The burden of heat-related mortality attributable to recent human-induced climate change

Climate change affects human health; however, there have been no large-scale, systematic efforts to quantify the heat-related human health impacts that have already occurred due to climate change. Here, we use empirical data from 732 locations in 43 countries to estimate the mortality burdens associated with the additional heat exposure that has resulted from recent human-induced warming, during the period 1991-2018. Across all study countries, we find that 37.0% (range 20.5-76.3%) of warm-season heat-related deaths can be attributed to anthropogenic climate change and that increased mortality is evident on every continent. Burdens varied geographically but were of the order of dozens to hundreds of deaths per year in many locations. Our findings support the urgent need for more ambitious mitigation and adaptation strategies to minimize the public health impacts of climate change.

Mental Component Score (MCS) from Health-Related Quality of Life Predicts Incidence of Dementia in U.S. Males

BACKGROUND

The Medical Outcomes Study Questionnaire Short Form 36 health survey (SF-36) measures health-related quality of life (HRQoL) from the individual's point of view and is an indicator of overall health status.

OBJECTIVE

To examine whether HRQoL shows differential changes over time prior to dementia onset and investigate whether HRQoL predicts incidence of dementia.

DESIGN

Prevention of Alzheimer's Disease (AD) by Vitamin E and Selenium (PREADViSE) trial, which recruited 7,547 non-demented men between 2002 and 2009. A subset of 2,746 PREADViSE participants who completed up to five SF-36 assessments at annual visits was included in the current analysis.

SETTING

Secondary data analysis of PREADViSE data.

PARTICIPANTS

A subset of 2,746 PREADViSE participants who completed up to five SF-36 assessments at annual visits was included in the current analysis.

MEASUREMENTS

Two summary T scores were generated for analysis: physical component score (PCS) and mental component score (MCS), each with a mean of 50 (standard deviation of 10); higher scores are better. Linear mixed models (LMM) were applied to determine if mean component scores varied over time or by eventual dementia status. Cox proportional hazards regression was used to determine if the baseline component scores were associated with dementia incidence, adjusting for baseline age, race, APOE-4 carrier status, sleep apnea, and self-reported memory complaint at baseline.

RESULTS

The mean baseline MCS score for participants who later developed dementia (mean± SD: 53.9±9.5) was significantly lower than for those participants who did not develop dementia during the study (mean±SD: 56.4±6.5; p = 0.005). Mean PCS scores at baseline (dementia: 49.3±7.9 vs. non-dementia: 49.8±7.8) were not significantly different (p = 0.5) but LMM analysis showed a significant time effect. For MCS, the indicator for eventual dementia diagnosis was significantly associated with poorer scores after adjusting for baseline age, race, and memory complaint. Adjusted for other baseline risk factors, the Cox model showed that a 10-unit increase in MCS was associated with a 44% decrease in the hazard of a future dementia diagnosis (95% CI: 32%-55%).

CONCLUSION

The SF-36 MCS summary score may serve as a predictor for future dementia and could be prognostic in longitudinal dementia research.

The treatment of uncertainties in reactive pollution dispersion models at urban scales

The ability to predict NO₂ concentrations ([NO₂]) within urban street networks is important for the evaluation of strategies to reduce exposure to NO₂. However, models aiming to make such predictions involve the coupling of several complex processes: traffic emissions under different levels of congestion; dispersion via turbulent mixing; chemical processes of relevance at the street-scale. Parameterisations of these processes are challenging to quantify with precision. Predictions are therefore subject to uncertainties which should be taken into account when using models within decision making. This paper presents an analysis of mean [NO₂] predictions from such a complex modelling system applied to a street canyon within the city of York, UK including the treatment of model uncertainties and their causes. The model system consists of a micro-scale traffic simulation and emissions model, and a Reynolds averaged turbulent flow model coupled to a reactive Lagrangian particle dispersion model. The analysis focuses on the sensitivity of predicted in-street increments of [NO₂] at different locations in the street to uncertainties in the model inputs. These include physical characteristics such as background wind direction, temperature and background ozone concentrations; traffic parameters such as overall demand and primary NO₂ fraction; as well as model parameterisations such as roughness lengths, turbulent time- and length-scales and chemical reaction rate coefficients. Predicted [NO₂] is shown to be relatively robust with respect to model parameterisations, although there are significant sensitivities to the activation energy for the reaction NO + O₃ as well as the canyon wall roughness length. Under off-peak traffic conditions, demand is the key traffic parameter. Under peak conditions where the network saturates, road-side [NO₂] is relatively insensitive to changes in demand and more sensitive to the primary NO₂ fraction. The most important physical parameter was found to be the background wind direction. The study highlights the key parameters required for reliable [NO₂] estimations suggesting that accurate reference measurements for wind direction should be a critical part of air quality assessments for in-street locations. It also highlights the importance of street scale chemical processes in forming road-side [NO₂], particularly for regions of high NO_x emissions such as close to traffic queues.

