Early changes of gene expression during cerulein supramaximal stimulation

Administration of supramaximal doses of cerulein results in acute interstitial pancreatitis. To understand the pathogenesis of this disease, it would be of great importance to elucidate the changes during the early phase of the process. We report changes of gene expression in the pancreas during the first 6 h of cerulein supramaximal stimulation. The expression of genes, including the secretory enzyme amylase, the lysosomal enzyme cathepsin B, as well as the housekeeping genes beta-actin and glyceraldehyde-3-phosphate dehydrogenase (GAPD), was investigated in this study. The most prominent alteration in gene expression is beta-actin messenger RNA (mRNA), which increased continuously after cerulein infusion. Immunostaining for beta-actin was observed along the membrane of large cytoplasmic vacuoles in pancreatic acinar cells. The level of amylase mRNA decreased during the first 30 min of cerulein infusion, recovered to the control level at 1 h and increased twofold at 2 h. An obvious increase in cathepsin B mRNA was observed after 3 h of cerulein infusion and reached sixfold of the control at 6 h. A significant increase of GAPD mRNA level was observed at 6 h of cerulein stimulation. In conclusion, this study provides direct evidence that the changes in gene expression, such as cathepsin B and amylase, after supramaximal cerulein stimulation, are regulated at the transcriptional level. It also suggests that beta-actin is involved in the formation of cytoplasmic vacuoles during supramaximal cerulein administration. Finally, this study indicates that beta-actin and GAPD may not be appropriate as RNA-loading controls for Northern blot analysis of pancreatic tissue.

Imipramine treatment in pediatric burn patients with symptoms of acute stress disorder: a pilot study

OBJECTIVE

Pediatric burn patients often exhibit acute stress disorder (ASD) symptoms. Information on psychopharmacological treatment of ASD symptoms in children is scarce. This pilot study used a prospective, randomized, double-blind design to test whether thermally injured children suffering ASD symptoms benefit from imipramine.

METHOD

Twenty-five children, aged 2 to 19 years, received either imipramine or chloral hydrate for 7 days. A structured interview (clinically useful, but validity and reliability not yet established) was used to assess the presence and frequency of ASD symptoms both before treatment and 3 times during the treatment period.

RESULTS

Eleven females and 14 males participated, with a mean total burn surface area of 45% (SD = 23%) and mean age of 8 years (SD = 6). Imipramine was more effective than chloral hydrate in treating ASD symptoms (chi 2 [1, N = 25] = 5.24, p < .02). Five of 13 were positive responders to chloral hydrate (38%). Ten of 12 were positive responders to low-dose imipramine (83%).

CONCLUSIONS

This pilot study suggests a place for cautious initial use of imipramine to reduce ASD symptoms in burned children. Care must be taken to minimize cardiovascular risks in an off-label application of imipramine in children, especially those receiving additional medications.

Vasectomy and prostate cancer

PURPOSE

Vasectomy has been associated with an increased risk of prostate cancer in some previous studies but not in others. We evaluated the association in a population based, case control study in Massachusetts.

MATERIALS AND METHODS

Included in our study were 1,216 patients younger than 70 years with newly diagnosed prostate cancer and 1,400 controls with no history of prostate cancer who were matched to patients by age and town of residence. Data on vasectomy and potential confounding factors were obtained by telephone interview, and confounding was controlled by conditional logistic regression analysis.

RESULTS

Overall 16% of patients and 15% of controls had undergone vasectomy. Compared with no vasectomy the odds ratio for ever having undergone vasectomy was 1.0 (95% confidence interval [CI] 0.8 to 1.3), which did not vary significantly by age at or interval since vasectomy. In men who reported urological symptoms and those without symptoms the odds ratio was 0.9 (95% CI 0.7 to 1.2) and 1.4 (1.0 to 1.9), respectively. In men younger than 55 years and those 55 years old or older at diagnosis of prostate cancer the odds ratio was 1.9 (95% CI 1.2 to 3.2) and 1.0 (0.8 to 1.3), respectively [corrected]. In the younger men with stages A or B and C or D disease the odds ratio was 2.3 (95% CI 1.2 to 4.3) and 1.3 (0.5 to 3.5), respectively.

CONCLUSIONS

Our findings do not support the hypothesis that vasectomy increases the risk of prostate cancer in men older than 55 years. Further study is needed to determine whether the observed association between vasectomy and prostate cancer in men younger than 55 years is due to chance, detection bias or a causal effect.

Pancreatic islet cell survival following islet isolation: the role of cellular interactions in the pancreas

The purpose of this study was to characterize the trophic effect of pancreatic duct cells on the islets of Langerhans. Ductal epithelium and islets were isolated from hamster pancreata. In addition, duct-conditioned medium (DCM) was prepared from primary duct cultures that had been passaged twice to remove other cellular elements. Three experimental groups were then established: Group 1, 100 islets alone; Group 2, 100 islets+80 duct fragments; and Group 3, 100 islets in 25% DCM. All tissues were embedded in rat tail collagen for up to 12 days and the influence of pancreatic ductal epithelium on islet cell survival was examined. By day 12, 20.6+/-3. 0% (S.E.M.) of the islets cultured alone developed central necrosis, compared with 6.7+/-2.0% of the islets co-cultured with ducts and 5.6+/-1.5% of the islets cultured in DCM (P<0.05). The presence of apoptotic cell death was determined by a TdT-mediated dUTP-biotin nick end labelling (TUNEL) assay and by a specific cell death ELISA. DNA fragmentation in islets cultured alone was significantly increased compared with islets cultured either in the presence of duct epithelium or in DCM (P<0.05). More than 80% of TUNEL-positive cells were situated in the inner 80% of the islet area, suggesting that most were beta-cells. DCM was analysed for known growth factors. The presence of a large amount of IGF-II (34 ng/ml) and a much smaller quantity of nerve growth factor (4 ng/ml) was identified. When the apoptosis studies were repeated to compare islets alone, islets+DCM and islets+IGF-II, the cell death ELISA indicated that IGF-II produced the same beneficial result as DCM when compared with islets cultured alone. We conclude that pancreatic ductal epithelium promotes islet cell survival. This effect appears to be mediated in a paracrine manner by the release of IGF-II from cells in the ductal epithelium.

