The Role of Selective Lymphadenectomy in Breast Cancer

BACKGROUND: Axillary node dissection is considered a standard staging procedure in patients with breast cancer. The procedure is associated with significant morbidity and provides pathologists with many lymph nodes to evaluate. METHODS: A total of 174 women participated in a trial that included preoperative lymphoscintigraphy and intraoperative lymphatic mapping using a combination of a vital blue dye and radiocolloid mapping. RESULTS: The intraoperative lymphatic mapping correctly identified a sentinel lymph node (SLN) in 160 (92%) of 174 patients. One skip metastasis (0.7%) occurred in 136 women who had a subsequent complete node dissection. CONCLUSIONS: Lymphatic mapping and SLN biopsy using a combination of mapping techniques provide accurate nodal staging for women with breast cancer. With this technique, approximately 70% to 80% of women with no axillary metastases could be spared the morbidity of a complete node dissection.

Use of 2% propofol to produce diurnal sedation in critically ill patients

OBJECTIVE

The assessment of propofol to produce diurnal sedation in critically ill patients.

DESIGN

Prospective clinical study.

SETTING

Intensive Care Unit, University Hospital.

PATIENTS AND PARTICIPANTS

Thirty consecutive patients admitted to the Intensive Care Unit older than 18 years who were expected to be sedated for more than 50 h.

INTERVENTIONS

The patients were randomised into two groups. All received sedation with a constant background infusion of morphine and a variable infusion rate of propofol, which was altered hourly to maintain the intended sedation score. The first group received constant light sedation (CLS) over 50 h aiming for a Ramsay score of 2-3. The second group received CLS between 0600 h and 2200 h and additional night sedation (ANS) with propofol between 2200 h and 0600 h, aiming for a sedation score of 4-5.

MEASUREMENTS AND RESULTS

Patients were studied for 50 h from 1800 h on the first day of admission. Recordings of heart rate, blood pressure, sedation scores and propofol and morphine infusion rates were made hourly. An APACHE II score was recorded for each patient. Sedation scores were analysed by blind visual assessment and cosinor analysis, which is used in chronobiology to examine the correlation of data with a cosine curve. Patients in the ANS group had significantly better rhythmicity of sedation levels using cosinor analysis (r = 26% v 8%) p < 0.01. There was no difference between the CLS and ANS groups with respect to age, sex or APACHE II scores. Nine out of 15 patients in the ANS group achieved diurnal sedation. Three patients in the CLS group showed diurnal rhythmicity of sedation, which can be attributed to natural sleep, and had a median APACHE II score of 12. Five patients in the CLS group and three in the ANS group showed a deep constant sedation pattern. They had high APACHE II scores (median 21.5) and an obtunded conscious level on admission due to severe sepsis.

CONCLUSION

Propofol can safely provide diurnal sedation in the critically ill when titrated against the Ramsay score. Sedation levels cannot be manipulated in some severely ill patients.

Extraordinary conservation of cysteines among homologous Chironomus silk proteins sp185 and sp220

Aquatic larvae of the midge, Chironomus tentans, synthesize a 185-kDa silk protein (sp185) with the cysteine-containing motif Cys-X-Cys-X-Cys (where X is any residue) every 20-28 residues. We report here the cloning and full-length sequence of cDNAs encoding homologous silk proteins from Chironomus pallidivittatus (sp185) and Chironomus thummi (sp220). Deduced amino acid sequences reveal proteins of nearly identical mass composed of 72 blocks of 20-28 residues, 61% of which can be described by the motif X5-8-Cys-X5-(Trp/Phe/Tyr)-X4-Cys-X-Cys-X-Cys. Spatial arrangement of these residues is preserved more than surrounding sequences. cDNA clones enabled us to map the genes on polytene chromosomes and identify for the first time the homolog of the Camptochironomus Balbiani ring 3 locus in Chironomus thummi. The apparent molecular weight difference between these proteins (185 vs 220 kDa) is not attributable to primary structure and may be due to differential N-linked glycosylation. DNA distances and codon substitutions indicate that the C. tentans and C. pallidivittatus genes are more related to each other than either is to C. thummi; however, substitution rates for the 5'- and 3'-halves of these genes are different. Blockwise sequence comparisons suggest intragenic variation in that some regions evolved slower or faster than the mean and may have been subjected to different selective pressures.

