Palliative treatment of advanced non small cell lung cancer with weekly fraction radiotherapy

Various hypofractionated radiotherapy schedules of radiotherapy have been tried in patients of advanced NSCLC with no conclusive superiority of either a more protracted low dose per fraction schedule or a rapid course of large fraction size. Present study evaluates the role of weekly high dose radiotherapy for the palliation of various intrathoracic symptoms like cough, chest pain, hemoptysis, dyspnoea. A total of 47 patients of advanced non-small cell lung cancer were treated with four weekly fraction of 5 Gy to a total dose of 20 Gy. Mean age at presentation was 53 years. Majority of patients had stage III disease. Pain relief was seen in 77% (23/30) patients with complete relief in 57%; haemoptysis was completely relieved in 77% patients (17/22); and cough was relieved in 68% (19/28) patients. Complete relief from dyspnoea was seen in only 5/12 (42%) patients whereas 2/12 (17%) patients had partial response. The present regime of 20 Gy in four weekly fractions was well tolerated by the patients without any identifiable acute toxicity and was simple and convenient to the patients, who traverse a long distance for radiotherapy in India. To conclude, weekly schedule af EBRT provide effective palliation of various intrathoracic symptoms in the patients with advanced NSCLC.

INCISIONAL HERNIA THROUGH NONVERTICAL INCISIONS

Although uncommon, incisional hernia may occur after operations where vertical or paramedian incision is not used. Fifteen patients of incisional hernia through nonvertical incisions in the age group of 22 to 65 years were studied. This included hernia through subcostal incision commonly used for cholecystectomy, gridiron incision, pfannensteil incision and lumbar incisions. Majority of these hernias were due to wound complications and factors which give rise to an increased strain on suture lines. Although the technique for anatomical repair of incisional hernia seems safe and dependable in patients with small defects, but in patients with large musculoaponeurotic defect, prolene mesh hernioplasty has proved successful. In one patient with giant incisional hernia through rooftop incision, large defect was covered with merselene mesh by inlay and onlay technique. After a median follow up of 18 months only one patient (6.6%) developed a recurrence. Merselene mesh has proved to be an excellent material for bridging of wide tissue gaps.

Temporal assessment of quality of life of head and neck cancer patients receiving radical radiotherapy

The study was undertaken to evaluate physical, psychological and functional aspects in quality of life (QoL) assessment prospectively in biopsy-proven head and neck cancer patients receiving radical radiotherapy. Fifty male patients were assessed using Karnofsky's Performance Status (KPS), Beck's Depression Inventory (BDI) and the Functional Living Index-Cancer (FLIC). Patient questionnaires were completed before radiotherapy, during 3-4 weeks of radiotherapy and 3 months after radiotherapy. Before the start of radiotherapy, KPS was 91 +/- 10.26, FLIC was 129.98 +/- 33.41 and BDI was 7.10 +/- 4.57. This indicated good performance and functional status with lower depression. In weeks 3-4 of radiotherapy, KPS (71.00 +/- 20.12) and FLIC (81.34 +/- 45.23) decreased, while BDI (16.56 +/- 9.01) increased, indicating impairment in QoL. Three months after radiotherapy, KPS (78.37 +/- 23.0), FLIC (119.51 +/- 43.62) and BDI (9.02 +/- 7.81) improved but were not restored to pre-treatment levels. When patients were scheduled for radical radiotherapy, maximum deterioration in QoL was seen in weeks 3-4. This is the time when maximum supportive care and psychologic counselling is required.

Chronic pain in the dental patient

This article reviews the pathophysiology and mediators of pain, and addresses the different subtypes of dental pain. An overview of pharmacotherapy is presented. Contributing factors to chronic pain syndromes are reviewed. Alternative methods of pain management are discussed.

Gastrointestinal imaging: a systems analysis comparing digital and conventional techniques

OBJECTIVE

The purpose of this study was to compare digital and conventional methods of gastrointestinal imaging based on the cost of image storage and estimated overall costs, radiation exposure to the patient, and duration of the examination.

MATERIALS AND METHODS

Our study sample consisted of 128 patients who underwent conventional gastrointestinal studies (64 double-contrast upper gastrointestinal examinations and 64 double-contrast barium enemas) and 139 patients who underwent digital gastrointestinal studies (66 double-contrast upper gastrointestinal examinations and 73 double-contrast barium enemas). The number of images and films for each study was recorded, and the mean cost of image storage and the estimated overall costs for digital versus conventional studies were calculated. Both the duration of fluoroscopy and the time from start to completion of the study were obtained from our radiology information system. From these data, we calculated mean radiation exposure to the patient and the duration of the examination. Finally, referring physicians completed a questionnaire about their level of satisfaction with paper prints generated from digital gastrointestinal studies.

