Antithrombin III Profiles in Malignancy, Relationship to Primary Tumors and Metastatic Sites

Variations of antithrombin III were studied in a non-ran-domized population of consecutive cancer cases admitted to a referral hospital. Differences between functional and immunologic assay were observed.

Decreases were observed in both assays when compared to a population of hospitalized controls. Patients with cancer of the colon, ovary and prostate showed a deficiency of antithrombin III more frequently than other common tumors. When all tumor cases were subdivided into those in remission compared to those with metastases, a significant decrease in antithrombin III also could be shown.

Metastases to the liver were strikingly common in cancer patients with decreased antithrombin III. In these patients, the decrease in antithrombin III could be statistically correlated with reduction in serum albumin.

Validation of prognostic factors and survival of patients with multiple myeloma in a real-life autologous stem cell transplantation setting: a Swiss single centre experience

PRINCIPLES

High-dose chemotherapy with subsequent autologous stem cell transplantation (ASCT) is an important treatment option in younger patients with multiple myeloma (MM). We analysed the outcome of patients treated at our institution outside the clinical trials framework and tried to identify risk factors prognostic for survival.

METHODS

Medical histories of the patients were screened for response, event-free survival (EFS) and overall survival (OS). Pre-transplant variables were analysed to identify possible prognostic risk factors.

RESULTS

Overall, 182 ASCT were performed in 120 patients with MM from 2002 to 2007. Treatment-related mortality (TRM) was 0.5%. Median EFS was 23.1 months (95% confidence interval [CI]: 19.4-28.4) and median OS was 49.8 months (95%CI: 43.7 - not reached) in the whole patient population. The median OS in patients who received one ASCT was 46.4 months (95%CI: 35.2 - not reached), and 63.7 months (95%CI: 48.9 - not reached) in patients who underwent double ASCT. Patients who already achieved a complete remission (CR) before ASCT had a longer EFS (p = 0.016) than patients without CR. Additionally, patients who achieved a CR after ASCT had a longer EFS (p = 0.0061) and OS (p = 0.0024) than patients without CR. ISS stage <III at first diagnosis strongly correlated with improved EFS (p = 0.0006) and OS (p <0.0001).

CONCLUSIONS

ASCT is a safe and effective treatment mode in eligible patients with MM. TRM was below average at our institution. Achievement of CR after transplantation was the most valuable predictor for improved overall survival.

Equivalence of pegfilgrastim and filgrastim in lymphoma patients treated with BEAM followed by autologous stem cell transplantation

OBJECTIVE

To evaluate the impact of pegfilgrastim on engraftment, hospital stay and resources in patients with Hodgkin's and non-Hodgkin's lymphoma after conditioning with high-dose BEAM followed by autologous peripheral blood stem cell transplantation (APBSCT) compared with filgrastim.

METHODS

We reviewed patient charts and our prospective transplantation database for clinical data from the post-transplant period. An integrated cost analysis, including the use of blood products and length of hospital stay, was also performed.

RESULTS

Fourteen (26%) patients with Hodgkin's lymphoma and 40 (74%) patients with non-Hodgkin's lymphoma were analyzed. Thirty-four (68%) patients received single-dose pegfilgrastim (6 mg), and 20 (32%) patients received daily filgrastim (5 μg/kg) after APBSCT. No differences were observed regarding duration of neutropenia grade 4 (pegfilgrastim median 7 days/filgrastim median 8 days; p = 0.13), thrombocytopenia grade 4 (7/9.5 days, respectively; p = 0.21), fever (4.5/2 days; p = 0.057), intravenous antibiotic treatment (11/10 days; p = 0.75) or length of hospital stay (16.5/16 days; p = 0.27) between the groups. The use of pegfilgrastim resulted in 12% higher treatment-related costs when compared to filgrastim, without reaching statistical significance (p = 0.38).

CONCLUSION

Pegfilgrastim appears to be equivalent to filgrastim after high-dose BEAM followed by APBSCT in the treatment of lymphoma patients.

