Prediction of amputation wound healing with skin perfusion pressure

PURPOSE

The purpose of this study was to determine whether laser Doppler skin perfusion pressure (LD-SPP) could accurately predict amputation wound healing.

METHODS

We studied a total of 62 limbs in 52 patients (28 men and 24 women) with a mean age of 62.2 years (range 34 to 93 years). From this, 39 limbs underwent major amputation (15 above-the-knee, 24 below-the-knee), and 23 limbs underwent minor amputations (4 transmetatarsal and 19 toes). There were five postoperative deaths, leaving a total of 57 limbs available for analysis.

RESULTS

Three of 13 above-knee amputations failed to heal. Twenty-one of 23 below-knee amputations healed. Three of four transmetatarsal amputations failed to heal and eight of 17 toe amputations failed to heal. Binary table analysis showed that an LD-SPP value of 30 mm Hg or greater had a negative predictive value (healing occurred) of 90%. An LD-SPP value of less than 30 mm Hg at the amputation site had a positive predictive value (healing failure) of 75%, (p < 0.001, chi square analysis). For major amputations, negative predictive value was 100%, and positive predictive value was 83%, (p < 0.001). For minor amputations, negative predictive value was 75% and positive predictive value was 66.7%, (p < 0.09).

CONCLUSION

These data support the use of the LD-SPP test in the selection of major amputation level consistent with healing in ischemic limbs. Further study of the value of this parameter in the determination of minor amputation wound healing is necessary.

"In-situ" Teicoplanin for central venous catheter infection

Infection of central venous catheters (CVC) is a relatively common occurrence in immunocompromised patients, management of which has included I.V. antibiotics +/- removal of catheter. We have previously demonstrated that intracatheter administration of Amikacin empirically, successfully eradicated all bacterial infections except those due to S. epidermidis. A study was subsequently undertaken to treat gram positive cocci infections of CVC with intracatheter Teicoplanin. Eleven patients attending a single institution with documented gram positive cocci infection of CVC over a one year period were included in the study. Teicoplanin was instilled with heparinised saline once daily into the infected lumen of the CVC and allowed to remain for 24 hours. Treatment was continued for 48 hours after negative cultures were reported. Teicoplanin was successful in eradicating infection in 100% of cases. Mean duration of treatment was six days (range 4-9 days). Four patients subsequently developed a further infection, a mean of 13 weeks from first infection, only one of which was due to the same organism and this was successfully treated by a further course of Teicoplanin. No side effects were reported and catheter life was prolonged a mean of 132 days after completion of treatment. The use of Teicoplanin in this way for treatment of gram positive cocci infection of CVC is highly effective; once daily administration of antibiotic enables treatment to be given on an outpatient basis, thereby minimising hospital admission.

Reproductive behaviour in schizophrenia relative to other mental disorders: evidence for increased fertility in men despite decreased marital rate

Using case register data, the overall marital rate among 5158 patients with mental illness was found to be comparable to the general population. The proportion of those ever married was markedly reduced in the schizophrenic group relative to those with a manic or neurotic illness. Men with schizophrenia had a particularly low rate of marriage. The overall marital fertility of the 3 groups was comparable to each other and appeared to be higher than that in the general population. In the schizophrenic group only, married men, particularly those with a family history of mental disorder, produced more children than married women. Men might represent a more fertile group of schizophrenic patients with some biological advantage of increased fecundity, which may help to compensate for negative selection pressures.

Immunological events in regressing genital warts

Little is known of the in vivo role of the immune system in controlling human papillomavirus infection in the genital tract. The authors have studied 125 closely monitored patients with genital warts. Of these 125 patients, wart regression was seen in 28 patients. This study provides evidence that clearance of human papillomavirus from the genital tract is characterized by an active cell-mediated immune response. Regressing warts (n = 14) contained significantly more T lymphocytes (P < .05, Wilcoxon rank sum test) and macrophages (P < .01) than did nonregressing controls (n = 14). CD4-positive lymphocytes predominated in regression, both within the wart stroma and the surface epithelium, where there was a significant change in the ratio of CD4+ to CD8+ cells (P < .01). Lymphocytes in regression also showed greater expression of activation markers, and the majority were of the "antigen-experienced" phenotype. There was no difference in Langerhans cell numbers, although there was significant induction of the immune accessory molecules HLA-DR and ICAM1 (P < .05) on keratinocytes, and E-selectin and VCAM1 (P < .05) on endothelial cells in regressing warts. The changes in regression are consistent with a delayed-type hypersensitivity reaction to foreign antigen, and the ability to induce and mount such a response may be a critical determinant of effective natural immunity to the genital HPVs. Specific targeting of delayed-type hypersensitivity responsiveness may increase the efficacy of strategies for immuno-intervention against HPV infection in the genital tract.