Perinatal methanol exposure in the rat. II. Behavioral effects in neonates and adults

The use of methanol as a component of automobile fuel will increase perinatal exposures in the general population. Few studies have addressed questions concerning neurotoxicity stemming from such exposures. In the current study, four cohorts of pregnant Long-Evans rats, each cohort consisting of an exposure and a control group, were exposed to 4500 ppm methanol vapor in Rochester-type inhalation chambers for 6 hr daily beginning on Gestation Day 6. Exposure continued for both dams and pups through Postnatal Day 21 (PND 21) to model gestational and neonatal toxicity in humans. Several behavioral procedures were used to assess exposure effects in the offspring. Male-female littermates were studied whenever possible to examine sex differences, with one pair from a litter for each procedure. Exposure to methanol did not affect suckling latency and nipple attachment on PND 5 or performance on an aversive olfactory conditioning procedure on PND 10. Exposure to methanol did alter performances in a motor activity procedure. Methanol-exposed neonates were less active on PND 18, but more active on PND 25 than the equivalent control group pups. Two operant conditioning procedures, not used previously in this context, assayed other littermates as adults. A fixed ratio schedule required the rat to rotate a running wheel a specified number of revolutions to obtain food-pellet reinforcers. When the fixed ratio requirement changed, number of responses (revolutions) per 1-hr session displayed a complex interaction with treatment. Changes in performance over the course of training differed between males and females depending on exposure to methanol. Compared to initial baseline performances, methanol-exposed males showed decreases, and methanol-exposed females increases, in the rate of running. A stochastic spatial discrimination procedure permitted subjects to respond on any three levers, with the probabilities of food-pellet delivery determined by the location of the preceding response. A reinforcement matrix defined the response sequence required to maximize reinforcements. When the matrix was changed, the methanol-exposed subjects responded less efficiently at asymptotic levels of performance than controls. Across procedures, developmental exposure to 4500 ppm methanol vapor was associated with subtle behavioral changes in both neonates and adults.

International scoring system for evaluating prognosis in myelodysplastic syndromes

Despite multiple disparate prognostic risk analysis systems for evaluating clinical outcome for patients with myelodysplastic syndrome (MDS), imprecision persists with such analyses. To attempt to improve on these systems, an International MDS Risk Analysis Workshop combined cytogenetic, morphological, and clinical data from seven large previously reported risk-based studies that had generated prognostic systems. A global analysis was performed on these patients, and critical prognostic variables were re-evaluated to generate a consensus prognostic system, particularly using a more refined bone marrow (BM) cytogenetic classification. Univariate analysis indicated that the major variables having an impact on disease outcome for evolution to acute myeloid leukemia were cytogenetic abnormalities, percentage of BM myeloblasts, and number of cytopenias; for survival, in addition to the above, variables also included age and gender. Cytogenetic subgroups of outcome were as follows: "good" outcomes were normal, -Y alone, del(5q) alone, del(20q) alone; "poor" outcomes were complex (ie, > or = 3 abnormalities) or chromosome 7 anomalies; and "intermediate" outcomes were other abnormalities. Multivariate analysis combined these cytogenetic subgroups with percentage of BM blasts and number of cytopenias to generate a prognostic model. Weighting these variables by their statistical power separated patients into distinctive subgroups of risk for 25% of patients to undergo evolution to acute myeloid leukemia, with: low (31% of patients), 9.4 years; intermediate-1 (INT-1; 39%), 3.3 years; INT-2 (22%), 1.1 years; and high (8%), 0.2 year. These features also separated patients into similar distinctive risk groups for median survival: low, 5.7 years; INT-1, 3.5 years; INT-2, 1.2 years; and high, 0.4 year. Stratification for age further improved analysis of survival. Compared with prior risk-based classifications, this International Prognostic Scoring System provides an improved method for evaluating prognosis in MDS. This classification system should prove useful for more precise design and analysis of therapeutic trials in this disease.

