Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer

The European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with gastric cancer (GC), published in late 2022 and the updated ESMO Gastric Cancer Living Guideline published in July 2023, were adapted in August 2023, according to previously established standard methodology, to produce the Pan-Asian adapted (PAGA) ESMO consensus guidelines for the management of Asian patients with GC. The adapted guidelines presented in this manuscript represent the consensus opinions reached by a panel of Asian experts in the treatment of patients with GC representing the oncological societies of China (CSCO), Indonesia (ISHMO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), the Philippines (PSMO), Singapore (SSO), Taiwan (TOS) and Thailand (TSCO), coordinated by ESMO and the Japanese Society of Medical Oncology (JSMO). The voting was based on scientific evidence and was independent of the current treatment practices, drug access restrictions and reimbursement decisions in the different Asian regions represented by the 10 oncological societies. The latter are discussed separately in the manuscript. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with GC across the different regions of Asia, drawing on the evidence provided by both Western and Asian trials, whilst respecting the differences in screening practices, molecular profiling and age and stage at presentation. Attention is drawn to the disparity in the drug approvals and reimbursement strategies, between the different regions of Asia.

Proton Radiation Therapy for Stage IIA/IIB Testicular Seminoma

PURPOSE/OBJECTIVE(S)

Testicular seminoma affects young men and is associated with very favorable prognosis. The evolution in treatment paradigm has focused on minimizing acute and especially late toxicities. Following orchiectomy, while surveillance is favored in Stage I patients, radiotherapy (RT) is a standard treatment option for de novo or relapsed stage IIA or select non-bulky stage IIB disease. Despite low doses, standard RT fields to paraaortic and pelvic lymphatics using x-rays exposes a large volume of uninvolved normal tissue/viscera to excess dose. This young patient population is especially vulnerable to risks of late RT toxicities including secondary malignancy. Proton beam therapy (PBT) has dosimetric advantage over x-ray-based RT due to lack of exit dose, and comparative dosimetric/modeling studies show significant sparing of uninvolved abdominal/pelvic organs. However, there is scant reported clinical data at this time for PBT. We review our early institutional outcomes with PBT for testicular seminoma.

MATERIALS/METHODS

Single institution retrospective review from a tertiary care center of patients treated with PBT from 2013-2022 for testicular seminoma. Recurrence free (RFS) and overall survival (OS) were calculated from the completion of PBT. Toxicities were graded (Gr) using CTCAE v5.0.

RESULTS

Four patients underwent PBT, median age 39 (range 36-47). All were Stage I at diagnosis (pT1b n = 3; pT2 n = 1) and were treated for recurrent stage II disease (IIA n = 3; IIB n = 1) at a median of 34 months from orchiectomy (range 3 - 74 months). Nodal extent included 2 with multiple paraaortic nodes, 1 with solitary paraaortic node and 1 with solitary pelvic node. PBT was delivered with pencil-beam scanning, treating paraaortic + ipsilateral pelvic fields (20 Gy in 10 fractions), then sequential boost to involved nodes (10 -16 Gy in 5-8 fractions). Typically, PA or posterior oblique fields were used to minimize dose to out-of-field abdominal/pelvic viscera. Treatment was well tolerated with minimal acute toxicities: fatigue Gr 1 (n = 3), nausea Gr 1 (n = 3). No Gr 2 or higher acute toxicities or significant late toxicities were observed. At median follow up of 30 months (range 3 - 54), no recurrences were observed, and RFS and OS were 100%. Two patients are without evidence of disease > 4 years post-treatment.

CONCLUSION

In this case series, PBT for retroperitoneal and pelvic metastases in Stage IIA/IIB testicular seminoma was associated with oncologic efficacy with minimal toxicity. PBT reduces unnecessary dose to abdominal/pelvic organs compared to x-ray techniques, which is advantageous in young patients who have anticipated long-term survival. This is one of the few series reporting clinical outcomes of PBT in the management of seminoma. Randomized comparisons with x-ray approaches are impractical given the relatively low volume of patients receiving RT in modern seminoma management, so it is essential to report and track longitudinal outcomes across institutions to validate this approach.

Does Loosening the Inclusion Criteria of the CROSS Trial Impact Outcomes in the Curative-Intent Trimodality Treatment of Oesophageal and Gastroesophageal Cancer Patients?

AIM

To determine the efficacy of preoperative chemoradiotherapy as per the CROSS protocol for oesophageal/gastroesophageal junction cancer (OEGEJC), when expanded to patients outside of the inclusion/exclusion criteria defined in the original clinical trial.

MATERIALS AND METHODS

Data were collected retrospectively on 229 OEGEJC patients referred for curative-intent preoperative chemoradiotherapy. Outcomes including pathological complete response (pCR), overall survival (OS), cancer-specific survival and recurrence-free survival (RFS) of patients who met CROSS inclusion criteria (MIC) versus those who failed to meet criteria (FMIC) were determined.