A European treatment protocol for bone sarcoma in patients older than 40 years

10516

Background: EUROpean Bone Over 40 Sarcoma Study (EURO-B.O.S.S.) is the first prospective multicenter international study for patients 41 - 65 years old with high-grade bone sarcoma. Methods: Patients with HG Osteosarcoma (OS), HG sarcoma NOS (S), Fibrosarcoma, MFH, Leiomyosarcoma, Dedifferentiated Chondrosarcoma (DCh) were included. Chemotherapy: Combinations of cisplatin/doxorubicin (CDP 100mg/m2/ADM 60mg/m2), ifosfamide/CDP(IFO 6g/m2/CDP 100mg/m2) and IFO/ADM (IFO 6g/m2/ADM 60mg/m2) were repeated three times (9 cycles). Surgery was planned after 3 cycles. Methotrexate (8g/m2) was postoperatively added in poor responders. Immediate surgery was allowed and 9 cycles with CDP, ADM, IFO were postoperatively given. Results: In December 2007, 140 patients were registered (median age 51 years). OS (51%), S (16%), and DCh (11%) were the more frequent histotypes. Synchronous metastases in 30 (21%) patients, central location of tumor in 45 (32%). Surgical complete remission (SCR) was achieved in 84% of patients, (localized 91%, metastatic 37%) without difference among the histology groups. One surgical-related and one chemotherapy-related death were reported. Grade 4 WBC and PLT incidence was 55% and 17%.Renal toxicity and peripheral neurotoxicity were reported in 16% and 20% of patients. With a median follow-up of 25 months (4–68) 3 year OS was 58% (95%CI 48–68%) [7% (95%CI 0–19%) without SCR]. In patients with SCR, 3 year OS and EFS were 46% (95%CI 9–83%) and 0% in case of synchronous metastases and 69% (95%CI58–80%) and 45% (95%CI33–57%) for localized patients; 50% (95%CI 29–71%) and 40% (95%CI 20–59%) for patients with central tumor, 73% (95%CI61–85%) and 44% (95%CI31–57%) for those with extremity tumor; 68% (95%CI 52–83%) and 46% (95%CI 32–54%) for OS, 64% (95%CI 42–85%) and 48% (95%CI 25–71%) for S, 48% (95%CI 13–82%) and 27% (95%CI 1–54%) for DCh. Conclusions: The protocol is feasible, but the chemotherapy-related toxicity is remarkable. Surgical complete remission is the main factor influencing survival. Central location and synchronous metastases are negative prognostic factors, but 50% 3-year OS can be achieved with aggressive local and systemic treatment. Osteosarcoma and high-grade sarcoma NOS benefit from chemotherapy more than patients with dedifferentiated chondrosarcoma.

No significant financial relationships to disclose.

Prognostic factors affecting long-term outcomes in patients with resected stage IIIA pN2 non-small-cell lung cancer: 5-year follow-up of a phase II study

The aim was to investigate the efficacy of neoadjuvant docetaxel-cisplatin and identify prognostic factors for outcome in locally advanced stage IIIA (pN2 by mediastinoscopy) non-small-cell lung cancer (NSCLC) patients. In all, 75 patients (from 90 enrolled) underwent tumour resection after three 3-week cycles of docetaxel 85 mg m-2 (day 1) plus cisplatin 40 or 50 mg m-2 (days 1 and 2). Therapy was well tolerated (overall grade 3 toxicity occurred in 48% patients; no grade 4 nonhaematological toxicity was reported), with no observed late toxicities. Median overall survival (OS) and event-free survival (EFS) times were 35 and 15 months, respectively, in the 75 patients who underwent surgery; corresponding figures for all 90 patients enrolled were 28 and 12 months. At 3 years after initiating trial therapy, 27 out of 75 patients (36%) were alive and tumour free. At 5-year follow-up, 60 and 65% of patients had local relapse and distant metastases, respectively. The most common sites of distant metastases were the lung (24%) and brain (17%). Factors associated with OS, EFS and risk of local relapse and distant metastases were complete tumour resection and chemotherapy activity (clinical response, pathologic response, mediastinal downstaging). Neoadjuvant docetaxel-cisplatin was effective and tolerable in stage IIIA pN2 NSCLC, with chemotherapy contributing significantly to outcomes.

Monitoring activated clotting time for combined heparin and aprotinin application: in vivo evaluation of a new aprotinin-insensitive test using Sonoclot☆

OBJECTIVE

Kaolin-based activated clotting time assessed by HEMOCHRON (HkACT) is a clinical standard for heparin monitoring alone and combined with aprotinin during cardiopulmonary bypass (CPB). However, aprotinin is known to prolong not only celite-based but also kaolin-based activated clotting time. Overestimation of activated clotting times implies a potential hazardous risk of subtherapeutic heparin anticoagulation. Recently, a novel 'aprotinin-insensitive' activated clotting time test has been developed for the SONOCLOT analyzer (SaiACT). The aim of our study was to evaluate SaiACT in patients undergoing CPB in presence of heparin and aprotinin.

METHODS

Blood samples were taken from 44 elective cardiac surgery patients at the following measurement time points: baseline (T0); before CPB after heparinization (T1 and T2); on CPB, before administration of aprotinin (T3); 15, 30, and 60 min on CPB after administration of aprotinin (T4, T5, and T6); after protamine infusion (T7). On each measurement time point, activated clotting time was assessed with HkACT and SaiACT, both in duplicate. Furthermore, the rate of factor Xa inhibition and antithrombin concentration were measured. Statistical analysis was done using Bland and Altman analysis, Pearson's correlation, and ANOVA with post hoc Bonferroni-Dunn correction.

RESULTS

Monitoring anticoagulation with SaiACT showed reliable readings. Compared to the established HkACT, SaiACT values were lower at all measurement time points. On CPB but before administration of aprotinin (T3), SaiACT values (mean+/-SD) were 44+/-118 s lower compared to HkACT. However, the difference between the two measurement techniques increased significantly on CPB after aprotinin administration (T4-T6; 89+/-152 s, P=0.032). Correlation of ACT measurements with anti-Xa activity was unchanged for SaiACT before and after aprotinin administration (r2=0.473 and 0.487, respectively; P=0.794), but was lower for HkACT after aprotinin administration (r2=0.481 and 0.361, respectively; P=0.041). On CPB after administration of aprotinin, 96% of all ACT values were classified as therapeutic by HkACT, but only 86% of all values were classified therapeutic if ACT was determined by SaiACT. Test variability was comparable for SaiACT and HkACT.

