Clay-shoveler’s fracture: A snapshot

The clay-shoveler’s fracture is a stable oblique fracture through the spinous process of a lower cervical vertebra, classically C6 or C7. Diagnosed on plain radiograph, computed tomography and occasionally magnetic resonance imaging, the injury is most commonly seen in road traffic collisions in the modern-day. A stable injury, the clay-shoveler’s fracture is managed non-operatively and requires symptomatic treatment only. This short article examines the history surrounding the injury and provides a comprehensive overview of the clay-shoveler’s fracture for the non-spinal surgeon.

2-¹⁸fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) for postchemotherapy seminoma residual lesions: a retrospective validation of the SEMPET trial

BACKGROUND

2-¹⁸fluoro-deoxy-D-glucose positron emission tomography (FDG-PET) has been recommended in international guidelines in the evaluation of postchemotherapy seminoma residuals. Our trial was designed to validate these recommendations in a larger group of patients.

PATIENTS AND METHODS

FDG-PET studies in patients with metastatic seminoma and residual masses after platinum-containing chemotherapy were correlated with either the histology of the resected lesion(s) or the clinical outcome.

RESULTS

One hundred and seventy seven FDG-PET results were contributed. Of 127 eligible PET studies, 69% were true negative, 11% true positive, 6% false negative, and 15% false positive. We compared PET scans carried out before and after a cut-off level of 6 weeks after the end of the last chemotherapy cycle. PET sensitivity, specificity, negative predictive value (NPV), and positive predictive value were 50%, 77%, 91%, and 25%, respectively, before the cut-off and 82%, 90%, 95%, and 69% after the cut-off. PET accuracy significantly improved from 73% before to 88% after the cut-off (P=0.032).

CONCLUSION

Our study confirms the high specificity, sensitivity, and NPV of FDG-PET for evaluating postchemotherapy seminoma residuals. When carried out at an adequate time point, FDG-PET remains a valuable tool for clinical decision-making in this clinical setting and spares patients unnecessary therapy.

Phenotypic variability in 17beta-hydroxysteroid dehydrogenase-3 deficiency and diagnostic pitfalls

OBJECTIVE

17beta-hydroxysteroid dehydrogenase type 3 isoenzyme (17beta-HSD3) is required to produce testosterone for male sex differentiation. Mutations in the HSD17B3 gene cause 17betaHSD3 deficiency and result in XY sex reversal of varying degree. We report the phenotypes of 14 subjects with 17betaHSD3 deficiency in relation to sex of rearing, androgen production, and HSD17B3 mutations.

DESIGN

Cases were identified through the Cambridge Disorders of Sex Development Database where detailed clinical information was recorded, results of hCG stimulation tests were available, and HSD17B3 mutation was identified.

RESULTS

Fourteen subjects from seven pedigrees (four consanguineous) had the following seven mutations: A56T, N130S, E215D, S232L, C268Y, V205E, and a novel mutation M197K. XY sex reversal was classified as complete in 10 infants at birth. Inguinal masses suggestive of androgen insensitivity syndrome (AIS) occurred in five infants. Contrasexual virilization reminiscent of 5alpha-reductase deficiency occurred in four subjects at puberty. The median (range) testosterone : androstenedione (T/A) ratio after a short hCG stimulation test was 0.32 (0.12-3.4). The S232L mutation identified in three affected family members caused isolated, severe hypospadias in one member who was raised male; virilization occurred despite in vitro studies showing an inactive mutant enzyme. Ratios of T/A in this pedigree were more than 0.8.

CONCLUSION

XY sex reversal is sufficiently variable in 17betaHSD3 deficiency to cause problems in accurate diagnosis, particularly in distinguishing it from AIS. It should be considered in undervirilized male infants with normal Wolffian duct structures, absent Müllerian ducts, and normal adrenal steroid biosynthesis; or when an assigned female subject virilizes at puberty. Elevated hCG-stimulated T/A ratio may occur, and sex of rearing may not be concordant within affected families with the same HSD17B3 mutation. The T/A ratio, mutation analysis and functional analysis of the mutant enzyme taken in isolation, respectively, may not conclusively establish a diagnosis of 17betaHSD3 deficiency in undervirilized male subjects; the reasons for these discrepancies remain unknown.