Screening for cervical abnormalities in women with anogenital warts in an STD clinic: an inappropriate use of colposcopy

An audit of the use of colposcopy in women with anogenital warts was performed. Fifty women attending a clinic for sexually transmitted diseases in a District General Hospital with anogenital warts were examined by cervical cytology and colposcopy for cervical infection by human papillomavirus (HPV) or epithelial abnormality indicating cervical intraepithelial neoplasia (CIN) or both. Collated results showed a high prevalence of both conditions in these 50 women; 20 (40%) had evidence of cervical infection by HPV and 11 (22%) epithelial abnormalities consistent with CIN 1 or 2. However, neither CIN 3 nor invasive disease was detected. Colposcopy in this setting was shown to be a specific but insensitive tool and its role in the routine management of women with anogenital warts at our institution is not warranted.

Detection and inheritance of RFLPs in Eucalyptus nitens

The level of polymorphism using genomic and cDNA probes with a number of restriction enzymes and the inheritance of the RFLP loci was investigated in E. nitens. The polymorphism detected with 366 genomic and cDNA probes and three to six restriction enzymes was analysed in three-generation outbred pedigrees. No difference in the level of polymorphism detected with genomic versus cDNA probes was observed. There was a difference in the efficiency of detection of polymorphism with six different restriction enzymes, with three of the enzymes (BglII, DraI and EcoRI) showing substantially more polymorphism than the others. There was no significant correlation between the size of the DNA fragments generated by the enzymes and the detection of polymorphism. Several cases of restriction-site mutations resulting in a polymorphism were observed. The inheritance of 69 loci was analysed in two pedigrees resulting from interpopulational crosses. The majority of the loci segregated according to expected ratios with distortion observed in only 3% of loci. Probes from the cDNA library detected a greater proportion of loci with more than two alleles than did probes from the genomic library. The high polymorphism, large number of alleles, and ease of interpretation of RFLPs in E. nitens means that they will be useful in a range of applications such as genetic linkage maps and paternity analysis.

Further evidence for anomalies in the hand-prints of patients with schizophrenia: a study of secondary creases

Finger and palm prints from 46 ICD-9 schizophrenic patients and 43 age and sex matched normal controls were examined independently and blind to diagnosis, by four raters. Seven prints were judged to have very high densities of secondary creases. These abnormal prints were all from the schizophrenic group. Patients with high densities of creases were more severely ill, having had more than five admissions to hospital and higher doses of neuroleptic medication. There was a trend for such patients to have had a complicated obstetric history and an earlier onset of their illness.

Meningococcal disease in childhood--a regional study in Ireland

A retrospective study of microbiology laboratory records of culture-confirmed cases of meningococcal disease in children under 14 years of age, admitted to four Dublin hospitals, was conducted for the period 1981-1991 inclusive. The study aimed to describe the epidemiology of meningococcal disease in childhood and to assess the potential of meningococcal group A and C vaccine in preventing disease. There were 406 cases of meningococcal disease of which 319 (78.6%) were in children under 5 years of age. The meningitis to septicaemia ratio was almost 4:1 (320 vs. 86 cases). Of the 406 cases, 216 (53.2%) cases occurred during the period November to March. The age-specific annual incidence rates for the Eastern Health Board region served was 64.2 per 100,000 under 1 year of age and 24.6 per 100,000 under 5 years of age. A relative increase in disease caused by meningococcal serogroup C was observed during the period of the study. Only 15% all cases could have been prevented by a policy of universal meningococcal group A and C immunisation at 2 years of age. Such a policy, therefore, is not recommended. A vaccine for preventing disease caused by meningococcal group B is urgently required.

Oral sumatriptan compared with placebo in the acute treatment of migraine

This multicentre, double-blind, parallel-group study compared the efficacy, safety and tolerability of oral sumatriptan, given as a new film-coated tablet, with placebo in the acute treatment of migraine. Patients were randomised unequally (1:2) to receive placebo or sumatriptan. Eighty-eight patients received placebo (plus an optional dose 2 h later if the headache persisted plus a further optional dose for recurrence within 24 h) and 162 patients received sumatriptan 100 mg (plus an optional 100 mg dose at 2 h and an optional 100 mg dose within 24 h). Sumatriptan was significantly more effective than placebo at relieving headache (defined as reduction in severity from severe or moderate pain to mild or no pain) at 2 h (51% versus 31%, P = 0.003) and 4 h (71% versus 35%, P < 0.001). Fewer sumatriptan-treated patients required a second dose compared with placebo-treated patients (49% versus 74%, P < 0.001). More sumatriptan-treated patients were completely pain free compared with placebo-treated patients at both 2 h (24% versus 12%) and 4 h (48% versus 18). Patients receiving sumatriptan reported earlier onset of headache relief than patients receiving placebo. Headache relief in sumatriptan-treated patients was similar, irrespective of the type of migraine (with or without aura) or the time of treatment < or = 4 h or > 4 h after onset of migraine). Sumatriptan was more effective than placebo at relieving nausea, vomiting and photophobia/phonophobia. Few patients were evaluable for treatment of headache recurrence, and statistical analysis was not possible.(ABSTRACT TRUNCATED AT 250 WORDS)

