxicity or transfusions. Women experienced more grade 3-4 emesis than men (P < 0.0001) and more dose delays (P = 0.02) or dose reductions (P < 0.0001).

CONCLUSION

The positive prognostic effect among women is confirmed in patients receiving platinum-based chemotherapy but appears confined to those with adenocarcinoma histology.

A randomized phase III trial of active symptom control (ASC) with or without chemotherapy in the treatment of patients with malignant pleural mesothelioma: First results of the Medical Research Council (MRC) / British Thoracic Society (BTS) MS01 trial

LBA7525

Background: Although chemotherapy is widely used in the treatment of mesothelioma it has never been compared in a randomized trial with ASC alone. Two chemotherapy regimens that had shown good symptom palliation in phase II studies were chosen for investigation. Methods: Patients with malignant pleural mesothelioma were randomized to ASC alone (regular follow-up in a specialist clinic, and treatment could include steroids, analgesics, bronchodilators, palliative radiotherapy, etc), ASC+MVP (4 × 3-weekly cycles of mitomycin 6g/m2, vinblastine 6mg/m2, and cisplatin 50mg/m2), or ASC+N (12 weekly injections of vinorelbine 30mg/m2). 420 patients were required to detect a 3-month improvement in median survival with ASC+CT (both chemotherapy arms combined). Quality of Life (QL) was assessed using the EORTC QLQ-C30. Results: 409 patients were accrued (136 ASC, 137 ASC+MVP, 136 ASC+N). Median age: 65 years, male: 91%, Performance status 0: 23%, Epithelial histology: 73%, Stage III: 33%, Stage IV: 48%. In the ASC+MVP group 61% received all 4 cycles, and in the ASC+N group 49% received at least 10 weekly cycles. Good symptom palliation (defined as prevention, control or improvement) was achieved in all 3 groups, and no between-group differences were observed in 4 pre-defined QL subscales (physical functioning, dyspnoea, pain and global QL). A small (not conventionally significant) survival benefit was seen for ASC+CT (349 deaths, HR 0.89, 95%CI 0.72, 1.12, p=0.32). Median survival: ASC: 7.6 months, ASC+CT: 8.5 months. Exploratory analyses suggested a survival advantage for vinorelbine compared to ASC alone (HR 0.81, 95%CI 0.63, 1.05, p=0.11), with a median survival of 9.4 months, but no evidence of a benefit with MVP (HR 0.98, 95%CI 0.76, 1.28), p=0.91). Conclusions: This is the 2nd largest ever randomized trial in mesothelioma and the first to compare ASC with or without chemotherapy. Although the addition of chemotherapy to ASC did not result in a conventionally significant survival benefit, there was an indication that vinorelbine should be investigated further, and that MVP probably has no role in this disease.

[Table: see text]

Development of injury criteria for pelvic fracture in frontal crashes

OBJECTIVE

This article assesses the position-dependent injury tolerance of the hip in the frontal direction based on testing of eight postmortem human subjects.

METHODS

For each subject, the left and right hemipelvis complex was axially loaded using a previously developed test configuration. Six positions were defined from a seated femur neutral condition, combining flexed, neutral, and extended femur positions with abducted, neutral, and adducted positions.

RESULTS

Axial injury tolerances based on peak force were found to be 6,850 +/- 840 N in the extended, neutral position and 4,080 +/- 830 N in the flexed, neutral position. From the flexed neutral orientation, the peak axial force increased 18% for 20 degrees abduction and decreased 6% for 20 degrees adduction. From the extended, neutral orientation, the peak axial force decreased 4% for 20 degrees abduction and decreased 3% for 20 degrees adduction. However, as there is evidence that increases in loading may occur after the initiation of fracture, the magnitude of the peak force is likely related to the extent of injury, not to the initial tolerance. Using the axial femur force at the initiation of fracture (assessed with acoustic crack sensors) as a potentially more relevant indicator of injury may lower the existing injury criteria. This fracture initiation force varied by position from 3,010 +/- 560 N in the flexed, neutral position to 5,470 N in the extended, abducted position. Further, there was a large position-dependent variation in the ratio of fracture initiation force to the peak axial force. The initiation of fracture was 83% of the peak axial force in the extended, abducted position, but the ratio was 34% in the extended, adducted position.