CONCLUSIONS

The use of SaiACT may result in more consistent heparin management that is less affected by aprotinin and a corresponding increase in heparin administration for patients receiving aprotinin.

A randomized phase II trial of capecitabine and two different schedules of irinotecan in first-line treatment of metastatic colorectal cancer: efficacy, quality-of-life and toxicity

BACKGROUND

To determine the efficacy, impact on quality-of-life (QoL) and tolerability of two different irinotecan administration schedules in combination with capecitabine as first-line treatment of metastatic colorectal cancer.

PATIENTS AND METHODS

We carried out a randomized phase II trial to select one of the following treatment regimens for further investigation: weekly irinotecan at a dose of 70 mg/m(2) days 1, 8, 15, 22, 29 (arm A) or 3-weekly irinotecan at a dose of 300/240 mg/m(2) day 1 and days 22 (arm B) in combination with capecitabine 1000 mg/m(2) twice daily days 1-14 and days 22-35 every 6 weeks.

RESULTS

Seventy-five patients with good performance status entered the trial. The two arms were well balanced for relevant patient and disease characteristics. The most frequent toxic effects were grade 3/4 diarrhea (arm A: 34%, B: 19%), grade 3/4 neutropenia (A: 5%, B: 19%) and grade 2/3 alopecia (A: 26%, B: 65%). Other grade 3/4 toxic effects were rare (<5%). Response rates were 34% [95% confidence interval (CI) 20% to 51%] in arm A and 35% (95% CI: 20% to 53%) in arm B. Median time to progression was 6.9 (4.6-10.1) and 9.2 (7.9-11.5) months and median overall survival was 17.4 (12.6-23.0+) and 24.7 (16.3-26.4+) months. Patients with an objective tumor response reported better physical well-being (P < 0.01), mood (P < 0.05), functional performance (P < 0.05) and less effort to cope (P < 0.05) compared with the non-responders and stable disease patients.

CONCLUSIONS

The primary end point of this study was the objective response rate and based on the statistical design of the trial, the 3-weekly irinotecan schedule was selected over weekly irinotecan administration. The 3-weekly irinotecan schedule also seemed advantageous in terms of grade 3/4 diarrhea, time to progression, overall survival and patient convenience, but the study was not designed to detect differences in these parameters. In addition, tumor response was shown to have a beneficial effect on QoL indicators.

The predictive characteristics of D-dimer testing in outpatients with suspected venous thromboembolism: a Bayesian approach

BACKGROUND

Despite the widespread use of quantitative methods to measure D-dimer, clinical decisions commonly are based only on binary test information (positive/negative). This study aimed to determine the significance of quantitative D-dimer results in the evaluation of venous thromboembolism (VTE) by means of a differentiated Bayesian approach.

METHODS

Prospective study in 118 outpatients referred for workup of suspected pulmonary embolism (n = 75) or deep vein thrombosis (n = 43). The sensitivity and specificity of D-dimer results obtained by DD VIDAS (Biomerieux, France), STA Liatest (Diagnostica Stago, France), and D-dimer plus (Dade, US) were assessed for five different cut-offs. Further, predictive values and multilevel likelihood ratios were calculated in order to assess the operative test characteristics in excluding or confirming VTE.

RESULTS

At a cut-off of 500 ng/ml and pretest probabilities < 47%, the VIDAS provides a negative predictive value (NPV) > 95%, whereas a positive predictive value (PPV) > 95% is obtained in patients with a D-dimer > 10,000 ng/ml and pretest probabilities > 50%. At a cut-off of 500 ng/ml and pretest probabilities < 33%, the Liatest exhibits a NPV > 95%, whereas a PPV > 95% is obtained in patients with a D-dimer >10,000 ng/ml and pretest probabilities > 37%. Finally, with the D-dimer plus, a NPV > 95% is seen at a cut-off of 150 ng/ml and pretest probabilities < 30%, whereas a PPV > 95% is obtained at a cut-off > 1000 ng/ml and pretest probabilities > 67%.

CONCLUSIONS

D-dimer measurements in outpatients cannot only allow for exclusion but, in some situations, also for confirmation of venous thromboembolism. It is therefore advisable to conduct a quantitative interpretation of D-dimer results.

Primary Lymphoma of Bone: MRI and CT Characteristics During and After Successful Treatment

OBJECTIVE

Our aim was to describe MRI and CT characteristics of primary lymphoma of bone during and after successful treatment.

CONCLUSION

MRI showed a rapid decrease of tumor volume with complete disappearance of the soft-tissue component. Minor signal abnormalities of bone marrow without clinical relevance persisted for up to 2 years. CT showed bone remodeling within months with a persistent architecture similar to that of Paget's disease of the bone.

Mediastinal lymph node clearance after docetaxel-cisplatin neoadjuvant chemotherapy is prognostic of survival in patients with stage IIIA pN2 non-small-cell lung cancer: a multicenter phase II trial

PURPOSE

A multicenter, phase II trial investigated the efficacy and toxicity of neoadjuvant docetaxel-cisplatin in locally advanced non-small-cell lung cancer (NSCLC) and examined prognostic factors for patients not benefiting from surgery.

