Multicentre study of short-course radiotherapy, systemic therapy and resection/ablation for stage IV rectal cancer

BACKGROUND

The optimal treatment sequence for patients with rectal cancer and synchronous liver metastases remains unclear. The aim of this study was to evaluate the feasibility and effectiveness of short-course pelvic radiotherapy (5 × 5 Gy) followed by systemic therapy and local treatment of all tumour sites in patients with potentially curable stage IV rectal cancer in daily practice.

METHODS

This was a retrospective study performed in eight tertiary referral centres in the Netherlands. Patients aged 18 years or above with rectal cancer and potentially resectable liver ± extrahepatic metastases, treated between 2010 and 2015, were eligible. Main outcomes included full completion of treatment schedule, symptom control and survival.

RESULTS

In total, 169 patients were included with a median follow-up of 49·5 (95 pr cent c.i. 43·6 to 55·6) months. The completion rate for the entire treatment schedule was 65·7 per cent. Three-year progression-free survival and overall survival (OS) rates were 24·2 (95 per cent c.i. 16·6 to 31·6) and 48·8 (40·4 to 57·2) per cent respectively. Median OS of patients who responded well and completed the treatment schedule was 51·5 months, compared with 15·1 months for patients who did not complete the treatment (P < 0·001). Adequate symptom control of the primary tumour was achieved in 87·0 per cent of all patients.

CONCLUSION

Multimodal treatment leads to relief of symptoms in most patients, and is associated with good survival rates in those able to complete the schedule. [Correction added on 12 February 2020, after first online publication: the Conclusion has been reworded for clarity].

Clinical outcomes of definitive chemoradiotherapy using carboplatin and paclitaxel in esophageal cancer

Patients with nonmetastatic esophageal cancer not suitable for surgery can be treated with definitive chemoradiotherapy with curative intent. The purpose of this retrospective study is to evaluate the clinical outcomes of definitive chemoradiotherapy using carboplatin and paclitaxel. Medical records were reviewed of patients treated for nonmetastatic squamous cell or adenocarcinoma of the esophagus between January 2009 and December 2013 in two collaborating institutes. Treatment consisted of external beam radiotherapy (28 fractions of 1.8 Gy) and 6 weekly courses of carboplatin (AUC = 2) and paclitaxel (50 mg/m2). Data on survival, progression, toxicity, and effect on dysphagia were recorded. Sixty-six patients were included. Median overall survival (OS) was 13.1 months (95% CI 4.7-21.5 months) and a 2-year OS was 30% (95% CI 18%-42%). At 2 years, 26% of patients developed local progression (95% CI 15%-37%) and 49% developed distant metastases (95% CI 36%-64%). Acute toxicity grade ≥3 was observed in 47% of patients. Late adverse events grade ≥3 were seen in 20%, mostly esophageal stenoses. Of patients with available data 3 months after treatment, 70% had relief of dysphagia. Definitive chemoradiotherapy led to a median OS of 13 months. Toxicity was common, mostly due to hematological toxicity. Given the relatively short median survival, an adequate selection of patients for this intensive treatment is required.

Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program

BACKGROUND AND STUDY AIMS

Endoscopic resection is the cornerstone of endoscopic treatment of esophageal high grade dysplasia or early cancer. Endoscopic resection is, however, a technically demanding procedure, which requires training and expertise. The aim of the current study was to prospectively evaluate efficacy and safety of the first 120 endoscopic resection procedures of early esophageal neoplasia performed by six endoscopists (20 endoscopic resections each) who were participating in an endoscopic resection training program.

PATIENTS AND METHODS

The program consisted of four tri-monthly 1-day courses with lectures, live-demonstrations, hands-on training on anesthetized pigs, and one-on-one hands-on training days. Gastroenterologists from centers with multidisciplinary expertise in upper gastrointestinal oncology participated, together with an endoscopy nurse and a pathologist. Outcome measures were complete endoscopic removal of the target area and acute complications.

