Heterozygous CAPN3 missense variants causing autosomal-dominant calpainopathy in seven unrelated families

AIMS

Recessive variants in CAPN3 gene are the cause of the commonest form of autosomal recessive limb girdle muscle dystrophy. However, two distinct in-frame deletions in CAPN3 (NM_000070.3:c.643_663del21 and c.598_621del15) and more recently, Gly445Arg and Arg572Pro substitutions have been linked to autosomal dominant (AD) forms of calpainopathy. We report 21 affected individuals from seven unrelated families presenting with an autosomal dominant form of muscular dystrophy associated with five different heterozygous missense variants in CAPN.

METHODS

We have used massively parallel gene sequencing (MPS) to determine the genetic basis of a dominant form of limb girdle muscular dystrophy in affected individuals from seven unrelated families.

RESULTS

The c.700G> A, [p.(Gly234Arg)], c.1327T> C [p.(Ser443Pro], c.1333G> A [p.(Gly445Arg)], c.1661A> C [p.(Tyr554Ser)] and c.1706T> C [p.(Phe569Ser)] CAPN3 variants were identified. Affected individuals presented in young adulthood with progressive proximal and axial weakness, waddling walking and scapular winging or with isolated hyperCKaemia. Muscle imaging showed fatty replacement of paraspinal muscles, variable degrees of involvement of the gluteal muscles, and the posterior compartment of the thigh and minor changes at the mid-leg level. Muscle biopsies revealed mild myopathic changes. Western blot analysis revealed a clear reduction in calpain 3 in skeletal muscle relative to controls. Protein modelling of these variants on the predicted structure of calpain 3 revealed that all variants are located in proximity to the calmodulin-binding site and are predicted to interfere with proteolytic activation.

CONCLUSIONS

We expand the genotypic spectrum of CAPN3-associated muscular dystrophy due to autosomal dominant missense variants.

Evolving concepts in ventral hernia repair and physical therapy: prehabilitation, rehabilitation, and analogies to tendon reconstruction

PURPOSE

The abdominal wall and musculoskeletal tendons share many anatomic, physiologic, and functional characteristics. This review aims to highlight these similar characteristics and to present a rationale why the treatment principles of successful musculoskeletal tendon reconstruction, including principles of surgical technique and physical therapy, can be used in the treatment of complex abdominal wall reconstruction or ventral hernia repair.

METHODS

The MEDLINE/PubMed database was used to identify published literature relevant to the purpose of this review.

CONCLUSIONS

There are several anatomical and functional similarities between the linea alba and musculoskeletal tendons. Because of this reason, many of the surgical principles for musculoskeletal tendon repair and ventral hernia repair overlap. Distribution of tension is the main driving principle for both procedures. Suture material and configuration are chosen to maximize tension distribution among the tissue edges, as seen in the standard of care multistrand repairs for musculoskeletal tendons, as well as in the small bites for laparotomy technique described in the STITCH trial. Physical therapy is also one of the mainstays of tendon repair, but surprisingly, is not routine in ventral hernia repair. The evidence surrounding physical therapy prehabilitation and rehabilitation protocols in other disciplines is significant. This review challenges the fact that these protocols are not routinely implemented for ventral hernia repair, and presents the rationale and feasibility for the routine practice of physical therapy in ventral hernia repair.

Sequential Combination Chemotherapy with Methotrexate and 5-Fluorouracil in Advanced Colorectal Carcinoma

Twenty patients bearing advanced colorectal carcinoma, confirmed by histology, were evaluated after undergoing a sequential chemotherapeutic schedule which consisted of methotrexate, 200 mg/m2 in intravenous infusion during 4 h followed 1 h later by 5-fluorouracil, 600 mg/m2 in intravenous bolus. Twenty hours after ending the MTX administration, leucovorine, 14 mg/m2, was given intramuscularly every 6 h, in 8 doses. Courses were repeated every 15 days. Of 20 patients, 3 bearing colon carcinoma, without previous radiotherapy or chemotherapy, had a partial response. No change was registered in 6 cases. There was no significant difference in the survival of responders, those with stable illness and those with progression. Results were no better than those obtained with 5-fluorouracil used as a single drug and are in agreement with studies that established a 1-h interval between the administration of both drugs.

Abstract P5-23-06: Metastatic pattern in stage IV male breast cancer at initial diagnosis: A population-based study

Background: Male breast cancer (MaBC) is a relatively uncommon disease, representing less than 1% of all breast cancers. Although men tend to present at more advanced stages, the prognostic influence of metastatic pattern (MP), sites of metastases and factors associated with specific organ involvement are unknown. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of patients (pts) with stage IV breast cancer at initial diagnosis (BCID). Secondary aims were to describe sites of metastases and evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated men with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2014. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 136 pts. Median age was 63 years (range 28-91). At diagnosis, bone only metastases represented 31.6% of pts, visceral 16.2%, bone and visceral 38.2% and other 14%. Median OS for the entire cohort was 33 months (95% CI 19 months – not reached). Bone was the most common site of metastases (69.9%), followed by lung (44.9%), liver (14%) and brain (8.1%). OS rate at 3 years by MP was: bone only 46.05%, visceral 53.57%, bone and visceral 37.23% and other 70.56% (p=0.41). There were no significant differences in pt or tumor characteristics between MP. However, in adjusted logistic regression, triple negative (TN) and ER/PR+/HER2+ tumors had higher odds of brain metastases than ER/PR+/HER2- (all p<0.05). Also, ER/PR+/HER2+ tumors had higher odds of liver metastases (p=0.027). Univariate analysis showed that older age (HR 1.7; p=0.03), no surgery (HR2.5; p=0.005), TN tumors (HR 5.6; p<0.001) and pts with brain metastases (HR 4.2; p<0.001) had worse prognosis. In multivariate analysis, TN subtype (HR 4.2; p=0.001) and pts with brain metastases (HR 3.44; p=0.012) had significantly shorter OS.

Conclusions: To our knowledge, this is the first study of MP in MaBC. The cohort had an acceptable median OS which did not differ significantly according to MP. Although brain metastases were less common, it is important to recognize their worse prognosis. Independent predictors of OS included tumor subtype and brain metastases. Tumor subtype had a clear influence on specific sites of metastases, particularly for brain and liver involvement.

Citation Format: Leone JP, Leone BA, Zwenger AO, Vallejo CT, Romero AO, Machiavelli MR, Perez JE, Leone J. Metastatic pattern in stage IV male breast cancer at initial diagnosis: A population-based study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-23-06.

Turbulent Kinetic Energy in the Energy Balance of a Solar Flare

The energy released in solar flares derives from a reconfiguration of magnetic fields to a lower energy state, and is manifested in several forms, including bulk kinetic energy of the coronal mass ejection, acceleration of electrons and ions, and enhanced thermal energy that is ultimately radiated away across the electromagnetic spectrum from optical to x rays. Using an unprecedented set of coordinated observations, from a suite of instruments, we here report on a hitherto largely overlooked energy component-the kinetic energy associated with small-scale turbulent mass motions. We show that the spatial location of, and timing of the peak in, turbulent kinetic energy together provide persuasive evidence that turbulent energy may play a key role in the transfer of energy in solar flares. Although the kinetic energy of turbulent motions accounts, at any given time, for only ∼(0.5-1)% of the energy released, its relatively rapid (∼1-10  s) energization and dissipation causes the associated throughput of energy (i.e., power) to rival that of major components of the released energy in solar flares, and thus presumably in other astrophysical acceleration sites.

