A Prospective Phase II Dose Escalation Study Using IMRT for High Risk N0M0 Prostate Cancer

PURPOSE/OBJECTIVE(S)

Published data supports the use of very high dose intensity modulated radiotherapy (IMRT) in achieving high efficacy and low toxicity for high-risk prostate cancer (HRPCa). This phase II multi-institutional non-randomized prospective dose escalation study using intensity modulated radiotherapy (IMRT) for high risk N0M0 prostate cancer was designed to investigate dose escalation using 1.8 Gy increments from baseline 75.6 Gy up to maximum 81 Gy, once dose volume constraints were adhered to.

MATERIALS/METHODS

Inclusion criteria were patients undergoing a radical course of RT for high and very high-risk disease, defined as one or more of the criteria ≥ T3*, ≥ Gleason 8, Prostate specific antigen (PSA) > 20ng/ml. All patients received Androgen Deprivation Therapy (ADT) and none had radiological evidence of distant metastatic disease. The primary objective was to determine if dose escalated IMRT for high risk localized prostate cancer could provide freedom from biochemical relapse (BR; PSA rising > nadir +2ng/mL or initiation of salvage hormone therapy) similar to that reported in the literature. The Kaplan-Meier method was used to estimate survival times. Secondary objectives included OS, Disease Free Survival (DFS), and the incidence and severity of Genito-urinary (GU), Gastro-intestinal (GI) and erectile dysfunction (ED) toxicities (CTCAE v.3). Toxicities and performance status were collected and graded weekly during RT, 2 months after completing RT, 8 months' post RT, and 6 monthly thereafter to year five and annually thereafter to year nine.

RESULTS

A total of 230 evaluable patients were enrolled between April 2009 and June 2016. The median follow-up was 7.3 years. The cumulative proportion of patients surviving without BR at 5 years was 91% (95% Confidence Interval (CI): 86% to 94%). Overall survival at 5 and 7 years was 92% (88% to 95%) and 89% (83% to 92%) respectively, while the cumulative proportion of patients free from disease was 89% (84% to 93%) at 5 years and 81% (75% to 86%) at 7 years. The incidence of acute G2 and G3 toxicities were; GU; 57.8% G2, 12.6% G3, GI; 15.2% G2, 0.4% G3, ED; 30.0% G2 and 61.7% G3. The incidence of late G2, G3 and G4 toxicities were; GU; 40.9% G2, 8.7% G3, GI; 36.5% G2, 2.2% G3, 0.4% G4, ED; 11.7% G2 and 86.1% G3. The percentage of patients receiving each dose level was; 3.5% received 75.6Gy in 42 fractions, 2.2% received 77.4Gy in 43 fractions, 93% received 81Gy in 45 fractions.

CONCLUSION

The findings indicate that high-dose IMRT is well tolerated and is associated with excellent long-term tumor-control outcomes in patients with localized high and very high-risk prostate cancer, with 91% of patients surviving at 5 years without biochemical relapse. The rates of long term G3 GU and GI toxicity were low at 8.7% and 0.4% respectively.

Updated Methods for the Production of Toxorhynchites rutilus septentrionalis (Diptera, Culicidae) for Use as Biocontrol Agent Against Container Breeding Pest Mosquitoes in Harris County, Texas

The complex biologies of pestiferous mosquito species complicate the development of a single, across the board effective control measure. The use of traditional biological control through predators, parasitoids, and microbes, though part of a multimodal, integrated pest management approach, is scant in current standard mosquito control operations. At this time, traditional, whole organism mosquito biocontrol agents are not commercially available, and if their integration into a release program is desired, they must be developed in-house. The aim of our program was to incorporate releasing natural enemies to disrupt and suppress the target pest mosquito's population by matching the agent with the target's biology, before or concurrent to pesticide use. A current focus is suppressing peridomestic, container breeders of high medical significance, such as Aedes aegypti (Linnaeus), (Diptera, Culicidae) and Aedes albopictus (Skuse) (Diptera, Culicidae), through larval reduction with augmentative releases of laboratory-reared, native mosquito assassins Toxorhynchites rutilus septentrionalis (Dyar & Knab). When raised in communal settings, Tx. rutilus' aggressive feeding behavior and cannibalistic tendencies require an extreme loss tolerance in adult production rates. In addition, offering prey mosquitoes exclusively as Tx. rutilus' juvenile food extends larval development by multiple days. While this may be desirous in the wild, it proves inefficient during production. Here, we provide an individual rearing method as well as an alternative diet protocol, which maximizes the adult yield while achieving quick development.