RESULTS

A total of 120 consecutive esophageal endoscopic resection procedures (85 ER-cap, 35 multiband mucosectomy [MBM]) were performed by six endoscopists: 109 in Barrett's esophagus, 11 for squamous neoplasia; 85 piecemeal endoscopic resections (median 3 specimens, interquartile range 2 - 4 specimens). Complete endoscopic removal was achieved in 111 /120 cases (92.5 %). Six perforations occurred (5.0 %): five were effectively treated endoscopically (clips, covered stent), and one patient underwent esophagectomy. There were 11 acute mild bleedings (9.2 %), which were managed endoscopically. Perforations occurred in ER-cap procedures performed by four participants (7.1 % ER-cap vs. 0 % MBM; P = 0.18), and in 1.7 % of the first 10 endoscopic resections and 8.3 % of the second 10 endoscopic resections per endoscopist (P = 0.26).

CONCLUSION

In this intense, structured training program, the first 120 esophageal endoscopic resections performed by six participants were associated with a 5.0 % perforation rate. Although perforations were adequately managed, performing 20 endoscopic resections may not be sufficient to reach the peak of the learning curve in endoscopic resection.

Stepwise radical endoscopic resection for Barrett's esophagus with early neoplasia: report on a Brussels' cohort

BACKGROUND AND STUDY AIMS

The aim of this retrospective study was to assess safety and efficacy of stepwise radical endoscopic resection (SRER) in patients with Barrett's esophagus with high-grade intraepithelial neoplasia (HGIN) or early cancer.

PATIENTS AND METHODS

Patients undergoing SRER between 2000 and 2006 were retrospectively evaluated. Patients with Barrett's esophagus who also had HGIN or early cancer were included if they had no signs of submucosal infiltration or metastases. SRER was performed using the cap-technique, at 8-week intervals until all Barrett's esophagus was removed. Follow-up endoscopy was scheduled every 6 months.

RESULTS

A total of 34 patients were included (31 male, mean 67 years, median Barrett's dimensions C1M4). HGIN / early cancer was eradicated in all patients in a median of two endoscopic resection sessions (IQR 1-2 sessions). Twelve patients underwent additional argon plasma coagulation for small islets or an irregular Z-line. Barrett's esophagus was eradicated in 28 patients (82 %). Complications occurred in 3/34 patients (9 %): two perforations, one delayed bleeding. In all, 19 patients (56 %) developed dysphagia, which was resolved with dilatation or stent placement. During a median follow-up period of 23 months (IQR 15 - 41 months), HGIN / early cancer recurred in three patients (9 %): two were retreated with endoscopic resection and one patient was referred for curative surgery. Five patients (15 %) had recurrence of nondysplastic Barrett's esophagus. At the end of the follow-up period all patients were free of HGIN / early cancer (one patient after surgery), and 23 patients (68 %) had complete endoscopic and histological eradication of Barrett's esophagus.

CONCLUSIONS

SRER resulted in complete eradication of HGIN/early cancer in all patients, and eradication of Barrett's esophagus in a majority of cases. A significant number of patients develop dysphagia, which can be successfully treated endoscopically.

Stepwise circumferential and focal ablation of Barrett's esophagus with high-grade dysplasia: results of the first prospective series of 11 patients

BACKGROUND AND STUDY AIMS

Stepwise circumferential and focal ablation of nondysplastic Barrett's esophagus has proven safe and effective. This study assessed the efficacy and safety of ablation for Barrett's esophagus with high-grade dysplasia (HGD), and residual Barrett's esophagus with dysplasia after prior endoscopic resection for visible lesions.

PATIENTS AND METHODS

This was a prospective cohort study. All visible abnormalities were resected prior to ablation. Persistence of dysplasia and absence of invasive cancer was confirmed with biopsies after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. Eradication of dysplasia and Barrett's esophagus was the main outcome measure.