RESULTS

When digital studies were compared with conventional studies, the mean cost of image storage decreased by 45% and the estimated overall 10-year costs decreased by 8%. The mean number of spot images increased by 8% for upper gastrointestinal examinations and by 25% for barium enema examinations, whereas the mean duration of fluoroscopy decreased by 4% and by 10%, respectively. As a result, radiation exposure to patients increased by only 2%, a difference that did not approach statistical significance. Finally, the mean duration of examinations decreased by 24% for upper gastrointestinal examinations and by 33% for barium enemas. Approximately 85% of the physicians who completed the questionnaires indicated that they reviewed the paper prints generated from digital studies and that they would like to continue receiving them.

CONCLUSION

Digital gastrointestinal imaging systems are associated with higher initial costs than conventional systems, but the long-term costs of these digital imaging systems are slightly less because of the lower cost of image storage, and radiation exposure to patients is comparable. The shorter duration of digital examinations is a potential benefit of this technology, allowing improved patient throughput. Finally, referring physicians have a high level of satisfaction with paper prints generated from digital imaging.

Control of recruitment and transcription-activating function of CBP determines gene regulation by NMDA receptors and L-type calcium channels

Recruitment of the coactivator CBP by signal-regulated transcription factors and stimulation of CBP activity are key regulatory events in the induction of gene transcription following Ca2+ flux through ligand- and/or voltage-gated ion channels in hippocampal neurons. The mode of Ca2+ entry (L-type Ca2+ channels versus NMDA receptors) differentially controls the CBP recruitment step to CREB, providing a molecular basis for the observed Ca2+ channel type-dependent differences in gene expression. In contrast, activation of CBP is triggered irrespective of the route of Ca2+ entry, as is activation of c-Jun, that recruits CBP independently of phosphorylation at major regulatory c-Jun phosphorylation sites, serines 63 and 73. This control of CBP recruitment and activation is likely relevant to other CBP-interacting transcription factors and represents a general mechanism through which Ca2+ signals associated with electrical activity may regulate the expression of many genes.

CBP: a signal-regulated transcriptional coactivator controlled by nuclear calcium and CaM kinase IV

Recruitment of the coactivator, CREB binding protein (CBP), by signal-regulated transcription factors, such as CREB [adenosine 3', 5'-monophosphate (cAMP) response element binding protein], is critical for stimulation of gene expression. The mouse pituitary cell line AtT20 was used to show that the CBP recruitment step (CREB phosphorylation on serine-133) can be uncoupled from CREB/CBP-activated transcription. CBP was found to contain a signal-regulated transcriptional activation domain that is controlled by nuclear calcium and calcium/calmodulin-dependent (CaM) protein kinase IV and by cAMP. Cytoplasmic calcium signals that stimulate the Ras mitogen-activated protein kinase signaling cascade or expression of the activated form of Ras provided the CBP recruitment signal but did not increase CBP activity and failed to activate CREB- and CBP-mediated transcription. These results identify CBP as a signal-regulated transcriptional coactivator and define a regulatory role for nuclear calcium and cAMP in CBP-dependent gene expression.

Pancreatic leiomyosarcoma in a middle-aged lady

Leiomyosarcoma is an uncommon malignant tumour of the pancreas. Many retroperitoneal leiomyosarcomas grow silently and are extremely large when diagnosed. We report a 45 year old lady who presented with abdominal lump and haemoptysis. Ultrasound guided biopsy of the mass revealed a pancreatic leiomyosarcoma. The patient had lung metastasis and received chemotherapy. She is alive with disease at last followup.

Stromal sarcoma of the breast: a case report

Malignant mesenchymal tumours of the breast are rare neoplasms. Their incidence varies from 1%-3% of all malignant breast tumours (1). Stromal sarcoma of the breast is an extremely uncommon tumour (2). We present a rare case of advanced stromal sarcoma of the breast successfully managed with radical surgery and radiotherapy.

Biliary tract neoplasms

From January 1993 to December 1995, complete records of patients with biliary neoplasms were analysed. A total of 124 patients were registered. Majority of patients were in the age range of 40-60 years (median 54 years). There were 38 males and 86 females. Histopathologically, adenocarcinoma was the commonest type (59%). Pain, jaundice and lump were noticed in 119, 54 and 77 patients respectively. Fifty six patients had associated gall stones. Ninety patients had metastatic disease at presentation. Majority of them (110/124) had advanced, inoperable disease and therefore were considered for palliative treatment. Only 14 patients (12%) were considered for curative treatment. Of these 14 patients, all the cases underwent surgery, 10 received radiotherapy and 10 received chemotherapy. Follow up was very poor. The survival of 14 patients, who received curative treatment, ranged from 2 months to 44 months with mean of 16 months.