PATIENTS AND METHODS

Ninety patients with previously untreated, potentially operable stage IIIA (mediastinoscopically pN2) NSCLC received three cycles of docetaxel 85 mg/m2 day 1 plus cisplatin 40 mg/m2 days 1 and 2, with subsequent surgical resection.

RESULTS

Administered dose-intensities were docetaxel 85 mg/m2/3 weeks (range, 53 to 96) and cisplatin 95 mg/m2/3 weeks (range, 0 to 104). The 265 cycles were well tolerated, and the overall response rate was 66% (95% confidence interval [CI], 55% to 75%). Seventy-five patients underwent tumor resection with positive resection margin and involvement of the uppermost mediastinal lymph node in 16% and 35% of patients, respectively (perioperative mortality, 3%; morbidity, 17%). Pathologic complete response occurred in 19% of patients with tumor resection. In patients with tumor resection, downstaging to N0-1 at surgery was prognostic and significantly prolonged event-free survival (EFS) and overall survival (OS; P =.0001). At median follow-up of 32 months, the median EFS and OS were 14.8 months (range, 2.4 to 53.4) and 33 months (range, 2.4 to 53.4), respectively. Local relapse occurred in 27% of patients with tumor resection, with distant metastases in 37%. Multivariate analyses identified mediastinal clearance (hazard ratio, 0.22; P =.0003) and complete resection (hazard ratio, 0.26; P =.0006) as strongly prognostic for increased survival.

CONCLUSION

Neoadjuvant docetaxel-cisplatin is effective and tolerable in stage IIIA pN2 NSCLC. Resection is recommended only for patients with mediastinal downstaging after chemotherapy.

Phase II study of capecitabine and oxaliplatin in first- and second-line treatment of advanced or metastatic colorectal cancer

PURPOSE

To determine the efficacy and tolerability of combining oxaliplatin with capecitabine in the treatment of advanced nonpretreated and pretreated colorectal cancer.

PATIENTS AND METHODS

Forty-three nonpretreated patients and 26 patients who had experienced one fluoropyrimidine-containing regimen for advanced colorectal cancer were treated with oxaliplatin 130 mg/m(2) on day 1 and capecitabine 1,250 mg/m(2) bid on days 1 to 14 every 3 weeks. Patients with good performance status (World Health Organization grade 0 to 1) were accrued onto two nonrandomized parallel arms of a phase II study.

RESULTS

The objective response rate was 49% (95% confidence interval [CI], 33% to 65%) for nonpretreated and 15% (95% CI, 4% to 35%) for pretreated patients. The main toxicity of this combination was diarrhea, which occurred at grade 3 or 4 in 35% of the nonpretreated and 50% of the pretreated patients. Grade 3 or 4 sensory neuropathy, including laryngopharyngeal dysesthesia, occurred in 16% of patients on both cohorts. Capecitabine dose reductions were necessary in 26% of the nonpretreated and 45% of the pretreated patients in the second treatment cycle. The median overall survival was 17.1 months and 11.5 months, respectively.

CONCLUSION

Combining capecitabine and oxaliplatin yields promising activity in advanced colorectal cancer. The main toxicity is diarrhea, which is manageable with appropriate dose reductions. On the basis of our toxicity experience, we recommend use of capecitabine in combination with oxaliplatin 130 mg/m(2) at an initial dose of 1,250 mg/m(2) bid in nonpretreated patients and at a dose of 1,000 mg/m(2) bid in pretreated patients.

Osseous lesions of the distal ulna: atypical location--unusual diagnosis. Report of three cases with similar imaging and different pathologic diagnoses

Three cases with destructive bone lesions of the distal end of the ulna caused by different pathologic entities (Ewing's sarcoma, osteosarcoma, rheumatoid pseudotumoral synovitis) are presented, all with similar clinical and comparable x-ray and magnetic resonance imaging features. Although the distal end of the ulna may be resected without significant functional impairment, careful evaluation of treatment strategies compatible with oncologic standards is warranted.

Docetaxel (Taxotere)-cisplatin (TC): an effective drug combination in gastric carcinoma. Swiss Group for Clinical Cancer Research (SAKK), and the European Institute of Oncology (EIO)

PURPOSE

A multi-centric trial was performed to explore the clinical activity, in terms of response and toxicity (primary objectives), duration of response and survival (secondary objectives), of docetaxel with cisplatin in advanced gastric cancer (AGC).

PATIENTS AND METHODS

Patients with measurable unresectable and/or metastatic gastric carcinoma, performance status < or = 1, normal hematological, hepatic and renal functions and not pretreated for advanced disease by chemotherapy received up to eight cycles of TC (docetaxel 85 mg/m2 dl, cisplatin 75 mg/m2 dl) q3w. Dose escalation to 100 mg/m2 was performed in five patients and was discontinued for excessive toxicity.