RESULTS

Eleven patients (eight men; median age 60 years) were treated (median Barrett's length 5 cm). Visible abnormalities were removed with endoscopic resection in six patients. The worst pathological grade of residual Barrett's esophagus after endoscopic resection and prior to ablation was LGD (n = 2) and HGD (n = 9). Patients underwent a median of two circumferential and two focal ablation sessions. Complete remission of dysplasia and complete endoscopic and histological removal of Barrett's esophagus was achieved in 11/11 patients (100%). There were no adverse events or strictures, and in none of the 473 biopsies of neo-squamous mucosa was subsquamous Barrett's esophagus ("buried Barrett's") observed. During a median follow-up period of 14 months after the last treatment session and a median number of two follow-up endoscopies, none of the patients showed recurrence of dysplasia or endoscopic signs of recurrent Barrett's mucosa.

CONCLUSIONS

Stepwise circumferential and focal ablation appears to be a safe and effective treatment for complete removal of Barrett's esophagus containing HGD, and can be safely performed after prior endoscopic resection for endoscopically visible abnormalities.

Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system

STUDY AIMS

The aim of the current study was to evaluate the efficacy and safety of stepwise circumferential and focal ablation using the HALO system for Barrett's esophagus containing flat, high-grade dysplasia (HGD) or residual dysplasia after endoscopic resection for HGD or intramucosal cancer (IMC).

METHODS

Visible abnormalities were removed with endoscopic resection prior to ablation. Persistence of dysplasia and absence of IMC were confirmed with biopsy after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation.

RESULTS

Twelve patients (nine men; median age 70 years) were treated (median Barrett's length 7 cm). Visible abnormalities were removed by endoscopic resection in seven patients. The worst pathological grade of residual Barrett's esophagus after resection and prior to ablation was low-grade dysplasia (LGD) (n = 1) and HGD (n = 11). Patients underwent a median of one circumferential and two focal ablation sessions. Complete remission of dysplasia was achieved in 12/12 patients (100%). Complete endoscopic and histological removal of Barrett's esophagus was achieved in 12/12 patients (100%). There were no ablation-related stenoses, and no subsquamous Barrett's esophagus was observed in 363 biopsies obtained from post-ablation neo-squamous mucosa. Protocolized cleaning of the ablation zone and electrode in between ablations resulted in superior regression of Barrett's esophagus compared with previous studies. During a median follow-up of 14 months no recurrence of dysplasia or Barrett's esophagus was observed.

CONCLUSIONS

Stepwise circumferential and focal ablation for Barrett's esophagus with flat HGD or for Barrett's with residual dysplasia after endoscopic resection for HGD/IMC is a safe and effective treatment modality. Its success rate and safety profile compare favorably with alternatives such as esophagectomy, widespread endoscopic resection or photodynamic therapy.

Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error

The study's aim was to retrospectively evaluate the surveillance history of Barrett's esophagus (BE) patients with endoscopically treated early neoplasia. All BE patients endoscopically treated for early cancer (EC) or high-grade intraepithelial neoplasia (HGIN) in a lesion or mass between 1998 and 2005 were included. Endoscopy and histology records were reviewed. Ninety-four patients (78 males, mean age 67 years, 24 HGIN, 70 EC) were included. In 36 (38%) patients, HGIN/EC was diagnosed at (or within 6 months after) initial endoscopy. The remaining 58 (62%) patients had a surveillance history (median duration 7 years, mean 6.7 endoscopies). Seventy-nine percent of these had low-grade intraepithelial neoplasia (LGIN) diagnosed at least once during their surveillance period with a median of seven endoscopies and a median number of biopsies that was 50% of what should have been taken according to the Seattle protocol. Patients without any dysplasia during earlier surveillance (n = 12, 21%) had undergone significantly less endoscopies (median four endoscopies, P = 0.02) and had a median biopsy percentage that was 23% of the Seattle protocol (P < 0.001 versus 50% in LGIN). In this selected cohort of patients with early Barrett's neoplasia, 38% of patients were diagnosed at initial endoscopy. Of the patients with a surveillance history, 79% had shown LGIN prior to HGIN/EC diagnosis. Only 21% of patients had a surveillance history without any dysplasia, which in general encompassed endoscopies with an insufficient number of biopsies, suggesting sampling error. This underlines the importance of obtaining an adequate number of biopsies during surveillance endoscopies.