Mechanisms controlling gene expression by nuclear calcium signals

Nuclear calcium is an important regulator of gene expression following membrane depolarisation of electrically excitable cells. Here we describe nuclear calcium transients in hippocampal neurons following activation of calcium influx through L-type voltage-sensitive calcium channels and N-methyl-D-aspartate (NMDA) receptors, as well as following calcium release from intracellular caffeine-sensitive stores. Increases in nuclear calcium activate gene transcription by a mechanism that is distinct from gene regulation by cytoplasmic calcium signals and involves the cAMP response element (CRE) and the CRE binding protein, CREB. The nuclear calcium/calmodulin dependent (CaM) protein kinase IV, which is expressed in cultured hippocampal neurons and in the mouse pituitary cell line AtT20, may function as a mediator of nuclear calcium-induced transcription.

Comparison of single-dose oral granisetron versus intravenous ondansetron in the prevention of nausea and vomiting induced by moderately emetogenic chemotherapy: a multicenter, double-blind, randomized parallel study

PURPOSE

The antiemetic effectiveness and safety of single-dose oral granisetron were compared with intravenous (I.V.) ondansetron in chemotherapy-naive patients who received moderately emetogenic chemotherapy.

PATIENTS AND METHODS

In this double-blind, parallel-group study, patients naive to emetogenic chemotherapy (N = 1,085) who were scheduled to receive cyclophosphamide- (500 to 1,200 mg/m2) or carboplatin (> or = 300 mg/m2) based chemotherapy, were randomized to receive either oral granisetron (n = 542) or I.V. ondansetron (n = 543). Efficacy assessments included the proportion of patients in each treatment group with total control over the 24 and 48 hours following chemotherapy initiation, as well as incidence and severity of nausea and emesis and use of antiemetic rescue medication. Prophylactic corticosteroids were allowed. Safety assessment was based on patients' reports of adverse experiences.

RESULTS

Approximately 80% of patients received prophylactic corticosteroids. Single-dose oral granisetron (2 mg) and I.V. ondansetron (32 mg) resulted in equivalent levels of total emetic control during the first 48 hours after chemotherapy. The proportion of nausea- and emesis-free patients at 24 and 48 hours were also approximately equivalent. The most commonly reported adverse experiences were headache, asthenia, and constipation. More patients who received ondonsetron than granisetron reported dizziness (9.6% v 5.4%, respectively; P = .011) and abnormal vision (4.2% v 0.6%, respectively; P < .001).

CONCLUSION

A single oral dose of granisetron (2 mg) resulted in equivalent levels of antiemetic protection as I.V. ondansetron (32 mg). Both agents were well tolerated, although more dizziness and abnormal vision were reported with ondansetron. Because the two antiemetic regimens exhibited equivalent efficacies, additional factors such as convenience and cost of therapy should be considered.

Integration of generalized vulnerability to drug and alcohol addiction

The vulnerability to develop addiction to alcohol has been well established in familial and genetic studies. Similar familial and genetic studies have supported a vulnerability to drug addiction. The co-occurrence of alcohol and drug addiction in the same individuals is highly prevalent in clinical populations. Common putative neurochemical mechanisms underlie addiction to both alcohol and drugs, namely, in the mesolimbic pathway and the locus ceruleus in the brain. Treatment strategies are directed at both alcohol and multiple drug addictions in patient populations. The formulation of a generalized vulnerability that extends to both alcohol and drug addiction is not only possible but necessary to explain the substantial numbers of individuals who develop both alcohol and drug addictions. Future research that is pertinent and relevant may depend on the understanding of a generalized vulnerability to develop alcohol and drug addiction and its application in diagnostic strategies and treatment models.

Calcium controls gene expression via three distinct pathways that can function independently of the Ras/mitogen-activated protein kinases (ERKs) signaling cascade

Calcium ions are the principal second messenger in the control of gene expression by electrical activation of neurons. However, the full complexity of calcium-signaling pathways leading to transcriptional activation and the cellular machinery involved are not known. Using the c-fos gene as a model system, we show here that the activity of its complex promoter is controlled by three independently operating signaling mechanisms and that their functional significance is cell type-dependent. The serum response element (SRE), which is composed of a ternary complex factor (TCF) and a serum response factor (SRF) binding site, integrates two calcium-signaling pathways. In PC12 cells, calcium-regulated transcription mediated by the SRE requires the TCF site and is not inhibited by expression of the dominant-negative Ras mutant, RasN17, nor by the MAP kinase kinase 1 inhibitor PD 98059. In contrast, TCF-dependent transcriptional regulation by nerve growth factor or epidermal growth factor is mediated by a Ras/MAP kinases (ERKs) pathway targeting the TCF Elk-1. In AtT20 cells and hippocampal neurons, calcium signals can stimulate transcription via a TCF-independent mechanism that requires the SRF binding site. The cyclic AMP response element (CRE), which cooperates with the TCF site in growth factor-regulated transcription, is a target of a third calcium-regulated pathway that is little affected by the expression of RasN17 or by PD 98059. Thus, calcium can stimulate gene expression via a TCF-, SRF-, and CRE-linked pathway that can operate independently of the Ras/MAP kinases (ERKs) signaling cascade in a cell type-dependent manner.