Use of colour duplex ultrasound as a first line surveillance tool following EVAR is associated with a reduction in cost without compromising accuracy

INTRODUCTION

CT scanning remains the postoperative surveillance imaging modality of choice following EVAR. Concerns regarding cost, exposure to ionising radiation and intravenous contrast have led to a search for a less expensive, equally efficacious and safer method of monitoring EVAR patients after endograft deployment. This study evaluated the cost saving obtained if CDUS was employed as a first line surveillance tool following EVAR, as well as comparing the two entities in terms of efficacy.

PATIENTS & METHODS

Postoperative surveillance CTs and CDUS scans in the 145 patients who have undergone EVAR from 1st June 2003 to 1st July 2010 were compared for the detection of endoleak and determination of residual sac size.

RESULTS

Adopting a protocol where CDUS was employed as the first line surveillance tool following EVAR would result in a reduction in the number of postoperative CTs required in 2010 from 235 to 36. Based on 2010 costings, this would equate to an estimated reduction in expenditure from €117,500 to €34,915 a saving of €82,585. CDUS had a sensitivity of 100% and a specificity of 85% in the detection of endoleaks compared to CT. The positive predictive value was 28% and negative predictive value 100%. The Pearson Coefficient correlation of 0.96 indicates a large degree of correlation between CDUS and CT when measuring residual aneurysm size following EVAR.

CONCLUSION

CDUS can replace CT as the first line surveillance tool following EVAR. This is associated with a significant reduction in the cost of surveillance without any loss of imaging accuracy.

Rising prevalence of asthma but declining wheeze in teenagers (1995-2003): ISAAC protocol

The results of the initial International Study of Asthma and Allergies in Childhood (ISAAC) undertaken in the mid 1990s demonstrated a substantial increase in asthma and wheeze symptoms prevalence in Irish teenagers aged 13-14 years from the 1980s. International research suggests that asthma has increased further in some countries and this study was undertaken to determine whether an upward trend in childhood asthma prevalence has continued in the Republic of Ireland in recent years. We therefore conducted two further national cross sectional studies in the same previously surveyed childhood population throughout the Republic of Ireland, one in 1998 (n=2580) and the other in 2002-3 (n=3089). We report here on rising prevalence trends of asthma (42.1% relative increase) but falling wheeze (10.4% relative reduction) prevalence in these teenage children in 2002-3.

Dental health of long-term survivors of childhood cancer: The childhood cancer survivor study (CCSS)

9017

Background: This study describes the frequencies of and risk factors for altered oral health and dental development in pediatric patients who have survived childhood cancer. Methods: We identified 8,522 participants and 2,831 siblings in the CCSS with information on dental health. Dental outcomes of treatment and socioeconomic-demographic (SED) data, were analyzed using univariate and multivariate logistic regression models to estimate odds ratios (OR). Results: Survivors included 4,249 females (49.9%), 7,367 white non-Hispanic (86.5%). Median age at cancer diagnosis, 6.8y (range, 0–20 y); time from diagnosis to interview, 31.4 y (range, 17–54 y). Overall, 30% of survivors self-reported ≥ 1 oral-dental abnormality: microdontia (10%), hypodontia (8%), > 5 caries (55%), root stunting (6%), enamel hypoplasia (13%), gingivitis (7%). Compared to siblings, survivors were at increased risk of ≥ 1 oral-dental abnormalities when adjusted for SED (OR = 2.0, p<0.001). Increased risk of abnormalities was associated with being female (p<0.001) or white non-Hispanic (p=0.001), having an income < $20K (p=0.001) or lower education (p=0.004), and lack of health insurance (p=0.02). Patients with central nervous system tumors, neuroblastoma and soft tissue sarcoma had highest risk of abnormality (all P-values < 0.001). In multivariate models adjusted for SED, radiation dose to jaw, and exposure to increasing doses of alkylating agents increased risk of oral-dental abnormalities (radiation dose = 20 Gy OR = 5.6, p < 0.001; alkylating agent score OR=1.6, p<0.0001). Conclusions: Childhood cancer therapy results in adverse long- term oral-dental sequelae and is associated with specific treatment factors.

No significant financial relationships to disclose.