RESULTS

In total, 42.8% of patients MIC, whereas 57.2% FMIC; 16.6% of patients did not complete definitive surgery. The MIC cohort had higher rates of pCR, when compared with the FMIC cohort (33.3% versus 20.6%, P = 0.039). The MIC cohort had a better RFS, cancer-specific survival and OS compared with the FMIC cohort (P = 0.006, P = 0.004 and P = 0.009, respectively). Age >75 years and pretreatment weight loss >10% were not associated with a poorer RFS (P = 0.541 and 0.458, respectively). Compared with stage I-III patients, stage IVa was associated with a poorer RFS (hazard ratio (HR) = 2.158; 95% confidence interval (CI) = 1.339-3.480, P = 0.001). Tumours >8 cm in length or >5 cm in width had a trend towards worse RFS (HR = 2.060; 95% CI = 0.993-4.274, P = 0.052).

CONCLUSION

Our study showed that the robust requirements of the CROSS trial may limit treatment for patients with potentially curable OEGEJC and can be adapted to include patients with a good performance status who are older than 75 years or have >10% pretreatment weight loss. However, the inclusion of patients with celiac nodal metastases or tumours >8 cm in length or >5 cm in width may be associated with poor outcomes.

Microwave dielectric characterisation of 3D-printed BaTiO3/ABS polymer composites

3D printing is used extensively in product prototyping and continues to emerge as a viable option for the direct manufacture of final parts. It is known that dielectric materials with relatively high real permittivity—which are required in important technology sectors such as electronics and communications—may be 3D printed using a variety of techniques. Among these, the fused deposition of polymer composites is particularly straightforward but the range of dielectric permittivities available through commercial feedstock materials is limited. Here we report on the fabrication of a series of composites composed of various loadings of BaTiO₃ microparticles in the polymer acrylonitrile butadiene styrene (ABS), which may be used with a commercial desktop 3D printer to produce printed parts containing user-defined regions with high permittivity. The microwave dielectric properties of printed parts with BaTiO₃ loadings up to 70 wt% were characterised using a 15 GHz split post dielectric resonator and had real relative permittivities in the range 2.6–8.7 and loss tangents in the range 0.005–0.027. Permittivities were reproducible over the entire process, and matched those of bulk unprinted materials, to within ~1%, suggesting that the technique may be employed as a viable manufacturing process for dielectric composites.

Mapping of multi-elements during melting and solidification using synchrotron X-rays and pixel-based spectroscopy

A new synchrotron-based technique for elemental imaging that combines radiography and fluorescence spectroscopy has been developed and applied to study the spatial distribution of Ag, Zr and Mo in an Al alloy during heating and melting to 700, and then re-soldification. For the first time, multi-element distributions have been mapped independently and simultaneously, showing the dissolution of Ag- and Zr-rich particles during melting and the inter-dendritic segregation of Ag during re-solidification. The new technique is shown to have wide potential for metallurgical and materials science applications where the dynamics of elemental re-distribution and segregation in complex alloys is of importance.

Cell types and structures involved in tench, Tinca tinca (L.), defence mechanisms against a systemic digenean infection

Histopathological and ultrastructural investigations were conducted on 36 tench, Tinca tinca (L.), from Lake Trasimeno (Italy). The gills, intestine, liver, spleen, kidney and heart of 21 individuals were found to harbour an extensive infection of larvae of an unidentified digenean trematode. The eyes, gonads, swim bladder and muscles were uninfected. The parasites in each tissue type were embedded in a granulomatous proliferation of tissue, forming a reactive fibroconnective capsule around each larva. Most of the encysted larvae were metacercariae, in a degenerative state, but on occasion some cercariae were found. Many of the granulomas were either necrotic or had a calcified core. Within the granuloma of each, the occurrence of granulocytes, macrophages, rodlet cells and pigment-bearing macrophage aggregates was observed. Hearts bore the highest parasitic infection. Whilst the presence of metacercariae within the intestine was found positioned between the submucosa and muscle layers, metacercariae in the liver were commonly found encysted on its surface where the hepatocytes in close contact with the granuloma were observed to have electron-lucent vesicles within their cytoplasm. Metacercariae encysting adjacent to the cartilaginous rods of gill filaments were seen to elicit a proliferation of the cartilage from the perichondrium. Rodlet cells, neutrophils and mast cells were frequently observed in close proximity to, and within, infected gill capillaries. Given the degenerated state of most granulomas, a morphology-based identification of the enclosed digeneans was not possible.

