Anti-PD-1 therapy in patients with advanced melanoma and preexisting autoimmune disorders or major toxicity with ipilimumab

Background

Anti-PD-1 antibodies (anti-PD-1) have clinical activity in a number of malignancies. All clinical trials have excluded patients with significant preexisting autoimmune disorders (ADs) and only one has included patients with immune-related adverse events (irAEs) with ipilimumab. We sought to explore the safety and efficacy of anti-PD-1 in such patients.

Patients and methods

Patients with advanced melanoma and preexisting ADs and/or major immune-related adverse events (irAEs) with ipilimumab (requiring systemic immunosuppression) that were treated with anti-PD-1 between 1 July 2012 and 30 September 2015 were retrospectively identified.

Results

One hundred and nineteen patients from 13 academic tertiary referral centers were treated with anti-PD-1. In patients with preexisting AD (N = 52), the response rate was 33%. 20 (38%) patients had a flare of AD requiring immunosuppression, including 7/13 with rheumatoid arthritis, 3/3 with polymyalgia rheumatica, 2/2 with Sjogren's syndrome, 2/2 with immune thrombocytopaenic purpura and 3/8 with psoriasis. No patients with gastrointestinal (N = 6) or neurological disorders (N = 5) flared. Only 2 (4%) patients discontinued treatment due to flare, but 15 (29%) developed other irAEs and 4 (8%) discontinued treatment. In patients with prior ipilimumab irAEs requiring immunosuppression (N = 67) the response rate was 40%. Two (3%) patients had a recurrence of the same ipilimumab irAEs, but 23 (34%) developed new irAEs (14, 21% grade 3-4) and 8 (12%) discontinued treatment. There were no treatment-related deaths.

Conclusions

In melanoma patients with preexisting ADs or major irAEs with ipilimumab, anti-PD-1 induced relatively frequent immune toxicities, but these were often mild, easily managed and did not necessitate discontinuation of therapy, and a significant proportion of patients achieved clinical responses. The results support that anti-PD-1 can be administered safely and can achieve clinical benefit in patients with preexisting ADs or prior major irAEs with ipilimumab.

Stoma complications: the Cook County Hospital experience

PURPOSE

A retrospective analysis of enteric stomas performed at Cook County Hospital was undertaken to evaluate stoma complications per stoma type and configuration and operating service. In addition, we attempted to identify factors predictive of increased enteric stoma complications.

METHODS

From 1976 to 1995, data cards on 1,616 patients with stomas were compiled by Cook County Hospital enteric stomal therapists. Data card information included age, gender, weight, early and late stoma complications, emergency status, operating service, type and configuration of the stoma, and whether the patient was seen preoperatively by an enteric stomal therapist. Data were then analyzed using a logistic regression model to identify those variables that influenced the rate of complications.

RESULTS

There were 553 (34 percent) patients with complications. Among the total complications, 448 (28 percent) occurred early (<1 month postoperative), and 105 (6 percent) occurred late (>1 month). The most common early complications were skin irritation (12 percent), pain associated with poor stoma location (7 percent), and partial necrosis (5 percent). The most common late complications were skin irritation (6 percent), prolapse (2 percent), and stenosis (2 percent). The enteric stoma with the most complications was the loop ileostomy (75 percent). The enteric stoma with the least complications was the end transverse colostomy (6 percent). The general surgery service had the most complications (47 percent), followed by gynecology (44 percent), surgical oncology (37 percent), colorectal (32 percent), pediatric surgery (29 percent), and trauma (25 percent). Age, operating service, enteric stoma type and configuration, and preoperative enteric stomal therapist marking were found to be variables that influenced stoma complications.

CONCLUSIONS

Complications from enteric stoma construction are common. Preoperative enteric stoma site marking, especially in older patients, and avoiding the ileostomy, particularly in the loop configuration, can help minimize complications.

The role of exercise training in the treatment of hypertension: an update

Hypertension is a very prevalent cardiovascular (CV) disease risk factor in developed countries. All current treatment guidelines emphasise the role of nonpharmacological interventions, including physical activity, in the treatment of hypertension. Since our most recent review of the effects of exercise training on patients with hypertension, 15 studies have been published in the English literature. These results continue to indicate that exercise training decreases blood pressure (BP) in approximately 75% of individuals with hypertension, with systolic and diastolic BP reductions averaging approximately 11 and 8mm Hg, respectively. Women may reduce BP more with exercise training than men, and middle-aged people with hypertension may obtain greater benefits than young or older people. Low to moderate intensity training appears to be as, if not more, beneficial as higher intensity training for reducing BP in individuals with hypertension. BP reductions are rapidly evident although, at least for systolic BP, there is a tendency for greater reductions with more prolonged training. However, sustained BP reductions are evident during the 24 hours following a single bout of exercise in patients with hypertension. Asian and Pacific Island patients with hypertension reduce BP, especially systolic BP, more and more consistently than Caucasian patients. The minimal data also indicate that African-American patients reduce BP with exercise training. Some evidence indicates that common genetic variations may identify individuals with hypertension likely to reduce BP with exercise training. Patients with hypertension also improve plasma lipoprotein-lipid profiles and improve insulin sensitivity to the same degree as normotensive individuals with exercise training. Some evidence also indicates that exercise training in hypertensive patients may result in regression of pathological left ventricular hypertrophy. These results continue to support the recommendation that exercise training is an important initial or adjunctive step that is highly efficacious in the treatment of individuals with mild to moderate elevations in BP.