Urethane anesthesia reverses the protective effect of noncompetitive NMDA receptor antagonists against cocaine intoxication

The present experiments examined whether pretreatment with the noncompetitive N-methyl-D-aspartate (NMDA) receptor antagonists, MK-801 and dextrorphan, could antagonize cocaine-induced convulsions and lethality in conscious Sprague-Dawley (SD) rats and whether urethane anesthesia alters the observed interactions. Conscious, restrained male SD rats received continuous i.v. infusions of cocaine hydrochloride (1.25 mg/kg.min) until convulsions and death occurred. Cocaine doses of 21.2 +/- 1.8 and 29.5 +/- 2.5 mg/kg caused convulsions and death, respectively, in saline treated rats (n = 8). Convulsions were absent in MK-801 (1 mg/kg, i.v.; n = 8) pretreated rats; the lethal cocaine dose was 44.0 +/- 2.7 mg/kg (p < 0.05). In contrast, urethane anesthesia (1.2 g/kg, i.p.) decreased the dose of cocaine required to cause toxicity, compared to that in saline controls (24.8 +/- 0.8 mg/kg, n = 13), in MK-801 (2.0 +/- 0.3, n = 7; p < 0.01) and in dextrorphan mg/kg, n = 13), in MK-801 (2.0 +/- 0.3, n = 7; p < 0.01) and in dextrorphan (25 mg/kg, i.v.; 13.1 +/- 1.4, n = 6; p < 0.01) pretreated rats. Pressor responses with little change in heart rate were evident during cocaine infusion in vehicle pretreated rats. Bradycardiac responses were noted to cocaine in groups following NMDA receptor blockade. Reversal of the pressor response to cocaine was noted in MK-801 pretreated animals, while dextrorphan pretreatment moderated cocaine-induced increases in blood pressure. Ventilatory support protected against cocaine lethality in urethane anesthetized rats, indicating that respiratory failure is the proximate cause of death with cocaine infusion. However, artificially ventilated rats, pretreated with MK-801, were more sensitive (lethal cocaine dose, 76.6 +/- 8.0 mg/kg, n = 5) than vehicle pretreated rats (129.4 +/- 15.8 mg/kg, n = 6), indicating that MK-801 may increase both the respiratory and the cardiac toxicity of cocaine in urethane anesthetized rats. Interactions between NMDA receptors and cocaine are modified by urethane anesthesia.

Interferon alpha and doxorubicin in malignant mesothelioma: a phase II study

BACKGROUND

Malignant mesothelioma is a tumour which is generally resistant to chemotherapy. While the addition of interferon to chemotherapy improves response rates in some other malignancies, such a combination has not been evaluated in the treatment of mesothelioma.

AIMS

To assess the anti-tumour effects and toxicity of interferon-alpha combined with doxorubicin in the treatment of pleural mesothelioma.

METHODS

Twenty five patients (mean age 54 +/- 11 years) were enrolled in a phase II study. All patients had a confirmed histological diagnosis, measurable tumour, a life expectancy of at least three months, and no prior chemotherapy or interferon. Interferon alpha-2a, 9 x 10(6) U sc daily, was administered together with doxorubicin 25 mg per m2 i.v. weekly, for 12 weeks. Response status was assessed by tumour measurements on clinical examination and thoracic CT scans before and after treatment.

RESULTS

A partial response was observed in four patients (16%; 90% CI, 8-30%), 11 remained stable, while six had progressive disease. Four patients withdrew within the first month because of toxicity. The median survival of all patients was 11 months (95% CI, 3-19). Dose modification as a result of toxicity was required in all patients. Lethargy, weight loss, leukopenia and vomiting were the most common side effects.

CONCLUSIONS

The combination of interferon-alpha and doxorubicin showed only modest activity and was associated with significant toxicity. It cannot be recommended in the treatment of malignant pleural mesothelioma.

The economic burden of unrecognized vasodepressor syncope

BACKGROUND

The objective of this study was to describe the cost of prior diagnostic evaluation in patients referred for evaluation of syncope whose history was typical of vasodepressor syncope.

METHODS AND RESULTS

Thirty consecutive patients who were referred for evaluation of syncope of undetermined origin and whose history was highly suggestive of vasodepressor syncope participated in this study. These 30 patients represented 19% of 158 patients referred for evaluation of syncope during the period of enrollment. All patients had positive results of an upright-tilt test, confirming the diagnosis of vasodepressor syncope. At the time of evaluation, the type and results of all diagnostic tests that had been performed prior to referral were recorded for each patient. The cost of diagnostic testing was then determined based on the 1991 cost of these tests at the University of Michigan Medical Center. A mean of 4 +/- 2 major diagnostic tests were performed before referral to the University of Michigan Medical Center. The mean and median costs of diagnostic testing per patient prior to referral were $3,763 +/- 3,820 and $2,678 (range: 0 to $16,606) respectively. Six patients underwent no major diagnostic tests prior to referral and, therefore, the cost of major diagnostic testing was zero in these patients. In the remaining patients, the mean and median costs of diagnostic testing per patient were $4,704 +/- 3,713 and $3,777 (range: $1,025 to $16,606) respectively.