Infiltration and activation of acidophilic granulocytes in skin lesions of gilthead seabream, Sparus aurata, naturally infected with lymphocystis disease virus

Light, ultrastructural and immunocytochemical investigations were carried out on the skin of gilthead seabream, Sparus aurata L., naturally infected with lymphocystis iridovirus, to assess pathology and host cellular responses. Of 220,000 young seabream examined, 32,400 (14.7%) had clinical signs of lymphocystis and within 6 months of disease appearance, 45% of clinically affected fish had died. A subsample of 20 S. aurata (80.0 ± 12.5mm total length, mean ± S.D.), including 10 with lymphocystis on the skin and 10 clinically normal, were examined via immunohistochemistry. Affected skin displayed macroscopic, wart-like clusters of hypertrophic fibroblasts which arose from the dermis and were covered by the epithelium. Clusters were encountered on the head, trunk and fins, but there was no evidence of visceral lymphocystis. The lymphocysts were surrounded by numerous granular cells that were positive for the antimicrobial peptide (AMP) piscidin 3 and underwent intense degranulation. To identify the type of granular cells involved in this viral disease, a double immunohistochemical staining with the monoclonal antibody G7 (mAb G7), which is specific for seabream acidophilic granulocytes (AGs), and with anti-histamine (as a marker for mast cells, MCs) was applied to the skin sections of the 10 clinically normal fish and 10 fish with lymphocystis. In infected skin, the number of G7-positive cells (i.e., AGs) (18.5 ± 10.5, mean number of cells per 20,000 μm(2) ± S.D.) was significantly higher compared to their density in uninfected skin (1.4 ± 2.2) (t test, p<0.01). Notably, the AGs that infiltrated the skin lesions of infected animals were found to be degranulated and to produce the pro-inflammatory cytokine interleukin-1β. No histamine-positive granular cells (i.e., MCs) were encountered in the lymphocystis lesions. The present study shows the response of skin to lymphocystis disease virus (LCDV) and provides evidence that AGs, but not MCs, are recruited and activated in response to this skin infection.

Socioeconomic status influences bystander CPR and survival rates for out-of-hospital cardiac arrest victims

OBJECTIVES

While lower socioeconomic status is associated with lower level of education and increased incidence of cardiovascular diseases, the impact of socioeconomic status on out-of-hospital cardiac arrest outcomes is unclear. We used residential property values as a proxy for socioeconomic status to determine if there was an association with: (1) bystander CPR rates and (2) survival to hospital discharge for out-of-hospital cardiac arrest.

METHODS

We performed a secondary data analysis of cardiac arrest cases prospectively collected as part of the Ontario Prehospital Advanced Life Support study, conducted in 20 cities with ALS and BLS-D paramedics. We measured patient and system characteristics for cardiac arrests of cardiac origin, not witnessed by EMS, occurring in a single residential dwelling. We obtained property values from the Municipal Property Assessment Corporation. Analyses included descriptive statistics with 95% CIs and stepwise logistic regression.

RESULTS

Three thousand six hundred cardiac arrest cases met our inclusion criteria between 1 January 1995 and 31 December 1999. Patient characteristics were: mean age 69.2, male 67.8%, witnessed 44.7%, bystander CPR 13.2%, VF/VT 33.8%, time to vehicle stop 5:36min:s, return of spontaneous circulation 12.7%, and survival 2.7%. Median property value was $184,000 (range $25,500-2,494,000). For each $100,000 increment in property value, the likelihood of receiving bystander CPR increased (OR=1.07; 95% CI 1.01-1.14; p=0.03) and survival decreased (OR=0.77; 95% CI 0.61-0.97; p=0.03).

CONCLUSIONS

This is the largest study showing an association between socioeconomic status and survival, and the first study showing an association with bystander CPR. Our findings suggest targeting CPR training among lower socioeconomic groups.

RANKL inhibition is an effective adjuvant for docetaxel in a prostate cancer bone metastases model

BACKGROUND

Docetaxel induces an anti-tumor response in men with advanced prostate cancer (PCa); however, the side effects associated with docetaxel treatment can be severe, resulting in discontinuation of therapy. Thus, identification of an effective adjuvant therapy to allow lower doses of docetaxel is needed. Advanced PCa is typically accompanied by skeletal metastasis. Receptor activator of NFkB ligand (RANKL) is a key pro-osteoclastic factor. Targeting RANKL decreases establishment and progression of PCa growth in bone in murine models.

METHODS

The efficacy of inhibiting RANKL, using a recombinant soluble RANK extracellular domain fused with the immunoglobulin Fc domain (RANK-Fc), was tested as an adjuvant therapy with docetaxel for PCa bone metastasis in a murine intra-tibial model.

RESULT

The combination of RANK-Fc and docetaxel reduced tumor burden in bone greater than either treatment alone.

CONCLUSION

The combination of docetaxel with a RANKL-inhibiting agent merits further investigation for treatment of advance PCa.

Effect of Acanthocephala infection on the reproductive potential of crustacean intermediate hosts

The effect of a naturally acquired infection by three acanthocephalan parasites Dentitruncus truttae, Echinorhynchus truttae, and Polymorphus minutus on the reproductive potential of their intermediate host, Echinogammarus tibaldii (Amphipoda) from Lake Piediluco (Centre of Italy) was assessed. During May 2007, 1135 amphipods were collected from two different samplings and examined for larval helminths. Forty-five amphipods were infected and of those, 16 were infected with D. truttae (intensity=1-3 larvae), 15 with E. truttae (intensity=1-2 larvae), and 14 with P. minutus (intensity=1 larva). The sex ratio was nearly 1:1 in all examined amphipods. One female infected with D. truttae contained six eggs in the brood pouch and another female infected with E. truttae contained five eggs. However, none of the eight female amphipods harbouring P. minutus larva contained eggs in their brood pouch. Uninfected females of the same size and body length as that of the infected females contained between 20 and 32 eggs. No acanthocephalan species were found to co-occur.