Short-term effects of ambient particles on mortality in the elderly: results from 28 cities in the APHEA2 project

Within the framework of the APHEA2 (Air Pollution on Health: a European Approach) project, the effects of ambient particles on mortality among persons > or = 65 yrs were investigated. Daily measurements for particles with a 50% cut-off aerodynamic diameter of 10 microm (PM10) and black smoke (BS), as well as the daily number of deaths among persons > or = 65 yrs of age, from 29 European cities, have been collected. Data on other pollutants and meteorological variables, to adjust for confounding effects and data on city characteristics, to investigate potential effect modification, were also recorded. For individual city analysis, generalised additive models extending Poisson regression, using a locally weighted regression (LOESS) smoother to control for seasonal effects, were applied. To combine individual city results and explore effect modification, second stage regression models were applied. The per cent increase (95% confidence intervals), associated with a 10 microg x m(-3) increase in PM10, in the elderly daily number of deaths was 0.8%, (0.7-0.9%) and the corresponding number for BS was 0.6%, (0.5-0.8%). The effect size was modified by the long-term average levels of nitrogen dioxide (higher levels were associated with larger effects), temperature (larger effects were observed in warmer countries), and by the proportion of the elderly in each city (a larger proportion was associated with higher effects). These results indicate that ambient particles have effects on mortality among the elderly, with relative risks comparable or slightly higher than those observed for total mortality and similar effect modification patterns. The effects among the older persons are of particular importance, since the attributable number of events will be much larger, compared to the number of deaths among the younger population.

Bronchitis symptoms in young teenagers who actively or passively smoke cigarettes

This study was undertaken to examine the prevalence of bronchitis (cough with phlegm) symptoms in teenagers who either smoked cigarettes on a regular basis (active smokers) or were non-smokers but who are exposed to passive smoking (passive smokers) in the home. The study was undertaken in 1995 and repeated in 1998. The 1995 study was a cross sectional questionnaire survey of smoking habits in secondary school children aged 13-14 years and was undertaken as part of the ISAAC questionnaire survey. Thirty representative and randomly selected schools from throughout the Republic of Ireland took part in the study. In the 1995 study, 3066 students completed a questionnaire on their current smoking habits and symptoms of cough and phlegm. We found that 634 (20.7%) of these young teenagers actively smoked cigarettes with significantly more females smoking than males with 23.3% of girls compared to 17.6% boys (p = 0.0001). We found that 46.3% of non-smoking children were exposed to smoking in the home (passive smokers) with parental smoking accounting for most of the passive smoking. Bronchitis symptoms were more commonly reported in active smokers compared to non-smokers with an odds ratio of 3.02 (95% CI 2.34-3.88) (p < 0.0001) or in passive smokers compared to those not exposed to smoking with odds ratio of 1.82 (95% CI 1.32-2.52) (p < 0.0001). The 1998 study showed similar results for smoking habits, passive smoking and prevalence of bronchitis symptoms as with the 1995 study. These results document that increased bronchitis symptoms occur in teenagers exposed to active or passive smoking.

Molecular epidemiologic studies within the Selenium and Vitamin E Cancer Prevention Trial (SELECT)

OBJECTIVE

To conduct timely epidemiologic investigations of molecular/genetic markers that may contribute to the development of prostate, lung, colorectal, or other cancers within the Selenium and Vitamin E Cancer Prevention Trial (SELECT), and to evaluate interactions between these markers and the study interventions.

METHODS

The epidemiologic studies within SELECT will be based on 32,400 men aged 55 years or older (age 50 or older for the African-American men) enrolled into an intergroup, randomized, placebo-controlled, double-blind, phase III prevention trial of supplemental selenium and vitamin E developed and funded by the National Cancer Institute, and coordinated by the Southwest Oncology Group. During the 12-year study period approximately 1500-2000 cases of prostate cancer, 800 lung cancers, and 500 colon cancers are estimated to be diagnosed, based on data from the ongoing Prostate Cancer Prevention Trial of finasteride. A modified fasting blood sample will be processed to collect plasma for analysis of micronutrients, hormones, cytokines, and other proteins. Buffy-coat derived white blood cells collected at baseline will be used for isolation of DNA and establishment of immortalized cell lines. Red blood cells will be stored for analysis of hemoglobin adducts and other components.