Oxidative stress, activity behaviour and body mass in captive parrots

Many parrot species are kept in captivity for conservation, but often show poor reproduction, health and survival. These traits are known to be influenced by oxidative stress, the imbalance between the production of reactive oxygen species (ROS) and ability of antioxidant defences to ameliorate ROS damage. In humans, oxidative stress is linked with obesity, lack of exercise and poor nutrition, all of which are common in captive animals. Here, we tested whether small parrots (budgerigars, Melopsittacus undulatus) maintained in typical pet cages and on ad libitum food varied in oxidative profile, behaviour and body mass. Importantly, as with many birds held in captivity, they did not have enough space to engage in extensive free flight. Four types of oxidative damage, single-stranded DNA breaks (low-pH comet assay), alkali-labile sites in DNA (high-pH comet assay), sensitivity of DNA to ROS (H2O2-treated comet assay) and malondialdehyde (a byproduct of lipid peroxidation), were uncorrelated with each other and with plasma concentrations of dietary antioxidants. Without strenuous exercise over 28 days in a relatively small cage, more naturally 'active' individuals had more single-stranded DNA breaks than sedentary birds. High body mass at the start or end of the experiment, coupled with substantial mass gain, were all associated with raised sensitivity of DNA to ROS. Thus, high body mass in these captive birds was associated with oxidative damage. These birds were not lacking dietary antioxidants, because final body mass was positively related to plasma levels of retinol, zeaxanthin and α-tocopherol. Individuals varied widely in activity levels, feeding behaviour, mass gain and oxidative profile despite standardized living conditions. DNA damage is often associated with poor immunocompetence, low fertility and faster ageing. Thus, we have candidate mechanisms for the limited lifespan and fecundity common to many birds kept for conservation purposes.

Satisfaction with continuous glucose monitoring in adults and youths with Type 1 diabetes

AIMS

To describe satisfaction with continuous glucose monitoring in Type 1 diabetes; to correlate continuous glucose monitoring satisfaction scores with usage; and to identify common themes in perceived benefits and barriers of monitoring reported by adults, youths and the parents of youths in the Juvenile Diabetes Research Foundation continuous glucose monitoring trials.

METHODS

The Continuous Glucose Monitoring Satisfaction Scale questionnaire was completed after 6 months of monitoring. Participants also answered open-ended queries of positive and negative attributes of continuous glucose monitoring.

RESULTS

More frequent monitoring was associated with higher satisfaction for adults (n = 224), youths (n = 208) and parents of youths (n = 192) (all P < 0.001) in both the 'benefits' and 'hassles' sub-scales of the Continuous Glucose Monitoring Satisfaction Scale, but the greatest differences between the two groups involved scores on hassle items. Common barriers to monitoring use included insertion pain, system alarms and body issues; while common benefits included glucose trend data, opportunities to self-correct out-of-range glucose levels and to detect hypoglycaemia.

CONCLUSIONS

As frequent use of continuous glucose monitoring is associated with improved glycaemic control without increased hypoglycaemia it is important to overcome barriers, reinforce benefits and set realistic expectations for this technology in order to promote its more consistent and frequent use in individuals with Type 1 diabetes.

Anthropomorphic and hormone abnormalities in testicular cancer patients

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Background: Studies show a range of environmental and genetic associations with testicular cancer, specifically testicular dysgenesis, increased height, and multiple dysplastic naevi. To confirm these findings, we studied a cohort of testicular cancer patients and healthy controls. We also studied a cohort of unaffected relatives of patients to identify if any noted differences might be due to shared genetic/environmental background.

Methods: We identified index cases from the hospital database. They nominated an unaffected relative and an unrelated friend. Controls were supplemented by recruitment of institutional staff.

Results: 183 index cases (IC), 57 unaffected relatives (UR) and 103 unrelated controls (UC) were identified. Mean age was 47 years (25-78) IC, 44 years (18-74) in UR and 42 years (20-74) in UC. IC treated by chemotherapy (ch) had higher mean FSH than non chemotherapy patients (s)[18.98 v 13.22 (p=0.01)] and lower mean testosterone [ch:12.21, s:13.52 (p=0.04)] though mean LH [ch:7.94, s:6.05 (p=0.10)] and BMI (ch:27.38 s:26.81 (p=0.33) were not significantly different.

Conclusions: In contrast to other studies, we found both testicular cancer patients and their relatives were shorter and with reduced arm length compared with controls; a sign of a possible shared genetic or environmental effect. There was no significant difference in weight, BMI, body fat %, lean body mass, and leg length. FSH and LH were significantly elevated and testosterone reduced in index cases (but not relatives) particularly in those who had chemotherapy. The lack of difference between relatives and controls suggests these are most in keeping with direct treatment effects.

[Table: see text]

No significant financial relationships to disclose.

Pentoxifylline to treat radiation proctitis: a small and inconclusive randomised trial

This prospective randomised controlled study of 40 patients could not show a statistically significant advantage with 6 months of pentoxifylline compared with standard measures for late radiation-induced rectal bleeding. However, a modest benefit cannot be excluded and larger randomised placebo-controlled trials with longer durations of pentoxifylline treatment may be justified.

Responsiveness and minimally important change for the Manchester-Oxford foot questionnaire (MOXFQ) compared with AOFAS and SF-36 assessments following surgery for hallux valgus

OBJECTIVES

To assess responsiveness and minimally important change (MIC) for the Manchester-Oxford foot questionnaire (MOXFQ) using anchor and distribution-based approaches. Responsiveness and estimates of minimal clinically important difference (MCID) and minimal detectable change are compared with those from the Short-Form 36 (SF-36) and American Orthopaedic Foot & Ankle Society (AOFAS) measures.

METHODS

A prospective observational study of 91 consecutive patients (125 foot operations) undergoing hallux valgus surgery at an orthopaedic hospital. Pre- and 12 month post-surgery, patients completed the MOXFQ and SF-36, and foot surgeons assessed all four AOFAS scores corresponding to four regions of the foot. Transition items were asked about perceived changes compared with before surgery.