Role of chemical interactions in bacterial adhesion to polymer surfaces

Development of biomaterial-related infections is attracting an increasing interest due to the significant percentage of implant failure in the hospital care. Recent literature puts in evidence the dependence of the infection risk on the different biomaterials used, because of the different interactions between material surface and micro-organisms. Despite this, the mechanisms underlying the adhesion of bacteria to the biomaterial surface are still unclear. Aim of this work is to study the initial events of the processes responsible for the bacterial adhesion on polymers in order to prevent the development of bacterial infections and the consequent failure and replacement of biomedical devices. Electrostatic and Lifshitz-van der Waals forces are usually considered responsible for the interactions at the biomaterial interface. A new term that involves Lewis acid-base interactions is here introduced to better describe the bacterial adhesion to the polymer surface. Two requirements are needed to test this hypothesis: the development of an ideal polymeric surface in terms of chemical and morphological properties and the choice of a specific bacterial strain to be utilized as "probe". Experiments were worked out using an Escherichia coli (Gram-) strain that represent one of the principal isolates from infected biomaterial implants and its adhesion was investigated on polymers having different acid/basic character. The findings indicate that the bacterial adhesion is influenced by the chemical properties of the polymeric surface. These results may be interpreted taking into account a mechanism in which the acid/base (Lewis) interaction plays an important role.

A multicentre trial of ropivacaine 7.5 mg x ml(-1) vs bupivacaine 5 mg x ml(-1) for supra clavicular brachial plexus anesthesia

PURPOSE

To compare the efficacy of ropivacaine 7.5 mg x ml(-1) with bupivacaine 5.0 mg x ml(-1) for subclavian perivascular brachial plexus block.

METHODS

After informed consent, 104 ASA I-III adults participated in a randomized, double-blind, multi-center trial to receive 30 ml of either ropivacaine 7.5 mg x ml(-1) or bupivacaine 5.0 mg x ml(-1) for subclavian perivascular brachial plexus block prior to upper limb surgery. Onset and duration of sensory and motor block in the distribution of the axillary, median, musculo-cutaneous, radial and ulnar nerves were assessed.

RESULTS

Onset times and duration of sensory and motor block were similar between groups. Mean duration of analgesia for the five nerves was between 11.3 and 14.3 hr with ropivacaine and between 10.3 and 17.1 hr with bupivacaine. Quality of muscle relaxation judged as excellent by the investigators was not significantly different (ropivacaine - 35/49, bupivacaine - 30/49). The median time to first request for analgesia was comparable between the two groups (11-12 hr). One patient developed a grand mal seizure shortly after receiving bupivacaine and recovered consciousness within 30 min. There were no serious adverse events in the ropivacaine group.

CONCLUSIONS

Thirty ml ropivacaine 7.5 mg x ml(-1) (225 mg) produced effective and well tolerated brachial plexus block of long duration by the subclavian perivascular route. In this study, the results were similar to those of 30 ml bupivacaine 5.0 mg x ml(-1).

Nonspecific inhibition of myogenic tone by PD98059, a MEK1 inhibitor, in rat middle cerebral arteries

Activation of MAP kinase kinase, also called ERK kinase (MEK), may lead to desinhibition of thin filament regulatory proteins and we therefore investigated the acute effects of the potent MEK inhibitor, PD98059 on the contractile properties of pressurized rat middle cerebral arteries. Cerebral arteries (diameter 100-150 microm) were mounted on a pressure myograph and PD98059 (10 microM, 40 microM) significantly inhibited (15% and 64%) myogenic tone (P < 0.001). At these concentrations, PD98059 also significantly reduced the vasopressin (0.1 microM)- and KCl (60 mM)-induced tone. Cumulative addition of exogenous Ca2+ (0.4-1.6 mM) increased myogenic tone to approximately 50% of constriction at 80 mmHg. This effect was inhibited by PD98059 (P < 0.001). These results demonstrate that pressure-induced myogenic tone is inhibited by PD98059 at the concentrations that have been reported to be selective for inhibition of MEK and the MAP kinase cascade. However, our results also demonstrate that PD98059 may have nonspecific effects on voltage-sensitive Ca2+ entry in vascular smooth muscle.

