Esophageal involvement as an uncommon modality of relapse of Hodgkin lymphoma

We present a case of systemic Hodgkin's lymphoma, relapsed with esophageal involvement after 3 years of complete remission. The importance of an accurate diagnostic work-up is emphasized. Esophagectomy and chemotherapy followed by bone marrow transplantation allowed a complete response and the long-term survival of the patient.

An escalating dose finding study of liposomal doxorubicin and vinorelbine for the treatment of refractory or resistant epithelial ovarian cancer

BACKGROUND

The aim of this study was to determine the maximum tolerated dose (MTD) of liposomal doxorubicin (LD)-vinorelbine (V) in patients with refractory or resistant ovarian cancer.

PATIENTS AND METHODS

Thirty patients were eligible. Seven levels were studied [LD 25-V20 (three patients enrolled); LD 30-V20 (three); LD 35-V20 (three); LD 20-V25 (three); LD 25-V25 (three); LD 30-V25 (10); LD 35-V25 (five)]. LD was given on day 1, while V was given on days 1 and 8 every 21 days. Cohorts of three patients were enrolled at each level, and another three patients were planned, if one dose-limiting toxicity (DLT) was registered.

RESULTS

DLT was observed in four patients: two febrile neutropenia, one grade 4 thrombocytopenia and one grade 3 palmar-plantar erythrodysesthesia (PPE) at level 7 (LD 35-V25). Thus, liposomal doxorubicin 30 mg/m(2) plus vinorelbine 25 mg/m(2) was the MTD. The most frequent toxicity was neutropenia. Fifteen patients (50%) experienced grade 3 neutropenia and 10 (33.3%) grade 4 neutropenia. Non-hematological toxicity was mild. Mucositis and PPE were the most frequent toxicities, but in most cases were grade 1. Out of 29 assessable patients, six (20.7%; 95% confidence interval 10%-39%) experienced an objective response, with one complete response.

CONCLUSIONS

In patients with refractory or resistant ovarian cancer, the recommended doses for the combination studied are liposomal doxorubicin 30 mg/m(2) (day 1) plus vinorelbine 25 mg/m(2) (day 1 and 8). Neutropenia is the most frequent toxicity, while non-hematological toxicity is mild. Substantial activity was recorded and a phase II study is justified.

A randomized comparison of 4 doses of intracoronary adenosine in the assessment of fractional flow reserve

BACKGROUND

Fractional flow reserve (FFR) is a measure of coronary stenosis severity that is based on pressure measurements obtained at maximal hyperemia. Therefore, achievement of maximal vasodilatation of the coronary microcirculation is a prerequisite for the measurement of FFR. The study was designed to address the hypothesis that intracoronary adenosine yields more complete vasodilatation of the coronary microcirculation when high doses are used, resulting in a more accurate FFR measurement.

METHODS

Thirty-six patients with 43 moderate lesions underwent determination of FFR during cardiac catheterization. FFR was calculated in all lesions as the ratio of the distal coronary pressure to the aortic pressure at hyperemia. Different incremental doses of intracoronary adenosine (16, 24, 32 and 40 microg for both coronary arteries) were administered in a randomized fashion.

RESULTS

No adverse events occurred with any intracoronary adenosine bolus. At baseline there were no significant differences for mean aortic and distal coronary pressure, heart rate as well as FFR values between the different doses. FFR was not significantly altered from the different incremental adenosine doses. However, in 27 (63%) out of 43 lesions there was a further reduction of FFR up to 0.23 when a dose >16 microg was injected.

CONCLUSIONS

This study suggests that doses of adenosine up to 40 microg are safe and can be used to achieve a more pronounced vasodilatation in individual patients compared to the standard doses. This may have therapeutic impact with FFR values near cut-off points in patients undergoing diagnostic coronary angiography as well as in patients in whom FFR is used to assess the outcome of interventions.

