Collaborative study for the establishment of the WHO 3(rd) International Standard for Endotoxin, the Ph. Eur. endotoxin biological reference preparation batch 5 and the USP Reference Standard for Endotoxin Lot H0K354

An international collaborative study was organised jointly by the World Health Organization (WHO)/National Institute for Biological Standards and Control (NIBSC), the United States Pharmacopeia (USP) and the European Directorate for the Quality of Medicines & HealthCare (EDQM/Council of Europe) for the establishment of harmonised replacement endotoxin standards for these 3 organisations. Thirty-five laboratories worldwide, including Official Medicines Control Laboratories (OMCLs) and manufacturers enrolled in the study. Three candidate preparations (10/178, 10/190 and 10/196) were produced with the same material and same formulation as the current reference standards with the objective of generating a new (3(rd)) International Standard (IS) with the same potency (10 000 IU/vial) as the current (2(nd)) IS, as well as new European Pharmacopoeia (Ph. Eur.). and USP standards. The suitability of the candidate preparations to act as the reference standard in assays for endotoxin performed according to compendial methods was evaluated. Their potency was calibrated against the WHO 2(nd) IS for Endotoxin (94/580). Gelation and photometric methods produced similar results for each of the candidate preparations. The overall potency estimates for the 3 batches were comparable. Given the intrinsic assay precision, the observed differences between the batches may be considered unimportant for the intended use of these materials. Overall, these results were in line with those generated for the establishment of the current preparations of reference standards. Accelerated degradation testing of vials stored at elevated temperatures supported the long-term stability of the 3 candidate preparations. It was agreed between the 3 organisations that batch 10/178 be shared between WHO and EDQM and that batches 10/190 and 10/196 be allocated to USP, with a common assigned value of 10 000 IU/vial. This value maintains the continuity of the global harmonisation of reference materials and unitage for the testing of endotoxins in parenteral pharmaceutical products. Based on the results of the collaborative study, batch 10/178 was established by the European Pharmacopoeia Commission as the Ph. Eur. Endotoxin Biological Reference Preparation (BRP) batch 5. The same batch was also established by the Expert Committee on Biological Standardisation (ECBS) of WHO as the WHO 3(rd) IS for Endotoxin. Batch 10/190 was adopted as the USP Endotoxin Reference Standard, lot H0K354 and vials from this same batch (10/190) will serve as the United States Food and Drug Administration (USFDA) Endotoxin Standard, EC-7.

Combined modality therapy of locally advanced adenocarcinoma of the rectum: Update of a phase I trial of preoperative radiation (RT) with concurrent capecitabine (Cap) and irinotecan (Ir)

13547

Background: We previously reported the combination of preoperative radiation (RT) with concurrent Irinotecan and 5-FU in locally advanced rectal cancer, was well tolerated and had an excellent pathologic complete response rate (CR) of 25%, but with catheter related infections and thromboses as major toxicities (Proc Am Soc Clin Onc 22: 2003). With the potential benefits of capecitabine (Cap) and no need for an implanted catheter, a phase I study was initiated to determine the toxicity and maximum tolerated dose (MTD) of Cap with concurrent Ir and RT. Methods: Eligible patients (pts) had primary or recurrent Stage II or III rectal adenocarcinoma, without a history of prior RT or chemotherapy. The treatment regimen was as follows: external beam RT at 1.8Gy daily M-F, to a total dose of 50.4 or 54 Gy; Ir 50 mg/m2 IV, d 1, 8, 15, 22; dose escalating Cap starting at 825 mg/m2 PO divided in 2 doses, Q 12h. Surgical resection occurred at 6–10 weeks. Dose limiting toxicity is defined as Gr4 heme or non-heme Gr3. Results: A total of 16 pts have enrolled on the study, 10 male and 6 female;the median age was 57 (range 44–77). All are evaluable for toxicity. The Table reviews the maximum toxicities. Grade three diarrhea is the only dose-limiting toxicity to date. There has also been 3 pts with Gr 3 hematologic toxicity. There has been no Gr 4 toxicity. Patients are currently accruing on the 4th dose level of capecitabine. A total of 13 pts have completed the preoperative phase and three are currently on treatment. Eleven pts have had surgical resection. One pt refused surgery due to a biopsy proven CR to chemoradiation. One pt refused surgery and died of disease. Of the 11 pts undergoing surgical resection, there have been 3 pathologic CR. Conclusions: The preoperative combination of capecitabine, irinotecan and radiation in locally advanced rectal cancer pts is feasible and well tolerated. The study continues to accrue, and the MTD has not been achieved. [Table: see text]

[Table: see text]

Preliminary report on reduction of esophagitis by amifostine in patients with non-small-cell lung cancer treated with chemoradiotherapy

Esophagitis is a major toxicity of chemoradiotherapy for lung cancer. Twenty-four patients with non-small-cell lung cancer received induction chemotherapy (paclitaxel/carboplatin) followed by concurrent thoracic irradiation (RT) and weekly paclitaxel. Acute esophagitis was scored weekly. Since a high rate of grade 3 esophagitis was noted in the initial group of 12 patients, amifostine (AMI) 500 mg intravenously twice weekly was added to the regimen in the subsequent 12 patients. Esophagitis Index (EI) was calculated as an area under the curve reflecting esophagitis grade over time. Median number of AMI doses was 12 per patient. AMI was well tolerated. Two patients were not evaluable for esophagitis. The incidence of grade 3 esophagitis was 18% in the initial 11 patients versus 9% in the AMI-treated patients (P = not significant). Mean EI was numerically lower in the AMI-treated patients than in the initial group (5.1 vs. 11.6, P = 0.14). The product of RT dose and length of esophagus in the RT field was larger in the AMI group (934 vs. 761, P = 0.035). Median survival time for all patients was 12.4 months. Esophagitis Index, a novel measure of the severity and duration of acute esophagitis, may be reduced in lung cancer patients receiving twice-weekly AMI with thoracic RT and paclitaxel. Twice weekly AMI did not eliminate grade 3 esophagitis; therefore, dose escalation of AMI is planned. The effect of AMI was not due to the shorter irradiated esophageal length. A phase III randomized trial is now open to assess AMI's effect on esophagitis.

Evaluating home environments of persons with dementia: interrater reliability and validity of the Home Environmental Assessment Protocol (HEAP)

PURPOSE

This article reports on an interrater reliability and preliminary validity study of an investigator-developed tool, the Home Environmental Assessment Protocol (HEAP) for use in homes of persons with dementia.

METHOD

The HEAP consists of 192 items that are summed into separate indices representing the number of hazards, adaptations, and level of clutter and comfort in eight areas of the home. Interrater reliability was examined among four raters, two environmental experts and two non-experts, who observed 22 dementia households.

