Intrahepatic or systemic infusion of fluorodeoxyuridine in patients with liver metastases from colorectal carcinoma. A randomized trial

OBJECTIVE

To compare the efficacy of direct hepatic arterial chemotherapy with systemic chemotherapy in patients with liver metastases from colorectal carcinoma.

DESIGN

Randomized trial with crossover allowed from systemic to intrahepatic therapy if tumor progression occurred on systemic therapy.

SETTING

Academic medical center, referral-based clinic.

PATIENTS

One hundred sixty-two patients with hepatic metastases from colorectal carcinoma agreed to be randomly assigned to treatment groups. At laparotomy, 63 were excluded from the study: 25 had hepatic resection; 33, extrahepatic disease; 1, infection; and 4, no tumor.

INTERVENTION

Fourteen-day continuous infusion of fluorodeoxyuridine each month using an infusaid pump (0.3 and 0.15 mg/kg body weight X d in the intrahepatic and systemic arms, respectively).

MAIN RESULTS

Intrahepatic therapy produced a significantly higher complete and partial response rate, 50%, compared with 20% for systemic therapy (p = 0.001). After tumor progression, 60% of the systemic patients crossed over to intrahepatic therapy; 25% then had a partial response, and 33% a minor response or stabilization of disease on intrahepatic therapy. Toxicity included ulcer disease (17%) and biliary sclerosis (8%) in patients receiving intrahepatic therapy and diarrhea (70%) in patients receiving systemic therapy. Extrahepatic disease occurred in 56% and 37% of the patients in the intrahepatic and systemic groups, respectively (p = 0.092). The median survivals were 17 and 12 months, for the intrahepatic and systemic groups, respectively.

CONCLUSION

When compared with systemic therapy, hepatic arterial chemotherapy significantly increases response rate for hepatic metastases from colorectal carcinoma and appears to be a more effective treatment.

Are we drinking our neurones away?

A quantitative neuropathological necropsy study of the human cerebral cortex showed that the number of cortical neurones in the superior frontal cortex in chronic alcoholic patients is significantly reduced compared with that in controls matched for age and sex. The number of neurones in the motor cortex did not differ significantly between the controls and alcoholics, but in both cortical regions there was evidence that alcoholic patients had smaller (shrunken) neurones than controls. Further studies are necessary to identify other regions of the cerebral cortex that are selectively damaged in brain damage associated with alcohol.

Stimulated formation of adenosine 3',5'-cyclic phosphate in cerebral cortex: synergism between electrical activity and biogenic amines

When cortical slices are incubated with adenine-(14)C, adenine nucleotides are labeled in a small and relatively stable pool. The ATP-(14)C of this pool is readily converted to cAMP-(14)C during incubations with depolarizing agents, such as K(+), ouabain, veratridine, or batrachotoxin. During incubations with these agents, release of acetylcholine and of adenosine into the medium is enhanced. The increase in release of adenosine parallels the enhanced formation of cAMP-(14)C elicited by depolarizing agents, providing further evidence that adenosine may serve to couple electrical activity in the central nervous system with formation of cAMP. When adenosine or a depolarizing agent are incubated, together with a biogenic amine, such as histamine, serotonin, or norepinephrine, the combined effect on cAMP-(14)C formation in cortical slices is much more than additive. Extracellular levels of biogenic amines could in this manner modulate cAMP formation and biochemical responses in nervous tissue during electrical activity.

Hepatic artery pump infusion: toxicity and results in patients with metastatic colorectal carcinoma

5-Fluorodeoxyuridine (FUDR) was infused continuously into the hepatic artery for 14 days a month at an initial dose of 0.3 mg/kg per day in 45 patients with liver metastases from colorectal carcinoma. In 41 adequately treated patients, partial responses (greater than 50% tumor regression) were observed in 12 (52%) of 23 previously untreated patients, and three (17%) of 18 previously treated patients. Severe gastrointestinal toxicity was endoscopically documented in 19 (46%) patients; 12 (29%) had discrete ulcers, and seven had diffuse gastritis or duodenitis. Significant hepatic-enzyme abnormality was seen in 29 patients (71%) and an elevated serum bilirubin in nine (22%). A significant factor influencing survival was the extent of tumor involvement in the liver; patients with less than 20% involvement have not yet reached a median survival at 13 months versus six months for patients with greater than 60% involvement (p less than 0.001). Studies comparing regional to systemic chemotherapy and stratifying patients according to the extent of hepatic tumor burden are needed to assess the true impact of hepatic infusion on response and survival.