Repair of fistulas-in-ano using fibrin adhesive: long-term follow-up

PURPOSE

Fibrin adhesive has been successfully used to treat fistulas-in-ano, but long-term data have been lacking. We report the results of our 18-month study examining the repair of fistulas-in-ano using autologous and commercial fibrin adhesive.

METHODS

A 79-patient, prospective, non-randomized clinical trial was performed in which fibrin adhesive was used to repair fistulas-in-ano. Twenty-six patients were treated with autologous fibrin tissue adhesive made from their own blood, and 53 patients were treated with commercial fibrin sealant. In the operating room the patient underwent an examination under anesthesia, with an attempt to identify the primary and secondary fistula tract openings. The fistula tract was then curetted. Fibrin adhesive was injected into the secondary fistula tract opening until adhesive was seen coming from the primary opening. A petroleum jelly gauze was then applied over both the primary and secondary openings, and the patient was sent home. Follow-up visits occurred one week, one month, three months, and one year later.

RESULTS

Fourteen of 26 (54 percent) patients treated with autologous fibrin tissue adhesive made from their own blood had complete closure of their fistulas after a one-year follow-up, whereas 34 of 53 (64 percent) patients treated with commercial fibrin sealant had closure of their fistulas. Most treatment failures occurred within the first 3 months, but late failures were seen as far as 11 months postoperative.

CONCLUSIONS

Fibrin tissue adhesive offers a unique mode of managing fistulas-in-ano, which is surgically less invasive, but recurrences up to one year later are being seen. Longer follow-up and further research is recommended for improvement.

Human thioredoxin reductase is efficiently inhibited by (2,2':6',2' '-terpyridine)platinum(II) complexes. Possible implications for a novel antitumor strategy

Malignant neoplasms of the brain represent the second leading cause of cancer-related mortality in children under the age of 15. The prognosis of patients with glioblastoma multiforme, the most malignant type of gliomas, remains poor offering a median survival time of only 1 year. (2,2':6',2"-Terpyridine)platinum(II) complexes are known to possess DNA-intercalating activity and have been shown to be potential chemotherapeutic agents. In the present study we identified the selenoenzyme thioredoxin reductase (TrxR) as a major target of (2,2':6',2"-terpyridine)platinum(II) complexes. New complexes were synthesized in order to optimize this inhibition. The NADPH-reduced enzyme is inhibited almost stoichiometrically by the complexes involving a reversible competitive and an irreversible tight-binding component. For the most potent inhibitor, N,S-bis(2,2':6',2"-terpyridine)platinum(II)-thioacetimine trinitrate, the K(i) for the competitive component of the inhibition is 4 nM and the IC(50) for the tight-binding component is 2 nM after an incubation time of 5 min. The closely related but non-selenium-containing enzyme glutathione reductase is much less inhibited (by a factor of >1000). The platinum complexes were found to strongly inhibit the proliferation of three different glioblastoma cell lines as well as of two different head-and-neck squamous carcinoma cell lines. In a glioblastoma cell culture, less than 10 microM of a platinum(II) compound caused an initial drop of hTrxR activity which was followed by an increase of activity in the surviving cells. A 10 microM inhibitor added every 24 h led to 4% residual hTrxR activity but 100% glutathione reductase activity in the cells surviving for 67 h. The potential of (2,2':6',2"-terpyridine)platinum(II) complexes acting simultaneously at two different intracellular targets-hTrxR and DNA-as antitumor agents is discussed.

Stratified mucin-producing intraepithelial lesions of the cervix: adenosquamous or columnar cell neoplasia?

BACKGROUND

Squamous (CIN) and glandular (ACIS) intraepithelial lesions often coexist in the same cervical specimen. However, a less common and little studied variant consists of a stratified epithelium resembling CIN in which conspicuous mucin production is present (Stratified Mucin-producing Intraepithelial LEsions (SMILE). This report describes the phenotypic characteristics of the SMILE, its associated lesions, and its immunophenotype.

