Predicting survival in malignant mesothelioma

Malignant mesothelioma (MM) of the pleura or peritoneum is a universally fatal disease attracting an increasing range of medical interventions and escalating healthcare costs. Changes in survival and the factors affecting survival of all patients ever diagnosed with MM in Western Australia over the past five decades and confirmed by the Western Australian Mesothelioma Registry to December 2005 were examined. Sex, age, date and method of diagnosis, site of disease and histological type were recorded. Date of onset of symptoms and performance status were obtained from clinical notes for a sample of cases. Cox regression was used to examine the association of the clinical variables and the 10-yr periods of disease onset with survival after diagnosis. Survival was inversely related to age, being worse for males (hazard ratio (HR) 1.4, 95% CI 1.2-1.6), and those with peritoneal mesothelioma (HR 1.4, 95% CI 1.1-1.7). Patients with sarcomatoid histology had worse prognosis than patients with epithelioid and biphasic histological subtypes. Survival improved after the 1970s and has made incremental improvements since then. Median (interquartile range) survival by decade, from 1960 until 2005, was 64 (0-198), 177 (48-350), 221 (97-504), 238 (108-502) and 301 (134-611) days; ~4 weeks of this apparent improvement can be attributed to earlier diagnosis. With increasing resources and treatment costs for MM over the past 40 yrs, there have been modest improvements in survival but no complete remissions.

The Effect of Dexmedetomidine on Agitation during Weaning of Mechanical Ventilation in Critically ill Patients

Ventilated patients receiving opioids and/or benzodiazepines are at high risk of developing agitation, particularly upon weaning towards extubation. This is often associated with an increased intubation time and length of stay in the intensive care unit and may cause long-term morbidity. Anxiety, fear and agitation are amongst the most common non-pulmonary causes of failure to liberate from mechanical ventilation. This prospective, open-label observational study examined 28 ventilated adult patients in the intensive care unit (30 episodes) requiring opioids and/or sedatives for >24 hours, who developed agitation and/or delirium upon weaning from sedation and failed to achieve successful extubation with conventional management. Patients were ventilated for a median (interquartile range) of 115 [87 to 263] hours prior to enrolment, Dexmedetomidine infusion was commenced at 0.4 μg/kg/hour for two hours, after which concurrent sedative therapy was preferentially weaned and titrated to obtain target Motor Activity Assessment Score score of 2 to 4. The median (range) maximum dose and infusion time of dexmedetomidine was 0.7 μg/kg/hour (0.4 to 1.0) and 62 hours (24 to 252) respectively. The number of episodes at target Motor Activity Assessment Score score at zero, six and 12 hours after commencement of dexmedetomidine were 7/30 (23.3%), 28/30 (93.3%) and 26/30 (86.7%), respectively (P <0.001 for 6 and 12 vs 0 hours). Excluding unrelated clinical deterioration, 22 episodes (73.3%) achieved successful weaning from ventilation with a median (interquartile range) ventilation time of 70 (28 to 96) hours after dexmedetomidine infusion. Dexmedetomidine achieved rapid resolution of agitation and facilitated ventilatory weaning after failure of conventional therapy. Its role as first-line therapy in ventilated, agitated patients warrants further investigation.

3,3',5,5'-Tetra-nitro-biphen-yl

The title compound, C(12)H(6)N(4)O(8), is a biphenyl system that was synthesized as a building block for a new series of anti-malarial compounds. The aromatic rings are oriented at a dihedral angle of 45.5 (2)°, and inter-molecular short O⋯O contacts form a chain along the b axis. The strength of the inter-actions involved in this chain cause one of the rings to be slightly distorted, with the torsion angle between the nitro groups being 23.4 (2)°, whereas, in the other ring, both nitro systems are parallel, forming an angle of 9.6 (2)° with the plane of the aromatic ring to which they are bound. Furthermore, the three ring C atoms around the ring-ring linkage belong to a plane inclined by 4.5 (1)° in relation to the plane containing the other three C atoms, i.e. (NO(2)-)C-C-C(NO(2)). This distortion of the ring causes uncommonly short intermolecular O⋯O [3.038 (2) Å] and O⋯C [3.000 (4) and 3.214 (1) Å] contacts.