Abstract P6-09-21: Prognostic impact of metastatic pattern in stage IV breast cancer at initial diagnosis

Background: Stage IV breast cancer at initial diagnosis (BCID) can be recognized in approximately 5% of all breast neoplasms. Clinical outcomes of these patients (pts) are highly variable and depend on tumor biology and pt characteristics. The prognostic influence of metastatic pattern (MP) at initial presentation and factors associated with specific organ involvement have been understudied. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of pts with stage IV BCID. The secondary aim was to evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated women with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2013. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 9143 pts. Median age was 61 years (range 19-102). Median OS for the entire cohort was 28 months (95% CI 27-29 months). At diagnosis, bone only metastases represented 37.5% of pts, visceral 21.9%, bone and visceral 28.8% and other 11.9%. Median OS by MP was: bone only 38 months, visceral 21 months, bone and visceral 19 months and other 33 months (p<0.0001). Bone was the most common site of metastases (66.2%), followed by lung (30.5%), liver (26.2%) and brain (7.4%). Pts with visceral metastases were more often black race, had higher grade, less likely to be lobular histology and more likely to be triple negative (TN) (all p<0.0001). Univariate analysis showed that older age, black race, grade 3/4 tumors, TN pts, bone and visceral MP, higher number of metastatic sites and unmarried pts had worse prognosis (all p<0.0001). In multivariate analysis, older age (HR 1.9; p<0.001), black race (HR 1.17; p=0.002), grade 3/4 tumors (HR 1.6; p<0.001), TN subtype (HR 2.24; p<0.001), bone and visceral MP (HR 2.07, p<0.001) and unmarried pts (HR 1.25; p<0.001) had significantly shorter OS. In adjusted logistic regression, as compared with ER/PR+/HER2- tumors, TN and ER/PR-/HER2+ had higher odds of brain, liver, lung and other metastases (all p<0.05). ER/PR+/HER2+ had higher odds of liver metastases (p<0.001). All three subtypes had lower odds of bone metastases (p<0.001).

Conclusions: To our knowledge, this is the largest study of MP in stage IV BCID. There were substantial differences in prognosis according to MP, bone only was the most common MP and had the best OS, whereas bone and visceral MP had the worst prognosis. We observed significant differences in pt characteristics according to MP. Independent predictors of OS included age at diagnosis, race, marital status, tumor grade, tumor subtype and MP. There was a clear influence of tumor subtype among other factors on specific sites of metastases. Our study identified several prognostic factors that could guide therapy selection in treatment naïve pts.Background: Stage IV breast cancer at initial diagnosis (BCID) can be recognized in approximately 5% of all breast neoplasms. Clinical outcomes of these patients (pts) are highly variable and depend on tumor biology and pt characteristics. The prognostic influence of metastatic pattern (MP) at initial presentation and factors associated with specific organ involvement have been understudied. The primary aim of this study was to analyze the influence of MP compared with other biologic and clinical factors in the survival of pts with stage IV BCID. The secondary aim was to evaluate factors associated with specific sites of metastatic spread.

Methods: We evaluated women with microscopically confirmed stage IV BCID with known metastatic sites, reported to the Surveillance, Epidemiology and End Results (SEER) 18 registries program from 2010 to 2013. Pts with other primary tumor either before or after breast cancer were excluded. MP was categorized as bone only, visceral (lung, liver or brain), bone and visceral and other. Pt characteristics were compared between MP. Univariate and multivariate analyses determined the effects of each variable on overall survival (OS). Logistic regression examined factors associated with specific sites of metastases.

Results: We included 9143 pts. Median age was 61 years (range 19-102). Median OS for the entire cohort was 28 months (95% CI 27-29 months). At diagnosis, bone only metastases represented 37.5% of pts, visceral 21.9%, bone and visceral 28.8% and other 11.9%. Median OS by MP was: bone only 38 months, visceral 21 months, bone and visceral 19 months and other 33 months (p<0.0001). Bone was the most common site of metastases (66.2%), followed by lung (30.5%), liver (26.2%) and brain (7.4%). Pts with visceral metastases were more often black race, had higher grade, less likely to be lobular histology and more likely to be triple negative (TN) (all p<0.0001). Univariate analysis showed that older age, black race, grade 3/4 tumors, TN pts, bone and visceral MP, higher number of metastatic sites and unmarried pts had worse prognosis (all p<0.0001). In multivariate analysis, older age (HR 1.9; p<0.001), black race (HR 1.17; p=0.002), grade 3/4 tumors (HR 1.6; p<0.001), TN subtype (HR 2.24; p<0.001), bone and visceral MP (HR 2.07, p<0.001) and unmarried pts (HR 1.25; p<0.001) had significantly shorter OS. In adjusted logistic regression, as compared with ER/PR+/HER2- tumors, TN and ER/PR-/HER2+ had higher odds of brain, liver, lung and other metastases (all p<0.05). ER/PR+/HER2+ had higher odds of liver metastases (p<0.001). All three subtypes had lower odds of bone metastases (p<0.001).

Conclusions: To our knowledge, this is the largest study of MP in stage IV BCID. There were substantial differences in prognosis according to MP, bone only was the most common MP and had the best OS, whereas bone and visceral MP had the worst prognosis. We observed significant differences in pt characteristics according to MP. Independent predictors of OS included age at diagnosis, race, marital status, tumor grade, tumor subtype and MP. There was a clear influence of tumor subtype among other factors on specific sites of metastases. Our study identified several prognostic factors that could guide therapy selection in treatment naïve pts.

Citation Format: Leone BA, Vallejo CT, Romero AO, Machiavelli MR, Perez JE, Leone J, Leone JP. Prognostic impact of metastatic pattern in stage IV breast cancer at initial diagnosis [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-09-21.

Effects of aging on left atrial reservoir, conduit, and booster pump function: a multi-institution acoustic quantification study

OBJECTIVE

To assess the feasibility of measuring left atrial (LA) function with acoustic quantification (AQ) and then assess the effects of age and sex on LA reservoir, conduit, and booster pump function.

PATIENTS AND SETTING

165 subjects without cardiovascular disease, 3-79 years old, were enrolled by six tertiary hospital centres.

INTERVENTIONS

Continuous LA AQ area data were acquired and signal averaged to form composite waveforms which were analysed off-line.

MAIN OUTCOME MEASURES

Parameters of LA performance according to age and sex.

RESULTS

Signal averaged LA waveforms were sufficiently stable and detailed to allow automated analysis in all cases. An age related increase in LA area was noted. LA reservoir function did not vary with age or sex. All parameters of LA passive and active emptying revealed a significant age dependency. Overall, the passive emptying phase accounted for 66% of total LA emptying ranging from 76% in the youngest to 44% in the oldest decade. LA contraction accounted for 34% of atrial emptying in all subjects combined with the older subjects being more dependent on atrial booster pump function. When adjusted for atrial size, there were no sex related differences in LA function.

CONCLUSIONS

LA reservoir, conduit, and booster pump function can be assessed with automated analysis of signal averaged LA area waveforms. As LA performance varies with age, establishment of normal values should enhance the evaluation of pathologic states in which LA function is important.

Variation in patient management and outcomes for acute coronary syndromes in Latin America and North America: results from the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial

BACKGROUND

Although more than 9500 patients have been enrolled in major clinical trials in Latin America, practice patterns in this region have rarely been examined. We sought to compare characteristics, resource utilization, and outcomes of patients treated for acute coronary syndromes in Latin America with those in North America.

METHODS

The Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Theraphy Trial (PURSUIT) enrolled 10,948 patients with non-ST-segment elevation acute coronary syndromes, including 585 in Latin America and 4358 in North America. We analyzed regional differences in patient groups, treatment patterns, and outcomes and used logistic regression analysis to identify association of enrollment region and survival.

RESULTS

For patients in Latin America, the length of hospital stay was significantly longer (10 [7, 15] days vs 6 [4, 9], P <.001). Angiograms, angioplasty, and bypass surgery were significantly less common in Latin America (46.2%, 17.6%, and 11.3% vs 79.4%, 33.6%, and 19.4%, P <.001). Thirty-day death/myocardial infarction was not significantly higher, although mortality alone was significantly higher (6.8% vs 3.1%, P <.001). After adjustment for baseline characteristics, enrollment in Latin America remained an independent predictor for death at 30 days (odds ratio [OR] [95% confidence interval (CI)] 2.42 [1.60-3.67]) and persisted at 6 months (OR [95% CI] 2.5 [1.8-3.4]).

CONCLUSIONS

Latin American patients treated for acute coronary syndromes were managed less invasively and were twice as likely as their North American counterparts to die within 6 months. This mortality difference was not explained by imbalances in baseline risk.