Economic evaluation of the use of octreotide for prevention of complications following pancreatic resection

Recent studies have concluded that octreotide can prevent complications in patients undergoing pancreatic resections. Given the acquisition cost of octreotide, a cost-effectiveness analysis was performed to establish whether if the additional cost associated with its use was justified by a decrease in the consumption of other resources. To evaluate success rates and complication rates, a meta-analysis of double-blind, randomized, controlled clinical trials was conducted. The rates for pancreatic fistula and fluid collection were 10.7% (95% confidence interval [CI] 7.9 to 13.4) and 3.6% (95% CI 1.9 to 5.2) for octreotide vs. 23.4% (95% CI 19.7 to 27. 1) and 8.8% (95% CI 6.2 to 11.3) for placebo. In a second phase we evaluated the treatment cost for patients with and without complications using two different models of cost savings. In the first model the cost to treat a pancreatic fistula was calculated as the per diem rate (as determined by Statistics Canada) multiplied by the incremental length of stay associated with the complication. In the second model we used data from institutions participating in the Ontario Case Costing Project. In model 1 the estimated incremental length of hospital stay attributed to a pancreatic fistula was 7 days, based on a review of the literature, and the per diem was $552. In model 2 the average cost of care for patients with or without complication was $32,347 (n = 17; 95% CI $20,882 to $43,812) and $11, 169 (n = 18; 95% CI $7558 to $14,779), respectively. The data suggest that when compared to placebo, octreotide is a dominant treatment strategy. In model 1, in a cohort of 100 patients, octreotide saved an average of $853 per patient while allowing 16 incremental patients to avoid complications. In model 2 use of octreotide resulted in an average savings of $1642 per patient while still allowing 16 patients to avoid complications. Detailed one-way and two-way sensitivity analyses suggest that both models were robust. The use of octreotide is a cost-effective strategy in patients undergoing elective pancreatic resection. Consideration should be given to extending its use to patients who are at high risk for development of complications following pancreatic surgery and who do not have any contraindications to the use of this drug.

Localized deficient root development associated with taurodontism: case report

Dentinal dysplasia type I (DDI) is a rare disturbance in dentin formation. This case report illustrates different radiographic features from other reported DDI cases in that only one quadrant (lower right posterior teeth) has the characteristic of DDI and both right and left upper molars exhibit taurodontism. This finding might be a variation of DDI. However, it is possible that this type of developmental defect could occur because of regionalized abnormalities in cellular function and proliferation as occurs in regional odontodysplasia.

A multicenter, randomized, double-blind, placebo-controlled trial of high-dose intravenous immunoglobulin for oral corticosteroid-dependent asthma

To determine the efficacy of high doses of intravenous gammaglobulin (IVIG) for the treatment of severe, steroid-dependent asthma in patients between 6 and 68 years of age, a randomized, double-blind, placebo-controlled multicenter clinical trial was conducted in private and university hospitals in the United States. Patients were randomized to one of three treatment arms: 2 g IVIG/kg/month (16 patients); 1 g IVIG/kg/month (9 patients); or 2 g iv albumin (placebo)/kg/month (15 patients). The treatment consisted of seven monthly infusions followed by a posttreatment observation period. The primary outcome measurement was mean daily prednisone-equivalent dose requirements, determined during the observation month preceding initiation of treatment and compared to the month preceding the seventh infusion. Secondary clinical endpoints measured were pulmonary function, frequency of emergency room visits or hospitalizations, and number of days absent from school or work. When adjusted for body weight, the mean dose requirements fell by 33, 39, and 33% in the placebo, IVIG (1 g/kg), and IVIG (2 g/kg) treatment arms, respectively. The differences between therapies were not statistically different (P = 0.9728). The mean percentage-of-predicted FEV1 fell in all three treatment groups during the treatment period but there was no significant difference between treatment groups (P = 0.8291). There was also no significant difference in the percentage of subjects requiring emergency room visits or hospitalizations or missing days of work/school, among the three treatment groups. The trial was terminated prematurely after interim analysis determined the adverse experience rate was different between the three groups. Three patients, all randomized to the 2-g/kg IVIG dose group, were hospitalized with symptoms consistent with aseptic meningitis. In summary, in this randomized, double-blind, placebo-controlled multicenter study, high doses of IVIG did not demonstrate a clinically or statistically significant advantage over placebo (albumin) infusions for the treatment of corticosteroid-dependent asthma. Subgroup analysis failed to identify markers predicting responsiveness. High-dose IVIG can also be associated with a significant incidence of serious adverse events.

Oral contraceptive use and risk of gestational trophoblastic tumors

BACKGROUND

Gestational trophoblastic disease refers to a spectrum of rare benign and malignant gynecologic disorders whose pathogenesis is not well understood. Recent studies from China and the United States have raised the hypothesis that long-term use of oral contraceptives before conception may increase the risk of gestational trophoblastic tumors. A multicenter case-control study of gestational trophoblastic tumors was undertaken to test this hypothesis.

METHODS

Telephone interviews were conducted with 235 case patients, including 50 with gestational choriocarcinoma, and 413 control subjects matched on recentness of pregnancy, age at pregnancy, and area of residence. Relative risks (odds ratios) were computed by conditional logistic regression. Reported P values are two-sided.

RESULTS

The relative risk estimate for ever having used oral contraceptives before the index pregnancy was 1.9 (95% confidence interval [CI] = 1.2-3.0), and the risk increased with duration of use (P for trend = .05). The estimate was highest for women who used oral contraceptives during the cycle in which they became pregnant (relative risk = 4.0; 95% CI=1.6-10), but there was no consistent pattern according to the time interval since last use. Separate analyses of choriocarcinoma and persistent mole yielded similar results, i.e., the relative risk estimates for oral contraceptive use were 2.2 (95% CI=0.8-6.4) and 1.8 (95% CI=1.0-3.0), respectively. Control for the number of sexual partners, which was independently associated with risk (P for trend = .05), did not materially change the results.

CONCLUSIONS

This study, the largest to date, indicates that long duration of oral contraceptive use before conception increases the risk of gestational trophoblastic tumors. These findings may provide clues to the pathogenesis of this rare disease. Changes in use of oral contraceptives are not warranted, however, because the incidence attributable to oral contraceptive use is very low.