Endoscopic cap resection for treatment of early Barrett's neoplasia is safe: a prospective analysis of acute and early complications in 216 procedures

This study aimed to prospectively evaluate the safety of endoscopic resection for early neoplasia in Barrett's esophagus (BE) using the endoscopic cap resection (ER cap) technique. All resections performed between September 2000 and March 2006 with the ER-cap technique in patients with BE were included. Complications were classified 'acute' (during the procedure) or 'early' (< 48 h after the procedure). A total of 216 ER-cap procedures were performed in 121 patients, of which 145 were performed with a standard hard cap and 71 with a large flexible cap. Specimens removed with the standard cap had a mean diameter of 20 mm (SD 5.0) versus 23 mm (SD 5.8) for the large cap (P < 0.001). Acute complications occurred in 51 procedures (24%), 49 bleedings and two perforations. All bleedings were effectively treated with hemostatic techniques and classified as mild complications. No patient experienced a drop in hemoglobin levels or required blood transfusions or repeat interventions. The two perforations were classified as severe complications and treated conservatively. Three (1%) early complications, all bleedings, occurred and were effectively treated with endoscopic hemostatic techniques and classified as moderately severe complications. In manova the indication for the resection (high-grade intraepithelial neoplasia or early cancer versus low-grade intraepithelial neoplasia or no dysplasia) was found to be significantly associated with an increased risk of acute bleeding. Endoscopic cap resection in BE is safe. Most complications become apparent immediately during the procedure and can be managed endoscopically. Bleeding after the endoscopic resection procedure and severe acute complications (i.e., perforations) are rare (2%).

High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett's esophagus: a prospective randomized crossover study

BACKGROUND AND STUDY AIMS

High-resolution endoscopy (HRE) may improve the detection of early neoplasia in Barrett's esophagus. Indigo carmine chromoendoscopy (ICC) and narrow-band imaging (NBI) may be useful techniques to complement HRE. The aim of this study was to compare HRE-ICC with HRE-NBI for the detection of high-grade dysplasia or early cancer (HGD/EC) in patients with Barrett's esophagus.

PATIENTS AND METHODS

Twenty-eight patients with Barrett's esophagus underwent HRE-ICC and HRE-NBI (separated by 6 - 8 weeks) in a randomized sequence. The two procedures were performed by two different endoscopists, who were blinded to the findings of the other examination. Targeted biopsies were taken from all detected lesions, followed by four-quadrant biopsies at 2-cm intervals. Biopsy evaluation was supervised by a single expert pathologist, who was blinded to the imaging technique used.

RESULTS

Fourteen patients were diagnosed with HGD/EC. The sensitivity for HGD/EC was 93 % and 86 % for HRE-ICC and HRE-NBI, respectively. Targeted biopsies had a sensitivity of 79 % with HRE alone. HGD was diagnosed from random biopsies alone in only one patient. ICC and NBI detected a limited number of additional lesions occult to HRE, but these lesions did not alter the sensitivity for identifying patients with HGD/EC.

CONCLUSIONS

In most patients with high-grade dysplasia or early cancer in Barrett's esophagus, subtle lesions can be identified with high-resolution endoscopy. Indigo carmine chromoendoscopy and narrow-band imaging are comparable as adjuncts to high-resolution endoscopy.

The effect of optimal treatment on elderly patients with aggressive non-Hodgkin's lymphoma: more patients treated with unaffected response rates