Five novel androgen receptor gene mutations associated with complete androgen insensitivity syndrome

Mutations in the androgen receptor (AR) gene result in androgen insensitivity syndrome (AIS). We have identified five novel mutations that result in a complete loss in AR function and are associated with complete AIS. The mutations span all three AR major functional domains. In two cases, the loss of AR function could be explained on the basis of the current knowledge of AR molecular structure and function. N-terminal mutation c.256C>T (p.Gln86X) leads to an early stop codon and abolishes all DNA and ligand binding. The DNA-binding domain mutation c.1685G>A (p.Cys562Tyr) is located in the N-terminal part of the first zinc finger; a mutation in this position is likely to impair the association of the mutated AR with the androgen response element of target genes. The splice site mutation at intron 2/exon 3 junction (c.1766-1G>A) is shown to lead to c.1765_1766 ins69 (p.[Gly589_Lys590ins23;Gly589Glu]). The two novel ligand-binding domain mutations identified were recreated by site-directed mutagenesis. Both mutations c.2171G>T (p.Gly724Val) and c.2435T>C (p.Leu812Pro) abolished AR ligand binding and severely impaired AR mediated transactivation. Residue p.Gly724 is located in the ligand binding domain, between helices 3 and 4. This region is known to be involved not only in ligand binding but also in AR N/C-terminal interactions. The mutation p.Leu812Pro is located in the C-terminal end of helix 8. This domain is highly conserved and critical for ligand binding. This study extends current understanding of AR mutations associated with CAIS.

Hormonal impact of the 17alpha-hydroxylase/C(17,20)-lyase inhibitor abiraterone acetate (CB7630) in patients with prostate cancer

A series of three dose escalating studies were conducted to investigate the ability of the 17α-hydroxylase/C_17,20-lyase inhibitor abiraterone acetate, to cause maximum suppression of testosterone synthesis when delivered to castrate and noncastrate males with prostate cancer. Study A was a single dose study in castrate males. Study B was a single dose study in noncastrate males and study C was a multiple dose study in noncastrate males. The drug was given orally in a once-daily dose and blood samples taken to assess pharmacokinetic (PK) parameters and hormone levels in all patients. The study drug was well tolerated with some variability in PKs. Suppression of testosterone levels to <0.14 nmol l⁻¹ was seen in four out of six castrate males treated with a single dose of 500 mg. At 800 mg given days 1–12 in noncastrate males, target suppression was achieved in three out of three patients, but a two- to three-fold increase of Luteinising Hormone (LH) levels in two out of three patients overcame suppression within 3 days. All patients in the multiple dose study developed an abnormal response to a short Synacthen test by day 11, although baseline cortisol levels remained normal. This is the first report of the use of a specific 17α-hydroxylase/_17,20-lyase inhibitor in humans. Repeated treatment of men with intact gonadal function with abiraterone acetate at a dose of 800 mg can successfully suppress testosterone levels to the castrate range. However, this level of suppression may not be sustained in all patients due to compensatory hypersecretion of LH. The enhanced testosterone suppression achieved in castrate men merits further clinical study as a second-line hormonal treatment for prostate cancer. Adrenocortical suppression may necessitate concomitant administration of replacement glucocorticoid.

Hypoglycaemia caused by secretion of insulin-like growth factor 2 in a primary renal cell carcinoma

Non-islet cell tumour hypoplycaemia (NICTH) due to the production of an aberrant form of insulin-like growth factor 2 (IGF 2) is a well-recognised phenomenon. This is the first formally reported case occurring in an adult with a primary renal cell carcinoma. This case report describes in detail the various treatment modalities that were used in an attempt to palliate this patient's severe hypoglycaemia.