Gene regulation by nuclear and cytoplasmic calcium signals

Calcium entry into neuronal cells through N-methyl-D-aspartate (NMDA)-type glutamate receptors or L-type voltage-gated calcium channels is a key event in the control of gene expression following electrical activation. Calcium acts both in the cytoplasm and the nucleus to activate signalling pathways that stimulate gene expression through different DNA regulatory elements. Differential control of transcription by spatially distinct calcium signals provides a mechanism by which a single second messenger can generate diverse transcriptional responses. This may allow for stimulation-specific modulation of gene expression critical for adaptive changes in the nervous system.

Distinct functions of nuclear and cytoplasmic calcium in the control of gene expression

Calcium entry into neuronal cells through voltage or ligand-gated ion channels triggers neuronal activity-dependent gene expression critical for adaptive changes in the nervous system. Cytoplasmic calcium transients are often accompanied by an increase in the concentration of nuclear calcium, but the functional significance of such spatially distinct calcium signals is unknown. Here we show that gene expression is differentially controlled by nuclear and cytoplasmic calcium signals which enable a single second messenger to generate diverse transcriptional responses. We used nuclear microinjection of a non-diffusible calcium chelator to block increases in nuclear, but not cytoplasmic, calcium concentrations following activation of L-type voltage-gated calcium channels. We showed that increases in nuclear calcium concentration control calcium-activated gene expression mediated by the cyclic-AMP-response element (CRE), and demonstrated that the CRE-binding protein CREB can function as a nuclear calcium-responsive transcription factor. A second signalling pathway, activating transcription through the serum-response element (SRE), is triggered by a rise in cytoplasmic calcium and does not require an increase in nuclear calcium.

Synthesis of 3-arsonopyruvate and its interaction with phosphoenolpyruvate mutase

3-Arsonopyruvate was prepared in four steps from glycine. The arsenic-carbon bond was formed by a Meyer reaction between alkaline arsenite and 2-bromo-3-hydroxy-2-(hydroxymethyl)propionic acid; the 3-arsono-2-hydroxy-2-(hydroxymethyl) propionic acid formed was oxidized with periodate to give 3-arsonopyruvate. This proves to be an alternative substrate for phosphoenolpyruvate mutase, giving pyruvate, which was assayed using lactate dehydrogenase. The K(m) is 20 microM, similar to that observed for the natural substrate phosphonopyruvate (17 microM), whereas the kcat. of 0.01 s-1 was much lower than that for phosphonopyruvate (58 s-1). Arsonopyruvate competitively inhibited the action of the mutase on phosphonopyruvate.

A study on the nutritional status of adolescent girls

One hundred and twenty school girls in the age group of 13-15 years from four Government schools of Ludhiana city were selected for the study. On the basis of their family income they were divided into three experimental groups i.e. income group I (IgI), income group II (IgII) and income group III (IgIII). The results showed that the intake was low for all the foods. However, the consumption of fruits, milk and milk-products, sugar and jaggery, fats and oils by the subjects of IgII and IgIII was significantly higher (p < 0.05) than IgI. The mean daily intake of energy, protein, iron, calcium, vitamin A & vitamin C was inadequate while the intake of fibre was adequate by the subjects as compared to ICMR recommendations. There was no significant difference in energy, protein and iron intakes among the subjects of three groups. However, the fibre intake by the subjects of IgI was significantly higher (p < 0.05) than the subjects of IgIII, whereas the intake of calcium, vitamin A and ascorbic acid by the subjects of IgII & IgIII was significantly higher (p < 0.05) than those of IgI. The average body weights and heights of the subjects were normal. The haemoglobin (Hb) level of the subjects ranged from 8.5-12.5 g/dl with a mean value of 10.73 + 0.07 and reported that only 23 percent of the subjects had acceptable level.

Enolase and the arsonomethyl analogue of 2-phosphoglycerate

(RS)-3-Arsono-2-(hydroxymethyl)propionic acid was synthesized by the action of alkaline arsenite on 3-bromo-2-(bromomethyl)propionic acid. It is a substrate for yeast enolase (EC 4.2.1.11) with a Km of 6.5 mM (for 2-phospho-D-glycerate Km = 0.08 mM). The catalytic constant of the enzyme with the arsonomethyl analogue is 230 times lower than with 2-phosphoglycerate.

