Does the working temperature affect the outcome following microwave endometrial ablation?

BACKGROUND

Menorrhagia is a common gynaecological complaint, with significant burden to both its sufferers and health service providers. The first line of treatment is usually medical/pharmaceutical although in some cases surgery is required. There are now a number of minimally invasive surgical techniques available that ablate the uterine lining and prevent the need for the removal of the uterus. Microwave endometrial ablation (MEA) is one of these techniques, and this paper investigates the effect of the working temperature on outcome.

METHODS

A retrospective case note review of women who underwent MEA between June 2000 and August 2004. All women had a hysteroscopy followed by MEA. The duration of the procedure and mean working temperature of the MEA treatment was calculated. Women were followed up 6-8 months after surgery.

FINDINGS

Two hundred and eleven women underwent the procedure, with an average duration of menorrhagia of 30 months prior to the procedure. Eighty-nine percent attended follow-up, 80 % were satisfied with the procedure and 40 % were amenorrhoeic. When the procedure was performed at higher working temperature within the manufacturers guidelines women were more likely to be amenorrhoeic (78.4 vs. 77.1 °C, p = 0.014).

CONCLUSION

MEA is more effective in treating menorrhagia when used at a higher operating temperature.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

Impact of temozolomide on gonadal function in patients with primary malignant brain tumors

BACKGROUND

Cumulative exposure to alkylating agents may produce impaired reproductive function. Temozolomide is an alkylating agent approved for treating malignant gliomas.

OBJECTIVE

A pilot study was undertaken to investigate the effects of temozolomide on semen integrity in men with newly diagnosed or recurrent malignant gliomas.

METHODS

Eligible patients had no known fertility problems or impotence. Comprehensive semen analysis and serum sex hormones were obtained at baseline and following 3 and at least 6 months of temozolomide.

RESULTS

Thirteen men were recruited. Mean age was 42 years (28-58). Three had recurrent and 10 newly diagnosed malignant glioma. Four were unable to ejaculate or were azoospermic at baseline. Four provided samples at baseline and after at least 6 months of temozolomide. Five were unable to complete the study. Two of four patients with paired baseline and 6-month samples received 6 months of standard monthly temozolomide. Two patients received standard radiation and concurrent temozolomide followed by adjuvant temozolomide. At 6 months, three of these four patients demonstrated low sperm motility (two low at baseline); three had abnormally low percent normal forms (one abnormal at baseline); two developed abnormally low sperm density. Sex hormone values were normal in all four patients at all time points.

CONCLUSION

Changes in semen analysis parameters following 6 months of temozolomide were observed. The small sample size precludes any firm conclusions regarding the importance and duration of these findings and their relation to temozolomide exposure. With validation in a larger study, these results may have important implications for counseling prior to initiation of temozolomide therapy in these patients.

SU-E-T-463: Biological-Based Optimization and VMAT is Unnecessary for Stereotactic Body Radiation Therapy

PURPOSE

This study shows that there is no clear dosimetric benefit of biological-based optimization for either fixed-beam IMRT or VMAT. Other than shorter delivery times, even VMAT does not offer additional advantage to fixed-beam IMRT.

METHODS

A small number of patients for lung, pancreas, spine and brain CA were planned with fixed-beam IMRT, optimized with (gEUD) and without (DV) biological objectives and, also planned for VMAT with and without gEUD, for comparison. For the lung and brain cases, a non-coplanar 7-11 beam arrangement was used for fixed- beam IMRT and a coplanar 'hybrid' arc simulated VMAT with beams set every 5° spacing. For the other treatment sites, all beams were coplanar. For each case, the fixed-beam IMRT and VMAT plans were optimized with the same objectives. It is important to note that, only 2 segments/beam were allowed for each plan, in order to create small fluence modulation, appropriate for small target volumes during SBRT.

RESULTS

For all plans we noticed that there were minor or no dosimetric differences between fixed- beam IMRT and VMAT, whether DV or gEUD objectives were used or whether fixed-beam IMRT or VMAT is used. Keeping the level of beam modulation as-low-as possible, for small SBRT targets, one can show that VMAT with or without gEUD optimization does not offer any dosimetric advantage against fixed-beam IMRT with multiple non-coplanar beams. This is against the expectation that gEUD-optimization can Result superior plans than DV-optimization. The difference is that, for small target volumes like those encountered in SBRT, the complexity of the fluence is not as high as in large field intensity modulated cases.