Gastrointestinal adaptation to diets of differing fat composition in human volunteers

The effect of a low fat diet (9 MJ) v a high fat diet (19.26 MJ), each consumed separately for four and 14 days, on gastric emptying and mouth to caecum transit time of a high fat test meal and body weight and satiety were examined in groups of 10 and six normal male volunteers. The half time for gastric emptying (t1/2) and the mouth to caecum transit time of a high fat test meal was significantly faster after the high fat diet than the low fat diet when consumed for 14 days (t1/2=98 (80-116) v 147 (88-206) minutes (median (range)), p less than 0.05; mouth to caecum transit time 240 (130-350) v 360 (200-520) minutes, p less than 0.05), but not when consumed for only four days. The mean (SEM) body weight of all subjects significantly increased during the 14 day high fat diet (74.7 (1.3) v 72.7 (1.6) kg, p less than 0.05) but was not influenced during the consumption of the low fat diet. When subjects were given an appetising meal to consume on the day that they had consumed the transit test meal, they ate similar amounts irrespective of their recent dietary history, though the eating rate was significantly slower after the high fat diet (mean (SEM)) 46.7 (1.9) v 71.3 (14.8)/min, p less than 0.05). Maintaining normal subjects on a high or low fat diet for two weeks resulted in a desensitisation or sensitisation respectively of the mechanisms by which nutrients regulate gastrointestinal transit. These findings emphasise the importance of the recent dietary history in the interpretation of gastric emptying and small bowel transit time data.

Pituitary gland: enzymic formation of methanol from S-adenosylmethionine

An enzyme has been found that can transform S-adenosylmethionine to methanol and S-adenosylhomocysteine. This enzyme is highly localized in the pituitary gland of several mammalian species.

Opening Pandora's box: the unpredictability of reassurance by a normal test result

OBJECTIVES

To determine the rate of failure of patient reassurance after a normal test result and study the determinants of failure.

DESIGN

Replicated single case study with qualitative and quantitative data analysis.

SETTING

University teaching hospital.

SUBJECTS

40 consecutive patients referred for echocardiography either because of symptoms (10 patients) or because of a heart murmur (30). 39 were shown to have a normal heart.

INTERVENTIONS

Medical consultations and semistructured patient interviews were tape recorded. Structured interviews with consultant cardiologists were recorded in survey form.

MAIN OUTCOME MEASURES

Patient recall of the explanation and residual understanding, doubt, and anxiety about the heart after the test and post-test consultation.

RESULTS

All 10 patients presenting with symptoms were left with anxiety about the heart despite a normal test result and reassurance by the consultant. Of 28 patients referred because of a murmur but shown to have no heart abnormality, 20 became anxious after detection of the murmur; 11 had residual anxiety despite the normal test result.

CONCLUSIONS

Reassurance of the "worried well"-anxious patients with symptoms or patients concerned by a health query resulting from a routine medical examination or from screening-constitutes a large part of medical practice. It seems to be widely assumed that explaining that tests have shown no abnormality is enough to reassure. The results of this study refute this and emphasise the importance of personal and social factors as obstacles to reassurance.

The naturalistic course of pharmacologic treatment of children with maniclike symptoms: a systematic chart review

OBJECTIVE

To assess the effectiveness of mood stabilizers in treating maniclike symptoms in children.

METHOD

Subjects were consecutively referred pediatric patients who, at initial intake, satisfied DSM-III-R criteria for mania on a structured diagnostic interview. We systematically reviewed their clinical records to assess (1) the course of maniclike symptoms and (2) all medications prescribed at each follow-up visit. Survival analysis was used to determine the effect of mood stabilizers and other medications on the course of maniclike symptoms.

RESULTS

Of the 59 subjects meeting criteria for mania, 44 (75%) exhibited evidence of maniclike symptoms during follow-up. The occurrence of manic symptoms significantly predicted the subsequent prescription of mood stabilizers (rate ratio = 2.9, 95% confidence interval [CI] = 1.6 to 5.5), and use of mood stabilizers predicted decreases in manic symptoms (rate ratio = 4.9, 95% CI = 1.2 to 20.8). However, improvement was slow and associated with a substantial risk for relapse.

CONCLUSION

Mood stabilizers were frequently used in children with maniclike symptoms, and their use was associated with significant improvement of maniclike symptoms, whereas use of antidepressant, antipsychotic, and stimulant medications was not.