Characterization of integrin expression in islets isolated from hamster, canine, porcine, and human pancreas

The reasons for the failure of clinical islet transplantation remain obscure. Islet isolation, however, exposes the islet to variety of cellular stresses, including disruption of the cell-matrix relationship, an event associated with apoptosis. The cell-matrix relationship is characterized by an interaction between cell surface integrin receptors and matrix molecules of the surrounding basement membrane (BM). The purpose of this study was to characterize integrin expression and the distribution of the peri-insular BM in human, porcine, canine, and hamster pancreas, and after routine islet isolation. Whereas islets in the porcine pancreas do not have a demonstrable BM, islets in the human, canine, and hamster pancreas have an almost continuous BM with very little direct exocrine to endocrine cell-cell contact. After islet isolation, the BM was destroyed, only to be reestablished during the period of culture. In the pancreas of all four species, integrin alpha3 was expressed only on islet cells, and integrin alpha5 was present on islet cells as well as on acinar, centroacinar, and duct cells. Integrin alphaV was detected only in human and canine pancreas. Integrin beta1 was demonstrated only in the human pancreas. In isolated islets, integrin alpha3, alpha5, and alphaV expression decreased during the culture period and the intensity of the staining was observed to be coincident with the distribution of the BM. In summary, this is the first report of integrin expression in hamster, canine, porcine, and human islets. After islet isolation, the altered islet cell-matrix relationship is reflected both in the decrease in integrin expression and in the destruction of the peri-insular BM. These profound changes will need to be considered as the process of islet isolation for transplantation is refined. (J Histochem Cytochem 47:499-506, 1999)

Obesity and hypertension among college-educated black women in the United States

It is established that obesity is an important risk factor for hypertension, but there is little information on this relationship among highly educated black women. We assessed the relationship of body mass index (weight (kg)/height2 (m)) to prevalent hypertension among US black women who had completed college, and among less educated women as well. The data were collected in 1995 in the Black Women's Health Study: 64530 African-American women aged 21 to 69 years enrolled by completing mailed health questionnaires; 44% of the participants had completed college. We compared the 9394 participants who reported a diagnosis of hypertension treated with a diuretic or antihypertensive drug (cases) with 9259 participants of similar ages who did not have hypertension (controls). Multivariate odds ratios were estimated by logistic regression. The odds ratio for treated hypertension increased with increasing body mass index at every educational level. Among college-educated women, the odds ratio for hypertension was 2.7 for overweight women (index 27.3-32.3) and 4.9 for severely overweight women (index > or =32.3), relative to women with a body mass index <22.8. The prevalences of obesity and hypertension were high among the college-educated women, although not as high as among women with fewer years of education. About a quarter of the difference in the prevalence of hypertension across educational levels was explained by the difference in the proportions who were overweight or severely overweight. These results document a high prevalence of obesity and hypertension, and a strong association of obesity with hypertension, among highly educated US black women.

On burn injuries related to airbag deployment

Airbags have been shown as a vital, supplemental restraining device that save lives and reduce morbidity associated with motor vehicles crashes. However, as with any developing technology, airbags have also been identified in some instances, as the source of injuries which, have been well described in the literature. To a significantly lesser degree, burns due to airbag deployment (about 7-8% of these injuries) have been reported. These injuries will be seen more frequently as more vehicles are equipped with airbags and should be suspected in drivers and passengers involved in accidents in which airbags have been activated. This article, reviews the various types of burns and their pathogenesis, found in crashes involving airbag deployments.

Early outcome and complications of the extended subcranial approach to the anterior skull base

OBJECTIVES

To present the technique of the extended subcranial approach to the anterior skull base and to review the results in 55 patients who underwent the procedure.

STUDY DESIGN

Retrospective review of the records of 55 patients who underwent the extended subcranial approach to the anterior skull base between 1994 and 1998 for the treatment of various neoplasms originating in the nasal cavity, nasopharynx, paranasal sinuses, orbit, or meninges, as well as for the repair of complex craniofacial trauma and/or cerebrospinal fluid (CSF) leak. Preoperative patient evaluation and the surgical technique are also reviewed.

METHODS

Patient records were retrospectively reviewed and tabulated for age, sex, and indications for procedure, with special focus on early outcome and complications.

RESULTS

Twenty-six patients underwent oncologic resections, 22 patients had reduction of complex fronto-naso-orbital and skull base fractures, and seven patients had repair of CSF leak. Significant complications in the oncologic group consisted of one hematoma requiring needle aspiration and two cases of temporary nontension pneumocephalus. In the fracture group, one patient died because of extensive intracerebral damage and multiorgan failure, and one patient had nontension pneumocephalus coupled with CSF leakage and one patient had temporary nontension pneumocephalus. The most common late complication in all three groups was anosmia.

CONCLUSIONS

Based on their review, the authors conclude that the extended subcranial approach to the anterior skull base is a safe, versatile, and effective procedure for the surgical treatment of various pathological conditions involving the anterior skull base.

The diagnosis of renal cell cancer in relation to hypertension (United States)

OBJECTIVES

Renal cell cancer has been associated with hypertension or with drugs to treat it in several studies. We assessed whether the association is explained by more frequent detection of early renal cell cancer among persons being treated for hypertension.

METHODS

The data were collected in our Case-Control Surveillance Study, in which patients aged 20 to 69 years were interviewed in hospitals in Baltimore, Boston, New York, and Philadelphia during 1976-1996. We compared 134 incident cases of renal cell cancer who were being treated with drugs for hypertension to 193 untreated cases with respect to the route to diagnosis and the stage.

RESULTS

The relative risk estimate for having been diagnosed incidentally during a routine examination or workup for another condition, relative to having been diagnosed because of symptoms of renal cell cancer, was 1.3 (95 percent confidence interval, 0.7-2.5). The estimate for diagnosis at stage I or II relative to stage III or IV was 1.2 (0.7-2.1).

CONCLUSION

In Case-Control Surveillance Study data, the relative risk estimate for renal cancer among users of various classes of antihypertensive drugs is 1.8 or 1.9. The present results suggest that this association can, at most, be explained only partially by the selective diagnosis of renal cell cancer among persons being treated for hypertension.

Clinical islet cell transplantation. Are we there yet?

Diabetes mellitus is perhaps the most devastating chronic disease of all time. A brief history of the evolution of treatment modalities is provided, culminating in the rationale for the physiologic replacement of a functioning beta-cell mass by transplantation. Vascularized pancreas transplantation is discussed briefly as an introduction to the transplantation of the isolated islet. A detailed review of the current state of human islet transplantation for the cure of diabetes is then described. Finally, areas for future development are highlighted.