METHODS

Eighteen SMILEs were identified by the presence of conspicuous cytoplasmic clearing or vacuoles in lesions otherwise resembling CIN. The morphologic spectrum of SMILEs was detailed; including associated intraepithelial and invasive cervical neoplasms. In addition, selected cases were stained for mucicarmine, markers of squamous cell/reserve cell differentiation (keratin-14 and p63), and proliferative activity (Mib-1).

RESULTS

Stratified neoplastic epithelial cells with a high Mib-1 index and a rounded or lobular contour at the epithelialstromal interface characterized SMILEs. In contrast to CIN, in which mucin droplets are confined to surface cells, mucin was present throughout the epithelium, varying from indistinct cytoplasmic clearing to discrete vacuoles. SMILEs were distinguished from benign metaplasia by nuclear hyperchromasia and a high Mib-1 index. All but three coexisted with either a squamous (CIN) or glandular (ACIS) precursor lesion. Nine of nine coexisting invasive carcinomas contained glandular, adenosquamous differentiation, or both. SMILEs stained negative for keratin-14 and variably for p63. When present, staining with p63 was confined to basal areas of SMILEs and was absent in areas of columnar differentiation.

CONCLUSIONS

SMILEs are unusual cervical intraepithelial lesions best classified as variants of endocervical columnar cell neoplasia based on immunophenotype. The distribution and immunophenotype of SMILEs are consistent with a neoplasm arising in reserve cells in the transformation zone. The coexistence of a wide spectrum of intraepithelial and invasive cell phenotypes suggests that SMILEs are a marker for phenotypic instability, emphasizing the importance of identifying SMILEs and ensuring a complete examination of specimens containing this unusual precursor lesion.

Androgen deprivation and radiation therapy: sequencing studies using the Shionogi in vivo tumor system

PURPOSE

To test the relative effect of neoadjuvant and adjuvant androgen deprivation on the radiation response of an androgen dependent tumor.

METHODS AND MATERIALS

The transplantable, androgen dependent, Shionogi adenocarcinoma was grown as allografts in the hind limbs of NCr/Sed (nu/nu) athymic nude mice. Bilateral orchiectomy was the chosen form of androgen deprivation. Groups of tumors were irradiated to graded tumor doses and then studied for durable tumor control. The radiation response was expressed as the radiation dose required to control 50% of the tumors (TCD50). The sequence of radiation and orchiectomy was studied.

RESULTS

When radiation was combined with orchiectomy the Shionogi tumor was significantly more likely to be controlled than when radiation was used alone. Orchiectomy 12 days prior to radiation (neoadjuvant therapy) produced a significantly greater decline in the TCD50 than when orchiectomy was used 1 day or 12 days after radiation (adjuvant therapy). If, before radiation, tumors were allowed to regrow after orchiectomy to their original size in an androgen independent fashion then the advantage was largely lost. Those tumors responding well to neoadjuvant orchiectomy (>50% volume decrease) were significantly more likely to be eradicated by radiation than those with a lesser response.

CONCLUSION

When using combinations of androgen deprivation and radiation in the treatment of the Shionogi tumor, sequence and timing of the therapies are crucial to maximize the effect.

Cytotoxicity of 2,2':6',2' '-terpyridineplatinum(II) complexes against human ovarian carcinoma

2,2':6',2''-Terpyridineplatinum(II) complexes are shown to possess cytotoxicity against a number of human ovarian tumor cell lines. Many of the complexes show similar activity against cisplatin- and doxorubicin-resistant cell lines as the parental cells suggesting that there is little or no cross-resistance with cisplatin or doxorubicin. The cytotoxicity of bis[2,2':6',2''-terpyridineplatinum(II)] complexes is strongly dependent on the nature of the linker. Bis[2,2':6',2''-terpyridineplatinum(II)] complexes with a flexible linker at the 4'-position show poor cytotoxicity; by contrast bis[2,2':6',2''- terpyridineplatinum(II)] complexes with rigid and short linkers at platinum(II) are strikingly effective. Several of the compounds show greater cytotoxicity against human ovarian cell lines than carboplatin, the therapeutic agent currently advocated for the treatment of human ovarian cancers.

Retinoic acid-mediated induction of neurons and glial cells from human umbilical cord-derived hematopoietic stem cells