A prospective study of circulating mutant KRAS2 in the serum of patients with colorectal neoplasia: strong prognostic indicator in postoperative follow up

BACKGROUND AND AIMS

Mutant tumour derived DNA has been detected in the sera of colorectal cancer patients. We investigated if mutant serum KRAS2 was detectable preoperatively in a large group of patients with colorectal neoplasia. A prospective study of 94 patients who underwent putative curative resection for colorectal carcinoma (CRC) was performed to ascertain if serum mutant KRAS2 could be used postoperatively as a disease marker.

METHODS

Preoperative sera from 78 patients were analysed (group A). Sera from 94 patients were obtained three monthly for up to three years during the postoperative period (group B). Codon 12 and 13 KRAS2 mutations were analysed in matched tumour and serum samples.

RESULTS

In the preoperative group (group A), KRAS2 mutation was found in 41/78 (53%) tumours and in 32/78 (41%) preoperative sera. Of 41 tumour KRAS2 mutation positive cases, 31/41 (76%) had an identical serum mutation detectable. In group B, the postoperative follow up group, 60/94 cases were primary tumour KRAS2 mutation positive. Of these 60, 16/60 (27%) became persistently serum mutant KRAS2 positive postoperatively. Ten of 16 (63%) of these developed a recurrence compared with only 1/44 (2%) patients who remained serum mutant negative (odds ratio 71.7 (95% confidence interval 7.7-663.9; p=0.0000). None of 34 tumour mutation negative cases became serum mutant KRAS2 positive postoperatively, despite recurrence in 9/34 patients. The relative hazard of disease recurrence in postoperative serum mutant KRAS2 positive patients was 6.37 (2.26-18.0; p=0.000).

CONCLUSIONS

Serum mutant KRAS2 can be detected preoperatively in all stages of colorectal neoplasia. Postoperatively, serum mutant KRAS2 is a strong predictor of disease recurrence, stronger even than Dukes' stage of disease, and thus shows potential for use in clinical practice as a marker of preclinical disease recurrence.

Acetylcholine receptor and ion conductance modulator sites at the murine neuromuscular junction: evidence from specific toxin reactions

The perhydro derivative of histrionicotoxin reversibly blocks the excitatory ionic transduction system in the synaptic and sarcolemmal membranes of mammalian skeletal muscle cells. The efficacy of perhydrohistrionicotoxin as an antagonist at the post-synaptic membrane is increased by the transient presence of acetylcholine in the endplate of innervated muscles and at extrajunctional receptors in denervated muscles. alpha-Bungarotoxin and [(3)H]monoacetyl-alpha-bungarotoxin block the endplate acetylcholine receptors, each binding to the same extent. The effect of bungarotoxin is partially reversible. These electrophysiological results, together with the effects of perhydrohistrionicotoxin and/or d-tubocurarine on the binding of [(3)H]monoacetyl-alpha-bungarotoxin at endplates of murine diaphragm muscle and on the bungarotoxin-elicited irreversible blockade of neuromuscular transmission, suggest that at least two types of sites participate in the synaptic excitation by acetylcholine. One site, competitively blocked by bungarotoxin and by curare, is presumably the acetylcholine receptor. Binding of bungarotoxin at this site is responsible for an irreversible blockade of neuromuscular transmission. The second site, competitively blocked by bungarotoxin and perhydrohistrionicotoxin, is proposed to be part of the cholinergic ion conductance modulator. Binding of bungarotoxin to this site does not result in an irreversible blockade.

Correlation of estrogen and progesterone receptors with histologic differentiation in mammary carcinoma

Using a modification of the histologic grading system of the NSABP, we observed a trend towards higher levels of estrogen (E2R) and progesterone receptor (PR) content in well (grade I) and moderately (grade II) differentiated mammary carcinomas. This relationship between receptor content and histologic grade is enhanced by considering estrogen and progesterone receptor simultaneously. The rank correlation between the quantitative levels of E2R and PR was 0.74 among histologic grade I tumors and 0.64 among histologic grade II tumors. Among the grade III carcinomas, the majority of tumors displayed either a paucity of measurable receptor or a divergence between levels of estrogen versus progesterone receptor (r = 0.19). The use of ultrastructural evaluation of features of differentiation is discussed in the evaluation of grade III tumors and in the evaluation of specific histologic types of mammary carcinoma.