Social support as a moderator of cardiovascular reactivity in women: a test of the direct effects and buffering hypotheses

This study examines the possibility that social support operates as a moderator of cardiovascular reactivity in women. Two models by which social support may operate were examined: the direct effects and buffering models. Twenty-six subjects were exposed to four conditions while playing a video game: two levels of stress (low, high) and two levels of social support (alone, together). Blood pressure and heart rate were monitored continuously. Ratings of stress were obtained for each condition. Results indicated that the support manipulation produced significant main effects for diastolic blood pressure and stress ratings, with lower diastolic blood pressure and ratings observed in the "together" condition, and that the interaction between support and stress produced lower reactivity for the cardiovascular measures in the high stress (but not the low stress) condition. No interaction was found for the stress ratings. We conclude that the results provide support for both the buffering and direct effects models. Implications concerning the (within-subjects) design of the study and the stress ratings are discussed.

Experience with intraluminal radiotherapy in advanced oesophageal cancer

Despite improvement in the diagnostic modalities, surgical technique, chemotherapy and radiotherapy, mortality and morbidity due to carcinoma esophagus continues to be dismal. Combination of external and intraluminal radio therapy (ILRT) has emerged as a powerful and promising palliative therapy in this disease. Thirty four patients with inoperable cancer esophagus treated with ILRT during June 1991 to December 1993 were evaluated to assess its palliative effects. Seventeen of these patients had received additional chemotherapy and external radiotherapy. Thirteen patients received only radiotherapy (both external radiotherapy + ILRT) and the remaining 4 received only ILRT. They were followed up for a mean period of 8.3 months (range 2 to 28 months) during which one patient was lost to follow up. Eight had a follow up of less than 6 months. Eight (33%) amongst the remaining 25 patients were considered disease free, 15 had recurrent and progressive disease, one developed metastasis and one patient died. In 21 (66%) dysphagia markedly improved. Nine (26%) patients survived beyond 1 year and the median survival for all patients was 8 months. Associated radiation morbidity was documented in 13 (38%) patients. We conclude that combination of external radiotherapy and ILRT is an effective and safe therapy for inoperable esophageal malignancies.

The Nd:YAG laser in caries removal

This paper shows how a laser can be used in the various stages of caries removal prior to the placement of a glass-ionomer restoration. In the future the laser may prove to be a valuable tool in enabling the dentist to perform surgical procedures with maximum comfort to the patient.

Predictors of perioperative morbidity and mortality in repeat valve replacement: a seven-year experience

Forty-nine consecutive repeat cardiac valve replacements in 46 patients were reviewed to define in-hospital morbidity, mortality, and determinants of risk. The overall operative mortality rate was 10.2%; it was 9% for the first reoperation and 25% for the second (four patients). The mortality rate was 12% at the mitral position (25 patients), 11% at the aortic position (18 patients), and 0% for repeat double valve replacement (four patients). Univariate and multivariate stepwise logistic regression models show that age over 70 years and the use of an intraaortic balloon pump preoperatively predict operative mortality, and age over 70, preoperative care in the coronary care unit, endocarditis, and the presence of an intraaortic balloon pump are determinants of perioperative morbidity in patients undergoing repeat valve replacement. Based on these data, close follow-up of patients with initial valve replacement is encouraged so that reoperation to correct prosthetic malfunction or periprosthetic leak can be done before hemodynamic collapse occurs. Furthermore, since age was the most significant factor affecting mortality (P < .01) and since most of the deaths (80%) in this study occurred in patients with torn bioprosthetic leaflets, the use of bioprostheses for initial valve replacement in patients under 70 years of age is discouraged.

Minor emergency clinic: key to the future of successful hospitals

This project set out to determine whether there is a relationship between the minor emergency facility an individual uses and their choice of a hospital for in-patient care. In studying this relationship, the factors that are important to persons choosing a clinic or hospital facility, as well as the influence of a physician, were also identified. A structured, undisguised telephone survey was used for interviewing a randomly selected sample population of 189 San Angelo residents. Analysis of the survey data indicated that dependency does exist between minor emergency clinic use and the hospital chosen for in-patient care. The results of this study also suggested that hospitals' marketing strategy should shift the emphasis of their advertising from the hospital itself to their physician association and clinics. In addition, a number of other interesting observations concerning the relative importance of various medical factors to the participants was also explored.

Cardio-vascular effects of vecuronium & pancuronium in patients undergoing elective closed mitral valvotomy

Vecuronium, a monoquaternary analogue of pancuronium, the neuromuscular blocker, was compared with pancuronium in 50 patients undergoing elective closed mitral valvotomy. The patients were randomly divided into two groups of 25 each, and the muscle relaxants were administered in a dose of 0.1 mg/kg body weight. Both the agents produced identical intubating conditions at 3 min. Vecuronium showed a significantly shorter onset of action, as compared to pancuronium. The latter significantly increased the heart rate throughout the period of study whereas vecuronium significantly decreased the heart rate, 25 min after administration. There was significant increase in the mean arterial pressure (MAP) at tracheal intubation in both the groups, which persisted throughout the period of study in pancuronium group. There was a significant fall in MAP at 30 min after relaxant in vecuronium group. The incidence of arrythmias was similar and significant in both the groups. Vecuronium, thus showed a quicker onset of action with minimal haemodynamic effects, as compared to pancuronium in patients undergoing closed mitral valvotomy.