CONCLUSIONS

The results of this study demonstrate that a diagnosis of vasodepressor syncope can be established clinically in approximately 20% of patients referred to a university hospital for evaluation of syncope of undetermined origin. Failure to recognize the clinical features of vasodepressor syncope in these patients resulted in up to $16,000 of unnecessary diagnostic testing. A greater awareness of the clinical features of vasodepressor syncope may, therefore, result in significant economic savings.

Randomized comparison of the effects of tamoxifen, megestrol acetate, or tamoxifen plus megestrol acetate on treatment response and survival in patients with metastatic breast cancer

BACKGROUND

The antioestrogen tamoxifen and progestins act via different receptors and may therefore have complementary effects against human breast cancer. This possibility was tested in a randomized study which compared the effects of tamoxifen, standard-dose megestrol acetate, and these two agents in combination, in patients with metastatic breast cancer.

PATIENTS AND METHODS

184 post-menopausal patients with metastatic breast cancer were randomized to initial treatment with either tamoxifen (TAM) 40 mg daily, megestrol acetate (MA) 160 mgm daily, or the combination of the two administered simultaneously. Patients crossed over to the alternative single agent on relapse or disease progression. Patients were evaluated for response, time to initial and ultimate treatment failure, and survival.

RESULTS

There were no significant differences between the three groups with respect to response rates, nor the other parameters. Patient survival was significantly associated with age > 60 years, ER positive status, and the absence of visceral metastases.

CONCLUSIONS

TAM and MA are both equally effective in response induction as initial treatments and the combination has no advantage. Sequential treatment is still optimal, TAM being the preferred initial agent in view of the reported side effects with MA.

The ethics of role conflict in research

While engaged in interviewing stroke patients, nurses found their research responsibilities conflicting with traditional patient care values. At the termination of the pilot project, the nurses, doubting their role, shared their concerns with the research team. They made recommendations regarding the appropriateness of tools and training needs of research assistants. Unresolved role conflict motivated the nurses to review the literature, seeking answers to the issue. Other nurses have experienced this same conflict. While nursing has been referred to as a profession that complements art with science, in practice, altruism may conflict with maintaining research integrity. The nurse, when functioning as a researcher, may find situations where a choice needs to be made whether to implement nursing interventions or continue the research protocol. The difficulty remains in deciding when the patient advocate role takes precedence over other legitimate concerns. Even though the ANA Code for Nurses with Interpretive Statements requires that the nurse participate in research to advance the profession's body of knowledge, the code's primary principle mandates respect for the rights of the individuals the nurse serves. Research need not be undertaken at the expense of human dignity. If conflicts develop, nursing's primary responsibility is to the individual. Concern for the individual always takes precedence over maintaining research integrity. Nurses are "advocates, where trust, compassion, and empathy encompass all our nursing endeavors, including research" (p. 161). While striving to achieve research goals, nurses must not lose sight of the traditional values inherent in nursing.

Clinical features and management of recurrent balanitis; association with atopy and genital washing

OBJECTIVE

To evaluate clinical features and diagnostic investigations in patients with recurrent or unresponsive balanitis in order to institute rational management.

DESIGN

Forty-three patients presenting to a genitourinary medicine clinic with recurrent or persistent balanitis were studied. All patients were asked whether they had a history of atopic illness and about their practice of genital washing. All patients were investigated by taking a swab specimen from the preputial area for bacterial and viral culture and 30 underwent biopsy of the affected skin. Follow-up was between three and six months.

SETTING

Outpatient genitourinary medicine clinic, St Mary's Hospital, London, UK.

RESULTS

In 31 (72%) of the patients a diagnosis of irritant dermatitis was made. In comparison with the remaining patients, they had a greater lifetime incidence of atopic illness and more frequent daily genital washing with soap. For 28 (90%) of these patients, use of emollient creams and restriction of soap washing alone controlled symptoms satisfactorily. For the remaining 12 patients, a variety of diagnoses were made. Biopsy proved a well tolerated and diagnostic investigation, but the isolation of microbial pathogens from preputial swabs was irrelevant to management.

CONCLUSION

A history of atopic illness and of the practice of penile washing are important aspects in the evaluation of patients with recurrent balanitis. Biopsy is an important investigation in the condition when it does not seem to be caused by irritant dermatitis.

A new method for the concentration of Cryptosporidium oocysts from water

A novel method for the concentration of Cryptosporidium oocysts from water has been developed, based upon the precipitation of calcium carbonate. A 10 l water sample is treated by adding solutions of calcium chloride and sodium bicarbonate and raising the pH value to 10 with sodium hydroxide. Crystals of calcium carbonate form and enmesh particles in the Cryptosporidium oocyst size range. The crystals are allowed to settle, the supernatant fluid is discarded and the calcium carbonate precipitate dissolved in sulphamic acid. The sample can be concentrated further by centrifugation. Recoveries of oocysts from seeded samples of deionized, tap and river water were in excess of 68%.