CONCLUSIONS

The fact that VMAT with or without gEUD can produce as good plans as fixed-IMRT does not make VMAT a preferred treatment modality, other than the fact that requires reduced treatment time.

A tale of three aspirations: foreign bodies in the airway

Tracheobronchial foreign body aspiration is a serious medical problem, with clinical manifestations ranging from acute asphyxiation to insidious lung damage, as demonstrated by the three presented cases. Patient 1 aspirated during dinner, emergency bronchoscopy retrieved pieces of food, and she fully recovered the following day. Patient 2 presented with recurrent pneumonia and a right lower lobe lung abscess. After right lower lobectomy, pathology revealed a foreign object in the right main stem bronchus, a peanut aspirated one year earlier. Patient 3 became unresponsive several days after spinal surgery. The differential diagnosis included myocardial infarction, stroke, and foreign body aspiration. The patient died and necropsy revealed a foreign body in the right main stem bronchus (cooked meat). Thus, foreign body aspiration is not always suspected clinically, and the pathologist may play an important role in making the diagnosis. Histological identification of the aspirated material may be necessary for definitive diagnosis. Therefore, sections of commonly aspirated foods are presented, together with a 10 year history of aspirated objects received by this institution's surgical pathology department.

Heritability of longitudinal change in lung function. The Framingham study

There have been multiple reports of heritability of lung function in cross-sectional analysis, but no prior reports of heritability of rate of change in lung function. We examined heritability of rate of change of lung function in families participating in the Framingham Heart Study. Spirometric measures from two time points were used to calculate annualized rate of change in FEV(1), FVC, and FEV(1)/FVC ratio, adjusting for the effects of age, height, and weight using multiple linear regression models. Standardized residuals from these models were used as phenotypic variables in variance components analysis to assess effects of smoking and heritable factors on rate of change in lung function. Heritable factors explained a modest proportion of the population variance, with heritability estimates for change in FEV(1), FVC, and ratio of 0.05, 0.18, and 0.13, respectively. Restricting the analysis to subjects concordant for smoking status during the interval over which lung function was measured, the heritability estimates increased to 0.18, 0.39, and 0.14, respectively, among interim smokers. These data suggest that in middle-aged and older persons in the general population, genetic factors contribute modestly to the overall population variance in rate of lung function decline, and further suggest the importance of gene-environment interactions.

Transgenic mice with a mutated collagen promoter display normal response during bleomycin-induced fibrosis and possess neurological abnormalities

We have previously identified a potential TGF-beta activation element (TAE) in the rat collagen alpha1(I) promoter at -1624 upstream of the transcriptional start site [Ritzenthaler et al., 1991, 1993]. To determine the importance of the TAE in vivo, we produced transgenic mice carrying 3.6 kb of the rat collagen alpha1(I) promoter linked to the reporter gene chloramphenicol acetyl transferase with and without site-directed mutations that eliminate DNA-protein binding at the TAE site. Tissue-specific expression of the reporter gene in transgenic mice with the mutated collagen promoter was similar to that of transgenic mice with the normal promoter in two genetic backgrounds as judged by in situ hybridization, reporter assays, and immunochemistry. Endotracheal instillation of bleomycin induces lung fibrosis, mediated in part by TGF-beta. Earlier studies indicated that expression of wild-type collagen-reporter gene was upregulated in transgenic mice lungs in response to endotracheal instillation of bleomycin. A similar level of reporter gene upregulation was observed in transgenic mice carrying the mutation in the TAE. Two lines of transgenic mice carrying the mutated promoter construct displayed unexpected neurological abnormalities. In the FVB genetic background, there was a higher than normal incidence of mortality, spontaneous seizures, and an inability to nurture offspring. Histological evidence demonstrated clear abnormalities, including disorderly arrangement of neurons in the hippocampus and significant laminar cortical necrosis in the cerebrum in animals after seizures. In the C57Bl/6 background, there was a high incidence of severe communicating hydrocephalus, early runting, and increased mortality similar to that in transgenic animals with astroglial overexpression of TGF-beta. These animals provide an interesting model system to investigate molecular mechanisms responsible for seizures and hydrocephalus.