RESULTS

Forty-eight patients were accrued. A median of 5 cycles/patient was given. We observed 2 complete and 25 partial responses for an overall intent to treat response rate of 56% (95% CI: 41%-71%). Twelve patients had stable disease for > or = 9 weeks (3 cycles). The median time to progression and overall survival were 6.6 and 9 months, respectively. Grade > or = 3 toxicities were neutropenia 81%, anemia 32%, thrombocytopenia 4%, alopecia 36%, fatigue 9%, mucositis 9%, diarrhea 6%, nausea/vomiting 4%, neurologic 2%, and one anaphylaxis precluding treatment administration. We recorded nine episodes of non-fatal febrile neutropenia in eight patients, two of them with docetaxel at 100 mg/m2. There were no direct treatment-related deaths.

CONCLUSIONS

TC is active in AGC with a high response rate in a multicentric trial. Despite its hematotoxicity, this regimen is well tolerated and can be recycled as originally planned in 78% of the cases. These results may serve as basis for further developments of docetaxel containing regimens in this disease.

A prospective study of risk-adapted therapy for large cell non-Hodgkin's lymphoma with VACOP-B followed by high-dose CBV and autologous progenitor cell transplantation for high-risk patients in remission

Several centres reported a favourable outcome after high-dose chemotherapy with autologous progenitor cell transplantation in selected patients with high-risk large cell non-Hodgkin's lymphoma in first remission. Based on these observations, we wanted to prospectively determine the outcome of a risk-adapted therapy for patients with large cell lymphoma. Patients aged 60 years or less received 12 weeks of VACOP-B chemotherapy. For high-risk patients in remission this was immediately followed by high-dose chemotherapy with cyclophosphamide, carmustine and etoposide and autologous progenitor cell transplantation. High-risk criteria were defined before the establishment of the International Index and included large cell lymphoma stage III or IV or mediastinal large lymphoma with sclerosis stage II or higher, and the presence of bulky tumours and/or an elevated LDH. 89 patients fulfilled the clinical selection criteria and were entered onto this multicentre study. 82 patients were evaluable after confirmation of large cell histology by pathology review. Of these, 51 were considered to be in the low-risk group and 31 in the high-risk group. The 3-year event-free survival for all patients was 68%. The 3-year event-free survival was 76% for the low-risk and 55% for the high-risk group (P = 0.061). Only 22/31 high-risk patients were able to receive the high-dose chemotherapy in first remission as intended. In conclusion, although our study demonstrated that a risk-adapted therapy for large cell lymphoma could be safely administered, the potential impact on outcome of the strategy chosen here is likely to be small.

Randomized trial showing equivalent efficacy of filgrastim 5 micrograms/kg/d and 10 micrograms/kg/d following high-dose chemotherapy and autologous bone marrow transplantation in high-risk lymphomas

PURPOSE

To evaluate the effect of two filgrastim dosages after autologous bone marrow transplantation (ABMT) in patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Eighty-six patients were enrolled onto a multicenter, randomized, open-label study. The study compared the efficacy and safety of two different doses of filgrastim, 5-microgram/kg/d subcutaneous (SC) bolus injection and 10-microgram/kg/d SC continuous infusion, starting on day 1 following ABMT.

RESULTS

Both patient groups were well matched in terms of demography and disease. The results showed no statistical difference in the median time to reach an absolute neutrophil count (ANC) of 0.5 x 10(9)/L (11 days; P = .685) and no difference in the median duration of neutropenia (10 v 11 days, respectively; P = .567) between either dose of filgrastim. The incidence and duration of fever and neutropenic fever were the same in both groups. The number and mean duration of clinically and documented infections, duration of intravenous (IV) antibiotics, time to discharge from hospital, and tumor response also were similar in both groups.

CONCLUSION

This study demonstrates that a dose of filgrastim 5 micrograms/kg/d administered as a daily SC bolus injection has a similar efficacy and safety profile compared with the 10-microgram/kg/d dose administered as a SC continuous infusion. The lower dose of filgrastim has potential cost-saving implications in terms of both the dose of drug administered and the ease of administration. Based on these findings, the recommended dose of filgrastim after ABMT should be 5 micrograms/kg/d.

Localization of bursicon in CCAP-immunoreactive cells in the thoracic ganglia of the cricket Gryllus bimaculatus

Bursicon is a neuropeptide that induces tanning of the cuticle in freshly moulted insects. In an earlier investigation, we demonstrated that bursicon activity can be detected throughout the ventral nerve cord of the cricket Gryllus bimaculatus. This study aims at identifying the neurosecretory cells within the thoracic ganglia that produce bursicon. When homogenates of anterior pieces of thoracic ganglia were separated using SDS gel electrophoresis, proteins with bursicon activity could be eluted only from a slice of the gel spanning the 28-33 kDa region. In the anterior lateral cortex of the thoracic ganglia, there are two bilaterally paired neurosecretory cells with large vacuoles that project contralaterally to neurohaemal release sites associated with segmental nerves N5 and N6. These cells and their processes in N5 and N6 were labelled using antisera against crustacean cardioactive peptide (CCAP). The cell projecting into N6 showed a Tyndall effect (i.e. appeared opaque under oblique illumination) in older adults, and single isolated somata contained bursicon activity. Homogenates of nerves N5 and N6 also showed bursicon activity, but neither bursicon activity nor CCAP-immunoreactive processes were found in segmental nerve N4. The thoracic connectives, which contain three major CCAP-immunoreactive processes, also showed bursicon activity. Homogenates of posterior pieces of the thoracic ganglia did not contain bursicon activity. Western blots demonstrated that the anti-CCAP serum does not recognize the 30 kDa bursicon-active protein fraction. These results suggest that a CCAP-like neuropeptide and a protein with bursicon activity are co-localized in the anterior lateral neurosecretory cells of the thoracic ganglia and in their segmental homologues in the other ganglia. Additionally, we have shown using western blots that a monoclonal antibody raised against a 56 kDa protein from the housefly Musca domestica, a protein thought to be bursicon, does not label the 30 kDa bursicon-active protein of crickets. However, this antibody does label an unidentified 56 kDa protein isolated from anterior as well as posterior pieces of thoracic ganglia.