RESULTS

Specific results anticipated from these molecular studies will provide information on factors hypothesized to contribute to prostate cancer risk and that may modify the efficacy of either trial supplement, including: steroid sex hormones and several polymorphic genes that encode proteins affecting androgenic stimulation of the prostate, including the androgen receptor, steroid 5alpha-reductase type II, CYP17, and beta-hydroxysteroid dehydrogenase; polymorphisms of DNA repair genes and carcinogen metabolism genes, including those involved in the activation of chemical carcinogens to reactive intermediates (e.g., CYP1A1) or the detoxification of reactive intermediates (e.g., glutathione S-transferase M1); DNA and protein adducts; and insulin-like growth factors and leptin.

CONCLUSION

SELECT offers an excellent opportunity to conduct molecular epidemiologic investigations to assess gene-environment interactions and their role in prostate, lung, and colon carcinogenesis.

The Prostate Cancer Prevention Trial: Current status and lessons learned

The Prostate Cancer Prevention Trial is the first phase 3 prevention trial for prostate cancer in the United States. The implementation of a large, randomized trial has provided a wealth of information that will aid in future cancer chemopreventive studies in US men. The experience from the implementation of the Prostate Cancer Prevention Trial was reviewed. Lessons learned from the study include: (1) US men are willing to enroll in prevention trials; (2) participants in chemoprevention trials are well educated and healthy; (3) the successful cancer prevention trial is viewed by participants as a "men's health trial"; (4) data management and discipline coordination at participating institutions are critical; (5) study design change is commonly required owing to changes in clinical practice over the course of the trial; and (6) training of institutional staff is essential. With proper design, robust data management, and a flexible staff, large-scale randomized chemoprevention trials can be accomplished in the United States. With the extraordinary number of potential agents, it is expected that much will be accomplished with this strategy in the near future.

The APC variants I1307K and E1317Q are associated with colorectal tumors, but not always with a family history

Classical familial adenomatous polyposis (FAP) is a high-penetrance autosomal dominant disease that predisposes to hundreds or thousands of colorectal adenomas and carcinoma and that results from truncating mutations in the APC gene. A variant of FAP is attenuated adenomatous polyposis coli, which results from germ-line mutations in the 5' and 3' regions of the APC gene. Attenuated adenomatous polyposis coli patients have "multiple" colorectal adenomas (typically fewer than 100) without the florid phenotype of classical FAP. Another group of patients with multiple adenomas has no mutations in the APC gene, and their phenotype probably results from variation at a locus, or loci, elsewhere in the genome. Recently, however, a missense variant of APC (I1307K) was described that confers an increased risk of colorectal tumors, including multiple adenomas, in Ashkenazim. We have studied a set of 164 patients with multiple colorectal adenomas and/or carcinoma and analyzed codons 1263-1377 (exon 15G) of the APC gene for germ-line variants. Three patients with the I1307K allele were detected, each of Ashkenazi descent. Four patients had a germ-line E1317Q missense variant of APC that was not present in controls; one of these individuals had an unusually large number of metaplastic polyps of the colorectum. There is increasing evidence that there exist germ-line variants of the APC gene that predispose to the development of multiple colorectal adenomas and carcinoma, but without the florid phenotype of classical FAP, and possibly with importance for colorectal cancer risk in the general population.

Influence of demographic variables in prehospital treatment of patients with chest pain

OBJECTIVE

To determine whether the number of interventions requested by EMS personnel for patients with acute, nontraumatic chest pain varied with the patient's gender or race.

METHODS

The authors conducted a retrospective chart review of the care requested for patients 17 years old or older complaining of acute, nontraumatic chest pain by one EMS squad in a city of 50,000 people over a six-month period. Interventions recorded for each patient included oxygen administration, artificial airway placement, intravenous fluid administration, defibrillation, and use of lidocaine and nitroglycerin.

RESULTS

Of the 169 patients in this study, 54% (n = 92) were white and 56% (n = 95) were female. Age was missing for two patients; of the remainder, 75% (n = 127) were 40 years old or older. The numbers of interventions requested ranged from 0 to 4. EMS personnel requested supplemental oxygen for 163 patients. 81% of the females had i.v. lines placed or attempted, compared with 70% of the males; EMS personnel requested orders for nitroglycerin for 43% of the females and 29% of the males. Whites were more likely than nonwhites to have requests for i.v. lines or nitroglycerin. Overall, the numbers of interventions were similar among young females and among older patients, regardless of race or gender. The pattern for young males was different, with significantly more requests for interventions for young white males than for young non-white males (1.89 vs 1.34).

CONCLUSIONS

Among older patients and among young females, EMS personnel requested similar numbers of interventions for patient complaining of acute, nontraumatic chest pain regardless of patients race. Patterns of care appeared to differ for young males, a finding that warrants further study.