Screening for depression in elderly primary care patients. A comparison of the Center for Epidemiologic Studies-Depression Scale and the Geriatric Depression Scale

BACKGROUND

Later-life depressive disorders are a major public health problem in primary care settings. A validated screening instrument might aid in the recognition of depression. However, available findings from younger patients may not generalize to older persons, and existing studies of screening instruments in older patient samples have suffered substantial methodological limitations.

METHODS

One hundred thirty patients 60 years or older attending 3 primary care internists' practices participated in the study. Two screening scales were used: the Center for Epidemiologic Studies-Depression Scale (CES-D) and the Geriatric Depression Scale (GDS). The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders. Third Edition, Revised, was used to establish "gold standard" diagnoses including major and minor depressive disorders. Receiver operating curve analysis was used to determine each scale's operating characteristics.

RESULTS

Both the CES-D and the GDS had excellent properties in screening for major depression. The optimum cutoff point for the CES-D was 21, yielding a sensitivity of 92% and a specificity of 87%. The optimum cutoff point for the GDS was 10, yielding a sensitivity of 100% and a specificity of 84%. A shorter version of the GDS had a sensitivity of 92% and a specificity of 81% using a cutoff point of 5. All scales lost accuracy when used to detect minor depression or the presence of any depressive diagnosis.

CONCLUSIONS

The CES-D and the GDS have excellent properties for use as screening instruments for major depression in older primary care patients. Because the GDS's yes or no format may ease administration, primary care clinicians should consider its routine use in their practices.

Cyclosporin A potentiates receptor-activated [Ca2+]c increase

The use of the immunosuppressant cyclosporin A (CsA) is frequently associated with hypertension. Drug-induced local vasoconstriction appears to be responsible for this effect. Using fura-2 and 45Ca2+ efflux techniques, we have examined variations in the cytosolic calcium concentration ([Ca2+]c) in rat aortic smooth muscle cells and have shown that increases in [Ca2+]c after [Arg8]vasopressin, serotonin, endothelin-1 or angiotensin II stimulation were potentiated after preincubation of cells with CsA. This effect was independent of cyclophilin or calcineurin inhibition by CsA. Measurements of inositol phosphates (InsPn) after agonist stimulation showed that CsA also potentiated their formation. As for 45Ca2+ efflux this effect was not related to cyclophilin or calcineurin inhibition. Direct stimulation of G proteins with aluminium tetrafluoride induced an increase in InsPn formation and 45Ca2+ efflux. Neither of these responses was potentiated by CsA. These results indicate that CsA acts on a target upstream of G protein activation, possibly at the receptor level, resulting in a potentiation of InsPn formation and subsequent calcium increase.

Intratracheal instillation versus intratracheal-inhalation of tracer particles for measuring lung clearance function