Genetic structure of susceptibility traits for hip dysplasia and microsatellite informativeness of an outcrossed canine pedigree

An outcrossed canine pedigree was developed for quantitative trait locus (QTL) mapping of hip dysplasia by breeding dysplastic Labrador retrievers to trait-free greyhounds. Measured susceptibility traits included age at onset of femoral capital chondroepiphyseal ossification (OSS), maximum hip distraction (laxity) index (DI), and the dorsolateral subluxation (DLS) score. The pedigrees consisted of 147 dogs representing four generations. For 59 dogs genotyped with 65 microsatellites, the median heterozygosity and polymorphic information content (PIC) values of the F(1) generation were 0.82 and 0.68, respectively. Seventy-seven percent of microsatellites had a PIC greater than 0.59 in the F(1)s. Ninety-six percent of alleles showed Mendelian inheritance. Based on marker informativeness, approximately 350 randomly selected markers would be required for genome-wide screening to obtain an average interval between informative markers of 10 cM. Heritability was estimated as 0.43, 0.5, and 0.61 for OSS, DI, and the DLS score, respectively. Biometric estimates of the mean (+/- variance) effective number of segregating QTLs was 1.2 (+/- 0.05), 0.8 (+/- 0.02), and 1.0 (+/- 0.03) for OSS, DI, and the DLS score, respectively. The distributions of simulated backcross trait data suggested that the loci controlling these traits acted additively and that the DI may be controlled by a major locus. When combined with previous power and quantitative genetic analyses, these estimates indicate that this pedigree is informative for QTL mapping of hip dysplasia traits.

Warthin's tumor of parotid gland: treatment of a retroneural lesion by enucleation

The papilliferous cystadenomas lymphomatosum or Warthin's tumor is a relatively rare and generally benign neoformation whose incidence is second only to the pleomorfic adenoma. 84% of all Warthin's tumor strikes the parotid gland. We report the two cases that come to our observation paying particular attention to the second one in which occurred a synchronous bilateral manifestation, a rarity in the clinical circle. We want to highlight that enucleation should be the preferred treatment in most cases due to extremely small dimension of Warthin's tumor. Moreover it is possible to perform this kind of surgical treatment even in the case of a retroneural lesion without causing any damage to the facial nerve and its main branches. As regards complications and sequelae we noticed neither a permanent nor a temporary injury of the facial mimicry and sensibility.

Black esophagus: should it be considered an unfavorable prognostic factor?

Black esophagus is a rare condition, reported for the first time in 1990. It is always noted in severely compromised patients. The diagnosis is possible using endoscopy. An esophageal ischemic injury should be considered. It is important that a differential diagnosis is made with consideration of other necrotic conditions of the esophagus. Only supportive treatment and the improvement of the associated disease appear possible.

Outcome of percutaneous coronary angioplasty (PTCA) performed in a low-volume institution by low-volume operators, evaluated by means of the one-month major adverse cardiac event rate

BACKGROUND

Since an inverse relationship between percutaneous coronary angioplasty (PTCA) case-load and in-hospital major adverse cardiac events (MACE) exists, we intended to evaluate the performance of low-volume PTCA operators, during the first year of our interventional program, by applying the more accurate index represented by the MACE rate within the first month.

METHODS

The data relative to both the PTCA procedure and the control visit 3-4 weeks later, were retrospectively reviewed. Death, myocardial infarction and need for revascularization were the end-points evaluated, both globally and with respect to the individual operators.

RESULTS

During 1999, 61 consecutive patients (53M, 8F; mean age: 59.9+/-10.4 years) were treated by two full-trained operators. Stable angina was the indication in 75% of cases. Comorbidities as diabetes and prior revascularization, were present in 16 and 5% of cases, respectively. Multivessel procedures were performed in 33% of cases, with a total number of lesions of 84 (77% A/B1 type). Stents were implanted in 70% of cases, as a bail-out in 12%. Procedural success rate was 93%. Overall one-month MACE rate was 3.3%, accounted for by 1 in-hospital emergency coronary surgery occurred to operator 1 (3.6% one-month MACE rate) and 1 elective coronary operation performed in a stable patient previously treated by operator 2 (3% one-month MACE rate).

CONCLUSIONS

PTCA performed in a low-volume center by low-volume operators is not necessarily associated with a poor outcome, provided that adequate selection of low-risk cases is accomplished. Although only 52% of the Italian centers met in 1999 the recommended volume standards, reaching optimal case-load should anyway be pursued. Some time should however be conceded, provided that close monitoring of one-month MACE rate shows adequate performance of both the institution and the operators.