Potent inhibition of human neuronal nitric oxide synthase by N(G)-nitro-L-arginine methyl ester results from contaminating N(G)-nitro-L-arginine

N(G)-Nitro-L-arginine methyl ester (L-NAME), inhibits the three isozymes of nitric oxide synthase (NOS) in vitro and in vivo. The mechanism of NOS inhibition by L-NAME is uncertain. L-NAME was a time-dependent inhibitor of neuronal NOS (nNOS). Concommitantly, L-NAME was hydrolyzed, non-enzymatically, to N(G)-Nitro-L-arginine (L-NA) during the enzyme assay. The time-dependent inhibition of nNOS by L-NAME was the result of this time-dependent formation of L-NA. Furthermore, N(G)-Nitro-L-arginine methyl amide, which is an isosteric analogue of L-NAME that is much less susceptible to hydrolysis, was a rapidly reversible weak inhibitor of NOS. These data suggested that L-NAME itself was a weak and rapidly reversible inhibitor of nNOS. Most of the inhibition of nNOS by a solution of L-NAME is the result of the formation of L-NA. L-NAME was a substrate for porcine liver esterase.

Reversal of age-related deficient influenza virus-specific CTL responses and IFN-gamma production by monophosphoryl lipid A

Old and young Balb/c mice, 24--26 and 2--4 months old, respectively, were infected with a 0.1 LD50 of influenza A/Taiwan/1/86 (A/H1N1) virus by small particle aerosol. Lung virus titers were determined 4, 6, 8, 12, and 17 days later. Old mice had significantly higher virus titers than young mice (P < 0.05-0.0001) and shed virus up to Day 17, while young mice were free of virus by Day 12. Splenic MHC class I CD8+ CTL activity (P < 0.08--0.001) and IFN-gamma production (0.1-0.008) measured on Days 8, 12, and 17 were significantly lower among old mice than among young mice. Coadministration of liposomal influenza vaccine with monophosphoryl lipid A (MPL) resulted in enhanced CD8+ CTL response and IFN-gamma production among old mice (35 and 12,000 times, respectively). These results demonstrate that MPL stimulates CTL and Th1 cytokines (IFN-gamma) in aged mice and may serve to reverse age-related CD8+ CTL deficiency and reduce severe influenza disease in elderly human populations.

Influenza--United States, 1988-89

PROBLEM/CONDITION

CDC monitors the emergence and spread of new influenza virus variants and the impact of influenza on morbidity and mortality annually from October through May.

REPORTING PERIOD COVERED

This report covers United States influenza surveillance conducted from October 1988 through May 1989.

DESCRIPTION OF SYSTEM

Weekly reports from the vital statistics offices of 121 cities provided an index of influenza's impact on mortality; 58 WHO collaborating laboratories reported weekly identification of influenza viruses; weekly morbidity reports were received both from the state and territorial epidemiologists and from 153 sentinel family practice physicians. Nonsystematic reports of outbreaks and unusual illnesses were received throughout the year.

RESULTS

During the 1988-89 influenza season, influenza A (H1N1) and B viruses were identified in the United States with essentially equal frequency overall, although both regional and temporal patterns of predominance shifted over the course of the season. Throughout the season increases in the indices of influenza morbidity in regions where influenza B predominated. Only 7% of identified viruses were influenza A (H3N2), but not isolations of this subtype increased as the season waned and it subsequently predominated during the 1989-90 season. During the 1988-89 season outbreaks in nursing homes were reported in association with influenza B and A (H3N2), but not influenza A (H1N1).

INTERPRETATION

The alternating temporal and geographic predominance of influenza strains A (H1N1) and B during the 1988-89 season emphasizes the importance of continual attention to regional viral strain surveillance, since amantadine is effective only for treatment and prophylaxis of influenza A.

ACTIONS TAKEN

Weekly interim analyses of surveillance data produced throughout the season allow physicians and public health officials to make informed choices regarding appropriate use of amantadine. CDC's annual surveillance allows the observed viral variants to be assessed as candidates for inclusion as components in vaccines used in subsequent influenza seasons.

Sequential comparison of low dose rate and hyperfractionated high dose rate endobronchial radiation for malignant airway occlusion

A pilot trial (S2) was conducted at the University of Wisconsin to determine the feasibility, efficacy, and toxicity of hyperfractionated high dose rate endobronchial radiation. To avoid multiple bronchoscopies, an optimized hyperfractionated schema was derived from the linear-quadratic model. Utilizing a single bronchoscopy, 31 patients with malignant airway occlusion received 4 Gy x 4 fractions over 2 days at 2 cm from source center using a high dose rate remote afterloader. Response and morbidity were compared to a previous trial (S1) in which 66 patients were treated with conventional low dose rate endobronchial radiation. Response was assessed by change in performance status, symptom resolution, percent of lifetime rendered symptom-free or improved, and radiographic reaeration. These parameters were highly comparable between the two groups. The mean ECOG performance status improved from 2.2 to 1.8 for S1 and 2.1 to 1.6 for S2; symptom improvement or resolution was noted in 78% for S1 and 79% for S2; lifetime rendered symptom-free or improved was 54% for S1 and 57% for S2; and the overall radiographic response rate was 78% for S1 and 85% for S2. The overall incidence of fistulae was 7/101. We conclude that endobronchial radiation is an effective and safe modality for palliation, and hyperfractionated high dose rate endobronchial radiation achieves responses similar to low dose rate endobronchial radiation with a similar complication rate.