The importance of bleomycin in combination chemotherapy for good-prognosis germ cell carcinoma. Australasian Germ Cell Trial Group

PURPOSE

In an effort to maintain the excellent long-term results achieved with combination chemotherapy for good-prognosis germ cell carcinoma, but to reduce the toxicities encountered, a randomized trial was conducted comparing cisplatin and vinblastine with or without bleomycin.

PATIENTS AND METHODS

Two hundred eighteen assessable patients with a good prognosis were randomized to receive induction chemotherapy with cisplatin 100 mg/m2 intravenously (IV) day 1 and vinblastine 6 mg/m2 IV days 1 and 2 every 3 weeks (PV) with or without bleomycin 30 mg intramuscularly (IM) weekly (PVB) for a maximum of 12 weeks. Once maximum response was achieved, patients with a complete remission (CR) received two courses of consolidation chemotherapy, while those with residual abnormalities and normal tumor markers underwent surgical resection whenever possible.

RESULTS

Toxicities encountered in this study were clearly greater for those patients who received bleomycin, with significantly more leukopenia, thrombocytopenia, anemia, alopecia, and renal and pulmonary toxicities. The proportion of patients who achieved CR and had no evidence of disease (resection of all viable malignancy) was 89% for PV and 94% for PVB (P = .29). After a minimum of 4 years of follow-up, relapses have occurred in 7% of patients who received PV and 5% who received PVB. A total of five patients on each therapy arm were successfully treated with further salvage chemotherapy and surgery. Thus, deaths from progressive malignancy have occurred in 15% of patients on PV and 5% on PVB (P = .02), a rate that was partly offset by the higher proportion of toxic deaths with PVB (P = .06).

CONCLUSION

Despite the toxicities encountered with bleomycin in cisplatin-based combination chemotherapy for these patients, complete deletion of this drug compromises therapeutic efficacy.

Routine monitoring of Cryptosporidium oocysts in water using flow cytometry

A flow cytometric method for the routine analysis of environmental water samples for the presence of Cryptosporidium oocysts has been developed. It uses a Coulter Epics Elite flow cytometer to examine water samples and to separate oocysts from contaminating debris by cell sorting. The sorted particles are then rapidly screened by microscopy. The method has been evaluated and compared with direct epifluorescence microscopy on 325 river, reservoir and drinking water samples. The technique was found to be more sensitive, faster and easier to perform than conventional epifluorescent microscopy for the routine examination of water samples for Cryptosporidium.

Susceptibility of type I collagen containing mutated alpha 1(1) chains to cleavage by human neutrophil collagenase

Two members of the matrix metalloproteinase family which can cleave native types I, II and III triple helical collagens are collagenases from fibroblasts and neutrophils. These enzymes are the products of different genes which share structural motifs but are only 57% identical. In this study, we determined the site of cleavage in the alpha 1(I) chains and showed that the neutrophil collagenase acted at the same site as the fibroblast collagenase. We also used collagens as substrates which were generated by site-directed mutagenesis of the murine Col1a1 gene and found that the pattern of susceptibility to cleavage by purified neutrophil collagenase was indistinguishable from that previously described for the fibroblast collagenase. Collagens containing substitutions of Pro for Ile-776 (P1) were not cleaved; whereas those containing substitutions of Met for Ile-776 were cleaved. Type I collagen which contained alpha 1(I) chains in which there were double substitutions of Pro for Gln-774 (P2) and Ala-777 (P2') were also not cleaved. These type I collagens contained wild type alpha 2(I) chains as well as mutant alpha 1(I) chains in the mixed helical trimers; the alpha 2(I) chain in the trimers containing the resistant alpha 1(I) chains were also not cleaved by the neutrophil collagenase.

Prognostic value of quality-of-life scores during chemotherapy for advanced breast cancer. Australian New Zealand Breast Cancer Trials Group

PURPOSE

We observed that quality-of-life (QL) scores, collected to evaluate treatment in a randomized trial in advanced breast cancer, predicted survival duration. This report explores the prognostic associations between QL and survival in more detail.

PATIENTS AND METHODS

In a randomized clinical trial comparing intermittent and continuous therapy policies for patients with advanced breast cancer, QL was measured by linear analog self-assessment (LASA) and the Quality-of-Life Index (QLI). Baseline scores and subsequent changes were included in statistical models of survival duration, with and without other prognostic factors.

RESULTS

Physician assessment of QLI and patient LASA scores for physical well-being (PWB), mood, nausea and vomiting, appetite, and overall QL (but not pain) at the commencement of treatment were significant predictors of subsequent survival. Scores for PWB and QLI were independent of other prognostic factors. Changes in scores were also prognostically important. Both baseline and change in scores for PWB, mood, pain, and QLI after the first three treatment cycles, but before an arbitrary 180-day time point, were significantly predictive of survival beyond that time. Both QLI and PWB were prognostically independent of tumor response. Although QL improvement was correlated with tumor response, continuous therapy yielded significantly better QL scores, even in nonresponders.