Empirical Bayes Gibbs sampling

The wide applicability of Gibbs sampling has increased the use of more complex and multi-level hierarchical models. To use these models entails dealing with hyperparameters in the deeper levels of a hierarchy. There are three typical methods for dealing with these hyperparameters: specify them, estimate them, or use a 'flat' prior. Each of these strategies has its own associated problems. In this paper, using an empirical Bayes approach, we show how the hyperparameters can be estimated in a way that is both computationally feasible and statistically valid.

A multivalent pairing model of linkage analysis in autotetraploids

Polyploidy has been recognized as an important step in the evolutionary diversification of flowering plants and may have a significant impact on plant breeding. Statistical analyses for linkage mapping in polyploid species can be difficult due to considerable complexities in polysomic inheritance. In this article, we develop a novel statistical method for linkage analysis of polymorphic markers in a full-sib family of autotetraploids. This method is established on multivalent pairings of homologous chromosomes at meiosis and can provide a simultaneous maximum-likelihood estimation of the double reduction frequencies of and recombination fraction between two markers. The EM algorithm is implemented to provide a tractable way for estimating relative proportions of different modes of gamete formation that generate identical gamete genotypes due to multivalent pairings. Extensive simulation studies were performed to demonstrate the statistical properties of this method. The implications of the new method for understanding the genome structure and organization of polyploid species are discussed.

A maximum likelihood-based method for mining major genes affecting a quantitative character

In this article, we present a maximum likelihood-based analytical approach for detecting a major gene of large effect on a quantitative trait in a progeny population derived from a mating design. Our analysis is based on a mixed genetic model specifying both major gene and background polygenic inheritance. The likelihood of the data is formulated by combining the information about population behaviors of the major gene during hybridization and its phenotypic distribution densities. The EM algorithm is implemented to obtain maximum likelihood estimates for population and quantitative genetic parameters of the major locus. This approach is applied to detect an overdominant gene governing stem volume growth in a factorial mating design of aspen trees. It is suggested that further molecular genetic research toward mapping single genes affecting aspen growth and production based on the same experimental data has a high probability of success.

Appropriateness of the use of coronary angiography in a population of patients with ischemic heart disease

BACKGROUND

Due to its pivotal role in the management of patients with ischemic heart disease, the use of coronary angiography has been continuously and progressively increasing over the years. However, an inappropriate rate of its utilization has been reported in 2 to 58% of cases. The aim of our study was therefore to evaluate the appropriateness of the indications for coronary angiography at our Institution.

METHODS

All the patients undergoing coronary angiography at the catheterization laboratory of the Maggiore Hospital in Bologna during 1999 were evaluated. By retrospectively reviewing the data forms filled in at the time of insertion of the patient on the waiting list, the indications for coronary angiography were categorized as appropriate (class I/IIa), of uncertain value (class IIb) and inappropriate (class III), according to the guidelines of the American College of Cardiology/American Heart Association. In a blind fashion to this classification, the reports of coronary angiography were also reviewed to determine, both globally and in the different clinical subsets, the prevalence of significant coronary stenoses and of angiographically normal vessels.

RESULTS

Class I/IIa indications were found in 72% of patients, as opposed to 28% in class lIb and none in class III. In the clinical subsets of stable angina, previous myocardial infarction and out-of-hospital cardiac arrest, the appropriateness was significantly higher, ranging from 74 to 100%, compared to recent myocardial infarction (63%) and unstable angina (59%) (accounting by itself for about one half of all class IIb indications). The overall prevalence of significant coronary artery disease was 87%, while in only 3% of cases did coronary angiography reveal normal vessels.

CONCLUSIONS

In our population, the use of coronary angiography was highly appropriate and only seldom of uncertain value. The accurate noninvasive selection of patients which, in view of the limited access to the catheterization laboratory, we needed to perform before proceeding to coronary angiography probably played a major role in these results.