Continuous epidural ropivacaine 0.2% for analgesia after lower abdominal surgery

The purpose of this study was to determine whether a lumbar epidural infusion of ropivacaine 0.2% would provide effective analgesia with an acceptably low incidence of motor blockade and side effects after lower abdominal surgery. After combined general and epidural anesthesia and surgery, 125 patients were randomly assigned to receive either saline or ropivacaine 0.2% at a rate of 6, 8, 10, 12, or 14 mL/h (Groups R6, R8, R10, R12, and R14, respectively) for 21 h. Supplemental analgesia, if required, was provided with intravenous patient-controlled analgesia with morphine. Data were collected at 4, 8, and 21 h, and included morphine consumption, pain scores at rest and with coughing, motor and sensory block, and adverse events. Cumulative morphine consumption was less in Groups R10, R12, and R14 compared with the saline group. At 4 h analgesia was better among patients receiving ropivacaine, but at 21 h pain scores were identical. Sensory blockade at 8 and 21 h was greater in the ropivacaine groups compared with the saline group. Approximately 30% of R8, R10, and R12 patients, and 63% of R14 patients had demonstrable motor block of the lower limbs at 21 hours. We conclude that lumbar epidural ropivacaine 0.2% reduces parenteral morphine requirements but has little effect on pain scores and may be associated with motor blockade.

[Conservative management of ectopic pregnancy]

BACKGROUND

The aim of this retrospective study was to analyze the safety and efficacy of the conservative approach in the management of ectopic pregnancy.

METHODS

Thirty-five women with a tubal ectopic pregnancy, from 1990 to 1995, were subdivided into 2 treatment groups. Inclusion criteria were the following: tubal diameter < 3 cm, free fluid < 100 ml, no embryo heart activity, haemodynamic stability. Desire of future fertility and informed consent were requested. Eighteen women were treated with a single intramuscular injection of methotrexate, whereas in 17 cases expectant management was adopted.

RESULTS

In the first group 2 cases required surgical treatment (resolution rate = 89%). In the second group no surgery was needed and spontaneous resolution was achieved in all cases (100%). In both groups the average resolution time was about 17 days. Serum hCG-beta levels were monitored daily until resolution. The initial hCG-beta value and its following trend seem to be the most important prognostic factors.

CONCLUSIONS

More studies are indeed needed to establish the effect of conservative management on fertility after ectopic pregnancy.

Continuous epidural infusion of ropivacaine for the prevention of postoperative pain after major orthopaedic surgery: a dose-finding study

PURPOSE

A dose-finding study to investigate the use of epidural infusions of ropivacaine for postoperative analgesia following orthopaedic surgery.

METHODS

This was a randomized, double-blind study. Surgery was performed using a combination of a lumbar epidural block utilizing ropivacaine 0.5% and a standardized general anaesthetic. Postoperatively, an epidural infusion of the study solution (saline, ropivacaine 0.1%, 0.2% or 0.3%) was started at the rate of 10 ml.hr-1 and continued for 21 hr after arrival in the PACU. Analgesia was supplemented with PCA morphine (dose = 1.0 mg, lock-out = 5 min).

RESULTS

Forty-four patients completed the study. The ropivacaine 0.1%, 0.2%, 0.3% groups required less morphine over the 21 hr than the saline group (P < 0.01). The VAS pain scores were also lower in the three ropivacaine groups (P < 0.001). The ropivacaine groups maintained sensory anaesthesia to pinprick when compared with saline (P < 0.05). The motor block in the 0.3% group was significantly higher than the saline group at all times (P < 0.05), and higher than the 0.1% group at eight hours (P < 0.01), while the 0.2% group had higher Bromage scores than saline at 4 and 21 hr (P < 0.05).

CONCLUSIONS

The use of continuous epidural infusions of ropivacaine 0.1%, 0.2% and 0.3% at 10 ml.hr-1 improved postoperative pain relief and decreased PCA morphine requirements in patients undergoing major orthopaedic surgery. The 0.1% and 0.2% concentrations produced similar sensory anaesthesia with less motor blockade than the 0.3% concentration.

[The donation of autologous blood in pregnancy. Observations on its safety and the cost-benefit relationship]

Experience with the collection of autologous blood during the last part of pregnancy in 57 women is reported. The authors confirm the safety of the autologous transfusion program but come to the conclusion that, with current entrance criteria, the cost-benefit ratio seems unfavourable. Therefore they suggest: a) the sole involvement of women with real potential hemorrhagic complications (placenta previa, multiple pregnancy); b) the collection, when possible, of at least 2 units of autologous blood.

Effect of insecticides (Dimiline WP 25, Torak EC 24 and Gamacide 20) on hydra (Hydra vulgaris Pallas)

Investigations showed that the three insecticides used had the most damaging effect upon hydra immediately after treatment. The tentacles and the hypostome are the parts most often damaged. Inse the affected cells, lesions appear in the intracellular membranes, the nucleus shell and the membranes of the mitochondria, Golgi complex and the endoplasmic reticulum, while the cell membrane is preserved. The damaged parts of the body regenerate within three days. Zymogen cells play a significant role in the course of regeneration. They dedifferentiate into gastrodermal interstitial cells and later into other types of cells of the ectoderm and the gastroderm. Apart from their intense participation in regeneration, these totipotent cells also invariably participate in the formation of new hydra buds. It was observed that Dimiline WP 25 and Torak EC 24 in the concentrations used stimulate asexual reproduction of this animal.