CONCLUSIONS

This may have significant implications for the development of pelvic injury criteria by automobile designers attempting to mitigate pelvis injuries.

Estimation of the additional costs of chemotherapy for patients with advanced non-small cell lung cancer

BACKGROUND

A large multicentre randomised trial, the Big Lung Trial, which in part compared supportive care with or without cisplatin-based chemotherapy in patients with advanced non-small cell lung cancer, provided an opportunity to evaluate the impact on the UK National Health Service of the costs incurred with the use of chemotherapy.

METHODS

This costing study was based on the retrospective collection of resource use data from hospital records. Case notes from 194 patients (98 chemotherapy + supportive care (C), 96 supportive care alone (NoC)) were inspected in eight centres recruiting the largest numbers of patients into the Big Lung Trial. Quantities were multiplied by fixed unit costs to calculate a total cost for each patient. The main outcome measure was the total cost incurred by the use of secondary care resources (including investigations, chemotherapy, radiotherapy, surgical procedures, inpatient days, outpatient attendances, and hospice inpatient care) in the two groups.

RESULTS

Patients randomised to receive cisplatin-based chemotherapy had an average of 3.4 more inpatient bed days than the mean of 11.9 days for patients randomised to supportive care alone, and more outpatient attendances. NoC patients were more likely to have received palliative radiotherapy. The mean total cost for C patients was 5355 sterling pound compared with 3595 sterling pound for the NoC group, difference 760 sterling pound (95% CI 781 sterling pound to 2742 sterling pound ). When split, the cost in the C group associated with the administration of chemotherapy was 1233 sterling pound and non-chemotherapy costs were 4122 sterling pound .

CONCLUSION

The additional cost of chemotherapy was not offset by a reduction in subsequent costs (as the non-chemotherapy costs were similar), so the survival benefit of about 10 weeks observed in the C group was achieved with the cost of chemotherapy administration.

Injury tolerance and response of the ankle joint in dynamic dorsiflexion

Forced dorsiflexion in frontal vehicle crashes is considered a common cause of injury to the ankle joint. Although a few studies have been published on the dynamic fracture tolerance of the ankle in dorsiflexion, this work reexamines the topic with increased statistical power, adds an evaluation of articular cartilage injury, and utilizes methods to detect the true time of fracture. The objective of this study was to measure the response and injury tolerance of the human ankle in a loading condition similar to that found in a vehicle crash with toepan intrusion. A test fixture was constructed to apply forefoot impacts to twenty cadaveric lower limbs, that were anatomically intact distal to the femur mid-diaphysis. Specimen instrumentation included implanted tibial and fibular load cells, accelerometers, angular rate sensors, and an acoustic sensor. Following the tests, specimens were radiographed and dissected to determine the extent of injury. Eleven of the twenty specimens sustained fracture of the ankle joint. Fractures of the medial malleolus were the most common, while two specimens sustained bimalleolar fractures, and two a talar neck fracture. Other injuries included ligament tears, osteochondral fractures, and cartilage abrasions. Analysis of the acoustic emission indicated that fracture did not always occur at the peak ankle moment. Based on the results of this study, an ankle joint moment of 59 N-m represents a 25% risk of ankle fracture in dorsiflexion for a 50(th) percentile male. When applied to the Thor-Lx dummy, the 25% risk of injury occurs at 36 degrees of dorsiflexion as measured by the ankle potentiometer.

Relationship power, condom use and HIV risk among women in the USA

Women's ability to negotiate safer sexual practices, particularly condom use, is a vital component of HIV/STD prevention strategies. Gender-based power imbalances may constrain women's negotiation ability, yet few empirical studies have tested the hypothesis that sexual relationship power constitutes a key factor in condom use negotiation. In this investigation, a new measure - the Sexual Relationship Power Scale (SRPS) - was applied. Data were collected from 388, mostly Latina, women at an urban community health centre in Massachusetts. Women with high levels of relationship power were five times as likely as women with low levels to report consistent condom use, after controlling for sociodemographic and psychosocial variables (p < 0.05). Population attributable risk estimates indicate that 52% of the lack of consistent condom use among women can be attributed to low sexual relationship power. The strong association between the Sexual Relationship Power Scale and consistent condom use supports the hypothesis that relationship power plays a key role in safer sex decision making. These findings underscore the importance of including the issue of relationship power in the design and implementation of programmes that promote sexual and reproductive health, as well as research investigating condom use and HIV risk.