RESULTS

Mean changes in all domains of each instrument were statistically significant, but foot-specific MOXFQ and AOFAS domains produced much larger effect sizes (>1) than any SF-36 domains, indicating superior responsiveness. Clear associations occurred between transition items and all MOXFQ and AOFAS scores, but with only one (physical function) SF-36 domain. Anchor and distribution-based approaches identified generally comparable measures of MIC, which for the MOXFQ and AOFAS domains were between 1 and 2 standard error of measurement. In metric terms, the MCIDs were 16, 12, and 24 for the MOXFQ Walking/standing, Pain, and Social Interaction domains, respectively.

CONCLUSIONS

For hallux valgus surgery, the MOXFQ is highly responsive. Performance is comparable to the AOFAS and notably better than the generic SF-36. Study estimates of MIC for the MOXFQ are useful to inform sample-size calculations for future clinical trials.

Characteristics of a single-centre series of familial testicular germ cell tumours

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Background: Testicular germ cell tumors (TGCTs) account for 1% of all male cancers with increasing incidence rates documented. A family history of TGCT occurs in 2% of patients, conferring relative risks of 8–10 for brothers and 4–6 for fathers or sons of patients. These risks are high in comparison to other solid cancers and suggest that the risk of developing TGCT may be, at least in part, inherited rather than acquired. Methods: Pedigrees with >1 male family member with TGCT were identified from a tumor database and systematically collected from 1992. Patients donated samples and medical details with full informed consent and under ethical review board approval. Pedigree and medical data were obtained by interview, mail and telephone contact. Results: This series examines 78 pedigrees, containing 160 cases and 170 TGCTs. In the period 1994–2003 6% of all cases had a family history of TGCT. It includes 35 sib-pairs, 12 father-son pairs, 11 uncle-nephew pairs, 10 cousin pairs and 4 pedigrees with ≥ 3 cases of TGCT. The dataset contains 66 seminomas, 56 non-seminomas, 17 mixed histology, 1 CIS and 30 tumors of unconfirmed histology. The median age at diagnosis was 33 (range 17 to 87). The median difference in age at diagnosis between the cases in each pedigree was 6 years (0–58). Histology was concordant between family members in 22 of the 53 (41.5%) 2-case pedigrees. 11 pedigrees contained a case with bilateral TGCTs (6.9% of all cases, compared to 1.1% in the sporadic patient population, p<0.001) with 50% histological concordance. The median age at diagnosis of bilateral tumors was 32 (21–42) for the first tumor and 35 (26–49) for second tumors. 24 TGCT cases (15%, compared to an expected rate of 10%, p=0.045) reported a history of UDT. 9/162 (5.5%) of TGCT cases also developed non-TGCT cancers, including penile, bladder, colorectal, hepatic and pancreatic tumors. Conclusions: When systematic collection is undertaken the incidence of familial TGCT may be higher than previously reported. Familial cases have a higher incidence of UDT and bilateral disease. The majority of this set has been used in an international genome-wide linkage analysis to identify TGCT susceptibility genes.

No significant financial relationships to disclose.

A phase 2 study of high-activity 186Re-HEDP with autologous peripheral blood stem cell transplant in progressive hormone-refractory prostate cancer metastatic to bone

PURPOSE

We investigated the potential for improvement in disease control by use of autologous peripheral blood stem cell transplant (PBSCT) to permit administration of high activities of (186)Re-hydroxyethylidene diphosphonate (HEDP) in patients with progressive hormone-refractory prostate cancer (HRPC).

METHODS

Eligible patients had progressive HRPC metastatic to bone, good performance status and minimal soft tissue disease. Patients received 5,000 MBq of (186)Re-HEDP i.v., followed 14 days later by PBSCT. Response was assessed using PSA, survival, pain scores and quality of life.

RESULTS

Thirty-eight patients with a median age of 67 years (range 50-77) and a median PSA of 57 ng/ml (range 4-3,628) received a median activity of 4,978 MBq (186)Re-HEDP (range 4,770-5,100 MBq). The most serious toxicity was short-lived grade 3 thrombocytopenia in 8 (21%) patients. The median survival of the group is 21 months (95%CI 18-24 months) with Kaplan-Meier estimated 1- and 2-year survival rates of 83% and 40% respectively. Thirty-one patients (81%, 95% CI 66-90%) had stable or reduced PSA levels 3 months post therapy while 11 (29%, 95% CI 15-49%) had PSA reductions of >50% lasting >4 weeks. Quality of life measures were stable or improved in 27 (66%) at 3 months.

CONCLUSION

We have shown that it is feasible and safe to deliver high-activity radioisotope therapy with PBSCT to men with metastatic HRPC. Response rates and survival data are encouraging; however, further research is needed to define optimal role of this treatment approach.

A discussion of the biology of testicular cancer and current concepts in the management of stage I and bilateral disease

This case was the subject of a Grand Round Presentation at the Royal Marsden Hospital, Sutton, UK on 8 June 2004. A case of metachronous, bilateral testicular germ-cell tumours (TGCTs) arising in a patient with a family history of this disease was presented. The second primary was managed conservatively. The rationale and outcome of this approach was presented, along with a discussion of the management of early stage TGCTs and the genetics of familial and bilateral disease.