A substantial part of elderly patients (with good performance) with intermediate or high-grade non-Hodgkin's lymphoma (NHL) are not treated with the standard chemotherapy of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). If NHL patients are not treated with CHOP, the outcome is inferior. By adding granulocyte colony-stimulating factor (G-CSF) to CHOP chemotherapy, we aimed at treating more patients with less toxicity. We performed a multicenter population-based study (in the southeast of the Netherlands) in which elderly patients (> or = 60 years) with intermediate or high-grade stage > or = IIB NHL were treated with CHOP chemotherapy and growth factor G-CSF to increase the number of patients treated according to standard protocols. We also evaluated elderly NHL patients who were not treated with CHOP chemotherapy. Adequate therapy was defined as > or = six cycles or a total of five cycles when complete remission was achieved after three cycles. Seventy-nine NHL patients fulfilled the selection criteria. The patients were treated with CHOP plus G-CSF (n=46), CHOP (n=19), cyclophosphamide, vincristine, and prednisone (COP) (n=2), chlorambucil and prednisone (n=2), or prednisone (n=1). Nine patients were not treated with chemotherapy. The median age was 72 years (60-87). Of the 79 NHL patients, 65 were treated with CHOP chemotherapy (82%); 38 of 65 patients (59%) were adequately treated. The complete remission rate in the NHL group treated with CHOP was 65% (42 of 65 patients). The overall 3-year survival was 50%. Most of the patients died from progressive NHL (53% in the CHOP and 77% in the group not treated with CHOP). The treatment-related mortality was 15% in the CHOP group. The most important reason for not treating patients with CHOP (with or without G-CSF) was poor performance (WHO > or = 2). A significant subset of patients can be treated with CHOP chemotherapy with acceptable toxicity. The combination of CHOP plus G-CSF increased the absolute number of treatable elderly patients, resulting in more (absolute) patients with complete remission and overall survival compared to our previous study.

Treatment of elderly patients with intermediate- and high-grade non-Hodgkin's lymphoma: a retrospective population-based study

PURPOSE AND METHODS

Nowadays more people are becoming older. The median age of a patient with non-Hodgkin's lymphoma (NHL) at diagnosis is over 60 years. The incidence of NHL in elderly has increased in the last decades. Therefore, in the future, NHL will be diagnosed more often in the elderly. Data of all patients in the south-east of the Netherlands with newly diagnosed NHL between January 1991 and January 1995 were analysed in a retrospective multicentre population-based study to investigate if and how elderly patients (> 60 years) with advanced NHL (Ann Arbor Staging > or = IIB) of intermediate- and high-grade malignancy were treated. Treatment modalities applied, outcome, and causes of death were evaluated. Treatment was considered inadequate if it deviated from the standard anthracycline-containing chemotherapy (CNOP/CHOP) for a minimum of six cycles.

RESULTS

The entry criteria were met by 68 patients. Of these patients, 57 (83.8%) were treated and 11 (16.2%) were not treated. The treatment consisted of CHOP (36 patients), CNOP (6 patients), chlorambucil (13 patients), or COP (2 patients). Forty-two of 68 patients had adequate treatment, but 14 of 42 (33.3%) patients had a suboptimal numbers of cycles (< 6). Of 28 patients with adequate chemotherapy, only 16 had the optimal number of cycles and dose; the result is that the treatment of 76.5% (52/68) of patients differed from that of their younger counterparts. The most important reason for treatment not being optimal was high age (23%) or poor performance (35%). In the appropriately treated patients, 62.5% (10/16) had a complete response. Survival in the CHOP/CNOP-treated group was better than in other groups. The main cause of death in the total study group was NHL. The results cannot be explained by the different international prognostic index.

CONCLUSION

A significant subset (76.5%) of elderly people with intermediate/high-grade NHL received suboptimal therapy, mainly because of a suboptimal performance status. However, a significant part of the patients (23%) were not treated optimally because of high age, despite a good performance. For improving the overall survival in the elderly, it is not only the schedule that is important, but also the intention to treat the elderly patient.

Intermediate and high grade non Hodgkin's lymphoma in the elderly

Many malignant tumors develop in the later years of life. One of malignancies that frequently occurs in older patients is non Hodgkin's lymphoma (NHL) with a median age at diagnosis over 60 years. The overall incidence of NHL has increased over the past decade and is expected to continue to rise in developed countries. So NHL will be diagnosed more in the future. In this review we discuss epidemiology, etiology, possible differences in tumor characteristics compared with younger NHL patients, treatment and treatment results in elderly NHL patients.