CONCLUSION

These findings support the validity of the simple QL measures used in the trial. They are compatible with the simple explanation that patients perceive disease progression before it is clinically evident, but also with a causal relationship between QL and survival duration.

Embryogenesis and Larval Development of the Asteroid Patiriella regularis Viewed by Light and Scanning Electron Microscopy

The sea star Patiriella regularis (Verrill, 1867) has indirect development through bipinnaria and brachiolaria larvae. Development of this species is typical of asteroids with planktotrophic larvae and takes 9-10 weeks. The embryos develop through a wrinkled blastula and hatch as early gastrulae. In contrast to most asteroids, a third enterocoel forms on the left side of the stomach of the bipinnaria. This structure gives rise to the left posterior coelom; its significance is discussed. We suggest that this coelom is homologous to the trunk coelom in enteropneust embryology. The surface features of the larvae were examined by scanning electron microscopy. Newly hatched gastrulae are covered by cilia, and the bipinnaria have bands of cilia that follow the contours of the larval processes. A previously undescribed plug-like structure positioned on the post-oral surface appears to function as a seal for the mouth. Brachiolaria larvae have three brachiolar arms and a centrally located adhesive disc. Each arm is covered by adhesive papillae. Raised epithelial cells that dot the surface of the papillae and adhesive disc may be batteries of secretory cells. The brachiolar arms have an extracellular coat that may serve as a protective cover for the adhesive surfaces. Competent brachiolaria swim along the substratum and exhibit searching behavior with flexure of the median brachium. They settle on the undersides of natural shell substrata and do not respond to a primary algal film. Shade appears to be an important factor in settlement and metamorphosis in P. regularis. Metamorphosis takes 5-6 days, and the post-larvae take up a free existence at a diameter of 450-500 {mu}m. The indirect development of P. regularis contrasts with the lecithotrophic and viviparous modes of development of other Patiriella species and provides the comparative basis to determine the ontogenic changes involved with evolution of direct development in the genus. The use of the divergent life histories of Patiriella as a model system for the study of evolutionary change in development is discussed.

Laparoscopic cholecystectomy: use and preparation for Operation Desert Shield

While stationed at Winn army hospital, Fort Stewart, Georgia as backfill surgeons during the initial stages of Operation Desert Shield, we performed eight laparoscopic cholecystectomies (LC) over a 2 1/2 week period. Our patients included four active duty soldiers, three dependents, and one retiree. There were no complications. The average hospital stay was 2 days, and the average time to return to duty was 10 days for LC compared to 5 and 30 days, respectively, with standard cholecystectomy (SC). Performing LC whenever possible can return soldiers back to duty in one-third the time and greatly reduce health care costs by reducing the hospital stay.

Risk factors of female HIV-seropositive patients attending the clinic for sexually transmitted diseases at St Mary's Hospital, London

Of 3450 women tested for antibodies to human immunodeficiency virus HIV-1 and HIV-2 between September 1985 and July 1989, 61 were positive (1.8%). Twenty-seven of these (44%) were presumed to have acquired their HIV infection by heterosexual contact and 23 (38%) were intravenous drug addicts. In geographical origin, 23 (38%) of the patients were from the UK and 19 (31%) from Africa. Amongst these 61 women, 2 (3%) have since died, one committed suicide and one was suspected of committing suicide.

A randomised trial of cisplatin and vindesine versus supportive care only in advanced non-small cell lung cancer

The value of chemotherapy in advanced non-small cell lung cancer (NSCLC) remains contentious. Because of this two separate but very similar trials were set up in Australia and Southampton (UK). Two hundred and one patients with stage IIIb or IV NSCLC were randomly assigned to cisplatin 120 mg m-2 on days 1 and 29 and vindesine 3 mg m-2 weekly x 6 or to no chemotherapy. Both groups were eligible to receive radiotherapy or other palliative treatment as required. Of 188 evaluable patients, 97 received chemotherapy and 91 were in the control arm. Response was assessed between days 42 and 49. Responders continued chemotherapy at the same doses though cisplatin being given 6 weekly x 4 and the vindesine 2 weekly x 12. The overall response rate to chemotherapy was 28%; there were no significant differences according to major prognostic criteria. Although the overall survival of the chemotherapy group (median 27 weeks) was longer than that of the no chemotherapy group (median 17 weeks) this was not statistically significant (log rank P = 0.33). For patients without dissemination (IIIb), median survival was 45 weeks in the chemotherapy arm and 26 weeks in the non-chemotherapy (log rank P = 0.075). Toxicity was universal and frequently severe: of 17 patients discontinuing chemotherapy after one cycle, 13 did so because of unacceptable toxicity. This chemotherapy cannot be recommended as routine treatment. Further phase III studies of chemotherapy in advanced NSCLC should continue to use a no chemotherapy control and should also attempt to measure quality of life, an issue not addressed effectively in this or other recent trials.