Therapy of non-Hodgkin's lymphoma

Non-Hodgkin's lymphomas are a heterogeneous group of malignancies of the lymphoid system. The exact etiology for most lymphomas has not been determined, but both viral and bacterial infections have been shown to be important etiologic factors. The WHO classification of hematopoietic and lymphoid tumours classifies lymphomas into B-cell and T-cell neoplasms. B-cell lymphomas account for more than 85% of all lymphomas. The Ann Arbor staging classification has been adopted by the AJCC and UICC as a standard for classifying extent of anatomic disease. The two most common histologic disease entities are follicular lymphomas and diffuse large B-cell lymphomas. The management of follicular lymphomas is used as a paradigm for the management of all indolent lymphomas. Radiation therapy is used for stage I and II disease, while alkylating agent chemotherapy, immunotherapy and radioimmunotherapy are most frequently used in stage III and IV disease that requires treatment. Most patients with follicular lymphoma enjoy prolonged survival, but at present there is no evidence that those with stage III and IV follicular lymphoma can be cured. Diffuse large B-cell lymphomas serve as a paradigm for treating aggressive lymphomas. Stage I and II diffuse large cell lymphomas are generally treated with combined modality therapy with doxorubicin-based chemotherapy followed by involved field radiation therapy, while those with stage III and IV disease are treated with chemotherapy alone. Patients who fail initial management are treated with further chemotherapy. High-dose chemotherapy with stem cell rescue has been shown to be particularly effective as salvage treatment for diffuse large cell lymphomas. The management of a heterogeneous group of primary extranodal lymphomas in general follows the above treatment principles, with additional treatment being required for those with a high risk of CNS failures, or involvement of contralateral paired organs. The management of MALT lymphomas, especially gastric MALT lymphoma, deserves special attention because of the high response rate to Helicobacter pylori eradication therapy.

Topical treatment of psoriasis in children

Psoriasis is a common dermatoses, affecting children in North America. Many papers have stressed the treatments available for adult psoriasis, but few have dealt with this disorder in children. Topical treatment modalities continue to be the first line therapy for childhood psoriasis. This paper summarizes the general topical treatments available including their clinical use, benefits, cost, and side-effects.

MRI-assessed volume of cerebellum correlates with associative learning

Richard F. Thompson's cerebellar model of classical eyeblink conditioning highlights Purkinje cells in cerebellar cortex and principal cells in the deep cerebellar nucleus as the integrating cells for acquisition of conditioned responses (CRs). CR acquisition is significantly slower in rabbits with lesions to cerebellar cortex and in Purkinje cell-deficient mice that lose all cerebellar cortical Purkinje cells. Purkinje cells are the largest neurons in the cerebellum and contribute significantly to cerebellar volume. Magnetic resonance imaging (MRI) was used to assess cerebellar volume in humans. Cerebellar volume was related to eyeblink conditioning (400-ms delay procedure) in 8 adults (21-35 years) and compared to 8 older adults (77-95 years) tested previously (Woodruff-Pak, Goldenberg, Downey-Lamb, Boyko, & Lemieux, 2000). In the young adult sample, there was a high correlation between percentage of CRs in a session and cerebellar volume (corrected for total intracranial volume [TIV], r =.58, p =.066). There were statistically significant age differences in cerebellar volume, t(14) = 8.96, p <.001, and percentage of CRs, t(14) = 3.85, p <.002, but no age difference in TIV. Combining the young and older adult sample, the correlation between percentage of CRs and cerebellar volume (corrected for TIV) was.832 (p <.001). Cerebellar volume showed age-related deficits likely due to Purkinje cell loss. Individual differences in classical eyeblink conditioning are associated with differences in cerebellar volume, supporting Thompson's model of a cerebellar cortical role in facilitating this form of associative learning.

Nuclear import of hepatic glucokinase depends upon glucokinase regulatory protein, whereas export is due to a nuclear export signal sequence in glucokinase

Hepatic glucokinase (GK) moves between the nucleus and cytoplasm in response to metabolic alterations. Here, using heterologous cell systems, we have found that at least two different mechanisms are involved in the intracellular movement of GK. In the absence of the GK regulatory protein (GKRP) GK resides only in the cytoplasm. However, in the presence of GKRP, GK moves to the nucleus and resides there in association with this protein until changes in the metabolic milieu prompt its release. GK does not contain a nuclear localization signal sequence and does not enter the nucleus in a GKRP-independent manner because cells treated with leptomycin B, a specific inhibitor of leucine-rich NES-dependent nuclear export, do not accumulate GK in the nucleus. Instead, entry of GK into the nucleus appears to occur via a piggy-back mechanism that involves binding to GKRP. Nuclear export of GK, which occurs after its release from GKRP, is due to a leucine-rich nuclear export signal within the protein ((300)ELVRLVLLKLV(310)). Thus, GKRP appears to function as both a nuclear chaperone and metabolic sensor and is a critical component of a hepatic GK translocation cycle for regulating the activity of this enzyme in response to metabolic alterations.