Radiotherapy with or without hyperthermia in the treatment of superficial localized breast cancer: results from five randomized controlled trials. International Collaborative Hyperthermia Group

PURPOSE

Claims for the value of hyperthermia as an adjunct to radiotherapy in the treatment of cancer have mostly been based on small Phase I or II trials. To test the benefit of this form of treatment, randomized Phase III trials were needed.

METHODS AND MATERIALS

Five randomized trials addressing this question were started between 1988 and 1991. In these trials, patients were eligible if they had advanced primary or recurrent breast cancer, and local radiotherapy was indicated in preference to surgery. In addition, heating of the lesions and treatment with a prescribed (re)irradiation schedule had to be feasible and informed consent was obtained. The primary endpoint of all trials was local complete response. Slow recruitment led to a decision to collaborate and combine the trial results in one analysis, and report them simultaneously in one publication. Interim analyses were carried out and the trials were closed to recruitment when a previously agreed statistically significant difference in complete response rate was observed in the two larger trials.

RESULTS

We report on pretreatment characteristics, the treatments received, the local response observed, duration of response, time to local failure, distant progression and survival, and treatment toxicity of the 306 patients randomized. The overall CR rate for RT alone was 41% and for the combined treatment arm was 59%, giving, after stratification by trial, an odds ratio of 2.3. Not all trials demonstrated an advantage for the combined treatment, although the 95% confidence intervals of the different trials all contain the pooled odds ratio. The greatest effect was observed in patients with recurrent lesions in previously irradiated areas, where further irradiation was limited to low doses.

CONCLUSION

The combined result of the five trials has demonstrated the efficacy of hyperthermia as an adjunct to radiotherapy for treatment of recurrent breast cancer. The implication of these encouraging results is that hyperthermia appears to have an important role in the clinical management of this disease, and there should be no doubt that further studies of the use of hyperthermia are warranted.

Lack of usefulness of radiographic screening for pulmonary disease in asymptomatic HIV-infected adults. Pulmonary Complications of HIV Infection Study Group

OBJECTIVE

To determine the use of chest radiographs in the screening of asymptomatic adults infected with the human immunodeficiency virus (HIV).

METHODS

A prospective, multicenter study of the pulmonary complications of HIV infection in a community-based cohort of persons with and without HIV infection. The subjects included 1065 HIV-seropositive subjects without the acquired immunodeficiency syndrome at the time of enrollment: 790 homosexual men, 226 injection drug users, and 49 women with heterosexually acquired infection. Frontal and lateral chest radiographs were performed at 3-, 6-, and 12-month intervals, CD4 lymphocyte measurements at 3- and 6-month intervals, tuberculin and mumps skin tests at 12-month intervals, and medical histories and physical examinations at 3- and 6-month intervals. Pulmonary diagnoses that occurred within 2 months following each radiograph were analyzed and correlated with the radiographic results.

RESULTS

Evaluable screening chest radiographs (5263) were performed in HIV-seropositive subjects while they were asymptomatic; of these, 5140 (98%) were classified as normal and 123 (2%) as abnormal. A new pulmonary diagnosis was identified within 2 months following a screening radiograph in 55 subjects. Only 11 of these subjects had abnormal radiographs; the sensitivity of the radiograph was 20%. The sensitivity was similarly low at baseline, within each transmission category, and in subjects whose CD4 lymphocyte counts were less than 0.2 x 10(9)/L (200/microL). The types of pulmonary diseases that occurred were similar in the subjects with normal and abnormal screening radiographs.

CONCLUSION

Screening chest radiography in asymptomatic HIV-infected adults is unwarranted because the diagnostic yield is low.

Structural and Solid-State Examination of Ca4Mn3O10 and Sr4Mn3O10

A comparative study of the manganates Ca4Mn3O10 and Sr4Mn3O10 shows them to belong to distinct structural classes, of Ruddlesden-Popper and Cs4Ni3F10 type respectively. Our determinations show both compounds to be orthorhombic, with Ca4Mn3O10 in space group Ccc2, with a = 5.240, b = 26.823, c = 5.276 Ǻ, and Sr4Mn3O10 in space group P2221, with the cell dimensions of a = 5.481(1), b = 6.237(1), c = 12.528(2) Ǻ. In addition, Ca4Mn3O10 is found to undergo a transition at 122 K, below which temperature there is evidence for antiferromagnetic ordering and for a sharp conductor-to-insulator transition. This appears to be a new form of giant magnetoresistance (GMR), differing from previous reports in that it occurs in an undoped , layered bulk perovskite.