Effect of a triaxial nuclear shape on proton tunneling: the decay and structure of 145Tm

Gamma rays deexciting states in the proton emitter 145Tm were observed using the recoil-decay tagging method. The 145Tm ground-state rotational band was found to exhibit the properties expected for an h{11/2} proton decoupled band. In addition, coincidences between protons feeding the 2{+} state in 144Er and the 2{+}-->0{+} gamma-ray transition were detected, the first measurement of this kind, leading to a more precise value for the 2{+} excitation energy of 329(1) keV. Calculations with the particle-rotor model and the core quasiparticle coupling model indicate that the properties of the pi{11/2} band and the proton-decay rates in 145Tm are consistent with the presence of triaxiality with an asymmetry parameter gamma approximately 20 degrees .

Phase II evaluation of suramin in advanced renal cell carcinoma. A Southwest Oncology Group study

Twenty-two eligible patients with advanced renal carcinoma were treated with suramin utilizing a fixed dose regimen. Therapy was reasonably well tolerated with 3 of 22 patients (14%) developing grade 4 toxicity and 11 of 22 patients (50%) having a maximum toxicity of grade 3. There were no responders; median survival was 10 months. Suramin is not an active agent in advanced renal carcinoma.

Southwest Oncology Group Study of paclitaxel and carboplatin for advanced transitional-cell carcinoma: the importance of survival as a clinical trial end point

PURPOSE

The combination of paclitaxel and carboplatin for the treatment of advanced transitional-cell carcinoma (TCC) of the urothelium has promising activity and acceptable toxicity. The purpose of this trial was to evaluate the efficacy of this regimen in a cooperative group setting.

PATIENTS AND METHODS

Twenty-nine patients with advanced TCC were treated every 21 days with paclitaxel 200 mg/m(2), administered as a 3-hour infusion, followed by carboplatin dosed to an area under the curve of 5. Prior systemic adjuvant or neoadjuvant platinum-based therapy was not permitted unless completed at least 1 year before enrollment. Patients were evaluated for response every three cycles, and follow-up was conducted to determine survival.

RESULTS

Twenty-nine patients were enrolled and were assessable. Four (14%) had received prior adjuvant or neoadjuvant therapy. Node-only disease was present in 24%, and 76% of patients had extranodal disease. The median number of cycles received was five. Grade 4 toxicity consisted primarily of neutropenia (38% of patients). Neurologic toxicity was noted in 16 patients (grade 1 in four patients, grade 2 in five patients, grade 3 in six patients, and grade 4 in one patient). Six partial responses and no complete responses were noted, for a response proportion of 20.7% (95% confidence interval, 8% to 40%). Median progression-free survival time was 4 months, and overall survival time was 9 months.

CONCLUSION

The combination of paclitaxel and carboplatin for the treatment of advanced TCC is reasonably well tolerated. However, a response proportion considerably lower than that previously reported was noted. In addition, the median survival time of 9 months was less than the survival time previously reported for patients treated with the combination of methotrexate, vinblastine, doxorubicin, and cisplatin. Although our results may reflect enrollment of patients with poor prognostic features, they also call into question the utility of this regimen.

Health and safety (consultation with employees) regulations 1996

The Health and Safety Commission (HSC) introduced the Health and Safety (Consultation with Employees) Regulations 1996 (HSCER) on 1st October, 1996. The HSCER 'top up' the existing Safety Representatives and Safety Committees Regulations 1997 (SRSCR). The HSCER require employers to consult with all employees, not just those covered by representatives appointed by recognised trade unions, on matters relating to health and safety. Employers have the choice of consulting whether directly with employees or via elected representatives.

Phase 1 trial of intraperitoneal AD-32 in gynecologic malignancies

AD-32 (N-trifluoroacetyladriamycin-14-valerate), an analogue of doxorubicin, was examined for intraperitoneal (ip) administration in a phase 2 trial involving 25 patients with advanced gynecologic malignancies. At an AD-32 dose of 600 mg/m2, the limiting toxicity was grade 4 neutropenia (64% of patients), while severe abdominal pain was relatively uncommon (12%). Intraperitoneal AD-32 administration was associated with a 200-fold pharmacokinetic advantage for cavity exposure, compared to the systemic compartment. At the 600 mg/m2 dose level, 4 of 9 patients (44%) with ascites experienced control of malignant fluid reaccumulation. Based on the results of this phase 1 trial, further exploration of a possible role for the ip administration of AD-32 in individuals with gynecological malignancies appears indicated, particularly in patients with either small volume residual disease after initial systemic chemotherapy or in those with intractable ascites.