Classification of mild Alzheimer's disease by artificial neural network analysis of SPET data

An evaluation of the performance of artificial neural networks (ANNs) for the classification of probable Alzheimer's disease (pAD) patients was undertaken using data extracted from four regions of interest constructed on single photon emission tomographic (SPET) cerebral perfusion images. Two studies using feed-forward neural networks (FFNNs) were undertaken. The first was to determine if it would be possible to classify pAD patients and normal subjects in a mixed group, comprising 29 patients diagnosed as having pAD varying in severity from mild, established dementia to moderate dementia and 10 healthy control subjects. The second was to determine if the networks generated in the first study could prospectively classify 15 additional patients with very mild or mild cognitive impairment. The results were compared to those obtained using the same data and discriminant analysis. The relative performances of the two analysis techniques were assessed on the basis of the area under receiver operating characteristics (ROC) curves. The FFNN successfully classified all datasets in the first study, achieving an area under the ROC curve of 1.00, whereas discriminant analysis achieved 0.94. When tested on data from the second group, the areas under the ROC curves varied between 0.86 and 1.00 for the FFNN, whereas that for discriminant analysis was 0.99. We conclude that FFNNs can accurately classify pAD patients with mild to moderate dementia using data obtained from SPET cerebral perfusion images.

What is the value of the lateral chest radiograph in the follow-up thoracic lymphoma?

Lateral chest radiography in the investigation of thoracic lymphoma remains a feature of the current literature. This study assessed what information the lateral chest radiograph (CXR) adds in the follow-up of such patients. Eighty-eight patients with known lymphoma who had a CXR and thoracic CT within the same 4-week period were assessed. Five radiologists scored eight mediastinal and hilar nodal groups and eight extramediastinal regions on the frontal CXR as normal, equivocal or definitely abnormal (denoted 0, 1 and 2, respectively). This was repeated 1 week later with a combination of frontal and lateral films. Results were compared with the findings on CT which were scored similarly using accepted criteria for the presence of lymphadenopathy. Where the lateral CXR caused a change in score at any site, this change was compared with CT to determine the effect on diagnostic accuracy. For four of the five observers, the lateral film made no significant difference in diagnostic accuracy in the assessment of mediastinal lymph nodes. A fifth observer derived a small benefit from the addition of the lateral film, although almost 30 % of this was accounted for by changing from a wrong to an equivocal diagnosis. The lateral film did cause a small increase in the detection of pleuro-parenchymal lung lesions, although none of these were clinically significant. We conclude that routine lateral chest radiography is unhelpful in the follow-up of patients with lymphoma.

Comparison of screw retention of nine abutment systems: a pilot study

Fracturing or loosening of abutment and retaining screws is a frequent occurrence. This study was designed to evaluate the retaining ability of nine abutment systems. Abutment and retaining screws were secured to the appropriate implant using a digital torque gauge, with the abutment screws placed at 30 N-cm and the retaining screws at 10 N-cm. Removal torque was recorded three times for each sample 10 minutes after initial placement, 20 minutes after retightening, and 24 hours after retightening. There was no statistical difference in removal torque relative to time or repeated tightening. Of the nine abutment systems, three were statistically less retentive as compared with the most retentive system. The retaining screws were less retentive as compared with the abutment screws. For maximum retention the elimination of retaining screws from the restorative design and using 30 N-cm of torque for the abutment screws is suggested.

Event-related potential prolongation in Alzheimer's disease signifies frontal lobe impairment: evidence from SPECT imaging

BACKGROUND

The N2 and P3 components of auditory event-related potentials (ERPs) and single-photon emission computed tomographic (SPECT) images are separate independent biological markers of cerebral function and are abnormal in Alzheimer's disease (AD). The relationship between ERP N2 and P3 latencies and regional cerebral perfusion abnormalities in AD is unknown.

METHODS

ERP and SPECT data were obtained one week apart in 18 patients with "probable" AD of mild or moderate severity, and 12 healthy age-matched elderly controls. Average premotor frontal, anterior temporal, inferior parietal, and occipital cortical/cerebellar perfusion ratios were calculated from the SPECT data and correlations with ERP N2 and P3 latencies derived for AD and control groups separately.

RESULTS

ERP N2 latency was correlated significantly with the average frontal perfusion ratio (r = -.59; p < .009), but correlations with average temporal, parietal, and occipital ratios were nonsignificant in the AD group. Similarly, ERP P3 latency was correlated significantly with the average frontal perfusion ratio (r = -.65; p < .004), but not with the other perfusion ratios in the AD group. In the control group, a partial correlation between the average frontal perfusion ratio and the ERP N2 latency was noted (r = -.52; p < .09), but no other ERP/SPECT correlations approached statistical significance.

CONCLUSION

ERP N2 and P3 latency delay in AD is a function of differential frontal lobe hypoperfusion.

Emergency procedures important to the training of emergency medicine residents: who performs them in the emergency department?

OBJECTIVE

To quantify one aspect of emergency medicine (EM) training by determining the proportion of emergency procedures performed by emergency physicians (EPs) in EDs with EM residency programs (EMRPs).

METHODS

Cross-sectional descriptive survey of all allopathic EMRPs accredited by the EM Residency Review Committee (RRC-EM) as of July 1, 1993. Using a modified visual analog scale, program directors indicated the proportion of ten index procedures performed in the ED by EPs vs all other physicians.