Randomized study of recombinant human granulocyte colony-stimulating factor after high-dose chemotherapy and autologous bone marrow transplantation for high-risk lymphoid malignancies

PURPOSE

The aim of this prospective randomized trial was to examine the efficacy and safety of filgrastim after high-dose chemotherapy and autologous bone marrow transplantation (ABMT).

PATIENTS AND METHODS

Patients with poor-risk non-Hodgkin's lymphoma or relapsed Hodgkin's disease were treated in a randomized, open-label trial to study the use of filgrastim as an adjunct to high-dose chemotherapy and ABMT. Of 43 assessable patients, 19 were randomized to receive filgrastim by continuous subcutaneous infusion at a dose of 10 micrograms/kg/d, 10 to filgrastim 20 micrograms/kg/d, and 14 to a parallel control group that received no filgrastim after ABMT.

RESULTS

For all filgrastim-treated patients analyzed together, the median time to neutrophil recovery > or = 0.5 x 10(9)/L after the day of ABMT was significantly accelerated to 10 days compared with 18 days in control patients (P = .0001). The median number of platelet transfusions was identical in both groups. Clinical parameters, including the median number of days with fever (1 v 4, P = .0418) and neutropenic fever (5 v 13.5, P = .0001) were significantly shorter in the filgrastim than in the control group. The number of days on intravenous antibiotics and duration of hospitalization were also shorter in the treated groups; however, the differences did not reach statistical significance. For patients treated with the two different dose levels of filgrastim, the neutrophil recovery and clinical results were similar. Filgrastim-associated toxicity appeared to be minimal, with five adverse events considered at least possibly related to filgrastim: two in the higher-dose group and three in the lower-dose group. All of these were rated moderate, except one case of severe bone pain that did not preclude continued filgrastim treatment at a lower dose. Survival and relapse-free survival were similar for control and filgrastim-treated patients.

CONCLUSION

Taken together, the results of this first randomized study support the role of filgrastim given as an adjunct to ABMT in accelerating neutrophil recovery, as well as in reducing treatment-related morbidity and overall duration of the treatment procedure.

[Pars plana vitrectomy in chronic uveitis]

Sixty-eight patients (74 eyes) with chronic endogenous uveitis underwent pars plana vitrectomy. An increase in visual acuity was observed in 70% postoperatively. Visual results basically depended on the extent of previous damage to the macula. A lensectomy-vitrectomy was done in 23 eyes, while 51 eyes underwent merely a pars plana vitrectomy. The frequency and severity of uveitic relapses were diminished in virtually all cases.

[Is pindolol suitable for the therapy of glaucoma? Evaluation of the dose-effect of various concentrations of pindolol eyedrops]

Various concentrations of Pindolol eye drops (0.17%, 0.35%, 0.5%, 0.72%, 1.0%), a beta-blocking agent with an intrinsic sympathomimetic activity, were investigated with regard to their pressure-lowering effect in open-angle glaucoma. It was found that all of these concentrations reduce intraocular pressure, but that only the 1% solution has a significantly stronger effect after 24 hours. It is therefore preferable to use this relatively high concentration, especially as it is not accompanied by a bronchopulmonary risk.

[Clinical suitability of pindolol eyedrops in the treatment of chronic open-angle glaucoma]

Pindolol eye drops were compared with Timolol in a randomized 4-week investigation carried out in patients suffering from open-angle glaucoma. The two drugs were found to have the same pressure-lowering effect. Pindolol has been used in internal medicine for more than 12 years now. It has less influence on airway resistance than Timolol.

Delayed alloimmunization using random single donor platelet transfusions: a prospective study in thrombocytopenic patients with acute leukemia

A randomized study was performed in 54 thrombocytopenic patients with acute leukemia. Alloimmunization of recipients of random multiple-donor platelet concentrates (MD group) was compared to that of patients receiving random single-donor platelets (SD group). In the SD patients, formation of alloantibodies (mostly anti-HLA) occurred less frequently (p less than 0.002), after a longer time period (p less than 0.002), and after a higher number of transfusions (p less than 0.005) as compared to MD patients. SD patients also became refractory to random platelets less frequently (p less than 0.005), after a longer time period, and after a higher number of transfusions (p less than 0.02). In SD patients, the increments after the first and the last transfusion were in the same range, whereas in MD patients, the 1-hr (p less than 0.001) and the 24-hr (p less than 0.025) increments decreased from the first to the last transfusion. Thus, the use of random SD platelet transfusions postponed alloimmunization.