ERCP in the evaluation of choledochal cyst due to anomalous pancreatobiliary junction

With the application of endoscopic retrograde cholangio pancreatography (ERCP), the association of anomalous pancreatobiliary junction and choledochal cyst is being increasingly recognized. We describe here the ERCP findings in three patients who had this anomaly in association with fusiform (Type I) choledochal cyst. Two of our patients also had evidence of pancreatitis. The importance of ERCP in the preoperative assessment of such patients is highlighted.

Small cell osteosarcoma. A clinicopathologic study of 27 cases

We report a study of 27 patients with small cell osteosarcoma (SCO), 17 from the M. D. Anderson Cancer Center (MDAH) and ten from the Pediatric Oncology Group (POG). There were 12 male patients and 15 female patients; 19 were white, five were black, and three were Hispanic. They ranged from 6 to 28 years of age with a median of 14 years. Histologically there were three patterns: Ewing's-like, lymphoma-like, and spindle cell. All cases showed osteoid formation and a few had chondroid areas. There was cytoplasmic glycogen in ten cases. Initial treatment for MDAH patients included intraarterial infusion of cisplatin in ten, amputation in four, partial mandibulectomies in two, and biopsy with local radiotherapy and systemic chemotherapy in one. All POG patients had resection or amputation followed by adjuvant chemotherapy. Twelve patients are alive, of whom nine have had significant follow-ups for 25 to 90 months. Fourteen patients are dead of lung, spine, and brain metastases from 1 to 23 months after initial diagnosis. One patient is alive with lung relapse at 4 months. In summary, SCO is a high-grade variant of osteosarcoma, with an incidence of up to 4% of all osteosarcomas, that affects patients of the same age group and has the same anatomic location as conventional osteosarcoma. Currently, SCO appears to have a prognosis that is the same as or slightly worse than that of conventional osteosarcoma. Furthermore, although intraarterial infusion is effective for the primary tumors in the bone, distant metastases are difficult to control.

A prospective evaluation of a triple-drug regimen containing cisplatin, vinblastine, and dacarbazine (CVD) for metastatic melanoma

Based on the independent activity of cisplatin, vinblastine, and dimethyl-triazeno-imidazole-carboxamide (DTIC) (CVD), a combination of these agents was used in the treatment of patients with advanced melanoma. Vinblastine was used in a dose of 1.6 mg/m2/d for 5 days, DTIC was used in a dose of 800 mg/m2 intravenously (IV) on day 1, and cisplatin was used in a dose of 20 mg/m2/d for 4 days starting on day 2 of chemotherapy. The courses of chemotherapy were repeated at 3-week intervals. All patients were premedicated with antiemetics, and IV hydration was used before cisplatin. Fifty-two consecutive patients were registered and 50 were evaluable for response. Two patients achieved a complete response (CR) and 18 patients had a partial response (PR) for an overall response rate of 40% (95% confidence interval, 27% to 55%). The median duration of response was 9 months and the median survival time of the responders was 12 months. The overall median survival time of patients treated on this protocol was 9 months. The treatment was associated with significant toxicity consisting of nausea, vomiting, diarrhea, and partial hair loss. Additionally, neutropenia with a median nadir granulocyte count of 500/microliters was observed, and significant anemia required blood transfusions in a majority of the patients after three to four courses of chemotherapy. The dose-limiting toxicity was peripheral neuropathy which required discontinuation of cisplatin after six to eight courses of chemotherapy. We believe that this triple-drug regimen has significant activity that appears to be superior to the single-agent activity of these drugs, both in terms of increased response rate and duration of response.

Cholangiographically guided aspiration cytology in the management of malignant biliary obstruction

Fifteen patients with malignant biliary obstruction were subjected to fine needle aspiration cytology (FNAC) under fluoroscopic guidance. Fourteen (93%) of them were correctly diagnosed to have a malignancy at FNAC. Simultaneous with FNAC or at a later date, all the patients underwent percutaneous biliary drainage with a drop in serum bilirubin from a mean of 23.2 mg/dl to 8.5 mg/dl. Ten patients were subjected to exploratory laparotomy and biopsy at which the diagnosis of FNAC was confirmed in nine of them. The tenth patient with a negative yield at FNAC had a 1.0 cm cholangiocarcinoma. The usefulness of FNAC combined with biliary drainage as an alternative to surgery is highlighted.