RESULTS

The Kappa statistic was used to evaluate agreement level for each measured item and found that agreement ranged from slight to almost perfect. Intraclass correlations (ICCs), were used to evaluate agreement level for indices. The hazard index in each room ranged from fair (0.36) to moderate (0.66) for all raters. For the adaptation, clutter and comfort indices in each room, ICCs ranged from 0.51 to 0.90 for all raters. Agreement level between expert and non-expert raters differed minimally for all indices. Adaptations to dining rooms (r= -0.080, p = 0.001), kitchens (r = -0.52, p = 0.02) and bedrooms (r = -0.76, p = 0.001) were associated with patient deficits such that more adaptations were made in homes of dependent persons. Low Mini-Mental Status Examination scores were associated with fewer hazards, more adaptations, and less clutter.

CONCLUSION

Findings show that both experts and non-expert raters use the HEAP consistently. Also, measured attributes are related to cognitive and functional status in the expected direction.

Assessment of lung cancer response after nonoperative therapy: tumor diameter, bidimensional product, and volume. A serial CT scan-based study

PURPOSE

Tumor response after nonoperative lung cancer therapy is traditionally evaluated by bidimensional measurement of maximum tumor diameters. The purpose of this analysis is to investigate whether tumor largest dimension (based on RECIST [Response Evaluation Criteria In Solid Tumors]), bidimensional tumor product, and volume correlate with each other in evaluating tumors of patients with locally advanced non-small-cell lung cancer (NSCLC). In addition, the pace of locally advanced NSCLC volumetric response over time, as well as the prognostic value of tumor size, was assessed in this report with software-assisted evaluation of sequential tumor measurement.

METHODS AND MATERIALS

Patients with locally advanced NSCLC treated with thoracic radiotherapy (RT) with or without chemotherapy were included, if the following were available: a pretreatment computed tomography (CT) simulation and at least two follow-up diagnostic thoracic CT scans taken at our institution after 1996 that were available in Dicom format for electronic transfer of images from diagnostic radiology to a computer terminal with commercial statistics software (AcQsim/CMS Focus). Primary lung tumor and grossly involved lymph nodes were contoured manually on pre-RT axial images and on all follow-up CT scans. Tumor/lymph node largest dimensions, bidimensional products (BP), and volumes were measured using the same software. Data were presented as percent change in volume or unidimensional and bidimensional measurements, with the CT simulation measurements serving as baseline.

RESULTS

A total of 22 patients were evaluated. The median thoracic RT dose was 62.4 Gy (range: 50.0-69.6), and all patients had a Karnofsky performance status > or =80. Chemotherapy (mostly carboplatin/paclitaxel) was given to 17 patients. Nineteen patients had Stage III NSCLC; 1 patient was in Stage I, 1 was in Stage IV, and 1 was recurrent. A total of 107 thoracic CT scans (22 pretreatment and 85 follow-up), averaging 4.9 scans per patient, were analyzed. Tumors reached the smallest volume at a median of 11.0 months from RT completion in all patients, 8.5 months in patients who subsequently failed locally (n = 8), and 11.9 months in those who did not fail locally. Failure rates were as follows: in-field, 36% (8/22); intrathoracic (lung nodules, effusion, pleura), 55% (12/22); and distant, 50% (11/22). Eleven patients are still alive, 4 free of disease. Overall median survival time (MST) is 27.3 months. The median initial tumor volume was 88.0 cc (range: 3.8-218) for all patients; median BP was 33.0 cm(2) (range: 3.1-112.1), and median tumor largest dimension was 7.6 cm (range: 2.2-13.5). The MST of patients with initial tumor volume < or =63.0 cc (n = 9) was >53.0 months and of those with tumor volume > 63.0 cc was 17.3 months. The MST of patients (n = 6) with initial bidimensional tumor product < or =16 cm(2) was >53.0 months and of those with tumor product >16 cm(2) was 17.3 months. The MST of patients with largest initial dimension < or =4 cm was >53.1 months and of those with largest dimension > 4 cm was 25.0 months. At 24 months, 79% of patients with a tumor volume < or =124.0 cc (n = 18) had locally controlled tumors, vs. 0% of patients with tumor volumes >124.0 cc. At the same time point, 93% of patients with BP < or =40 cm(2) were locally controlled, vs. 0% of those with BP > 40 cm(2); 100% of patients with tumor dimensions < or =7.5 cm were locally controlled, vs. 40% of those with dimensions >7.5 cm. The partial responses in our series (assessed as the best response obtained during observation period) were as follows: 4 patients assessed based on either dimension only, product only, or volume only; 15 partial responses based on dimension or product; 16 partial responses based on volume alone; 3 cases of no tumor response, based on dimension or product; and 2 cases based on tumor volume alone. That represents good to excellent agreement among all three methods of measurement.

CONCLUSIONS

(1) The response of locally advanced NSCLC to nonoperative therapy is a slow process, with tumor volumes reaching their nadir several months after treatment. (2) Smaller initial tumor size, as measured by largest tumor dimension, bidimensional product, or tumor volume, is associated with better local control and survival than larger initial measurements. (3) Any of the three tumor measurements (largest dimension, bidimensional product, or volume) can be used as a reliable tool in assessing lung cancer response to nonoperative therapy. This confirms further the validity of RECIST and does not suggest that tumor volume is significantly superior for response evaluation.

Supercritical fluid simulated moving bed chromatography II. Langmuir isotherm

The simulated moving bed (SMB) technology offers the possibility of scaling up single column, batch chromatographic separations to continuous operation. This has proved particularly effective for the separation of enantiomers, and has been applied in the liquid and gas phase, as well as using a supercritical fluid as eluent (SF-SMB). In the last case, the main performance improvements are due to the possibility of tuning the elution strength of the mobile phase, by changing the pressure in the four sections of the SMB unit. Thus a SF-SMB can be operated in two modes, i.e. the isocratic and the pressure gradient mode. In this research, design criteria for these two operating modes have been developed, which can be applied to systems described by linear as well as nonlinear Langmuir adsorption isotherms. The role and effect of an appropriate modifier in increasing solubility and reducing retention times have been investigated. The results reported allow to identify the operating conditions, including the pressure levels and the modifier concentration, which lead to optimal separation performance in terms of productivity and desorbent requirement.

Predictors of severe esophagitis include use of concurrent chemotherapy, but not the length of irradiated esophagus: a multivariate analysis of patients with lung cancer treated with nonoperative therapy

PURPOSE

To identify in a multivariate analysis treatment-related factors predisposing patients (pts) with lung cancer to acute esophagitis, expressed as a severity grade or Esophagitis Index (EI).