Secondary radiation environments in heavy space vehicles and instruments

Secondary radiations produced by the interactions of primary cosmic rays and trapped protons with spacecraft materials and detectors provides an important, and sometimes dominant, radiation environment for sensitive scientific instruments and biological systems. In this paper the success of a number of calculations in predicting a variety of effects will be examined. The calculation techniques include Monte Carlo transport codes and semi-empirical fragmentation calculations. Observations are based on flights of the Cosmic Radiation Environment and Activation Monitor at a number of inclinations and altitudes on Space Shuttle. The Shuttle experiments included an active cosmic-ray detector as well as metal activation foils and passive detector crystals of sodium iodide which were counted for induced radioactivity soon after return to earth. Results show that cosmic-ray secondaries increase the fluxes of particles of linear energy transfer less than 200 MeV/(gm cm-2), while the activation of the crystals is enhanced by about a factor of three due to secondary neutrons. Detailed spectra of induced radioactivity resulting from spallation products have been obtained. More than a hundred significant radioactive nuclides are included in the calculation and overall close agreement with the observations is obtained.

Responsible alcohol service: a study of server, manager, and environmental impact

A responsible alcohol-service training program was evaluated for its impact on changing beliefs, knowledge, and behavior in 97 servers and 43 managers and on changing establishment policies that encourage safer drinking environments. The training program had a significant impact on changing the beliefs and knowledge of both servers and managers. Observation 4 to 6 weeks after training showed no effects on server behavior, but there was a tendency toward more establishment policies compared with controls.

Community-based health promotion: a survey of churches, labor unions, supermarkets, and restaurants

A telephone survey of randomly-sampled churches, labor unions, supermarkets and restaurants was conducted in San Diego, California to determine the level of health promotion activities offered for members and customers. Nearly two-thirds of the churches offered health promotion programs, the bulk of which were single educational sessions. A similar proportion of labor unions reported programs, and most of them consisted of the distribution of materials and single-session group meetings. About one-third of the supermarkets reported activities, with most of these being the distribution of brochures. Similarly, about one-third of restaurants reported programs, which primarily consisted of the enforcement of no-smoking regulations. Very few organizations evaluated programs or desired assistance from health professionals. It was concluded that while secular health promotion programs are common and are available to many people, their quality and effectiveness are unknown. These findings present a challenge for public health professionals and agencies.

Combination chemotherapy and systemic irradiation consolidation for poor prognosis breast cancer

Seventy patients with poor prognosis, metastatic breast cancer were treated with FUVAC induction chemotherapy (5-fluorouracil, vinblastine, Adriamycin [doxorubicin] and cyclophosphamide). Consolidation therapy was given to 30 of 48 responders (63%), of whom 23 received sequential hemibody irradiation (HBI) at 8 cGy, corrected in the upper half for lung transmission. Seven received high dose cyclophosphamide and total body irradiation (TBI) with subsequent infusion of stored, cryopreserved autologous bone marrow. The response rate to induction therapy was 71% (complete [CR] in 21%). The median survival for all patients entered in this study is 12 months. With consolidation, one CR patient who received cyclophosphamide and TBI is disease free at 20+ months, off all treatment, while HBI did not produce longterm remissions. Of 17 partial response (PR) patients, two of 12 improved to CR with HBI, and one of five improved with cyclophosphamide plus TBI, but all ultimately relapsed. The main toxicity of sequential HBI was myelosuppression, with prolonged thrombocytopenia in 13%; only one case of radiation pneumonitis occurred (3%). Cyclophosphamide and TBI produced temporary, reversible marrow aplasia without other major toxicity. We recommend further investigation of Cytoxan (Bristol Myers Oncology Division, Evansville, IN) and TBI for breast cancer patients in remission after chemotherapy.