Primary CA1 and conditionally immortal MHP36 cell grafts restore conditional discrimination learning and recall in marmosets after excitotoxic lesions of the hippocampal CA1 field

Common marmosets (Callithrix jacchus, n = 18) were trained to discriminate between rewarded and non-rewarded objects (simple discriminations, SDs) and to make conditional discriminations (CDs) when presented sequentially with two different pairs of identical objects signifying reward either in the right or left food well of the Wisconsin General Test Apparatus. After bilateral N-methyl-D-aspartate (0.12 M) lesions through the cornu ammonis-1 (CA1) field (7 microl in five sites), marmosets showed profound impairment in recall of CDs but not SDs, and were assigned to lesion only, lesion plus CA1 grafts and lesion plus Maudsley hippocampal cell line, clone 36 (MHP36) grafts groups matched for lesion-induced impairment. Cell suspension grafts (4 microl, 15-25 000 cells/microl) of cells dissected from the CA1 region of foetal brain at embryonic day 94-96, or of conditionally immortalized MHP36 cells, derived from the H-2Kb-tsA58 transgenic mouse neuroepithelium and labelled with [3H]thymidine, were infused at the lesion sites. The lesion plus MHP36 grafts group was injected five times per week with cyclosporin A (10 mg/kg) throughout testing. Lesion, grafted and intact control marmosets (n = 4-5/group) were tested on recall of SDs and CDs learned before lesioning and on acquisition of four new CDs over a 6-month period. Lesioned animals were highly impaired in recall and acquisition of CD tasks, but recall of SDs was not significantly disrupted. Both grafted groups of marmosets showed improvement to control level in recall of CDs. They were significantly slower in learning the first new CD task, but mastered the remaining tasks as efficiently as controls and were substantially superior to the lesion-only group. Visualized by Nissl staining, foetal grafts formed clumps of pyramidal-like cells within the denervated CA1 field, or jutted into the lateral ventricles. MHP36 cells, identified by beta-galactosidase staining and autoradiography, showed neuronal and astrocytic morphology, and were distributed evenly throughout the CA1 region. The results indicate that MHP36 cell grafts are as functionally effective as foetal grafts and appear to integrate into the host brain in a structurally appropriate manner, showing the capacity to differentiate into both mature neurons and glia, and to develop morphologies appropriate to the site of migration. These findings, which parallel the facilitative effects of foetal and MHP36 grafts in rats with ischaemic CA1 damage, offer encouragement for the development of conditionally immortal neuroepithelial stem cell lines for grafting in conditions of severe amnesia and hippocampal damage following recovery from cardiac arrest or other global ischaemic episodes.

Psychophysics of reading. XVII. Low-vision performance with four types of electronically magnified text

Most people with low vision need magnification to read. Page navigation is the process of moving a magnifier during reading. Modern electronic technology can provide many alternatives for navigating through text. This study compared reading speeds for four methods of displaying text. The four methods varied in their page-navigation demands. The closed-circuit television (CCTV) and MOUSE methods involved manual navigation. The DRIFT method (horizontally drifting text) involved no manual navigation, but did involve both smooth-pursuit and saccadic eye movements. The rapid serial visual presentation (RSVP) method involved no manual navigation, and relatively few eye movements. There were 7 normal subjects and 12 low-vision subjects (7 with central-field loss, CFL group, and 5 with central fields intact, CFI group). The subjects read 70-word passages at speeds that yielded good comprehension. Taking the CCTV reading speed as a benchmark, neither the normal nor low-vision subjects had significantly different speeds with the MOUSE method. As expected from the reduced navigational demands, normal subjects read faster with the DRIFT method (85% faster) and the RSVP method (169%). The CFI group read significantly faster with DRIFT (43%) and RSVP (38%). The CFL group showed no significant differences in reading speed for the four methods.

Evaluation of the in-vitro activity of the glycopeptide antibiotic LY333328 in comparison with vancomycin and teicoplanin

The in-vitro activity of a new glycopeptide antibiotic, LY333328, was compared with vancomycin and teicoplanin against clinical isolates of Staphylococcus aureus, coagulase-negative staphylococci, vancomycin and teicoplanin resistant enterococci, and vancomycin sensitive and resistant enterococci. MIC, MBC, and time-kill kinetics were determined for each agent. LY333328 displayed similar or improved MIC/MBC values in comparison with vancomycin and teicoplanin. Time-kill kinetics for LY333328 demonstrated significantly improved bactericidal activity against the isolates. These findings suggest that LY333328 has improved in-vitro activity over vancomycin and teicoplanin against a range of gram-positive organisms.