Current perspectives on patient education in the US

Patient education has evolved from its medically-dominated and narrow origin in patient teaching to support of patient empowerment in interpersonal, organizational, and policy domains relevant to health. This essay reflects on both the historical and contemporary context of patient education in the US and explores implications of the empowerment movement on new initiatives and directions in patient education. By using diabetes education as an exemplar, innovations in patient activation and empowerment are explored and future directions and challenges to the field are considered.

Treatment of psychogenic polydipsia: comparison of risperidone and olanzapine, and the effects of an adjunctive angiotensin-II receptor blocking drug (irbesartan)

OBJECTIVE

Our objective was to determine the outcome of novel strategies in managing a case of severe polydipsia.

CLINICAL PICTURE

The patient was a 39-year-old male with a 20-year history of paranoid schizophrenia who, despite only mild residual psychotic symptoms, had been hospitalized for the previous 10 years because of severe polydipsic behaviour complicated by water intoxication.

TREATMENT

Novel antipsychotic agents, risperidone and olanzapine, as well as the specific angiotensin-II receptor blocking drug, irbesartan were employed at selected intervals in a study lasting nearly 3 years. A strict behavioural management programme was ongoing, in which diurnal weight change and the number of breaches of weight limits, requiring management in a low-stimulus environment, were documented on a daily basis. Summary measures of diurnal weight change and behavioural intervention were charted against changes in treatment.

OUTCOME

Polydipsic behaviour improved on risperidone up to 4 mg daily, but was not sustained. Olanzapine was similarly successful in stabilizing polydipsia, and improvement was achieved with the addition of irbesartan.

CONCLUSION

We suggest that the D2-sparing profiles of receptor binding achieved with low-dose risperidone and olanzapine may account for this beneficial effect. The benefit derived with irbesartan implicates the involvement of brain angiotensin systems centrally in helping to regulate drinking behaviour.

A qualitative evaluation of the Harvard Cancer Risk Index

There is an extensive amount of information in the popular press about cancer risk factors. The volume and sometimes contradictory nature of this information makes it difficult for individuals to understand their own level of risk or how one risk factor compares with another. The Harvard Cancer Risk Index (HCRI) was developed by an interdisciplinary working group of epidemiologists and behavioral scientists to educate the public about the major risk factors associated with the 11 most common forms of cancer in the United States. Following the development and validation of the HCRI, we initiated a qualitative research study to obtain initial feedback on the wording and presentation of the index and to elicit information regarding the meaning of risks, perception of cancer, and interpretation of the HCRI results. The results indicated that the HCRI was well received by participants and that they highly regarded the inclusion of information related to the latest risks for cancer and the description of the mechanisms by which these factors impact on risk. Personalization of the risk score helped participants to focus on behaviors that they could change. However, dissatisfaction with the HCRI was noted by some participants because exposures they believed to be important were not included (e.g., poverty, toxic waste, air pollution). Evaluation of the impact of the index on intention to change provided preliminary evidence that this may be an effective toll for helping mobilize individuals toward change across a number of risk factors. Further quantitative evaluation of the HCRI is planned.

A randomised, concentration-controlled, comparison of standard (5-day) vs. prolonged (15-day) infusions of etoposide phosphate in small-cell lung cancer

PURPOSE

This randomised trial was designed to investigate the activity and toxicity of continuous infusion etoposide phosphate (EP), targeting a plasma etoposide concentration of either 3 micrograms/ml for five days (5d) or 1 microgram/ml for 15 days (15d), in previously untreated SCLC patients with extensive disease.

PATIENTS AND METHODS

EP was used as a single agent. Plasma etoposide concentration was monitored on days 2 and 4 in patients receiving 5d EP and on days 2, 5, 8 and 11 in patients receiving 15d EP, with infusion modification to ensure target concentrations were achieved. Treatment was repeated every 21 days for up to six cycles, with a 25% reduction in target concentration in patients with toxicity.