Stage I testicular seminoma: results of adjuvant irradiation and surveillance

PURPOSE

To assess the results of treatment and patterns of relapse in a contemporary group of patients with stage I testicular seminoma managed by adjuvant radiation therapy (RT) and surveillance.

PATIENTS AND METHODS

Between January 1981 and December 1991, 364 patients with stage I seminoma were treated at Princess Margaret Hospital. Of these, 194 were treated with adjuvant RT (92% received a dose of 25 Gy in 20 fractions for 4 weeks) and 172 were managed by surveillance. Two patients were included in this series twice--both had postorchiectomy RT for stage I disease, developed a contralateral seminoma, and were placed on surveillance and analyzed for outcome of both primary tumors. The median follow-up period for patients treated with adjuvant RT was 8.1 years (range, 0.2 to 12), and for patients managed by surveillance, it was 4.2 years (range, 0.6 to 10.1).

RESULTS

The overall 5-year actuarial survival rate for all patients was 97%, and the cause-specific survival rate was 99.7%. Only one patient died of seminoma. Of 194 patients treated with RT, 11 have relapsed, with a 5-year relapse-free rate of 94.5%. Prognostic factors for relapse included histology, tunica invasion, spermatic cord involvement, and epididymal involvement. Twenty-seven patients developed disease progression on surveillance, which resulted in a 5-year progression-free rate of 81.9%. The only factor identified to predict progression on surveillance was age at diagnosis: patients aged < or = 34 years had a 26% risk of progression at 5 years, in contrast to a 10% risk of progression in those greater than 34 years of age.

CONCLUSION

The outcome of patients with stage I testicular seminoma is excellent, with only one of 364 patients (0.27%) dying of disease. In our experience, both a policy of adjuvant RT and of surveillance resulted in a high probability of cure. Our surveillance experience showed that four of five patients with stage I seminoma are cured with orchiectomy alone. The benefit of adjuvant RT was reflected in a decreased relapse rate. We have identified a number of prognostic factors for relapse in patients managed with both approaches, but further study of prognostic factors is required, particularly to identify patients at high risk of disease progression on surveillance.

Radiation treatment of cervical lymph node metastases from an unknown primary: an analysis of outcome by treatment volume and other prognostic factors

One hundred and forty-four patients with diagnosis of carcinoma involving cervical lymph nodes from an unknown primary site were seen at the Princess Margaret Hospital, Toronto between 1970 and 1986. This paper addresses the outcome of two treatment approaches using radiation treatment as potentially curative therapy. The treatment approaches compared in a retrospective analysis are radiation to the involved node regions alone (85 cases), and radiation to both the nodes and to potential primary sites in the head and neck (59 cases). The overall 5-year survival rate of the entire group of 144 cases was 41%. There was a trend to increased survival in favour of the group receiving radiation to the nodes and potential primary sites (p = 0.07), however, when differences in extent of nodal involvement were considered and adjusted for using the Cox Proportional Hazard Model, no difference in survival, or cause-specific survival was found between the two treatment groups (p = 0.18 and 0.22, respectively). A total of seven head and neck primary cancers were subsequently discovered, six in the group receiving radiation only to the nodes and one in the group receiving radiation to the nodes and primary sites. The results of this retrospective analysis need to be interpreted with caution but suggest that, for some patients with this diagnosis, radiation to the involved node region alone is adequate. A discussion of the literature is presented with attention to the effect of extent of treatment on outcome.

Effects of a fast-track closing on a nursing facility population

Sixty-nine patients in a nursing facility were subjected to sudden, forced relocation to other nursing facilities when the facility they were in failed to meet conditions for participation in the Medicaid program. A retrospective study was conducted to examine the effects one year after transfer. Comparisons between those returned following recertification of the facility and those not returned demonstrated dramatic differences; 65 percent of the first group suffered deterioration or death, compared with 19 percent of the second group. Other factors found to be associated with high death rates or worsening of condition one year later were being male, severe physical or mental impairment, and lack of social support. Findings verify that serious adverse effects occur when unprepared patients are suddenly relocated and suggest that return to the facility of origin can mitigate those effects. Implications for policy and practice are discussed.

Significance of percutaneous needle biopsy in patients with multiple pulmonary nodules and a single known primary malignancy

OBJECTIVE

To determine the necessity of percutaneous lung biopsy in patients with a single known primary malignancy and multiple pulmonary nodules.

DESIGN

Retrospective study.

SETTING

Tertiary care university hospital.