Recent studies reporting trans-differentiation of mononucleated cells derived from human umbilical cord blood into neuronal cells aroused interest among investigators for their clinical implication and significance in regenerative medicine. In the present study, purified populations of hematopoietic stem cells were isolated via magnetic bead sorting and fluorescence-activated cell sorter (FACS) using a specific CD133 antibody, a cell type-specific marker for hematopoietic stem cells, and grown in culture in the presence of retinoic acid (RA). CD133+ hematopoietic stem cells expressed neuronal and glial phenotypes after RA treatment. RT-PCR analysis indicated that the RA treated CD133+ cells expressed mRNA transcripts for ATP-binding cassettes transporter ABCG2 (a universal stem cell marker), nestin (a specific cell type marker for neural stem cells), Musashi1 (a specific marker for neural stem cells) and RA receptors (RAR) including RAR-alpha, RAR-beta, and retinoid X receptor (RXR)-gamma. RA-treated CD133+ cells expressed mRNA transcripts for neuron-specific markers neurofilament proteins (NF-L, -M, -H) and synaptophysin as determined by RT-PCR, structural proteins characteristic of neurons including tubulin beta III and neuron specific enolase (NSE) by Western blot, and neuron-specific markers NeuN and microtubule-associated protein-2 (MAP2) by immunocytochemistry. RA-treated CD133+ cells also expressed the astrocyte-specific marker glial fibrillary acidic protein (GFAP), as demonstrated by RT-PCR, Western blot, and immunocytochemistry. In addition, RA-treated CD133+ cells expressed cell type-specific markers for oligodendrocytes including myelin basic protein (MBP) as shown by RT-PCR, proteolipid protein (PLP) by Western blot analysis, and cyclic nucleotide phosphodiesterase (CNPase) by immunostaining. Upregulated expression of several basic helix-loop-helix (bHLH) transcription factors important for early neurogenesis, including Otx2, Pax6, Wnt1, Olig2, Hash1 and NeuroD1, was also demonstrated in CD133+ cells after RA treatment. These results indicate that human cord blood-derived CD133+ hematopoietic stem cells could trans-differentiate into neural cell types of neuron-like cells, astrocytes, and oligodendrocytes by RA treatment.

Self-reported sleep quality and quality of life for individuals with chronic pain conditions

OBJECTIVE

To determine the sleep quality and quality of life for individuals with degenerative spinal disease or failed back surgery syndrome.

DESIGN

Cross-sectional survey design utilizing standardized instruments. Data were analyzed with use of hierarchical stepwise multiple regression analyses.

PATIENTS

One hundred sixty-seven individuals with degenerative spinal disease or postlaminectomy syndrome who presented to a tertiary care outpatient patient pain center.

OUTCOME MEASURES

The Center for Epidemiological Studies Depression Index measured depressive symptomatology. A modified Pittsburgh Sleep Quality Index (PSQI) measured sleep quality. The arithmetic average of least and usual VAS ratings of pain measured everyday pain. A visual analog scale rating of highest pain during the past 2 weeks measured highest pain. The Epworth Sleepiness Scale measured daytime sleepiness. The Medical Outcome Study-Short Form-Health Survey (SF-36) measured the mental health and general health components of quality of life.

RESULTS

Higher overall sleep quality and lower sleep latency primarily were related to higher ratings of physical functioning and shorter duration of pain. Ratings of the highest pain, but not everyday pain, were independent predictors of overall sleep quality and sleep latency. Daytime sleepiness was associated with younger age and depressed mood. Pain was not associated independently with daytime sleepiness. The quality of life related to mental functioning was associated positively with depressed mood and with the interaction of pain and depressed mood. None of the variables in the model (i.e., pain intensity, sleep quality, depression, and demographic variables) predicted quality of life related to overall general health.

CONCLUSIONS

These data suggest that physical functioning, duration of pain, and age may be more important than pain intensity and depressed mood in contributing to decreased overall sleep quality and sleep latency. The contribution of physical functioning was particularly strong and should be included in subsequent studies of sleep, pain, and mood. The SF-36 should be compared to pain-specific quality-of-life measures to further evaluate the usefulness of this instrument with outpatients with chronic nonmalignant pain conditions.

Comprehensive pharmaceutical care in the chain setting

A controlled, randomized study was conducted in two chain pharmacies to determine the clinical value of comprehensive pharmacy services for hypertensive patients in a chain pharmacy setting. Twenty-seven patients were enrolled as intervention participants with 26 control subjects. Monthly services for the intervention group included blood pressure and heart rate assessments and counseling on lifestyle modifications and drug therapy. Control patients received initial and final blood pressure measurements and minimal counseling. Both study and control groups completed quality-of-life questionnaires upon entering and completing the study. Results showed that blood pressure control was significantly improved in the study group. Compliance rates as well as energy/fatigue scores (a quality-of-life scale) improved in the study group compared with the control population. Community pharmacists in chain stores could have a beneficial effect on the health care of large numbers of patients if pharmaceutical care programs were developed.

Repair of fistulas-in-ano using autologous fibrin tissue adhesive

PURPOSE

Our goal was to determine if autologous fibrin tissue adhesive derived from the precipitation of fibrinogen using a combination of ethanol and freezing, could be used to completely close both simple and complex fistulas-in-ano.