RESULTS

All 98 EMRPs meeting entry criteria responded to the survey. The medians for the percentage of times index procedures were performed in the ED by an EP were as follows (parentheses following percentages enclose 95% CIs): endotracheal intubation, 97% (95%, 100%); reduction of anterior shoulder dislocation, 93% (88%, 97%); thoracostomy, 63% (50%, 75%); transvenous pacer insertion, 60% (50%, 75%); cricothyrotomy, 50% (50%, 75%); thoracotomy, 50% (25%, 50%); diagnostic peritoneal lavage, 50% (25%, 50%); fiberoptic laryngoscopy, 22% (6%, 25%); sigmoidoscopy, 0% (0%, 6%); and pelvic sonography, 0% (0%, 0%).

CONCLUSION

EPs in EDs of institutions that have EMRPs perform, on average, 50% of all index procedures (95% CI 47%, 52%). This information may assist EM programs experiencing difficulty in ensuring that their residents receive an equitable share of those procedures that are critical to their training.

The discriminant value of semiquantitative SPECT data in mild Alzheimer's disease

In most semiquantitative SPECT studies, overlap between groups of patients with Alzheimer's disease (AD) and age-matched elderly controls is such that single posterior cortical perfusion measurements lack sensitivity. In the present study, the value of a combination of semiquantitative temporoparietal SPECT parameters was examined.

METHODS

Supratentorial transaxial perfusion measurements were obtained in frontal, anterior temporal, posterior temporoparietal and occipital cortical areas in both hemispheres, in a baseline population of 10 healthy elderly controls and 30 mild to moderately impaired AD patients, as well as in a prospective group of 15 patients with mild cognitive impairment, 12 patients with a diagnosis of probable AD and individual cases of multi-infarct dementia, dementia-frontal type and paranoid psychosis. A linear discriminant function (LDF) was calculated from the baseline subjects' data to classify control and AD subjects individually.

RESULTS

Highly significant hypoperfusion was noted in both the anterior temporal and posterior temporoparietal regions of interest in the AD group compared with controls, but with significant overlap. Using an LDF incorporating these perfusion measurements in both hemispheres, 10/10 (100%) controls and 26/30 (87%) AD baseline subjects were correctly classified. Using the baseline LDF in the prospective 15 mildly impaired cases, 11/12 new mild AD cases and none of the 3 non-AD cases were classified in the AD group.

CONCLUSION

These results support the use of a combination of semiquantitative SPECT perfusion estimates from cortical areas with predictable pathological involvement in AD in a linear discriminant format in the clinical assessment of patients with suspected AD.

Dental pain evoked by hydrostatic pressures applied to exposed dentin in man: a test of the hydrodynamic theory of dentin sensitivity

The hydrodynamic theory of dentin sensitivity holds that pain is evoked by stimuli producing minute shifts in tubule fluid. In human volunteers hydrostatic pressures were applied to prepared dentinal cavities. The subjects reported the magnitude and quality of their sensations of pain by means of an intermodal matching technique in combination with verbal descriptors. No pain could be elicited when the smear layer was present. After removal of this layer, pressure stimuli of either direction evoked sharp pain. Rapid changes in pressure induced higher pain intensities than slow changes, indicating that the dental A-delta system is dynamic and gradient dependent. These results provide support for the hydrodynamic theory of dentin sensitivity and also lend credence to the notion that the movement of fluid across dentin induces a selective activation of the A-delta nerves in healthy pulps which is highly correlated with a sensation of sharp and/or shooting pain.

Ro 32-0432, a selective and orally active inhibitor of protein kinase C prevents T-cell activation

Several lines of circumstantial evidence support the assumption that protein kinase C (PKC) activation together with elevated levels of cytosolic Ca++ are necessary for T-cell activation and proliferation in response to a physiological stimulus, i.e., MHC class II restricted antigen presentation. By using a potent, cell-permeable and selective inhibitor of PKC, Ro 32-0432, we have tested this hypothesis. Ro 32-0432 inhibits interleukin-2 (IL-2) secretion, IL-2 receptor expression in, and proliferation of, peripheral human T-cells stimulated with phorbol ester together with phytohemagglutin or anti-CD3, but does not inhibit IL-2 induced proliferation in cells already stimulated to express IL-2 receptors. Proliferation of the influenza peptide antigen HA 307-319-specific human T-cell clone (HA27) after exposure to antigen-pulsed autologous presenting cells was also inhibited by Ro 32-0432. Oral administration of Ro 32-0432 inhibited subsequent phorbol ester-induced edema in rats demonstrating the systemic efficacy of the compound to inhibit PKC-driven responses. Induction of more physiologically T-cell driven responses such as host vs. graft responses and the secondary paw swelling in adjuvant-induced arthritis were also inhibited by Ro 32-0432. These data demonstrate the crucial role for PKC in T-cell activation and that selective p.o. bioavailable PKC inhibitors are efficacious in preventing T-cell driven chronic inflammatory responses in vivo. Inhibition of PKC represents an important mechanistic approach to prevent T-cell activation and compounds of this class may have important therapeutic applicability to chronic inflammatory and autoimmune diseases.

Whatever happened to abstracts from different sections of the association for research in vision and ophthalmology?

PURPOSE

The authors investigated the fate of abstracts from each ARVO section (May 1985 meeting), the overall publication percentage, and the journals in which the abstract-derived articles were published.

METHODS

They performed a MEDLINE search by first author for 25 or 26 randomly selected abstracts from each section to identify those that led to full-length articles in peer-reviewed journals.