Effective elimination of particles deposited in the respiratory tract is an important defense function to protect the organism from potentially adverse effects of inhaled particles. Delivery of radioactively labeled tracer particles and subsequent measurement in vivo of their retention in different regions of the respiratory tract provides an adequate method for characterizing this defensive function. However, the delivery of such tracer particles by inhalation may result in some external contamination of the animals and requires specific protective measures while working with radioactive aerosols. In this study, 85Sr-labeled tracer particles (3 microns) were administered to the lower respiratory tract of rats by intratracheal inhalation to avoid external contamination, and also by intratracheal instillation in order to compare the 2 technique with respect to their suitability for measuring normal and impaired particle clearance rates. It was postulated that particle clearance function in the alveolar region can be determined equally well with intratracheally instilled particles despite their uneven distribution in the lung. For both techniques, rats were anesthesized with halothane and the particles were administered via oral intubation. Retention in the lower respiratory tract of about 30 micrograms (inhalation) and 6 micrograms (instillation) of the administered particles was followed over a period of 180 days by external counting of lung 85Sr-activity in a collimated detection system. To impair alveolar particle clearance rates, groups of rats were subjected to 12 weeks of inhalation exposure prior to delivery of the tracer particles as follows: (1) sham-exposed control; (2) pigment-grade TiO2 particles to induce lung overload: (3) ultrafine TiO2 particles: (4) crystalline SiO2 particles (cristobalite). The following results were obtained: The long-term retention half-times (T1/2) of the tracer particles reflecting alveolar clearance consistently showed the same ranking of the treatment groups whether measured after intratracheal inhalation or instillation. Control values were 66 and 72 days, respectively, and significantly prolonged long-term clearance was measured by both methods for pigment-grade TiO2 (117 and 99 days), ultrafine TiO2 (541 and 600 days) and SiO2 (1901 and 1368 days). Comparison of these values between the two modes of administration of tracer particles showed no significant differences. In contrast, the short-term T1/2 (mucociliary clearance) of the intratracheally instilled tracer particles in the different treatment groups were variable and did not accurately reflect particle clearance from the conducting airways. However, short-term T1/2 after intratracheal inhalation of tracer particles were consistent with fast conducting airway clearance, and mucociliary clearance appears to be stimulated when alveolar clearance is significantly impaired due to particle overload or to effects of cytotoxic particles. The results suggest that intratracheal instillation of a low dose (< or = 10 micrograms) of tracer particles in the rat provides an adequate method for reliably determining effects of inhaled toxicants on alveolar particle clearance function. Further, intratracheal inhalation of tracer particles is useful for measuring both short-term (mucociliary) and long-term (alveolar) particle clearance rates in the lower respiratory tract of the rat.

Ozone responsiveness in smokers and nonsmokers

Short-term exposure to ozone causes decrements in lung function, but predictors of responsiveness remain largely unknown. Ninety healthy volunteers (56 never-smokers, age [mean +/- SD] 25 +/- 4 yr; 34 current smokers, 13 +/- 9 pack-yr, age 28 +/- 1 yr) were exposed to 0.22 ppm ozone for 4 h, with exercise, in an environmental chamber. We measured spirometry and specific airway conductance before, during, and immediately after exposure, and assessed symptoms by questionnaire. Smokers experienced a smaller increase in respiratory symptoms following exposure to ozone than did nonsmokers. Decrements in FEV1 were significantly less than for smokers than for nonsmokers (p = 0.0013). Ozone responsiveness (> 15% fall in FEV1) occurred in 16 of 56 never-smokers (28.6%) and 4 of 34 smokers (11.8%). Multiple logistic regression analysis found pack-yr of smoking to be associated with decreased ozone responsiveness (odds ratio [OR] 0.87, p = 0.017). Age, gender, and methacholine responsiveness were not predictive of responder status. Fourteen smokers and 25 nonsmokers were subsequently exposed once to air and twice to ozone; smokers as well as nonsmokers were consistent in their subsequent responsiveness (or lack of responsiveness) to ozone. Healthy smokers have smaller decrements in lung function and fewer symptoms in response to ozone exposure than do nonsmokers.

Thresholds for fetal hemorrhages produced by a piezoelectric lithotripter

Hemorrhage to fetal tissues occurred when late-term pregnant mice were exposed to lithotripter fields of relatively low amplitude. These hemorrhages were always observed in tissues near developing bone or cartilaginous structures such as the head, limbs and ribs, while soft tissues distant from bone were relatively free of hemorrhage. Thresholds for hemorrhage in the fetus were determined for exposures of pregnant mice on the 18th day of gestation to 200 pulses from a piezoelectric lithotripter. Animals were exposed to axial peak positive pressures of either 0 (sham), 1, 2, 3, 5 or 10 MPa. Thresholds for hemorrhage to the head, limbs, ribs and lung were all < 1 MPa.