METHODS

A 26-patient pilot study was performed in which 100 ml of a patient's blood was drawn 90 minutes before surgery. Autologous fibrin tissue adhesive was prepared. In the operating room the patient underwent an examination under anesthesia, and the primary and secondary fistula tract openings were attempted to be identified. The fistula tract was curetted, and autologous fibrin tissue adhesive was injected into the secondary fistula tract opening until fibrin glue was seen coming from the primary opening. A petroleum jelly gauze was then applied over the secondary opening, and the patient was sent home. Follow-up visits were scheduled for one week, one month, three months, and one year later.

RESULTS

Twenty-six patients received autologous fibrin tissue adhesive fistula injections, with a mean follow-up of 3.5 months. Initial results were encouraging. Twenty-one of 26 patients (81 percent) had successful initial closure of their fistulas. Two of five failures were injected a second time, and one closed, giving an overall successful closure rate of 85 percent (22/26 patients). Of five patients who failed, mean time to failure was 3.8 weeks. In addition, there was no evidence of infection or complications related to the procedure.

CONCLUSION

Our initial results are optimistic and require further support through longer follow-up data. Fibrin glue treatment of anorectal fistulas offers a unique mode of management that is safe, simple, and easy for the surgeon to perform. By using autologous fibrin tissue adhesive the patient avoids the risk of anal incontinence and the discomfort of prolonged wound healing which may be associated with fistulotomy.

Assessing quality of life in Australian patients with Graves' ophthalmopathy

AIMS

To determine quality of life and adequacy of education and counselling in Australian patients with Graves' ophthalmopathy during the course of their illness.

METHODS

A cross sectional study was conducted at the orbital and endocrinology clinics of Royal Brisbane Hospital on 162 consecutive patients with Graves' ophthalmopathy who were managed between the 1992 and 2000. The Graves' ophthalmopathy quality of life (GO-QOL) survey modified for Australian conditions was distributed to study participants. Of the 19 questions asked, nine questions related to visual functioning, eight questions were about the psychosocial consequences of changed appearance, and two questions referred to education and counselling. Additionally, clinical data on the severity of illness were collected retrospectively from the medical notes of these patients.

RESULTS

Completed questionnaires were received from 128 patients. The majority of patients reported limitations in daily activities such as hobbies, driving, watching television and reading, as well as impaired self confidence. The mean GO-QOL scores in this study were (100 representing maximum QOL): visual functioning 59.0 (SD 28.0), psychosocial consequences of changed appearance 54.5 (28.4), and education and counselling 59.1 (38.8). Only about a quarter of patients indicated that education and counselling were adequate and helpful.

CONCLUSION

Graves' ophthalmopathy profoundly affects QOL and adequate education and counselling are essential for helping patients to cope with their illness. The GO-QOL survey is a simple, practical tool that can be used easily in a clinic to determine the QOL issues in subjects with Graves' ophthalmopathy.

Ethanol enhances growth factor-induced neurite formation in PC12 cells

Ethanol can injure the nervous system by disturbing the growth of neural processes. PC12 cells, which form neurites in response to nerve growth factor (NGF), fibroblast growth factor (FGF), and cAMP analogues, were used to study mechanisms by which ethanol alters process outgrowth. Ethanol potentiated NGF-induced neurite outgrowth in cells cultured on different substrata and in serum-containing or defined medium. Ethanol did not increase NGF receptor binding or internalization of NGF. Neurite outgrowth induced by basic FGF was also increased by ethanol but outgrowth induced by forskolin was not. Ethanol potentiated NGF-induced expression of Thy-1, but not of neural cell adhesion molecule (N-CAM), indicating that some, but not all actions of NGF are enhanced by ethanol. In some brain regions, chronic exposure to ethanol increases the growth of dendrites. This has been explained as a compensatory response of surviving neurons to the loss of neighboring cells, and not as a direct effect of ethanol. The present findings suggest that, in some cells, ethanol directly promotes growth factor-mediated neurite formation. This could harm the nervous system by disturbing the balanced development and organization of synapses.

Age-related change in the number of neurons in the human vestibular ganglion

Dysequilibrium of aging in humans has been speculated to arise from progressive deterioration within anatomical components of the vestibular system. An integral part of this system is vestibular ganglions, which are bipolar neurons that relay peripheral vestibular information to the central nervous system. To assess the effect of aging on the number of human vestibular ganglion neurons, assumption-free stereology in the form of the optical fractionator was used on 20 serially sectioned archival human temporal bone specimens. Donors had no history of vestibular pathology and ranged in age from 2 to 88 years. An average of 25,812 (coefficient of variation = 0.13) vestibular ganglion neurons was found throughout this age range, a significant departure from the results of past studies. Logistics-based regression analysis pointed to a nonlinear pattern of decline in the neuronal population: the number of cells remained roughly constant at about 28,952 cells in youth and then declined gradually between 30 and 60 years of age before leveling off at approximately 23,349 cells in older individuals. This study confirmed the existence of an age-related decline in the primary neurons of the human vestibular system, thus providing one anatomical basis for the increased incidence of imbalance seen with age.