Elective oral tracheal intubation in cervical spine-injured adults

There is controversy regarding the optimal mode of elective tracheal intubation in the patient with an unstable cervical spine following trauma. A ten-year review of 150 patients with traumatic cervical spine injuries with well-preserved neurological function, presenting for operative stabilization, was conducted to compare neurological outcome with the mode of tracheal intubation. Preoperative neurological deficits were identified in 49 patients (33%); most were single-level radiculopathies. Intubation occurred after induction of general anaesthesia in 83 patients (55%) and in 67 patients (45%) the tracheas were intubated with the patient awake. One hundred and six patients (71%) underwent oral tracheal intubation and 44 underwent nasal tracheal intubation. Ten intubations were deemed to be difficult requiring more than one attempt to effect intubation. Cervical spine immobilization during intubation was documented in 86 patients (57%). Weighted traction or manual in-line traction were the two manoeuvres most commonly employed to maintain spinal alignment during intubation. After surgery, two patients had new neurological deficits. There were no differences in neurological outcome whether intubation was performed while the patient was awake or under general anaesthesia, or comparing oral tracheal intubation with all other techniques (P = 0.5, Fisher exact test). Also, in-line traction did not affect neurological outcome. Oral tracheal intubation with in-line stabilization, either performed after induction of general anaesthesia or with the patient awake, remains an excellent option for elective airway management in patients with cervical spine injuries.

Endogenous opioids are involved in the genetically determined high preference for ethanol consumption

The link between endogenous opioid peptides and the genetic predisposition to preferentially consume ethanol was examined in alcohol preferring C57BL/6J mice compared with the alcohol nonpreferring DBA/2 mice. Concentrations of Met-enkephalin pentapeptide or precursor in various brain regions of potential relevance were not different between the two strains. C57BL/6J mice had a significantly lower pain threshold that could be increased by a selective mu-receptor opioid agonist [D-Ala2, MePhe4, Met(O)5-ol]-enkephalin. Treatment with this drug also decreased ethanol consumption in C57BL/6J mice. Increasing the synaptic half-life of endogenous enkephalins by the enkephalinase inhibitor kelatorphan also decreased ethanol consumption. Assay of endogenous enkephalin degrading activity showed increased enkephalinase activity in striatal issue of C57BL/6J compared with DBA/2 tissue. These results suggest that a relative lack of enkephalin peptides trans-synaptically, possibly resulting from enhanced enkephalin degradation may contribute to increase alcohol consumption in C57BL/6J mice.

Structures of paralytic acylpolyamines from the spider Agelenopsis aperta

The structures are given for five paralytic acylpolyamines from the venom of the funnel web spider, Agelenopsis aperta. The acyl moieties are derived from (3-indolyl)acetic acid, (4-hydroxy-3-indolyl)acetic acid, and 4-hydroxybenzoic acid. The polyamine portions of the toxins are novel. Three toxins (AG489, AG505, and AG452) contain 1, 5, 9, 13, 18, 22-hexaazadocosane which is unique as a natural polyamine because of its length and hydroxylation at the 5-aza position. The polyamine portions of two other alpha-agatoxins (AG488 and AG504) are unusual also, containing guanidinooxy moieties.

The adult cervical spine: implications for airway management

Anaesthetists are responsible for the management of the airway in patients with unstable cervical spines. Unfortunately, the anaesthetic literature does not contain a recent, critical analysis of the current medical literature to aid anaesthetists attending such patients. This review is intended to serve such a purpose. Using the Index Medicus as a guide, 30 years of medical literature were reviewed, with emphasis on the last ten years. Key words employed for this review are cited in the manuscript. Relevant papers were selected from anaesthetic, orthopaedic, rheumatologic, emergency medicine and trauma journals and reviewed. Relevant findings included the high prevalence of cervical spinal instability in such disorders such as Trisomy 21 and rheumatoid arthritis and the relatively low incidence after trauma. There are deficiencies in the minimalist approaches to assessing the cervical spine, such as a simple cross table lateral radiograph after trauma, as they are neither sensitive nor specific. Finally, recognizing the potential for instability and intubating with care, while avoiding spinal movement, appears to be more important than any particular mode of intubation in preserving neurological function.

Chemical characterization of acylpolyamine toxins from venom of a trap-door spider and two tarantulas

Two acylpolyamines are identified from venom of the trap-door spider, Hebestatis theveniti. These toxins (paralytic to lepidopteran insect larvae) are amides containing 3-(3-indolyl)lactic acid joined to spermine or 1,13-diamino-4,10-diazatridecane (Het389 and Het403, respectively). Het389 is also abundant in venom from a tarantual from Mozambique (Harpactirella sp.). Two additional acylpolyamines (Apc600 and Apc728) are partially characterized from venom of another tarantula, Aphonopelma chalcodes.