[Stress on the eyeball caused by mechanical vibration. Studies of patient transport and experimental models]

The acceleration forces which occur in the eye and in the head region in transport of patients were investigated. It was to be established whether the finding often deteriorates appreciably in perforating eye injuries between the accident site and the ophthalmological operating theater. The investigation showed that smaller acceleration forces become active in the eye in the sitting position than in the lying position in patient transport. In transport in the hospital area, e.g., in the patient lift and on a stretcher, the maximum acceleration amplitudes which occur are greater than those occurring in the ambulance.--In the second part of the study, the region of the eyeball most sensitive to oscillation was determined experimentally in cadaver eyes in order to permit an evaluation of the acceleration parameters relevant in patient transport. It was shown that the eye is largely insensitive to the accelerations occurring in patient transport. It was shown that the eye is largely insensitive to the accelerations occurring in patient transport. Furthermore, it was shown that a vitreous prolapse cannot occur for this reason in an experimentally induced sclera injury.--Therefore, deteriorations in the condition of the bulb occurring in patient transport are due to movements of the eyelid and eyeball.

Acute myelogenous leukemia: successful treatment of relapse with cytosine arabinoside, VP 16-213, vincristine and vinblastine (A-triple-V)

Between March 1980 and January 1982, 15 patients with acute myelogenous leukemia (AML) in relapse were treated with one or more cycles of a combination chemotherapy consisting of cytosine arabinoside (Ara-C), VP 16-213, vincristine and vinblastine (A-triple-V). Of a total of 20 treatment cycles given, one partial and 15 complete remissions were achieved, there was no change in the bone marrow in two cases, one patient died due to Pseudomonas septicemia during an apparently normal bone marrow regeneration and one patient died of Candida infection while in aplasia. With 15 out of 20 (75%) successful relapse treatment courses, A-triple-V should be tested in first-line protocols.

Organophosphorus intermediates. VIII. The synthesis of some 2,6-dioxo-1,2,3,4,6,7,8,8a-octahydro-2λ5-isophosphinoline derivatives

Methyl 1-methoxy-1,4-dioxo-1λ5-phosphorinan-3-carboxylate (3) adds readily to but-3-en-2-one to give an adduct (5) which cyclizes under mild non-aqueous conditions to the novel tricyclic compound(6). Substance (5) may be cyclized to mixtures of bicyclic derivatives with either acid or base but the combination LiL/LiOH affords 2-hydroxy-1,2,3,4,8,8a-hexahydroisophosphinolin-6(7H)-one 2-oxide (7a) in an overall yield of 65%. 1H, 13C and 31P n.m.r., and mass spectra are reported and discussed.

Thrombin inhibition by malignant and normal cells: a cell-bound antithrombin effect

Analysis of fresh surgical specimens of normal tissue and tumor tissue show a cellular antithrombin activity to be present in certain organs. In normal tissues it was noted chiefly in normal colon, testes, breast, and uterus. In malignant tissues it was prominent in adenocarcinomas of the colon, breast, and lung. No epidermoid tumors showed evidence of thrombin binding. The thrombin- binding activity required the presence of intact cells and was distinct from the soluble antithrombins normally present in plasma and serum. There is growing evidence to suggest an interrelationship between clotting and the growth and dissemination of cancer. The implications of cellular antithrombins are reviewed in this context.

Antithrombin III profiles in malignancy, relationship primary tumors and metastatic sites

Variations of antithrombin III were studied in a non-randomized population of consecutive cancer cases admitted to a referral hospital. Differences between functional and immunologic assay were observed. Decreases were observed in both assays when compared to a population of hospitalized controls. Patients with cancer of the colon, ovary and prostate showed a deficiency of antithrombin III more frequently than other common tumors. When all tumor cases were subdivided into those in remission compared to those with metastases, a significant decrease in antithrombin III also could be shown. Metastases to the liver were strikingly common in cancer patients with decreased antithrombin III. In these patients, the decrease in antithrombin III could be statistically correlated with reduction in serum albumin.

Organophosphorus intermediates. VI. The acid-catalysed reaction of trialkyl orthoformates with phosphinic acid

Trialkyl orthoformates react with phosphinic acid to give the corresponding alkyl phosphinate and alkyl mono- or bis- (dialkoxymethyl)phosphinates; dialkyl phosphonites and phosphine, PH3, are also formed. The formation of P-alkylated products is acid- catalysed and is believed to proceed by alkylation of the trivalent tautomer of phosphinic acid (or its ester) by the dialkoxymethyl carbonium ion arising from the ortho ester in the presence of acid. A comparison with the corresponding reactions of phosphonic acid suggests that the trivalent tautomer of phosphinic acid [HP(OH)2] is formed much more readily than the trivalent form of phosphonic acid [P(OH)3] and this is accounted for by proposing that the equilibria RPH(O)OR′ +H+ ↔ RP+H(OH)OR' ↔ RP(OH)OR'+H+ (R = H, OH; R' = H, alkyl) lie further to the right for R = H than for R = OH because of inductive effects. 31P and 1H n.m.r. data are reported.