RESULTS

Overall, 63% of abstracts led to full-length articles in peer-reviewed journals within our search period of 87 months. The publication rate of oral presentation abstracts (68%) was significantly higher than that of poster presentation abstracts (56%). A greater proportion of basic science-oriented abstracts (67%) led to publication than the clinically oriented abstracts (56%). The rate of publication was lowest for the Cornea section (40%) and highest for Physiology and Pharmacology (80%) and Biochemistry (76%). The abstract-derived articles were published in 67 different peer-reviewed journals, with 43% of the articles appearing in only five journals.

CONCLUSIONS

The fact that the majority of abstracts led to full-length articles supports ARVO's goal of a large interdisciplinary appeal with the exchange of ideas among different investigators.

Level of accuracy and degree of precision in attempting to maintain steady levels of biting force

The primary purpose of this study was to assess the level of accuracy (bias) and degree of precision for a group of 24 normal subjects attempting to maintain a constant biting force at levels of 100 gm, 500 gm, 1000 gm and 2000 gm for a period of 10 s each. Accuracy is defined as the difference between subjects' actual level of biting force and the target value they were trying to achieve. Precision is the level or range of variability demonstrated by the subjects while attempting to bite with a constant level of force. Subjects' performance relative to accuracy and precision was also compared when using the central incisors vs. the first permanent molars. Assessment of bite force was measured using a specially designed strain gauge scale which permitted subjects to visually monitor when their biting force equalled a preset resistance. Each subject was instructed to bite on the end of a plastic sheathed steel beam with enough force to activate the indicator needle on the voltage meter to its central position and to try to maintain a constant level of biting force (by attempting to keep the indicator needle steady in its central position). No significant (P > 0.05) differences were found in mean accuracy in bite force for gender or specific teeth used in the biting task. However, a significant difference (P < 0.0001) in mean accuracy in bite force was found to exist between the target levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Pentafraction reduces the lung lymph response after endotoxin administration in the ovine model

For the past half-century, several high molecular weight compounds have been used for volume expansion during cardiopulmonary resuscitation. However, the effectiveness and side effects of these different expanders are varied. We have compared plasma, pentastarch, and a new product, pentafraction, for effective plasma volume expansion before and after tissue injury with endotoxin administration. In each group, eight range ewes instrumented with a Swan-Ganz, arterial, and venous catheters, and lung and flank lymphatic cannulas were compared. Each group received 15 ml/kg of either 6% pentafraction, 6% pentastarch, or plasma followed two hours later by 1.5 micrograms/kg/0.5 hr E. Coli endotoxin over 30 min. Data were collected for an additional 24 hr after endotoxin administration. Our results indicated a plasma volume expansion in all three groups. However, the prior administration of pentafraction significantly attenuated the increase in the lung lymph flow and early evaluation of systemic vascular resistance noted with endotoxin in comparison to the other two groups.

Retrotracheal goiter: a diagnostic and therapeutic problem

A patient with chronic cough and recent dysphagia was found to have a retrotracheal mass extending into the visceral mediastinum on chest roentgenogram. A computed tomographic scan confirmed a retrotracheal lesion, which was believed to be of lymphatic origin. A thyroid scan demonstrated downward displacement of the left lobe but little uptake in the mass. Histological findings of mediastinal biopsies were inconclusive. A large retrotracheal thyroid adenoma was easily excised through a right thoracotomy. The approach to diagnosis and, in cases of doubt, the safety of surgical access through thoracotomy for thyroid lesions in this unusual site is discussed.

Cellular and extracellular phospholipase A2 activity in zymosan pleurisy in rat

The pleural exudate from rats treated intrapleurally with zymosan contains phospholipase A2 (PLA2) activity which is Ca2(+)-independent and optimally active at a neutral pH. This PLA2 activity was found in approximately equal amounts in both the cellular and extracellular fractions of the exudate. The Ca2(+)-independency of the PLA2's in the pleural exudate distinguishes them from plasma PLA2's and this suggests that the source of the exudate PLA2's is not plasma. The appearance of PLA2 activity in zymosan-induced pleural exudate correlates temporally with increases in exudate volume and pleural cell number. In all cases, the maximum response was seen 24 hr after zymosan challenge. All parameters of pleurisy and PLA2 activity are similarly sensitive to the steroid dexamethasone which has been hypothesized to act, in part, through the synthesis of PLA2 inhibitory peptides. In its entirety, this information suggests that there is a relationship between pleural PLA2 activity and the appearance of pleural inflammation (exudate volume and cells) and that PLA2 may play an important role in the initiation and propagation of this inflammatory process in rats. Furthermore, the zymosan-induced pleurisy model may serve as a useful model for the identification of PLA2 inhibitors with antiinflammatory activity.

Chemical characterization and regulation of endogenous morphine and codeine in the rat

Data on the tissue distribution of morphine and codeine in rat are presented. The concentration of these two opiate alkaloids seems to be distributed uniformly in the cortex, midbrain, pons/medulla and cerebellum. The spinal cord and the adrenal gland have high levels of morphine and codeine and the adrenal has more codeine than morphine. The major fraction of the alkaloids reside in a synaptosomal fraction and are present in tissues as the sulfate conjugate. The levels of morphine in the spinal cord and the urinary excretion of morphine are elevated in the arthritic rat model. We used extracted alkaloid samples from arthritic rats spinal cord for analysis by mass spectrometry and found molecular ions identical with morphine and codeine. The results are discussed in the light of possible physiological roles of endogenous morphine and codeine.