Training resident physicians in fiberoptic sigmoidoscopy. How many supervised examinations are required to achieve competence?

Twenty-five resident physicians performed 495 fiberoptic sigmoidoscopic examinations that were graded for overall skill according to a six-point competence scale. In general, 24 to 30 examinations were required to become competent at fiberoptic sigmoidoscopy. Trainees with prior rigid sigmoidoscopy experience achieved competence more quickly than those with no prior rigid sigmoidoscopy experience. As experience increased, unassisted insertion distance and luminal visualization increased, insertion time and assisted time decreased, and management scores and percent correct diagnoses improved. Trainees detected 93 to 100 percent of polyps and cancers viewed by the experienced sigmoidoscopist once competence was achieved. These data indicate that programs for training primary care physicians in fiberoptic sigmoidoscopy are feasible, help define the number of examinations required to become competent, and indicate that such trainees should be effective in cancer screening.

Relationship between body store of vitamin B6 and plasma pyridoxal-P clearance: metabolic balance studies in humans

Factors that regulate the clearance of plasma pyridoxal-P (PLP) are unknown. Four volunteers were given a diet supplying approximately 12 mumol pyridoxine (PN) per day. The pharmacokinetics of plasma PLP clearance were measured in these subjects before and after 4 weeks of intravenous PN supplementation (122 mumol/day). Urinary B6 excretion, mainly as 4-pyridoxic acid (4-PA), increased progressively after initiation of PN supplementation until a new steady state was reached on day 10 of supplementation, whereupon greater than 93% of the daily injected PN could be recovered in the urine. Hence, urinary excretion is almost the sole route for vitamin B6 elimination. Fasting plasma PLP concentration increased with supplementation and also reached a new steady state at this time. When supplementation was terminated, urinary B6 excretion decreased in 5 days to an amount only slightly higher than that before supplementation. This amount was maintained for 2 months. By comparison, plasma PLP decreased more slowly and remained considerably higher than the presupplementation level for the rest of the study. These data confirm that urinary 4-PA excretion is a better indicator of B6 intake than is plasma PLP content, whereas plasma PLP content is a better indicator of the body store of the vitamin. Plasma clearance and volume of distribution of PLP decreased significantly after supplementation, but half-life t 1/2 did not change. Plasma clearance of PLP, therefore, is dependent on the vitamin B6 status of an individual.

The measurement of plasma vitamin B6 compounds: comparison of a cation-exchange HPLC method with the open-column chromatographic method and the L-tyrosine apodecarboxylase assay

A cation-exchange high-performance liquid chromatographic (HPLC) method was found to be comparable to the open-column (OCC) method for measuring six different B6 compounds in human plasma and the L-tyrosine apodecarboxylase (LTD) assay for pyridoxal-P (PLP). Plasma samples were obtained from 9 subjects before and after 7 days of pyridoxine (PN) supplementation. PLP, pyridoxal (PL) and 4-pyridoxic acid (4-PA) were the major B6 compounds in plasma and the only compounds which increased after supplementation. The coefficients of correlation between any 2 of the 3 methods in measuring plasma PLP were greater than 0.93, and between HPLC and OCC in quantifying PL and 4-PA were 0.82 and 0.63, respectively. With the low plasma levels of pyridoxamine-P, PN and pyridoxamine, the results from OCC were consistently higher than those from HPLC. However, recoveries of spiked B6 compounds in plasma by these methods were between 84 to 105 percent for all the 5 vitamers and 4-PA.

Comparison of the use of L-tyrosine apodecarboxylase and D-serine apodehydratase for plasma pyridoxal phosphate assay

The enzymatic methods for plasma pyridoxal 5'-phosphate (PLP) assay using L-tyrosine apodecarboxylase (apo-LTD) and D-serine apodehydratase (apo-DSD) were compared with respect to their operating characteristics, accuracy and precision. With the apo-LTD assay, the recovery of authentic PLP added to irradiated plasma was 96-100% and the precision for within-run and run-to-run replicates was 4-5% (coefficient of variation). The recovery of authentic PLP with the apo-DSD assay tended to be lower (viz., 95%) and the within-run and run-to-run coefficients of variation tended to be higher (viz., 5-6%), but these differences were not statistically significant. When these two assay methods were directly compared in determining the plasma PLP levels of 67 hospitalized patients, the regression lines exhibited correlation coefficients of 0.89 and 0.92 and slopes of 0.77 and 0.78, respectively. When the plasma PLP values were less than 7.5 ng/ml, the values determined by the apo-DSD assay tended to be higher than those measured by the apo-LTD method and vice versa. The lack of better agreement between the two assay methods may be explained by the fact that an inhibitor exists in plasma extracts that impairs the binding of PLP to apo-DSD and that the correction for this interference may not be uniform from one plasma sample to another. However, if one is willing to tolerate the small discrepancies between the values obtained by the apo-DSD and apo-LTD assays, these assay methods can be used interchangeably. The apo-DSD assay has the advantage of being easily adapted to a modern automated spectrophotometric centrifugal analyzer.