Calcium channel blocker use and the risk of prostate cancer

A recent study suggested that the risk of all cancers, including prostate cancer, is increased by the use of calcium channel blockers. The objective of this study was to determine whether prostate cancer is associated with calcium channel blocker use. A case-control study was conducted in Massachusetts using cases diagnosed from December 1992 through February 1995. Cases were men identified by tumor registrars who were less than 70 years old with newly diagnosed prostate cancer. Controls were men with no history of prostate cancer or symptoms of undiagnosed prostate cancer, and were matched to the cases on precinct of residence and half-decade of age. A total of 1217 cases of prostate cancer and 1400 community controls are included in this analysis. Data were collected by telephone interview. Multiple logistic regression was used to estimate relative risks for calcium channel blockers use while controlling for confounding. The relative risk for prostate cancer for any use of calcium channel blockers relative to nonuse was 1.2 (95% confidence interval [CI], 0.9-1.5). There was no evidence of a trend according to duration of use. When the analysis was confined to symptomatic men, the relative risk estimate was 1.1 (0.8-1.4) overall and 1.2 (0.8-1.7) among those aged 65 to 69 years. Relative risk estimates for the use of other classes of antihypertensive drugs among symptomatic men were close to 1.0; the corresponding estimates among asymptomatic men were generally further from 1.0. These findings suggest that calcium channel blockers do not increase the risk of prostate cancer. The differences in the relative risk estimates between symptomatic and asymptomatic men are compatible with detection bias. Because of the widespread use of Prostate-Specific Antigen testing for early detection of prostate cancer, potential detection bias needs to be considered in future studies of prostate cancer.

Induction of islet cell neogenesis in the adult pancreas: the partial duct obstruction model

The proliferative capacity of adult pancreatic islet cells is limited, although the formation of new islets from cells associated with the ductal epithelium is achievable even in the adult gland. Understanding the mechanism whereby proliferation and subsequent differentiation of putative precursor cells leads the appearance of new islets, i.e., islet neogenesis, may be important as a modality for treatment of both Type I and type II diabetes, in which there is an absolute or relative deficiency of insulin. It appears that certain genes and their protein products are essential to the initiation of the initial step in the pathway. We have shown that partial obstruction of the hamster pancreas is able to reverse streptozotocin-induced diabetes more than 50% of the time. An extract, termed ilotropin, prepared from obstructed pancreata, also reverses the diabetes, whereas extracts of control non-obstructed pancreata do not. Ilotropin contains a protein that is heat and acid stable with MW around 20-45 kDa that is capable of stimulating the proliferation of isolated duct cells in culture. Using mRNA and a differential display technique, 20 genes were found to be expressed in the partially obstructed (regenerating), but not the non-obstructed (non-regenerating) pancreas. One of these islet neogenesis-associated proteins (INGAP) proved to be unique to the obstructed pancreas, and a peptide contained within the sequence was capable of stimulating the proliferation of ductal cells in culture. INGAP was found to be expressed early in the neogenic process before the onset of ductal cell proliferation, and was capable of stimulating tritiated thymidine uptake into protodifferentiated epithelial cells, compatible with the notion that it might be involved in initiating the process of islet neogenesis.

Nonsteroidal antiinflammatory drug use and reduced risk of large bowel carcinoma

BACKGROUND

Animal experiments and epidemiologic data have suggested that the use of nonsteroidal antiinflammatory drugs (NSAIDs) may decrease the incidence of large bowel carcinoma. Our purpose was to assess the relation of the use of aspirin and nonaspirin NSAIDs with the risk of large bowel carcinoma.

METHODS

A population-based case-control study of colon and rectal carcinoma was conducted in Massachusetts from 1992 to 1994. Data on NSAID use and risk factors for large bowel carcinoma were collected by interview from 1201 incident cases of large bowel carcinoma and 1201 controls matched by age, gender, and area of residence.

RESULTS

Regular NSAID use that continued into the year before diagnosis was associated with a significantly decreased relative risk estimate overall (0.7; 95% confidence interval [CI], 0.5-0.8) and among Stage II-IV tumors (0.6; 95% CI, 0.4-0.7). There was no reduction in risk for discontinued use. The inverse association with regular continuing use was present across age and gender and for both colon and rectal carcinoma. Similar inverse associations were present for regular continuing use of aspirin and nonaspirin NSAIDs. There was no significant evidence of a trend for the relative risk to decrease as the duration of use increased, nor was there a trend across the dose of aspirin, which ranged from less than one-half of a 325 mg tablet per day to > or = 2 tablets per day. Discontinuation of use in response to symptoms of carcinoma did not appear to explain the inverse association, nor did bias related to diagnosis of the carcinoma.

CONCLUSIONS

These data add to the growing body of evidence that suggests a protective effect of NSAIDs against large bowel carcinoma.

Nonsteroidal antiinflammatory drug use and reduced risk of large bowel carcinoma

BACKGROUND

Animal experiments and epidemiologic data have suggested that the use of nonsteroidal antiinflammatory drugs (NSAIDs) may decrease the incidence of large bowel carcinoma. Our purpose was to assess the relation of the use of aspirin and nonaspirin NSAIDs with the risk of large bowel carcinoma.

METHODS

A population-based case-control study of colon and rectal carcinoma was conducted in Massachusetts from 1992 to 1994. Data on NSAID use and risk factors for large bowel carcinoma were collected by interview from 1201 incident cases of large bowel carcinoma and 1201 controls matched by age, gender, and area of residence.

RESULTS

Regular NSAID use that continued into the year before diagnosis was associated with a significantly decreased relative risk estimate overall (0.7; 95% confidence interval [CI], 0.5-0.8) and among Stage II-IV tumors (0.6; 95% CI, 0.4-0.7). There was no reduction in risk for discontinued use. The inverse association with regular continuing use was present across age and gender and for both colon and rectal carcinoma. Similar inverse associations were present for regular continuing use of aspirin and nonaspirin NSAIDs. There was no significant evidence of a trend for the relative risk to decrease as the duration of use increased, nor was there a trend across the dose of aspirin, which ranged from less than one-half of a 325 mg tablet per day to > or = 2 tablets per day. Discontinuation of use in response to symptoms of carcinoma did not appear to explain the inverse association, nor did bias related to diagnosis of the carcinoma.

CONCLUSIONS

These data add to the growing body of evidence that suggests a protective effect of NSAIDs against large bowel carcinoma.

P53 auto-antibodies in non-small cell lung cancer patients can predict increased life expectancy after radiotherapy

BACKGROUND

In this study we investigated whether the presence of p53 antibodies in sera before of during/after radiation therapy can predict increased survival in patients with non-small cell lung cancer.

PATIENTS AND MATERIALS

Sera from 67 patients with a histopathologically confirmed diagnosis of nonsmall cell lung cancer have been investigated using sandwich ELISA (Dianova, Hamburg, Germany). Sera was collected before or during/after radiation therapy.

RESULTS

Antibodies were detected in 18 (27%) patients. 46/67 (69%) of the sera had been taken before start of radiation therapy and the presence of p53 antibodies was a statistically significantly good prognostic factor in terms of increased survival (p = 0.025).

CONCLUSION

p53 antibodies in sera, before the start of radiation therapy, can predict increased survival after radiation treatment in patients with non-small cell lung cancer.