RESULTS

We reviewed all percutaneous lung biopsy specimens over a 6-year period. One hundred forty-six patients with a single known primary malignancy and multiple pulmonary nodules had biopsies performed up to 19 years following diagnosis of the primary neoplasm. One hundred thirty-seven biopsy specimens (93.8%) were positive for metastases. Eight patients (5.5%) had a nondiagnostic biopsy specimen; however, subsequent imaging studies and the clinical course strongly suggested diffuse metastatic disease. One patient (< 1%) with breast carcinoma developed nodules 3 years after initial diagnosis and had resolution without a definitive diagnosis or therapy.

CONCLUSION

Patients with a single known primary malignancy and multiple pulmonary nodules who present for percutaneous needle biopsy will have pulmonary metastases in the vast majority of cases. Biopsy in these patients rarely changes the clinical course as other diagnoses are rarely established.

Multiple pulmonary nodules as a manifestation of cat-scratch disease

Cat-scratch disease is an unusual bacterial illness that only rarely shows pulmonary involvement. The authors describe a 19-year-old woman with chronic renal failure who presented with multiple pulmonary nodules, a previously undescribed manifestation of cat-scratch disease.

Adenocarcinoma of the rectum treated by radical external radiation therapy

PURPOSE

To assess the long-term survival and response rates of patients with primary rectal cancer to radical radiation therapy.

METHODS AND MATERIALS

Between 1978 and 1987, 229 patients were treated at the Princess Margaret Hospital with radical external radiation therapy for adenocarcinoma of the rectum. Patients were treated with radiation either because they were considered to have unresectable tumors, were medically unfit, or refused surgery, or for a combination of these factors. Doses ranged from 40 Gy in 10 fractions by a split course over 6 weeks to 60 Gy in 30 fractions in 6 weeks. The most commonly prescribed treatment was 52 Gy target absorbed dose in 20 daily fractions over 4 weeks.

RESULTS

The overall 5-year actuarial survival rate was 27%; for patients with mobile tumors, it was 48%, partially fixed 27%, and fixed tumor 4%. Forty-eight of the 97 patients (50%) with mobile tumors, 11 of the 37 patients (30%) with partially fixed tumors, and 7 of the 77 patients (9%) with fixed tumors had clinically complete tumor regression following radiation. Of these, 18 of the mobile, 6 of the partially fixed, and 5 of the fixed tumors later relapsed locally. Fifty patients had salvage surgery after failing to achieve complete remission or for local relapse, with a 5-year actuarial survival rate of 42% from the time of surgery.

CONCLUSION

Although radiation therapy can cure some patients with mobile or partially fixed rectal adenocarcinomas who refuse or are unsuitable for surgery, local control remains a problem; salvage surgery should be considered in patients who relapse or fail to go into complete remission and who are fit to undergo surgery. For patients with fixed rectal cancers, high-dose external-beam radiation should be part of a planned preoperative regimen or be palliative in intent.

Patterns of fluid accumulation in splenic trauma: demonstration by CT

Detection of hemoperitoneum in splenic trauma is as important as detection of the visceral injury itself. Observation of a consistent spectrum of fluid accumulation in patients with splenic trauma prompted us to investigate the patterns in more detail. Twenty-three computed tomographic (CT) scans in 20 patients were evaluated with respect to presence of fluid collections in various peritoneal and retroperitoneal compartments. These were correlated with severity of injury and operative and pathologic findings. Hemoperitoneum was detected in the pelvis (65%), paracolic gutters (52%), left subphrenic space (48%), perihepatic space (48%), Morison's pouch (17%) and in the lesser sac (9%). In addition to free fluid, pleural fluid (39%) and retroperitoneal hematoma in the left anterior pararenal space (13%) were also encountered. These ancillary findings may help to substantiate the diagnosis of splenic trauma in equivocal cases, particularly when the spleen itself is obscured by artifacts. Early detection may reduce mortality and morbidity associated with splenic trauma.

Lymphoepithelial cyst of the pancreas

Lymphoepithelial cyst of the pancreas is a rare lesion which may mimic a pancreatic pseudocyst or mucinous cystic neoplasm. To our knowledge, this lesion has never been reported in the radiologic literature. We present a patient with lymphoepithelial cyst of the pancreas, and we discuss the radiographic and pathologic findings.

Spontaneous mucocele of the upper esophagus: radiologic demonstration

We present a patient with dysphagia resulting from a pedunculated, spontaneous mucocele of the upper esophagus. We briefly discuss the radiologic, endoscopic, and pathologic findings of this unusual lesion.