METHODS AND MATERIALS

Acute esophagitis is prospectively scored as an RTOG Grade in our institution during and after thoracic radiotherapy. Charts, toxicity forms and digitally reconstructed radiographs (DRRs) of all pts with lung cancer who received thoracic radiotherapy (RT) between 11/95 and 1/99 were reviewed. Esophagitis grades for each time point were verified by review of weekly physician and nursing treatment notes, hospital discharge summaries and referring physician notes and then plotted on graph against time. The area under the curve was calculated for each patient's graph and was defined as an Esophagitis Index. The length of esophagus was measured on each anterior DRR while assuming that esophagus overlies the vertebral bodies on the anterior films and projects over the edge of the vertebral body on the oblique DRRs. This assumption was confirmed in 10 pts by digitizing esophagus on CT simulator-derived slices and visualizing its position on DRRs. To compare RT doses delivered with different fractionation schemes to standard fractionated doses, the equivalent RT doses were calculated using the linear-quadratic formula and alpha/beta ratio of 10. Univariate and multivariate analyses of several factors potentially influencing the maximum esophagitis grade, as well as EI, were performed.

RESULTS

A total of 277 pts were identified. Pts were included in the analysis (n = 105) if they fulfilled the following criteria: chart, toxicity form and DRRs were all available; parallel opposed fields (no multiple fields) were used for both the initial and off cord/cone down fields; and an equivalent dose of 45.0 Gy or more was delivered. Seventy-eight pts had Stage III; 32, Stage IV, and the remainder, Stages I, II, or recurrent lung cancer (85 non-small cell and 18, small cell). Seventy-four pts were treated with definitive intent. Chemotherapy was given concurrently with RT in 58 pts (in 7 pts, with twice daily, or b.i.d., RT) and as induction treatment, in 11. Only 2 pts required a treatment break of more than 1 week. Median total and equivalent RT doses, fraction size, and anterior esophageal length were as follows: 59.9 Gy, 59.9 Gy, 2.0 Gy, and 14 cm (range, 4.2-21). The following maximum grades of esophagitis were recorded: 1, in 54 pts; 2, in 17 pts; 3, in 13 pts, and 4, in 1 pt. The mean EI for all pts; pts treated with standard RT alone; induction chemotherapy and standard RT; concurrent chemotherapy and standard (QD) RT; and b.i.d. RT with concurrent chemotherapy, was 41. 5 (range, 0-317); 13.6; 24.5; 52.4; and 132.1, respectively (p < 0. 001). Three pts developed an esophageal stricture within 3 months beginning RT. In multivariate analysis, the following factors were significantly associated with increasing EI: concurrent chemotherapy with QD RT and concurrent chemotherapy with b.i.d. RT (p < 0.001, considered jointly). Both factors were also associated with increasing maximum esophagitis grade (p = 0.011). Esophageal length was not associated with increasing EI or esophagitis grade in either univariate or multivariate analyses.

CONCLUSION

Concurrent chemotherapy and twice daily radiotherapy, especially if combined together, were associated with the highest acute maximum esophagitis grade and esophagitis index in pts with lung cancer. The duration of acute esophagitis was also longest in the concurrent chemotherapy/twice daily radiotherapy group. Esophagitis Index appeared to be a more sensitive measure of acute esophagitis than the maximum esophagitis grade. The increasing length of esophagus in the radiation field did not predict for the severity of acute esophagitis.

Deregulation of cyclooxygenase and nitric oxide synthase gene expression in the inflammatory cascade triggered by experimental group B streptococcal meningitis in the newborn brain and cerebral microvessels

Group B Streptococcus (GBS) is the most common cause of neonatal sepsis and meningitis. Despite antibiotics, GBS in the newborn initiates a cascade of molecular and biological events leading to altered cerebral perfusion, blood-brain barrier disruption, cerebral edema, intracranial hypertension, neurological damage, and even death. Having previously shown that GBS infection impairs cerebral blood flow autoregulation and increases prostaglandin (PG) levels, we examined the regulation of some crucial inflammatory mediators (PGs, nitric oxide (NO), tumor necrosis factor-a) in the brain and cerebral microvessels (MVs) from newborn piglets. Cyclooxygenase (COX), the key enzyme in PG biosynthesis, exists in two isoforms, COX-1 and COX-2. Both may be directly induced by NO in a model of renal inflammation. Besides its neurotransmitter role, NO is a potent vasorelaxant whose production is catalyzed by at least three distinct nitric oxide synthases (NOS) (bNOS, ecNOS, iNOS). Western blot analyses showed that the newborn (4 day old) brain expressed lower levels of COX-1 (8-fold), COX-2 (20-fold), bNOS (12-fold), and ecNOS (5-fold) than in the 1 day old. MV showed approximately equal levels of COX-2, lower levels of COX-1 (4-fold), bNOS (5-fold), and higher levels of ecNOS (20-fold) in comparison to 4-day-old cerebral MV. A 4-day-old brain expressed lower levels of bNOS (5-fold), ecNOS (10-fold), and COX-1 (2-fold) than the 6-week-old pig. COX-2 protein was undetected in a 4-day-old pig brain, but present in great excess in MV. Purified MV showed lower ecNOS (14-fold), COX-1 (2-fold), and about equal levels of bNOS and COX-2 in comparison with MV from 6-week-old pigs. Reverse transcription polymerase chain reaction analyses confirmed these results. Treatment with noo-nitro-L-arginine (LNA), a NOS inhibitor, downregulated COX-1 expression in the newborn brain and both COX-1 and COX-2 cerebral MV expression. GBS infection (10(9) colony-forming units, 0.5 mL intracerebroventricular) of sedated newborn piglets induced the expression of tumor necrosis factor-alpha in the cerebrospinal fluid after 2 hours, upregulated bNOS expression in both brain and MVs, upregulated ecNOS in MVs, and downregulated COX-1, COX-2, and ecNOS in the brain. GBS did not trigger the expression of iNOS. Our data suggest that there is a net deficiency of NOS isoforms in the immature brain and microvasculature of the 4-day-old piglet and that the differences in expression lead to the immature control of NO and PG production, rendering newborns particularly susceptible to neurological damage because of the undeveloped nature of their response mechanisms. Moreover, the GBS-induced cascade deregulates the gene expression of interacting inflammatory mediators and may cause a net vasoconstrictor/vasodilator imbalance, leading to cerebral hypertension and edema in the early stages of infection. Pharmacological manipulations of the inflammatory cascade could lead to novel therapeutic approaches for the treatment of GBS meningitis.

Molecular alterations to human chromosome 3p loci in neuroendocrine lung tumors

BACKGROUND

The origins of and interrelations between low grade and high grade neuroendocrine lung tumors, typical and atypical carcinoids, and small cell lung carcinoma (SCLC) have not been elucidated. Karyotypic and molecular genetic studies have demonstrated deletions in 3p in 100% of SCLCs and the candidate lung tumor suppressor gene, FHIT, at 3p14.2 is not expressed in the majority of SCLCs. Similar studies of typical and atypical carcinoids could clarify the interrelations among these tumors.