Calcium channel blockers and the risk of cancer

CONTEXT

Recent epidemiologic studies have raised the concern that calcium channel blocker use may increase the risk of cancer overall and of several specific cancers.

OBJECTIVE

To assess whether calcium channel blocker use increases the risk of cancer overall and of specific cancers.

DESIGN

Case-control drug surveillance study based on data collected from 1983 to 1996.

SETTING

Hospitals in Baltimore, Md, New York, NY, and Philadelphia, Pa.

PATIENTS

A total of 9513 patients aged 40 to 69 years with incident cancer of various sites and 6492 controls aged 40 to 69 years admitted for nonmalignant conditions.

MAIN OUTCOME MEASURES

Incident cancer overall and 23 specific cancers.

RESULTS

Calcium channel blocker use was unrelated to the risk of cancer overall (relative risk [RR], 1.1; 95% confidence interval [CI], 0.9-1.3). Use was not significantly associated with increased risks of individual cancers, including those previously implicated, except cancer of the kidney (RR, 1.8; 95% CI, 1.1 -2.7). Recent use, use for 5 or more years, and use of individual calcium channel blocker drugs were also not associated with cancer incidence. Use of beta-blockers and angiotensin-converting enzyme inhibitors was generally unrelated to cancer overall or individual cancers, but both were associated with kidney cancer (RR, 1.8; 95% CI, 1.3-2.5; and RR, 1.9; 95% CI, 1.2-3.0, respectively).

CONCLUSIONS

The present study suggests that the use of calcium channel blockers is unrelated to an increase in the overall risk of cancer or of individual cancers, except kidney cancer, which has been associated with hypertension or drugs to treat hypertension in previous studies.

Basic fibroblast growth factor and vascular endothelial growth factor in sera from non-small cell lung cancer patients

BACKGROUND

The formation of new microvessels from the existing vascular bed is known as angiogenesis and is normally under the tight regulatory control of angiogenic factors. This control is lost in malignant tumours. Previous studies have correlated increased microvessel density with poor prognosis in patients with primary lung cancer.

MATERIALS AND METHODS

Our group measured levels of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in sera from 68 patients with non-small cell lung cancer (NSCLC) and compared elevated levels of VEGF and bFGF with clinical outcome. Serum basic FGF and VEGF were measured using commercially available enzyme- linked immunosorbent assays (R & D Systems Inc., Minneapolis, MN USA).

RESULTS

In 26/68 (38%) patients we found that elevated circulating levels of bFGF and in 27/68 (39%) serum samples levels of VEGF were elevated. Elevated bFGF values in sera was a statistically significant good prognostic factor, p- value = 0.048, when adjusted to stage and there was a trend in that patients with elevated levels of bFGF had a higher fraction of adenocarcinomas compared with squamous epithelial carcinomas (chi 2 = 2.0). No significant correlations could be demonstrated when elevated levels of VEGF in serum was present. Elevated levels of both VEGF and bFGF was present in 45% of the patients.

CONCLUSIONS

We found that elevated levels of bFGF is a good prognostic factor when measured in sera from NSCLC patients. As this result disagrees with earlier studies on other malignancies the results from our study needs to be further investigated in a prospective study.

Correlates of postmenopausal female hormone use among black women in the United States

OBJECTIVE

To assess correlates of the use of postmenopausal female hormone supplements among black women.

METHODS

We assessed information obtained from 64,564 U.S. black women 21-69 years of age who enrolled in the Black Women's Health Study in 1995 by completing postal questionnaires. Included in the present analyses were 13,352 women 40-69 years of age who had ceased menstruating. Most resided in ten states, with 66% from California, New York, Illinois, Michigan, Georgia, and New Jersey; 41.0% had completed college.

RESULTS

Among the 13,352 women 40 years of age or older who had ceased menstruating, 49.2% reported ever use of female hormone supplements and 33.3% were using them currently. Unopposed oral estrogens accounted for 63.4% of the medications being used currently. The use of supplements was highest in the western U.S. and lowest in the Northeast. The strongest correlate of use was menopause due to bilateral oophorectomy. Use peaked at 50-54 years of age and then declined, and also was associated positively with lower body mass index, greater years of education, participation in vigorous exercise, and past oral contraceptive use. Use was associated inversely with having a positive history of diabetes, heart attack, or breast cancer. Some of the drug use reported was at variance with suggested guidelines: unopposed estrogen was taken by some women who had a uterus, and estrogen together with a progestin was taken by some women who had had a hysterectomy.

CONCLUSION

These data indicate that patterns of use of postmenopausal female hormone supplements among black women who participated in the present study are similar to those documented in white women. Women with risk factors for coronary artery disease were not more likely to use supplements than women at lower risk, a pattern that is not in accordance with suggestions that the greatest benefit of supplements may accrue to high-risk women. Because users differ from nonusers in important characteristics that may affect the incidence of coronary heart disease, breast cancer, and other illnesses, observational studies of the health effects of these medications must control carefully for correlates of use.

Are we making an impact? A review of a burn prevention program in Israeli schools

In an attempt to challenge the immense toll of burn and scald injuries among children in Israel, a structured educational program was developed by our university center for plastic surgery in Beer-Sheva. Since 1986, more than 250,000 children and 10,000 teachers, in more than 460 elementary schools nationwide, have been exposed to our program. This article reviews the design of the program, the implementation procedures, and the studies evaluating its effectiveness. The studies revealed significant improvements in children's risk-related knowledge and injury-control beliefs. Both teachers and principals assessed the program as important, and the in-training workshops and intervention activities won high approval. An overall trend of reduction in the number of patients hospitalized with burn injuries in the southern part of Israel was found also. Although it is clear that the project is instructive, further comprehensive efforts are needed to make a dramatic nationwide impact. Some of the efforts already underway target the most vulnerable group of the non-Jewish population in Israel.

Transitional cell cancer of the urinary tract and renal cell cancer in relation to acetaminophen use (United States)

Experimental and epidemiologic evidence have suggested that phenacetin use increases the risk of transitional cell cancers of the urinary tract. The drug is no longer marketed but a commonly used metabolite, acetaminophen, has been linked recently to an increased risk of renal cancer. We assessed the relation of acetaminophen use to the risk of transitional cell cancer of the urinary tract and of renal cell cancer with data from a hospital-based study of cancers and medication use conducted from 1976-96 in the eastern United States. We compared 498 cases of transitional cell cancer and 383 cases of renal cell cancer with 8,149 noncancer controls and 6,499 cancer controls and controlled confounding factors with logistic regression. For transitional cell cancer, the relative risk (RR) estimate for regular acetaminophen use that had begun at least a year before admission was 1.1 (95 percent confidence interval [CI] = 0.6-1.9) based on noncancer controls, and 0.9 (CI = 0.5-1.6) based on cancer controls. RR estimates for use that lasted at least five years, and for nonregular use, were also close to 1.0. For renal cell cancer, the corresponding estimates were again close to 1.0. Our results suggest that acetaminophen, as used in present study population, does not influence the risk of transitional cell cancer of the urinary tract or of renal cell cancer.