Abdominal complications in organ transplant recipients

A variety of intraabdominal complications are associated with organ transplantation. These include inflammatory changes involving the bowel, liver, and pancreas and range from technical complications associated with the surgery to organ rejection, opportunistic infections, and an increased risk of de novo malignancy in transplantation patients.

Phase I pharmacokinetic study of cyclosporin A combined with doxorubicin

We performed a phase I trial of cyclosporin A (CsA) in combination with doxorubicin (dox) to determine the maximally tolerated dose (MTD) of the combination in man, to define the quantitative and qualitative toxicities of the combination, and to determine the pharmacokinetics of the two drugs when used together. CsA was administered as a continuous infusion for 6 days, and dox was administered as a single 10-min infusion 24 h after the initiation of CsA. The starting CsA infusion rate was 5 micrograms/kg/min, and the dox starting dose was 30 mg/m2. Courses were administered every 4 weeks with first CsA and then dox being escalated in consecutive cohorts of patients until the MTD was determined. Twenty-three patients and 40 courses were evaluable for toxicity. Pharmacokinetic analysis was performed in 23 patients on the first course for whole blood CsA and plasma dox and doxorubicinol. The MTD of CsA was 6 micrograms/kg/min, and for dox it was 45 mg/m2. Dose-limiting toxicity was neutropenia. Serum creatinine and creatinine clearance did not change over the infusion period. Bilirubin increased from a median of 10 mumol/liter at the initiation of the infusion to a median of 40.4 mumol/liter at the end of the infusion but returned to normal before the next cycle of therapy. Nausea and vomiting were common and marked, whereas thrombocytopenia was mild. Two patients, one with small cell lung cancer and one with breast cancer, had stable disease while receiving treatment for 5 and 6 months, respectively. Mean whole blood steady state concentrations of CsA were 2210 ng/ml during the infusion with total body clearance of 0.177 liter/h/kg. The area under the concentration x time curve (AUC) increased linearly with dose of dox, and total body clearance was independent of dose. The mean total body clearance was 2.46 liters/h/m2, and terminal half-life was 49.6 h. The AUC for dox was greater and clearance was less than has been previously reported at the doses administered in this study. The ratio of AUC for doxorubicinol to AUC for dox was less than expected, suggesting that the metabolism and/or excretion of dox was decreased when administered with CsA. We conclude that dox can be combined with infusioned CsA but at a lower dose than when given alone. This may be due to altered metabolism and/or excretion of dox or increased bone marrow stem cell sensitivity to dox.

Operative cholangiography performed during laparoscopic cholecystectomy

Operative cholangiography is an important adjunct to laparoscopic cholecystectomy, a recently developed surgical procedure in which cholecystectomy is performed through four abdominal ports under sustained pneumoperitoneum and the direct vision of a video laparoscope. Operative cholangiogram can effectively identify incidental choledocholithiasis or anatomic variation in the biliary system that may significantly influence the surgical approach or postoperative management of the patient. Unique features portrayed on operative cholangiogram in patients undergoing laparoscopic cholecystectomy include unusual displays of pneumoperitoneum, subcutaneous emphysema, visualization of the unresected gallbladder, and overlying surgical hardware that must remain in the operating field during film exposure.

Direct invasion of the transverse colon by a cecal tumor

Direct invasion of the transverse colon is known to result from noncontiguous primary tumors spreading along ligamentous attachments or from direct extension of metastatic disease involving the greater omentum. The resultant desmoplastic reaction produces characteristic findings on barium enema. However, to our knowledge, these findings have not been reported to result from extension of a cecal tumor to the transverse colon via the pericolonic fat. We present such a case and discuss the radiographic findings.

Severe subcutaneous hemiatrophy following treatment of Wilms' tumor: CT demonstration

Hemiatrophy of the subcutaneous tissues following radiation therapy for Wilms' tumor has received little attention in the radiologic literature. We present a patient with this complication, and discuss the findings on computed tomography (CT).

Postoperative atrophy of posterolateral chest wall musculature: CT demonstration

We review five cases in which CT demonstrated severe unilateral atrophy of the latissimus dorsi muscle. In four of these cases, similar findings were also seen in the inferior portion of the serratus anterior muscle. All patients had undergone thoracic surgery on the ipsilateral side 10 months to 3 1/2 years prior to CT. All patients had undergone posterolateral thoracotomy, including one who had undergone successive right and left posterolateral thoracotomies. The most likely explanation for the CT finding of atrophy is denervation injury resulting from surgical incision. We discuss normal innervation of the posterolateral chest wall musculature, with emphasis on the relationship of unilateral atrophy of posterolateral chest wall musculature to previous surgical incision.