An unusual aspiration

Images

Myelodysplasia presenting with pulmonary manifestations associated with neutrophilic dermatosis

We present the case of a patient who suffered from severe pneumonia. Extensive diagnostic procedures revealed negative cultures and a severe neutrophilia in the bronchoalveolar lavage fluid suggestive of Sweet's syndrome. The persistent toxic leukocyte differentiation (not induced by infection) suggested an underlying hematologic disorder. One week later, she developed cutaneous lesions indicative of neutrophilic dermatosis. Bone marrow investigation showed refractory anemia with excess of blasts (RAEB). Both the pulmonary and cutaneous infiltrates improved after treatment with chemotherapy.

Treatment of recent onset atrial fibrillation with intravenous sotalol and/or flecainide

AIM

The purpose of our study (conducted between August 1995 and September 1996) was to evaluate prospectively the efficacy of intravenous administration (in 10 min) of sotalol, flecainide or the combination of these drugs to restore sinus rhythm in patients (without cardiac/pulmonary failure) who came to the First Heart Aid of our hospital with atrial fibrillation lasting less than 24 h.

METHODS AND RESULTS

Patients in whom the rhythm was not converted to sinus rhythm by intravenous sotalol within 60 min, we started to give flecainide intravenously (2 mg/kg). In patients on oral beta blockade we started flecainide intravenously (2 mg/kg) over 10 min. Of the 92 patients who fulfilled the entry criteria 51 were on oral beta blocking agents for angina, hypertension or to prevent atrial fibrillation. Of these patients, 43 (84%) converted to sinus rhythm with intravenous flecainide. The 41 patients not on a beta blocking agents were treated with 40 mg sotalol intravenously which led to sinus rhythm in 22 patients (54%). Sixteen of the 19 remaining patients (84%) converted to sinus rhythm after subsequent administration of flecainide. Therefore of the whole group of 70 patients treated with flecainide, 59 (84%) were successfully converted. Out of the 92 patients, 11 patients were not converted to sinus rhythm. Six were treated successfully by electrical cardioversion. The others were treated with oral flecainide/sotalol or digoxine with persistence of atrial fibrillation.

CONCLUSION

The findings of this study suggest that intravenous sotalol is a good choice for termination of recent onset atrial fibrillation in a patient with a good left ventricular function. If not successful then flecainide had to be added.

Fabry's disease: a multidisciplinary disorder

Fabry's disease is an X-linked hereditary disorder resulting in accumulation of a glycolipid (galactosylgalactosyl glucosylceramide) due to deficiency of alpha-galactosidase A. The diagnosis can be made by histopathologic examination of skin biopsy, low activity of alpha-galactosidase in leucocytes and genetic examination. Treatment is symptomatic. We want to stress the multidisciplinary collaboration necessary to deal with this condition, in order to prevent acceleration of symptoms.

Pulmonary infiltration associated with myelodysplasia

Four case histories are reported in which the initial signs and symptoms were those of pulmonary infiltration and in which subsequently a diagnosis of myelodysplasia was made. The analysis of bronchoalveolar lavage fluid--demonstrating predominantly neutrophils and lymphocytes, and, occasionally blast cells as well as plasma cells--indicated that the pulmonary infiltration was related to the myelodysplastic process. As no other causes of pulmonary infiltration could be found, it seems that a pulmonary infiltrate can be the presenting symptom of a myelodysplastic syndrome. Although pleuropulmonary infiltrates most often are caused by infections, these cases illustrate that myelodysplasia related infiltrates should also be considered.

Cerebral relapse of sarcoidlike Whipple's disease

Whipple's disease, an infection with the recently identified intracellular bacillus Tropheryma whippelii, is a systemic disorder that can be life threatening when untreated. In a few patients, the signs and symptoms of the disease are similar to those of sarcoidosis, and this illness is referred to as sarcoidlike Whipple's disease. This variant must be recognized because patients with sarcoidlike Whipple's disease must be treated with antibiotics instead of corticosteroids, which would be indicated for patients with true sarcoidosis. We describe a 53-year-old man who had sarcoidlike Whipple's diseases with polyvisceral granulomatous dissemination that was treated with procaine penicillin G and streptomycin followed by doxycycline. His condition initially improved. However, during his 4-month course of treatment he developed a cerebral relapse; this relapse was successfully treated with ceftriaxone and cefixime.