RESULTS

The study has closed early after entry of 29 patients (14 with 5d EP, 15 with 15d EP). Objective responses were seen in seven of 12 (58%, confidence interval (CI): 27%-85%) evaluable patients after 5d EP, and two of 14 (14%, CI: 4%-42%) evaluable patients after 15d EP (P = 0.038). Grade 3 or 4 neutropenia or leucopenia during the first cycle of treatment was observed in six of 12 patients after 5d EP and 0/14 patients after 15d EP (P = 0.004), with median nadir WBC count of 2.6 x 10(9)/1 after 5d and 5.0 x 10(9)/1 after 15d EP (P = 0.017). Only one of 49 cycles of 15d EP was associated with grade 3 or worse haematological toxicity, compared to 14 of 61 cycles of 5d EP.

CONCLUSIONS

Although the number of patients entered into this trial was small, the low activity seen at 1 microgram/ml in the 15d arm suggests that this concentration is below the therapeutic window in this setting. Further concentration-controlled studies with prolonged EP infusions are required.

Clonal evolution of lung tumors

Lung tumors, particularly squamous cell carcinomas, are believed to develop through a series of morphological abnormalities, driven by underlying somatic genetic changes. One way of studying this process is to analyze candidate somatic genetic changes in samples of squamous metaplasia and bronchial dysplasia of varying degrees of severity as well as tumor from the same patient. This assumes a clonal relationship between these lesions. In this article, we provide evidence that adjacent, physically distinct bronchial abnormalities are clonally related. This has been achieved using a plaque assay technique to detect the same p53 mutation, present throughout a tumor specimen, in a small proportion of cells in an adjacent squamous metaplasia. In addition, we have obtained two dysplasia samples from a tumor-free patient over a 9-month interval. The earlier sample had one p53 mutation, whereas the later sample has to p53 mutations on different alleles. Thus, the pattern of clonal evolution detected in the parallel samples mimics the pattern seen in longitudinal samples and supports the analysis of synchronously collected samples for the study of tumor progression.

Sequential molecular genetic changes in lung cancer development

Epithelial tumours develop through a sequence of pre-invasive lesions of increasing disarray driven by underlying somatic genetic changes. We have studied the occurrence of the two most common somatic genetic changes associated with lung cancer in a series of premalignant bronchial lesions representing different stages in lung tumorigenesis. We present evidence that allele loss on chromosome 3 precedes damage to the p53 gene. Damage to chromosome 3 itself appears to be sequential in that the pattern of allele loss seen in dysplasia is often much more discrete than in invasive tumours. This implies that preneoplastic lesions may be a useful source of material for deletion mapping studies aimed at localising the position of tumour suppressor genes. We illustrate this by the comparison of an interstitial deletion described in this study with a homozygous deletion we have described previously, which has resulted in a better definition of the localisation of a tumour suppressor gene believed to be involved in lung cancer development.

Randomized trial comparing weekly versus 3-week chemotherapy in small-cell lung cancer: a Cancer Research Campaign trial

PURPOSE

A randomized trial of chemotherapy, given on either a 1-week or a 3-week schedule, was performed in small-cell lung cancer (SCLC) patients. The aim was to determine if weekly scheduling produced survival superior to conventional treatment.

PATIENTS AND METHODS

Four hundred thirty-eight patients with SCLC with either limited disease (LD; 276 patients) or good-prognosis extensive disease (ED; 162 patients) were randomized. Weekly chemotherapy was 12 alternating cycles of ifosfamide/doxorubicin and cis-platin/etoposide (PE), while 3-week treatment was six alternating cycles of cyclophosphamide/doxorubicin/vincristine (CAV) and PE. Thoracic irradiation was administered 3 weeks after completion of chemotherapy to LD patients who attained a complete response (CR) or partial response (PR). Patients were well matched for clinical characteristics and prognostic factors.

RESULTS

Overall response was the same in both arms: 82.3% (39.4% CR) with weekly and 81.1% (36.9% CR) with 3-week treatment. The median survival (MS) durations were 10.8 and 10.6 months for weekly and 3-week chemotherapy, respectively. The 2-year survival rates were 11.8% and 11.7% in the weekly and 3-week arms, respectively. Received dose-intensity (DI) was 73.9% of projected for weekly treatment and 92.7% for 3-week treatment. Hematologic toxicity was the major dose-limiting toxicity for the weekly treatment.