Rectal carcinoma: staging at MR imaging with endorectal surface coil. Work in progress

To increase the accuracy of local staging of rectal carcinomas at magnetic resonance (MR) imaging, the authors placed on endorectal coil mounted on a balloon in a position adjacent to the lesion. Use of such a local coil resulted in increased signal-to-noise ratio compared with use of a body coil; higher-resolution images were obtained because the field of view was decreased. The depth of wall invasion by rectal carcinoma was correctly staged with endorectal MR imaging in 11 of 12 patients. In the detection of perirectal adenopathy, use of MR enabled correct identification of positive perirectal nodes in four of seven patients (57%). There were no false-positive diagnoses of perirectal adenopathy at MR. Endorectal MR imaging is an evolving and promising technique for the local staging of rectal carcinomas, but further studies are needed to demonstrate its efficacy.

Radioimmunoguided surgery using iodine 125 B72.3 in patients with colorectal cancer

Preliminary data using B72.3 murine monoclonal antibody labeled with iodine 125 suggested that both clinically apparent as well as occult sites of colorectal cancer could be identified intraoperatively using a hand-held gamma detecting probe. We report the preliminary data of a multicenter trial of this approach in patients with primary or recurrent colorectal cancer. One hundred four patients with primary, suspected, or known recurrent colorectal cancer received an intravenous infusion of 1 mg of B72.3 monoclonal antibody radiolabeled with 7.4 x 10 Bq of iodine 125. Twenty-six patients with primary colorectal cancer and 72 patients with recurrent colorectal cancer were examined. Using the gamma detecting probe, 78% of the patients had localization of the antibody in their tumor; this included 75% of primary tumor sites and 63% of all recurrent tumor sites; 9.2% of all tumor sites identified represented occult sites detected only with the gamma detecting probe. The overall sensitivity was 77% and a predictive value of a positive detection was 78%. A total of 30 occult sites in 26 patients were identified. In patients with recurrent cancer, the antibody study provided unique data that precluded resection in 10 patients, and in another eight patients it extended the potentially curative procedure.

Abrupt changes in mixed venous blood gas composition after the onset of exercise

It has been assumed that increases in both O2 uptake and ventilation occurring within the first few seconds after the onset of exercise cannot be the result of changes in blood gas composition reaching the central circulation because of the circulatory delay from the exercising limbs (A. Krogh and J. Lindhard, J. Physiol. Lond. 42: 112-136, 1913). We sought to validate this assumption by measuring the time course of pulmonary arterial blood gases during the transition from rest to exercise. Six healthy men underwent pulmonary arterial catheterization and then performed transitions from rest to moderate cycle ergometer exercise. An anaerobic sampling manifold withdrew 19 samples of blood during the rest-to-exercise transition; sampling interval was usually 4 s. Blood gas analysis showed that, on average, from rest-to-steady-state exercise, O2 saturation (Svo2) fell from 71 to 41% and mixed venous PCO2 (PvCO2) rose from 42 to 59 Torr. Contrary to our expectations, Svo2 decreased and PvCO2 increased with no discernible latency after exercise onset (by 10% and 2 Torr, respectively, within 6 s). The half time for the Svo2 decrease was 32 s, whereas for the PvCO2 increase it was 80 s. The time course of superior vena cava blood gas composition was determined in several experiments; no rapid changes after exercise onset were found. We conclude that at exercise onset there is a rapid fall in Svo2 and rise in PvCO2 well in advance of arrival of blood produced by exercising legs.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical leadership in contemporary clinical practice: implications for nursing in Australia

BACKGROUND

Leadership in the clinical practice environment is important to ensure both optimal patient outcomes and successive generations of motivated and enthusiastic clinicians.

AIM

The present paper seeks to define and describe clinical leadership and identify the facilitators and barriers to clinical leadership. We also describe strategies to develop clinical leaders in Australia. Key drivers to the development of nursing leaders are strategies that recognize and value clinical expertise. These include models of care that highlight the importance of the nursing role; evidence-based practice and measurement of clinical outcomes; strategies to empower clinicians and mechanisms to ensure participation in clinical decision-making.

KEY ISSUES

Significant barriers to clinical leadership are organizational structures that preclude nurses from clinical decision making; the national shortage of nurses; fiscal constraints; absence of well evaluated models of care and trends towards less skilled clinicians.

CONCLUSIONS

Systematic, strategic initiatives are required to nurture and develop clinical leaders. These strategies need to be collegial collaborations between the academic and health care sectors in order to provide a united voice for advancing the nursing profession.