Pneumonitis induced by sulphasalazine

We describe a 65-year-old woman with eosinophilic pneumonitis induced by sulphasalazine. Laboratory findings revealed peripheral eosinophilia. The chest X-ray showed bilateral infiltrations, which disappeared after sulphasalazine was discontinued.

Whipple's disease: a difficult diagnosis?

We present 3 patients with Whipple's disease all characterized by a longstanding prodromal period with progressive weight loss, diarrhoea, lymphadenitis and arthralgia or arthritis. Sarcoid-like Whipple's disease was diagnosed in one patient. He was treated with antibiotics. Initially his condition improved; however, a cerebral relapse developed which was treated successfully by ceftriaxone and cefixime. Extraintestinal Whipple's disease (lymph node localisation) was diagnosed in another patient treated successfully with antibiotics. A third case of Whipple's disease was unexpectedly diagnosed by laparotomy and partial small bowel resection. He was not treated till 2 years later with tetracycline. After 1 year of treatment his condition had improved.

Adrenomyeloneuropathy: a rare cause of Addison's disease?

A 31-year-old male patient is reported who presented with neurological symptoms. He developed a urinary tract infection and an Addisonian crisis. This was due to adrenomyeloneuropathy, a form of X-linked adrenoleukodystrophy and characterized by accumulation of very-long-chain fatty acids in the adrenal cortex and nervous tissues.

Abscess of the spleen

Two unusual cases are presented of splenic abscesses caused by metastatic infection with different organisms. The patients were treated with splenectomy and antibiotics.

Is Recormon less painful than Eprex after subcutaneous administration?

In this study, we examined the differences in pain score after subcutaneous injection of the epoetin preparations Eprex and Recormon. Patients (n = 30) received 5 injections Eprex and 5 injections Recormon in a randomized double-blind sequence. 10 Min after receiving the injection the patient was asked to complete a visual and a verbal analogue scale and two descriptive scales. The results of 25 patients were used for statistical evaluation. The overall results indicate that there are significantly more patients reporting pain after subcutaneous injection of Eprex than after Recormon (11 versus 2 patients, p less than 0.05; McNemar test). 12 Patients reported no differences in pain. 43 Out of 123 injections Eprex and 69 out of 125 injections Recormon caused no pain (p less than 0.01; chi 2 9.455). For 4 patients Recormon was significantly (p less than 0.05) less painful than Eprex. It can be concluded that Recormon may be a less painful alternative for individual patients reporting pain after subcutaneous injection of Eprex.

Behaviour of L-gamma-glutamyl-4-nitroanilide and L-gamma-glutamyl-3-carboxy-4-nitroanilide with respect to gamma-glutamyltransferases of different origin

In this paper we compare the measurement of catalytic activity concentrations of gamma-glutamyltransferase with the non-carboxylated and the carboxylated substrate in preparations of different origin. Fresh human sera, commercial test sera and preparations of gamma-glutamyltransferase purified from human liver, porcine kidney and bovine kidney were used as sample materials. When assayed with both substrates preparations of gamma-glutamyltransferase from bovine kidney behaved in a different manner as did the enzyme in preparations from human liver or porcine kidney and the enzyme in fresh human sera. On account of the results obtained with both substrates we classified the commercial test sera for their enrichment using multi-inductive component analysis. The differences observed for the various methods of determination seem to have significance in quality control.

The unusual structure of heat shock locus 2-48B in Drosophila hydei

We have previously isolated a 500 bp-long cDNA clone, NO9-15, which is derived from a nuclear transcript originating from the heat shock locus 2-48B of Drosophila hydei (Peters et al. 1982). Sequence analysis shows that this clone carries 4 complete copies and 1 partial copy of a 115 bp repeat unit. The repeats are closely homologous with a maximal sequence divergence of about 10%. The sequence does not contain an open reading frame. The genomic organization of heat shock locus 2-48B, as probed with the cloned cDNA sequence NO9-15, is highly polymorphic. Four different allelic arrangements have been found in different inbred strains. A number of genomic clones isolated from region 2-48B, both in phage lambda and in cosmid vectors, all differ in length, mainly due to varying numbers of the NO9-15 repeat unit. These differences are found primarily in the proximal region of the locus. The transcribed region of these clones includes the distal sequence flanking the NO9-15 repeat as well as the NO9-15 repeat itself. An oligo A stretch was found between the distal flanking sequence and the NO9-15 repeat region.