Systematic overestimation of intracranial pressure measured using a Camino pressure monitor

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ThioTEPA pharmacokinetics during intravesical chemotherapy: the influence of dose and volume of instillate on systemic uptake and dose rate to the tumour

ThioTEPA is given intravesically in a variety of schedules to treat superficial bladder cancer. In this study, the influence of the dose of ThioTEPA and the volume of instillate on the dose rate to the tumour and the systemic uptake of ThioTEPA was investigated in eight patients with pTa or pTl disease. Each patient received four courses of ThioTEPA consisting of 30 mg of drug/30 ml of distilled water, 30 mg/60 ml, 60 mg/30 ml and 60 mg/60 ml. Blood and urine samples were obtained for 8 h following instillation, and ThioTEPA and TEPA levels were measured. The AUC(infinity) values (areas under the concentration-time curve, extrapolated to infinity) in plasma were approximately 2 factors higher at the two 60-mg doses. However, the AUC value in the bladder was nearly 70% higher when 60 mg of drug was instilled in 30 ml of distilled water as compared with 60 mg in 60 ml. Thus, by decreasing the volume of instillate it is possible to increase the dose rate to the tumour without increasing the systemic toxicity.

Non-Hodgkin's lymphoma of the testis

Primary non-Hodgkin's lymphoma of the testis is rare. From 1976 to 1989 32 patients have been registered with the British National Lymphoma Investigation and two with the Institute of Urology. All 34 patients had disease of high grade histology (BNLI) although in four patients there were some areas with features similar to those described in lymphomas of Mucosal Associated Lymphoid Tissue (MALT). Twenty-three of 34 (67.5%) patients had early stage disease (I/II); 17/34 (50%) achieved complete remission from their initial treatment, and the relapse-free survival of these patients was 66% at 5 years. The disease-free survival for the 34 patients as a whole was 33% and their overall survival 39% at 5 years. The life expectancy for those presenting with advanced (stage III/IV) disease was very poor (median survival 9 months) with a low complete remission rate from chemotherapy. The salvage rate from recurrent disease (17%) was poor. Bilateral testicular involvement (18%) and a high rate of central nervous system disease (21%) occurred in the series, and two patients were HIV positive. Stage at presentation was the most important prognostic factor.

Effectiveness of carboplatin, etoposide, and bleomycin combination chemotherapy in good-prognosis metastatic testicular nonseminomatous germ cell tumors

The combination of carboplatin, etoposide, and bleomycin (CEB) was evaluated as initial chemotherapy in 76 patients with good-prognosis metastatic nonseminomatous germ cell tumors (NSGCT) between 1984 and 1988. The classification of eligible patients included Royal Marsden Hospital (RMH) stages IM, IIA, IIB, IIC, IIIA, IIIB, IV0ABCL1, and IV0ABL2. Four courses of combination chemotherapy were administered in a 21-day cycle, and surgical excision of residual mass was performed in 27 cases (23 laparotomies and four thoracotomies). At the time of analysis, median follow-up was 24 months from start of chemotherapy (range, 6 to 54 months). The 2-year cause-specific survival probability was 98.5%, the single cause-related mortality being caused by bleomycin pneumonitis. Five patients failed CEB chemotherapy, but all have been successfully salvaged with a combination of surgery and intensive chemotherapy, follow-up from completion of all treatment being 35 to 44 months. The toxicity of CEB included bone marrow suppression and alopecia in all patients but no significant neurotoxicity or ototoxicity, and minimal renal toxicity. Only four (5%) patients had a decrease in the glomerular filtration rate greater than 15%. In 51% of patients, the hemoglobin fell below 10 g/dL. The WBC count nadir was less than 1,500/microL in 11% of treatment cycles and in 16% the platelet nadir fell below 50,000/microL. Decreases in the WBC and platelet counts were of very brief duration. Only one of 310 CEB cycles was complicated by neutropenic sepsis, and there were no episodes of thrombocytopenic purpura or bleeding. We conclude that the CEB combination represents an effective alternative to cisplatin-based chemotherapy in good-prognosis NSGCT and that the replacement of cisplatin by carboplatin leads to reduced toxicity.