Age dependence of ultrasonically induced lung hemorrhage in mice

Thresholds for ultrasonically induced lung hemorrhage were determined in neonatal mice (24-36 h old), juvenile mice (14 d old) and adult mice (8-10 weeks old) to assess whether or not the threshold for lung hemorrhage is dependent upon age. Ultrasonic exposures were at 1.15 MHz with a pulse length of 10 microseconds, pulse repetition frequency of 100 Hz and a total exposure duration of 3 min. The threshold for lung hemorrhage occurred at a peak positive acoustic pressure of approximately 1 MPa for mice in all three age groups. Although the thresholds were similar for neonatal, juvenile and adult mice, the sizes of the suprathreshold hemorrhages were significantly larger in adult mice than in neonatal or juvenile mice.

Ultrasonically induced lung hemorrhage in young swine

Ten-day old swine were used in the final step of a study of the age dependence of the threshold for lung hemorrhage resulting from exposure to diagnostically relevant levels of pulsed ultrasound. A 2.3-MHz focused transducer (pulse length of 10 microseconds, 100-Hz pulse repetition frequency) was incremented vertically at several sites for a distance of 2 or 2.5 cm over the chest of the subject for a total exposure period of 16 or 20 min. The procedure was repeated at a total of four sites per animal. Animals were euthanized and lungs were scored by visual inspection for numbers and areas of gross hemorrhages. The threshold level for hemorrhage was approximately 1.3-MPa peak positive pressure in water and the surface of the animal or, at the surface of the lung, 0.8-MPa peak positive pressure, 0.8-MPa fundamental pressure, 0.7-MPa maximum negative pressure and 20 Wcm-2 pulse average intensity. These values are essentially the same as those reported previously for neonatal swine, and neonatal, juvenile and adult mice.

Hemolysis in vivo from exposure to pulsed ultrasound

Ultrasonically induced hemolysis in vivo when a commercial ultrasound contrast agent, Albunex, was present in the blood. Murine hearts were exposed for 5 min at either 1.15 or 2.35 MHz with a pulse length of 10 microseconds and pulse repetition frequency of 100 Hz. During the exposure period, four boluses of Albunex were injected into a tail vein for a total of approximately 0.1 mL of Albunex. Following exposure, blood was collected by heart puncture and centrifuged, and the plasma was analyzed for hemoglobin concentration. With Albunex present in the blood, the threshold for hemolysis at 1.15 MHz was 3.0 +/- 0.8 MPa (mean +/- SD) peak positive pressure (approximately 1.9 MPa negative pressure, approximately 180 W cm-2 pulse average intensity). For the highest exposure levels (10 MPa peak positive pressure at the surface of the animal), the mean value for hemolysis was approximately 4% at 1.15 MHz and 0.46% at 2.35 MHz, i.e., the threshold at 2.35 MHz is > 10 MPa peak positive pressure. In contrast, hemolysis in control mice receiving saline injections at 10 MPa or sham-exposed (0 MPa) mice receiving Albunex was approximately 0.4%.

Hemolysis of 40% hematocrit, Albunex-supplemented human erythrocytes by pulsed ultrasound: frequency, acoustic pressure and pulse length dependence

The dependence of hemolysis produced by pulsed ultrasound on ultrasound frequency, acoustic pressure and pulse length was explored. Human erythrocytes (40% hematocrit; in Albunex-supplemented autologous plasma) were exposed (60 s) to 20 or 200 microns pulses of ultrasound at frequencies of 1.02, 2.24 or 3.46 MHz and at peak negative pressures [P-] ranging from 0.0 to approximately 3.0 MPa in 0.5 MPa increments. The duty factor was 0.01. At each frequency, hemolysis increased with increasing acoustic pressure and depended weakly on pulse duration. At relatively high acoustic pressures, hemolysis depended strongly on ultrasound frequency; at lower pressures, the frequency dependence was weaker. The potential clinical significance of ultrasonic hemolysis is discussed.