Management of children with short stature

325 patients referred to an endocrine clinic with short stature were reviewed, 32 (9.8%) were above the third centile for height and maintained normal growth velocities, fourteen (4.3%) have not had assessment completed. Of 279 children in whom the cause of short stature was established, 140 (50%) had constitutional short stature/delayed puberty (CSS/DP). Seventy-three (26%) had idiopathic growth hormone deficiency (GHD), complete in 23, while 66 patients (34%) had short stature due to other causes. Girls presented earlier (mean age 11.9) than boys (mean age 13.3) and GHD patients earlier than CSS/DP patients with bimodal peaks at 12 and 16 years. Male CSS/DP patients reached their mid pubertal point later than normal at 16.06 +/- 1.19 years (p less than .05) while in GHD males the mid pubertal age was 16.6 years (p less than .05). In female patients with short stature no significant pubertal delay was observed. The average growth velocity of complete GHD patients pre treatment was 3.7 cms/year. Velocity rose to 6.2 cms/year on human growth hormone (HGH) extract and rose further to 8.1 cms/year on biosynthetic HGH. In partial GHD patients the average pre-treatment velocity of 4.3 cm/year rose to an average of 6.0 cm/yr on HGH extract and maintained this velocity on biosynthetic HGH.

Effective salvage chemotherapy with etoposide, dactinomycin, and methotrexate in refractory germ cell cancer. Australasian Germ Cell Trial Group

Fifty-one patients with advanced germ cell malignancy who had either failed to achieve complete remission with initial cisplatin, vinblastine, and bleomycin chemotherapy or who had relapsed after complete response (CR) to this therapy and then proven refractory on retreatment, were treated with etoposide (75 mg/m2 for 3 days), dactinomycin (1 mg/m2 day 1), and methotrexate (30 mg/m2 day 1) (EAM) every 3 weeks. Courses were continued until maximum response without empirical limit, and if complete remission was achieved, two courses of consolidation therapy were given before cessation of treatment. Thirteen patients (25%) were complete responders with residual masses containing fibrosis or benign teratoma being subsequently resected in seven patients. Two patients had persisting viable carcinoma within residual masses that were completely resected, leaving no evidence of disease (NED); the combined CR plus NED rate was 29%. The only pretreatment factor significantly influencing this response rate was tumor volume. Toxicities were moderate, with leukopenia being observed in 28% of patients, but it was severe in only 2%. There was one death from septicemia. Severe nausea and vomiting occurred in only 9% of patients and treatment-related stomatitis was observed in 42%. All patients achieving CR plus NED have been followed for a minimum of 5 years and no relapses have occurred, suggesting that these patients are cured. Unlike other regimens of salvage chemotherapy, this treatment program did not contain cisplatin and it is contended that a completely noncrossresistant drug regimen based on etoposide provides the opportunity to further improve the curability of patients with advanced germ cell cancer.

Growth factors influencing bone development

We have approached the study of growth factors affecting cartilage and bone development by investigating those factors present in bone which are able to initiate new cartilage and bone formation in vivo. This has led to the identification and molecular cloning of seven novel human factors which we have named BMP-1 through BMP-7. Six of these molecules are related to each other, and are also distantly related to TGF-beta. The presence of one of these molecules, recombinant human BMP-2 (rhBMP-2) is sufficient to produce the complex developmental system of cartilage and bone formation when implanted subcutaneously in a rat assay system. In this model, administration of rhBMP-2 ultimately results in the formation of a piece of trabecular bone, which is filled with mature bone marrow. While our studies demonstrate that rhBMP-2 by itself has the ability to induce cartilage and bone formation in vivo, we find other BMP molecules present along with BMP-2 in our highly purified nonrecombinant bone-inductive material. These results suggest that the bone inductive capacity of bone-derived proteins may reside in the combinatorial or synergistic activities of this set of BMP-2 related molecules.

Dose intensity and outcome with combination chemotherapy for germ cell carcinoma. Australasian Germ Cell Trial Group

Two hundred and fifty-three patients with advanced stage germ cell carcinoma received induction chemotherapy with vinblastine, bleomycin and cisplatin, sometimes with subsequent surgical resection of residual masses. Overall, 191 patients (76%) achieved complete remission or no evidence of disease after surgery (CR + NED). With 64 months median follow-up only 24 patients have relapsed (13%) and 68% of all patients treated are long-term survivors and 84% of patients entering CR + NED are alive. Toxicity with this chemotherapy was considerable, including seven deaths from leukopenia and septicaemia and eight deaths from bleomycin lung toxicity. Dose reductions or omissions of the drug from the treatment programme was necessary with cisplatin in 8% of patients, with vinblastine in 37% and with bleomycin in 35% of patients. Analysis of these alterations in dose intensity for each drug revealed that initial treatment response and subsequent survival were not compromised by reductions in intended doses of drug administered for either vinblastine or bleomycin. Too few patients had dose reductions of cisplatin for meaningful analysis. This apparent lack of major dose-response effect for either vinblastine or bleomycin in the present treatment programme for germ cell carcinoma has prompted the initiation of a randomized study to determine whether deletion of bleomycin from treatment for patients with good prognostic pretreatment characteristics improves the therapeutic index of this very successful therapy.