Repair of chronic anorectal fistulae using commercial fibrin sealant

HYPOTHESIS

Commercially produced fibrin sealant can be used to completely close both simple and complex fistulae in ano.

METHODS

A 29-patient prospective nonrandomized clinical trial was performed. In the operating room, the patient underwent an examination with anesthesia and the primary and secondary fistula tract openings were attempted to be identified. The fistula tract was curetted and fibrin sealant was injected into the secondary fistula tract opening until fibrin sealant was seen coming from the primary opening. A petroleum jelly gauze was then applied over the secondary opening and the patient was sent home. Follow-up visits were scheduled for 1 week, 1 month, 3 months, and 1 year later.

RESULTS

Twenty-nine consecutive patients received fibrin sealant injections for their fistulae in ano, with a mean follow-up of 6 months. Two patients had a history of Crohn disease (regional enteritis) and 2 patients had human immunodeficiency virus infection. Overall, 17 (68%) of 25 patients have had successful closure of their fistula with 4 patients lost to follow-up. Two patients required reinjection with fibrin sealant, and neither of these subsequently had closure. One of the 2 patients with Crohn disease had closure, as well as 1 human immunodeficiency virus-positive patient. In addition, there has been no evidence of incontinence or complications related to the use of fibrin sealant in this procedure.

CONCLUSIONS

Initial results in the treatment of chronic anorectal fistulae using commercial fibrin sealant are optimistic, but require further support through longer follow-up data. Fibrin sealant treatment of anorectal fistulae offers a unique mode of management which is safe, simple, and easy for the surgeon to perform. By using fibrin sealant, the patient avoids the risk of fecal incontinence and the discomfort of prolonged wound healing that may be associated with fistulotomy.

Self-expanding coil stent with a long delivery system for palliation of unresectable malignant gastric outlet obstruction: a prospective study

BACKGROUND AND STUDY AIMS

Peroral intubation of a self-expanding metal stent is usually difficult in patients with unresectable malignant gastric outlet obstruction, because the delivery systems currently available are not long enough and cannot easily pass the angulated gastroduodenal structure. We carried out a prospective study to assess the efficacy of a coil stent with a newly developed long delivery system, for palliation of unresectable malignant gastric outlet obstruction.

PATIENTS AND METHODS

In 29 patients with unresectable malignant gastric outlet obstruction, caused by gastric cancer (26 patients), pancreatic head cancer (two patients), or duodenal cancer (one patient), peroral intubation of a self-expanding nickel-titanium coil stent was attempted, using a lengthened delivery system of 150 cm, under endoscopic and fluoroscopic guidance.

RESULTS

Management was successful in 26 of 29 patients (89.7 %) without immediate major complications. In one patient in whom peroral intubation failed, percutaneous intubation of the coil stent via percutaneous endoscopic gastrostomy was done. After insertion of the coil stent, food ingestion with symptomatic improvement with regard to vomiting was achieved in 26 of 27 patients (96.3 %), including the patient with percutaneous stent insertion. During the follow-up period, dysphagia and Karnofsky scores improved significantly. Stent migration occurred in two patients, and tumor ingrowth in another two; re-intervention was done successfully performed in two instances. The mean survival time was 124 days (range 34 - 310 days) in the 22 patients who had no need for re-intervention during follow-up; among these was a patient who experienced stent occlusion by food material, which was easily corrected with endoscopic flushing.

CONCLUSIONS

Peroral intubation of a self-expanding coil stent using a long delivery system is a safe and effective palliative technique for unresectable malignant gastric outlet obstruction, and significantly improves the quality of life of patients.

Metachromatic activity of heparin and heparin fragments

Heparin of an average molecular weight of 13,000 was fractionated on the basis of size into five fractions of different weight-average molecular weight ranging from 8500 to 20,000. The heparin was also degraded using microbial heparinase resulting in products ranging from a disaccharide of molecular weight 500 to an oligosaccharide of molecular weight 3100. These products were also size fractionated. The individual heparin fractions and products were tested for metachromatic activity with Azure A. The metachromatic activity of the heparin fractions was independent of molecular weight, while the metachromatic activity of the products was dependent on molecular weight. Metachromatic activity was found in a fragment as small as a tetrasaccharide. Anticoagulant activity was found in fragments of tetrasaccharide or larger by a Factor Xa clotting assay and in fragments of hexasaccharide or larger by a Factor Xa amidolytic chromogenic assay.