Domestic and peridomestic transmission of American cutaneous leishmaniasis: changing epidemiological patterns present new control opportunities

Predictions that deforestation would reduce American cutaneous leishmaniasis incidence have proved incorrect. Presentations at a recent international workshop, instead, demonstrated frequent domestication of transmission throughout Latin America. While posing new threats, this process also increases the effectiveness of vector control in and around houses. New approaches for sand fly control and effective targeting of resources are reviewed.

Molecular analysis of chronic granulomatous disease caused by defects in gp91-phox

Chronic granulomatous disease (CGD) is an uncommon inherited disorder of phagocytic cells in which a defective respiratory burst leads to severe recurrent bacterial and fungal infections. The disease is a consequence of mutations in one of the four molecules that constitute the NADPH oxidase system of electron transport, whose most critical component is an unusual flavocytochrome b localized in the plasma and specific granule membranes. Mutations in the CYBB gene (localized in the short arm of the X chromosome) encoding the beta-subunit of this flavocytochrome (gp91-phox), which is are responsible for 60-65% of all cases of CGD. In this paper, we report the molecular characterization of seven unrelated kindreds native from Colombia and Brazil with CGD caused by gp91-phox deficiency. The exons with the possible mutation were identified by single-strand conformational polymorphism (SSCP) of genomic DNA and then confirmed by DNA sequencing. In one patient we found a substitution of A to G in the penultimate nucleotide of intron 12 (IVS12-2A-->G). In four other cases, four different nonsense mutations were detected: R91X, W106X, R157X, and R290X and the other two patients showed missense substitutions: E225V and C244Y. In six of these kindreds, all mothers were carriers but one that did not present any change in the gp91-phox gene, which indicates a de novo mutation in this kindred. Then, these family-specific mutations in gp91-phox produce different structural defects that alter the expression or function of an essential component of phagocyte oxidase.

Factor structure of the Beck Depression Inventory-Second Edition (BDI-II) in a student sample

A confirmatory factor analysis was performed to evaluate the factorial validity of the Beck Depression Inventory-Second Edition (BDI-II) in a large sample of undergraduates (N = 576). Results suggest that the revised measure is internally consistent and consists of two underlying factors assessing cognitive-affective and somatic symptoms of depression. Results support the use of the BDI-II as a severity measure of symptoms of depression.

Effects of myocardial fiber orientation in echocardiography: quantitative measurements and computer simulation of the regional dependence of backscattered ultrasound in the parasternal short-axis view

We measured the regional disparity in backscattered ultrasound by means of obtaining integrated backscatter images of 10 healthy subjects and placing a region of interest in 18 distinct positions. A computer model simulating the short-axis view was implemented on the basis of previously measured values for the anisotropic ultrasonic properties of myocardium. Measurements showed that the integrated backscatter value was greatest for the anterior septum and decreased by 15.9 +/- 3.5 dB for the lateral wall and 17.7 +/- 3.5 dB for the inferior septum. The value in the posterior wall was 8.1 +/- 3.8 dB below the value for the anterior septum. The regional variation of backscatter predicted with the simulation correlated well with the clinical measurements. These results suggested that analyses based on measurements of backscatter may require compensation for the inherent anisotropic properties of myocardium.

Phase III multicenter trial comparing the efficacy of 2% dodecafluoropentane emulsion (EchoGen) and sonicated 5% human albumin (Albunex) as ultrasound contrast agents in patients with suboptimal echocardiograms

OBJECTIVES

This study was performed to compare the safety and efficacy of intravenous 2% dodecafluoropentane (DDFP) emulsion (EchoGen) with that of active control (sonicated human albumin [Albunex]) for left ventricular (LV) cavity opacification in adult patients with a suboptimal echocardiogram.

BACKGROUND

The development of new fluorocarbon-based echocardiographic contrast agents such as DDFP has allowed opacification of the left ventricle after peripheral venous injection. We hypothesized that DDFP was clinically superior to the Food and Drug Administration-approved active control.

METHODS

This was a Phase III, multicenter, single-blind, active controlled trial. Sequential intravenous injections of active control and DDFP were given 30 min apart to 254 patients with a suboptimal echocardiogram, defined as one in which the endocardial borders were not visible in at least two segments in either the apical two- or four-chamber views. Studies were interpreted in blinded manner by two readers and the investigators.

RESULTS

Full or intermediate LV cavity opacification was more frequently observed after DDFP than after active control (78% vs. 31% for reader A; 69% vs. 34% for reader B; 83% vs. 55% for the investigators, p < 0.0001). LV cavity opacification scores were higher with DDFP (2.0 to 2.5 vs. 1.1 to 1.5, p < 0.0001). Endocardial border delineation was improved by DDFP in 88% of patients versus 45% with active control (p < 0.001). Similar improvement was seen for duration of contrast effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to affect patient management. There was no difference between agents in the number of patients with adverse events attributed to the test agent (9% for DDFP vs. 6% for active control, p = 0.92).

CONCLUSIONS

This Phase III multicenter trial demonstrates that DDFP is superior to sonicated human albumin for LV cavity opacification, endocardial border definition, duration of effect, salvage of suboptimal echocardiograms, diagnostic confidence and potential to influence patient management. The two agents had similar safety profiles.

Effects of tissue anisotropy on the spectral characteristics of ultrasonic backscatter measured with a clinical imaging system

In this paper, we report the effects of inherent tissue anisotropy on the spectral properties of backscattered ultrasound when measured with a commercially-available imaging system. We insonified five specimens of bovine tendon immersed in a water tank and rotated in 10 degrees increments while being imaged with a Hewlett-Packard Sonos 1500 system. The backscattered RF signals corresponding to each angle of insonification were digitized and the spectral characteristics of the backscattered ultrasound were determined. The mean anisotropy, defined as the average difference between values at perpendicular and parallel insonification, for band-limited estimates of backscattered power, centroid frequency, upper-band to lower-band power ratio, and upper-band to total-band power ratio were found to be 24.6 +/- 1.1 dB, 142 +/- 27 kHz, 32 +/- 13%, and 22 +/- 5%, respectively (mean +/- SE). The magnitude of each of these backscatter spectral parameters was larger at perpendicular insonification compared with the corresponding values at parallel insonification, consistent with previous measurements of the inherent anisotropy of ultrasonic attenuation and backscatter in tissue.

Double modulation of 5-fluorouracil by methotrexate and high-dose L-leucovorin in advanced colorectal cancer

A phase II trial was performed to evaluate the efficacy and toxicity of a double modulation of 5-fluorouracil (5-FU) by methotrexate (MTX) and L-leucovorin (L-LV) in patients with advanced recurrent (inoperable) or metastatic colorectal carcinoma (ACC). Between July 1993 and October 1995, 41 patients with ACC received a regimen that consisted of MTX 150 mg/m2 i.v., infused over a 20-minute period at hour 0, followed 19 hours later by L-LV 250 mg/m2 in a 2-hour i.v. infusion. 5-FU, 900 mg/m2, was administered by i.v. push injection at hour 20. Beginning 24 hours after MTX administration, all patients received four doses of L-LV, 15 mg/m2 i.m., every 6 hours. Cycles were repeated every 15 days. Two patients were not assessable for response. Objective regression was observed in 11 of 39 (28%) patients, [95% confidence interval (CI), 14-42%]. One (2%) patient achieved complete response (CR) and 10 (26%) partial response (PR). No change was recorded in 15 (39%) patients and progressive disease was noted in 13 (33%) patients. The median time to treatment failure was 6 months and the median survival time was 10 months. Toxicity was within acceptable limits, but one therapy-related death due to severe leukopenia was observed. The dose-limiting toxicity was mucositis. Eight episodes of grade 3 or 4 stomatitis were observed, and were responsible for dosage modifications of MTX and 5-FU. In conclusion, further in experimental and clinical studies are clearly necessary in order to design the best modulatory strategy of 5-FU.

Comparison of integrated backscatter values obtained with acoustic densitometry with values derived from spectral analysis of digitized signals from a clinical imaging system

Time-domain-based integrated backscatter values obtained with the use of acoustic densitometry (AD) were compared with values determined from a spectral-based analysis of the radio-frequency (RF) signals with a modified Hewlett-Packard Sonos 1500 imaging system. Integrated backscatter images of five specimens of bovine tendon were acquired in the AD acquisition mode, and the corresponding signals related to the backscattered RF were digitized for each angle of insonification as the specimens were rotated in 10-degree increments. The integrated backscatter images were analyzed with the AD analysis package, and the corresponding values determined from the RF power spectra were obtained from the digitized ultrasonic signals. Good agreement was found between the two methods over the entire range of measured values. The mean anisotropy in the measured integrated backscatter (mean +/- standard error) was found to be 27 +/- 2 dB for time-domain-based analysis and 25 +/- 2 dB for RF spectral-based analysis.