Chronic treatment with typical and atypical antipsychotics increases the AMPA-preferring form of AMPA receptor in rat brain

We assessed the effects of chronic (21 day) administration of antipsychotic drugs on the density of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) receptor in rat brain. We used two typical antipsychotic drugs, haloperidol and pimozide, and two atypical antipsychotic drugs, risperidone and clozapine. Antipsychotic drugs as a group significantly elevated the density of the AMPA receptor measured with an AMPA receptor agonist ([3H]AMPA), but not with an AMPA receptor antagonist, 6-cyano-7-nitro-quinoxaline-2,3-dione ([3H]CNQX). In all regions studied, the magnitude of the increase seen with chronic typical antipsychotic drugs was significantly greater than that seen with chronic atypical antipsychotic drugs. In frontal cortex and striatum, typical antipsychotics but not atypical antipsychotics elevated AMPA receptor binding over control. These findings suggest that antipsychotic drugs alter the agonist affinity of the AMPA receptor without altering the number of AMPA receptors. Typical antipsychotic drugs may be more potent in this effect than atypical antipsychotic drugs, especially in critical corticostriatal circuits.

Long-term care: a comparison of policies and services in Israel and the United Kingdom and implications for the United States

The issue of long-term care continues to be a main concern in the United States. As the country wrestles with the development of policies and services, the experiences of Israel, whose system rests upon national insurance, and that of the United Kingdom, which is based on grants to local authorities, can act as valuable teaching aids in the development of programs in the United States. Although both countries focus on community care with virtually universal access, concern over resources is forcing each to target their services increasingly to the most frail. The findings underscore the necessity for accurate planning and adequate resources if services are to meet the needs of the frail elderly population.

Computer database for melanoma registry. A clinical management and research tool to monitor outcomes and ensure continuous quality improvement

The need for an efficient method of handling data is more apparent today in medical practice than at any time in the past. This PC-based database helps with the daily collection, filing, storage, and abstraction of data for clinical management and research. The program also provides a mechanism for continuous quality assessment to monitor clinical standards of care and make interventions to improve the care of the melanoma patient.

Sperm concentrations and quality in beta-thalassaemia major

We report semen analyses in eight patients with beta-thalassaemia major, with poor results in all but the youngest. The causation is multi-factorial, with iron deposition in the pituitary gland resulting from life-long dependence on blood transfusions being a major factor. We speculate on other contributing causes, but further research is required to elucidate these. Improving haematological care means that these men are increasingly surviving to adult life. Relevant techniques to enable them to achieve their desire for fatherhood are considered.

Perinatal methanol exposure in the rat. I. Blood methanol concentration and neural cell adhesion molecules

Although the acute toxicity of methanol is well documented, few studies have addressed the consequences of perinatal exposures to the low concentrations that are expected to arise from its proposed use as a component of automobile fuel. This report describes the general research design of a series of studies, the effects of methanol exposures on blood concentrations in dams and neonates, and indices of brain development. Four cohorts of Long-Evans pregnant rats, each cohort consisting of an exposure (n = 12) and a control (n = 12) group, were exposed whole-body to 4500 ppm methanol vapor or air for 6 hr daily beginning on Gestation Day 6. Both dams and pups were then exposed through Postnatal Day 21 (PND 21). Blood methanol concentrations determined by gas chromatography from samples obtained immediately following a 6-hr exposure reached approximately 500-800 micrograms/ml in the dams during gestation and lactation. Average concentrations for pups attained levels about twice those of the dams. Selected offspring from Cohort 4 were exposed for one additional 6-hr session at ages that extended out to PND 52. Regression analyses showed that the blood methanol concentrations of the pups declined until about PND 48, at which time their levels approximated those of their dams. Such pharmacokinetic differences might increase the risks posed to developing organisms. Light-microscopic analysis showed no significant abnormalities in the brains of the methanol-treated animals. However, assays of neural cell adhesion molecules (NCAMs) in brains of pups sacrificed on PND 4 showed staining for both the 140 and the 180 kDa isoforms to be less intense in the cerebellum of exposed animals. NCAM differences were not apparent in animals sacrificed 15 months after their final exposure.