Kits for enzyme determinations compared: relation between composition and quality

Kits of five different suppliers, composed according to the Dutch recommendations for determination of the enzyme activity of alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, gamma-glutamyltransferase, alkaline phosphatase, and creatine kinase, were intercompared. Activity concentrations of the enzymes in human sera were measured under defined conditions, evaluated, and related to the actual composition of the kits. Concentrations of all kit components were determined by various analytical techniques. The overall results of the activity measurements and the composition of at least three kits inter-agree well. We found deviations as great as 10% in our analytical evaluation of the kits of the other two suppliers, which can partly be accounted for.

Kits for enzyme determinations compared: relation between composition and quality

Kits of five different suppliers, composed according to the Dutch recommendations for determination of the enzyme activity of alanine aminotransferase, aspartate aminotransferase, lactate dehydrogenase, gamma-glutamyltransferase, alkaline phosphatase, and creatine kinase, were intercompared. Activity concentrations of the enzymes in human sera were measured under defined conditions, evaluated, and related to the actual composition of the kits. Concentrations of all kit components were determined by various analytical techniques. The overall results of the activity measurements and the composition of at least three kits inter-agree well. We found deviations as great as 10% in our analytical evaluation of the kits of the other two suppliers, which can partly be accounted for.

Identification of the heat shock band 2-48B of Drosophila hydei and determination of its haploid DNA content

The heat shock locus 2-48B situated at the tip of the second chromosome of Drosophila hydei has been studied by various cytologic methods. Both from puffing behaviour and in situ hybridization on both wildtype animals and heterozygotes for the mutant chromosome Df(2)e20 the actual site is localized in band 2-48B8. Electron microscopically this band appears to be a medium size, dotted band. From cytophotometric measurements on Feulgen stained chromosomes and electron microscopic observations the DNA content of band 2-48B8 is calculated to be approximately 40 kb on the haploid level, with a compaction of the DNA of about 160 times. The interbands 2-48B7-8 and 2-48B8-9, flanking the heat shock band, were calculated to contain on the haploid level 1.5 kb and 3.0 kb, respectively. The results are discussed also in relation to the present data on the molecular organization of this locus.

Chromosomal arrangement of heat shock locus 2-48B in Drosophila hydei

cDNA, copied from nuclear RNA isolated from heat shocked Drosophila hydei cells, has been cloned. From this collection of clones a clone, N09-15, with a 450 bp insert has been isolated that hybridizes in situ to the heat shock locus-2-48B of Drosophila hydei. The N09-15 sequence is present in two different genomic arrangements, as shown by restriction mapping, in our wild type D. hydei population. These genomic arrangements are allelic. Both alleles contain multiple copies of the N09-15 sequence but differ in their lengths and in the distribution of Msp I and Taq I sites.

Rapid sequence divergence in a heat shock locus of Drosophila

In situ hybridization of cRNA transcribed from cloned D. melanogaster heat shock sequences to D. hydei chromosomes has shown that the D. hydei locus 2--32 A corresponds to the D. melanogaster locus 87 A/C and the D. hydei locus 2--36 A to the D. melanogaster locus 95 D, while the D. hydei locus 4--81 B corresponds to the D. melanogaster locus 63 BC. No hybridization to D. hydei chromosomes was found with cRNA transcribed from a clone containing the alpha beta sequences encoded by the D. melanogaster locus 87 C. Neither D. melanogaster heat shock RNA nor D virilis heat shock RNA hybridized significantly to the D. hydei heat shock locus 2--48 B. Furthermore, D. hydei heat shock RNA did not hybridize to the cytological homologs of locus 2--48 B found in D. repleta or in D. virilis. D. hydei heat shock. RNA did hybridize to the cytological homologs of locus 2--48 B in D. neohydei and D. eohydei, both of which belong to the hydei subgroup.