Laser photoradiation therapy of cancer: an update of the experience at the University of California, Irvine

This update of the experience at the University of California at Irvine with laser photoradiation therapy (PRT) encompasses the period between May 1981 and June 1983. The results of treatment of 77 patients are reported (head and neck, 39; breast, 33; and lung 5). Head and neck cancer patients received treatment to 114 sites with a complete response (CR) in 28, partial response (PR) in 42, stable disease (SD) in three, and no response (NR) in 34, and an undetermined response in seven. Breast cancer patients were treated in 395 sites with CR in 222, PR in 74, SD in one, NR in 92, and undetermined response in six. The lung cancer patients in this series responded poorly, if at all. In addition to the above patient trials, we have investigated the interaction of laser hematoporphyrin derivative (HPD)-PRT with a chemotherapeutic agent, Cisplatin, against an experimental tumor (RIF-1) in an animal model. We have been unable to demonstrate an additive effect of laser HPD-PRT at total light doses of 25 J/cm2 and 75 J/cm2 with Cisplatin at a dose of 7 mg/kg. However, no additional toxicity was observed in combination therapy, suggesting that sequential application of laser HPD-PRT and Cisplatin may be safely employed in clinical situations. Another area of investigation has been the evaluation of the light-scattering characteristics of a lipid emulsion designed for laser HPD-PRT of bladder tumors. We have demonstrated that it is feasible to gain uniform illumination of the bladder surface with the use of this light-dispersing medium.(ABSTRACT TRUNCATED AT 250 WORDS)

Laser photoradiation therapy of cancer: possible role of hyperthermia

Two patients were treated at 20 different tumor sites by hematoporphyrin derivative (HPD) photoradiation therapy (PRT). An infrared detector was used to record changes in surface temperature during laser exposure. A temperature rise of up to 4.9 degrees C was recorded for a total energy of 15-30 J/cm2 and less than 150 mW/cm2. For 508 mW/cm2 and 15-20 J/cm2 a temperature rise of 7.0 degrees C was detected. The results suggest a possible role of hyperthermia in HPD-PRT.

Mineral and trace element content of vegetarian diets

Lacto-ovo, lacto, and vegan vegetarian diets were analyzed for calcium, phosphorus, magnesium, zinc, iron, and nitrogen at four calorie intake levels ranging from 1,700 to 2,800 kcal/day. Diets containing dairy products had a high calcium and phosphorus content, ranging from 1,279 to 1,755 mg calcium and 1,378 to 2,160 mg phosphorus for the four calorie levels, respectively, and vegan diets contained less calcium, ranging from 612 to 810 mg. The magnesium content of all three types of vegetarian diets was adequate or high, ranging from 366 to 560 mg/day. The zinc content was lower than that of the RDA (15 mg/day), and was particularly low at the 1,700 calorie intake levels of all diets. The iron content of these diets varied widely and ranged from 12.7 to 22.7 mg. This study has shown that vegetarian diets planned and presented at the higher calorie intake levels contain adequate amounts of minerals and trace elements, whereas this is not the case at the 1,700 calorie intake level. This observation is of importance as the mineral and trace element content of relatively low calorie vegetarian diets would not supply sufficient amounts of these nutrients. In addition, the bioavailability of minerals and trace elements from these diets remains to be determined.

Exposure (dose) tables for hematoporphyrin derivative photoradiation therapy

Two sets of tables are presented that permit the rapid determination of (1) milliwatts per centimeter2 based upon known site diameter and power output from fiber optic and (2) time of exposure (minutes and seconds) based upon known site diameter and power output from fiber optic.

Response of psoriasis to red laser light (630 nm) following systemic injection of hematoporphyrin derivative

Systemically injected hematoporphyrin derivative (HPD) in combination with red laser light (630 nm) was used to treat a patient with intraepithelial neoplasia of the vulva. Since the patient had psoriasis in the mons pubis area this region also was exposed to the red light. The psoriasis treatment area was divided into two regions receiving 40 and 20 J/cm2. Both psoriatic zones responded vigorously to the HPD + light treatment, forming eschars by 1 week postirradiation. All three treatment zones (the neoplastic area and the two psoriatic areas) underwent normal reepithelialization by 17 days.

Systemic distribution of N2 paste containing 14C paraformaldehyde following root canal therapy in dogs

Using rubber-dam isolation and an aseptic and standardized endodontic technique, root canal therapy was performed on the right and left fourth mandibular premolars in four dogs. Each tooth was obturated with N2 paste containing 6.5 percent 14C paraformaldehyde. In each dog at 1 hour, 1, 7, 14, and 28 days, blood was drawn and biopsy specimens were taken of the adjacent lymph nodes, liver, and kidney. At 28 days, the animals were killed, and the experimental and adjacent tissues were processes for light microscopy. Histologic examination demonstrated that particles of the paste placed in the root canal were present in pulp, periapical, and periodontal tissues remote from the original site in the root canal. In addition, 14C-labeled paraformaldehyde which was contained in the N2 paste was found in blood, regional lymph nodes, kidney, and liver. The amount of radioactivity in all the body organs decreased with time.