Cutaneous seeding after ultrasound-guided percutaneous ethanol injection for treatment of hepatocellular carcinoma

Cutaneous seeding is a rare complication of interventional ultrasound procedures. We describe a case of needle-track cutaneous seeding of hepatocellular carcinoma (HCC) after sonographically guided percutaneous ethanol injection (PEI). In our case, the seeding might have been related to the type of needle used and the multiple passes required to treat the liver lesion. Despite the risk of needle-track seeding, PEI remains useful in the treatment of HCC.

Negative and positive predictive values of routine exercise testing in stable, medically-treated patients several years following a Q-wave myocardial infarction

BACKGROUND

Exercise testing (ET) is the preferred initial strategy for risk stratification after acute myocardial infarction (MI) in patients who are able to exercise and have an interpretable electrocardiogram (ECG). Although the current guidelines do not recommend annual follow-up ET of symptom-free patients years after MI, this is still common practice worldwide. Thus, this study was undertaken to explore the value of ET in the prediction of cardiac events in stable, medically-treated patients with a remote history of Q-wave MI.

METHODS

Seven hundred sixty-six consecutive patients (male gender 89%, mean age 57 +/- 8.6 years) with a remote history of Q-wave MI (mean time from MI 2.8 +/- 0.75 years), who underwent Bruce treadmill ET and whose data were prospectively entered into our institutional database, were enrolled. Patients were followed up for an average of 7 +/- 0.6 years. The endpoints were: 1) primary (cardiac death or non-fatal reinfarction), 2) secondary (cardiac death, non-fatal reinfarction or unstable angina), and 3) all-cause mortality.

RESULTS

Two hundred and eighty-two recurrent ischemic events occurred [cardiac death (n = 67), non-fatal infarction (n = 54), and unstable angina (n = 161)] and an additional 103 patients underwent revascularization procedures. Multivariate risk predictors for the primary endpoints were: older age relative risk-RR 1.04 (95% confidence interval-CI 1.01-1.06 per year), baseline heart rate > or = 90 b/min RR 2.34 (95% CI 1.37-4.0), and ST segment depression at rest ECG RR 1.91 (95% CI 1.22-2.98). For the secondary endpoints the predictors were: older age RR 1.02 (95% CI 1.01-1.04 per year), baseline heart rate > or = 90 b/min RR 1.61 (95% CI 1.06-2.45), ST segment depression at rest ECG RR 1.8 (95% CI 1.33-2.44), exercise angina RR 1.94 (95% CI 1.4-2.69), and exercise time stage < or = II RR 1.56 (95% CI 1.16-2.1). The addition of exercise variables improved the predictive power of the multivariate model only for secondary and all-cause mortality endpoints. Furthermore, clinical stratification alone had a predictive value comparable to that of ET results.

CONCLUSIONS

Although the identification of patients at risk for recurrent cardiac events is still the main goal of re-stratification in stable, asymptomatic patients with previous MI, the value of ET in these cases is negligible. Markers of exercise ischemia or ventricular dysfunction would be weak at best. The poor predictive performance of ET severely limits its usefulness as a screening measure for identifying patients likely to benefit from cardiac catheterization and revascularization. Therefore, cost-ben-efit considerations would suggest that risk stratification by means of ET in stable, asymptomatic patients with a remote history of Q-wave MI is inappropriate.

Complete regression of primary gastric MALT-lymphoma after double eradication Helicobacter pylori therapy: role and importance of endoscopic ultrasonography

The authors report on a case of complete regression of primary gastric Mucosa Associated Lymphoid Tissue MALT-lymphoma after double eradication Helicobacter pylori therapy. They analyze the diagnostic role of endoscopic ultrasonography and the therapeutic aspects, on the grounds of literature data and personal experience are analyzed.

Serial intravascular ultrasound and quantitative coronary angiography after self-expandable wallstent coronary artery implantation

Serial intracoronary ultrasound studies revealed significant postprocedural stent expansion accompanied by significant stent shortening during long-term follow-up. The disadvantageous lumen loss by neointimal formation could be balanced by late stent expansion.