METHODS

For molecular genetic analyses, archival carcinoids and paired normal cells were microdissected from paraffin sections, deparaffinized, and DNA prepared. Oligonucleotide primer pairs for 12 microsatellite markers mapping between 3p14.2 and 3p21.3 were used to amplify allelic DNA fragments from 13 typical and 6 atypical carcinoids. In addition, an independent series of archival sections of carcinoids and SCLCs was tested by immunohistochemistry for expression of Fhit protein.

RESULTS

Of the six atypical carcinoids examined, three had lost an allele at all informative markers, whereas one had lost alleles in two distinct regions and two showed allele loss in a subregion of the chromosome region tested. Of the 13 typical carcinoids, 3 showed allele loss at only 1 or 2 loci each. Typical carcinoids, similar to normal lung epithelia, were strongly positive for the cytoplasmic Fhit protein, SCLCs were uniformly negative, and atypical carcinoids appeared to express an intermediate level of Fhit protein.

CONCLUSIONS

Loss of heterozygosity at 3p14.2-p21.3 is significantly more extensive in all atypical carcinoids. Atypical carcinoids, which exhibit clinicopathologic features intermediate between typical carcinoids and small cell carcinomas and have been considered well differentiated neuroendocrine carcinomas, also are intermediate between typical carcinoids and SCLC on the basis of extent of loss of 3p alleles and reduced expression of Fhit protein.

Will primary central nervous system lymphoma be the most frequent brain tumor diagnosed in the year 2000?

BACKGROUND

There has been a dramatic increase in the diagnosis of primary lymphoma of the brain during the past decade, prompting speculation that it may become the most frequently diagnosed tumor of the central nervous system by the year 2000. The current analysis drew from the updated Surveillance, Epidemiology, and End Results (SEER) database to establish projections for the incidence of brain lymphoma. The study also attempted to determine whether increased incidence rates are attributable to the increasing incidence of acquired immunodeficiency syndrome (AIDS) and whether there is gender or age dependence.

METHODS

Primary brain lymphoma case data and population census data for calculating incidence rates for the period 1973-1992 were obtained from the SEER program. In an attempt to determine the contribution of AIDS to the increasing incidence of the disease, separate analyses were performed with and without the inclusion of never married men (a high risk group for the development of AIDS). Separate analyses were also performed within the San Francisco SEER registry because a higher incidence of AIDS-related cancers has been documented in this geographic region. Finally, a piece-wise linear model (using one regression line until 1982 and another regression line from 1982 onward) was used to predict incidence rates for the year 2000.

RESULTS

During the period of study, the incidence rates of brain lymphoma increased more than 10-fold, from 2.5 cases per 10 million population in 1973 to 30 in 1991-1992 (chi-square trend, 17.76: P < 0.0001). These increased incidence rates were independent of age and gender. The incidence rates of primary brain lymphoma did not differ significantly when comparing the San Francisco registry with the remainder of the SEER database for any comparison that excluded never married males. However, when the analysis included never married males, a statistically significantly higher incidence rate of primary central nervous system lymphoma was observed among San Franciscans compared with age-matched controls from the remainder of the SEER database. In the year 2000, the projected incidence rate of brain lymphoma would reach 51.1 per 10 million population and 118.2 per 10 million population, with never married men excluded and included, respectively. These incidence rates would still fall below the corresponding projections for glioma and glioblastoma multiforme.

CONCLUSIONS

There continues to be a significantly increasing incidence of brain lymphoma that is independent of age and gender. Indirect evidence implicates the AIDS epidemic as a contributor to this trend. Although the rate of increase in the incidence of non-Hodgkin's lymphoma of the brain is higher than for peripheral non-Hodgkin's lymphoma and other glial tumors, brain lymphoma is not projected to surpass glial tumors as the most frequently diagnosed intracranial malignancy by the year 2000.

Alternative pathway activation of the complement system in preterm infants with early onset infection

The increased incidence of infection in preterm neonates has been related in part to their relative deficiency of most complement components, because complement is known to participate in the defense against bacterial and viral infections. In a prospective study, complement activation products were determined in 52 preterm infants. Twenty preterm infants suffered from proven early onset infection, 11 infants were presumed to suffer from infection, which could not be confirmed. Twenty-one preterm infants without infection or perinatal asphyxia formed the control group. EDTA plasma was obtained within the first 6 h after birth, and follow-up examinations were done in 15 patients with proven infection during the next 24 h. The complement activation products C3a-desArg, C3bBbP, and sC5b-9 were measured with enzyme immunoassay systems. In preterm neonates with early onset infection, a significant elevation of C3a-desArg was found in the very early course of the disease. C3a-desArg generation resulted from alternative pathway activation as shown by a concurrent increase of C3bBbP concentration. In addition, significantly higher concentrations of sC5b-9 predicted infection in the first few hours after birth. Thus, despite very low levels of native complement proteins, preterm babies are able to generate remarkable amounts of activation products of the complement cascade. The elevation of these activation products preceded by hours significant changes of routine laboratory markers of infection, such as leukocyte count, differential blood count, and C-reactive protein. Thus they might help to identify preterm neonates with severe systemic infection earlier than other laboratory parameters.

Signal characteristics of tumors shown by high-resolution endorectal coil magnetic resonance imaging may predict outcome among patients with cervical carcinoma treated with irradiation. A preliminary study

BACKGROUND

The purpose of this study was to evaluate the role of high-resolution magnetic resonance imaging with the endorectal coil (eMRI) in the management of cervical carcinoma treated with definitive irradiation.

METHODS

Eighteen patients with invasive cervical carcinoma (International Federation of Gynecology and Obstetrics Stages Ib-IIIb) consented to evaluation with eMRI on a 1.5 tesla system with high resolution (400 x 400 microM). Images were read to provide staging information and to grade the signal characteristics of the individual tumors as low (dark), intermediate, or high (bright) relative to surrounding isointense fat. Patients were treated with standard megavoltage irradiation (prescribed dose, 80-85 Gray); shaped antero-posterior/postero-anterior or 4-field box techniques, plus brachytherapy, were used.

RESULTS

In 39% of patients, tumors were determined to be in a higher stage by eMRI because of proximal vaginal involvement (n = 4) or the combination of proximal vaginal involvement and parametrial extension (n = 3). Features predictive of improved local control and survival without evidence of disease included stage, hemoglobin levels > or = 11, complete response to external irradiation, and bright signal characteristics. Compared with those who had dark and/or intermediate tumors, patients who had tumors with bright signal characteristics tended to present with earlier stage disease, were less likely to have anemia, and were more likely to have complete response to external irradiation.