Massive necrosis of fat and skin as complication of obesity

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The clinical spectrum of anomalous pancreatobiliary junction

Anomalous junction of pancreatobiliary ducts (AJPB) is known to be associated with choledochal cyst and gallbladder cancer. This report describes our experience with eight patients with AJPB, six of whom were diagnosed at endoscopic retrograde cholangiography and two at transhepatic cholangiography. Four of the patients with AJPB had an associated congenital choledochal cyst, two had a normal biliary tree and one each had inspissated bile syndrome and cholangiocarcinoma. The last two associations have not been previously described. It is felt that the clinical spectrum of AJPB may unfold further with the widespread use of the cholangiographic techniques.

Double blind study on the efficacy and safety of tetrabamate and chlordiazepoxide in the treatment of the acute alcohol withdrawal syndrome

1. Efficacy and safety of tetrabamate and chlordiazepoxide in the treatment of the acute or Primary Alcohol Withdrawal Syndrome (PAWS) were assessed during a randomized double blind clinical trial, carried out on sixty male alcoholic in-patients. 2. The two drugs were administered four times a day in double dummy conditions, according to a fixed-flexible decreasing dosage schedule (six days basic regimen). 3. Drug efficacy was measured daily throughout the study period using a battery of standard instruments for collecting quantitative clinical, behavioral, psychopathological and laboratory data. Side effects were daily recorded. 4. Tetrabamate was found to be as efficient as chlordiazepoxide in reducing the intensity of the PAWS, improving sleep and vital signs rapidly and alleviating anxiety progressively. 5. Tetrabamate was found particularly beneficial for severe tremor. Psychomotor and mood scores consistently favored tetrabamate, suggesting psychoanaleptic properties of this compound (increased diurnal vigilance). 6. Side effects were minimal with tetrabamate and generally of weak intensity with chlordiazepoxide. 7. The results of this study indicate that tetrabamate may represent a new alternative drug of choice for the therapy of the acute alcohol withdrawal syndrome.

Aberrant oncogene expression in uncultured human sarcoma and melanoma

Protooncogenes have the ability to induce and/or maintain the transformed state when they are overly expressed or altered by mutation or gene rearrangement. To study the possible involvement of these cellular oncogenes in the neoplastic transformation, we have analyzed their expression in 44 fresh samples obtained from primary, recurrent, or metastatic tumors from patients with a variety of sarcomas and a melanoma. Our analysis was carried out by the northern blot technique using poly (A)+ RNA hybridized with human cellular DNA probes. A normal 2.3-kb c-myc transcript was observed almost universally at various levels. A normal c-k-ras transcript of 5.2-kb was detected at a low level in most of the samples. In three samples we detected aberrant c-k-ras transcripts of 7.0 and 8.5-kb, while in two other samples we found an aberrant lower-molecular-weight transcript of 1.4-kb. N-myc was expressed in only three samples, and in all instances, the transcripts were aberrant (more than 10-kb). A normal 3.7-kb c-sis transcript was expressed at a low level in most of the sarcomas and the melanoma but was uniquely overexpressed in giant cell tumors of bone. C-fos (2.2-kb) was expressed at a low level in almost half of the samples; c-myb was never expressed. We conclude that c-k-ras, n-myc, c-sis, and c-myc are aberrantly or overexpressed in sarcoma/melanoma, and their activation may play a role in the transforming events leading to development and/or progression of these tumors.

Capgras syndrome: a case report from Zimbabwe

A case of Capgras syndrome in a black Zimbabwean patient is described. The syndrome occurs in the setting of a schizophrenic illness, but psychodynamic factors are readily identified despite the patient's different cultural background.

On the pathogenesis and therapy of dementia of the Alzheimer type: some neuropathological, biochemical, genetic and pharmacotherapeutic considerations

The extensive literature on dementia of Alzheimer type (DAT) testifies to the enormous progress achieved in the clinical and biochemical delineation of this disease. Newly developed laboratory and imaging techniques are also being applied to the diagnosis of DAT. Nevertheless, unequivoval diagnosis still relies primarily on morphological data from biopsy or autopsy. An overview is presented of major morphological changes occurring at different levels of organization in the central nervous system (CNS) in DAT. Currently formulated etiopathogenic hypotheses of DAT are reviewed and discussed in the context of morphological alterations. Some of the recombinant DNA methods, that are currently available for gene analysis, are described. Some approaches for studying Alzheimer specific genes using the above methods have been suggested. Finally, a critical overview of the current pharmacotherapeutic armamentarium used in DAT and senile dementia is presented. The efficacy, side effects, and the main mechanisms of action of the two categories of drug therapy -supposed etiopathogenic and symptomatic- are presented.