CONCLUSION

This trial excludes at 90% power a benefit of greater than 10% for 2-year survival for weekly treatment. The received DI was reduced to a greater extent with weekly treatment, mainly due to hematologic toxicity.

Laparoscopic correction of vesicoureteral reflux in the pig

Extravesical detrusorrhaphy is a modification of the Lich-Gregoir antireflux procedure that incorporates ureteral advancement into the repair. We report on our use of laparoscopic detrusorrhaphy to correct vesicoureteral reflux in an animal model. Reflux was created by transurethral incision of the roof of each ureteral orifice. In phase 1 of this study, laparoscopic repair was performed 1 week later in 3 pigs and an open technique was done in the remainder. In phase 2 laparoscopic repair was done in 3 pigs 3 weeks after inducing vesicoureteral reflux. All phase 1 repairs successfully corrected reflux but 1 ureter in the laparoscopic group developed obstruction. All phase 2 repairs were successful, which was determined by preoperative and postoperative cystography, and a postoperative excretory urogram. Average time was 2 hours 21 minutes for laparoscopic repair and 1 hour 10 minutes for the open procedure. Complications included bladder perforation and ureteral obstruction in 1 case each with no postoperative deaths. These preliminary results indicate that laparoscopic detrusorrhaphy is a feasible procedure in a porcine model.

Phase II study of fotemustine in untreated inoperable non-small-cell lung cancer

A total of 43 patients with advanced, previously untreated non-small-cell lung cancer (NSCLC) were treated with a novel nitrosourea, fotemustine, given at 100 mg/m2 on days 1 and 8. Maintenance treatment consisted of a single injection of 100 mg/m2 given every 21 days. 37 patients were evaluable for response. Of these, 5 patients had a partial response (13.5%; 95% confidence interval, 6%-28%). Toxicity comprised mainly anaemia and thrombocytopenia. Other toxicities were mild. This phase II study confirms that fotemustine is a moderately active and well-tolerated drug in NSCLC.

p53 and chromosome 3 abnormalities, characteristic of malignant lung tumours, are detectable in preinvasive lesions of the bronchus

Bronchial epithelial dysplasia is believed to precede invasive squamous cell carcinoma of the lung. Six paired dysplasia and tumour samples were distinguished histologically in sections of formalin-fixed paraffin-embedded lung tissue from patients with lung cancer. Additionally, samples of dysplastic bronchial epithelium were obtained from patients without lung tumours. Microdissection of the unstained sections provided dysplastic and tumour samples from which DNA was prepared for comparison with the patients' constitutional genotype, using polymerase chain reaction-based restriction fragment length polymorphism analysis. All six samples of tumour and the paired adjacent samples of bronchial dysplasia showed loss of heterozygosity (LOH) at loci on the short arm of chromosome 3. Five of the six cases showed involvement of the p53 gene as assessed by LOH at the AccII site within the gene, and by immunoreactivity to CM-1, an antibody which recognizes the mutated form of the p53 protein in paraffin-embedded material. Of the dysplastic samples, obtained from patients without invasive tumours, all three showed LOH at 3p; one sample showed LOH at the AccII polymorphic locus within the p53 gene, and another sample, uninformative at this locus, stained positively with this antibody. These results indicate that somatic genetic changes are present in preinvasive lesions in the bronchus.

Clinical value of the measurement of Mycobacterium tuberculosis specific antibody in pulmonary tuberculosis

BACKGROUND

A serological test that could help to diagnose tuberculosis, especially smear negative disease, would contribute to patient management.

METHODS

Levels of antibody to distinct antigens of Mycobacterium tuberculosis were assessed for their value in the diagnosis and management of pulmonary tuberculosis. Serum was taken from 52 patients who were smear positive, from 27 patients who were smear negative but with evidence of active tuberculosis (sputum culture positive in 16, response to antituberculosis chemotherapy in 11), from 11 patients with old healed tuberculosis (pre-antibiotic era), and from 39 healthy subjects vaccinated with BCG.