Psychosocial implications of recurrent genital herpes simplex virus infection

Fifty seven patients experiencing first attacks of genital herpes simplex virus infection (HSVI) were compared with 50 patients who were concerned about frequently recurring attacks despite routine counselling and reassurance. Using the general health questionnaire this latter group was found to be more psychologically distressed and more socially naive than the first attack group, as measured by socioeconomic class and the lie score of the Eysenck personality questionnaire; otherwise the two groups were similar. Patients presenting to clinics with frequently recurring genital HSVI may therefore be especially psychologically distressed, socially naive, and disadvantaged. Managing these patients needs to include understanding these problems as well as giving advice and using antiviral agents.

Callus formation and plantlet regeneration from protoplasts derived from suspension cultures of wheat (Triticum aestivum L.)

Protoplasts were isolated from anther-derived suspension cultures of commercial wheat (Triticum aestivum L. cv. Chris). The protoplasts were released enzymatically and isolated by centrifugation on a sucrose cushion. The isolated protoplasts were initially cultured in a liquid medium in the dark. Numerous microcalli were produced under these conditions, some of which differentiated into globular embryos. Upon transfer to a solid medium and exposure to 16h/8h light/dark cycle, the protocalli proliferated and many of the somatic embryos matured. Complete plantlets were obtained and maintained in sterile culture.

A prospective study of cisplatin-based combination chemotherapy in advanced germ cell malignancy: role of maintenance and long-term follow-up

Two hundred fifty-three patients with advanced germ cell malignancy received initial chemotherapy with cisplatin, vinblastine, and bleomycin followed by surgical resection of residual masses if possible. Patients achieving complete remission (CR) were prospectively randomized to receive 6 months maintenance therapy with vinblastine or no further treatment. CR was achieved in 183 patients (72%) and a further eight patients (4%) had complete resection of residual viable malignancy (no evidence of disease [NED]). Pretreatment factors having a significant adverse influence on response by univariate analysis included extragonadal origin of the tumor, poor performance status, advanced lung or lung and abdominal disease, and elevated serum levels of human chorionic gonadotropin (HCG) and alpha-fetoprotein (AFP) greater than 1,000 ng/mL. Multivariate regression analysis indicated the independent prognostic factors of significance were advanced lung or advanced lung and abdominal disease, total tumor diameter greater than 10 cm, and a serum level of HCG greater than 1,000 ng/mL. Of the toxicities encountered, myelosuppression was significant, being exacerbated by radiotherapy, and seven deaths occurred from septicemia. Bleomycin pulmonary toxicity occurred in 46% of patients and was severe in 4%, resulting in eight deaths. With a median follow-up of 64 months, relapses have occurred in 25 patients with no significant difference between those patients receiving or not receiving maintenance vinblastine. Eight of these relapses occurred beyond 1 year and four beyond 2 years of follow-up. Presently, 68% of the total patient population is alive and disease-free, with 84% of the CR and NED patients alive and 81% alive and disease-free. It is concluded that with prolonged follow-up, vinblastine maintenance therapy does not improve treatment outcome. Moreover, late relapses occur, cautioning against premature pronouncements of cure.

DNA hybridisation of cervical scrapes: comparison with cytological findings in Papanicolaou smears

One hundred and sixty four cervical scrapes were taken over 26 months from 143 women aged 17 to 53 years, using an Ayre spatula. A smear was prepared from each sample for Papanicolaou staining and for cytological examination for evidence of human papillomavirus (HPV) infection. The cells remaining on the spatula were harvested for DNA analysis. These samples were probed for HPV 6, 16, and 18 and the results of DNA hybridisation and cytology were compared. Cytological changes of HPV (anucleate keratinised and keratinised squamous cells, koilocytic change and dyskeratosis, or multinucleation, or both) were detected in 103 (72%) of the samples where HPV DNA was detected; koilocytic changes were present in only 67 (48%). It is concluded that screening for a range of viral changes is a more sensitive method of detecting HPV infection than screening for koilocytic change alone.

Chronic occupational exposure to asbestos: more than medical effects?

One hundred and twenty-nine workers chronically exposed to asbestos were interviewed regarding their perceived health status and concerns, their health behaviors, particularly their smoking behavior, and their psychologic well-being. In contrast to a non-exposed comparison group of postal workers, asbestos workers exhibited significantly elevated levels of somatic concern (P less than .03), and significantly lower levels of mental health functioning only when experiencing high levels of stress (P less than .01). Despite feeling significantly more susceptible to developing cancer (P less than .0001), 34% of asbestos workers were cigarette smokers (compared to 32% of the postal group) and long-term mask usage was minimal. Asbestos workers' increased sensitivity to stress and changes in health status along with the lack of adaptation of health-promotive behaviors indicate the need for interventions to attend to the psychologic effects of increased risk status.