Ethanol metabolizing system in Drosophila. Aldehyde dehydrogenase: functional aspects in adult and during development

Alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) activities were determined in adult flies from several Drosophila species endowed with widely different tolerance to ethanol (ETOH). Plotting ALDH against ADH activities resulted in a high correlation coefficient (r = 0.966). This finding was confirmed in developmental studies. From early larval stage up to late adult life, DH and ALDH activities demonstrated almost parallel profiles. In the highly ETOH tolerant species D. melanogaster (D.m.), ADH and ALDH profiles were U-shaped: high activities in larvae, low activities in pupae and high activities in adults. In D. simulans (D.s.), a species less tolerant to ETOH, the profiles were L-shaped: high activities in larvae but low activities in both pupae and adults. Interestingly, similar activities (ADH and ALDH) were observed in the larvae of both species. Subcellular distribution studies of larval ALDH in both species revealed that the total ALDH activity is largely contributed by a mitochondrial high affinity enzyme. ALDH activity, clearly distinguishable from aldehyde oxidase (ALDOX), was visualized through analytical isoelectric focusing of the subcellular fractions. The estimated pIs for D.m. and D.s. were 4.9 and 5.2 respectively, thus different from those of ADH. The key biological role initially attributed to Drosophila ALDH is further supported by the present data. In addition the Drosophila developmental model opens new avenues for research on the study of genetic regulation of ADH and ALDH expression.

Aldehyde dehydrogenase in Drosophila: developmental and functional aspects

Alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH) activities were determined in adult flies from several Drosophila species endowed with widely different tolerance to ethanol (ETOH). Plotting ALDH against ADH activities resulted in a high correlation coefficient (r = 0.966). This finding was confirmed in developmental studies. From early larval stage up to late adult life, ADH and ALDH activities demonstrated almost parallel profiles. In the highly ETOH tolerant species D. melanogaster (D.m.), ADH and ALDH profiles were U-shaped: high activities in larvae, low activities in pupae and high activities in adults. In D. simulans (D.s.), a species less tolerant to ETOH, the profiles were L-shaped: high activities in larvae but low activities in both pupae and adults. Interestingly, similar activities (ADH and ALDH) were observed in the larvae of both species. Subcellular distribution studies of larval ALDH in both species revealed that the total ALDH activity is largely contributed by a mitochondrial high affinity enzyme. ALDH activity, clearly distinguishable from aldehyde oxidase (ALDOX), was visualized through analytical isoelectric focusing of the subcellular fractions. The estimated pIs for D.m. and D.s. were 4.9 and 5.2 respectively, thus different from those of ADH. The key biological role initially attributed to Drosophila ALDH is further supported by the present data. In addition the Drosophila developmental model opens new avenues for research on the study of genetic regulation of ADH and ALDH expression.

Osseous manifestations in congenital syphilis: a study of 55 cases

Radiology plays an important role in the early diagnosis of congenital syphilis. Osseous manifestations in 55 cases of congenital syphilis have been analysed and their radiological appearances described. In addition to the common findings of metaphysitis, periostitis and osteitis of the long bones, unusual involvement of the skull, mandible, nasal septum, scapulae and short bones of the hands and feet was observed.

Biochemical correlates of tolerance in rodents and in Drosophila. Possible role of alcohol dehydrogenase, aldehyde dehydrogenase and superoxide dismutase

In the rat, prolonged exposure to ethanol (ETOH) vapor induced an acquired increase in tolerance. After a single ETOH administration, the duration of recovery was decreased by 20% as compared to control animals and the rate of ETOH elimination from blood was increased by 27%. From the data obtained on liver enzymes--alcohol dehydrogenase (ADH), aldehyde dehydrogenase (ALDH) and superoxide dismutase (SOD)--it is suggested that the increased ALDH activity would be the consequence of an increased formation of the product of ETOH oxidation, the acetaldehyde. This over-production would not be accounted for by ADH. It is assumed that among others, the coupled reaction SOD-catalase would represent a possible alternate pathway. Data on Drosophila demonstrate that initial tolerance to ETOH is well correlated with ADH activity. It is suggested that ETOH metabolites (mainly acetaldehyde) would act also as determinant of this initial tolerance. The value of Drosophila as animal model for the study of behavioral and biochemical correlates of initial tolerance is discussed.

Congenital duodenal stenosis. The duodenal cervix sign

A case of congenital duodenal stenosis is reported complicated by recurrent pancreatitis. The diagnosis was not initially entertained because of the pancreatitis. The radiographic appearance on gastrointestinal series was unusual for pancreatitis. The finding of an anomalous celiac axis on arteriography suggested the possibility of other congenital anomalies. The diagnosis of congenital duodenal stenosis was confirmed at laparotomy. The obstruction was relieved with a duodenojejunostomy. Two year follow-up reveals the patient to be asymptomatic without recurrence of pancreatitis. This is the first endoscopic report of this lesion and the presence of the duodenal cervix sign should suggest the diagnosis of congenital duodenal stenosis.