Cardiac and glycemic benefits of troglitazone treatment in NIDDM. The Troglitazone Study Group

Troglitazone is a thiazolidinedione under development for the treatment of NIDDM and potentially other insulin-resistant disease states. Treatment with troglitazone is associated with an improvement in hyperglycemia, hyperinsulinemia, and insulin-mediated glucose disposal. No significant side effects have been observed in humans. Because of reported cardiac changes in animals treated with drugs of this class, this multicenter 48-week study was conducted to evaluate whether NIDDM patients treated with troglitazone develop any cardiac mass increase or functional impairment. A total of 154 NIDDM patients were randomized to receive troglitazone 800 mg q.d. or glyburide titrated to achieve glycemic control (< or =20 mg b.i.d. or q.d.). Two-dimensional echocardiography and pulsed Doppler were used to measure left ventricular mass index (LVMI), cardiac index (CI), and stroke volume index (SVI). All echocardiograms were performed at each center (baseline, 12, 24, 36, and 48 weeks), recorded on videotape, and forwarded to a blinded central echocardiographic interpreter for analysis. The results showed that LVMI of patients treated with troglitazone was not statistically or clinically different from baseline after 24 or 48 weeks. Statistically significant increases in SVI and CI and a statistically significant decrease in diastolic pressure and estimated peripheral resistance were observed in troglitazone-treated patients. These results were not sex-specific. Glycemic benefits of troglitazone treatment were observed as evidenced by long-term improvement of HbA1c and C-peptide levels. Furthermore, triglycerides were significantly lower, and HDL was significantly higher at weeks 24 and 48. In conclusion, NIDDM patients treated with troglitazone do not show any cardiac mass increase or cardiac function impairment. Conversely, patients on troglitazone benefited from enhanced cardiac output and stroke volume, possibly as a result of decreased peripheral resistance. Treatment with troglitazone appears to have a favorable impact on known cardiovascular risk factors and could potentially lower cardiovascular morbidity in NIDDM patients.

Vinorelbine as neoadjuvant chemotherapy in advanced cervical carcinoma

PURPOSE

To evaluate the efficacy and toxicity of vinorelbine (VNB) as single-agent neoadjuvant chemotherapy in advanced cervical carcinoma (ACC).

PATIENTS AND METHODS

Between December 1993 and October 1995, 43 untreated patients with stages IIB to IVA squamous cell cervical cancer were entered onto this study. Forty-two patients are assessable for response and 43 for toxicity. The median age was 46 years (range, 28 to 65). Distribution by stages (International Federation of Gynecology and Obstetrics [FIGO]) was as follows: IIB, 18 patients; IIIA, one; IIIB, 19; and IVA, five. Therapy consisted of VNB 30 mg/m2 by 20-minute intravenous (IV) infusion repeated weekly for 12 injections and followed by radical surgery if feasible or definitive radiotherapy. Both staging and response assessment were performed by a multidisciplinary team.

RESULTS

One patient was considered not assessable for response. A total of 493 cycles of therapy were administered and objective remissions were observed in 19 of 42 patients (45%; 95% confidence interval, 30% to 60%). Two patients (5%) had a complete response (CR) and 17 (40%) a partial response (PR); no change (NC) was observed in 16 (38%) and progressive disease (PD) in seven (17%). Six of 19 patients (32%) who achieved objective responses (ORs) underwent surgery. The median time to failure and median survival time have not been reached yet. There were no therapy-related deaths. The dose-limiting toxicity was myelosuppression. Leukopenia occurred in 35 patients (81%) and was grade 3 or 4 in seven (17%). Twelve patients (28%) developed peripheral neuropathy, while myalgias occurred in 10 (23%). Constipation was observed in nine patients (21%), one with a prolonged ileum. Phlebitis was recorded in 18 patients (41%). In contrast, emesis and mucositis were rarely observed. No patient developed alopecia grade 3. By the end of the twelfth course of treatment, the average received dose-intensity was 85.4% of that projected.

CONCLUSION

VNB is an active drug against ACC with moderate toxicity. Its activity is among the highest reported for single agents. Further evaluation in association with other agents is clearly justified.

Delayed tension pneumothorax after laparoscopy

Laparoscopy is a safe and useful procedure in evaluating intraabdominal disease. Serious complications have been reported but are rare. Laparoscopy related pneumothorax is one such complication that may occur during the procedure or in the immediate period thereafter. This complication is typically neither hemodynamically significant nor tension in nature. We report the unique case of a 52-year-old woman who not only developed acute respiratory compromise from a tension pneumothorax but did so 3 h after the completion of a seemingly uneventful laparoscopic procedure. Prompt recognition of this potential complication may permit immediate and effective treatment of this life-threatening complication.

Anisotropy of the apparent frequency dependence of backscatter in formalin fixed human myocardium

Measurements of the frequency dependence of ultrasonic backscatter are presented for specific angles of insonification for regions of infarcted and noninfarcted human myocardium. A 5-MHz transducer was used to insonify cylindrical cores taken from 7 noninfarcted regions and 12 infarcted regions of the left ventricular free wall of 6 formalin-fixed human hearts explanted because of ischemic cardiomyopathy. The dependence of apparent (uncompensated for diffraction effects and attenuation) backscatter on frequency was approximated by a power-law dependence, magnitude of B(f)2 = afn. Under ideal conditions in a lossless medium, the effect of not compensating for the effects of diffraction and attenuation leads to the value of n to be 2.0 for Rayleigh scatterers while the frequency dependence of the fully compensated backscatter coefficient would be f4. The value of n was determined over the frequency range, 3-7 MHz. Both nonifarcted and infarcted myocardium exhibited anisotropy of the frequency dependence of backscatter, with maxima occurring at angles that were perpendicular to the predominant myofiber direction and minima when parallel to the fibers. Perpendicular insonification yielded results for n of 1.8 +/- 0.1 for noninfarcted myocardium and 1.2 +/- 0.1 for infarcted myocardium while parallel insonification yielded results of 0.4 +/- 0.1 for noninfarcted and 0.0 +/- 0.1 for infarcted myocardium. The functional form of the angle-dependent backscatter is similar for both noninfarcted and infarcted myocardium, although the frequency dependence is clearly different for both tissue states for all angles of insonification. The results of this study indicate that the anisotropy of the frequency dependence of backscatter may play a significant role in ultrasonic imaging and is an important consideration for ultrasonic tissue characterization in myocardium.

Ifosfamide and vinorelbine as first-line chemotherapy for metastatic breast cancer

PURPOSE

To evaluate the efficacy and toxicity of the combination of ifosfamide (IFX) and vinorelbine (VNB) as first-line chemotherapy in metastatic breast cancer (MBC).

PATIENTS AND METHODS

Between August 1993 and August 1995, 45 patients with untreated MBC received a regimen that consisted of IFX 2 g/m2 by 1-hour intravenous (i.v.) infusion on days 1 to 3, mesna 400 mg/m2 by i.v. bolus at hours 0 and 4 and 800 mg/m2 orally at hour 8 on days 1 to 3, and VNB 35 mg/m2 by 20-minute i.v. infusion on days 1 and 15. Courses were repeated every 28 days. During the first course only, half-dose VNB (17.5 mg/m2) was administered on days 8 and 22. The median age was 53 years and 30 patients (67%) were postmenopausal. Dominant sites of disease were soft tissue in nine patients, bone in seven, and visceral in 29.

RESULTS

Objective responses (ORs) were recorded in 25 of 43 assessable patients (58%; 95% confidence interval, 43% to 73%). Complete remissions (CRs) occurred in six patients (14%) and partial remissions (PRs) in 19 (44%). No change (NC) was recorded in 10 patients (23%) and progressive disease (PD) in eight patients (19%). The median time to treatment failure was 12 months and the median survival duration 19 months. Myelosuppression was the limiting toxicity, mainly leukopenia in 32 patients (74%). In contrast, anemia and thrombocytopenia were mild. Other significant toxicities included peripheral neuropathy in nine patients (21%), constipation in 15 (35%), and myalgias in 11 (26%).