Variation in the volume of zebra finch song control nuclei is heritable: developmental and evolutionary implications

In many songbird species, females prefer males that sing a larger repertoire of syllables. Males with more elaborate songs have a larger high vocal centre (HVC) nucleus, the highest structure in the song production pathway. HVC size is thus a potential target of sexual selection. Here we provide evidence that the size of the HVC and other song production nuclei are heritable across individual males within a species. In contrast, we find that heritabilities of other nuclei in a song-learning pathway are lower, suggesting that variation in the sizes of these structures is more closely tied to developmental and environmental differences between individuals. We find that evolvability, a statistical measure that predicts response to selection, is higher for the HVC and its target for song production, the robustus archistriatalis (RA), than for all other brain volumes measured. This suggests that selection based on the functions of these two structures would result in rapid major shifts in their anatomy. We also show that the size of each song control nucleus is significantly correlated with the song related nuclei to which it is monosynaptically connected. Finally, we find that the volume of the telencephalon is larger in males than in females. These findings begin to join theoretical analyses of the role of female choice in the evolution of bird song to neurobiological mechanisms by which the evolutionary changes in behaviour are expressed.

Hypocalcemic tetany due to coeliac disease. May this symptoms disappear?

We described a rare case of hypocalcemia whit tetanic symptoms. This condition of our patient could be avoided if some symptoms, present from many years, were diagnosed as factors related to coeliac disease, anemia was present from many years and it was more important during four pregnancies. The appearance of diffuse bone pain from two years is correlated to a metabolic osteopathy due to coeliac disease. Unexplained increase of liver enzymes is an expression of coeliac disease. We stress the importance to always consider extra-intestinal manifestation of coeliac disease in every patients, because this disease has an high incidence (1 in 200 people). Our patient could had important clinical advantages, if his disease was diagnosed by extra-intestinal alterations (anaemia, bone pain and increased blood levels of liver enzymes in our patient). Coeliac disease must be researched in every different and particular clinical and sub-clinical manifestation; in 65% of all cases, the patients with coeliac disease haven't gastrointestinal symptoms.

Hyperventilation increases muscle protein synthesis in critically ill trauma patients

BACKGROUND

Critically ill trauma patients are often in negative nitrogen balance and demonstrate advanced muscle protein wasting, which is in part due to a decrease in muscle protein synthesis. Previous studies have been performed on the relationship between pH and protein metabolism. Some evidence suggests that alkalosis might enhance protein synthesis. The purpose of the present study is to determine whether protein synthesis is increased in trauma patients who have a respiratory alkalosis from hyperventilation.

METHODS

Trauma patients in the intensive care unit (n = 8) who were treated with hyperventilation for elevated intracranial pressures were enrolled. Muscle protein synthesis rates were determined in vivo using the flooding method with l-[(2)H(5)]phenylalanine. Measurements were performed twice on each patient within a 36-h period, first during hyperventilation and then after hyperventilation was discontinued. Hemoglobin oxygen saturation was maintained above 95% for all measurements.

RESULTS

Protein synthesis in muscle was 1.38 +/- 0.11%/day during hyperventilation (pH 7.50 +/- 0.02, pCO(2) 27.3 +/- 1.0 mm Hg) and 0.93 +/- 0.15%/day after respiratory parameters were normalized (pH 7.39 +/- 0.01, pCO(2) 39.4 +/- 1.5 mm Hg). The synthesis rate was significantly higher (P < 0.01, paired t test), 0.46 +/- 0.13%/day (32.6%), at the time of hyperventilation.

CONCLUSION

Muscle protein synthesis is elevated during hyperventilation in critically ill patients with traumatic brain injury. We believe this preliminary study provides data that warrant confirmation in larger clinical studies. It suggests that this ventilatory therapeutic strategy may have a role in mitigating the negative nitrogen balance and muscle protein wasting that can impair the recovery of these patients.

A phase I study of gemcitabine and epirubicin for the treatment of platinum-resistant or refractory advanced ovarian cancer

BACKGROUND

Gemcitabine is active in patients with otherwise resistant or refractory ovarian cancer. As the drug is well tolerated, studies using gemcitabine combined with other antineoplastic agents are needed. The aim of the study was to determine the maximum tolerated dose (MTD) of epirubicin combined with gemcitabine, with and without support of G-CSF.