Morphological changes of the corneal epithelium after application of topical anaesthetic ointments

The effect of topical anaesthetic ointments (4% cocaine, 4% xylocaine, 0.5% proparacaine, 0.2% oxybuprocaine) on the corneal epithelium of rabbits was examined using a scanning electron microscope. Even after a single application, the more toxic effect of cocaine compared to the other topical anaesthetics was evident. Cocaine caused disruption of both the plasma membrane and the cytoplasm. After a single application, the other preparations caused a marked decrease in the microvilli and microplicae, disruption of the intercellular spaces and the prominence of the cell nucleus which under normal condition is not visible. Repeated applications caused regular cell desquamation and damage to the plasma membrane and cytoplasm. The damage also affected several cell layers. The cell reactions described are clearly a consequence of the topical anaesthetics, as the ointment base itself produced no essential cell damage. The scanning electron microscope findings were supported by results from the transmission electron microscope.

Coagulant Effects of Normal and Malignant Tissue

A prospective study has been conducted on the procoagulant activity of tumor tissues and normal tissues removed during the course of surgery and therapeutic procedures. The presence of potent tissue thromboplastic action was demonstrated in cells removed from certain types of normal and malignant tissue. A less potent incomplete thromboplastin can be isolated from certain tumor tissues. The bulk of the activity is present in the cellular fraction although partial recovery can be achieved from the supernate after freezing and thawing. Assays for prothrombin, thrombin, fibrinogen and coagulant inhibitors revealed no activity by the standard assays which were employed.

Early morphological changes of the corneal epithelium after burning with hydrochloric acid. A scanning electron microscope study

The morphological changes of the corneal epithelium after burning with hydrochloric acid were examined using a scanning electron microscope. A drop of hydrochloric acid of differing concentrations (1--0.000001 N HCl) was applied under standardized conditions to normal rabbit eyes for a reaction period of 5 or 30 min. The changes in the cell surface, which are dependent on the concentration of the acid, include a loss of microvilli and microplicae, outlining of the cell nucleus, disruption of the intercellular spaces, cell desquamation and even the most severe damage to the cell membrane and cytoplasm of the corneal epithelial cells.

[The influence of local anesthetics on corneal epithelium. A scanning electron microscopic study (author's transl)]

The effect of different local anesthetics (Cocain 4%, Lidocaine 2%, Proparacain) on the corneal epithelium in rabbits was examined under scanning electron microscope. The experiment was divided into three groups. Group 1 received one application of two drops of the given local anesthetic for a reaction time of 5 minutes. Group 2 received two drops of the given anesthetic after 0, 5 and 10 minutes. The cornea was excised after 15 minutes. Group 3 were measured after a single application of Proparacain using a Schiötz or hand applanation tonometer according to Draeger. After a single dose of a local anesthetic principally the same changes in the surface of the cornea were observed with all the preparations used: a distinct decrease in the number of microvilli and microplicae, disruption of the intercellular spaces and the prominence of the cell nuclei which under normal conditions are not visible. After several applications the greater toxicity of Cocain compared with the other preparations was clearly seen through the disruption of the plasma membrane and the cytoplasm. The damage effected several layers of cells. Tonometry when correctly performed causes no additional damage to the cell surface.- The effect of local anesthetics on the cell membrane can only take place after the disruption of the tear film. The results emphasize that local anesthetics should only be applied when absolutely essential.

[Perimetry during monocular and binocular fixation with the phase-difference haploscope of Aulhorn]

For the first time it was possible to compare perimetry during monocular and binocualr fixation under homogeneous conditions by the aid of phase-difference haploscopy. A binocular perimetry was not practicable using common perimeters. The examination was based on the anatomical fixed papilla nervi optici, which appears in the visual field as the blind spot. Its extension corresponds more to the anatomical size during binocular examination than during monocular examination. The difference is highly significant. Likewise the binocular perimetry refers to the quality of reproduction of paracentral retinal diseases significantly improved compared with the monocular examination. Supposing that the use of a larger fixation target during monocular perimetry contributes to the stabilization of normal eye movements, all examinations were additionally made with two fixation targets of different sizes. We have shown that there is no significant difference between the measurement either concerning the extension of the blind spot or the paracentral retinal diseases, which means a larger fixation target represents no fixation aid.

[Tonography test according to Leydhecker. Clinical comparison by tonography according to Grant (author's transl)]

In our 1st series of examinations the Grant's 4-minutes-tonography, combined with waterdrinking (Becker), was compared with Leydhecker's modification of 7-minutes-tonography. Out of 60 healthy eyes were 13,3% false-positive with the 4-minutes-tonography, combined with waterdrinking, however with the 7-minutes-tonography none of these were glaucoma-suspicious. For 92 glaucoma-suspicious eyes, which were tested with both methods, the 7-minutes-tonography proved to be much more valuable. Leydhecker's value P3/CL3-7 offers 38,4% positive results at a starting pressure of 18-22 mm Hg, and 51,1% positive results at a starting pressure of 20-24 mmHg. Grant's 4-minutes-tonography, combined with waterdrinking (Becker), may show suspicious values at pressures of 18-22 mm Hg, however is not able to register with certainty existing pathological findings. In 2nd series of examinations 54 eyes with proven glaucoma chronicum simplex were tested with the 7-minutes-tonography. It showed a reliability of 83%.