In vitro analysis of bromine chemical burns with use of full-thickness human skin

Parameters of bromine injury were studied in vitro with the use of full-thickness human skin (HS) specimens--discards from various surgical procedures. The morphology of in vitro-treated HS resembled that of in vivo-injured skin. The damage was pronounced in the epidermis (destruction of the stratum corneum, and extensive vacuolation of keratinocytes) and the dermis (collagen coagulation), depending on the bromine concentration, exposure time, and application method. A decreased viability of epidermal cells, assayed by dye exclusion, was observed as well. Permeation parameters of bromine via abdominal HS were determined by quantitating bromine concentration in the donor and receiving compartments. The amount of bromine that permeated HS was inversely related to the concentration gradient applied. This in vitro study suggests that prompt treatment and early medical intervention may be required for successful healing of both severe and mild cases of bromine injuries.

Phenotypic modulation of hamster acinar cells by culture in collagen matrix

The aim of this study was to assess the effect of different culture conditions on the survival and morphological phenotype of cultured acinar cells. Acinar fragments isolated from hamster pancreas were embedded in rat-tail collagen. Four groups were established: Medium 1-5% NuSerum + basic medium (basic medium = DMEM/F12 supplemented with dexamethasone, 3-isobutyl-2-methylxanthine, and antibiotics); Medium 2-10% NuSerum + basic medium. Medium 3-Medium 2 supplemented with epidermal growth factor and cholera toxin; and Medium 4:-Medium 3 supplemented with soybean trypsin inhibitor. Freshly isolated acinar cells were retrieved morphologically intact. In Medium 1, more than 80% of cells retained a normal histological appearance at 34 days in culture. Immunostaining for amylase was observed at the apical pole of the cells. The remaining cells showed variable degrees of degeneration. In Medium 2, approximately 50% of acinar cells appeared normal at 34 days in culture, while the remainder were severely degenerated. A few cystic structures were also observed. Positive immunostaining for amylase was limited to the cells with a normal histological appearance. The cells grown in Media 3 and 4 had similar courses of morphological changes. After 8 days in culture, most acinar fragments disappeared and were replaced by cystic structures, lined by a single layer of cuboidal cells. Some amylase-positive immunoreactive cells were integral components of the cystic wall. Cellular amylase activity was a function of the different culture media, a more rapid decrease in amylase activity being observed in Media 3 and 4. Uptake of [3H]thymidine did not show any significant differences between the media. It was also found that the ductlike cells cultured in Medium 4 had a limited capacity to redifferentiate into acinar cells. This study shows that the acinar cell phenotype can be maintained in vitro for more than 1 month. This study also suggests that ductal-like epithelial structures arise from transformation of acinar cells.

Induced and spontaneous abortion in relation to risk of breast cancer (United States)

The relation of induced and spontaneous abortion to the risk of breast cancer is evaluated in a hospital-based case-control interview study conducted in three cities in the United States from 1985 through 1995. Cases were 1,803 women aged 25 to 64 years with newly diagnosed invasive breast cancer; controls were 4,182 women of the same ages admitted for conditions unrelated to reproductive factors. Other breast cancer risk-factors were controlled through multiple logistic regression. The reference for all analyses was women who had never had an abortion, either induced or spontaneous. Among parous women, the relative risk (RR) estimate was 1.1 (95 percent confidence interval [CI] = 0.9-1.5) for induced abortion overall, 1.0 (CI = 0.7-1.4) for abortion before the first birth, and 1.3 (CI = 1.0-1.8) for abortion after at least one birth. Among nulliparous women, the relative risk estimate for induced abortion was 1.3 (CI = 0.9-1.9). There was no trend of increased risk with number of abortions, nor was there consistent evidence of an increased risk in any particular subgroup. Spontaneous abortion was not associated with increased risk of breast cancer, either among nulliparous women or among parous women. These findings provide little support for the hypothesis that induced abortion increases breast cancer risk overall or in particular subgroups.

Effects of bone CS-proteoglycans, DS-decorin, and DS-biglycan on hydroxyapatite formation in a gelatin gel

The small leucine-rich bone proteoglycans, biglycan and decorin, can be purified by chromatography on hydroxyapatite columns, demonstrating their potential affinities for bone apatite. To determine their effects on in vitro apatite formation and growth, a mixture of the chondroitin-sulfate (CS) bone proteoglycans, or purified fractions of the dermatan sulfate (DS) containing proteoglycans, DS-decorin and DS-biglycan obtained from skin and articular cartilage, respectively, were analyzed in a gelatin gel diffusion system in which apatite formation occurs in the absence of proteins in a 3.5 day period. Low concentrations of the bone CS-proteoglycan mixture and low DS-biglycan concentrations (5-25 microg/ml) increased apatite formation relative to proteoglycan-free controls at 3.5 days. The CS-proteoglycan mixture was less effective at 50 microg/ml than at 10 microg/ml. DS-biglycan was similarly most effective at 5-25 microg/ml. At 5 days, when apatite growth and proliferation were assessed, 10 and 50 microg/ml of both CS-bone proteoglycan and DS-biglycan increased mineral yields. DS-decorin, in contrast, had no significant effect on mineral accumulation at any of these concentrations. In seeded growth experiments, 1 and 10 microg/ml CS-proteoglycan and 10 and 50 microg/ml DS-biglycan were significant effective inhibitors of mineral accretion, whereas DS-decorin showed no tendency to inhibit seeded growth. Using molar extinction coefficients to determine concentrations, the binding of DS-biglycan and DS-decorin to apatite (specific surface 54 m2/g) was determined using a Langmuir adsorption isotherm model. DS-biglycan had a greater affinity for apatite than DS-decorin (0.285 ml/micromol versus 0.0098 ml/micromol). DS-biglycan binding was more specific with fewer binding sites (3.5 micromol/m2 compared with 18. 2 micromol/m2 for DS-decorin). Data suggest that of the small proteoglycans, biglycan may play a more significant role than decorin in the regulation of mineralization.