Biliary excretion of 14C-labeled vitamin B-6 in rats

The biliary excretion of vitamin B-6 was studied in the intact rat and isolated perfused rat liver. In the whole animal, 21% of the radioactivity administered intravenously as [14C]pyridoxine was excreted in the urine over 4 hours, whereas only 2.1% was recovered in the bile. In the perfused liver, 3% of the radioactivity added to the medium was detected in the bile after 4 hours of perfusion. These data suggest that biliary excretion and enterohepatic circulation of vitamin B-6 probably play only a minor role in the overall economy of this vitamin. The concentration of the radiolabeled B-6 compounds in the bile of perfused liver was much higher than that in the perfusate and the pattern of the distribution of radioactivity among difference B-6 compounds was also different. These results suggest that [14C]pyridoxine and its metabolites are released separately by the hepatocytes into the bile and the perfusate and that paracellular transport of vitamin B-6 is not the predominant pathway for the biliary excretion of this vitamin.

Regeneration of hydra damaged by zolone PM insecticide

The zolone PM (phosalone) insecticide in the suspensions used destroys parts of the hypostome, ruins many buds and budless hydras. In the insecticide suspension a hydra shrinks and assumes the smallest surface. It is due to this that the surface mucous layer thickens and epidermal and gastrodermal cells become highly squeezed together. The insecticide penetrates the hypostomal opening and destroys hypostomal cells but does not act specifically upon a certain type of cells. Gradually, other cells replace the destroyed ones. They arrive from the gastrodermal region. Among them, zymogen cells, capable of differentiation und dedifferentiation into other types of cells, play the most significant part.

Transport of pyridoxine and pyridoxal 5'-phosphate in isolated rat liver mitochondria

The transport of [14C]pyridoxal-P and [14C]pyridoxine into isolated rat mitochondria was studied by centrifugal filtration. The incubation medium contained 20 mM 2-oxoglutarate and 10 mM inorganic phosphate to inhibit metabolism of pyridoxal-P by the mitochondria. The ratio of [14C]pyridoxine space to [3H]H2O space rapidly attained unity independent of the [14C]pyridoxine concentration in the medium and remained unchanged for up to 90 min of incubation. These data suggest simple passive diffusion for the transport of pyridoxine into the mitochondria. By contrast, the ratio of [14C]pyridoxal-P space to [3H]H2O space rose rapidly to exceed 1 in the first 15 min and continued to rise at a slower rate for as long as it was measured. The accumulation of [14C]pyridoxal-P was not decreased by inhibitors and uncouplers of oxidative phosphorylation. Fractionation of the mitochondria with digitonin revealed that 19 and 340 pmol of [14C]pyridoxal-P/mg of protein were taken up by the mitochondria at 15 and 60 min of incubation, respectively. Most of the uptake in the first 15 min occurred in the intermembrane space, whereas the largest increase of [14C]pyridoxal-P between 15 and 60 min of incubation appeared in the matrix fraction. Significant binding of the [14C]pyridoxal-P to proteins in the two compartments was demonstrated by gel filtration. These data indicate that pyridoxal-P can rapidly enter the intermembrane space of isolated mitochondria, but its penetration into the matrix occurs at a slower and more sustained rate (i.e. 9-16 pmol/h/mg of protein). It is concluded that the transport of pyridoxal-P into isolated rat liver mitochondria is energy-independent and is most consistent with passive diffusion facilitated by protein binding once this coenzyme enters the different compartments of the mitochondria.

Single copy DNA homology in sea stars

The sequence homology in the single copy DNA of sea stars has been measured. Labeled single copy DNA from Pisaster ochraceus was reannealed with excess genomic DNA from P. brevispinus, Evasterias troschelii, Pycnopodia helianthoides, Solaster stimpsoni, and Dermasterias imbricata. Reassociation reactions were performed under two criteria of salt and temperature. The extent of reassociation and thermal denaturation characteristics of hybrid single copy DNA molecules follow classical taxonomic lines. P. brevispinus DNA contains essentially all of the sequences present in P. ochraceus single copy tracer while Evasterias and Pycnopodia DNAs contain 52% and 46% of such sequences respectively. Reciprocal reassociation reactions with labeled Evasterias single copy DNA confirm the amount and fidelity of the sequence homology. There is a small definite reaction of uncertain homology between P. ochraceus single copy DNA and Solaster or Dermasterias DNA. Similarly Solaster DNA contains sequences homologous to approximately 18% of Dermasterias unique DNA. The thermal denaturation temperatures of heteroduplexes indicate that the genera Pisaster and Evasterias diverged shortly after the divergence of the subfamilies Pycnopodiinae and Asteriinae. The two Pisaster species diverged more recently, probably in the most recent quarter of the interval since the separation of the genera Pisaster and Evasterias.