CONCLUSION

IFX/VNB is an active combination against MBC with moderate toxicity and deserves further evaluation.

Description of Warileya lumbrerasi n. sp. (Diptera:Psychodidae) from Peru

Warileya lumbrerasi n. sp. is described from the northern Peruvian Andes. This species was collected inside houses, and is the seventh species described within the genus Warileya Hertig, 1948.

Delineation of myocardial stunning and hibernation by positron emission tomography in advanced coronary artery disease

With positron emission tomography, the resting flow abnormalities underlying reversible left ventricular dysfunction in 17 patients with chronic coronary artery disease were delineated. The level of flow in reversible dysfuncTional segments (i.e., those demonstrating improvement after revascularization) was markedly variable, ranging from 0.32 to 1.25 ml/gm/min. In 20 of these segments, flow was preserved, whereas in 12 segments, flow was reduced, when compared with that in, age-matched controls. Preservation of flow was associated with preservation of myocardial oxygen consumption and no alterations in myocardial substrate use. In contrast, a reduction in flow resulted in a decrease myocardial oxygen consumption and an increase in myocardial glucose use. Thus resting reversible left ventricular dysfunction in patients with chronic coronary artery disease can reflect a diversity of resting flow abnormalities. Moreover, myocardial perfusion at rest is frequently within normal limits, suggesting that the reversible mechanical dysfunction in these patients is attributable to intermittent myocardial stunning and not hibernation.

Intravenous albunex during dobutamine stress echocardiography: enhanced localization of left ventricular endocardial borders

Albunex is an intravenous contrast agent that opacifies the left ventricle (LV). This study evaluated the effect of Albunex on the enhancement of LV endocardial border localization during dobutamine stress echocardiography (DSE). Albunex was infused in 30 patients at baseline and with low- and high-dosage dobutamine. Apical two- and four-chamber views were divided into six segments each, and enhancement of LV border localization was compared with precontrast images graded as follows: 0 = none; 1 = faint; or 2 = optimal. The mean grade and percentage of segments with optimal localization of LV endocardial borders were determined. There was a significant increase in enhancement with low- and high-dosage dobutamine when compared with baseline. Of 179 segments with suboptimal enhancement at baseline, 137 (77%) became optimal during DSE with Albunex. We conclude that Albunex improves localization of LV endocardial borders and that this localization is enhanced during DSE.

Quantitative assessment of myocardial ultrasound tissue characterization through receiver operating characteristic analysis of Bayesian classifiers

OBJECTIVES

This work proposes a self-consistent assessment methodology for quantitative evaluation of any combination of diagnostic features, with the immediate goal of quantitatively assessing the discriminating power in diabetic patients of features derived from ultrasound backscatter from myocardium.

BACKGROUND

Four features from analysis of left ventricular myocardial ultrasound backscatter have previously been shown to be sensitive to potentially cardiomyopathic changes in patients with insulin-dependent diabetes mellitus who have no overt heart disease. The measured features were significantly different between such patients and normal control subjects, as well as among groups of such patients with and without systemic complications of the disease. The quantitative discriminating potential of the features was not assessed.

METHODS

Multivariate classifier functions were constructed and analyzed by using the methodology of the receiver operating characteristic curve, which allows quantitative assessment of the discriminating power of these features, alone or in combination. The area under the receiver operating characteristic curve--the true positive rate averaged over all false positive rates--was used as a summary measure of performance.

RESULTS

In distinguishing patients with insulin-dependent diabetes mellitus from normal control subjects, the most discriminating combination of ultrasound features for the detection of such changes in these patients yielded receiver operating characteristic curves with area measures of approximately 0.80; for such patients with retinopathy the measure increased to 0.90. This performance is comparable to that of many commonly used diagnostic tests.

CONCLUSIONS

A self-consistent set of evaluation methodologies has quantitatively demonstrated the sensitivity of four ultrasound backscatter features to otherwise latent changes in myocardial structure that accompany the evolution of insulin-dependent diabetes mellitus. The results are remarkable in themselves and suggest the potential of the features for the general field of cardiac ultrasound tissue characterization.

High-dose cisplatin with dipyridamole in advanced non-small cell lung cancer. A Grupo Oncológico Cooperativo del Sur study

From March 1991 to October 1992, 41 patients with advanced non-small cell lung cancer (NSCLC) (20 stage IIIB and 21 stage IV) received a regimen consisting of cisplatin (CP) 100 mg/m2 i.v. days 1 and 8, and dipyridamole (DPD) 100 mg p.o. 75 minutes before CP, and then at hours 6, 12, and 18 as first-line chemotherapy. Cycles were repeated every 28 days for a total of 3. Median age was 56 years (range: 40-70). All patients had a performance status 0 to 1 and a weight loss < or = 10%. Squamous-cell carcinoma was diagnosed in 19 patients; adenocarcinoma in 16, and large-cell carcinoma in 6. A total of 37 patients were fully evaluable for response, whereas 39 were assessable for toxicity. No complete responses were observed: 5 patients (14%) achieved partial response; 23 patients (62%) showed no change, and progressive disease was observed in 9 (24%). The median time to treatment failure was 4 months, whereas median survival was 8 months. The average dose intensity received at the end of the third course of therapy was 46 mg/m2/week. There were no drug-related deaths. Toxicity was mild to moderate, with a high incidence of ototoxicity (54%) and emesis (67%). In conclusion, these results failed to demonstrate any significant advantage from a high-dose CP regimen modulated by DPD in patients with advanced NSCLC.

Identification of bloodmeal sources of Lutzomyia spp. in Peru

Bloodmeal sources of Lutzomyia spp. were determined, using the bloodmeal analysis precipitin test, in Chaute, Lima, Peru, an area endemic for cutaneous leishmaniasis (uta). From April 1990 to May 1991, sandflies were sampled in and around the village houses, with CDC light traps and a Shannon trap with protected human bait, respectively. Overall, 1424 sandflies were collected engorged. In indoor collections, human blood (N = 275) was the most frequent bloodmeal found, followed by cow (171) and cat (152). The most frequent bloodmeals of the flies caught in the Shannon trap collections were from cow (31), man (23) and cat (23). Of the two predominant sandfly species in the area, Lutzomyia peruensis was more anthropophilic than Lu. verrucarum (chi 2 = 14.13, P < 0.001). The sandflies from Chaute appear to be opportunistic feeders; 16 different hosts were identified. There was evidence of bloodmeals from more than one host in each of 151 sandflies, including bloodmeals containing blood from an animal only present within the houses mixed with blood from animals only present in the corrals near the house. Some sandflies must therefore have flown from the corrals to the houses (or vice versa) to take the last bloodmeals before their capture.

Enhancement of regional myocardial efficiency and persistence of perfusion, oxidative, and functional reserve with paired pacing of stunned myocardium

BACKGROUND

Stunned myocardium reflects postreperfusion dysfunction in myocardium that is destined to ultimately fully recover. Most investigators attribute postreperfusion stunning to a primary defect in excitation-contraction coupling or to an altered sensitivity of the myofilaments to calcium. The aim of the present study was to evaluate the interrelation between myocardial perfusion, oxidative metabolism, and function in an effort to better characterize the phenomenon of myocardial stunning, to define the regional efficiency of stunned myocardium, and to characterize its reserve capacity.