Transabdominal fine needle aspiration of retroperitoneal lymph nodes in staging of genitourinary tract cancer (correlation with lymphography and lymph node dissection findings)

Percutaneous fine needle aspiration of retroperitoneal pelvic and abdominal lymph nodes was done in 100 patients with clinically localized bladder, prostatic, testis and penile cancer. A diagnosis of metastases to regional lymph nodes was detected by this method in 20 patients. Fine needle aspiration revealed evidence of regional lymph node involvement in 6 of 40 patients (15 per cent) with negative findings on lymphography and computerized tomography scan. Lymph node aspiration was followed by lymph node dissection in 50 patients. The correlation between aspiration and dissection was 68 per cent. The accuracy of obtaining representative material from the lymph node aspiration was 83 per cent. Negative results of lymph node aspiration cannot be used in clinical management. However, positive aspiration results provide the clinician with valuable information obtainable otherwise only by laparotomy or lymph node dissection. Positive aspiration results may spare patients with prostatic and bladder cancer an unnecessary radical operation, and may indicate early chemotherapy or surgery in patients with testis and penile cancer.

Safety and efficacy of currently available fibrin tissue adhesives

PURPOSE

The purpose of this study is to review preparation methods, bonding power, preparation time, and costs associated with currently available autologous and homologous fibrin tissue adhesive preparations.

METHODS

Two autologous fibrin tissue adhesive preparations (AFTA-A and AFTA-E), a single-donor homologous preparation, and 2 multiple-donor pooled homologous fibrin tissue adhesives, Vi-Guard and Tisseel, were evaluated and compared in relation to bonding power, preparation time, cost, bicompatibility, and biodegradability.

RESULTS

Vi-Guard and Tisseel showed significantly greater bonding strengths than their single-donor counterparts. AFTA-C offers the quickest preparation time. All preparations were found to be similar in biocompatibility and biodegradability in soft tissue tests. Histology showed no infection or tissue reaction from adhesive exposure in any of the preparations.

CONCLUSION

The optimal choice of a fibrin tissue adhesive is determined by the particular clinical indication. Currently available fibrin tissue adhesives vary appreciably in their bonding strength, cost, level of exposure risk, and preparation methods and times. Autologous preparations, which offer optimal safety, lack the strength and availability characteristics found with the multiple-donor preparations.

Natural occurrence of Fusarium mycotoxins in field samples from the 1992 Wisconsin corn crop

Analysis of 98 moldy corn samples collected in Wisconsin between November 1992 and January 1993 for Fusarium toxins by various immunochemical assays revealed overall average mycotoxin concentrations of 305.6, 237.7, and 904.3 ng/g for type A trichothecenes (TCTCs), deoxynivalenol (DON)-related type B TCTCs (total DON), and zearalenone (ZE), respectively. A small portion (5.1%) of the samples was found to be contaminated with high levels ( > 1 microgram/g) of type A TCTCs and total DON during the whole survey. Over 40% of the samples had 100 to 1,000 ng of total DON per g, while 17% of the samples had the same levels of type A TCTCs. The analytical data were consistent with those from mycological examinations for the samples in which various toxic Fusarium spp., including F. sporotrichioides, F. poae, and F. graminearum, were found. The samples received in November 1992 had relatively low concentrations of toxin; the average levels of type A TCTCs and total DON were 9.9 and 79 ng/g, respectively. The toxin concentrations became progressively higher in the samples received in December. The average levels for the type A TCTCs and total DON increased to 920 and 335 ng/g, respectively. However, the levels of ZE were higher in the samples collected earlier. The average levels for samples collected in November and late December were 1,195 and 242 ng/g, respectively. Analysis of selected samples by high-performance liquid chromatography monitoring with an enzyme-linked immunosorbent assay revealed that T-2 toxin, HT-2 toxin, diacetoxyscirpenol, neosolaniol, and T-2 tetraol (T-2-4ol) were common in these samples. Statistical analysis revealed a weak correlation between the levels of total type A TCTCs and total DON in the samples (r = 0.18, P = 0.09), but a strong correlation between the levels of ZE and total type B TCTCs (r = 0.75, P < 0.0001) was found. The mycotoxin levels of total type A TCTCs, total DON-related type B TCTCs, and ZE in the cobs (5.2, 3.9, and 21 micrograms/g, respectively) were considerably higher than those in the kernels (1.0, 0.5, and 0.5 microgram/g, respectively). The type A toxin levels increased from a range of 14 to 35 ng/g to a range of 110 to 538 ng/g after the moldy corn samples were held at 5 degrees C for 8 days in the laboratory.