CONCLUSIONS

Prognostic information for clinical staging of cervical carcinoma was contributed by eMRI. The technique was more likely to suggest proximal vaginal involvement by a tumor than was examination under anesthesia. Signal characteristics of tumors may provide valuable predictive information that is supplementary to conventional discriminants of outcome that follow definitive irradiation. Such information could allow physicians to tailor treatment (e.g., by the addition of radiation sensitizers) at an earlier point in disease management.

Focal adhesion kinase (pp125FAK) expression, activation and association with paxillin and p50CSK in human metastatic prostate carcinoma

pp125FAK, a protein tyrosine kinase (PTK) co-localized with integrins in focal adhesion plaques, is known to transduce signals involved in the regulation of cell adhesion and motility as well as the anchorage-independent growth of transformed cells. We investigated whether pp125FAK could be part of a signalling pathway that contributes to the progression of human prostate carcinoma (PCa). Up-regulation of pp125FAK expression, its activation by phosphorylation on tyrosine and its association with paxillin and p50csk were preferentially observed in PCa tissues from patients with metastases, whereas normal and hyperplastic prostates and localized PCa tissues showed undetectable or low levels of both FAK mRNA and protein and an absence of pp125FAK signalling complexes. The increase in expression and activation of pp125FAK in metastatic PCa tissues was also corroborated by our findings in human PCa cell lines. Indeed, higher levels of pp125FAK and FAK mRNA were observed in highly tumorigenic PC-3 cells as was the presence of activated pp125FAK, as opposed to an inactive form in LNCaP cells, which have a lower tumorigenic ability. In addition, pp125FAK formed signalling complexes with both paxillin and p50csk in PC-3 cells as in metastatic PCa tissues. Together, our results show that an increase in FAK mRNA and protein, as well as pp125FAK activation and association with signalling proteins, correlates with progression and invasion in human PCa tissues and cells.

Focal adhesion kinase (pp125FAK) expression, activation and association with paxillin and p50CSK in human metastatic prostate carcinoma

pp125FAK, a protein tyrosine kinase (PTK) co-localized with integrins in focal adhesion plaques, is known to transduce signals involved in the regulation of cell adhesion and motility as well as the anchorage-independent growth of transformed cells. We investigated whether pp125FAK could be part of a signalling pathway that contributes to the progression of human prostate carcinoma (PCa). Up-regulation of pp125FAK expression, its activation by phosphorylation on tyrosine and its association with paxillin and p50csk were preferentially observed in PCa tissues from patients with metastases, whereas normal and hyperplastic prostates and localized PCa tissues showed undetectable or low levels of both FAK mRNA and protein and an absence of pp125FAK signalling complexes. The increase in expression and activation of pp125FAK in metastatic PCa tissues was also corroborated by our findings in human PCa cell lines. Indeed, higher levels of pp125FAK and FAK mRNA were observed in highly tumorigenic PC-3 cells as was the presence of activated pp125FAK, as opposed to an inactive form in LNCaP cells, which have a lower tumorigenic ability. In addition, pp125FAK formed signalling complexes with both paxillin and p50csk in PC-3 cells as in metastatic PCa tissues. Together, our results show that an increase in FAK mRNA and protein, as well as pp125FAK activation and association with signalling proteins, correlates with progression and invasion in human PCa tissues and cells.

Regulation and activation of focal adhesion kinase and paxillin during the adhesion, proliferation, and differentiation of prostatic epithelial cells in vitro and in vivo

Focal adhesion kinase (pp125FAK) is a nonreceptor protein tyrosine kinase transducing signals initiated through integrin activation triggered by cell/extracellular matrix (ECM) interactions. To examine its role in epithelial cell adhesion, proliferation, and differentiation, we have studied pp125FAK expression, activity, and association with paxillin in two canine prostate models in which these functions can be selectively regulated: in vitro by vitronectin (VN) and serum factors, and in vivo by sex steroids. Kinetic studies revealed that the adhesion and spreading of prostatic epithelial cells in primary culture was regulated by serum VN and a natural ECM containing VN produced by prostate cells. While barely detectable in freshly isolated prostate cells, proliferating cells, after 72 h in culture, expressed higher levels of FAK mRNA (8-fold), pp125FAK (50-fold), and paxillin (50-fold). In prostate cells with a reduced growth rate after 2 weeks in culture, we observed a decrease in pp125FAK (4-fold) and its transcript (3-fold), but no change in paxillin. In vivo, both proteins were undetectable in normal and hyperplastic glands composed of a well differentiated epithelium, and in prostates restored by androgen supplementation. In contrast, pp125FAK and paxillin were up-regulated by androgen deprivation (castration) and further increased by estrogen treatment, which yielded metaplastic prostates mostly composed of proliferating basal epithelial cells. Moreover, both proteins were constitutively phosphorylated on tyrosine in the metaplastic prostate, as well as in proliferating cultured cells. Together, these results demonstrate that pp125FAK expression is regulated at the protein and mRNA levels and forms active signaling complexes with paxillin when epithelial cells in contact with ECM proteins are induced to proliferate in vivo and in vitro.

[Evaluating the morphology of uncertain breast tumors using color coded Doppler ultrasound]

AIM

The relationship between tumour vessel density and tumour vitality in breast carcinoma has been well established in histopathological studies. Our objective was to find out if colour-coded sonography is helpful in the evaluation of suspicious breast masses.

METHOD

106 patients were studied; in all cases a biopsy was obtained. Peripheral and central blood vessels in a lesion were counted and peak systolic velocities (PSV) were measured as well as the resistive index (RI). The grade of vascularisation was scored on a scale from I-IV indicating an increasing vessel count and increasing PSV.

RESULTS

83% of the carcinoma (n = 61) and 45% of the benign lesions (n = 45) showed vascularity grade III or IV (hypervascularity). The mean PSV of all carcinomas was 0.23 m/s, in benign lesions 0.14 m/s (p < 0.005). Although G3 carcinomas showed higher vascularisation than G2 carcinomas, the difference was not statistically significant. T3 + 4 tumours had significantly higher PSV than T1 + 2 carcinomas (p < 0.01). In 12 of 23 cases with unclear morphology in the B-mode, the additional finding of hypervascularity led to the misinterpretation of a benign lesion as a carcinoma.

CONCLUSION

Although increased vascularity correlated with degree of malignancy the finding of hypervascularity did not help to distinguish a benign from a malignant lesion in individual cases. Consequently, it did not help to reduce the biopsy rate. In benign lesions with hypervascularity and borderline morphology, the risk of a false positive diagnosis is high.