METHODS AND RESULTS

Regional myocardial perfusion (measured with radiolabeled microspheres), myocardial oxygen consumption (MVO2) (quantified with positron emission tomography using 1-11C-acetate), and myocardial function (assessed with two-dimensional echocardiography) were evaluated in 12 anesthetized, closed-chest dogs subjected to 15 minutes of left anterior descending coronary artery occlusion followed by reperfusion. To evaluate flow, oxidative, and functional reserve after measurements were obtained 1 hour after reperfusion, dogs were subjected to paired pacing (an inotropic stimulus that does not alter systemic hemodynamics), and measurements were repeated. One hour after reperfusion, stunned myocardium was characterized by near-normal levels of myocardial perfusion (0.57 +/- 0.13 mL/g per minute, 81 +/- 13% of that in remote, normal regions) but severe dyskinesis (echo score, 2.6 +/- 0.7; percent wall thickening, 14 +/- 20%). Despite the low level of contractile function, MVO2 averaged 1.72 +/- 0.7 mumol/g per minute, 71 +/- 27% of that observed in remote myocardium. Regional myocardial efficiency (systolic wall thickening divided by MVO2) was markedly diminished. With paired pacing, myocardial perfusion increased proportional to that in remote myocardium, systolic function improved (echo score, 1.4 +/- 0.7; percent wall thickening, 30 +/- 15%), and regional MVO2 nearly doubled (to 3.41 +/- 1.82 mumol/g per minute, P < .05 for each paired measurement). Importantly, with paired pacing, regional myocardial efficiency nearly normalized in reperfused myocardium.

CONCLUSIONS

Stunned myocardium is characterized by near-normal levels of perfusion and oxygen consumption despite marked dyskinesis. Myocardial efficiency is poor. With inotropic stimulation (in the present study, paired pacing), reperfused myocardium demonstrated considerable perfusion, oxidative, and functional reserve and a dramatic improvement in myocardial efficiency. These results may have implications for the treatment of postreperfusion pump failure.

Natural Leishmania infection of Lutzomyia spp. in Peru

Natural infection of Lutzomyia spp. with Leishmania was studied with the aid of the polymerase chain reaction (PCR) in Chaute, Lima, Perú, a locality endemic for Andean cutaneous leishmaniasis (uta). The PCR, with primers specific for the L. braziliensis complex, was applied to sandfly pools. Sandflies were sampled from April 1990 to May 1991 with CDC light traps in homes, and from near homes with a Shannon trap using protected human bait. Lu. verrucarum (4 pools) and Lu. peruenis (2 pools) from the anthropophilic collections, and Lu. verrucarum (2 pools) from indoors were found to be infected with Leishmania. The majority of infected sandflies were recorded mainly in April 1991 (4 pools), coinciding with the highest sandfly densities and the maximum number of new cases of uta (7). Non-infected sandflies were found from May to October 1990 and January to March 1991. Thus, these 2 sandfly species play a role in the spread of leishmaniasis among humans and other animals in Chaute.

Vinorelbine as first-line chemotherapy for metastatic breast carcinoma

PURPOSE

A phase II trial was performed to evaluate the efficacy and toxicity of vinorelbine (VNB) as first-line chemotherapy for metastatic breast carcinoma.

PATIENTS AND METHODS

Between August 1991 and February 1993, 45 patients with metastatic breast cancer were entered onto the study. Therapy consisted of VNB 30 mg/m2 diluted in 500 mL of normal saline administered as a 1-hour intravenous infusion. Injections were repeated weekly until evidence of progressive disease (PD) or severe toxicity developed.

RESULTS

One patient was considered not assessable for response. An objective response (OR) was observed in 18 of 44 patients (41%; 95% confidence interval, 26% to 56%). Three patients (7%) had a complete response (CR) and 15 (34%) had a partial response (PR). The median time to treatment failure for the entire group was 6 months (range, 1 to 15), and the median duration of response was 9 months (range, 1 to 15). The median survival duration has not been reached yet. There were no treatment-related deaths. The dose-limiting toxicity was myelosuppression. Leukopenia occurred in 35 patients (78%) and was grade 3 or 4 in 16 (36%). Phlebitis was observed in 19 of 29 patients (66%) who did not have central implantable venous systems. Fifteen patients (33%) developed peripheral neurotoxicity. Myalgia occurred in 20 patients (44%).

CONCLUSION

VNB is an active drug against metastatic breast cancer with moderate toxicity, which justifies further evaluation in association with other agents.

Two-dimensional Doppler color flow imaging in adults with L-transposition of the great arteries

Abnormalities of the left atrioventricular (AV) (tricuspid) valve and pulmonic stenosis are part of the spectrum of manifestations in patients with corrected transposition of the great arteries (L-TGA). However, the utility of Doppler color flow imaging combined with two-dimensional echocardiography in L-TGA has not been established. Thus, we evaluated 14 adults (mean age 33 +/- 8 {SD} years) with L-TGA. Two-dimensional echocardiography demonstrated Ebstein's anomaly in five patients. Color flow imaging detected left AV valve regurgitation in 13 (moderate to severe in six); the other patient had a prosthetic valve. Right AV valve regurgitation was detected in two (mild in both). Aortic regurgitation was present in five (moderate in three). Pulmonic regurgitation was present in nine (moderate to severe in three). Pulmonic stenosis was detected in three (subvalvular in two, valvular in one) and two patients had pulmonary atresia. One patient had a bicuspid aortic valve with mild stenosis. Mean right ventricular ejection fraction (apical, area-length) was 44%; only 1 of 9 patients had a value greater than 55%. Thus, two-dimensional Doppler echocardiography with color flow imaging detects a high incidence of systemic AV valvular regurgitation and reduced right (systemic) ventricular systolic function in adults with L-TGA.

Functional recovery after reperfusion is predicated on recovery of myocardial oxidative metabolism

To test the hypothesis that recovery of myocardial oxidative metabolism (MVO2) is a necessary prerequisite for recovery of contractile function following reperfusion and to evaluate its dependency on the interval of antecedent ischemia before reflow, we evaluated 11 dogs serially for 4 weeks. Six dogs were subjected to prompt reperfusion (after 1 hour of coronary artery occlusion) and five were subjected to delayed reperfusion (after 4 hours of ischemia). Despite equivalent levels of myocardial blood flow with reperfusion, hearts subjected to prompt reperfusion had faster and more complete recovery of MVO2 (assessed by sequential positron emission tomography with [11C]acetate) and function (assessed by echocardiography) compared with dogs subjected to delayed reperfusion. Infarct size was diminished in dogs with prompt reperfusion. In all dogs, recovery of function with reperfusion was predicted and correlated with early recovery of MVO2 (r = 0.61, p < 0.04). The results demonstrate that prompt reperfusion is associated with more rapid and complete recovery of oxidative metabolism and function and support the hypothesis that the ability to metabolize substrate oxidatively is a necessary prerequisite for recovery of function.

Ifosfamide and mitoxantrone as first-line chemotherapy for metastatic breast cancer

PURPOSE

A phase II trial was performed to evaluate the efficacy and toxicity of a combination of ifosfamide (IFX) and mitoxantrone (MXN) as first-line chemotherapy for metastatic breast carcinoma.

PATIENTS AND METHODS

Between January 1990 and August 1991, 48 patients with metastatic breast cancer were entered onto the study. Therapy consisted of IFX 2 g/m2 given as a 1-hour intravenous (IV) infusion on days 1 to 3; mesna 400 mg/m2 as an IV bolus immediately before and 4 hours after IFX administration and 2,000 mg orally 8 hours after IFX administration on days 1 to 3; and MXN 12 mg/m2 as an i.v. bolus on day 3. Cycles were repeated every 21 days until progressive disease (PD) or severe toxicity developed.

RESULTS

One patient was considered not assessable for response. Objective regression (OR) was observed in 28 of 47 patients (60%; 95% confidence interval, 46% to 74%). Six patients (13%) had a complete response (CR) and 22 (47%) had a partial response (PR). The median time to treatment failure for the whole group was 9 months (range, 1 to 28); median survival was 19 months (range, 2 to 28). There were no treatment-related deaths. The limiting toxicity was myelosuppression. Leukopenia occurred in 37 patients (77%) and was grade 3 or 4 in 19 patients (40%). Nausea and vomiting were observed in 38 patients (80%), mucositis in 16 patients (33%), and grade 2 hematuria in two patients (4%). Eight patients (16%) developed mild neurotoxicity.

CONCLUSION

The combination of IFX plus MXN is an active regimen against metastatic breast cancer with moderate toxicity that deserves further evaluation.

Pathogenesis of a double rupture (septal and free wall rupture) after acute myocardial infarction

Rupture of both the ventricular septum and free wall (double rupture) is an unusual and, typically fatal, post-myocardial infarction complication. We report here the sequence of events leading to the formation of a double rupture.