Procuring incentives for community health promotion programs

Many community health promotion programs have used incentives to encourage participation and to reward health behavior change. To minimize expenses and to enhance a sense of shared responsibility, a number of projects have turned to community merchants as a source of incentives. This study investigated the relative effectiveness of solicitation methods used to procure incentives from local merchants for community health promotion programs. The effect of setting, i.e. level of urban development, and type of business were also analyzed in terms of procurement rates. Two hundred and eighteen merchants were solicited to gain incentives for two programs. Twenty-four incentives were procured at a total value of $480. Telemarketing and face-to-face contact had similar procurement rates, restaurants were by far the type of business most likely to donate, and rural merchants provided incentives significantly more often than urban merchants, while developing urban area merchants' donation rates were midway in between. Telemarketing was the solicitation method clearly most cost effective.

Phase I trial of carboplatin-cyclophosphamide and iproplatin-cyclophosphamide in advanced ovarian cancer: a Southwest Oncology Group study

The Southwest Oncology Group has carried out a phase I clinical trial of carboplatin plus cyclophosphamide and iproplatin plus cyclophosphamide in 20 patients with stages III and IV ovarian cancer prior to initiating a phase III trial to compare these platinum analog-cyclophosphamide combinations with standard cisplatin-cyclophosphamide therapy. Myelosuppression proved the dose-limiting toxicity of both the carboplatin (300 mg/m2) plus cyclophosphamide (600 mg/m2) and iproplatin (180 mg/m2) plus cyclophosphamide (600 mg/m2) regimens. Evaluating up to six courses of therapy (repeated at 4-week intervals), the median nadir WBC and platelet counts associated with carboplatin-cyclophosphamide therapy were 1800 (range, 900-4000) and 69 000 per microliter, respectively, and those associated with iproplatin-cyclophosphamide therapy were 1400 (1100-1600) and 140 000 per microliter, respectively. Although the starting doses of carboplatin and iproplatin required a median decrease of 25%, the median doses of each administered through six courses of therapy were 300 and 180 mg/m2, respectively. Neither nephrotoxicity nor neuropathy were experienced by the patients, but mild to moderate nausea and vomiting occurred in more than 75% of those treated with either drug combination. Alopecia of mild to severe degree was observed in 40% of patients. Although the results of this phase I trial are still preliminary, we can recommend for future phase III trials 300 mg/m2 carboplatin and 180 mg/m2 iproplatin when combined with 600 mg/m2 cyclophosphamide repeated a 4-week intervals for six treatment courses.

Chemohormonal therapy for advanced breast cancer with tamoxifen, adriamycin, and cyclophosphamide (TAC)

Combined chemohormonal therapy is an attractive therapeutic strategy for the treatment of Stage IV breast cancer. Between 1977 and 1979, the authors evaluated a new chemohormonal therapy program in 63 evaluable women with advanced breast cancer who previously had not received cytotoxic chemotherapy or tamoxifen. The chemohormonal therapy consisted of 21- to 28-day cycles of tamoxifen (10 mg orally twice daily), Adriamycin (doxorubicin) (40 mg/m2 intravenously on day 1) and cyclophosphamide (200 mg/m2 orally on days 3-6) (TAC). Objective responses were observed in 82% of the patients (22% complete response, 60% partial response). With a median follow-up of 104 weeks (2 years), the median relapse-free survival for the 52 responding patients was 80 weeks. The median survival for the entire group of 63 patients was 118 weeks. Eleven pretreatment patient characteristics were evaluated via univariate and multivariate analysis to determine their effect on response and survival. Prognostic factors with a significant association with longer survivals were as follows: a lack of soft tissue involvement, a lack of pleural involvement, and a long disease-free interval (DFI). Estrogen receptor (ER)-unknown patients, being composed primarily of postmenopausal patients with a long DFI and single-organ involvement (primarily bone), comprised 62% of the patient population and achieved a survival similar to the smaller number of ER-positive patients and was superior to the survival of ER-negative patients. Toxicities were recorded on all patients and overall the treatment was well tolerated. Combined chemohormonal therapy with TAC resulted in a high objective response rate and a long median survival. This study would support additional trials of chemohormonal therapy in patients with ER-positive tumors or in those whose tumors are likely to be ER-positive (e.g., postmenopausal patients with long DFIs).