RESULTS

In smear positive tuberculosis an enzyme linked immunosorbent assay using a single 38 kDa antigen gave a diagnostic sensitivity of 80% with a 100% specificity. In smear negative pulmonary tuberculosis, however, combination of the 19 kDa antigen, lipoarabinomannan (ML 34 epitope), and hsp 65 (TB 78 epitope) was needed to achieve a sensitivity of 64% with a specificity of 95%. Recurrent and extensive radiographic disease with a poor prognosis was associated with high anti-38 kDa and low anti-14 kDa antibody levels in patients with active disease. Patients with less pulmonary cavitation had high anti-19 kDa titres. Bacteriological relapse during treatment was indicated by a rise in anti-14 kDa (TB68 epitope) antibodies. Four patients with non-tuberculous mycobacterial infection showed no anti-38 kDa antibody.

CONCLUSION

Antigen or epitope specific serology may help in the diagnosis, assessment of prognosis, and monitoring of chemotherapy in patients with pulmonary tuberculosis.

Epithelial differentiation in the absence of extracellular matrix

To investigate the regulation of epithelial differentiation, normal human epidermal keratinocytes were cultured floating on the surface of culture medium without attachment to a solid substrate. Keratinocytes spread out on the surface of the medium, proliferated and differentiated either into several flat lacy sheets 1 to 3 cells thick (on medium containing 0.15 mM calcium) or formed one single aggregate of cells from 5 to 15 cells in thickness on medium containing 1.15 mM calcium. The cell aggregates demonstrated a pattern of ordered epithelial differentiation. Levels of progressive differentiation resembling the structure of normal human epidermis were identified by light microscopy, immunohistochemistry, and electron microscopy. Differentiation proceeded from cells at the air side toward cells at the medium side with basal appearing cells on the air side and keratinocytes expressing filaggrin and involucrin on the side toward the medium. These results demonstrate that organized epithelial differentiation can occur in the absence of extracellular matrix. In contrast with other air-liquid interface cultures, epithelial differentiation in the absence of extracellular matrix progresses from air towards medium.

Intensive weekly chemotherapy for good-prognosis patients with small-cell lung cancer

A weekly, intensive chemotherapy regimen has been used to treat 70 patients with small-cell lung cancer (SCLC). Forty-five patients had limited disease (LD) and 25 extensive disease (ED) with good prognostic features. The regimen consisted of cisplatin 50 mg/m2 intravenously (IV) day 1 and etoposide 75 mg/m2 IV days 1 and 2, alternating weekly with ifosfamide 2 g/m2 IV day 8 and doxorubicin 25 mg/m2 IV day 8, for a total of 12 weeks. Dose modifications were made according to defined hematologic criteria. Responding patients with limited disease subsequently received mediastinal radiotherapy. Overall response to chemotherapy was 91% with a complete response (CR) rate of 50%. Forty-five patients with limited disease (LD) achieved an overall response rate of 91% with a CR rate of 51%, and 25 patients with extensive disease (ED) achieved an overall response rate of 92% with a CR rate of 48%. Median survival for the whole group was 54 weeks (LD, 58 weeks; ED, 42 weeks). Hematologic toxicity was predictable, without the wide fluctuations in WBC count seen in conventional 3-weekly regimens. In all, one quarter of treatment courses were delayed, most frequently because of leukopenia. Dose reductions were required in 63% of cases. The average delivered dose intensity was calculated and shown to be 73% of projected. Nonhematologic toxicity was mild with nausea and vomiting being the most common. This weekly schedule of chemotherapy has proved to be active and well tolerated and is currently being compared with conventional 3-weekly chemotherapy in a randomized study.

Mitomycin, ifosfamide and cisplatin in non-small-cell lung cancer

Chemotherapy with mitomycin C, ifosfamide and cisplatin (MIC) is reported to produce responses of 56% and 69% in inoperable non-small-cell lung cancer (NSCLC). We evaluated the regimen in 45 similar patients who received up to six courses of 6 mg/m2 mitomycin C, 3 g/m2 ifosfamide, and 50 mg/m2 cisplatin every 3 weeks. In all, 18 patients had limited disease (LD) and 27 had extensive disease (ED). A total of 18 patients responded (40%), 9/18 with LD and 9/27 with ED; there were 4 complete responders. The median duration of response was 25 weeks, and median survival was 32 weeks (range, 2-96 weeks). Toxicity was moderate. Nausea and vomiting were controlled with i.v. dexamethasone and high-dose metoclopramide. Other toxicities included myelosuppression and alopecia. This study confirms that MIC is one of the most active regimens for treatment of NSCLC, with acceptable toxicity.