Aphid derived sugars in the neotropical sandfly--Lutzomyia peruensis

It is known that a sugar meal is a prerequisite for the transmission of Leishmania by sandflies in the laboratory. Lutzomyia peruensis the proven vector of Leishmania peruviana, was caught by aspiration from crevices in rocks near Chaute in the Rimac Valley, Peru, cryopreserved and analysed for sugars using HPLC. The major sugars present are glucose and fructose as well as smaller amounts of sucrose, maltose, melibiose, turanose and a trisaccharide, probably raffinose. The results indicate that the major carbohydrate sugar meal of Lutzomyia peruensis is aphid honeydew. This is the first report of such behaviour in Neotropical sandflies.

The effect of frequency on the magnitude of cyclic variation of backscatter in dogs and implications for prompt detection of acute myocardial ischemia

The magnitude of cyclic variation of integrated backscatter was measured for 3-4, 4-5, 5-6, 6-7, and 7-8 MHz. In ten normal dogs, the magnitude of cyclic variation (M) was found to increase with ultrasonic frequency in an approximately linear fashion. The least squares linear fit to the data yielded M=2.5 dB+0.24f dB/MHz where f is the ultrasonic frequency (MHz). The potential frequency dependence of detection of the immediate consequences of myocardial ischemia was investigated. Acute ischemic injury was induced in each of seven dogs by ligation of a coronary artery. The magnitude of cyclic variation of integrated backscatter was measured in regions of myocardium supplied by this artery before and after ligation. Ischemic myocardium was clearly differentiable from normal myocardium in all five frequency bands. The magnitude of cyclic variation of integrated backscatter demonstrated substantial recovery upon reperfusion. The results offer promise for the detection of ischemia in humans using clinical imaging systems.

Bone-only versus visceral-only metastatic pattern in breast cancer: analysis of 150 patients. A GOCS study. Grupo Oncológico Cooperativo del Sur

The medical records of 510 patients with metastatic breast cancer were retrospectively reviewed. Seventy-seven patients with metastases confined to skeleton and 73 patients bearing visceral-only disease were identified. All patients had a disease-free interval greater than or equal to 6 months and received systemic therapy with any of the following modalities: chemotherapy, hormonotherapy, or chemohormonotherapy. The clinical features, response to treatment, and survival were analyzed and compared for both groups. Median survival of patients with osseous metastases was 28 months, while it was 13 months for those patients with a visceral pattern (p less than 0.001). Response rates to first and second line systemic therapy for both metastatic patterns showed no significant differences, suggesting a similar degree of sensitivity or resistance in both groups. Objective regression to first therapy was 45% in the group with bony disease and 41% among patients with visceral involvement; median duration of response was 16 months and 13 months, respectively. In both groups progressive disease conserved the original metastatic pattern in most patients. We conclude that although a superiority in survival was evident for the osseous metastatic pattern, for these patients efforts should be made to select the least aggressive therapy in order to avoid excessive toxicity. Further studies are needed to confirm our findings.

Normal left ventricular performance in children with X-linked hypophosphatemic rickets: a Doppler echocardiography study

To determine if chronic hypophosphatemia causes myocardial dysfunction, we explored one model for this metabolic derangement by prospectively investigating 11 patients (aged 5-18 years) with X-linked hypophosphatemic rickets (XLH) by M-mode, two-dimensional, and Doppler echocardiography. Inorganic phosphate and calcitriol (1,25-dihydroxyvitamin D3) treatment was withheld 72 h prior to study. None of the patients had cardiovascular symptoms. Fasting serum inorganic phosphate concentrations were subnormal in all: 2.6 +/- 0.5 mg/dl (SD). Serum total and ionized calcium, magnesium, sodium, potassium, and creatine kinase myocardial fraction (CK-MB) levels were unremarkable. Electrocardiograms revealed early repolarization abnormalities in 3 of the 11 patients: 1 had significant QT prolongation (corrected for heart rate), and 2 had T wave abnormalities. Exaggerated U waves occurred in 4 subjects. Resting echocardiograms were normal in 9 patients. In 1 subject there was mitral valve prolapse, and 1 patient possibly had an atrial septal defect (these findings were considered unrelated to hypophosphatemia). All M-mode measurements were normal. The two-dimensionally derived end-diastolic and end-systolic left ventricular volumes were 60.3 +/- 18.0 and 20.5 +/- 6.9 ml, respectively. Left ventricular ejection fraction was 66.1 +/- 4.7%, and the cardiac index by Doppler study was 4.1 +/- 0.8 liters/min per m2 (both values were within normal limits). Although the precise pathogenesis of XLH is unknown and our findings suggest that some electrocardiographic abnormalities may be common in this disorder, we found no evidence for left ventricular dysfunction in this human model of clinically significant long-standing hypophosphatemia.

Phase II Trial of Cytarabine, Cisplatin and Vindesine for Advanced Non-Small Cell Lung Cancer

Thirty-two patients with advanced non-small cell lung cancer (NSCLC) were entered in this study to evaluate the efficacy and toxicity of a chemotherapy schedule including cisplatin (C) 40 mg/m2 intravenously (i.v.) on days 1–3; vindesine (V) 3 mg/m2 i.v. on day 1, and cytarabine (ara-C) 15 mg/m2 subcutaneously every 12 hours on days 1–3 (total dose: 90 mg/m2). Cisplatin was administered simultaneously with one dose of ara-C. Cycles were repeated every 28 days. Five patients out of 28 (18 %) fully evaluable for response presented partial remissions. No complete response was observed. Median survival was 8 months and median duration of response was 4 months. Hematologic toxicity was severe in 3 patients. There were no toxicity-related deaths. Other adverse reactions included nausea and vomiting, alopecia and peripheral neuropathy. We conclude that this chemotherapy combination is marginally effective against NSCLC showing in this group of patients a low number of responses of short duration without a significant impact on survival.

Differentiation between acutely ischemic myocardium and zones of completed infarction in dogs on the basis of frequency-dependent backscatter

The goal of this work was to determine whether the frequency dependence of apparent backscatter coefficient (not corrected for attenuation within the myocardium) could differentiate completed, remote infarction from acute myocardial injury in vivo. Myocardial infarcts were produced in six dogs by coronary artery occlusion. One to 12 months later, acute ischemic injury was induced in each dog by ligation of a coronary artery that supplied a region of myocardium adjacent to the established infarct. Infarct, ischemic, and normal regions were interrogated with a 5-MHz, circular, 0.5-in. diam, broadband, focused, piezoelectric transducer mounted in a water-filled stand-off device placed against the exposed, beating heart. Apparent backscatter coefficients were measured over the range of frequencies from 3-7 MHz. The frequency dependence was obtained from the slope of log apparent backscatter coefficient versus log frequency. No significant difference in frequency dependence was found between normal and acutely ischemic myocardium for periods of up to 2 h of ischemia. In contrast, frequency dependence in regions of remote infarct (1.8 +/- 0.1, mean +/- standard error) was significantly lower than that in acutely ischemic or nonischemic regions (2.3 +/- 0.1) (p less than 0.01). These results suggest that remote myocardial infarction can be differentiated from acutely injured but still potentially salvageable myocardium in vivo on the basis of the frequency dependence of backscatter.

Normal left ventricular performance documented by Doppler echocardiography in patients with long-standing hypocalcemia

INTRODUCTION

Several reports suggest significantly reduced left ventricular performance in subjects with chronic hypocalcemia. We prospectively investigated eight patients, aged 13 to 31 years, with long-standing hypocalcemia due to idiopathic hypoparathyroidism or pseudohypoparathyroidism by echocardiography.

PATIENTS AND METHODS

Six subjects had symptomatic hypocalcemia manifested as recurrent tetany (four), seizures (four), mental retardation (three), behavior disorder (one), and skeletal abnormalities (four); three subjects were untreated when studied. None had cardiovascular symptoms. Each patient underwent clinical, biochemical, and cardiac studies, including Doppler, two-dimensional, and M-mode echocardiography, on the same day.