Metastatic colon carcinoma detected with radiolabeled F(ab')2 monoclonal antibody fragments

Nine patients with colonic carcinoma were studied with I-131-labeled F(ab')2 fragments of an anti-colorectal carcinoma monoclonal antibody. A total of 69% of colon cancer sites were detected without background subtraction; metastases from a concurrent breast carcinoma in one patient were not seen. Lesions ranged from 1.5 to 8 cm. The mean thyroid uptake of I-131 at 24 hours was 0.25%. Half-lives of I-131 in the blood (protein-bound and total) fit a two-compartment model, with half-lives of 3.5 and 27.6 hours for the protein-bound fraction and 3.6 and 23.8 hours for total I-131. Using quantitative methods, a mean value of 0.0047%/cm3 of the administered dose was localized in the tumor at peak concentration, which occurred approximately 48 hours post-administration. This has implications for therapy planning.

Munchausen syndrome in a methadone maintenance patient

A case of chronic factitious illness in a methadone maintenance patient is presented. We believe that this is the first published report of chemical dependence as a presenting complaint in a Munchausen syndrome case.

Sequential complement changes after childhood acute nephritis

A group of 29 children with acute nephritis have been studied in relation to complement changes during and after their illness. Eighty-two percent had evidence of a streptococcal aetiology. C3 levels were initially depressed in 96.5 percent, but by 12 months all children were normal clinically and had normal complement status. The role of complement is discussed in relation to acute nephritis.

Evidence for abstract response codes: ear--hand correspondence effects in a three-choice reaction-time task

A three-choice reaction-time task was used to investigate the source-of-stimulation effect, that is, the tendency for subjects to react faster and more accurately to a stimulus if the spatial locations of the stimulus and the response correspond than if they do not. Auditory stimuli varied on dimensions of tonal frequency and spatial location, although only the former was relevant for response selection. Responses were found to be faster for the conditions in which stimulus location and response location corresponded than for those in which they did not, but stimulus location had no effect on differences between the two hands with bimanual responses. These results support the hypothesis that the source-of-stimulation effect is due to response plans which interact at a level prior to the programming of the motor response.

Predictive value of bone scans in an adjuvant breast cancer program

Technetium 99m phosphate-complex bone scans were performed in 43 women within two months of mastectomy for stage I (1 patient), stage II (28 patients), and stage III (14 patients) breast cancer. Twelve (28%) initial bone scans were interpreted as either equivocally abnormal (6 scans) or definitely abnormal (6 scans). Radiographs confirmed metastatic disease in 2 patients who were then considered ineligible for adjuvant therapy (adriamycin-cyclophosphamide with or without local radiotherapy). Of the remaining 41 eligible patients, all have received adjuvant therapy and 36 have had at least one additional bone scan at 6-month intervals. Among 20 patients whose serial bone scans were unchanged, there has been no clinical recurrence with a mean followup of 20 months. In contrast, among 16 patients whose serial bone scans have changed (e.g., appearance of new focal lesions, disappearance of old lesions), there have been 6 clinical recurrences (p = 0.01) with a mean followup of 43 months. We conclude that carefully performed technetium pyrophosphate bone scans are helpful in the accurate initial staging of patients being considered for adjuvant breat cancer treatment, and that serial changes in the bone scan identify a group of patients at high risk for early recurrence.

Bacterial meningitis: a review of 53 patients

The mortality figures and incidence of bacterial meningitis in children from Tauranga are reviewed. The high rate of meningitis in relationship to overseas countries is discussed.

Acute glomerulonephritis: the current role of the streptococcus

Thirty-one patients who presented with acute glomerulonephritis have been reviewed with respect to the involvement of the streptococcus in their disease. The high incidence of the condition and the fact that 76 percent of the patients had evidence of streptococcal infection, as indicated by a raised anti-streptolysin O-titre is discussed.

Changes in serum tryptophan and albumin binding of tryptophan in chlorpromazine-treated chronic schizophrenics on withdrawal and restoration of drug therapy

Withdrawal of drug from a group of chlorpromazine-treated chronic male schizophrenics led to a significant rise in the initially low serum tryptophan concentration, and a rise in the fraction freely diffusible. These changes, which would be expected to lead to an increase in tryptophan influx into the brain, and hence to an increase in cerebral serotonin synthesis, could be related to the clinical effects of drug withdrawal.

Obsidian Trade Routes in the Mayan Area

Obsidian from two sources in highland Guatemala has been found at 23 sites of the Classic Mayan civilization, mainly in the nonvolcanic lowlands to the north. The distribution, together with trade routes suggested by topography and documentary sources, suggests efficient waterborne transport and competition between sources for the lowland market.