Regional lung microvascular permeability using dual isotope scintigraphy

We have extended the dual isotope probe technique of Basran et al. for the measurement of pulmonary microvascular permeability (PMVP) to include gamma camera data acquisition and functional imaging of the plasma protein accumulation index (PPA) throughout the lung fields. The study group consisted of 11 patients with possible increased PMVP following the drainage of a pleural effusion or the evacuation of air from a pneumothorax, and 11 control patients. The PPA was calculated (1) for probe data, (2) on a pixel by pixel basis for the camera data, the results being stored in a functional image and (3) for four pixel x four pixel regions of interest positioned over the lung fields using the functional image and raw data as a guide. Functional images of the control group showed uniformly low PPAs throughout the lung fields. Nine of the eleven patients in the effusion/pneumothorax group showed discrete areas of increased PPA on the functional images. In the effusion/pneumothorax group, the re-expanded lung four pixel x four pixel ROI PPA values were significantly higher than the nonexpanded lung ROI values (p less than 0.001). The re-expanded lung ROI values were also significantly higher than the mean of the left and right lung ROIs in the control group (p less than 0.01). Five of the eleven patients in the effusion/pneumothorax group had probe PPAs that differed significantly from zero. We believe that probe positioning problems in the absence of sufficient clinical guidelines were largely responsible for there being no overall significant difference in the probe PPAs between the two study groups.

Systemic autoimmune disease and concurrent nematode infection in a dog

Systemic lupus erythematosus was diagnosed in a dog with concurrent nematode infection. The clinical signs of disease were unusually severe and included multiple neurologic deficits, polyarthritis, and weight loss. The dog was thrombocytopenic, and serotest results included positive lupus erythematosus test, positive rheumatoid factor test, positive antinuclear antibody test, hypergammaglobulinemia, and high platelet-associated IgG concentration. After treatment of hookworm, whipworm, and heartworm infections concurrently with corticosteroid and empiric treatment, the dog's condition improved. However, 10 days later, cyclophosphamide administration was necessary for continued immunosuppression. The dog was euthanatized because of progressive deterioration and development of canine coronavirus diarrhea. Serotest data generated from the dog's serum obtained at the time of referral suggested that autoantibodies and circulating immune complexes may have included IgE isotypes.

Humoral response to defined epitopes of tubercle bacilli in adult pulmonary and child tuberculosis

In order to investigate the humoral response to tuberculosis in different categories of patients, serum antibody levels to six epitopes of Mycobacterium tuberculosis in adult pulmonary and child tuberculosis were determined. Serum antibody titres were determined by competitive inhibition with radio-labelled murine monoclonal antibodies in 67 adults and 85 children with tuberculosis and in 79 age-matched controls. BCG vaccination (n = 39) and self-healed tuberculosis (n = 11) in adults gave rise to higher antibody titres to TB68, TB23 and TB72 epitopes (all p less than 0.003) when compared to non-vaccinated controls (n = 18). TB68 titres were higher (p = 0.006) in self-healed than in vaccinated adults. Adult sputum-negative patients (n = 15) had higher titres to TB71 (p = 0.015) and ML34 (p = 0.02) epitopes compared to BCG-vaccinated healthy controls, while sputum-positive patients (n = 41) had higher titres to all epitopes tested (all p less than 10(-4]. The diagnostic sensitivity, with a 95% specificity, was best with the combination of probes TB23, TB68, TB72 for sputum-positive (85%) and TB78, ML34 (53%) for sputum-negative patients. Antibody titres in children with tuberculosis were lower than in adult patients; diagnostic sensitivity in histologically or microbiologically proven cases (n = 18) was only 44%, while that in mediastinal lymph-adenitis (n = 67) was 13.5%. This study suggests that the magnitude and specificity of the humoral response to tubercle bacilli varies with site and severity of infection; the implications for pathogenesis or protective immunity are discussed.