Prenatal care of HIV-infected women: analysis of a large New York State cohort

We examined the effect of methadone treatment, duration of Medicaid enrollment during pregnancy, and other maternal characteristics on receipt of prenatal care by 2,254 women infected with human immunodeficiency virus (HIV) delivering a singleton in New York state from 1985 through 1990. Data were obtained from the New York State Medicaid HIV/AIDS Research Data Base and vital statistics records. Adequacy of the number of prenatal visits reported by the mother on vital statistics records was assessed with use of the Kessner Index, which adjusts for gestational age at delivery. Too few visits were reported by 65% of the study population. Illicit drug users had higher odds of having too few visits [1.64, 95% confidence interval (CI) 1.24-2.17] than methadone-treated women but the odds were similar for non-drug users and methadone-treated women (0.79, 95% CI 0.60-1.25). Women with brief Medicaid enrollment (< or = 25% of pregnancy) had 45% higher odds of having too few visits than did longer enrollees. Treatment for drug addiction and longer Medicaid enrollment during pregnancy may offer important interventions to increase prenatal care of HIV-infected women. Approaches to increase prenatal care of HIV-infected women are especially important given trials showing a reduction in vertical transmission from zidovudine treatment during pregnancy.

Transcriptional regulation of the carcinoembryonic antigen gene. Identification of regulatory elements and multiple nuclear factors

Human carcinoembryonic antigen (CEA) belongs to a family of membrane glycoproteins that are overexpressed in many carcinomas; CEA functions in vitro as a homotypic intercellular adhesion molecule and can inhibit differentiation when expressed ectopically in myoblasts. The regulation of expression of CEA is therefore of considerable interest. The CEA gene promoter region between -403 and -124 base pairs upstream of the translation initiation site directed high levels of expression in CEA-expression SW403 cells and was 3 times more active in differentiated than in undifferentiated Caco-2 cells, correlating exactly with the 3-fold increase in CEA mRNA seen in differentiated Caco-2 cells. Inclusion of additional upstream sequences between -1098 and -403 base pairs repressed all activity. By in vitro footprinting and deletion analyses, four cis-acting elements were mapped within the positive regulatory region, and one element within the silencing region. Several nuclear factors binding to these domains were identified: USF, Sp1, and an Sp1-like factor. By co-transfection, USF directly activated the CEA gene promoter in vivo in both SW403 and Caco-2 cells. In addition, the levels of factors binding to each positively acting element increased dramatically with differentiation in Caco-2 cells. Thus the transcriptional control of the CEA gene depends on the interaction of several regulatory elements that bind multiple specific factors.

Transcriptional control of the human biliary glycoprotein gene, a CEA gene family member down-regulated in colorectal carcinomas

Biliary glycoprotein (BGP) isoantigens are derived by alternative splicing from a single gene and are the human homologs of rat C-CAM and the mouse Bgp species. These glycoproteins represent a family of cell-adhesion molecules. The mouse Bgp isoforms also act as receptors for the hepatitis viral capsid-protein. BGP is a member of the carcinoembryonic antigen (CEA) gene family, which belongs to the immunoglobulin supergene family, yet it displays restricted expression patterns and unique functions. Since the loss or reduced expression of BGP is associated with human colorectal carcinomas, the elements in its upstream regulatory region were analyzed. A cluster of transcriptional initiation sites and the minimal promoter, located within 150 bp upstream of the major transcriptional start site, were active in human colon carcinoma and hepatoma cells. Unlike the CEA gene, BGP gene transcription was not modulated by a silencer region; repetitive elements in the BGP upstream region were not involved in activation or repression. Footprinting experiments identified two cis-acting elements and mobility-shift assays demonstrated that these elements bound several transcription factors, among them, USF, HNF-4 and an AP-2-like factor. In cotransfection experiments, both the USF and HNF-4 transcription factors transactivate the BGP gene promoter and compete for the same regulatory element. The Sp1 transcription factor, shown to be involved in CEA gene transcriptional regulation, does not bind to the BGP gene promoter. We, therefore, propose that the relative distributions and interactions of these transcription factors mediate distinct transcriptional regulation of the BGP gene in colon and liver; this regulation could be distorted during the oncogenic process.

Validation of virus inactivation by heat treatment in the manufacture of diaspirin crosslinked hemoglobin

Diaspirin crosslinked hemoglobin (DCLHb), a hemoglobin based oxygen carrying solution prepared from outdated human blood, is subjected to a heat treatment step to inactivate viruses in our manufacturing process. To validate the efficacy of this inactivation, we have simulated the heat treatment procedure at a reduced scale using hemoglobin solution spiked with representative viruses. Human Immuno-deficiency Virus (HIV), Cytomegalovirus (CMV), and Duck Hepatitis B Virus (DHBV) were used in this validation. Inoculation with concentrated virus was performed just prior to the heat treatment to determine the effect of that specific process step. Samples were taken before, during, and after heat treatment and assayed for virus titer in an attempt to assess the rate as well as the extent of virus inactivation. CMV was analyzed in a plaque assay using MRC-5 indicator cells. The titer was reduced from 3.3 x 10(6) plaque forming units (PFU) per mL to less than 5 x 10(1) PFU/mL (detection limit) within 30 minutes. DHBV was analyzed by inoculation of serially diluted samples into Pekin ducklings, followed at intervals by screening sera for DHBV DNA by dot blot hybridization. The titer was reduced from 5.0 x 10(6) duck infectious units (DIU) per mL to less than 5 x 10(0) DIU/mL (detection limit) within 1 hour. HIV titers were determined through an ELISA assay for p24 antigen present in peripheral blood lymphocyte cocultivation supernatants. The titer was reduced from 2.0 x 10(4) infectious units (IU) per mL to less than 2 x 10(0) IU/mL (detection limit) within 1 hour. These data indicate that high titers of these blood borne viruses are rapidly inactivated by this heat treatment process.

Contributions to biorheology during hemodialysis

Thrombogenicity is the property of a foreign surface to induce clotting processes or formation of aggregates after contact with blood. Beside the sort of anticoagulation patient's prethrombotic state, rheological factors as well as physicochemical properties of foreign membranes decisively influence thrombogenicity. We examined the influence of chronic renal failure and different hemodialyzers and blood transfusion therapy during hemodialysis on hemorheological parameters. Different membranes cannot be discriminated by the used hemorheological parameters. We clearly could demonstrate the close relationship between the hemofiltration rate and an increase of viscosity. Blood transfusion therapy or elevated hematocrit in combination with increased hemofiltration rate have influence on the flow behaviour of blood, especially in disturbed microcirculation.