Endurance capacity of untrained males and females in isometric and dynamic muscular contractions

The capacity to perform isometric and dynamic muscle contractions at different forces has been measured in two separate groups of subjects: 25 men and 25 women performed sustained isometric contractions of the knee-extensor muscles of their stronger leg to fatigue, at forces corresponding to 80%, 50% and 20% of the maximum voluntary force of contraction (MVC). The second experimental model involved a bilateral elbow-flexion weight lifting exercise. Eleven women and 12 men performed repetitions at loads corresponding to 90%, 80%, 70%, 60% and 50% of maximum load (1RM), at a rate of 10 X min-1 to the point of fatigue. Males were stronger (p less than 0.001) than females in both the static (675 +/- 120 N vs 458 +/- 80 N; mean +/- SD) and dynamic (409 +/- 90 N vs 190 +/- 33 N) contractions. Isometric endurance time of the males at a force corresponding to 20% of MVC was less than that of the females (180 +/- 51 s vs 252 +/- 56 s; p less than 0.001) but there was no difference between the sexes at 50% or 80% of MVC. Similarly, when the sexes were compared using dynamic elbow-flexion exercise, the female subjects were able to perform a greater number of repetitions than males at loads of 50% (p less than 0.005), 60% (p less than 0.001) and 70% (p less than 0.025) of 1RM, but there was no difference between the sexes at loads of 80% or 90% of 1RM.(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship between muscle myosin ATP-ase activity and isometric endurance in untrained male subjects

The influence of variations in muscle fibre composition on isometric endurance capacity was measured in 23 young healthy untrained male volunteers. After determination of the maximum voluntary force of contraction (MVC), subjects sustained to fatigue contractions at forces of 80%, 50% and 20% of MVC with a 5-min rest between each. A needle biopsy was obtained from m. vastus lateralis and used for histochemical determination of fibre composition based on myosin ATP-ase activity, and fibre are a based on succinate dehydrogenase (SDH) activity. Endurance times were 21 +/- 9 s (mean +/- SD) at 80% of MVC, 56 +/- 17 s at 50% of MVC and 203 +/- 89 s at 20% of MVC. A wide range of muscle fibre compositions was observed with Type I fibres accounting for 48.0 +/- 10.5% of the total, corresponding to 45.0 +/- 11.5% of the total muscle area. Muscle fibre composition, whether expressed as the proportions of the different fibre types present, or as the fraction of total muscle cross-sectional area occupied by each fibre type was not correlated with isometric endurance capacity at any of the three forces studied. Endurance time was also unrelated to MVC. In contrast to the results of previous studies where trained subjects were used, or where different muscle groups were compared, these results suggest that isometric endurance is not influenced by muscle fibre composition.

Leukocyte interferon-induced tumor regression in human metastatic breast cancer, multiple myeloma, and malignant lymphoma

Thirty-eight patients with advanced breast cancer, multiple myeloma, and malignant lymphoma were treated with partially purified (about 0.1%) leukocyte interferon. Patients were treated with a remission-induction schedule of 3 million to 9 million antiviral units daily intramuscularly for 4 to 26 weeks. Responding patients were maintained on a schedule of 3 million U three times weekly. Tumor regression was observed in seven of 17 patients with breast cancer. Six of 10 patients with multiple myeloma responded with a decrease of at least 50% in serum myeloma protein levels or Bence Jones protein excretion. Six of the 11 lymphoma patients achieved tumor regression. Complete remissions occurred in two patients. Of the 19 responding patients, five remain on study for 52 to 63 weeks. Toxicity included low-grade fever, fatigue, anorexia, and partial alopecia. Myelosuppression (lowest median leukocyte count, 2500/mm3; granulocytes, 1300/mm3) occurred in most patients. On the basis of this pilot study, we conclude that leukocyte interferon can induce tumor regression in patients with advanced cancer.