Neurogenesis and cell migration into the sexually dimorphic preoptic area/anterior hypothalamus of the fetal ferret

A sexually dimorphic male nucleus (MN) of the preoptic area/anterior hypothalamus (POA/AH), comprising large, estradiol-receptor containing neurons, is formed in male ferrets due to the action of estradiol, derived from the neural aromatization of circulating testosterone, during the last quarter of a 41-day gestation. Two experiments were conducted to compare the birthdates and the migration pattern of cells into the sexually dimorphic portion of the dorsomedial POA/AH as well as the nondimorphic ventral nucleus (VN) of the POA/AH of males and females. In experiment 1 the thymidine analog, bromodeoxyuridine (BrdU), was injected into the amniotic sacs of fetuses of different mothers between embryonic (E) days 18 and 30. Kits from all mothers were sacrificed on E38, and brains were processed to localize BrdU immunoreactivity (IR) for determining the birthdates of neurons in the POA/AH. Cells in the MN-POA/AH of males and in a comparable region of females were born between E22 and E28; cells in the nondimorphic VN-POA/AH of both sexes were born between these same ages. These results suggest that cells in the sexually dimorphic as well as the nondimorphic subdivision of the ferret POA/AH are born during the same embryonic period. This is well before the ages (E30-E41) when administering testosterone to females can stimulate, and blocking androgen aromatization in males can inhibit, MN-POA/AH differentiation. In experiment 2 BrdU was injected on E24, and kits from different litters were perfused on E30, E34, or E38. Brains were processed for BrdU-IR as well as glial fibrillary acidic protein (GFAP), which served as a marker for radial glial processes. The orientation of radial glial processes in fetal brains of both sexes suggested that cells migrate into the dorsomedial POA/AH from proliferative zones lining the lateral as well as the third ventricles. Quantitative, computer-assisted image analysis of BrdU-IR in groups of male and female brains supported this hypothesis. There were no significant sex differences in the distribution of BrdU-IR over the three ages studied, suggesting that formation of the MN-POA/AH in males cannot be attributed to an effect of estradiol on the migration of those cells born on E24 into this sexually dimorphic structure. Finally, total BrdU-IR did not change significantly in the POA/AH of male and female kits killed at E30, E34, or E38 while the area of the POA/AH increased more than 2.5-fold over this period, suggesting that few of the POA/AH cells born on E24 die during this period in either sex. In the absence of evidence that formation of the male ferret's MN-POA/AH depends on steroid-induced changes in neurogenesis, cell migration, or death, we suggest that the specification of a particular neuronal phenotype (e.g., large somal size; capacity to produce some undetermined neurotransmitter or neuropeptide) may be responsible.

Posterior interosseous free flap: various types

The posterior interosseous artery is located in the intermuscular septum between the extensor carpi ulnaris and extensor digiti minimi muscles. The posterior interosseous artery is anatomically united through two main anastomoses: one proximal (at the level of the distal border of the supinator muscle) and one distal (at the most distal part of the interosseous space). In the distal part, the posterior interosseous artery joins the anterior interosseous artery to form the distal anastomosis between them. The posterior interosseous flap can be widely used as a reverse flow island flap because it is perfused by anastomoses between the anterior and the posterior interosseous arteries at the level of the wrist. The flap is not reliable whenever there is injury to the distal forearm or the wrist. To circumvent this limitation and to increase the versatility of this flap, we have refined its use as a direct flow free flap. The three types of free flaps used were (1) fasciocutaneous, (2) fasciocutaneous-fascia, and (3) fascia only. Described are 23 posterior interosseous free flaps: 13 fasciocutaneous flaps, 6 fasciocutaneous-fascial flaps, and 4 fascial flaps. There were 13 sensory flaps using the posterior antebrachial cutaneous nerve. The length and external diameter of the pedicle were measured in 35 cases. The length of the pedicle was on average 3.5 cm (range, 3.0 to 4.0 cm) and the external diameter of the artery averaged 2.2 mm (range, 2.0 to 2.5 mm). The hand was the recipient in 21 patients, and the foot in 2. All 23 flaps covered the defect successfully.

Emission of a hot electron jet from intense femtosecond-laser-cluster interactions

A directional hot electron jet with energy higher than 100 keV was generated along the laser propagation direction from Ar clusters irradiated with a laser pulse of duration 28 fs and intensity 1 x 10(17) W/cm(2). The hot electron jet was detected only with linearly polarized laser pulses, not with circularly polarized pulses. Channel betatron resonance is believed to be the main accelerating mechanism for this directional hot electron jet.

Successful treatment of Boerhaave's syndrome with endoscopic insertion of a self-expandable metallic stent: report of three cases and a review of the literature

Boerhaave's syndrome is a rare but life-threatening condition which presents a diagnostic as well as therapeutic challenge. Early diagnosis and prompt surgical repair are critical for survival; however late recognition of esophageal rupture is not unusual. A variety of nonsurgical approaches have been proposed, particularly in the case of delayed diagnosis. In recent years, the insertion of a metallic stent has been described as a promising modality in the treatment of spontaneous esophageal rupture. We report three cases of Boerhaave's syndrome treated with self-expandable metallic stents and review previously published cases.