PATIENTS AND METHODS

Patients with platinum-resistant or refractory ovarian cancer were eligible. Gemcitabine (G) (starting dose 800 mg/m2 day 1 and 8; 200 mg/m2 escalation per level) and epirubicin (E) (starting dose 60 mg/m2 day 1; 15 mg/m2 escalation per level) were given every 21 days for four to six cycles. G-CSF (filgrastim 5 microg/kg/die) was given in case of grade 4 neutropenia (levels without support) or from day 9 up to leukocyte count > 10.000/mm3 after nadir (levels with support). Cohorts of three patients were enrolled at each level, and another three patients were planned, if one dose-limiting toxicity (DLT) was registered. MTD was determined first without and then with G-CSF.

RESULTS

Four levels were studied (G 800 + E 60; G 1000 + E 60; G 1000 + E 75; G 1000 + E 75 + G-CSF) with four, four, three and three patients enrolled, respectively. DLT (grade 4 febrile neutropenia) was observed in two patients at level 3. Thus, G1000 + E 60 mg/m2 was the MTD without G-CSF. The addition of prophylactic G-CSF did not allow a further increase of the dose and grade 4 thrombocytopenia was the DLT at level 4. Non-hematological toxicity was mild. Grade 2 mucositis was reported in four patients. Among the 13 patients with measurable or evaluable disease, 3 partial responses were observed for an overall response rate of 23.1%.

CONCLUSIONS

The combination of gemcitabine 1000 mg/m2 (day 1, 8) and epirubicin at 60 mg/m2 (day 1) is a feasible therapy. Grade 4 neutropenia is frequent and G-CSF support is often required. With prophylactic support of G-CSF, the DLT is thrombocytopenia.

Phase I study with weekly cisplatin-paclitaxel and concurrent radiotherapy in patients with carcinoma of the cervix uteri

BACKGROUND

Cisplatin and paclitaxel are active in cervical cancer and both are able to potentiate the effects of radiotherapy. In this study we evaluated the maximum-tolerated dose (MTD) of paclitaxel in combination with a fixed dose of cisplatin when given weekly concurrently with pelvic radiotherapy to patients with carcinoma of the cervix uteri.

PATIENTS AND METHODS

Eighteen patients with cervical cancer were enrolled in this study. Cisplatin (30 mg/m2) and paclitaxel (starting dose 40 mg/m2; 5 mg/m2 escalation per level) were given on day 1 of radiotherapy and then weekly for six times. Radiotherapy was given to the pelvis with a four-field box technique for five days each week. Patients received 65 Gy in 1.8 Gy fractions. Cohorts of three patients were enrolled at each level and three further patients were included if one or two dose-limiting severe adverse events (SAE) were recorded. SAE was defined as grade 3 or 4 nonhematologic toxicity, excluding nausea or vomiting and alopecia, grade 4 neutropenia or thrombocytopenia, and prolonged (> 1 week) neutropenia or thrombocytopenia.

RESULTS

Four levels were studied (paclitaxel 40, 45, 50, 55 mg/m2) with three, five, four and six patients enrolled, respectively. The MTD of paclitaxel was found at 50 mg/m2/wk and cisplatin 30 mg/m2/wk. Diarrhea was the dose-limiting toxicity. Thirteen patients were evaluable for response: seven complete and five partial responses were obtained with an overall response rate of 92.3%.

CONCLUSIONS

The MTD of paclitaxel is 50 mg/m2/wk when associated to cisplatin 30 mg/m2/wk and concurrent pelvic radiotherapy. Diarrhea is the dose limiting side effect. Preliminary data suggest that concurrent chemoradiotherapy with paclitaxel and cisplatin could be a very active treatment for patients with locally advanced carcinoma of the cervix.

Pressure-wire guided balloon angioplasty in allograft coronary vasculopathy

We report a case of successful percutaneous transluminal coronary angioplasty guided from pressure-wire measurements in a transplanted patient. Fractional flow reserve, a lesion-specific, pressure-independent index of functional stenosis severity, was used to guide the intervention.