N-methyl antitumour agents. A distinct class of anticancer drugs?

This article reviews the structure-activity characteristics, mode of action, pharmacokinetics and clinical utility of a group of chemically dissimilar antitumour agents which have as a common structural feature the N-methyl moiety. The importance of this feature is shown by the fact that molecules without a substituent on the nitrogen or compounds with N-alkyl groups other than methyl are usually inactive in experimental systems. This observation is supported by structure-activity studies with N-alkyl derivatives of s-triazines, triazenes, formamides, hydrazines and nitrosoureas. Representatives of these structural types which have found clinical application are, respectively, hexamethylmelamine, dacarbazine, N-methylformamide, procarbazine and streptozotocin. Mode of action studies have shown that dacarbazine, procarbazine and streptozotocin can give rise to species capable of methylating nucleic acid. This may be the lesion which produces antitumour activity. The mechanism of action of N-methylmelamines and N-methylformamide remains unclear. There is good evidence that, with the exception of N-methylnitrosoureas, host metabolism is prerequisite for activity with these agents. Although not pronounced, the clinical activity of N-methyl antitumour agents is useful, particularly as activity is not associated with severe haematological toxicity. Furthermore, responses may be observed in patients resistant to bifunctional alkylating agents. It is concluded that the drugs reviewed herein show a degree of coincidence in terms of their biological properties which may warrant a common classification. The term N-methyl antitumour agent is proposed.

A randomised trial of cyclophosphamide pretreatment ('priming') before short-duration chemotherapy for small cell lung carcinoma

Forty-five patients with small cell anaplastic carcinoma of the bronchus were treated with four four-weekly courses of a combination of cyclophosphamide, vincristine and methotrexate. Randomisation was carried out to determine whether they received in addition 1 g/m2 of cyclophosphamide 1 week before the three-drug therapy. Patients with limited disease received radiotherapy after their chemotherapy. Myelosuppression was similar in the two groups, but the additional cyclophosphamide did not improve remission duration or survival. Confining the chemotherapy to four courses did not give shorter survival times to those reported in other studies.

Immunodiagnosis and monitoring of gonadotrophin-producing metastases in the central nervous system

Measurements of human chorionic gonadotrophin (HCG) concentration in plasma and cerebrospinal fluid (CSF) have been made on patients with gonadotrophin-producing tumors. In the absence of brain metastases the spinal fluid concentration is, within wide limits, proportional to that in the plasma. In 73 patients with gestational choriocarcinoma the mean plasma/spinal fluid ratio was 286 with a lowest value of 64. In five patients with gonadotrophin-producing teratomas the mean ratio was 208 with a lowest value of 104. In 29/33 patients with brain metastases the plasma:CSF ratio was less than 60 at the time confirmatory evidence of brain metastases was obtained. One patient with a gonadotrophin-producing teratoma had a brain metastasis that apparently failed to produce HCG and this metastasis failed to show the histologic features of choriocarcinoma. Monitoring the plasma:CSF ratio provided evidence of brain metastases in 13/18 patients who were undergoing chemotherapy for extensive metastatic disease before confirmatory evidence was obtained by other methods. The lead-in time between assay diagnosis and diagnosis by other methods ranged from 1-20 weeks. Monitoring the plasma:CSF ratio provided a means of observing the response of cerebral metastases to therapy. In some patients the CSF HCG concentration exceeded the plasma concentration indicating that the higher CSF values in patients with CNS metastases cannot be attributed to impairment of the blood-brain barrier. Direct secretion of tumor products into CSF or indirect secretion into CSF via cerebral extracellular fluid evidently occurs. In contrast with radiographic and radionucleide detection methods, a chemical marker indicates the metabolic activity of tumor cells within the central nervous system and provides a basis for monitoring that activity.