Treatment of pancreatic cancer. Promises and problems of tamoxifen, somatostatin analogs, and gemcitabine

The clinical problem posed by pancreatic cancer is introduced, and the epidemiology and pathology of the disease are briefly presented. The natural history of this tumor is then described in order to highlight the deficiencies of current therapeutic modalities. The extremely poor results of the early drug trials are reviewed, followed by a detailed discussion and critique of the trials of novel treatments that include gemcitabine, somatostatin analogs, and tamoxifen. Finally, areas for future development are indicated.

Measuring postoperative complications in general surgery patients using an outcomes-based strategy: comparison with complications presented at morbidity and mortality rounds

BACKGROUND

This study was undertaken to compare the incidence of adverse postoperative outcomes recorded in a prospective general surgery database with that identified through weekly morbidity and mortality (M&M) rounds and to measure the impact of feedback of information to the providers of care.

METHODS

Data were collected on patients admitted to one general surgery service between October 1, 1995, and May 15, 1996, and recorded in a computer database. Postoperative complications were graded in severity from I (minor) to IV (mortality).

RESULTS

Of 479 admissions entered into the database during the study period, 325 (311 patients) led to operations and were further analyzed. Admissions resulting in complications were associated with longer hospital stays, regardless of complication grade, compared to uncomplicated admissions (p < 0.01). A total of 29 of 106 patients with postoperative complications were presented at M&Ms (27.4%). Whereas 15.4% of database patients with grade I complications were presented at M&Ms, this proportion increased to 22.2% for grade IIa, 34.8% for grade IIb, 33.3% for grade III, and 87.5% for grade IV. (p < 0.05 for grade I, IIa, and IIb compared to grade IV). A total of 58 of 142 patients in the first part of the study period developed complications (40.8%), compared to 53 of 183 patients in the second part of the study (29%, p = 0.034).

CONCLUSIONS

Although most severe complications are recorded at M&M rounds, a large proportion of complications remain unreported. Monitoring of outcomes may contribute to improvements in quality of care.

Modern oral contraceptives and cardiovascular disease

We reviewed evidence that bears on the cardiovascular safety of combined oral contraceptives containing second- and third-generation progestogens and < 50 micrograms of estrogen. Recent epidemiologic studies indicate that current use of these formulations is associated with a smaller increase in the incidence of venous thromboembolism than earlier formulations. In some studies the increase for third-generation formulations containing desogestrel or gestodene was about 1.5 to 2 times that for second-generation formulations, but there is evidence that differences between users in underlying risk and likelihood of being diagnosed contributed to this result. Recent studies of myocardial infarction suggest a smaller increase in risk associated with modern formulations than with earlier ones; one study suggests a threefold increase for second-generation formulations and no increase for third-generation formulations, but the finding requires confirmation. Recent studies of stroke indicate little or no increase in risk for modern formulations among women without risk factors. We conclude that modern combined oral contraceptives are safer than earlier formulations with respect to cardiovascular disease, which occurs rarely in young women.

Hot bitumen burns: 92 hospitalized patients

Bitumen burns while comprising a small percentage of all types of burns are troublesome. They affect persons engaged in gainful employment which the burns then curtail, as well as requiring special attention because the substance adheres to the skin and is therefore difficult to remove. Ninety-two consecutive patients with such burns who were admitted as in-patients over a 10-year period (1985-1995) have been reviewed. Most of the burns occurred on a worksite and involved active young persons (mean age 29.6 years) the mean size of the burn was 3.87 per cent TBSA, mainly affecting the upper extremities and hands. Mean hospitalization time was 10.6 days. Bitumen burns are fully predictable and can easily be prevented by avoiding unsafe practice and/or equipment. Bitumen is a general term for petroleum-derived substances ranging from true petroleum through so-called mineral tars, to asphalt. Asphalt (Asphaltum) is a semi-solid mixture of several hydrocarbons probably formed by the evaporation of the lighter or more volatile constituents. It is amorphous of low specific gravity, 1-2, with a black or brownish black colour and pitchy lustre. At room temperature it is solid becoming molten and spreadable when heated to 93 degrees C and over. Roofing tars and asphalts are usually heated to temperatures of 232 degrees C to achieve desirable viscosities (e.g. for spraying), whereas lower temperatures are required for the manageable form to pave roads. Notable localities for asphaltum are the island of Trinidad and the Dead Sea region where lake asphaltums were long known to the ancient. Ironically, none of the 92 patients who were treated for bitumen injuries in the 'Soroka' (Beer-Sheba, Israel) and 'Barzilai' (Ashkelon, Israel) Medical Centres (80 and 150 km from the lake respectively) had anything to do with the Dead Sea area.

Characterization of epiphycan, a small proteoglycan with a leucine-rich repeat core protein

The epiphysis of developing bones is a cartilaginous structure that is eventually replaced by bone during skeletal maturation. We have separated a dermatan sulfate proteoglycan, epiphycan, from decorin and biglycan by using dissociative extraction of bovine fetal epiphyseal cartilage, followed by sequential ion-exchange, gel permeation, hydrophobic, and Zn2+ chelate chromatographic steps. Epiphycan is a member of the small leucine-rich proteoglycan family, contains seven leucine-rich repeats (LRRs), is related to osteoglycin (osteoinductive factor) (Bentz, H., Nathan, R. M., Rosen, D. M., Armstrong, R. M., Thompson, A. Y., Segarini, P. R., Mathews, M. C., Dasch, J., Piez, K. A., and Seyedin, S. M. (1989) J. Biol. Chem. 264, 20805-20810), and appears to be the bovine equivalent of the chick proteoglycan PG-Lb (Shinomura, T., and Kimata, K. (1992) J. Biol. Chem. 267, 1265-1270). The intact proteoglycan had a median size of approximately 133 kDa. The core protein was 46 kDa by electrophoretic analysis, had a calculated size of 34,271 Da, and had two approximately equimolar N termini (APTLES ... and ETYDAT ... ) separated by 11 amino acids. There were at least three O-linked oligosaccharides in the N-terminal region of the protein, based on blank cycles in Edman degradation and corresponding serine or threonine residues in the translated cDNA sequence. The glycosaminoglycans ranged in size from 23 to 34 kDa were more heterogeneous than those in other dermatan sulfate small leucine-rich proteoglycans and were found in the acidic N-terminal region of the protein core, N-terminal to the LRRs. A four-cysteine cluster was present at the N terminus of the LRRs, and a disulfide-bonded cysteine pair was present at the C terminus of the protein core. The seventh LRR and an N-linked oligosaccharide were between the two C-terminal cysteines. An additional potential N-glycosylation site near the C terminus did not appear to be substituted at a significant level.