Control of carcinoembryonic antigen gene family expression in a differentiating colon carcinoma cell line, Caco-2

The levels of control involved in the regulation of expression of the carcinoembryonic antigen (CEA) gene family members were investigated using cultured Caco-2 cells that differentiated after confluence as characterized by the production of polarized monolayers and the subsequent appearance of domes. Three transcripts representing CEA (3.0 and 3.5 kilobases) and nonspecific cross-reacting antigen (NCA) (2.6 kilobases) were detected in Northern analyses of mRNA preparations of such cells when probed with human CEA cDNA, albeit at different levels. The major CEA 3.0-kilobase transcript increased 3-fold over an 11-day culture period after confluence, whereas the NCA transcript increased 25-fold over the same time period. gamma-interferon treatment enhanced CEA mRNA levels 32-fold and NCA mRNA levels 53-fold in Caco-2 monolayers 11 days after confluence. The NCA gene thus appears to be regulated by a mechanism different from that of CEA. During gamma-interferon treatment, the normal increase in Caco-2 dome formation with time in culture was increased further by a factor of 2. Over the 13-day time span for Caco-2 cultures, CEA protein levels increased 7-fold, NCA (Mr 48,000) protein 5-fold, while gamma-interferon treatment augmented CEA 18.5-fold further and NCA 20-fold. In 2 other colon carcinoma cell lines, SW1222 and T84, which are differentiated in culture to varying degrees, little if any changes were seen in CEA and NCA mRNA and protein levels in pre- versus postconfluent cultures. Both cell lines, however, responded to gamma-interferon treatment by increases in CEA and NCA mRNA levels and, in some cases, disproportionate increases in the corresponding proteins. The lack of direct proportionality between mRNA and protein expression suggests that, as observed in human colon carcinoma and adjacent normal tissue, both transcriptional and post-transcriptional control mechanisms regulate CEA gene family member expression in colon carcinoma cells.

Comparison of blood biocompatibility during haemodialysis with cuprophane and polyacrylonitrile membranes

Clotting within the dialyser is one of the most significant clinical parameters of biocompatibility. A study was designed to evaluate the biocompatibility of two different dialysis membranes (cuprophane and polyacrylonitrile) during therapy with conventional heparin. Transient leukopenia during cuprophane but not during polyacrylonitrile haemodialysis was observed, and elastase release using polyacryonitrile membranes was reduced (P less than 0.001). An elevation in F VIII:C activity during cuprophane haemodialysis has to be taken as an indication of endothelial disturbances. There was a significant (P less than 0.001) platelet activation (beta-thromboglobulin) and combined thrombin/plasmin generation using cuprophane membranes. This new synthetic polyacrylonitrile membrane inactivates the clotting in an extracorporeal system to a sufficient degree and allows a reduction in dosages of heparin. Platelet activation, platelet turnover, disturbances of endothelium, fibrinolysis activation, and granulocyte activation are reproducible parameters of a described interaction model. They also permit a comparison of different haemodialysis membranes.

[Ultrasound study of the newborn hip: results and consequences]

From October 1985 to September 1988 3000 neonatal hips were controlled clinically and by ultrasound. 3% of those needed an immediate treatment. In 45 of these 90 hips there were no directing clinical signs or suspicious hints in the family history or during the course of pregnancy. This means, that these inconspicuous cases would not have got their necessary therapy without the ultrasound-screening. Thus the results of this investigation supports the call for the general ultrasound-screening of the neonatal hip.

Periodontal effects associated with the use of smokeless tobacco

This report describes periodontal findings from a comprehensive study of smokeless tobacco use in professional baseball players. Subjects consisted of 1,094 players, coaches, and training staff of seven major league and their associated minor league teams. Before being examined, subjects completed questionnaires on patterns of smokeless tobacco use (validated by blood chemistry studies), rinsed their mouths under supervision, and were cautioned not to discuss their use of tobacco with the dental examiners. They then received a complete oral examination that included recording of all mucosal abnormalities, missing teeth, caries, extrinsic stain, attrition, Plaque Index, Gingival Index, pocket depth, attachment loss, and gingival recession. More than 50% of team members reported using smokeless tobacco, and 39% reported use during the current week. Among current week users, 46% had oral mucosal lesions, located primarily in the mandible at sites where the smokeless tobacco quid was placed. The use of smokeless tobacco was not necessarily associated with severe forms of periodontal disease, and the presence of poor oral hygiene and gingivitis in these users was not related to the development of oral lesions. However, sites adjacent to mucosal lesions in smokeless tobacco users showed significantly greater recession and attachment loss than in sites not adjacent to lesions in users or comparable sites in non-users.

Oral mucosal lesions found in smokeless tobacco users

The risk for oral mucosal lesions associated with use of smokeless tobacco among 1,109 professional baseball players during spring training in 1988 was investigated. Leukoplakia was very strongly associated with use of smokeless tobacco in this population of healthy young men. Of the 423 current smokeless tobacco users, 196 had leukoplakia compared to seven of the 493 nonusers (OR = 60.0, 95% CI = 40.5-88.8). The amount of smokeless tobacco used (in hours per day that smokeless tobacco was held in the mouth), recency of smokeless tobacco use (hours since last use), type (snuff versus chewing tobacco), and brand of snuff used were significantly associated with risk for leukoplakic lesions among smokeless tobacco users. Ninety-eight leukoplakic areas in 92 subjects were biopsied and examined microscopically. All lesions were benign, but one specimen had mild epithelial dysplasia. The long-term significance of leukoplakia in smokeless tobacco users and their relation to oral cancer is not clear.

External catheter immobilization improves wound healing in micropigs

Recurrent traumatic damage by mechanical action is a major cause of catheter exit site problems in CAPD patients. The purpose of this study was to determine the efficacy of a new external immobilization device (Immobilizer) on wound healing characteristics at the catheter exit site. Sixteen Tenckhoff catheters were surgically implanted in four Yucatan micropigs (two catheters per flank). Immobilization devices were placed on one catheter on each side of each animal; the other catheter was allowed free movement. The devices were changed daily, and exit sites were examined for wound healing progress and infection. Fourteen days following implantation the animals were sacrificed, and the catheter exit sites explanted for histologic examination. The results of this study suggest that immobilization of catheters with this device improves wound healing at the exit site, as evidenced by decreased (p less than 0.05) marsupialization/epidermal down-growth (nonimmobilized 2.9 mm vs. immobilized 1.6 mm), and an increased (p less than 0.05) macrophage/epithelioid cell/giant cell response within the exit tract or in the Dacron cuff (granulomatous response histology score of 2.3 for immobilized vs. a histology score of 1.6 for nonimmobilized). Thus, use of this device may help reduce catheter exit site problems in CAPD patients.

Estimation of a common odds ratio in paired-cluster randomization designs

We develop two estimators of a common odds ratio psi for designs in which the investigator randomly assigns each of two clusters to interventions within strata. The estimators rely on an empirical adjustment for clustering to provide improved estimators of psi relative to the standard Woolf and Mantel-Haenszel estimators, respectively. The results of a simulation study show that the suggested adjustment improves the accuracy of both of these well-known estimators under conditions likely to arise in practice. We find the clustered Woolf estimator as particularly effective in terms of mean squared error reduction. We also discuss interval estimation.