RESULTS

In serum, both total and ionized calcium concentrations were reduced and averaged 7.2 mg/dl (range: 5.3 to 8.5 mg/dl; normal: 9.0 to 10.3 mg/dl) and 3.6 mg/dl (range: 3.0 to 3.9 mg/dl; normal: 4.5 to 5.3 mg/dl), respectively. Electrocardiograms revealed prolonged QTc intervals in six patients. Also noted were prominent U waves (five), T-wave abnormalities (four), and right-axis deviation (one). Resting echocardiography, however, demonstrated normal left ventricular function in all subjects. All M-mode measurements were normal. Two-dimensional-derived left ventricular end-diastolic and end-systolic volumes were 87.1 +/- 20.1 ml and 30.2 +/- 9.7 ml (mean +/- SD), respectively. Left ventricular ejection fraction was 65 percent (61.2 to 74.7 percent). Doppler-derived cardiac output and cardiac index averaged 5.1 liters/minute (2.9 to 6.7 liters/minute) and 3.0 liters/minute/m2 (1.7 to 4.3 liters/minute/m2), respectively.

CONCLUSION

Our prospective study of eight subjects with functional hypoparathyroidism demonstrated that, despite electrocardiographic abnormalities, long-standing hypocalcemia was not associated with left ventricular dysfunction.

Quantitative real-time imaging of myocardium based on ultrasonic integrated backscatter

The integrated backscatter calculation over the full, two-dimensional echocardiographic sector is implemented to produce images from closed-chest dogs. This new real-time integrated backscatter measurement system allows a continuous determination of integrated backscatter from all myocardial regions in the ultrasonic view. By replacing the conventional video processor in a commercial two-dimensional echocardiographic imager with this new real-time backscatter measurement system, it is possible to produce real-time two-dimensional images based on integrated backscatter.

Stage IV breast cancer: clinical course and survival of patients with osseous versus extraosseous metastases at initial diagnosis. The GOCS (Grupo Oncológico Cooperativo del Sur) experience

The medical records of 414 patients with metastatic breast carcinoma treated between 1978 and 1986 were reviewed and 44 women were identified as having stage IV disease when the primary breast lesion was detected. Of these 44 women, 25 had metastatic disease limited to the skeleton while 19 had extraosseous lesions only. The clinical features, response to therapy, and survival were analyzed and compared for both groups. The median survival of those patients with bone-only metastases was 52 months as compared with 13 months for those with extraskeletal lesions (p = 0.0025). The response rate to first-line systemic therapy was similar for both groups (47% for bone metastases and 44% for extraosseous metastases). The median duration of response was 14 months (range, 3-55 months) for patients with bone disease and 8 months (range, 4-43 months) for those with extraskeletal lesions. We conclude that patients with metastatic breast cancer confined to the skeleton at initial diagnosis tend to follow an indolent, chronic course with prolonged survival. Therefore the increase in response rate with aggressive chemotherapy should be balanced against its higher morbidity. Further studies are needed to confirm whether the better prognosis of these patients is determined by the anatomical confinement of the disease to the skeleton or merely reflects the influence of other prognostic factors.

High-dose alpha-tocopherol as a preventive of doxorubicin-induced alopecia

The effectiveness of alpha-tocopherol acetate as a preventive of doxorubicin-induced alopecia was evaluated in 20 patients with different types of solid tumors. All received therapy containing doxorubicin in a dose range of 50-60 mg/m2/cycle of treatment. The observed hair loss was severe in 90% and moderate in 10% of the patients. No protective activity of alpha-tocopherol was demonstrated in this trial.

Sensitive detection of the effects of reperfusion on myocardium by ultrasonic tissue characterization with integrated backscatter

We have shown recently that tissue characterization of myocardium with ultrasound reflects changes associated with contractile function throughout the cardiac cycle. To determine whether ultrasonic tissue characterization can sensitively detect the impact of ischemic injury and reperfusion on contractile properties of the heart, we studied the time course of change of backscatter after 5, 20, and 60 min of coronary occlusion followed by reperfusion in 15 dogs. The time-averaged integrated backscatter (IB) and the amplitude and phase of cyclic variation of IB (phase relative to the left ventricular pressure waveform) were measured. A novel ultrasonic index of acute injury was identified, the phase-weighted amplitude of cyclic variation, and calculated by weighting the amplitude of cyclic variation of IB with respect to the phase. We hypothesized that backscatter variables would change dramatically after occlusion and that their restitution after reperfusion would sensitively reflect the extent and time course of reversibility of ischemic injury. After coronary occlusion, segmental wall thickening decreased from approximately 55% to 5% regardless of the duration of ischemia. Changes in backscatter associated with this decrease included an increase in time-averaged IB of approximately 5 dB, a 5 dB decrease in cyclic variation, an 80 degree phase shift, and a 7 dB decrease in phase-weighted amplitude. Wall thickening after reperfusion immediately after the 5, 20, or 60 min occlusions recovered to 45%, 27%, and 12% of baseline values, respectively. Within 3 hr it recovered to 53%, 44%, and 22%. Time-averaged IB recovered initially by 89%, 61%, and 44% (all p less than .05) and continued to recover subsequently although more slowly. Ultimate recovery was virtually complete. In contrast to the rapid recovery of time-averaged IB, phase-weighted amplitude recovered initially to only 72%, 41%, and -7% of baseline (all p less than .05) and manifested slower and incomplete recovery when ischemia had been present for 20 or 60 min. After reperfusion, the time course of both cyclic variation and phase were reflected by changes in the phase-weighted amplitude. The backscatter variables assessed appear to sensitively delineate the duration, time course of recovery, and reversibility of ischemic injury in response to reperfusion. The results suggest that early recovery of time-averaged IB corresponds in part to the restoration of tissue ultrastructural integrity.(ABSTRACT TRUNCATED AT 400 WORDS)

Cardiac dysfunction during acute lung injury induced by oleic acid in dogs

Circulatory abnormalities are common during the adult respiratory distress syndrome and contribute importantly to the high mortality seen with this illness, but what causes them is not well characterized. Oleic acid-induced acute lung injury is an experimental model of the human syndrome in which hemodynamic changes are also common. To characterize a possible link between lung injury and cardiac dysfunction in this model, we evaluated cardiac function in mongrel dogs after oleic acid administration. Stroke volume index decreased, the radionuclide ventriculographically determined ejection fraction decreased, and end-diastolic volume increased after oleic acid. These results suggested a decrease in myocardial contractility, a conclusion confirmed when other experiments demonstrated a consistent rightward displacement of the end-systolic pressure-diameter relationship after oleic acid. Histologic examination of the myocardium showed little evidence of vascular injury, and myocardial tissue wet-to-dry weight ratios were normal. Thus, although the pulmonary effects of oleic acid are due to microvascular injury, similar mechanisms are not responsible for the depression in myocardial contractility.

Sequential therapy with methotrexate and 5-fluorouracil in the treatment of advanced colorectal carcinoma

Twenty-nine patients with advanced colorectal carcinoma were entered in this study to evaluate the efficacy and toxicity of a sequential chemotherapeutic schedule with methotrexate (MTX), 200 mg/m2 intravenously (IV) (push injection) and 5-fluorouracil (5-FU), 1,200 mg/m2 in continuous IV infusion, using a 20-hour time interval. All patients received calcium leucovorin (LV), 25 mg, intramuscularly (IM) every six hours for eight doses beginning 24 hours after methotrexate administration. Courses were administered every 15 days. Of the 24 patients evaluable for response, 11 (46%) had major objective regressions (one complete remission [CR] and ten partial remissions [PR]). The survival rate of patients who responded to treatment was 60% at 16 months, whereas patients with no change and those in whom the disease progressed had a median survival of 9 months and 3 months, respectively. The median duration of response has not yet been reached in patients who presented objective tumor regression, and was 7.5 months in those with no change. Significant differences were found between objective regression and no change (P less than .0005) and between no change and tumor progression (P less than .05). All patients were evaluable for toxicity. There were three toxic-related deaths (10%) because of severe myelosuppresion, sepsis, and hemorrhage. These promising results, despite important toxicity, reveal the synergism between the two chemotherapeutic agents and also indicate that the response rate achieved could be a consequence of the 20-hour interval and high dose of 5-FU. Further studies are necessary to determine the optimal time interval and the adequate 5-FU dose.