Pancreatic schwannoma: report of two cases and review of the literature

Solitary intrapancreatic schwannoma is a rare tumor. We present two patients with this tumor and review 13 previously reported cases from the English-language literature. While the final diagnosis was made based on pathological examination of the tumors, both computed tomography scan and magnetic resonance imaging helped establish the benign nature of the lesion, narrow the differential diagnosis, and define the anatomical locations of the small tumors. Both tumors were treated by enucleation from the surrounding pancreatic parenchyma, and both patients, after 2 years of follow-up, are alive and well. It is concluded that multimodality radiologic investigations are useful in the workup of unusual pancreatic masses. In addition, based on the known biologic behavior of schwannomas occurring elsewhere in the body, simple enucleation, rather than more radical resection, is likely to be adequate therapy for these tumors.

Cloning and sequencing of the pancreatic islet neogenesis associated protein (INGAP) gene and its expression in islet neogenesis in hamsters

Induction of islet neogenesis by cellophane wrapping (CW) reverses streptozotocin-induced (STZ) diabetes. Administration of Ilotropin, a protein extract isolated from CW pancreata, causes recapitulation of normal islet ontogeny and reverses STZ diabetes, reducing mortality by 50%. We investigated the hypothesis that a novel gene encoding a constituent of Ilotropin was expressed in the hamster pancreas undergoing islet neogenesis. Islet neogenesis associated protein (INGAP) is a product of a novel gene expressed in regenerating hamster pancreas. Northern blot analysis showed a strong single transcript of 850 bp at 1 and 2 d after CW that disappeared by the 6th day and was absent from untreated control pancreata. INGAP gene is expressed in acinar cells, but not in islets. Western blot analysis demonstrated the presence of INGAP in Ilotropin but not in extracts from control pancreata. A synthetic pentadecapeptide, corresponding to a region unique to INGAP, stimulated a 2.4-fold increase in [3H]thymidine incorporation into hamster duct epithelium in primary culture and a rat pancreatic duct cell line but had no effect on a hamster insulinoma tumor cell line. A portion of human INGAP gene was cloned and appears to be highly homologous to the hamster gene. This data suggests that the INGAP gene is a novel pancreatic gene expressed during islet neogenesis whose protein product is a constituent of Ilotropin and is capable of initiating duct cell proliferation, a prerequisite for islet neogenesis.

Combined thermal and crush injury to the hand and fingers

Combined thermal and crush injury is a relatively rare type of injury, although it may be more common in industrial settings. The combined insult of heat and pressure results in an injury that apparently is more severe than the simple additive effect, as the heat is transmitted deeper through the crushed tissues. The full extent of tissue destruction cannot always be fully recognized initially. Treatment in stages is the preferred approach, rather than attempted immediate reconstruction procedures. Failure of immediate skin grafting procedures in some of the cases presented herein was the result of underestimation of the severity of trauma. Early debridement should be done soon after admission. Definitive treatment as dictated by the magnitude of injury needs to be delayed until the extent of injury is delineated. Our conclusions from the presented experience with this type of injury were successfully applied in the treatment of the last presented patient.

A case control study of breast cancer risk and exposure to injectable progestogen contraceptives. Methods and patterns of use among controls

OBJECTIVE

To describe the patterns of use of injectable progestogen contraceptives (IPCs) among coloured and black women in the Western Cape. These data are part of an ongoing study in the Western Cape, the main aim of which is to explore the relationship between IPCs and breast cancer.

DESIGN

A population-based case-control study of breast cancer risk in relation to the use of IPCs among coloured and black women.

SETTING

The Western Cape, including the Cape metropole and surrounding rural areas.

STUDY SUBJECTS

All coloured and black women with newly diagnosed breast cancer, resident in the study area and below age 55 years, who present at either of the two tertiary care hospitals in the Western Cape are recruited. Controls are a sample of hospitalised patients representative of the populations from which the patients are drawn. Cases are frequency-matched to controls according to cross-tabulation of age, ethnic group and residential area in a ratio of approximately 1:3.

MEASUREMENTS

Questionnaires are administered by trained nurse interviewers, information is elicited on a wide range of variables, including sociodemographic variables, medical history, family history of breast disease, lifetime history of all methods of contraception and use of non-contraceptive female steroids, reproductive variables, cigarette smoking, alcohol consumption and other potentially confounding variables.

RESULTS

Between January and December 1994, 122 incident cases and 389 controls were enrolled. Ever-use of IPCs among the controls was 72% (N = 280) and use for 5 years or more was 30% (N = 117). Use of IPCs in the distant past was common, with 61% (N = 232) of all controls having initiated use 10 or more years previously. Current use was also high (19%). Other contraceptive methods were used far less commonly.

CONCLUSION

Coloured and black women in South Africa have been using and continue to use IPCs for more commonly and for longer periods than women anywhere else in the world. It is therefore especially important to evaluate the risk of breast cancer and other health effects of IPCs. The rates of use identified in this study ensure that there will be adequate statistical power to evaluate long-term use, use in the distant past and current use of IPCs.

A thermal burn to a prolapsed uterus

Burns to the concealed area of the perineum, are relatively rare and usually associated with massive burns and a high mortality rate. A rare case of a thermal burn to a prolapsed uterus is described. The victim was a 72-year-old Bedouin woman, with a 70 per cent total body surface area deep burn from an open fire. In addition to the conventional treatment dictated by such a burn, two unique problems must be considered: (1) the common pathogens of the uterus, Neisseria gonorrhoeae, Chlamydia trachomatis and mycoplasma, are different from those of the skin; (2) the lymphatics of the uterus drain directly into the abdominal cavity and the risk of peritonitis and generalized infection is potentially higher. Intravenous, prophylactic, broad-spectrum antibiotics were therefore initiated immediately following admission. These included: cefoxitin, gentamicin and metronidazole a combination that covers both the potential pathogens of the uterus and the common pathogens of the skin. In addition, and for the same reason, Betadine substituted Flamazine for the local treatment of the exposed uterus. Our patient did not survive the burn, but in a similar, unusual case, the local and systematic remedies must protect against uterine pathogens that are not commonly seen in a burn victim.

A volumetric approach to virtual simulation of functional endoscopic sinus surgery

Advanced display technologies have made the virtual exploration of relatively complex models feasible in many applications. Unfortunately, only a few human interfaces allow natural interaction with the environment. Moreover, in surgical applications, such realistic interaction requires real-time rendering of volumetric data-placing an overwhelming performance burden on the system. We report on a collaboration of an interdisciplinary group developing a virtual reality system that provides intuitive interaction with volume data by employing real-time volume rendering and force feedback (haptic) sensations. We describe our rendering methods and the haptic devices and explain its utility of this system in the real-world application of Endoscopic Sinus Surgery (ESS) simulation.