Organic anions and the diarrhea of inflammatory bowel disease

To determine if organic anions contribute to the diarrhea of inflammatory bowel disease, we measured osmolality, electrolytes, short-chain fatty acids, lactic acid, and some Krebs cycle anions in 24-hr fecal collections from 18 patients with chronic ulcerative colitis, 20 with Crohn's disease of the colon, and 16 normals. Mean lactic acid concentration was significantly elevated in ulcerative and Crohn's colitis, but values correlated with fecal weight only in the former syndrome. In ulcerative colitis, concentrations of each short-chain fatty acid, especially butyrate, were decreased compared with those from normals or Crohn's disease. Lactate and short-chain fatty acids accounted for nearly half the variability in fecal weight in ulcerative colitis. Crohn's patients had elevated mean fecal water osmolality and osmotic gap not observed in ulcerative colitis. Increased lactic acid and/or deficient short-chain fatty acids may modulate the diarrhea of ulcerative colitis. This mechanism seems less important in Crohn's colitis where an additional osmotic component may be significant.

Estimation of a common odds ratio in case-control studies of familial aggregation

A new estimator of a common odds ratio is proposed for case-control studies of familial aggregation. The proposed estimator is a modification to the usual Mantel-Haenszel estimator that relies on an empirical adjustment for the within-family clustering which is typical of such designs. A simulation study shows that the estimator tends to have smaller mean squared error than the unmodified Mantel-Haenszel estimator under conditions likely to arise in practice. The construction of confidence intervals is also discussed.

Multiple forms of the sigma 3 protein of reovirus: occurrence and binding properties

The sigma 3 protein of reovirus serotype 3 is present in different forms differing in isoelectric point, as already described by other authors. Proteolytic digestion of each of these forms generates similar peptides. The different forms are present in the mature virus and have affinity for double-stranded RNA and for ribosomes. The observations that the different forms have the same functional properties and are absent in reovirus serotype 1 suggest that the presence of multiple forms is dispensable. The different forms can be synthesized by in vitro translation of mRNA extracted from infected cells. However, only one form is clearly made when mRNA synthesized in vitro, using the cloned S4 gene encoding sigma 3 as a template, is translated in vitro. Similarly the cloned S4 gene expressed in vivo produces only one form of the protein. These results indicate that the other forms are not derived by post-translational modification. The different forms are possibly due to the presence of mutant viruses.

Oculoauriculovertebral dysplasia and variants: phenotypic characteristics of 294 patients

Here we describe the phenotypic characteristics of a single craniofacial clinic population of 294 individuals affected with oculoauriculovertebral dysplasia (OAV) and variants. To our knowledge, this is the largest population so described in the literature. The study population was divided into five subgroups based on the presence of combinations of minimal diagnostic criteria: microtia, mandibular hypoplasia, anomalies of the cervical spine and/or epibulbar or lipodermoids. The following data were recorded: sex (M:F 191:103); race (78% Caucasian); the presence of unilateral or bilateral microtia (193 unilateral, 98 bilateral); the presence of symmetric microtia in bilateral cases (34/98); the presence of mandibular hypoplasia ipsilateral or contralateral to the microtic ear or most severely microtic ear in bilateral cases (135/137 were ipsilateral in unilateral cases, 55/62 were ipsilateral in bilateral cases); the number of individuals with no other congenital anomaly in addition to the minimal diagnostic criteria (154/294), with only one other congenital anomaly (51/294), and with two or more other congenital anomalies (89/294); and the type of other congenital anomalies. Finally, we compared our results with other studies. Findings from our study include: mandibular asymmetry should be expected in patients with unilateral or bilateral microtia; bilateral involvement is frequent in patients with microtia; other malformations are seen frequently in all subgroups; anomalies of the cervical spine are more likely to be associated with other anomalies; and other malformations are seen in all systems and should be searched for to provide optimal management.

Estramustine affects bone mineral metabolism in metastatic prostate cancer

A patient with metastatic prostate cancer is described where treatment with Adriamycin (doxorubicin) and estramustine produced severe hypophosphatemia (serum phosphate level, 1.2 mg/dl), which was reversible when treatment was discontinued. Previous studies have shown no effect of Adriamycin on serum phosphate levels. A retrospective study of serial serum chemistry values was done in 15 patients treated with estramustine. A significant fall in the serum phosphate level (mean, 0.8 +/- 0.3 mg/dl) was observed during the first 6 weeks of treatment. When compared with similar patients treated with bilateral orchiectomy, estramustine-treated patients had lower levels of serum calcium, fractional excretion of calcium, serum phosphate, and renal tubular threshold for phosphate reabsorption (TmPO4/GFR). Qualitatively similar but quantitatively smaller effects were also seen in a group of patients treated with diethylstilbestrol (DES) in a dose of 1 to 3 mg daily. Estramustine appears to have significant effects on bone mineral metabolism, particularly on renal phosphate handling resulting in significant hypophosphatemia. This is probably due to an estrogenic effect.

Antithrombin III activity in women with hypertension during pregnancy

Antithrombin III activity was measured prospectively in 127 pregnant women within four weeks of delivery, and the results were tabulated with respect to the clinical diagnosis of their hypertensive disorder. Plasma antithrombin III activity was significantly lower than controls in women with preeclampsia and in women with chronic hypertension and superimposed preeclampsia (P less than .001). In contrast, women with chronic hypertension alone had antithrombin III activities similar to controls. Based on discriminant analysis, an antithrombin III activity of less than 70% was selected as indicative of the preeclampsia-eclampsia syndrome. The sensitivity and specificity of plasma antithrombin III for preeclampsia was 76 and 91%, respectively. Importantly, an antithrombin III activity in excess of 70% accurately predicted the absence of preeclampsia in 89% of study patients. Although gestational ages at delivery were similar in preeclamptic women with antithrombin III activity above and below 70%, women with antithrombin III activity above 70% delivered larger infants and experienced less fetal distress during labor. These findings suggest antithrombin III measurement may be useful in the management of hypertensive pregnant patients who are unresponsive to bedrest.

Aminopyrine--an effective modifier of liver and serum gamma glutamyl transpeptidase

Serum activities of gamma glutamyl transpeptidase, alanine and aspartate aminotransferases, and alkaline phosphatase were determined in children on long-term treatment with aminopyrine. Gamma glutamyl transpeptidase activity was increased up to 15 times above the upper normal limit in children, who received aminopyrine for two weeks or longer. Livers of rats treated with aminopyrine (600 mg/kg/day for 18 to 25 days) had an exceedingly increased activity of gamma glutamyl transpeptidase and a slightly elevated microsomal cytochrome P-450 content. Apparently isolated enhancement of serum gamma glutamyl transpeptidase during aminopyrine medication represents a drug-induced increase of microsomal liver enzymes without clinical relevance and without evidence of damage of liver cells.